2020-03-26T08:12:32-05:00 2019-06-30 410746749 CLIFTONLARSONALLEN LLP 220 SOUTH SIXTH STREET SUITE 300 MINNEAPOLIS MN 55402 990 2018-07-01 810240726 MARCUS DALY MEMORIAL HOSPITAL MARC 4063632211 1200 WESTWOOD DRIVE HAMILTON MT 59840 JOHN BISHOP CEO, SECRETARY AND TREASURER 4063632211 2020-03-24 1 KURT BENNION P01469618 6123764500 2020-03-24 67.137.57.251 2020-03-24 16:40:55 PD P E168BB59A4AC1B98DF6FDFCBC72C1446FCA85D8B 1250CDEA66690A135E88A5DFE9E1EBF2AB9DD2FD 2018 2020-09-23 17:36:50Z JOHN BISHOP 1200 WESTWOOD DRIVE HAMILTON MT 59840 78773921 0 X WWW.MDMH.ORG X 1929 MT OUR COMMITMENT TO THE BITTERROOT VALLEY IS QUALITY, ACCESSIBLE, PERSONALIZED HEALTHCARE. 11 9 675 70 0 0 159574 99859 68912486 77888500 103241 237483 249312 128493 69424613 78354335 136750 74518 0 0 43098401 46538871 0 0 154995 22586039 25022621 65821190 71636010 3603423 6718325 80105197 85795326 43325789 41881011 36779408 43914315 X OUR COMMITMENT TO THE BITTERROOT VALLEY IS QUALITY, ACCESSIBLE, PERSONALIZED HEALTHCARE. 0 0 58255195 74518 77888500 MARCUS DALY MEMORIAL HOSPITAL OWNS AND OPERATES A 25 LICENSED BED ACUTE CARE CRITICAL ACCESS HOSPITAL. THE HOSPITAL PROVIDES ACUTE CARE SERVICES TO PATIENTS IN RAVALLI COUNTY. THE SERVICES PROVIDED INCLUDE ACUTE CARE HOSPITAL, RELATED ANCILLARY SERVICES SUCH AS LABORATORY, RADIOLOGY, THERAPY, INPATIENT AND OUTPATIENT SURGERY, EMERGENCY CARE, AMBULANCE, HOME HEALTH, CLINIC, INPATIENT AND OUTPATIENT HOSPICE CARE. THE HOSPITAL PROVIDES EMS SERVICES WITH 3 CREWS PROVIDING 911 SERVICE TO THE COUNTY. THE GOAL IS TO RESPOND WITHIN 20 MINUTES OR LESS TO ANY CALL WITHIN THE COUNTY. THE HOSPITAL IS A PEDIATRIC REHABILITATION PROVIDER OF PHYSICAL THERAPY, OCCUPATIONAL THERAPY AND SPEECH THERAPY USING CERTIFIED THERAPISTS. THE HOSPITAL CLINICS SEE ALL PATIENTS REGARDLESS OF INSURANCE OR ABILITY TO PAY AND ENABLE THE COMMUNITY ACCESS TO PRIMARY CARE. 58255195 1 1 0 0 0 0 0 0 0 1 1 0 0 0 1 1 1 0 0 0 0 0 0 0 0 0 1 1 1 0 1 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 0 0 0 1 88 0 675 1 0 0 0 0 0 0 0 0 0 0 0 0 X 11 9 0 0 0 0 0 0 0 1 1 0 0 1 1 1 1 1 1 1 0 0 X X JOHN BISHOP 4063632211 1200 WESTWOOD DRIVE HAMILTON MT 59840 BILL BEAN CHAIRMAN (THROUGH MAY 2019) 1.00 0.00 X X 0 0 0 LOIS HEDG-PETH VICE CHAIRMAN AND CHAIRMAN 1.00 0.00 X X 0 0 0 TOM ANDERSON BOARD MEMBER 1.00 0.00 X 0 0 0 SUSANNAH BENJAMIN BOARD MEMBER 1.00 0.00 X 0 0 0 LAWRENCE BROUWER MD BOARD MEMBER/PHYSICIAN 10.00 0.00 X 196578 0 8903 LINDA DODDS BOARD MEMBER 1.00 0.00 X 0 0 0 LISA GLENN BOARD MEMBER 1.00 0.00 X 0 0 0 BRIAN KELLEHER MD BOARD MEMBER 1.00 0.00 X 0 0 0 TOM KORST BOARD MEMBER 1.00 0.00 X 0 0 0 ROBERT WHALEN BOARD MEMBER 1.00 0.00 X 0 0 0 TIMOTHY WOODS MD BOARD MEMBER/PHYSICIAN 40.00 0.00 X 461740 0 42785 BRET YOUNG BOARD MEMBER 1.00 0.00 X 0 0 0 JOHN BISHOP CEOSECRETARY TREASURER 39.00 1.00 X 217281 0 2006 DONJA ERDMAN CFO 39.00 1.00 X 157335 0 19773 TROY HANSON COO 40.00 0.00 X 180856 0 23777 RICHARD DAY MD PHYSICIAN 40.00 0.00 X 1117335 0 25998 MARK CALDERWOOD MD PHYSICIAN 40.00 0.00 X 472009 0 17932 MICHAEL DOLECKI MD PHYSICIAN 40.00 0.00 X 468900 0 26693 KEVIN GURNEY MD PHYSICIAN 40.00 0.00 X 402811 0 24082 CLINTON ADKINS MD PHYSICIAN 40.00 0.00 X 408465 0 184 JOHN BARTOS FORMER CEO 0.00 0.00 X 382485 0 9267 4465795 0 201400 55 1 1 0 SWANK CONSTRUCTION PO BOX 568 VALIER MT 59486 HOSPITAL CONSTRUCTION 7658357 CERNER CORPORATION PO BOX 959156 ST LOUIS MT 63195 EHR