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PAWNEE VALLEY COMMUNITY HOSPITAL INC: Form 990, tax year 2010

View the entire original 990 at ProPublica ↗

Organization
PAWNEE VALLEY COMMUNITY HOSPITAL INC (EIN 48-1253246)
Tax period
2010-07-01 to 2011-06-30
Filed
2012-05-15
IRS object ID
201221369349305812
Schema version
2010v3.4
Source
Download XML · Original 990 at ProPublica

Every field in the e-filed return. Faint text is the IRS element name, for citing.

Return header ReturnHeader

FieldValueIRS element (for citing)
Timestamp2012-05-15T14:24:21-05:00Timestamp
Tax Period End Date2011-06-30TaxPeriodEndDate

Preparer Firm PreparerFirm

Preparer Firm Business Name PreparerFirmBusinessName

FieldValueIRS element (for citing)
Business Name Line1Wendling Noe Nelson & Johnson LLCBusinessNameLine1

Preparer Firm US Address PreparerFirmUSAddress

FieldValueIRS element (for citing)
Address Line1534 S Kansas Ave Suite 1500AddressLine1
CityTopekaCity
StateKSState
ZIP Code666033491ZIPCode
FieldValueIRS element (for citing)
Return Type990ReturnType
Tax Period Begin Date2010-07-01TaxPeriodBeginDate

Filer Filer

FieldValueIRS element (for citing)
EIN481253246EIN

Name Name

FieldValueIRS element (for citing)
Business Name Line1Pawnee Valley Community Hospital IncBusinessNameLine1
FieldValueIRS element (for citing)
Name ControlPAWNNameControl
Phone6202853161Phone

US Address USAddress

FieldValueIRS element (for citing)
Address Line1923 Carroll AveAddressLine1
CityLarnedCity
StateKSState
ZIP Code67550ZIPCode

Officer Officer

FieldValueIRS element (for citing)
NameJohn JeterName
TitlePresidentTitle
Phone7856235000Phone
Date Signed2012-05-14DateSigned
Authorize Third Party1AuthorizeThirdParty

Preparer Preparer

FieldValueIRS element (for citing)
NameGary D KnollName
Phone7852334226Phone
Date Prepared2012-05-14DatePrepared
FieldValueIRS element (for citing)
Tax Year2010TaxYear
Build TS2016-02-24 21:20:13ZBuildTS

Form 990 IRS990

FieldValueIRS element (for citing)
Name Of Principal Officer PersonJohn JeterNameOfPrincipalOfficerPerson

