2025-01-24T15:45:39-06:00 2024-03-31 201941244 HORNE LLP 661 SUNNYBROOK ROAD STE 100 RIDGELAND MS 39157 990 2023-04-01 383807713 CHICOT MEMORIAL MEDICAL CENTER CHIC 8702659229 2729 HWYS 65 82 SOUTH LAKE VILLAGE AR 71653 JOHN HEARD CEO 8702659229 2025-01-22 1 1 AMIE WHITTINGTON DEAN CPA P01082167 6013261000 2025-01-22 2023 2025-03-06 01:10:19Z JOHN HEARD 2729 HWYS 65 82 SOUTH LAKE VILLAGE AR 71653 22053737 0 X WWW.CHICOTMEMORIAL.COM X 2010 AR TO PROVIDE CONVENIENT, QUALITY HEALTHCARE TO EVERYONE IN A CARING, EFFICIENT AND FINANCIALLY RESPONSIBLE MANNER THAT WILL ENHANCE THE QUALITY OF LIFE IN OUR COMMUNITY, TO PROMOTE COMMUNITY WELLNESS; AND, TO DO SO WITH COMPASSION, DIGNITY, AND RESPECT FOR THOSE WE SERVE. 7 7 197 20 0 0 1429811 801230 19811936 20695484 221830 261120 272437 295903 21736014 22053737 0 200 0 0 9338377 9917495 0 0 0 10818235 12105045 20156612 22022740 1579402 30997 19443980 19858169 4719878 5103070 14724102 14755099 TO PROVIDE CONVENIENT, QUALITY HEALTHCARE TO EVERYONE IN A CARING, EFFICIENT AND FINANCIALLY RESPONSIBLE MANNER THAT WILL ENHANCE THE QUALITY OF LIFE IN OUR COMMUNITY, TO PROMOTE COMMUNITY WELLNESS; AND, TO DO SO WITH COMPASSION, DIGNITY, AND RESPECT FOR THOSE WE SERVE. 0 0 16515564 200 19266179 CHICOT MEMORIAL MEDICAL CENTER IS A PRIVATE, NOT-FOR-PROFIT CORPORATION OPERATING A 25-BED CRITICAL ACCESS HOSPITAL IN LAKE VILLAGE, CHICOT COUNTY, ARKANSAS. IN ADDITION TO THE 25 ACUTE CARE BEDS, CMMC ALSO OPERATES A PROVIDER BASED HEALTH CLINIC WITH ONE PHYSICIAN IN THE CLINIC THAT SPECIALIZES IN GENERAL SURGERY. ADDITIONALLY, CMMC OPERATES A HOME HEALTH AGENCY, A PROVIDER-BASED DENTAL CLINIC AND A COMMUNITY BASED FITNESS CENTER, ALL ON A NOT-FOR-PROFIT BASIS. 16515564 1 1 0 0 0 0 0 0 0 0 1 0 0 0 1 1 1 0 0 0 0 0 0 0 0 0 1 1 0 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 45 0 1 197 1 0 0 0 0 0 0 0 0 0 0 X 7 7 0 0 0 0 0 0 0 1 1 0 0 1 1 1 1 1 1 1 1 0 X TIFFANY ADAMS 8702659219 2729 HWYS 65 82 SOUTH LAKE VILLAGE AR 71653 SAM ANGEL CHAIRMAN 1.00 X 0 0 0 TODD POTTER MEMBER - PART YEAR 1.00 X 0 0 0 LINDA THOMAS MEMBER 1.00 X 0 0 0 DR JP BURGE MEMBER 1.00 X 0 0 0 BILL ELLIOT JR MEMBER 1.00 X 0 0 0 DINO SABBATINI MEMBER 1.00 X 0 0 0 SHIRLEY CATALANI MEMBER 1.00 X 0 0 0 CARRIE H PIERONI MEMBER - PART YEAR 1.00 X 0 0 0 LAJUAN M SCALES CNO/RN 50.00 X 125875 0 13344 JOHN HEARD CEO 50.00 X 160677 0 0 VICKI ALLEN CFO 50.00 X 90009 0 12620 MICHAEL BRADLEY MAYFIELD CMO/SURGEON 50.00 X 386057 0 24459 HALEY BURSON DENTIST 50.00 X 189873 0 19326 CHERYL BUSH PHARMACIST 50.00 X 119037 0 8882 SONYA SWAIN RN 50.00 X 121472 0 8194 KRISTA HALL PT/THERAPY