POWELL VALLEY HEALTH CARE INC: Form 990, tax year 2016
View the entire original 990 at ProPublica ↗
- Organization
- POWELL VALLEY HEALTH CARE INC (EIN 83-0300467)
- Tax period
- 2016-07-01 to 2017-06-30
- Filed
- 2018-05-15
- IRS object ID
- 201811359349302431
- Schema version
- 2016v3.0
- Source
- Download XML · Original 990 at ProPublica
Every field in the e-filed return. Faint text is the IRS element name, for citing.
- Return header
- Form 990
- Schedule A
- Schedule B
- Schedule D
- Schedule H
- Schedule I
- Schedule J
- Schedule L
- Schedule O
- Schedule R
Return header ReturnHeader
| Field | Value | IRS element (for citing) |
|---|---|---|
| Return | 2018-05-15T09:16:25-05:00 | ReturnTs |
| Tax Period End | 2017-06-30 | TaxPeriodEndDt |
Preparer Firm PreparerFirmGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Preparer Firm EIN | 460403496 | PreparerFirmEIN |
Preparer Firm Name PreparerFirmName
| Field | Value | IRS element (for citing) |
|---|---|---|
| Business Name Line1 | CASEY PETERSON LTD | BusinessNameLine1Txt |
Preparer US Address PreparerUSAddress
| Field | Value | IRS element (for citing) |
|---|---|---|
| Address Line1 | 909 ST JOSEPH ST SUITE 101 | AddressLine1Txt |
| City | RAPID CITY | CityNm |
| State Abbreviation | SD | StateAbbreviationCd |
| ZIP | 57701 | ZIPCd |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Return Type | 990 | ReturnTypeCd |
| Tax Period Begin | 2016-07-01 | TaxPeriodBeginDt |
Filer Filer
| Field | Value | IRS element (for citing) |
|---|---|---|
| EIN | 830300467 | EIN |
Business Name BusinessName
| Field | Value | IRS element (for citing) |
|---|---|---|
| Business Name Line1 | POWELL VALLEY HEALTH CARE INC | BusinessNameLine1Txt |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Business Name Control | POWE | BusinessNameControlTxt |
| Phone | 3077542267 | PhoneNum |
US Address USAddress
| Field | Value | IRS element (for citing) |
|---|---|---|
| Address Line1 | 777 AVENUE H | AddressLine1Txt |
| City | POWELL | CityNm |
| State Abbreviation | WY | StateAbbreviationCd |
| ZIP | 82435 | ZIPCd |
Business Officer BusinessOfficerGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Person | TERRY ODOM | PersonNm |
| Person Title | CEO | PersonTitleTxt |
| Phone | 3077542267 | PhoneNum |
| Signature | 2018-05-15 | SignatureDt |
| Discuss With Paid Preparer | Yes (1) | DiscussWithPaidPreparerInd |
Preparer Person PreparerPersonGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Preparer Person | DEIDRE BUDAHL CPA | PreparerPersonNm |
| PTIN | P01273830 | PTIN |
| Phone | 6053481930 | PhoneNum |
| Preparation | 2018-05-15 | PreparationDt |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Tax | 2016 | TaxYr |
| Build TS | 2022-09-23 18:48:47Z | BuildTS |
Form 990 IRS990
Doing Business As Name DoingBusinessAsName
| Field | Value | IRS element (for citing) |
|---|---|---|
| Business Name Line1 | POWELL VALLEY HOSPITAL | BusinessNameLine1Txt |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Principal Officer | TERRY ODOM | PrincipalOfficerNm |
US Address USAddress
| Field | Value | IRS element (for citing) |
|---|---|---|
| Address Line1 | 777 AVENUE H | AddressLine1Txt |
| City | POWELL | CityNm |
| State Abbreviation | WY | StateAbbreviationCd |
| ZIP | 82435 | ZIPCd |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Gross Receipts | $48,450,420 | GrossReceiptsAmt |
| Group Return For Affiliates | 0 | GroupReturnForAffiliatesInd |
| Organization501c3 | Yes (X) | Organization501c3Ind |
| Website Address | WWW.PVHC.ORG | WebsiteAddressTxt |
| Type Of Organization Corp | Yes (X) | TypeOfOrganizationCorpInd |
| Formation | 1992 | FormationYr |
| Legal Domicile State | WY | LegalDomicileStateCd |
| Activity Or Mission | PROVISION OF HEALTHCARE SERVICES | ActivityOrMissionDesc |
| Voting Members Governing Body | 10 | VotingMembersGoverningBodyCnt |
| Voting Members Independent | 8 | VotingMembersIndependentCnt |
| Total Employee | 536 | TotalEmployeeCnt |
| Total Volunteers | 100 | TotalVolunteersCnt |
| Total Gross UBI | $0 | TotalGrossUBIAmt |
| Net Unrelated Bus Txbl Incm | $0 | NetUnrelatedBusTxblIncmAmt |
| PY Contributions Grants | $959,643 | PYContributionsGrantsAmt |
| CY Contributions Grants | $707,275 | CYContributionsGrantsAmt |
| PY Program Service Revenue | $47,421,056 | PYProgramServiceRevenueAmt |
| CY Program Service Revenue | $47,649,664 | CYProgramServiceRevenueAmt |
| PY Investment Income | $39,119 | PYInvestmentIncomeAmt |
| CY Investment Income | $68,181 | CYInvestmentIncomeAmt |
| PY Other Revenue | $21,900 | PYOtherRevenueAmt |
| CY Other Revenue | $25,300 | CYOtherRevenueAmt |
| PY Total Revenue | $48,441,718 | PYTotalRevenueAmt |
| CY Total Revenue | $48,450,420 | CYTotalRevenueAmt |
| PY Grants And Similar Paid | $19,699 | PYGrantsAndSimilarPaidAmt |
| CY Grants And Similar Paid | $30,750 | CYGrantsAndSimilarPaidAmt |
| PY Benefits Paid To Members | $0 | PYBenefitsPaidToMembersAmt |
| CY Benefits Paid To Members | $0 | CYBenefitsPaidToMembersAmt |
| PY Salaries Comp Emp Bnft Paid | $30,098,111 | PYSalariesCompEmpBnftPaidAmt |
| CY Salaries Comp Emp Bnft Paid | $30,765,107 | CYSalariesCompEmpBnftPaidAmt |
| PY Total Prof Fndrsng Expns | $0 | PYTotalProfFndrsngExpnsAmt |
| CY Total Prof Fndrsng Expns | $0 | CYTotalProfFndrsngExpnsAmt |
| CY Total Fundraising Expense | $0 | CYTotalFundraisingExpenseAmt |
| PY Other Expenses | $18,852,606 | PYOtherExpensesAmt |
| CY Other Expenses | $16,109,803 | CYOtherExpensesAmt |
| PY Total Expenses | $48,970,416 | PYTotalExpensesAmt |
| CY Total Expenses | $46,905,660 | CYTotalExpensesAmt |
| PY Revenues Less Expenses | -$528,698 | PYRevenuesLessExpensesAmt |
| CY Revenues Less Expenses | $1,544,760 | CYRevenuesLessExpensesAmt |
| Total Assets BOY | $28,550,737 | TotalAssetsBOYAmt |
| Total Assets EOY | $28,928,238 | TotalAssetsEOYAmt |
| Total Liabilities BOY | $19,274,479 | TotalLiabilitiesBOYAmt |
| Total Liabilities EOY | $18,107,220 | TotalLiabilitiesEOYAmt |
| Net Assets Or Fund Balances BOY | $9,276,258 | NetAssetsOrFundBalancesBOYAmt |
| Net Assets Or Fund Balances EOY | $10,821,018 | NetAssetsOrFundBalancesEOYAmt |
| Info In Schedule O Part III | Yes (X) | InfoInScheduleOPartIIIInd |
| Mission | TO IMPROVE QUALITY OF LIFE THROUGH EXCELLENT HEALTHCARE. | MissionDesc |
| Significant New Program Srvc | 0 | SignificantNewProgramSrvcInd |
| Significant Change | 0 | SignificantChangeInd |
| Expense | $39,013,165 | ExpenseAmt |
| Grant | $30,750 | GrantAmt |
| Revenue | $47,674,964 | RevenueAmt |
| Desc | POWELL VALLEY HEALTH CARE, INC. (HOSPITAL) PROVIDES QUALITY CARE REGARDLESS OF RACE, CREED, SEX, NATIONAL ORIGIN, HANDICAP, AGE, OR ABILITY TO PAY. ALTHOUGH REIMBURSEMENT FOR SERVICES RENDERED IS CRITICAL TO THE OPERATION OF THE HOSPITAL, IT IS RECOGNIZED THAT NOT ALL INDIVIDUALS POSSESS THE ABILITY TO PURCHASE THESE ESSENTIAL SERVICES. IT IS THE HOSPITAL'S MISSION TO SERVE THE SURROUNDING AREA BY PROVIDING HEALTH CARE SERVICES AND HEALTH CARE EDUCATION TO ALL COMMUNITY MEMBERS. DURING THE YEAR ENDED JUNE 30, 2017, THE HOSPITAL PROVIDED $591,896 OF MEDICAL SERVICES, BASED ON THE AMOUNTS OF CHARGES FOREGONE, UNDER THE HOSPITAL'S CHARITY CARE POLICY AND GUIDELINES TO INDIVIDUALS WHO WERE DETERMINED UNABLE TO PURCHASE SUCH SERVICES. IN ADDITION TO FREE CARE AND/OR SUBSIDIZED CARE, CARE IS ALSO PROVIDED AT BELOW COST RATES TO PERSONS COVERED BY GOVERNMENTAL PROGRAMS. RECOGNIZING ITS MISSION TO THE COMMUNITY, SERVICES ARE PROVIDED TO BOTH MEDICARE AND MEDICAID PATIENTS. THE UNREIMBURSED VALUE (based on cost) OF PROVIDING CARE TO ALL PATIENTS WAS $5,035,098 FOR THE YEAR ENDED JUNE 30, 2017. DURING THE FISCAL YEAR ENDED JUNE 30, 2017, THE HOSPITAL PROVIDED 2,397 DAYS OF HOSPITAL SERVICES. THE NURsiNG HOME PROVIDED 31,558 DAYS OF RESIDENT SERVICES, AND THE ASSISTED LIVING FACILITY PROVIDED 9,072 DAYS OF RESIDENT SERVICES DURING THE YEAR. THE HOSPITAL ALSO provides community care and services through many health activities and programs provided to support the community. these activities include support to the heart mountain volunteer medical clinic, HERITAGE HEALTH CENTER CLINIC, A COMMUNITY HEALTH CENTER FQHC, WELLNESS PROGRAM, COMMUNITY EDUCATION PROGRAM, SPECIAL PROGRAMS FOR SPECIFIC PURPOSES, AND A VARIETY OF COMMUNITY SUPPORTED ACTIVITIES. | Desc |
