2017-01-31T16:36:41-06:00 2016-06-30 450250958 EIDE BAILLY LLP 1545 ASSOCIATES DR STE 101 DUBUQUE IA 52002 990 2015-07-01 420818642 Central Community Hospital CENT 5632457000 901 Davidson St NW Elkader IA 520439015 Brooke Kensinger CEO 5632457000 2017-01-27 1 Carmen Krantz P00031958 5635561790 2017-01-27 2015 2021-01-29 14:40:06Z Brooke Kensinger 901 Davidson St NW Elkader IA 520439015 7349054 0 X www.centralcommunityhospital.com X 1961 IA Provide healthcare services to the surrounding community 7 7 94 32 0 0 38635 143736 6323207 7143314 7015 9438 42740 40948 6411597 7337436 400 1100 0 0 2552801 2890414 0 0 38759 3563392 4057493 6116593 6949007 295004 388429 7464631 7939907 1566429 1632034 5898202 6307873 X "Every patient matters" 0 0 5524646 1100 7143314 Central Community Hospital is a 25-Bed Critical Access Hospital serving residents of Clayton County, Iowa. Requirements of the IRS community benefit standard for tax-exempt organizations are integral to Central Community Hospital's charitable mission. Central Community Hospital is governed by an independent Board, which includes community leaders, consumer representatives and business experts. The Board has a history of commitment to acting with the highest integrity. During this year, the Board worked with management to continue to make improvements to assure the organization is in compliance with all rules and regulations governing the healthcare industry and non-profit organizations.Central Community Hospital makes care accessible to the entire community it serves. Central Community Hospital operates a full-time emergency room and provides care regardless of ability to pay. Central Community Hospital had 994 emergency visits and 153 outpatient surgery cases this year.The Hospital provided 917 acute, swing-bed, and respect patient days and 5,873 outpatient visits to the residents in the service area. Central Community Hospital provided care at many levels including SCU, Acute, Skilled, Intermediate, Same-Day-Surgery, Observation Care, Outpatient, and Rehab services. In addition, Central Community Hospital provides non-emergency services. These services are accessible to the community through participation in government programs like Medicare and Medicaid. Financial counseling is available to patients. The Hospital provides care to patients who meet certain criteria under its charity care policy without charge or at amounts less than established rates. Because the Hospital does not pursue collection of amounts determined to qualify as charity care, they are not reported as revenue. The amount of charges foregone for services provided under the Hospital's charity care policy were $85,419 for the year ended June 30, 2016. The direct and indirect costs related to these forgone charges were $51,000 at June 30, 2016, based on an average ratio of costs to gross charges.The Hospital 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. 5524646 1 1 0 0 0 0 0 0 0 0 1 0 0 0 1 1 1 0 0 0 0 0 0 0 0 0 1 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 26 0 1 94 1 0 0 0 0 0 0 0 0 0 0 X 7 7 1 0 0 0 1 1 0 1 0 0 0 1 1 1 1 1 1 1 0 0 X Brooke Kensinger 5632457000 901 Davidson St NW Elkader IA 520439015 Robert Bodensteiner President 0.50 X X 0 0 0 Jennifer Cowsert Vice President 0.50 X X 0 0 0 Tom Neuhaus Treasurer 0.50 X X 0 0 0 Kevin Ihde Secretary 0.50 X X 0 0 0 Jay Moser Member 0.50 X 0 0 0 William Reimer Member 0.50 X 0 0 0 Justin Vorwald Member 0.50 X 0 0 0 Darwin Winke Member until July 2015 0.50 X 0 0 0 Fran Zichal CEO 40.00 X 139176 0 10286 139176 0 10286 1 0 0 0 WMG Red Hawthorne LLC 107 Flynn Drive Suite 600 Milbank SD 57252 ER physicians 493886 Northern Iowa Therapy 217 East Bremer Ave Suite B Waverly IA 50677 PT, OT, ST 413945 Mercy Health Network Dept CH14370 Palatine IL 600554370 Purchased services 247510 Medical Associates Clinic 1500 Associates Drive Dubuque IA 52002 Purchased services 122975 4 19075 124661 143736 Patient service revenu 622110 6919913 6919913 Electronic health reco 900099 210826 210826 Supporting revenue 900099 12575 12575 7143314 9438 9438 52566 11618 40948 40948 40948 7337436 7143314 0 50386 X 1100 1100 173150 173150 2242080 1847196 363406 31478 50321 41062 8553 706 262082 215923 42479 3680 162781 134112 26384 2285 87513 87513 59402 59402 2171811 1786896 384915 21379 21379 220514 130039 89865 610 89530 85959 3571 39604 24545 15059 3529 3529 501357 501357 94864 94864 Medical supplies 608577 608577 Bad debt 90409 90409 Food 27881 27881 Community benefits 9049 8877 172 32074 17184 14890 6949007 5524646 1385602 38759 3176156 3362061 