2017-02-13T13:49:11-06:00 2016-03-31 351178661 Blue & Co LLC 2650 Eastpoint Parkway Suite 300 Louisville KY 40223 990 2015-09-01 616008014 Clinton County Hospital Inc CLIN 6063876421 723 Burkesville Road ALBANY KY 42602 Ronald G Sowell Executive Vice President of CHC 6063876421 2017-02-10 1 Angela Zirkelbach CPA P00572603 5029923500 2017-02-10 2015 2021-01-29 14:40:06Z X Ronald G Sowell 723 Burkesville Road ALBANY KY 42602 4999357 0 X WWW.CLINTONCOUNTYHOSPITAL.COM X 1965 KY ACUTE HOSPITAL CARE X 5 4 168 12 0 0 8945 8604 10102698 4851517 18252 4121 107107 135115 10237002 4999357 0 0 0 0 6085411 3316757 0 0 0 7712984 4887301 13798395 8204058 -3561393 -3204701 4125000 0 20286845 0 -16161845 0 X Clinton County Hospital is dedicated to providing the highest quality care possible in a safe and secure environment. We are committed to the promotion of wellness and restoration of health in a cost-effective manner. We continuously strive to improve the quality of health in the communities we serve. 0 1 7236719 4851517 Clinton County Hospital is a Not-for-Profit, 42 licensed-bed acute care hospital organized for the purpose of providing healthcare services to the residents of Clinton County. The hospital's primary sources of support are from patient revenue received from Medicare, state agencies and insurance companies. There were 8,820 bed days available for the fiscal year ended 2016.The Hospital provides care to patients who meet certain criteria under its charity care policy without charge or at amounts less than its established rates. Amounts determined to qualify as charity care are reported as deductions from Revenue on Page 9 Part X. The amount of charity care for the fiscal year ended 2016 was $126,767. 7236719 1 1 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 1 0 0 0 0 0 0 0 0 0 0 0 0 0 1 0 0 0 0 0 0 1 22 0 1 168 1 0 0 0 0 0 0 0 0 X 5 4 0 0 0 0 0 0 0 1 1 0 0 0 1 1 1 1 1 1 1 0 KY X Clinton County Hospital 6063876421 723 Burkesville Rd ALBANY KY 42602 KEITH MCWHORTER Chair 2.00 X 0 0 1551 Rodney Little VICE-CHAIR 2.00 X 0 0 2295 BoB TALBOTT SECRETARY 2.00 X 0 0 1464 W C POWELL MD MEMBER 2.00 X 0 0 0 TOMMY BERTRAM Member (retired 2/1/2016) 2.00 X 0 0 0 JD MULLINS JR CEO 36.00 X 82237 0 18824 Donald Hay MD Gynecologist 40.00 X 109391 0 0 Shelia Kingry Pharmacist 36.00 X 108831 0 0 Kevin Lowhorn Pharmacist 36.00 X 106173 0 0 406632 0 24134 3 0 0 0 The ERX Group 9724 Kingston Pike Ste 405 Knoxville TN 37922 ER Physician Coverage 1538008 CPSI PO Box 850309 Mobile AL 366850309 Computer Services 392181 Premier Care Inc 603 Main Street WIndermere FL 34786 management fee 291336 Resource Anesthesia PC 12752 Kingston Pike knoxville TN 37934 Anesthesia Physician coverage 235845 Phillips Medical System NA PO Box 100355 Atlanta GA 303840355 Maintenance Contracts 205674 8 8604 8604 Net Patient Services R 621300 4851517 4851517 4851517 4121 4121 32056 0 32056 32056 32056 MIsc Revenue 621300 93577 93577 cafeteria revenue 621300 9482 9482 103059 4999357 4851517 0 139236 X 2750222 2061832 688390 566535 566535 89245 80065 9180 1218890 1218890 1028944 968781 60163 754751 693201 61550 1886 1886 598904 598904 709269 709269 148056 148056 Miscellaneous 332494 332494 Dues & Subscriptions 4862 4862 8204058 7236719 967339 0 0 629245 0 0 1398355 0 0 9000 0 121484 0 372842 0 164595 0 0 1429479 0 0 0 0 0 0 4125000 0 253373 20033472 0 20286845 0 X -16161845 0 -16161845 0 4125000 0 X -3204701 19366546 X X 0 0 0 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 0 0 0 0 0 0 0 0 1 1369 1369 0 Part II-B, Line 1: 15.1% OF THE HOSPITAL'S ANNUAL MEMBERSHIP DUES OF KENTUCKY HOSPITAL ASSOCIATION ARE ALLOCATED TO LOBBYING ACTIVITIES. 