CUERO Charles W. Papacek REGIONAL HOSPITAL...2020/07/23 · PAPRS - Powered Air Purifying Respirators. A quote from Owens & Minor for $30,112.60 was recommended. Mrs. Cindy Sheppard

CUERO REGIONAL HOSPITAL Lynn Falcone, CEO

2550 N. Esplanade • Cuero, Texas 77954

Board of Directors: Dr. John Frels

Charles W. Papacek Cindy Sheppard Faye Sheppard

Richard Wheeler

Quality Care. Close to Horne. (361) 275-6191 • Fax (361) 275-3999 • www.cuerohospital.org

NOTICE

BOARD OF DIRECTORS

CUERO REGIONAL HOSPITAL

The Board of Directors of the Cuero Regional Hospital will hold their regular monthly meeting via conference

call, Thursday, July 23, 2020, at 5:30 P.M. Board packet will be available online for viewing. The public toll-free

dial-in number and access code is 1-888-204-5987, Access Code 6265946 and will be available on the Cuero

Regional Hospital website - cuerohospital.org :

The subjects to be considered at such meeting are:

I. Call to Order

II. Community Input

Ill. Review of Minutes of the June 25, 2020 Regular Called Meeting

IV. Review of Financial Statement and Statistical Report

1. Financial and Statistical Report

2. Finance Committee Report

3. Quarterly Investment Report

V. Report from Chief of Staff

Appointments: Carolyn Dale Denton, DO, Family Practice, Nicholas Lemley, DO, Family Practice

Reappointments: Madeline Andrew, MD, Psychiatry, Neil Campbell, DPM, Podiatry, Hermelinda

Fitts, FNP, Family Practice, Azhar Malik, MD, Nephrology, George Osuchukwu, MD, Nephrology,

Ashesh Parikh, MD, Cardiology-Telemedicine, Gustavo Sandigo, MD, Sleep Medicine, Bruce

Scaff, MD, Emergency Medicine, Caroline Valdes, MD, Pathology, Cody Walthall, MD, Family

Practice

VI. Report from Marketing & Development Director - List of Advertising and Events

VII. Clinic Operations Report by Interim Clinic Administrator

VIII. Report on Quality/Safety, Finance and Community from Asst. Administrator

IX. Report Quality/Safety, People, Growth and Community from Chief Nursing Officer

X. Report on Quality/Safety, People, Growth and Community from Chief Executive Officer

XI. Report on Quality

XII. Compliance Update

XIII. Committee Reports

XIV. Old Business

1. Annual Audit Report and Board Education Tabled Until Otherwise Noted

XV. New Business

1. Capital Expenditure Request for Med Surg Wing Wall's in Handicap Showers - Review and

Take Appropriate Action

CUERO HEALTH

Cuero Regional Hospital • Cuero Home Health • Bfit Cuero Wellness Center

Cuero Medical Clinic • Goliad Family Practice • Kenedy Family Practice • Parkside Family Clinic • Yorktown Medical Clinic

1

Cuero Regional Hospital

Notice of Board Meeting

July 23, 2020

2. Capital Expenditure Request for Roof Replacement at Kenedy Clinic - Review and Take Appropriate

Action

3. Emergency Approved Capital Expenditure Request for 4 Addit ional Airvo Units - Review and Take

Appropriate Action

4. Emergency Approved Capital Expenditure Request for UV Disinfection Robot- Review and Take

Appropriate Action

5. Emergency Approved Capital Expenditure Request for Lucas-Chest Compression System - Review and

Take Appropriate Action

6. Emergency Approved Capital Expenditure Request for Goliad Clinic - Install New 320 Amp Electrical

Service to Clinic and Replace a 3-Ton & 4-Ton A/C Split System - Review and Take Appropriate Action

7. Authorization for the CEO/CFO to Sign Lease Agreements beyond the Methodist Healthcare System

Contract for Equipment less than $20,000.00 - Consider and Take Appropriate Action

8. November and December Board Meeting Dates - Consider and Take Appropriate Action

XVI. The Board reserves the right to retire into executive session concerning any of the items listed on this

Agenda, whenever it is considered necessary and legally justified under the Open Meetings Act, for:

• 551.071 Consultation with attorney regarding pending, potential litigation involving the Hospital

and/or Hospital District

• 551.072 Deliberations about Real Property to deliberate the purchase, exchange, lease, or value of

real property if deliberations in an open session would have a detrimental effect on the position of the

District

• 551.073 Deliberation Regarding Prospective Gifts or Donations

• 551.074 Personnel matters relating to the appointment, employment, evaluation, discipline or

dismissal of an officer or employee

• 551.076 Deliberation regarding security devices

• 551.085 Discussion of pricing and/or financial planning information related to negotiation for the

arrangement of provision of services or product lines for DeWitt Medical District and proposed new

physician services for DeWitt Medical District, and any other non-profit health maintenance

organizations under the umbrella of DeWitt Medical District.

XVII. Communications

XVIII. Adjournment

I certify that, in compliance w ith the Texas Open Meetings Act , I provided this notice of th is meeting to the DeWitt County Clerk and posted this agenda at

the designated location at the DeWitt County Courthouse, Cuero, Texas, and also at the designated location for the City of Cuero and by the switchboard

on the first floor of Cuero Regional Hospital, 2550 N. Esplanade, Cuero, Texas 77954 and online at cuerohospital.org by 5:00 p.m. on the 20th day of July,

2020. <

2

CUERO REGIONAL HOSPITAL BOARD OF DIRECTORS MEETING

June 25, 2020

The Board of Directors of Cuero Regional Hospital held their regular monthly meeting, via conference call, on Thursday, June 25, 2020, Cuero Regional Hospital, DeWitt County, Texas, at 5:30 P.M. The agenda was posted in compliance with the Open Meetings Act. A board packet was posted online at cuerohospital.org, along with a dial in Toll-Free number and access code.

Board members present via conference call were: Mrs. Faye Sheppard, Vice Chairman Mr. Charles Papacek, Secretary Dr. John Frels, DDS, Member Mrs. Cindy Sheppard, Member, joined after the minutes were approved

Board members not present were: Mr. Richard Wheeler, Chairman

Leadership members present were: Mrs. Lynn Falcone, Chief Executive Officer Mrs. Alma Alexander, Chief Financial Officer Mrs. Judy Krupala, Chief Nursing Officer Mrs. Denise McMahan, Assistant Administrator Dr. Paul Willers, II, Chief of Staff, arrived after financial report was given Dr. David Hill, Chief Medical Officer Mrs. Kathy Simon, Administrative Assistant

Guests via conference call: Ms. Allison Flores, Cuero Record, Mrs. Tamy Hackney, HR Director, Mrs. Judy Mazak, ED Director and Mrs. Ismelda Garza, IT Consultant

The Board Vice Chairman called the meeting to order at 5:35 p.m.

Community Input: None

Mr. Papacek moved, Dr. Frels seconded, to approve the minutes of the Annual meeting on May 28, 2020 and the Regular called meeting on May 28, 2020 as presented with the addition of clarifying on page 2 of the Regular minutes that it was Mrs. Faye Sheppard that made the note regarding the community support; the motion carried unanimously.

The Chief Financial Officer's Financial Statement and Statistical Report were provided. The Chief Financial Officer spoke on hospital financials and on clinic financials. The reports were accepted as presented.

Dr. Frels moved, Mr. Papacek seconded, based upon the recommendation of Medical Staff, to approve the initial appointments (limited to the privileges delineated) for the Rad

CALL TO ORDER

COMMUNITY INPUT

MINUTES

FINANCIAL/ ST A TISTICAL

MEDICAL STAFF

3

Cuero Regional Hospital Board of Directors Meeting

2

Partners Tele-Radiologists as presented on page 3 of the agenda (copy provided at the end of this document); the motion carried unanimously.

Mr. Papacek moved, Dr. Frels seconded, based upon the recommendation of Medical Staff, to approve the two year re-appointments (limited to the privileges delineated) as presented on the agenda for Thao Duong, MD, Tele-Cardiology, Chet Schwab, MD, Pathology, Fazila Siddiqi, MD, Psychiatry; the motion carried unanimously.

The Marketing and Development Director report was provided and consisted of a list of advertising and current events.

The Interim Clinic Administrator's report regarding operations was provided. Mrs. Falcone noted that Dr. Lemley and Dr. Dale Denton will start August 3, 2020.

The Assistant Administrator's report on Quality/Safety, Finance, and Community was provided.

The Chief Nursing Officer's report on Quality/Safety, People, Growth and Community was provided. She also shared that a Root Cause Analysis (RCA) for patient falls was being performed. Jill Saenz is leading this team. The RCA is a structured facilitated team process to identify root causes of an event that resulted in an undesired outcome and develop corrective actions. The RCA process provides a way to identify breakdowns in processes and systems that contributed to the event and how to prevent future events. The purpose of this RCA is to find out what happened, why it happened, and determine what changes need to be made.

The Chief Executive Officer's report on Quality/Safety, People, Growth and Community was provided.

The Quality report was reviewed.

The Assistant Administrator reported that she completed a Compliance Program Self-Assessment and is currently working on the action plan for some deficiencies that were discovered. A copy of the Self-Assessment will be provided at next month's board meeting. She also reported that the hospital did have a HIPPA occurrence where a patient's lab work was faxed to the wrong nursing home. The lab had just received a new fax machine and the nursing home fax number was programmed to the wrong nursing home. This error has been corrected.

Committee Reports: None

Old Business:

The Board Vice Chairman requested the board to again table the Annual Audit Report and board education by BKD, LLC until the board is able to meet in person. Dr. Frels moved, Mr. Papacek seconded, to table the BKD, LLC Annual Audit Report and board training until the board can meet in person or other arrangements can be made; motion carried unanimously.

MARKETING

CLINIC LEADERSHIP

ASST. ADMIN. REPORT

CNOREPORT

CEO REPORT

QUALITY

COMPLIANCE

COMMITTEE REPORT

ANNUAL AUDIT BKD,LLC

4

New Business:


3

The Board reviewed the Human Resources Annual Report for 2019. The report reflected the recruiting; turnover; terminations; resignations; credentialing; and patterns, issues and trends. Mr. Papacek moved, Mrs. Cindy Sheppard seconded, to accept the 2019 Human Resources Annual Report as presented; the motion carried unanimously.

The amount disbursed for indigent care out-of-hospital expenses as of May 31, 2019 is approximately $79,000.00. The program limit is $100,000.00. The CFO made a request for the board to extend the program past the $100,000.00 limit for this fiscal year. Dr. Frels moved, Mr. Papacek seconded, to extend the indigent care program expenses an additional $50,000.00 for this fiscal year, raising the program limit to $150,000.00; the motion carried unanimously.

The Chairman of the Board requested that we designate a representative to the Planning Commission for the Golden Crescent Regional Planning Commission. After discussion, Dr. Frels moved, Mrs. Cindy Sheppard seconded, for Mr. Papacek to continue as the hospital district's representative to the Planning Commission; motion carried unanimously.

The Chief Executive Officer and Senior Leaders gave a revised informational overview regarding current Capital Risks and answered related questions from the board.

The Chief Nursing Officer requested the capital expenditure purchase for CAPRS/ PAPRS - Powered Air Purifying Respirators. A quote from Owens & Minor for $30,112.60 was recommended. Mrs. Cindy Sheppard moved, Dr. Frels seconded, to approve the capital expenditure purchase up to $30,112.60 from Owens & Minor for Complete System Powered Air Purifying Respirators; motion carried unanimously.

