CAMBRIDGE MEMORIAL HOSPITAL INC: Form 990, tax year 2012
View the entire original 990 at ProPublica ↗
- Organization
- CAMBRIDGE MEMORIAL HOSPITAL INC (EIN 47-6028103)
- Tax period
- 2012-05-01 to 2013-04-30
- Filed
- 2014-03-06
- IRS object ID
- 201430659349300908
- Schema version
- 2012v2.1
- Source
- Download XML · Original 990 at ProPublica
Every field in the e-filed return. Faint text is the IRS element name, for citing.
Return header ReturnHeader
| Field | Value | IRS element (for citing) |
|---|---|---|
| Timestamp | 2014-03-06T13:26:04-06:00 | Timestamp |
| Tax Period End Date | 2013-04-30 | TaxPeriodEndDate |
Preparer Firm PreparerFirm
| Field | Value | IRS element (for citing) |
|---|---|---|
| EIN | 450250958 | EIN |
Preparer Firm Business Name PreparerFirmBusinessName
| Field | Value | IRS element (for citing) |
|---|---|---|
| Business Name Line1 | EIDE BAILLY LLP | BusinessNameLine1 |
Preparer Firm US Address PreparerFirmUSAddress
| Field | Value | IRS element (for citing) |
|---|---|---|
| Address Line1 | 3999 PENNSYLVANIA AVE SUITE 100 | AddressLine1 |
| City | DUBUQUE | City |
| State | IA | State |
| ZIP Code | 52002 | ZIPCode |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Return Type | 990 | ReturnType |
| Tax Period Begin Date | 2012-05-01 | TaxPeriodBeginDate |
Filer Filer
| Field | Value | IRS element (for citing) |
|---|---|---|
| EIN | 476028103 | EIN |
Name Name
| Field | Value | IRS element (for citing) |
|---|---|---|
| Business Name Line1 | Cambridge Memorial Hospital Inc | BusinessNameLine1 |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Name Control | CAMB | NameControl |
| Phone | 3086971522 | Phone |
US Address USAddress
| Field | Value | IRS element (for citing) |
|---|---|---|
| Address Line1 | PO Box 488 | AddressLine1 |
| City | Cambridge | City |
| State | NE | State |
| ZIP Code | 69022 | ZIPCode |
Officer Officer
| Field | Value | IRS element (for citing) |
|---|---|---|
| Name | Roger Steinkruger | Name |
| Title | Chief Executive Officer | Title |
| Phone | 3086971522 | Phone |
| Date Signed | 2014-02-27 | DateSigned |
| Authorize Third Party | 1 | AuthorizeThirdParty |
Preparer Preparer
| Field | Value | IRS element (for citing) |
|---|---|---|
| Name | Carmen Krantz | Name |
| PTIN | P00031958 | PTIN |
| Phone | 5635561790 | Phone |
| Date Prepared | 2014-02-27 | DatePrepared |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Tax Year | 2012 | TaxYear |
| Build TS | 2015-11-30 17:44:51Z | BuildTS |
Form 990 IRS990
Doing Business As DoingBusinessAs
| Field | Value | IRS element (for citing) |
|---|---|---|
| Business Name Line1 | Tri Valley Health System | BusinessNameLine1 |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Name Of Principal Officer Person | Roger Steinkruger | NameOfPrincipalOfficerPerson |
Address Principal Officer US AddressPrincipalOfficerUS
| Field | Value | IRS element (for citing) |
|---|---|---|
| Address Line1 | PO Box 488 | AddressLine1 |
| City | Cambridge | City |
| State | NE | State |
| ZIP Code | 69022 | ZIPCode |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Gross Receipts | 20472841 | GrossReceipts |
| Group Return For Affiliates | 0 | GroupReturnForAffiliates |
| Organization501c3 | X | Organization501c3 |
| Web Site | www.trivalleyhealth.com | WebSite |
| Type Of Organization Corporation | X | TypeOfOrganizationCorporation |
| Year Formation | 1955 | YearFormation |
| State Legal Domicile | NE | StateLegalDomicile |
| Activity Or Mission Description | Providing quality, compassionate, local healthcare services. | ActivityOrMissionDescription |
| Nbr Voting Members Governing Body | 9 | NbrVotingMembersGoverningBody |
| Nbr Independent Voting Members | 9 | NbrIndependentVotingMembers |
| Total Nbr Employees | 267 | TotalNbrEmployees |
| Total Nbr Volunteers | 259 | TotalNbrVolunteers |
| Total Gross UBI | 16340 | TotalGrossUBI |
| Net Unrelated Business Txbl Income | -430 | NetUnrelatedBusinessTxblIncome |
| Contributions Grants Prior Year | 876424 | ContributionsGrantsPriorYear |
| Contributions Grants Current Year | 286515 | ContributionsGrantsCurrentYear |
| Program Service Revenue Prior Year | 18045004 | ProgramServiceRevenuePriorYear |
| Program Service Revenue CY | 19810433 | ProgramServiceRevenueCY |
| Investment Income Prior Year | -178386 | InvestmentIncomePriorYear |
| Investment Income Current Year | 12885 | InvestmentIncomeCurrentYear |
| Other Revenue Prior Year | 172044 | OtherRevenuePriorYear |
| Other Revenue Current Year | 353617 | OtherRevenueCurrentYear |
| Total Revenue Prior Year | 18915086 | TotalRevenuePriorYear |
| Total Revenue Current Year | 20463450 | TotalRevenueCurrentYear |
| Grants And Similar Amnts Prior Year | 0 | GrantsAndSimilarAmntsPriorYear |
| Grants And Similar Amnts CY | 359 | GrantsAndSimilarAmntsCY |
| Benefits Paid To Members Prior Year | 0 | BenefitsPaidToMembersPriorYear |
| Benefits Paid To Members CY | 0 | BenefitsPaidToMembersCY |
| Salaries Etc Prior Year | 8930828 | SalariesEtcPriorYear |
| Salaries Etc Current Year | 9336217 | SalariesEtcCurrentYear |
| Total Prof Fundrsng Exp Prior Year | 0 | TotalProfFundrsngExpPriorYear |
| Total Prof Fundrsng Exp CY | 0 | TotalProfFundrsngExpCY |
| Total Fundrsng Exp Current Year | 0 | TotalFundrsngExpCurrentYear |
| Other Expense Prior Year | 10032507 | OtherExpensePriorYear |
| Other Expenses Current Year | 10811998 | OtherExpensesCurrentYear |
| Total Expenses Prior Year | 18963335 | TotalExpensesPriorYear |
| Total Expenses Current Year | 20148574 | TotalExpensesCurrentYear |
| Revenues Less Expenses Prior Year | -48249 | RevenuesLessExpensesPriorYear |
| Revenues Less Expenses CY | 314876 | RevenuesLessExpensesCY |
| Total Assets BOY | 32429469 | TotalAssetsBOY |
| Total Assets EOY | 32088363 | TotalAssetsEOY |
| Total Liabilities BOY | 21801304 | TotalLiabilitiesBOY |
| Total Liabilities EOY | 20787704 | TotalLiabilitiesEOY |
| Net Assets Or Fund Balances BOY | 10628165 | NetAssetsOrFundBalancesBOY |
| Net Assets Or Fund Balances EOY | 11300659 | NetAssetsOrFundBalancesEOY |
| Info In Schedule O Part III | X | InfoInScheduleOPartIII |
