2016-02-02T13:28:30-07:00 2015-06-30 990 2014-07-01 920077523 CENTRAL PENINSULA GENERAL HOSPITAL INC CENT 9077144404 250 Hospital Place Soldotna AK 99669 Lance Spindler CFO 9077144722 2016-02-02 2014 2016-04-25 22:37:26Z Central Peninsula Hospital Richard Davis CEO 250 Hospital Place Soldotna AK 99669 275466374 0 X www.cpgh.org X 1994 AK We are a community initiated and community nurtured organization dedicated to promoting wellness and providing high quality health care that ensures the confidence and loyalty of our patients. We strive to improve individual and community health and achieve national standards of excellence. 11 9 927 198 -1133 0 690205 599171 229904499 268614128 259080 249248 3844998 5396380 234698782 274858927 151055 205388 0 0 69552860 76976428 0 0 0 151767800 180500141 221471715 257681957 13227067 17176970 191966077 212108821 80731761 83697535 111234316 128411286 We are a community initiated and community nurtured organization dedicated to promoting wellness and providing high quality health care that ensures the confidence and loyalty of our patients. We strive to improve individual and community health and achieve national standards of excellence. We are dedicated to providing the highest quality patient and resident centered care in a healing environment. 0 0 228844915 237439074 Our 49 bed hospital provided patient and ancillary services to 2,549 inpatients and 96,143 outpatients during the 2014 tax year. The hospital provides emergency medical services regardless of ability to pay. Emergency medical services were provided to 16,510 individuals, and 1,637 of those individuals were admitted to the hospital. 4,585 surgical procedures were performed in the hospital during the tax year. The imaging department performed 44,729 procedures. Over 78,396 physical therapy 15-minute procedures were provided to area residents. During the 2014 tax year, free medical services in the amount of $6,296,354(gross charges) were provided to patients eligible for charity care. 11274358 12545465 Skilled nursing and long term care services were provided by our 60 bed skilled nursing facility. Heritage Place provides healing and compassionate residential care in a home like setting. Total admissions for the 2014 tax year were 109 and total resident days of care were 19,331. An average of 53 residents per day were provided long term care and nursing. Ancillary services for residents included 16,016 physical therapy treatments, while outpatients received 6,268 therapy treatments. 16067610 18629589 The hospital operates 8 family and specialty physician services clinics providing care in the following areas: Family medicine, Pediatrics, Neurology, Pain Management, Surgery, Urology, Podiatry, and Orthopedics. Other outpatient clinics include Wound care, Sleep studies, Forensic services, and the provision of Durable medical equipment. During the 2014 tax year physician and specialty services were provided for 26,389 patients. Over 3,640 wound care procedures, 114 forensic exams, and 181 sleep studies were also performed. 0 0 0 256186883 1 1 0 1 0 0 1 0 0 0 1 0 0 1 1 0 1 1 0 0 0 0 0 0 0 0 1 1 1 0 1 1 0 0 0 0 0 0 0 1 0 1 0 0 0 0 0 1 0 1 0 1 125 0 1 927 1 1 1 0 0 0 0 0 0 0 0 0 X 11 9 0 0 0 0 0 0 1 1 1 0 0 1 1 1 1 1 1 1 1 0 X X Central Peninsula Hospital Finance Department 9077144525 250 Hospital Place Soldotna AK 99669 Silverio Mattero Board Member 4 X 5125 0 0 Alyson Stogsdill President (former) 6 X X 1250 0 0 Trena Richardson President 6 X 14375 0 0 Irving Carlisle Secretary/Treasurer 6 X 4575 0 0 Henry Peter Sprague Vice President 4 X 5700 0 0 Gregg Motonaga Anesthesia MD/Board Member 44 X X 658860 0 42342 Mark Dixson Board Member 4 X 6175 0 0 Mark Premo Board Member 4 X 3350 0 0 Steven Manley Board Member 4 X 0 0 0 Stephen Horn Board Member 4 X 4525 0 0 James McHale Board Member 4 X 4100 0 0 Debra Shuey Board Member 4 X 4225 0 0 John Bramante Board Member 4 X 0 0 0 Andrea D Posey CNO (former) 40 X 34773 0 76 Johnny L Dodd VP of Human Resources 40 X 165432 0 28471 Matthew Dammeyer COO 40 X 238446 0 38072 Richard Davis CEO 40 X 394512 0 32249 Shaun Keef CFO (former) 40 X 120132 0 15415 Lance Spindler CFO (current) 40 X 89332 0 8853 Karen Scoggins CNO (current) 40 X 19363 0 363 David S Innes Orthopedic Surgeon 40 X 1856925 0 34687 Cynthia Kahn Pain Management Physician 40 X 539118 0 15057 Justin Evans Anethesia MD 40 X 577509 0 52187 Jason Lattin Surgeon 40 X 755184 0 34687 5502986 0 302459 70 1 1 0 C&A Industries dba Focus One Solutions PO Box 3037 Omaha NE 68103 Contract Labor Provider 1166229 Alaska Hospitalist Group LLC 4300 B Street Suite 200 Anchorage AK 99503 Physician Services 688749 Derek Leichliter 46113 Sather Ct Soldotna AK 99669 Electrical Contractor 455527 Curtis Buchholz 44455 Sterling Hwy Soldotna AK 996697936 Pathology services 256107 AK Surgical Services PO Box 96024 Las Vegas NV 89193 Surgical 243634 9 0 0 0 16164 555747 27260 7260 599171 Hospital Service Revenue 622000 237439074 237439074 0 0 Skilled Nursing Revenue 623000 12545465 12545465 0 0 Physician Clinic Revenue 621110 18629589 18629589 0 0 0 0 0 0 268614128 248205 0 0 248205 0 0 0 0 0 0 0 0 437312 6731 437276 