2020-07-10T11:50:14-05:00 2019-12-31 410746749 CLIFTONLARSONALLEN LLP 10700 NORTHUP WAY SUITE 200 BELLEVUE WA 98004 990 2019-01-01 943079770 PENINSULA COMMUNITY HEALTH SERVICES PENI 3604782366 PO BOX 960 BREMERTON WA 98337 JENNIFER KREIDLER-MOSS CEO 3604782366 2020-06-25 1 KURT BENNION CPA P01469618 4252506100 2020-06-25 67.137.57.251 2020-06-25 20:05:04 PD P DA39A3EE5E6B4B0D3255BFEF95601890AFD80709 13D2D6CE62C2C3BC6CBA5B3F38E71F8D2ADB3C18 2019 2021-01-29 14:40:06Z JENNIFER KREIDLER-MOSS PO BOX 960 BREMERTON WA 98337 37889598 0 X WWW.PCHSWEB.ORG X 1987 WA PROVIDE ACCESSIBLE, AFFORDABLE, QUALITY HEALTH AND WELLNESS SERVICES FOR OUR COMMUNITIES. 14 14 373 20 0 0 6072589 9914132 27181832 27738361 94425 210968 6115 26137 33354961 37889598 1032 1200 0 0 19092954 22671230 0 0 0 9328450 11203418 28422436 33875848 4932525 4013750 34693512 38636440 6324754 5648068 28368758 32988372 X TO PROVIDE ACCESS TO AFFORDABLE, QUALITY HEALTH AND WELLNESS SERVICES AND REDUCE HEALTHCARE DISPARITIES FOR OUR COMMUNITIES. PENINSULA COMMUNITY HEALTH SERVICES OFFERS ALL SERVICES ON A SLIDING FEE SCHEDULE FOR THOSE THAT QUALIFY. 0 0 13997625 1200 16288440 MEDICAL - DURING 2019, PCHS PROVIDED 85,240 MEDICAL ENCOUNTERS TO 27,012 PATIENTS AT NINE CLINICAL SITES LOCATED IN BREMERTON (THREE SITES), BELFAIR (TWO SITES), KINGSTON, PORT ORCHARD, POULSBO AND SHELTON, AS WELL AS ONE MOBILE SITE. SERVICES INCLUDE COMPREHENSIVE PRIMARY MEDICAL SERVICES FOR CHILDREN AND ADULTS, EMPHASIZING A WHOLE-PERSON, PATIENT-CENTERED APPROACH. 8108561 0 6967894 DENTAL - IN 2019, PCHS PROVIDED 31,967 DENTAL VISITS TO 14,215 CHILDREN AND ADULTS FOR PREVENTATIVE AND RESTORATIVE CARE. DENTAL SERVICES ARE PROVIDED AT FIVE CLINICAL SITES IN BREMERTON (TWO SITES), POULSBO, PORT ORCHARD AND BELFAIR. SERVICES INCLUDE PREVENTATIVE CARE, ORAL EXAMS, ORAL HYGIENE, X-RAYS, EMERGENCY CARE AND DENTAL EDUCATION. REFERRAL SERVICES ARE OFFERED FOR MORE SPECIALIZED CARE. 2950617 0 1683415 BEHAVIORAL HEALTH - DURING 2019, PCHS PROVIDED 13,339 BEHAVIORAL HEALTH ENCOUNTERS TO 2,031 PATIENTS AT SEVEN CLINICAL SITES LOCATED IN BREMERTON (TWO SITES), BELFAIR (TWO SITES), KINGSTON, PORT ORCHARD, AND POULSBO, AS WELL AS TWO MOBILE SITES. BY FOCUSING ON A PATIENT'S BEHAVIORAL HEALTH AS PART OF AN INTEGRATED CARE MODEL, WE ARE ABLE TO BETTER COORDINATE COMPLETE AND TIMELY ACCESS TO CARE. OUR LICENSED, CERTIFIED COUNSELORS AND SUBSTANCE USE DISORDER PROFESSIONALS ADDRESS THE INDIVIDUALIZED NEEDS OF OUR PATIENTS BY WORKING ALONGSIDE OUR PRIMARY CARE PROVIDERS. 2168924 0 2798612 PHARMACY - IN 2019, PCHS PROVIDED 89,023 PRESCRIPTIONS TO ITS ELIGIBLE PATIENTS. FULLY LICENSED PHARMACIES ARE LOCATED AT FIVE CLINICAL SITES IN BREMERTON (TWO SITES), BELFAIR, POULSBO AND PORT ORCHARD. 