2022-07-11T15:04:07-05:00 2021-09-30 420714325 RSM US LLP 227 WEST FIRST STREET SUITE 700 DULUTH MN 55802 990 2020-10-01 410743546 COMMUNITY MEMORIAL HOSPITAL ASSOCIATION COMM 2188787027 512 SKYLINE BLVD CLOQUET MN 55720 BRAD ANDERSON CFO 2188787027 2022-07-07 1 BRAD ANDERSON 999009999 JULIE BOYER P01278549 2187275025 2022-07-07 2 AAL1 IAL1 2020 2022-09-23 18:48:47Z RICK BREUER 512 SKYLINE BLVD CLOQUET MN 55720 78846850 0 X WWW.CLOQUETHOSPITAL.COM X 1954 MN 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. 9 7 569 50 -26991 0 623398 13153218 60737423 64940758 126566 66236 1462256 675580 62949643 78835792 0 0 0 0 41473110 43811666 0 0 0 25053443 26379349 66526553 70191015 -3576910 8644777 63683107 59723821 47415843 34781961 16267264 24941860 X 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. 0 0 63548833 65478244 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 TAX YEAR ENDING SEPTEMBER 30, 2021, CMH PROVIDED 4,109 INPATIENT DAYS, 1,967 SURGERIES, 9,918 EMERGENCY ROOM VISITS, 12,658 LTC RESIDENT DAYS AND 46,786 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. 63548833 1 1 0 1 0 0 0 0 1 1 1 0 0 0 1 1 1 0 0 0 0 0 0 0 0 0 1 1 0 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 1 0 0 0 1 43 0 1 569 1 1 1 0 0 0 0 0 0 0 0 0 0 0 X 9 7 0 0 0 0 1 1 0 1 1 0 0 1 1 1 1 1 1 1 1 0 MN X BRAD ANDERSON 2188787027 512 SKYLINE BLVD CLOQUET MN 55720 JOANNA ROBNIK MD PHYSICIAN / DIRECTOR 40.00 X 254962 0 21479 KARA UNDERWOOD MD PHYSICIAN / DIRECTOR 40.00 X 389140 0 14250 JENNIFER DUPUIS DIRECTOR 2.00 X 0 0 0 STEVE RISACHER DIRECTOR 2.00 X 0 0 0 LES RIESS MD DIRECTOR 2.00 X 0 0 0 DAVID HALL CHAIR 2.00 X X 0 0 0 LEE OLSON VICE CHAIR 2.00 X X 0 0 0 NANCY KLASSEN TREASURER 2.00 X X 0 0 0 KIRK WIMMER SECRETARY 2.00 X X 0 0 0 KEVIN TOBOLESKI SECRETARY UNTIL 12/31/20 2.00 X X 0 0 0 ALVIN ALM VICE CHAIR UNTIL 12/31/20 2.00 X X 0 0 0 RICK BREUER CEO 40.00 4.00 X 377860 0 49060 BRAD ANDERSON CFO 40.00 2.00 X 244307 0 48236 KYLE MENZEL MD PHYSICIAN 40.00 X 784006 0 36943 PAUL VOLLMAR MD PHYSICIAN 40.00 X 607680 0 34240 ADRIANNE WESTMORELAND MD PHYSICIAN 40.00 X 493774 0 46507 JOSEPH LEMKER MD PHYSICIAN 40.00 X 488404 0 14250 JEFF RAPP MD PHYSICIAN 40.00 X 467952 0 64306 4108085 0 329271 69 0 1 0 CENTRAL MINNESOTA DIAGNOSTIC INC 911 NORTHLAND DRIVE PRINCETON MN 55371 IMAGING SERVICES 1807611 SISU MEDICAL SOLUTIONS LLC 4960 MILLER TRUNK HWY SUITE 500 HERMANTOWN MN 55811 IT SERVICES 1243258 RADIOLOGISTS ASSOCIATED IN DULUTH LTD 23 W CENTRAL ENTRANCE SUITE 160 DULUTH MN 55811 RADIOLOGY READINGS 576396 ACCELECARE WOUND CENTER 28525 NETWORK PLACE CHICAGO IL 60673 WOUNDCARE SERVICES 442542 AGILITI HEALTH INC 6625 W 78TH STREET SUITE 300 MINNEAPOLIS MN 55439 EQUIPMENT MAINTENANCE 401788 14 40242 12961806 151170 13153218 PATIENT