2013-05-15T15:02:21-05:00 2012-06-30 BKD LLP 2800 Post Oak Blvd Ste 3200 HOUSTON TX 77056 990 2011-07-01 751976930 MOTHER FRANCES HOSPITAL - JACKSONVILLE % MOTHER FRANCES HOSP ACCTG DE MOTH 9035315764 1315 DOCTORS DRIVE TYLER TX 75701 JOYCE HESTER 2013-05-15 true Amanda Maya 7134994600 2011 2016-02-25 16:41:14Z B RAY THOMPSON 910 E HOUSTON SUITE 500 TYLER TX 75702 37803409 false X WWW.TMFHS.ORG X 2000 TX TO PROVIDE THE COMMUNITY WITH A FULL RANGE OF COMPREHENSIVE HEALTHCARE SERVICES WITHOUT REGARD TO RACE, CREED, SEX, NATIONAL ORIGIN, HANDICAP, AGE, OR ABILITY TO PAY. 6 3 186 4 0 0 0 0 37733895 37803399 0 0 46821 10 37780716 37803409 946111 1010437 0 0 9569354 9802949 0 0 0 25172933 25418456 35688398 36231842 2092318 1571567 23941694 34548586 11431023 20466348 12510671 14082238 TO PROVIDE THE COMMUNITY WITH A FULL RANGE OF COMPREHENSIVE HEALTHCARE SERVICES WITHOUT REGARD TO RACE, CREED, SEX, NATIONAL ORIGIN, HANDICAP, AGE, OR ABILITY TO PAY. false false 30241534 1010437 37803399 THE HOSPITAL'S OPERATING PLAN INCORPORATES PROVISIONS FOR INDIVIDUALS WHO DO NOT POSSESS THE ABILITY TO PURCHASE ESSENTIAL MEDICAL SERVICES. OUR COMMITMENT TO OUR COMMUNITY EXTENDS TO FREE OR SUBSIDIZED INDIVIDUAL CARE, SUBSIDIZED EDUCATION OF HEALTHCARE PROFESSIONALS, DISCOUNTED FEES FOR PARTICIPANTS IN GOVERNMENT PROGRAMS, COMMUNITY HEALTH EDUCATION AND DONATIONS TO OTHER COMMUNITY AGENCIES. SPECIFIC COMMUNITY SERVICES AND PROGRAMS INCLUDE: WELLNESS AND PREVENTION EDUCATION PROGRAMS, COMMUNITY DIAGNOSTIC SCREENING PROGRAMS, SENIOR CITIZEN HEALTH AWARENESS PROGRAMS, AWARENESS PROGRAMS FOR YOUTH AT RISK, AND AWARENESS PROGRAMS FOR PERSONS WITH SPECIAL PHYSICAL OR MENTAL NEEDS. 30241534 true false false true false false false false false false true false false true true false false true false false false false false false false false true true true false true false false false false false false false false false false false false false true false false false false true X 29 0 true 186 true false false false false false false false false false false X 6 3 false true false false true true true true true false false true true true true true true true true false X MOTHER FRANCES HOSP ACCTG DE 9035315764 1315 DOCTORS DRIVE TYLER TX 75701 X MATTHEW A VIERKANT MD 40.0 X 515661 12813 RAY THOMPSON 5.0 X X 0 1501469 546683 GLEN T HAMILTON 1.0 X X 0 0 0 WILLIAM MILAWSKI MD 40.0 X 0 241289 11555 DICK STONE 1.0 X 0 0 0 RANDY GORHAM 1.0 X 0 0 0 THOMAS N CAMMACK JR 40.0 X 287283 15342 MICHAEL LEWIS 40.0 X 127185 0 11952 JOYCE HESTER 5.0 X 0 229601 12196 J LINDSEY BRADLEY JR 1.0 X 0 1705258 18259 PAM VUKOVICH 5.0 X 0 0 0 BARRY L THIBODEAUX 40.0 X 240483 0 9274 JACK CAPPS 40.0 X 234025 0 16654 BEN BEATHARD 40.0 X 102350 0 9232 KLEANTHE CARUSO 40.0 X 119505 0 4464 WILLIAM BELLENFANT SR 0.0 X 0 2149403 2234 1110831 6342681 670658 6 true true false CARDIAC IMAGING SERVICES 1737 DOMINION PLAZA TYLER TX 75703 CARDIAC IMAGING 353310 COMPLETERX LTD 3100 S GEENER RD HOUSTON TX 77063 PMARMACY SERVICES 329240 SIEMENS MEDICAL SOLUTIONS PO BOX 120001 DALLAS TX 75312 SOFTWARE