2022-08-03T09:22:46-05:00 2021-09-30 450250958 EIDE BAILLY LLP 200 E 10TH ST STE 500 SIOUX FALLS SD 571046375 990 2020-10-01 860107344 WINSLOW MEMORIAL HOSPITAL INC WINS 9282896303 1501 N WILLIAMSON AVE WINSLOW AZ 86047 JOHN J DEMPSEY CEO 9282896303 2022-07-28 1 JOHN DEMPSEY 999009999 LAURIE HANSON CPA P00851848 6053391999 2022-07-28 2 AAL1 IAL1 2020 2022-09-23 18:48:47Z LITTLE COLORADO MEDICAL CENTER JOHN J DEMPSEY 1501 N WILLIAMSON AVE WINSLOW AZ 86047 47523722 0 X WWW.LCMCWMH.COM X 1951 AZ COMPASSIONATE CARE FOR NORTHEASTERN ARIZONA. 12 11 306 15 0 0 621055 6624626 39856629 40629060 48226 251804 16380 18232 40542290 47523722 6000 7246 0 0 19610282 19967271 0 0 0 19174001 18427503 38790283 38402020 1752007 9121702 44665290 47384616 27657751 21261366 17007539 26123250 X COMPASSIONATE CARE FOR NORTHEASTERN ARIZONA. 0 0 31980543 7246 40629060 WINSLOW MEMORIAL HOSPITAL D/B/A LITTLE COLORADO MEDICAL CENTER (LCMC) GENERAL MEDICAL & SURGICAL HOSPITAL - PRIMARILY ENGAGED IN PROVIDING DIAGNOSTIC, MEDICAL TREATMENT (BOTH SURGICAL AND NONSURGICAL) TO PATIENTS WITH A WIDE VARIETY OF MEDICAL CONDITIONS. LCMC MAINTAINED 25-BEDS, PROVIDED INPATIENTS WITH FOOD SERVICES THAT MET THEIR NUTRITIONAL REQUIREMENTS, AND USED AN ORGANIZED STAFF OF PHYSICIANS AND OTHER MEDICAL STAFF TO PROVIDE PROFESSIONAL CARE SERVICES AS WELL AS OTHER SERVICES. THESE SERVICES INCLUDE OUTPATIENT SERVICES, ANATOMICAL PATHOLOGY SERVICES, DIAGNOSTIC X-RAY SERVICES, CLINICAL LABORATORY SERVICES, OPERATING ROOM SERVICES FOR A VARIETY OF PROCEDURES, AND PHARMACY SERVICES IN THE CITY OF WINSLOW, NAVAJO COUNTY, ARIZONA. LCMC MAINTAINS RECORDS TO IDENTIFY AND MONITOR THE LEVEL OF CHARITY CARE IT PROVIDES WHICH INCLUDE THE COST OF SUPPLIES AND SERVICES FURNISHED UNDER THE CHARITY CARE POLICY ALONG WITH ASSOCIATED EQUIVALENT SERVICE STATISTICS. 31980543 1 1 0 0 0 0 0 0 0 0 1 1 0 0 1 1 1 0 0 0 0 0 0 0 0 0 1 1 1 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 1 1 0 0 0 1 36 0 1 306 1 0 0 0 0 0 0 0 0 0 0 0 0 X 12 11 0 0 0 0 0 0 0 1 0 0 0 0 1 1 1 1 1 1 0 0 X JANICE FREET 9282894691 1501 NORTH WILLIAMSON AVENUE WINSLOW AZ 86047 BRIAN BUCINA MD, SURGEON 40.00 X 441063 0 46666 JOHN J DEMPSEY CEO 40.00 X 339924 0 43534 RANDALL REID MD, GENERAL MEDICINE 40.00 X 330687 0 46942 THOMAS GREENWOOD DIRECTOR, MD, CHIEF OF STAFF 40.00 0.50 X 321818 0 46909 ELLEN CLAXTON MD, GENERAL MEDICINE 40.00 X 