Address Principal Officer US AddressPrincipalOfficerUS

FieldValueIRS element (for citing)
Address Line1923 Carroll AveAddressLine1
CityLarnedCity
StateKSState
ZIP Code67550ZIPCode
FieldValueIRS element (for citing)
Gross Receipts11004995GrossReceipts
Group Return For Affiliates0GroupReturnForAffiliates
Organization501c3XOrganization501c3
Web Sitewww.pawneevalleyhospital.comWebSite
Type Of Organization CorporationXTypeOfOrganizationCorporation
Year Formation2001YearFormation
State Legal DomicileKSStateLegalDomicile
Activity Or Mission DescriptionPawnee Valley Community Hospital, Inc. is a tax-exempt charitable organization under Section 501(c)(3) of the Internal Revenue Code and is licensed by the State of Kansas Department of Health and Environment. The purpose of the Organization is to provide healthcare to inpatients and outpatients who are acutely ill or who otherwise require medical care and related services. The Organization is striving to be the best Critical Access Hospital in rural America.ActivityOrMissionDescription
Nbr Voting Members Governing Body5NbrVotingMembersGoverningBody
Nbr Independent Voting Members0NbrIndependentVotingMembers
Total Nbr Employees116TotalNbrEmployees
Total Nbr Volunteers90TotalNbrVolunteers
Total Gross UBI0TotalGrossUBI
Net Unrelated Business Txbl Income0NetUnrelatedBusinessTxblIncome
Contributions Grants Prior Year158669ContributionsGrantsPriorYear
Contributions Grants Current Year93394ContributionsGrantsCurrentYear
Program Service Revenue Prior Year4411961ProgramServiceRevenuePriorYear
Program Service Revenue CY10903508ProgramServiceRevenueCY
Investment Income Prior Year1418InvestmentIncomePriorYear
Investment Income Current Year8093InvestmentIncomeCurrentYear
Other Revenue Prior Year0OtherRevenuePriorYear
Other Revenue Current Year0OtherRevenueCurrentYear
Total Revenue Prior Year4572048TotalRevenuePriorYear
Total Revenue Current Year11004995TotalRevenueCurrentYear
Grants And Similar Amnts Prior Year0GrantsAndSimilarAmntsPriorYear
Grants And Similar Amnts CY0GrantsAndSimilarAmntsCY
Benefits Paid To Members Prior Year0BenefitsPaidToMembersPriorYear
Benefits Paid To Members CY0BenefitsPaidToMembersCY
Salaries Etc Prior Year3180486SalariesEtcPriorYear
Salaries Etc Current Year3739930SalariesEtcCurrentYear
Total Prof Fundrsng Exp Prior Year0TotalProfFundrsngExpPriorYear
Total Prof Fundrsng Exp CY0TotalProfFundrsngExpCY
Total Fundrsng Exp Current Year0TotalFundrsngExpCurrentYear
Other Expense Prior Year4693290OtherExpensePriorYear
Other Expenses Current Year6636374OtherExpensesCurrentYear
Total Expenses Prior Year7873776TotalExpensesPriorYear
Total Expenses Current Year10376304TotalExpensesCurrentYear
Revenues Less Expenses Prior Year-3301728RevenuesLessExpensesPriorYear
Revenues Less Expenses CY628691RevenuesLessExpensesCY
Total Assets BOY2297833TotalAssetsBOY
Total Assets EOY4821252TotalAssetsEOY
Total Liabilities BOY2297833TotalLiabilitiesBOY
Total Liabilities EOY4821252TotalLiabilitiesEOY
Net Assets Or Fund Balances BOY0NetAssetsOrFundBalancesBOY
Net Assets Or Fund Balances EOY0NetAssetsOrFundBalancesEOY
Info In Schedule O Part IIIXInfoInScheduleOPartIII
Mission DescriptionPawnee Valley Community Hospital, Inc. is a tax-exempt charitable organization under Section 501(c)(3) of the Internal Revenue Code and is licensed by the State of Kansas Department of Health and Environment. The purpose of the Organization is to provide healthcare facitities and services for the care and treatment of inpatients and outpatients who are acutely ill or who otherwise require medical care and related services. The core purpose of the Corporation is to help people be healthy.MissionDescription
Significant New Program Services0SignificantNewProgramServices
Significant Change0SignificantChange
Expense9180874Expense
Revenue10790570Revenue
DescriptionPatient care: Program services consist of routine and ancillary department healthcare services provided by a healthcare organization as described in 501(c)(3) of the IRS code.Description
Total Program Service Expense9180874TotalProgramServiceExpense
Described In501 C31DescribedIn501C3
Schedule B Required0ScheduleBRequired
Political Activities0PoliticalActivities
Lobbying Activities0LobbyingActivities
Donor Advised Funds0DonorAdvisedFunds
Conservation Easements0ConservationEasements
Collections Of Art0CollectionsOfArt
Credit Counseling0CreditCounseling
Term Or Permanent Endowments0TermOrPermanentEndowments
Report Land Bldg Equip0ReportLandBldgEquip
Report Invest Oth Securities0ReportInvestOthSecurities
Report Prog Rel Invest0ReportProgRelInvest
Report Other Assets0ReportOtherAssets
Report Other Liabilities1ReportOtherLiabilities
Report Fin48 Footnote0ReportFin48Footnote
Independent Audit Financial Stmt0IndependentAuditFinancialStmt
Consolidated Audit Financial Stmt1ConsolidatedAuditFinancialStmt
School0School
Foreign Office0ForeignOffice
Foreign Activities0ForeignActivities
More Than5000 K To Organizations0MoreThan5000KToOrganizations
More Than5000 K To Individuals0MoreThan5000KToIndividuals
Professional Fundraising0ProfessionalFundraising
Fundraising Activities0FundraisingActivities
Gaming0Gaming
Hospital1Hospital
Financial Stmt Attached1FinancialStmtAttached
Grants To Organizations0GrantsToOrganizations
Grants To Individuals0GrantsToIndividuals
Schedule J Required1ScheduleJRequired
Tax Exempt Bonds0TaxExemptBonds
Excess Benefit Transaction0ExcessBenefitTransaction
Prior Excess Benefit Transaction0PriorExcessBenefitTransaction
Loan To Officer Or DQP0LoanToOfficerOrDQP
Grant To Related Person0GrantToRelatedPerson
Bsnss Rltnshp With Organization0BsnssRltnshpWithOrganization
Bsnss Rltnshp Thru Family Member0BsnssRltnshpThruFamilyMember
Officer Entity With Bsnss Rltnshp1OfficerEntityWithBsnssRltnshp
Deductible Non Cash Contributions0DeductibleNonCashContributions
Deductible Contributions Of Art0DeductibleContributionsOfArt
Terminated0Terminated
Partial Liquidation0PartialLiquidation
Disregarded Entity0DisregardedEntity
Related Entity1RelatedEntity
Related Org Controlled Entity0RelatedOrgControlledEntity
Transaction Related Entity0TransactionRelatedEntity
Transfers To Exempt Non Chrtbl Org0TransfersToExemptNonChrtblOrg
Activities Conducted Partnership0ActivitiesConductedPartnership
Schedule O Required1ScheduleORequired
Number Forms Transmitted With10960NumberFormsTransmittedWith1096
Number W2 G Included0NumberW2GIncluded
Number Of Employees116NumberOfEmployees
Employment Tax Returns Filed1EmploymentTaxReturnsFiled
Unrelated Business Income0UnrelatedBusinessIncome
Foreign Financial Account0ForeignFinancialAccount
Prohibited Tax Shelter Trans0ProhibitedTaxShelterTrans
Taxable Party Notification0TaxablePartyNotification
Non Deductible Contributions0NonDeductibleContributions
Quid Pro Quo Contributions0QuidProQuoContributions
Form8282 Property Disposed Of0Form8282PropertyDisposedOf
Funds To Pay Premiums0FundsToPayPremiums
Premiums Paid0PremiumsPaid
Indoor Tanning Services0IndoorTanningServices
Info In Schedule O Part VIXInfoInScheduleOPartVI
Nbr Voting Governing Body Members5NbrVotingGoverningBodyMembers
Number Independent Voting Members0NumberIndependentVotingMembers
Family Or Business Relationship0FamilyOrBusinessRelationship
Delegation Of Management Duties0DelegationOfManagementDuties
Changes To Organizing Docs0ChangesToOrganizingDocs
Material Diversion Or Misuse0MaterialDiversionOrMisuse
Members Or Stockholders1MembersOrStockholders
Election Of Board Members1ElectionOfBoardMembers
Decisions Subject To Approval1DecisionsSubjectToApproval
Minutes Of Governing Body1MinutesOfGoverningBody
Minutes Of Committees1MinutesOfCommittees
Officer Mailing Address0OfficerMailingAddress
Local Chapters0LocalChapters
Form990 Provided To Governing Body1Form990ProvidedToGoverningBody
Conflict Of Interest Policy1ConflictOfInterestPolicy
Annual Disclosure Covered Persons1AnnualDisclosureCoveredPersons
Regular Monitoring Enforcement1RegularMonitoringEnforcement
Whistleblower Policy1WhistleblowerPolicy
Document Retention Policy1DocumentRetentionPolicy
Compensation Process CEO1CompensationProcessCEO
Compensation Process Other1CompensationProcessOther
Investment In Joint Venture0InvestmentInJointVenture
Upon RequestXUponRequest

