2022-11-04T10:28:12-05:00 2021-12-31 450250958 Eide Bailly LLP 800 Nicollet Mall Ste 1300 Minneapolis MN 554027033 990 2021-01-01 860096775 Community Hospital Association Inc COMM 9286845421 520 Rose Lane Wickenburg AZ 85390 Patti Clavette CFO 9286845421 2022-11-04 1 Patti Clavette 999009999 Kim Hunwardsen CPA P00484560 6122536500 2022-11-04 3 AAL1 IAL1 2021 2022-09-23 18:48:47Z Wickenburg Community Hospital Jackie Lundblad 520 Rose Lane Wickenburg AZ 85390 45605433 0 X www.wickhosp.com X 1946 AZ Provide quality health and wellness services where patient, family and community come first. 8 8 368 63 0 0 9204402 3508190 38026074 41812342 49156 182484 92925 102417 47372557 45605433 0 0 0 0 20918998 20055134 0 0 170245 23330952 26558138 44249950 46613272 3122607 -1007839 38344388 37961811 27486540 28807223 10857848 9154588 To provide quality health and wellness services where the patient, family and community come first. 0 0 42877108 41812342 Community Hospital Association, Inc. d/b/a Wickenburg Community Hospital is a 25-bed critical access hospital that provides inpatient and outpatient diagnostic and therapeutic health care services to the residents and visitors of greater Wickenburg, Arizona, a rural community of approximately 23,000. The Hospital operates physician clinics and a surgery center in the same geographic area. 42877108 1 1 0 0 0 0 0 0 0 0 1 0 0 0 1 1 1 0 0 0 0 0 0 0 0 0 1 1 0 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 67 0 1 368 1 0 0 0 0 0 0 0 0 0 0 0 0 X 8 8 0 0 0 0 0 0 0 1 0 0 0 1 1 1 1 1 1 1 0 0 X Patti Clavette 9286681837 520 Rose Lane Wickenburg AZ 85390 Michell Wagner Orthopedic Surgeon 40.00 X 361473 0 19971 Todd Kravetz MD - Chief of Staff, Clinical Medical Director 40.00 X 303787 0 45747 Juan Vazquez Physician 40.00 X 270875 0 43483 Robert Ripley General Surgeon 40.00 X 264629 0 32855 Jackie Lundblad CEO 39.00 X 229413 0 29533 Diane Bejerano Family Physician 40.00 X 241581 0 10292 Steven Berstein Radiologist 40.00 X 223160 0 18630 Roger Rose Director of Pharmacy Services 40.00 X 181330 0 11675 Peter Stachowicz COO 39.00 X 175612 0 15672 Linda Rankin CNO 40.00 X 185996 0 3499 Dede Schmallen CHRO 40.00 X 164045 0 16278 Patti Clavette CFO 39.00 X 136081 0 26556 Dee Pollock Chair 1.00 X X 0 0 0 Brian Warnock Vice Chair 1.00 X X 0 0 0 Virginia Collier Secretary 1.00 X X 0 0 0 Dean Sandvik Treasurer 1.00 X X 0 0 0 Dave Bennett Director 1.00 X 0 0 0 Bob Dunn Director 1.00 X 0 0 0 Jenifer Finley Director 1.00 X 0 0 0 Bob Johnson Director 1.00 X 0 0 0 2737982 0 274191 26 0 1 0 Emergency Physicians LLC 1210 Pebble Springs Prescott AZ 86301 Physician Staffing 2353248 Nordic Consulting Partners Inc PO Box 415000 Nashville TN 37241 Consulting 940129 Rural Physicians Management Company LLC 10624 S Eastern Ave Ste A-263 Henderson NV 89052 Physician Staffing 751004 Voyageur Radiology LLC 323 Washington Ave N Suite 200 Minneapolis MN 55401 Imaging 597623 Alliance Physical Therapy Group LLC 607 Dewey Ave NW Suite 300 Grand Rapids MI 49501 Physician Staffing 582154 16 3243840 264350 3508190 Patient Service Revenue 621990 38620566 38620566 340B Drug Program 621990 1155299 1155299 2036477 2036477 41812342 182484 182484 102417 0 102417 102417 102417 45605433 41812342 0 284901 X 1544758 1544758 15458540 15300393 158147 233425 233425 1656047 1656047 1162364 1053454 96812 12098 2588 2588 71721 71721 67734 67734 11352431 9845395 1507036 754662 754662 940494 940494 1257579 1257579 47713 47713 467927 115528 352399 2177415 2112501 64914 415302 415302 Medical Supplies 7163315 7163315 AHCCCS Tax 852930 852930 Repairs & Maintenance 645217 645217 Food 68909 68909 272201 272201 46613272 42877108 3565919 170245 2858794 4549410 7110554 7195603 1665970 1102029 271376 477212 34829739 15565551 19672008 19264188 5373177 4500137 1392509 873232 38344388 37961811 5114335 6849415 15993409 16792935 300000 6378796 4864873 27486540 28807223 X 10377811 8643642 480037 510946 10857848 9154588 38344388 37961811 X -1007839 -148152 -370854 -176415 X 0 1 X 1 0 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 1518183 1518183 20944876 8527573 12417303 14689 2263 12426 11857587 6843060 5014527 494404 192655 301749 19264188 CMS Advanced Payments 2227863 Capital Leases 1223359 Estimated Third-Party Payor Settlements 953169 457b Retirement Liability 460482 4864873 X 45280866 -148152 -176415 -324567 45605433 0 45605433 46613272 0 46613272 0 46613272 Part X, Line 2: 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. Part XI, Line 2d - Other Adjustments: Change in Interest of Foundation -176,415. 