MAINTENANCE 323271 CAREFUSION SOLUTIONS LLC 3750 TORREY VIEW CT SAN DIEGO CA 92130 MEDICAL SERVICES 261542 CAPSTONE PERSONNEL SERVICES INC PO BOX 5744 TYLER TX 75711 CONTRACT STAFFING 211499 5 0 NET PATIENT REVENUE 621110 35086481 35086481 UPL MEDICAID REVENUE 900099 1757064 1757064 EHR INCENTIVE REVENUE 900099 225074 225074 PHARMACY REVENUE 446110 623044 623044 RENTAL REVENUE - PROGRAM SERVICE 532000 98164 98164 13572 13572 37803399 0 0 0 0 0 0 0 MEDICAL RECORDS FEES 900099 10 10 10 37803409 37803399 10 1010437 1010437 0 0 0 441762 441762 0 7373967 6366389 1007578 0 1987220 1645419 341801 0 411568 21996 389572 0 0 0 0 0 11539671 10547919 991752 29752 29752 112033 58894 53139 6996 5229 1767 0 2579911 384091 2195820 2622 2044 578 0 7311 4764 2547 0 0 438077 438077 47605 47605 BAD DEBT EXPENSE 6750366 6750366 0 MEDICAL SUPPLIES 2761251 2728774 32477 FOOD 104270 101241 3029 REPAIRS AND MAINTENANCE 572596 568795 3801 54427 45176 9251 36231842 30241534 5990308 0 118507 38333 0 0 0 0 4311646 4588047 0 0 0 0 0 0 158986 170953 104529 197308 9660106 8219634 1069104 1440472 0 0 0 0 0 0 0 0 18178922 28113473 23941694 34548586 1639796 2137460 0 0 0 0 0 0 0 0 0 0 0 0 0 0 9791227 18328888 11431023 20466348 X 12510671 14082238 0 0 0 0 12510671 14082238 23941694 34548586 1571567 X false true true X false X false false false false false true 1921 false false false 1921 false 9660106 8219634 1440472 1440472 DUE FROM AFFILIATES 28113473 28113473 0 THIRD PARTY PAYOR LIABILITIES 846957 DUE TO AFFILIATES 17204437 ESTIMATED SELF INSURANCE COSTS 277494 18328888 37803409 36231842 1571567 1571567 31051488 31051488 6751921 6751921 37803409 29479921 29479921 6751921 6751921 36231842 REVENUE INCLUDED ON BOOKS, NOT ON RETURN: SCHEDULE D, PART XII, QUESTION 4B REBATES IN AUDIT EXPENSE $ 1,555 BAD DEBT EXPENSE IN AUDIT REVENUE 6,750,366 ------------- $6,751,921 EXPENSES INCLUDED ON RETURN, NOT ON BOOKS: SCHEDULE D, PART XIII, QUESTION 4B REBATES IN AUDIT EXPENSE $ 1,555 BAD DEBT EXPENSE IN AUDIT REVENUE 6,750,366 ----------- $6,751,921 true true X true X true X true true true false true true 1263935 0 1263935 0.04290 2049901 3421706 -1371805 0.00000 369273 278641 90632 0.00310 3683109 3700347 -17238 0.04600 8354 8354 0.00030 441565 441565 0.01500 1010437 1010437 0.03430 1460356 1460356 0.04960 5143465 3700347 1443118 0.09560 false 6750366 0 10344176 9897832 446344 X true true 1 1 MOTHER FRANCES HOSPITAL - JACKSONVILLE

1026 S JACKSON STREET JACKSONVILLE TX 75766

X X X X MOTHER FRANCES HOSPITAL - JACKSONVILLE 1 false true true 200. true 200. true X true true X X true false X X X true X false false BAD DEBT EXPENSE SCHEDULE H, PART III, SECTION A, QUESTION 4 ACCOUNTS RECEIVABLE ARE REDUCED BY AN ALLOWANCE FOR DOUBTFUL ACCOUNTS. IN EVALUATING THE COLLECTABILITY OF ACCOUNTS RECEIVABLE, THE HEALTH SYSTEM ANALYZES ITS PAST HISTORY AND IDENTIFIES TRENDS FOR EACH OF ITS MAJOR PAYER SOURCES OF REVENUE TO ESTIMATE THE APPROPRIATE ALLOWANCE FOR DOUBTFUL ACCOUNTS AND THE PROVISION FOR UNCOLLECTIBLE ACCOUNTS. MANAGEMENT REGULARLY REVIEWS DATA ABOUT THESE MAJOR PAYER