2014-05-15T08:56:59-05:00 2013-06-30 481026809 Wendling Noe Nelson & Johnson LLC 534 S Kansas Ave Suite 1500 Topeka KS 666033491 990 2012-07-01 481253246 Pawnee Valley Community Hospital Inc PAWN 6202853161 923 Carroll Ave Larned KS 67550 Shae Veach 7856235000 2014-05-14 1 Derek H Hart P01054116 7852334226 2014-05-14 2012 2015-11-30 17:44:51Z Shae Veach 923 Carroll Ave Larned KS 67550 13172773 0 X www.pawneevalleyhospital.com X 2001 KS Pawnee Valley Community Hospital, Inc. is a tax-exempt charitable organization under Section 501(c)(3) of the Internal Revenue Code and is licensed by the State of Kansas Department of Health and Environment. The purpose of the Organization is to provide healthcare to inpatients and outpatients who are acutely ill or who otherwise require medical care and related services. The Organization is striving to be the best Critical Access Hospital in rural America. 5 0 124 91 0 0 0 9589 12491037 13157124 11890 6060 0 0 12502927 13172773 0 0 0 0 4832801 5575159 0 0 0 5963639 5881353 10796440 11456512 1706487 1716261 5312244 5634463 5312244 5634463 0 0 X Pawnee Valley Community Hospital, Inc. is a tax-exempt charitable organization under Section 501(c)(3) of the Internal Revenue Code and is licensed by the State of Kansas Department of Health and Environment. The purpose of the Organization is to provide healthcare facitities and services for the care and treatment of inpatients and outpatients who are acutely ill or who otherwise require medical care and related services. The core purpose of the Corporation is to help people be healthy. 0 0 8391332 13087469 Patient care: Program services consist of routine and ancillary department healthcare services provided by a healthcare organization as described in 501(c)(3) of the IRS code. 8391332 1 0 0 1 0 0 0 0 0 0 0 0 0 1 1 1 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 1 0 0 0 1 0 0 124 1 0 0 0 0 0 0 0 0 0 0 X 5 0 0 0 0 0 1 1 1 1 1 0 0 1 1 1 1 1 1 1 1 0 X Shae Veach President 7856235000 2220 Canterbury Hays KS 67601 Shae Veach 4.00 X X 0 171034 58831 Bryce Young 4.00 X X 0 294000 85301 William Overbey 4.00 X X 0 304265 82350 John Jeter MD 4.00 X 0 589737 142673 Matt Heyn 40.00 X X 0 141083 31880 0 1500119 401035 0 0 1 0 Hays Medical Center 2220 Canterbury Drive Hays KS 67601 Contract Services 2651425 Docs Who Care 1337 S Fountain Drive Olathe KS 66061 ER Physician Coverage 503022 Allstaff Chartered 2000 Washington Great Bend KS 67530 Contract Nursing 222451 Quest Diagnostics PO Box 14730 St Louis MO 63150 Lab Services 173530 Shared Medical Services Inc PO Box 330 Cottage Grove WI 53527 Contract Nursing 111220 5 8525 1064 9589 Net patient service revenue 622000 12937413 12937413 Rental income 900099 69655 69655 Meals sold to non-patients 900099 50436 50436 Outreach therapy services 900099 38270 38270 Lab fairs 900099 26691 26691 34659 34659 13157124 5560 5560 500 0 500 500 500 13172773 13087469 0 75715 X 180873 180873 4271593 3680410 591183 162443 142103 20340 652139 565807 86332 308111 256707 51404 1539715 1539715 10290 10290 1010 1010 1747557 1563815 183742 80106 1527 78579 38300 26028 12272 84279 50540 33739 168868 122801 46067 15893 10307 5586 6817 6817 66894 40136 26758 Pharmaceuticals 584041 584041 Medical supplies 431800 431744 56 Contract labor 280032 280032 Equipment rent 214265 183261 31004 611486 445256 166230 11456512 8391332 3065180 0 560 630 2764507 2958801 1263463 2012785 9199 0 316765 242175 115912 110847 841838 309225 5312244 5634463 942625 862199 4369619 4772264 5312244 5634463 X 0 0 5312244 5634463 X 1716261 -1716261 X X 0 1 X 1 0 X 0 0 0 0 0 1 2027 0 0 0 2027 0 Explanation of Lobbying Activities: Part II-B, Line 1: Pawnee Valley Community Hospital is a member of the Kansas Hospital Association and the American Hospital Association. Both of these organizations engage in lobbying activities for hospitals and health care as part of the services provided to members. 0 Other receivables 90548 Reinsurance proceeds recoverable 9880 Estimated thrid-party payor settlements 208797 309225 Due to Pawnee County 2847963 Due to Hays Medical Center, Inc. 1843301 Estimated third-party payor settlements 81000 4772264 X 13172773 0 13172773 0 13172773 11456512 0 11456512 0 11456512 Description of Uncertain Tax Positions Under FIN 48: Part X, Line 2: Management is not aware of any uncertainties in income tax positions. 1 1 1 X 125.000000000000 1 X 1 1 0 1 1 136644 136644 0.01190 766712 432169 334543 0.02920 903356 432169 471187 0.04110 881496 580922 300574 0.02620 3300 3300 0.00030 884796 580922 303874 0.02650 1788152 1013091 775061 0.06760 1 722633 50584 7234154 7191897 42257 X 1 1 1 1 Pawnee Valley Community Hospital Inc

923 Carroll Avenue Larned KS 67550