7864 36 -1133 -1097 36 -1133 0 0 1043 0 0 0 1043 1043 1043 0 0 0 515521 162307 353214 353214 0 0 Property Tax Revenue 900099 48694 48694 0 0 USAC Telephone Revenue 900099 569526 569526 0 0 EHR Incentive Payments 900099 979809 979809 0 0 3446234 3446234 0 0 5044263 274858927 274012684 -1133 248205 205388 205388 0 0 0 0 0 0 5739163 4523074 1216089 0 0 0 0 0 49890178 49890178 0 0 1622171 1622171 0 0 16144732 16144732 0 0 3580184 3580184 0 0 0 0 0 166594 0 166594 0 88048 0 88048 0 24343 0 24343 0 0 0 0 0 0 0 3768115 3768115 0 0 276118 276118 0 0 23145331 23145331 0 0 5295405 5295405 0 0 0 0 0 0 2713943 2713943 0 0 275792 275792 0 0 0 0 0 0 295023 295023 0 0 916081 916081 0 0 0 0 0 0 8464095 8464095 0 0 1136309 1136309 0 0 Medicare patient deductions 63075360 63075360 0 0 Medicaid patient deductions 21162889 21162889 0 0 Uncompensated Care patient deductions 19107923 19107923 0 0 Commercial, government, other patient deductions 27369204 27369204 0 0 3219568 3219568 0 0 257681957 256186883 1495074 0 30230384 31905467 5278059 5732944 94772 49290 24663984 28938252 0 0 0 0 0 0 4488685 5169890 1555004 1409211 153217077 60066030 71387990 93151047 0 0 500000 500000 0 0 497662 2169698 53269537 43083022 191966077 212108821 12401135 16817431 0 0 9676 11005 67333899 65878691 0 0 0 0 153953 89411 0 0 833098 900997 80731761 83697535 X 106540914 122377174 4693402 6034112 0 0 111234316 128411286 191966077 212108821 17176970 0 0 0 0 0 X 0 1 X 1 1 1 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 0 1 0 0 0 0 1 14764 0 1 9579 24343 0 Schedule C, Part II-B, Line 1 Line 1g consists of travel expenses and compensation of employees for three trips to Washington DC to discuss the Medicare Rural Demonstration project with legislators and three trips to Juneau AK to discuss Medicaid Expansion with state legislators. Line 1i consists of the portion of dues paid to outside organizations which was spent on lobbying. These outside organizations include the American Hospital Association and the Alaska Hospital and Nursing Home Association. X 1 40 0 0 0 1 0 0 0 0 2245217 0 2245217 79481040 0 39022215 40458825 567520 0 298146 269374 41324069 0 19753687 21570382 29599231 0 991982 28607249 93151047 Plant Replacement and Expansion fund 18838950 Debt Service Reserve Fund 4569037 Bond Proceeds reserved for capital projects 18468485 Deferred loss on 2011 Bond refunding 1206550 43083022 Reserves payable to third party payors 852751 Other current liabilities 48246 900997 144313724 0 0 0 170171 170171 144143553 0 130715374 130715374 274858927 139948324 0 0 0 170171 170171 139778153 0 117903804 117903804 257681957 Schedule D, Part II, Line 9 In 2008 the Hospital purchased a building which resides on 40 acres of land subject to a perpetual covenant for the benefit of all Alaska residents, restricting the use of the land for agricultural purposes pursuant to AK statute 38.05.321. The building on the property is used by the Hospital's chemical dependency department. There is no value placed on the easement itself and therefore it does not appear on the Hospital Financial statements or footnotes. The cost of the real property is recorded on the Hospital's balance sheet at its net book value. Schedule D, Part XI, Line 2d In IRS Form 990, expenses related to personal property rental revenue and cost of goods sold are reported in Part VIII as a reduction of revenue. For financial statement purposes, these expenses are reported in operating expenses. Schedule D, Part XI, Line 4b On IRS Form 990 all Hospital revenues are reported gross and related deductions from third party payers such as Medicare, Medicaid, VA, and Uncompensated care such as Charity and Bad debt are reported as expenses in Part IX. However, in accordance with Generally accepted accounting principles all revenues on the audited financial statements are reported net of these deductions. Schedule D, Part XII, Line 2d In IRS Form 990 expenses related to personal property rentals and cost of goods sold for medical equipment are reported as a reduction of revenues in Part VIII whereas they are reported as operating expenses on the audited financial statements. Schedule D, Part XII, Line 4b On IRS Form 990 all uncompensated care and unpaid deductions from revenue from third party payers such as Medicare, Medicaid, and others is reported in Part IX on the statement of functional expenses. However on our audited financial statements, deductions are reported net of patient revenues in accordance with Generally Accepted Accounting principles. 