753090 875079 72484 70995 62388 60100 10456666 7094966 3211783 3361700 186082 207324 2648 2648 7464631 7939907 336815 473336 858862 702117 56752 38581 314000 418000 1566429 1632034 X 5700272 6088701 197930 219172 5898202 6307873 7464631 7939907 X 388429 21242 X 0 1 X 1 0 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 26015 26015 4039909 2427027 1612882 6390742 4667939 1722803 3361700 Estimated third-party payor settlements 418000 418000 X 7258645 -90409 -90409 7349054 -11618 -11618 7337436 6870216 11618 11618 6858598 90409 90409 6949007 Part X, Line 2: The Hospital is organized as an Iowa nonprofit corporation and has been recognized by the Internal Revenue Service (IRS) as exempt from federal income taxes under Interanl Revenue Code Section 501(c)(3). The Hospital is annually required to file a Return of Organization Exempt from Income Tax (Form 990) with the IRS. In addition, the Hospital is subject to income tax on net income that is derived from business activities that are unrelated to its exempt purpose. The Hospital has determined that 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. The Hospital 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 Hospital 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. Part XI, Line 2d - Other Adjustments: Bad debt expense included in expenses on Form 990 -90,409. Part XI, Line 4b - Other Adjustments: Monona Clinic rent expenses included in revenue on Form 990 -11,618. Part XII, Line 2d - Other Adjustments: Monona Clinic rent expenses included in revenue on Form 990 11,618. Part XII, Line 4b - Other Adjustments: Bad debt expense included in expenses on Form 990 90,409. 1 1 X 1 X 1 X 0 1 1 0 1 1 51000 51000 0.00740 51000 51000 0.00740 1122071 754932 367139 0.05350 1122071 754932 367139 0.05350 1173071 754932 418139 0.06090 52 296 20693 20693 0.00300 7 32 3663 3663 0.00050 100 1944 14484 14484 0.00210 159 2272 38840 38840 0.00560 1 90409 4701 3360490 3391203 -30713 X 1 1 1 1 Central Community Hospital 901 Davidson St NW Elkader IA 520439015 www.centralcommunityhospital.com 220051H X X X X Central Community Hospital 1 0 0 1 X X X X X X X X X 15 1 1 1 1 X www.centralcommunityhospital.com/patient-info/community-assessment/ X 1 15 1 www.centralcommunityhospital.com/patient-info/community-assessment/ 0 0 1 X 200.000000000000 300.000000000000 X X X 1 1 X X X X 1 X www.centralcommunityhospital.com/billing/financial-assistance/ X www.centralcommunityhospital.com/billing/financial-assistance/ X www.centralcommunityhospital.com/billing/financial/assistance/ X X X X X X 1 X 0 X X X X 1 X 0 1 Central Community Hospital Part V, Section B, Line 5: In conducting the needs assessment, CCH consulted the local nursing home, local clinic, Substance Abuse and Prevention Services, Clayton County Public Health, Northland Agency on Aging, Guttenberg Municipal Hospital, Central Community School, Clayton Ridge School, MFLMarMac School, SHIIP volunteers, Clayton County Board of Health, Clayton County EMS, Northeast Iowa Community Action, Northeast Iowa Mental Health, and HAWC Partnership for Children. Central Community Hospital Part V, Section B, Line 6a: The community health needs assessment was conducted with Guttenberg Municipal Hospital in Guttenberg, Iowa. Central Community Hospital Part V, Section B, Line 6b: The CHNA was conducted with Clayton County Public Health. Central Community Hospital Part V, Section B, Line 11: The Community Health Needs Assessment identified seven significant needs to be addressed by the Central Community Hospital staff over the next three years (2015, 2016, 2017). The seven needs are: mental health, obesity, unintended pregnancy, substance abuse, EMS Volunteer crisis, falls and water fluoridation.* Mental Health will be addressed through the addition of tele-psychiatry in the ER. This program will give CCH providers access to board-certified psychiatrists MD or ARNP. Opportunities for community education on mental health will be identified each year in the Marketing Plan. * Obesity will be addressed working with schools and regional Food and Fitness program. CCH will identify educational opportunities in the Marketing Plan. * Unintended Pregnancies will be addressed with limited activities. CCH does not have OB services which limits access to pregnant mothers. CCH staff will provide basic sex and pregnancy information to students at Central Community School. Working with the local teachers, a schedule will be developed. The Medical Staff will be solicited for suggestions and ideas for presentations.