| Mission Description | To improve the lives we touch by providing care of the highest quality throughout life's journey. | MissionDescription |
| Significant New Program Services | 0 | SignificantNewProgramServices |
| Significant Change | 0 | SignificantChange |
| Expense | 13461135 | Expense |
| Grants | 359 | Grants |
| Revenue | 14375812 | Revenue |
| Description | 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 1,152 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 $31,000 for the year ended April 30, 2013. Total direct and indirect costs related to these foregone charges were approximately $20,000 at April 30, 2013, 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. | Description |
Activity2 Activity2
| Field | Value | IRS element (for citing) |
|---|---|---|
| Expense | 2379408 | Expense |
| Revenue | 3506446 | Revenue |
| Description | Tri Valley has rural health clinics in Arapahoe, Indianola, and Cambridge, Nebraska. During the year, the clinics had 14,954 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 $400 is reduced to a fee of approximately $35 (depending on tests requested). | Description |
Activity3 Activity3
| Field | Value | IRS element (for citing) |
|---|---|---|
| Expense | 1725461 | Expense |
| Revenue | 2281792 | Revenue |
| Description | 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 16 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. | Description |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Program Service Expense | 17566004 | TotalProgramServiceExpense |
| Described In501 C3 | 1 | DescribedIn501C3 |
| Schedule B Required | 1 | ScheduleBRequired |
| Political Activities | 0 | PoliticalActivities |
| Lobbying Activities | 0 | LobbyingActivities |
| Subject To Proxy Tax | 0 | SubjectToProxyTax |
| Donor Advised Funds | 0 | DonorAdvisedFunds |
| Conservation Easements | 0 | ConservationEasements |
| Collections Of Art | 0 | CollectionsOfArt |
| Credit Counseling | 0 | CreditCounseling |
| Term Or Permanent Endowments | 0 | TermOrPermanentEndowments |
| Report Land Bldg Equip | 1 | ReportLandBldgEquip |
| Report Invest Oth Securities | 1 | ReportInvestOthSecurities |
| Report Prog Rel Invest | 0 | ReportProgRelInvest |
| Report Other Assets | 0 | ReportOtherAssets |
| Report Other Liabilities | 1 | ReportOtherLiabilities |
| Report Fin48 Footnote | 1 | ReportFin48Footnote |
| Independent Audit Financial Stmt | 1 | IndependentAuditFinancialStmt |
| Consolidated Audit Financial Stmt | 0 | ConsolidatedAuditFinancialStmt |
| School | 0 | School |
| Foreign Office | 0 | ForeignOffice |
| Foreign Activities | 0 | ForeignActivities |
| More Than5000 K To Organizations | 0 | MoreThan5000KToOrganizations |
| More Than5000 K To Individuals | 0 | MoreThan5000KToIndividuals |
| Professional Fundraising | 0 | ProfessionalFundraising |
| Fundraising Activities | 0 | FundraisingActivities |
| Gaming | 0 | Gaming |
| Hospital | 1 | Hospital |
| Financial Stmt Attached | 1 | FinancialStmtAttached |
| Grants To Organizations | 0 | GrantsToOrganizations |
| Grants To Individuals | 0 | GrantsToIndividuals |
| Schedule J Required | 1 | ScheduleJRequired |
| Tax Exempt Bonds | 0 | TaxExemptBonds |
| Excess Benefit Transaction | 0 | ExcessBenefitTransaction |
| Prior Excess Benefit Transaction | 0 | PriorExcessBenefitTransaction |
| Loan To Officer Or DQP | 0 | LoanToOfficerOrDQP |
| Grant To Related Person | 0 | GrantToRelatedPerson |
| Bsnss Rltnshp With Organization | 0 | BsnssRltnshpWithOrganization |
| Bsnss Rltnshp Thru Family Member | 0 | BsnssRltnshpThruFamilyMember |
| Officer Entity With Bsnss Rltnshp | 0 | OfficerEntityWithBsnssRltnshp |
| Deductible Non Cash Contributions | 0 | DeductibleNonCashContributions |
| Deductible Contributions Of Art | 0 | DeductibleContributionsOfArt |
| Terminated | 0 | Terminated |
| Partial Liquidation | 0 | PartialLiquidation |
| Disregarded Entity | 0 | DisregardedEntity |
| Related Entity | 0 | RelatedEntity |
| Related Org Controlled Entity | 0 | RelatedOrgControlledEntity |
| Transfers To Exempt Non Chrtbl Org | 0 | TransfersToExemptNonChrtblOrg |
| Activities Conducted Partnership | 0 | ActivitiesConductedPartnership |
| Schedule O Required | 1 | ScheduleORequired |
| Number Forms Transmitted With1096 | 33 | NumberFormsTransmittedWith1096 |
| Number W2 G Included | 0 | NumberW2GIncluded |
| Compliance With Backup Witholding | 1 | ComplianceWithBackupWitholding |
| Number Of Employees | 267 | NumberOfEmployees |
| Employment Tax Returns Filed | 1 | EmploymentTaxReturnsFiled |
| Unrelated Business Income | 1 | UnrelatedBusinessIncome |
| Form990-T Filed | 1 | Form990-TFiled |
| Foreign Financial Account | 0 | ForeignFinancialAccount |
| Prohibited Tax Shelter Trans | 0 | ProhibitedTaxShelterTrans |
| Taxable Party Notification | 0 | TaxablePartyNotification |
| Non Deductible Contributions | 0 | NonDeductibleContributions |
| Quid Pro Quo Contributions | 0 | QuidProQuoContributions |
| Form8282 Property Disposed Of | 0 | Form8282PropertyDisposedOf |
| Funds To Pay Premiums | 0 | FundsToPayPremiums |
| Premiums Paid | 0 | PremiumsPaid |
| Indoor Tanning Services | 0 | IndoorTanningServices |
| Info In Schedule O Part VI | X | InfoInScheduleOPartVI |
| Nbr Voting Governing Body Members | 9 | NbrVotingGoverningBodyMembers |
| Number Independent Voting Members | 9 | NumberIndependentVotingMembers |
| Family Or Business Relationship | 1 | FamilyOrBusinessRelationship |
| Delegation Of Management Duties | 1 | DelegationOfManagementDuties |
| Changes To Organizing Docs | 1 | ChangesToOrganizingDocs |
| Material Diversion Or Misuse | 0 | MaterialDiversionOrMisuse |
| Members Or Stockholders | 1 | MembersOrStockholders |
| Election Of Board Members | 1 | ElectionOfBoardMembers |
| Decisions Subject To Approval | 0 | DecisionsSubjectToApproval |
| Minutes Of Governing Body | 1 | MinutesOfGoverningBody |
| Minutes Of Committees | 0 | MinutesOfCommittees |
| Officer Mailing Address | 0 | OfficerMailingAddress |
| Local Chapters | 0 | LocalChapters |
| Form990 Provided To Governing Body | 1 | Form990ProvidedToGoverningBody |
| Conflict Of Interest Policy | 1 | ConflictOfInterestPolicy |
| Annual Disclosure Covered Persons | 1 | AnnualDisclosureCoveredPersons |
