2021-03-11T20:12:42-06:00 2020-04-30 450250958 Eide Bailly LLP 800 Nicollet Mall Ste 1300 Minneapolis MN 554027033 990 2019-05-01 476028103 Cambridge Memorial Hospital Inc CAMB 3086973329 1305 W Hwy 6 34 Cambridge NE 69022 Jessica Fisher CEO 3086973329 2021-03-10 1 KIm Hunwardsen CPA P00484560 6122536500 2021-03-10 2019 2022-09-23 18:48:47Z X Tri Valley Health System Jessica Fisher 1305 W Hwy 6 34 Cambridge NE 69022 22443056 0 X www.trivalleyhealth.com X 1955 NE Providing quality, compassionate, local healthcare services. 8 8 231 44 0 0 516722 514422 22225060 20960496 62281 81333 535 845805 22804598 22402056 0 0 0 0 10465136 10273171 0 0 0 13471177 12544219 23936313 22817390 -1131715 -415334 25416084 26374690 17305315 18932225 8110769 7442465 X To improve the lives we touch by providing care of the highest quality throughout life's journey. 0 1 15443674 17961176 Cambridge Memorial Hospital, Inc., dba Tri Valley Health System operates a 20-bed critical access hospital located in Cambridge, Nebraska. The hospital provides short-term inpatient and outpatient care.Tri Valley Health System operates a full-time emergency room and provides emergency care regardless of the ability to pay. The emergency room had 1,113 emergency center visits this year. Through its integrated network of providers, Tri Valley Health System provides emergency and non-emergency services to the communities it serves. Tri Valley Health System initiated a "walk-in" clinic through one of their Rural Health Clinics. (Continued on Schedule O)Throughout the year, 2,804 patients were seen through the "walk-in" clinics.Services are accessible to the communities through participation in government programs like Medicare and Medicaid and by offering assistance through the Tri Valley Health System Charity Program. The Tri Valley Health System Charity Program provides discounted and free services to patients who lack the resources to be fully responsible for the health care they receive. The Charity Program is designed to ensure the communities served by Tri Valley Health System have access to needed healthcare services. The Tri Valley Health System Board of Trustees oversees services delivered under the Charity Care Policy including assessing community needs, approving eligibility criteria and monitoring the effectiveness of the program in providing community access to medical care. Records are maintained to identify and monitor the level of charity care provided. The estimated cost of providing these services was $113,000 for the year ended April 30, 2020 calculated by multiplying the ratio of cost to gross charges for the Health System by the gross uncompensated charges associated with providing charity to its patients.In addition, the Health System provides services to other patients under certain government-reimbursed public aid programs. Such programs pay providers amounts which are less than established charges for the services provided to the recipients, and for some services the payments are less than the cost of rendering the services provided.The Health System also commits significant time and resources to endeavors and critical services which meet otherwise unfulfilled community needs. Many of these activities are sponsored with the knowledge that they will not be self-supporting or financially viable. 2551525 3386012 Tri Valley Health System has rural health clinics in Arapahoe, Indianola, and Cambridge, Nebraska. During the year, the clinics had 11,036 visits. The employed physicians are active in the community and provide support services such as attendance at community sport programs and medical directors for EMT groups. They also offer educational programs for the local school systems and people in the community with programs such as "Healthier Me", a diabetes prevention program. Yearly the clinics provides "flu clinics" in which flu vaccinations are provided at reduced rates. Also, the clinics annually offer a "health fair" to the communities they serve. (Continued on Schedule O)Health fair lab profile testing completed which normally would cost the Health System $665 (based on an average ratio of cost to gross charges) is reduced to a fee of approximately $35 (depending on tests requested). 805518 458308 Tri Valley Health System's senior services programs include an Assisted Living Facility and an Independent Living Facility. Additional services are provided including a home monitoring system, Meals on Wheels, and Public Transportation. During the fiscal year, Tri Valley's Assisted Living Facility averaged 13 residents a day. Tri Valley Health System is encouraging community members to stay as independent as possible and assuring the patients/residents are in the appropriate location based on their level of care needs. 