SERVICE REVENUE 621500 64594630 64594630 OTHER INCOME 621500 343300 343300 OUTSIDE LAB SALES 621500 2828 2828 64940758 72294 72294 164413 0 164413 164413 164413 5000 11058 -6058 -6058 -6058 EARNINGS IN CMDI 900099 537486 537486 TAX REFUND 900099 3500 3500 EARNINGS IN SISU MEDICAL SOLUTION 900099 -29819 -29819 511167 78835792 65475416 -26991 234149 1329659 630572 699087 33824375 32602607 1221768 1317945 1275443 42502 5053941 4589723 464218 2285746 2158132 127614 11825 11825 81734 81734 3490 3490 5474108 5404694 69414 164949 164949 743919 553582 190337 1511544 1266291 245253 137534 132057 5477 1094086 1094086 2943104 2442784 500320 374901 92111 282790 MEDICAL SUPPLIES 5193078 5190560 2518 DRUGS 3730691 3730691 IMPLICIT PRICE CONCESSI 1442612 1442612 REPAIRS & MAINTENANCE 1324584 1232752 91832 2147190 804222 1342968 70191015 63548833 6642182 0 3786976 2276547 12621099 12942154 10981459 10199950 1526690 1447979 2200176 2178077 423695 779855 65450560 39414997 27923451 26035563 2773746 2574186 1445815 1289510 63683107 59723821 5486414 5693310 5762855 15825 22155 28924349 27287496 6746400 480000 1779000 47415843 34781961 X 15974807 24646991 292457 294869 16267264 24941860 63683107 59723821 X 8644777 29819 X 0 1 X 1 1 1 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 0 0 0 0 0 0 0 0 1 3490 3490 0 PART II-B, LINE 1: 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. 0 1 X 292457 2588 176 294869 417785 4135 129463 292457 297010 125000 3139 7364 417785 294993 2017 297010 297583 1397 3987 294993 1.00000 0.00000 0.00000 0 0 659448 659448 49992161 28276808 21715353 13132112 9802795 3329317 1666839 1335394 331445 26035563 THIRD-PARTY PAYOR SETTLEMENTS 1779000 1779000 X 77425557 -1442612 -1442612 78868169 -32377 -32377 78835792 68750961 2558 2558 68748403 1442612 1442612 70191015 PART IV, LINE 2B: THE HOSPITAL IS THE CUSTODIAN OF FUNDS FOR 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 2018. PART XI, LINE 2D - OTHER ADJUSTMENTS: IMPLICIT PRICE CONCESSIONS -1,442,612. PART XI, LINE 4B - OTHER ADJUSTMENTS: SISU MEDICAL SOLUTIONS, LLC SCHEDULE K-1 ACTIVITY -29,819. LOSS ON SALE OF ASSETS -6,058. TAX REFUND 3,500. PART XII, LINE 2D - OTHER ADJUSTMENTS: LOSS ON SALE OF ASSETS 6,058. TAX REFUND -3,500. PART XII, LINE 4B - OTHER ADJUSTMENTS: IMPLICIT PRICE CONCESSIONS 1,442,612. 1 1 X 1 X 1 X 1 1 1 0 0 1622695 1622695 0.02360 13429361 10220022 3209339 0.04670 2753406 2404543 348863 0.00510 17805462 12624565 5180897 0.07540 623127 41759 581368 0.00850 55350 55350 0.00080 678477 41759 636718 0.00930 18483939 12666324 5817615 0.08470 1 1442612 17950440 21533180 -3582740 X 1 1 1 1 COMMUNITY MEMORIAL HOSPITAL 512 SKYLINE BLVD CLOQUET MN 55720 395241 X X X X NONE COMMUNITY MEMORIAL HOSPITAL ASSOCIATION 1 0 0 1 X X X X X X X X X 18 