2014-11-14T07:28:20-06:00 2013-12-31 450250958 EIDE BAILLY LLP 1601 NW Expressway Oklahoma City OK 73118 990 2013-01-01 731279909 Okmulgee Memorial Hospital Inc OKMU 9187564233 1401 Morris Drive Okmulgee OK 74447 Sheridan Pickering Administrator 9187564233 2014-11-13 1 Carolyn Levings P01083874 4054783334 2014-11-13 2013 2015-11-30 17:44:51Z Sheridan Pickering 1401 Morris Drive Okmulgee OK 74447 19188782 0 X www.creekhealth.org X 1967 OK Provide quality health care services X 9 9 286 25 0 0 0 1000 19611517 17077691 1996 3150556 0 1475 19613513 20230722 0 0 0 0 10379723 9549579 0 0 0 10188705 10107202 20568428 19656781 -954915 573941 5658007 0 6231948 0 -573941 0 X Okmulgee Memorial Hospital's mission is to put our patients and customers first and to provide quality health care in an efficient manner. 0 1 16285153 17077691 Okmulgee Memorial Hospital, Inc. is a 66-bed acute care hospital located in Okmulgee, Oklahoma. It also operates a home health agency in the same geographic area. Emergency Care services are provided to the general public regardless of ability to pay.The Hospital provides care to patients who meet certain criteria under its charity care policy without charge or at amounts less than established rates. Because the Hospital does not pursue collection of amounts determined to qualify as charity care, they are not reported as revenue. The amount of charges foregone for services provided under the Hospital's charity care policy were approximately $326,000 for the period and year ended December 30, 2013. Total direct and indirect costs related to these foregone charges were $132,000 for the period and year ended December 31, 2013, based on an average ratio of cost to gross charges. 16285153 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 1 0 0 0 0 0 0 0 0 0 1 1 0 0 1 0 0 0 0 0 0 0 0 0 0 0 1 0 1 0 0 0 1 10 0 1 286 1 0 0 0 0 0 0 0 0 0 0 X 9 9 0 1 0 0 0 1 0 1 1 0 0 1 1 1 1 1 1 1 1 0 OK X Sheridan Pickering 9187583102 1401 Morris Drive Okmulgee OK 74447 Nevyle Cable President 1.00 0.30 X X 0 0 0 John Fidler President-Elect 1.00 0.30 X X 0 0 0 Greg Marriott Treasurer 1.00 0.30 X X 0 0 0 Barbara Osborn Secretary 1.00 0.30 X X 0 0 0 Kim Gage MD Trustee 1.00 0.00 X 0 0 0 Linda Janzen Trustee 1.00 0.30 X 0 0 0 Walter McGown OD Trustee 1.00 0.30 X 0 0 0 Timothy Sanford DO Trustee 1.00 0.00 X 0 0 0 Jason Winters Trustee 1.00 0.30 X 0 0 0 George Miller-Mgmt Company CEO until August 2013 40.00 0.00 X 0 0 0 Roshanda Gray Interim CEO Aug-Dec 2013 40.00 0.00 X 69413 0 6966 Doran Hammett-Mgmt Company CFO 40.00 5.00 X 0 0 0 Benjamin Kamp DO Surgeon 40.00 0.00 X 180634 0 9969 Jason Bruce CRNA Nurse Anesthesiologist 40.00 0.00 X 220142 0 8687 Brent Galloway MD Family Practitioner 40.00 0.00 X 180270 0 0 Ben Bradley Chief Nursing Officer 40.00 0.00 X 134922 0 0 Ahmad Masood MD Psychiatrist 40.00 0.00 X 191550 0 0 976931 0 25622 5 0 1 0 Okmulgee Emergency PLCC 607 South Broadway Coweta OK 74429 Emergency Room Physician Services 278500 Quorum Health Resources 105 Continental Pl Brentwood TN 37027 Management Services 273595 CPSI PO Box 850309 Mobile AL 36695 Internet & Computer Serv. 246065 3 1000 1000 Patient service revenue 622110 16052561 16052561 EHR incentive 900099 833706 833706 Supporting revenue 900099 78919 78919 Dietary 900099 65572 65572 Maintenance/Janitorial 561720 46933 46933 17077691 109 109 1475 0 1475 1475 1475 2108507 -1041940 3150447 3150447 3150447 20230722 17077691 0 3152031 X 76379 76379 7456545 6003432 1453113 80635 64322 16313 1345546 1078894 266652 590474 471019 119455 273595 273595 74577 74577 94439 94439 2600421 2202385 398036 792042 320849 471193 6829 6829 309984 282668 27316 82862 64839 18023 102456 102456 603856 603856 298424 223440 74984 Bad debt expense 3447745 3447745 Medical supplies 954483 954483 Government programs 401441 401441 Dues & Subscriptions 64048 63324 724 19656781 16285153 3371628 0 16043 2811226 591105 529713 0 1709920 5658007 0 3317478 3206 2438439 472825 0 6231948 0 X -573941 0 -573941 0 5658007 0 573941 0 X 0 1 X 1 0 X 0 X 13632530 -3447745 -3447745 17080275 3150447 3150447 20230722 16209036 0 16209036 3447745 3447745 19656781 Part X, Line 2: The Hospital is organized as an Oklahoma nonprofit corporation and has been recognized by the Internal Revenue Service (IRS) as exempt from federal income taxes under Internal Revenue Code Section 501(c)(3). The Hospital is annually required to file a Return of Organization Exempt from Income Tax (Form 990) with the IRS. In addition, the Hospital is subject to income tax on net income that is derived from business activities that are unrelated to its exempt purpose. The Hospital has determined it is not subject to unrelated business income tax and has not filed an Exempt Organization Business Income Tax Return (Form 990T) with the IRS. The Hospital believes that it has appropriate support for any tax positions taken affecting its annual filing requirements, and as such, does not have any uncertain tax positions that are material to the financial statements. The Hospital would recognize future accrued interest and penalties related to unrecognized tax benefits and liabilities in income tax expense if such interest and penalties are incurred. Part XI, Line 2d - Other Adjustments: Bad debt expense reported in revenue for the financial statements -3,447,745. Part XI, Line 4b - Other Adjustments: Gain on sale of Hospital included in revenue for Form 990 3,150,447. Part XII, Line 4b - Other Adjustments: Bad debt expense reported in revenue for the financial statements 3,447,745. 