The Assistant Administrator requested the capital expenditure purchase of High Flow Nasal Cannulas. A quote from Fisher & Paykel for $11,994.90 was recommended. Mr. Papacek moved, Mrs. Cindy Sheppard seconded, to approve the capital expenditure purchase up to $11,994.90 from Fisher & Paykel for 2 Airvo Fisher & Paykel high flow heat moisture exchange units with variable FI02 for treatment of COVID patients; motion carried unanimously.

The Chief Nursing Officer requested the capital expenditure purchase of a New Patient Telemetry Monitoring and Surveillance System for the ICU and ED. A quote from Spacelabs for $169,651.83 was recommended. Mrs. Cindy Sheppard moved, Dr. Frels seconded, to approve the capital expenditure purchase up to $169,651.83 from Spacelabs for a New Patient Telemetry Monitoring and Surveillance System; motion carried unanimously.

The Chief Financial Officer and Mrs. Ismelda Garza, IT, requested the capital expenditure purchase for Network Remediation - Implement Backup Solution for Disaster Recovery. This was a budgeted item as part of original request and is one part of Phase III of this project. A quote from Edge for $273,420.94 was recommended. Mr. Papacek moved, Mrs. Cindy Sheppard seconded, to approve the capital expenditure purchase up to $273,420.94 from Edge for Network Remediation - Implement Backup Solution for Disaster Recovery; motion carried

ANNUAL HR REPORT

EXT. INDIGENT CARE PROGRAJ

GCRPC REPRESENT A Tl DESIGNATION

REVISED CAPITAL RISK

PAPRS

HIGHFLOW NASALCANNU

TELEMETRY SYSTEM

NETWORK REMEDIATION BACKUP FOR DISASTER RECOVERY

5

unanimously.


4

Mrs. Wilma Reedy, Childbirth Director, presented a resolution of support by the board to approve the Perinatal Program Plan for Maternal Designation. Mrs. Cindy Sheppard moved, Mr. Papacek seconded, to sign in support and approval of the Perinatal Program Plan for Maternal Designation. It was noted, that Mrs. Faye Sheppard did speak with Mrs. Reedy and Mrs. Judy Krupala and they made a few changes to the Perinatal Program Plan regarding "neonates post discharge." It was also noted the plan needed to be updated on current hospital letterhead.

There was no further business; Mr. Papacek moved, Mrs. Cindy Sheppard seconded, to adjourn; the motion carried unanimously. The meeting adjourned at 6:22 p.m.

Faye Sheppard, Chairman Charles Papacek, Secretary

PERINATAL PROGRAMPLA MATERNAL DESIGNATION

ADJOURN

6

CUERO REGIONAL HOSPITAL FINANCIAL STATEMENT SUMMARY

Financial Summary - JUNE 2020

EBIDA – Hosp. Only $795,839 $239,674 $556,165 $113,434 $682,405 $10,270,593 $6,799,666 $3,470,927 $6,232,949 $4,037,644

Net Operating Income – Hosp. Only ($23,938) ($235,603) $211,665 ($252,542) $228,604 $963,758 ($1,877,814) $2,841,572 ($1,238,682) $2,202,440

Clinic - Net Operating Income ($16,287) $3,328 ($19,615) $23,034 ($39,321) ($11,396) $48,708 ($60,104) $334,375 ($345,771)

EBIDA Consolidated $779,552 $243,002 $536,550 $136,467 $643,085 $10,259,198 $6,848,374 $3,410,824 $6,567,324 $3,691,874

Net Income - Consolidated $573,179 $35,491 $537,688 ($31,314) $604,493 $8,439,641 $4,980,785 $3,458,856 $5,029,009 $3,410,632

Net District Tax Revenue $18,122 $0 $18,122 $38,798 ($20,676) $4,323,969 $4,400,000 ($76,031) $4,030,351 $293,618

Nursing Home Revenue $595,281 $267,766 $327,515 $159,397 $435,884 $3,163,310 $2,409,891 $753,419 $1,902,965 $1,260,345

Admissions

Admissions 69 77 (8) 74 (5) 666 707 (41) 686 (20)

Patient Days 228 254 (26) 225 3 2,150 2,333 (183) 2,270 (120)

ADC include Obs 10.0 11.1 (1.1) 10.1 (0.1) 9.8 10.9 (1.1) 10.7 (0.9)

Outpatient Visits (ex RHC & ED) 3,637 3,540 97 3,526 111 30,681 32,708 (2,027) 32,558 (1,877)

Clinic Visits 5,219 5,645 (426) 5,387 (168) 47,274 54,914 (7,640) 55,126 (7,852)

Births 12 10 2 15 (3) 115 108 7 103 12

ED Visits 687 726 (39) 725 (38) 7,177 7,087 90 7,076 101

Total Surgeries/less Endo 62 64 (2) 62 0 485 521 (36) 505 (20)

Revenue/Net Revenue

Net Revenue $2,615,132 $2,657,975 ($42,843) $2,448,542 $166,590 $24,472,250 $24,339,508 $132,742 $23,119,670 $1,352,580

Net Revenue PAPD $2,145 $2,374 ($229) $2,425 ($281) $2,518 $2,369 $150 $2,315 $203

Deductions as % of Gross 65% 60% 5% 65% 0% 65% 60% 5% 62% 3%

Expenses

Total Expenses $2,639,069 $2,893,578 $254,509 $2,701,084 $62,015 $23,508,492 $26,217,322 $2,708,830 $24,358,352 $849,860

Total Expenses PAPD $2,164 $2,584 $420 $2,675 $511 $2,419 $2,551 $132 $2,439 $20

Total Staffing PAPD $1,099 $1,317 $217 $1,247 $147 $1,267 $1,301 $34 $1,242 ($25)

Supplies PAPD $189 $315 $126 $368 $179 $232 $316 $83 $279 $47

Stats & Ratios -

FTE's 218.98 215.90 3.08 239.00 -20.02 221.83 220.41 1.42 224.16 -2.33

FTE/EEOB 5.39 5.78 -0.40 6.63 -1.24 6.25 5.88 0.38 6.13 0.13

Avg Hourly Rate $27.76 $29.76 ($2.00) $24.10 $3.66 $27.45 $28.87 ($1.42) $24.48 $2.97

Net A/R Days 20.0 23.8 -3.8 25.9 -5.9 19.6 23.8 -4.2 24.9 -5.3

Cash Net Revenue % 89.2% 100% -11% 70.6% 19% 99.7% 100% 0% 97.5% 2%

Days Cash on Hand 377.63 180.00 197.63 210.23 167.40 377.63 180.00 197.63 210.23 167.40

YTD YTD BudgetVAR to Budget

YTDPY YTD VAR to PY YTDSummary Measures

Current

MonthBudget

VAR to

BudgetPrior Year VAR to PY

7

June EBIDA at a positive $796K was higher than Budget by $556K and Prior Year by $682K. Net loss for Operations $23.9K compared to a budgeted

loss of $236K. Due to the effects of COVID19, Clinics on a consolidated basis were lower than Budget by $19.6K. The breakdown of revenue and

expenses performance indicators were as follows:

NET REVENUE:

•Hospital Patient Net Revenue was lower than Budget by $6.2K due to a negative rate variance by $231K, driven by a lower Payor Mix with Medicare

down 11.1% and Managed Medicare down 3.7%. In addition, Surgeries were lower with Ortho cases lower by 3, and Gen Surgeries down by 2.

Higher Adjusted Patient Days drove a positive volume variance by $225K compared to Budget

•Other Revenue at $90.7K was higher than Budget by $55K due to Interest Income higher by 21.6K, Contributions and Grants higher by $21.7K, and

Cafe Sales higher by $3.1K

•Supplemental dollars were lower than Budget by $91.7K with no additional UC and/or DSH payments anticipated for the remainder of the year

EXPENSES:

•Total Expenses were lower than Budget by $254.5K due to lower expenses compared to Budget in several categories. Salaries were lower than

Budget by $59.4K due to lower FTEs caused by lower volume. FTEs were lower than Budget by 3.1, however COVID related pay totaled $27.6K and

6.3 FTEs for the month of June. Supplies were lower than Budget by $123K due to lower Implant costs ($66K), Pharmaceuticals ($34.6K), and Supplies

Charged to Patients ($12.2K). No Spine cases were performed in June. Purchased Services were lower than Budget by $43.2K driven by lower Repairs

& Maintenance ($38.7K). Professional Contracts were up $48K due to higher ER Physician expense by $33.7K and Physical Therapy up by $14.3K

CLINICS:

•Clinic Net Operating Loss of $16.3K was lower than Budget due to lower volume in the RHCs due to the effects of COVID. RHC Net Operating Income

was negative at $18.5K, lower than Budget by $38K due to lower volume (down 426 visits). Expenses were lower than Budget by $63K due to lower

Salaries ($43K) and Prof Contracts ($26K). Specialty Clinic positive income of $2K was due to positive Net Income in Podiatry. General Surgeon loss

was lower than Budget by $14.3K due to higher case acuity in June and Podiatry Net Income was higher than Budget by $3.9K with surgery cases up

by 2

OTHER:

•Wellness Net Operating Income at $19.2K was lower than Budget by $4K mainly due to lower Revenue by $6K. The Wellness Center reopened in

June within the State COVID19 guidelines. Membership was lower by 236 members compared to February

•340B Net Operating Income was higher than Budget by $60.2K, mainly due to higher Revenue by $52.9K driven by higher clinic volumes compared to

May, up by 1K visits

•Capital Expenditures - update: Electrical upgrades Phase 1 complete, Phase 2 in progress - $1.1M through June; Computer Network Optimization -

phase two in progress - $401.4K spend of $898M Budget; and 3D Mammo completed $181K. Current Capital Risk estimated spend $1M in addition to

projects in progress

8

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CUERO REGIONAL HOSPITAL BALAICE SHEET

PERIOD ENDED 06/30/20

CURRENT PRIOR YEAR YEAR-'1'0-DATE YEAR-'1'0-DATE

ASSETS --------------------

CURRENT:

CASH 19,325,913.64 7,892,601.43

MARKETABLE SECURITIES 2,046,696.99 2,024,058.06

ACCOUNTS RECEIVABLE 11,227,388.92 9,985,390.28

ALLOWANCE FOR UNCOLLECTIBLES (8,193,966.92) (7,062,355.91)

INTER-COMPANY RECEIVABLE 0.00 0.00

OTHER RECEIVABLES 5,445,831.53 4,148,768.33

INVENTORY 676,785.08 578,519.92

PREPAID EXPENSES 6,919,772.39 6,761,752.51

TOTAL CURRENT ASSETS $ 37,448,421.63 $ 24,328,734.62

OTHER ASSETS:

ASSETS WHOSE USE IS LIMITED 16,484,615.29 11,903, 954 . 62

OTHER ASSETS

TOTAL OTHER ASSETS $ 16,484,615.29 $ 11,903,954.62

PROPERTY, PLANT, & EQUIPMENT:

LAND 1,139,140.08 1,139,140.08

BUILDING AND IMPROVEMENTS 22,558,636.38 22,168,002.48

EQUIPMENT 33,673,877.45 29,057,72:.32

TOTAL PROPERTY, PLANT, & EQUIPMENT $ 57,371,653.91 $ 52,364,863.88

LESS ACCUMULATED DEPRECIATION (35,855,206.11) (33,551,035.45)

