2020-11-09T15:55:21-06:00 2019-12-31 390758449 WIPFLI LLP PO BOX 12237 GREEN BAY WI 543072237 990 2019-01-01 810475376 PLAINS HOSPITAL CORPORATION PLAI 4068264800 PO BOX 768 PLAINS MT 59859 GREGORY S HANSON MD CEO 4068264800 2020-11-09 1 TERRI REXRODE CPA MST P00096513 9206620016 2020-11-09 184.100.211.94 2020-11-09 13:09:54 CS P DA39A3EE5E6B4B0D3255BFEF95601890AFD80709 7D2FE2EA17AC540A2D29D4112E82844D375299C1 2019 2021-01-29 14:40:06Z CLARK FORK VALLEY HOSPITAL CARLA NEIMAN PO BOX 768 PLAINS MT 59859 27009272 0 X WWW.CFVH.ORG X 1992 MT CLARK FORK VALLEY HOSPITAL AND FAMILY MEDICINE NETWORK IS A 16-BED CRITICAL ACCESS FACILITY SERVING THE RESIDENTS OF SANDERS COUNTY AND THE SURROUNDING AREA SINCE 1971 (INCORPORATED IN 1992). OUR MISSION: CLARK FORK VALLEY HOSPITAL AND FAMILY MEDICINE NETWORK WILL PARTNER WITH OUR COMMUNITIES TO IMPROVE THE HEALTH OF THOSE WE SERVE. 12 9 298 26 0 0 157056 79468 22515057 26197221 -274298 218210 789656 514373 23187471 27009272 0 0 0 0 12984100 14823547 0 0 0 8644303 10951747 21628403 25775294 1559068 1233978 18519098 20499617 11231949 11856366 7287149 8643251 X CLARK FORK VALLEY HOSPITAL AND FAMILY MEDICINE NETWORK WILL PARTNER WITH OUR COMMUNITIES TO IMPROVE THE HEALTH OF THOSE WE SERVE. 0 0 22703496 26600186 THE HOSPITAL PROVIDED 1,401 DAYS OF ACUTE CARE SERVICES AND 9,202 DAYS OF SKILLED NURSING CARE. IN ADDITION, THE HOSPITAL PROVIDED 7,611 OBSERVATION HOURS, 22,883 RURAL HEALTH CLINIC VISITS, AND 2,508 HOME HEALTH VISITS. THE HOSPITAL PROVIDED $462,197 IN CHARITABLE SERVICES TO PATIENTS UNABLE TO PAY FOR HEALTH CARE SERVICES. HOSPITAL SERVICES INCLUDE LABORATORY, RADIOLOGY, PHARMACY, RESPIRATORY THERAPY, EKG, ULTRASOUND, CT SCANNER, DIABETES MANAGEMENT, SURGERY, HOME HEALTH, AND HOSPICE. THE HOSPITAL SIGNIFICANTLY EXPANDED ITS ORTHOPEDIC SURERY PROGRAM AFTER RECRUITING A HIGHLY QUALIFIED EMPLOYED ORTHOPEDIC SURGEON, PERFORMING 245 ORTHOPEDIC CASES DURING 2019. THE HOSPITAL CONTINUED ITS WORK WITH THE NATIONAL RURAL ACO AND EXPERIENCED SUCCESS THROUGH CARE CORDINATION AND FOCUSED QUALITY IMPROVEMENT EFFORTS IN PURSUIT OF MEDICARE SHARED SAVINGS. 22703496 1 1 0 1 0 0 0 0 0 1 1 0 0 1 1 0 1 0 0 0 0 0 0 0 0 0 1 1 0 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 1 1 1 0 0 1 74 0 298 1 0 0 0 0 0 0 0 0 0 0 0 0 X 12 9 0 0 0 0 0 0 0 1 1 0 0 1 1 1 1 1 1 1 0 0 X X CARLA NEIMAN CFO 4068264800 PO BOX 768 PLAINS MT 59859 ROBERT BLEASE MD 40.00 X 481560 0 936 DONALD DAMSCHEN CHIEF OF STAFF 20.00 X 300000 0 0 RONALD BLACK PHYSICIAN MEMBER 40.00 X 256900 0 38863 JESSICA VALENTINE MD 40.00 X 246261 0 28483 GREGORY HANSON PRESIDENT, CEO 40.00 X 239711 0 34799 JEANNE WILLIAMS MD 40.00 X 228867 0 