2011-11-15T16:27:37-05:00 2010-12-31 BKD LLP 111 South Tejon Suite 800 Colorado Springs CO 809039848 990 2010-01-01 860096775 Community Hospital Association Inc COMM 9286844390 520 Rose Lane Wickenburg AZ 85390 James R Smith 2011-11-15 true Rita F Worster CPA 7194714290 2010 2016-03-07 17:11:31Z Wickenburg Community Hospital Jim Tavary 520 Rose Lane Wickenburg AZ 85390 14911672 false X www.wickhosp.com X 1946 AZ To provide quality health and wellness services where the patient, family and community come first. 10 9 189 25 236931 -124241 105336 256872 13057544 14368981 33338 40359 92486 34996 13288704 14701208 0 0 0 0 6255710 7726135 0 0 0 6946155 7662168 13201865 15388303 86839 -687095 18535835 18100175 8458020 8622730 10077815 9477445 To provide quality health and wellness services where the patient, family, and community come first. false false 12883640 14269957 Provide inpatient and outpatient diagnostic and therapeutic health care services to the residents and visitors of greater Wickenburg, a rural community of approximately 23,000. 12883640 true true false false false false false false true true false false false true false true false false false false false false false false false true false false false true true false false false false false false false false false true false false false false false true true true false false true 45 0 true 189 true true true false false false false false false false false false false false false X 10 9 false false false false false false false true true false false true true true true false false false false false AZ X THE ORGANIZATION 9286844390 520 ROSE LANE Wickenburg AZ 85390 X Uwe Gross 1.0 X X 0 0 0 Jerry Diddy 1.0 X 0 0 0 Betsy Deibel 1.0 X X 0 0 0 John Marzolf 1.0 X 0 0 0 Dennis Barraco DO 1.0 X 0 0 0 Hank Brubaker 1.0 X 0 0 0 Sallie Hershkowitz 1.0 X X 0 0 0 John Snavely 1.0 X 0 0 0 Kevin Armstrong 1.0 X X 0 0 0 Robert McCoy 1.0 X 0 0 0 Paul Broser 40.0 X 140558 0 14386 Dale Decker 39.0 X 263864 0 2000 James Smith 39.0 X 157828 0 10413 Jim Tavary 39.0 X 64272 0 3899 William Firth MD 40.0 X 242688 0 29788 Dov Levine DO 40.0 X 116214 0 6024 985424 0 66510 5 false true false QUEST DIAGNOSTICS INC 3924 COLLECTION CENTER DR CHICAGO IL 606930039 LABORATORY SERVICES 164162 CPSI PO BOX 850309 MOBILE AL 366850309 SOFTWARE SUPPORT 177267 EMERGENCY PHY PROF ASSN 1470 W PORT AU PRINCE LANE PHOENIX AZ 85023 PHYSICIANS 648000 MEDICAL DIAGNOSTIC IMAGING GROUP L PO BOX 17049 PHOENIX AZ 85011 Medical Imaging 371360 ALLIANCE IMAGING INC FILE 55826 LOS ANGELES CA 900745826 MEDICAL IMAGING 146804 6 132872 124000 256872 PATIENT SERVICES 621990 6919406 6919406 WELLNESS CENTER 812900 236931 236931 MEDICARE 621990 7212644 7212644 14368981 72030 72030 0 0 72682 178793 -106111 -106111 -106111 0 31671 -31671 -31671 -31671 0 0 0 OTHER REVENUE 900099 141107 137907 3200 141107 14701208 14269957 236931 -62552 0 0 0 0 929697 406191 523506 0 5630391 4913124 717267 0 687603 600008 87595 478444 402553 75891 0 110550 110550 86495 86495 0 0 0 1939267 1770730 168537 0 812925 755759 57166 128155 128155 0 318851 310740 8111 19642 11065 8577 0 100097 66829 33268 460782 460782 0 1180551 1169980 10571 192374 192374 REPAIRS & MAINTENANCE 450884 428613 22271 0 PROVISION FOR BAD DEBTS 477981 477981 0 0 MEDICAL SUPPLIES 1137916 1137916 0 0 OTHER 245698 111622 134076 0 15388303 12883640 2504663 0 4510687 2747283 47948 51203 79000 0 1752708 1790876 868373 784338 206305 240059 282651 338693 20398763 9347869 9781521 11050894 491457 491277 515185 605552 18535835 18100175 1079558 1235394 5760000 5670000 1571327 1653237 47135 64099 8458020 8622730 X 10009700 9450560 68115 26885 10077815 9477445 18535835 18100175 X -687095 86725 X false true true X false X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 68115 1000 -3500 38730 26885 116962 -16413 32434 68115 1146828 5000 -8423 1026443 116962 0.00000 0.00000 1.00000 false true true 1199482 1199482 13339176 5818243 7520933 5161561 3314981 1846580 698544 214645 483899 11050894 0 INSURANCE FINANCING 64099 64099 14701208 15388303 -687095 86725 86725 -600370 14966726 265518 265518 14701208 14701208 15567096 178793 178793 15388303 15388303 Part XII, Line 2d Other revenue included on books, not on return Change in Interest in Net Assets of Wickenburg Community Hospital Foundation 86,725 Rental expenses netted against rental income on 990 178,793 Total 265,518 Part XIII, Line 2d Other expenses on books, not on return Rental expenses netted against rental income on 990 178,793 Endowment intended use Part V line 4 The endowment funds are to be used for educational purposes and to acquire property and equipment for the hospital. Part X Uncertain Tax Positions Management has evaluated their income tax positions under the guidance included in ASC 740. Based on their review, management has not identified any material uncertain tax positions to be recorded or disclosed in the financial statements. Part XI, Line 8 Other Changes to Net Assets Change in Interest in Net Assets of Wickenburg Community Hospital Foundation 86,725 true true true X true X true true false false 38704 38704 0.00260 1172767 1026561 146206 0.00980 1211471 1026561 184910 0.01240 21117 14925 6192 0.00040 18346 18346 0.00120 39463 14925 24538 0.00160 1250934 1041486 209448 0.01400 false 299127 149564 4590423 4590423 X true false 1 1 Wickenburg Community Hospital

