2022-08-16T15:20:17-05:00 2021-09-30 FORVIS LLP 14241 DALLAS PARKWAY SUITE 1100 DALLAS TX 75254 990 2020-10-01 237169376 Pawhuska Hospital Inc % JASON MCBRIDE PAWH 9182873232 1101 East 15th Street Pawhuska OK 74056 JASON MCBRIDE ADMINISTRATOR 9182873232 2022-08-15 true JASON MCBRIDE 999009999 Jeanette Verrelli P00742631 9727028262 2 2020 2022-09-23 18:48:47Z JASON MCBRIDE 1101 EAST 15TH STREET PAWHUSKA OK 740561920 21549601 false X WWW.PAWHUSKAHOSPITAL.COM X 1959 OK PAWHUSKA HOSPITAL IS COMMITTED TO IMPROVING THE HEALTH AND LIVES IN THE COMMUNITIES WE SERVE. 5 4 148 4 0 0 4480630 5681229 11833525 15857174 9829 1000 -459750 10198 15864234 21549601 1350 5160 0 0 7034969 6822425 0 0 0 10349457 11373627 17385776 18201212 -1521542 3348389 9467479 8271887 17217541 12673560 -7750062 -4401673 X WE, THE PHYSICIANS, STAFF, AND GOVERNING BOARD OF PAWHUSKA HOSPITAL, INC. ARE COMMITTED TO PROVIDING THE HIGHEST LEVEL OF HEALTHCARE POSSIBLE FOR OUR FACILITY. RECOGNIZING THE HEALTH NEEDS OF OUR COMMUNITY AND SURROUNDING AREA, WE PLEDGE TO PROVIDE, IN A COST-EFFECTIVE MANNER, THE SERVICES NECESSARY TO ENHANCE THE QUALITY OF LIFE. UNDERSTANDING THE CONSTANT AND DRAMATIC CHANGES IN THE HEALTHCARE INDUSTRY, WE WILL STRIVE TO ACHIEVE EXCELLENCE AND CONTINUE OUR SUPPORT OF THE COMMUNITY. false false 14431013 5160 15863200 PAWHUSKA HOSPITAL, INC. IS A 25-BED CRITICAL ACCESS HOSPITAL AND RURAL HEALTH CLINIC LOCATED IN PAWHUSKA, OKLAHOMA, AND PROVIDES MEDICAL SERVICES TO PAWHUSKA AND SURROUNDING AREA. THE HOSPITAL AND CLINIC IS MANAGED THROUGH AN AGREEMENT WITH COHESIVE HEALTHCARE MANAGEMENT AND CONSULTING. THE HOSPITAL PROVIDES CARE TO PATIENTS WHO MEET CERTAIN CRITERIA UNDER ITS CHARITY CARE POLICY WITHOUT CHARGE OR AT AMOUNTS LESS THAN ESTABLISHED RATES. 14431013 true true false true false false false false false false true false false false true true false false false false false false false false false false true true false false true false false false false false false false false false false false false false true false false false true 26 0 true 148 true false false false false false false false false false false false false X 5 4 false true false false false true false true true false false true true true true true true true true false OK X JASON MCBRIDE 9182875123 1101 EAST 15TH STREET PAWHUSKA OK 740561920 X MATTHEW C RUMSEY CHIEF MEDICAL OFFICER 40.0 0.0 X X 484722 0 15278 RON DUNKLE APRN 40.0 0.0 X 330883 0 9857 Adam Helm Nurse Practitioner 40.0 0.0 X 201379 0 0 HEATHER ARRINGTON PHYSICIAN 40.0 0.0 X 171499 0 1986 JOHN CHIAFFITELLI PHYSICIAN 40.0 0.0 X 134711 0 15278 DALTON SMITH PHYSICAL THERAPIST 40.0 0.0 X 148617 0 727 AMANDA BRAY COMPLIANCE & RISK OFFICER 40.0 0.0 X 127267 0 883 BEN WEST SECRETARY 2.0 0.0 X X 0 0 0 BEVERLY TOLSON TRUSTEE 2.0 0.0 X 0 0 0 