2019-04-10T19:43:36-05:00 2018-06-30 390758449 WIPFLI LLP 101 EAST FRONT STREET 301 MISSOULA MT 59802 990 2017-07-01 810469886 POWELL COUNTY MEMORIAL HOSPITAL ASSOC POWE 4068462212 1100 HOLLENBACK LANE DEER LODGE MT 59722 TONY PFAFF CEO 4068462212 2019-04-03 1 WAYNE R HIETT CPA P00159424 4067281800 2019-04-03 65.158.74.97 2019-04-03 19:02:45 MD P DA39A3EE5E6B4B0D3255BFEF95601890AFD80709 9D52B5E6069EE514AD23D25426376044F7108321 2017 2019-02-21 02:37:17Z DEER LODGE MEDICAL CENTER TONY PFAFF 1100 HOLLENBACK LANE DEER LODGE MT 59722 14862351 0 X DLMED.ORG X 1991 MT THE MISSION OF THE HOSPITAL IS TO PROVIDE HIGH QUALITY HEALTHCARE TO ALL THEY SERVE. 7 7 131 10 0 0 90122 106762 13785046 14533416 13362 18806 240318 196390 14128848 14855374 0 0 0 0 6949925 7480234 0 0 0 5827043 6163507 12776968 13643741 1351880 1211633 24314269 26119575 17643276 18236949 6670993 7882626 THE MISSION OF THE HOSPITAL IS TO PROVIDE HIGH QUALITY HEALTHCARE TO ALL THEY SERVE. 0 0 12137073 14533416 THE HOSPITAL PROVIDES DAILY PATIENT CARE SERVICES AND IS THE ONLY SOURCE OF THESE SERVICES IN THE AREA. 12137073 1 1 0 0 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 0 0 0 0 0 1 0 0 0 1 15 0 131 1 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 JAENA RICHARDS CHIEF OPERATING OFFICER 40.00 X 135509 0 14414 JENNIFER SPRING CHIEF FINANCIAL OFFICER 40.00 X 82302 0 891 ERIC TREVELLINE MD PHYSICIAN 40.00 X 293698 0 6193 WAYNE MARTIN MD PHYSICIAN 40.00 X 266824 0 13860 JUDITH WILSON MD PHYSICIAN 40.00 X 221659 0 7724 SUMERA QAMAR OD 40.00 X 182063 0 14047 CYNTHIA JEAN SMITH PA 40.00 X 143578 0 0 1325633 0 57129 11 0 1 0 CYPRESS HEALTHCARE LLC 791 EASTSIDE ROAD DEER LODGE MT 59722 MANAGEMENT, CEO, REVENUE INTEGRITY SERVI 417366 ALLEVANT SOLUTIONS 4714 GETTYSBURG ROAD MECHANICSBURG PA 17055 TRANSITIONAL CARE PROGRAM CONSULTING SER 220000 MONIDA SHARED IMAGING 1200 S RESERVE ST SUITE H MISSOULA MT 59801 MRI SERVICES 185739 MAYO COLLABORATIVE SERVICES INC PO BOX 9146 MINNEAPOLIS MN 554809146 LAB TESTING SERVICES 119272 CTA INC PO BOX 30071 BILLINGS MT 59107 ARCHITECTURAL SERVICES 115850 7 655 14750 91357 106762 NET PATIENT SERVICE REVENUE 621110 13875245 13875245 UTILIZATION FEE REVENUE 621110 530877 530877 OTHER OPERATING REVENUE 621110 127294 127294 14533416 20201 20201 30176 5582 24594 24594 24594 1395 -1395 -1395 -1395 OTHER INCOME 621110 171796 171796 171796 14855374 14533416 0 215196 X 218719 218719 5474195 5167484 306711 48451 45270 3181 1738869 1488274 250595 2084760 1872406 212354 50115 4522 45593 32770 30866 1904 61651 38720 22931 707987 679668 28319 875492 840472 35020 144853 139304 5549 SUPPLIES 1538617 1519892 18725 OTHER DIRECT