The Books Are In Care Of TheBooksAreInCareOf

FieldValueIRS element (for citing)
Name PersonWilliam Overbey TreasurerNamePerson
Telephone Number7856235000TelephoneNumber

Address US AddressUS

FieldValueIRS element (for citing)
Address Line12220 CanterburyAddressLine1
CityHaysCity
StateKSState
ZIP Code67601ZIPCode

Form990 Part VII Section A Form990PartVIISectionA (8 entries)

TitleTitleAverage Hours Per WeekAverageHoursPerWeekIndividual Trustee Or DirectorIndividualTrusteeOrDirectorOfficerOfficerReportable Comp From OrganizationReportableCompFromOrganizationReportable Comp From Related OrgsReportableCompFromRelatedOrgsOther CompensationOtherCompensationFormerFormer
John Jeter MD
President4.00XX0593274142269
Bryce Young
Vice President4.00XX027975085301
William Overbey
Secretary/Treasurer4.00XX027712084847
Shae Veach
Board Member4.00X080573344
David Sanger MD
Physician4.00X0425779505
Matt Heyn
Hospital Administrator40.00X08330715470
Ken Lindsey thru March 2011
Former Board Member4.00037091194260X
Jodi Schmidt thru August 2010
Former VP Regional Development4.00016427149582X
FieldValueIRS element (for citing)
Total Reportable Comp From Org0TotalReportableCompFromOrg
Total Reportable Comp Frm Rltd Orgs1819267TotalReportableCompFrmRltdOrgs
Total Other Compensation484578TotalOtherCompensation
Number Individuals GT100 K0NumberIndividualsGT100K
Formers Listed1FormersListed
Total Comp GT150 K1TotalCompGT150K
Compensation From Other Sources0CompensationFromOtherSources

Contractor Compensation ContractorCompensation (5 entries)

Address Line1AddressOfContractor/AddressUS/AddressLine1CityAddressOfContractor/AddressUS/CityStateAddressOfContractor/AddressUS/StateZIP CodeAddressOfContractor/AddressUS/ZIPCodeDescription Of ServicesDescriptionOfServicesCompensationCompensation
Docs Who Care
1337 S Fountain DrOlatheKS66061ER Physician Coverage972944
Allstaff Chartered
2000 WashingtonGreat BendKS67530Contract Nursing541314
Quest Diagnostics
PO Box 14730St LouisMO631504730Lab Service183665
Great Bend Regional Hospital
514 ClevelandGreat BendKS67530Lab Service138580
Medical Solutions
9101 Western Ave Suite 101OmahaNE68114Nursing & Lab Coverage128202
FieldValueIRS element (for citing)
Number Of Contractors GT100 K11NumberOfContractorsGT100K
Government Grants93298GovernmentGrants
All Other Contributions96AllOtherContributions
Total Contributions93394TotalContributions

Program Service Revenue ProgramServiceRevenue (3 entries)

DescriptionDescriptionBusiness CodeBusinessCodeTotal Revenue ColumnTotalRevenueColumnRelated Or Exempt Function IncomeRelatedOrExemptFunctionIncomeExclusionExclusionAmount
Net patient service re6220001079057010790570
Other operating revenu900099101896$101,896
Other operating revenu90009911042$11,042
FieldValueIRS element (for citing)
Total Program Service Revenue10903508TotalProgramServiceRevenue

Investment Income InvestmentIncome

FieldValueIRS element (for citing)
Total Revenue Column7783TotalRevenueColumn
Exclusion$7,783ExclusionAmount

Gross Amount Sales Assets GrossAmountSalesAssets

FieldValueIRS element (for citing)
Other310Other

Gain Or Loss GainOrLoss

FieldValueIRS element (for citing)
Other310Other

Net Gain Or Loss Investments NetGainOrLossInvestments

FieldValueIRS element (for citing)
Total Revenue Column310TotalRevenueColumn
Exclusion$310ExclusionAmount

