Annual Utilization Report of Primary Care Clinic
Facility Name:ST JOSEPH MOBILE DENTAL CLINIC
OSHPD ID:306494112Report Status:Submitted
License Category:Community ClinicReport Year:2014
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
1.Facility Name:ST JOSEPH MOBILE DENTAL CLINIC
2.OSHPD ID Number:306494112
3.Street Address:751 LOMBARDI CT
STE A
4.City:SANTA ROSA
5.Zip:95407
6.Facility Phone No.:(707) 547 - 2221 ext.
7.Administrator Name:stacey stirling
8.Administrator E-mail Address:stacey.stirling@stjoe.org
9.Was this clinic in operation at any time during the year?:Yes
10.Operation Open From:1/1/2014
11.Operation Open To:12/31/2014
12.Name of Parent Corporation:Santa Rosa Memorial hospital
13.Corporate Business Address:1165 Montgomery Dr.
14.City:Santa Rosa
15.State:CA
16.Zip:95405 -
17.Person Completing Report:Stacey Stirling
18.Phone No.:707-522-4307
19.Fax No.:707-547-2230
20.E-mail Address:Stacey.stirling@stjoe.org
30.Submitted by:sstirling
31.Submitted Date and Time:2/13/2015 9:56:05 AM
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:Neither
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 CareNo
11.Child CareNo
12.Community EducationNo
13.Community NutritionYes
14.Disaster ReliefNo
15.Environmental HealthNo
16.HomelessNo
17.LegalNo
18.OutreachYes
19.Social ServicesNo
20.Substance AbuseNo
21.TransportationNo
22.Vocational Training PlacementNo
23.OtherNo
HEALTH SERVICES
Check one or more boxes for each service provided.
Line
No.		(1)
Offered
100.Medical
101.DentalYes
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.ArabicNoNo
31.ArmenianNoNo
32.CambodianNoYes
33.ChineseNoYes
34.HindustaniNoYes
35.HmongNoYes
36.JapaneseNoNo
37.KoreanNoYes
38.LaotianNoYes
39.PortugueseNoNo
40.PunjabiNoYes
41.RussianNoYes
42.Sign LanguageNoYes
43.SpanishYesYes
44.TagalogYesYes
45.VietnameseNoYes
Language Summary
Line
No.		Language Summary(1)
55.Percentage (%) of patient population best served in a non-English language (round to nearest WHOLE percent):83%
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		(2)
Contract
FTE's		(3)
Volunteer
FTE's		(4)
Total
FTE's
(5)
No. of
Encounters
60.Physicians0.000
61.Physician Assistants0.000
62.Family Nurse Practitioners0.000
63.Certified Nurse Midwives0.000
64.Visiting Nurses0.000
65.Dentists0.800.809,251
66.Registered Dental Hygienists (Alternative Practice)0.000
67.Psychiatrists0.000
68.Clinical Psychologists0.000
69.Licensed Clinical Social Workers (LCSW)0.000
70.Other Providers billable to Medi-Cal**0.000
74.Other Certified CPSP providers not listed above***0.000
75.Subtotal0.800.000.000.809,251
** 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		(2)
Contract
FTE's		(3)
Volunteer
FTE's		(4)
Total
FTE's
(5)
No. of
Contacts
80.Registered Dental Hygienists (not Alternative Practice)0.000
81.Registered Dental Assistants2.002.009,251
82.Dental Assistants - Not licensed0.000
83.Marriage and Family Therapists (MFT)0.000
84.Registered Nurses0.000
85.Licensed Vocational Nurses0.000
86.Medical Assistants - Not licensed (1)0.000
87.Non-Licensed Patient Education Staff0.000
88.Substance Abuse Counselors (2)0.000
89.Billing Staff (3)0.200.20
90.Other Administrative Staff (4)0.200.20
94.Other Providers not listed above0.00
95.Subtotal2.400.000.002.409,251
(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)3,766
2.Black18
3.Native American / Alaskan Native23
4.Asian / Pacific Islander12
5.More than one race14
9.Other / Unknown45
10.Total Patients *3,878
Ethnicity
Line
No.		Ethnicity(1)
# of
Patients
11.Hispanic3,460
12.Non-Hispanic306
13.Unknown112
15.Total Patients *3,878

