2015-11-16T11:46:49-06:00 2014-12-31 BKD LLP 111 South Tejon Suite 800 Colorado Springs CO 809039848 990 2014-01-01 860096775 Community Hospital Association Inc % THE ORGANIZATION COMM 9286845421 520 Rose Lane Wickenburg AZ 85390 Jim Tavary CEO 9286845421 2015-11-16 true Rita F Worster CPA P00290681 7194714290 2014 2016-04-25 22:37:26Z Wickenburg Community Hospital Jim Tavary 520 Rose Lane Wickenburg AZ 85390 26335046 false X www.wickhosp.com X 1946 AZ To provide quality health and wellness services where the patient, family and community come first. 9 9 255 34 139230 151771 839741 22642812 25316274 -11916 -54548 -17595 32582 22765072 26134049 0 0 0 0 10580610 11458175 0 0 0 11266788 13369866 21847398 24828041 917674 1306008 21526294 24218741 10675010 10105750 10851284 14112991 TO PROVIDE QUALITY HEALTH AND WELLNESS SERVICES WHERE THE PATIENT, FAMILY, AND COMMUNITY COME FIRST. false false 21592762 0 25154435 Provide inpatient and outpatient diagnostic and therapeutic health care services to the residents and visitors of greater Wickenburg, Arizona, a rural community of approximately 23,000. 412604 0 246277 Provide Fitness Center for residents and visitors of greater Wickenburg, Arizona, promoting a wellness environment for the community. 22005366 true true false false false false false false false true true false false true true false true false false false false false false false false false true true false false true true false false false false false false false false false false false false false false false true true true false false 69 0 true 255 true true true false false false false false false false false false X 9 9 false false false false false false false true true false false true true true true true true false false false AZ X THE ORGANIZATION 9286845421 520 ROSE LANE Wickenburg AZ 85390 UWE GROSS PRESIDENT 1.0 0.0 X X 0 0 0 KEVIN ARMSTRONG BOARD VICE PRESIDENT 1.0 0.0 X X 0 0 0 RICHARD ABBUHL BOARD SECRETARY 1.0 0.0 X X 0 0 0 GARY TURNER TREASURER 1.0 0.0 X X 0 0 0 DEE POLLOCK DIRECTOR 1.0 0.0 X 0 0 0 MAUREEN SERRANO DIRECTOR 1.0 0.0 X 0 0 0 BRIAN WARNOCK DIRECTOR 1.0 0.0 X 0 0 0 JOHN COOK DIRECTOR 1.0 0.0 X 0 0 0 Leonard Kirschner DIRECTOR 1.0 0.0 X 0 0 0 JIM TAVARY CHIEF EXECUTIVE OFFICER 39.0 1.0 X 180901 0 56701 JAMES SMITH CHIEF FINANCIAL OFFICER THROUGH 08/2014 39.0 1.0 X 126154 0 4773 CHRISTOPH STAUDER INTERIM CFO 39.0 1.0 X 67329 0 0 MICHAEL ELLIS CHIEF FINANCIAL OFFICER EFFECTIVE 10/2014 39.0 1.0 X 23323 0 1397 TODD KRAVETZ MD CHIEF OF STAFF 40.0 0.0 X 285054 0 34181 MARILYN HALDER MD MEDICAL DIRECTOR 40.0 0.0 X 181247 0 32703 ROGER ROSE DIRECTOR OF PHARMACY SERVICES 40.0 0.0 X 178618 0 21613 LINDA BROCKWELL CHIEF NURSING OFFICER 40.0 0.0 X 107668 0 2639 NANCY CARTER PHYSICIAN ASSISTANT 40.0 0.0 X 111387 0 9054 PETER STACHOWICZ DIRRECTOR OF ANCILLARY SERVICE 40.0 0.0 X 102871 0 16914 RICHARD WEDIG DIRECTOR OF CLINIC & SURGICAL CENTER 40.0 0.0 X 128574 0 13972 SUZANNE YOUNG PHARMACIST 40.0 0.0 X 102450 0 7445 1595576 0 201392 10 false true false EMCARE PHYSICIAN SERVICES INC 7032 COLLECTION CENTER DR CHICAGO IL 60693 PHYSICIANS 945182 Medical Diagnostic Imaging Group L PO Box 17049 PHOENIX AZ 85011 MEDICAL IMAGING 513967 CPSI PO Box 850309 MOBILE AL 36685 Software Services 359592 Alliance Imaging File 55826 LOS ANGELES CA 90074 Medical Imaging 297000 BKD LLP 111 SOUTH TEJON STREET SUITE 800 COLORADO SPRINGS CO 80903 ACCOUNTING SERVICES 179102 5 615441 25000 199300 19300 839741 MEDICARE 621990 9645005 9645005 PATIENT SERVICES 621990 12247354 12118304 129050 340B DRUG PRICING PROGRAM REVENUE 621990 2512173 2512173 PHARMACY REVENUE 621990 665465 665465 WELLNESS CENTER 621990 246277 246277 25316274 7049 7049 0 0 75200 138700 -63500 0 -63500 10180 -73680 700 62297 -61597 -61597 -61597 0 0 0 OTHER REVENUE 900099 96082 74258 21824 96082 26134049 25261482 139230 -106404 X 0 0 0 0 1193994 733415 460579 0 0 8677739 8137495 540244 0 904230 847936 56294 682212 616945 65267 0 20914 