2019-03-15T13:58:32-05:00 2018-04-30 450250958 Eide Bailly LLP 800 Nicollet Mall Ste 1300 Minneapolis MN 554027033 990 2017-05-01 476028103 Cambridge Memorial Hospital Inc CAMB 3086971522 PO Box 488 Cambridge NE 69022 Keith Luedders Interim CEO 3086971522 2019-03-15 1 Kim Hunwardsen P00484560 6122536500 2019-03-15 74.84.124.22 2019-03-15 13:03:29 CD P 330E77A2EC15986A2DC713C7FDB26B906589BB96 330E77A2EC15986A2DC713C7FDB26B906589BB96 2017 2019-02-21 02:37:17Z Tri Valley Health System Keith Luedders PO Box 488 Cambridge NE 69022 20796688 0 X www.trivalleyhealth.com X 1955 NE Providing quality, compassionate, local healthcare services. 9 9 246 53 0 634 448968 399659 19833359 20248583 62758 122007 3900 4843 20348985 20775092 0 0 0 0 10457906 10293871 0 0 0 11201120 11529086 21659026 21822957 -1310041 -1047865 28851468 26801021 18746383 17611343 10105085 9189678 X To improve the lives we touch by providing care of the highest quality throughout life's journey. 1 0 13383784 14772148 Tri Valley Health System operates a 20-bed critical access hospital and a 34-bed nursing facility located in Cambridge, Nebraska, which provides short-term inpatient and outpatient care as well as long-term intermediate care. The Cambridge Memorial Hospital operates a full-time emergency room and provides emergency care regardless of the ability to pay. The emergency room had 767 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. Throughout the year, 2,531 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 Directors 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. These records include the amount of charges foregone for services and supplies furnished under its Charity Care Policy and equivalent service statistics. The amount of charges foregone for services provided under the Health System's charity care policy was approximately $35,000 for the year ended April 30, 2018. Total direct and indirect costs related to these foregone charges were approximately $27,000 at April 30, 2018, based on an average ratio of cost to gross charges.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. 2697568 3470350 Tri Valley has rural health clinics in Arapahoe, Indianola, and Cambridge, Nebraska. During the year, the clinics had 11,870 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 our Healthy in the Heartland programs. Yearly the clinic 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. Health fair lab testing completed which normally would cost the patient $800 is reduced to a fee of approximately $30 (depending on tests requested). 1877187 2006085 Tri Valley Health System's senior services programs include a Long Term Care Facility, an Assisted Living Facility and an Independent Living Facility. During the fiscal year, Tri Valley averaged over 22 residents a day in long-term care and 11 residents a day in the assisted living facility. By providing a continuum of care from independent, to assisted, to long term care, Tri Valley 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. 17958539 1 1 0 0 0 0 0 0 0 0 1 0 1 0 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 0 0 0 0 0 0 0 0 0 1 46 0 1 246 1 1 1 0 0 0 0 0 0 0 0 0 X 9 9 0 0 0 0 1 1 0 1 0 0 0 1 1 1 1 1 1 1 0 0 X Diana Swindler 3086973329 PO Box 488 Cambridge NE 69022 Randy Heitmann President 3.00 X X 0 0 0 Patrick Horwart Vice President 3.00 X X 0 0 0 Kristy Witte Secretary 3.00 X X 0 0 0 Troy Westadt Treasurer 3.00 X X 0 0 0 Eric Eisenhart Director 3.00 X 0 0 0 Clark Andrews Director 3.00 X 0 0 0 Paul Shellabarger Director 3.00 X 0 0 0 LaVern Banzhaf Director 3.00 X 0 0 0 Cathy Kubik Director 3.00 X 0 0 0 Deb Herzberg CEO 40.00 X 185313 0 21023 Diana Swindler CFO 40.00 X 95285 0 8339 Constance Hill CRNA Anesthetist 40.00 X 176125 0 13094 Josh Hill CRNA Anesthetist 40.00 X 173581 0 18004 Shiuvaun Jaeger MD Family Practice/Obstetrics 40.00 X 286910 0 19500 Lennie Deaver MD Family Practice/Obstetrics 40.00 X 264666 0 17176 Rachelle Kaspar-Cope MD Family Practice/Obstetrics 40.00 X 260580 0 21314 1442460 0 118450 10 0 1 0 Inspire Rehabilitation LLC 2810 W 35th Street Kearney NE 68845 Rehab services 879462 Heartland Pain Clinics LLC 603 N Diers Ave Suite 02 Grand Island NE 68803 Pain management 187813 Aureus Radiology 13609 California Street Omaha NE 68154 Contract staffing 170519 Aureus Group Finance PO Box 3037 Omaha NE 68103 Contract staffing 163025 Avera Health 3900 West Avera Drive Suite 307 Sioux Falls SD 57108 ePharmacy and mgmt services 154613 7 9000 390659 399659 Patient & Resident