* Substance Abuse. Because there is a prevention agency in town, CCH will support their activities and watch for opportunities to suggest programs successful in other communities. * EMS Volunteer Crisis. Increasing community awareness and assuring access to EMS will be the primary goal. Multi-disciplinary teams will work on studying the models of EMS care delivery.* Falls. Falls are the number one reason to call an ambulance or seek ER care. Assessment and community engagement will be the key to addressing this need.* Water fluoridation. CCH will be a limited partner in this program. Key to this need is offering appropriate education to the community and city leadership to assure our citizens have appropriate fluoridation levels in the water we drink. In summary three of the seven needs will have little activity initiated by CCH. The remaining four will constitute the major portion of the CCH Implementation Plan. Central Community Hospital Part V, Section B, Line 13b: 1. Patients whose family income is at or below 200% of the FPL are eligible to receive free care. 2. Patients whose family income is above 200% but not more than 300% of the FPL are eligible to receive discounts. 3. Patients whose family income exceeds 300% of the FPL may be eligible to receive discounted rates on a case-by-case basis based on their specific circumstances, such as catastrophic illness or medical indigence, at the discretion of Central Community Hospital; however the discounted rates shall not be greater than the AGB. Central Community Hospital Part V, Section B, Line 13h: There are instances when a patient may appear eligible for financial discounts, but there is no financial assistance form on file or a lack of supporting documentation. Central Community Hospital may use outside agencies to determine eligibility. These resources may use demographic and household information and/or credit scoring technology to determine eligibility. Patients who meet presumptive eligibility criteria may be granted financial assistance without completing the application. Presumptive eligibility awards must be 100% discounts. Other forms of presumptive eligibility include: Eligible for the Iowa Cares Program, bankruptcy, death with no estate resources, and Title XIX eligible and receiving non-covered services. Central Community Hospital Part V, Section B, Line 16i: At the time of registrations, CCH staff makes every effort to determine if a patient may possibly need or qualify for any financial assistance. We notify patients of the availability of these programs by posting information in our registration and emergency room areas. We offer a private meeting with a financial counselor. Inpatients are offered an opportunity to meet with the counselor upon discharge. Financial assistance information is provided in all correspondence regarding patient bills. Our financial counselor attempts phone contact whenever possible. We do an annual article about the service in our newsletter. Central Community Hospital Part V, Section B, Line 22d: Central Community Hospital uses the Look Back Method and determines the amounts generally billed by multiplying the gross charges for such services by an AGB percentage, which is based on all claims allowed by Medicare, together with all private health insurers over a specified 12-month period, divided by the associated gross charges for the claims. Central Community Hospital Part V, Section B, Line 24: All individuals eligible under the hospital financial assistance policy are provided a discount for emergency and other medically necessary care. The financial assistance policy does not apply to elective procedures. Therefore, FAP-eligible patients without insurance may be charged gross charges on elective procedures. Part I, Line 3c: Income Criteria as a % of US Government poverty income guidelines:Less than or equal to 200% 0% paid by patientGreater than 200% but less than 300% Discounts to patientPatients whose family income exceeds 300% of the FPL may be eligible to receive discounted rates on a case-by-case basis based on their specific circumstances, such as catastrophic illness or medical indigence, at the discretion of Central Community Hospital; however the discounted rates shall not be greater than the AGB. There are instances when a patient may appear eligible for financial discounts, but there is no financial assistance form on file or a lack of supporting documentation. Central Community Hospital may use outside agencies to determine eligibility. These resources may use demographic and household information and/or credit