26004 DRUE WEBB MD 40.00 X 234790 0 12299 CARLA NEIMAN CFO 40.00 X 137705 0 6190 LISA EBERHARDT NURSING ADMINISTRATION 40.00 X 115707 0 17671 MICHAEL BAXTER CHAIR 2.00 X X 0 0 0 ERIKA LAWYER VICE CHAIR 2.00 X X 0 0 0 BINA EGGENSPERGER MEMBER 2.00 X 0 0 0 DAN CLARIDGE MEMBER 2.00 X 0 0 0 DENISE BENSON MEMBER 2.00 X 0 0 0 ERIN MCCARTHY MEMBER 2.00 X 0 0 0 VIRGINIA HOLLAND MEMBER 2.00 X 0 0 0 JAMES GILLHOUSE MEMBER 2.00 X 0 0 0 2241501 0 165245 8 0 1 0 MONIDA SHARED IMAGING 1200 S RESERVE SUITE H MISSOULA MT 59801 MRI SERVICES 338514 PROVIDENCE HEALTH & SERVICES PO BOX 84395 SEATTLE WA 981245692 EHR SERVICES 335632 WILDHORSE MANAGEMENT INC PO BOX 1310 PLAINS MT 59859 SURGEON 300000 MEDICAL SOLUTIONS LLC PO BOX 310737 DES MOINES IA 503310737 TRAVELERS 252608 MONIDA SHARED STAFFING 1200 S RESERVE SUITE H MISSOULA MT 59801 TRAVELERS 187355 5 25000 13843 40625 79468 NET PATIENT SERVICE REV. 621400 26042354 26042354 CAFETERIA 621400 98740 98740 MOB RENTAL 621400 26945 26945 JOINT VENTURE MRI INCOME 621400 26524 26524 MEDICAL RECORDS 621400 2658 2658 26197221 176443 176443 10010 0 10010 10010 10010 41267 500 0 0 41267 500 41767 41767 OTHER OPERATING REVENUE 621400 504363 504363 504363 27009272 26600186 0 329618 X 714169 295763 418406 11632690 10532583 1100107 144812 122973 21839 1098411 955736 142675 1233465 1136163 97302 23646 23646 50480 50480 3011253 2635901 375352 4677284 4542985 134299 107011 98501 8510 307723 238302 69421 149193 125002 24191 363447 363447 996978 758676 238302 230253 230253 LICENSES & TAXES 484169 293091 191078 BAD DEBT 324075 324075 DUES & SUBSCRIPTIONS 95399 19322 76077 RECRUITMENT 93619 27987 65632 37217 2736 34481 25775294 22703496 3071798 0 8626263 4182264 2985831 3856177 369567 267132 616117 863863 24864 32312 17681839 13454502 4937368 4227337 5313413 959088 1757119 18519098 20499617 2888980 3416028 8342969 7694189 0 746149 11231949 11856366 X 7035245 8383527 251904 259724 7287149 8643251 18519098 20499617 1233978 122124 0 X X 0 1 X 0 0 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 0 0 0 0 0 0 0 0 1 5531 5531 0 PART II-B, LINE 1: THE FACILITY PAYS DUES TO THE MONTANA HOSPITAL ASSOCIATION, AMERICAN HOSPITAL ASSOCIATION, AND AMERICAN ASSOCIATION FOR HOMES AND SERVICES FOR THE AGING. A PORTION OF THE DUES ARE USED FOR LOBBYING ACTIVITIES ON BEHALF OF THE MEMBERS OF THE ASSOCIATIONS. 