18800717 1 1 0 0 0 0 0 0 0 0 1 0 0 1 0 1 1 0 0 0 0 0 0 0 0 0 1 1 0 0 1 0 0 0 0 0 0 1 0 1 0 0 0 0 0 0 0 0 1 76 0 1 231 1 0 0 0 0 0 0 0 0 0 0 0 0 X 8 8 0 0 0 0 1 1 0 1 0 0 0 1 1 1 1 1 1 1 0 0 X Diana Swindler 3086973329 1305 W Hwy 6 34 Cambridge NE 69022 Rachelle Kaspar-Cope MD Family Practice/Obstetrics 40.00 X 286350 0 28229 Lennie Deaver MD Family Practice/Obstetrics 40.00 X 279860 0 10732 Shiuvaun Jaeger MD Family Practice/Obstetrics 40.00 X 273010 0 28505 Josh Hill CRNA Anesthetist 40.00 X 187472 0 31346 Sarah Norton PA-C Family Practice 40.00 X 144463 0 28 Keith Luedders COO 40.00 X 131592 0 5341 Jessica Fisher CEO 40.00 X 108180 0 10108 Diana Swindler CFO 40.00 X 98332 0 14057 Paul Shellabarger President 3.00 X X 0 0 0 James Jones Vice President 3.00 X X 0 0 0 Joan Koch Secretary 3.00 X X 0 0 0 LaVern Banzhaf Treasurer 3.00 X X 0 0 0 John Kutnink Trustee until 4/22/20 3.00 X 0 0 0 Dale Fohnholz Trustee as of February 2020 3.00 X 0 0 0 Drew Cramer Trustee as of March 2020 3.00 X 0 0 0 Ginger tenBensel Trustee as of March 2020 3.00 X 0 0 0 John Paulsen Trustee 3.00 X 0 0 0 1509259 0 128346 10 0 1 0 Inspire Rehabilitation LLC 8181 Arista Place Ste 100 Broomfield CO 80021 Rehab services 848698 Psychiatric Medical Care LLC PO Box 734606 Dallas TX 75230 Psychiatric services 456592 FocusOne Solutions 13609 California Street Omaha NE 68103 Medical & Healthcare 324713 Avant Healthcare Professionals LLC PO Box 744554 Atlanta GA 303744554 Contract Staffing 286994 Rural Partners in Medicine LLC 11880 Airport Way Broomfield CO 80021 Medical & Healthcare 279476 7 78489 435933 68319 514422 Patient & Resident revenue 622110 19156934 19156934 Pharmacy revenue 900099 1557958 1557958 Cafeteria 900099 104967 104967 Wellness & rehab 900099 39462 39462 101175 101175 20960496 72267 72267 15434 0 15434 15434 15434 9066 0 9066 9066 9066 26371 41000 -14629 -14629 Settlement proceeds 900099 845000 845000 845000 22402056 21805496 0 82138 X 425237 425237 52655 52655 7940716 6628290 1312426 282394 225237 57157 1001956 770907 231049 570213 431774 138439 143465 143465 59725 59725 5287282 4828822 458460 149419 2487 146932 418239 290313 127926 514981 514981 102548 71605 30943 683110 577842 105268 2224317 1881548 342769 348635 348635 Medical supplies 1652664 1652664 Repairs and maintenance 530396 530396 Food costs 154330 154330 275108 186866 88242 22817390 18800717 4016673 0 1039685 3227798 2911366 2212337 55500 119956 374601 432190 279679 191280 36866526 24832718 13463750 12033808 3253404 4234197 153573 138027 3884526 3785097 25416084 26374690 2163241 2067663 46289 101349 15095785 14364522 0 2398691 17305315 18932225 X 4729729 4080201 3381040 3362264 8110769 7442465 25416084 26374690 X -415334 -18837 -234133 X X 0 1 X 1 0 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 113289 113289 22280571 14212910 8067661 11868866 9011254 2857612 2603800 1608554 995246 12033808 Other receivables 363318 Estimated third-party payor settlements 75000 Interest in Tri Valley Medical Foundation 3144099 Insurance Escrow 202680 3785097 X 22383219 -18837 -18837 22402056 0 22402056 22817390 0 22817390 0 22817390 Part X, Line 2: The Health System believes that it has appropriate support for any tax positions taken affecting its annual filing requirements, and as such, does not have any uncertain tax positions that are material to the financial statements. The Health System would recognize future accrued interest and penalties related to unrecognized tax benefits and liabilities in income tax expense, if such interest and penalties are incurred. The Health System has determined it is not subject to unrelated business income tax and has not filed an Exempt Organization Business Income Tax Return (Form 990T) with the IRS. 1 1 X 1 X 1 X 0 1 0 0 113000 113000 0.00500 1158169 1075073 83096 0.00360 1271169 1075073 196096 0.00860 6059470 3680342 2379128 0.10430 6059470 3680342 2379128 0.10430 7330639 4755415 2575224 0.11290 1 1024935 111718 9524217 9596031 -71814 X 1 1 1 1 Cambridge Memorial Hospital Inc 1305 W Hwy 6 34 Cambridge NE 69022 www.trivalleyhealth.com 310001 X X X X 3 provider based rural health clinics Cambridge Memorial Hospital Inc 1 0 0 1 X X X X X X X X X 18 1 0 0 1 X See Part V, Section C X 1 18 1 See Part V, Section C 0 1 X 100.000000000000 200.000000000000 X X 1 1 X X X X 1 X https://www.trivalleyhealth.com/financial-assistance.html X https://www.trivalleyhealth.com/financial-assistance.html X https://www.trivalleyhealth.com/financial-assistance.html X X X X X X 1 X 0 X X X X 1 X 0 0 Cambridge Memorial