2019-07-15T13:43:58-05:00 2018-12-31 621046406 JOHNSON HICKEY & MURCHISON PC 2215 OLAN MILLS DRIVE CHATTANOOGA TN 37421 990 2018-01-01 261861676 HUMPHREYS COUNTY COMMUNITY HEALTH SERVICES INC HUMP 9312960232 451 HIGHWAY 13 SOUTH WAVERLY TN 37185 SHANNON ALLISON CFO 9312960232 2019-07-15 1 BARRY R HUGGINS P00627334 4237560052 64.88.174.3 2019-07-15 10:54:42 ED P 03DDD3A2DB8B99EBDE291B49A1E23A5A7EE85A51 04448735707D6E2DFCE97B9D8C23A7CC138A826F 2018 2019-02-21 02:37:17Z THREE RIVERS HOSPITAL SHANNON ALLISON 451 HIGHWAY 13 SOUTH WAVERLY TN 37185 7572243 0 X THREERIVERSHOSPITAL.COM X 2008 TN THE MISSION OF THE HOSPITAL IS TO CONTINUOUSLY IMPROVE THE HEALTH OF THE PEOPLE OF ITS COMMUNITY. IN CARRYING OUT ITS MISSION THE HOSPITAL SERVES THE COMMUNITY IN A VARIETY OF WAYS. ONE OF THE PRIMARY WAYS THE HOSPITAL SERVES THE COMMUNITY IS BY PROVIDING CHARITY CARE TO POPULATIONS FOR WHICH IT RECEIVES NO COMPENSATION OR COMPENSATION AT RATES SIGNIFICANTLY LESS THAN THE ESTABLISHED RATES. A LARGE MAJORITY OF THE POPULATION SERVED ARE MEDICARE/TENNCARE PATIENTS.THREE RIVERS HOSPITAL IS COMMITTED TO IMPROVING THE HEALTH IN HUMPHREYS COUNTY BY PROVIDING WELLNESS PROGRAMS, COMMUNITY HEALTH EDUCATION PROGRAMS AND OTHER COMMUNITY BENEFIT ACTIVITIES IDENTIFIED FOR ALL THE STAGES OF LIFE. 10 8 191 1 0 0 14170 55466 8093383 7424997 1018 450 150583 91330 8259154 7572243 0 0 0 0 4341356 4092265 0 0 0 4396032 3955797 8737388 8048062 -478234 -475819 2461042 2148376 5076165 5239318 -2615123 -3090942 THE MISSION OF THE HOSPITAL IS TO CONTINUOUSLY IMPROVE THE HEALTH OF THE PEOPLE OF ITS COMMUNITY. 0 0 7002383 7460433 THREE RIVERS PROVIDES 24 HOUR EMERGENCY ROOM, LABORATORY, PEDIATRIC, SOCIAL SERVICES, CLINICAL DIETICIAN COUNSELING, PHYSICAL THERAPY, RADIOLOGY, RESPIRATORY THERAPY AND SURGERY TO MEMBERS OF THE COMMUNITY INCLUDING THOSE PROVIDED CHARITY CARE. THREE RIVERS PROVIDED 2264 PATIENT DAYS AND 6076 EMERGENCY ROOM VISITS. 7002383 1 1 0 1 0 0 0 0 0 0 1 0 0 0 1 1 1 0 0 0 0 0 0 0 0 0 1 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 16 0 191 1 0 0 0 0 0 0 0 0 0 0 0 0 X 10 8 0 0 0 0 0 0 0 1 1 0 0 1 1 1 1 1 1 1 1 0 TN X SHANNON ALLISON 9312960232 451 HIGHWAY 13 SOUTH WAVERLY TN 37185 FRANK RUSHTON BOARD MEMBER 1.00 X 0 0 0 TED MOORE BOARD MEMBER 1.00 X 0 0 0 DANIEL COLLIER VICE CHAIRMAN 1.00 X X 0 0 0 JOHNNY WHITFIELD BOARD MEMBER 1.00 X 0 0 0 KEVIN RYE CPA CHAIRMAN 1.00 X X 0 0 0 JACKIE BOSWELL SECRETARY 1.00 X X 0 0 0 SUBHI D ALI MD BOARD MEMBER 1.00 X 0 0 0 LAWRENCE R JACKSON JR MD BOARD MEMBER 1.00 X 0 0 0 DRGEORGE MATHAI CHIEF OF STAFF 1.00 X X 0 0 0 FREDA RUSSELL CEO/CNO 40.00 