247675 0 23550 JANICE FREET CFO 40.00 X 214365 0 19221 JAMES PAGE MD, GENERAL MEDICINE 40.00 X 199025 0 36971 PAMELA RULAND RN 40.00 X 191365 0 17782 RHONDA GREER CHAIRPERSON 5.00 0.50 X X 0 0 0 FRANK ARMAO MD SECRETARY/TREASURER 1.00 0.50 X X 0 0 0 JR DESPAIN DIRECTOR 1.00 0.50 X 0 0 0 CHRIS BAVASI DIRECTOR 1.00 0.50 X 0 0 0 ROBERT SALABYE DIRECTOR 1.00 0.50 X 0 0 0 ROBERTA CANO DIRECTOR 1.00 0.50 X 0 0 0 ANDREW DITTO MD DIRECTOR 1.00 0.50 X 0 0 0 DARRIN FRY DIRECTOR 1.00 0.50 X 0 0 0 ELIZABETH MCKEY DIRECTOR 1.00 0.50 X 0 0 0 GREG HACKLER DIRECTOR BEG NOV 2020 1.00 0.50 X 0 0 0 ALLYSEN KELLY DIRECTOR BEG AUG 2021 1.00 0.50 X 0 0 0 2285922 0 281575 43 0 1 0 MEDICAL SOLUTIONS LLC PO BOX 310737 DES MOINES IA 50331 TEMP STAFFING 1851751 WINNCARE LLC 1031 N WARREN WINSLOW AZ 86047 CRNA SERVICES 399769 DANIEL WESCHE 1058 N WAKONDA STREET FLAGSTAFF AZ 86004 CRNA SERVICES 307140 ANDREW J ALDRIDGE MD PC 2810 N SANDSTONE WAY FLAGSTAFF AZ 86004 CRNA SERVICES 292460 GITTELMAN ANESTHESIA SERVICES LLC 25587 CONIFER RD CONIFER CO 80433 CRNA SERVICES 251560 12 6607647 16979 6624626 PATIENT SERVICE REVENUE 622110 39940590 39940590 PHARMACY REVENUE 900099 276985 276985 MEAL & VENDING REVENUE 900099 41041 41041 370444 370444 40629060 251804 251804 18232 0 18232 18232 18232 47523722 40629060 0 270036 X 6000 6000 1246 1246 1029193 396470 632723 14895403 11811524 3083879 544805 514140 30665 2365639 2212750 152889 1132231 1047592 84639 228197 228197 72990 72990 7483331 7331604 151727 35847 3388 32459 1990289 1899407 90882 528012 528012 420944 419094 1850 64989 64989 149006 136031 12975 714077 552292 161785 1644828 1281673 363155 436636 371184 65452 SUPPLIES 2750842 2742323 8519 EQUIPMENT RENTAL & MAIN 310445 304894 5551 FOOD 134686 132418 2268 DUES AND SUBSCRIPTIONS 68942 44132 24810 1393442 707392 686050 38402020 31980543 6421477 0 20530305 21394222 7041083 7555378 1179422 1298108 402086 539476 37569633 24546735 12442363 13022898 3070031 3312856 0 261678 44665290 47384616 2478451 3040253 6634037 126390 14330999 13983752 3165471 3165471 1048793 945500 27657751 21261366 X 17007539 26123250 17007539 26123250 44665290 47384616 X 9121702 -5991 X 0 1 X 1 0 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 135526 72347 207873 16912978 10057331 6855647 19364857 14489404 4875453 1083925 1083925 13022898 INVESTMENT IN FOUNDATION 99388 F ASSETS LIMITED AS TO USE 1603568 