2021-07-27T09:14:38-05:00 2020-09-30 450250958 EIDE BAILLY LLP 200 E 10TH ST STE 500 SIOUX FALLS SD 571046375 990 2019-10-01 860107344 WINSLOW MEMORIAL HOSPITAL INC WINS 9282894691 1501 NORTH WILLIAMSON AVENUE WINSLOW AZ 86047 JOHN J DEMPSEY CEO 9282894691 2021-07-22 1 LAURIE HANSON CPA P00851848 6053391999 2021-07-16 2019 2022-09-23 18:48:47Z LITTLE COLORADO MEDICAL CENTER JOHN J DEMPSEY 1501 NORTH WILLIAMSON AVENUE WINSLOW AZ 86047 40542290 0 X WWW.LCMCWMH.COM X 1951 AZ COMPASSIONATE CARE FOR NORTHEASTERN ARIZONA. 10 9 311 10 0 0 15889 621055 38152765 39856629 12880 48226 41379 16380 38222913 40542290 6250 6000 0 0 17635794 19610282 0 0 0 19603199 19174001 37245243 38790283 977670 1752007 33576544 44665290 18299632 27657751 15276912 17007539 X COMPASSIONATE CARE FOR NORTHEASTERN ARIZONA. 0 0 33261010 6000 39856629 WINSLOW MEMORIAL HOSPITAL D/B/A LITTLE COLORADO MEDICAL CENTER (LCMC) GENERAL MEDICAL & SURGICAL HOSPITAL - PRIMARILY ENGAGED IN PROVIDING DIAGNOSTIC, MEDICAL TREATMENT (BOTH SURGICAL AND NONSURGICAL) TO PATIENTS WITH A WIDE VARIETY OF MEDICAL CONDITIONS. LCMC MAINTAINED 25-BEDS, PROVIDED INPATIENTS WITH FOOD SERVICES THAT MET THEIR NUTRITIONAL REQUIREMENTS, AND USED AN ORGANIZED STAFF OF PHYSICIANS AND OTHER MEDICAL STAFF TO PROVIDE PROFESSIONAL CARE SERVICES AS WELL AS OTHER SERVICES. THESE SERVICES INCLUDE OUTPATIENT SERVICES, ANATOMICAL PATHOLOGY SERVICES, DIAGNOSTIC X-RAY SERVICES, CLINICAL LABORATORY SERVICES, OPERATING ROOM SERVICES FOR A VARIETY OF PROCEDURES, AND PHARMACY SERVICES IN THE CITY OF WINSLOW, NAVAJO COUNTY, ARIZONA. LCMC MAINTAINS RECORDS TO IDENTIFY AND MONITOR THE LEVEL OF CHARITY CARE IT PROVIDES WHICH INCLUDE THE COST OF SUPPLIES AND SERVICES FURNISHED UNDER THE CHARITY CARE POLICY ALONG WITH ASSOCIATED EQUIVALENT SERVICE STATISTICS. 33261010 1 1 0 0 0 0 0 0 0 0 1 1 0 0 1 1 1 0 0 0 0 0 0 0 0 0 1 1 1 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 1 1 0 0 0 1 37 0 1 311 1 0 0 0 0 0 0 0 0 0 0 0 0 X 10 9 1 0 0 0 0 0 0 1 0 0 0 0 1 1 1 1 1 0 0 0 AZ X JANICE FREET 9282894691 1501 NORTH WILLIAMSON AVENUE WINSLOW AZ 86047 BRIAN BUCINA MD, SURGEON 40.00 0.00 X 423748 0 48957 RANDALL REID MD, GENERAL MEDICINE 40.00 0.00 X 315693 0 44296 JOHN J DEMPSEY CEO 40.00 0.00 X 313440 0 43553 THOMAS GREENWOOD DIRECTOR, MD, CHIEF OF STAFF BEG 6/20 40.00 0.50 X 254858 0 45716 JANICE FREET CFO 40.00 0.00 X 220552 0 18090 JAMES PAGE MD, GENERAL MEDICINE 40.00 0.00 X 183272 0 36507 JULIA WILLIAMS MD, GENERAL MEDICINE 40.00 0.00 X 167125 0 12724 MICHAEL ROMAN PHARMACIST 40.00 0.00 X 152762 0 18364 RHONDA GREER CHAIRPERSON 5.00 0.50 X X 0 0 0 LOREN SADLER CHARIMAN UNTIL 1/20 5.00 0.50 X 0 0 0 FRANK ARMAO MD SECRETARY/TREASURER 1.00 0.50 X X 0 0 0 JR DESPAIN DIRECTOR 1.00 0.50 X 0 0 0 CHRIS BAVASI DIRECTOR 1.00 0.50 X 0 0 0 ROBERT SALABYE DIRECTOR 1.00 0.50 X 0 0 0 ROBERTA CANO DIRECTOR 1.00 0.50 X 0 0 0 ANDREW DITTO MD DIRECTOR 