2012-08-10T17:33:34-05:00 2011-09-30 WIPFLI LLP 12 E ROWAN STE 2 SPOKANE WA 99207 990 2010-10-01 237314364 NAVAJO HEALTH FOUNDATION SAGE MEMORIAL HOSPITAL INC NAVA 9287554500 PO BOX 457 GANADO AZ 86505 CHARITY L ASKIE 9287554500 2012-08-10 1 MICHAEL R BELL 5094894524 2012-08-10 2010 2016-02-24 21:20:13Z AHMAD RAZAGHI PO BOX 457 GANADO AZ 86505 29013146 0 X WWW.SAGEMEMORIAL.ORG X 1974 AZ PROVIDES QUALITY HEALTHCARE SERVICES IN A FISCALLY RESPONSIBLE MANNER 8 8 308 0 0 0 479995 525294 25810665 28115328 57183 49548 0 51684 26347843 28741854 1632 8888 0 5866 9801072 9862259 0 0 0 17530625 15282453 27333329 25159466 -985486 3582388 15619706 18731887 7437792 5879153 8181914 12852734 OUR MISSION IS TO PROVIDE QUALITY PATIENT CARE IN A FISCALLY RESPONSIBLE MANNER FOCUSING ON THE PATIENTS PHYSICAL, SOCIAL AND SPIRITUAL WELL-BEING. 0 0 18354430 8888 28115328 NAVAJO HEALTH FOUNDATION- SAGE MEMORIAL HOSPITAL CONTRACTED WITH INDIAN HEALTH SERVICE WITH A SELF-DETERMINATION CONTRACT WHICH PROVIDED CARE TO APPROXIMATELY 400 INPATIENTS AND 45,000 OUTPATIENTS, AS WELL AS PROVIDING EMERGENCY CARE AND DENTAL CARE SERVICES. SAGE MEMORIAL HOSPITAL SERVES PRIMARILY MEMBERS OF THE NAVAJO NATION. SAGE MEMORIAL HOSPITAL ADMINISTERED SPECIAL DIABETES PREVENTION AND TREATMENT PROJECTS FOR NAVAJOS. DEVELOPED PUBLIC HEALTH AND SOCIAL SERVICES EMERGENCY RESPONSE PLAN. 18354430 1 1 0 0 0 0 0 0 1 1 1 0 0 1 1 1 0 0 0 0 0 0 0 0 0 1 1 0 1 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 232 0 1 308 1 0 0 0 0 0 0 0 0 0 0 X 8 8 0 0 0 0 0 0 0 1 1 0 0 1 1 1 1 0 0 1 1 0 AZ X CHARITY L ASKIE 9257554615 PO BOX 457 GANADO AZ 86505 KELEWOOD MAYBELLE 1.00 X X 12500 0 0 DEDMAN APRIL N 1.00 X 4000 0 0 SHEPHERD AMBROSE 1.00 X 6750 0 0 SIMPSON ANDREW 1.00 X X 11250 0 0 YAZZIE LINDA A 1.00 X X 7500 0 0 WAUNEKA STETSON 1.00 X X 5500 0 0 BALDWIN DOROTHY 1.00 X 14500 0 0 MOORE JOYCE 1.00 X 4000 0 0 RAZAGHI AHMAD 60.00 X 126571 0 0 ASKIE CHARITY 60.00 X 49826 0 10075 ANDEMICHAEL MERON 40.00 X 195484 0 12575 LABIB- KIYARASH FARID 80.00 X 534240 0 10075 GOLPARIAN MOHAMMAD 80.00 X 219472 0 0 WRAY JEREMY 80.00 X 279059 0 0 1470652 0 32725 5 0 1 0 SKILLED STAFFING SOLUTIONS 7910 HOSBROOK LANE CINCINNATI OH 45243 PROFESSIONAL STAFFING 418625 STAFF CARE INC PO BOX 281923 ATLANTA GA 30384 PROFESSIONAL STAFFING 393268 AMN HEALTHCARE INC FILE 56157 LOS ANGELES CA 90074 PROFESSIONAL STAFFING 370508 NATIONWIDE NURSES PO BOX 21228 DEPT 115 TULSA OK 74121 OTHER SERVICES 363243 RPH ON THE GO INC PO BOX 102460 ATLANTA GA 30368 OTHER SERVICES 339859 7 256890 268404 