1 1 X 1 X 1 X 1 1 0 0 1 2505 2802721 0 2802721 0.0223 1 10102 17367981 20029571 -2661590 0.0 1 158 39324 25619 13705 0.0001 3 12765 20210026 20055190 154836 0.0224 382 27232 645117 121290 523826 0.0042 109 670 73586 8950 64636 0.0005 13 25831 11590906 9047254 2543652 0.0203 2 50 8366 0 8366 0.0001 1072 3538 280771 0 280771 0.002 1578 57321 12598746 9177494 3421251 0.0271 1581 70086 32808772 29232684 3576087 0.0495 0 0 0 0 0 0 0 0 0 0 0 0 2 0 204 0 204 0 0 0 0 0 0 0 0 0 0 0 0 0 1 30 1436 0 1436 0 0 0 0 0 0 0 1 199 65355 0 65355 0.0005 0 0 0 0 0 0 4 229 66995 0 66995 0.0005 0 5637091 4115076 31321095 35526985 -4205890 X 1 1 1 1 Central Peninsula Hospital 250 Hospital Place Soldotna AK 99669 X X X Central Peninsula Hospital 1 0 0 1 X X X X X X X X X X 12 1 0 0 1 X www.cpgh.org X 1 14 1 www.cpgh.org/2013CommunityHealthNeedsAssessment 0 0 1 X 200 300 X 1 1 X X X 1 X http://www.cpgh.org/PatientFinancialServices X http://www.cpgh.org/PatientFinancialServices X http://www.cpgh.org/PatientFinancialServices X X X X X X 1 X 1 X X X 1 X 0 0 Schedule H, Part V, Section B, Line 3-Central Peninsula Hospital In conducting a Community Health Needs Assessment (CHNHA), the University of New England (UNE) reached out to a broad cross section of the local community in order to gather health data through phone interviews. The UNE also used published census and health data for the community, state, and nation in their needs assessment. Hospital management supplements health information provided in the CHNA by partnerships and collaborations around the state and the nation through involvement in the Alaska State Hospital and Nursing Home Association, Rural health Care and Small Hospital Association, and also on a local level with the Kenai Peninsula Borough, the Patient Advisory committee, and the Service Area board. Schedule H, Part V, Section B, Line 5-Central Peninsula Hospital In addition to the above methods of disbursement, the CHNHA was also provided through email to all Hospital Administrators, Hospital Board Members, and supervisory staff. Schedule H, Part V, Section B, Line 6a-Central Peninsula Hospital Hospital Management collaborates with the Board of Directors to address the CHNHA health findings through annual strategic planning. Implementation of new services in response to these health needs are performed as soon as is financially and strategically possible. Additionally, the Hospital supports the provision of health services by community health partners when it cannot supply those needs itself. Schedule H, Part V, Section B, Line 7-Central Peninsula Hospital Two of the 2013 CHNA health findings require long-term planning and community collaboration to meet the health need. 1. Respiratory Health and COPD affect over 10% of the population surveyed. Although the service area reports lower rates of smoking than peer communities, COPD rates remain the same. In order to combat this healthcare need, the Hospital has focused attention on two of the causal factors for COPD, smoking and obesity. The Hospital provides smoking cessation patches to all admitted patients free of charge during their hospital stay and has also created a non-smoking campus to support the health of patients and staff. The Hospital also provides Healthy lifestyles and diet-free classes for a nominal fee to staff and community members to fight obesity. However, the Hospital has not created a smoking cessation program for the community at large, which was suggested by the CHNA. 2. Diabetes - nearly 10% of the population surveyed reported a diagnosis of diabetes. Age and obesity are major risk factors in developing diabetes, and nearly 68% of the population is either overweight or obese. The Hospital has focused much of its attention on diabetes education and prevention of diabetes through is Healthy lifestyles department which specifically targets healthy eating an living habits. During the 2014 tax year the Hospital also ventured into the provision of foot and ankle services by opening a specialty Physician clinic. Many diabetes patients have significant issues with their feet which can now be treated by this additional service. Additionally, the diabetes education department provides education, counseling, and support groups to area residents that suffer from diabetes. Schedule H, Part V, Section B, Line 7d-Central Peninsula Hospital In addition to the methods described above, the CHNA was also made available to the public through electronic means (email) upon request. Schedule H, Part V, Section B, Line 11-Central Peninsula Hospital Per the Community Health Needs Assessment, the Key Health Findings for the Hospital Service area are 1)Cardiovascular health, 2)Respiratory Health, 3)Diabetes and Chronic conditions, 4)Cancer health and screenings, 5)Mental Health and Substance abuse, and 6)Youth Mental health and Substance abuse. The Hospital is seeking to provide solutions for each of these health needs either through programs or collaborations and partnerships with others. Here are just a few of the strategies that Hospital is pursuing to meet these needs: CANCER HEALTH AND SCREENINGS - a)Completed construction of a radiation oncology center in 2013 and contracted with an Oncology group to operate the center. b)Began construction of a Medical office Building in 2015 to create a comprehensive cancer center. c)Actively recruiting for a local oncologist. d)Actively recruiting OB/GYN to increase PAP screenings. d)Increase focus on cancer awareness campaigns that promote cancer screening. CARDIOVASCULAR HEALTH - a)Added eICU program in 2014 to enable ICU staff to care for higher acuity patients with cardiovascular illnesses, b)Contracted with a new Hospitalist group in 2013 that could provide care to higher acuity patients, c)Implementation of