2016-11-07T13:48:26-06:00 2015-09-30 450250958 EIDE BAILLY LLP 1601 NW EXPRESSWAY SUITE 1900 OKLAHOMA CITY OK 73118 990 2014-10-01 237169376 Pawhuska Hospital Inc PAWH 9182873232 1101 East 15th Street Pawhuska OK 740561920 Godwin Feh Administrator 9182873232 2016-11-07 1 Kim Hunwardsen CPA P00484560 4054783334 2016-11-07 2014 2017-02-10 21:41:12Z Godwin Feh 1101 East 15th Street Pawhuska OK 740561920 6374707 0 X www.pawhuskahospital.org X 1959 OK Pawhuska Hospital is committed to improving the health and lives in the communities we serve. 5 5 92 42 0 0 120064 9275 5863970 6360251 2609 5181 0 0 5986643 6374707 0 0 0 0 2736456 3246289 0 0 0 2783069 4086834 5519525 7333123 467118 -958416 5107774 3532874 1735378 1118894 3372396 2413980 X We, the Physicians, Staff, and Governing Board of Pawhuska Hospital, Inc., are committed to providing the highest level of healthcare possible for our facility.Recognizing the health needs of our community and surrounding area, we pledge to provide, in a cost-effective manner, the services necessary to enhance the quality of life. Understanding the constant and dramatic change in the healthcare industry, we will strive to achieve excellence and continue our support of the community. 0 0 5481284 6360251 Pawhuska Hospital, Inc. is a 25-bed Critical Access Hospital located in Pawhuska, Oklahoma, and provides medical services to Pawhuska and surrounding area. The Hospital is managed through an agreement with Carter Professional Care, PC.The Hospital provides care to patients who meet certain criteria under its charity care policy without charge or at amounts less than established rates. Continued on Schedule O.Because the Hospital does not pursue collection of amounts determined to qualify as charity care, they are not reported as revenue. The amount of charges foregone for services provided under the Hospital's charity care policy were approximately $9,984 for the year ended September 30, 2015. Total direct and indirect costs related to these foregone charges were approximately $10,000 at September 30, 2015, based on an average ratio of cost to gross charges. 5481284 1 0 0 0 0 0 0 0 0 0 1 0 0 0 1 1 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 1 0 0 0 1 12 0 1 92 1 0 0 0 0 0 0 0 0 0 0 X 5 5 1 1 0 0 0 1 0 1 1 0 0 1 1 1 1 1 1 1 0 0 OK X Shaun Beggs 9182875123 1101 E 15th Street Pawhuska OK 740561920 X Beth Reed Chair 1.00 X X 0 0 0 Ben West Secretary 1.00 X X 0 0 0 Beverly Moore Trustee 1.00 X 0 0 0 Jerry Mosley Trustee 1.00 X 0 0 0 Nancy Woodyard Trustee 1.00 X 0 0 0 Shaun Beggs Administrator-commenced 6/15/15 40.00 X 0 0 0 Jason McCauley Regional Administrator until 6/14/15 40.00 X 0 0 0 Shawn Parkhurst Regional Controller until 6/14/15 40.00 X 0 0 0 John Ham PA-C ER Provider 48.00 X 155983 0 5311 Theresa Flowerette APN ER Provider 60.00 X 201304 0 5731 William Ward RN 60.00 X 121380 0 6752 478667 0 17794 3 0 1 0 Emergency Physician Staffing 2360 Corporate Circle Henderson NV 89074 Contracted Physician Services 535209 Carter Professional Care 700 W 15th Street Edmond OK 73013 Management services 304777 McAfee and Taft Two W Second Street Suite 1100 Tulsa OK 74103 Legal services 195163 M&L Rehabilitation 18491 N Jamestown Skiatook OK 74002 Contracted Physical Therapy 179876 4 9275 9275 Patient service revenu 621110 6136442 6136442 Water fees 900099 109083 109083 EHR incentives 900099 89940 89940 24786 24786 6360251 5181 5181 6374707 6360251 0 5181 X 2648957 2292951 356006 424962 215564 209398 172370 147722 24648 370647 370647 195343 195343 53685 53685 1274890 850099 424791 11671 11671 173494 66551 106943 95442 22582 72860 11520 4376 7144 39026 30255 8771 41599 41599 389221 389221 79952 79952 Bad debt expense 1015845 1015845 Medical Supplies 190099 190099 Repairs and Maintenance 84482 75471 9011 Food 48965 48965 10953 10032 921 7333123 5481284 1851839 0 500 1471797 855410 1144375 1047183 105196 141884 12212 10033 4876406 3398542 1729096 1477864 645098 0 5107774 3532874 375039 503177 1046942 338659 313397 277058 1735378 1118894 X 3372396 2413980 3372396 2413980 5107774 3532874 -958416 0 X 0 1 X 1 0 X 34360 34360 1193069 786758 406311 3612998 2579040 1033958 35979 32744 3235 1477864 Estimated third party payor settlements 277058 277058 X 5249779 -1015845 -1015845 6265624 109083 109083 6374707 6317278 0 6317278 1015845 1015845 7333123 Part X, Line 2: The Hospital is organized as an Oklahoma nonprofit corporation and has been recognized by the Internal Revenue Service (IRS) as exempt from federal income taxes under Internal Revenue Code Section 501(c)(3). The Hospital is annually required to file a Return of Organization Exempt from Income Tax (Form 990) with the IRS. In addition, the Hospital is subject to income tax on net income that is derived from business activities that are unrelated to its exempt purpose. The Hospital has determined it is not subject to unrelated business income tax and has not filed an Exempt Organization Business Income Tax Return (Form 990-T) with the IRS. 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: Provision for bad debts included in expense for Form 990 -1,015,845. Part XI, Line 4b - Other Adjustments: Contribution included in revenue per Form 990 109,083. Part XII, Line 4b - Other Adjustments: Provision for bad debts included in expense for Form 990 1,015,845. 