2019-01-09T10:47:42-06:00 2018-03-31 752570395 DURBIN & COMPANY LLP 2950 50TH STREET LUBBOCK TX 79413 990 2017-04-01 452750258 EL CAMPO MEMORIAL HOSPITAL ELCA 9795436251 303 SANDY CORNER RD EL CAMPO TX 77437 NATHAN TUDOR CHIEF EXECUTIVE OFFICER 9795436251 2019-01-09 GAYLE DE HAAS P01774581 8067911591 12.86.242.26 2019-01-09 10:47:39 CS P DA39A3EE5E6B4B0D3255BFEF95601890AFD80709 00DC5DC89968C6BE560901454C496131615A7D99 2017 2019-02-21 02:37:17Z NATHAN TUDOR 303 SANDY CORNER RD EL CAMPO TX 77437 33352074 0 X WWW.ECMH.ORG X 2011 TX THE HOSPITAL PROVIDES EL CAMPO AND SURROUNDING AREAS WITH THE HIGHEST STANDARD OF CARE THROUGH A BROAD RANGE OF SERVICES: INPATIENT, SWING BED, EMERGENCY, SURGICAL, LABORATORY, IMAGING, RESPIRATORY, ETC. 7 7 94 0 0 0 756793 58787 25348842 26964481 11571 1101 577633 6327705 26694839 33352074 0 0 0 0 9783231 11931305 0 0 0 16600986 18238000 26384217 30169305 310622 3182769 4870248 6628135 4684707 3259825 185541 3368310 THE HOSPITAL PROVIDES EL CAMPO AND SURROUNDING AREAS WITH THE HIGHEST STANDARD OF CARE THROUGH A BROAD RANGE OF SERVICES: INPATIENT, SWING BED, EMERGENCY, SURGICAL, LABORATORY, IMAGING, RESPIRATORY, ETC. 0 0 26610799 33292186 PROVIDE HEALTHCARE TO EL CAMPO AND SURROUNDING AREAS WITH A BROAD RANGE OF SERVICES: INPATIENT, SWING BED, EMERGENCY, SURGICAL, LABORATORY, IMAGING, RESPIRATORY, AND THERAPY. 26610799 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 0 0 0 0 0 1 0 0 0 0 0 0 0 0 0 0 0 1 285 0 1 94 0 0 0 0 0 0 0 0 0 X 7 7 0 0 0 0 0 0 0 1 1 0 0 1 1 1 1 0 1 1 0 0 X THE ORGANIZATION 9795436251 303 SANDY CORNER RD EL CAMPO TX 77437 RANDY CLAPP BOARD CHAIRMAN 1.00 X 0 0 0 STEPHEN COOPER BOARD VICE - CHAIRMAN 1.00 X 0 0 0 MARY JOHNSON BOARD SECRETARY 1.00 X 0 0 0 BILL JENKINS DIRECTOR 1.00 X 0 0 0 CLAY HARRIS DIRECTOR 1.00 X 0 0 0 MELISSA ERWIN DIRECTOR 1.00 X 0 0 0 THAI HUYNH DIRECTOR 1.00 X 0 0 0 DAVID MAK CFO 40.00 X 57057 0 0 NATHAN TUDOR CEO 40.00 X 206727 0 0 SANDY BYSTREK OCCUPATIONAL THERAPIST 40.00 X 108354 0 0 CLAY ZBORIL OCCUPATIONAL THERAPIST 40.00 X 124581 0 0 ASHLEY KOUDELA PHYSICIAN ASSISTANT 40.00 X 129906 0 0 KAYLA CERNY PHYSICIAN ASSISTANT 40.00 X 145445 0 0 DANA FOSTER PHYSICIAN ASSISTANT 40.00 X 155141 0 0 927211 0 0 7 0 1 0 VICTORIA EMERGENCY ASSOCIATION 802 BARTON BLVD AUSTIN TX 78701 ER SERVICES 694069 CONCORD MEDICAL GROUP 3004 50TH STREET SUITE D LUBBOCK TX 79413 