EXPENSES 585686 280947 304739 LICENSES & TAXES 81576 29248 52328 13643741 12137073 1506668 0 281756 804675 3499752 5132268 3306951 2101990 336583 372145 98985 100594 21120230 6809376 13258674 14310854 3531568 3297049 24314269 26119575 1601228 1773000 15760000 15295000 282048 1168949 17643276 18236949 X 6670993 7882626 6670993 7882626 24314269 26119575 1211633 0 X X 0 1 X 1 0 X 695642 695642 12923421 2650570 10272851 5656599 4158806 1497793 1844568 1844568 14310854 BOND FUNDS 3021404 INVESTMENT IN YELLOWSTONE INSURANCE EXCHANGE RRG 217595 INVESTMENT IN WORKERS COMPENSATION 58050 3297049 X 14860956 5582 5582 14855374 0 14855374 13649323 5582 5582 13643741 0 13643741 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 5,582. PART XII, LINE 2D - OTHER ADJUSTMENTS: DIRECT RENT EXPENSE DEDUCTED FROM GROSS RENTS FOR 990 REVENUE 5,582. 1 1 1 X 1 X 1 1 1 0 0 89000 89000 0.00650 2830443 2406731 423712 0.03110 2919443 2406731 512712 0.03760 81539 81539 0.00600 6067 6067 0.00040 2717 2717 0.00020 90323 90323 0.00660 3009766 2406731 603035 0.04420 662 662 0.00000 3610 3610 0.00030 4782 4782 0.00040 9054 9054 0.00070 1 652504 4004 6350806 6352539 -1733 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 X 15 1 0 0 1 X WWW.DLMED.ORG 1 16 1 WWW.DLMED.ORG 0 1 X 200.000000000000 300.000000000000 X 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 1 X 0 X X X X 1 X 0 0 POWELL COUNTY MEMORIAL HOSPITAL PART V, SECTION B, LINE 5: THE HOSPITAL CONVENED A STEERING COMMITTEE REPRESENTING VARIOUS ORGANIZATIONS AND POPULATIONS WITHIN THE COMMUNITY. SURVEYS TO THE GENERAL PUBLIC WERE SENT OUT AS WELL. MEMBERS OF THE STEERING COMMITTEE REPRESENTED THE AREA'S SCHOOLS, LARGEST EMPLOYERS, PUBLIC HEALTH, COUNCIL ON AGING, LOCAL CHURCHES, BANKS, AND THE COMMUNITY IN GENERAL. SEVERAL OF THESE MEMBERS WORK WITH OR FOR THE UNINSURED AND UNDERSERVED EITHER DIRECTLY THROUGH PROGRAMS DESIGNED TO ASSIST THOSE POPULATIONS, OR INDIRECTLY AS EDUCATORS, LENDERS, PASTORS, AND EMPLOYERS. POWELL COUNTY MEMORIAL HOSPITAL PART V, SECTION B, LINE 11: CHNA SIGNIFICANT NEED NO. 1: ACCESS TO HEALTH CARE. PCMH IS ADDRESSING THIS NEED BY DEVELOPING AND PUBLICIZING A LIST OF ALL SERVICES AVAILABLE AT PCMH. WE CONTINUE TO ADVERTISE CURRENT AND NEW SERVICES ON (AT) BILLBOARDS, FLYERS, SOCIAL MEDIA, HEALTH FAIRS, AND JOB FAIRS. IN JULY 2018, PCMH BEGAN OFFERING CARDIO-PULMONARY REHAB SERVICES. WE PARTNER WITH POWELL COUNTY AND THE COUNCIL ON AGING TO HELP STAFF THE PUBLIC HEALTH NURSE AND HOME VISITING NURSE POSITIONS. A PCMH NURSE REGULARLY VISITS THE LOCAL SENIOR CENTER TO PROVIDE FREE BLOOD PRESSURE CHECKS AND GLUCOSE MONITORING. WE SPONSOR TICKETS FOR