2014-05-13T17:04:57-05:00 2013-06-30 450250958 Eide Bailly LLP 800 Nicollet Mall Ste 1300 Minneapolis MN 554027033 990 2012-07-01 830300467 Powell Valley Health Care Inc POWE 3077542267 777 Avenue H Powell WY 82435 Bill Patten 3077542267 2014-05-09 1 Kim Hunwardsen CPA P00484560 6122536500 2014-05-06 2012 2015-11-30 17:44:51Z Powell Valley Hospital Bill Patten 777 Avenue H Powell WY 82435 50030157 0 X www.pvhc.org X 1992 WY Provision of healthcare services. 10 6 558 110 3093 0 193493 215501 44332429 49739884 93277 48844 29340 25928 44648539 50030157 58560 11251 0 0 27310627 28104482 0 0 65471 16217404 22414249 43586591 50529982 1061948 -499825 18119075 18732691 6266338 7377345 11852737 11355346 X To provide excellent health care, create exceptional customer experiences, and promote community health. 0 0 43514056 11251 49736791 Powell Valley Health Care, Inc. (Hospital) provides quality care regardless of race, creed, sex, national origin, handicap, age, or ability to pay. Although reimbursement for services rendered is critical to the operation of the Hospital, it is recognized that not all individuals possess the ability to purchase these essential services. It is the Hospital's mission to serve the surrounding area by providing health care services and health care education to all community members.During the year ended June 30, 2013, the Hospital provided $1,122,308 of medical services, based on the amounts of charges foregone, to individuals who were determined unable to purchase such services under the Hospital's charity care policy and guidelines. In addition to free care and/or subsidized care, care is also provided at below cost rates to persons covered by governmental programs. Recognizing its mission to the community, services are provided to both Medicare and Medicaid patients. The unreimbursed value of providing care to all patients was $18,456,064 for the year ended June 30, 2013.During the fiscal year ended June 30, 2013, the Hospital provided 2,585 days of hospital services. The nursing home provided 30,871 days of resident services, and the assisted living facility provided 8,298 days of resident services during the year.The Hospital also provides community care and services through many health activities and programs provided to support the community. These activities include: support to the Heart Mountain Volunteer Medical Clinic, wellness programs, community education programs, special programs for specific purposes, and a variety of community supported activities. 43514056 1 1 0 0 0 0 0 0 1 0 1 0 0 0 0 1 0 1 0 0 0 0 0 0 0 0 1 1 0 1 1 0 0 0 1 0 0 1 0 0 0 0 0 0 1 1 0 0 0 1 46 0 1 558 1 1 1 0 0 0 0 0 0 0 0 0 X 10 6 0 1 0 0 0 1 1 1 0 0 0 1 1 1 1 1 1 0 0 0 X Russ Lundvall Accountant 3077547722 777 Avenue H Powell WY 82435 Mark Wurzel MD 40.00 0.00 X X 158213 0 22500 Jim Beukelman 1.00 1.00 X X 0 0 0 Larry Parker 1.00 1.00 X X 0 0 0 Jim Carlson 1.00 1.00 X X 0 0 0 Renee Humphries Reel 1.00 1.00 X 0 0 0 Bonita Katz 1.00 1.00 X 0 0 0 Valerie Lengfelder MD 40.00 0.00 X 169589 0 27206 RJ Kost 1.00 1.00 X 0 0 0 Deb Kleinfeldt 1.00 1.00 X 0 0 0 Mike Tracy MD 40.00 0.00 X 313066 0 38583 Bill Patten 40.00 0.00 X 0 0 0 Sandra Ehman 40.00 0.00 X 147878 0 0 Jeffrey Hansen 40.00 0.00 X 1406705 0 22500 Kelly Christensen 40.00 0.00 X 410926 0 11767 Michael Bohlman 40.00 0.00 X 300237 0 17000 Nathaniel Rieb 40.00 0.00 X 276575 0 17000 Paul Laveau 40.00 0.00 X 440033 0 12500 3623222 0 169056 30 0 1 0 North Platte Physical Therapy PO Box 1790 Douglas WY 82633 Physical Therapy Services 1155266 HealthTech Management Services Inc 105 Westwood Place Suite 300 Brentwood TN 37037 Management Company 563510 Wilson Gynecology PO Box 243 Wilson WY 83014 OB Physician 479388 Delta Locum