Survey Info.

Annual Utilization Report of Primary Care Clinic
Facility Name:	BURRE MOBILE DENTAL
OSHPD ID:	306124038	Report Status:	Submitted
License Category:	Community Clinic	Report Year:	2017

Table of Contents

Click on any of the links listed below to view the corresponding section.

Section 1 - General Information

Section 2 - Clinic Services

Section 3 - Patient Demographics

Section 4 - Encounters by Principal Diagnosis

Section 5 - Encounters by Principal Service

Section 6 - Revenue and Utilization by Payer

Section 7 - Income Statement

Section 8 - Capital Projects and Funds

General Comments

View Errors and Warnings

Section 1 - General Information

Facility Name:

BURRE MOBILE DENTAL

OSHPD ID Number:

306124038

Street Address:

959 MYRTLE AVE

City:

EUREKA

Zip:

95501

Facility Phone No.:

(707) 442 - 7078 ext.

Administrator Name:

Barbara Davis

Administrator E-mail Address:

bdavis@opendoorhealth.com

Was this clinic in operation at any time during the year?:

Yes

10.

Operation Open From:

1/1/2017

11.

Operation Open To:

12/31/2017

12.

Name of Parent Corporation:

Open Door Community Health Centers

13.

Corporate Business Address:

1275 8th Street

14.

City:

Arcata

15.

State:

16.

Zip:

95521 -

17.

Person Completing Report:

Christopher Peters

18.

Phone No.:

707-826-8633x5132

19.

Fax No.:

707-826-8638

20.

E-mail Address:

cpeters@opendoorhealth.com

30.

Submitted by:

cpeters

31.

Submitted Date and Time:

2/14/2018 12:52:06 PM

Section 2 - Clinic Services

LICENSE CATEGORY (TYPE) (Completed by OSHPD.)

Line No.		(1)
1.	License Category:	Community Clinic

Federally Qualified Health Clinic (FQHC)

Line No.	Federally Qualified Health Clinics	(1)
2.	Indicate clinic type, if applicable:	FQHC

Rural Health Clinic

Line No.	Rural Health Clinic	(1)
3.	Is this a 95-210 Rural Health Clinic?	No

Table 2.1 - Community Services

Check one or more boxes for each service provided.

Line No.	Community Services	(1) Offered
10.	Adult Day Care	No
11.	Child Care	No
12.	Community Education	Yes
13.	Community Nutrition	No
14.	Disaster Relief	No
15.	Environmental Health	No
16.	Homeless	Yes
17.	Legal	No
18.	Outreach	Yes
19.	Social Services	No
20.	Substance Abuse	No
21.	Transportation	No
22.	Vocational Training Placement	No
23.	Other	No

HEALTH SERVICES

Check one or more boxes for each service provided.

Line No.		(1) Offered
100.	Medical
101.	Dental	Yes
102.	Vision
103.	Mental Health (Psychology / Psychiatry / Behavioral health)
104.	Substance Abuse (Alcohol / Drug Services)
105.	Domestic Violence
106.	Basic Lab
107.	Radiological Services
108.	Urgent Care
109.	Pharmacy
110.	Women's Health (Ob-Gyn/Family Planning/Midwives)

Table 2.2 - Languages Spoken By Staff and Patients

Check the staff box if one or more of your staff members speak a listed language. Check the patients box if 100 patients (or more than 1% of your patient population) are best served in a listed language. Estimates are acceptable if exact counts are not available.

Line No.	Language Spoken By	(1) Staff	(2) Patients
30.	Arabic	No	No
31.	Armenian	No	No
32.	Cambodian	No	No
33.	Chinese	No	No
34.	Hindustani	No	No
35.	Hmong	No	No
36.	Japanese	No	No
37.	Korean	No	No
38.	Laotian	No	No
39.	Portuguese	No	No
40.	Punjabi	No	No
41.	Russian	No	No
42.	Sign Language	No	No
43.	Spanish	Yes	Yes
44.	Tagalog	No	No
45.	Vietnamese	No	No

Language Summary

Line No.	Language Summary	(1)
55.	Percentage (%) of patient population best served in a non-English language (round to nearest WHOLE percent):	15%
56.	Primary non-English language spoken by patients (from list above):	Spanish

