2014-02-11T10:15:02-06:00 2013-06-30 450250958 EIDE BAILLY LLP 3999 PENNSYLVANIA AVE SUITE 100 DUBUQUE IA 52002 990 2012-07-01 420818642 Central Community Hospital CENT 5632457000 901 Davidson St NW Elkader IA 520439015 Pat Borel 5632457000 2014-02-11 1 Carmen Krantz P00031958 5635561790 2014-02-11 2012 2015-11-30 17:44:51Z Pat Borel 901 Davidson St NW Elkader IA 520439015 6000796 0 X www.centralcommunityhospital.com X 1961 IA Provide healthcare services to the surrounding community 7 7 84 24 0 0 150659 90572 6039963 5845313 4315 8333 40364 41922 6235301 5986140 0 0 0 0 2659091 2636904 0 0 26375 3414638 3240491 6073729 5877395 161572 108745 5897985 6171298 389295 550101 5508690 5621197 X Every patient matters. 0 0 4630194 5845313 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 over 970 emergency visits this year with an additional 67 observation days. The Hospital works with the City of Elkader to provide emergency response and emergency transport services for the local communities. This year the Hospital provided 847 days of inpatient care and 7,217 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, 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. Central Community Hospital takes its mission to improve the health and quality of life of the people it serves a step further by reaching out to meet the broad health needs of the community. It strives to identify community needs beyond basic healthcare, working collaboratively with other community organizations. Needs assessments are completed every three years and updated annually by a county wide multi-disciplinary team and used to prioritize community projects.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 $150,647 for the year ended June 30, 2013. The direct and indirect costs related to these forgone charges were $105,000 at June 30, 2013, based on an average ratio of costs to gross charges.In addition, the Hospital 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 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. 4630194 1 1 0 0 0 0 0 0 0 0 1 0 0 0 0 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 27 0 1 84 1 0 0 0 0 0 0 0 0 0 0 X 7 7 1 1 0 0 1 1 0 1 1 0 0 1 1 1 1 1 1 1 1 0 X Pat Borel 5632457000 901 Davidson St NW Elkader IA 520439015 Robert Bodensteiner 0.50 X X 0 0 0 Jennifer Cowsert 0.50 X X 0 0 0 Tom Neuhaus 0.50 X X 0 0 0 Randall Johnson 0.50 X X 0 0 0 Kevin Ihde 0.50 X X 0 0 0 Darwin Winke 0.50 X 0 0 0 Russell Knight 0.50 X 0 0 0 William Reimer 0.50 X 0 0 0 Max Winemiller 0.50 X 0 0 0 Frances Zichal 40.00 X 122282 0 14099 Pat Borel 40.00 X 82255 0 7977 204537 0 22076 1 0 0 0 Wapiti Box 92 Newell SD 57760 ER physicians 438099 Mercy Medical Center - Dubuque 250 Mercy Drive Dubuque IA 52001 Purchased services 398583 Northern Iowa Therapy 1810 4th St SW Suite 103 Waverly IA 50677 PT, OT, ST 386012 Medical Associates Clinic 1500 Associates Drive Dubuque IA 52002 Purchased services 123836 4 34958 55614 90572 Patient service revenu 622110 5785481 5785481 Supporting revenue 900099 41142 41142 Affiliation agreement 900099 18690 18690 5845313 8333 8333 56578 14656 41922 41922 41922 5986140 5845313 0 50255 X 226057 226057 1950975 1607287 322233 21455 42685 35007 7218 460 264005 210363 50823 2819 153182 120541 31000 1641 64551 64551 50080 50080 1720338 1614855 105483 20327 20327 177814 53225 124589 101310 101310 96023 93042 2981 34431 13649 20782 1280 1280 413561 413561 67910 67910 Patient supplies 387136 387136 Bad Debt Expense 57275 57275 48455 22973 25482 5877395 4630194 1220826 26375 816415 372489 2765 11367 706546 594523 89913 90357 182189 104287 8688004 5596657 3069275 3091347 629281 1723565 168953 172715 232648 10648 5897985 6171298 359195 460600 30100 89501 389295 550101 X 5315393 5396429 193297 224768 5508690 5621197 5897985 6171298 X 108745 3762 X 0 1 X 1 0 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 26015 26015 4026113 1995871 2030242 4370858 3600786 770072 265018 265018 3091347 X 5915812 -55705 -55705 5971517 14623 14623 5986140 5834776 14656 14656 5820120 57275 57275 5877395 Description of Uncertain Tax Positions Under FIN 48: 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 -57,275. Net assets released from restrictions included in revenue for financial stmt 1,570. Part XI, Line 4b - Other Adjustments: Monona Clinic rent expenses included in revenue on Form 990 -14,656. Restricted donations recorded in fund balance for financial statements 29,279. Part XII, Line 2d - Other Adjustments: Monona Clinic rent expenses included in revenue on Form 990 14,656. Part XII, Line 4b - Other Adjustments: Bad debt expense included in expenses on Form 990 57,275. 1 1 X 1 X 1 X 0 1 1 0 1 1 105000 105000 0.01800 105000 105000 0.01800 14543 14543 0.00250 887287 733922 153365 0.02640 901830 733922 167908 0.02890 1006830 733922 272908 0.04690 793 793 0.00010 90 90 0.00000 6447 6447 0.00110 7330 7330 0.00120 0 57275 5727 3072075 3056081 15994 X 1 1 1 1 Central Community Hospital

901 Davidson St NW Elkader IA 520439015

X X X X Central Community Hospital 1 1 X X X X X X X X X 12 1 1 1 X X X X X X X X X X X 1 0 1 1 150.000000000000 1 200.000000000000 1 X X X X 1 1 X X X 1 0 X X X 1 X 0 1 Part I, Line 3c: Income Criteria as a % of US Government poverty income guidelines:Less than or equal to 150% 0% paid by patient151% - 175% 30% paid by patient176% - 200% 50% paid by patientGreater than 200% 100% paid by patientThere 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. Part I, Line 6a: The community benefit report is available upon request. 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. Community health improvement services, line 7e, and cash and in-kind contributions, line 7f, were reported based on actual expenses recorded in the Organization's general ledger. The cost for subsidized health services on line 7g was determined using the Medicare Cost Report. Part I, L7 Col(f): The amount of bad debt expense backed out of total expenses to determine the percentage was $57,275. Part II: 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 have a strong presence in our local school systems by developing school wellness policies and trying to promote good health habits at an early age. Central Community Hospital is also involved in public health emergency preparedness activities including drills and exercises, Mission Health Drug Program, community health work groups, infection control meetings on policies and procedures, and NE Iowa Leadership and economic development meetings to try to create additional employment opportunities. We are also active in the Northeast Iowa Food and Fitness Initiative. Part III, Line 4: 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.The estimated amount of the organization's bad debt expense attributable to patients eligible under the organization's charity care policy is calculated based on the percentage of incomplete applications. Approximately 10% were not completed and therefore the accounts were written off to bad debt. 