revenue 622110 18955937 18955937 Pharmacy revenue 900099 909751 909751 Cafeteria 900099 92776 92776 Wellness & rehab 900099 48665 48665 241454 241454 20248583 122007 122007 26439 21596 4843 4843 20775092 20248583 0 126850 X 333852 333852 27344 27344 8153220 7052310 1100910 242508 212389 30119 888265 760865 127400 648682 541594 107088 44397 44397 53600 53600 2989471 2727721 261750 188340 2100 186240 782776 433360 349416 537265 513659 23606 47552 31873 15679 548744 33573 515171 737474 737474 2227728 2227728 280558 1326 279232 Medical supplies 1450655 1450655 Repairs and maintenance 898317 543263 355054 Bad debt expense 460366 460366 Food costs 200939 200939 80904 80904 21822957 17958539 3864418 0 2035984 903739 2378564 2883557 42500 44000 376468 276836 417667 250406 35600465 20726385 15855145 14874080 3929189 3502268 3425705 3563500 390246 502635 28851468 26801021 1918221 1642853 198485 89901 16629677 15878589 18746383 17611343 X 6824273 5776408 2386469 2518927 894343 894343 10105085 9189678 28851468 26801021 X -1047865 132458 X X 0 1 X 1 1 1 X 113289 113289 22160453 11941335 10219118 9880472 7522855 2357617 3446251 1262195 2184056 14874080 Interest in Tri Valley Medical Foundation 3412971 F Interest in Auxiliary 149736 F Scholarship Account 793 F 3563500 X 20015536 -460366 -460366 20475902 299190 299190 20775092 21362591 0 21362591 460366 460366 21822957 Part X, Line 2: The Health System is organized as a Nebraska nonprofit corporation and has been recognized by the Internal Revenue Service (IRS) as exempt from federal income taxes under Internal Revenue Code Section 501(c)(3). The Health System is required annually to file a Return of Organization Exempt from Income Tax (Form 990) with the IRS. In addition, the Health System is subject to income tax on net income that is derived from business activities that are unrelated to its exempt purpose, if applicable. 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. Part XI, Line 2d - Other Adjustments: Provision for bad debts included in revenue for financial statements -460,366. Part XI, Line 4b - Other Adjustments: Contributions for long-lived assets incl in fund balance for financial stmts 299,190. Part XII, Line 4b - Other Adjustments: Provision for bad debts included in revenue for financial statements 460,366. 1 1 X 1 X 1 X 0 1 0 0 27000 27000 0.00130 1558104 1343517 214587 0.01000 1585104 1343517 241587 0.01130 287230 21510 265720 0.01240 4516988 3227787 1289201 0.06030 4804218 3249297 1554921 0.07270 6389322 4592814 1796508 0.08400 0 460366 71817 8277317 8342675 -65358 X 1 1 1 1 Cambridge Memorial Hospital dba Tri Valley Health System 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 15 1 0 0 1 X www.trivalleyhealth.com X 1 15 1 www.trivalleyhealth.com 0 1 X 100.000000000000 200.000000000000 X X 1 1 X X X X 1 X www.trivalleyhealth.com/financialassistance.aspx X www.trivalleyhealth.com/financialassistance.axpx X www.trivalleyhealth.com/financialassistance.axpx X X X X X X 1 X 0 X X X 1 X 0 0 Cambridge Memorial Hospital, Inc. Part V, Section B, Line 5: Tri Valley 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 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 2016. Tri Valley Health System approved an implementation plan to address all nine needs identified in the CHNA. (1) The uninsured adult population rate in Furnas County is 14%, higher than the rural Nebraska norm of 13.7%. With Tri Valley being the largest employer in the county, the community feedback conclusion was Tri Valley needed to provide affordable health insurance options to employees. In calendar year 2017, 2018 and 2019, Tri Valley was able to offer insurance to employees. Tri Valley will continue to provide affordable hospital enrollment assistance education and services for Medicare/Medicaid and other third-party payors. (2) The second need identified was an awareness of the aging primary care providers. Tri Valley hired a full time APRN and a full time Physician's Assistant. A recruitment agreement was signed with a Physician who will start working at Tri Valley in June 2019. Tri Valley will solidify and implement the on-boarding process for new providers when hired as well as complete a provider satisfaction survey. Additionally, Tri Valley has partnered with local schools to educate high school students on health care career options. (3) The number of poor mental health days in Furnas County is 2.8, higher than the rural Nebraska norm of 2.7. The community feedback conclusion was mental