Annual Utilization Report of Home Health Agencies / Hospices
Facility Name:KAWEAH DELTA HOSPICE
OSHPD ID:406544026Report Status:Submitted
License Category:HospiceReport Year:2008
Table of Contents
Click on any of the links listed below to view the corresponding section.
Section 1 - General Information
Section 2 - Home Health Agency
Section 3 - Home Health Agency Patients and Visits
Section 4 - Health Care Utilization
Section 5 - Hospice Description
Section 6 - Hospice Services
Section 7 - Hospice Patient Information
Section 8 - Hospice Utilization
Section 9 - Hospice Care And Source Of Payment
Section 10 - Hospice Income and Expenses Statement
General Comments
View Errors and Warnings
Section 1 - General Information
1.Facility Name:KAWEAH DELTA HOSPICE
2.OSHPD ID Number:406544026
3.Street Address:900 W. OAK STREET
4.City:VISALIA
5.Zip:93291
6.Facility Phone No.:( 559) 733 - 0642 ext.
7.Administrator Name:Karrie Decker
8.Administrator E-mail Address:kdecker@kdhcd.org
9.Was this agency in operation at any time during the year?:Yes
10.Operation Open From:1/1/2008
11.Operation Open To:12/31/2008
12.Name of Parent Corporation:Kaweah Delta Health Care District
13.Corporate Business Address:400 West Mineral King
14.City:Visalia
15.State:CA
16.Zip:93247 -
17.Person Completing Report:Karrie Decker
18.Phone No.:559-733-0642
19.Fax No.:559-733-0658
20.E-mail Address:kdecker@kdhcd.org
25.Entity Type:Hospice Only
26.Entity RelationSole Facility
30.Submitted by:kdecker1
31.Submitted Date and Time:3/5/2009 12:01:49 PM
Section 2 - Home Health Agency
LICENSEE TYPE OF CONTROL
Line
No.		(1)
1.Select the one category that best describes the licensee type of control of your home health agency:Unselected Type of Control
Medicare/Medi-Cal Certification
Line
No.		(1)
Certification
5.Unknown certification
Agency Accreditation Status
Line
No.		(1)
Accreditation Status
10.Accredited by ACHCUnknown Accreditation Status
11.Accredited by CHAPUnknown Accreditation Status
12.Accredited by JCAHOUnknown Accreditation Status
13.Accredited by otherUnknown Accreditation Status
Home Infusion Therapy / Pharmacy Only
Line
No.		(1)
15.Is your agency a licensed Pharmacy?Unspecified
16.Do you have a Registered Nurse on staff who makes home visits?Unspecified
Note: If the facility is a licensed Pharmacy that only provides home infusion equipment, check “No” on line 40, then submit the report to OSHPD. The rest of the report is not applicable.
Special Services
Line
No.		(1)
20.AIDS ServicesNo
21.Blood TransfusionsNo
22.Enterostomal TherapyNo
23.IV Therapy (Includes Chemo and TPN)No
24.Mental Health CounselingNo
25.PediatricNo
26.Psychiatric NursingNo
27.Respiratory / Pulmonary TherapyNo
28.OtherNo
Persons Receiving Services
Line
No.		(1)
30.Number of unduplicated persons seen by your agency during the reporting year.0
Home Health Care
Line
No.		Other Home Health Visits(1)
No. of Visits
31.Pre-Admission Screening / Evaluations0
32.Outpatient Visits0
33.Other0
34.Total0
Other Home Health Services (Home Care Service, e.g. Continous Care)
Note: Do not complete lines 50-54 if these services were provided by an organization other than your licensed agency
Line
No.		(1)
40.Did your agency perform other Home Care Services?Unspecified
41.How many total hours of other Home Care did your agency provide?0
Other Home Care Services, Staff, and Functions
Line
No.		(1)
50.Certified Nurse Assistant (CNA)No
51.Home Health AideNo
52.Homemaker ServicesNo
53.Non-intermittent Nursing (RN / LVN)No
54.OtherNo
Section 3 - Home Health Agency Patients And Visits