DIRECTOR 50.00 X 109158 0 16469 HILDA LAUHON COMPLIANCE/EMPLOYEE HEALTH RN 50.00 X 106817 0 0 1408975 0 103294 9 0 1 0 EMERGENCY STAFFING SOLUTIONS 17304 PRESTON ROAD SUITE 1400 DALLAS TX 75252 ER PHYSICIANS 912000 TRILOGY REVENUE CYCLE SOLUTIONS 911 FLYNT DR FLOWOOD MS 39232 BILLING & CODING SERVICES 454760 AMERICAN CLEANING SYSTEMS PO BOX 772 CROSSETT AR 71635 HOUSEKEEPING 301475 GATES ANESTHESIA LLC 214 BRADLEY 20 WARREN AR 71671 CONTRACT ANESTHESIA 295369 QUALIVIS LLC PO BOX 123847 DALLAS TX 75312 STAFFING SERVICES 154628 8 688368 112862 801230 PATIENT SERVICE REVENUE 621990 19266179 19266179 SALES TAX REVENUE 621990 1242071 1242071 COUNTY TAX PROCEEDS 621990 187234 187234 20695484 260650 260650 85210 0 85210 85210 85210 470 0 470 470 470 DIETARY MEALS 722514 198839 198839 OTHER 900099 10904 10904 VENDING MACHINE 722515 950 950 210693 22053737 19266179 0 1986328 X 200 200 762618 762618 6756470 5880946 875524 109092 85092 24000 1706989 1211932 495057 582326 454214 128112 4814998 3073181 1741817 33016 33016 711889 51499 660390 104761 91371 13390 152716 152716 762520 762520 312491 312491 SUPPLIES 3627098 3526455 100643 BAD DEBT EXPENSE 1298926 1298926 DUES AND SUBSCRIPTIONS 123042 123042 MISC 102717 24899 77818 60871 54329 6542 22022740 16515564 5507176 0 6140703 4083703 595329 4438069 3277910 3791663 185167 204183 166293 213964 28875092 22513434 6582413 6361658 2496165 764929 19443980 19858169 1368164 2506394 290055 2191676 3061659 405000 4719878 5103070 X 14724102 14755099 14724102 14755099 19443980 19858169 30997 0 X X 0 1 X 1 0 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 1 4050 4050 0 PART II-B, LINE 1: CHICOT MEMORIAL MEDICAL CENTER PAYS DUES TO ARKANSAS HOSPITAL ASSOCIATION AND AMERICAN HOSPITAL ASSOCIATION, TOTALING $20,251, OF WHICH 20% ($4,050.20) IS ATTRIBUTABLE TO LOBBYING. 115000 115000 8854320 7557416 1296904 862871 665717 197154 15466719 13076276 2390443 3576182 1214025 2362157 6361658 2017 BONDS PAYABLE TAXABLE 405000 405000 X 20754341 0 20754341 1299396 1299396 22053737 20723344 0 20723344 1299396 1299396 22022740 PART X, LINE 2: THE MEDICAL CENTER IS ORGANIZED AS AN ARKANSAS NONPROFIT CORPORATION AND HAS BEEN RECOGNIZED AS EXEMPT FROM FEDERAL INCOME TAXES UNDER INTERNAL REVENUE CODE SECTION 501(C)(3). AS SUCH, THE MEDICAL CENTER IS REQUIRED TO FILE A RETURN OF ORGANIZATION EXEMPT FROM INCOME TAX, FORM 990, WITH THE INTERNAL REVENUE SERVICE ("IRS"). IN ADDITION, THE MEDICAL CENTER IS SUBJECT TO FEDERAL INCOME TAX ON NET INCOME THAT IS DERIVED FROM BUSINESS ACTIVITIES THAT ARE UNRELATED TO ITS EXEMPT PURPOSE. MANAGEMENT HAS DETERMINED THAT THE MEDICAL CENTER IS NOT SUBJECT TO UNRELATED BUSINESS INCOME TAX AND HAS NOT FILED AN EXEMPT ORGANIZATION BUSINESS INCOME TAX RETURN, FORM 990-T, WITH THE IRS. PART XI, LINE 4B - OTHER ADJUSTMENTS: BAD DEBTS 1,298,926. REVENUE CLASSIFIED AS EXPENSE 470. PART XII, LINE 4B - OTHER ADJUSTMENTS: BAD DEBT 1,298,926. REVENUE CLASSIFIED AS EXPENSE 470. 