Total Revenue TotalRevenue

FieldValueIRS element (for citing)
Total Revenue Column11004995TotalRevenueColumn
Related Or Exempt Function Income10790570RelatedOrExemptFunctionIncome
Unrelated Business Revenue0UnrelatedBusinessRevenue
Exclusion$121,031ExclusionAmount

Comp Current Officers Directors CompCurrentOfficersDirectors

FieldValueIRS element (for citing)
Total136300Total
Management And General136300ManagementAndGeneral

Other Salaries And Wages OtherSalariesAndWages

FieldValueIRS element (for citing)
Total2804856Total
Program Services2514208ProgramServices
Management And General290648ManagementAndGeneral

Pension Plan Contributions PensionPlanContributions

FieldValueIRS element (for citing)
Total73989Total
Program Services66322ProgramServices
Management And General7667ManagementAndGeneral

Other Employee Benefits OtherEmployeeBenefits

FieldValueIRS element (for citing)
Total522276Total
Program Services483625ProgramServices
Management And General38651ManagementAndGeneral

Payroll Taxes PayrollTaxes

FieldValueIRS element (for citing)
Total202509Total
Program Services181524ProgramServices
Management And General20985ManagementAndGeneral

Fees For Services Management FeesForServicesManagement

FieldValueIRS element (for citing)
Total50055Total
Management And General50055ManagementAndGeneral

Fees For Services Legal FeesForServicesLegal

FieldValueIRS element (for citing)
Total48602Total
Management And General48602ManagementAndGeneral

Fees For Services Invst Mgmnt Fees FeesForServicesInvstMgmntFees

FieldValueIRS element (for citing)
Total107Total
Management And General107ManagementAndGeneral

Fees For Services Other FeesForServicesOther

FieldValueIRS element (for citing)
Total1998265Total
Program Services1841594ProgramServices
Management And General156671ManagementAndGeneral

Advertising Advertising

FieldValueIRS element (for citing)
Total79023Total
Program Services1777ProgramServices
Management And General77246ManagementAndGeneral

Office Expenses OfficeExpenses

FieldValueIRS element (for citing)
Total30088Total
Program Services22444ProgramServices
Management And General7644ManagementAndGeneral

Information Technology InformationTechnology

FieldValueIRS element (for citing)
Total66092Total
Program Services39655ProgramServices
Management And General26437ManagementAndGeneral

Occupancy Occupancy

FieldValueIRS element (for citing)
Total513202Total
Program Services295447ProgramServices
Management And General217755ManagementAndGeneral

Travel Travel

FieldValueIRS element (for citing)
Total46443Total
Program Services44531ProgramServices
Management And General1912ManagementAndGeneral

Interest Interest

FieldValueIRS element (for citing)
Total37511Total
Program Services37511ProgramServices

Insurance Insurance

FieldValueIRS element (for citing)
Total38997Total
Program Services23398ProgramServices
Management And General15599ManagementAndGeneral

Other Expenses OtherExpenses (5 entries)

DescriptionDescriptionTotalTotalProgram ServicesProgramServicesManagement And GeneralManagementAndGeneral
Bad debts14084501408450
Contract labor854093854093
Pharmaceuticals511618511618
Medical supplies3278203258681952
Repairs & maintenance1754211726822739

All Other Expenses AllOtherExpenses

FieldValueIRS element (for citing)
Total450587Total
Program Services356127ProgramServices
Management And General94460ManagementAndGeneral

Total Functional Expenses TotalFunctionalExpenses

FieldValueIRS element (for citing)
Total10376304Total
Program Services9180874ProgramServices
Management And General1195430ManagementAndGeneral
Fundraising0Fundraising

Cash Non Interest Bearing CashNonInterestBearing

FieldValueIRS element (for citing)
BOY210BOY
EOY560EOY

Savings And Temp Cash Investments SavingsAndTempCashInvestments

FieldValueIRS element (for citing)
BOY171340BOY
EOY2678839EOY

Accounts Receivable AccountsReceivable

FieldValueIRS element (for citing)
BOY1960702BOY
EOY1879340EOY

Other Notes Loans Receivable Net OtherNotesLoansReceivableNet

FieldValueIRS element (for citing)
BOY290BOY
EOY641EOY

Inventories For Sale Or Use InventoriesForSaleOrUse

FieldValueIRS element (for citing)
BOY113446BOY
EOY195512EOY

Prepaid Expenses Deferred Charges PrepaidExpensesDeferredCharges

FieldValueIRS element (for citing)
BOY51845BOY
EOY66360EOY

Total Assets TotalAssets

FieldValueIRS element (for citing)
BOY2297833BOY
EOY4821252EOY

Accounts Payable Accrued Expenses AccountsPayableAccruedExpenses

FieldValueIRS element (for citing)
BOY2297833BOY
EOY4192561EOY

Other Liabilities OtherLiabilities

FieldValueIRS element (for citing)
BOY0BOY
EOY628691EOY

Total Liabilities TotalLiabilities

FieldValueIRS element (for citing)
BOY2297833BOY
EOY4821252EOY
FieldValueIRS element (for citing)
Follow SFAS117XFollowSFAS117