Hospital, Inc. Part V, Section B, Line 5: Tri Valley Health System held a town hall meeting and invited members of the community which includes local hospital, public health community, mental health community, service providers, local residents, community leaders, school leaders, business leaders, local government, faith-based organizations and person with chronic conditions, uninsured community members, low income residents and minority groups. VVV Consultants, LLC was the principal consultant. Tri Valley Health System also completed an online survey which was widely published as well as individual letters sent to community members requesting the survey be completed. Cambridge Memorial Hospital, Inc. Part V, Section B, Line 11: A Community Health Needs Assessment was completed in the first quarter of 2019. Tri Valley Health System approved an implementation plan to address six of the eight needs identified in the plan. Tri Valley Health System chose not to address the need of Child Care Services or Housing as they are not part of Tri Valley Health System's mission of critical operations. The areas being addressed include:(1) Recruitment/Add Visiting Specialists. Work/contract with area specialists to provide specialty services in TVHS Specialty Clinic. Current relationship with Platte Valley Medical Group in Kearney, NE, Rural Partners in Medicine in Steamboat, CO and other various medical groups in the state who can provide specialized services. TVHS will network with other neighboring Specialty Clinics to share services (if able). TVHS recruited the following specialists/providers in FY2020: APRN Wound Care; APRN Family Practice; MD Family Practice; and CRNA.(2) Healthcare Staffing Shortages. Through Workforce Connections Program, TVHS will continue to work on selecting and supporting non-traditional students in the pursuit of furthering their education to meet our staffing needs. During FY2020, TVHS supported four (4) Workforce Connection students. (3) Aging Nursing Home Facilities. The Board of Trustees made a decision to close the Nursing Home.(4) Healthcare Insurance Options. TVHS will perform annual due diligence to evaluate health insurance providers as well as self-insurance options to provide affordable coverage options to employees. During FY2020, TVHS added a 3rd insurance option for employees. Also, TVHS switched retirement plan administrators to increase employee satisfaction.(5) Build Community Awareness/Support. TVHS will develop and implement a marketing plan focused on increasing awareness of healthcare services offered. TVHS will partner with Nex-Tech Marketing to provide assistance with a marketing plan and an upgraded and regularly updated website. TVHS will also use social media for marketing purposes. Although TVHS ended the contract with Nex-Tech during FY20, TVHS implemented "The Beat" which is a CEO weekly/bi-weekly Facebook video post to share updates. A quarterly newsletter by using direct mail services called "The Pulse" was implemented. "The Pulse" is now sent out quarterly. (6) Drugs (Opioids, Meth, Marjuana). TVHS will collaborate with schools, law enforcement, pharmacies, and neighboring agencies to prevent the unauthorized usage of prescription and illicit substances within our communities. Furthermore, TVHS will work with TVHS providers to prescribe and dispense substances in accordance with the Opioid Stewardship initiative to reduce the prevalence of drug abuse in our community. During FY2020, e-Prescribe went live and is currently used by TVHS providers. Cambridge Memorial Hospital, Inc. Part V, Section B, Line 16j: A plain language summary is conspicuously displayed in Hospital patient waiting areas and in the Patient Accounting Department in a manner that is reasonably calculated to attract visitors' attention. A plain language summary of this Policy and a copy of the financial assistance application will be included in all admission packets provided to inpatients upon admission to the Hospital. A plain language summary of this policy will be offered to all outpatients registering for services. The Hospital publishes the plain language summary of the Policy in the local newspaper on at least an annual basis and may publicize the Policy using other media at the option of Hospital administration. Schedule H, Part V, Section B, Line 7a and 10a: https://www.trivalleyhealth.com/community-health-needs.html 1 1 - Heritage Plaza 1205 Nelson Street Cambridge NE 69022 Independent living Part I, Line 7: Charity care expense was converted to cost on line 7a based on an overall cost-to-charge ratio addressing all payor segments. Unreimbursed Medicaid on line 