Board MDeetins May 25, 2016bloximages.newyork1.vip.townnews.com/trinity...f'viT& a^,ci^, ^p May...

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Board MDeetins

May 25, 20166:00 p.m.

Trinity County Library

Weaverville CA

Meetings convene at 6 p.m. on the last Wednesday of the month. Citizens wishing to schedule matters for Board consideration

or to appear before the Board must contact the Clerk of the Board m writing stating the action requested. Appropriate

requests will be scheduled before the Board as time allows. Deadline for submission of written materials is seven days iu

advance of the meeting.

Public Presentations; The law provides the opportunity for the public to be heard on any item within the subject matter

jurisdiction of the Board, before or during the consideration of that item by the Board. For all items, includmg items not on

the agenda, fhe public presentation time is appropriate. The President may set time limits as appropriate to manage the

Agenda. State law does not allow action to be taken on any item not on the Agenda.

The agenda shall be made available upon request ia alternative formats to persons wife a disability, as required by the

Americans with Disabilities Act of 1990 (U.S.C.§ 12132) the Ralph M. Brown Act (California Government Code § 54954.2).

Persons requesting a disability related modification or accommodation in order to participate in the meeting should contact

the Board Clerk at (530) 623-5541 Ext. 3255 during regular business hours, at least twenty four hours prior to the time offhe

meetmg.

Pursuant to the Brown Act as codified m Government Code Section 54957.5, any documents pertaining to a non-closed

agenda item distributed to a majority of the Board of Directors in less than 72 hours before a Board meeting shall be available

for public iaspection. Said documents shall be available for inspection at the Mountain Communities Healthcare District

Administrative Office located at 60 Easter Avenue, Weavenalle, California, Monday through Friday, except HoUdays,

between the hours of 9:00 a.m. and 12:00 p.m.

The Board may take action on any offhe items listed on this agenda regardless of whether the matter is described as action

item, a report, a communication, public input, or discussion item.

Call to order

Report from Closed Session on April 27. 2016 and May 10,2016

Public ItlpUt (3) Minute Time Limit)

2015 Audit Presentation

Reports

a. Medical Staff Report - Daoiel Harwood, MD/Donald Krouse, MD

b. Chief Executive Officer - Aaron Rogers, CEO

c. Financial Report - Jon Marshall, CFO and Jennifer Van Matre, Director of Finance

d. Chief Nursing Officer - Peggy Manning, RN, Chief Nursing Officer

e. Quality Improvement - Sarah Cordtz, RN, Coordinator

Mountain Comm.unities Healthcare District - Regular Bqa^d Meeting

April 27, 2016

Consent Agenda

All matters listed under the Consent Agenda, are considered by the Board to be routine, and will be

enacted by one motion in the form listed below. There will be no separate discussion of these items

unless a request for discussion is made prior to the time the Board votes on the motion to approve.

All policies have been approved by the Manager/Director, Midlevel/Interdisciplmary Practice

Committee, Medical Staff/Medical Director, and Chief Executive Officer per policy. The intent is

that the MCHD Board of Director's role is to assure the policy approval process for each policy.

a. Policies and Procedures - See Attached

b. Minutes from April 17, 2016

c. Minutes from May 10,2016

Discussion Items

a. Clinic

Actionltems

a. Items removed from the Consent Agenda

b. Approve Authorization to Bind for the Small Rural Hospital Improvement Program

c. Consulting Contract - Lew Edwards Group

BoardReports

a. Board Member Reports

Close Public Session

Closed Session

» MEDICAL STAFF PRWILEGES

Government Code Section 54962; Health and Safety Code

Section 1461

o Mary Baraccho, CNM

o Brett Williams, FNP

o Rodney Grover, DO

o Steven Lengle, MD

o Waikeong Wong, MD

a QUALITY MPROVEMENT/RISK MANAGEMENTGovernment Code Section 54962: Health and Safety Code

Section 32155

• PUBLIC EMPLOYEE PERFORMANCE EVALUATION

Government Code Section 54957 - Public Employee

Title: Chief Executive Officer

Adioum Closed Session and Reconvene in Public Session

Report of any actions taken during Closed Session

Adjourn

Posted: May 20, 2016 1600 By: Rebecca Huber

Audited Financial Statements

MOUNTAIN COMMUNITIES

HEALTHCARE DISTRICT

December 31,2015 and 2014

JWT & Associates, LLPAdvisory Assurance Tax

MOUNTAIN COMMUNTIES HEALTHCARE DISTRICT

Table of Contents

Report of Independent Auditors.................................................................................................................................!

Management's Discussion and Analysis....................................................................................................................3

Audited Fiaancial Statements:

Statements of Net Position.....................................................................................................................................5

Statement of Revenues, Expenses and Changes in Net Position............................................................................6

Statement of Cash Flows.......................................................................................................................................7

Notes to Financial Statements ............................................................................................................;...................9

Advisory Assurance Tax1111 E. Hemdon Avenue, Suite 211, Fresno, CA 93720

Voice: (559) 431-7708 Fax: (559) 431-7685

Report of Independent Auditors

To the Board of Directors

Mountain Communities Healthcare District

Weaverville, California

Report on the Financial Statements

We have audited the accompanying financial statements of Mountain Communities Healthcare District (the Disb-ict)

as of December 31,2015 and 2014 which comprise the statement of net position as of December 31,2015 and 2014

and the related statements of revenue, expenses and changes in net position and cash flow for the years then ended,

and the related notes to the financial statements.

Management's Responsibility for the Financial Statements

Management is responsible for the preparation and fair presentation of these financial statements in accordance with

the accounting principles generally accepted in the United States of America; this includes the design,

implementation and maintenance of internal control relevant to the preparation and fair presentation of consolidated

financial statements that are free from material misstatement, whether due to fraud or error.

Auditor's Responsibility

Our responsibility is to express an opinion on these financial statements based on our audits. We conducted our

audits in accordance with auditing standards generally accepted in the United States of America and the standards

applicable to financial audits contained in Government Auditing Standards, issued by the Comptroller General of

the United States. Those standards require that we plan and perform the audit to obtain reasonable assurance about

whether the financial statements are free of material misstatement.

An audit involves performing procedures to obtain audit evidence about the amounts and disclosures in the financial

statements. The procedures selected depend on the auditor's judgment, including the assessment of the risks of

material misstatement of the financial statements, whether due to fraud or error. In making those risk assessments,

the auditor considers internal control relevant to the entity's preparation and fair presentation of the financial

statements in order to design audit procedures that are appropriate in the circumstances, but not for the purpose of

expressing an opinion on the effectiveness of the entity's internal control. Accordingly, we express no such opinion.

An audit also includes evaluating the appropriateness of accounting policies used and the reasonableness of

significant accounting estimates made by management, as well as evaluating the overall presentation of the financial

statements.

We believe that the audit evidence we have obtained is sufficient and appropriate to provide a basis for our audit

opinion.

Opinion

In our opinion, the 2015 and 2014 financial statements referred to above present fairly, in all material respects, the

financial position of Mountain Communities Healthcare District at December 31,2015 and 2014, and the results of

its operations and its cash flows for the years then ended, in conformity with accounting principles generally

accepted in the United States of America.

Other Matters

Management's discussion and analysis is not a required part of the financial statements but is supplementary

mfonnation required by accounting principles generally accepted in the United States of America. We have applied

limited procedures, which consisted principally of inquiries of management regarding the methods of measurement

and presentation of the supplementary information. However, we did not audit the information and express no

opinion on it.

f'viT& a^,ci^, ^pMay 25,2016


Management's Discussion and Analysis

Year Ended December 31, 2015

This discussion and analysis has been prepared by the management of Mountain Communities Healthcare District

(the District) in order to provide an overview of the District's financial and operating performance for the years

ended December 31, 2015 and 2014. This is in accordance with the Governmental Accounting Standards Board

Statement No, 34, Basic Financial Statements; Management's Discussion and Analysis for State and Local

Governments.

This discussion and analysis, read in conjimction with the District's audited financial statements for the years ended

December 31, 2015 and 2014, along with the accompanymg notes to the financial statements, is intended to help

the reader better understand the District's financial performance and position. It should be noted that the audited

financial statements prepared by JWT & Associates, LLP, Certified Public Accountants included an unmodified

opinion dated February 16, 2015. The District owns and operates Trinity Hospital (the Hospital) in Weaverville,

California. In addition to the Hospital's acute and skilled nursmg facility operation, there are community health

clinics in Weaverville and Hayfork, California.

The District increased its net position by $1,320,861 during the year ended December 31, 2015, compared to a

reduction of ($27,864) during the prior year. As a result, net position as of December 31, 2015 are $4,758,172.

The District's operating income during the year was $3,010,815, compared to the prior year operating loss of

($956,551). Total operating revenues grew by 36% from $13.1 millionm 2014 to $17.9 million m 2015. This $4.8

million growth in revenue is made up ofa$900k increase in patient revenues, along with $4,8 million of incoming

IGT funds (outgoing funds are recorded as a reduction in net position), and a decrease in Other Operating Revenue

of $900k due to a decline in meaningful use revenue. Total operating expenses grew with patient volumes as well

as inflation, from $14.1 million m 2014 to $14.9 million in-2015. Non-operating gains and losses this year uiclude

($2.6) million of outgoing IGT funds, plus incoming District Tax Revenue of$850k. Grant Revenue of$35k, the

receipt of a loan refinance rebate of $ 127k, and Interest Expense which is down to ($76k).

The net position of the District as of December 31,2015 are made up of $8.50 million in assets, including $290k in

Cash, $1.19 million in Patient Accounts Receivables, $645k in Other Accounts Receivables, and $4.33 milUon in

capital assets net of depreciation. The assets are offset by liabilities including $1.15 million in short and long term

debt, $687k in Accoimts Payable, $445k in Medicare cost report settlement liabilities, $65 5k in Accrued Payroll

Liabilities, and $929k in Deferred Inflows of Resources.

The District once again showed significantly improved results in 2015 compared to 2014, and the focus is in

business development, as a new clinic building has been acquired and is the basis of expansion plans. Hospital

senior leadership has been stable since changes in the CEO and CFO roles over the last two years. Focus areas

include the following:

® Continue to improve Swing bed utilization

o Identify and provide billable preventative healthcare services as a new source of revenue

• Recruit providers into Clinic and Hospital roles in order to increase capacity

MOUNTAIN COMMUNTmS HEALTHCARE DISTRICT

Management's Discussion and Analysis (continued)

Year Ended December 31, 2015

• Operate and demonstrate success ia the Skilled Nursing Facility

• Continue to effectively manage and collect the Patient and Other Accounts Receivable

» Continue to work towards paying off all debt

• Identify and participate m non-patient funding sources such as the AB-113 inter-govemmental transfer

program, grant funding for new and existing programs, and more

• Closely manage all expenses, including payroll, in order to drive efficiency in cost.

Mountain Communities Healthcare District, Trinity Hospital, Trmity Clinic, and Hayfork Clinic all remain

committed and available to meet the community healthcare needs.


