2016-05-11T19:02:35-07:00 2015-06-30 990 2014-07-01 237429117 MADERA COMMUNITY HOSPITAL MADE 5596755555 1250 E Almond Avenue Madera CA 93637 Diane Neff Accounting Manager 5596752823 2016-05-05 2014 2016-08-17 19:52:53Z Evan Rayner 1250 E Almond Avenue Madera CA 93637 93812227 0 X www.maderahospital.org X 1971 CA Madera Community Hospital is dedicated to actively promoting and maintaining the health and well being of residents throughout the Central Valley of California. 17 12 984 80 0 0 3086512 207110 69568112 90888014 18269 50917 3264142 2666186 75937035 93812227 0 0 0 0 45378803 42363280 0 0 0 33875076 41429417 79253879 83792697 -3316844 10019530 75905063 84688515 24143131 22907053 51761932 61781462 Madera Community Hospital provides Inpatient and Outpatient healthcare services to the citizens of Madera and its surrounding communities. 0 0 50114911 0 92039265 Delivery and Management of General Inpatient and Outpatient Healthcare Services were provided to the citizens of Madera and its surrounding communities. 0 0 0 50114911 1 1 0 0 0 0 0 0 0 0 1 0 0 0 1 0 1 0 0 0 0 0 0 0 0 0 1 1 0 0 1 0 0 0 0 0 1 0 1 0 0 0 0 0 1 0 0 0 1 122 0 1 984 1 0 0 0 0 0 0 X 17 12 1 0 0 0 0 0 0 1 1 0 0 0 1 1 1 1 1 1 1 0 CA X X Mark J Foote 5596755505 1250 E Almond Avenue Madera CA 93637 Steve Barsotti Vice Chair 1 0 X 0 0 0 Anna DaSilva Board Member 1 0 X 0 0 0 Deirdre DaSilva Board Member 1 0 X 0 0 0 Margaret Diebert Board Member 1 0 X 0 0 0 Michael Diebert Board Member 1 1 X 0 0 0 Duane Furman Board Member 1 0 X 0 0 0 Anita Eden Board Member 1 0 X 0 0 0 Stell Manfredi Board Member 1 0 X 0 0 0 Aftab Naz Board Member 1 0 X 6400 0 0 Wally Nishimoto Board Member 1 0 X 0 0 0 Monte Pistoresi Secretary 1 0 X 0 0 0 Robert Poythress Chair 1 0 X 0 0 0 Steve Schafer Board Member 1 0 X 0 0 0 Kanwal Singh Board Member 1 0 X 0 0 0 Charles Ugwu-Oju MD Board Member 1 0 X 0 0 0 Don Warnock Board Member 1 0 X 0 0 0 Jan Zitek Board Member 1 0 X 0 0 0 Evan Rayner Exec Director/CEO 40 0 X 147766 0 0 Mark J Foote VP - Finance 40 0 X 190112 0 0 Karen Paolinelli Chief Operating Officer 40 0 X 193994 0 0 Meri Combs Chief Nursing Officer 40 0 X 164957 0 0 Laurene Cox Chief Nursing Officer 40 0 X 120918 0 0 Dale Costantino Director of Pharmacy 40 0 X 163395 0 0 Angelica Malagon Pharmacist II 40 0 X 143361 0 0 Matthew Kobzeff Pharmacist II 40 0 X 140606 0 0 Alma Mendoza Pharmacist II 40 0 X 136518 0 0 Nancy G Rowell Medical Staff Office Director 40 0 X 134955 0 0 John W Frye Chief Executive Officer 0 0 X 196829 0 0 1739811 0 0 39 1 1 0 Galen Inpatient Physicians 2100 Powell Street Suite 920 Emeryville CA 94608 Hospital Physician Services 1138698 Madera Anesthesia Consultants PO Box 7096 Stockton CA 95267 Anesthesia Services 660000 Zaks 1906 Howard Road Madera CA 93637 Security Services 564260 CEP America 2100 Powell Street Suite 920 Emerville CA 94608 Emergency Room Physicians Services 540000 ARUP PO Box 27964 Salt Lake City UT 84127 Laboratory Services 427745 22 0 0 0 145500 8000 53610 3610 207110 Medicare 622000 17312496 17312496 0 0 Medi-Cal 622000 58664076 58664076 0 0 CMSP 622000 152163 152163 0 0 Other 3rd Party Payers 622000 13171563 13171563 0 0 All Other Payers 622000 1587716 1587716 0 0 0 0 0 0 90888014 50917 50917 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 EMR Incentive Payments 622000 1100334 1100334 0 0 Non-Patient Food Sales 722212 813805 0 0 813805 Rebates & Refunds 622000 321580 0 0 321580 430467 0 0 430467 2666186 93812227 92039265 0 1565852 0 0 0 0 0 0 0 0 799032 349380 449652 0 0 0 0 0 29931221 24249837 5681384 0 0 0 0 0 8112679 6127620 1985059 0 3520348 2821895 698453 0 0 0 0 0 131782 0 131782 0 39750 0 39750 0 0 0 0 0 0 0 0 0 0 0 582509 337562 244947 0 22537 0 22537 0 493282 130305 362977 0 1138069 0 1138069 0 0 0 0 0 197772 193808 3964 0 23526 8291 15235 0 0 0 0 0 26543 20251 6292 0 400512 0 400512 0 0 0 0 0 3993714 547787 3445927 0 1569824 0 1569824 0 Supplies 9720543 7874577 1845966 0 Quality Assurance Provider Fees 11364768 0 11364768 