2020-06-24T16:31:35-05:00 2019-06-30 390758449 WIPFLI LLP 101 EAST FRONT STREET 301 MISSOULA MT 59802 990 2018-07-01 810469886 POWELL COUNTY MEMORIAL HOSPITAL ASSOC POWE 4068462212 1100 HOLLENBACK LANE DEER LODGE MT 59722 TONY PFAFF CEO 4068462212 2020-05-18 1 PHILIP L YASENAK CPA P01248379 4067281800 2020-05-18 72.174.139.103 2020-05-18 11:56:38 MD P DA39A3EE5E6B4B0D3255BFEF95601890AFD80709 BE7A92E7B0152C1C6812F3C99C620D56F411D8FD 2018 2021-01-29 14:40:06Z DEER LODGE MEDICAL CENTER TONY PFAFF 1100 HOLLENBACK LANE DEER LODGE MT 59722 17517525 0 X DLMED.ORG X 1991 MT THE MISSION OF THE HOSPITAL IS TO PROVIDE HIGH QUALITY HEALTHCARE TO ALL THEY SERVE. 7 7 122 9 0 0 106762 139410 14533416 15405988 18806 104286 196390 336475 14855374 15986159 0 0 0 0 7480234 8069676 0 0 0 6163507 6545712 13643741 14615388 1211633 1370771 26119575 26733441 18236949 17376335 7882626 9357106 THE MISSION OF THE HOSPITAL IS TO PROVIDE HIGH QUALITY HEALTHCARE TO ALL THEY SERVE. 0 0 12626435 15716649 THE HOSPITAL PROVIDES DAILY PATIENT CARE SERVICES AND IS THE ONLY SOURCE OF THESE SERVICES IN THE AREA. 12626435 1 1 0 1 0 0 0 0 0 0 1 0 0 1 0 1 1 0 0 0 0 0 0 0 0 0 1 1 0 0 1 1 0 0 0 0 0 0 0 1 0 1 1 0 0 0 0 1 0 0 0 1 13 0 1 122 1 0 0 0 0 0 0 0 0 0 0 0 0 X 7 7 0 1 0 0 0 0 0 1 1 0 0 1 1 1 1 1 1 1 1 0 X JAENA RICHARDS 4068462212 1100 HOLLENBACK LANE DEER LODGE MT 59722 X LEIGHTON LEE JEWELL PRESIDENT 1.00 X X 0 0 0 JACK ANDERSON VICE PRESIDENT 1.00 X X 0 0 0 TERRY MOSIER SECRETARY/TREASURER 1.00 X X 0 0 0 HOWARD NECKELS DIRECTOR 1.00 X 0 0 0 ALLEN ROME DIRECTOR 1.00 X 0 0 0 JIM DECKER DIRECTOR 1.00 X 0 0 0 CARLEE HANSEN DIRECTOR 1.00 X 0 0 0 TONY PFAFF CHIEF EXECUTIVE OFFICER 40.00 X 0 0 0 JENNIFER SPRING CHIEF FINANCIAL OFFICER 40.00 X 98462 0 2430 JUDITH WILSON MD PHYSICIAN 40.00 X 233905 0 9692 SUMERA QAMAR OD 40.00 X 225297 0 0 WAYNE MARTIN MD PHYSICIAN 40.00 X 222734 0 13710 LORI DRUMM OD 40.00 X 218492 0 21220 ERIK KINZER NP 40.00 X 178308 0 29125 1177198 0 76177 12 0 1 0 CYPRESS HEALTHCARE LLC 791 EASTSIDE ROAD DEER LODGE MT 59722 MANAGEMENT, CEO, REVENUE INTEGRITY SERVI 391706 ALLEVANT SOLUTIONS 4714 GETTYSBURG ROAD MECHANICSBURG PA 17055 TRANSITIONAL CARE PROGRAM CONSULTING SER 230000 MONIDA SHARED IMAGING 1200 S RESERVE ST SUITE H MISSOULA MT 59801 MRI SERVICES 212029 TRANSCENDENT ANES & PAIN SERVICE 330 TRIPLE TREE ROAD BOZEMAN MT 59715 ANESTHESIA AND PAIN MGMT. SERVICES 166246 THOMAS CUISINE MANAGEMENT 700 E FRANKLIN ROAD MERIDIAN ID 83642 CAFE/DIETARY MANAGEMENT 164440 7 58179 8843 72388 58179 139410 NET PATIENT SERVICE