|
| 1. | Facility Name: | OPEN DOOR - MCKINLEYVILLE |
| 2. | OSHPD ID Number: | 306124017 |
| 3. | Street Address: | 1644 CENTRAL AVENUE, SUITE F |
| | |
| 4. | City: | MCKINLEYVILLE |
| 5. | Zip: | 95519 |
| 6. | Facility Phone No.: | (707) 839 - 3068 ext. |
| 7. | Administrator Name: | HERRMANN SPETZLER |
| 8. | Administrator E-mail Address: | HSPETZLER@OPENDOORHEALTH.COM |
| 9. | Was this clinic in operation at any time during the year?: | Yes |
| 10. | Operation Open From: | 1/1/2003 |
| 11. | Operation Open To: | 12/31/2003 |
| 12. | Name of Parent Corporation: | OPEN DOOR COMMUNITY HEALTH CENTERS |
| 13. | Corporate Business Address: | 785 18TH STREET
|
| 14. | City: | ARCATA |
| 15. | State: | CA |
| 16. | Zip: | 95521 - 6210 |
| 17. | Person Completing Report: | Alan Moreno |
| 18. | Phone No.: | 916-323-6904 |
| 19. | Fax No.: | 916-322-1442 |
| 20. | E-mail Address: | amoreno@oshpd.state.ca.us |
| 30. | Submitted by: | amoreno |
| 31. | Submitted Date and Time: | 3/7/2005 3:02:21 PM |
|
| Federally Qualified Health Clinic (FQHC) |
Line
No. | Federally Qualified Health Clinics and Rural Clinics | (1) |
|---|
| 2. | Indicate clinic type, if applicable: | FQHC |
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| Rural Health Clinic |
Line
No. | Rural Health Clinic | (1) |
|---|
| 3. | Is this a 95-210 Rural Health Clinic? | Yes |
|
|
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 | No | | 17. | Legal | No | | 18. | Outreach | No | | 19. | Social Services | No | | 20. | Substance Abuse | No | | 21. | Transportation | No | | 22. | Vocational Training Placement | No | | 23. | Other (See Survey) | No |
| | Table 2.2 - Languages Spoken By Check the staff box if one or more staff members speaks the 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. | Portugese | No | No | | 40. | Punjabi | No | No | | 41. | Russian | No | No | | 42. | Sign Language | No | No | | 43. | Spanish | No | No | | 44. | Tagalog | No | No | | 45. | Vietnamese | No | No |
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|
| | Language Summary | Line
No. | Language Summary | (1) |
|---|
| 55. | Percentage (%) of patient population best served in a non-English language: | 0% | | 56. | Primary non-English language spoken by patients (from list above): | Select primary language |
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| FTE's and Encounters by Primary Care Provider |
Line
No. | Primary Care Provider | (1)
Salaried
FTE's | (2)
Contract
FTE's | (3)
Volunteer
FTE's | (4)
Total
FTE's
| (5)
No. of
Encounters
|
|---|
| 60. | Physicians | 1.46 | 0.00 | 0.00 | 1.46 | 4,722 | | 61. | Physician Assistants | 0.06 | 0.00 | 0.00 | 0.06 | 203 | | 62. | Family Nurse Practitioners | 1.13 | 0.00 | 0.00 | 1.13 | 3,081 | | 63. | Certified Nurse Midwives | 0.00 | 0.00 | 0.00 | 0.00 | 0 | | 64. | Visiting Nurses | 0.00 | 0.00 | 0.00 | 0.00 | 0 | | 65. | Dentists | 0.00 | 0.00 | 0.00 | 0.00 | 0 | | 66. | Registered Dental Hygienists | 0.00 | 0.00 | 0.00 | 0.00 | 0 | | 67. | Psychiatrist | 0.00 | 0.00 | 0.00 | 0.00 | 0 | | 68. | Clinical Psychologist | 0.00 | 0.00 | 0.00 | 0.00 | 0 | | 69. | Licensed Clinical Social Worker (LCSW) | 0.00 | 0.00 | 0.00 | 0.00 | 0 | | 70. | Marriage, Family and Child Counselors (MFCC) | 0.00 | 0.00 | 0.00 | 0.00 | 0 | | 71. | Other Profiders billable to Medi-Cal** | 0.00 | 0.00 | 0.00 | 0.00 | 0 | | 74. | Other Certified CPSP prividers not listed above*** | 0.00 | 0.00 | 0.00 | 0.00 | 0 | | 75. | Subtotal | 2.65 | 0.00 | 0.00 | 2.65 | 8,006 |
