Pennant Group, Inc. (PNTG) FY 2023 MD&A
This page reproduces the company's own Item 7 MD&A text from the linked SEC filing. It is filer text, not grepcent analysis, scoring, or investment advice.
Item 7. Management’s Discussion and Analysis of Financial Condition and Results of Operations
The following discussion should be read in conjunction with the consolidated financial statements and accompanying notes, which appear elsewhere in this Annual Report. This discussion contains forward-looking statements that involve risks and uncertainties. Our actual results could differ materially from those anticipated in these forward-looking statements as a result of various factors, including those discussed below and elsewhere in this Annual Report. See Item 1A., Risk Factors and Cautionary Note Regarding Forward-Looking Statements.
Overview
We are a leading provider of high-quality healthcare services to patients and residents of all ages, including the growing senior population, in the United States. We strive to be the provider of choice in the communities we serve through our innovative operating model. We operate in multiple lines of businesses including home health, hospice and senior living services across Arizona, California, Colorado, Idaho, Montana, Nevada, Oklahoma, Oregon, Texas, Utah, Washington, Wisconsin and Wyoming. As of December 31, 2023, our home health and hospice business provided home health, hospice and
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home care services from 111 agencies operating across 13 states, and our senior living business operated 51 senior living communities throughout six states.
The following table summarizes our affiliated home health and hospice agencies and senior living communities as of:
| 2014 | 2015 | 2016 | 2017 | 2018 | 2019 | 2020 | 2021 | 2022 | 2023 | |||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Home health and hospice agencies | 25 | 32 | 39 | 46 | 54 | 63 | 76 | 88 | 95 | 111 | ||||||||||||||||||
| Senior living communities | 15 | 36 | 36 | 43 | 50 | 52 | 54 | 54 | 49 | 51 | ||||||||||||||||||
| Senior living units | 1,587 | 3,184 | 3,184 | 3,434 | 3,820 | 3,963 | 4,127 | 4,127 | 3,500 | 3,588 | ||||||||||||||||||
| Total number of home health, hospice, and senior living operations | 40 | 68 | 75 | 89 | 104 | 115 | 130 | 142 | 144 | 162 |
Recent Activities
Acquisitions. During 2023, we expanded our operations with the addition of three home health agencies, eight hospice agencies, two home care agencies, and two senior living communities. A subsidiary of the Company entered into a separate operations transfer agreement with the prior operator of each acquired operation as part of each transaction.
Trends
We have experienced modest senior living occupancy improvement through the year ended December 31, 2023, as a result of renewed consideration of senior living communities as a home-based care setting as the negative impacts of the global pandemic have subsided. Though we have seen steady improvements in occupancy throughout 2022 and 2023, the highly competitive environment for senior living residents and inflationary factors will continue to impact the rate at which we return our occupancy levels in our senior living communities to pre-pandemic levels.
When we acquire turnaround or start-up operations, we expect that our combined metrics may be impacted. We expect these metrics to vary from period to period based upon the maturity of the operations within our portfolio. We have generally experienced lower occupancy rates and higher costs at our senior living communities and lower census and higher costs at our home health and hospice agencies for recently acquired operations; as a result, we generally anticipate lower and/or fluctuating consolidated and segment margins during years of acquisition growth.
Segments
We have two reportable segments: (1) home health and hospice services, which includes our home health, home care and hospice businesses; and (2) senior living services, which includes the operation of assisted living, independent living and memory care communities. Our Chief Executive Officer, who is our Chief Operating Decision Maker (“CODM”), reviews financial information at the operating segment level using segment adjusted EBITDAR from operations. We also report an “all other” category that includes general and administrative expense from our Service Center.
Key Performance Indicators
We manage the fiscal aspects of our business by monitoring key performance indicators that affect our financial performance. These indicators and their definitions include the following:
Home Health and Hospice Services
•Total home health admissions. The total admissions of home health patients, including new acquisitions, new admissions and readmissions.
•Total Medicare home health admissions. Total admissions of home health patients, who are receiving care under Medicare reimbursement programs, including new acquisitions, new admissions and readmissions.
•Average Medicare revenue per completed 60-day home health episode. The average amount of revenue for each completed 60-day home health episode generated from patients who are receiving care under Medicare reimbursement programs.
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•Total hospice admissions. Total admissions of hospice patients, including new acquisitions, new admissions and recertifications.
•Average hospice daily census. The average number of patients who are receiving hospice care during any measurement period divided by the number of days during such measurement period.
•Hospice Medicare revenue per day. The average daily Medicare revenue recorded during any measurement period for services provided to hospice patients.
The following table summarizes our overall home health and hospice services statistics for the periods indicated:
| Year Ended December 31, | ||||||
|---|---|---|---|---|---|---|
| 2023 | 2022 | |||||
| Home health services: | ||||||
| Total home health admissions | 43,508 | 40,436 | ||||
| Total Medicare home health admissions | 19,389 | 18,641 | ||||
| Average Medicare revenue per completed 60-day home health episode(a) | $ | 3,533 | $ | 3,531 | ||
| Hospice services: | ||||||
| Total hospice admissions | 9,746 | 9,166 | ||||
| Average hospice daily census | 2,607 | 2,296 | ||||
| Hospice Medicare revenue per day | $ | 185 | $ | 178 |
| Column 1 | Column 2 | Column 3 |
|---|---|---|
| (a) | The year to date average for Medicare revenue per 60-day completed episode includes post period claim adjustments for prior periods. |
Senior Living Services
•Occupancy. The ratio of actual number of days our units are occupied during any measurement period to the number of units available for occupancy during such measurement period.
•Average monthly revenue per occupied unit. The revenue for senior living services during any measurement period divided by actual occupied senior living units for such measurement period divided by the number of months for such measurement period.