| Regular Monitoring Enforcement | 1 | RegularMonitoringEnforcement |
| Whistleblower Policy | 1 | WhistleblowerPolicy |
| Document Retention Policy | 1 | DocumentRetentionPolicy |
| Compensation Process CEO | 1 | CompensationProcessCEO |
| Compensation Process Other | 0 | CompensationProcessOther |
| Investment In Joint Venture | 0 | InvestmentInJointVenture |
| Upon Request | X | UponRequest |
The Books Are In Care Of TheBooksAreInCareOf
Name Business NameBusiness
| Field | Value | IRS element (for citing) |
|---|---|---|
| Business Name Line1 | Diana Rippe | BusinessNameLine1 |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Telephone Number | 3086973329 | TelephoneNumber |
Address US AddressUS
| Field | Value | IRS element (for citing) |
|---|---|---|
| Address Line1 | PO Box 488 | AddressLine1 |
| City | Cambridge | City |
| State | NE | State |
| ZIP Code | 69022 | ZIPCode |
Form990 Part VII Section A Form990PartVIISectionA (16 entries)
| TitleTitle | Average Hours Per WeekAverageHoursPerWeek | Individual Trustee Or DirectorIndividualTrusteeOrDirector | OfficerOfficer | Reportable Comp From OrganizationReportableCompFromOrganization | Reportable Comp From Related OrgsReportableCompFromRelatedOrgs | Other CompensationOtherCompensation | Highest Compensated EmployeeHighestCompensatedEmployee |
|---|---|---|---|---|---|---|---|
| Patrick Horwart | |||||||
| President | 3.00 | X | X | 0 | 0 | 0 | |
| Randy Heitmann | |||||||
| 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 | 40.00 | X | 0 | 0 | 0 | ||
| Diana Rippe | |||||||
| CFO | 40.00 | X | 73211 | 0 | 19891 | ||
| Lennie Deaver MD | |||||||
| Provider | 40.00 | 254982 | 0 | 42761 | X | ||
| Rachelle Kaspar-Cope MD | |||||||
| Provider | 40.00 | 232868 | 0 | 34618 | X | ||
| Paul Shellabarger PA | |||||||
| Provider | 40.00 | 171103 | 0 | 29078 | X | ||
| Bill Duff | |||||||
| Pharmacist | 40.00 | 165136 | 0 | 37785 | X | ||
| Shiuvaun Jaeger MD | |||||||
| Provider | 40.00 | 250970 | 0 | 25630 | X | ||
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Reportable Comp From Org | 1148270 | TotalReportableCompFromOrg |
| Total Reportable Comp Frm Rltd Orgs | 0 | TotalReportableCompFrmRltdOrgs |
| Total Other Compensation | 189763 | TotalOtherCompensation |
| Number Individuals GT100 K | 8 | NumberIndividualsGT100K |
| Formers Listed | 0 | FormersListed |
| Total Comp GT150 K | 1 | TotalCompGT150K |
| Compensation From Other Sources | 0 | CompensationFromOtherSources |
Contractor Compensation ContractorCompensation (5 entries)
| Address Line1AddressOfContractor/AddressUS/AddressLine1 | CityAddressOfContractor/AddressUS/City | StateAddressOfContractor/AddressUS/State | ZIP CodeAddressOfContractor/AddressUS/ZIPCode | Description Of ServicesDescriptionOfServices | CompensationCompensation |
|---|---|---|---|---|---|
| Southwest Nebraska Physical Therapy | |||||
| PO Box 789 | McCook | NE | 690010789 | Physical therapy services | 1019866 |
| HealthTech Management Services Inc | |||||
| PO Box 636426 | Cincinnati | OH | 452636426 | Management services | 517293 |
| Healthcare Management Systems | |||||
| 2739 Momentum Place | Chicago | IL | 606895327 | Software and support | 184666 |
| Eide Bailly LLP | |||||
| PO Box 2545 | Fargo | ND | 581082545 | Accounting services | 135765 |
| Quality Urgent Care | |||||
| PO Box 788 | McCook | NE | 690010788 | Contract physician assistants | 135369 |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Number Of Contractors GT100 K | 9 | NumberOfContractorsGT100K |
| All Other Contributions | 286515 | AllOtherContributions |
| Total Contributions | 286515 | TotalContributions |
Program Service Revenue ProgramServiceRevenue (4 entries)
| DescriptionDescription | Business CodeBusinessCode | Total Revenue ColumnTotalRevenueColumn | Related Or Exempt Function IncomeRelatedOrExemptFunctionIncome | Unrelated Business RevenueUnrelatedBusinessRevenue |
|---|---|---|---|---|
| Patient & Resident revenue | 621300 | 19385973 | 19385973 | |
| Supporting revenue | 900099 | 369319 | 369319 | |
| Wellness & Rehab Ctr | 713940 | 38801 | 38801 | |
| Medical Spa | 812900 | 16340 | 16340 |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Program Service Revenue | 19810433 | TotalProgramServiceRevenue |
Investment Income InvestmentIncome
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Revenue Column | 20276 | TotalRevenueColumn |
| Exclusion | $20,276 | ExclusionAmount |
Gross Amount Sales Assets GrossAmountSalesAssets
| Field | Value | IRS element (for citing) |
|---|---|---|
| Other | 2000 | Other |
Less Cost Oth Basis Sales Expenses LessCostOthBasisSalesExpenses
| Field | Value | IRS element (for citing) |
|---|---|---|
| Other | 9391 | Other |
Gain Or Loss GainOrLoss
| Field | Value | IRS element (for citing) |
|---|---|---|
| Other | -7391 | Other |
Net Gain Or Loss Investments NetGainOrLossInvestments
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Revenue Column | -7391 | TotalRevenueColumn |
| Exclusion | -$7,391 | ExclusionAmount |
Other Revenue Misc OtherRevenueMisc
| Field | Value | IRS element (for citing) |
|---|---|---|
| Description | Insurance proceeds | Description |
| Business Code | 900099 | BusinessCode |
| Total Revenue Column | 353617 | TotalRevenueColumn |
| Related Or Exempt Function Income | 353617 | RelatedOrExemptFunctionIncome |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Other Revenue | 353617 | TotalOtherRevenue |
Total Revenue TotalRevenue
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Revenue Column | 20463450 | TotalRevenueColumn |
| Related Or Exempt Function Income | 20147710 | RelatedOrExemptFunctionIncome |
| Unrelated Business Revenue | 16340 | UnrelatedBusinessRevenue |
| Exclusion | $12,885 | ExclusionAmount |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Info In Schedule O Part IX | X | InfoInScheduleOPartIX |
Grants To Domestic Individuals GrantsToDomesticIndividuals
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | 359 | Total |
| Program Services | 359 | ProgramServices |
Comp Current Officers Directors CompCurrentOfficersDirectors
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | 93226 | Total |
