2012-09-20T15:50:40-05:00 2011-10-31 STEVEN M DEROUEN CPA P O BOX 4265 LAKE CHARLES LA 70606 990 2010-11-01 720491106 WEST LOUISIANA HEALTH SERVICES INC BEAUREGARD MEMORIAL HOSPITAL WEST 3374627106 P O BOX 730 DERIDDER LA 70634 DARRELL KINGHAM 3374627106 2012-09-17 STEVEN M DEROUEN 3375134915 X 2010 2016-02-24 21:20:13Z DARRELL KINGHAM PO BOX 730 DERIDDER LA 70634 35127073 0 X WWW.BEAUREGARD.ORG X 1946 LA TO PROVIDE MEDICAL CARE AND HEALTH PROGRAMS BY OPERATING A 60 BED FACILITY FOR HOSPITAL SERVICE DISTRICT #2 OF BEAUREGARD PARISH AND FIVE PHYSICIAN CLINICS; RECRUIT AND EMPLOY PHYSICIANS IN HPSA. 14 14 446 90 0 0 0 0 31386563 34476756 -10568 107175 23923 1522 31399918 34585453 0 0 0 0 1058249 2291832 0 0 0 31346829 33555117 32405078 35846949 -1005160 -1261496 8104055 10049179 4353335 7222975 3750720 2826204 TO PROVIDE MEDICAL CARE AND HEALTH PROGRAMS BY OPERATING A 60 BED FACILITY FOR HOSPITAL SERVICE DISTRICT #2 OF BEAUREGARD PARISH AND FIVE PHYSICIAN'S CLINICS; RECRUIT AND EMPLOY PHYSICIANS IN HPSA. 0 0 32470481 32442671 OPERATED A 60 BED FACILITY FOR HOSPITAL SERVICE DISTRICT #2 OF BEAUREGARD PARISH, PROVIDING GENERAL SHORT TERM CARE TO 2,486 INPATIENTS FOR 9,096 DAYS; 323 NEWBORNS; 1,569 SURGERIES; 16,656 E/R VISITS; AND 25,904 OUTPATIENTS; OPERATED PHYSICIAN'S CLINIC. 74.3% OF HOPITAL ADMISSIONS ARE MEDICARE AND MEDICAID. THE HOSPITAL ALSO CONDUCTS NUMEROUS COMMUNITY SEMINARS AND SERVICES TO BENEFIT THE COMMUNITY. 3376468 2034085 OPERATED BEAUREGARD PHYSICIANS GROUP WHICH CONSISTS OF FIVE PHYSICIAN'S CLINICS WHICH PROVIDE MEDICAL SERVICES TO BEAUREGARD PARISH. 35846949 1 0 0 0 0 0 0 0 1 1 0 1 0 1 1 0 1 0 0 0 0 0 0 0 0 1 1 0 0 1 0 0 0 0 0 1 0 0 0 0 0 0 1 0 0 0 0 0 1 46 0 1 446 1 0 0 0 0 0 0 0 0 X 14 14 0 0 0 0 0 0 0 1 1 0 0 1 1 1 1 1 1 1 1 0 X DARRELL L KINGHAM CPA VP OF FINA 3374627106 600 SOUTH PINE STREET DERIDDER LA 70634 JULIE OZSOY CPA 2.00 X 0 0 0 CARL SLOVER 2.00 X 0 0 0 TERRI THEAUX 2.00 X X 0 0 0 JARED MORRIS 2.00 X 0 0 0 NATHA GANTT 2.00 X 0 0 0 CHUEN KWOK MD 2.00 X 0 0 0 TOM DOBBINS MD 2.00 X 0 0 0 CHRISTOPHER GRANGER MD 2.00 X 0 0 0 TOM RHODES 2.00 X X 0 0 0 GERALD JOHNSON 2.00 X 0 0 0 MARARETTA MAYES 2.00 X 0 0 0 ED O'NEAL 2.00 X X 0 0 0 THOMAS SHIRLEY DDS 2.00 X 0 0 0 JIM MORRIS 2.00 X 0 0 0 THEODORE BADGER JR 45.00 X 246829 0 11000 DARRELL L KINGHAM 52.00 X 187927 0 9222 DARREN CAILLOUET 40.00 X 203450 0 10172 JOSEPH CARAWAY 40.00 X 131591 0 0 PATSY JEFFERS 40.00 X 174962 0 0 ALEX MANITZAS RPH 40.00 X 137949 0 6943 JANET LEWIS 40.00 X 650000 0 0 1732708 0 37337 7 0 1 0 JENNIFER MCCANN MD 206 W 5TH STREET DERIDDER LA 70634 PHYSICIAN SERVICES 140150 