STAFFING 653602 HOSPITAL HOUSEKEEPING SYSTEMS PO BOX 826 SAN ANTONIO TX 78293 HOUSEKEEPING 284592 BLS CONSTRUCTION 207 FAHRENTHOLD ST EL CAMPO TX 77437 CONSTRUCTION 242452 ENTRADA INC DEPT CH 19610 PALATINE IL 60055 146660 8 58787 58787 PROGRAM SERVICE REVENU 621990 26964481 26964481 26964481 1101 1101 35100 0 35100 35100 35100 1115 WAIVER 624100 5357630 5357630 OTHER 624100 510084 510084 COST REPORT SETTLEMENT 624100 190927 190927 233964 233964 6292605 33352074 33292186 0 1101 X 263784 263784 8927733 7523657 1404076 271745 222435 49310 1719535 1407514 312021 748508 654692 93816 5695032 5149131 545901 195925 66322 129603 384534 299550 84984 3226913 2825148 401765 119650 26519 93131 21234 17395 3839 19606 19606 272850 272850 86040 86040 BAD DEBT 5871396 5871396 MEDICAL SUPPLIES 2096295 2096295 LICENSES 84092 51633 32459 BANK FEES AND FINANCE C 66037 66037 98396 20616 77780 30169305 26610799 3558506 0 789800 908403 1959047 3066291 463914 558816 92041 190756 4141048 2654076 1032269 1486972 533177 416897 4870248 6628135 4160618 3072351 255051 187474 269038 0 4684707 3259825 X 185541 3368310 185541 3368310 4870248 6628135 3182769 0 X 1 X 1 X 1 0 X 276671 54794 221877 53261 1998 51263 3811116 2597284 1213832 1486972 DUE TO/FROM MEDICARE 100000 ACCOUNTS RECEIVABLE MISCELLANEOUS 302559 ACCOUNTS RECEIVABLE EL CAMPO EMS 1398 ACCOUNTS RECEIVABLE EL CAMPO LOIUSE SE COOP 12940 416897 X 27480678 -5871396 -5871396 33352074 0 33352074 24297909 0 24297909 5871396 5871396 30169305 PART X, LINE 2: THE HOSPITAL IS NOT-FOR-PROFIT ORGANIZATION THAT IS EXEMPT FROM INCOME TAXES UNDER SECTION 501(C)(3) OF THE INTERNAL REVENUE CODE. THE HOSPITAL EVALUATES AND ACCOUNTS FOR UNCERTAIN TAX POSITIONS IN ACCORDANCE WITH FINANCIAL ACCOUNTING STANDARDS BOARD (FASB) ACCOUNTING STANDARDS CODIFICATION (ASC) 740, INCOME TAXES (FORMERLY FASB INTERPRETATION 48 (FIN 48) ACCOUNTING FOR UNCERTAINTY IN INCOME TAXES. THIS STANDARD REQUIRES CERTAIN DISCLOSURES ABOUT UNCERTAIN INCOME TAX POSITIONS. THE HOSPITAL EVALUATES ANY UNCERTAIN TAX POSITIONS USING THE PROVISIONS OF ASC 450, CONTINGENCIES. AS A RESULT, MANAGEMENT DOES NOT BELIEVE THAT ANY UNCERTAIN TAX POSITIONS CURRENTLY EXIST AND NO LOSS CONTINGENCY HAS BEEN RECOGNIZED IN THE ACCOMPANYING FINANCIAL STATEMENTS. THE HOSPITAL HAS FILED ALL APPLICABLE TAX RETURNS. PART XI, LINE 2D - OTHER ADJUSTMENTS: BAD DEBT EXPENSE -5,871,396. PART XII, LINE 4B - OTHER ADJUSTMENTS: BAD DEBT EXPENSE 5,871,396. 