2017-04-24T18:13:25-05:00 2016-06-30 460403496 CASEY PETERSON LTD 909 ST JOSEPH ST SUITE 101 RAPID CITY SD 57701 990 2015-07-01 830300467 POWELL VALLEY HEALTH CARE INC POWE 3077542267 777 AVENUE H POWELL WY 82435 TERRY ODOM INTERIM CEO 3077542267 2017-04-21 1 DEIDRE BUDAHL CPA P01273830 6053481930 2017-04-24 2015 2021-01-29 14:40:06Z POWELL VALLEY HOSPITAL TERRY ODOM 777 AVENUE H POWELL WY 82435 48441718 0 X WWW.PVHC.ORG X 1992 WY PROVISION OF HEALTHCRE SERVICES 10 8 544 103 0 0 650692 959643 45828351 47421056 53000 39119 26200 21900 46558243 48441718 27292 19699 0 0 28987930 30098111 0 0 0 17725746 18852606 46740968 48970416 -182725 -528698 28525396 28550737 18720440 19274479 9804956 9276258 X TO IMPROVE QUALITY OF LIFE THROUGH EXCELLENT HEALTH CARE. 0 0 40854124 19699 47442956 POWELL VALLEY HEALTH CARE, INC. (HOSPITAL) PROVIDES QUALITY CARE REGARDLESS OF RACE, CREED, SEX, NATIONAL ORIGIN, HANDICAP, AGE, OR ABILITY TO PAY. ALTHOUGH REIMBURSEMENT FOR SERVICES RENDERED IS CRITICAL TO THE OPERATION OF THE HOSPITAL, IT IS RECOGNIZED THAT NOT ALL INDIVIDUALS POSSESS THE ABILITY TO PURCHASE THESE ESSENTIAL SERVICES. IT IS THE HOSPITAL'S MISSION TO SERVE THE SURROUNDING AREA BY PROVIDING HEALTH CARE SERVICES AND HEALTH CARE EDUCATION TO ALL COMMUNITY MEMBERS. DURING THE YEAR ENDED JUNE 30, 2016, THE HOSPITAL PROVIDED $460,263 OF MEDICAL SERVICES, BASED ON THE AMOUNTS OF CHARGES FOREGONE, TO INDIVIDUALS WHO WERE DETERMINED UNABLE TO PURCHASE SUCH SERVICES UNDER THE HOSPITAL'S CHARITY CARE POLICY AND GUIDELINES. IN ADDITION TO FREE CARE AND/OR SUBSIDIZED CARE, CARE IS ALSO PROVIDED AT BELOW COST RATES TO PERSONS COVERED BY GOVERNMENTAL PROGRAMS. RECOGNIZING ITS MISSION TO THE COMMUNITY, SERVICES ARE PROVIDED TO BOTH MEDICARE AND MEDICAID PATIENTS. THE UNREIMBURSED VALUE (based on cost) OF PROVIDING CARE TO ALL PATIENTS WAS $5,432,529 FOR THE YEAR ENDED JUNE 30, 2016. DURING THE FISCAL YEAR ENDED JUNE 30, 2016, THE HOSPITAL PROVIDED 2,821 DAYS OF HOSPITAL SERVICES. THE NURsiNG HOME PROVIDED 31,087 DAYS OF RESIDENT SERVICES, AND THE ASSISTED LIVING FACILITY PROVIDED 8,962 DAYS OF RESIDENT SERVICES DURING THE YEAR. THE HOSPITAL ALSO provides community care and services through many health activities and programs provided to support the community. these activities include support to the heart mountain volunteer medical clinic, HERITAGE HEALTH CENTER CLINIC, A COMMUNITY HEALTH CENTER FQHC, WELLNESS PROGRAM, COMMUNITY EDUCATION PROGRAM, SPECIAL PROGRAMS FOR SPECIFIC PURPOSES, AND A VARIETY OF COMMUNITY SUPPORTED ACTIVITIES. 