Annual Utilization Report of Home Health Agencies / Hospices
Facility Name:MERCY HOSPICE
OSHPD ID:406344139Report Status:Submitted
License Category:HospiceReport Year:2012
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
Section 11 - Hospice Inpatient Facility/Unit
General Comments
View Errors and Warnings
Section 1 - General Information
1.Facility Name:MERCY HOSPICE
2.OSHPD ID Number:406344139
3.Street Address:9912 BUSINESS PARK DR
STE. 100
4.City:SACRAMENTO
5.Zip:95827
6.Facility Phone No.:( 916) 281 - 3900 ext.
7.Administrator Name:Steve Bell
8.Administrator E-mail Address:steve.bell@dignityhealth.org
9.Was this agency in operation at any time during the year?:Yes
10.Operation Open From:1/1/2012
11.Operation Open To:12/31/2012
12.Name of Parent Corporation:
13.Corporate Business Address:
14.City:
15.State:
16.Zip:-
17.Person Completing Report:Steve Bell
18.Phone No.:916-281-2300
19.Fax No.:916-281-2396
20.E-mail Address:s2bell@chw.edu
25.Entity Type:Hospice Only
26.Entity RelationSole Facility
30.Submitted by:406342246
31.Submitted Date and Time:3/11/2013 11:24:07 AM
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, 209.21, 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 - 209.36,
230.0 - 234.9		00
7.Non-malignant neoplasms: All sites209.40 - 209.79
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 disorders240.00 - 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:Non-profit Corporation (incl. Church-related)
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 JCAHOAccredited
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.Primarily Urban
Section 6 - Hospice Services
Bereavement Services
Line
No.		Bereavement Services(1)
People Served
1.Survivors of hospice patients1,425
2.Survivors of persons not receiving hospice care0
Volunteer Services
Line
No.		Volunteer Services(2)
Volunteer Hours
3.Patient / Family Services2,248
4.Bereavement804
5.Administrative792
6.Medicare Reportable Hours
(sum lines 3-5)		3,844
7.Fundraising0
9.Other591
10.Total4,435
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 Inpatient Facility / UnitNo
12.Specialized Pediatric ProgramNo
13.Bereavement services to survivors of persons not receiving hospice careNo
14.Adult Day CareNo
15.Hospice Physician Consultation VisitsNo
16.Non-hospice Palliative Care Service ProvidedNo
17.Other ServicesNo
(1) If Line 11 is checked then complete Section 11, Lines 1 through 20.
Visits By Type Of Staff
(Include After-Hours and Bereavement Visits)
Line
No.		Type of Staff(1)
Visits
21.Nursing - RN9,901
22.Nursing - LVN0
23.Social Services2,256
24.Hospice Physician Services1
25.Homemaker and Home Health Aide7,437
26.Chaplain1,043
29.Other Clinical Services181
30.Total20,819
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 Years1001
2.2 - 5 Years1001
3.6 - 10 Years0000
4.11 - 20 Years0000
5.21 - 30 Years1001
6.31 - 40 Years1203
7.41 - 50 Years1410024
8.51 - 60 Years2933062
9.61 - 70 Years4157098
10.71 - 80 Years77730150
11.81 - 90 Years1132140327
12.91 + Years581170175
15.Total3365060842
Unduplicated Hospice Patients By Gender and Race
Line
No.		Race
(1)

Male
(2)

Female		(3)
Other / Unknown
(4)

Total
21.White2644080672
22.Black1226038
23.Native American2103
24.Asian / Pacific Islander2638064
25.Other / Unknown3233065
26.More than one race0000
30.Total3365060842
Unduplicated Hospice Patients By Gender And Ethnicity
Line
No.		Ethnicity
(1)

Male
(2)

Female		(3)
Other / Unknown
(4)