ELIZABETH REED CHAIRWOMAN 4.0 0.0 X X 0 0 0 PAM CARPENTER TRUSTEE 2.0 0.0 X 0 0 0 Tina Steele Finance Director 40.0 0.0 X 0 0 0 JASON MCBRIDE ADMINISTRATOR 40.0 0.0 X 0 0 0 JILL GRAY CCO 40.0 0.0 X 0 0 0 1599078 0 44009 7 false true false Cohesive Healthcare 2510 Independence St Suite 100 SHAWNEE OK 74804 MANAGEMENT SERVICES 1322330 COHESIVE REVOPS PO BOX 679227 DALLAS TX 75267 REVENUE CYCLE SVCS 1288574 COHESIVE STAFFING 2510 INDEPENDENCE ST SUITE 100 SHAWNEE OK 74804 CONTRACT LABOR STAFF 843699 AMERISOURCEBERGEN PO BOX 978526 DALLAS TX 75297 PHARMACEUTICAL DISTB 491759 Cerner Corporation 2800 Rock Creek Pkwy KANSAS CITY MO 64117 software svcs 458887 13 5681229 0 5681229 patient service revenue 621110 15856936 15856936 Other Operating Revenue 900099 238 238 15857174 0 0 0 0 0 0 1000 1000 1000 1000 0 0 0 0 0 0 0 0 0 medical records 900099 770 770 Pharmacy Rebate 900099 4641 4641 Cafeteria Revenue 722514 4172 4172 615 615 10198 21549601 15863200 5172 X 5160 5160 0 0 0 628151 533928 94223 0 5265727 5094018 171709 0 470544 429839 40705 458003 383942 74061 2700000 167965 2532035 486 486 43390 43390 0 0 0 4368026 4338087 29939 9385 2954 6431 371061 244837 126224 126788 47549 79239 0 196650 112490 84160 578 578 0 2153 1267 886 127463 19125 108338 0 229779 42669 187110 125197 125197 bad debt expense 1359633 1359633 medical supplies 1065049 1065049 Equipment 528795 471115 57680 food 109438 109438 9756 1370 8386 18201212 14431013 3770199 0 587217 0 5358929 3305465 0 0 1507116 1764738 0 0 0 0 0 0 333101 364340 16462 46624 7955001 5164281 1664654 2790720 0 0 0 0 0 0 0 0 0 0 9467479 8271887 1883583 5134742 0 0 5642086 0 0 0 0 0 0 0 7764446 7188542 0 0 1927426 350276 17217541 12673560 X -7750062 -4401673 0 0 -7750062 -4401673 9467479 8271887 3348389 X X false false true false X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED false false false false false false false false true 915 915 false SCHEDULE C, PART II-B, LINE 1I OTHER ACTIVITIES: THE HOSPITAL PAID DUES TO THE OKLAHOMA HOSPITAL ASSOCIATION, A PORTION OF WHICH IS DESIGNATED FOR LOBBYING EXPENSES. 52140 52140 2563745 1284778 1278967 35979 35048 931 5128780 3844455 1284325 174357 174357 2790720 0 Est 3rd Party Payor Settlement 350276 350276 X SCHEDULE D, PART X, LINE 2 ASC 740 FOOTNOTE: THE HOSPITAL IS ORGANIZED AS AN OKLAHOMA NONPROFIT CORPORATION AND HAS BEEN RECOGNIZED BY THE INTERNAL REVENUE SERVICE (IRS) AS EXEMPT FROM FEDERAL INCOME TAXES UNDER INTERNAL REVENUE CODE SECTION 501(C)(3). THE HOSPITAL IS ANNUALLY REQUIRED TO FILE A RETURN OF ORGANIZATION EXEMPT FROM INCOME TAX (FORM 990) WITH THE IRS. IN ADDITION, THE HOSPITAL IS SUBJECT TO INCOME TAX ON NET INCOME THAT IS DERIVED FROM BUSINESS ACTIVITIES THAT ARE UNRELATED TO ITS EXEMPT PURPOSE. THE HOSPITAL HAS DETERMINED IT IS NOT SUBJECT TO