2014-11-08T13:50:04-06:00 2014-03-31 DURBIN & COMPANY LLP 2950 50TH STREET LUBBOCK TX 79413 990 2013-04-01 452750258 EL CAMPO MEMORIAL HOSPITAL ELCA 9795436251 303 SANDY CORNER RD EL CAMPO TX 77437 TISHA ZALMAN CHIEF EXECUTIVE OFFICER 9795436251 2014-11-08 JONATHAN PHILLIPS P01605460 8067911591 2014-11-08 2013 2015-11-30 17:44:51Z TISHA ZALMAN 303 SANDY CORNER RD EL CAMPO TX 77437 21148461 0 X WWW.ECMH.ORG X 2011 TX THE HOSPITAL PROVIDES EL CAMPO AND SURROUNDING AREAS WITH THE HIGHEST STANDARD OF CARE THROUGH A BROAD RANGE OF SERVICES: INPATIENT, SWING BED, EMERGENCY, SURGICAL, LABORATORY, IMAGING, RESPIRATORY, ETC. 5 5 239 36 0 0 118738 1414044 18288002 16974476 1200 6504 3036215 2753437 21444155 21148461 0 0 0 0 8341904 8566035 0 0 0 12639573 13184946 20981477 21750981 462678 -602520 5291183 4328009 5236158 4875504 55025 -547495 THE HOSPITAL PROVIDES EL CAMPO AND SURROUNDING AREAS WITH THE HIGHEST STANDARD OF CARE THROUGH A BROAD RANGE OF SERVICES: INPATIENT, SWING BED, EMERGENCY, SURGICAL, LABORATORY, IMAGING, RESPIRATORY, ETC. 0 0 20851654 19727913 PROVIDE HEALTHCARE TO EL CAMPO AND SURROUNDING AREAS WITH A BROAD RANGE OF SERVICES: INPATIENT, SWING BED, EMERGENCY, SURGICAL, LABORATORY, IMAGING, RESPIRATORY, THERAPY AND HOME HEALTH. 20851654 1 1 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 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 254 0 239 1 0 0 0 0 0 0 0 0 0 0 0 0 X 5 5 0 0 0 0 0 0 0 1 1 0 0 1 1 1 1 0 1 1 0 0 TX X TISHA ZALMAN 9795436251 303 SANDY CORNER RD EL CAMPO TX 77437 RANDY CLAPP BOARD CHAIRMAN 1.00 X 0 0 0 STEPHEN COOPER BOARD VICE - CHAIRMAN 1.00 X 0 0 0 MARY JOHNSON BOARD SECRETARY 1.00 X 0 0 0 FRANK CAVALLO DIRECTOR 1.00 X 0 0 0 WILLIAM CHIP JENKINS DIRECTOR 1.00 X 0 0 0 TISHA ZALMAN CEO 40.00 X 140231 0 0 DANA FOSTER PHYSICIAN ASSISTANT 40.00 X 133380 0 0 LAURA WILLIAMS PHYSICIAN ASSISTANT 40.00 X 127705 0 0 401316 0 0 3 0 0 0 JERRY D YOUNG DO PA 740 12TH STREET BAY CITY TX 77414 PROVIDER 124700 1 1414044 1414044 PROGRAM SERVICE REVENU 621990 16974476 16974476 16974476 6504 6504 47050 0 47050 47050 47050 1115 WAIVER PROGRAM 624100 1306140 1306140 EHR INCENTIVE 624100 1035321 1035321 DSRIP 624100 247863 247863 117063 117063 2706387 21148461 19727913 0 6504 X 229463 87386 142077 7780074 7552095 227979 556498 494700 61798 68444 68444 6484 6484 3726110 3510386 215724 89210 75983 13227 1016146 943501 72645 83337 83337 3202548 3197516 5032 36679 22370 14309 24668 11188 13480 86409 86409 844268 844268 126723 126723 BAD DEBT 3208627 3208627 MEDICAL SUPPLIES 497154 497154 DUES AND SUBSCRIPTIONS 113156 82182 30974 MISCELLANEOUS 32402 5248 