2020-08-11T14:59:49-05:00 2019-09-30 450250958 EIDE BAILLY LLP 200 E 10TH ST STE 500 SIOUX FALLS SD 571046375 990 2018-10-01 860107344 WINSLOW MEMORIAL HOSPITAL INC WINS 9282894691 1501 NORTH WILLIAMSON AVENUE WINSLOW AZ 86047 JOHN J DEMPSEY CEO 9282894691 2020-08-04 1 LAURIE HANSON P00851848 6053391999 2020-08-04 96.2.77.247 2020-08-04 16:24:08 CD P DA39A3EE5E6B4B0D3255BFEF95601890AFD80709 87C603189A7DF35062A6A77CB1DDE10F911D97AB 2018 2020-09-22 18:59:49Z LITTLE COLORADO MEDICAL CENTER JOHN J DEMPSEY 1501 NORTH WILLIAMSON AVENUE WINSLOW AZ 86047 38229922 0 X WWW.LCMCWMH.COM X 1951 AZ 1 11 9 318 15 0 0 11900 15889 39512267 38152765 14619 12880 34557 41379 39573343 38222913 6000 6250 0 0 16693970 17635794 0 0 0 23482780 19603199 40182750 37245243 -609407 977670 32486456 33576544 18187246 18299632 14299210 15276912 X COMPASSIONATE CARE FOR NORTHEASTERN ARIZONA. 0 0 32532334 6250 38152765 WINSLOW MEMORIAL HOSPITAL D/B/A LITTLE COLORADO MEDICAL CENTER (LCMC) GENERAL MEDICAL & SURGICAL HOSPITAL - PRIMARILY ENGAGED IN PROVIDING DIAGNOSIS AND MEDICAL TREATMENT (BOTH SURGICAL AND NONSURGICAL) TO PATIENTS WITH A WIDE VARIETY OF MEDICAL CONDITIONS. LCMC MAINTAINED 25-BEDS, PROVIDED INPATIENTS WITH FOOD SERVICES THAT MET THEIR NUTRITIONAL REQUIREMENTS, AND USED AN ORGANIZED STAFF OF PHYSICIANS AND OTHER MEDICAL STAFF TO PROVIDE PROFESSIONAL CARE SERVICES AS WELL AS OTHER SERVICES. THESE SERVICES INCLUDE OUTPATIENT SERVICES, ANATOMICAL PATHOLOGY SERVICES, DIAGNOSTIC X-RAY SERVICES, CLINICAL LABORATORY SERVICES, OPERATING ROOM SERVICES FOR A VARIETY OF PROCEDURES, AND PHARMACY SERVICES IN THE CITY OF WINSLOW, NAVAJO COUNTY, ARIZONA. LCMC MAINTAINS RECORDS TO IDENTIFY AND MONITOR THE LEVEL OF CHARITY CARE IT PROVIDES WHICH INCLUDE THE COST OF SUPPLIES AND SERVICES FURNISHED UNDER THE CHARITY CARE POLICY ALONG WITH ASSOCIATED EQUIVALENT SERVICE STATISTICS. 32532334 1 1 0 0 0 0 0 0 0 0 1 0 0 0 1 1 1 0 0 0 0 0 0 0 0 0 1 1 1 0 1 0 0 0 1 0 0 0 0 0 0 0 0 0 1 1 0 0 0 1 38 0 1 318 1 0 0 0 0 0 0 0 0 0 0 0 0 X 11 9 1 1 0 0 0 0 0 1 0 0 0 0 1 1 1 1 1 0 0 0 AZ X JANICE FREET 9282894691 1501 NORTH WILLIAMSON AVENUE WINSLOW AZ 86047 BRIAN BUCINA MD, SURGEON 40.00 0.00 X 430862 0 47761 RANDALL REID MD, GENERAL MEDICINE 40.00 0.00 X 292862 0 42666 CRAIG SEAL MD, GENERAL MEDICINE 40.00 0.00 X 292619 0 14898 THOMAS GREENWOOD DIRECTOR, MD, CHIEF OF STAFF 40.00 0.50 X 243081 0 33284 JAMES PAGE MD, GENERAL MEDICINE 40.00 0.00 X 204786 0 32449 JANICE FREET CFO 40.00 0.00 X 178003 0 16727 JOHN SEARS MD, GENERAL MEDICINE 40.00 0.00 X 171331 0 20553 LOREN SADLER CHAIRPERSON 5.00 0.50 X X 0 0 0 RHONDA GREER VICE-CHAIRPERSON 1.00 0.50 X X 0 0 0 FRANK ARMAO MD SECRETARY/TREASURER 1.00 0.50 X X 0 0 0 JR DESPAIN DIRECTOR 1.00 0.50 X 0 0 0 CHRIS BAVASI DIRECTOR 1.00 0.50 X 0 0 0 DAVID COOLIDGE DIRECTOR UNTIL 06/2019 1.00 0.50 X 0 0 0 ROBERT SALABYE DIRECTOR 1.00 0.50 X 0 0 0 ELIAS JOUEN DIRECTOR UNTIL 06/2019 1.00 0.50 X 0 0 0 DR MATTHEW SUTTON DIRECTOR, MD, CHIEF OF STAFF 1.00 0.50 X 0 0 0 ROBERTA CANO DIRECTOR FROM 06/2019 1.00 0.50 X 0 0 0 ANDREW DITTO MD DIRECTOR FROM 06/2019 1.00 0.50 X 0 0 0 JOHN J DEMPSEY CEO 40.00 0.00 X 0 0 0 1813544 0 208338 19 0 1 0 XTEND HEALTHCARE LLC 90 VOLUNTEER DR SUITE 150 HENDERSONVILLE TN 37075 BILLING SERVICES 690644 MEDICAL SOLUTIONS LLC PO BOX 310737 DES MOINES IA 50331 TEMP STAFFING 397058 WINNCARE LLC 1031 