Total Net Assets Fund Balances TotalNetAssetsFundBalances

FieldValueIRS element (for citing)
BOY0BOY
EOY0EOY

Total Liab Net Assets Fund Balances TotalLiabNetAssetsFundBalances

FieldValueIRS element (for citing)
BOY2297833BOY
EOY4821252EOY
FieldValueIRS element (for citing)
Info In Schedule O Part XIXInfoInScheduleOPartXI
Reconcilation Revenue Expenses628691ReconcilationRevenueExpenses
Reconcilation Other Changes-628691ReconcilationOtherChanges
Info In Schedule O Part XIIXInfoInScheduleOPartXII
Method Of Accounting AccrualXMethodOfAccountingAccrual
Accountant Compile Or Review0AccountantCompileOrReview
FS Audited1FSAudited
Audit Committee1AuditCommittee
Financial Statement ConsolidatedXFinancialStatementConsolidated
Federal Grant Audit Required0FederalGrantAuditRequired

Schedule A IRS990ScheduleA

FieldValueIRS element (for citing)
Hospital170b1 AiiiXHospital170b1Aiii

Schedule D IRS990ScheduleD

FieldValueIRS element (for citing)
Total Of Book Value Land Buildings0TotalOfBookValueLandBuildings

Other Liabilities OtherLiabilities

FieldValueIRS element (for citing)
DescriptionDue to Pawnee CountyDescription
Amount$628,691Amount
FieldValueIRS element (for citing)
Total Of Amounts628691TotalOfAmounts
Total Revenue11004995TotalRevenue
Total Expenses10376304TotalExpenses
Excess Or Deficit For Year628691ExcessOrDeficitForYear
Other-$628,691OtherAmount
Total Adjustments-628691TotalAdjustments
Excess Or Deficit Per FS0ExcessOrDeficitPerFS
Tot Revenue Etc Audited Fincl Stmt11004995TotRevenueEtcAuditedFinclStmt
Revenue Not Rptd F9900RevenueNotRptdF990
Revenue Subtotal11004995RevenueSubtotal
Revenue Not Rptd On Fin Stmt0RevenueNotRptdOnFinStmt
Total Revenue Per Form99011004995TotalRevenuePerForm990
Tot Expenses Etc Audited Fincl Stmt10376304TotExpensesEtcAuditedFinclStmt
Expenses Not Rptd F9900ExpensesNotRptdF990
Expenses Subtotal10376304ExpensesSubtotal
Expenses Not Rptd On Fin Stmt0ExpensesNotRptdOnFinStmt
Total Expenses Per Form99010376304TotalExpensesPerForm990

Form990 Schedule D Part XIV Form990ScheduleDPartXIV

FieldValueIRS element (for citing)
IdentifierPart XI, Line 8 - Other Adjustments:Identifier
ExplanationIncrease in amount due to Pawnee CountyExplanation

Schedule H IRS990ScheduleH

FieldValueIRS element (for citing)
Charity Care Policy1CharityCarePolicy
Written Policy1WrittenPolicy
FPG Reference Free Care1FPGReferenceFreeCare

Other Percentage OtherPercentage

FieldValueIRS element (for citing)
OtherXOther
Free Other Percentage125.000000000000FreeOtherPercentage
FieldValueIRS element (for citing)
FPG Reference Discounted Care1FPGReferenceDiscountedCare
Pcent400XPcent400
Free Disc Care Medically Indigent1FreeDiscCareMedicallyIndigent
Amounts Budgeted For Charity Care1AmountsBudgetedForCharityCare
Expenses Exceeded Budget1ExpensesExceededBudget
Unable To Provide Care0UnableToProvideCare
Annual Community Benefit Report1AnnualCommunityBenefitReport
Report Publically Available0ReportPublicallyAvailable

Charity Care At Cost CharityCareAtCost

FieldValueIRS element (for citing)
Total Community Benefit Expense176017TotalCommunityBenefitExpense
Net Community Benefit Expense176017NetCommunityBenefitExpense
Percent Of Total Expense0.01960PercentOfTotalExpense

Unreimbursed Medicaid UnreimbursedMedicaid

FieldValueIRS element (for citing)
Total Community Benefit Expense337779TotalCommunityBenefitExpense
Direct Offsetting Revenue337779DirectOffsettingRevenue

Total Charity Care TotalCharityCare

FieldValueIRS element (for citing)
Total Community Benefit Expense513796TotalCommunityBenefitExpense
Direct Offsetting Revenue337779DirectOffsettingRevenue
Net Community Benefit Expense176017NetCommunityBenefitExpense
Percent Of Total Expense0.01960PercentOfTotalExpense

Subsidized Health Services SubsidizedHealthServices

FieldValueIRS element (for citing)
Total Community Benefit Expense974543TotalCommunityBenefitExpense
Direct Offsetting Revenue883869DirectOffsettingRevenue
Net Community Benefit Expense90674NetCommunityBenefitExpense
Percent Of Total Expense0.01010PercentOfTotalExpense

Cash And In Kind Contributions CashAndInKindContributions

FieldValueIRS element (for citing)
Total Community Benefit Expense7452TotalCommunityBenefitExpense
Net Community Benefit Expense7452NetCommunityBenefitExpense
Percent Of Total Expense0.00080PercentOfTotalExpense

