COMMUNITY MEMORIAL HOSPITAL ASSOCIATION: Form 990, tax year 2021
View the entire original 990 at ProPublica ↗
- Organization
- COMMUNITY MEMORIAL HOSPITAL ASSOCIATION (EIN 41-0743546)
- Tax period
- 2021-10-01 to 2022-09-30
- Filed
- 2023-06-30
- IRS object ID
- 202341819349300244
- Schema version
- 2021v4.2
- Source
- Download XML · Original 990 at ProPublica
Every field in the e-filed return. Faint text is the IRS element name, for citing.
- Return header
- Form 990
- Schedule A
- Schedule B
- Schedule C
- Schedule D
- Schedule H
- Schedule I
- Schedule J
- Schedule O
- Schedule R
Return header ReturnHeader
| Field | Value | IRS element (for citing) |
|---|---|---|
| Return | 2023-06-30T12:04:26-05:00 | ReturnTs |
| Tax Period End | 2022-09-30 | TaxPeriodEndDt |
Preparer Firm PreparerFirmGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Preparer Firm EIN | 420714325 | PreparerFirmEIN |
Preparer Firm Name PreparerFirmName
| Field | Value | IRS element (for citing) |
|---|---|---|
| Business Name Line1 | RSM US LLP | BusinessNameLine1Txt |
Preparer US Address PreparerUSAddress
| Field | Value | IRS element (for citing) |
|---|---|---|
| Address Line1 | 227 WEST FIRST STREET SUITE 700 | AddressLine1Txt |
| City | DULUTH | CityNm |
| State Abbreviation | MN | StateAbbreviationCd |
| ZIP | 55802 | ZIPCd |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Return Type | 990 | ReturnTypeCd |
| Tax Period Begin | 2021-10-01 | TaxPeriodBeginDt |
Filer Filer
| Field | Value | IRS element (for citing) |
|---|---|---|
| EIN | 410743546 | EIN |
Business Name BusinessName
| Field | Value | IRS element (for citing) |
|---|---|---|
| Business Name Line1 | COMMUNITY MEMORIAL HOSPITAL ASSOCIATION | BusinessNameLine1Txt |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Business Name Control | COMM | BusinessNameControlTxt |
| Phone | 2188787027 | PhoneNum |
US Address USAddress
| Field | Value | IRS element (for citing) |
|---|---|---|
| Address Line1 | 512 SKYLINE BLVD | AddressLine1Txt |
| City | CLOQUET | CityNm |
| State Abbreviation | MN | StateAbbreviationCd |
| ZIP | 55720 | ZIPCd |
Business Officer BusinessOfficerGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Person | BRAD ANDERSON | PersonNm |
| Person Title | CFO | PersonTitleTxt |
| Phone | 2188787027 | PhoneNum |
| Signature | 2023-06-29 | SignatureDt |
| Discuss With Paid Preparer | Yes (1) | DiscussWithPaidPreparerInd |
Signing Officer SigningOfficerGrp
Person Full Name PersonFullName
| Field | Value | IRS element (for citing) |
|---|---|---|
| Person First | BRAD | PersonFirstNm |
| Person Last | ANDERSON | PersonLastNm |
| Field | Value | IRS element (for citing) |
|---|---|---|
| SSN | 999009999 | SSN |
Preparer Person PreparerPersonGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Preparer Person | JULIE BOYER | PreparerPersonNm |
| PTIN | P01278549 | PTIN |
| Phone | 2187275025 | PhoneNum |
| Preparation | 2023-06-29 | PreparationDt |
Additional Filer Information AdditionalFilerInformation
Trusted Customer TrustedCustomerGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Trusted Customer | 3 | TrustedCustomerCd |
| Authentication Assurance Level | AAL1 | AuthenticationAssuranceLevelCd |
| Identity Assurance Level | IAL1 | IdentityAssuranceLevelCd |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Tax | 2021 | TaxYr |
| Build TS | 2023-04-26 12:10:37Z | BuildTS |
Form 990 IRS990
| Field | Value | IRS element (for citing) |
|---|---|---|
| Principal Officer | RICK BREUER | PrincipalOfficerNm |
US Address USAddress
| Field | Value | IRS element (for citing) |
|---|---|---|
| Address Line1 | 512 SKYLINE BLVD | AddressLine1Txt |
| City | CLOQUET | CityNm |
| State Abbreviation | MN | StateAbbreviationCd |
| ZIP | 55720 | ZIPCd |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Gross Receipts | $71,392,085 | GrossReceiptsAmt |
| Group Return For Affiliates | 0 | GroupReturnForAffiliatesInd |
| Organization501c3 | Yes (X) | Organization501c3Ind |
| Website Address | WWW.CLOQUETHOSPITAL.COM | WebsiteAddressTxt |
| Type Of Organization Corp | Yes (X) | TypeOfOrganizationCorpInd |
| Formation | 1954 | FormationYr |
| Legal Domicile State | MN | LegalDomicileStateCd |
| Activity Or Mission | THE MISSION OF COMMUNITY MEMORIAL HOSPITAL IS TO IMPROVE AND ENHANCE THE HEALTH AND WELL-BEING OF INDIVIDUALS AND OUR COMMUNITY THROUGH EDUCATION, PREVENTION, TREATMENT AND INTERVENTION. | ActivityOrMissionDesc |
| Voting Members Governing Body | 8 | VotingMembersGoverningBodyCnt |
| Voting Members Independent | 6 | VotingMembersIndependentCnt |
| Total Employee | 567 | TotalEmployeeCnt |
| Total Volunteers | 71 | TotalVolunteersCnt |
| Total Gross UBI | $49,749 | TotalGrossUBIAmt |
| Net Unrelated Bus Txbl Incm | $16,376 | NetUnrelatedBusTxblIncmAmt |
| PY Contributions Grants | $13,153,218 | PYContributionsGrantsAmt |
| CY Contributions Grants | $2,226,780 | CYContributionsGrantsAmt |
| PY Program Service Revenue | $64,940,758 | PYProgramServiceRevenueAmt |
| CY Program Service Revenue | $68,605,964 | CYProgramServiceRevenueAmt |
| PY Investment Income | $66,236 | PYInvestmentIncomeAmt |
| CY Investment Income | $70,764 | CYInvestmentIncomeAmt |
| PY Other Revenue | $675,580 | PYOtherRevenueAmt |
| CY Other Revenue | $484,608 | CYOtherRevenueAmt |
| PY Total Revenue | $78,835,792 | PYTotalRevenueAmt |
| CY Total Revenue | $71,388,116 | CYTotalRevenueAmt |
| PY Grants And Similar Paid | $0 | PYGrantsAndSimilarPaidAmt |
| CY Grants And Similar Paid | $20,955 | CYGrantsAndSimilarPaidAmt |
| PY Benefits Paid To Members | $0 | PYBenefitsPaidToMembersAmt |
| CY Benefits Paid To Members | $0 | CYBenefitsPaidToMembersAmt |
| PY Salaries Comp Emp Bnft Paid | $43,811,666 | PYSalariesCompEmpBnftPaidAmt |
| CY Salaries Comp Emp Bnft Paid | $44,500,350 | CYSalariesCompEmpBnftPaidAmt |
| PY Total Prof Fndrsng Expns | $0 | PYTotalProfFndrsngExpnsAmt |
| CY Total Prof Fndrsng Expns | $0 | CYTotalProfFndrsngExpnsAmt |
| CY Total Fundraising Expense | $0 | CYTotalFundraisingExpenseAmt |
| PY Other Expenses | $26,379,349 | PYOtherExpensesAmt |
| CY Other Expenses | $29,318,977 | CYOtherExpensesAmt |
| PY Total Expenses | $70,191,015 | PYTotalExpensesAmt |
| CY Total Expenses | $73,840,282 | CYTotalExpensesAmt |
| PY Revenues Less Expenses | $8,644,777 | PYRevenuesLessExpensesAmt |
| CY Revenues Less Expenses | -$2,452,166 | CYRevenuesLessExpensesAmt |
| Total Assets BOY | $59,723,821 | TotalAssetsBOYAmt |
| Total Assets EOY | $55,410,390 | TotalAssetsEOYAmt |
| Total Liabilities BOY | $34,781,961 | TotalLiabilitiesBOYAmt |
| Total Liabilities EOY | $32,967,891 | TotalLiabilitiesEOYAmt |
| Net Assets Or Fund Balances BOY | $24,941,860 | NetAssetsOrFundBalancesBOYAmt |
| Net Assets Or Fund Balances EOY | $22,442,499 | NetAssetsOrFundBalancesEOYAmt |
| Info In Schedule O Part III | Yes (X) | InfoInScheduleOPartIIIInd |
| Mission | THE MISSION OF COMMUNITY MEMORIAL HOSPITAL IS TO IMPROVE AND ENHANCE THE HEALTH AND WELL-BEING OF INDIVIDUALS AND OUR COMMUNITY THROUGH EDUCATION, PREVENTION, TREATMENT AND INTERVENTION. | MissionDesc |
| Significant New Program Srvc | 0 | SignificantNewProgramSrvcInd |
| Significant Change | 0 | SignificantChangeInd |
| Expense | $66,819,871 | ExpenseAmt |
| Grant | $20,955 | GrantAmt |
| Revenue | $68,862,089 | RevenueAmt |
| Desc | CMH IS A CRITICAL ACCESS HOSPITAL LOCATED IN CLOQUET, MN WHICH RESIDES IN CARLTON COUNTY. CMH SERVES PRIMARILY AN ELEVEN ZIP CODE AREA WITH A POPULATION OF APPROXIMATELY 35,000 RESIDENTS. CMH OFFERS THE COMMUNITY A ROBUST SERVICE LINE OFFERING WHICH INCLUDES INPATIENT & OUTPATIENT SERVICES ALONG WITH A 44 BED SKILLED NURSING FACILITY. CMH PROVIDES A NEWLY CONSTRUCTED STATE OF THE ART INPATIENT FACILITY HOUSING MED/SURG, ICU, OB, AND SWING BED SERVICES. CMH PROVIDES A FULL ARRAY OF OUTPATIENT SERVICES WHICH INCLUDE: A 24 HOUR E/R, A FULL SPECTRUM OF IMAGING SERVICES, LAB, SURGERY, CHEMO/INFUSION, PHARMACY, R.T., CARDIAC REHAB, PHYSICAL THERAPY, OCCUPATIONAL THERAPY, SPEECH THERAPY, DIABETIC EDUCATION, SLEEP STUDIES, AND A NUMBER OF OTHER MEDICAL SERVICES NEEDED BY OUR COMMUNITY. CMH OPERATES A 44 BED SKILLED NURSING FACILITY THAT MAINTAINS A HIGH OCCUPANCY RATE. CMH ALSO EMPLOYS A NUMBER OF PHYSICIANS IN SPECIALTIES THAT ARE IN HIGH DEMAND IN OUR SERVICE AREA. THESE INCLUDE GENERAL SURGEONS, ORTHOPEDIC SURGEONS, AND OB/GYN. CMH HAS GROWN AT A FAST PACE TO MEET THE NEEDS OF OUR COMMUNITY. IN THE TAX YEAR ENDING SEPTEMBER 30, 2022, CMH PROVIDED 3,975 INPATIENT DAYS, 2,059 SURGERIES, 11,111 EMERGENCY ROOM VISITS, 14,415 LTC RESIDENT DAYS AND 48,876 OUTPATIENT VISITS. IN ADDITION, CMH REACHES OUT TO THE COMMUNITY TO ENHANCE THE HEALTH AND WELL BEING OF OUR SERVICE AREA BY OFFERING NUMEROUS EDUCATIONAL OPPORTUNITIES, HEALTH SCREENINGS, AND SUPPORT GROUPS. | Desc |
| Total Program Service Expenses | $66,819,871 | TotalProgramServiceExpensesAmt |
| Described In Section501c3 | Yes (1) | DescribedInSection501c3Ind |
| Schedule B Required | Yes (1) | ScheduleBRequiredInd |
| Political Campaign Acty | 0 | PoliticalCampaignActyInd |
| Lobbying Activities | Yes (1) | LobbyingActivitiesInd |
| Subject To Proxy Tax | 0 | SubjectToProxyTaxInd |
| Donor Advised Fund | 0 | DonorAdvisedFundInd |
| Conservation Easements | 0 | ConservationEasementsInd |
| Collections Of Art | 0 | CollectionsOfArtInd |
| Credit Counseling | Yes (1) | CreditCounselingInd |
| Donor Rstr Or Quasi Endowments | Yes (1) | DonorRstrOrQuasiEndowmentsInd |
| Report Land Building Equipment | Yes (1) | ReportLandBuildingEquipmentInd |
| Report Investments Other Sec | 0 | ReportInvestmentsOtherSecInd |
| Report Program Related Invst | 0 | ReportProgramRelatedInvstInd |