X X X X Pawnee Valley Community Hospital Inc 1 1 X X X X X X X X X 12 1 0 1 X X X X X 1 0 1 1 125.000000000000 1 400.000000000000 1 X X X X X X 1 1 X X X X X 1 0 X X X 1 X 0 0 Part I, Line 7: A cost-to-charge ratio derived from Worksheet 2 was used to determine financial assistance at cost and the cost of subsidized health services. A cost-to-charge ratio derived from Worksheet 2 was used to determine the costs of serving Medicaid beneficiaries. Part III, Line 4: Bad debt expense was calculated using a cost-to-charge ratio derived from Worksheet 2. The estimate for the amount of bad debt expense attributable to patients eligible under the FAP is based upon the experience of a related organization. The footnote from the hospital's financial statements follows:Accounts receivable are reduced by an allowance for uncollectible accounts. In evaluating the collectability of accounts receivable, the Hospital analyzes its past history and identifies trends for each of its major payor sources of revenue to estimate the appropriate allowance for uncollectible accounts and provision for bad debts. Management regularly reviews data about these major payor sources of revenue in evaluating the sufficiency of the allowance for uncollectible accounts. For receivables associated with services provided to patients who have third-party coverage, the Hospital analyzes contractually due amounts and provides an allowance for uncollectible accounts and a provision for bad debts, if necessary (for example, for expected uncollectible deductibles and copayments on accounts for which the third-party payor has not yet paid, or for payors who are known to be having financial difficulties that make the realization of amounts due unlikely). For receivables associated with self-pay patients (which includes both patients without insurance and patients with deductible and copayment balances due for which third-party coverage exists for part of the bill), the Hospital records a significant provision for bad debts in the period of service on the basis of its past experience, which indicates that many patients are unable or unwilling to pay the portion of their bill for which they are financially responsible. The difference between the standard rates (or the discounted rates if negotiated) and the amounts actually collected after all reasonable collection efforts have been exhausted is charged off against the allowance for uncollectible accounts. Part III, Line 8: The Medicare cost report was the costing methodology used to determine the allowable Medicare costs pertaining to Medicare net revenue. Allowable costs of care reported on line 6 were determined using amounts from Worksheet D, Part V and Worksheet D-1 in the Pawnee Valley Community Hospital, Inc., Medicare cost report for fiscal year ended June 30, 2013. Part III, Line 9b: Whenever possible, the customer service representatives (CSR's) of Pawnee Valley Community Hospital try to determine the estimated self-pay balance prior to the patient receiving services. Charity care eligibility is first considered at this point in time. In addition, if full payment is not received or payment is not made within 30 days, the CSR contacts the patient. If it is determined that at least a two-year payment plan cannot be established with the patient, the CSR will screen for charity care and request that the charity care application be completed by the patient. Pawnee Valley Community Hospital, Inc. Part V, Section B, Line 3: The CHNA was conducted in collaboration with the Pawnee County Health Department. A Town Hall Meeting was organized to provide an objective consensus building method of reviewing and prioritizing county health issues. During the Town Hall meeting, the group reflected on the size and seriousness of any health concerns cited and discussed current community health strengths. The group identified and ranked top community health concerns, and all Town Hall attendees were encouraged to continue to contribute ideas by going online and taking a feedback survey that addresses any additional thoughts related to the CHNA. All Town Hall priority-setting and scoring processes involved the input of a diverse group with knowledge and/or expertise in public health as well as persons who represent the broad interests of the community served by the hospital. Key stakeholders in attendance included representatives from: United Way, Welcome Inn Senior Center, Center for Counseling, Elder Care, Inc., Smith Dental Clinic, Pawnee County Sherriff's Office, Larned Police Department, Pawnee County Health Department, County Commissioners, members of the Chamber of Commerce, members of the USD 495 School Board, school nurses of USD 495, local members of the media, local religious organizations, city council members, and representatives of Pawnee Valley Community Hospital. The CHNA was coordinated and produced by VVV Research & Development, Inc. from Olathe, Kansas. Pawnee Valley Community Hospital, Inc. Part V, Section B, Line 14g: Pawnee Valley Community Hospital, Inc. (PVCH) will proactively seek out applicants who may be in need of financial assistance. PVCH will post notice of this policy to all patients/guarantors through its registration, pre-registration, and financial counseling process. This policy will also be posted in prominent areas of the hospital and on the hospital's website. Pawnee Valley Community Hospital, Inc. Part V, Section B, Line 20d: The hospital used the look-back method based