2014-06-16T13:08:04-07:00 2013-06-30 990 2012-07-01 850141285 Cibola General Hospital Inc CIBO 5052874446 1016 E Roosevelt Avenue Grants NM 87020 Bob Phillips 5052875300 2014-06-16 2012 2015-11-30 17:44:51Z Cibola General Hospital Bob Phillips 1016 E Roosevelt Avenue Grants NM 87020 29257556 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 9 195 0 0 0 1377 4450 23704132 23412736 102703 72306 4105786 4501165 27913998 27990657 0 0 12058373 12888586 0 0 9253102 9784488 21311475 22673074 6602523 5317583 31319772 37099471 2614235 3090993 28705537 34008478 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 15098216 4450 23412736 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 15098216 1 1 0 0 0 0 0 0 0 0 1 0 1 0 0 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 0 0 0 0 1 0 0 1 195 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 2 0 X 0 0 0 Les Gaines 2 0 X 0 0 0 Nestor Griego 2 0 X 0 0 0 Paul Milan 2 0 X 0 0 0 Karl Gutierrez MD 2 0 X 0 0 0 Laura Council 2 0 X 0 0 0 Karna Patel MD 2 0 X 0 0 0 Carlos Tapia 2 0 X 0 0 0 Bob Tenequer 2 0 X 0 0 0 Michael Makosky 40 0 X 0 0 0 James F Rimel 40 0 X 0 0 0 Ann Church MD 40 0 X 320000 0 0 David Gammon MD 40 X 239378 0 0 Angela Studer 40 0 X 227424 0 0 Patricia Rocha MD 40 0 X 214634 0 0 Merton Johnson 40 0 X 202300 0 0 Charles Onyeama MD 0 0 X 285516 0 0 Karla Vitale DO 0 0 X 214357 0 0 Pamela Akin 0 0 X 131574 0 0 1835183 0 0 10 1 1 0 EmCare Inc 1717 Main Street Ste 5200 Dallas TX 75201 Emergency Room Physician Coverage 702066 Healthcare Management Systems 3102 West End Avenue Nashville TN 37203 Computer Processing 335959 Quorum Health Resources 105 Continental Place Brentwood TN 37027 Hospital Management 244705 Life Coach Plus Inc 699 Old Church Road Corrales NM 87048 Social Work and Case Management 207726 Tricore Reference Laboratory 2811 Stanford NE Albuquerque NM 87107 Clinical Pathology Services 175256 9 0 0 0 0 0 4450 0 4450 General medical and surgical hospitals 622110 23412736 23412736 0 0 0 0 0 0 23412736 79088 79088 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 -6782 0 0 0 -6782 -6782 -6782 0 0 0 0 0 0 0 0 0 0 0 0 0 0 5768064 1266899 4501165 4501165 0 0 0 27990657 27986207 0 0 0 0 0 0 0 0 0 0 334549 0 334549 0 0 0 0 0 10270614 7923835 2346779 0 0 0 0 0 1493176 1152732 340444 0 790247 608490 181757 0 313314 0 313314 0 52343 0 52343 0 74418 0 74418 0 0 0 0 0 0 0 0 0 0 0 945303 945303 0 0 211028 0 211028 0 219516 8214 211302 0 0 0 0 0 0 0 0 0 295536 0 295536 0 135602 61186 74416 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1035218 737532 297686 0 387629 0 387629 0 Supplies 1549332 1206268 343064 0 Purchased Services 3007165 1843235 1163930 0 Repairs and Maintenance 830451 379154 451297 0 Leases and Rentals 470324 174157 296167 0 257309 58110 199199 0 22673074 15098216 7574858 0 750 7083029 4428705 3041655 0 0 8752993 5483105 0 0 0 0 0 0 241914 223920 318231 422225 17708218 6502111 9819430 11206107 0 0 0 0 7757749 9639430 0 0 0 0 31319772 37099471 2402766 2903191 0 0 187802 187802 0 0 0 0 0 0 0 0 0 0 23667 0 2614235 3090993 X 28705537 34008478 0 0 0 0 28705537 34008478 31319772 37099471 5317583 -14642 0 0 0 0 X 1 X 1 X 1 0 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 733729 0 733729 7402637 0 636406 6766231 1934451 0 1006739 927712 7206686 0 4858966 2347720 430715 0 0 430715 11206107 Certificates Of Deposit 9639430 F 9639430 0 0 X 29257556 0 0 0 1266899 1266899 27990657 0 0 0 27990657 23939973 0 0 0 1266899 1266899 22673074 0 0 0 22673074 SchD_P10_S00_L01 Schedule D, Part X, Line 1 Federal Income Taxes SchD_P10_S00_L02 Schedule D, Part X, Line 2 The footnotes contain no such references. SchD_P11_S00_L02d Schedule D, Part XI, Line 