Annual Utilization Report of Home Health Agencies / Hospices
Facility Name:KAISER FOUNDATION HOSPITAL HOME HEALTH -SANTA ROSA
OSHPD ID:406494092Report Status:Submitted
License Category:Home Health AgencyReport Year:2009
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:KAISER FOUNDATION HOSPITAL HOME HEALTH -SANTA ROSA
2.OSHPD ID Number:406494092
3.Street Address:3550 ROUNDBARN BLVD
STE 112
4.City:SANTA ROSA
5.Zip:95403
6.Facility Phone No.:( 707) 566 - 5488 ext.
7.Administrator Name:Donna Schlarb
8.Administrator E-mail Address:Donna.J.Schlarb@kp.org
9.Was this agency in operation at any time during the year?:Yes
10.Operation Open From:1/1/2009
11.Operation Open To:12/31/2009
12.Name of Parent Corporation:Kaiser Foundation Hospital Home Health -Santa Rosa
13.Corporate Business Address:1950 Franklin 19th Floor
14.City:Oakland
15.State:CA
16.Zip:94612 -
17.Person Completing Report:Christine Carolan
18.Phone No.:415-833-4274
19.Fax No.:415-833-4885
20.E-mail Address:christine.carolan@kp.org
25.Entity Type:Home Health Agency Only
26.Entity RelationSole Facility
30.Submitted by:carolan4092
31.Submitted Date and Time:3/12/2010 5:43:51 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:Non-profit Corporation (incl. Church-related)
Medicare/Medi-Cal Certification
Line
No.		(1)
Certification
5.Medicare and Medi-Cal
Agency Accreditation Status
Line
No.		(1)
Accreditation Status
10.Accredited by ACHCNone
11.Accredited by CHAPNone
12.Accredited by JCAHOAccredited
13.Accredited by otherNone
Home Infusion Therapy / Pharmacy Only
Line
No.		(1)
15.Is your agency a licensed Pharmacy?No
16.Do you have a Registered Nurse on staff who makes home visits?No
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)Yes
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.1,397
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?No
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 Years787
3.21 - 30 Years1264
4.31 - 40 Years27181
5.41 - 50 Years53491
6.51 - 60 Years1821,657
7.61 - 70 Years2852,634
8.71 - 80 Years3483,052
9.81 - 90 Years3783,579
10.91 Years and Older105778
15.Total1,397 12,523
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.)862
26.Local Health Department0
27.Long Term Care Facility (SN / IC)323
28.MSSP0
29.Payer (Insurance, HMO, etc.)0
30.Physician316
31.Self0
32.Social Service Agency0
34.Other0
35.Total1,501
Discharges By Reasons
Line
No.		Reason for Discharge(1)
Discharges
41.Admitted to Hospital49
42.Admitted to SN / IC Facility23
43.Death3
44.Family / Friends Assumed Responsibility1
45.Lack of Funds0
46.Lack of Progress1
47.No Further Home Health Care Needed1,329
48.Patient Moved out of Area6
49.Patient Refused Service40
50.Physician Request1
51.Transferred to Another HHA1
52.Transferred to Home Care (Personal Care)0
53.Transferred to Hospice44
54.Transferred to Outpatient Rehabilitation6
59.Other1
60.Total1,505
Visits By Type Of Staff
Line
No.		Type of Staff(1)
Visits
71.Home Health Aide604
72.Nutritionist (Diet Counseling)0
73.Occupational Therapist505
74.Physical Therapist5,190
75.Physician0
76.Skilled Nursing5,623
77.Social Worker377
78.Speech Pathologist / Audiologist169
79.Spiritual and Pastoral Care0
84.Other55
85.Total12,523
Visits By Primary Source Of Payment
Line
No.		Source Of Payment(1)
Visits
91.Medicare303
92.Medi-Cal0
93.TRICARE (CHAMPUS)0
94.Other Third Party (Insurance, etc.)2,968
95.Private (Self Pay)0
96.HMO / PPO (Includes Medicare and Medi-Cal HMOs)9,189