THE COMMUNITY VAN AND ATTEND MEETINGS OF THE TRANSPORTATION ACCESS COUNCIL. PARTNERSHIPS WITH OTHER PROVIDERS IN SURROUNDING CITIES AND STATES ARE CONTINUOUSLY PURSUED TO PROVIDE SPECIALTY SERVICES INCLUDING CARDIOLOGY, ONCOLOGY, NEUROLOGY, ORTHOPEDICS, PODIATRY, GASTROENTEROLOGY, PULMONOLOGY, AND TELEMEDICINE (STROKE, PSYCHIATRY, BURN, AND EMERGENCY).CHNA SIGNIFICANT NEED NO. 2: ALCOHOL AND SUBSTANCE ABUSE. PCMH HAS CONTRACTED TO EMPLOY A PSYCHIATRIST BEGINNING IN OCTOBER 2019. UNTIL THEN, WE HAVE IMPLEMENTED TELEPSYCHIATRY SERVICES. WE ALSO REGULARLY DONATE, BOTH IN CASH AND VOLUNTEER SERVICES, TO ACTIVITIES FOR YOUTH DESIGNED TO PROVIDE HEALTHY ALTERNATIVES TO SUBSTANCE ABUSE. CHNA SIGNIFICANT NEED NO. 3: OUTREACH AND EDUCATION. PCMH HAS INCREASED AWARENESS OF AVAILABLE HEALTHCARE RESOURCES AS MENTIONED ABOVE. WE'VE ALSO IMPLEMENTED OUTREACH AND EDUCATION SERVICES SUCH AS STOP THE BLEED AND ACTIVE SHOOTER TRAINING, AND FREE COMMUNITY HEALTH FAIRS (WITH LOW COST LAB WORK), DIABETIC EDUCATION, FOOT CLINICS, AND CONCUSSION BASELINE TESTS FOR LOCAL STUDENT ATHLETES. 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 EMPLOYEES HELPED REPAIR THE GRANDSTANDS AT THE COUNTY FAIRGROUNDS TO MAKE THEM SAFER ($490); A PCMH EMPLOYEE SERVED ON A TRAILS COMMITTEE WORKING TO BRING FREE AND SAFE PUBLIC TRAILS TO THE AREA ($172).COMMUNITY SUPPORT: PCMH PAID AN EMPLOYEE TO ATTEND THE POWELL COUNTY LOCAL EMERGENCY PREPAREDNESS COMMITTEE AND PROVIDED THE ROOM FOR FREE TO THE COMMITTEE ($241); SEVERAL PCMH EMPLOYEES VOLUNTEERED, ON PCMH TIME, TO WORK AT THE SPORTING EVENTS OF THE LOCAL HIGH SCHOOL AND PCMH SUPPLIED PINK, LOGO-FREE, JERSEYS FOR THE ATHLETES TO WEAR AS PART OF BREAST CANCER AWARENESS MONTH ($548). PART III, LINE 2: TREND ANALYSIS OF SELF-PAY ACCOUNT COLLECTIONS IS USED TO ESTIMATE THE PROVISION FOR BAD DEBT ON SELF-PAY ACCOUNTS RECEIVABLE AT FISCAL YEAR-END. 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: AN ASSESSMENT OF INCOMPLETE FINANCIAL ASSISTANCE APPLICATIONS WAS USED TO DETERMINE THE AMOUNT OF BAD DEBT EXPENSE ATTRIBUTABLE TO PATIENTS WHO MAY BE ELIGIBLE FOR FINANCIAL ASSISTANCE. PART III, LINE 4: SEE PAGES 8 AND 9 OF THE ATTACHED AUDITED FINANCIAL STATEMENTS. PART III, LINE 8: NONE OF THE SHORTFALL ON LINE 7 SHOULD BE TREATED AS COMMUNITY BENEFIT. COST ACCOUNTING (VIA THE MEDICARE COST REPORT) WAS USED TO DETERMINE THE ALLOWABLE MEDICARE COSTS. PART III, LINE 9B: THE BILLING AND COLLECTION POLICY MANDATED THAT A PLAIN LANGUAGE SUMMARY OF OUR FAP BE INCLUDED IN THE SECOND OR THIRD BILLING STATEMENT, ALONG WITH A FINANCIAL ASSISTANCE APPLICATION. PATIENTS COVERED BY MEDICAID ARE CONSIDERED PRESUMPTIVELY