N WARREN WINSLOW AZ 86047 PHYSICIAN SERVICES 381600 LEDBETTER LAW FIRM PLC THE 1003 NORTH MAIN STREET COTTONWOOD AZ 86326 LEGAL SERVCES 371922 JG ANESTHESIA SERVICES LLC 2973 N KRISTEN DRIVE FLAGSTAFF AZ 86001 CRNA SERVICES 252525 9 8835 7054 15889 PATIENT SERVICE REVENUE 622110 37225905 37225905 PHARMACY REVENUE 900099 534247 534247 MEAL & VENDING REVENUE 900099 61611 61611 331002 331002 38152765 19889 19889 41379 0 41379 41379 41379 7009 -7009 -7009 -7009 38222913 38152765 0 54259 X 6250 6250 523097 296816 226281 13516750 12068252 1448498 401326 351833 49493 2221033 1912941 308092 973588 837233 136355 350301 350301 333248 333248 88855 88855 5351000 5262898 88102 42485 42485 1452719 1391369 61350 420885 420885 390628 388474 2154 4698 4698 226546 171602 54944 723984 559412 164572 1616094 1329464 286630 407948 365045 42903 BAD DEBT EXPENSE 3854056 3854056 SUPPLIES 2659607 2646122 13485 EQUIPMENT RENTAL & MAIN 289314 280872 8442 FOOD 134270 130971 3299 1256561 674026 582535 37245243 32532334 4712909 0 7080853 10513763 7550448 6777393 173925 173925 908547 977948 329055 247427 35804940 22444217 14678510 13360723 1423118 1525365 342000 0 32486456 33576544 2518840 2804941 14890271 14581684 778135 913007 18187246 18299632 X 14299210 15276912 14299210 15276912 32486456 33576544 X 977670 32 X 0 1 X 1 0 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 135526 72347 207873 16594516 8813713 7780803 18950463 13630504 5319959 52088 52088 13360723 ASSET RETIREMENT OBLIGATION 627407 SETTLEMENT AGREEMENT 138000 DEFERRED COMPENSATION 147600 913007 X 34368889 -3854024 -3854024 38222913 0 38222913 33391187 0 33391187 3854056 3854056 37245243 PART X, LINE 2: THE HOSPITAL BELIEVES THAT IT HAS APPROPRIATE SUPPORT FOR ANY TAX POSITIONS TAKEN AFFECTING ITS ANNUAL FILING REQUIREMENTS, AND AS SUCH, DOES NOT HAVE ANY UNCERTAIN TAX POSITIONS THAT ARE MATERIAL TO THE FINANCIAL STATEMENTS. THE HOSPITAL WOULD RECOGNIZE FUTURE ACCRUED INTEREST AND PENALTIES RELATED TO UNRECOGNIZED TAX BENEFITS AND LIABILITIES IN INCOME TAX EXPENSE IF SUCH INTEREST AND PENALTIES ARE INCURRED. PART XI, LINE 2D - OTHER ADJUSTMENTS: PROVISION FOR BAD DEBTS -3,854,056. CHANGE IN NET ASSETS OF FOUNDATION 32. PART XII, LINE 4B - OTHER ADJUSTMENTS: PROVISION FOR BAD DEBTS 3,854,056. 1 1 X 1 X 125.000000000000 1 X 1 1 0 0 258000 258000 0.00770 11204779 9394670 1810109 0.05420 11462779 9394670 2068109 0.06190 57884 57884 0.00170 105923 7797 98126 0.00290 163807 7797 156010 0.00460 11626586 9402467 2224119 0.06650 6000 6000 0.00020 6000 6000 0.00020 0 3854056 1233298 6029053 6022369 6684 X 1 1 1 1 LITTLE COLORADO MEDICAL CENTER 1501 N WILLIAMSON AVE WINSLOW AZ 86047 WWW.LCMCWMH.COM RGH 0076 X X X X LITTLE COLORADO MEDICAL CENTER 1 0 0 1 X X X X X X X X X 16 1 0 1 1 X SEE 7D NARRATIVE X X 1 16 1 HTTPS://WWW.LCMCWMH.COM/ABOUT-US 0 1 X 125.000000000000 300.000000000000 X X X X 1 1 X X X X 1 X SEE 16A-C NARRATIVE X SEE 16A-C NARRATIVE X SEE 16A-C NARRATIVE X X X X X X 1 X 0 X X X X 1 X 0 0 LITTLE COLORADO MEDICAL CENTER PART V, SECTION B, LINE 5: LCMC SOLICITED INPUT FROM MULTIPLE SOURCES IN THE COMMUNITY, INCLUDING GROUPS THAT WORK WITH DISADVANTAGED POPULATIONS. LCMC CONDUCTED THE CHNA DURING THE YEAR ENDED 9/30/17. LCMC SOLICITED INPUT THROUGH FOCUS GROUPS, TOWN MEETINGS, COMMUNITY COALITIONS, COMMUNITY HEALTH SURVEYS, PUBLIC HEALTH AND HOSPITAL DATA, INTERVIEWS