REVENUE 621110 14824396 14824396 UTILIZATION FEE REVENUE 621110 466354 466354 OTHER OPERATING REVENUE 621110 115238 115238 15405988 111231 111231 45747 19933 25814 25814 25814 1504488 1511433 -6945 -6945 -6945 OTHER INCOME 621110 310661 310661 310661 15986159 15716649 0 130100 X 107420 107420 6631285 5601240 1030045 86798 78952 7846 807782 710848 96934 436391 384024 52367 4099 4099 1643923 1545472 98451 52630 52630 124624 63877 60747 186119 13475 172644 158567 158567 64220 42221 21999 725685 696632 29053 899097 863133 35964 149708 144223 5485 SUPPLIES 1591250 1576478 14772 OTHER OPERATING EXPENSE 561988 427158 134830 REPAIRS AND MAINTENANCE 164427 159024 5403 LICENSES AND TAXES 92078 33814 58264 127297 127297 14615388 12626435 1988953 0 804675 369658 5132268 2083252 2101990 2989642 372145 384905 100594 139004 21708109 7678472 14310854 14029637 4075649 3297049 2661694 26119575 26733441 1773000 1803382 15295000 14525000 1168949 1047953 18236949 17376335 X 7882626 9357106 7882626 9357106 26119575 26733441 1370771 103709 0 X X 0 1 X 1 0 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 0 0 0 0 0 1 1000 0 0 0 1000 0 PART II-B, LINE 1: LINE (F) GRANTS TO OTHER ORGANIZATIONS FOR LOBBYING PURPOSES - A CONTRIBUTION WAS MADE TO MONTANANS FOR THE 6 MILL LEVY CAMPAIGN FOR HIGHER EDUCATION FINANCING IN THE STATE OF MONTANA. 695642 695642 15007913 3084620 11923293 6004554 4593852 1410702 14029637 BOND FUNDS 2314685 INVESTMENT IN YELLOWSTONE INSURANCE EXCHANGE RRG 212768 INVESTMENT IN WORKERS COMPENSATION 59241 INVESTMENT IN MONIDA SHARED IMAGING 75000 2661694 X 16020821 103709 19933 123642 15897179 88980 88980 15986159 14546341 19933 19933 14526408 88980 88980 14615388 PART X, LINE 2: THE HOSPITAL IS A TAX-EXEMPT CORPORATION AS DESCRIBED IN SECTION 501(C)(3) OF THE INTERNAL REVENUE CODE (THE "CODE") AND IS EXEMPT FROM FEDERAL INCOME TAXES ON RELATED INCOME PURSUANT TO SECTION 501(A) OF THE CODE. THE HOSPITAL IS ALSO EXEMPT FROM STATE TAXES ON RELATED INCOME PURSUANT TO SIMILAR STATE OF MONTANA TAX LAWS. PART XI, LINE 2D - OTHER ADJUSTMENTS: DIRECT RENT EXPENSE DEDUCTED FROM GROSS RENTS FOR 990 REVENUE 19,933. PART XI, LINE 4B - OTHER ADJUSTMENTS: 340B PHARMACEUTICAL EXPENSES NETTED W/ REVENUE ON FINANCIAL STATEMENTS 88,980. PART XII, LINE 2D - OTHER ADJUSTMENTS: DIRECT RENT EXPENSE DEDUCTED FROM GROSS RENTS FOR 990 REVENUE 19,933. PART XII, LINE 4B - OTHER ADJUSTMENTS: 340B PHARMACEUTICAL EXPENSES NETTED W/ REVENUE ON FINANCIAL STATEMENTS 88,980. 