Patients And Visits By Age
Line
No.		Age(1)
Patients		(2)
Visits
1.0 - 10 Years00
2.11 - 20 Years00
3.21 - 30 Years00
4.31 - 40 Years00
5.41 - 50 Years00
6.51 - 60 Years00
7.61 - 70 Years00
8.71 - 80 Years00
9.81 - 90 Years00
10.91 Years and Older00
15.Total0 0
Admissions By Source Of Referral
Line
No.		Source Of Referral(1)
Admissions
21.Another Home Health Agency0
22.Clinic0
23.Family / Friend0
24.Hospice0
25.Hospital (Discharge Planner, etc.)0
26.Local Health Department0
27.Long Term Care Facility (SN / IC)0
28.MSSP0
29.Payer (Insurance, HMO, etc.)0
30.Physician0
31.Self0
32.Social Service Agency0
34.Other0
35.Total0
Discharges By Reasons
Line
No.		Reason for Discharge(1)
Discharges
41.Admitted to Hospital0
42.Admitted to SN / IC Facility0
43.Death0
44.Family / Friends Assumed Responsibility0
45.Lack of Funds0
46.Lack of Progress0
47.No Further Home Health Care Needed0
48.Patient Moved out of Area0
49.Patient Refused Service0
50.Physician Request0
51.Transferred to Another HHA0
52.Transferred to Home Care (Personal Care)0
53.Transferred to Hospice0
54.Transferred to Outpatient Rehabilitation0
59.Other0
60.Total0
Visits By Type Of Staff
Line
No.		Type of Staff(1)
Visits
71.Home Health Aide0
72.Nutritionist (Diet Counseling)0
73.Occupational Therapist0
74.Physical Therapist0
75.Physician0
76.Skilled Nursing0
77.Social Worker0
78.Speech Pathologist / Audiologist0
79.Spiritual and Pastoral Care0
84.Other0
85.Total0
Visits By Primary Source Of Payment
Line
No.		Source Of Payment(1)
Visits
91.Medicare0
92.Medi-Cal0
93.TRICARE (CHAMPUS)0
94.Other Third Party (Insurance, etc.)0
95.Private (Self Pay)0
96.HMO / PPO (Includes Medicare and Medi-Cal HMOs)0
97.No Reimbursement0
99.Other (Includes MSSP)0
100.Total0
Section 4 - Health Care Utilization
Patients And Visits By Principal Diagnosis For Which Care Was Given*
Line
No.		Principal DiagnosisICD-9-CM Code(1)
Patients		(2)
Visits
1.Infectious and Parasitic diseases (exclude HIV)001.0 - 041.9,
045.00 - 139.8		00
2.HIV infections04200
3.Malignant neoplasms: Lung162.2 - 162.9,
197.0, 209.22, 231.2		00
4.Malignant neoplasms: Breast174.0 - 174.9,
175.0 - 175.9,
198.2, 198.81, 233.0		00
5.Malignant neoplasms: Intestines152.0 - 154.0,
159.0,  197.4,  197.5,  197.8,
209.00 - 209.17  230.3,  
230.4, 230.7		00
6.Malignant neoplasms: All other sites, excluding those in #3, 4, 5140.0 - 209.30,
230.0 - 234.9		00
7.Non-malignant neoplasms: All sites209.40 - 209.69
210.0 - 229.9,
235.0 - 238.9,
239.0 - 239.9		00
8.Diabetes mellitus249.00 - 250.9300
9.Endocrine, metabolic, and nutritional diseases; Immunity disorders240.0 - 246.9,
251.0 - 279.9		00
10.Diseases of blood and blood forming organs280.0 - 289.900
11.Mental disorder290.0 - 31900
12.Alzheimer's disease331.000
13.Disease of nervous system and sense organs320.0 - 330.9,
331.11 - 389.9		00
14.Diseases of cardiovascular system391.0 - 392.0,
393 - 402.91,
404.00 - 429.9		00
15.Diseases of cerebrovascular system430 - 438.900
16.Diseases of all other circulatory system390,  392.9,
403.00 - 403.91,
440.0 - 459.9		00
17.Diseases of respiratory system460 - 519.900
18.Diseases of digestive system520.0 - 579.900
19.Diseases of genitourinary system580.0 - 608.9,
614.0 - 629.9		00
20.Diseases of breast610.0 - 611.900
21.Complications of pregnancy, childbirth, and the puerperium630 - 679.1400
22.Diseases of skin and subcutaneous tissue680.0 - 709.900
23.Diseases of musculosketal system and connective tissue (include pathological fx, malunion fx, and nonunion fx)710.0 - 739.900
24.Congenital anormalies and perinatal conditions (include birth fractures)740.0 - 779.900