scoring technology to determine eligibility. Patients who meet presumptive eligibility criteria may be granted financial assistance without completing the application. Presumptive eligibility awards must be 100% discounts. Other forms of presumptive eligibility include: Eligible for Bankruptcy, death with no estate resources, and Title XIX eligible and receiving non-covered services. Part I, Line 6a: The community benefit report is can be found on its website at www.centralcommunityhospital.com. Part I, Line 7: Charity care expense was reported at cost on line 7a based on an overall cost-to-charge ratio which addresses all patient segments. Medicaid is cost reimbursed therefore there is no community benefit expense reported. The cost for subsidized health services 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 $90,409. Part II, Community Building Activities: We make every effort to have a constant presence at the community level to promote health related activities and report on the value a hospital brings to a small community. Based on our health needs assessment, we encourage the involvement of all community organizations in activities to promote better health for our service area residents. We offer assistance to patients who qualify for reduced cost of medication through the drug companies. This ensures these individuals receive the prescriptions they need. Two individuals counsel Medicare Part D participants on the program and annually review the participant's choice to assure the most appropriate insurance program is selected. The Hospital's EMTs attend the Central Community School football games to provide immediate assistance to athletes, coaches and fans. Part III, Line 2: All forms of payment, including self-pay, insurance, contractual allowances, and discounts, are applied to the patient's account before the account is classified as bad debt. A payment received on an account previously written off as bad debt reduces bad debt expense. Central Community Hospital does not refuse services to patients that generate bad debt.Bad debt expense on line 2 is reported at charges as presented on the financial statements. Part III, Line 3: A reasonable estimate of the Hospital's bad debt expense attributable to patients eligible under the charity care policy is 5.2% of bad debt expense. This is based on the percentage of individuals below the poverty level in the area. Part III, Line 4: The footnote to the Organization's financial statements can be found on pages 8 and 9 of the attached audited financial statements. Part III, Line 8: Central Community Hospital has a Medicare shortfall and considers this a community benefit. The Hospital provides services to Medicare patients regardless of the shortfall because access to healthcare and individual's health is important. Total revenue received from Medicare is the gross reimbursement plus settlement. Both total revenue received from Medicare and the Medicare allowable costs are reported from the Medicare Cost Report. The Medicare Cost Report is completed based on the rules and regulations set forth by Centers for Medicare and Medicaid Services. Part III, Line 9b: We make every effort to determine if a patient is eligible for financial assistance. If a patient cannot pay their balance in full in 30 days, a financial counselor is available to discuss payment options. After financial assistance is determined, any personal portion due follows the same debt collection policy as other patients without financial assistance. If a bankruptcy notice is received on any account, all collection activities will cease immediately. Central Community Hospital will not harass a patient for their past due account, nor make false statements to get the patient to pay their account. There are instances when a patient may appear eligible for financial discounts, but there is no financial assistance form on file or a lack of supporting documentation. Central Community Hospital may use outside agencies to determine eligibility. These resources may use demographic and household information and/or credit scoring technology to determine eligibility. Patients who meet presumptive eligibility criteria may be granted financial assistance without completing the application. Presumptive eligibility awards must be 100% discount. Other forms of presumptive eligibility include: eligible for the Iowa Cares Program, bankruptcy, death with no estate resources, and Title XIX eligible and receiving non-covered services (reviewed case by case). Part VI, Line 2: The Community Health Needs