1 1 1 X 1 X 1 1 1 0 0 1 128718 139196 -10478 0.00000 76 1791620 1408824 382796 0.04670 77 1920338 1548020 372318 0.04670 77 1920338 1548020 372318 0.04670 0 1656937 0 2156372 2950157 -793785 X 1 1 1 1 CLINTON COUNTY HOSPITAL INC 723 Burkesville Road Albany KY 42602 WWW.CLINTONCOUNTYHOSPITAL.COM 100078 X X X CLINTON COUNTY HOSPITAL 1 0 0 1 X X X X X X X 12 1 0 0 1 X WWW.CHC.NET/SERVICES/HOSPITALS/THE_MEDICAL_CENTER_AT_ALBANY/COMMUNITY_HEALT X 1 12 1 WWW.CHC.NET/SERVICES/HOSPITALS/THE_MEDICAL_CENTER_AT_ALBANY/COMMUNITY_HEALT 0 0 1 X 200.000000000000 400.000000000000 X X X X X 1 1 X 1 X www.clintoncountyhospital.com X X X 1 0 1 X 0 0 CLINTON COUNTY HOSPITAL Part V, Section B, Line 5: The Hospital Facility took into account input from persons who represent the community through community surveys and focus groups. In addition the hospital had a community volunteer steering committee that represented individuals from organizations and agencies from the service area. CLINTON COUNTY HOSPITAL Part V, Section B, Line 7d: The Community Health needs assessment is available at WWW.CHC.NET/SERVICES/HOSPITALS/THE_MEDICAL_CENTER_AT_ALBANY/ COMMUNITY_HEALTh. The hospital took into account input from the community through the use of focus group discussions and community surveys. CLINTON COUNTY HOSPITAL Part V, Section B, Line 11: SOME PRIORITIES WILL NOT BE ADDRESSED BY THE HOSPITAL IN THE COMMUNITY HEALTH NEEDS ASSESMENT. SOME OF THESE ISSUES ARE INCLUDED BELOW WITH THE REASON FOR NOT ADDRESSING THE NEED: - NEED FOR MORE SPECIALISTS: THE HOSPITAL HAS ENGAGED CONVERSATIONS WITH SPECIALISTS, BUT IT IS NOT A TOP PRIORITY AT THIS TIME.- BILLING ISSUES: THE HOSPITAL CONTINUES TO WORK ON COMMUNICATION, HOWEVER, IT IS NOT DEEMED A TOP HEALTHCARE NEED PRIORITY AT THIS TIME.- COST OF SERVICES ARE TOO HIGH: THE HOSPITAL CONTINUES TO REVIEW, BUT IT IS NOT DEEMED A TOP HEALTHCARE NEED PRIORITY AT THIS TIME.- NEED FOR MENTAL HEALTH SERVICES: THE HOSPITAL DOES NOT HAVE THE RESOURCES AT THIS TIME TO MAKE IT A TOP PRIORITY.- NEED FOR DRUG TREATMENT FACILITIES: THE HOSPITAL DOES NOT HAVE THE RESOURCES AT THIS TIME TO MAKE IT A TOP PRIORITY.- TELEPHONE AUTOMATED SERVICE IS TOO CONFUSING AND LONG: THIS HAS NOT BEEN DEEMED A TOP HEALTHCARE NEED PRIORITY. ADDITIONALLY, A CALLER CAN TALK TO SOMEONE DIRECTLY BY DIALING ZERO. CLINTON COUNTY HOSPITAL Part V, Section B, Line 16i: Financial Assistance Policy is provided to all private pay patients residing in Kentucky upon admission. CLINTON COUNTY HOSPITAL Part V, Section B, Line 22d: A Clinton Co. Hospital Financial Counselor or designated business office representative will review individual cases and make a determination of financial assistance that may be offered.Clinton County Hospital determines the need for financial assistance by reviewing insurance coverage, other sources of payment, patient's historical financial profile and current financial situation. This allows for a fair and objective way to assist patients who are experiencing financial hardship. Partial and/or full charity care will be granted based on the individual's ability to pay. Eligible individuals include patients who do not have insurance and patients who have insurance but are underinsured. Patients must cooperate with any insurance claim submission and exhaust their insurance or potential insurance coverage before becoming eligible for financial assistance.Other factors affecting eligibility are: Income 1. 200% of the most recent Federal Poverty Income Guidelines will be the minimum level for 100% (full) charity write-off. 2. 201%-400% of the most recent Federal Poverty Guidelines will be eligible for a 50% discount. 