25.Symptoms, signs, and ill-defined conditions (exclude HIV positive test)780.01 - 795.6,
795.79,
796.0 - 799.9		00
26.Fractures (exclude birth fx, pathological fx, malunion fx, nonunion fx)800.00 - 829.100
27.All other injuries830.0 - 959.900
28.Poisonings and adverse effects of external causes960.0 - 995.9400
29.Complications of surgical and medical care996.00 - 999.900
30.Health services related to reproduction and developmentV20.0 - V26.9,
V28.0 - V29.9		00
31.Infants born outside hospital (infant care)V30.1,  V30.2,  V31.1,  V31.2,  V32.1,
V32.2,  V33.1,  V33.2,  V34.1,  V34.2,
V35.1,  V35.2,  V36.1,  V36.2,  V37.1,
V37.2, V39.1, V39.2		00
32.Health hazards related to communicable diseasesV01.0 - V07.9,
V09.0 - V19.8,
V40.0 - V49.9		00
33.Other health services for specific procedures and aftercareV50.0 - V58.900
34.Visits for Evaluation and AssessmentV60.0 - V89.0900
45.Total00
* The list of ICD-9-CM codes excluded: 795.71, V08, V27.0-V27.9, V30-V39 with 5th digits 0 or 1, V59.01-V59.9.
How many of the patients you reported in Section 3 "Patients and Visits by Age" Table had a principal or secondary diagnosis of HIV or Alzheimer's Disease and how many health care visits were made to them? The principal diagnosis for which an HIV or Alzheimer's patient was visited may have been a fracture, a skin infection, cancer, or any number of principal diagnoses. What we are asking relates to the number of HIV or Alzheimer's patients among your total patient load, regardless of the nature of the treatment received or the principal diagnosis of the patient.
Line
No.		ICD-9-CM Code(1)
Patients		(2)
Visits
51.HIV04200
52.Alzheimer's Disease331.000
Section 5 - Hospice Description
LICENSEE TYPE OF CONTROL
Line
No.		(1)
1.Select the one category that best describes the licensee type of control of your hospice from drop down list:District
Medicare/Medi-Cal Certification
Line
No.		(1)
Certification
5.Medicare and Medi-Cal
Hospice Accreditation Status
Line
No.		(1)
Accreditation Status
10.Accredited by ACHCNone
11.Accredited by CHAPNone
12.Accredited by JCAHODeemed Status
13.Accredited by otherNone
Agency Type As Reported On Medicare Cost Report
Line
No.		(1)
20.Hospital based
Location of Service Delivery
Line
No.		(1)
25.Mixed Urban and Rural
Section 6 - Hospice Services
Bereavement Services
Line
No.		Bereavement Services(1)
People Served
1.Survivors of hospice patients406
2.Survivors of persons not receiving hospice care79
Volunteer Services
Line
No.		Volunteer Services(1)
No. of Volunteers		(2)
Volunteer Hours
3.Patient / Family Services27647
4.Bereavement337
5.Administrative157,027
6.Medicare Reportable Hours
(sum lines 3-5)		7,711
7.Fundraising00
9.Other00
10.Total457,711
Additional And Specialized Services
Check all services directly provided by OR contracted for by the hospice.
Line
No.		Additional and Specialized Hospice Services(1)
Services
11.Hospice Designated Inpatient Facility / UnitNo
12.Specialized Pediatric ProgramYes
13.Bereavement services to survivors of persons not receiving hospice careYes
14.Adult Day CareNo
15.Specialized Palliative Care ProgramNo
16.OtherNo
Visits By Type Of Staff
(Include After-Hours and Bereavement Visits)
Line
No.		Type of Staff(1)
Visits
21.Nursing - RN3,469
22.Nursing - LVN0
23.Social Services845
24.Hospice Physician Services0
25.Homemaker and Home Health Aide2,565
26.Chaplain541
29.Other Clinical Services0
30.Total7,420
Section 7 - Hospice Patient Information
Unduplicated Hospice Patients By Gender And Age Category
Line
No.		Age
(1)