525294 CAPITATION REVENUE 900099 17176498 17176498 NET PATIENT REVENUE 900099 10852531 10852531 DEPARTMENT MISC REVENU 900099 86299 86299 28115328 49548 49548 322976 271292 51684 51684 51684 28741854 28115328 0 101232 8888 8888 5866 5866 1465589 733512 732077 7176340 5132389 2043951 57883 33533 24350 496839 287828 209011 665608 385599 280009 1293568 371533 922035 212347 212347 155260 155260 6310308 6175777 134531 140649 2801 137848 4439138 3233212 1205926 151510 151510 551249 548480 2769 616494 470276 146218 71644 71644 66363 66363 844761 725267 119494 191312 191312 BAD DEBT EXPENSE 172806 172806 0 MISCELLANEOUS 65044 300 64744 0 25159466 18354430 6805036 0 5553356 7964999 1211738 1735150 1870208 283156 243331 62810 72676 21670493 15376777 6571748 6293716 1413486 1075219 0 15619706 18731887 5342139 4850722 2073672 1004137 21981 24294 7437792 5879153 X 6564227 11220858 964699 1030967 652988 600909 8181914 12852734 15619706 18731887 X 3582388 1088432 X X 0 1 1 X 1 1 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED X 806316 5495 8888 68381 734542 705976 100340 806316 680080 25896 705976 0 0 26000 26000 11508717 7183740 4324977 9821393 8193037 1628356 314383 314383 6293716 HOUSING DEPOSITS 24294 24294 28741854 25159466 3582388 1088432 1088432 4670820 29013146 271292 271292 28741854 0 28741854 25430758 271292 271292 25159466 0 25159466 PART III, LINE 4: HUBBELL'S TRADING POST MANAGES ALL COLLECTIONS, OBJECTS AND ARTIFACTS IN ACCORDANCE TO PROPER MUSEUM STANDARDS AND CONDITIONS. DESCRIPTION OF INTENDED USE OF ENDOWMENT FUNDS: PART V, LINE 4: THE HOSPITAL'S ENDOWMENT CONSISTS OF SCANDLING MEMORIAL SCHOLARSHIP FUNDS ESTABLISHED TO PROVIDE FINANCIAL SCHOLARSHIP OPPORTUNITIES FOR FULL-TIME NAVAJO COLLEGE STUDENTS. DESCRIPTION OF UNCERTAIN TAX POSITIONS UNDER FIN 48: PART X: INCOME TAXES THE HOSPITAL HAS BEEN RECOGNIZED AS EXEMPT FROM INCOME TAXES UNDER SECTION 501(C)(3) OF THE INTERNAL REVENUE CODE AND A SIMILIAR PROVISION OF THE STATE LAW. HOWEVER, THE HOSPITAL IS SUBJECT TO FEDERAL INCOME TAX ON ANY UNRELATED BUSINESS TAXABLE INCOME. THE HOSPITAL UNDERGOES AN ANNUAL ANALYSIS OF ITS VARIOUS TAX POSITIONS, ASSESSING THE LIKELIHOOD OF THOSE POSITIONS BEING UPHELD UPON EXAMINATION WITH RELEVANT TAX AUTHORITIES, AS DEFINED BY ACCOUNTING PRINCIPLES GENERALLY ACCEPTED IN THE UNITED STATES OF AMERICA (GAAP). THE HOSPITAL BELIEVES THAT THEY ARE IN SUBSTANTIAL COMPLIANCE WITH ALL IRS TAX REGULATIONS AND AS OF SEPTEMBER 30, 2011, HAVE NOT RECORDED ANY UNRECOGNIZED TAX BENEFIT OR LIABILITY FOR INCOME TAXES. THE HOSPITAL