2016-03-04T14:58:25-06:00 2014-06-30 450250958 EIDE BAILLY LLP 1601 NW EXPRESSWAY SUITE 1900 OKLAHOMA CITY OK 73118 990 2013-07-01 730618679 Kingfisher Regional Hospital KING 4053754152 PO Box 449 Kingfisher OK 73750 Pat Cheap President 4053754152 2016-03-03 1 Kim Hunwardsen CPA P00484560 4054783334 2016-03-02 2013 2016-08-17 19:52:53Z X Pat Cheap PO Box 449 Kingfisher OK 73750 6393212 0 X N/A X 1950 OK To serve the healthcare needs of our communities with excellence, compassion, and commitment. 9 9 154 38 0 0 25691 193522 15143071 4890995 35997 114312 740138 1169882 15944897 6368711 570 0 0 0 6091581 1822428 0 0 0 10976389 6650996 17068540 8473424 -1123643 -2104713 28003895 22900098 27814832 24604607 189063 -1704509 X Our mission is to serve the healthcare needs of our communities with excellence, compassion and commitment. 0 1 7293968 6060877 Kingfisher Regional Hospital is a not-for-profit corporation formed in 1950. The Hospital owns and operated a 25-bed critical access facility located in Kingfisher, Oklahoma. On November 1, 2013, the Hospital entered into a lease agreement with Mercy Health Oklahoma Communities, Inc. and Mercy Hospital Kingfisher to lease the operations of the Facility. The hospital retained the assets of the hospital and contiues to lease those to Mercy Hospital Kingfisher. 7293968 1 1 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 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 1 0 0 0 1 28 0 1 154 1 0 0 0 0 0 0 0 0 0 0 X 9 9 0 1 0 0 1 1 1 1 0 0 0 1 1 1 1 1 1 0 0 0 OK X Storm & Hause PC 4053754152 PO Box 449 Kingfisher OK 73750 J Juan Jech President 2.00 X X 0 0 0 Max Thomas Vice President 2.00 X X 0 0 0 Jim Lemon Treasurer 2.00 X 0 0 0 Heath Myers Secretary 2.00 X 0 0 0 Brenda Walta Director 2.00 X 0 0 0 Kim Grellner Director 2.00 X 0 0 0 Jack Stuteville Director 2.00 X 0 0 0 Pat Cheap Director 2.00 X 0 0 0 Gerald Knecht Director 2.00 X 0 0 0 Nancy Schmid CEO 40.00 X 0 0 0 John Parigi II CFO 40.00 X 282600 0 0 Deborah Day CRNA 40.00 X 155472 0 0 438072 0 0 2 0 1 1 Stephen R Arthurs MD 521 W Bowman Ave Kingfisher OK 73750 Medical Professional 504196 Matson Enterprises RR 1 BOx 133M Kingfisher OK 73750 Medical Professional 291964 CPP Wound Care LLC 1401 E Broadway St Morrilton AR 72110 Wound Care 260650 Imaging Solutions 3223 32nd Avenue South Suite 201 Fargo ND 58103 Radiologist 258727 Mcafee and Taft 211 N Robinson Oklahoma City OK 731027103 Legal Fees 207247 5 193522 193522 Patient Revenue 622110 4851405 4851405 39590 39590 4890995 2078 2078 177554 0 177554 177554 177554 136735 24501 112234 112234 112234 Appropriations 900099 961757 961757 Miscellaneous 900099 30571 30571 992328 6368711 6060877 0 114312 438072 438072 857248 857248 39378 39378 364665 364665 123065 67428 55637 269281 269281 399834 399834 7704 7704 998898 989970 8928 4033 4033 188997 188997 105418 105418 43400 43400 2086 2086 1151395 1151395 2385234 2385234 233176 233176 Restructuring Fees 563910 563910 Bad Debt Expense 290072 290072 Drugs and Food 88791 88791 Rental/Lease 65371 65371 -146604 -146604 8473424 7293968 1179456 0 3183824 981687 903552 1459518 562224 29366 196663 97881 6301 30228351 11469670 21549686 18758681 2260616 505270 408724 28003895 22900098 1678733 79545 24556078 24412452 1576116 3905 112610 27814832 24604607 X 184063 -1709509 5000 5000 189063 -1704509 28003895 22900098 -2104713 211141 0 X 0 1 X 1 0 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 730215 730215 24732329 8483613 16248716 22624 22624 0 4364107 2885217 1478890 379076 78216 300860 18758681 Due to Foundation 3905 Accrued Interest 74207 Estimated Third-Party Payor Settlements 34498 112610 X 1477716 0 1477716 4890995 4890995 6368711 4180735 0 4180735 4292689 4292689 8473424 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 990T) with the IRS. Part XI, Line 4b - Other Adjustments: Revenue from discontinued operations reported net of expenses in financials 4,890,995. Part XII, Line 4b - Other Adjustments: Expenses from discontinued operations reported net of revenue in financials 4,292,689. 