2017-08-07T16:53:31-05:00 2016-12-31 476097913 SEIM JOHNSON LLP 18081 BURT STREET SUITE 200 OMAHA NE 680224722 990 2016-01-01 420670596 SUMNER COMMUNITY CLUB SUMN 5635783275 909 W 1ST STREET PO BOX 148 SUMNER IA 506740148 STEVE SLESSOR INTERIM CEO 5635783275 2017-08-01 1 WENDY R COOLEY P01523804 4023302660 209.34.201.180 2017-08-01 10:51:10 CD P FCEDDD786A52D146CD6D5AF04BB3D8B974087028 FCEDDD786A52D146CD6D5AF04BB3D8B974087028 2016 2021-01-29 14:40:06Z COMMUNITY MEMORIAL HOSPITAL STEVE SLESSOR 909 W 1ST STREET PO BOX 148 SUMNER IA 506740148 12301633 0 X WWW.CMHSUMNER.ORG X 1950 IA COMMUNITY MEMORIAL HOSPITAL SERVES THE AREA THROUGH ITS HEALTHCARE AND EDUCATIONAL SERVICES. WE EMPHASIZE CONCERN FOR THE QUALITY OF A PERSON'S LIFE, THROUGH EVERY MEASURE INTENDED TO PRESERVE LIFE WITH DIGNITY AND RESPECT. WE ARE DEDICATED TO CREATING AND MAINTAINING AN ENVIRONMENT SUPPORTING EXCELLENCE IN HEALTHCARE. WE PROVIDE QUALIFIED AND PROPERLY TRAINED PERSONNEL AND MEDICAL STAFF IN AN ATMOSPHERE WHICH INSPIRES A CREATIVE APPROACH TO THE COMPLEX HEALTHCARE CHALLENGES OF TODAY AND TOMORROW. 11 11 0 7 1526 -1206 180538 122358 11917881 12058125 38773 39817 74341 81333 12211533 12301633 0 0 0 0 5646893 6223207 0 0 0 7200580 7124795 12847473 13348002 -635940 -1046369 29572705 27799099 19884839 19270547 9687866 8528552 X TO PROVIDE QUALITY HEALTH CARE TO THE PEOPLE OF SUMNER AND SURROUNDING AREAS, WHILE COORDINATING OTHER NEEDED SERVICES. 0 0 7784535 6292447 REVENUE AND EXPENSES RELATING TO OUTPATIENT DEPARTMENTS THAT OPERATE WITHIN COMMUNITY MEMORIAL HOSPITAL. THESE DEPARTMENTS INCLUDE, BUT ARE NOT LIMITED TO, LABORATORY, RADIOLOGY, OPERATING AND RECOVERY ROOM, AND PHYSICAL, OCCUPATIONAL AND SPEECH THERAPY SERVICES. EACH OF THESE OUTPATIENT DEPARTMENTS PROVIDES STATISTICAL INFORMATION BASED ON VOLUME RELATED TO THE SPECIFIC SERVICE ARE AND WORKS IN CONJUNCTION WITH SERVICES PROVIDED IN THE CMH MEDICAL CLINIC, EMERGENCY DEPARTMENT AND ACUTE NURSING SERVICES. 1450447 3187118 COMMUNITY MEMORIAL HOSPITAL (CMH) MEDICAL CLINIC CONTINUED TO SERVE SUMNER, IA AND THE SURROUNDING AREA IN THE YEAR 2016. CMH CLINIC WAS STAFFED WITH 4 PROVIDERS. THE CMH CLINIC HAS TWO NURSE PRACTITIONERS AND TWO PHYSICIANS. PATIENTS WERE SERVED IN MANY CAPACITIES INCLUDING, BUT NOT LIMITED TO, WELL CHILD VISITS, IMMUNIZATIONS, ROUTINE PEDIATRIC CARE, SHARED MATERNITY CARE, WOUND CARE, THERAPEUTIC INJECTIONS AND MANIPULATION TREATMENTS. PATIENTS RANGED FROM NEWBORN TO GERIATRIC. A 50-MILE RADIUS OF SUMNER WAS SERVED WITH A TOTAL PATIENT VOLUME OF 12,800 FOR 2016. IN ADDITION TO CLINIC VISITS, OUR PROVIDERS CONTINUE THEIR SERVICE TO SURROUNDING NURSING HOMES AND ASSISTED LIVING FACILITIES WITH PATIENTS SEEN MONTHLY AT HILLCREST HOME IN SUMNER, MAPLECREST MANOR IN FAYETTE, TRIPOLI NURSING & REHAB IN TRIPOLI, AND COBBLESTONE ASSISTED LIVING IN SUMNER. OTHER SERVICES TO THE COMMUNITY WERE PHYSICALS FOR AREA FIREFIGHTERS AND EMS AGENCIES AND POST-JOB OFFER PHYSICALS FOR FIVE LOCAL BUSINESSES. PROVIDERS CONTINUE TO TAKE CALL FOR THE EMERGENCY DEPARTMENT ON A REGULAR SCHEDULED BASIS IN THE EVENING AND ON WEEKENDS THROUGHOUT EACH MONTH. IN THE PAST, CLINICAL STAFF FROM THE HOSPITAL WENT TO THE AREA BANK ON THE FIRST TUESDAY OF EACH MONTH TO OFFER FREE BLOOD PRESSURE CHECKS TO ANYONE ON A WALK-IN BASIS. INDIVIDUALS ARE NOW ALLOWED TO WALK INTO THE CLINIC FOR THIS SAME SERVICE ONSITE AS OPPOSED TO BEING LOCATED AT THE BANK. PROVIDERS AVIDLY PRECEPT FOR STUDENT'S