WILL RECOGNIZE FUTURE ACCRUED INTEREST AND PENALTIES RELATED TO UNRECOGNIZED TAX LIABILITIES IN INCOME TAX IF INCURRED. SCHEDULE D, PART XI, LINE 7, PRIOR PERIOD ADJUSTMENT PRIOR PERIOD ADJUSTMENT TO REFLECT PRIOR YEAR AUDITED FINANCIAL STATMENT AMOUNTS. PRIOR ACCOUNTANT FILED FORM 990 PRIOR TO THE AUDITED FINANCIAL STATEMENTS BEING AVAILABLE, THIS RESULTED IN A DIFFERENCE IN NET ASSETS OF $1,088,432. SCHEDULE D, PART V ENDOWMENT FUND PRIOR YEAR BALANCES ARE CARRIED FORWARD FROM PRIOR YEAR FILED 990. CURRENT YEAR ENDING BALANCE IS FROM SEPTEMBER 30, 2011 AUDITED FINANCIAL STATEMENTS. AN ADJUSTMENT TO ADMINISTRATIVE EXPENSES IS MADE TO MATCH AUDITED FINANCIALS. 1 1 X 1 X 1 X 0 0 0 0 172806 468 6500658 6027762 472896 X 0 1 1 NAVAJO HEALTH FDNSAGE MEM HOSPITAL INC

PO BOX 457 GANADO AZ 86505

X X X X DENTAL CARE NAVAJO HEALTH FDNSAGE MEM HOSPITALINC 1 0 4 OUTPATIENT CLINIC

PO BOX 457 GANADO AZ 86505

OUTPATIENT SERVICES SPECIALITY CLINIC

PO BOX 457 GANADO AZ 86505

CARDIOLOGY AND ECHO DENTAL CLINIC

PO BOX 457 GANADO AZ 86505

DENTAL SERVICES GREASEWOOD CLINIC

PO BOX 457 GANADO AZ 86505

DENTAL AND OUTPATIENT SERVICES PART I, LINE 3C: IT IS THE POLICY OF SAGE MEMORIAL HOSPITAL TO PROVIDE ESSENTIAL MEDICAL SERVICES REGARDLESS OF THE PATIENT'S ABILITY TO PAY. DISCOUNTS ARE OFFERED BASED UPON HOUSEHOLD INCOME AND SIZE. A SLIDING FEE SCHEDULE IS USED TO CALCULATE THE BASIC DISCOUNT AND IS UPDATED EACH YEAR USING THE FEDERAL POVERTY GUIDELINES. ONCE APPROVED, THE DISCOUNT WILL BE HONORED FOR SIX MONTHS, AFTER WHICH THE PATIENT MUST REAPPLY. PART I, LINE 7, COLUMN (F): THE BAD DEBT EXPENSE INCLUDED ON FORM 990, PART IX, LINE 25, COLUMN (A), BUT SUBTRACTED FOR PURPOSES OF CALCULATING THE PERCENTAGE IN THIS COLUMN IS $ 172806. PART II: CURRENTLY, NAVAJO HEALTH FOUNDATION/ SAGE MEMORIAL HOSPITAL DOES NOT HAVE A COMMUNITY BUILDING ACTIVITY IN PLACE AT THIS TIME. PART III, LINE 4: MANAGEMENT REVIEWS PATIENT RECEIVABLES BY PAYOR CLASS AND APPLIES PERCENTAGES TO DETERMINE ESTIMATED AMOUNTS THAT WILL NOT BE COLLECTED FROM THIRD PARTIES UNDER CONTRACTUAL AGREEMENTS AND AMOUNTS THAT WILL NOT BE COLLECTED FROM PATIENTS DUE TO BAD DEBTS. MANAGEMENT CONSIDERS HISTORICAL WRITE OFF AND RECOVERY INFORMATION IN DETERMINING THE ESTIMATED BAD DEBT PROVISION. MANAGEMENT ALSO REVIEWS ACCOUNTS TO DETERMINE IF CLASSIFICATION AS CHARITY CARE IS APPROPRIATE.BAD DEBT AND CHARITY CARE WAS CONVERTED TO COST USING THE COST-TO-CHARGE RATIO. PART III, LINE 8: MEDICARE ALLOWABLE COSTS OF CARE ARE BASED ON THE COST TO CHARGE RATIO CALCULATED