2017-05-10T12:35:32-05:00 2016-06-30 205949532 RICCI & COMPANY LLC 6200 UPTOWN BLVD NE STE 400 ALBUQUERQUE NM 87110 990 2015-07-01 850442957 CLAYTON HEALTH SYSTEMS INC DBA UNION COUNTY GENERAL HOSPITAL CLAY 5753747008 300 WILSON STREET CLAYTON NM 88415 WILLIAM ROHLOFF CEO 5753747008 2017-05-10 1 MARIA MATONTI P01790899 5053380800 2015 2021-01-29 14:40:06Z WILLIAM ROHLOFF 300 WILSON STREET CLAYTON NM 88415 12819495 0 X WWW.UNIONCOUNTYGENERAL.COM X 1997 NM 25-BED ACUTE CARE CRITICAL ACCESS HOSPITAL SERVING THOSE IN NEED IN AND NEAR UNION COUNTY, NM. 5 5 118 0 0 0 993292 1402633 9746163 11364896 13707 6758 357682 45208 11110844 12819495 0 0 0 0 3599572 4158270 0 0 0 7303328 8098936 10902900 12257206 207944 562289 16919425 16808314 9402359 8728959 7517066 8079355 X THE ORGANIZATION IS A 25-BED ACUTE CARE CRITICAL ACCESS HOSPITAL THAT SERVES THOSE IN NEED IN THE RURAL NEW MEXICO AREA IN, AND AROUND UNION COUNTY, NM. 0 0 9845548 11410104 THE ORGANIZATION OPERATES A 25-BED ACUTE CARE CRITICAL CARE HOSPITAL THAT PROVIDES SERVICES TO INDIVIDUALS FROM NORTHEASTERN NEW MEXICO, SOUTHEASTERN COLORADO, WESTERN PANHANDLE OF OKLAHOMA, AND THE WESTERN PANHANDLE OF TEXAS. THESE SERVICES INCLUDE INPATIENT, SWINGBED, OUTPATIENT AND EMERGENCY TYPES OF PATIENT CARE. THERE WERE A TOTAL OF 7,731 PATIENT VISITS AT UNION COUNTY GENERAL HOSPITAL, AS WELL AS 4,642 AT THE CLAYTON FAMILY PRACTICE CLINIC DURING FISCAL YEAR ENDING 6/30/2016. ALSO, UNION COUNTY GENERAL HOSPITAL IS ONE OF THE SPONSORS OF AN ANNUAL COUNTY-WIDE HEALTH FAIR WHERE HOSPITAL PERSONNEL OBTAIN BLOOD SAMPLES FOR TESTING - 423 PATIENTS WERE DRAWN AT THE HEALTH FAIR, AT SIX LOCAL BUSINESSES, AND SIX SURROUNDING COMMUNITIES BY 54 HOSPITAL PERSONNEL WORKING 228 HOURS. THE PHYSICAL THERAPY DEPARTMENT, AS WELL AS THE RADIOLOGY DEPARTMENT WERE ALSO INVOLVED IN THE HEALTH FAIR, EDUCATING THE PUBLIC ON SERVICES THEY OFFER. 9845548 1 0 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 0 0 0 0 0 0 0 0 0 0 0 0 1 67 0 1 118 1 0 0 0 0 0 0 0 0 0 0 X 5 5 0 1 0 0 0 0 0 1 1 0 0 1 1 1 1 1 1 0 0 0 NM X X THE ORGANIZATION 5753747008 300 WILSON STREET CLAYTON NM 88415 JUDITH COOPER PRESIDENT 2.00 X X 0 0 0 HOLLIE STEEN SECRETARY/TREASURER 2.00 X X 0 0 0 JIM MAYFIELD VICE-PRESIDENT 2.00 X X 0 0 0 GLORIA RICE RAEL DIRECTOR 2.00 X 0 0 0 JIM L BROOK DIRECTOR 2.00 X 0 0 0 GERALD WIESNER INTERIM CEO 40.00 X 0 0 0 ALEXANDER ALTMAN OUTGOING CFO 40.00 X 122962 0 0 PAMELA GALLAGHER INTERIM CFO 40.00 X 0 0 0 TAMMIE CHAVEZ INTERIM