2016-05-11T16:13:01-05:00 2015-06-30 481026809 Wendling Noe Nelson & Johnson LLC 534 S Kansas Ave Suite 1500 Topeka KS 666033491 990 2014-07-01 481253246 Pawnee Valley Community Hospital Inc PAWN 6202853161 923 Carroll Ave Larned KS 67550 George Harms Secretary/Treasurer 7856235000 2016-05-04 1 Heather R Eichem P01515553 7852334226 2016-05-04 2014 2016-08-17 19:52:53Z George Harms 923 Carroll Ave Larned KS 67550 18321805 0 X www.pawneevalleyhospital.com X 2001 KS Pawnee Valley Community Hospital, Inc. is a tax-exempt charitable organization under Section 501(c)(3) of the Internal Revenue Code and is licensed by the State of Kansas Department of Health and Environment. The purpose of the Organization is to improve the quality of life for the communities we serve through exceptional healthcare and service excellence. The Organization is striving to be the best Critical Access Hospital in rural America. 7 2 163 99 0 0 190261 907604 15182064 17240485 7294 4292 0 169424 15379619 18321805 179198 901744 0 0 5961003 7917015 0 0 0 6339813 6688940 12480014 15507699 2899605 2814106 8019575 7788872 7610192 6709764 409383 1079108 X Pawnee Valley Community Hospital, Inc. is a tax-exempt charitable organization under Section 501(c)(3) of the Internal Revenue Code and is licensed by the State of Kansas Department of Health and Environment. The purpose of the Organization is to provide healthcare facitities and services for the care and treatment of inpatients and outpatients who are acutely ill or who otherwise require medical care and related services. The core purpose of the Corporation is to improve the quality of life for the communities we serve through exceptional healthcare and service excellence. 0 0 11647456 901744 17262899 Patient care: Program services consist of routine and ancillary department healthcare services provided by a healthcare organization as described in 501(c)(3) of the IRS code. 11647456 1 1 0 1 0 0 0 0 0 1 0 0 0 1 1 1 1 1 0 0 0 0 0 0 0 0 1 1 1 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 1 0 0 0 1 0 0 1 163 1 0 0 0 0 0 0 0 0 0 0 X 7 2 0 0 0 0 1 1 1 1 1 0 0 1 1 1 1 1 1 1 1 0 X George Harms Treasurer 7856235000 2220 Canterbury Hays KS 67601 Bryce Young President 4.00 36.00 X X 0 260247 80480 Shae Veach Vice President 4.00 36.00 X X 0 200871 60537 George Harms Secretary/Treasurer 4.00 36.00 X X 0 156923 40863 John Jeter MD Director 4.00 36.00 X 0 521550 134596 Larry Watts Director 4.00 36.00 X 0 306053 77354 David Sanger MD Director/Physician 40.00 X 94338 120898 37203 John Settle Director 4.00 X 0 0 0 John Haas Director 4.00 X 0 0 0 John Hughes Administrator 40.00 X 0 0 0 Amanda Bickle APRN 40.00 X 131292 0 26185 Cynthia Carter RN 40.00 X 108301 0 15775 Cristine Goodwin Physician 34.00 X 70385 82115 24669 Christian Whittington Physician 40.00 X 91269 106346 30212 495585 1755003 527874 2 0 1 0 Hays Medical Center 2220 Canterbury Drive Hays KS 67601 Contract Services 3399671 Quest Diagnostics PO Box 14730 St Louis MO 63150 Lab Services 170009 Shared Medical Services Inc 209 Limestone Pass Cottage Grove WI 53527 MRI services 143380 Docs Who Care 1337 S Foundatin Drive Olathe KS 66061 Emergency Room Physician Services 104333 4 901744 5860 907604 Net patient service revenue 622000 17143934 17143934 Outreach therapy services 900099 68272 68272 Lab fairs 900099 28279 28279 17240485 4292 4292 1300 0 1300 1300 1300 Meals sold to employees and guest 722210 147010 147010 Other miscellaneous revenue 900099 21114 21114 168124 18321805 17262899 0 151302 901744 901744 321226 256012 65214 6152504 5556770 595734 223602 199483 24119 754056 680167 73889 465627 418200 47427 2348032 2348032 26433 26433 23559 23559 1541452 1329840 211612 77690 5115 72575 41504 27976 13528 105235 63641 41594 340935 282396 58539 13703 12044 1659 3408 3408 108180 64908 43272 Pharmaceuticals 655073 655073 Medical supplies 453555 453232 323 Dietary 164924 156275 8649 Service contracts 143496 130464 13032 641761 450708 191053 15507699 11647456 3860243 0 246579 432300 4529204 2592523 2330522 1745586 265762 280864 113774 136365 533734 2601234 8019575 7788872 908936 1054368 6701256 5655396 7610192 6709764 X 409383 1079108 409383 1079108 8019575 7788872 X 2814106 -2144381 X X 0 1 X 1 0 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 0 0 0 0 0 1 2827 0 0 0 2827 0 Part II-B, Line 1: Pawnee Valley Community Hospital is a member of the Kansas Hospital Association and the American Hospital Association. Both of these organizations engage in lobbying activities for hospitals and health care as part of the services provided to members. 