2013-05-14T16:51:23-05:00 2012-06-30 450250958 EIDE BAILLY LLP 800 NICOLLET MALL STE 1300 MINNEAPOLIS MN 554027033 990 2011-07-01 830300467 POWELL VALLEY HEALTH CARE INC POWE 3077542267 777 AVENUE H POWELL WY 82435 SANDRA EHMAN 3077541125 2013-05-10 1 KIM C HUNWARDSEN P00484560 6122536500 2013-05-13 2011 2016-02-24 21:20:13Z POWELL VALLEY HOSPITAL BILL PATTEN 777 AVENUE H POWELL WY 82435 44648539 0 X WWW.PVHC.ORG X 1992 WY PROVISION OF HEALTHCARE SERVICES. 10 7 598 130 4478 0 491244 193493 40812619 44332429 126138 93277 32040 29340 41462041 44648539 68095 58560 0 0 28285953 27310627 0 0 63651 14033280 16217404 42387328 43586591 -925287 1061948 17616900 18119075 6811525 6266338 10805375 11852737 X TO PROVIDE EXCELLENT HEALTH CARE, CREATE EXCEPTIONAL CUSTOMER EXPERIENCES, AND PROMOTE COMMUNITY HEALTH. 0 0 36423971 58560 44327951 POWELL VALLEY HEALTH CARE, INC. (HOSPITAL) PROVIDES QUALITY CARE REGARDLESS OF RACE, CREED, SEX, NATIONAL ORIGIN, HANDICAP, AGE, OR ABILITY TO PAY. ALTHOUGH REIMBURSEMENT FOR SERVICES RENDERED IS CRITICAL TO THE OPERATION OF THE HOSPITAL, IT IS RECOGNIZED THAT NOT ALL INDIVIDUALS POSSESS THE ABILITY TO PURCHASE THESE ESSENTIAL SERVICES. IT IS THE HOSPITAL'S MISSION TO SERVE THE SURROUNDING AREA BY PROVIDING HEALTH CARE SERVICES AND HEALTH CARE EDUCATION TO ALL COMMUNITY MEMBERS.DURING THE YEAR ENDED JUNE 30, 2012, THE HOSPITAL PROVIDED $1,594,994 OF MEDICAL SERVICES, BASED ON THE AMOUNTS OF CHARGES FOREGONE, TO INDIVIDUALS WHO WERE DETERMINED UNABLE TO PURCHASE SUCH SERVICES UNDER THE HOSPITAL'S CHARITY CARE POLICY AND GUIDELINES. IN ADDITION TO FREE CARE AND/OR SUBSIDIZED CARE, CARE IS ALSO PROVIDED AT BELOW COST RATES TO PERSONS COVERED BY GOVERNMENTAL PROGRAMS. RECOGNIZING ITS MISSION TO THE COMMUNITY, SERVICES ARE PROVIDED TO BOTH MEDICARE AND MEDICAID PATIENTS. THE UNREIMBURSED VALUE OF PROVIDING CARE TO ALL PATIENTS WAS $17,587,188 FOR THE YEAR ENDED JUNE 30, 2012.DURING THE FISCAL YEAR ENDED JUNE 30, 2012, THE HOSPITAL PROVIDED NEARLY 3,200 DAYS OF HOSPITAL SERVICES. THE NURSING HOME PROVIDED APPROXIMATELY 32,500 DAYS OF RESIDENT SERVICES, AND THE ASSISTED LIVING FACILITY PROVIDED OVER 8,600 DAYS OF RESIDENT SERVICES DURING THE YEAR.THE HOSPITAL ALSO PROVIDES COMMUNITY CARE AND SERVICES THROUGH MANY HEALTH ACTIVITIES AND PROGRAMS PROVIDED TO SUPPORT THE COMMUNITY. THESE ACTIVITIES INCLUDE: SUPPORT TO THE HEART MOUNTAIN VOLUNTEER MEDICAL CLINIC, WELLNESS PROGRAMS, COMMUNITY EDUCATION PROGRAMS, SPECIAL PROGRAMS FOR SPECIFIC PURPOSES, AND A VARIETY OF COMMUNITY SUPPORTED ACTIVITIES. 