Statements of Net Position

December 31, 2015 and 2014

2015 2014

Assets

Current Assets

Cash and cash equivalents

Patient accounts receivable, net ofallownaces

Other receivables and physician advances

Due from third-party payers

Supplies

Prepaid expenses and deposits

Total current assets

Assets whose use is limited, less current portion

Capital assets, net of accumulated depreciation

Total assets

Liabilities and Net Position

Current liabilities

Line of credit

Current portion of long-term debt

Accounts payable and accrued expenses

Accrued payroll and related liabilities

Thtrd-party payor settlements

Total current liabilities

Long-term debt, less current portion

Total liabilities

Deferred inflows of resources

Net position

Invested in capital assets, net of related debt

Unrestricted

Total net position

Total liabilities and net position

$ 1,905,399

1,192,243

645,419

149,106

252,264

4,144,431

24,818

4,334,564

$ 8,503,813_

$

^

426,795

1,387,429

829,287

219,209

151,434

186,522

3,200,676

35,072

5,030,616

8,266,364

224,606

687,371

655,861

445,323

$ 301,150

689,430

1,704,836

580,094

_$_

2,013,161

929,643

2,942,804

802,837

3,745,641

3,180,315

1,577,857

4,758,172

8,503,813 $_

3,275,510

724,135

3,999,645

829,408

4,829,053

3,617,051

(179,740)

3,437,311

8,266,364

See accompanying notes to the financial statements


Statements of Revenues, Expenses and Changes m Net position

For The Years Ended December 31, 2015 and 2014

2015 2014

Operating revenues

Net patient service revenue

Capitation revenue

Other operating revenue

Total operating revenues

Operating expenses

Salaries & wages

Employee benefits

Professional Fees

Purchased services

Supplies

Repairs & maintenance

Utilities

Rentals and leases

Depreciation & amortization

Insurance

Other operating expenses

Total operating expenses

Operating loss

Nonoperating revenues (expenses)

District tax revenues

Grants and donations

Other non-operating revenue

Interest expense

Total nonoperatmg revenues (expenses)

Excess of revenues (expenses)

Inter-governmental transfers

Increase (decrease) in net position

Net position, beginning of the year

Net position, end of year

$ 17,317,429

502,550

144,501

17,964,480

6,490,225

1,679,500

2,529,794

635,513

1,455,833

207,453

242,307

102,521

1,116,112

128,359

366,048

14,953,665

3,010,815

850,905

34,904

127,503

(76,436)936,876

3,947,691

(2,626,830)

1,320,861

3,437,311

$ 4,758,172

$ 11,684,463

467,744

1,018,777

13,170,984

> 6,278,007

1,481,037

2,128,896

887,836

1,330,921

142,891

322,416

75,274

1,170,846

139,548

169,863

14,127,535

(956,551)

862,367

158,395

(92,075)

928,687

(27,864)

(27,864)

3,465,175

$ 3,437,311



Statements of Cash Flows

For The Years Ended December 31, 2015 and 2014

2015 2014

Cash flows from operating activities

Cash received from patients and third-party payers $ 18,679,697 $ 12,030,058

Cash received from other 328,890 452,854

Cash payments to suppliers and contractors (6,748,707) (4,568,044)

Cash payments to employees and benefit programs (8,093,958) _(7,679,102)

Net cash provided by operating activities 4,165,922 235,766

Cash flows from non-capital and related fisancing

activities

District tax revenue

Grant re venue

IGT transactions

Other non-operating revenue

Net cash provided by (used in) non-capital and related financing

activities (1,613,518) 1,020,762

Cash flows from capital and related financing activities

Purchase of property, plant & equipment (447,152) (249,736)

Proceeds from lon-tem debt borrowings 1,209,500

Payments of long-term debt (1,769,966) (763,490)

Interest paid on capital debt _(76,436) _(92,075)

Net cash used-in capital and related financing activities (1,084,054) (1,105,301)

Cash flows from investing activities

Net change in assets limited as to use 10,254 53,251

Net cash provided by (used in) investing activities

Increase (decrease) in cash and cash equivalents

Cash and cash equivalents at beginning of year

Cash and cash equivalents at end of year


850,905

34,904

(2,626,830)

127,503

862,367

158,395

10,254

1,478,604

426,795

_$_ 1,905,399 A.

53,251

204,478

222,317

426,795


Statements of Cash Flows (continued)

For The Years Ended December 31,2015 and 2014

2015 2014

Reconciliation of operating income (loss) to net cash

provided by operating activities

Operating iacome (loss)

Adjustments to reconcile operating income to net cash

provided by operating activities

Depreciation

Loss on disposal of property, plant and equipment

Changes in operating assets and liabilities

Patient accounts receivable

Other receivables

Supplies

Prepaid expenses

Accounts payable and accmed expenses

Accmed payroll and related expenses

Third-party payor settlements

Deferred revenue

Net cash provided by operating activities

$ 3,010,815 $ (956,551)

1,116,112

27,092

195,186

183,868

2,328

(65,742)

(1,017,465)

75,767

664,532

(26,571)

$ 4,165,922 -1-

1,170,846

374,260

(87,480)

8,053

28,811

592,737

79,942

(496,409)

(478,443)

235,766



Notes to Financial Statements


Note 1 - Organization

Reporting Entity - Mountain Communities Healthcare District (the District) is apublic entity organized under Local

Hospital District Law as set forth in the Health and Safety Code of the State of California. The District is a political

subdivision of the State of California and is generally not subject to federal or state income taxes. The District is

governed by a Board of Directors, elected from within the healthcare district to specified terms of office. The District

was approved by the voters residing within the District in November 2006 and began operations in January 2007.

The District owns and operates a hospital, Trinity Hospital (the Hospital), located in Weaverville, California. The

Hospital was donated to the District by Trinity County, the former owner and operator of the Hospital, in June 2007.

The District lias been responsible for the ownership and operation of the Hospital since that time. The Hospital is a

51 bed facility which provides acute care, skilled nursing care, 24-hour emergency care, surgery and other inpatient

and outpatient healthcare services. The District also operates two rural health clinics and a dental clinic.

Basis of Financial Statements Preparation - The accounting policies and financial statements of the Distinct

generally conform with the recommendations of the audit and accounting guide, Health Care Organizations,

published by the American Institute of Certified Public Accountants. The financial statements are presented inaccordance witih the pronouncements of the Governmental Accounting Standards Board (GASB). For purposes of

presentation, transactions deemed by management to be ongoing, major or central to the provision of health care

services are reported as operational revenues and expenses.

Based on GASB Statement Number 20, Accounting and Financial Reporting for Proprietary Funds and Other

Governmental Entities That Use Proprietaiy Fund Accounting, as amended, the District has elected to apply the

provisions of all relevant pronouncements of the Financial Accounting Standards Board (FASB), including those

issued after November 30,1989, that do not conflict with or contradict GASB pronouncements.

The District has also adopted the provisions of GASB 34, Basic Financial Statements - and Management's

Discussion and Analysis - for State and Local Governments (Statement 34), as amended by GASB 37, Basic

Financial Statements - and Management's Discussion and Analysis -for State and Local Governments: Omnibus,

and Statement 38, Certain Financial Statement Note Disclosures. Statement 34 established financial reporting

standards for all state and local governments and related entities. Statement 34 primarily relates to presentation and

disclosure requirements. The impact of this change was related to the format of the financial statements; the

iuclusion of management's discussion and analysis; and the preparation of the statement of cash flows on the direct

method. The application of these accountmg standards had no impact on the total net assets.

MOUNTAIN COMMUNTffiS HEALTHCARE DISTRICT



Note 2 - Summary of Significant Accounting Policies

The District has incorporated the following recent GASB issued statements within this financial statement

presentation: GASB 61 - The Financial Reporting Entity: Omnibus which helps better define financial presentation

and component units; GASB 62 - Codification of Accounting and Financial Reporting Guidance Contained in Pre-

November 30, 1989 FASB and AICPA Pronouncements which supercedes GASB 20; and GASB 65 - Items

Previously Reported as Assets and Liabilities relates to certain assets that are to be combined with deferred outflows

of resources and certam liabilities that are to be combined with deferred outflows of resources. For purposes of

financial statement presentation, deferred outflows are shown with the assets of the District on the balance sheet

and deferred inflows are shown with the liabilities of the District on the balarifce sheet. The adoption of these

pronouncements had no material effect to the District's financial statements.

Use of Estimates - The preparation of financial statements m conformity with accounting principles generally

accepted in the United States of America requires management to make estimates and assumptions that affect the

reported amounts of assets and liabilities and disclosure of contingent assets and liabilities at the date of the financial

statements and the reported amount of revenues and expenses during the reporting period. Actual results could

differ from those estimates.

Cash and Cash Equivalents and Investments - The District considers all highly liquid mvestments with an original

maturity of three months or less when purchased to be cash equivalents. Short-term investments consist solely of

certificates of deposit with original maturities greater than three months when purchased.

Assets Limited as to Use - Assets limited as to use include assets held by the District in trust accounts for current

patients and assets segregated and restricted by debt agreement.

Patient Accounts Receivable - Receivables from government agencies represent the only concentrated group of

credit risk for the District, Management does not beUeve that there is any significant credit risk associated with

these governmental agencies. Contracted and other receivables consist of receivables from various payors, includmg

mdividuals involved in diverse activities, subject to differing economic conditions and do not represent concentrated

credit risks to the District. Furthermore, management continually monitors and adjusts reserves and allowances

associated with these receivables to assure they are appropriately stated.

Supplies - Supplies are stated at cost, determined by the first-m, first-out method, which is not in excess of market.

Capital Assets - Property, plant, and equipment are recorded at cost at the date of acquisition or fair market value

at the date of donation, Expenditures, which increase values, change capacities, or extend useful Uves are

capitalized. The costs of normal mamtenance, repairs and minor replacements are charged to expense when

incurred. Depreciation of property and equipment and amortization of property under capital leases are computed

by the sti-aight-lme mefhod for both financial reporting and cost reimbursement purposes over the estimated useful

lives of the assets, which range from 5 to 50 years for buildings and improvements, and 3 to 20 years for equipment.

The District periodically reviews its capital assets for value impaument. As of December 31,2015, the District has

determmed that no capital assets are impaired.

10




Note 2 - Summary of Significant Accounting Policies (continued)

Charity Care and Unsponsored Community Benefit - The District provides needed medical care to the community

regardless of ability to pay. The evaluation of the necessity for medical treatment of any patient is based upon

clinical judgment, irrespective ofthe financial status of the patient. Because the District does not pursue collection

of amounts determined to qualify as charity care, they are not included in net patient service revenue.

The District strives to assist patients, if qualified, to receive financial assistance for their care through available

government programs such as Medi-CaI and the County indigent services program. These programs typically

reimburse the District at substantial discounts from established rates, often below the actual cost of providing

services.

The District also provides a number of benefits and services to the community for which it receives no

reimbursement or where only a nominal fee is charged. These services mclude community medical and welhiess

education programs, medical screenmgs, support groups and other services.

Compensated Absences - The District's employees earn vacation benefits at varying rates depending on years of

service. Employees also earn sick leave benefits based on varying rates depending on years of service. Both benefits

can accumulate up to specified maximum levels. Employees are not paid for accumulated sick leave benefits if they

leave either upon termination or before retirement. However, accumulated vacation benefits are paid to an employee

upon either termination or retirement. Accrued vacation liability as of December 31, 2015 and 2014 is

approxunately $300,000 and $268,000 respectively.

Net Position - Net position is presented in three categories. The first category is net position "invested in capital

assets, net of related debt." This category of net position consists of capital assets (both restricted and unrestricted),

net of accumulated depreciation and reduced by the outstanding principal balances of any debt borrowings that were

attributable to the acquisition, construction, or improvement of those capital assets.

The second category is "restricted" net position. This category consists of externally designated constraints placed

on this net position by creditors (such as through debt covenants), grantors, contributors, law or regulations of other

governments or government agencies, or law or constitutional provisions or enabling legislation. The District has

no restricted net position at December 31,2015.

The third category is "unrestricted" net position. This category consists of net position that do not meet the definition

or criteria of the previous two categories.

Net Patient Service Revenues - Net patient service revenue is reported at estimated net realizable amounts from

patients, third-party payers and others for services rendered, including estimated retroactive adjustments under

reimbursement agreements with federal and state government programs and other third-party payors. In some cases,

reimbursement is based on formulas, which cannot be determined until after cost reports are filed and audited or

otherwise settled by the various programs. Estimation differences between final settlements and amounts accrued

in previous years are reflected in net patient service revenue.

11




Note 2 - Summary of Significant Accounting Policies (continued)

Risk Management - The District is exposed to various risks of loss from torts; theft of, damage to, and destruction

of assets; business interruption; errors and omissions; employee mjuries and illnesses; natural disasters; and medical

malpractice. Commercial insurance coverage is purchased for claims arising from such matters.

Grants and Contributions - From tune to time, the District receives grants from various governmental agencies

and private organizations. The District also receives contributions from related auxiliary organizations, as well as

from individuals and other private organizations. Revenues from grants and contributions are recognized when aU

eligibility requirements, mcluding time requirements are met. Grants and contributions may be restricted for either

specific operating purposes or capital acquisitions. These amounts, when recognized upon meeting all requirements,

are reported as components of the statement of revenues, expenses and changes in net assets.

Operating Revenues and Expense - The District's statement of revenues, expenses and changes in net assets

distinguishes between operating and non-operating revenues and expenses. Operating revenues result &om

exchange transactions associated with providing healthcare services, which is the District's principal activity.

Operating expenses are all expenses incurred to provide healthcare services, other than financing costs. Non-

operating revenues and expenses are those transactions not considered du-ectly linked to providing healthcare

services.

Meaningful use incentives - The Hospital recognizes revenue related to meaningful use incentives foUowmg the

grant accounting model, recognizing income ratably over the applicable reporting period as management becomes

reasonably assured of meeting the required criteria.

Management's Discussion and Analysis - Statement 34 requires that financial statements be accompanied by a

narrative mtroduction and analytical overview of the District's financial activities in the form of "management's

discussion and analysis." This analysis is similar to the analysis provided in the annual reports of organizations in

the private sector.