1 1 1 X 1 X 1 1 0 0 649790 0 649790 0.02670 1634008 918884 715124 0.02940 2283798 918884 1364914 0.05610 2283798 918884 1364914 0.05610 1 2970641 1155864 7637736 4342077 3295659 X 1 1 1 1 EL CAMPO MEMORIAL HOSPITAL 303 SANDY CORNER RD EL CAMPO TX 77437 WWW.ECMH.ORG 000426 X X X X EL CAMPO MEMORIAL HOSPITAL 1 0 0 1 X X X X X X X X X 16 1 0 0 1 X WWW.ECMH.ORG X 1 16 1 WWW.ECMH.ORG 0 1 X 150.000000000000 200.000000000000 X X X X X X 1 1 X 1 X X 1 X X 0 1 0 0 EL CAMPO MEMORIAL HOSPITAL PART V, SECTION B, LINE 5: THE COMMUNITY HEALTH NEEDS ASSESSMENT FOR EL CAMPO MEMORIAL HOSPITAL INCLUDED INTERVIEWS/FOCUS GROUPS WITH REPRESENTATIVES OF THE HOSPITAL'S ADMINSTRATIVE STAFF AND BOARD OF DIRECTORS, TEXAS DEPARTMENT OF STATE HEALTH SERVICES, TEXANA CENTER, MEMORIAL HERMANN, KINDRED HOSPTIAL SUGAR LAND, SPJST, BETHANY HOME HEALTH SERVICES, NATIONAL CHURCH RESIDENCES, ANGMAR MEDICAL HOLDINGS, COURT APPOINTED SPECIAL ADVOCATE FOR CHILDREN, ALZHEIMER'S ASSOCIATION AND THE KNIGHTS OF COLUMBUS, AND LOCAL CITIZENS REPRESENTING SENIORS, LOW INCOME HOUSEHOLDS, HISPANIC/LATINOS AND AFRICAN AMERICANS. EL CAMPO MEMORIAL HOSPITAL PART V, SECTION B, LINE 16J: EACH PATIENT APPLYING FOR CHARITY CARE WILL BE ASKED TO COMPLETE AN EL CAMPO MEMORIAL HOSPITAL APPLICATION FOR HEALTH CARE ASSISTANCE ("ASSISTANCE APPLICATION"). ASSISTANCE APPLICATIONS CAN BE REQUESTED FROM THE INDIGENT /CHARITY PROGRAM COORDINATOR AT EL CAMPO MEMORIAL HOSPITAL, 303 SANDY CORNER RD, EL CAMPO, TX 77437, (979) 543-6251 EXTENSION 262. ASSISTANCE APPLICATIONS CAN ALSO BE PICKED UP IN THE HOSPITAL BUSINESS OFFICE AND FROM A MID COAST MEDICAL CLINIC RECEPTIONIST. EL CAMPO MEMORIAL HOSPITAL STAFF MUST GIVE OR MAIL ASSISTANCE APPLICATIONS THE SAME DAY THEY ARE REQUESTED. A BRIEF EXPLANATION, IF POSSIBLE, SHOULD BE GIVEN TO THE APPLICANT EXPLAINING THE PROCESS AND THE APPLICANT'S RESPONSIBILITIES. ASSISTANCE IN COMPLETING THE ASSISTANCE APPLICATION WILL BE PROVIDED IF NEEDED. APPLICANTS SHALL BE INFORMED THAT THEY SHOULD CONTACT THE INDIGENT/CHARITY PROGRAM COORDINATOR AT EL CAMPO MEMORIAL HOSPITAL AT (979) 578-5194. 