2012-03-28T16:34:48-07:00 2011-06-30 990 2010-07-01 237429117 MADERA COMMUNITY HOSPITAL MADE 5596755555 1250 E Almond Avenue Madera CA 93637 Diane Neff 5596752823 2012-03-28 2010 2016-02-24 21:20:13Z John W Frye 6498 N Pleasant Fresno CA 93711 94475333 0 X www.maderahospital.org X 1971 CA Madera Community Hospital is dedicated to actively promoting and maintaining the health and well being of residents throughout the Central Valley of California. 17 9 1030 118 0 0 212064 377641 73955896 92462558 111592 58490 1400154 1576644 75679706 94475333 0 0 0 0 48422473 49369773 0 0 0 25945549 37127867 74368022 86497640 1311684 7977693 59547366 73683709 24651766 30810416 34895600 42873293 Madera Community Hospital provides Inpatient and Outpatient healthcare services to the citizens of Madera and its surrounding communities. 0 0 55545315 92462558 Delivery and Management of General Inpatient and Outpatient Healthcare Services were provided to the citizens of Madera and its surrounding communities. 0 0 0 55545315 1 1 0 0 0 0 0 0 0 0 1 1 0 0 1 0 1 0 0 0 0 0 0 0 0 0 1 1 0 0 1 0 0 0 0 0 1 0 1 0 0 0 0 0 1 0 0 0 0 1 140 0 1 1030 1 0 0 0 0 0 0 X 17 9 1 0 0 0 0 0 0 1 1 0 0 0 1 1 1 1 1 1 1 0 CA X X Mark J Foote 5596755505 1250 E Almond Avenue Madera CA 93637 Mohammad Arain MD 1.00 X 0 0 0 Steve Barsotti 1.00 X 0 0 0 Anna DaSilva 1.00 X 0 0 0 Margaret Diebert 1.00 X 0 0 0 William Driggs 1.00 X 0 0 0 Duane Furman 1.00 X 0 0 0 Jo Guthrie 1.00 X 0 0 0 Jim Monreal 1.00 X 0 0 0 Sohaila Mojadaddi MD 1.00 X 0 0 0 Theodore Nassar MD 1.00 X 0 0 0 Wally Nishimoto 1.00 X 0 0 0 Monte Pistoresi 1.00 X 0 0 0 Ted Pistoresi 1.00 X 0 0 0 Robert Poythress 1.00 X 0 0 0 Khalid Rauf MD 1.00 X 0 0 0 Don Warnock 1.00 X 0 0 0 Jan Zitek 1.00 X 0 0 0 John W Frye 40.00 X 276844 0 4900 Mary C Farrell 40.00 X 177166 0 3626 Mark J Foote 40.00 X 174242 0 3537 Dale Costantino 40.00 X 164146 0 3302 Karen Paolinelli 40.00 X 161073 0 3242 Donna Aldrich 40.00 X 132605 0 2652 Angelica Malagon 40.00 X 130951 0 2627 Meri G Combs 40.00 X 129204 0 2601 1346231 0 26487 36 0 1 0 New England Sheet Metal PO Box 11158 Fresno CA 93771 Mechanical Subcontractor 1066194 Valley Unique Electric 5096 N Blythe Suite 100 Fresno CA 93722 Electrical Services 846697 Madera Anesthesia Consultants PO Box 7096 Stockton CA 95267 Anesthesia Services 660000 Madera Hospitalists 1111 W Fourth Street Madera CA 93637 Hospital Physician Services 550000 CEP America 2100 Powell Street Suite 920 Emerville CA 94608 Emergency Room Physicians Services 528660 17 0 0 0 0 157541 220100 0 377641 Hospital Services-Medicare 622000 21763145 21763145 0 0 Hospital Services-Medicaid 622000 41295833 41295833 0 0 Hospital Services-CMSP 622000 2894010 2894010 0 0 Hospital Services-Other 3rd Parties 622000 24564985 24564985 0 0 Hospital Services-Other Payors 622000 1944585 1944585 0 0 0 0 0 0 92462558 58490 58490 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 Non-Patient Food Sales 622000 896297 896297 0 0 Rebates & Refunds 622000 376610 376610 0 0 Fees for Miscellaneous Services 622000 144681 144681 0 0 159056 159056 0 0 1576644 94475333 94097692 0 0 0 0 0 0 0 0 0 0 680947 0 680947 0 0 0 0 0 35907001 28297555 7609446 0 709667 549251 160416 0 8952142 6719665 2232477 0 3120016 2424294 695722 0 0 0 0 82014 0 82014 0 31000 0 31000 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 6372 0 6372 0 470013 500 469513 0 366702 0 366702 0 0 0 0 0 232146 232146 0 0 72019 53299 18720 0 0 0 0 0 50628 28256 22372 0 10521 0 10521 0 0 0 0 0 1572441 568986 1003455 0 1690361 0 1690361 0 Supplies 13194540 10856128 2338412 0 Quality Assurance Provider Fees 9101991 0 9101991 0 Other Purchased Services 4399844 1941224 2458620 0 Physicians Fees 2798195 2774195 24000 0 Equipment Rental & Maintenance 1580674 977770 602904 0 1468406 122046 1346360 0 86497640 55545315 30952325 0 3308397 8670135 10281355 11518024 0 0 11229446 15364625 0 0 0 0 870942 735455 1739071 1725634 256364 3207619 65078183 36615311 20489993 28462872 0 0 11226228 3859476 80001 80001 0 0 65569 59868 59547366 73683709 3126919 4356146 0 0 0 0 0 0 0 0 0 0 13241815 12685281 2814479 7997998 5468553 5770991 24651766 30810416 X 34895600 42873293 0 0 0 0 34895600 42873293 59547366 73683709 7977693 0 X 0 1 1 X 0 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 130000 84936 214936 0 22662618 12425049 10237569 0 1696 848 848 0 26346848 23142879 3203969 0 15852085 1046535 14805550 28462872 Tax Exempt Lease 3859476 F 3859476 0 Accrued Payroll and Related Liabilities 5770991 5770991 94475333 86497640 7977693 0 0 0 0 0 0 7977693 100341229 0 0 0 5865896 5865896 94475333 0 0 0 94475333 92363536 0 0 0 5865896 5865896 86497640 0 0 0 86497640 SchD_P12_S00_L02d Schedule D, Part XII, Line 2d Bad Debt Expense SchD_P13_S00_L02d Schedule D, Part XIII, Line 2d Bad Debt Expense 1 1 1 X 1 X 0 1 1 0 1 1 1716607 0 1716607 0.02 33362609 25668495 7694114 0.089 27860749 17669044 10191705 0.118 0 0 62939965 43337539 19602426 0.227 208366 0 208366 0.002 211071 0 211071 0.002 1291 0 1291 0 0 0 0 0 57388 0 57388 0.001 0 0 478116 0 478116 0.005 0 0 63418081 43337539 20080542 0.232 0 0 0 1772 0 1772 69438 0 69438 10821 0 10821 0 0 0 1757 0 1757 2250 0 2250 84622 0 84622 0 0 0 0 0 170660 0 170660 0 1 2212616 0 17669044 27860749 -10191705 X 1 1 6 1 Madera Community Hospital