UNRELATED BUSINESS INCOME TAX AND HAS NOT FILED AN EXEMPT ORGANIZATION BUSINESS INCOME TAX RETURN (FORM 990T) WITH THE IRS. THE HOSPITAL BELIEVES THAT IT HAS APPROPRIATE SUPPORT FOR ANY TAX POSITIONS TAKEN AFFECTING ITS ANNUAL FILING REQUIREMENTS, AND AS SUCH, DOES NOT HAVE ANY UNCERTAIN TAX POSITIONS THAT ARE MATERIAL TO THE FINANCIAL STATEMENTS. THE HOSPITAL WOULD RECOGNIZE FUTURE ACCRUED INTEREST AND PENALTIES RELATED TO UNRECOGNIZED TAX BENEFITS AND LIABILITIES IN INCOME TAX EXPENSE IF SUCH INTEREST AND PENALTIES ARE INCURRED. true true X true X true X true false false 147453 147453 0.00880 1039365 1080401 0.00000 1186818 1080401 147453 0.00880 375133 375133 0.02230 375133 375133 0.02230 1561951 1080401 522586 0.03110 false 1359633 11569292 8979924 2589368 X true true 1 1 PAWHUSKA HOSPITAL INC 1101 E 15TH STREET PAWHUSKA OK 74056 WWW.PAWHUSKAHOSPITAL.COM 2271 X X X X PAWHUSKA HOSPITAL INC false false true X X X X X X X X X 18 true false true true X WWW.PAWHUSKAHOSPITAL.COM X true 18 true WWW.PAWHUSKAHOSPITAL.COM false true X 200. 300. X X X X true true X X X X true X SEE PART V, SECTION C X SEE PART V, SECTION C X SEE PART V, SECTION C X X X X X X true X false X X X X true X false false SCHEDULE H, PART V, SECTION B, LINE 5 PERSONS WHO REPRESENT THE COMMUNITY: A NEW CHNA WAS PERFORMED FOR THE 2019 FISCAL YEAR. THE HOSPITAL HOSTED FOUR COMMUNITY MEETINGS BETWEEN APRIL AND MAY OF 2019 WITH THE ASSISTANCE OF THE OKLAHOMA OFFICE OF RURAL HEALTH. THE INDIVIDUALS ATTENDING THESE MEETINGS INCLUDED, BUT WERE NOT LIMITED TO, INDIVIDUALS FROM THE FOLLOWING ORGANIZATIONS: PAWHUSKA HOSPITAL, PAWHUSKA CHAMBER OF COMMERCE, OSAGE NATION, OKLAHOMA STATE DEPARTMENT OF HEALTH, PAWHUSKA EMS AND PAWHUSKA HOSPITAL BOARD MEMBERS. ADDITIONAL INPUT CAME FROM A COMMUNITY SURVEY THAT HAD A TOTAL OF 104 RESPONSES FROM VARIOUS MEMBERS OF THE COMMUNITY. THE SURVEYS WERE DISTRIBUTED TO THE SCHOOLS, SENIOR HOUSING, OSAGE NATION PROGRAMS AND RESTAURANTS IN THE AREA. SCHEDULE H, PART V, SECTION B, LINE 11 NEEDS ADDRESSED AND NOT ADDRESSED IN CHNA: Pawhuska Hospital partnered with the Oklahoma Office of Rural Health to complete a CHNA during the 2019 fiscal year. Through this process, secondary data was gathered, a survey was completed, and key community partners including public health were solicited for input. The following identifies each priority, implementation taken, and an evaluation or impact of the implementation. PRIORITY: MENTAL HEALTH AND WELLNESS INCLUDING SUBSTANCE ABUSE AND CHEMICAL DEPENDANCY THE HOSPITAL WILL CONTINUE TO OFFER AND GROW THE SENIOR STRONG PROGRAM AND CONTINUE TO HAVE MONTHLY EDUCATION DISCUSSIONS ABOUT THE TOPIC. THE HOSPITAL PLANS TO PARTNER WITH Grand Lake Mental Health FOR SERVICEs aND PLACEMENT FOR PATIENTS IN NEED. THEY ALSO PLAN TO PARTNER