2016-08-10T13:45:33-05:00 2015-12-31 476097913 SEIM JOHNSON LLP 18081 BURT STREET SUITE 200 OMAHA NE 680224722 990 2015-01-01 420670596 SUMNER COMMUNITY CLUB SUMN 5635783275 909 W 1ST STREET PO BOX 148 SUMNER IA 506740148 DUSTIN WRIGHT CEO 5635783275 2016-08-04 1 WENDY R COOLEY P01523804 4023302660 2015 2016-12-15 16:53:06Z COMMUNITY MEMORIAL HOSPITAL DUSTIN WRIGHT 909 W 1ST STREET PO BOX 148 SUMNER IA 506740148 12211533 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 12 702 -316 270074 180538 12024244 11917881 59135 38773 75312 74341 12428765 12211533 0 0 0 0 5494836 5646893 0 0 0 6914607 7200580 12409443 12847473 19322 -635940 30109425 29572705 19600548 19884839 10508877 9687866 X TO PROVIDE QUALITY HEALTH CARE TO THE PEOPLE OF SUMNER AND SURROUNDING AREAS, WHILE COORDINATING OTHER NEEDED SERVICES. 0 0 7430619 5936561 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. 1331013 3059603 COMMUNITY MEMORIAL HOSPITAL (CMH) MEDICAL CLINIC CONTINUED TO SERVE SUMNER, IA AND THE SURROUNDING AREA IN THE YEAR 2015. CMH CLINIC WAS STAFFED WITH 3 PROVIDERS. THE CMH CLINIC HAS ONE NURSE PRACTITIONER 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 10,879 FOR 2015. IN ADDITION TO CLINIC VISITS, OUR PROVIDERS CONTINUE THEIR SERVICE TO SURROUNDING NURSING HOMES WITH PATIENTS SEEN MONTHLY AT HILLCREST HOME IN SUMNER, MAPLECREST MANOR IN FAYETTE AND TRIPOLI NURSING & REHAB IN TRIPOLI. OTHER SERVICES TO THE COMMUNITY WERE PHYSICALS FOR AREA FIREFIGHTERS AND EMS AGENCIES AND POST-JOB OFFER PHYSICALS FOR THREE LOCAL BUSINESSES. PROVIDERS CONTINUE TO TAKE CALL FOR THE EMERGENCY DEPARTMENT ON A REGULAR SCHEDULED BASIS THROUGHOUT EACH MONTH. CLINICAL STAFF FROM THE HOSPITAL CONTINUED TO GO TO AN AREA BANK THE FIRST TUESDAY OF EACH MONTH TO OFFER FREE BLOOD PRESSURE CHECKS TO ANYONE ON A WALK-IN BASIS. PROVIDERS AVIDLY PRECEPT FOR STUDENT'S VARIOUS PROGRAMS WITH UNIVERSITY OF IOWA, IOWA CITY, IA, ALLEN COLLEGE IN WATERLOO, IA AND KAPLAN UNIVERSITY IN CEDAR FALLS, IA TAKING ADVANTAGE OF THIS IN 2015. THE CLINIC HOURS ARE MONDAY THROUGH FRIDAY STARTING AT 7 AM AND ENDING AT 5 PM. 1124930 1612540 ACUTE NURSING HAD 364 ADMISSIONS IN 2015. 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 57.44 HOURS. THIS IS WELL BELOW THE 96 HOURS THRESHOLD FOR CRITICAL ACCESS. THERE WERE A TOTAL OF 340 ACUTE PATIENT DAYS AND 834 SWING BED DAYS IN 2015. 1053538 1309177 THE CMH EMERGENCY DEPARTMENT SERVED 1,436 PATIENTS IN 2015. THIS IS AN INCREASE OF 84 PATIENT VISITS FROM 1,352 VISITS IN 2014. THE NUMBER OF PHYSICIAN HOURS SPENT IN THE EMERGENCY DEPARTMENT DECREASED FROM 2,540 IN 2014 TO 2,907 IN 2015. THE EDUCATIONAL FOCUS FOR 2015 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, IO TRAINING, HAZMAT TRAINING AND STROKE WITH TPA. WE WERE ALSO FORTUNATE ENOUGH TO HAVE THE RURAL TRAMA TEAM DEVELOPMENT COURSE (RTTDC) COME AND PROVIDE A DAY-LONG SEMINAR FOR EMS, PROVIDERS, NURSING, LAB AND RADIOLOGY. 