2014-05-13T12:38:47-07:00 2013-06-30 990 2012-07-01 237429117 MADERA COMMUNITY HOSPITAL MADE 5596755555 1250 E Almond Avenue Madera CA 93637 Diane Neff 5596752823 2014-05-12 2012 2015-11-30 17:44:51Z John W Frye 6498 N Pleasant Fresno CA 93637 86361403 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. 16 11 1070 115 0 0 315690 1270935 93807489 82691293 63001 34090 2430774 2365085 96616954 86361403 0 0 0 0 48587670 46519011 0 0 0 38515430 37150762 87103100 83669773 9513854 2691630 84457740 83346055 32070594 28267279 52387146 55078776 Madera Community Hospital provides Inpatient and Outpatient healthcare services to the citizens of Madera and its surrounding communities. 0 0 53768695 0 82691293 Delivery and Management of General Inpatient and Outpatient Healthcare Services were provided to the citizens of Madera and its surrounding communities. 0 0 0 53768695 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 1 123 0 1 1070 1 0 0 0 0 0 0 X 16 11 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 1 X 0 0 0 Anna DaSilva 1 X 0 0 0 Margaret Diebert 1 X 0 0 0 Michael Diebert 1 X 0 0 0 William Driggs 1 X 0 0 0 Duane Furman 1 X 0 0 0 Anita Eden 1 X 0 0 0 Stell Manfredi 1 X 0 0 0 Sohaila Mojadaddi MD 1 X 12444 0 0 Jim Monreal 1 X 0 0 0 Wally Nishimoto 1 X 0 0 0 Monte Pistoresi 1 X 0 0 0 Robert Poythress 1 X 0 0 0 Don Warnock 1 X 0 0 0 Victor Yanez MD 1 X 39000 0 0 Jan Zitek 1 X 0 0 0 John W Frye 40 X 312247 0 2110 Mary C Farrell 40 X 188307 0 3060 Mark J Foote 40 X 181379 0 2771 Karen Paolinelli 40 X 188644 0 2626 Angelica Malagon 40 X 145099 0 437 Matthew Kobzeff 40 X 138264 0 7889 Donna Aldrich 40 X 137425 0 0 Dale Costantino 40 X 129473 0 709 1472282 0 19602 34 0 1 0 Madera Anesthesia Consultants PO Box 7096 Stockton CA 95267 Anesthesia Services 660000 Madera Hospitalists 1111 W Fourth Street Madera CA 93637 Hospital Physicians Services 550000 Valley Unique Electric 5096 N Blythe Suite 100 Fresno CA 93722 Electrical Services 549477 Navin Haffty and Associates 1900 West Park Drive Suite 180 Westborough MA 01581 Consulting Services 544924 CEP America 2100 Powell Street Suite 920 Emerville CA 94608 Emergency Room Physicians Services 527554 25 0 0 0 1225000 39410 6525 0 1270935 Medicare 622000 26850490 26850490 0 0 Medicaid 622000 33304996 33304996 0 0 County Medical Services Program (CMSP) 622000 3240114 3240114 0 0 Other 3rd Party Payors 622000 16593565 16593565 0 0 All Other Payors 622000 2702128 2702128 0 0 0 0 0 0 82691293 34090 34090 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 790500 790500 0 0 Non-Patient Food Sales 722212 903737 903737 0 0 Rebates and Refunds 622000 495282 495282 0 0 175566 175566 0 0 2365085 86361403 85090468 0 0 0 0 0 0 0 0 0 0 698243 192975 505268 0 0 0 0 0 34402447 27826010 6576437 0 0 0 0 0 8469230 6508018 1961212 0 2949091 2366330 582761 0 0 0 0 178073 0 178073 0 38700 0 38700 0 0 0 0 0 0 0 0 0 0 0 1595909 1382659 213250 0 0 0 0 0 550666 164208 386458 0 0 0 0 0 0 0 0 0 202313 200483 1830 0 70191 54027 16164 0 0 0 0 0 34154 20230 13924 0 541199 0 541199 0 0 0 0 0 3142412 600677 2541735 0 1596432 0 1596432 0 Supplies 10206820 8093167 2113653 Quality Assurance Provider Fees 7430164 0 7430164 0 Other Purchased Services 5437914 2314361 3123553 Professional Fees 2905773 2881773 24000 0 3220042 1163777 2056265 0 83669773 53768695 29901078 0 2116386 2681168 12712660 16645423 0 0 14866215 17313621 0 0 0 0 15269356 6209803 1725634 1725634 250120 340959 79479724 41272685 37383202 38207039 0 0 0 0 0 0 0 0 134167 222408 84457740 83346055 3807082 3726366 0 0 0 0 0 0 0 0 0 0 15602563 16920334 0 0 12660949 7620579 32070594 28267279 X 52387146 55078776 0 0 0 0 52387146 55078776 84457740 83346055 2691630 0 0 0 0 0 X 0 1 X 0 0 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 130000 84936 214936 0 44481876 16633114 27848762 0 1696 1526 170 0 28592867 23478821 5114046 0 6188349 1159224 5029125 38207039 0 Accrued Payroll and Related Liabilities 4716163 Due to 3rd Party Payors 34458 Quality Assurance Fees Payable 2869958 7620579 86361403 0 0 0 0 0 86361403 0 0 0 86361403 83669773 0 0 0 0 0 83669773 0 0 0 83669773 1 1 X 1 X 1 X 0 1 1 0 1 1 0 0 2360869 0 2360869 0.028 0 0 35450413 23889589 11560824 0.138 0 0 28422475 19194567 9227908 0.11 0 0 66233757 43084156 23149601 0.276 0 0 313564 0 313564 0.004 0 0 74465 0 74465 0.001 0 0 0 0 0 0.0 0 0 0 0 0 0 0 0 71151 0 71151 0.001 0 0 459180 0 459180 0.006 0 0 66692937 43084156 23608781 0.282 0 0 0 0 0 0 0 1274 0 1274 0 0 52914 0 52914 0 0 0 0 0 0 0 0 0 0 0 0 2451 0 2451 0 0 3342 0 3342 0 0 28060 0 28060 0 0 0 0 0 0 0 88041 0 88041 0 1 2143702 0 19194567 28422475 -9227908 X 1 1 5 1 Madera Community Hospital