Total Other Benefits TotalOtherBenefits

FieldValueIRS element (for citing)
Total Community Benefit Expense981995TotalCommunityBenefitExpense
Direct Offsetting Revenue883869DirectOffsettingRevenue
Net Community Benefit Expense98126NetCommunityBenefitExpense
Percent Of Total Expense0.01090PercentOfTotalExpense

Total Community Benefits TotalCommunityBenefits

FieldValueIRS element (for citing)
Total Community Benefit Expense1495791TotalCommunityBenefitExpense
Direct Offsetting Revenue1221648DirectOffsettingRevenue
Net Community Benefit Expense274143NetCommunityBenefitExpense
Percent Of Total Expense0.03050PercentOfTotalExpense
FieldValueIRS element (for citing)
Bad Debt Expense Reported0BadDebtExpenseReported
Bad Debt Expense$517,465BadDebtExpenseAmount
Amount Attributable To36223AmountAttributableTo
Amount Reimbursed By Medicare6421747AmountReimbursedByMedicare
Cost Of Care Reimbursed By Medicare6358165CostOfCareReimbursedByMedicare
Medicare Surplus Or Shortfall63582MedicareSurplusOrShortfall

Costing Methodology Used CostingMethodologyUsed

FieldValueIRS element (for citing)
OtherXOther
FieldValueIRS element (for citing)
Written Debt Collection Policy1WrittenDebtCollectionPolicy
Provision For Charity Care1ProvisionForCharityCare
Number Of Hospital Facilities1NumberOfHospitalFacilities

Form990 Schedule H Part V Section A Form990ScheduleHPartVSectionA

FieldValueIRS element (for citing)
Facility Number1FacilityNumber

Name Name

FieldValueIRS element (for citing)
Business Name Line1Pawnee Valley Community Hospital IncBusinessNameLine1

Address Address

FieldValueIRS element (for citing)
Address Line1923 Carroll AvenueAddressLine1
CityLarnedCity
StateKSState
ZIP Code67550ZIPCode
FieldValueIRS element (for citing)
Licensed HospitalXLicensedHospital
General Medical And SurgicalXGeneralMedicalAndSurgical
Critical Access HospitalXCriticalAccessHospital
Er24 HoursXEr24Hours

Form990 Schedule H Part V Section B Form990ScheduleHPartVSectionB

Hospital Facility Name HospitalFacilityName

FieldValueIRS element (for citing)
Business Name Line1Pawnee Valley Community Hospital IncBusinessNameLine1
FieldValueIRS element (for citing)
Hospital Facility Number1HospitalFacilityNumber
Eligibility Criteria Explained1EligibilityCriteriaExplained
Uses FPG Free1UsesFPGFree
FPG Free Percent125.000000000000FPGFreePercent
Uses FPG Discounted1UsesFPGDiscounted
FPG Discount Percent400.000000000000FPGDiscountPercent
Explains Basis1ExplainsBasis
Income LevelXIncomeLevel
Asset LevelXAssetLevel
Uninsured DiscountXUninsuredDiscount
Medicaid MedicareXMedicaidMedicare
Explains Application Method1ExplainsApplicationMethod
Includes Publicity Measures1IncludesPublicityMeasures
Posted On WebsiteXPostedOnWebsite
Posted In Admission OfficeXPostedInAdmissionOffice
Available On RequestXAvailableOnRequest
Other PublicityXOtherPublicity
Actions On Nonpayment1ActionsOnNonpayment
Permit Report To Credit AgencyXPermitReportToCreditAgency
Permit LawsuitXPermitLawsuit
Collection Activities1CollectionActivities
Report To Credit AgencyXReportToCreditAgency
LawsuitXLawsuit
Notify Upon AdmissionXNotifyUponAdmission
Notify Before DischargeXNotifyBeforeDischarge
Notified All PatientsXNotifiedAllPatients
Documented DeterminationXDocumentedDetermination
Nondiscrim Emergency Care Policy1NondiscrimEmergencyCarePolicy
Lowest Negotiated RatesXLowestNegotiatedRates
Amounts Generally Billed0AmountsGenerallyBilled
Gross Charges0GrossCharges

Form990 Schedule H Part VI Form990ScheduleHPartVI (11 entries)