NET PROPERTY, PLANT, & EQUIPMENT $ 21,516,447.80 $ 18,813,828.43

TOTAL ASSETS $ 75,449,484.72 $ 55,046,517.67

-----==---==--=- =======-========

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CUERO REGIONAL HOSPITAL BALAN:E SHEET

PERIOD ENDED 06/30/20

CURRENT PRIOR YEAR YEAR-TO-DATE YEAR-TO-DA1'E

LIABILITIES AND FUND BALANCE ------------------------------

CURRENT:

ACCOUNTS PAYABLE (839,788.23) (119,755.43)

ACCRUED SALARIES & WAGES (2,227,877.71) (1,688,925.43)

ACCRUED INTEREST 0.00 0.00

CURRENT PORTION LTD (6,023,959.87) 0.00

DUE TO/FROM 3RD PARTY PAYORS (511,432.67) (268,328.43)

DUE TO/FROM AFFILIATES (3,312,024.84) (972,249.41)

TOTA:. CURRENT LIABILITIES $ (12,915,083.32) $ (3,049,258.70)

LONG TERM DEBT:

NOTES/LEASES PAYABLE (1,614,539.57) 0.00

BONDS PAYABLE 0.00 0.00

TOTAL LONG TERM DEBT $ (1,614,539.57) $ 0.00

FUND BALANCE (52,480,221.25) (46,968,250.07)

CURRENT YEAR (INCOME) LOSS (8,439,640.58) (5,029,008.90)

TOTAL FUND BALANCE (60,919,861.83) (51,997,258.97)

TOTAL LIABILITIES AND FUND BALANCE $ (75,449,484.72) $ (55,046,517.67)

================ ~ ===============

10

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CUERO REGIONAL HOSPITAL FIW\NCIAL STMEMENT

JUN 20

ACTUAL BUDGET PR ACTUAL Y'l'D J\CTt1AL Y'l'D BUDGET PY J\CTU1u.

OPERATING REVENUE: -----------------INPAT:ENT REVENUE 1,363, ll5 1,434,672 1,372, 02" 13,363,155 13,177,485 12,585,460

OUTPATIENT REVENUE 5,597,830 4,613,268 4,647,968 44,729,716 42,373,018 41,150,231

34 OB PROGRAM 329,465 276,620 136,330 2,308,626 2,489,580 1,587,757

GROSS REVENUE FROM PATIENTS $ 7,290,409 $ 6,324,560 $ 6,156,318 $ 60,401,497 $ 58,040,083 $ 55,323,449

REVENGE JEDUCTIONS: CHAR:::TY (262,087) (184,906) (172,964) (2,460,587) (1,698,369) (1,571,335)

D:SCOUN~S (1,593,380) (857,709) (904,913) ill,283, 9271 (7,878,089) (7,912,483)

BAD DEBT (537,984) (461,738) (832,698) (5,358,747) (4,241,079) (3,922,413)

CONTRACTUALS (2,372,531) I 2,289, 6ll I (2,121,063: (19,999,431) (21,030,161) (20,628,276)

TOTAL REVENUE DEDUCTIONS $ (4,765,981) $ 13,793,964 I $ (4,031,637) $ (39,102,692) $(34,847,698) $(34,034,506)

NET PATIENT REVENUE $ 2,524,429 $ 2,530,596 $ 2,"24,681 $ 21,298,805 $ 23,192,385 $ 21,288,943

OTHER OPERATING REVENUE 90,703 35, 712 61,194 2,211,120 322,123 538,173

SUPPLEMENTAL MCD PMTS 0 91,667 262,66" 962,326 825,000 1,292,554

TOTAL OPERATING REVENUE $ 2,615,132 $ 2,657,975 $ 2,448,:,42 $ 24,472,250 $ 24,339,508 $ 23,119,670

OPERATING EXPENSES: ------------------SALAR:ES Al'iD WAGES (1,042,179) (1,101,608) (999,205) (9,533,233)

(9,964,332) (9,141,255)

AGENC':' ?ERSONNEL !"RINGE ENEFITS (219,509) (278,490) (:82,848)

(2,085,682) (2,543,546) (2,581,956)

PAYROLL TAXES (79,016) (94,485) (76,700) (696,226) (864, 1661 (685,372)

SUPPLIES (230,259) I 353,077 I (371,512) (2,256,534 I (3,242,934) (2,786,614)

PURCHASED SERVICES (284,040) (327,262) (288,022) (2,356,049) (2,954,546) (2,756,147)

PROFESSIONAL CONTRACTS (480,121) (432,105) (448,955) (3,899,074) (3,888,931) (3,808,250)

DEPRECIA,ION EXPENSE (203,529) (202,084) (167,781) (1,791,330) (1,818,745) I 1,537, 4 93 I

INSURANCE EXPENSE (14,145) (16,112) (16,112) (164,880) (145,008) (144,008)

INTEREST EXPENSE (2,844 I (5,427) G (28,227) (48,844) (822)

OTHER OPERATING EXPENSE (83,427) (82,928) (149,949) (697,255) (746,270) I 916, 4361

TOTAL OPERATING EXPENSES (2,639,069) (2,893,578) (2,701,084) (23,508,492) (26,217,322) (24,358,352)

NET OPERATING INCOME (LOSS) (23,938) (235,603) (252,542) 963,758 (1,877,814) (1,238,682)

NET JISTRICT OPERATING INCOM 18,122 0 38,798 4,323,969 4,400,000 4,030,351

NURSING HOME UPL 595,281 267,766 159,397 3,163,310 2,409,891 1,902,965

NET IKCOME (LOSS) $ 589,466 $ 32,163 $ (54,347) $ 8,451,036 $ 4,932,077 $ 4,694,634

-====-====== ---=======-= ===-====-==- =======-==== ============ =========-==

11

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CUERO REGIONAL HOSPITAL & CLINICS FINl\NCD\L STATEMENT

JUN 20

ACTlTJ\L BUDGET PR ACTUAL YTD ACTlTJ\L YTD BODGET PY J\CTUAL

OPERATING REVENUE: -----------------INPATIEN7 REVENUE 1,363,115 1,434,672 1,372,021 13,363,155 13,177,485 12,585,460

OUTPATIENT REVENUE 5,597,830 4,613,268 4,647,968 44,729, 716 42,373,018 41,150,231

34 CB ??.OGRAM 329,465 276,620 136,330 2,308,626 2,489,580 1,587,757

CLINIC REVENUES 836,455 910,658 785,010 7,321,854 8,232,949 7,879,702

GROSS REVENUE FROM PATIENTS $ 8,126,864 $ 7,235,218 $ 6,941,328 $ 67,723,351 $ 66,273,032 $ 63,203,151

REVE:-JUE DEDUCTIONS: CHAR::TY (262,087) (184,906) (172,964) (2,460,587) (1,698,369) (1,571,335)

DISCQ"Jt;~S (1,593,380) (857,709) (904,913) (11,283,927) (7,878,089) (7,912,483)

BAD DEBT (537,984) (461,738) (832,698) (5,358,747) (4,241,079) (3,922,413)

CONTRACTUAc ALLOWANCES (2,372,531) (2,289,611) (2,121,063) (19,999,431) (21,030,161) (20,628,276)

CLIN:C ALLOWANCES (222,169) (216,550) ( 228, 969 I (1,945,072) (1,982,864) (2,030,032)

TOTA: REVE!,'UE DEDUCTIONS $ (4,988,150) $ (4,010,514) $ (4,260,606) $(41,047, 764) $ (36,830,562) $(36,064,539)

NET ?ATIENT REVENUE $ 3,138,714 $ 3,224,704 $ 2,680,72: $ 26,675,587 $ 29,442,470 $ 27,138,612

OTHER OPERATING REVENUE 90,703 35,712 61, 194 2,211,120 322,123 538,173

SUPPLEMENTAL MCD PMTS 0 91, 667 262,667 962,326 825,000 1,292,554

CLIN:C OTHER OPERATING REV 0 0 C 363,111 0 0

TOTAl OPERATING REVENUE $ 3,229,417 $ 3,352,083 $ 3,004,583 $ 30,212,143 $ 30,589,593 $ 28,969,340

OPERAT,NG EXPENSES: ------------------SALARIES AND WAGES (1,492,740) (1,590,202) (1,398,295) (13,629,917) (14,323,737) (13,046,026)

AGENCY PERSONNEL FRINGE 3ENEFITS (219,509 I (278,490) (182,848) (2,085,682) (2,543,546) (2,581,956)

Pl\YRC:aL TAXES (100,912) (122,048) (98,575) (952,035) (1,116,070) (918,926)

SUPPLIES (258,485) (381,245) (387,159) (2,518,490) (3,501,565) (3,044,337)

PURC!-iASED SERVICES (304,705) (343,855) (301,245) (2,521,644) (3,104,753) (3,062,519)

PROFESSIONAL CONTRACTS (551,469) (529,891) (501,020) (4,590,901) (4,776,230) (4,350,139)

DEPRECIATION EXPENSE (203,529) (202,084) (167,781) (1,791,330) (1,818, 7451 (1,537,493)

INSURANCE EXPENSE (16,850) (17,912) (18,245) (188,706) (166,408) (163,952)

INTEREST EXPENSE (2,844) I 5, 427 I 0 (28,227) (48,844) (822 I

OTHER OPERATING EXPENSE (118,599) (113,204) (178,922) (952,849) (1,018,801) (1,167,477)

TOTAl OPERATING EXPENSES (3,269,642) (3,584,358) (3,234,091) (29,259,781) (32,418,699) (29,873,647)

NE~ O?SRAT:NG INCOME (LOSS) (40,225) (232,275 I (229,509) 952,362 (1,829,106) (904,307)

NET DISTRICT OPERATING INCOM 18,122 0 38,798 4,323,969 4,400,000 4,030,351

NURSING HOME UPL 595,281 267,766 159,397 3,163,310 2,409,891 1,902,965

NET :NCOME (LOSS) $ 573,179 $ 35,491 $ (31,314) $ 8,439,641 $ 4,980, 785 $ 5,029,009

12

CRH CLINICS PERIOD VS PRIOR YEAR FINAN:IAL STATEMENT

JUN 20

}IC'l'Ul\L BUDGET PR J\CTUAL YTD }IC'l'UJ\L YTD BUDGET PY }IC'l'UJ\L

OPERAT:NG REVENUE: -----------------CLINIC REVENUES 836,455 910,658 785,010 7,321,854 8,232,949 7,879,702

GROSS REVENUE FROM PATIENTS $ 836,455 $ 910,658 $ 785,010 $ 7,321,854 $ 8,232,949 $ 7,879,702

REVENUE DEDUCT IONS : CLINIC ALLOWANCES (222,169) (216,550) (228,969) (1,945,072) 11,982,864) (2,030,032)

TOTAL REVENUE DEDUCTIONS $ (222,169) $ (216,550) $ (228,969) $ (1,945,072) $ (1,982,864) $ (2,030,032)