251904 47631 -4180 35631 259724 246299 35135 578 30108 251904 238845 22625 922 16093 246299 216125 44750 2130 24160 238845 207361 52567 -1029 42774 216125 1.00000 0 1 1 249632 249632 10863638 8414736 2448902 744682 670287 74395 5823887 4369479 1454408 4227337 MEDICARE RECEIVABLE 268951 HOSPITAL BED TAX RECEIVABLE 1442690 INVESTMENT IN JOINT VENTURE 45478 1757119 MEDICAID PAYABLE 746149 746149 26807321 122124 -324075 -201951 27009272 0 27009272 25451219 0 25451219 324075 324075 25775294 PART V, LINE 4: THE ENDOWMENT FUNDS CONSIST OF FUNDS HELD BY CLARK FORK VALLEY HOSPITAL FOUNDATION, INC. AND FUNDS DESIGNATED FOR CAPITAL PROJECTS. PART XI, LINE 2D - OTHER ADJUSTMENTS: PROVISION FOR DOUBTFUL ACCOUNTS -324,075. PART XII, LINE 4B - OTHER ADJUSTMENTS: BAD DEBT EXPENSE 324,075. 1 1 X 1 X 1 X 1 1 0 1 1 265764 265764 0.01030 1728422 3036012 0 0.00000 1994186 3036012 265764 0.01030 284740 284740 0.01100 232156 232156 0.00900 3001661 2468035 533626 0.02070 131344 131344 0.00510 3649901 2468035 1181866 0.04580 5644087 5504047 1447630 0.05610 0 324075 81019 13999912 11139811 2860101 X 1 1 1 1 CLARK FORK VALLEY HOSPITAL 10 KRUGER ROAD PLAINS MT 59859 WWW.CFVH.ORG 10608 X X X X CLARK FORK VALLEY HOSPITAL 1 0 0 1 X X X X X X X X X 17 1 0 0 1 X HTTPS://WWW.CFVH.ORG/MEDIA/1364/2017-CHNA-REPORT-CFVH-FINAL.PDF X 1 17 1 HTTPS://WWW.CFVH.ORG/MEDIA/1364/2017-CHNA-REPORT-CFVH-FINAL.PDF 0 1 X 100.000000000000 250.000000000000 X X X 1 1 X X X 1 X WWW.CFVH.ORG X WWW.CFVH.ORG X WWW.CFVH.ORG X X X X 1 X 0 X X X 1 X 0 0 CLARK FORK VALLEY HOSPITAL PART V, SECTION B, LINE 5: WE SELECTED KEY INFORMANTS IN OUR COMMUNITY BY INDENTIFYING INDIVIDUALS WHOSE WORK ENCOMPASSES AND INFLUENCES MULTIPLE LEVELS OF SOCIOECONOMIC FACTORS IE. HEALTH, EDUCATION, VOLUNTEERISM, FINANCE, ETC. AND DIRECTLY SERVICES COMMUNITY MEMBERS IN THOSE CAPACITIES. WE ALSO ENSURED KEY INFORMANTS WERE SELECTED FROM MULTIPLE COMMUNITIES TO PROVIDE BROADER INPUT AND REPRESENTATION OF OUR COUNTY. CLARK FORK VALLEY HOSPITAL PART V, SECTION B, LINE 11: CURRENTLY CFVH IS FOLLOWING THE IMPLEMENTATION PLAN DEVELOPED IN 2017 TO ADDRESS THE FEASIBLE NEEDS THROUGH OUR ORGANIZATION, IDENTIFIED IN THROUGH THE 2017 CHNA. THE FOUR PRIORITIES IDENTIFIED WERE MOST LIKELY HAVE A LARGE IMPACT TO SANDERS COUNTY AND REMAIN WITHIN THE MISSION OF CFVH AND ITS RESOURCE CAPACITY. WHILE THE FOUR PRIORITIES ARE THE FOCUS OF THE 2017 IMPLEMENTATION PLAN OVER THE NEXT THREE YEARS, THE OTHER HEALTH ISSUES THAT WERE IDENTIFIED WILL ALSO BE EXPLORED OUTSIDE OF THE CHNA FRAMEWORK. THE NEEDS CURRENTLY BEING ADDRESSED ARE: SUBSTANCE ABUSE AND BEHAVIORAL HEALTH PRIMARY CARE OBESITY AND HEALTHY LIFESTYLE HEALTH CARE EDUCATION AND OUTREACH FOR FURTHER INFORMATION ON THIS PLEASE VISIT HTTPS://WWW.CFVH.ORG/MEDIA/1364/2017-CHNA-REPORT-CFVH-FINAL.PDF TO ACCESS OUR IMPLEMENTATION PLAN FOR MORE DETAIL. NEEDS WE ARE CURRENTLY UNABLE TO ADDRESS AT THIS TIME, WHICH WERE IDENTIFIED THROUGH OUR CHNA PROCESS, INCLUDE:DENTAL ACCESS AND