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: 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). Central Community Hospital Part V, Section B, Line 3: The following individuals and groups were consulted as individuals representing the community interests: Board of Health, Board of Supervisors, Central Community Hospital Board, Elkader Manager and Mayor. They were identified by the CHNA-HIP committee. Central Community Hospital Part V, Section B, Line 4: The community health needs assessment was conducted with Guttenberg Municipal Hospital in Guttenberg, Iowa. Central Community Hospital Part V, Section B, Line 5c: The community health needs assessment can be accessed at www.centralcommunityhospital.com. Central Community Hospital Part V, Section B, Line 6i: Central Community Hospital adopted an implementation strategy to address the community health needs identified in its Community Health Needs Assessment. The implementation strategy is posted to the Hospital's website at www.centralcommunityhospital.com. Central Community Hospital Part V, Section B, Line 14g: 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 22: 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 VI, Line 2: The Community Health Needs Assessment was completed and posted to the website by June 30, 2013. The assessment was conducted with Guttenberg Municipal Hospital in Guttenberg, Iowa. Representatives of 18 facilities compiled Clayton County data on their services and populations served. The Board of Health, Board of Supervisors, Central Community Hospital's Board of Directors and Elkader's Manager and Mayor were consulted as individuals representing the communities' interests. Six priorities for health care needs were established including: obesity, substance abuse, falls, lead poisoning, mental health and care coordination. 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 "Mission Health" 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 Clayton County. It is a rural, agricultural community. Employers in the area are generally small and often do not offer employee health benefits. The county has one of the lowest income per capita levels in the state. Residents would have to travel approximately 70 to 90 miles to reach a larger health facility. The area is accessed via state and county two-lane roads, often difficult to travel in the winter.The 2012 population for Clayton County was 17,835. The 2009 median household income for a family was $41,469. Approximately 8.60% of the population in Clayton County were below the poverty level. Part VI, Line 5: Our Organization has a Board of Directors representing the entire service area and with varied backgrounds. We have an open medical staff. In addition to our local physicians, we encourage specialty physicians to hold clinics at our facility to improve access to our local residents. We have made great efforts to minimize long-term debt and instead take the approach of reinvesting cash flow back into the organization. Part VI, Line 6: Central Community Hospital is affiliated with Mercy Medical Center - Dubuque, a private, non-profit organization. The Hospital entered into a Master Affiliation Agreement with Mercy Medical Center - Dubuque to provide hospital, physician, and other health care services in Elkader, Iowa. Mercy is committed to supporting health care in rural areas, as demonstrated by their joint operations and subsidy of medical clinics as well as their rural outreach programs. Reports Filed With States Part VI, Line 7 IA 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 Fran Zical, CEO, and Russel Knight, Board member, have a business relationship. Form 990, Part VI, Section A, line 3 Fran Zichal, CEO, is employed by Mercy Medical Center - Dubuque. Central Community Hospital has a Master Affiliation Agreement with Mercy Medical Center - Dubuque. The Board of Directors of the reporting organization retains all authority over decisions made. Form 990, Part VI, Section A, line 6 The Organization has members, 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 B, line 11 The Form 990 is made available to all Board Members before it is filed. The CEO and CFO review and approve 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, CEO and CFO 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 15 The process for determining compensation for the CEO is based on salary adjustment recommendations based on an annual evaluation, use of wage scales, committee approval (Board Chair and Mercy Medical Center - Dubuque's CEO), and Board approval. Also, Mercy Medical Center - Dubuque's compensation system is utilized. This includes review of wages in comparison to comparable positions. The organization documents and provides substantiation for their compensation process for the CEO. The process was last undertaken in FY 2013. The Hospital's Board determines compensation for the CFO through an annual evaluation and use of wage scales. The process is documented and was last undertaken in FY 2013. 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. Other Fees Form 990, Part IX, line 11g Purchased services: Program service expenses 1,393,408. Management and general expenses 103,296. Fundraising expenses 0. Total expenses 1,496,704. Repairs and maintenance: Program service expenses 220,407. Management and general expenses 2,187. Fundraising expenses 0. Total expenses 222,594. Equipment rent and lease: Program service expenses 1,040. Management and general expenses 0. Fundraising expenses 0. Total expenses 1,040. Changes in Net Assets or Fund Balances: Form 990, Part XI, line 9: Change in interest in net assets of Central Community Hospital Foundation 3,762.