2168924 0 2798612 27225727 1 1 0 0 0 0 0 0 0 0 1 0 0 0 0 1 1 0 0 0 0 0 0 0 0 0 0 0 0 1 1 0 0 0 0 0 0 0 0 0 0 1 0 0 0 0 0 0 0 0 1 44 0 373 1 0 0 0 0 0 0 0 0 0 0 0 0 X 14 14 0 0 1 0 0 0 0 1 1 0 0 1 1 1 1 1 1 1 1 0 X JOEL EMERY 3604756710 400 WARREN AVENUE SUITE 200 BREMERTON WA 98337 CHRISTOPHER COOK PRESIDENT 3.00 X X 0 0 0 EVELYN HETRICK VICE PRESIDENT 2.00 X X 0 0 0 YOLANDA FONG SECRETARY 2.00 X X 0 0 0 PAUL HATHAWAY TREASURER 2.00 X X 0 0 0 SUSAN ASTLE DIRECTOR 1.00 X 0 0 0 MONICA BERNHARD DIRECTOR 1.00 X 0 0 0 BERYL COCHRAN DIRECTOR 1.00 X 0 0 0 SHARON CROMLEY DIRECTOR 1.00 X 0 0 0 BRYNN FELIX DIRECTOR 1.00 X 0 0 0 MARGARET MOORE DIRECTOR 1.00 X 0 0 0 AL PINKHAM DIRECTOR 1.00 X 0 0 0 JEANELL RASMUSSEN DIRECTOR 1.00 X 0 0 0 SHANNON TURNER DIRECTOR 1.00 X 0 0 0 DAVID WINDOM DIRECTOR 1.00 X 0 0 0 JENNIFER KREIDLER-MOSS PHARMD CEO 40.00 X 386604 0 23840 JOEL EMERY CFO 40.00 X 143030 0 7270 AARON FORSTER CIO 40.00 X 158884 0 180 REGINA BONNEVIE ROGERS MD CHIEF MEDICAL OFFICER 40.00 X 327532 0 2124 MICHAEL INSANI DDS DENTAL DIRECTOR 40.00 X 226373 0 7800 MANDEEP DHAWAN MD PHYSICIAN 40.00 X 267136 0 7188 DONNAVILLE ORTIZ MD PHYSICIAN 40.00 X 263513 0 7128 CLEMENT LE THANH MD PHYSICIAN 40.00 X 221793 0 2221 FAIRYAL KASSAM MD PHYSICIAN 40.00 X 212958 0 6868 CHI LAP LI DDS DENTIST 40.00 X 205054 0 7524 2412877 0 72143 55 0 1 0 NEW DIRECTIONS 3501 COLBY AVENUE 102 EVERETT WA 98201 CONSULTING 259415 CLIFTONLARSONALLEN LLP PO BOX 31001-2443 PASADENA CA 91110 AUDITING 203899 JOHNSON OAKLIEF 2124 THIRD AVENUE SUITE 200 SEATTLE WA 98121 ARCHITECTURE 163134 COMMUNITY CLINIC CONTRACTING NETWORK 18 S MISSION ST STE 300 WENATCHEE WA 98801 CONSULTING 160668 MCS JANITORAL PO BOX 11044 TACOMA WA 98411 JANITORIAL 150935 6 7949585 1964547 810225 9914132 PATIENT SERVICE REVENUE 621400 27738361 27738361 27738361 210968 210968 OTHER INCOME 621400 26137 26137 26137 37889598 27738361 0 237105 1200 1200 1283637 892184 391453 17096039 13927361 3168678 2609057 2065270 543787 1682497 1329523 352974 42404 27678 14726 225986 147505 78481 29787 19442 10345 1496140 981153 514987 8827 5655 3172 190444 138857 51587 888793 725027 163766 1701717 1309500 392217 131812 39733 92079 498262 363728 134534 1135896 1006377 129519 96705 76060 20645 MEDICAL SUPPLIES 2993317 2993317 MISCELLANEOUS 855088 461808 393280 EQUIP MAINT & REPAIR 557707 454946 102761 COMMUNICATIONS 350315 259185 91130 218 218 33875848 27225727 6650121 0 16246463 17036106 191366 142087 3712415 3255732 218139 222220 259502 403783 23463844 9300765 11359263 14163079 2706364 3413433 34693512 38636440 3632978 2697101 838551 1248525 1822020 1700106 31205 2336 6324754 5648068 X 28368758 32988372 28368758 32988372 34693512 38636440 4013750 605864 0 X 0 1 X 1 1 1 X 2872155 2923608 4213085 6072589 9914132 25995569 2872155 2923608 4213085 6072589 9914132 25995569 25995569 74842 