1 1 X 1 X 1 X 240.000000000000 1 0 0 114000 114000 0.00240 4776619 4163227 613392 0.01320 4890619 4163227 727392 0.01560 70426 70426 0.00150 48083 48083 0.00100 8930642 7471006 1459636 0.03130 9049151 7471006 1578145 0.03380 13939770 11634233 2305537 0.04940 1 1765411 14764 14715796 14655587 60209 X 1 1 1 1 Wickenburg Community Hospital 520 Rose Lane Wickenburg AZ 85390 www.wickhosp.com RGH3505 X X X Wickenburg Community Hospital 1 0 0 1 X X X X X X X X X 19 1 0 0 1 X See Page 8 1 19 1 See Page 8 0 1 X 200.000000000000 240.000000000000 X X X 1 1 X X X X 1 X See Page 8 X See Page 8 X See Page 8 X X X X X X 1 X 0 X X X X 1 X 0 0 Wickenburg Community Hospital Part V, Section B, Line 5: The development of the CHNA survey process began with the formation of the 2019 project team. The survey was delivered both in English and in Spanish, electronically and by paper to meet the needs of the majority of residents in the regional service area. Distribution of the survey was accomplished through community partnerships with the town of Wickenburg, Wickenburg Chamber of Commerce, Wickenburg Unified School District, Wickenburg Ranch and the Wickenburg Health Care Coalition. The Coalition is a nonprofit, nonpartisan, community collaboration organized to support a healthy, active lifestyle in the town of Wickenburg and surrounding areas, and by notification in the town newspaper.Wickenburg Community Hospital and each community partner distributed the survey electronically and/or by paper to their clients, employees, families, and other community members throughout the region. They also published display ads in the town newspaper and encouraged regional residents to take the anonymous survey online through Survey Monkey or by paper which was distributed and collected through the region at various locations. Wickenburg Community Hospital Part V, Section B, Line 11: The 2019 CHNA identified five significant health needs in the community. These needs are Overall Health Status, Barriers to Accessing Health Care, Use of Services, Defining a Healthy Community and Increase Respondents in decreasing order by intensity as indicated from secondary and primary research. In 2021, the organization did not address the need to increase respondents identified in our assessment. This will be addressed in 2022 when the next assessment is open. We plan to increase the awareness of this assessment and its importance by using more public channels: paper, electronically (social media & email) and through person to person conversation in our organization as well as at community events.The following actions were taken to address the needs identified from the 2019 CHNA: 1) Improvements in our surgical center by partnering with Rural Partners in Medicine and adding another specialist who can provide care for hands. This has allowed us meet the needs of more community members suffering with issues in their hands and elbows. We continue work on the expansion of specialty providers for the community. 2) We have continued to partner with the local newspaper, The Wickenburg Sun, to issue a free health and wellness magazines to the community. We have also provided free safety education from our emergency department which is delivered both in the local paper and through our social media and email channels. We also provide weekly article publications to help educate the community on topics like nutrition, disease & treatment education, as well as continued awareness of COVID-19 and other AZDH information. 3) We have increased the number of community awareness publications both in the local paper as well as electronic communication channels (including adding a newsletter via email) to better inform the public about preventive care and how to access it. 4) Wickenburg Community Hospital has opened more employee positions for our community by growing our service lines and continues to contribute by offering multiple job opportunities. Schedule H, Part V, Section B, Line 10a: Line 10a:https://www.wickhosp.com/wp-content/uploads/2020/12/2019-CHNA-Implementation-Strategy-1.pdf Schedule H, Part V, Section B, Line 7a: https://www.wickhosp.com/wp-content/uploads/2020/06/2019-CHNA-Report.pdf Schedule H, Part V, Section B, Line 16a-16c: Line 16a:https://www.wickhosp.com/wp-content/uploads/2016/01/Financial-Assistance-Policy.pdfLine 16b:https://www.wickhosp.com/wp-content/uploads/2018/09/Financial-Assistance-Application-Letter-App.pdfLine 16c:https://www.wickhosp.com 3 1 - Community Hospital Clinic - Wickenburg 519 Rose Lane Wickenburg AZ 85390 Primary Care Clinic, Rural Health Clinic 2 - Community Hospital Clinic - Congress 26750 S Santa Fe Road Suite B Congress AZ 