Survey Info.

Annual Utilization Report of Primary Care Clinic
Facility Name:	TELEHEALTH AND VISITING SPECIALIST CENTER
OSHPD ID:	306124030	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:

TELEHEALTH AND VISITING SPECIALIST CENTER

OSHPD ID Number:

306124030

Street Address:

2426 BUHNE ST

City:

EUREKA

Zip:

95501

Facility Phone No.:

(707) 443 - 4666 ext.

Administrator Name:

Thomas Steenblock

Administrator E-mail Address:

tsteenblock@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 2:47:57 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	Yes
14.	Disaster Relief	No
15.	Environmental Health	No
16.	Homeless	Yes
17.	Legal	No
18.	Outreach	Yes
19.	Social Services	Yes
20.	Substance Abuse	Yes
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	Yes
101.	Dental
102.	Vision
103.	Mental Health (Psychology / Psychiatry / Behavioral health)	Yes
104.	Substance Abuse (Alcohol / Drug Services)	Yes
105.	Domestic Violence
106.	Basic Lab	Yes
107.	Radiological Services
108.	Urgent Care	Yes
109.	Pharmacy
110.	Women's Health (Ob-Gyn/Family Planning/Midwives)	Yes

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):	6%
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	4.23	4.23	13,776
61.	Physician Assistants	0.56	0.56	1,335
62.	Family Nurse Practitioners	1.13	1.13	1,188
63.	Certified Nurse Midwives	0.00	0.00	0
64.	Visiting Nurses	0.00	0.00	0
65.	Dentists	0.00	0.00	0
66.	Registered Dental Hygienists (Alternative Practice)	0.00	0.00	0
67.	Psychiatrists	1.05	1.05	2,630
68.	Clinical Psychologists	0.00	0.00	0
69.	Licensed Clinical Social Workers (LCSW)	0.76	0.76	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	7.73	7.73	18,929

** 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	0.00	0.00	0
82.	Dental Assistants - Not licensed	0.00	0.00	0
83.	Marriage and Family Therapists (MFT)	0.51	0.51	0
84.	Registered Nurses	8.18	8.18	1,836
85.	Licensed Vocational Nurses	0.95	0.95	0
86.	Medical Assistants - Not licensed (1)	16.71	16.71	0
87.	Non-Licensed Patient Education Staff	0.00	0.00	0
88.	Substance Abuse Counselors (2)	1.10	1.10	0
89.	Billing Staff (3)	2.19	2.19
90.	Other Administrative Staff (4)	22.11	22.11
94.	Other Providers not listed above	0.00	0.00
95.	Subtotal	51.75	51.75	1,836

(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)	5,017
2.	Black	83
3.	Native American / Alaskan Native	81
4.	Asian / Pacific Islander	292
5.	More than one race	37
9.	Other / Unknown	210
10.	Total Patients *	5,720

Ethnicity

Line No.	Ethnicity	(1) # of Patients
11.	Hispanic	334
12.	Non-Hispanic	5,266
13.	Unknown	120
15.	Total Patients *	5,720

Federal Poverty Level

Line No.	Federal Poverty Level	(1) # of Patients
20.	Under 100%	511
21.	100 - 138%	217
22.	139 - 200%	225
23.	201 - 400%	302
24.	Above 400%	129
25.	Unknown	4,336
26.	Total Patients by Federal Poverty Level *	5,720

Seasonal Agricultural And Migratory Workers

Line No.	Seasonal Agricultural and Migratory Workers	(1) Number
30.	Total Patients	13
31.	Total Encounters	46

Age Category

Line No.	Age Category	(1) Males	(2) Females
40.	Under 1 year	0	0
41.	1 - 4 years	0	2
42.	5 - 12 years	11	3
43.	13 - 14 years	4	4
44.	15 - 19 years	16	29
45.	20 - 34 years	358	601
46.	35 - 44 years	379	508
47.	45 - 64 years	1,091	1,166
48.	65 and over	707	841
55.	Total Patients *	2,566	3,154