F OTHER INVESTMENT 1609900 F 3312856 ASSET RETIREMENT OBLIGATION 582425 SETTLEMENT AGREEMENT 114000 DEFERRED COMPENSATION 249075 945500 X 47517731 -5991 -5991 47523722 0 47523722 38402020 0 38402020 0 38402020 PART X, LINE 2: THE HOSPITAL BELIEVES THAT IT HAS APPROPRIATE SUPPORT FOR ANY TAX POSITIONS TAKEN AFFECTING ITS ANNUAL FILING REQUIREMENTS, AND AS SUCH, DOES NOT HAVE ANY UNCERTAIN TAX POSITIONS THAT ARE MATERIAL TO THE FINANCIAL STATEMENTS. THE HOSPITAL WOULD RECOGNIZE FUTURE ACCRUED INTEREST AND PENALTIES RELATED TO UNRECOGNIZED TAX BENEFITS AND LIABILITIES IN INCOME TAX EXPENSE IF SUCH INTEREST AND PENALTIES ARE INCURRED. PART XI, LINE 2D - OTHER ADJUSTMENTS: CHANGE IN INTEREST IN NET ASSETS OF FOUNDATION -5,991. 1 1 X 1 X 125.000000000000 1 X 1 1 0 0 285000 285000 0.00740 17370993 17987045 0 0.00000 17655993 17987045 285000 0.00740 40986 40986 0.00110 3234026 916029 2317997 0.06040 3275012 916029 2358983 0.06150 20931005 18903074 2643983 0.06890 6000 6000 0.00020 6000 6000 0.00020 1 3673215 1296645 6994546 6925293 69253 X 1 1 1 1 LITTLE COLORADO MEDICAL CENTER 1501 N WILLIAMSON AVE WINSLOW AZ 86047 WWW.LCMCWMH.COM RGH 0076 X X X X LITTLE COLORADO MEDICAL CENTER 1 0 0 1 X X X X X X X X X 19 1 0 1 1 X SEE 7D NARRATIVE X X 1 19 1 HTTPS://WWW.LCMCWMH.COM/ABOUT-US 0 1 X 125.000000000000 300.000000000000 X X X X 1 1 X X X X 1 X HTTPS://WWW.LCMCWMH.COM/PATIENTS---VISITORS X SEE 16A-C NARRATIVE X SEE 16A-C NARRATIVE X X X X X X 1 X 0 X X X X 1 X 0 0 LITTLE COLORADO MEDICAL CENTER PART V, SECTION B, LINE 5: LCMC SOLICITED INPUT FROM MULTIPLE SOURCES IN THE COMMUNITY, INCLUDING GROUPS THAT WORK WITH DISADVANTAGED POPULATIONS. LCMC CONDUCTED THE CHNA DURING THE YEAR ENDED 9/30/20. LCMC SOLICITED INPUT THROUGH FOCUS GROUPS, TOWN MEETINGS, COMMUNITY COALITIONS, COMMUNITY HEALTH SURVEYS, PUBLIC HEALTH AND HOSPITAL DATA, INTERVIEWS WITH MENTAL AND BEHAVIORAL HEALTH PROVIDERS, EMERGENCY SERVICES PERSONNEL, A COMMUNITY ADVISORY COMMITTEE, VOLUNTEER ORGANIZATIONS, AND INDIAN HEALTH SERVICES TO IDENTIFY THE NEEDS OF THE COMMUNITY. DUE TO THE PANDEMIC, ALL OF THIS INFORMATION WAS SOLICITED THROUGH VIDEOCONFERENCING, TELECONFERENCING, AND SURVEYS. LITTLE COLORADO MEDICAL CENTER PART V, SECTION B, LINE 6B: COLLEGE OF PUBLIC HEALTH, THE UNIVERSITY OF ARIZONA, AND HEALTH EQUITY RESEARCH GROUP, NORTHERN ARIZONA UNIVERSITY. LITTLE COLORADO MEDICAL CENTER