1 1 1 X 1 X 1 1 0 0 105606 105606 0.00510 362368 1436329 0 0.00000 467974 1436329 105606 0.00510 48665 48665 0.00230 58078 7101 50977 0.00250 106743 7101 99642 0.00480 574717 1443430 205248 0.00990 1 1298926 649463 5988385 5994355 -5970 X 1 1 1 1 CHICOT MEMORIAL MEDICAL CENTER 2729 HIGHWAY 65 82 SOUTH LAKE VILLAGE AR 71653 X X X X HOME HEALTH AGENCY CHICOT MEMORIAL MEDICAL CENTER 0 0 1 X X X X X X X X X 21 1 0 0 1 X HTTPS://WWW.CHICOTMEMORIAL.COM/WP-CONTENT/UPLOADS/2023/02/2022-CMMC-CHNA-AS X 1 21 1 HTTPS://WWW.CHICOTMEMORIAL.COM/WP-CONTENT/UPLOADS/2023/02/2022-CMMC-CHNA-AS 0 1 X 200.000000000000 200.000000000000 1 1 X X X 1 X HTTP://WWW.CHICOTMEMORIAL.COM/FINANCIALASSISTANCEPOLICY.ASPX X HTTP://WWW.CHICOTMEMORIAL.COM/FINANCIALASSISTANCEPOLICY.ASPX X HTTP://WWW.CHICOTMEMORIAL.COM/PATIENTFINANCIALSERVICES X X X X X X X 1 X X 1 X X X X X X 1 X 0 0 CHICOT MEMORIAL MEDICAL CENTER PART V, SECTION B, LINE 5: EVERY THREE YEARS CMMC CONDUCTS A SURVEY ASSESSING THE NEEDS OF CHICOT COUNTY RESIDENTS AND HOSPITAL STAKEHOLDERS IN THE SURROUNDING AREA. THE ASSESSMENT INCLUDES INPUT FROM PERSONS REPRESENTING BROAD INTERESTS OF THE COMMUNITY SERVED BY THE CHICOT MEMORIAL MEDICAL CENTER, INCLUDING THOSE WITH PUBLIC HEALTH EXPERTISE. THESE INDIVIDUALS FORM THE COMMUNITY ADVISORY COMMITTEE. THE COMMUNITY ADVISORY COMMITTEE ASSISTED HOSPITAL STAFF IN COLLECTING SURVEY DATA THAT INDICATE THE MOST PRESSING HEALTH CONCERNS IN THE HOSPITAL SERVICE AREA. PLEASE SEE THE CHNA: HTTPS://WWW.CHICOTMEMORIAL.COM/WP-CONTENT/UPLOADS/2023/02/2022-CMMC-CHNA-ASSESSMENT-FINAL-WITH-ATTACHMENTS.PDF CHICOT MEMORIAL MEDICAL CENTER PART V, SECTION B, LINE 11: PLEASE SEE THE IMPLEMENTATION STRATEGY FOR INFORMATION AND INFORMATION IN THE CHNA REGARDING NEEDS THAT WERE NOT ADDRESSED DUE TO LACK OF RESOURCES: HTTPS://WWW.CHICOTMEMORIAL.COM/WP-CONTENT/UPLOADS/2023/02/2022-CMMC-CHNA-ASSESSMENT-FINAL-WITH-ATTACHMENTS.PDF CHICOT MEMORIAL MEDICAL CENTER PART V, SECTION B, LINE 16J: THE FAP, APPLICATION AND PLAIN LANGUAGE SUMMARY ARE CURRENTLY BEING TRANSLATED INTO SPANISH AND WILL BE AVAILABE IN SPANISH, UPON COMPLETION OF TRANSLATION. CHICOT MEMORIAL MEDICAL CENTER PART V, SECTION B, LINE 20E: PLEASE NOTE THAT THIRD PARTY VENDORS ARE REQUIRED TO INFORM PATIENTS OF THE