2012-08-15T18:19:34-05:00 2011-09-30 MOSS ADAMS LLP 6100 UPTOWN BLVD NE STE 400 ALBUQUERQUE NM 87110 990 2010-10-01 860817397 THE FORT DEFIANCE INDIAN HOSPITAL BOARD INC DBA TSEHOOTSOOI MEDICAL CENT FORT 9287298000 PO BOX 649 FORT DEFIANCE AZ 86504 DR LEONARD LELAND 9287298000 2012-08-15 1 MARLA CASTNER 5058787200 2010 2016-02-24 21:20:13Z DR LELAND LEONARD PO BOX 649 FORT DEFIANCE AZ 86504 104774987 0 X FDIHB.ORG X 1995 AZ TO PROVIDE HEALTHCARE SERVICES TO THE COMMUNITY. 10 10 756 107 0 0 73703148 54862937 28672731 48073245 1117 -113797 690570 353723 103067566 103176108 0 0 0 0 24738148 60277947 0 0 0 24931402 36774038 49669550 97051985 53398016 6124123 58417852 66957253 4983380 7398658 53434472 59558595 X TO PROVIDE SUPERIOR AND COMPASSIONATE HEALTHCARE TO OUR COMMUNITY BY RAISING THE LEVEL OF HEALTH, HOZHO AND QUALITY OF LIFE. 0 0 37299083 46236011 PROVIDE MEDICAL CARE TO COMMUNITY. THIS INCLUDES PHYSICIAN SALARIES, MEDICAL SUPPLIES, TRANSPORTATION, MEDICAL EQUIPMENT AND CONTRACT HEALTH SERVICES. 17373681 PROVIDE NURSING SERVICES TO SUPPORT HEALTHCARE PROVIDED TO THE COMMUNITY. THIS INVOLVES SUPPLIES, NURSING SALARIES AND OTHER EQUIPMENT NEEDED TO PROVIDE NURSING SERVICES 2618010 COMMUNITY HEALTH SERVICES EXPENSES 6148433 1837234 CONTRACT HEALTH SERVICES AND SUPPORT SERVICES INCLUDING HUMAN RESOURCES, FINANCE, OPERATIONS AND EXECUTIVE DIVISIONS 6148433 1837234 63439207 1 1 0 0 0 0 0 0 0 1 0 0 0 0 0 1 0 0 0 0 0 0 0 0 0 1 1 0 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 66 0 1 756 1 0 0 0 0 0 0 0 0 0 0 X 10 10 0 0 1 0 0 0 0 1 1 0 1 1 0 1 1 1 0 1 1 1 0 AZ X RACHEL SORRELL CHIEF FINANCIAL OFFICER 9287298250 PO BOX 649 FORT DEFIANCE AZ 86504 ROY DEMPSEY 2.00 X X 18200 0 0 CALEB ROANHORSE 2.00 X X 21000 0 0 MARTIN ASHLEY 2.00 X X 14800 0 0 LORRAINE NELSON 2.00 X X 18200 0 0 MARTIN BEGAY 2.00 X 8200 0 0 JERRY FREDDIE 2.00 X 12800 0 0 DR RAYMOND REID 2.00 X 9600 0 0 TIM GOODLUCK 2.00 X 12800 0 0 ELMER MILFORD 2.00 X 1500 0 0 LELAND ANTHONY 2.00 X 18600 0 0 DR LELAND LEONARD 40.00 X 247939 0 33167 VIVIAN SANTISTEVAN 40.00 X 188745 0 20743 TAL MOORE 40.00 X 103840 0 8173 DR DAVID DOWNING 40.00 X 225027 0 37469 VALONIA HARDY 40.00 X 113654 0 10768 RACHEL SORRELL 40.00 X 65165 0 5264 TORI DAVIDSON 40.00 X 131866 0 19938 DANIEL JOHNSON 40.00 X 270043 0 17240 NAZHONE P YAZZIE 40.00 X 224848 0 4236 JOHN GARSON 40.00 X 261580 0 20895 1968407 0 177893 9 0 1 0 SMILING DRAGON LLC PO BOX 402 MEDANALES NM 87548 CRNA 175348 MICHAEL MALIK 1020 W 122ND ST LOS ANGELES CA 90044 