VARIOUS PROGRAMS WITH UNIVERSITY OF IOWA, IOWA CITY, IA, ALLEN COLLEGE IN WATERLOO, IA, DES MOINES UNIVERSITY IN DES MOINES, IA AND KAPLAN UNIVERSITY IN CEDAR FALLS, IA TAKING ADVANTAGE OF THIS IN 2016. THE CLINIC HOURS WERE EXPANDED IN 2016 TO MONDAY THROUGH THURSDAY STARTING AT 7 AM AND ENDING AT 8 PM AND HOURS ON FRIDAY ARE 7 AM TO 5 PM. 1140656 1295196 ACUTE NURSING HAD 139 ADMISSIONS IN 2016. CMH UTILIZES A COMPANY CALLED MCKESSON'S INTERQUAL FOR QUALIFYING PATIENTS TO DETERMINE IF THEY MEET INPATIENT ADMISSION CRITERIA. THE AVERAGE LENGTH OF STAY FOR ACUTE WAS 58.73 HOURS. THIS IS WELL BELOW THE 96 HOURS THRESHOLD FOR CRITICAL ACCESS. THERE WERE A TOTAL OF 379 ACUTE PATIENT DAYS AND 546 SWING BED DAYS IN 2016. 1049974 1283364 THE CMH EMERGENCY DEPARTMENT SERVED 1,377 PATIENTS IN 2016. THIS IS A DECREASE OF 59 PATIENT VISITS FROM 1,436 VISITS IN 2015. THE NUMBER OF PHYSICIAN HOURS SPENT IN THE EMERGENCY DEPARTMENT INCREASED FROM 2,907 IN 2015 TO 2,984 IN 2016.IN 2016, THE EMERGENCY DEPARTMENT IMPLEMENTED CQI PROJECTS FOR PATIENT BARCODE SCANNING, MEDICATION BARCODE SCANNING, TRAUMA ALERTS, TEMPERATURES, AND EDUCATIONAL TRAUMA WEBINARS. THE EDUCATIONAL FOCUS FOR 2016 ONCE AGAIN CENTERED ON MONTHLY TRAUMA TRAINING TRACC'S PROVIDED BY HENNEPIN COUNTY HOSPITAL. OTHER AREAS OF EDUCATION WERE THE CONTINUATION OF MONTHLY MOCK CODES, C.Q.I: CONTINUOUS QUALITY IMPROVEMENT PROGRAM, SAFE AT HOME PROGRAM, TRAUMA ALERTS, ITP TELE-MEDICINE, AND MENTAL HEALTH. NURSING COMPETENCIES INCLUDED: ACLS, CPR, FALL PREVENTION, PICC AND MEDPORT CARE, WOUND DOCUMENTATION, CODE BLUE DOCUMENTATION, CAPNOGRAPHY, CPI (CRISIS PREVENTION INTERVENTIONS), ORGAN AND TISSUE DONATION, HAZ MAT, AND ANKLE-BRACHIAL INDEX TRAINING. 1049974 1283364 11425612 1 1 0 0 0 0 0 0 0 1 1 1 0 0 1 1 0 1 0 0 0 0 0 0 0 0 1 1 0 0 1 0 0 0 0 0 0 0 1 0 0 0 0 0 1 1 1 0 0 1 9 0 1 0 1 1 0 0 0 0 0 0 0 0 0 X 11 11 0 1 0 0 1 1 1 1 1 0 0 1 1 1 1 1 1 0 0 0 X DAWN EVERDING 5635783275 909 WEST 1ST STREET PO BOX 148 SUMNER IA 50674 CONNIE LEICHER BOARD MEMBER - CHAIR 1.30 0.80 X X 0 0 0 WILLIAM SCHWAKE BOARD MEMBER - VICE CHAIR 1.30 0.80 X X 0 0 0 LUARA NECKER BOARD MEMBER - SEC/TREAS 1.30 0.00 X X 0 0 0 DEBRA TOENGES BOARD MEMBER - SEC/TREAS THRU 03/16 0.80 0.00 X X 0 0 0 DUANE HILDEBRANDT BOARD MEMBER 0.80 0.00 X 0 0 0 DONNA TREMAINE BOARD MEMBER 0.80 0.00 X 0 0 0 DIANE PAGEL BOARD MEMBER 0.80 0.00 X 0 0 0 ANGELA LEETE BOARD MEMBER 0.80 0.00 X 0 0 0 MARK SEEHASE BOARD MEMBER 0.80 0.00 X 0 0 0 GENE RHEA BOARD MEMBER 0.80 0.00 X 0 0 0 BRENDA WINZENBURG BOARD MEMBER 0.80 0.00 X 0 0 0 LAVERNE BUHR BOARD MEMBER 0.80 0.00 X 0 0 0 HOLLY SCHEMMEL BOARD MEMBER 0.80 0.00 X 0 0 0 RICK PEDERSON BOARD MEMBER THRU 03/16 0.80 0.00 X 0 0 0 DAVE VOSS BOARD MEMBER THRU 03/16 0.80 0.00 X 0 0 0 DUSTIN WRIGHT CEO 38.00 2.00 X 133388 0 13209 DAWN EVERDING CFO 39.50 0.50 X 116691 0 7411 LYNNE NIEMANN DIRECTOR OF NURSING & PATI 39.70 0.30 X 100680 0 10756 KYLE TEELING DIRECTOR OF SUPPORT SERV. THRU 05/16 38.00 2.00 X 33350 0 5136 TROY BUCHHOLZ MD PHYSICIAN 40.00 0.00 X 385035 0 34846 JEFFREY ROSKE DO PHYSICIAN 40.00 0.00 X 375422 0 29016 1144566 0 100374 5 0 1 0 EMERGENCY PRACTICE ASSOCIATES PO BOX 1260 WATERLOO IA 50704 ER COVERAGE 424472 PERFORMANCE REHAB LLC 909 W 1ST ST SUMNER IA 50674 REHAB SERVICES 423469 UNITYPOINT HEALTH PO BOX 83381 CHICAGO IL 60691 IT SUPPORT 339832 HEALTH ENTERPRISES OF IOWA 5825 DRY CREEK LANE NE CEDAR RAPIDS IA 52402 RADIOLOGY/CRNA SERVICES 286412 UNITYPOINT