2016-05-13T08:36:30-05:00 2015-06-30 480573184 REGIER CARR & MONROE LLP 4801 E BROADWAY BLVD STE 501 TUCSON AZ 857113648 990 2014-07-01 860208451 NORTHERN COCHISE COMMUNITY HOSPITAL INC NORT 5203843541 901 WEST REX ALLEN DRIVE WILLCOX AZ 856431009 ROLAND KNOX CEO 5203843541 2016-05-12 1 DAVID B BARBER CPACFE P00348638 5206248229 2014 2016-08-17 19:52:53Z ROLAND KNOX 901 WEST REX ALLEN DRIVE WILLCOX AZ 856431009 18793446 0 X WWW.NCCH.COM X 1966 AZ TO PROVIDE FOR THE HEALTHCARE NEEDS OF THE GREATER WILLCOX COMMUNITY AND SOUTHEAST ARIZONA. 6 6 248 52 0 0 1631789 1773008 18607343 16935165 1382 13307 69912 71966 20310426 18793446 0 0 0 0 9588874 9639071 0 0 0 11001429 9091894 20590303 18730965 -279877 62481 5692816 5907937 2832979 2985620 2859837 2922317 TO PROVIDE FOR THE HEALTHCARE NEEDS OF THE GREATER WILLCOX COMMUNITY AND SOUTHEAST ARIZONA. 0 0 12209090 16947497 THE HOSPITAL PROVIDES HEALTHCARE TO THE GENERAL PUBLIC REGARDLESS OF AGE, RACE, OR ABILITY TO PAY. SERVICES INCLUDE, BUT ARE NOT LIMITED TO, EMERGENCY ROOM, PHYSICAL THERAPY, SPEECH THERAPY, RESP THERAPY, CT SCAN, MRI, NURSING HOME SERVICES, RURAL HEALTH CLINIC, LABORATORY SERVICE, AND OTHER SERVICES. 12209090 1 1 0 0 0 0 0 0 0 0 1 0 0 0 1 1 0 1 0 0 0 0 0 0 0 0 1 1 0 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 1 0 0 0 1 45 0 1 248 1 0 0 0 0 0 0 0 0 X 6 6 0 0 0 0 0 0 0 1 1 0 0 1 1 1 1 1 1 1 1 0 AZ X X THE ORGANIZATION 5203843541 901 WEST REX ALLEN DRIVE WILLCOX AZ 856431009 STEVE METTS VICE-CHAIRMAN 1.00 X 0 0 0 DR JAMES MALONE CHAIRMAN 1.00 X 0 0 0 CAROL DUNAGAN DIRECTOR 1.00 X 0 0 0 KATHY COOK SECRETARY 1.00 X 0 0 0 E RICHARD SINGER DIRECTOR 1.00 X 0 0 0 HISHAM HAMAM MD CHIEF OF STAFF DIRECTOR 1.00 X 0 0 0 ROLAND KNOX CEO 40.00 X 224327 0 20023 JULIE HILTON E.R. NURSE PRACTITIONER 55.00 X 188425 0 16648 HELEN ROWE PHYSICAL THERAPIST 40.00 X 106572 0 9508 LAUREL KIBLER ANP - PROVIDER 40.00 X 108848 0 8910 FRANCIS PAUL SMITH PHARMACIST IN CHARGE 40.00 X 102663 0 7472 730835 0 62561 5 0 1 0 ANTHONY LLEWELLYN MD PLC 5782 PLACITA DELEITE TUCSON AZ 85750 PHYSICIAN 442125 MEDICAL DIAGNOSTIC IMAGING GROUP PO BOX 17049 PHOENIX AZ 85011 RADIOLOGY 382588 ELHAM MEDICAL INTERNATIONAL INC PO BOX 12578 TUCSON AZ 85732 HOSPITALIST 327125 JOSHUA DOPKO MD 3697 PINNACLE COURT SIERRA VISTA AZ 85650 PHYSICIAN 263098 4 1699000 14192 59816 1773008 PATIENT SERVICE REVENUE 900099 16801897 16801897 OTHER SERVICE REVENUE 900099 133268 133268 16935165 975 975 71966 0 71966 71966 71966 12332 0 12332 12332 12332 18793446 16947497 0 72941 X 850135 512294 337841 6984128 5692410 1291718 246541 246541 1010692 1010692 547575 441053 106522 28654 18698 9956 90188 58851 31337 2606358 2264619 341739 33602 33602 48000 48000 57065 42538 14527 62660 62660 384546 148608 235938 384140 25156 358984 MATERIALS AND SUPPLIES 1492995 1379235 113760 BAD DEBTS 1419905 1419905 REPAIRS AND MAINTENANCE 836637 660364 176273 RENT-EQUIPMENT 830587 701735 128852 816557 263529 553028 18730965 12209090 6521875 0 455558 609036 534603 536341 2469907 2671589 182384 188341 188834 112372 7231484 5459726 1841481 1771758 20049 18500 5692816 5907937 1871287 2114897 1140940 972843 -179248 -102120 2832979 2985620 X 2793403 2880791 66434 41526 2859837 2922317 5692816 5907937 X 62481 -1 X X 0 1 X 1 0 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 1722539 670738 1051801 311026 236027 74999 5197919 4552961 644958 1771758 PORTION OF A/P & ACCRUED EXPENSES DUE FROM RELATED TAX-EXEMPT ORG -102120 -102120 X PART X, LINE 2: THE HOSPITAL HAS BEEN RECOGNIZED AS TAX EXEMPT PURSUANT TO SECTION 501(C)(3) OF THE INTERNAL REVENUE CODE; HOWEVER, THE HOSPITAL IS SUBJECT TO FEDERAL INCOME TAX ON ANY UNRELATED BUSINESS TAXABLE INCOME. GENERALLY ACCEPTED ACCOUNTING PRINCIPLES FOR INCOME TAXES SETS A "MORE LIKELY THAN NOT" CRITERION FOR RECOGNIZING THE TAX BENEFITS OF UNCERTAIN TAX POSITIONS AND A MEASUREMENT CRITERIA FOR TAX BENEFITS. THE HOSPITAL BELIEVES THAT ITS INCOME TAX FILING POSITIONS AND DEDUCTIONS WILL BE SUSTAINED UPON EXAMINATION AND, ACCORDINGLY, HAVE NOT RECORDED ANY RESERVES OR RELATED ACCRUALS FOR INTEREST AND PENALTIES AT JUNE 30, 2015 FOR UNCERTAIN INCOME TAX POSITIONS PURSUANT TO THE STANDARD. INCOME TAX RELATED INTEREST AND PENALTIES ARE REPORTED IN GENERAL AND ADMINISTRATIVE EXPENSES WHEN INCURRED. THE ACCOMPANYING FINANCIAL STATEMENTS DO NOT INCLUDE ANY INTEREST OR PENALTIES RELATED TO INCOME TAXES. NO INCOME TAX EXAMINATIONS ARE CURRENTLY UNDERWAY OR ANTICIPATED. THE STATUTE OF LIMITATIONS IS THREE YEARS FOR FEDERAL INCOME TAX PURPOSES AND FOUR YEARS FOR THE STATE OF ARIZONA. 1 1 X 1 X 0 0 1 1 0 1 1 9462 9462 0.00050 5054096 1871286 3182810 0.16990 5063558 1871286 3192272 0.17040 5063558 1871286 3192272 0.17040 54542 54542 0.00290 39334 39334 0.00210 93876 93876 0.00500 1 1444128 4376005 5850275 -1474270 X 1 0 1 1 NORTHERN COCHISE COMMUNITY HOSPITAL 901 REX ALLEN DR WILLCOX AZ 85643 X X X X NORTHERN COCHISE COMMUNITY HOSPITAL 1 0 0 1 X X X X X X X X X 13 1 0 0 1 X WWW.NCCH.COM X 1 12 0 0 0 1 X 100.000000000000 X X X X X 1 1 X X X 1 X 1 X 1 X X X 1 X 0 0 NORTHERN COCHISE COMMUNITY HOSPITAL PART V, SECTION B, LINE 5: THE ASSESSMENT PROCESS WAS INITIATED AND CHAIRED BY NORTHERN COCHISE COMMUNITY HOSPITAL INC. (NCCH). OVER 34 AGENCIES/INDIVIDUALS WERE INVITED TO PARTICIPATE IN THE CHNA PROCESS. THOSE INVITED INCLUDED MEDICAL, DENTAL, PHARMACY, VISION, CHIROPRACTIC, EDUCATIONAL, FIRST RESPONDERS, PROVIDERS FOR THE UNINSURED AND MINORITY POPULATIONS, AHCCCS (MEDICAID), MENTAL HEALTH, COUNTY HEALTH DEPARTMENT, AGING POPULATION, COUNTY SUPERVISORS, FAITH COMMUNITY, MUNICIPAL GOVERNMENT, HOSPICE, HOME HEALTH, PRIVATE BUSINESS, MEDIA, ADULT CARE, SERVICE ORGANIZATION, STATE PRISON, AND THE CHAMBER OF COMMERCE REPRESENTATIVES. PARTICIPATION RATE FOR THE CHNA PROCESS WAS JUST UNDER ONE-HALF OF THOSE WHO HAD INITIALLY BEEN INVITED. INCLUDED IN THE PARTICIPATION WERE INDIVIDUALS WITH OVER 50 YEARS OF COMBINED EXPERIENCE WORKING WITH CHRONIC DISEASE MANAGEMENT, END OF LIFE ISSUES, MINORITY POPULATIONS, THE ELDERLY, DOMESTIC VIOLENCE, AND THE UN/UNDERINSURED POPULATIONS. A QUESTIONNAIRE WAS ALSO UTILIZED AS PART OF THE PROCESS. A TOTAL OF 115 SURVEYS WERE DISTRIBUTED, WITH 47 BEING RETURNED AND FILLED OUT COMPLETELY. NORTHERN COCHISE COMMUNITY HOSPITAL PART V, SECTION B, LINE 22D: THE HOSPITAL UTILIZES THE SLIDING FEE SCHEDULE BASED ON THE POVERTY GUIDELINES TO DETERMINE AMOUNT OF DISCOUNT. 