2019-05-15T16:26:37-05:00 2018-06-30 381357951 PLANTE & MORAN PLLC 8181 E TUFTS AVE SUITE 600 DENVER CO 80237 990 2017-07-01 841262971 POUDRE VALLEY HEALTH CARE INC POUD 9702377000 2315 E HARMONY ROAD NO 200 FORT COLLINS CO 80528 STEVE SCHWARTZ CHIEF FINANCIAL OFFICER 9702377000 2019-05-15 1 DORI J EGGETT P00645252 3037409400 2019-05-15 208.42.238.142 2019-05-15 10:57:38 MD P 2B300E1FC09CCA321063079848B1E489E0A7BF4B 321DDE24B35CC1D1467AEA03569F7C6B0A555C82 2017 2019-02-21 02:37:17Z KEVIN UNGER 2315 E HARMONY RD 200 FT COLLINS CO 80528 1545168059 0 X WWW.UCHEALTH.ORG X 1994 CO WE IMPROVE LIVES THROUGH LEARNING, HEALING, DISCOVERY, AND THROUGH HUMAN CONNECTION. 12 11 4347 526 8402483 7232949 2840052 2438879 577191100 659740233 22577481 38386133 12670163 12210328 615278796 712775573 41334657 43656988 0 0 216412492 231007789 0 0 0 259555547 276218006 517302696 550882783 97976100 161892790 4835353781 5905134945 3498192542 4290573331 1337161239 1614561614 WE IMPROVE LIVES. IN BIG WAYS THROUGH LEARNING, HEALING AND DISCOVERY. IN SMALL, PERSONAL WAYS THROUGH HUMAN CONNECTION. BUT IN ALL WAYS, WE IMPROVE LIVES. 0 0 507475284 43656988 656997915 POUDRE VALLEY HEALTH CARE INC. (PVHC) PROVIDES TERTIARY, ACUTE, INPATIENT, OUTPATIENT AS WELL AS EMERGENCY CARE. PVHC SERVICES COMMUNITIES IN NORTHERN COLORADO, SOUTHWESTERN NEBRASKA, AND SOUTHEASTERN WYOMING. DURING FISCAL YEAR 2018, PVHC RECORDED 58,908 PATIENT DAYS, 15,669 ADMISSIONS, 292,627 OUTPATIENT VISITS, 65,233 EMERGENCY VISITS, 1,986 DELIVERIES, 4,105 INPATIENT SURGERIES, AND 5,759 OUTPATIENT SURGERIES. 507475284 1 1 0 1 0 0 0 0 0 1 1 0 0 1 1 0 0 1 0 0 0 0 0 0 0 0 1 1 1 0 1 1 0 0 0 0 0 0 0 0 0 0 1 0 0 0 1 1 1 1 0 0 1 225 0 1 4347 1 1 1 0 0 0 0 0 0 0 0 0 X 12 11 0 0 0 0 0 0 0 1 1 0 0 1 1 1 1 1 1 1 1 1 1 X STEVE SCHWARTZ 9702377000 2315 E HARMONY ROAD SUITE 200 FORT COLLINS CO 80528 MIKE DELLENBACH BOARD CHAIR 1.00 2.00 X X 0 0 0 DENNIS HOUSKA VICE BOARD CHAIR 1.00 2.00 X X 0 0 0 CHRISTINE CHIN BOARD MEMBER 1.00 2.00 X 0 0 0 LISA CLAY BOARD MEMBER 1.00 2.00 X 0 0 0 DOUG ERION BOARD MEMBER 1.00 2.00 X 0 0 0 CHRIS OSBORN BOARD MEMBER 1.00 2.00 X 0 0 0 JIM PARKE BOARD MEMBER 1.00 2.00 X 0 0 0 JAMES SPROWELL MD BOARD MEMBER 1.00 2.00 X 0 0 0 DAN STROH BOARD MEMBER 1.00 2.00 X 0 0 0 KEVIN UNGER PRESIDENT/CEO 25.00 26.00 X X 428022 428022 102724 TESS HEFFERNAN DIRECTOR 1.00 2.00 X 0 0 0 RICH LOWE DIRECTOR 1.00 2.00 X 0 0 0 STEPHANIE DOUGHTY CHIEF FINANCIAL OFFICER 25.00 26.00 X 308293 308293 62176 DIANA BREYER VP CHIEF QUALITY OFFICER 25.00 26.00 X 162675 325352 38210 THOMAS DOWNES CHIEF MEDICAL OFFICER 25.00 26.00 X 310908 310908 58292 YVONNE ROCKWOOD COO (TERM ENDED 07/17) 25.00 26.00 X 153837 153838 27104 RYAN ROHMAN CHIEF OPERATING OFFICER 25.00 26.00 X 145397 145397 30024 DONNA PODUSKA CHIEF NURSING OFFICER 50.00 X 274086 0 37141 DAVID MARCHANT MEDICAL DIRECTOR 50.00 X 318163 0 47597 HERMANN MORENO PSYCHIATRIST 50.00 X 278883 0 48130 DAVID SEHR MEDICAL DIRECTOR 50.00 X 287543 0 50004 KENNETH WATANABE MEDICAL DIRECTOR 50.00 X 320967 0 45692 JANELL WOZNIAK PROGRAM DIRECTOR, FMC 50.00 X 303688 0 40419 3292462 1671810 587513 186 0 1 0 ALLIED UNIVERSITY SECURITY PO BOX 31001-2374 PASADENA CA 91110 SECURITY 3248161 NORTHERN COLORADO HOSPITALISTS 2121 E HARMONY RD 300 FT COLLINS CO 80528 MEDICAL 2247758 FORT COLLINS WOMEN'S CLINIC 1107 S LEMAY AVE 300 FT COLLINS CO 80524 MEDICAL 1966525 SUMMIT PATHOLOGY 5802 WRIGHT DR LOVELAND CO 80538 MEDICAL 1806309 ARUP LABRORATORIES PO BOX 27964 SALT LAKE CITY UT 84127 MEDICAL 1508757 40 1056629 1030696 351554 897843 2438879 NET PATIENT SVC REV 900099 617911409 617911409 PROVIDER FEE INCOME 621400 36118359 36118359 JOINT VENTURE 621400 3438275 2957824 480451 DIETARY SVC INCOME 900099 2223489 2223489 48701 10323 38378 659740233 18358401 18358401 310484 310484 12382457 163477 1809983 163477 10572474 0 10572474 7883654 2688820 850005864 830282737 5879 19723127 -5879 19717248 19717248 365816 130410 235406 235406 MISCELLANEOUS REVENUE 621400 1363719 1363719 EHR REVENUE 624100 31598 31598 INCOME TAX REFUND 624100 7131 7131 1402448 712775573 658393232 8402483 43540979 43656988 43656988 2024361 331575 1692786 176394567 163643267 12751300 16253750 14937911 1315839 34024055 31269603 2754452 2311056 2123962 187094 2051 2051 83083 15144 67939 37798 37798 1666643 1666643 26939652 19567353 7372299 3033314 2966964 66350 4066795 3679072 387723 9113678 8331739 781939 2805052 2201071 603981 1204710 974802 229908 504755 476944 27811 7622944 7622944 26465931 23781256 2684675 2569012 134703 2434309 MEDICAL SUPPLIES 121344726 120995558 349168 PROVIDER FEE EXPENSE 27673042 27673042 BAD DEBT 22561634 22561634 TAXES PAID 2823056 2823056 15700130 10529752 5170378 550882783 507475284 43407499 0 101680312 103317710 1910410 2094616 59387946 64649593 44807 44543 9500542 10047221 7126559 9552888 685340817 390967241 309635211 294373576 1039103384 1217788470 26424622 24535932 3280539988 4178730396 4835353781 5905134945 85287624 102376764 1494757 1655984 196985054 184335104 19705807 17304433 85807 68772 3194633493 3984832274 3498192542 4290573331 X 1337161239 1614561614 1337161239 1614561614 4835353781 5905134945 X 161892790 52434159 63073426 X 0 1 X 1 0 X 0 0 0 0 0 0 1 37798 0 0 37798 0 PART II-B, LINE 1: PORTION OF DUES FROM MEMBERSHIP IN CHA AND AHA THAT ARE ATTRIBUTABLE TO LOBBYING ACTIVITIES. 