aggressive ECCO training program for ICU nursing staff. d)Collaborate with community partners to reduce obesity rates and promote health living, e)Provide Hypertension and lipid management education through speakers bureaus, and health fairs. MENTAL HEALTH AND SUBSTANCE ABUSE -a)Establish a transitional housing building for recovering mothers with children, men, and women, b)Recruit a psychiatrist to meet patient need, c)recruited two licensed clinicians to provide additional outpatient behavioral health services. DIABETES AND CHRONIC CONDITIONS - a)Develop a specialized spine treatment beyond primary care model. b)Integrate pain management, physical therapy, and psychology with spine program. c)Collaborate with local programs for adults and youth to reduce the rate of obesity, a common risk factor of diabetes. RESPIRATORY HEALTH - a)Collaborate with local programs that educate the public about the dangers of smoking and asthma, and provide smoking cessation patches to inpatients, b)Promote healthy living and eating habits through the Healthy Lifestyles program to reduce the rate of obesity. Schedule H, Part V, Section B, Line 14-Central Peninsula Hospital The Hospital makes its financial assistance policy widely available to the public and to its patients through various means. Financial Assistance brochures are displayed at each of the main entrances to the Hospital as well as in the Emergency Department waiting area. During the discharge process, admissions staff attempt to provide a copy of the financial assistance policy to every patient. Additionally, financial counselors contact patients about their bills and discuss the financial assistance policy with them over the phone or in person. They also offer assistance in completing the applications. The Financial assistance policy is posted on our website at www.cpgh.org and is reported quarterly at meetings of the local governing body. Finally, the policy is advertised in the local newspaper to the general public, along with instructions for how to contact a financial counselor. Schedule H, Part V, Section B, Line 16a-Central Peninsula Hospital The FAP is widely available on our public website at www.cpgh.org/PatientFinancialServices Schedule H, Part V, Section B, Line 16b-Central Peninsula Hospital The FAP application is available on our public website at www.cpgh.org/PatientFinancialServices Schedule H, Part V, Section B, Line 16c-Central Peninsula Hospital A plain language summary of our FAP is available on our public website at www.cpgh.org/PatientFinancialServices Schedule H, Part V, Section B, Line 16i-Central Peninsula Hospital In addition to the methods described above, the FAP is also referenced on our patient billing statements, as well as advertised in the local newspaper. Schedule H, Part V, Section B, Line 20-Central Peninsula Hospital The Hospital offers all self pay patients (regardless of eligibility for free or discounted care) a 25% prompt pay discount on all hospital charges if paid within 30 days of billing. This discount is more advantageous than all of our negotiated commercial rates. For those patients who are unable to pay because they are financially or medically indigent, they are provided an opportunity to enroll in our financial assistance program for a further discount or free care. Schedule H, Part V, Section B, Line 22d-Central Peninsula Hospital In accordance with 501(r), the hospital uses a blend of the Medicare rates and the most advantageous commercial rates to determine the maximum amount that can be charged to FAP-eligible individuals. 20 Heritage Place 232 Rockwell Ave Soldotna AK 99669 Skilled nursing facility, longterm care Serenity House 47480 Kristina Way Soldotna AK 99669 Chemical dependency treatment center Central Peninsula Pain Management 289 N Fireweed Unit C/D Soldotna AK 99669 Pain management clinic Central Peninsula Neurology 289 N Fireweed St Suite C/D Soldotna AK 99669 Neurology clinic Central Peninsula Family Practice Kenai 506 Lake Street Kenai AK 99611 Family practice clinic Kenai Physical Medicine 260 Caviar St Kenai AK 99611 Physical therapy clinic Soldotna Physical Medicine 245 N Binkley Soldotna AK 99669 Physical Therapy clinic Kenai Health Center 630 Barnacle Way Kenai AK 99611 Diagnostic imaging, lab, and domestic violence services Central Peninsula Family & Pediatrics 245 N Binkley St Suite 101 Soldotna AK 99669 Family practice clinic Central Peninsula Surgical Services 289 N Fireweed St Unit B Soldotna AK 99669 Surgical clinic Serenity House intake office 245 N Binkley Street Suite 203 Soldotna AK 99669 Chemical dependency intake, behavioral health clinic Peninsula Medical Center 265 N Binkley Street Soldotna AK 99669 Owned medical office building Central Peninsula Medical Center 245 N Binkley Street Soldotna AK 99669 Owned medical office building Vacant building 158 Corral Street Soldotna AK 99669 Vacant building for remodel Serenity House transitional housing 166 W Corral Street Soldotna AK 99669 Transitional housing for Serenity House clients Kenai Spine Ctr 108 E Corral St Soldotna AK 99669 Medical office building partly leased to Kenai Spine, CP Radiology