HEALTH - ALLEN MEMORIAL HOSPI PO BOX 83381 CHICAGO IL 60691 MEDICAL SERVICES 241287 8 7449 17986 96923 122358 MEDICARE/MEDICAID PAYMENTS 621400 5920889 5920889 PATIENT REVENUE - PRIVATE PAY 621400 5659953 5659953 340B INCOME 621990 229445 229445 AMH OPERATING AGREEMENT INCOME 561000 200000 200000 COMMUNITY WELLNESS 621990 26605 26605 21233 21233 12058125 38399 38399 43627 0 43627 43627 43627 1418 0 1418 1418 1418 CAFETERIA EMPLOYEES 900099 36180 36180 CATERING 722320 1526 1526 37706 12301633 12058125 1526 119624 X 420621 420621 4543597 4095534 448063 913984 790813 123171 345005 287279 57726 36000 36000 20451 20451 94076 94076 2141134 2049904 91230 42407 42407 489170 443317 45853 222914 222914 199813 171802 28011 49765 42406 7359 711881 612086 99795 1620146 1393026 227120 72119 72119 MEDICAL SUPPLIES 1033558 1033558 PROVISION FOR BAD DEBT 174059 174059 DUES AND SUBSCRIPTIONS 154667 154667 FOOD 52387 52387 10248 10248 13348002 11425612 1922390 0 100 100 7527265 7943948 2175613 1526767 175940 208097 164201 237625 21747165 8038215 15067537 13708950 3954520 3841575 507529 332037 29572705 27799099 1279716 1249727 17179805 16995253 1425318 1025567 19884839 19270547 X 5733346 4686977 3954520 3841575 9687866 8528552 29572705 27799099 -1046369 -112945 0 X X 0 1 X 1 0 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 3954520 -112945 3841575 4139591 -185071 3954520 4483296 -343705 4139591 4171601 563439 251744 4483296 3544459 858953 231811 4171601 0.00000 1.00000 0.00000 1 0 100421 100421 13358930 3338372 10020558 6190677 4152257 2038420 2097137 547586 1549551 13708950 PERPETUAL TRUST 3841575 F 3841575 CAPITAL LEASE OBLIGATIONS 383641 ESTIMATED THIRD-PARTY PAYOR SETTLEMENT 641926 1025567 X PART V, LINE 4: THE HOSPITAL IS BENEFICIARY OF A DONOR CREATED PERPETUAL TRUST. ASSETS HELD BY THE TRUST INCLUDE CASH AND CASH EQUIVALENTS, CDS, EQUITIES, AND FARMLAND. A PROVISION OF THE TRUST REQUIRES THAT INCOME EARNED BE DISTRIBUTED AT LEAST ANNUALLY TO THE HOSPITAL. INCOME DISTRIBUTIONS FROM THE TRUST ARE UNRESTRICTED AND CAN BE USED FOR ANY PURPOSE DEEMED BENEFICIAL. IN 2015, THE GRAIN, LIVESTOCK AND EQUIPMENT THAT WERE PREVIOUSLY HELD BY THE TRUST WERE LIQUIDATED IN FULL AND THE FARMLAND IS BEING OPERATED ON A CASH BASIS RENTAL AGREEMENT. PART X, LINE 2: THE HOSPITAL AND FOUNDATION ARE NOT-FOR-PROFIT CORPORATIONS AS DESCRIBED IN SECTION 501(C)(3) OF THE INTERNAL REVENUE SERVICE AND ARE EXEMPT FROM FEDERAL INCOME TAXES IN RELATED INCOME PURSUANT TO SECTION 501(A) OF THE CODE. THE INTERNAL REVENUE SERVICE HAS ESTABLISHED STANDARDS TO BE MET TO MAINTAIN THE HOSPITAL'S TAX EXEMPT STATUS. IN GENERAL, SUCH STANDARDS REQUIRE THE HOSPITAL TO MEET A COMMUNITY BENEFITS STANDARD AND COMPLY WITH VARIOUS LAWS AND REGULATIONS. THE HOSPITAL ACCOUNTS FOR UNCERTAINTIES IN ACCOUNTING FOR INCOME TAX ASSETS AND LIABILITIES USING GUIDANCE INCLUDED IN FASB ASC TOPIC 740, INCOME TAXES. THE HOSPITAL RECOGNIZES THE EFFECT OF INCOME TAX POSITIONS ONLY IF THOSE POSITIONS ARE MORE LIKELY THAN NOT OF BEING SUSTAINED. AT DECEMBER 31, 2016 AND 2015, THE HOSPITAL HAD NO UNCERTAIN TAX POSITIONS ACCRUED. 