7098243 34394 536004 4257 100183 35255 7528946 6872466 76668 163048 -6188 -12899 33026 7098243 7151577 39217 55040 19049 317893 36426 6872466 7079697 46722 95036 22644 14222 33012 7151577 6455719 409384 261997 4960 9813 32630 7079697 0.06070 0.86190 0.07740 1 1 1 58703442 58703442 283212522 129694847 153517675 99989388 76042388 23947000 189846485 139524164 50322321 53588980 45705842 7883138 294373576 INTERCOMPANY RECEIVABLE 4160946587 DEFERRED DEBT ISSUANCE COSTS 2527838 OTHER RECEIVABLES 4426701 DEFERRED PENSION OUTFLOW COSTS 10829270 4178730396 INTERCOMPANY PAYABLES 3963975964 ACCRUED INTEREST PAYABLE 1816229 OTHER DEFERRED EXPENSES 2525841 PENSION LIABILITIES 16514240 3984832274 739160148 52434159 2103870 54538029 684622119 1666643 26486811 28153454 712775573 525102236 2103870 2103870 522998366 1666643 26217774 27884417 550882783 PART V, LINE 4: ENDOWMENT FUNDS ARE USED FOR THE INTENDED PURPOSE TO FUND SCHOLARSHIPS, EDUCATION, PROGRAMS, AND COMMUNITY BENEFIT. TEMPORARILY RESTRICTED NET ASSETS ARE THOSE WHOSE USE BY THE FOUNDATION HAVE BEEN LIMITED BY THE DONOR TO A SPECIFIC TIME PERIOD OR PURPOSE. THESE NET ASSETS ARE AVAILABLE FOR VARIOUS HEALTH CARE PURPOSES AS DEFINED BY DONORS. THE ENDOWMENT FUND IS OWNED BY POUDRE VALLEY HEALTH SYSTEM FOUNDATION. PART XI, LINE 2D - OTHER ADJUSTMENTS: RENTAL EXPENSE INCLUDED IN EXPENSE ON AFS 1,973,460. COGS REPORTED AS EXPENSE ON AFS 130,410. PART XI, LINE 4B - OTHER ADJUSTMENTS: PROVISION FOR BAD DEBT IN AFS INCOME 22,561,634. CONTRIBUTIONS FROM PV FOUNDATION NOT IN AFS INCOME 158,785. PHARMACY SALES INCLUDED IN EXPENSE ON AFS 38,378. INCOME TAX REFUND REDUCED EXPENSES ON AFS 7,131. RENTAL EXP AS INCOME ON 990 11,828. BOOK VS. TAX ADJUSTMENT IN EQUITY EARNINGS 269,037. INTERCOMPANY EXPENSE ALLOCATIONS 3,440,018. PART XII, LINE 2D - OTHER ADJUSTMENTS: RENTAL EXPENSE INCLUDED IN EXPENSE ON AFS 1,973,460. COGS REPORTED AS EXPENSE ON AFS 130,410. PART XII, LINE 4B - OTHER ADJUSTMENTS: PROVISION FOR BAD DEBT IN AFS INCOME 22,561,634. RENTAL EXP AS INCOME ON 990 11,828. PHARMACY SALES INCLUDED IN EXPENSE ON AFS 38,378. CASH CONTRIBUTIONS FROM FOUNDATION NOT IN AFS REVENUE 158,785. INCOME TAX REFUND REDUCED EXPENSES ON AFS 7,131. INTERCOMPANY EXPENSE ALLOCATION 3,440,018. 1 1 X 1 X 250.000000000000 1 X 0 0 1 1 288236 288236 0.00050 111451742 74897068 36554674 0.06950 14112628 9160001 4952627 0.00940 125852606 84057069 41795537 0.07940 3514901 226978 3287923 0.00630 6094735 809182 5285553 0.01010 4631768 2908724 1723044 0.00330 21293 21293 0.00000 43752223 43752223 0.08320 58014920 3944884 54070036 0.10290 183867526 88001953 95865573 0.18230 22989 22989 0.00000 38650 38650 0.00010 61639 61639 0.00010 1 22882420 129572389 150645413 -21073024 X 0 1 HARMONY SURGERY CENTER LLC AMBULATORY SURGERY 0.50000 0.50000 2 PEAK SURGICAL MANAGEMENT MANAGEMENT SERVICES 0.14000 0.86000 3 HARMONY IMAGING CENTER LLC MEDICAL IMAGING 0.46000 0.54000 4 SURGERY CENTER OF FORT COLLINS AMBULATORY SURGERY 0.26000 0.49000 5 GATEWAY MEDICAL SERVICES REAL ESTATE/MEDICAL EQUIPMENT 0.50000 0.50000 6 EYE AND LASER CENTER OF NORTHERN COLO LLC LASER SURGERY 0.50000 0.50000 7 VEIN AND LASER CENTER OF N COLO LASER SURGERY 0.33000 0.67000 8 PVHS-ICM EHW LLC MEDICAL CLINIC 0.50000 0.50000 1 1 POUDRE VALLEY HOSPITAL 1024 S LEMAY FORT COLLINS CO 80524 X X X X X PHARMACY, LAB, CARDIOVASCULAR POUDRE VALLEY HEALTH CARE 1 0 0 1 X X X X X X X X X 15 1 1 1 1 X SEE PART V, SECTION C X 1 15 0 0 0 1 X 250.000000000000 400.000000000000 X X X X 0 1 X X X 1 X SEE PART V, SECTION C X SEE PART V, SECTION C X X X X 0 1 X X X X X X 1 1 0 POUDRE VALLEY HEALTH CARE PART V, SECTION B, LINE 5: TWO COMMUNITY MEETINGS WERE HELD DURING NOVEMBER 2015 WHERE FINDINGS FROM THE CHNA WERE PRESENTED, QUESTIONS AND COMMENTS WERE RECEIVED AND RESPONSES PROVIDED. PARTICIPANTS IDENTIFIED ADDITIONAL HEALTH ISSUES AND PROVIDED FEEDBACK AS TO HOW THE HOSPITALS MIGHT ADDRESS THEM. ATTENDEES REPRESENTED ORGANIZATIONS SERVING LOW-INCOME, UNINSURED AND MINORITY POPULATIONS. A LIST OF THE ORGANIZATIONS REPRESENTED IS INCLUDED AS AN APPENDIX TO THE CHNA REPORT. THE SECOND MEETING INCLUDED MEMBERS OF A COALITION SERVING LOW-INCOME, HISPANIC INDIVIDUALS. THE SYNOPSIS OF INFORMATION GATHERED DURING THESE MEETINGS IS INCLUDED IN AN APPENDIX OF THE 2016 CHNA REPORT. POUDRE VALLEY HEALTH CARE PART V, SECTION B, LINE 6A: MEDICAL CENTER OF THE ROCKIES ALSO PARTICIPATED IN THE 2016 CHNA. THE GEOGRAPHIC SERVICE AREA FOR BOTH POUDRE VALLEY HOSPITAL & MEDICAL CENTER OF THE ROCKIES IS THE SAME. POUDRE VALLEY HEALTH CARE PART V, SECTION B, LINE 6B: CENTENNIAL HIGH SCHOOL HEALTH CENTER POUDRE SCHOOL DISTRICT - WELLNESS TEAM THOMPSON SCHOOL DISTRICT TEAM WELLNESS & PREVENTION LUTHERAN FAMILY SERVICES THE MATTHEWS HOUSE CITY OF FORT COLLINS - HOUSING AUTHORITY FAMILY CENTER/LA FAMILIA HEALTH DISTRICT OF NORTHERN LARIMER COUNTY HOUSE OF NEIGHBORLY SERVICES LARIMER COUNTY FOOD BANK LARIMER COUNTY DEPARTMENT OF HEALTH AND ENVIRONMENT SALUD FAMILY HEALTH CENTER-FORT COLLINS SUMMITSTONE BEHAVIORAL HEALTH THE CENTER FOR FAMILY OUTREACH VIDA SANA COALITION COLUMBINE HEALTH SYSTEM DEMENTIA FRIENDLY COMMUNITY PARTNERSHIP FOR AGE-FRIENDLY COMMUNITIES SHARING THE CARE CAMPAIGN UCHEALTH - COMMUNITY HEALTH IMPROVEMENT UNITED WAY OF LARIMER COUNTY WELD COUNTY DEPARTMENT OF PUBLIC HEALTH AND ENVIRONMENT PART V, SECTION B, LINE 7A: HTTPS://S3.AMAZONAWS.COM/UCHEALTH-WP-UPLOADS/WP-CONTENT/UPLOADS/2017/04/13015710/COMHEA-CHNA-PVH-MCR-INTERACTIVE.PDF