FTE's and Encounters by Primary Care Provider

Line No.	Primary Care Provider	(1) Salaried FTE's	(4) Total FTE's	(5) No. of Encounters
60.	Physicians	0.00	0.00	0
61.	Physician Assistants	0.00	0.00	0
62.	Family Nurse Practitioners	0.00	0.00	0
63.	Certified Nurse Midwives	0.00	0.00	0
64.	Visiting Nurses	0.00	0.00	0
65.	Dentists	0.60	0.60	2,226
66.	Registered Dental Hygienists (Alternative Practice)	0.00	0.00	0
67.	Psychiatrists	0.00	0.00	0
68.	Clinical Psychologists	0.00	0.00	0
69.	Licensed Clinical Social Workers (LCSW)	0.00	0.00	0
70.	Other Providers billable to Medi-Cal**	0.00	0.00	0
74.	Other Certified CPSP providers not listed above***	0.00	0.00	0
75.	Subtotal	0.60	0.60	2,226

** Other Providers billable to Medi-Cal - Included here are Chiropractors, Physical Therapists, Optometrists and any other professionals who are able to be reimbursed through the Medi-Cal program.

*** Comprehensive Perinatal Services Program - List all other professional not listed above that are certified by the CPSP program to render services and can be reimbursed.

FTE's and Contacts by Clinical Support Staff

Line No.	Clinical Support Staff	(1) Salaried FTE's	(4) Total FTE's	(5) No. of Contacts
80.	Registered Dental Hygienists (not Alternative Practice)	0.00	0.00	0
81.	Registered Dental Assistants	1.59	1.59	0
82.	Dental Assistants - Not licensed	0.00	0.00	0
83.	Marriage and Family Therapists (MFT)	0.00	0.00	0
84.	Registered Nurses	0.00	0.00	0
85.	Licensed Vocational Nurses	0.00	0.00	0
86.	Medical Assistants - Not licensed (1)	0.00	0.00	0
87.	Non-Licensed Patient Education Staff	0.00	0.00	0
88.	Substance Abuse Counselors (2)	0.00	0.00	0
89.	Billing Staff (3)	0.11	0.11
90.	Other Administrative Staff (4)	0.90	0.90
94.	Other Providers not listed above	0.00	0.00
95.	Subtotal	2.60	2.60	0

(1) Also includes Certified Medical Assistants

(2) Does not include substance abuse counseling performed by providers listed elsewhere

(3) Staff must spend 80% of time on billing

(4) Includes Executive Directors, CFO's, Medical & Dental Records staff, Medical & Dental Receptionists & other management staff

Section 3 - Patient Demographics

Race

Line No.	Race	(1) # of Patients
1.	White (include Hispanic)	805
2.	Black	19
3.	Native American / Alaskan Native	12
4.	Asian / Pacific Islander	47
5.	More than one race	29
9.	Other / Unknown	78
10.	Total Patients *	990

Ethnicity

Line No.	Ethnicity	(1) # of Patients
11.	Hispanic	218
12.	Non-Hispanic	718
13.	Unknown	54
15.	Total Patients *	990

Federal Poverty Level

Line No.	Federal Poverty Level	(1) # of Patients
20.	Under 100%	298
21.	100 - 138%	97
22.	139 - 200%	69
23.	201 - 400%	60
24.	Above 400%	2
25.	Unknown	464
26.	Total Patients by Federal Poverty Level *	990

Seasonal Agricultural And Migratory Workers

Line No.	Seasonal Agricultural and Migratory Workers	(1) Number
30.	Total Patients	0
31.	Total Encounters	0

Age Category

Line No.	Age Category	(1) Males	(2) Females
40.	Under 1 year	0	0
41.	1 - 4 years	270	280
42.	5 - 12 years	186	202
43.	13 - 14 years	6	4
44.	15 - 19 years	1	0
45.	20 - 34 years	7	0
46.	35 - 44 years	5	1
47.	45 - 64 years	14	2
48.	65 and over	11	1
55.	Total Patients *	500	490

Patient Coverage

Line No.	Patient Coverage	(1) # of Patients
60.	Medicare	4
61.	Medicare - Managed Care	0
62.	Medi-Cal	735
63.	Medi-Cal - Managed Care	0
64.	County Indigent / CMSP / MISP	0
65.	Private Insurance	38
66.	Covered California	0
67.	Alameda Alliance for Health	0
68.	My Health LA (MHLA)	0
69.	PACE Program	0
70.	Self-Pay / Sliding Fee	213
71.	Free	0
74.	All Other Payers	0
75.	Total Patients *	990

Episodic Programs

Line No.	Episodic Programs	(1) # of Patients
80.	BCCTP	0
81.	CHDP	0
82.
83.	Family PACT	0
84.	Other County Programs	0
85.	Childrens Treatment Program	0
89.	Other Payer - covered by a grant	0
90.	Total Episodic Patients (duplicated)	0

Child Health And Disability Prevention (CHDP)

Line No.	Child Health And Disability Prevention (CHDP)	(1) # of Assessments
95.	CHDP Assessments	0

* Totals for these tables must agree.

