2015-01-28T14:02:49-07:00 2014-06-30 990 2013-07-01 850141285 Cibola General Hospital Inc CIBO 5052874446 1016 E Roosevelt Avenue Grants NM 87020 Donald Weidemann CEO 5052875300 2015-01-30 2013 2016-04-25 22:37:26Z Cibola General Hospital Donald Weidemann 1016 E Roosevelt Avenue Grants NM 87020 28773463 0 X http://www.cibolahospital.com/ X 1958 NM To provide health care services to our community, without regard to ability to pay, utilizing state of the art practices and equipment to provide care second to none. 9 9 248 0 0 0 4450 4030 23412736 22397119 72306 70351 4501165 5106802 27990657 27578302 0 0 0 0 12888586 13269047 0 0 0 9784488 10195984 22673074 23465031 5317583 4113271 37099471 40389253 3090993 2886435 34008478 37502818 To provide excellent health care that our community is proud of by committing to: SERVICE (Meet expectations of patients & families). QUALITY (Establish national best practices as standards) PEOPLE (Embrace personal role to help meet Organization's goals). FINANCE (Maintain financial stability to ensure we continue to meet the needs of our Community). GROWTH (Improve Access to care through physicians partnerships and new services). 0 0 15915430 4450 22397119 Our program service is providing patient care to the residents of our service area, therefore, we consider each patient encounter an accomplishment. 0 0 0 See number 1 0 0 0 See number 1. 0 0 0 15915430 1 0 0 0 0 0 0 0 0 0 1 0 1 0 0 0 1 1 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 0 0 0 0 1 0 0 1 248 1 0 0 0 0 0 0 X 9 9 0 1 0 0 0 1 1 1 1 0 0 1 1 1 1 1 1 1 1 0 NM X J F Rimel 5052874446 1016 E Roosevelt Avenue Grants NM 87020 Ron Ortiz Board Chair 2 0 X 0 0 0 Bob Tenequer Vice Chair 2 0 X 0 0 0 Nestor Griego Secretary 2 0 X 0 0 0 Paul Milan Treasurer 2 0 X 0 0 0 Karl Gutierrez MD Chief of Medical Staff 2 0 X 0 0 0 Carlos Tapia Member 2 0 X 0 0 0 Chase Elkins Member 2 0 X 0 0 0 Donna Deming Member 2 0 X 0 0 0 Lloyd Felipe Member 2 0 X 0 0 0 Donald Weidemann Chief Executive Officer 40 0 X 0 0 0 James F Rimel Assistant Administrator and CFO 40 0 X 0 0 0 Ann Church MD Obstetrics Gynecology Physician 40 0 X 320000 0 0 Robert Pendrak MD General Surgeon 40 0 X 299998 0 0 Patricia Rocha MD FP / OB Physician 40 0 X 256323 0 0 David Gammon MD Internist 40 0 X 218152 0 0 Angela Studer Certified Registered Nurse Anesthetist 40 0 X 210038 0 0 1304511 0 0 15 0 1 0 EmCare Inc 1717 Main Street Ste 5200 Dallas TX 75201 Emergency Room Physician Coverage 798298 Medhost of Tennessee 3102 West End Avenue Nashville TN 37203 Computer Processing 602392 Harmonix Technologies 4915 Paseo Del Norte Ste A Albuquerque NM 87113 Information Technology support 325907 Quorum Health Resources 105 Continental Place Brentwood TN 37027 Hospital Management 321597 Comprehensive Pharmacy Services 6409 Quail Hollow Road Memphis TN 38120 Clinical Pathology Services 314972 11 0 0 0 0 0 4030 0 4030 22397119 22397119 0 0 22397119 96969 96969 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 -26618 0 0 0 -26618 0 -26618 -26618 0 0 0 0 0 0 0 0 0 0 0 0 0 0 6301963 1195161 5106802 5106802 0 0 0 27578302 27574272 0 0 0 0 0 0 0 0 0 0 335285 0 335285 0 0 0 0 0 10557943 8206874 2351069 0 0 0 0 0 1607201 1248795 358406 0 768618 597216 171402 0 320597 0 320597 0 86295 0 86295 0 52787 0 52787 0 0 0 0 0 0 0 0 0 0 0 912089 912089 0 0 151348 0 151348 0 294069 -614 294683 0 0 0 0 0 0 0 0 0 298244 0 298244 0 150884 62117 88767 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1214196 821694 392502 0 308754 0 308754 0 Supplies 1519723 1150172 369551 0 Purchased services 3244495 2266202 978293 0 Repairs and maintenance 857520 462845 394675 0 784983 188040 596943 0 23465031 15915430 7549601 0 7083029 5105425 3041655 3041655 0 0 5483105 3525839 0 0 0 0 0 0 223920 191427 422225 288808 18083416 6473442 11206107 11609974 0 0 0 0 9639430 16626125 0 0 0 0 37099471 40389253 2903191 2886435 0 0 187802 0 0 0 0 0 0 0 0 0 0 0 0 3090993 2886435 X 34008478 37502818 0 0 0 0 34008478 37502818 37099471 40389253 X 4113271 -13976 0 0 -604952 -3 X 1 X 1 X 1 0 X 128777 0 128777 7162990 0 939688 6223302 2183940 0 1128726 1055214 7943272 0 4405028 3538244 664437 0 0 664437 11609974 Certificates of deposit 16626125 F 16626125 28773460 0 0 0 1195161 1195161 27578299 0 3 3 27578302 24660192 0 0 0 1195161 1195161 23465031 0 0 0 23465031 Schedule D, Part XI, Line 2d Net cost of goods sold - not included in either revenue nor expense. Schedule D, Part XI, Line 4b Elimination of rounding difference. Schedule D, Part XII, Line 2d Net cost of goods sold. Excluded from both revenue and expense. 