SOURCES OF REVENUE IN EVALUATING THE SUFFICIENCY OF THE ALLOWANCE FOR DOUBTFUL ACCOUNTS. FOR RECEIVABLES ASSOCIATED WITH SERVICES PROVIDED TO PATIENTS WHO HAVE THIRD-PARTY COVERAGE, THE HEALTH SYSTEM ANALYZES CONTRACTUALLY DUE AMOUNTS AND PROVIDES AN ALLOWANCE FOR DOUBTFUL ACCOUNTS AND A PROVISION FOR UNCOLLECTIBLE ACCOUNTS, IF NECESSARY (FOR EXAMPLE, FOR EXPECTED UNCOLLECTIBLE DEDUCTIBLES AND COPAYMENTS ON ACCOUNTS FOR WHICH THE THIRD-PARTY PAYER HAS NOT YET PAID, OR FOR PAYERS WHO ARE KNOWN TO BE HAVING FINANCIAL DIFFICULTIES THAT MAKE THE REALIZATION OF AMOUNTS DUE UNLIKELY). THE AMOUNT REPORTED ON LINE 2 IS BASED ON BAD DEBTS PER THE AUDITED FINANCIAL STATEMENTS. THE ORGANIZATION IS UNABLE TO ESTIMATE THE AMOUNT FOR LINE 3 AND HAS ELECTED TO LEAVE IT BLANK. BAD DEBT EXPENSE SHOULD BE CONSIDERED COMMUNITY BENEFIT BECAUSE THIS IS UNCOMPENSATED HEALTHCARE PROVIDED TO RESIDENTS OF THE COMMUNITY. MEDICARE SHORTFALL SCHEDULE H, PART III, SECTION B, QUESTION 8 THE MEDICAL CENTER USES MEDICARE COST REPORT METHODOLOGY, WHICH APPORTIONS ROUTINE COSTS (ROOM AND BOARD) BASED ON MEDICARE OR MEDICAID DAYS TO TOTAL DAYS AND APPORTIONS ANCILLARY COSTS BASED ON PROGRAM CHARGES TO TOTAL CHARGES. COLLECTION POLICY SCHEDULE H, PART III, SECTION C, QUESTION 9B THE ORGANIZATION HAS A WRITTEN POLICY COVERING PROCEDURES FOR COLLECTING AND WRITING OFF BAD DEBTS. ACCORDING TO THE POLICY, IF A PATIENT APPEARS TO BE INDIGENT, ACCOUNTS SHOULD BE REVIEWED, AT ANY TIME DURING THE COLLECTION PROCESS, FOR POSSIBLE CONSIDERATION AS A CHARITY CASE IN ACCORDANCE WITH THE ORGANIZATION'S CHARITY CARE POLICY. NEEDS ASSESSMENT SCHEDULE H, PART VI, QUESTION 2 THE HOSPITAL'S COMMUNITY HEALTH PROFILES PROVIDE A SNAPSHOT OF SUBURBAN, URBAN, AND RURAL SERVICE AREAS WITHIN TEXAS USING KEY HEALTH INDICATORS, WHICH FACILITATE COMPARISONS LOCALLY, REGIONALLY, AND OVER TIME. COMMUNITY HEALTH PROFILES ARE INTENDED TO ASSIST INTERNAL STAKEHOLDERS, COMMUNITY HEALTH COUNCIL MEMBERS, AND THE COMMUNITY HEALTH IMPROVEMENT DEPARTMENT IN DECIDING WHERE TO ALLOCATE RESOURCES AND ADDRESS HEALTH INEQUALITIES. ALL ENTITY ADVOCATES USE NATIONAL, STATE, AND LOCAL SECONDARY AND PRIMARY DATA SOURCES TO PROVIDE A CURRENT OVERVIEW OF LOCAL HEALTH NEEDS, FACTORS IMPACTING DISEASE AND INJURY BURDEN, SOCIOECONOMIC STATUS, ACCESS TO HEALTH CARE, AGE DISTRIBUTION, INDICATORS AND LIFESTYLE BEHAVIORS. THIS DATA IS USED TO GALVANIZE JOINT COMMUNITY HEALTH EFFORTS TO IMPROVE HEALTH AND REDUCE HEALTH INEQUALITIES AND TO EMPOWER THE GREATER COMMUNITY. PATIENT EDUCATION OF ELIGIBILITY FOR ASSISTANCE SCHEDULE H, PART VI, QUESTION 3 THE HOSPITAL'S FINANCIAL ASSISTANCE POLICY AND CONTACT INFORMATION IS POSTED IN VARIOUS AREAS OF THE HOSPITAL INCLUDING ADMISSIONS & REGISTRATION, EMERGENCY, AND OUTPATIENT DEPARTMENTS. ADDITIONALLY, FINANCIAL ASSISTANCE INFORMATION IS PROVIDED, VERBALLY AND IN WRITTEN BROCHURES, TO ALL SELF PAY PATIENTS BY FINANCIAL COUNSELORS. FINANCIAL ASSISTANCE INFORMATION IS ALSO INCLUDED IN EVERY PATIENT BILL. THE HOSPITAL'S FINANCIAL ASSISTANCE POLICY IS COMMUNICATED TO THE PATIENT