Annual Utilization Report of Home Health Agencies / Hospices
Facility Name:KAISER FOUNDATION HOSP SAN DIEGO HHA-PARENT
OSHPD ID:406371016Report Status:Submitted
License Category:Home Health AgencyReport Year:2015
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 HOSP SAN DIEGO HHA-PARENT
2.OSHPD ID Number:406371016
3.Street Address:10992 SAN DIEGO MISSION RD
STE 3
4.City:SAN DIEGO
5.Zip:92108
6.Facility Phone No.:( 619) 641 - 4663 ext.
7.Administrator Name:Daniele Wilson
8.Administrator E-mail Address:Daniele.M.Wilson@kp.org
9.Was this agency in operation at any time during the year?:Yes
10.Operation Open From:1/1/2015
11.Operation Open To:12/31/2015
12.Name of Parent Corporation:Kaiser Foundation Hospital
13.Corporate Business Address:10992 San Diego Mission Rd Suite 3601
14.City:San Diego
15.State:CA
16.Zip:92108 -
17.Person Completing Report:Lilian Paredes
18.Phone No.:619-641-4812
19.Fax No.:619-641-4100
20.E-mail Address:lilian.s.paredes@kp.org
25.Entity Type:Home Health Agency with Hospice Program
26.Entity RelationParent
30.Submitted by:lilianparedes
31.Submitted Date and Time:3/31/2016 4:48:12 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 JCAHODeemed Status
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 ServicesYes
21.Blood TransfusionsNo
22.Enterostomal TherapyYes
23.IV Therapy (Includes Chemo and TPN)Yes
24.Mental Health CounselingYes
25.PediatricYes
26.Psychiatric NursingNo
27.Respiratory / Pulmonary TherapyNo
28.Non-hospice Palliative CareNo
29.OtherNo
Persons Receiving Services
Line
No.		(1)
30.Number of unduplicated persons seen by your agency during the reporting year.5,401
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 Years132753
2.11 - 20 Years38301
3.21 - 30 Years89521
4.31 - 40 Years115765
5.41 - 50 Years2542,034
6.51 - 60 Years6555,389
7.61 - 70 Years1,1019,824
8.71 - 80 Years1,60313,721
9.81 - 90 Years16,53416,988
10.91 Years and Older5125,611
15.Total21,033 55,907
Admissions By Source Of Referral
Line
No.		Source Of Referral(1)
Admissions
21.Another Home Health Agency2
22.Clinic0
23.Family / Friend0
24.Hospice9
25.Hospital (Discharge Planner, etc.)3,064
26.Local Health Department0
27.Long Term Care Facility (SN / IC)873
28.MSSP0
29.Payer (Insurance, HMO, etc.)0
30.Physician1,667
31.Self0
32.Social Service Agency0
34.Other21
35.Total5,636
Discharges By Reasons
Line
No.		Reason for Discharge(1)
Discharges
41.Admitted to Hospital404
42.Admitted to SN / IC Facility89
43.Death71
44.Family / Friends Assumed Responsibility287
45.Lack of Funds5
46.Lack of Progress19
47.No Further Home Health Care Needed4,021
48.Patient Moved out of Area19
49.Patient Refused Service219
50.Physician Request2
51.Transferred to Another HHA4
52.Transferred to Home Care (Personal Care)0
53.Transferred to Hospice205
54.Transferred to Outpatient Rehabilitation214
59.Other0
60.Total5,559
Visits By Type Of Staff
Line
No.		Type of Staff(1)
Visits
71.Home Health Aide6,100
72.Nutritionist (Diet Counseling)0
73.Occupational Therapist2,367
74.Physical Therapist10,249
75.Physician0
76.Skilled Nursing33,601
77.Social Worker2,598
78.Speech Pathologist / Audiologist992
79.Spiritual and Pastoral Care0
84.Other0
85.Total55,907
Visits By Primary Source Of Payment
Line
No.		Source Of Payment(1)
Visits
91.Medicare3,347
92.Medi-Cal234
93.TRICARE (CHAMPUS)0
94.Other Third Party (Insurance, etc.)5
95.Private (Self Pay)29
96.HMO / PPO (Includes Medicare and Medi-Cal HMOs)52,212
97.No Reimbursement11
99.Other (Includes MSSP)69
100.Total55,907
Section 4 - Health Care Utilization
Patients And Visits By Principal Diagnosis For Which Care Was Given*
Line
No.		Principal Diagnosis
ICD-9-CM Code
on/before 9/30/2015
ICD-10-CM Codes
on/after 10/1/2015
Patients
(1)		Visits
(2)
1.Infectious and Parasitic diseases (exclude HIV)001.0 - 041.9,
045.00 - 139.8		A00-B99 (exclude B20)1561,299
2.HIV infections042B2000
3.Malignant neoplasms: Lung162.2 - 162.9,
197.0, 209.21, 231.2		C34, C78.0, C7A.090, D02.20-D02.2245312
4.Malignant neoplasms: Breast174.0 - 174.9,
175.0 - 175.9,
198.2, 198.81, 233.0		C50, C79.2, C79.80- C79.89, D05.90-D05.9217352
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		C17-C21, C26.0, C78.4, C78.5, C7A.010-C7A.029, D01.0-D01.4912176