NET PAT:ENT REVENUE $ 614,286 $ 694,108 $ 556,041 $ 5,376,782 $ 6,250,085 $ 5,849,669

OTHER CLINIC REVENUE 0 0 0 363,111 0 0

TOTAL OPERATING REVENUE $ 614,286 $ 694,108 $ 556,04l $ 5,739,893 $ 6,250,085 $ 5,849,669

OPERAT:NG EXPENSES: ------------------SALAR=ES AND WAGES (450,561) (488,594) (399,090) 14,096,683) (4,359,405) (3,904,771) AGENCY PERSONNEL FRINGE BENEFITS 0 0 0 0 0 0 PAYROL'., TAXES (21,896) (27,563) (21, 87S) (255,809) (251,904) (233,554) STJPP::ES (28,226) (28,168) (15,647) (261,955) (258,631) (257,723) PURCHASE~ SERVICES (20,665) (16,593) (13,224) (165,595) (150,207) I 306,372 I PROFESSIONAL CONTRACTS (71, 3481 (97,786) (52,065) (691,827) (887,299) (541,889) DEFREC:ATION EXPENSE INSURANCE EXPENSE (2,706) (1,800) I 2, 134 I (23,826) (21,400) (19,944) INTEREST EXPENSE OTHER OPERATING EXPENSE (35,172) I 30, 2761 (28,973) (255,594) 1272, 531 I 1251, 041 I

TOTAL OPERATING EXPENSES (630,573) (690,780) (533,007) (5,751,289) I 6,201,377 I 15,515,294 I

NET OPERATING INCOME (LOSS) (16,287) 3,328 23,034 (11,396) 48,708 334,375

13

RUN DATE: 07/10/20 PAGE 1

RUN T:iME: 164 7 RUN USER: SSUTTON

CRH RURAL HEALTH CLINICS FINANCIAL STATEMENT

JUN 20

ACTUAL BUDGET PR ACT0AL YTD ACT0AL YTD BUDGET PY ACTUAL

OPERATIKG REVENUE: -----------------CL:NIC REVENUES 636,649 765,669 612,384 5,862,529 6,901,227 6,563,933


REVENUE DEDUCTIONS: CLINIC ALLOWANCES (90,354) (118,968) (102,661) (894,258) 11,086,569) (1,095,307)

TOTAL REVENUE DEDUCTIONS $ (90,354) $ ("18,968) $ (102,661) $ (894,258) $ (1,086,569) $ (1,095,307)

NET PATIENT REVENUE $ 546,294 $ 646,701 $ 509,723 $ 4,968,271 $ 5,814,658 $ 5,468,626

OTHER CLINIC REVENUE 0 0 0 363,111 0 0

TOTAL OPERATING REVENUE $ 546,294 $ 646,701 $ 509,723 $ 5,331,382 $ 5,814,658 $ 5,468,626

OPERATING EXPENSES: ------------------SALARIES AND WAGES (389,692) (432,176) (347,256) (3,547,894) (3,841,207) (3,414,559) AGENCY PERSONNEL !'RINGE aENE FI TS 0 0 0 0 0 0 PAYROE TAXES (19,364) (24,445) (19,594) 1226, 214 I 1223, 264 I 1207, 077 I SUPPLIES (27,812) (27,479) I 15,053) 1255, 712 I (252,370) (251,440) PURCHASED SERVICES (20,651) (16,430) ( 12,871) (165,185) (148,737) (304,901 I PROFESSIONAL CONTRACTS 171,348) (97,714) (52,065) (691,827) (886,649) I 541,239 I DEPRECIATION EXPENSE INSURANCE EXPENSE (2,706) I 1, 800 I 12,134 I (23,826) (21, 4001 (19,944) INTEREST EXPENSE OTHER OPERATING EXPENSE (33,219) (27,329) (24,942) (228,640) 1245, 977 I (224,483)

TOTAL OPERATING EXPENSES (564,791) (627,373) (473,914) (5,139,297) (5,619,604) (4,963,642)

NET OPERATING INCOME (LOSS) (18,497) 19,328 35,808 192,085 195,054 504,984

14

RUN DATE: 07 /10/20 PAGE 1 RUN TIME: 1648 RUN USER: SSUTTON

CRH SPECIALTY HEALTH CLINICS FINl\NCIAL STATEMENT

JUN 20

ACTUAL BUDGET PR ACTUAL YTD ACTUAL YTD BUDGET PY J\CTUAL

OPERATING REVENUE: -----------------CLINIC REVENUES 199,806 144,989 172,626 1,459,325 1,331,722 1,315,769


REVENUE DEDUCTIONS: CLINIC ALLOWANCES (131,815) (97,582) (126,308) (1,050,815) (896,295) (934,725)

':'OTAL REVENUE DEDUCTIONS $ (131,815) $ (97,582) $ (126,308) $ (1,050,815) $ (896,295) $ (934,725)

NET PATIENT REVENUE $ 67,992 $ 47,407 $ 46,318 $ 408,5ll $ 435,427 $ 381,044

TOT~ OPERATING REVENUE $ 67, 992 $ 4 7, 4 07 $ 46,318 $ 408,5ll $ 435,427 $ 381,044

OPERATING EXPENSES: ------------------SALARIES AND WAGES (60,868) (56,418) (51,834) (548,790) (518,198) (490,213) AGENCY PERSONNEL FRINGE 3ENEFITS PAYROLL TAXES (2,532) (3,118) I 2,281 I (29,595) (28,640) (26,477) SUPPLIES I 414 I (689) I 594 I (6,244) (6,261) (6,283) PURCHASED SERVICES (14) I 163 I I 353 I I 4091 {1,470) I 1,471 I PROFESSIONAL CONTRACTS 0 172 I 0 0 (650) (650) DEPRECIATION EXPENSE INSURANCE EXPENSE 0 0 0 0 0 0 INTEREST EXPENSE OTHER OPERATING EXPENSE (1,953) I 2,947 I I 4, 031 I (26,954) (26,554) (26,559)

TOTA: OPERATING EXPENSES (65,782) (63,407) (59,093) (611,991) (581,773) (551,652)

NET OPERATING INCOME (LOSS) 2,210 (16,000) (12,775) (203,481) (146,346) (170,609)

15

RUN DA'::E: 07 /10/20 PAGE 1 RUN ':'IME: 1657 RUN USER: SSUTTON

BUDGET CCMPARSION REPORT WELLNESS CENTER 7085

FOR PERIOD ENDING 06/30/20

J\CTlJAL BUDGET PR 1ICTUAL YTD J\CTlJAL YTD BUDGET PY ACTUAL

REVEKTJE

IN PATIENT REVENUE OUT PATIENT REVENUE 45,952 52,130 51,615 354,415 478,815 468,955

~OTA: REVENUE 45,952 52,130 51,615 354,415 478,815 468,955

DEDUCT,ONS FROM REVENUE

CHARITY

DISCOUNTS PROVISION FOR BAD DEBT CONTRACTU.~ ALLOWANCES CLINIC ALLOWANCES

TOTA:c DECUCT,ONS FROM REVENU

OTHER OPERATING REVENUE OTHER OPERATING REVENUE 0 0 0 0 0 0

DISTR:CT NET INCOME (LOSS) D,SPRO-SHARE REVENUE CLD!IC OTHER OPERATING REV

TOTAL OTHER REVENUE 0 0 D 0 0 0

EXPENSES SALARcES (11,659) (12,441) (10,480) (104,439) (112,516) (102,460)

FICA (806) (938) (765) (7,246) (8,617) (7,271)

MED/SURG SUPPLIES (11) 128 I D (112) (256) (230)

OFFICE SCPPLIES I 16 I (86) 0 (899) (790) (755)

OTHER S\JPP'"IES (2,255) I 1, 639 I (843) (11,458) (15,061) (12,666)

UNIFOR.'1S 0 I 14 I 0 0 I 131 I (128)

CHEMICA: COST 0 0 0 0 0 214

FOOD (997) (1,021) (1,078) (5,998) (9,373) 18,201 I

ELECTRICITY (5,010) (4,350) (4,856) (34,241) (39,731) (38,588)

FUEL & GAS I 128 I 1200 I I 164 I 13,300 I 1, 8291 (1,908)

WATER I 194 I I 140 I (135) (1,377) I 1, 280 I (1,164)

MAINTENAc'!CE CONTRACTS (55) (397) I 325 I (930) (3,572) (3,559)

REPAIRS & MAINTENANCE 1123) I 2, 418 I : 989) (16,829) (21,767) (29,900)

PROFESSIONAL CONTRACTS (1,053) (920) { 1, 192 J (9,457) (8,279) (8,166)

16

RUN DATE: 07/10/20 PAGE 2 RUN TIME: 1657 RUN USER: SSUTTON

BUDGET CCMPARSION REPORT

WELLNESS CENTER 7085

FOR PERIOD ENDING 06/30/20

ACTUAL BUDGET PR ACTUAL YTD ACTUAL YTD BUDGET PY ACTUAL

PROFESS:ONAL SERVICES (3,986) (3,435) I 3, 152 I (19,722) (30,911) (28,836)

LICENSES 132 I (8) 0 (387) (75) (20)

PHONE/CABLE/INTERNET I 415 I (539) (544) (4,258) I 4,848 I I 4,814 I DUES & SUBSCRIPTIONS 0 (542) 0 (2,299) I 4,875 I I 416 I

ADVERTISING 0 (50) G (131) I 4 50 I 0

TRAVEL & MEETING 0 I 42 I 0 I 3, 125 I (375) I 158 I

POSTAGE 0 I 15 I 0 12 I 1134 I I 14 8 I BOI'.D_'.NG RENT 0 I 301 (300) 0 I 271 I (300)

EQU:PMENT RENTAL 0 0 0 (56) 0 (64 I

PUBLIC EDUCATIONAL ACTIVITIE 0 (7) 0 (3,178) I 64 I (2,878)

LINEN ?TJRCHES 0 I 42 I 0 (301) (375) (338 I

FREIGH: 0 0 0 0 0 I 45 I

TOTAL ~XPENSES (26,737) (29,302) (24,823) (213,142) (265,580) (252,798)

NE~ PROF=T/(LOSS) 19,215 22,828 26,792 141,273 213,235 216,157

=========--- ============ ============ ============ ====---===== --=========-

17

Cuero Community Hospital Inventory Holdings Report For the Quarter of April, May and June 2020 Prepared July 16, 2020