36423971 1 1 0 0 0 0 0 0 1 0 1 0 0 0 0 1 1 0 0 0 0 0 0 0 0 0 1 1 0 1 1 0 1 0 1 0 0 0 0 0 0 0 0 0 1 1 1 0 0 1 37 0 1 598 1 1 1 0 0 0 0 0 0 0 0 0 X 10 7 0 1 0 1 0 1 1 1 0 0 0 1 1 1 1 1 1 0 0 0 X RUSS LUNDVALL ACCOUNTANT 3077547722 777 AVENUE H POWELL WY 82435 X MARK WURZEL MD 40.00 X X 146807 0 2013 DEB KLEINFELDT 1.00 X X 0 0 0 LARRY PARKER 1.00 X X 0 0 0 JIM BEUKELMAN 1.00 X X 0 0 0 RENEE HUMPHRIES 1.00 X 0 0 0 MARK KITCHEN 1.00 X 0 0 0 VALERIE LENGFELDER MD 40.00 X 157718 0 21690 RJ KOST 1.00 X 0 0 0 JIM CARLSON 1.00 X 0 0 0 ELIZABETH SPOMER MD 1.00 X 273560 0 7984 PAUL CARDWELL 40.00 X 0 0 0 CALVIN CAREY 40.00 X 149526 0 5484 MIKE LIEB 40.00 X 0 0 0 BILL PATTEN 40.00 X 0 0 0 DEREK JONES 40.00 X 0 0 0 SANDRA EHMAN 40.00 X 0 0 0 JEFFREY HANSEN 40.00 X 907199 0 45491 KELLY CHRISTENSEN 40.00 X 399922 0 37293 MICHAEL TRACY 40.00 X 349130 0 32547 NATHANIEL RIEB 40.00 X 276369 0 17540 PAUL LAVEAU 40.00 X 220148 0 3658 2880379 0 173700 32 0 1 0 NORTH PLATTE PHYSICAL THERAPY PO BOX 1790 DOUGLAS WY 82633 PHYSICAL THERAPY SERVICES 1094660 WILSON GYNECOLOGY PO BOX 243 WILSON WY 83014 OB PHYSICIAN 686722 HEALTHTECH MANAGEMENT SERVICES INC 105 WESTWOOD PLACE SUITE 300 BRENTWOOD TN 37037 MANAGEMENT COMPANY 545613 NUANCE TRANSCRIPTION PO BOX 7343 PHILADELPHIA PA 19170 MEDICAL RECORDS TRANSCRIPTION SERVICES 203953 R VISIONS PO BOX 460 NEWCASTLE WY 82701 NURSING HOME CONTRACT LABOR 199476 9 31279 53428 108786 193493 NET PATIENT SERVICE RE 622110 43066461 43066461 OTHER INCOME 900099 577146 577146 PHARMACY CONTRACT REVE 446110 471691 471691 CAFETERIA 722210 125223 125223 AUXILIARY INCOME 900099 87430 87430 4478 4478 44332429 92827 92827 29340 0 29340 29340 29340 450 0 450 450 450 44648539 44327951 4478 122617 58560 58560 739012 640660 98352 19582651 17090399 2440629 51623 423455 359435 62349 1671 5103031 4193879 908576 576 1462478 1254170 203942 4366 435482 435482 118699 118699 76100 76100 4547694 3658983 888711 146083 3804 142279 779594 575326 201221 3047 1751578 1409820 341073 685 353139 201969 150056 1114 59569 59569 903451 594349 309102 465569 8832 456737 MEDICAL SUPPLIES 5790127 5790127 DUES & SUBSCRIPTIONS 173080 95691 77389 EQUIPMENT RENT 172926 145075 27851 AUXILIARY EXPENSES 64058 64058 380255 219265 160421 569 43586591 36423971 7098969 63651 3212132 2911263 8056282 9121926 62500 127686 136048 823883 898388 217691 139036 8757831 5095581 3751840 3662250 1174853 1185789 252533 1875 17616900 18119075 5398381 4556738 12387 12387 1400757 1697213 6811525 6266338 X 8454292 9887700 2351083 1965037 10805375 11852737 17616900 18119075 X 1061948 -14586 X 0 1 1 X 0 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 1 15178 87429 72844 29763 1 2107490 972708 1134782 677372 269113 408259 5188719 3853760 1334959 784250 784250 3662250 44648539 43586591 1061948 -14586 -14586 1047362 44499248 -61861 -61861 44561109 87430 87430 44648539 43451886 0 43451886 134705 134705 43586591 PART IV, LINE 1B: THE ORGANIZATION IS ACTING AS AGENT FOR THE PVHC AUXILIARY. PART IV, LINE 2B: ORGANIZATION HOLDS FUNDS IN TRUST ON BEHALF OF NURSING HOME RESIDENTS. DESCRIPTION OF UNCERTAIN TAX POSITIONS UNDER FIN 48: PART X: THE HOSPITAL AND FOUNDATION ARE ORGANIZED AND HAVE BEEN RECOGNIZED BY