40854124 1 1 0 0 0 0 0 0 1 0 1 0 0 1 0 1 0 1 0 0 0 0 0 0 0 0 1 1 0 1 1 0 0 0 1 0 0 1 0 0 0 0 0 0 1 1 0 0 0 1 32 0 1 544 1 0 0 0 0 0 0 0 0 0 0 X 10 8 0 1 0 0 0 1 1 1 1 0 0 1 1 1 1 1 1 0 0 0 X CONTROLLER 3077542267 777 AVENUE H POWELL WY 82435 DEB KLEINFELDT VICE PRESIDENT 1.00 1.00 X X 0 0 0 LARRY PARKER TREASUREr 1.00 1.00 X X 0 0 0 BONITA KATZ SECRETAry 1.00 1.00 X X 0 0 0 JIM CARLSON DIRECTOr 1.00 1.00 X 0 0 0 BETH GILB DIRECTOr 1.00 1.00 X 0 0 0 WILLIAM JARVIS DIRECTOR/PHYSICIAN - ORTHo 40.00 X 1309552 0 27730 RJ KOST PRESIDENT 1.00 1.00 X X 0 0 0 MICHAEL TRACY MD DIRECToR/PHYSICIAN - FAMIL 40.00 1.00 X 179065 0 9309 NATHANIEL RIEB PHYSICIAN - GENERAL SURGeR 40.00 X 438207 0 26768 MARK OLSEN DIRECTOr 1.00 1.00 X 0 0 0 MIKE LONG CFo 40.00 X 167931 0 16052 VALERIE LENGFELDER MD pHYSICIAN - FAMILY PrACTIC 40.00 X 289824 0 26550 PAUL LAVEAU PHYSICIaN - CARDIOLOGY 40.00 X 418319 0 9083 KELLY CHRISTENSEN PHYSICIAN - FAMILY PrACTIC 40.00 X 380469 0 26459 James Lloyd Physician - oBSTETRICs 40.00 X 358950 0 8996 JENKINS CLARKSON PHYSICIAN - OBSTETRICs 40.00 X 368591 0 18908 Michael Bohlman Physician 40.00 X 412087 0 26214 4322995 0 196069 27 0 1 0 NORTH PLATTE PHYSICAL INC PO BOX 1790 DOUGLAS WY 82633 PHYSICAL THERAPY 1187685 McKesson Corp 14500 East 39th Ave Aurora CO 80011 RX and OTC Drugs 989014 Health Tech Mgmnt 5110 Maryland Way STE 20 BRENTWOOD TN 37027 MANAGEMENT SERVICES 658645 SYSCO PO BOX 31198 BILLINGS MT 59107 FOOD SERVICES PRODUCTS AND PAPER GOODS 532037 OWENS & MINOR PO BOX 841420 DALLAS TX 75284 HOSPITAL SUPPLIES 415217 27 540279 419364 959643 PATIENT SERVICE REVENUE 622110 46406565 46406565 PHARMACY CONTRACT REVENUE 446110 751637 751637 CAFETERIA 722210 133955 133955 OTHER INCOME 900099 128899 128899 47421056 39119 39119 21900 0 21900 21900 21900 48441718 47442956 0 39119 19699 19699 23213637 20503694 2709943 361078 321465 39613 5063163 4445164 617999 1460233 1269289 190944 288633 288633 275817 275817 51967 51967 4122238 3459524 662714 232799 154313 78486 490429 299839 190590 406301 110528 295773 1550187 952147 598040 290744 200109 90635 77867 77867 1094878 712729 382149 1406740 383 1406357 MEDICAL SUPPLIES 3758752 3758752 PROVISIONS FOR BAD DEBT 3426738 3426738 REPAIRS AND MAINTENANCE 695494 572142 123352 FOOD 458697 458697 224325 111045 113280 48970416 40854124 8116292 0 3462401 4228022 8856368 8273163 45000 30000 227108 136129 746515 759144 239458 900249 10700876 8307557 3172443 2393319 11776103 11830711 28525396 28550737 15784528 17078521 22007 9315 2913905 2186643 18720440 19274479 X 9804956 9276258 9804956 9276258 28525396 28550737 -528698 0 X X 0 1 X 1 0 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 1 20825 38132 46000 12957 1 X 677371 394955 282416 10023505 7912602 2110903 2393319 Insurance Recoveries Receivable 11450000 Estimated third party settlements 380711 11830711 X Part IV, Line 1b: THE ORGANIZATION