2012-05-08T17:25:33-05:00 2011-06-30 EIDE BAILLY LLP 800 NICOLLET MALL STE 1300 MINNEAPOLIS MN 554027033 990 2010-07-01 830300467 POWELL VALLEY HEALTH CARE INC POWE 3077542267 777 AVENUE H POWELL WY 82435 BILL PATTEN 3077542267 2012-05-03 1 KIM HUNWARDSEN 6122536500 2012-05-03 2010 2016-02-24 21:20:13Z POWELL VALLEY HOSPITAL BILL PATTEN 777 AVENUE H POWELL WY 82435 41462041 0 X WWW.PVHC.ORG X 1992 WY PROVISION OF HEALTHCARE SERVICES 10 7 611 115 40524 -35667 326245 491244 42673206 40812619 117398 126138 85641 32040 43202490 41462041 102398 68095 0 0 27087646 28285953 0 0 61283 15012337 14033280 42202381 42387328 1000109 -925287 19218453 17616900 7503996 6811525 11714457 10805375 X TO PROVIDE EXCELLENT HEALTH CARE, CREATE EXCEPTIONAL CUSTOMER EXPERIENCES, AND PROMOTE COMMUNITY HEALTH. 0 0 34403870 68095 40772095 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, 2011, THE HOSPITAL PROVIDED $1,252,951 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 $14,545,511 FOR THE YEAR ENDED JUNE 30, 2011.DURING THE FISCAL YEAR ENDED JUNE 30, 2011, THE HOSPITAL PROVIDED OVER 3,000 DAYS OF HOSPITAL SERVICES. THE NURSING HOME PROVIDED APPROXIMATELY 33,300 DAYS OF RESIDENT SERVICES, AND THE ASSISTED LIVING FACILITY PROVIDED OVER 7,900 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. 34403870 1 1 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 0 0 0 0 0 0 0 0 0 0 1 1 1 0 0 1 32 0 1 611 1 1 1 0 0 0 0 0 0 0 0 0 X 10 7 0 1 0 0 0 1 1 1 0 1 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 144006 0 14737 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 KATHLEEN BIEKE 1.00 X X 0 0 0 BRENT FOULGER 1.00 X 0 0 0 RENEE HUMPHRIES 1.00 X 0 0 0 MARK KITCHEN 1.00 X 0 0 0 ROBERT CHANDLER MD 40.00 X 243404 0 27456 MICHAEL K BOHLMAN MD 40.00 X 246734 0 29519 LAURA BIRKY 1.00 X 0 0 0 RJ KOST 1.00 X 0 0 0 JIM CARLSON 1.00 X 0 0 0 ELIZABETH SPOMER MD 1.00 X 192864 0 18667 PAUL CARDWELL 40.00 X 0 0 0 CALVIN CAREY 40.00 X 3600 0 0 ROBIN ROLING 40.00 X 125212 0 25621 ROD BARTON 40.00 X 0 0 0 LARRY MAGERS 40.00 X 0 0 0 STEVE RAMSEY 40.00 X 0 0 0 JEFFREY HANSEN 40.00 X 809992 0 43926 KELLY CHRISTENSEN 40.00 X 329321 0 26520 MICHAEL TRACY 40.00 X 314326 0 31617 ANDREW BAKER 40.00 X 317472 0 31717 LAWRENCE DIRKSEN MD 40.00 X 555658 0 27656 3282589 0 277436 32 0 1 0 NORTH PLATTE PHYSICAL THERAPY PO BOX 1790 DOUGLAS WY 82633 PHYSICAL THERAPY SERVICES 745135 HEALTHTECH MANAGEMENT SERVICES INC 105 WESTWOOD PLACE SUITE 300 BRENTWOOD TN 37037 MANAGEMENT COMPANY 622181 HEALTHLAND DEPT CH 17945 PLANTINE IL 60055 HOSPITAL INFORMATION SYSTEMS 382150 WESTERN IMAGING SERVICES 821 N 27TH ST 249 BILLINGS MT 59101 RADIOLOGY EQUIPMENT SERVICE 174060 DMS HEALTH TECHNOLOGIES PO BOX 86 MINNEAPOLIS MN 554892208 SERVICE CONTRACT REPAIR 136732 7 22436 468808 491244 NET PATIENT SERVICE RE 622110 40292891 40292891 OTHER INCOME 900099 256371 256371 CAFETERIA 722210 111623 111623 AUXILIARY INCOME 900099 111210 111210 PHYSICIAN