2022-05-16T11:40:19-05:00 2021-06-30 460403496 CASEY PETERSON LTD 909 ST JOSEPH ST STE 101 RAPID CITY SD 57701 990 2020-07-01 830300467 POWELL VALLEY HEALTH CARE INC POWE 3077542267 777 AVENUE H POWELL WY 82435 TERRY ODOM CEO 3077542267 2022-05-10 1 TERRY ODOM 999009999 KAYLA GIESEY CPA P01874520 6053481930 2022-05-13 2 AAL1 IAL1 2020 2022-09-23 18:48:47Z POWELL VALLEY HOSPITAL TERRY ODOM 777 AVENUE H POWELL WY 82435 75395152 0 X WWW.PVHC.ORG X 1992 WY PROVISION OF HEALTHCARE SERVICES 12 8 571 33 0 0 147036 10286976 54357420 65012809 49521 49407 37513 45960 54591490 75395152 19132 17656 0 0 33466475 37473071 0 0 0 20100468 25026716 53586075 62517443 1005415 12877709 31052930 35284547 18521167 9875075 12531763 25409472 X TO IMPROVE QUALITY OF LIFE THROUGH EXCELLENT HEALTHCARE. 0 0 54136808 17656 65058769 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, 2021, THE HOSPITAL PROVIDED $458,188 OF MEDICAL SERVICES, BASED ON THE AMOUNTS OF CHARGES FOREGONE, UNDER THE HOSPITAL'S CHARITY CARE POLICY AND GUIDELINES TO INDIVIDUALS WHO WERE DETERMINED UNABLE TO PURCHASE SUCH SERVICES. 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 (BASED ON COST) OF PROVIDING CARE TO ALL PATIENTS WAS $2,716,543 FOR THE YEAR ENDED JUNE 30, 2021. DURING THE FISCAL YEAR ENDED JUNE 30, 2021, THE HOSPITAL PROVIDED 3,696 DAYS OF HOSPITAL SERVICES. THE NURSING HOME PROVIDED 28,444 DAYS OF RESIDENT SERVICES, AND THE ASSISTED LIVING FACILITY PROVIDED 6,641 DAYS OF RESIDENT SERVICES. THE HOSPITAL ALSO PROVIDES COMMUNITY CARE AND SERVICES THROUGH MANY HEALTH ACTIVITIES AND PROGRAMS PROVIDED TO SUPPORT THE COMMUNITY. THESE ACTIVITIES INCLUDE SUPPORT TO HERITAGE HEALTH CENTER CLINIC, A COMMUNITY HEALTH CENTER FQHC, WELLNESS PROGRAM, COMMUNITY EDUCATION PROGRAM, SPECIAL PROGRAMS FOR SPECIFIC PURPOSES, AND A VARIETY OF COMMUNITY SUPPORTED ACTIVITIES. 54136808 1 1 0 0 0 0 0 0 1 0 1 0 0 0 1 1 0 1 0 0 0 0 0 0 0 0 1 1 0 1 1 0 0 0 0 0 0 1 0 0 0 0 0 0 1 0 0 0 1 27 0 1 571 1 0 0 0 0 0 0 0 0 0 0 0 0 X 12 8 0 0 0 0 0 1 1 1 1 0 0 1 1 1 1 1 1 1 0 0 X THE ORGANIZATION 3077542267 777 AVENUE H POWELL WY 82435 RJ KOST PRESIDENT 1.00 1.00 X X 0 0 0 BONITA KATZ VICE PRESIDENT 1.00 1.00 X X 0 0 0 GERRI ACKLEY SECRETARY 1.00 1.00 X X 0 0 0 NATHANIEL RIEB MD TREASURER/PHYSICIAN 40.00 X X 452602 0 35494 JIM CARLSON DIRECTOR 1.00 1.00 X 0 0 0 RICHARD STEARNS DIRECTOR 1.00 1.00 X 0 0 0 SYD THOMPSON DIRECTOR 1.00 1.00 X 0 0 0 DEB KLEINFELDT DIRECTOR 1.00 1.00 X 0 0 0 BRADLEY NORTH DO DIRECTOR/PHYSICIAN 40.00 X 324388 0 34069 ADAM CHILDERS DO CHIEF OF STAFF BEG. 3/1/21 40.00 X 288100 0 34069 JOHN PENDER IV MD DIRECTOR 1.00 X 0 0 0 BRIAN JONES DIRECTOR 1.00 X 0 0 0 JACOB MERRELL MD CHIEF OF STAFF TERMED 3/1/21 1.00 X 0 0 0 BETH GILB