1 1 X 1 X 1 X 1 1 0 0 132000 132000 0.00810 2807072 2327974 479098 0.02960 2939072 2327974 611098 0.03770 2939072 2327974 611098 0.03770 0 3447745 29995 6331163 6792078 -460915 X 1 1 1 1 Okmulgee Memorial Hospital Inc 1401 Morris Drive Okmulgee OK 74447 www.creekhealth.org 2165 X X X Psych-16 Beds Okmulgee Memorial Hospital Inc 1 1 X X X X X X X X X 13 1 0 1 X www.creekhealth.org X X 0 0 1 1 200.000000000000 1 300.000000000000 1 X X X 1 1 X X 1 0 X X X X 1 X 0 0 Okmulgee Memorial Hospital, Inc. Part V, Section B, Line 3: A 17 question survey was distributed to persons within the City of Okmulgee water service. 522 completed surveys were returned to the Oklahoma County Wellness Coalition and analyzed by the Oklahoma State Department of Health. Okmulgee Memorial Hospital, Inc. Part V, Section B, Line 6i: Okmulgee Memorial Hospital did not formally complete an implementation strategy because the Hospital assets were purchased by Muscogee (Creek) Nation as of 12/31/2013. In 2014, the Hospital will no longer be required to comply with 501(r) as it no longer operates a hospital. The needs identified in the community health needs assessment were informally discussed and it was determined that other organizations in the community would be able to address the needs. Okmulgee Memorial Hospital, Inc. Part V, Section B, Line 7: No actions were taken as of December 31, 2013 on the needs identified in the community health needs assessment as the Hospital assets were purchased by Muscogee (Creek) Nation. The current entity will not be subject to 501(r) in 2014. The needs identified in the community health needs assessment were informally discussed and it was determined that other organizations in the community would be able to address the needs. Okmulgee Memorial Hospital, Inc. Part V, Section B, Line 14g: The financial assistance policy is available from the patient Financial Counselor and is also included on patient billing statements. Summary of financial assistance is available in the waiting rooms, emergency room, and outpatient areas of the Hospital. 1 OMH Home Health 1401 Morris Drive Okmulgee OK 744476419 Home health agency Part I, Line 3c: Patients may qualify for financial assistance at three different levels. Approval is contingent upon income, expenses, and documentation:1. Income and family size at or below 200% of the Federal Poverty Guidelines may qualify for 100% financial assistance.2. Income and family size at or below 250% but greater than 200% of the Federal Poverty Guidelines may qualify for 75% financial assistance, resulting in expectation that the patient will pay 25% of the charges for services rendered.3. Income and family size at or below 300% but greater than 250% of the Federal Poverty Guidelines may qualify for 50% financial assistance, resulting in expectation that the patient will pay 50% of the charges for services rendered.4. Income and family size greater than 300% of the Federal Poverty Guidelines will be denied financial assistance, unless and exception is granted by the CFO or CEO.Financial assistance may be extended when income is greater than described in the Federal Poverty Guidelines when there is a clear and overwhelming circumstance documented, i.e. catastrophic illness and/or event. This determination can only be made by the Chief Financial Officer or Chief Executive Officer. Part I, Line 7: Charity care expense was converted to cost on line 7a based on an overall cost-to-charge ratio addressing all patient segments. Unreimbursed Medicaid on line 7b was calculated using the costing methods to prepare the cost reports. Part I, Ln 7 Col(f): The amount of bad debt expense removed from total expenses to determine the percentage was $3,447,745. Part III, Line 2: Bad debt is determined by our bad debt policy considering actual patient care charges. Charges become bad debt once a reasonable opportunity has been made by the Hospital to collect an open account and the responsible party has been contacted regarding the unpaid balance. After policy based collection attempts have been exhausted, the account is written off to bad debt.All payments and contractual are applied to the account before