PART V, SECTION B, LINE 7D: THE CHNA REPORT IS AVAILABLE AT HTTPS://WWW.LCMCWMH.COM/ABOUT-US. LITTLE COLORADO MEDICAL CENTER PART V, SECTION B, LINE 11: NEEDS IDENTIFIED IN THE MOST RECENT CHNA IMPLEMENTATION STRATEGY INCLUDE THE FOLLOWING:1. DRUG AND ALCOHOL USE DISORDER2. HEALTH PROVIDER SHORTAGES3. CHRONIC HEALTH ISSUES4. SOCIO-ECONOMIC CONDITIONS5. COVID-19 PANDEMICLCMC HAD A GOOD IMPLEMENTATION PLAN AND STRATEGIES IN PLACE TO APPROPRIATELY MEASURE, HOWEVER, WE WERE STILL IN THE THROES OF COVID THROUGH MUCH OF THE REPORTING YEAR. THEREFORE, WE REMAINED FOCUSED ON COVID COMMUNITY RELATED EFFORTS.DURING THE CURRENT YEAR, LITTLE COLORADO MEDICAL CENTER AND LITTLE COLORADO PHYSICIAN OFFICES CONTINUED TO SUPPORT THE COMMUNITY THROUGH MEALS ON WHEELS FOR OUR HOMEBOUND SENIORS, AND PROVIDED LUNCHTIME MEALS THROUGH THE CAFETERIA BY DELIVERING MEALS TO SENIORS IN A DRIVE THRU METHOD. WE CONTINUED TO PROVIDE HEALTHIER EATING OPTIONS IN THE CAFETERIA IN A SOCIALLY DISTANCED MANNER. WE ARE CONTINUING TO ASSIST SAINT MARY'S FOOD BANK IN DISTRIBUTING FOOD BOXES MONTHLY, PROVIDING MUCH NEEDED ASSISTANCE TO THE COMMUNITY. LITTLE COLORADO MEDICAL CENTER PART V, SECTION B, LINE 13H: PRESUMPTIVE ELIGIBILITY MAY BE DETERMINED ON A CASE-BY-CASE BASIS. LITTLE COLORADO MEDICAL CENTER PART V, SECTION B, LINE 16J: PART V, SECTION B, LINE 16A, B & C: THE FINANCIAL ASSISTANCE POLICY, APPLICATION, AND PLAIN LANGUAUGE SUMMARY OF THE FAP ARE POSTED ON THE ORGANIZATION'S WEBSITE AT HTTPS://WWW.LCMCWMH.COM/PATIENTS---VISITORS.PART V, SECTION B, LINE 16J:A SUMMARY OF THE FINANCIAL ASSISTANCE POLICY WAS POSTED IN THE EMERGENCY ROOM, WAITING ROOMS, ADMISSIONS OFFICE AND WAS MADE AVAILABLE UPON REQUEST.MORE THAN THE LESSER OF 5% OR 1,000 INDIVIDUALS IN THE SERVICE AREA ARE LEP. HOWEVER, THE LANGUAGE SPOKEN, NAVAJO, RECENTLY BECAME A WRITTEN LANGUAGE. THE FACILITY HAS STAFF WHO SPEAK NAVAJO AND ARE ABLE TO ASSIST PATIENTS IN COMPLETING FINANCIAL ASSISTANCE FORMS, BECAUSE THE FORMS ARE STILL PREDOMINATELY IN ENGLISH. LITTLE COLORADO MEDICAL CENTER PART V, SECTION B, LINE 24: THE HOSPITAL FINANCIAL ASSISTANCE POLICY DOES NOT COVER ELECTIVE PROCEDURES. THE HOSPITAL MAY HAVE CHARGED FAP ELIGIBLE PATIENTS GROSS CHARGES FOR SERVICES THAT ARE NOT COVERED UNDER THE FINANCIAL ASSISTANCE POLICY. 