2021-11-10T13:26:07-06:00 2020-12-31 621046406 JOHNSON HICKEY & MURCHISON PC 2215 OLAN MILLS DRIVE CHATTANOOGA TN 37421 990 2020-01-01 261861676 HUMPHREYS COUNTY COMMUNITY HEALTH SERVICES INC HUMP 9312960232 451 HIGHWAY 13 SOUTH WAVERLY TN 37185 SHANNON ALLISON CFO 9312960232 2021-11-09 1 SHANNON ALLISON XXX-XX-XXXX BARRY R HUGGINS P00627334 4237560052 2 AAL1 IAL1 2020 2022-09-23 18:48:47Z THREE RIVERS HOSPITAL SHANNON ALLISON 451 HIGHWAY 13 SOUTH WAVERLY TN 37185 9624981 0 X THREERIVERSHOSPITAL.COM X 2008 TN 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. 10 8 203 1 0 0 12247 1931235 6736786 7579500 203 5386 82416 95860 6831652 9611981 0 0 0 0 3879080 4084334 0 0 0 3785427 4087092 7664507 8171426 -832855 1440555 1674065 5982366 5650348 8518094 -3976283 -2535728 THE MISSION OF THE HOSPITAL IS TO CONTINUOUSLY IMPROVE THE HEALTH OF THE PEOPLE OF ITS COMMUNITY. 0 0 6710245 7613201 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. 6710245 1 1 0 1 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 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 22 0 203 1 0 0 0 0 0 0 0 0 0 0 0 0 X 10 8 0 0 0 0 0 0 0 1 1 0 0 1 1 1 1 1 1 1 1 0 TN X SHANNON ALLISON 9312960232 451 HIGHWAY 13 SOUTH WAVERLY TN 37185 FRANK RUSHTON BOARD MEMBER 1.00 X 0 0 0 TED MOORE BOARD MEMBER 1.00 X 0 0 0 DANIEL COLLIER VICE CHAIRMAN 1.00 X X 0 0 0 JOHNNY WHITFIELD SECRETARY 1.00 X X 0 0 0 KEVIN RYE CPA TREASURER 1.00 X X 0 0 0 JACKIE BOSWELL CHAIRMAN 1.00 X X 0 0 0 SUBHI D ALI MD BOARD MEMBER 1.00 X 0 0 0 LAWRENCE R JACKSON JR MD BOARD MEMBER 1.00 X 0 0 0 DR GEORGE MATHAI CHIEF OF MEDICAL STAFF 1.00 X X 0 0 0 FREDA RUSSELL CEO 40.00 X X 125305 0 9449 SHANNON ALLISON CFO 40.00 X 80217 0 785 HEATHER THOMPSON CNO 40.00 X 65833 0 608 ALANA PETERS CNO 40.00 X 18861 0 2298 290216 0 13140 1 0 0 0 CONCORD MEDICAL GROUP 3004 50TH STREET SUITE D LUBBOCK TX 794134129 ER PHYSICIANS 690580 RIVER VALLEY PHYSICAL THERAPY PO BOX 441 CAMDEN TN 38320 THERAPY SERVICES 213881 2 1915342 15893 1931235 NET PATIENT REVENUE 621990 7579500 7579500 7579500 3273 3273 62159 0 62159 62159 62159 15113 13000 2113 2113 2113 OTHER INCOME 621990 33701 33701 33701 9611981 7613201 0 67545 X 303356 268077 35279 3269623 2605556 664067 7983 6420 1563 284656 228940 55716 218716 175906 42810 12362 12362 43500 43500 1245489 881124 364365 1914 1914 191581 149238 42343 1688 1171 517 170811 130500 40311 201995 154324 47671 117230 117230 BAD DEBT 1047830 1047830 OTHER SUPPLIES AND EXPE 604687 511329 93358 MEDICAL SUPPLIES DRUGS 239396 239396 REPAIRS AND MAINTENANCE 188618 182397 6221 19991 10807 9184 8171426 6710245 1461181 0 4681 3685901 739082 969896 142149 164854 27427 35922 5862836 5012860 725879 849976 19237 22355 15610 253462 1674065 5982366 1403124 979578 4023527 3794042 223697 3744474 5650348 8518094 X -3976283 -2535728 -3976283 -2535728 1674065 5982366 1440555 0 X 0 1 X 1 0 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 0 0 0 0 0 1 1051 0 0 0 1051 0 PART II-B, LINE 1: PART OF HOSPITAL DUES. 313716 313716 2041475 1904200 137275 3507645 3108660 398985 849976 ESTIMATED THIRD PARTY SETTLEMENT 1394300 PPP PROTECTION PROGRAM LOAN 609355 COVID-19 ECONOMIC INJURY DISASTER LOAN 150000 CARES PROVIDER RELIEF FUNDS REFUNDABLE ADVANCE 1590819 3744474 X 8564151 0 8564151 1047830 1047830 9611981 7123596 0 7123596 1047830 1047830 8171426 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. 1 1 1 X 1 X 150.000000000000 1 1 0 0 22233 22233 0.00310 683355 1676186 0 0.00000 705588 1676186 22233 0.00310 4928 4928 0.00070 4928 4928 0.00070 710516 1676186 27161 0.00380 1 1158470 811330 2867831 2867831 X 1 1 1 1 THREE RIVERS HOSPITAL 451 HIGHWAY 13 SOUTH WAVERLY TN 37185 00000036 X X X HUMPHREYS COUNTY COMMUNITY HEALTH 1 0 0 1 X X X X X X X X X 20 1 0 0 1 X THREERIVERSHOSPITAL.COM X 1 20 1 THREERIVERSHOSPITAL.COM 0 1 X 200.000000000000 275.000000000000 X X X 1 1 1 X X 1 X 1 X X X X 1 X 0 0 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. 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. X X 0 0 0 0 0 0 0 0 0 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.