0 Other Purchased Services 4719940 2513760 2206180 0 Physician Professional Fees 3851167 3827167 24000 0 3153179 1112671 2040508 0 83792697 50114911 33677786 0 1996772 5118696 14216461 21955295 0 0 18087920 8104902 0 0 0 0 3123492 13677154 1638922 1582846 562388 570262 82207467 48720534 36071692 33486933 0 0 0 0 0 0 0 0 207416 192427 75905063 84688515 3227997 2609389 0 0 0 0 0 0 0 0 0 0 15822980 14339823 0 0 5092154 5957841 24143131 22907053 X 51761932 61781462 0 0 0 0 51761932 61781462 75905063 84688515 10019530 0 0 0 0 0 X 0 1 X 0 0 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 410000 84936 494936 0 45162915 19592946 25569969 0 1696 1696 0 0 34973109 27863930 7109179 0 1574811 1261962 312849 33486933 Accrued Payroll & Related Liabilities 4108887 Quality Assurance Fees Payable 1848954 5957841 93812228 0 0 0 1 1 93812227 0 0 0 93812227 83792698 0 0 0 1 1 83792697 0 0 0 83792697 Schedule D, Part XI, Line 2d Rounding Difference Schedule D, Part XII, Line 2d Rounding Difference 1 1 X 1 X 1 X 0 1 0 1 1 193 1297250 0 1297250 0.015 40131800 26482730 13649070 0.162 25785311 14470706 11314605 0.135 0 193 67214361 40953436 26260925 0.312 217246 0 217246 0.003 90978 0 90978 0.001 0 0 0 0 0 0 0 0 41167 0 41167 0.0 0 0 349391 0 349391 0.004 0 193 67563752 40953436 26610316 0.316 0 0 0 0 0 0 0 0 60413 0 60413 0 0 0 0 0 0 0 0 0 0 0 0 0 1422 0 1422 0 13566 0 13566 0 0 0 0 0 0 0 75401 0 75401 0 1 3636876 0 13620000 23409731 -9789731 X 1 1 4 1 Madera Community Hospital 1250 E Almond Avenue Madera CA 93637 www.maderahospital.org X X X A 2 Madera Community Hospital Family Health Services 1210 E Almond Avenue Madera CA 93637 www.maderahospital.org Provider-Based Rural Health Clinic A 3 Chowchilla Medical Center Clinic 205 Hospital Drive Chowchilla CA 93610 www.maderahospital.org Provider-Based Rural Health Clinic A 4 Madera Community Hospital Outpatient Center 1270 E Almond Avenue Madera CA 93637 www.maderahospital.org Provider-Based Outpatient Laboratory and Radiology Services A A 1 0 1 X X X X X X X X X 13 1 1 0 1 X www.maderahospital.org X www.hospitalcouncil.org 1 13 0 0 0 1 X 200 350 1 1 X X X 1 X www.maderahospital.org X 1 X X 0 X X X 1 X 0 0 Schedule H, Part V, Section B, Line 5-Group A Madera Community Hospital participated in the 4-County Community Needs Assessment that was completed in March 2013. There were 14 focus groups convened within the 4-county area. Participants in the interviews included the Madera County Director of Public Health, the Executive Director of First 5 of Madera County, Madera Community Hospital CEO and other local healthcare facilities executives. Schedule H, Part V, Section B, Line 6a-Group A Adventist Health Central Valley Network, Kaweah Delta Medical Center, Sierra View District Hospital, Coalinga Regional Medical Center, Corcoran District Hospital, San Joaquin Valley Rehabilitation Hospital, Tulare Regional Medical Center, Community Medical Centers, Children's Hospital Central California, Kaiser Permanente, Saint Agnes Medical Center, Madera Community Hospital. Schedule H, Part V, Section B, Line 11-Group A Madera Community Hospital has designed and implemented programs to meet the health needs of the community as identified in the most recent and previous Community Health Needs Assessment. The hospital has understood the health needs of this community for many years and has provided a number of special services to the community to address them, such as the Better Breathers Club, Sweet Success Program for pregnant diabetic mothers and child birth classes to address proper prenatal care. Schedule H, Part I, Line 7 The amounts included in the table for Line 7 are based on amounts taken from the hospital's Medicare Cost Report and the Annual Community Benefits Report. Schedule H, Part II Madera Community Hospital's community building activities mainly consist of training local residents in careers in healthcare. As a result, this activity promotes health in the community by raising the awareness