DAVENPORT FAMILY MEDICAL CLINIC 101 W 6TH STREET DERIDDER LA 70634 PHYSICIAN SERVICES 131848 GUILLERMO FAMILY MEDICAL CLINIC 301 S WASHINGTON DERIDDER LA 70634 PHYSICIAN SERVICES 115020 3 REIMBURSEMENTS FROM HO 900099 32442671 32442671 PATIENT SERVICES 621400 2034085 2034085 34476756 118683 118683 530112 541620 -11508 -11508 -11508 OTHER INCOME 900099 1522 1522 1522 34585453 34585453 0 0 454978 454978 1836854 1836854 4500 4500 2141 2141 1682 1682 28875 28875 461 461 12687 12687 62513 62513 183999 183999 OTHER PROFESSIONAL EXPE 16097501 16097501 FISCAL & ADMINISTRATIVE 8218688 8218688 NURSING EXPENSES 4783410 4783410 GENERAL SERVICE EXPENSE 3343072 3343072 SUPPLIES 183338 183338 632250 632250 35846949 35846949 0 0 857339 2408030 170456 374736 568813 395792 13462 7234 94430 107282 420830 94856 42534 325974 5285067 5466007 873805 670498 198149 293626 8104055 10049179 1259450 1945677 3093885 5277298 4353335 7222975 X 0 0 0 0 3750720 2826204 3750720 2826204 8104055 10049179 X -1261496 336980 X X 0 1 1 X 0 X 7472 41 7513 7416 56 7472 7342 74 7416 0 0 420830 94856 325974 325974 CERTIFICATES OF DEPOSIT 670498 C 670498 DUE TO HSD #2 3957777 ACCRUED PAYROLL 487378 ACCRUED VACATION PAYABLE 661461 ACCRUED DISABILITY BENEFITS 170682 5277298 FOOTNOTE FOR UNCERTAIN TAX POSITION UNDER FIN 48 (PART X) WEST LOUISIANA HEALTH SERVICES, INC. IS A NONPROFIT CORPORATION AS DESCRIBED IN CODE SECTION 501(C)(3) OF THE INTERNAL REVENUE SERVICE AND IS EXEMPT FROM FEDERAL AND STATE INCOME TAXES ON RELATED INCOME PURSUANT TO SECTION 501(A) OF THE CODE. 1 1 1 X 1 X 1 0 0 4318895 3439233 879662 0.02450 6734116 5806790 927326 0.02590 11053011 9246023 1806988 0.05040 74386 74386 0.00210 357917 357917 0.01000 3870174 1966706 1903468 0.05310 4302477 1966706 2335771 0.06520 15355488 11212729 4142759 0.11560 114292 114292 0.00320 114292 114292 0.00320 1 1088037 435215 10271408 11696355 -1424947 X 1 1 1 1 HOSPITAL SERVICE DISTRICT #2

600 S PINE STREET DERIDDER LA 70634

X X X BEAUREGARD MEMORIAL HOSPITAL 1 0 0 0 0 0 0 0 0 0 0 0 1 BEAUREGARD PHYSICIANS GROUP

PO BOX 1540 DERIDDER LA 70634

FIVE PHYSICIAN CLINICS PART I, LINE 7: PART I, LINE 7 - COSTS ON 7A AND 7B WERE TAKEN FROM THE SCHEDULE OF UNCOMPENSATED CARE COST FOR SMALL RURAL HOSPITALS, A REPORT USED BY THE LA. DEPT. OF HEALTH AND HOSPITALS TO DETERMINE UNCOMPENSATED MEDICAID AND INDIGENT COSTS AND REIMBURSEMENTS. A COST TO CHARGH RATIO WAS ALSO DERIVED FROM WORKSHEET 2, RATIO OF PATIENT CARE COST TO CHARGES AND USED WHEN NEEDED. COSTS ON LINE 7E, 7F AND 7G ARE ACTUAL COSTS PER RECORDS. PART I, LINE 7G: PART I, LINE 7 G - IN ACCORDANCE WITH IDENTIFIED