Annual Utilization Report of Home Health Agencies / Hospices
Facility Name:ADVENTIST HEALTH HOME CARE AND HOSPICE SVCS - MENDO CTY
OSHPD ID:406234033Report 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:ADVENTIST HEALTH HOME CARE AND HOSPICE SVCS - MENDO CTY
2.OSHPD ID Number:406234033
3.Street Address:100 SAN HEDRIN CIR
4.City:WILLITS
5.Zip:95490
6.Facility Phone No.:( 707) 459 - 1818 ext.
7.Administrator Name:Nancy Runyan
8.Administrator E-mail Address:nancy.runyan@ah.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:Western Health Resources
13.Corporate Business Address:2100 Douglas Blvd.
14.City:Roseville
15.State:CA
16.Zip:95661 -
17.Person Completing Report:NANCY RUNYAN
18.Phone No.:707-456-3242
19.Fax No.:707-459-9298
20.E-mail Address:RUNYANNL@AH.ORG
25.Entity Type:Home Health Agency with Hospice Program
26.Entity RelationSole Facility
30.Submitted by:adventil95
31.Submitted Date and Time:3/10/2016 11:50:30 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 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)No
24.Mental Health CounselingNo
25.PediatricNo
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.957
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 Years218
3.21 - 30 Years14115
4.31 - 40 Years15225
5.41 - 50 Years48368
6.51 - 60 Years1281,227
7.61 - 70 Years2602,915
8.71 - 80 Years2613,023
9.81 - 90 Years2893,085
10.91 Years and Older1241,419
15.Total1,141 12,395
Admissions By Source Of Referral
Line
No.		Source Of Referral(1)
Admissions
21.Another Home Health Agency0
22.Clinic35
23.Family / Friend0
24.Hospice0
25.Hospital (Discharge Planner, etc.)623
26.Local Health Department0
27.Long Term Care Facility (SN / IC)158
28.MSSP0
29.Payer (Insurance, HMO, etc.)0
30.Physician218
31.Self0
32.Social Service Agency0
34.Other0
35.Total1,034
Discharges By Reasons
Line
No.		Reason for Discharge(1)
Discharges
41.Admitted to Hospital55
42.Admitted to SN / IC Facility19
43.Death23
44.Family / Friends Assumed Responsibility0
45.Lack of Funds1
46.Lack of Progress2
47.No Further Home Health Care Needed804
48.Patient Moved out of Area1
49.Patient Refused Service25
50.Physician Request4
51.Transferred to Another HHA1
52.Transferred to Home Care (Personal Care)0
53.Transferred to Hospice39
54.Transferred to Outpatient Rehabilitation12
59.Other10
60.Total996
Visits By Type Of Staff
Line
No.		Type of Staff(1)
Visits
71.Home Health Aide907
72.Nutritionist (Diet Counseling)0
73.Occupational Therapist279
74.Physical Therapist2,670
75.Physician0
76.Skilled Nursing8,068
77.Social Worker243
78.Speech Pathologist / Audiologist195
79.Spiritual and Pastoral Care33
84.Other0
85.Total12,395
Visits By Primary Source Of Payment
Line
No.		Source Of Payment(1)
Visits
91.Medicare9,590
92.Medi-Cal1,271
93.TRICARE (CHAMPUS)465
94.Other Third Party (Insurance, etc.)498
95.Private (Self Pay)18
96.HMO / PPO (Includes Medicare and Medi-Cal HMOs)553
97.No Reimbursement0
99.Other (Includes MSSP)0
100.Total12,395
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)971
2.HIV infections042B2000
3.Malignant neoplasms: Lung162.2 - 162.9,
197.0, 209.21, 231.2		C34, C78.0, C7A.090, D02.20-D02.22758
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-D05.92435
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-D01.49325
6.Malignant neoplasms: All other sites, excluding those in #3, 4, 5140.0 - 209.36,
230.0 - 234.9		C00-D09*26389
7.Non-malignant neoplasms: All sites209.40 - 209.79
210.0 - 229.9,
235.0 - 238.9,