PO Box 202940 Dallas TX 753202940 Locum Physician Services 348161 Solient Health Corp PO Box 1024640 Atlanta GA 303684640 Temporary Contract Labor 213764 8 59840 66291 89370 215501 Patient Service Revenue 622110 49038268 49038268 Other Income 900099 362495 362495 Pharmacy Contract Revenue 446110 154762 154762 Cafeteria 722210 108686 108686 Auxiliary Income 900099 72580 72580 3093 3093 49739884 47476 47476 25928 0 25928 25928 25928 1368 0 1368 1368 1368 50030157 49736791 3093 74772 11251 11251 756833 622005 134828 146491 146491 20558072 17892914 2612276 52882 459510 393665 63928 1917 4699069 4453953 244575 541 1484507 1259078 220758 4671 41274 41274 233045 233045 37000 37000 4889190 4065786 823404 123265 1456 121809 701609 471581 227165 2863 1941337 1511503 429834 434458 229826 202452 2180 63546 63546 1078259 547800 530459 562743 758 561985 Medical Supplies 6715557 6715557 Provisions for bad debt 4531810 4531810 Equipment rent 187183 157304 29879 Auxiliary Expenses 63762 63762 810211 374010 435784 417 50529982 43514056 6950455 65471 2911263 2021333 9121926 9882247 62500 43750 136048 156496 898388 891167 139036 175279 10314070 6165222 3662250 4148848 1185789 661876 1875 751695 18119075 18732691 4556738 5635266 12387 12387 1697213 1729692 6266338 7377345 X 9887700 8936190 1965037 2419156 11852737 11355346 18119075 18732691 X -499825 2434 X 0 1 X 1 0 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 1 29763 72580 75004 27339 1 X 2107490 1057356 1050134 677372 303673 373699 7529208 4804193 2725015 4148848 X 45425767 -4531810 -4531810 49957577 72580 72580 50030157 45923158 0 45923158 4606824 4606824 50529982 Part IV, Line 1b: The organization is acting as agent for the PVHC Auxiliary. Part IV, Line 2b: Organization holds funds in trust on behalf of nursing home residents. Description of Uncertain Tax Positions Under FIN 48: Part X, Line 2: The Hospital is organized and has been recognized by the Internal Revenue Service (IRS) as exempt from federal income taxes under Internal Revenue Code Section 501(c)(3). The Hospital is annually required to file a Return of Organization Exempt from Income Tax (Form 990) with the IRS. In addition, the Hospital is subject to income tax on net income that is derived from business activities that are unrelated to its exempt purpose. The Hospital files an Exempt Organization Business Income Tax Return (Form 990-T) with the IRS to report its unrelated business taxable income. The Organization believes that it has appropriate support for any tax positions taken affecting its annual filing requirements, and as such, does not have any uncertain tax positions that are material to the financial statements. The Hospital would recognize future accrued interest and penalties related to unrecognized tax benefits and liabilities in income tax expense if such interest and penalties are incurred. The Hospital is no longer subject to federal or state tax examinations by tax authorities for years before 2010. Part XI, Line 2d - Other Adjustments: Provision for bad debts reported in revenue on financial statements -4,531,810. Part XI, Line 4b - Other Adjustments: Auxiliary income not recorded for financial statements 72,580. Part XII, Line 4b - Other Adjustments: Auxiliary expenses not recorded for financial statements 75,014. Provision for bad debts reported in revenue on financial statements 4,531,810. 1 1 X 1 X 1 X 1 1 0 1 1 735000 735000 0.01600 735000 735000 0.01600 40300 40300 0.00090 317037 317037 0.00690 10406000 7180653 3225347 0.07010 5616 5616 0.00010 10768953 7180653 3588300 0.07800 11503953 7180653 4323300 0.09400 14854 14854 0.00030 8539 8539 0.00020 23393 23393 0.00050 0 4531810 625390 9806494 9743789 62705 X 1 1 1 1 Powell Valley Hospital

