2015-10-26T11:46:30-05:00 2014-12-31 481026809 Wendling Noe Nelson & Johnson LLC 534 S Kansas Ave Suite 1500 Topeka KS 666033491 990 2014-01-01 480892178 Citizens Medical Center Inc CITI 7854627511 100 E College Drive Colby KS 67701 Greg Unruh CEO 7854627511 2015-10-13 1 Heather R Eichem P01515553 7852334226 2015-10-13 2014 2016-02-25 16:41:14Z Greg Unruh 100 E College Drive Colby KS 67701 26791307 0 X www.nwkshealthcare.com X 1979 KS We are a team of health care professionals leading the region by providing superior health care services and exceptional customer care. 7 7 383 63 0 0 46697 212735 24123730 26174442 28270 141530 83246 242376 24281943 26771083 10148 18112 0 0 14256998 16345953 0 0 71269 9446325 10287498 23713471 26651563 568472 119520 20790158 20737052 9317347 9094041 11472811 11643011 Providing compassionate care that promotes dignity and well-being. 0 0 23501122 18112 26413602 CMCI provided a wide range of healthcare services to residents of its service area. 3,263 patient days of inpatient care, 18,676 patient days of nursing facility care, 2,718 emergency room visits and 28,329 physician clinic visits were provided during the fiscal year. 23501122 1 1 0 1 0 0 0 0 0 0 1 0 0 1 1 1 1 0 0 0 0 0 0 0 0 0 1 1 0 1 1 0 0 0 0 0 0 0 0 0 0 0 0 0 1 0 0 0 1 49 0 1 383 1 0 0 0 0 0 0 0 0 0 0 X 7 7 0 0 0 0 1 1 0 1 1 0 0 1 1 1 1 1 1 1 1 0 X Patsy Evans 7854627511 100 E College Drive Colby KS 67701 Phillip Knox Chairperson 4.00 X X 0 0 0 Vernon Schwanke Vice Chairperson 4.00 X X 0 0 0 Janet Saddler Secretary 4.00 X X 0 0 0 AJ Hurst Treasurer 4.00 X X 0 0 0 Patricia Erickson Trustee 4.00 X 0 0 0 Michael Kersenbrock Trustee 4.00 X 0 0 0 Dorthy Kistler Trustee 4.00 X 0 0 0 Clyde Kevan Trenkle CEO 40.00 X 209490 0 31748 Patsy Evans CFO 40.00 X 128880 0 10706 Darren Matchell Physician 40.00 X 315242 0 48832 Kelly Gabel Physician 40.00 X 305806 0 32746 John Dygert Physician 40.00 X 288618 0 49441 Sarah Gabel Physician 40.00 X 214604 0 5204 Brian Unruh Physician Assistant 40.00 X 205447 0 21635 1668087 0 200312 13 0 1 0 Colby Anesthesia Services Inc 2287 K 25 Colby KS 67701 CRNA Coverage 601663 CPSI PO Box 850309 Mobile AL 36685 Computer support services 177918 Charles E Frankum MD LLC 1960 North Ogden RD STE 530 Denver CO 80218 Surgeon 144000 C&A Industries Inc 13609 California St Omaha NE 68154 Contract nursing 140823 Wendling Noe Nelson & Johnson 534 S Kansas Ave Suite 1500 Topeka KS 66603 Accounting & consulting services 126652 5 177894 9529 25312 212735 Net patient service revenue 621990 26122039 26122039 Clinical outreach 621400 52403 52403 26174442 18379 18379 14800 0 14800 14800 14800 143375 20224 123151 123151 123151 Miscellaneous 900099 98371 98371 Cafeteria & vending 621990 73964 73964 Pharmacy sales 446110 44395 44395 10846 10846 227576 26771083 26413602 0 144746 18112 18112 388375 388375 12887575 11649255 1186029 52291 577615 526722 48528 2365 1611409 1438679 166272 6458 880979 775573 101924 3482 10047 10047 1985516 1675391 309939 186 33683 13643 20040 383110 270720 111640 750 488066 441345 46064 657 96650 60531 35473 646 285672 285672 1778218 1636672 139234 2312 158736 39238 119498 Drugs 2283108 2283108 Medical supplies 1236108 1236108 0 0 Repairs and maintenance 867945 653703 214091 151 Food expense 321746 321746 358893 174904 182018 1971 26651563 23501122 3079172 71269 397985 27464 546373 1588340 4099369 3461859 49920 88640 169570 734313 922148 353110 441247 35211180 23457841 11717880 11753339 405042 450198 2397526 1922887 20790158 20737052 2060573 2140190 6703512 6497378 420000 133262 456473 9317347 9094041 X 9862899 9999988 1239917 1273028 369995 369995 11472811 11643011 20790158 20737052 X 119520 7152 43528 X 0 1 X 1 0 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 0 0 0 0 0 1 4490 0 0 0 4490 0 Part II-B, Line 1: Citizens Medical Center, Inc., is a member of the Kansas Hospital Association. This organization engages in lobbying activities for hospital and general health care interests as part of the services provided to members. 