1053538 1309177 10940100 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 8 0 1 0 0 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 MICHAEL MEYER BOARD MEMBER - CHAIR THRU 03/15 1.30 0.80 X X 0 0 0 WILLIAM SCHWAKE BOARD MEMBER - VICE CHAIR 1.30 0.80 X X 0 0 0 DEBRA TOENGES BOARD MEMBER - SEC/TREAS 1.30 0.00 X X 0 0 0 DUANE HILDEBRANDT BOARD MEMBER 0.80 0.00 X 0 0 0 LUARA NECKER BOARD MEMBER 0.80 0.00 X 0 0 0 DIANE PAGEL BOARD MEMBER 0.80 0.00 X 0 0 0 RICK PEDERSON BOARD MEMBER 0.80 0.00 X 0 0 0 MARK SEEHASE BOARD MEMBER 0.80 0.00 X 0 0 0 DAVE VOSS 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 DEBRA BECKNER BOARD MEMBER THRU 03/15 0.80 0.00 X 0 0 0 RANDIE MUELLER BOARD MEMBER THRU 03/15 0.80 0.00 X 0 0 0 DUSTIN WRIGHT CEO 38.00 2.00 X 61265 0 7753 MARY WELLS CEO THRU 06/15 38.00 2.00 X 108380 0 10485 DAWN EVERDING CFO 39.50 0.50 X 123256 0 8469 LYNNE NIEMANN DIRECTOR OF NURSING & PATI 40.00 0.00 X 107312 0 10558 KYLE TEELING DIRECTOR OF SUPPORT SERVIC 40.00 0.00 X 64996 0 8600 TROY BUCHHOLZ MD PHYSICIAN 40.00 0.00 X 349359 0 35156 JEFFREY ROSKE DO PHYSICIAN 40.00 0.00 X 339265 0 22296 ROBERTA MITTELSTED ARNP-BC ARNP 40.00 0.00 X 108543 0 17016 1262376 0 120333 6 0 1 0 EMERGENCY PRACTICE ASSOCIATES PO BOX 1260 WATERLOO IA 50704 ER COVERAGE 569064 PERFORMANCE REHAB LLC 909 W 1ST ST SUMNER IA 50674 REHAB SERVICES 414244 UNITYPOINT HEALTH PO BOX 83381 CHICAGO IL 60691 IT SUPPORT 307043 HEALTH ENTERPRISES OF IOWA 5825 DRY CREEK LANE NE CEDAR RAPIDS IA 52402 RADIOLOGY/CRNA SERVICES 264543 UNITYPOINT HEALTH - ALLEN MEMORIAL HOSPI PO BOX 83381 CHICAGO IL 60691 MEDICAL SERVICES 241635 10 9365 29439 141734 180538 MEDICARE/MEDICAID PAYMENTS 621400 7461383 7461383 PATIENT REVENUE - PRIVATE PAY 621400 4152416 4152416 AMH OPERATING AGREEMENT INCOME 561000 200000 200000 340B INCOME 621990 64262 64262 COMMUNITY WELLNESS 621990 24760 24760 15060 15060 11917881 38773 38773 41153 0 41153 41153 41153 CAFETERIA EMPLOYEES 900099 32486 32486 CATERING 722320 702 702 33188 12211533 11917881 702 112412 X 511074 511074 4103283 3736565 366718 710048 618338 91710 322488 262836 59652 36000 36000 13500 13500 73791 73791 2257551 2197588 59963 57780 57780 488730 442861 45869 261233 261233 219286 188545 30741 43274 33412 9862 724432 622878 101554 1752727 1507021 245706 69507 69507 MEDICAL SUPPLIES 894439 894439 DUES AND SUBSCRIPTIONS 147727 147727 PROVISION FOR BAD DEBT 78882 78882 FOOD 59881 59881 21840 21840 12847473 10940100 1907373 0 100 100 7164611 7527265 1685136 2175613 128886 175940 