1 1 1 X 250.000000000000 0 1 1 1 0 0 389398 389398 0.02660 3355720 2692894 662826 0.04540 3745118 2692894 1052224 0.07200 10056 900 9156 0.00060 4284 4284 0.00030 78339 78339 0.00540 92679 900 91779 0.00630 3837797 2693794 1144003 0.07830 251 251 0.00000 3885 3885 0.00030 16683 16683 0.00110 20819 20819 0.00140 1 38317 6029451 6104981 -75530 X 1 1 1 CYPRESS HEALTHCARE LLC MANAGEMENT SERVICES 0.00000 1.00000 0.00000 1 1 POWELL COUNTY MEMORIAL HOSPITAL 1100 HOLLENBACK LANE DEER LODGE MT 59722 WWW.DLMED.ORG 12992 X X X X POWELL COUNTY MEMORIAL HOSPITAL 1 0 0 1 X X X X X X X X 18 1 0 0 1 X WWW.DLMED.ORG X 1 18 1 WWW.DLMED.ORG 0 1 X 250.000000000000 X X X 1 1 X X X 1 X WWW.DLMED.ORG X WWW.DLMED.ORG X WWW.DLMED.ORG X X X X X X 1 X 0 X X X 1 X 0 0 POWELL COUNTY MEMORIAL HOSPITAL PART V, SECTION B, LINE 5: A STEERING COMMITTEE WAS CONVENED TO ASSIST DEER LODGE MEDICAL CENTER IN CONDUCTING CHSD. A DIVERSE GROUP OF COMMUNITY MEMBERS REPRESENTING VARIOUS ORGANIZATIONS AND POPULATIONS WITHIN THE COMMUNITY (EX. PUBLIC HEALTH, ELDERLY, UNINSURED) CAME TOGETHER IN DECEMBER 2018. THE COMMITTEE MET TWICE DURING THE CHSD PROCESS; FIRST TO DISCUSS HEALTH CONCERNS IN THE COMMUNITY AND OFFER THEIR PERSPECTIVE IN DESIGNING THE SURVEY INSTRUMENT, AND AGAIN TO REVIEW RESULTS OF THE SURVEY AND FOCUS GROUPS AND TO ASSIST IN THE PRIORITIZATION OF HEALTH NEEDS TO ADDRESS. POWELL COUNTY MEMORIAL HOSPITAL PART V, SECTION B, LINE 11: CHNA SIGNIFICANT NEED #1: IMPROVE ACCESS TO BEHAVIORAL HEALTH SERVICES IN POWELL COUNTY. STRATEGY #1: EXPAND BEHAVIORAL HEALTH SERVICES OFFERED AT DEER LODGE MEDICAL CENTER ACTIVITIES: HIRE FULL-TIME PSYCHIATRIST AT DLMC AND CONTINUE TO OFFER TELE-PSYCH CONSULTS IN CLINIC AND EMERGENCY ROOM STRATEGY #2: ENHANCE COMMUNITY OUTREACH AND EDUCATION RELATED TO BEHAVIORAL HEALTH IN POWELL COUNTY ACTIVITIES: DEVELOP A MENTAL/BEHAVIORAL HEALTH COMMUNITY RESOURCE PAGE HOSTED ON DLMC'S WEBSITE; CREATE MARKETING AND EDUCATIONAL OUTREACH PROMOTING NEW MH/BH RESOURCE LIST FOR DLMC STAFF, COMMUNITY PARTNERS, AND POWELL COUNTY COMMUNITY; CONTINUE TO PARTICIPATE IN COMMUNITY GROUPS/COALITIONS THAT ADDRESS BEHAVIORAL HEALTH NEEDS IN POWELL COUNTY; CONTINUE TO SUPPORT COMMUNITY PROGRAMS AND EVENTS THAT PROMOTE HEALTHY BEHAVIORS AND SUBSTANCE ABUSE PREVENTION (EX. AFTER PROM PARTY)CHNA SIGNIFICANT NEED #2: ENHANCE DEER LODGE MEDICAL CENTER'S HEALTH AND WELLNESS OUTREACH IN POWELL COUNTY. STRATEGY #1: EXPAND AND ENHANCE HEALTH AND WELLNESS PROGRAMS AND RESOURCES AT DEER LODGE MEDICAL CENTER ACTIVITIES: EXPLORE OPPORTUNITIES TO EXPAND PLANETREE MINDFULNESS AND WELLNESS PROGRAMS