97.No Reimbursement0
99.Other (Includes MSSP)63
100.Total12,523
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, 209.21, 231.2		00
4.Malignant neoplasms: Breast174.0 - 174.9,
175.0 - 175.9,
198.2, 198.81, 233.0		11
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		13
6.Malignant neoplasms: All other sites, excluding those in #3, 4, 5140.0 - 209.36,
230.0 - 234.9		211
7.Non-malignant neoplasms: All sites209.40 - 209.79
210.0 - 229.9,
235.0 - 238.9,
239.0 - 239.9		117
8.Diabetes mellitus249.00 - 250.93751
9.Endocrine, metabolic, and nutritional diseases; Immunity disorders240.00 - 246.9,
251.0 - 279.9		16
10.Diseases of blood and blood forming organs280.0 - 289.9261
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		320
14.Diseases of cardiovascular system391.0 - 392.0,
393 - 402.91,
404.00 - 429.9		650
15.Diseases of cerebrovascular system430 - 438.917164
16.Diseases of all other circulatory system390,  392.9,
403.00 - 403.91,
440.0 - 459.9		00
17.Diseases of respiratory system460 - 519.91175
18.Diseases of digestive system520.0 - 579.9211
19.Diseases of genitourinary system580.0 - 608.9,
614.0 - 629.9		324
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 - 709.96168
23.Diseases of musculosketal system and connective tissue (include pathological fx, malunion fx, and nonunion fx)710.0 - 739.9769
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		102776
26.Fractures (exclude birth fx, pathological fx, malunion fx, nonunion fx)800.00 - 829.1229
27.All other injuries830.0 - 959.915109
28.Poisonings and adverse effects of external causes960.0 - 995.9411
29.Complications of surgical and medical care996.00 - 999.97174
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		84514
33.Other health services for specific procedures and aftercareV50.0 - V58.91,11510,160
34.Visits for Evaluation and AssessmentV60.0 - V89.0913
45.Total1,39712,497
* 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:Unselected Type of Control
Medicare/Medi-Cal Certification
Line
No.		(1)
Certification
5.Unknown certification
Hospice 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
Agency Type As Reported On Medicare Cost Report
Line
No.		(1)
20.Unknown Agency Type
Location of Service Delivery
Line
No.		(1)
25.Unknown Location
Section 6 - Hospice Services
Bereavement Services
Line
No.		Bereavement Services(1)
People Served
1.Survivors of hospice patients0
2.Survivors of persons not receiving hospice care0
Volunteer Services
Line
No.		Volunteer Services(1)
No. of Volunteers		(2)
Volunteer Hours
3.Patient / Family Services00
4.Bereavement00
5.Administrative00
6.Medicare Reportable Hours
(sum lines 3-5)		0
7.Fundraising00
9.Other00
10.Total00
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 ProgramNo
13.Bereavement services to survivors of persons not receiving hospice careNo
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 - RN0
22.Nursing - LVN0
23.Social Services0
24.Hospice Physician Services0
25.Homemaker and Home Health Aide0
26.Chaplain0
29.Other Clinical Services0
30.Total0
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 Years0000
2.2 - 5 Years0000
3.6 - 10 Years0000
4.11 - 20 Years0000
5.21 - 30 Years0000
6.31 - 40 Years0000
7.41 - 50 Years0000
8.51 - 60 Years0000
9.61 - 70 Years0000
10.71 - 80 Years0000
11.81 - 90 Years0000
12.91 + Years0000
15.Total0000
Unduplicated Hospice Patients By Gender and Race
Line
No.		Race
(1)