IS ACTING AS AN AGENCY FOR THE PVHC AUXILIARY Part IV, Line 2b: THE ORGANIZATION HOLDS FUNDS IN TRUST ON BEHALF OF NURSING HOME RESIDENTS. Part X, Line 2: The Hospital follows the accounting guidance for uncertainty in income taxes using the provisions of Financial Accounting Standards Board (FASB) ASC 740, Income Taxes. Using that guidance, tax positions are recognized in the financial statements when it is more-likely-than-not the position will be sustained upon examination by the taxing authorities. As of June 30, 2016, the Hospital had no uncertain tax positions that qualify for either recognition or disclosure in the financial statements. The Hospital and Foundations' income tax filings are subject to audit by various taxing authorities. The Hospital and Foundation are no longer subject to federal and state income tax examinations by taxing authorities for years before 2013. 1 1 X 1 X 1 X 1 1 0 0 280059 280059 0.00610 4242348 2399950 1842398 0.04050 4522407 2399950 2122457 0.04660 3 63414 2300 0 2300 0.00010 1 71 400 400 0.00000 6799806 5789764 1010042 0.02220 4 63485 6802506 5789764 1012742 0.02230 4 63485 11324913 8189714 3135199 0.06890 0 3426738 490024 10622315 11847297 -1224982 X 1 1 1 1 POWELL VALLEY HOSPITAL 777 AVENUE H POWELL WY 82435 X X X POWELL VALLEY HOPSITAL 1 0 0 1 X X X X X X X X X 15 1 0 0 1 X http://pvhc.org/about-us/community-he X X 1 14 0 0 0 1 X 100.000000000000 200.000000000000 X X X 1 1 X X X X 0 1 0 X X X X 0 X 0 0 POWELL VALLEY HOPSITAL Part V, Section B, Line 5: In FY 2016, a new CHNA was completed. The survey was handed out to current users of PVHC health services. 273 completed surveys were returned. A prioritization meeting of individuals with expertise and knowledge regarding communioty needs was held. Those unable to attend, were able to communicate their feedback and comments via email. POWELL VALLEY HOPSITAL Part V, Section B, Line 7d: We now have TV video displays in various locations in our facility. It is advertised there, where individuals can access the CHNA so guests know they can read the results on our website. POWELL VALLEY HOPSITAL Part V, Section B, Line 11: THE MOST RECENT CHNA WAS COMPLETED IN APRIL 2016. THE TOP THREE COMMUNITY HEALTH NEEDS WERE DETERMINED. PVHC, IN COLLABORATION WITH COMMUNITY PARTNERS, HAVE DEVELOPED AN IMPLEMENTATION PLAN FOR EACH OF THE PRIORITY HEALTH NEEDS. SOME OF THESE STRATEGIES HAVE ALREADY BEGUN INCLUDING COMMUNITY HEALTH EDUCATION EVENTS ON HEART HEALTH, GETTING SMART ABOUT ANTIBIOTICS AND DIABETES EDUCATION, WHICH INCLUDED A REDUCED RATE FOR A1C LAB TESTING. 