Annual Utilization Report of Home Health Agencies / Hospices
Facility Name:MERCY HOME HEALTH - SACRAMENTO
OSHPD ID:406342246Report Status:Submitted
License Category:Home Health AgencyReport Year:2003
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:MERCY HOME HEALTH - SACRAMENTO
2.OSHPD ID Number:406342246
3.Street Address:3400 DATA DRIVE
4.City:RANCHO CORDOVA
5.Zip:95670-7956
6.Facility Phone No.:( 916) 281 - 2300 ext.
7.Administrator Name:Kay Kallas
8.Administrator E-mail Address:kkallas@chw.edu
9.Was this agency in operation at any time during the year?:Yes
10.Operation Open From:1/1/2003
11.Operation Open To:12/31/2003
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:Home Health Agency with Hospice Program
26.Entity RelationUnknown Entity Relation
30.Submitted by:406342246
31.Submitted Date and Time:3/10/2004 3:01:45 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
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.Do you have a Registered Nurse on staff who makes home visits?No
16.Is your agency a licensed Pharmacy?No
Note: If the agency is a licensed pharmacy that provides only home infusion therapy equipment then there is no need to complete the remainder of the report
Special Services
Line
No.		(1)
20.AIDS ServicesYes
21.Blood TransfusionsNo
22.Enterostomal TherapyYes
23.IV Therapy (Includes Chemo and TPN)No
24.Mental Health CounselingYes
25.PediatricYes
26.Psychiatric NursingNo
27.Respiratory / Pulmonary TherapyNo
28.OtherYes
Patient Information
Line
No.		(1)
30.Number of unduplicated patients seen by your agency during the reporting year.3,984
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 Years226889
2.11 - 20 Years21151
3.21 - 30 Years38369
4.31 - 40 Years88897
5.41 - 50 Years2222,490
6.51 - 60 Years3554,525
7.61 - 70 Years5617,864
8.71 - 80 Years1,12616,077
9.81 - 90 Years1,09215,131
10.91 Years and Older2553,521
15.Total3,984 51,914
Admissions By Source Of Referral
Line
No.		Source Of Referral(1)
Admissions
21.Another Home Health Agency2
22.Clinic2
23.Family / Friend0
24.Hospice1
25.Hospital (Discharge Planner, etc.)3,404
26.Local Health Department2
27.Long Term Care Facility (SN / IC)157
28.MSSP0
29.Payer (Insurance, HMO, etc.)0
30.Physician823
31.Self4
32.Social Service Agency0
34.Other0
35.Total4,395
Discharges By Reasons
Line
No.		Reason for Discharge(1)
Discharges
41.Admitted to Hospital135
42.Admitted to SN / IC Facility125
43.Death136
44.Family / Friends Assumed Responsibility230
45.Lack of Funds0
46.Lack of Progress0
47.No Further Home Health Care Needed3,491
48.Patient Moved out of Area0
49.Patient Refused Service122
50.Physician Request0
51.Transferred to Another HHA21
52.Transferred to Home Care (Personal Care)0
53.Transferred to Hospice105
54.Transferred to Outpatient Rehabilitation0
59.Other42
60.Total4,407
Visits By Type Of Staff
Line
No.		Type of Staff(1)
Visits
71.Home Health Aide2,804
72.Nutritionist (Diet Counseling)0
73.Occupational Therapist2,654
74.Physical Therapist11,958
75.Physician0
76.Skilled Nursing32,814
77.Social Worker1,019
78.Speech Pathologist / Audiologist665
79.Spiritual and Pastoral Care0
84.Other0
85.Total51,914
Visits By Primary Source Of Payment
Line
No.		Source Of Payment(1)
Visits
91.Medicare24,397
92.Medi-Cal2,443
93.TRICARE (CHAMPUS)0
94.Other Third Party (Insurance, etc.)258
95.Private (Self Pay)6
96.HMO / PPO (Includes Medicare and Medi-Cal HMOs)24,216
97.No Reimbursement0
99.Other (Includes MSSP)594
100.Total51,914
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, 045.0-139.824227
2.HIV infections (include AIDS, ARC, HIV)04217
3.Malignant neoplasms: Lung162.0-162.9, 197.0, 231.229369
4.Malignant neoplasms: Breast174.1-174.9, 175.0-175.9, 198.2, 198.81, 233.026280
5.Malignant neoplasms: Intestines152.0-154.8, 159.0, 197.4, 197.5, 197.8, 198.89, 230.3, 230.4, 230.724333
6.Malignant neoplasms: All other sites, excluding those in #3, 4, 5140.0-208.91, 230.0-234.968891
7.Non-malignant neoplasms: All sites210.0-229.9, 235.0-238.9, 239.0-239.9438
8.Diabetes mellitus250.00-250.931391,960
9.Endocrine, metabolic, and nutritional diseases; Immunity disorders240.0-246.9, 251.0-279.941391
10.Diseases of blood and blood forming organs280.0-289.924306
11.Mental disorder290.0-319962
12.Alzheimer's disease331.0328
13.Disease of nervous system and sense organs320.0-330.9, 331.1-389.939527
14.Diseases of cardiovascular system391.0-392.0, 393-402.91, 404.00-429.95446,048
15.Diseases of cerebrovascular system430-438.91783,256