THE INTERNAL REVENUE SERVICE (IRS) AS EXEMPT FROM FEDERAL INCOME TAXES UNDER INTERNAL REVENUE CODE SECTION 501(C)(3). THE HOSPITAL AND FOUNDATION ARE 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 FILES AN EXEMPT ORGANIZATION BUSINESS INCOME TAX RETURN (FORM 990T) WITH THE IRS TO REPORT ITS UNRELATED BUSINESS TAXABLE INCOME. THE ORGANIZATION 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 AND FOUNDATION 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. THE HOSPITAL AND FOUNDATION ARE NO LONGER SUBJECT TO FEDERAL OR STATE TAX EXAMINATIONS BY TAX AUTHORITIES FOR YEARS BEFORE 2009. PART XI, LINE 8 - OTHER ADJUSTMENTS: CHANGES IN CURRENT YEAR AUXILIARY ACTIVITY NOT REPORTED FOR AUDIT PURPOSES -14,586. PART XII, LINE 2D - OTHER ADJUSTMENTS: PHYSICIAN BILLING EXPENSE RECORDED IN REVENUE FOR FINANCIAL STATEMENTS -2,292. INTEREST EXPENSE RECORDED IN REVENUE FOR FINANCIAL STATEMENTS -59,569. PART XII, LINE 4B - OTHER ADJUSTMENTS: AUXILIARY INCOME NOT RECORDED FOR FINANCIAL STATEMENTS 87,430. PART XIII, LINE 4B - OTHER ADJUSTMENTS: PHYSICIAN BILLING EXPENSE RECORDED IN REVENUE FOR FINANCIAL STATEMENTS 2,292. AUXILIARY EXPENSES NOT RECORDED FOR FINANCIAL STATEMENTS 72,844. INTEREST EXPENSE RECORDED IN REVENUE FOR FINANCIAL STATEMENTS 59,569. 1 1 X 1 X 1 X 1 1 0 1 1 1031000 1031000 0.02370 1031000 1031000 0.02370 29553 29553 0.00070 350111 350111 0.00800 10392202 7101251 3290951 0.07550 33000 33000 0.00080 10804866 7101251 3703615 0.08500 11835866 7101251 4734615 0.10870 10 32423 32423 0.00070 5 28148 22069 6079 0.00010 2 192 192 0.00000 17 60763 22069 38694 0.00080 0 2183040 1262202 9533796 9415770 118026 X 1 1 1 1 POWELL VALLEY HOSPITAL

777 AVENUE H POWELL WY 82435

X X X X PHYSICIAN PROVIDER BASED CLINIC POWELL VALLEY HOSPITAL 1 0 1 1 100.000000000000 1 200.000000000000 1 X X X 1 1 X X 1 0 1 X 0 0 6 POWELL VALLEY CLINIC

777 AVENUE H POWELL WY 82435

OUTPATIENT PHYSICIAN CLINIC POWELL VALLEY CARE CENTER

777 AVENUE H POWELL WY 82435

NURSING HOME HEARTLAND ASSISTED LIVING

777 AVENUE H POWELL WY 82435

ASSISTED LIVING FACILITY POWELL VALLEY HOME HEALTH

777 AVENUE H POWELL WY 82435

HOME HEALTH AGENCY POWELL VALLEY HOSPICE

777 AVENUE H POWELL WY 82435

HOSPICE EXPRESS CARE CLINIC

777 AVENUE H POWELL WY 82435

IMMEDIATE CARE CENTER PART I, LINE 3C: IN ADDITION TO PROVIDING FREE OR DISCOUNTED CARE BASED ON FEDERAL POVERTY GUIDELINES, WE REVIEW INCOME TAX RETURNS AND PAY STUBS. THIS INFORMATION HELPS US MORE ACCURATELY DETERMINE A PATIENT'S ABILITY TO PAY.PART I, LINE 6B: THE COMMUNITY BENEFIT REPORT IS POSTED ON THE ORGANIZATION'S WEBSITE. 