372016 1515575 952795 934796 142777 408437 179198 372016 1026228 883451 142777 0.00000 0.00000 1.00000 0 1 1 0 Estimated third-party payor settlements 1501813 Other receivables 8260 Receivables from related parties 12053 Beneficial interest in net assets of foundation 1079108 2601234 Due to Pawnee County 5063815 Due to Hays Medical Center, Inc. 531581 Estimated third-party payor settlements 60000 5655396 X 18991530 669725 669725 18321805 0 18321805 14605955 0 14605955 901744 901744 15507699 Part V, Line 4: Donations are requested for specific items or improvements to the Hospital. When a donation is received for that specific item, it is restricted for that use by the Board until the specific item or improvement is purchased. At any one time, one or more such projects can be in progress. Part X, Line 2: Management is not aware of any uncertainties in income tax positions. Part XI, Line 2d - Other Adjustments: Change in beneficial interest in net assets of Foundation 669,725. Part XII, Line 4b - Other Adjustments: Transfer of equipment to Pawnee County 901,744. 1 1 1 X 130.000000000000 1 X 1 1 0 0 107209 107209 0.00690 1167382 389127 778255 0.05020 1274591 389127 885464 0.05710 2862393 1925591 936802 0.06040 13679 13679 0.00090 2876072 1925591 950481 0.06130 4150663 2314718 1835945 0.11840 1 797186 55803 8174315 8359350 -185035 X 1 1 1 1 Pawnee Valley Community Hospital Inc 923 Carroll Avenue Larned KS 67550 X X X X Pawnee Valley Community Hospital Inc 1 0 0 1 X X X X X X X X X 14 1 0 1 1 X http://www.pawneevalleyhospital.com/ X http://www.pawneecountykansas.com/ X 1 14 0 1 0 1 X 130.000000000000 400.000000000000 X X X 1 1 X X X 1 X http://http://www.pawneevalleyhospital.com/ X http://http://www.pawneevalleyhospital.com/ X http://http://www.pawneevalleyhospital.com/ X X X X X 1 X 0 X X X X 1 X 0 0 Pawnee Valley Community Hospital, Inc. Part V, Section B, Line 5: The CHNA was conducted in collaboration with the Pawnee County Health Department. A Town Hall meeting was organized to provide an objective consensus building method of reviewing and prioritizing county health issues. During the Town Hall meeting, the group reflected on the size and seriousness of any health concerns cited and discussed current community health strengths. The group identified and ranked top community health concerns, and all Town Hall attendees were encouraged to continue to contribute ideas by going online and taking a feedback survey that addresses any additional thoughts related to the CHNA. All Town Hall priority-setting and score processes involved the input of a diverse group with knowledge and/or expertise in public health as well as persons who represent the broad interests of the community served by the hospital. Key stakeholders in attendance included representatives from: United Way, Welcome Inn Senior Center, Center for Counseling, Angels Care Home Health, Golden Belt Foundation, Larned City Council, Burdett City Council and Garfield City Council and Rozel Community, Pawnee County Sherriff's office, Larned Police Department, Pawnee County Health Department, County Commissioners, members of the Chamber of Commerce, members of the USD 495 School Board, school nurses of USD 495, local members of the media, local religious organizations and representative of Pawnee Valley Community Hospital. The CHNA was coordinated and produced by VVV Research & Development, Inc. from Olathe, Kansas. Pawnee Valley Community Hospital, Inc. Part V, Section B, Line 6b: Pawnee County, KS Pawnee Valley Community Hospital, Inc. Part V, Section B, Line 11: Annual description of the actions taken by the Hospital during the fiscal year to address the significant health needs identified throught the most recently conducted CHNA:Build and/or develop Exercise Facilities was #1 on the health needs Priorities- with 37 votes, 22.8%. Pawnee Valley Community Hospital supported USD #495 in 2015 to pass a bond for a new elementary school and renovations to the high school. Because of the CHNA and the school districts involvement and listening to the needs of Pawnee County, they have incorporated an exercise facility, in the renovations to the high school, which will be open to the public. PVCH once again had their annual fun run in June 2015. LA Psycle, opened its doors in 2015 for the community to sign up for spin classes. Pride Committee also added a second walking trail to the community. This walking trail goes around Camp Pawnee. PVCH staff have done community presentations for heart disease awareness. Expand Oncology Treatment was #2 on the health needs priorities - with 25 votes, 15.4%. In order to implement an effective oncology service line, many factors must come together. We have explored the feasibility of offering oncology services and providers in Pawnee County and it was determined not to be feasible at this time. We have had the great fortune of being able to partner with the Dreiling/Schmidt Cancer Institute at HaysMed. In lieu of this partnership, we hope to continue to be an outreach clinic for Dreiling/Schmidt Cancer Institute. It is vitally important to maintain the relationship with both primary care medical staff as well as specialists. This will ensure consistent continuity for our patients as they move through the continuum of their cancer treatment course. Improve Quality Air Flow was #3 on health needs priorities - with 20 votes, 12.3%. We plan to continue to look into improving air quality in Pawnee County. More research needs to be done to determine if it is feasible for PVCH to implement a plan to address air quality issues. Reducing Drug/Alcohol Abuse was #4 on health needs priorities - with 20 votes, 12.3%. The Pawnee County Health Department in coordination with the Center For Counseling & Consultation has received a grant for improving health in rural communities from the Centene Foundation. As part of this grant opportunity, we are working with Wichita State University's Community Engagement Institute to administer a behavioral health survey to identified community partners/stakeholders in Pawnee, Barton, Rice and Stafford Counties. The survey is designed to bring a better understanding of current awareness and support for community based mental health and substance abuse services. While the survey's primary purpose is to identify demand for specific behavioral health services, areas for improvement, and past utilization/referrals, the survey will also serve a primary role in starting conversations for change and greater community involvement in each of these counties. We hope to increase the recognition and understanding of the importance of mental health and substance abuse issues in our county. Provide Healthy Food Options was #5 on health needs priorities - with 14 votes, 8.6%. Pawnee Valley Community Hospital is promoting healthy eating lifestyles focusing on food labels, healthy meal options, nutrition, and portion control. There are no vending machines in our hospital and candy bars and sweet snacks have been eliminated from the grab and go section of the cafeteria. We continue to offer diabetic education classes and have increased the class to a two day session. Participants eat at the facility and go through the cafeteria line and are encouraged to make healthier food choices. PVCH continues to educate children at their annual sixth grade health fair and includes education on portion control, label reading, and exercise. PVCH and Pawnee County Health Department have both had educational booths at the county fair and twice a year at the community health fair. The health department has increased their educational items pertaining to healthy food options for the public to obtain. Increase Access to Home Health/Hospice was #6 on health needs priorities with 11 votes, 6.8%. Continuing to look at the feasibility and what we can do to increase access to home health/hospice. We will continue to promote existing agencies and educate patients of services available. PVCH has partnered with the Kansas Heart and Stroke Collaborative and have a part time staff member that goes into the home and checks on the patient and makes sure they are following the guidelines provided by their physician, pertaining to heart and stroke. Offer Nursing Home - Dementia Services was #7 on health needs priorities with 11 votes, 6.8%. Country Living Assisted Living facility in Pawnee County recently opened a building specifically for dementia patients. We will continue to work on identifying nursing home dementia services in Pawnee County and educate entities and individuals who may be in need of these services. Pawnee Valley Community Hospital, Inc. Part V, Section B, Line 22d: The hospital used the look-back method based on actual paid claims by Medicare and all other private health insurers paying claims to the hospital. Part V, Section B, Line 16 Financial Assistance Policy Website Availability Pawnee Valley Community Hospital, Inc. Part V, Section B, line 16a website: http://http://www.pawneevalleyhospital.com/ Pawnee Valley Community Hospital, Inc. Part V, Section B, line 16b website: http://http://www.pawneevalleyhospital.com/ Pawnee Valley Community