The following table summarizes our senior living statistics for the periods indicated:
| Year Ended December 31, | ||||||
|---|---|---|---|---|---|---|
| 2023 | 2022 | |||||
| Occupancy | 78.5 | % | 75.7 | % | ||
| Average monthly revenue per occupied unit | $ | 3,969 | $ | 3,516 |
Revenue Sources
Home Health and Hospice Services
Home Health. We derive the majority of our home health revenue from Medicare and managed care. The Medicare payment is adjusted for differences between estimated and actual payment amounts, an inability to obtain appropriate billing documentation or authorizations acceptable to the payor and other reasons unrelated to credit risk. Net service revenue is recognized in accordance with PDGM methodology. Under PDGM, Medicare provides agencies with payments for each 30-day period of care provided to beneficiaries. If a beneficiary is still eligible for care after the end of the first 30-day payment period, a second 30-day payment period can begin. There are no limits to the number of periods of care a beneficiary who remains eligible for the home health benefit can receive. While payment for each 30-day period of care is adjusted to reflect the beneficiary’s health condition and needs, a special outlier provision exists to ensure appropriate payment for those beneficiaries that have the most expensive care needs. The PDGM payment under the Medicare program is also adjusted for certain variables including, but not limited to: (a) a low utilization payment adjustment if the number of visits is below an established threshold that varies based on the diagnosis of a beneficiary; (b) a partial payment if the patient transferred to another provider or the Company received a patient from another provider before completing the period of care; (c) adjustment to the admission source
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of claim if it is determined that the patient had a qualifying stay in a post-acute care setting within 14 days prior to the start of a 30-day payment period; (d) the timing of the 30-day payment period provided to a patient in relation to the admission date, regardless of whether the same home health provider provided care for the entire series of episodes; (e) changes to the acuity of the patient during the previous 30-day period of care; (f) changes in the base payments established by the Medicare program; (g) adjustments to the base payments for case mix and geographic wages; and (h) recoveries of overpayments.
Hospice. We derive the majority of our hospice business revenue from Medicare reimbursement. The estimated payment rates are calculated as daily rates for each of the levels of care we deliver. Rates are set based on specific levels of care, are adjusted by a wage index to reflect healthcare labor costs across the country and are established annually through federal legislation. The following are the four levels of care provided under the hospice benefit:
•Routine Home Care (“RHC”). Care that is not classified under any of the other levels of care, such as the work of nurses, social workers or home health aides.
•General Inpatient Care. Pain control or acute or chronic symptom management that cannot be managed in a setting other than an inpatient Medicare-certified facility, such as a hospital, skilled nursing facility or hospice inpatient facility.
•Continuous Home Care. Care for patients experiencing a medical crisis that requires nursing services to achieve palliation and symptom control, if the agency provides a minimum of eight hours of care within a 24-hour period.
•Inpatient Respite Care. Short-term, inpatient care to give temporary relief to the caregiver who regularly provides care to the patient.
CMS has established a two-tiered payment system for RHC. Hospices are reimbursed at a higher rate for RHC services provided from days of service 1 through 60 and a lower rate for all subsequent days of service. CMS also provided for a Service Intensity Add-On, which increases payments for certain RHC services provided by registered nurses and social workers to hospice patients during the final seven days of life.
Medicare reimbursement is adjusted for an inability to obtain appropriate billing documentation or authorizations acceptable to the payor and other reasons unrelated to credit risk. Additionally, as Medicare hospice revenue is subject to an inpatient cap limit and an overall payment cap, we monitor our provider numbers and based upon empirical experience estimate amounts due back to Medicare to the extent that the cap has been exceeded.
Senior Living Services. Within our senior living operations, we generate revenue primarily from private pay sources, with a portion earned from Medicaid or other state-specific programs.
Primary Components of Expense
Cost of Services (excluding rent, general and administrative expense and depreciation and amortization). Our cost of services represents the costs of operating our independent operating subsidiaries, which primarily consists of employee wages and related benefits, share-based compensation, supplies, purchased services, and ancillary expenses such as the cost of pharmacy and therapy services provided to patients or residents. Cost of services also includes the cost of general and professional liability insurance and other general cost of services specifically attributable to our operations.
Rent—Cost of Services. Rent—cost of services consists solely of base minimum rent amounts payable under lease agreements to our landlords. Our subsidiaries lease and operate but do not own the underlying real estate at our operations, and these amounts do not include taxes, insurance, impounds, capital reserves or other charges payable under the applicable lease agreements, which are included in cost of services and general and administrative expense.
General and Administrative Expense. General and administrative expense consists primarily of payroll and related benefits and travel expenses for our Service Center personnel in providing training and other operational support. General and administrative expense also includes professional fees (such as accounting and legal fees), costs relating to our information systems, share-based compensation and rent for our Service Center offices.
Depreciation and Amortization. Property and equipment are initially recorded at their historical cost. Depreciation is computed using the straight-line method over the estimated useful lives of the depreciable assets (ranging from one to 40 years). Leasehold improvements are amortized on a straight-line basis over the shorter of their estimated useful lives or the remaining lease term.