WITH LOCAL LAW ENFORCEMENT TO BETTER RESPOND TO PATIENTS WHO HAVE MENTAL HEALTH AND/OR SUBSTANCE ABUSE ISSUES. PRIORITY: OUTPATIENT DIALYSIS THE HOSPITAL UNDERSTANDS THIS IS A BROAD NEED OF THE COMMUNITY. HOWEVER, THIS IS BEYOND THE SCOPE OF SERVICES, SPACE AND STAFFING OF THE HOSPITAL. THE HOSPITAL WILL CONTINUE TO HELP COORDINATE THIS SERVICE FOR PATIENTS THROUGH OTHER PROVIDERS. PRIORITY: EXPANSION OF CLINIC/HOSPITAL THE HOSPITAL AND CLINIC ARE CONTINUING TO LOOK TO EXPAND SERVICES INCLUDING OFFERING A VARIETY OF SPECIALTY SERVICES OFFERED ON WEEKLY/MONTHLY BASIS TO ALLEVIATE TRANSPORTATION BURDENS OF LOCAL RESIDENTS. THE HOSPITAL RECENTLY ADDED AN INFECTIOUS DISEASE SPECIALIST THAT PROVIDES EDUCATION AND CONSULTS TO THE HOSPITAL AND CLINIC REGARDING ANTIBIOTIC STEWARDSHIP AND EMERGING INFECTIOUS DISEASE TRENDS. THIS PROVIDER WILL ALSO MANAGE THE CARE OF THE PATIENTS WITH COMPLEX INFECTIOUS DISEASE NEEDS WHICH WOULD PREVIOUSLY HAVE BEEN TRANSFERRED. PRIORITY: WELLNESS OPPORTUNITIES AND NEED FOR NUTRITION EDUCATION THE CLINIC HAS STARTED PROVIDING FREE COMMUNITY EDUCATION IN THE AREAS OF DIABETIC, COPD, AND FALL RISK WITH MORE TOPICS TO BE COVERED OVER THE NEXT THREE YEARS. THE HOSPITAL IS ALSO EXPLORING THE OPPORTUNITY TO HOST A HEALTH FAIR IN THE COMMUNITY TO FOCUS ON TOPICS SUCH AS STROKE, SUBSTANCE ABUSE, ETC. SCHEDULE H, PART V, SECTION B, LINE 6B CHNA CONDUCTED WITH OTHER ORGANIZATIONS: THE HOSPITAL COMPLETED THE CHNA IN PARTNERSHIP WITH THE OKLAHOMA OFFICE OF RURAL HEALTH. THE OFFICE OF RURAL HEALTH ASSISTED WITH GATHERING DATA AND ANALYZING THE LOCAL HEALTH DATA, AS WELL AS ASSISTED WITH DEVELOPING THE IMPLEMENTATION STRATEGY. SCHEDULE H, PART V, SECTION B, LINES 16A, 16B & 16C FINANCIAL ASSISTANCE POLICY AVAILABILITY: THE FINANCIAL ASSISTANCE POLICY, APPLICATION AND PLAIN LANGUAGE SUMMARY ARE AVAILABLE UPON REQUEST AND AT THE FOLLOWING WEBSITE: https://pawhuskahospital.com/financial-services/ 1 PAWHUSKA FAMILY MEDICAL CLINIC 1101 E 15TH STREET PAWHUSKA OK 74056 RURAL HEALTH CLINIC SCHEDULE H, PART III, SECTION A, LINE 2 BAD DEBT EXPENSE: PATIENTS ACCOUNTS ARE WRITTEN OFF TO BAD DEBT AFTER EVERY EFFORT IS MADE TO COLLECT THE BALANCE AND PATIENTS ARE GIVEN OPPORTUNITIES TO COMPLETE CHARITY CARE APPLICATIONS OR SET UP PAYMENT PLANS. ALL DISCOUNTS AND CONTRACTUAL ADJUSTMENTS ARE APPLIED TO ACCOUNTS BEFORE THEY ARE WRITTEN OFF TO BAD DEBT. CURRENT PAYMENTS ON ACCOUNTS PREVIOUSLY WRITTEN OFF AS BAD DEBT REDUCES BAD DEBT EXPENSE. SCHEDULE H, PART III, SECTION A, LINE 3 BAD DEBT ATTRIBUTABLE TO PATIENTS ELIGIBLE UNDER THE FINANCIAL ASSISTANCE POLICY: THE ORGANIZATION IS UNABLE TO ESTIMATE THE AMOUNT FOR LINE 3 AND HAS ELECTED TO LEAVE IT BLANK. SCHEDULE H, PART III, SECTION B, LINE 8 COSTING METHODOLOGY: THE HOSPITAL USES COST REPORT