UTILIZATION FOR MEDICAID PATIENTS CURRENTLY MOST PRIMARY CARE DENTAL LOCATION DO NOT ACCEPT MEDICAID PATIENTS AND THIS IS AN AREA FOR OUR LOCAL DENTIST TO REVISIT. THIS HAS BEEN BROUGHT UP TO THEM BY PROVIDING THEM WITH THE CHNA. SOCIO-ECONOMIC DETERMINATES OF HEALTH- SPECIFICALLY RELATING TO HOUSING AND POVERTY. WE ARE CURRENTLY ONE OF THE LARGEST EMPLOYERS IN SANDERS COUNTY AND OFFER CHARITY CARE, FINANCIAL COUNSELING, AND SERVICES TO MEDICAID AND MEDICARE PATIENTS. THERE IS A LACK OF AFFORDABLE HOUSING THOUGH IN SANDERS COUNTY. SANDERS COUNTY IS ALSO ONE OF THE POOREST COUNTIES IN MONTANA. TRANSPORTATION AND SENIOR SERVICES- WE CURRENTLY WORK WITH SANDERS COUNTY COUNCIL ON AGING AND TRANSPORTATION. WE CANNOT AFFORD THE COST OF SUSTAINING AN ASSISTED LIVING FACILITY AND ARE CURRENTLY WORKING ON STREAMLINING THE PROCESS FOR OUT WAITING LIST FOR OUR NURSING HOME. ACCESS TO SPECIALTY SERVICES- THESE SERVICES INCLUDE ONCOLOGY, DIALYSIS, EYE CARE, OB/GYN, AND ORTHOPEDICS. ONCOLOGY AND DIALYSIS ARE TOO LOW OF A DEMAND TO FINANCIALLY SUSTAIN A FULL PROGRAM. CURRENTLY WE OFFER OB/GYN AND ARE LOOKING TO EXPAND OB/GYN SERVICES IN 2018 WITH THE ADDITION OF A NEW PROVIDER. WE ARE LOOKING AT PURSING AN OPTION FOR ORTHOPEDICS POTENTIALLY IN 2018. CFVH PROMOTES AND TEACHES THE STRONG WOMEN PROGRAM FOR COMMUNITY MEMBERS. THIS IS AN OSTEOPOROSIS PREVENTION PROGRAM WHICH PROVIDES LOW IMPACT STRENGTH TRAINING WHICH IS ALSO BENEFICIAL FOR REDUCING SYMPTOMS OF ARTHRITIS AND PREVENTING FALLS AS IT IMPROVES STRENGTH, BALANCE, COORDINATION.UNDER OUR CURRENT CHNA IMPLEMENTATION, CFVH HAS GREATLY EXPANDED BEHAVIORAL HEALTH SERVICES WITH TWO PROVIDERS SERVING ALL THREE OF OUR CLINICS. WE HAVE ADDED TELE-PSYCHIATRY TO SUPPORT ONSITE BEHAVIORAL HEALTH. WE ARE BEGINNING TO ADDRESS SUBSTANCE ABUSE WITH A MEDICATION ASSISTED TREATMENT PROGRAM IN CURRENT DEVELOPMENT.CFVH HAS PROVIDED A MYRIAD OF COMMUNITY HEALTH OUTREACH AND EDUCATION PROGRAMS IN RESPONSE TO OUR CURRENT CHNA, INCLUDING VARIOUS EXERCISE CLASSES, DIABETES-RELATED EDUCATION, JOURNEY TO WELLNESS, LIFESTYLE BALANCE, COOKING AND NUTRITION CLASSES, MEDICARE 101, SAFE DRIVING FOR SENIORS, ADVANCED DIRECTIVES, AND CHILDBIRTH EDUCATION. THE HOSPITAL HAS ALSO WORKED WITH LOCAL SCHOOLS TO PROVIDE OUTREACH TO PROMOTE SAFETY AND HEALTH CAREERS, INCLUDING CAREER SPEAKERS AND STUDENT SHADOWING OPPORTUNITIES. 