PROVIDER 1332955 HEALTHCARE OUTSOURCING NETWORK 1597 COLE BLVD 150 LAKEWOOD CO 80401 PATIENT PAYMENT ASSISTANCE 452068 FIVE VALLEYS UROLOGY 2875 TINA AVE 101 MISSOULA MT 59808 UROLOGY SERVICES PROVIDER 312718 WEATHERBY LOCUMS INC PO BOX 972633 DALLAS TX 75397 NURSING LOCUM STAFFING 284412 19 61758 36079 2022 99859 NET PATIENT SERVICE REVENUE 621400 71053297 71053297 HOSPITAL UTILZTN. REV. 621400 5565302 5565302 OTHER OPERATING INCOME 621400 1269901 1269901 77888500 295616 295616 96230 96230 236254 220018 16236 16236 16236 3667 41538 0 199568 3667 -158030 -154363 -154363 MISCELLANEOUS 900099 83984 83984 EDUCATION 900099 16316 16316 CAFETERIA/VENDING 900099 11957 11957 112257 78354335 77888500 0 365976 74518 74518 1500558 1457032 39619 3907 230191 218681 11510 36485853 29467154 6934331 84368 1491213 1204621 283131 3461 4460456 3626817 823385 10254 2370600 1882867 481311 6422 164275 164275 51484 51484 3864195 1784862 2070247 9086 96972 96972 5398473 5109697 287886 890 1506021 909391 596630 361192 339850 21342 202615 160621 41994 826059 735719 72272 18068 4058430 3773625 267233 17572 834693 834693 PROVISION FOR BAD DEBTS 3312198 3312198 PHARMACY/ LAB EXPENSES 2126642 2112605 14037 MAINTENANCE AND REPAIRS 1216014 1055754 160260 MISCELLANEOUS EXPENSES 904351 40130 863304 917 99007 57388 41569 50 71636010 58255195 13225820 154995 13054921 6827213 12539320 14287028 10980931 13726111 146568 226625 2084849 1987155 587388 629788 86786621 43109261 37066621 43677360 1447473 1819872 2197126 2614174 80105197 85795326 7700100 8316591 15535 0 23477725 22650365 7595957 7356404 270604 99696 4265868 3457955 43325789 41881011 X 34590066 41360334 1285138 1649777 904204 904204 36779408 43914315 80105197 85795326 X 6718325 44183 372399 X 0 1 X 1 0 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 313190 1833 1833 313190 313190 1416 1416 313190 313190 724 724 313190 313190 984 984 313190 313190 1019 1019 313190 0.00000 1.00000 0.00000 0 0 2187280 2187280 59206058 25659462 33546596 1989748 1170167 819581 22587340 16279632 6307708 816195 816195 43677360 THIRD PARTY SETTLEMENT 927998 EMPLOYEE BENEFIT OBLIGATION 2529957 3457955 X 74562645 44183 201803 245986 74316659 4037676 4037676 78354335 68525615 201803 201803 68323812 3312198 3312198 71636010 PART V, LINE 4: THE ENDOWMENT FUND IS DESIGNATED FOR THE PURPOSE OF BUILDING AND CARRYING ON A HOSPITAL IN HAMILTON, MONTANA. THE EVANS ENDOWMENT IS TO BE USED FOR THE CARE AND TREATMENT OF CRIPPLED CHILDREN. PART X, LINE 2: PER THE AUDITED FINANCIAL STATEMENTS, NOTE 1: THE INTERNAL REVENUE SERVICE (IRS) HAS DETERMINED THAT MARCUS DALY MEMORIAL HOSPITAL IS A TAX-EXEMPT, NONPROFIT CORPORATION UNDER SECTION 501(C)(3) OF THE INTERNAL REVENUE CODE (IRC). THE HOSPITAL FOLLOWS THE GUIDANCE IN THE ACCOUNTING STANDARDS REGARDING THE RECOGNITION AND MEASUREMENT OF UNCERTAIN TAX POSITIONS. THE GUIDANCE CLARIFIES THE ACCOUNTING FOR UNCERTAINTY IN INCOME TAXES RECOGNIZED IN AN ENTITY'S FINANCIAL STATEMENTS. THE GUIDANCE FURTHER PRESCRIBES RECOGNITION AND MEASUREMENT OF TAX PROVISIONS TAKEN OR EXPECTED TO BE TAKEN ON A TAX RETURN THAT ARE NOT CERTAIN TO BE REALIZED. THE APPLICATION OF THIS STANDARD HAS NO IMPACT ON THE HOSPITAL'S FINANCIAL STATEMENTS. PART XI, LINE 2D - OTHER ADJUSTMENTS: RENTAL EXPENSES 201,803. PART XI, LINE 4B - OTHER ADJUSTMENTS: PROVISION FOR UNCOLLECTIBLE ACCOUNTS 3,312,198. INVESTMENT INCOME 439,696. UNRESTRICTED GRANTS AND CONTRIBUTIONS 16,753. OTHER NONOPERATING REVENUES 182,190. TEMPORARILY RESTRICTED CONTRIBUTIONS AND GRANTS 83,106. AUXILIARY INCOME 3,733. PART XII, LINE 2D - OTHER ADJUSTMENTS: RENTAL EXPENSES 201,803. PART XII, LINE 4B - OTHER ADJUSTMENTS: PROVISION FOR UNCOLLECTIBLE ACCOUNTS 3,312,198. 