HUMPHREYS COUNTY COMMUNITY HEALTH SERVICES INC: Form 990, tax year 2020
View the entire original 990 at ProPublica ↗
- Organization
- HUMPHREYS COUNTY COMMUNITY HEALTH SERVICES INC (EIN 26-1861676)
- Tax period
- 2020-01-01 to 2020-12-31
- Filed
- 2021-11-10
- IRS object ID
- 202123149349304582
- Schema version
- 2020v4.1
- Source
- Download XML · Original 990 at ProPublica
Every field in the e-filed return. Faint text is the IRS element name, for citing.
Return header ReturnHeader
| Field | Value | IRS element (for citing) |
|---|---|---|
| Return | 2021-11-10T13:26:07-06:00 | ReturnTs |
| Tax Period End | 2020-12-31 | TaxPeriodEndDt |
Preparer Firm PreparerFirmGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Preparer Firm EIN | 621046406 | PreparerFirmEIN |
Preparer Firm Name PreparerFirmName
| Field | Value | IRS element (for citing) |
|---|---|---|
| Business Name Line1 | JOHNSON HICKEY & MURCHISON PC | BusinessNameLine1Txt |
Preparer US Address PreparerUSAddress
| Field | Value | IRS element (for citing) |
|---|---|---|
| Address Line1 | 2215 OLAN MILLS DRIVE | AddressLine1Txt |
| City | CHATTANOOGA | CityNm |
| State Abbreviation | TN | StateAbbreviationCd |
| ZIP | 37421 | ZIPCd |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Return Type | 990 | ReturnTypeCd |
| Tax Period Begin | 2020-01-01 | TaxPeriodBeginDt |
Filer Filer
| Field | Value | IRS element (for citing) |
|---|---|---|
| EIN | 261861676 | EIN |
Business Name BusinessName
| Field | Value | IRS element (for citing) |
|---|---|---|
| Business Name Line1 | HUMPHREYS COUNTY COMMUNITY HEALTH | BusinessNameLine1Txt |
| Business Name Line2 | SERVICES INC | BusinessNameLine2Txt |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Business Name Control | HUMP | BusinessNameControlTxt |
| Phone | 9312960232 | PhoneNum |
US Address USAddress
| Field | Value | IRS element (for citing) |
|---|---|---|
| Address Line1 | 451 HIGHWAY 13 SOUTH | AddressLine1Txt |
| City | WAVERLY | CityNm |
| State Abbreviation | TN | StateAbbreviationCd |
| ZIP | 37185 | ZIPCd |
Business Officer BusinessOfficerGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Person | SHANNON ALLISON | PersonNm |
| Person Title | CFO | PersonTitleTxt |
| Phone | 9312960232 | PhoneNum |
| Signature | 2021-11-09 | SignatureDt |
| Discuss With Paid Preparer | Yes (1) | DiscussWithPaidPreparerInd |
Signing Officer SigningOfficerGrp
Person Full Name PersonFullName
| Field | Value | IRS element (for citing) |
|---|---|---|
| Person First | SHANNON | PersonFirstNm |
| Person Last | ALLISON | PersonLastNm |
| Field | Value | IRS element (for citing) |
|---|---|---|
| SSN | XXX-XX-XXXX | SSN |
Preparer Person PreparerPersonGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Preparer Person | BARRY R HUGGINS | PreparerPersonNm |
| PTIN | P00627334 | PTIN |
| Phone | 4237560052 | PhoneNum |
Additional Filer Information AdditionalFilerInformation
Trusted Customer TrustedCustomerGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Trusted Customer | 2 | TrustedCustomerCd |
| Authentication Assurance Level | AAL1 | AuthenticationAssuranceLevelCd |
| Identity Assurance Level | IAL1 | IdentityAssuranceLevelCd |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Tax | 2020 | TaxYr |
| Build TS | 2022-09-23 18:48:47Z | BuildTS |
Form 990 IRS990
Doing Business As Name DoingBusinessAsName
| Field | Value | IRS element (for citing) |
|---|---|---|
| Business Name Line1 | THREE RIVERS HOSPITAL | BusinessNameLine1Txt |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Principal Officer | SHANNON ALLISON | PrincipalOfficerNm |
US Address USAddress
| Field | Value | IRS element (for citing) |
|---|---|---|
| Address Line1 | 451 HIGHWAY 13 SOUTH | AddressLine1Txt |
| City | WAVERLY | CityNm |
| State Abbreviation | TN | StateAbbreviationCd |
| ZIP | 37185 | ZIPCd |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Gross Receipts | $9,624,981 | GrossReceiptsAmt |
| Group Return For Affiliates | 0 | GroupReturnForAffiliatesInd |
| Organization501c3 | Yes (X) | Organization501c3Ind |
| Website Address | THREERIVERSHOSPITAL.COM | WebsiteAddressTxt |
| Type Of Organization Corp | Yes (X) | TypeOfOrganizationCorpInd |
| Formation | 2008 | FormationYr |
| Legal Domicile State | TN | LegalDomicileStateCd |
| Activity Or Mission | THE MISSION OF THE HOSPITAL IS TO CONTINUOUSLY IMPROVE THE HEALTH OF THE PEOPLE OF ITS COMMUNITY. IN CARRYING OUT ITS MISSION THE HOSPITAL SERVES THE COMMUNITY IN A VARIETY OF WAYS. ONE OF THE PRIMARY WAYS THE HOSPITAL SERVES THE COMMUNITY IS BY PROVIDING CHARITY CARE TO POPULATIONS FOR WHICH IT RECEIVES NO COMPENSATION OR COMPENSATION AT RATES SIGNIFICANTLY LESS THAN THE ESTABLISHED RATES. A LARGE MAJORITY OF THE POPULATION SERVED ARE MEDICARE/TENNCARE PATIENTS.THREE RIVERS HOSPITAL IS COMMITTED TO IMPROVING THE HEALTH IN HUMPHREYS COUNTY BY PROVIDING WELLNESS PROGRAMS, COMMUNITY HEALTH EDUCATION PROGRAMS AND OTHER COMMUNITY BENEFIT ACTIVITIES IDENTIFIED FOR ALL THE STAGES OF LIFE. | ActivityOrMissionDesc |
| Voting Members Governing Body | 10 | VotingMembersGoverningBodyCnt |
| Voting Members Independent | 8 | VotingMembersIndependentCnt |
| Total Employee | 203 | TotalEmployeeCnt |
| Total Volunteers | 1 | TotalVolunteersCnt |
| Total Gross UBI | $0 | TotalGrossUBIAmt |
| Net Unrelated Bus Txbl Incm | $0 | NetUnrelatedBusTxblIncmAmt |
| PY Contributions Grants | $12,247 | PYContributionsGrantsAmt |
| CY Contributions Grants | $1,931,235 | CYContributionsGrantsAmt |
| PY Program Service Revenue | $6,736,786 | PYProgramServiceRevenueAmt |
| CY Program Service Revenue | $7,579,500 | CYProgramServiceRevenueAmt |
| PY Investment Income | $203 | PYInvestmentIncomeAmt |
| CY Investment Income | $5,386 | CYInvestmentIncomeAmt |
| PY Other Revenue | $82,416 | PYOtherRevenueAmt |
| CY Other Revenue | $95,860 | CYOtherRevenueAmt |
| PY Total Revenue | $6,831,652 | PYTotalRevenueAmt |
| CY Total Revenue | $9,611,981 | CYTotalRevenueAmt |
| PY Grants And Similar Paid | $0 | PYGrantsAndSimilarPaidAmt |
| CY Grants And Similar Paid | $0 | CYGrantsAndSimilarPaidAmt |
