2016-11-15T15:58:02-06:00 2015-12-31 BKD LLP 111 South Tejon Suite 800 Colorado Springs CO 809039848 990 2015-01-01 860096775 Community Hospital Association Inc % THE ORGANIZATION COMM 9286845421 520 Rose Lane Wickenburg AZ 85390 MICHAEL V ELLIS CFO 9286845421 2016-11-15 true David S Mason CPA P00137279 7194714290 2015 2017-02-10 21:41:12Z Jim Tavary 520 Rose Lane Wickenburg AZ 85390 31442070 false X www.wickhosp.com X 1946 AZ To provide quality health and wellness services where the patient, family and community come first. 9 9 270 50 121837 839741 3612213 25316274 27452533 -54548 -135171 32582 -454846 26134049 30474729 0 0 0 0 11458175 12377361 0 0 0 13369866 14867312 24828041 27244673 1306008 3230056 24218741 26266200 10105750 10516161 14112991 15750039 TO PROVIDE QUALITY HEALTH AND WELLNESS SERVICES WHERE THE PATIENT, FAMILY, AND COMMUNITY COME FIRST. false false 22945378 0 27117464 Provide inpatient and outpatient diagnostic and therapeutic health care services to the residents and visitors of greater Wickenburg, Arizona, a rural community of approximately 23,000. 417661 0 253722 Provide Fitness Center for residents and visitors of greater Wickenburg, Arizona, promoting a wellness environment for the community. 23363039 true true false false false false false false false false true false false true true false true false false false false false false false false false true true false false true false false false false false false false false false false false false false true true true false true 76 0 true 270 true true true false false false false false false false false false X 9 9 false false false false false false false true true false false true true true true true true false false false AZ X THE ORGANIZATION 9286845421 520 ROSE LANE Wickenburg AZ 85390 X UWE GROSS CHAIRMAN THRU 10/2015 1.0 0.0 X X 0 0 0 KEVIN ARMSTRONG VICE CHAIRMAN 1.0 0.0 X X 0 0 0 RICHARD ABBUHL DIRECTOR 1.0 0.0 X 0 0 0 GARY TURNER TREASURER 1.0 0.0 X X 0 0 0 DEE POLLOCK SECRETARY 1.0 0.0 X X 0 0 0 MAUREEN SERRANO DIRECTOR 1.0 0.0 X 0 0 0 BRIAN WARNOCK DIRECTOR 1.0 0.0 X 0 0 0 JOHN COOK DIRECTOR 1.0 0.0 X 0 0 0 TROY JONES DMD DIRRECTOR 1.0 0.0 X 0 0 0 LEONARD KIRSCHNER DIRECTOR 1.0 0.0 X 0 0 0 JAMES TAVARY CHIEF EXECUTIVE OFFICER 39.0 1.0 X 183099 0 2028 MICHAEL ELLIS CHIEF FINANCIAL OFFICER 39.0 1.0 X 133555 0 5357 TODD KRAVETZ MD CHIEF OF STAFF 40.0 0.0 X 249248 0 21635 ROGER ROSE DIRECTOR OF PHARMACY SERVICES 40.0 0.0 X 169286 0 11882 CRAIG SIMONS PHYSICIAN 40.0 0.0 X 228741 0 17209 MARILYN HALDER PHYSICIAN 40.0 0.0 X 178109 0 19078 SUZANNE YOUNG PHARMACIST 40.0 0.0 X 150888 0 9331 JENA SAVAGE PHYSICIAN ASSISTANT 40.0 0.0 X 128182 0 513 RICHARD WEDIG - DIRECTOR OF SURGICAL CTR & CLINIC 40.0 0.0 X 122918 0 4109 1544026 0 91142 14 false true false EMCARE PHYSICIAN SERVICES INC 7032 COLLECTION CENTER DR CHICAGO IL 60693 PHYSICIANS 887688 MEDICAL DIAGNOSTIC PO BOX 17049 PHOENIX AZ 85011 IMAGING SERVICES 574633 Alliance Imaging File 55826 LOS ANGELES CA 90074 IMAGING SERVICES 540000 DENNIS BARRACO 34522 N SCOTTSDALE ROAD SCOTTSDALE AZ 85262 PHYSICIAN SERVICES 130500 YARNELL MEDICAL INC PO BOX 130 MORRISTOWN AZ 85342 PHYSICIAN SERVICES 140452 5 2612113 1000100 3612213 MEDICARE 621990 11107584 11107584 PATIENT SERVICES 621990 11970139 11861319 108820 340B DRUG PRICING PROGRAM REVENUE 621990 2609246 2609246 PATIENT PHARMACY REVENUE 621990 1511842 1511842 WELLNESS CENTER 621990 253722 253722 27452533 0 0 0 73200 167908 -94708 0 -94708 13017 -107725 664262 799433 -135171 -135171 -135171 0 0 0 OTHER REVENUE 900099 41472 27473 13999 LOSS ON EXTINGUISHMENT OF DEBT 900099 -401610 -401610 -360138 30474729 27371186 121837 -630507 X 0 0 0 0 776090 452051 324039 0 0 0 0 0 9703769 8973692 730077 19000 19000 1104207 961747 142460 774295 700758 73537 0 40950 40950 156701 156701 0 0 0 3589743 3309632 280111 0 376020 200180 175840 274723 274723 0 477587 458175 19412 55291 43901 11390 0 99853 85897 13956 500068 500068 0 1289078 562949 726129 388968 143087 245881 MEDICAL SUPPLIES 4529845 4529845 PROVISION FOR BAD DEBTS 2090847 2090847 REPAIRS & MAINTENANCE 474544 432007 42537 DUES, FEES & SUBS 48212 24297 23915 474882 100251 374631 27244673 23363039 3881634 0 2044048 1792936 91398 9890 0 1000000 3476335 4215978 0 0 0 0 3489 0 875916 1090630 437502 442330 27862718 13904648 11118402 13958070 476521 0 0 0 0 0 49274 35523 5645856 3720843 24218741 26266200 2262299 2523856 0 0 0 0 5235000 0 0 0 0 0 2556034 7952436 0 0 52417 39869 10105750 10516161 X 8816762 12662959 5296229 3087080 0 0 14112991 15750039 24218741 26266200 X 3230056 -1593008 X false true X true false X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 1379772 1379772 13090990 8384053 4706937 8690 4559 4131 7594534 5283454 2311080 5788732 232582 5556150 13958070 FOUNDATION 3720843 3720843 0 INSURANCE FINANCING 39869 39869 26958782 167908 167908 26790874 3683855 3683855 30474729 25321734 167908 167908 25153826 2090847 2090847 27244673 Schedule D, Part X, Line 2 UNCERTAIN TAX POSITIONS: MANAGEMENT HAS EVALUATED THEIR INCOME TAX POSITIONS UNDER THE GUIDANCE INCLUDED IN ASC 740. BASED ON THEIR REVIEW, MANAGEMENT HAS NOT IDENTIFIED ANY MATERIAL UNCERTAIN TAX POSITIONS TO BE RECORDED OR DISCLOSED IN THE FINANCIAL STATEMENTS. SCHEDULE D, PART XI, LINE 2D REVENUE ON BOOKS, NOT ON RETURN: Rental Expense reclassed from expense to revenue 167,908 SCHEDULE D, PART XI, LINE 4B REVENUE ON RETURN, NOT ON BOOKS: Provision for uncollectable accounts reclassed to expense 2,090,847 Change in interest in net assets of wickenburg community hospital foundation 1,593,008 Total 3,683,855 SCHEDULE D, PART XII, LINE 2D EXPENSE ON BOOKS, NOT ON RETURN: Rental Expense reclassed from expense to revenue 167,908 SCHEDULE D, PART XII, LINE 4B EXPENSE ON RETURN, NOT ON BOOKS: Provision for uncollectable accounts reclassed to expense 2,090,847 true true X true X true X true true false true true 1093665 109365 0.00430 2439024 2269439 169585 0.00670 3532689 2269439 278950 0.01100 417661 253722 163939 0.00650 417661 253722 163939 0.00650 3950350 2523161 442889 0.01750 true 2090847 522712 10788291 11023000 -234709 X true true 1 1 Wickenburg Community Hospital 520 Rose Lane Wickenburg AZ 85390 www.wickhosp.com RGH3505 X X 1 Wickenburg Community Hospital 1 false false true X X X X X X X X X 13 true false false true X SEE PART V, SECTION C, FOR DIRECT URL X true 13 true SEE PART V, SECTION C, FOR DIRECT URL false false true X 200. 400. X X X X true true X X X X true X PART V, SECTION C FOR URL X PART V, SECTION C FOR URL X X X X X true X false X X X X true X false false SCHEDULE H, PART V, SECTION B, LINE 5 DESCRIBE HOW THE HOSPITAL TOOK INTO ACCOUNT INPUT FROM PERSONS WHO REPRESENT THE COMMUNITY: In conducting the CHNA for Wickenburg Community Hospital (WCH), WCH gathered data using a survey format designed by the Cochise County Health & Social Services Department for the Cochise County arizona Community Health assessment. The survey was developed in both an English and Spanish language version and were distributed in the following ways/venues: - The survey questions were posted on Survey Monkey - Newspaper display ads in the Wickenburg Sun and the Congress Yellow page encouraged readers to go to a Survey Monkey link sponsored by the Hospital - Notices were mailed/sent electronically to the