| Total Program Service Expenses | $39,013,165 | TotalProgramServiceExpensesAmt |
| Described In Section501c3 | Yes (1) | DescribedInSection501c3Ind |
| Schedule B Required | Yes (1) | ScheduleBRequiredInd |
| Political Campaign Acty | 0 | PoliticalCampaignActyInd |
| Lobbying Activities | 0 | LobbyingActivitiesInd |
| Subject To Proxy Tax | 0 | SubjectToProxyTaxInd |
| Donor Advised Fund | 0 | DonorAdvisedFundInd |
| Conservation Easements | 0 | ConservationEasementsInd |
| Collections Of Art | 0 | CollectionsOfArtInd |
| Credit Counseling | Yes (1) | CreditCounselingInd |
| Temp Or Permanent Endowments | 0 | TempOrPermanentEndowmentsInd |
| Report Land Building Equipment | Yes (1) | ReportLandBuildingEquipmentInd |
| Report Investments Other Sec | 0 | ReportInvestmentsOtherSecInd |
| Report Program Related Invst | 0 | ReportProgramRelatedInvstInd |
| Report Other Assets | Yes (1) | ReportOtherAssetsInd |
| Report Other Liabilities | 0 | ReportOtherLiabilitiesInd |
| Include FIN48 Footnote | Yes (1) | IncludeFIN48FootnoteInd |
| Independent Audit Fincl Stmt | 0 | IndependentAuditFinclStmtInd |
| Consolidated Audit Fincl Stmt | Yes (1) | ConsolidatedAuditFinclStmtInd |
| School Operating | 0 | SchoolOperatingInd |
| Foreign Office | 0 | ForeignOfficeInd |
| Foreign Activities | 0 | ForeignActivitiesInd |
| More Than5000 K To Org | 0 | MoreThan5000KToOrgInd |
| More Than5000 K To Individuals | 0 | MoreThan5000KToIndividualsInd |
| Professional Fundraising | 0 | ProfessionalFundraisingInd |
| Fundraising Activities | 0 | FundraisingActivitiesInd |
| Gaming Activities | 0 | GamingActivitiesInd |
| Operate Hospital | Yes (1) | OperateHospitalInd |
| Audited Financial Stmt Att | Yes (1) | AuditedFinancialStmtAttInd |
| Grants To Organizations | 0 | GrantsToOrganizationsInd |
| Grants To Individuals | Yes (1) | GrantsToIndividualsInd |
| Schedule J Required | Yes (1) | ScheduleJRequiredInd |
| Tax Exempt Bonds | 0 | TaxExemptBondsInd |
| Engaged In Excess Benefit Trans | 0 | EngagedInExcessBenefitTransInd |
| PY Excess Benefit Trans | 0 | PYExcessBenefitTransInd |
| Loan Outstanding | Yes (1) | LoanOutstandingInd |
| Grant To Related Person | 0 | GrantToRelatedPersonInd |
| Business Rln With Org Mem | 0 | BusinessRlnWithOrgMemInd |
| Business Rln With Fam Mem | Yes (1) | BusinessRlnWithFamMemInd |
| Business Rln With Officer Ent | 0 | BusinessRlnWithOfficerEntInd |
| Deductible Non Cash Contri | 0 | DeductibleNonCashContriInd |
| Deductible Art Contribution | 0 | DeductibleArtContributionInd |
| Terminate Operations | 0 | TerminateOperationsInd |
| Partial Liquidation | 0 | PartialLiquidationInd |
| Disregarded Entity | 0 | DisregardedEntityInd |
| Related Entity | Yes (1) | RelatedEntityInd |
| Related Organization Ctrl Ent | Yes (1) | RelatedOrganizationCtrlEntInd |
| Transaction With Control Ent | 0 | TransactionWithControlEntInd |
| Trnsfr Exmpt Non Chrtbl Rltd Org | 0 | TrnsfrExmptNonChrtblRltdOrgInd |
| Activities Conducted Prtshp | 0 | ActivitiesConductedPrtshpInd |
| Schedule O Required | Yes (1) | ScheduleORequiredInd |
| IRP Document | 20 | IRPDocumentCnt |
| IRP Document W2 G | 0 | IRPDocumentW2GCnt |
| Backup Wthld Compliance | Yes (1) | BackupWthldComplianceInd |
| Employee | 536 | EmployeeCnt |
| Employment Tax Returns Filed | Yes (1) | EmploymentTaxReturnsFiledInd |
| Unrelated Bus Incm Over Limit | 0 | UnrelatedBusIncmOverLimitInd |
| Foreign Financial Account | 0 | ForeignFinancialAccountInd |
| Prohibited Tax Shelter Trans | 0 | ProhibitedTaxShelterTransInd |
| Taxable Party Notification | 0 | TaxablePartyNotificationInd |
| Nondeductible Contributions | 0 | NondeductibleContributionsInd |
| Quid Pro Quo Contributions | 0 | QuidProQuoContributionsInd |
| Form8282 Property Disposed Of | 0 | Form8282PropertyDisposedOfInd |
| Rcv Fnds To Pay Prsnl Bnft Cntrct | 0 | RcvFndsToPayPrsnlBnftCntrctInd |
| Pay Premiums Prsnl Bnft Cntrct | 0 | PayPremiumsPrsnlBnftCntrctInd |
| Indoor Tanning Services | 0 | IndoorTanningServicesInd |
| Info In Schedule O Part VI | Yes (X) | InfoInScheduleOPartVIInd |
| Governing Body Voting Members | 10 | GoverningBodyVotingMembersCnt |
| Independent Voting Member | 8 | IndependentVotingMemberCnt |
| Family Or Business Rln | 0 | FamilyOrBusinessRlnInd |
| Delegation Of Mgmt Duties | Yes (1) | DelegationOfMgmtDutiesInd |
| Change To Org Documents | 0 | ChangeToOrgDocumentsInd |
| Material Diversion Or Misuse | 0 | MaterialDiversionOrMisuseInd |
| Members Or Stockholders | 0 | MembersOrStockholdersInd |
| Election Of Board Members | Yes (1) | ElectionOfBoardMembersInd |
| Decisions Subject To Approva | Yes (1) | DecisionsSubjectToApprovaInd |
| Minutes Of Governing Body | Yes (1) | MinutesOfGoverningBodyInd |
| Minutes Of Committees | Yes (1) | MinutesOfCommitteesInd |
| Officer Mailing Address | 0 | OfficerMailingAddressInd |
| Local Chapters | 0 | LocalChaptersInd |
| Form990 Provided To Gvrn Body | Yes (1) | Form990ProvidedToGvrnBodyInd |
| Conflict Of Interest Policy | Yes (1) | ConflictOfInterestPolicyInd |
| Annual Disclosure Covered Prsn | Yes (1) | AnnualDisclosureCoveredPrsnInd |
| Regular Monitoring Enfrc | Yes (1) | RegularMonitoringEnfrcInd |
| Whistleblower Policy | Yes (1) | WhistleblowerPolicyInd |
| Document Retention Policy | Yes (1) | DocumentRetentionPolicyInd |
| Compensation Process CEO | 0 | CompensationProcessCEOInd |
| Compensation Process Other | 0 | CompensationProcessOtherInd |
| Investment In Joint Venture | 0 | InvestmentInJointVentureInd |
| Upon Request | Yes (X) | UponRequestInd |
Books In Care Of Detail BooksInCareOfDetail
Business Name BusinessName
| Field | Value | IRS element (for citing) |
|---|---|---|
| Business Name Line1 | THE ORGANIZATION | BusinessNameLine1Txt |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Phone | 3077542267 | PhoneNum |
US Address USAddress
| Field | Value | IRS element (for citing) |
|---|---|---|
| Address Line1 | 777 AVENUE H | AddressLine1Txt |
| City | POWELL | CityNm |
| State Abbreviation | WY | StateAbbreviationCd |
| ZIP | 82435 | ZIPCd |
Form990 Part VII Section A Form990PartVIISectionAGrp (18 entries)
| TitleTitleTxt | Average Hours Per WeekAverageHoursPerWeekRt | Average Hours Per Week Rltd OrgAverageHoursPerWeekRltdOrgRt | Individual Trustee Or DirectorIndividualTrusteeOrDirectorInd | OfficerOfficerInd | Reportable Comp From OrgReportableCompFromOrgAmt | Reportable Comp From Rltd OrgReportableCompFromRltdOrgAmt | Other CompensationOtherCompensationAmt | Highest Compensated EmployeeHighestCompensatedEmployeeInd |
|---|---|---|---|---|---|---|---|---|
| RJ KOST | ||||||||
| PRESIDENT | 1.00 | 1.00 | Yes (X) | Yes (X) | $0 | $0 | $0 | |
| DEB KLEINFELDT | ||||||||
| VICE PRESIDENT | 1.00 | 1.00 | Yes (X) | Yes (X) | $0 | $0 | $0 | |
| LARRY PARKER | ||||||||
| TREASUREr | 1.00 | 1.00 | Yes (X) | Yes (X) | $0 | $0 | $0 | |
| BONITA KATZ | ||||||||
| SECRETAry | 1.00 | 1.00 | Yes (X) | Yes (X) | $0 | $0 | $0 | |
| JIM CARLSON | ||||||||
| DIRECTOr | 1.00 | 1.00 | Yes (X) | $0 | $0 | $0 | ||
| BETH GILB | ||||||||
| DIRECTOr | 1.00 | 1.00 | Yes (X) | $0 | $0 | $0 | ||
| GERRI ACKLEY | ||||||||
| DIRECTOR | 1.00 | 1.00 | Yes (X) | $0 | $0 | $0 | ||
| WILLIAM JARVIS MD | ||||||||
| DIRECTOR/PHYSICIAN | 40.00 | Yes (X) | $1,119,133 | $0 | $25,799 | |||
| JACOB MERRELL MD | ||||||||
| DIRECTOR | 40.00 | Yes (X) | $0 | $0 | $0 | |||
| NATHANIEL RIEB | ||||||||
| PHYSICIAN - CHIEF OF STAFF | 40.00 | Yes (X) | $435,162 | $0 | $25,799 | |||
| PAUL LAVEAU | ||||||||
| Physician | 40.00 | $433,271 | $0 | $7,950 | Yes (X) | |||
| KELLY CHRISTENSEN | ||||||||
| PHYSICIAN | 40.00 | $406,699 | $0 | $25,799 | Yes (X) | |||
| JENKINS CLARKSON | ||||||||