AT DLMC TO COMMUNITY MEMBERS; EXPLORE DEVELOPMENT AND FUNDING SOURCES FOR A COMMUNITY PARK/PLAYGROUND ON DLMC CAMPUS IN PARTNERSHIP WITH LOCAL COMMUNITY BUSINESSES AND THE CITY OF DEER LODGE; DEVELOP NUTRITIONAL OUTREACH (SUCH AS MONTHLY HEALTHY RECIPES TO BE FEATURED IN CAF AND ON DLMC FACEBOOK PAGE) THAT PROMOTE PREVENTION AND HEALTHY DIETS; CONTINUE TO PROVIDE HEALTH EDUCATION OPPORTUNITIES THAT PROMOTE HEALTH AND WELLNESS (PRE -DIABETES SUPPORT GROUP, WOMEN'S NIGHT OUT, STOP THE BLEED, HEALTH FAIR). STRATEGY #2: CONTINUE TO SUPPORT AND SPONSOR ACTIVITIES AND PROGRAMS THAT PROMOTE PHYSICAL ACTIVITY IN POWELL COUNTY ACTIVITIES: DMLC WILL PROVIDE STAFF TO PARTICIPATE ON LOCAL TRAIL COMMITTEE AND EXPLORE OPPORTUNITIES TO PROMOTE TRAIL UTILIZATION (WALK BIKE MONTANA); SPONSOR LOCAL ADULT AND YOUTH RECREATIONAL LEAGUES; CONTINUE TO HOST COMMUNITY EVENTS THAT PROMOTE PHYSICAL ACTIVITY (GOLF TOURNAMENT, ANNUAL HEALTH WALK); CONTINUE TO PROVIDE YOUTH SPORTS PHYSICALS, CONCUSSION SCREENING AND HELMET PROMOTION PROGRAM.CHNA SIGNIFICANT NEED #3: ENHANCE ACCESS TO HEALTHCARE SERVICES IN POWELL COUNTY. STRATEGY #1: IMPROVE AND SUSTAIN ACCESS TO HEALTHCARE SERVICE IN POWELL COUNTY ACTIVITIES: DLMC WILL WORK WITH AREA PARTNERS SUSTAIN AMBULANCE SERVICES IN POWELL COUNTY; DEVELOP AND IMPLEMENT A FACILITY RETENTION PLAN TO IMPROVE CONTINUITY OF PROVIDERS AND IMPROVE ACCESS TO HEALTHCARE SERVICES; CONTINUE TO PROVIDE AND PROMOTE PATIENT NAVIGATOR SERVICES LINKING PATIENTS TO COMMUNITY RESOURCES; DEVELOP FINANCIAL RESOURCES AND PROGRAMS EDUCATION FOR PATIENTS (I.E. MEDICAID, MEDICARE, 340B PROGRAM, ETC.); DEVELOP METHODOLOGY AND PROTOCOLS TO SHARE FINANCIAL ASSISTANCE RESOURCES (CLINIC, ED, WEBSITE, ETC.). STRATEGY #2: IMPROVE KNOWLEDGE OF SERVICES AVAILABLE AT DEER LODGE MEDICAL CENTER AND IN COMMUNITY ACTIVITIES: CONVENE A DLMC WORKGROUP TO DISCUSS CURRENT MARKETING EFFORTS, GAPS AND NEW OPPORTUNITIES; CREATE A COMMUNITY RESOURCES PAGE ON DLMC WEBSITE; CREATE MARKETING FLYERS/HANDOUTS FOR DLMC STAFF/PROVIDERS AND PARTNERS, DETAILING LOCAL RESOURCES (SENIOR SERVICES, MENTAL HEALTH RESOURCES, ETC.); CREATE OUTREACH/INFORMATION ABOUT DLMC PROVIDERS AND SERVICES; CONTINUE TO PROVIDE EDUCATION/PRESENTATIONS TO LOCAL ORGANIZATIONS.DLMC IS UNABLE TO ADDRESS THE FOLLOWING NEEDS AT THIS TIME:1. TOP DESIRED HEALTHCARE SERVICES NOT CURRENTLY AVAILABLE ARE URGENT CARE AND HOME HEALTH SERVICES. AT THIS TIME, IT IS NOT FINANCIALLY VIABLE FOR DLMC TO PROVIDE URGENT CARE AND/OR HOME HEALTH SERVICES. DLMC REFERS PATIENTS TO THE NEAREST RESOURCE AVAILABLE RELATED TO THESE SERVICES AS WELL AS OFFERING A 24/7 EMERGENCY DEPARTMENT.2. 