64387 106424 95088 210968 551709 64971 29794 121592 6115 26137 248609 26795887 114928202 0.97010 0.99450 X 0.99450 0.00350 SCHEDULE A, PART II, LINE 10, EXPLANATION OF OTHER INCOME: OTHER INCOME RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 1929927 1929927 6742461 3920216 2822245 5499496 2033106 3466390 5629902 3347443 2282459 3662058 3662058 14163079 X 37296050 0 37296050 593548 593548 37889598 33875848 0 33875848 0 33875848 PART X, LINE 2: THE ORGANIZATION HAS RECEIVED A DETERMINATION LETTER FROM THE INTERNAL REVENUE SERVICE THAT STATES IT IS EXEMPT FROM FEDERAL INCOME TAXES UNDER SECTION 501(C)(3) OF THE INTERNAL REVENUE CODE. ACCORDINGLY, NO PROVISION FOR INCOME TAXES IS SHOWN IN THE FINANCIAL STATEMENTS. MANAGEMENT EVALUATED THE ORGANIZATION'S TAX POSITIONS AND CONCLUDED THAT THE ORGANIZATION HAD TAKEN NO SIGNIFICANT UNCERTAIN TAX POSITIONS THAT REQUIRE ADJUSTMENTS TO THE FINANCIAL STATEMENTS TO COMPLY WITH THE PROVISIONS OF TOPIC 740 OF THE ACCOUNTING STANDARDS CODIFICATION (ASC). PART XI, LINE 4B - OTHER ADJUSTMENTS: CONTRIBUTIONS 33,847. CAPITAL DEVELOPMENT GRANT 559,701. X 1 1 X X X X X 0 0 0 0 0 0 0 0 0 JENNIFER KREIDLER-MOSS PHARMD CEO 369179 0 17425 0 0 0 18500 0 5340 0 410444 0 0 0 JOEL EMERY CFO 143030 0 0 0 0 0 0 0 7270 0 150300 0 0 0 AARON FORSTER CIO 158884 0 0 0 0 0 0 0 180 0 159064 0 0 0 REGINA BONNEVIE ROGERS MD CHIEF MEDICAL OFFICER 327532 0 0 0 0 0 0 0 2124 0 329656 0 0 0 MICHAEL INSANI DDS DENTAL DIRECTOR 226373 0 0 0 0 0 0 0 7800 0 234173 0 0 0 MANDEEP DHAWAN MD PHYSICIAN 259636 0 7500 0 0 0 0 0 7188 0 274324 0 0 0 DONNAVILLE ORTIZ MD PHYSICIAN 253513 0 10000 0 0 0 0 0 7128 0 270641 0 0 0 CLEMENT LE THANH MD PHYSICIAN 218293 0 3500 0 0 0 0 0 2221 0 224014 0 0 0 FAIRYAL KASSAM MD PHYSICIAN 212958 0 0 0 0 0 0 0 6868 0 219826 0 0 0 CHI LAP LI DDS DENTIST 201554 0 3500 0 0 0 0 0 7524 0 212578 0 0 0 PART I, LINE 1A EMPLOYEES WHO PARTICIPATE IN THE YMCA PROGRAM AND WHO HAVE TAXABLE LIFE INSURANCE COVERAGE OVER $150,000 RECEIVE TAX GROSS-UP PAYMENTS. ALL EMPLOYEES LISTED IN FORM 990, PART VII, SECTION A RECEIVED AT LEAST ONE OF THESE BENEFITS. THESE AMOUNTS ARE INCLUDED IN THEIR TAXABLE COMPENSATION. A WA HEALTH CARE FACILITIES AUTHORITY 911108929 2005-12-18 3000000 CONSTRUCTION FINANCING 0 0 1 A 1296187 3000000 51942 2948058 2005 0 0 1 1 A 0 0 0 0 0 0 0 A 0 0 1 0 0 0 0 0 0 A 1 X 121 810225 INVOICE PRICE 0 0 0 0 FORM 990, PART VI, SECTION A, LINE 1 THE ORGANIZATION'S EXECUTIVE COMMITTEE CONSISTS OF THE OFFICERS OF THE BOARD. IT MAY ALSO INCLUDE THE PAST PRESIDENT FOR ONE YEAR AFTER THEY FINISH THEIR SERVICE AS BOARD PRESIDENT AND/OR ONE ADDITIONAL AT-LARGE MEMBER. THE EXECUTIVE COMMITTEE ACTS ONLY AS NECESSARY BETWEEN THE MEETINGS OF THE BOARD OF DIRECTORS WITH ALL THE POWERS OF THE BOARD AND REPORTS AND PRESENTS