| Report Other Assets | 0 | ReportOtherAssetsInd |
| Report Other Liabilities | Yes (1) | ReportOtherLiabilitiesInd |
| Include FIN48 Footnote | Yes (1) | IncludeFIN48FootnoteInd |
| Independent Audit Fincl Stmt | Yes (1) | IndependentAuditFinclStmtInd |
| Consolidated Audit Fincl Stmt | 0 | ConsolidatedAuditFinclStmtInd |
| School Operating | 0 | SchoolOperatingInd |
| Foreign Office | 0 | ForeignOfficeInd |
| Foreign Activities | 0 | ForeignActivitiesInd |
| More Than5000 K To Org | 0 | MoreThan5000KToOrgInd |
| More Than5000 K To Individuals | 0 | MoreThan5000KToIndividualsInd |
| Professional Fundraising | 0 | ProfessionalFundraisingInd |
| Fundraising Activities | 0 | FundraisingActivitiesInd |
| Gaming Activities | 0 | GamingActivitiesInd |
| Operate Hospital | Yes (1) | OperateHospitalInd |
| Audited Financial Stmt Att | Yes (1) | AuditedFinancialStmtAttInd |
| Grants To Organizations | Yes (1) | GrantsToOrganizationsInd |
| Grants To Individuals | 0 | GrantsToIndividualsInd |
| Schedule J Required | Yes (1) | ScheduleJRequiredInd |
| Tax Exempt Bonds | 0 | TaxExemptBondsInd |
| Engaged In Excess Benefit Trans | 0 | EngagedInExcessBenefitTransInd |
| PY Excess Benefit Trans | 0 | PYExcessBenefitTransInd |
| Loan Outstanding | 0 | LoanOutstandingInd |
| Grant To Related Person | 0 | GrantToRelatedPersonInd |
| Business Rln With Org Mem | 0 | BusinessRlnWithOrgMemInd |
| Business Rln With Fam Mem | 0 | BusinessRlnWithFamMemInd |
| Business Rln With35 Ctrl Ent | 0 | BusinessRlnWith35CtrlEntInd |
| Deductible Non Cash Contri | 0 | DeductibleNonCashContriInd |
| Deductible Art Contribution | 0 | DeductibleArtContributionInd |
| Terminate Operations | 0 | TerminateOperationsInd |
| Partial Liquidation | 0 | PartialLiquidationInd |
| Disregarded Entity | 0 | DisregardedEntityInd |
| Related Entity | Yes (1) | RelatedEntityInd |
| Related Organization Ctrl Ent | 0 | RelatedOrganizationCtrlEntInd |
| Trnsfr Exmpt Non Chrtbl Rltd Org | 0 | TrnsfrExmptNonChrtblRltdOrgInd |
| Activities Conducted Prtshp | 0 | ActivitiesConductedPrtshpInd |
| Schedule O Required | Yes (1) | ScheduleORequiredInd |
| IRP Document | 39 | IRPDocumentCnt |
| IRP Document W2 G | 0 | IRPDocumentW2GCnt |
| Backup Wthld Compliance | Yes (1) | BackupWthldComplianceInd |
| Employee | 567 | EmployeeCnt |
| Employment Tax Returns Filed | Yes (1) | EmploymentTaxReturnsFiledInd |
| Unrelated Bus Incm Over Limit | Yes (1) | UnrelatedBusIncmOverLimitInd |
| Form990 T Filed | Yes (1) | Form990TFiledInd |
| Foreign Financial Account | 0 | ForeignFinancialAccountInd |
| Prohibited Tax Shelter Trans | 0 | ProhibitedTaxShelterTransInd |
| Taxable Party Notification | 0 | TaxablePartyNotificationInd |
| Nondeductible Contributions | 0 | NondeductibleContributionsInd |
| Quid Pro Quo Contributions | 0 | QuidProQuoContributionsInd |
| Form8282 Property Disposed Of | 0 | Form8282PropertyDisposedOfInd |
| Rcv Fnds To Pay Prsnl Bnft Cntrct | 0 | RcvFndsToPayPrsnlBnftCntrctInd |
| Pay Premiums Prsnl Bnft Cntrct | 0 | PayPremiumsPrsnlBnftCntrctInd |
| Indoor Tanning Services | 0 | IndoorTanningServicesInd |
| Subj To Tax Rmnrtn Ex Prcht Pymt | 0 | SubjToTaxRmnrtnExPrchtPymtInd |
| Subject To Excs Tax Net Invst Inc | 0 | SubjectToExcsTaxNetInvstIncInd |
| Info In Schedule O Part VI | Yes (X) | InfoInScheduleOPartVIInd |
| Governing Body Voting Members | 8 | GoverningBodyVotingMembersCnt |
| Independent Voting Member | 6 | IndependentVotingMemberCnt |
| Family Or Business Rln | 0 | FamilyOrBusinessRlnInd |
| Delegation Of Mgmt Duties | 0 | DelegationOfMgmtDutiesInd |
| Change To Org Documents | 0 | ChangeToOrgDocumentsInd |
| Material Diversion Or Misuse | 0 | MaterialDiversionOrMisuseInd |
| Members Or Stockholders | Yes (1) | MembersOrStockholdersInd |
| Election Of Board Members | Yes (1) | ElectionOfBoardMembersInd |
| Decisions Subject To Approva | 0 | DecisionsSubjectToApprovaInd |
| Minutes Of Governing Body | Yes (1) | MinutesOfGoverningBodyInd |
| Minutes Of Committees | Yes (1) | MinutesOfCommitteesInd |
| Officer Mailing Address | 0 | OfficerMailingAddressInd |
| Local Chapters | 0 | LocalChaptersInd |
| Form990 Provided To Gvrn Body | Yes (1) | Form990ProvidedToGvrnBodyInd |
| Conflict Of Interest Policy | Yes (1) | ConflictOfInterestPolicyInd |
| Annual Disclosure Covered Prsn | Yes (1) | AnnualDisclosureCoveredPrsnInd |
| Regular Monitoring Enfrc | Yes (1) | RegularMonitoringEnfrcInd |
| Whistleblower Policy | Yes (1) | WhistleblowerPolicyInd |
| Document Retention Policy | Yes (1) | DocumentRetentionPolicyInd |
| Compensation Process CEO | Yes (1) | CompensationProcessCEOInd |
| Compensation Process Other | Yes (1) | CompensationProcessOtherInd |
| Investment In Joint Venture | 0 | InvestmentInJointVentureInd |
| States Where Copy Of Return Is Fld | MN | StatesWhereCopyOfReturnIsFldCd |
| Upon Request | Yes (X) | UponRequestInd |
Books In Care Of Detail BooksInCareOfDetail
Business Name BusinessName
| Field | Value | IRS element (for citing) |
|---|---|---|
| Business Name Line1 | BRAD ANDERSON | BusinessNameLine1Txt |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Phone | 2188787027 | PhoneNum |
US Address USAddress
| Field | Value | IRS element (for citing) |
|---|---|---|
| Address Line1 | 512 SKYLINE BLVD | AddressLine1Txt |
| City | CLOQUET | CityNm |
| State Abbreviation | MN | StateAbbreviationCd |
| ZIP | 55720 | ZIPCd |
Form990 Part VII Section A Form990PartVIISectionAGrp (16 entries)
| TitleTitleTxt | Average Hours Per WeekAverageHoursPerWeekRt | Average Hours Per Week Rltd OrgAverageHoursPerWeekRltdOrgRt | Highest Compensated EmployeeHighestCompensatedEmployeeInd | Reportable Comp From OrgReportableCompFromOrgAmt | Reportable Comp From Rltd OrgReportableCompFromRltdOrgAmt | Other CompensationOtherCompensationAmt | OfficerOfficerInd | Individual Trustee Or DirectorIndividualTrusteeOrDirectorInd |
|---|---|---|---|---|---|---|---|---|
| KYLE MENZEL MD | ||||||||
| PHYSICIAN | 40.00 | 0.00 | Yes (X) | $659,720 | $0 | $37,218 | ||
| ADRIANNE WESTMORELAND MD | ||||||||
| PHYSICIAN | 40.00 | 0.00 | Yes (X) | $508,176 | $0 | $18,674 | ||
| JOSEPH LEMKER MD | ||||||||
| PHYSICIAN | 40.00 | 0.00 | Yes (X) | $504,094 | $0 | $14,500 | ||
| MATTHEW LEWIS | ||||||||
| CRNA | 40.00 | 0.00 | Yes (X) | $414,357 | $0 | $58,641 | ||
| RICK BREUER | ||||||||
| CEO | 40.00 | 4.00 | $406,592 | $0 | $49,334 | Yes (X) | ||
| CHAD FEY MD | ||||||||
| PHYSICIAN | 40.00 | 0.00 | Yes (X) | $377,614 | $0 | $23,960 | ||
| KARA UNDERWOOD MD | ||||||||
| PHYSICIAN / DIRECTOR | 40.00 | 0.00 | $356,570 | $0 | $14,500 | Yes (X) | ||
| BRAD ANDERSON | ||||||||
| CFO | 40.00 | 2.00 | $240,131 | $0 | $47,356 | Yes (X) | ||
| JOANNA ROBNIK MD | ||||||||
| PHYSICIAN / DIRECTOR | 40.00 | 0.00 | $248,817 | $0 | $35,981 | Yes (X) | ||
| JENNIFER DUPUIS | ||||||||
| DIRECTOR UNTIL 5/16/22 | 2.00 | 0.00 | $0 | $0 | $0 | Yes (X) | ||
| LES RIESS MD | ||||||||
| DIRECTOR | 2.00 | 0.00 | $0 | $0 | $0 | Yes (X) | ||
| STEVE RISACHER | ||||||||
| DIRECTOR | 2.00 | 0.00 | $0 | $0 | $0 | Yes (X) | ||
| NANCY KLASSEN | ||||||||
| TREASURER | 2.00 | 0.00 | $0 | $0 | $0 | Yes (X) | Yes (X) | |
| KIRK WIMMER | ||||||||
| SECRETARY | 2.00 | 0.00 | $0 | $0 | $0 | Yes (X) | Yes (X) | |
| DAVID HALL | ||||||||
| VICE CHAIR | 2.00 | 0.00 | $0 | $0 | $0 | Yes (X) | Yes (X) | |
| LEE OLSEN | ||||||||
| CHAIR | 2.00 | 0.00 | $0 | $0 | $0 | Yes (X) | Yes (X) | |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Reportable Comp From Org | $3,716,071 | TotalReportableCompFromOrgAmt |
| Tot Reportable Comp Rltd Org | $0 | TotReportableCompRltdOrgAmt |
| Total Other Compensation | $300,164 | TotalOtherCompensationAmt |
| Indiv Rcvd Greater Than100 K | 68 | IndivRcvdGreaterThan100KCnt |
| Former Ofcr Employees Listed | 0 | FormerOfcrEmployeesListedInd |
| Total Comp Greater Than150 K | Yes (1) | TotalCompGreaterThan150KInd |
| Compensation From Other Srcs | 0 | CompensationFromOtherSrcsInd |
Contractor Compensation ContractorCompensationGrp (5 entries)
| Address Line1ContractorAddress/USAddress/AddressLine1Txt | CityContractorAddress/USAddress/CityNm | State AbbreviationContractorAddress/USAddress/StateAbbreviationCd | ZIPContractorAddress/USAddress/ZIPCd | ServicesServicesDesc | CompensationCompensationAmt |
|---|---|---|---|---|---|
| SISU MEDICAL SOLUTIONS LLC | |||||
| 4960 MILLER TRUNK HIGHWAY STE 500 | HERMANTOWN | MN | 55811 | IT SERVICES | $1,424,042 |
| CENTRAL MINNESOTA DIAGNOSTIC INC | |||||
| 525 10TH STREET NE | MILACA | MN | 56353 | IMAGING SERVICES | $1,165,709 |
| RADIOLOGISTS ASSOCIATED IN DULUTH LTD | |||||
| 304 N POKEGAMA AVENUE STE 300 | GRAND RAPIDS | MN | 55744 | IMAGING SERVICES | $682,337 |
| ST LUKES' HOSPITAL | |||||
| 915 EAST 1ST STREET | DULUTH | MN | 55805 | LAB SERVICES | $679,409 |
| AGILITI HEALTH INC | |||||
| 6625 W 78TH STREET STE 300 | MINNEAPOLIS | MN | 55439 | EQUIPMENT MAINTENANCE | $411,748 |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Cntrct Rcvd Greater Than100 K | 14 | CntrctRcvdGreaterThan100KCnt |
| Related Organizations | $218,301 | RelatedOrganizationsAmt |
| Government Grants | $1,814,889 | GovernmentGrantsAmt |
| All Other Contributions | $193,590 | AllOtherContributionsAmt |
| Total Contributions | $2,226,780 | TotalContributionsAmt |
Program Service Revenue ProgramServiceRevenueGrp (3 entries)
| DescDesc | BusinessBusinessCd | Total Revenue ColumnTotalRevenueColumnAmt | Related Or Exempt Func IncomeRelatedOrExemptFuncIncomeAmt | Unrelated Business RevenueUnrelatedBusinessRevenueAmt |
|---|---|---|---|---|
| PATIENT SERVICE REVENUE | 621500 | $68,316,507 | $68,316,507 | |
| OTHER INCOME | 621500 | $286,903 | $286,903 | |
