2019-05-14T13:18:12-07:00 2018-06-30 990 2017-07-01 237429117 MADERA COMMUNITY HOSPITAL MADE 5596755555 1250 E Almond Avenue Madera CA 93637 Diane Neff Accounting Manager 5596752823 2019-05-07 216.31.245.206 2017 2019-02-21 02:37:17Z Karen Paolinelli 1250 E Almond Ave Madera CA 93637 93302041 0 X www.maderahospital.org X 1971 CA Madera Community Hospital is dedicated to actively promoting and maintaining the health and well being of residents throughout the Central Valley of California. 21 15 929 87 0 0 632641 312879 89180004 90998360 205692 233584 2053994 1757218 92072331 93302041 0 0 0 0 42249480 43992113 0 0 0 50121133 46040132 92370613 90032245 -298282 3269796 91191085 90612803 28272762 24424684 62918323 66188119 Madera Community Hospital provides Inpatient and Outpatient healthcare services to the citizens of Madera and its surrounding communities. 0 0 57492990 0 91352841 Delivery and Management of General Inpatient and Outpatient Healthcare Services were provided to the citizens of Madera and its surrounding communities. 0 0 0 57492990 1 1 0 0 0 0 0 0 0 0 1 0 0 0 1 0 1 0 0 0 0 0 0 0 0 0 1 1 0 0 1 0 0 0 0 0 1 0 1 0 0 0 0 0 1 0 0 0 1 160 0 1 929 1 0 0 0 0 0 0 X 21 15 1 0 0 0 0 0 0 1 1 0 0 0 1 1 1 1 1 1 1 0 CA X X Mark J Foote 5596755505 1250 E Almond Avenue Madera CA 93637 Mohammad Anwar Board Member 0.5 0 X 0 0 0 Mohammad Arain Board Member 0.5 0 X 0 0 0 Mohammad Ashraf Board Member 0.5 0 X 0 0 0 Jon Basila Board Member 0.5 0 X 0 0 0 Steve Barsotti Board Member 0.5 0 X 0 0 0 Michael Diebert Board Member 0.5 0 X 0 0 0 Anna DaSilva Board Member 0.5 0 X 0 0 0 Deirdre DaSilva Vice Chair 1 0 X 0 0 0 Anita Eden Board Member 0.5 0 X 0 0 0 Brenda Garcia Board Member 0.5 0 X 0 0 0 Stell Manfredi Chairman 1 0 X 0 0 0 Jay Mayhill Board Member 0.5 0 X 0 0 0 Aftab Naz Board Member 0.5 0 X 0 0 0 Wally Nishimoto Board Member 0.5 0 X 0 0 0 Bruce Norton Board Member 0.5 0 X 0 0 0 Monte Pistoresi Secretary 1.00 0 X 0 0 0 Robert Poythress Board Member 0.5 0 X 0 0 0 Liz Salas Board Member 0.5 0 X 0 0 0 Steve Schafer Board Member 0.5 0 X 0 0 0 Don Warnock Board Member 0.5 0 X 0 0 0 Jan Zitek Board Member 0.5 0 X 0 0 0 Karen Paolinelli Exec Director/CEO 40 0 X 225946 0 0 Mark J Foote Vice President - Finance 40 0 X 206770 0 0 Jane Winning Chief Nursing Officer 40 0 X 204348 0 0 Dale Costantino Director, Pharmacy 40 0 X 177844 0 0 Eva Singsing Clinical Coordinator, Med/Surg 36.00 0 X 164351 0 0 Jennifer Holt Director, Maternal Child 40 0 X 158427 0 0 Paula Duclo Family Nurse Practitioner, FHS 40 0 X 151367 0 0 Tammy Thomas ER Clinical Coordinator 36 0 X 149678 0 0 Evan Rayner Former Exec Director/CEO 0.00 0 X 411471 0 0 William Kidd Former Director, Human Resources 40 0 X 149386 0 0 1999588 0 0 69 1 1 0 ARYA Medical Group 1660 E Herndon Ave Suite 101 Fresno CA 93720 Hospital Physician Services 1773015 Gateway Acceptance Co PO Box 4083 Corcard CA 945244053 Registry Nurses Services 1116923 Zaks 1906 Howard Road Madera CA 93637 Security Services 878446 Westways Staffing Services Inc PO Box 970 San Jose CA 95108 Registry Nurses Services 790272 Madera Anesthesia Consultants PO Box 7096 Stockton CA 95267 Anesthesia Services 660000 38 0 0 0 252000 19179 41700 0 312879 Medicare 622000 26227132 26227132 0 0 Medi-Cal 622000 47788352 47788352 0 0 Other Third Party Payers 622000 1317020 1317020 0 0 Other Payers 622000 15665856 15665856 0 0 0 0 0 0 90998360 233584 233584 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 EMR Incentive Payments 622000 120897 120897 0 0 Non-Patient Food Sales 722212 799397 0 0 799397 Rebates & Refunds 622000 355010 0 0 355010 481914 0 0 481914 1757218 93302041 91352841 0 1636321 0 0 0 0 0 0 0 0 637064 204348 432716 0 0 0 0 0 32663707 26018287 6645420 0 244531 189710 54821 0 7706929 5649070 2057859 0 2739882 2174164 565718 0 0 0 0 0 96458 0 96458 0 34500 0 34500 0 0 0 0 0 0 0 0 0 0 0 4174551 4004469 170082 0 27523 0 27523 0 573203 120347 452856 0 1329327 0 1329327 0 0 0 0 0 176987 