it is written off to bad debt. If any payments are received for bad debts that have been written off, they are applied to the current year bad debt expense.Bad debt expense on line 2 is reported at charges as presented on the financial statements. Part III, Line 3: The estimated amount of the Organization's bad debt expense attributable to patients eligible under the Organization's charity care policy is calculated based on an estimate of charges foregone to gross patient charges. Part III, Line 4: The footnote to the Organization's financial statements can be found on page 7 of the attached audited financial statements. Part III, Line 8: Okmulgee Memorial Hospital provides services to patients under the Medicare program knowing they will not recover all the costs associated with providing these services. Providing these services is essential to these patients and the community and increases their access to healthcare services. Therefore, the Medicare shortfall is considered a community benefit.The costs associated with Medicare were taken from the Medicare Cost Report. The Medicare Cost Report is completed based on the rules and regulations set forth by Centers for Medicare and Medicaid Services. Part III, Line 9b: The Hospital has a charity care policy and patients must meet certain established criteria for charity service consistent with Okmulgee Memorial Hospital's mission. No collections actions are filed while an application is in review, any personal portion due after a determination of assistance would follow normal collections practices. Part VI, Line 2: The Oklahoma County Wellness Coalition conducted a Community Health Needs Assessment. The Okmulgee County Wellness Coalition was created in 2006 by a concerned group of individuals from four different agencies, Okmulgee County Health Department, Anne Moroney Youth Services, Okmulgee Memorial Hospital, and Area Prevention Resource Center, who were interested in improving the health status of Okmulgee County. Since then, the coalition has brought together a wide circle of community agencies and partners, coordinating efforts and resources to more effectively improve the wellness of the people of Okmulgee County.The purpose of the Community Health Needs Assessment was to understand the current needs and health status of Okmulgee County residents. Health problems reported were high blood pressure, dental problems, high cholesterol, arthritis, hearing/vision loss, stress/depression, diabetes, obesity, lung/respiratory disease and heart disease. The full needs assessment can be accessed at http://creekhealth.org/index.php/facilities/medical-centers. Part VI, Line 3: The Hospital uses an electronic program during admissions to determine if a patient is eligible for assistance. If a patient is determined to be eligible, then the patient is referred to a financial counselor. The financial counselor works with the patient to determine if the patient is eligible for Medicaid. If the patient is not eligible for Medicaid, the Hospital then works with the patient to determine if the patient is eligible for charity care. The Financial Counselor contact information is included in the patient billing statements if further assistance is needed. Summary of financial assistance is available in the waiting rooms, emergency room, and outpatient areas of the Hospital. Part VI, Line 4: Okmulgee Memorial Hospital is an acute care hospital located in Okmulgee, which is in Okmulgee County, Oklahoma. Okmulgee County is a federally underserved area according to the Health Resources and Services Administration. Okmulgee is a small community of about 13,000 residents. There are two other hospitals in the county with one about twenty miles from Okmulgee Memorial Hospital. The median household income is $35,615 and 19.2% of families and 21.4% of individuals of the population are below the poverty line. Part VI, Line 5: The Organization has a volunteer board comprised of members of the community. Medical staff privileges are extended to all qualified physicians in the community and to those who wish to render services at Okmulgee Memorial Hospital. Any surplus funds, if available, are reinvested in the facilities to improve patient care. X X X 0 0 0 0 0 0 0 0 0 Benjamin Kamp DO Surgeon 180634 0 0 0 0 0 9969 0 0 0 190603 0 0 0 Jason Bruce CRNA Nurse Anesthesiologist 220142 0 0 0 0 0 8687 0 0 0 228829 0 0 0 Brent Galloway MD Family Practitioner 180270 0 0 0 0 0 0 0 0 0 180270 0 0 0 Ahmad Masood MD Psychiatrist 191550 0 0 0 0 0 0 0 0 0 191550 0 0 0 Okmulgee Memorial Hospital, Inc. entered into an asset purchase agreement to sell all of the assets of the Hospital as of December 30, 2013 to the Muscogee (Creek) Nation. The Muscogee (Creek) Nation purchased the assets and assumed the debt and liabilities of the Hospital. 2013-12-31 -1041940 The FMV is the book value of the assets at the time of the transfer. 