WITH MENTAL AND BEHAVIORAL HEALTH PROVIDERS, EMERGENCY SERVICES PERSONNEL, A COMMUNITY ADVISORY COMMITTEE, VOLUNTEER ORGANIZATIONS, AND INDIAN HEALTH SERVICES TO IDENTIFY THE NEEDS OF THE COMMUNITY. LITTLE COLORADO MEDICAL CENTER PART V, SECTION B, LINE 6B: COLLEGE OF PUBLIC HEALTH, THE UNIVERSITY OF ARIZONA, AND HEALTH EQUITY RESEARCH GROUP, NORTHERN ARIZONA UNIVERSITY. LITTLE COLORADO MEDICAL CENTER PART V, SECTION B, LINE 7D: THE CHNA REPORT IS AVAILABLE AT HTTPS://WWW.LCMCWMH.COM/ABOUT-US. LITTLE COLORADO MEDICAL CENTER PART V, SECTION B, LINE 11: THE FOLLOWING COMMUNITY HEALTH NEEDS WERE IDENTIFIED DURING THE COMMUNITY HEALTH NEEDS ASSESSMENT ("CHNA") PROCESS PERFORMED IN 2017. LCMC HAS COMMENCED WORK TO ADDRESS THOSE COMMUNITY CONDITIONS.LOW INCOME AND POVERTY A. ACCESS TO CARE LCMC CONTINUES TO ASSIST PEOPLE TO ENROLL IN ARIZONA HEALTH CARE COST CONTAINMENT SYSTEM (AHCCCS) AND TRIES TO CONNECT THEM WITH RESOURCES WHEN THEY ARE IN THE HOSPITAL. PATIENTS ALSO HAVE ACCESS TO FINANCIAL COUNSELORS TO HELP THEM ENROLL IN AHCCCS. ADDITIONALLY, DURING THE 2019 FISCAL YEAR, LCMC HAS DEVELOPED STRONGER TIES AND COLLABORATION WITH LOCAL SOCIAL SERVICE AGENCIES TO SUPPORT THOSE LIVING IN POVERTY. LCMC ALSO WORKS TO HIRE LOCALLY AND OFFERS PROGRAMS TO SUPPORT AND TRAIN COMMUNITY MEMBERS FOR CAREERS AS NURSES.B. PROGRAM DEVELOPMENT THE HOSPITAL ALSO TRIES TO HIRE LOCALLY AND OFFERS PROGRAMS TO SUPPORT AND TRAIN COMMUNITY MEMBERS FOR CAREERS AS NURSES. LCMC WORKS CLOSELY WITH NORTHLAND PIONEER COLLEGE AS WELL AS OTHER EDUCATIONAL FACILITIES TO PROVIDE A PLACE FOR TRAINING AS WELL AS A FUTURE CAREER. LCMC NOW HAS RURAL HEALTH CLINIC (RHC) STATUS; THIS IS THE HOSPITAL'S FIRST FULL FISCAL YEAR DESIGNATED AS A RHC. LCMC IS WORKING TO CHANGE ITS CLINIC FROM HOSPITAL BASED TO AN RHC TO DECREASE COSTS TO PATIENTS BY ELIMINATING FACILITY FEES. C. EDUCATIONEDUCATION HAS BEEN RECOGNIZED AS AN IMPORTANT FACTOR IN REDUCING POVERTY, AS WELL AS PROVIDING A LADDER OUT OF POVERTY. LCMC MAINTAINS AND CONTINUES TO IMPROVE UPON ACTIVE ENGAGEMENT WITH THE LOCAL HIGH SCHOOL AND COMMUNITY COLLEGE, INCLUDING SERVICE ON THE HEALTH PROFESSIONS AND BUSINESS ADVISORY COMMITTEES. WE ANTICIPATE IMPLEMENTING OVER THE NEXT FISCAL YEAR A RENEWED VOLUNTEER PROGRAM, WHICH WILL INCLUDE A SPECIFIC FOCUS TO HIGH SCHOOL STUDENTS TO INTRODUCE THEM TO HEALTH PROFESSIONALS. II. MENTAL AND BEHAVIORAL HEALTH LCMC'S NURSING ADMINISTRATION AND SOCIAL WORK TEAM COLLABORATE ON PATIENT SPECIFIC BASIS WITH A LOCAL BEHAVIORAL HEALTH AGENCY, ADULT PROTECTIVE SERVICES AND SOCIAL SECURITY. LCMC IS ALSO DEVELOPING A CLINICALLY SUPPORTED TRANSPORTATION MODEL. THE HOSPITAL ACTIVELY COMMUNICATES WITH THE LOCAL PRISON AND DEPARTMENT OF CORRECTIONS STAFF REGARDING SAFE AND EFFECTIVE CARE OF INMATES WITH BEHAVIORAL HEALTH ISSUES. WE ALSO PARTICIPATE IN STATE AND HEALTH CHOICE INTEGRATED CARE, ASU BEHAVIORAL HEALTH CENTER, AND PLANNED ASSISTANCE NETWORK OF ARIZONA TO IMPROVE THE QUALITY OF BEHAVIORAL HEALTH AND INTEGRATED MEDICAL CARE. THE BEHAVIORAL HEALTH UNIT HAS IMPLEMENTED THE FOLLOWING ELEMENTS INTO ITS COMPREHENSIVE STRATEGY TO ADDRESS BEHAVIORAL HEALTH ISSUES:MEETING QUARTERLY WITH CHANGEPOINT INCLUDING THE LEADERSHIP TEAM FROM WINSLOW, HOLBROOK AND THE INPATIENT BEHAVIORAL HEALTH FACILITY IN SHOW LOW;MEETING MONTHLY WITH THE WIHCC CARE COORDINATORS AND