Male
(2)

Female		(3)
Other / Unknown
(4)

Total
21.White0000
22.Black0000
23.Native American0000
24.Asian / Pacific Islander0000
25.Other / Unknown0000
30.Total0000
Unduplicated Hospice Patients By Gender And Ethnicity
Line
No.		Ethnicity
(1)

Male
(2)

Female		(3)
Other / Unknown
(4)

Total
31.Hispanic0000
32.Non-Hispanic0000
33.Unknown0000
35.Total0000
Hospice Patient Admissions By Source Of Referral
Line
No.		Source of Referral(1)
Patients
41.Home Health Agency0
42.Hospital (Discharge Planner, etc.)0
43.Long-Term Care Facility0
44.Other Hospice0
45.Payer (Insure, HMO,etc.)0
46.Physician0
47.RCFE / ARF/ CLHF0
48.Self / Family / Friend0
49.Social Service Agency0
54.Other0
55.Total0
Hospice Patient Discharges By Reason
Line
No.		Reason for Discharge(1)
Patients
61.Death0
62.Patient Moved Out of Area0
63.Patient Refused Service0
64.Transferred to Another Local Hospice0
65.Prognosis Extended0
66.Patient Desired Curative Treatment0
69.Other0
70.Total0
Hospice Patients Discharged By Length Of Stay
Line
No.		Length of Stay
(Days)		(1)
Patients
71.0-5 Days0
72.6-10 Days0
73.11-15 Days0
74.16-20 Days0
75.21-30 Days0
76.31-60 Days0
77.61-90 Days0
78.91-120 Days0
79.121-150 Days0
80.151-180 Days0
84.181 + Days0
85.Total0
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
91.0000
92.0000
93.0000
94.0000
95.0000
96.0000
97.0000
98.0000
99.0000
100.Total0000
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		000
2.Heart391.0 - 392.0,
393 - 402.91,
404.0 - 404.9 with fifth digit 1 or 3,
410.00 - 429.9
996.00 - 996.09, 996.61, 996.71
996.72, 996.83		000
3.Dementia and Cerebral Degeneration290.0 - 294.9,
331.0-331.9		000
4.Lung, excluding cancer460 - 519.9,  996.84
997.31 - 997.39		000
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, 996.73, 996.81		000
6.Liver, excluding cancer570 - 573.9, 996.82000
7.HIV042000
8.Brain Stroke and late effects430 - 436,
438.0 - 438.9,
997.02		000
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*335.20000
12.GI disease, excluding cancer531.00 - 534.91,
535.0 - 535.7 (with fifth digit 1),
537.83 - 537.84, 562.02, 562.03, 562.12,
562.13, 569.89, 578.0 - 578.9		000
13.Multiple Sclerosis340000
14.Congenital Defects759.9000
15.General Debility and Failure to Thrive783.41, 783.7, 797, 799.3000
19.OtherAll other codes that are not in lines 1-11.000
20.Total000
* 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.Medicare000000
2.Medi-Cal000000
3.Medi-Cal Managed Care000000
4.Managed Care000000
5.Private Insurance000000
6.Self Pay000000
7.Charity000000
8.Veterans Administration000000
9.Other*000000
10.Total000000
* 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)
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
21.Home00000
22.Hospital00000
23.SNF000000
24.CLHF000000
25.RCFE / ARF / RCFCI0000
26.ICF / MR0000
27.Prison0000
28.Homeless0000
29.Other000000
30.Total000000
Section 10 - Hospice Income and Expenses Statement
Detail Of Operating Expenses
Line
No.		(1)
Total
General Service Cost Centers
30.Administrative and General0
Inpatient Care Service
31.Inpatient - General Care0
32.Inpatient - Respite Care0
Nursing Home
33.Room and Board SNFMedi-Cal Pass through Payments( 0 )
34.Medi-Cal Room and Board Contractual Payments0
Program Supervision
35.Hospice Program / Team Supervision (Non-visit wages)0
Visiting Services
36.Physician Services0
37.Nursing Care0
38.Rehabilitation Services (PT, OT, Speech)0
39.Medical Social Services - Direct0
40.Spiritual Counseling0
41.Dietary Counseling0
42.Counseling - Other0
43.Home Health Aides and Homemakers0
44.Other Visiting Services0
Hospice Service Cost Centers
45.Drugs, Biologicals and Infusion0
46.Durable Medical Equipment / Oxygen0
47.Patient Transportation0
48.Imaging, Lab and Diagnostics0
49.Medical Supplies0
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$0
* Program costs including community education and outreach program costs.
Hospice Income Statement
Line
No.		(1)
Total
Gross Patient Revenue
101.Medicare0
102.Medi-Cal (Excluding Room and Board)0
103.Medi-Cal Managed Care (Excluding Room and Board)0
104.Managed Care (Non Medi-Cal)0
105.Private Insurance0
106.Self-Pay0
109.Other Payers0
110.Total Gross Patient Revenue (sum of lines 101 through 109)$0
Write-Offs and Adjustments
111.Contractual Adjustments0
112.Denials / Bad Debt0
113.Charity0
119.Other Write-offs and Adjustments0
120.Total Write-Offs and Adjustments (sum of lines 111 through 119)$0
125.Net Patient Revenue (line 110 minus line 120)$0
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)$0
Operating Expenses
151.General Service Cost Centers$0
152.Inpatient Care Service$0
153.Nursing Home$0
154.Program Supervision$0
155.Visiting Services$0
156.Hospice Service Cost Centers$0
157.Other Hospice Costs$0
159.Other Costs$0
160.Total Operating Expenses (sum of lines 151 through 159)$0
165.Net from Operations (line 145 minus line 160)$0
170.Income Tax0
175.Net Income (line 165 minus line 170)$0
General Comments:
Errors and Warnings