27154 22581 22581 21750981 20851654 899327 0 549196 348631 1732748 1678537 376748 443332 88172 187933 3102500 1688776 2042014 1413724 502305 255852 5291183 4328009 2649772 3333520 2102207 1255617 484179 286367 5236158 4875504 X 55025 -547495 55025 -547495 5291183 4328009 -602520 0 X X 1 X 1 X 1 0 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 77002 14376 62626 2902951 1674400 1228551 122547 122547 1413724 DUE TO/FROM MEDICARE 2012 9466 ACCOUNTS RECEIVABLE MISCELLANEOUS 241200 ACCOUNTS RECEIVABLE EL CAMPO EMS 1046 ACCOUNTS RECEIVABLE HEADSTART 3900 ACCOUNTS RECEIVABLE HHH COMMUNITY SERVICES 240 255852 ACCOUNTS RECEIVABLE WWCHD 88347 REFUND CLEARING 145339 HEALTH PAYABLE 52681 286367 X 17939834 0 17939834 3208627 3208627 21148461 18542354 0 18542354 3208627 3208627 21750981 PART X, LINE 2: THE HOSPITAL IS NOT-FOR-PROFIT ORGANIZATION THAT IS EXEMPT FROM INCOME TAXES UNDER SECTION 501(C)(3) OF THE INTERNAL REVENUE CODE. THE HOSPITAL EVALUATES AND ACCOUNTS FOR UNCERTAIN TAX POSITIONS IN ACCORDANCE WITH FINANCIAL ACCOUNTING STANDARDS BOARD (FASB) ACCOUNTING STANDARDS CODIFICATION (ASC) 740, INCOME TAXES (FORMERLY FASB INTERPRETATION 48 (FIN 48) ACCOUNTING FOR UNCERTAINTY IN INCOME TAXES. THIS STANDARD REQUIRES CERTAIN DISCLOSURES ABOUT UNCERTAIN INCOME TAX POSITIONS. THE HOSPITAL EVALUATES ANY UNCERTAIN TAX POSITIONS USING THE PROVISIONS OF ASC 450, CONTINGENCIES. AS A RESULT, MANAGEMENT DOES NOT BELIEVE THAT ANY UNCERTAIN TAX POSITIONS CURRENTLY EXIST AND NO LOSS CONTINGENCY HAS BEEN RECOGNIZED IN THE ACCOMPANYING FINANCIAL STATEMENTS. THE HOSPITAL HAS FILED ALL APPLICABLE TAX RETURNS. PART XI, LINE 4B - OTHER ADJUSTMENTS: BAD DEBT EXPENSE PART XII, LINE 4B - OTHER ADJUSTMENTS: BAD DEBT EXPENSE 1 1 X 1 X 1 X 1 1 1 0 0 739055 577520 161535 0.00870 1495796 758095 737701 0.03980 2234851 1335615 899236 0.04850 2234851 1335615 899236 0.04850 1 2093610 1068908 9724313 5893360 3830953 X 1 1 1 1 EL CAMPO MEMORIAL HOSPITAL 303 SANDY CORNER RD EL CAMPO TX 77437 X X X X EL CAMPO MEMORIAL HOSPITAL 1 1 X X X X X X X X X 12 1 0 1 X WWW.ECMH.ORG X X X X X X X 1 0 1 1 150.000000000000 1 200.000000000000 1 X X X X X X X X 1 1 X X X X X 1 X X 0 X X X X 1 X 0 0 EL CAMPO MEMORIAL HOSPITAL PART V, SECTION B, LINE 3: THE COMMUNITY HEALTH NEEDS ASSESSMENT FOR EL CAMPO MEMORIAL HOSPITAL INCLUDED INTERVIEWS/FOCUS GROUPS WITH REPRESENTATIVES OF THE FOLLOWING CONSTITUENCIES: BUSINESS LEADERS (CHAMBER OF COMMERCE, WHARTON COUNTY LIBRARY, NORTHSIDE EDUCATION CENTER) MEMBERS OF THE AFRICAN AMERICAN COMMUNITY MEMBERS OF THE HISPANIC COMMUNITY MEMBERS OF THE MENNONITE COMMUNITY SUPERINTENDENT OF THE