1250 E Almond Avenue Madera CA 93637

X X X 2 Madera Community Hospital Rehabilitation Center

1200 E Almond Avenue Madera CA 93637

X Provider-based Outpatient Rehabilitation Center 3 Madera Community Hospital Family Health Services

1210 E Almond Avenue Madera CA 93637

X Provider-based Rural health Clinic 4 Madera Community Hospital Outpatient Center

1270 E Almond Avenue Madera CA 93637

X Provider-based Outpatient Lab, Radiology, and Infusion Center 5 Madera Community Hospital Home Health Agency

360 E Almond Avenue Madera CA 93637

X Provider-based Home Health Agency 6 Chowchilla Medical Center Clinic

205 Hospital Drive Chowchilla CA 93610

X Provider-based Rural Health Clinic Madera Community Hospital 1 Madera Community Hospital Rehabilitation Center 2 Madera Community Hospital Family Health Services 3 Madera Community Hospital Outpatient Center 4 Madera Community Hospital Home Health Agency 5 Chowchilla Medical Center Clinic 6 SchH_P01_S00_L07 Schedule H, Part I, Line 7 The amounts included in the table for Line 7 are based on amounts taken from the hospital's Medicare Cost Report. SchH_P02_S00_L00 Schedule H, Part II Madera Community Hospital's community building activities mainly consist of training local residents in careers in healthcare. As a result, this activity promotes health in the community by raising the awareness of local residents in our training programs about healthcare topics and these people also help promote good healthcare practices with the people they interact with. SchH_P03_S0A_L04 Schedule H, Part III, Section A, Line 4 Bad Debt Expense is recorded in the financial statements as the amount of charges written off for each account determined to be uncollectable. The amount on Line 2 is determined by the bad debt expense reported in the financial statements times a cost-to-charge ratio from this year's Medicare Cost Report. SchH_P03_S0B_L08 Schedule H, Part III, Section B, Line 8 All of the shortfall reported on Line 7 is included in the Comminuty Benefit costs. The costs were calculated in the Medicare Cost Report for this period. The revenue was derived from actual and estimated collections on Medicare accounts. SchH_P03_S0C_L09b Schedule H, Part III, Section C, Line 9b The Bad Debt Collection policy does contain procedures for contracted debt collection agencies to return accounts to the hospital if they qualify for the hospital's Charity Care program. SchH_P06_S00_L02 Schedule H, Part VI, Line 2 Madera Community Hospital Participated in a 4-county Community Needs Assessment that was published in July 2011. Various focus groups were formed from members of the local communities to discuss the health needs. SchH_P06_S00_L03 Schedule H, Part VI, Line 3 There are notices on each billing that goes to the patient regarding information about the financial assistance policy. Also, all self-pay patients are given a pamplet about the availability of the financial assistance program and their access to public benefit programs. There is information also displayed in all public registration areas. SchH_P06_S00_L04 Schedule H, Part VI, Line 4 The direct service area of the hospital contains about 100,000 residents, mostly made up of western Madera County. The population is about 55% Hispanic, 30% White/Caucasian, with a mix of other ethnicities. The population has a high number of Medicaid and Medicare patients, many low income families and is generally an agriculture-based economy. Most of the County is part of a Health Professional Shortage Area (HPSA). SchH_P06_S00_L05 Schedule H, Part VI, Line 5 Madera Community Hospital is the only local hospital in a wide geographic area. It is governed by a community-based, volunteer Board of Trustees. The Medical Staff is open to any qualified practitioner that meets credentialing criteria. The hospital is one of the largest employers in the