BY FINANCIAL COUNSELORS WHO ALSO SCREEN SELF PAY PATIENTS FOR POTENTIAL ELIGIBILITY FOR OTHER GOVERNMENTAL ASSISTANCE PROGRAMS. IF IT IS DETERMINED THAT THE PATIENT IS POTENTIALLY ELIGIBLE FOR GOVERNMENTAL ASSISTANCE, THE FINANCIAL COUNSELOR WILL ASSIST THE PATIENT IN COMPLETING ANY FORMS NECESSARY TO APPLY FOR THE ASSISTANCE. AT THE SAME TIME, THE PATIENTS ARE PROVIDED WITH A CHARITY CARE APPLICATION AND INFORMATIONAL FLYER. THE PATIENT IS INFORMED THAT MOTHER FRANCES HOSPITAL-JACKSONVILLE IS A NON-PROFIT CHARITABLE ORGANIZATION OFFERING FINANCIAL ASSISTANCE TO PATIENTS WHO ARE DEEMED MEDICALLY OR FINANCIALLY INDIGENT. THE FINANCIAL COUNSELORS WILL THEN ASSIST THE PATIENT IN COMPLETING THE CHARITY CARE APPLICATION AND OBTAIN ANY AVAILABLE VERIFICATIONS. ONCE THE PATIENT IS DISCHARGED, THE FINANCIAL COUNSELORS WILL CONTINUE TO CONTACT THE PATIENT TO ENSURE ALL NEEDED FORMS AND VERIFICATIONS NEEDED TO FILE AN APPLICATION FOR GOVERNMENTAL ASSISTANCE AND CHARITY CARE HAVE BEEN PROVIDED. COMMUNITY INFORMATION SCHEDULE H, PART VI, QUESTION 4 MOTHER FRANCES HOSPITAL-JACKSONVILLE IS A 25-BED ACUTE CARE MEDICARE CERTIFIED CRITICAL ACCESS HOSPITAL. CHEROKEE COUNTY, THE PRIMARY SERVICE AREA FOR MFH-JACKSONVILLE, HAS A POPULATION OF APPROXIMATELY 57,000 AND IS PRIMARILY 48,000 IN A 1,052 SQUARE MILE AREA. THE SECONDARY SERVICE AREA INCLUDES THE SOUTHERN PART OF SMITH COUNTY. PROMOTION OF COMMUNITY HEALTH SCHEDULE H, PART VI, QUESTION 5 MOTHER FRANCES HOSPITAL-JACKSONVILLE PROMOTES HEALTHCARE AND WELLNESS EDUCATION BY OFFERING OUTREACH PROGRAMS AND SPECIAL INITIATIVES THAT IMPROVE THE QUALITY OF LIFE AND HEALTH IN THE COMMUNITIES SERVED. COMMUNITY BENEFIT IS PROVIDED THROUGH MANY REDUCED PRICE SERVICES AND FREE PROGRAMS TO THE COMMUNITY. THESE SERVICES ARE ESSENTIAL TO PROVIDE COMPLETE HEALTHCARE TO THE COMMUNITIES SERVED, SOME OF THESE PROGRAMS INCLUDE THE FOLLOWING: CHEROKEE COUNTY RELAY FOR LIFE - PROVIDED SPONSORSHIP AND STAFFING SUPPORT FOR CHEROKEE COUNTY RELAY FOR LIFE. STAFF PLANNED ACTIVITIES FOR THE ALL - NIGHT EVENT AND MANNED THE EVENT. THIS IS AN ANNUAL SPONSORSHIP. THE PURPOSE OF THE PROGRAM IS TO INCREASE AWARENESS ABOUT CANCER AND TO HELP IN FUNDRAISING EFFORTS FOR A COUNTY THAT HAS AN ABOVE AVERAGE RATE OF CANCER. EDUCATIONAL PROGRAMS TARGETED THE COMMUNITY AT LARGE BUT EFFORTS WERE MADE TO REACH THE UNINSURED. FAMILY CARE CENTER - WOMEN'S SERVICES - OVER 300 VISITS FOR GYNECOLOGICAL SERVICES AT THE LOCAL CLINIC WERE PROVIDED FOR WOMEN THAT DID NOT HAVE A PRIMARY CARE OR SPECIALTY MEDICAL HOME. THE PURPOSE IS TO PROVIDE WOMEN WITH GYNECOLOGICAL SERVICES WHO DO NOT HAVE ACCESS TO MEDICAL CARE. MANY OF THESE WOMEN WERE TRAVELING TO TYLER TO RECEIVE CARE BUT CAN NOW RECEIVE IT CLOSER TO HOME. JACKSONVILLE RODEO - HANDED OUT FANS AND WATER TO PARTICIPANTS AND SPECTATORS AT THE RODEO. PROVIDED VOLUNTEERS TO INTERACT ON ISSUES FOR 3 HOURS EACH OF 4 NIGHTS. THIS IS AN ANNUAL SPONSORSHIP. THE PURPOSE IS TO HELP EDUCATE PARTICIPANTS ABOUT THE DANGERS OF HEAT AND INJURIES CAUSED BY EXTENSIVE HEAT. THIS PROGRAM REACHED OVER 1,000 