SCHOOL DISTRICT AUXILIARY/VOLUNTEERS MAYOR OF EL CAMP, CHIEF OF POLICE, EMS DIRECTOR MINISTERIAL ALLIANCE COMMUNITY RESOURCE COORDINATION GROUP EL CAMPO MEMORIAL HOSPITAL PART V, SECTION B, LINE 10: EL CAMPO MEMORIAL HOSPITAL SHALL PROVIDE CHARITY CARE WITH NO OBLIGATION TO PAY FOR SERVICES RENDERED TO THOSE UNINSURED AND UNDERINSURED PATIENTS WHO HAVE A NET MONTHLY INCOME LESS THAN OR EQUAL TO 150% OF THE FEDERAL POVERTY GUIDELINES FOR THE HOUSEHOLD'S SIZE. EL CAMPO MEMORIAL HOSPITAL PART V, SECTION B, LINE 11: THE HOSPITAL SHALL PROVIDE A 50% DISCOUNT FOR SERVICES RENDERED TO UNINSURED OR UNDERINSURED PATIENTS WHO HAVE A NET MONTHLY INCOME BETWEEN 151% AND 200% OF THE FEDERAL POVERTY GUIDELINES FOR THE HOUSEHOLD'S SIZE. EL CAMPO MEMORIAL HOSPITAL PART V, SECTION B, LINE 12I: AS EXPLAINED IN PART I, LINE 4, EL CAMPO MEMORIAL HOSPITAL SHALL REQUEST THAT THE APPLICANT VERIFY HIS OR HER GROSS ANNUAL HOUSEHOLD INCOME BY SUPPLYING THE FOLLOWING: TAX RETURN AND IRS FORM W-2, WAGE AND EARNINGS STATEMENT, PAY CHECK REMITTANCE, SOCIAL SECURITY, WORKERS COMPENSATION, UNEMPLOYMENT COMPENSATION OR GOVERNMENT PROGRAM DETERMINATION LETTERS, TELEPHONE VERIFICATION BY EMPLOYER OF THE APPLICANT'S ANNUAL GROSS INCOME, AND/OR BANK STATEMENTS. EL CAMPO MEMORIAL HOSPITAL PART V, SECTION B, LINE 14G: EACH PATIENT APPLYING FOR CHARITY CARE WILL BE ASKED TO COMPLETE AN EL CAMPO MEMORIAL HOSPITAL APPLICATION FOR HEALTH CARE ASSISTANCE ("ASSISTANCE APPLICATION"). ASSISTANCE APPLICATIONS CAN BE REQUESTED FROM THE INDIGENT /CHARITY PROGRAM COORDINATOR AT EL CAMPO MEMORIAL HOSPITAL, 303 SANDY CORNER RD, EL CAMPO, TX 77437, (979) 543-6251 EXTENSION 262. ASSISTANCE APPLICATIONS CAN ALSO BE PICKED UP IN THE HOSPITAL BUSINESS OFFICE AND FROM A MID COAST MEDICAL CLINIC RECEPTIONIST. EL CAMPO MEMORIAL HOSPITAL STAFF MUST GIVE OR MAIL ASSISTANCE APPLICATIONS THE SAME DAY THEY ARE REQUESTED. A BRIEF EXPLANATION, IF POSSIBLE, SHOULD BE GIVEN TO THE APPLICANT EXPLAINING THE PROCESS AND THE APPLICANT'S RESPONSIBILITIES. ASSISTANCE IN COMPLETING THE ASSISTANCE APPLICATION WILL BE PROVIDED IF NEEDED. APPLICANTS SHALL BE INFORMED THAT THEY SHOULD CONTACT THE INDIGENT/CHARITY PROGRAM COORDINATOR AT EL CAMPO MEMORIAL HOSPITAL AT (979) 578-5194. EL CAMPO MEMORIAL HOSPITAL PART V, SECTION B, LINE 20D: PER THE ORGANIZATION'S CHARITY CARE POLICY: "EL CAMPO MEMORIAL HOSPITAL SHALL PROVIDE CHARITY CARE WITH NO OBLIGATION (100% DISCOUNT OF AGB) TO PAY FOR SERVICES RENDERED TO THOSE UNINSURED AND UNDERINSURED PATIENTS WHO HAVE A NET MONTHLY INCOME LESS THAN OR EQUAL TO 150% OF THE FEDERAL POVERTY GUIDELINES FOR THE