Town of Wickenburg, Bagdad, Congress and Salome church organizations encouraging participation in the electronic survey through the survey monkey link. - Hard copy surveys and survey collection boxes were placed at various locations throughout the region including medical clinics, grocery stores, and the Wickenburg Chamber of Commerce. - Survey forms were distributed and the survey monkey link was announced at the Town Hall meeting in October 2013 hosted by the Hospital at the Wickenburg Community Center. - Specific survey questions and the full survey was distributed, completed and discussed at focus group meetings sponsored by the hospital and held at locations in Wickenburg, Congress and Salome. - Informational posters were placed throughout communities in the region to encourage participation in the survey through survey monkey. SCHEDULE H, PART V, SECTION B, LINE 7A DIRECT URL FOR CHNA REPORT: http://wickhosp.com/wp-content/uploads/2015/06/Community-Health-Needs-Asse ssment-Final-Report-December-2013-Final.pdf SCHEDULE H, PART V, SECTION B, LINE 10A DIRECT URL FOR IMPLEMENTATION PLAN: http://wickhosp.com/wp-content/uploads/2015/06/Community-Health-Needs-Asse ssment-Final-Report-December-2013-Final.pdf THE IMPLEMENTATION PLAN CAN BE FOUND DIRECTLY IN THE CHNA, LOCATED AT THE VERY END OF THE DOCUMENT. SCHEDULE H, PART V, SECTION B, LINE 11 DESCRIBE HOW THE HOSPITAL IS ADDRESSING THE SIGNIFICANT NEEDS IDENTIFIED IN ITS MOST RECENTLY CONDUCTED CHNA AND ANY NEEDS NOT BEING ADDRESSED: most recently conducted CHNAs identified needs are being addressed in the following ways: The availability of local healthcare services is being increased. After years of strategic planning and effort, CHA (Community Hospital Association, Inc.) opened a new MOB (medical office building) and a new surgery wing in August of 2016. The MOB expansion makes available significant improved space for both CHAs employed primary care physicians and the visiting physician specialists. The surgery wing with its state-of-the-art equipment adds a service that has not been available locally for over 15 years. Included are a variety of surgical and diagnostic services ranging from general, orthopedic and podiatric surgery to endoscopy and pain management services. The MOB and other efforts have made it possible to attract a dermatology physician group (visiting physician specialists), an ophthalmologist, and an acupuncture program to the community for expanded times/services. CHA is currently planning to build a new Fitness Center to replace the current one that is cramped and inefficient. The new Fitness Center will allow CHA to expand its efforts in promoting a community wellness program, including a more variety and a greater amount of group fitness classes. CHA makes a concerted effort to have a community awareness of health issues. Specific resources are devoted such as having a Community Awareness Manager, placing health education articles in the local newspaper, conducting educational meetings/seminars, participating in health fairs, providing a free school-sports physicals day, etc. CHA is currently completing a new CHNA that will be integrated into a formal strategic planning process in year 2017, wanting to reassess the communitys needs and look for opportunities to improve the communitys health. SCHEDULE H, PART V, SECTION B, LINE 16A DIRECT URL FOR FINANCIAL ASSISTANCE POLICY: http://wickhosp.com/wp-content/uploads/2016/01/Financial-Assistance-Policy .pdf SCHEDULE H, PART V, SECTION B, LINE 16C DIRECT URL FOR PLAIN LANGUAGE SUMMARY: http://wickhosp.com/financial-services/ SCHEDULE H, PART V, SECTION B, LINE 22D MAXIMUM AMOUNTS THAT CAN BE CHARGED TO FAP-ELIGIBLE INDIVIDUALS: The maximum amounts the hospital charges to FAP-eligible individuals for emergency or other medically necessary care is limited to amounts generally billed (AGB). AGB is a calculated percent of the total reimbursement for hospital charges that the hospital received from Medicare and commercial insurance companies over the previous 12 month look-back period. 