PEOPLE WITH HEAT PREVENTION INFORMATION AND MEDICAL SUPPORT ON SITE. JACKSONVILLE ROTARY, ACCESS, AND OTHERS - PROVIDED SPONSORSHIP, STAFFING, AND DEVELOPMENT OF PROGRAMS AND EVENTS FOR THE LOCAL COMMUNITY. ORGANIZATIONS INCLUDED LIONS CLUB, ROTARY, KIWANIS, ACCESS, HOPE CENTER, UNITED FUND, AND AMERICAN CANCER SOCIETY, JACKSONVILLE CHAMBER OF COMMERCE, JACKSONVILLE LITERACY COUNCIL. MEMBERS OF THE STAFF SERVE IN LEADERSHIP POSITIONS AND AS VOLUNTEERS FOR PROGRAMS ON VARIOUS BOARDS AND NON PROFITS IN THE COMMUNITY. THESE PROGRAMS BENEFITS THE RESIDENTS OF THE AREA AND ORGANIZATIONS THAT PROVIDE SERVICES WHICH ARE NOT PROVIDED BY THE HOSPITAL BUT IMPACT THE HEALTH OF THE RESIDENTS IN ANDERSON/CHEROKEE COUNTIES. FINDING LEADERSHIP TALENT FOR VOLUNTEER POSITIONS IS AN EVER GROWING PROBLEM FOR ALL COMMUNITIES. TARGET POPULATION FOR SERVICES IS THE GENERAL PUBLIC. KID FEST - A COMMUNITY PROGRAM WAS HELD TO PROVIDE BICYCLE SAFETY AND TO DISTRIBUTE BIKE HELMETS. OVER 100 CHILDREN PARTICIPATED IN THE PROGRAM THAT WAS CO-SPONSORED BY THE JACKSONVILLE DAILY PROGRESS AND MOTHER FRANCES HOSPITAL - JACKSONVILLE. THIS IS AN ANNUAL PROGRAM. THE PURPOSE IS TO EDUCATE THE ENTIRE FAMILY, PARENTS AND CHILDREN, ON THE IMPORTANCE OF BICYCLE SAFETY AS THE SUMMER APPROACHED. THE COMMUNITY DOES NOT HAVE BICYCLE LANES SO ESPECIALLY DURING THE SUMMER MANY CHILDREN ARE RIDING THE BIKES ACROSS TOWN IN RANDOM FASHION. COMMUNITY HEALTH INFORMATION AND SCREENINGS - A VARIETY OF COMMUNITY EVENTS AND OPPORTUNITIES FOR SCREENINGS WERE HELD INCLUDING CHEROKEE COUNTY COOP HEALTH FAIR, METHODIST CHURCH, AND EDUCATIONAL FACILITIES. TO HELP EDUCATE AND IDENTIFY INDIVIDUALS AT RISK AND WAYS TO IMPROVE THEIR HEALTH. OVER 500 PEOPLE WERE SERVED THROUGH THESE ACTIVITIES. HEALTH EDUCATION PROGRAMS - COMMUNITY EDUCATION FOR HEALTHY LIFE STYLES WERE OFFERED THROUGHOUT THE REGION FOR A VARIETY OF CONDITIONS INCLUDING CANCER, CHOLESTEROL, DIABETES, SMOKING CESSATION, STRESS, WEIGHT MANAGEMENT, AND HEALTHY HEARTS. OVER 100 PEOPLE WERE REACHED. EAST TEXAS HAS AN EXTREMELY HIGH RATE FOR DIABETES, STROKE, HEART DISEASE, AND PULMONARY DISEASE. THIS EAST TEXAS REGION OF THE STATE HAS ONE OF THE FASTEST GROWING AGING GROUPS AND HIGH RISK FOR ETHNIC MINORITIES; BOTH WERE TARGETED. COMMUNITY NON PROFITS AND RURAL HOSPITAL SUPPORT PROGRAMS - MOTHER FRANCES HOSPITAL - JACKSONVILLE PROVIDES DIRECT FINANCIAL SUPPORT TO NOT-FOR- PROFIT ORGANIZATIONS AND COMMUNITY SUPPORTED RURAL HOSPITALS WITHIN THE REGION TO HELP PROVIDE NEEDED SERVICES TO THE COMMUNITY. PRIORITY IS GIVEN TO AGENCIES OR ORGANIZATIONS THAT PROVIDE SUPPORT OR DIRECT HEALTH RELATED SERVICES OR BENEFITS AND HAVE A MISSION TO SERVE THE UNDERINSURED AND UNINSURED. NEW PROGRAMS INCLUDED ARE CHEROKEE HEALTH ADVISORY BOARD AND EMS, FIRE DEPARTMENT AND PUBLIC SAFETY OFFICES. THESE ORGANIZATIONS OR AGENCIES PROVIDE SERVICES THAT OTHERWISE WOULD HAVE TO BE PROVIDED BY MOTHER FRANCES HOSPITAL - JACKSONVILLE OR COULD BE PREVENTING PATIENTS FROM ENTERING OUR FACILITIES, PARTICULARLY THE EMERGENCY ROOM. MANY PROVIDE PHYSICIAN