777 Avenue H Powell WY 82435

X X X X Physician provider based clinic Powell Valley Hospital 1 1 X X X X X X X X X 12 1 0 1 X X X X X X 0 0 1 1 100.000000000000 1 200.000000000000 1 X X X X 1 1 X X 1 0 X X X X 1 X 0 0 6 Powell Valley Clinic

777 Avenue H Powell WY 82435

Outpatient physician clinic Powell Valley Care Center

777 Avenue H Powell WY 82435

Nursing home Heartland Assisted Living

777 Avenue H Powell WY 82435

Assisted living facility Powell Valley Home Health

777 Avenue H Powell WY 82435

Home health agency Powell Valley Hospice

777 Avenue H Powell WY 82435

Hospice Express Care Clinic

777 Avenue H Powell WY 82435

Immediate care center Part I, Line 3c: In addition to providing free or discounted care based on Federal Poverty Guidelines, we review income tax returns and pay stubs. This information helps us more accurately determine a patient's ability to pay.Part I, line 6b: The community benefit report is posted on the Organization's website. Part I, Line 7: Charity care expense was converted to cost on line 7a based on an overall cost to charge ratio addressing all patient segments. The expenses associated with community health improvement services, line 7e, and health professions education, line 7f were determined using an average hourly rate for staff time, space use, and ambulances. Cash and in-kind contributions to community groups, line 7i, were reported based on actual expenses recorded in the organization's general ledger. The cost for subsidized health services reported on line 7g was determined using the Medicare Cost Report. Part I, L7 Col(f): The amount of bad debt expense removed from the denominator of the calculation on Part 1, Line 7, column f was $4,531,810. Part II: Powell Valley Health Care coordinated and hosted various community coalitions such as Suicide Prevention Coalition, Human Services Providers Coalition, and Park County Health Coalition. Involvement in the coalitions are all health related and therefore promote health in the community.Powell Valley Healthcare conducts and hosts various support groups for the community including a support group for local Veterans. Support groups focus on helping community members who are dealing with grief and loss, diabetes and family members suffering from dementia. Our EMS service also provides a great deal of support to the community from stand-by emergency services for sporting events and the local county fair to CPR & First Aid training for the local fire and police departments. Powell Valley Healthcare is also instrumental in providing the annual blood screening and health and safety fair in collaboration with Powell Valley Community Education. This annual event draws participants from throughout the Big Horn Basin and beyond and is a great source for community wellness and access to free health and safety information and inexpensive health screenings. Part III, Line 4: The organization's bad debt is reported as charges incurred during the year.The estimated amount of bad debt expense attributable to patients eligible under the organization's financial assistance policy is 13.8% (based upon US Census Bureau Quickfacts for percent of citizens below the povertly level in the city of Powell). This represents a reasonable percentage of individuals who potentially qualify for charity care but may not have applied and and therefore were written off to bad debt.Footnote from organization's financial statements: The footnote that describes bad debt expense is found on page 9 and 10 of the attached audit report. Part III, Line 8: Medicare allowable costs of care are based on the Medicare cost report. The Medicare cost report is completed based on the rules and regulations set forth by Centers for Medicare and Medicaid Services. Part III, Line 9b: Powell Valley Health Care, Inc. tries to determine if a patient needs financial assistance before services are rendered, except in emergency situations. No patient is denied acute care in an emergency situation. The Health Center will pursue all possible forms of third-party payments such as insurance, state Medicaid programs, and county indigent care programs before granting financial assistance. Collection efforts are not pursued during this time. Collection efforts are not pursued while a completed charity care application is under review. Decisions on charity care applications are made within 30 days of the completed application. Once a decision is made, any personal portion due will follow the same collection procedures as other accounts. If a determination for financial assistance is made on an account or further insurance processing is needed after an account is sent to collections, all collection efforts will cease and any negative reporting will be reversed. Powell Valley Hospital Part V, Section B, Line 3: Former Local Public Health Nurse, Behavioral Health Professional, Focus groups, women, seniors, general community members Four focus groups with a total of 24 individual. 