DIRECTOR 1.00 1.00 X 0 0 0 TERRY ODOM CEO 40.00 X 244171 0 19242 JOY COULSTON CFO 40.00 X 164353 0 26693 WILLIAM JARVIS PHYSICIAN 40.00 X 1398348 0 34069 CARLETTA COLLINS PHYSICIAN 40.00 X 585016 0 29162 JENKINS CLARKSON PHYSICIAN 40.00 X 398186 0 34069 KELLY CHRISTENSEN PHYSICIAN 40.00 X 359676 0 36919 KURT PETTIPIECE PHYSICIAN 40.00 X 347464 0 30312 4562304 0 314098 44 0 1 0 NORTH PLATTE PHYSICAL THERAPY INC PO BOX 1790 DOUGLAS WY 82633 PHYSICAL THERAPY 1442620 HOLISTIC PAIN MANAGEMENT PO BOX 1476 LOVELAND CO 80537 PAIN MANAGEMENT 936980 DEVCO 936 STEAMBOAT BLVD STEAMBOAT SPRINGS CO 80487 SURGICAL CONTRACT SERVICES 622594 BILLINGS CLINIC PO BOX 30977 BILLINGS MT 59107 MANAGEMENT SERVICES 596821 FOCUSONE 13609 CALIFORNIA STREET SUITE 420 OMAHA NE 68154 TRAVELING/CONTRACT STAFF 453506 12 79534 10183925 23517 10286976 PATIENT SERVICE REVENUE 621110 63643678 63643678 PHARMACY CONTRACT REVENUE 446110 898770 898770 OTHER INCOME 900099 334408 334408 CAFETERIA 722514 135953 135953 65012809 48907 48907 45960 0 45960 45960 45960 500 0 500 500 500 75395152 65058769 0 49407 17656 17656 1623179 1168721 454458 27542817 24355068 3187749 564253 493550 70703 5926360 4997384 928976 1816462 1571835 244627 473853 473853 7480 7480 67713 67713 5624226 5202810 421416 230294 119349 110945 614802 396096 218706 794978 197057 597921 1230967 622206 608761 63055 55976 7079 164971 164971 284030 244172 39858 852006 852006 MEDICAL SUPPLIES 10716509 10716509 PROVISION FOR BAD DEBTS 2424818 2424818 FOOD 503813 503813 MISCELLANEOUS EXPENSES 400319 384613 15706 572882 500204 72678 62517443 54136808 8380635 0 19557892 13045263 8666620 15500206 109000 172972 1211907 1658484 343412 335709 15034176 10462263 1164099 4571913 31052930 35284547 5407872 5299721 8836 6386 868053 1379026 6533910 1190891 5702496 1999051 18521167 9875075 X 12531763 25409472 12531763 25409472 31052930 35284547 12877709 0 X X 0 1 X 1 1 1 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 1 7980 43580 26523 25037 1 X 1997348 557566 1439782 12074981 9904697 2170284 961847 961847 4571913 ESTIMATED THIRD-PARTY SETTLEMENTS 1516625 ADVANCED GRANTS 482426 1999051 X PART IV, LINE 1B: THE ORGANIZATION IS ACTING AS AN AGENCY FOR THE PVHC AUXILIARY PART IV, LINE 2B: THE ORGANIZATION HOLDS FUNDS IN TRUST ON BEHALF OF NURSING HOME RESIDENTS. PART X, LINE 2: AS OF JUNE 30, 2020, THE HOSPITAL HAD NO UNCERTAIN TAX POSITIONS THAT QUALIFY FOR EITHER RECOGNITION OR DISCLOSURE IN THE FINANCIAL STATEMENTS. THE HOSPITAL'S INCOME TAX FILINGS ARE SUBJECT TO AUDIT BY VARIOUS TAXING AUTHORITIES. THE HOSPITAL IS NO LONGER SUBJECT TO FEDERAL AND STATE INCOME TAX EXAMINATIONS BY TAXING AUTHORITIES FOR FISCAL YEARS BEFORE 2017. 