SUMNER COMMUNITY CLUB: Form 990, tax year 2012
View the entire original 990 at ProPublica ↗
- Organization
- SUMNER COMMUNITY CLUB (EIN 42-0670596)
- Tax period
- 2012-01-01 to 2012-12-31
- Filed
- 2013-11-04
- IRS object ID
- 201343089349300684
- 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
- Form 990
- Schedule A
- Schedule B
- Schedule D
- Schedule H
- Schedule J
- Schedule K
- Schedule L
- Schedule O
- Schedule R
Return header ReturnHeader
| Field | Value | IRS element (for citing) |
|---|---|---|
| Timestamp | 2013-11-04T10:14:40-06:00 | Timestamp |
| Tax Period End Date | 2012-12-31 | TaxPeriodEndDate |
Preparer Firm PreparerFirm
| Field | Value | IRS element (for citing) |
|---|---|---|
| EIN | 476097913 | EIN |
Preparer Firm Business Name PreparerFirmBusinessName
| Field | Value | IRS element (for citing) |
|---|---|---|
| Business Name Line1 | SEIM JOHNSON LLP | BusinessNameLine1 |
Preparer Firm US Address PreparerFirmUSAddress
| Field | Value | IRS element (for citing) |
|---|---|---|
| Address Line1 | 18081 BURT STREET SUITE 200 | AddressLine1 |
| City | OMAHA | City |
| State | NE | State |
| ZIP Code | 680224722 | ZIPCode |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Return Type | 990 | ReturnType |
| Tax Period Begin Date | 2012-01-01 | TaxPeriodBeginDate |
Filer Filer
| Field | Value | IRS element (for citing) |
|---|---|---|
| EIN | 420670596 | EIN |
Name Name
| Field | Value | IRS element (for citing) |
|---|---|---|
| Business Name Line1 | SUMNER COMMUNITY CLUB | BusinessNameLine1 |
| Business Name Line2 | D/B/A COMMUNITY MEMORIAL HOSPITAL | BusinessNameLine2 |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Name Control | SUMN | NameControl |
| Phone | 5635783275 | Phone |
US Address USAddress
| Field | Value | IRS element (for citing) |
|---|---|---|
| Address Line1 | 909 W 1ST STREET PO BOX 148 | AddressLine1 |
| City | SUMNER | City |
| State | IA | State |
| ZIP Code | 506740148 | ZIPCode |
Officer Officer
| Field | Value | IRS element (for citing) |
|---|---|---|
| Name | MARY S WELLS | Name |
| Title | CEO | Title |
| Phone | 5635783275 | Phone |
| Date Signed | 2013-10-30 | DateSigned |
| Authorize Third Party | 1 | AuthorizeThirdParty |
Preparer Preparer
| Field | Value | IRS element (for citing) |
|---|---|---|
| Name | BARBARA J FAJEN | Name |
| PTIN | P00400874 | PTIN |
| Phone | 4023302660 | Phone |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Tax Year | 2012 | TaxYear |
| Build TS | 2016-02-24 21:20:13Z | BuildTS |
Form 990 IRS990
| Field | Value | IRS element (for citing) |
|---|---|---|
| Name Of Principal Officer Person | MARY S WELLS | NameOfPrincipalOfficerPerson |
Address Principal Officer US AddressPrincipalOfficerUS
| Field | Value | IRS element (for citing) |
|---|---|---|
| Address Line1 | 909 W 1ST STREET PO BOX 148 | AddressLine1 |
| City | SUMNER | City |
| State | IA | State |
| ZIP Code | 506740148 | ZIPCode |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Gross Receipts | 11390517 | GrossReceipts |
| Group Return For Affiliates | 0 | GroupReturnForAffiliates |
| Organization501c3 | X | Organization501c3 |
| Web Site | WWW.CMHSUMNER.ORG | WebSite |
| Type Of Organization Corporation | X | TypeOfOrganizationCorporation |
| Year Formation | 1950 | YearFormation |
| State Legal Domicile | IA | StateLegalDomicile |
| Activity Or Mission Description | COMMUNITY MEMORIAL HOSPITAL SERVES THE AREA THROUGH ITS HEALTHCARE AND EDUCATIONAL SERVICES. WE EMPHASIZE CONCERN FOR THE QUALITY OF A PERSON'S LIFE, THROUGH EVERY MEASURE INTENDED TO PRESERVE LIFE WITH DIGNITY AND RESPECT. WE ARE DEDICATED TO CREATING AND MAINTAINING AN ENVIRONMENT SUPPORTING EXCELLENCE IN HEALTHCARE. WE PROVIDE QUALIFIED AND PROPERLY TRAINED PERSONNEL AND MEDICAL STAFF IN AN ATMOSPHERE WHICH INSPIRES A CREATIVE APPROACH TO THE COMPLEX HEALTHCARE CHALLENGES OF TODAY AND TOMORROW. | ActivityOrMissionDescription |
| Nbr Voting Members Governing Body | 12 | NbrVotingMembersGoverningBody |
| Nbr Independent Voting Members | 12 | NbrIndependentVotingMembers |
| Total Nbr Employees | 0 | TotalNbrEmployees |
| Total Nbr Volunteers | 0 | TotalNbrVolunteers |
| Total Gross UBI | 1586 | TotalGrossUBI |
| Net Unrelated Business Txbl Income | -787 | NetUnrelatedBusinessTxblIncome |
| Contributions Grants Prior Year | 240028 | ContributionsGrantsPriorYear |
| Contributions Grants Current Year | 1694875 | ContributionsGrantsCurrentYear |
| Program Service Revenue Prior Year | 9454740 | ProgramServiceRevenuePriorYear |
| Program Service Revenue CY | 9527751 | ProgramServiceRevenueCY |
| Investment Income Prior Year | 14433 | InvestmentIncomePriorYear |
| Investment Income Current Year | -6172 | InvestmentIncomeCurrentYear |
| Other Revenue Prior Year | 81493 | OtherRevenuePriorYear |
| Other Revenue Current Year | 149207 | OtherRevenueCurrentYear |
| Total Revenue Prior Year | 9790694 | TotalRevenuePriorYear |
| Total Revenue Current Year | 11365661 | TotalRevenueCurrentYear |
| Grants And Similar Amnts Prior Year | 0 | GrantsAndSimilarAmntsPriorYear |
| Grants And Similar Amnts CY | 0 | GrantsAndSimilarAmntsCY |
| Benefits Paid To Members Prior Year | 0 | BenefitsPaidToMembersPriorYear |
| Benefits Paid To Members CY | 0 | BenefitsPaidToMembersCY |
| Salaries Etc Prior Year | 4902735 | SalariesEtcPriorYear |
| Salaries Etc Current Year | 5088957 | 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 | 4468049 | OtherExpensePriorYear |
| Other Expenses Current Year | 4766967 | OtherExpensesCurrentYear |
| Total Expenses Prior Year | 9370784 | TotalExpensesPriorYear |
| Total Expenses Current Year | 9855924 | TotalExpensesCurrentYear |
| Revenues Less Expenses Prior Year | 419910 | RevenuesLessExpensesPriorYear |
| Revenues Less Expenses CY | 1509737 | RevenuesLessExpensesCY |
| Total Assets BOY | 20417085 | TotalAssetsBOY |