1) IN ORDER TO INCREASE ACCESS TO PRIMARY CARE SERVICES, DR. NICOLE COMER JOINED THE PVHC TEAM AS A FAMILY PRACTICE DOCTOR IN AUGUST, 2016. A FNP, DARLENE HAUSER, JOINED THE PVHC TEAM IN MARCH, 2016. PHYSICIAN ASSISTANT, AMY BUCK, JOINED THE PVHC TEAM IN AUGUST, 2016. 2) IN ORDER TO FACILITATE IMPROVED ACCESS TO MENTAL HEALTH SERVICES, PVHC PARTICIPATED IN MEETINGS TO ESTABLISH A FQHC. THE CENTER OPENED IN SEPTEMBER 2015 AND OFFERS ACCESS TO MENTAL HEALTH SERVICES THRU A CONTRACT WITH YELLOWSTONE BEHAVIORAL HEALTH. PVHC DONATED CASH AND IN-KIND SUPPORT. IN ADDITION, PVHC FACILITATES ALZHEIMERS SUPPORT GROUPS AS WELL AS MENTAL HEALTH SUPPORT GROUPS. 3) PVHC CONTINUES TO COMMUNICATE AVAILABLE PREVENTATIVE SERVICES TO THE COMMUNITY THROUGH PRINT MEDIA, RADIO SPOTS, ON SOCIAL MEDIA AND THROUGH COMMUNICATIONS TO PVHC EMPLOYEES. PVHC OFFERS COMMUNITY BLOOD SCREENINGS AND WELLNESS LAB TESTS AT A DISCOUNTED RATE. PVHC AGAIN HOSTED A DRIVE-THRU FLU SHOT CLINIC AND HOSTED SEVERAL COMMUNITY BLOOD DRIVES DURING THE YEAR. PVHC HOSTED A VARIETY OF PREVENTATIVE EDUCATIONAL AND SUPPORT ACTIVITIES INCLUDING THREE EMERGENCY MANAGEMENT AND HANDS-ONLY CPR CLASSES AT POWELL HIGH SCHOOL; HANDS-ONLY CPR FOR THE PUBLIC, CPR TRAINING FOR POWELL HIGH SCHOOL INSTRUCTORS, AND CPR FOR THE POWELL HIGH SCHOOL HEALTH CLASSES. PVHC CONTINUED TO OFFER SAFESITTER CLASSES FOR LOCAL CHILDREN AGES 11-14. POWELL VALLEY HOPSITAL Part V, Section B, Line 13b: IN ADDITION TO PROVIDING FREE OR DISCOUNTED CARE BASED ON FEDERAL PROVERTY GUIDELINES, WE REVIEW INCOME TAX RETURNS AND PAY STUBS. THIS INFORMATION HELPS US MORE ACCURATELY DETERMINE A PATIENT'S ABILITY TO PAY. POWELL VALLEY HOPSITAL Part V, Section B, Line 16i: A SUMMARY OF THE FINANCIAL ASSISTANCE POLICY IS MADE AVAILABLE TO THE COMMUNITY ON THE HOSPITAL'S WEBSITE, ATTACHED TO BILLING INVOICES, POSTED IN THE HOSPITAL EMERGENCY ROOMS OR WAITING ROOMS, POSTED IN THE HOSPITAL ADMISSIONS OFFICES, AND PROVIDED, IN WRITING, TO PATIENTS ON ADMISSION TO THE HOSPITAL. 4 1 - POWELL VALLEY CLINIC 777 AVENUE H POWELL WY 82435 OUTPATIENT PHYSICIAN CLINIC 2 - POWELL VALLEY CARE CENTER 777 AVENUE H POWELL WY 82435 NURSING HOME 3 - HEARTLAND ASSISTED LIVING 777 AVENUE H POWELL WY 82435 ASSISTED LIVING FACILITY 4 - EXPRESS CARE CLINIC 777 AVENUE H POWELL WY 82435 URGENT CARE Part I, Line 3c: IN ADDITION TO PROVIDING FREE OR DISCOUNTED CARE BASED ON FEDERAL PROVERTY GUIDELINES, WE REVIEW INCOME TAX RETURNS AND PAY STUBS. THIS INFORMATION HELPS US MORE ACCURATELY DETERMINE A PATIENT'S ABILITY TO PAY PART I, LINE 6B. THE COMMUNITY BENEFIT REPORT IS POSTED ON THE ORGANIZATION'S WEBSITE. Part I, Line 7: charity care expense was converted to cost on line 7a based on an overall cost to the charge ratio addressing all patient segments. the expenses associated with community health improvement services, line 