2021-10-28T11:29:11-05:00 2020-12-31 450250958 Eide Bailly LLP 800 Nicollet Mall Ste 1300 Minneapolis MN 554027033 990 2020-01-01 860096775 Community Hospital Association Inc COMM 9286845421 520 Rose Lane Wickenburg AZ 85390 Patti Clavette CFO 9286845421 2021-10-27 1 Patti Clavette 999009999 Kim Hunwardsen CPA P00484560 6122536500 2021-10-27 0 AAL1 IAL1 2020 2022-09-23 18:48:47Z Wickenburg Community Hospital Patti Clavette 520 Rose Lane Wickenburg AZ 85390 47400278 0 X www.wickhosp.com X 1946 AZ Provide quality health and wellness services where patient, family and community come first. 9 9 341 68 0 0 1184601 9204402 38661755 38026074 74878 49156 51073 92925 39972307 47372557 0 0 0 0 19039073 20918998 0 0 241870 23541717 23330952 42580790 44249950 -2608483 3122607 30512691 38344388 22942122 27486540 7570569 10857848 To provide quality health and wellness services where the patient, family and community come first. 0 0 40677893 38026074 Provide 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. 40677893 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 83 0 1 341 1 0 0 0 0 0 0 0 0 0 0 0 0 X 9 9 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 Dee Pollock Chair 1.00 0.00 X X 0 0 0 Betsy Deibel Vice Chair 1.00 0.00 X X 0 0 0 Jan Currier Secretary 1.00 0.00 X X 0 0 0 John Cook - Director Jan- Feb)/Treasurer (Mar-Dec) 1.00 0.00 X X 0 0 0 Brian Warnock Director 1.00 0.00 X 0 0 0 Bob Johnson Director 1.00 0.00 X 0 0 0 Jenifer Finley Director 1.00 0.00 X 0 0 0 Bob Dunn Director 1.00 0.00 X 0 0 0 Dean Sandvik Director 1.00 0.00 X 0 0 0 Jeanne Morris Director (Jan-Mar) 1.00 0.00 X 0 0 0 Troy Jones DMD Director (Jan-Mar) 1.00 0.00 X 0 0 0 Jackie Lundblad - CFO Jan- Nov)/Interim CEO (Dec) 39.00 1.00 X 170732 0 28289 James Tavary CEO (Jan-Nov) 39.00 1.00 X 195605 0 33674 Todd Kravetz MD - Chief of Staff, Clinical Medical Director 40.00 0.00 X 314361 0 45314 Roger Rose Director of Pharmacy Services 40.00 0.00 X 186924 0 11592 Linda Rankin CNO 40.00 0.00 X 170013 0 23 Michell Wagner Orthopedic Surgeon 40.00 0.00 X 552663 0 18285 Robert Ripley General Surgeon 40.00 0.00 X 402966 0 39618 Juan Vazquez Physician 40.00 0.00 X 255842 0 31595 Lisa Erlinger - Director of Surgical Services & Anesthesia 40.00 0.00 X 232899 0 33981 Tanner Moore Podiatrist 40.00 0.00 X 232495 0 35165 2714500 0 277536 29 0 1 0 Emergency Physicians LLC 1210 Pebble Springs Prescott AZ 86301 Physician Staffing 2313592 Alliance Physical Therapy Group LLC 607 Dewey Ave NW Suite 300 Grand Rapids MI 49501 Physician Staffing 1131846 Rural Physicians Management Company LLC 10624 S Eastern Ave Ste A-263 Henderson NV 89052 Physician Staffing 799129 The Weitz Company LLC 2111 East Highland Avenue Suite 40 Phoenix AZ 85016 Construction 555864 Voyageur Radiology LLC 323 Washington Ave N Suite 200 Minneapolis MN 55401 Imaging 520366 23 9038698 165704 9204402 Patient Service Revenue 621990 34386259 34386259 340B Drug Program 621990 1703216 1703216 1936599 1936599 38026074 76877 76877 92925 0 92925 92925 92925 27721 -27721 -27721 -27721 47372557 38026074 0 142081 X 1169467 1169467 16237011 15895177 99964 241870 268419 268419 2072150 1962754 109396 1171951 1073346 98605 3572 3572 184585 184585 153347 153347 10135564 8698066 1437498 492658 492658 763927 763927 1370300 1370300 168957 168957 444845 106518 338327 2043016 1966086 76930 356300 356300 Medical Supplies 5828503 5828503 Repairs & Maintenance 654365 654365 AHCCCS Tax 510484 510484 Food 82527 82527 138002 138002 44249950 40677893 3330187 241870 219931 2116028 2858794 6284608 7110554 1493215 1665970 122205 271376 33281438 13609430 19210303 19672008 5373177 1066401 1392509 30512691 38344388 4967039 5114335 17975083 15993409 0 6378796 22942122 27486540 X 6890093 10377811 680476 480037 7570569 10857848 30512691 38344388 X 3122607 -80744 260734 -15318 X 0 1 X 1 0 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 1518183 1518183 20937463 7401050 13536413 7873 7873 10434061 6046802 4387259 383858 161578 222280 19672008 CMS Advanced Payments 4435959 Capital Leases 1942837 6378796 X 47304216 -80744 -15318 -96062 47400278 -27721 -27721 47372557 44277671 27721 27721 44249950 0 44249950 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 -15,318. Part XI, Line 4b - Other Adjustments: Loss on Disposal of Assets Reported with Expenses in Audit -27,721. Part XII, Line 2d - Other Adjustments: Loss on Disposal of Assets Reported with Revenue on Form 990 27,721. 