135587 164201 21637245 6569708 16406698 15067537 4139591 3954520 448816 507529 30109425 29572705 1181312 1279716 17214612 17179805 1204624 1425318 19600548 19884839 X 6369286 5733346 4139591 3954520 10508877 9687866 30109425 29572705 -635940 -185071 0 X X 0 1 X 1 0 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 4139591 -185071 3954520 4483296 -343705 4139591 4171601 563439 251744 4483296 3544459 858953 231811 4171601 2684825 1033086 173452 3544459 0.00000 1.00000 0.00000 1 0 100421 100421 13358930 2489593 10869337 6036556 3672338 2364218 2141338 407777 1733561 15067537 PERPETUAL TRUST 3954520 F 3954520 CAPITAL LEASE OBLIGATIONS 601637 ESTIMATED THIRD-PARTY PAYOR SETTLEMENT 823681 1425318 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. THE FARMLAND IS ALSO OPERATED ON A CASH BASIS RENTAL AGREEMENT BEGINNING IN 2015. 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, 2015 AND 2014, THE HOSPITAL HAD NO UNCERTAIN TAX POSITIONS ACCRUED. 1 1 1 X 1 X 1 1 0 1 1 14248 14248 0.00110 1020565 766949 253616 0.01990 19831 18018 1813 0.00010 1054644 784967 269677 0.02110 25623 2785 22838 0.00180 18558 18558 0.00150 234698 33060 201638 0.01580 14113 14113 0.00110 292992 35845 257147 0.02020 1347636 820812 526824 0.04130 1 78882 14000 6827156 6571686 255470 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 X 13 1 1 0 1 X WWW.CMHSUMNER.ORG 1 13 1 WWW.CMHSUMNER.ORG 0 0 1 X 200.000000000000 400.000000000000 0 1 X X X 1 X 1 X 1 X X X 1 X 0 0 COMMUNITY MEMORIAL HOSPITAL PART V, SECTION B, LINE 3J: THE STEERING COMMITTEE FROM THE NEEDS ASSESSMENT UTILIZED THE INFORMATION GATHERED TO IDENTIFY A LIST OF 15 NEED CATEGORIES. THESE CATEGORIES INCLUDED: 1) ACCESS, 2) CHRONIC DISEASE MANAGEMENT, 3) DENTAL HEALTH, 4) ELDERLY POPULATION, 5) ETHNICITIES/MINORITIES, 6) HEALTH LITERACY, 7) MENTAL HEALTH, 8) NUTRITION, 9) PHYSICAL ACTIVITY, 10) SEXUAL HEALTH, 11) SUBSTANCE ABUSE, 12) VETERANS, 13) VISION HEALTH, 14) WOMEN'S HEALTH AND 15) YOUTH. COMMUNITY MEMORIAL HOSPITAL USED THE INFORMATION PRESENTED IN THIS PROCESS TO FOCUS IN ON RESULTS RECEIVED FROM THOSE WE SERVE AND DEVELOP STRATEGIES TO BENEFIT OUR LOCAL AREA AND RESIDENTS. THE BOARD OF DIRECTORS OF COMMUNITY MEMORIAL HOSPITAL HAVE CHOSEN TO ADDRESS MENTAL HEALTH, ACCESS AND CHRONIC DISEASE MANAGEMENT AS THE PRIMARY NEEDS FROM THE ASSESSMENT. ALTHOUGH THE REMAINING IDENTIFIED NEEDS ARE NOT BEING ADDRESSED AT THE CURRENT TIME, THEY CONTINUE TO HAVE IMPORTANCE AND WILL BE MONITORED AS WELL. COMMUNITY MEMORIAL HOSPITAL PART V, SECTION B, LINE 5: THERE WERE 51 AGENCIES THAT RESPONDED TO THE NEEDS ASSESSMENT SURVEY THAT WAS CONDUCTED. THE AGENCIES CONSISTED OF SCHOOLS, BUSINESSES, CHURCHES, COMMUNITY ORGANIZATIONS, PUBLIC HEALTH AGENCIES, HEALTHCARE