| Management And General | 93226 | ManagementAndGeneral |
Other Salaries And Wages OtherSalariesAndWages
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | 7361307 | Total |
| Program Services | 6640409 | ProgramServices |
| Management And General | 720898 | ManagementAndGeneral |
Pension Plan Contributions PensionPlanContributions
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | 141563 | Total |
| Program Services | 119936 | ProgramServices |
| Management And General | 21627 | ManagementAndGeneral |
Other Employee Benefits OtherEmployeeBenefits
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | 1170947 | Total |
| Program Services | 1058534 | ProgramServices |
| Management And General | 112413 | ManagementAndGeneral |
Payroll Taxes PayrollTaxes
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | 569174 | Total |
| Program Services | 507991 | ProgramServices |
| Management And General | 61183 | ManagementAndGeneral |
Fees For Services Management FeesForServicesManagement
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | 479554 | Total |
| Management And General | 479554 | ManagementAndGeneral |
Fees For Services Legal FeesForServicesLegal
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | 90924 | Total |
| Management And General | 90924 | ManagementAndGeneral |
Fees For Services Accounting FeesForServicesAccounting
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | 54340 | Total |
| Management And General | 54340 | ManagementAndGeneral |
Fees For Services Other FeesForServicesOther
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | 2271049 | Total |
| Program Services | 2112093 | ProgramServices |
| Management And General | 158956 | ManagementAndGeneral |
Advertising Advertising
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | 205725 | Total |
| Management And General | 205725 | ManagementAndGeneral |
Office Expenses OfficeExpenses
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | 865907 | Total |
| Program Services | 617145 | ProgramServices |
| Management And General | 248762 | ManagementAndGeneral |
Occupancy Occupancy
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | 483429 | Total |
| Program Services | 475943 | ProgramServices |
| Management And General | 7486 | ManagementAndGeneral |
Travel Travel
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | 72791 | Total |
| Program Services | 60625 | ProgramServices |
| Management And General | 12166 | ManagementAndGeneral |
Conferences Meetings ConferencesMeetings
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | 31128 | Total |
| Program Services | 22381 | ProgramServices |
| Management And General | 8747 | ManagementAndGeneral |
Interest Interest
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | 1282387 | Total |
| Program Services | 1282387 | ProgramServices |
Depreciation Depletion DepreciationDepletion
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | 2215129 | Total |
| Program Services | 2215129 | ProgramServices |
Insurance Insurance
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | 270513 | Total |
| Program Services | 696 | ProgramServices |
| Management And General | 269817 | ManagementAndGeneral |
Other Expenses OtherExpenses (4 entries)
| DescriptionDescription | TotalTotal | Program ServicesProgramServices | Management And GeneralManagementAndGeneral |
|---|---|---|---|
| Patient care supplies | 1317040 | 1317040 | |
| Provision for bad debts | 862172 | 862172 | |
| Food costs | 268492 | 268492 | |
| Agency commission | 33889 | 33889 |
All Other Expenses AllOtherExpenses
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | 7529 | Total |
| Program Services | 4672 | ProgramServices |
| Management And General | 2857 | ManagementAndGeneral |
Total Functional Expenses TotalFunctionalExpenses
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | 20148574 | Total |
| Program Services | 17566004 | ProgramServices |
| Management And General | 2582570 | ManagementAndGeneral |
| Fundraising | 0 | Fundraising |
Savings And Temp Cash Investments SavingsAndTempCashInvestments
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | 702429 | BOY |
| EOY | 1047409 | EOY |
Accounts Receivable AccountsReceivable
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | 3138021 | BOY |
| EOY | 2996030 | EOY |
Inventories For Sale Or Use InventoriesForSaleOrUse
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | 347758 | BOY |
| EOY | 387603 | EOY |
Prepaid Expenses Deferred Charges PrepaidExpensesDeferredCharges
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | 618955 | BOY |
| EOY | 626249 | EOY |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Land Buildings Equipment Basis | 34100614 | LandBuildingsEquipmentBasis |
| Land Bldg Equipment Accum Deprec | 11697046 | LandBldgEquipmentAccumDeprec |
Land Buildings Equipment Basis Net LandBuildingsEquipmentBasisNet
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | 23113594 | BOY |
| EOY | 22403568 | EOY |
Investments Pub Traded Securities InvestmentsPubTradedSecurities
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | 1994142 | BOY |
| EOY | 2076114 | EOY |
Investments Other Securities InvestmentsOtherSecurities
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | 2239570 | BOY |
| EOY | 2485659 | EOY |
Investments Program Related InvestmentsProgramRelated
| Field | Value | IRS element (for citing) |
|---|---|---|
| EOY | 6935 | EOY |
Other Assets Total OtherAssetsTotal
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | 275000 | BOY |
| EOY | 58796 | EOY |
Total Assets TotalAssets
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | 32429469 | BOY |
| EOY | 32088363 | EOY |
Accounts Payable Accrued Expenses AccountsPayableAccruedExpenses
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | 2327454 | BOY |
| EOY | 1671301 | EOY |
Deferred Revenue DeferredRevenue
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | 353617 | BOY |
Mort Notes Pybl Secured Invest Prop MortNotesPyblSecuredInvestProp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | 19120233 | BOY |
| EOY | 18638403 | EOY |
Other Liabilities OtherLiabilities