85332 Primary Care Clinic, Rural Health Clinic 3 - Community Hospital Clinic - Wittmann 32919 Center St Wittmann AZ 85361 Primary Care Clinic, Rural Health Clinic Part I, Line 7: Part I, line 7a:Financial Assistance was calculated using the cost-to-charge ratio. All patient segments are addressed using this method. The methodology used is to be in compliance with laws and regulations set forth by Medicare and the filing of the annual cost report. Part I, Line 7b and 7g:Unreimbursed Medicaid and Subsidized Health Services were calculated using the cost report and analyzing the Medicare ratio of cost to charge for the respective cost centers. Part I, line 7e and 7f:Community health improvement services and health professions education are actual costs reported in the general ledger. Part I, Line 7g: Line 7g includes $614,301 of expenses related to a rural health clinic. Part III, Line 2: The amount reported on line 2 represents implicit price concessions. The implicit price concessions included represent the difference between amounts billed to patients and the amounts the Hospital expects to collect based on its collection history with those patients. Part III, Line 3: The organization calculated the amount of implicit price concessions attributable to patients eligible under the financial assistance policy by applying the percentage of charity care of total net patient revenue to the amount of line 2 implicit price concessions. Part III, Line 4: The financial statement footnote regarding implicit price concessions may be found on page 11 and 12 of the attached financial statements. Part III, Line 8: Medicare allowable costs were obtained from the Medicare Cost Report. The Medicare Cost Report is completed based on the rules & regulations set forth by Centers for Medicare and Medicaid Services.If there is a shortfall, the entire Medicare shortfall is a community benefit. Medicare patients are accepted regardless of whether or not a surplus or deficit is realized from providing the services. This basis therefore means providing Medicare services promotes access to healthcare services which is a key community benefit. Part III, Line 9b: The accounts remain in the program for a period of 120 days, if no payments are being made, or longer if the payments are being made on the outstanding balance. After this time period and collection efforts have been exhausted, the accounts will then be placed into a "collection" status, and sent to our Collection Agency; Revenue Enterprise for Health Care, to further final collection efforts. After these accounts have been placed with the Collection Agency and have no activity for 120 days, they will be returned to the business officer for additional consideration and disposition of account. During the entire 240 days they will accept applications for financial assistance. Part VI, Line 2: Community Hospital Association, Inc. continually assesses the community's medical needs through the relationship of our staff to community leaders and community programs that identify community needs, often medical in nature. Although the hospital is not always in a position to expand services and meet all identified needs, maintaining a core menu of services that meets the greatest community need has and continues to direct our strategic planning. Part VI, Line 3: All uninsured and under-insured patients at time of registration are provided with options available in our community for payment of the services provided. This is most often verbal along with a written charity care application. Part VI, Line 4: Wickenburg Community Hospital serves a primary service area population of approximately 23,000 in a rural service area clustered around Wickenburg, AZ. Wickenburg Community Hospital is the only hospital in the service area. The distribution of service area population by age is 0-17, 21%; 18-44, 25%; 45-64, 29%; 65+, 24%. The service area is home to a great number of winter residents, changing the population significantly from winter months to summer months, when the population grows by approximately 40%. Part VI, Line 5: The Hospital's governing body is comprised of persons who reside in the Organization's primary service area. The Hospital applies any surplus funds to improve the Facility and equipment to improve patient care. The Hospital also extends medical staff privileges to other qualified physicians in the community.Wickenburg Community Hospital, designated as a critical access hospital, serves a rural population approximately 35 miles West of the urban area of the greater Phoenix market place of Surprise, AZ. While