1 1 X 1 X 1 X 1 1 0 1 1 143413 143413 0.00210 12164217 8494798 3669419 0.05370 12307630 8494798 3812832 0.05580 183702 183702 0.00270 77298 77298 0.00110 3920466 3211430 709036 0.01040 59608 59608 0.00090 4241074 3211430 1029644 0.01510 16548704 11706228 4842476 0.07090 3582 3582 0.00010 136304 136304 0.00200 139886 139886 0.00210 1 3312198 0 13636936 20887879 -7250943 X 1 1 1 1 MARCUS DALY MEMORIAL HOSPITAL 1200 WESTWOOD DRIVE HAMILTON MT 59840 WWW.MDMH.ORG 12911 X X X X MARCUS DALY MEMORIAL HOSPITAL 1 0 0 1 X X X X X X X X X 17 1 0 0 1 X SEE LINE 7D X X 1 17 1 SEE LINE 7D 0 1 X 100.000000000000 200.000000000000 X X X X X X 1 1 X X X X 1 X SEE LINE 16J X SEE LINE 16J X SEE LINE 16J X X X X X X X 1 X 0 X X X 1 X 0 0 MARCUS DALY MEMORIAL HOSPITAL PART V, SECTION B, LINE 5: MDMH GATHERED QUALITATIVE INFORMATION AND PERSPECTIVES ON COMMUNITY HEALTH NEEDS THROUGH SIXTEEN ONE-ON-ONE INTERVIEWS WITH KEY COMMUNITY STAKEHOLDERS IN FEBRUARY 2018. THE FOLLOWING AGENCIES, ORGANIZATIONS AND BUSINESSES, LISTED IN ALPHABETICAL ORDER, PARTICIPATED IN MDMH'S COMMUNITY HEALTH NEEDS ASSESSMENT PROCESS BY CONTRIBUTING THEIR PERSPECTIVES, OPINIONS AND OBSERVATIONS.- CORVALLIS SCHOOL DISTRICT- DARBY SCHOOL DISTRICT- HAMILTON POLICE DEPARTMENT- HAMILTON SCHOOL DISTRICT- MARCUS DALY MEMORIAL HOSPITAL- MONTANA STATE UNIVERSITY COLLEGE OF NURSING- RAVALLI COUNTY COUNCIL ON AGING- RAVALLI COUNTY PUBLIC HEALTH DEPARTMENT- RAVALLI COUNTY SHERIFFS OFFICE- WESTERN MONTANA MENTAL HEALTH (RIVERFRONT) IN ADDITION TO THE INTERVIEWS, FOUR COMMUNITY FORUMS WERE HELD IN FEBRUARY 2018 IN HAMILTON, DARBY, STEVENSVILLE AND VICTOR. THESE COMMUNITY FORUMS WERE ADVERTISED TO THE COMMUNITY IN THE LOCAL NEWSPAPER, ON OUR WEBSITE, AND BY WORD OF MOUTH. IN TOTAL, EIGHTEEN COMMUNITY MEMBERS PARTICIPATED IN THE COMMUNITY FORUMS WITH DARBY HAVING THE GREATEST PARTICIPATION. MARCUS DALY MEMORIAL HOSPITAL PART V, SECTION B, LINE 7D: THE ORGANIZATION'S COMMUNITY HEALTH NEEDS ASSESSMENT REPORT AND IMPLEMENTATION STRATEGY ARE AVAILABLE ONLINE AT HTTPS://WWW.MDMH.ORG/PATIENTS-AND-VISITORS/COMMUNITY-RESOURCES/COMMUNITY- HEALTH-NEEDS-ASSESSMENTS.ASPX. MARCUS DALY MEMORIAL HOSPITAL PART V, SECTION B, LINE 11: BASED ON THE 2018 COMMUNITY HEALTH NEEDS ASSESSMENT AND IMPLEMENTATION STRATEGY, MARCUS DALY MEMORIAL HOSPITAL ADDRESSED SUBSTANCE ABUSE BY PLACING A MEDICATION SAFE DISPOSAL BOX ON ITS CAMPUS THAT THE PUBLIC MAY ACCESS TO SAFELY DISPOSED OF USED DRUGS. MARCUS DALY MEMORIAL HOSPITAL ALSO PARTNERED WITH RAVALLI COUNTY ON ISSUES REGARDING MENTAL HEALTH AND MENTAL HEALTH ILLNESS IN OUR COMMUNITY.IN REGARDS TO MENTAL HEALTH THE FOCUS OF OUR QUALITY TEAM HAS BEEN DEPRESSION SCREENING. DEPRESSION SCREENING WAS IMPLEMENTED AT ENTRY POINTS INTO CLINICS AS WELL AS THE HOSPITAL TO IMPROVE IDENTIFICATION OF PATIENTS WITH MODERATE TO SEVERE DEPRESSION INCLUDING SUICIDAL THOUGHTS. GUIDANCE WAS PROVIDED FOR APPROPRIATE FOLLOW-UP WITH THE PRIMARY CARE PROVIDER OR IN SOME CASES IMMEDIATE ESCALATION TO THE EMERGENCY DEPARTMENT. IN ADDITION, MANAGEMENT OF MENTAL HEALTH AT THE HOSPITAL WAS REVIEWED WITH CHANGES MADE TO