3. Patients with an income over 400% of the most recent Federal Poverty Income Guidelines will be eligible for some degree of charity in special circumstances only. Part I, Line 7g: The organization does not provide any subsidized health services attributable to physician clinics. Part II, Community Building Activities: COMMUNITY BUILDING: CLINTON COUNTY HOSPITAL TAKES PRIDE IN BEING AN ACTIVE MEMBER OF OUR COMMUNITY. FROM SIMPLY BEING PRESENT AT MEETINGS LIKE THE CHAMBER OF COMMERCE AND COMMUNITY ADVISORY COMMITTEE OR TAKING THE LEAD IN ACTIVITIES LIKE HEALTH FAIRS, RELAY FOR LIFE AND CAREER DAY AT THE LOCAL HIGH SCHOOL. CLINTON COUNTY HOSPITAL BENEFITS THIS COMMUNITY IN MANY WAYS ABOVE AND BEYOND JUST BEING A HOSPITAL. WITH AN EAR TO THE GROUND, HOSPITAL EMPLOYEES LISTEN FOR THE MOST PRESSING AND URGENT NEEDS IN THE COMMUNITY AND PASS THEM ON TO ADMINISTRATION SO THAT ACTIONS CAN BE TAKEN. CLINTON COUNTY HOSpITAL IS LOCATED IN A SMALL RURAL AREA AND VERY SUPPORTIVE OF COMMUNITY NEEDS. Part III, Line 4: The audited footnote to the organizations financial statements describing bad debt expense: The hospital adopted Accounting Standards Update 2011-07, "Presentation and Disclosure of Patient Service Revenue, Provision for Bad Debts, and the Allowance for Doubtful Accounts for Certain Healthcare Entities." This requires certain healthcare entities to present provision for bad debts relating to patient service revenue as a deduction from patient service revenue in the statements of operations and changes in net assets rather than as an operating expense. All periods presented have been reclassified to conform to this presentation. The Hospital's adoption of this standard had no net impact on financial position, results of operations, or cash flows. This standard also requires healthcare entities to provide enhanced disclosure about their policies for recognizing revenue and assessing bad debts, as well as qualitative and quantitative information about changes in the allowance for doubtful accounts. Accounts receivable are reduced by an allowance for doubtful accounts based on the Hospital's evaluation of its major payor sources of revenue, the aging of the accounts, historical losses, current economic conditions, and other factors unique to their service area and the healthcare industry. Management regularly reviews data about the major payor sources of revenue in evaluating the sufficiency of the allowance for doubtful accounts.For receivables associated with services provided to patients who have third-party coverage, the Hospital analyzes contractually due amounts and provides an allowance for doubtful accounts and a provision for bad debts, if necessary (for example, for expected uncollectible deductibles and copayments on accounts for which the third-party payor has not yet paid, or for payors who are known to be having financial difficulty that make the realization of amounts due unlikely). For receivables associated with self-pay payments, which includes both patients without insurance and patients with deductible and copayment balances due for which third-party coverage exists for part of the bill, the Hospital records a significant provision for bad debts in the period of service on the basis of its past experience, which indicates that many patients are unable or unwilling to pay the portion of their bill for which they are financially responsible. The difference between the standard rates (or the discounted rates if negotiated) and the amounts actually collected after all reasonable collection efforts have been exhausted is charged off against the allowance for doubtful accounts.The Hospital's current allowance for doubtful accounts