Annual Utilization Report of Primary Care Clinic
Facility Name:FAMILY HEALTH CENTER
OSHPD ID:306196123Report Status:Submitted
License Category:Community ClinicReport Year:2016
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 GROVE AVE., STE. 101
4.City:POMONA
5.Zip:91767
6.Facility Phone No.:(909) 469 - 9494 ext.
7.Administrator Name:Darlene McPherson, PhD
8.Administrator E-mail Address:darlene.mcpherson@pvhmc.org
9.Was this clinic in operation at any time during the year?:Yes
10.Operation Open From:1/1/2016
11.Operation Open To:12/31/2016
12.Name of Parent Corporation:Pomona Valley Hospital Medical Center
13.Corporate Business Address:1798 N. Garey Ave.
14.City:Pomona
15.State:CA
16.Zip:91767 -
17.Person Completing Report:Darlene McPherson
18.Phone No.:909-469-9495
19.Fax No.:909-620-7285
20.E-mail Address:darlene.mcpherson@pvhmc.org
30.Submitted by:fhcpomona
31.Submitted Date and Time:3/24/2017 10:13:03 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 EducationYes
13.Community NutritionNo
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.MedicalYes
101.Dental
102.Vision
103.Mental Health (Psychology / Psychiatry / Behavioral health)Yes
104.Substance Abuse (Alcohol / Drug Services)
105.Domestic Violence
106.Basic LabYes
107.Radiological Services
108.Urgent Care
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.ArabicYesYes
31.ArmenianNoNo
32.CambodianNoYes
33.ChineseYesYes
34.HindustaniNoNo
35.HmongNoNo
36.JapaneseNoYes
37.KoreanNoYes
38.LaotianNoYes
39.PortugueseNoYes
40.PunjabiYesNo
41.RussianYesYes
42.Sign LanguageNoYes
43.SpanishYesYes
44.TagalogYesYes
45.VietnameseYesYes
Language Summary
Line
No.		Language Summary(1)
55.Percentage (%) of patient population best served in a non-English language (round to nearest WHOLE percent):10%
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.Physicians5.005.0031,792
61.Physician Assistants0.000
62.Family Nurse Practitioners0.200.20249
63.Certified Nurse Midwives0.000
64.Visiting Nurses0.000
65.Dentists0.000
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.Subtotal0.205.000.005.2032,041
** 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 Assistants0.000
82.Dental Assistants - Not licensed0.000
83.Marriage and Family Therapists (MFT)0.000
84.Registered Nurses0.000
85.Licensed Vocational Nurses4.004.000
86.Medical Assistants - Not licensed (1)10.5010.500
87.Non-Licensed Patient Education Staff0.000
88.Substance Abuse Counselors (2)0.000
89.Billing Staff (3)0.00
90.Other Administrative Staff (4)10.0010.00
94.Other Providers not listed above4.004.00
95.Subtotal28.500.000.0028.500
(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)6,647
2.Black703
3.Native American / Alaskan Native29
4.Asian / Pacific Islander423
5.More than one race114
9.Other / Unknown411
10.Total Patients *8,327
Ethnicity
Line
No.		Ethnicity(1)
# of
Patients
11.Hispanic4,830
12.Non-Hispanic2,964
13.Unknown533
15.Total Patients *8,327

Federal Poverty Level
Line
No.		Federal Poverty Level(1)
# of
Patients
20.Under 100%1
21.100 - 138%0
22.139 - 200%0
23.201 - 400%0
24.Above 400%0
25.Unknown8,326
26.Total Patients by Federal Poverty Level *8,327
Seasonal Agricultural And Migratory Workers
Line
No.		Seasonal Agricultural and Migratory Workers(1)
Number
30.Total Patients7
31.Total Encounters35
Age Category
Line
No.		Age Category(1)
Males		(2)
Females
40.Under 1 year103109
41.1 - 4 years186176
42.5 - 12 years320294
43.13 - 14 years8892
44.15 - 19 years220297
45.20 - 34 years5141,313
46.35 - 44 years339649
47.45 - 64 years8891,307
48.65 and over546885
55.Total Patients *3,2055,122
Patient Coverage
Line
No.		Patient Coverage(1)
# of
Patients
60.Medicare723
61.Medicare - Managed Care793
62.Medi-Cal2,061
63.Medi-Cal - Managed Care3,065
64.County Indigent / CMSP / MISP0
65.Private Insurance1,454
66.Covered California125
67.Alameda Alliance for Health0
68.My Health LA (MHLA)0
69.PACE Program0
70.Self-Pay / Sliding Fee100
71.Free0
74.All Other Payers6
75.Total Patients *8,327
Episodic Programs
Line
No.		Episodic Programs(1)
# of
Patients
80.BCCTP0
81.CHDP940
82.