1 1 X 1 X 1 X 1 1 0 0 261969 261969 0.00440 5957563 6032605 0 0.00000 6219532 6032605 261969 0.00440 4 131 820 0 820 0.00000 8862406 5753935 3108471 0.05170 4 131 8863226 5753935 3109291 0.05170 4 131 15082758 11786540 3371260 0.05610 101562 101562 0.00170 101562 101562 0.00170 0 2424818 295828 20066136 21209362 -1143226 X 1 1 1 1 POWELL VALLEY HOSPITAL 777 AVENUE H POWELL WY 82435 X X X POWELL VALLEY HOPSITAL 1 0 0 1 X X X X X X X X X 18 1 1 1 1 X HTTPS://WWW.PVHC.ORG/ X X 1 19 1 HTTPS://WWW.PVHC.ORG 0 1 X 100.000000000000 200.000000000000 X X X 1 1 X X X X 1 X HTTPS://WWW.PVHC.ORG X HTTPS://WWW.PVHC.ORG X HTTPS://WWW.PVHC.ORG X X X X 1 X 0 X 1 X 0 0 POWELL VALLEY HOPSITAL PART V, SECTION B, LINE 5: IN FISCAL YEAR 2019 (TAX YEAR 2018), A CHNA WAS COMPLETED. THE SURVEY WAS DISTRIBUTED TO CURRENT USERS OF PVHC HEALTH SERVICES. 313 COMPLETED SURVEYS WERE RETURNED. A PRIORITIZATION MEETING OF INDIVIDUALS WITH EXPERTISE AND KNOWLEDGE REGARDING COMMUNITY NEEDS WAS HELD. THOSE UNABLE TO ATTEND WERE ABLE TO COMMUNICATE THEIR FEEDBACK AND COMMENTS VIA EMAIL. POWELL VALLEY HOPSITAL PART V, SECTION B, LINE 6A: CODY REGIONAL HEALTH POWELL VALLEY HOPSITAL PART V, SECTION B, LINE 6B: HERITAGE HEALTH CENTERPARK COUNTY PUBLIC HEALTHHEALTHY PARK COUNTY POWELL VALLEY HOPSITAL PART V, SECTION B, LINE 7D: WE HAVE TV MONITORS IN VARIOUS LOCATIONS ON CAMPUS. THE CHNA IS ADVERTISED THERE, WHERE INDIVIDUALS MAY ACCESS THE DOCUMENT SO GUESTS KNOW THEY CAN READ THE RESULTS ON OUR WEBSITE. POWELL VALLEY HOPSITAL PART V, SECTION B, LINE 11: POWELL VALLEY HEALTHCARE WILL SERVE AS A MEMBER OF THE HEALTH COALITION (HEALTHY PARK COUNTY) AND SUPPORT EFFORTS TO ADDRESS THE 5 SIGNIFICANT HEALTH NEEDS IDENTIFIED IN THE FISCAL YEAR 2019 (CALENDAR YEAR 2018) COMMUNITY HEALTH NEEDS ASSESSMENT (CHNA) COMPLETED IN COLLABORATION WITH PARK COUNTY PUBLIC HEALTH, CODY REGIONAL HEALTH, HERITAGE HEALTH AND HEALTHY PARK COUNTY. PVHC AFFILIATED WITH THE BILLINGS CLINIC IN JANUARY 2020. THE AFFILIATION PROVIDES A RANGE OF WAYS THE TWO ORGANIZATIONS CAN COLLABORATE TO IMPROVE AND ENHANCE PATIENT CARE IN POWELL AND THE BIG HORN BASIN. THE CLINIC HAS COMMITTED TO SUPPORT PVHC WITH OUTREACH PROVIDERS FOR SPECIALTIES TOO COSTLY FOR PVHC TO EMPLOY. THE COMMUNITY WILL BENEFIT WITH LOCAL, LESS EXPENSIVE CARE OPTIONS. PVHC HAS COMPLETED THE PROCESS OF CLINICAL INTEGRATION AND ADOPTION OF AN INTEGRATED MEDICAL RECORD.IN ADDITION, PVHC WILL IDENTIFY SPECIFIC ORGANIZATION GOALS FOR SOME OF THE NEEDS AS STATED BELOW.HEALTH NEED 1 ACCESSIBILITY/AFFORDABILITYA CONCERN EXPRESSED BY COMMUNITY MEMBERS VIA THE COMMUNITY HEALTH SURVEY AS WELL AS DATA FROM THE HERITAGE HEALTH NEEDS ASSESSMENT WAS AFFORDABILITY OF HEALTH CARE. ONE AREA IN PARTICULAR THAT PATIENTS EXPRESSED CONCERN ABOUT