Annual Utilization Report of Primary Care Clinic
Facility Name:FAMILY HEALTH CENTER
OSHPD ID:306196123Report Status:Revised
License Category:Community ClinicReport Year:2003
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:FAMILY HEALTH CENTER
2.OSHPD ID Number:306196123
3.Street Address:1760-70 N ORANGE AVE., STE. 101
4.City:POMONA
5.Zip:91767
6.Facility Phone No.:(909) 469 - 9494 ext. 5106
7.Administrator Name:Renee V. Burgos
8.Administrator E-mail Address:Renee.Burgos@PVHMC.Org
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:Pomona Valley Hospital Medical Center
13.Corporate Business Address:1798 North Garey Avenue
14.City:Pomona
15.State:CA
16.Zip:91711 -
17.Person Completing Report:RENEE BURGOS
18.Phone No.:909-469-9499
19.Fax No.:909-620-7285
20.E-mail Address:RENEE.BURGOS@PVHMC.ORG
30.Submitted by:rburgos
31.Submitted Date and Time:3/16/2004 4:08:57 PM
Section 2 - Clinic Services
1.License Category:Community Clinic
Federally Qualified Health Clinic (FQHC)
Line
No.		Federally Qualified Health Clinics and Rural 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.OutreachNo
19.Social ServicesNo
20.Substance AbuseNo
21.TransportationNo
22.Vocational Training PlacementNo
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.ArabicNoNo
31.ArmenianNoNo
32.CambodianNoNo
33.ChineseNoNo
34.HindustaniNoNo
35.HmongNoNo
36.JapaneseNoNo
37.KoreanNoNo
38.LaotianNoNo
39.PortugeseNoNo
40.PunjabiNoNo
41.RussianNoNo
42.Sign LanguageNoNo
43.SpanishYesYes
44.TagalogNoNo
45.VietnameseNoNo
Language Summary
Line
No.		Language Summary(1)
55.Percentage (%) of patient population best served in a non-English language:40%
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.Physicians9.609.6040,561
61.Physician Assistants0.000
62.Family Nurse Practitioners0.200.20822
63.Certified Nurse Midwives0.000
64.Visiting Nurses0.000
65.Dentists0.000
66.Registered Dental Hygienists0.000
67.Psychiatrist0.000
68.Clinical Psychologist0.000
69.Licensed Clinical Social Worker (LCSW)0.000
70.Marriage, Family and Child Counselors (MFCC)0.000
71.Other Profiders billable to Medi-Cal**0.000
74.Other Certified CPSP prividers not listed above***0.000
75.Subtotal0.209.600.009.8041,383
** 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 Assistants0.000
81.Registered Nurses0.000
82.Licensed Vocational Nurses0.000
83.Non-Licensed Patient Education Staff0.000
89.Other Providers not listed above0.000
90.Subtotal0.000.000.000.000
Section 3 - Patient Demographics
Race
Line
No.		Race(1)
# of
Patients
1.White (include Hispanic)9,656
2.Black2,759
3.Native American / Alaskan Native0
4.Asian / Pacific Islander0
9.Other / Unknown1,379
10.Total Patients *13,794
Ethnicity
Line
No.		Ethnicity(1)
# of
Patients
11.Hispanic6,897
12.Non-Hispanic6,207
13.Unknown690
15.Total Patients *13,794

Federal Poverty Level
Line
No.		Federal Poverty Level(1)
# of
Patients
20.Under 100%0
21.100 - 200%0
22.Above 200%0
23.Unknown13,794
24.Total Patients *13,794
Seasonal Agricultural And Migratory Workers
Line
No.		Seasonal Agricultural and Migratory Workers(1)
#
30.Total Patients0
31.Total Encounters0
Age Category
Line
No.		Age Category(1)
Males		(2)
Females
40.Under 1 year12177
41.1 - 4 years425386
42.5 - 12 years637618
43.13 - 14 years182154
44.15 - 19 years425463
45.20 - 34 years1,3352,165
46.35 - 44 years9711,236
47.45 - 64 years1,3361,622
48.65 and over6371,004
55.Total Patients *6,0697,725
Patient Coverage
Line
No.		Patient Coverage(1)
# of
Patients
60.Medicare552
61.Medicare - Managed Care2,483
62.Medi-Cal414
63.Medi-Cal - Managed Care1,931
64.County Indigent / CMSP / MISP69
65.Healthy Families69
66.Private Insurance138
67.Alameda Alliance for Health0
68.LA Co. Public Private Partnership0