7e, and health professions education, line 7f were determined using an average hourly rate for staff time, space use, and ambulances. cash and in-kind contributions to community groups, line 7i, were reported based on actual expenses recorded in the organization's general ledger. the cost for subsidized health services reported on line 7g was determined using the Medicare Cost Report. Part I, Ln 7 Col(f): the amouNT of bad debt expense removed from the denominator of the calculation on part 1, line 7 column f was $3,426,738. Part II, Community Building Activities: AT POWELL VALLEY HEALTH CARE, WE UNDERSTAND THAT HEALTHCARE IS EVOLVING. THE ADVANCEMENT IN MEDICINE AND STRIDES IN TECHNOLOGY ARE PROVIDING LOCAL COMMUNITIES ACCESS TO BETTER HEALTHCARE. OUR BOARD OF TRUSTEES IS COMPRISED PRIMARILY OF LOCAL BUSINESS LEADERS WHO RESIDE IN OUR PRIMARY SERVICE AREA. TO MEET THE NEEDS OF OUR COMMUNITY, THE HOPSITAL EXTENDS PRIVILEGES TO MEDICAL STAFF THAT ARE QUALIFIED THROUGH LICENSURE. OUR EMERGENCY ROOM IS AVAILABLE 7 DAYS A WEEK AND IS AVAILABLE TO ALL REGARDLESS OF A PATIENT'S ABILITY TO PAY. EXCESS FUNDS ARE REINVESTED AND USED FOR PATIENT CARE AND FACILITY UPGRADES. Part III, Line 4: THE ORGANIZATION'S BAD DEBT IS REPORTED AS CHARGES INCURRED DURING THE YEAR. THE ESTIMATED AMOUNT OF BAD DEBT EXPENSE ATTRIBUTABLE TO PATIENTS ELIGIBLE UNDER THE ORGANIZATION'S FINANCIAL ASSISTANCE POLICY IS 14.3% (BASED UPON US CENSUS BUREAU QUICKFACTS FOR PERCENTAGE OF CITIZENS BELOW THE POVERTY LEVEL IN THE CITY OF POWELL, WY). THIS REPRESENTS A REASONABLE PERCENTAGE OF INDIVIDUALS WHO POTENTIALLY QUALIFY FOR CHARITY CARE, BUT MAY NOT HAVE APPLIED AND THEREFORE WERE WRITTEN OFF TO BAD DEBT. THE FOOTNOTE THAT DESCRIBES BAD DEBT EXPENSE IS FOUND ON PAGE 24 OF THE ATTACHED AUDIT REPORT. Part III, Line 8: MEDICARE ALLOWABLE COSTS OF CARE ARE BASED ON THE MEDICARE COST REPORT. THE MEDICARE COST REPORT IS COMPLETED BASED ON THE RULES AND REGULATIONS SET FORTH BY THE CENTERS FOR MEDICARE AND MEDICAID SERVICES. POWELL VALLEY HEALTH CARE PROVIDES SERVICES TO PATIENTS UNDER THE MEDICARE PROGRAM KNOWING THEY WILL NOT RECOVER ALL THE COSTS ASSOCIATED WITH PROVIDING THESE SERVICES. PROVIDING THESE SERVICES IS ESSENTIAL TO THESE PATIENTS AND THE COMMUNITY AND INCREASES THEIR ACCESS TO HEALTHCARE SERVICES. THEREFORE, THE MEDICARE SHORTFALL SHOULD BE CONSIDERED A COMMUNITY BENEFIT. Part III, Line 9b: POWELL VALLEY HEALTH CARE, INC. TRIES TO DETERMINE IF A PATIENT NEEDS FINANCIAL ASSISTANCE BEFORE SERVICES ARE RENDERED, EXCEPT IN EMERGENCY SITUATIONS. NO PATIENT IS DENIED ACUTE CARE IN AN EMERGENCY SITUATION. THE HEALTH CENTER WILL PURSUE ALL POSSIBLE FORMS OF THIRD-PARTY PAYMENTS SUCH AS INSURANCE, STATE MEDICAID