Annual Utilization Report of Home Health Agencies / Hospices
Facility Name:KAISER FOUNDATION HOSPITAL HHA - FONTANA
OSHPD ID:406361335Report Status:Submitted
License Category:Home Health AgencyReport Year:2013
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:KAISER FOUNDATION HOSPITAL HHA - FONTANA
2.OSHPD ID Number:406361335
3.Street Address:17284 SLOVER AVE
4.City:FONTANA
5.Zip:92337
6.Facility Phone No.:( 909) 609 - 3800 ext.
7.Administrator Name:Nanette Antonio
8.Administrator E-mail Address:nanette.v.antonio@kp.org
9.Was this agency in operation at any time during the year?:Yes
10.Operation Open From:1/1/2013
11.Operation Open To:12/31/2013
12.Name of Parent Corporation:
13.Corporate Business Address:
14.City:
15.State:
16.Zip:-
17.Person Completing Report:Yvonne Jackson
18.Phone No.:909-609-3893
19.Fax No.:909-609-3822
20.E-mail Address:yvonne.x.jackson@kp.org
25.Entity Type:Home Health Agency with Hospice Program
26.Entity RelationSole Facility
30.Submitted by:yvonnejackson
31.Submitted Date and Time:3/18/2014 9:16:36 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: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 JCAHODeemed Status
13.Accredited by otherDeemed Status
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?Yes
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.PediatricYes
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.5,631
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 Years96266
2.11 - 20 Years48170
3.21 - 30 Years117603
4.31 - 40 Years1541,063
5.41 - 50 Years3201,602
6.51 - 60 Years9265,895
7.61 - 70 Years1,5189,370
8.71 - 80 Years1,74811,481
9.81 - 90 Years1,4298,710
10.91 Years and Older3041,804
15.Total6,660 40,964
Admissions By Source Of Referral
Line
No.		Source Of Referral(1)
Admissions
21.Another Home Health Agency23
22.Clinic0
23.Family / Friend0
24.Hospice5
25.Hospital (Discharge Planner, etc.)3,877
26.Local Health Department0
27.Long Term Care Facility (SN / IC)453
28.MSSP0
29.Payer (Insurance, HMO, etc.)0
30.Physician1,837
31.Self0
32.Social Service Agency0
34.Other2
35.Total6,197
Discharges By Reasons
Line
No.		Reason for Discharge(1)
Discharges
41.Admitted to Hospital250
42.Admitted to SN / IC Facility55
43.Death67
44.Family / Friends Assumed Responsibility441
45.Lack of Funds0
46.Lack of Progress8
47.No Further Home Health Care Needed3,809
48.Patient Moved out of Area29
49.Patient Refused Service119
50.Physician Request10
51.Transferred to Another HHA14
52.Transferred to Home Care (Personal Care)1
53.Transferred to Hospice238
54.Transferred to Outpatient Rehabilitation635
59.Other0
60.Total5,676
Visits By Type Of Staff
Line
No.		Type of Staff(1)
Visits
71.Home Health Aide1,945
72.Nutritionist (Diet Counseling)0
73.Occupational Therapist1,544
74.Physical Therapist11,145
75.Physician0
76.Skilled Nursing24,478
77.Social Worker1,852
78.Speech Pathologist / Audiologist0
79.Spiritual and Pastoral Care0
84.Other0
85.Total40,964
Visits By Primary Source Of Payment
Line
No.		Source Of Payment(1)
Visits
91.Medicare2,032
92.Medi-Cal134
93.TRICARE (CHAMPUS)0
94.Other Third Party (Insurance, etc.)3
95.Private (Self Pay)41
96.HMO / PPO (Includes Medicare and Medi-Cal HMOs)37,649
97.No Reimbursement8
99.Other (Includes MSSP)1,097
100.Total40,964
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		14
2.HIV infections04255
3.Malignant neoplasms: Lung162.2 - 162.9,