SOCIAL WORK DIRECTOR;OUR CARE COORDINATION TEAM IS DEVELOPING RELATIONSHIPS WITH BEHAVIORAL HEALTH FACILITIES ACROSS ARIZONA TO ASSURE APPROPRIATE PLACEMENT OF PATIENTS IN NEED; PLANNING TRAINING FOR OUR SOCIAL WORKERS TO DO BEHAVIORAL HEALTH INTAKE ASSESSMENTS IN COORDINATION WITH CHANGEPOINT; AND, LOOKING INTO OFFERING TELEHEALTH BEHAVIORAL COUNSELING IN THE CLINIC.III. IMPROVED HEALTH CARE DELIVERYLCMC'S QUALITY DEPARTMENT COMMENCED A COMMUNITY COLLABORATION INITIATIVE. SEVERAL MEETINGS HAVE BEEN HELD WITH SOCIAL SERVICE AND CLINICAL ORGANIZATIONS IN THE WINSLOW COMMUNITY, INCLUDING: WIHCC; NORTH COUNTRY AND COMMUNITY BRIDGES; LOCAL BEHAVIORAL HEALTH AGENCIES; AND ADULT PROTECTIVE SERVICES AND SOCIAL SECURITY. THOSE MEETINGS HAVE ALREADY CONTRIBUTED TO MORE EFFECTIVE COLLABORATION ON PATIENT CARE MATTERS. LCMC CONTINUES TO WORK WITH REGIONAL GOVERNMENT AND PRIVATE AGENCIES TO DEVELOP A TRANSPORTATION MODEL IN SUPPORT OF VULNERABLE AND POOR MEMBERS OF OUR COMMUNITY. THE HOSPITAL CONTINUES ITS WORK WITH THE LOCAL PRISON AND DEPARTMENT OF CORRECTIONS STAFF REGARDING SAFE AND EFFECTIVE CARE OF INMATES WITH BEHAVIORAL HEALTH ISSUES. WE ALSO PARTICIPATE IN STATE AND HEALTH CHOICE INTEGRATED CARE AND PLANNED ASSISTANCE NETWORK OF ARIZONA TO IMPROVE THE QUALITY OF BEHAVIORAL HEALTH AND INTEGRATED MEDICAL CARE. IV. SUBSTANCE ABUSELCMC CONTINUES TO WORK WITH THE CITY AND TRIBAL AUTHORITIES TO ADDRESS THIS LONGSTANDING LOCAL ISSUE. LCMC'S CEO HAS CONTACTED NORTHERN ARIZONA BEHAVIORAL HEALTH ASSOCIATION (NARBA) REGARDING ISSUES WITH THE LOCAL DETOX CENTER DECLINING ADMISSION OF CERTAIN INDIVIDUALS.THE HOSPITAL HAS MADE THE FOLLOWING STRATEGIC CHOICES TO ADDRESS SUBSTANCE ABUSE IN THE COMMUNITY: DIRECT DELIVERY OF NARCAN KITS TO THE ED; MEMBERS OF THE HOSPITAL'S CARE COORDINATION TEAM HAVE GONE TO CONFERENCES TO LEARN MORE ON HOW TO ADDRESS THE OPIOID ISSUE AND REPORTED BACK WITH NEW IDEAS; AND CHRONIC PAIN PATIENTS THAT WERE BEING SEEN IN OUR CLINIC HAVE BEEN REFERRED TO PAIN MANAGEMENT SPECIALIST PROVIDERS FOR SPECIALIZED CARE.V. SENIOR HEALTH CARELCMC PROVIDES INFORMATION TO OUR PATIENTS ON THE SERVICES OFFERED BY THE SENIOR CENTER. ANOTHER NEED FOR SENIORS IS PHYSICAL THERAPY AND REHABILITATION. ALTHOUGH WINSLOW HAS AN EXCELLENT PHYSICAL THERAPY PRACTICE, IT IS NOT ABLE TO KEEP UP WITH THE INCREASING NEEDS OF THE AGING POPULATION. LCMC IS ACTIVELY WORKING TO EXPAND OUR SERVICES TO INCLUDE PHYSICAL THERAPY TO MEET THE INCREASED NEED WITHIN THE COMMUNITY. THERE IS SIGNIFICANT NEED FOR OUTPATIENT TREATMENTS FOR PATIENTS LOCALLY, SUCH AS WOUND CARE AND INTRAVENOUS ANTIBIOTICS. LCMC RECENTLY EXPANDED ITS WOUND CARE CLINIC ON THE HOSPITAL CAMPUS. LCMC ED HAS EXPANDED ITS INFUSION THERAPY FOR MANY ANTIBIOTICS AND CERTAIN OTHER INFUSIONS. MANY OF THE PATIENTS CURRENTLY USING THESE SERVICES WERE PREVIOUSLY TRAVELING TO FLAGSTAFF OR REQUIRING A STAY IN A NURSING HOME FOR TREATMENT. VI. OBESITY AND DIABETESLCMC CONTINUES TO PROVIDE HOT, NUTRITIOUS MEALS ON HOSPITAL PREMISES AND TO FACILITATE DELIVERY OF NUTRITIOUS MEALS TO HOME BOUND SENIORS. VII. PROVIDER SHORTAGELCMC HAS EFFECTIVELY WORKED WITH HRSA TO OBTAIN LCMC HPSA STATUS TO FACILITATE PROVIDER RECRUITMENT AND RETENTION, INCLUDING LOAN REPAYMENT QUALIFICATION. LCMC HAS RECRUITED A NEW EMERGENCY MEDICINE GROUP, INCLUDING SEVERAL NEW PROVIDERS DELIVERING CARE TO