1 0 1 1 X SEE PART V, PAGE 8 X 1 18 1 SEE PART V, PAGE 8 0 1 X 200.000000000000 250.000000000000 X X X X 1 1 X X X 1 X SEE PART V, PAGE 8 X SEE PART V, PAGE 8 X SEE PART V, PAGE 8 X X X X X X 1 X 0 X X X X 1 X 0 0 COMMUNITY MEMORIAL HOSPITAL ASSOCIATION PART V, SECTION B, LINE 5: ONE CORE DOCUMENT CMH USED AT THE ONSET WAS THE COMMUNITY HEALTH ASSESSMENT MOST RECENTLY COMPLETED BY OUR LOCAL PUBLIC HEALTH AGENCY AND THE COMMUNITY HEALTH BOARD. WE REVIEWED DATA AND RECEIVED INPUT FROM REPRESENTATIVES OF PUBLIC HEALTH, THE FON DU LAC RESERVATION AND OTHER LOCAL HEALTH PROVIDERS. SPECIFIC INDIVIDUALS PROVIDING SUCH INPUT INCLUDED: LOUISE ANDERSON, EXECUTIVE DIRECTOR, CARLTON/COOK/LAKE/ST. LOUIS COMMUNITY HEALTH BOARD; DAVE LEE, DIRECTOR, CARLTON COUNTY PUBLIC HEALTH; JOANNE ERSPAMER, FAMILY & COMMUNITY UNIT PUBLIC HEALTH SUPERVISOR, CARLTON COUNTY PUBLIC HEALTH; JOHN STRANGE, CEO, ST. LUKE'S HOSPITAL; CASSANDRA BEARDSLEY, EXECUTIVE DIRECTOR, WILDERNESS HEALTH; NATE SANDMAN, ASSOCIATE DIRECTOR, MIN-NO-AYA-WAN HUMAN SERVICES CENTER. COMMUNITY MEMORIAL HOSPITAL ASSOCIATION PART V, SECTION B, LINE 6B: OTHER ORGANIZATIONS ASSISTING IN THE PREPARATION OF THE CHNA INCLUDED: CARLTON COUNTY PUBLIC HEALTH; CARLTON/COOK/LAKE/ST. LOUIS COMMUNITY HEALTH BOARD; GENERATIONS HEALTH CARE; FOND DU LAC RESERVATION; WILDERNESS HEALTH. COMMUNITY MEMORIAL HOSPITAL ASSOCIATION PART V, SECTION B, LINE 11: CMH RECOGNIZES THAT EACH OF THESE NEEDS IS BROAD AND REQUIRES LONG-TERM COMMITMENTS AND MEASUREMENTS. OUR GOALS ARE SET WITH THIS IN MIND. MENTAL HEALTH: 1) INCREASE ACCESS POINTS OF CARE FOR THOSE NEEDING OUTPATIENT MENTAL HEALTH SERVICES. 2) EXPLORE OPPORTUNITIES TO PARTNER WITH OTHER AGENCIES AROUND INCREASING CAPACITY FOR INPATIENT MENTAL HEALTH SERVICES. 3) INTEGRATE MENTAL HEALTH SERVICES WITHIN THE PRIMARY CARE CLINICAL SETTING. 4) CONTINUE COMMUNITY EDUCATION EFFORTS AROUND MAKE IT OKAY CAMPAIGN. DRUG & ALCOHOL USE: 1) OFFER REHABILITATIVE SERVICES ON AN OUTPATIENT BASIS LOCALLY. 2) EXPLORE OPPORTUNITY TO PROVIDE DETOX SERVICES ON AN INPATIENT BASIS. 3) CONTINUE WORK ON COUNTYWIDE DRUG PREVENTION COALITION TO IDENTIFY COLLABORATIVE OPPORTUNITIES FOR ALL STAKEHOLDERS. 4) INTEGRATE SUBSTANCE USE AND ABUSE SERVICES AND TREATMENT INTO EXISTING MENTAL AND BEHAVIORAL HEALTH OFFERINGS. 5) EXPLORE OPPORTUNITIES TO EXPAND MEDICATION ASSISTED TREATMENT (MAT) OPTIONS AND AVAILABILITY. LACK OF AFFORDABLE HOUSING: 1) SUPPORT COMMUNITY AND COUNTY EFFORTS TO INCREASE HOUSING STOCK. 2) EXPLORE OPTIONS TO REDUCE HEALTH EXPENSE BURDEN ON CITIES AND OTHER GOVERNMENTAL UNITS TO KEEP OVERALL GOVERNMENTAL SPENDING LOWER, MINIMIZING TAX BURDEN ON RESIDENTS. 