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Critical Accounting Policies and Estimates
Our discussion and analysis of our financial condition and results of operations are based on our consolidated financial statements, which have been prepared in accordance with U.S. generally accepted accounting principles (“GAAP”). The preparation of these financial statements and related disclosures requires us to make judgments, estimates and assumptions that affect the reported amounts of assets and liabilities and disclosure of contingent assets and liabilities at the date of the financial statements and the reported amounts of revenue and expenses during the reporting periods. On an ongoing basis we review our judgments and estimates, including but not limited to those related to self-insurance reserves, revenue, and intangible assets and goodwill. We base our estimates and judgments upon our historical experience, knowledge of current conditions and our belief of what could occur in the future considering available information, including assumptions that we believe to be reasonable under the circumstances. By their nature, these estimates and judgments are subject to an inherent degree of uncertainty, and actual results could differ materially from the amounts reported. While we believe that our estimates, assumptions, and judgments are reasonable, they are based on information available when the estimate was made. Refer to Note 2, Basis of Presentation and Summary of Significant Accounting Policies, within the Consolidated Financial Statements for further information on our critical accounting estimates and policies, which are as follows:
•Self-insurance reserves - The valuation methods and assumptions used in estimating costs up to retention amounts to settle open claims of insureds and an estimate of the cost of insured claims up to retention amounts that have been incurred but not reported;
•Revenue recognition - The amounts owed by private pay individuals for services and estimate of variable considerations to arrive at the transaction price, including methods and assumptions, used to determine settlements with Medicare and Medicaid adjustments due to audits and reviews; and
•Acquisition accounting and goodwill - The assumptions used to allocate the purchase price paid for assets acquired and liabilities assumed in connection with our acquisitions, and the review of goodwill for impairment at the Company’s annual impairment test date or upon the occurrence of a triggering event.
Recent Accounting Pronouncements
Information concerning recently issued accounting pronouncements which are not yet effective is included in Note 2, Basis of Presentation and Summary of Significant Accounting Policies in the Consolidated Financial Statements.
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Results of Operations
The following table sets forth details of our expenses and earnings as a percentage of total revenue for the periods indicated:
| Year Ended December 31, | ||||||||
|---|---|---|---|---|---|---|---|---|
| 2023 | 2022 | 2021 | ||||||
| Total revenue | 100.0 | % | 100.0 | % | 100.0 | % | ||
| Expense: | ||||||||
| Cost of services | 80.4 | 79.6 | 79.7 | |||||
| Rent—cost of services | 7.3 | 8.0 | 9.3 | |||||
| General and administrative expense | 6.7 | 7.2 | 8.2 | |||||
| Depreciation and amortization | 0.9 | 1.0 | 1.1 | |||||
| Loss on asset dispositions and impairment, net | — | 1.5 | 0.6 | |||||
| Total expenses | 95.3 | 97.3 | 98.9 | |||||
| Income from operations | 4.7 | 2.7 | 1.1 | |||||
| Other income (expense), net: | ||||||||
| Other income | 0.1 | — | — | |||||
| Interest expense, net | (1.2) | (0.8) | (0.5) | |||||
| Other expense, net | (1.1) | (0.8) | (0.5) | |||||
| Income before provision for income taxes | 3.6 | 1.9 | 0.6 | |||||
| Provision for income taxes | 1.0 | 0.4 | 0.1 | |||||
| Net income | 2.6 | 1.5 | 0.5 | |||||
| Less: net income (loss) attributable to noncontrolling interest | 0.1 | 0.1 | (0.1) | |||||
| Net income attributable to Pennant | 2.5 | % | 1.4 | % | 0.6 | % |
| Year Ended December 31, | ||||||||||
|---|---|---|---|---|---|---|---|---|---|---|
| 2023 | 2022 | 2021 | ||||||||
| (In thousands) | ||||||||||
| Consolidated GAAP Financial Measures: | ||||||||||
| Total revenue | $ | 544,891 | $ | 473,241 | $ | 439,694 | ||||
| Total expenses | 519,722 | 460,502 | 434,999 | |||||||
| Income from operations | $ | 25,169 | $ | 12,739 | $ | 4,695 |
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The following table presents certain financial information regarding our reportable segments. General and administrative expenses are not allocated to the reportable segments and are included in “All Other”:
| Home Health and Hospice Services | Senior Living Services | All Other | Total | ||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| (In thousands) | |||||||||||||||
| Segment GAAP Financial Measures: | |||||||||||||||
| Year Ended December 31, 2023 | |||||||||||||||
| Revenue | $ | 394,464 | $ | 150,427 | $ | — | $ | 544,891 | |||||||
| Segment Adjusted EBITDAR from Operations | $ | 65,606 | $ | 45,294 | $ | (31,704) | $ | 79,196 | |||||||
| Year Ended December 31, 2022 | |||||||||||||||
| Revenue | $ | 342,249 | $ | 130,992 | $ | — | $ | 473,241 | |||||||
| Segment Adjusted EBITDAR from Operations | $ | 61,827 | $ | 37,563 | $ | (31,435) | $ | 67,955 | |||||||
| Year Ended December 31, 2021 | |||||||||||||||
| Revenue | $ | 309,570 | $ | 130,124 | $ | — | $ | 439,694 | |||||||
| Segment Adjusted EBITDAR from Operations | $ | 55,565 | $ | 37,517 | $ | (26,208) | $ | 66,874 |
The table below provides a reconciliation of Segment Adjusted EBITDAR from Operations above to income from operations:
| Year Ended December 31, | ||||||||||
|---|---|---|---|---|---|---|---|---|---|---|
| 2023 | 2022 | 2021 | ||||||||
| (In thousands) | ||||||||||
| Segment Adjusted EBITDAR from Operations(a) | $ | 79,196 | $ | 67,955 | $ | 66,874 | ||||
| Less: Depreciation and amortization | 5,130 | 4,900 | 4,784 | |||||||
| Rent—cost of services | 39,759 | 38,018 | 40,863 | |||||||
| Other (expense) income | 339 | (31) | (24) | |||||||
| Adjustments to Segment EBITDAR from Operations: | ||||||||||
| Less: Costs at start-up operations(b) | 102 | 1,435 | 1,045 | |||||||
| Share-based compensation expense(c) | 5,565 | 3,363 | 10,040 | |||||||
| Acquisition related costs and credit allowances(d) | 476 | 731 | 80 | |||||||