| PHYSICIAN | 40.00 | $397,988 | $0 | $17,849 | Yes (X) | |||
| Michael Bohlman | ||||||||
| Physician | 40.00 | $318,314 | $0 | $25,799 | Yes (X) | |||
| ANDREW BAKER | ||||||||
| CRNA | 40.00 | $410,056 | $0 | $25,799 | Yes (X) | |||
| RYAN SHEDD | ||||||||
| CRNA | 40.00 | $423,091 | $0 | $25,799 | Yes (X) | |||
| BRADLEY NORTH | ||||||||
| PHYSICIAN | 40.00 | $349,132 | $0 | $27,799 | Yes (X) | |||
| KURT PETTIPIECE | ||||||||
| PHYSICIAN | 40.00 | $334,761 | $0 | $19,805 | Yes (X) | |||
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Reportable Comp From Org | $4,627,607 | TotalReportableCompFromOrgAmt |
| Tot Reportable Comp Rltd Org | $0 | TotReportableCompRltdOrgAmt |
| Total Other Compensation | $228,197 | TotalOtherCompensationAmt |
| Indiv Rcvd Greater Than100 K | 10 | IndivRcvdGreaterThan100KCnt |
| Former Ofcr Employees Listed | 0 | FormerOfcrEmployeesListedInd |
| Total Comp Greater Than150 K | Yes (1) | TotalCompGreaterThan150KInd |
| Compensation From Other Srcs | 0 | CompensationFromOtherSrcsInd |
Contractor Compensation ContractorCompensationGrp (5 entries)
| Address Line1ContractorAddress/USAddress/AddressLine1Txt | CityContractorAddress/USAddress/CityNm | State AbbreviationContractorAddress/USAddress/StateAbbreviationCd | ZIPContractorAddress/USAddress/ZIPCd | ServicesServicesDesc | CompensationCompensationAmt |
|---|---|---|---|---|---|
| NORTH PLATTE PHYSICAL INC | |||||
| PO BOX 1790 | DOUGLAS | WY | 82633 | PHYSICAL THERAPY | $1,206,924 |
| Health Tech MANAGEMENT | |||||
| 5110 Maryland Way STE 20 | BRENTWOOD | TN | 37027 | MANAGEMENT SERVICES | $675,571 |
| MARKUS WILLIAMS YOUNG AND ZIMMERMAN | |||||
| 106 Lincolnway | CHEYENNE | WY | 82001 | LEGAL SERVICES | $376,003 |
| SPENCER FANE LLP | |||||
| PO Box 872037 | KANSAS CITY | MO | 64187 | LEGAL SERVICES | $262,257 |
| QUEST DIAGNOSTICS INC | |||||
| PO Box 14730 | ST LOUIS | MO | 63150 | LAB SERVICES | $201,394 |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Cntrct Rcvd Greater Than100 K | 12 | CntrctRcvdGreaterThan100KCnt |
| Related Organizations | $166,999 | RelatedOrganizationsAmt |
| All Other Contributions | $540,276 | AllOtherContributionsAmt |
| Total Contributions | $707,275 | TotalContributionsAmt |
Program Service Revenue ProgramServiceRevenueGrp (4 entries)
| DescDesc | BusinessBusinessCd | Total Revenue ColumnTotalRevenueColumnAmt | Related Or Exempt Func IncomeRelatedOrExemptFuncIncomeAmt |
|---|---|---|---|
| PATIENT SERVICE REVENUE | 621110 | $46,623,853 | $46,623,853 |
| PHARMACY CONTRACT REVENUE | 446110 | $724,452 | $724,452 |
| CAFETERIA | 722210 | $151,298 | $151,298 |
| OTHER INCOME | 900099 | $150,061 | $150,061 |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Program Service Revenue | $47,649,664 | TotalProgramServiceRevenueAmt |
Investment Income InvestmentIncomeGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Revenue Column | $68,181 | TotalRevenueColumnAmt |
| Exclusion | $68,181 | ExclusionAmt |
Gross Rents GrossRentsGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Real | $25,300 | RealAmt |
Less Rental Expenses LessRentalExpensesGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Real | $0 | RealAmt |
Rental Income Or Loss RentalIncomeOrLossGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Real | $25,300 | RealAmt |
Net Rental Income Or Loss NetRentalIncomeOrLossGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Revenue Column | $25,300 | TotalRevenueColumnAmt |
| Related Or Exempt Func Income | $25,300 | RelatedOrExemptFuncIncomeAmt |
Total Revenue TotalRevenueGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Revenue Column | $48,450,420 | TotalRevenueColumnAmt |
| Related Or Exempt Func Income | $47,674,964 | RelatedOrExemptFuncIncomeAmt |
| Unrelated Business Revenue | $0 | UnrelatedBusinessRevenueAmt |
| Exclusion | $68,181 | ExclusionAmt |
Grants To Domestic Individuals GrantsToDomesticIndividualsGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $30,750 | TotalAmt |
| Program Services | $30,750 | ProgramServicesAmt |
Comp Current Ofcr Directors CompCurrentOfcrDirectorsGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $4,855,806 | TotalAmt |
| Program Services | $4,855,806 | ProgramServicesAmt |
Other Salaries And Wages OtherSalariesAndWagesGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $19,610,001 | TotalAmt |
| Program Services | $16,996,748 | ProgramServicesAmt |
| Management And General | $2,613,253 | ManagementAndGeneralAmt |
Pension Plan Contributions PensionPlanContributionsGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $336,044 | TotalAmt |
| Program Services | $294,698 | ProgramServicesAmt |
| Management And General | $41,346 | ManagementAndGeneralAmt |
Other Employee Benefits OtherEmployeeBenefitsGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $4,470,244 | TotalAmt |
| Program Services | $3,824,584 | ProgramServicesAmt |
| Management And General | $645,660 | ManagementAndGeneralAmt |
Payroll Taxes PayrollTaxesGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $1,493,012 | TotalAmt |
| Program Services | $1,309,479 | ProgramServicesAmt |
| Management And General | $183,533 | ManagementAndGeneralAmt |
Fees For Services Management FeesForServicesManagementGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $275,393 | TotalAmt |
| Management And General | $275,393 | ManagementAndGeneralAmt |
Fees For Services Legal FeesForServicesLegalGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $1,049,653 | TotalAmt |
| Management And General | $1,049,653 | ManagementAndGeneralAmt |
Fees For Services Accounting FeesForServicesAccountingGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $57,337 | TotalAmt |
| Management And General | $57,337 | ManagementAndGeneralAmt |
Fees For Services Other FeesForServicesOtherGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $3,381,807 | TotalAmt |
| Program Services | $2,653,699 | ProgramServicesAmt |
| Management And General | $728,108 | ManagementAndGeneralAmt |
Advertising AdvertisingGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $215,143 | TotalAmt |
| Program Services | $165,604 | ProgramServicesAmt |
| Management And General | $49,539 | ManagementAndGeneralAmt |
Office Expenses OfficeExpensesGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $476,586 | TotalAmt |
| Program Services | $297,544 | ProgramServicesAmt |
| Management And General | $179,042 | ManagementAndGeneralAmt |
Information Technology InformationTechnologyGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $547,567 | TotalAmt |
| Program Services | $105,859 | ProgramServicesAmt |
| Management And General | $441,708 | ManagementAndGeneralAmt |
Occupancy OccupancyGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $1,522,976 | TotalAmt |
| Program Services | $943,968 | ProgramServicesAmt |
| Management And General | $579,008 | ManagementAndGeneralAmt |
Travel TravelGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $161,052 | TotalAmt |
| Program Services | $86,430 | ProgramServicesAmt |
| Management And General | $74,622 | ManagementAndGeneralAmt |
Interest InterestGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $67,400 | TotalAmt |
| Program Services | $67,400 | ProgramServicesAmt |
Depreciation Depletion DepreciationDepletionGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $741,298 | TotalAmt |
| Program Services | $672,259 | ProgramServicesAmt |
| Management And General | $69,039 | ManagementAndGeneralAmt |
Insurance InsuranceGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $646,618 | TotalAmt |
| Program Services | $108 | ProgramServicesAmt |
| Management And General | $646,510 | ManagementAndGeneralAmt |
Other Expenses OtherExpensesGrp (4 entries)
| DescDesc | TotalTotalAmt | Program ServicesProgramServicesAmt | Management And GeneralManagementAndGeneralAmt |
|---|---|---|---|
| MEDICAL SUPPLIES | $3,919,384 | $3,919,384 | |
| PROVISION FOR BAD DEBTS | $1,678,630 | $1,678,630 | |
| REPAIRS AND MAINTENANCE | $693,428 | $570,979 | $122,449 |