FINANCIAL ASSISTANCE POLICY AND PROVIDE THEM WITH AN APPLICATION AHEAD OF ANY COLLECTION ACTIONS. PART I, LINE 7: COSTING METHODOLOGY USED ON LINE 7 IS THE RATIO OF PATIENT CARE COST TOCHARGES DERIVED FROM WORKSHEET 2. PART I, LINE 7G: CHICOT MEMORIAL MEDICAL CENTER INCURS COSTS TO HAVE SPECIALTY DOCTORS COME AND SERVE THEIR PATIENT BASE. CHICOT RECEIVES NO REVENUE FROM HAVING THESE DOCTORS VISIT CHICOT PATIENTS, THE COST CHICOT INCURS IS PURELY FOR BENEFIT OF PATIENT TO SUBSIDIZE THE HEALTH SERVICES THAT THESE PATIENTS RECEIVE. PART I, LINE 7, COLUMN (F): THE BAD DEBT EXPENSE INCLUDED ON FORM 990, PART IX, LINE 25, COLUMN (A), BUT SUBTRACTED FOR PURPOSES OF CALCULATING THE PERCENTAGE IN THIS COLUMN IS $ 1,298,926. PART III, LINE 2: THE BAD DEBT EXPENSE IS THAT AMOUNT REFLECTED ON THE INTERNAL TRIAL BALANCE OF THE HOSPITAL. FOR AUDIT PURPOSES, THESE AMOUNTS ARE CLASSIFIED AS IMPLICIT PRICE CONCESSIONS. PLEASE SEE NOTE ONE ON THE ATTACHED AUDITED FINANCIALS FOR AN EXPLANATION OF IMPLICIT PRICE CONCESSIONS. PART III, LINE 3: METHODOLGY USED IS BASED ON NUMBER OF FINANCIAL ASSISTANCE APPLICATIONS RECEIVED, RESULTS OF THOSE APPLICATIONS AND RATIO OF APPLICATIONS RECEIVED TO TOTAL PATIENTS, TAKING INTO CONSIDERATION DEMOGRAPHICS AND POVERTY LEVELS OF THE AREA. PART III, LINE 4: FOOTNOTE 1 OF THE AUDITED FINANCIALS CONTAINS THE INFORMATION REGARDING PATIENT ACCOUNTS RECEIVABLE. PART III, LINE 8: THE COST OF PROVIDING SERVICES TO MEDICARE PATIENTS HAS HISTORICALLY EXCEEDED REVENUE. THIS COST PROVIDES A NECESSARY HEALTH BENEFIT TO THE ELDERLY POPULATION IN THE HOSPITAL'S SERVICE AREA AND SHOULD BE CONSIDERED COMMUNITY BENEFIT. PART III, LINE 9B: FINANCIAL ASSISTANCE MAY BE GRANTED PROSPECTIVELY OR RETROSPECTIVELY. ALL OVERDUE ACCOUNTS WILL BE REVIEWED INTERNALLY TO DETERMINE WHETHER ANY FINANCIAL ASSISTANCE IS AVAILABLE PRIOR TO THE INITIATION OF ANY LEGAL PROCEEDINGS OR COLLECTION ACTIONS OUTSIDE OF THE HOSPITAL. PART VI, LINE 2: THE HOSPITAL CONDUCTS A CHNA EVERY 3 YEARS TO ASSESS THE HEALTH CARE NEEDS OF THE COMMUNITY IT SERVES AND FOLLOWS IT UP WITH AN IMPLEMENTATION STRATEGY. SEE IMPLEMENTATION STRATEGY, ATTACHED, AND THE CHNA AND IMPLEMENTATION STRATEGY CAN BE FOUND AT: HTTPS://WWW.CHICOTMEMORIAL.COM/WP-CONTENT/UPLOADS/2023/02/2022-CMMC-CHNA-ASSESSMENT-FINAL-WITH-ATTACHMENTS.PDF PART VI, LINE 3: THE HOSPITAL PROVIDES FINANCIAL ASSISTANCE INFORMATION ON THEIR WEBISTE, INFORMS PATIENTS UPON ADMISSION AND ALSO POSTS CONSPICUOUS NOTICE OF POLICIES THROUGHT THE HOSPITAL. PART VI, LINE 4: THE COMMUNITY SERVED BY THE HOSPITAL IS A RURAL SETTING WITH A PREDOMINANTLY