2014-08-13T10:47:14-05:00 2013-12-31 481026809 Wendling Noe Nelson & Johnson LLC 534 S Kansas Ave Suite 1500 Topeka KS 666033491 990 2013-01-01 480576039 Clara Barton Hospital Association Inc CLAR 6206532114 250 West 9th Street Hoisington KS 675441799 Jim Blackwell Chief Financial Officer 6206532114 2014-08-13 1 Derek H Hart P01054116 7852334226 2014-08-13 2013 2015-11-30 17:44:51Z Jim Blackwell 250 West 9th Street Hoisington KS 675441799 20708963 0 X www.clarabartonhospital.org X 1946 KS Provision of inaptient and outpatient hospital services, primary care services, and surgical services to residents of our service area. 10 8 223 11 0 0 63906 140112 16490844 16864249 121773 136642 337734 347188 17014257 17488191 0 0 0 0 9414491 9750596 0 0 75564 7198005 7639474 16612496 17390070 401761 98121 12384240 12690483 5391017 5339164 6993223 7351319 X Clara Barton Hospital Association is dedicated to meeting the health care needs and improving the quality of life for the community we serve. We continually pursue clinical excellence in an atmosphere of caring and compassion. We are deeply committed to serving all in need within our resources. 0 0 14769903 16864249 Clara Barton Hospital Association provided a wide range of health care services to residents of its service area including 3,280 patient days of inpatient care, 20,588 outpatient hospital visits and 25,950 visits to our primary care and surgical clinics. 14769903 1 1 0 1 0 0 0 0 0 0 1 0 0 1 0 1 1 0 0 0 0 0 0 0 0 0 1 1 0 0 1 1 0 0 0 0 0 1 0 0 1 0 0 0 0 0 0 1 0 0 0 1 49 0 1 223 1 0 0 0 0 0 0 0 0 0 0 X 10 8 0 0 0 0 1 1 0 1 1 0 0 1 1 1 1 1 1 1 0 0 X Jim Blackwell 6206532114 250 West 9th Street Hoisington KS 675441799 Curt J Colson President/CEO 40.00 X X 130127 0 33707 Jon Radke Secretary 1.00 X X 0 0 0 Troy Bailey Chairman 1.00 X X 0 0 0 Paul Woydziak Vice-Chariman 1.00 X X 0 0 0 Mike Aylward Director 1.00 X 0 0 0 Nathaniel Knackstedt Director/Chief of Staff 40.00 X 233387 0 36177 Marla Mooney Treasurer 1.00 X X 0 0 0 Taylor Smith Director 1.00 X 0 0 0 Karla Crissman Director 1.00 X 0 0 0 Jim Carney Director 1.00 X 0 0 0 James G Blackwell Vice President/CFO 40.00 X 107896 0 33243 Robin Durrett Surgeon 40.00 X 544137 0 22565 Timothy Webb Physician 40.00 X 352204 0 27697 Phillip Barnes Physician Assistant 40.00 X 127113 0 29942 Linda Krug Physician Assistant 40.00 X 121036 0 21573 Celeste M Meitner Pharmacist 40.00 X 108205 0 17021 1724105 0 221925 9 0 1 0 Docs Who Care PA 1337 South Fountain Drive Olathe KS 66061 ER Physician Coverage 486366 Aramark Uniform Services 115 N First St Burbank CA 91502 Laundry services 302467 Leslie M Landau DO PA PO Box 470 Kirksville MO 63501 Surgeon 253170 MModal Services LTD 9009 Carothers Parkway Suite C-2 Franklin TN 37067 Transcription 191212 Mobile Imaging Inc 3520 Lakin Ave Great Bend KS 67530 Sonography 179934 11 111792 23385 4935 140112 Patient service revenue 621990 16738594 16738594 Purchase discounts and rebates 621990 54182 54182 Lab fairs 621990 24837 24837 Miscellaneous 621990 24373 24373 Patient account interest 621990 22263 22263 16864249 163118 163118 275864 275864 14709 0 14709 14709 14709 3194296 3220772 -26476 -26476 -26476 Cafeteria 722210 56615 56615 56615 17488191 16864249 0 483830 576765 270606 306159 7722691 6632937 1037078 52676 135273 118300 16019 954 756625 680139 71029 5457 559242 468622 87025 3595 15903 15903 1325 1325 2736532 2537502 198953 77 49609 27179 22430 713732 611560 93156 9016 162390 162390 308570 263477 44180 913 40753 36564 4188 1 180356 180356 769279 640040 126623 2616 114878 114878 Medical supplies 998151 998151 Pharmacy supplies 763308 763308 Repairs and maintenance 259738 246738 12762 238 Minor equipment 233423 116476 116928 19 291527 177948 113577 2 17390070 14769903 2544603 75564 987 987 1227760 1796417 1503193 1723828 123111 100028 1500 4500 511806 487893 210142 220392 12546110 8819146 4009365 3726964 2947819 3111883 5547 5547 1843010 1512044 12384240 12690483 1636884 1963536 3480697 3210611 273436 165017 5391017 5339164 X 6187195 6473147 536138 603839 269890 274333 6993223 7351319 12384240 12690483 X 98121 187831 72144 X 0 1 X 1 0 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 0 0 0 0 0 1 4725 0 0 0 4725 0 Part II-B, Line 1: The portion of annual dues paid to hospital and medical associations attributed to lobbying activities by the associations. 554300 388441 165859 6404736 4367906 2036830 4550784 3507903 1042881 1036290 554896 481394 3726964 Beneficial interest in net assets of CBH Foundation 849242 Deferred financing costs 96050 Accrued interest receivable 3318 Estimated third-party payor settlements 563434 1512044 X 17488191 0 17488191 0 17488191 17390070 0 17390070 0 17390070 Part X, Line 2: The Hospital is a not-for-porfit corporation as described in Section 501(c)(3) of the Internal Revenue Code and is exempt from federal income taxes on related income pursuant to Sectin 501(a) of the code. Management is not aware of any uncertainties in income tax positions. Tax years ending on and before December 31, 2010, are not subject to examination by taxing authorities. 