1 1 1 X 1 X 600.000000000000 1 1 0 1 1 28176 0 28176 0.00210 1070584 745245 325339 0.02470 19478 13205 6273 0.00050 1118238 758450 359788 0.02730 27018 3371 23647 0.00180 55537 55537 0.00420 303129 34040 269089 0.02040 6112 6112 0.00050 391796 37411 354385 0.02690 1510034 795861 714173 0.05420 1 174059 27000 5695953 5692736 3217 X 1 1 1 1 SUMNER COMMUNITY CLUB DBA COMMUNITY MEMORIAL HOSP 909 W 1ST ST PO BOX 148 SUMNER IA 50674 WWW.CMHSUMNER.ORG 090086H X X X PROVIDER-BASED MEDICAL CLINIC COMMUNITY MEMORIAL HOSPITAL 1 0 0 1 X X X X X X X X X 16 1 1 1 1 X WWW.CMHSUMNER.ORG 1 16 1 WWW.CMHSUMNER.ORG 0 1 X 200.000000000000 600.000000000000 1 1 X X X X 1 X WWW.CMHSUMNER.ORG X WWW.CMHSUMNER.ORG X WWW.CMHSUMNER.ORG X X X X 1 X 0 X X X X 1 X 0 0 COMMUNITY MEMORIAL HOSPITAL PART V, SECTION B, LINE 5: THE 28-QUESTION SURVEY OPPORTUNITY WAS PUBLICIZED IN AREA NEWSPAPERS AND ONLINE. THE MEDIA RELEASE WAS SENT OUT TO PRINT, RADIO, CABLE AND TELEVISION CONTACTS. IN ADDITION, EMAILS WERE SENT WITH A LINK TO THE SURVEY (OR HARD COPY WAS MADE AVAILABLE) TO AREA CHURCHES, AREA SCHOOL CONTACTS, AND LOCAL ORGANIZATIONS. THE INFORMATION WAS ALSO INCLUDED IN THE SCHOOL NEWSLETTERS. THERE WERE 715 INDIVIDUALS THAT RESPONDED TO THE NEEDS ASSESSMENT SURVEY THAT WAS CONDUCTED. THIS SURVEY SAMPLE REPRESENTED A LARGE CROSS-SECTION OF THE POPULATION AREAS IN THE COMMUNITIES INCLUDED IN THE ASSESSMENT. THE SERVICE AREA THAT WAS SURVEYED INCLUDED 3 COUNTIES THAT ARE ALL SERVED BY THE HOSPITALS AND AGENCIES THAT COLLABORATED IN THE NEEDS ASSESSMENT PROCESS. COMMUNITY MEMORIAL HOSPITAL PART V, SECTION B, LINE 6A: WAVERLY HEALTH CENTER, WAVERLY, IA COMMUNITY MEMORIAL HOSPITAL PART V, SECTION B, LINE 6B: BREMER COUNTY PUBLIC HEALTH AGENCY, WAVERLY, IAWAVERLY-SHELL ROCK AREA UNITED WAY, WAVERLY, IA COMMUNITY MEMORIAL HOSPITAL PART V, SECTION B, LINE 11: THE BOARD OF DIRECTORS REVIEWED THE LIST OF NEEDS IDENTIFIED BY REVIEWING THE NUMBER OF RESPONSES RECEIVED FOR EACH INDIVIDUAL NEED. THIS PROCESS IDENTIFIED THE TOP 4 NEEDS THAT WERE RECOGNIZED BY COMMUNITY MEMORIAL HOSPITAL BOARD OF DIRECTORS TO DEVELOP A PLAN AND CREATE AN IMPLEMENTATION PLAN. THE NEEDS THAT HAVE BEEN CHOSEN TO BE ADDRESSED INCLUDE: ACCESS TO HEALTHCARE, CHRONIC DISEASE MANAGEMENT, WELLNESS INITIATIVES (INCLUDING OBESITY, AFFORDABLE WELLNESS AND FITNESS, HEALTHY BEHAVIOR LIFESTYLES AND EMPLOYEE WELLNESS) AND ACCESS TO MENTAL HEALTH SERVICES. THE BOARD OF DIRECTORS HAS ACKNOWLEDGED THAT THESE NEEDS FALL WITHIN THE SCOPE OF THE MISSION AND EACH COVERS A BROAD SPECTRUM AND OFFER ONGOING OPPORTUNITIES FOR IMPROVEMENT. THE BOARD OF DIRECTORS IS COMMITTED TO THE SUCCESS AND SUSTAINABILITY OF QUALITY LOCAL HEALTHCARE AND PLACING A FOCUS ON THESE NEEDS HELPS ACHIEVE THIS. COMMUNITY MEMORIAL HOSPITAL HAS INCLUDED FUNDS IN THE OPERATING BUDGET TO CONTINUE TO SUPPORT THE NEEDS ASSESSMENT MOVING FORWARD.THE REMAINING NEEDS IDENTIFIED INCLUDE RISKY BEHAVIORS (SUCH AS TEXTING AND DRIVING), CHILDREN'S HEALTH (INCLUDING TOO MUCH SCREEN TIME), PHYSICAL ACTIVITY AND LACK OF MOTIVATION, AFFORDABLE FOOD OPTIONS, AND SOCIAL ISSUES RELATED TO PARENTING AND HOUSING OPTIONS. IT IS NOT TO SAY THAT THESE NEEDS WILL NOT BE ADDRESSED OR FOLLOWED BY THE HOSPITAL, BUT INSTEAD ARE NOT INCLUDED IN THE CHNA IMPLEMENTATION STRATEGY. THE HOSPITAL WILL MONITOR THE OVERALL NEEDS OF THE COMMUNITY SERVED AND REASSESS AS WE MOVE FORWARD. IN ADDITION, THERE ARE SERVICES, ORGANIZATIONS AND BUSINESSES WITHIN THE SERVICE AREA THAT ARE IDENTIFIED TO FOCUS ON THESE NEEDS CURRENTLY. COMMUNITY MEMORIAL HOSPITAL PART V, SECTION B, LINE 15E: COMMUNITY MEMORIAL HOSPITAL PATIENT STATEMENTS INCLUDES INFORMATION ON HOW TO APPLY FOR FINANCIAL ASSISTANCE. IN ADDITION TO THE STANDARD INFORMATION, COMMUNITY MEMORIAL HOSPITAL ALSO HAS A DESIGNATED STAFF MEMBER THAT MONITORS PATIENT