health services (diagnosis and placement) needs improvement. While Tri Valley already offers mental health services, the implementation plan is to encourage and increase depression screenings by primary care physicians. Tri Valley opened a program called Senior Life Solutions which is for mental health services for the elderly population. Tri Valley will also be completing evaluations to determine the appropriate specialties to add to our specialty clinic which will include evaluating the need for urgent care services, cancer services, child care, chiropractors, optometrist, family planning services, home health and school nurses. (4) The need to increase awareness of health care services offered was identified in the CHNA. Nex-Tech Marketing was hired to establish and execute our strategic communication goals. (5) The aging of nursing home facilities in our community was identified as a need. Tri Valley addressed this by completing an analysis of the senior services currently offered and the financial impact for continuing to offer these services. Tri Valley engaged an outside vendor to evaluate the current facilities and costs associated with the improvements needed. Tri Valley will then recommend an alternative way to manage senior services to the Board of Directors. A recommendation was made to the Board of Directors in 2018. At the end of the fiscal year, a decision had not been made yet on the recommendations. (6) Nursing shortage was identified in the assessment. Tri Valley redefined behavioral standards through development of frontline staff and senior team led committee. Tri Valley developed a communication plan and communicated employee standards, hardwired rounding on every employee every month, developed and implemented peer interview processes, developed and implemented a new employee onboarding process as well as an employee satisfaction survey. Tri Valley will partner with local schools to educate students on health care career options and offer on-site experiences. (7) The assessment identified drug abuse. Tri Valley will establish a community task force to explore how to stop black market sales of prescription meds and set up a program to monitor prescription drug abuse. Tri Valley will develop education handouts for medical providers to distribute to patients when prescribing schedule II drugs. Tri Valley will continue to promote a drug drop program twice a year through a DEA sponsored national medication take-back initiative. Tri Valley will partner with the schools to increase and train school-based programs regarding substance abuse. Tri Valley will also evaluate a need for a chronic pain clinic.(8) The number of mothers who began prenatal care in the first trimester in Furnas County is 159, lower than the rural Nebraska norm of 393. Tri Valley addressed this by implementing a system to ensure all pregnant women presenting to the Emergency Room are scheduled for an OB appointment with their choice of provider before discharge. Tri Valley will promote OB provider adherence to ACOG guidelines pertaining to first trimester entry to prenatal care. Tri Valley also educates the community on availability of prenatal care resources and other support services through Tri Valley.(9) The adult obesity rate in Furnas County is 33%, higher than the rural Nebraska norm of 31.3%. Also, the percent of diabetic monitoring is lower than the rural Nebraska norm of 84.2%. Furnas County residents also identified a limited access to healthy foods. Tri Valley continues to promote fitness and healthy lifestyles focusing on promoting walking trails, restaurant healthy meals and health fairs, classes and speakers. Furthermore, Tri Valley promotes a community farmer's market and Tri Valley started a community wide fitness challenge initiative focusing on fitness, nutrition and physical activity. The program is called "Healthier Me and classes start in October of each year. 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 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. 