1.00 0.50 X 0 0 0 DR MATTHEW SUTTON DIRECTOR/CHIEF OF STAFF UNTIL 6/20 1.00 0.50 X 0 0 0 DAREN FRY DIRECTOR BEG 7/20 1.00 0.50 X 0 0 0 ELIZABETH MCKEY DIRECTOR BEG 7/20 1.00 0.50 X 0 0 0 2031450 0 268207 37 0 1 0 MEDICAL SOLUTIONS LLC PO BOX 310737 DES MOINES IA 50331 TEMP STAFFING 521183 WINNCARE LLC 1031 N WARREN WINSLOW AZ 86047 CRNA SERVICES 398772 GITTELMAN ANESTHESIA SERVICES LLC 25587 CONIFER RD CONIFER CO 80433 CRNA SERVICES 244220 DANIEL TUCKER 3520 W COOPER DRIVE FLAGSTAFF AZ 86001 CRNA SERVICES 238900 JG ANESTHESIA SERVICES LLC 2973 N KRISTEN DRIVE FLAGSTAFF AZ 86001 CRNA SERVICES 232220 10 549385 71670 621055 PATIENT SERVICE REVENUE 622110 38531047 38531047 PHARMACY REVENUE 900099 797740 797740 MEAL & VENDING REVENUE 900099 49158 49158 478684 478684 39856629 41268 41268 16380 0 16380 16380 16380 6958 0 6958 6958 6958 40542290 39856629 0 64606 X 6000 6000 968823 366939 601884 14725481 12035362 2690119 439124 414433 24691 2394356 2236360 157996 1082498 1004534 77964 262851 262851 100353 100353 5612145 5479451 132694 26683 7745 18938 1653250 1511123 142127 405539 405539 371048 368944 2104 9508 9508 138352 123027 15325 725652 560315 165337 1574096 1275922 298174 396816 318622 78194 BAD DEBT EXPENSES 3542602 3542602 SUPPLIES 2419129 2411457 7672 EQUIPMENT RENTAL & MAIN 401466 395649 5817 FOOD 146114 143768 2346 1388397 1049249 339148 38790283 33261010 5529273 0 10513763 20530305 6777393 7041083 173925 977948 1179422 247427 402086 35415064 22972701 13360723 12442363 1525365 3070031 33576544 44665290 2804941 2478451 6634037 14581684 14330999 3165471 913007 1048793 18299632 27657751 X 15276912 17007539 15276912 17007539 33576544 44665290 X 1752007 -21380 X 0 1 X 1 0 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 135526 72347 207873 16604224 9454910 7149314 18497615 13517791 4979824 105352 105352 12442363 INVESTMENT IN FOUNDATION 105379 F ASSETS LIMITED AS TO USE 1501026 F OTHER INVESTMENT 1463626 F 3070031 ASSET RETIREMENT OBLIGATION 636818 SETTLEMENT AGREEMENT 126000 DEFERRED COMPENSATION 285975 1048793 X 36978308 -3563982 -3563982 40542290 0 40542290 35247681 0 35247681 3542602 3542602 38790283 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 NET ASSETS OF FOUNDATION -21,380. BAD DEBT EXPENSES -3,542,602. PART XII, LINE 4B - OTHER ADJUSTMENTS: BAD DEBT EXPENSES 3,542,602. 1 1 X 1 X 125.000000000000 1 X 1 1 0 0 425000 425000 0.01210 13188622 15253736 0 0.00000 13613622 15253736 425000 0.01210 8361 8361 0.00020 3651689 1232053 2419636 0.06860 3660050 1232053 2427997 0.06880 17273672 16485789 2852997 0.08090 6000 6000 0.00020 6000 6000 0.00020 0 3542602 1250539 6352847 6325388 27459 X 1 1 1 1 LITTLE COLORADO MEDICAL CENTER 1501 N WILLIAMSON AVE WINSLOW AZ 86047 WWW.LCMCWMH.COM RGH 0076 X X X X LITTLE COLORADO MEDICAL CENTER 1 0 0 1 X X X X X X X X X 19 1 0 1 1 X SEE 7D NARRATIVE X X 1 19 1 HTTPS://WWW.LCMCWMH.COM/ABOUT-US 0 1 X 