197.0, 209.21, 231.2		48360
4.Malignant neoplasms: Breast174.0 - 174.9,
175.0 - 175.9,
198.2, 198.81, 233.0		33278
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		1274
6.Malignant neoplasms: All other sites, excluding those in #3, 4, 5140.0 - 209.36,
230.0 - 234.9		2701,434
7.Non-malignant neoplasms: All sites209.40 - 209.79
210.0 - 229.9,
235.0 - 238.9,
239.0 - 239.9		15
8.Diabetes mellitus249.00 - 250.93741,304
9.Endocrine, metabolic, and nutritional diseases; Immunity disorders240.00 - 246.9,
251.0 - 279.9		2321,012
10.Diseases of blood and blood forming organs280.0 - 289.9167906
11.Mental disorder290.0 - 31966
12.Alzheimer's disease331.082231
13.Disease of nervous system and sense organs320.0 - 330.9,
331.11 - 389.9		125858
14.Diseases of cardiovascular system391.0 - 392.0,
393 - 402.91,
404.00 - 429.9		1,2615,113
15.Diseases of cerebrovascular system430 - 438.92601,206
16.Diseases of all other circulatory system390,  392.9,
403.00 - 403.91,
440.0 - 459.9		45362
17.Diseases of respiratory system460 - 519.95082,673
18.Diseases of digestive system520.0 - 579.92241,295
19.Diseases of genitourinary system580.0 - 608.9,
614.0 - 629.9		148647
20.Diseases of breast610.0 - 611.900
21.Complications of pregnancy, childbirth, and the puerperium630 - 679.142766
22.Diseases of skin and subcutaneous tissue680.0 - 709.97818,469
23.Diseases of musculosketal system and connective tissue (include pathological fx, malunion fx, and nonunion fx)710.0 - 739.91,5756,505
24.Congenital anormalies and perinatal conditions (include birth fractures)740.0 - 779.92939
25.Symptoms, signs, and ill-defined conditions (exclude HIV positive test)780.01 - 795.6,
795.79,
796.0 - 799.9		4131,430
26.Fractures (exclude birth fx, pathological fx, malunion fx, nonunion fx)800.00 - 829.14522,084
27.All other injuries830.0 - 959.98514,209
28.Poisonings and adverse effects of external causes960.0 - 995.9400
29.Complications of surgical and medical care996.00 - 999.91251
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 - V58.914213
34.Visits for Evaluation and AssessmentV60.0 - V89.0946127
45.Total7,70240,966
* 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.HIV04270225
52.Alzheimer's Disease331.082231
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 JCAHODeemed Status
13.Accredited by otherNone
Agency Type As Reported On Medicare Cost Report
Line
No.		(1)
20.Home Health 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 patients670
2.Survivors of persons not receiving hospice care30
Volunteer Services
Line
No.		Volunteer Services(2)
Volunteer Hours
3.Patient / Family Services786
4.Bereavement137
5.Administrative157
6.Medicare Reportable Hours
(sum lines 3-5)		1,080
7.Fundraising0
9.Other226
10.Total1,306
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 careYes
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 - RN7,824
22.Nursing - LVN1,579
23.Social Services2,556
24.Hospice Physician Services721
25.Homemaker and Home Health Aide5,772
26.Chaplain656
29.Other Clinical Services19
30.Total19,127
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 Years1001
4.11 - 20 Years0101
5.21 - 30 Years1203
6.31 - 40 Years3205
7.41 - 50 Years118019
8.51 - 60 Years3434068
9.61 - 70 Years77710148
10.71 - 80 Years1111070218
11.81 - 90 Years1351650300
12.91 + Years30700100
15.Total4034600863
Unduplicated Hospice Patients By Gender and Race
Line
No.		Race
(1)