area, tries to hire employees locally and sponsors programs for high school students and others to enter nursing and other medical fields. The hospital promotes a wide number of programs to support the better health of the residents it serves. All of the various community health and educational programs done by or sponsored by Madera Community Hospital are fully discussed in the Community Benefit Report for this year. SchH_P06_S00_L06 Schedule H, Part VI, Line 6 The hospital is a free-standing, community-based, 501(c)(3) organization and is not affiliated with any health system. SchH_P06_S00_L07 Schedule H, Part VI, Line 7 California X X 0 0 0 0 0 0 0 0 0 John W Frye 224699 0 40000 0 12145 0 4600 0 2152 0 283596 0 0 0 Mary C Farrell 159484 0 16291 0 1391 0 3626 0 4155 0 184947 0 0 0 Mark J Foote 157749 0 15777 0 716 0 3537 0 2601 0 180380 0 0 0 Dale Costantino 155820 0 7861 0 465 0 3302 0 957 0 168405 0 0 0 Karen Paolinelli 153129 0 7292 0 652 0 3242 0 1041 0 165356 0 0 0 Donna Aldrich 125414 0 6195 0 996 0 2652 0 0 0 135257 0 0 0 Angelica Malagon 130951 0 0 0 0 0 2627 0 396 0 133974 0 0 0 Meri G Combs 122726 0 6135 0 343 0 2601 0 825 0 132630 0 0 0 SchJ_P01_S00_L03 Schedule J, Part I, Line 3 The Board of Trustees reviews and approves the salary for the CEO on an annual basis. The Board uses the California Hospital Association Executive Salary Survey when determining the salary for the CEO. Mohammad Arain MD Board Member 182014 Lease of Property and Medical Services 0 F990_P06_S0A_L02 Form 990, Part VI, Section A, Line 2 Margaret Diebert is Don Warnock's Sister-in-Law. Monte Pistoresi is Ted Pistoresi's Father. F990_P06_S0B_L11a Form 990, Part VI, Section B, Line 11a The Staff Accountant completes the draft of the Form 990 and Related Schedules and submits them to the Accounting Manager for review. The Chief Financial Officer completes Schedule H and assists in answering the questions related to the governance of the organization. All financial information is tied back to the Audited Financial Statements. The Accounting Manager submits the final draft of the Form 990 and Related Schedules to the Chief Financial Officer for review. The Chief Financial Officer reviews the final draft of the Form 990 and Related Schedules before it is filed. F990_P06_S0B_L12c Form 990, Part VI, Section B, Line 12c For any conflicts of interest or complaints of such, an investigation is conducted. Depending upon the outcome of the investigation, employee re-education, training and counseling are conducted as necessary. F990_P06_S0B_L15 Form 990, Part VI, Section B, Line 15 Each officer or key employee receives a written performance evaluation on an annual basis. All rate changes are made in accordance with the hospital's wage and salary plan. The hospital uses the California Hospital Association Executive Salary Survey in setting the annual compensation rates. The CEO was reviewed by a Board of Trustees Committee in September 2010. The VP-Finance, VP-Patient Care Services, the AVP-Human Resources were all reviewed by the CEO in January 2011. F990_P06_S0C_L19 Form 990, Part VI, Section C, Line 19 The Audited Financial Statements are available in the Administration office upon request. They are also part of the information that is available to the public on the California Office of Statewide Health and Planning Department website. The Conflict of Interest policy and the Governing documents are currently not available for public inspection. Madera Community Hospital Foundation 1250 E Almond Avenue Madera CA 93637 942514197 Fundraising CA 501(c)(3) 7 N/A 0 0 1 1 0 0 0 0 0 0 0 0 0 0 1 0 0 0 0 Madera Community Hospital Foundation b 10000 Cash Madera Community Hospital Foundation c 152000 Cash Madera Community Hospital Foundation n 48465 Cash Due to the 2-month suspension of IRS Modernized E-file Operations as noted in Notice 2012-4.