| PY Benefits Paid To Members | $0 | PYBenefitsPaidToMembersAmt |
| CY Benefits Paid To Members | $0 | CYBenefitsPaidToMembersAmt |
| PY Salaries Comp Emp Bnft Paid | $3,879,080 | PYSalariesCompEmpBnftPaidAmt |
| CY Salaries Comp Emp Bnft Paid | $4,084,334 | CYSalariesCompEmpBnftPaidAmt |
| PY Total Prof Fndrsng Expns | $0 | PYTotalProfFndrsngExpnsAmt |
| CY Total Prof Fndrsng Expns | $0 | CYTotalProfFndrsngExpnsAmt |
| CY Total Fundraising Expense | $0 | CYTotalFundraisingExpenseAmt |
| PY Other Expenses | $3,785,427 | PYOtherExpensesAmt |
| CY Other Expenses | $4,087,092 | CYOtherExpensesAmt |
| PY Total Expenses | $7,664,507 | PYTotalExpensesAmt |
| CY Total Expenses | $8,171,426 | CYTotalExpensesAmt |
| PY Revenues Less Expenses | -$832,855 | PYRevenuesLessExpensesAmt |
| CY Revenues Less Expenses | $1,440,555 | CYRevenuesLessExpensesAmt |
| Total Assets BOY | $1,674,065 | TotalAssetsBOYAmt |
| Total Assets EOY | $5,982,366 | TotalAssetsEOYAmt |
| Total Liabilities BOY | $5,650,348 | TotalLiabilitiesBOYAmt |
| Total Liabilities EOY | $8,518,094 | TotalLiabilitiesEOYAmt |
| Net Assets Or Fund Balances BOY | -$3,976,283 | NetAssetsOrFundBalancesBOYAmt |
| Net Assets Or Fund Balances EOY | -$2,535,728 | NetAssetsOrFundBalancesEOYAmt |
| Mission | THE MISSION OF THE HOSPITAL IS TO CONTINUOUSLY IMPROVE THE HEALTH OF THE PEOPLE OF ITS COMMUNITY. | MissionDesc |
| Significant New Program Srvc | 0 | SignificantNewProgramSrvcInd |
| Significant Change | 0 | SignificantChangeInd |
| Expense | $6,710,245 | ExpenseAmt |
| Revenue | $7,613,201 | RevenueAmt |
| Desc | THREE RIVERS PROVIDES 24 HOUR EMERGENCY ROOM, LABORATORY, PEDIATRIC, SOCIAL SERVICES, CLINICAL DIETICIAN COUNSELING, PHYSICAL THERAPY, RADIOLOGY, RESPIRATORY THERAPY AND SURGERY TO MEMBERS OF THE COMMUNITY INCLUDING THOSE PROVIDED CHARITY CARE. THREE RIVERS PROVIDED 2066 PATIENT DAYS AND 5829 EMERGENCY ROOM VISITS. | Desc |
| Total Program Service Expenses | $6,710,245 | TotalProgramServiceExpensesAmt |
| Described In Section501c3 | Yes (1) | DescribedInSection501c3Ind |
| Schedule B Required | Yes (1) | ScheduleBRequiredInd |
| Political Campaign Acty | 0 | PoliticalCampaignActyInd |
| Lobbying Activities | Yes (1) | LobbyingActivitiesInd |
| Subject To Proxy Tax | 0 | SubjectToProxyTaxInd |
| Donor Advised Fund | 0 | DonorAdvisedFundInd |
| Conservation Easements | 0 | ConservationEasementsInd |
| Collections Of Art | 0 | CollectionsOfArtInd |
| Credit Counseling | 0 | CreditCounselingInd |
| Donor Rstr Or Quasi Endowments | 0 | DonorRstrOrQuasiEndowmentsInd |
| Report Land Building Equipment | Yes (1) | ReportLandBuildingEquipmentInd |
| Report Investments Other Sec | 0 | ReportInvestmentsOtherSecInd |
| Report Program Related Invst | 0 | ReportProgramRelatedInvstInd |
| Report Other Assets | 0 | ReportOtherAssetsInd |
| Report Other Liabilities | Yes (1) | ReportOtherLiabilitiesInd |
| Include FIN48 Footnote | Yes (1) | IncludeFIN48FootnoteInd |
| Independent Audit Fincl Stmt | Yes (1) | IndependentAuditFinclStmtInd |
| Consolidated Audit Fincl Stmt | 0 | ConsolidatedAuditFinclStmtInd |
| School Operating | 0 | SchoolOperatingInd |
| Foreign Office | 0 | ForeignOfficeInd |
| Foreign Activities | 0 | ForeignActivitiesInd |
| More Than5000 K To Org | 0 | MoreThan5000KToOrgInd |
| More Than5000 K To Individuals | 0 | MoreThan5000KToIndividualsInd |
| Professional Fundraising | 0 | ProfessionalFundraisingInd |
| Fundraising Activities | 0 | FundraisingActivitiesInd |
| Gaming Activities | 0 | GamingActivitiesInd |
| Operate Hospital | Yes (1) | OperateHospitalInd |
| Audited Financial Stmt Att | Yes (1) | AuditedFinancialStmtAttInd |
| Grants To Organizations | 0 | GrantsToOrganizationsInd |
| Grants To Individuals | 0 | GrantsToIndividualsInd |
| Schedule J Required | 0 | ScheduleJRequiredInd |
| Tax Exempt Bonds | 0 | TaxExemptBondsInd |
| Engaged In Excess Benefit Trans | 0 | EngagedInExcessBenefitTransInd |
| PY Excess Benefit Trans | 0 | PYExcessBenefitTransInd |
| Loan Outstanding | 0 | LoanOutstandingInd |
| Grant To Related Person | 0 | GrantToRelatedPersonInd |
| Business Rln With Org Mem | 0 | BusinessRlnWithOrgMemInd |
| Business Rln With Fam Mem | 0 | BusinessRlnWithFamMemInd |
| Business Rln With35 Ctrl Ent | 0 | BusinessRlnWith35CtrlEntInd |
| Deductible Non Cash Contri | 0 | DeductibleNonCashContriInd |
| Deductible Art Contribution | 0 | DeductibleArtContributionInd |
| Terminate Operations | 0 | TerminateOperationsInd |
| Partial Liquidation | 0 | PartialLiquidationInd |
| Disregarded Entity | 0 | DisregardedEntityInd |
| Related Entity | 0 | RelatedEntityInd |
| Related Organization Ctrl Ent | 0 | RelatedOrganizationCtrlEntInd |
| Trnsfr Exmpt Non Chrtbl Rltd Org | 0 | TrnsfrExmptNonChrtblRltdOrgInd |
| Activities Conducted Prtshp | 0 | ActivitiesConductedPrtshpInd |
| Schedule O Required | Yes (1) | ScheduleORequiredInd |
| IRP Document | 22 | IRPDocumentCnt |
| IRP Document W2 G | 0 | IRPDocumentW2GCnt |
| Employee | 203 | EmployeeCnt |
| Employment Tax Returns Filed | Yes (1) | EmploymentTaxReturnsFiledInd |
| Unrelated Bus Incm Over Limit | 0 | UnrelatedBusIncmOverLimitInd |
| Foreign Financial Account | 0 | ForeignFinancialAccountInd |
| Prohibited Tax Shelter Trans | 0 | ProhibitedTaxShelterTransInd |
| Taxable Party Notification | 0 | TaxablePartyNotificationInd |
| Nondeductible Contributions | 0 | NondeductibleContributionsInd |
| Quid Pro Quo Contributions | 0 | QuidProQuoContributionsInd |
| Form8282 Property Disposed Of | 0 | Form8282PropertyDisposedOfInd |
| Rcv Fnds To Pay Prsnl Bnft Cntrct | 0 | RcvFndsToPayPrsnlBnftCntrctInd |
| Pay Premiums Prsnl Bnft Cntrct | 0 | PayPremiumsPrsnlBnftCntrctInd |
| Indoor Tanning Services | 0 | IndoorTanningServicesInd |
| Subj To Tax Rmnrtn Ex Prcht Pymt | 0 | SubjToTaxRmnrtnExPrchtPymtInd |
| Subject To Excs Tax Net Invst Inc | 0 | SubjectToExcsTaxNetInvstIncInd |
| Info In Schedule O Part VI | Yes (X) | InfoInScheduleOPartVIInd |
| Governing Body Voting Members | 10 | GoverningBodyVotingMembersCnt |
| Independent Voting Member | 8 | IndependentVotingMemberCnt |