Section 4 - Encounters By Principal Diagnosis

Encounters by Principal Diagnosis

Report the diagnosis (or symptom, condition, problem or complaint) as the main reason for the encounter. Do not report the secondary diagnosis(es). There should be only one principal diagnosis for each encounter.

Line
No.

Classification of Diseases and/or Injuries
for each Principal Diagnosis

ICD - 10-CM Codes

(1)
# of Encounters

Infectious and Parasitic Diseases

A00-B99

Neoplasms

C00-D49

Endocrine, Nutritional, and Metabolic Diseases; and Immunity Disorders

E00-E89

Blood and Blood Forming Disorders

D50-D89

Mental, Behavioral, and Neurodevelopment Disorders

F01-F99

Nervous System and Sense Organs Diseases

G00-H95

Circulatory System Diseases

I00-I99

Respiratory System Diseases

J00-J99

Digestive System Diseases, excluding dental diagnosis

K20-K95

10.

Genitourinary System Diseases

N00-N99

11.

Pregnancy, Childbirth & the Puerperium

O00-O9A

12.

Skin and Subcutaneous Tissue Diseases

L00-L99

13.

Musculoskeletal System and Connective Tissue Diseases

M00-M99

14.

Congenital Anomalies

Q00-Q99

15.

Certain Conditions Originating in the Perinatal Period

P00-P96

16.

Symptoms, Signs, and Ill-defined Conditions

R00-R99

17.

Injury and Poisoning

S00-T88

18.

Factors Influencing Health Status and Contact with Health Services

Z00 – Z29, Z40 – Z99

1,273

19.

Dental Diagnosis

K00-K14

953

20.

Family Planning "Z" Codes

Z30 – Z39

21.

Other

All other codes not in lines 1-20

25.

Total

2,226

Section 5 - Encounters By Principal Service

Encounters by Principal Service

Classify each encounter by the principal CPT code that was reported on the billing document for this encounter. Do not report secondary procedures. There should be one and only one procedure code reported for each encounter.

Line No.	Principal Services	CPT Codes - 2012	(1) # of Encounters
1.	Evaluation and Management (new patient)	99201 - 99205	0
2.	Evaluation and Management (established patient)	99211 - 99215	0
3.	Hospital Related Services	99217 – 99226, 99231 - 99239, 99477	0
4.	Consultations	99241 - 99245, 99441 - 99444	0
5.	Other Evaluation and Management Services	99291 - 99292, 99354 - 99360, 99450, 99455 - 99456, 99499	0
6.	Nursing Facility Related Services	99304 - 99318	0
7.	Case Management Services	99363 - 99364, 99366 - 99368	0
8.	Preventive Medicine (infant, child, adolescent)	99381 - 99384, 99391 - 99394, 99461	0
9.	Preventive Medicine (adult)	99385 - 99387, 99395 - 99397	0
10.	Counseling	99401 - 99404, 99406 – 99409, 99411 – 99412, 99420 – 99429, 99605 – 99607	0
	All Other Services
11.	Anesthesia	00100 – 01999, 99100, 99116, 99135, 99140, 99151-99153	0
12.	Integumentary System	10021 - 19499	0
13.	Musculoskeletal System	20005 - 29999	0
14.	Respiratory System	30000 - 32999	0
15.	Cardiovascular System	33010 - 37799	0
16.	Hemic and Lymphatic System	38100 - 38999	0
17.	Mediastinum and Diaphragm System	39000 - 39599	0
18.	Digestive System	40490 - 49999	0
19.	Urinary System	50010 - 53899	0
20.	Male Genital System	54000 - 55920	0
21.	Intersex Surgery	55970, 55980	0
22.	Female Genital System	56405 - 58999	0
23.	Maternal Care and Delivery	59000 - 59899	0
24.	Endocrine System	60000 - 60699	0
25.	Nervous System	61000 - 64999	0
26.	Eye and Ocular Adnexa System	65091 - 68899	0
27.	Auditory System	69000 - 69979	0
28.	Radiology	70010 - 79999	0
29.	Pathology / Laboratory	80047 – 89356, 89398	0
30.	Medicine - Special Services	90281 – 99091, 99170 – 99199	0
31.	Family Planning "Z" Codes	"Z" codes	0
32.	Dental Encounters (CDT codes)	D0100-D0999	2,226
33.	CPT Category III Codes	0042T - 0463T	0
44.	Other	All other codes not in lines 1-33	0
45.	Total		2,226

Selected Procedure Code

Report the number of procedures for each code (or range of codes) regardless of whether it is the principal or secondary procedure code.