HOUSEHOLD'S SIZE. THOSE UNINSURED AND UNDERINSURED PATIENTS WHO HAVE A NET MONTHLY INCOME BETWEEN 151% AND 200% OF THE FEDERAL POVERTY GUIDELINES FOR THE HOUSEHOLD'S SIZE SHALL RECEIVE 0% DISCOUNT OF AMOUNTS GENERALLY BILLED. IN ADDITION, PATIENTS WHO ARE OVER 200% AND ARE UNINSURED OR UNDERINSURED CAN APPLY FOR THE DISCOUNT CARD PROGRAM. THE CARD IS FREE AND THERE IS NO ASSET OR INCOME REQUIREMENTS TO MEET FOR PATIENTS TO BECOME ELIGIBLE. BECAUSE THE DISCOUNT CARD PROGRAM IS NOT A MEANS-TESTED PROGRAM, IT IS NOT CONSIDERED CHARITY CARE OR FINANCIAL ASSISTANCE." 1 MID COAST MEDICAL CLINIC 305 SANDY CORNER EL CAMPO TX 77437 RURAL HEALTH CLINIC PART I, LINE 3C: EL CAMPO MEMORIAL HOSPITAL SHALL REQUEST THAT THE APPLICANT VERIFY HIS OR HER GROSS ANNUAL HOUSEHOLD INCOME BY SUPPLYING THE FOLLOWING: TAX RETURN AND IRS FORM W-2, WAGE AND EARNINGS STATEMENT, PAY CHECK REMITTANCE, SOCIAL SECURITY, WORKERS COMPENSATION, UNEMPLOYMENT COMPENSATION OR GOVERNMENT PROGRAM DETERMINATION LETTERS, TELEPHONE VERIFICATION BY EMPLOYER OF THE APPLICANT'S ANNUAL GROSS INCOME, AND/OR BANK STATEMENTS. CURRENT ELIGIBILITY BEGINS ON THE FIRST CALENDAR DAY IN THE MONTH THAT AN IDENTIFIABLE APPLICATION IS FILED OR THE EARLIEST, SUBSEQUENT MONTH IN WHICH ALL ELIGIBILITY CRITERIA ARE MET. THE APPLICANT MAY BE RETROACTIVELY ELIGIBLE IN ANY OF THE THREE CALENDAR MONTHS BEFORE THE MONTH THE IDENTIFIABLE APPLICATION IS RECEIVED IF ALL ELIGIBILITY CRITERIA ARE MET. PART I, LINE 7, COLUMN (F): THE BAD DEBT EXPENSE INCLUDED ON FORM 990, PART IX, LINE 25, COLUMN (A), BUT SUBTRACTED FOR PURPOSES OF CALCULATING THE PERCENTAGE IN THIS COLUMN IS $ 3,208,627. PART III, LINE 4: THE HOSPITAL PROVIDES CARE TO PATIENTS WHO MEET CERTAIN CRITERIA UNDER ITS CHARITY CARE POLICY WITHOUT CHARGE AT AMOUNTS LESS THAN ITS ESTABLISHED RATES. BECAUSE THE HOSPITAL DOES NOT PURSUE COLLECTION OF AMOUNTS DETERMINED TO QUALIFY AS CHARITY CARE, CHARITY CARE IS EXCLUDED FROM NET PATIENT REVENUE.THE VALUE OF CHARITY CARE PROVIDED BY THE HOSPITAL BASED UPON ITS ESTABLISHED RATES, WAS $1,132,661 IN 2014 AND $1,365,739 IN 2013. ASU 2010-23 REQUIRES CHARITY CARE TO BE DISCLOSED ON A COST BASIS. THE HOSPITAL UTILIZES THE COST TO CHARGE RATIO, AS CALCULATED BASED ON ITS MOST RECENT COST REPORTS, TO DETERMINE THE TOTAL COST. THE HOSPITAL'S COST OF PROVIDING CHARITY CARE WAS ESTIMATED AT $720,119 AND $823,777 FOR THE PERIODS ENDING MARCH 31, 2014 AND 2013, RESPECTIVELY.THE EVALUATION OF NECESSITY FOR MEDICAL TREATMENT OF ANY PATIENT WILL BE BASED UPON CLINICAL JUDGMENT REGARDLESS OF THE FINANCIAL STATUS OF THE PATIENT. THE CLINICAL JUDGMENT OF THE