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | 0 | BOY |
| EOY | 478000 | EOY |
Total Liabilities TotalLiabilities
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | 21801304 | BOY |
| EOY | 20787704 | EOY |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Follow SFAS117 | X | FollowSFAS117 |
Unrestricted Net Assets UnrestrictedNetAssets
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | 8387526 | BOY |
| EOY | 8814289 | EOY |
Temporarily Restricted Net Assets TemporarilyRestrictedNetAssets
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | 1346296 | BOY |
| EOY | 1592027 | EOY |
Permanently Restricted Net Assets PermanentlyRestrictedNetAssets
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | 894343 | BOY |
| EOY | 894343 | EOY |
Total Net Assets Fund Balances TotalNetAssetsFundBalances
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | 10628165 | BOY |
| EOY | 11300659 | EOY |
Total Liab Net Assets Fund Balances TotalLiabNetAssetsFundBalances
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | 32429469 | BOY |
| EOY | 32088363 | EOY |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Info In Schedule O Part XI | X | InfoInScheduleOPartXI |
| Reconcilation Revenue Expenses | 314876 | ReconcilationRevenueExpenses |
| Reconciliation Unrealized Invest | 111529 | ReconciliationUnrealizedInvest |
| Reconcilation Other Changes | 246089 | ReconcilationOtherChanges |
| Info In Schedule O Part XII | X | InfoInScheduleOPartXII |
| Method Of Accounting Accrual | X | MethodOfAccountingAccrual |
| Accountant Compile Or Review | 0 | AccountantCompileOrReview |
| FS Audited | 1 | FSAudited |
FS Audited Basis FSAuditedBasis
| Field | Value | IRS element (for citing) |
|---|---|---|
| Financial Statement Separate | X | FinancialStatementSeparate |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Audit Committee | 0 | AuditCommittee |
| Federal Grant Audit Required | 0 | FederalGrantAuditRequired |
Schedule A IRS990ScheduleA
| Field | Value | IRS element (for citing) |
|---|---|---|
| Hospital170b1 Aiii | X | Hospital170b1Aiii |
Schedule B IRS990ScheduleB
Contributor Info ContributorInfo
| Field | Value | IRS element (for citing) |
|---|---|---|
| Contributor Number | RESTRICTED | ContributorNumber |
Contributor Name Business ContributorNameBusiness
| Field | Value | IRS element (for citing) |
|---|---|---|
| Business Name Line1 | RESTRICTED | BusinessNameLine1 |
Contributor Address US ContributorAddressUS
| Field | Value | IRS element (for citing) |
|---|---|---|
| Address Line1 | RESTRICTED | AddressLine1 |
| Address Line2 | RESTRICTED | AddressLine2 |
| City | RESTRICTED | City |
| State | RESTRICTED | State |
| ZIP Code | RESTRICTED | ZIPCode |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Aggregate Contributions | RESTRICTED | AggregateContributions |
Schedule D IRS990ScheduleD
Land Land
| Field | Value | IRS element (for citing) |
|---|---|---|
| Other Cost Or Other Basis | 113289 | OtherCostOrOtherBasis |
| Book Value | 113289 | BookValue |
Buildings Buildings
| Field | Value | IRS element (for citing) |
|---|---|---|
| Other Cost Or Other Basis | 21701853 | OtherCostOrOtherBasis |
| Depreciation | 5890476 | Depreciation |
| Book Value | 15811377 | BookValue |
Equipment Equipment
| Field | Value | IRS element (for citing) |
|---|---|---|
| Other Cost Or Other Basis | 9869674 | OtherCostOrOtherBasis |
| Depreciation | 5367433 | Depreciation |
| Book Value | 4502241 | BookValue |
Other Land Buildings OtherLandBuildings
| Field | Value | IRS element (for citing) |
|---|---|---|
| Other Cost Or Other Basis | 2415798 | OtherCostOrOtherBasis |
| Depreciation | 439137 | Depreciation |
| Book Value | 1976661 | BookValue |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Of Book Value Land Buildings | 22403568 | TotalOfBookValueLandBuildings |
Other Securities OtherSecurities
| Field | Value | IRS element (for citing) |
|---|---|---|
| Description | Interest in Tri Valley Medical Foundation | Description |
| Book Value | 2485659 | BookValue |
| Method Of Valuation | F | MethodOfValuation |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Of Book Value Securities | 2485659 | TotalOfBookValueSecurities |
Other Liabilities OtherLiabilities
| Field | Value | IRS element (for citing) |
|---|---|---|
| Description | Estimated third-party payor settlements | Description |
| Amount | $478,000 | Amount |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Of Amounts | 478000 | TotalOfAmounts |
| Footnote In Part XIII | X | FootnoteInPartXIII |
| Tot Revenue Etc Audited Fincl Stmt | 19564762 | TotRevenueEtcAuditedFinclStmt |
| Other Revenues | -862172 | OtherRevenues |
| Revenue Not Rptd F990 | -862172 | RevenueNotRptdF990 |
| Revenue Subtotal | 20426934 | RevenueSubtotal |
| Other Revenues Not Included | 36516 | OtherRevenuesNotIncluded |
| Revenue Not Rptd On Fin Stmt | 36516 | RevenueNotRptdOnFinStmt |
| Total Revenue Per Form990 | 20463450 | TotalRevenuePerForm990 |
| Tot Expenses Etc Audited Fincl Stmt | 19286043 | TotExpensesEtcAuditedFinclStmt |
| Expenses Not Rptd F990 | 0 | ExpensesNotRptdF990 |
| Expenses Subtotal | 19286043 | ExpensesSubtotal |
| Other Expenses Not Included | 862531 | OtherExpensesNotIncluded |
| Expenses Not Rptd On Fin Stmt | 862531 | ExpensesNotRptdOnFinStmt |
| Total Expenses Per Form990 | 20148574 | TotalExpensesPerForm990 |
Form990 Schedule D Part XIII Form990ScheduleDPartXIII (4 entries)
| IdentifierIdentifier | Return ReferenceReturnReference | ExplanationExplanation |
|---|---|---|
| Description of Uncertain Tax Positions Under FIN 48: | 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 2009. |
| Part XI, Line 2d - Other Adjustments: | Provision for bad debts included in revenue for financial statements -862,172. | |
| Part XI, Line 4b - Other Adjustments: | Contributions for long-lived assets incl in fund balance for financial stmts 36,515. 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 862,172. Scholarships recorded in fund balance for financial statements 359. |
Schedule H IRS990ScheduleH
| Field | Value | IRS element (for citing) |
|---|---|---|
| Charity Care Policy | 1 | CharityCarePolicy |