| Family Or Business Rln | 0 | FamilyOrBusinessRlnInd |
| Delegation Of Mgmt Duties | 0 | DelegationOfMgmtDutiesInd |
| Change To Org Documents | 0 | ChangeToOrgDocumentsInd |
| Material Diversion Or Misuse | 0 | MaterialDiversionOrMisuseInd |
| Members Or Stockholders | 0 | MembersOrStockholdersInd |
| Election Of Board Members | 0 | ElectionOfBoardMembersInd |
| Decisions Subject To Approva | 0 | DecisionsSubjectToApprovaInd |
| Minutes Of Governing Body | Yes (1) | MinutesOfGoverningBodyInd |
| Minutes Of Committees | Yes (1) | MinutesOfCommitteesInd |
| Officer Mailing Address | 0 | OfficerMailingAddressInd |
| Local Chapters | 0 | LocalChaptersInd |
| Form990 Provided To Gvrn Body | Yes (1) | Form990ProvidedToGvrnBodyInd |
| Conflict Of Interest Policy | Yes (1) | ConflictOfInterestPolicyInd |
| Annual Disclosure Covered Prsn | Yes (1) | AnnualDisclosureCoveredPrsnInd |
| Regular Monitoring Enfrc | Yes (1) | RegularMonitoringEnfrcInd |
| Whistleblower Policy | Yes (1) | WhistleblowerPolicyInd |
| Document Retention Policy | Yes (1) | DocumentRetentionPolicyInd |
| Compensation Process CEO | Yes (1) | CompensationProcessCEOInd |
| Compensation Process Other | Yes (1) | CompensationProcessOtherInd |
| Investment In Joint Venture | 0 | InvestmentInJointVentureInd |
| States Where Copy Of Return Is Fld | TN | StatesWhereCopyOfReturnIsFldCd |
| Upon Request | Yes (X) | UponRequestInd |
Books In Care Of Detail BooksInCareOfDetail
Business Name BusinessName
| Field | Value | IRS element (for citing) |
|---|---|---|
| Business Name Line1 | SHANNON ALLISON | BusinessNameLine1Txt |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Phone | 9312960232 | PhoneNum |
US Address USAddress
| Field | Value | IRS element (for citing) |
|---|---|---|
| Address Line1 | 451 HIGHWAY 13 SOUTH | AddressLine1Txt |
| City | WAVERLY | CityNm |
| State Abbreviation | TN | StateAbbreviationCd |
| ZIP | 37185 | ZIPCd |
Form990 Part VII Section A Form990PartVIISectionAGrp (13 entries)
| TitleTitleTxt | Average Hours Per WeekAverageHoursPerWeekRt | Individual Trustee Or DirectorIndividualTrusteeOrDirectorInd | Reportable Comp From OrgReportableCompFromOrgAmt | Reportable Comp From Rltd OrgReportableCompFromRltdOrgAmt | Other CompensationOtherCompensationAmt | OfficerOfficerInd |
|---|---|---|---|---|---|---|
| FRANK RUSHTON | ||||||
| BOARD MEMBER | 1.00 | Yes (X) | $0 | $0 | $0 | |
| TED MOORE | ||||||
| BOARD MEMBER | 1.00 | Yes (X) | $0 | $0 | $0 | |
| DANIEL COLLIER | ||||||
| VICE CHAIRMAN | 1.00 | Yes (X) | $0 | $0 | $0 | Yes (X) |
| JOHNNY WHITFIELD | ||||||
| SECRETARY | 1.00 | Yes (X) | $0 | $0 | $0 | Yes (X) |
| KEVIN RYE CPA | ||||||
| TREASURER | 1.00 | Yes (X) | $0 | $0 | $0 | Yes (X) |
| JACKIE BOSWELL | ||||||
| CHAIRMAN | 1.00 | Yes (X) | $0 | $0 | $0 | Yes (X) |
| SUBHI D ALI MD | ||||||
| BOARD MEMBER | 1.00 | Yes (X) | $0 | $0 | $0 | |
| LAWRENCE R JACKSON JR MD | ||||||
| BOARD MEMBER | 1.00 | Yes (X) | $0 | $0 | $0 | |
| DR GEORGE MATHAI | ||||||
| CHIEF OF MEDICAL STAFF | 1.00 | Yes (X) | $0 | $0 | $0 | Yes (X) |
| FREDA RUSSELL | ||||||
| CEO | 40.00 | Yes (X) | $125,305 | $0 | $9,449 | Yes (X) |
| SHANNON ALLISON | ||||||
| CFO | 40.00 | $80,217 | $0 | $785 | Yes (X) | |
| HEATHER THOMPSON | ||||||
| CNO | 40.00 | $65,833 | $0 | $608 | Yes (X) | |
| ALANA PETERS | ||||||
| CNO | 40.00 | $18,861 | $0 | $2,298 | Yes (X) | |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Reportable Comp From Org | $290,216 | TotalReportableCompFromOrgAmt |
| Tot Reportable Comp Rltd Org | $0 | TotReportableCompRltdOrgAmt |
| Total Other Compensation | $13,140 | TotalOtherCompensationAmt |
| Indiv Rcvd Greater Than100 K | 1 | IndivRcvdGreaterThan100KCnt |
| Former Ofcr Employees Listed | 0 | FormerOfcrEmployeesListedInd |
| Total Comp Greater Than150 K | 0 | TotalCompGreaterThan150KInd |
| Compensation From Other Srcs | 0 | CompensationFromOtherSrcsInd |
Contractor Compensation ContractorCompensationGrp (2 entries)
| Address Line1ContractorAddress/USAddress/AddressLine1Txt | CityContractorAddress/USAddress/CityNm | State AbbreviationContractorAddress/USAddress/StateAbbreviationCd | ZIPContractorAddress/USAddress/ZIPCd | ServicesServicesDesc | CompensationCompensationAmt |
|---|---|---|---|---|---|
| CONCORD MEDICAL GROUP | |||||
| 3004 50TH STREET SUITE D | LUBBOCK | TX | 794134129 | ER PHYSICIANS | $690,580 |
| RIVER VALLEY PHYSICAL THERAPY | |||||
| PO BOX 441 | CAMDEN | TN | 38320 | THERAPY SERVICES | $213,881 |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Cntrct Rcvd Greater Than100 K | 2 | CntrctRcvdGreaterThan100KCnt |
| Government Grants | $1,915,342 | GovernmentGrantsAmt |
| All Other Contributions | $15,893 | AllOtherContributionsAmt |
| Total Contributions | $1,931,235 | TotalContributionsAmt |
Program Service Revenue ProgramServiceRevenueGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Desc | NET PATIENT REVENUE | Desc |
| Business | 621990 | BusinessCd |
| Total Revenue Column | $7,579,500 | TotalRevenueColumnAmt |
| Related Or Exempt Func Income | $7,579,500 | RelatedOrExemptFuncIncomeAmt |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Program Service Revenue | $7,579,500 | TotalProgramServiceRevenueAmt |
Investment Income InvestmentIncomeGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Revenue Column | $3,273 | TotalRevenueColumnAmt |
| Exclusion | $3,273 | ExclusionAmt |
Gross Rents GrossRentsGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Real | $62,159 | RealAmt |
Less Rental Expenses LessRentalExpensesGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Real | $0 | RealAmt |
Rental Income Or Loss RentalIncomeOrLossGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Real | $62,159 | RealAmt |
Net Rental Income Or Loss NetRentalIncomeOrLossGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Revenue Column | $62,159 | TotalRevenueColumnAmt |
| Exclusion | $62,159 | ExclusionAmt |
Gross Amount Sales Assets GrossAmountSalesAssetsGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Other | $15,113 | OtherAmt |