2d Cost of Goods Sold is excluded from revenue reported on Part VIII, Line 12, column A. SchD_P12_S00_L02d Schedule D, Part XII, Line 2d ost of goods sold is excluded from expenses reported on Part IX, Line 25, column A. 1 1 1 X 500 0 1 1 1 0 0 677336 0 677336 0.03 5454549 4347497 1107052 0.049 0 0 0 0 0 0 6131885 4347497 1784388 0.079 88985 0 88985 0.004 80000 0 80000 0.004 0 0 0 0.0 0 0 0 0 0 0 0 0 0 0 168985 0 168985 0.008 0 0 6300870 4347497 1953373 0.087 1 1908011 954055 4712759 4959051 -246292 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 1 SchH_P01_S00_L03c Schedule H, Part I, Line 3c The applicant for Financial Assistance must submit the following as substantiation of income: (1) Completed Financial Analysis form, which requires disclosure of the 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 tax filing status. (4) Disclosure of other income-supporting benefits received. SchH_P01_S00_L07 Schedule H, Part I, Line 7 Amount reported on Line a Column c is based on our cost to charge ratio. Line b column d uses cost to charge ratio offset by a contractual percentage leading to amount reported in column e. Line e column c and line f column c are based on cost. SchH_P03_S0A_L04 Schedule H, Part III, Section A, Line 4 We calculate Bad Debt expense based upon taking 100% of certain Accounts Receivable and assuming uncollectibilty. SchH_P03_S0B_L08 Schedule H, Part III, Section B, Line 8 Cost calculated based on cost to charge ratio. We feel that the entire shortfall should be considered Community Benefit. SchH_P03_S0C_L09b Schedule H, Part III, Section C, Line 9b We follow currrent law with respect to when we present bills, and when not, when dealing with patients known to qualify for financial assistance - essentially, we present no bills unless the terms of the assistance are not followed by the patient or responsible party. SchH_P05_S0B_L03 Schedule H, Part V, Section B, Line 3 line 3 Section B Part V 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 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. SchH_P05_S0B_L11 Schedule H, Part V, Section B, Line 11 Income and household expenses are the qualifying criteria for discounted care. SchH_P05_S0B_L16 Schedule H, Part V, Section B, Line 16 Outside collections agencies are used. The recovery rates by these agencies are typically under 10%. SchH_P05_S0B_L20 Schedule H, Part V, Section B, Line 20 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. SchH_P05_S0B_L22 Schedule H, Part V, Section B, Line 22 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. SchH_P06_S00_L01 Schedule H, Part VI, Line 1 line 3c Part I The applicant for Financial Assistance must submit the following as substantiation of income: 1. Completed Financial Analysis form, which requires disclosure of the 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. 2. Disclosure of tax filing status. 4. Disclosure of other income supporting benefits received. Part II. The Hospital continues to host meeting space for various groups such as an MS Support Group, Breastfeeding group, Diabetes Support, and Childbirth Classes. We also are a strong presence at the annual Relay for Life event typically held in June. These activities do not involve any significant expense to the Hospital, as volunteer labor is used. lines 2, 3 & 4; Part III. We used calculated Cost to Charge ratio of 43.9% to determine cost of bad Debt. 