6 key informants were identified and interviewed. Powell Valley Hospital Part V, Section B, Line 5c: The needs assessment can be accessed at: http://www.pvhc.org/docs/PVHC_Summary_Report_rev.pdf Powell Valley Hospital Part V, Section B, Line 7: Due to the timing of adoption and implementation strategy the hospital was not able to address the needs identified with the exception of hiring an additional Physician to increase accessibility. The needs identified that the hospital plans to address in the future are:1. Access to primary care services2. Access to mental health services3. Public transportation4. Access to dental health services5. Access to preventive services Powell Valley Hospital Part V, Section B, Line 12h: In addition to providing free or discounted care based on Federal Poverty Guidelines, we review income tax returns and pay stubs. This information helps us more accurately determine a patient's ability to pay. Powell Valley Hospital Part V, Section B, Line 14g: A summary of the Financial Assistance Policy is made available to the community on the hospital's website, attached to billing invoices, posted in the hospital emergency rooms or waiting rooms, posted in the hospital admissions offices, and provided, in writing, to patients on admission to the hospital. Part VI, Line 2: Powell Valley Health Care is served by a publicly elected District Board. The Board members actively provide information relative to the health care needs of the community. Additionally, we survey patients, residents, and their families and in doing so, look for trends and/or suggestions for improvements/ expansion/or initiation of services. Our guest relations process also assists us in identifying any unmet community health needs. Administration, Providers, and the Board Trustees also review county-wide market/utilization data annually. Part VI, Line 3: Powell Valley Health Care is committed to providing financial assistance to persons who have health care needs and are unable to pay for medically necessary care. We strive to ensure that people who are uninsured, underinsured, ineligible for a government program, or otherwise unable to pay are still able to receive care. Notifications about charity care are included in patient bills, posted in emergency rooms, admitting and registration departments, the Business Office, and waiting rooms. Information is also included in patient information packets. Staff also discusses financial assistance upon admitting and discharge. Part VI, Line 4: Powell Valley Health Care is a 25 bed critical access hospital, 100 bed intermediate care nursing facility, a 24 apartment assisted living facility, and a doctor's clinic located in the northwest corner of Wyoming, 75 miles east of Yellowstone National Park, and 98 miles south of Billings, MT. Powell has a diverse commercial, industrial, educational, and agricultural/ranching based economy. In 2011, 10.7% of the residents lived in poverty. The median household income was $49,309 and the population was 6,393. The nearest city with a population of 50,000+ is Billings, MT. The nearest hospitals are North Big Horn Hospital District, a critical access hospital located approximately 22 miles Northeast and West Park Hospital, a critical access hospital located approximately 25 miles Southwest.Net revenue from Medicare and Medicaid account for approximately 32% and 16% respectively. Part VI, Line 5: At Powell Valley Health Care, we understand that healthcare is evolving. The advancement in medicine and strides in technology are providing local communities access to better healthcare. Our Board of Trustees is comprised primarily of local business leaders who reside in our primary service area. To meet the needs of our community, the hospital extends privileges to medical staff that are qualified through licensure. Our emergency room is available 7 days a week and is available to all regardless of a patient's ability to pay. Excess funds are reinvested and used for patient care and facility upgrades. 1 Scholarships 9 11251 Procedure for Monitoring Grants in the U.S.: Part I, Line 2: Schedule I, Part I, Line 2: The Organization provided scholarships to individuals and required the individual to provide information to support the purpose of the scholarship. 