COMMUNITY NEEDS THE HOSPITAL HAD RECRUITED PHYSICIANS TO SERVE IN THE COMMUNITY, WHICH IS IN A PROFESSIONAL SHORTAGE AREA (HPSA). SUBSIDIZED HEALTH SERVICES INCLUDE SUBSIDIES OF $1,811,684 TO NINE CLINICS WHICH PROVIDE ORTHOPEDIC, SURGICAL, PEDIATRIC, INTERNAL MEDICINE, OB/GYN, CARDIOLOGY AND FAMILY PRACTICE SERVICES TO THE COMMUNITY. THE HOSPITAL SUBSIDIZED AN OB/GYN CLINIC $20,429 FOR MALPRACTICE INSURANCE AS THE MAJORITY OF PATIENTS SERVED WERE MEDICAID. PART I, L7 COL(F): PART 3 LINE 4 BAD DEBT EXPENSE - LINE 2, BAD DEBT COST WAS CALCULATED BY MULTIPLYING BAD DEBT CHARGES PER ACCOUNTING RECORDS BY THE WORKSHEET 2 COST TO CHARGE RATIO. LINE 3 IS 40% OF THE BAD DEBT COSTS, BASED ON HISTORICAL INFORMATION. SELF PAY PATIENTS PAY 1.5% OF CHARGES ON AVERAGE, WHICH CHARGES TOTALED $13.9 MILLION. THE COMMUNITY BENEFITS FROM THE HOSPITAL'S POLICY THAT ALL PATIENTS WHO ARE UNINSURED ARE ACCEPTED BY THE HOSPITAL. PART II: IN ACCORDANCE WITH IDENTIFIED COMMUNITY NEEDS THE HOSPITAL TRAINED AND RECRUITED PHYSICIANS TO SERVE IN THE COMMUNITY, WHICH IS IN A PROFESSIONAL SHORTAGE AREA (HPSA). PART III, LINE 4: THE ACCOUNTING POLICY OF THE HOSPITAL REGARDING BAD DEBTS STATES THAT THE ALLOWANCE METHOD IN ACCOUNTING FOR BAD DEBTS IS USED. THE ALLOWANCE ACCOUNT CONSISTS OF AN ESTIMATE OF UNCOLLECTABLE ACCOUNTS AND A GENERAL RESERVE. MANAGEMENT'S EVALUATION OF THE ADEQUACY OF THE ALLOWNACE IS BASED ON A CONTINUING REVIEW OF ALL ACCOUNTS AND INCLUDES A CONSIDERATION OF PAST PATIENT HISTORY, AND ADVERSE SITUATIONS THAT MIGHT AFFECT THE PATIENT'S ABILITY TO PAY, AND CURRENT ECONOMIC CONDITIONS. PART III, LINE 8: PART III, LINE 8 - THE COSTING METHODOLOGY FOR MEDICARE WAS DERIVED FROM THE MEDICARE FORM CMS-2552 FILED FOR FYE 10/31/11. THE HOSPITAL CONTINUES TO TREAT MEDICARE PATIENTS, EVEN AS MEDICARE REIMBURSEMENT IS DECLINING. THE HOSPITAL VIEWS THE $1,424,947 MEDICARE SHORTFALL AS A COMMUNITY BENEFIT, AS ALL HOSPITAL PATIENTS ARE ACCEPTED REGARDLESS OF REIMBURSENT. PART III, LINE 9B: PART III, LINE 9B - REGARDING COLLECTION PRACTICES TO BE FOLLOWED FOR PATIENTS WHO ARE KNOWN TO QUALIFY FOR FINANCIAL ASSISTANCE, THE HOSPITAL TRIES TO CONDUCT A PRE ADMISSION INTERVIEW WITH THE PATIENT OR GUARANTOR PRIOR TO ADMISSION WHEN POSSIBLE. POTENTIAL CHARITY CARE PATIENTS ARE OFFERED THE OPPORTUNITY TO APPLY FOR CHARITY CARE AT THE TIME OF ADMISSION. OUTPATIENTS AND ER PATIENTS ARE SENT A NOTIFICATION ABOUT CHARITY CARE THROUGH THE MAIL. PATIENT WITH NO INSURANCE RECEIVE A LETTER WITHIN 30 DAYS OF SERVICE, STATING THAT THE HOSPITAL HAS GIVEN THEM A 52% DISCOUNT AND THAT THEY ARE RESPONSIBLE FOR