2016-02-15T00:00:00-06:00 2015-04-30 450250958 EIDE BAILLY LLP 1545 ASSOCIATES DR STE 101 DUBUQUE IA 52002 990 2014-05-01 476028103 Cambridge Memorial Hospital Inc CAMB 3086971522 PO Box 488 Cambridge NE 69022 Deborah Herzberg CEO 3086971522 2016-02-03 1 Carmen Krantz P00031958 5635561790 2016-02-03 2014 2016-08-17 19:52:53Z Tri Valley Health System Deborah Herzberg PO Box 488 Cambridge NE 69022 21811154 0 X www.trivalleyhealth.com X 1955 NE Providing quality, compassionate, local healthcare services. 9 9 252 195 6310 -1044 100856 235312 19203030 21539195 53090 36647 0 0 19356976 21811154 0 1991 0 0 9851593 10041588 0 0 0 10138674 11676349 19990267 21719928 -633291 91226 31084131 30612357 20079502 19193783 11004629 11418574 X To improve the lives we touch by providing care of the highest quality throughout life's journey. 0 1 14145322 1991 14910521 Tri Valley Health System operates a critical access hospital with an attached long-term care unit, three rural health clinics, an Assisted Living Facility, a Home Medical Supply store and an Independent Retirement Center.The Cambridge Memorial Hospital, a 25 bed critical access hospital, operates a full-time emergency room and provides emergency care regardless of the ability to pay. The emergency room had 1,162 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. It makes these services 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 $66,000 for the year ended April 30, 2015. Total direct and indirect costs related to these foregone charges were approximately $43,000 at April 30, 2015, 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. 2710222 4223219 Tri Valley has rural health clinics in Arapahoe, Indianola, and Cambridge, Nebraska. During the year, the clinics had 15,224 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). 1819015 2399145 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 26 residents a day in the Long Term Care and 17 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. Tri Valley launched the "Frog" Program which is a free exercise program for the older generation that meets three times a week. The program is currently offered in Arapahoe and Cambridge because of the high utilization and request. 18674559 1 1 0 0 0 0 0 0 0 0 1 1 0 0 1 1 1 0 0 0 0 0 0 0 0 0 1 1 0 0 1 0 0 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 1 30 0 1 252 1 1 1 0 0 0 0 0 0 0 0 0 X 9 9 1 1 0 0 1 1 0 1 0 0 0 1 1 1 1 1 1 1 0 0 X Diana Rippe 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 Reginald Warner Director 3.00 X 0 0 0 Bill Minnick Director 3.00 X 0 0 0 Cathy Kubik Director 3.00 X 0 0 0 Roger Steinkruger CEO until June 2014 40.00 X 0 0 0 Mike Lieb Interim CEO until July 2014 40.00 X 0 0 0 Gregg Magers Interim CEO until November 2014 40.00 X 0 0 0 Margie Molitor Interim CEO until January 2015 40.00 X 0 0 0 Deb Herzberg CEO commenced January 2015 40.00 X 0 0 0 Diana Rippe CFO 40.00 X 77754 0 20985 Constance Hill CRNA Anesthetist 40.00 X 155297 0 24520 Paul Shellabarger PA-C Family Practice 40.00 X 158338 0 29691 Shiuvaun Jaeger MD Family Practice/Obstetrics 40.00 X 269691 0 39290 Lennie Deaver MD Family Practice/Obstetrics 40.00 X 276120 0 34724 Rachelle Kaspar-Cope MD Family Practice/Obstetrics 40.00 X 227449 0 34876 1164649 0 184086 9 0 1 0 Inspire Rehabilitation LLC 2810 W 35th Street Kearney NE 68845 PT, OT and ST services 659102 MedHost of Tennessee Inc 2739 Momentum Place Chicago IL 606895327 Software and support 454713 HealthTech Management Services Inc 5110 Maryland Way Brentwood TN 37027 Management services 412341 Platte Valley Medical Group PC 816 22nd Ave Ste 100 Kearney NE 688452206 Contract cardio services 147242 Nebraska Methodist Hospital PO Box 2797 Omaha NE 68103 Pathology services 113422 6 10606 224706 235312 Patient & Resident revenue 622110 20217248 20217248 Supporting revenue 900099 1281884 1281884 Wellness & Rehab Ctr 713940 33753 33753 Medical Spa 812900 6310 6310 21539195 36647 36647 21811154 21532885 6310 36647 X 1991 1991 102409 102409 7803406 6940044 863362 191513 171241 20272 1340511 1187376 153135 603749 530913 72836 656676 656676 37123 37123 69314 69314 2467685 2175664 292021 155367 155367 845989 597900 248089 503824 492001 11823 69183 52913 16270 50458 37673 12785 1179400 1179400 2398662 2398662 297605 696 296909 Medical supplies 1755602 1755602 Bad debt expense 906447 906447 Food costs 246036 246036 Agency commission 34815 34815 2163 2163 21719928 18674559 3045369 0 384037 1932324 3183778 2870836 15000 15000 407103 387612 566847 158915 34204881 15385979 20616404 18818902 2573549 2961424 2739766 3005454 60893 75086 536754 386804 31084131 30612357 1678459 1670473 479007 511776 17922036 16829727 0 181807 20079502 19193783 X 8261621 8411868 1848665 2112363 894343 894343 11004629 11418574 31084131 30612357 X 91226 57031 265688 X X 0 1 X 0 1 1 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 113289 113289 21868279 8336038 13532241 9732692 6285614 