ACCOUNTS THAT ARE RECEIVING A SECOND OR THIRD STATEMENT. THIS STAFF MEMBER MAKES CONTACT WITH THE INDIVIDUAL PATIENTS TO DETERMINE IF A FINANCIAL ASSISTANCE APPLICATION SHOULD BE MAILED OUT FOR COMPLETION. THE FINANCIAL ASSISTANCE APPLICATION PROVIDES A LISTING OF THE INFORMATION THAT WILL BE NEEDED IN ORDER TO PROCEED WITH ITS REVIEW. PART I, LINE 3C: NOT APPLICABLE PART I, LINE 6A: THE REPORT IS PREPARED BY THE STAFF OF COMMUNITY MEMORIAL HOSPITAL. PART I, LINE 7: THE COST TO CHARGE RATIO PER IRS WORKSHEET 2 WAS USED TO CALCULATE THE AMOUNTS IN THE UPPER PORTION OF THE TABLE. COSTING OF THE "OTHER BENEFITS" PORTION OF THE TABLE WAS CALCULATED PER GUIDANCE PROVIDED BY THE IOWA HOSPITAL ASSOCIATION IN TERMS OF PROPER REPORTING OF COMMUNITY BENEFITS. PART I, LINE 7G: NO COSTS ASSOCIATED WITH PHYSICIAN CLINICS WERE INCLUDED. PART I, LN 7 COL(F): THE BAD DEBT EXPENSE INCLUDED ON FORM 990, PART IX, LINE 25, COLUMN (A), BUT SUBTRACTED FOR PURPOSES OF CALCULATING THE PERCENTAGE IN THIS COLUMN IS $174,059. PART II, COMMUNITY BUILDING ACTIVITIES: COMMUNITY MEMORIAL HOSPITAL DID NOT REPORT ANY COMMUNITY BUILDING ACTIVITIES IN PART II OF SCHEDULE H. PART III, LINE 2: THE ALLOWANCES REFLECT MANAGEMENT'S ESTIMATE OF AMOUNTS THAT WILL NOT BE COLLECTED IN THE FUTURE AND ARE BASED ON REVIEWS OF PATIENT BALANCES BY PAYER CLASSES. PERCENTAGES ARE APPLIED TO EACH PAYER CLASS BASED ON CONTRACTUAL AGREEMENTS AND HISTORICAL COLLECTION AND RECOVERY INFORMATION TO DETERMINE THAT NET REALIZABLE VALUE OF THE PATIENT RECEIVABLES. PART III, LINE 3: THE HOSPITAL PROVIDES CHARITY CARE TO PATIENTS WHO ARE FINANCIALLY UNABLE TO PAY FOR THE HEALTHCARE SERVICES THEY RECEIVE. PATIENTS WHO QUALIFY FOR CHARITY CARE ARE GIVEN A PERCENTAGE DISCOUNT FROM ESTABLISHED CHARGES BASED ON A SLIDING SCALE USING POVERTY GUIDELINES. IT IS THE POLICY OF THE HOSPITAL NOT TO PURSUE COLLECTION OF AMOUNTS DETERMINED TO QUALIFY AS CHARITY CARE. ACCORDINGLY, THE HOSPITAL DOES NOT REPORT THESE AMOUNTS IN NET OPERATING REVENUE OR IN THE ALLOWANCE FOR DOUBTFUL ACCOUNTS. THE HOSPITAL DETERMINES THE COSTS ASSOCIATED WITH PROVIDING CHARITY CARE BY AGGREGATING THE DIRECT AND INDIRECT COSTS, INCLUDING SALARIES, BENEFITS, SUPPLIES, AND OTHER OPERATING EXPENSES, BASED ON THE OVERALL COST TO CHARGE RATIO FOR THE HOSPITAL. PART III, LINE 4: THE HOSPITAL'S FINANCIAL STATEMENTS DO NOT CONTAIN A SPECIFIC FOOTNOTE DESCRIBING BAD DEBT. HOWEVER, PAGES 8, 9 & 10 OF THE ATTACHED AUDITED FINANCIAL STATEMENTS INCLUDE FOOTNOTES TITLED "PATIENT RECEIVABLES, NET" "NET PATIENT SERVICE REVENUE, AND "CHARITY CARE". PART III, LINE 9B: COMMUNITY MEMORIAL HOSPITAL'S COLLECTIONS POLICY STATES THAT THE HOSPITAL WILL "REFRAIN FROM INITIATING EXTRAORDINARY COLLECTION ACTIONS FOR 120 DAYS FROM THE DATE OF THE PATIENT'S FIRST POST DISCHARGE BILLING STATEMENT" IF ELIGIBILITY FOR FINANCIAL ASSISTANCE IS UNDETERMINED. IN ADDITION, "IF THE PATIENT SUBMITS A COMPLETE FINANCIAL ASSISTANCE APPLICATION AT ANY TIME WITHIN THE APPLICATION PERIOD, THE HOSPITAL MUST SUSPEND ANY EXTRAORDINARY COLLECTION ACTIONS, DETERMINE THE ELIGIBILITY, AND NOTIFY THE PATIENT". ONCE A DECISION IS MADE ON THE FINANCIAL ASSISTANCE APPLICATION, COLLECTION EFFORTS WILL STOP IF IT IS APPROVED OR CONTINUE WHERE THE EFFORTS LEFT OFF IF THE APPLICATION IS DECLINED. PART VI, LINE 2: COMMUNITY MEMORIAL HOSPITAL COMPLETED THE CHNA PROCESS IN 2016. THE CHNA IS CURRENTLY POSTED ON THE HOSPITAL WEBSITE (WWW.CMHSUMNER.ORG). THE FOUR