3) PARTNER WITH LIKE-MINDED ENTITIES AROUND OPPORTUNITIES TO SUPPORT AND STRENGTHEN QUALITY OF EXISTING HOUSING STOCK THROUGH SPONSORSHIP AND PHYSICAL ASSISTANCE IN HOMEBUILDING AND RESTORATION PROJECTS. EACH OF THESE GOALS 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 ISSUES NOTED ABOVE. WE WILL ACTIVELY PARTICIPATE IN THE SUICIDE PREVENTION TASK FORCE AND DRUG PREVENTION COALITION ALREADY IN PLACE IN THE COUNTY, SHARING OUR DATA AND INCORPORATING OUR GOALS INTO THE WORK OF THE GROUP. OUR EFFORTS TO TACKLE THE LACK OF AFFORDABLE HOUSING WILL FOCUS ON ACTIVELY PARTICIPATING IN AND SUPPORTING HOUSING PROJECTS LOCATED IN CARLTON COUNTY. ADEQUATE RESOURCES WILL BE ALLOCATED TO ADDRESS EACH OF THESE PRIORITIES. INITIAL EXPENDITURES ARE EXPECTED TO BE MODEST, AS IT WILL MOSTLY INVOLVE EXISTING PEOPLE COMMITTING TIME TO MEET AND DEVISE NEW WAYS OF COMBATING THESE ISSUES. BY THE END OF THE THREE-YEAR PERIOD, IT IS EXPECTED THAT SOME INVESTMENTS WILL NEED TO BE MADE IN ADDITIONAL STAFF, TRAINING, EDUCATION MATERIALS, OR ENTIRELY NEW PROGRAMS OR SERVICES DESIGNED TO SERVE AREA COMMUNITIES. OTHER NEEDS WERE IDENTIFIED AS A PART OF THIS PROCESS THAT CMH DOES NOT PLAN TO ADDRESS IN ITS CURRENT IMPLEMENTATION PLAN. SUCH NEEDS IDENTIFIED AS IMPORTANT BUT NOT BEING ADDRESSED BY CMH INCLUDE:1) POVERTY2) LACK OF TRANSPORTATION SERVICES3) LACK OF PHYSICAL ACTIVITYWHILE THESE ISSUES ARE SEEN AS IMPORTANT, CMH DOES NOT HAVE THE PROPER RESOURCES OR EXPERTISE TO ADDRESS THESE ISSUES AT THIS TIME. AS WE WORK WITH OTHER PROVIDERS IN THE YEARS AHEAD ON RELATED EFFORTS, WE WILL LOOK FOR OPPORTUNITIES TO FURTHER THESE CAUSES WITH PARTIES WHO ARE BETTER SUITED TO ADDRESS THE NEEDS.THE 2020 TAX YEAR WAS ONE DOMINATED BY COVID-19. MUCH OF OUR WORK IN OTHER AREAS WAS LIMITED OR SUSPENDED DUE TO THE NEED TO CONSOLIDATE OUR RESOURCES AROUND PROVIDING CARE AND COORDINATING SERVICES WITH OTHER HEALTHCARE PROVIDERS AND AGENCIES ACROSS THE COMMUNITY, REGION, AND STATE.THAT BEING SAID, WE CONTINUE TO SUPPORT AND ATTEND MEETINGS OF A COUNTYWIDE TASK FORCE WORKING ON SUBSTANCE ABUSE AND MENTAL HEALTH ISSUES. WE WERE ABLE TO RESTART A STRATEGIC PLANNING PROCESS THAT WAS INTERRUPTED DUE TO THE PANDEMIC. DURING THE TAX YEAR, WE COMPLETED OVER 40 INDIVIDUAL EXTERNAL AND INTERNAL STAKEHOLDER INTERVIEWS. WE ALSO CONVENED SIX GATHERINGS OF FORMAL AND INFORMAL LEADERS TO SHARE AND DISCUSS FINDINGS. THROUGH THAT WORK, WE IDENTIFIED HIGH LEVEL OBJECTIVES FOR THE ORGANIZATION TO PURSUE OVER THE NEXT FIVE TO TEN YEARS. SOME OF THESE OBJECTIVES DIRECTLY TIE INTO INCREASING ACCESS TO MENTAL HEALTH SERVICES WITHIN OUR COMMUNITY, FOCUSING ON FORMING SUSTAINABLE COMMUNITY PARTNERSHIPS TO ACHIEVE THAT. NO SIGNIFICANT PROGRESS WAS MADE TOWARDS IMPROVING THE LACK OF AFFORDABLE HOUSING DURING THE TAX YEAR. OPPORTUNITIES TO ENGAGE OTHER COMMUNITY STAKEHOLDERS WHO WOULD