Male
(2)

Female		(3)
Other / Unknown
(4)

Total
1.0 - 1 Years1506
2.2 - 5 Years0000
3.6 - 10 Years0000
4.11 - 20 Years0000
5.21 - 30 Years2406
6.31 - 40 Years3306
7.41 - 50 Years4408
8.51 - 60 Years2425049
9.61 - 70 Years3326059
10.71 - 80 Years4048088
11.81 - 90 Years54570111
12.91 + Years2027047
15.Total1811990380
Unduplicated Hospice Patients By Gender and Race
Line
No.		Race
(1)

Male
(2)

Female		(3)
Other / Unknown
(4)

Total
21.White1231470270
22.Black3003
23.Native American0000
24.Asian / Pacific Islander3205
25.Other / Unknown52500102
30.Total1811990380
Unduplicated Hospice Patients By Gender And Ethnicity
Line
No.		Ethnicity
(1)

Male
(2)

Female		(3)
Other / Unknown
(4)

Total
31.Hispanic51490100
32.Non-Hispanic1291490278
33.Unknown1102
35.Total1811990380
Hospice Patient Admissions By Source Of Referral
Line
No.		Source of Referral(1)
Patients
41.Home Health Agency20
42.Hospital (Discharge Planner, etc.)147
43.Long-Term Care Facility8
44.Other Hospice1
45.Payer (Insure, HMO,etc.)0
46.Physician131
47.RCFE / ARF/ CLHF0
48.Self / Family / Friend44
49.Social Service Agency0
54.Other0
55.Total351
Hospice Patient Discharges By Reason
Line
No.		Reason for Discharge(1)
Patients
61.Death309
62.Patient Moved Out of Area2
63.Patient Refused Service7
64.Transferred to Another Local Hospice1
65.Prognosis Extended4
66.Patient Desired Curative Treatment9
69.Other13
70.Total345
Hospice Patients Discharged By Length Of Stay
Line
No.		Length of Stay
(Days)		(1)
Patients
71.0-5 Days119
72.6-10 Days60
73.11-15 Days31
74.16-20 Days18
75.21-30 Days30
76.31-60 Days28
77.61-90 Days26
78.91-120 Days10
79.121-150 Days5
80.151-180 Days4
84.181 + Days14
85.Total345
Hospice Patient Admissions By County And Discharges By Disposition
Line
No.
(1)
County of Patients's
Residence at Time of Admission
(2)

No. of
Admissions
(3)

No. of
Deaths		(4)
No. of
Non-Death Discharges		(5)
No. of
Patients Served
91.Kings5405
92.Tulare34630523375
93.0000
94.0000
95.0000
96.0000
97.0000
98.0000
99.0000
100.Total35130923380
Section 8 - Hospice Utilization
Please provide the number of patients discharged during calendar year reported regardless of payment source. Count the patient only under the principal diagnosis for which the patient was admitted for hospice care. Report each patient only once. The ICD-9-CM codes are provided only as a guide for you. You may use your hospice's existing definitions for diagnosis groups or the LMRP diagnosis codes from your fiscal intermediary, provided they match in a general way with the ICD-9-CM codes suggested.
Discharged Hospice Patients, Visits And Patient Days By Diagnosis
Line
No.		DiagnosisICD-9-CM Code
(1)

No. of Patient Discharges
(2)

Visits for Discharged Patients		(3)
Discharged Patients Total Days of Care
1.Cancer140.0 - 209.30,
230.0 - 234.9		1652,8365,068
2.Heart391.0 - 392.0,
393 - 402.91,
404.0 - 404.9 with fifth digit 1 or 3,
410.00 - 429.9		32284759
3.Dementia and Cerebral Degeneration290.0 - 294.9,
331.0-331.9		491,2092,146
4.Lung, excluding cancer460 - 519.9, 573.918482998
5.Kidney, excluding cancer403.00 - 403.91,
404.0 - 404.9 with fifth digit 0, 2 or 3,
405.0 - 405.9 with fifth digit 1,
580.0 - 589.9		1585115
6.Liver, excluding cancer570 - 573.91182143
7.HIV04213188
8.Brain Stroke and late effects430 - 436,
438.0 - 438.9,
997.02		29322650
9.Coma, with or without brain injury780.01 - 780.09,
850.4,
851.0 - 854.1 with fifth digit 5		000
10.Diabetes249.00 - 250.93000
11.ALS*335.2032948
19.OtherAll other codes that are not in lines 1-11.223751,703
20.Total3455,73511,718
* Amyotrophic lateral sclerosis (ALS), also called Lou Gehrig's Disease
Section 9 - Hospice Care and Source of Payment
Please provide patient days for all patients served, including those in nursing facilities during the calendar year reported. Patients who change primary pay source during the calendar year reported should be reported for each pay source with the number of days of care recorded for each source (count each day only once even if there is more than one pay source on any one day).
Level of Care and Source of Payment
Line
No.		Source of Payment(1)
No. of Patients Served		(2)
Days of Routine Home Care		(3)
Days of Inpatient Care		(4)
Days of Respite Care		(5)
Days of Continuous Care
(6)