COO/CNO 40.00 X 0 0 0 RICHARD FOUTCH DO CHIEF OF STAFF 40.00 X 0 0 0 STACYE BRADLEY DIRECTOR OF NURSING 40.00 X 110702 0 10688 JESSICA MARTIN NURSE PRACTITIONER 40.00 X 117743 0 4422 BARRY DALTON B.O. MANAGER 40.00 X 104960 0 0 456367 0 15110 4 0 0 1 COMMUNITY HOSPITAL CONSULTING 7000 N DALLAS PARKWAY PLANO TX 75024 MEDICAL & ADMIN SERVICES 827469 RHINO MEDICAL SERVICES PO BOX 16253 GREENVILLE SC 29606 MEDICAL SERVICES 586108 DR PAUL WILLETTE 81 BUTTONWOOD RD BEDFORD NH 03110 MEDICAL SERVICES 393400 MEDICAL SERVICES NETWORK LLC 216 W 4TH ST KEENE TX 76059 ANESTHESIA SERVICES 322696 AUREUS RADIOLOGY LLC 13609 CALIFORNIA ST OMAHA NE 68154 RADIOLOGY SERVICES 256543 11 1400291 2342 1402633 NET PATIENT SERVICE REVENUE 621400 11364896 11364896 11364896 6758 6758 OTHER NON-OPERATING INCOME 621400 45208 45208 45208 12819495 11410104 0 6758 X 122962 98370 24592 3400116 2720093 680023 31360 25088 6272 348383 278706 69677 255449 204359 51090 150609 120487 30122 8786 7029 1757 2678219 2133890 544329 25353 20282 5071 397491 317993 79498 206143 164914 41229 193750 135525 58225 182666 146133 36533 705550 564440 141110 368075 294460 73615 PURCHASED SERVICES 1605930 1284744 321186 HOSPITAL & MEDICAL SUPP 864477 691582 172895 EQUIPMENT RENTAL & MAIN 372167 297733 74434 BAD DEBT EXP 339720 339720 12257206 9845548 2411658 0 2624030 1851169 2225399 2734500 436494 1599099 1313391 752393 256085 170148 84918 87340 13481222 3891613 9846278 9589609 132830 24056 16919425 16808314 921103 684635 6735202 6404868 1746054 1639456 9402359 8728959 X 7467066 8029355 50000 50000 7517066 8079355 16919425 16808314 562289 0 X X 0 1 X 1 0 X 11428573 3119154 8309419 2000975 772459 1228516 51674 51674 9589609 ESTIMATED THIRD PARTY SETTLEMENTS 1639456 1639456 13275661 456166 456166 12819495 0 12819495 12713372 456166 456166 12257206 0 12257206 1 1 X 1 X 1 X 1 1 0 1 1 314251 314251 0.02560 398542 398542 0.03250 4158551 1099125 3059426 0.24960 4871344 1099125 3772219 0.30770 4871344 1099125 3772219 0.30770 1241 1241 0.00010 1241 1241 0.00010 0 1257478 943108 3121418 4129327 -1007909 X 1 1 1 1 UNION COUNTY GENERAL HOSPITAL 300 WILSON ST CLAYTON NM 88415 X X X UNION COUNTY GENERAL HOSPITAL 0 0 1 X X X X X X X X X 15 1 0 0 1 X WWW.UCGH.NET X 1 15 1 WWW.UCGH.NET 0 0 1 X 200.000000000000 200.000000000000 X 1 1 X X X 1 X X X 1 0 1 0 0 UNION COUNTY GENERAL HOSPITAL PART V, SECTION B, LINE 5: A COMMUNITY MEETING WAS HELD AT UNION COUNTY GENERAL HOSPITAL. THE HOSPITAL INVITED NUMEROUS MEMBERS