BE POSITIONED TO BRING ABOUT IMPROVEMENTS IN THAT AREA WERE SEVERELY LIMITED DUE TO PANDEMIC-RELATED REGULATORY RESTRICTIONS AND THE NEED FOR THOSE OTHER ORGANIZATIONS TO FOCUS THEIR EFFORTS ON COVID-19 PREPARATION AND MITIGATION.OUR STRATEGIC PLAN IS NOW BEING IMPLEMENTED, AND WE EXPECT SIGNIFICANT PROGRESS DURING THE CURRENT TAX YEAR IN THE AREAS IDENTIFIED IN THE MOST RECENTLY COMPLETED COMMUNITY HEALTH NEEDS ASSESSMENT, WHILE ALSO RECOGNIZING THAT A NEW ASSESSMENT WILL BE COMPLETED THIS YEAR AS WELL. PART V, LINE 7A, CHNA - HOSPITAL'S WEBSITE: HTTPS://CLOQUETHOSPITAL.COM/WP-CONTENT/UPLOADS/2019/09/COMMUNITY-HEALTH-NEEDS-ASSESSMENT-FY2019.PDF PART V, LINE 10, IMPLEMENTATION PLAN WEBSITE: HTTPS://CLOQUETHOSPITAL.COM/WP-CONTENT/UPLOADS/2019/09/COMMUNITY-HEALTH-NEEDS-ASSESSMENT-FY2019.PDF PART V, LINE 16A, FAP WEBSITE: HTTPS://CLOQUETHOSPITAL.COM/WP-CONTENT/UPLOADS/2017/06/EMERGENCY-AND-FINANCIAL-ASSIST-POLICY.PDF PART V, LINE 16B, FAP APPLICATION FORM WEBSITE: HTTPS://CLOQUETHOSPITAL.COM/WP-CONTENT/UPLOADS/2022/02/COMMUNITY-CARE-APPLICATION-2022.PDF PART V, LINE 16C, FAP PLAIN LANGUAGE SUMMARY: HTTPS://CLOQUETHOSPITAL.COM/WP-CONTENT/UPLOADS/2018/04/FAP-PLAIN-LANGUAGE-SUMMARY-2018.PDF 2 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 PART I, LINE 7: COSTS ARE CALCULATED USING FINANCIAL DATA AND THE COST TO CHARGE RATIO FROM THE AS FILED 2021 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 $1,442,612. 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 PAGES 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 2010 CENSUS ESTIMATED AT 34,000. WHILE 42% OF THE POPULATION IS 45 AND OLDER, 19% OF THE RESIDENTS ARE FEMALE AGE 15-44. GROWTH IS PROJECTED OVER THE NEXT FIVE PLUS YEARS. MEDIAN HOUSEHOLD INCOME FOR THE AREA IS $48,000 WHICH IS 18% 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 X X X 0 0 0 0 0 0 0 0 0 KYLE MENZEL MD PHYSICIAN 783576 0 0 0 430 0 14250 0 22693 0 820949 0 0 0 PAUL VOLLMAR MD PHYSICIAN 607250 0 0 0 430 0 14250 0 19990 0 641920 0 0 0 ADRIANNE WESTMORELAND MD PHYSICIAN 493606 0 0 0 168 0 14250 0 32257 0 540281 0 0 0 JEFF RAPP MD PHYSICIAN 466718 0 0 0 1234 0 14250 0 50056 0 532258 0 0 0 JOSEPH LEMKER MD PHYSICIAN 487600 0 0 0 804 0 14250 0 0 0 502654 0 0 0 RICK BREUER CEO 377430 0 0 0 430 0 14250 0 34810 0 426920 0 0 0 KARA UNDERWOOD MD PHYSICIAN / DIRECTOR 388711 0 0 0 429 0 14250 0 0 0 403390 0 0 0 BRAD ANDERSON CFO 243877 0 0 0 430 0 12730 0 35506 0 292543 0 0 0 JOANNA ROBNIK MD PHYSICIAN / DIRECTOR 254800 0 0 0 162 0 0 0 21479 0 276441 0 0 0 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 29,819. CLOQUET COMMUNITY MEMORIAL HOSPITAL FOUNDATION 512 SKYLINE BLVD CLOQUET MN 55720 363588501 SUPPORT MN 501(C)(3) LINE 12C, III-FI N/A 0 0 0 1 0 0 0 0 0 0 0 0 0 0 1 1 0 1 0 0