135000 41987 0 23231 14871 8360 0 0 0 0 0 43101 31992 11109 0 278411 0 278411 0 0 0 0 0 3370684 522561 2848123 0 1537107 0 1537107 0 Supplies 11386167 9391187 1994980 0 Quality Assurance Provider Fees 9050547 0 9050547 0 Other Purchase Service 5051951 2351835 2700116 0 Physician Professional Services 5780597 5756597 24000 0 3105787 928552 2177235 0 90032245 57492990 32539255 0 3178533 6879310 29742284 16958987 0 0 6088861 6352344 0 0 0 0 21873503 28994944 2113373 2169911 607587 609839 88262520 59695053 27506943 28567467 0 0 0 0 0 0 0 0 80001 80001 91191085 90612803 3969880 2864487 0 0 0 0 0 0 0 0 0 0 10130465 7905904 0 0 14172417 13654293 28272762 24424684 X 62918323 66188119 0 0 0 0 62918323 66188119 91191085 90612803 3269796 0 0 0 0 0 X 1 1 0 0 X 130000 84936 214936 0 48921208 23957382 24963826 0 1696 1696 0 0 37421011 34361969 3059042 0 1703669 1374006 329663 28567467 0 Accrued Payroll & Related Liabilities 5476656 Quality Assistance Fees Payable 5474785 Due to Third Party Payor 2702852 13654293 93302041 0 0 0 0 0 93302041 0 0 0 93302041 90032245 0 0 0 0 0 90032245 0 0 0 90032245 1 1 X 1 X 1 X 0 1 0 1 1 349 799675 0 799675 43401257 27012088 16389169 30882879 20598692 10284187 0 349 75083811 47610780 27473031 0 171962 0 171962 122895 0 122895 0 0 0 0 0 0 44294 0 44294 0 0 339151 0 339151 0 0 349 75422962 47610780 27812182 0 64229 0 64229 907 0 907 34806 0 34806 0 0 99942 0 99942 0 1 1356955 0 19890863 28226970 -8336107 X 1 1 4 1 Madera Community Hospital 1250 E Almond Avenue Madera CA 93637 www.maderahospital.org X X X A 2 Madera Community Hospital Family Health Services 1210 E Almond Avenue Madera CA 93637 www.maderahospital.org Provider-Based Rural Health Clinic A 3 Chowchilla Medical Center Clinic 285 Hospital Drive Chowchilla CA 93610 www.maderahospital.org Provider-Based Rural Health Clinic A 4 Madera Community Hospital Outpatient Center 1270 E Almond Avenue Madera CA 93637 www.maderahospital.org Provider-Based Outpatient Laboratory and Radiology Services A A 1 0 1 X X X X X X X X X 16 1 1 0 1 X www.maderahospital.org X www.hospitalcouncil.org 1 16 1 www.maderahospital.org 0 0 1 X 200 350 1 1 X X X 1 X www.maderahospital.org X www.maderahospital.org X X X X 1 X 0 X X X 1 X 0 0 Schedule H, Part V, Section B, Line 5-Group A Madera Community Hospital participated in the 4-County Community Health Needs Assessment that was completed in March, 2016. There were many local focus groups convened within the 4-county area. Participants in the interviews in Madera County included the Madera County Public Health Director, the Executive Director of First 5 of Madera County, Madera Community Hospital CEO and management, Valley Children's Hospital CEO and management and various other local stakeholders. More information about how the Community Health Needs Assessment can be found on the hospital website at www.maderahospital.org. Schedule H, Part V, Section B, Line 6a-Group A Adventist Health Central Valley Network, Kaweah Delta Medical Center, Sierra View District Hospital, Coalinga Regional Medical Center, San Joaquin Valley Rehabilitation Hospital, Tulare Regional Medical Center, Community Medical Centers, Children's Hospital Central California, Kaiser Permanente, Saint Agnes Medical Center, Madera Community Hospital. Schedule H, Part V, Section B, Line 11-Group A Madera Community Hospital has designed and implemented programs to meet the health needs of the community as identified in the most recent and previous Community Health Needs Assessment. The hospital has created and implemented an Implementation Plan to address the top five health needs identified in Madera County. The Implementation Plan can be found on the hospital website www.maderahospital.org. Schedule H, Part I, Line 7 The amounts included in the table for Line 7 are based on amounts taken from the hospital's Medicare Cost Report and the Annual Community Benefits Report. Schedule H, Part II Madera Community Hospital's community