| Total Assets EOY | 30929002 | TotalAssetsEOY |
| Total Liabilities BOY | 11938897 | TotalLiabilitiesBOY |
| Total Liabilities EOY | 20970674 | TotalLiabilitiesEOY |
| Net Assets Or Fund Balances BOY | 8478188 | NetAssetsOrFundBalancesBOY |
| Net Assets Or Fund Balances EOY | 9958328 | NetAssetsOrFundBalancesEOY |
| Info In Schedule O Part III | X | InfoInScheduleOPartIII |
| Mission Description | TO PROVIDE QUALITY HEALTH CARE TO THE PEOPLE OF SUMNER AND SURROUNDING AREAS, WHILE COORDINATING OTHER NEEDED SERVICES. | MissionDescription |
| Significant New Program Services | 0 | SignificantNewProgramServices |
| Significant Change | 0 | SignificantChange |
| Expense | 1019576 | Expense |
| Revenue | 1111830 | Revenue |
| Description | THE CMH EMERGENCY DEPARTMENT SERVED 1,118 PATIENTS IN 2012. THIS IS A DECREASE OF 122 PATIENT VISITS FROM 1,240 VISITS IN 2011. THE NUMBER OF PHYSICIAN HOURS SPENT IN THE EMERGENCY DEPARTMENT DECREASED FROM 2,490 IN 2011 TO 2,062 IN 2012. IN 2012, THE EMERGENCY DEPARTMENT IMPLEMENTED CQI PROJECTS FOR PATIENT CALLBACKS, CONSENT FOR TRANSFER PAPERWORK FILLED OUT COMPLETELY, CORRECT PROCESS WAIVERS COMPLETED, MEDICATION REASSESSMENT, AND RETURN VISITS BY PATIENTS WITH THE SAME DIAGNOSIS.THE EDUCATIONAL FOCUS FOR 2012 WAS TRAUMA TRAINING WITH MOCK CODES. OTHER AREAS OF EDUCATION HIGHLIGHTED IN 2012 WERE NEGATIVE AIR PRESSURE ROOMS, MEDICATION VERIFICATION, COMMITTAL PROCESS FOR MENTAL HEALTH, AND TRAUMA ALERT ACTIVATION. | Description |
Activity2 Activity2
| Field | Value | IRS element (for citing) |
|---|---|---|
| Expense | 885088 | Expense |
| Revenue | 1783422 | Revenue |
| Description | COMMUNITY MEMORIAL HOSPITAL (CMH) MEDICAL CLINIC CONTINUED TO SERVE SUMNER, IA AND THE SURROUNDING AREA IN THE YEAR 2012. CMH WAS STAFFED WITH THREE PROVIDERS; TWO NURSE PRACTITIONERS AND ONE PHYSICIAN. PATIENTS WERE SERVED IN MANY CAPACITIES INCLUDING, BUT NOT LIMITED TO, WELL CHILD VISITS, IMMUNIZATIONS, ROUTINE PEDIATRIC CARE, SHARED MATERNITY CARE, WOUND CARE AND THERAPEUTIC INJECTIONS. PATIENTS RANGED FROM NEWBORN TO GERIATRIC. A 50-MILE RADIUS OF SUMNER WAS SERVED WITH A TOTAL PATIENT VOLUME OF 6,939 FOR 2012. IN ADDITION TO CLINIC VISITS, OUR PROVIDERS EXTENDED THEIR SERVICE TO SURROUNDING NURSING HOMES WITH PATIENTS SEEN MONTHLY AT HILLCREST HOME IN SUMNER AND TRIPOLI NURSING HOME IN TRIPOLI. OTHER SERVICES TO THE COMMUNITY WERE PHYSICALS FOR AREA FIREFIGHTERS AND EMS AGENCIES AND POST-JOB OFFER PHYSICALS FOR TWO LOCAL BUSINESSES. PROVIDERS CONTINUE TO TAKE CALL FOR THE EMERGENCY DEPARTMENT ON A REGULAR SCHEDULED BASIS THROUGHOUT EACH MONTH. CLINIC STAFF CONTINUED TO GO TO AN AREA BANK THE FIRST TUESDAY OF EACH MONTH TO OFFER FREE BLOOD PRESSURE CHECKS TO ANYONE ON A WALK-IN BASIS. PROVIDERS AVIDLY PRECEPT FOR STUDENTS FROM VARIOUS PROGRAMS WITH ALLEN COLLEGE IN WATERLOO, IA TAKING ADVANTAGE OF THIS IN 2012. THE CLINIC HOURS ARE MONDAY THROUGH FRIDAY STARTING AT 7 AM AND ENDING AT 5 PM. | Description |
Activity3 Activity3
| Field | Value | IRS element (for citing) |
|---|---|---|
| Expense | 880236 | Expense |
| Revenue | 358112 | Revenue |
| Description | ACUTE NURSING HAD 127 ADMISSIONS IN 2012. CMH UTILIZES A COMPANY CALLED MCKESSON'S INTERQUAL FOR QUALIFYING PATIENTS TO DETERMINE IF THEY MEET INPATIENT ADMISSION CRITERIA. THE AVERAGE LENGTH OF STAY FOR ACUTE WAS 54.72 HOURS. THIS IS WELL BELOW THE 96 HOURS THRESHOLD FOR CRITICAL ACCESS. | Description |
Activity Other ActivityOther
| Field | Value | IRS element (for citing) |
|---|---|---|
| Expense | 5571079 | Expense |
| Revenue | 6291173 | Revenue |
| Description | VARIOUS INPATIENT AND OTHER HEALTH CARE SERVICES. | Description |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Of Other Program Service Exp | 5571079 | TotalOfOtherProgramServiceExp |
| Total Of Other Program Service Rev | 6291173 | TotalOfOtherProgramServiceRev |
| Total Program Service Expense | 8355979 | 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 | 1 | 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 | 0 | IndependentAuditFinancialStmt |
| Consolidated Audit Financial Stmt | 1 | 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 | 1 | TaxExemptBonds |
| Invest Tax Exempt Bonds | 0 | InvestTaxExemptBonds |
| Escrow Account | 0 | EscrowAccount |
| On Behalf Of Issuer | 0 | OnBehalfOfIssuer |
| 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 | 1 | BsnssRltnshpThruFamilyMember |
| Officer Entity With Bsnss Rltnshp | 1 | 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 | 1 | RelatedEntity |
| Related Org Controlled Entity | 1 | RelatedOrgControlledEntity |
| Transaction Related Entity | 1 | TransactionRelatedEntity |
| Transfers To Exempt Non Chrtbl Org | 0 | TransfersToExemptNonChrtblOrg |
| Activities Conducted Partnership | 0 | ActivitiesConductedPartnership |
| Schedule O Required | 1 | ScheduleORequired |
| Number Forms Transmitted With1096 | 11 | NumberFormsTransmittedWith1096 |
| Number W2 G Included | 0 | NumberW2GIncluded |
| Compliance With Backup Witholding | 1 | ComplianceWithBackupWitholding |
| Number Of Employees | 0 | NumberOfEmployees |
| 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 | 12 | NbrVotingGoverningBodyMembers |
| Number Independent Voting Members | 12 | NumberIndependentVotingMembers |
| Family Or Business Relationship | 0 | FamilyOrBusinessRelationship |
| Delegation Of Management Duties | 1 | DelegationOfManagementDuties |
| Changes To Organizing Docs | 0 | ChangesToOrganizingDocs |
| Material Diversion Or Misuse | 0 | MaterialDiversionOrMisuse |
| Members Or Stockholders | 1 | MembersOrStockholders |
| Election Of Board Members | 1 | ElectionOfBoardMembers |
| Decisions Subject To Approval | 1 | DecisionsSubjectToApproval |
| Minutes Of Governing Body | 1 | MinutesOfGoverningBody |