1 1 X 1 X 1 X 1 1 0 1 0 101843 101843 0.01240 101843 101843 0.01240 101843 101843 0.01240 1 290072 0 2779370 2800592 -21222 X 1 1 1 1 Kingfisher Regional Hospital 1000 Kingfisher Regional Hospital Dr Kingfisher OK 73750 X X X X Kingfisher Regional Hospital 1 1 X X X X X X X X X 12 1 1 1 X www.okruralhealthworks.org/pdfweb/ae-13153.pdf X X X X 1 0 1 1 100.000000000000 1 300.000000000000 1 X 1 1 X X X X 1 0 X X X X 1 X 0 0 Kingfisher Regional Hospital Part V, Section B, Line 3: The hospital hosted community meetings and included local physicians, several hospital representatives, the school nurse and a social worker. Kingfisher Regional Hospital Part V, Section B, Line 6i: A copy of the implementationg strategy is available at www.okruralhealthworks.org/pdfweb/ae-13153.pdf Part I, Line 7: Charity care at cost was calculated based on the Medicare cost report. Part I, Line 7, Column (f): The Bad Debt expense included on Form 990, Part IX, Line 25, Column (A), but subtracted for purposes of calculating the percentage in this column is $ 290,072. Part III, Line 2: Bad debt expense is shown at charges per financial statements. Part III, Line 4: There is no footnote in the audited financial statements describing bad debt. Part III, Line 8: The entire shortfall should be considered community benefit as services are provided to Medicare patients even though the hospital is not provided full payment for the services. The services are critical to serivng this population. Part III, Line 9b: The hospital will treat a patient regardless of their ability to pay. If a patient is unable to pay, the hospital will provide uncompensated services, assist in third party billing, or bill the patient depending on the need and resources of the patient. If the patient indicates a need for financial assistance, the patient account representative will discuss the various payment plans and other options available. No collection actions are taken if the patient is eligible for charity care. Part VI, Line 2: The hospital uses a variety of resources to assess the health care needs of the communities it serves. Those resources include the following: 3-year strategic business plan and market assetssment of current and potential service areas utilizing consultants from Quorum Health Resources. Health assessments in conjunction with offices of the Oklahoma State Department of health and Oklahoma State University Economic Development. Part VI, Line 3: Information regarding charity care is available in the admission area and the emergency room. A copy of the charity care policy is given to patients when they come to register. The hospital also discusses with patients the availability of medicaid and assists them with the qualifications of such programs. They will also inform them of other discounts that may be available to them. Part VI, Line 4: The county of Kingfisher is a rural community with a county population of 10,397. The average household income is $32,471 with 10.4% of population under the poverty level as reported in the year 2005, our lastest current data. Kingfisher county has an unemployment rate of 2.7% as of January, 2008. Based on the bureau of economic analysis data, the 2006 per capita is slightly higher than the state of Oklahoma's average, but lower than the United States Average. Medical payments for the county included public assist medical care at a 11.6% rate with additional family assistance at .4% and food stamps at 1.2%. The hospital is the only hospital in this county. The Kingfisher health department also serves this county as well as DHS. Part VI, Line 5: The hospital sponsors a student governing body where area high school students participate on the board. THe hospital provides employees to oversee the meeting, provide lunch and provide a speaker. The students learn about