PATIENT'S PERSONAL PHYSICIAN OR THE EMERGENCY DEPARTMENT PHYSICIAN WILL BE THE SOLE DETERMINING CRITERION FOR A PATIENT'S ADMISSION TO EL CAMPO MEMORIAL HOSPITAL IN ACCORDANCE WITH THE MEDICAL STAFF BYLAWS. IN CASES WHERE A MEDICAL EMERGENCY CONDITION EXISTS, EL CAMPO MEMORIAL HOSPITAL'S EVALUATION OF POSSIBLE PAYMENT ALTERNATIVES WILL OCCUR ONLY AFTER URGENT MEDICAL CARE EVALUATION AND TREATMENT HAVE BEEN RENDERED IN ACCORDANCE WITH FEDERAL [EMTALA], STATE OR LOCAL LAW. PART III, LINE 8: THE HOSPITAL USES A COST TO CHARGE RATIO CALCULATED THROUGH THE ANNUAL MEDICARE/MEDICAID COST REPORT TO REPORT THE AMOUNT REPRESENTED ON LINE 7. PART III, LINE 9B: THE HOSPITAL DOES NOT PURSUE COLLECTION OF AMOUNTS FROM THOSE WHO ARE KNOWN TO QUALIFY FOR CHARITY CARE. FORM 990, PART VI, SECTION B, LINE 11 THE HOSPITAL HAS A THIRD-PARTY ACCOUNTING FIRM PREPARE FORM 990. ONCE THE 990 IS COMPLETED IT IS PRESENTED TO THE BOARD OF DIRECTORS IN DRAFT FORM. ANY QUESTIONS OR CONCERNS ARE THEN ADDRESSED, AND THE FINAL FORM 990 IS PREPARED WITH THE NECESSARY ADJUSTMENTS AND FILED. FORM 990, PART VI, SECTION B, LINE 12C EACH DIRECTOR SHALL INDIVIDUALLY DISCLOSE TO EL CAMPO MEMORIAL HOSPITAL AND TO THE BOARD OF DIRECTORS AT THE TIME OF NOMINATION AND APPOINTMENT AND TO THE TEXAS STATE BOARD OF MEDICAL EXAMINERS AT THE TIMES OF INITIAL APPLICATION AND BENNIAL REPORT THE IDENTITY OF EACH FINANCIAL RELATIONSHIP KNOWN TO THE DIRECTOR, IF ANY, WHICH HE OR SHE HAS WITH ANY OTHER DIRECTOR OR ANY SUPPLIER OF THE ORGANIZATION, AND TO PROVIDE A CONCISE EXPLANATION OF THE NATURE OF EACH SUCH FINANCIAL RELATIONSHIP. FORM 990, PART VI, SECTION B, LINE 15A THE PROCESS FOR DETERMINING COMPENSATION FOR EL CAMPO MEMORIAL HOSPITAL'S CEO INCLUDES AN ANNUAL REVIEW AND APPROVAL BY THE BOARD OF DIRECTORS, COMPARABILITY DATA FOR SIMILAR HOSPITALS AND HOSPITAL ORGANIZATIONS IN NEARBY COMMUNITIES OR SIMILAR ECONOMIES OF SCALE, AND CONTEMPORANEOUS DOCUMENTATION OF THE DELIBERATION AND DISCUSSION BETWEEN THE HOSPITAL AND ITS ADMINISTRATOR. FORM 990, PART VI, SECTION C, LINE 19 THE HOSPITAL DOES NOT MAKE ITS GOVERNING DOCUMENTS, CONFLICT OF INTEREST POLICY, AND FINANCIAL STATEMENTS AVAILABLE TO THE PUBLIC. FORM 990, PART IX, LINE 11G HOSPITAL PURCHASE SERVICES: PROGRAM SERVICE EXPENSES 3,510,386. MANAGEMENT AND GENERAL EXPENSES 215,724. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 3,726,110. FORM 990, PART XII, LINE 2C: THE BOARD OF DIRECTORS ASSUMES OVERSIGHT AND RESPONSIBILITY FOR THE FINANCIAL STATEMENT AUDIT AND SELECTION OF AN INDEPENDENT, THIRD-PARTY ACCOUNTANT. THIS PROCESS HAS NOT CHANGED FROM THE PRIOR YEAR.