2 Community Hospital Clinic - WICKENBURG 519 Rose Lane Wickenburg AZ 85390 PRIMARY CARE CLINIC RURAL HEALTH CLINIC Community Hospital Clinic - Congress 26750 S Santa Fe Road Suite B Congress AZ 85332 PRIMARY CARE CLINIC RURAL HEALTH CLINIC SCHEDULE H, PART I, LINE 7, COLUMN F BAD DEBT EXPENSE: TOTAL BAD DEBT EXPENSE REMOVED FROM THE DENOMINATOR PRIOR TO THE PERCENTAGE CALCULATION = $2,090,847 SCHEDULE H, PART I, LINE 7 CALCULATION OF COMMUNITY BENEFIT EXPENSES: The organization used a cost-to charge ratio for lines 7a & 7b. The cost-to-charge ratio was derived from Worksheet 2, Ratio of Patient Care Cost-to-Charges. The information for line 7e was derived from information in the general ledger and other financial data related specifically to the various types of community benefits. SCHEDULE H, PART III, SECTION A, LINE 2 EXPLAIN THE ORGANIZATION'S METHODOLOGY TO ESTIMATE THE AMOUNT REPORTED FOR BAD DEBT EXPENSE: THE HOSPITAL PROVIDES AN ALLOWANCE FOR UNCOLLECTIBLE ACCOUNTS BASED UPON A REVIEW OF OUTSTANDING RECEIVABLES, HISTORICAL COLLECTION INFORMATION, AND EXISTING ECONOMIC CONDITIONS AND TRENDS. DISCOUNTS AND PAYMENTS ON PATIENT ACCOUNTS ARE RECORDED AS AN ADJUSTMENT TO REVENUE, NOT BAD DEBT EXPENSE. SCHEDULE H, PART III, SECTION A, LINE 3 BAD DEBT ATTRIBUTABLE TO PATIENTS ELIGIBLE UNDER THE ORGANIZATION'S FINANCIAL ASSISTANCE POLICY: Most of the bad debt expense results from uninsured patients receiving services primarily through the Emergency Room. The Manager of Patient Financial Services estimates that approximately 25% of all bad debt would qualify for charity care, but it is difficult to get the patients to complete the Financial Assistance application. SCHEDULE H, PART III, SECTION A, LINE 4 Footnote on bad debt expense: see page 8-9 of the attached audited financial statements for the footnote that describes bad debt expense. SCHEDULE H, PART III, SECTION B, LINE 8 MEDICARE SHORTFALL AS A COMMUNITY BENEFIT: Medicare pays the critical access hospital 1% less than allowable cost. This shortfall must be born by all other payers and programs, limiting the profits necessary to create new programs and provide necessary benefits to community members who have no or limited resources to pay for healthcare services. The cost to charge ratio was used to determine the allowable costs reported on line 6. SCHEDULE H, PART III, SECTION C, LINE 9B DEBT COLLECTION POLICY: Our practice is to provide all patients at time of registration who do not demonstrate the ability to pay for the anticipated services (no insurance, no deposit, etc.) an opportunity to complete a charity application. The collection policy remains the same for potential charity cases and all avenues of collection are pursued, just as if the charity application had not been offered. While we believe many of the charity cases end up as a bad debt, it is not for lack of effort to educate the potential charity applicant of the availability of assistance and keep the amounts out of our bad debt category. SCHEDULE H, PART VI, LINE 2 NEEDS ASSESSMENT: Community Hospital Association, Inc. continually accesses the community's medical needs through the relationship of our staff to community leaders and community programs