| Transition services costs(e) | — | — | 2,008 | |||||||
| Costs associated with transitioning operations(f) | 612 | 6,103 | 2,835 | |||||||
| Unusual or non-recurring charges(g) | 2,575 | 1,297 | — | |||||||
| Add: Net income (loss) attributable to noncontrolling interest | 531 | 600 | (548) | |||||||
| Income from operations | $ | 25,169 | $ | 12,739 | $ | 4,695 |
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| (a) | Segment Adjusted EBITDAR from Operations is net income attributable to the Company's reportable segments excluding interest expense, provision for income taxes, depreciation and amortization expense, rent, and, in order to view the operations performance on a comparable basis from period to period, certain adjustments including: (1) costs at start-up operations, (2) share-based compensation expense, (3) acquisition related costs and credit allowances, (4) transition services costs, (5) costs associated with transitioning operations, (6) unusual, non-recurring or redundant charges, and (7) net income (loss) attributable to noncontrolling interest. General and administrative expenses are not allocated to the reportable segments, and are included as “All Other”, accordingly the segment earnings measure reported is before allocation of corporate general and administrative expenses. The Company's segment measures may be different from the calculation methods used by other companies and, therefore, comparability may be limited. | |
|---|---|---|
| (b) | Represents results related to start-up operations. This amount excludes rent and depreciation and amortization expense related to such operations. | |
| (c) | Share-based compensation expense and related payroll taxes incurred, including the impact of the modification of certain restricted stock units described below in Note 12, Options and Awards, to the Consolidated Financial Statements. Share-based compensation expense and related payroll taxes are included in cost of services and general and administrative expense. | |
| (d) | Non-capitalizable costs associated with acquisitions and credit allowances for amounts in dispute with the prior owners of certain acquired operations. | |
| (e) | Costs identified as redundant or non-recurring incurred by the Company as a result of the Spin-Off. The 2021 amounts represents part of the costs incurred under the Transition Services Agreement. All amounts are included in general and administrative expense. Fees incurred under the Transition Services Agreement were $1,035, $1,561, and $3,124 for the year ended December 31, 2023, 2022 and 2021, respectively. | |
| (f) | During the year ended December 31, 2023, an affiliate of the Company placed its memory care units into transition and is actively seeking to sublease the units to an unrelated third party. The amount above represents the net operating impact attributable to the units in transition. The amounts reported exclude rent and depreciation and amortization expense related to such operations and include legal settlement costs associated with one of the entities transitioned to Ensign. During January 2022, affiliates of the Company entered into Transfer Agreements with affiliates of Ensign, providing for the transfer of the operations of certain senior living communities (the “Transaction”) from affiliates of the Company to affiliates of Ensign. The closing of the Transaction was completed in two phases with the transfer of two operations on March 1, 2022 and the remainder transferred on April 1, 2022. The amount above represents the net impact on revenue and cost of service attributable to all of the transferred entities. The amounts reported exclude rent and depreciation and amortization expense related to such operations. | |
| (g) | Represents unusual or non-recurring charges for legal services, implementation costs, integration costs, and consulting fees in general and administrative and cost of services expenses. The amounts reported for the year ended December 31, 2022 include certain costs identified as redundant or non-recurring incurred by the Company for services provided by Ensign under the Transition Services Agreement, and were included in general and administrative expense. |
Performance and Valuation Measures:
| Year Ended December 31, | ||||||||||
|---|---|---|---|---|---|---|---|---|---|---|
| 2023 | 2022 | 2021 | ||||||||
| (In thousands) | ||||||||||
| Consolidated Non-GAAP Financial Measures: | ||||||||||
| Performance Metrics | ||||||||||
| Consolidated EBITDA | $ | 30,107 | $ | 17,008 | $ | 10,003 | ||||
| Consolidated Adjusted EBITDA | $ | 40,716 | $ | 31,545 | $ | 26,407 | ||||
| Valuation Metric | ||||||||||
| Consolidated Adjusted EBITDAR | $ | 79,196 |
| Year Ended December 31, | ||||||||||
|---|---|---|---|---|---|---|---|---|---|---|
| 2023 | 2022 | 2021 | ||||||||
| (In thousands) | ||||||||||
| Segment Non-GAAP Measures:(a) | ||||||||||
| Segment Adjusted EBITDA from Operations | ||||||||||
| Home health and hospice services | $ | 60,128 | $ | 56,977 | $ | 51,045 | ||||
| Senior living services | $ | 12,293 | $ | 6,003 | $ | 1,570 |
| Column 1 | Column 2 | Column 3 |
|---|---|---|
| (a) | General and administrative expenses are not allocated to any segment for purposes of determining segment profit or loss. |
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The table below reconciles Consolidated Net Income to Consolidated EBITDA, Consolidated Adjusted EBITDA and Consolidated Adjusted EBITDAR for the periods presented:
| Year Ended December 31, | ||||||||||
|---|---|---|---|---|---|---|---|---|---|---|
| 2023 | 2022 | 2021 | ||||||||
| (In thousands) | ||||||||||
| Consolidated Net income | $ | 13,910 | $ | 7,243 | $ | 2,148 | ||||
| Less: Net income (loss) attributable to noncontrolling interest | 531 | 600 | (548) | |||||||
| Add: Provision for income taxes | 5,674 | 1,649 | 582 | |||||||
| Net interest expense | 5,924 | 3,816 | 1,941 | |||||||
| Depreciation and amortization | 5,130 | 4,900 | 4,784 | |||||||
| Consolidated EBITDA | 30,107 | 17,008 | 10,003 | |||||||
| Adjustments to Consolidated EBITDA | ||||||||||
| Add: Costs at start-up operations(a) | 102 | 1,435 | 1,045 | |||||||
| Share-based compensation expense(b) | 5,565 | 3,363 | 10,040 | |||||||
| Acquisition related costs and credit allowances(c) | 476 | 731 | 80 | |||||||
| Transition services costs(d) | — | — | 2,008 | |||||||
| Costs associated with transitioning operations(e) | 612 | 6,103 | 2,835 | |||||||