3447078 2490621 764327 1726294 18818902 Interest in Tri Valley Medical Foundation 3005454 F 3005454 Estimated third-party payor settlements 181807 181807 X 20726425 57031 -906447 -849416 21575841 235313 235313 21811154 20811490 0 20811490 908438 908438 21719928 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's federal Form 990T filings are no longer subject to federal tax examinations by tax authorities for years before 2011. Part XI, Line 2d - Other Adjustments: Provision for bad debts included in revenue for financial statements -906,447. Part XI, Line 4b - Other Adjustments: Contributions for long-lived assets incl in fund balance for financial stmts 235,312. Investment income included in fund balance for financial statements 1. Part XII, Line 4b - Other Adjustments: Provision for bad debts included in revenue for financial statements 906,447. Scholarships given recorded in fund balance for financial statements 1,991. 1 1 X 1 X 1 X 0 1 0 0 43000 43000 0.00210 588412 380264 208148 0.01000 631412 380264 251148 0.01210 4028476 3225893 802583 0.03860 4028476 3225893 802583 0.03860 4659888 3606157 1053731 0.05070 0 906447 153190 7432661 7490885 -58224 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 12 1 0 0 1 X www.trivalleyhealth.com X 1 12 1 www.trivalleyhealth.com 0 0 1 X 100.000000000000 200.000000000000 X 1 1 X X X X 1 X www.trivalleyhealth.com X www.trivalleyhealth.com X www.trivalleyhealth.com X X X X X X 1 X 0 X X X X 1 X 0 0 Cambridge Memorial Hospital, Inc. Part V, Section B, Line 5: 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. Cambridge Memorial Hospital, Inc. Part V, Section B, Line 11: Binge drinking and motor vehicle crash rates were not included as potential health needs to address in the community due to lack of resources.Other activities that are still ongoing include: cancer services, elderly transportation services, and recruiting and retaining quality providers and nursing shortages.During the year, TVHS dietician offered the Nuval Supermarket tour to the Cambridge High School Economic's class. Diabetic education classes are offered on a regular basis.Telehealth psychiatric services are now being offered at TVHS. A visiting oncologist and a pain specialist are now providing regular services.An additional vehicle was added to the Public Transportation program. Cambridge Memorial Hospital, Inc. Part V, Section B, Line 16i: 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 in pdf form in English and in any other language spoken by more than 10 percent of the residents of the community served by the Hospital as determined using the most current data published by the Census Bureau. 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 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. Cambridge Memorial Hospital, Inc. Part V, Section B, Line 20e: A plain language summary of the financial assistance policy is offered to all outpatients registering for services.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. Part V, Section B, Line 16 Financial Assistance Policy Website Availability Cambridge Memorial Hospital, Inc. Part V, Section B, line 16a website: www.trivalleyhealth.com Cambridge Memorial Hospital, Inc. Part V, Section B, line 16b website: www.trivalleyhealth.com Cambridge Memorial Hospital, Inc. Part V, Section B, line 16c website: www.trivalleyhealth.com 2 Heritage Plaza 1205 Nelson Street Cambridge NE 69022 Independent living 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 patient 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 percetage was $906,447. 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 16.9%. 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 $906,447. We can assume that 16.9%, or $153,190, 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: Between January and February 2013, a 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 in pdf form in English and in any other language spoken by more than 10 percent of the residents of the community served by the Hospital as determined using the most current data published by the Census Bureau. 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 $41,537 and the average household income is $52,373. 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 2014 range from 3.4% (Gosper), 2.7% (Frontier), 2.85% (Red Willow) to 3.1% (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 Trustees whose members reside within the system's primary service area and have no immediate family ties to any employees. These individuals also do not benefit financially through their businesses by means of contracts or other agreements. Surplus funds, if available, are used to purchase equipment or are re-invested in the facility to improve patient care. Tri Valley Health System extends medical staff privileges to all qualified physicians in the community. Throughout Tri Valley Health System's fiscal year, strides were made to increase the community outreach and education as well as the health of the communities. In 2011 Tri Valley opened the Healthy Living Center which includes a Wellness and Rehab Center. Every day people with chronic diseases, such as diabetes and heart failure, are monitored, educated, and cared for by dedicated health care professionals who help them enjoy the best quality of life possible. 