that identify community needs, often medical in nature. Although the hospital is not always in a position to expand services and meet all identified needs, maintaining a core menu of services that meets the greatest community need has and continues to direct our strategic planning. SCHEDULE H, PART VI, LINE 3 PATIENT EDUCATION OF ELIGIBILITY FOR ASSISTANCE: All uninsured and under-insured patients at time of registration are provided with options available in our community for payment of the services provided. This is most often verbal with a written Charity Care Application. SCHEDULE H, PART VI, LINE 4 COMMUNITY INFORMATION: Wickenburg Community Hospital serves a primary service area population of approximately 17,000 in a rural service area clustered around Wickenburg, AZ. Wickenburg Community Hospital is the only hospital in the service area. The distribution of service area population by age is 0-17, 21%; 18-44, 25%; 45-64, 29%; 65+, 24%. The service area is home to a great number of winter residents, changing the population significantly from summer months to winter months, when the population grows by approximately 40%. SCHEDULE H, PART VI, LINE 5 PROMOTION OF COMMUNITY HEALTH: Wickenburg Community Hospital, designated as a Critical Access Hospital, serves a rural population approximately 35 miles west of the urban area of the greater Phoenix market place of Surprise, AZ. While the distance is not overly great, many of our patients come from rural areas west and north of Wickenburg, requiring them to drive much greater distances to obtain health care services if Wickenburg Community Hospital were not available to them. The most important service we provide is our Emergency Services and could not exist without our Critical Access Hospital status. Additionally, our Rural Health Clinic provides access to primary care providers in our community that probably would not exist if the hospital did not employ these providers. The availability of diagnostic services locally is very important to our community as a higher average age exists in our community, making it difficult to drive longer distances and spend a greater amount of time in obtaining diagnostic services required by their primary care providers. X true true X X false false false false false false false false true false JAMES TAVARY CHIEF EXECUTIVE OFFICER 183099 0 0 0 0 0 0 0 2028 0 185127 0 0 0 TODD KRAVETZ MD CHIEF OF STAFF 229339 0 19633 0 276 0 7750 0 13885 0 270883 0 0 0 ROGER ROSE DIRECTOR OF PHARMACY SERVICES 168494 0 0 0 792 0 0 0 11882 0 181168 0 0 0 CRAIG SIMONS PHYSICIAN 228465 0 0 0 276 0 7500 0 9709 0 245950 0 0 0 MARILYN HALDER PHYSICIAN 176045 0 1884 0 180 0 7750 0 11328 0 197187 0 0 0 SUZANNE YOUNG PHARMACIST 150708 0 0 0 180 0 0 0 9331 0 160219 0 0 0 Schedule J, Part I, line 1 Information Regarding Benefits Provided: ALL KEY EMPLOYEES ARE PROVIDED WITH A COMPLEMENTARY FITNESS CENTER MEMBERSHIP AT THE WICKENBURG COMMUNITY HOSPITAL FITNESS CENTER. Schedule J, Part I, line 8 PAYMENTS MADE PURSUANT TO AN INITIAL CONTRACT EXCEPTION: MR. TAVARY IS QUALIFIED BY TRAINING AND EXPERIENCE TO ACT AS CHIEF EXECUTIVE OFFICER OF THE ORGANIZATION. DUTIES SHALL BE PERFORMED TO THE BEST OF MR. TAVARY'S ABILITY, EXPERIENCE, AND TALENT TO THE REASONABLE SATISFACTION OF THE ORGANIZATION. BASE COMPENSATION IS PAID FOR SERVICES, WITH THE ELIGIBILITY OF PERFORMANCE BASED BONUSES. THE TERM OF THE CONTRACT SHALL BE THREE YEARS, WITH THE POSSIBLITY OF EXTENSION MADE BY MUTUAL AGREEMENT OF THE ORGANIZATION AND MR. TAVARY. Schedule J, Part I, line 9 REBUTTABLE PRESUMPTION PROCEDURE: THE ORGANIZATION FOLLOWS THE REBUTTABLE PRESUMPTION