16.Diseases of all other circulatory system390, 392.9, 403.00-403.91, 440.0-459.91092,065
17.Diseases of respiratory system460-519.94946,034
18.Diseases of digestive system520.0-579.91771,807
19.Diseases of genitourinary system580.0-608.9, 614.0-629.9841,229
20.Diseases of breast610.0-611.9214
21.Complications of pregnancy, childbirth, and the puerperium630-6772163
22.Diseases of skin and subcutaneous tissue680.0-709.92405,383
23.Diseases of musculosketal system and connective tissue (include pathological fx, malunion fx, and nonunion fx)710.00-739.94625,263
24.Congenital anormalies and perinatal conditions (include birth fractures)740.0-779.9196763
25.Symptoms, signs, and ill-defined conditions (exclude HIV positive test)780.01-795.6, 795.77, 796.0-799.92213,080
26.Fractures (exclude birth fx, pathological fx, malunion fx, nonunion fx)800.00-829.11712,389
27.All other injuries830.0-959.9952,181
28.Poisonings and adverse effects of external causes960.0-995.94538
29.Complications of surgical and medical care996.00-999.91212,637
30.Health services related to reproduction and developmentV20.0-V26.9, V28.0-V29.911
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, V39.200
32.Health hazards related to communicable diseasesV01.0-V19.8, V40.0-V49.918
33.Other health services for specific procedures and aftercareV50.0-V58.94314,236
34.Visits for Evaluation and AssessmentV60.0-V83.8900
45.Total3,98451,914
* The list of ICD-9-CM codes excluded: 795.71, V08, V27.0-V27.9
How many of the patients you reported in Section 3 "Patients and Visits by Age"Table had a primary or secondary diagnosis of HIV or Alzheimer's Disease and how many health care visits were made to them? The primary condition for which an HIV or Alzheimer's patient was visited may have been a fracture, a skin infection, cancer, or any number of primary conditions. 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 primary condition of the patient.
Line
No.		ICD-9-CM Code(1)
Patients		(2)
Visits
51.HIV042436
52.Alzheimer's Disease331.044541
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
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 patients958
2.Survivors of persons not receiving hospice care0
Volunteer Services
Line
No.		Volunteer Services(1)
No. of Volunteers		(2)
Volunteer Hours
3.Patient / Family Services273,187
4.Bereavement470
5.Administrative7598
6.Medicare Reportable Hours
(sum lines 3-5)		3,855
7.Fundraising00
9.Other201,289
10.Total585,144
Additional And Specialized Services
Check all services directly 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 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 - RN5,447
22.Nursing - LVN0
23.Social Services1,139
24.Hospice Physician Services6
25.Homemaker and Home Health Aide2,257
26.Chaplain376
29.Other Clinical Services31
30.Total9,256
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 Years2002
2.2 - 5 Years0000
3.6 - 10 Years0000
4.11 - 20 Years1001
5.21 - 30 Years0000
6.31 - 40 Years1405
7.41 - 50 Years4509
8.51 - 60 Years1711028
9.61 - 70 Years3333066
10.71 - 80 Years51600111
11.81 - 90 Years67970164
12.91 + Years1444058
15.Total1902540444
Unduplicated Hospice Patients By Gender and Race
Line
No.		Race(1)
Male		(2)
Female		(3)
Other / Unknown		(4)
Total
21.White1311990330
22.Black1315028
23.Native American0101
24.Asian / Pacific Islander128020
25.Other / Unknown3431065
30.Total1902540444
Unduplicated Hospice Patients By Gender And Ethnicity
Line
No.		Ethnicity(1)
Male		(2)
Female		(3)
Other / Unknown		(4)
Total
31.Hispanic99018
32.Non-Hispanic1812450426
33.Unknown0000
35.Total1902540444
Hospice Patient Admissions By Source Of Referral
Line
No.		Source of Referral(1)
Patients
41.Home Health Agency1
42.Hospital (Discharge Planner, etc.)121
43.Long-Term Care Facility3
44.Other Hospice0
45.Payer (Insure, HMO,etc.)0
46.Physician287
47.RCFE / ARFCLHF0
48.Self / Family / Friend1
49.Social Service Agency0
54.Other0
55.Total413
Hospice Patient Discharges By Reason
Line
No.		Reason for Discharge(1)
Patients
61.Death366
62.Patient Moved Out of Area4
63.Patient Refused Service5
64.Transferred to Another Local Hospice0
65.Prognosis Extended35
66.Patient Desired Curative Treatment0
69.Other16
70.Total426
Hospice Patients Discharged By Length Of Stay
Line
No.		Length of Stay
(Days)		(1)
Patients
71.0-5 Days87
72.6-10 Days65
73.11-15 Days38
74.16-20 Days27
75.21-30 Days49
76.31-60 Days66
77.61-90 Days40
78.91-120 Days19