| FOOD | $474,330 | $474,330 |
All Other Expenses AllOtherExpensesGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $201,201 | TotalAmt |
| Program Services | $64,906 | ProgramServicesAmt |
| Management And General | $136,295 | ManagementAndGeneralAmt |
Total Functional Expenses TotalFunctionalExpensesGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $46,905,660 | TotalAmt |
| Program Services | $39,013,165 | ProgramServicesAmt |
| Management And General | $7,892,495 | ManagementAndGeneralAmt |
| Fundraising | $0 | FundraisingAmt |
Cash Non Interest Bearing CashNonInterestBearingGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $4,228,022 | BOYAmt |
| EOY | $5,684,271 | EOYAmt |
Accounts Receivable AccountsReceivableGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $8,273,163 | BOYAmt |
| EOY | $7,555,987 | EOYAmt |
Receivables From Officers Etc ReceivablesFromOfficersEtcGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $30,000 | BOYAmt |
| EOY | $24,394 | EOYAmt |
Oth Notes Loans Receivable Net OthNotesLoansReceivableNetGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $136,129 | BOYAmt |
| EOY | $109,231 | EOYAmt |
Inventories For Sale Or Use InventoriesForSaleOrUseGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $759,144 | BOYAmt |
| EOY | $767,479 | EOYAmt |
Prepaid Expenses Defrd Charges PrepaidExpensesDefrdChargesGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $900,249 | BOYAmt |
| EOY | $815,552 | EOYAmt |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Land Bldg Equip Cost Or Other Bss | $10,785,740 | LandBldgEquipCostOrOtherBssAmt |
| Land Bldg Equip Accum Deprec | $9,042,311 | LandBldgEquipAccumDeprecAmt |
Land Bldg Equip Basis Net LandBldgEquipBasisNetGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $2,393,319 | BOYAmt |
| EOY | $1,743,429 | EOYAmt |
Other Assets Total OtherAssetsTotalGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $11,830,711 | BOYAmt |
| EOY | $12,227,895 | EOYAmt |
Total Assets TotalAssetsGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $28,550,737 | BOYAmt |
| EOY | $28,928,238 | EOYAmt |
Accounts Payable Accr Expnss AccountsPayableAccrExpnssGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $17,078,521 | BOYAmt |
| EOY | $16,581,302 | EOYAmt |
Escrow Account Liability EscrowAccountLiabilityGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $9,315 | BOYAmt |
| EOY | $6,365 | EOYAmt |
Mortg Notes Pybl Scrd Invst Prop MortgNotesPyblScrdInvstPropGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $2,186,643 | BOYAmt |
| EOY | $1,519,553 | EOYAmt |
Total Liabilities TotalLiabilitiesGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $19,274,479 | BOYAmt |
| EOY | $18,107,220 | EOYAmt |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Organization Follows SFAS117 | Yes (X) | OrganizationFollowsSFAS117Ind |
Unrestricted Net Assets UnrestrictedNetAssetsGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $9,276,258 | BOYAmt |
| EOY | $10,821,018 | EOYAmt |
Total Net Assets Fund Balance TotalNetAssetsFundBalanceGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $9,276,258 | BOYAmt |
| EOY | $10,821,018 | EOYAmt |
Tot Liab Net Assets Fund Balance TotLiabNetAssetsFundBalanceGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $28,550,737 | BOYAmt |
| EOY | $28,928,238 | EOYAmt |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Reconcilation Revenue Expnss | $1,544,760 | ReconcilationRevenueExpnssAmt |
| Other Changes In Net Assets | $0 | OtherChangesInNetAssetsAmt |
| Info In Schedule O Part XII | Yes (X) | InfoInScheduleOPartXIIInd |
| Method Of Accounting Accrual | Yes (X) | MethodOfAccountingAccrualInd |
| Accountant Compile Or Review | 0 | AccountantCompileOrReviewInd |
| FS Audited | Yes (1) | FSAuditedInd |
FS Audited Basis FSAuditedBasisGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Consolidated Basis Fincl Stmt | Yes (X) | ConsolidatedBasisFinclStmtInd |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Audit Committee | Yes (1) | AuditCommitteeInd |
| Federal Grant Audit Required | 0 | FederalGrantAuditRequiredInd |
Schedule A IRS990ScheduleA
| Field | Value | IRS element (for citing) |
|---|---|---|
| Hospital | Yes (X) | HospitalInd |
Schedule B IRS990ScheduleB
Contributor Information ContributorInformationGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Contributor | RESTRICTED | ContributorNum |
Contributor Business Name ContributorBusinessName
| Field | Value | IRS element (for citing) |
|---|---|---|
| Business Name Line1 | RESTRICTED | BusinessNameLine1 |
Contributor US Address ContributorUSAddress
| Field | Value | IRS element (for citing) |
|---|---|---|
| Address Line1 | RESTRICTED | AddressLine1 |
| Address Line2 | RESTRICTED | AddressLine2 |
| City | RESTRICTED | City |
| State | RESTRICTED | State |
| ZIP Code | RESTRICTED | ZIPCode |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Contributions | RESTRICTED | TotalContributionsAmt |
Schedule D IRS990ScheduleD
| Field | Value | IRS element (for citing) |
|---|---|---|
| Agent Trustee Etc | Yes (1) | AgentTrusteeEtcInd |
| Beginning Balance | $12,957 | BeginningBalanceAmt |
| Additions During Year | $44,637 | AdditionsDuringYearAmt |
| Distributions During Year | $33,383 | DistributionsDuringYearAmt |
| Ending Balance | $24,211 | EndingBalanceAmt |
| Incl Escrow Custodial Acct Liab | Yes (1) | InclEscrowCustodialAcctLiabInd |
| Explanation Provided | Yes (X) | ExplanationProvidedInd |
Leasehold Improvements LeaseholdImprovementsGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Other Cost Or Other Basis | $677,371 | OtherCostOrOtherBasisAmt |
| Depreciation | $426,995 | DepreciationAmt |
| Book Value | $250,376 | BookValueAmt |
Equipment EquipmentGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Other Cost Or Other Basis | $10,108,369 | OtherCostOrOtherBasisAmt |
| Depreciation | $8,615,316 | DepreciationAmt |
| Book Value | $1,493,053 | BookValueAmt |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Book Value Land Buildings | $1,743,429 | TotalBookValueLandBuildingsAmt |
Other Assets Org OtherAssetsOrgGrp (2 entries)
| DescDesc | Book ValueBookValueAmt |
|---|---|
| Insurance Recoveries Receivable | $11,450,000 |
| Estimated third party settlements | $777,895 |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Book Value Other Assets | $12,227,895 | TotalBookValueOtherAssetsAmt |
| Footnote Text | Yes (X) | FootnoteTextInd |
Supplemental Information Detail SupplementalInformationDetail (3 entries)
| Form And Line ReferenceFormAndLineReferenceDesc | ExplanationExplanationTxt |
|---|---|
| Part IV, Line 1b: | THE ORGANIZATION IS ACTING AS AN AGENCY FOR THE PVHC AUXILIARY |
| Part IV, Line 2b: | THE ORGANIZATION HOLDS FUNDS IN TRUST ON BEHALF OF NURSING HOME RESIDENTS. |
| Part X, Line 2: | The Hospital follows the accounting guidance for uncertainty in income taxes using the provisions of Financial Accounting Standards Board (FASB) ASC 740, Income Taxes. Using that guidance, tax positions are recognized in the financial statements when it is more-likely-than-not the position will be sustained upon examination by the taxing authorities. As of June 30, 2017, the Hospital had no uncertain tax positions that qualify for either recognition or disclosure in the financial statements. The Hospital's income tax filings are subject to audit by various taxing authorities. The Hospital is no longer subject to federal and state income tax examinations by taxing authorities for fiscal years before 2014. |
Schedule H IRS990ScheduleH
| Field | Value | IRS element (for citing) |
|---|---|---|
| Financial Assistance Policy | Yes (1) | FinancialAssistancePolicyInd |
| Written Policy | Yes (1) | WrittenPolicyInd |
| All Hospitals Policy | Yes (X) | AllHospitalsPolicyInd |
| FPG Reference Free Care | Yes (1) | FPGReferenceFreeCareInd |
| Percent100 | Yes (X) | Percent100Ind |
| FPG Reference Discounted Care | Yes (1) | FPGReferenceDiscountedCareInd |
| Percent200 D | Yes (X) | Percent200DInd |