| OUTSIDE LAB SALES | 621500 | $2,554 | $2,554 |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Program Service Revenue | $68,605,964 | TotalProgramServiceRevenueAmt |
Investment Income InvestmentIncomeGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Revenue Column | $70,282 | TotalRevenueColumnAmt |
| Exclusion | $70,282 | ExclusionAmt |
Gross Rents GrossRentsGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Real | $173,476 | RealAmt |
Less Rental Expenses LessRentalExpensesGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Real | $0 | RealAmt |
Rental Income Or Loss RentalIncomeOrLossGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Real | $173,476 | RealAmt |
Net Rental Income Or Loss NetRentalIncomeOrLossGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Revenue Column | $173,476 | TotalRevenueColumnAmt |
| Exclusion | $173,476 | ExclusionAmt |
Gross Amount Sales Assets GrossAmountSalesAssetsGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Other | $4,451 | OtherAmt |
Less Cost Oth Basis Sales Expnss LessCostOthBasisSalesExpnssGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Other | $3,969 | OtherAmt |
Gain Or Loss GainOrLossGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Other | $482 | OtherAmt |
Net Gain Or Loss Investments NetGainOrLossInvestmentsGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Revenue Column | $482 | TotalRevenueColumnAmt |
| Exclusion | $482 | ExclusionAmt |
Other Revenue Misc OtherRevenueMiscGrp (3 entries)
| DescDesc | BusinessBusinessCd | Total Revenue ColumnTotalRevenueColumnAmt | Related Or Exempt Func IncomeRelatedOrExemptFuncIncomeAmt | Unrelated Business RevenueUnrelatedBusinessRevenueAmt | ExclusionExclusionAmt |
|---|---|---|---|---|---|
| EARNINGS IN CMDI | 900099 | $256,125 | $256,125 | ||
| EARNINGS IN SISU MEDICAL SOLUTION | 900099 | $47,195 | $47,195 | ||
| TAX REFUND | 900099 | $7,812 | $7,812 |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Other Revenue Total | $311,132 | OtherRevenueTotalAmt |
Total Revenue TotalRevenueGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Revenue Column | $71,388,116 | TotalRevenueColumnAmt |
| Related Or Exempt Func Income | $68,859,535 | RelatedOrExemptFuncIncomeAmt |
| Unrelated Business Revenue | $49,749 | UnrelatedBusinessRevenueAmt |
| Exclusion | $252,052 | ExclusionAmt |
Grants To Domestic Orgs GrantsToDomesticOrgsGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $20,955 | TotalAmt |
| Program Services | $20,955 | ProgramServicesAmt |
Comp Current Ofcr Directors CompCurrentOfcrDirectorsGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $1,507,302 | TotalAmt |
| Program Services | $695,237 | ProgramServicesAmt |
| Management And General | $812,065 | ManagementAndGeneralAmt |
Other Salaries And Wages OtherSalariesAndWagesGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $35,161,736 | TotalAmt |
| Program Services | $33,801,971 | ProgramServicesAmt |
| Management And General | $1,359,765 | ManagementAndGeneralAmt |
Pension Plan Contributions PensionPlanContributionsGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $1,435,637 | TotalAmt |
| Program Services | $1,380,458 | ProgramServicesAmt |
| Management And General | $55,179 | ManagementAndGeneralAmt |
Other Employee Benefits OtherEmployeeBenefitsGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $4,042,371 | TotalAmt |
| Program Services | $3,492,278 | ProgramServicesAmt |
| Management And General | $550,093 | ManagementAndGeneralAmt |
Payroll Taxes PayrollTaxesGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $2,353,304 | TotalAmt |
| Program Services | $2,211,290 | ProgramServicesAmt |
| Management And General | $142,014 | ManagementAndGeneralAmt |
Fees For Services Legal FeesForServicesLegalGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $29,216 | TotalAmt |
| Management And General | $29,216 | ManagementAndGeneralAmt |
Fees For Services Accounting FeesForServicesAccountingGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $86,602 | TotalAmt |
| Management And General | $86,602 | ManagementAndGeneralAmt |
Fees For Services Lobbying FeesForServicesLobbyingGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $3,529 | TotalAmt |
| Management And General | $3,529 | ManagementAndGeneralAmt |
Fees For Services Other FeesForServicesOtherGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $6,493,367 | TotalAmt |
| Program Services | $6,407,670 | ProgramServicesAmt |
| Management And General | $85,697 | ManagementAndGeneralAmt |
Advertising AdvertisingGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $198,069 | TotalAmt |
| Management And General | $198,069 | ManagementAndGeneralAmt |
Office Expenses OfficeExpensesGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $730,537 | TotalAmt |
| Program Services | $582,823 | ProgramServicesAmt |
| Management And General | $147,714 | ManagementAndGeneralAmt |
Occupancy OccupancyGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $1,715,357 | TotalAmt |
| Program Services | $1,445,782 | ProgramServicesAmt |
| Management And General | $269,575 | ManagementAndGeneralAmt |
Travel TravelGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $176,274 | TotalAmt |
| Program Services | $164,522 | ProgramServicesAmt |
| Management And General | $11,752 | ManagementAndGeneralAmt |
Interest InterestGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $1,014,690 | TotalAmt |
| Management And General | $1,014,690 | ManagementAndGeneralAmt |
Depreciation Depletion DepreciationDepletionGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $2,902,936 | TotalAmt |
| Program Services | $2,463,263 | ProgramServicesAmt |
| Management And General | $439,673 | ManagementAndGeneralAmt |
Insurance InsuranceGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $374,923 | TotalAmt |
| Program Services | $69,405 | ProgramServicesAmt |
| Management And General | $305,518 | ManagementAndGeneralAmt |
Other Expenses OtherExpensesGrp (4 entries)
| DescDesc | TotalTotalAmt | Management And GeneralManagementAndGeneralAmt | Program ServicesProgramServicesAmt |
|---|---|---|---|
| UBI TAX | $6,000 | $6,000 | |
| MEDICAL SUPPLIES | $5,013,432 | $292 | $5,013,140 |
| DRUGS | $4,907,688 | $4,907,688 | |
| IMPLICIT PRICE CONCESSI | $2,104,950 | $2,104,950 |
All Other Expenses AllOtherExpensesGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $3,561,407 | TotalAmt |
| Program Services | $2,058,439 | ProgramServicesAmt |
| Management And General | $1,502,968 | ManagementAndGeneralAmt |
Total Functional Expenses TotalFunctionalExpensesGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $73,840,282 | TotalAmt |
| Program Services | $66,819,871 | ProgramServicesAmt |
| Management And General | $7,020,411 | ManagementAndGeneralAmt |
| Fundraising | $0 | FundraisingAmt |
Cash Non Interest Bearing CashNonInterestBearingGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $2,276,547 | BOYAmt |
| EOY | $1,148,744 | EOYAmt |
Savings And Temp Cash Invst SavingsAndTempCashInvstGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $12,942,154 | BOYAmt |
| EOY | $12,020,045 | EOYAmt |
Accounts Receivable AccountsReceivableGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $10,199,950 | BOYAmt |
| EOY | $10,965,245 | EOYAmt |
Oth Notes Loans Receivable Net OthNotesLoansReceivableNetGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $1,447,979 | BOYAmt |
| EOY | $1,363,206 | EOYAmt |
Inventories For Sale Or Use InventoriesForSaleOrUseGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $2,178,077 | BOYAmt |
| EOY | $2,225,933 | EOYAmt |
Prepaid Expenses Defrd Charges PrepaidExpensesDefrdChargesGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $779,855 | BOYAmt |
| EOY | $453,399 | EOYAmt |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Land Bldg Equip Cost Or Other Bss | $65,909,095 | LandBldgEquipCostOrOtherBssAmt |
| Land Bldg Equip Accum Deprec | $41,826,035 | LandBldgEquipAccumDeprecAmt |
Land Bldg Equip Basis Net LandBldgEquipBasisNetGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $26,035,563 | BOYAmt |
| EOY | $24,083,060 | EOYAmt |
Investments Program Related InvestmentsProgramRelatedGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $2,574,186 | BOYAmt |
| EOY | $2,017,552 | EOYAmt |
Intangible Assets IntangibleAssetsGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $1,289,510 | BOYAmt |
| EOY | $1,133,206 | EOYAmt |
Total Assets TotalAssetsGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $59,723,821 | BOYAmt |
| EOY | $55,410,390 | EOYAmt |
Accounts Payable Accr Expnss AccountsPayableAccrExpnssGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $5,693,310 | BOYAmt |
| EOY | $6,199,393 | EOYAmt |
Escrow Account Liability EscrowAccountLiabilityGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $22,155 | BOYAmt |
| EOY | $27,877 | EOYAmt |
Mortg Notes Pybl Scrd Invst Prop MortgNotesPyblScrdInvstPropGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $27,287,496 | BOYAmt |
| EOY | $25,667,621 | EOYAmt |
Other Liabilities OtherLiabilitiesGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $1,779,000 | BOYAmt |
| EOY | $1,073,000 | EOYAmt |
Total Liabilities TotalLiabilitiesGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $34,781,961 | BOYAmt |
| EOY | $32,967,891 | EOYAmt |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Organization Follows FASB117 | Yes (X) | OrganizationFollowsFASB117Ind |
No Donor Restriction Net Assets NoDonorRestrictionNetAssetsGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $24,646,991 | BOYAmt |
| EOY | $22,146,054 | EOYAmt |
Donor Restriction Net Assets DonorRestrictionNetAssetsGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $294,869 | BOYAmt |