6 1 - PLAINS FAMILY MEDICINE 10 KRUGER ROAD PLAINS MT 59859 RURAL HEALTH CLINIC 2 - THOMPSON FALLS FAMILY MEDICINE 120 POND STREET THOMPSON FALLS MT 59873 RURAL HEALTH CLINIC 3 - CFVH NURSING HOME 10 KRUGER ROAD PLAINS MT 59859 SKILLED NURSING FACILITY 4 - HOT SPRINGS FAMILY MEDICINE 209 MAIN STREET HOT SPRINGS MT 59845 RURAL HEALTH CLINIC 5 - CFVH HOME HEALTH AGENCY 10 KRUGER ROAD PLAINS MT 59859 HOME HEALTH AGENCY 6 - CFVH HOSPICE 10 KRUGER ROAD PLAINS MT 59859 HOSPICE CARE PART I, LINE 7: WORKSHEET 2 (COST-TO-CHARGE RATIO) WAS USED FOR THE COSTING METHODOLOGY. PART I, LINE 7G: NONE OF THE SUBSIDIZED SERVICES WERE FROM PHYSICIAN CLINICS. PART II, COMMUNITY BUILDING ACTIVITIES: COMMUNITY BUILDING ACTIVITIES CONSISTED OF SUPPORT OF ARTS AND BUSINESS DEVELOPMENT IN THE LOCAL COMMUNITY. IN ADDITION, THE HOSPITAL CONDUCTED ACTIVITIES IN SUPPORT OF LEADERSHIP TRAINING, BREAST HEALTH OUTREACH, ACA EDUCATION, THE LOCAL RELAY FOR LIFE, HEALTH CARE CAREERS AND WORKFORCE DEVELOPMENT. THE HOSPITAL ALSO PROVIDED SPACE FREE OF CHARGE TO VARIOUS NON-PROFIT GROUPS WORKING IN BETTERMENT OF THE LOCAL COMMUNITY. PART III, LINE 4: WHILE THE FACILITY DOES NOT HAVE A NOTE REGARDING BAD DEBT EXPENSE IN ITS FINANCIAL STATEMENTS, THE NOTE FOR PATIENT ACCOUNTS RECEIVABLE DESCRIBES HOW PROBABLE UNCOLLECTABLE ACCOUNTS ARE CHARGED TO BAD DEBT EXPENSE. THE RELEVENT NOTE CAN BE FOUND ON PAGE 10 OF THE ATTACHED AUDITED FINANCIAL STATEMENTS.BAD DEBT EXPENSE IS REPORTED AS IT IS REPORTED ON THE ORGANIZATION'S FINANCIAL STATEMENTS. THIS INCLUDES BAD DEBT WRITE-OFFS, AS WELL AS A REASONABLE ALLOWANCE FOR DOUBTFUL ACCOUNTS STILL INCLUDED IN ACCOUNTS RECEIVABLE AT YEAR-END. BAD DEBT EXPENSE IS REPORTED NET OF RECOVERIES FOR THE YEAR AND ADJUSTED TO COST WITH THE COST-TO-CHARGE RATIO WORKSHEET.THE AMOUNT REPORTED ON SCHEDULE H, PART III, SECTION A, LINE 3 IS 25% OF THE TOTAL BAD DEBT EXPENSE AT COST, WHICH IS THE ORGANIZATION'S BEST ESTIMATE OF THE PROPORTION OF BAD DEBT ATTRIBUTABLE TO PATIENTS WHO WOULD HAVE BEEN ELIGIBLE FOR CHARITY CARE, HAD THE ORGANIZATION BEEN SUCCESSFUL IN OBTAINING THEIR COOPERATION FOR AN APPLICATION FOR FINANCIAL ASSISTANCE, BASED ON THE COLLECTORS' EXPERIENCE AND RESPONSE RECEIVED.IT WOULD BE REASONABLE TO ASSUME THAT 25% OF BAD DEBT EXPENSE ESTIMATED AS ATTRIBUTABLE TO PATIENTS WHO WOULD HAVE BEEN ELIGIBLE FOR CHARITY CARE BE CONSIDERED A COMMUNITY BENEFIT, SIMILAR TO A BONAFIDE CHARITY CARE. PART III, LINE 8: THE FACILITY IS DESIGNATED AS A CRITICAL ACCESS HOSPITAL AND IS REIMBURSED BY MEDICARE AT 101% OF MEDICARE'S COSTS.THE TOTAL REVENUE RECEIVED FROM MEDICARE AND RELATED MEDICARE ALLOWABLE COSTS WERE DERIVED FROM THE FACILITY'S FILED 2019 MEDICARE COST REPORT. PART III, LINE 9B: MEDICAID CO-PAYS AND INELIGIBLE BILLS FOR MEDICAID PATIENTS THAT ARE UNCOLLECTIBLE AFTER REASONABLE COLLECTION EFFORTS HAVE BEEN MADE WILL BE AUTOMATICALLY DEEMED ELIGIBLE FOR CHARITY DISCOUNT. IN CERTAIN SITUATIONS, CIRCUMSTANCES MAY