IMPROVE COMMUNICATION AMONG CAREGIVERS AND TO IMPLEMENT ADDITIONAL SAFETY MEASURES FOR PATIENTS. COMMUNITY RESOURCES WERE UPDATED AND DISTRIBUTED TO PROVIDERS AT ALL LEVELS OF THE ORGANIZATION.FOR TRANSPORTATION, A POLICY HAS BEEN CREATED TO USE OUR AMBULANCE SERVICES TO ASSIST PATIENTS NEEDING TRANSPORTATION TO RETURN TO THEIR RESIDENCE AFTER RECEIVING TREATMENT. WE HAVE ALSO ESTABLISHED A VOUCHER SYSTEM FOR LOCAL TAXI SERVICES.FOR CHRONIC AND COMMUNICABLE DISEASES, WE HAVE IMPLEMENTED DATA ANALYTICS SOFTWARE AND HIRED A POPULATION HEALTH MANAGER AND AN ADDITIONAL CHRONIC CARE NURSE TO BETTER MANAGE CHRONIC DISEASE PATIENTS. OUR CARDIAC CLINIC WAS EXPANDED AND AN ADDITIONAL PROVIDER WAS ADDED TO BE ABLE TO ACCOMMODATE PATIENT NEEDS. OUR QUALITY FOCUS WAS ON INCREASING PREVENTATIVE MAINTENANCE FOR PATIENTS VIA IMMUNIZATION, HEALTH WEIGHT, TOBACCO CESSATION, CANCER SCREENINGS, AND DEPRESSION SCREENING. ALTHOUGH HEAVILY FOCUSED IN THE CLINICS, THE MEASURES APPLICABLE TO OTHER SERVICES WERE INCLUDED IN THE SCOPE AS APPROPRIATE. TO ACCOMPLISH INITIATIVES, BARRIERS TO IMPROVE MAINTENANCE WERE IDENTIFIED VIA ROUNDING WITH STAFF, PROVIDER FEEDBACK AND REVIEW OF PROCESS FLOW. AS A RESULT OF THE REVIEWS: 1) NURSE DRIVEN PROTOCOLS WERE CREATED, 2) MODULES WERE DEVELOPED FOR STANDARDIZED DOCUMENTATION, 3)COLLABORATION WITH ELECTRONIC MEDICAL RECORDS FOR IMPROVED DOCUMENTATION, 4) EDUCATION PROVIDED TO PATENTS WAS EXPANDED, AND 5) ANNUAL WELLNESS EXAMS WERE INCREASED FOR THE COMMUNITY. HEALTH EDUCATION WAS ALSO A FOCUS FOR MARCUS DALY MEMORIAL HOSPITAL, INCLUDING HEALTHY COOKING, STRETCHING, DIET AND EXERCISE TIPS, HEALTHY HEART AND AWARENESS AND RESOURCES FOR MENTAL HEALTH DISEASE. MARCUS DALY MEMORIAL HOSPITAL PART V, SECTION B, LINE 13H: ELIGIBILITY FOR PATIENT ASSISTANCE SHALL BE MADE REGARDLESS OF RACE, GENDER, AGE, SEXUAL ORIENTATION, RELIGIOUS AFFILIATION, AND SOCIAL OR IMMIGRANT STATUS. MAJOR AREAS OF CONSIDERATIONS 1) RELATIONSHIP TO FEDERAL INCOME POVERTY GUIDELINES ADJUSTED FOR FAMILY SIZE 2) FAMILY NET ASSETS 3) DEMONSTRATION OF INABILITY TO WORK 4) COMPLETED APPLICATION AND 5) RESIDENT OF RAVALLI COUNTY MONTANA WITH EXCEPTIONS. MARCUS DALY MEMORIAL HOSPITAL PART V, SECTION B, LINE 16J: THE ORGANIZATION'S FINANCIAL ASSISTANCE POLICY, APPLICATION AND PLAIN LANGUAGE SUMMARY ARE AVAILABLE ONLINE AT HTTPS://WWW.MDMH.ORG/PATIENTS-AND-VISITORS/PATIENT-BILLING/PATIENT- FINANCIAL-ASSISTANCE.ASPX 5 1 - CORVALLIS FAMILY MEDICINE CLINIC 1037 MAIN STREET CORVALLIS MT 59828 FAMILY PRACTICE CLINIC 2 - BITTERROOT VALLEY EYE ASSOCIATES 300 N 10TH STREET HAMILTON MT 59840 OPTICAL SPECIALTY CLINIC 3 - BITTERROOT PHYSICIAN CLINIC SOUTH 3334 DVN LANE DARBY MT 59829 FAMILY PRACTICE CLINIC 4 - BITTERROOT PHYSICIAN CLINIC NORTH 2386 HIGHWAY 93 NORTH VICTOR MT 59875 FAMILY PRACTICE CLINIC 5 - RAVALLI UROLOGY 1224 WEST MAIN STREET HAMILTON MT 59840 UROLOGY SERVICES PART I, LINE 3C: ELIGIBILITY FOR FINANCIAL ASSISTANCE IS BASED ON MULTIPLE FACTORS, INCLUDING THE NATURE OF THE CONDITION AND CARE REQUIRED, INSURANCE COVERAGE OR OTHER SOURCES OF PAYMENT, INCOME (FEDERAL POVERTY LEVEL GUIDELINES ARE USED TO DETERMINE THE AMOUNT OF FINANCIAL ASSISTANCE OFFERED), FAMILY SIZE, ASSETS, AND RESIDENCY IN RAVALLI COUNTY UNLESS SERVICES WERE FOR EMERGENCY CARE.FULL FINANCIAL ASSISTANCE WILL BE GRANTED BASED ON INCOME EQUAL TO OR LESS THAN 100% OF FEDERAL POVERTY LEVEL GUIDELINES. PARTIAL