SERVICES, EDUCATION OR RESEARCH PROGRAMS WHICH ARE NOT AVAILABLE AT MFH-J OR IT MAY BE TOO FAR FOR THEIR PATIENTS TO TRAVEL TO RECEIVE SERVICES AT OUR PRIMARY FACILITIES. AFFILIATED HEALTH CARE SYSTEM SCHEDULE H, PART VI, QUESTION 6 MOTHER FRANCES HOSPITAL-JACKSONVILLE IS PART OF AN AFFILIATED HEALTH CARE SYSTEM CALLED TRINITY MOTHER FRANCES HEALTH SYSTEM. TRINITY MOTHER FRANCES IS A FAITH-BASED ORGANIZATION DEDICATED TO CREATING HEALTHY LIVES FOR PEOPLE AND COMMUNITIES. MFH-JACKSONVILLE AND ITS AFFILIATES PROMOTE THE HEALTH OF THE COMMUNITIES SERVED BY PROVIDING ACUTE CARE FACILITIES AND CRITICAL ACCESS FACILITIES, WHOSE OPERATIONS CONSIST PRIMARILY OF PROVIDING INPATIENT AND OUTPATIENT ACUTE CARE AND MEDICAL SERVICES TO PATIENTS RESIDING IN EAST TEXAS. PERCENT OF TOTAL EXPENSE SCHEDULE H, PART I, LINE 7, COLUMN F TO ARRIVE AT THE PERCENT OF TOTAL EXPENSES, THE DENOMINATOR WHICH EQUALS TOTAL OPERATING EXPENSES PER PART IX, LINE 25, OF THE FORM 990 WAS REDUCED BY BAD DEBT EXPENSE, TOTALING $6,750,366. BILLING AND COLLECTIONS SCHEDULE H, PART V, QUESTION 15, 16, & 17 NEITHER MOTHER FRANCES HOSPITAL - JACKSONVILLE, NOR THIRD PARTIES AUTHORIZED BY MFH-J, TAKE ANY ACTIONS UPON NON-PAYMENT FROM A PATIENT BEFORE MAKING A REASONABLE EFFORT TO DETERMINE IF THE PATIENT IS ELIGIBLE FOR THE FACILITY'S FINANCIAL ASSISTANCE POLICY. STATE OF FILING COMMUNITY BENEFIT REPORT SCHEDULE H, PART VI, QUESTION 7 TEXAS true SERVICE ORGANIZATION OF PINEY WOODS 2950 50TH STREET LUBBOCK TX 79314 300630886 501(C)(3) 912937 COMMUNITY HEALTHCARE SERVICE ORGANIZATION OF NORTH EAST TEXAS 2950 50TH STREET LUBBOCK TX 79314 260468622 501(C)(3) 97500 COMMUNITY HEALTHCARE 2 0 PROCEDURES FOR MONITORING THE USE OF GRANT FUNDS IN THE U.S. SCHEDULE I, PART I, QUESTION 2 GRANT RECIPIENTS ARE REQUIRED TO ACKNOWLEDGE PRIOR TO THE ISSUANCE OF GRANT FUNDS THAT THE GRANT WILL BE USED IN ACCORDANCE WITH THE STATED PURPOSE OF THE GRANT APPLICATION AND ANY UNUSED FUNDS RELATED TO THE SPECIFIC PURPOSE OF THE GRANT WILL BE RETURNED TO THE ORGANIZATION. THE ORGANIZATION MONITORS AND REVIEWS THE FINANCIAL DATA OF RECIPIENTS TO ENSURE THAT THE GRANTED FUNDS ARE BEING USED PROPERLY. X X X X X false true false false false false false false false THOMAS N CAMMACK JR 208784 44029 34470 9210 0 6132 0 302625 0 0 0 MATTHEW A VIERKANT MD 368928 133737 12996 0 10413 0 2400 0 528474 0 0 RAY THOMPSON 0 690314 0 348118 0 463037 0 538645 0 8038 0 2048152 0 463037 BARRY L THIBODEAUX 218374 0 0 0 22109 0 7416 0 1858 0 249757 0 0 0 JACK CAPPS 213785 0 0 0 20240 0 7802 0 8852 0 250679 0 0 0 WILLIAM MILAWSKI MD 0 236513 0 0 0 4776 0 9155 0 2400 0 252844 0 0 JOYCE HESTER 0 174243 0 36644 0 18714 0 8163 0 4033 0 241797 0 0 J LINDSEY BRADLEY JR 0 813271 0 441987 0 450000 0 10413 0 7846 0 1723517 0 0 WILLIAM BELLENFANT SR 0 1890888 0 0 0 258515 0 0 0 2234 0 2151637 0 258515 PARTICIPATION IN OR PAYMENT FROM SUPPLEMENTAL NONQUALIFIED RETIREMENT PLAN SCHEDULE J, PART I, QUESTION 4B PARTICIPANTS IN SERP REPORTED IN W-2 DEFERRED COMPENSATION -------------------- --------------- --------------------- RAY