POUDRE VALLEY HEALTH CARE PART V, SECTION B, LINE 11: HEALTH NEED - ACCESS TO CARE FOR OLDER ADULTS, MINORITY AND LOW-INCOME INDIVIDUALS: BOTH POUDRE VALLEY HOSPITAL AND MEDICAL CENTER OF THE ROCKIES PROVIDE A NO-COST COMMUNITY PARAMEDIC HOME BASED SERVICE WHICH PROVIDES CLINICAL REVIEW OF CHRONIC CONDITIONS TO HOME-BOUND OR FRAIL INDIVIDUALS. BOTH HOSPITALS ALSO PROVIDE AN RN HOME VISIT PROGRAM, SERVING MEDICAID-ELIGIBLE WOMEN WITH POST-PARTUM NEWBORN ASSESSMENTS AND LIMITED CASE MANAGEMENT SERVICES. COMMUNITY CASE MANAGEMENT NURSES PROVIDE NO-COST IN-HOME SERVICES TO PERSONS NEEDING ASSISTANCE IN MANAGING CHRONIC DISEASE. HEALTH NEED - CARDIOVASCULAR DISEASE PREVENTION AND CONTROL: BOTH HOSPITALS SUPPORT A SCHOOL-BASED HEART DISEASE SCREENING AND EDUCATION PROGRAM FOR ELEMENTARY, MIDDLE AND HIGH SCHOOL-AGED YOUTH; CHRONIC DISEASE SELF-MANAGEMENT PROGRAMS PROVIDE COUNSELING AND ACHIEVE INCREASED SELF-EFFICACY BY PARTICIPANTS TO MANAGE THEIR CONDITION; COMMUNITY HEALTH WORKER MODEL PROVIDES NO-COST, COMMUNITY-BASED HEART DISEASE ASSESSMENT AND REFERRAL TO SCREENING SERVICES TO LOW-INCOME, OLDER ADULT AND/OR MINORITY POPULATIONS. HEALTH NEED - SUICIDE PREVENTION / SUBSTANCE ABUSE PREVENTION & TREATMENT: PLANNING TEAM FORMED TO DEVELOP METHODS TO IMPLEMENT EVIDENCE-BASED ZERO SUICIDE INITIATIVE AT BOTH HOSPITALS RESULTING IN ADDITIONAL STAFF RECRUITED TO TRAIN NON-BEHAVIORAL STAFF ON SUICIDE PREVENTION AND ALSO FOR BEHAVIORAL HEALTH PREVENTIVE SERVICES; SEVERAL NO-COST CARE COORDINATION INITIATIVES WORK TO REMOVE BARRIERS TO BEHAVIORAL HEALTH CARE FOR VULNERABLE POPULATIONS (E.G. CHILDREN IN FOSTER CARE OR AT RISK FOR REMOVAL FROM BIOLOGICAL HOME / LOW-INCOME, MEDICAID-ELIGIBLE COMMUNITY MEMBERS) BY ENROLLING INDIVIDUALS INTO A PATIENT-CENTERED MEDICAL HOME, ENSURING TIMELY ACCESS TO BEHAVIORAL HEALTH SERVICES, REMOVING TRANSPORTATION OR CHILD-CARE BARRIERS, ETC. FULL DESCRIPTION OF ALL INITIATIVES IS INCUDED IN THE IMPLEMENTATION STRATEGY REPORT ATTACHED. PART V, LINE 16A, FAP WEBSITE:HTTPS://WWW.UCHEALTHBILLPAY.ORG/PAYMENTOPTIONS.ASPX?TABID=4PART V, LINE 16B, FAP APPLICATION WEBSITE:HTTPS://WWW.UCHEALTHBILLPAY.ORG/PAYMENTOPTIONS.ASPX?TABID=4 POUDRE VALLEY HEALTH CARE PART V, SECTION B, LINE 16J: IN ADDITION TO THE ACTIONS PVH TOOK TO WIDELY PUBLICIZE ITS FAP, WHICH ARE CHECKED IN RESPONSE TO PART V, LINE 16, PVH PROVIDED A CONSPICUOUS WRITTEN NOTICE ABOUT THE FAP ON PATIENTS' BILLING STATEMENTS AND VIA CONSPICUOUS PUBLIC DISPLAYS AND OTHER MEASURES REASONABLY CALCULATED TO ATTRACT PATIENTS' ATTENTION, AND IT TRANSLATED THE FAP AND FAP APPLICATION FORM INTO THE PRIMARY LANGUAGE SPOKEN BY LEP POPULATIONS. BECAUSE PVH DID NOT HAVE A PLAIN LANGUAGE SUMMARY OF THE FAP AVAILABLE DURING THE TAX YEAR, IT DID NOT NOTIFY INDIVIDUALS BY OFFERING A PLAIN LANGUAGE SUMMARY. PVH HAS SINCE CORRECTED ITS PRACTICE BY CREATING A PLAIN LANGUAGE SUMMARY AND MAKING IT AVAILABLE WITHOUT CHARGE, UPON REQUEST IN PUBLIC LOCATIONS THROUGHOUT THE HOSPITAL FACILITY AND BY MAIL, AND BY MAKING A PAPER COPY AVAILABLE TO INDIVIDUALS. PVH ALSO IS MAKING A DISCLOSURE IN SECTION VI OF SCHEDULE H, CONSISTENT WITH IRS CORRECTIVE ACTION GUIDELINES OUTLINED IN REVENUE PROCEDURE 2015-21." POUDRE VALLEY HEALTH CARE PART V, SECTION B, LINE 20E: IN ADDITION TO THE REASONABLE EFFORTS CHECKED IN RESPONSE TO PART V, LINE 20, PVH PROVIDED A WRITTEN NOTICE ABOUT UPCOMING ECAS (EXTRAORDINARY COLLECTION ACTION) AT LEAST 30 DAYS PRIOR TO INITIATING THOSE ECAS, BUT BECAUSE PVH DID NOT HAVE A PLAIN LANGUAGE SUMMARY OF THE FAP AVAILABLE DURING THE TAX YEAR, IT DID NOT INCLUDE A PLAIN LANGUAGE SUMMARY WITH SUCH NOTICE. PVH IS CORRECTING ITS PRACTICE BY INCLUDING A PLAIN LANGUAGE SUMMARY WITH THE WRITTEN NOTICE ABOUT UPCOMING ECAS PROVIDED AT LEAST 30 DAYS BEFORE INITIATING ECAS (AND BY WIDELY PUBLICIZING ITS PLAIN LANGUAGE SUMMARY, AS REQUIRED BY REGULATIONS). PVH ALSO IS MAKING A DISCLOSURE IN SECTION VI OF SCHEDULE H, CONSISTENT WITH IRS CORRECTIVE ACTION GUIDELINES OUTLINED IN REVENUE PROCEDURE 2015-21." POUDRE VALLEY HEALTH CARE PART V, SECTION B, LINE 23: DURING THE TAX YEAR, PVH DID NOT CALCULATE AGB, DUE TO A LACK OF CLARITY REGARDING 501(R) REQUIREMENTS. PVH APPLIED A DISCOUNT TO PATIENTS WHO WERE ELIGIBLE FOR FINANCIAL ASSISTANCE, BUT EVEN AFTER APPLICATION OF THE DISCOUNT, SOME PATIENTS PAID MORE THAN AGB (HAD AGB BEEN CALCULATED FOR THE TAX YEAR). PVH HAS SINCE CORRECTED ITS PRACTICES BY CALCULATING AGB AND INCLUDING A DESCRIPTION OF HOW AGB IS CALCULATED IN PVH'S FINANCIAL ASSISTANCE POLICY AND PLAIN LANGUAGE SUMMARY, AND IS INITIATING CORRECTIVE ACTION BY REFUNDING TO FAP-ELIGIBLE PATIENTS AMOUNTS PAID IN EXCESS OF AGB BY SUCH PATIENTS AND BY REVERSING ECAS TAKEN AGAINST SUCH PATIENTS IN RELATION TO AMOUNTS PAID IN EXCESS OF AGB, THUS RESTORING THE INDIVIDUALS TO THE PLACE THEY WOULD HAVE OCCUPIED IF NOT FOR PVH'S ERROR. PVH ALSO IS MAKING A DISCLOSURE IN SECTION VI OF SCHEDULE H, CONSISTENT WITH IRS CORRECTIVE ACTION GUIDELINES OUTLINED IN REVENUE PROCEDURE 2015-21." 