1 1 X 1 X 1 X 240.000000000000 1 0 0 222000 222000 0.00500 3832323 2917103 915220 0.02070 4054323 2917103 1137220 0.02570 72439 72439 0.00160 64386 64386 0.00150 8953531 7357040 1596491 0.03610 9090356 7357040 1733316 0.03920 13144679 10274143 2870536 0.06490 1 2859350 33777 13942364 13888593 53771 X 1 1 1 1 Wickenburg Community Hospital 520 Rose Lane Wickenburg AZ 85390 www.wickhosp.com RGH3505 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 2020, we published two Quality Health & Wellness Magazines and distributed them free of charge to the community. This magazine had a spring issue and a fall issue. We partnered with The Wickenburg Sun to help distribute once inside the Wednesday paper, once inside the Weekly Shopper and maintained free access to pick them up at magazine racks through out the towns of Wickenburg, Aguila, Congress and Yarnell. These were also made available through local realtor offices and the Chamber of Congress. The magazines covered a variety of free health care education as well as direction on how to access care in the Wickenburg area. This free to the community publication cost WCH roughly $12,000 in 2020.In addition, education was published electronically through the following channels: -on our website service pages & in the news center blog.-WCH Social media platforms (Facebook, Twitter, Instagram, LinkedIn, Pinterest)-Revel Slides 4 TV Monitors in Waiting areas (ED, Wickenburg Clinic, Surgical Clinic & Specialty Clinic)-Weekly emails to the Wickenburg Chamber and the Town of Wickenburg.In addition to offering free education, the Community Relations office participated in the SW Yavapai Transportation Service committee monthly meetings to assist in planning and implementation of free transportation for community members who needed to travel from Yavapai County down to Wickenburg or Congress for care.Another service that was highly marketed and expanded in 2020 was Pharmacy delivery services which expanded to Yarnell, Salome & Wenden, in addition to Wickenburg and Congress.There were no needs identified in the CHNA that are not being addressed. 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 $845,248 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 1 0 0 0 0 0 0 0 0 Michell Wagner Orthopedic Surgeon 550000 0 0 0 2663 0 18262 0 5731 0 576656 0 0 0 Robert Ripley General Surgeon 388303 0 12000 0 2663 0 16179 0 29069 0 448214 0 0 0 Todd Kravetz MD - Chief of Staff, Clinical Medical Director 245653 0 66045 0 2663 0 13790 0 37232 0 365383 0 0 0 Juan Vazquez Physician 233275 0 21829 0 738 0 13285 0 24018 0 293145 0 0 0 Lisa Erlinger - Director of Surgical Services & Anesthesia 224464 0 7350 0 1085 0 1257 0 37217 0 271373 0 0 0 Tanner Moore Podiatrist 231713 0 0 0 782 0 9701 0 28233 0 270429 0 0 0 James Tavary CEO (Jan-Nov) 184109 0 150 0 11346 0 8210 0 27434 0 231249 0 0 0 Jackie Lundblad - CFO Jan- Nov)/Interim CEO (Dec) 169768 0 150 0 814 0 3805 0 26299 0 200836 0 0 0 Roger Rose Director of Pharmacy Services 178978 0 5550 0 2396 0 3462 0 10023 0 200409 0 0 0 Linda Rankin CNO 168927 0 0 0 1086 0 0 0 1577 0 171590 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. Part I, Line 4a James Tavary received a severance payment of $10,331 in 2020. 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 6,301,117. Management and general expenses 1,261,612. Fundraising expenses 0. Total expenses 7,562,729. Professional Fees: Program service expenses 2,396,949. Management and general expenses 175,886. Fundraising expenses 0. Total expenses 2,572,835. Form 990, Part XI, line 9: Change in Interest of Foundation -15,318.