69.San Diego Co. Medical Plan0
70.Self-Pay / Sliding Fee414
71.Free0
74.All Other Payers7,724
75.Total Patients *13,794
Episodic Programs
Line
No.		Episodic Programs(1)
# of
Patients
80.BCCCP0
81.CHDP0
82.EAPC0
83.Family PACT143
84.Other County Programs0
85.Childrens Treatment Program0
89.Other Payer - covered by a grant0
90.Total Episodic Patients (duplicated)143
Child Health And Disability Prevention (CHDP)
Line
No.		Child Health And Disability Prevention (CHDP)(1)
# of
Assessments
95.CHDP Assessments0
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 - 139766
2.Neoplasms140 - 239579
3.Endocrine, Nutritional, and Metabolic Diseases; and Immunity Disorders240 - 2793,604
4.Blood and Blood Forming Disorders280 - 289281
5.Mental Disorders290 - 319492
6.Nervous System and Sense Organs Diseases320 - 3891,324
7.Circulatory System Diseases390 - 4533,418
8.Respiratory System Diseases460 - 5194,113
9.Digestive System Diseases520 - 5791,399
10.Genitourinary System Diseases580 - 6292,164
11.Pregnancy, Childbirth & the Puerperium630 - 679240
12.Skin and Subcutaneous Tissue Diseases680 - 7095,003
13.Musculoskeletal System and Connective Tissue Diseases710 - 7393,629
14.Congenital Anomalies740 - 75941
15.Certain Conditions Originating in the Perinatal Period760 - 779161
16.Symptoms, Signs, and Ill-defined Conditions780 - 7993,315
17.Injury and Poisoning800 - 999964
18.Factors Influencing Health Status and Contact with Health ServicesV01 - V828,657
19.Dental Diagnosis0
20.Family Planning S-Codes166
21.Other1,067
25.Total41,383
Section 5 - Encounters By Principal Service
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 ServicesCPT Codes - 2003(1)
# of
Encounters
1.Evaluation and Management (new patient)99201 - 992052,799
2.Evaluation and Management (established patient)99211 - 9921526,556
3.Hospital Related Services99217 - 992392,418
4.Consultations99241 - 9927515
5.Other Evaluation and Management Services99281 - 99285
99354 - 99360
99420 - 99429
99450 - 99456
99499		20
6.Nursing Facility Related Services99301 - 99316199
7.Case Management Services99361 - 993730
8.Preventive Medicine (infant, child, adolescent)99381 - 99384
99391 - 99394
99431 - 99440		1,421
9.Preventive Medicine (adult)99385 - 99387
99395 - 99397		2,418
10.Counseling99401 - 994121
All Other Services
11.Anesthesia00100 - 019990
12.Integumentary System10021 - 194991,045
13.Musculoskeletal System20000 - 29999589
14.Respiratory System30000 - 329990
15.Cardiovascular System33010 - 377990
16.Hemic and Lymphatic System38100 - 389990
17.Mediastinum and Diaphragm System39000 - 395990
18.Digestive System40490 - 49999103
19.Urinary System50010 - 538997
20.Male Genital System54000 - 5589948
21.Intersex Surgery55970, 559800
22.Female Genital System56405 - 58999127
23.Maternal Care and Delivery59000 - 598991,514
24.Endocrine System60000 - 606991
25.Nervous System61000 - 649992
26.Eye and Ocular Adnexa System65091 - 688991
27.Auditory System69000 - 69990143
28.Radiology70010 - 799990
29.Pathology / Laboratory80048 - 893990
30.Medicine - Special Services90281 - 991991,956
31.Family Planning "Z" Codes"Z" codes0
32.Dental Encountersall CDT codes0
33.Category III Codes0001T - 0044T0
44.Any other encounters0
45.Total41,383
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 ServicesCPT Codes - 2003(1)
# of
Procedures
50.Mammogram76085, 76090 - 760920
51.HIV Testing86701 - 86703
86689
87390 - 87391		0
52.Pap Smear88141 - 88155
88164 - 88167
88174 - 88175		0
53.Contraceptive Management11975 - 11977
55250, 55450, 57170,
58300 - 58301
58600 - 58611		69
Vaccinations
60.Diphtheria, Tetanus, and Pertussis (DTP)90701, 90718, 90700319
61.Hemophilus Influenza B (Hib)90645 - 90648153