24 1 - HARMONY CAMPUS MOB 2121 E HARMONY RD FORT COLLINS CO 80528 ONCOLOGY, HCOR, CARDIAC REHAB, CANCER CENTER 2 - UCHEALTH HARMONY EMERGENCY 4630 SNOW MESA DRIVE FORT COLLINS CO 80528 HARMONY ED 3 - HARMONY CAMPUS AMBULATORY CARE CENTER 2127 E HARMONY RD FORT COLLINS CO 80528 SURGERY CENTER, DIAGNOSTIC CENTER, IMAGING 4 - UCHEALTH PENNOCK PLACE 1025 PENNOCK PLACE FORT COLLINS CO 80524 PHYSICIAN OFFICES (FMC), BLOOD BANK 5 - CENTRE AVE HEALTH AND REHAB-JV 915 CENTRE AVE FORT COLLINS CO 80526 REHAB 6 - MOUNTAIN CREST BEHAVIORAL HEALTH 4601 CORBETT DR FORT COLLINS CO 80528 BEHAVIORAL HEALTH 7 - UCHEALTH WESTBRIDGE 1107 S LEMAY FORT COLLINS CO 80524 SLEEP LAB, WEE STEPS, 8 - UCHEALTH PROSPECT MEDICAL PLAZA 1106 E PROSPECT SUITE 100 FORT COLLINS CO 80524 OUTPATIENT REHAB 9 - SURGERY CENTER OF FT COLLINS-JV 1100 E PROSPECT RD FORT COLLINS CO 80524 SURGERY CENTER 10 - UCHEALTH CHILDREN'S THERAPY 1500 S LEMAY FORT COLLINS CO 80526 THERAPY 11 - UCHEALTH GREELEY MEDICAL CLINIC 1900 16TH STREET GREELEY CO 80631 LAB, RADIOLOGY & ONCOLOGY 12 - UCHEALTH EXPRESS LAB 1025 GARFIELD ST SUITE C FORT COLLINS CO 80524 EXPRESS LAB 13 - WALK IN CLINIC 2211 S COLLEGE AVE FORT COLLINS CO 80525 WALK IN CLINIC 14 - UCHEALTH WINDSOR MEDICAL CENTER 1455 MAIN STREET WINDSOR CO 80550 RADIOLOGY, LAB 15 - THE VEIN AND LASER CENTER-JV 2008 CARIBOU DRIVE FORT COLLINS CO 80525 PHYSICIAN OFFICES 16 - CSU MEDICAL CENTER 151 WEST LAKE FORT COLLINS CO 80525 MEDICAL CENTER 17 - EYE LASER CENTER OF N COLORADO-JV 1725 EAST PROSPECT RD FORT COLLINS CO 80525 PHYSICIAN OFFICES 18 - UCHEALTH WATER VALLEY 1870 MARINA PLAZA DRIVE WINDSOR CO 80550 CLINICAL EDUCATION, MED FITNESS CENTER 19 - PHLEBOTOMY STATION 1107 SOUTH LEMAY AVE FORT COLLINS CO 80526 LAB DRAWS 20 - PHLEBOTOMY STATION 1113 OAKRIDGE DRIVE FORT COLLINS CO 80525 LAB DRAWS 21 - PHLEBOTOMY STATION 2001 S SHIELDS FORT COLLINS CO 80526 LAB DRAWS 22 - PHLEBOTOMY STATION 2025 BIG HORN DRIVE FORT COLLINS CO 80525 LAB DRAWS 23 - PHLEBOTOMY STATION 3519 RICHMOND DRIVE FORT COLLINS CO 80526 LAB DRAWS 24 - COLUMBINE POUDRE HOMECARE-JV 915 CENTRE AVE FORT COLLINS CO 80526 HOME HEALTHCARE PART I, LINE 7: THE ORGANIZATION USED A COST-TO-CHARGE RATIO FOR LINE 7B AND 7C. THE COST-TO-CHARGE RATIO WAS DERIVED FROM WORKSHEET 2, RATIO OF PATIENT CARE TO COST-TO-CHARGES.LINE 7A WAS DERIVED USING A COST-TO-CHARGE RATIO FROM THE COST REPORT.THE INFORMATION FOR LINES 7E THROUGH 7I WAS DERIVED FROM INFORMATION IN THE GENERAL LEDGER AND OTHER FINANCIAL DATA RELATED SPECIFICALLY TO THE VARIOUS TYPES OF COMMUNITY BENEFITS. PART I, LINE 7G: INCLUDES PHYSICIAN GROUPS AS A SUBSIDIZED SERVICE. THESE CLINICS PROVIDE SERVICES IN UNDERSERVED AREAS IN COLORADO, NEBRASKA AND WYOMING. PART I, LN 7 COL(F): TOTAL BAD DEBT EXPENSE REMOVED FROM THE DENOMINATOR PRIOR TO THE PERCENTAGE CALCULATION = $22,882,420 PART II, COMMUNITY BUILDING ACTIVITIES: AS MENTIONED UNDER PROMOTION OF COMMUNITY HEALTH WE HAVE A MULTITUDE OF PROGRAMS DESIGNED TO ADDRESS THE HEALTH OF OUR COMMUNITY INVOLVING ALL AGE GROUPS AND FOCUS ON WHAT AN INDIVIDUAL CAN DO TO IMPROVE HIS/HER HEALTH. MANY OF THE PROGRAMS REFLECTED IN PART II ARE DESIGNED TO PROMOTE HEALTHY OPTIONS AND CHOICES FOR OUR COMMUNITY WHICH IS AN IMPORTANT PART OF OVERALL COMMUNITY HEALTH AND THEREFORE A BENEFIT TO THE COMMUNITY.PART III, LINE 2: ACCOUNTS WITH UNRESOLVED PATIENT LIABILITY AFTER REASONABLE COLLECTION EFFORTS, SET BY POLICY AND IN CONJUNCTION WITH FEDERAL, STATE, AND PAYOR SPECIFIC REGULATIONS, WILL BE ASSIGNED TO BAD DEBT. THESE ACCOUNTS SHALL BE REFERRED TO AN OUTSIDE COLLECTION AGENCY, OR IN SELECTED INSTANCES, ATTORNEYS, FOR ADDITIONAL COLLECTION ACTIVITIES. PART III, LINE 4: PATIENT ACCOUNTS RECEIVABLE ARE REPORTED NET OF ALLOWANCES FOR DOUBTFUL ACCOUNTS, CONTRACTUAL ADJUSTMENTS, AND MEDICALLY INDIGENT ALLOWANCES.PART III, LINE 5: MEDICARE REVENUE WAS COMPUTED AS FOLLOWS:PVHC COST REPORT: $117,918,704CENTER AVE COST REPORT: $3,196,836COLUMBINE HOMECARE COST REPORT: $1,236,216PVHC DISALLOWED PROGRAMS: $2,339,209JOINT VENTURES: $4,881,424TOTAL TO LINE 5: $129,572,389PART III, LINE 6: ALLOWABLE COSTS AS REPORTED ON THE POUDRE VALLEY HEALTH CARE INC. 2017 COST REPORT AGGREGATED WITH DISREGARDED ENTITIES AND OWNERSHIP PORTIONS OF JOINT VENTURES. PART III, LINE 6: MEDICARE ALLOWABLE COSTS OF CARE RELATING TO PAYMENTS WAS COMPUTED AS FOLLOWS:PVHC COST REPORT: $136,446,887CENTRE AVE COST REPORT: $5,923,581COLUMBINE HOMECARE COST REPORT: $1,553,280PVHC DISALLOWED PROGRAMS: $1,188,669JOINT VENTURES: $5,532,996TOTAL TO LINE 6: $150,645,413 PART III, LINE 8: APPROXIMATELY 26.7% OF NET PATIENT SERVICE REVENUE IS FROM PARTICIPATION IN THE MEDICARE PROGRAM, THUS PROVIDING MEDICARE SERVICES PROMOTES ACCESS TO HEALTHCARE SERVICES TO A SIGNIFICANT PORTION OF THE COMMUNITY POPULATION. PART VI, LINE 2: HEALTH CARE NEEDS ARE ADDITIONALLY IDENTIFIED THROUGH COLLABORATIVE RELATIONSHIPS WITH HEALTHCARE PROVIDERS IN THE COMMUNITIES WE SERVE. AN EXAMPLE IS OUR CARE COORDINATION INITIATIVE TARGETED TO AT-RISK CHILDREN WITH SPECIAL HEALTHCARE NEEDS . PHYSICIANS IDENTIFIED THE NEED TO IMPROVE THE COORDINATION AND TIMELINESS OF CARE FOR THIS POPULATION; WE RESPONDED BY DEVELOPING AND STAFFING A CARE COORDINATION / PATIENT NAVIGATION SERVICE MODEL (HEALTHY HARBORS). PART VI, LINE 3: THERE ARE SEVERAL WAYS WE NOTIFY THE PATIENT AND ATTEMPT TO ASSIST THEM. FOR SURGERIES AND HIGH DOLLAR SCHEDULED PROCEDURES, WE PROVIDE THEM WITH AN ESTIMATE AT REGISTRATION AND GO OVER ALL FINANCIAL ASSISTANCE OPTIONS AVAILABLE IF THEY ARE INTERESTED. WE ALSO HAVE FINANCIAL COUNSELORS AVAILABLE EACH DAY THAT CAN ANSWER QUESTIONS AND HELP THEM FILL OUT CHARITY APPLICATIONS. FOR THOSE THAT ARE UNINSURED, OUR CONDITIONS OF SERVICE FORM HAS A SPOT THEY INITIAL STATING THAT WE HAVE OFFERED