1 1 1 X 1 X 1 1 0 0 259072 259072 0.01490 1119667 530309 589358 0.03390 1378739 530309 848430 0.04880 2533 2533 0.00010 5973 5973 0.00030 1485945 961787 524158 0.03010 2100 2100 0.00010 1496551 961787 534764 0.03060 2875290 1492096 1383194 0.07940 1 427176 42718 6359106 6389339 -30233 X 1 1 1 1 Clara Barton Hospital 250 West 9th Street Hoisington KS 675441799 H005003 X X X X Physician clinics & rural health clinics Clara Barton Hospital Association Inc 1 1 X X X X X X X X X 12 1 1 1 X www.clarabartonhospital.org X X X X X X X X 0 0 1 1 100.000000000000 1 300.000000000000 1 X X X X X X 1 1 X X X X X X 1 0 X X X X X 1 X 0 0 Clara Barton Hospital Association, Inc. Part V, Section B, Line 3: The CHNA was conducted in collaboration with Great Bend Regional, Ellinwood District Hospital, St. Rose's ASC, and the Barton County Health Department. The Hospital reached out to members of the community with broad interests in the community served and special knowledge of or expertise in public health from groups such as local hospitals, public health community, mental health community, free clinics, community based clinics, service providers, local residents, community leaders, opinion leaders, school leaders, business leaders, local government, faith-based organizations and persons (or organizations serving them), people with chronic conditions, uninsured community members, low income residents, and minority groups. A Town Hall meeting of 37 attendees was conducted. The Town Hall meeting reflected on the size and seriousness of any health concerns cited and discussed current community health strengths, as well as identifying and ranking top community health concerns. In addition to the Town Hall meeting, CHNA surveys were mailed to 2,000 randomly selected Barton County residents. 230 area households in the community completed the CHNA survey. The survey was created to measure Barton County residents' views regarding health care perceptions of delivery, access, and health practices. Clara Barton Hospital Association, Inc. Part V, Section B, Line 4: Great Bend Regional (located in Great Bend, KS - Barton County), Ellinwood District Hospital (located in Ellinwood, KS - Barton County), and St. Rose's ASC (located in Great Bend, KS - Barton County) Clara Barton Hospital Association, Inc. Part V, Section B, Line 7: The teen pregnancy rate and health care transportation out of the county were not addressed due to limited resources. Clara Barton Hospital Association, Inc. Part V, Section B, Line 18e: Clara Barton Hospital Association, Inc., notified all uninsured patients about the Hospital's charity care program by letter. Clara Barton Hospital Association, Inc. Part V, Section B, Line 20d: Maximum amounts that can be charged were determined by calculating the amounts generally billed (AGB). AGB is calculated based on the look back method. 2 Russell Family Medical Care 410 N Main Street Suite C Russell KS 67665 Rural health clinic Clara Barton Hospital Surgical Clinic 1301 Jackson Street Great Bend KS 67530 Physician clinic Part I, Line 7: Financial assistance at cost was determined by utilizing departmental cost-to-charge ratios for financial assistance provided in areas that are reported as subsidized health services. An overall cost-to-charge ratio derived from Worksheet 2 was used to determine the cost of financial assistance provided for services not reported as subsidized health services.Unreimbursed Medicaid costs were also determined using a blend of cost-to-charge ratios for certain services and an overall cost-to-charge ratio derived from Worksheet 2 for all other services.The cost of providing subsidized health services was determined using a cost-to-charge ratio for each service.Actual costs and revenues were utilized for all other items reported on line 7. Part I, Line 7g: Subsidized health services are comprised of services that the Hospital provides despite a financial loss to the organization. These services include the operation of a 24-hour emergency room. Part III, Line 4: The Hospital recognizes patient service revenue associated with services provided to patients who have third-party payor coverage on the basis of contractual rates for the services rendered. For uninsured patients that do not qualify for charity care, the Hospital recognizes revenue on the basis of its standard rates for services provided. On the basis of historical experience, a significant portion of the Hospital's uninsured patients will be unable or unwilling to pay for the services provided. Thus, the Hospital records a significant provision for bad debts related to uninsured patients in the period the services are provided.Bad debt expense at cost was determined by utilizing departmental cost-to-charge ratios for financial assistance provided in areas that are reported as subsidized health services. An overall cost-to-charge ratio derived from Worksheet 2 was applied to the charges deemed uncollectible during the year for all other services.Bad debt expense attributable to patients eligible under the organization's financial assistance policy was determined using an estimated 10% of total bad debts. The Hospital