235982 235982 17766519 10918591 6847928 14366967 10772407 3594560 2841712 1766843 1074869 11753339 Interest receivable 854 Beneficial interest in net assets of Citizens Foundation 1643023 Reinsurance proceeds recoverable 86000 Other receivables 47127 Estimated third party payor settlements 145883 1922887 Estimated third-party payor settlements 456473 456473 X 26821763 7152 43528 50680 26771083 0 26771083 26651563 0 26651563 0 26651563 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 foundations net of transfers 43,528. 1 1 1 X 1 X 1 1 0 0 352216 9817 342399 0.01280 4402568 3435505 967063 0.03630 4754784 3445322 1309462 0.04910 19907 19907 0.00070 1016 1016 0.00000 4989381 4141613 847768 0.03180 1050 1050 0.00000 5011354 4141613 869741 0.03250 9766138 7586935 2179203 0.08160 1 599807 521352 7799628 7876596 -76968 X 1 1 1 1 Citizens Medical Center Inc 100 E College Drive Colby KS 67701 X X X X Nursing facility and rural health clinic Citizens Medical Center 1 0 0 1 X X X X X X X X X 13 1 0 1 1 X www.nwkshealthcare.com X 1 13 1 http://www.nwkshealthcare.com/ 0 0 1 X 100.000000000000 250.000000000000 X X X X 1 1 X X 1 X X X X 1 0 X X X X 1 X 0 0 Citizens Medical Center Part V, Section B, Line 5: Each community has a wealth of expertise to be tapped to conduct the CHNA. For this purpose, town hall meetings are the perfect forum to gather community insight. Town hall sessions were organized to provide an objective consensus-building method of reviewing and prioritizing county health issues. All town hall priority-setting and scoring processes involved the input of key stakeholders in attendance.The individuals and organizations comprising the town halls were critically important to the success of the CHNA. The following list outlines partners invited to each town hall meeting: local hospital, public health community, mental health community, community-based clinics, service providers, local residents, community leaders, opinion leaders, school leaders, business leaders, local government, faith-based organizations and person (or organizations serving them), people with chronic conditions, uninsured community members, low income residents, and minority groups. Citizens Medical Center Part V, Section B, Line 11: Dietary personnel worked in conjunction with Thomas County Coalition on programs to promote healthy eating and other desireable practices and on programs to promote active lifestyle. Dietary personnel also taught Kansas for Optimizing Health Program (KOHP) classes for community members and community diabetes education classes. The Medical Center also established a pulmonary rehab program. Citizens Medical Center Part V, Section B, Line 16i: The availability of financial assistance is published on the Medical Center's website. A plain language summary of the financial assistance policy is printed on each patient's statement. Information about financial assistance availability is given to patients each time they are spoken to by billing personnel. Information sheets summarizing the financial assistance policy and instructions on how to obtain more information is distributed to the Family Center for Health Care and the Thomas County Health Department. Citizens Medical Center Part V, Section B, Line 22d: Charges for medical care provided to uninsured patients will be limited to not more than the amounts generally billed to those individuals who have insurance. Amounts generally billed to individuals who have insurance are determined annually using the look-back method for Medicare and private health insurers. All payments received from Medicare and private health insurers in a 12-month period are dividued by the gross charges for these services to determine the percentage of charges that were paid by Medicare and private health insurers. 