Less Cost Oth Basis Sales Expnss LessCostOthBasisSalesExpnssGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Other | $13,000 | OtherAmt |
Gain Or Loss GainOrLossGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Other | $2,113 | OtherAmt |
Net Gain Or Loss Investments NetGainOrLossInvestmentsGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Revenue Column | $2,113 | TotalRevenueColumnAmt |
| Exclusion | $2,113 | ExclusionAmt |
Other Revenue Misc OtherRevenueMiscGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Desc | OTHER INCOME | Desc |
| Business | 621990 | BusinessCd |
| Total Revenue Column | $33,701 | TotalRevenueColumnAmt |
| Related Or Exempt Func Income | $33,701 | RelatedOrExemptFuncIncomeAmt |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Other Revenue Total | $33,701 | OtherRevenueTotalAmt |
Total Revenue TotalRevenueGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Revenue Column | $9,611,981 | TotalRevenueColumnAmt |
| Related Or Exempt Func Income | $7,613,201 | RelatedOrExemptFuncIncomeAmt |
| Unrelated Business Revenue | $0 | UnrelatedBusinessRevenueAmt |
| Exclusion | $67,545 | ExclusionAmt |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Info In Schedule O Part IX | Yes (X) | InfoInScheduleOPartIXInd |
Comp Current Ofcr Directors CompCurrentOfcrDirectorsGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $303,356 | TotalAmt |
| Program Services | $268,077 | ProgramServicesAmt |
| Management And General | $35,279 | ManagementAndGeneralAmt |
Other Salaries And Wages OtherSalariesAndWagesGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $3,269,623 | TotalAmt |
| Program Services | $2,605,556 | ProgramServicesAmt |
| Management And General | $664,067 | ManagementAndGeneralAmt |
Pension Plan Contributions PensionPlanContributionsGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $7,983 | TotalAmt |
| Program Services | $6,420 | ProgramServicesAmt |
| Management And General | $1,563 | ManagementAndGeneralAmt |
Other Employee Benefits OtherEmployeeBenefitsGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $284,656 | TotalAmt |
| Program Services | $228,940 | ProgramServicesAmt |
| Management And General | $55,716 | ManagementAndGeneralAmt |
Payroll Taxes PayrollTaxesGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $218,716 | TotalAmt |
| Program Services | $175,906 | ProgramServicesAmt |
| Management And General | $42,810 | ManagementAndGeneralAmt |
Fees For Services Legal FeesForServicesLegalGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $12,362 | TotalAmt |
| Management And General | $12,362 | ManagementAndGeneralAmt |
Fees For Services Accounting FeesForServicesAccountingGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $43,500 | TotalAmt |
| Management And General | $43,500 | ManagementAndGeneralAmt |
Fees For Services Other FeesForServicesOtherGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $1,245,489 | TotalAmt |
| Program Services | $881,124 | ProgramServicesAmt |
| Management And General | $364,365 | ManagementAndGeneralAmt |
Advertising AdvertisingGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $1,914 | TotalAmt |
| Management And General | $1,914 | ManagementAndGeneralAmt |
Occupancy OccupancyGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $191,581 | TotalAmt |
| Program Services | $149,238 | ProgramServicesAmt |
| Management And General | $42,343 | ManagementAndGeneralAmt |
Travel TravelGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $1,688 | TotalAmt |
| Program Services | $1,171 | ProgramServicesAmt |
| Management And General | $517 | ManagementAndGeneralAmt |
Interest InterestGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $170,811 | TotalAmt |
| Program Services | $130,500 | ProgramServicesAmt |
| Management And General | $40,311 | ManagementAndGeneralAmt |
Depreciation Depletion DepreciationDepletionGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $201,995 | TotalAmt |
| Program Services | $154,324 | ProgramServicesAmt |
| Management And General | $47,671 | ManagementAndGeneralAmt |
Insurance InsuranceGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $117,230 | TotalAmt |
| Program Services | $117,230 | ProgramServicesAmt |
Other Expenses OtherExpensesGrp (4 entries)
| DescDesc | TotalTotalAmt | Program ServicesProgramServicesAmt | Management And GeneralManagementAndGeneralAmt |
|---|---|---|---|
| BAD DEBT | $1,047,830 | $1,047,830 | |
| OTHER SUPPLIES AND EXPE | $604,687 | $511,329 | $93,358 |
| MEDICAL SUPPLIES DRUGS | $239,396 | $239,396 | |
| REPAIRS AND MAINTENANCE | $188,618 | $182,397 | $6,221 |
All Other Expenses AllOtherExpensesGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $19,991 | TotalAmt |
| Program Services | $10,807 | ProgramServicesAmt |
| Management And General | $9,184 | ManagementAndGeneralAmt |
Total Functional Expenses TotalFunctionalExpensesGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $8,171,426 | TotalAmt |
| Program Services | $6,710,245 | ProgramServicesAmt |
| Management And General | $1,461,181 | ManagementAndGeneralAmt |
| Fundraising | $0 | FundraisingAmt |
Savings And Temp Cash Invst SavingsAndTempCashInvstGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $4,681 | BOYAmt |
| EOY | $3,685,901 | EOYAmt |
Accounts Receivable AccountsReceivableGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $739,082 | BOYAmt |
| EOY | $969,896 | EOYAmt |
Inventories For Sale Or Use InventoriesForSaleOrUseGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $142,149 | BOYAmt |
| EOY | $164,854 | EOYAmt |
Prepaid Expenses Defrd Charges PrepaidExpensesDefrdChargesGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $27,427 | BOYAmt |
| EOY | $35,922 | EOYAmt |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Land Bldg Equip Cost Or Other Bss | $5,862,836 | LandBldgEquipCostOrOtherBssAmt |
| Land Bldg Equip Accum Deprec | $5,012,860 | LandBldgEquipAccumDeprecAmt |
Land Bldg Equip Basis Net LandBldgEquipBasisNetGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $725,879 | BOYAmt |
| EOY | $849,976 | EOYAmt |
Investments Other Securities InvestmentsOtherSecuritiesGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $19,237 | BOYAmt |
| EOY | $22,355 | EOYAmt |
Other Assets Total OtherAssetsTotalGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $15,610 | BOYAmt |
| EOY | $253,462 | EOYAmt |
Total Assets TotalAssetsGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $1,674,065 | BOYAmt |
| EOY | $5,982,366 | EOYAmt |
Accounts Payable Accr Expnss AccountsPayableAccrExpnssGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $1,403,124 | BOYAmt |
| EOY | $979,578 | EOYAmt |
Mortg Notes Pybl Scrd Invst Prop MortgNotesPyblScrdInvstPropGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $4,023,527 | BOYAmt |
| EOY | $3,794,042 | EOYAmt |
Other Liabilities OtherLiabilitiesGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $223,697 | BOYAmt |
| EOY | $3,744,474 | EOYAmt |
Total Liabilities TotalLiabilitiesGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $5,650,348 | BOYAmt |
| EOY | $8,518,094 | EOYAmt |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Organization Follows FASB117 | Yes (X) | OrganizationFollowsFASB117Ind |
No Donor Restriction Net Assets NoDonorRestrictionNetAssetsGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | -$3,976,283 | BOYAmt |
| EOY | -$2,535,728 | EOYAmt |
Total Net Assets Fund Balance TotalNetAssetsFundBalanceGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | -$3,976,283 | BOYAmt |
| EOY | -$2,535,728 | EOYAmt |
Tot Liab Net Assets Fund Balance TotLiabNetAssetsFundBalanceGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $1,674,065 | BOYAmt |
| EOY | $5,982,366 | EOYAmt |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Reconcilation Revenue Expnss | $1,440,555 | ReconcilationRevenueExpnssAmt |
| Other Changes In Net Assets | $0 | OtherChangesInNetAssetsAmt |
| Method Of Accounting Accrual | Yes (X) | MethodOfAccountingAccrualInd |
| Accountant Compile Or Review | 0 | AccountantCompileOrReviewInd |
| FS Audited | Yes (1) | FSAuditedInd |
FS Audited Basis FSAuditedBasisGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Separate Basis Fincl Stmt | Yes (X) | SeparateBasisFinclStmtInd |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Audit Committee | Yes (1) | AuditCommitteeInd |
| Federal Grant Audit Required | 0 | FederalGrantAuditRequiredInd |
Schedule A IRS990ScheduleA
| Field | Value | IRS element (for citing) |
|---|---|---|
| Hospital | Yes (X) | HospitalInd |
Schedule B IRS990ScheduleB
Contributor Information ContributorInformationGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Contributor | RESTRICTED | ContributorNum |
Contributor Business Name ContributorBusinessName
| Field | Value | IRS element (for citing) |
|---|---|---|
| Business Name Line1 | RESTRICTED | BusinessNameLine1 |
Contributor US Address ContributorUSAddress
| Field | Value | IRS element (for citing) |
|---|---|---|
| Address Line1 | RESTRICTED | AddressLine1 |
| Address Line2 | RESTRICTED | AddressLine2 |
| City | RESTRICTED | City |
| State | RESTRICTED | State |
| ZIP Code | RESTRICTED | ZIPCode |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Contributions | RESTRICTED | TotalContributionsAmt |
Schedule C IRS990ScheduleC
| Field | Value | IRS element (for citing) |
|---|---|---|
| Volunteers | 0 | VolunteersInd |
| Paid Staff Or Management | 0 | PaidStaffOrManagementInd |
| Media Advertisements | 0 | MediaAdvertisementsInd |
| Mailings Members | 0 | MailingsMembersInd |
| Publications Or Broadcast | 0 | PublicationsOrBroadcastInd |
| Grants Other Organizations | Yes (1) | GrantsOtherOrganizationsInd |
| Grants Other Organizations | $1,051 | GrantsOtherOrganizationsAmt |
| Direct Contact Legislators | 0 | DirectContactLegislatorsInd |
| Rallies Demonstrations | 0 | RalliesDemonstrationsInd |
| Other Activities | 0 | OtherActivitiesInd |
| Total Lobbying Expenditures | $1,051 | TotalLobbyingExpendituresAmt |
| Not Described Section501c3 | 0 | NotDescribedSection501c3Ind |
Supplemental Information Detail SupplementalInformationDetail
| Field | Value | IRS element (for citing) |
|---|---|---|
| Form And Line Reference | PART II-B, LINE 1: | FormAndLineReferenceDesc |
| Explanation | PART OF HOSPITAL DUES. | ExplanationTxt |
Schedule D IRS990ScheduleD
Land LandGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Other Cost Or Other Basis | $313,716 | OtherCostOrOtherBasisAmt |
| Book Value | $313,716 | BookValueAmt |
Buildings BuildingsGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Other Cost Or Other Basis | $2,041,475 | OtherCostOrOtherBasisAmt |
| Depreciation | $1,904,200 | DepreciationAmt |
| Book Value | $137,275 | BookValueAmt |
Equipment EquipmentGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Other Cost Or Other Basis | $3,507,645 | OtherCostOrOtherBasisAmt |
| Depreciation | $3,108,660 | DepreciationAmt |
| Book Value | $398,985 | BookValueAmt |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Book Value Land Buildings | $849,976 | TotalBookValueLandBuildingsAmt |
Other Liabilities Org OtherLiabilitiesOrgGrp (4 entries)
| DescDesc | AmtAmt |
|---|---|
| ESTIMATED THIRD PARTY SETTLEMENT | $1,394,300 |
| PPP PROTECTION PROGRAM LOAN | $609,355 |
| COVID-19 ECONOMIC INJURY DISASTER LOAN | $150,000 |
| CARES PROVIDER RELIEF FUNDS REFUNDABLE ADVANCE | $1,590,819 |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Liability | $3,744,474 | TotalLiabilityAmt |
| Footnote Text | Yes (X) | FootnoteTextInd |
| Total Rev Etc Audited Fincl Stmt | $8,564,151 | TotalRevEtcAuditedFinclStmtAmt |
| Revenue Not Reported | $0 | RevenueNotReportedAmt |
| Revenue Subtotal | $8,564,151 | RevenueSubtotalAmt |
| Other Revenues Not Included | $1,047,830 | OtherRevenuesNotIncludedAmt |
| Revenue Not Reported Fincl Stmt | $1,047,830 | RevenueNotReportedFinclStmtAmt |
| Total Revenue Per Form990 | $9,611,981 | TotalRevenuePerForm990Amt |
| Tot Expns Etc Audited Fincl Stmt | $7,123,596 | TotExpnsEtcAuditedFinclStmtAmt |
| Expenses Not Reported | $0 | ExpensesNotReportedAmt |
| Expenses Subtotal | $7,123,596 | ExpensesSubtotalAmt |
| Other Expenses Not Included | $1,047,830 | OtherExpensesNotIncludedAmt |