the distance is not overly great, many of our patients come from rural areas West and North of Wickenburg, requiring them to drive much greater distances to obtain health care services if Wickenburg Community Hospital was not available to them. The most important service we provide is our emergency services and could not exist without our critical access hospital status. Additionally, our rural health clinic provides access to primary care providers in our community that probably would not exist if the hospital did not employ these providers. The availability of diagnostic services locally is very important to our community as a higher average age exists in our community, making it difficult to drive longer distances and spend a greater amount of time in obtaining diagnostic services required by their primary care providers. X 1 1 X X 0 0 0 0 0 0 0 0 0 Michell Wagner Orthopedic Surgeon 359615 0 260 0 1598 0 19951 0 5728 0 387152 0 0 0 Todd Kravetz MD - Chief of Staff, Clinical Medical Director 245209 0 55915 0 2663 0 13849 0 37606 0 355242 0 0 0 Juan Vazquez Physician 227411 0 42378 0 1086 0 19331 0 29861 0 320067 0 0 0 Robert Ripley General Surgeon 255386 0 7645 0 1598 0 20570 0 17982 0 303181 0 0 0 Jackie Lundblad CEO 228599 0 0 0 814 0 4844 0 27853 0 262110 0 0 0 Diane Bejerano Family Physician 215053 0 23933 0 2595 0 9866 0 6132 0 257579 0 0 0 Steven Berstein Radiologist 183160 0 40000 0 0 0 0 0 24338 0 247498 0 0 0 Roger Rose Director of Pharmacy Services 178834 0 100 0 2396 0 3567 0 10873 0 195770 0 0 0 Peter Stachowicz COO 172879 0 100 0 2633 0 3060 0 14912 0 193584 0 0 0 Linda Rankin CNO 177710 0 0 0 8286 0 3479 0 1575 0 191050 0 0 0 Dede Schmallen CHRO 163382 0 0 0 663 0 3416 0 15087 0 182548 0 0 0 Patti Clavette CFO 134783 0 0 0 1298 0 2726 0 25648 0 164455 0 0 0 Part I, Line 1a Description of health club dues: Wickenburg Community Hospital reimburses employees for health club dues which are recorded in the individuals' taxable compensation. Golf club dues were paid to the golf club by the organization, but are not paid for a specific employee. Form 990, Part VI, Section A, line 8b The organization does not have any committees with the authority to act on behalf of the governing body. Form 990, Part VI, Section B, line 11b The Form 990 is prepared by a third party and is reviewed by the CFO. A copy of the Form 990 is made available to the governing board prior to filing with the IRS. Form 990, Part VI, Section B, line 12c All board members and officers are covered under the policy. In connection with any actual or possible conflict of interest, an interested person must disclose the existence of any financial interest and conflict of interest and be given the opportunity to disclose all material facts to the board of directors of the organization. In addition, all interested persons review and sign a compliance certificate annually. After disclosure of any potential conflicts and all material facts, and after any discussion with the interested person, he/she shall leave the governing board meeting and is recused from the discussion and voting on the issue. The remaining board members shall decide if a conflict of interest exists. Form 990, Part VI, Section B, line 15a Review of CEO or top management official compensation: The board chairman, with consultation of other members of the board, reviews independent survey data acquired through the Arizona Hospital & Healthcare Association on executive salaries and reviews the performance of the CEO. This review is done annually by the board in executive session. The salary is documented on a personnel action form (PAF), entered into the payroll system, and then added to the HR file. Review of other officer or key employees compensation: The CEO and HR director use the Arizona Hospital & Healthcare Association survey data to review all positions in the facility, including key employees and other officers. The salary is documented on a Personnel Action Form (PAF), entered into the payroll system, and then added to the HR file. Form 990, Part VI, Section C, line 19 Governing documents, conflict of interest policy, and financial statements are made available to the public by a formal request in writing. Form 990, Part IX, line 11g Purchased Services: Program service expenses 6,262,394. Management and general expenses 1,300,161. Fundraising expenses 0. Total expenses 7,562,555. Professional Fees: Program service expenses 3,583,001. Management and general expenses 206,875. Fundraising expenses 0. Total expenses 3,789,876. Form 990, Part XI, line 9: Change in Interest of Foundation -176,415.