1 1 1 X 5 0 1 1 1 0 0 561020 0 561020 0.024 5575102 5207650 367452 0.016 0 0 0 0 0 0 6136122 5207650 928472 0.040 63491 0 63491 0.003 80000 0 80000 0.003 0 0 0 0 0 0 0 0 0 0 0 0 0 0 143491 0 143491 0.006 0 0 6279613 5207650 1071963 0.046 1 1748088 874044 4717599 5973405 -1255806 X 1 1 Quorum Health Resources Manages the Hospital under a management contract. 0 0 0 1 1 Cibola General Hospital Inc 1016 E Roosevelt Avenue Grants NM 87020 www.cibolahospital.com X Cibola General Hospital Inc 1 1 X X X X X X X X X 13 1 0 1 X X X X X X X X 1 0 1 1 500 0 1 X X X 1 1 X X 1 X X 1 X X X X X X 1 X 0 0 Schedule H, Part V, Section B, Line 3-Cibola General Hospital Inc The Community Health Needs Assessment sought input from all persons in our service area, including county government and leaders of the business community. The needs assessment was offered online from a link to it in the Hospital's website, and was also offered in a "paper" version to any who preferred to do it that way. The persons consulted included, but were not limited to, the CEO, CFO, CCO, HR Director, all members of the Board, and the medical staff. The needs assessment was heavily advertised in the media. Schedule H, Part V, Section B, Line 11-Cibola General Hospital Inc Income and household expenses are the qualifying criteria for discounted care. Schedule H, Part V, Section B, Line 16-Cibola General Hospital Inc Outside collections agencies are used. The recovery rates by these agencies are typically under 10%. Schedule H, Part V, Section B, Line 20-Cibola General Hospital Inc The Hospital will bill the patient based upon its fee schedule, but patient will pay whatever portion of the bill our process determines he or she is liable for (or nothing at all), and the remaining balance will be written off as a charitable write off. Schedule H, Part V, Section B, Line 22-Cibola General Hospital Inc The gross amount charged is the same for all. If a patient gets financial assistance, then a portion of the bill, or all of it, is written off as a charitable write off. Schedule H, Part I, Line 3c Schedule H, Part I, Line 3c - The applicant for Financial Assistance must submit the following as proff of income: (1) Completed financial analysis form, including number of persons in the household, location of employer and length of employment, disclosure of property and real estate owned, income of responsible party and spouse, bank balances, and listing of monthly expenses. (2) Proof of household income. (3) Disclosure of any other support received. Schedule H, Part I, Line 7 Schedule H, Part I, Line 7 - Amount reported on Lina a column c is based on our overall cost to charge ratio. Line b column d uses cost to charge ratio offset by a contractual percentage leading to the amount reportd in column e. Line e column c and f column c are based on actual cost. Schedule H, Part I, Line 7, Column f Not applicable Schedule H, Part I, Line 7g Not applicable. Schedule H, Part III, Section A, Line 4 Schedule H, Part III, Section A, Line 4 - We used calculated Cost to Charge ratio of 37.5% to determine cost of bad Debt. This percentage was based on our filed 2014 Cost Report, using totals from Worsheet C, Part I. We make every effort to educate the uninsured or underinsured about our Financial Assistance policies. Nonetheless, we estimate that about half the Bad Debts we have arise from persons who would likely qualify for Financial Assistance, but refuse to fill out the required paperwork to permit us to assess them. Accordingly, we feel that we are providing a community benefit when a service falls into Bad Debt as a result of failure to apply for assistance. In our audited financial statements, there is no specific footnote description of Bad Debts methodology. Schedule H, Part III, Section B, Line 8 Schedule H, Part III, Section B, Line 8 - No shortfall exists for this tax year. Schedule H, Part III, Section C, Line 9b Schedule H, Part III, Section C, Line 9b - Yes, patients eligible for financial assistance are considered in our process. We take the phrase "known to qualify for financial assistance" to mean a patient who has gone through the qualification process and has been approved for financial assistance. A patient who has qualified for financial assistance is not subject to further collection efforts. Schedule H, Part VI, Line 2 We get lots of informal feedback from patients and visitors. Our executives are active in community organizations