|
| ** Other Provider billable to Medi-Cal - Included here are Chiropractors, Physical Therapists, Optometrists, Acupuncturists and any other professional who is 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 Primary Care Provider |
Line
No. | Primary Care Provider | (1)
Salaried
FTE's | (2)
Contract
FTE's | (3)
Volunteer
FTE's | (4)
Total
FTE's
| (5)
No. of
Contacts
|
|---|
| 80. | Registered Dental Assistants | 0.00 | 0.00 | 0.00 | 0.00 | 0 | | 81. | Registered Nurses | 0.00 | 0.00 | 0.00 | 0.00 | 0 | | 82. | Licensed Vocational Nurses | 0.00 | 0.00 | 0.00 | 0.00 | 0 | | 83. | Non-Licensed Patient Education Staff | 0.00 | 0.00 | 0.00 | 0.00 | 0 | | 89. | Other Providers not listed above | 0.00 | 0.00 | 0.00 | 0.00 | 0 | | 90. | Subtotal | 0.00 | 0.00 | 0.00 | 0.00 | 0 |
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|
| Race |
Line
No. | Race | (1)
# of
Patients |
|---|
| 1. | White (include Hispanic) | 2,079 | | 2. | Black | 12 | | 3. | Native American / Alaskan Native | 37 | | 4. | Asian / Pacific Islander | 13 | | 9. | Other / Unknown | 1,432 | | 10. | Total Patients * | 3,573 |
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|
| Ethnicity |
Line
No. | Ethnicity | (1)
# of
Patients |
|---|
| 11. | Hispanic | 35 | | 12. | Non-Hispanic | 2,106 | | 13. | Unknown | 1,432 | | 15. | Total Patients * | 3,573 |
|
| Federal Poverty Level |
Line
No. | Federal Poverty Level | (1)
# of
Patients |
|---|
| 20. | Under 100% | 929 | | 21. | 100 - 200% | 429 | | 22. | Above 200% | 215 | | 23. | Unknown | 2,000 | | 24. | Total Patients * | 3,573 |
|
|
Seasonal Agricultural And Migratory Workers Line
No. | Seasonal Agricultural and Migratory Workers | (1)
# |
|---|
| 30. | Total Patients | 0 | | 31. | Total Encounters | 0 |
|
|
| Age Category |
Line
No. | Age Category | (1)
Males | (2)
Females |
|---|
| 40. | Under 1 year | 22 | 14 | | 41. | 1 - 4 years | 71 | 65 | | 42. | 5 - 12 years | 130 | 128 | | 43. | 13 - 14 years | 41 | 54 | | 44. | 15 - 19 years | 124 | 324 | | 45. | 20 - 34 years | 415 | 650 | | 46. | 35 - 44 years | 257 | 334 | | 47. | 45 - 64 years | 331 | 430 | | 48. | 65 and over | 69 | 114 | | 55. | Total Patients * | 1,460 | 2,113 |
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|
| Patient Coverage |
Line
No. | Patient Coverage | (1)
# of
Patients |
|---|
| 60. | Medicare | 313 | | 61. | Medicare - Managed Care | 0 | | 62. | Medi-Cal | 911 | | 63. | Medi-Cal - Managed Care | 0 | | 64. | County Indigent / CMSP / MISP | 198 | | 65. | Healthy Families | 39 | | 66. | Private Insurance | 1,073 | | 67. | Alameda Alliance for Health | 0 | | 68. | LA Co. Public Private Partnership | 0 | | 69. | San Diego Co. Medical Plan | 0 | | 70. | Self-Pay / Sliding Fee | 1,039 | | 71. | Free | 0 | | 74. | All Other Payers | 0 | | 75. | Total Patients * | 3,573 |
|
|
| Episodic Programs |
Line
No. | Episodic Programs | (1)
# of
Patients |
|---|
| 80. | BCCCP | 23 | | 81. | CHDP | 31 | | 82. | EAPC | 380 | | 83. | Family PACT | 504 | | 84. | Other County Programs | 0 | | 85. | Childrens Treatment Program | 0 | | 89. | Other Payer - covered by a grant | 0 | | 90. | Total Episodic Patients (duplicated) | 938 |