125.000000000000 300.000000000000 X X X X 1 1 X X X X 1 X SEE 16A-C NARRATIVE X SEE 16A-C NARRATIVE X SEE 16A-C NARRATIVE X X X X X X 1 X 0 X X X X 1 X 0 0 LITTLE COLORADO MEDICAL CENTER PART V, SECTION B, LINE 5: LCMC SOLICITED INPUT FROM MULTIPLE SOURCES IN THE COMMUNITY, INCLUDING GROUPS THAT WORK WITH DISADVANTAGED POPULATIONS. LCMC CONDUCTED THE CHNA DURING THE YEAR ENDED 9/30/20. LCMC SOLICITED INPUT THROUGH FOCUS GROUPS, TOWN MEETINGS, COMMUNITY COALITIONS, COMMUNITY HEALTH SURVEYS, PUBLIC HEALTH AND HOSPITAL DATA, INTERVIEWS WITH MENTAL AND BEHAVIORAL HEALTH PROVIDERS, EMERGENCY SERVICES PERSONNEL, A COMMUNITY ADVISORY COMMITTEE, VOLUNTEER ORGANIZATIONS, AND INDIAN HEALTH SERVICES TO IDENTIFY THE NEEDS OF THE COMMUNITY. DUE TO THE PANDEMIC, ALL OF THIS INFORMATION WAS SOLICITED THROUGH VIDEOCONFERENCING, TELECONFERENCING, AND SURVEYS. LITTLE COLORADO MEDICAL CENTER PART V, SECTION B, LINE 6B: COLLEGE OF PUBLIC HEALTH, THE UNIVERSITY OF ARIZONA, AND HEALTH EQUITY RESEARCH GROUP, NORTHERN ARIZONA UNIVERSITY. LITTLE COLORADO MEDICAL CENTER PART V, SECTION B, LINE 7D: THE CHNA REPORT IS AVAILABLE AT HTTPS://WWW.LCMCWMH.COM/ABOUT-US. LITTLE COLORADO MEDICAL CENTER PART V, SECTION B, LINE 11: THE COMMUNITY HEALTH NEEDS ASSESSMENT WAS COMPLETED DURING THE TAX YEAR AND AS SUCH THE HOSPITAL HAS NOT TAKEN SPECIFIC ACTIONS WITH RESPECT TO THE CURRENT IMPLEMENTATION STRATEGY. THE FOLLOWING COMMUNITY HEALTH AREAS WERE IDENTIFIED AND THE FOLLOWING ACTIONS WILL BE TAKEN BY THE HOSPITAL DURING FUTURE YEARS.KEY FINDINGS OF COMMUNITY HEALTH NEEDS ASSESSMENT 2019:1. DRUG AND ALCOHOL USE DISORDER:WHILE LCMC IS AWARE THAT DRUG AND ALCOHOL DISORDER IS A LONGSTANDING ISSUE, IT REMAINS A SIGNIFICANT CONCERN IN THE COMMUNITY AS WELL, AS PEOPLE STILL GRAPPLE WITH DISPROPORTIONATELY HIGH POVERTY RATES.IMPLEMENTATION PLAN:A. MEASURE ED NUMBERS- QUALITY STAFF WILL BEGIN TRACKING AND TRENDING THE FREQUENCY OF DRUG AND ALCOHOL VISITS IN THE EDB. ESTABLISH COMMUNITY TASK FORCE- WHEN INITIAL NUMBERS HAVE BEEN STUDIED IN APPROXIMATELY THREE MONTHS' TIME, A TASK FORCE WITH COMMUNITY STAKEHOLDERS WILL BE ASSEMBLED TO DISCUSS SHORT/LONG TERM GOALS AND IMPLEMENTATION PLANI. TASK FORCE WILL INCLUDE MEMBERS FROM: COMMUNITY BRIDGES, INC., LCMC ED, ACTION MEDICAL, WINSLOW PD AND WIHCC.C. METRICS WILL BE FOLLOWED, TEAM WILL MEET QUARTERLY2. HEALTH PROVIDER SHORTAGES:CHRONIC PROVIDER SHORTAGES STILL INTERFERE WITH THE EFFICIENT DELIVERY OF HEALTHCARE. LCMC HAS WORKED CLOSELY WITH ITS LOCAL COMMUNITY COLLEGE, NORTHLAND PIONEER COLLEGE, TO CREATE AN INTERCOMMUNITY PIPELINE OF NURSES AND TECHNICIANS. FURTHERMORE, TRANSPORTATION OPTIONS IN THE COMMUNITY HAVE IMPROVED, SUCH AS THE DEVELOPMENT OF THE CITY OF WINSLOW'S TRANSPORTATION SERVICE, WHICH HELPS PATIENTS REACHING PROVIDERS OUTSIDE OF LCMC'S SERVICE AREA. STILL, LCMC IS IN NEED OF PHYSICIANS AND SPECIALISTS. DELAYED CARE IS PRIMARILY