ELIGIBLE FOR FINANCIAL ASSISTANCE. PART VI, LINE 2: TO ASSESS THE HEALTH CARE NEEDS OF THE COMMUNITIES IT SERVICES, PCMH WORKS WITH COUNTY AGENCIES (I.E. PUBLIC HEALTH, SENIOR SERVICES, EMERGENCY PREPAREDNESS, ETC.), SCHOOL DISTRICTS, AND MAJOR EMPLOYERS. PART VI, LINE 3: PCMH WORKS WITH THE LOCAL MEDICAID OFFICE AND PUBLIC HEALTH AGENCY TO ASSIST QUALIFYING INDIVIDUALS WITH ACCESSING SERVICES. A PCMH STAFF MEMBER IN THE BUSINESS OFFICE IS ABLE TO ASSIST INDIVIDUALS IN APPLYING FOR MEDICAID. PATIENTS ARE INFORMED OF THE AVAILABILITY OF FINANCIAL ASSISTANCE WITH EVERY STATEMENT THEY RECEIVE. FURTHERMORE, BEING A SMALL COMMUNITY, WE OFTEN HAVE AN IDEA OF A PATIENT'S FINANCIAL SITUATION AND CAN ENCOURAGE THEM TO APPLY FOR STATE OR FEDERAL BENEFITS FOR FINANCIAL ASSISTANCE THROUGH PCMH. ALSO, BEFORE ACCOUNTS ARE SENT TO OUR 3RD PARTY COLLECTION AGENCY, THEY ARE REVIEWED TO SEE IF THEY MEET OUR PRESUMPTIVE ELIGIBILITY CRITERIA FOR FINANCIAL ASSISTANCE. 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 HOSPITAL'S GOVERNING BOARD IS COMPRISED OF PERSONS WHO RESIDE IN THE HOSPITAL'S PRIMARY SERVICE AREA AND ARE NEITHER EMPLOYEES NOR INDEPENDENT CONTRACTORS (OTHER THAN DISCLOSED ON THIS FORM) OF THE ORGANIZATION, NOR FAMILY MEMBERS THEREOF.PCMH EXTENDS MEDICAL STAFF PRIVILEGES TO QUALIFIED PROVIDERS IN THE COMMUNITY.SURPLUS FUNDS ARE USED TO UPDATE FACILITIES AND EQUIPMENT OR EMPLOY ADDITIONAL STAFF IN ORDER 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 RN STUDENTS- SCHOLARSHIPS TO HIGH SCHOOL STUDENTS PURSUING DEGREES IN HEALTH CARE 0 0 0 0 0 0 0 0 0 ERIC TREVELLINE MD PHYSICIAN 293698 0 0 0 0 0 0 0 6193 0 299891 0 0 0 WAYNE MARTIN MD PHYSICIAN 266824 0 0 0 0 0 5400 0 8460 0 280684 0 0 0 JUDITH WILSON MD PHYSICIAN 221659 0 0 0 0 0 0 0 7724 0 229383 0 0 0 SUMERA QAMAR OD 182063 0 0 0 0 0 0 0 14047 0 196110 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 15000000 1184142 13557042 258697 2011 0 0 1 1 B 2560000 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. 25200 MR. ANDERSEN SERVES AS THE HOSPITAL'S PHARMACIST. 0 TONY PFAFF MR. PFAFF IS PCMH'S CURRENT CEO. 177320 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 2280 THE HOSPITAL RENTS AN APARTMENT FROM MS. HANSEN. 0 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 262,619. MANAGEMENT AND GENERAL EXPENSES 62,815. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 325,434. PURCHASED SERVICES: PROGRAM SERVICE EXPENSES 1,609,787. MANAGEMENT AND GENERAL EXPENSES 149,539. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 1,759,326. 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 6139 POWELL COUNTY MEDICAL FOUNDATION C 655