239.0 - 239.9		D10-D49429
8.Diabetes mellitus249.00 - 250.93E08-E1333397
9.Endocrine, metabolic, and nutritional diseases; Immunity disorders240.00 - 246.9,
251.0 - 279.9		E00-E07, E15-E881184
10.Diseases of blood and blood forming organs280.0 - 289.9D50-D77, D80-D89316
11.Mental disorder290.0 - 319F01-F9914134
12.Alzheimer's disease331.0G30.0-G30.938
13.Disease of nervous system and sense organs320.0 - 330.9,
331.11 - 389.9		G00-G26, G31-G96, G98-H57, H60-H9443641
14.Diseases of cardiovascular system391.0 - 392.0,
393 - 402.91,
404.00 - 429.9		I10-I11, I13, I20-I521361,400
15.Diseases of cerebrovascular system430 - 438.9I60-I6932470
16.Diseases of all other circulatory system390,  392.9,
403.00 - 403.91,
440.0 - 459.9		I00, I02.9, I12, I15, I70-I96, I9930460
17.Diseases of respiratory system460 - 519.9J00-J94, J96-J991291,259
18.Diseases of digestive system520.0 - 579.9K00-K90, K9247474
19.Diseases of genitourinary system580.0 - 608.9,
614.0 - 629.9		N00-N53, N70-N9746337
20.Diseases of breast610.0 - 611.9N60-N65141
21.Complications of pregnancy, childbirth, and the puerperium630 - 679.14O00-O9A18
22.Diseases of skin and subcutaneous tissue680.0 - 709.9L00-L75, L80-L99651,102
23.Diseases of musculosketal system and connective tissue (include pathological fx, malunion fx, and nonunion fx)710.0 - 739.9M00-M95, M9947499
24.Congenital anormalies and perinatal conditions (include birth fractures)740.0 - 779.9P00-P96, Q00-Q9900
25.Symptoms, signs, and ill-defined conditions (exclude HIV positive test)780.01 - 795.6,
795.79,
796.0 - 799.9		R00-R9926323
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, S9218161
27.All other injuries, *excluding fractures830.0 - 959.9S00-T34* , T51-T7920296
28.Poisonings and adverse effects of external causes960.0 - 995.94T36-T50314
29.Complications of surgical and medical care996.00 - 999.9D78, E89, G97, H59, H95, I97, J95, K91, K94, L76, M96, N98-N99, T80-T8816173
30.Health services related to reproduction and developmentV20.0 - V26.9,
V28.0 - V29.9		Z00.1-Z00.3, Z30-Z36, Z39, Z7600
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-Z99334
33.Other health services for specific procedures and aftercareV50.0 - V58.9Z40-Z533603,449
34.Visits for Evaluation and AssessmentV60.0 - V89.09Z00.0, Z01-Z18, Z55-Z6800
45.Total1,14012,387
** 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.HIV042B20114
52.Alzheimer's Disease331.0G30.0-G30.917115
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.Home Health based
Location of Service Delivery
Line
No.		(1)
25.Primarily Rural
Section 6 - Hospice Services
Bereavement Services
Line
No.		Bereavement Services(1)
People Served
1.Survivors of hospice patients698
2.Survivors of persons not receiving hospice care1
Volunteer Services
Line
No.		Volunteer Services(2)
Volunteer Hours
3.Patient / Family Services802
4.Bereavement328
5.Administrative976
6.Medicare Reportable Hours
(sum lines 3-5)		2,106
7.Fundraising124
9.Other0
10.Total2,230
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 - RN1,668
22.Nursing - LVN811
23.Social Services728
24.Hospice Physician Services37
25.Homemaker and Home Health Aide1,070
26.Chaplain304
29.Other Clinical Services12
30.Total4,630
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 Years2103
7.41 - 50 Years4004
8.51 - 60 Years1412026
9.61 - 70 Years2917046
10.71 - 80 Years2323046
11.81 - 90 Years3030060
12.91 + Years1325038
15.Total1151080223
Unduplicated Hospice Patients By Gender and Race
Line
No.		Race
(1)