6.Malignant neoplasms: All other sites, excluding those in #3, 4, 5140.0 - 209.36,
230.0 - 234.9		C00-D09*1762,284
7.Non-malignant neoplasms: All sites209.40 - 209.79
210.0 - 229.9,
235.0 - 238.9,
239.0 - 239.9		D10-D49573
8.Diabetes mellitus249.00 - 250.93E08-E132012,192
9.Endocrine, metabolic, and nutritional diseases; Immunity disorders240.00 - 246.9,
251.0 - 279.9		E00-E07, E15-E8861471
10.Diseases of blood and blood forming organs280.0 - 289.9D50-D77, D80-D8918146
11.Mental disorder290.0 - 319F01-F9958534
12.Alzheimer's disease331.0G30.0-G30.919121
13.Disease of nervous system and sense organs320.0 - 330.9,
331.11 - 389.9		G00-G26, G31-G96, G98-H57, H60-H941451,701
14.Diseases of cardiovascular system391.0 - 392.0,
393 - 402.91,
404.00 - 429.9		I10-I11, I13, I20-I524235,324
15.Diseases of cerebrovascular system430 - 438.9I60-I6957601
16.Diseases of all other circulatory system390,  392.9,
403.00 - 403.91,
440.0 - 459.9		I00, I02.9, I12, I15, I70-I96, I992323,523
17.Diseases of respiratory system460 - 519.9J00-J94, J96-J993123,329
18.Diseases of digestive system520.0 - 579.9K00-K90, K921451,465
19.Diseases of genitourinary system580.0 - 608.9,
614.0 - 629.9		N00-N53, N70-N972461,898
20.Diseases of breast610.0 - 611.9N60-N65317
21.Complications of pregnancy, childbirth, and the puerperium630 - 679.14O00-O9A1378
22.Diseases of skin and subcutaneous tissue680.0 - 709.9L00-L75, L80-L992433,245
23.Diseases of musculosketal system and connective tissue (include pathological fx, malunion fx, and nonunion fx)710.0 - 739.9M00-M95, M9998801
24.Congenital anormalies and perinatal conditions (include birth fractures)740.0 - 779.9P00-P96, Q00-Q991781
25.Symptoms, signs, and ill-defined conditions (exclude HIV positive test)780.01 - 795.6,
795.79,
796.0 - 799.9		R00-R99111942
26.Fractures (exclude birth fx, pathological fx, malunion fx, nonunion fx)800.00 - 829.1S02, S12, S22, S32, S42, S49, S52, S59, S62, S72, S79, S82, S89, S9200
27.All other injuries, *excluding fractures830.0 - 959.9S00-T34* , T51-T791,0468,823
28.Poisonings and adverse effects of external causes960.0 - 995.94T36-T50219
29.Complications of surgical and medical care996.00 - 999.9D78, E89, G97, H59, H95, I97, J95, K91, K94, L76, M96, N98-N99, T80-T881421,634
30.Health services related to reproduction and developmentV20.0 - V26.9,
V28.0 - V29.9		Z00.1-Z00.3, Z30-Z36, Z39, Z7656349
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		Z38.1, Z38.2, Z38.4, Z38.5, Z38.7, Z38.800
32.Health hazards related to communicable diseases (exclude HIV test result)V01.0 - V07.9,
V09.0 - V19.8,
V40.0 - V49.9		Z21-Z28, Z77-Z99681
33.Other health services for specific procedures and aftercareV50.0 - V58.9Z40-Z532,03213,323
34.Visits for Evaluation and AssessmentV60.0 - V89.09Z00.0, Z01-Z18, Z55-Z6869623
45.Total6,16655,817
** The list of ICD-9-CM codes excluded: Ecodes, V27.0-V27.9, V30-V39 with 5th digits 0 or 1, V59.01-V59.9
** The list of ICD-10-CM codes excluded: V00-Y99, Z37, and Z52.
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 CodeICD-10-CM Code(1)
Patients		(2)
Visits
51.HIV042B20314
52.Alzheimer's Disease331.0G30.0-G30.91411,203
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.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 patients1,612
2.Survivors of persons not receiving hospice care291
Volunteer Services
Line
No.		Volunteer Services(2)
Volunteer Hours
3.Patient / Family Services1,714
4.Bereavement204
5.Administrative1,966
6.Medicare Reportable Hours
(sum lines 3-5)		3,884
7.Fundraising0
9.Other395
10.Total4,279
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 ProvidedYes
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 - RN10,165
22.Nursing - LVN1,199
23.Social Services2,746
24.Hospice Physician Services499
25.Homemaker and Home Health Aide8,578
26.Chaplain1,066
29.Other Clinical Services96
30.Total24,349
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 Years0202
6.31 - 40 Years4105
7.41 - 50 Years718025
8.51 - 60 Years53620115
9.61 - 70 Years91710162
10.71 - 80 Years111970208
11.81 - 90 Years1571680325
12.91 + Years61940155
15.Total4845130997
Unduplicated Hospice Patients By Gender and Race
Line
No.		Race
(1)