520 Rose Lane Wickenburg AZ 85390

X X Wickenburg Community Hospital 1 1 Community Hospital Clinic

519 Rose Lane Wickenburg AZ 85390

Rural Health Clinic SCHEDULE H, PART I, LINE 7, COLUMN F BAD DEBT EXPENSE TOTAL BAD DEBT EXPENSE REMOVED FROM THE DENOMINATOR PRIOR TO THE PERCENTAGE CALCULATION = 477,981. SCHEDULE H, PART I, LINE 7 CALCULATION OF COMMUNITY BENEFIT EXPENSES The organization used a cost-to charge ratio for lines 7a and 7b. The cost-to-charge ratio was derived from Worksheet 2, Ratio of Patient Care Cost-to-Charges. The information for lines 7e through 7i was derived from information in the general ledger and other financial data related specifically to the various types of community benefits. SCHEDULE H, PART III, LINE 4 BAD DEBT EXPENSE The Hospital reports patient accounts receivable for services rendered at net realizable amounts from third party payers, patients, and others. The hospital provides an allowance for doubtful accounts based upon a review of the outstanding receivables, historical collection information, and existing economic conditions. As a service to the patient, the Hospital bills third-party payers directly and bills the patient when the patient's liability is determined. Patient accounts receivable are due in full when billed. Accounts are considered delinquent and subsequently written-off as bad debts based on credit evaluation and specific circumstances of the account. Bad Debt Expense (at cost) is determined by multiplying the gross bad debts by the cost to charge ratio calculated on Worksheet 2. Most of the bad debt expense results from uninsured patients receiving services primarily through the Emergency Room. The Director of Patient Financial Services estimates that approximately 50% of all bad debt would qualify for charity care, but it is difficult to get the patients to complete the Financial Assistance application. SCHEDULE H, PART III, LINE 8 MEDICARE The Medicare allowable costs is derived from the Medicare Cost Report. As a Critical Access Hospital, Medicare pays our allowable cost plus 1% including Medicare bad debts; therefore there is no Community Benefit for underpayments. SCHEDULE H, PART III, LINE 9B DEBT COLLECTION POLICY Although our collection policy does not address how patients who may qualify for charity care or financial assistance, our practice is to provide all patients at time of registration who do not demonstrate the ability to pay for the anticipated services (no insurance, no deposit, etc.) an opportunity to complete a charity application. Often the charity application is not returned and charity is not recorded. In that event the collection policy remains the same for those potential charity cases and all avenues of collection are pursued, just as if the charity application had not been offered. While we believe many or most of the charity cases end up as a bad debt, it is not for lack of effort to educate the potential charity applicant of the availability of assistance and keep the amounts out of our bad debt category. We further believe that many or most of these cases do not consider the impact on their financial credit rating and therefore do not return the application and the supporting documentation to complete the charity funding, and ignore the attempts to collect the medical billings. SCHEDULE H, PART VI NEEDS ASSESSMENT Community Hospital Association, Inc. continually accesses the community's medical needs through the relationship of our staff to community leaders and community programs that identify community needs, often medical in nature. Although the hospital is not always in a position to expand services and meet all identified needs, maintaining a core menu of services that meets the greatest community need has and continues to direct our strategic planning. SCHEDULE H, PART VI PATIENT EDUCATION OF ELIGIBILITY FOR ASSISTANCE All uninsured and under-insured patients at time of registration are provided with options available in our community for payment of the services provided. This is most often verbal with a written Charity Care Application. SCHEDULE H, PART VI COMMUNITY INFORMATION Wickenburg Community Hospital serves a primary service area population of approximately 17,000 in a rural service area clustered around Wickenburg, AZ. Wickenburg Community Hospital is the only hospital in the service area. The distribution of service area population by age is 0-17, 21%; 18-44, 25%; 45-64, 29%; 65+, 24%. The service area is home to a great number