1 1 - MID COAST MEDICAL CLINIC 305 SANDY CORNER EL CAMPO TX 77437 RURAL HEALTH CLINIC PART I, LINE 3C: EL CAMPO MEMORIAL HOSPITAL SHALL REQUEST THAT THE APPLICANT VERIFY HIS OR HER GROSS ANNUAL HOUSEHOLD INCOME BY SUPPLYING THE FOLLOWING: TAX RETURN AND IRS FORM W-2, WAGE AND EARNINGS STATEMENT, PAY CHECK REMITTANCE, SOCIAL SECURITY, WORKERS COMPENSATION, UNEMPLOYMENT COMPENSATION OR GOVERNMENT PROGRAM DETERMINATION LETTERS, TELEPHONE VERIFICATION BY EMPLOYER OF THE APPLICANT'S ANNUAL GROSS INCOME, AND/OR BANK STATEMENTS. CURRENT ELIGIBILITY BEGINS ON THE FIRST CALENDAR DAY IN THE MONTH THAT AN IDENTIFIABLE APPLICATION IS FILED OR THE EARLIEST, SUBSEQUENT MONTH IN WHICH ALL ELIGIBILITY CRITERIA ARE MET. THE APPLICANT MAY BE RETROACTIVELY ELIGIBLE IN ANY OF THE THREE CALENDAR MONTHS BEFORE THE MONTH THE IDENTIFIABLE APPLICATION IS RECEIVED IF ALL ELIGIBILITY CRITERIA ARE MET. PART I, LINE 7, COLUMN (F): THE BAD DEBT EXPENSE INCLUDED ON FORM 990, PART IX, LINE 25, COLUMN (A), BUT SUBTRACTED FOR PURPOSES OF CALCULATING THE PERCENTAGE IN THIS COLUMN IS $ 5,871,396. PART III, LINE 2: COST TO CHARGE RATIO PART III, LINE 3: COST TO CHARGE RATIO PART III, LINE 4: THE HOSPITAL PROVIDES CARE TO PATIENTS WHO MEET CERTAIN CRITERIA UNDER ITS CHARITY CARE POLICY WITHOUT CHARGE AT AMOUNTS LESS THAN ITS ESTABLISHED RATES. BECAUSE THE HOSPITAL DOES NOT PURSUE COLLECTION OF AMOUNTS DETERMINED TO QUALIFY AS CHARITY CARE, CHARITY CARE IS EXCLUDED FROM NET PATIENT REVENUE.THE VALUE OF CHARITY CARE PROVIDED BY THE HOSPITAL BASED UPON ITS ESTABLISHED RATES, WAS $1,530,078 IN 2015 AND $1,293,492 IN 2014. ASU 2010-23 REQUIRES CHARITY CARE TO BE DISCLOSED ON A COST BASIS. THE HOSPITAL UTILIZES THE COST TO CHARGE RATIO, AS CALCULATED BASED ON ITS MOST RECENT COST REPORTS, TO DETERMINE THE TOTAL COST. THE HOSPITAL'S COST OF PROVIDING CHARITY CARE WAS ESTIMATED AT $858,450 AND $800,703 FOR THE PERIODS ENDING MARCH 31, 2016 AND 2015, RESPECTIVELY.THE EVALUATION OF NECESSITY FOR MEDICAL TREATMENT OF ANY PATIENT WILL BE BASED UPON CLINICAL JUDGMENT REGARDLESS OF THE FINANCIAL STATUS OF THE PATIENT. THE CLINICAL JUDGMENT OF THE PATIENT'S PERSONAL PHYSICIAN OR THE EMERGENCY DEPARTMENT PHYSICIAN WILL BE THE SOLE DETERMINING CRITERION FOR A PATIENT'S ADMISSION TO EL CAMPO MEMORIAL HOSPITAL IN ACCORDANCE WITH THE MEDICAL STAFF BYLAWS. IN CASES WHERE A MEDICAL EMERGENCY CONDITION EXISTS, EL CAMPO MEMORIAL HOSPITAL'S EVALUATION OF POSSIBLE PAYMENT ALTERNATIVES WILL OCCUR ONLY AFTER URGENT MEDICAL CARE EVALUATION AND TREATMENT HAVE BEEN RENDERED