FROM 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. PART VI, LINE 2: SAGE MEMORIAL HOSPITAL WORKS WITH THE NAVAJO AREA OFFICE (NAO) TO DETERMINE NEEDS ASSESSMENTS OF THEIR SERVICE AREA. THIS OFFICE SUPPLIES THE NEEDS ASSESSMENT BASED ON NEEDS THAT HAVE BEEN IDENTIFIED THROUGH ALL FACILITIES SERVING THE AREA AND WHO SEND IN QUARTERLY REPORTS ON SERVICES PROVIDED. AFTER REVIEWING THE SEVICES THAT THE FACILITIES HAVE PROVIDED, THE NAO DOES A NEEDS ANALYSIS AND PASSES THE INFORMATION ON TO THE FACILITIES. PART VI, LINE 3: THE MAJORITY OF THE PATIENTS ARE NATIVE AMERICAN AND QUALIFY FOR THE INDAIN HEALTH SERVICE PROGRAM. THESE PATIENTS QUALIFY FOR THE FEDERAL PROGRAM AND DO NOT CARRY SEPARATE HEALTH INSURANCE. THERE ARE VERY FEW PATIENTS THAT WOULD FALL OUTSIDE THE IHS PROGRAM. CURRENTLY THERE IS NO INFORMATION IN THE PATIENT REGISTRATION AREA AND NO DISCUSSION WITH PATIENTS ON PARTICIPATING IN THE CHARITY CARE PROGRAM. PART VI, LINE 4: NAVAJO HEALTH FOUNDATION/SAGE MEMORIAL HOSPITAL IS LOCATED IN APACHE COUNTY ARIZONA. IT IS ONE OF FOUR FACILITIES LOCATED IN APACHE COUNTY. GANADO IS LOCATED IN A RURAL AREA WITH THE CITY'S POPULATION BEING 660 AND THE OVERALL COUNTY POPULATION OF 38,737 (2005-2009 CENSUS). THE PER CAPITA INCOME FOR THE CITY WAS $9,993. ABOUT 29% OF THE FAMILIES AND 39.2% OF THE POPULATION WERE BELOW THE POVERY LINE. NAVAJO HEALTH FOUNDATION/SAGE MEMORIAL HOSPITAL DELIVERS QUALITY HEALTH CARE SERVICES MOSTLY TO NAVAJO MEMBERS IN ITS CATCHMENT AREA, DEFINED IN AGREEMENT WITH THE INDIAN HEALTH SERVICES AS THE EIGHT AREA CHAPTERS THAT ADD UP TO ABOUT 20,000 PEOPLE IN 1,500 SQUARE MILES. THESE LOCAL CHAPTERS ARE:GANADO, KINLICHEE, KLAGETOH, WIDE RUINS, GREASEWOOD, CORNFIELDS, NAZLINI, AND STEAMBOATADDITIONALLY, DENTAL SERVICES ARE PROVIDED TO THE NAVAJOS FROM THREE MORE CHAPTERS: HOUCK, LUPTON, AND SANDERSTO FACILITATE NON-URGENT CARE TO PEOPLE MORE THAN 15 MILES FROM GANADO, SAGE MEMORIAL HOSPITAL OPERATES THREE FIELD CLINICS: GREASEWOOD, WIDE RUINS, AND SANDERS. ALSO ARRANGEMENTS CAN BE MADE FOR TRANSPORTATION OF PATIENTS THAT HAVE TROUBLE GETTING A RIDE TO AND FROM THE HOSPITAL. PART VI, LINE 6: THERE ARE EIGHT NAVAJO COMMUNITY MEMBERS THAT MAKE UP THE BOARD OF DIRECTORS. THERE ARE EIGHT CHAPTERS (COMMUNITIES) AND EACH CHAPTER ELECTS THIER REPRESENTATIVE ON A LOCAL LEVEL AND THOSE ELECTED INDIVIDUALS SERVE AS THE BOARD OF DIRECTORS. THOSE BOARD MEMBERS GO BACK TO THEIR COMMUNITES AND EDUCATE THEIR COMMUNITY MEMBERS ON WHAT IS HAPPENING AT THE HOSPITAL AND ON THE SERVICES BEING