PROVIDERS, WELLNESS PROVIDERS, INSTITUTIONS OF HIGHER LEARNING AND OTHERS. THIS SURVEY SAMPLE REPRESENTED A LARGE CROSS-SECTION OF THE POPULATION AREAS IN ALL OF THE COMMUNITIES INCLUDED IN THE ASSESSMENT. THE SERVICE AREA THAT WAS SURVEYED INCLUDED 10 COUNTIES THAT ARE ALL SERVED BY THE HOSPITALS THAT COLLABORATED IN THE NEEDS ASSESSMENT PROCESS. COMMUNITY MEMORIAL HOSPITAL PART V, SECTION B, LINE 6A: GRUNDY COUNTY MEMORIAL HOSPITAL, GRUNDY CENTER, IAUNITYPOINT - ALLEN HOSPITAL, WATERLOO, IAWAVERLY HEALTH CENTER, WAVERLY, IAWHEATON FRANSISCAN HEALTHCARE - COVENANT MEDICAL CENTER, WATERLOO, IAWHEATON FRANSISCAN HEALTHCARE - SARTORI MEMORIAL HOSPITAL, CEDAR FALLS, IAWHEATON FRANSISCAN HEALTHCARE - MERCY HOSPITAL, OELWEIN, IA COMMUNITY MEMORIAL HOSPITAL PART V, SECTION B, LINE 11: THE BOARD OF DIRECTORS REVIEWED THE LIST OF NEEDS IDENTIFIED USING 2 DIFFERENT METHODS. THE FIRST METHOD WAS BY SIMPLY LOOKING AT THE NUMBER OF RESPONSES RECEIVED FOR EACH INDIVIDUAL NEED. THE SECOND METHOD WAS TO LOOK AT WEIGHTED RESULTS FROM THE SURVEY. THE WEIGHTED RESULTS ARE DONE BY ASSIGNING A POINT VALUE FOR LEVEL OF PRIORITY ASSIGNED, WHICH THEN TAKES INTO ACCOUNT THE LEVEL OF IMPORTANCE FOR THE RESPONDENT. THESE SEPERATE MECHANISMS RESULTED IN THE SAME TOP 3 NEEDS BEING 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 MENTAL HEALTH, ACCESS AND CHRONIC DISEASE MANAGEMENT. THE BOARD OF DIRECTORS SAW 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 THREE NEEDS HELPS ACHIEVE THIS.THE REMAINING NEEDS ON THE NEEDS ASSESSMENT INCLUDE ELDERLY, YOUTH, NUTRITION, WOMEN'S HEALTH, DENTAL HEALTH, PHYSICAL ACTIVITY, SUBSTANCE ABUSE, SEXUAL HEALTH, ETHNIC/MINORITY GROUPS, VISION/EYE HEALTH, HEALTH LITERACY AND VETERANS. 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 RE-ASSESS AS WE MOVE FORWARD. IN ADDITION, THERE ARE SERVICES, ORGANIZATIONS AND BUSINESSES WITHIN THE SERVICE AREA THAT WERE IDENTIFIED THAT FOCUS ON THESE NEEDS CURRENTLY. COMMUNITY MEMORIAL HOSPITAL PART V, SECTION B, LINE 18D: CMH SENDS OUT A SERIES OF 3 STATEMENTS TO PATIENTS WITH AN OPEN ACCOUNT. ON THE STATEMENTS, INFORMATION IS PROVIDED ON HOW TO RECEIVE AN APPLICATION FOR FINANCIAL ASSISTANCE. AFTER THE 3 STATEMENTS ARE SENT FROM CMH AND NO ACTION IS INITIATED BY THE PATIENT, THE ACCOUNT IS TURNED OVER TO A COLLECTION AGENCY. THE COLLECTION AGENCY THEN SENDS ANOTHER SET OF 4 LETTERS TO THE PATIENT TO CONTACT THEM TO ESTABLISH A PAYMENT PLAN OR PAY THE ACCOUNT IN FULL. THE PATIENT ALSO HAS THE OPPORTUNITY TO CONTACT CMH TO COMPLETE A FINANCIAL ASSISTANCE APPLICATION THROUGHOUT THE PROCESS. AFTER THESE 4 LETTERS ARE SENT, THE PATIENT ACCOUNT IS FINALLY TURNED OVER TO "ATTORNEY STATUS", WHICH PROMPTS COLLECTION