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 COST-TO-CHARGE RATIO DERIVED FROM WORKSHEET 2. THE EXPENSES ASSOCIATED WITH COMMUNITY HEALTH IMPROVEMENT SERVICES, LINE 7E, AND HEALTH PROFESSIONS EDUCATION, LINE 7F WERE DETERMINED USING AN AVERAGE HOURLY RATE FOR STAFF TIME, SPACE USE, AND AMBULANCES. CASH AND IN-KIND CONTRIBUTIONS TO COMMUNITY GROUPS, LINE 7I, WERE REPORTED BASED ON ACTUAL EXPENSES RECORDED IN THE ORGANIZATION'S GENERAL LEDGER. THE COST FOR SUBSIDIZED HEALTH SERVICES REPORTED ON LINE 7G WAS DETERMINED USING THE MEDICARE COST REPORT. PART II: POWELL VALLEY HEALTH CARE COORDINATED AND HOSTED VARIOUS COMMUNITY COALITIONS SUCH AS SUICIDE PREVENTION COALITION, HUMAN SERVICES PROVIDERS COALITION, AND PARK COUNTY HEALTH COALITION. INVOLVEMENT IN THE COALITIONS ARE ALL HEALTH RELATED AND THEREFORE PROMOTE HEALTH IN THE COMMUNITY.POWELL VALLEY HEALTHCARE CONDUCTS AND HOSTS VARIOUS SUPPORT GROUPS FOR THE COMMUNITY INCLUDING A SUPPORT GROUP FOR LOCAL VETERANS. SUPPORT GROUPS FOCUS ON HELPING COMMUNITY MEMBERS WHO ARE DEALING WITH GRIEF AND LOSS, DIABETES AND FAMILY MEMBERS SUFFERING FROM DEMENTIA. OUR EMS SERVICE ALSO PROVIDES A GREAT DEAL OF SUPPORT TO THE COMMUNITY FROM STAND-BY EMERGENCY SERVICES FOR SPORTING EVENTS AND THE LOCAL COUNTY FAIR TO CPR & FIRST AID TRAINING FOR THE LOCAL FIRE AND POLICE DEPARTMENTS. POWELL VALLEY HEALTHCARE IS ALSO INSTRUMENTAL IN PROVIDING THE ANNUAL BLOOD SCREENING AND HEALTH AND SAFETY FAIR IN COLLABORATION WITH POWELL VALLEY COMMUNITY EDUCATION. THIS ANNUAL EVENT DRAWS PARTICIPANTS FROM THROUGHOUT THE BIG HORN BASIN AND BEYOND AND IS A GREAT SOURCE FOR COMMUNITY WELLNESS AND ACCESS TO FREE HEALTH AND SAFETY INFORMATION AND INEXPENSIVE HEALTH SCREENINGS. POWELL VALLEY HEALTHCARE ALSO PROVIDES A PATIENT ADVOCATE NURSE THROUGH THE CLINIC. THIS STAFF MEMBER FOCUSES ON PROVIDING PATIENT ASSISTANCE TO HELP PATIENTS WHO CAN'T AFFORD MEDICATIONS TO GET THE MEDICATIONS THAT THEY NEED. THIS STAFF MEMBER ALSO CONDUCTS THE WYOMING IMMUNIZATION PROGRAM FOR COMMUNITY MEMBERS WHO HAVE LOW INCOMES. PART III, LINE 4: THE ORGANIZATION'S BAD DEBT IS REPORTED AS CHARGES INCURRED DURING THE YEAR.POWELL VALLEY HEALTH CARE HAS WRITE-OFFS TO BAD DEBT EXPENSES AFTER ALL PAYMENTS ARE APPLIED INCLUDING CONTRACTUAL ALLOWANCES AND DISCOUNTS, ELIGIBLE CHARITY CARE DISCOUNTS, AND EVERY EFFORT HAS BEEN MADE WITH THE CLIENT TO COLLECT THE OUTSTANDING BALANCE. A PAYMENT ON AN ACCOUNT PREVIOUSLY WRITTEN OFF REDUCES BAD DEBT EXPENSE IN THE CURRENT YEAR.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 A PERCENTAGE OF INCOMPLETE CHARITY CARE APPLICATIONS DENIED DUE TO LACK OF INFORMATION.FOOTNOTE TO FINANCIAL STATEMENTS:THE CARRYING AMOUNT OF RECEIVABLES IS REDUCED BY A VALUATION ALLOWANCE THAT REFLECTS MANAGEMENT'S BEST ESTIMATE OF THE AMOUNTS THAT WILL NOT BE COLLECTED. MANAGEMENT REVIEWS PATIENT AND RESIDENT RECEIVABLES BY PAYOR CLASS AND APPLIES PERCENTAGES TO DETERMINE ESTIMATED AMOUNTS THAT WILL NOT BE COLLECTED FROM THIRD PARTIES UNDER CONTRACTUAL AGREEMENTS AND AMOUNTS THAT WILL NOT BE COLLECTED FROM PATIENTS OR RESIDENTS DUE TO BAD DEBTS. MANAGEMENT CONSIDERS HISTORICAL WRITE OFF AND