| Unusual or non-recurring charges(f) | 2,575 | 1,297 | — | |||||||
| Rent related to items (a) and (e) above | 1,279 | 1,608 | 396 | |||||||
| Consolidated Adjusted EBITDA | 40,716 | 31,545 | 26,407 | |||||||
| Rent—cost of services | 39,759 | 38,018 | 40,863 | |||||||
| Rent related to items (a) and (e) above | (1,279) | (1,608) | (396) | |||||||
| Adjusted rent—cost of services | 38,480 | 36,410 | 40,467 | |||||||
| Consolidated Adjusted EBITDAR | $ | 79,196 |
| (a) | Represents results related to start-up operations. This amount excludes rent and depreciation and amortization expense related to such operations. | |
|---|---|---|
| (b) | Share-based compensation expense and related payroll taxes incurred, including the impact of the modification of certain restricted stock units described below in Note 12, Options and Awards, to the Consolidated Financial Statements. Share-based compensation expense and related payroll taxes are included in cost of services and general and administrative expense. | |
| (c) | Non-capitalizable costs associated with acquisitions and credit allowances for amounts in dispute with the prior owners of certain acquired operations. | |
| (d) | Costs identified as redundant or non-recurring incurred by the Company as a result of the Spin-Off. The 2021 amounts represents part of the costs incurred under the Transition Services Agreement. All amounts are included in general and administrative expense. Fees incurred under the Transition Services Agreement were $1,035, $1,561, and $3,124 for the year ended December 31, 2023, 2022 and 2021, respectively. | |
| (e) | During the year ended December 31, 2023, an affiliate of the Company placed its memory care units into transition and is actively seeking to sublease the units to an unrelated third party. The amount above represents the net operating impact attributable to the units in transition. The amounts reported exclude rent and depreciation and amortization expense related to such operations and include legal settlement costs associated with one of the entities transitioned to Ensign. During January 2022, affiliates of the Company entered into Transfer Agreements with affiliates of Ensign, providing for the transfer of the operations of certain senior living communities (the “Transaction”) from affiliates of the Company to affiliates of Ensign. The closing of the Transaction was completed in two phases with the transfer of two operations on March 1, 2022 and the remainder transferred on April 1, 2022. The amount above represents the net impact on revenue and cost of service attributable to all of the transferred entities. The amounts reported exclude rent and depreciation and amortization expense related to such operations. | |
| (f) | Represents unusual or non-recurring charges for legal services, implementation costs, integration costs, and consulting fees in general and administrative and cost of services expenses. The amounts reported for the year ended December 31, 2022 include certain costs identified as redundant or non-recurring incurred by the Company for services provided by Ensign under the Transition Services Agreement, and were included in general and administrative expense. |
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The table below reconciles Segment Adjusted EBITDAR from Operations to Segment Adjusted EBITDA from Operations for the periods presented:
| Year Ended December 31, | ||||||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Home Health and Hospice | Senior Living | |||||||||||||||||||||
| 2023 | 2022 | 2021 | 2023 | 2022 | 2021 | |||||||||||||||||
| (In thousands) | ||||||||||||||||||||||
| Segment Adjusted EBITDAR from Operations | $ | 65,606 | $ | 61,827 | $ | 55,565 | $ | 45,294 | $ | 37,563 | $ | 37,517 | ||||||||||
| Less: Rent—cost of services | 5,791 | 5,060 | 4,906 | 33,967 | 32,958 | 35,957 | ||||||||||||||||
| Rent related to start-up and transitioning operations | (313) | (210) | (386) | (966) | (1,398) | (10) | ||||||||||||||||
| Segment Adjusted EBITDA from Operations | $ | 60,128 | $ | 56,977 | $ | 51,045 | $ | 12,293 | $ | 6,003 | $ | 1,570 |
The following discussion includes references to certain performance and valuation measures, which are non-GAAP financial measures, including Consolidated EBITDA, Consolidated Adjusted EBITDA, Segment Adjusted EBITDA from Operations, and Consolidated Adjusted EBITDAR (collectively, “Non-GAAP Financial Measures”). Non-GAAP Financial Measures are used in addition to, and in conjunction with, results presented in accordance with GAAP and should not be relied upon to the exclusion of GAAP financial measures. Non-GAAP Financial Measures reflect an additional way of viewing aspects of our operations and company that, when viewed with our GAAP results and the accompanying reconciliations to corresponding GAAP financial measures, we believe can provide a more comprehensive understanding of factors and trends affecting our business.
We believe these Non-GAAP Financial Measures are useful to investors and other external users of our financial statements regarding our results of operations because:
•they are widely used by investors and analysts in our industry as a supplemental measure to evaluate the overall performance of companies in our industry without regard to items such as interest expense, rent expense and depreciation and amortization, which can vary substantially from company to company depending on the book value of assets, the length of the lease to which the asset applies, the method by which assets were acquired, and differences in capital structures;
•they help investors evaluate and compare the results of our operations from period to period by removing the impact of our asset base and capital structure from our operating results; and
•Consolidated Adjusted EBITDAR is used by investors and analysts in our industry to value the companies in our industry without regard to capital structures.
We use Non-GAAP Financial Measures:
•as measurements of our operating performance to assist us in comparing our operating performance on a consistent basis from period to period;
•to allocate resources to enhance the financial performance of our business;
•to assess the value of a potential acquisition;
•to assess the value of a transformed operation’s performance;
•to evaluate the effectiveness of our operational strategies; and
•to compare our operating performance to that of our competitors.