WAS THE COST OF MR IMAGING SERVICES. PVHC HAS REDUCED AND SIMPLIFIED CHARGES RELATED TO OUR MRI. PVHC HAS NOT INCREASED PRICES FOR THE PAST 2 YEARS. HEALTH NEED 2 SUICIDE/MENTAL HEALTHPVHC WILL SUPPORT HEALTHY PARK COUNTY'S EFFORTS IN PREVENTING SUICIDE AND RAISING AWARENESS ABOUT SUICIDE AND MENTAL HEALTH. PVHC HAS ADDED A PROVIDER PSYCHIATRIC NURSE PRACTITIONER TO OUR STAFF. WE CONTINUE TO WORK WITH COMMUNITY PARTNERS COLLABORATIVELY TO CONTINUE TO ENHANCE AVAILABILITY OF BEHAVIORAL HEALTHCARE FOR PATIENTS IN THE BIG HORN BASIN STRUGGLING WITH MENTAL HEALTH CHALLENGES.HEALTH NEED 3 UNINTENTIONAL INJURY/SUBSTANCE ABUSEPVHC WILL SUPPORT HEALTHY PARK COUNTY'S EFFORTS TO RAISE AWARENESS OF INJURY PREVENTION AND SUBSTANCE ABUSE.HEALTH NEED 4 OBESITY/PHYSICAL INACTIVITYPVHC WILL SUPPORT HEALTHY PARK COUNTY'S EFFORTS TO RAISE AWARENESS ABOUT THE IMPORTANCE OF PHYSICAL ACTIVITY AND ITS IMPACT ON HEALTH, OPTIONS AVAILABLE TO COMMUNITY MEMBERS, AND THE RISKS ASSOCIATED WITH OBESITY AND SEDENTARY LIFESTYLE.IN ADDITION, PVHC WILL CONTINUE TO WORK ON OFFERING ITS EMPLOYEES OPPORTUNITIES FOR PHYSICAL FITNESS, SUCH AS FREE ACCESS TO A LOCATION AND EQUIPMENT FOR EXERCISES. PVHC REHAB SERVICES CONTINUES TO OFFER THIS SERVICE TO EMPLOYEES AT ITS OUTPATIENT LOCATION. PVHC CONTRIBUTES TO THE MEMBERSHIP FOR EMPLOYEES AT A LOCAL FITNESS CENTER.HEALTH NEED 5 CANCERPVHC WILL SUPPORT HEALTHY PARK COUNTY'S EFFORTS TO RAISE AWARENESS ABOUT THE IMPORTANCE OF APPROPRIATE CANCER SCREENINGS AND SERVICES AVAILABLE IN PARK COUNTY. IN ADDITION PVHC HAS HIRED AN ONCOLOGIST TO SERVICE THE PATIENTS IN THE BIG HORN BASIN DEALING WITH CANCER. PVHC CURRENTLY PROVIDES 2 ONCOLOGY CLINICS TO OUTREACH LOCATIONS. PVHC HAS ADDED A DEDICATED INFUSION THERAPY CENTER TO BETTER SERVE THE NEEDS OF OUR ONCOLOGY PATIENTS. POWELL VALLEY HOPSITAL PART V, SECTION B, LINE 13B: IN ADDITION TO PROVIDING FREE OR DISCOUNTED CARE BASED ON FEDERAL PROVERTY GUIDELINES, WE REVIEW INCOME TAX RETURNS AND PAY STUBS. THIS INFORMATION HELPS US MORE ACCURATELY DETERMINE A PATIENT'S ABILITY TO PAY. POWELL VALLEY HOPSITAL PART V, SECTION B, LINE 16J: A SUMMARY OF THE FINANCIAL ASSISTANCE POLICY IS MADE AVAILABLE TO THE COMMUNITY ON THE HOSPITAL'S WEBSITE, ATTACHED TO BILLING INVOICES, POSTED IN THE HOSPITAL EMERGENCY ROOM AND WAITING ROOMS, POSTED IN THE HOSPITAL ADMISSIONS OFFICES, AND PROVIDED, IN WRITING, TO PATIENTS ON ADMISSION TO THE HOSPITAL. 