20914 152456 152456 0 0 0 3981285 3571725 409560 0 382261 178162 204099 242708 242708 0 412380 394771 17609 51721 36260 15461 0 68144 58084 10060 490706 490706 0 1126804 1123372 3432 310254 271116 39138 MEDICAL SUPPLIES 3206631 3206631 PROVISION FOR BAD DEBTS 2014053 2014053 REPAIRS & MAINTENANCE 447711 412107 35604 MISCELLANEOUS 461838 160586 301252 24828041 22005366 2822675 0 X 2806368 2044048 149206 91398 0 0 3688532 3476335 0 0 0 0 1181 3489 493055 875916 294345 437502 24397934 13279532 9816526 11118402 510994 476521 0 0 0 0 68754 49274 3697333 5645856 21526294 24218741 3517936 2262299 0 0 0 0 5355000 5235000 0 0 0 0 1740568 2556034 0 0 61506 52417 10675010 10105750 X 7366876 8816762 3484408 5296229 0 0 10851284 14112991 21526294 24218741 X 1306008 1955699 X false true X true false X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 3582509 0 2718407 993405 5307511 137187 98101 3701284 354063 3582509 98635 217877 179325 137187 26885 397587 325837 98635 68115 1000 -3500 38730 26885 0.00213 0.00000 0.99787 false true true 1379772 1379772 14115549 8148040 5967509 7125 3183 3942 7114393 4693111 2421282 1781095 435198 1345897 11118402 CARE FOUNDATION 5273217 DEFERRED FINANCING COSTS 368703 INTEREST RECEIVABLE 3936 5645856 0 INSURANCE FINANCING 52417 52417 26214396 2094399 2094399 24119997 2014052 2014052 26134049 22952689 138700 138700 22813989 2014052 2014052 24828041 Schedule D, Part V, Line 4 Describe the intended uses of the organization's endowment funds: The endowment funds are to be used for educational purposes and to acquire property & equipment for the hospital. Schedule D, Part X, Line 2 UNCERTAIN TAX POSITIONS: MANAGEMENT HAS EVALUATED THEIR INCOME TAX POSITIONS UNDER THE GUIDANCE INCLUDED IN ASC 740. BASED ON THEIR REVIEW, MANAGEMENT HAS NOT IDENTIFIED ANY MATERIAL UNCERTAIN TAX POSITIONS TO BE RECORDED OR DISCLOSED IN THE FINANCIAL STATEMENTS. SCHEDULE D, PART XI, LINE 2D REVENUE ON BOOKS, NOT ON RETURN Change in interest in net assets of wickenburg community hospital foundation 1,955,699 Rental Expense reclassed from expense to revenue 138,700 Total 2,094,399 SCHEDULE D, PART XI, LINE 4B REVENUE ON RETURN, NOT ON BOOKS Provision for uncollectable accounts reclassed to expense 2,014,052 SCHEDULE D, PART XII, LINE 2D EXPENSE ON BOOKS, NOT ON RETURN Rental Expense reclassed from expense to revenue 138,700 SCHEDULE D, PART XII, LINE 4B EXPENSE ON RETURN, NOT ON BOOKS Provision for uncollectable accounts reclassed to expense 2,014,052 true true X true X true X true true false true true 100386 100386 0.00440 1918352 1810019 108333 0.00470 2018738 1810019 208719 0.00910 412605 246277 166328 0.00730 412605 246277 166328 0.00730 2431343 2056296 375047 0.01640 true 2014052 503513 9645005 9411828 233177 X true false 1 1 Wickenburg Community Hospital 520 Rose Lane Wickenburg AZ 85390 www.wickhosp.com X X Wickenburg Community Hospital 1 false false true X X X X X X X X X 13 true false false true X http://wickhosp.com/ X true 13 true http://wickhosp.com/ false false true X 200. 400. X X X true true X X X X true X X X X true X false X X X X true X false false SCHEDULE H, PART V, LINE 3 DESCRIBE HOW THE HOSPITAL TOOK INTO ACCOUNT INPUT FROM PERSONS WHO REPRESENT THE COMMUNITY: In conducting the CHNA for Wickenburg Community Hospital (WCH), WCH gathered data using a survey format designed by the Cochise County Health & Social Services Department for the Cochise County arizona Community Health assessment. The survey was developed in both an English and Spanish language version and were distributed in the following ways/venues: - The survey questions were posted on Survey Monkey - Newspaper display ads in the Wickenburg Sun and the Congress Yellow page encouraged readers to go to a Survey Monkey link sponsored by the Hospital - Notices were mailed/sent electronically to the Town of Wickenburg, Bagdad, Congress and Salome church organizations encouraging participation in the electronic survey