| Expenses Not Rpt Fincl Stmt | $1,047,830 | ExpensesNotRptFinclStmtAmt |
| Total Expenses Per Form990 | $8,171,426 | TotalExpensesPerForm990Amt |
Supplemental Information Detail SupplementalInformationDetail (3 entries)
| Form And Line ReferenceFormAndLineReferenceDesc | ExplanationExplanationTxt |
|---|---|
| PART X, LINE 2: | UNCERTAIN TAX POSITIONS - THE HOSPITAL IS EXEMPT FROM FEDERAL INCOME TAXES UNDER 501(C)(3) OF THE INTERNAL REVENUE CODE. THE HOSPITAL BELIEVES THAT IT HAS APPROPRIATE SUPPORT FOR ANY TAX POSITIONS TAKEN, AND AS SUCH, DOES NOT HAVE ANY UNCERTAIN TAX POSITIONS THAT ARE MATERIAL TO THE FINANCIAL STATEMENTS. THE HOSPITAL'S FORMS 990, RETURN OF ORGANIZATION EXEMPT FROM INCOME TAX, FOR THE YEARS ENDING 2017, 2018, AND 2019 ARE SUBJECT TO EXAMINATION BY THE IRS, GENERALLY FOR 3 YEARS AFTER THEY WERE FILED. |
| PART XI, LINE 4B - OTHER ADJUSTMENTS: | BAD DEBT 1,047,830. |
| PART XII, LINE 4B - OTHER ADJUSTMENTS: | BAD DEBT 1,047,830. |
Schedule H IRS990ScheduleH
| Field | Value | IRS element (for citing) |
|---|---|---|
| Financial Assistance Policy | Yes (1) | FinancialAssistancePolicyInd |
| Written Policy | Yes (1) | WrittenPolicyInd |
| FPG Reference Free Care | Yes (1) | FPGReferenceFreeCareInd |
| Percent100 | Yes (X) | Percent100Ind |
| FPG Reference Discounted Care | Yes (1) | FPGReferenceDiscountedCareInd |
Discounted Care Oth Percentage DiscountedCareOthPercentageGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Other | Yes (X) | OtherInd |
| Discounted Care Other | 150.000000000000 | DiscountedCareOtherPct |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Free Care Medically Indigent | Yes (1) | FreeCareMedicallyIndigentInd |
| Financial Assistance Budget | Yes (1) | FinancialAssistanceBudgetInd |
| Expenses Exceed Budget | 0 | ExpensesExceedBudgetInd |
| Annual Community Bnft Report | 0 | AnnualCommunityBnftReportInd |
Financial Assistance At Cost Typ FinancialAssistanceAtCostTyp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Community Benefit Expns | $22,233 | TotalCommunityBenefitExpnsAmt |
| Net Community Benefit Expns | $22,233 | NetCommunityBenefitExpnsAmt |
| Total Expense | 0.00310 | TotalExpensePct |
Unreimbursed Medicaid UnreimbursedMedicaidGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Community Benefit Expns | $683,355 | TotalCommunityBenefitExpnsAmt |
| Direct Offsetting Revenue | $1,676,186 | DirectOffsettingRevenueAmt |
| Net Community Benefit Expns | $0 | NetCommunityBenefitExpnsAmt |
| Total Expense | 0.00000 | TotalExpensePct |
Total Financial Assistance Typ TotalFinancialAssistanceTyp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Community Benefit Expns | $705,588 | TotalCommunityBenefitExpnsAmt |
| Direct Offsetting Revenue | $1,676,186 | DirectOffsettingRevenueAmt |
| Net Community Benefit Expns | $22,233 | NetCommunityBenefitExpnsAmt |
| Total Expense | 0.00310 | TotalExpensePct |
Community Health Services CommunityHealthServicesGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Community Benefit Expns | $4,928 | TotalCommunityBenefitExpnsAmt |
| Net Community Benefit Expns | $4,928 | NetCommunityBenefitExpnsAmt |
| Total Expense | 0.00070 | TotalExpensePct |
Total Other Benefits TotalOtherBenefitsGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Community Benefit Expns | $4,928 | TotalCommunityBenefitExpnsAmt |
| Net Community Benefit Expns | $4,928 | NetCommunityBenefitExpnsAmt |
| Total Expense | 0.00070 | TotalExpensePct |
Total Community Benefits TotalCommunityBenefitsGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Community Benefit Expns | $710,516 | TotalCommunityBenefitExpnsAmt |
| Direct Offsetting Revenue | $1,676,186 | DirectOffsettingRevenueAmt |
| Net Community Benefit Expns | $27,161 | NetCommunityBenefitExpnsAmt |
| Total Expense | 0.00380 | TotalExpensePct |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Bad Debt Expense Reported | Yes (1) | BadDebtExpenseReportedInd |
| Bad Debt Expense | $1,158,470 | BadDebtExpenseAmt |
| Bad Debt Expense Attributable | $811,330 | BadDebtExpenseAttributableAmt |
| Reimbursed By Medicare | $2,867,831 | ReimbursedByMedicareAmt |
| Cost Of Care Reimbursed By Medcr | $2,867,831 | CostOfCareReimbursedByMedcrAmt |
Costing Methodology Used CostingMethodologyUsedGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Cost To Charge Ratio | Yes (X) | CostToChargeRatioInd |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Written Debt Collection Policy | Yes (1) | WrittenDebtCollectionPolicyInd |
| Financial Assistance Prvsn | Yes (1) | FinancialAssistancePrvsnInd |
| Hospital Facilities | 1 | HospitalFacilitiesCnt |
Hospital Facilities HospitalFacilitiesGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Facility | 1 | FacilityNum |
Business Name BusinessName
| Field | Value | IRS element (for citing) |
|---|---|---|
| Business Name Line1 | THREE RIVERS HOSPITAL | BusinessNameLine1Txt |
US Address USAddress
| Field | Value | IRS element (for citing) |
|---|---|---|
| Address Line1 | 451 HIGHWAY 13 SOUTH | AddressLine1Txt |
| City | WAVERLY | CityNm |
| State Abbreviation | TN | StateAbbreviationCd |
| ZIP | 37185 | ZIPCd |
| Field | Value | IRS element (for citing) |
|---|---|---|
| State License | 00000036 | StateLicenseNum |
| Licensed Hospital | Yes (X) | LicensedHospitalInd |
| General Medical And Surgical | Yes (X) | GeneralMedicalAndSurgicalInd |
| Emergency Room24 Hrs | Yes (X) | EmergencyRoom24HrsInd |
Hospital Fclty Policies Prctc HospitalFcltyPoliciesPrctcGrp
Hospital Facility Name HospitalFacilityName
| Field | Value | IRS element (for citing) |
|---|---|---|
| Business Name Line1 | HUMPHREYS COUNTY COMMUNITY HEALTH | BusinessNameLine1Txt |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Facility | 1 | FacilityNum |
| First Licensed CY Or PY | 0 | FirstLicensedCYOrPYInd |
| Tax Exempt Hospital CY Or PY | 0 | TaxExemptHospitalCYOrPYInd |
| CHNA Conducted | Yes (1) | CHNAConductedInd |
| Community Definition | Yes (X) | CommunityDefinitionInd |
| Community Demographics | Yes (X) | CommunityDemographicsInd |
| Existing Resources | Yes (X) | ExistingResourcesInd |