1 1 - LITTLE COLORADO PHYSICIANS OFFICE 201 LEE STREET WINSLOW AZ 86047 PROVIDER BASED RURAL HEALTH CLINIC PART I, LINE 3C: IN ADDITION TO UTILIZING FPG TO DETERMINE ELIGIBILITY FOR FINANCIAL ASSISTANCE, THE HOSPITAL CONSIDERED MEDICAL INDIGENCY, INSURANCE STATUS, AND UNDERINSURANCE STATUS OF PATIENTS. PRESUMPTIVE ELIGIBILITY MAY BE USED ON A CASE-BY-CASE BASIS. 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. LINES 7B AND 7E WERE DETERMINED UTILIZING THE ACTUAL GENERAL LEDGER SYSTEM. LINE 7G WAS DETERMINED BASED ON THE COST REPORT. PART I, LINE 7G: SUBSIDIZED HEALTH SERVICES INCLUDES NET COMMUNITY BENEFIT EXPENSE FROM THE CLINIC OF $3,229,402. PART II, COMMUNITY BUILDING ACTIVITIES: LCMC GAVE $6,000 TO THE LOCAL SENIOR CENTER TO HELP FUND MEALS ON WHEELS AND OTHER HEALTH AND WELLNESS INITIATIVES. PART III, LINE 2: THE AMOUNT ON LINE 2 REPRESENTS IMPLICIT PRICE CONCESSIONS. THE ORGANIZATION DETERMINES ITS ESTIMATE OF IMPLICIT PRICE CONCESSION BASED ON ITS HISTORICAL COLLECTION EXPERIENCE WITH THIS CLASS OF PATIENTS. PART III, LINE 3: THE IMPLICIT PRICE CONCESSION INCLUDES AN ESTIMATED $1,296,645 OF CHARITY CARE-ELIGIBLE ACCOUNTS THAT ARE CURRENTLY LISTED AS AN IMPLICIT PRICE CONCESSION. UPON REVIEWING THE ACCOUNTS AND THE POVERTY LEVELS OF NAVAJO AND APACHE COUNTIES IN ARIZONA, IT WAS FOUND THAT ABOUT 35.3% OF THE OUTSTANDING BALANCES MAY HAVE BEEN ELIGIBLE UNDER THE FACILITY'S CHARITY CARE POLICY. ALSO FOR THIS REVIEW PROCESS, ANY FAMILIES WITH PRIOR APPLICATIONS FOR CHARITY CARE WERE GIVEN CONSIDERATION. PART III, LINE 4: THE FOOTNOTE TO THE ORGANIZATION'S FINANCIAL STATEMENTS THAT DESCRIBES IMPLICIT PRICE CONCESSION IS LOCATED IN FOOTNOTE 1 ON PAGES 11 & 12 OF THE ATTACHED FINANCIAL STATEMENTS. PART III, LINE 8: MEDICARE ALLOWABLE COST OF CARE WAS CALCULATED FROM THE MEDICARE COST REPORT FOR THE FISCAL YEAR ENDING 9/30/2021. MEDICAL SERVICES ARE PROVIDED TO PATIENTS WITH MEDICARE COVERAGE REGARDLESS OF WHETHER OR NOT A SURPLUS OR DEFICIT IS REALIZED. PROVIDING MEDICARE SERVICES PROMOTES ACCESS TO HEALTHCARE SERVICES WHICH ARE VITALLY NEEDED BY OUR COMMUNITY. THE MEDICARE COST REPORT IS COMPLETED BASED ON THE RULES AND REGULATIONS SET FORTH BY THE CENTERS FOR MEDICARE AND MEDICAID SERVICES. PART III, LINE 9B: ONCE THE BALANCE ON THE PATIENT'S ACCOUNT IS READY FOR BILLING THE PATIENT RECEIVES AN INITIAL STATEMENT. THE PATIENT WILL THEN RECEIVE A SECOND STATEMENT AT DAY 30 ALONG WITH A FOLLOW UP PHONE CALL, A THIRD STATEMENT