AREAS OF FOCUS CHOSEN BY COMMUNITY MEMORIAL HOSPITAL FROM THE CHNA INCLUDE: ACCESS TO HEALTHCARE, CHRONIC DISEASE MANAGEMENT, WELLNESS INITIATIVES (INCLUDING OBESITY, AFFORDABLE WELLNESS AND FITNESS, HEALTHY BEHAVIOR LIFESTYLES AND EMPLOYEE WELLNESS), AND ACCESS TO MENTAL HEALTH SERVICES.MANY OF THE BOARD OF DIRECTORS ARE INVOLVED IN VARIOUS GROUPS AND BUSINESSES IN THE COMMUNITY AND RECEIVE INPUT FROM COMMUNITY MEMBERS. THIS COMMUNITY INVOLVEMENT IS INCREASED WITH ANOTHER GROUP OF INDIVIDUALS WHO ARE INVOLVED IN THE HOSPITAL AUXILIARY AND FOUNDATION. IN A SMALLER TOWN, PEOPLE ARE AWARE OF WHO SERVES ON THE HOSPITAL BOARD AND FOUNDATION BOARDS, IN THE AUXILIARY AND HOSPITAL ADMINISTRATION. COMMUNITY MEMBERS FEEL COMFORTABLE APPROACHING THEM WITH THE NEEDS THAT THEY SEE AS A BENEFIT TO THE COMMUNITY, SUCH AS, IMPROVING ACCESS TO SPECIALIST SERVICES WITH INCREASED OFFERINGS OF OUTPATIENT CLINICS WITHIN THE HOSPITAL.THE HOSPITAL SEES ITS ROLE AS CARE OF ILLNESS BUT ALSO IMPROVEMENT OF HEALTH AND WELLNESS. IN REGARD TO THESE GOALS, ALMOST MONTHLY THERE ARE OPPORTUNITIES FOR EDUCATION ON VARIOUS HEALTH TOPICS OFFERED IN THE COMMUNITY. THE HOSPITAL ADDITIONALLY SPONSORS LOCAL INDUSTRY-HOSTED HEALTH FAIRS AND COMMUNITY WELLNESS TESTING. THE WELLNESS TESTING OFFERINGS HAVE SEEN INCREASING PARTICIPATION BY COMMUNITY MEMBERS AND PRESENT THE OPPORTUNITY FOR ADDITIONAL COMMUNITY INPUT.AS THE HOSPITAL PLANNED FOR THE NEW REPLACEMENT FACILITY, A GREAT DEAL OF PREPARATION WORK WAS DONE TO BE SURE TO BUILD FOR THE PRESENT NEEDS AS TO HEALTH SERVICES BUT TO ALSO MAKE SURE THAT WE CAN ADDRESS FUTURE NEEDS. WE KNEW THAT DIAGNOSTIC SERVICES WOULD BE AN INCREASING FOCUS AS TO STANDARDS OF CARE. THE IMPLEMENTATION STRATEGY FOR THE CHNA IS ALSO LOCATED WITHIN THE CHNA REPORT LOCATED ON THE WWW.CMHSUMNER.ORG WEBSITE. THIS STRATEGY WAS ALSO IMPLEMENTED IN 2016. PART VI, LINE 3: CMH HAS A PAYMENT BROCHURE THAT IS LOCATED AT THE REGISTRATION DESK FOR ALL PATIENTS TO TAKE WITH THEM EXPLAINING OUR PAYMENT TERMS AND THE AVAILABILITY OF FINANCIAL ASSISTANCE. THERE IS ALSO AN AREA ON THE STATEMENTS SENT TO PATIENTS THAT ALLOWS FOR MESSAGES TO BE PRINTED. THE MESSAGE INDICATES THE AVAILABILITY FOR ASSISTANCE FOR THOSE WHO QUALIFY. IN ADDITION, A DESIGNATED STAFF MEMBER WORKS DIRECTLY WITH PATIENTS WITH OPEN ACCOUNT BALANCES TO PROVIDE PAYMENT PLANS, FINANCIAL ASSISTANCE APPLICATIONS OR ADDITIONAL INSURANCE COVERAGE POSSIBILITIES. PART VI, LINE 4: CMH'S PRIMARY SERVICE AREA CONSISTS OF CITIES FROM THE FOLLOWING SEVEN ZIP CODES, WHICH INCLUDE SUMNER (50674), TRIPOLI (50676), FREDERICKSBURG (50630), HAWKEYE (52147), WESTGATE (50681), FAIRBANK (50629) AND FAYETTE (52142). THE COMMUNITIES THAT ARE INCLUDED IN THE CMH SERVICE AREA PRIMARILY CONSIST OF FARMING BACKGROUNDS AND RURAL AREAS. THE PRIMARY POPULATION IS LOCATED IN A RURAL SETTING WITH SUMNER BEING THE LARGEST CITY WITH A POPULATION OF APPROXIMATELY 2,000. PART VI, LINE 5: COMMUNITY MEMORIAL HOSPITAL (CMH) IS A PILLAR IN THE COMMUNITY AND STRIVES TO BE A STRONG COMMUNITY PARTNER. CMH CONTINUES TO REACH OUT AND PARTNER WITH THE COMMUNITY IN MANY AREAS. CMH HELPS TO PROMOTE HEALTH AND WELLNESS BY SUPPORTING COMMUNITY GROUPS AND INITIATIVES AND CONSISTENTLY OFFERS "HEALTH HIGHLIGHTS," WHICH PROVIDE FREE EDUCATION ON VARIOUS HEALTH-RELATED TOPICS. IN ADDITION, CMH STAFF OFFER MATTER OF BALANCE CLASSES TWO TIMES A YEAR AIMED AT CREATING AN ACTIVE LIFESTYLE FOR THE OLDER GENERATION. CMH