Subsequent events - Subsequent events are events or transactions that occur after the balance sheet date but before

financial statements are available to be issued. The Hospital recognizes in the financial statements the effects of all

subsequent events that provide additional evidence about conditions that existed at the date of the balance sheet,

mcluding the estimates inherent m the process of preparing the financial statements. The Hospital's financial

statements do not recognize subsequent events that provide evidence about conditions that did not exist at the date

of the balance sheet but arose after the balance sheet date and before financial statements were available to be

issued. The Hospital has evaluated subsequent events through the date of the Independent Auditor's Report, which

is the date the financial statements were available to be issued.

Reclassiflcations - Certain financial statement amounts as presented in the prior year financial statements have been

reclassified in these, the current year financial statements, m order to conform to the current year financial statement

presentation.

12




Note 3 ~ Cash and Cash Equivalents

As of December 31, 2015 and 2014, the District had deposits in various fmancial institutions in the form of cash

and cash equivalents amounting to $1,928,691 and $460,542. All of these funds were held in deposits, which are

collateralized in accordance with the California Government Code (CGC), except for $250,000 per account that is

federally insured.

Under the provisions of the CGC, California banks and savings arid loan associations are required to secure the

District's deposits by pledging government securities as collateral. The market value of pledged securities must

equal at least 110% of the District's deposits. California law also allows financial instihitions to secure Hospital

deposits by pledging first trust deed mortgage notes having a value of 150% of the District's total deposits. The

pledged securities are held by the pledging financial mstitution's tmst department m the name of the District.

Note 4 ~ Concentration of Credit Risk

The District grants credit without collateral to its patients and third-party payers. Patient accounts receivable from

government agencies rqpresent the only concentrated group of credit risk for the District and management does not

believe that there is any credit risk associated with these governmental agencies. Contracted and other patient

accounts receivable consist of various payors including individuals involved in diverse activities, subject to differing

economic conditions and do not represent any concentrated credit risks to the District.

Concentration of patient accounts receivable at December 31, 2015 and 2014 is as follows:

Medicare

Medi-Cal

Commercial insurance and other third-party payers

Private pay

Gross patient accounts receivable

2015

$ 1,017,185

849,581

649,010

739.298

3,255,074

$2014

1,488,370

1,282,212

590,411

619.396

3,980,389

Less allowances for contractual adjustments and bad debts ('2,062,831.') f2,592.96D

Net patient accounts receivable $ 1.192.243 $ 1.387.428

13




Note 5 - Net Patient Service Revenues

The District has agreements with third-party payers that provide for payments to the District at amounts different

from its established rates. A summary of the payment arrangements with major third-party payers follows:

Medicare - Payments for iapatient and outpatient services to Medicare patients are based on prior years' cost

reports. The District is paid an interim rate per day based on these costs. The District submits an annual cost

report with final setdement determined by the Medicare fiscal intermediary. At December 31, 2015, cost reports

through 2013 have been audited or otherwise final settled.

Medi-Cal: Payments for inpatient services rendered to Medi-Cal and County Medical Services Program (CMSP)

patients are made based on reasonable costs wtiile outpatient payments are based on pre-determined fee

schedules. The District is paid for cost-based inpatient services at an interim rate with final settlement determmed

after submission of annual cost reports and audits thereof by the State of California. At December 31,2015, cost

reports through 2013, have been audited or otherwise final settled.

Other: Payments for services rendered to other than Medicare, Medi-Cal and CMSP patients are based on

established rates or on agreements with certain commercial insurance companies, health maintenance

organizations and preferred provider organizations which provide for various discounts from established rates.

Medicare andMedi-Cal revenue accoimts for approximately 80%, for the year ended December 31,2015, and 81%,

for the year ended December 31,2014, of the District's gross patient revenues. Laws and regulations governing the

Medicare and Medi-Cal programs are extremely complex and subject to interpretation. As a result, there is at least

a reasonable possibility that recorded estimates will change as additional information is received.

California Hospital Fee Program - In November 2009, the California Hospital Fee Program (the Program) was

initiated and signed into California state law. The Program provides supplemental Medi-Cal payments to certain

California hospitals. The Program is funded by a quality assurance fee paid in the form of an Inter-Govemmental

Transfer (the Fee) paid by participating hospitals and by matching federal fluids. Hospitals receive supplemental

payments from either DHS, managed care plans or a combination of both. The Program is administered the

California Hospital Association (CBA) and the California State Department of Health Care Services (DHS) and

requires final approval by the Federal Government's Center for Medicare and Medicaid Services (CMS). The

District has participated in this program since its incept. Program fee revenue for the year ended December 31,

2015 was $4,822,661, and corresponding Inter-Govemmental Transfer required to participate in the Program was

$2,626,830, resulting ia a net gain of $2,195,831. There was no fee revenue or corresponding Inter-Govemmental

Transfer for the year ended December 31, 2014, as the Program for that year had not yet been final approved by

CMS.

14




Note 6 - Investments

The District's investment balances and average maturities were as follows at December 31,2015 and 2014:

2015 ,

Investment Maturities in Years

FairValue Less than 1 1 to 5 Over 5

Money market and other interest

bearing accounts $ 1,647,879 $ 1,647,879 $ -0- $_-_0^

Total investments $ 1.647.879 $ 1 -.647.879 S _-0= $_-0=.

2014

Investment Maturities in Years

FairValue Lessthmil U:o_5 Over 5

Money market and other interest

bearing accounts $ 40,363 $ 40.363 ^_-0^ $_-_Q^

Total investments $ 40,363 $ 40.363 S_=0= $_-Q^

The District's investments are reported at fair value as previously discussed. The District's investment policy allows

for various forms of investments generally set to mature within a few months to others over 15 years. The policy

identifies certain provisions which address interest rate risk, credit risk and concentration of credit risk.

Interest Rate Risk - Interest rate risk is the risk that changes in market interest rates will adversely affect the fair

value of an investment. Generally, the longer the maturity of an investment the greater the sensitivity of its fair

value to changes in market interest rates. The District's exposure to interest rate risk is minimal as 100% of their

investments have a maturity of less than one year. Information about the sensitivity of the fair values of the District's

investments to market interest rate fluctuations is provided by the preceding schedules that shows the distribution

of the District's investments by maturity.

Credit Risk - Credit risk is the risk that the issuer of an investment will not fulfill its obligation to the holder of the

investment. This is measured by the assignment of a rating by a nationally recognized statistical rating organization,

such as Ivloody's Investor Service, Inc. The District believes that there is mininial credit risk with their accounts at

this time.

Custodial Credit Risk - Custodial credit risk is the risk that, in the event of the failure of the counterparty (e.g.

broker-dealer), the District will not be able to recover the value of its investment or collateral securities that are in

the possession of another party. The District's investments are generally held by banks or government agencies.

The District believes that there is minimal custodial credit risk with their investments at this time. District

management monitors fhe entities which hold the various investments to ensure they remain in good standing.

15

MOUNTAIN COMMUNTffiS HEALTHCARE DISTRICT



Note 6 - Investments (continued)

Concentration of Credit Risk - Concentration of credit risk is the risk of loss attributed to the magnitude of the

District's investment in a single issuer. The District's investments are held 100% by banks. The District believes

that there is minimal custodial credit risk with their investments at this tune. District management monitors the

entities which hold the various investments to ensure they remain in good standing.

Note 7 - Capital Assets

Capital assets as of December 31,2015 and 2014 are comprised of the followmg:

Land

Buildings and improvements

Equipment

Construction in progress

Totals at historical cost

Less accumulated depreciadon for:


Equipment

Total accumulated depreciation

Capital assets, net

Balance at

December 31,

2014

$ 440,000

6,177,736

3,955,403

42,092

Transfers &

Additions

$ 91,094

340,603

15,455

-0-

Transfers &

Retirements

$ -0-

-0-

-0-

27,092

Balance at

December 31,

2015

$ 531,094

6,518,339

3,970,858

15.000

S 5.030.616

10,615,231 $ 447.152 $, -ZLQ22

(2,640,301) $ (407,124) $

C2.944.314) . C708.988) _

f5.584.615'> $ ri.H6.112) $ -0-

-0-

_-0-

11,035,291

(3,047,425)

f3.653,302)

('6.700,727)

$ 4.334.564

16




Note 7 - Capital Assets (continued)

Land


Equipment

Construction in progress

Totals at historical cost

Less accumulated depreciation for:


Equipment


Capital assets, net

Balance at

December 31,

2013

$ 440,000

6,051,605

3,873,890

-0-

Transfers &

Additions

$ -0-

126,131

81,513

42.092

Transfers &

Retirements

$ -0-

-0-

-0-

-0-

Balance at

December 31,

2014

$ 440,000

6,177,736

3,955,403

42.092

10,365,495 $ 249.736

(2,239,397)

f2.174,372)

f4.413.7691 S ri.l70.846-)

(400,904)(-769.942)

$ 5.951.726

$

s_

-0-

-0-

-0-

-0-

10,615,231

(2,640,301)

f2.944.314)

f5.584.615)

S 5.030.616

Note 8 - Bank Line of Credit

In June 2015, the District obtained a line of credit from the Trinity Public Utilities District allowing borrowings up

to $250,000 to provide operating capital as needed. The line of credit bears an interest rate of 6.0%. The line of

credit matures in 2016. Interest is payable monthly calculated on any current outstanding balance and principal is

due at maturity. The outstanding balance for the line of credit at December 31, 2015 is $0.

17




Note 9 - Debt Borrowings

Long-Term debt at December 31,2015 and 2014 consists of the following:

2015 2014

Note payable to a bank, original amount of $350,000, bearing interest at

5.25%, principal and interest payable monthly in the amount of $10,546for 36 months, maturing in December 2015, secured by patient and district

taxes receivable. $ -0- $ 123,019

Note payable to a bank, original amount of $1,209,500, bearing interest at

4.25%, principal and interest payable monthly, maturing in September2020, secured by certain assets of the District.

J

Note payable to UHC of California, original amount of $1,700,000,

bearing interest at 3.75%, principal payable per schedule in 2015,2015 and2016,securedby certain assets of the District. _-Q- 1,290.546

Total debt borrowings 1,154,249 1,413,565

Less current portion (224.606) C689.430')

Debt bon-owiags, net of current maturities $ 929.643 $ 724.135

Future required principal payments under the above long-term debt are as follows: $224,606 in 2016; $234,340 in

2017; $244,495 in 2018; $255,091 in 2019; and $195,717 in 2020.

18




Note 10 -Deferred Inflow of Resources

Deferred inflows of resources are comprised of the following at December 31, 2015 and 2015:

2015 2014

Deferred tax revenue $ 802,837 $ 775,950

Deferred grant revenue - EMR _-^ 53,458

$ 802.837 $_ 829A08

Note 11 - Pension Plan

The Disb-ict has a defined contribution retirement plan covering substantially all of the District's employees. In a

defined contribution retirement plan, benefits depend solely on amounts contributed by the District and participants

to the plan plus iavestment earnings. The District contributes to the plan at a rate of two percent of eligible

compensation for all eligible employees, as defmed by the plan. Eligible employees have the option to make

additional contributions to the Plan individually, within certain limitations set forth in the Plan and as required by

regulation. The District's pension expense for the plan was approximately $53,000 during the year ended December

31,2015 and $47,000 during the year ended December 31, 2014

Note 12 - Mledical M[alpractice Insurance Coverage

The District purchases commercial malpractice liability insurance on an occurrence basis. The policy coverage is

$3,000,000 per occurrence for acute hospital services and $1,000,000 per occurrence for the skilled nursing facility,

with a $10,000 deductible for both. There is an aggregate limitation of $10,000,000 for acute hospital services and

$3,000,000 for the skilled nursing facility. The District accmes the deductible for all open claims,

Note 13 - Commitments and Contingencies

Litigation - The District is subject to legal proceedings and claims, which arise, in the ordinary course of its

business. After consultation with legal counsel, management estimates that matters existing as of December 31,

2015 will be resolved without material adverse effect on the District's future financial position, results from

operations or cash flows.

19




Note 13 - Commitments and Contingencies (continued)

Health Care Reform - The health care industry is subject to numerous laws and regulations of federal, state and

local governments. These laws and regulations include, but are not necessarily limited to, matters such as licensure,

accreditation, governmental health care program participation requirements, reimbursement for patient services,

and Medicare and Medi-Cal fraud and abuse. Government activity has increased with respect to investigations and

allegations concerning possible violations of fraud and abuse statutes and regulations by health care providers.

Violations of these laws and regulations could result m expulsion from government health care programs together

with the imposition of significant fines and penalties, as well as significant repayments for patient services

previously billed. Management believes that the District is in compliance with fraud and abuse regulations as well

as other applicable government laws and regulations. While no material regulatory mquiries have been made,

compliance with such laws and regulations can be subject to future government review and interpretation as well

as regulatory actions imlaiown or unasserted at this tune.