AT DAY 60, AND A FINAL STATEMENT AT DAY 90 WITH A FOLLOW UP PHONE CALL. THE 90 DAY LETTER INFORMS THE PATIENT THAT COLLECTION ACTIONS WILL BEGIN AT 120 DAYS IF NO ATTEMPTS HAVE BEEN MADE TO RESOLVE THEIR ACCOUNT. THE PATIENT'S ACCOUNT IS TURNED TO COLLECTIONS AT DAY 121 WITH A NOTIFICATION LETTER SENT TO THE PATIENT INFORMING THEM OF SUCH. IF OUR COLLECTION AGENCY IDENTIFIES A PATIENT IS MEETING FINANCIAL ASSISTANCE ELIGIBILITY CRITERIA, THE PATIENT'S ACCOUNT MAY BE CONSIDERED FOR FINANCIAL ASSISTANCE. COLLECTION ACTIVITY WILL BE SUSPENDED ON ACCOUNTS, AND THE FINANCIAL ASSISTANCE APPLICATION WILL BE REVIEWED. IF THE ENTIRE ACCOUNT BALANCE IS ADJUSTED, THE ACCOUNT WILL BE RETURNED. IF A PARTIAL ADJUSTMENT OCCURS, THE PATIENT FAILS TO COOPERATE WITH THE FINANCIAL ASSISTANCE PROCESS, OR IF THE PATIENT IS NOT ELIGIBLE FOR FINANCIAL ASSISTANCE, COLLECTION ACTIVITY WILL RESUME. REQUESTS FOR CHARITY SHALL BE PROCESSED PROMPTLY AND LITTLE COLORADO MEDICAL CENTER SHALL NOTIFY THE PATIENT OR APPLICANT IN WRITING WITHIN 30 DAYS OF RECEIPT OF A COMPLETED APPLICATION. ACCOUNTS ELIGIBLE FOR CHARITY CARE ARE TO BE ADDRESSED WITHIN 240 DAYS OF FIRST BILL. PART VI, LINE 2: LCMC ASSESSES HEALTH NEEDS BY EVALUATING THE PATIENTS SERVED IN THE CLINICS AND HOSPITAL. LCMC HAS STAFF THAT PARTICIPATE IN VARIOUS ORGANIZATIONS INCLUDING THE COUNCIL FOR AGING, ALICE'S PLACE, THE WINSLOW ROTARY, ETC. STAFF ARE MADE AWARE OF NEEDS OF THE COMMUNITY THROUGH THEIR INVOLVEMENT WITH THESE ORGANIZATIONS. ADDITIONALLY, LCMC HAS MONTHLY MEDICAL EXECUTIVE AND BI-ANNUAL MEDICAL STAFF MEETINGS TO DETERMINE THE HEALTH NEEDS OF THE COMMUNITY. PART VI, LINE 3: LCMC'S PATIENT BILLING STATEMENTS HAVE A NARRATIVE ATTACHED DESCRIBING THE AVAILABILITY OF FINANCIAL ASSISTANCE AND THE CONTACT INFORMATION FOR HOW TO OBTAIN ADDITIONAL INFORMATION. NOTICES OF FINANCIAL ASSISTANCE AVAILABILITY ARE POSTED IN THE ER, WAITING ROOMS, AND ADMISSIONS OFFICE. PART VI, LINE 4: LCMC IS LOCATED IN THE COMMUNITY OF WINSLOW WHICH IS LOCATED IN NAVAJO COUNTY, ARIZONA, AND SERVES THE HEALTHCARE NEEDS OF THE COMMUNITY AND SURROUNDING AREAS. THE SERVICE AREA IS MOSTLY RURAL WITH A POPULATION OF APPROXIMATELY 21,160 PEOPLE. THE AVERAGE HOUSEHOLD INCOME IS $45,742 WITH 50% OF THE POPULATION HAVING AN INCOME OF LESS THAN $35,000. MORE THAN 40% OF THE PATIENTS SERVED BY LCMC ARE ON THE ARIZONA HEALTH CARE COST