PROVIDED.THE FACILITY EXTENDS MEDICAL STAFF TO ALL QUALIFIED PHYSICIANS IN ITS COMMUNITIES. IF THERE IS A SURPLUS, THE FUNDS WOULD GO INTO PATIENT CARE AREAS INCLUDING EDUCATION, INCREASING PATIENT SERVICES, WELLNESS, AND PREVENTIVE CARE TO IT'S PATIENTS.THE NAVAJO HEALTH FOUNDATION MISSION IS TO PROVIDE HIGH QUALITY HEALTHCARE SERVICES TO THE RESIDENTS OF THE AREA IN ACCORDANCE WITH THE JOINT COMMISSION ON ACCREDITATION OF HEALTHCARE ORGANIZATION'S HOLISTIC APPROACH TO HEALTHCARE, FOCUSING ON THE PATIENT'S PHYSICAL, SOCIAL AND SPIRITUAL WELL BEING. WE ARE COMMITTED TO THE PREVENTION OF ILLNESS AND PROMOTION OF HEALTH; DELIVERY OF QUALITY PRIMARY INPATIENT AND OUTPATIENT CARE; PROMOTION OF EDUCATION AND TRAINING OF QUALIFIED NATIVE AMERICAN HEALTHCARE PROFESSIONALS.TO FULFILL THIS MISSION, WE WILL PROVIDE PREVENTIVE HEALING AND REHABILITATIVE SERVICES THROUGH A SYSTEM THAT LINKS NATIVE CULTURE WITH WESTERN MEDICINE; PRESERVE THE DIGNITY OF EACH INDIVIDUAL REGARDLESS OF CREED, RACE, SEX, RELIGION, SOCIAL STATUS, OR PHYSICAL HANDICAP; STRIVE TO ACHEIVE AND MAINTAIN EXCELLENCE IN ALL ASPECTS OF HEALTHCARE; PROMOTE THE EDUCATION AND TRAINING OF NATIVE AMERICAN HEALTHCARE PROFESSIONALS; AND OPERATE THE FACILITY IN A COST-EFFECTIVE AND FINACIALLY RESPONSIBLE MANNER. SAGE DENTAL CLINIC PROVIDES SERVICES TO PERSONS OF ALL AGES. WITH OUR FULL-TIME DENTISTS AND HYGIENIST, WE ARE COMITTED TO PROVIDING YOU WITH PROFESSIONAL AND QUALITY SERVICES. IT SERVICES A WIDE AREA OF 1,800 SQUARE MILES AND 22,000 PATIENTS AND OVER 10% OF THE NAVAJO NATION.SAGE DENTAL OFFERS SERVICES AT FIELD CLINICS IN GREASEWOOD (TWO CHAIRS) AND SANDERS (FOUR CHAIRS) WITH A ROTATING DENTIST FROM THE MAIN CLINIC FOUR TIMES A WEEK. OUR MAIN CLINIC IN GANADO CONSISTS OF EIGHT CHAIRS AND FIVE DENTISTS. WE ARE REACHING ONLY 20% OF OUR POTENTIAL NEED. THE CONTINUED GROWTH OF THE DENTAL CLINIC HAS BEEN A MAJOR PROJECT FOR DIRECTOR ANDEMICHAEL. CONSTANT SEARCH AND RECRUITMENT OF DENTISTS WITH TALENT AND A WILLINGNESS TO PRACTICE IN A RURAL AND REMOTE ENVIRONMENT REMAINS A PRIORITY. WITH THE RISING DEMAND, SAGE DENTAL ONLY ACCEPTS NEW PATIENTS ONE DAY PER MONTH. WALK-INS ARE ACCEPTED EVERY DAY FOR EMERGENCY VISITS. SAGE DENTAL HAS SEALANT PROGRAMS WITH THE LOCAL SCHOOLS AND WE OFFER DIAGNOSIS AND TREATMENT FOR CHILDREN SO THAT GOOD DENTAL HABITS AND CAVITY PREVENTION CAN BEGIN AT AN EARLY AGE. 1 SCHOLARSHIP EDUCATION ASSISTANCE TO EMPLOYEES OF SAGE MEMORIAL HOSPITAL, INC. 6 8888 PROCEDURE FOR MONITORING GRANTS IN THE U.S.: PART I, LINE 2: SCHEDULE I, PART