LCMC PATIENTS. LCMC HAS ALSO RECRUITED THREE PRIMARY CARE PROVIDERS TO THE LCMC CLINIC. FURTHERMORE, THE HOSPITAL PERFORMS OUTREACH TO THE LOCAL SCHOOL DISTRICT AND COMMUNITY COLLEGE TO INTRODUCE AND SUPPORT STUDENTS IN HEALTHCARE FIELDS. LITTLE COLORADO MEDICAL CENTER PART V, SECTION B, LINE 13H: PRESUMPTIVE ELIGIBILITY MAY BE DETERMINED ON A CASE-BY-CASE BASIS. LITTLE COLORADO MEDICAL CENTER PART V, SECTION B, LINE 16J: PART V, SECTION B, LINE 16A, B & C: THE FINANCIAL ASSISTANCE POLICY, APPLICATION, AND PLAIN LANGUAUGE SUMMARY OF THE FAP ARE POSTED ON THE ORGANIZATION'S WEBSITE AT WWW.LCMCWMH.COM/PATIENTS---VISITORSPART V, SECTION B, LINE 16J:A SUMMARY OF THE FINANCIAL ASSISTANCE POLICY WAS POSTED IN THE EMERGENCY ROOM, WAITING ROOMS, ADMISSIONS OFFICE AND WAS MADE AVAILABLE UPON REQUEST.MORE THAN THE LESSER OF 5% OR 1,000 INDIVIDUALS IN THE SERVICE AREA ARE LEP. HOWEVER, THE LANGUAGE SPOKEN, NAVAJO, IS NOT A WRITTEN LANGUAGE. THE FACILITY HAS STAFF WHO SPEAK NAVAJO AND ARE ABLE TO ASSIST PATIENTS IN COMPLETING FINANCIAL ASSISTANCE FORMS. LITTLE COLORADO MEDICAL CENTER PART V, SECTION B, LINE 24: THE HOSPITAL FINANCIAL ASSISTANCE POLICY DOES NOT COVER ELECTIVE PROCEDURES. THE HOSPITAL MAY HAVE CHARGED FAP ELIGIBLE PATIENTS GROSS CHARGES FOR SERVICES THAT ARE NOT COVERED UNDER THE FINANCIAL ASSISTANCE POLICY. PART V, LINE 10 IMPLEMENTATION STRATEGY DESCRIPTION OF FAILURE:TYPE OF FAILURE: 501(R)(3) THE MOST RECENT AND PRIOR IMPLEMENTATION STRATEGY REPORTS WERE NOT AVAILABLE ON THE ORGANIZATION'S WEBSITE FOR A PERIOD OF TIME. THE DOCUMENTS WERE AVAILABLE BY CONTACTING THE HOSPITAL.CAUSE OF THE FAILURE: AN INADVERTENT TECHNOLOGICAL MALFUNCTION CAUSED THE DOCUMENTS TO BE REMOVED FROM THE WEBSITE.FACILITY OR FACILITIES WHERE THE FAILURE OCCURRED: THE FAILURE OCCURRED AT WINSLOW MEMORIAL HOSPITAL INC.THE DATE(S) OF THE FAILURE AND ITS DISCOVERY: UNKNOWN, MARCH 5, 2020THE NUMBER OF OCCURRENCES: NOT APPLICABLEDESCRIPTION OF THE CORRECTION OF THE FAILURE:METHOD OF CORRECTION: THE IMPLEMENTATION STRATEGY REPORTS WERE MADE AVAILABLE ON THE WEBSITE.DATE OF CORRECTION: MARCH 17, 2020DESCRIPTION OF THE PRACTICES OR PROCEDURES PUT INTO PLACE:THE IMPLEMENTATION STRATEGY REPORTS WERE POSTED ON THE WEBSITE AT WWW.LCMCWMH.COM/ABOUT-US. THE DOCUMENTS ARE ALSO AVAILABLE AT THE HOSPITAL. PART V, LINE 16A FINANCIAL ASSISTANCE POLICY, AND 16C PLAIN LANGUAGE SUMMARY DESCRIPTION OF FAILURE:TYPE OF FAILURE: 501(R)(4) THE FINANCIAL ASSISTANCE POLICY AND PLAIN LANGUAGE SUMMARY WERE NOT AVAILABLE ON THE ORGANIZATION'S WEBSITE FOR A PERIOD OF TIME. THE DOCUMENTS WERE AVAILABLE BY CONTACTING THE HOSPITAL AND WERE INCLUDED IN PATIENT BILLINGS AS REQUIRED.CAUSE OF THE FAILURE: AN INADVERTENT TECHNOLOGICAL MALFUNCTION CAUSED THE DOCUMENTS TO BE REMOVED FROM THE WEBSITE.FACILITY OR FACILITIES WHERE THE FAILURE OCCURRED: THE FAILURE OCCURRED AT WINSLOW MEMORIAL HOSPITAL INC.THE DATE(S) OF THE FAILURE AND ITS DISCOVERY: UNKNOWN, MARCH 5, 2020THE NUMBER OF OCCURRENCES: NOT APPLICABLEDESCRIPTION OF THE CORRECTION OF THE FAILURE:METHOD OF CORRECTION: THE FINANCIAL ASSISTANCE POLICY AND PLAIN LANGUAGE SUMMARY WERE MADE AVAILABLE ON THE WEBSITE.DATE OF CORRECTION: MARCH 17, 2020DESCRIPTION OF THE PRACTICES OR PROCEDURES PUT INTO PLACE:THE FINANCIAL ASSISTANCE POLICY AND PLAIN LANGUAGE SUMMARY WERE POSTED ON THE WEBSITE AT WWW.LCMCWMH.COM/PATIENTS---VISITORS. THE DOCUMENTS ARE ALSO AVAILABLE AT THE HOSPITAL. 