OF THE COMMUNITY REPRESENTING A WIDE RANGE OF SECTORS INCLUDING BUSINESS, HEALTH CARE, EDUCATION, AND NON-PROFIT ORGANIZATIONS. A LINK TO A SURVEY FOR ADDITIONAL INPUT TO THE COMMUNITY ASSESSMENT PROCESS WAS INCLUDED WITH THE INVITATION. UNION COUNTY GENERAL HOSPITAL PART V, SECTION B, LINE 11: NEEDS OF MEMBERS OF THE COMMUNITY WERE OUTLINED AND PRIORITIZED AND ARE CONTINUALLY REVIEWED AND ADDRESSED AS A RESULT OF THE CHNA PREPARED IN 2016. ALL NEEDS WERE ADDRESSED IN THE IMPLEMENTATION PLAN. PART I, LINE 7: THE COST METHOD USED TO CALCULATE THE AMOUNTS IN THIS TABLE IS A COST TO CHARGE RATIO. PART II, COMMUNITY BUILDING ACTIVITIES: COMMUNITY HEALTH IS PROMOTED VIA COMMUNITY SUPPORT AND COMMUNITY HEALTH IMPROVEMENT ADVOCACY. PART III, LINE 4: PATIENT ACCOUNTS RECEIVABLE REPRESENT THE AMOUNT BILLED BUT UNCOLLECTED FOR SERVICES PROVIDED TO PATIENTS. SUCH RECEIVABLES ARE CARRIED AT THE BILLED AMOUNT LESS ESTIMATES FOR CONTRACTUAL DISCOUNTS AND ALLOWANCES AS WELL AS FOR DOUBTFUL ACCOUNTS. MANAGEMENT DETERMINES THE ALLOWANCE FOR DOUBTFUL ACCOUNTS BY EXAMINING AGING CATEGORIES BY PAYOR AND BY USING HISTORICAL EXPERIENCE APPLIED TO THE AGING. INDIVIDUAL ACCOUNTS RECEIVABLE ARE WRITTEN OFF WHEN DEEMED UNCOLLECTIBLE. RECOVERIES OF PATIENT ACCOUNTS RECEIVABLE PREVIOUSLY WRITTEN OFF ARE RECORDED WHEN RECEIVED. DELINQUENT STATUS IS BASED ON HOW RECENTLY PAYMENTS HAVE BEEN RECEIVED. THE HOSPITAL DOES NOT ACCRUE INTEREST ON PAST-DUE ACCOUNTS. MANAGEMENT BELIEVES THAT THE ALLOWANCES FOR DOUBTFUL ACCOUNTS AND CONTRACTUAL ALLOWANCES ARE ADEQUATE. BECAUSE OF THE UNCERTAINTY REGARDING THE ULTIMATE COLLECTABILITY OF PATIENT ACCOUNTS RECEIVABLE, THERE IS A POSSIBILITY THAT RECORDED ESTIMATES OF THE ALLOWANCE FOR DOUBTFUL ACCOUNTS AND CONTRACTUAL ALLOWANCES MAY CHANGE IN THE NEAR TERM. PART III, LINE 8: SERVING PATIENTS WITH GOVERNMENT HEALTH BENEFITS, SUCH AS MEDICARE, IS A COMPONENT OF THE COMMUNITY BENEFIT STANDARD THAT TAX-EXEMPT HOSPITALS ARE HELD TO. THIS IMPLIES THAT SERVING MEDICARE PATIENTS IS A COMMUNITY BENEFIT AND THAT THE HOSPITAL OPERATES TO PROMOTE THE HEALTH OF THE COMMUNITY. THE HOSPITAL USES MEDICARE COST REPORT ROUTINE COSTS BASED ON MEDICAID OR MEDICARE DAYS TO TOTAL DAYS AND APPORTIONS ANCILLARY COSTS BASED ON PROGRAM CHARGES TO TOTAL CHARGES. PART III, LINE 9B: WHEN A PATIENT HAS INDICATED OR DEMONSTRATED AN INABILITY TO PAY, AN APPROPRIATE HOSPITAL REPRESENTATIVE WILL PROVIDE THE PATIENT WITH A CHARITY CARE APPLICATION. APPLICATIONS MUST BE