| Minutes Of Committees | 1 | 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 | 0 | 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 | DAWN EVERDING | BusinessNameLine1 |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Telephone Number | 5635783275 | TelephoneNumber |
Address US AddressUS
| Field | Value | IRS element (for citing) |
|---|---|---|
| Address Line1 | 909 WEST 1ST STREET PO BOX 148 | AddressLine1 |
| City | SUMNER | City |
| State | IA | State |
| ZIP Code | 50674 | ZIPCode |
Form990 Part VII Section A Form990PartVIISectionA (17 entries)
| TitleTitle | Average Hours Per WeekAverageHoursPerWeek | Average Hours Per Week RelatedAverageHoursPerWeekRelated | Individual Trustee Or DirectorIndividualTrusteeOrDirector | OfficerOfficer | Reportable Comp From OrganizationReportableCompFromOrganization | Reportable Comp From Related OrgsReportableCompFromRelatedOrgs | Other CompensationOtherCompensation | Highest Compensated EmployeeHighestCompensatedEmployee |
|---|---|---|---|---|---|---|---|---|
| PAUL BAHE | ||||||||
| BOARD MEMBER - CHAIR | 1.30 | 0.80 | X | X | 0 | 0 | 0 | |
| MIKE MEYER | ||||||||
| BOARD MEMBER - VICE CHAIR | 1.30 | 0.00 | X | X | 0 | 0 | 0 | |
| DEB TOENGES | ||||||||
| BOARD MEMBER - SEC/TREAS | 1.30 | 0.00 | X | X | 0 | 0 | 0 | |
| DEB BECKNER | ||||||||
| BOARD MEMBER | 0.80 | 0.00 | X | 0 | 0 | 0 | ||
| CONNIE LEICHER | ||||||||
| BOARD MEMBER | 0.80 | 0.00 | X | 0 | 0 | 0 | ||
| RANDIE MUELLER | ||||||||
| BOARD MEMBER | 0.80 | 0.00 | X | 0 | 0 | 0 | ||
| LUARA NECKER | ||||||||
| BOARD MEMBER | 0.80 | 0.00 | X | 0 | 0 | 0 | ||
| DIANE PAGEL | ||||||||
| BOARD MEMBER | 0.80 | 0.00 | X | 0 | 0 | 0 | ||
| RICK PEDERSON | ||||||||
| BOARD MEMBER | 0.80 | 0.00 | X | 0 | 0 | 0 | ||
| BILL SCHWAKE | ||||||||
| BOARD MEMBER | 0.80 | 0.80 | X | 0 | 0 | 0 | ||
| DAVE VOSS | ||||||||
| BOARD MEMBER | 0.80 | 0.00 | X | 0 | 0 | 0 | ||
| JENNIFER YEAROUS | ||||||||
| BOARD MEMBER | 0.80 | 0.00 | X | 0 | 0 | 0 | ||
| MARY WELLS | ||||||||
| CEO | 38.00 | 2.00 | X | 148536 | 0 | 19895 | ||
| SARA TRAINOR | ||||||||
| CFO | 39.50 | 0.50 | X | 112499 | 0 | 28292 | ||
| LYNNE NIEMANN | ||||||||
| DIRECTOR OF NURSING & PATI | 39.70 | 0.30 | X | 90062 | 0 | 15932 | ||
| TROY BUCHHOLZ | ||||||||
| PHYSICIAN | 40.00 | 0.00 | 326865 | 0 | 35977 | X | ||
| ROBERTA MITTELSTED | ||||||||
| ARNP | 40.00 | 0.00 | 130677 | 0 | 25623 | X | ||
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Reportable Comp From Org | 808639 | TotalReportableCompFromOrg |
| Total Reportable Comp Frm Rltd Orgs | 0 | TotalReportableCompFrmRltdOrgs |
| Total Other Compensation | 125719 | TotalOtherCompensation |
| Number Individuals GT100 K | 4 | 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 |
|---|---|---|---|---|---|
| GRAHAM CONSTRUCTION | |||||
| 421 GRAND AVENUE | DES MOINES | IA | 50309 | CONSTRUCTION SERVICES | 10452961 |
| DR JAYASWAL | |||||
| 8315 W 119TH TERRACE | OVERLAND | KS | 66213 | ED COVERAGE | 435250 |
| PERFORMANCE REHAB LLC | |||||
| 909 W 1ST ST | SUMNER | IA | 50674 | REHAB SERVICES | 409502 |
| IOWA HEALTH SYSTEM | |||||
| 1776 W LAKES PARKWAY SUITE 400 | WEST DES MOINES | IA | 50266 | IT (EPIC) SUPPORT | 250000 |
| EMERGENCY PRACTICE ASSOCIATES INC | |||||
| PO BOX 1260 | WATERLOO | IA | 50704 | ED COVERAGE | 232056 |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Number Of Contractors GT100 K | 10 | NumberOfContractorsGT100K |
| Related Organizations | 1604984 | RelatedOrganizations |
| Government Grants | 17725 | GovernmentGrants |
| All Other Contributions | 72166 | AllOtherContributions |
| Total Contributions | 1694875 | TotalContributions |
Program Service Revenue ProgramServiceRevenue (3 entries)
| DescriptionDescription | Business CodeBusinessCode | Total Revenue ColumnTotalRevenueColumn | Related Or Exempt Function IncomeRelatedOrExemptFunctionIncome |
|---|---|---|---|
| MEDICARE/MEDICAID PAYM | 621400 | 6081673 | 6081673 |
| PATIENT REVENUE - PRIVATE PAY | 621400 | 3423513 | 3423513 |
| COMMUNITY WELLNESS | 621990 | 22565 | 22565 |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Program Service Revenue | 9527751 | TotalProgramServiceRevenue |
Investment Income InvestmentIncome
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Revenue Column | 17884 | TotalRevenueColumn |
| Exclusion | $17,884 | ExclusionAmount |
Gross Rents GrossRents
| Field | Value | IRS element (for citing) |
|---|---|---|
| Real | 26768 | Real |
Less Rental Expenses LessRentalExpenses
| Field | Value | IRS element (for citing) |
|---|---|---|
| Real | 0 | Real |
Rental Income Or Loss RentalIncomeOrLoss
| Field | Value | IRS element (for citing) |
|---|---|---|
| Real | 26768 | Real |
Net Rental Income Or Loss NetRentalIncomeOrLoss
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Revenue Column | 26768 | TotalRevenueColumn |
| Exclusion | $26,768 | ExclusionAmount |
Gross Amount Sales Assets GrossAmountSalesAssets
| Field | Value | IRS element (for citing) |
|---|---|---|
| Other | 800 | Other |
Less Cost Oth Basis Sales Expenses LessCostOthBasisSalesExpenses
| Field | Value | IRS element (for citing) |
|---|---|---|
| Other | 24856 | Other |
Gain Or Loss GainOrLoss
| Field | Value | IRS element (for citing) |
|---|---|---|
| Other | -24056 | Other |
Net Gain Or Loss Investments NetGainOrLossInvestments
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Revenue Column | -24056 | TotalRevenueColumn |
| Exclusion | -$24,056 | ExclusionAmount |
Other Revenue Misc OtherRevenueMisc (3 entries)
| DescriptionDescription | Business CodeBusinessCode | Total Revenue ColumnTotalRevenueColumn | ExclusionExclusionAmount | Related Or Exempt Function IncomeRelatedOrExemptFunctionIncome |
|---|---|---|---|---|
| AMH OPERATING AGREEMENT INCOME | 561000 | 78978 | $78,978 | |
| CAFETERIA EMPLOYEES | 900099 | 25089 | $25,089 | |
| MISCELLANEOUS INCOME | 900099 | 16786 | 16786 |
Miscellaneous Revenue MiscellaneousRevenue