3 1 - POWELL VALLEY CLINIC 777 AVENUE H POWELL WY 82435 OUTPATIENT PHYSICIAN CLINIC 2 - POWELL VALLEY CARE CENTER 777 AVENUE H POWELL WY 82435 NURSING HOME 3 - HEARTLAND ASSISTED LIVING 777 AVENUE H POWELL WY 82435 ASSISTED LIVING FACILITY PART I, LINE 3C: IN ADDITION TO PROVIDING FREE OR DISCOUNTED CARE BASED ON FEDERAL PROVERTY 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 THE CHARGE RATIO ADDRESSING ALL PATIENT SEGMENTS. THE EXPENSES ASSOCIATED WITH COMMUNITY HEALTH IMPROVEMENT SERVICES, LINE 7E 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 I, LN 7 COL(F): THE AMOUNT OF BAD DEBT EXPENSE REMOVED FROM THE DENOMINATOR OF THE CALCULATION ON PART 1, LINE 7 COLUMN F WAS $2,424,818. PART II, COMMUNITY BUILDING ACTIVITIES: AT POWELL VALLEY HEALTH CARE, WE UNDERSTAND THAT HEALTHCARE IS EVOLVING. THE ADVANCEMENT 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 HOPSITAL 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 III, LINE 3: THE ESTIMATED AMOUNT OF BAD DEBT EXPENSE ATTRIBUTABLE TO PATIENTS ELIGIBLE UNDER THE ORGANIZATION'S FINANCIAL ASSISTANCE POLICY IS 12.2% (BASED UPON US CENSUS BUREAU QUICKFACTS FOR PERCENTAGE OF CITIZENS BELOW THE POVERTY LEVEL IN THE CITY OF POWELL, WY). THIS REPRESENTS A REASONABLE PERCENTAGE OF INDIVIDUALS WHO POTENTIALLY QUALIFY FOR CHARITY CARE, BUT MAY NOT HAVE APPLIED AND THEREFORE WERE WRITTEN OFF TO BAD DEBT. PART III, LINE 4: THE ORGANIZATION'S BAD DEBT IS REPORTED AS CHARGES INCURRED DURING THE YEAR. THE FOOTNOTE THAT DESCRIBES BAD DEBT EXPENSE IS FOUND ON PAGE 26 OF THE ATTACHED AUDIT REPORT. 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 THE CENTERS FOR MEDICARE AND MEDICAID SERVICES. POWELL VALLEY HEALTH CARE PROVIDES SERVICES TO PATIENTS UNDER THE MEDICARE PROGRAM KNOWING THEY WILL NOT RECOVER ALL THE COSTS ASSOCIATED WITH PROVIDING THESE SERVICES. PROVIDING THESE SERVICES IS ESSENTIAL TO THESE PATIENTS AND THE COMMUNITY AND INCREASES THEIR ACCESS TO HEALTHCARE SERVICES. THEREFORE, THE MEDICARE SHORTFALL SHOULD BE CONSIDERED A COMMUNITY BENEFIT. 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 DISCUSS FINANCIAL ASSISTANCE UPON ADMITTING AND DISCHARGE. PART VI, LINE 4: POWELL VALLEY HEALTHCARE 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 2020, 12.2% OF THE RESIDENTS LIVED IN POVERTY. THE MEDIAN HOUSEHOLD INCOME WAS $60,227 AND THE POPULATION WAS 6,419. THE NEAREST CITY WITH A POPULATION OF 50,000+ IS BILLINGS, MT. THE NEAREST HOSPITALS ARE NORTH BIG HORN HOPSITAL 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 32.78% AND 2.66%, RESPECTIVELY. PART VI, LINE 5: AT POWELL VALLEY HEALTH CARE, WE UNDERSTAND THAT HEALTHCARE IS EVOLVING. THE ADVANCEMENT 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. 