ASSISTANCE MAY BE GRANTED BASED ON INCOME BETWEEN 100% AND 200% OF FEDERAL POVERTY LEVEL GUIDELINES. VALUE OF ASSETS MAY BE CONSIDERED IN DETERMINING THE LEVEL OF ASSISTANCE. PART I, LINE 7: EXPLANATION OF COSTING METHOD:FINANCIAL ASSISTANCE AT COST AND MEDICAID AMOUNTS REPORTED IN PART I, LINE 7 ARE COMPUTED USING THE COST TO CHARGE RATIO DERIVED FROM WORKSHEET 2 OF THE IRS INSTRUCTIONS. COMMUNITY HEALTH IMPROVEMENTS SERVICES, COMMUNITY BENEFIT OPERATIONS, HEALTH PROFESSIONAL EDUCATION, AND CASH AND IN-KIND CONTRIBUTIONS TO COMMUNITY GROUPS ARE REPORTED AT COST. GENERAL SUBSIDIZED SERVICES ARE COMPUTED USING THE IRS GUIDELINES OF COST ADJUSTED NET PAYMENTS RECEIVED. THE MEDICARE COST REPORT WAS USED TO DETERMINE THE TOTAL SUBSIDY FOR THE HOME HEALTH / HOSPICE DEPARTMENTS. PART I, LINE 7G: INCLUDED IN THE SUBSIDIZED HEALTH SERVICES ARE THE FOLLOWING DEPARTMENTS: BITTERROOT SURGICAL SERVICES, BITTERROOT GENERAL/VASCULAR SURGERY, HAMILTON GENERAL SURGERY, HOME HEALTH, AND HOSPICE AND PALLIATIVE CARE. PART I, LN 7 COL(F): THE AMOUNT OF BAD DEBT EXPENSES THAT WAS EXCLUDED FROM THE CALCULATION TO DETERMINE THE NET COMMUNITY BENEFIT EXPENSES AS A PERCENT OF TOTAL EXPENSES WAS $3,312,198. PART II, COMMUNITY BUILDING ACTIVITIES: THE HOSPITAL PROMOTES THE HEALTH OF THE COMMUNITY BY PARTICIPATION IN BOTH ECONOMIC AND COALITION BUILDING EVENTS. THE HOSPITAL PARTNERS WITH LOCAL HIGH SCHOOLS, WITH A "JOB SHADOW" PROGRAM. THE GOAL IS TO EXPOSE THOSE AREA YOUTH WHO MAY BE INTERESTED IN PURSUING A CAREER IN HEALTHCARE. WE HAVE ADDED RESIDENCY TRAINING OPPORTUNITIES TO THOSE NEW PHYSICIANS WHO ARE INTERESTED IN EXPERIANCING MEDICAL PRACTICE IN A RUAL SETTING. THE HOSPITAL CONTINUES TO RECRUIT NEW PHYSICIANS TO THE AREA TO PROVIDE BASIC AND EXPANDED SERVICES TO BETTER SERVE THE NEEDS OF THE LOCAL COMMUNITY. PART III, LINE 2: BAD DEBT EXPENSE IS CALCULATED BY REVIEWING PAYMENT ARRANGEMENTS WHICH INCLUDE PROSPECTIVELY DETERMINED RATES PER DISCHARGE, REIMBURSED COSTS, DISCOUNTED CHARGES AND PER DIEM PAYMENTS. NET PATIENT SERVICE REVENUE IS REPORTED AT THE ESTIMATED NET REALIZABLE AMOUNTS FROM PATIENTS, THIRD-PARTY PAYORS, AND OTHERS FOR SERVICES RENDERED, INCLUDING ESTIMATED RETROACTIVE ADJUSTMENTS UNDER REIMBURSEMENT AGREEMENTS WITH THIRD-PARTY PAYORS. PART III, LINE 3: THE HOSPITAL HAS NOT IDENTIFIED A METHOD FOR REASONABLY CALCULATING THE PORTION OF BAD DEBT EXPENSE ATTRIBUTABLE TO PATIENTS WHO WOULD QUALIFY FOR FINANCIAL ASSISTANCE HAD THEY APPLIED. PART III, LINE 4: SEE THE "PATIENT ACCOUNTS RECEIVABLE" PARAGRAPH ON PAGE 10 OF THE HOSPITAL'S ATTACHED AUDITED FINANCIAL STATEMENTS FOR AN EXPLANATION OF THE ORGANIZATION'S BAD DEBT EXPENSE. PART III, LINE 8: MDMH HAS A MEDICARE SHORTFALL IN EXCESS OF APPROXIMATELY $7.25 MILLION. THE HOSPITAL HAS CRITICAL ACCESS HOSPITAL STATUS AND IS REIMBURSED BY MEDICARE FOR INPATIENT AND OUTPATIENT SERVICES ON A COST BASIS AS DEFINED AND LIMITED BY THE MEDICARE PROGRAM. MDMH PROVIDES A SIGNIFICANT RURAL LINK FOR BOTH THE HEALTH AND WELL-BEING OF RAVALLI COUNTY RESIDENTS. WE ARE COMMITTED TO LOCAL HEALTHCARE CLOSE TO HOME AND WORK HARD TO EARN AND KEEP THE TRUST OF THE LOCAL COMMUNITY. TO ENSURE THAT A VARIETY OF CLINIC, HOSPITAL AND EMERGENCY SERVICES ARE OPEN AND AVAILABLE TO ALL THOSE WITHIN OUR SERVICE AREA WE STRIVE TO OPERATE AT THE HIGHEST LEVEL OF FISCAL RESPONSIBILITY AND TO BE A GOOD STEWARD OF OUR RESOURCES. THE