9.4% OF SURVEY RESPONDENTS INDICATED THEY WORRIED THEY WOULD NOT HAVE ENOUGH FOOD TO EAT AT SOME POINT IN THE LAST YEAR. DLMC BELIEVES THERE ARE OTHER ENTITIES ADDRESSING THIS HEALTH NEED IN THE COMMUNITY. HOWEVER, DLMC PROVIDES ASSISTANCE TO THESE PROGRAMS NUMEROUS TIMES THROUGHOUT THE YEAR.3. ELDERLY TRANSPORTATION, AGING ISSUES, AND SOCIAL ISOLATION WERE IDENTIFIED BY KEY INFORMANT INTERVIEWEES AS SERVICES/NEEDS IN THE COMMUNITY. DLMC IS EXPLORING OPTIONS RELATED TO TRANSPORTATION AND SOCIAL ISOLATION. DLMC IS WORKING WITH LOCAL ORGANIZATIONS AND GROUPS TO ASSIST IN ANY WAY POSSIBLE. UPON AMBULANCE INTEGRATION WITH DLMC, TRANSPORTATION WILL BE MORE WIDELY AVAILABLE TO THOSE IN NEED.4. POWELL COUNTY HAS A HIGH RATE OF CHILDREN LIVING IN POVERTY (24.7% COMPARED TO 17.6% IN MONTANA). DLMC ASSISTS WITH PUBLIC HEALTH OFFICIALS IN THE COUNTY AND CITY. IN ADDITION, DLMC OFFERS CHARITY CARE TO THOSE WHO QUALIFY. POWELL COUNTY HEALTH DEPARTMENT IS ADDRESSING THIS ON AN ONGOING BASIS.5. POWELL COUNTY HAS A HIGHER PERCENTAGE OF WOMEN WHO REPORT SMOKING DURING PREGNANCY (22.9% VS. 16.3% IN MONTANA). DLMC DOES NOT OFFER OBSTETRIC SERVICES THEREFORE IT IS DIFFICULT TO IDENTIFY THESE INDIVIDUALS.6. POWELL COUNTY HAS A HIGH RATE OF HEPATITIS C (874.70 PER 100,000 POPULATION COMPARED TO 122.95 IN MONTANA). DLMC ASSISTS THE PUBLIC HEALTH PROGRAM BY PROVIDING TESTING FOR THESE INDIVIDUALS. DLMC IS WILLING TO ASSIST THE PUBLIC HEALTH PROGRAM AS NEEDED. PART I, LINE 7: PCMH USED COST-TO-CHARGE RATIOS FROM ITS MOST RECENT MEDICARE COST REPORT TO DETERMINE THE COST OF FINANCIAL ASSISTANCE AND MEDICAID. COST ACCOUNTING, WHICH INCLUDED ALL SEGMENTS (INPATIENT, OUTPATIENT, ER, ET AL) WAS USED TO DETERMINE ALL OTHER AMOUNTS REPORTED IN THE TABLE.BAD DEBT EXPENSE WAS NOT A FACTOR IN CALCULATING THE PERCENTAGES FOR COLUMN F. PART II, COMMUNITY BUILDING ACTIVITIES: PHYSICAL IMPROVEMENTS AND HOUSING: PCMH EMPLOYEE SERVED ON THE COUNTY TRAILS COMMITTEE THAT WORKS TO BRING SAFE, FREE PUBLIC TRAILS TO THE COMMUNITY.COMMUNITY SUPPORT: PCMH EMPLOYEES TOOK PART IN THE POWELL COUNTY LOCAL EMERGENCY PREPAREDNESS COMMITTEE MEETINGS AND THE PCMH PROVIDED A FREE MEETING SPACE FOR THE MEETINGS ($938). PCMH SUPPLIED PINK, LOGO-FREE JERSEYS FOR LOCAL STUDENT ATHLETES TO WEAR AS PART OF BREAST CANCER AWARENESS MONTH ($2,685); A PCMH EMPLOYEE VOLUNTEERED TO GIVE JUNIOR GOLF LESSONS ($263). WORKFORCE DEVELOPMENT: PCMH WORKED WITH THE