ASSISTANCE AND MADE THEM AWARE OF PROGRAMS AVAILABLE TO THEM. ONCE A PERSON HAS RECEIVED CARE IN THE ED, WE ALSO HAVE EDUCATED STAFF THAT ASSISTS THEM AND EDUCATES THEM OF WHAT IS AVAILABLE FOR FINANCIAL ASSISTANCE. IN ADDITION, ONCE A PATIENT DOES RECEIVE A STATEMENT OR BILL, THERE IS INFORMATION ON THE BILL OF WHO THEY CAN CALL TO GET INFORMATION ON FINANCIAL ASSISTANCE. ADDITIONALLY, WE WIDELY PUBLICIZE OUR FINANCIAL ASSISTANCE POLICY, AS REQUIRED BY LAW, WITH THE EXCEPTION THAT WE DID NOT HAVE A PLAIN LANGUAGE SUMMARY OF OUR FAB AVAILABLE DURING THE TAX YEAR. PART VI, LINE 4: POUDRE VALLEY HOSPITAL IS A LOCALLY OWNED, PRIVATE, NON-PROFIT ORGANIZATION WITH A STRONG VISION: FROM HEALTHCARE TO HEALTH. BASED IN NORTHERN COLORADO, PVH PROVIDES EVIDENCE-BASED HEALTHCARE AND WELLNESS SERVICES AND PRODUCTS IN COLORADO, NEBRASKA AND WYOMING, ACROSS A SERVICE AREA COVERING MORE THAN 50,000 SQUARE MILES.PVH IS A PART OF UCHEALTH WHICH AIMS TO DELIVER THE HIGHEST QUALITY PATIENT CARE WITH THE HIGHEST QUALITY PATIENT EXPERIENCE. THE PARTNERSHIP COMBINES POUDRE VALLEY HOSPITAL, MEDICAL CENTER OF THE ROCKIES, UCHEALTH MEDICAL GROUP, UNIVERSITY OF COLORADO HOSPITAL AND MEMORIAL HEALTH SYSTEM INTO AN ORGANIZATION DEDICATED TO BUILDING HEALTHIER COMMUNITIES AND PROVIDING UNMATCHED PATIENT CARE IN THE ROCKY MOUNTAIN WEST. THE ORGANIZATION'S MISSION IS WE IMPROVE LIVES. IN BIG WAYS THROUGH LEARNING, HEALING AND DISCOVERY. IN SMALL, PERSONAL WAYS THROUGH HUMAN CONNECTION. BUT IN ALL WAYS WE IMPROVE LIVES. PART VI, LINE 5: WE HAVE IMPLEMENTED A MULTITUDE OF PROGRAMS AND SERVICES THAT ADDRESS THE HEALTH NEEDS OF OUR BROADER COMMUNITY TARGETING ALL AGE GROUPS WHILE MAINTAINING A SPECIAL FOCUS ON SERVING VULNERABLE POPULATIONS. WE ALSO GIVE DOLLARS TO OTHER ENTITIES THAT WORK TO IMPROVE THE HEALTH OF OUR COMMUNITY. EXAMPLES ARE: TEEN PREGNANCY PREVENTION EDUCATION; SUBSTANCE ABUSE PREVENTION EDUCATION FOR YOUTH AND YOUNG ADULTS; OBESITY PREVENTION; IMPROVED FOOD SECURITY FOR LOW INCOME RESIDENTS; AND MENTAL HEALTH SERVICES FOR THE UNDERSERVED. PART VI, LINE 6: ALL THE SERVICES WE OFFER ARE AVAILABLE TO ANYONE THAT USES ANY OF OUR FACILITIES IN THE HEALTH SYSTEM. OUR GEOGRAPHY IS NOT THAT LARGE SO WE ARE ABLE TO ACCOMMODATE THE DIFFERENT COMMUNITIES THAT UTILIZE OUR SERVICES WITH THE SAME LEVEL OF COMMUNITY HEALTH PROGRAMMING. PART VI, LINE 7, REPORTS FILED WITH STATES CO PART VI DISCLOSURE PROVIDED PURSUANT TO REV. PROC. 2015-21:POUDRE VALLEY HEALTH CARE INC ("PVH") PROVIDES THE FOLLOWING INFORMATION PURSUANT TO SECTION 7 OF REVENUE PROCEDURE 2015-21 TO DISCLOSE CERTAIN NONCOMPLIANCE WITH THE REQUIREMENTS APPLICABLE TO CHARITABLE HOSPITALS AT 26 C.F.R. 1-501(R). THE REVENUE PROCEDURE REQUIRES NONCOMPLIANCE TO BE REPORTED ON THE FORM 990 FILED FOR THE YEAR SUCH NONCOMPLIANCE WAS DISCOVERED. SECTION 7.01(1)THE IMPLEMENTING REGULATIONS FOR INTERNAL REVENUE CODE (CODE) SECTIONS 26 U.S.C. 1-501(R)(4), (R)(5), AND (R)(6) REQUIRE A HOSPITAL FACILITY, IN PART, TO: (A) ESTABLISH A FINANCIAL ASSISTANCE POLICY ("FAP"); (B) ENSURE THAT INDIVIDUALS ELIGIBLE FOR ASSISTANCE UNDER THE FAP ARE CHARGED FOR EMERGENCY AND OTHER MEDICALLY NECESSARY CARE NO MORE THAN THE AMOUNT GENERALLY BILLED TO INDIVIDUALS WHO HAVE INSURANCE COVERING EMERGENCY AND OTHER MEDICALLY NECESSARY CARE ("AGB"); AND (C) REFRAIN FROM ENGAGING IN EXTRAORDINARY COLLECTION ACTIONS ("ECAS"), AS DEFINED BY THE REGULATIONS, AGAINST AN INDIVIDUAL TO OBTAIN PAYMENT FOR CARE BEFORE THE HOSPITAL FACILITY HAS MADE REASONABLE EFFORTS TO DETERMINE WHETHER THE INDIVIDUAL IS ELIGIBLE FOR ASSISTANCE FOR THE CARE UNDER ITS FAP. IN THE SUMMER OF 2018, UCHEALTH DISCOVERED CERTAIN ERRORS WITH RESPECT TO ITS FAP AND PLAIN LANGUAGE SUMMARY AND ITS CALCULATION OF AGB DURING A ROUTINE REVIEW CONDUCTED IN 2018 BY UCHEALTH'S FINANCE DEPARTMENT. THE ERRORS, WHICH ARE FURTHER DESCRIBED BELOW, APPLY TO TAX YEARS 2015 THROUGH 2017 AND RESULTED FROM A LACK OF CLARITY OF THE 501(R) REQUIREMENTS AT THE TIME UCHEALTH INITIALLY IMPLEMENTED THE POLICY. PVH'S NONCOMPLIANCE PURSUANT TO 26 C.F.R. SECTIONS 1-501(R)-4, 1-501(R)-5, AND 1-501(R)-6 CONSISTED OF THE FOLLOWING:1. THE FAP THAT PVH ESTABLISHED AND IMPLEMENTED THROUGHOUT THE PERIOD SPECIFIED ABOVE WAS NOT WIDELY PUBLICIZED, PURSUANT TO 26 C.F.R. 1.501(R)-4(B)(1)(II), BECAUSE PVH DID NOT DEVELOP AND MAKE AVAILABLE A PLAIN LANGUAGE SUMMARY, AS FURTHER DESCRIBED AT 26 C.F.R. 1.501(R)-4(B)(5).2. THE FAP THAT PVH ESTABLISHED AND IMPLEMENTED THROUGHOUT THE PERIOD SPECIFIED ABOVE DID NOT INCLUDE ALL ACTIONS THAT PVH MAY HAVE TAKEN IN THE EVENT OF NONPAYMENT, AS REQUIRED BY 26 C.F.R. 1.501(R)-4(B)(1)(III)(D).3. THE FAP THAT PVH ESTABLISHED AND IMPLEMENTED THROUGHOUT THE PERIOD SPECIFIED ABOVE DID NOT INCLUDE A LIST OF PROVIDERS DELIVERING EMERGENCY OR MEDICALLY NECESSARY CARE IN THE HOSPITAL FACILITY THAT SPECIFIED WHICH PROVIDERS WERE COVERED BY PVH'S FAP AND WHICH WERE NOT, AS REQUIRED BY 26 C.F.R. 1.501(R)-4(B)(1)(III)(F).4. THE FAP THAT PVH ESTABLISHED AND IMPLEMENTED THROUGHOUT THE PERIOD SPECIFIED ABOVE DID NOT INCLUDE THE METHODOLOGY USED TO CALCULATE AGB, PURSUANT TO 26 C.F.R. 1.501(R)-4(B)(2)(I)(C). 