PROGRAMS, AND COUNTY INDIGENT CARE PROGRAMS BEFORE GRANTING FINANCIAL ASSISTANCE. COLLECTION EFFORTS ARE NOT PURSUED DURING THIS TIME. COLLECTION EFFORTS ARE NOT PURSUED WHILE A COMPLETED CHARITY CARE APPLICATION IS UNDER REVIEW. DECISIONS ON CHARITY CARE APPLICATIONS ARE MADE WITHIN 30 DAYS OF THE COMPLETED APPLICATION. ONCE A DECISION IS MADE, ANY PERSONAL PORTION DUE WILL FOLLOW THE SAME COLLECTION PROCEDURES AS OTHER ACCOUNTS. IF A DETERMINATION FOR FINANCIAL ASSISTANCE IS MADE ON AN ACCOUNT OR FURTHER INSURANCE PROCESSING IS NEEDED AFTER AN ACCOUNT IS SENT TO COLLECTIONS, ALL COLLECTION EFFORTS WILL CEASE AND ANY NEGATIVE REPORTING WILL BE REVERSED. Part VI, Line 2: POWELL VALLEY HEALTH CARE IS SERVED BY A PUBLICLY ELECTED DISTRICT BOARD. THE BOARD MEMBERS ACTIVELY PROVIDE INFORMATION RELATIVE TO THE HEALTH CARE NEEDS OF THE COMMUNITY. ADDITIONALLY, WE SURVEY PATIENTS, RESIDENTS, AND THEIR FAMILIES AND IN DOING SO, LOOK FOR TRENDS AND/OR SUGGESTIONS FOR IMPROVEMENTS/EXPANSION/OR INITIATION OF SERVICES. OUR GUEST RELATIONS PROCESS ALSO ASSISTS US IN IDENTIFYING ANY UNMET COMMUNITY HEALTH NEEDS. ADMINISTRATION, PROVIDERS, AND THE BOARD TRUSTEES ALSO REVIEW COUNTY-WIDE MARKET/UTILIZATION DATA ANNUALLY. Part VI, Line 3: POWELL VALLEY HEALTH CARE IS COMMITTED TO PROVIDING FINANCIAL ASSISTANCE TO PERSONS WHO HAVE HEALTH CARE NEEDS AND ARE UNABLE TO PAY FOR MEDICALLY NECESSARY CARE. WE STIVE TO ENSURE THAT PEOPLE WHO ARE UNINSURED, UNDERINSURED, INELIGIBLE FOR A GOVERNMENT PROGRAM, OR OTHERWISE UNABLE TO PAY ARE STILL ABLE TO RECEIVE CARE. NOTIFICATIONS ABOUT CHARITY CARE ARE INCLUDED IN PATIENT BILLS, POSTED IN EMERGENCY ROOMS, ADMITTING AND REGISTRATION DEPARTMENTS, THE BUSINESS OFFICE, AND WAITING ROOMS. INFORMATION IS ALSO INCLUDED IN PATIENT INFORMATION PACKETS. STAFF ALSO DISCUSS FINANCIAL ASSISTANCE UPON ADMITTING AND DISCHARGE. Part VI, Line 4: POWELL VALLEY HEALTHCARE IS A 25 BED CRITICAL ACCESS HOSPITAL, 100 BED INTERMEDIATE CARE NURSING FACILITY, A 24 APARTMENT ASSISTED LIVING FACILITY, AND A DOCTOR'S CLINIC LOCATED IN THE NORTHWEST CORNER OF WYOMING, 75 MILES EAST OF YELLOWSTONE NATIONAL PARK, AND 98 MILES SOUTH OF BILLINGS, MT. POWELL HAS A DIVERSE COMMERCIAL, INDUSTRIAL, EDUCATIONAL, AND AGRICULTURAL/RANCHING BASED ECONOMY. IN 2015, 14.3% OF THE RESIDENTS LIVED IN POVERTY. THE MEDIAN HOUSEHOLD INCOME WAS $47,956 AND THE POPULATION WAS 6,407. THE NEAREST CITY WITH A POPULATION OF 50,000+ IS BILLINGS, MT. THE NEAREST HOSPITALS ARE NORTH BIG HORN HOPSITAL DISTRICT, A CRITICAL ACCESS HOSPITAL LOCATED APPROXIMATELY 22 MILES NORTHEAST AND WEST PARK HOSPITAL, A CRITICAL ACCESS HOSPITAL LOCATED APPROXIMATELY 25 MILES SOUTHWEST. NET REVENUE FROM MEDICARE AND MEDICAID