X X 122123 0 8494 SHANNON ALLISON CFO 40.00 X 78171 0 1505 200294 0 9999 1 0 0 0 CONCORD MEDICAL GROUP 3004 50TH STREET SUITE D LUBBOCK TX 794134129 ER PHYSICIANS 596583 1 53206 2260 55466 NET PATIENT REVENUE 621990 7424997 7424997 7424997 450 450 55894 0 55894 55894 55894 CAFETERIA SALES 621990 24483 24483 OTHER INCOME 621990 10953 10953 35436 7572243 7460433 0 56344 X 210293 186558 23735 3375431 2982597 392834 13192 11659 1533 229828 203956 25872 263521 233822 29699 2215 2215 42000 42000 1039024 985081 53943 1802 1802 170608 36884 133724 192159 2250 189909 142463 119618 22845 2612 1658 954 190982 190982 285174 285174 101195 101195 BAD DEBT 1008297 1008297 MEDICAL SUPPLIES DRUGS 421508 421508 EQUIPMENT RENTAL MAINTE 255671 248508 7163 OTHER SUPPLIES 83579 83579 16508 252 16256 8048062 7002383 1045679 0 108378 87238 1046871 885878 153904 177329 33306 29669 5505896 4577802 1049909 928094 53064 24558 15610 15610 2461042 2148376 1183447 1138691 3415780 3608559 476938 492068 5076165 5239318 X -2615123 -3090942 -2615123 -3090942 2461042 2148376 -475819 0 X 0 1 X 1 0 X 0 0 0 0 0 1 1000 0 0 0 1000 0 PART II-B, LINE 1: PART OF HOSPITAL DUES 313716 313716 1977734 1721382 256352 3214446 2856420 358026 928094 ESTIMATED THIRD PARTY SETTLEMENT 492068 492068 X 7572243 0 7572243 0 7572243 8048062 0 8048062 0 8048062 PART X, LINE 2: UNCERTAIN TAX POSITIONS - THE HOSPITAL IS EXEMPT FROM FEDERAL INCOME TAXES UNDER 501(C)(3) OF THE INTERNAL REVENUE CODE. THE HOSPITAL BELIEVES THAT IT HAS APPROPRIATE SUPPORT FOR ANY TAX POSITIONS TAKEN, AND AS SUCH, DOES NOT HAVE ANY UNCERTAIN TAX POSITIONS THAT ARE MATERIAL TO THE FINANCIAL STATEMENTS. THE HOSPITAL'S FORMS 990, RETURN OF ORGANIZATION EXEMPT FROM INCOME TAX, FOR THE YEARS ENDING 2015, 2016, AND 2017 ARE SUBJECT TO EXAMINATION BY THE IRS, GENERALLY FOR 3 YEARS AFTER THEY WERE FILED. 1 1 1 X 1 X 150.000000000000 1 1 0 0 29063 29063 0.00410 738366 969819 0 0.00000 767429 969819 29063 0.00410 10586 10586 0.00150 10586 10586 0.00150 778015 969819 39649 0.00560 1 1058376 712811 3025834 3025834 X 1 1 1 1 THREE RIVERS HOSPITAL 451 HIGHWAY 13 SOUTH WAVERLY TN 37185 00000036 X X X HUMPHREYS COUNTY COMMUNITY HEALTH 1 0 0 1 X X X X X X X X X 17 1 0 0 1 X THREERIVERSHOSPITAL.COM X 1 14 1 THREERIVERSHOSPITAL.COM 0 1 X 100.000000000000 150.000000000000 X X X 1 1 1 X X 1 X 1 X X X X 1 X 0 0 HUMPHREYS COUNTY COMMUNITY HEALTH PART V, SECTION B, LINE 11: THREE RIVERS HOSPITAL IS TEAMING UP WITH OTHER COMMUNITY AGENCIES, ORGANIZATIONS AND INSTITUTIONS TO HELP ADDRESS THE UNMET HEALTH NEEDS OF HUMPHREYS COUNTY. WITH THIS COMMUNITY PARTICIPATION, THE