Fund: Hospital District

Sec Type

Maturity Yield to CUSIP Date Interest Maturity

Securities

0 0 110/1900 3.823%

Totals

Money Marlcet - Mutual Funds

Wells Fargo• Logic* MBIA - General• MBIA-Funded Dep Totals

0.810% 0.000% 1.470% 1.470%

Checking and Savings Accounts

0.851%

Face Value

$0.00

$0.00

Pun::hase Principal

$0.00

$0.00

Beginning Book

$0.00

$0.00

Beginning Book

$1.994,886.81 $0.50

$68,155.85 $21,945.09

$2,084,988.25

Beginning MarlcetValue

$0.00

$0.00

Beginning MarlcetValue

$1,994,886.81 $0.50

$68,155.85 $21,945.09

$2,084,988.25

Ending Book

$0.00

$0.00

Ending Book

$1,996,907.48 $0.50

$68,294.06 $21,989.59

$2,087, 191.63

Ending MarlcetValue

$0.00

$0.00

Ending Marlcet Value

$1,996,907.48 $0.50

$68,294.06 $21,989.59

$2,087,191.63

General Fund 1.510% $8, 182,922.69 $8, 182,922.69 $12.275,351.58 $12,275,351.58 Payroll Acct 1.510% $8,908.29 $8.908.29 $12,200.00 $12,200.00 Clinic Account 1.510% $605,378.15 $605,378.15 $16,589.87 $16,589.87 Specialty Account 1.510% $49,843.53 $49,843.53 $5,918.84 $5,918.84 Brookshire 1.510% $49,907.67 $49,907.67 $111,584.64 $111,584.64 Stockdale 1.510% $26,659.49 $26,659.49 $88,305.89 $88,305.89 Floresville 1.510% $263.528.50 $263,528.50 $237,529.24 $237,529.24 Victoria 1.510% $245.74 $245.74 $246.65 $246.65 Corpus NH 1.510% 5334 $0.00 $0.00 $6,006.00 $6,006.00 Winsor-Corpus NH 1.510% 5342 $4,775.78 $4,775.78 $0.00 $0.00 Kingsville NH 1.510% 5350 $6,524.93 $6,524.93 $32.473.09 $32.473.09 Calallen NH 1.510% 847 $12,078.29 $12,078.29 $0.00 $0.00 Calallen NH - HUD 1.510% 5647 $342,581.69 $342,581.69 $193.913.38 $193,913.38 Plugerville NH 1.510% 804 $0.00 $0.00 $9,114.38 $9,114.38 CC NH-HUD 1.510% 5590 $191,755.64 $191,755.64 $184,955.49 $184,955.49 Kingsville NH-HUD 1.510% 5612 $131,112.21 $131.112.21 $219,913.07 $219,913.07 Plugerville NH-HUD 1.510% 5620 $128,350.50 $128,350.50 $208,444.56 $208,444.56 Legend-SA 1.510% 1193 $165,876.55 $165,876.55 $348,663.30 $348,663.30 Legend-SA West 1.510% 1207 $150,770.91 $150,770.91 $515,665.86 $515,665.86 Sonterra 1.510% 1215 $267,083.07 $267,083.07 $243,905.84 $243,905.84 Corpus-Windsor HUD 1.510% 5655 $245,250.66 $245,250.66 $160,631.76 $160,631.76 Luling 1.510% $42,170.52 $42,170.52 $51,662.57 $51,662.57 Oakmont - Humble 1.510% $94,677.60 $94,677.60 $238,720.19 $238,720.19 Parklane 1.510% $52,605.45 $52,605.45 $74,024.18 $74,024.18 Yorktown 1.510% $67,719.26 $67,719.26 $103,071.22 $103,071.22 Lampasas 1.510% $74,178.51 $74,178.51 $127,590.26 $127,590.26 Self Funded Acct 1.510% $949, 189.87 $949, 189.87 $952, 734.29 $952, 734.29 Funded Depreciation 1.510% $16,343,862.35 $16,343,862.35 $16,462,625.70 $16,462,625.70 Building Fund 1.510% $481,859.45 $481,859.45 $483,658.78 $483,658.78 Government Funds 1.510% $0.00 $0.00 $3,024,023.06 $3,024,023.06 Champs 0.000% $5,854.08 $5,854.08 $3,636.30 $3,636.30 Totals $28,945,671.38_ j2_8,945,671.38 $36,393,159.99 $36,393,159.99

Change in MKTValue

$0.00

$0.00

Current D-T-M

0

#DIV/01 WAM

Accrued Interest

$0.00

$0.00

[10ti1Hospital District Funds $31,030,659.63 $31,030,659.63 $38,480,351.62 $38,480,351.62 I

This report is in compliance With GAAP, the District Investment Policy, the District Investment Strategies and the Public Funds Investment Act.

Alma Alexander 7/16/2020 Investment Officer Date

18

CUERO REGIONAL HOSPITAL MEDICAL STAFF PRIVILEGES REVIEW SHEET

INITIAL APPOINTMENT

APPLICANT NAME: Carolyn Dale Denton, DO

The following has been verified by Administration:

1. Completed Application 2. Current Texas License 3. Board Certification

If No, explain--------------4. Current DEA Certificate

If No, explain _____________ _ S. Evidence of Adequate P fess· nal Liability Insurance

Expiration Date: -Llll~KL.l.:L.&---1--

DATE: 07101/2020

NO NO NO

NO

6. Adverse infonnati n with Da Bank Query (MD/DO only)

YES'~ YES CEQ:) @NO YES@

7. Board of Medical Examiners Query 8. Current CPR/ L /ATLS ti r ER privil~es

If No, explain -"':ia...L....JJ.J01U--AJ~~~a....-+.u.....L-L..:::ll!:~ 9. Current ACL or Board Cer • to

If No, explain ......,....,...._.~""---F=="'l~..i...;...-=......J......._:...=:....:;..._a.:;;;....:..,.. 10. Evidence of CME requirements

If No, explain---------------11. In good standing at other hospitals where privileged

If No, explain ______________ _ 12. Malpractice claims in the last ten years

Specialty: Family Practice

YES@

@i)No (£0 NO YES@

19


INITIAL APPOINTMENT

APPLICANT NAME: Nicholas Lemley, ~o


1. Completed Application 2. Current Texas License 3. Board Certificatiru •

IfNo,explain_ .... ~......,. ......... lfl..:...~-+----------4. Current DEA Ce "fie te

If No, explain -~.:....;:;...l.:l:..:......,~---------5. Evidence of Ade 'flattI:fo essional Liability Insurance

Expiration Date: j.!& l AA 6. Adverse information with i>JJa Bank Query (MD/DO only) 7. Board of Medical Examiners Query 8. Current CPR/ CLS/ ATLS for ER privileges

If No, explain -'"""""""...._...._......._-+'.....,.~~_......._~_,_.,,_,,,.."'""'l,...... 9. Current ACLS or Board Cert. to perform ca diac str

If No, explain---------------10. Evidence of CME !6quirem~ : ~}

If No, explain jU~ tfn1 ~ {~enec.., 11. In good standing at othrr hospitals where privileg~



DATE: 07/01/2020

rYESJ NO ~NO YES @)' YES ~ YES fiil ~d~ YES~ ~NO

YES@)

@NO

YESG{)

20


REAPPOINTMENT APPOINTMENT

APPLICANT NAME: Madeline Andrew, MD




If No, explain _____________ _

5. Evidence of Adequl\te P~al Liability Insurance Expiration Date: (Q -I~

6. Adverse information with Data Bank Query (MD/DO only) 7. Board of Medical Examiners Queried 8. Current CPR/A,(:LS/ATLS ~ER privileges.

If No, explain JlX2$ (]()t- M.t. 12 eAYfl v '.S 9. Current ACLS N!!:oard Cert. to perfor~~rdiac ~test

IfNo,explain ~ flo\- p4f-O(W1 ~eSS ~ 10. Evidence of CME requirements

If No, explain ______________ _ 11. In good standing at other hospitals where privileged

If No, explain---------------12. Malpractice claims in the last ten years

Specialty: Psychiatry

DATE: 07/01/2020

@~~ @No @No

@No

~NO ~NO YES (No:=;

YES@

@:>No

~NO YES@

21



APPLICANT NAME: Neil Campbell, Of «l ----DATE: 07101/2020



If No, explain _____________ _ 4. Current DEA Certificate

If No, explain--------------5. Evidence of Adequate Professional Liability Insurance

Expiration Date: 10 · C> I· ~.,lt.I 6. Adverse information with Data Bank Query (MD/DO only) 7. Board of Medical Examiners Query 8. Current CPR/ CLS/AT S r E privileges. .

If No, explain .MM~-1J,1!!....1-1::..!i=:l~ot..!..!.:...:...L.l!~~_u.:.LL_ 10. Evidence of CME require ents



~NO ~~g @'NO

§' NO cm-- NO ~NO YES~

YES

~NO

@NO

YES ®J'

Specialty: ;:;.P~o=di::a:=.:trv'-'----------------------

Commenu:~----------------------~

22

CUERO REGIONAL HOSPITAL ALLIED HEALTH PRIVILEGES REVIEW SHEET


APPLICANT NAME: Hermelinda Fitts, FNP




If No, explain _____________ _ 5. Evidence of Adequate Professional Liability Insurance

Expiration Date: ------6. Adverse information with Data Bank Query 7. Board of Medical Examiners Queried 8. Current CPRJACLS/ATLS for ER privileges

If No, explain---------------9. Current ACLS or Board Cert. to perform cardiac stress tests

IfNo,explain ______________ _

10. Evidence of CME requirements If No, explain ______________ _

11. In good standing at other hospitals where privileged If No, explain ______________ _

12. Malpractice claims in the last ten years

Specialty: Family Practice-Parkside Clinic

DATE: 07/01/2020

NO NO NO

NO

NO

~~ ~NO YES



APPLICANT NAME: :..:Az:h:.::a::.:.r...:.Ma=l.:.:;ik.=..!.:.:M~D:;...._ ______ DATE: 07/0112020





Expiration Date: 8 ... J~QJet}t 6. Adverse information with Data Bank Query (MD/DO only) 7. Board of Medical Examiners Query 8. Current CPR/ACLS/ATLSM p~~ ·

If No, explain ())Q.$ (\Qt ~ ~l vdo CIA 9. Current AC:~oard ~om:rd~ tests IfNo,expla10~ Mt~~ i:~

10. Evidence of CME requirements If No, explain---------------

11. In good standing at other hospitals where privileged If No, explain ______________ _


Specialty: Nepbrology

NO NO NO

NO

@ NO YES~ ~_Ml.._ YES~

,·y~(No)

~· NO

Q;NO

YES@

24



APPLICANT NAME: George Osuchukwu, MD




If No, explain _____________ _

5. Evidence of Adequtte Professional Liability Insurance Expiration Date: ~·lb-~

6. Adverse information with Data Bank Query (MD/DO only) 7. Board of Medical Examiners Query 8. Current CPR/ CLS/ATL for ER privileges

If No, explain .J.4.IU..J,..1.1.U..-"'""'"~...L...i.l.£.~LILl~~::::!....-9, Current ACL or Board C rt. to tests

If No, explain l,4j~_u:w.i_~~~L.!..!...!.....;~~=---L::;...w.i_ 10. Evidence of CME requirements



Specialty: Nepbrology

DATE: 07101/2020

@~g ~NO ~NO

~NO

~~ YES @;-

YES@

& NO &' NO YEQ

25



APPLICANT NAME: =...A=sh=es=h.-P ... a.:..:ri=k=h,._.MD=------- DATE: 07/01/2020


1. Completed Application l. Current Texas License 3. Board Certification


If No, explain--------------5. Evidence of Adequfte,Professional Liability Insurance

Expiration Date: U,.. l,... ~ ft1 6. Adverse information with Data Bank Query (MD/DO only) 7. Board of Medical Examiners Query 8. Current CPR/A LS/ATLS or ER privileges.