5. PVH DID NOT DETERMINE AGB PURSUANT TO 26 C.F.R. 1.501(R)-5(B).6. PVH DID NOT ENSURE THAT ALL INDIVIDUALS WHO RECEIVED EMERGENCY OR MEDICALLY NECESSARY CARE AT PVH WHO WERE ELIGIBLE FOR ASSISTANCE UNDER PVH'S FAP WERE CHARGED NO MORE THAN AGB FOR SUCH CARE, PURSUANT TO 26 C.F.R. 1.501(R)-5(A)(1).PVH CALCULATED THAT THE NUMBER OF PATIENT ACCOUNTS THAT RECEIVED EMERGENCY OR MEDICALLY NECESSARY CARE AT PVH, WERE ELIGIBLE FOR ASSISTANCE UNDER PVH'S FAP, AND WERE CHARGED MORE THAN AGB IS 198. AN ESTIMATE OF THE TOTAL AMOUNT OF THE CHARGES THAT EXCEEDED AGB FOR HOSPITAL SERVICES PROVIDED BY PVH IS $141,630.7. PVH DID NOT HAVE A PLAIN LANGUAGE SUMMARY AVAILABLE AS PART OF ITS REASONABLE EFFORTS TO DETERMINE WHETHER THE INDIVIDUAL IS FAP-ELIGIBLE BASED ON NOTIFICATION, AS REQUIRED BY 26 C.F.R. 1.501(R)-6(C)(3)(I) AND FURTHER DEFINED AT 26 C.F.R. 1.501(R)-6(C)(4)(I)(B).SECTION 7.01(2)PVH'S NONCOMPLIANCE AS DESCRIBED ABOVE WAS INADVERTENT AND DID NOT RISE TO THE LEVEL OF WILLFUL OR EGREGIOUS CONDUCT. PROMPTLY UPON DISCOVERY OF THE NONCOMPLIANCE, PVH EXERCISED REASONABLE DILIGENCE TO IDENTIFY THE FULL SCOPE OF NONCOMPLIANCE AND PROMPTLY TOOK CORRECTIVE ACTION. PVH'S CORRECTIVE ACTIONS HAVE INCLUDED, TO DATE, AND WILL INCLUDE:1. UCHEALTH SUBSTANTIALLY REWROTE ITS FAP AND VERIFIED THAT THE FAP CONTAINED ALL OF THE ELEMENTS REQUIRED AT 26 C.F.R. 1.501(R)-4(B), INCLUDING (A) ALL OF THE ACTIONS THAT PVH WILL TAKE IN THE EVENT OF NONPAYMENT, AS REQUIRED BY 26 C.F.R. 1.501(R)-4(B)(1)(III)(D); (B) A LIST OF PROVIDERS DELIVERING EMERGENCY OR MEDICALLY NECESSARY CARE IN THE HOSPITAL FACILITY THAT SPECIFIES WHICH PROVIDERS ARE COVERED BY PVH'S FAP AND WHICH ARE NOT, AS REQUIRED BY 26 C.F.R. 1.501(R)-4(B)(1)(III)(F); AND (C) THE METHODOLOGY USED TO CALCULATE AGB, AS REQUIRED BY 26 C.F.R. 1.501(R)-4(B)(2)(I)(C). UCHEALTH'S REVISED FAP WILL BE APPROVED FOR THE ENTIRE UCHEALTH SYSTEM BY THE UCHEALTH GOVERNING BODY AT ITS MAY OF 2019 MEETING.2. UCHEALTH DEVELOPED A PLAIN LANGUAGE SUMMARY AND VERIFIED THAT IT CONTAINED ALL OF THE ELEMENTS REQUIRED AT 26 C.F.R. 1.501(R)-1(B)(24). UCHEALTH BEGIN IMPLEMENTING ITS REVISED PLAIN LANGUAGE SUMMARY IN MAY OF 2019.3. UCHEALTH TOOK STEPS TO ENSURE THAT ITS REVISED FAP AND PLAIN LANGUAGE SUMMARY ARE WIDELY PUBLICIZED BY POSTING BOTH ON UCHEALTH'S WEBSITE AND MAKING BOTH AVAILABLE THROUGHOUT UCHEALTH FACILITIES, AS REQUIRED BY 26 C.F.R. 1.501(R)-4(B)(1)(II). UCHEALTH ACCOMPLISHED THIS IN MAY OF 2019.4. IN THE FALL OF 2018, PVH CALCULATED ITS AGB FOR EMERGENCY AND OTHER MEDICALLY NECESSARY CARE PROVIDED AT PVH, IN ACCORDANCE WITH 26 C.F.R. 1.501(R)-5(B).5. PVH ISSUED TO EACH INDIVIDUAL WHO RECEIVED EMERGENCY OR MEDICALLY NECESSARY CARE AT PVH DURING THE RELEVANT PERIOD WHO WAS ELIGIBLE FOR ASSISTANCE UNDER PVH'S FAP AND WHO PAID MORE THAN AGB FOR HOSPITAL SERVICES A REFUND FOR THE AMOUNT OF SUCH OVERPAYMENT. PVH ISSUED SUCH REFUND BY SENDING IT VIA U.S. MAIL, ALONG WITH A LETTER DESCRIBING THE PURPOSE OF THE REFUND, ON MAY 15, 2019. UCHEALTH WILL USE DUE DILIGENCE TO LOCATE AN UPDATED ADDRESS FOR ANY INDIVIDUALS WHOSE LETTER AND REFUND CHECK ARE RETURNED DUE TO AN OUTDATED ADDRESS. 6. AS OF THIS FILING, UCHEALTH HAS NOT COMPLETED CALCULATIONS OF OVERPAYMENTS BY INDIVIDUALS ELIGIBLE FOR FINANCIAL ASSISTANCE WHO RECEIVED PROFESSIONAL SERVICES AT PVH PROVIDED BY THE UCHEALTH MEDICAL GROUP ("MEDICAL GROUP"), WHICH DURING THE REQUISITE PERIOD WAS PVH'S SUBSTANTIALLY RELATED ENTITY AS DEFINED AT 26 C.F.R. 1.501(R)-1(B)(28). UCHEALTH WILL SEND REFUNDS, ALONG WITH A LETTER DESCRIBING THE PURPOSE OF THE REFUND, AS SOON AS THOSE CALCULATIONS ARE COMPLETE, WHICH UCHEALTH EXPECTS TO BE ON OR BEFORE MAY 31, 2019. UCHEALTH WILL USE DUE DILIGENCE TO LOCATE AN UPDATED ADDRESS FOR ANY INDIVIDUALS WHOSE LETTER AND REFUND CHECK ARE RETURNED DUE TO AN OUTDATED ADDRESS.7. PVH IS IN THE PROCESS OF REVERSING ANY ECAS ISSUED AGAINST EACH INDIVIDUAL WHO RECEIVED EMERGENCY OR MEDICALLY NECESSARY CARE AT PVH DURING THE RELEVANT PERIOD WHO WAS ELIGIBLE FOR ASSISTANCE UNDER PVH'S FAP AND WHO PAID MORE THAN AGB. REVERSAL INCLUDES, AS APPLICABLE: (A) UNWINDING ANY NEGATIVE REPORT MADE TO CREDIT BUREAUS OR CREDIT REPORTING AGENCIES IN RELATION TO ANY AMOUNT OWED BY AN INDIVIDUAL ELIGIBLE FOR FINANCIAL ASSISTANCE WHO PAID MORE THAN AGB FOR HOSPITAL SERVICES; (B) REFUNDING ATTORNEYS' FEES AND COURT COSTS IN RELATION TO LEGAL PROCESSES INITIATED BY PVH PAID BY INDIVIDUALS ELIGIBLE FOR FINANCIAL ASSISTANCE WHO PAID MORE THAN AGB FOR HOSPITAL SERVICES, WHICH AMOUNT TOTALS $1,053 FOR ALL AFFECTED INDIVIDUALS; AND (C) REFUNDING INTEREST PAID ON LOANS (OF WHICH UCHEALTH IS AWARE) TAKEN BY INDIVIDUALS ELIGIBLE FOR FINANCIAL ASSISTANCE WHO PAID MORE THAN AGB FOR HOSPITAL SERVICES, WHICH AMOUNT TOTALS $138 FOR ALL AFFECTED INDIVIDUALS. UCHEALTH NOTIFIED EACH AFFECTED INDIVIDUAL WHOSE ECA WAS REVERSED OF THE ACTION TAKEN AND THE PURPOSE FOR SUCH ACTION IN THE LETTER DESCRIBED IN ITEM (5), ABOVE, AND INCLUDED THE REFUND, IF ANY, WITH THE REFUND CHECK DESCRIBED IN ITEM (5). UCHEALTH EXPECTS THE CREDIT BUREAUS TO REVERSE NEGATIVE REPORTS BY JULY 30, 2019, DEPENDING ON WHEN THEY UPDATE THEIR RECORDS. 8. PVH WILL INCLUDE A PLAIN LANGUAGE SUMMARY AS PART OF ITS REASONABLE EFFORTS TO DETERMINE WHETHER THE INDIVIDUAL IS FAP-ELIGIBLE BASED ON NOTIFICATION, AS REQUIRED BY 26 C.F.R. 1.501(R)-6(C)(3)(I) AND FURTHER DEFINED AT 26 C.F.R. 1.501(R)-6(C)(4)(I)(B), AND WILL NOT INITIATE ECAS UNTIL MAKING ALL REASONABLE EFFORTS TO DETERMINE WHETHER THE INDIVIDUAL IS FAP-ELIGIBLE.SECTION 7.01(3)PVH HAS REVISED AND NEWLY ESTABLISHED PRACTICES AND PROCEDURES TO MINIMIZE THE LIKELIHOOD OF RECURRING NONCOMPLIANCE WITH THE IRS'S REQUIREMENTS FOR CHARITABLE HOSPITALS AND TO FACILITATE THE PROMPT IDENTIFICATION AND CORRECTION OF ANY FAILURES THAT DO OCCUR, AND WILL PERIODICALLY REVIEW IT POLICIES AND PROCEDURES TO ASSURE THEY ARE UP-TO-DATE AND TO CONFIRM COMPLIANCE. IN ADDITION, PVH HAS APPOINTED SPECIFIC INDIVIDUALS TO ASSURE CONTINUED COMPLIANCE WITH THE 501(R) REGULATIONS. 