and Physical medicine Radiation Oncology Building 240 Hospital Place Soldotna AK 99669 Radiation Oncology Building - leased to RBS Evolution CP Foot & Ankle Clinic 198 W Corral Soldotna AK 99669 Hospital owned physician clinic Serenity House transitional housing II 146 W Corral Street Soldotna AK 99669 Residential building providing transitional housing to patients leaving chemical dependency CP Urology Clinic 262 N Binkley St Soldotna AK 99669 Urology Physician clinic Schedule H, Part I, Line 7 Costs reported in Part I, line 7a-c are based on the Medicare and Medicaid Cost report data for tax year 2014. Costs reported in Part I, line 7e-i are based on actual identifiable costs associated with these community benefit activities. Schedule H, Part I, Line 7, Column f Bad debt was reported at gross charges in 990 Part IX, line 25, column A at $12,811,570 along with gross charity care of $6,296,352. However, for the purposes of the Schedule H we have used the cost to charge ratio calculated herein (44%) to reduce our uncompensated care (bad debt plus charity) to the estimated cost to provide care ($5,637,091 in bad debt). Of this balance, approximately 73% is estimated to be attributable to patients who may have been eligible to receive free or discounted care under the Hospital's financial assistance policy but who failed to apply for assistance. Schedule H, Part I, Line 7g The Hospital reported 4 Physician clinics in Subsidized Health Services line 7 g. The physician clinics were Pain Management, Family Practice, Surgical services, and Orthopedic Services. Total costs associated with these four clinics were -$925,592. Schedule H, Part II The Hospital supports local educational and workforce institutions through monetary donations, job fairs, job shadowing programs, internships, community partnerships and coalitions, and skills training. Community workforce development and health education improves the quality of life and the health of the community by fostering positive activities and by engaging the community in health initiatives. Schedule H, Part III, Section A, Line 4 Footnote: Bad debt provisions are made for the amount of revenue that will not be collected from patients to whom services were billed but not paid. The Hospital has determined these patients are neither medically nor financially indigent and do not qualify for the Hospital's charity care program. Bad debt provisions are determined by management's assessment with consideration of business and economic conditions, changes and trends in healthcare coverage, and other collection indicators. The adequacy of this provision is periodically reviewed and further modified based upon the accounts receivable payor composition and aging, and historical write-off experience by payor category. Schedule H, Part III is based on the estimated cost to provide care for individuals whose accounts were classified as bad debt during the year. The amount which may be attributable to patients who qualify for charitable assistance or free care is estimated at approximately 73% of that total. These are accounts which our financial counselors made every effort to contact and assist patients to apply for financial assistance, but the patient refused to do so. It is our belief that all of these bad debts should be considered community benefits because they provide a necessary and vital health benefit to community members free of charge. Schedule H, Part III, Section B, Line 8 It is our belief that the shortfall in actual receipts from Medicare compared to the cost to provide care to Medicare patients should be considered a community benefit. The reason for this stance is that the Hospital is required to write off all contractual allowances for Medicare patients regardless of the amount of the shortfall. The Hospital may only collect the portion which is a patients co-pay or deductible and may not engage in collection efforts for the remainder. As Medicare patients comprise a significant percentage of our community members, our community Hospital must provide needed medical services to this population irrespective of the payments received. The Medicare costs reported herein are based on the fiscal year 2015 Medicare cost report filed. Schedule H, Part III, Section C, Line 9b The Hospital's collection policy PFS-546 addresses private pay patients and defines the individuals which are eligible to receive financial assistance based on either financial or medical indigence. The collection policy refers to the charity care policy for instructions on determining eligibility. As noted in Part I, the charity care policy is based on FPG which is the basis for a sliding scale between 200% and 300% of those guidelines. Applicants on the upper end of the scale (300%) are eligible for a discount on their bills, while those on the lower end (200%) are eligible to free care. Schedule H, Part VI, Line 2 In addition to the preparation of a Community Health Needs Assessment (CHNA) and a strategic plan to meet those needs, the Hospital also determines health deficits in the community through a variety of other ways. Hospital Administrators round on patients