policy is to reserve 85 percent of all self-pay accounts less than 120 days old and include all accounts 120 days old and older, net of contractual allowances already taken.Part III, line 3, Explanation for rational for including other bad debt amount in community benefit: No other bad debt amounts have been included as community benefit. The hospital has a detailed financial assistance policy. In addition, the hospital educates patients with limited ability to pay regarding financial assistance. For this reason, the organization believes it accurately captures all charity care deductions provided according to the financial assistance policy and the amount of bad debt expense attributable to patients eligible under the organization's charity care policy is negligible. Part III, Line 8: THE SOURCE USED TO DETERMINE THE AMOUNT OF MEDICARE ALLOWABLE COSTS REPORTED FOR PART III, SECTION B, MEDICARE HAS BEEN PROVIDED FROM THE YEAR ENDED SEPTEMBER 30, 2015 REPORT: HOSPITAL STATEMENT OF REIMBURSABLE COST. Part III, Line 9b: THE ORGANIZATION'S COLLECTION POLICY INCLUDES PROVISIONS ON THE COLLECTION PRACTICES TO BE FOLLOWED FOR PATIENTS WHO ARE KNOWN TO QUALIFY FOR CHARITY CARE OR FINANCIAL ASSISTANCE. AFTER THE FINANCIAL COUNSELOR AND CHIEF FINANCIAL OFFICER REVIEW AND APPROVE A CHARITY CARE APPLICATION, CHARITY CARE AMOUNTS AND DIRECT WRITE OFF AMOUNTS ARE DETERMINED AND DOCUMENTED. APPROVED CHARITY CARE ACCOUNTS ARE THEN SEPARATELY FILED AND HELD FOR AUDIT REVIEW. Part VI, Line 2: NEEDS ASSESSMENT: IN ADDITION TO THE COMMUNITHY HEALTH NEEDS ASSESMENT CONDUCTED IN 2012; INFORMATION CONCERNING LOCAL HEALTH CARE NEEDS IS PROVIDED TO THE HOSPITAL THROUGH LOCAL AGENCIES, PHYSICIANS AND PUBLIC HEALTH DEPARTMENTS. Part VI, Line 3: PATIENT EDUCATION OF ASSISTANCE ELIGIBILITY: PATIENTS ARE OFFERED AN APPLICATION FOR ASSISTANCE, EITHER AT TIME OF REGISTRATION OR BY MAIL WITH AN EXPLANATION SHEET ON HOW TO APPLY AND ANY DOCUMENTS REQUIRED FOR APPROVAL. Part VI, Line 4: Community Description: The area served by Clinton County Hospital is rural in nature and somewhat remote. The education level, household income, and access to healthcare are all below the national average. Part VI, Line 5: Community Health Promotion: The organization furthers its exempt purpose by promoting health of the community through the following: The majority of the organization's governing body is comprised of persons who reside in the organization's primary service area. These volunteers are neither employees nor independent contractors of the organization, nor family members thereof. The hospital administration and employees take an active role in local health care initiatives and activities. Whenever possible surplus items are donated to public agencies. Part VI, Line 6: Affiliated Health Care System: The organization is not part of an affiliated health care system. X 0 0 0 0 0 0 0 0 0 Accounts Receivable 2016-03-31 1398355 Fair value was determined by the present value of cash inflows of such asset and based upon the sale of all the Hospital's assets as discussed in the Prior Year financials statements. 311118087 Commonwealth Health Corporation 800 Park Street BOwling Green KY 42101 501(c)(3) Inventory 2016-03-31 372842 Fair value was determined by the present value of cash inflows of such asset 311118087 Commonwealth Health Corporation 800 Park Street BOwling Green KY 42101 501(c)(3) prepaid expenses 2016-03-31 164595 Fair value was determined by the present value of cash inflows of such asset 311118087 Commonwealth Health Corporation 800 Park Street BOwling Green KY 42101 501(c)(3) Assets whose use is limited 2016-03-31 629245 Fair value was determined