1 PVH FOUNDATION 2315 E HARMONY ROAD 200 FORT COLLINS CO 80528 741894581 501(C )(3) 1261481 SEE SCH I, PART IV UNIVERSITY OF COLORADO SCHOOL OF MEDICINE 13001 E 17TH PL AURORA CO 80045 846000555 GOVERNMENT 5201007 SEE SCH I, PART IV UCHEALTH MEDICAL GROUP 2315 E HARMONY ROAD 200 FORT COLLINS CO 80528 800348943 501(C )(3) 37117299 SEE SCH I, PART IV UNITED WAY OF LARIMER COUNTY 424 PINE STREET 102 FORT COLLINS CO 80524 846031503 501(C )(3) 27560 SEE SCH I, PART IV 4 PART I, LINE 2: THE ORGANIZATION AWARDS GRANTS BASED ON THE BENEFIT TO THE COMMUNITY. THE ORGANIZATION REQUESTS INFORMATION FROM THE GRANTEES TO ENSURE THAT THE FUNDS WILL BE USED FOR THE SPECIFIED PURPOSE. QUESTION I, PART II, COLUMN H PURPOSE OF GRANT OR ASSISTANCE FOR RELATED ENTITIES, THE GRANTS ARE RELATED TO SPECIFIC REQUESTS. THE FUNDS ARE TO BE USED TO BENEFIT THE HEALTHCARE COMMUNITY OF NORTHERN COLORADO. EACH REQUEST IS EVALUATED ON AN INDIVIDUAL BASIS. FOR NON-RELATED COMMUNITY AND GOVERNMENTAL ORGANIZATIONS, THE GRANTS ARE MADE AT THE DISCRETION OF THE ORGANIZATION. THESE DISCRETIONARY GRANTS ARE TO BE USED TO BENEFIT THE HEALTHCARE COMMUNITY OF NORTHERN COLORADO. X X 1 1 X X X X 1 0 0 0 0 0 0 0 0 KEVIN UNGER PRESIDENT/CEO 283889 283889 135848 135848 8285 8285 47575 47575 3787 3787 479384 479384 0 0 STEPHANIE DOUGHTY CHIEF FINANCIAL OFFICER 239752 239752 64974 64974 3567 3567 24958 24958 6130 6130 339381 339381 0 0 DIANA BREYER VP CHIEF QUALITY OFFICER 147099 294199 15300 30600 276 553 8676 17352 4061 8121 175412 350825 0 0 THOMAS DOWNES CHIEF MEDICAL OFFICER 260372 260372 47813 47813 2723 2723 20036 20036 9110 9110 340054 340054 0 0 YVONNE ROCKWOOD COO (TERM ENDED 07/17) 53885 53886 0 0 99952 99952 10210 10210 3342 3342 167389 167390 0 0 RYAN ROHMAN CHIEF OPERATING OFFICER 116502 116502 28679 28679 216 216 13444 13444 1568 1568 160409 160409 0 0 DONNA PODUSKA CHIEF NURSING OFFICER 211924 0 54763 0 7399 0 25919 0 11222 0 311227 0 0 0 DAVID MARCHANT MEDICAL DIRECTOR 294625 0 23229 0 309 0 26028 0 21569 0 365760 0 0 0 HERMANN MORENO PSYCHIATRIST 271760 0 6538 0 585 0 26028 0 22102 0 327013 0 0 0 DAVID SEHR MEDICAL DIRECTOR 280629 0 6547 0 367 0 26028 0 23976 0 337547 0 0 0 KENNETH WATANABE MEDICAL DIRECTOR 288131 0 32191 0 645 0 26028 0 19664 0 366659 0 0 0 JANELL WOZNIAK PROGRAM DIRECTOR, FMC 274625 0 28662 0 401 0 25727 0 14692 0 344107 0 0 0 PART I, LINE 1A GROSS-UP PAYMENTS: GROSS UP PAYROLL IS CALCULATED AT YEAR END FOR SPECIAL CHECKS CREATED TO ADD SPECIFIC ITEMS TO EMPLOYEE'S FORM W-2 WAGES INCLUDING COUNTRY CLUB DUES, SPOUSE TRAVEL FOR ANNUAL BOARD RETREAT AND SELECT CONFERENCES, AND IMPUTED INCOME ON LIFE INSURANCE POLICIES. CLUB DUES: THE HEALTH SYSTEM EXPECTS THE HOSPITAL MANAGEMENT TO PARTICIPATE IN COMMUNITY LIFE AND THEREFORE THE SYSTEM PAYS SOCIAL CLUB DUES FOR SPECIFIC MEMBERS OF THE SENIOR MANAGEMENT GROUP. THE CLUB DUES ARE ADDED TO THE SENIOR MANAGEMENT'S FORM W-2 ON AN ANNUAL BASIS. PART I, LINE 4A YVONNE ROCKWOOD RECEIVED A SEVERANCE PAYMENT OF $93,463 FROM THE FILING ORGANIZATION AND $93,463 FROM A RELATED ORGANIZATION. A COLORADO HEALTH FACILITIES AUTHORITY SERIES A 840752932 196474W48 2005-03-31 50000000 REFUNDING 1999A BONDS 0 0 0 B COLORADO HEALTH FACILITIES AUTHORITY SERIES B 840752932 196474W48 2005-03-31 26560000 PAYMENT OF COMMERCIAL PAPER DEBT 0 0 0 C UNIVERSITY OF COLORADO HOSPITAL AUTHORITY 2017 SERIES A 841179794 914183BB3 2017-02-16 43493450 REFUNDING 2015A BONDS 0 0 0 D UNIVERISTY OF COLORADO HOSPITAL AUTHORITY 2017 SERIES B1B2 841179794 914183BD9 2017-02-16 57125000 REFUNDING 2015BC BONDS 0 0 0 A 50000000 3645870 653467 1578477 44122186 2005 0 1 1 1 B 26560000 1936686 347122 2384523 21891669 2005 1 0 1 1 C 43493450 43493450 2017 1 0 1 1 D 57125000 97273 57027727 2017 1 0 1 1 A 0 1 0 0 0.00050 0.00050 0 0 1 B 0 1 0 0 0.00050 0.00050 0 0 1 C 0 1 0 0 0.00050 0.00050 0 0 1 D 0 1 0 0 0.00050 0.00050 0 0 1 A 0 0 0 1 0 0 0 0 1 B 0 0 0 1 0 0 0 0 1 C 0 1 0 0 0 1 CITI 10.000000000000 0 0 0 0 1 D 0 1 0 0 1 0 0 0 1 A 1 B 1 C 1 D 1 SCHEDULE K, PART I, COLUMN E BOND ISSUE PRICE THE BOND ISSUE PRICE FOR THE SERIES B BOND DOES NOT EQUAL THE ISSUE PRICE LISTED ON THE FILED FORM 8038 AS THIS BOND WAS SPLIT WITH A RELATED ENTITY. ISSUE PRICE AS REPORTED ON FORM 8038: $83,000,000. SCHEDULE K, PART IV, LINE 2C THE REBATE CALCULATION WAS PERFORMED IN APRIL 2015 FOR BOND ISSUANCES A AND B. A UNIVERISTY OF COLORADO HOSPITAL AUTHORITY 2017 SERIES C1C2 841179794 914183BA5 2017-02-16 18406000 NEW CONSTRUCTION 0 0 0 A 18406000 55315 18350685 2017 0 0 0 1 A 0 1 0 0 0.00050 0.00050 0 0 1 A 0 1 0 0 0 0 0 0 1 A 1 X MEDICAL EQUIPMENT 47 897843 FMV 0 1 0 FORM 990, PART I, LINE 6 PVH HAS 526 ACTIVE VOLUNTEERS IN FISCAL YEAR 2018. AT POUDRE VALLEY HOSPITAL, MEDICAL CENTER OF THE ROCKIES, AND OFF-SITE LOCATIONS, VOLUNTEERS PLAY AN INTEGRAL ROLE IN PROVIDING MUCH NEEDED SUPPORT FOR PATIENTS, VISITORS, PHYSICIANS, AND STAFF. FROM ASSISTING IN SURGERY AND CARDIAC WAITING ROOMS, INFORMATION DESK, VOLUNTEER PATIENT LIASONS, BABY KNITTERS, VOLUNTEENS, AND