and meet regularly with an advisory committee comprised of area residents and former patients to determine the physician and specialty services necessary to meet the health needs of the community. The Hospital periodically employs consultants to determine the physician and specialty services needed in the community for strategic planning and physician recruiting. Finally, an open dialogue exists between Hospital management and patients, staff, and area medical providers which is another source of identifying community health needs. Schedule H, Part VI, Line 3 Hospital staff attempt to provide a financial assistance brochure to every patient during the admission or discharge process. The brochure is also available at each entrance, upon request, on the Hospital's public website, and is published in the local newspaper. Financial counselors personally contact patients with past due balances and explain the financial assistance policy, assist with applications for assistance, and set up payment plans if necessary. The Hospital employs 2 full time financial counselors that meet personally with patients to review their bills, set up payment arrangements, explain the financial assistance policy, and assist with the application process. In addition, the Hospital purchases advertising space in the local newspaper to notify the public of its financial assistance program and explain how patients can contact a financial counselor to apply. Schedule H, Part VI, Line 4 The area served by the Hospital is comprised of 13 Census designated places or towns and has a total population of approximately 36,000 residents according to the 2010 census. The geographic region is in the Central Kenai Peninsula in the State of Alaska. Based on the 2010 census, approximately 11% of the population is 65 years or older, 32% are between 45 and 64, and 32% are between 19 and 44. Basic socioeconomic characteristics of the region indicate an 8.6% unemployment rate with a median household income of $60,378, while 8.9% of residents live below the federal poverty line. More than 22% of adults age 18 to 64 years are uninsured, just 1% higher than the National average. Schedule H, Part VI, Line 5 The Hospital engages in numerous community efforts year-round to improve health awareness and education in our service area. Monetary donations to local non-profits that support health initiatives, healthy living programs, personnel support to local non-profits, public service announcements, conference room space for community organizations and support groups, health speaker bureaus, child safety programs, health professions education, health fairs, immunization clinics, community health newsletters, and numerous other programs, initiatives and collaborations. 1 Boys and Girls Club of the Kenai Peninsula 705 Frontage Rd Suite B Kenai AK 99611 943067142 501c3 20600 To support safe and healthy activities for local youths, ranging from after school care of school age children to athletic programs year-round. Kenai Peninsula United Way 11355 Frontage Rd Benco Building Suite 101 Kenai AK 99611 920111698 501c3 10000 Monetary support of United Way of the Kenai Peninsula, which promotes healthy living, financial stability, and educational improvement through is many community programs. Hospice of the Central Peninsula PO Box 2584 Soldotna AK 99669 920118694 501c3 54000 Two annual sponsorships for the 2014 and 2015 Hospice Bereavement Program which offers spiritual, emotional, and education support to families that have suffered a loss. Bridges Community Resource Network PO Box 1612 Soldotna AK 99669 920151271 501c3 9200 Sponsorship of the Imagination library ($9,000), Funny river quilters association ($100), and the Pink Ribbon rally ($100) Greater Soldotna Chamber of Commerce 44790 Sterling Hwy Soldotna AK 99669 920061612 501c6 9935 Two years of sponsorships for 2014 and 2015 community partner. Kenai Peninsula Youth Foundation Kenai River Brown Bears PO Box 2605 Soldotna AK 99669 262580744 501c3 20000 Monetary support for the 2014-2015 youth hockey season ($12,500) and support for Cancer awareness night ($7,500). The Kenai Peninsula Youth foundation is dedicated to providing developmental programs for aspiring student athletes. Kenai Peninsula Food Bank 33955 Community College Rd Soldotna AK 99669 943112445 501c3 5000 7816 Cost Turkeys and Hams Monetary and In Kind support for the Food bank annual fundraiser. The Food Bank provides low-cost or free nutritious food to families with financial need. Alaska State Hospital and Nursing Home Association 1049 W 5th Ave Ste 100 Anchorage AK 99501 920034538 501c6 8500 This represents two sponsorships for ASHNHA meetings. This organizations assists the hospital in collaborating with other healthcare entities. Kenai River Foundation PO Box 3944 Soldotna AK 99669 271570362 501c3 10000 Monetary support for the Wounded Heroes program. 