RECOVERY INFORMATION IN DETERMINING THE ESTIMATED BAD DEBT PROVISION. PART III, LINE 8: MEDICARE ALLOWABLE COSTS OF CARE ARE BASED ON THE MEDICARE COST REPORT. THE MEDICARE COST REPORT IS COMPLETED BASED ON THE RULES AND REGULATIONS SET FORTH BY CMS. PART III, LINE 9B: POWELL VALLEY HEALTH CARE, INC. TRIES TO DETERMINE IF A PATIENT NEEDS FINANCIAL ASSISTANCE BEFORE SERVICES ARE RENDERED, EXCEPT IN EMERGENCY SITUATIONS. NO PATIENT IS DENIED ACUTE CARE IN AN EMERGENCY SITUATION. THE HEALTH CENTER WILL PURSUE ALL POSSIBLE FORMS OF THIRD-PARTY PAYMENTS SUCH AS INSURANCE, STATE MEDICAID PROGRAMS, AND COUNTY INDIGENT CARE PROGRAMS BEFORE GRANTING FINANCIAL ASSISTANCE. COLLECTION EFFORTS ARE NOT PURSUED DURING THIS TIME. COLLECTION EFFORTS ARE NOT PURSUED WHILE A COMPLETED CHARITY CARE APPLICATION IS UNDER REVIEW. DECISIONS ON CHARITY CARE APPLICATIONS ARE MADE WITHIN 30 DAYS OF THE COMPLETED APPLICATION. ONCE A DECISION IS MADE, ANY PERSONAL PORTION DUE WILL FOLLOW THE SAME COLLECTION PROCEDURES AS OTHER ACCOUNTS. IF A DETERMINATION FOR FINANCIAL ASSISTANCE IS MADE ON AN ACCOUNT OR FURTHER INSURANCE PROCESSING IS NEEDED AFTER AN ACCOUNT IS SENT TO COLLECTIONS, ALL COLLECTION EFFORTS WILL CEASE AND ANY NEGATIVE REPORTING WILL BE REVERSED. POWELL VALLEY HOSPITAL PART V, SECTION B, LINE 13G: A SUMMARY OF THE FINANCIAL ASSISTANCE POLICY IS MADE AVAILABLE TO THE COMMUNITY ON THE HOSPITAL'S FACILITY'S WEBSITE, ATTACHED TO BILLING INVOICES, POSTED IN THE HOSPITAL FACILITY'S EMERGENCY ROOMS OR WAITING ROOMS, POSTED IN THE HOSPITAL FACILITY'S ADMISSIONS OFFICES, AND PROVIDED, IN WRITING, TO PATIENTS ON ADMISSION TO THE HOSPITAL FACILITY. PART VI, LINE 2: POWELL VALLEY HEALTH CARE IS SERVED BY A PUBLICLY ELECTED DISTRICT BOARD. THE BOARD MEMBERS ACTIVELY PROVIDE INFORMATION RELATIVE TO THE HEALTH CARE NEEDS OF THE COMMUNITY. ADDITIONALLY, WE SURVEY PATIENTS, RESIDENTS, AND THEIR FAMILIES AND IN DOING SO, LOOK FOR TRENDS AND/OR SUGGESTIONS FOR IMPROVEMENTS/ EXPANSION/OR INITIATION OF SERVICES. OUR GUEST RELATIONS PROCESS ALSO ASSISTS US IN IDENTIFYING ANY UNMET COMMUNITY HEALTH NEEDS. ADMINISTRATION, PROVIDERS, AND THE BOARD TRUSTEES ALSO REVIEW COUNTY-WIDE MARKET/UTILIZATION DATA ANNUALLY. PART VI, LINE 3: POWELL VALLEY HEALTH CARE IS COMMITTED TO PROVIDING FINANCIAL ASSISTANCE TO PERSONS WHO HAVE HEALTH CARE NEEDS AND ARE UNABLE TO PAY FOR MEDICALLY NECESSARY CARE. WE STRIVE TO ENSURE THAT PEOPLE WHO ARE UNINSURED, UNDERINSURED, INELIGIBLE FOR A GOVERNMENT PROGRAM, OR OTHERWISE UNABLE TO PAY ARE STILL ABLE TO RECEIVE CARE. NOTIFICATIONS ABOUT CHARITY CARE ARE INCLUDED IN PATIENT BILLS, POSTED IN EMERGENCY ROOMS, ADMITTING AND REGISTRATION DEPARTMENTS, THE BUSINESS OFFICE, AND WAITING ROOMS. INFORMATION IS ALSO INCLUDED IN PATIENT INFORMATION PACKETS. STAFF ALSO DISCUSSES FINANCIAL ASSISTANCE UPON ADMITTING AND DISCHARGE. PART VI, LINE 4: POWELL