CAUSED BY LACK OF READY ACCESS TO PROVIDERS.IMPLEMENTATION PLAN:A. LCMC SHALL CONTINUE TO RECRUIT AND RETAIN SKILLED HEALTHCARE PROVIDERS AND PROFESSIONALS:I. FINDER'S FEE IMPLEMENTATION-FOR PHYSICIANS WHO SIGN A CONTRACT, THE RECRUITING EMPLOYEE WILL GAIN A KICKBACK.II. TELEMEDICINE SERVICES ARE IN THE PROCESS OF BEING IMPLEMENTED AT LITTLE COLORADO PHYSICIAN'S OFFICE (LCPO). LCPO RECENTLY ADDED CAMERAS TO TWO MAIN PROVIDERS' OFFICE COMPUTERS, SO AUDIO/VIDEO APPOINTMENTS ARE NOW AVAILABLE.III. LCPO IS WORKING TO INCREASE THE NUMBER OF VISITING PROVIDERS IN THE CLINIC. SERVICES PROVIDED ARE PAIN MANAGEMENT, PODIATRY, OPHTHALMOLOGY, AND DISABILITY ELIGIBILITY.1. THE CLINIC IS ACTIVELY RECRUITING FOR CARDIOLOGY, ENT, ORTHOPEDICS, UROLOGY, AND BEHAVIORAL HEALTH PROVIDERS.IV. LCPO RENEWED DESIGNATION THE HEALTH RESOURCES SERVICE ADMINISTRATION (HRSA) AS A HEALTH PROVIDERS SHORTAGE AREA (HPSA). THE CURRENT FAMILY PRACTICE HPSA FOR LCPO IS AT 19, WHICH IS AN INCREASE FROM THE PAST SCORE OF 12. THIS WILL ALLOW LCPO TO OFFER IMPROVED STUDENT LOAN FORGIVENESS FOR NEW HIRE PHYSICIANS.3. CHRONIC HEALTH ISSUES:MAJOR CHRONIC HEALTH ISSUES CITED IN THE CHNA 2017 REMAIN A CONCERN FOR THE COMMUNITY. SPECIFICALLY, HEART DISEASE, DIABETES AND BEHAVIORAL HEALTH; THESE ARE AMONG THE MOST FREQUENTLY MENTIONED CHRONIC HEALTH ISSUES OF CHNA PARTICIPANTS IN 2020.IMPLEMENTATION PLAN:A. LCMC WILL CONTINUE TO OFFER CLASSES TO THE COMMUNITY, AS IT STARTED IN EARLY 2020. THESE INCLUDE HEALTHY EATING AND EXERCISE, MANAGEMENT OF ASTHMA AND ALLERGIES, MANAGING STRESS AND INSOMNIA, MANAGING DIABETES: DIET AND MEDICINE, AND MANAGING HIGH BLOOD PRESSURE AND CHOLESTEROL.B. ESTABLISH MENTAL HEALTH TASK FORCE:I. ED NUMBERS WILL BE TRACKED AND TRENDED TO EVALUATE BEHAVIORAL HEALTH VISITS.II. TASK FORCE WITH COMMUNITY STAKEHOLDERS WILL BE ASSEMBLED: COMMUNITY BRIDGES, INC., CHANGEPOINT, HEALTHCHOICE, WIHCC AND LCPO TO DISCUSS SHORT/LONG TERM GOALS AND IMPLEMENTATION PLAN.C. OUTPATIENT CARE COORDINATION: LCPO IMPLEMENTED AN RN OUTPATIENT CARE COORDINATOR IN EARLY 2020. THIS POSITION WILL CONTINUE TO WORK TOWARDS CHRONIC CARE AND PREVENTATIVE CARE MANAGEMENT FOR THE COMMUNITY AND LCPO PATIENTS.4. SOCIO-ECONOMIC CONDITIONS:SOCIO-ECONOMIC CONDITIONS SUCH AS POVERTY, LACK OF ACCESS TO HEALTHY FOOD AND CLEAN WATER ARE ALSO IN THE FOREFRONT OF COMMUNITY CONCERNS. THESE ARE MAJOR FACTORS CONTRIBUTING TO THE CHRONIC AND ACUTE HEALTH CONDITIONS DISCUSSED IN MORE DETAIL IN THE CHNA.IMPLEMENTATION PLAN:A. LCMC WILL CONTINUE TO SUPPORT LOCAL NON-PROFITS-SUCH AS ST. MARY'S FOOD BANK ONCE A MONTH AND DAILY SENIOR CENTER LUNCHES- TO INCREASE THE AVAILABILITY OF COMMUNITY FOOD DELIVERIES AND HEALTH EDUCATION.B. LCMC SHALL REQUEST TO PARTNER WITH COMMUNITY STAKEHOLDERS WITHIN THE NEXT THREE MONTHS TO COLLABORATE ON EDUCATION TO COMMUNITY MEMBERS ON HYGIENE, EXERCISE AND HEALTHY EATING HABITS AS A