7 2 Schedule I, Part I, Line 2 The Hospital provides cash contributions to local organizations which support community initiatives and health living on the Kenai Peninsula. Contributions are only made to organizations in good community standing. Hospital officials are responsible for approving all assistance to outside organizations and do so with discretion. X 0 1 X X X X X 0 1 0 1 0 1 0 0 0 Gregg Motonaga Anesthesia MD/Board Member 629300 0 31002 0 917 0 22348 0 21353 0 704920 0 0 0 Justin Evans Anethesia MD 553060 0 28672 0 866 0 23348 0 33928 0 639874 0 0 0 David S Innes Orthopedic Surgeon 1861123 0 20 0 872 0 5848 0 33928 0 1901791 0 0 0 Jason Lattin Surgeon 759382 0 20 0 872 0 5848 0 33928 0 800050 0 0 0 Cynthia Kahn Pain Management Physician 407597 0 64227 0 68438 0 5848 0 10353 0 556463 0 0 0 Richard Davis CEO 302446 0 32386 0 65625 0 12732 0 22962 0 436151 0 0 0 Shaun Keef Chief Financial Officer (former) 100504 0 10 0 21839 0 2828 0 14808 0 139989 0 0 0 Lance Spindler CFO (current) 64136 0 0 0 26529 0 1299 0 8887 0 100851 0 0 0 Andrea D Posey CNO (former) 1896 0 0 0 32877 0 76 0 0 0 34849 0 0 0 Karen Scoggins CNO (current) 17522 0 0 0 1842 0 383 0 0 0 19747 0 0 0 Johnny L Dodd VP of Human Resources 139100 0 4966 0 25060 0 8953 0 22962 0 201041 0 0 0 Matthew Dammeyer Chief Operating Officer 184447 0 15277 0 42208 0 10005 0 31553 0 283490 0 0 0 Schedule J, Part I, Line 1a Gross up payments are made for certain taxable fringe benefits including the value of life insurance over $50,000. A year-end wage adjustment is made for all affected employees to include the gross up for fringe benefits and excess life insurance benefits. The hospital has historically paid all social security and Medicare taxes on such benefits while the employee is responsible for federal income taxes. Schedule J, Part I, Line 1b The year end gross up adjustment for fringe benefits and life insurance over $50,000 is based on historical practice and is not governed by a written policy. The hospital maintains that at some future date, employees may be required to pay their own FICA taxes on these fringe benefits. Schedule J, Part I, Line 3 The Hospital contracts with an independent consultant every three years to perform a review of executive salaries and benefits. The most recent review was performed in October 2014. The resulting report was provided to the Board of Directors and Management for review. The Board then sets compensation levels for the CEO through a written employment contract. The CEO is responsible for hiring the remainder of the Hospital's executive staff and for using comparable data studies to set their salaries. Schedule J, Part I, Line 4 The Hospital provides a 457 top hat plan to certain key employees and executives. The following individuals on Schedule J participated in the 457 plan and either deferred their own compensation or received hospital contributions into the plan during the tax year: Gregg Motonaga $17,513, Justin Evans $17,513, Richard Davis $7,152, Lance Spindler $3,458, Karen Scoggins $2,158, Johnny Dodd $3,250, and Matthew Dammeyer $4,376. Schedule J, Part I, Line 5 In accordance with their employment contracts, Emergency room physicians and surgeons receive a percentage of their professional fees billed as compensation. This compensation is not based directly on the Hospital's overall revenue, but on the individual charges that are generated by the physician. Schedule J, Part I, Line 6 The Hospital pays an annual incentive plan bonus to all employees, supervisors, and executive staff based on a series of 4 operational and quality measures in order to maintain the highest standard of patient care. One of these 4 measures is meeting the Hospital's net earnings budget. The element comprises only one-fourth of the potential plan bonus payment. The bonus is not calculated based on the amount of the Hospital earnings. The remaining three measures are 1)Quality of care, 2)Patient satisfaction, and 3)Utilization. A Kenai Peninsula Borough 920030894 01179PX51 2011-09-15 27905000 Refunding bonds - 2011 GO 0 0 1 B Kenai Peninsula Borough 920030894 01179RDP5 2014-02-20 32490000 2014 Medical Office Building construction bonds 0 0 1 C Kenai Peninsula Borough 920030894 001179RJV 2015-06-15 3200000 2015 Medical Office Building construction bonds 0 0 0 A 0 0 32616814 0 0 0 201610 0 0 0 0 0 2008 0 1 1 1 B 0 0 34999563 2960067 1260277 1233670 127595 0 0 24887516 0 10039931 2016 0 0 0 1 C 0 0 3200000 320000 2651 54500 22868 0 0 929501 0 2247631 2016 0 0 0 1 A 0 0 0 0 0 0 0 0 0 1 B 0 1 0 0 0 0 0 1 0 1 C 0 1 0 0 0 0 0 1 0 1 A 0 0 0 0 1 0 0 0 0 B 0 1 0 0 1 0 0 0 1 C 0 1 0 0 1 0 0 0 1 A 1 B 1 C 1 Gregg Motonaga Dr. Motonaga is an employed physician and board member 704920 Total amount of employee compensation and benefits 0 Peninsula Internal Medicine Dr. Bramante, a board member, is an employed physician of Peninsula Internal Medicine 93385 Total invoices paid to Peninsula Internal Medicine during FY15. 