If No, explain (I 9. Current ACLS or Board Cert. to perform

If No, explain ______________ _ 10. Evidence of CME requirements

If No, explain ______________ _ 11. In good standing at other hospitals where privileged


Specialty: Cardiology-Telemedicine

~~g ~NO ~NO

~ NO

~·~ YES@

~NO GNo ~NO

YES€>

26



APPLICANT NAME: Gustavo Sandigo, MD DATE: 07101/2020



If No, explain _____________ _ 4. Current DEA Certificate


Expiration Date: {}', '3 {- OJI) t;).(.) 6. Adverse information with Data Bank Query (MD/DO only) 7. Board of Medical Examiners Query 8. Current CPR/~§/ATL~(o~rivileges · 'l

If No, explain JJJf~ 0Dt~



APPLICANT NAME: _,B ..... ru ... c .... e_..S....,c .... aff...,. .... MD......., ________ DATE: 07/01/2020




If No, explain _____________ _ S. Evidence of Adequate Professional Liability Insurance

Expiration Date: lJ.-1-:JJX)Q 6. Adverse information with Data Bank Query (MD/DO only) 7. Board of Medical Examiners Query 8. Current CPR/ACLS/ATLS for ER privileges

If No, explain---------------9. Current ACLS or Board Cert. to perform cardiac stress tests

If No, explain ______________ _ 10. Evidence of CME requirements

If No, explain ______________ _ 11. In good standin a ot er ho

If No, explain ~LU~L.;:;.;:o:..L..-a:-:-'-'



APPLICANT NAME: Caroline Valdes, MD





Expiration Date: l- ~ -~ 6. Adverse information with Data Bank Query (MD/DO only) 7. Board of Medical Examiners Query 8. Current CPR/ACLS/AT S for ER rivileges lf~ex~~ ~

9. Current AC or Board Cert. to perfor c rdiac If No, explain '( S

10. Evidence of CME requirem nts If No, explain ______________ _

11. In good standing at other hospitals where privileged If No, explain---------------


Specialty: Pathology

DATE: 07101/2020

NO NO NO

NO

NO

YES®) GP' NO YES~

YES €i)

@""'NO

~NO YES Cfili:)

29



APPLICANT NAME: Cody Walthall, MD




If No, explain--------------5. Evidence of Adequf,te P~ofessional Liability Insurance

Expiration Date: RJ .... 01-~ 6. Adverse information with Data Bank Query (MD/DO only) 7. Board of Medical Examiners Query 8. Current CPR/ /AT S or ER pr'vileges • •

v


DA TE: 07 /01/2020

~:g &No (YE§) NO

~NO

YES ~ ~NO ~

Marketing and Development Board Report July

2020

Marketing Campaign Reporting/Analytics: Review reporting for all campaigns and see the creative for June/mid-July:

https://www.dropbox.com/sh/vq0iigzho0tmtyr/AAAl4ucY-iIQyoK_fjEgQPjna?dl=0

Video o We resumed our YouTube Preroll campaign with Wood Agency in early June,

and the full report is in the dropbox o For June, we rotated two :15 spots – 3D Mammograms & Cardiopulmonary:

(https://www.youtube.com/watch?v=iIgUSJRBfO0) with 24,962 views (https://www.youtube.com/watch?v=PhyA0xUD1sA) with 25,590 views

o We also received a $300 credit to run our 50th anniversary spot and received 25,918 views.

Social Media o We saw some growth in the area of likes on Facebook (up 41 new likes for a total

of 2,794. We are still right behind Citizens with 3K and ahead of other rural hospitals with similar markets that I compare us to. I included that comparison in the social media reporting in dropbox.

o Twitter and Instagram continue hold their numbers. o Social media posts continue to be the main driver of traffic to our website at this

time. Thanks to our partnership with Coffey for our website, we have had access to great material to share on social, as well as great info from Methodist as well!

Website o Reporting is included in the Dropbox link above. Traffic is holding steady

considering that info is not sought after like it was back in March/April where our numbers climbed.

o Emily continues to work on SEO to increase search engine referrals to the site. This is done with particular keywords and metatags used when new content is posted to the site.

Public relations o Dueling Pianos – Postponed – no new date set. Worked with Nikki to inform

ticket holders and public at large. o Press releases continue to result in great traction and coverage due to slight lull

period with COVID-19. Seeing great response from local media after releases submitted.

Development: o From Bump to Baby: Family and Baby Expo/ Fair – rescheduled to Saturday,

Sept. 26th. Currently working to finalize the speaker schedule, attendee flow through the facility and finalizing external vendors to come in for the event.

This event may be postponed once more given COVID-19 activity in our area.

o Runway for a Cure – working on a digital solution via FB live to record the fashion show IN the boutiques, as well as some of our providers speaking on breast cancer for a DIGITAL event. Working with a film crew in Victoria to produce. More to come! Will seek one large sponsor to cover the cost, and will invite individuals to donate to cover the cost of a $65 mammogram.

31

https://www.dropbox.com/sh/vq0iigzho0tmtyr/AAAl4ucY-iIQyoK_fjEgQPjna?dl=0https://www.dropbox.com/sh/vq0iigzho0tmtyr/AAAl4ucY-iIQyoK_fjEgQPjna?dl=0https://www.youtube.com/watch?v=iIgUSJRBfO0https://www.youtube.com/watch?v=PhyA0xUD1sA

o Dr. Lemley promotion – working with him now to develop print and video promotion. Also promoting Dr. Dale Denton joining the Yorktown Clinic/Dr. Barth’s retirement and Dr. Kevin Denton joining Goliad with Dr. Heard retirement.

o Dr. Campbell – Dr. Campbell & staff went with marketing to deliver lunch to Sievers Medical Clinic in Shiner. They have a new FP doctor – Dr. Kody Selzer. Great visit with Dr. Selzer and their team on our specialists, our 3T MRI, DME (they are currently sending patients to Victoria), telepsych and other opportunities. Great outreach and potential!

Coverage in mid-June – July 2020: o To see all press releases submitted to area print, radio, TV, magazines, etc,

visit: https://www.cueroregionalhospital.org/news/ o Cuero Record:

June 3 - https://www.cuerorecord.com/news/crh-receives-federal-state-funding-covid-19-relief%C2%A0

June 30 - https://www.dewittcountytoday.com/news/crh-staff-members-test-positive-covid-19

o Yorktown News-Views: Nominated in several categories in DeWitt Co. Readers Choice

Awards: https://www.dewittcountytoday.com/ o KAVU/Crossroads Today:

June 20 - https://www.crossroadstoday.com/cuero-health-facilities-updates-related-to-covid-19-for-july-2020/

June 21 - https://www.crossroadstoday.com/cuero-regional-hospital-explains-how-covid-19-could-lead-to-heart-disease/

July 8 - https://www.crossroadstoday.com/cuero-regional-hospital-and-dewitt-medical-foundation-receive-10000-from-conoco-phillips/

o Victoria Advocate:

June 11 - https://www.victoriaadvocate.com/premium/crossroads-hospitals-loosen-visitor-policies/article_e7a47a56-ac23-11ea-b117-237309c8c15c.html

June 16 - https://www.victoriaadvocate.com/counties/dewitt/cuero-regional-hospital-launches-in-home-sleep-studies/article_5a34a736-afed-11ea-99a3-7f913aa05132.html

July 6 - https://www.victoriaadvocate.com/counties/dewitt/cuero-hospitals-drive-thru-lab-relocates/article_d14594ec-bfca-11ea-a739-7bde94a52df1.html

July 12 - https://www.victoriaadvocate.com/opinion/letter-conocophillips-donates-to-cuero-regional-hospital/article_401cd6f6-c254-11ea-99b7-5b5a9b109c0c.html

32

https://www.cueroregionalhospital.org/news/https://www.cuerorecord.com/news/crh-receives-federal-state-funding-covid-19-relief%C2%A0https://www.cuerorecord.com/news/crh-receives-federal-state-funding-covid-19-relief%C2%A0https://www.dewittcountytoday.com/news/crh-staff-members-test-positive-covid-19https://www.dewittcountytoday.com/news/crh-staff-members-test-positive-covid-19https://www.dewittcountytoday.com/https://www.crossroadstoday.com/cuero-health-facilities-updates-related-to-covid-19-for-july-2020/https://www.crossroadstoday.com/cuero-health-facilities-updates-related-to-covid-19-for-july-2020/https://www.crossroadstoday.com/cuero-regional-hospital-explains-how-covid-19-could-lead-to-heart-disease/https://www.crossroadstoday.com/cuero-regional-hospital-explains-how-covid-19-could-lead-to-heart-disease/https://www.crossroadstoday.com/cuero-regional-hospital-and-dewitt-medical-foundation-receive-10000-from-conoco-phillips/https://www.crossroadstoday.com/cuero-regional-hospital-and-dewitt-medical-foundation-receive-10000-from-conoco-phillips/https://www.victoriaadvocate.com/premium/crossroads-hospitals-loosen-visitor-policies/article_e7a47a56-ac23-11ea-b117-237309c8c15c.htmlhttps://www.victoriaadvocate.com/premium/crossroads-hospitals-loosen-visitor-policies/article_e7a47a56-ac23-11ea-b117-237309c8c15c.htmlhttps://www.victoriaadvocate.com/premium/crossroads-hospitals-loosen-visitor-policies/article_e7a47a56-ac23-11ea-b117-237309c8c15c.htmlhttps://www.victoriaadvocate.com/counties/dewitt/cuero-regional-hospital-launches-in-home-sleep-studies/article_5a34a736-afed-11ea-99a3-7f913aa05132.htmlhttps://www.victoriaadvocate.com/counties/dewitt/cuero-regional-hospital-launches-in-home-sleep-studies/article_5a34a736-afed-11ea-99a3-7f913aa05132.htmlhttps://www.victoriaadvocate.com/counties/dewitt/cuero-regional-hospital-launches-in-home-sleep-studies/article_5a34a736-afed-11ea-99a3-7f913aa05132.htmlhttps://www.victoriaadvocate.com/counties/dewitt/cuero-hospitals-drive-thru-lab-relocates/article_d14594ec-bfca-11ea-a739-7bde94a52df1.htmlhttps://www.victoriaadvocate.com/counties/dewitt/cuero-hospitals-drive-thru-lab-relocates/article_d14594ec-bfca-11ea-a739-7bde94a52df1.htmlhttps://www.victoriaadvocate.com/counties/dewitt/cuero-hospitals-drive-thru-lab-relocates/article_d14594ec-bfca-11ea-a739-7bde94a52df1.htmlhttps://www.victoriaadvocate.com/opinion/letter-conocophillips-donates-to-cuero-regional-hospital/article_401cd6f6-c254-11ea-99b7-5b5a9b109c0c.htmlhttps://www.victoriaadvocate.com/opinion/letter-conocophillips-donates-to-cuero-regional-hospital/article_401cd6f6-c254-11ea-99b7-5b5a9b109c0c.htmlhttps://www.victoriaadvocate.com/opinion/letter-conocophillips-donates-to-cuero-regional-hospital/article_401cd6f6-c254-11ea-99b7-5b5a9b109c0c.html

Clinic Administrator Report

• Allscripts upgrade completed on July 3, 2020

July, 2020 Board Report

• After interviewing two good candidates, Mr. Bill Bohl was selected as the new Clinic Administrator. Mr. Bohl will begin August 3, 2020

• Dr. Dale Denton will begin in Yorktown on August 3; Dr. Barth will use the month of August and the first part of September to phase out of his practice by reducing to two days a week. This will allow for a smooth transition as Dr. Denton begins her practice in Yorktown . Dr. Denton will also help build our aesthetics program to operate out of the wellness center

• When Dr. Heard retires August 27; Dr Kevin Denton will begin working 2-3 days a week in Goliad and 2-3 days a week in Cuero Medical

• Dr. Nick Lemley will also begin his practice in Cuero Medical Clinic on August 3, 2020 • Mid Level providers working on re-certification to do Veterans Exams

• We have posted a clinic manager position for Yorktown Clinic. Dr. Dale Denton will help interview candidates.