Male
(2)

Female		(3)
Other / Unknown
(4)

Total
21.White2352740509
22.Black3541076
23.Native American0101
24.Asian / Pacific Islander711018
25.Other / Unknown1261330259
26.More than one race0000
30.Total4034600863
Unduplicated Hospice Patients By Gender And Ethnicity
Line
No.		Ethnicity
(1)

Male
(2)

Female		(3)
Other / Unknown
(4)

Total
31.Hispanic65730138
32.Non-Hispanic3383870725
33.Unknown0000
35.Total4034600863
Hospice Patient Discharges By Reason
Line
No.		Reason for Discharge(1)
Patients
61.Death653
62.Patient Moved Out of Area3
63.Patient Refused Service47
64.Transferred to Another Local Hospice12
65.Prognosis Extended59
66.Patient Desired Curative Treatment9
69.Other25
70.Total808
Hospice Patients Discharged By Length Of Stay
Line
No.		Length of Stay
(Days)		(1)
Patients
71.0-7 Days207
72.8-30 Days318
73.31-90 Days175
74.91-179 Days78
75.180+ Days30
85.Total808
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.San Bernardino685547125750
92.Los Angeles70521277
93.Riverside74541880
94.0000
95.0000
96.0000
97.0000
98.0000
99.0000
100.Total829653155907
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 - 234.9384049433
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		97020117
103.Dementia & Cerebral
Degeneration		290.0 - 294.9
331.0 - 331.9		105029134
104.Lung, excluding cancer460 - 519.9, 996.84, 997.31 - 997.39490958
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		240529
106.Liver, excluding cancer570 - 573.9, 996.82100010
107.HIV0421001
108.Brain Stroke and late effects430 - 436, 438.0 - 438.9
997.02		160117
109.Coma, with or without brain injury780.01 - 780.09, 850.4
851.0 - 854.1 with fifth digit 5		0011
110.Diabetes250.00 - 250.930000
111.ALS*335.204004
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		0033
113.Multiple Sclerosis3403003
114.Congenital Defects740 - 7590000
115.General Debility and Failure to Thrive783.41, 783.7, 797 and 799.3370542
119.OtherAll other codes that are not in lines 101-115460955
120.TOTAL7760131907
*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		463433897,92915,491
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		2969982,2714,881
3.Dementia and Cerebral Degeneration290.0 - 294.9,
331.0-331.9		25921172,7344,646
4.Lung, excluding cancer460 - 519.9,  996.84
997.31 - 997.39		1434481,1591,993
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		42024452858
6.Liver, excluding cancer570 - 573.9, 996.82099111210
7.HIV04200000
8.Brain Stroke and late effects430 - 436,
438.0 - 438.9,
997.02		21214210333
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*335.200331420
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		033164341
13.Multiple Sclerosis34001153101
14.Congenital Defects740 - 75900000
15.General Debility and Failure to Thrive783.41, 783.7, 797, 799.3824328831,737
19.OtherAll other codes that are not in lines 1-11.1060701,2782,311
20.Total13867080817,25832,922
* 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.Medicare70727,21130128027,369
2.Medi-Cal000000
3.Medi-Cal Managed Care000000
4.Managed Care000000
5.Private Insurance000000
6.Self Pay000000
7.Charity000000
8.Veterans Administration000000
9.Other*1976,1650006,165
10.Total90433,37630128033,534
* 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.Home90430,970030,970
22.Hospital00000
23.SNF666301280224
24.CLHF000000
25.RCFE / ARF / RCFCI502,34002,340
26.ICF / MR0000
27.Prison0000
28.Homeless0000
29.Other000000
30.Total96033,37630128033,534
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
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
Gross Patient Revenue for Hospice Four Levels of Care
101.Medicare0
102.Medi-Cal (Excluding SNF Room and Board)0
103.Medi-Cal Managed Care (Excluding SNF Room and Board)0
104.Managed Care (Non Medi-Cal)0
105.Private Insurance0
106.Self-Pay0
109.Other Payers0
110.Total Revenue for Hospices Four Levels of Care$0
Room & Board Revenue
1101.SNF Room & Board pass Through Receivable from Medi-Cal0
1102.Medi-Cal Room & Board Contractual Payments to SNF( 0)
1103.Net Room & Board Revenue$0
1104.Total Gross Patient Revenue (Sum of Lines 110 and 1103)$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 1104 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
160.Total Operating Expenses (from line 59)$0
165.Net from Operations (line 145 minus line 160)$0
170.Income Tax0
175.Net Income (line 165 minus line 170)$0
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 Care30
12.Inpatient Respite care128
13.Continuous Care0
14.Routine Care33,376
20TOTAL33,534
General Comments:
Kaiser is exempt from reporting income and expenses.
Errors and Warnings