0 Form 990, Part VI, Section A, Line 7b Central Peninsula Hospital Inc. operates the Hospital through a lease and operating agreement with the Kenai Peninsula Borough. The CPGH Board's decisions regarding the acquisition of significant capital assets and plant expansion are subject to the approval of the Kenai Peninsula Borough assembly. Bonds, loans, and capital expenditures not funded through the Hospital's plant replacement fund must be approved by a vote of the Borough constituents if greater than $1.0 million. Form 990, Part VI, Section B, Line 11b The 990 is prepared by the Hospital's Finance Department and submitted to Hospital management for review. Management then returns any edits to the Finance Department for preparation of a second draft. The second draft of the 990 and all schedules and statements are then submitted to each member of the Board for review and comment. The board proposes any edits to the Finance Department and gives authority to the CFO or Board President to sign and file the return. Form 990, Part VI, Section B, Line 12c Both senior leadership and members of the Board of Directors complete an annual conflict of interest statement which is reviewed by management and the finance team. The board reviews and discusses any conflicts of interest which arise throughout the year and takes appropriate action if needed. Form 990, Part VI, Section B, Line 15 An independent professional executive remuneration study is performed every 2-3 years. The most recently performed study by the Haygroup was executed in October 2014. Remuneration reports are submitted to the Board for review and used to set the wage scales for the CEO, CFO, CNO, COO and VP of Human Resources. Contemporaneous documentation exists for this study. Form 990, Part VI, Section C, Line 19 The Hospital makes its governing documents, conflict of interest policy, and audited financial statements available to the public upon request. The audited financial statements are also published on its website at www.cpgh.org. Central Peninsula Health Foundation 250 Hospital Place Soldotna AK 99669 202778670 To support quality healthcare activities AK 501(c)3 Public Charity N/A 0 Kenai Peninsula Borough 144 N Binkley Street Soldotna AK 99669 920030894 Local Government which owns the hospital assets. AK 115 N/A 0 0 0 1 0 0 0 0 1 0 1 1 0 1 1 1 1 1 1 0 Central Peninsula Health Foundation c 187812 This is the value of total contributions received from the Foundation in payment for programs, capital, grants to individuals for assistance. The Hospital initially paid for each of these program expenses, capital, or grants, and the Foundation reimbursed the Hospital with either restricted or unrestricted funds depending on the expenditure type. Kenai Peninsula Borough h 8950 In September 2014, the Hospital purchased a used 2004 Chevy 1500 Silverado maintenance truck from the Kenai Peninsula Borough. The amount of cash transferred to the borough was $8950.00. Central Peninsula Health Foundation j 15036 The Hospital provides office space to the Foundation Director for the cost of $1,253 per month. This amount includes janitorial and utilities. Kenai Peninsula Borough k 1 The Hospital is operated by Central Peninsula General Hospital Inc through a lease and operating agreement with the Kenai Peninsula Borough. The amount of the lease as stated in that agreement is $1 per annum. Central Peninsula Health Foundation m 187812 The Foundation performs fundraising for which a portion benefits the Hospital and the Hospital's programs. The value of those programs for which the Foundation transferred solicited funds during 2015 was $187,812. Central Peninsula Health Foundation n 15036 The Hospital provides office space to Central Peninsula Health Foundation. The value of the space is determined based on the most recently filed Medicare Cost Report (2014) expenses for facility, admin, and support services per square foot. During the 2014 tax year, the Foundation began to pay for the portion of their operating expenses which exceeded $4,000 per month. The office space expense was included in that $4,000 donation to the Foundation. Central Peninsula Health Foundation o 67307 The Hospital shares certain paid employees for directorship and accounting functions necessary to operate the Foundation. The Foundation in return pays the Hospital for any operating, facility, or staff costs which exceed $4,000 per month. Kenai Peninsula Borough p 6753395 The Hospital reimbursed the Kenai Peninsula Borough for debt service, property insurance premiums, refuse, and sales tax. This amount represents the actual cash payments to the borough for these expenses. Central Peninsula Health Foundation q 78538 The Foundation is billed for operating expenses incurred by the Hospital which exceed $4,000 per month. This represents the actual cash value of those expenses which were billed to Foundation and reimbursed to the Hospital. These expenses include facilities, staffing, supplies, and other operating expenses. Kenai Peninsula Borough r 9896658 Central Peninsula Hospital Inc operates the Hospital on behalf of the Kenai Peninsula Borough through a lease and operating agreement. That agreements requires that all operating cash in excess of 90 days expenses at the end of each quarter, be transferred into a Plant Replacement fund at the Kenai Peninsula Borough. This is the total amount of cash transferred to the borough during FY2015. The audited financial statements were not completed in time to prepare and file the 990. Therefore an extension was filed by the Hospital and accepted by the IRS.