| Written Policy | 1 | WrittenPolicy |
| Policy Applied To All Hospitals | X | PolicyAppliedToAllHospitals |
| FPG Reference Free Care | 1 | FPGReferenceFreeCare |
| Pcent100 | X | Pcent100 |
| FPG Reference Discounted Care | 1 | FPGReferenceDiscountedCare |
| Pcent200 D | X | Pcent200D |
| Free Disc Care Medically Indigent | 0 | FreeDiscCareMedicallyIndigent |
| Amounts Budgeted For Charity Care | 1 | AmountsBudgetedForCharityCare |
| Expenses Exceeded Budget | 0 | ExpensesExceededBudget |
| Annual Community Benefit Report | 0 | AnnualCommunityBenefitReport |
Charity Care At Cost CharityCareAtCost
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Community Benefit Expense | 20000 | TotalCommunityBenefitExpense |
| Net Community Benefit Expense | 20000 | NetCommunityBenefitExpense |
| Percent Of Total Expense | 0.00100 | PercentOfTotalExpense |
Unreimbursed Medicaid UnreimbursedMedicaid
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Community Benefit Expense | 855279 | TotalCommunityBenefitExpense |
| Direct Offsetting Revenue | 706760 | DirectOffsettingRevenue |
| Net Community Benefit Expense | 148519 | NetCommunityBenefitExpense |
| Percent Of Total Expense | 0.00770 | PercentOfTotalExpense |
Total Charity Care TotalCharityCare
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Community Benefit Expense | 875279 | TotalCommunityBenefitExpense |
| Direct Offsetting Revenue | 706760 | DirectOffsettingRevenue |
| Net Community Benefit Expense | 168519 | NetCommunityBenefitExpense |
| Percent Of Total Expense | 0.00870 | PercentOfTotalExpense |
Community Health Services CommunityHealthServices
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Community Benefit Expense | 4100 | TotalCommunityBenefitExpense |
| Net Community Benefit Expense | 4100 | NetCommunityBenefitExpense |
| Percent Of Total Expense | 0.00020 | PercentOfTotalExpense |
Subsidized Health Services SubsidizedHealthServices
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Community Benefit Expense | 3498642 | TotalCommunityBenefitExpense |
| Direct Offsetting Revenue | 2624028 | DirectOffsettingRevenue |
| Net Community Benefit Expense | 874614 | NetCommunityBenefitExpense |
| Percent Of Total Expense | 0.04530 | PercentOfTotalExpense |
Total Other Benefits TotalOtherBenefits
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Community Benefit Expense | 3502742 | TotalCommunityBenefitExpense |
| Direct Offsetting Revenue | 2624028 | DirectOffsettingRevenue |
| Net Community Benefit Expense | 878714 | NetCommunityBenefitExpense |
| Percent Of Total Expense | 0.04550 | PercentOfTotalExpense |
Total Community Benefits TotalCommunityBenefits
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Community Benefit Expense | 4378021 | TotalCommunityBenefitExpense |
| Direct Offsetting Revenue | 3330788 | DirectOffsettingRevenue |
| Net Community Benefit Expense | 1047233 | NetCommunityBenefitExpense |
| Percent Of Total Expense | 0.05420 | PercentOfTotalExpense |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Bad Debt Expense Reported | 0 | BadDebtExpenseReported |
| Bad Debt Expense | $862,172 | BadDebtExpenseAmount |
| Amount Attributable To | 148293 | AmountAttributableTo |
| Amount Reimbursed By Medicare | 6588673 | AmountReimbursedByMedicare |
| Cost Of Care Reimbursed By Medicare | 6530045 | CostOfCareReimbursedByMedicare |
| Medicare Surplus Or Shortfall | 58628 | MedicareSurplusOrShortfall |
Costing Methodology Used CostingMethodologyUsed
| Field | Value | IRS element (for citing) |
|---|---|---|
| Other | X | Other |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Written Debt Collection Policy | 1 | WrittenDebtCollectionPolicy |
| Provision For Charity Care | 1 | ProvisionForCharityCare |
| Number Of Hospital Facilities | 1 | NumberOfHospitalFacilities |
Form990 Schedule H Part V Section A Form990ScheduleHPartVSectionA
| Field | Value | IRS element (for citing) |
|---|---|---|
| Facility Number | 1 | FacilityNumber |
Name Name
| Field | Value | IRS element (for citing) |
|---|---|---|
| Business Name Line1 | Cambridge Memorial Hospital dba Tri | BusinessNameLine1 |
Address Address
| Field | Value | IRS element (for citing) |
|---|---|---|
| Address Line1 | Valley Health System 1305 W Hwy 6 | AddressLine1 |
| Address Line2 | 34 | AddressLine2 |
| City | Cambridge | City |
| State | NE | State |
| ZIP Code | 69022 | ZIPCode |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Website Address | www.trivalleyhealth.com | WebsiteAddress |
| Licensed Hospital | X | LicensedHospital |
| General Medical And Surgical | X | GeneralMedicalAndSurgical |
| Critical Access Hospital | X | CriticalAccessHospital |
| Er24 Hours | X | Er24Hours |
| Other | 3 provider based rural health clinics | Other |
Form990 Schedule H Part V Section B Form990ScheduleHPartVSectionB
Hospital Facility Name HospitalFacilityName
| Field | Value | IRS element (for citing) |
|---|---|---|
| Business Name Line1 | Cambridge Memorial Hospital Inc | BusinessNameLine1 |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Hospital Facility Number | 1 | HospitalFacilityNumber |
| CHNA Conducted | 1 | CHNAConducted |
| Community Definition | X | CommunityDefinition |
| Community Demographics | X | CommunityDemographics |
| Existing Resources | X | ExistingResources |
| How Data Obtained | X | HowDataObtained |
| Community Health Needs | X | CommunityHealthNeeds |
| Other Health Issues | X | OtherHealthIssues |
| Identifying Process | X | IdentifyingProcess |
| Consulting Process | X | ConsultingProcess |
| Information Gaps | X | InformationGaps |
| Needs Assessment Conducted | 12 | NeedsAssessmentConducted |
| Take Into Account | 1 | TakeIntoAccount |
| Other Facilities | 0 | OtherFacilities |
| CHNA Widely Available | 1 | CHNAWidelyAvailable |
| Own Website | X | OwnWebsite |
| On Request | X | OnRequest |
| Other Method | X | OtherMethod |
| Adopt Implement Strategy | X | AdoptImplementStrategy |
| Execute Implement Strategy | X | ExecuteImplementStrategy |
| Prioritize Health Needs | X | PrioritizeHealthNeeds |
| Prioritize Services | X | PrioritizeServices |
| Other Needs Addressed | X | OtherNeedsAddressed |