PRIORITY GOALS WERE SELECTED AND WORK BEGAN ON STRATEGIES TO IMPROVE THE HEALTH NEEDS IN OUR COMMUNITY. SOME OF THE PARTNERS THAT PARTICIPATED IN THE ASSESSMENT AND ACTION PLAN AND CONTINUE THREE RIVERS HOSPITAL WANTS TO PROVIDE HIGH QUALITY, COST EEFECTIVE, AND COMPASSIONATE CARE THAT IS RESPONSIVE TO THE COMMUNITIES WE SERVE. THIS IMPLEMENTATION ACTION PLAN WILL DIRECT OUR EFFORTS IN WORKING TO ADDRESS SOME OF THE UNMET HEALTH NEEDS OF OUR COMMUNITY.FOURTEEN DISTINCT NEEDS WERE IDENTIFIED BUT BASED ON INPUT FROM THE PRIORITIZATION AT THE COMMUNITY SUMMIT, THREE RIVER HOSPITAL CHOSE THESE PRIORITIES: (1)OBESITY/EXERCISE/NUTRITION (2)CHRONIC DISEASE-DIABETES, HEART DISEASE AND CANCER DEATHS (3)ACCESS TO PRIMARY CARE, DENTAL SERVICES, MENTAL HEALTH AND INSURANCE. TO ADDRESS THESE NEEDS VARIOUS AGENCIES ARE WORKING WITH THREE RIVERS HOSPITAL TO PROVIDE MORE EDUCATION, INCREASE PHYSICAL ACTIVITY,IMPROVE NUTRITION,PROVIDE MORE SCREENINGS, AND PROVIDE MORE ACCESS TO AFFORDABLE EXERCISE FACILITIES IN THE COMMUNITY. TO HELP WITH THESE EFFORTS ARE: HUMPHREYS COUNTY HEALTH COUNCIL, HUMPHREYS COUNTY COORDINATED SCHOOL HEALTH, HUMPHREYS COUNTY HEALTH DEPARTMENT, HUMPHREYS COUNTY CHAMBER OF COMMERCE, AND HUMPHREYS COUNTY UT EXTENSION SERVICES. HUMPHREYS COUNTY COMMUNITY HEALTH PART V, SECTION B, LINE 16J: CHARITY CARE MUST BE REQUESTED BY THE PATIENT. IF A PATIENT INDICATES THAT THEY CAN NOT PAY, A CHARITY APPLICATION IS SUGGESTED. THERE ARE NOTICES POSTED IN THE REGISTRATION AREAS INDICATING THAT THE HOSPITAL GIVES CHARITY CARE AND HOW TO OBTAIN FURTHER INFORMATION ABOUT CHARITY CARE. HUMPHREYS COUNTY COMMUNITY HEALTH PART V, SECTION B, LINE 18E: WHATEVER IS DEEMED NECESSARY BY COLLECTION AGENCY PART I, LINE 7: HOSPITAL USES THE COST TO CHARGE RATIO IN DETERMINING THE AMOUNT OF THE ORGANIZATION'S BAD DEBT EXPENSE AT COST AND APPLIES AN ESTIMATE OF THE PERCENTAGE OF BAD DEBT COST TO DETERMINE THE AMOUNT ATTRIBUTABLE TO PATIENTS ELIGIBLE UNDER THE HOSPITAL'S FINANCIAL ASSISTANCE POLICY. PART I, LN 7 COL(F): HOSPITAL POLICIES STATE THAT A BAD DEBT IS AN ACCOUNT ON WHICH THERE HAS BEEN NO SIGNIFICANT PAYMENT ACTIVITY FOR A PERIOD OF THREE MONTHS. AGING WILL COMMENCE WITH THE DAY OF DISCHARGE OR THE DAY OF LAST PAYMENT. PART III, LINE 4: PER FINANCIAL STATEMENT FOOTNOTE: ACCOUNTS RECEIVABLE ARE STATED AT THE AMOUNT THE HOSPITAL EXPECTS TO COLLECT. THE HOSPITAL MAINTAINS ALLOWANCES FOR DOUBTFUL ACCOUNT FOR ESTIMATED LOSSES RESULTING FROM THE INABILITY OF ITS PATIENTS TO MAKE REQUIRED PAYMENTS. MANAGEMENT CONSIDERS THE FOLLOWING FACTORS WHEN DETERMINING THE COLLECTABILITY OF