Health Insurance Portability and Accountability Act - The Health Insurance Eprtability and Accountability Act

(HIPAA) was enacted August 21, 1996, to ensure health msurance portability, reduce health care fraud and abuse,

guarantee security and privacy of health mformation, and enforce standards for health information. Organizations

are subject to significant fines and penalties if found not to be compliant with the provisions outlined in the

regulations. The District's management has evaluated the impact of this legislation on its operations, rucludmg any

future financial commitments that may be required. Management feels that current policy and procedures m place

comply with the requirements ofEQPAA.

Note 14 - Medi-Cal Rate Reductions Under AB97

On March 24th of 2011, California's Governor Brown signed AB 97 (Budget Act of 2011), which included

significant cuts to Medi-Cal reimbursement rates for skilled-nursmg facilities that are distinct parts (DP/SNF's) of

hospitals. Medi-Cal rates for these facilities were to be reduced to rates fhat were applicable in the 2008-09 rate

year reduced by 10%." For most affected facilities, the reduction would haye resulted in a decrease of approximately

20% to 25% or more. Reimbursement reduction of this magnitude would have devastating consequences for the

California health care community, mcluding the Hospital. Also, this reduction would be retroactive to June 1,2011,

thus compounding the problem.

As a result, the California Hospital Association (CHA) filed a lawsuit dated November 1, 2011 against the

Department of Health Care Services (DHCS) and the Centers for Medicare and Medicaid Services (CMS)

challenging rate cuts to MIedi-Cal reimbursement for DP/SNF's within acute-care hospitals. The lawsuit asserts that

the rate reductions violate federal Medicaid law requiring that payment be sufficient to ensure access for Medicaid

beneficiaries, and that CMS did not act properly in approving the reductions.

20




Note 14 - Medi-Cal Rate Reductions Under AB97 (continued)

In a hearing held December 19, 2011, the U.S. District Court, Central District, approved CHA's request for a

preliminary injunction prohibiting DHCS from implementing reductions to Medi-Cal reimbursement for DP/SNF' s.

CHA argued that the payment reduction and retroactive recoupment would cause m-eparable harm and lead to

additional facility closures and reductions of service,

The U. S. District Court ruled on the State's request for a modification of the court's previous order for apreliminary

injunction prohibiting DHCS from implementing reductions as mentioned above. The modification meant that the

State would be able to implement rate cuts on reimbursement paid for a limited period prior to December 28,2011,

the date of the injunction. Payments for services that had been provided, but not yet paid as of that date, would be

subject to the rate cut. In a decision handed down IVtarch 8, 2014, the judge agreed with the State's argument that

they should be able to recover the difference between the rate paid and the reduced rate for services provided prior

to December 28, 2011. The judge did however limit the retroactive implementation of the rate cuts to

reimbursements for Medi-Cal services rendered but not paid as of December 28, 2011. Subsequent to fhis, the

decision was overturned.

The U. S. District Court ruled on the State's request for a modification of the court's previous order for a prelmunary

injunction prohibiting DHCS from implementing reductions as mentioned above. The modification meant that the

State would be able to implement rate cuts on rehnbursement paid for a limited period prior to December 28,2011,

the date of the injunction. Payments for services that had been provided, but not yet paid as of that date, would be

subject to the rate cut. la a decision handed down March 8, 2014, the judge agreed with the State's argument that

they should be able to recover the difference between the rate paid and the reduced rate for services provided prior

to December 28, 2011. The judge did however limit the retroactive implementation of the rate cuts to

reimbursements for Medi-Cal services rendered but not paid as of December 28, 2011. Subsequent to this, the

decision was overturned.

Arguments, discussions and other legislation were proposed, such as AB900 and SB640, over the past two years,

Recent announcements have been most encouraging and the suit has been settled. A settlement which is intended

to exempt all rural and frontier DP/SNF's (Level B) from AB97 has been agreed to. Determination of "rural" status

will be defined by OSHPD that uses data from the 2011 Final Database Rural and Frontier from the Metropolitan

Study Services Areas Designations. The effective date for this exemption is September 1, 2015, or any other date

as approved by the Centers for Medicare and Medicaid Services.

This decision means that the DP/SNF's operated by the Hospital, as classified by the Department of Health Care

Services (DHCS) as "rural" facilities, are exempt from the 10% per diem rate reduction as of September 1, 2014

and the related "claw back" period between June 1, 201 1 and August 31, 2012 for which the Hospital was liable.

The potential liability amount had been estimated to be $386,129 by management and recorded at December 31,

2013. The Hospital also has chosen to participate in the DHCS's supplemental reimbursement program designed to

offset a portion of the DP/SNF liability noted above.

21




Note 14 - Medi-CaI Rate Reductions Under AB97 (continued)

CHA is working closely with CMS to have them agree to exempt the DP/SWs also from the "claw back" period.

If CMS agrees to this later exemption, the State will then not be authorized to "claw back" it's part of the fundmg,

thus eliminating any possible liability. Though the Hospital believes this will be the likely outcome (since CMS has

ah-eady paid its share of the reimbursement and may not want to retroactively take the funding away) it has chosen

to reflect the liability till such time as a final decision is rendered.

22

TRINIPf HOSPITALOwned and Operated by


Chief Executive Officer

Report to the Board of DirectorsMay 2016

From Aaron Rogers, CEO:

The following is an update on the ongoing matters of interest as of this date. I will provide a

status update as appropriate, at the Board Meeting on April 25,2016.

Employee of the IVlonth: Laurie Olson—Skilled Nursing

Laurie Olson has stepped up and has been instrumental in supporting the changes on SNF.

She has worked additional shifts.

Recruitment:

We continue to recruit nurses, providers, physical therapist, and clinical laboratory scientist. HR

and administration are ramping up recruitment and working closely with departments who are

recruiting themselves.

Utilization:

Census was high in April with an average 8.1 per day.

Skilled Nursing Facility:We have completed the required information for Noridian and sent it in Friday, May 20.

Policies:

We are continuing to work on policy consolidation.

Mock Survey:

The staff is working very hard to get everything found by Carolyn St. Charles in compliance. We

are revamping swing paperwork along with other findings. Carolyn is very helpful and we

appreciate her expertise to assist us in being ready for future surveys.

Provider Stats:

Providers are delinquent on 3 of 31 discharge summaries. (90.5%). Discharge summaries must

be completed within seven days of discharge. Stats are continually improving and our goal is

100%.

Trinity Care:

We have been in discussions with Trinity Cares and the Lew Edwards Group regarding the tax

ballot. Kevin Cahill had been very active as we look to ramp up.

TRINITY HOSPITALOwned and Operated byMountain Communities

Healthcare District

Financial Narrative for the month of April 2016

Prepared by Jan Marshall

Sum mar v

Mountain Communities Healthcare District incurred a loss from operations of ($322,934) for the month, which

is ($251,844) worse than the budgeted operating loss of ($71,090). The month includes lower inpatient but

higher outpatient revenues, and expenses close to the anticipated amount, all of which are detailed below. For

the year-to-date, our loss from operations is ($823k) compared to a budget of ($447k).

200

0

(200)

(400)

(600)

Operating income/(loss) - Month 2016

Jan Feb Mar Apr May Jun Jui Aug Sep Oct Nov Dec,»_ Actual 2016 —•—Budget 2016 .-...5;,y.-".-. Actual 2015

Volume and Revenue

Patient days are under budget by 24 in Acute and 563 in SNF, but over by 110 in Swing

Outpatient volumes are under budget in most areas of the hospital except Lab and Imaging

Trinity Clinic visits are under budget by 45, Hayfork Clinic visits are over budget by 103

Total patient revenue is under budget by ($26k) or 1.1%

Net Patient Revenues are down to 39.3% of Total patient revenue (compared to budgeted 49.5%) as a

result of losing SNF volume, which pays at approximately 80% of charges. Net patient revenue is under

budget by $241k or 21%

For the year-to-date, net patient revenues are $4.4 million compared to a budget of $4.3 million

3,000

2,500

2,000

1,500

Gross Revenue - Month 2016

Jan Feb Mar Apr May Jun Jul Aug Sep

^-Actual 2016 —®—Budget 2016 .-- -;-'Actual 2015

Oct Nov Dec

Page 1 of 2

Expenses

Salaries, benefits, and registry expenses are down to $714kforthe month, $40k lower than budget

All other expense categories combined are over budget by $49k

SNF costs are up $50k compared to budget in Professional Fees alone

As a result, total expenses are $1.20 million, only $9k higher than budget of $1.19 million

Year-to-date expenses are $5.24 million compared to a budget of $4.81 million.

1,600

1,400

1,200

1,000

Total Expenses - Month 2016


,^^—Actual 2016 —B—Budget 2016 -—'Actual 2015

Oct Nov Dec

850

750

650

550

Labor Expense - Month 2016


"^—Actual 2016 Budget 2016 -^—Actual 2015

Oct Nov Dec

Non-Operating Revenue and Expense

® Non-operating activity includes a $736k payment from Partnership Health for IGT

® Net Income for the month is $484k compared to a budgeted loss of ($12k)

® Year-to-date net income is $218k compared to a budgeted loss of ($212k)

BalanceSheet

® Cash increased from 28 to 46 days this month

® Gross Accounts Receivable dropped due to payments coming in, and is now $3.64 million. Net

Accounts Receivable are also down, to $1.75 million.

® Days in Accounts Receivable are down to 46

® Days in Accounts Payable remain low at 41

• Debt borrowings are up with the recording of a loan for Ultrasound

® No other major fluctuations in the Balance Sheet

Page 2 of 2

Assets

Current assets:

Cash and cash equivalents

Gross accounts receivable

Net accounts receivable

Net % of gross

Other Receivables

Estimated third party settlements, net

Inventories

Prepaid expenses and deposits

Total current assets

Apr-16

(Unaudited)

1,911,793

3,640,660

1,758,758

48.31%

459,236

150,591

204,943

4,485,321

Mar-16

(Unaudited)

1,210,790

4,020,211

1,992,261

49.56%

518,151

148,671

185,648

4,055,521

Dec-15

(Unaudited)

1,905,399

3,255,074

1,192,243

36.63%

645,419

149,106

252,264

4,144,431

Assets limited as to use

Total capital assets


Capital assets,net of accumulated depreciation

Total assets

Liabilities and Net Assets

Current Liabilities:

Current maturities of debt borrowing

Accounts payable and accrued expenses

Accrued payroll and related liabilities

Estimated third party settlements, net

Deferred Revenue

Total current liabilities

22,603 22,603 24,818

11,093,641

6,884,639

4,209,002

8,716,925

11,035,831

6,839,608

4,196,222

8,274,346

11,035,;

6,700,727

4,334,564

8,503,813

237,478

941,535

656,656

479,459

509,547

2,824,675

221,822

921,235

676,961

372,588

582,869

2,775,476

224,606

687,371

655,861

445,323

802,837

2,706,343

Debt borrowings,net of current maturities

Days in cash

Days in accounts receivable (gross)

Days in accounts payable

916,166 877,305 929,643

Total liabilities

Net assets:

Invested in capital assets, net of related debt

Unrestricted

Total net assets/deficit

Total liabilities and net assets

3,740,841

3,055,357

1,920,727

4,976,084

8,716,925

3,652,781

3,097,095

1,524,470

4,621,565

8,274,346

3,638,770

3,180,315

1,577,857

4,758,172

8,630,618

46

46

41

28

50

39

50

44

44

(322,934)


Statement of Operations

Apr-16

Actual

946,290

1,290,700

2,236,990

1,357,735

879,255

39.3%

1,717

880,972

571,914

110,334

32,231

205,134

107,906

90,024

14,680

45,031

26,652

1,203,906

Apr-16

Budget

1,076,246

1,186,731

2,262,977

1,143,034

1,119,943

49.5%

3,138

1,123,081

584,415

143,847

25,963

152,059

115,576

64,873

20,025

42,407

45,006

1,194,171

Monthly

Variance

(129,956)

103,969

(25,987)

214,701

(240,688)

(1,421)

(242,109)

(12,501)

(33,513)

6,268

53,075

(7,670)

25,150

(5,345)

2,624

(18,354)

9,735

Operating Revenues:

Inpatient revenue

Outpatient revenue

Total gross patient service revenue

Contractuals & Bad Debt

Net patient service revenue

Net Revenue as a % of gross

Other operating revenue

Total operating revenues

Operating expenses:

Salaries

Benefits

Registry

Professional fees

Supplies

Purchased services

Utilities

Depreciation and amortization

Other operating expenses

Total operating expenses

YTD

Actual

4,659,259

4,822,889

9,482,148

5,073,331

4,408,817

46.5%

15,785

4,424,602

2,353,600

612,981

227,736

817,068

507,828

298,478

87,916

183,913

158,956

5,248,476

YTD

Budget

4,340,859

4,461,786

8,802,645

4,446,233

4,356,412

49.5%

12,657

4,369,069

2,357,141

580,181

104,717

613,305

466,157

261,656

80,769

171,040

181,523

4,816,490

YTD

Variance

318,400

361,103

679,504

627,098

52,405

3,128

55,533

(3,541)

32,800

123,019

203,764

41,672

36,821

7,147

12,872

(22,567)

431,986

(71,090) (251,844)

736,757

73,323

1,000

_(4,152)

806.927

483,993

529,024

81.3%

136.9%

66,111

(7,665)

58,446

(12,644)

29,763

67.3%

106.6%

736,757

7,212

1,000

3,512

748,481

496,637

(277,903)

Operating gain/floss)

Non-operating revenues/expenses:

Intergovernmental Transfer

District tax revenue

Non-operatlng revenues/expenses

Grants and contributions

Interest expense

Total non-operating revenues/expenses

Net income/floss)

Trinity EBIDTA

Staffing costs as a % of net patient revenue

Total operating expenses as a % of net patient revenue

(823,874)

736,757

293,291

27,979

200

(16,441)

1,041,786

217,912

(447,421)

266,646

(30,914)

235,732

(211,689)

401,824

72.5%

119.0%

(40,649)

69.8%

110.6%

(376,453)

736,757

26,645

27,979

200

14,473

806,054

429,601

442,473

SNF Home Health

Trinity

Community

Health Clinic

Hayfork

Community

Health Clinic

Hospital with

Emergency

Department

attached

Total

14,053

15,792

(1,740)

6,264

(8,004)

1,351

(6,654)

13,571

6,9.17

121,616

89,694

31,922

23,894

8,028

5,151

16

13,195

51,763

64,957

62,259

56,385

5,874

13,722

(7,848)

2,958

(4,890)

29,725

24,836

681,328

701,940

(20,612)

296,219

(316,832)

63,863

(1,458)

(254,426)

641,709

387,283

879,255

863,812

15,443

340,100

(324,656)

73,324

(1,442)

(252,775)

736,768

483,993

Expected Net Revenue

Direct Expense

Direct Expense - Net Gain/floss)

Overhead Expense

Operating Gain/floss)

Non-operating revenues/expenses

District Tax Revenue

Non-operating revenues/expenses

Grants and contributions

Wet Income/floss) - Nonrecurring Items Excluded

Intergovernmental Transfers

Net lncome/(loss)

Note:

This supplemental schedule is designed to be an activity statement that shows details and results of the line ofbusiness's profit-related activities for a

period of time. Overhead and Non Operating Revenue/Expense Is allocated based on the most recent as filed Medicare Cost Report. This schedule is not

an income statement. This analysis is designed to determine if a line of business is covering direct expenses and is contributing towards overhead

expense.

Page 3 of 5

PATIENT DAYS:

Acute

Swing Bed

SNFTOTAL PATIENT DAYS:

TESTS/VISITS:

Observation

CT Scan Tests

Echocardlogram Tests

Emergency Department Visits

Hayfork Clinic Visits

Home Health Visits

laboratory Tests

Physicai Therapy Visits

Respiratory Therapy Tests

Top Care Visits

Trinity CIInfc Visits

Ultrasound Tests

Diagnostic Imaging Tests

TOTAL TESTS/VISITS:


Monthly Activity Log

Apr-15

91

84

556731

12

57

10

467

377

88

17,636

60

97918

945

57367

21,061

MavlS

94

87559740

04

58

IS

466355

69

15,166

eo

694

26

694

36257

17,896

Jun-15

86

88581

755

11

74

27

471378

84

19,259

64822

18

929

54

324

22,504

Jul-15

100

137595832

10

81

57513

372

81

20,828

77839

12

955

81296

24,192

AUK-15

104

165553822

12

7133

478

300

82

17,442

72

1,132

17

726

42

294

20,689

Sep-15

112

62519

693

14

6860

437

377

79

18,140

54

984

27

880

56302

21,464

Oct-15

69

72520

661

7

68

18

371

350

99

17,322

100

837

22

858

60

312

20,417

Npy-15

56

70490616

3

71

54

389

269

3715.S13

69

783

50

887

64

260

18,446

Oec-15

79

U4503696

264

42353

325

3717,231

91

763

37

933

73

284

20,233

2015 YTD

1,039

9766,623

8,638

146

792

355

5,178

4,227

8G7206.165

761

10,384

316

10,276

690

3,649

243,660

Jan-li

58

181

527766

2

56

30

357

322

3816,780

124

1,207

24

898

52

305

20,195

Feb-16

57

20643S701

1

77

27372

390

68

17,683

200

946

27

888

15328

21,022

Mar-16

57

239

266562

1

70

0394

476

6717,710

285

1,025

12

1,000

0

377

21,417

AET-16

68

1760

165

16

370

463

54

16.75S

264

651

12

940

69

347

20,007

zaieyro

240

8021,231

2,273

5

268

73

1,493

1,651

22768,928

873

3,829

753,726

1361,357

82,641

i016AorilBudget

9266

S63721

1666

21

417

360

70

16,414

856809

19

985

54299

20,386

March 2016 2015

Budget MQnthIv Monthly

Variance AveraRe Averaf

-38%

262%-53%

57

20943.0

86

36

S03-22%

-94%

6K-100%

-6%

32%-4%

8%-67%

27%-37%

2%-100%

26%

676

168

19374

396

58

17,391

2031,059

21

929

22

337

725

24

SB

21399

401

68

16,127

3D

895

17

957

59

365

SK 20,877 19,397

Cash Received

Beginning Cash Balance

Patient Receipts

1GT Activity

Cost Report Activity

Tax Receipts

Miscellaneous Cash Receipts

Total Cash Coliected

Total CashAvaHable

Cash Disbursed

Payroll

Accounts Payable

Cost Report Activity

Transfer to/f rom Cash Resi

IGT Activity

Cash Position

BaSance Before Financing

Financing

Total Disbursements

Mountain Communities Heatthcare District

Cash Projection - 2016

Actual

January, 2016

212,019

311,258

57,644

53,063

M.3S71.036,321

1,248340

736,462

489,106

161.000)

1,164,568

Actual

February, 2016

83,772

1,070,062

23,732

32.207

46,704

1,178,706

1,262,WL

756,528

577,119

(333,830}

993,817

Aetna!

March, 2016

268,661

827,999

32,554

20,874

88M27

1.150,088

764,227

3<8,598

101,526

(159,849)

1,054,503

Actual

April, 2016

35,585

1,117,536

736,757

54,564

1,988

1,910,846

2,006.430

7M.79S495,044

737,000

1.S1M43

Projection

May, 2015

59,588

907,439

7,365

3.190

918,595

978.183

688.203

607,394

1506,000)

789.603

Projection

June, 2016

188,580

863,536

40,097

3.190

906.824

1,095,403>

730,257

400,000

(soa/aoo)

690.000

1,020.257

Projection

July, 2016

75,146307,439

20,487

3.190

931.116

1,006,263

754,599

400,000

(250,000)

9B4.599

Projection

August 2015

101,664

900,004

9,422

3,190

312,616

1,OM,280

754,539

400,000

(250,000}

904,599

Projection

September. 2016

109,681

363,536

100,392

3,190

367.118

1.076,739

730,257

400,000

(150,000}

980,257

Projection

October, 2016

96,542

1,067,439

1,335.305

179.494

3,190

2.58S.429

2,681,371

754,599400,000

1,300,000

2,454,599

Projection

November, 2016

227,372

863,536

142,930

3,130

1,009,717

1,237,088

730.257

400,000

1.130.257

ProjectionDecember, 2025

106,831

907.439

100,677

3,1SO

1,011,307

1,118,139

754,599

400,000

(150,000)

1,004,399

Cash Reserve Balance

Total Cash on Hand

l,514,8S4

1.698,657

I,Z75,DS4

1,543.715

1,115,205

1,210,790

1,852,205

1,911,793

1,346.205

1,534,785

546,205

6Z1.352

296,205

337.863

46,205

155,886

(103,795)

(•7,253)

1,196,205

1,423,577

1,196,205

1,31)S,037

1,046,205

1,159,745

TRINITY HOSPITALOwned and Operated by


Chief Nursing Officer

Report to the Board of DirectorsMay 2016

From Peggy Manning, BSN, CNO

Patient Acuity Meeting and new form: The staff and I met to fulfill our annual requirement. We

came up with the new form (attached). Each patient is evaluated in each area then the patient is

awarded a numerical value (acuity). Patient assignment is driven by these numbers. The form is

also sent to Gary to help justify charges. This has increased gross charges by $40,000 for 1

month (comparing April 2015 to April 2016)

On-line Learning platform: We are close to signing and implementing an on-line learning platform

which includes: procedures for nursing, respiratory therapy and physical therapy. This will

eliminate large portion procedures from Navex which will increase consistence across the

hospital system.

Pyxis: Fully implemented, this was the smoothest one I have ever been involved with. Patients

are now profiled with their medications from admit ion to discharge increasing patient and

employee safety.

2 new RNs hired, they will start soon.

Donor Network West awarded us the 2015 Bronze Award for our support of tissue recovery. Only

12 out of 170 hospitals were received awards.

^.L

'\li

Owned and Operated byMountain Communities Healthcare District

P.O. Box 1229

60 Easter Avenue

Weaverville, CA 96093

Phone: (530) 623-5541

To: BOD 5/16/2016Re: Quality Assurance

Greetings,

This is an update for the Quality Assurance Program. We have completed the 2016 1st

Quarter report. Attached is the scorecard for the hospital. Please note that there are measures

related to SNF for the months of January and February but are discontinued in March.

A few highlights:

• MedSurg Nutrional Screening is at 100%

® ER lobby to provider median time for the quarter was 9 minutes

• Active participation by BOD members in the CQI program was 100%

• Respiratory therapy patient satisfaction for March was 100%

• TCHC has started new projects related to a Partnership measure for controlling high blood

pressure. They exceeded their initial goal.

As intended by this process, we have identified area that provide opportunities for improvement and

will continue to work at reaching and exceeding our goals through process improvements, staff

education and continued monitoring.

Thank you for your time.

Sarah Cordtz, RN

Coordinator Quality Assurance / Risk Management.

Mountain Communities Healthcare District Scorecard 2015

Department / Service: Freformance Improvement 2015

•partment

dministratii

[i/Medical

Staff

Anesthesia

Biomed/

Maint

Bus Svs

Dietary

DP/UR

Employee

Health

Fin Svs

Hayfork

clinic

HIM

HH

HR

Infection

control

IT

Lab

Nursing

•asure

INV prevention

Work orders 85%

completed

:rease clean claims b}

> / month

lys

admissions within 30 days

/ cause/ reduce to 5%

admissions within 15 days

^ cause.

nployee Health

lysical, fit mask, PPD

•ported Occupational

•edle stick and

iposures

u shots for employee:

•view of policies that are

rrent

)l5 Phy. Reviews

ompletion of swg

3C

F referrals

mployee Turnover ra

ackground ck rehune

/ company within 24

rs

eference ck

[and Hygiene

iMEdeanmgER/ME

SNF/ THCC/ RAD/

ab

IRSAptedu

UP:AUTI occurances

jmual Staff PPE

raining

mnual 1C staff

Latio: Open to dosed

ictets

JRTrop.TAT

R: Resp Rate assessment ai

ocumentation

,R: Discharge VS

2015

nnual

0;

87'

4'

^

5'

6'

90'

A

85

A

A

56

NA

3

[A

83

77

79%

TJ

c

89%

90%

8(

61

5l

rget

;%

85°

1°

90°

5"

5'

90'

36'

100

80

50

5%

100

100

80

80

80

IOC

8E

9C

1:

8;

9;

9:

I b ^r

No submmission

0%| 0°, 05

No submission

-6%

100% I 100%| 67°

No Submission

No Submission

90% I 100" 89'

No data

33% | 5- 24'

97%

0%| 50' 25

31%

3.2% |

80% |90% I80%

83% |100% I

IA

60% |90% I

40/298

74.2% |

100%

76%

'•)'

36

100

77

88

100

IA

100

100

07/3<

91.7

10C

81

1.8

100

100

78

82

0

IA

89

8S

44/31

90.(

10C

8(

:Qtr

0°;

:fr

89°

93'

1"-%'

97

"M

2

97

78

84

e»

JA

c

83

93

85.5C

10C

7S

rget EL :a2_ jie idQtr irget il5_ ug !EL -dQtr arget )ct lov )ec thQtr

Discontinue


Phannacy

FT

Radiolog

(Diagnost

imaging)

QA

RT

Admission Med Rec

Admission VS

Reassessment after pain

I

Care plan in 24 hr

Pain Level documneted q

Nursing nutrition

wiing

: Nutritional rescreening ii

eek

Lobby to Provider in

mtes

Lobby to Dishcarge in

mtes

Lobby to Acute Floor

: Restraint Log

.armadst verification

orders in 24 hr

itimicrobial

•wardship

.ily check for

sdlcation outdafces

it pt FT baling withi

hrs

TCumentation DLP o]

'porting of CT exam

suiting in >20% of

)rmal radiation

nployee film badge

onitor

aily DME cleaning

ismfecting US

idocavity transducer

ithHLD

TSTATfromMDI

:tive participation by MD

i visor

:tive participation by BOD

embers

k Satisfaction

esp med errors RT

.ati

ransfer check list

/eekly summaries

miplete

/ound Assessment /

^assessment

4 hr Chart check%

hange of Condition

)M; careplanning

ypo/hyperglycemic

:ocumentation

48°,

96°,

^.