1 1 X 1 X 1 X 1 0 0 10000 10000 0.00160 10000 10000 0.00160 1578831 1079943 498888 0.07900 1578831 1079943 498888 0.07900 1588831 1079943 508888 0.08060 0 1015845 229581 3332162 3361501 -29339 X 1 1 1 1 Pawhuska Hospital Inc 1101 E 15th Street Pawhuska OK 74056 www.pawhuskahospital.org 2271 X X X X Pawhuska Hospital Inc 1 0 0 1 X X X X X X X X X 12 1 0 0 1 X www.pawhuskahospital.org X 1 12 1 www.pawhuskahospital.org 0 0 1 X 100.000000000000 400.000000000000 X X X X 1 1 X X X X 1 X X X X 1 X 0 X X X X 1 X 0 0 Pawhuska Hospital, Inc. Part V, Section B, Line 5: Community input was provided through key informant discussions of 20 stakeholders and a community health survey was distributed with a total response of 132 surveys. In addition, secondary data was compiled from demographic and socioeconomic sources as well as national state and local sources of information on disease prevalence. Pawhuska Hospital, Inc. Part V, Section B, Line 11: The communities served by Pawhuska Hospital, Inc. struggle with the health challenges arising from many socio-economic factors including: relatively large numbers of individuals living in households with incomes near or below federal poverty levels; relatively large numbers of individuals with no or "poor" health insurance coverage; relatively large numbers of individuals with overall "poor" health status and chronic health problems, including mental health issues; a shortage of health care resources and providers available to provide services to the underserved parts of our communities, a disparate safety net system that suffers from lack of resources and largely uncoordinated efforts to address community needs.The unfortunate reality is that there are simply not enough private resources to effectively address all of the community needs identified. In particular, Pawhuska Hospital, Inc. provides annually over one million dollars each year in uncompensated care to the poor in the form of free or discounted care to the uninsured, the underinsured, and to Medicaid beneficiaries.A more sustainable public / private partnership is needed to provide adequate resources to address the community needs in a more effective and more financially sustainable way. Pawhuska Hospital, Inc. will continue to work with State and Local policy and political leaders, safety net providers and community leaders and advocates to build sustainable partnerships to better address the community needs. As we work to improve health care delivery in Pawhuska and Osage County, Pawhuska Hospital will continue to be an advocate for the poor, the vulnerable and the underserved.Pawhuska Hospital Inc.'s Community Needs Assessment Team initiated the development of implementation strategies for each health priority identified through the assessment process. The Team worked with community partners and health issue experts and developed work plans to support effective implementation, created mechanisms to monitor and measure outcomes and developed a report care to provide on-going status and results of the efforts to improve community health. 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. 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 removed from total expenses to determine the percentage was $1,015,845. Part III, Line 2: Patient accounts are written off to bad debt after every effort is made to collect the balance and patients are given opportunities to complete charity care applications or set up payment plans. All discounts and contractual adjustments are applied to accounts before they are written off to bad debt. Current payments on accounts previously written off as bad debt reduces bad debt expense.Bad debt expense on line 2 is reported at charges as presented on the financial statements. Part III, Line 3: The estimated amount of the Organization's bad debt expense attributable to patients eligible under the Organization's charity care policy is calculated based on the percentage of individuals living below the poverty level. 22.6% of bad debt can reasonably be considered a community benefit as it would have been written off to charity care using this methodology. Part III, Line 4: The footnote to the Organization's financial statements can be found on page 8 of the attached audited financial statements. Part III, Line 8: Even though Medicare was at a loss, the Hospital provides services to these patients because access to healthcare and individual's health is important to the Hospital. Therefore, the Medicare shortfall is considered a community benefit.Both the total revenue received from Medicare and the Medicare allowable costs are reported from 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. Part III, Line 9b: All collections efforts cease when a patient is determined to be eligible for financial assistance. Normal collections efforts continue on any personal amount owed by the patient. Part VI, Line 2: Administration, medical staff and the governing board regularly discuss the health care needs of the local community during governing board meetings as well as in the bimonthly meetings of the medical staff. The Oklahoma Office of Rural Health and Pawhuska Hospital developed a Community Needs Assessment during tax year 2012. Pawhuska Hospital implemented strategies for each health priority identified through the needs assessment. In addition, when looking at the potential of adding new services, the Hospital researches how such services will meet and address the needs of the community. The Hospital is planning on developing future programs that allow opportunities to gather a larger community audience that can express the issues that are important to the community. Focus groups will enable the Hospital to further educate to meet the needs of the community. The next CHNA will be completed in FY2016. Part VI, Line 3: Pawhuska Hospital, Inc. provides a letter to patients upon admission that states the Hospital provides assistance to those patients with limited