PROCEDURE, HOWEVER, THE COMPARABILITY DATA USED IS NOT DOCUMENTED, THEREFORE QUESTION 9 IS ANSWERED AS NO. Form 990, Part VI, Section B, line 11b Process to Review the Form 990: The Form 990 is prepared by a third party and is reviewed by the CFO. A copy of the 990 is made available to the governing board prior to filing with the IRS. Form 990, Part VI, Section B, line 12c Process for Monitoring Compliance with Conflict of Interest Policy: All Board members and officers are covered under the policy. In connection with any actual or possible conflict of interest, an interested person must disclose the existence of any financial interest and conflict of interest and be given the opportunity to disclose all material facts to the board of directors of the organization. In addition, all interested persons review and sign a compliance certificate annually. After disclosure of any potential conflicts and all material facts, and after any discussion with the interested person, he/she shall leave the governing board meeting and is recused from the discussion and voting on the issue. The remaining board members shall decide if a conflict of interest exists. Form 990, Part VI, Section B, line 15a Review of CEO or Top Mgmt Official Compensation: The Board Chairman, with consultation of other members of the Board, reviews independent survey data acquired through the Arizona Hospital & Healthcare Association on executive salaries and reviews the performance of the CEO. This review is done annually by the Board in Executive Session. Form 990, Part VI, Section B, line 15b Review of Other Officer or Key Employees Compensation: The CEO and HR Director use the Arizona Hospital & Healthcare Association survey data to review all positions in the facility, including key employees and other officers. Form 990, Part VI, Section C, line 19 Governing Documents Available to the Public: Governing documents, conflict of interest policy, and financial statements are made available to the public by a formal request in writing. FORM 990, PART XI, LINE 9 OTHER CHANGES IN NET ASSETS OR FUND BALANCES: Change in interest in net assets of wickenburg community hospital foundation 1,593,008 FORM 990 PART IX LINE 11G DESCRIPTION:PHYSICIANS TOTAL FEES:1906614 FORM 990 PART IX LINE 11G DESCRIPTION:340B MANAGEMENT FEE TOTAL FEES:60341 FORM 990 PART IX LINE 11G DESCRIPTION:PHARMACY TOTAL FEES:21037 FORM 990 PART IX LINE 11G DESCRIPTION:MEDICAL IMAGING TOTAL FEES:578322 FORM 990 PART IX LINE 11G DESCRIPTION:RESPIRATORY THERAPY TOTAL FEES:94592 FORM 990 PART IX LINE 11G DESCRIPTION:REHABILITATION TOTAL FEES:34990 FORM 990 PART IX LINE 11G DESCRIPTION:HR/ADMIN TOTAL FEES:293335 FORM 990 PART IX LINE 11G DESCRIPTION:LAB FEES TOTAL FEES:257915 FORM 990 PART IX LINE 11G DESCRIPTION:MEDICAL RECORDS TOTAL FEES:105359 FORM 990 PART IX LINE 11G DESCRIPTION:PHYSICAL THERAPY TOTAL FEES:23420 FORM 990 PART IX LINE 11G DESCRIPTION:LAUNDRY/HOUSEKEEPING TOTAL FEES:95656 FORM 990 PART IX LINE 11G DESCRIPTION:COLLECTION TOTAL FEES:27037 FORM 990 PART IX LINE 11G DESCRIPTION:MISCELLANEOUS TOTAL FEES:91125 Wickenburg Community Hospital Foundation 520 Rose Lane Wickenburg AZ 85390 742521618 Fundraising AZ 501(C)(3) Line 7 na false Wickenburg Community Hospital Auxiliary 520 Rose Lane Wickenburg AZ 85390 866056824 Support Org AZ 501(C)(3) LN11TYPEIII NA false false false true true false false false false false false false false true true true false true false false WICKENBURG COMMUNITY HOSPITAL FOUNDATION C 2597405 AMOUNT RECEIVED WICKENBURG COMMUNITY HOSPITAL FOUNDATION D 56857 interco amount WICKENBURG COMMUNITY HOSPITAL FOUNDATION Q 145258 interco amount