PATIENT ACCOUNTS: PAYOR CREDIT-WORTHINESS, PAST TRANSACTION HISTORY WITH THE PAYOR, CURRENT ECONOMIC INDUSTRY TRENDS, AND CHANGES IN PAYOR PAYMENT TERMS. IF THE FINANCIAL CONDITION OF THE HOSPITAL'S PAYORS OR PATIENTS WERE TO DETERIORATE, ADVERSELY AFFECTING THEIR ABILITY TO MAKE PAYMENTS, ADDITIONAL ALLOWANCES WOULD BE REQUIRED. BASED ON MANAGEMENT'S ASSESSMENT, THE HOSPITAL PROVIDES FOR ESTIMATED UNCOLLECTIBLE AMOUNTS THROUGH A CHARGE TO EARNINGS AND A CREDIT TO AN ALLOWANCE. BALANCES THAT REMAIN OUTSTANDING AFTER THE HOSPITAL HAS USED REASONABLE COLLECTION EFFORTS ARE WRITTEN OFF THROUGH A CHARGE TO THE ALLOWANCE AND A CREDIT TO ACCOUNTS RECEIVABLE. THE HOSPITAL REGULARLY PERFORMS HINDSIGHT PROCEDURES TOE EVALUATE HISTORICAL WRITE-OFF AND COLLECTION EXPERIENCE THROUGHOUT THE YEAR TO ASSIST IN DETERMINING THE REASONABLENESS OF ITS PROCESS FOR ESTIMATING THE ALLOWANCE FOR DOUBTFUL ACCOUNTS. PART III, LINE 8: MANY ACCOUNTS ARE LEFT WITH A LARGE PATIENT PORTION AFTER MEDICARE HAS PAID. THERE ARE NO SERVICES THAT ARE EXEMPT FROM CHARITY CARE. THE DETERMINATION TO TREAT A PATIENT IS NOT BASED ON THEIR ABILITY TO PAY. REVENUE IS EQUAL TO THE COST REIMBURSEMENT FOR ALLOWABLE EXPENSE. PART III, LINE 9B: ALL PATIENT ACCOUNTS WILL BE CLASSIFIED BY PRIMARY SOURCE OF PAYMENT. THESE ARE MEDICARE, BLUE CROSS, SELF PAY, AND OTHER. ANY ACCOUNT WHICH AGES TO 90 DAYS WITHOUT SIGNIFICANT ACTIVITY WILL BE TURNED OVER TO COLLECTION AGENCIES, BANK COLLECTION OR TAX ASSESSOR'S OFFICE AS APPROPRIATE. WHEN AN ACCOUNT IS DETERMINED TO BE ABLE BUT UNWILLING TO PAY, THE ACCOUNT SHOULD BE TURNED OVER FOR COLLECTION REGARDLESS OF IT'S AGE. NEEDS ASSESSMENT THREE RIVERS HOSPITAL ASSESSES THE HEALTH CARE NEEDS OF THE COMMUNITY IN THE FOLLOWING WAYS: (1) PARTICIPATING IN THE COMMUNITY HEALTH COUNCIL WHICH CONSIDERS ALL HEALTH CARE NEEDS FOR THE AREA, (2) INTERACTING WITH THE MEDICAL STAFF AND NURSE PRACTITIONERS TO ASCERTAIN THEIR NEEDS FOR THE CARE OF THE PATIENTS THEY ARE SEEING AND (3) ASSESSING DATA BANKS TO DETERMINE WHAT NEEDS ARE BEING MET BY OTHER HEALTH CARE PROVIDERS OUTSIDE OF THE SERVICE AREA. PATIENT EDUCATION OF ELIGIBILITY FOR ASSISTANCE CHARITY CARE MUST BE REQUESTED BY THE PATIENT. IF A PATIENT INDICATES THAT THEY CAN NOT PAY, A CHARITY APPLICATION IS SUGGESTED. THERE ARE NOTICES POSTED IN THE REGISTRATION AREAS INDICATING THAT THE HOSPITAL GIVES CHARITY CARE AND HOW TO OBTAIN FURTHER INFORMATION ABOUT CHARITY CARE. COMMUNITY INFORMATION THREE RIVERS HOSPITAL IS LOCATED IN WAVERLY, TENNESSEE (HUMPHREYS COUNTY). WAVERLY IS 65 MILES WEST OF NASHVILLE. THE POPULATION OF HUMPHREYS