LOW-COST, UPSTREAM APPROACH TO PREVENTATIVE MEDICINE.C. CONTINUE QUARTERLY LCMC LOWDOWN NEWSLETTERS IN THE CITY OF WINSLOW RESIDENT'S WATER BILLS THAT WERE INITIATED EARLY 2020.5. COVID-19 PANDEMIC:COVID-19 BECAME A STRESS TEST FOR THE COMMUNITY AND HIGHLIGHTED SOME OF THE WEAKNESSES IN A HEALTHCARE SYSTEM THAT DEALS WITH HIGH RATES OF CHRONIC DISEASE AND POVERTY. HOWEVER, COVID-19 ALSO DEMONSTRATED THE INHERENT STRENGTH OF LCMC'S HEALTHCARE PROVIDERS AND THE COMMUNITY THEY SERVE.IMPLEMENTATION PLAN:A. LCMC WILL CONTINUE PARTNERSHIP WITH COMMUNITY STAKEHOLDERS AS IT INITIATED WITH THE COMMUNITY MEETINGS BIWEEKLY.I. LCMC SHALL PLAN TO CONTINUE THIS MEETING MONTHLY/QUARTERLY WITH STAKEHOLDERS AFTER COVID-19 IS NOT A PRIMARY CONCERN FOR THE COMMUNITY.SENIOR HEALTHCARE THROUGH MEALS ON WHEELS. WE CONTINUED TO PROVIDE LUNCHTIME MEALS THROUGH THE CAFETERIA BY DELIVERING MEALS TO SENIORS IN A DRIVE THRU METHOD. WE CONTINUED TO PROVIDE HEALTHIER EATING OPTIONS IN THE CAFETERIA IN A SOCIALLY DISTANCED MANNER. WE HELPED SAINT MARY'S FOOD BANK DISTRIBUTE FOOD BOXES DURING THE PANDEMIC. LITTLE COLORADO MEDICAL CENTER PART V, SECTION B, LINE 13H: PRESUMPTIVE ELIGIBILITY MAY BE DETERMINED ON A CASE-BY-CASE BASIS. LITTLE COLORADO MEDICAL CENTER PART V, SECTION B, LINE 16J: PART V, SECTION B, LINE 16A, B & C: THE FINANCIAL ASSISTANCE POLICY, APPLICATION, AND PLAIN LANGUAUGE SUMMARY OF THE FAP ARE POSTED ON THE ORGANIZATION'S WEBSITE AT HTTPS://WWW.LCMCWMH.COM/PATIENTS---VISITORS.PART V, SECTION B, LINE 16J:A SUMMARY OF THE FINANCIAL ASSISTANCE POLICY WAS POSTED IN THE EMERGENCY ROOM, WAITING ROOMS, ADMISSIONS OFFICE AND WAS MADE AVAILABLE UPON REQUEST.MORE THAN THE LESSER OF 5% OR 1,000 INDIVIDUALS IN THE SERVICE AREA ARE LEP. HOWEVER, THE LANGUAGE SPOKEN, NAVAJO, IS NOT A WRITTEN LANGUAGE. THE FACILITY HAS STAFF WHO SPEAK NAVAJO AND ARE ABLE TO ASSIST PATIENTS IN COMPLETING FINANCIAL ASSISTANCE FORMS. LITTLE COLORADO MEDICAL CENTER PART V, SECTION B, LINE 24: THE HOSPITAL FINANCIAL ASSISTANCE POLICY DOES NOT COVER ELECTIVE PROCEDURES. THE HOSPITAL MAY HAVE CHARGED FAP ELIGIBLE PATIENTS GROSS CHARGES FOR SERVICES THAT ARE NOT COVERED UNDER THE FINANCIAL ASSISTANCE POLICY. 1 1 - LITTLE COLORADO PHYSICIANS OFFICE 201 LEE STREET WINSLOW AZ 86047 PROVIDER BASED RURAL HEALTH CLINIC PART I, LINE 3C: IN ADDITION TO UTILIZING FPG TO DETERMINE ELIGIBILITY FOR FINANCIAL ASSISTANCE, THE HOSPITAL CONSIDERED MEDICAL INDIGENCY, INSURANCE STATUS, AND UNDERINSURANCE STATUS OF PATIENTS. PRESUMPTIVE ELIGIBILITY MAY BE USED ON A CASE-BY-CASE BASIS. PART I, LINE 7: CHARITY CARE EXPENSE WAS CONVERTED TO COST ON LINE 7A BASED ON AN OVERALL COST-TO-CHARGE RATIO ADDRESSING ALL PATIENT SEGMENTS. LINES 7B AND 7E WERE DETERMINED UTILIZING THE ACTUAL GENERAL LEDGER SYSTEM. LINE 7G WAS DETERMINED BASED ON THE COST REPORT. PART I, LINE 7G: SUBSIDIZED HEALTH SERVICES INCLUDES NET COMMUNITY BENEFIT