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|
| Child Health And Disability Prevention (CHDP) |
Line
No. | Child Health And Disability Prevention (CHDP) | (1)
# of
Assessments |
|---|
| 95. | CHDP Assessments | 197 |
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|
| 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-9-CM Codes | (1)
# of Encounters |
|---|
| 1. | Infectious and Parasitic Diseases | 001 - 139 | 340 | | 2. | Neoplasms | 140 - 239 | 64 | | 3. | Endocrine, Nutritional, and Metabolic Diseases; and Immunity Disorders | 240 - 279 | 548 | | 4. | Blood and Blood Forming Disorders | 280 - 289 | 27 | | 5. | Mental Disorders | 290 - 319 | 489 | | 6. | Nervous System and Sense Organs Diseases | 320 - 389 | 560 | | 7. | Circulatory System Diseases | 390 - 453 | 259 | | 8. | Respiratory System Diseases | 460 - 519 | 1,120 | | 9. | Digestive System Diseases | 520 - 579 | 185 | | 10. | Genitourinary System Diseases | 580 - 629 | 266 | | 11. | Pregnancy, Childbirth & the Puerperium | 630 - 679 | 3 | | 12. | Skin and Subcutaneous Tissue Diseases | 680 - 709 | 448 | | 13. | Musculoskeletal System and Connective Tissue Diseases | 710 - 739 | 1,026 | | 14. | Congenital Anomalies | 740 - 759 | 8 | | 15. | Certain Conditions Originating in the Perinatal Period | 760 - 779 | 0 | | 16. | Symptoms, Signs, and Ill-defined Conditions | 780 - 799 | 594 | | 17. | Injury and Poisoning | 800 - 999 | 282 | | 18. | Factors Influencing Health Status and Contact with Health Services | V01 - V82 | 829 | | 19. | Dental Diagnosis | | 0 | | 20. | Family Planning S-Codes | | 958 | | 21. | Other | | 0 | | 25. | Total | | 8,006 |
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|
| Encounters by Principal Service |
| Classify each encounter by the primary 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. | Evaluation and Management Services | CPT Codes - 2003 | (1)
# of
Encounters |
|---|
| 1. | Evaluation and Management (new patient) | 99201 - 99205 | 831 | | 2. | Evaluation and Management (established patient) | 99211 - 99215 | 6,659 | | 3. | Hospital Related Services | 99217 - 99239 | 0 | | 4. | Consultations | 99241 - 99275 | 0 | | 5. | Other Evaluation and Management Services | 99281 - 99285
99354 - 99360
99420 - 99429
99450 - 99456
99499 | 0 | | 6. | Nursing Facility Related Services | 99301 - 99316 | 0 | | 7. | Case Management Services | 99361 - 99373 | 0 | | 8. | Preventive Medicine (infant, child, adolescent) | 99381 - 99384
99391 - 99394
99431 - 99440 | 197 | | 9. | Preventive Medicine (adult) | 99385 - 99387
99395 - 99397 | 212 | | 10. | Counseling | 99401 - 99412 | 0 | | All Other Services | | | | 11. | Anesthesia | 00100 - 01999 | 0 | | 12. | Integumentary System | 10021 - 19499 | 63 | | 13. | Musculoskeletal System | 20000 - 29999 | 3 | | 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 | 2 | | 19. | Urinary System | 50010 - 53899 | 0 | | 20. | Male Genital System | 54000 - 55899 | 5 | | 21. | Intersex Surgery | 55970, 55980 | 0 | | 22. | Female Genital System | 56405 - 58999 | 3 | | 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 - 69990 | 0 | | 28. | Radiology | 70010 - 79999 | 0 | | 29. | Pathology / Laboratory | 80048 - 89399 | 0 | | 30. | Medicine - Special Services | 90281 - 99199 | 0 | | 31. | Family Planning "Z" Codes | "Z" codes | 31 | | 32. | Dental Encounters | all CDT codes | 0 | | 33. | Category III Codes | 0001T - 0044T | 0 | | 44. | Any other encounters | | 0 | | 45. | Total | | 8,006 |