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Revenue Column | 1586 | TotalRevenueColumn |
| Unrelated Business Revenue | 1586 | UnrelatedBusinessRevenue |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Other Revenue | 122439 | TotalOtherRevenue |
Total Revenue TotalRevenue
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Revenue Column | 11365661 | TotalRevenueColumn |
| Related Or Exempt Function Income | 9544537 | RelatedOrExemptFunctionIncome |
| Unrelated Business Revenue | 1586 | UnrelatedBusinessRevenue |
| Exclusion | $124,663 | ExclusionAmount |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Info In Schedule O Part IX | X | InfoInScheduleOPartIX |
Comp Current Officers Directors CompCurrentOfficersDirectors
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | 309222 | Total |
| Management And General | 309222 | ManagementAndGeneral |
Comp Disqual Persons CompDisqualPersons
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | 42738 | Total |
| Program Services | 42738 | ProgramServices |
Other Salaries And Wages OtherSalariesAndWages
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | 3688045 | Total |
| Program Services | 3103703 | ProgramServices |
| Management And General | 584342 | ManagementAndGeneral |
Other Employee Benefits OtherEmployeeBenefits
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | 696053 | Total |
| Program Services | 586610 | ProgramServices |
| Management And General | 109443 | ManagementAndGeneral |
Payroll Taxes PayrollTaxes
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | 352899 | Total |
| Program Services | 282213 | ProgramServices |
| Management And General | 70686 | ManagementAndGeneral |
Fees For Services Management FeesForServicesManagement
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | 60000 | Total |
| Management And General | 60000 | ManagementAndGeneral |
Fees For Services Accounting FeesForServicesAccounting
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | 113262 | Total |
| Management And General | 113262 | ManagementAndGeneral |
Fees For Services Other FeesForServicesOther
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | 2066009 | Total |
| Program Services | 1870591 | ProgramServices |
| Management And General | 195418 | ManagementAndGeneral |
Advertising Advertising
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | 26290 | Total |
| Program Services | 26290 | ProgramServices |
Office Expenses OfficeExpenses
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | 459642 | Total |
| Program Services | 409239 | ProgramServices |
| Management And General | 50403 | ManagementAndGeneral |
Occupancy Occupancy
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | 132819 | Total |
| Program Services | 132819 | ProgramServices |
Travel Travel
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | 45483 | Total |
| Program Services | 38314 | ProgramServices |
| Management And General | 7169 | ManagementAndGeneral |
Interest Interest
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | 13514 | Total |
| Program Services | 13514 | ProgramServices |
Depreciation Depletion DepreciationDepletion
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | 775698 | Total |
| Program Services | 775698 | ProgramServices |
Insurance Insurance
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | 62039 | Total |
| Program Services | 62039 | ProgramServices |
Other Expenses OtherExpenses (4 entries)
| DescriptionDescription | TotalTotal | Program ServicesProgramServices |
|---|---|---|
| MEDICAL SUPPLIES | 616399 | 616399 |
| PROVISION FOR BAD DEBT | 230818 | 230818 |
| DUES AND SUBSCRIPTIONS | 141137 | 141137 |
| MISC. EXPENSES | 23857 | 23857 |
Total Functional Expenses TotalFunctionalExpenses
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | 9855924 | Total |
| Program Services | 8355979 | ProgramServices |
| Management And General | 1499945 | ManagementAndGeneral |
| Fundraising | 0 | Fundraising |
Cash Non Interest Bearing CashNonInterestBearing
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | 100 | BOY |
| EOY | 100 | EOY |
Savings And Temp Cash Investments SavingsAndTempCashInvestments
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | 2766551 | BOY |
| EOY | 3435704 | EOY |
Pledges And Grants Receivable PledgesAndGrantsReceivable
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | 545171 | BOY |
Accounts Receivable AccountsReceivable
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | 1611764 | BOY |
| EOY | 1301417 | EOY |
Inventories For Sale Or Use InventoriesForSaleOrUse
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | 110936 | BOY |
| EOY | 108269 | EOY |
Prepaid Expenses Deferred Charges PrepaidExpensesDeferredCharges
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | 72771 | BOY |
| EOY | 302422 | EOY |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Land Buildings Equipment Basis | 21472222 | LandBuildingsEquipmentBasis |
| Land Bldg Equipment Accum Deprec | 5422436 | LandBldgEquipmentAccumDeprec |
Land Buildings Equipment Basis Net LandBuildingsEquipmentBasisNet
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | 4157465 | BOY |
| EOY | 16049786 | EOY |
Investments Pub Traded Securities InvestmentsPubTradedSecurities
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | 7434698 | BOY |
| EOY | 5204499 | EOY |
Investments Other Securities InvestmentsOtherSecurities
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | 3544459 | BOY |
| EOY | 4171601 | EOY |
Other Assets Total OtherAssetsTotal
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | 173170 | BOY |
| EOY | 355204 | EOY |
Total Assets TotalAssets
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | 20417085 | BOY |
| EOY | 30929002 | EOY |
Accounts Payable Accrued Expenses AccountsPayableAccruedExpenses
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | 2070548 | BOY |
| EOY | 2885944 | EOY |