Assessment was completed and posted to the website June, 2016. The assessment was conducted beginning February, 2016 with the help of Guttenberg Municipal Hospital in Guttenberg, Iowa (located in Clayton County). Representatives of 18 organizations compiled Clayton County data on their services and populations served. Seven priorities for health care needs were established for the county. When Central Community Hospital (CCH) created their Action Plan, they selected these seven priorities. CCH completes a quarterly report that is posted to the website and distributed internally. CCH established action steps to be taken under each of the priorities. Part VI, Line 3: At the time of registrations, CCH staff makes every effort to determine if a patient may possibly need or qualify for any financial assistance. We notify patients of the availability of these programs by posting information in our registration and emergency room areas. We offer a private meeting with a financial counselor. Inpatients are offered an opportunity to meet with the counselor upon discharge. Financial assistance information is provided in all correspondence regarding patient bills. Our financial counselor attempts phone contact whenever possible. Our charity program information is available on our website. We do an annual article about the service in our newsletter. Our financial counselor will also assist with enrollment in external programs. Part VI, Line 4: Central Community Hospital serves the residents of the central part of Clayton County into the northeast section of the county. It is a rural, agricultural area. The geographic area of Clayton County is 778.54 square miles. The nearest larger city is Dubuque, Iowa, which is 72 miles from Elkader, the county seat. With 17,773 people, Clayton County is the 39th most populated county in the state of 99 counties. The population saw a 1.4% decline from 2008-2012. In 2012, the median household income of Clayton County residents was $46,617. 12.9% of Clayton County residents live in poverty. The median age for Clayton County residents is 44.7 years young. The largest Clayton County racial/ethnic groups are White (96.9%) followed by Hispanic (1.7%) and Other (0.9%). Part VI, Line 5: Central Community Hospital's board members reside in the primary service area except for one who lives in Dubuque, IA. None of the board members are employed by the Hospital nor are they contractors of the Hospital. None of the board members have family members employed by Central Community Hospital. Central Community Hospital extends hospital privileges to all qualified physicians in our service area extending to Dubuque, Iowa, where specialists serve our area. CCH encourages specialists to offer clinics in our facility to improve access for our local residents. Many of CCH older patients are apprehensive to drive 72 miles one-way to a large city to see a specialist. When the Hospital creates its budget, efforts are made by the Administrative Team to allocate funds to improve patient care through updating equipment, expanding supplies or hiring staff. Each year dollars are allocated to improve services based on recommendations submitted by department managers.Central Community Hospital (CCH) works with the city of Elkader to assure tax dollars are collected to purchase ambulances when needed, provide annual maintenance and tires for the vehicles and purchase 50% of the gas consumed. CCH pays the other 50% of the gas bill. The committee that oversees community health and education is the AIM committee, whose purpose is to align with the community needs with hospital goals, inspire staff to cooperatively improve the health of the community and manage those needs to best capability of CCH. Their annual goals are set primarily by the community health needs assessment plan and the needs determined by CCH staff. AIM offers classes at schools and in the community, Corporate Wellness program targeting businesses looking for opportunities to improve the health of their employees and participation in public awareness activities. Part VI, Line 6: Central Community Hospital is affiliated with Mercy Health Network, Des Moines, IA. Mercy Health Network provides 29 affinity meetings on a regular basis covering all aspects of services in the hospital (administrative, clinical, supportive). The staff is available daily to answer questions, provide assistance with policies and procedures and assign experts to offer classes, webinars, written materials and telephone conferences. They offer additional services that