62.Hepatitis A90633 - 9063667
63.Hepatitis B or HepB-HIB90740 - 90747182
64.HepB and Hib907487
65.Influenza Virus Vaccine90657 - 90660982
66.Measles, Mumps and Rubella (MMR)9070785
67.Pneumococcal90669163
68.Poliovirus90712 - 90713108
69.Varicella9071646
Section 6 - Revenue and Utilization by Payer
Line
No.		(1)
Medicare		(2)
Medicare
Managed		(3)
Medi-Cal		(4)
Medi-Cal
Managed		(5)
County/
CMSP/MISP		(6)
Healthy
Families
1.Encounters1,6557,4491,2415,794207207
2.Gross Revenue
(Charges at 100% Rate)		$293,237$685,894$366,393$526,716$23,866$18,526
3.Sliding Fee Scale
Write-offs		$180,850$23,852$13,840
4.Free/Complimentary
Write-offs
5.Contractual Adjustments$106,470$222,648$173,170
6.Bad Debts
7.Grants
enter positive numbers		( )( )
8.Other Adjustments
9.Reconciliation
10.Total Write-offs &
      Adjustments
(sum lines 3 through 9)		$106,470$222,648$180,850$173,170$23,852$13,840
15.Net Patient Revenue (collected)$186,767$463,246$185,543$353,546$14$4,686
Line
No.		(7)
Private
Insurance		(8)
Self-Pay/
Sliding Fee		(9)
Free		(10)
Breast
Cancer*		(11)
CHDP		(12)
EAPC
1.Encounters4141,2410000
2.Gross Revenue
(Charges at 100% Rate)		$30,078$125,376
3.Sliding Fee Scale
Write-offs		$53,912
4.Free/Complimentary
Write-offs
5.Contractual Adjustments$5,691
6.Bad Debts
7.Grants
enter positive numbers		( )( )( )( )( )
8.Other Adjustments
9.Reconciliation
10.Total Write-offs &
      Adjustments
(sum lines 3 through 9)		$5,691$53,912$0$0$0$0
15.Net Patient Revenue (collected)$24,387$71,464$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)
San Diego
Med Plan		(15)
LA County
Partnership		(16)
Alameda
Alliance		(17)
Other
County		(18)
All Other
Payers
1.Encounters166000023,009
2.Gross Revenue
(Charges at 100% Rate)		$15,577$1,894,505
3.Sliding Fee Scale
Write-offs
4.Free/Complimentary
Write-offs
5.Contractual Adjustments$7,602$448,896
6.Bad Debts
7.Grants
enter positive numbers		( )( )( )( )( )( )
8.Other Adjustments
9.Reconciliation
10.Total Write-offs &
      Adjustments
(sum lines 3 through 9)		$7,602$0$0$0$0$448,896
15.Net Patient Revenue (collected)$7,975$0$0$0$0$1,445,609
Line
No.		(19)
Grand Totals
1.Encounters41,383
2.Gross Revenue
(Charges at 100% Rate)		$3,980,168
3.Sliding Fee Scale Write-offs$272,454
4.Free/Complimentary Write-offs$0
5.Contractual Adjustments$964,477
6.Bad Debts$0
7.Grants, enter positive numbers( $0 )
8.Other Adjustments$0
9.Reconciliation$0
10.Total Write-offs & Adjustments
(sum lines 3 through 9)		$1,236,931
15.Net Patient Revenue (collected)$2,743,237
Section 7 - Income Statement
Income Statement
Line
No.		Revenue(1)
1.Gross Patient Revenue (from Sec 6, line 2, column 19)$3,980,168
2.Total Write-offs and Adjustments (from Sec 6, line 10 column 19)$1,236,931
3.Net Patient Revenue (from Sec 6, line 15, column 19)$2,743,237
Other Operating Revenue
4.Federal Funds
5.State Funds
6.County Funds
7.Local (City or District) Funds
8.Private
9.Donations/Contributions
19.Other
20.Total Other Revenue (Sum Lines 4 through 19)$0
25.Total Operating Revenue (Line 3 + Line 20)$2,743,237

Line
No.		Operating Expenses(1)
30.Salaries, Wages, and Emplyee Benefits$1,085,875
31.Contract Services - Professional$1,150,842
32.Supplies - Medical and Dental$48,654
33.Supplies - Office$104,443
34.Outside Patient Care Services$1
35.Rent / Depreciation / Mortgage Interest$1
36.Utilities$87,094
37.Professional Liability Insurance$126,822
38.Other Insurance$1
39.Continuing Education$1
44.All Other Expenses$209,365
45.Total Expenses (Sum Lines 30 through 44)$2,813,099
50.Net from Operations (Line 25 - Line 45)-$69,862
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
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
General Comments:
Errors and Warnings