2015-12-15T08:15:14-06:00 2014-09-30 450250958 EIDE BAILLY LLP 1601 NW EXPRESSWAY SUITE 1900 OKLAHOMA CITY OK 73118 990 2013-10-01 237169376 Pawhuska Hospital Inc PAWH 9182873232 1101 E 15th Street Pawhuska OK 740561920 Shaun Beggs Administrator 9182873232 2015-12-08 1 Kim Hunwardsen CPA P00484560 4054783334 2015-12-07 2013 2016-03-07 17:11:31Z Shaun Beggs 1101 E 15th Street Pawhuska OK 740561920 5986643 0 X www.pawhuskahospital.org X 1959 OK To provide the highest level of healthcare possible, in a cost-effective manner. 5 5 69 25 0 0 130997 120064 4471123 5863970 5854 2609 0 0 4607974 5986643 0 0 0 0 2566250 2736456 0 0 0 1883438 2783069 4449688 5519525 158286 467118 4376918 5107774 1471638 1735378 2905280 3372396 X We, the Physicians, Staff, and Governing Board of Pawhuska Hospital, Inc., are committed to providing the highest level of healthcare possible for our facility.Recognizing the health needs of our community and surrounding area, we pledge to provide, in a cost-effective manner, the services necessary to enhance the quality of life. Understanding the constant and dramatic change in the healthcare industry, we will strive to achieve excellence and continue our support of the community. 0 0 4615045 5863970 Pawhuska Hospital, Inc. is a 25-bed Critical Access Hospital that operates in Pawhuska, Oklahoma. The Hospital is managed through an agreement with Jane Phillips Memorial Medical Center, which is an entity of the St. John Health System. Pawhuska Hospital and the Jane Phillips Health System have had this management relationship for the past 27 years, going back to the initial management agreement that was executed back in 1986.The Hospital provides care to patients who meet certain criteria under its charity care policy without charge or at amounts less than established rates. Continued on Schedule O.Because the Hospital does not pursue collection of amounts determined to qualify as charity care, they are not reported as revenue. The amount of charges foregone for services provided under the Hospital's charity care policy were approximately $122,852 for the year ended September 30, 2014. Total direct and indirect costs related to these foregone charges were approximately $126,000 at September 30, 2014, based on an average ratios of cost to gross charges. 4615045 1 0 0 0 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 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 1 0 0 0 1 8 0 1 69 1 0 0 0 0 0 0 0 0 0 0 X 5 5 1 1 0 0 0 1 0 1 1 0 0 1 1 1 1 1 1 1 0 0 OK X Shaun Beggs 9182875123 1101 E 15th Street Pawhuska OK 740561920 Beth Reed Chair 1.00 X X 0 0 0 Ben West Secretary 1.00 X X 0 0 0 Beverly Moore Trustee 1.00 X 0 0 0 Jerry Mosley Trustee 1.00 X 0 0 0 Nancy Woodyard Trustee 1.00 X 0 0 0 Jason McCauley Regional Administrator 40.00 X 0 0 0 Shawn Parkhurst Regional Controller 40.00 X 0 0 0 John Ham PA-C Emergency room 48.00 X 167850 0 7467 Theresa Flowerette APN ER Provider 60.00 X 118154 0 8331 William Ward RN 60.00 X 114622 0 10457 Donna Baxter Lab Manager 40.00 X 101920 0 0 Mary Dagenais ER Provider 40.00 X 124248 0 1027 626794 0 27282 5 0 1 0 M&L Rehabilitation 18491 N Jamestown Skiatook OK 74002 Contracted Pysical Therapy 208679 Emergency Physician Staffing 2360 Corporate Circle Henderson NV 89074 Contracted Physician Services 202500 Jane Phillips Medical Center 3500 E Frank Phillips Blvd Bartlesville OK 74006 Management and Accounting 167334 3 108601 11463 120064 Patient service revenu 621110 5213842 5213842 EHR incentives 900099 645098 645098 5030 5030 5863970 2609 2609 5986643 5863970 0 2609 X 2158077 1915212 242865 304923 147314 157609 273456 225925 47531 150007 150007 66925 66925 958462 890093 68369 5652 5652 123709 44011 79698 86360 76053 10307 12343 5942 6401 53218 53218 346001 346001 49976 49976 Bad Debt 609394 609394 Medical Supplies 172997 172997 Repairs and Maintenance 103600 100847 2753 Food 28038 28038 16387 16387 5519525 4615045 904480 0 745923 1471797 437580 1144375 101382 105196 11314 12212 4738418 3009322 1983557 1729096 1097162 645098 4376918 5107774 413392 375039 1058246 1046942 0 313397 1471638 1735378 X 2905280 3372396 2905280 3372396 4376918 5107774 467118 -2 0 X 0 1 X 1 0 X 34360 34360 1248194 737618 510576 35979 31941 4038 3419885 2239763 1180122 1729096 Electronic health record incentives 645098 645098 Estimated third party payor settlements 313397 313397 X 5268648 -609394 -609394 5878042 108601 108601 5986643 4910131 0 4910131 609394 609394 5519525 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 990-T) with the IRS. The Hospital believes that it has appropriate support for any tax positions taken affecting its annual filing requirements, and as such, does not have any uncertain tax positions that are material to the financial statements. The Hospital would recognize future accrued interest and penalties related to unrecognized tax benefits and liabilities in income tax expense if such interest and penalties are incurred. Part XI, Line 2d - Other Adjustments: Provision for bad debts included in revenue on the Financial Statements -609,394. Part XI, Line 4b - Other Adjustments: Contribution included in revenue per Form 990 108,601. Part XII, Line 4b - Other Adjustments: Provision for Bad Debts included in Revenue on the Financial Statements 609,394. 