ER PHYSICIAN 171360 STAFF CARE 5001 STATESMAN DR IRVING TX 75063 MEDICAL OFFICER 148941 RICHARD ROUGEUX 511 NINTH STREET APT 8 LAS VEGAS NM 87701 PEDIATRICIAN 145560 ROBIN LE 24749 FAY AVE MORENO CA 92551 DENTIST 142843 8 54861937 1000 54862937 NET PATIENT SERVICE RE 624100 48073245 48073245 48073245 2571 2571 1014158 1482511 -468353 -468353 -468353 116368 -116368 -116368 -116368 MISCELLANEOUS 900099 478132 478132 CAFETERIA INCOME 722210 343944 343944 822076 103176108 48073245 0 239926 1232636 831436 401200 48210696 32701054 15509642 705165 442861 262304 8233553 5449087 2784466 1895897 1151188 744709 648928 648928 116624 116624 11814981 8520174 3294807 31896 7653 24243 2522838 684791 1838047 524783 22727 502056 1192925 1192925 711704 332973 378731 302253 135844 166409 844563 844563 577258 577258 MEDICAL SUPPLIES 6617063 6617063 CONTRACT HEALTH SERVICE 6149432 6149432 MISCELLANEOUS 4017215 180063 3837152 NON CAPITAL EQUIPMENT 698826 212861 485965 REPAIRS & MAINTENANCE 2749 2749 97051985 63439207 33612778 0 42573169 49828679 8969455 9476633 1788568 1694957 273129 1117400 6130103 1290519 4813531 4839584 58417852 66957253 4983380 7398658 4983380 7398658 X 45184155 48988906 4813531 4839584 3436786 5730105 53434472 59558595 58417852 66957253 6124123 0 X 0 1 1 X 1 1 X 27801 73703148 54862937 128593886 27801 73703148 54862937 128593886 128593886 691687 1016729 1708416 822076 822076 131124378 76745976 0.98070 0.99010 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 179405 8965 170440 5950698 1281554 4669144 4839584 103176108 97051985 6124123 0 6124123 104658619 1482511 1482511 103176108 0 103176108 98534496 1482511 1482511 97051985 0 97051985 1 1 X 1 X 1 X 1 1 1 0 0 2564427 2564427 0.02640 44138443 36367346 7771097 0.08010 46702870 36367346 10335524 0.10650 0 0 1000 -1000 0.00000 1000 -1000 46702870 36368346 10334524 0.10650 93 19265 170000 170000 0.00180 6 9565 25500 25500 0.00030 5 20 3000 3000 0.00000 8 37645 3000 3000 0.00000 6 10100 2000 2000 0.00000 1 37 2700 2700 0.00000 4 10000 55000 55000 0.00060 123 86632 261200 261200 0.00270 8525860 5943793 2582067 X 1 0 1 NAHATA' DZIL HEALTH CENTER OUTPATIENT SERVICES FOR GENERAL PRIMARY CARE 0.01710 2 1 TSEHOOTSOI MEDICAL CENTER

PO BOX 649 CORNER OF ROUTES N7 AND N12 FORT DEFIANCE AZ 86504

X X X 2 NAHATA' DZIIL HEALTH CENTER

PO BOX 125 CHIIHTOH BLVD 2 SANDERS AZ 86512