METHODOLOGY, WHICH APPORTIONS ROUTINE COSTS BASED ON MEDICARE OR MEDICAID DAYS TO TOTAL DAYS AND APPORTIONS ANCILLARY COSTS BASED ON PROGRAM CHARGES TO TOTAL CHARGES. SCHEDULE H, PART III, SECTION C, LINE 9B COLLECTION POLICY: ALL COLLECTION EFFORTS CEASE WHEN A PATIENT IS DETERMINED TO BE ELIGIBLE FOR FINANCIAL ASSISTANCE. NORMAL COLLECTIONS EFFORTS CONTINUE ON ANY PERSONAL AMOUNT OWED BY THE PATIENT. SCHEDULE H, PART VI, LINE 2 NEEDS ASSESSMENT: ADMINISTRATION, MEDICAL STAFF AND THE GOVERNING BOARD REGULARLY DISCUSS THE HEALTH CARE NEEDS OF THE LOCAL COMMUNITY DURING GOVERNING BOARD MEETINGS AS WELL AS IN THE BIMONTHLY MEETINGS OF THE MEDICAL STAFF. THE OKLAHOMA OFFICE OF RURAL HEALTH AND PAWHUSKA HOSPITAL DEVELOPED A COMMUNITY NEEDS ASSESSMENT DURING FISCAL YEAR 2019. PAWHUSKA HOSPITAL IMPLEMENTED STRATEGIES FOR EACH HEALTH PRIORITY IDENTIFIED THROUGH THE NEEDS ASSESSMENT. IN ADDITION, WHEN LOOKING AT THE POTENTIAL OF ADDING NEW SERVICES, THE HOSPITAL RESEARCHES HOW SUCH SERVICES WILL MEET AND ADDRESS THE NEEDS OF THE COMMUNITY. THE HOSPITAL IS PLANNING ON DEVELOPING FUTURE PROGRAMS THAT ALLOW OPPORTUNITIES TO GATHER A LARGER COMMUNITY AUDIENCE THAT CAN EXPRESS THE ISSUES THAT ARE IMPORTANT TO THE COMMUNITY. FOCUS GROUPS WILL ENABLE THE HOSPITAL TO FURTHER EDUCATE TO MEET THE NEEDS OF THE COMMUNITY. THE NEXT CHNA WILL BE COMPLETED IN FY2022. SCHEDULE H, PART VI, LINE 3 PATIENT EDUCATION OF ELIGIBILITY FOR ASSISTANCE: PAWHUSKA HOSPITAL, INC PROVIDES A LETTER TO PATIENTS UPON ADMISSION THAT STATES THE HOSPITAL PROVIDES ASSISTANCE TO THOSE PATIENTS WITH LIMITED INCOME TO HELP PAY FOR HOSPITAL EXPENSES. THE LETTER INDICATES THAT CHARITY CARE APPLICATIONS ARE AVAILABLE TO ALL PATIENTS AND CAN BE PICKED UP AT THE TIME OF SERVICE OR AT A LATER DATE. THE CHARITY CARE APPLICATION GIVES AN OVERVIEW OF THE CHARITY CARE POLICY AND NOTES THAT MEDICARE AND OTHER STATE PROGRAMS ARE ALSO AVAILABLE TO PATIENTS THAT MEET INCOME REQUIREMENTS. THE HOSPITAL STAFF IS AVAILABLE TO OFFER PATIENTS ASSISTANCE IN COMPLETING THE CHARITY CARE AND MEDICAID APPLICATIONS IF NEEDED. SCHEDULE H, PART VI, LINE 4 COMMUNITY INFORMATION: PAWHUSKA HOSPITAL, INC. PRIMARILY SERVES THE CITIZENS OF THE COMMUNITY OF PAWHUSKA, OKLAHOMA AND THE SURROUNDING AREA. PAWHUSKA SERVES AS THE COUNTY SEAT OF OSAGE COUNTY, OKLAHOMA AND IS ALSO THE CAPITAL OF THE OSAGE NATION. THE HOSPITAL IS ONE OF TWO FACILITIES LOCATED IN OSAGE COUNTY. PAWHUSKA IS A RURAL AREA WITH A POPULATION OF 3,589 FROM THE 2010 U.S. CENSUS. THE PER CAPITA INCOME FOR THE CITY WAS $13,916. ABOUT 137 OF FAMILIES AND 175 OF THE POPULATION WERE BELOW THE POVERTY LINE, INCLUDING 223 OF THOSE UNDER AGE 18 AND 149 OF THOSE AGED 65 OR OVER. THE HOSPITAL IS A FEDERALLY DESIGNATED UNDERSERVED AREA FOR PRIMARY CARE HEALTH PROFESSIONALS, MENTAL