PET THERAPY TO NAME JUST A FEW OF THE MANY PROGRAMS, EVERY VOLUNTEER CONTRIBUTES TO THE SUCCESS OF POUDRE VALLEY HEALTH SYSTEM TO ENHANCE THE COMFORT AND CARE OF THE PATIENTS AND THEIR FAMILIES. FORM 990, PART VI, SECTION B, LINE 11B THE FORM 990 IS PREPARED BY INDEPENDENT CPAS. A PRELIMINARY DRAFT IS REVIEWED BY THE INTERNAL FINANCE DEPARTMENT. THE FINAL COPY OF THE FORM 990 IS PROVIDED IN AN ELECTRONIC FORMAT TO ALL BOARD OF DIRECTORS PRIOR TO FILING WITH THE IRS. FORM 990, PART VI, SECTION B, LINE 12C THE ORGANIZATION'S CONFLICT OF INTEREST POLICY REQUIRES COMPLETION OF THE FORM ON AN ANNUAL BASIS BY THE BOARD MEMBERS, OFFICERS AND KEY EMPLOYEES OF THE ORGANIZATION. COMPLETED FORMS ARE SUBMITTED AND REVIEWED BY THE INTERNAL COMPLIANCE DEPARTMENT TO ENSURE COMPLIANCE WITH THE WRITTEN POLICY. ANY QUESTIONS OR ULTIMATE ENFORCEMENT WOULD BE HANDLED BY THE COMPLIANCE DEPARTMENT. FORM 990, PART VI, SECTION B, LINE 15 UCHEALTH CONTRACTS WITH HAYGROUP FOR EXECUTIVE COMPENSATION CONSULTING SERVICES. ON OUR BEHALF THE HAYGROUP COLLECTS AND REVIEWS COMPENSATION LEVELS FROM LIKE ORGANIZATION FOR LIKE JOBS AND PROVIDES UCHEALTH WITH THE COMPARATIVE MARKET DATA. THE DATA IS SUBMITTED TO THE CHIEF HUMAN RESOURCES OFFICER WHO ADVISES THE SYSTEM PRESIDENT AND CEO ON COMPENSATION DECISIONS FOR SENIOR EXECUTIVES. BASED ON THE MARKET DATA, THE SYSTEM PRESIDENT AND CEO DETERMINES THE SALARY OF THE ENTITY CEO'S COMPENSATION ANNUALLY. FORM 990, PART VI, SECTION C, LINE 19 GOVERNING DOCUMENTS, CONFLICT OF INTEREST POLICIES, AND FINANCIAL STATEMENTS ARE PROVIDED TO THE PUBLIC BASED ON THE BUSINESS PURPOSE FOR THE REQUEST. THESE REQUESTS ARE ADDRESSED BY THE SENIOR MANAGEMENT TEAM ON A CASE BY CASE BASIS. FORM 990, PART XI, LINE 9: MCR DISTRIBUTIONS TO PVH 64,232,682. BOOK VS. TAX ADJUSTMENT IN EQUITY EARNINGS -269,037. YAMPA EPIC TRANSFER -890,219. TIMBERLINE MEDICAL CLINIC 131 STANLEY AVE ESTES PARK CO 80517 043772090 OUTPATIENT CO -16785 PVHC INC LAKOTA LAKE LLC 2315 E HARMONY RD STE 200 FORT COLLINS CO 80528 841447761 OUTPATIENT CO 7664586 38557887 PVHC INC HERON LAKE LLC 2315 E HARMONY RD STE 200 FORT COLLINS CO 80528 264189163 OUTPATIENT CO 657338 PVHC INC MEDICAL CENTER OF THE ROCKIES 2315 E HARMONY RD STE 200 FORT COLLINS CO 80528 043730045 TERTIARY CARE CO 501(C)(3) LINE 3 PVHC INC 1 PVHS FOUNDATION 2315 E HARMONY RD STE 200 FORT COLLINS CO 80528 741894581 BENEFIT HEALTH CO 501(C)(3) LINE 7 PVHC INC 1 POUDRE VALLEY MEDICAL GROUP 2315 E HARMONY RD STE 200 FORT COLLINS CO 80528 800348943 MEDICAL SERVICES CO 501(C)(3) LINE 10 PVH INC 1 EYE LASER CENTER OF NO COLORADO 1725 E PROSPECT RD FORT COLLINS CO 80525 841518334 LASER SURGERY CO N/A UNRELATED 65102 115431 0 0 0.50000 GATEWAY MEDICAL SERVICES 2500 E PROSPECT RD FORT COLLINS CO 80525 841427970 REAL EST/MED CO N/A UNRELATED 8517865 12361479 0 0 0.50000 THE VEIN AND LASER CENTER OF NO COLORADO 2008 CARIBOU DRIVE FORT COLLINS CO 80525 204943970 MEDICAL SERVICES CO N/A UNRELATED -13185 33798 0 0 0.33330 SURGERY CENTER OF FORT COLLINS 1100 E PROSPECT ROAD FORT COLLINS CO 80525 841541559 SURGICAL PROC CO N/A UNRELATED 399777 1039876 0 0 0.26000 CENTRE AVENUE HEALTH & REHAB FACILITY 947 WORTHINGTON CIRCLE FT COLLINS CO 80526 841560494 NURSING FACILITY CO N/A RELATED -292315 526168 0 0 0.50000 COLUMBINE POUDRE HOME CARE 947 WORTHINGTON CIRCLE FT COLLINS CO 80526 841529817 NURSING CARE CO N/A RELATED 310794 372591 0 0 0.50000 HARMONY SURGERY CENTER 2127 E HARMONY RD 200 FT COLLINS CO 80528 841479751 AMBULATORY SURG CO N/A RELATED 2364475 3060198 0 0 0.50000 HARMONY IMAGING CENTER 1951 WILMINGTON DRIVE FORT COLLINS CO 80528 582479187 MEDICAL IMAGING CO N/A RELATED 698769 1657028 0 0 0.46000 PVHS-ICM EHW 2315 E HARMONY RD STE 200 FORT COLLINS CO 80528 463311308 MEDICAL SERVICES CO N/A RELATED 36056 199412 0 0 0.50000 PEAK SURGICAL MANAGEMENT 2127 E HARMONY RD 200 FORT COLLINS CO 80528 260899618 SURGICAL MGMT CO N/A UNRELATED 151750 87046 0 0 0.14300 PVHS HOME MEDICAL SUPPLY 6820 N COUNTY RD 13 LOVELAND CO 80538 202034599 MEDICAL SUPPLY CO N/A UNRELATED 163490 847939 0 1 0.50000 INNOVATION ENTERPRISES 2315 E HARMONY RD STE 200 FORT COLLINS CO 80528 202036774 IT CONSULTING CO PVHC C 822450 1661359 1.00000 1 1 1 1 1 0 0 1 1 0 1 0 1 1 1 1 1 1 0 1 INNOVATION ENTERPRISES A 119218 TRANSACTION TOTAL INNOVATION ENTERPRISES A 260376 TRANSACTION TOTAL HARMONY SURGERY CENTER A 981917 TRANSACTION TOTAL CENTRE AVENUE HEALTH AND REHAB B 600000 TRANSACTION TOTAL PVHS FOUNDATION B 1261481 TRANSACTION TOTAL POUDRE VALLEY MEDICAL GROUP LLC B 37117299 TRANSACTION TOTAL PVHS FOUNDATION C 1954472 TRANSACTION TOTAL MEDICAL CENTER OF THE ROCKIES G 54482 TRANSACTION TOTAL POUDRE VALLEY MEDICAL GROUP LLC G 85049 TRANSACTION TOTAL POUDRE VALLEY MEDICAL GROUP LLC J 2132787 TRANSACTION TOTAL MEDICAL CENTER OF THE ROCKIES L 9236285 TRANSACTION TOTAL POUDRE VALLEY MEDICAL GROUP LLC L 4062753 TRANSACTION TOTAL EYE LASER CENTER OF NO COLORADO M 152237 TRANSACTION TOTAL POUDRE VALLEY MEDICAL GROUP LLC M 4915864 TRANSACTION TOTAL MEDICAL CENTER OF THE ROCKIES N 4098944 TRANSACTION TOTAL POUDRE VALLEY MEDICAL GROUP LLC N 2682211 TRANSACTION TOTAL HARMONY SURGERY CENTER Q 644663 TRANSACTION TOTAL HARMONY SURGERY CENTER S 2250000 TRANSACTION TOTAL COLUMBINE POUDRE HOME CARE S 550000 TRANSACTION TOTAL GATEWAY MEDICAL SERVICES S 8147677 TRANSACTION TOTAL MEDICAL CENTER OF THE ROCKIES S 64232682 TRANSACTION TOTAL