ExplanationExplanationIdentifierIdentifierReturn ReferenceReturnReference
Part I, Line 7: Hays Medical Center, Inc., cost accounting system was used to calculate subsidized health services, health professions education, and community health improvement services. A cost-to-charge ratio was computed and used to calculate charity care and unreimbursed Medicaid reported on line 7.
Part I, L7 Col(f): Bad debt expense of $1,408,450 is included in Part IX line 25. This amount was subtracted from total expenses when computing the denominator for the percentage calculated for line 7(f).
Part III, Line 4: Bad debt expense was calculated using the same cost-to-charge ratio computed for charity care and unreimbursed Medicaid. The estimate for the amount of bad debt expense attributable to patients that would qualify for charity care is based upon the experience of a related organization. The hospital's financial statements are included in a consolidated set of audited financial statements. The footnotes from these financial statements follow: Patient service revenue is recorded at HMC's established rates with contractual adjustments from third-party payors, charity allowances and other discounts deducted to arrive at net patient service revenue. Patient accounts receivable represent an estimate of net realizable amounts due from patients, third-party payors, and others for unpaid patient services, which is determined on historical payment experience. Retroactively calculated contractual adjustments arising under reimbursement agreements with Medicare and other third-party payors are accrued on an estimated basis in the periods the related services are rendered and adjusted in future periods as final settlements are determined. Medicare is HMC's most significant third-party payor.
Part III, Line 8: The Medicare cost report was the costing methodology used to determine the above costs. Allowable costs of care reported on line 6 were determined using amounts from Worksheet D, Part V and Worksheet D-1 in the Pawnee Valley Community Hospital, Inc. Medicare cost report for fiscal year ended June 30, 2011.
Part III, Line 9b: Whenever possible, the customer service representatives (CSR's) of Pawnee Valley Community Hospital try to determine the estimated self-pay balance prior to the patient receiving services. Charity care eligibility is first considered at this point in time. In addition, if full payment is not received or payment is not made with 30 days, the CSR contacts the patient. If it is determined that at least a two-year payment plan cannot be established with the patient, the CSR will screen for charity care and request that the charity care application be completed by the patient.
Part V, Section B, Line 13g: Pawnee Valley Community Hospital, Inc. (PVCH) will proactively seek out applicants who may be in need of financial assistance. PVCH will post notice of this policy to all patients/guarantors through its registration, pre-registration, and financial counseling process. This policy will also be posted in prominent areas of the hospital.Pawnee Valley Community Hospital, Inc.
Part VI, Line 3: Information regarding the Pawnee Valley Community Hospital, Inc. charity care program is located on the Hays Medical Center, Inc. website for patients and community members to view, and the financial assistance application is also on the website to print off and complete. In addition, if a customer service representative contacts a patient about a bill and in visiting with them they determine that patient could possibly qualify for the hospital's charity care policy, the CSR will send the application to the patient as well.
Part VI, Line 4: Pawnee Valley Community Hospital, Inc. is located in Larned, Kansas, which has a population of approximately 4,050 people, as of the 2010 census. The median household income of Larned was $46,464. Approximately 5.9% of families were below the poverty line, and 7.4% of the total population was below the poverty line. Approximately 7.8% of the hospital's revenue is from services provided to patients eligible for Medicaid. Pawnee Valley Community Hospital, Inc. is the only hospital in Larned, Kansas. It mainly serves the community of Larned.
Part VI, Line 6: Pawnee Valley Community Hospital, Inc. promotes the health of the community by extending medical privileges to most qualified, local physicians.
Part VI, Line 7: Pawnee Valley Community Hospital, Inc. is not a part of an affiliated health care system.
Pawnee Valley Community Hospital, Inc. has begun its assessment of the health care needs of the communities it serves; however, this assessment is not yet completed.Sch J - Part VI - Line 2

Schedule J IRS990ScheduleJ

FieldValueIRS element (for citing)
Independent ConsultantXIndependentConsultant
Board Or Committee ApprovalXBoardOrCommitteeApproval
Severance Payment0SeverancePayment
Supplemental Nonqual Retire Plan1SupplementalNonqualRetirePlan
Equity Based Comp Arrangement0EquityBasedCompArrangement
Comp Based On Revenue Of Filing Org0CompBasedOnRevenueOfFilingOrg
Comp Based On Revenue Related Orgs0CompBasedOnRevenueRelatedOrgs
Comp Based Net Earnings Filing Org0CompBasedNetEarningsFilingOrg
Comp Based Net Earnings Relate Orgs1CompBasedNetEarningsRelateOrgs
Any Non Fixed Payments0AnyNonFixedPayments
Initial Contract Exception0InitialContractException

Form990 Schedule J Part II Form990ScheduleJPartII (5 entries)

Base Compensation Filing OrgBaseCompensationFilingOrgComp Based On Related OrgsCompBasedOnRelatedOrgsBonus Filing OrgBonusFilingOrgBonus Related OrgsBonusRelatedOrgsOther Compensation Filing OrgOtherCompensationFilingOrgOther Compensation Related OrgsOtherCompensationRelatedOrgsDeferred Comp Filing OrgDeferredCompFilingOrgDeferred Comp Related OrgsDeferredCompRelatedOrgsNontaxable Benefits Filing OrgNontaxableBenefitsFilingOrgNontaxable Benefits Related OrgsNontaxableBenefitsRelatedOrgsTotal Compensation Filing OrgTotalCompensationFilingOrgTotal Compensation Related OrgsTotalCompensationRelatedOrgsComp Report Prior990 Filing OrgCompReportPrior990FilingOrgComp Report Prior990 Related OrgsCompReportPrior990RelatedOrgs
John Jeter MD
04007260166740025808011572702654207355430209673
Bryce Young
02120550631200457505599102931003650510105200
William Overbey
02106720631500329805553702931003619670105250
Ken Lindsey thru March 2011
027513908112001465206771802654204651710140930
Jodi Schmidt thru August 2010
01090540351900200270323900171920213853077053

Form990 Schedule J Part III Form990ScheduleJPartIII (2 entries)