of winter residents, changing the population significantly from summer months to winter months, when the population grows by approximately 40%. SCHEDULE H, PART VI PROMOTION OF COMMUNITY HEALTH Wickenburg Community Hospital, designated as a Critical Access Hospital, serves a rural population approximately 35 miles west of the urban area of the greater Phoenix market place of Surprise, AZ. While the distance is not overly great, many of our patients come from rural areas west and north of Wickenburg, requiring them to drive much greater distances to obtain health care services if Wickenburg Community Hospital were not available to them. The most important service we provide is our Emergency Services and could not exist without our Critical Access Hospital status. Additionally, our Rural Health Clinic provides access to primary care providers in our community that probably would not exist if the hospital did not employ these providers. The availability of diagnostic services locally is very important to our community as a higher average age exists in our community, making it difficult to drive longer distances and spend a greater amount of time in obtaining diagnostic services required by their primary care providers. X false true X X true false false false false false false false false Paul Broser 140558 0 0 0 0 0 0 0 14386 0 154944 0 0 0 Dale Decker 145676 0 0 0 118188 0 0 0 2000 0 265864 0 0 0 James Smith 155351 0 0 0 2477 0 0 0 10413 0 168241 0 0 0 William Firth MD 219763 0 22925 0 0 0 15500 0 14288 0 272476 0 0 0 PART I, QUESTION 1B REIMBURSEMENT OR PROVISION OF EXPENSES Golf Club Membership: The Community Hospital Association pays golf club membership dues for James R. Smith, CFO, Dale A. Decker, CEO, and James F. Tavary, CEO. A portion of the club dues are treated as taxable income based on a ratio of personal to business use. The personal use of the membership dues are reported on their W-2's. PART I, QUESTION 4A SEVERANCE PAYMENTS DALE A. DECKER- $93,658 ARIZONA HEALTH FACILITIES AUTHORITY 860453292 040507GK5 2005-06-09 6000000 CAPITAL PROJECTS AND EQUIPMENT false false false 330000 0 6072257 491277 72257 0 120000 0 0 5390100 0 0 2007 false false true true false false false false false 0.00000 0.00000 0.00000 true false false false false false false Emergency Physicians Professional A See Part V Disclosure 648000 Emergency Physician Services false Part IV, Column B Relationship between interested person and the organization Dennis Barraco, DO serves as a director of the Hospital. He also is a key employee of Emergency Physicians Professional Association. Part VI, Question 12c Describe how conflict of interest policy is monitored & enforced All Board members are covered under the policy. Each Board Member must review the policy and sign a compliance certificate annually. The Board reviews the compliance certificates to determine if any conflicts exist. Conflicts are reviewed at the Board level. Any Board member who may have a conflict in any discussion is recused from the discussion and voting on the issue. Part VI, Question 15a Describe process for determining compensation The Board Chairman, with consultation of other members of the Board, reviews independent survey data acquired through the Arizona Hospital & Healthcare Association on executive salaries and reviews the performance of the CEO. This review is done annually by the Board in Executive Session. Part VI, Question 15b Describe process for determining compensation The CEO and HR Director use the Arizona Hospital & Healthcare Association survey data to review all positions in the facility, including key employees and other officers. Part VI, Question 19 Describe how documents are made available to the public Governing documents, conflict of interest policy, and financial statements are made available to the public by a formal request in writing. Part VI, Question 11B 990 Review Process The Form 990 is prepared by a third party and is reviewed by the CFO. A copy of the 990 is made available to the governing prior to filing with the IRS. Part XI, Line 5 Other Changes to Net Assets Change in Interest in Net Assets of Wickenburg Community Hospital Foundation 86,725 HOURS DEVOTED FOR RELATED ORGANIZATION FORM 990 PART VII NAME:Dale Decker TITLE:Chief Executive Officer HOURS:1 HOURS DEVOTED FOR RELATED ORGANIZATION FORM 990 PART VII NAME:James Smith TITLE:Chief Financial Officer HOURS:1 HOURS DEVOTED FOR RELATED ORGANIZATION FORM 990 PART VII NAME:Jim Tavary TITLE:Chief Executive Officer HOURS:1 Wickenburg Community Hospital Foundation 520 Rose Lane Wickenburg AZ 85390 742521618 Fundraising AZ 501(c)(3) Line 7 NA Wickenburg Community Hospital Auxiliary 520 Rose Lane Wickenburg AZ 85390 866056824 Support Org AZ 501(c)(3) 11 Type III NA false false true true false false false false false false false false true true false true false false Wickenburg Community Hospital Foundation Line 117872