| EOY | $296,445 | EOYAmt |
Total Net Assets Fund Balance TotalNetAssetsFundBalanceGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $24,941,860 | BOYAmt |
| EOY | $22,442,499 | EOYAmt |
Tot Liab Net Assets Fund Balance TotLiabNetAssetsFundBalanceGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $59,723,821 | BOYAmt |
| EOY | $55,410,390 | EOYAmt |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Info In Schedule O Part XI | Yes (X) | InfoInScheduleOPartXIInd |
| Reconcilation Revenue Expnss | -$2,452,166 | ReconcilationRevenueExpnssAmt |
| Other Changes In Net Assets | -$47,195 | OtherChangesInNetAssetsAmt |
| Method Of Accounting Accrual | Yes (X) | MethodOfAccountingAccrualInd |
| Accountant Compile Or Review | 0 | AccountantCompileOrReviewInd |
| FS Audited | Yes (1) | FSAuditedInd |
FS Audited Basis FSAuditedBasisGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Separate Basis Fincl Stmt | Yes (X) | SeparateBasisFinclStmtInd |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Audit Committee | Yes (1) | AuditCommitteeInd |
| Federal Grant Audit Required | Yes (1) | FederalGrantAuditRequiredInd |
| Federal Grant Audit Performed | Yes (1) | FederalGrantAuditPerformedInd |
Schedule A IRS990ScheduleA
| Field | Value | IRS element (for citing) |
|---|---|---|
| Hospital | Yes (X) | HospitalInd |
Schedule B IRS990ScheduleB
Contributor Information ContributorInformationGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Contributor | RESTRICTED | ContributorNum |
Contributor Business Name ContributorBusinessName
| Field | Value | IRS element (for citing) |
|---|---|---|
| Business Name Line1 | RESTRICTED | BusinessNameLine1 |
Contributor US Address ContributorUSAddress
| Field | Value | IRS element (for citing) |
|---|---|---|
| Address Line1 | RESTRICTED | AddressLine1 |
| Address Line2 | RESTRICTED | AddressLine2 |
| City | RESTRICTED | City |
| State | RESTRICTED | State |
| ZIP Code | RESTRICTED | ZIPCode |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Contributions | RESTRICTED | TotalContributionsAmt |
Schedule C IRS990ScheduleC
| Field | Value | IRS element (for citing) |
|---|---|---|
| Volunteers | 0 | VolunteersInd |
| Paid Staff Or Management | 0 | PaidStaffOrManagementInd |
| Media Advertisements | 0 | MediaAdvertisementsInd |
| Mailings Members | 0 | MailingsMembersInd |
| Publications Or Broadcast | 0 | PublicationsOrBroadcastInd |
| Grants Other Organizations | 0 | GrantsOtherOrganizationsInd |
| Direct Contact Legislators | 0 | DirectContactLegislatorsInd |
| Rallies Demonstrations | 0 | RalliesDemonstrationsInd |
| Other Activities | Yes (1) | OtherActivitiesInd |
| Other Activities | $3,529 | OtherActivitiesAmt |
| Total Lobbying Expenditures | $3,529 | TotalLobbyingExpendituresAmt |
| Not Described Section501c3 | 0 | NotDescribedSection501c3Ind |
Supplemental Information Detail SupplementalInformationDetail
| Field | Value | IRS element (for citing) |
|---|---|---|
| Form And Line Reference | PART II-B, LINE 1: | FormAndLineReferenceDesc |
| Explanation | COMMUNITY MEMORIAL HOSPITAL ASSOCIATION PAYS DUES TO CERTAIN ORGANIZATIONS RELATED TO THE INDUSTRY WHICH HAVE LOBBYING EXPENSES. THE AMOUNT LISTED IS THE PERCENTAGE OF THE DUES PAID THAT WERE USED FOR LOBBYING. | ExplanationTxt |
Schedule D IRS990ScheduleD
| Field | Value | IRS element (for citing) |
|---|---|---|
| Agent Trustee Etc | 0 | AgentTrusteeEtcInd |
| Incl Escrow Custodial Acct Liab | Yes (1) | InclEscrowCustodialAcctLiabInd |
| Explanation Provided | Yes (X) | ExplanationProvidedInd |
CY Endwmt Fund CYEndwmtFundGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Beginning Year Balance | $294,869 | BeginningYearBalanceAmt |
| Investment Earnings Or Losses | $1,576 | InvestmentEarningsOrLossesAmt |
| End Year Balance | $296,445 | EndYearBalanceAmt |
CY Minus1 Yr Endwmt Fund CYMinus1YrEndwmtFundGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Beginning Year Balance | $292,457 | BeginningYearBalanceAmt |
| Investment Earnings Or Losses | $2,588 | InvestmentEarningsOrLossesAmt |
| Other Expenditures | $176 | OtherExpendituresAmt |
| End Year Balance | $294,869 | EndYearBalanceAmt |
CY Minus2 Yr Endwmt Fund CYMinus2YrEndwmtFundGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Beginning Year Balance | $417,785 | BeginningYearBalanceAmt |
| Investment Earnings Or Losses | $4,135 | InvestmentEarningsOrLossesAmt |
| Other Expenditures | $129,463 | OtherExpendituresAmt |
| End Year Balance | $292,457 | EndYearBalanceAmt |
CY Minus3 Yr Endwmt Fund CYMinus3YrEndwmtFundGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Beginning Year Balance | $297,010 | BeginningYearBalanceAmt |
| Contributions | $125,000 | ContributionsAmt |
| Investment Earnings Or Losses | $3,139 | InvestmentEarningsOrLossesAmt |
| Other Expenditures | $7,364 | OtherExpendituresAmt |
| End Year Balance | $417,785 | EndYearBalanceAmt |
CY Minus4 Yr Endwmt Fund CYMinus4YrEndwmtFundGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Beginning Year Balance | $294,993 | BeginningYearBalanceAmt |
| Investment Earnings Or Losses | $2,017 | InvestmentEarningsOrLossesAmt |
| End Year Balance | $297,010 | EndYearBalanceAmt |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Board Designated Balance EOY | 1.00000 | BoardDesignatedBalanceEOYPct |
| Prmnnt Endowment Balance EOY | 0.00000 | PrmnntEndowmentBalanceEOYPct |
| Term Endowment Balance EOY | 0.00000 | TermEndowmentBalanceEOYPct |
| Endowments Held Unrelated Org | 0 | EndowmentsHeldUnrelatedOrgInd |
| Endowments Held Related Org | 0 | EndowmentsHeldRelatedOrgInd |
Land LandGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Other Cost Or Other Basis | $659,448 | OtherCostOrOtherBasisAmt |
| Book Value | $659,448 | BookValueAmt |
Buildings BuildingsGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Other Cost Or Other Basis | $50,064,627 | OtherCostOrOtherBasisAmt |
| Depreciation | $30,213,568 | DepreciationAmt |
| Book Value | $19,851,059 | BookValueAmt |
Equipment EquipmentGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Other Cost Or Other Basis | $13,454,939 | OtherCostOrOtherBasisAmt |
| Depreciation | $10,224,149 | DepreciationAmt |
| Book Value | $3,230,790 | BookValueAmt |
Other Land Buildings OtherLandBuildingsGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Other Cost Or Other Basis | $1,730,081 | OtherCostOrOtherBasisAmt |
| Depreciation | $1,388,318 | DepreciationAmt |
| Book Value | $341,763 | BookValueAmt |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Book Value Land Buildings | $24,083,060 | TotalBookValueLandBuildingsAmt |
Other Liabilities Org OtherLiabilitiesOrgGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Desc | THIRD-PARTY PAYOR SETTLEMENTS | Desc |
| Amt | $1,073,000 | Amt |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Liability | $1,073,000 | TotalLiabilityAmt |
| Footnote Text | Yes (X) | FootnoteTextInd |
| Total Rev Etc Audited Fincl Stmt | $69,227,677 | TotalRevEtcAuditedFinclStmtAmt |
| Other Revenue | -$2,104,950 | OtherRevenueAmt |
| Revenue Not Reported | -$2,104,950 | RevenueNotReportedAmt |
| Revenue Subtotal | $71,332,627 | RevenueSubtotalAmt |
| Other Revenues Not Included | $55,489 | OtherRevenuesNotIncludedAmt |
| Revenue Not Reported Fincl Stmt | $55,489 | RevenueNotReportedFinclStmtAmt |
| Total Revenue Per Form990 | $71,388,116 | TotalRevenuePerForm990Amt |
| Tot Expns Etc Audited Fincl Stmt | $71,727,038 | TotExpnsEtcAuditedFinclStmtAmt |
| Other Expenses Included | -$8,294 | OtherExpensesIncludedAmt |
| Expenses Not Reported | -$8,294 | ExpensesNotReportedAmt |
| Expenses Subtotal | $71,735,332 | ExpensesSubtotalAmt |
| Other Expenses Not Included | $2,104,950 | OtherExpensesNotIncludedAmt |
| Expenses Not Rpt Fincl Stmt | $2,104,950 | ExpensesNotRptFinclStmtAmt |
| Total Expenses Per Form990 | $73,840,282 | TotalExpensesPerForm990Amt |
Supplemental Information Detail SupplementalInformationDetail (7 entries)
| Form And Line ReferenceFormAndLineReferenceDesc | ExplanationExplanationTxt |
|---|---|
| PART IV, LINE 2B: | THE HOSPITAL IS THE CUSTODIAN OF FUNDS BELONGING TO RESIDENTS OF THE NURSING HOME. THE HOSPITAL HOLDS THESE FUNDS FOR PURCHASES MADE BY THE RESIDENTS. |
| PART V, LINE 4: | THE FUNDS ARE TO BE USED ONLY FOR EQUIPMENT NEEDS IN SUNNYSIDE (SNF) OR ICU AND TO BRING DIALYSIS INTO THE COMMUNITY. |
| PART X, LINE 2: | NONPROFIT ORGANIZATIONS MAY BECOME SUBJECT TO INCOME TAXES IF QUALIFICATION AS A TAX-EXEMPT ENTITY CHANGES, IF UNRELATED BUSINESS INCOME IS GENERATED, AND IN CERTAIN OTHER INSTANCES. NONPROFIT ORGANIZATIONS ARE REQUIRED TO ASSESS THE CERTAINTY OF THEIR TAX POSITIONS RELATED TO THESE MATTERS AND, IN SOME CASES, RECORD LIABILITIES FOR POTENTIAL TAXES, INTEREST AND PENALTIES ACCOMPANIED BY FOOTNOTE DISCLOSURES. THE ASSOCIATION HAS NOT IDENTIFIED ANY UNCERTAIN TAX POSITIONS THAT WOULD REQUIRE THE ACCRUAL OF AN INCOME TAX PROVISION. GENERALLY, THE ASSOCIATION IS NO LONGER SUBJECT TO INCOME TAX EXAMINATIONS BY THE U.S. FEDERAL OR STATE TAX AUTHORITIES FOR YEARS BEFORE 2019. |
| PART XI, LINE 2D - OTHER ADJUSTMENTS: | IMPLICIT PRICE CONCESSIONS -2,104,950. |
| PART XI, LINE 4B - OTHER ADJUSTMENTS: | SISU MEDICAL SOLUTIONS, LLC SCHEDULE K-1 ACTIVITY 47,195. GAIN ON SALE OF ASSETS 482. TAX REFUND 7,812. |
| PART XII, LINE 2D - OTHER ADJUSTMENTS: | GAIN ON SALE OF ASSETS -482. TAX REFUND -7,812. |
| PART XII, LINE 4B - OTHER ADJUSTMENTS: | IMPLICIT PRICE CONCESSIONS 2,104,950. |
Schedule H IRS990ScheduleH
| Field | Value | IRS element (for citing) |
|---|---|---|
| Financial Assistance Policy | Yes (1) | FinancialAssistancePolicyInd |
| Written Policy | Yes (1) | WrittenPolicyInd |