takes steps to assist individuals who are believed to qualify for financial assistance prior to writing accounts off as uncollectible.All non-reimbursed costs for treatment of patients in our community provides a community benefit since patients unwilling or unable to pay have received a valuable service at no cost or at a reduced cost to them. This improves the health of our community as a whole. Part III, Line 8: Medicare allowable costs were determined by using amounts from the Hospital's Medicare cost report as filed with the Medicare Administrative Contractor. The Medicare cost report apportions actual costs to the Medicare program using charges for ancillary services and patient days for nursing services. Part III, Line 9b: The collection policy states that the patient must cooperate with the Hospital to provide the information and documentation necessary to apply for other existing financial resources that may be available to pay for health care services, such as Medicaid. Then the information is gathered and assessed in order to determine eligibility for charity care. Whenever possible, prior to admission, the Hospital will conduct a pre-admission interview with the patient, the guarantor, and/or the patient's legal representative. Those patients who may qualify for financial assistance from a governmental program will be referred to the appropriate program, prior to the consideration for charity care. Part VI, Line 3: There is signage posted at admissions desk. Patients are referred to a financial counselor at admission if they do not have insurance. The financial counselor also works with a Medicaid helper to try and get qualified patients register for the Medicaid program. Effort is made during billing of deductible and co-payment to see if patient can qualify for charity care. Part VI, Line 4: The community being served is located in central Kansas and consists of approximately 2,800 residents. The average household income is $32,993. 15.4% of the community residents live below federal poverty level, and 4.7% of the community residents live below 50% of the federal poverty level. Neighboring hospitals include facilities in Ellinwood and Great Bend. They are approximately 18 and 11 miles away respectively. Part VI, Line 5: The Hospital's Board of Directors is elected from the community at large. This allows independent individuals who reside in the primary service area to serve as a director. The Hospital also extends medical staff privileges to all qualified physicians in the community. Any surplus in funds is retained by the Hospital and aids in improving overall patient care and facility maintenance. X X X 0 0 0 0 0 0 0 0 0 Curt J Colson President/CEO 125127 0 5000 0 0 0 3765 0 29942 0 163834 0 0 0 Nathaniel Knackstedt Director/Chief of Staff 233387 0 0 0 0 0 6010 0 30167 0 269564 0 0 0 Robin Durrett Surgeon 482557 0 61580 0 0 0 7500 0 15065 0 566702 0 0 0 Timothy Webb Physician 352204 0 0 0 0 0 7650 0 20047 0 379901 0 0 0 Phillip Barnes Physician Assistant 112735 0 14378 0 0 0 0 0 29942 0 157055 0 0 0 A Hoisington Public Building Commission Hoisington Kansas 486012386 000434661 2006-03-23 5019230 Refund outstanding bonds issued on 12/19/2000 and 2/27/2003 0 0 0 A 1730000 5165979 459077 97212 79389 4842628 2006 1 1 1 1 A 0 0 0 0 0 0 0 A 0 0 0 1 0 0 0 0 0 A 0 Date Rebate Computation Performed Issuer Name: Hoisington Public Building Commission, Hoisington, Kansas Date the Rebate Computation was Performed: 03/23/2011 Schedule K, Part II, Line 3, Total proceeds of issue The difference between Part II, Line 3 and Part I, Column (e) is investment earnings. Timothy Webb Highly compensated employee Recruitment X 138500 100028 0 1 1 100028 Anita Blackwell Spouse of Jim Blackwell, current officer 41686 Employment arrangement 0 Form 990, Part VI, Section A, line 6 Members of Clara Barton Hospital Foundation, Inc., are automatically members of Clara Barton Hospital Association, Inc. Form 990, Part VI, Section A, line 7a Members of Clara Barton Hospital Association, Inc., elect members of the governing body. Form 990, Part VI, Section B, line 11 Form 990 provided to governing body and reviewed prior to filing. Form 990, Part VI, Section B, line 12c A conflict of interest disclosure form is provided to each Board Member and is reviewed annually. Form 990, Part VI, Section B, line 15a The organization uses the KHA Salary Survey as a guide for determining CEO compensation with Board of Directors approval. The KHA Salary Survey is used by the CEO when determining compensation for other officers and key employees. Form 990, Part VI, Section C, line 19 The organization makes its governing documents, conflict of interest policy, and financial statements available to the public upon written request. Form 990, Part XI, line 9: Change in permanently restricted beneficial interest in Foundation 4,443. Change in temporarily restricted beneficial interest in Foundation 67,701. Clara Barton Hospital Foundation Inc PO Box 25 Hoisington KS 67544 481077460 Provide support to Clara Barton Hospital KS 501(c)(3) Line 7 N/A 0 0 1 1 0 0 0 0 0 0 0 0 1 0 1 1 0 0 0 0