Hospital, Inc. Part V, Section B, line 16c website: http://http://www.pawneevalleyhospital.com/ 1 Pawnee Valley Medical Associates 713 W 11th St Larned KS 67550 Family Medicine Part I, Line 7: A cost-to-charge ratio derived from Worksheet 2 was used to determine financial assistance at cost and the cost of subsidized health services. A cost-to-charge ratio derived from Worksheet 2 was used to determine the costs of serving Medicaid beneficiaries. Part I, Line 7g: Subsidized health services community benefit expenses include $2,039,012 of expenses attributable to physician clinics that have net operating losses. Part III, Line 4: The footnote from the hospital's financial statements follows:Accounts receivable are reduced by an allowance for uncollectible accounts. In evaluating the collectability of accounts receivable, the Hospital analyzes its past history and identifies trends for each of its major payor sources of revenue to estimate the appropriate allowance for uncollectible accounts and provision for bad debts. Management regularly reviews data about these major payor sources of revenue in evaluating the sufficiency of the allowance for uncollectible accounts. For receivables associated with services provided to patients who have third-party coverage, the Hospital analyzes contractually due amounts and provides an allowance for uncollectible accounts and a provision for bad debts, if necessary (for example, for expected uncollectible deductibles and copayments on accounts for which the third-party payor has not yet paid, or for payors who are known to be having financial difficulties that make the realization of amounts due unlikely). For receivables associated with self-pay patients (which includes both patients without insurance and patients with deductible and copayment balances due for which third-party coverage exists for part of the bill), the Hospital records a significant provision for bad debts in the period of service on the basis of its past experience, which indicates that many patients are unable or unwilling to pay the portion of their bill for which they are financially responsible. The difference between the standard rates (or the discounted rates if negotiated) and the amounts actually collected after all reasonable collection efforts have been exhausted is charged off against the allowance for uncollectible accounts.Part III Line 2:Costing methodology: A cost-to-charge ratio derived from Worksheet 2 was used to calculate bad debt expense at cost.Part III Line 3:Methodology for bad debt cost for financial assistance eligible: The estimate for the amount of bad debt expense attributable to patients eligible under the FAP is based upon the experience of a related organization. Part III, Line 8: The Medicare cost report was the costing methodology used to determine the allowable Medicare costs pertaining to Medicare net revenue. Allowable costs of care reported on line 6 were determined using amounts from Worksheet D, Part V and Worksheet D-1 in the Pawnee Valley Community Hospital, Inc., Medicare cost report for fiscal year ended June 30, 2015. Part III, Line 9b: Whenever possible, the customer service representatives (CSR's) of Pawnee Valley Community Hospital try to determine the estimated self-pay balance prior to the patient receiving services. Charity care eligibility is first considered at this point in time. In addition, if full payment is not received or payment is not made with 30 days, the CSR contacts the patient. If it is determined that at least a two-year payment plan cannot be established with the patient, the CSR will screen for charity care and request that the charity care application be completed by the patient. Part VI, Line 3: Information regarding the Pawnee Valley Community Hospital, Inc. charity care program is located on the Pawnee Valley Community Hospital and Hays Medical Center, Inc. website for patients and community members to view, and the financial assistance application is also on the HMC website to print off and complete. In addition, if a customer service representative contacts a patient about a bill and in visiting with them they determine that patient could possibly qualify for the hospital's charity care policy, the CSR will send the application to the patient as well. Part VI, Line 4: Pawnee Valley Community Hospital, Inc. is located in Larned, Kansas, which has a population of approximately 4,050 people, as of the 2010 census. The median household income of Larned was $46,464. Approximately 5.9% of families were below the poverty line, and 7.4% of the total population was below the poverty line. Approximately 9.2% of the hospital's revenue is from services provided to patients eligible for Medicaid. Pawnee Valley Community Hospital, Inc. is the only hospital in Larned, Kansas. It mainly serves the community of Larned. Part VI, Line 5: Pawnee Valley Community Hospital, Inc. promotes the health of the community by extending medical privileges to most qualified, local physicians. Part VI, Line 6: Pawnee Valley Community Hospital, Inc. is not a part of an affiliated health care system. 