BILLING SERV 561499 40524 40524 40812619 126138 126138 32040 32040 32040 32040 41462041 40772095 40524 158178 68095 68095 1137986 900928 237058 19554889 16464332 3038505 52052 267951 219668 47282 1001 5868202 4716500 1151072 630 1456925 1189241 263425 4259 413164 413164 34518 34518 30425 30425 3270902 2494887 776015 141525 141525 5702461 5374888 324813 2760 1336991 1293887 43104 385252 215603 169624 25 74487 74487 920717 564814 355903 453719 8221 445498 EQUIPMENT RENT 270012 243228 26784 DUES & SUBSCRIPTIONS 205788 80643 125145 AUXILIARY EXPENSES 119315 119315 674004 375133 298315 556 42387328 34403870 7922175 61283 5003112 3212132 7499631 8056282 738214 823883 193908 217691 7990429 4238589 4045487 3751840 1157893 1174853 150000 127686 430208 252533 19218453 17616900 5266846 5398381 12387 12387 1664174 1400757 560589 0 7503996 6811525 X 11714457 8454292 2351083 11714457 10805375 19218453 17616900 X -925287 16205 X 0 1 1 X 0 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 1 31426 111210 127415 15221 1 2107490 888060 1219430 656786 235499 421287 5226153 3115030 2111123 3751840 41462041 42387328 -925287 16205 16205 -909082 41200153 -150678 -150678 41350831 111210 111210 41462041 42109235 0 42109235 278093 278093 42387328 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 UNDERGOES AN ANNUAL ANALYSIS OF ITS VARIOUS TAX POSITIONS, ASSESSING THE LIKELIHOOD OF THOSE POSITIONS BEING UPHELD UPON EXAMINATION WITH RELEVANT TAX AUTHORITIES. AS OF JUNE 30,2011 AND 2010, THE UNRECOGNIZED TAX BENEFIT ACCRUAL IS ZERO. THE HOSPITAL WILL RECOGNIZE FUTURE ACCRUED INTEREST AND PENALTIES RELATED TO UNRECOGNIZED TAX BENEFITS IN INCOME TAX EXPENSE, IF INCURRED. THE HOSPITAL IS NO LONGER SUBJECT TO FEDERAL OR STATE TAX EXAMINATIONS BY TAX AUTHORITIES FOR YEARS BEFORE 2008. PART XI, LINE 8 - OTHER ADJUSTMENTS: CHANGES IN CURRENT YEAR AUXILIARY ACTIVITY NOT REPORTED FOR AUDIT PURPOSES 16,205. PART XII, LINE 2D - OTHER ADJUSTMENTS: PHYSICIAN BILLING EXPENSE RECORDED IN REVENUE FOR FINANCIAL STATEMENTS -76,191. INTEREST EXPENSE RECORDED IN REVENUE FOR FINANCIAL STATEMENTS -74,487. PART XII, LINE 4B - OTHER ADJUSTMENTS: AUXILIARY INCOME NOT RECORDED FOR FINANCIAL STATEMENTS 111,210. PART XIII, LINE 4B - OTHER ADJUSTMENTS: PHYSICIAN BILLING EXPENSE RECORDED IN REVENUE FOR FINANCIAL STATEMENTS 76,191. AUXILIARY EXPENSES NOT RECORDED FOR FINANCIAL STATEMENTS 127,415. INTEREST EXPENSE RECORDED IN REVENUE FOR FINANCIAL STATEMENTS 74,487. 1 1 X 1 X 1 X 1 1 0 1 1 863000 863000 0.02040 5860642 7261112 -1400470 0.00000 6723642 7261112 -537470 0.02040 11 2349 28496 19145 9351 0.00020 2 172680 10000 162680 0.00380 10305678 7481835 2823843 0.06660 4 30471 30471 0.00070 17 2349 10537325 7510980 3026345 0.07130 17 2349 17260967 14772092 2488875 0.09170 192 192 0.00000 6400 6400 0.00020 1460 1460 0.00000 2 40 45956 45956 0.00110 2 40 54008 54008 0.00130 0 1206433 410187 8306412 8191118 115294 X 1 0 1 1 POWELL VALLEY HOSPITAL