| All Hospitals Policy | Yes (X) | AllHospitalsPolicyInd |
| FPG Reference Free Care | Yes (1) | FPGReferenceFreeCareInd |
| Percent200 | Yes (X) | Percent200Ind |
| FPG Reference Discounted Care | Yes (1) | FPGReferenceDiscountedCareInd |
| Percent250 | Yes (X) | Percent250Ind |
| Free Care Medically Indigent | Yes (1) | FreeCareMedicallyIndigentInd |
| Financial Assistance Budget | Yes (1) | FinancialAssistanceBudgetInd |
| Expenses Exceed Budget | Yes (1) | ExpensesExceedBudgetInd |
| Unable To Provide Care | 0 | UnableToProvideCareInd |
| Annual Community Bnft Report | Yes (1) | AnnualCommunityBnftReportInd |
| Report Publically Available | Yes (1) | ReportPublicallyAvailableInd |
Financial Assistance At Cost Typ FinancialAssistanceAtCostTyp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Community Benefit Expns | $1,745,173 | TotalCommunityBenefitExpnsAmt |
| Net Community Benefit Expns | $1,745,173 | NetCommunityBenefitExpnsAmt |
| Total Expense | 0.02430 | TotalExpensePct |
Unreimbursed Medicaid UnreimbursedMedicaidGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Community Benefit Expns | $12,690,307 | TotalCommunityBenefitExpnsAmt |
| Direct Offsetting Revenue | $9,717,951 | DirectOffsettingRevenueAmt |
| Net Community Benefit Expns | $2,972,356 | NetCommunityBenefitExpnsAmt |
| Total Expense | 0.04140 | TotalExpensePct |
Unreimbursed Costs UnreimbursedCostsGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Community Benefit Expns | $3,296,537 | TotalCommunityBenefitExpnsAmt |
| Direct Offsetting Revenue | $3,091,341 | DirectOffsettingRevenueAmt |
| Net Community Benefit Expns | $205,196 | NetCommunityBenefitExpnsAmt |
| Total Expense | 0.00290 | TotalExpensePct |
Total Financial Assistance Typ TotalFinancialAssistanceTyp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Community Benefit Expns | $17,732,017 | TotalCommunityBenefitExpnsAmt |
| Direct Offsetting Revenue | $12,809,292 | DirectOffsettingRevenueAmt |
| Net Community Benefit Expns | $4,922,725 | NetCommunityBenefitExpnsAmt |
| Total Expense | 0.06860 | TotalExpensePct |
Health Professions Education HealthProfessionsEducationGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Community Benefit Expns | $775,843 | TotalCommunityBenefitExpnsAmt |
| Direct Offsetting Revenue | $25,859 | DirectOffsettingRevenueAmt |
| Net Community Benefit Expns | $749,984 | NetCommunityBenefitExpnsAmt |
| Total Expense | 0.01050 | TotalExpensePct |
Cash And In Kind Contributions CashAndInKindContributionsGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Community Benefit Expns | $54,255 | TotalCommunityBenefitExpnsAmt |
| Net Community Benefit Expns | $54,255 | NetCommunityBenefitExpnsAmt |
| Total Expense | 0.00080 | TotalExpensePct |
Total Other Benefits TotalOtherBenefitsGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Community Benefit Expns | $830,098 | TotalCommunityBenefitExpnsAmt |
| Direct Offsetting Revenue | $25,859 | DirectOffsettingRevenueAmt |
| Net Community Benefit Expns | $804,239 | NetCommunityBenefitExpnsAmt |
| Total Expense | 0.01130 | TotalExpensePct |
Total Community Benefits TotalCommunityBenefitsGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Community Benefit Expns | $18,562,115 | TotalCommunityBenefitExpnsAmt |
| Direct Offsetting Revenue | $12,835,151 | DirectOffsettingRevenueAmt |
| Net Community Benefit Expns | $5,726,964 | NetCommunityBenefitExpnsAmt |
| Total Expense | 0.07990 | TotalExpensePct |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Bad Debt Expense Reported | Yes (1) | BadDebtExpenseReportedInd |
| Bad Debt Expense | $2,104,950 | BadDebtExpenseAmt |
| Reimbursed By Medicare | $19,809,939 | ReimbursedByMedicareAmt |
| Cost Of Care Reimbursed By Medcr | $24,997,663 | CostOfCareReimbursedByMedcrAmt |
| Medicare Surplus Or Shortfall | -$5,187,724 | MedicareSurplusOrShortfallAmt |
Costing Methodology Used CostingMethodologyUsedGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Cost To Charge Ratio | Yes (X) | CostToChargeRatioInd |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Written Debt Collection Policy | Yes (1) | WrittenDebtCollectionPolicyInd |
| Financial Assistance Prvsn | Yes (1) | FinancialAssistancePrvsnInd |
| Hospital Facilities | 1 | HospitalFacilitiesCnt |
Hospital Facilities HospitalFacilitiesGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Facility | 1 | FacilityNum |
Business Name BusinessName
| Field | Value | IRS element (for citing) |
|---|---|---|
| Business Name Line1 | COMMUNITY MEMORIAL HOSPITAL | BusinessNameLine1Txt |
US Address USAddress
| Field | Value | IRS element (for citing) |
|---|---|---|
| Address Line1 | 512 SKYLINE BLVD | AddressLine1Txt |
| City | CLOQUET | CityNm |
| State Abbreviation | MN | StateAbbreviationCd |
| ZIP | 55720 | ZIPCd |
| Field | Value | IRS element (for citing) |
|---|---|---|
| State License | 398824 | StateLicenseNum |
| Licensed Hospital | Yes (X) | LicensedHospitalInd |
| General Medical And Surgical | Yes (X) | GeneralMedicalAndSurgicalInd |
| Critical Access Hospital | Yes (X) | CriticalAccessHospitalInd |
| Emergency Room24 Hrs | Yes (X) | EmergencyRoom24HrsInd |
| Other | NONE | OtherDesc |
Hospital Fclty Policies Prctc HospitalFcltyPoliciesPrctcGrp
Hospital Facility Name HospitalFacilityName
| Field | Value | IRS element (for citing) |
|---|---|---|
| Business Name Line1 | COMMUNITY MEMORIAL HOSPITAL ASSOCIATION | BusinessNameLine1Txt |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Facility | 1 | FacilityNum |
| First Licensed CY Or PY | 0 | FirstLicensedCYOrPYInd |
| Tax Exempt Hospital CY Or PY | 0 | TaxExemptHospitalCYOrPYInd |
| CHNA Conducted | Yes (1) | CHNAConductedInd |
| Community Definition | Yes (X) | CommunityDefinitionInd |
| Community Demographics | Yes (X) | CommunityDemographicsInd |
| Existing Resources | Yes (X) | ExistingResourcesInd |
| How Data Obtained | Yes (X) | HowDataObtainedInd |
| Community Health Needs | Yes (X) | CommunityHealthNeedsInd |
| Other Health Issues | Yes (X) | OtherHealthIssuesInd |
| Community Hlth Needs Id Process | Yes (X) | CommunityHlthNeedsIdProcessInd |
| Consulting Process | Yes (X) | ConsultingProcessInd |
| Prior CHNA Impact | Yes (X) | PriorCHNAImpactInd |
| CHNA Conducted | 21 | CHNAConductedYr |
| Take Into Account Others Input | Yes (1) | TakeIntoAccountOthersInputInd |
| CHNA Conducted With Other Fclts | 0 | CHNAConductedWithOtherFcltsInd |
| CHNA Conducted With Non Fclts | Yes (1) | CHNAConductedWithNonFcltsInd |
| CHNA Report Widely Available | Yes (1) | CHNAReportWidelyAvailableInd |
| Rpt Available On Own Website | Yes (X) | RptAvailableOnOwnWebsiteInd |
| Own Website URL | SEE PART V, PAGE 8 | OwnWebsiteURLTxt |
| Paper Copy Public Inspection | Yes (X) | PaperCopyPublicInspectionInd |
| Implementation Strategy Adopt | Yes (1) | ImplementationStrategyAdoptInd |
| Implementation Strategy Adpt | 21 | ImplementationStrategyAdptYr |
| Strategy Posted Website | Yes (1) | StrategyPostedWebsiteInd |
| Strategy Website URL | SEE PART V, PAGE 8 | StrategyWebsiteURLTxt |
| Organization Incur Excise Tax | 0 | OrganizationIncurExciseTaxInd |
| Elig Criteria Explained | Yes (1) | EligCriteriaExplainedInd |
| FPG Family Incm Lmt Free Dscnt | Yes (X) | FPGFamilyIncmLmtFreeDscntInd |
| FPG Family Incm Lmt Free Care | 200.000000000000 | FPGFamilyIncmLmtFreeCarePct |
| FPG Family Incm Lmt Dscnt Care | 250.000000000000 | FPGFamilyIncmLmtDscntCarePct |
| Asset Level Criteria | Yes (X) | AssetLevelCriteriaInd |
| Medical Indigency Criteria | Yes (X) | MedicalIndigencyCriteriaInd |
| Insurance Status Criteria | Yes (X) | InsuranceStatusCriteriaInd |
| Underinsurance Stat Criteria | Yes (X) | UnderinsuranceStatCriteriaInd |
| Explained Basis | Yes (1) | ExplainedBasisInd |
| App Financial Asst Expln | Yes (1) | AppFinancialAsstExplnInd |
| Described Info | Yes (X) | DescribedInfoInd |
| Described Suprt Doc | Yes (X) | DescribedSuprtDocInd |
| Provided Hospital Contact | Yes (X) | ProvidedHospitalContactInd |
| Includes Publicity Measures | Yes (1) | IncludesPublicityMeasuresInd |
| FAP Available On Website | Yes (X) | FAPAvailableOnWebsiteInd |
| FAP Available On Website URL | SEE PART V, PAGE 8 | FAPAvailableOnWebsiteURLTxt |
| FAP App Available On Website | Yes (X) | FAPAppAvailableOnWebsiteInd |
| FAP App Available On Website URL | SEE PART V, PAGE 8 | FAPAppAvailableOnWebsiteURLTxt |
| FAP Summary On Website | Yes (X) | FAPSummaryOnWebsiteInd |
| FAP Summary On Website URL | SEE PART V, PAGE 8 | FAPSummaryOnWebsiteURLTxt |
| FAP Avlbl On Request No Charge | Yes (X) | FAPAvlblOnRequestNoChargeInd |
| FAP App Avlbl On Request No Chrg | Yes (X) | FAPAppAvlblOnRequestNoChrgInd |
| FAP Sum Avlbl On Request No Chrg | Yes (X) | FAPSumAvlblOnRequestNoChrgInd |
| Notified FAP Copy Bill Display | Yes (X) | NotifiedFAPCopyBillDisplayInd |
| Communtity Notified FAP | Yes (X) | CommuntityNotifiedFAPInd |
| FAP Translated | Yes (X) | FAPTranslatedInd |
| FAP Actions On Nonpayment | Yes (1) | FAPActionsOnNonpaymentInd |
| Permit No Actions | Yes (X) | PermitNoActionsInd |
| Collection Activities | 0 | CollectionActivitiesInd |
| Provided Written Notice | Yes (X) | ProvidedWrittenNoticeInd |
| Made Effort Orally Notify | Yes (X) | MadeEffortOrallyNotifyInd |
| Processed FAP Application | Yes (X) | ProcessedFAPApplicationInd |
| Made Presumptive Elig Determ | Yes (X) | MadePresumptiveEligDetermInd |
| Nondis Emergency Care Policy | Yes (1) | NondisEmergencyCarePolicyInd |
| Look Back Medicare Private | Yes (X) | LookBackMedicarePrivateInd |
| Amounts Generally Billed | 0 | AmountsGenerallyBilledInd |
| Gross Charges | 0 | GrossChargesInd |
Supplemental Information SupplementalInformationGrp (8 entries)