| Free Care Medically Indigent | Yes (1) | FreeCareMedicallyIndigentInd |
| Financial Assistance Budget | Yes (1) | FinancialAssistanceBudgetInd |
| Expenses Exceed Budget | 0 | ExpensesExceedBudgetInd |
| Annual Community Bnft Report | 0 | AnnualCommunityBnftReportInd |
Financial Assistance At Cost Typ FinancialAssistanceAtCostTyp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Community Benefit Expns | $351,519 | TotalCommunityBenefitExpnsAmt |
| Net Community Benefit Expns | $351,519 | NetCommunityBenefitExpnsAmt |
| Total Expense | 0.00780 | TotalExpensePct |
Unreimbursed Medicaid UnreimbursedMedicaidGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Community Benefit Expns | $3,851,454 | TotalCommunityBenefitExpnsAmt |
| Direct Offsetting Revenue | $2,394,664 | DirectOffsettingRevenueAmt |
| Net Community Benefit Expns | $1,456,790 | NetCommunityBenefitExpnsAmt |
| Total Expense | 0.03220 | TotalExpensePct |
Total Financial Assistance Typ TotalFinancialAssistanceTyp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Community Benefit Expns | $4,202,973 | TotalCommunityBenefitExpnsAmt |
| Direct Offsetting Revenue | $2,394,664 | DirectOffsettingRevenueAmt |
| Net Community Benefit Expns | $1,808,309 | NetCommunityBenefitExpnsAmt |
| Total Expense | 0.04000 | TotalExpensePct |
Community Health Services CommunityHealthServicesGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Activities Or Programs | 12 | ActivitiesOrProgramsCnt |
| Persons Served | 31294 | PersonsServedCnt |
| Total Community Benefit Expns | $609 | TotalCommunityBenefitExpnsAmt |
| Direct Offsetting Revenue | $0 | DirectOffsettingRevenueAmt |
| Net Community Benefit Expns | $609 | NetCommunityBenefitExpnsAmt |
| Total Expense | 0.00000 | TotalExpensePct |
Subsidized Health Services SubsidizedHealthServicesGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Community Benefit Expns | $4,346,852 | TotalCommunityBenefitExpnsAmt |
| Direct Offsetting Revenue | $3,864,745 | DirectOffsettingRevenueAmt |
| Net Community Benefit Expns | $482,107 | NetCommunityBenefitExpnsAmt |
| Total Expense | 0.01070 | TotalExpensePct |
Total Other Benefits TotalOtherBenefitsGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Activities Or Programs | 12 | ActivitiesOrProgramsCnt |
| Persons Served | 31294 | PersonsServedCnt |
| Total Community Benefit Expns | $4,347,461 | TotalCommunityBenefitExpnsAmt |
| Direct Offsetting Revenue | $3,864,745 | DirectOffsettingRevenueAmt |
| Net Community Benefit Expns | $482,716 | NetCommunityBenefitExpnsAmt |
| Total Expense | 0.01070 | TotalExpensePct |
Total Community Benefits TotalCommunityBenefitsGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Activities Or Programs | 12 | ActivitiesOrProgramsCnt |
| Persons Served | 31294 | PersonsServedCnt |
| Total Community Benefit Expns | $8,550,434 | TotalCommunityBenefitExpnsAmt |
| Direct Offsetting Revenue | $6,259,409 | DirectOffsettingRevenueAmt |
| Net Community Benefit Expns | $2,291,025 | NetCommunityBenefitExpnsAmt |
| Total Expense | 0.05070 | TotalExpensePct |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Bad Debt Expense Reported | 0 | BadDebtExpenseReportedInd |
| Bad Debt Expense | $1,678,630 | BadDebtExpenseAmt |
| Bad Debt Expense Attributable | $248,437 | BadDebtExpenseAttributableAmt |
| Reimbursed By Medicare | $11,118,766 | ReimbursedByMedicareAmt |
| Cost Of Care Reimbursed By Medcr | $12,172,280 | CostOfCareReimbursedByMedcrAmt |
| Medicare Surplus Or Shortfall | -$1,053,514 | MedicareSurplusOrShortfallAmt |
Costing Methodology Used CostingMethodologyUsedGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Other | Yes (X) | OtherInd |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Written Debt Collection Policy | Yes (1) | WrittenDebtCollectionPolicyInd |
| Financial Assistance Prvsn | Yes (1) | FinancialAssistancePrvsnInd |
| Hospital Facilities | 1 | HospitalFacilitiesCnt |
Hospital Facilities HospitalFacilitiesGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Facility | 1 | FacilityNum |
Business Name BusinessName
| Field | Value | IRS element (for citing) |
|---|---|---|
| Business Name Line1 | POWELL VALLEY HOSPITAL | BusinessNameLine1Txt |
US Address USAddress
| Field | Value | IRS element (for citing) |
|---|---|---|
| Address Line1 | 777 AVENUE H | AddressLine1Txt |
| City | POWELL | CityNm |
| State Abbreviation | WY | StateAbbreviationCd |
| ZIP | 82435 | ZIPCd |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Licensed Hospital | Yes (X) | LicensedHospitalInd |
| Critical Access Hospital | Yes (X) | CriticalAccessHospitalInd |
| Emergency Room24 Hrs | Yes (X) | EmergencyRoom24HrsInd |
Hospital Fclty Policies Prctc HospitalFcltyPoliciesPrctcGrp
Hospital Facility Name HospitalFacilityName
| Field | Value | IRS element (for citing) |
|---|---|---|
| Business Name Line1 | POWELL VALLEY HOPSITAL | BusinessNameLine1Txt |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Facility | 1 | FacilityNum |
| First Licensed CY Or PY | 0 | FirstLicensedCYOrPYInd |
| Tax Exempt Hospital CY Or PY | 0 | TaxExemptHospitalCYOrPYInd |
| CHNA Conducted | Yes (1) | CHNAConductedInd |
| Community Definition | Yes (X) | CommunityDefinitionInd |
| Community Demographics | Yes (X) | CommunityDemographicsInd |
| Existing Resources | Yes (X) | ExistingResourcesInd |
| How Data Obtained | Yes (X) | HowDataObtainedInd |
| Community Health Needs | Yes (X) | CommunityHealthNeedsInd |
| Other Health Issues | Yes (X) | OtherHealthIssuesInd |
| Community Hlth Needs Id Process | Yes (X) | CommunityHlthNeedsIdProcessInd |
| Consulting Process | Yes (X) | ConsultingProcessInd |
| Prior CHNA Impact | Yes (X) | PriorCHNAImpactInd |
| CHNA Conducted | 15 | CHNAConductedYr |
| Take Into Account Others Input | Yes (1) | TakeIntoAccountOthersInputInd |
| CHNA Conducted With Other Fclts | 0 | CHNAConductedWithOtherFcltsInd |
| CHNA Conducted With Non Fclts | 0 | CHNAConductedWithNonFcltsInd |
| CHNA Report Widely Available | Yes (1) | CHNAReportWidelyAvailableInd |
| Rpt Available On Own Website | Yes (X) | RptAvailableOnOwnWebsiteInd |
| Own Website URL | https://www.pvhc.org | OwnWebsiteURLTxt |
| Paper Copy Public Inspection | Yes (X) | PaperCopyPublicInspectionInd |
| Rpt Available Thru Other Method | Yes (X) | RptAvailableThruOtherMethodInd |
| Implementation Strategy Adopt | Yes (1) | ImplementationStrategyAdoptInd |
| Implementation Strategy Adpt | 16 | ImplementationStrategyAdptYr |
| Strategy Posted Website | Yes (1) | StrategyPostedWebsiteInd |
| Strategy Website URL | https://www.pvhc.org | StrategyWebsiteURLTxt |
| Organization Incur Excise Tax | 0 | OrganizationIncurExciseTaxInd |
| Elig Criteria Explained | Yes (1) | EligCriteriaExplainedInd |
| FPG Family Incm Lmt Free Dscnt | Yes (X) | FPGFamilyIncmLmtFreeDscntInd |
| FPG Family Incm Lmt Free Care | 100.000000000000 | FPGFamilyIncmLmtFreeCarePct |
| FPG Family Incm Lmt Dscnt Care | 200.000000000000 | FPGFamilyIncmLmtDscntCarePct |
| Income Level Criteria | Yes (X) | IncomeLevelCriteriaInd |
| Asset Level Criteria | Yes (X) | AssetLevelCriteriaInd |
| Medical Indigency Criteria | Yes (X) | MedicalIndigencyCriteriaInd |
| Explained Basis | Yes (1) | ExplainedBasisInd |
| App Financial Asst Expln | Yes (1) | AppFinancialAsstExplnInd |
| Described Info | Yes (X) | DescribedInfoInd |
| Described Suprt Doc | Yes (X) | DescribedSuprtDocInd |
| Provided Hospital Contact | Yes (X) | ProvidedHospitalContactInd |
| Provided Nonprofit Contact | Yes (X) | ProvidedNonprofitContactInd |
| Includes Publicity Measures | Yes (1) | IncludesPublicityMeasuresInd |
| FAP Available On Website | Yes (X) | FAPAvailableOnWebsiteInd |
| FAP Available On Website URL | https://www.pvhc.org | FAPAvailableOnWebsiteURLTxt |
| FAP App Available On Website | Yes (X) | FAPAppAvailableOnWebsiteInd |
| FAP App Available On Website URL | https://www.pvhc.org | FAPAppAvailableOnWebsiteURLTxt |
| FAP Summary On Website | Yes (X) | FAPSummaryOnWebsiteInd |