X OUTPATIENT CLINIC ONLY TSEHOOTSOI MEDICAL CENTER 1 PART I, LINE 7: THE FDIHB USES A MIX OF COSTING METHODOLOGIES. COST ACCOUNTING IS USED FOR REVENUES, BUT NOT ENTIRELY FOR EXPENSES. MOST EXPENSES ARE RECORDED TO THE COST CENTERS THEY RELATE TO WITH THE EXCEPTION OF UTILITIES, SOME SUPPLIES AND SMALLER EXPENSES WHICH ARE CENTRALIZED. PART II: COMMUNITY SUPPORT - PROVIDES DIRECT AND A MORE COHESIVE ENVIRONMENT OF STAFFING SUPPORT TO IMPROVE PREVENTION, INTERVENTION, AND POST-TERTIARY WELLNESS SERVICES THAT INVOLVE PHYSICAL ACTIVITY BEHAVIOR MODIFICATION, REINFORCEMENT OF HEALTHY BEHAVIORS LEARNED AND PRACTICES, AND INCREASE ADHERENCE AND RETENTION OF PARTICIPATION IN WELLNESS PROGRAM ACTIVITIES TO REDUCE HEALTH RISK FACTORS AND STRENGTHEN PREVENTION OF HEALTH RISKS, REINFORCE SKILLS, AND REDUCE RISK OF RELAPSE AMONG THE CLIENTS WE SERVE. COMMUNITY SUPPORT FOR PUBLIC HEALTH NUTRITION RANGES FROM TECHNICAL ASSISTANCE (SCHOOLS, NAVAJO AREA OFFICE, TRIBAL PROGRAMS, INTERNAL PARTNERS) PRESENTATIONS AT CONFERENCES, NUTRITION EDUCATION, FOOD SECURITY PROJECTS, AND HEALTH FAIRS. THESE ACTIVITIES ARE FUNDED BY THE FOLLOWING GRANTS: AZNN, FIRST THINGS FIRST, AND SDPI. PROGRAM INVOLVEMENT FOR COMMUNITY SUPPORT INCLUDES SUPPORTING THE FOLLOWING COALITIONS (BREASTFEEDING, BREAST CANCER AWARENESS, CANCER AWARENESS, WOMEN'S HEALTH, AND YOUTH PHYSICAL ACTIVITY). IN ADDITION, PROGRAM SUPPORT SERVICES HAVE INCLUDED PROVIDING HEALTH EDUCATION FOR COMMUNITY ON THE FOLLOWING AREAS: TEEN WELLNESS, WOMEN'S HEALTH, AND SUICIDE PREVENTION. ENVIRONMENTAL IMPROVEMENTS - ENVIRONMENTAL IMPROVEMENTS INCLUDE CREATING A MORE FEASIBLE, ACCESSIBLE, AND SAFE PHYSICAL ACTIVITY AREA FOR WORKSITE, CLINICAL INTERVENTION, AFTERSCHOOL ACTIVITIES, COMMUNITY AND FAMILY INVOLVEMENT. ESTABLISH AND OVERSEE COMMUNITY BILLBOARDS SITUATED IN THREE CHAPTER COMMUNITIES WHICH PROMOTE HEALTHY ENVIRONMENTAL MESSAGES; ADVOCATE ON CLEAN AND HEALTHY COMMUNITIES THROUGH SUPPORTING LOCAL COMMUNITY CLEAN UP I.E. REDLAKE COMMUNITY TRASH PICK UP; STEAMBOAT EARTH DAY EVENT AND ADVOCACY TO PROMOTE CLEAN NAVAJO NATION TASK FORCE. FORMERLY ORGANIZED A PROPER TRASH DISPOSAL CAMPAIGN FOR THE ANNUAL TRIBAL PARADE THAT ATTRACTED AN ESTIMATED POPULATION OF 100,000 SPECTATORS FOR ONE-DAY EVENT. PRODUCE WRITTEN MATERIAL TO BE PUBLISHED IN HOSPITAL NEWSLETTER REGARDING ENVIRONMENTAL SAFETY ISSUES: EXTREME WEATHER PREPARATION FOR COLD WEATHER, ROAD SAFETY IN UNSAFE DRIVING CONDITIONS, ETC.LEADERSHIP DEVELOPMENT & TRAINING COMMUNITY MEMBERS - THE ORGANIZATION PROMOTES CAPACITY BUILDING TRAININGS SUCH AS ONE VOICE, TRAINING FOR NAVAJO AREA NUTRITION EDUCATORS, AND TRAININGS FOR TRIBAL