Male
(2)

Female		(3)
Other / Unknown
(4)

Total
21.White101940195
22.Black1001
23.Native American2103
24.Asian / Pacific Islander0000
25.Other / Unknown1113024
26.More than one race0000
30.Total1151080223
Unduplicated Hospice Patients By Gender And Ethnicity
Line
No.		Ethnicity
(1)

Male
(2)

Female		(3)
Other / Unknown
(4)

Total
31.Hispanic4408
32.Non-Hispanic104950199
33.Unknown79016
35.Total1151080223
Hospice Patient Discharges By Reason
Line
No.		Reason for Discharge(1)
Patients
61.Death169
62.Patient Moved Out of Area0
63.Patient Refused Service0
64.Transferred to Another Local Hospice0
65.Prognosis Extended9
66.Patient Desired Curative Treatment18
69.Other5
70.Total201
Hospice Patients Discharged By Length Of Stay
Line
No.		Length of Stay
(Days)		(1)
Patients
71.0-7 Days49
72.8-30 Days67
73.31-90 Days50
74.91-179 Days24
75.180+ Days11
85.Total201
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.Mendocino20316932223
92.0000
93.0000
94.0000
95.0000
96.0000
97.0000
98.0000
99.0000
100.Total20316932223
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-D09821588
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-T86.3201122
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-G32240529
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, T86.8170320
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, T86.16006
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, T86.44004
107.HIV042B200000
108.Brain Stroke and late effects430 - 436, 438.0 - 438.9
997.02		A52.04, A52.05, G45, I60-I69, I97.81-I97.82140317
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-E130000
111.ALS*335.20G12.213003
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, K921012
113.Multiple Sclerosis340G350000
114.Congenital Defects740 - 759Q00.0 - Q99.90000
115.General Debility and Failure to Thrive783.41, 783.7, 797 and 799.3G93.3, R41.81, R53.8, R54, R62.51, R62.70000
119.OtherAll other codes that are not in lines 101-115120012
120.TOTAL183218203
*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-D092568931,7743,860
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-T86.3119203801,028
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-G32520252851,026
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, T86.8117185961,355
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, T86.10666667
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, T86.40553073
7.HIV042B2000000
8.Brain Stroke and late effects430 - 436,
438.0 - 438.9,
997.02		A52.04, A52.05, G45, I60- I69, I97.81-I97.8201818196405
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-E1300000
11.ALS*335.20G12.21033148406
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, K9201143
13.Multiple Sclerosis340G3500000
14.Congenital Defects740 - 759Q00.0 - Q99.900000
15.General Debility and Failure to Thrive783.41, 783.7, 797, 799.3G93.3, R41.81, R53.8, R54, R62.51, R62.700000
19.OtherAll other codes that are not in lines 1-11.01212182452
20.Total321692013,6618,675
* 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.Medicare1848,6480208,650
2.Medi-Cal000000
3.Medi-Cal Managed Care25798700805
4.Managed Care000000
5.Private Insurance10289000289
6.Self Pay000000
7.Charity000000
8.Veterans Administration4426000426
9.Other*000000
10.Total22310,16172010,170
* 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.Home2169,03309,033
22.Hospital10707
23.SNF6613020615
24.CLHF000000
25.RCFE / ARF / RCFCI05150515
26.ICF / MR0000
27.Prison0000
28.Homeless0000
29.Other000000
30.Total22310,16172010,170
Section 10 - Hospice Income and Expenses Statement
Detail Of Operating Expenses
Line
No.		(1)
Total
General Service Cost Centers
30.Administrative and General$635,425
Inpatient Care Service
31.Inpatient - General Care$5,700
32.Inpatient - Respite Care$0
Program Supervision
35.Hospice Program / Team Supervision (Non-visit wages)$117,567
Visiting Services
36.Physician Services$54,000
37.Nursing Care$271,903
38.Rehabilitation Services (PT, OT, Speech)$0
39.Medical Social Services - Direct$88,472
40.Spiritual Counseling$50,558
41.Dietary Counseling$0
42.Counseling - Other$0
43.Home Health Aides and Homemakers$37,319
44.Other Visiting Services$0
Hospice Service Cost Centers
45.Drugs, Biologicals and Infusion$108,044
46.Durable Medical Equipment / Oxygen$125,659
47.Patient Transportation$2,907
48.Imaging, Lab and Diagnostics$3,960
49.Medical Supplies$25,479
50.Outpatient Services (including ER Dept.)$11,909
51.Radiation Therapy$0
52.Chemotherapy$0
53.Other Hospice Service Costs$0
Other Hospice Costs
54.Bereavement Program Costs$1,179
55.Volunteer Program Costs$821
56.Fundraising$1,565
Other Costs
57.Other Program Costs*$4,119
59.Total Operating Expenses$1,546,586
* 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$1,975,427
102.Medi-Cal (Excluding SNF Room and Board)$0
103.Medi-Cal Managed Care (Excluding SNF Room and Board)$106,357
104.Managed Care (Non Medi-Cal)$0
105.Private Insurance$244,232
106.Self-Pay$0
109.Other Payers$0
110.Total Revenue for Hospices Four Levels of Care$2,326,016
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)$2,326,016
Write-Offs and Adjustments
111.Contractual Adjustments$437,501
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)$437,501
125.Net Patient Revenue (line 1104 minus line 120)$1,888,515
Other Operating Revenue
131.Grants$0
132.Donations / Contributions$36,274
133.Unrelated Business Income$0
139.Other$0
140.Total Other Operating Revenue (sum of lines 131 through 139)$36,274
145.Total Operating Revenue (line 125 plus line 140)$1,924,789
Operating Expenses
160.Total Operating Expenses (from line 59)$1,546,586
165.Net from Operations (line 145 minus line 160)$378,203
170.Income Tax$0
175.Net Income (line 165 minus line 170)$378,203
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