THE BALANCE OF THE BILL. THE LETTER ALSO STATES THAT THE HOSPITAL HAS A CHARITY CARE/FINANCIAL ASSISTANCE PROGRAM AND GIVES THE CONTACT PERSON'S NAME AND PHONE NUMBER TO OBTAIN AN APPLICATION. THE LETTER ALSO GIVES THE NAME AND NUMBER TO APPLY FOR MEDICAID AT THE HOSPITAL. THE LETTER STATES THE ACCOUNT BALANCE THAT IS DUE AND THAT PAYMENTS CAN BE SPREAD OVER 12 TO 18 MONTHS. IT ALSO STATES THAT FAILURE TO PAY THE BILL OR SET UP FINANCIAL ARRANGEMENTS WILL RESULT IN ADDITIONAL COLLECTION EFFORTS. A SECOND LETTER IN THE FOLLOWING MONTH IS SENT THAT STATES THEIR ACCOUNT IS DELINQUENT, IS DUE AND FAILURE TO RESPOND WILL RESULT IN FURTHER COLLECTION ACTION. IF NO RESPONSE, A THIRD LETTER IS SENT STATING THEIR ACCOUNT IS DELIQUENT AND IS BEING REVIEWED TO GO TO AN OUTSIDE COLLECTION AGENCY. A FINAL NOTICE IS SENT STATING THIS A FINAL NOTICE, FAILURE TO PAY WILL RESULT IN THE ACCOUNT BEING PLACED WITH A COLLECTION AGENCY, AND THAT THEY MUST HAVE AN AUTHORIZED FINANCIAL AGREEMENT WITH THE HOSPITAL TO STOP THE ACCOUNT FROM BEING PLACED WITH AN OUTSIDE COLLECTION AGENCY. THE ORGANIZATION DID NOT FILE A COMMUNITY BENEFIT REPORT. PART VI, LINE 2: THE HOSPIAL ASSESSES THE HEALTH CARE NEEDS OF THE COMMUNITY THROUGH VARIOUS STUDIES, DISCUSSIONS WITH COMMUNITY LEADERS, AND PATIENT DEMAND. PART VI, LINE 3: SEE "COLLECTION PRACTICES" EXPLANATION (PART III, LINE 9B). PART VI, LINE 4: THE HOSPITAL PRIMARILY SERVICES BEAUREGARD PARISH IN LOUISIANA WHICH CONSISTS OF A RURAL AND SUBURBAN POPULATION. PART VI, LINE 6: THE ORGANIZATION OPERATED A 60 BED FACILITY FOR HOSPITAL SERVICE DISTRICT 2 OF BEAUREGARD PARISH, PROVIDING GENERAL SHORT TERM CARE TO 2,486 INPATIENTS FOR 9,096 DAYS; 323 NEWBORNS; 1,569 SURGERIES, 16,656 ER VISITS; AND 25,904 OUTPATIENTS. 74.3% OF HOSPITAL ADMISSIONS ARE MEDICAID AND MEDICARE. THE HOSPITAL ALSO CONDUCTS NUMEROUS COMMUNITY SEMINARS AND SERVICES TO BENEFIT THE COMMUNITY. PART VI, LINE 7: THE ORGANIZATION IS NOT PART OF AN AFFILIATED HEALTH CARE SYSTEM. X 1 1 X X X 0 0 0 0 0 0 0 0 0 THEODORE BADGER JR 246829 0 0 0 0 0 11000 0 0 0 257829 0 0 0 DARRELL L KINGHAM 187927 0 0 0 0 0 9222 0 0 0 197149 0 0 0 DARREN CAILLOUET 203450 0 0 0 0 0 10172 0 0 0 213622 0 0 0 PATSY JEFFERS 174962 0 0 0 0 0 0 0 0 0 174962 0 0 0 JANET LEWIS 650000 0 0 0 0 0 0 0 0 0 650000 0 0 0 PART I, LINE 1B SCHEDULE J, PART 1, LINE 1A - REASONABLE EXPENSES SUBMITTED FOR A TRAVELING SPOUSE (EXCEPT FOR AIRFARE) ACCOMPANYING A TRUSTEE ON APPROVED TRAVEL IS REIMBURSED. DR STEVEN FARQUAR WEST LA HEALTH SERVICES BOARD MEMBER 41868 BUILDING RENTAL PAYMENTS 0 DR CHUEN KWOK WEST LA HEALTH SERVICES BOARD MEMBER 