4 SULPHUR SPRINGS MEDICAL CENTER 900 W SCOTT WILLCOX AZ 85643 MEDICAL CENTER NORTHERN COCHISE NURSING HOME 901 REX ALLEN DR WILLCOX AZ 85643 NURSING HOME SUNSITES MEDICAL CENTER 223 N FRONTAGE RD PEARCE AZ 85625 MEDICAL CENTER SPECIALTY CLINICS 900 W SCOTT WILLCOX AZ 85643 CLINIC PART I, LINE 3C: THE ORGANIZATION PROVIDES DISCOUNTED CARE BASED ON A CASE BY CASE EVALUATION. ALL INFORMATION IS REVIEWED BY THE PFS DIRECTOR AND COMPARED WITH THE POVERTY GUIDELINES AS WELL AS ALL OUTSTANDING MEDICAL EXPENSES. OTHER FACTORS WILL CONTRIBUTE TO THE FINAL DECISION. PART I, LN 7 COL(F): THE BAD DEBT EXPENSE INCLUDED ON FORM 990, PART IX, LINE 25(A), BUT SUBTRACTED FOR PURPOSES OF CALCULATING THE PERCENTAGE IN THIS COLUMN IS 1,419,905. X X X X X 0 0 0 1 0 0 0 0 0 ROLAND KNOX CEO 224327 0 0 0 0 0 11481 0 8542 0 244350 0 0 0 JULIE HILTON E.R. NURSE PRACTITIONER 188425 0 0 0 0 0 16648 0 0 0 205073 0 0 0 PART I, LINE 5 PURSUANT TO THE ORGANIZATION'S EMPLOYEE AGREEMENT WITH THE CEO, AN ANNUAL INCENTIVE BONUS MAY BE PAID. THIS BONUS IS DEPENDENT ON THE ORGANIZATION'S OVERALL FINANCIAL CONDITION AND THE CEO'S ACHIEVEMENT OF A VARIETY OF PREVIOUSLY ESTABLISHED GOALS RELATED TO COMMUNITY INVOLVEMENT, EMPLOYEE DEVELOPMENT, OPERATIONAL COMPLIANCE, INDUSTRY KNOWLEDGE, AND THE IMPLEMENTATION OF NEW PROGRAMS. UNDER ADDENDUM 1 OF THE CEO'S EMPLOYMENT AGREEMENT, $30,000 WAS PAID TO THE CEO IN NOVEMBER 2014. FORM 990, PART VI, SECTION B, LINE 11 THE RETURN IS REVIEWED BY THE CEO AND MADE AVAILABLE TO THE BOARD OF DIRECTORS BEFORE IT IS FILED. FORM 990, PART VI, SECTION B, LINE 12C ALL OFFICERS AND DIRECTORS ARE REQUIRED TO FILL OUT A CONFLICT OF INTEREST FORM ANNUALLY. THE FORMS ARE REVIEWED BY THE COMPLIANCE OFFICER FOR POTENTIAL CONFLICTS. ANY ACTUAL CONFLICTS ARE REVIEWED BY THE BOARD OF DIRECTORS. A PERSON WITH A CONFLICT IS RESTRICTED FROM VOTING ON RELATED MATTERS. FORM 990, PART VI, SECTION B, LINE 15 THE CEO'S COMPENSATION IS DETERMINED ON AN ANNUAL BASIS BY A COMPENSATION COMMITTEE BASED ON COMPARABILITY DATA. FORM 990, PART VI, SECTION C, LINE 19 THE ORGANIZATION MAKES ITS GOVERNING DOCUMENTS, CONFLICTS OF INTEREST POLICY, AND FINANCIAL STATEMENTS AVAILABLE TO THE PUBLIC UPON REQUEST. FORM 990, PART IX, LINE 11G OTHER: PROGRAM SERVICE EXPENSES 1,913,518. MANAGEMENT AND GENERAL EXPENSES 217,941. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 2,131,459. OUTSIDE SERVICES: PROGRAM SERVICE EXPENSES 351,101. MANAGEMENT AND GENERAL EXPENSES 123,798. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 474,899. FORM 990, PART XI, LINE 9: ROUNDING -1. FORM 990, PART XII, LINE 2C: THE ORGANIZATION DID NOT CHANGE ITS OVERSIGHT OR REVIEW PROCESS DURING THE YEAR. NORTHERN COCHISE HOSPITAL DISTRICT 901 REX ALLEN DR WILCOX AZ 85643 TO ENSURE THE OPERATION OF THE HOSPITAL WITHIN THE DISTRICT AZ 170(C)(1) N/A N/A 0 0 0 1 0 0 0 0 0 0 0 1 0 0 0 0 0 0 0 0 NORTHERN COCHISE HOSPITAL DISTRICT C 1699000 ACTUAL CASH AMOUNT TRANSFERRED NORTHERN COCHISE HOSPITAL DISTRICT K 48000 ACTUAL EXPENSE INCURRED