79.121-150 Days8
80.151-180 Days9
84.181 + Days18
85.Total426
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.Placer77011
92.Yolo99010
93.El Dorado2020021
94.Sacramento37733060402
95.00000
96.00000
97.00000
98.00000
99.00000
100.Total41336660444
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 Patient's 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.Cancer140.0-208.91, 230.0-234.92336,54411,192
2.Heart391.0-392.0, 393-402.91, 404.0-404.9 with fifth digit 1 or 3, 410.00-429.9331,3001,878
3.Dementia and Cerebral Degeneration290.0-294.9, 331.0-331.921466951
4.Lung, excluding cancer460-519.931567805
5.Kidney, excluding cancer580.0-589.9, 403.00-403.91, 404.0-404.9 with fifth digit 2 or 3, 405.0-405.9 with fifth digit 114157230
6.Liver, excluding cancer570-573.9468108
7.HIV042000
8.Brain Stroke and late effects430-436, 438.0-438.9, 997.02883145
9.Coma, with or without brain injury780.01-780.09, 850.4, 851.x-854.x with fifth digit 5000
10.Diabetes250.00-250.9311443
11.ALS*335.203119226
19.OtherAll other codes that are not in lines 1-11.781,3892,704
20.Total42610,70718,282
Note: "x" for any numeric code
* 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.Medicare35915,2241866015,308
2.Medi-Cal381,3747001,381
3.Medi-Cal Managed Care000000
4.Managed Care332,0350002,035
5.Private Insurance14710850723
6.Self Pay000000
7.Charity000000
9.Other*000000
10.Total44419,3433371019,447
* 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.Home19,2800019,280
22.Hospital033033
23.SNF630710134
24.CLHF00000
25.RCFE / ARF0000
29.Other00000
30.Total19,3433371019,447
Section 10 - Hospice Income and Expenses Statement
Detail Of Operating Expenses
Line
No.		(1)
Total
General Service Cost Centers
30.Administrative and General$996,392
Inpatient Care Service
31.Inpatient - General Care$30,516
32.Inpatient - Respite Care$11,765
Nursing Home
33.Room and Board SNFMedi-Cal Pass through Payments( $809 )
34.Medi-Cal Room and Board Contractual Payments$809
Program Supervision
35.Hospice Program / Team Supervision (Non-visit wages)$0
Visiting Services
36.Physician Services$2,546
37.Nursing Care$591,289
38.Rehabilitation Services (PT, OT, Speech)$3,641
39.Medical Social Services - Direct$160,998
40.Spiritual Counseling$63,460
41.Dietary Counseling$15,157
42.Counseling - Other$0
43.Home Health Aides and Homemakers$92,651
44.Other Visiting Services$0
Hospice Service Cost Centers
45.Drugs, Biologicals and Infusion$349,698
46.Durable Medical Equipment / Oxygen$85,469
47.Patient Transportation$12,450
48.Imaging, Lab and Diagnostics$9,207
49.Medical Supplies$14,563
50.Outpatient Services (including ER Dept.)$12,830
51.Radiation Therapy$0
52.Chemotherapy$0
53.Other Hospice Service Costs$2,388
Other Hospice Costs
54.Bereavement Program Costs$116,730
55.Volunteer Program Costs$20,822
56.Fundraising$6,590
Other Costs
57.Other Program Costs*$0
59.Total Operating Expenses$2,599,162
* Program costs including community education and outreach program costs.
Hospice Income Statement
Line
No.		(1)
Total
Gross Patient Revenue
101.Medicare$2,229,454
102.Medi-Cal (Excluding Room and Board)$203,780
103.Medi-Cal Managed Care (Excluding Roam and Board)$0
104.Managed Care (Non Medi-Cal)$80,774
105.Private Insurance$108,900
106.Self-Pay$0
109.Other Payers$0
110.Total Gross Patient Revenue (sum of lines 101 through 109)$2,622,908
Write-Offs and Adjustments
111.Contractual Adjustments$21,395
112.Denials / Bad Debt$0
113.Charity$0
119.Other Write-offs and Adjustments$0
120.Total Write-Offs and Adjustments (sum of lines 111 through 119)$21,395
125.Net Patient Revenue (line 110 minus line 120)$2,601,513
Other Operating Revenue
131.Grants$0
132.Donations / Contributions$168,000
133.Unrelated Business Income$0
139.Other$0
140.Total Other Operating Revenue (sum of lines 131 through 139)$168,000
145.Total Operating Revenue (line 125 plus line 140)$2,769,513
Operating Expenses
151.General Service Cost Centers$996,392
152.Inpatient Care Service$42,281
153.Nursing Home$0
154.Program Supervision$0
155.Visiting Services$929,742
156.Hospice Service Cost Centers$486,605
157.Other Hospice Costs$144,142
159.Other Costs$0
160.Total Operating Expenses (sum of lines 151 through 159)$2,599,162
165.Net from Operations (line 145 minus line 160)$170,351
170.Income Tax$0
175.Net Income (line 165 minus line 170)$170,351
General Comments:
I used our Cost Report Year ending 3/30/03 for above breakout of operational expenses.
Errors and Warnings