| How Data Obtained | Yes (X) | HowDataObtainedInd |
| Community Health Needs | Yes (X) | CommunityHealthNeedsInd |
| Other Health Issues | Yes (X) | OtherHealthIssuesInd |
| Community Hlth Needs Id Process | Yes (X) | CommunityHlthNeedsIdProcessInd |
| Consulting Process | Yes (X) | ConsultingProcessInd |
| Prior CHNA Impact | Yes (X) | PriorCHNAImpactInd |
| CHNA Conducted | 20 | CHNAConductedYr |
| Take Into Account Others Input | Yes (1) | TakeIntoAccountOthersInputInd |
| CHNA Conducted With Other Fclts | 0 | CHNAConductedWithOtherFcltsInd |
| CHNA Conducted With Non Fclts | 0 | CHNAConductedWithNonFcltsInd |
| CHNA Report Widely Available | Yes (1) | CHNAReportWidelyAvailableInd |
| Rpt Available On Own Website | Yes (X) | RptAvailableOnOwnWebsiteInd |
| Own Website URL | THREERIVERSHOSPITAL.COM | OwnWebsiteURLTxt |
| Paper Copy Public Inspection | Yes (X) | PaperCopyPublicInspectionInd |
| Implementation Strategy Adopt | Yes (1) | ImplementationStrategyAdoptInd |
| Implementation Strategy Adpt | 20 | ImplementationStrategyAdptYr |
| Strategy Posted Website | Yes (1) | StrategyPostedWebsiteInd |
| Strategy Website URL | THREERIVERSHOSPITAL.COM | StrategyWebsiteURLTxt |
| Organization Incur Excise Tax | 0 | OrganizationIncurExciseTaxInd |
| Elig Criteria Explained | Yes (1) | EligCriteriaExplainedInd |
| FPG Family Incm Lmt Free Dscnt | Yes (X) | FPGFamilyIncmLmtFreeDscntInd |
| FPG Family Incm Lmt Free Care | 200.000000000000 | FPGFamilyIncmLmtFreeCarePct |
| FPG Family Incm Lmt Dscnt Care | 275.000000000000 | FPGFamilyIncmLmtDscntCarePct |
| Income Level Criteria | Yes (X) | IncomeLevelCriteriaInd |
| Medical Indigency Criteria | Yes (X) | MedicalIndigencyCriteriaInd |
| Underinsurance Stat Criteria | Yes (X) | UnderinsuranceStatCriteriaInd |
| Explained Basis | Yes (1) | ExplainedBasisInd |
| App Financial Asst Expln | Yes (1) | AppFinancialAsstExplnInd |
| Includes Publicity Measures | Yes (1) | IncludesPublicityMeasuresInd |
| FAP Avlbl On Request No Charge | Yes (X) | FAPAvlblOnRequestNoChargeInd |
| Other Publicity | Yes (X) | OtherPublicityInd |
| FAP Actions On Nonpayment | Yes (1) | FAPActionsOnNonpaymentInd |
| Permit Other Actions | Yes (X) | PermitOtherActionsInd |
| Collection Activities | Yes (1) | CollectionActivitiesInd |
| Reporting To Credit Agency | Yes (X) | ReportingToCreditAgencyInd |
| Engaged Legal Judicial Process | Yes (X) | EngagedLegalJudicialProcessInd |
| Made Effort Orally Notify | Yes (X) | MadeEffortOrallyNotifyInd |
| Processed FAP Application | Yes (X) | ProcessedFAPApplicationInd |
| Nondis Emergency Care Policy | Yes (1) | NondisEmergencyCarePolicyInd |
| Look Back Medicare Private | Yes (X) | LookBackMedicarePrivateInd |
| Amounts Generally Billed | 0 | AmountsGenerallyBilledInd |
| Gross Charges | 0 | GrossChargesInd |
Supplemental Information SupplementalInformationGrp (4 entries)
| Form And Line ReferenceFormAndLineReferenceDesc | ExplanationExplanationTxt |
|---|---|
| HUMPHREYS COUNTY COMMUNITY HEALTH | PART V, SECTION B, LINE 5: BOTH PRIMARY AND SECONDARY DATA SOURCES WERE USED IN THE CHNA. PRIMARY METHODS INCLUDED 20 INDIVIDUAL INTERVIEWS WITH COMMUNITY MEMBERS. SECONDARY METHODS INCLUDED PUBLIC HEALTH DATA-DEATH STATISTICS, COUNTY HEALTH RANKINGS, CANCER INCIDENCE, DEMOGRAPHICS AND SOCIOECONOMICS-POPULATION, POVERTY, UNINSURED,UNEMPLOYMENT, PSYCHOGRAPHICS-BEHAVIOR MEASURED BY SPENDING AND MEDIA PREFERENCES. |
| HUMPHREYS COUNTY COMMUNITY HEALTH | PART V, SECTION B, LINE 11: THREE RIVERS HOSPITAL IS TEAMING UP WITH OTHER COMMUNITY AGENCIES, ORGANIZATIONS AND INSTITUTIONS TO HELP ADDRESS THE UNMET HEALTH NEEDS OF HUMPHREYS COUNTY. WITH THIS COMMUNITY PARTICIPATION, THE PRIORITY GOALS WERE SELECTED AND WORK BEGAN ON STRATEGIES TO IMPROVE THE HEALTH NEEDS IN OUR COMMUNITY. SOME OF THE PARTNERS THAT PARTICIPATED IN THE ASSESSMENT AND ACTION PLAN AND CONTINUE THREE RIVERS HOSPITAL WANTS TO PROVIDE HIGH QUALITY, COST EEFECTIVE, AND COMPASSIONATE CARE THAT IS RESPONSIVE TO THE COMMUNITIES WE SERVE. THIS IMPLEMENTATION ACTION PLAN WILL DIRECT OUR EFFORTS IN WORKING TO ADDRESS SOME OF THE UNMET HEALTH NEEDS OF OUR COMMUNITY.FOURTEEN DISTINCT NEEDS WERE IDENTIFIED BUT BASED ON INPUT FROM THE PRIORITIZATION AT THE COMMUNITY SUMMIT, THREE RIVER HOSPITAL CHOSE THESE PRIORITIES: (1)HEALTHY EATING/ACTIVE LIVING (2)CHRONIC DISEASE-DIABETES, HEART DISEASE AND CANCER DEATHS (3)ACCESS TO PRIMARY CARE, DENTAL SERVICES, MENTAL HEALTH AND INSURANCE (4)SUBSTANCE USE DISORDER. TO ADDRESS THESE NEEDS VARIOUS AGENCIES ARE WORKING WITH THREE RIVERS HOSPITAL TO PROVIDE MORE EDUCATION, INCREASE PHYSICAL ACTIVITY,IMPROVE NUTRITION,PROVIDE MORE SCREENINGS, AND PROVIDE MORE ACCESS TO AFFORDABLE EXERCISE FACILITIES IN THE COMMUNITY. TO HELP WITH THESE EFFORTS ARE: HUMPHREYS COUNTY HEALTH COUNCIL, HUMPHREYS COUNTY COORDINATED SCHOOL HEALTH, HUMPHREYS COUNTY HEALTH DEPARTMENT, HUMPHREYS COUNTY CHAMBER OF COMMERCE, AND HUMPHREYS COUNTY UT EXTENSION SERVICES. |
| HUMPHREYS COUNTY COMMUNITY HEALTH | PART V, SECTION B, LINE 16J: CHARITY CARE MUST BE REQUESTED BY THE PATIENT. IF A PATIENT INDICATES THAT THEY CAN NOT PAY, A CHARITY APPLICATION IS SUGGESTED. THERE ARE NOTICES POSTED IN THE REGISTRATION AREAS INDICATING THAT THE HOSPITAL GIVES CHARITY CARE AND HOW TO OBTAIN FURTHER INFORMATION ABOUT CHARITY CARE. |
| HUMPHREYS COUNTY COMMUNITY HEALTH | PART V, SECTION B, LINE 18E: WHATEVER IS DEEMED NECESSARY BY COLLECTION AGENCY. |
Supplemental Information Detail SupplementalInformationDetail (10 entries)
| Form And Line ReferenceFormAndLineReferenceDesc | ExplanationExplanationTxt |
|---|---|
| PART I, LINE 7: | HOSPITAL USES THE COST TO CHARGE RATIO IN DETERMINING THE AMOUNT OF THE ORGANIZATION'S BAD DEBT EXPENSE AT COST AND APPLIES AN ESTIMATE OF THE PERCENTAGE OF BAD DEBT COST TO DETERMINE THE AMOUNT ATTRIBUTABLE TO PATIENTS ELIGIBLE UNDER THE HOSPITAL'S FINANCIAL ASSISTANCE POLICY. |
| PART I, LN 7 COL(F): | HOSPITAL POLICIES STATE THAT A BAD DEBT IS AN ACCOUNT ON WHICH THERE HAS BEEN NO SIGNIFICANT PAYMENT ACTIVITY FOR A PERIOD OF THREE MONTHS. AGING WILL COMMENCE WITH THE DAY OF DISCHARGE OR THE DAY OF LAST PAYMENT. |