| FAP Summary On Website URL | https://www.pvhc.org | FAPSummaryOnWebsiteURLTxt |
| FAP Avlbl On Request No Charge | Yes (X) | FAPAvlblOnRequestNoChargeInd |
| FAP App Avlbl On Request No Chrg | Yes (X) | FAPAppAvlblOnRequestNoChrgInd |
| FAP Sum Avlbl On Request No Chrg | Yes (X) | FAPSumAvlblOnRequestNoChrgInd |
| Notified FAP Copy Bill Display | Yes (X) | NotifiedFAPCopyBillDisplayInd |
| FAP Actions On Nonpayment | Yes (1) | FAPActionsOnNonpaymentInd |
| Permit No Actions | Yes (X) | PermitNoActionsInd |
| Collection Activities | 0 | CollectionActivitiesInd |
| Provided Written Notice | Yes (X) | ProvidedWrittenNoticeInd |
| Made Effort Orally Notify | Yes (X) | MadeEffortOrallyNotifyInd |
| Nondis Emergency Care Policy | Yes (1) | NondisEmergencyCarePolicyInd |
| Look Back Medicaid Medcr Prvt | Yes (X) | LookBackMedicaidMedcrPrvtInd |
| Amounts Generally Billed | 0 | AmountsGenerallyBilledInd |
| Gross Charges | 0 | GrossChargesInd |
Supplemental Information SupplementalInformationGrp (5 entries)
| Form And Line ReferenceFormAndLineReferenceDesc | ExplanationExplanationTxt |
|---|---|
| POWELL VALLEY HOPSITAL | Part V, Section B, Line 5: In FY 2016, a CHNA was completed. The survey was handed out to current users of PVHC health services. 273 completed surveys were returned. A prioritization meeting of individuals with expertise and knowledge regarding communioty needs was held. Those unable to attend, were able to communicate their feedback and comments via email. |
| POWELL VALLEY HOPSITAL | Part V, Section B, Line 7d: We have TV video displays in various locations in our facility. It is advertised there, where individuals can access the CHNA so guests know they can read the results on our website. |
| POWELL VALLEY HOPSITAL | Part V, Section B, Line 11: THE MOST RECENT CHNA WAS COMPLETED IN APRIL 2016. THE TOP THREE COMMUNITY HEALTH NEEDS WERE DETERMINED. PVHC, IN COLLABORATION WITH COMMUNITY PARTNERS, HAVE DEVELOPED AN IMPLEMENTATION PLAN FOR EACH OF THE PRIORITY HEALTH NEEDS. SOME OF THESE STRATEGIES HAVE ALREADY BEGUN INCLUDING COMMUNITY HEALTH EDUCATION EVENTS ON HEART HEALTH, GETTING SMART ABOUT ANTIBIOTICS AND DIABETES EDUCATION, WHICH INCLUDED A REDUCED RATE FOR A1C LAB TESTING. 1) IN ORDER TO INCREASE ACCESS TO PRIMARY CARE SERVICES, DR. NICOLE COMER JOINED THE PVHC TEAM AS A FAMILY PRACTICE DOCTOR IN AUGUST, 2016. A FNP, DARLENE HAUSER, JOINED THE PVHC TEAM IN MARCH, 2016. PHYSICIAN ASSISTANT, AMY BUCK, JOINED THE PVHC TEAM IN AUGUST, 2016. 2) IN ORDER TO FACILITATE IMPROVED ACCESS TO MENTAL HEALTH SERVICES, PVHC PARTICIPATED IN MEETINGS TO ESTABLISH A FQHC. THE CENTER OPENED IN SEPTEMBER 2015 AND OFFERS ACCESS TO MENTAL HEALTH SERVICES THRU A CONTRACT WITH YELLOWSTONE BEHAVIORAL HEALTH. PVHC DONATED CASH AND IN-KIND SUPPORT. IN ADDITION, PVHC FACILITATES ALZHEIMERS SUPPORT GROUPS AS WELL AS MENTAL HEALTH SUPPORT GROUPS. 3) PVHC CONTINUES TO COMMUNICATE AVAILABLE PREVENTATIVE SERVICES TO THE COMMUNITY THROUGH PRINT MEDIA, RADIO SPOTS, ON SOCIAL MEDIA, AND THROUGH COMMUNICATIONS TO PVHC EMPLOYEES. PVHC OFFERS COMMUNITY BLOOD SCREENINGS AND WELLNESS LAB TESTS AT A DISCOUNTED RATE. PVHC AGAIN HOSTED A DRIVE-THRU FLU SHOT CLINIC AND HOSTED SEVERAL COMMUNITY BLOOD DRIVES DURING THE YEAR. PVHC HOSTED A VARIETY OF PREVENTATIVE EDUCATIONAL AND SUPPORT ACTIVITIES INCLUDING THREE EMERGENCY MANAGEMENT AND HANDS-ONLY CPR CLASSES AT POWELL HIGH SCHOOL; HANDS-ONLY CPR FOR THE PUBLIC, CPR TRAINING FOR POWELL HIGH SCHOOL INSTRUCTORS, AND CPR FOR THE POWELL HIGH SCHOOL HEALTH CLASSES. PVHC CONTINUED TO OFFER SAFESITTER CLASSES FOR LOCAL CHILDREN AGES 11-14. |
| POWELL VALLEY HOPSITAL | Part V, Section B, Line 13b: IN ADDITION TO PROVIDING FREE OR DISCOUNTED CARE BASED ON FEDERAL PROVERTY GUIDELINES, WE REVIEW INCOME TAX RETURNS AND PAY STUBS. THIS INFORMATION HELPS US MORE ACCURATELY DETERMINE A PATIENT'S ABILITY TO PAY. |
| POWELL VALLEY HOPSITAL | Part V, Section B, Line 16j: A SUMMARY OF THE FINANCIAL ASSISTANCE POLICY IS MADE AVAILABLE TO THE COMMUNITY ON THE HOSPITAL'S WEBSITE, ATTACHED TO BILLING INVOICES, POSTED IN THE HOSPITAL EMERGENCY ROOMS OR WAITING ROOMS, POSTED IN THE HOSPITAL ADMISSIONS OFFICES, AND PROVIDED, IN WRITING, TO PATIENTS ON ADMISSION TO THE HOSPITAL. |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Facility | 4 | FacilityNum |
Oth Hlth Care Fclts Not Hospital OthHlthCareFcltsNotHospitalGrp
Oth Hlth Care Fclts OthHlthCareFcltsGrp (4 entries)
| Address Line1USAddress/AddressLine1Txt | CityUSAddress/CityNm | State AbbreviationUSAddress/StateAbbreviationCd | ZIPUSAddress/ZIPCd | FacilityFacilityTxt |
|---|---|---|---|---|
| 1 - POWELL VALLEY CLINIC | ||||
| 777 AVENUE H | POWELL | WY | 82435 | OUTPATIENT PHYSICIAN CLINIC |
| 2 - POWELL VALLEY CARE CENTER | ||||
| 777 AVENUE H | POWELL | WY | 82435 | NURSING HOME |
| 3 - HEARTLAND ASSISTED LIVING | ||||
| 777 AVENUE H | POWELL | WY | 82435 | ASSISTED LIVING FACILITY |
| 4 - EXPRESS CARE CLINIC | ||||
| 777 AVENUE H | POWELL | WY | 82435 | URGENT CARE |
Supplemental Information Detail SupplementalInformationDetail (11 entries)
| Form And Line ReferenceFormAndLineReferenceDesc | ExplanationExplanationTxt |
|---|---|
| Part I, Line 3c: | IN ADDITION TO PROVIDING FREE OR DISCOUNTED CARE BASED ON FEDERAL PROVERTY GUIDELINES, WE REVIEW INCOME TAX RETURNS AND PAY STUBS. THIS INFORMATION HELPS US MORE ACCURATELY DETERMINE A PATIENT'S ABILITY TO PAY PART I, LINE 6B. THE COMMUNITY BENEFIT REPORT IS POSTED ON THE ORGANIZATION'S WEBSITE. |
| Part I, Line 7: | charity care expense was converted to cost on line 7a based on an overall cost to the charge ratio addressing all patient segments. the expenses associated with community health improvement services, line 7e were determined using an average hourly rate for staff time, space use, and ambulances. cash and in-kind contributions to community groups, line 7i, were reported based on actual expenses recorded in the organization's general ledger. the cost for subsidized health services reported on line 7g was determined using the Medicare Cost Report. |
| Part I, Ln 7 Col(f): | the amouNT of bad debt expense removed from the denominator of the calculation on part 1, line 7 column f was $1,678,630. |
| Part II, Community Building Activities: | AT POWELL VALLEY HEALTH CARE, WE UNDERSTAND THAT HEALTHCARE IS EVOLVING. THE ADVANCEMENT IN MEDICINE AND STRIDES IN TECHNOLOGY ARE PROVIDING LOCAL COMMUNITIES ACCESS TO BETTER HEALTHCARE. OUR BOARD OF TRUSTEES IS COMPRISED PRIMARILY OF LOCAL BUSINESS LEADERS WHO RESIDE IN OUR PRIMARY SERVICE AREA. TO MEET THE NEEDS OF OUR COMMUNITY, THE HOPSITAL EXTENDS PRIVILEGES TO MEDICAL STAFF THAT ARE QUALIFIED THROUGH LICENSURE. OUR EMERGENCY ROOM IS AVAILABLE 7 DAYS A WEEK AND IS AVAILABLE TO ALL REGARDLESS OF A PATIENT'S ABILITY TO PAY. EXCESS FUNDS ARE REINVESTED AND USED FOR PATIENT CARE AND FACILITY UPGRADES. |
| Part III, Line 4: | THE ORGANIZATION'S BAD DEBT IS REPORTED AS CHARGES INCURRED DURING THE YEAR. THE ESTIMATED AMOUNT OF BAD DEBT EXPENSE ATTRIBUTABLE TO PATIENTS ELIGIBLE UNDER THE ORGANIZATION'S FINANCIAL ASSISTANCE POLICY IS 14.8% (BASED UPON US CENSUS BUREAU QUICKFACTS FOR PERCENTAGE OF CITIZENS BELOW THE POVERTY LEVEL IN THE CITY OF POWELL, WY). THIS REPRESENTS A REASONABLE PERCENTAGE OF INDIVIDUALS WHO POTENTIALLY QUALIFY FOR CHARITY CARE, BUT MAY NOT HAVE APPLIED AND THEREFORE WERE WRITTEN OFF TO BAD DEBT. THE FOOTNOTE THAT DESCRIBES BAD DEBT EXPENSE IS FOUND ON PAGE 24 OF THE ATTACHED AUDIT REPORT. |
| Part III, Line 8: | MEDICARE ALLOWABLE COSTS OF CARE ARE BASED ON THE MEDICARE COST REPORT. THE MEDICARE COST REPORT IS COMPLETED BASED ON THE RULES AND REGULATIONS SET FORTH BY THE CENTERS FOR MEDICARE AND MEDICAID SERVICES. POWELL VALLEY HEALTH CARE PROVIDES SERVICES TO PATIENTS UNDER THE MEDICARE PROGRAM KNOWING THEY WILL NOT RECOVER ALL THE COSTS ASSOCIATED WITH PROVIDING THESE SERVICES. PROVIDING THESE SERVICES IS ESSENTIAL TO THESE PATIENTS AND THE COMMUNITY AND INCREASES THEIR ACCESS TO HEALTHCARE SERVICES. THEREFORE, THE MEDICARE SHORTFALL SHOULD BE CONSIDERED A COMMUNITY BENEFIT. |