through the survey monkey link. - Hard copy surveys and survey collection boxes were placed at various locations throughout the region including medical clinics, grocery stores, and the Wickenburg Chamber of Commerce. - Survey forms were distributed and the survey monkey link was announced at the Town Hall meeting in October 2013 hosted by the Hospital at the Wickenburg Community Center. - Specific survey questions and the full survey was distributed, completed and discussed at focus group meetings sponsored by the hospital and held at locations in Wickenburg, Congress and Salome. - Informational posters were placed throughout communities in the region to encourage participation in the survey through survey monkey. SCHEDULE H, PART V, LINE 22D MAXIMUM AMOUNTS CHARGED TO FAP-ELIGIBLE INDIVIDUALS: For those patients presenting at the hospital's emergency room and those patients seeking outpatient services that have no insurance, the patients are given the hospital's financial assistance policy that includes information for application for AHCCCS and information for the hospital's charity discount, and all gross charges qualifying for a minimum 25% cash discount. 2 Community Hospital Clinic - WICKENBURG 519 Rose Lane Wickenburg AZ 85390 PRIMARY CARE CLINIC RURAL HEALTH CLINIC Community Hospital Clinic - Congress 26750 S Santa Fe Road Suite B Congress AZ 85332 PRIMARY CARE CLINIC RURAL HEALTH CLINIC SCHEDULE H, PART I, LINE 7, COLUMN F BAD DEBT EXPENSE: TOTAL BAD DEBT EXPENSE REMOVED FROM THE DENOMINATOR PRIOR TO THE PERCENTAGE CALCULATION = $2,014,052 SCHEDULE H, PART I, LINE 7 CALCULATION OF COMMUNITY BENEFIT EXPENSES: The organization used a cost-to charge ratio for lines 7a & 7b. The cost-to-charge ratio was derived from Worksheet 2, Ratio of Patient Care Cost-to-Charges. The information for line 7e was derived from information in the general ledger and other financial data related specifically to the various types of community benefits. SCHEDULE H, PART III, LINE 2 EXPLAIN THE ORGANIZATION'S METHODOLOGY TO ESTIMATE THE AMOUNT REPORTED FOR BAD DEBT EXPENSE: THE HOSPITAL PROVIDES AN ALLOWANCE FOR UNCOLLECTIBLE ACCOUNTS BASED UPON A REVIEW OF OUTSTANDING RECEIVABLES, HISTORICAL COLLECTION INFORMATION, AND EXISTING ECONOMIC CONDITIONS AND TRENDS. DISCOUNTS AND PAYMENTS ON PATIENT ACCOUNTS ARE RECORDED AS AN ADJUSTMENT TO REVENUE, NOT BAD DEBT EXPENSE. SCHEDULE H, PART III, LINE 3 BAD DEBT ATTRIBUTABLE TO PATIENTS ELIGIBLE UNDER THE ORGANIZATION'S FINANCIAL ASSISTANCE POLICY: Most of the bad debt expense results from uninsured patients receiving services primarily through the Emergency Room. The Manager of Patient Financial Services estimates that approximately 25% of all bad debt would qualify for charity care, but it is difficult to get the patients to complete the Financial Assistance application. SCHEDULE H, PART III, LINE 4 Footnote on bad debt expense: see page 10-11 of the attached audited financial statements for the footnote that describes bad debt expense. SCHEDULE H, PART III, LINE 8 MEDICARE SHORTFALL AS A COMMUNITY BENEFIT: Medicare pays the critical access hospital 1% less than allowable cost. This shortfall must be born by all other payers and programs, limiting the profits necessary to create new programs and provide necessary benefits to community members who have no or limited resources to pay for healthcare services. The cost report was used to determine the allowable costs reported on line 6. SCHEDULE H, PART III, LINE 9B DEBT COLLECTION POLICY: Our practice is to provide all patients at time of registration who do not demonstrate the ability to pay for the anticipated services (no insurance, no deposit, etc.) an opportunity to complete a charity application. The collection policy remains the same for potential charity cases and all avenues of collection are pursued, just as if the charity application had not been offered. While we believe many of the charity cases end up as a