Total
31.Hispanic1920039
32.Non-Hispanic3084790787
33.Unknown97016
35.Total3365060842
Hospice Patient Discharges By Reason
Line
No.		Reason for Discharge(1)
Patients
61.Death640
62.Patient Moved Out of Area4
63.Patient Refused Service20
64.Transferred to Another Local Hospice4
65.Prognosis Extended50
66.Patient Desired Curative Treatment10
69.Other10
70.Total738
Hospice Patients Discharged By Length Of Stay
Line
No.		Length of Stay
(Days)		(1)
Patients
71.0-7 Days231
72.8-30 Days245
73.31-90 Days151
74.91-179 Days69
75.180+ Days42
85.Total738
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.El Dorado1101
92.Placer4204
93.Sacramento73363698836
94.Yolo0101
95.0000
96.0000
97.0000
98.0000
99.0000
100.Total73864098842
Number Of Hospice Admissions By Diagnosis
Line
No.		DiagnosisICD-9-CM Codes
(1)

No. of New
Admissions
(2)

Re-admissions
Previously Seen
by Another
Hospice
Program
(3)

Re-admissions
Previously Seen
by This
Hospice
Program		(4)
Total
Admissions
(1)+(2)+(3)
101.Cancer140.0 - 209.30, 230.0 - 234.9295013308
102.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		450247
103.Dementia & Cerebral
Degeneration		290.0 - 294.9
331.0 - 331.9		10406110
104.Lung, excluding cancer460 - 519.9, 996.84, 997.31 - 997.39440347
105.Kidney, excluding cancer403.00 - 403.91,
404.0-404.9 with fifth digit 2 or 3,
405.0 - 405.9 with fifth digit 1
580.0 - 589.9, 996.73, 996.81		130013
106.Liver, excluding cancer570 - 573.9, 996.8290110
107.HIV0420000
108.Brain Stroke and late effects430 - 436, 438.0 - 438.9
997.02		160016
109.Coma, with or without brain injury780.01 - 780.09, 850.4
851.0 - 854.1 with fifth digit 5		0000
110.Diabetes250.00 - 250.930000
111.ALS*335.200000
112.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		0000
113.Multiple Sclerosis3401001
114.Congenital Defects740 - 7590000
115.General Debility and Failure to Thrive783.41, 783.7, 797 and 799.3151010161
119.OtherAll other codes that are not in lines 101-115230225
120.TOTAL701037738
*Amytrophic lateral sclerosis (ALS), also called Lou Gehrig's Disease
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)

Number of Live Discharges
(2)

No. of Discharges due to Death
(3)

Total Number of Discharges
(4)

Visits for Discharged Patients		(5)
Discharged Patients Total Days of Care
1.Cancer140.0 - 209.30,
230.0 - 234.9		342743085,88411,927
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		640466041,046
3.Dementia and Cerebral Degeneration290.0 - 294.9,
331.0-331.9		20931133,7018,517
4.Lung, excluding cancer460 - 519.9,  996.84
997.31 - 997.39		736438252,342
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		01212175292
6.Liver, excluding cancer570 - 573.9, 996.82358180350
7.HIV04200000
8.Brain Stroke and late effects430 - 436,
438.0 - 438.9,
997.02		21618209358
9.Coma, with or without brain injury780.01 - 780.09,
850.4,
851.0 - 854.1 with fifth digit 5		00000
10.Diabetes249.00 - 250.9300000
11.ALS*335.2000000
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		00000
13.Multiple Sclerosis3400111722
14.Congenital Defects740 - 75900000
15.General Debility and Failure to Thrive783.41, 783.7, 797, 799.3251371623,5669,222
19.OtherAll other codes that are not in lines 1-11.126276741,534
20.Total9864073815,83535,610
* 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 Inpatient Respite Care		(5)
Days of Continuous Care		(6)
Total Patient Care Days
1.Medicare65833,2271536033,278
2.Medi-Cal512,79761502,818
3.Medi-Cal Managed Care110001
4.Managed Care762,5978002,629
5.Private Insurance361,0480301,051
6.Self Pay000000
7.Charity000000
8.Veterans Administration000000
9.Other*000000
10.Total82239,6702978039,777
* 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 Inpatient Respite Care		(5)
Days of Continuous Care
(6)