7b was calculated using the costing methods to prepare the cost reports. The cost for subsidized health services reported on line 7g was determined using the Medicare Cost Report. Part III, Line 2: The amount reported on line 2 represents implicit price concessions. The Health System determines its estimate of implicit price concessions based on its historical collection experience with this class of patients and residents. Part III, Line 3: The Hospital reasonably estimates the portion of implicit price concessions that could have qualified for charity care by identifying the uninsured, underinsured, and account balances assinged to a collection agency in the current year.In Furnas County, Nebraska, the percentage of residents that are at or below poverty level is 10.9%. We can assume that the same percentage of implicit price concessions are attributable to patients potentially eligible for charity care. Part III, Line 4: The ability to estimate the collectability of uninsured and other self-pay patients or residents is contingent on the patient's or resident's ability or willingness to pay for the services provided. Subsequent changes that are determined to be the result of an adverse change in the patient's or resident's ability to pay are recorded as bad debt expense. Bad debt expense for the years ended April 30, 2020 and 2019 was not significant. Part III, Line 8: Even though Tri Valley Health System has a Medicare shortfall patients with Medicare coverage are accepted regardless of whether or not a surplus or deficit is realized from providing the services. The Hospital provides services to these patients because access to healthcare is important to the Hospital. This is a key advantage to the community and therefore the shortfall is considered a community benefit.Medicare allowable costs of care are based on the Medicare cost report. The Medicare cost report is completed based on the rules and regulations set forth by the Centers for Medicare and Medicaid Services. Part III, Line 9b: If an individual submits an incomplete application during the Application Period, the Hospital will:1. Suspend any extraordinary collection actions, 2. Provide written notice that contains a summary of the Policy and that describes the additional information or documentation required under the Policy or in the application to complete the application; and3. Provide at least one written notice that informs the individual about the extraordinary collection actions the Hospital may take or reinstate if the individual does not complete an application or pay the amount due by a date that is not earlier than the last day of the Application Period and thirty (30) days of the date of the notice.If an individual submits a completed application during the Application Period, the Hospital will:1. Suspend any extraordinary collection actions;2. Determine and document whether the individual is an individual who qualifies for financial assistance under the Policy;3. Notify the individual in writing of the determination and the basis for the determination; and4. If the individual is an individual who qualifies for assistance under the Policy, provide the individual with a billing statement that indicates the amount the individual owes as adjusted under the Policy and how the Hospital determined the amount the individual owes. The Hospital will also refund any excess payments made by the individual and take reasonable measures to reverse any extraordinary collection action taken against the individual.The Application Period begins on the date the care is provided to the individual and ends on the 240th day after the Hospital provides the individual with the first bill for care provided.Extraordinary collection actions do not include deferring or denying care based on a pattern of nonpayment, requiring deposits before providing care or charging interest, to the extent that such practices are not prohibited with respect to the Hospital's obligation to provide emergency medical care (MSE and any necessary stabilizing treatment as required by EMTALA). Part VI, Line 2: In addition to the community health needs assessment, the Hospital assesses the health care needs of the community it serves through patient feedback using various surveys. The surveys are provided by an outside vendor for inpatient care, Emergency Department, and Rural Health Clinics. In-house surveys are completed by various departments.In March, 2019, round three of the Community Health Needs Assessment (CHNA) was conducted by Tri Valley Health System for the approximately 21,000 residents in their designated service area. To ensure input from persons