| Form And Line ReferenceFormAndLineReferenceDesc | ExplanationExplanationTxt |
|---|---|
| COMMUNITY MEMORIAL HOSPITAL ASSOCIATION | PART V, SECTION B, LINE 5: WE MET WITH OUR HEALTH PARTNERS AT CARLTON COUNTY PUBLIC HEALTH AND HUMAN SERVICES TO REVIEW EXISTING DATA AND CONCLUSIONS DRAWN FROM THE DATA. WE ALSO WORKED WITH THEM AND A LARGER GROUP OF PARTNERS TO DEVELOP ADDITIONAL DATA SOURCES, WHERE WE RECEIVED FEEDBACK AND INPUT FROM MEMBERS AS TO THE VALIDITY OF OUR ASSESSMENT. MEMBERS OF THAT COMMITTEE SPAN ACROSS VARIOUS AGENCIES OF PUBLIC HEALTH, AS WELL AS INVOLVING COMMUNITY VOLUNTEERS, SOCIAL SERVICES AGENCIES, AND HEALTH EDUCATION PERSONNEL FROM CLOQUET AND THE REGION. |
| COMMUNITY MEMORIAL HOSPITAL ASSOCIATION | PART V, SECTION B, LINE 6B: BECAUSE WE WERE THE ONLY ENTITY REQUIRED TO COMPLETE A CHNA IN 2022 AND OUR PARTNERING ENTITIES ARE REQUIRED TO PERFORM A CHNA IN 2023, NONE OF THOSE ENTITIES HAD THE SAME TIMEFRAME FOR COMPLETING THE PROCESS AS US. THAT BEING SAID, WE OBTAINED DATA FROM THOSE GROUPS AND SOUGHT INPUT AND FEEDBACK ON THE FINDINGS WE COMPILED INTERNALLY AS PART OF OUR PROCESS. WE SPECIFICALLY FOCUSED ON A SHARED AGENDA THAT WOULD ANSWER OUR NEEDS AND GIVE THEM DATA THAT COULD BE USED WITHIN THEIR PROCESS. THOSE PARTNERS INCLUDE REPRESENTATIVES FROM THE FOLLOWING AGENCIES THAT WERE EITHER CONTACTED INDIVIDUALLY OR THROUGH GROUPS SUCH AS THE CARLTON COUNTY PUBLIC HEALTH ADVISORY COMMITTEE: CARLTON COUNTY PUBLIC HEALTH, CARLTON COUNTY CHILDREN & FAMILY SERVICES, FOND DU LAC TRIBAL & COMMUNITY COLLEGE, STATEWIDE HEALTH IMPROVEMENT PROGRAM (SHIP) COMMUNITY LEADERSHIP TEAM, ARROWHEAD AGENCY ON AGING, AND COMMUNITY HEALTH BOARD REPRESENTATIVES. |
| COMMUNITY MEMORIAL HOSPITAL ASSOCIATION | PART V, SECTION B, LINE 11: EACH OF THESE NEEDS REQUIRES WORK BEYOND THE WALLS OF CMH. WE WILL PARTNER WITH OTHER COUNTY GROUPS AND TASK FORCES ALREADY IN PLACE TO ADDRESS, OR IN SOME CASES CONTINUE TO ADDRESS THE NEEDS NOTED. MENTAL HEALTH -THESE EFFORTS WILL FOCUS MORE IN THE SCHOOLS AND COMMUNITIES AT LARGE. WE INTEND TO PARTNER WITH OTHER AGENCIES TO IMPLEMENT SCHOOL CURRICULUM AND POLICIES THAT SUPPORT MENTAL WELLBEING. WE WILL ALSO INCREASE TRAINING OPPORTUNITIES WITHIN THE COMMUNITY TO UNDERSTAND AND SUPPORT MENTAL HEALTH. FINALLY, WE WILL RESEARCH THE FEASIBILITY OF SUPPORTING THE CREATION OF A PUBLIC HEALTH COMMUNITY NAVIGATOR POSITION TO FIND AND PROMOTE EXISTING GROUPS, REPLICATE EXISTING PROGRAMS, PROVIDE EDUCATION TO SPECIFIC POPULATIONS ON HOW PROCESSES WORK IN THE COMMUNITY, AND ORGANIZE VOLUNTEER OPPORTUNITIES.SUBSTANCE USE -AGAIN, MOST OF THIS WORK WILL TAKE PLACE OUTSIDE OF CMH ITSELF. WE INTEND TO PROMOTE POSITIVE WELL-BEING RESOURCES AND MAKE IT EASIER FOR COMMUNITY MEMBERS TO SHARE RESOURCES. WE SEEK TO EXPAND POSITIVE COMMUNITY NORMS AND STIGMA REDUCTION CAMPAIGNS THROUGH THE COUNTY ACROSS ALL AGES. WE ALSO WILL WORK TO INCREASE COLLABORATION FOR DRUG DROP BOXES, GROWING THE PROGRAM BEYOND LOCAL POLICE DEPARTMENTS.OBESITY -THIS WORK WILL REQUIRE STRONG PARTNERSHIPS ACROSS THE COMMUNITY. WE WANT TO INCREASE ACCESS TO HEALTHY FOODS AND PRODUCE. WE WILL WORK TO CREATE A CULTURE OF HEALTHY BEHAVIORS - HEALTHY EATING, ACTIVE LIVING. WE WILL SUPPORT ACTIVE TRANSPORTATION INITIATIVES, AND WE WILL EXPAND BREAST FEEDING PROMOTION PROGRAMS.CMH WILL NOT BE ADDRESSING OTHER NEEDS IDENTIFIED IN THE FIELDS OF HOUSING AND AGING. THESE ARE BROAD TOPICS, AND OUR EFFORTS WILL BE FOCUSED IN THE AREAS ALREADY LISTED. OUR ONGOING OPERATIONS DO SUPPORT HEALTHY AGING THROUGH MANY OF THE SERVICES WE ALREADY OFFER, BUT WE SIMPLY DO NOT HAVE THE ORGANIZATIONAL BANDWIDTH TO TACKLE ANY OF THE OTHER PRIORITY AREAS IDENTIFIED AT THIS TIME. |
| PART V, LINE 7A, CHNA - HOSPITAL'S WEBSITE: | HTTPS://CLOQUETHOSPITAL.COM/WP-CONTENT/UPLOADS/2023/05/COMMUNITY-HEALTH-NEEDS-ASSESSMENT-FY2022.PDF |
| PART V, LINE 10, IMPLEMENTATION PLAN WEBSITE: | HTTPS://CLOQUETHOSPITAL.COM/WP-CONTENT/UPLOADS/2023/05/COMMUNITY-HEALTH-NEEDS-ASSESSMENT-FY2022.PDF |
| PART V, LINE 16A, FAP WEBSITE: | HTTPS://CLOQUETHOSPITAL.COM/WP-CONTENT/UPLOADS/2022/06/PFS-COMMUNITY-CARE-PROGRAM.PDF |
| PART V, LINE 16B, FAP APPLICATION FORM WEBSITE: | HTTPS://CLOQUETHOSPITAL.COM/WP-CONTENT/UPLOADS/2023/01/COMMUNITY-CARE-APPLICATION-2023.PDF |
| PART V, LINE 16C, FAP PLAIN LANGUAGE SUMMARY: | HTTPS://CLOQUETHOSPITAL.COM/WP-CONTENT/UPLOADS/2022/06/FAP-PLAIN-LANGUAGE-SUMMARY-2022.PDF |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Facility | 2 | FacilityNum |
Oth Hlth Care Fclts Not Hospital OthHlthCareFcltsNotHospitalGrp
Oth Hlth Care Fclts OthHlthCareFcltsGrp (2 entries)
| Address Line1USAddress/AddressLine1Txt | CityUSAddress/CityNm | State AbbreviationUSAddress/StateAbbreviationCd | ZIPUSAddress/ZIPCd | FacilityFacilityTxt |
|---|---|---|---|---|
| 1 - SUNNYSIDE HEALTH CARE CENTER | ||||
| 512 SKYLINE BLVD | CLOQUET | MN | 55720 | SKILLED NURSING FACILITY |
| 2 - CMH RAITER FAMILY CLINIC | ||||
| 417 SKYLINE BLVD | CLOQUET | MN | 55720 | FAMILY MEDICINE CLINIC |
Supplemental Information Detail SupplementalInformationDetail (14 entries)
| Form And Line ReferenceFormAndLineReferenceDesc | ExplanationExplanationTxt |
|---|---|
| PART I, LINE 7: | COSTS ARE CALCULATED USING FINANCIAL DATA AND THE COST TO CHARGE RATIO FROM THE AS FILED 2022 MEDICARE COST REPORT (LINES 7A, 7B, 7C). LINE 7I IS LISTED AS ACTUAL WITH THE EXCEPTION OF AN ESTIMATE FOR SPACE UTILIZATION FOR VARIOUS COMMUNITY PROGRAMS. |
| PART I, LN 7 COL(F): | IMPLICIT PRICE CONCESSIONS FROM FINANCIAL STATEMENTS ARE $2,104,950. |
| PART II, COMMUNITY BUILDING ACTIVITIES: | N/A |
| PART III, LINE 2: | THE HOSPITAL GENERALLY ESTIMATES THE AMOUNT OF IMPLICIT PRICE CONCESSIONS FOR THE CURRENT YEAR BY USING THE PERCENTAGE OF REVENUE AS SHOWN AS IMPLICIT PRICE CONCESSIONS IN SUPPLEMENTAL INFORMATION TO THE AUDITED FINANCIAL STATEMENT FROM THE PRIOR YEAR. |
| PART III, LINE 3: | AT COMMUNITY MEMORIAL HOSPITAL, IMPLICIT PRICE CONCESSIONS ARE CONSIDERED THE UNWILLINGNESS TO PAY, WHILE CHARITY CARE AND FREE CARE REFLECT AN INABILITY TO PAY. |
| PART III, LINE 4: | SEE FOOTNOTE 1 ON PAGE 8 OF THE AUDITED FINANCIAL STATEMENTS. |
| PART III, LINE 8: | THE COSTING METHODOLOGY USED IN DETERMINING THE MEDICARE ALLOWABLE COST REPORTED IN THE ORGANIZATION'S MEDICARE COST REPORT AS REFLECTED IN THE AMOUNT REPORTED IN PART III, LINE 6:THE HOSPITAL FOLLOWED MEDICARE'S PRESCRIBED METHODS OF DETERMINING COSTS PAYABLE UNDER TITLE XVIII (MEDICARE) IN COMPLETING ITS ANNUAL MEDICARE COST REPORT (COST REPORT) USING DATA AVAILABLE FROM THE INSTITUTION'S BASIC ACCOUNTS, AS USUALLY MAINTAINED, TO ARRIVE AT EQUITABLE AND PROPER PAYMENT FOR SERVICES. THE COST REPORT WAS COMPLETED USING THE HOSPITAL'S TRIAL BALANCE OF EXPENSES, AS WELL AS OTHER STATISTICAL AND FINANCIAL RECORDS MAINTAINED BY THE HOSPITAL. AS REQUIRED BY MEDICARE REGULATIONS, CERTAIN RECLASSIFICATIONS AND ADJUSTMENTS TO COSTS WERE INCLUDED IN THE COST REPORT TO DETERMINE MEDICARE ALLOWABLE COSTS.AFTER MEDICARE ALLOWABLE COSTS ARE DETERMINED, THE COST REPORT PROVIDES FOR THE STEP DOWN METHOD OF COST FINDING. THIS METHOD PROVIDES FOR ALLOCATING THE COST OF SERVICES RENDERED BY EACH GENERAL SERVICE COST CENTER TO OTHER COST CENTERS, WHICH UTILIZE THE SERVICES. ONCE THE COSTS OF A GENERAL SERVICE COST CENTER HAVE BEEN ALLOCATED, THAT COST CENTER IS CONSIDERED CLOSED. ONCE CLOSED, IT DOES NOT RECEIVE ANY OF THE COSTS SUBSEQUENTLY ALLOCATED FROM THE REMAINING GENERAL SERVICE COST CENTERS. AFTER ALL COSTS OF THE GENERAL SERVICE COST CENTERS HAVE BEEN ALLOCATED TO THE REMAINING COST CENTERS, THE TOTAL COSTS OF THESE REMAINING COST CENTERS ARE FURTHER DISTRIBUTED TO THE DEPARTMENTAL CLASSIFICATION TO WHICH THEY PERTAIN, E.G., HOSPITAL GENERAL INPATIENT ROUTINE, SUBPROVIDER, ANCILLARY, ETC.AFTER THE STEP-DOWN PROCESS, THE COST REPORT PROVIDES FOR THE APPORTIONMENT OF COSTS TO THE MEDICARE PROGRAM BASED ON A NUMBER OF DIFFERENT METHODOLOGIES INCLUDING PER PATIENT DAY, PER VISIT, AND PERCENTAGE OF CHARGES, AS MOST PREVALENT. MEDICARE COSTS AS DETERMINED BY THE COST REPORT METHODOLOGIES DESCRIBED PREVIOUSLY WERE UTILIZED TO COMPLETE THE APPLICABLE MEDICARE ALLOWABLE COSTS OF CARE FOR SCHEDULE H (FORM 990) PART III SECTION B LINE 6. |
| PART III, LINE 9B: | COMMUNITY MEMORIAL HOSPITAL HAS BOTH SELF-PAY COLLECTIONS AND COMMUNITY CARE PROGRAM (CHARITY CARE) POLICIES THAT ARE UTILIZED AND APPLIED FLUIDLY. SELF-PAY (MINNESOTA ATTORNEY GENERAL) DISCOUNTS ARE APPLIED IMMEDIATELY TO A SELF-PAY PATIENTS' LIABILITY. ALL INPATIENT AND OUTPATIENT ACCOUNTS ARE ELIGIBLE FOR CHARITY CARE. ALL PATIENTS ARE ADVISED OF THIS PROGRAM AND APPLICATIONS ARE MADE READILY AVAILABLE. ELIGIBILITY IS DETERMINED BY THE APPLICANTS INCOME (FEDERAL TAX RETURN AND OTHER FINANCIAL DISCLOSURES) COMPARED TO THE FEDERAL POVERTY GUIDELINES. QUALIFYING PATIENTS CAN RECEIVE A PARTIAL SLIDING SCALE REDUCTION UP TO 100%. PATIENTS WHO MAY QUALIFY BUT DO NOT COMPLETE THE COMMUNITY CARE APPLICATION WOULD BE MOVED TO OUR SELF-PAY COLLECTION POLICY. THIS POLICY OUTLINES THE SERIES OF STATEMENT MAILINGS, 30-60-90 DAY LETTERS, COURTESY CALLS AS WELL AS THE AVAILABILITY OF COMMUNITY CARE. THIS CYCLE IS PURSUED RATHER THAN THE ACCOUNT BEING CONSIDERED FOR BAD DEBT COLLECTION.COMMUNITY MEMORIAL HOSPITAL ASSOCIATION'S BILLING AND COLLECTIONS POLICY STATES:I. PURPOSE: THE COLLECTION OF PATIENT BALANCES IS INTENDED TO PRESERVE A SOUND FINANCIAL BASIS FOR OPERATIONS IN ORDER THAT VITAL ESSENTIAL SERVICES CONTINUE TO BE PROVIDED.II. POLICY: SELF-PAY BALANCES ARE DUE UPON RECEIPT OF AN ITEMIZED BILL OR STATEMENT WHEN THE ACCOUNT BALANCE IS DETERMINED TO BE THE PATIENT'S RESPONSIBILITY (AFTER THIRD-PARTY BENEFITS ARE EXHAUSTED). CMH IS OBLIGATED TO