EXPENSE FROM THE CLINIC OF $2,444,332. PART I, LN 7 COL(F): BAD DEBT EXPENSE OF $3,542,602 WAS SUBTRACTED FROM TOTAL OPERATING EXPENSE. PART II, COMMUNITY BUILDING ACTIVITIES: LCMC GAVE $6,000 TO THE LOCAL SENIOR CENTER TO HELP FUND MEALS ON WHEELS AND OTHER HEALTH AND WELLNESS INITIATIVES. PART III, LINE 2: BAD DEBT EXPENSE ON PART III LINES 2 AND 3 IS BASED ON CHARGES. IF AN ACCOUNT IS WRITTEN OFF TO BAD DEBTS, PAYMENTS RECEIVED OR DISCOUNTS GIVEN AFTER THE WRITE OFF FOR THAT ACCOUNT ARE POSTED TO THE CURRENT YEAR RECOVERY FOR BAD DEBT ACCOUNT AS AN OFFSET AGAINST THE CURRENT BAD DEBT EXPENSE. PART III, LINE 3: THE BAD DEBT EXPENSE INCLUDES AN ESTIMATED $1,250,539 OF CHARITY CARE-ELIGIBLE ACCOUNTS THAT ARE CURRENTLY LISTED AS BAD DEBT. UPON REVIEWING THE ACCOUNTS AND THE POVERTY LEVELS OF NAVAJO AND APACHE COUNTIES IN ARIZONA, IT WAS FOUND THAT ABOUT 35.3% OF THE OUTSTANDING BALANCES MAY HAVE BEEN ELIGIBLE UNDER THE FACILITY'S CHARITY CARE POLICY. ALSO FOR THIS REVIEW PROCESS, ANY FAMILIES WITH PRIOR APPLICATIONS FOR CHARITY CARE WERE GIVEN CONSIDERATION. PART III, LINE 4: THE FOOTNOTE TO THE ORGANIZATION'S FINANCIAL STATEMENTS THAT DESCRIBES BAD DEBT EXPENSES IS LOCATED IN FOOTNOTE 1 ON PAGES 7 & 8 OF THE ATTACHED FINANCIAL STATEMENTS. PART III, LINE 8: MEDICARE ALLOWABLE COST OF CARE WAS CALCULATED FROM THE MEDICARE COST REPORT FOR THE FISCAL YEAR ENDING 9/30/2020. MEDICAL SERVICES ARE PROVIDED TO PATIENTS WITH MEDICARE COVERAGE REGARDLESS OF WHETHER OR NOT A SURPLUS OR DEFICIT IS REALIZED. PROVIDING MEDICARE SERVICES PROMOTES ACCESS TO HEALTHCARE SERVICES WHICH ARE VITALLY NEEDED BY OUR COMMUNITY. THE MEDICARE COST REPORT IS COMPLETED BASED ON THE RULES AND REGULATIONS SET FORTH BY THE CENTERS FOR MEDICARE AND MEDICAID SERVICES. PART III, LINE 9B: ONCE THE BALANCE ON THE PATIENT'S ACCOUNT IS READY FOR BILLING THE PATIENT RECEIVES AN INITIAL STATEMENT. THE PATIENT WILL THEN RECEIVE A SECOND STATEMENT AT DAY 30 ALONG WITH A FOLLOW UP PHONE CALL, A THIRD STATEMENT AT DAY 60, A FINAL STATEMENT AT DAY 90 (INCLUDING A NOTICE OF COLLECTION ACTIONS THAT MAY BE TAKEN) WITH A FOLLOW UP PHONE CALL AND IF NO ATTEMPTS HAVE BEEN MADE TO RESOLVE THEIR ACCOUNT, THE PATIENT'S ACCOUNT IS TURNED TO COLLECTIONS AT DAY 121 WITH A NOTIFICATION LETTER SENT TO THE PATIENT INFORMING THEM OF SUCH. IF OUR COLLECTION AGENCY IDENTIFIES A PATIENT IS MEETING FINANCIAL ASSISTANCE ELIGIBILITY CRITERIA, THE PATIENT'S ACCOUNT MAY BE CONSIDERED FOR FINANCIAL ASSISTANCE. COLLECTION ACTIVITY WILL BE SUSPENDED ON ACCOUNTS, AND THE FINANCIAL ASSISTANCE APPLICATION WILL BE REVIEWED. IF THE ENTIRE ACCOUNT BALANCE IS ADJUSTED, THE ACCOUNT WILL BE RETURNED. IF A PARTIAL ADJUSTMENT OCCURS, THE PATIENT FAILS TO COOPERATE WITH THE FINANCIAL ASSISTANCE PROCESS, OR IF THE PATIENT IS NOT ELIGIBLE FOR FINANCIAL ASSISTANCE, COLLECTION ACTIVITY WILL RESUME. REQUESTS FOR CHARITY SHALL BE