0 0 0 0 0 0 0 0 0 Mark Wurzel MD 150413 0 0 0 7800 0 22500 0 0 0 180713 0 0 0 Valerie Lengfelder MD 147691 0 0 0 21898 0 5308 0 21898 0 196795 0 0 0 Mike Tracy MD 279745 0 0 0 33321 0 16685 0 21898 0 351649 0 0 0 Jeffrey Hansen 370555 0 1002669 0 33481 0 22500 0 0 0 1429205 0 0 0 Kelly Christensen 103221 0 268807 0 38898 0 11767 0 0 0 422693 0 0 0 Michael Bohlman 117746 0 143593 0 38898 0 17000 0 0 0 317237 0 0 0 Nathaniel Rieb 221285 0 16392 0 38898 0 17000 0 0 0 293575 0 0 0 Paul Laveau 423996 0 0 0 16037 0 12500 0 0 0 452533 0 0 0 Supplemental Information Part III Schedule J, Part I, Line 3: The Organization does not pay compensation to the CEO directly. The CEO is compensated by an unrelated management company, HealthTech Management Services, Inc. The Board of Directors approves the compensation paid by HealthTech Management Services, Inc. Nathaniel Rieb Highest Compensated Employee Relocation Expenses X 75000 18750 0 1 1 Paul Laveau Highest Compensated Employee Relocation Expenses X 25000 25000 0 1 1 43750 Steve Katz Husband of board member Boni Katz 146491 Compensation 0 Form 990, Part VI, Section A, line 1 The Executive Committee shall consist of the officers of the Board. The Executive Committee shall take action on behalf of the Board as may be necessary and prudent between regular Board meetings. The committee shall meet as often as needed. Form 990, Part VI, Section A, line 3 The CEO, Bill Patten, is an employee of HealthTech Management Services, Inc, a healthcare management company. As this position is held outside the organization, the control over management duties customarily performed by and under direct supervision of officers, directors or trustees, or key employees has effectively been delegated outside of the organization. Bill Patten is compensated by HealthTech Management Services, Inc. His compensation for services provided to the organzation for calendar year 2012 was $236,148. Form 990, Part VI, Section A, line 7a Seven Board members from the Hospital District Board of Trustees shall be appointed by virtue of their election to the Hospital District Board of Directors. Form 990, Part VI, Section A, line 7b A Board member who is from the Hospital District Board of Trustees may only be removed by action of the District Board of Directors. Form 990, Part VI, Section A, line 8b The Executive Committee did not meet during the year. Had they met during the year, their meeting would have been documented in the same manner as the governing body. Form 990, Part VI, Section B, line 11 A copy of Form 990 is provided to the CEO and CFO to review. The CEO or CFO will either make changes or approve the Form 990. After Form 990 is finalized, but prior to being filed, a copy will be provided to the Board of Directors at a Board meeting. Form 990, Part VI, Section B, line 12c Individuals covered by the conflict of interest policy include members of the Board of Directors, officers and key employees (if applicable). The process used to determine if any conflicts of interest exist, consists of sending the Members a document for them to complete prior to the Board of Directors meeting. Each individual completes the document which entails disclosing any possible conflicts and returns for review to the President of the Board. If a member has a conflict they are not allowed to vote on the conflicted issues. In addition, employees have access to October Odyssey which is a program for employees to disclose conflicts. Administration tracks the employee conflicts and brings to the next Board meeting. Compensation for the CEO is determined by HealthTech Management Services, Inc. which is the management company that employs the CEO. Once HealthTech Management Services, Inc. has determined the compensation, they present the compensation to the Board of Directors for them to approve. This process occurs yearly and was last completed during fiscal year end 2013. The compensation of the CFO and Physicians is not within the Board of Directors administrative powers; therefore a Senior Management Team determines compensation for the physicians. The steps taken include comparing to other hospitals similar in size and experience, budget constraints, market, HealthTech Management Services, Inc. professional recruiting resources and salary surveys. The Management Team discusses and comes to an agreement for compensation and reports it to the Human Resources Department. Form 990, Part VI, Section C, line 19 The organization makes its governing documents, conflict of interest policy, and financials statements available to the public by request. The public may request a copy by calling, via mail, or walk-in. Changes in Net Assets or Fund Balances: Form 990, Part XI, line 9: Changes in current year auxiliary activity not reported for audit purposes 2,434. Powell Hospital District #1 777 Avenue H Powell WY 82435 830200759 Related - Provision of health care services WY Government N/A N/A 0 Powell Medical Foundation PO Box 801 Powell WY 82435 742275540 Promote public health and improve facilities around the city of Powell, WY WY 501(c)(3) Line 8 N/A 0 Powell Valley Integrated Health Services Inc 777 Avenue H Powell WY 82435 830319855 Public Benefit Corporation/Health Care Contract WY Powell Valley Health Care Inc C 904847 815887 1.00000 1 0 0 1 0 0 0 0 0 0 0 1 1 0 0 0 1 1 0 1