with broad knowledge of the community, a Community Advisory Committee was organized with specific individuals from the community served. Personal invitations were sent to individuals representing various community, business, and educational groups throughout the four-county area along with representatives from Tri Valley Health System.The community health needs assessment and implementation strategy are posted to the Hospital's website at www.trivalleyhealth.com. Part VI, Line 3: The Financial Assistance Policy, an application, a plain language summary of the Policy, and any notices or publications regarding the Policy will be made available on the Hospital's website. The Policy, applications, and plain language summaries are available upon request, without charge at the Patient Accounting Department and by mail.A plain language summary is conspicuously displayed in Hospital patient waiting areas and in the Patient Accounting Department in a manner that is reasonably calculated to attract visitors' attention. A plain language summary of the Policy and a copy of the Financial Assistance Application will be included in all admission packets provided to inpatients upon admission to the Hospital. A plain language summary of the Policy is offered to all outpatients registering for services.The Hospital will publish the plain language summary of the Policy in the local newspaper on at least an annual basis and may publicize the Policy using other media at the option of Hospital Administration.Social services staff discusses with patients the availability of state programs (i.e. Medicaid), and assists them with the necessary paperwork. This is usually done primarily for inpatients and nursing home residents. Social Services contacts patient accounting staff about any other individuals in need of our Charity Care Program. We ask all patients having financial hardships to please contact our patient accounting office. After self-pay accounts generate a patient statement, they are reviewed by self-pay patient accounting staff. When deemed appropriate, an explanatory letter and financial application are mailed to the patient. We provide them with all the necessary contact information and documentation requirements. Numerous attempts are made to obtain the needed information to qualify our patients for either charity care and/or Medicaid, if appropriate. Part VI, Line 4: Tri Valley Health System's service area includes the southwest Nebraska counties of Furnas, Frontier, Gosper and Red Willow. Median household income in the service area was $48,977 in 2018. These income values are below the median and average for both the state of Nebraska and the United States. About 10.9% of the population were below the poverty level.Unemployment rates for the service area for 2019 range from 2.6% (Gosper), 2.7% (Frontier), 2.6% (Red Willow) to 2.7% (Furnas). These rates compare favorably to the state of Nebraska and the United States.The largest industries in Cambridge, NE are health care and social assistance, educational services, and manufacturing. Part VI, Line 5: Tri Valley Health System is governed by a Board of Trustees whose members reside within the Health System's primary service area and have no immediate family ties to any employees. These individuals also do not benefit financially through their businesses by means of contracts or other agreements. Surplus funds, if available, are used to purchase equipment or are re-invested in the facility to improve patient care. Tri Valley Health System extends medical staff privileges to all qualified physicians in the community. Throughout Tri Valley Health System's fiscal year, strides were made to increase the community outreach and education as well as the health of the communities. In 2011, Tri Valley Health System opened the Healthy Living Center which includes a Wellness and Rehab Center. Every day people with chronic diseases, such as diabetes and heart failure, are monitored, educated, and cared for by dedicated health care professionals who help them enjoy the best quality of life possible. In 2016, the Health System started a "Healthy Living" program directed toward diabetes and obesity through the Nutrition Education Department. The Hospital opens its doors to the community to use conference areas for groups such as Alcohol Anonymous, ministerial associations, Weight Watchers, and community volunteer emergency medical technician training. Other improvements to community outreach and education were accomplished through more frequent healthy living lunch lectures, and the development of Fitness Reaching Older Generations (FROG) classes within