PROCESSED PROMPTLY AND LITTLE COLORADO MEDICAL CENTER SHALL NOTIFY THE PATIENT OR APPLICANT IN WRITING WITHIN 30 DAYS OF RECEIPT OF A COMPLETED APPLICATION. ACCOUNTS ELIGIBLE FOR CHARITY CARE ARE TO BE ADDRESSED WITHIN 240 DAYS OF FIRST BILL. PART VI, LINE 2: LCMC ASSESSES HEALTH NEEDS BY EVALUATING THE PATIENTS SERVED IN THE CLINICS AND HOSPITAL. LCMC HAS STAFF THAT PARTICIPATE IN VARIOUS ORGANIZATIONS INCLUDING THE COUNCIL FOR AGING, ALICE'S PLACE, THE WINSLOW ROTARY, ETC. STAFF ARE MADE AWARE OF NEEDS OF THE COMMUNITY THROUGH THEIR INVOLVEMENT WITH THESE ORGANIZATIONS. ADDITIONALLY, LCMC HAS MONTHLY MEDICAL EXECUTIVE AND BI-ANNUAL MEDICAL STAFF MEETINGS TO DETERMINE THE HEALTH NEEDS OF THE COMMUNITY. PART VI, LINE 3: LCMC'S PATIENT BILLING STATEMENTS HAVE A NARRATIVE ATTACHED DESCRIBING THE AVAILABILITY OF FINANCIAL ASSISTANCE AND THE CONTACT INFORMATION FOR HOW TO OBTAIN ADDITIONAL INFORMATION. NOTICES OF FINANCIAL ASSISTANCE AVAILABILITY ARE POSTED IN THE ER, WAITING ROOMS, AND ADMISSIONS OFFICE. PART VI, LINE 4: LCMC IS LOCATED IN THE COMMUNITY OF WINSLOW WHICH IS LOCATED IN NAVAJO COUNTY, ARIZONA, AND SERVES THE HEALTHCARE NEEDS OF THE COMMUNITY AND SURROUNDING AREAS. THE SERVICE AREA IS MOSTLY RURAL WITH A POPULATION OF APPROXIMATELY 23,000 PEOPLE. THE AVERAGE HOUSEHOLD INCOME IS $47,236 WITH 50% OF THE POPULATION HAVING AN INCOME OF LESS THAN $35,000. MORE THAN 40% OF THE PATIENTS SERVED BY LCMC ARE ON THE ARIZONA HEALTH CARE COST CONTAINMENT SYSTEM, AND MORE THAN 60% OF THE SERVICE AREA ARE OF NATIVE AMERICAN DESCENT. THE NEAREST HOSPITAL IS 60 MILES FROM WINSLOW. WINSLOW IS IN AN AREA FEDERALLY DESIGNATED AS A HEALTH PROFESSIONAL SHORTAGE AREA, A MEDICALLY UNDERSERVED AREA, AND A PERSISTENT POVERTY COUNTY. PART VI, LINE 5: LCMC'S BOARD OF DIRECTORS ALL RESIDE IN THE ORGANIZATION'S SERVICE AREA WITH THE EXCEPTION OF THREE MEMBERS AT LARGE WHO ARE FROM FLAGSTAFF, AZ. LCMC EXTENDS MEDICAL STAFF PRIVILEGES TO ALL QUALIFIED PROVIDERS IN ITS COMMUNITY AND SURROUNDING AREA FOR SOME OR ALL OF ITS DEPARTMENTS. LCMC REINVESTS SURPLUS FUNDS, IF ANY, TO IMPROVEMENTS IN PATIENT CARE, INCLUDING BUT NOT LIMITED TO EXPANSION OF SERVICES OFFERED, PATIENT EDUCATION, EMPLOYEE EDUCATION, AND EQUIPMENT AND FACILITY RENOVATIONS. PART VI, LINE 6: NONE 1 WINSLOW COUNCIL ON AGING 212 EAST SECOND STREET WINSLOW AZ 86047 860310351 501(C)(3) 6000 MEALS ON WHEELS PROGRAM ASSISTANCE 1 PART I, LINE 2: LCMC PROVIDES ASSISTANCE TO THE COALITION ON AGING TO ASSIST WITH MEALS ON WHEELS, FOOD BANK, AND TRANSPORTATION FOR SENIORS. LCMC MAY PERIODICALLY CONTACT THE COALITION AND REQUEST CONFIRMATION THAT FUNDS ARE USED AS INTENDED. X 0 1 0 0 0 0 0 1 0 BRIAN BUCINA MD, SURGEON 423748 0 0 0 0 0 16900 0 32787 0 473435 0 0 0 RANDALL REID MD, GENERAL MEDICINE 315693 0 0 0 0 0 12600 0 32425 0 360718 0 0 0 JOHN J DEMPSEY CEO 295940 0 17500 0 0 0 12600 0 31673 0 357713 0 0 0 THOMAS