731357965 Muscogee (Creek) Nation Hwy 75 Loop 56 Okmulgee OK 74447 Government 1 1 0 0 Part II, Line 2e: Person(s) Involved: Nevyle Cable, John Fidler, Greg Marriott, Barbara Osborn, Kim Gage, MD, Linda Janzen, Walter McGown, O.D., Timothy Sanford, D.O., and Jason Winters became the board members for the successor hospital, Muscogee (Creek) Nation Medical Center. Form 990, Part III, line 3 On December 30, 2013, Okmulgee Memorial Hospital Authority entered into an asset purchase agreement with Muskogee (Creek) Nation who purchased the assets and assumed the liabilities of the Hospital. Muskogee (Creek) Nation began operations of the Hospital December 31, 2013. Form 990, Part VI, Section A, line 1 Seven Directors serve on the Executive Committee of the Board. The Executive Committee consists of the President, Vice President and Treasurer of the Corporation and four other Directors. Two of the Directors selected by St. Francis Hospital, Inc. serve on the Executive Committee. The Board delegates full operational authority of the Corporation to the Executive Committee, subject to control and ratification by the Board. All elections and designations to the Executive Committee will be made at the annual meeting of the Board. The Executive Committee keeps regular minutes of its proceedings and reports the same to the Board. Elected members of the Executive Committee serve only until expiration of their term, or if succession is delayed, until their successors are duly elected and qualified. A quorum of the Executive Committee consists of not less than four members of the Executive Committee present in person. Less than a quorum may vote to adjourn the meeting until another time. At any meeting of the Executive Committee, a majority vote of its members present in person is required to pass any measure coming before the meeting. Form 990, Part VI, Section A, line 3 George Miller, CEO until August 2013, and Doran Hammett, CFO, are common law employees of Quorum Health Resources, an unrelated management company. The CEO has the responsibility of supervising the management, administration and operation of the Organization. The CFO has the responsibility for managing the Organization's finances. George Miller was compensated $18,704 for services to Okmulgee Memorial Hospital, Inc. Doran Hammett was compensated $16,000 for services to Okmulgee Memorial Hospital. Form 990, Part VI, Section A, line 7a At least three Directors are selected by St. Francis Hospital, Inc. Form 990, Part VI, Section B, line 11 The Form 990 is prepared by an outside accounting firm and is reviewed internally by the CEO and the Finance Committee prior to filing with the IRS. The Board of Directors is also provided a copy prior to filing. Form 990, Part VI, Section B, line 12c The Organization has a conflict of interest policy which is applicable to all employees of Okmulgee Memorial Hospital. Once a potential conflict is identified, Compliance and administration determine the level and risk of the conflict. Depending on the severity of conflict an employee may be asked to refrain involvement. If there is a known conflict that is not disclosed by an employee, they will be subject to the disciplinary action policy. Form 990, Part VI, Section B, line 15 The Board of Directors reviews and approves salaries of top management positions, including the interim CEO, annually. Salary determination is based on comparability data from industry standards. During the period when Quorum Health Resources provided management services the CEO and CFO compensation was recommended by Quorum Health Resources and Board approved. The process and determination was documented in the Board minutes and management contract with Quorum Health Resources. Form 990, Part VI, Section C, line 19 The Organization makes its governing documents, conflict of interest policy, and financial statements available to the public upon request. Form 990, Part IX, line 11g Contract labor: Program service expenses 1,258,386. Management and general expenses 31,632. Fundraising expenses 0. Total expenses 1,290,018. Maintenance and repairs: Program service expenses 335,279. Management and general expenses 72,525. Fundraising expenses 0. Total expenses 407,804. Professional fees: Program service expenses 608,720. Management and general expenses 54,344. Fundraising expenses 0. Total expenses 663,064. Recruitment expense: Program service expenses 0. Management and general expenses 19,328. Fundraising expenses 0. Total expenses 19,328. Collection fees: Program service expenses 0. Management and general expenses 220,207. Fundraising expenses 0. Total expenses 220,207. Okmulgee Medical Foundation Inc PO Box 1038 Okmulgee OK 74447 730766656 Support Okmulgee Memorial Hospital, Inc. OK 501(c)(3) PF N/A 0 0 0 0 1 0 0 0 0 0 0 0 1 0 1 0 0 0 0 0