income to help pay for hospital expenses. The letter indicates that Charity Care applications are available to all patients and can be picked up at the time of service or at a later date. The Charity Care application gives an overview of the charity care policy and notes that Medicare and other state programs are also available to patients that meet income requirements. The Hospital staff is available to offer patients assistance in completing the Charity Care and Medicaid applications if needed. Part VI, Line 4: Pawhuska Hospital, Inc. primarily serves the citizens of the community of Pawhuska, Oklahoma and the surrounding area. Pawhuska serves as the county seat of Osage County, Oklahoma and is also the capital of the Osage Nation. The Hospital is one of two facilities located in Osage County. Pawhuska is a rural area with a population of 3,589 from the 2010 U.S. Census. The per capita income for the city was $13,916. About 137 of families and 175 of the population were below the poverty line, including 223 of those under age 18 and 149 of those aged 65 or over. The Hospital is a federally designated underserved area for primary care health professionals, mental health professionals and dental care health professionals. Part VI, Line 5: Pawhuska Hospital's governing body is comprised of volunteer members who reside in the community. Medical staff privileges are extended to all qualified physicians in the community. Surplus funds are reinvested in facilities to improve patient care. The Hospital operates an emergency room that is available to all regardless of a patient's ability to pay. Free health screenings were offered to the community at an open house in January. Other local healthcare entities were invited to participate. X X 0 0 0 0 0 0 0 0 0 John Ham PA-C ER Provider 155983 0 0 0 0 0 0 0 5311 0 161294 0 0 0 Theresa Flowerette APN ER Provider 201304 0 0 0 0 0 0 0 5731 0 207035 0 0 0 Schedule J, Part I, Question 3: Pawhuska Hospital, Inc. does not pay compensation to the Administrator directly. The Administrator is compensated under a management agreement through Carter Professional Care. Carter Professional Care uses the Oklahoma Hospital Association annual survey data to determine competitive compensation based on similar sized organizations and approval from Pawhuska's Board of Directors. Form 990, Part VI, Section A, line 1 The Executive Committee consists of the Chair of the Board as presiding officer and the Vice Chair of the Board, the Secretary or Treasurer, and the CEO. Other members may be appointed to the Executive Committee as required by the Chair. The primary purpose is to take definitive and immediate action on any matter that might occur between regular meetings that falls outside the scope of the duties and responsibilities of the CEO. Record of action taken by the Executive Committee is made a part of the minutes of the next regular board meeting. Form 990, Part VI, Section A, line 2 Ben West and Nancy Woodyard have a business relationship. Form 990, Part VI, Section A, line 3 Jane Phillips Medical Center, a non-profit organization, provided administrative oversight for day-to-day operations, accounting services, and operational consulting services until 6/14/15. Jason McCauley was the Regional Administrator and Shawn Parkhurst was the Regional Controller. The amount paid to Jane Phillips Medical Center for services in calendar year 2014 was $67,623. Carter Professional Care, a professional corporation, assumed administrative oversight for day-to-day operations on 6/15/15. Shaun Beggs served as the Administrator on behalf of Carter Professional Care. The amount paid to Carter Professional Care was $304,777. Form 990, Part VI, Section A, line 7a There are a total of five Trustees. All are appointed by the City Council of Pawhuska Board of Incorporators. Form 990, Part VI, Section B, line 11 The Form 990 is presented to the Administrator for review and then presented to the Board of Directors. Form 990, Part VI, Section B, line 12c All employees, board members, and contract employees are covered in our policies. The employee and contract employee determinations are made by Administration and any board determinations are made by the Governing Board. The employee will be asked to remedy the situation and the board member will be asked to leave after presenting their conflict and the remainder of the Governing Board will discuss and then vote. Copies of both policies can be provided upon request. Form 990, Part VI, Section B, line 15a Pawhuska Hospital, Inc. follows the pay guidelines of Carter Professional Care. Salary data is reviewed against survey data from the Oklahoma Hospital Association. Increases are tied to an annual performance evaluation and approval from the Board of Directors. The process and determination is documented in the personnel file and Board minutes. Form 990, Part VI, Section C, line 19 The Hospital's governing documents, conflict of interest policy, and financial statements are available to the public upon request. Form 990, Part IX, line 11g Professional Fees: Program service expenses 826,842. Management and general expenses 382,486. Fundraising expenses 0. Total expenses 1,209,328. Contracted Services: Program service expenses 23,257. Management and general expenses 0. Fundraising expenses 0. Total expenses 23,257. Consulting: Program service expenses 0. Management and general expenses 42,305. Fundraising expenses 0. Total expenses 42,305. City of Pawhuska 118 W Main Street Pawhuska OK 74056 736005371 Provide services to the residents of Pawhuska OK N/A 0 0 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0