| Part III, Line 9b: | POWELL VALLEY HEALTH CARE, INC. TRIES TO DETERMINE IF A PATIENT NEEDS FINANCIAL ASSISTANCE BEFORE SERVICES ARE RENDERED, EXCEPT IN EMERGENCY SITUATIONS. NO PATIENT IS DENIED ACUTE CARE IN AN EMERGENCY SITUATION. THE HEALTH CENTER WILL PURSUE ALL POSSIBLE FORMS OF THIRD-PARTY PAYMENTS SUCH AS INSURANCE, STATE MEDICAID PROGRAMS, AND COUNTY INDIGENT CARE PROGRAMS BEFORE GRANTING FINANCIAL ASSISTANCE. COLLECTION EFFORTS ARE NOT PURSUED DURING THIS TIME. COLLECTION EFFORTS ARE NOT PURSUED WHILE A COMPLETED CHARITY CARE APPLICATION IS UNDER REVIEW. DECISIONS ON CHARITY CARE APPLICATIONS ARE MADE WITHIN 30 DAYS OF THE COMPLETED APPLICATION. ONCE A DECISION IS MADE, ANY PERSONAL PORTION DUE WILL FOLLOW THE SAME COLLECTION PROCEDURES AS OTHER ACCOUNTS. IF A DETERMINATION FOR FINANCIAL ASSISTANCE IS MADE ON AN ACCOUNT OR FURTHER INSURANCE PROCESSING IS NEEDED AFTER AN ACCOUNT IS SENT TO COLLECTIONS, ALL COLLECTION EFFORTS WILL CEASE AND ANY NEGATIVE REPORTING WILL BE REVERSED. |
| Part VI, Line 2: | POWELL VALLEY HEALTH CARE IS SERVED BY A PUBLICLY ELECTED DISTRICT BOARD. THE BOARD MEMBERS ACTIVELY PROVIDE INFORMATION RELATIVE TO THE HEALTH CARE NEEDS OF THE COMMUNITY. ADDITIONALLY, WE SURVEY PATIENTS, RESIDENTS, AND THEIR FAMILIES AND IN DOING SO, LOOK FOR TRENDS AND/OR SUGGESTIONS FOR IMPROVEMENTS/EXPANSION/OR INITIATION OF SERVICES. OUR GUEST RELATIONS PROCESS ALSO ASSISTS US IN IDENTIFYING ANY UNMET COMMUNITY HEALTH NEEDS. ADMINISTRATION, PROVIDERS AND THE BOARD TRUSTEES ALSO REVIEW COUNTY-WIDE MARKET/UTILIZATION DATA ANNUALLY. |
| Part VI, Line 3: | POWELL VALLEY HEALTH CARE IS COMMITTED TO PROVIDING FINANCIAL ASSISTANCE TO PERSONS WHO HAVE HEALTH CARE NEEDS AND ARE UNABLE TO PAY FOR MEDICALLY NECESSARY CARE. WE STRIVE TO ENSURE THAT PEOPLE WHO ARE UNINSURED, UNDERINSURED, INELIGIBLE FOR A GOVERNMENT PROGRAM, OR OTHERWISE UNABLE TO PAY ARE STILL ABLE TO RECEIVE CARE. NOTIFICATIONS ABOUT CHARITY CARE ARE INCLUDED IN PATIENT BILLS, POSTED IN EMERGENCY ROOMS, ADMITTING AND REGISTRATION DEPARTMENTS, THE BUSINESS OFFICE, AND WAITING ROOMS. INFORMATION IS ALSO INCLUDED IN PATIENT INFORMATION PACKETS. STAFF ALSO DISCUSS FINANCIAL ASSISTANCE UPON ADMITTING AND DISCHARGE. |
| Part VI, Line 4: | POWELL VALLEY HEALTHCARE IS A 25-BED CRITICAL ACCESS HOSPITAL, 100-BED INTERMEDIATE CARE NURSING FACILITY, A 24-APARTMENT ASSISTED LIVING FACILITY, AND A DOCTOR'S CLINIC LOCATED IN THE NORTHWEST CORNER OF WYOMING, 75 MILES EAST OF YELLOWSTONE NATIONAL PARK, AND 98 MILES SOUTH OF BILLINGS, MT. POWELL HAS A DIVERSE COMMERCIAL, INDUSTRIAL, EDUCATIONAL, AND AGRICULTURAL/RANCHING BASED ECONOMY. IN 2016, 14.8% OF THE RESIDENTS LIVED IN POVERTY. THE MEDIAN HOUSEHOLD INCOME WAS $46,971 AND THE POPULATION WAS 6,407. THE NEAREST CITY WITH A POPULATION OF 50,000+ IS BILLINGS, MT. THE NEAREST HOSPITALS ARE NORTH BIG HORN HOPSITAL DISTRICT, A CRITICAL ACCESS HOSPITAL LOCATED APPROXIMATELY 22 MILES NORTHEAST AND WEST PARK HOSPITAL, A CRITICAL ACCESS HOSPITAL LOCATED APPROXIMATELY 25 MILES SOUTHWEST. NET REVENUE FROM MEDICARE AND MEDICAID ACCOUNT FOR APPROXIMATELY 24.74% AND 5.33%, RESPECTIVELY. |
| Part VI, Line 5: | AT POWELL VALLEY HEALTH CARE, WE UNDERSTAND THAT HEALTHCARE IS EVOLVING. THE ADVANCEMENT IN MEDICINE AND STRIDES IN TECHNOLOGY ARE PROVIDING LOCAL COMMUNITIES ACCESS TO BETTER HEALTHCARE. OUR BOARD OF TRUSTEES IS COMPRISED PRIMARILY OF LOCAL BUSINESS LEADERS WHO RESIDE IN OUR PRIMARY SERVICE AREA. TO MEET THE NEEDS OF OUR COMMUNITY, THE HOPSITAL EXTENDS PRIVILEGES TO MEDICAL STAFF THAT ARE QUALIFIED THROUGH LICENSURE. OUR EMERGENCY ROOM IS AVAILABLE 7 DAYS A WEEK AND IS AVAILABLE TO ALL REGARDLESS OF A PATIENT'S ABILITY TO PAY. EXCESS FUNDS ARE REINVESTED AND USED FOR PATIENT CARE AND FACILITY UPGRADES. |
Schedule I IRS990ScheduleI
| Field | Value | IRS element (for citing) |
|---|---|---|
| Grant Records Maintained | Yes (1) | GrantRecordsMaintainedInd |
Grants Other Asst To Indiv In US GrantsOtherAsstToIndivInUSGrp (3 entries)
| Grant TypeGrantTypeTxt | RecipientRecipientCnt | Cash GrantCashGrantAmt |
|---|---|---|
| SCHOLARSHIPS | 8 | $4,800 |
| TUITION REIMBURSEMENTS | 16 | $22,950 |
| Employee Education Grants | 6 | $3,000 |
Supplemental Information Detail SupplementalInformationDetail
| Field | Value | IRS element (for citing) |
|---|---|---|
| Form And Line Reference | Part I, Line 2: | FormAndLineReferenceDesc |
| Explanation | THE ORGANIZATION PROVIDED SCHOLARSHIPS TO INDIVIDUALS AND REQUIRED THE INDIVIDUAL TO PROVIDE INFORMATION TO SUPPORT THE PURPOSE OF THE SCHOLARSHIP. TUITION REIMBURSEMENTS ARE PAID OUT AT 50% OF TUITION AFTER EMPLOYEES SHOW PASSING GRADES. | ExplanationTxt |
Schedule J IRS990ScheduleJ
| Field | Value | IRS element (for citing) |
|---|---|---|
| Severance Payment | 0 | SeverancePaymentInd |
| Supplemental Nonqual Rtr Plan | 0 | SupplementalNonqualRtrPlanInd |
| Equity Based Comp Arrngm | 0 | EquityBasedCompArrngmInd |
| Comp Based On Revenue Of Flng Org | 0 | CompBasedOnRevenueOfFlngOrgInd |
| Comp Bsd On Rev Related Orgs | 0 | CompBsdOnRevRelatedOrgsInd |
| Comp Bsd Net Earns Flng Org | Yes (1) | CompBsdNetEarnsFlngOrgInd |
| Comp Bsd Net Earns Rltd Orgs | 0 | CompBsdNetEarnsRltdOrgsInd |
| Any Non Fixed Payments | 0 | AnyNonFixedPaymentsInd |
| Initial Contract Exception | 0 | InitialContractExceptionInd |
Rltd Org Officer Trst Key Empl RltdOrgOfficerTrstKeyEmplGrp (10 entries)
| TitleTitleTxt | Base Compensation Filing OrgBaseCompensationFilingOrgAmt | Compensation Based On Rltd OrgsCompensationBasedOnRltdOrgsAmt | Bonus Filing OrganizationBonusFilingOrganizationAmount | Bonus Related OrganizationsBonusRelatedOrganizationsAmt | Other Compensation Filing OrgOtherCompensationFilingOrgAmt | Other Compensation Rltd OrgsOtherCompensationRltdOrgsAmt | Deferred Compensation Flng OrgDeferredCompensationFlngOrgAmt | Deferred Comp Rltd OrgsDeferredCompRltdOrgsAmt | Nontaxable Benefits Filing OrgNontaxableBenefitsFilingOrgAmt | Nontaxable Benefits Rltd OrgsNontaxableBenefitsRltdOrgsAmt | Total Compensation Filing OrgTotalCompensationFilingOrgAmt | Total Compensation Rltd OrgsTotalCompensationRltdOrgsAmt | Comp Report Prior990 Filing OrgCompReportPrior990FilingOrgAmt | Comp Report Prior990 Rltd OrgsCompReportPrior990RltdOrgsAmt |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| WILLIAM JARVIS MD | ||||||||||||||
| DIRECTOR/PHYSICIAN | $494,000 | $0 | $503,827 | $0 | $121,306 | $0 | $7,950 | $0 | $17,849 | $0 | $1,144,932 | $0 | $0 | $0 |
| NATHANIEL RIEB | ||||||||||||||
| PHYSICIAN - CHIEF OF STAFF | $354,483 | $0 | $37,679 | $0 | $43,000 | $0 | $7,950 | $0 | $17,849 | $0 | $460,961 | $0 | $0 | $0 |
| PAUL LAVEAU | ||||||||||||||
| Physician | $421,824 | $0 | $0 | $0 | $11,447 | $0 | $7,950 | $0 | $0 | $0 | $441,221 | $0 | $0 | $0 |
| KELLY CHRISTENSEN | ||||||||||||||
| PHYSICIAN | $206,464 | $0 | $161,652 | $0 | $38,583 | $0 | $7,950 | $0 | $17,849 | $0 | $432,498 | $0 | $0 | $0 |
| JENKINS CLARKSON | ||||||||||||||
| PHYSICIAN | $325,000 | $0 | $13,656 | $0 | $59,332 | $0 | $0 | $0 | $17,849 | $0 | $415,837 | $0 | $0 | $0 |
| Michael Bohlman | ||||||||||||||
| Physician | $205,743 | $0 | $83,020 | $0 | $29,551 | $0 | $7,950 | $0 | $17,849 | $0 | $344,113 | $0 | $0 | $0 |
| ANDREW BAKER | ||||||||||||||
| CRNA | $165,006 | $0 | $238,850 | $0 | $6,200 | $0 | $7,950 | $0 | $17,849 | $0 | $435,855 | $0 | $0 | $0 |
| RYAN SHEDD | ||||||||||||||
| CRNA | $165,006 | $0 | $252,350 | $0 | $5,735 | $0 | $7,950 | $0 | $17,849 | $0 | $448,890 | $0 | $0 | $0 |
| BRADLEY NORTH | ||||||||||||||
| PHYSICIAN | $282,144 | $0 | $8,454 | $0 | $58,534 | $0 | $7,950 | $0 | $19,849 | $0 | $376,931 | $0 | $0 | $0 |
| KURT PETTIPIECE | ||||||||||||||
| PHYSICIAN | $281,280 | $0 | $10,000 | $0 | $43,481 | $0 | $4,491 | $0 | $15,314 | $0 | $354,566 | $0 | $0 | $0 |
Supplemental Information Detail SupplementalInformationDetail (2 entries)
| Form And Line ReferenceFormAndLineReferenceDesc | ExplanationExplanationTxt |