building activities mainly consist of training local residents in careers in healthcare. As a result, this activity promotes health in the community by raising the awareness of local residents in our training programs about healthcare topics and these people also help promote good healthcare practices with the people they interact with. Schedule H, Part III, Section A, Line 4 Bad Debt Expense is recorded in the financial statements as the amount of charges written off for each account determined to be uncollectable. The amount on Line 2 is determined by the bad debt expense reported in the financial statements times a cost-to-charge ratio from this year's Medicare Cost Report. The text of the footnote describing bad debt expense in Note A on page 6 of the attached Audited Financial Statements under the paragraph titled "Patient accounts receivable". Schedule H, Part III, Section B, Line 8 All of the shortfall reported on Line 7 is treated as a community benefit cost as they are the unreimbursed costs of providing services to Medicare patients residing in our community. The costs were calculated in the Medicare Cost Report for this period. The revenue was derived from actual and estimated collections on Medicare accounts. Schedule H, Part III, Section C, Line 9b The Bad Debt Collection policy contains procedures for contracted debt collection agencies to return accounts to the hospital if the debtor qualifies for the hospital's Financial Assistance program. Schedule H, Part VI, Line 2 Madera Community Hospital participated in a 4-county Community Health Needs Assessment that was published in March 2016. Various focus groups were formed from members of the local communities to discuss the health needs. Data from a variety of sources was also used to identify certain health needs that need to be address in the hospital's service area. Schedule H, Part VI, Line 3 There are notices on each billing statement that goes to the patient regarding information about the Hospital's Financial Assistance policy. All self-pay patients are given a pamphlet about the availability of the financial assistance program and their access to public benefit programs. There is information also displayed in all public registration areas. Schedule H, Part VI, Line 4 The direct service area of the hospital contains about 125,000 residents, mostly made up of western Madera County. The population is about 54% Hispanic, 30% White/Caucasian, with a mix of other ethnicities. The population has a high number of Medicaid and Medicare patients, many low income families and is generally an agriculture-based economy. Most of the County is part of a Health Professional Shortage Area (HPSA). Schedule H, Part VI, Line 5 Madera Community Hospital is the only local hospital serving all ages in a wide geographic area. It is governed by a community-based, volunteer Board of Trustees. The Medical Staff is open to any qualified practitioner that meets credentialing criteria. The hospital is one of the largest employers in the area, tries to hire employees locally and sponsors programs for high school students and others to enter nursing and other medical fields. The hospital promotes a wide number of programs to support the better health of the residents it serves. All of the various community health and educational programs done by or sponsored by Madera Community Hospital are fully discussed in the Community Benefit Report for this year. Schedule H, Part VI, Line 6 The hospital is a free-standing, community-based, 501(c)(3) organization and is not affiliated with any health system. Schedule H, Part VI, Line 7 California 1 0 0 0 0 0 0 0 0 Evan Rayner Former Exec Director/CEO 315693 0 93000 0 2777 0 2700 0 3128 0 417298 0 0 0 Karen Paolinelli Exec Director/CEO 212141 0 11981 0 1824 0 2274 0 1458 0 229678 0 0 0 Mark J Foote Vice President - Finance 175693 0 28606 0 2471 0 2095 0 2727 0 211592 0 0 0 Jane Winning Chief Nursing Officer 