1 SCHOLARSHIPS 4 4000 TUITION REIMBURSEMENTS 6 13656 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 REIMBURSEMENTS ARE PAID OUT AT 50% OF TUITION AFTER EMPLOYEES SHOW PASSING GRADES. X 0 0 0 0 0 1 0 0 0 WILLIAM JARVIS PHYSICIAN 640000 0 650958 0 107390 0 8550 0 25519 0 1432417 0 0 0 CARLETTA COLLINS PHYSICIAN 550000 0 15000 0 20016 0 8550 0 20612 0 614178 0 0 0 NATHANIEL RIEB MD TREASURER/PHYSICIAN 379438 0 8467 0 64697 0 9975 0 25519 0 488096 0 0 0 JENKINS CLARKSON PHYSICIAN 331250 0 0 0 66936 0 8550 0 25519 0 432255 0 0 0 KELLY CHRISTENSEN PHYSICIAN 223468 0 88131 0 48077 0 11400 0 25519 0 396595 0 0 0 KURT PETTIPIECE PHYSICIAN 266328 0 0 0 81136 0 8550 0 21762 0 377776 0 0 0 BRADLEY NORTH DO DIRECTOR/PHYSICIAN 265000 0 0 0 59388 0 8550 0 25519 0 358457 0 0 0 ADAM CHILDERS DO CHIEF OF STAFF BEG. 3/1/21 254400 0 0 0 33700 0 8550 0 25519 0 322169 0 0 0 TERRY ODOM CEO 229020 0 0 0 15151 0 7334 0 11908 0 263413 0 0 0 JOY COULSTON CFO 161411 0 0 0 2942 0 4931 0 21762 0 191046 0 0 0 PART I, LINE 5 BONUSES ARE CALCULATED AS A PERCENTAGE OF NET REVENUE PER QUARTER PER CONTRACT FOR EACH INDIVIDUAL BASED ON BILLED CHARGES FOR THAT QUARTER. STEPHEN KATZ HUSBAND OF BOARD MEMBER BONITA KATZ 334449 COMPENSATION 0 FORM 990, PART IV, LINE 20B AT THE TIME OF FILING THE FORM 990, THE AUDIT OF POWELL VALLEY HEALTH CARE, INC.'S FINANCIAL STATEMENTS FOR THE FOR THE YEAR ENDED JUNE 30, 2021 WAS IN PROGRESS. AS A RESULT, THE FISCAL YEAR 2021 AUDITED FINANCIAL STATEMENTS ARE NOT AVAILABLE; INSTEAD THE FISCAL YEAR 2020 AUDITED FINANCIAL STATEMENTS (THE MOST RECENT AUDITED FINANCIAL STATEMENTS) ARE ATTACHED. THE 2021 FINANCIAL STATEMENT AUDIT ALSO INCLUDES A SINGLE AUDIT OF FEDERAL FUND EXPENDITURES, WHICH IS ALSO IN PROGRESS AS OF THE DATE OF FILING. 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 OF DIRECTORS. 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 OF DIRECTORS. FORM 990, PART VI, SECTION B, LINE 11B 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 THE 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. FORM 990, PART VI, SECTION B, LINE 15A COMPENSATION OF THE CEO IS REVIEWED AND APPROVED BY THE BOARD OF DIRECTORS ANNUALLY. FORM 990, PART VI, SECTION C, LINE 19 THE HOSPITAL MAKES ITS GOVERNING DOCUMENTS, CONFLICT OF INTEREST POLICY, AND FINANCIAL STATEMENTS AVAILABLE TO THE PUBLIC BY REQUEST. THE PUBLIC MAY REQUEST A COPY BY CALLING, VIA MAIL, OR WALK-IN. FORM 990, PART XII, LINE 2C: THIS PROCESS HAS NOT CHANGED FROM THE PREVIOUS YEAR. POWELL HOSPITAL DISTRICT #1 777 AVENUE H POWELL WY 82435 830200759 RELATED - PROVISION OF HEALTH CARE SERVICES WY GOVERNMENT N/A 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 0 0 1 1 0 0 0 0 0 0 1 0 0 1 1 0 0 0 0 POWELL HOSPITAL DISTRICT K 450000 ACTUAL RENT PAID FOR BUILDINGS POWELL HOSPITAL DISTRICT N 360000 FMV OF DONATED USE OF FACILITIES POWELL MEDICAL FOUNDATION O 94470 CASH PAID BY PVHC FOR PMF'S ED POWELL MEDICAL FOUNDATION C 79534 CASH PAID POWELL HOSPITAL DISTRICT D 18688 RECEIVABLES FROM PHD AT YEAR END