1250 E Almond Avenue Madera CA 93637

X X X A 2 Madera Community Hospital Family Health Services

1210 E Almond Avenue Madera CA 93637

Provider-Based Rural Health Clinic A 3 Chowchilla Medical Center Clinic

205 Hospital Drive Chowchilla CA 93610

Provider-Based Rural Health Clinic A 4 Madera Community Hospital Outpatient Center

1270 E Almond Avenue Madera CA 93637

Provider-Based Outpatient Laboratory and Radiology Services A 5 Madera Community Hospital Home Health Agency

360 E Almond Avenue Madera CA 93637

Provider-Based Home Health Agency A A 1 11 1 1 1 X 1 0 1 1 200 1 350 1 X 1 1 X X 1 X X X 0 X X X 1 X 0 0 SchH_P01_S00_L07 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. SchH_P02_S00_L00 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. SchH_P03_S0A_L04 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. SchH_P03_S0B_L08 Schedule H, Part III, Section B, Line 8 All of the shortfall reported on Line 7 is included in the Community Benefit costs. The costs were calculated in the Medicare Cost Report for this period. The revenue was derived from actual and estimated collections on Medicare accounts. SchH_P03_S0C_L09b 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 Charity Care program. SchH_P05_S0B_L04 Schedule H, Part V, Section B, Line 4 Adventist Health Central Valley Network, Community Medical Centers, Children's Hospital Central California, Kaiser Permanente, Saint Agnes Medical Center, Madera Community Hospital. SchH_P06_S00_L02 Schedule H, Part VI, Line 2 Madera Community Hospital participated in a 4-county Community Needs Assessment that was published in July 2011. Various focus groups were formed from members of the local communities to discuss the health needs. SchH_P06_S00_L03 Schedule H, Part VI, Line 3 There are notices on each billing that goes to the patient regarding information about the financial assistance policy. All self-pay patients are given a pamplet 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. SchH_P06_S00_L04 Schedule H, Part VI, Line 4 The direct service area of the hospital contains about 100,000 residents, mostly made up of western Madera County. The population is about 55% 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). SchH_P06_S00_L05 Schedule H, Part VI, Line 5 Madera Community Hospital is the only local hospital 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. SchH_P06_S00_L06 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. SchH_P06_S00_L07 Schedule H, Part VI, Line 7 California X X 0 0 0 0 0 0 0 0 0 John W Frye 295901 0 0 0 16346 0 0 0 2110 0 314357 0 0 Mary C Farrell 165863 0 20979 0 1465 0 0 0 3060 0 191367 0 0 Mark J Foote 159652 0 20316 0 1411 0 0 0 2771 0 184150 0 0 Karen Paolinelli 180444 0 7513 0 687 0 0 0 2626 0 191270 0 0 0 Angelica Malagon 145099 0 0 0 0 0 0 0 437 0 145536 0 0 0 Matthew Kobzeff 138264 0 0 0 0 0 0 0 7889 0 146153 0 0 0 Donna Aldrich 129427 0 6382 0 1616 0 0 0 0 0 137425 0 0 0 Dale Costantino 120811 0 8098 0 564 0 0 0 709 0 130182 0 0 0 SchJ_P01_S00_L03 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. Madera Anesthesia Associates Owner is Board Member Victor Yanez 660000 Anesthesia Services 0 F990_P06_S0A_L02 Form 990, Part VI, Section A, Line 2 Steve Barsotti is MCH Insurance Agent at Foster and Parker Insurance Company. Margaret Diebert and Mike Diebert are Stepmother and Stepson. Margaret Diebert and Don Warnock are Sister in Law and Brother in Law. Robert Poythress is Manager of Citizen's Business Bank that does Business with MCH. Mario Beltramo of Law Firm McCormick Barstow that is used by MCH is CEO John Frye's Brother in Law. F990_P06_S0B_L11b 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. F990_P06_S0B_L12c 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, employee re-education, training and counseling are conducted as necessary. F990_P06_S0B_L15 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 October 2012. The VP-Finance, VP-Patient Care Services, the AVP-Human Resources were all reviewed by the CEO in January 2013. F990_P06_S0C_L19 Form 990, Part VI, Section C, Line 19 The Audited Financial Statements are available upon request in the 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 1225000 Cash Madera Community Hospital Foundation o 50009 Payroll History Madera Community Hospital Foundation p 1071 Cash We received an approved Extension of Time to File an Exempt Organization Return on Notice Number CP211A dated March 24, 2014.