|---|---|
| Part I, Line 3 | THE ORGANIZATION DOES NOT PAY COMPENSATION TO THE INTERIM CEO DIRECTLY. THE INTERIM CEO IS COMPENSATED BY AN UNRELATED MANAGEMENT COMPANY, HEALTHTECH MANAGEMENT SERVICES, INC. THE BOARD OF DIRECTORS APPROVES THE COMPENSATION PAID BY HEALTHTECH MANAGEMENT SERVICES, INC. |
| Part I, Line 5 | BONUSES ARE CALCULATED AS A PERCENTAGE OF NET REVENUE PER QUARTER PER CONTRACT FOR EACH INDIVIDUAL BASED ON BILLED CHARGES FOR THAT QUARTER. |
Schedule L IRS990ScheduleL
Loans Btwn Org Interested Prsn LoansBtwnOrgInterestedPrsnGrp (2 entries)
| Relationship With OrgRelationshipWithOrgTxt | Loan PurposeLoanPurposeTxt | Loan From OrganizationLoanFromOrganizationInd | Original PrincipalOriginalPrincipalAmt | Balance DueBalanceDueAmt | DefaultDefaultInd | Board Or Committee ApprovalBoardOrCommitteeApprovalInd | Written AgreementWrittenAgreementInd |
|---|---|---|---|---|---|---|---|
| JACOB MERREL | |||||||
| DIRECTOR | RELOCATION, FINANCIAL ASSISTANCE, EQUIPMENT PURCHASE | Yes (X) | $24,789 | $12,394 | 0 | Yes (1) | Yes (1) |
| KURT PETTIPIECE | |||||||
| HIGHEST COMPENSATED EMPLOYEE | EMPLOYEE RECRUITMENT | Yes (X) | $20,000 | $12,000 | 0 | Yes (1) | Yes (1) |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Balance Due | $24,394 | TotalBalanceDueAmt |
Bus Tr Involve Interested Prsn BusTrInvolveInterestedPrsnGrp
Name Of Interested NameOfInterested
| Field | Value | IRS element (for citing) |
|---|---|---|
| Person | STEVE KATZ | PersonNm |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Relationship Description | HUSBAND OF BOARD MEMBER BONI KATZ | RelationshipDescriptionTxt |
| Transaction | $188,499 | TransactionAmt |
| Transaction | COMPENSATION | TransactionDesc |
| Sharing Of Revenues | 0 | SharingOfRevenuesInd |
Schedule O IRS990ScheduleO
Supplemental Information Detail SupplementalInformationDetail (7 entries)
| Form And Line ReferenceFormAndLineReferenceDesc | ExplanationExplanationTxt |
|---|---|
| Form 990, Part VI, Section A, line 3 | THE INTERIM CEO, TERRY ODOM, WAS AN EMPLOYEE OF HEALTHTECH MANAGEMENT SERVICES, INC, A HEALTHCARE MANAGEMENT COMPANY, DURING THE YEAR ENDED JUNE 30, 2017. AS THIS POSITION IS HELD OUTSIDE THE ORGANIZATION, THE CONTROL OVER MANAGEMENT DUTIES CUSTOMARILY PERFORMED BY AND UNDER DIRECT SUPERVISION OF OFFICERS, DIRECTORS OR TRUSTEES, OR KEY EMPLOYEES HAS EFFECTIVELY BEEN DELEGATED OUTSIDE OF THE ORGANIZATION. TERRY ODUM WAS COMPENSATED BY HEALTHTECH MANAGEMENT SERVICES, INC. EFFECTIVE JULY 1, 2017 (AFTER THE PERIOD REPORTED ON THIS FORM), TERRY ODOM BECAME AN EMPLOYEE OF THE HOSPITAL AND HEALTHTECH MANAGEMENT SERVICES, INC IS NO LONGER PROVIDING SERVICES TO THE HOSPITAL. |
| Form 990, Part VI, Section A, line 7a | SEVEN BOARD MEMBERS FROM THE HOSPITAL DISTRICT BOARD OF TRUSTEES SHALL BE APPOINTED BY VIRTUE OF THEIR ELECTION TO THE HOSPITAL DISTRICT BOARD OF DIRECTORS. |
| Form 990, Part VI, Section A, line 7b | A BOARD MEMBER WHO IS FROM THE HOSPITAL DISTRICT BOARD OF TRUSTEES MAY ONLY BE REMOVED BY ACTION OF THE DISTRICT BOARD OF DIRECTORS. |
| Form 990, Part VI, Section B, line 11b | A COPY OF FORM 990 IS PROVIDED TO THE CEO AND CFO TO REVIEW. THE CEO OR CFO WILL EITHER MAKE CHANGES OR APPROVE THE FORM 990. AFTER THE FORM 990 IS FINALIZED BUT PRIOR TO BEING FILED, A COPY WILL BE PROVIDED TO THE BOARD OF DIRECTORS AT A BOARD MEETING. |
| Form 990, Part VI, Section B, line 12c | INDIVIDUALS COVERED BY THE CONFLICT OF INTEREST POLICY INCLUDE MEMBERS OF THE BOARD OF DIRECTORS, OFFICERS, AND KEY EMPLOYEES (IF APPLICABLE). THE PROCESS USED TO DETERMINE IF ANY CONFLICTS OF INTEREST EXIST CONSISTS OF SENDING THE MEMBERS A DOCUMENT FOR THEM TO COMPLETE PRIOR TO THE BOARD OF DIRECTORS MEETING. EACH INDIVIDUAL COMPLETES THE DOCUMENT WHICH ENTAILS DISCLOSING ANY POSSIBLE CONFLICTS AND RETURNS FOR REVIEW TO THE PRESIDENT OF THE BOARD. IF A MEMBER HAS A CONFLICT THEY ARE NOT ALLOWED TO VOTE ON THE CONFLICTED ISSUES. |
| Form 990, Part VI, Section C, line 19 | THE HOSPITAL MAKES ITS GOVERNING DOCUMENTS, CONFLICT OF INTEREST POLICY, AND FINANCIAL STATEMENTS AVAILABLE TO THE PUBLIC BY REQUEST. THE PUBLIC MAY REQUEST A COPY BY CALLING, VIA MAIL, OR WALK-IN. |
| Form 990, Part XII, Line 2c: | THIS PROCESS HAS NOT CHANGED FROM THE PREVIOUS YEAR. |
Schedule R IRS990ScheduleR
Id Related Tax Exempt Org IdRelatedTaxExemptOrgGrp (2 entries)
| Address Line1USAddress/AddressLine1Txt | CityUSAddress/CityNm | State AbbreviationUSAddress/StateAbbreviationCd | ZIPUSAddress/ZIPCd | EINEIN | Primary ActivitiesPrimaryActivitiesTxt | Legal Domicile StateLegalDomicileStateCd | Exempt Code SectionExemptCodeSectionTxt | Public Charity StatusPublicCharityStatusTxt | Direct Controlling NADirectControllingNACd | Controlled OrganizationControlledOrganizationInd |
|---|---|---|---|---|---|---|---|---|---|---|
| POWELL HOSPITAL DISTRICT #1 | ||||||||||
| 777 AVENUE H | POWELL | WY | 82435 | 830200759 | RELATED - PROVISION OF HEALTH CARE SERVICES | WY | GOVERNMENT | N/A | N/A | 0 |
| POWELL MEDICAL FOUNDATION | ||||||||||
| PO BOX 801 | POWELL | WY | 82435 | 742275540 | PROMOTE PUBLIC HEALTH AND IMPROVE FACILITIES AROUND THE CITY OF POWELL, WY | WY | 501(C)(3) | LINE 8 | N/A | 0 |
Id Related Org Txbl Corp Tr IdRelatedOrgTxblCorpTrGrp
Related Organization Name RelatedOrganizationName
| Field | Value | IRS element (for citing) |
|---|---|---|
| Business Name Line1 | POWELL VALLEY INTEGRATED HEALTH SERVICES INC | BusinessNameLine1Txt |
US Address USAddress
| Field | Value | IRS element (for citing) |
|---|---|---|
| Address Line1 | 777 AVENUE H | AddressLine1Txt |
| City | POWELL | CityNm |
| State Abbreviation | WY | StateAbbreviationCd |
| ZIP | 82435 | ZIPCd |
| Field | Value | IRS element (for citing) |
|---|---|---|
| EIN | 830319855 | EIN |
| Primary Activities | PUBLIC BENEFIT CORPORATION/HEALTH CARE CONTRACT | PrimaryActivitiesTxt |
| Legal Domicile State | WY | LegalDomicileStateCd |
| Entity Type | C | EntityTypeTxt |
| Ownership | 1.00000 | OwnershipPct |
| Controlled Organization | Yes (1) | ControlledOrganizationInd |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Receipt Of Int Annts Rnts Rylts | 0 | ReceiptOfIntAnntsRntsRyltsInd |
| Gift Grnt Or Cap Contri To Oth Org | 0 | GiftGrntOrCapContriToOthOrgInd |
| Gift Grnt Cap Contri From Oth Org | Yes (1) | GiftGrntCapContriFromOthOrgInd |
| Loans Or Guarantees To Other Org | Yes (1) | LoansOrGuaranteesToOtherOrgInd |
| Loans Or Guarantees From Oth Org | 0 | LoansOrGuaranteesFromOthOrgInd |
| Div Related Organization | 0 | DivRelatedOrganizationInd |
| Asset Sale To Other Org | 0 | AssetSaleToOtherOrgInd |
| Asset Purchase From Other Org | 0 | AssetPurchaseFromOtherOrgInd |
| Asset Exchange | 0 | AssetExchangeInd |
| Rental Of Facilities To Oth Org | 0 | RentalOfFacilitiesToOthOrgInd |
| Rental Of Fclts From Oth Org | Yes (1) | RentalOfFcltsFromOthOrgInd |
| Perform Of Services For Oth Org | 0 | PerformOfServicesForOthOrgInd |
| Perform Of Services By Other Org | 0 | PerformOfServicesByOtherOrgInd |
| Sharing Of Facilities | 0 | SharingOfFacilitiesInd |
| Paid Employees Sharing | Yes (1) | PaidEmployeesSharingInd |
| Reimbursement Paid To Other Org | 0 | ReimbursementPaidToOtherOrgInd |
| Reimbursement Paid By Other Org | Yes (1) | ReimbursementPaidByOtherOrgInd |
| Transfer To Other Org | 0 | TransferToOtherOrgInd |
| Transfer From Other Org | 0 | TransferFromOtherOrgInd |
Transactions Related Org TransactionsRelatedOrgGrp (5 entries)
| Transaction TypeTransactionTypeTxt | InvolvedInvolvedAmt | Method Of Amount DeterminationMethodOfAmountDeterminationTxt |
|---|---|---|
| POWELL HOSPITAL DISTRICT | ||
| C | $540,276 | CASH VALUE |
| POWELL VALLEY INTEGRATED HEALTH SERVICES INC | ||
| D | $121,905 | RECEIVABLES FROM PVIHS AT YEAR EN |
| POWELL HOSPITAL DISTRICT | ||
| K | $810,000 | ACTUAL RENT PAID FOR BUILDINGS |
| POWELL MEDICAL FOUNDATION | ||
| O | $71,292 | CASH PAID BY PVHC FOR PMF'S ED |
| POWELL MEDICAL FOUNDATION | ||
| Q | $6,618 | ACTUAL EXPENSES INCURRED |