HEALTH PROFESSIONALS AND DENTAL CARE HEALTH PROFESSIONALS. SCHEDULE H, PART VI, LINE 5 PROMOTION OF COMMUNITY HEALTH: PAWHUSKA HOSPITAL'S GOVERNING BODY IS COMPRISED OF VOLUNTEER MEMBERS WHO RESIDE IN THE COMMUNITY. MEDICAL STAFF PRIVILEGES ARE EXTENDED TO ALL QUALIFIED PHYSICIANS IN THE COMMUNITY. SURPLUS FUNDS ARE REINVESTED IN FACILITIES TO IMPROVE PATIENT CARE. THE HOSPITAL OPERATES AN EMERGENCY ROOM THAT IS AVAILABLE TO ALL REGARDLESS OF A PATIENT'S ABILITY TO PAY. SCHEDULE H, PART VI, LINE 6 AFFILIATED HEALTH CARE SYSTEM: N/A SCHEDULE H, PART VI, LINE 7 STATE FILING OF COMMUNITY BENEFIT REPORT: not applicable for 2021 fISCAL YEAR SCHEDULE H, PART I, LINE 3C FACTORS OTHER THAN FPG DETERMINING FREE OR DISCOUNTED CARE: THE HOSPITAL USES THE FOLLOWING CRITERIA TO DETERMINE ELIGIBILITY FOR FREE OR DISCOUNTED CARE: -ASSET LEVEL -MEDICAL INDIGENCY -INSURANCE STATUS -UNDERINSURANCE STATUS SCHEDULE H, PART I, line 7, col (f) PERCENT OF TOTAL EXPENSE: TO ARRIVE AT THE PERCENT OF TOTAL EXPENSES, THE DENOMINATOR WHICH EQUALS TOTAL OPERATING EXPENSES PER PART IX, LINE 25, OF THE FORM 990 WAS REDUCED BY BAD DEBT EXPENSE, TOTALING $1,359,633. Schedule H, Part III, Section A, Line 4 BAD DEBT EXPENSE FOOTNOTE: THE FOOTNOTE TO THE ORGANIZATION'S FINANCIAL STATEMENTS CAN BE FOUND ON PAGE 10 & PAGE 11 OF THE ATTACHED AUDITED FINANCIAL STATEMENTS. SCHEDULE H, PART I, LINE 7 COSTING METHODOLOGY FOR COMMUNITY BENEFIT COSTS: THE COST TO CHARGE RATIO CALCULATED ON IRS WORKSHEET 2 WAS USED IN THE CALCULATION OF COST ON IRS WORKSHEETS 1 AND 3. THE RATIO WAS COMPUTED FROM THE MEDICARE COST REPORT. THE COST COMPUTED ON WORKSHEET 8 WERE FROM THE HOSPITAL'S INCOME STATEMENT AND GRANT SCHEDULE. X X false false false false false false false false false MATTHEW C RUMSEY CHIEF MEDICAL OFFICER 484722 0 0 0 0 0 0 0 15278 0 500000 0 0 0 HEATHER ARRINGTON PHYSICIAN 167179 0 4320 0 0 0 0 0 1986 0 173485 0 0 0 RON DUNKLE APRN 330883 0 0 0 0 0 0 0 9857 0 340740 0 0 0 Adam Helm Nurse Practitioner 201379 0 0 0 201379 FORM 990, PART VI, SECTION A, LINE 3 DELEGATION OF CONTROL OVER MANAGEMENT DUTIES: COHESIVE HEALTHCARE MANAGEMENT AND CONSULTING PROVIDED ADMINISTRATIVE OVERSIGHT FOR DAY-TO-DAY OPERATIONS, ACCOUNTING SERVICES, AND OPERATIONAL CONSULTING SERVICES. JASON MCBRIDE IS THE ADMINISTRATOR AND DENNIS BOYD IS THE CFO ON BEHALF OF COHESIVE HEALTHCARE MANAGEMENT AND CONSULTING. PER IRS GUIDANCE, THE COMPENSATION PAID BY THE MANAGEMENT COMPANY IS NOT SHOWN ON FORM 990, PART VII, FOR THE 2020 CALENDAR YEAR FOR THESE INDIVIDUALS: JILL GRAY $60,677 JASON MCBRIDE $98,817 Tina Steele $118,799 FORM 990, PART VI, SECTION A, LINE 7A PERSONS WITH POWER TO ELECT OR APPOINT GOVERNING BODY: THERE ARE A TOTAL OF FIVE TRUSTEES. ALL ARE APPOINTED BY THE CITY COUNCIL OF PAWHUSKA BOARD OF INCORPORATORS. FORM 