INDICATE THAT A PATIENT WOULD QUALIFY FOR CHARITY CARE, DESPITE THE FACT THAT THE PATIENT IS UNWILLING OR UNABLE TO COOPERATE WITH THE APPLICATION PROCESS. AN EXAMPLE MIGHT BE A HOMELESS PERSON OR TRANSIENT WHO HAS LEFT THE AREA OR AN INDIVIDUAL WHO HAS QUALIFIED FOR MEDICAID IN THE PAST BUT DID NOT MEET THE DEADLINE TO REAPPLY FOR BENEFITS. IN A CASE SUCH AS THIS, THE PATIENT CAN BE CLASSIFIED AS "DEEMED QUALIFIED" FOR CHARITY ASSISTANCE, WITH APPROPRIATE DOCUMENTATION EXPLAINING THE RATIONALE PLACED ON FILE. SUCH CASES WILL BE APPROVED ON AN INDIVIDUAL BASIS BY THE REVENUE CYCLE MANAGER AND/OR THE CFO. IN ADDITION, FINAL EVALUATION OF ACCOUNTS ELIBIBLE FOR BAD DEBT WRITE-OFF ARE REVIEWED TO IDENTIFY PATIENTS WHO HAVE QUALIFIED FOR CHARITY CARE IN THE PAST FOR ADDITIONAL QUALIFICATION EFFORTS OR POSSIBLE "DEEMED" STATUS. PART VI, LINE 2: THE HOSPITAL'S GOVERNING BOARD INCLUDES DIVERSE REPRESENTATION FROM EACH OF OUR VARIOUS COMMUNITIES AND WE DRAW ON THIS RESOURCE, AS WELL AS OUR PROVIDERS, STAFF, AND PATIENTS FOR INPUT REGARDING EMERGING NEEDS IN OUR SERVICE AREA. STRATEGIC PLANNING IS CONDUCTED ON AN ANNUAL BASIS INVOLVING THE BOARD AND VARIOUS STAKEHOLDERS AND, THROUGH THIS PROCESS, COMMUNITY NEEDS THAT HAVE BEEN IDENTIFIED ARE EVALUATED ALONG WITH POTENTIAL ADJUSTMENTS TO PROGRAMS AND SERVICES TO MEET THESE NEEDS. PART VI, LINE 3: THE AVAILABLILITY OF THE HOSPITAL'S FINANCIAL ASSISTANCE PROGRAM IS COMMUNICATED TO PATIENTS THROUGH THE FOLLOWING MEANS: HOSPITAL WEBSITE, ENCLOSURES WITH BILLS AND STATEMENTS, NOTICES IN ADMISSIONS AREA FOR THE HOSPITAL AND EMERGENCY ROOM, AND DIRECTLY THROUGH HOSPITAL STAFF WHO ARE EDUCATED ON THE AVAILABILITY OF THE PROGRAM. FINANCIAL COUNSELORS ARE PLACED AT VARIOUS SERVICE LOCATIONS TO ASSIST PATIENTS, AND THEY ARE WELL-VERSED ON EXTERNAL RESOURCES THAT MIGHT BE AVAILABLE TO ASSIST PATIENTS WITH FINANCIAL OBLIGATIONS FOR HEALTH CARE, AS WELL AS OUR IN-HOUSE PROGRAMS. PART VI, LINE 4: CLARK FORK VALLEY HOSPITAL AND FAMILY MEDICINE NETWORK SERVES THE RESIDENTS OF SANDERS COUNTY. THIS RURAL COUNTY IS LOCATED IN WESTERN MONTANA WITH A POPULATION OF APPROXIMATELY 11,400. THE HOSPITAL IS CENTRALLY LOCATED IN THE COUNTY WITHIN THE COMMUNITY OF PLAINS AND OPERATES REMOTE FAMILY PRACTICE CLINICS IN HOT SPRINGS AND THOMPSON FALLS. THE MEDIAN INCOME IN SANDERS COUNTY IS AMONG THE LOWEST IN THE STATE OF MONTANA (50TH OF 56 COUNTIES IN 2010) AND THE UNEMPLOYMENT RATE IS AMONG THE HIGHEST IN THE STATE AT 6.9% IN 2015. APPROXIMATELY 22% OF COUNTY RESIDENTS LIVE BELOW THE POVERTY LEVEL AND APPROXIMATELY 30% OF RESIDENTS UNDER THE AGE OF 65 LACKED HEALTH INSURANCE IN 2013. THE COUNTY HAS AN AGING