2013-03-14T14:32:48-05:00 2012-04-30 450250958 EIDE BAILLY LLP 3999 PENNSYLVANIA AVE SUITE 100 DUBUQUE IA 52002 990 2011-05-01 476028103 Cambridge Memorial Hospital Inc CAMB 3086971522 PO Box 488 Cambridge NE 69022 Roger Steinkruger 3086971522 2013-03-13 1 Carmen Krantz P00031958 5635561790 2013-03-13 2011 2016-02-25 16:41:14Z Tri Valley Health System Roger Steinkruger PO Box 488 Cambridge NE 69022 19117242 0 X www.trivalleyhealth.com X 1955 NE Providing quality, compassionate, local healthcare services. 9 9 242 212 13134 -7234 255075 876424 15738073 18045004 27955 -178386 0 172044 16021103 18915086 0 0 0 0 8585467 8930828 0 0 0 8072546 10032507 16658013 18963335 -636910 -48249 33930433 32429469 22632440 21801304 11297993 10628165 X To improve the lives we touch by providing care of the highest quality throughout life's journey. 0 0 12596516 12537483 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 1,084 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 for 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 $17,017 for the year ended April 30, 2012. Total direct and indirect costs related to these foregone charges were approximately $12,000 at April 30, 2012, based on an average ratio of cost to gross charges.In addition, the Health System provides services to other medically indigent 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. 2200719 3521164 Tri Valley has rural health clinics in Arapahoe, Indianola, and Cambridge, Nebraska. During the year, the clinics had 14,954 visits. The employed physician's 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). 1780197 2158401 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 and because of the high utilization and by request. 16577432 1 1 0 0 0 0 0 0 0 0 1 1 0 0 0 1 1 0 0 0 0 0 0 0 0 0 1 1 0 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 29 0 1 242 1 1 1 0 0 0 0 0 0 0 0 0 X 9 9 1 1 0 0 1 1 0 1 0 0 0 1 1 1 1 1 1 1 0 0 X Diana Rippe 3086973329 PO Box 488 Cambridge NE 69022 Randy Heitmann 3.00 X X 0 0 0 Cathy Kubik 3.00 X X 0 0 0 Patrick Horwart 3.00 X X 0 0 0 Troy Westadt 3.00 X X 0 0 0 Eric Eisenhart 3.00 X 0 0 0 Clark Andrews 3.00 X 0 0 0 Reginald Warner 3.00 X 0 0 0 Bill Minnick 3.00 X 0 0 0 Kristy Witte 3.00 X 0 0 0 Roger Steinkruger 40.00 X 0 0 0 Diana Rippe 40.00 X 68818 0 19367 Lennie Deaver MD 40.00 X 263248 0 30207 Rachelle Kaspar-Cope MD 40.00 X 216503 0 25999 Paul Shellabarger PA 40.00 X 178138 0 20392 Bill Duff 40.00 X 164851 0 26378 William Malchow PA 40.00 X 111436 0 27061 1002994 0 149404 5 0 1 0 Southwest Nebraska Physical Therapy PO Box 789 McCook NE 690010789 Physical Therapy 716342 Neenan Company LLP 2620 East Prospect Fort Collins CO 80525 Construction 454054 HealthTech Management Services Inc PO Box 636426 Cincinnati OH 452636426 Management services 202719 Connie Hill CRNA 72195 Cross Creek Rd Cambridge NE 69022 Anesthesia 151170 Josh Hill CRNA 404 Prairie Ridge Rd McCook NE 69001 Anesthesia 150620 5 8631 867793 876424 Patient & Resident rev 621300 17791488 17791488 Supporting revenue 900099 201896 201896 Wellness and Rehab Cen 713940 38486 38486 Medical Spa 812900 13134 13134 18045004 23770 23770 202156 -202156 -202156 -202156 Insurance proceeds 900099 172044 172044 172044 18915086 18203914 13134 -178386 80227 80227 6865532 6188056 677476 207929 188321 19608 1239189 1143202 95987 537951 480219 57732 462843 462843 95455 95455 68152 68152 2258730 2122144 136586 214450 214450 306022 128219 177803 483911 476232 7679 60920 43254 17666 47174 32862 14312 1429106 1429106 2175622 2175622 193875 193875 Patient care supplies 1501337 1501337 Provision for bad debts 547376 547376 Agency commission 33765 33765 153769 121482 32287 18963335 16577432 2385903 0 73164 702429 2637896 3138021 317149 347758 750767 618955 32698942 9585348 24897210 23113594 2108020 1994142 2870227 2239570 276000 275000 33930433 32429469 1960569 2327454 353617 20671871 19120233 22632440 21801304 X 8426701 8387526 1976949 1346296 894343 894343 11297993 10628165 33930433 32429469 X -48249 -621579 X X 0 1 0 X 0 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 113289 113289 21340788 4727748 16613040 8820029 4579608 4240421 2424836 277992 2146844 23113594 Interest in Tri Valley Medical Foundation 2239570 F 2239570 18915086 18963335 -48249 9078 -630657 -621579 -669828 18538658 0 18538658 376428 376428 18915086 18963335 0 18963335 0 18963335 Description of Uncertain Tax Positions Under FIN 48: Part X: 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 liabilities in income tax expense, if such interest and penalties are incurred. Part XI, Line 8 - Other Adjustments: Change in interest in net assets of Tri Valley Medical Foundation -630,657. Part XII, Line 4b - Other Adjustments: Contributions for long-lived assets incl in fund balance for financial stmts 376,424. Investment income included in fund balance for financial statements 4. 1 1 X 1 X 1 X 0 1 0 0 12000 12000 0.00070 1063769 1060407 3362 0.00020 1075769 1060407 15362 0.00090 16651 60 16591 0.00090 1976912 1159570 817342 0.04440 1993563 1159630 833933 0.04530 3069332 2220037 849295 0.04620 0 547376 94149 6480883 6437473 43410 X 1 1 1 1 Cambridge Memorial Hospital dba Tri