Patient Coverage

Line No.	Patient Coverage	(1) # of Patients
60.	Medicare	1,920
61.	Medicare - Managed Care	0
62.	Medi-Cal	161
63.	Medi-Cal - Managed Care	1,770
64.	County Indigent / CMSP / MISP	0
65.	Private Insurance	1,555
66.	Covered California	116
67.	Alameda Alliance for Health	0
68.	My Health LA (MHLA)	0
69.	PACE Program	0
70.	Self-Pay / Sliding Fee	194
71.	Free	0
74.	All Other Payers	4
75.	Total Patients *	5,720

Episodic Programs

Line No.	Episodic Programs	(1) # of Patients
80.	BCCTP	1
81.	CHDP	2
82.
83.	Family PACT	3
84.	Other County Programs	0
85.	Childrens Treatment Program	0
89.	Other Payer - covered by a grant	0
90.	Total Episodic Patients (duplicated)	6

Child Health And Disability Prevention (CHDP)

Line No.	Child Health And Disability Prevention (CHDP)	(1) # of Assessments
95.	CHDP Assessments	6

* 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

935

Neoplasms

C00-D49

107

Endocrine, Nutritional, and Metabolic Diseases; and Immunity Disorders

E00-E89

1,441

Blood and Blood Forming Disorders

D50-D89

Mental, Behavioral, and Neurodevelopment Disorders

F01-F99

6,677

Nervous System and Sense Organs Diseases

G00-H95

1,458

Circulatory System Diseases

I00-I99

1,497

Respiratory System Diseases

J00-J99

825

Digestive System Diseases, excluding dental diagnosis

K20-K95

358

10.

Genitourinary System Diseases

N00-N99

581

11.

Pregnancy, Childbirth & the Puerperium

O00-O9A

12.

Skin and Subcutaneous Tissue Diseases

L00-L99

473

13.

Musculoskeletal System and Connective Tissue Diseases

M00-M99

1,859

14.

Congenital Anomalies

Q00-Q99

15.

Certain Conditions Originating in the Perinatal Period

P00-P96

16.

Symptoms, Signs, and Ill-defined Conditions

R00-R99

1,402

17.

Injury and Poisoning

S00-T88

269

18.

Factors Influencing Health Status and Contact with Health Services

Z00 – Z29, Z40 – Z99

832

19.

Dental Diagnosis

K00-K14

20.

Family Planning "Z" Codes

Z30 – Z39

21.

Other

All other codes not in lines 1-20

25.

Total

18,929

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	2,529
2.	Evaluation and Management (established patient)	99211 - 99215	14,237
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	4
9.	Preventive Medicine (adult)	99385 - 99387, 99395 - 99397	141
10.	Counseling	99401 - 99404, 99406 – 99409, 99411 – 99412, 99420 – 99429, 99605 – 99607	39
	All Other Services
11.	Anesthesia	00100 – 01999, 99100, 99116, 99135, 99140, 99151-99153	0
12.	Integumentary System	10021 - 19499	29
13.	Musculoskeletal System	20005 - 29999	4
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	11
28.	Radiology	70010 - 79999	0
29.	Pathology / Laboratory	80047 – 89356, 89398	503
30.	Medicine - Special Services	90281 – 99091, 99170 – 99199	541
31.	Family Planning "Z" Codes	"Z" codes	0
32.	Dental Encounters (CDT codes)	D0100-D0999	0
33.	CPT Category III Codes	0042T - 0463T	0
44.	Other	All other codes not in lines 1-33	891
45.	Total		18,929

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	19
52.	Pap Smear	88141 - 88155, 88164 - 88167, 88174 - 88175	2
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	458
61.	Hemophilus Influenza B (Hib)	90647, 90645 - 90648	0
62.	Hepatitis A	90632 – 90634, 90636	147
63.	Hepatitis B	90740, 90743 - 90744, 90746 - 90747	120
64.	HepB and Hib	90748	0
65.	Influenza Virus Vaccine	90630, 90654-90658, 90660-90662, 90664, 90666-90668, 90685-90688	381
66.	Measles, Mumps and Rubella (MMR) and Varicella (MMRV)	90705-90708, 90710, 90716	0
67.	Pneumococcal	90669 - 90670, 90732	591
68.	Poliovirus	90713	0
69.	Varicella	90396, 90716	1