POPULATION WITH A MEDIAN AGE OF 48.7 IN 2010. THE HOSPITAL IS THE SOLE PROVIDER OF ACUTE HEALTH CARE SERVICES IN THE COUNTY AND IS ITS LARGEST EMPLOYER. PART VI, LINE 5: THE HOSPITAL IS AN INDEPENDENT 501(C)(3) ENTITY AND IS ESSENTIALLY OWNED BY THE COMMUNITIES IT SERVES. THE GOVERNING BOARD IS COMPRISED PRIMARILY OF LOCAL INDIVIDUALS WHO REPRESENT A CROSS SECTION OF THE COMMUNITIES AND DEMOGRAPHIC GROUPS SERVED BY THE ORGANIZATION. THESE INDIVIDUALS CONTRIBUTE THEIR INSIGHT TO THE GOVERNANCE OF THE ORGANIZATION BASED ON THEIR EXPERIENCE IN THE COMMUNITY AS HEALTH CARE CONSUMERS, BUSINESS OWNERS, AND COMMUNITY LEADERS. THEY ALSO ACT AS ADVOCATES IN THEIR COMMUNITIES FOR HEALTH CARE ISSUES AND RESOURCES MADE AVAILABLE THROUGH THE ORGANIZATION. THE HOSPITAL AND ITS AFFILIATED ENTITIES FULLY PARTICIPATE IN ALL GOVERNMENT-SPONSORED HEALTH CARE PROGRAMS AND CONTRACTS WITH MOST PRIVATE PAYERS FOR SERVICES IN AN EFFORT TO ENABLE FULL ACCESS TO ITS SERVICES, REGARDLESS OF THE SPONSOR OF CARE. THE HOSPITAL TAKES A LEADERSHIP ROLE IN THE COMMUNITY WITH RESPECT TO HEALTH CARE COMMUNICATION AND EDUCATION, PROVIDING PRESS RELEASES TO LOCAL NEWSPAPERS, SPEAKERS TO COMMUNITY GROUPS, PARTICIPATION IN COMMUNITY EVENTS, PARTICULARLY THOSE THAT ARE HEALTH RELATED, AND WORKING WITH SCHOOLS IN OUR AREA TO PROMOTE WELLNESS AND HEALTH CARE CAREERS. THE HOSPITAL COLLABORATES WITH COUNTY GOVERNMENT AND VARIOUS AGENCIES TO PLAN FOR DISASTERS. THE HOSPITAL ALSO COLLABORATES WITH THE COUNTY HEALTH DEPARTMENT AND OTHER LOCAL PROVIDERS IN PLANNING FOR PUBLIC HEALTH CONCERNS, SUCH AS PANDEMIC, FLU VACCINE AVAILABILITY, ETC. THE HOSPITAL, THROUGH ITS HOSPICE AGENCY, CONDUCTS GRIEF SUPPORT GROUPS AND REFERS PATIENTS IN FAMILIES TO VARIOUS RESOURCES IN THE COMMUNITY TO ASSIST THEM IN THEIR TIME OF NEED. X X X X 0 0 0 0 0 0 0 0 0 ROBERT BLEASE MD 481560 0 0 0 0 0 0 0 0 0 481560 0 0 0 DONALD DAMSCHEN CHIEF OF STAFF 300000 0 0 0 0 0 0 0 0 0 300000 0 0 0 RONALD BLACK PHYSICIAN MEMBER 256900 0 0 0 0 0 0 0 0 0 256900 0 0 0 JESSICA VALENTINE MD 246261 0 0 0 0 0 0 0 0 0 246261 0 0 0 GREGORY HANSON PRESIDENT, CEO 239711 0 0 0 0 0 0 0 0 0 239711 0 0 0 JEANNE WILLIAMS MD 228867 0 0 0 0 0 0 0 0 0 228867 0 0 0 DRUE WEBB MD 234790 0 0 0 0 0 0 0 0 0 234790 0 0 0 FORM 990, PART VI, SECTION B, LINE 11B A DRAFT COPY OF THE 990 IS PROVIDED TO THE CLIENT PRIOR TO FILING. THE DRAFT IS ALSO PROVIDED TO THE BOARD FOR APPROVAL BEFORE FILING. FORM 990, PART VI, SECTION B, LINE 12C THE ORGANIZATION MAINTAINS A COMPREHENSIVE ORGANIZATIONAL INTEGRITY (COI) PROGRAM. ALL EMPLOYEES ARE REQUIRED TO READ AND SIGN THE STANDARDS OF CONDUCT DOCUMENT THAT INCLUDES AN EXTENSIVE COI POLICY. THE