Valley Health System 1305 W Hwy 6 34 Cambridge NE 69022

X X X X 3 provider based rural health clinics Cambridge Memorial Hospital Inc 1 0 1 1 100.000000000000 1 200.000000000000 1 X 1 1 X X 1 0 1 X 1 1 2 Heritage Plaza

1205 Nelson Street Cambridge NE 69022

Independent living Tri Valley Health System Assisted Living

711 Mousel Ave Cambridge NE 69022

Assisted living Part I, Line 7: Charity care expense was converted to cost on line 7a based on an overall cost to charge ratio addressing all patient segments. Unreimbursed Medicaid on line 7b was calculated using the costing methods to prepare the cost reports. The cost for subsidized health services reported on line 7g was determined using the Medicare Cost Report. Part I, L7 Col(f): The amount of bad debt expense removed from the denominator is $547,376. Part III, Line 4: Financial Statement Bad Debt Expense Footnote:The carrying amount of patient and resident receivables is reduced by a valuation allowance that reflects management's estimate of amounts that will not be collected from patients, residents, and third-party payors. Management reviews patient and resident receivables by payor class and applies percentages to determine estimated amounts that will not be collected from third parties under contractual agreements and amounts that will not be collected from patients and residents due to bad debts. Management considers historical write off and recovery information in determining the estimated bad debt provision.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 $547,376. We can assume that 17.2%, or $94,149, of this bad debt was attributable to patients who were eligible for the charity care program. 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 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). Cambridge Memorial Hospital, Inc. Part V, Section B, Line 13g: Information on eligibility for available assistance programs is usually communicated on an individual basis. Social Services contacts patient accounting staff about any other individuals in need of our Charity Care Program. We have financial brochures available for all patients. The same financial brochure information is posted on our website, and 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. Cambridge Memorial Hospital, Inc. Part V, Section B, Line 19d: At a minimum an eligible individual would be given a 25% discount off billed charges and a 100% maximum discount. This is more than our lowest negotiated commercial rate or an average negotiated rate. The Hospital is currently reviewing the "Look Back Method" and "Prospective Medicare Method." One of these methods will be used to reduce gross charges and be in compliance with the 501(r) requirements. Cambridge Memorial Hospital, Inc. Part V, Section B, Line 20: The Hospital did not reduce gross charges by one of the approved methods. The discount was applied directly to gross charges, therefore some patients may have been charged more than the amounts generally billed to individuals who had insurance covering such care. Cambridge Memorial Hospital, Inc. Part V, Section B, Line 21: The Hospital did not reduce gross charges by one of the approved methods. The discount was applied directly to gross charges, therefore patients were charged gross charges for services provided. Part VI, Line 2: Tri Valley Health System is currently completing a community health needs assessment with anticipated completion date before 04/30/13. The completed community health needs assessment will be made available on our website. Part VI, Line 3: Information on eligibility for available assistance programs is usually communicated on an individual basis. 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 have financial brochures available for all patients. The same financial brochure information is posted on our website, and 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 primary service area is in Furnas County, Nebraska, consisting of 719 square miles. The county population in 2011 was 4,957. 22.6% of the population is over 65 years old. The most common occupations are farmers and agricultural workers. In 2007-2011, 17.2% of the persons in Furnas County were below poverty level and the median household income was $38,650. There are no other hospitals in Furnas County. 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. X X 1 1 0 0 0 1 0 1 0 0 0 Lennie Deaver MD 183133 0 79590 0 525 0 0 0 30478 0 293726 0 0 0 Rachelle Kaspar-Cope MD 167883 0 47943 0 677 0 16664 0 9335 0 242502 0 0 0 Paul Shellabarger PA 92137 0 85520 0 481 0 0 0 20592 0 198730 0 0 0 Bill Duff 163082 0 0 0 1769 0 0 0 26497 0 191348 0 0 0 Part I, Line 1a Spouses of board members attend one conference up to a maximum of $600. Providers can choose to belong to either a health club or a golf club. Payments are made directly to the health club or golf club. Part I, Line 5 Each provider has an incentive payment schedule written in their contract. Incentive bonus is paid out monthly based on services performed. Part I, Line 6 The CFO is under the employee bonus program offered to all employees which allows for bonuses based on financial indicators and quality indicators. Supplemental Information Part III Part I, Line 3: Tri Valley Health System does not pay compensation to the CEO directly. The CEO is considered a common law employee and is compensated by HealthTech Management Services, Inc., an unrelated 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. 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 The CEO is employed by HealthTech Management Services. 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. Changes in Net Assets or Fund Balances: Form 990, Part XI, line 5: Net unrealized gains on investments: 9,078. Change in interest in net assets of Tri Valley Medical Foundation -630,657. Total to Form 990, Part XI, Line 5: -621,579. Form 990, Part XII, Line 2c: The Board of Trustees assumes responsibility for oversight of the audit and selection of an independent accountant.