PROCESSES TO BEGIN FROM THE COLLECTION AGENCY. COMMUNITY MEMORIAL HOSPITAL PART V, SECTION B, LINE 19D: CMH SENDS OUT A SERIES OF 3 STATEMENTS TO PATIENTS WITH AN OPEN ACCOUNT. ON THE STATEMENTS, INFORMATION IS PROVIDED ON HOW TO RECEIVE AN APPLICATION FOR FINANCIAL ASSISTANCE. IT IS NOT UNTIL THESE 3 STATEMENTS, WHICH REPRESENTS 3 MONTHS OF BILLING, ARE SENT THAT ANY COLLECTION ACTIONS ARE TAKEN OUTSIDE OF THE FACILITY. CMH DOES NOT INITIATE ANY LEGAL ACTIONS OR COLLECTIONS UNTIL AFTER THE END OF THE 3 STATEMENT ROTATION. THIS PROCESS LEAVES THE PATIENT RESPONSIBLE FOR MAKING THE CONTACT FOR FINANCIAL ASSISTANCE AND TO FOLLOW-THROUGH ON THIS PORTION OF IT.CMH HAS ALSO DESIGNATED A STAFF MEMBER THAT REVIEWS THE STATEMENT PROCESS TO DETERMINE IF THERE ARE PATIENTS THAT HAVE NOT MADE CONTACT OR PAYMENT ON THEIR ACCOUNT. THIS STAFF MEMBER REACHES OUT TO THESE PATIENTS TO PROVIDE ASSISTANCE AND LOOK FOR ADDITIONAL INSURANCE ELIGIBILITY AND OFFERS ASSISTANCE WITH PAYMENT PLANS. THIS CONTACT IS BEING MADE TO THE PATIENT BETWEEN THE SECOND AND THIRD STATEMENTS TO DETERMINE IF THE FINANCIAL ASSISTANCE APPLICATION IS AN OPTION. COMMUNITY MEMORIAL HOSPITAL PART V, SECTION B, LINE 20E: THE HOSPITAL NOTIFIES THE INDIVIDUALS OF THE FINANCIAL ASSISTANCE POLICY ON THE BILLING STATEMENTS. INDIVIDUALS THAT RESPOND TO THE BILLING STATEMENT NOTIFICATIONS OF SUCH ASSISTANCE APPLICATION ARE GIVEN THE OPPORTUNITY TO DISCUSS WITH EMPLOYEES FROM THE HOSPITAL REGARDING THIS OPTION. COMMUNITY MEMORIAL HOSPITAL PART V, SECTION B, LINE 22D: CMH CHARGES ALL PATIENTS THE SAME AMOUNT WHEN THE SAME CARE IS GIVEN REGARDLESS OF IF THEY HAVE INSURANCE COVERAGE OR WHAT CARRIER THEY HAVE FOR INSURANCE. IF A PATIENT IS DETERMINED TO BE ELIGIBLE FOR FINANCIAL ASSISTANCE, AN ADJUSTMENT IS MADE TO THEIR ACCOUNT BASED ON THEIR QUALIFYING RATES. 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 $78,882. 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 AND 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 "ALL COLLECTION EFFORTS WILL CEASE IF A COMPLETE CHARITY CARE APPLICATION HAS BEEN RECEIVED OR IF IT IS KNOWN THAT THE PATIENT QUALIFIES FOR PRESUMED CHARITY CARE. THE CFO WILL NOTIFY THE BUSINESS OFFICE MANAGER IN EACH OF THESE CASES. ONCE A DECISION HAS BEEN MADE ON THE CHARITY CARE APPLICATION, COLLECTION EFFORTS WILL STOP IF IT WAS APPROVED, OR CONTINUE WHERE THEY LEFT OFF IF THE APPLICATION WAS DENIED." PART VI, LINE 2: COMMUNITY MEMORIAL HOSPITAL COMPLETED THE COMMUNITY HEALTH NEEDS ASSESSMENT PROCESS IN 2013. THE CHNA IS CURRENTLY POSTED ON THE HOSPITAL WEBSITE. THE THREE AREAS OF FOCUS CHOSEN BY COMMUNITY MEMORIAL HOSPITAL FROM THE CHNA INCLUDE: MENTAL HEALTH, ACCESS AND CHRONIC DISEASE MANAGEMENT.