2 Prairie Senior Living Complex 1625 S Franklin Ave Colby KS 67701 Long-term care facility Family Center for Health Care 310 E College Dr Colby KS 67701 Rural health clinic Part I, Line 7: Financial assistance at cost was determined by utilizing departmental cost-to-charge ratios for financial assistance provided in areas that are reported as subsidized health services. An overall cost-to-charge ratio derived from Worksheet 2 was used to determine the cost of financial assistance provided for services not reported as subsidized health services.Unreimbursed Medicaid costs were also determined using a blend of cost-to-charge ratios for certain services and an overall cost-to-charge ratio derived from Worksheet 2 for all other services.The cost of providing subsidized health services was determined using a cost-to-charge ratio for each service.Actual costs and revenues were utilized for all other items reported on line 7. Part I, Line 7g: Subsidized health services are comprised of services that the Medical Center provides despite a financial loss to the organization. These services include the operation of a clinic with visiting physicians in various specialties and a rural health clinic. Costs attributable to physician clinics included on line 7(g), column (c), were $4,989,381 and unreimbursed costs attributable to physician clinics included on line 7(g), column (e), were $847,768. Part II, Community Building Activities: N/A Part III, Line 4: For uninsured patients that do not qualify for charity care, CMCI recognizes revenue on the basis of its standard rates for services provided. On the basis of historical experience, a significant portion of CMCI's uninsured patients will be unable or unwilling to pay for the services provided. Thus, CMCI records a significant provision for bad debts related to uninsured patients in the period the services are provided.Part III, Line 2Bad debts at cost were determined by utilizing departmental cost-to-charge ratios for bad debts in areas that are reported as subsidized health services. An overall cost-to-charge ratio derived from Worksheet 2 was used to determine the cost of bad debts in all other areas.Part III, Line 3Bad debt provisions attributable to patients eligible under the organization's financial assistance policy were determined using an estimated 86.9% of total bad debts. The Medical Center takes steps to assist individuals who are believed to qualify for financial assistance prior to writing accounts off as uncollectible. The Medical Center considers $521,352 of bad debt cost as community benefit. As a tax-exempt hospital, we must provide necessary services regardless of the patient's ability to pay for that care. Making quality patient care available to all in our community, regardless of their economic means, qualfies bad debts as a community benefit. Part III, Line 8: Medicare allowable costs were determined by using amounts from the Medical Center's Medicare cost report. The Medicare cost report apportions actual costs to the Medicare program using charges for ancillary services and patient days for nursing services. The Medical Center believes that all of the $76,968 Medicare shortfall should be considered as community benefit. The IRS Community Benefit Standard includes the provision of care to the elderly and Medicare patients. Medicare shortfalls must be absorbed by the Hospital in order to continue treating the elderly in our community. The Medical Center provides care regardless of this shortfall and thereby relieves the federal government of the burden of paying the full cost for Medicare beneficiaries. Part III, Line 9b: The financial assistance policy states that patients qualifying for charity care must complete a Financial Assistance Questionnaire and submit a copy of the patient's or relative's most recently-filed tax return. If charity care is considered appropriate by a committee, the patient's liability will be reduced by the approved amount. Any remaining balance on patient accounts is subject to the debt collection procedures articulated in the written policy. Part VI, Line 2: The Medical Center assesses the community health care needs primarily from responses from patients, community members, and health professionals. The Medical Center will take into account concerns or requests for services that are expressed by all patients and community members. Also, the Medical Center considers requests made by health professionals who include, but are not limited to, physicians, mid-level providers, social workers, nurses, and dieticians. Part VI, Line 3: All uninsured and under-insured patients are identified and screened upon admission by the Patient Financial Advisor. During this interview process, payment terms are discussed. If