186154 0 11232 0 6962 0 1755 0 1128 0 207231 0 0 0 William Kidd Former Director, Human Resources 139689 0 6017 0 3679 0 492 0 1128 0 151005 0 0 0 Dale Costantino Director, Pharmacy 171103 0 5189 0 1552 0 1795 0 1648 0 181287 0 0 0 Eva Singsing Clinical Coordinator, Med/Surg 163919 0 0 0 432 0 1682 0 3844 0 169877 0 0 0 Jennifer Holt Director, Maternal Child 153370 0 4586 0 470 0 1596 0 1128 0 161150 0 0 0 Paula Duclo Family Nurse Practitioner, FHS 147780 0 1440 0 2147 0 1536 0 2254 0 155157 0 0 0 Tammy Thomas ER Clinical Coordinator 148999 0 0 0 678 0 567 0 582 0 150826 0 0 0 Schedule J, Part I, Line 3 The Board of Trustees reviews and approves the salary for the CEO on an annual basis. The Board uses the California Hospital Association Executive Salary Survey when determining the salary for the CEO. Schedule J, Part I, Line 4 Former CEO Evan Rayner received severance payments in the amount of $178,848. Mohammad Arain Board Member 181364 Physician Services 0 Creative Copy Family Member of Owner 37634 Printing Services 0 Pistoresi Ambulance Owner is Board Member 20617 Ambulance Services 0 Mohammad Ashraf Board Member 117066 Physician Services 0 Aftab Naz Board Member 19400 Physician Services 0 Mohammad Anwar Board Member 228187 Physician Services 0 Form 990, Part VI, Section A, Line 2 Steve Barsotti, Board Member, is MCH Insurance Agent at Foster & Parker Insurance Company that does Business with MCH. Anna da Silva, Board Member, and Deidre da Silva, Board Member, are Mother-in-Law & Daughter-in-Law. Robert Poythress, Board Member, is Manager of Citizen's Business Bank that does Business with MCH. Form 990, Part VI, Section B, Line 11b The Staff Accountant prepares the draft of the Form 990 and Related Schedules and submits them to the Accounting Manager for review. The Chief Financial Officer completes Schedule H and assists in answering the questions related to the governance of the organization. All financial information is tied back to the Audited Financial Statements. The Accounting Manager submits the final draft of the Form 990 and Related Schedules to the Chief Financial Officer for review. The Chief Financial Officer reviews the final draft of the Form 990 and Related Schedules before it is filed. Form 990, Part VI, Section B, Line 12c For any conflicts of interest or complaints of such, an investigation is conducted by the Human Resources Department, Compliance Officer or the Board of Trustees. Depending upon the outcome of the investigation, re-education, training and counseling are conducted as necessary. Form 990, Part VI, Section B, Line 15 Each officer or key employee receives a written performance evaluation on an annual basis. All rate changes are made in accordance with the hospital's wage and salary plan. The hospital uses the California Hospital Association Executive Salary Survey in setting the annual compensation rates. The CEO is reviewed by a Board of Trustees Committee annually. The VP-Finance/CFO, Chief Operating Officer and Chief Nursing Officer are reviewed annually by the CEO. Form 990, Part VI, Section C, Line 19 The Audited Financial Statements and the Form 990 are available upon request in the Hospital's Administration office during normal business hours. They are also part of the information that is available to the public on the California Office of Statewide Health and Planning Department website. The Conflict of Interest policy and the Governing documents are currently not available for public inspection. Madera Community Hospital Foundation 1250 E Almond Avenue Madera CA 93637 942514197 Fundraising CA 501(c)(3) 7 N/A 0 0 0 1 0 0 0 0 0 0 0 0 0 0 0 1 0 1 0 0 Madera Community Hospital Foundation c 252000 Cash Donations Madera Community Hospital Foundation o 92111 Payroll Records Madera Community Hospital Foundation q 5613 Cash We received an approved Extension of Time to File an Exempt Organization Return on Notice Number CP211A dated December 3, 2018.