10875 MEDICAL SERVICES 0 FORM 990, PART VI, SECTION B, LINE 11 PART VI SECTION A, LINE 10: AVAILABILITY OF FORM 990 - THE FORM 990 IS AVAILABLE TO THE BOARD OF TRUSTEES BY ITS POSTING ON THE HOSPITAL'S INTRANET PORTAL FOR SUBSEQUENT BOARD MEETING DISCUSSION. FORM 990, PART VI, SECTION B, LINE 12C PART VI SECTION B, LINE 12C: CONFLICT OF INTEREST POLICY - EVERY JANUARY, A CONFLICT OF INTEREST QUESTIONAIRE IS COMPLETED BY EACH TRUSTEE. THESE DOCUMENTS ARE REVIEWED AND RETAINED IN THE BOARD OF TRUSTEE'S FILES. FORM 990, PART VI, SECTION B, LINE 15 PART VI SECTION B, LINE 15A: CEO COMPENSATION PROCESS - THE BOARD OF TRUSTEES' EXECUTIVE COMMITTEE CONDUCTS AN ANNUAL PERFORMANCE EVALUATION FOLLOWING THE END OF EACH FISCAL YEAR. COMPARABLE COMPENSATION DATA FOR CEOS AT OTHER SIMILIARLY SITUATED ORGANIZATIONS IS USED. RESOURCES INCLUDE THE VHA GULF STATES CEO COMPENSATION SURVEY, THE HAY GROUP HOSPITAL COMPENSATION REPORT, THE JACKSON SURVEY FOR QUALITY GOALS, HEALTH STREAM EMPLOYEE SATISFACTION, EMERGENCY DEPARTMENT, INPATIENT, SAME DAY SURGERY, LAB AND RADIOLOGY SATIFACTION SURVEYS, AND OTHER VARIOUS REPORTS. THE CEO'S COMPENSATION IS CRITERIA BASED. A BONUS IS DEPENDENT ON ACHIEVING GOALS IN COMMUNITY HEALTH, QUALITY AND FINANCIAL AREAS. A ANALYSIS OF SALARY HISTORY, EMPLOYEE RETENTION AND SELF EVALUATION IS ALSO CONSIDERED. PART VI SECTION B, LINE 15B: OTHER KEY EMPLOYEE COMPENSATION PROCESS - ANNUAL EMPLOYEE EVALUATIONS ARE CONDUCTED IN NOVEMBER OF EACH YEAR. THESE EVALUATIONS CONSIDER THE EMPLOYEE'S ACHIEVEMENT OF GOALS, SALARY AND EXPENSE BUDGETS, COMPLIANCE WITH QUALITY CONTROLS AND JOINT COMMISSION, PERFORMANCE AND COMPETENCY, AND OTHER CRITERIA BASED OBJECTIVES IN DETERMINING REMUNERATION. IN ADDITION, THE CEO ALSO CONSIDERS THE FOLLOWING SALARY SURVEYS: THE HAY GROUP, VHA DEPARTMENT HEAD SURVEY, LOUISIANA HOSPITAL SALARY AND BENEFITS SURVEY, GREATER NEW ORLEANS SOCIETY FOR HEALTHCARE HUMAN RESOURCES ADMINISTRATION EXECUTIVE DIRECTOR AND MANAGEMENT SURVEY. FORM 990, PART VI, SECTION C, LINE 19 PART VI SECTION C, LINE 19: AVAILABILITY OF THE ORGANIZATION'S DOCUMENTS AND POLICIES - INFORMATION IS AVAILABLE UPON REQUEST. CHANGES IN NET ASSETS OR FUND BALANCES: FORM 990, PART XI, LINE 5: NET UNREALIZED GAINS ON INVESTMENTS: 192284. PRIOR PERIOD ADJUSTMENTS: 144696. TOTAL TO FORM 990, PART XI, LINE 5: 336980. CHANGE IN PROCESS FROM PRIOR YEAR FORM 990, PART XII, LINE 2C THERE WAS NO CHANGE IN THE ORGANIZATION'S OVERSIGHT OR SELECTION PROCESS DURING THE YEAR. BEAUREGARD PHYSICIAN GROUP LLC P O BOX 1540 DERIDDER LA 70634 270602265 PHYSICIAN SERVICES LA 2035701 2097433 N/A