45°

91'

V

1

67.

197,

100'

93'

40

100

A

100

100

100

10C

10C

9;

5C

^

10(

IA

z

7:

81

8:8'

9:

7i

50°,

95°,

95?

95°

95°

95°

95'

3

12

24

100'

90'

100

95

6t

10C

8C

8(

10(

10(

101

101

101

101

101

Hold

98% I

80%]

info

info

info

info

6411471

\

94% I

100°i

63°,

27°,

13°

100°

66°

1

7

19

A

96'

55°,

66°

100°

100°

6

18

A

90-

No Data

No Data

A 100 98

No submission

No submission

No submission

No submission

No submission

No submission

0%

100% I

fA

IA

67.0% |

98.5% I

75.0% |

ioo.o%'|

92.87. |

100.0% I

100.0% ]

100

10G

IA

IA

100.C

90.;

83.:

1A

93.:

100.(

100.1

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10C

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IA

IA

JA

1A

JA

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^A

99°,

:''SK

^ 31"

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93.33'

99

.^5'

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I T I" r i T T -

Discontinued I 99%

Discontinue


SNFIC

Staff

Development

TCHC

lM Mar have all

laments

all Risk Care planning

'ost fall charting

omplete

'PD

umual PPE braining

3ME Cleaning

annual 1C in-sennce

land Hygiene

land Hygiene

3ME Cleaning

Vnnual PPD

\imual PPE

\imualIC

<TEO

Turn away

Controlled substance

program.

ControUingHighBP

85%

82%

921

JA

JA

IA

JA

JA

;TA

•IA

sTA

<IA

<TA

95°,

•JA

94?

100%

100%

100%

100%

100%

l00°i

100°<

100°i

80%

80%

100°1

85'),

90°,

100°,

;5%

80°,

50°

100.0% ]

ioo,o%|

100.07.1

100.0% I

100.0% I

7.4% |

ioo.o%|

86.7%]

77.0% |

0.0%|

100.0% I

100.0% I

100.0% I

100% I

2% I

100.0%

100.0%

100.0%

<IA

100.0%

32.0%

100.0%

92.6°i

79.0°i

41.0°<

100.0%

100.0°^

100.0%

100°,

6°,

•IA

^A

•}A

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78.0°i

76.5°!

100.0%

100.0°i

100.0»/

100°,

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100%

100%

100%

100%

100%

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100%~;ss

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ICOT

100?

100°,

100°,

4°;

95°

53° I:

100%

100%

100%

100%

4%

95%

53%

Color Key

Meets or Exceeds goal

Within 3% of meeting goal

missed goal but made

improvement

Hospital

Wide Pattentl

Safety Goals. I

Misses goal by >3% and

improvment

Patient identifiers

Hand Hygiene

OR has

arge

no large

California Transplant Donor Network

All Deaths

Eligible deaths

Hospital Referrals

Missed Referrals

Missed Imminent/

Eligible

3rt

3~0

3

0

0/0

Mov

2~0

2

0

0/0

Sec

1~0

1

0

0/0

Donor Network West

lan

2\~CT1

2|

0|

0/0

:eb

1~0

1

0

0/0

Mar

3~u

3

0

0/0

Apr

2~D

2

0

0/0

May

3~D

3

0

0/0

lun

0~0

0

0

0/0

lul

2~D

2

0

0/0

'\ug

40

4

0

0/0

Sep

3~0

3

0

0/0

Oct

3"0

3

0

0/0

Mov

1^0

1

0

0/0

Dec

2

Owned and Operated by


Policies Completing the Internal Review Process for May, 2016

In accordance with Mountain Communities Healthcare District guidelines for review and update for

administrative, operational and patient care poficies, I hereby certify the following:

Nursing patient care policies were reviewed by no less than the Chief Nursing Officer, Medical

Director, Interdisciplinary Practice Committee, Medical Staff Committee and Chief Executive

Officer.

Ancillary patient care policies were reviewed by no less than the Medical Director, Interdisciplinary

Practice Committee, Medical Staff Committee and Chief Executive Officer.

Operational and Administrative policies were reviewed by no less than the Department Manager,

Department Director and Chief Executive Of

Jennifer Van Matre,T5if@ctor5fFinance

All policies are maintained within the Navex Policy Tech system which is a secure, centralized and

auditable repository. Each approver has electronically approved each document within Navex

which ensures audit tracking and accountability for ali documents. The following is a listing of

policies that have completed the District's policy and procedure review and approval process and

are now ready for publication. Once the Board has approved the listing, a Board designee wiil

complete the electronic approval process in Navex allowing publication of the finai document.

Aaron Rogers, Chief Executive Officer

Jerry Cousins, Board President

(on behalf of the Board of Directors)

Document ID Group

6550 Board of Directors




6553 Board of Directora

6554 Board afDireclors





6823 Board of Directore

5954 Board of Direclors


G559 Board of Directors











6563 Board of DErectora












5973 Board of DErecfore






6573 Board of Dlrectore






6575 Board of Dlrectore



8758 Board of Dlrectora



6578 Board of Directore

6655 Board of Dirsctore

6579 Board of Direclore









SiteMountain Communities Heaithcare District

Mountain Communities Hea!thcare District


Mountain Communities HeaSthcare District

Mountain Communities Heaithcsre District


Mountain Communities Heafthcare District




Mountain Cammunittes Heafthcare District














Mountain Communities Heallhcare DIslricfc


Mountain Communities Keallhcare District

Mountain Communities Hea)thcare District


Mountain Communities Heaithcare Dislrict


Mountain Communities Heallhcare District


Mountain Communities Heaithcare District

Mountain Communiyes Heallhcare District














Mountain Communities Heallhcare District

Mountain Communities Heaithcars District


Mountain Communities Heailhcare District







Mountain Communities Healthcsre District


Mountain Communities Heailhcare District

Mountain Cammunlties Healthcare District




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MOUNTAIN COMMUNITIES HEALTHCARE DISTRICTMEETING MINUTES

BOARD MEETING

April 27, 2016

6:00 p.m.

Trinity County Library

Weavendlle CA

DISTRICT BOARD MEMBERS

GERALD BRASUELL DEROFORSLUND JERRY H. COUSINS LYNN JUNGWIRTH FRANCIS MOORE

Vice-President Clerk President Treasurer Member

Note: These minutes contain a description for each item to be considered. Supporting documentation is

available in the public packet at the Board meeting or at the Administrative Office at Trinity Hospital.

District Board Members Present:

Dero Forshmd, Clerk

Gerald Brasuell, Vice-President

Jerry H. Cousins, President

Lymi Jungwirth, Treasurer

Francis Moore

District Board Members Absent:

None

Staff Present:

Aaron Rogers, CEO

Peggy Manning, RN, Chief Nursing Officer

Jeamie Silvers, Executive Assistant

Jennifer Van Matre, Director of Finance

Michael Novak, PA, Director of Clinic Services

Donald Krouse, MD, Vice Chief of Staff

6LOO_PM CALLS MEETING TO ORDER IN OPEN SESSION

Report from Closed Session on March 30,2016

The Board entered into closed session at 6:54 pm on the following:

• MEDICAL STAFF PRIVILEGES


Section 1461

The Board came out of Closed Session at 7:00 pm and immediately reconvened ia Open Session.

Treasurer Jungwirfh reported that the Board reviewed the recommended actions on Medical Staff Privileges. For each

applicant the followmg mformation has been reviewed and/or verified:

Privilege List, NPDB Report, and AMA Profile, peer references and verifications of staff privileges at other facility and

ongoing professional practice evaluations. Items verified were Liability Insurance Coverage, Licenses, Certifications, and the

Medicare exclusion list was checked.


Board of Directors Board Meeting

April 27, 2016

On motion of Director Moore seconded by Director Forslund approves the following appomtments/reappointments and

accepts the resignations upon the recommendation from the Medical Staff.

Appointments/Reappoititments:

Frank Welte, MD Provisional Staff Specialty: Emergency Medicine

Alison Robiaetter, MD Consultmg Staff Specialty: Tele-radiology

Resignations

Clara Gordon, PA

Stanley Nyarko, MD

The motion passed with the following voice vote:

Ayes: Dero Forslund; Lynn Jungwirth; Francis Moore

Noes: None

Absent: Gerald Brasuell; Jerry Cousins

Abstain: None

Public Input - SNF Closure and Special Focus Facility Program

Reports

Medical Staff Report

Received written /verbal report from Daniel Harwood, MD, Chief of Staff and/or Donald Krouse, MD,

Vice Chief of Staff on the Trinity hospital Medical Staff. Other items discussed:

• Donald Krouse, MD and Randall ]V[eredith, MD have been reviewing the plans for the clinic

expansion with Michael Novak, PA.

Chief Executive Officer

Received written /verbal report from Aaron Rogers, CEO on the current operations of the hospital.

a Letter from Noridan regarding SNF closure. Our attorney is reviewing the letter and whether the

statute referenced applies to our facility.

Chief Financial Officer

Received written /verbal report from Jon Marshall, CFO and Jennifer Van Matre, Director of Finance,

on the current financial states and current status of revenue cycle management and accounts receivable.

Other items discussed:

» Our line of credit with Redding Bank of Commerce will not be renewed. Staff is researching

other options.

Chief Nursing Officer

Received written/verbal report from Peggy Maiming, RN, CNO on the current status of the nursing

departments.

® Pyxis medication system will be installed and ready for staff to implement on April 28., 2016



April 27,2016

Quality Improvement

Received written/verbal report from Sarah Cordtz, RN, Coordinator, Q/RM on the cuiTent status of the

Quality Program. The Board reviewed the data which included the Annual Critical Access Hospital

Evaluation for 2015.

Consent Agenda

All matters listed under the Consent Agenda, are considered by the Board to be routine, and will be

enacted by one motion in the fonn listed below. There will be no separate discussion of these items

unless a request for discussion is made prior to the time the Board votes on the motion to approve.

On Motion of Director Brasuell and seconded by Director Jungwirth approves the following consent

items:

a. Policies and Procedures - See Attached


Ayes: Dero Forslund; Gerald Brasuell; Jerry Cousins; Lymi Jungwirth

Francis Moore

Noes: None

Absent: None

Abstain: None

Discussion Items

a. Clinic

Michael Novak, PA reported that there was a meeting with Jack Freeman regarding the floor

plan, rendering and use permit for the clinic expansion on Monday. The expectation is that

we will be able to submit the use permit to the Planning Commission in June.

There was a 20% increase in visits at the Hayfork Community Health Clinic last month and a

10% increase at the Trinity Community Health Clinic.

There are three practitioner interviews scheduled. Telemedicine is increasing every month

and we have had a good response for visits with the dietician. In the near future, there will

be a Certified Nurse Midwife applying for privileges to work one day per week in the clinic.

b. Parcel Tax

Aaron Rogers reported that he met with Catherine Lew from "The Lew Edwards Group"

regarding collaboration for the vote to renew the parcel tax.