the patient appears to not have the ability to pay, they are asked to complete a financial questionnaire and provide a copy of their most recently filed tax return for determining their ability to pay under the Medical Center's financial assistance policy. If, during this interview process, it appears that a patient may qualify for assistance under state or federal assistance programs, they are referred to CMCI's Social Services Department for assistance in completing the applicable applications. Part VI, Line 4: The Medical Center is located in Colby, KS and serves the nine-county region of northwest Kansas, several of which are medically underserved. There are a total of eight small hospitals serving this nine-county region; however, CMCI provides many services that are unavailable in the smaller hospitals. The closest hospitals to the Medical Center are located in Oakley, Atwood, and Hoxie. These hospitals are approximately 23, 30, and 36 miles from Colby, respectively. The highest concentration of population for the service area is located in Colby, KS. Colby has a population of approximately 5,400 people. The median household income for the city is approximately $42,600. A major portion of the population that the Medical Center serves is Medicare-eligible citizens who live on a fixed income. Part VI, Line 5: The Medical Center is a grantee of the Kansas Department of Health & Environment, Kansas Quality of Care Project, and participates in programs identified by the state as needed to help improve the health of residents of our state and local area. Kansas Promoting Health Program is a chronic disease support group and is a program in which the Medical Center has trained facilitators and offers classes. 1 Scholarships 13 18112 Part I, Line 2 The Medical Center monitors the use of grant funds by sending nursing scholarship funds to the Kansas Board of Regents to ensure that the funds are used for the intended purpose and by requiring scholarship recipients to show proof of satisfactory course work. X X X 0 0 0 0 0 1 0 0 0 Clyde Kevan Trenkle CEO 166248 0 28035 0 15207 0 12784 0 18964 0 241238 0 0 0 Darren Matchell Physician 307938 0 7304 0 0 0 16194 0 32638 0 364074 0 0 0 Kelly Gabel Physician 305564 0 242 0 0 0 5012 0 27734 0 338552 0 0 0 John Dygert Physician 194664 0 93954 0 0 0 17467 0 31974 0 338059 0 0 0 Sarah Gabel Physician 190856 0 23748 0 0 0 3863 0 1341 0 219808 0 0 0 Brian Unruh Physician Assistant 134555 0 70892 0 0 0 12477 0 9158 0 227082 0 0 0 Part I, Line 6 The CEO and CFO have a bonus arrangement that is triggered if income from operations exceeds 2 percent of expenses. Form 990, Part VI, Section A, line 6 The Medical Center is a not-for-profit corporation with 21 members at December 31, 2014. Form 990, Part VI, Section A, line 7a The Medical Center's corporate members elect the governing body. Form 990, Part VI, Section B, line 11 Form 990 is provided to the Chief Executive Officer who e-mails notices to members of the Board of Trustees that the Form 990 is available for review prior to filing the return. Form 990, Part VI, Section B, line 12c A conflict of interest disclosure form is provided with a copy of the current conflict of interest policy. This disclosure form is completed by each member of the Board of Trustees upon election and annually thereafter. Form 990, Part VI, Section B, line 15 The Board of Trustees reviews the compensation of the CEO and senior management. The Medical Center relies on a joint wage salary report published by the Kansas Hospital and Missouri Hospital Associations, as well as any and all available local data. Form 990, Part VI, Section C, line 19 The Medical Center makes its governing documents, conflict of interest policy, and financial statements available to the public upon written request. Form 990, Part XI, line 9: Change in beneficial interest in net assets of foundations net of transfers 43,528. Citizens Foundation 100 E College Drive Colby KS 67701 481112955 Fundraising for the benefit of Citizens Medical Center, Inc. KS 501(c)(3) Line 7 0 Med-Serv Inc 100 E College Drive Colby KS 67701 480994564 Inactive KS C 1.00000 1 0 0 1 0 1 0 0 0 0 0 0 0 0 1 1 0 1 0 0