VALLEY HEALTH CARE IS A 25 BED CRITICAL ACCESS HOSPITAL, 100 BED INTERMEDIATE CARE NURSING FACILITY, A 24 APARTMENT ASSISTED LIVING FACILITY, AND A DOCTOR'S CLINIC LOCATED IN THE NORTHWEST CORNER OF WYOMING, 75 MILES EAST OF YELLOWSTONE NATIONAL PARK, AND 98 MILES SOUTH OF BILLINGS, MT. POWELL HAS A DIVERSE COMMERCIAL, INDUSTRIAL, EDUCATIONAL, AND AGRICULTURAL/RANCHING BASED ECONOMY. IN 2011, 10.7% OF THE RESIDENTS LIVED IN POVERTY. THE MEDIAN HOUSEHOLD INCOME WAS $49,309 AND THE POPULATION WAS 6,393. THE NEAREST CITY WITH A POPULATION OF 50,000+ IS BILLINGS, MT. THE NEAREST HOSPITALS ARE NORTH BIG HORN HOSPITAL DISTRICT, A CRITICAL ACCESS HOSPITAL LOCATED APPROXIMATELY 22 MILES NORTHEAST AND WEST PARK HOSPITAL, A CRITICAL ACCESS HOSPITAL LOCATED APPROXIMATELY 25 MILES SOUTHWEST.NET REVENUE FROM MEDICARE AND MEDICAID ACCOUNT FOR APPROXIMATELY 32% AND 16% RESPECTIVELY. PART VI, LINE 5: AT POWELL VALLEY HEALTH CARE, WE UNDERSTAND THAT HEALTHCARE IS EVOLVING. THE ADVANCEMENT IN MEDICINE AND STRIDES IN TECHNOLOGY ARE PROVIDING LOCAL COMMUNITIES ACCESS TO BETTER HEALTHCARE. OUR BOARD OF TRUSTEES IS COMPRISED PRIMARILY OF LOCAL BUSINESS LEADERS WHO RESIDE IN OUR PRIMARY SERVICE AREA. TO MEET THE NEEDS OF OUR COMMUNITY, THE HOSPITAL EXTENDS PRIVILEGES TO MEDICAL STAFF THAT ARE QUALIFIED THROUGH LICENSURE. OUR EMERGENCY ROOM IS AVAILABLE 7 DAYS A WEEK AND IS AVAILABLE TO ALL REGARDLESS OF A PATIENT'S ABILITY TO PAY. EXCESS FUNDS ARE REINVESTED AND USED FOR PATIENT CARE AND FACILITY UPGRADES. 1 SCHOLARSHIPS 8 8786 TUITION REIMBURSEMENT 22 49774 PROCEDURE FOR MONITORING GRANTS IN THE U.S.: PART I, LINE 2: SCHEDULE I, PART I, LINE 2: THE ORGANIZATION PROVIDED SCHOLARSHIPS TO INDIVIDUALS AND REQUIRED THE INDIVIDUAL TO PROVIDE INFORMATION TO SUPPORT THE PURPOSE OF THE SCHOLARSHIP. TUITION AND STUDENT LOAN REIMBURSEMENT IS PROVIDED TO EMPLOYEES PURSUING OR ADVANCING THEIR CAREER IN HEALTHCARE. PAYMENT IS MADE DIRECTLY TO INSTITUTION. 0 0 0 0 0 0 0 0 0 VALERIE LENGFELDER MD 156968 0 750 0 0 0 3556 0 18134 0 179408 0 0 0 ELIZABETH SPOMER MD 123239 0 150321 0 0 0 578 0 7958 0 282096 0 0 0 CALVIN CAREY 149526 0 0 0 0 0 0 0 5484 0 155010 0 0 0 JEFFREY HANSEN 238027 0 669172 0 0 0 21641 0 24806 0 953646 0 0 0 KELLY CHRISTENSEN 140738 0 259184 0 0 0 12529 0 25088 0 437539 0 0 0 MICHAEL TRACY 159387 0 189743 0 0 0 8827 0 24367 0 382324 0 0 0 NATHANIEL RIEB 258625 0 17744 0 0 0 0 0 18496 0 294865 0 0 0 PAUL LAVEAU 220148 0 0 0 0 0 0 0 4703 0 224851 0 0 0 SUPPLEMENTAL INFORMATION PART III SCHEDULE J, PART I, LINE 3: THE ORGANIZATION DOES NOT PAY COMPENSATION TO THE CEO DIRECTLY. THE CEO IS COMPENSATED BY AN UNRELATED MANAGEMENT COMPANY. THE BOARD OF DIRECTORS APPROVES THE COMPENSATION PAID BY THE MANAGEMENT COMPANY. PAUL CARDWELL THE ORGANIZATION LEARNED THAT FROM APRIL 7 THROUGH SEPTEMBER 20, 2011, THE PRIOR CEO ENGAGED IN A FRAUDULENT SCHEME IN WHICH