Line No.	Evaluation and Management Services	CPT Codes - 2012	(1) # of Procedures
50.	Mammogram	77053-77067	0
51.	HIV Testing	86689, 86701 - 86703, 87390 - 87391	0
52.	Pap Smear	88141 - 88155, 88164 - 88167, 88174 - 88175	0
53.	Contraceptive Management	11976, 55250, 55300, 55400, 55450, 57170, 58300 - 58301, 58600 58605, 58611, 58615, 58670 - 58671	0
	Vaccinations
60.	DTap, DTP, Diphtheria and Tetanus	90389, 90696-90698, 90700 -90702, 90714 - 90715, 90723	0
61.	Hemophilus Influenza B (Hib)	90647, 90645 - 90648	0
62.	Hepatitis A	90632 – 90634, 90636	0
63.	Hepatitis B	90740, 90743 - 90744, 90746 - 90747	0
64.	HepB and Hib	90748	0
65.	Influenza Virus Vaccine	90630, 90654-90658, 90660-90662, 90664, 90666-90668, 90685-90688	0
66.	Measles, Mumps and Rubella (MMR) and Varicella (MMRV)	90705-90708, 90710, 90716	0
67.	Pneumococcal	90669 - 90670, 90732	0
68.	Poliovirus	90713	0
69.	Varicella	90396, 90716	0

Section 6 - Revenue and Utilization by Payer

Revenue and Utilization by Payment Source

(Do not put any "$" signs, commas or decimals, round up to whole dollar)

Line No.		(1) Medicare	(2) Medicare Managed	(3) Medi-Cal	(4) Medi-Cal Managed	(5) County/ CMSP/MISP	(6) Private Insurance
1.	Encounters	0	0	1,928	0	0	27

2.	Gross Revenue (Charges at 100% Rate)	$0	$0	$331,932	$0	$0	$4,771
3.	Sliding Fee Scale Write-offs	$0	$0				$413
4.	Free/Complimentary Write-offs
5.	Contractual Adjustments	$0	$0	$33,070	$0	$0	$498
6.	Bad Debts	$0	$0				$0
7.	Grants (see Section 7)
8.	Other Adjustments	$0	$0	$0	$0	$0	$0
9.	Reconciliation	$0	$0	$0	$0	$0
10.	Total Write-offs & Adjustments (sum lines 3 through 9)	$0	$0	$33,070	$0	$0	$911
15.	Net Patient Revenue (collected) (line 2 – line 10)	$0	$0	$298,862	$0	$0	$3,860

*Include LIHP encounters under County Indigent/CMSP/MISP

Line No.		(7) Covered California	(8) Self-Pay/ Sliding Fee	(9) Free	(10) Breast Cancer*	(11) CHDP
1.	Encounters	0	271	0	0	0

2.	Gross Revenue (Charges at 100% Rate)	$0	$1,051	$0	$0	$0
3.	Sliding Fee Scale Write-offs	$0	$155
4.	Free/Complimentary Write-offs			$0
5.	Contractual Adjustments	$0			$0	$0
6.	Bad Debts	$0	$0
7.	Grants (see Section 7)
8.	Other Adjustments	$0	$0		$0	$0
9.	Reconciliation
10.	Total Write-offs & Adjustments (sum lines 3 through 9)	$0	$155	$0	$0	$0
15.	Net Patient Revenue (collected) (line 2 – line 10)	$0	$896	$0	$0	$0

* These include the following:
Breast Cancer Early Detection Program
Breast Cancer & Cervical Cancer Control Program

Line No.		(13) Family PACT	(14) PACE Program**	(15) My Health LA (MHLA)	(16) Alameda Alliance	(17) Other County	(18) All Other Payers
1.	Encounters	0	0	0	0	0	0

2.	Gross Revenue (Charges at 100% Rate)	$0	$0	$0	$0	$0	$0
3.	Sliding Fee Scale Write-offs					$0	$0
4.	Free/Complimentary Write-offs						$0
5.	Contractual Adjustments	$0		$0	$0	$0	$0
6.	Bad Debts					$0	$0
7.	Grants (see Section 7)
8.	Other Adjustments	$0	$0	$0	$0	$0	$0
9.	Reconciliation		$0	$0	$0	$0	$0
10.	Total Write-offs & Adjustments (sum lines 3 through 9)	$0	$0	$0	$0	$0	$0
15.	Net Patient Revenue (collected) (line 2 – line 10)	$0	$0	$0	$0	$0	$0