83.Family PACT30
84.Other County Programs0
85.Childrens Treatment Program0
89.Other Payer - covered by a grant0
90.Total Episodic Patients (duplicated)970
Child Health And Disability Prevention (CHDP)
Line
No.		Child Health And Disability Prevention (CHDP)(1)
# of
Assessments
95.CHDP Assessments1,397
* 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
1.Infectious and Parasitic DiseasesA00-B99837
2.NeoplasmsC00-D49434
3.Endocrine, Nutritional, and Metabolic Diseases; and Immunity DisordersE00-E892,710
4.Blood and Blood Forming DisordersD50-D89353
5.Mental DisordersF01-F991,141
6.Nervous System and Sense Organs DiseasesG00-H951,514
7.Circulatory System DiseasesI00-I992,866
8.Respiratory System DiseasesJ00-J992,686
9.Digestive System Diseases, excluding dental diagnosisK20-K941,103
10.Genitourinary System DiseasesN00-N991,332
11.Pregnancy, Childbirth & the PuerperiumO00-O9A237
12.Skin and Subcutaneous Tissue DiseasesL00-L991,181
13.Musculoskeletal System and Connective Tissue DiseasesM00-M992,991
14.Congenital AnomaliesQ00-Q9930
15.Certain Conditions Originating in the Perinatal PeriodP00-P9617
16.Symptoms, Signs, and Ill-defined ConditionsR00-R994,325
17.Injury and PoisoningS00-T881,374
18.Factors Influencing Health Status and Contact with Health ServicesZ00-Z996,832
19.Dental DiagnosisK00-K1464
20.Family Planning "Z" Codes0
21.OtherAll other codes not in lines 1-2014
25.Total32,041
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 - 992051,561
2.Evaluation and Management (established patient)99211 - 9921521,281
3.Hospital Related Services99217 – 99226,
99231 - 99239,
99477		4,270
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 - 99318291
7.Case Management Services99363 - 99364,
99366 - 99368		0
8.Preventive Medicine (infant, child, adolescent)99381 - 99384,
99391 - 99394,
99461		1,152
9.Preventive Medicine (adult)99385 - 99387,
99395 - 99397		1,486
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 - 1949975
13.Musculoskeletal System20005 - 2999914
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 - 5899910
23.Maternal Care and Delivery59000 - 59899126
24.Endocrine System60000 - 606990
25.Nervous System61000 - 649990
26.Eye and Ocular Adnexa System65091 - 688990
27.Auditory System69000 - 699794
28.Radiology70010 - 799990
29.Pathology / Laboratory80047 – 89356, 89398743
30.Medicine - Special Services90281 – 99091,
99170 – 99199		298
31.Family Planning "Z" Codes"Z" codes281
32.Dental Encounters (CDT codes)D0100-D09990
33.CPT Category III Codes0001T - 9999T0
44.OtherAll other codes not in lines 1-33449
45.Total32,041
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		89
Vaccinations
60.DTap, DTP, Diphtheria and Tetanus90389, 90696, 90698,
90700 – 90703, 90714, 90715,
90718 - 90721, 90723		1,069
61.Hemophilus Influenza B (Hib)90371, 90645 - 90648306
62.Hepatitis A90632 – 90634,
90636		209
63.Hepatitis B90740, 90743 - 90744, 90746, 90747144
64.HepB and Hib907480
65.Influenza Virus Vaccine90654 – 90658,
90660 - 90668		62
66.Measles, Mumps and Rubella (MMR) and Varicella (MMRV)90704 - 90708, 90710203
67.Pneumococcal90669, 90670, 90732660
68.Poliovirus90712 - 90713126
69.Varicella90396, 90716209
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.Encounters2,8843,2047,39811,01705,447
2.Gross Revenue