LOCAL HIGH SCHOOL TO PROVIDE AN INTERNSHIP FOR STUDENTS INTERESTED IN PURSUING DEGREES IN HEALTH CARE. STUDENTS ROTATED THROUGHOUT THE HOSPITAL SHADOWING VARIOUS EMPLOYEES AND DEPARTMENT HEADS ($13,712); PCMH TOOK PART IN THE REACH PROGRAM (RESEARCH AND EXPLORE AWESOME CAREERS IN HEALTHCARE IS A ONE-DAY PROGRAM THAT TAKES PLACE AT A LOCAL HEALTHCARE FACILITY AND PROVIDES HIGH SCHOOL STUDENTS WITH THE OPPORTUNITY TO EXPLORE THE HEALTHCARE FIELD THROUGH A VARIETY OF HANDS-ON STATION ACTIVITIES. PROFESSIONALS FROM THE SPONSORING HEALTHCARE FACILITY LEAD THE STATIONS, VOLUNTEERING THEIR TIME AND TALENT TO MENTOR STUDENTS AND SHARE THEIR EXPERTISE.) ($2,724); PCMH PRESENTED AT THE LOCAL HIGH SCHOOL CAREER FAIR ($110), AND GAVE A GUIDED TOUR TO LOCAL KINDERGARTEN CLASSES ($139). PART III, LINE 2: TREND ANALYSIS OF SELF-PAY ACCOUNT COLLECTIONS IS USED TO CREATE AN INITIAL ESTIMATE OF THE PROVISION FOR BAD DEBT ON SELF-PAY ACCOUNTS RECEIVABLE AT FISCAL YEAR-END. THE ESTIMATE IS THEN REDUCED FOR IMPLICIT PRICE CONCESSIONS. THE INCREASE OR DECREASE IN THE PROVISION IS ADJUSTED TO BAD DEBT EXPENSE. SUBSEQUENT COLLECTIONS RECEIVED ON ACCOUNTS PREVIOUSLY WRITTEN OFF REDUCE THE CURRENT BAD DEBT EXPENSE. PART III, LINE 3: NONE OF THE ABOVE BAD DEBT IS INCLUDED AS COMMUNITY BENEFIT. PART III, LINE 4: SEE PAGE 8 OF THE ATTACHED AUDITED FINANCIAL STATEMENTS. PART III, LINE 8: BY CONTINUING TO TREAT PATIENTS ELIGIBLE FOR MEDICARE, THE HOSPITAL ALLEVIATES THE FEDERAL GOVERNMENT'S BURDEN FOR DIRECTLY PROVIDING MEDICAL SERVICES. PART III, LINE 9B: PER OUR POLICY DLMC (PCMH) WILL NOT ENGAGE IN ECAS, EITHER DIRECTLY OR BY ANY DEBT COLLECTION AGENCY OR OTHER PARTY TO WHICH DLMC HAS REFERRED THE PATIENT'S DEBT, BEFORE REASONABLE EFFORTS ARE MADE TO DETERMINE WHETHER A RESPONSIBLE INDIVIDUAL(S) IS ELIGIBLE FOR ASSISTANCE UNDER THE FAP. PART VI, LINE 2: PCHM CONTINUES TO WORK THE LOCAL SCHOOLS, THE POWELL COUNTY PUBLIC HEALTH DEPARTMENT, POWELL COUNTY LOCAL EMERGENCY PREPAREDNESS COMMITTEE, MAJOR EMPLOYERS (SUN MOUNTAIN LUMBER, MONTANA STATE PRISON), POWELL COUNTY SENIOR CITIZEN CENTER, AND POWELL COUNTY COUNCIL ON AGING TO CONTINUALLY ASSESS THE HEALTH CARE NEEDS OF THE COMMUNITY WE SERVE. WE STRONGLY ENCOURAGE EMPLOYEES TO VOLUNTEER, ON PCMH TIME, FOR ORGANIZATIONS THAT STRIVE TO IMPROVE THE WELL-BEING OF OUR COMMUNITY MEMBERS. PART VI, LINE 3: PCMH POSTS SIGNAGE THROUGHOUT THE FACILITY, ESPECIALLY AT PATIENT INTAKE AREAS, THAT NOTIFY PATIENTS OF THE AVAILABILITY OF FINANCIAL ASSISTANCE. NOTICES ARE ALSO INCLUDED WITH