Federal Poverty Level
Line
No.		Federal Poverty Level(1)
# of
Patients
20.Under 100%2,225
21.100 - 200%1,483
22.Above 200%35
23.Unknown135
24.Total Patients *3,878
Seasonal Agricultural And Migratory Workers
Line
No.		Seasonal Agricultural and Migratory Workers(1)
Number
30.Total Patients714
31.Total Encounters714
Age Category
Line
No.		Age Category(1)
Males		(2)
Females
40.Under 1 year11
41.1 - 4 years12995
42.5 - 12 years1,7841,713
43.13 - 14 years5461
44.15 - 19 years1611
45.20 - 34 years58
46.35 - 44 years00
47.45 - 64 years00
48.65 and over00
55.Total Patients *1,9891,889
Patient Coverage
Line
No.		Patient Coverage(1)
# of
Patients
60.Medicare0
61.Medicare - Managed Care0
62.Medi-Cal1,860
63.Medi-Cal - Managed Care0
64.County Indigent / CMSP / MISP1
65.
66.Private Insurance0
67.Alameda Alliance for Health0
68.Healthy Way LA - Unmatched0
69.PACE Program0
70.Self-Pay / Sliding Fee0
71.Free2,017
74.All Other Payers0
75.Total Patients *3,878
Episodic Programs
Line
No.		Episodic Programs(1)
# of
Patients
80.BCCTP0
81.CHDP0
82.
83.Family PACT0
84.Other County Programs0
85.Childrens Treatment Program0
89.Other Payer - covered by a grant0
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 Assessments0
* 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-9-CM Codes(1)
# of Encounters
1.Infectious and Parasitic Diseases001 - 1390
2.Neoplasms140 - 2390
3.Endocrine, Nutritional, and Metabolic Diseases; and Immunity Disorders240 - 2790
4.Blood and Blood Forming Disorders280 - 2890
5.Mental Disorders290 - 3190
6.Nervous System and Sense Organs Diseases320 - 3890
7.Circulatory System Diseases390 - 4590
8.Respiratory System Diseases460 - 5190
9.Digestive System Diseases, excluding dental diagnosis530 - 5790
10.Genitourinary System Diseases580 - 6290
11.Pregnancy, Childbirth & the Puerperium630 - 6790
12.Skin and Subcutaneous Tissue Diseases680 - 7090
13.Musculoskeletal System and Connective Tissue Diseases710 - 7390
14.Congenital Anomalies740 - 7590
15.Certain Conditions Originating in the Perinatal Period760 - 7790
16.Symptoms, Signs, and Ill-defined Conditions780 - 7990
17.Injury and Poisoning800 - 9990
18.Factors Influencing Health Status and Contact with Health ServicesV01 - V910
19.Dental Diagnosis520-5299,251
20.Family Planning S-Codes0
21.OtherAll other codes not in lines 1-200
25.Total9,251
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 ServicesCPT Codes - 2012(1)
# of
Encounters
1.Evaluation and Management (new patient)99201 - 992050
2.Evaluation and Management (established patient)99211 - 992150
3.Hospital Related Services99217 – 99226,
99231 - 99239,
99477		0
4.Consultations99241 - 99245,
99441 - 99444		0
5.Other Evaluation and Management Services99291 - 99292,
99354 - 99360,
99450, 99455 - 99456, 99499		0
6.Nursing Facility Related Services99304 - 993180
7.Case Management Services99363 - 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.Counseling99401 - 99404,
99406 - 99409
99411 - 99412
99420 - 99429
99605 - 99607		0
All Other Services
11.Anesthesia00100 – 01999,
99100,
99116,
99135,
99140,
99143 - 99150		0
12.Integumentary System10021 - 194990
13.Musculoskeletal System20005 - 299990
14.Respiratory System30000 - 329990
15.Cardiovascular System33010 - 377990
16.Hemic and Lymphatic System38100 - 389990
17.Mediastinum and Diaphragm System39000 - 395990
18.Digestive System40490 - 499990
19.Urinary System50010 - 538990
20.Male Genital System54000 - 559200
21.Intersex Surgery55970, 559800
22.Female Genital System56405 - 589990
23.Maternal Care and Delivery59000 - 598990
24.Endocrine System60000 - 606990
25.Nervous System61000 - 649990
26.Eye and Ocular Adnexa System65091 - 688990
27.Auditory System69000 - 699790
28.Radiology70010 - 799990
29.Pathology / Laboratory80047 – 89356, 893980
30.Medicine - Special Services90281 – 99091,
99170 – 99199		0
31.Family Planning "Z" Codes"Z" codes0
32.Dental Encounters (CDT codes)D0100-D09999,251
33.CPT Category III Codes0001T - 9999T0
44.OtherAll other codes not in lines 1-330
45.Total9,251
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 ServicesCPT Codes - 2012(1)
# of
Procedures
50.Mammogram77051 – 770590
51.HIV Testing86689,
86701 - 86703,
87390 - 87391		0
52.Pap Smear88141 - 88155,
88164 - 88167,
88174 - 88175		0
53.Contraceptive Management11975 - 11977, 55250,
55300, 55400, 55450, 57170,
58300 - 58301, 58600
58605, 58611, 58670 - 58671		0
Vaccinations
60.DTap, DTP, Diphtheria and Tetanus90389, 90696, 90698,
90700 – 90703, 90714, 90715,
90718 - 90721, 90723		0
61.Hemophilus Influenza B (Hib)90371, 90645 - 906480
62.Hepatitis A90632 – 90634,
90636		0
63.Hepatitis B90740, 90743 - 90744, 90746, 907470
64.HepB and Hib907480
65.Influenza Virus Vaccine90654 – 90658,
90660 - 90668		0
66.Measles, Mumps and Rubella (MMR) and Varicella (MMRV)90704 - 90708, 907100
67.Pneumococcal90669, 90670, 907320
68.Poliovirus90712 - 907130
69.Varicella90396, 907160
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)
Healthy
Families
1.Encounters001,91301
2.Gross Revenue
(Charges at 100% Rate)		$460,772$153
3.Sliding Fee Scale
Write-offs
4.Free/Complimentary
Write-offs
5.Contractual Adjustments$397,300$143
6.Bad Debts
7.Grants (see Section 7)
8.Other Adjustments
9.Reconciliation
10.Total Write-offs &
      Adjustments
(sum lines 3 through 9)		$0$0$397,300$0$143
15.Net Patient Revenue (collected)
(line 2 – line 10)		$0$0$63,472$0$10
*Include LIHP encounters under County Indigent/CMSP/MISP
Line
No.
(7)