Return ReferenceReturnReferenceExplanationExplanationIdentifierIdentifier
Part I, Line 4bOfficers and key employees of Hays Medical Center, Inc, a related organization, are eligible to participate in Hays Medical Center, Inc.'s non-qualified retirement plan. Contributions from employer are contributed to the plan on an annual basis. Contributions to the plan for listed persons are included in Schedule J as a component of deferred compensation. Contribution amounts for listed persons for FYE 6-30-11 were: officers - $227,255.
Part IIISchedule J, Part I, Line 6 - A portion of incentive compensation for officers and key employees of Hays Medical Center, Inc., a related organization, is determined by net earnings exceeding budget for the fiscal year.Supplemental Information

Schedule L IRS990ScheduleL

Form990 Schedule L Part IV Form990ScheduleLPartIV (4 entries)

RelationshipRelationshipSharing Of RevenuesSharingOfRevenues
John Jeter MD Board President Pa
Board President and CEO, Hays Medical Center, Inc.0
Bryce Young Board Vice-President
COO, Hays Medical Center, Inc.0
William Overbey Board SecTreas P
CFO, Hays Medical Center, Inc.0
Shea Veach Board Member Pawnee Va
Director of Regional Operations, Hays Medical Center, Inc.0

Schedule O IRS990ScheduleO

General Explanation GeneralExplanation (9 entries)

IdentifierIdentifierExplanationExplanationReturn ReferenceReturnReference
Form 990, Part VI, Section A, line 6The organization has one member, HaysMed Partners, Inc., which became the sole member as of March 1, 2010. HaysMed Partners, Inc. is a wholly-owned subsidiary of Hays Medical Center, Inc.
Form 990, Part VI, Section A, line 7aThe Board members of HaysMed Partners, Inc, the sole member of Pawnee Valley Community Hospital, appoints the Board members of Pawnee Valley Community Hospital Inc.
Form 990, Part VI, Section A, line 7bHaysMed Partners, the sole member of Pawnee Valley Community Hospital, elects the Board members of Pawnee Valley Community Hospital.
Form 990, Part VI, Section B, line 11Form 990 was reviewed with the Board members prior to filing.
Officers, directors & key employees, along with all associates, are required to complete a conflict of interest statement annually. The statements are used to monitor and enforce compliance with the policy.Form 990, Part VI, Section B, line 12c
The hospital administrator, officers and key employees' salaries are reviewed annually by an independent consulting group and the Board members.Form 990, Part VI, Section B, line 15
These documents are not made available to the public.Form 990, Part VI, Section C, line 19
Changes in Net Assets or Fund Balances:Increase in amount due to Pawnee CountyForm 990, Part XI, line 5:
Financial Statements and ReportingHays Medical Center, Inc. has an audit committee that is responsible for the oversight of the Pawnee Valley Community Hospital, Inc. financial statement audit and the selection process of an independent accountant.Form 990. Part XII, line 2c

Schedule R IRS990ScheduleR

Form990 Schedule R Part II Form990ScheduleRPartII (2 entries)

Address Line1AddressUS/AddressLine1CityAddressUS/CityStateAddressUS/StateZIP CodeAddressUS/ZIPCodeEINEINPrimary ActivitiesPrimaryActivitiesLegal Domicile StateLegalDomicileStateExempt Code SectionExemptCodeSectionPublic Charity StatusPublicCharityStatusControlled OrgControlledOrg
HaysMed Partners Inc
2220 Canterbury DrHaysKS67601270877152Owns management contract for Pawnee Valley Community HospitalKS501(c)(3)170(b)(1)(A)(iii)0
Hays Medical Center Inc
2220 Canterbury DrHaysKS67601480559088HospitalKS501(c)(3)170(b)(1)(A)(iii)0
FieldValueIRS element (for citing)
Receipt Of Int Ann Rents Royalties0ReceiptOfIntAnnRentsRoyalties
Gift Grant Or Cap Contr To Other Org0GiftGrantOrCapContrToOtherOrg
Gift Grant Or Cap Contr Fr Other Org0GiftGrantOrCapContrFrOtherOrg
Loans Or Guarantees To Other Org0LoansOrGuaranteesToOtherOrg
Loans Or Guarantees From Other Org1LoansOrGuaranteesFromOtherOrg
Sale Of Assets To Other Org0SaleOfAssetsToOtherOrg
Purchase Of Assets From Other Org1PurchaseOfAssetsFromOtherOrg
Exchange Of Assets0ExchangeOfAssets
Rental Of Facilities To Other Orgs0RentalOfFacilitiesToOtherOrgs
Rental Of Facilities Fr Other Orgs0RentalOfFacilitiesFrOtherOrgs
Perform Of Services For Other Orgs0PerformOfServicesForOtherOrgs
Perform Of Services By Other Orgs1PerformOfServicesByOtherOrgs
Sharing Of Facilities0SharingOfFacilities
Sharing Of Paid Employees0SharingOfPaidEmployees
Reimbursement Paid To Other Org1ReimbursementPaidToOtherOrg
Reimbursement Paid By Other Org0ReimbursementPaidByOtherOrg
Other Transfer To Other Org0OtherTransferToOtherOrg
Other Transfer From Other Org0OtherTransferFromOtherOrg

Transactions Related Orgs Table TransactionsRelatedOrgsTable (5 entries)

Transaction TypeTransactionTypeAmount InvolvedAmountInvolved
Hays Medical Center Inc
E57169
Hays Medical Center Inc
L485309
Hays Medical Center Inc
N92600
Hays Medical Center Inc
G1000
Hays Medical Center Inc
I77803