** Report number of patients on Line 1 for the PACE Program

Line No.		(19) Grand Totals
1.	Encounters	2,226

2.	Gross Revenue (Charges at 100% Rate)	$337,754
3.	Sliding Fee Scale Write-offs	$568
4.	Free/Complimentary Write-offs	$0
5.	Contractual Adjustments	$33,568
6.	Bad Debts	$0
7.	Grants (see Section 7)
8.	Other Adjustments	$0
9.	Reconciliation	$0
10.	Total Write-offs & Adjustments (sum lines 3 through 9)	$34,136
15.	Net Patient Revenue (collected) (line 2 – line 10)	$303,618

Section 7 - Income Statement

Income Statement

(Do not input any "$" signs, commas or decimals, round up to whole dollar.)

Line No.	Revenue	(1)
1.	Gross Patient Revenue (from Sec 6, line 2, column 19)	$337,754
2.	Total Write-offs and Adjustments (from Sec 6, line 10, column 19)	$34,136
3.	Net Patient Revenue (from Sec 6, line 15, column 19)	$303,618
Other Operating Revenue
4.	Federal Funds - Grants - all others (e.g. 330 funds)	$14,995
400.	Federal Stimulus Grants - American Recovery and Reinvestment Act (ARRA)
401.	Federal Funds - New Access Point (NAP)	$0
402.	Federal Funds - Increased Demand for Services (IDS)	$0
403.	Federal Funds - Capital Improvement Project (CIP)
	State Funds
6.	Other	$2,823
	County Funds
10.	Other County Grant Programs	$47
11.	Local (City or District) Funds	$0
12.	Private	$10,032
13.	Donations/Contributions	$1,386
19.	Other	$188,227
20.	Total Other Operating Revenue (Sum lines 4 through 19)	$217,510
25.	Total Operating Revenue (line 3 + line 20)	$521,128
Operating Expenses
30.	Salaries, Wages, and Emplyee Benefits	$316,028
31.	Contract Services - Professional	$0
32.	Supplies - Medical and Dental	$150,226
33.	Supplies - Office	$6,299
34.	Outside Patient Care Services	$0
35.	Rent / Depreciation / Mortgage Interest	$46,804
36.	Utilities	$1,120
37.	Professional Liability Insurance	$1,163
38.	Other Insurance	$1,508
39.	Continuing Education	$38
40.	Information Technology (including EHR)	$8,324
44.	All Other Expenses	$24,248
45.	Total Operating Expenses (Sum lines 30 through 44)	$555,758
50.	Net from Operations (line 25 - line 45)	-$34,630

Section 8 - Major Capital Expenditures

Section 127285(3) of the Health and Safety Code requires each clinic to report "acquisitions of diagnostic or therapeutic equipment during the reporting period with a value in excess of five hundred thousand dollars ($500,000)."

Diagnostic and Therapeutic Equipment Acquired During The Report Period

Line No.		(1)
1.	Did your clinic acquire any diagnostic or therapeutic equipment that had a value in excess of $500,000? (If 'Yes', fill out lines 2 through 11, as necessary, below.)	No

Diagnostic and Therapeutic Equipment Detail

Line No.	(1) Description of Equipment	(2) Value	(3) Date of Aquisition MM/DD/YYYY	(4) Means of Acquisition
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.

Building Projects Commenced During Report Period Costing Over $1,000,000

Section 127285(4) of the Health and Safety Code requires each clinic to report the "commencement of projects during the reporting period that require a capital expenditure for the facility or clinic in excess of one million dollars ($1,000,000)."

Line No.		(1)
25.	Did your clinic commence any building projects during the report period which will require an aggregate capital expenditure exceeding $1,000,000? (If 'Yes', fill out lines 26 through 30, as necessary, below.)	No

Detail of Capital Expenditures

Line No.	(1) Description of Project	(2) Projected Total Capital Expenditure	(3) OSHPD Project No. (if applicable)
26.
27.
28.
29.
30.

Capital Fund

Line No.	Capital Fund	(1)
40.	Beginning Fund Balance
41.	Current Year Contribution
42.	Current Year Interest Earnings
43.	Current Year Expenditures
44.	Ending Fund Balance (line 40 + line 41 + line 42 - line 43)	$0

General Comments:

Errors and Warnings