CONTINUES TO HELP COORDINATE AND PLAN PREPAREDNESS TRAINING AND DRILLS FOR THE COMMUNITY, WORKING WITH SEVERAL LOCAL AND COUNTY AGENCIES. THE RELATIONSHIPS AND COLLABORATION CREATED IS BENEFICIAL FOR ALL INVOLVED AND THE RESIDENTS WE SERVE. IN ADDITION, HOSPITAL PREPAREDNESS STAFF HAVE PARTNERED WITH COUNTY RESOURCES TO INTRODUCE ALICE TRAINING TO AREA BUSINESSES. LASTLY, CRITICAL INCIDENT STRESS DEBRIEFING (CISD) TRAINED STAFF HAVE BEEN UTILIZED ON MULTIPLE OCCASIONS TO LEAD DEBRIEFINGS FOR AREA EMERGENCY RESPONSE AGENCIES FOLLOWING FIRES, DEATHS, ETC. CMH IS INVOLVED WITH A GROUP OF COMMUNITY PROVIDERS (KNOWN IN THE COMMUNITY AS C2T2) THAT MEETS QUARTERLY TO SERVE AS A NETWORK TO MEET THE NEEDS OF THE COMMUNITY. THIS ORGANIZED GROUP INCLUDES INDIVIDUALS FROM THE HOSPITAL, LONG-TERM CARE FACILITIES, HOME HEALTH, AND PUBLIC HEALTH. PART VI, LINE 6: COMMUNITY MEMORIAL HOSPITAL IS NOT PART OF AN AFFILIATED HEALTH CARE SYSTEM. PART VI, LINE 7, REPORTS FILED WITH STATES IA X 0 0 0 0 0 0 0 0 0 TROY BUCHHOLZ MD PHYSICIAN 341475 0 43250 0 310 0 13250 0 21596 0 419881 0 0 0 JEFFREY ROSKE DO PHYSICIAN 341722 0 33250 0 450 0 13250 0 15766 0 404438 0 0 0 PART I, LINE 3 THE ORGANIZATION IS JOINTLY OPERATED WITH UNITYPOINT HEALTH-WATERLOO, FORMERLY KNOW AS ALLEN HEALTH SYSTEM. THE CEO OF UNITYPOINT HEALTH-WATERLOO IS RESPONSIBLE FOR SETTING THE SALARY FOR DUSTIN WRIGHT, CEO OF CMH. THE CEO OF UNITYPOINT HEALTH-WATERLOO, USES SALARY SURVEY INFORMATION FROM THE IOWA HOSPITAL ASSOCIATION TO DETERMINE A REASONABLE RANGE FOR THE CEO'S COMPENSATION. JUSTIN TRAINOR SPOUSE OF SARA TRAINOR, FORMER CFO 423469 PERFORMANCE REHAB IS 40% OWNED BY JUSTIN TRAINOR, THE SPOUSE OF SARA TRAINOR, FORMER CFO. THIS ENTITY PROVIDES PHYSICAL AND OCCUPATIONAL THERAPIES AT CMH. PERFORMANCE REHAB'S COMPENSATION FROM CMH IS CALCULATED AS A PERCENTAGE OF CMH'S NET REIMBURSEMENT FOR THERAPY SERVICES. 1 FORM 990, PART V, LINE 2A: ALL CMH EMPLOYEES ARE EMPLOYEES OF UNITYPOINT HEALTH - WATERLOO (FORMERLY ALLEN HEALTH SYSTEMS). UNITYPOINT HEALTH - WATERLOO COMPLETES ALL PAYROLL FUNCTIONS AND CMH REIMBURSES UNITYPOINT HEALTH - WATERLOO FOR ALL WAGE AND BENEFIT EXPENSES INCURRED. FORM 990, PART VI, SECTION A, LINE 3 THE ORGANIZATION HAS AN EXTENDED MANAGEMENT CONTRACT WITH UNITYPOINT HEALTH - WATERLOO, FORMALLY KNOWN AS ALLEN HEALTH SYSTEMS. FORM 990, PART VI, SECTION A, LINE 6 THE ORGANIZATION'S ARTICLES OF INCORPORATION PROVIDE THAT THE CORPORATION "HAS NO CAPITAL STOCK AND THE CAPITAL OF THIS ASSOCIATION SHALL BE THE MEMBERSHIP FEES . . . FIXED BY THE BOARD OF DIRECTORS". ANYONE IN THE COMMUNITY MAY BE A MEMBER OF THE CORPORATION UPON PAYMENT OF THE $1 MEMBERSHIP FEE, AS FIXED BY THE BOARD OF DIRECTORS ACCORDING TO THE BYLAWS. THE ORGANIZATION'S MEMBERS ELECT THE BOARD OF DIRECTORS. FORM 990, PART VI, SECTION A, LINE 7A EACH BOARD OF DIRECTOR SHALL BE ELECTED BY THE LARGEST VOTE CAST BY THE MEMBERS PRESENT AT THE ANNUAL MEETING. ABSENTEE BALLOTS WILL BE ALLOWED FOR EMPLOYEES WORKING AT COMMUNITY MEMORIAL HOSPITAL DURING THE ACTUAL HOURS OF THE ANNUAL MEETING. FORM 990, PART VI, SECTION A, LINE 7B IN 2003, COMMUNITY MEMORIAL HOSPITAL (CMH) ENTERED INTO AN OPERATING AGREEMENT WITH ALLEN HEALTH SYSTEM (AHS), NOW REFERRED TO AS UNITYPOINT HEALTH - WATERLOO. UNDER THE TERMS OF THAT AGREEMENT, A JOINT GOVERNANCE STRUCTURE WAS ESTABLISHED, WHEREBY UNITYPOINT HEALTH AND THE BOARD OF DIRECTORS OF CMH EXERCISE JOINT AUTHORITY FOR THE OPERATION OF THE HOSPITAL. WHILE