IN ACCORDANCE WITH FEDERAL [EMTALA], STATE OR LOCAL LAW. PART III, LINE 8: THE HOSPITAL USES A COST TO CHARGE RATIO CALCULATED THROUGH THE ANNUAL MEDICARE/MEDICAID COST REPORT TO REPORT THE AMOUNT REPRESENTED ON LINE 7. PART III, LINE 9B: THE HOSPITAL DOES NOT PURSUE COLLECTION OF AMOUNTS FROM THOSE WHO ARE KNOWN TO QUALIFY FOR CHARITY CARE. 0 0 0 0 0 0 0 0 0 NATHAN TUDOR CEO 206727 0 0 0 0 0 0 0 0 0 206727 0 0 0 DANA FOSTER PHYSICIAN ASSISTANT 155141 0 0 0 0 0 0 0 0 0 155141 0 0 0 BILL JENKINS DIRECTOR 1028488 BANK ACCOUNT DEPOSITS 0 PART IV BILL JENKINS, A DIRECTOR, IS AN EMPLOYEE/1% OWNER OF FIRST STATE BANK. THE HOSPITAL HOLDS DEPOSITS WITH FIRST STATE BANK. MR. JENKINS ABSTAINS FROM VOITING ON MATTERS RELATING TO FIRST STATE BANK. FORM 990, PART VI, SECTION B, LINE 11B THE HOSPITAL HAS A THIRD-PARTY ACCOUNTING FIRM PREPARE FORM 990. ONCE THE 990 IS COMPLETED IT IS PRESENTED TO THE BOARD OF DIRECTORS IN DRAFT FORM. ANY QUESTIONS OR CONCERNS ARE THEN ADDRESSED, AND THE FINAL FORM 990 IS PREPARED WITH THE NECESSARY ADJUSTMENTS AND FILED. FORM 990, PART VI, SECTION B, LINE 12C EACH DIRECTOR SHALL INDIVIDUALLY DISCLOSE TO EL CAMPO MEMORIAL HOSPITAL AND TO THE BOARD OF DIRECTORS AT THE TIME OF NOMINATION AND APPOINTMENT AND TO THE TEXAS STATE BOARD OF MEDICAL EXAMINERS AT THE TIMES OF INITIAL APPLICATION AND BENNIAL REPORT THE IDENTITY OF EACH FINANCIAL RELATIONSHIP KNOWN TO THE DIRECTOR, IF ANY, WHICH HE OR SHE HAS WITH ANY OTHER DIRECTOR OR ANY SUPPLIER OF THE ORGANIZATION, AND TO PROVIDE A CONCISE EXPLANATION OF THE NATURE OF EACH SUCH FINANCIAL RELATIONSHIP. FORM 990, PART VI, SECTION B, LINE 15A THE PROCESS FOR DETERMINING COMPENSATION FOR EL CAMPO MEMORIAL HOSPITAL'S CEO INCLUDES AN ANNUAL REVIEW AND APPROVAL BY THE BOARD OF DIRECTORS, COMPARABILITY DATA FOR SIMILAR HOSPITALS AND HOSPITAL ORGANIZATIONS IN NEARBY COMMUNITIES OR SIMILAR ECONOMIES OF SCALE, AND CONTEMPORANEOUS DOCUMENTATION OF THE DELIBERATION AND DISCUSSION BETWEEN THE HOSPITAL AND ITS ADMINISTRATOR. FORM 990, PART VI, SECTION C, LINE 19 THE HOSPITAL DOES NOT MAKE ITS GOVERNING DOCUMENTS, CONFLICT OF INTEREST POLICY, AND FINANCIAL STATEMENTS AVAILABLE TO THE PUBLIC. FORM 990, PART IX, LINE 11G OTHER PROFESSIONAL FEES: PROGRAM SERVICE EXPENSES 5,149,131. MANAGEMENT AND GENERAL EXPENSES 545,901. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 5,695,032.