Male
(2)

Female		(3)
Other / Unknown
(4)

Total
21.White3153460661
22.Black1423037
23.Native American1304
24.Asian / Pacific Islander2419043
25.Other / Unknown1301220252
26.More than one race0000
30.Total4845130997
Unduplicated Hospice Patients By Gender And Ethnicity
Line
No.		Ethnicity
(1)

Male
(2)

Female		(3)
Other / Unknown
(4)

Total
31.Hispanic3838076
32.Non-Hispanic4464740920
33.Unknown0101
35.Total4845130997
Hospice Patient Discharges By Reason
Line
No.		Reason for Discharge(1)
Patients
61.Death698
62.Patient Moved Out of Area2
63.Patient Refused Service3
64.Transferred to Another Local Hospice77
65.Prognosis Extended79
66.Patient Desired Curative Treatment1
69.Other140
70.Total1,000
Hospice Patients Discharged By Length Of Stay
Line
No.		Length of Stay
(Days)		(1)
Patients
71.0-7 Days133
72.8-30 Days223
73.31-90 Days289
74.91-179 Days273
75.180+ Days82
85.Total1,000
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 Diego1,6026982901,889
92.0000
93.0000
94.0000
95.0000
96.0000
97.0000
98.0000
99.0000
100.Total1,6026982901,889
Number Of Hospice Admissions By Diagnosis
Line
No.		Diagnosis
ICD-9-CM Code
on/before 9/30/2015
ICD-10-CM Codes
on/after 10/1/2015