990, PART VI, SECTION B, LINE 11B PROCESS TO REVIEW FORM 990: THE FORM 990 IS PRESENTED TO THE ADMINISTRATOR FOR REVIEW AND THEN PRESENTED TO THE BOARD OF TRUSTEES. FORM 990, PART VI, SECTION B, LINE 12C PROCESS TO MONITOR COMPLIANCE WITH CONFLICT OF INTEREST POLICY: ALL EMPLOYEES, BOARD MEMBERS, AND CONTRACT EMPLOYEES ARE COVERED IN OUR POLICIES. THE EMPLOYEE AND CONTRACT EMPLOYEE DETERMINATIONS ARE MADE BY ADMINISTRATION AND ANY BOARD DETERMINATIONS ARE MADE BY THE GOVERNING BOARD. THE EMPLOYEE WILL BE ASKED TO REMEDY THE SITUATION AND THE BOARD MEMBER WILL BE ASKED TO LEAVE AFTER PRESENTING THEIR CONFLICT AND THE REMAINDER OF THE GOVERNING BOARD WILL DISCUSS AND THEN VOTE. COPIES OF BOTH POLICIES CAN BE PROVIDED UPON REQUEST. FORM 990, PART VI, SECTION B, LINE 15A & 15B COMPENSATION REVIEW: PAWHUSKA HOSPITAL, INC. FOLLOWS THE PAY GUIDELINES OF COHESIVE HEALTHCARE. SALARY DATA IS REVIEWED AGAINST SURVEY DATA FROM THE OKLAHOMA HOSPITAL ASSOCIATION. INCREASES ARE TIED TO AN ANNUAL PERFORMANCE EVALUATION AND APPROVAL FROM THE BOARD OF DIRECTORS. THE PROCESS AND DETERMINATION IS DOCUMENTED IN THE PERSONNEL FILES AND BOARD MINUTES. THE OTHER OFFICERS' COMPENSATION REVIEW IS PERFORMED EVERY YEAR BY THE HR DIRECTOR AND THEN REVIEWED BY THE COHESIVE CFO AND ADMINISTRATOR. FORM 990, PART VI, SECTION C, LINE 19 AVAILABILITY OF DOCUMENTS: THE HOSPITAL'S GOVERNING DOCUMENTS, CONFLICT OF INTEREST POLICY, AND FINANCIAL STATEMENTS ARE AVAILABLE TO THE PUBLIC UPON REQUEST. FORM 990, PART IV, LINE 12 & PART XII, LINE 2 AUDITED FINANCIAL STATEMENTS: THE ORGANIZATION HAS ANSWERED "NO" TO THE QUESTIONS REGARDING AN AUDIT IN PART IV, LINE 12a AND PART XII. THE ORGANIZATION IS IN THE PROCESS OF AN AUDIT OF THE FINANCIAL STATEMENTS FOR THE YEAR ENDED SEPTEMBER 30, 2021. HOWEVER, AT THE TIME OF FILING THIS RETURN, THE AUDIT IS NOT YET COMPLETE. THE ORGANIZATION HAS ATTACHED A COPY OF ITS MOST RECENT AUDITED FINANCIAL STATEMENTS FOR THE YEAR ENDED SEPTEMBER 30, 2020 AND SEPTEMBER 30, 2019 TO THE 990 AND ANSWERED YES TO PART IV, LINE 20B. FORM 990, PART XII, LINE 3B SINGLE AUDIT: THE ORGANIZATION DID UNDERGO THE REQUIRED SINGLE AUDIT, BUT IT WAS STILL IN PROCESS AT THE TIME OF FILING THE FORM 990. FORM 990 PART IX LINE 11G DESCRIPTION:PROFESSIONAL FEES TOTAL FEES:2585415 FORM 990 PART IX LINE 11G DESCRIPTION:CONTRACT STAFF TOTAL FEES:1646229 FORM 990 PART IX LINE 11G DESCRIPTION:LAUNDRY TOTAL FEES:89668 FORM 990 PART IX LINE 11G DESCRIPTION:AMBULANCE SERVICES TOTAL FEES:35008 FORM 990 PART IX LINE 11G DESCRIPTION:ADMIN CREDENTIALING FEES TOTAL FEES:11706 CITY OF PAWHUSKA 118 W MAIN STREET PAWHUSKA OK 74056 736005371 COMMUNITY SVC OK GOVT N/A NA false false false false false false false false false false false false false false false false false false false false