COUNTY IS 18,600. HUMPHREYS COUNTY ESTIMATES THAT THE MEDIAN AGE IS 42.8 YEARS. THE 2014 MEDIAN INCOME WAS ESTIMATED TO BE $37,175. HOUSEHOLD POPULATION 7,480. AVERAGE HEALTH EXPENDITURES (2014) $3,699. TOTAL HEALTH EXPENDITURES $27.7 MILLION FOR 2014. COMMUNITY BUILDING ACTIVITIES MEMBERSHIP IN VARIOUS CIVIC GROUPS SUCH AS THE CHAMBER OF COMMERCE, CIVITANS, ETC. ENABLES THE HOSPITAL TO REPRESENT HEALTH CARE PROVIDERS IN THE GROWTH PLANS OF THE COMMUNITY. IT ALSO ALLOWS FOR GREATER INSIGHT INTO THE HEALTHCARE NEEDS OF THE INDUSTRIAL AND GOVERNMENTAL SECTORS OF THE SERVICE AREA. IT CAN PROMOTE SERVICE OPPORTUNITIES IN RELATION TO THE VARIOUS PROJECTS OF THESE GROUPS. THE HOSPITAL DID NOT TRACK THE MONETARY COSTS AND BENEFITS OF THESE COMMUNITY BUILDING ACTIVITIES. HEALTH OF THE COMMUNITY IN RELATION TO EXEMPT PURPOSE THE HOSPITAL PARTICIPATES IN FUNDRAISING "RELAY FOR LIFE AND "THE UNITED WAY". THE MISSION OF THE HOSPITAL IS TO CONTINUOUSLY IMPROVE THE HEALTH OF THE PEOPLE OF ITS COMMUNITY. IN CARRYING OUT ITS MISSION THE HOSPITAL SERVES THE COMMUNITY IN A VARIETY OF WAYS. ONE OF THE PRIMARY WAYS THE HOSPITAL SERVES THE COMMUNITY IS BY PROVIDING CHARITY CARE TO POPULATIONS FOR WHICH IT RECEIVES NO COMPENSATION OR RECEIVES COMPENSATION AT RATES SIGNIFICANTLY LESS THAN ESTABLISHED RATES FROM PATIENTS WHO RECEIVE PARTIAL CHARITY. SEVENTY PERCENT OF THE POPULATION SERVED IS MEDICARE/TENNCARE PATIENTS AND THE REIMBURSEMENT RECEIVED FROM THE GOVERNMENT FOR PROVIDING SERVICES AT BEST 101% OF COVERED COSTS. X X 0 0 0 0 0 0 0 0 0 FORM 990, PART VI, SECTION B, LINE 11B 990 WILL BE REVIEWED BY MANAGEMENT BEFORE IT IS FILED. FORM 990, PART VI, SECTION B, LINE 12C REQUIRED TO DISCLOSE IF THERE IS A CONFLICT OF INTEREST FORM 990, PART VI, SECTION B, LINE 15 SALARIES ARE DETERMINED BY STUDYING SALARY SURVEYS FROM THE TN HOSPITAL ASSOCIATION AND OFFERING COMPARABLE SALARIES FOR THE POSITION. SALARIES FOR OFFICERS ARE DETERMINED BY USING SALARY SURVEY INFORMATION OF COMPARABLE POSITIONS. FORM 990, PART VI, SECTION C, LINE 19 DOCUMENTS ARE MADE AVAILABLE UPON REQUEST. FORM 990, PART IX, LINE 11G ER PHYSICIANS PURCHASED SERVICES: PROGRAM SERVICE EXPENSES 606,434. MANAGEMENT AND GENERAL EXPENSES 0. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 606,434. PURCHASED SERVICES: PROGRAM SERVICE EXPENSES 299,954. MANAGEMENT AND GENERAL EXPENSES 53,943. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 353,897. SURGERY PHYSICIANS PURCHASED SERVICES: PROGRAM SERVICE EXPENSES 78,693. MANAGEMENT AND GENERAL EXPENSES 0. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 78,693.