(Charges at 100% Rate)		$716,783$940,139$380,541$2,371,337$0$1,381,961
3.Sliding Fee Scale
Write-offs
4.Free/Complimentary
Write-offs
5.Contractual Adjustments$322,905$560,320$292,335$1,364,330$0$641,630
6.Bad Debts$3,051$0$20,844
7.Grants (see Section 7)
8.Other Adjustments
9.Reconciliation
10.Total Write-offs &
      Adjustments
(sum lines 3 through 9)		$325,956$560,320$292,335$1,364,330$0$662,474
15.Net Patient Revenue (collected)
(line 2 – line 10)		$390,827$379,819$88,206$1,007,007$0$719,487
*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
(12)


EAPC
1.Encounters558100001,397
2.Gross Revenue
(Charges at 100% Rate)		$71,662$19,322$348,278
3.Sliding Fee Scale
Write-offs
4.Free/Complimentary
Write-offs
5.Contractual Adjustments$36,956$272,601
6.Bad Debts$349$4,002
7.Grants (see Section 7)
8.Other Adjustments
9.Reconciliation
10.Total Write-offs &
      Adjustments
(sum lines 3 through 9)		$37,305$4,002$0$0$272,601
15.Net Patient Revenue (collected)
(line 2 – line 10)		$34,357$15,320$0$0$75,677
*  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.Encounters3000006
2.Gross Revenue
(Charges at 100% Rate)		$20,169$1,625
3.Sliding Fee Scale
Write-offs
4.Free/Complimentary
Write-offs
5.Contractual Adjustments$10,619$331
6.Bad Debts$0
7.Grants (see Section 7)
8.Other Adjustments
9.Reconciliation
10.Total Write-offs &
      Adjustments
(sum lines 3 through 9)		$10,619$0$0$0$0$331
15.Net Patient Revenue (collected)
(line 2 – line 10)		$9,550$0$0$0$0$1,294
**  Report number of patients on Line 1 for the PACE Program
Line
No.		(19)
Grand Totals
1.Encounters32,041
2.Gross Revenue
(Charges at 100% Rate)		$6,251,817
3.Sliding Fee Scale Write-offs$0
4.Free/Complimentary Write-offs$0
5.Contractual Adjustments$3,502,027
6.Bad Debts$28,246
7.Grants (see Section 7)
8.Other Adjustments$0
9.Reconciliation$0
10.Total Write-offs & Adjustments
(sum lines 3 through 9)		$3,530,273
15.Net Patient Revenue (collected)
(line 2 – line 10)		$2,721,544
Section 7 - Income Statement
Income Statement
(Do not input any "$" signs, commas or decimals, round up to whole dollar.)
Line
No.		Revenue(1)
1.Gross Patient Revenue (from Sec 6, line 2, column 19)$6,251,817
2.Total Write-offs and Adjustments (from Sec 6, line 10, column 19)$3,530,273
3.Net Patient Revenue (from Sec 6, line 15, column 19)$2,721,544
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)
State Funds
6.Other
County Funds
10.Other County Grant Programs
11.Local (City or District) Funds
12.Private
13.Donations/Contributions
19.Other
20.Total Other Operating Revenue (Sum lines 4 through 19)$0
25.Total Operating Revenue (line 3 + line 20)$2,721,544
Operating Expenses
30.Salaries, Wages, and Emplyee Benefits$1,089,523
31.Contract Services - Professional$1,710,659
32.Supplies - Medical and Dental$327,537
33.Supplies - Office$51,305
34.Outside Patient Care Services
35.Rent / Depreciation / Mortgage Interest$245,808
36.Utilities$59,886
37.Professional Liability Insurance$67,340
38.Other Insurance
39.Continuing Education$5,089
40.Information Technology (including EHR)$75,599
44.All Other Expenses$670,006
45.Total Operating Expenses (Sum lines 30 through 44)$4,302,752
50.Net from Operations (line 25 - line 45)-$1,581,208
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