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|
| Selected Procedure Code |
Report the number of procedures for each code (or range of codes) regardless of whether it is the primary or subsequent procedure code.Line
No. | Evaluation and Management Services | CPT Codes - 2003 | (1)
# of
Procedures |
|---|
| 50. | Mammogram | 76085, 76090 - 76092 | 0 | | 51. | HIV Testing | 86701 - 86703
86689
87390 - 87391 | 218 | | 52. | Pap Smear | 88141 - 88155
88164 - 88167
88174 - 88175 | 240 | | 53. | Contraceptive Management | 11975 - 11977
55250, 55450, 57170,
58300 - 58301
58600 - 58611 | 4 | | Vaccinations | | | | 60. | Diphtheria, Tetanus, and Pertussis (DTP) | 90701, 90718, 90700 | 180 | | 61. | Hemophilus Influenza B (Hib) | 90645 - 90648 | 4 | | 62. | Hepatitis A | 90633 - 90636 | 38 | | 63. | Hepatitis B or HepB-HIB | 90740 - 90747 | 193 | | 64. | HepB and Hib | 90748 | 18 | | 65. | Influenza Virus Vaccine | 90657 - 90660 | 224 | | 66. | Measles, Mumps and Rubella (MMR) | 90707 | 63 | | 67. | Pneumococcal | 90669 | 63 | | 68. | Poliovirus | 90712 - 90713 | 53 | | 69. | Varicella | 90716 | 25 |
|
|
|
Line
No. | | (1)
Medicare | (2)
Medicare
Managed | (3)
Medi-Cal | (4)
Medi-Cal
Managed | (5)
County/
CMSP/MISP | (6)
Healthy
Families |
|---|
| 1. | Encounters | 1,131 | 0 | 2,295 | 0 | 521 | 89 |  | | 2. | Gross Revenue
(Charges at 100% Rate) | $75,989 | $0 | $168,616 | $0 | $37,182 | $6,557 | | 3. | Sliding Fee Scale
Write-offs | $0 | $0 | $0 | $0 | $0 | $0 | | 4. | Free/Complimentary
Write-offs | $0 | $0 | $0 | $0 | $0 | $0 | | 5. | Contractual Adjustments | -$28,289 | $0 | -$80,092 | $0 | -$18,780 | $2,678 | | 6. | Bad Debts | $0 | $0 | $0 | $0 | $0 | $0 | | 7. | Grants
enter positive numbers | | | | | ( $0 ) | ( $0 ) | | 8. | Other Adjustments | $0 | $0 | $0 | $0 | $0 | $0 | | 9. | Reconciliation | $0 | $0 | $0 | $0 | $0 | $0 | | 10. | Total Write-offs &
Adjustments
(sum lines 3 through 9) | -$28,289 | $0 | -$80,092 | $0 | -$18,780 | $2,678 | | 15. | Net Patient Revenue (collected) | $104,278 | $0 | $248,708 | $0 | $55,962 | $3,879 |
|
|
Line
No. | | (7)
Private
Insurance | (8)
Self-Pay/
Sliding Fee | (9)
Free | (10)
Breast
Cancer* | (11)
CHDP | (12)
EAPC |
|---|
| 1. | Encounters | 1,601 | 1,007 | 0 | 25 | 32 | 380 | | | 2. | Gross Revenue
(Charges at 100% Rate) | $122,701 | $74,734 | $0 | $2,225 | $4,053 | $28,173 | | 3. | Sliding Fee Scale
Write-offs | $0 | $30,166 | | $0 | $0 | $12,304 | | 4. | Free/Complimentary
Write-offs | $0 | $0 | $0 | $0 | $0 | $0 | | 5. | Contractual Adjustments | $37,673 | $0 | | $1,139 | $2,748 | $4,560 | | 6. | Bad Debts | $0 | $2,473 | | $0 | $0 | $0 | | 7. | Grants
enter positive numbers | ( $0 ) | ( $0 ) | | ( $0 ) | ( $0 ) | ( $27,170 ) | | 8. | Other Adjustments | $0 | $0 | | $0 | $0 | $0 | | 9. | Reconciliation | $0 | $0 | | $0 | $0 | $0 | | 10. | Total Write-offs &
Adjustments
(sum lines 3 through 9) | $37,673 | $32,639 | $0 | $1,139 | $2,748 | -$10,306 | | 15. | Net Patient Revenue (collected) | $85,028 | $42,095 | $0 | $1,086 | $1,305 | $38,479 |