ACCOUNT FOR APPROXIMATELY 24.71% AND 5.58%, RESPECTIVELY. Part VI, Line 5: AT POWELL VALLEY HEALTH CARE, WE UNDERSTAND THAT HEALTHCARE IS EVOLVING. THE ADVANCEMENT IN MEDICINE AND STRIDES IN TECHNOLOGY ARE PROVIDING LOCAL COMMUNITIES ACCESS TO BETTER HEALTHCARE. OUR BOARD OF TRUSTEES IS COMPRISED PRIMARILY OF LOCAL BUSINESS LEADERS WHO RESIDE IN OUR PRIMARY SERVICE AREA. TO MEET THE NEEDS OF OUR COMMUNITY, THE HOPSITAL EXTENDS PRIVILEGES TO MEDICAL STAFF THAT ARE QUALIFIED THROUGH LICENSURE. OUR EMERGENCY ROOM IS AVAILABLE 7 DAYS A WEEK AND IS AVAILABLE TO ALL REGARDLESS OF A PATIENT'S ABILITY TO PAY. EXCESS FUNDS ARE REINVESTED AND USED FOR PATIENT CARE AND FACILITY UPGRADES. 1 SCHOLARSHIPS 4 4000 TUITION REIMBURSEMENTS 8 9475 Employee Education Grants 5 3112 Part I, Line 2: THE ORGANIZATION PROVIDED SCHOLARSHIPS TO INDIVIDUALS AND REQUIRED THE INDIVIDUAL TO PROVIDE INFORMATION TO SUPPORT THE PURPOSE OF THE SCHOLARSHIP. TUITION REIMBURSEMENTS ARE PAID OUT AT 50% OF TUITION AFTER EMPLOYEES SHOW PASSING GRADES. 0 0 0 0 0 1 0 0 0 WILLIAM JARVIS DIRECTOR/PHYSICIAN - ORTHo 878463 0 431089 0 0 0 7950 0 19780 0 1337282 0 0 0 MICHAEL TRACY MD DIRECToR/PHYSICIAN - FAMIL 154472 0 24283 0 310 0 0 0 9309 0 188374 0 0 0 NATHANIEL RIEB PHYSICIAN - GENERAL SURGeR 386039 0 51839 0 329 0 7950 0 18818 0 464975 0 0 0 MIKE LONG CFo 161385 0 6000 0 546 0 0 0 16052 0 183983 0 0 0 VALERIE LENGFELDER MD pHYSICIAN - FAMILY PrACTIC 232412 0 56991 0 421 0 7950 0 18600 0 316374 0 0 0 PAUL LAVEAU PHYSICIaN - CARDIOLOGY 413399 0 0 0 4920 0 7950 0 1133 0 427402 0 0 0 KELLY CHRISTENSEN PHYSICIAN - FAMILY PrACTIC 194046 0 186146 0 277 0 7950 0 18509 0 406928 0 0 0 James Lloyd Physician - oBSTETRICs 350856 0 6000 0 2094 0 7950 0 1046 0 367946 0 0 0 JENKINS CLARKSON PHYSICIAN - OBSTETRICs 358226 0 9000 0 1365 0 0 0 18908 0 387499 0 0 0 Michael Bohlman Physician 310559 0 101528 0 0 0 7950 0 18264 0 438301 0 0 0 Part I, Line 3 THE ORGANIZATION DOES NOT PAY COMPENSATION TO THE INTERIM CEO DIRECTLY. THE INTERIM CEO IS COMPENSATED BY AN UNRELATED MANAGEMENT COMPANY, HEALTHTECH MANAGEMENT SERVICES, INC. THE BOARD OF DIRECTORS APPROVES THE COMPENSATION PAID BY HEALTHTECH MANAGEMENT SERVICES, INC. Part I, Line 5 BONUSES ARE CALCULATED AS A PERCENTAGE OF NET REVENUE PER QUARTER PER CONTRACT FOR EACH INDIVIDUAL BASED ON BILLED CHARGES FOR THAT QUARTER. WILLIAMS JARVIS DIRECTOR EMPLOYEE RECRUITMENT X 30000 9000 0 1 1 JENKINS CLARKSON HIGHEST COMPENSATED EMPLOYEE EMPLOYEE RECRUITMENT X 30000 9000 0 1 1 MICHAEL LONG OFFICER EMPLOYEE RECRUITMENT X 15000 3000 0 1 1 JAMES LLOYD HIGHEST COMPENSATED EMPLOYEE EMPLOYEE RECRUITMENT X 20000 9000 0 1 1 30000 STEVE KATZ HUSBAND OF BOARD MEMBER BONI KATZ 171670 COMPENSATION 0 