No. of New
Admissions

(1)
Re-admissions
Previously Seen
by Another
Hospice
Program

(2)
Re-admissions
Previously Seen
by This
Hospice
Program
(3)
Total
Admissions
(1)+(2)+(3)
(4)
101.Cancer140.0 - 209.30, 230.0 - 234.9C00-D0949900499
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		A01.02, A18.84, A32.82, A36.81, A39.5, A52.00, A52.03, A52.06, A54.83, B26.82, B33.2, B37.6, B58.81, I01-I09, I10-I11, I13, I20-I52, I97.0-I97.1, I97.3-I97.7, M05.3, M32.11-M32.12, T82.0-T82.2, T82.5-T82.9, T86.2-T86.312100121
103.Dementia & Cerebral
Degeneration		290.0 - 294.9
331.0 - 331.9		A50.17, F01-F09, F10.27, F10.97, F13.27, F13.97, F18.27, F18.97, F19.27, F19.97, G30-G32540054
104.Lung, excluding cancer460 - 519.9, 996.84, 997.31 - 997.39A01.03, A02.22, A15, A22.1, A36.0-A36.2, A37, A42.0, A43.0, A54.5, A54.84, B00.2, B01.2, B05.2, B06.81, B08.5, B25.0, B37.1, B38.0-B38.2, B59, B77.81, J00-J99, M32.13, T81.82, T86.8260026
105.Kidney, excluding cancer
and diabetic
kidney disease
403.00 - 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		A02.25, A18.11, A36.84, A54.21, A51.44, I12, I15.0-I15.1, M32.14-M32.15, N00-N29, T82.4, T86.1240024
106.Liver, excluding cancer570 - 573.9, 996.82A06.4, A51.45, A52.74, B00.81, B15-B19, B25.1, B26.81, B58.1, B67.0, B67.5, B67.8, K00-K77, K91.81, T86.4110011
107.HIV042B200000
108.Brain Stroke and late effects430 - 436, 438.0 - 438.9
997.02		A52.04, A52.05, G45, I60-I69, I97.81-I97.82130013
109.Coma, with or without brain injury780.01 - 780.09, 850.4
851.0 - 854.1 with fifth digit 5		R40.0-R40.4, S060000
110.Diabetes250.00 - 250.93E08-E137007
111.ALS*335.20G12.212002
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		K25-K63, K921001
113.Multiple Sclerosis340G351001
114.Congenital Defects740 - 759Q00.0 - Q99.9220022
115.General Debility and Failure to Thrive783.41, 783.7, 797 and 799.3G93.3, R41.81, R53.8, R54, R62.51, R62.71001
119.OtherAll other codes that are not in lines 101-11520800208
120.TOTAL99000990
*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.		Diagnosis
ICD-9-CM Code
on/before 9/30/2015
ICD-10-CM Codes
on/after 10/1/2015
Number of Live Discharges