GREENWOOD DIRECTOR, MD, CHIEF OF STAFF BEG 6/2 254858 0 0 0 0 0 12900 0 33546 0 301304 0 0 0 JANICE FREET CFO 180552 0 40000 0 0 0 8804 0 9956 0 239312 0 0 0 JAMES PAGE MD, GENERAL MEDICINE 183272 0 0 0 0 0 3690 0 33546 0 220508 0 0 0 JULIA WILLIAMS MD, GENERAL MEDICINE 167125 0 0 0 0 0 3687 0 9645 0 180457 0 0 0 MICHAEL ROMAN PHARMACIST 152762 0 0 0 0 0 6970 0 11966 0 171698 0 0 0 PART I, LINE 3 THE CEO IS COMPENSATED THROUGH A MANAGEMENT AGREEMENT WITH NORTHERN ARIZONA HEALTHCARE (NAH), AN UNRELATED ORGANIZATION. NAH USES THE PROCESSES DESCRIBED IN PART I, QUESTION 3 TO DETERMINE APPROPRIATE COMPENSATION FOR THE CEO. PART I, LINE 4B LCMC ENTERED INTO AN AGREEMENT WITH JOHN DEMPSEY TO PAY HIM A RETENTION BONUS WHICH WILL BE VESTED ON 7/31/2020. THE FULL RETENTION BONUS WILL BE PAID OVER AN EIGHT-YEAR PERIOD IF HE STAYS IN HIS CURRENT POSITION AS CEO UNTIL JULY 31, 2020. THIS DEFERRED COMPENSATION BENEFIT BECAME EFFECTIVE JANUARY 1, 2019. MONTHLY PAYMENTS BEGAN ON JULY 1, 2020. PART I, LINE 7 BONUSES WERE PROVIDED BASED ON COMPLETION OF TASKS DETERMINED AS PART OF THEIR PERFORMANCE PLANS. FORM 990, PART VI, SECTION A, LINE 2 FRANK ARMAO, MD AND MATTHEW SUTTON, MD HAVE A BUSINESS RELATIONSHIP. FORM 990, PART VI, SECTION A, LINE 8B ALL COMMITTEES UTILIZED BY LCMC ARE STRICTLY ADVISORY IN NATURE. FORM 990, PART VI, SECTION B, LINE 11B THE ORGANIZATION'S CEO AND CFO WILL REVIEW THE FORM 990. FORM 990, PART VI, SECTION B, LINE 12C THE ORGANIZATION'S CONFLICT OF INTEREST POLICY IS REVIEWED ON AN ANNUAL BASIS. BOARD MEMBERS, ADMINISTRATOR, AND MANAGERS ARE COVERED UNDER LITTLE COLORADO MEDICAL CENTER'S CONFLICT OF INTEREST POLICY. WHEN A CONFLICT OF INTEREST ARISES, THE COVERED PERSON IS TO DISCLOSE THE CONFLICT TO HIS OR HER IMMEDIATE SUPERVISOR BEFORE A DECISION INVOLVING THE AREA OF CONFLICT IS MADE. MEMBERS WITH A CONFLICT OF INTEREST ARE ALSO NOT ALLOWED TO PARTICIPATE IN THE DECISION MAKING PROCESS. FORM 990, PART VI, SECTION C, LINE 19 THE ORGANIZATION'S GOVERNING DOCUMENTS, CONFLICT OF INTEREST POLICY, AND FINANCIAL STATEMENTS ARE MADE AVAILABLE TO THE PUBLIC UPON REQUEST. FORM 990, PART IX, LINE 11G CONTRACT LABOR: PROGRAM SERVICE EXPENSES 1,541,515. MANAGEMENT AND GENERAL EXPENSES 13,000. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 1,554,515. PROFESSIONAL FEES - MEDICAL: PROGRAM SERVICE EXPENSES 2,341,993. MANAGEMENT AND GENERAL EXPENSES 0. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 2,341,993. PURCH SVCES-OTHER: PROGRAM SERVICE EXPENSES 1,595,943. MANAGEMENT AND GENERAL EXPENSES 119,694. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 1,715,637. FORM 990, PART XI, LINE 9: CHANGE IN NET ASSETS OF FOUNDATION -21,380. LITTLE COLORADO HEALTHCARE FOUNDATION 1501 NORTH WILLIAMSON AVENUE WINSLOW AZ 86047 208504703 CHARITABLE AZ 501(C)(3) LINE 11 WINSLOW MEMORIAL HOSPITAL INC 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0