EMPLOYEES THROUGH CCDF AND OTHER PARTNERS. IT RECRUITS COMMUNITY MEMBERS TO BE TRAINED IN COMMUNITY ADVOCACY AND NAVAJO WELLNESS TO STRENGTHEN ADVOCACY ROLE IN HEALTH AND WELLNESS. HPDP STAFF MEMBERS COMPLETED A COMBINED 72 HOURS OF COMMUNITY ADVOCACY TRAINING HOURS FOR COMMUNITY POPULATIONS. COALITION BUILDING - COALITION BUILDING TEAMS INVOLVED RESOURCES WHO COLLECTIVELY PLAN, DESIGN, IMPLEMENT AND STRATEGIZE ON PREVENTION AND INTERVENTION PROGRAMS FOR YOUTH TO ELDERLY PARTICIPATION REQUIRING MEETINGS, STRATEGIC PLANNING AND CELEBRATION, ALL TO STRENGTHEN RESOURCE NETWORKING, COMMUNITY IMPACT, AND SHARING OF RESOURCES. IT WORKS WITH THE NAVAJO NATION BREASTFEEDING COALITION AND THE NAVAJO NATION FOOD POLICY TEAM, WHICH ARE BOTH ORGANIZATIONS THAT COVER THE WHOLE NAVAJO NATION WITH AN ESTIMATED POPULATION OF 280,000. IT SUPPORTS AND ASSISTS LOCAL COALITIONS WITH TECHNICAL ASSISTANCE IN PLANNING AND IDENTIFYING LOCAL HEALTH ISSUES, INCLUDING REDLAKE HEALTH COUNCIL, STEAMBOAT HEALTH COUNCIL AND REDLAKE YOUTH GROUP. IT PARTICIPATES IN AND SUPPORTS COALITION GROUPS IN THE FORMATION OF COMMUNITY IMPROVEMENT EVENTS; FORT-A TEAM AND NAVAJO NATION LOCAL GOVERNANCE CENTER. COMMUNITY HEALTH IMPROVEMENT ADVOCACY - THIS CAN BE HELD WITH SCHOOL, COMMUNITY, AND CHAPTER LEADERS TO MEET AND FACILITATE HEALTH ISSUES, POLICY DEVELOPMENT, COMMUNITY SHARING, AND OFFER A SENSE OF UNITY TO ADDRESS THE COMBATING ISSUES THAT NEED PROBLEM SOLVING, TEAM WORK, AND DISCUSSION TO MAKE CAMPAIGNING AND IMPACT EFFECTIVE. WORKFORCE DEVELOPMENT - PH NUTRITION SPONSORED A TIME MANAGEMENT CLASS FOR DCH AND OTHER TMC STAFF. IF ALL 37 PARTICIPANTS WERE ABLE TO INCREASE PRODUCTIVITY BY AS LITTLE AS 15 MINUTES PER WEEK, THE ADDED VALUE WOULD BE $12,000 OVER THE COURSE OF A YEAR. THE ORGANIZATION RECRUITS COMMUNITY MEMBERS TO PARTICIPATE IN COMMUNITY ADVOCACY TRAINING AND THE NAVAJO WELLNESS MODEL. IT PROVIDES TECHNICAL ASSISTANCE AND SUPPORT FOR THE DEVELOPMENT OF THE RESERVATION-WIDE JUNK FOOD TAXATION POLICY. IT ORGANIZES PUBLIC HEALTH COMMUNITY HEALTH PROGRAMS AIMED TO PREVENT CHRONIC DISEASES AND PROMOTE PHYSICAL ACTIVITY SUCH AS: JOURNEY TO WELLNESS SERIES TO INCLUDE WALKING TOGETHER FOR HEALTHIER NATIONS, JUST MOVE IT, AND TURKEY TROT. THE ORGANIZATION IMPLEMENTS A PERSONAL MOTIVATION PLAN FOR PHYSICAL ACTIVITY SUSTAINABILITY THROUGH INCENTIVE-BASED PROGRAM AND ORGANIZES COMMUNITY WELLNESS TEAM CONSISTING OF LOCAL TRIBAL AFFILIATIONS AND ORGANIZATIONS TO CARRY OUT PHYSICAL ACTIVITY PROGRAM AND EVENTS. OTHER - THE FACILITY PROVIDES FOR PHYSICAL ACTIVITY AND FITNESS INSTRUCTION WHICH IS MORE FREQUENTLY ACCESSIBLE TO THE COMMUNITY THROUGH OUT THE DAY. IT OFFERS EDUCATIONAL SESSIONS FOR ALL AGES, FREQUENT CLIENT CONSULTATION, AND AN ON-SITE OFFICE AREA FOR STAFF TO PROVIDE INSTRUCTION, DEMONSTRATION, CLIENT MONITORING, AND PROGRESS AND IMPACT DATA. THIS REINFORCES THE LIKELIHOOD THAT EACH CLIENT AND HIS/HER FAMILY WILL BE ABLE TO CHANGE THEIR BEHAVIOR SO AS TO REDUCE THEIR RISK OF LIVING AN UNHEALTHY LIFESTYLE. PART III, LINE 8: USED COST ACCOUNTING METHODOLOGY; HAVE COST CENTERS SET UP TO CAPTURE COSTS AND REVENUES RELATED TO THOSE COST CENTERS. PART III, LINE 9B: NO PROVISION INDICATED IN THE COLLECTION POLICY WHICH REFERENCES FINANCIAL ASSISTANCE. PURSUANT TO IRS ANNOUNCEMENT 2011-37, TAX-EXEMPT ORGANIZATIONS THAT OPERATE FORM 990, SCH H, PART V, SECTION B ONE OR MORE HOSPITAL FACILITIES ARE NOT REQUIRED TO COMPLETE SCHEDULE H, PART V, SECTION B FOR THE 2010 TAX YEAR. FORT DEFIANCE INDIAN HOSPITAL BOARD HAS ELECTED NOT TO COMPLETE PART V, SECTION B, SO THEY CAN FAMILIARIZE THEMSELVES WITH THE INFORMATION REQUIRED AND TO REPORT COMPLETE AND ACCURATE INFORMATION ON SECTION B. PART VI, LINE 2: THE COMMUNITY HEALTH DIVISON ASSESSES THE NEEDS OF THE COMMUNITY THE FDIHB SERVES VIA SURVEY, FACE TO FACE INTERVIEWS AND DATA COLLECTED AT VARIOUS COMMUNITY HEALTH EVENTS SUCH AS THE JUST MOVE IT AND PERSONAL WELLNESS PLAN SURVEYS CONDUCTED DURING THE JUST MOVE IT EVENTS IN THE SUMMER OF 2011.THE PLANNING OFFICE CONDUCTED A SURVEY WITH ALL THE CHAPTERS IN THE FALL OF 2011 TO ASSESS TELECOMMUNICATION NEEDS.THE PLANNING OFFICE CONDUCTED A COMMUNICATION NEEDS ASSESSMENT WITH THE HOSPITAL DEPARTMENTS IN THE FALL OF 2011.PHNS COLLABORATE WITH CHR'S WHO WORK IN COMMUNITY AND BASED ON THEIR FINDINGS WE PROVIDE HEALTH EDUCATION TOPICS.COORDINATED SCHOOL PROGRAM CONDUCTS SCHOOL HEALTH SURVEYS (NYRBS IN 2011) TO MEASURE YOUTH RISK BEHAVIORS AT SELECTED SCHOOLS. PRE- AND POST- FITNESSGRAM ASSESSMENTS ARE CONDUCTED TO INDICATE BMI MEASURES (OBESITY LEVELS) FOR ELEMENTARY-AGED CHILDREN IN SELECTED SCHOOLS. NAVAJO AREA HPDP ALSO SHARES COLLECTED CONGREGATE DATA WHICH ASSESS FAMILY CULTURAL AND HEALTH DATA EVERY YEAR A SURVEY IS SENT TO INDIVIDUAL NAVAJO HOUSEHOLD. CUSTOMER SERVICE SURVEYS ARE CONDUCTED AFTER COMMUNITY FITNESS EVENT SUCH AS JMI WTHN AND TURKEY TROT TO ASSESS CUSTOMER SATISFACTION AND THEIR EXPERIENCE WITH EACH EVENT. PART VI, LINE 3: PATIENT REGISTRATION - PATIENT BENEFITS