HE DIRECTED TWELVE PAYMENTS TOTALING $1,137,631 TO A PURPORTED PHYSICIAN RECRUITER WHOM THE CEO KNEW WOULD NEVER PROVIDE SERVICES TO THE ORGANIZATION. IT IS BELIEVED THAT THE CEO RECEIVED A "KICKBACK" FROM THE PURPORTED RECRUITER OF APPROXIMATELY 75% OF THE AMOUNT SENT BY THE ORGANIZATION TO THE RECRUITER, WHILE THE PURPORTED RECRUITER KEPT APPROXIMATELY 25%. ON MARCH 15, 2012, THE GRAND JURY FOR THE FEDERAL DISTRICT OF WYOMING INDICTED THE CEO, PAUL CARDWELL, AND THE PURPORTED RECRUITER, MICHAEL J. PLAKE ON MULTIPLE COUNTS OF MAIL FRAUD, WIRE FRAUD, CONSPIRACY TO COMMIT MAIL AND WIRE FRAUD, AND CONSPIRACY TO COMMIT MONEY LAUNDERING. THE ORGANIZATION HAS RECEIVED PAYMENTS FROM ITS INSURANCE COMPANY TOTALING $289,747 PRIOR TO THE END OF THE YEAR. ADDITIONALLY THE ORGANIZATION HAS A RECEIVABLE FROM THE INSURANCE COMPANY FOR $847,884. 0 NATHANIEL RIEB RELOCATION EXPENSES X 75000 37500 0 1 1 PAUL LAVEAU RELOCATION EXPENSES X 25000 25000 0 1 1 62500 FORM 990, PART VI, SECTION A, LINE 1 THE EXECUTIVE COMMITTEE SHALL CONSIST OF THE OFFICERS OF THE BOARD. THE EXECUTIVE COMMITTEE SHALL TAKE ACTION ON BEHALF OF THE BOARD AS MAY BE NECESSARY AND PRUDENT BETWEEN REGULAR BOARD MEETINGS. THE COMMITTEE SHALL MEET AS OFTEN AS NEEDED. FORM 990, PART VI, SECTION A, LINE 3 THE CEO IS AN EMPLOYEE OF HEALTHTECH MANAGEMENT SERVICES, INC, A HEALTHCARE MANAGEMENT COMPANY. AS THIS POSITION IS HELD OUTSIDE THE ORGANIZATION, THE CONTROL OVER MANAGEMENT DUTIES CUSTOMARILY PERFORMED BY AND UNDER DIRECT SUPERVISION OF OFFICERS, DIRECTORS OR TRUSTEES, OR KEY EMPLOYEES HAS EFFECTIVELY BEEN DELEGATED OUTSIDE OF THE ORGANIZATION. FORM 990, PART VI, SECTION A, LINE 5 THE ORGANIZATION LEARNED THAT FROM APRIL 7 THROUGH SEPTEMBER 20, 2011, THE PRIOR CEO ENGAGED IN A FRAUDULENT SCHEME IN WHICH HE DIRECTED TWELVE PAYMENTS TOTALING $1,137,631 TO A PURPORTED PHYSICIAN RECRUITER WHOM THE CEO KNEW WOULD NEVER PROVIDE SERVICES TO THE ORGANIZATION. FORM 990, PART VI, SECTION A, LINE 7A SEVEN BOARD MEMBERS FROM THE HOSPITAL DISTRICT BOARD OF TRUSTEES SHALL BE APPOINTED BY VIRTUE OF THEIR ELECTION TO THE HOSPITAL DISTRICT BOARD OF DIRECTORS. FORM 990, PART VI, SECTION A, LINE 7B A BOARD MEMBER WHO IS FROM THE HOSPITAL DISTRICT BOARD OF TRUSTEES MAY ONLY BE REMOVED BY ACTION OF THE DISTRICT BOARD OF DIRECTORS. FORM 990, PART VI, SECTION A, LINE 8B THE EXECUTIVE COMMITTEE DID NOT MEET DURING THE YEAR. HAD THEY MET DURING THE YEAR, THEIR MEETING WOULD HAVE BEEN DOCUMENTED IN THE SAME MANNER AS THE GOVERNING BODY. FORM 990, PART VI, SECTION B, LINE 11 A COPY OF FORM 990 IS PROVIDED TO THE CEO AND CFO TO REVIEW. THE CEO OR CFO WILL EITHER MAKE CHANGES OR APPROVE THE FORM 990. AFTER FORM 990 IS FINALIZED, BUT PRIOR TO BEING FILED, A COPY WILL BE PROVIDED TO THE BOARD OF DIRECTORS AT A BOARD MEETING. FORM 990, PART VI, SECTION B, LINE 12C INDIVIDUALS COVERED BY THE CONFLICT OF INTEREST