by the present value of cash inflows of such asset 311118087 Commonwealth Health Corporation 800 Park Street BOwling Green KY 42101 501(c)(3) Property and Equipment 2016-03-31 1429479 Fair value was determined by the present value of cash inflows of such asset 311118087 Commonwealth Health Corporation 800 Park Street BOwling Green KY 42101 501(c)(3) Other Assets 2016-03-31 130484 Fair value was determined by the present value of cash inflows of such asset 311118087 Commonwealth Health Corporation 800 Park Street BOwling Green KY 42101 501(c)(3) 0 0 0 0 1 1 1 1 1 1 Part I, Line 6c: The Hospital filed for Chapter 11 bankruptcy in October 2014. All of the liabilities were subject to settlement under the reorganization proceedings. The Bankruptcy Court agreed to the sale of Clinton County Hospital to Commonwealth Health Corporatition for $4,125,000 on March 31, 2016. CHC purchased the assets free and clear of Clinton County Hospital's liabilities. The court approved the disposition of the sale proceeds and the proceeds were allocated as follows: a.) $3,775,000 to the USDA Rural Development and b.) $350,000 to First and Farmers Bank. Form 990, Part III, line 3 Clinton County Hospital was acquired by Commonwealth Health Corporation on March 31, 2016. Clinton County Hospital was dissolved as of March 2016. Form 990, Part VI, Section B, line 11 This entity was dissolved and the board members listed on the return are no longer available. THe management Company, Commonweath Health Corporation, Inc (CHC), was assigned by the United States Bankruptcy Court on February 4, 2016. CHC's management has reviewed the 990 including requested schedules, as ultimately filed with the IRS, prior to the filing. Form 990, Part VI, Section B, line 12c The written conflict of interest policy is regularly and consistently monitored and compliance enforced by the Administrator of the hospital and Chairperson of the Board of Directors. The scope of this policy includes members of the Board of Directors, Medical Staff, and all persons employed by Clinton County Hospital. The policy is in place to prevent actual or potential conflicts of interests from being violated and provide procedures and guidelines for determination of an actual or potential conflict of interest. The covered persons are to conduct their relationships in compliance with this policy to ensure that decisions are made for the best interest of the hospital. A self disclosure from covered persons in writing to the Administrator of the Hospital or Chairperson of the Board is required on any actual or contemplated transaction which appears to violate the conflict of interest policy. Based on the decision of the board the individual may be required to discontinue the situation or institute other appropriate actions. Form 990, Part VI, Section B, line 15 THE CHIEF EXECUTIVE OFFICER'S COMPENSATION IS SET BY THE BOARD OF DIRECTORS. THE BOARD OF DIRECTORS VOTE ON AN OVERALL PERCENTAGE RAISE ANNUALLY FOR ALL EMPLOYEES INCLUDING KEY EMPLOYEES. THE CHIEF EXECUTIVE OFFICER CAN GIVE SINGLE RAISES OVER AND BEYOND THE ANNUAL RAISE. 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. Form 990, Part IX, line 11g Purchased Services: Program service expenses 1,218,890. Management and general expenses 0. Fundraising expenses 0. Total expenses 1,218,890. Form 990, Part XI, line 9: Bankruptcy and release of Clinton County Hospital liabilities 23,491,546. Sale of Clinton County Hospital -4,125,000. Form 990, Part XI, Line 2c, Oversight of Audit: THE BOARD OF DIRECTORS ASSUMES RESPONSiBILITY FOR OVERSIGHT OF THE AUDIT OF THE FINANCIAL STATEMENTS AND NO PROCESSES HAVE CHANGED FROM THE PRIOR YEAR.