Tax Exempt Bond Liabilities TaxExemptBondLiabilities
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | 9000000 | BOY |
| EOY | 18000000 | EOY |
Mort Notes Pybl Secured Invest Prop MortNotesPyblSecuredInvestProp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | 185706 | BOY |
| EOY | 62978 | EOY |
Other Liabilities OtherLiabilities
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | 682643 | BOY |
| EOY | 21752 | EOY |
Total Liabilities TotalLiabilities
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | 11938897 | BOY |
| EOY | 20970674 | EOY |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Follow SFAS117 | X | FollowSFAS117 |
Unrestricted Net Assets UnrestrictedNetAssets
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | 4571957 | BOY |
| EOY | 5786727 | EOY |
Temporarily Restricted Net Assets TemporarilyRestrictedNetAssets
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | 425039 | BOY |
| EOY | 0 | EOY |
Permanently Restricted Net Assets PermanentlyRestrictedNetAssets
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | 3481192 | BOY |
| EOY | 4171601 | EOY |
Total Net Assets Fund Balances TotalNetAssetsFundBalances
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | 8478188 | BOY |
| EOY | 9958328 | EOY |
Total Liab Net Assets Fund Balances TotalLiabNetAssetsFundBalances
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | 20417085 | BOY |
| EOY | 30929002 | EOY |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Info In Schedule O Part XI | X | InfoInScheduleOPartXI |
| Reconcilation Revenue Expenses | 1509737 | ReconcilationRevenueExpenses |
| Reconciliation Unrealized Invest | 627142 | ReconciliationUnrealizedInvest |
| Reconcilation Prior Adjustment | -545172 | ReconcilationPriorAdjustment |
| Reconcilation Other Changes | -111567 | 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 Consolidated | X | FinancialStatementConsolidated |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Audit Committee | 1 | AuditCommittee |
| Federal Grant Audit Required | 1 | FederalGrantAuditRequired |
| Federal Grant Audit Performed | 1 | FederalGrantAuditPerformed |
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
Current Year CurrentYear
| Field | Value | IRS element (for citing) |
|---|---|---|
| Beginning Of Year Balance | 3544459 | BeginningOfYearBalance |
| Investment Earnings Or Losses | 858953 | InvestmentEarningsOrLosses |
| Other Expenditures | 231811 | OtherExpenditures |
| End Of Year Balance | 4171601 | EndOfYearBalance |
Current Year Minus1 Year CurrentYearMinus1Year
| Field | Value | IRS element (for citing) |
|---|---|---|
| Beginning Of Year Balance | 2684825 | BeginningOfYearBalance |
| Investment Earnings Or Losses | 1033086 | InvestmentEarningsOrLosses |
| Other Expenditures | 173452 | OtherExpenditures |
| End Of Year Balance | 3544459 | EndOfYearBalance |
Current Year Minus2 Years CurrentYearMinus2Years
| Field | Value | IRS element (for citing) |
|---|---|---|
| Beginning Of Year Balance | 2638298 | BeginningOfYearBalance |
| Investment Earnings Or Losses | 110582 | InvestmentEarningsOrLosses |
| Other Expenditures | 64055 | OtherExpenditures |
| End Of Year Balance | 2684825 | EndOfYearBalance |
Current Year Minus3 Years CurrentYearMinus3Years
| Field | Value | IRS element (for citing) |
|---|---|---|
| Beginning Of Year Balance | 2634633 | BeginningOfYearBalance |
| Investment Earnings Or Losses | 58750 | InvestmentEarningsOrLosses |
| Other Expenditures | 55085 | OtherExpenditures |
| End Of Year Balance | 2638298 | EndOfYearBalance |
Current Year Minus4 Years CurrentYearMinus4Years
| Field | Value | IRS element (for citing) |
|---|---|---|
| Beginning Of Year Balance | 2889909 | BeginningOfYearBalance |
| Investment Earnings Or Losses | -246778 | InvestmentEarningsOrLosses |
| Other Expenditures | 8498 | OtherExpenditures |
| End Of Year Balance | 2634633 | EndOfYearBalance |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Permanent Endowment EOY Balance | 1.00000 | PermanentEndowmentEOYBalance |
| Endowments Held By Unrelated Orgs | 1 | EndowmentsHeldByUnrelatedOrgs |
| Endowments Held By Related Orgs | 0 | EndowmentsHeldByRelatedOrgs |
Land Land
| Field | Value | IRS element (for citing) |
|---|---|---|
| Other Cost Or Other Basis | 100421 | OtherCostOrOtherBasis |
| Book Value | 100421 | BookValue |
Buildings Buildings
| Field | Value | IRS element (for citing) |
|---|---|---|
| Other Cost Or Other Basis | 2684715 | OtherCostOrOtherBasis |
| Depreciation | 2689573 | Depreciation |
| Book Value | -4858 | BookValue |
Equipment Equipment
| Field | Value | IRS element (for citing) |
|---|---|---|
| Other Cost Or Other Basis | 3980405 | OtherCostOrOtherBasis |
| Depreciation | 2649518 | Depreciation |
| Book Value | 1330887 | BookValue |
Other Land Buildings OtherLandBuildings
| Field | Value | IRS element (for citing) |
|---|---|---|
| Other Cost Or Other Basis | 14706681 | OtherCostOrOtherBasis |
| Depreciation | 83345 | Depreciation |
| Book Value | 14623336 | BookValue |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Of Book Value Land Buildings | 16049786 | TotalOfBookValueLandBuildings |
Other Securities OtherSecurities
| Field | Value | IRS element (for citing) |
|---|---|---|
| Description | PERPETUAL TRUST | Description |
| Book Value | 4171601 | BookValue |
| Method Of Valuation | F | MethodOfValuation |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Of Book Value Securities | 4171601 | TotalOfBookValueSecurities |
Other Liabilities OtherLiabilities
| Field | Value | IRS element (for citing) |
|---|---|---|
| Description | CAPITALIZED LEASE OBLIGATIONS | Description |
| Amount | $21,752 | Amount |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Of Amounts | 21752 | TotalOfAmounts |
| Footnote In Part XIII | X | FootnoteInPartXIII |
Form990 Schedule D Part XIII Form990ScheduleDPartXIII (2 entries)