We typically use Non-GAAP Financial Measures to compare the operating performance of each operation from period to period. We find that Non-GAAP Financial Measures are useful for this purpose because they do not include such costs as interest expense, income taxes, depreciation and amortization expense, which may vary from period-to-period depending upon various factors, including the method used to finance operations, the date of acquisition of a community or business, and the tax law of the state in which a business unit operates.
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Non-GAAP Financial Measures have no standardized meaning defined by GAAP. Therefore, our Non-GAAP Financial Measures have limitations as analytical tools, and they should not be considered in isolation, or as a substitute for analysis of our results as reported in accordance with GAAP. Some of these limitations are:
•they do not reflect our current or future cash requirements for capital expenditures or contractual commitments;
•they do not reflect changes in, or cash requirements for, our working capital needs;
•they do not reflect the net interest expense, or the cash requirements necessary to service interest or principal payments, on our debt;
•in the case of Consolidated Adjusted EBITDAR, it does not reflect rent expenses, which are normal and recurring operating expenses that are necessary to operate our leased operations;
•they do not reflect any income tax payments we may be required to make;
•although depreciation and amortization are non-cash charges, the assets being depreciated and amortized will often have to be replaced in the future, and these non-cash charges do not reflect any cash requirements for such replacements; and
•other companies in our industry may calculate the same Non-GAAP Financial Measures differently than we do, which may limit their usefulness as comparative measures.
We compensate for these limitations by using Non-GAAP Financial Measures only to supplement net income on a basis prepared in accordance with GAAP in order to provide a more complete understanding of the factors and trends affecting our business.
We strongly encourage investors to review our Consolidated Financial Statements, included in this report in their entirety and to not rely on any single financial measure. Because these Non-GAAP Financial Measures are not standardized, it may not be possible to compare these financial measures with other companies’ Non-GAAP financial measures having the same or similar names. These Non-GAAP Financial Measures should not be considered a substitute for, nor superior to, financial results and measures determined or calculated in accordance with GAAP. We strongly urge you to review the reconciliation of income from operations to the Non-GAAP Financial Measures in the table presented above, along with our Consolidated Financial Statements and related notes included elsewhere in this report.
We believe the following Non-GAAP Financial Measures are useful to investors as key operating performance measures and valuation measures:
Performance Measures:
Consolidated EBITDA
We believe Consolidated EBITDA is useful to investors in evaluating our operating performance because it helps investors evaluate and compare the results of our operations from period to period by removing the impact of our asset base (depreciation and amortization expense) from our operating results.
We calculate Consolidated EBITDA as net income, adjusted for net income (loss) attributable to noncontrolling interest, before (a) interest expense (b) provision for income taxes and (c) depreciation and amortization.
Consolidated Adjusted EBITDA
We adjust Consolidated EBITDA when evaluating our performance because we believe that the exclusion of certain additional items described below provides useful supplemental information to investors regarding our ongoing operating performance. We believe that the presentation of Consolidated Adjusted EBITDA, when considered with Consolidated EBITDA and GAAP net income is beneficial to an investor’s complete understanding of our operating performance.
We calculate Consolidated Adjusted EBITDA by adjusting Consolidated EBITDA to exclude the effects of non-core business items, which for the reported periods includes, to the extent applicable:
•costs at start-up operations;
•share-based compensation expense;
•acquisition related costs and credit allowances;
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•redundant or nonrecurring costs associated with the Transition Services Agreement (as defined in Note 3, Transactions with Ensign);
•costs associated with transitioning operations; and
•unusual or non-recurring charges.
Segment Adjusted EBITDA from Operations
We calculate Segment Adjusted EBITDA from Operations by adjusting Segment Adjusted EBITDAR from Operations to include rent-cost of services. We believe that the inclusion of rent-cost of services provides useful supplemental information to investors regarding our ongoing operating performance for each segment.
Valuation Measure:
Consolidated Adjusted EBITDAR
We use Consolidated Adjusted EBITDAR as one measure in determining the value of prospective acquisitions. It is also a measure commonly used by us, research analysts and investors to compare the enterprise value of different companies in the healthcare industry, without regard to differences in capital structures. Additionally, we believe the use of Consolidated Adjusted EBITDAR allows us, research analysts and investors to compare operational results of companies without regard to operating or financed leases. A significant portion of financed lease expenditures are recorded in interest, whereas operating lease expenditures are recorded in rent expense.
This measure is not displayed as a performance measure as it excludes rent expense, which is a normal and recurring operating expense and, as such, does not reflect our cash requirements for leasing commitments. Our presentation of Consolidated Adjusted EBITDAR should not be construed as a financial performance measure.
The adjustments made and previously described in the computation of Consolidated Adjusted EBITDA are also made when computing Consolidated Adjusted EBITDAR. We calculate Consolidated Adjusted EBITDAR by excluding rent-cost of services and rent related to start up operations from Consolidated Adjusted EBITDA.
Year Ended December 31, 2023 Compared to the Year Ended December 31, 2022
Revenue
| Year Ended December 31, | |||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 2023 | 2022 | ||||||||||||
| Revenue Dollars | Revenue Percentage | Revenue Dollars | Revenue Percentage | ||||||||||
| (In thousands) | |||||||||||||
| Home health and hospice services | |||||||||||||
| Home health | $ | 175,044 | 32.1 | % | $ | 159,858 | 33.8 | % | |||||
| Hospice | 194,627 | 35.7 | 160,520 | 33.9 | |||||||||
| Home care and other(a) | 24,793 | 4.6 | 21,871 | 4.6 | |||||||||
| Total home health and hospice services | 394,464 | 72.4 | 342,249 | 72.3 | |||||||||
| Senior living services | 150,427 | 27.6 | 130,992 | 27.7 | |||||||||
| Total revenue | $ | 544,891 | 100.0 | % | $ | 473,241 | 100.0 | % |
| Column 1 | Column 2 | Column 3 |
|---|---|---|
| (a) | Home care and other revenue is included with home health revenue in other disclosures in this report. |
Our consolidated revenue increased $71.7 million, or 15.1%, driven by the net organic growth of existing operations across all segments of $58.4 million or 12.3% as well as increased revenue from acquired operations of $13.3 million, or 2.8%, during the year ended December 31, 2023.