33

Quality/Safety

Assistant Administrator Board Report

July 2020

1. The new air cooled chiller was started up on July 2nd and it has been working great. We will now work to get it on the automated logic system.

Finance 1. We received 1 of the 2 Sofia machines for rapid COVID testing, correlation

studies have been completed and the machine will be put into service on July 10th after the staff has been in-serviced. We were notified that we will not receive the second Sofia until September.

2. We hope to receive two of the High flow oxygen cannulas next week. We heard on a THA call that many hospitals are trying to get these machines because the hospitals that are currently utilizing them are reporting that it is helping to prevent patients from being placed on a ventilator.

3. We have two patients waiting for approval to begin our pulmonary rehab program.

Personnel 1. Due to family issues, Sabrina Perez, has resigned as the Laboratory Director.

Her knowledge and expertise will be missed. We will begin interviewing for her position next week. To date we have 2 qualified applicants.

34

BOARD REPORT NURSING ADMINISTRATION 7-10-2020

Safety/Quality

• We had 1 inpatient fall in June with serious injury. This was a reportable event.

• We were 100% compliant with our Sepsis patients in June. We had 5 patients.

People

• I submitted a request for ICU nurses from the STRAC (Southwest Texas Regional Advisory

Council) on Thursday. Traceee Rose, RN Acute Care Division Director from STRAC, informed me that she is sending 4 ICU RN 's and they will arrive on Sunday and begin orientation on

Monday morning. I am now staffing my ICU with 3 nurses to accommodate 6 patients.

• Two nursing students have signed their LINC Contracts this week. Megan Elliott and Emily Bertram are in the Victoria College ADN Program. Megan will be working with the Med Surg Staff and Emily will be with the ER Staff.

• We have a new RN in OB. Our LINC student, Samantha Fenter completed the RN Program in Victoria and passed her exams. Her commitment is for 5 years after completing her exams.

• As I am typing this report, we currently have 5 ICU patients, 14 patients on the Med Surg floor, 2 moms/2 babies and 2 triage OB patients. There are 9 positive COVID patients and 2 PUT' s

(patients under investigation awaiting test results) in our hospital.

• Wilma Reedy, OB Director, has submitted our Maternal Designation packet.

Over the past several years, state lawmakers have passed laws changing the way Texas hospitals are reimbursed for neonatal and maternal care provided. In 2011 , the 83rd Texas Legislature passed House Bill 15, which requires the development of initial rules to create neonatal and maternal level of care designation. In 2013 , the 84th Texas Legislature passed House Bill 3433, which requires hospitals that provide neonatal care to have neonatal designations from TDSHS by Sept. 1, 2018 to receive Medicaid reimbursements for neonatal services provided. It also requires Texas hospitals to have a maternal designation by Sept. l , 2020 to receive Medicaid reimbursements for maternal services provided. We are Level l Neonatal Designation and currently applying for Level l Maternal Designation.

Growth

• Our Cardio/Pulmonary Rehab is progressing. We currently have 2 patients and awaiting the

approval for 3 additional patients.

Community

Yours in service,

Judy Krupala, CNO 35

Quality/Safety • Sepsis remained at 100% for June and looks good for July • There was one fall in June with injury. An RCA has been initiated • Provider order entry dropped a little but chart delinquency stayed steady

July, 2020 Board Report

• COVID continues to be the focus - increased census; staffing constraints assisted HERO bonus program and by visiting nurses obtained through STRAC; PPE inventory and re-use protocols; rapid testing up and running, correlations with DeTar complete, currently doing comparative studies with CPL

People • Clinic Administrator offer made; he will start on August 3 • Dr. Nick Lemley will begin August 3 as will Dr. Dale Denton

• Dr. Barth will begin phasing his retirement and working 2 days a week in the month of August as a transition with Dr. Denton

• The postponed employee engagement survey will be held in September

Growth • Cardiopulmonary Rehab continues, but slow given our situation with COVID • Direct mail piece for OB services will go out announcing our new physician joining the

team and our 99% patient sat with OB nurses and physicians

Nursing Homes/QIPP

• CRH monthly QIPP Nursing Home calls held • All nursing homes following state and CDC guidelines for COVID • As of our June calls 6 of our homes had positive patients and/or staff; appropriate

protocols in place to protect patient • The state is using a 3 rd party to do the second round of infection control on site surveys

to assure appropriate practices in place

36

FY 2020 OCT NOV DEC JAN FEB MAR APR MAY JUNE JULY AUG SEPT

Total RL Solutions Reported 32 26 14 27 23 16 17 18 19

Near Miss 2 5 0 3 2 3 1 0 1

Precursor 21 15 11 21 15 12 11 17 13

Serious Safety 1 0 1 0 1 0 0 0 1

Medication Error 0 0 0 0 2 0 0 0 0 0Hand Off Communication Incidents 0 5 2 1 1 1 0 1 1 0

2-patient identifier 95% 77% 92% 93% 97% 97% 94% 98% 100% 98%

Medication Override-Overall

FY2020 OCT NOV DEC JAN FEB MAR APR MAY JUNE JULY AUG SEPT

Total RL Solutions Reported for Clinics 3 7 1 2 7 2 4 2 3

Near Miss 0 1 0 0 2 0 0 0 0Precursor 2 4 1 1 4 2 1 0 1

Serious Safety 0 0 0 0 0 0 0 0 0Other 1 2 0 1 1 0 3 2 2

Handwashing compliance 92% 88% 93% 87% 100% 93% 92% 93%

Wait Time- average time from check-in to check-out

FY 2020 OCT NOV DEC JAN FEB MAR APR MAY JUNE JULY AUG SEPT

Cuero Overall Satisfaction Score: 51st 10 1 10 52 14 11 10 1Cuero would recommend practice: 51st 6 6 8 61 9 4 6 1Goliad Overall Satisfaction Score: 51st 1 73 2 5 43 31 2 23Goliad would recommend practice: 51st 13 99 1 2 90 2 1 53Kenedy Overall Satisfaction Score: 51st 92 33 46 2 99 99 99 -Kenedy would recommend practice: 51st 99 99 10 2 99 99 99 -Parkside Overall Satisfaction Score: 51st 46 5 3 9 43 7 97 99Parkside would recommend practice: 51st 24 4 1 14 23 1 99 99Yorktown Overall Satisfaction Score: 51st 7 5 3 9 15 41 1 99Yorktown would recommend practice: 51st 7 4 9 15 6 7 1 99Combined Clinics Overall Satisfaction Score:

51st 7 4 9 27 24 16 9 7

Combined Clinics would recommend practice:

51st 8 8 4 29 21 3 6 4

Goal Met

updated 7/6/2020

Patient SatisfactionPress Ganey Texas Rank Percentile

Clinics Quality Improvement Dashboard

1Q2019 2Q2020 3Q2020 4Q2020

GO

AL

39

Name/Title of Person completing assessment: Denise McMahan-Compliance Officer Date of Assessment: June 2020 Description Yes No Evidence of Compliance or Action required 1 Do you have written polices/procedures and

Standard of Conduct that address Medicare fraud, waste and abuse?

√ Compliance Plan-Standard of Practice #2

2 Do your written policies/procedures articulate the organization’s commitment to comply with all applicable Federal and State standards?


3 Do your written policies/procedures and Standards of Conduct describe compliance expectations of employees?


4 Do you have a policy/procedure that articulates the obligation to report compliance issues and FWA?

√ Compliance Plan-Developing effective lines of communication

5 Do you policies/procedure include the obligation to assist in the resolution of compliance and FWA issues?

√ Added statement to Investigation and Corrective Action policy.

6 Do you have a written plan describe the operation of the compliance program?

√ Compliance Plan

7 Do your written policies/procedures and Standards of Conduct describe ramifications of your employees’ and FDR’s failure to meet compliance expectations?

√ Compliance Plan-Enforcement & Discipline “b” Rural Health Clinics, Home Health & Wellness employees follow same policies/procedures and Standards of Conduct Will give a copy of Compliance Plan and Standards of Conduct to PT employees and Hospitalist-PT and Hospitalist contract states that all company employees agree to abide by policies/procedures of the hospital

8 Do your written policies/procedures provide guidance to employees and FDR’s on dealing with potential compliance issues?

√ Compliance Plan-Developing effective lines of communication Rural Health Clinics, Home Health & Wellness employees follow same policies/procedures and Standards of Conduct Will give a copy of Compliance Plan to PT employees and Hospitalist-PT

40

and Hospitalist contracts state that all company employees agree to abide by policies/procedures of the hospital

9 Do your written policies/procedures explain how employees and FDR’s can communicate compliance issues to appropriate compliance personnel?

√ Compliance Plan-Developing effective lines of communication Rural Health Clinics, Home Health & Wellness employees follow same policies/procedures and Standards of Conduct Will give a copy of Compliance Plan to PT employees and Hospitalist-PT and Hospitalist contracts state that all company employees agree to abide by policies/procedures of the hospital

10 Do your written policies/procedures describe how potential compliance issues are investigated and resolved?

√ Compliance Plan-Responding promptly to detected offenses & undertaking corrective action Investigative & Corrective Action policy/procedure

11 Do your written policies/procedures include a policy of non-intimidation and non-retaliation against employees and FDR’s for good faith participation in the compliance program, including but not limited to reporting potential issues, investigating issues and conducting audits?

√ Compliance Plan-Developing effective lines of communication Non-retaliation policy/procedure Rural Health Clinics, Home Health & Wellness employees follow same policies/procedures and Standards of Conduct Will give a copy of Compliance Plan and Non-retaliation policy to PT employees and Hospitalist. PT and Hospitalist contracts state that all company employees agree to abide by policies/procedures of the hospital

12 Do your written policies/procedures state the obligation of employees and FDR’s to report Medicare non-compliance and/or FWA to the compliance officer?

√ Compliance Plan-Developing effective lines of communication Non-retaliation policy/procedure Rural Health Clinics, Home Health & Wellness employees follow same policies/procedures and Standards of Conduct Will give a copy of Compliance Plan and Non-retaliation policy to PT employees and Hospitalist. PT and Hospitalist contracts state that all company employees agree to abide by policies/procedures of the hospital

13 Do your written policies/procedures include a requirement that all board members, employees, and FDR’s to submit a statement regarding conflict of interest at least annually?

Conflict of Interest Policy Will add Board of Directors and FDR’s to current policy

14 Do you require employees and FDR’s to √ Employees currently sign a paper during their initial orientation stating

41

provide a written or electronic certification that they have received, read, understood and will comply with all Standards of Conduct?

that they have received, read and understand the Standards of Conduct Will have PT employees and Hospitalist sign the same form when they are provided the Standards of Conduct

15 Do you have a written policy/procedure requiring screening of all vendors and physicians against the OIG and GSA exclusion lists upon hire and monthly thereafter?

√ Currently working with Verifycomply.com to complete monthly checks of all vendors and providers. Will write policy/procedure on this process

16 Do you have a written policy/procedure requiring immediate removal of any excluded person or entity that furnishes orders or prescribes items or services that are paid in whole or in part, directly or indirectly from Federal funds?

√ Will write policy/procedure requiring immediate removal of any excluded person or entity

17 Do you have a written policy/procedure that require appropriate corrective action when violations are identified (such as repayment, repayment for items or services paid for by Federal funds that were ordered, furnished or prescribed by an excluded person or entity, and disciplinary actions against responsible employee and/or FDR’s?