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. During the year, Tri Valley offered "DayBreakers" program to the students in Cambridge, NE. This program was initiated to encourage exercise in grade school students. During the summer months, Tri Valley sponsored "TVHS Kids Summer Program" which encouraged healthy eating and exercise for children. Tri Valley also sponsored testing school age children's BMI to determine if nutrition education was further needed in the community and school system. 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 two communities of the primary service area. 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 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, otolaryngology, podiatry, pulmonology, and urology. Tri Valley Health System is also a member of the Nebraska Telehealth Network providing additional services such as neurology and psychiatry. X X 1 1 0 0 0 1 0 0 0 0 0 Constance Hill CRNA Anesthetist 142707 0 12000 0 590 0 4577 0 20412 0 180286 0 0 0 Paul Shellabarger PA-C Family Practice 148644 0 9040 0 654 0 7685 0 22511 0 188534 0 0 0 Shiuvaun Jaeger MD Family Practice/Obstetrics 196588 0 72307 0 796 0 14274 0 25536 0 309501 0 0 0 Lennie Deaver MD Family Practice/Obstetrics 210888 0 64860 0 372 0 14675 0 20644 0 311439 0 0 0 Rachelle Kaspar-Cope MD Family Practice/Obstetrics 184548 0 41912 0 989 0 9357 0 26083 0 262889 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. Part I, Line 5 Each provider has an incentive payment schedule written in their contract. Incentive bonus is paid out monthly based on services performed. Schedule J, Part I, Line 3: Tri Valley Health System does not pay compensation to the CEO directly. The CEO is compensated by HealthTech Management Services, Inc., an unrelated management company and is also considered a common law employee of the management company. Tri Valley Health System has a written contract with HealthTech Management Services that is reviewed and approved by the Board. The methods listed on Part I, line 3 are used by the management company to establish compensation for the CEO. Shiuvaun Jaeger MD Physician employed by Hospital Physician recruitment X 45000 15000 0 1 1 15000 Form 990, Part III, line 3 The Medical Spa closed in November 2014. Form 990, Part VI, Section A, line 2 Randy Heitmann and Bill Minnick serve together as board members of a separate organization. Connie Hill and Josh Hill have a family relationship. Form 990, Part VI, Section A, line 3 The CEO for Tri Valley Health System is employed by HealthTech Management Services, Inc., an unrelated management company. The CEO's that served during FY2015 were considered common law employees of HealthTech Management Services, Inc. Calendar year 2014 compensation for supervising the management, administration and operation of Tri Valley Health System is listed below. Roger Steinkruger, CEO until June 2014 $212,124 Mike Lieb, Interim CEO until July 2014 0 Gregg Magers, Interim CEO until November 2014 61,959 Margie Molitor, Interim CEO until January 2015 63,627 Deb Herzberg, CEO commenced January 2015 0 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 11 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 CEO's compensation is determined by HealthTech Management Services, an unrelated management company. The CEO is considered a common law employee of HealthTech Management Services. Annually, the Regional Vice-President from HealthTech Management Services provides a CEO evaluation form to each Board member to complete. After completing the form the Board members return it directly to the Regional Vice-President. He also meets with the Board in a private meeting to review the evaluations and approve the compensation. 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 staff's 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 done annually. 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 460,515. Management and general expenses 16,130. Fundraising expenses 0. Total expenses 476,645. Purchased services: Program service expenses 1,213,183. Management and general expenses 51,862. Fundraising expenses 0. Total expenses 1,265,045. Maintenance and repair: Program service expenses 501,966. Management and general expenses 224,029. Fundraising expenses 0. Total expenses 725,995. Form 990, Part XI, line 9: Change in interest in net assets of Tri Valley Medical Foundation 265,688. Form 990, Part XII, Line 2c: The Board of Trustees assumes responsibility for oversight of the audit and selection of an independent accountant.