of local residents in our training programs about healthcare topics and these people also help promote good healthcare practices with the people they interact with. Schedule H, Part III, Section A, Line 4 Bad Debt Expense is recorded in the financial statements as the amount of charges written off for each account determined to be uncollectable. The amount on Line 2 is determined by the bad debt expense reported in the financial statements times a cost-to-charge ratio from this year's Medicare Cost Report. The text of the footnote describing bad debt expense in Note A on page 6 of the attached Audited Financial Statements under the paragraph titled "Patient accounts receivable". Schedule H, Part III, Section B, Line 8 All of the shortfall reported on Line 7 is treated as s community benefit as they are the unreimbursed costs of providing services to Medicare patients residing in our community. The costs were calculated in the Medicare Cost Report for this period. The revenue was derived from actual and estimated collections on Medicare accounts. Schedule H, Part III, Section C, Line 9b The Bad Debt Collection policy contains procedures for contracted debt collection agencies to return accounts to the hospital if the debtor qualifies for the hospital's Financial Assistance program. Schedule H, Part VI, Line 2 Madera Community Hospital participated in a 4-county Community Needs Assessment that was published in March 2013. Various focus groups were formed from members of the local communities to discuss the health needs. Schedule H, Part VI, Line 3 There are notices on each billing statement that goes to the patient regarding information about the Hospital's Financial Assistance policy. All self-pay patients are given a pamphlet about the availability of the financial assistance program and their access to public benefit programs. There is information also displayed in all public registration areas. Schedule H, Part VI, Line 4 The direct service area of the hospital contains about 125,000 residents, mostly made up of western Madera County. The population is about 54% Hispanic, 30% White/Caucasian, with a mix of other ethnicities. The population has a high number of Medicaid and Medicare patients, many low income families and is generally an agriculture-based economy. Most of the County is part of a Health Professional Shortage Area (HPSA). Schedule H, Part VI, Line 5 Madera Community Hospital is the only local hospital serving all ages in a wide geographic area. It is governed by a community-based, volunteer Board of Trustees. The Medical Staff is open to any qualified practitioner that meets credentialing criteria. The hospital is one of the largest employers in the area, tries to hire employees locally and sponsors programs for high school students and others to enter nursing and other medical fields. The hospital promotes a wide number of programs to support the better health of the residents it serves. All of the various community health and educational programs done by or sponsored by Madera Community Hospital are fully discussed in the Community Benefit Report for this year. Schedule H, Part VI, Line 6 The hospital is a free-standing, community-based, 501(c)(3) organization and is not affiliated with any health system. Schedule H, Part VI, Line 7 California X X 0 0 X X X 0 0 0 0 0 0 0 0 0 Evan Rayner Exec Director/CEO 128359 0 0 0 19407 0 0 0 418 0 148184 0 0 0 Mark J Foote VP - Finance 180094 0 8500 0 1518 0 0 0 2893 0 193005 0 0 0 Karen Paolinelli Chief Operating Officer 183661 0 9500 0 833 0 0 0 1267 0 195261 0 0 0 Meri Combs Chief Nursing Officer 155725 0 8500 0 732 0 0 0 3503 0 168460 0 0 0 Laurene Cox Chief Nursing Officer 117347 0 3016 0 555 0 0 0 3003 0 123921 0 0 0 Dale Costantino Director of Pharmacy 158485 0 4116 0 794 0 0 0 1003 0 164398 0 0 0 Angelica Malagon Pharmacist II 143361 0 0 0 0 0 0 0 482 0 143843 0 0 0 Matthew Kobzeff Pharmacist II 140606 0 0 0 0 0 0 0 4857 0 145463 0 0 0 Alma Mendoza Pharmacist