777 AVENUE H POWELL WY 82435

X X X X PHYSICIAN PROVIDER BASED CLINIC NOT REQUIRED 1 6 POWELL VALLEY CLINIC

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OUTPATIENT PHYSICIAN CLINIC POWELL VALLEY CARE CENTER

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NURSING HOME HEARTLAND ASSISTED LIVING

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ASSISTED LIVING FACILITY POWELL VALLEY HOME HEALTH

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HOME HEALTH AGENCY POWELL VALLEY HOSPICE

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HOSPICE EXPRESS CARE CLINIC

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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 HEALTH CARE COORDINATED THE TEMPORARY ASSISTANCE FOR NEEDY FAMILIES PROGRAM WHICH BENEFITS SELECT CNA STUDENTS WHO NEED FINANCIAL ASSISTANCE.THE EMS OF POWELL VALLEY HEALTH CARE PROVIDED COMMUNITY TRAINING DRILLS FOR DISASTER PREPAREDNESS AND PANDEMIC PLANNING.POWELL VALLEY HEALTH CARE PROVIDED AN EMPLOYEE TO ASSIST INDIVIDUALS IN NEED OF HELP WITH THE COST OF THEIR MEDICATION.POWELL VALLEY HEALTH CARE ALSO PROVIDED EMT SUPPORT FOR HIGH SCHOOL FOOTBALLS GAMES, WRESTLING, AND THE PARK COUNTY FAIR. PART III, LINE 4: THE ORGANIZATION'S BAD DEBT EXPENSE WAS CONVERTED TO COST USING THE COST-TO-CHARGE RATIO DERIVED FROM WORKSHEET 2.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. 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 2010, 7.4% OF THE RESIDENTS LIVED IN POVERTY. THE MEDIAN HOUSEHOLD INCOME WAS $41,429 AND THE POPULATION WAS 6,314. 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 29.7% AND 17% RESPECTIVELY. PART VI, LINE 6: AT POWELL VALLEY HEALTH CARE, WE UNDERSTAND THAT HEALTHCARE IS EVOLVING. THE ADVANCE 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. PART VI, LINE 7: 1 SCHOLARSHIPS 5 8100 TUITION REIMBURSEMENT 36 59995 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 MARK WURZEL MD 144006 0 0 0 0 0 4446 0 11094 0 159546 0 0 0 ROBERT CHANDLER MD 125720 0 117684 0 0 0 7581 0 20666 0 271651 0 0 0 MICHAEL K BOHLMAN MD 152747 0 93987 0 0 0 7770 0 22943 0 277447 0 0 0 ELIZABETH SPOMER MD 122776 0 70088 0 0 0 5853 0 12814 0 211531 0 0 0 ROBIN ROLING 125212 0 0 0 0 0 3158 0 22462 0 150832 0 0 0 JEFFREY HANSEN 238651 0 571341 0 0 0 22000 0 23120 0 855112 0 0 0 KELLY CHRISTENSEN 134628 0 194693 0 0 0 10041 0 17298 0 356660 0 0 0 MICHAEL TRACY 128738 0 185588 0 0 0 9768 0 23043 0 347137 0 0 0 ANDREW BAKER 258737 0 58735 0 0 0 9862 0 23049 0 350383 0 0 0 LAWRENCE DIRKSEN MD 248441 0 307217 0 0 0 16716 0 12134 0 584508 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 AFTER THE TAX YEAR, AND BEFORE THE FILING OF THE TAX RETURN, THE ORGANIZATION LEARNED THAT FROM APRIL 7 THROUGH SEPTEMBER 20, 2011, THE CEO ENGAGED IN A FRAUDULENT SCHEME IN WHICH HE DIRECTED TWELVE PAYMENTS TOTALING $847,884 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. ATTEMPTS ARE BEING MADE TO GET RESTITUTION BUT HAVE NOT BEEN SUCCESSFUL TO DATE. 0 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 7A SEVEN BOARD MEMBERS FROM THE HOSPITAL DISTRICT BOARD OF TRUSTEES SHALL BE APPOINTED BY VIRTUE OF THEIR ELECTION TO THE HOSPITAL DISTRICT BOARD. 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. FORM 990, PART VI, SECTION A, LINE 8B THE ORGANIZATION DOES NOT HAVE ANY COMMITTEES THAT HAVE AUTHORITY TO ACT ON BEHALF OF THE GOVERNING BOARD. IF THE ORGANIZATION HAD SUCH A COMMITTEE, THEIR MEETINGS 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. FORM 990, PART VI, SECTION B, LINE 15: 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 2011. THE COMPENSATION OF 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 RESOURCE 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 16,205. TOTAL TO FORM 990, PART XI, LINE 5: 16,205. FORM 990, PART VI, LINE 9: THE FOLLOWING OFFICERS MAY BE REACHED AT THE ADDRESSES BELOW, RATHER THAN AT THE ORGANIZATION'S MAILING ADDRESS: CALVIN CAREY 431 MORGAN DR REXBURG, ID 83440 ROBIN ROLING 844 RIVERSIDE AVE POWELL, WY 82435 PAUL CARDWELL 1407 INDIAN HILLS MONTICELLO, IN 47960 FORM 990, PART VI, LINE 5: AFTER THE TAX YEAR AND BEFORE THE FILING OF THE TAX RETURN, 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 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 C 887186 457269 1.00000 0 0 1 0 0 0 0 0 0 1 1 0 0 0 1 1 1 0 POWELL VALLEY INTEGRATED HEALTH SERVICES INC Q 90572 FINANCIAL STATEMENTS