UNITYPOINT HEALTH HAS DAY-TO-DAY OPERATIONAL CONTROL, CERTAIN GOVERNANCE AUTHORITY ACTIONS REQUIRE THE PARTICIPATION OF BOTH UNITYPOINT'S AND CMH'S BOARD OF DIRECTORS. FORM 990, PART VI, SECTION B, LINE 11B THE IRS FORM 990 IS PRESENTED TO THE CMH BOARD OF DIRECTORS AT A REGULARLY SCHEDULED MONTHLY MEETING FOR REVIEW. IT WILL BE NOTED AS AN AGENDA ITEM UNDER "NEW BUSINESS AND REQUIRES THE PROPER APPROVAL FROM THE BOARD PRIOR TO BEING SUBMITTED TO IRS. FORM 990, PART VI, SECTION B, LINE 12C THE BOARD OF DIRECTORS AND KEY EMPLOYEES ARE REQUIRED TO ANNUALLY COMPLETE A CONFLICT OF INTEREST DISCLOSURE/QUESTIONNAIRE. THESE ARE REVIEWED BY THE CEO AND BOARD CHAIR. EACH MONTH THERE IS AN AGENDA ITEM AT THE BOARD MEETING FOR ANY CONFLICTS RELATED TO THE REST OF THE AGENDA TO BE DISCLOSED. IF NONE ARE NOTED, BUT THE BOARD CHAIR FEELS ONE EXISTS, IT IS THE CHAIR'S RESPONSIBILITY TO INQUIRE ABOUT IT BEFORE PROCEEDING. WHEN THERE IS A CONFLICT OF INTEREST, THE PERSON WITH THE CONFLICT ABSTAINS FROM VOTING. FORM 990, PART VI, SECTION B, LINE 15 THE ORGANIZATION IS JOINTLY OPERATED WITH UNITYPOINT HEALTH - WATERLOO, F/K/A ALLEN HEALTH SYSTEM. THE CEO OF UNITYPOINT HEALTH IS RESPONSIBLE FOR SETTING THE SALARY FOR DUSTIN WRIGHT, CEO OF CMH. THE CEO OF UNITYPOINT HEALTH USES SALARY SURVEY INFORMATION FROM THE IOWA HOSPITAL ASSOCIATION TO DETERMINE A REASONABLE RANGE FOR THE CEO'S COMPENSATION. THE CMH CEO IS RESPONSIBLE FOR SETTING THE SALARY OF DAWN EVERDING, CFO (OFFICER) AND LYNNE NIEMANN, DIRECTOR OF NURSING. COMPARABILITY DATA IS ALSO USED IN SETTING THE COMPENSATION FOR THE OFFICERS. FORM 990, PART VI, SECTION C, LINE 19 THE ORGANIZATION DOES NOT MAKE ITS GOVERNING DOCUMENTS, CONFLICT OF INTEREST POLICY OR FINANCIAL STATEMENTS AVAILABLE TO THE PUBLIC. HOWEVER, FINANCIAL STATEMENTS ARE MADE AVAILABLE AT THE SUMNER COMMUNITY CLUB MEETING AND A PERSON MAY BECOME A MEMBER OF THE SUMNER COMMUNITY CLUB BY PAYING THE $1.00 ANNUAL MEMBERSHIP FEE. FORM 990, PART IX, LINE 11G OUTSIDE SERVICES: PROGRAM SERVICE EXPENSES 546,919. MANAGEMENT AND GENERAL EXPENSES 91,230. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 638,149. EMERGENCY ROOM SPECIALIST FEES: PROGRAM SERVICE EXPENSES 715,015. MANAGEMENT AND GENERAL EXPENSES 0. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 715,015. PHYSICAL THERAPY FEES: PROGRAM SERVICE EXPENSES 433,493. MANAGEMENT AND GENERAL EXPENSES 0. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 433,493. ANESTHESIOLOGIST FEES: PROGRAM SERVICE EXPENSES 210,442. MANAGEMENT AND GENERAL EXPENSES 0. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 210,442. LAB FEES: PROGRAM SERVICE EXPENSES 144,035. MANAGEMENT AND GENERAL EXPENSES 0. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 144,035. FORM 990, PAGE 12, PART XII, LINE 2C: THERE HAVE BEEN NO CHANGES FROM THE PRIOR YEAR. THE BOARD OF DIRECTORS HAS THE RESPONSIBILITY OF SELECTING THE INDEPENDENT ACCOUNTANT TO COMPLETE THE AUDIT WORK. THE FINANCE COMMITTEE OF THE BOARD OF DIRECTORS HAS THE RESPONSIBILITY FOR THE OVERSIGHT OF THE AUDIT. UPON CONCLUSION OF THE AUDIT, THE AUDITING FIRM PRESENTS THE RESULTS AND FINDINGS TO THE BOARD OF DIRECTORS. FRIENDS OF CMH SUMNER COMMUNITY MEMORIAL HOSPITAL FOUNDATION 909 W 1ST STREET SUMNER IA 50674 421408693 HOSPITAL FOUNDATION IA 501(C)(3) LINE 7 SUMNER COMMUNITY CLUB 1 CHARITABLE TRUST TRUST IA T 1.00000 1 0 0 1 0 0 0 0 0 0 0 0 0 1 1 1 0 1 0 0 CHARITABLE TRUST C 92148 CASH TRANSFERRED EQUALS FMV