(1)
No. of Discharges due to Death

(2)
Total Number of Discharges

(3)
Visits for Discharged Patients

(4)
Discharged Patients Total Days of Care

(5)
1.Cancer140.0 - 209.30,
230.0 - 234.9		C00-D09683954638,86125,595
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		A01.02, A18.84, A32.82, A36.81, A39.5, A52.00, A52.03, A52.06, A54.83, B26.82, B33.2, B37.6, B58.81, I01-I09, I10-I11, I13, I20-I52, I97.0-I97.1, I97.3- I97.7, M05.3, M32.11-M32.12, T82.0-T82.2, T82.5-T82.9, T86.2-T86.332781103,0527,747
3.Dementia and Cerebral Degeneration290.0 - 294.9,
331.0-331.9		A50.17, F01-F09, F10.27, F10.97, F13.27, F13.97, F18.27, F18.97, F19.27, F19.97, G30-G322331542,4454,755
4.Lung, excluding cancer460 - 519.9,  996.84
997.31 - 997.39		A01.03, A02.22, A15, A22.1, A36.0-A36.2, A37, A42.0, A43.0, A54.5, A54.84, B00.2, B01.2 B05.2, B06.81, B08.5, B25.0, B37.1, B38.0-B38.2 B59, B77.81, J00-J99, M32.13, T81.82, T86.8519242821,941
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		A02.25, A18.11, A36.84, A54.21, A51.44, I12, I15.0- I15.1, M32.14-M32.15, N00- N29, T82.4, T86.1519245061,153
6.Liver, excluding cancer570 - 573.9, 996.82A06.4, A51.45, A52.74, B00.81, B15-B19, B25.1, B26.81, B58.1, B67.0, B67.5, B67.8, K00-K77, K91.81, T86.4178163363
7.HIV042B2000000
8.Brain Stroke and late effects430 - 436,
438.0 - 438.9,
997.02		A52.04, A52.05, G45, I60- I69, I97.81-I97.827310148847
9.Coma, with or without brain injury780.01 - 780.09,
850.4,
851.0 - 854.1 with fifth digit 5		R40.0-R40.4, S0600000
10.Diabetes249.00 - 250.93E08-E132133164
11.ALS*335.20G12.2100000
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		K25-K63, K920113229
13.Multiple Sclerosis340G3500000
14.Congenital Defects740 - 759Q00.0 - Q99.941014701,080
15.General Debility and Failure to Thrive783.41, 783.7, 797, 799.3G93.3, R41.81, R53.8, R54, R62.51, R62.71013371
19.OtherAll other codes that are not in lines 1-11.1541342887,06615,690
20.Total3026981,00022,66159,435
* 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.Medicare98824,9561641723025,322
2.Medi-Cal31751100186
3.Medi-Cal Managed Care000000
4.Managed Care000000
5.Private Insurance000000
6.Self Pay000000
7.Charity000000
8.Veterans Administration000000
9.Other*1833,927144110154,196
10.Total1,17429,0583092924529,704
* 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.Home98823,1813723,218
22.Hospital0141230137
23.SNF045515770547
24.CLHF000000
25.RCFE / ARF / RCFCI01,48121,483
26.ICF / MR0000
27.Prison0000
28.Homeless0000
29.Other1833,92717121564,319
30.Total1,17129,0583092924529,704
Section 10 - Hospice Income and Expenses Statement
Detail Of Operating Expenses
Line
No.		(1)
Total
General Service Cost Centers
30.Administrative and General$0
Inpatient Care Service
31.Inpatient - General Care$0
32.Inpatient - Respite Care$0
Program Supervision
35.Hospice Program / Team Supervision (Non-visit wages)$0
Visiting Services
36.Physician Services$0
37.Nursing Care$0
38.Rehabilitation Services (PT, OT, Speech)$0
39.Medical Social Services - Direct$0
40.Spiritual Counseling$0
41.Dietary Counseling$0
42.Counseling - Other$0
43.Home Health Aides and Homemakers$0
44.Other Visiting Services$0
Hospice Service Cost Centers
45.Drugs, Biologicals and Infusion$0
46.Durable Medical Equipment / Oxygen$0
47.Patient Transportation$0
48.Imaging, Lab and Diagnostics$0
49.Medical Supplies$0
50.Outpatient Services (including ER Dept.)$0
51.Radiation Therapy$0
52.Chemotherapy$0
53.Other Hospice Service Costs$0
Other Hospice Costs
54.Bereavement Program Costs$0
55.Volunteer Program Costs$0
56.Fundraising$0
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.Medicare$0
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 Insurance$0
106.Self-Pay$0
109.Other Payers$0
110.Total Revenue for Hospices Four Levels of Care$0
Room & Board Revenue
1101.SNF Room & Board pass Through Receivable from Medi-Cal$0
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 Adjustments$0
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)$0
125.Net Patient Revenue (line 1104 minus line 120)$0
Other Operating Revenue
131.Grants$0
132.Donations / Contributions$0
133.Unrelated Business Income$0
139.Other$0
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 Tax$0
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.n/a
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