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	5,907	0	193	8,354	0	3,726

2.	Gross Revenue (Charges at 100% Rate)	$1,028,049	$0	$26,890	$1,457,251	$0	$625,012
3.	Sliding Fee Scale Write-offs	$105	$0				$2,181
4.	Free/Complimentary Write-offs
5.	Contractual Adjustments	$99,456	$0	-$9,003	$220,737	$0	$176,640
6.	Bad Debts	$0	$0				$805
7.	Grants (see Section 7)
8.	Other Adjustments	$0	$0	$0	$0	$0	$0
9.	Reconciliation	-$16,971	$0	$0	-$2,453	$0
10.	Total Write-offs & Adjustments (sum lines 3 through 9)	$82,590	$0	-$9,003	$218,284	$0	$179,626
15.	Net Patient Revenue (collected) (line 2 – line 10)	$945,459	$0	$35,893	$1,238,967	$0	$445,386

*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	300	439	0	1	2

2.	Gross Revenue (Charges at 100% Rate)	$47,988	$77,175	$0	$282	$423
3.	Sliding Fee Scale Write-offs	$77	$54,397
4.	Free/Complimentary Write-offs			$0
5.	Contractual Adjustments	$20,303			$281	$233
6.	Bad Debts	$151	$179
7.	Grants (see Section 7)
8.	Other Adjustments	$0	$0		$0	$0
9.	Reconciliation
10.	Total Write-offs & Adjustments (sum lines 3 through 9)	$20,531	$54,576	$0	$281	$233
15.	Net Patient Revenue (collected) (line 2 – line 10)	$27,457	$22,599	$0	$1	$190

* 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	3	0	0	0	0	4

2.	Gross Revenue (Charges at 100% Rate)	$294	$0	$0	$0	$0	$342
3.	Sliding Fee Scale Write-offs					$0	$95
4.	Free/Complimentary Write-offs						$0
5.	Contractual Adjustments	$233		$0	$0	$0	$247
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)	$233	$0	$0	$0	$0	$342
15.	Net Patient Revenue (collected) (line 2 – line 10)	$61	$0	$0	$0	$0	$0

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

Line No.		(19) Grand Totals
1.	Encounters	18,929

2.	Gross Revenue (Charges at 100% Rate)	$3,263,706
3.	Sliding Fee Scale Write-offs	$56,855
4.	Free/Complimentary Write-offs	$0
5.	Contractual Adjustments	$509,127
6.	Bad Debts	$1,135
7.	Grants (see Section 7)
8.	Other Adjustments	$0
9.	Reconciliation	-$19,424
10.	Total Write-offs & Adjustments (sum lines 3 through 9)	$547,693
15.	Net Patient Revenue (collected) (line 2 – line 10)	$2,716,013

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)	$3,263,706
2.	Total Write-offs and Adjustments (from Sec 6, line 10, column 19)	$547,693
3.	Net Patient Revenue (from Sec 6, line 15, column 19)	$2,716,013
Other Operating Revenue
4.	Federal Funds - Grants - all others (e.g. 330 funds)	$1,787,200
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	$42,866
	County Funds
10.	Other County Grant Programs	$712
11.	Local (City or District) Funds	$0
12.	Private	$160,056
13.	Donations/Contributions	$22,115
19.	Other	$3,308,419
20.	Total Other Operating Revenue (Sum lines 4 through 19)	$5,321,368
25.	Total Operating Revenue (line 3 + line 20)	$8,037,381
Operating Expenses
30.	Salaries, Wages, and Emplyee Benefits	$5,212,809
31.	Contract Services - Professional	$13,759
32.	Supplies - Medical and Dental	$1,985,901
33.	Supplies - Office	$151,723
34.	Outside Patient Care Services	$0
35.	Rent / Depreciation / Mortgage Interest	$394,262
36.	Utilities	$125,631
37.	Professional Liability Insurance	$4,885
38.	Other Insurance	$8,770
39.	Continuing Education	$26,969
40.	Information Technology (including EHR)	$291,382
44.	All Other Expenses	$215,813
45.	Total Operating Expenses (Sum lines 30 through 44)	$8,431,904
50.	Net from Operations (line 25 - line 45)	-$394,523

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