1 1 - LITTLE COLORADO PHYSICIANS OFFICE 201 LEE STREET WINSLOW AZ 86047 PROVIDER BASED RURAL HEALTH CLINIC PART I, LINE 3C: IN ADDITION TO UTILIZING FPG TO DETERMINE ELIGIBILITY FOR FINANCIAL ASSISTANCE, THE HOSPITAL CONSIDERED MEDICAL INDIGENCY, INSURANCE STATUS, AND UNDERINSURANCE STATUS OF PATIENTS. PRESUMPTIVE ELIGIBILITY MAY BE USED ON A CASE-BY-CASE BASIS. PART I, LINE 7: CHARITY CARE EXPENSE WAS CONVERTED TO COST ON LINE 7A BASED ON AN OVERALL COST-TO-CHARGE RATIO ADDRESSING ALL PATIENT SEGMENTS. LINES 7B AND 7E WERE DETERMINED UTILIZING THE ACTUAL GENERAL LEDGER SYSTEM. LINE 7G WAS DETERMINED BASED ON THE COST REPORT. PART I, LN 7 COL(F): BAD DEBT EXPENSE OF $3,854,056 WAS SUBTRACTED FROM TOTAL OPERATING EXPENSE. PART II, COMMUNITY BUILDING ACTIVITIES: LCMC GAVE $6,000 TO THE LOCAL SENIOR CENTER TO HELP FUND MEALS ON WHEELS AND OTHER HEALTH AND WELLNESS INITIATIVES. PART III, LINE 2: BAD DEBT EXPENSE ON PART III LINES 2 AND 3 IS BASED ON CHARGES. IF AN ACCOUNT IS WRITTEN OFF TO BAD DEBTS, PAYMENTS RECEIVED OR DISCOUNTS GIVEN AFTER THE WRITE OFF FOR THAT ACCOUNT ARE POSTED TO THE CURRENT YEAR RECOVERY FOR BAD DEBT ACCOUNT AS AN OFFSET AGAINST THE CURRENT BAD DEBT EXPENSE. PART III, LINE 3: THE BAD DEBT EXPENSE INCLUDES AN ESTIMATED $1,233,298 OF CHARITY CARE-ELIGIBLE ACCOUNTS THAT ARE CURRENTLY LISTED AS BAD DEBT. UPON REVIEWING THE ACCOUNTS AND THE POVERTY LEVELS OF NAVAJO AND APACHE COUNTIES IN ARIZONA, IT WAS FOUND THAT ABOUT 32% OF THE OUTSTANDING BALANCES MAY HAVE BEEN ELIGIBLE UNDER THE FACILITY'S CHARITY CARE POLICY. ALSO FOR THIS REVIEW PROCESS, ANY FAMILIES WITH PRIOR APPLICATIONS FOR CHARITY CARE WERE GIVEN CONSIDERATION. PART III, LINE 4: THE FOOTNOTE TO THE ORGANIZATION'S FINANCIAL STATEMENTS THAT DESCRIBES BAD DEBT EXPENSES IS LOCATED IN FOOTNOTE 1 ON PAGES 7 & 8 OF THE ATTACHED FINANCIAL STATEMENTS. PART III, LINE 8: MEDICARE ALLOWABLE COST OF CARE WAS CALCULATED FROM THE MEDICARE COST REPORT FOR THE FISCAL YEAR ENDING 9/30/2019. MEDICAL SERVICES ARE PROVIDED TO PATIENTS WITH MEDICARE COVERAGE REGARDLESS OF WHETHER OR NOT A SURPLUS OR DEFICIT IS REALIZED. PROVIDING MEDICARE SERVICES PROMOTES ACCESS TO HEALTHCARE SERVICES WHICH ARE VITALLY NEEDED BY OUR COMMUNITY. THE MEDICARE COST REPORT IS COMPLETED BASED ON THE RULES AND REGULATIONS SET FORTH BY THE CENTERS FOR MEDICARE AND MEDICAID SERVICES. PART III, LINE 9B: ONCE THE BALANCE ON THE PATIENT'S ACCOUNT IS READY FOR BILLING THE PATIENT RECEIVES AN INITIAL STATEMENT. THE PATIENT WILL THEN RECEIVE A SECOND STATEMENT AT DAY 30 ALONG WITH A FOLLOW UP PHONE CALL, A THIRD STATEMENT AT DAY 60, A FINAL STATEMENT AT DAY 90 WITH A FOLLOW UP PHONE CALL AND IF NO ATTEMPTS HAVE BEEN MADE TO RESOLVE THEIR ACCOUNT, THE PATIENT'S ACCOUNT IS TURNED TO COLLECTIONS AT DAY 121 WITH A NOTIFICATION LETTER SENT TO THE PATIENT INFORMING THEM OF SUCH. THE 90 DAY FINAL STATEMENT INCLUDES A NOTE INFORMING THE PATIENT THAT THE ACCOUNT MAY GO TO COLLECTIONS IF PAYMENT IN FULL OR OTHER ARRANGEMENTS ARE NOT MADE WITHIN THE NEXT 30 DAYS. IF OUR COLLECTION AGENCY IDENTIFIES A PATIENT IS MEETING FINANCIAL ASSISTANCE ELIGIBILITY CRITERIA, THE PATIENT'S ACCOUNT MAY BE CONSIDERED FOR FINANCIAL ASSISTANCE. COLLECTION ACTIVITY WILL BE SUSPENDED ON ACCOUNTS, AND THE FINANCIAL ASSISTANCE APPLICATION WILL