1 1 X 1 X 1 X 1 0 126000 126000 0.02570 126000 126000 0.02570 1236237 830975 405262 0.08250 1236237 830975 405262 0.08250 1362237 830975 531262 0.10820 0 609394 16088 2997289 3024576 -27287 X 1 1 1 1 Pawhuska Hospital Inc 1101 E 15th Street Pawhuska OK 74056 www.pawhuskahospital.org 2271 X X X X Pawhuska Hospital Inc 1 1 X X X X X X X X X 12 1 0 1 X www.pawhuskahospital.org X X X X X X X X 1 0 1 1 100.000000000000 1 300.000000000000 1 X X X X X X 1 1 X X 1 0 X X X X 1 X 0 0 Pawhuska Hospital, Inc. Part V, Section B, Line 3: Community input was provided through key informant discussions of 20 stakeholders and a community health survey was distributed with a total response of 132 surveys. In addition, secondary data was compiled from demographic and socioeconomic sources as well as national state and local sources of information on disease prevalence. Pawhuska Hospital, Inc. Part V, Section B, Line 6i: Pawhuska Hospital, Inc. has adopted an implementation strategy to address the community health needs identified in its Community Health Needs Assessment. The implementation strategy is posted to the Hospital's website at www.pawhuskahospital.org. Part I, Line 7: Charity care expense was converted to cost on line 7a based on an overall cost-to-charge ratio addressing all patient segments. The cost for subsidized health services reported on line 7g was determined using the Medicare Cost Report. Part I, Ln 7 Col(f): The amount of bad debt removed from total expenses to determine the percentage was $609,394. Part III, Line 2: Patient accounts are written off to bad debt after every effort is made to collect the balance and patients are given opportunities to complete charity care applications or set up payment plans. All discounts and contractual adjustments are applied to accounts before they are written off to bad debt. Current payments on accounts previously written off as bad debt reduces bad debt expense.Bad debt expense on line 2 is reported at charges as presented on the financial statements. Part III, Line 3: The estimated amount of the Organization's bad debt expense attributable to patients eligible under the Organization's charity care policy is calculated based on an estimate of charges foregone to gross patient charges. This portion can reasonably be considered a community benefit as it would have been written off to charity care. Part III, Line 4: The footnote to the Organization's financial statements can be found on page 7 of the attached audited financial statements. Part III, Line 8: Even though Medicare was at a loss, the Hospital provides services to these patients because access to healthcare and individual's health is important to the Hospital. Therefore, the Medicare shortfall is considered a community benefit.Both the total revenue received from Medicare and the Medicare allowable costs are reported from the Medicare Cost Report. The Medicare Cost Report is completed based on the rules and regulations set forth by the Centers for Medicare and Medicaid Services. Part III, Line 9b: All collections efforts cease when a patient is determined to be eligible for financial assistance. Normal collections efforts continue on any personal amount owed by the patient. Part VI, Line 2: Administration, medical staff and the governing board regularly discuss the health care needs of the local community during governing board meetings as well as in the bimonthly meetings of the medical staff. The Oklahoma Office of Rural Health and Pawhuska Hospital developed a Community Needs Assessment during tax year 2012. Pawhuska Hospital implemented strategies for each health priority identified through the needs assessment. In addition, when looking at the potential of adding new services, the Hospital researches how such services will meet and address the needs of the community. The Hospital is planning on developing future programs that allow opportunities to gather a larger community audience that can express the issues that are important to the community. Focus groups will enable the Hospital to further educate to meet the needs of the community. Part VI, Line 3: Pawhuska Hospital, Inc. provides a letter to patients upon admission that states the Hospital provides assistance to those patients with limited income to help pay for hospital expenses. The letter indicates that Charity Care