II 136518 0 0 0 0 0 0 0 2091 0 138609 0 0 0 Nancy G Rowell Medical Staff Office Director 129833 0 3402 0 1720 0 0 0 1596 0 136551 0 0 0 John W Frye Chief Executive Officer 112818 0 0 0 84010 0 0 0 1136 0 197964 0 0 0 Schedule J, Part I, Line 1a The CEO is provided a housing allowance in his employment contract with the Board of Directors. The housing allowance is grossed up in order to provide the CEO with net amount per the contract. Schedule J, Part I, Line 1b The grossed up housing allowance is an obligation of an emploment contract between the Board of Directors and the CEO. Schedule J, Part I, Line 3 The Board of Trustees reviews and approves the salary for the CEO on an annual basis. The Board uses the California Hospital Association Executive Salary Survey when determining the salary for the CEO. Creative Copy Owner is Board Member Margaret Diebert 34302 Printing Services 0 Aftab Naz Board Member 11400 Physician Services 0 Pistoresi Ambulance Owner is Baord Member Monte Pistoresi 27395 Ambulance Services 0 Kanwal Singh Board Member 64756 Physician Services 0 Charles Ugwu-Oju Board Member 53760 Physician Services 0 Form 990, Part VI, Section A, Line 2 Steve Barsotti is MCH Insurance Agent at Foster & Parker Insurance Company that does Business with MCH. Anna daSilva and Deidre daSilva are Mother-in-Law & Daughter-in-Law. Margaret Diebert and Mike Diebert are Stepmother & Stepson. Margaret Diebert and Don Warnock are Sister-in-Law & Brother-in-Law. Robert Poythress is Manager of Citizen's Business Bank that does Business with MCH. Form 990, Part VI, Section B, Line 11b The Staff Accountant completes the draft of the Form 990 and Related Schedules and submits them to the Accounting Manager for review. The Chief Financial Officer completes Schedule H and assists in answering the questions related to the governance of the organization. All financial information is tied back to the Audited Financial Statements. The Accounting Manager submits the final draft of the Form 990 and Related Schedules to the Chief Financial Officer for review. The Chief Financial Officer reviews the final draft of the Form 990 and Related Schedules before it is filed. Form 990, Part VI, Section B, Line 12c For any conflicts of interest or complaints of such, an investigation is conducted by the Human Resources department. Depending upon the outcome of the investigation, re-education, training and counseling are conducted as necessary. Form 990, Part VI, Section B, Line 15 Each officer or key employee receives a written performance evaluation on an annual basis. All rate changes are made in accordance with the hospital's wage and salary plan. The hospital uses the California Hospital Association Executive Salary Survey in setting the annual compensation rates. The CEO was reviewed by a Board of Trustees Committee in December 2015. The VP-Finance was reviewed by the CEO in March 2015, the AVP-Human Resources and Chief Operating Officer were each reviewed by the CEO in April 2015, and the Chief Nursing Officer was reviewed by the CEO in September 2015. Form 990, Part VI, Section C, Line 19 The Audited Financial Statements and the Form 990 are available upon request in the Hospital's Administration office during normal business hours. They are also part of the information that is available to the public on the California Office of Statewide Health and Planning Department website. The Conflict of Interest policy and the Governing documents are currently not available for public inspection. Madera Community Hospital Foundation 1250 E Almond Avenue Madera CA 93637 942514197 Fundraising CA 501(c)(3) 7 N/A 0 0 0 1 0 0 0 0 0 0 0 0 0 0 0 1 1 0 0 0 Madera Community Hospital Foundation c 145500 Cash Receipts Madera Community Hospital Foundation o 51596 Payroll Records Madera Community Hospital Foundation p 3323 Cash Disbursements We received an approved Extension of Time to File an Exempt Organization Return on Notice Number CP211A dated March 28, 2016.