| IdentifierIdentifier | Return ReferenceReturnReference | ExplanationExplanation |
|---|---|---|
| DESCRIPTION OF INTENDED USE OF ENDOWMENT FUNDS: | PART V, LINE 4: | THE HOSPITAL IS BENEFICIARY OF A DONOR CREATED PERPETUAL TRUST. ASSETS HELD BY THE TRUST INCLUDE CASH AND CASH EQUIVALENTS, CDS, EQUITITIES, FARMLAND, LIVESTOCK, EQUIPMENT, GRAINS, ETC. A PROVISION OF THE TRUST REQUIRES THAT INCOME EARNED BE DISTRIBUTED AT LEAST ANNUALLY TO THE HOSPITAL. INCOME DISTRIBUTIONS FROM THE TRUST ARE UNRESTRICTED AND CAN BE USED FOR ANY PURPOSE DEEMED BENEFICIAL. |
| DESCRIPTION OF UNCERTAIN TAX POSITIONS UNDER FIN 48: | PART X, LINE 2: | THE HOSPITAL AND FOUNDATION ARE NOT-FOR-PROFIT CORPORATIONS AS DESCRIBED IN SECTION 501(C)(3) OF THE INTERNAL REVENUE SERVICE AND ARE EXEMPT FROM FEDERAL INCOME TAXES IN RELATED INCOME PURSUANT TO SECTION 501(A) OF THE CODE. THE HOSPITAL ACCOUNTS FOR UNCERTAINTIES IN ACCOUNTING FOR INCOME TAX ASSETS AND LIABILITIES USING GUIDANCE INCLUDED IN FASB ASC 740, INCOME TAXES. THE HOSPITAL RECOGNIZES THE EFFECT OF INCOME TAX POSITIONS ONLY IF THOSE POSITIONS ARE MORE LIKELY THAN NOT OF BEING SUSTAINED. AT DECEMBER 31, 2012 AND 2011, THE HOSPITAL HAD NO UNCERTAIN TAX POSITIONS ACCRUED. WITH FEW EXCEPTIONS, THE HOSPITAL IS NO LONGER SUBJECT TO INCOME TAX EXAMINATIONS FOR YEARS ENDED PRIOR TO DECEMBER 31, 2009. |
Schedule H IRS990ScheduleH
| Field | Value | IRS element (for citing) |
|---|---|---|
| Charity Care Policy | 1 | CharityCarePolicy |
| Written Policy | 1 | WrittenPolicy |
| FPG Reference Free Care | 1 | FPGReferenceFreeCare |
Other Percentage OtherPercentage
| Field | Value | IRS element (for citing) |
|---|---|---|
| Other | X | Other |
| Free Other Percentage | 125.000000000000 | FreeOtherPercentage |
| Field | Value | IRS element (for citing) |
|---|---|---|
| FPG Reference Discounted Care | 1 | FPGReferenceDiscountedCare |
| Pcent300 | X | Pcent300 |
| Free Disc Care Medically Indigent | 1 | FreeDiscCareMedicallyIndigent |
| Amounts Budgeted For Charity Care | 1 | AmountsBudgetedForCharityCare |
| Expenses Exceeded Budget | 0 | ExpensesExceededBudget |
| Annual Community Benefit Report | 1 | AnnualCommunityBenefitReport |
| Report Publically Available | 0 | ReportPublicallyAvailable |
Charity Care At Cost CharityCareAtCost
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Community Benefit Expense | 50414 | TotalCommunityBenefitExpense |
| Direct Offsetting Revenue | 0 | DirectOffsettingRevenue |
| Net Community Benefit Expense | 50414 | NetCommunityBenefitExpense |
| Percent Of Total Expense | 0.00520 | PercentOfTotalExpense |
Unreimbursed Medicaid UnreimbursedMedicaid
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Community Benefit Expense | 515923 | TotalCommunityBenefitExpense |
| Direct Offsetting Revenue | 515080 | DirectOffsettingRevenue |
| Net Community Benefit Expense | 843 | NetCommunityBenefitExpense |
| Percent Of Total Expense | 0.00010 | PercentOfTotalExpense |
Total Charity Care TotalCharityCare
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Community Benefit Expense | 566337 | TotalCommunityBenefitExpense |
| Direct Offsetting Revenue | 515080 | DirectOffsettingRevenue |
| Net Community Benefit Expense | 51257 | NetCommunityBenefitExpense |
| Percent Of Total Expense | 0.00530 | PercentOfTotalExpense |
Community Health Services CommunityHealthServices
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Community Benefit Expense | 22304 | TotalCommunityBenefitExpense |
| Direct Offsetting Revenue | 3127 | DirectOffsettingRevenue |
| Net Community Benefit Expense | 19177 | NetCommunityBenefitExpense |
| Percent Of Total Expense | 0.00200 | PercentOfTotalExpense |
Health Professions Education HealthProfessionsEducation
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Community Benefit Expense | 94461 | TotalCommunityBenefitExpense |
| Direct Offsetting Revenue | 0 | DirectOffsettingRevenue |
| Net Community Benefit Expense | 94461 | NetCommunityBenefitExpense |
| Percent Of Total Expense | 0.00980 | PercentOfTotalExpense |
Subsidized Health Services SubsidizedHealthServices
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Community Benefit Expense | 238971 | TotalCommunityBenefitExpense |
| Direct Offsetting Revenue | 30720 | DirectOffsettingRevenue |
| Net Community Benefit Expense | 208251 | NetCommunityBenefitExpense |
| Percent Of Total Expense | 0.02160 | PercentOfTotalExpense |
Research Research
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Community Benefit Expense | 0 | TotalCommunityBenefitExpense |
| Direct Offsetting Revenue | 0 | DirectOffsettingRevenue |
Cash And In Kind Contributions CashAndInKindContributions
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Community Benefit Expense | 16086 | TotalCommunityBenefitExpense |
| Direct Offsetting Revenue | 0 | DirectOffsettingRevenue |
| Net Community Benefit Expense | 16086 | NetCommunityBenefitExpense |
| Percent Of Total Expense | 0.00170 | PercentOfTotalExpense |
Total Other Benefits TotalOtherBenefits
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Community Benefit Expense | 371822 | TotalCommunityBenefitExpense |
| Direct Offsetting Revenue | 33847 | DirectOffsettingRevenue |
| Net Community Benefit Expense | 337975 | NetCommunityBenefitExpense |
| Percent Of Total Expense | 0.03510 | PercentOfTotalExpense |
Total Community Benefits TotalCommunityBenefits
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Community Benefit Expense | 938159 | TotalCommunityBenefitExpense |
| Direct Offsetting Revenue | 548927 | DirectOffsettingRevenue |
| Net Community Benefit Expense | 389232 | NetCommunityBenefitExpense |
| Percent Of Total Expense | 0.04040 | PercentOfTotalExpense |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Bad Debt Expense Reported | 1 | BadDebtExpenseReported |
| Bad Debt Expense | $230,818 | BadDebtExpenseAmount |