POLICY INCLUDE MEMBERS OF THE BOARD OF DIRECTORS, OFFICERS AND KEY EMPLOYEES (IF APPLICABLE). THE PROCESS USED TO DETERMINE IF ANY CONFLICTS OF INTEREST EXIST, CONSISTS OF SENDING THE MEMBERS A DOCUMENT FOR THEM TO COMPLETE PRIOR TO THE BOARD OF DIRECTORS MEETING. EACH INDIVIDUAL COMPLETES THE DOCUMENT WHICH ENTAILS DISCLOSING ANY POSSIBLE CONFLICTS AND RETURNS FOR REVIEW TO THE PRESIDENT OF THE BOARD. IF A MEMBER HAS A CONFLICT THEY ARE NOT ALLOWED TO VOTE ON THE CONFLICTED ISSUES. IN ADDITION, EMPLOYEES HAVE ACCESS TO OCTOBER ODYSSEY WHICH IS A PROGRAM FOR EMPLOYEES TO DISCLOSE CONFLICTS. ADMINISTRATION TRACKS THE EMPLOYEE CONFLICTS AND BRINGS TO THE NEXT BOARD MEETING. COMPENSATION FOR THE CEO IS DETERMINED BY HEALTHTECH MANAGEMENT SERVICES, INC. WHICH IS THE MANAGEMENT COMPANY THAT EMPLOYS THE CEO. ONCE HEALTHTECH MANAGEMENT SERVICES, INC. HAS DETERMINED THE COMPENSATION, THEY PRESENT THE COMPENSATION TO THE BOARD OF DIRECTORS FOR THEM TO APPROVE. THIS PROCESS OCCURS YEARLY AND WAS LAST COMPLETED DURING FISCAL YEAR END 2012. THE COMPENSATION OF THE CFO AND PHYSICIANS IS NOT WITHIN THE BOARD OF DIRECTORS ADMINISTRATIVE POWERS; THEREFORE A SENIOR MANAGEMENT TEAM DETERMINES COMPENSATION FOR THE PHYSICIANS. THE STEPS TAKEN INCLUDE COMPARING TO OTHER HOSPITALS SIMILAR IN SIZE AND EXPERIENCE, BUDGET CONSTRAINTS, MARKET, HEALTHTECH MANAGEMENT SERVICES, INC. PROFESSIONAL RECRUITING RESOURCES AND SALARY SURVEYS. THE MANAGEMENT TEAM DISCUSSES AND COMES TO AN AGREEMENT FOR COMPENSATION AND REPORTS IT TO THE HUMAN RESOURCES DEPARTMENT. FORM 990, PART VI, SECTION C, LINE 19 THE ORGANIZATION MAKES ITS GOVERNING DOCUMENTS, CONFLICT OF INTEREST POLICY, AND FINANCIALS STATEMENTS AVAILABLE TO THE PUBLIC BY REQUEST. THE PUBLIC MAY REQUEST A COPY BY CALLING, VIA MAIL, OR WALK-IN. FORM 990, PART VII, SECTION A ALL BOARD MEMBERS, OTHER THAN EMPLOYED PHYSICIANS, SERVE ON THE DISTRICT BOARD SERVING THE DISTRICT ONE HOUR PER MONTH. CHANGES IN NET ASSETS OR FUND BALANCES: FORM 990, PART XI, LINE 5: CHANGES IN CURRENT YEAR AUXILIARY ACTIVITY NOT REPORTED FOR AUDIT PURPOSES -14,586. TOTAL TO FORM 990, PART XI, LINE 5: -14,586. FORM 990, PART VI, LINE 5: THE ORGANIZATION BECAME AWARE OF EMBEZZLEMENT BY THE CEO, AN EMPLOYEE OF HEALTHTECH MANAGEMENT SERVICES, INC. SEE SCHEDULE L, PART I FOR ADDITIONAL INFORMATION. POWELL HOSPITAL DISTRICT #1 777 AVENUE H POWELL WY 82435 830200759 RELATED - PROVISION OF HEALTH CARE SERVICES WY GOVERNMENT N/A N/A 0 POWELL MEDICAL FOUNDATION PO BOX 801 POWELL WY 82435 742275540 PROMOTE PUBLIC HEALTH AND IMPROVE FACILITIES AROUND THE CITY OF POWELL, WY WY 501(C)(3) LINE 8 N/A 0 POWELL INTEGRATED HEALTH SERVICES INC 777 AVENUE H POWELL WY 82435 830319855 PUBLIC BENEFIT CORPORATION/HEALTH CARE CONTRACT WY POWELL VALLEY HEALTH CARE INC C 485302 1.00000 0 0 1 0 0 0 0 0 0 1 1 0 0 0 1 1 0 1 POWELL INTEGRATED HEALTH SERVICES INC R