healthcare and related healthcare occupations. Once a year, the students work on a project related to health care. This provides students an opportunity to learn about the industry and make a difference in the community. The 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 ability to pay. The hospital serves a major role in the education of the population of the Kingfisher county. The hospital provides free health screenings; glucose, blood pressure checks, weight and BMI at various health and wellness fairs; major sponsor of the Kingfisher county life to the max, a healthy fit-lifestyle change weight challenge; women's health fairs; Kingfisher county fair, Kingfisher county teachers halth fair; the 8th grade mini-health conference; student governing board health scholarships; and businesses flu shots. The hospital also provides information out of the primary area and secondary areas by way of a "health scene" magazine flyer and their internet site. 0 0 0 0 0 0 0 0 0 John Parigi II CFO 282600 0 0 0 0 0 0 0 0 0 282600 0 0 0 Deborah Day CRNA 155472 0 0 0 0 0 0 0 0 0 155472 0 0 0 Part I, Line 3 The CEO is paid by an unrelated management company for services provided to the organization. A Kingfisher Hospital Authority 261537909 495713AD1 2013-11-01 17300000 To refund prior issued 12/12/07 0 0 0 A 17300000 17300000 2013 0 0 0 0 A 0 0 0 0 0.00000 0.00000 0.00000 0 0 0 A 0 0 0 0 0 0 0 0 0 A 0 Form 990, Part III, line 3 Kingfisher entered into a lease with Mercy Hospital and leased all assets to them effective 11/1/2013. Mercy is now has operational control of the hospital and provides all medical services. Form 990, Part VI, Section A, line 3 Mercy - provided a CEO and advisory services to Kingfisher Regional Hospital. The following individuals were compensated by Mercy for services provided to the hospital: Nancy Schmid, CEO: $269,281 Form 990, Part VI, Section A, line 6 There is only one class of membership. Form 990, Part VI, Section A, line 7a Any person may become a member in the corporation by filing a written application for membership; agreeing to comply with and be bound by the certificate of incorporation and bylaws of the corporation and any rules and regulations adopted by the board; paying a membership fee of $100; and acceptance for membership by the board of the members. The board of Directors are elected by the members of the corporation. Form 990, Part VI, Section A, line 7b The members must approve any material changes in the purposes of the corporation for which it was formed by a 2/3 vote of the members. The members must also approve by a 2/3 vote any amendments, restatements, or repeals to the certificate of incorporation, any voluntary petition in bankruptcy, or for the corporation to make any assignment for the benefit of creditors. The corporation must have approval by a majority of the members entitled to vote in order to dissolve. Form 990, Part VI, Section A, line 8b The organization does not have any committees with the authority to act on behalf of the governing body. Form 990, Part VI, Section B, line 11 The return will be disbursed by electronic mail to the board and approved the same way. Form 990, Part VI, Section B, line 12c We have a fulltime compliance officer, compliance hot line, compliance education, compliance orientation, and compliance meetings and presentations to the board. Form 990, Part VI, Section B, line 15 The CEO is compensated by Quorum Health Management and provides services to the hospital through a managment agreement. The board of directors approves the managment agreement on an annual basis. Form 990, Part VI, Section C, line 19 The organization makes its governing documents, conflict of interest policy and financial statements available to the public upon request. Kingfisher Medical Foundation 1000 Kingfisher Reg Hosp Dr Kingfisher OK 75750 263029117 Foundation OK 501(c)(3) Line 7 N/A 1 0 0 0 0 0 0 0 0 0 0 0 0 1 1 0 0 0 0 0