ORGANIZATIONAL INTEGRITY OFFICER PRESENTS THE IMPORTANCE OF COMPLIANCE AND INTEGRITY IN ALL ASPECTS OF THE BUSINESS TO ALL NEW EMPLOYEES AND DURING ANNUAL INSERVICE. ADDITIONALLY, THE ORGANIZATION UTILIZES THE SERVICES OF AN ANONYMOUS REPORTING SERVICE TO FURTHER SEEK REPORTS ON COI AND OTHER COMPLIANCE ISSUES. POTENTIAL COMPLIANCE VIOLATIONS, INCLUDING COI, ARE PROMPTLY INVESTIGATED. THE COMPLIANCE COMMITTEE MEETS AT LEAST QUARTERLY TO REVIEW VARIOUS AREAS OF THE ORGANIZATION FOR POTENTIAL COMPLIANCE VIOLATIONS. BOARD MEMBERS AND SENIOR MANAGERS ARE REQUIRED TO SIGN COI STATEMENTS ANNUALLY. BOARD MEMBERS, EXECUTIVE MANAGEMENT, PHYSICIANS, AND VOLUNTEER LEADERS ARE COVERED UNDER THE COI POLICY. IF PRESENT, POTENTIAL CONFLICTS OF INTEREST ARE DETERMINED BY SENIOR MANAGEMENT, THE ORGANIZATION'S INTEGRITY OFFICE, AND THE BOARD. ACTUAL CONFLICTS ARE REVIEWED BY SENIOR MANAGEMENT AND THE INTEGRITY OFFICE. IF A CONFLICT IS DETERMINED TO EXIST, PERSONS DETERMINED TO HAVE A CONFLICT OF INTEREST ARE EXCUSED FROM PARTICIPATION IN ACTIONS WHERE THE CONFLICT LIES. FORM 990, PART VI, SECTION B, LINE 15A THE HOSPITAL PRIMARILY USES THE MONTANA HOSPITAL ASSOCIATION'S ANNUAL WAGE SURVEY TO REVIEW SALARY COMPARABILITY TO SIMILAR ORGANIZATIONS IN THE STATE OF MONTANA. THE HOSPITAL ALSO USES RESOURCES SUCH AS MEDICAL GROUP MANAGEMENT ASSOCIATION (FOR PROVIDER COMPENSATION INFORMATION), INDUSTRY SURVEYS & PUBLICATIONS, AND CONSULTATIONS WITH OTHER ORGANIZATIONS AND PROVIDERS. THE BOARD HAS FULL DETERMINATION OF THE CEO'S COMPENSATION. DECISIONS ARE MADE BY THOSE WITHOUT CONFLICT AND THE DECISIONS ARE DOCUMENTED. FORM 990, PART VI, SECTION C, LINE 19 THE FACILITY'S GOVERNING DOCUMENTS, CONFLICT OF INTEREST POLICY, AND FINANCIAL STATEMENTS ARE NOT AVAILABLE TO THE PUBLIC. FORM 990, PART IX, LINE 11G OTHER PURCHASED SERVICES: PROGRAM SERVICE EXPENSES 1,044,118. MANAGEMENT AND GENERAL EXPENSES 375,352. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 1,419,470. TECHNICIAN PROFESSIONAL FEES: PROGRAM SERVICE EXPENSES 1,276,633. MANAGEMENT AND GENERAL EXPENSES 0. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 1,276,633. PHYSICIAN PROFESSIONAL FEES: PROGRAM SERVICE EXPENSES 315,150. MANAGEMENT AND GENERAL EXPENSES 0. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 315,150. FORM 990, PART XII, LINE 2C THERE HAVE BEEN NO CHANGES FROM PRIOR YEARS. CLARK FORK VALLEY HOSPITAL FOUNDATION INC PO BOX 768 PLAINS MT 59859 810304386 FUNDRAISING FOR CLARK FORK VALLEY HOSPITAL MT 501(C)(3) LINE 12A, I CLARK FORK VALLEY HOSPITAL 1 0 0 1 0 0 0 0 0 0 0 0 0 1 1 0 0 0 0 1 CLARK FORK VALLEY HOSPITAL FOUNDATION INC C 25000 FOUNDATION BOARD APPROVAL