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Home Health and Hospice Services
| Year Ended December 31, | ||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 2023 | 2022 | Change | % Change | |||||||||||
| (In thousands) | ||||||||||||||
| Home health and hospice revenue | ||||||||||||||
| Home health services | $ | 175,044 | $ | 159,858 | $ | 15,186 | 9.5 | % | ||||||
| Hospice services | 194,627 | 160,520 | 34,107 | 21.2 | ||||||||||
| Home care and other | 24,793 | 21,871 | 2,922 | 13.4 | ||||||||||
| Total home health and hospice revenue | $ | 394,464 | $ | 342,249 | $ | 52,215 | 15.3 | % | ||||||
| Year Ended December 31, | ||||||||||||||
| 2023 | 2022 | Change | % Change | |||||||||||
| Home health services: | ||||||||||||||
| Total home health admissions | 43,508 | 40,436 | 3,072 | 7.6 | % | |||||||||
| Total Medicare home health admissions | 19,389 | 18,641 | 748 | 4.0 | ||||||||||
| Average Medicare revenue per 60-day completed episode(a) | $ | 3,533 | $ | 3,531 | $ | 2 | 0.1 | |||||||
| Hospice services: | ||||||||||||||
| Total hospice admissions | 9,746 | 9,166 | 580 | 6.3 | ||||||||||
| Average daily census | 2,607 | 2,296 | 311 | 13.5 | ||||||||||
| Hospice Medicare revenue per day | $ | 185 | $ | 178 | $ | 7 | 3.9 | |||||||
| Number of home health and hospice agencies at period end | 111 | 95 | 16 | 16.8 | % |
| Column 1 | Column 2 | Column 3 |
|---|---|---|
| (a) | The year to date average for Medicare revenue per 60-day completed episode includes post period claim adjustments for prior periods. |
Home health and hospice revenue increased $52.2 million, or 15.3%. Revenue grew due to an increase in all key performance indicators including an increase in total home health admissions of 7.6%, an increase in Medicare home health admissions of 4.0%, an increase in average Medicare revenue per 60-day completed episode of 0.1%, an increase of 6.3% in total hospice admissions, an increase of 3.9% in hospice Medicare revenue per day, and an increase of 13.5% in hospice average daily census. The improvement in these metrics resulted in net organic revenue growth of $40.8 million for the year ended December 31, 2023. Growth was also driven by the acquisition of 11 home health, home care, and hospice operations, between December 31, 2022 and December 31, 2023, resulting in an increase in revenue of $11.4 million, or 3.3% overall.
Senior Living Services
| Year Ended December 31, | ||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 2023 | 2022 | Change | % Change | |||||||||||
| Revenue (in thousands) | $ | 150,427 | $ | 130,992 | $ | 19,435 | 14.8 | % | ||||||
| Number of communities at period end | 51 | 49 | 2 | 4.1 | ||||||||||
| Occupancy | 78.5 | % | 75.7 | % | 2.8 | % | ||||||||
| Average monthly revenue per occupied unit | $ | 3,969 | $ | 3,516 | $ | 453 | 12.9 | % |
Senior living revenue increased $19.4 million, or 14.8%, for the year ended December 31, 2023 when compared to the same period in the prior year primarily due to a 12.9% increase in average monthly revenue per occupied unit and a 2.8% increase in occupancy rate between December 31, 2022 and December 31, 2023. Growth in revenue was also driven by the acquisition of two senior living communities, between December 31, 2022 and December 31, 2023, resulting in an increase of $1.9 million, or 1.4% overall.
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Cost of Services
The following table sets forth total cost of services by each of our reportable segments for the periods indicated:
| Year Ended December 31, | ||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 2023 | 2022 | Change | % Change | |||||||||||
| (In thousands) | ||||||||||||||
| Home Health and Hospice | $ | 331,844 | $ | 282,988 | $ | 48,856 | 17.3 | % | ||||||
| Senior Living | 106,252 | 93,650 | 12,602 | 13.5 | ||||||||||
| Total cost of services | $ | 438,096 | $ | 376,638 | $ | 61,458 | 16.3 | % |
Consolidated cost of services increased $61.5 million, or 16.3%, for the year ended December 31, 2023 when compared to the year ended December 31, 2022. The increase in the amount of cost of services was driven primarily by volume of services provided. Cost of services as a percentage of revenue increased by 80 basis points from 79.6% to 80.4% over the same time period. The increase was driven primarily by increased wages and benefits.
Home Health and Hospice Services
| Year Ended December 31, | ||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 2023 | 2022 | Change | % Change | |||||||||||
| (In thousands) | ||||||||||||||
| Cost of service | $ | 331,844 | $ | 282,988 | $ | 48,856 | 17.3 | % | ||||||
| Cost of services as a percentage of revenue | 84.1 | % | 82.7 | % | 1.4 | % |
Cost of services related to our Home Health and Hospice services segment increased $48.9 million, or 17.3%, primarily due to increased volume of services from the growth in admissions and average daily census. Cost of services as a percentage of revenue for the year ended December 31, 2023 increased by 140 basis points compared to the year ended December 31, 2022 primarily due to increased wages and benefits.