CONTAINMENT SYSTEM, AND MORE THAN 60% OF THE SERVICE AREA ARE OF NATIVE AMERICAN DESCENT. THE NEAREST HOSPITAL IS 60 MILES FROM WINSLOW. WINSLOW IS IN AN AREA FEDERALLY DESIGNATED AS A HEALTH PROFESSIONAL SHORTAGE AREA, A MEDICALLY UNDERSERVED AREA, AND A PERSISTENT POVERTY COUNTY. PART VI, LINE 5: LCMC'S BOARD OF DIRECTORS ALL RESIDE IN THE ORGANIZATION'S SERVICE AREA WITH THE EXCEPTION OF FOUR MEMBERS AT LARGE, ONE RESIDES IN PHOENIX, AZ, ONE RESIDES IN PAYSON, AZ, AND TWO RESIDE IN FLAGSTAFF, AZ. IN ADDITION, NONE OF THE BOARD MEMBERS ARE RELATED TO THE ORGANIZATION. LCMC EXTENDS MEDICAL STAFF PRIVILEGES TO ALL QUALIFIED PROVIDERS IN ITS COMMUNITY AND SURROUNDING AREA FOR SOME OR ALL OF ITS DEPARTMENTS. LCMC REINVESTS SURPLUS FUNDS, IF ANY, TO IMPROVEMENTS IN PATIENT CARE, INCLUDING BUT NOT LIMITED TO EXPANSION OF SERVICES OFFERED, PATIENT EDUCATION, EMPLOYEE EDUCATION, AND EQUIPMENT AND FACILITY RENOVATIONS. 1 WINSLOW COUNCIL ON AGING 212 EAST SECOND STREET WINSLOW AZ 86047 860310351 501(C)(3) 6000 MEALS ON WHEELS PROGRAM ASSISTANCE 1 PART I, LINE 2: LCMC PROVIDES ASSISTANCE TO THE COALITION ON AGING TO ASSIST WITH MEALS ON WHEELS, FOOD BANK, AND TRANSPORTATION FOR SENIORS. LCMC MAY PERIODICALLY CONTACT THE COALITION AND REQUEST CONFIRMATION THAT FUNDS ARE USED AS INTENDED. X X X X 0 1 0 0 0 0 0 1 0 BRIAN BUCINA MD, SURGEON 436063 0 5000 0 0 0 12825 0 34570 0 488458 0 0 0 JOHN J DEMPSEY CEO 324774 0 15150 0 0 0 12825 0 31428 0 384177 0 0 0 RANDALL REID MD, GENERAL MEDICINE 325687 0 5000 0 0 0 12825 0 34846 0 378358 0 0 0 THOMAS GREENWOOD DIRECTOR, MD, CHIEF OF STAFF 316818 0 5000 0 0 0 12825 0 34813 0 369456 0 0 0 ELLEN CLAXTON MD, GENERAL MEDICINE 245525 0 2150 0 0 0 23550 0 0 0 271225 0 0 0 JANICE FREET CFO 201865 0 12500 0 0 0 9263 0 10638 0 234266 0 0 0 JAMES PAGE MD, GENERAL MEDICINE 194025 0 5000 0 0 0 3880 0 33793 0 236698 0 0 0 PAMELA RULAND RN 181365 0 10000 0 0 0 8286 0 9871 0 209522 0 0 0 PART I, LINE 4B LCMC ENTERED INTO AN AGREEMENT WITH JOHN DEMPSEY TO PAY HIM A RETENTION BONUS WHICH VESTED ON 7/31/2020. THE FULL RETENTION BONUS WILL BE PAID OVER AN EIGHT-YEAR PERIOD. THIS DEFERRED COMPENSATION BENEFIT BECAME EFFECTIVE JANUARY 1, 2019. MONTHLY PAYMENTS BEGAN ON JULY 1, 2020. JOHN DEMPSEY WAS PAID $12,825 IN DEFERRED COMPENSATION IN 2020. PART I, LINE 7 BONUSES WERE PROVIDED BASED ON COMPLETION OF TASKS DETERMINED AS PART