bad debt, it is not for lack of effort to educate the potential charity applicant of the availability of assistance and keep the amounts out of our bad debt category. SCHEDULE H, PART VI: NEEDS ASSESSMENT Community Hospital Association, Inc. continually accesses the community's medical needs through the relationship of our staff to community leaders and community programs that identify community needs, often medical in nature. Although the hospital is not always in a position to expand services and meet all identified needs, maintaining a core menu of services that meets the greatest community need has and continues to direct our strategic planning. SCHEDULE H, PART VI: PATIENT EDUCATION OF ELIGIBILITY FOR ASSISTANCE All uninsured and under-insured patients at time of registration are provided with options available in our community for payment of the services provided. This is most often verbal with a written Charity Care Application. SCHEDULE H, PART VI: COMMUNITY INFORMATION Wickenburg Community Hospital serves a primary service area population of approximately 17,000 in a rural service area clustered around Wickenburg, AZ. Wickenburg Community Hospital is the only hospital in the service area. The distribution of service area population by age is 0-17, 21%; 18-44, 25%; 45-64, 29%; 65+, 24%. The service area is home to a great number of winter residents, changing the population significantly from summer months to winter months, when the population grows by approximately 40%. SCHEDULE H, PART VI: PROMOTION OF COMMUNITY HEALTH Wickenburg Community Hospital, designated as a Critical Access Hospital, serves a rural population approximately 35 miles west of the urban area of the greater Phoenix market place of Surprise, AZ. While the distance is not overly great, many of our patients come from rural areas west and north of Wickenburg, requiring them to drive much greater distances to obtain health care services if Wickenburg Community Hospital were not available to them. The most important service we provide is our Emergency Services and could not exist without our Critical Access Hospital status. Additionally, our Rural Health Clinic provides access to primary care providers in our community that probably would not exist if the hospital did not employ these providers. The availability of diagnostic services locally is very important to our community as a higher average age exists in our community, making it difficult to drive longer distances and spend a greater amount of time in obtaining diagnostic services required by their primary care providers. X true true X X false false false false false false false false true JIM TAVARY CHIEF EXECUTIVE OFFICER 179871 0 0 0 1030 0 36000 0 20701 0 237602 0 0 0 TODD KRAVETZ MD CHIEF OF STAFF 284585 0 0 0 469 0 7750 0 26431 0 319235 0 0 0 MARILYN HALDER MD MEDICAL DIRECTOR 181022 0 0 0 225 0 7750 0 24953 0 213950 0 0 0 ROGER ROSE DIRECTOR OF PHARMACY SERVICES 177588 0 0 0 1030 0 0 0 21613 0 200231 0 0 0 Schedule J, Part I, line 1 Information Regarding Benefits Provided: ALL KEY EMPLOYEES ARE PROVIDED WITH A COMPLEMENTARY FITNESS CENTER MEMBERSHIP AT THE WICKENBURG COMMUNITY HOSPITAL FITNESS CENTER. Schedule J, Part I, line 8 PAYMENTS MADE PURSUANT TO AN INITIAL CONTRACT EXCEPTION: MR. TAVARY IS QUALIFIED BY TRAINING AND EXPERIENCE TO ACT AS CHIEF EXECUTIVE OFFICER OF THE ORGANIZATION. DUTIES SHALL BE PERFORMED TO THE BEST OF MR. TAVARY'S ABILITY, EXPERIENCE, AND TALENT TO THE REASONABLE SATISFACTION OF THE ORGANIZATION. BASE COMPENSATION IS PAID FOR SERVICES, WITH THE ELIGIBILITY OF PERFORMANCE BASED BONUSES. THE TERM OF THE CONTRACT SHALL BE THREE YEARS, WITH THE POSSIBLITY OF EXTENSION MADE BY MUTUAL AGREEMENT OF THE ORGANIZATION AND MR. TAVARY. Schedule J, Part I, line 9 REBUTTABLE PRESUMPTION PROCEDURE: THE ORGANIZATION FOLLOWS THE REBUTTABLE PRESUMPTION PROCEDURE, HOWEVER, THE COMPARABILITY DATA USED IS NOT DOCUMENTED, THEREFORE QUESTION 9 IS ANSWERED