the Cambridge Community. Tri Valley Health System is reaching out to the communities through the school system and providing education to students in topics such as smoking cessation, bone health, spinal trauma and thyroid issues. Tri Valley Health System also provided baseline trauma testing to football players in all the schools in the communities they serve as well as offering athletic trainers to the school systems at no cost. As a critical access hospital, Tri Valley Health System invites specialists throughout the state to conduct weekly or monthly clinics in the specialty clinic. Services offered to patients during the fiscal year were cardiology, general surgery, mental health, obstetrics/gynecology, orthopedics, ophthalmology, otolaryngology, podiatry, pulmonology, and urology. Tri Valley Health System also offers telehealth psychiatric services. X X 1 1 X X 0 0 0 0 0 0 0 0 0 Rachelle Kaspar-Cope MD Family Practice/Obstetrics 286350 0 0 0 0 0 0 0 28808 0 315158 0 0 0 Lennie Deaver MD Family Practice/Obstetrics 279860 0 0 0 0 0 0 0 12198 0 292058 0 0 0 Shiuvaun Jaeger MD Family Practice/Obstetrics 273010 0 0 0 0 0 0 0 28856 0 301866 0 0 0 Josh Hill CRNA Anesthetist 187472 0 0 0 0 0 0 0 31591 0 219063 0 0 0 Part I, Line 1a Spouses of board members attend one conference up to a maximum of $600. Providers & CEO choose to belong to either a health club or a golf club. Payments are made directly to the health club or golf club. This is reported as income on the providers and CEO's W-2. Maranda Lee Family member of Diana Swindler, CFO 52655 Employee Compensation 0 X 2 68319 Cost 0 0 0 0 Part I, Column (b): Part I, column (b) is the number of items received. Form 990, Part III, line 3 The Cambridge Manor long-term care facility closed May 1, 2019. Form 990, Part VI, Section A, line 6 Members pay an annual membership fee of $10. Form 990, Part VI, Section A, line 7a Members select the Board of Trustees at the annual meeting. All members have the same voting rights. Form 990, Part VI, Section A, line 8b There are no committees with the authority to act on behalf of the governing body. Form 990, Part VI, Section B, line 11b The CEO and CFO will review the Form 990. The 990 will then be electronically distributed to the Board Trustees prior to it being filed. Form 990, Part VI, Section B, line 12c At the November board meeting the newly elected Board of Trustees complete an annual disclosure. At the January board meeting all Board of Trustees, CEO, and CFO complete an annual disclosure. The CEO reviews the disclosures. Anyone with a conflict must abstain from voting on the issue and is not able to participate in discussions regarding the issue. Form 990, Part VI, Section B, line 15a The Board of Trustees determines compensation and benefits for the CEO through an employment contract. Review and determination of compensation is done on an annual basis using the Nebraska Hospital Association Compensation Survey as comparability data. Documentation is provided in the CEO's personnel file. For the CFO, the Human Resources department participates in the Nebraska Hospital Association Compensation Survey on an annual basis. Once the results are received, they review the staffs' years of experience as well as their position responsibilities to determine if the salary range is appropriate. A wage range is recommended to the CEO and the CEO determines the final wage for the CFO. This process is completed on an annual basis and documentation is made in the CFO's personnel file. Market Wage Adjustments are made on an as-needed basis to adjust salaries that fall outside the survey guidelines. Form 990, Part VI, Section C, line 19 The governing documents, conflict of interest policy and financial statements are available upon request. The financial statements are also attached to the Form 990. Form 990, Part IX, line 11g Professional fees: Program service expenses 2,782,063. Management and general expenses 0. Fundraising expenses 0. Total expenses 2,782,063. Purchased services: Program service expenses 1,417,354. Management and general expenses 350,889. Fundraising expenses 0. Total expenses 1,768,243. Pharmacy Fees: Program service expenses 629,405. Management and general expenses 0. Fundraising expenses 0. Total expenses 629,405. Other Fees: Program service expenses 0. Management and general expenses 107,571. Fundraising expenses 0. Total expenses 107,571. Form 990, Part XI, line 9: Change in interest in net assets of Tri Valley Medical Foundation -234,133. Form 990, Part XII, Line 2c: The Board of Trustees assumes responsibility for oversight of the audit and selection of an independent accountant.