MEDICARE ALLOWABLE COSTS INCLUDED IN PART III, LINE 6 WAS DERIVED USING THE 2019 FILED MEDICARE COST REPORT. PART III, LINE 9B: IF A PATIENT IS PRESUMED TO BE FINANCIALLY INDIGENT, THE PATIENT REPRESENTATIVE WILL OFFER A PERSONAL FINANCIAL STATEMENT (PFS) TO BE FILLED OUT. THE PFS WILL BE FORWARDED TO THE PATIENT FINANCIAL ASSISTANCE COMMITTEE FOR REVIEW AND DETERMINATION OF PATIENT FINANCIAL ASSISTANCE STATUS. A PATIENT MAY REQUEST A MONTHLY PAYMENT ARRANGMENT. A MINIMUM PAYMENT OF $50 MUST BE PAID MONTHLY, WITH THE GOAL OF THE BALANCE BEING PAID IN FULL WITHIN 5 YEARS. ACCOUNTS THAT CANNOT BE COLLECTED AFTER NORMAL IN-HOUSE COLLECTION PROCEDURES MAY BE REFERRED TO A COLLECTION AGENCY, MAGISTRATE OR ATTORNEY FOR FURTHER COLLECTION ACTION. PART VI, LINE 2: BY LISTENING TO OUR PATIENTS, FRIENDS, FAMILY AND NEIGHBORS AS WE INTERACT WITH THEM DAILY WE HEAR THEIR CARES AND CONCERNS. WE ALWAYS ARE LOOKING FOR NEW WAY TO RESPOND TO, AND PROVIDE BETTER CARE FOR, THE LOCAL COMMUNITY. PART VI, LINE 3: THE HOSPITAL'S FINANCIAL ASSISTANCE PROGRAM IS POSTED ON THEIR WEBSITE AT HTTPS://WWW.MDMH.ORG/PATIENTS-AND-VISITORS/PATIENT-BILLING/PATIENT- FINANCIAL-ASSISTANCE.ASPXIN ADDITION THE HOSPITAL INFORMS PATIENTS UNABLE TO PAY THEIR BILLS ABOUT THEIR FINANCIAL ASSISTANCE WHILE TALKING TO THEM OVER THE PHONE AND SENDS THEM A FINANCIAL ASSISTANCE PACKET. PART VI, LINE 4: THE HOSPITAL SERVES A RURAL POPULATION WHERE THE AVERAGE ANNUAL WAGE IS $40,546. THE PAYER MIX IS 55% MEDICARE, 18% MEDICAID, 27% SELF PAY, NO INSURANCE, WITH THE BALANCE AT OTHER COMMERCIAL PAYORS. THE UNEMPLOYMENT RATE IN RAVALLI COUNTY IS CURRENTLY AT 6.3% ACCORDING TO THE MONTANTA DEPARTMENT OF LABOR AND INDUSTRY. PART VI, LINE 5: THE HOSPITAL IS PROUD OF ITS EFFORTS TO PROMOTE COMMUNITY HEALTH AND WELLNESS. THE COLORS OF CANCER PROGRAM IS A COMMUNITY-WIDE PROGRAM TO RAISE AWARENESS FOR ALL TYPES OF CANCER. THE HOSPITAL CONTINUES TO PROVIDE NO-COST MAMMOGRAMS TO QUALIFIED LOW-INCOME AREA RESIDENTS. THE HOSPITAL COORDINATES AND SPONSORS THE ANNUAL SPORTS PHYSICAL CLINIC TO SUPPORT AND ENCOURAGE AREA YOUTH TO PARTICIPATE IN PHYSICAL ACTIVITIES. PART VI, LINE 6: THE ORGANIZATION IS NOT PART OF AN AFFILIATED HEALTH CARE SYSTEM. PART VI, LINE 7, REPORTS FILED WITH STATES MT 1 DALY HOSPITAL FOUNDATION 1200 WESTWOOD DRIVE HAMILTON MT 59840 810287203 501(C)(3) 25458 GENERAL OPERATING SUPPORT HAMILTON SCHOOL DISTRICT 217 DALY AVENUE HAMILTON MT 59840 816000830 GOVERNMENTAL 6600 SUPPORT FOR SCHOOL RN PROGRAM AND STUDENT ATHLETICS CORVALLIS SCHOOL DISTRICT PO BOX 700 1045 MAIN STREET CORVALLIS MT 59828 816000828 GOVERNMENTAL 7600 SUPPORT FOR SCHOOL RN PROGRAM AND STUDENT ATHLETICS STEVENSVILLE SCHOOL DISTRICT 300 PARK STREET STEVENSVILLE MT 59870 816000829 GOVERNMENTAL 6500 SUPPORT FOR SCHOOL RN PROGRAM AND STUDENT ATHLETICS FLORENCE CARTON SCHOOL DISTRICT 5602 OLD HWY 93 FLORENCE MT 59833 816000836 GOVERNMENTAL 6500 SUPPORT FOR SCHOOL RN PROGRAM AND STUDENT ATHLETICS 5 0 PART I, LINE 2: THE HOSPITAL IS COMMITTED TO SUPPORT THE HEALTH AND WELL-BEING OF AREA SCHOOL AGED CHILDREN BY PROVIDING FUNDING GRANTS RESTRICTED TO THE DISTRICT'S SCHOOL NURSE PROGRAM. THE HOSPITAL HAS ALSO COMMITTED TO SUPPORT STUDENT ATHLETICS BY PROVIDING A VOLUNTEER BASED, LOW-COST SPORTS PHYSICAL CLINIC DURING THE SUMMER. THE PROCEEDS ARE GIVEN TO THE PARTICIPATING STUDENTS' HOME DISTRICT TO SUPPORT THE DISTRICT'S ATHLETIC