BE REVIEWED. IF THE ENTIRE ACCOUNT BALANCE IS ADJUSTED, THE ACCOUNT WILL BE RETURNED. IF A PARTIAL ADJUSTMENT OCCURS, THE PATIENT FAILS TO COOPERATE WITH THE FINANCIAL ASSISTANCE PROCESS, OR IF THE PATIENT IS NOT ELIGIBLE FOR FINANCIAL ASSISTANCE, COLLECTION ACTIVITY WILL RESUME. REQUESTS FOR CHARITY SHALL BE PROCESSED PROMPTLY AND LITTLE COLORADO MEDICAL CENTER SHALL NOTIFY THE PATIENT OR APPLICANT IN WRITING WITHIN 30 DAYS OF RECEIPT OF A COMPLETED APPLICATION. ACCOUNTS ELIGIBLE FOR CHARITY CARE ARE TO BE ADDRESSED WITHIN 240 DAYS OF FIRST BILL. FOR FINANCIAL ASSISTANCE BEFORE AN ACCOUNT GETS TO COLLECTIONS. PART VI, LINE 2: LCMC ASSESSES HEALTH NEEDS BY EVALUATING THE PATIENTS SERVED IN THE CLINICS AND HOSPITAL. LCMC HAS STAFF THAT PARTICIPATE IN VARIOUS ORGANIZATIONS INCLUDING THE COUNCIL FOR AGING, ALICE'S PLACE, THE WINSLOW ROTARY, ETC. STAFF ARE MADE AWARE OF NEEDS OF THE COMMUNITY THROUGH THEIR INVOLVEMENT WITH THESE ORGANIZATIONS. ADDITIONALLY, LCMC HAS MONTHLY MEDICAL EXECUTIVE AND BI-ANNUAL MEDICAL STAFF MEETINGS TO DETERMINE THE HEALTH NEEDS OF THE COMMUNITY. PART VI, LINE 3: LCMC'S PATIENT BILLING STATEMENTS HAVE A NARRATIVE ATTACHED DESCRIBING THE AVAILABILITY OF FINANCIAL ASSISTANCE AND THE CONTACT INFORMATION FOR HOW TO OBTAIN ADDITIONAL INFORMATION. NOTICES OF FINANCIAL ASSISTANCE AVAILABILITY ARE POSTED IN THE ER, WAITING ROOMS, AND ADMISSIONS OFFICE. PART VI, LINE 4: LCMC IS LOCATED IN THE COMMUNITY OF WINSLOW WHICH IS LOCATED IN NAVAJO COUNTY, ARIZONA, AND SERVES THE HEALTHCARE NEEDS OF THE COMMUNITY AND SURROUNDING AREAS. THE SERVICE AREA IS MOSTLY RURAL WITH A POPULATION OF APPROXIMATELY 23,000 PEOPLE. THE AVERAGE HOUSEHOLD INCOME IS $47,236 WITH 50% OF THE POPULATION HAVING AN INCOME OF LESS THAN $35,000. MORE THAN 40% OF THE PATIENTS SERVED BY LCMC ARE ON THE ARIZONA HEALTH CARE COST CONTAINMENT SYSTEM, AND MORE THAN 60% OF THE SERVICE AREA ARE OF NATIVE AMERICAN DESCENT. THE NEAREST HOSPITAL IS 60 MILES FROM WINSLOW. WINSLOW IS IN AN AREA FEDERALLY DESIGNATED AS A HEALTH PROFESSIONAL SHORTAGE AREA, A MEDICALLY UNDERSERVED AREA, AND A PERSISTENT POVERTY COUNTY. PART VI, LINE 5: LCMC'S BOARD OF DIRECTORS ALL RESIDE IN THE ORGANIZATION'S SERVICE AREA WITH THE EXCEPTION OF THREE MEMBERS AT LARGE WHO ARE FROM FLAGSTAFF, AZ. LCMC EXTENDS MEDICAL STAFF PRIVILEGES TO ALL QUALIFIED PROVIDERS IN ITS COMMUNITY AND SURROUNDING AREA FOR SOME OR ALL OF ITS DEPARTMENTS. LCMC REINVESTS SURPLUS FUNDS, IF ANY, TO IMPROVEMENTS IN PATIENT CARE, INCLUDING BUT NOT LIMITED TO EXPANSION OF SERVICES OFFERED, PATIENT EDUCATION, EMPLOYEE EDUCATION, AND EQUIPMENT AND FACILITY RENOVATIONS. PART VI, LINE 6: NONE 1 WINSLOW COUNCIL ON AGING 212 EAST SECOND STREET WINSLOW AZ 86047 860310351 501(C)(3) 6000 MEALS ON WHEELS PROGRAM ASSISTANCE 1 PART I, LINE 2: LCMC PROVIDES ASSISTANCE TO THE COALITION ON AGING TO ASSIST WITH MEALS ON WHEELS, FOOD BANK, AND TRANSPORTATION FOR SENIORS. LCMC MAY PERIODICALLY CONTACT THE COALITION AND REQUEST CONFIRMATION THAT FUNDS ARE USED AS INTENDED. X 0 1 0 0 0 0 0 1 0 BRIAN BUCINA MD, SURGEON 430862 0 0 0 0 0 18960 0 29557 0 479379 0 0 0 RANDALL REID MD, GENERAL MEDICINE 292862 0 0 0 0 0 13457 0 29965 0 336284 0 0 0 CRAIG SEAL MD, GENERAL MEDICINE 271619 0 21000 0 0 0 13257 0 1640 0 307516 0 0 0 THOMAS GREENWOOD DIRECTOR, MD, CHIEF OF STAFF 243081 0 0 0 0 0 10243 0 29798 0 