Form 990, Part VI, Section A, line 3 THE INTERIM CEO, TERRY ODUM, IS AN EMPLOYEE OF HEALTHTECH MANAGEMENT SERVICES, INC., A HEALTHCARE MANAGEMENT COMPANY. AS THIS POSITION IS HELD OUTSIDE THE ORGANIZATION, THE CONTROL OVER MANAGEMENT DUTIES CUSTOMARILY PERFORMED BY AND UNDER DIRECT SUPERVISION OF OFFICERS, DIRECTORS OR TRUSTEES, OR KEY EMPLOYEES HAS EFFECTIVELY BEEN DELEGATED OUTSIDE OF THE ORGANIZATION. TERRY ODUM IS COMPENSATED BY HEALTHTECH MANAGEMENT SERVICES, INC. Form 990, Part VI, Section A, line 7a SEVEN BOARD MEMBERS FROM THE HOSPITAL DISTRICT BOARD OF TRUSTEES SHALL BE APPOINTED BY VIRTUE OF THEIR ELECTION TO THE HOSPITAL DISTRICT BOARD OF DIRECTORS. Form 990, Part VI, Section A, line 7b A BOARD MEMBER WHO IS FROM THE HOSPITAL DISTRICT BOARD OF TRUSTEES MAY ONLY BE REMOVED BY ACTION OF THE DISTRICT BOARD OF DIRECTORS. Form 990, Part VI, Section B, line 11 A COPY OF FORM 990 IS PROVIDED TO THE CEO AND CFO TO REVIEW. THE CEO OR CFO WILL EITHER MAKE CHANGES OR APPROVE THE FORM 990. AFTER THE FORM 990 IS FINALIZED BUT PRIOR TO BEING FILED, A COPY WILL BE PROVIDED TO THE BOARD OF DIRECTORS AT A BOARD MEETING. Form 990, Part VI, Section B, line 12c INDIVIDUALS COVERED BY THE CONFLICT OF INTEREST POLICY INCLUDE MEMBERS OF THE BOARD OF DIRECTORS, OFFICERS AND KEY EMPLOYEES (IF APPLICABLE). THE PROCESS USED TO DETERMINE IF ANY CONFLICTS OF INTEREST EXIST CONSISTS OF SENDING THE MEMBERS A DOCUMENT FOR THEM TO COMPLETE PRIOR TO THE BOARD OF DIRECTORS MEETING. EACH INDIVIDUAL COMPLETES THE DOCUMENT WHICH ENTAILS DISCLOSING ANY POSSIBLE CONFLICTS AND RETURNS FOR REVIEW TO THE PRESIDENT OF THE BOARD. IF A MEMBER HAS A CONFLICT THEY ARE NOT ALLOWED TO VOTE ON THE CONFLICTED ISSUES. Form 990, Part VI, Section C, line 19 THE HOSPITAL MAKES ITS GOVERNING DOCUMENTS, CONFLICT OF INTEREST POLICY, AND FINANCIAL STATEMENTS AVAILABLE TO THE PUBLIC BY REQUEST. THE PUBLIC MAY REQUEST A COPY BY CALLING, VIA MAIL, OR WALK-IN. Form 990, Part XII, Line 2c: THIS PROCESS HAS NOT CHANGED FROM THE PREVIOUS YEAR. POWELL HOSPITAL DISTRICT #1 777 AVENUE H POWELL WY 82435 830200759 RELATED - PROVISION OF HEALTH CARE SERVICES WY GOVERNMENT N/A N/A 0 POWELL MEDICAL FOUNDATION PO BOX 801 POWELL WY 82435 742275540 PROMOTE PUBLIC HEALTH AND IMPROVE FACILITIES AROUND THE CITY OF POWELL, WY WY 501(C)(3) LINE 8 N/A 0 POWELL VALLEY INTEGRATED HEALTH SERVICES INC 777 AVENUE H POWELL WY 82435 830319855 PUBLIC BENEFIT CORPORATION/HEALTH CARE CONTRACT WY C 1.00000 1 0 0 1 0 0 0 0 0 0 0 0 0 0 0 0 1 1 0 0 POWELL HOSPITAL DISTRICT C 540279 CASH VALUE POWELL MEDICAL FOUNDATION C 15000 CASH VALUE POWELL MEDICAL FOUNDATION Q 19702 ACTUAL EXPENSES INCURRED POWELL HOSPITAL DISTRICT P 810000 ACTUAL RENT PAID FOR BUILDINGS