applications are available to all patients and can be picked up at the time of service or at a later date. The Charity Care application gives an overview of the charity care policy and notes that Medicare and other state programs are also available to patients that meet income requirements. The Hospital staff is available to offer patients assistance in completing the Charity Care and Medicaid applications if needed. Part VI, Line 4: Pawhuska Hospital, Inc. primarily serves the citizens of the community of Pawhuska, Oklahoma and the surrounding area. Pawhuska serves as the county seat of Osage County, Oklahoma and is also the capital of the Osage Nation. The Hospital is one of two facilities located in Osage County. Pawhuska is a rural area with a population of 3,589 from the 2010 U.S. Census. The per capita income for the city was $13,916. About 137 of families and 175 of the population were below the poverty line, including 223 of those under age 18 and 149 of those aged 65 or over. The Hospital is a federally designated underserved area for primary care health professionals, mental health professionals and dental care health professionals. Part VI, Line 5: Pawhuska 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 a patient's ability to pay. Free health screenings were offered to the community at an open house in January. Other local healthcare entities were invited to participate. 0 0 0 0 0 0 0 0 0 John Ham PA-C Emergency room 166413 0 1437 0 0 0 0 0 7467 0 175317 0 0 0 Schedule J, Part I, Question 3: Pawhuska Hospital, Inc. does not pay compensation to the Regional Administrator directly. The Regional Administrator is compensated by an unrelated organization, Jane Phillips Medical Center. The Hospital's Board of Directors and Jane Phillips Medical Center use the processes described in Part I, Question 3 to determine appropriate compensation for the Regional Administrator. Form 990, Part VI, Section A, line 1 The Executive Committee consists of the Chair of the Board as presiding officer and the Vice Chair of the Board, the Secretary or Treasurer, and the CEO. Other members may be appointed to the Executive Committee as required by the Chair. The primary purpose is to take definitive and immediate action on any matter that might occur between regular meetings that falls outside the scope of the duties and responsibilities of the CEO. Record of action taken by the Executive Committee is made a part of the minutes of the next regular board meeting. Form 990, Part VI, Section A, line 2 Ben West and Nancy Woodyard have a business relationship. Form 990, Part VI, Section A, line 3 Jane Phillips Medical Center, a non-profit organization, provides administrative oversight for day-to-day operations, accounting services, and operational consulting services. Jason McCauley was the Regional Administrator and Shawn Parkhurst was the Regional Controller. The amount paid to Jane Phillips Medical Center for services in calendar year 2013 was $167,334. Form 990, Part VI, Section A, line 7a There are a total of five Trustees. All are appointed by the City Council of Pawhuska Board of Incorporators. Form 990, Part VI, Section B, line 11 The Form 990 is presented to the Administrator for review and then presented to the Board of Directors. Form 990, Part VI, Section B, line 12c All employees, board members, and contract employees are covered in our policies. The employee and contract employee determinations are made by Administration and any board determinations are made by the Governing Board. The employee will be asked to remedy the situation and the board member will be asked to leave after presenting their conflict and the remainder of the Governing Board will discuss and then vote. Copies of both policies can be provided upon request. Form 990, Part VI, Section B, line 15a Pawhuska Hospital, Inc. follows the pay guidelines of Jane Phillips Medical Center. Salary is reviewed against survey data from the Oklahoma Hospital Association. Increases are tied to an annual performance evaluation and approval from the Board of Directors. The process and determination is documented in the personnel file and Board minutes. Form 990, Part VI, Section C, line 19 The Hospital's governing documents, conflict of interest policy, and financial statements are available to the public upon request. Form 990, Part IX, line 11g Professional Fees: Program service expenses 871,085. Management and general expenses 68,369. Fundraising expenses 0. Total expenses 939,454. Contracted Services: Program service expenses 19,008. Management and general expenses 0. Fundraising expenses 0. Total expenses 19,008. City of Pawhuska 118 W Main Street Pawhuska OK 74056 736005371 Provide services to the residents of Pawhuska OK N/A 0 0 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0