283122 0 0 0 JAMES PAGE MD, GENERAL MEDICINE 204786 0 0 0 0 0 3728 0 29478 0 237992 0 0 0 JANICE FREET CFO 163003 0 15000 0 0 0 8263 0 8865 0 195131 0 0 0 JOHN SEARS MD, GENERAL MEDICINE 171331 0 0 0 0 0 7726 0 13580 0 192637 0 0 0 PART I, LINE 3 THE CEO IS COMPENSATED THROUGH A MANAGEMENT AGREEMENT WITH NORTHERN ARIZONA HEALTHCARE (NAH), AN UNRELATED ORGANIZATION. NAH USES THE PROCESSES DESCRIBED IN PART I, QUESTION 3 TO DETERMINE APPROPRIATE COMPENSATION FOR THE CEO. PART I, LINE 4B LCMC ENTERED INTO AN AGREEMENT WITH JOHN DEMPSEY TO PAY HIM A RETENTION BONUS WHICH WILL BE VESTED ON 7/31/2020. THE FULL RETENTION BONUS WILL BE PAID OVER AN EIGHT-YEAR PERIOD IF HE STAYS IN HIS CURRENT POSITION AS CEO UNTIL JULY 31, 2020. THIS DEFERRED COMPENSATION BENEFIT BECAME EFFECTIVE JANUARY 1, 2019. THE ORGANIZATION ACCRUED $147,600 FOR THE 9 MONTHS ENDED SEPTEMBER 2019. PART I, LINE 7 BONUSES WERE PROVIDED BASED ON COMPLETION OF TASKS DETERMINED AS PART OF THEIR PERFORMANCE PLANS. JEFFREY HAMBLIN FORMER CEO TO FUND PURCHASE OF SPLIT-DOLLAR LIFE INSURANCE POLICY X 173925 173925 1 1 1 173925 FORM 990, PART VI, SECTION A, LINE 2 FRANK ARMAO, MD AND MATTHEW SUTTON, MD HAVE A BUSINESS RELATIONSHIP. FORM 990, PART VI, SECTION A, LINE 3 LCMC HAS ENTERED INTO A MANAGEMENT AGREEMENT WITH NORTHERN ARIZONA HEALTHCARE, INC., TO PROVIDE MANAGEMENT SERVICES FOR THE FACILITY. THE CEO OF LCMC IS AN EMPLOYEE OF NORTHERN ARIZONA HEALTHCARE. J. DEMPSEY SERVED AS CEO FOR FISCAL YEAR ENDED 9.30.19. COMPENSATION AND BENEFITS FOR J. DEMPSEY WERE $350,301 FOR HIS SERVICES AS CEO OF LCMC. THE DUTIES OF THE CEO INVOLVE COMPREHENSIVE OVERSIGHT OF ALL CLINICAL AND ADMINISTRATIVE ACTIVITIES. FORM 990, PART VI, SECTION A, LINE 8B ALL COMMITTEES UTILIZED BY LCMC ARE STRICTLY ADVISORY IN NATURE. FORM 990, PART VI, SECTION B, LINE 11B THE ORGANIZATION'S CEO AND CFO WILL REVIEW THE FORM 990. FORM 990, PART VI, SECTION B, LINE 12C THE ORGANIZATION'S CONFLICT OF INTEREST POLICY IS REVIEWED ON AN ANNUAL BASIS. BOARD MEMBERS, ADMINISTRATOR, AND MANAGERS ARE COVERED UNDER LITTLE COLORADO MEDICAL CENTER'S CONFLICT OF INTEREST POLICY. WHEN A CONFLICT OF INTEREST ARISES, THE COVERED PERSON IS TO DISCLOSE THE CONFLICT TO HIS OR HER IMMEDIATE SUPERVISOR BEFORE A DECISION INVOLVING THE AREA OF CONFLICT IS MADE. MEMBERS WITH A CONFLICT OF INTEREST ARE ALSO NOT ALLOWED TO PARTICIPATE IN THE DECISION MAKING PROCESS. FORM 990, PART VI, SECTION C, LINE 19 THE ORGANIZATION'S GOVERNING DOCUMENTS, CONFLICT OF INTEREST POLICY, AND FINANCIAL STATEMENTS ARE MADE AVAILABLE TO THE PUBLIC UPON REQUEST. FORM 990, PART IX, LINE 11G CONTRACT LABOR: PROGRAM SERVICE EXPENSES 1,814,966. MANAGEMENT AND GENERAL EXPENSES 13,000. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 1,827,966. PROFESSIONAL FEES - MEDICAL: PROGRAM SERVICE EXPENSES 2,254,019. MANAGEMENT AND GENERAL EXPENSES 0. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 2,254,019. PURCH SVCES-OTHER: PROGRAM SERVICE EXPENSES 1,193,913. MANAGEMENT AND GENERAL EXPENSES 75,102. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 1,269,015. FORM 990, PART XI, LINE 9: CHANGE IN NET ASSETS OF FOUNDATION 32. LITTLE COLORADO HEALTHCARE FOUNDATION 1501 NORTH WILLIAMSON AVENUE WINSLOW AZ 86047 208504703 CHARITABLE AZ 501(C)(3) LINE 11 WINSLOW MEMORIAL HOSPITAL INC 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0