COORDINATOR EDUCATES THE COMMUNITY AND PATIENTS ON THE ELIGIBILITY FOR ALTERNATIVE RESOURCES (MEDICARE, MEDICAID,SCHIP,KIDSCARE,COMMERICAL PAYERS) PART VI, LINE 4: FORT DEFIANCE INDIAN HOSPITAL BOARD, INC (FDIHB) IS LOCATED ON THE NAVAJO INDIAN RESERVATION AND IS ONE OF 8 HOSPITALS (SERVICE UNITS) THAT SERVICE THE RESERVATION. IN FY 2011, FDIHB HAD APPROXIMATELY 111,434 LIVING PATIENTS REGISTERED. IN 2011 THERE WERE 298,017 VISITS TO FDIHB'S ACTIVE CLINICS. THERE WERE 12,037 PATIENTS ENROLLED IN MEDICARE PART A AND 11,664 PATIENTS ENROLLED IN PART B AT THE END OF FY 2011. THERE WERE 3,322 PATIENTS ENROLLED IN MEDICARE PART D. THERE WERE ALSO 39,977 PATIENTS ENROLLED IN MEDICAID AND 18,297 PATIENTS WITH AN ACTIVE PRIVATE INSURANCE POLICY. X X X 0 0 0 0 0 0 0 0 0 DR LELAND LEONARD 247939 0 0 0 0 0 14227 0 18940 0 281106 0 0 0 VIVIAN SANTISTEVAN 188745 0 0 0 0 0 6607 0 14136 0 209488 0 0 0 DR DAVID DOWNING 225027 0 0 0 0 0 13357 0 24112 0 262496 0 0 0 TORI DAVIDSON 131866 0 0 0 0 0 8061 0 11877 0 151804 0 0 0 DANIEL JOHNSON 270043 0 0 0 0 0 7986 0 9254 0 287283 0 0 0 NAZHONE P YAZZIE 224848 0 0 0 0 0 0 0 4236 0 229084 0 0 0 JOHN GARSON 261580 0 0 0 0 0 15958 0 4937 0 282475 0 0 0 FORM 990, PART VI, SECTION A, LINE 4 THE BOARD BYLAWS WERE REVISED ON 6/25/2011 WITH CHANGES TO THE FOLLOWING: DUTIES OF THE BOARD WERE ADDED TO INCLUDE OVERSIGHT OF WORK AND FINANCES OF THE HOSPITAL, APPOINT THE OFFICERS, APPROVE THE ANNUAL BUDGET, AND APPOINT AN AUDITOR TO THE CORPORATION. LANGUAGE WAS ADDED TO THE BYLAWS TO STAGGER THE TERMS OF BOARD MEMBERS AND COMPENSATION LANGUAGE WAS ADDED TO COMPENSATE BOARD MEMBERS FOR MEETINGS ATTENDED. FORM 990, PART VI, SECTION B, LINE 11 THE FORM 990 IS REVIEWED BY THE CHIEF FINANCIAL OFFICER BEFORE IT IS FILED. FORM 990, PART VI, SECTION B, LINE 12C THE COMPLIANCE COMMITTEE MONITORS AND ENFORCES THE CONFLICT OF INTEREST POLICY. BOARD MEMBERS, SENIOR LEADERS, DIRECTORS AND KEY EMPLOYEES MUST COMPLETE A CONFLICT OF INTEREST POLICY ANNUALLY. FORM 990, PART VI, SECTION B, LINE 15 AN INDEPENDENT MANAGEMENT COMPANY UTILIZES SURVEYS AND COMPARATIVE DATA TO DETERMINE COMPENSATION FOR THE CEO, TOP MANAGEMENT OFFICIALS, OFFICERS AND KEY EMPLOYEES. FORM 990, PART VI, SECTION C, LINE 18 THE FORM 990 AND FORM 1023 ARE AVAILABLE FOR PUBLIC INSPECTION UPON REQUEST. FORM 990, PART VI, SECTION C, LINE 19 THE AUDITED FINANCIAL STATEMENTS, CONFLICT OF INTEREST POLICY, AND ALL OTHER GOVERNING AND ORGANIZING DOCUMENTS ARE AVAILABLE FOR PUBLIC INSPECTION UPON REQUEST.