Private
Insurance		(8)
Self-Pay/
Sliding Fee
(9)


Free
(10)

Breast
Cancer*
(11)


CHDP
(12)


EAPC
1.Encounters007,33700
2.Gross Revenue
(Charges at 100% Rate)		$339,080
3.Sliding Fee Scale
Write-offs
4.Free/Complimentary
Write-offs		$339,080
5.Contractual Adjustments
6.Bad Debts
7.Grants (see Section 7)
8.Other Adjustments
9.Reconciliation
10.Total Write-offs &
      Adjustments
(sum lines 3 through 9)		$0$0$339,080$0$0
15.Net Patient Revenue (collected)
(line 2 – line 10)		$0$0$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)

Healthy Way
LA -
Unmatched
(16)

Alameda
Alliance
(17)

Other
County
(18)

All Other
Payers
1.Encounters000000
2.Gross Revenue
(Charges at 100% Rate)
3.Sliding Fee Scale
Write-offs
4.Free/Complimentary
Write-offs
5.Contractual Adjustments
6.Bad Debts
7.Grants (see Section 7)
8.Other Adjustments
9.Reconciliation
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.Encounters9,251
2.Gross Revenue
(Charges at 100% Rate)		$800,005
3.Sliding Fee Scale Write-offs$0
4.Free/Complimentary Write-offs$339,080
5.Contractual Adjustments$397,443
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)		$736,523
15.Net Patient Revenue (collected)
(line 2 – line 10)		$63,482
Section 7 - Income Statement
Income Statement
(Do not input any "$" signs, commas or decimals, round up to whole dollar.)
Line
No.		Revenue(1)
1.Gross Patient Revenue (from Sec 6, line 2, column 19)$800,005
2.Total Write-offs and Adjustments (from Sec 6, line 10, column 19)$736,523
3.Net Patient Revenue (from Sec 6, line 15, column 19)$63,482
Other Operating Revenue
4.Federal Funds - Grants - all others (e.g. 330 funds)
400.Federal Stimulus Grants - American Recovery and Reinvestment Act (ARRA)
401.Federal Funds - New Access Point (NAP)
402.Federal Funds - Increased Demand for Services (IDS)
403.Federal Funds - Capital Improvement Project (CIP)
5.State Funds - EAPC
6.State Funds - Other
7.County Funds - Healthy Way LA - Unmatched
10.County Funds - Other County Grant Programs
11.Local (City or District) Funds
12.Private$19,013
13.Donations/Contributions
19.Other$218,244
20.Total Other Operating Revenue (Sum lines 4 through 19)$237,257
25.Total Operating Revenue (line 3 + line 20)$300,739
Operating Expenses
30.Salaries, Wages, and Emplyee Benefits$301,803
31.Contract Services - Professional
32.Supplies - Medical and Dental$35,247
33.Supplies - Office$1,549
34.Outside Patient Care Services
35.Rent / Depreciation / Mortgage Interest$1,356
36.Utilities
37.Professional Liability Insurance
38.Other Insurance
39.Continuing Education
40.Information Technology (including EHR)
44.All Other Expenses$45,795
45.Total Operating Expenses (Sum lines 30 through 44)$385,750
50.Net from Operations (line 25 - line 45)-$85,011
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