AGRICULTURAL BASED WORKFORCE. THE AVERAGE INCOME FOR THE AREA IS AT OR BELOW THE FEDERAL POVERTY GUIDELINES. MOST RESIDENTS ARE HIGH SCHOOL EDUCATED AND OF AN ADVANCED AGE. PART VI, LINE 5: CHICOT MEMORIAL MEDICAL CENTER PROVIDES GENERAL MEDICAL AND SURGICAL CARE FOR INPATIENT, OUTPATIENT AND EMERGENCY REOOM PATIENTS. THE HOSPITAL PARTICIPATES IN BOTH MEDICARE AND MEDICAID PROGRAMS. THE HOSPITAL PROMOTES COMMUNITY WELLNESS THROUGH VOLUNTEERING AND DONATIONS TO THE COMMUNITY, AS WELL AS HELPING TO PROVIDE A FREE COMMUNITY CENTER THAT OFFERS VARIOUS EXCERCISE CLASSES. X 0 0 0 0 0 0 0 0 0 MICHAEL BRADLEY MAYFIELD CMO/SURGEON 386057 0 0 0 0 0 12617 0 11842 0 410516 0 0 0 HALEY BURSON DENTIST 189873 0 0 0 0 0 7484 0 11842 0 209199 0 0 0 JOHN HEARD CEO 160677 0 0 0 0 0 0 0 0 0 160677 0 0 0 PART I, LINE 3 THE CEO'S SALARY IS APPROVED BY THE BOARD AND IS BASED ON REGIONAL DATA AND LEVEL OF EXPERIENCE. THE BOARD PERIODICALLY CONDUCTS EVALUATIONS OF THE CEO AND ADJUST SALARY, ACCORDINGLY. FORM 990, PART VI, SECTION B, LINE 11B THE 990 IS REVIEWED BY A MEMBER OF MANAGEMENT WHO THEN PRESENTS TO FINANCE COMMITTEEE FOR APPROVAL. THE 990 IS ALSO MADE AVAILABLE FOR BOARD MEMBER REVIEW. FORM 990, PART VI, SECTION B, LINE 12C INDIVIDUALS WHO SERVE AS DIRECTORS, MANAGERS, SUPERVISORS OF CLINICAL DEPARTMENTS AND ANY OTHER EMPLOYEE OR MEDICAL STAFF MEMBER DEEMED BY AN ADMINISTRATIVE OFFICER TO BE IN A POSITION TO INFLUENCE DECISION-MAKING FOR THE HOSPITAL, ARE REQUIRED TO DISCLOSE ALL CONFLICTS OF INTEREST. DISCLOSURE WILL OCCUR THROUGH AN ANNUAL CONFLICT OF INTEREST STATEMENT AND THE DISCLOSURE OF OTHER ACTUAL OR POTENTIAL CONFLICTS AS THEY ARISE. PRIOR TO DECISIONS BEING MADE, DIRECTORS, OFFICERS, AND KEY EMPLOYEES STATE ALL CONFLICTS AND DO NOT DISCUSS THE ISSUES OF POTENTIAL CONFLICT AND DO NOT PARTICIPATE IN DECISION MAKING OF THOSE ISSUES. FORM 990, PART VI, SECTION B, LINE 15 CEO AND TOP MANAGEMENT COMPENSATION IS APPROVED BY THE BOARD OF DIRECTORS AND IS BASED ON MARKET CONDITIONS, REGIONAL DATA, EXPERIENCE LEVEL AND PERFORMANCE EVALUATIONS. OFFICER'S AND KEY EMPLOYEE'S COMPENSATION IS APPROVED BY THE CEO AND IS BASED ON SALARY SURVEYS AND PERFORMANCE EVALUATIONS. FORM 990, PART VI, SECTION C, LINE 19 THE GOVERNING DOCUMENTS, CONFLICT OF INTEREST POLICY AND THE FINANCIAL STATEMENTS ARE AVAILABLE TO THE PUBLIC UPON REQUEST. FORM 990, PART IX, LINE 11G PURCHASED SERVICES: PROGRAM SERVICE EXPENSES 3,073,181. MANAGEMENT AND GENERAL EXPENSES 1,741,817. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 4,814,998. FORM 990, PART XII, LINE 2C: PROCESS HAS NOT CHANGED FROM PRIOR YEAR.