whose members talk to them about concerns and suggestions for improvement of health and health care. Quorum Health Resources, the management company of the Hospital, assisted us in our most recent needs assessment. Schedule H, Part VI, Line 3 If during the patient registration process it is determined that the patient lacks the ability to pay, then the registration person will present to the patient the information needed for them to apply for Financial Assistance. The patient will be referred to the on staff financial counselors. These financial counselors will make a concerted effort to assist the patient in correctly and completely filling out the paperwork, and guiding them to the appropriate available resources. Schedule H, Part VI, Line 4 Cibola General Hospital, Inc. provides medical services in a county that represents 28,000 lives. Our population is 21% White, 37% Hispanic, 1% Black, and 41% Native American. Our population is impacted significantly by many chronic illnesses including diabetes, hypertension, obesity and cardiovascular disease. Community outreach is the answer to this problem. Cibola General Hospital, Inc. is the sole hospital for our region. The community depends on us to provide access to both primary and specialty care. Our efforts to find better ways to coordinate care are based on evidence that better coordinated care reduces overall costs of care and improves quality. Our newly-constructed hospital owned clinic (Cibola Family Health Center) allows for greater access to patient care. Schedule H, Part VI, Line 5 Community health is promoted in the following ways. Hospital Board is a community-based, all volunteer group. Surplus funds are used to reinvest in our facilities to keep them state of the art. Financial support to the local college funds the salary of the Nursing program administrator. The Hospital co-sponsors an annual health fair to educate the community. Annual vaccination clinics are staffed by Hospital nurses. Free classes are sponsored in diabetes management, childbirth, and breastfeeding. Employees volunteer for the Relay For Life each year. Schedule H, Part VI, Line 6 We have no such affiliations. Schedule H, Part VI, Line 7 Copies of our Form 990 and related schedules, which document our community benefit efforts, are filed annually with the State of New Mexico. X X 0 0 0 0 0 0 0 0 0 Ann Church MD Obstetrics Gynecology Physician 320000 0 0 0 0 0 0 0 0 0 320000 0 320000 0 Robert Pendrak MD General Surgeon 299998 0 0 0 0 0 0 0 0 0 299998 0 0 0 Patricia Rocha MD FP / OB Physician 256323 0 0 0 0 0 0 0 0 0 256323 0 0 David Gammon MD Internist 218152 0 0 0 0 0 0 0 0 0 218152 0 0 0 Angela Studer Certified Registered Nurse Anesthetist 210038 0 0 0 0 0 0 0 0 0 210038 0 0 0 Form 990, Part VI, Section A, Line 3 Part VI, Section A, Line 3 - Yes. We are managed by Quorum Health Resources. Form 990, Part VI, Section A, Line 7a The County appoints 4 board members, one of whom will be a County Commissioner. The Hospital Board appoints 4 board members, one of whom will be the Chief of the Medical Staff. The 9th member of the Board will be appointed based on majority vote of the other 8 members of the Board, at their first meeting. Form 990, Part VI, Section A, Line 7b Part VI, Section A, Line 7b - The Board will refer significant capital project proposals and Trustee appointments to the County Commission for approval. Form 990, Part VI, Section B, Line 11b Part VI, Section B, Line 11b - The 990 and all related schedules were provided to the governing body prior to the filing of the form. Form 990, Part VI, Section B, Line 12c Part VI, Section B, Line 12c - All trustees, officers and employees are required annually to disclose any potential or actual conflicts of interest each year, in writing. The form is signed and dated, and monitored by the Compliance coordinator. Form 990, Part VI, Section B, Line 15 Part VI, Section B, Line 15- Compensation of officers and highly paid employees is determined by review of comparable pay for comparable duties by recruiters, and / or other consultants. All amounts are approved by the Board. Form 990, Part VI, Section C, Line 19 Part VI, Section C, Line 19 - The Hospital operates in a climate of transparency. In addition to the Board holding monthly public meetings, the CEO reports regularly to the County Commission at a public meeting, to brief them on financial and other significant activities. Form 990, Part XI, Line 9 Elimination of rounding difference. Extension accepted