Senior Living Services
| Year Ended December 31, | ||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 2023 | 2022 | Change | % Change | |||||||||||
| (In thousands) | ||||||||||||||
| Cost of service | $ | 106,252 | $ | 93,650 | $ | 12,602 | 13.5 | % | ||||||
| Cost of services as a percentage of revenue | 70.6 | % | 71.5 | % | (0.9) | % |
Cost of services related to our Senior Living services segment increased $12.6 million, or 13.5%, during the year ended December 31, 2023 in response to higher occupancy and wage rate increases. As a percentage of revenue, costs of service decreased by 90 basis points during the year ended December 31, 2023 when compared to the year ended December 31, 2022 due to cost optimization, as occupancy increases toward approximately 80.0%.
Rent—Cost of Services. Rent increased 4.6% from $38.0 million to $39.8 million for the year ended December 31, 2023 compared to the year ended December 31, 2022, primarily as a result of the newly acquired senior living communities. As a percentage of revenue, rent—cost of services decreased 70 basis points when compared to the year ended December 31, 2022 due to improved senior living performance.
General and Administrative Expense. General and administrative expense increased $2.7 million, or 7.9%, from $34.0 million to $36.7 million for the year ended December 31, 2023 when compared to the year ended December 31, 2022. The increase in general and administrative expense was due to an increase of $1.5 million in share-based compensation for the year ended December 31, 2023 when compared to the year ended December 31, 2022.
Depreciation and Amortization. Depreciation and amortization expense decreased slightly as a percentage of total revenue.
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Loss on Asset Dispositions and Impairment, Net. Loss on asset dispositions and impairment, net decreased $6.9 million for the year ended December 31, 2023 when compared to the year ended December 31, 2022 due to the transfer of senior living communities to Ensign in 2022.
Provision for Income Taxes. Our effective tax rate for the year ended December 31, 2023 was 29.0% of earnings before income taxes compared with an effective tax rate of 18.5% for the year ended December 31, 2022. The increase in the effective tax rate is primarily due to a change in nondeductible equity compensation expenses. See Note 14, Income Taxes, to the Consolidated Financial Statements included elsewhere in this report filed on Form 10-K for further discussion.
Comparison of Prior Year Information
For a comparison of our results of operations of the fiscal year ended December 31, 2022 as compared to the year ended December 31, 2021 refer to Item 7. Management's Discussion and Analysis of Financial Condition and Results of Operations on Form 10-K filed with the SEC on February 23, 2023.
Liquidity and Capital Resources
Our primary sources of liquidity are cash generated through operating activities and borrowings under our revolving credit facility.
Revolving Credit Facility
On June 12, 2023, Pennant entered into the Second Amendment to its existing credit agreement (as amended, the “Credit Agreement”), to replace the LIBOR-based rates in the Credit Agreement with Standard Overnight Financing Rate (“SOFR”) based rates, due to the phase-out of LIBOR as a preferred global reference rate. The Credit Agreement provides for a revolving credit facility with a syndicate of banks with a borrowing capacity of $150.0 million (the “Revolving Credit Facility”). The Revolving Credit Facility is not subject to interim amortization and the Company will not be required to repay any loans under the Revolving Credit Facility prior to maturity in 2026, except that the loans may become due immediately if the Company triggers an event of default under the terms of the Credit Agreement. The Company is permitted to prepay all or any portion of the loans under the Revolving Credit Facility prior to maturity without premium or penalty, subject to reimbursement of any LIBOR breakage costs of the lenders.
The Credit Agreement contains customary covenants that, among other things, restrict, subject to certain exceptions, the ability of the Company and its independent operating subsidiaries to grant liens on their assets, incur indebtedness, sell assets, make investments, engage in acquisitions, mergers or consolidations, amend certain material agreements and pay certain dividends and other restricted payments. Financial covenants require compliance with certain levels of leverage ratios that impact the amount of interest. As of December 31, 2023, we were in compliance with all covenants.
As of December 31, 2023 we had $6.1 million of cash and $80.8 million of available borrowing capacity on our Revolving Credit Facility.
We believe that our existing cash, cash generated through operations, and access to available borrowing capacity under our Credit Agreement, will be sufficient to provide adequate liquidity for the next twelve months for both our operating activities and opportunities for acquisition growth.
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The following table presents selected data from our statement of cash flows for the periods presented:
| Year Ended December 31, | ||||||
|---|---|---|---|---|---|---|
| 2023 | 2022 | |||||
| (In thousands) | ||||||
| Net cash provided by operating activities | $ | 33,090 | $ | 9,044 | ||
| Net cash used in investing activities | (30,222) | (24,239) | ||||
| Net cash provided by financing activities | 1,112 | 12,084 | ||||
| Net change in cash | 3,980 | (3,111) | ||||
| Cash at beginning of year | 2,079 | 5,190 | ||||
| Cash at end of year | $ | 6,059 | $ | 2,079 |
Year Ended December 31, 2023 Compared to the Year Ended December 31, 2022
Our net cash flow from operating activities for the year ended December 31, 2023 increased by $24.0 million when compared to the year ended December 31, 2022. The primary drivers of this difference was a $6.7 million increase in net income, a $12.9 million net increase in cash flows from the change in operating assets and liabilities, and an increase of $4.4 million in non-cash expenses.
Our net cash used in investing activities for the year ended December 31, 2023 increased by $6.0 million compared to the year ended December 31, 2022, primarily driven by a $11.9 million increase in business acquisitions and other assets, offset by a $6.1 million decrease in purchases of property and equipment during the year ended December 31, 2023 compared to the year ended December 31, 2022.
Our net cash provided by financing activities decreased by $11.0 million for the year ended December 31, 2023 when compared to the year ended December 31, 2022 primarily due to a decrease in our net borrowings.