I, LINE 2: THE SCHOLARSHIP FUNDS ARE REQUESTED BY THE RECIPIENT THROUGH THE OFFICE OF THE CEO AND ARE APPROVED THROUGH THE OFFICE OF THE CEO. THE APPROVED DOCUMENTATION IS THEN SENT TO THE FINANCE DEPARTMENT TO BE DISBURSED TO THE SCHOOL OR RECIPIENT WITH ALL REQUIRED DOCUMENTATION. CURRENTLY, THE SCHOLARSHIP POLICY IS BEING REVISED AND THE FINANCE DEPARTMENT CONTINUALLY MONITORS THE FINANCE PORTION. X 1 1 X X 0 0 0 0 0 0 0 0 0 ANDEMICHAEL MERON 195484 0 0 0 0 0 0 0 0 0 195484 0 0 0 LABIB- KIYARASH FARID 534240 0 0 0 0 0 0 0 0 0 534240 0 0 0 GOLPARIAN MOHAMMAD 219472 0 0 0 0 0 0 0 0 0 219472 0 0 0 WRAY JEREMY 279059 0 0 0 0 0 0 0 0 0 279059 0 0 0 SUPPLEMENTAL INFORMATION PART III 1A: SAGE PROVIDES SUBSIDIZED HOUSING FOR ALL EMPLOYEES, AND HAS OFFERED A HOUSING ALLOWANCE FOR PROFESSIONAL STAFF. 1B: THIS IS BASED ON THE HOSPITAL'S HOUSING POLICY AND IS INCLUDED IN THE RENTAL AGREEMENTS. THE ORGANIZATION'S CEO HAS A WRITTEN EMPLOYMENT CONTRACT WITH THE BOARD OF DIRECTORS AND ALL OTHER DIRECTORS COMPENSATION IS NEGOTIATED DIRECTLY WITH THE CEO. FORM 990, PART VI, SECTION B, LINE 11 THE FORM 990 IS REVIEWED BY THE DIRECTOR OF FINANCE AND THE CHIEF EXECUTIVE OFFICER BEFORE FILLING. IT IS THEN PRESENTED TO THE BOARD OF DIRECTORS. FORM 990, PART VI, SECTION B, LINE 12C THE EMPLOYEES AND BOARD OF DIRECTORS ARE COVERED BY THE POLICY. THE LEVEL AT WHICH A DETERMINATION OF WHETHER A CONFLICT EXISTS IS MADE AT THE EXECUTIVE LEVEL. THE EXECUTIVE LEVEL ALSO ACTUALLY REVIEWS THE CONFLICTS. FORM 990, PART VI, SECTION B, LINE 15 THE CEO'S SALARY IS DETERMINED THROUGH AN EMPLOYMENT CONTRACT AND AGREEMENT WITH THE BOARD OF DIRECTORS. THE SALARY IS REVIEWED AND APPROVED BY INDEPENDENT PERSONS, AND THERE IS CONTEMPORANEOUS SUBSTANTIATION OF THE DELIBERATION AND DECISION. ALL DIRECTORS AND KEY EMPLOYEES COMPENSATION IS NEGOTIATED DIRECTLY WITH THE CEO AND COMPARABLE MARKET VALUE AND EDUCATION IS USED TO DETERMINE THE SALARY. FORM 990, PART VI, SECTION C, LINE 19 DOCUMENTS ARE AVAILABLE UPON REQUEST. CHANGES IN NET ASSETS OR FUND BALANCES: FORM 990, PART XI, LINE 5: PRIOR PERIOD ADJUSTMENTS: 1,088,432. CHANGE IN AUDIT OVERSIGHT PROCESS OR SELECTION PROCESS FORM 990, PART XII, QUESTION 2C PROCESS HAS NOT CHANGED FROM PRIOR YEAR. OTHER CHANGES IN NET ASSETS OR FUND BALANCES FORM 990, PART XI, LINE 5 PRIOR PERIOD ADJUSTMENT TO REFLECT PRIOR YEAR AUDITED FINANCIAL STATEMENT AMOUNTS. PRIOR ACCOUNTANT FILED FORM 990 PRIOR TO THE AUDITED FINANCIAL STATEMNTS BEING AVAILABLE, THIS RESULTED IN A DIFFERENCE IN NET ASSETS OF $1,088,432.