BILLING STATEMENTS. WE'RE STRIVING TO MEET WITH EVERY SELF-PAY PATIENT TO DETERMINE THEIR ABILITY TO PAY, AND OFFER FINANCIAL ASSISTANCE, MEDICAID PRESUMPTIVE ELIGIBILITY SCREENING, OR MONTHLY PAYMENT PLANS AS NEEDED. BEFORE TURNING AN ACCOUNT OVER TO 3RD PARTY COLLECTORS, WE REVIEW THE ACCOUNTS THAT MEET THE POSSIBLE PRESUMPTIVE ELIGIBILITY CRITERIA OF OUR FINANCIAL ASSISTANCE POLICY. PART VI, LINE 4: PCMH SERVES THE COUNTIES OF POWELL, GRANITE, DEER LODGE, AND SILVER BOW, AND ALSO PROVIDES SERVICES TO INMATES AT THE MONTANA STATE PRISON. PART VI, LINE 5: THE GOVERNING BOARD OF PCMH CONSISTS OF RESIDENTS OF THE HOSPITAL'S PRIMARY SERVICE AREA. EMPLOYEES NOR INDEPENDENT CONTRACTORS (OTHER THAN DISCLOSED ON THIS FORM) OF THE ORGANIZATION, NOR FAMILY MEMBERS THEREOF, ARE ALLOWED TO BE BOARD MEMBERS.PCMH EXTENDS MEDICAL STAFF PRIVILEGES TO QUALIFIED PROVIDERS IN THE COMMUNITY. WE'VE ALSO CONTRACTED WITH SEVERAL VISITING SPECIALISTS TO OFFER SERVICES NOT OTHERWISE AVAILABLE IN OUR COMMUNITY (CARDIOLOGY, PAIN MANAGEMENT, UROLOGY, PODIATRY).PCMH CONTINUALLY REINVESTS SURPLUS FUNDS BY UPDATING OUR FACILITIES AND EQUIPMENT AND EMPLOYING ADDITIONAL STAFF TO EXPAND THE SERVICES OFFERED TO THE COMMUNITY OR IMPROVE CURRENTLY OFFERED SERVICES. SURPLUS FUNDS ARE ALSO USED TO OFFER PROGRAMS AT FREE OR REDUCED CHARGES TO THE COMMUNITY, SUCH AS THE FOLLOWING:- FREE ANNUAL HEALTH FAIR WITH LOW COST LAB WORK AVAILABLE- FREE STOP THE BLEED TRAINING- FREE BLOOD PRESSURE AND BLOOD SUGAR CHECKS AT THE LOCAL SENIOR CENTER- FREE BASELINE CONCUSSION TESTING FOR LOCAL STUDENT ATHLETES- DONATIONS TO THE FREE BREAKFAST PROGRAM AT THE HIGH SCHOOL- FREE MENTORING TO STUDENTS IN HEALTH CARE PROFESSIONS- SCHOLARSHIPS TO HIGH SCHOOL STUDENTS PURSUING DEGREES IN HEALTH CARESURPLUS FUNDS ARE ALSO BEING USED TO HELP BUILD A COMMUNITY PLAYGROUND THAT WILL PROVIDE A SAFE AREA FOR THE LOCAL YOUTH TO ENJOY HEALTHY OUTDOOR PLAY. 0 0 0 0 0 0 0 0 0 JUDITH WILSON MD PHYSICIAN 233905 0 0 0 0 0 0 0 9692 0 243597 0 0 0 SUMERA QAMAR OD 225297 0 0 0 0 0 0 0 0 0 225297 0 0 0 WAYNE MARTIN MD PHYSICIAN 222734 0 0 0 0 0 4482 0 9228 0 236444 0 0 0 LORI DRUMM OD 218492 0 0 0 0 0 0 0 21220 0 239712 0 0 0 ERIK KINZER NP 178308 0 0 0 0 0 3737 0 25388 0 207433 0 0 0 A MONTANA FACILITY FINANCE AUTHORITY 364615115 612043GQ6 2010-08-01 15000000 TO FINANCE THE CONSTRUCTION AND EQUIPPING OF A NEW HEALTH CARE FACILITY 0 0 0 B MONTANA FACILITY FINANCE AUTHORITY 364615115 612043GX1 2010-08-01 2855000 TO FINANCE THE CONSTRUCTION AND EQUIPPING OF A NEW HEALTH CARE FACILITY 0 0 0 A 475000 15000000 1184142 13557042 258697 2011 0 0 1 1 B 2855000 2855000 285605 2569395 2011 0 0 1 1 A 0 0 0 0 0 0 1 B 0 0 0 0 0 0 1 A 0 0 0 0 0 0 0 0 0 B 0 0 0 0 0 0 0 0 0 A 0 B 0 JACK ANDERSEN MR. ANDERSEN IS A MEMBER OF PCMC'S BOARD OF DIRECTORS. 