on actual paid claims by Medicare and all other private health insurers paying claims to the hospital. Part VI, Line 3: Information regarding the Pawnee Valley Community Hospital, Inc., charity care program is located on the Hays Medical Center, Inc., website for patients and community members to view, and the financial assistance application is also on the website to print off and complete. In addition, if a customer service representative contacts a patient about a bill and in visiting with them they determine that patient could possibly qualify for the hospital's charity care policy, the CSR will send the application to the patient as well. Part VI, Line 4: Pawnee Valley Community Hospital, Inc., is located in Larned, Kansas, which has a population of approximately 4,050 people, as of the 2010 census. The median household income of Larned was $46,464. Approximately 5.9% of families were below the poverty line, and 7.4% of the total population was below the poverty line. Approximately 7.3% of the hospital's revenue is from services provided to patients eligible for Medicaid. Pawnee Valley Community Hospital, Inc. is the only hospital in Larned, Kansas. It mainly serves the community of Larned. Part VI, Line 5: Pawnee Valley Community Hospital, Inc., promotes the health of the community by extending medical privileges to most qualified, local physicians. Part VI, Line 6: Pawnee Valley Community Hospital, Inc. is not a part of an affiliated health care system. X X 0 1 0 0 0 1 1 0 0 Shae Veach 0 142127 0 25970 0 2937 0 34622 0 24209 0 229865 0 0 Bryce Young 0 233847 0 55284 0 4869 0 57570 0 27731 0 379301 0 0 William Overbey 0 237941 0 54516 0 11808 0 57619 0 24731 0 386615 0 0 John Jeter MD 0 437483 0 142252 0 10002 0 117710 0 24963 0 732410 0 0 Matt Heyn 0 124385 0 16698 0 0 0 7911 0 23969 0 172963 0 0 Part I, Line 3 The hospital Administrator's salary is reviewed annually by an independent consulting group and the Board of Directors. Part I, Line 4b Shae Veach - $25,215 Bryce Young - $43,820 William Overbey - $43,869 John Jeter, M.D. - $86,960 Part I, Line 6 A portion of the Administrator's incentive compensation is determined by net earnings exceeding budget for the fiscal year. A portion of incentive compensation for officers and key employees of Hays Medical Center, Inc., a related organization, is determined by net earnings exceeding budget for the fiscal year. Form 990, Part VI, Section A, line 6 The organization has one member, HaysMed Partners, Inc., which became the sole member as of March 1, 2010. HaysMed Partners, Inc., is a wholly-owned subsidiary of Hays Medical Center, Inc. Form 990, Part VI, Section A, line 7a The Board members of HaysMed Partners, Inc., the sole member of Pawnee Valley Community Hospital, appoint the Board members of Pawnee Valley Community Hospital, Inc. Form 990, Part VI, Section A, line 7b HaysMed Partners, Inc., the sole member of Pawnee Valley Community Hospital, elects the Board members of Pawnee Valley Community Hospital. Form 990, Part VI, Section B, line 11 Form 990 was reviewed with the Board members prior to filing. Form 990, Part VI, Section B, line 12c Officers, directors & key employees, along with all associates, are required to complete a conflict of interest statement annually. The statements are used to monitor and enforce compliance with the policy. Form 990, Part VI, Section B, line 15 The hospital Administrator and officers' salaries are reviewed annually by an independent consulting group and the Board members. Form 990, Part VI, Section C, line 19 These documents are not made available to the public. Other Fees Form 990, Part IX, line 11g Medical professional fees: Program service expenses 957,985. Management and general expenses 2,022. Fundraising expenses 0. Total expenses 960,007. Laboratory professional fees: Program service expenses 210,213. Management and general expenses 0. Fundraising expenses 0. Total expenses 210,213. Other professional fees: Program service expenses 225,101. Management and general expenses 26,340. Fundraising expenses 0. Total expenses 251,441. Collection agency services: Program service expenses 0. Management and general expenses 30,067. Fundraising expenses 0. Total expenses 30,067. Other purchased services: Program service expenses 170,516. Management and general expenses 125,313. Fundraising expenses 0. Total expenses 295,829. Changes in Net Assets or Fund Balances: Form 990, Part XI, line 9: Increase in amount due to Pawnee County -1,246,211. Transfers to Pawnee County -470,050. Financial Statements and Reporting Form 990. Part XII, Line 2c Hays Medical Center, Inc., has an audit committee that is responsible for the oversight of Pawnee Valley Community Hospital, Inc's., financial statement audit and the selection process of an independent accountant. HaysMed Partners Inc 2220 Canterbury Dr Hays KS 67601 270877152 Owns management contract for Pawnee Valley Community Hospital KS 501(c)(3) Line 3 0 Hays Medical Center Inc 2220 Canterbury Dr Hays KS 67601 480559088 Hospital KS 501(c)(3) Line 3 0 0 0 0 0 1 0 0 0 0 1 1 0 1 0 1 1 0 0 0