COLLECT FOR SERVICES PROVIDED FROM PATIENTS THAT HAVE THE ABILITY TO PAY. PATIENTS UNABLE TO PAY BALANCES IN FULL MAY MAKE MINIMUM MONTHLY PAYMENTS. CMH WILL ASSIST PATIENTS IN OBTAINING PUBLIC PROGRAMS AND OTHER SOURCES WHENEVER APPROPRIATE.PRIOR TO ASSIGNING AN ACCOUNT TO A COLLECTION AGENCY FOR NON-PAYMENT OR INSUFFICIENT PAYMENT, THE BILLING CYCLE WILL BE FOLLOWED AND THE EVENTS AND ALL PATIENT/GUARANTOR COMMUNICATION MUST BE CLEARLY DOCUMENTED IN THE ACCOUNT NOTES.III. DEFINITIONS/SPECIAL CONSIDERATIONSA BAD DEBT IS AN ACCOUNT RECEIVABLE BASED ON SERVICES FURNISHED TO A PATIENT THAT IS REGARDED AS UNCOLLECTABLE FOLLOWING REASONABLE COLLECTION EFFORTS. ACCOUNTS WILL BE TRANSFERRED TO A COLLECTION AGENCY AS AUTHORIZED BY ADMINISTRATION.A GUARANTOR IS THE PERSON RESPONSIBLE FOR THE PAYMENT OF THE MEDICAL DEBT. THE GUARANTOR IS TYPICALLY THE SAME AS THE ADULT PATIENT. THE GUARANTOR FOR A MINOR CHILD IS TYPICALLY THE PARENT OR LEGAL GUARDIAN THAT BRINGS THE CHILD IN FOR SERVICES.PAYMENTS MAY BE MADE BY CASH, CHECK OR CREDIT CARD (VISA, MASTERCARD OR DISCOVER). CHECKS RETURNED BY A FINANCIAL INSTITUTION WILL INCUR A $30 RETURN CHECK FEE.IV. PROCEDURE1. SELF-PAY/UNINSURED AT TIME OF SERVICE:A. SCHEDULED SURGICAL PROCEDURES REQUIRE A MINIMUM $500 PREPAYMENT ON OR BEFORE THE DATE OF SERVICE IF THE PATIENT/GUARANTOR DOES NOT QUALIFY FOR ANY OTHER PROGRAM. OTHER SCHEDULED OUTPATIENT SERVICES REQUIRE A MINIMUM 10% PREPAYMENT.B. AN ITEMIZED BILL IS MAILED APPROXIMATELY 7 - 10 DAYS AFTER SERVICE/DISCHARGE DATE ALONG WITH A SELF- PAY LETTER (NEWSP) REQUESTING ANY POSSIBLE HEALTH PLAN COVERAGE INFORMATION AND INFORMING THE GUARANTOR ABOUT THE SELF-PAY DISCOUNTS AND COMMUNITY CARE PROGRAM (POLICY BUS-2002). THE SELF PAY DISCOUNT FOR UNINSURED (POLICY BUS-2005) IS APPLIED TO THE ACCOUNT IF APPROPRIATE.C. FIRST STATEMENT PRINTS APPROXIMATELY 14 DAYS LATER. A PROMPT PAY DISCOUNT (10%) IS OFFERED ON BALANCES OVER $50 IF PAID IN FULL WITHIN 30 DAYS. A COMMUNITY CARE APPLICATION WILL BE MAILED FOR ACCOUNT BALANCES OVER $1,500.D. SECOND STATEMENT PRINTS APPROXIMATELY 30 DAYS LATER WITH PAST DUE MESSAGE IF THERE HAS BEEN NO PAYMENT MADE OR NO CONTRACT FOR PAYMENT ESTABLISHED.E. THIRD STATEMENT PRINTS APPROXIMATELY 30 DAYS LATER WITH FIRST COLLECTION LETTER (#55) IF NO PAYMENT OR CONTRACT.F. FOURTH STATEMENT PRINTS APPROXIMATELY 30 DAYS LATER WITH SECOND/LAST COLLECTION LETTER (#25) STATING THEY HAVE 1O DAYS TO RESPOND OR THE ACCOUNT WILL BE PLACED WITH A PROFESSIONAL COLLECTION AGENCY IF NO PAYMENT IS RECEIVED OR CONTRACT ESTABLISHED.G. APPROXIMATELY 10 -30 DAYS LATER THE ACCOUNT IS REVIEWED FOR PLACEMENT WITH AN AGENCY.A. ROUTINE REVIEWS INCLUDE BUT ARE NOT LIMITED TO:I. CHECKING MN-ITS FOR MEDICAID ELIGIBILITYII. CHECKING IF ALL THIRD PARTY PAYER PAYMENTS HAVE BEEN RECEIVED OR IF DENIED PENDING INFORMATION FROM PATIENT, INSURED OR PROVIDERIII. CHECKING FOR RECENT PAYMENTS ON ALL ACCOUNTS WITH THE SAME PATIENT/GUARANTORIV. DETERMINING IF PATIENT MAY QUALIFY FOR CONTRACT HEALTH SERVICE (PHS) COVERAGEV. CHECKING IF A COMMUNITY CARE APPLICATION IS PENDINGVI. NEWBORNS CHECKED IF THEY ARE ENROLLED ON PARENT(S) HEALTH PLAN OR STATE MEDICAIDVII. REVIEW ACCOUNT COMMENTS/NOTES FOR RECENT PATIENT COMMUNICATION2. SELF-PAY BALANCE AFTER THIRD PARTY PAYERS:A. FIRST SELF-PAY STATEMENT PRINTS APPROXIMATELY 3 DAYS AFTER FINAL THIRD PARTY PAYMENT IS POSTED TO ACCOUNT. PROMPT PAY DISCOUNT (10%) IS OFFERED ON BALANCES OVER $50 IF PAID IN FULL WITHIN 30 DAYS.B. SUBSEQUENT STATEMENTS AND LETTERS FOLLOW THE SAME PROCESS AS ABOVE IF NO PAYMENT OR CONTRACT IS ESTABLISHED.3. PLACEMENT OF BAD DEBT ACCOUNTS WITH AN AGENCY OR OTHER RESOLUTION:A. THE DECISION TO ADVANCE A DEBT TO AN AGENCY FOR COLLECTION WILL BE BASED ON SUCH FACTORS AS LACK OF PAYMENT, INSUFFICIENT PAYMENTS, FAILURE TO APPLY FOR AVAILABLE PROGRAMS, FAILURE TO RESPOND TO PROVIDER OR PAYER REQUESTS FOR INFORMATION, OR FAILURE TO CONTACT THE BUSINESS OFFICE AS REQUESTED.B. AN ACCOUNT MAY BE DETERMINED UNCOLLECTIBLE AND TRANSFERRED TO AN AGENCY IF MAIL HAS BEEN RETURNED FOR A BAD ADDRESS AND ATTEMPTS WERE UNSUCCESSFUL TO FIND A CURRENT ADDRESS FOLLOWING THE RETURNED MAIL PROCEDURE.C. MINIMUM PAYMENT GUIDELINES WERE ESTABLISHED FOR PATIENTS THAT ARE FINANCIALLY UNABLE TO PAY THEIR ACCOUNT BALANCE IN FULL. A LETTER (INSUF) WILL BE SENT TO PATIENTS THAT ARE NOT MAKING MINIMUM PAYMENTS ACCORDING TO CMH GUIDELINES WHICH ARE PRINTED ON THE BACK OF STATEMENTS.A. IF MINIMUM PAYMENTS ARE NOT SUBSEQUENTLY RECEIVED, INFORMATION MUST BE PROVIDED JUSTIFYING WHY THE MINIMUM PAYMENT CANNOT BE MADE AND WHY THEY ARE NOT ELIGIBLE FOR OTHER PROGRAMS SUCH AS MEDICAID AND COMMUNITY CARE. IF A FINANCIAL HARDSHIP IS INDICATED, A REDUCED PAYMENT PLAN MAY BE ESTABLISHED WITH PERIODIC REVIEW IN SIX TO NINE MONTHS. FINANCIAL HARDSHIP WILL BE DETERMINED UPON REVIEW OF SUPPORTING DOCUMENTATION.B. IF THE PATIENT/GUARANTOR DOES NOT RESPOND TO THE INSUFFICIENT PAYMENT LETTER, CONTINUED COLLECTION ACTIVITY WILL BE PURSUED.C. IF THE PATIENT/GUARANTOR DOES NOT RESPOND TO ANY ATTEMPTS TO DISCUSS THE INSUFFICIENT PAYMENT PLAN, THE ACCOUNT MAY BE TURNED OVER TO AN AGENCY.D. TRANSFERRING SELF-PAY BALANCES ONTO ONE ACCOUNT MAY ONLY BE DONE IF THE MINIMUM PAYMENT IS MADE ON THE NEW COMBINED BALANCE.D. PATIENTS KNOWN OR REPORTED TO HAVE EXPIRED, WITHOUT AN ESTATE OR PROBATE FILED, WILL NOT BE TRANSFERRED TO AN AGENCY IF THERE IS NO INDICATION THAT THE ACCOUNT WILL BE PAID. BALANCES WILL BE A WRITE-OFF ADJUSTMENT WHEN DEEMED APPROPRIATE.E. ACCOUNT BALANCES LESS THAN $25 WILL FOLLOW NORMAL COLLECTION PROCEDURES BUT WILL NOT BE TRANSFERRED TO AN AGENCY. IF THERE IS NO OTHER PATIENT OR GUARANTOR ACCOUNT BALANCES TO COMBINE WITH, THE BALANCE MAY BE A WRITE-OFF ADJUSTMENT.F. SMALL BALANCE WRITE-OFF ADJUSTMENTS WILL BE DONE MONTHLY ON ACCOUNT BALANCES LESS THAN $4.99 IF THERE IS NOT OTHER SELF-PAY ACCOUNT BALANCES TO COMBINE WITH. STATEMENTS ARE NOT SENT OUT FOR BALANCES UNDER $3.00.G. COLLECTION AGENCIES ARE DIRECTED TO RETURN ANY UNCOLLECTIBLE ACCOUNTS WITHIN NINE MONTHS OF TRANSFER IF NO PAYMENTS HAVE BEEN MADE OR PROVIDE INFORMATION TO CMH THAT WARRANTS RETAINING SUCH ACCOUNTS. |
| PART VI, LINE 2: | NEEDS ASSESSMENT:WE ARE A SPONSOR OF THE BRIDGE TO HEALTH SURVEY INSTRUMENT. THE SURVEY IS DESIGNED TO GATHER POPULATION-BASED HEALTH STATUS DATA ON RESIDENTS IN A NINE-COUNTY REGION IN NORTHEASTERN MINNESOTA AND NORTHWESTERN WISCONSIN. THE SURVEY IS A COLLABORATIVE EFFORT INVOLVING REPRESENTATIVES FROM OVER 60 HEALTH-RELATED ORGANIZATIONS. WE UTILIZE THE INFORMATION GATHERED FROM THIS SURVEY BROKEN DOWN TO OUR SPECIFIC SERVICE AREA TO IDENTIFY UNMET NEEDS AND OPPORTUNITIES FOR COMMUNITY HEALTH IMPROVEMENT. |
| PART VI, LINE 3: | PATIENT EDUCATION OF ELIGIBILITY FOR ASSISTANCE:SELF PAY PATIENTS ARE INFORMED AT THE TIME OF SERVICE THAT WE CAN PROVIDE COMMUNITY CARE SERVICES AND PROVIDE A FORM. WE ADVISE THE PATIENT TO APPLY FOR MEDICAL ASSISTANCE TO THE MINNESOTA COUNTY HUMAN SERVICES OFFICE WHERE THEY RESIDE SO THAT THEY CAN APPLY FOR ASSISTANCE. COMMUNITY CARE (CHARITY CARE) APPLICATIONS ARE PROVIDED IN OUR REGISTRATION OFFICES, WAITING ROOMS AND ON OUR WEBSITE. THE ORGANIZATION ALSO SENDS INFORMATION TO PATIENTS WITH THEIR ITEMIZED BILLS. WE REQUEST THAT PATIENTS CALL US WITH QUESTIONS OR FOR HELP REGARDING MEDICAL ASSISTANCE OR OUR COMMUNITY CARE PROGRAM. |
| PART VI, LINE 4: | COMMUNITY INFORMATION:COMMUMITY MEMORIAL HOSPITAL (CMH) MEETS THE STATE OF MINNESOTA'S CRITERIA OF A RURAL HOSPITAL AND HAS BEEN GRANTED NECESSARY PROVIDER STATUS AS A CRITICAL ACCESS HOSPITAL. CMH IS LOCATED IN CLOQUET, MINNESOTA, WHICH IS IN CARLTON COUNTY, A NORTHEASTERN COUNTY IN MINNESOTA, APPROXIMATELY 25 MILES FROM DULUTH, MINNESOTA AND LAKE SUPERIOR. CMH SERVES PRIMARILY AN ELEVEN ZIP CODE AREA WITH 85% OF ITS PATIENTS RESIDING IN CARLTON COUNTY. CARLTON COUNTY'S 2020 CENSUS ESTIMATED THE POPULATION AT 36,207. GROWTH IS PROJECTED OVER THE NEXT FIVE PLUS YEARS. MEDIAN HOUSEHOLD INCOME FOR THE AREA IS $68,579 WHICH IS 12% LOWER THAN THE MINNESOTA AVERAGE. THE ECONOMY OF THE SERVICE AREA IS MIXED AND INCLUDES MANUFACTURING, EDUCATIONAL SERVICES, RECREATIONAL CASINO-RESORT AND HEALTHCARE SERVICES. THIS MIX HAS HAD A STABILIZING EFFECT ON UNEMPLOYMENT. WHILE BEING GENERALLY HIGHER THAN THE MINNESOTA AVERAGE, THIS MEASURE HAS NOT SEEN LARGE SWINGS THAT THE NATION HAS SEEN. |
| PART VI, LINE 5: | PROMOTION OF COMMUNITY HEALTH:COMMUNITY MEMORIAL HOSPITAL (CMH) CONTINUES TO HAVE A STRONG ECONOMIC IMPACT ON OUR SERVICE REGION. WE KNOW WE COULD NOT BE SUCCESSFUL WITHOUT THE SUPPORT OF OUR COMMUNITY. OUR BOARD OF DIRECTORS ARE COMPRISED OF COMMUNITY MEMBERS WITH DIVERSE BACKGROUNDS AND INTERESTS. WE HAVE AN OPEN MEDICAL STAFF POLICY THAT SHARES OUR INTEREST OF PROVIDING QUALITY HEALTH CARE LOCALLY. WE TAKE "COMMUNITY" IN OUR NAME SERIOUSLY. CMH REACHES OUT BY OFFERING SCREENINGS, EDUCATION GROUPS AND OTHER CONNECTIONS TO IMPROVE THE HEALTH OF OUR CITIZENS. EDUCATIONAL SEMINARS INCLUDE: DIZZINESS, DIABETES, CHILDBIRTH AND URINARY INCONTINENCE. ONGOING STROKE AND GRIEF SUPPORT GROUPS HELP FAMILIES DEALING WITH THESE ISSUES. CMH HOSTS EXERCISE PROGRAMS IN ARTHRITIS CARE AND PILATES. MANY CONSULTING SERVICES ARE OFFERED THROUGH OUR OCCUPATIONAL THERAPY DEPARTMENT. WE CAN ASSIST IN DESIGNING AND PERFORMING EMPLOYMENT SCREENINGS, FUNCTIONAL JOB DESCRIPTIONS, WORK-SITE EVALUATIONS, WORKER EDUCATION, ETC. COMMUNITY MEMORIAL HOSPITAL GOES OUT INTO THE AREA TO CONDUCT HEALTH FAIRS AND EXPOS PROVIDING SCREENINGS FOR VISION, BLOOD GLUCOSE, BLOOD PRESSURE, GRIP STRENGTH AS WELL AS BODY FAT ANALYSIS. COMMUNITY MEMORIAL HOSPITAL WILL CONTINUE TO GROW THE PROMOTION OF HEALTH IN THE COMMUNITY AND FURTHER ITS PURPOSE AS A EXEMPT ORGANIZATION. |