| All Needs Addressed | 0 | AllNeedsAddressed |
| Organization Incur Excise Tax | 0 | OrganizationIncurExciseTax |
| Eligibility Criteria Explained | 1 | EligibilityCriteriaExplained |
| Uses FPG Free | 1 | UsesFPGFree |
| FPG Free Percent | 100.000000000000 | FPGFreePercent |
| Uses FPG Discounted | 1 | UsesFPGDiscounted |
| FPG Discount Percent | 200.000000000000 | FPGDiscountPercent |
| Explains Basis | 1 | ExplainsBasis |
| Income Level | X | IncomeLevel |
| Asset Level | X | AssetLevel |
| Explains Application Method | 1 | ExplainsApplicationMethod |
| Includes Publicity Measures | 1 | IncludesPublicityMeasures |
| Posted On Website | X | PostedOnWebsite |
| Available On Request | X | AvailableOnRequest |
| Other Publicity | X | OtherPublicity |
| Actions On Nonpayment | 1 | ActionsOnNonpayment |
| Collection Activities | 0 | CollectionActivities |
| Notify Upon Admission | X | NotifyUponAdmission |
| Notified All Patients | X | NotifiedAllPatients |
| Documented Determination | X | DocumentedDetermination |
| Other Actions Taken | X | OtherActionsTaken |
| Nondiscrim Emergency Care Policy | 1 | NondiscrimEmergencyCarePolicy |
| Used Other Method | X | UsedOtherMethod |
| Amounts Generally Billed | 0 | AmountsGenerallyBilled |
| Gross Charges | 0 | GrossCharges |
Form990 Schedule H Part V Section C Form990ScheduleHPartVSectionC
| Field | Value | IRS element (for citing) |
|---|---|---|
| Number Of Other Facilities | 2 | NumberOfOtherFacilities |
Other Facilities OtherFacilities (2 entries)
| Address Line1Address/AddressLine1 | CityAddress/City | StateAddress/State | ZIP CodeAddress/ZIPCode | Facility TypeFacilityType |
|---|---|---|---|---|
| Heritage Plaza | ||||
| 1205 Nelson Street | Cambridge | NE | 69022 | Independent living |
| Tri Valley Health System Assisted Living | ||||
| 711 Mousel Ave | Cambridge | NE | 69022 | Assisted living |
Form990 Schedule H Part VI Form990ScheduleHPartVI (16 entries)
| ExplanationExplanation | IdentifierIdentifier |
|---|---|
| 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. Community health improvement services reported on line 7e are actual expenses recorded from the events. The cost for subsidized health services reported on line 7g was determined using the Medicare Cost Report. | |
| Part I, L7 Col(f): The amount of bad debt expense removed from total expenses to determine the percetage was $862,172. | |
| Part III, Line 4: 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.In Furnas County, Nebraska, the percentage of residents that are at or below poverty level is 17.2%. 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 $862,172. We can assume that 17.2%, or $148,293, of this bad debt was attributable to patients who were eligible for the charity care program.The footnote to the Organization's financial statements can be found on page 8 of the attached audited financial statements. | |
| Part III, Line 8: 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 extraoradinary 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 V, Section B, Line 3: 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 5c: The community health needs assessment can be accessed at www.trivalleyhealth.com. | Cambridge Memorial Hospital, Inc. |
| Part V, Section B, Line 6i: Tri Valley Health System has 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.trivalleyhealth.com. | Cambridge Memorial Hospital, Inc. |
| Part V, Section B, Line 7: Based on the health needs identified in the review of health data, Community Advisory Committee feedback and survey results, a list of 16 potential community needs was developed.The Community Advisory Committee members agreed on a set of criteria to use to evaluate the list of potential needs identified through the fact finding process. The criteria included: Potential to Impact Community Health; Cost to the Community; and Community Urgency. The Community Advisory Committee discussed each of the 16 identified health issues in terms of whether it truly was an issue, the potential health improvement impact, cost and urgency. Committee members then determined a number of the potential issues to be eliminated from the listing and determined a number of the items could be combined into broader categories. The Community Advisory Committee members then each identified ten of the issues they felt had the highest community priority. This process involved casual group discussion as committee members placed their priority votes on the items, allowing for individuals to make decisions with input from their fellow committee members. Binge drinking and motor vehicle crash rates were not included as potential health needs to address in the community. | Cambridge Memorial Hospital, Inc. |
| Part V, Section B, Line 14g: 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 18e: 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. | Cambridge Memorial Hospital, Inc. |
| Part V, Section B, Line 20d: The maximum amount charged to a patient under the financial assistance policy for emergency and medically necessary care is 75% of the gross charges. This is based on the lowest discount under the charity care policy of 25%. This is more than our lowest negotiated commercial rate or an average negotiated rate. | Cambridge Memorial Hospital, Inc. |
| 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.Based on the health needs identified in the review of health data, Community Advisory Committee feedback and survey results, a list of 16 potential community needs was developed. These included obesity/lack of physical fitness, diabetes, binge drinking, motor vehicle crash rates, cost of healthcare, cancer services, elderly transportation services, wellness programs and preventative care education, attracting and retaining quality physicians, mental health services, access to specialty care services, improvements to long term care facility, nursing shortages, improvements to physical therapy facility in Arapahoe, need for Urgent Care, and uninsured/underinsured access to care. The Community Advisory Committee discussed each of the 16 identified health issues in terms of whether it truly was an issue, the potential health improvement impact, cost and urgency. Committee members then determined a number of the potential issues to be eliminated from the listing and determined a number of the items could be combined into broader categories. The Community Advisory Committee members then each identified ten of the issues they felt had the highest community priority. This process involved casual group discussion as committee members placed their priority votes on the items, allowing for individuals to make decisions with input from their fellow committee members. The members then further ranked the top eight needs in order to determine a priority ranking based on all factors considered. | |