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. line 8 Part III. Our position is that the entire $246,292 shortfall should be considered Community benefit. Our mission obligates us to provide care to the individuals of Cibola County. We are the only hospital available for 63 miles, and so we naturally are providing a substantial community benefit to our Medicare patient population. The source of the information reported in Part III, Section B is our 2012 Medicare Cost Report. The revenue is from Worksheet E-1 of the Cost Report. The cost is based on our total Medicare charges, times the 43.9% overall cost to charge ratio. line 9b; Part III. 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. SchH_P06_S00_L02 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. SchH_P06_S00_L03 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. SchH_P06_S00_L04 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. SchH_P06_S00_L05 Schedule H, Part VI, Line 5 5. Promotion of Community Health 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. The upcoming needs assessment will guide Hospital management in designing health promotions that will be specific to our county, as well as being cost-effective. SchH_P06_S00_L06 Schedule H, Part VI, Line 6 We have no such affiliations. SchH_P06_S00_L07 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 0 0 0 0 0 0 0 0 0 Ann Church MD 320000 0 0 0 0 0 0 0 0 0 320000 0 0 0 David Gammon MD 239387 0 0 0 0 0 0 0 0 0 239387 0 0 0 Angela Studer 227424 0 0 0 0 0 0 0 0 0 227424 0 0 0 Patricia Rocha MD 214634 0 0 0 0 0 0 0 0 0 214634 0 0 0 Merton Johnson 202300 0 0 0 0 0 0 0 0 0 202300 0 0 0 Charles Onyeama MD 285516 0 0 0 0 0 0 0 0 0 285516 0 0 0 Karla Vitale DO 214357 0 0 0 0 0 0 0 0 0 214357 0 0 0 Pamela Akin 131574 0 0 0 0 0 0 0 0 0 131574 0 0 0 F990_P06_S0A_L03 Form 990, Part VI, Section A, Line 3 Yes, we are managed by QHR (Quorum Health Resources). F990_P06_S0A_L07a Form 990, Part VI, Section A, Line 7a The trustees hold the power to nominate for approval by Cibola County Government, new trustees when there are openings. F990_P06_S0A_L07b Form 990, Part VI, Section A, Line 7b The Trustees refer certain significant decisions, such as Trustee appointments, and major capital projects, to the County Commission for their apporval. F990_P06_S0B_L11b Form 990, Part VI, Section B, Line 11b The 990 and related schedules were provided to all members of the governing body prior to the filing of the form. F990_P06_S0B_L12c Form 990, Part VI, Section B, Line 12c All directors, officers and employees are required to disclose any potential or actual conflicts of interest each year. The form is signed and dated by each person. These are collected and monitored by the Hospital's Compliance Officer. F990_P06_S0B_L15 Form 990, Part VI, Section B, Line 15 Compensation of officers and highly-paid employees is determined by review of comparable pay for comparable duties by recruiter or consultants. F990_P06_S0C_L19 Form 990, Part VI, Section C, Line 19 The Hospital operates in a climate of transparency. In addition to the Board holding monthly public Board meetings, the CEO reports quarterly to the County Commissioners at a public meeting, to present operating results and significant activities. We are requesting abeyance of any applicable penalties for the following reasons: First, we made a timely paper filing prior to our extended due date of February 15, 2014. Secondly, we made what we feel were reasonable efforts to understand the law as it pertains to the number of returns that require an organization to EFile. We are a small hospital which does its own 990, and are aware of how to get to the IRS documentation, however, we rely on our good faith interpretation of what we read to be sure we comply with the law. Thus, until notified by a telephone call, we were unaware that we were not compliant. We thank the Service for its consideration of our request.