| Amount Attributable To | 51000 | AmountAttributableTo |
| Amount Reimbursed By Medicare | 4790858 | AmountReimbursedByMedicare |
| Cost Of Care Reimbursed By Medicare | 4743424 | CostOfCareReimbursedByMedicare |
| Medicare Surplus Or Shortfall | 47434 | MedicareSurplusOrShortfall |
Costing Methodology Used CostingMethodologyUsed
| Field | Value | IRS element (for citing) |
|---|---|---|
| Cost To Charge Ratio | X | CostToChargeRatio |
| 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 | SUMNER COMMUNITY CLUB DBA COMMUNITY | BusinessNameLine1 |
Address Address
| Field | Value | IRS element (for citing) |
|---|---|---|
| Address Line1 | MEMORIAL HOSP 909 W 1ST ST PO BOX | AddressLine1 |
| Address Line2 | 148 | AddressLine2 |
| City | SUMNER | City |
| State | IA | State |
| ZIP Code | 50674 | ZIPCode |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Licensed Hospital | X | LicensedHospital |
| Critical Access Hospital | X | CriticalAccessHospital |
| Er24 Hours | X | Er24Hours |
| Other | PROVIDER-BASED MEDICAL CLINIC | Other |
Form990 Schedule H Part V Section B Form990ScheduleHPartVSectionB
Hospital Facility Name HospitalFacilityName
| Field | Value | IRS element (for citing) |
|---|---|---|
| Business Name Line1 | COMMUNITY MEMORIAL HOSPITAL | BusinessNameLine1 |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Hospital Facility Number | 1 | HospitalFacilityNumber |
| Eligibility Criteria Explained | 1 | EligibilityCriteriaExplained |
| Uses FPG Free | 1 | UsesFPGFree |
| FPG Free Percent | 125.000000000000 | FPGFreePercent |
| Uses FPG Discounted | 1 | UsesFPGDiscounted |
| FPG Discount Percent | 300.000000000000 | FPGDiscountPercent |
| Explains Basis | 0 | ExplainsBasis |
| Explains Application Method | 1 | ExplainsApplicationMethod |
| Includes Publicity Measures | 1 | IncludesPublicityMeasures |
| Available On Request | X | AvailableOnRequest |
| Actions On Nonpayment | 1 | ActionsOnNonpayment |
| Collection Activities | 0 | CollectionActivities |
| Nondiscrim Emergency Care Policy | 1 | NondiscrimEmergencyCarePolicy |
| Used Other Method | X | UsedOtherMethod |
| Amounts Generally Billed | 0 | AmountsGenerallyBilled |
| Gross Charges | 0 | GrossCharges |
Form990 Schedule H Part VI Form990ScheduleHPartVI (15 entries)
| ExplanationExplanation | IdentifierIdentifier | Return ReferenceReturnReference |
|---|---|---|
| PART I, LINE 3C: NOT APPLICABLE. | ||
| PART I, LINE 6A: THE REPORT IS PREPARED BY THE STAFF OF COMMUNITY MEMORIAL HOSPITAL. | ||
| PART I, LINE 7: THE COST TO CHARGE RATIO PER IRS WORKSHEET 2 WAS USED TO CALCULATE THE AMOUNTS IN THE UPPER PORTION OF THE TABLE. COSTING OF THE "OTHER BENEFITS" PORTION OF THE TABLE WAS CALCULATED PER GUIDANCE PROVIDED BY THE IOWA HOSPITAL ASSOCIATION IN TERMS OF PROPER REPORTING OF COMMUNITY BENEFITS. | ||
| PART I, LINE 7G: NO COSTS ASSOCIATED WITH PHYSICIAN CLINICS WERE INCLUDED. | ||
| PART I, L7 COL(F): THE BAD DEBT EXPENSE INCLUDED ON FORM 990, PART IX, LINE 25, COLUMN (A), BUT SUBTRACTED FOR PURPOSES OF CALCULATING THE PERCENTAGE IN THIS COLUMN IS $230,818. | ||
| PART II: COMMUNITY MEMORIAL HOSPITAL DID NOT REPORT ANY COMMUNITY BUILDING ACTIVITIES IN PART II OF SCHEDULE H. | ||
| PART III, LINE 4: THE ORGANIZATION'S FINANCIAL STATEMENTS DO NOT CONTAIN A SPECIFIC FOOTNOTE DESCRIBING BAD DEBT. HOWEVER, THE FOLLOWING IS THE TEXT OF THE FOOTNOTES TITLED "PATIENT RECEIVABLES, NET", "NET PATIENT SERVICE REVENUE", AND "CHARITY CARE":PATIENT RECEIVABLES, NET:NET PATIENT RECEIVABLES CONSIST OF UNCOLLATERALIZED PATIENT AND THIRD PARTY OBLIGATIONS REDUCED BY A VALUATION ALLOWANCE FOR DOUBTFUL ACCOUNTS AND CONTRACTUAL ADJUSTMENTS FROM THIRD PARTY PAYERS. THE ALLOWANCES REFLECT MANAGEMENT'S ESTIMATE OF AMOUNTS THAT WILL NOT BE COLLECTED IN THE FUTURE AND ARE BASED ON REVIEWS OF PATIENT BALANCES BY PAYER CLASSES. PERCENTAGES ARE APPLIED TO EACH PAYER CLASS BASED ON CONTRACTUAL AGREEMENTS AND HISTORICAL COLLECTION AND RECOVERY INFORMATION TO DETERMINE THE NET REALIZABLE VALUE OF THE PATIENT RECEIVABLES.PAYMENT FOR SERVICES IS EXPECTED WITHIN THIRTY DAYS OF RECEIPT OF THE BILLING. ACCOUNTS CONSIDERED PAST DUE ARE SENT TO COLLECTION AGENCIES WHEN INTERNAL COLLECTION EFFORTS HAVE BEEN UNSUCCESSFUL. ANY AMOUNTS DEEMED UNCOLLECTIBLE ARE WRITTEN OFF ON A MONTHLY BASIS. THE HOSPITAL DOES NOT CHARGE INTEREST ON OUTSTANDING BALANCES OWED.NET PATIENT SERVICE REVENUE:THE HOSPITAL HAS AGREEMENTS WITH THIRD-PARTY PAYERS THAT PROVIDE FOR PAYMENTS TO THE HOSPITAL AT AMOUNTS DIFFERENT FROM ITS ESTABLISHED RATES. PAYMENT ARRANGEMENTS INCLUDE PROSPECTIVELY DETERMINED RATES PER DISCHARGE, REIMBURSED COSTS, DISCOUNTED CHARGES AND PER DIEM PAYMENTS. NET PATIENT SERVICE REVENUE IS REPORTED AT THE ESTIMATED NET REALIZABLE AMOUNTS FROM PATIENTS, THIRD-PARTY PAYERS, AND OTHERS FOR SERVICES RENDERED, INCLUDING ESTIMATED RETROACTIVE ADJUSTMENTS UNDER REIMBURSEMENT AGREEMENTS WITH THIRD-PARTY PAYERS. RETROACTIVE ADJUSTMENTS ARE ACCRUED ON AN ESTIMATED BASIS IN THE PERIOD THE RELATED SERVICES ARE RENDERED AND ADJUSTED IN FUTURE PERIODS AS FINAL SETTLEMENTS ARE DETERMINED.CHARITY CARE:TO FULFILL ITS MISSION OF COMMUNITY SERVICE, THE HOSPITAL PROVIDES CARE TO PATIENTS WHO MEET CERTAIN CRITERIA UNDER ITS CHARITY CARE POLICY WITHOUT CHARGE OR AT AMOUNTS LESS THAN ITS ESTABLISHED RATES. BECAUSE THE HOSPITAL DOES NOT PURSUE COLLECTION OF AMOUNTS DETERMINED TO QUALIFY AS CHARITY CARE, THEY ARE NOT REPORTED AS NET PATIENT SERVICE REVENUE.THE HOSPITAL IS DEDICATED TO PROVIDING COMPREHENSIVE HEALTHCARE SERVICES TO ALL SEGMENTS OF SOCIETY, INCLUDING THE AGED AND OTHERWISE ECONOMICALLY DISADVANTAGED. IN ADDITION, THE HOSPITAL PROVIDES A VARIETY OF COMMUNITY HEALTH SERVICES AT OR BELOW COST. | ||