FOR RATIFICATION ANY SUCH ACTION TO THE BOARD AT ITS NEXT MEETING. HOWEVER, THE EXECUTIVE COMMITTEE DOES NOT HAVE AUTHORITY TO BIND THE BOARD OR THE ORGANIZATION ON ANY MATTERS INVOLVING THE PURCHASE OR SALE OF ANY REAL PROPERTY, OR THE PURCHASE OR SALE OF EQUIPMENT, FURNITURE OR FIXTURES IN EXCESS OF 1% OF THE ORGANIZATION'S ANNUAL BUDGET. THE EXECUTIVE COMMITTEE INITIATES ANNUALLY THE PERFORMANCE REVIEW OF THE CEO AND MAKES RECOMMENDATIONS TO THE BOARD FOR APPROVAL. THE EXECUTIVE COMMITTEE REVIEWS AND REVISES THE ORGANIZATION'S GOVERNANCE AND EMPLOYEE POLICIES AND PROVIDES BROAD OVERSIGHT OF ALL EMPLOYMENT MATTERS. THE EXECUTIVE COMMITTEE KEEPS RECORDS OF THE TERMS OF OFFICE AND REPLACEMENTS FOR ANY VACANCIES WHICH MAY ARISE, AND SUPERVISES THE NOMINATIONS OF BOARD MEMBERS. THE EXECUTIVE COMMITTEE SOLICITS AND SCREENS POTENTIAL BOARD MEMBERS AND DETERMINES THEIR QUALIFICATIONS AND WILLINGNESS TO SERVE. THE EXECUTIVE COMMITTEE ALSO HAS THE RESPONSIBILITY OF PREPARING A SLATE OF OFFICERS TO BE SELECTED FROM THE BOARD MEMBERS. FORM 990, PART VI, SECTION A, LINE 4 THE BYLAWS WERE AMENDED IN DECEMBER 2019 TO UPDATE THE ORGANIZATION'S MISSION STATEMENT (WITHOUT MATERIALLY CHANGING THE ORGANIZATION'S MISSION) AND UPDATE THE DUTIES OF BOARD MEMBERS. FORM 990, PART VI, SECTION B, LINE 11B THE FORM 990 WAS REVIEWED BEFORE SIGNATURE BY BOTH THE CFO AND CEO, AND WAS PRESENTED TO THE FINANCE COMMITTEE. THE BOARD TREASURER MADE A REPORT TO THE FULL BOARD. FORM 990, PART VI, SECTION B, LINE 12C PENINSULA COMMUNITY HEALTH SERVICES HAS A WRITTEN CONFLICT OF INTEREST POLICY THAT ALL BOARD DIRECTORS ARE REQUIRED TO SIGN ON AN ANNUAL BASIS. UPON SIGNING THE POLICY, EACH BOARD MEMBER AGREES TO DISCLOSE AN ACTUAL OR PERCEIVED CONFLICT OF INTEREST. THE BOARD OF DIRECTORS, AT ANY TIME A POTENTIAL CONFLICT ARISES, MAY REQUIRE AN INDIVIDUAL TO REFRAIN FROM DISCUSSION OF THE MATTER, REFRAIN FROM VOTING ON THE MATTER, OR BE EXCUSED FROM ATTENDING THE PORTION OF THE MEETING ABOUT THE MATTER OF CONFLICT. FORM 990, PART VI, SECTION B, LINE 15 PENINSULA COMMUNITY HEALTH SERVICES ATTEMPTS TO COMPENSATE ALL EMPLOYEES FAIRLY, EQUITABLY AND COMPETITIVELY. A SALARY SURVEY THAT INCLUDES A SALARY ANALYSIS OF LIKE JOB DESCRIPTIONS IN THE GEOGRAPHICAL AREA IS COMPLETED BY THE HUMAN RESOURCE DEPARTMENT. THE BOARD OF DIRECTORS APPROVES THE WAGE SCALE ANNUALLY. FOR THE POSITION OF THE CEO THE SALARY DATA IS PRESENTED TO THE EXECUTIVE COMMITTEE OF THE BOARD OF DIRECTORS. BASED ON THE INFORMATION PROVIDED, THE EXECUTIVE COMMITTEE DETERMINES THE COMPENSATION FOR THE CEO FOR THE ENSUING YEAR WHICH THE FULL BOARD APPROVES. THIS PROCESS LAST OCCURRED IN 2019. FORM 990, PART VI, SECTION C, LINE 19 ALL GOVERNING DOCUMENTS, POLICIES, FINANCIAL STATEMENTS AND FORMS 990 ARE PROVIDED UPON REQUEST.