Action Items

a. Items removed from the Consent Agenda

None

b. Minutes from April 13,2016

On Motion of Director Brasuell and seconded by Director Jungwirth approves the

minutes from April 13, 2016



April 27, 2016


Ayes: Dero Forslund; Gerald Brasuell; Jerry Cousins; Lynn Jungwirth

Francis Moore

Noes: None

Absent: None

Abstain: None

c. Minutes from March 30,2016

On IVIotion of Director Forslund and seconded by Director Moore approves the minutes

from April 13, 2016


Ayes: Dero Forslund; Gerald Brasuell; Jerry Cousins; Lynn Jungwirth

Francis Moore

Noes: None

Absent: None

Abstain: None

Board Reeprts

Director Jungwirth reported that the residents ofHayfork have expressed that they are excited about the

changes at the Hayfork Community Health Clinic. The CEO from Southern Trinity has stated that they

now have resources to expand but does not want to infringe on services that we already offer.


Closed Session

The Board entered into closed session at 6:45 pm on the following:

9 MEDICAL STAFF PRIVILEGES


Section 1461

• QUALITY IMPROVEMENT/RISK MANAGEMENT

Government Code Section 54962: Health and Safety Code

Section 32155

» PUBLIC EMPLOYEE PERFORMANCE EVALUATION

Government Code Section 54957 - Public Employee

Title: Chief Executive Officer

The Board came out of Closed Session at 7:45 pm and immediately reconvened in Open Session.

President Cousins reported that the Board reviewed the recommended actions on IVledical Staff

Privileges. For each applicant the following information has been reviewed and/or verified:

4



April 27, 2016

Privilege List, NPDB Report, and AMA Profile, peer references and verifications of staff privileges at

other facility and ongoing professional practice evaluations. Items verified were Liability Insurance

Coverage, Licenses, Certifications, and the Medicare exclusion list was checked.

On motion of Director Moore seconded by Director Forslund approves the following

appointments/reappointments and accepts the resignations upon the recommendation from the Medical

Staff.

Appomtments/Reappointments:

Jon Fong, DO

Aymel Tarar, MD

Paulalan Genstler, MD

Robert Evans, MD

Aaron Castro, MD

Andrea McCullough, MD

Kevin McDoimell, MD

Provisional Staff

Provisional Staff

Provisional Staff

Provisional Staff

Provisional Staff

Provisional Staff

Consulting Staff

Specialty: Emergency Medicine






Specialty: Tele-radiology


Ayes: Dero Forslund; Gerald Brasuell; Jerry Cousins; Lynn Jungwirth; Francis Moore

Noes: None

Absent; None

Abstain: None

QUALITY IMPROVEMENT/RISK MANAGEMENT

President Cousins reported that the Board thoroughly reviewed the quality data presented and there no

action was taken.

PUBLIC EMPLOYEE PERFORMANCE EVALUATION

President Cousins reported that the Board discussed the evaluation of the Chief Executive Officer.

Adjourn:

There being no further business, the meeting was adjourned at 7:50 p.m.

Dero Forslund, Clerk of the Board

Mountain Commimities Healthcare District

MOUNTAIN COMMUNITIES HEALTHCARE DISTRICTMEETING MINUTES

"SPECIAL" BOARD MEETING

May 10,20166:00 p.m.

Trinity Hospital

Weaverville CA

DISTRICT BOARD MEMBERS

GERALD BRASUELL DERO FORSLUND JERRY H. COUSINS LYNN JUNGWIRTH FRANCIS MOORE

Vice-President Clerk President Treasurer Member

Note: These minutes contain a description for each item to be considered. Supporting documentation is

available m the public packet at the Board meeting or at the Administrative Office at Trinity Hospital.

District Board Members Present:

Dero Forslund, Clerk

Gerald Brasuell, Vice-President

Jerry H. Cousins, President

Lymi Jungwirth, Treasurer

Francis Moore

District BoardMembers Absent:

None

Staff Present:

None

10:30 AM CALLS MEETING TO ORDER IN OPEN SESSION

Public Input - None


Closed Session

The Board entered into closed session at 10:31 am on the following:

• PUBLIC EMPLOYEE PERFORMANCE EVALUATIONGo'vermnent Code Section 54957 — Public Employee

Title: CMef Executive Officer

The Board came out of Closed Session at 11:45 am and immediately reconvened in Open Session.


Board of Directors "Special" Board Meeting

May 10, 2016

PUBLIC EMPLOYEE PERFORMANCE EVALUATION

President Cousins reported that the Board discussed the evaluation for the Chief Executive Officer.

Adjourn:

There being no further business, the meeting was adjourned at 11 :46 a.m.

Dero Forslund, Clerk of the Board


Department Health Care ServicesPrimary, Rural, and Indian Health Care Division

Small Rural Hospital Improvement ProgramAuthorization to Bind

The Authorization to Bind permits the designee(s) listed below to negotiate and sign the SmallRural Hospital Improvement Program Application and/or Grant Agreement for any paymentrequests that may result.

The Board of Directors of Mountain Communities Healthcare , in a duly executed meeting and

held on ygy 25, 2016 where a quorum was present, resolved to authorize:

Aaron Rogers ^^ designee Jennifer van Matre

(Typed Name) (Typed Name)

Chief Executive Officer Director of Finance

(Title) (Title)

(Signature) (Signature)

The undersigned hereby affirms he/she is a duly authorized officer of the corporation andstatements contained in this application package are true and complete to the best of the his/herknowledge, and accepts as a condition of a grant award the obligation to comply with theapplicable state and federal requirements, policies, standards, and regulations. The undersignedrecognizes this is a public document and open for public inspection.

Authority to contract:

If someone other than the corporate board of director's chairperson is to negotiate and sign anyresultant grant of this application, a letter of agreement and authorization must be signed anddated by the board of director's chairperson, indicating the name of such person and stating thatperson's area of responsibility in this matter.

Board Chairperson: jerry H. Cousins

(Typed Name)

(Chairperson's Signature)

(Date)

Board ChairpersonMailing Address: P 0 Box 1229

City: Weaverville

Zip Code: gg093

Please mail one original copy to Department of Health Care Services, Primary, Rural, and Indian

Health Division, 1500 Capitol Avenue, Suite 72-338, MS 8502, Sacramento, CA 95899-7413 and

e-mail or fax a duplicate copy- (916) 449-5777.

Reset Form Print Form

To: Mr. Aaron Rogers/ CEO


From: Catherine Lew, CEO

The Lew Edwards Group

Date: May 12, 2016

Re; DRAFT Proposal/Background Document

Dear Aaron:

Thank you for convening such a helpful team of folks for our call last week. The Lew Edwards

Group (LEG) is looking forward to another effective collaboration with Mountain Community

Healthcare District (MCHD) for its 2016 No Tax Increase Funding Renewal.

This document includes the following:

-As our firm is not new to the District but the two of us haven't worked together before/ background

and typical scope of services on our firm

-Background on LEG'S past collaborations with the District

-Thoughts and perspectives on the upcoming environment

This document should be treated as a discussion draft which is not for public dissemination.

Following our discussion/ this draft will be refined so it is appropriate as a final document.

ABOUT THE LEW EDWARDS GROUP

The Lew Edwards Group (LEG) offers significant expertise m effective California public revenue

measure preparation and healthcare election preparation. A collaboration with LEG in 2016 offers

MCHD the following:

•^ A successful track record of success in California revenue, healthcare communications and

revenue projects;

^ Understanding unique opportunities, risks/ and sensitivities related to California revenue and

public healthcare measures specifically;

m

^ Strong experience and success in mountain and rural communities and districts;

^ Extensive experience enacting tough finance measures— more than $33 Billion enacted in

California revenue measures, with a. 95% success rate;

^ Nationally recognized/ award-wirming communications products and experience

developing effective community communications plans; and

^ A community and stakeholder-supportive management style in workmg effectively to meet

your revenue objectives.

The Lew Edwards Group (LEG) is a top California consulting firm providing revenue measure

preparation and strategic communications services and strategic advice to municipalities/ counties/

public agencies/ special districts, and healthcare clients.

LEG'S clients benefit from its experienced team of communications experts, who between them have

decades of experience in cutting edge strategies and tactics. The firm and its specialists represent

public agencies (cities, counties/ and special districts) and healthcare clients throughout California.

Pertinent Healthcare Experience

In 2005 and 2006, L£G zoas pleased to represent TPUD/M.CM.S in their effort to successftilly establish M.CHD

and pass its parcel tax through Measures 0 &' P. In 2010 and 2011, LEG was also pleased to collaborate with

M.CHD on its effort to enact M-easin'e T to continue that local funding measure/ with NO increase in tax

rate.

The Lew Edwards Group also led efforts on behalf of Proposition BB for San Diego County's Palomar

Pomerado Health, CaUfornia's larsest Public Healt'hcare District raisins $496 Million, the larses-t Svecial

District Hospital Bond in California history. In addition, LEG has represented the followmg healthcare

organizations in their revenue and communications efforts: Palm Drive Healthcare District

(Sonoma County); Tri-City Healthcare District (San Diego County); Antelope Valley Healthcare

District (Los Angeles County); Catholic Healthcare West (Santa Clara County); Sierra Kings

Healthcare District (Tulare County); Sutter Health (Alameda and San Francisco Counties); Kaiser

Permanente (Santa Clara, Marin and San Francisco Counties); Alta Bates Medical Center (City of

Berkeley); Summit Hospital (City of Oakland); and St. Luke's Hospital (City of San Francisco).

For a comprehensive list of LEG clients, visit i^Q^vilewedj^ardsgnxip^coM

LEG'S typical scope of services uicludes:

• Recommend a community outreach plan to expand awareness of the Hospital's current funding

and service needs and what is at stake;

• Conceiving, writing and producing informational brochures/ letters, mailers, presentation

materials, and advertising;

• Recommending an overall timeline and project budget;

• Recommending/identifying other professionals as needed;

® Working with MCHD's Special Counsel on the ballot question and other submittals during all

phases of project planning/ to ensure that effective communication as well as legal requirements

are met; and

® Developing an Earned (nonpaid) Media plan for informational press coverage.

The Lew Edwards Group continues to recommend the firm of FM3 Research — one of California's

leading public opinion research firms/ to meet MCHD's needs as the District plans for its measure.

VM3 conducted two community surveys in your previous planning, leading to the successful

outcomes in Measures 0/P and Measure T. FMS's extensive healthcare experience includes several

joint projects with LEG cited above, and others such as Scripps Health/ Saint John's Health Center/

UCLA Medical Center/ Northern Inyo County Hospital District, the American Hospital

Association/ the Arizona Hospital and Healthcare Association, the Community Hospitals of

Central California/ Community Medical Centers, Downey Community Hospital/ Fountain Valley

Hospital/ Jackson Memorial Hospital (Dade County, Florida)/ John Muir Hospital, Mills Peninsula

Health Services/ the Northern Inyo County Hospital District/ Valley Care Health System/ and the

Washington State Hospital Association.

Both LEG and FM3 offer institutional knowledge of your District and its past successful planning

efforts/ an unmatched combination of in-depth experience with healthcare as an issue and successful

California revenue measures of all types.

OVERALL ENVIRONMENT FOR CALIFORNIA REVENUE MEASURES

Environment

As we discussed last week:

• Since our Measure T collaboration, additional healthcare districts have shuttered. Others have

not been successful at the ballot box/ most recently Kaweah Delta Local Health Care District

(not a LEG client).

• Voters continue to be concerned about the economy and "government handouts." And the

upcoming Presidential election presents both an opportunity and a risk. On the one hand, a

high turnout election will bring diverse constituencies to the ballot, which typically favors a

two-thirds requirement measure. On the other hand/ in your region's case/ the message of one

of the Presidential candidates may draw larger numbers of anti-establishment or angry voters

to the polls/ which could be a wildcard factor in your case. In the last two even numbered

November election years (2012 and 2014), only 44% and 48% of two-thirds requirement taxes

for Special Districts passed.

• However/ LEG still finds that messages and information that speak to the issue of all parcel tax

funds staying local/ and none of the money going to Sacramento/ remain compelling to voters.

And as in our past collaborations/ it will be necessary to create an appropriate and compelling

sense of urgency as to the information about the consequences to the Hospital if the parcel tax

is not renewed.

HIGHLIGHTS OF PAST MCHD PLANNING

This section will address LEG'S scope of legally-permissible services related to our past collaborations

with MCHD.

Measures 0/P (High Turnout Election)

® A baseline public opinion research survey was conducted by FM3 Research to assess measure

viability, tax tolerance, and areas of concern for the community/ mduding a hypothetical ballot

question approved by Counsel which was tested. Baseline survey results were utilized by all

parties to inform, the basis of the planning and to craft informational messages to educate the

public,

® A Community Outreach Plan was developed which included the following components:

o A message focused exclusively in potential Hospital closure and the availability of a 24-

hour Emergency Room.

o Informational community materials/ including Powerpoint presentation materials/ flip

charts. Frequently Asked Questions, and website copy.

o Five Town Hall meetings were conducted (in addition to smaller organizational

presentations and one-on-one Key Influential outreach) in Junction City/ Lewiston/

Trinity Center/ Hyampom/ and Hayfork.

o Regular media releases and media placements.

o Key Influential updates.

o Seven district informational (nonadvocacy) mailers paid for by MCMS/TPUD, in

addition to the two mailers developed by Trinity Cares.

