Annual Utilization Report of Home Health Agencies / Hospices
Facility Name:KAISER RIVERSIDE HOME HEALTH AGENCY (PARENT)
OSHPD ID:406334024Report 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 RIVERSIDE HOME HEALTH AGENCY (PARENT)
2.OSHPD ID Number:406334024
3.Street Address:10917 MAGNOLIA AVE
4.City:RIVERSIDE
5.Zip:92505
6.Facility Phone No.:( 951) 358 - 2600 ext. 2619
7.Administrator Name:Odylin Bundalian RN
8.Administrator E-mail Address:Odylin.Bundalian@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 RIVERSIDE HOME HEALTH AGENCY
13.Corporate Business Address:10800 MAGNOLIA AVENUE
14.City:RIVERSIDE
15.State:CA
16.Zip:92505 -
17.Person Completing Report:Danilo Volpe
18.Phone No.:951-358-2619
19.Fax No.:
20.E-mail Address:Danilo.G.Volpe@kp.org
25.Entity Type:Home Health Agency with Hospice Program
26.Entity RelationSole Facility
30.Submitted by:danilo4024
31.Submitted Date and Time:3/15/2016 6:04:07 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 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 ServicesYes
21.Blood TransfusionsNo
22.Enterostomal TherapyYes
23.IV Therapy (Includes Chemo and TPN)Yes
24.Mental Health CounselingNo
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.3,698
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 Years112267
2.11 - 20 Years35214
3.21 - 30 Years74401
4.31 - 40 Years111593
5.41 - 50 Years2782,378
6.51 - 60 Years6745,096
7.61 - 70 Years1,0378,321
8.71 - 80 Years1,11110,167
9.81 - 90 Years7256,934
10.91 Years and Older1671,299
15.Total4,324 35,670
Admissions By Source Of Referral
Line
No.		Source Of Referral(1)
Admissions
21.Another Home Health Agency2
22.Clinic2
23.Family / Friend0
24.Hospice0
25.Hospital (Discharge Planner, etc.)3,196
26.Local Health Department0
27.Long Term Care Facility (SN / IC)515
28.MSSP0
29.Payer (Insurance, HMO, etc.)0
30.Physician606
31.Self0
32.Social Service Agency0
34.Other3
35.Total4,324
Discharges By Reasons
Line
No.		Reason for Discharge(1)
Discharges
41.Admitted to Hospital220
42.Admitted to SN / IC Facility42
43.Death38
44.Family / Friends Assumed Responsibility186
45.Lack of Funds0
46.Lack of Progress26
47.No Further Home Health Care Needed2,229
48.Patient Moved out of Area43
49.Patient Refused Service102
50.Physician Request21
51.Transferred to Another HHA36
52.Transferred to Home Care (Personal Care)0
53.Transferred to Hospice142
54.Transferred to Outpatient Rehabilitation1,032
59.Other1
60.Total4,118
Visits By Type Of Staff
Line
No.		Type of Staff(1)
Visits
71.Home Health Aide2,567
72.Nutritionist (Diet Counseling)0
73.Occupational Therapist713
74.Physical Therapist10,467
75.Physician0
76.Skilled Nursing21,225
77.Social Worker698
78.Speech Pathologist / Audiologist0
79.Spiritual and Pastoral Care0
84.Other0
85.Total35,670
Visits By Primary Source Of Payment
Line
No.		Source Of Payment(1)
Visits
91.Medicare1,587
92.Medi-Cal234
93.TRICARE (CHAMPUS)0
94.Other Third Party (Insurance, etc.)13
95.Private (Self Pay)122
96.HMO / PPO (Includes Medicare and Medi-Cal HMOs)33,679
97.No Reimbursement0
99.Other (Includes MSSP)35
100.Total35,670
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)443
2.HIV infections042B2000
3.Malignant neoplasms: Lung162.2 - 162.9,
197.0, 209.21, 231.2		C34, C78.0, C7A.090, D02.20-D02.2211145
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-D05.92316
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-D01.4919
6.Malignant neoplasms: All other sites, excluding those in #3, 4, 5140.0 - 209.36,
230.0 - 234.9		C00-D09*21179
7.Non-malignant neoplasms: All sites209.40 - 209.79
210.0 - 229.9,
235.0 - 238.9,
239.0 - 239.9		D10-D4900
8.Diabetes mellitus249.00 - 250.93E08-E132459
9.Endocrine, metabolic, and nutritional diseases; Immunity disorders240.00 - 246.9,
251.0 - 279.9		E00-E07, E15-E88634
10.Diseases of blood and blood forming organs280.0 - 289.9D50-D77, D80-D8929134
11.Mental disorder290.0 - 319F01-F99313
12.Alzheimer's disease331.0G30.0-G30.923481
13.Disease of nervous system and sense organs320.0 - 330.9,
331.11 - 389.9		G00-G26, G31-G96, G98-H57, H60-H9417234
14.Diseases of cardiovascular system391.0 - 392.0,
393 - 402.91,
404.00 - 429.9		I10-I11, I13, I20-I526243,890
15.Diseases of cerebrovascular system430 - 438.9I60-I691211,012
16.Diseases of all other circulatory system390,  392.9,
403.00 - 403.91,
440.0 - 459.9		I00, I02.9, I12, I15, I70-I96, I99842
17.Diseases of respiratory system460 - 519.9J00-J94, J96-J991011,211
18.Diseases of digestive system520.0 - 579.9K00-K90, K9256397
19.Diseases of genitourinary system580.0 - 608.9,
614.0 - 629.9		N00-N53, N70-N97562,021
20.Diseases of breast610.0 - 611.9N60-N6500
21.Complications of pregnancy, childbirth, and the puerperium630 - 679.14O00-O9A00
22.Diseases of skin and subcutaneous tissue680.0 - 709.9L00-L75, L80-L993677,320
23.Diseases of musculosketal system and connective tissue (include pathological fx, malunion fx, and nonunion fx)710.0 - 739.9M00-M95, M991,3847,034
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-R991891,198
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, S921781,111
27.All other injuries, *excluding fractures830.0 - 959.9S00-T34* , T51-T7951675
28.Poisonings and adverse effects of external causes960.0 - 995.94T36-T5011
29.Complications of surgical and medical care996.00 - 999.9D78, E89, G97, H59, H95, I97, J95, K91, K94, L76, M96, N98-N99, T80-T8800
30.Health services related to reproduction and developmentV20.0 - V26.9,
V28.0 - V29.9		Z00.1-Z00.3, Z30-Z36, Z39, Z7615
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-Z9900
33.Other health services for specific procedures and aftercareV50.0 - V58.9Z40-Z537115,987
34.Visits for Evaluation and AssessmentV60.0 - V89.09Z00.0, Z01-Z18, Z55-Z683342,419
45.Total4,32435,670
** 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.HIV042B2012
52.Alzheimer's Disease331.0G30.0-G30.947734
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 patients264
2.Survivors of persons not receiving hospice care0
Volunteer Services
Line
No.		Volunteer Services(2)
Volunteer Hours
3.Patient / Family Services19
4.Bereavement96
5.Administrative361
6.Medicare Reportable Hours
(sum lines 3-5)		476
7.Fundraising0
9.Other0
10.Total476
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 VisitsYes
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 - RN3,494
22.Nursing - LVN600
23.Social Services623
24.Hospice Physician Services492
25.Homemaker and Home Health Aide2,111
26.Chaplain486
29.Other Clinical Services2
30.Total7,808
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 Years2002
6.31 - 40 Years2507
7.41 - 50 Years46010
8.51 - 60 Years3828066
9.61 - 70 Years4030070
10.71 - 80 Years4238080
11.81 - 90 Years3653089
12.91 + Years725032
15.Total1711850356
Unduplicated Hospice Patients By Gender and Race
Line
No.		Race
(1)