Total Patient Care Days
21.Home76328,053028,053
22.Hospital201828046
23.SNF842,50017802,579
24.CLHF000000
25.RCFE / ARF / RCFCI1519,09909,099
26.ICF / MR0000
27.Prison0000
28.Homeless0000
29.Other000000
30.Total1,01839,6702978039,777
Section 10 - Hospice Income and Expenses Statement
Detail Of Operating Expenses
Line
No.		(1)
Total
General Service Cost Centers
30.Administrative and General$1,485,958
Inpatient Care Service
31.Inpatient - General Care$23,327
32.Inpatient - Respite Care$18,283
Program Supervision
35.Hospice Program / Team Supervision (Non-visit wages)$564,136
Visiting Services
36.Physician Services$102,000
37.Nursing Care$2,893,209
38.Rehabilitation Services (PT, OT, Speech)$19,148
39.Medical Social Services - Direct$532,623
40.Spiritual Counseling$160,483
41.Dietary Counseling0
42.Counseling - Other0
43.Home Health Aides and Homemakers$491,556
44.Other Visiting Services0
Hospice Service Cost Centers
45.Drugs, Biologicals and Infusion$425,550
46.Durable Medical Equipment / Oxygen$143,419
47.Patient Transportation$22,240
48.Imaging, Lab and Diagnostics$1,246
49.Medical Supplies$67,158
50.Outpatient Services (including ER Dept.)$42,799
51.Radiation Therapy0
52.Chemotherapy0
53.Other Hospice Service Costs0
Other Hospice Costs
54.Bereavement Program Costs$132,150
55.Volunteer Program Costs$65,195
56.Fundraising0
Other Costs
57.Other Program Costs*0
59.Total Operating Expenses$7,190,480
* Program costs including community education and outreach program costs.
Hospice Income Statement
Line
No.		(1)
Total
Gross Patient Revenue
Gross Patient Revenue for Hospice Four Levels of Care
101.Medicare$7,628,710
102.Medi-Cal (Excluding SNF Room and Board)$601,940
103.Medi-Cal Managed Care (Excluding SNF Room and Board)$3,780
104.Managed Care (Non Medi-Cal)$385,290
105.Private Insurance$356,961
106.Self-Pay$6,781
109.Other Payers0
110.Total Revenue for Hospices Four Levels of Care$8,983,462
Room & Board Revenue
1101.SNF Room & Board pass Through Receivable from Medi-Cal$243,600
1102.Medi-Cal Room & Board Contractual Payments to SNF( $251,316)
1103.Net Room & Board Revenue-$7,716
1104.Total Gross Patient Revenue (Sum of Lines 110 and 1103)$8,975,746
Write-Offs and Adjustments
111.Contractual Adjustments$1,393,758
112.Denials / Bad Debt$26,261
113.Charity$138
119.Other Write-offs and Adjustments0
120.Total Write-Offs and Adjustments (sum of lines 111 through 119)$1,420,157
125.Net Patient Revenue (line 1104 minus line 120)$7,555,589
Other Operating Revenue
131.Grants0
132.Donations / Contributions$113,738
133.Unrelated Business Income0
139.Other0
140.Total Other Operating Revenue (sum of lines 131 through 139)$113,738
145.Total Operating Revenue (line 125 plus line 140)$7,669,327
Operating Expenses
160.Total Operating Expenses (from line 59)$7,190,480
165.Net from Operations (line 145 minus line 160)$478,847
170.Income Tax0
175.Net Income (line 165 minus line 170)$478,847
Section 11 - Hospice Inpatient Facility/Unit
HOSPICE OPERATED SITES AND NUMBER OF BEDS
Line
No.		(1)
Name		(2)
Address		(3)
City		(4)
State		(5)
Zip		(6)
Type of Licensed Beds		(7)
No. of Beds
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.Total0
LEVELS OF CARE HOSPICE SITES PROVIDE
Line
No.		Type of Care(1)
No. of Patient days
11.General Inpatient Care0
12.Inpatient Respite care0
13.Continuous Care0
14.Routine Care0
20TOTAL0
General Comments:
Errors and Warnings