Total Patient Care Days
1.Medicare27910,361015210,378
2.Medi-Cal401,8630001,863
3.Medi-Cal Managed Care7393000393
4.Managed Care461,3050001,305
5.Private Insurance000000
6.Self Pay230003
7.Charity8244000244
9.Other*000000
10.Total38214,169015214,186
* Other payment sources may include but not limited to Workers Comp., Home Health benefit, etc.
Location of Care Provided
Line
No.		Location of Care(1)
Days of Routine Home Care		(2)
Days of Inpatient Care		(3)
Days of Respite Care		(4)
Days of Continuous Care		(5)
Total Patient Care Days
21.Home9,980029,982
22.Hospital0000
23.SNF2,56401502,579
24.CLHF00000
25.RCFE / ARF1,625001,625
29.Other00000
30.Total14,169015214,186
Section 10 - Hospice Income and Expenses Statement
Detail Of Operating Expenses
Line
No.		(1)
Total
General Service Cost Centers
30.Administrative and General$235,686
Inpatient Care Service
31.Inpatient - General Care0
32.Inpatient - Respite Care0
Nursing Home
33.Room and Board SNFMedi-Cal Pass through Payments( $394,252 )
34.Medi-Cal Room and Board Contractual Payments$415,002
Program Supervision
35.Hospice Program / Team Supervision (Non-visit wages)0
Visiting Services
36.Physician Services$39,165
37.Nursing Care$1,146,240
38.Rehabilitation Services (PT, OT, Speech)0
39.Medical Social Services - Direct$291,348
40.Spiritual Counseling$64,930
41.Dietary Counseling0
42.Counseling - Other0
43.Home Health Aides and Homemakers$106,931
44.Other Visiting Services$388,469
Hospice Service Cost Centers
45.Drugs, Biologicals and Infusion$218,644
46.Durable Medical Equipment / Oxygen$7,962
47.Patient Transportation0
48.Imaging, Lab and Diagnostics0
49.Medical Supplies$26,422
50.Outpatient Services (including ER Dept.)0
51.Radiation Therapy0
52.Chemotherapy0
53.Other Hospice Service Costs0
Other Hospice Costs
54.Bereavement Program Costs0
55.Volunteer Program Costs0
56.Fundraising0
Other Costs
57.Other Program Costs*0
59.Total Operating Expenses$2,546,547
* Program costs including community education and outreach program costs.
Hospice Income Statement
Line
No.		(1)
Total
Gross Patient Revenue
101.Medicare$1,540,512
102.Medi-Cal (Excluding Room and Board)$643,131
103.Medi-Cal Managed Care (Excluding Room and Board)$13,676
104.Managed Care (Non Medi-Cal)$152,466
105.Private Insurance0
106.Self-Pay-$654
109.Other Payers$44,868
110.Total Gross Patient Revenue (sum of lines 101 through 109)$2,393,999
Write-Offs and Adjustments
111.Contractual Adjustments$124,854
112.Denials / Bad Debt0
113.Charity0
119.Other Write-offs and Adjustments0
120.Total Write-Offs and Adjustments (sum of lines 111 through 119)$124,854
125.Net Patient Revenue (line 110 minus line 120)$2,269,145
Other Operating Revenue
131.Grants0
132.Donations / Contributions0
133.Unrelated Business Income0
139.Other0
140.Total Other Operating Revenue (sum of lines 131 through 139)$0
145.Total Operating Revenue (line 125 plus line 140)$2,269,145
Operating Expenses
151.General Service Cost Centers$235,686
152.Inpatient Care Service$0
153.Nursing Home$20,750
154.Program Supervision$0
155.Visiting Services$2,037,083
156.Hospice Service Cost Centers$253,028
157.Other Hospice Costs$0
159.Other Costs$0
160.Total Operating Expenses (sum of lines 151 through 159)$2,546,547
165.Net from Operations (line 145 minus line 160)-$277,402
170.Income Tax0
175.Net Income (line 165 minus line 170)-$277,402
General Comments:
Errors and Warnings