26200 MR. ANDERSEN SERVES AS THE HOSPITAL'S PHARMACIST. 0 TONY PFAFF MR. PFAFF IS PCMH'S CURRENT CEO. 254400 MR. PFAFF IS THE OWNER OF CYPRESS HEALTHCARE, LLC, THE INDEPENDENT CONTRACTOR HIRED TO MANAGE THE HOSPITAL. HE RECEIVES ALL COMPENSATION FOR HIS SERVICES AS CEO FROM CYPRESS HEALTHCARE, LLC. 0 CARLEE HANSEN MS. HANSEN IS A MEMBER OF PCMH'S BOARD OF DIRECTORS 4380 THE HOSPITAL RENTS AN APARTMENT FROM MS. HANSEN. 0 X 4 58179 FMV 0 0 0 PART I, COLUMN (B): THE ORGANIZATION IS REPORTING THE NUMBER OF ITEMS CONTRIBUTED. FORM 990, PART VI, SECTION A, LINE 3 THE HOSPITAL DELEGATED CONTROL OF MANAGEMENT SERVICES TO CYPRESS HEALTHCARE, LLC. TONY PFAFF, CEO OF THE HOSPITAL, IS THE OWNER OF CYPRESS HEALTHCARE, LLC. FORM 990, PART VI, SECTION B, LINE 11B THE CEO AND CFO REVIEW THE 990 PRIOR TO ITS FILING. THE BOARD IS THEN INFORMED THE 990 IS AVAILABLE TO BE REVIEWED AT THEIR REQUEST. FORM 990, PART VI, SECTION B, LINE 12C THE COMPLIANCE PROGRAM IS REVIEWED ANNUALLY. ANY STAFF MEMBER CAN REPORT ANY SUSPECTED ISSUE TO THE FACILITY COMPLIANCE OFFICER. FORM 990, PART VI, SECTION B, LINE 15 COMPENSATION DETERMINATION IS A JOINT EFFORT BY THE MANAGEMENT COMPANY AND THE BOARD OF DIRECTORS. FORM 990, PART VI, SECTION C, LINE 19 THE HOSPITAL MAKES ITS GOVERNING DOCUMENTS, CONFLICT OF INTEREST POLICY & FINANCIAL STATEMENTS AVAILABLE TO THE PUBLIC UPON REQUEST. PART VII, SECTION A, LINE 1A THE ORGANIZATION'S CEO, TONY PFAFF, IS THE OWNER OF CYPRESS HEALTHCARE, LLC AND RECEIVES NO COMPENSATION FROM DEER LODGE MEDICAL CENTER. SEE SCHEDULE L FOR ADDITIONAL INFORMATION. FORM 990, PART IX, LINE 11G PROFESSIONAL FEES: PROGRAM SERVICE EXPENSES 285,410. MANAGEMENT AND GENERAL EXPENSES 23,149. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 308,559. PURCHASED SERVICES: PROGRAM SERVICE EXPENSES 1,260,062. MANAGEMENT AND GENERAL EXPENSES 75,302. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 1,335,364. FORM 990 PART XII, LINE 2C: THE PROCESS HAS NOT CHANGED FROM THE PRIOR YEAR. POWELL COUNTY MEDICAL FOUNDATION 1100 HOLLENBACK LANE DEER LODGE MT 59722 810438377 RAISE FUNDS FOR POWELL COUNTY MEMORIAL HOSPITAL. MT 501(C)(3) LINE 12C, III-FI 0 0 0 1 0 0 0 0 0 0 0 0 0 0 0 1 0 0 0 0 POWELL COUNTY MEDICAL FOUNDATION O 7450 POWELL COUNTY MEDICAL FOUNDATION C 58179