PROGRAMS. OTHER COMMUNITY ORGANIZATIONS MAY SUBMIT A GRANT PROPOSAL DIRECTLY TO THE HOSPITAL CEO FOR CONSIDERATION. THE REQUESTS ARE EVALUATED BASED UPON BROAD BASED COMMUNITY SUPPORT AND THE URGENCY OF NEED. X X 0 0 X X X X X X 0 0 0 0 0 0 0 0 0 LAWRENCE BROUWER MD BOARD MEMBER/PHYSICIAN 178078 0 0 0 18500 0 8903 0 0 0 205481 0 0 0 TIMOTHY WOODS MD BOARD MEMBER/PHYSICIAN 443240 0 0 0 18500 0 13250 0 29535 0 504525 0 0 0 JOHN BISHOP CEOSECRETARY TREASURER 217281 0 0 0 0 0 0 0 2006 0 219287 0 0 0 DONJA ERDMAN CFO 145334 0 0 0 12001 0 7867 0 11906 0 177108 0 0 0 TROY HANSON COO 180856 0 0 0 0 0 0 0 23777 0 204633 0 0 0 RICHARD DAY MD PHYSICIAN 1098835 0 0 0 18500 0 13250 0 12748 0 1143333 0 0 0 MARK CALDERWOOD MD PHYSICIAN 472009 0 0 0 0 0 0 0 17932 0 489941 0 0 0 MICHAEL DOLECKI MD PHYSICIAN 450900 0 0 0 18000 0 13250 0 13443 0 495593 0 0 0 KEVIN GURNEY MD PHYSICIAN 402811 0 0 0 0 0 0 0 24082 0 426893 0 0 0 CLINTON ADKINS MD PHYSICIAN 408465 0 0 0 0 0 0 0 184 0 408649 0 0 0 JOHN BARTOS FORMER CEO 363985 0 0 0 18500 0 0 0 9267 0 391752 0 0 0 PART I, LINE 1A DR RICHARD DAY RECEIVES A NON-PAID HOUSING ALLOWANCE. THE HOUSE IS OWNED BY THE HOSPITAL AND PROVIDED TO DR. DAY AS A CONVENIENCE TO MARCUS DALY MEMORIAL HOSPITAL. THE EMPLOYEES REPORTED IN FORM 990, PART VII, SECTION A RECEIVED TAX GROSS-UP PAYMENTS FOR THEIR TAXABLE COMPENSATION RELATED TO LONG-TERM DISABILITY INSURANCE PROVIDED BY MARCUS DALY MEMORIAL HOSPITAL. THE TOTAL VALUE OF THE PAYMENTS DURING CALENDAR YEAR 2018 WAS $30,050. A MT FACILITY FINANCE AUTHORITY 364615155 2017-06-22 9505000 REFINANCE SERIES 2000A AND SERIES 2007A BONDS AND REFINANCE EXISTING LOANS 0 0 0 B MT FACILITY FINANCE AUTHORITY 364615155 2017-12-15 15000000 FINANCE CONSTRUCTION OF A NEW SURGERY CENTER 0 0 0 A 605000 9505000 190100 9314900 2017 1 0 1 1 B 530000 15000000 1040407 300000 13659593 0 0 0 1 A 0 0 0 0 0 0 1 B 0 0 0 0 0 0 1 A 0 1 0 0 0 0 0 0 1 B 0 1 0 0 0 0 0 0 1 A 1 B 1 FORM 990, PART VI, SECTION B, LINE 11B A REPRESENTATIVE FROM CLIFTONLARSONALLEN, THE PAID PREPARER, PRESENTED THE FORM 990 TO THE HOSPITAL FINANCE COMMITTEE. UPON APPROVAL, THE FORM 990 WAS PRESENTED TO THE BOARD OF DIRECTORS FOR ACCEPTANCE AND APPROVAL PRIOR TO FILING WITH THE IRS. FORM 990, PART VI, SECTION B, LINE 12C ANY DIRECTOR, CORPORATE OFFICER, SENIOR MANAGER, TRUSTEE OR MEMBER OF A COMMITTEE WITH GOVERNING BOARD DELEGATED POWERS, WHO HAS A DIRECT OR INDIRECT FINANCIAL INTEREST, IS AN INTERESTED PERSON. IF A PERSON IS AN INTERESTED PERSON WITH RESPECT TO ANY ENTITY IN THE HEALTH CARE SYSTEM OF WHICH THE HOSPITAL IS A PART, HE OR SHE IS AN INTERESTED PERSON WITH RESPECT TO ALL ENTITIES IN THE HEALTH CARE SYSTEM. UPON APPOINTMENT, HIRE OR TRANSFER AND ANNUALLY THEREAFTER, EACH INTERESTED PERSON SHALL EXECUTE AND SUBMIT TO THE HOSPITAL'S CEO A STATEMENT WHICH AFFIRMS SUCH PERSON: A. HAS RECEIVED A COPY OF THE CONFLICT OF INTEREST POLICY; B. HAS READ AND UNDERSTANDS THE POLICY; C. HAS AGREED TO COMPLY WITH THE POLICY; AND D. UNDERSTANDS THAT THE HOSPITAL IS A CHARITABLE ORGANIZATION AND IN ORDER TO MAINTAIN ITS FEDERAL AND STATE TAX EXEMPTIONS IT MUST ENGAGE PRIMARILY IN ACTIVITIES WHICH ACCOMPLISH ONE OR MORE OF ITS TAX-EXEMPT PURPOSES. IN CONNECTION WITH ANY ACTUAL OR POSSIBLE CONFLICT OF INTEREST, AN INTERESTED PERSON MUST DISCLOSE THE EXISTENCE OF THE CONFLICTING FINANCIAL INTEREST AND MUST BE GIVEN THE OPPORTUNITY TO DISCLOSE ALL