COMPLETE IN THEIR ENTIRETY BEFORE CHARITY CARE CAN BE CONSIDERED. THOSE PATIENTS WHO QUALITY FOR FINANCIAL ASSISTANCE FROM A GOVERNMENT PROGRAM SHOULD BE REFERRED TO THE APPROPRIATE AGENCY PRIOR TO CONSIDERATION FOR CHARITY CARE. AN APPLICATION FOR FINANCIAL ASSISTANCE FROM AN OUTSIDE AGENCY SHOULD BE OBTAINED PRIOR TO CHARITY CARE APPROVAL. PART VI, LINE 2: PUBLIC MEETINGS, BOARD MEETINGS, PERFORMANCE IMPROVEMENT AND QUALITY ASSURANCE MEETINGS, EMERGENCY ROOM CALL BACKS. PART VI, LINE 3: PATIENTS ARE INFORMED OF THEIR RIGHTS AND ELIGIBILITY FOR ASSISTANCE AS THEY GO THROUGH THE ADMISSIONS PROCESS. PART VI, LINE 4: UNION COUNTY IS A FRONTIER HOSPITAL WITH A COUNTY POPULATION OF 2,700. THE TOWN OF CLAYTON, WHERE THE HOSPITAL IS LOCATED, IS 45 MILES FROM THE NEAREST HOSPITAL. 0 0 0 0 0 0 0 0 0 PART VII, SECTION A, LINE 5 EXPLANATION: THE ORGANIZATION'S INTERIM CEO, GERALD WIESNER, AS WELL AS THE INTERIM CFO, AND COO/CNO ARE PAID BY COMMUNITY HOSPITAL CORPORATION, AN UNRELATED ORGANIZATION THAT PROVIDES HOSPITAL ADMINISTRATION SERVICES AS WELL AS HOSPITAL BILLING SERVICES. THE CHIEF OF STAFF WAS ALSO PAID BY AN UNRELATED ORGANIZATION THAT PROVIDES HOSPITAL ADMINISTRATIVE SERVICES, RHINO MEDICAL. FORM 990, PART VI, SECTION A, LINE 3 THE HOSPITAL'S CEO, CFO, AND COO/CNO ARE EMPLOYED BY A MANAGEMENT COMPANY. THE CEO IS RESPONSIBLE TO CARRY OUT ALL EXECUTIVE-TYPE DUTIES NORMALLY PERFORMED BY AN EMPLOYEE IN THIS POSITION. FORM 990, PART VI, SECTION B, LINE 11 A DRAFT OF THE ORGANIZATION'S FORM 990 IS PROVIDED TO THE CEO & CFO AND ANY QUESTIONS OR CORRECTIONS ARE ADDRESSED. THEN A COPY OF THE FINAL FORM 990 WITH ALL REQUIRED SCHEDULE IS PROVIDED TO ALL VOTING BOARD MEMBERS FOR THEIR REVIEW PRIOR TO FILING WITH THE IRS. FORM 990, PART VI, SECTION B, LINE 12C THE BOARD OF DIRECTORS, CEO AND ALL OTHER OFFICERS ARE REQUIRED TO ANNUALLY SIGN THE CONFLICT OF INTEREST POLICY AND DISCLOSE ANY POTENTIAL CONFLICTS OF INTEREST AS THEY ARISE. FORM 990, PART VI, SECTION C, LINE 19 THE ORGANIZATION'S FINANCIAL STATEMENTS, GOVERNING DOCUMENTS, AND CONFLICT OF INTEREST POLICY ARE AVAILABLE TO THE PUBLIC UPON REQUEST AT THE ADMINISTRATION OFFICE LOCATED AT 300 WILSON STREET IN CLAYTON, NM. FORM 990, PART IX, LINE 11G PROFESSIONAL & CONSULTING FEES: PROGRAM SERVICE EXPENSES 2,133,890. MANAGEMENT AND GENERAL EXPENSES 544,329. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 2,678,219. FORM 990, PART XII, LINE 2C: THE AUDIT PROCESS HAS NOT CHANGED FROM THE PRIOR YEAR.