Male
(2)

Female		(3)
Other / Unknown
(4)

Total
21.White63970160
22.Black1313026
23.Native American0000
24.Asian / Pacific Islander2204
25.Other / Unknown93730166
26.More than one race0000
30.Total1711850356
Unduplicated Hospice Patients By Gender And Ethnicity
Line
No.		Ethnicity
(1)

Male
(2)

Female		(3)
Other / Unknown
(4)

Total
31.Hispanic1819037
32.Non-Hispanic1531660319
33.Unknown0000
35.Total1711850356
Hospice Patient Discharges By Reason
Line
No.		Reason for Discharge(1)
Patients
61.Death264
62.Patient Moved Out of Area7
63.Patient Refused Service10
64.Transferred to Another Local Hospice7
65.Prognosis Extended11
66.Patient Desired Curative Treatment4
69.Other13
70.Total316
Hospice Patients Discharged By Length Of Stay
Line
No.		Length of Stay
(Days)		(1)
Patients
71.0-7 Days73
72.8-30 Days47
73.31-90 Days81
74.91-179 Days83
75.180+ Days32
85.Total316
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.Riverside35626451356
92.0000
93.0000
94.0000
95.0000
96.0000
97.0000
98.0000
99.0000
100.Total35626451356
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-D0925100251
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-T86.3240024
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-G32290029
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, T86.8170017
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, T86.1160016
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, T86.49009
107.HIV042B200000
108.Brain Stroke and late effects430 - 436, 438.0 - 438.9
997.02		A52.04, A52.05, G45, I60-I69, I97.81-I97.823003
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-E132002
111.ALS*335.20G12.214004
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 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 101-1150000
120.TOTAL35600356
*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-D09221812034,3737,830
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-T86.331821428616
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-G32101929601885
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, T86.851217416611
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, T86.151116153364
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, T86.4189134292
7.HIV042B2000000
8.Brain Stroke and late effects430 - 436,
438.0 - 438.9,
997.02		A52.04, A52.05, G45, I60- I69, I97.81-I97.8211255
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-E130222421
11.ALS*335.20G12.211343353
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, K9201153
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 1-11.3912277402
20.Total512653166,44911,082
* 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.Medicare2228,75852038,786
2.Medi-Cal000000
3.Medi-Cal Managed Care000000
4.Managed Care000000
5.Private Insurance000000
6.Self Pay000000
7.Charity000000
8.Veterans Administration000000
9.Other*1345,4310005,431
10.Total35614,189520314,217
* 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.Home35614,189314,192
22.Hospital00505
23.SNF00020020
24.CLHF000000
25.RCFE / ARF / RCFCI0000
26.ICF / MR0000
27.Prison0000
28.Homeless0000
29.Other000000
30.Total35614,189520314,217
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
1.0
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 Care5
12.Inpatient Respite care20
13.Continuous Care3
14.Routine Care14,189
20TOTAL14,217
General Comments:
Section 10 Hospice Income and Expenses statement: This is a Hospital based Hospice, cost report filed by the Riverside Medical Center Kaiser Permanente.
Errors and Warnings