MATERIAL FACTS TO THE DIRECTORS AND MEMBERS OF COMMITTEES WITH GOVERNING BOARD DELEGATED POWERS CONSIDERING THE PROPOSED TRANSACTION OR ARRANGEMENT. ANY OTHER MEMBER OF THE BOARD OR COMMITTEE MAY RAISE THE QUESTION OF WHETHER A CONFLICT EXISTS, DISCLOSE FACTS RELATING TO THE CONFLICT AND REQUEST THE INTERESTED PERSON TO PROVIDE FURTHER DETAILS. THE BOARD CHAIR (OR VICE CHAIR ACTING IN THE PLACE OF THE CHAIR) OR THE HOSPITAL'S LEGAL COUNSEL MAY, BASED ON THEIR INFORMATION ABOUT THE CONFLICT, DISCLOSE THE CONFLICT AND REQUEST THE INTERESTED PERSON TO WITHDRAW FROM DISCUSSION OF THE TRANSACTION AND/OR NOT VOTE. THE INTERESTED PERSON SHALL LEAVE THE MEETING OR REQUEST A DETERMINATION BY THE BOARD OR COMMITTEE OF WHETHER A CONFLICT OF INTEREST EXISTS. AFTER DISCLOSURE OF THE CONFLICTING INTEREST AND ALL MATERIAL FACTS, AND AFTER ANY DISCUSSION WITH THE INTERESTED PERSON, HE/SHE SHALL LEAVE THE GOVERNING BOARD OR COMMITTEE MEETING WHILE THE DETERMINATION OF A CONFLICT OF INTEREST IS DISCUSSED AND VOTED UPON. THE REMAINING, DISINTERESTED BOARD OR COMMITTEE MEMBERS SHALL DECIDE IF A CONFLICT OF INTEREST EXISTS BEFORE CONSIDERING OR ACTING UPON ANY OTHER BUSINESS. AFTER EXERCISING DUE DILIGENCE, THE GOVERNING BOARD OR COMMITTEE SHALL DETERMINE WHETHER THE HOSPITAL CAN OBTAIN WITH REASONABLE EFFORTS A MORE ADVANTAGEOUS TRANSACTION OR ARRANGEMENT WITH REASONABLE EFFORTS FROM A PERSON OR ENTITY THAT WOULD NOT GIVE RISE TO A CONFLICT OF INTEREST. IF A MORE ADVANTAGEOUS TRANSACTION OR ARRANGEMENT IS NOT REASONABLY ATTAINABLE UNDER CIRCUMSTANCES NOT PRODUCING A CONFLICT OF INTEREST, THE GOVERNING BOARD OR COMMITTEE SHALL DETERMINE BY A MAJORITY VOTE OF THE DISINTERESTED DIRECTORS WHETHER THE TRANSACTION OR ARRANGEMENT IS IN THE HOSPITAL'S BEST INTEREST, FOR ITS OWN BENEFIT, AND WHETHER IT IS FAIR AND REASONABLE. IN CONFORMITY WITH THE ABOVE DETERMINATION, THE GOVERNING BOARD OR COMMITTEE SHALL MAKE ITS DECISION AS TO WHETHER TO ENTER INTO THE TRANSACTION OR ARRANGEMENT. FORM 990, PART VI, SECTION B, LINE 15A ON AN ANNUAL BASIS, THE NON-CONFLICTED HOSPITAL BOARD MEMBERS (COMPENSATION COMMITTEE) RECEIVE THE ANNUAL COMPENSATION AND BENEFIT SURVEY PREPARED BY THE MONTANA HOSPITAL ASSOCIATION (MHA). THE COMMITTEE ALSO RECEIVES A REPORT FROM THE HOSPITAL THAT INCLUDES RESEARCH OF ALL CRITICAL ACCESS HOSPITALS IN THE STATES OF MONTANA, IDAHO, AND WYOMING. USING THIS INFORMATION THE COMPENSATION COMMITTEE THEN PROVIDES A RECOMMENDATION FOR CEO COMPENSATION TO THE FULL HOSPITAL BOARD. THE CEO HAS THE AUTHORITY TO SET THE COMPENSATION OF OTHER OFFICERS AND KEY EMPLOYEES OF THE HOSPITAL. FOR PHYSICIAN COMPENSATION, THE HOSPITAL USES A THIRD-PARTY CPA FIRM TO GATHER COMPENSATION DATA FROM MGMA AND NON-PHYSICAN COMPENSATION INFORMATION IS FROM THE MHA COMPENSATION SURVEY. FORM 990, PART VI, SECTION C, LINE 18 IN ADDITION TO BEING AVAILABLE UPON REQUEST, A COPY OF THE FORM 990 IS ALSO AVAILABLE AT WWW.GUIDESTAR.ORG. FORM 990, PART VI, SECTION C, LINE 19 GOVERNING DOCUMENTS AND CONFLICT OF INTEREST POLICY ARE NOT MADE AVAILABLE TO THE PUBLIC. FINANCIAL STATEMENTS ARE MADE AVAILABLE TO THE PUBLIC UPON REQUEST. FORM 990, PART XI, LINE 9: CHANGE IN BENEFICIAL INTEREST IN NET ASSETS OF DALY HOSPITAL FOUNDATION 372,399. DALY HOSPITAL FOUNDATIONINC 1200 WESTWOOD DRIVE HAMILTON MT 59840 363766000 CHARITABLE SERVICES MT 501(C)(3) LINE 7 N/A 0 0 1 1 0 0 0 0 0 0 1 0 1 1 1 1 1 1 0 0