THOMPSON $463,037 NONE WILLIAM BELLENFANT $285,515 NONE DESCRIBE REVIEW PROCESS OF FORM 990 FORM 990, PART VI, QUESTION 11B THE ORGANIZATION ENGAGES AN OUTSIDE ACCOUNTING FIRM TO PREPARE FORM 990. ONCE PREPARED, THE FORM IS REVIEWED BY THE ORGANIZATION'S INTERNAL ACCOUNTANTS PRIOR TO FILING. DESCRIBE THE ORGANIZATION'S MEMBERS OR STOCKHOLDERS FROM 990, PART VI, QUESTION 6 TRINITY MOTHER FRANCES HEALTH SYSTEM IS THE SOLE MEMBER OF MOTHER FRANCES HOSPITAL - JACKSONVILLE. MEMBERS OR STOCKHOLDERS WHO MAY ELECT MEMBERS OF THE GOVERNING BOARD FORM 990, PART VI, QUESTION 7A THE SOLE MEMBER, TRINITY MOTHER FRANCES HEALTH SYSTEM, APPOINTS ALL DIRECTORS AND THEIR SUCCESSORS TO THE GOVERNING BOARD. DECISIONS OF GOVERNING BODY SUBJECT TO APPROVAL BY MEMBER FORM 990, PART VI, QUESTION 7B THE MEMBER HAS THE RIGHT TO APPROVE OR DISAPPROVE CERTAIN ACTIONS THAT HAVE BEEN APPROVED BY THE BOARD OF DIRECTORS. HOW DOES THE ORGANIZATION MONITOR AND ENFORCE COMPLIANCE WITH POLICY FORM 990, PART VI, QUESTION 12C THE BOARD REVIEWS AND RESOLVES, IF NECESSARY, ANY TRANSACTIONS AS THEY ARISE THROUGHOUT THE YEAR IN ACCORDANCE WITH POLICY STANDARDS. PROCESS FOR DETERMINING COMPENSATION OF CEO, OFFICERS, OR KEY EMPLOYEES FORM 990, PART VI, QUESTIONS 15A & 15B THE ORGANIZATION USES COMPENSATION CONSULTANTS AND NATIONAL COMPENSATION SURVEYS TO DETERMINE COMPENSATION OF EMPLOYEES. COMPENSATION IS APPROVED BY THE ORGANIZATION'S GOVERNING BODY. DESCRIBE WHETHER THE ORGANIZATION MAKES ITS DOCUMENTS AVAILABLE TO PUBLIC FORM 990, PART VI, QUESTION 19 THE ORGANIZATION MAKES ITS GOVERNING DOCUMENTS, CONFLICT OF INTEREST POLICY, AND FINANCIAL STATEMENTS AVAILABLE TO THE PUBLIC UPON REQUEST. COMPENSATION FROM RELATED ORGANIZATIONS FORM 990, PART VII & SCHEDULE J THE GOVERNING BOARD OF TRINITY MOTHER FRANCES HEALTH SYSTEM, UPON ADVICE FROM NATIONALLY RECOGNIZED COMPENSATION CONSULTANTS, WHO PERIODICALLY REVIEW ALL EXECUTIVE COMPENSATION, APPROVED A DEFERRED COMPENSATION PLAN THAT PROVIDES A 65% TOTAL RETIREMENT BENEFIT FOR SENIOR EXECUTIVES THAT SERVE 20 YEARS OR MORE. THIS PROGRAM HAS BOTH RETENTION AND NON-COMPETITION CLAUSES THAT CREATE A RISK OF FORFEITURE. DEFERRED COMPENSATION IS SUBJECT TO A RISK OF FORFEITURE BASED ON RETENTION, NON-COMPETITION AND OTHER CONTRACTUAL FACTORS. ACCRUALS OF DEFERRED COMPENSATION ARE NOT INCLUDIBLE IN W-2 COMPENSATION UNTIL PAID. OTHER EMPLOYEE BENEFITS INCLUDE QUALIFIED PENSION PLANS. HEALTH, DENTAL AND LIFE INSURANCE PLANS, DISABILITY INSURANCE, ETC. TAXABLE EXPENSES ARE INCLUDED IN THE W-2 PAID COMPENSATION SALARY AMOUNT. 1099S REPORTED BY ORGANIZATION FORM 990, PART V, QUESTION 1A THE ORGANIZATION'S 1099S ARE ISSUED BY A RELATED ORGANIZATION, MOTHER FRANCES HOSPITAL REGIONAL HEALTH CARE CENTER, WHO REPORTS ALL 1099S FOR THE ENTIRE SYSTEM AND ALLOCATES EXPENSES TO THE APPROPRIATE RELATED ORGANIZATION. DELEGATION OF MANAGEMENT DUTIES FORM 990, PART VI, QUESTION 3 THE ORGANIZATION HAS HIRED A MANAGEMENT COMPANY TO PERFORM THE DUTIES OF THE INTERIM CFO. UNDER EMPLOYMENT FOR THE UNRELATED MANAGEMENT COMPANY, THE FOLLOWING INDIVIDUAL