OF THEIR PERFORMANCE PLANS. FORM 990, PART VI, SECTION A, LINE 8B ALL COMMITTEES UTILIZED BY LCMC ARE STRICTLY ADVISORY IN NATURE. FORM 990, PART VI, SECTION B, LINE 11B THE ORGANIZATION'S CEO AND CFO WILL REVIEW THE FORM 990. FORM 990, PART VI, SECTION B, LINE 12C THE ORGANIZATION'S CONFLICT OF INTEREST POLICY IS REVIEWED ON AN ANNUAL BASIS. BOARD MEMBERS, OFFICERS, AND MANAGERS ARE COVERED UNDER LITTLE COLORADO MEDICAL CENTER'S CONFLICT OF INTEREST POLICY. WHEN A CONFLICT OF INTEREST ARISES, THE COVERED PERSON IS TO DISCLOSE THE CONFLICT TO HIS OR HER IMMEDIATE SUPERVISOR BEFORE A DECISION INVOLVING THE AREA OF CONFLICT IS MADE. MEMBERS WITH A CONFLICT OF INTEREST ARE ALSO NOT ALLOWED TO PARTICIPATE IN THE DECISION MAKING PROCESS. FORM 990, PART VI, SECTION B, LINE 15A THE ORGANIZATION REVIEWS AND DETERMINES THE CEO'S COMPENSATIONS EVERY FEW YEARS. THE ORGANIZATION BRINGS IN THE LEDBETTER LAW FIRM, PLC TO AID IN DETERMINING THE REASONABLENESS OF THE COMPENSATION. THE LAW FIRM CONSIDERS CEO COMPENSATION FROM OTHER HOSPITALS WITHIN THE CRITICAL ACCESS HOSPITALS IN ARIZONA, WHICH LCMC IS APART OF. THIS DATA IS COLLECTED THROUGH THE ARIZONA HOSPITAL ASSOCIATION. LEDBETTER LAW FIRM PLC WAS ENGAGED TO REVIEW AND ANALYZE THE COMPENSATION FOR THE CEO IN JANUARY, 2019. THE BOARD OF DIRECTORS APPROVED THE COMPENSATION RECOMMENDATION. NO PAY ADJUSTMENTS HAVE BEEN PROVIDED SINCE THAT TIME. FORM 990, PART VI, SECTION C, LINE 19 THE ORGANIZATION'S GOVERNING DOCUMENTS, CONFLICT OF INTEREST POLICY, AND FINANCIAL STATEMENTS ARE MADE AVAILABLE TO THE PUBLIC UPON REQUEST. FORM 990, PART IX, LINE 11G CONTRACT LABOR: PROGRAM SERVICE EXPENSES 2,932,666. MANAGEMENT AND GENERAL EXPENSES 13,000. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 2,945,666. PROFESSIONAL FEES - MEDICAL: PROGRAM SERVICE EXPENSES 2,835,420. MANAGEMENT AND GENERAL EXPENSES 0. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 2,835,420. PURCH SVCES-OTHER: PROGRAM SERVICE EXPENSES 1,563,518. MANAGEMENT AND GENERAL EXPENSES 138,727. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 1,702,245. FORM 990, PART XI, LINE 9: CHANGE IN INTEREST IN NET ASSETS OF FOUNDATION -5,991. LITTLE COLORADO HEALTHCARE FOUNDATION 1501 NORTH WILLIAMSON AVENUE WINSLOW AZ 86047 208504703 CHARITABLE AZ 501(C)(3) LINE 11 WINSLOW MEMORIAL HOSPITAL INC 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0