| PART III, LINE 4: | NET PATIENT REVENUE IS REPORTED AT THE AMOUNT THAT REFLECTS THE CONSIDERATION TO WHICH THE HOSPITAL EXPECTS TO BE ENTITLED FOR PROVIDING PATIENT CARE. THESE AMOUNTS ARE DUE FROM THE PATIENTS, THIRD PARTY PAYORS, AND OTHERS AND INCLUDE VARIABLE CONSIDERATION FOR RETROACTIVE REVENUE ADJUSTMENTS DUE TO SETTLEMENT OF REVIEWS AND AUDITS. GENERALLY THE HOSPITAL BILLS THE PATIENTS AND THIRD-PARTY PAYORS SEVERAL DAYS AFTER THE SERVICES ARE PERFORMED OR SHORTLY AFTER DISCHARGE. REVENUE IS RECOGNIZED AS PERFORMANCE OBLIGATIONS ARE SATIFIED.THE HOSPITAL IMPLEMENTED ASU 2014-09 USING A FULL RETROSPECTIVE METHOD OF APPLICATION. THE ADOPTION OF ASU 2014-09 RESULTED IN CHANGES TO TH RECOGNITION OR PRESENTATION OF REVENUE AS A RESULT OF THE APPLICATION OF ASU 2014-09. AS A RESULT, NO CUMULATIVE EFFECT ADJUSTMENT WAS RECORDED UPON ADOPTION. |
| PART III, LINE 8: | MANY ACCOUNTS ARE LEFT WITH A LARGE PATIENT PORTION AFTER MEDICARE HAS PAID. THERE ARE NO SERVICES THAT ARE EXEMPT FROM CHARITY CARE. THE DETERMINATION TO TREAT A PATIENT IS NOT BASED ON THEIR ABILITY TO PAY. REVENUE IS EQUAL TO THE COST REIMBURSEMENT FOR ALLOWABLE EXPENSE. |
| PART III, LINE 9B: | ALL PATIENT ACCOUNTS WILL BE CLASSIFIED BY PRIMARY SOURCE OF PAYMENT. THESE ARE MEDICARE, BLUE CROSS, SELF PAY, AND OTHER. ANY ACCOUNT WHICH AGES TO 90 DAYS WITHOUT SIGNIFICANT ACTIVITY WILL BE TURNED OVER TO COLLECTION AGENCIES, BANK COLLECTION OR TAX ASSESSOR'S OFFICE AS APPROPRIATE. WHEN AN ACCOUNT IS DETERMINED TO BE ABLE BUT UNWILLING TO PAY, THE ACCOUNT SHOULD BE TURNED OVER FOR COLLECTION REGARDLESS OF IT'S AGE. |
| NEEDS ASSESSMENT | THREE RIVERS HOSPITAL ASSESSES THE HEALTH CARE NEEDS OF THE COMMUNITY IN THE FOLLOWING WAYS: (1) PARTICIPATING IN THE COMMUNITY HEALTH COUNCIL WHICH CONSIDERS ALL HEALTH CARE NEEDS FOR THE AREA, (2) INTERACTING WITH THE MEDICAL STAFF AND NURSE PRACTITIONERS TO ASCERTAIN THEIR NEEDS FOR THE CARE OF THE PATIENTS THEY ARE SEEING AND (3) ASSESSING DATA BANKS TO DETERMINE WHAT NEEDS ARE BEING MET BY OTHER HEALTH CARE PROVIDERS OUTSIDE OF THE SERVICE AREA. |
| PATIENT EDUCATION OF ELIGIBILITY FOR ASSISTANCE | CHARITY CARE MUST BE REQUESTED BY THE PATIENT. IF A PATIENT INDICATES THAT THEY CAN NOT PAY, A CHARITY APPLICATION IS SUGGESTED. THERE ARE NOTICES POSTED IN THE REGISTRATION AREAS INDICATING THAT THE HOSPITAL GIVES CHARITY CARE AND HOW TO OBTAIN FURTHER INFORMATION ABOUT CHARITY CARE. |
| COMMUNITY INFORMATION | THREE RIVERS HOSPITAL IS LOCATED IN WAVERLY, TENNESSEE (HUMPHREYS COUNTY). WAVERLY IS 65 MILES WEST OF NASHVILLE. THE POPULATION OF HUMPHREYS COUNTY IS 18,600. HUMPHREYS COUNTY ESTIMATES THAT THE MEDIAN AGE IS 42.8 YEARS. THE 2014 MEDIAN INCOME WAS ESTIMATED TO BE $37,175. HOUSEHOLD POPULATION 7,480. AVERAGE HEALTH EXPENDITURES (2014) $3,699. TOTAL HEALTH EXPENDITURES $27.7 MILLION FOR 2014. |
| COMMUNITY BUILDING ACTIVITIES | MEMBERSHIP IN VARIOUS CIVIC GROUPS SUCH AS THE CHAMBER OF COMMERCE, CIVITANS, ETC. ENABLES THE HOSPITAL TO REPRESENT HEALTH CARE PROVIDERS IN THE GROWTH PLANS OF THE COMMUNITY. IT ALSO ALLOWS FOR GREATER INSIGHT INTO THE HEALTHCARE NEEDS OF THE INDUSTRIAL AND GOVERNMENTAL SECTORS OF THE SERVICE AREA. IT CAN PROMOTE SERVICE OPPORTUNITIES IN RELATION TO THE VARIOUS PROJECTS OF THESE GROUPS. THE HOSPITAL DID NOT TRACK THE MONETARY COSTS AND BENEFITS OF THESE COMMUNITY BUILDING ACTIVITIES. |
| HEALTH OF THE COMMUNITY IN RELATION TO EXEMPT PURPOSE | THE HOSPITAL PARTICIPATES IN FUNDRAISING "RELAY FOR LIFE AND "THE UNITED WAY". THE MISSION OF THE HOSPITAL IS TO CONTINUOUSLY IMPROVE THE HEALTH OF THE PEOPLE OF ITS COMMUNITY. IN CARRYING OUT ITS MISSION THE HOSPITAL SERVES THE COMMUNITY IN A VARIETY OF WAYS. ONE OF THE PRIMARY WAYS THE HOSPITAL SERVES THE COMMUNITY IS BY PROVIDING CHARITY CARE TO POPULATIONS FOR WHICH IT RECEIVES NO COMPENSATION OR RECEIVES COMPENSATION AT RATES SIGNIFICANTLY LESS THAN ESTABLISHED RATES FROM PATIENTS WHO RECEIVE PARTIAL CHARITY. SEVENTY PERCENT OF THE POPULATION SERVED IS MEDICARE/TENNCARE PATIENTS AND THE REIMBURSEMENT RECEIVED FROM THE GOVERNMENT FOR PROVIDING SERVICES AT BEST 101% OF COVERED COSTS. |
Schedule J IRS990ScheduleJ
| Field | Value | IRS element (for citing) |
|---|---|---|
| Compensation Survey | Yes (X) | CompensationSurveyInd |
| Board Or Committee Approval | Yes (X) | BoardOrCommitteeApprovalInd |
| Severance Payment | 0 | SeverancePaymentInd |
| Supplemental Nonqual Rtr Plan | 0 | SupplementalNonqualRtrPlanInd |
| Equity Based Comp Arrngm | 0 | EquityBasedCompArrngmInd |
| Comp Based On Revenue Of Flng Org | 0 | CompBasedOnRevenueOfFlngOrgInd |
| Comp Bsd On Rev Related Orgs | 0 | CompBsdOnRevRelatedOrgsInd |
| Comp Bsd Net Earns Flng Org | 0 | CompBsdNetEarnsFlngOrgInd |
| Comp Bsd Net Earns Rltd Orgs | 0 | CompBsdNetEarnsRltdOrgsInd |
| Any Non Fixed Payments | 0 | AnyNonFixedPaymentsInd |
| Initial Contract Exception | 0 | InitialContractExceptionInd |
Schedule O IRS990ScheduleO
Supplemental Information Detail SupplementalInformationDetail (5 entries)
| Form And Line ReferenceFormAndLineReferenceDesc | ExplanationExplanationTxt |
|---|---|
| FORM 990, PART VI, SECTION B, LINE 11B | 990 WILL BE REVIEWED BY MANAGEMENT BEFORE IT IS FILED. |
| FORM 990, PART VI, SECTION B, LINE 12C | REQUIRED TO DISCLOSE IF THERE IS A CONFLICT OF INTEREST. |
| FORM 990, PART VI, SECTION B, LINE 15 | SALARIES ARE DETERMINED BY STUDYING SALARY SURVEYS FROM THE TN HOSPITAL ASSOCIATION AND OFFERING COMPARABLE SALARIES FOR THE POSITION. SALARIES FOR OFFICERS ARE DETERMINED BY USING SALARY SURVEY INFORMATION OF COMPARABLE POSITIONS. |
| FORM 990, PART VI, SECTION C, LINE 19 | DOCUMENTS ARE MADE AVAILABLE UPON REQUEST. |
| FORM 990, PART IX, LINE 11G | PHYSICIANS PURCHASED SERVICES: PROGRAM SERVICE EXPENSES 716,442. MANAGEMENT AND GENERAL EXPENSES 216,749. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 933,191. PURCHASED SERVICES: PROGRAM SERVICE EXPENSES 164,682. MANAGEMENT AND GENERAL EXPENSES 147,616. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 312,298. |