include provider recruitment, legal services and administrative support for major decision-making projects including major construction, adding service line or addressing new regulatory mandates. CCH also has a Critical Access Network Agreement with Mercy Medical Center, Dubuque, IA to meet the regulations regarding support for critical access including transportation, communication, quality and credentialing. Mercy Medical Center is committed to supporting health care in rural areas as demonstrated by their joint operations and subsidy of the Elkader Medical Clinic. Form 990, Part VI, Section A, line 1 The Executive Committee consists of the officers of the Board. The President of the Board chairs the Committee. The Committee has the power to exercise authority of the Board when necessary or advisable between meetings of the Board. The Committee reports all of its actions to the Board at the next regular or special meeting of the Board, and such actions are subject to revision and alteration by the Board; provided however, that the rights of third parties are not affected by any revision or alteration. The Committee has the duty of reviewing the Bylaws of the Board at least annually and recommending to the Board the amendment of the Bylaws of the Hospital. The Executive Committee oversees compliance of the Hospital with requirements of regulatory bodies and meets on the call of the President. Minutes are kept of all meetings. Form 990, Part VI, Section A, line 2 Kevin Ihde and Justin Vorwald have a family relationship. Form 990, Part VI, Section A, line 6 The Organization has members who are all of one class and resident citizens of the Central Community Hospital service area. Form 990, Part VI, Section A, line 7a Members of the Board are elected by the resident citizens of the Central Community Hospital service area at the annual meeting to serve for a term of four years. Form 990, Part VI, Section A, line 8b The Executive Committee did not meet during FY 2016. Form 990, Part VI, Section B, line 11 The Form 990 is made available to all Board Members before it is filed. The CEO reviews and approves the 990. Form 990, Part VI, Section B, line 12c Any duality of interest or possible conflict of interest on the part of any Board member and officer is disclosed to the other members of the Board and made a matter of record through an annual procedure and also when the interest becomes a matter of Board action. Any individual having a duality of interest or possible conflict of interest on any matter should not vote or use his or her personal influence on the matter, and should not be counted in determining the quorum for the meeting, even where permitted by law. The minutes of the meeting reflect the disclosure, the abstention from voting, and the quorum situation. Any new member of the Board will be advised of this policy upon entering on the duties of office. The governing board and CEO complete and sign the conflict of interest form yearly. The forms are reviewed by the Board President, and if a potential conflict is identified the Board President follows up. Form 990, Part VI, Section B, line 15a Fran Zichal, CEO, is considered a common law employee of Central Community Hospital. The process for determining compensation for the CEO is based on salary adjustment recommendations using a variety of tools. The process uses an annual evaluation, CEO wage scales, and scales from a variety of sources and Mercy Medical Center Dubuque compensation system. All of the tools include a review of wages in comparison to comparable positions, bed size of hospital, size of community, and other factors. The CEO of Mercy Medical Center Dubuque documents and provides substantiation of the recommended CEO wage to the board. Form 990, Part VI, Section C, line 19 The Organization's governing documents and conflict of interest policy are available upon written request. The financial statements are attached to the Form 990 and therefore available for public inspection. Form 990, Part IX, line 11g Purchased services: Program service expenses 1,461,023. Management and general expenses 159,170. Fundraising expenses 0. Total expenses 1,620,193. Repairs and maintenance: Program service expenses 187,161. Management and general expenses 225,745. Fundraising expenses 0. Total expenses 412,906. Professional fees: Program service expenses 138,712. Management and general expenses 0. Fundraising expenses 0. Total expenses 138,712. Form 990, Part XI, line 9: Change in interest in net assets of Central Community Hospital Foundation 21,242.