| 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 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.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 is $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 2012 range from 2.3% (Gosper), 2.5% (Frontier), 3.1% (Red Willow) to 3.3% (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 March 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. The Hospital opens its doors to the community to use conference areas for groups such as Alcohol Anonymous, ministerial associations 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. 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. |
Schedule J IRS990ScheduleJ
| Field | Value | IRS element (for citing) |
|---|---|---|
| Travel For Companions | X | TravelForCompanions |
| Club Dues Or Fees | X | ClubDuesOrFees |
| Written Policy Re T And E Expenses | 1 | WrittenPolicyReTAndEExpenses |
| Substantiation Required | 1 | SubstantiationRequired |
| Severance Payment | 0 | SeverancePayment |
| Supplemental Nonqual Retire Plan | 0 | SupplementalNonqualRetirePlan |
| Equity Based Comp Arrangement | 0 | EquityBasedCompArrangement |
| Comp Based On Revenue Of Filing Org | 1 | CompBasedOnRevenueOfFilingOrg |
| Comp Based On Revenue Related Orgs | 0 | CompBasedOnRevenueRelatedOrgs |
| Comp Based Net Earnings Filing Org | 0 | CompBasedNetEarningsFilingOrg |
| Comp Based Net Earnings Relate Orgs | 0 | CompBasedNetEarningsRelateOrgs |
| Any Non Fixed Payments | 0 | AnyNonFixedPayments |
| Initial Contract Exception | 0 | InitialContractException |
Form990 Schedule J Part II Form990ScheduleJPartII (5 entries)
| TitleTitle | Base Compensation Filing OrgBaseCompensationFilingOrg | Comp Based On Related OrgsCompBasedOnRelatedOrgs | Bonus Filing OrgBonusFilingOrg | Bonus Related OrgsBonusRelatedOrgs | Other Compensation Filing OrgOtherCompensationFilingOrg | Other Compensation Related OrgsOtherCompensationRelatedOrgs | Deferred Comp Filing OrgDeferredCompFilingOrg | Deferred Comp Related OrgsDeferredCompRelatedOrgs | Nontaxable Benefits Filing OrgNontaxableBenefitsFilingOrg | Nontaxable Benefits Related OrgsNontaxableBenefitsRelatedOrgs | Total Compensation Filing OrgTotalCompensationFilingOrg | Total Compensation Related OrgsTotalCompensationRelatedOrgs | Comp Report Prior990 Filing OrgCompReportPrior990FilingOrg | Comp Report Prior990 Related OrgsCompReportPrior990RelatedOrgs |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Lennie Deaver MD | ||||||||||||||
| Provider | 187366 | 0 | 66906 | 0 | 710 | 0 | 13702 | 0 | 29654 | 0 | 298338 | 0 | 0 | 0 |
| Rachelle Kaspar-Cope MD | ||||||||||||||
| Provider | 183424 | 0 | 48465 | 0 | 979 | 0 | 9115 | 0 | 26066 | 0 | 268049 | 0 | 0 | 0 |
| Paul Shellabarger PA | ||||||||||||||
| Provider | 90535 | 0 | 79745 | 0 | 823 | 0 | 8437 | 0 | 21165 | 0 | 200705 | 0 | 0 | 0 |
| Bill Duff | ||||||||||||||
| Pharmacist | 164154 | 0 | 0 | 0 | 982 | 0 | 8320 | 0 | 29722 | 0 | 203178 | 0 | 0 | 0 |
| Shiuvaun Jaeger MD | ||||||||||||||
| Provider | 176382 | 0 | 73562 | 0 | 1026 | 0 | 586 | 0 | 25563 | 0 | 277119 | 0 | 0 | 0 |
Form990 Schedule J Part III Form990ScheduleJPartIII (3 entries)
| Return ReferenceReturnReference | ExplanationExplanation | IdentifierIdentifier |
|---|---|---|
| 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. | |
| Part III | 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. | Supplemental Information |
Schedule O IRS990ScheduleO
General Explanation GeneralExplanation (13 entries)
| Return ReferenceReturnReference | ExplanationExplanation | IdentifierIdentifier |
|---|---|---|
| Form 990, Part VI, Section A, line 2 | Randy Heitmann and Bill Minnick serve together as board members of a separate organization. | |
| Form 990, Part VI, Section A, line 3 | Roger Steinkruger, CEO, is employed by HealthTech Management Services, Inc., an unrelated management company. Roger is considered a common law employee of HealthTech Management Services, Inc. and was compensated $165,000 for supervising the management, administration and operation of Tri Valley Health System. | |
| Form 990, Part VI, Section A, line 4 | Authority was given to the Chief Executive Officer to sign official documents on behalf of the Corporation related to the Medicare and Medicaid programs and other third party payors, including provider enrollment documents. The Board of Directors was able to designate committees to function as Peer Review Committees to perform Peer Review functions. The Bylaws now state the Board of Directors act as a peer review committee as that term is used in the Nebraska Health Care Quality Improvement Act whenever the Board receives or acts on peer review information. | |
| 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 417,188. Management and general expenses 69,533. Fundraising expenses 0. Total expenses 486,721. Purchased services: Program service expenses 1,294,562. Management and general expenses 0. Fundraising expenses 0. Total expenses 1,294,562. Maintenance and repair: Program service expenses 400,343. Management and general expenses 89,423. Fundraising expenses 0. Total expenses 489,766. | Other Fees |
| Form 990, Part XI, line 9: | Change in interest in net assets of Tri Valley Medical Foundation 246,089. | Changes in Net Assets or Fund Balances: |
| Form 990, Part XII, Line 2c: | The Board of Trustees assumes responsibility for oversight of the audit and selection of an independent accountant. |
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