• Following all of these activities/ a tracking survey was conducted to reassess support and

finalize effective ballot measure language prior to placing the measures on the ballot.

® Once the measures were placed on the ballot:

o MCMS/TPUD continued legally-permissible informational efforts up until Election Day/

including the mailings and outreach activities described above,

o Per California law, a public hearmg was conducted in the event that the measures failed

and the Hospital needed to close.

o Kevm Cahill and Trinity Cares identified 2000 supporters and hundreds of endorsers,

and effectively localized the message. Both the Trinity Journal and Record Searchlight

endorsed the measures.

Measure T (Low Turnout Election)

An updated baseline public opinion research survey was conducted by FM3 Research which revealed

that:

o Respondents exhibited cost-sensitivity, leading to our recommendation that no increase

to the tax rate be made

o Defining the issue as one of "Keeping Trinity Hospital Open" was critical to our

branding

o The Hospital's favorability rating had increased and for those that had utilized the

Hospital, quality of care remained consistently positive

o However/ 21% fewer respondents than in. 2005 felt that the lack of adequate emergency

care is an extremely or very serious problem

o The top priorities for Parcel Tax spending were:

• Continuing to provide 24-hour emergency care at Trinity Hospital, with a doctor

on duty

" Continuing to provide emergency medical care locally/ rather than an hour to 90

minutes away

• Keeping Trinity Hospital open

• A Community Outreach Plan was developed which included:

o Branding the message of Keeping Trinity Hospital Open

o Informational community materials were developed similar to the 2005/2006 effort

o There was a greater emphasis placed on Letters to the Editor and media release

coverage

o As it was a low turnout election and the Renewal was the only item on the ballot/ only

two district informational (nonadvocacy) mailers were disseminated in. addition to the

mailers developed by Trinity Cares

® Trinity Cares identified 700 supporters through its advocacy efforts (the number was lower as

it was a low turnout election)

KEY CONSIDERATIONS & RECOMMENDED ACTIVITIES MOVING FORWARD

Demographic Considerations

Previous polling showed that support for your past measures was highest among women/ older

voters, and No Party Preference voters. Women will constitute half of your electorate/ voters age 65+

two-thirds/ and NPP voters about 30%.

Essential Planning and Outreach Activities

The approach previously deployed by our team on behalf of MCHD has continued to be critical to the

success of our revenue measure clients in. today's challenging economic environment. The District's

2016 No Tax Increase Renewal Program will need to include the following components/scope of

services:

1. Update Public Opinion Survey Research

As we discussed, it will be necessary for MCHD to invest in an updated community survey as the

first step tn your Renewal process^ to assess and evaluate current attitudes and how they have shifted

or evolved over the past five years/ identify specific information that constituents need to know about

your parcel tax renewal, and to re-assess tax tolerance, sunset, exemption and other issues. Doing so

will allow our team to:

^ Statistically assess preferences and attitudes across different demographic categories,

mcluding evaluating similarities and differences among your voters geographically/ by age,

party affiliation, gender/ and income, among other factors;

^ Evaluate how to maximize opportunities and minimize risks;

^ Assess today's tax tolerance and other parcel tax nuances (sunset clause/ exemption, inflation

factor/ oversight/ etc.)/ to determine the most acceptable proposal for your public at this time;

^ Fully test a variety of informational messages m the research, allowing MCHD to identify and

understand the information/messages your constituents need at this time;

^ Inform the development/ refinement and deployment of MCHD's Community Outreach

Program to maximize the feasibility and viability of your Parcel Tax Renewal.

LEG and FM3 will work in close consultation with MCHD on the design of the survey questionnaire.

Several drafts of the survey will be developed to ensure that we fully explore all the information

desired by MCHD in an impartial, third party fashion that independently assesses the feasibility of

your Parcel Tax Renewal.

Please note that how people receive or respond to information, including survey research/ has

changed dramatically since our 2010-2011 collaboration. As such/ far fewer people answer their

landlines or even cell phones. An innovation that FM3 has implemented smce 2011 is that all

interviews are now done both by telephone (landline and cell), AND online/ which is called a "dual-

mode survey."

2. Recommend and Implement Community Outreach Program

Following the updated baseline survey/ LEG will evaluate survey results and can develop the

following strategies:

• Identify Key Informational Messages

• Develop an Outreach Communications Plan to Internal/External Stakeholders

® Conceive a Direct Mail/ Paid Media/ and Earned IVtedia Plan

® Design an Orgardzing/Outreach Plan to Build Awareness of What's at Stake and Current Needs

a Develop Community Presentation/Information Mlaterials

a Conduct Communications Training for Staff/Stakeholders

Project Components would be implemented with the following objectives:

a Effectively Frame the issue

a M.ethodicall-y Inform &' Educate Key Audiences and Stakeholders

» Effectively Address Community Questions

• M.axmme and. increase Awareness of Hospital Needs

Develop Informational Messages. The updated public opinion research will identify informational

messages that resonate with the public and their attitudes towards various aspects of the Parcel Tax

Renewal. Messages that effectively explain information to the community will be maximized to their

fullest effect in a disciplined and focused fashion. As noted, in 2011 the key message was Keeping

Trinity Hospital Open.

Implement a focused Communications Plan to key Opinion Leaders. This component of the plan is

primarily targeted to Key Influentials and stakeholders within the District:

c Develop regular Informational Updates.

a Produce visual aids for a Speakers' Bureau.

® Write "Keep Trinity Hospital Open" fact sheets.

• Develop "Commonly Asked Questions &' Answers."

Conceive a Direct Mail and Earned Media Plan. As m our 2006 and 2011 plarmmg, LEG

recommends that an informational direct mail program be implemented/ to educate your community

on current Hospital needs. The topics and information provided in these mailings is determined by

the updated community survey. Implementing these mailings is particularly important as your

District is geographically diverse, comprised of unique communities, and not concentrated within a

concentrated urban core, making various and methodical forms of communications critical.

As in the past/ any information provided m these mailings is factual, not advocacy/ and would be

approved by the District's Special Counsel. An example of a past mailing is contained in the

Appendix.

In balancing the need for these mailings to provide information in an "alphabet soup" of a busy

election and communications environment, for planning purposes we would suggest three

informational mailings as being prudent, though polling results could dictate that additional

education is necessary. Remember that there will be as many as two dozen measures on the

November ballot.

Community Meeting Outreach Plan: As in the past/ LEG can provide MCHD with suggestions on

any Town Hall or other community engagement as needed.

3. Effective Presentation of the No Tax Increase Renewal Measure in the Voter Handbook

As in the past/ LEG will work with District Counsel on the wordmg and presentation of Voter

Handbook materials for viability. District Counsel will finalize and transmit all official documents to

the Registrar of Voters, but LEG will collaborate with Counsel to add critical value to these

documents.

CONSULTANT FEES and RECOMMENDED PROJECT COSTS

The below are what our records show as being spent by the District in our past collaborations. The

below reflects District budgeting only and does not include Trmity Care's separate expenditures.

Measure T

$45,000

$22/500-0-

$300

$15,000

$3,500

$86,000+

Proposed 2016 Planning Model

In the past two collaborations/ LEG consulted with the District through Election Day. For this

collaboration, in consideration of your frugal budget and the fact that this will be the District's third

partnership with LEG, we recommend only consulting with the District through the end of August to

Category of Expenditure

LEG Professional Fee

Baseline Survey

Tracking Poll

Mailing Data

Direct Mail

Travel/Out of Pocket NTE

TOTAL

Measures 0/P

$70,000

$25,000

$15/000

$1/500

$25,000

$3/500

$140,000

save money. We would then prepare all the collaterals needed by the District before our exit/ so that

the District can be self sufficient in the Fall weeks September through Election Day.

LEG'S proposed consulting fee for these services is $25,000, not including travel expenses/ as we

believe that it is possible to save money and time by doing our Message Training and other planning

through teleconference or Skype,

As m our Measure T collaboration/ the District needs to budget separately for its polling and mailing

costs. Last time/ the District contracted separately with FM3 Research and did its printing/mailing

locally through your own area vendors. LEG assisted by recommending the data universe and

graphics and the data/graphics providers billed the District directly.

In general/ LEG would recommend the following budget:

-As noted/ our professional services through August would be $25,000

-The District should budget $28/850 for polling (polling costs have increased because dual mode is

more expensive) through a separate contract with FM3 Research

-Data costs are likely to run about $300 again from the same data vendor the District has used

-The District should budget $6,000 for graphics if using the same artist the District has used

-As for printing/mailing, LEG has no idea what your area vendors would charge; the District should

get bids for printing/mailing about 3/500 units per mailing (three are recommended currently)

SAMPLE TIMELINE

MOUNTAIN COMMUNITY HEALTHCARE DISTRICT

SAMPLE TIMELINE As

MAY 2016

JUNE 2016

JULY 2016

LAUNCH PARTNERSHIP

Q Review additional District background information and media clips

1-1 Conduct KickOff Teleconference

Q Develop and finalize Opinion Research Survey

CONTINUE PREPARATIONS

Q Initiate survey interviews

LI Identify outreach engagement opportunities (District)

1.-1 Assess and update database of Opinion Leaders (District)

Q Update Speaker Training Materials

ASSESS CURRENT VIABILITY, PREPARE FOR MEASURE PLACEMENT

Q Complete survey interviews and analysis

a Present results to District Staff/ reach consensus on communications

approach

a Present results to Board

Q Assist with staff reports and measure preparation

Q Advise on Media Strategy

a Assist in preparing for Board adoption vote

AUGUST 2016

SEPTEMBER-

OCTOBER 2016

Q Media Updates

Q Community participation

PLACE MEASURE/ ADDRESS POST-PLACEMENT NEEDS

L] District Board acts to place measure on Ballot

Q Measure materials are submitted to County Elections Office by statutory

deadline of August 12th

Q Issue Opinion Leader Update announcing placement of the measure on

the ballot

1-1 Address Rapid Response Needs as necessary

1_] Draft Information Collaterals (Community Powerpoint/ FAQs)

Q Update District website and other informational vehicles (District) with

information developed by LEG

a Develop answers for community questions/ continue to update

communications/engagement materials

Q Update Speakers Message Training Toolkit

U Conduct Speakers Training

Q Copy write Opinion Leader updates and develop Mailer texts

MCHD opt to its

cannot in LEG at

POST ADOPTION ACTIVITIES

t-l Implement mformation-only presentations (District)

Q Implement Earned Media/Internet Communications

Q Issue three (3) informational ballot measure mailings

Q Address Rapid Response Needs as necessary

[-] Provide two-way media comments

1-1 Thank the community for participating in the election (District)^

APPENDIX

^oyn-htte CtHitEKtir^ie-tHs-<i^fn<ir» 0-ithlri

Dear

Trinity Hospital ensures that lite-saving, 24-bour emergency care with a

doctor on duty is avaitabte for you or someone you low.

Every year we have atmost 5,000 visits to our emcrgenc}' room, and

<iy-£r..A£,!3S.tfQMtJ?ar^1_rmin> HQspi|iiiJias_s3v.cd.soine,o!i.e_*»li{.c

255 times.

In addition to providing bigh-quality, 24-bour emergency care. Trinity

Hospital's tocat lab, ctinics and skilled nursing services ensure Aaf

residents and local businesses have access co cost-eftecriw primar)- and

preventive bealthcarc services.

• FutI-Swicc, Walk-in Rural Health Clinics in Weawn'aie and

Hayfork receive 12,000+ visits aiinuaUy.

• Local lab runs 200,000+ cluiicat tests and receives 6.000+ visits

annuaHy.

• Hospital performs almost 6,000 annual imaging procedures,

inctudmg x-ray, ultrasound, mobtle mammograph}', and CT scans.

Trinity Hospital is proud to be the comerstotic for emergency and

primary care in Trinity County and our doors are always open vvtwnever

you need us.

Please visit www.mcmc-dical.org for more information.

Sincerely,

^';^.Dc Hauk Edctsicin

Director, Trinity Hospital ER

A)Diane Rieke

Chief Nursing Officec, Truuty Hospitsd

Board MDeetins May 25, 2016bloximages.newyork1.vip.townnews.com/trinity...f'viT& a^,ci^, ^p May...

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Transcript of Board MDeetins May 25, 2016bloximages.newyork1.vip.townnews.com/trinity...f'viT& a^,ci^, ^p May...