| PART VI, LINE 6: | AFFILIATED HEALTH CARE SYSTEM:N/A |
| PART VI, LINE 7, REPORTS FILED WITH STATES | MN |
Schedule I IRS990ScheduleI
| Field | Value | IRS element (for citing) |
|---|---|---|
| Grant Records Maintained | 0 | GrantRecordsMaintainedInd |
Recipient Table RecipientTable
Recipient Business Name RecipientBusinessName
| Field | Value | IRS element (for citing) |
|---|---|---|
| Business Name Line1 | CLOQUET SCHOOLS | BusinessNameLine1Txt |
US Address USAddress
| Field | Value | IRS element (for citing) |
|---|---|---|
| Address Line1 | 1000 18TH STREET | AddressLine1Txt |
| City | CLOQUET | CityNm |
| State Abbreviation | MN | StateAbbreviationCd |
| ZIP | 55720 | ZIPCd |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Recipient EIN | 416000450 | RecipientEIN |
| IRC Section | GOVERNMENTAL | IRCSectionDesc |
| Cash Grant | $15,040 | CashGrantAmt |
| Non Cash Assistance | $0 | NonCashAssistanceAmt |
| Purpose Of Grant | ATHLETIC TRAINER | PurposeOfGrantTxt |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total501c3 Org | 1 | Total501c3OrgCnt |
| Total Other Org | 0 | TotalOtherOrgCnt |
Supplemental Information Detail SupplementalInformationDetail
| Field | Value | IRS element (for citing) |
|---|---|---|
| Form And Line Reference | PART I, LINE 2: | FormAndLineReferenceDesc |
| Explanation | THE ORGANIZATION GIVES THE FUNDS DIRECTLY TO THE LOCAL SCHOOL. | ExplanationTxt |
Schedule J IRS990ScheduleJ
| Field | Value | IRS element (for citing) |
|---|---|---|
| Written Employment Contract | Yes (X) | WrittenEmploymentContractInd |
| Compensation Survey | Yes (X) | CompensationSurveyInd |
| Board Or Committee Approval | Yes (X) | BoardOrCommitteeApprovalInd |
| Severance Payment | 0 | SeverancePaymentInd |
| Supplemental Nonqual Rtr Plan | 0 | SupplementalNonqualRtrPlanInd |
| Equity Based Comp Arrngm | 0 | EquityBasedCompArrngmInd |
| Comp Based On Revenue Of Flng Org | 0 | CompBasedOnRevenueOfFlngOrgInd |
| Comp Bsd On Rev Related Orgs | 0 | CompBsdOnRevRelatedOrgsInd |
| Comp Bsd Net Earns Flng Org | 0 | CompBsdNetEarnsFlngOrgInd |
| Comp Bsd Net Earns Rltd Orgs | 0 | CompBsdNetEarnsRltdOrgsInd |
| Any Non Fixed Payments | 0 | AnyNonFixedPaymentsInd |
| Initial Contract Exception | 0 | InitialContractExceptionInd |
Rltd Org Officer Trst Key Empl RltdOrgOfficerTrstKeyEmplGrp (9 entries)
| TitleTitleTxt | Base Compensation Filing OrgBaseCompensationFilingOrgAmt | Compensation Based On Rltd OrgsCompensationBasedOnRltdOrgsAmt | Bonus Filing OrganizationBonusFilingOrganizationAmount | Bonus Related OrganizationsBonusRelatedOrganizationsAmt | Other Compensation Filing OrgOtherCompensationFilingOrgAmt | Other Compensation Rltd OrgsOtherCompensationRltdOrgsAmt | Deferred Compensation Flng OrgDeferredCompensationFlngOrgAmt | Deferred Comp Rltd OrgsDeferredCompRltdOrgsAmt | Nontaxable Benefits Filing OrgNontaxableBenefitsFilingOrgAmt | Nontaxable Benefits Rltd OrgsNontaxableBenefitsRltdOrgsAmt | Total Compensation Filing OrgTotalCompensationFilingOrgAmt | Total Compensation Rltd OrgsTotalCompensationRltdOrgsAmt | Comp Report Prior990 Filing OrgCompReportPrior990FilingOrgAmt | Comp Report Prior990 Rltd OrgsCompReportPrior990RltdOrgsAmt |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| KYLE MENZEL MD | ||||||||||||||
| PHYSICIAN | $659,306 | $0 | $0 | $0 | $414 | $0 | $14,500 | $0 | $22,718 | $0 | $696,938 | $0 | $0 | $0 |
| ADRIANNE WESTMORELAND MD | ||||||||||||||
| PHYSICIAN | $508,014 | $0 | $0 | $0 | $162 | $0 | $14,500 | $0 | $4,174 | $0 | $526,850 | $0 | $0 | $0 |
| JOSEPH LEMKER MD | ||||||||||||||
| PHYSICIAN | $503,320 | $0 | $0 | $0 | $774 | $0 | $14,500 | $0 | $0 | $0 | $518,594 | $0 | $0 | $0 |
| MATTHEW LEWIS | ||||||||||||||
| CRNA | $413,943 | $0 | $0 | $0 | $414 | $0 | $14,500 | $0 | $44,141 | $0 | $472,998 | $0 | $0 | $0 |
| RICK BREUER | ||||||||||||||
| CEO | $406,178 | $0 | $0 | $0 | $414 | $0 | $14,500 | $0 | $34,834 | $0 | $455,926 | $0 | $0 | $0 |
| CHAD FEY MD | ||||||||||||||
| PHYSICIAN | $376,870 | $0 | $0 | $0 | $744 | $0 | $14,500 | $0 | $9,460 | $0 | $401,574 | $0 | $0 | $0 |
| KARA UNDERWOOD MD | ||||||||||||||
| PHYSICIAN / DIRECTOR | $356,156 | $0 | $0 | $0 | $414 | $0 | $14,500 | $0 | $0 | $0 | $371,070 | $0 | $0 | $0 |
| BRAD ANDERSON | ||||||||||||||
| CFO | $239,717 | $0 | $0 | $0 | $414 | $0 | $12,522 | $0 | $34,834 | $0 | $287,487 | $0 | $0 | $0 |
| JOANNA ROBNIK MD | ||||||||||||||
| PHYSICIAN / DIRECTOR | $248,655 | $0 | $0 | $0 | $162 | $0 | $13,026 | $0 | $22,955 | $0 | $284,798 | $0 | $0 | $0 |
Schedule O IRS990ScheduleO
Supplemental Information Detail SupplementalInformationDetail (7 entries)
| Form And Line ReferenceFormAndLineReferenceDesc | ExplanationExplanationTxt |
|---|---|
| FORM 990, PART VI, SECTION A, LINE 6 | COMMUNITY MEMORIAL HOSPITAL ASSOCIATION HAS MEMBERS WHO ELECT THE BOARD OF DIRECTORS. |
| FORM 990, PART VI, SECTION A, LINE 7A | COMMUNITY MEMORIAL HOSPITAL ASSOCIATION HAS MEMBERS WHO ELECT THE BOARD OF DIRECTORS. |
| FORM 990, PART VI, SECTION B, LINE 11B | 990 IS COMPLETED BY AN INDEPENDENT CPA FIRM, REVIEWED BY ADMINISTRATION AND FINANCE FOR ACCURACY AND PRESENTED TO THE BOARD OF DIRECTORS. |
| FORM 990, PART VI, SECTION B, LINE 12C | THE CONFLICT OF INTEREST INDIVIDUAL ANNUAL STATEMENTS WILL BE SIGNED ANNUALLY BY BOARD MEMBERS, CORPORATE OFFICERS, EXECUTIVES, MEDICAL STAFF, PHYSICIANS, AND DEPARTMENT DIRECTORS. EDUCATION IS DONE ON A YEARLY BASIS TO PHYSICIANS, DEPT DIRECTORS AND THE BOARD OF DIRECTORS. ITEMS LISTED ON THE STATEMENTS ARE REVIEWED BY THE CEO, COMPLIANCE OFFICER AND/OR THE CHAIRMAN OF THE BOARD TO SEE IF CONFLICTS EXIST. IF CONFLICTS EXIST, THE CEO, COMPLIANCE OFFICER AND/OR THE CHAIRMAN SHALL: 1. IF APPROPRIATE, APPOINT A DISINTERESTED PERSON OR COMMITTEE TO INVESTIGATE ALTERNATIVES TO THE PROPOSED TRANSACTION OR ARRANGEMENT. 2. AFTER EXERCISING DUE DILIGENCE, THE BOARD SHALL DETERMINE WHETHER CMH CAN OBTAIN A MORE ADVANTAGEOUS TRANSACTION OR ARRANGEMENT WITH REASONABLE EFFORTS FROM A PERSON OR ENTITY THAT WOULD NOT GIVE RISE TO A CONFLICT OF INTEREST. 3. IF A MORE ADVANTAGEOUS TRANSACTION OR ARRANGEMENT IS NOT REASONABLY ATTAINABLE UNDER CIRCUMSTANCES THAT WOULD NOT GIVE RISE TO A CONFLICT OF INTEREST, THE BOARD OR COMMITTEE OR CEO OF CMH SHALL DETERMINE WHETHER THE TRANSACTION OR ARRANGEMENT IS IN CMH'S BEST INTEREST, IS FOR CMH'S OWN BENEFIT, AND IS FAIR AND REASONABLE TO CMH AND SHALL MAKE ITS DECISION AS TO WHETHER TO ENTER INTO THE TRANSACTION OR ARRANGEMENT IN CONFORMITY WITH SUCH DETERMINATION. |
| FORM 990, PART VI, SECTION B, LINE 15 | AN ORGANIZATIONAL POLICY "SALARY ADMINISTRATION POLICY - NON CONTRACT EMPLOYEES" IS FOLLOWED. ANNUALLY, AN INDUSTRY SALARY SURVEY IS COMPLETED AND RESULTS ARE USED TO SET WAGE SCALES FOR POSITIONS BY JOB CODE. ANY CHANGES TO WAGE SCALES ARE PRESENTED TO THE HUMAN RESOURCES COMMITTEE OF THE BOARD OF DIRECTORS WHICH REVIEWS AND MAKES RECOMMENDATIONS TO THE BOARD OF DIRECTORS FOR APPROVAL. |
| FORM 990, PART VI, SECTION C, LINE 19 | THE GOVERNING DOCUMENTS, CONFLICT OF INTEREST POLICY, AND FINANCIAL STATEMENTS ARE KEPT ON-SITE FOR REVIEW BY THE PUBLIC DURING NORMAL BUSINESS HOURS FOR THE SAME PERIOD OF DISCLOSURE AS SET FORTH IN SECTION 6104(D). |
| FORM 990, PART XI, LINE 9: | SISU MEDICAL SOLUTIONS, LLC SCHEDULE K-1 ACTIVITY -47,195. |
Schedule R IRS990ScheduleR
Id Related Tax Exempt Org IdRelatedTaxExemptOrgGrp
Disregarded Entity Name DisregardedEntityName
| Field | Value | IRS element (for citing) |
|---|---|---|
| Business Name Line1 | CLOQUET COMMUNITY MEMORIAL HOSPITAL FOUNDATION | BusinessNameLine1Txt |
US Address USAddress
| Field | Value | IRS element (for citing) |
|---|---|---|
| Address Line1 | 512 SKYLINE BLVD | AddressLine1Txt |
| City | CLOQUET | CityNm |
| State Abbreviation | MN | StateAbbreviationCd |
| ZIP | 55720 | ZIPCd |
| Field | Value | IRS element (for citing) |
|---|---|---|
| EIN | 363588501 | EIN |
| Primary Activities | SUPPORT | PrimaryActivitiesTxt |
| Legal Domicile State | MN | LegalDomicileStateCd |
| Exempt Code Section | 501(C)(3) | ExemptCodeSectionTxt |
| Public Charity Status | LINE 12C, III-FI | PublicCharityStatusTxt |
| Direct Controlling NA | N/A | DirectControllingNACd |
| Controlled Organization | 0 | ControlledOrganizationInd |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Receipt Of Int Annts Rnts Rylts | 0 | ReceiptOfIntAnntsRntsRyltsInd |
| Gift Grnt Or Cap Contri To Oth Org | Yes (1) | GiftGrntOrCapContriToOthOrgInd |
| Gift Grnt Cap Contri From Oth Org | Yes (1) | GiftGrntCapContriFromOthOrgInd |
| Loans Or Guarantees To Other Org | 0 | LoansOrGuaranteesToOtherOrgInd |
| Loans Or Guarantees From Oth Org | 0 | LoansOrGuaranteesFromOthOrgInd |
| Div Related Organization | 0 | DivRelatedOrganizationInd |
| Asset Sale To Other Org | 0 | AssetSaleToOtherOrgInd |
| Asset Purchase From Other Org | 0 | AssetPurchaseFromOtherOrgInd |
| Asset Exchange | 0 | AssetExchangeInd |
| Rental Of Facilities To Oth Org | 0 | RentalOfFacilitiesToOthOrgInd |
| Rental Of Fclts From Oth Org | 0 | RentalOfFcltsFromOthOrgInd |
| Perform Of Services For Oth Org | 0 | PerformOfServicesForOthOrgInd |
| Perform Of Services By Other Org | 0 | PerformOfServicesByOtherOrgInd |
| Sharing Of Facilities | Yes (1) | SharingOfFacilitiesInd |
| Paid Employees Sharing | Yes (1) | PaidEmployeesSharingInd |
| Reimbursement Paid To Other Org | 0 | ReimbursementPaidToOtherOrgInd |
| Reimbursement Paid By Other Org | Yes (1) | ReimbursementPaidByOtherOrgInd |
| Transfer To Other Org | 0 | TransferToOtherOrgInd |
| Transfer From Other Org | 0 | TransferFromOtherOrgInd |
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