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. ONE EXAMPLE OF THIS IS THE SPACE BEING RESERVED AS "SHELL" SPACE SO MRI CAN BE ADDED IN THE FUTURE FOR CRITICAL INTERVENTION FOR STROKE CARE. 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. PART VI, LINE 4: CMH'S PRIMARY SERVICE AREA CONSISTS OF CITIES FROM THE FOLLOWING FIVE ZIP CODES, WHICH INCLUDE SUMNER (50674), TRIPOLI (50676), WESTGATE (50681), FREDERICKSBURG (50630), AND HAWKEYE (52147). THE PRIMARY POPULATION FROM THESE ZIP CODES CONSISTS OF FARMING AND RURAL AREAS. THE PRIMARY SETTING FOR MOST HOUSEHOLDS FROM THIS SERVICE AREA IS A RURAL SETTING WITH THE LARGEST CITY BEING SUMNER WITH AN APPROXIMATE POPULATION OF 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 (ALERT, LOCKDOWN, INFORM, COUNTER AND EVACUATE) 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. 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 317049 0 32000 0 310 0 13250 0 21906 0 384515 0 0 0 JEFFREY ROSKE DO PHYSICIAN 318815 0 0 0 20450 0 8541 0 13755 0 361561 0 0 0 PART I, LINE 3 THE ORGANIZATION IS JOINTLY OPERATED WITH UNITYPOINT HEALTH-WATERLOO, ALLEN HEALTH SYSTEM. A CEO OF UNITYPOINT HEALTH IS RESPONSIBLE FOR SETTING THE SALARY FOR MARY WELLS, FORMER CEO OF CMH AND DUSTIN WRIGHT, CURRENT CEO OF CMH. THE CEO OF UNITYPOINT HEALTH-WATERLOO, ALLEN HEALTH SYSTEM 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 414244 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 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 11 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. A CEO OF UNITYPOINT HEALTH IS RESPONSIBLE FOR SETTING THE SALARY FOR MARY WELLS, FORMER CEO OF CMH AND DUSTIN WRIGHT, CURRENT 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), LYNNE NIEMANN, DIRECTOR OF NURSING, AND KYLE TEELING, DIRECTOR OF SUPPORT SERVICES (BOTH ARE ADMINISTRATIVE KEY EMPLOYEES). 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 657,509. MANAGEMENT AND GENERAL EXPENSES 59,963. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 717,472. EMERGENCY ROOM SPECIALIST FEES: PROGRAM SERVICE EXPENSES 837,383. MANAGEMENT AND GENERAL EXPENSES 0. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 837,383. PHYSICAL THERAPY FEES: PROGRAM SERVICE EXPENSES 383,210. MANAGEMENT AND GENERAL EXPENSES 0. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 383,210. ANESTHESIOLOGIST FEES: PROGRAM SERVICE EXPENSES 160,722. MANAGEMENT AND GENERAL EXPENSES 0. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 160,722. LAB FEES: PROGRAM SERVICE EXPENSES 158,764. MANAGEMENT AND GENERAL EXPENSES 0. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 158,764. 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 132556 CASH TRANSFERRED EQUALS FMV