SERVES AS AN OFFICER FOR THE HOSPITAL AND IS PAID COMPENSATION BY THE MANAGEMENT COMPANY FOR SERVICES TO THE HOSPITAL. PER IRS GUIDANCE, NO COMPENSATION IS SHOWN ON FORM 990, PART VII, FOR THIS INDIVIDUAL: PAM VUKOVICH - $218,341 HOURS DEVOTED FOR RELATED ORGANIZATION FORM 990 PART VII NAME:RAY THOMPSON TITLE:SYS EXEC/VP/CEO/DIRECTOR HOURS:38 HOURS DEVOTED FOR RELATED ORGANIZATION FORM 990 PART VII NAME:DICK STONE TITLE:DIRECTOR HOURS:1 HOURS DEVOTED FOR RELATED ORGANIZATION FORM 990 PART VII NAME:JOYCE HESTER TITLE:SYSTEM VP, FINANCE, CFO HOURS:37 HOURS DEVOTED FOR RELATED ORGANIZATION FORM 990 PART VII NAME:J LINDSEY BRADLEY JR TITLE:SYSTEM PRESIDENT/DIRECTOR HOURS:42 HOURS DEVOTED FOR RELATED ORGANIZATION FORM 990 PART VII NAME:PAM VUKOVICH TITLE:INTERIM CFO HOURS:37 CHAMPION EMERGENCY SERVICES LLC 2201 S MOBBERLY AVE LONGVIEW TX 75602 752747708 AMBULANCE SVC TX 501(C)(3) 9 NA false MOTHER FRANCES HOSP REGIONAL HC CENTER 1315 DOCTORS DRIVE TYLER TX 75701 750818167 HOSPITAL TX 501(C)(3) 3 TMFHS false TRINITY MOTHER FRANCES HEALTH SYSTEM FDN 1315 DOCTORS DRIVE TYLER TX 75701 752028241 SUPPORT TX 501(C)(3) 11A I TMFHS false REGIONAL MEDICAL SERVICES ASSOCIATION 1315 DOCTORS DRIVE TYLER TX 75701 752511459 HEALTHCARE TX 501(C)(3) 3 MFH REG false TRINITY MOTHER FRANCES HEALTH SYSTEM 1315 DOCTORS DRIVE TYLER TX 75701 752616975 HEALTHCARE TX 501(C)(3) 11A I NA false TRINITY CLINIC 1315 DOCTORS DRIVE TYLER TX 75701 752616977 HEALTHCARE TX 501(C)(3) 3 TMFHS false MOTHER FRANCES HOSPITAL - WINNSBORO 1315 DOCTORS DRIVE TYLER TX 75701 752771569 HOSPITAL TX 501(C)(3) 3 TMFHS false TRI-STATE FINANCIAL LLC 1315 DOCTORS DRIVE TYLER TX 75701 752728318 COLLECTION AGENCY TX NA C-CORPORATION TRINCARE INC 1315 DOCTORS DRIVE TYLER TX 75701 752161369 RETAIL HEALTH SVC TX NA C-CORPORATION HEALTHPLAN OF TEXAS INC 514 S BECKHAM TYLER TX 75701 752636832 THIRD PARTY ADMIN TX NA C-CORPORATION REGIONAL HEALTHCARE ALLIANCE 1315 DOCTORS DRIVE TYLER TX 75701 752484109 PREFER PROVIDER TX NA C-CORPORATION TEXAS HEALTH FACILITIES INSUR CORP LTD PO BOX 1109 BWI GRAND CAYMAN CJ 980136025 INSURANCE CJ NA C-CORPORATION CONCORDIUM HEALTH LLC 1315 DOCTORS DRIVE TYLER TX 75701 702811022 INACTIVE TX NA C-CORPORATION EMPLOYER SERVICES INC 1315 DOCTORS DRIVE TYLER TX 75701 752602556 INACTIVE TX NA C-CORPORATION HERITAGE HEALTH PLANS OF TX 1315 DOCTORS DRIVE TYLER TX 75701 752622622 INACTIVE TX NA C-CORPORATION QUALITY CARE ALLIANCE 1315 DOCTORS DRIVE TYLER TX 75701 752662965 INACTIVE TX NA C-CORPORATION false false false false false false false false false true false true false true false false false false DIRECT CONTROLLING ENTITY SCHEDULE R, PART II, COLUMN F THE FOLLOWING RELATED ORGANIZATIONS REPORTABLE IN PART II ARE DIRECTLY CONTROLLED BY TRINITY MOTHER FRANCES HEALTH SYSTEM ("TMFHS"): MOTHER FRANCES HOSPITAL REGIONAL HEALTH CARE CENTER TRINITY MOTHER FRANCES HEALTH SYSTEM FOUNDATION TRINITY CLINIC MOTHER FRANCES HOSPITAL - WINNSBORO REGIONAL MEDICAL SERVICES ASSOCIATION IS DIRECTLY CONTROLLED BY MOTHER FRANCES HOSPITAL REGIONAL HEALTH CARE CENTER ("MFH REG").