0 Pawnee County 715 Broadway Larned KS 67550 486007542 901744 Cash paid Transfer of equipment Pawnee County owns all fixed assets (land, building, equipment) used by the Hospital. To expedite the purchase of equipment and obtain favorable purchasing terms, the Hospital purchased equipment on behalf of the County. The Pawnee Valley Community Hospital Foundation reimbursed the Hospital for the purchase. The Hospital then transferred ownership of the equipment to Pawnee County. 1 0 0 1 0 0 0 1 1 0 0 Bryce Young President 0 257922 0 0 0 2325 0 54663 0 25817 0 340727 0 0 Shae Veach Vice President 0 163194 0 0 0 37677 0 36741 0 23796 0 261408 0 0 George Harms Secretary/Treasurer 0 156923 0 0 0 0 0 23538 0 17325 0 197786 0 0 John Jeter MD Director 0 519639 0 0 0 1911 0 111046 0 23550 0 656146 0 0 Larry Watts Director 0 299172 0 0 0 6881 0 60476 0 16878 0 383407 0 0 David Sanger MD Director/Physician 94338 111731 0 0 0 9167 5719 6785 10484 14215 110541 141898 0 0 Amanda Bickle APRN 131081 0 211 0 0 0 2744 0 23441 0 157477 0 0 0 Cristine Goodwin Physician 70385 82115 0 0 0 0 4292 5008 1154 14215 75831 101338 0 0 Christian Whittington Physician 91269 106346 0 0 0 0 5538 0 10459 14215 107266 120561 0 0 Part I, Line 3 A related organization uses a compensation committee, independent compensation consultant, written employment contract, and approval by the board or compensation committee to establish the compensation of the Hospital's Administrator. Part I, Line 4b Contributions to the plan: John Jeter, M.D. - $77,946 Bryce Young - $39,063 George Harms - $23,538 Shae Veach - $24,629 Larry Watts - $44,876 Part I, Line 6 A portion of the Administrator's incentive compensation is determined by net earnings exceeding budget for the fiscal year. A portion of incentive compensation for officers and key employees of Hays Medical Center, Inc., a related organization, is determined by net earnings exceeding budget for the fiscal year. Form 990, Part VI, Section A, line 6 The organization has one member, HaysMed Partners, Inc., which became the sole member as of March 1, 2010. HaysMed Partners, Inc., is a wholly-owned subsidiary of Hays Medical Center, Inc. Form 990, Part VI, Section A, line 7a The Board members of HaysMed Partners, Inc., the sole member of Pawnee Valley Community Hospital, appoint the Board members of Pawnee Valley Community Hospital, Inc. Form 990, Part VI, Section A, line 7b HaysMed Partners, Inc., the sole member of Pawnee Valley Community Hospital, elects the Board members of Pawnee Valley Community Hospital. Form 990, Part VI, Section B, line 11 Form 990 was reviewed with the Board members prior to filing. Form 990, Part VI, Section B, line 12c Officers, directors & key employees, along with all associates, are required to complete a conflict of interest statement annually. The statements are used to monitor and enforce compliance with the policy. Form 990, Part VI, Section B, line 15 The hospital administrator and officers' salaries are reviewed annually by an independent consulting group and the Board members. Form 990, Part VI, Section C, line 19 These documents are not made available to the public. Form 990, Part XI, line 9: Increase in amount due to Pawnee County -1,946,187. Transfers to Pawnee County -867,919. Change in beneficial interest in net assets of foundation 669,725. Form 990. Part XII, Line 2c Hays Medical Center, Inc., has an audit committee that is responsible for the oversight of Pawnee Valley Community Hospital, Inc's., financial statement audit and the selection process of an independent accountant. HaysMed Partners Inc 2220 Canterbury Dr Hays KS 67601 270877152 Owns management contract for Pawnee Valley Community Hospital KS 501(c)(3) 170(b)(1)(A)(iii) 0 Hays Medical Center Inc 2220 Canterbury Dr Hays KS 67601 480559088 Hospital KS 501(c)(3) 170(b)(1)(A)(iii) 0 Pawnee Valley Community Hospital Foundation 923 Carroll Ave Larned KS 67550 455333776 Support the activities and mission of the Hospital KS 501(c)(3) 509(A)(3), Type I 0 0 0 1 1 1 0 0 0 0 1 0 1 1 0 1 1 1 0 0