2 1 - Heritage Plaza 1205 Nelson Street Cambridge NE 69022 Independent living 2 - Tri Valley Health System Assisted Living 711 Mousel Ave Cambridge NE 69022 Assisted 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 I, Ln 7 Col(f): The amount of bad debt expense removed from total expenses to determine the percentage was $460,366. Part III, Line 2: The reserve for doubtful accounts is determined by a percentage of the remaining account receivables after discounts and payments are applied based on the age of the account. Payments received on accounts previously written off to bad debt reduces bad debt expense in the current year.Bad debt expense on line 2 is reported at charges as presented on the financial statements. Part III, Line 3: In Furnas County, Nebraska, the percentage of residents that are at or below poverty level is 15.6%. We can assume that the same percentage of patients would be eligible for charity care, however either did not apply or were denied charity care based on lack of information. Bad debt expense was $460,366. We can assume that 15.6%, or $71,817, of this bad debt was attributable to patients who were eligible for the charity care program. Part III, Line 4: The footnote to the Organization's financial statements can be found on page 9 of the attached audited financial statements. 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 April, 2016, round two 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 $40,445 in 2016. These income values are below the median and average for both the state of Nebraska and the United States.Unemployment rates for the service area for 2018 range from 2.6% (Gosper), 2.4% (Frontier), 2.4% (Red Willow) to 2.6% (Furnas). These rates compare favorably to the state of Nebraska and the United States. Part VI, Line 5: Tri Valley Health System is governed by a nine-person Board of Directors. 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. 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. Healthy Women in the Heartland program provides monthly newsletters and quarterly educational programs at no cost to the members. The programs offered include everything from healthy eating by the Hospital's dietician to foot care by a podiatrist. Annually the Hospital promotes a Women's Day of Health which includes a full day of activities and educational programs to encourage and educate women on healthy living. The 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 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 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's Cambridge Memorial Hospital 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, 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 Deb Herzberg CEO 183838 0 0 0 1475 0 6349 0 15286 0 206948 0 0 0 Constance Hill CRNA Anesthetist 174668 0 0 0 1457 0 5101 0 8497 0 189723 0 0 0 Josh Hill CRNA Anesthetist 173105 0 0 0 476 0 5930 0 12579 0 192090 0 0 0 Shiuvaun Jaeger MD Family Practice/Obstetrics 226681 0 59324 0 905 0 6374 0 13897 0 307181 0 0 0 Lennie Deaver MD Family Practice/Obstetrics 217006 0 46029 0 1631 0 6620 0 11299 0 282585 0 0 0 Rachelle Kaspar-Cope MD Family Practice/Obstetrics 217836 0 41476 0 1268 0 8100 0 13949 0 282629 0 0 0 Part I, Line 1a Spouses of board members attend one conference up to a maximum of $600. Providers can 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 provider's W-2. Maranda Lee Family member of Diana Swindler, CFO 27344 employee compensation 0 Form 990, Part III, line 2 In March 2018, a new program called Senior Life Solutions was offered. The program is an intensive outpatient group counseling program, designed to meet the unique needs of older adults over the age of 65 struggling with depression and anxiety often related to aging. Form 990, Part VI, Section A, line 6 Members pay a $5 fee to become a lifetime member. Form 990, Part VI, Section A, line 7a Members select the Board of Directors 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 Members prior to it being filed. Form 990, Part VI, Section B, line 12c At the October board meeting all board members complete an annual disclosure. The policy covers the board of directors. 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 Directors 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 412,168. Management and general expenses 27,135. Fundraising expenses 0. Total expenses 439,303. Purchased services: Program service expenses 426,367. Management and general expenses 233,989. Fundraising expenses 0. Total expenses 660,356. Contracted services: Program service expenses 1,889,186. Management and general expenses 626. Fundraising expenses 0. Total expenses 1,889,812. Form 990, Part XI, line 9: Change in interest in net assets of Tri Valley Medical Foundation 132,951. Net assets released from restrictions -493. Form 990, Part XII, Line 2c: The Board of Trustees assumes responsibility for oversight of the audit and selection of an independent accountant.