√ Compliance Plan-Responding promptly to detected offenses and undertaking corrective action Investigation and Corrective Action policy/procedure

18 Do you have written a requirement for FDR’s to disclose their exclusion and that of their employees from participation in Federal health care programs?

Will include Hospitalist and PT employees on monthly checks

19 Does your Medicare Compliance Officer report directly to the Chief Executive Officer (CEO) of your organization?

√

20 If the answer to the above question (#36) is “no” explain the Medicare Compliance Officer’s reporting structure

21 Is there a Medicare Compliance report at √ Have added compliance report to monthly board meeting agenda

42

least quarterly to the board of directors? 22 Do you require employees who have

responsibilities related to the Medicare program to have general compliance training on the operation of the Medicare compliance program upon hiring an annually thereafter?

√ Yes through Health.edu

23 Do you require all board members who oversee any aspect of the Medicare program to have general compliance training upon initial appointment and annually thereafter?

N/A no board member directly oversees any aspect of the Medicare program; however, will work to set up a general compliance training for the board that includes stork and anti-kick back regulations

24 Does the FWA training provided to your employees, board members and FDR’s include an overview of HIPAA and the importance of maintaining confidentiality of Personal Health Information?

Employees receive HIPPA training and sign confidentiality statements during initial orientation Will need to verify PT employees and Board are provided training and sign confidentiality statements

25 Do you require employees to have specialized compliance training on issues posing Medicare compliance risks based on their job function?

√ Will have business office and medical records show the topics of the training provided on hire

26 Is such specialized compliance training provided upon hire, when requirements change, when an area has been found to be noncompliant and at least annually thereafter?

√ Will have business office and medical records show the topics of the training provided on an annual basis

27 Are there one or more methods for employees to report compliance issues and FWA to the Compliance Department, such as hot lines, emails or other methods?

√ Compliance Plan-Developing effective lines of communication

28 Is there at least one method to report compliance issues and FWA that is anonymous, such as a hotline?

√ Compliance Plan-Developing effective lines of communication Hotline

29 Are the methods of reporting compliance issues and FWA available to all employees,

√

43

FDR’s and board members? 30 Are the methods of reporting compliance

issues and FWA available 24 hours a day, seven days a week?

√ Hotline

31 Do you widely publicize to employees method(s) for reporting compliance issues and FWA?

√ Employee forums; new employee orientation; magnet with Hotline phone number given to each employee at employee forums and new employee orientation

32 Do you initiate investigations stemming from reported inquiries and complaints within two weeks of receiving the inquiry or complaint?

√ Investigation & Corrective Action policy/procedure

33 Do you initiate investigation of FWA reports within three days of receipt of the report?

√ Investigation & Corrective Action policy/procedure –states 5 days but has now been changed to 3 days

34 Do you conclude investigations of FWA reports within 60 calendar days of receipt, unless you can justify an extension?

√ 60 days was not specified- The statement “All investigations will be completed within 60(sixty) calendar days of receipt unless there is a reasonable justification for an extension” has been added to the Investigation and Corrective Action Policy

35 Do you track reported concerns and issues including the status of related investigations and corrective actions?

√ Compliance Plan-Developing effective lines of communication (e) Investigation and Corrective Action policy/procedure

36 Do you analyze reported concerns and inquiries to identify patterns of possible misconduct within your organization?

√ This was not specified in policy-The statement “The compliance committee will analyze all reported compliance concerns and issues for any potential patterns or trends” has been added to the Compliance Plan under Internal Auditing and Monitoring section.

37 Do you conduct internal monitoring and audits?

√ Auditing & Monitoring policy/procedure

38 Does your internal monitoring and audits test for FWA in the Medicare program?

√

39 Do you prioritize your monitoring and auditing activities based upon a risk assessment?

√ Was not specified in policy-statements regarding annual risk assessment and prioritizing of risks were added to Auditing and Monitoring Policy

40 Do you have a policy/procedure for monitoring/auditing within your organization?

√ Auditing & Monitoring policy/procedure

44

41 Do you use dashboards, scorecards or other mechanisms to measure Medicare compliance?

√ Have developed several dashboards for various departments to monitor compliance standards. These will be distributed to the departments to begin monitoring during third quarter of this year.

42 Are the results on dashboards, scorecards or other measurements reported to the CEO and board of directors at least quarterly?

√ Goal is to have the dashboards ready to share with the board by end of the 4th quarter

43 Do you evaluate the compliance program at least annually?

√ Compliance Plan-duties and responsibilities of compliance officer

44 Is your evaluation of the effectiveness of the compliance program reported to the board of directors and CEO?

√ Compliance Plan-duties and responsibilities of compliance officer

45 Do you have a policy/procedure to voluntarily self-report to CMS or its designee, OIG or law enforcement significant Medicare non-compliance and/or FWA violations.

√ Compliance Plan-Responding promptly to detected offenses and undertaking corrective action. Investigation and corrective action policy/procedure

45

OLD BUSINESS AGENDA ITEM#l

Annual Audit Report and Board Education Tabled Until Otherwise Noted

2020 07 23

46

AGENDA ITEM #1

Capital Expenditure Request for Med Sorg Wing Walls in Handicap Showers - Review and Take Appropriate Action

Proposals Attached:

Langer $12,968.00 Recommended

2020 07 23

47

Cuero Regional Hospital CAPITAL EXPENDITURE REQUEST

HOSPITAL/ENTITY Cuero Regional Hospital

DEPARTMENT Med Surg DATE PREPARED 7 /9/2020

Is the requested purchase in compliance with the Healthtrust

GPO?

PROJECT NAME DESIRED DELIVERY/START DATE

D Wing Wall 's in Handicap Showers E PROJECT DESCRIPTION Add approximately 28" of floor to ceiling tiled PURPOSE FOR REQUEST

s partitions on the head walls of each handicap shower on the second floor New Service D c to contain the water and overspray from getting on or near door to the Replacement D R estroom. Code Compliance D I JUSTIFICATION lndiate present situation~ need for the item requested and alternative considerations.

p Shower water not flowing to drain causing water to exit into patient room

T BUDGET REFERENCE Amount Budgeted

I BUDGET LINE ITEM IF NOT BUDGETED, WHY IS IT NEEDED AT THIS TIME?

0

N

F EQUIPMENT/PROJECT COSTS Attach copies of proposals ASSET DISPOSITION DATA

I Bid #1 Bid #2 Bid #3 Description of Disposed Assets :

N Name of Bidder Lauger

A Land and/or Acquisition

N Construction BOOK VALUE OF DISPOSED ASSET I c Equipment METHOD OF Trade In D I TOTAL COSTS $12,968.00 DISPOSITION Sale D A Less Trade In Abandonment D L NET CAPITAL REQUIRED

RECOMMENDATION (Check one) 0 D D A

DEPA:ztL~ u T H DATE: 7/9/2020 , 0

R SLT LEADER ' I

~~ 1 1 z DATE: Odac:s A " ' T CHIEF EXECUTIVE OFFICER or CHIEF FINANCIAL OFFICER

I

~IL~ ~_p. /.. __ ,,./" 1/q )do 0 DATE: -N

= = =

DATE:

II !Board Member Signature if greater than $5,000

48

Cuero Regional Hospital 2550 N. Esplanade St. Cuero, TX 77954 Office: 361-275-6191

Attn: Rick Caron / Lynn Falcone

RE: Handicap Showers on Second Floor

To whom it may concern,

JULY2, 2020

The following proposal covers materials and labor to add approximately 28" of floor to ceiling tiled partitions on the head walls of each handicap shower on the second floor to contain the water and overspray from getting on or near the door to the restroom. The walls will be framed using metal studs then covered with hardi-board, aqua defense liner, thin set, and Linden Point Daltile to match the existing tile in each shower. Cost also includes adding one waterproof can light fixture in each handicap shower that will be connected to existing light switch. We will also make necessary repairs to the sheetrock that was damaged from water in one of the handicap exam rooms on the second floor.

Tile Work & Water Proofing: Partitions Materials & Labor: Electrical: Overhead:

Total Cost:

$6,008.00 $5,040.00 $1,680.00 $240.00

$12,968.00 Tax Excluded

On behalf of Lauger Companies, Inc., I would like to thank you for the opportunity to provide this estimate to you. Should you have any questions, please do not hesitate to contact me at your convenience and we look forward to hearing from you soon.

Resoectfullv Submitted:

Luke Zettlemoyer Sr. Project Manager / Estimator

PO Box 2146 + VICTORIA, TX 77902 I (361) 578-0003 + (361) 578-1626 FAX

49

AGENDA ITEM #2 Capital Expenditure Request for Roof Replacement at Kenedy Clinic - Review and Take Appropriate Action

Proposals Attached:

T. Flores $27,700.00

Cox Bros. $37 ,500.00 Recommended

HCHR $85,774.00

2020 07 23

50

Cuero Regional Hospital CAPITAL EXPENDITURE REQUEST

HOSPITAL/ENTITY Kennedy Clinic

DEPARTMENT Clinic DATE PREPARED 6/30/2020

Is the requested purchase in compliance with the Healthtrust

GPO?

PROJECT NAME DESIRED DELIVERY/START DATE

D Replace the Roof at Kenj(edy Clinic E Remove old roof and haul off. Install new roof as per PURPOSE FOR REQUEST

s quote New Service D c Replacement 0 R Code Compliance D I JUSTIFICATION lndiate present situation1 need for the item requested and alternative considerations.

p Existing roof has leaks throught-out clinic. 20+ years old T BUDGET REFERENCE Amount Budgeted

I BUDGET LINE ITEM IF NOT BUDGETED, WHY IS IT NEEDED AiHIS TIME?

0 We selected Cox Brother over other bidded a.&'\~having another roofing contractor N recommending them

F EQUIPMENT/PROJECT COSTS Attach copies of proposals ASSET DISPOSITION DATA

I Bid #1 Bid #2 Bid #3 Description of Disposed Assets:

N Name of Bidder T. Flores Cox Bro HCH R

A Land and/or Acquisition

N Construction BOOK VALUE OF DISPOSED ASSET I c Equipment METHOD OF Trade In D I TOTAL COSTS $27,700.00 $37,500.00 $85,774.00 DISPOSITION Sale D A Less Trade In Abandonment D L NET CAPITAL REQUIRED

RECOMMENDATION (Check one) D 0 D A

u DEPARTMEM~

T

H DATE: 6/30/2020 0

R SLT LEADER

c /J ., ;:,cJ-;:d I &w\~~ z DATE: A

I J T CHIEF EXECUTIVE OFFICER or CHIEF FINANCIAL OFFICER

I ~-Jl~001/,. __ J,. 1/8/~ . 0 DATE:

N = = = DATE:

Board Member Signature if greater than $5,000

51

ADDRESS:

PHONE:

CUERO REGIONAL HOSPITAL MAINTENANCE

REQUISITION FORM

REQUISITION DATE:

Meditech P.O. No. Issued

Manual P.O. No. Issued

6/30/20

~Product ~ Service r:J Subscription r:J Reimbursement

HOSPITAL VENDOR PRICE PER OTY. PKG T

Documents

CUERO Charles W. Papacek REGIONAL HOSPITAL...2020/07/23 · PAPRS - Powered Air Purifying Respirators. A quote from Owens & Minor for $30,112.60 was recommended. Mrs. Cindy Sheppard