AS NO. A ARIZONA HEALTH FACILITIES AUTHORITY 860453292 040507GK5 2005-12-01 6000000 CAPITAL PROJECTS AND EQUIPMENT false false false A 765000 0 6072257 489900 72257 0 120000 0 0 5390100 0 0 2007 false false true true A false false false false 0.00000 0.00000 0.00000 false false 0.00000 false true A false false false true false false 0 false 0 false true A false PART VI, LINE 2C THE REBATE COMPUTATION WAS PERFORMED ON JUNE 8, 2010 FOR THE PERIOD JUNE 9, 2005 TO MARCH 31, 2010. Form 990, Part VI, Section B, line 11b Process to Review the Form 990: The Form 990 is prepared by a third party and is reviewed by the CFO. A copy of the 990 is made available to the governing board prior to filing with the IRS. Form 990, Part VI, Section B, line 12c Process for Monitoring Compliance with Conflict of Interest Policy: All Board members and officers are covered under the policy. In connection with any actual or possible conflict of interest, an interested person must disclose the existence of any financial interest and conflict of interest and be given the opportunity to disclose all material facts to the board of directors of the organization. In addition, all interested persons review and sign a compliance certificate annually. After disclosure of any potential conflicts and all material facts, and after any discussion with the interested person, he/she shall leave the governing board meeting and is recused from the discussion and voting on the issue. The remaining board members shall decide if a conflict of interest exists. Form 990, Part VI, Section B, line 15a Review of CEO or Top Mgmt Official Compensation: The Board Chairman, with consultation of other members of the Board, reviews independent survey data acquired through the Arizona Hospital & Healthcare Association on executive salaries and reviews the performance of the CEO. This review is done annually by the Board in Executive Session. Form 990, Part VI, Section B, line 15b Review of Other Officer or Key Employees Compensation: The CEO and HR Director use the Arizona Hospital & Healthcare Association survey data to review all positions in the facility, including key employees and other officers. Form 990, Part VI, Section C, line 19 Governing Documents Available to the Public: Governing documents, conflict of interest policy, and financial statements are made available to the public by a formal request in writing. FORM 990, PART XI, LINE 9 OTHER CHANGES IN NET ASSETS OR FUND BALANCES: Change in interest in net assets of wickenburg community hospital foundation 1,955,699 FORM 990 PART IX LINE 11G DESCRIPTION:PHYSICIANS TOTAL FEES:1428575 FORM 990 PART IX LINE 11G DESCRIPTION:340B MANAGEMENT FEE TOTAL FEES:57652 FORM 990 PART IX LINE 11G DESCRIPTION:PHARMACY TOTAL FEES:912566 FORM 990 PART IX LINE 11G DESCRIPTION:MEDICAL IMAGING TOTAL FEES:304119 FORM 990 PART IX LINE 11G DESCRIPTION:PATIENT SERVICES TOTAL FEES:38509 FORM 990 PART IX LINE 11G DESCRIPTION:CLINICS TOTAL FEES:222218 FORM 990 PART IX LINE 11G DESCRIPTION:HR/ADMIN TOTAL FEES:508139 FORM 990 PART IX LINE 11G DESCRIPTION:LAB FEES TOTAL FEES:244862 FORM 990 PART IX LINE 11G DESCRIPTION:MEDICAL RECORDS TOTAL FEES:110615 FORM 990 PART IX LINE 11G DESCRIPTION:PHYSICAL THERAPY TOTAL FEES:33557 FORM 990 PART IX LINE 11G DESCRIPTION:LAUNDRY/HOUSEKEEPING TOTAL FEES:85978 FORM 990 PART IX LINE 11G DESCRIPTION:COLLECTION FEES TOTAL FEES:11126 FORM 990 PART IX LINE 11G DESCRIPTION:MISCELLANEOUS TOTAL FEES:23369 Wickenburg Community Hospital Foundation 520 Rose Lane Wickenburg AZ 85390 742521618 Fundraising AZ 501(C)(3) Line 7 na false Wickenburg Community Hospital Auxiliary 520 Rose Lane Wickenburg AZ 85390 866056824 Support Org AZ 501(C)(3) LN11TYPEIII NA false false false true true false false false false false false false false true true true false true false false WICKENBURG COMMUNITY HOSPITAL FOUNDATION C 570678 AMOUNT RECEIVED WICKENBURG COMMUNITY HOSPITAL FOUNDATION Q 809457 ACTUAL AMOUNT