|
* These include the following:
Breast Cancer Early Detection Program
Breast Cancer & Cervical Cancer Control Program |
|
Line
No. | | (13)
Family
PACT | (14)
San Diego
Med Plan | (15)
LA County
Partnership | (16)
Alameda
Alliance | (17)
Other
County | (18)
All Other
Payers |
|---|
| 1. | Encounters | 925 | 0 | 0 | 0 | 0 | 0 | | | 2. | Gross Revenue
(Charges at 100% Rate) | $90,930 | $0 | $0 | $0 | $0 | $0 | | 3. | Sliding Fee Scale
Write-offs | $0 | $0 | $0 | $0 | $0 | $0 | | 4. | Free/Complimentary
Write-offs | $0 | $0 | $0 | $0 | $0 | $0 | | 5. | Contractual Adjustments | $39,366 | $0 | $0 | $0 | $0 | $0 | | 6. | Bad Debts | $0 | $0 | $0 | $0 | $0 | $0 | | 7. | Grants
enter positive numbers | ( $0 ) | ( $0 ) | ( $0 ) | ( $0 ) | ( $0 ) | ( $0 ) | | 8. | Other Adjustments | $0 | $0 | $0 | $0 | $0 | $0 | | 9. | Reconciliation | $0 | $0 | $0 | $0 | $0 | $0 | | 10. | Total Write-offs &
Adjustments
(sum lines 3 through 9) | $39,366 | $0 | $0 | $0 | $0 | $0 | | 15. | Net Patient Revenue (collected) | $51,564 | $0 | $0 | $0 | $0 | $0 |
|
|
|
Line
No. | | (19)
Grand Totals |
|---|
| 1. | Encounters | 8,006 | | | 2. | Gross Revenue
(Charges at 100% Rate) | $611,160 | | 3. | Sliding Fee Scale Write-offs | $42,470 | | 4. | Free/Complimentary Write-offs | $0 | | 5. | Contractual Adjustments | -$38,997 | | 6. | Bad Debts | $2,473 | | 7. | Grants, enter positive numbers | ( $27,170 ) | | 8. | Other Adjustments | $0 | | 9. | Reconciliation | $0 | | 10. | Total Write-offs & Adjustments
(sum lines 3 through 9) | -$21,224 | | 15. | Net Patient Revenue (collected) | $632,384 |
|
|
| Income Statement |
Line
No. | Revenue | (1) |
|---|
| 1. | Gross Patient Revenue (from Sec 6, line 2, column 19) | $611,160 | | 2. | Total Write-offs and Adjustments (from Sec 6, line 10 column 19) | -$21,224 | | 3. | Net Patient Revenue (from Sec 6, line 15, column 19) | $632,384 | | Other Operating Revenue | | 4. | Federal Funds | $58,919 | | 5. | State Funds | $49,112 | | 6. | County Funds | $0 | | 7. | Local (City or District) Funds | $0 | | 8. | Private | $9,088 | | 9. | Donations/Contributions | $0 | | 19. | Other | $4,377 | | 20. | Total Other Revenue (Sum Lines 4 through 19) | $121,496 | | 25. | Total Operating Revenue (Line 3 + Line 20) | $753,880 |
Line
No. | Operating Expenses | (1) |
|---|
| 30. | Salaries, Wages, and Emplyee Benefits | $564,691 | | 31. | Contract Services - Professional | $452 | | 32. | Supplies - Medical and Dental | $32,598 | | 33. | Supplies - Office | $9,557 | | 34. | Outside Patient Care Services | $0 | | 35. | Rent / Depreciation / Mortgage Interest | $33,675 | | 36. | Utilities | $22,518 | | 37. | Professional Liability Insurance | $3,189 | | 38. | Other Insurance | $3,453 | | 39. | Continuing Education | $4,004 | | 44. | All Other Expenses | $65,946 | | 45. | Total Expenses (Sum Lines 30 through 44) | $740,083 | | 50. | Net from Operations (Line 25 - Line 45) | $13,797 |
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| 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 |
| 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)." |
| 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 Years Expenditures | | | 44. | Ending Fund Balance
(Line 40 + Line 41 + Line 42 - Line 43) | $0 |
|
|