| PART III, LINE 9B: COMMUNITY MEMORIAL HOSPITAL'S COLLECTIONS POLICY STATES "ALL COLLECTION EFFORTS WILL CEASE IF A COMPLETE CHARITY CARE APPLICATION HAS BEEN RECEIVED OR IF IT IS KNOWN THAT THE PATIENT QUALIFIES FOR PRESUMED CHARITY CARE. THE CFO WILL NOTIFY THE BUSINESS OFFICE MANAGER IN EACH OF THESE CASES. ONCE A DECISION HAS BEEN MADE ON THE CHARITY CARE APPLICATION, COLLECTION EFFORTS WILL STOP IF IT WAS APPROVED, OR CONTINUE WHERE THEY LEFT OFF IF THE APPLICATION WAS DENIED." | ||
| PART V, SECTION B, LINE 20D: CMH CHARGES ALL PATIENTS THE SAME AMOUNT WHEN THE SAME CARE IS GIVEN REGARDLESS OF IF THEY HAVE INSURANCE COVERAGE OR WHAT CARRIER THEY HAVE FOR INSURANCE. IF A PATIENT IS DETERMINED TO BE ELIGIBLE FOR FINANCIAL ASSISTANCE, AN ADJUSTMENT IS MADE TO THEIR ACCOUNT BASED ON THEIR QUALIFYING RATES. | COMMUNITY MEMORIAL HOSPITAL | |
| PART VI, LINE 2: COMMUNITY MEMORIAL HOSPITAL BEGAN THE COMMUNITY HEALTH NEEDS ASSESSMENT PROCESS IN 2012 WITH INTERVIEWS WITH DIFFERENT GROUPS WITHIN THE COMMUNITY AND SURROUNDING COMMUNITIES. THE BOARD REVIEWED THE INITIAL FINDINGS AT THE JUNE 27TH BOARD OF DIRECTORS MEETING AND IDENTIFIED THREE KEY AREAS TO FOCUS ON: ACCESS, MENTAL HEALTH AND VISION SERVICES AVAILABILITY. MANY OF THE BOARD OF DIRECTORS ARE INVOLVED IN VARIOUS GROUPS AND BUSINESSES IN THE COMMUNITY AND RECEIVE INPUT FROM COMMUNITY MEMBERS. THIS COMMUNITY INVOLVEMENT IS INCREASED WITH ANOTHER GROUP OF INDIVIDUALS WHO ARE INVOLVED IN THE HOSPITAL AUXILIARY AND FOUNDATION. IN A SMALLER TOWN, PEOPLE ARE AWARE OF WHO SERVES ON THE HOSPITAL BOARD AND FOUNDATION BOARDS, IN THE AUXILIARY AND HOSPITAL ADMINISTRATION. COMMUNITY MEMBERS FEEL COMFORTABLE APPROACHING THEM WITH THE NEEDS THAT THEY SEE AS A BENEFIT TO THE COMMUNITY, SUCH AS, IMPROVING ACCESS TO SPECIALIST SERVICES WITH INCREASED OFFERINGS OF OUTPATIENT CLINICS WITHIN THE HOSPITAL. THE HOSPITAL SEES ITS ROLE AS CARE OF ILLNESS BUT ALSO IMPROVEMENT OF HEALTH AND WELLNESS. IN REGARD TO THESE GOALS, ALMOST MONTHLY THERE ARE OPPORTUNITIES FOR EDUCATION ON VARIOUS HEALTH TOPICS OFFERED IN THE COMMUNITY. THE HOSPITAL ADDITIONALLY SPONSORS LOCAL INDUSTRY-HOSTED HEALTH FAIRS AND COMMUNITY WELLNESS TESTING. THE WELLNESS TESTING OFFERINGS HAVE SEEN INCREASING PARTICIPATION BY COMMUNITY MEMBERS AND PRESENT THE OPPORTUNITY FOR ADDITIONAL COMMUNITY INPUT. IN THE HOSPITAL PLANNING FOR THE NEW REPLACEMENT FACILITY, A GREAT DEAL OF PREPARATION WORK WAS DONE TO BE SURE TO BUILD FOR THE PRESENT NEEDS AS TO HEALTH SERVICES BUT TO ALSO MAKE SURE THAT WE CAN ADDRESS FUTURE NEEDS. WE KNOW THAT DIAGNOSTIC SERVICES WILL BE AN INCREASING FOCUS AS TO STANDARDS OF CARE. ONE EXAMPLE OF THIS WOULD BE THE SPACE BEING RESERVED AS "SHELL" SPACE SO MRI CAN BE ADDED IN THE FUTURE FOR CRITICAL INTERVENTION FOR STROKE CARE. WE ARE ANXIOUS FOR A MORE FORMAL PROCESS TO GAIN AWARENESS OF THE COMMUNITY HEALTH NEEDS WITH THE ACCUMULATION OF DATA AND INPUT FROM THE HEALTH NEEDS ASSESSMENT 2013 REPORT. | ||
| PART VI, LINE 3: CMH HAS A PAYMENT BROCHURE THAT IS LOCATED AT THE REGISTRATION DESK FOR ALL PATIENTS TO TAKE WITH THEM EXPLAINING OUR PAYMENT TERMS AND THE AVAILABILITY OF FINANCIAL ASSISTANCE. THERE IS ALSO AN AREA ON THE STATEMENTS SENT TO PATIENTS THAT ALLOWS FOR MESSAGES TO BE PRINTED. THE MESSAGE ROTATES, BUT AT TIMES INDICATES THE AVAILABILITY FOR ASSISTANCE FOR THOSE WHO QUALIFY. | ||
| PART VI, LINE 4: CMH'S PRIMARY SERVICE AREA CONSISTS OF FIVE ZIP CODES, WHICH INCLUDE SUMNER (50674), TRIPOLI (50676) WESTGATE (50681), FREDERICKSBURG (50630) AND HAWKEYE (52147). | ||
| PART VI, LINE 5: COMMUNITY MEMORIAL HOSPITAL HAS MADE PURPOSEFUL STEPS TO EXPAND OUTSIDE OF THE INTERNAL CONFINES TO REACH OUT INTO THE COMMUNITY AND SHARE HEALTH-RELATED FINDINGS AND PROGRAMS. ONE AREA THAT HAS BEEN WIDELY ACCEPTED THIS LAST YEAR INVOLVES "ALICE" TRAINING ("ALERT LOCKDOWN INFORM COUNTER EVACUATE"). OUR HOSPITAL PREPAREDNESS STAFF PARTICIPATED IN TRAINING ON THIS THROUGH COUNTY RESOURCES. THEY BROUGHT BACK THIS TRAINING INTERNALLY AND OUTREACHED TO DO THIS TRAINING IN THE LOCAL SCHOOL, BUSINESSES, NURSING HOME, ETC. WE HAVE HAD SEVERAL COMMUNITY-PLANNING SESSIONS ON PREPAREDNESS DRILLS - INVOLVING BUSINESS, SCHOOLS, HEALTHCARE, PUBLIC SERVICES SUCH AS CITY CLERK, FIRE CHIEF, POLICE - SHARING INFORMATION GAINED FROM TRAINING ON THE COUNTY PLANNING LEVEL. WE HELD "CISD" - "CRITICAL INCIDENT STRESS DEBRIEFING" CERTIFIED TRAINING AT THE FACILITY WITH 20 INDIVIDUALS ATTENDING, WHICH INCLUDED COMMUNITY BUSINESS REPRESENTATIVES, HEALTHCARE/NURSING HOMES, SCHOOL ADMINISTRATION, AND REPRESENTATIVES FROM THE MINISTERIAL/CLERGY. | ||
| PART VI, LINE 6: COMMUNITY MEMORIAL HOSPITAL IS NOT PART OF AN AFFILIATED HEALTH CARE SYSTEM. | ||
| IA | REPORTS FILED WITH STATES | PART VI, LINE 7 |
Schedule J IRS990ScheduleJ
| Field | Value | IRS element (for citing) |
|---|---|---|
| Compensation Survey | X | CompensationSurvey |
| Severance Payment | 0 | SeverancePayment |
| Supplemental Nonqual Retire Plan | 0 | SupplementalNonqualRetirePlan |
| Equity Based Comp Arrangement | 0 | EquityBasedCompArrangement |
| Comp Based On Revenue Of Filing Org | 0 | 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 (3 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 |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| MARY WELLS | ||||||||||||||
| CEO | 132049 | 0 | 16487 | 0 | 0 | 0 | 7591 | 0 | 12304 | 0 | 168431 | 0 | 0 | 0 |
| TROY BUCHHOLZ | ||||||||||||||
| PHYSICIAN | 182537 | 0 | 55500 | 0 | 88828 | 0 | 12500 | 0 | 23477 | 0 | 362842 | 0 | 0 | 0 |
| ROBERTA MITTELSTED | ||||||||||||||
| ARNP | 90563 | 0 | 34750 | 0 | 5364 | 0 | 6776 | 0 | 18847 | 0 | 156300 | 0 | 0 | 0 |
Form990 Schedule J Part III Form990ScheduleJPartIII
| Field | Value | IRS element (for citing) |
|---|---|---|
| Return Reference | PART I, LINE 3 | ReturnReference |
| Explanation | THE ORGANIZATION IS JOINTLY OPERATED WITH ALLEN HEALTH SYSTEM. A CEO OF ALLEN HEALTH SYSTEM IS RESPONSIBLE FOR SETTING THE SALARY FOR MARY WELLS, CEO OF CMH. THE CEO OF ALLEN HEALTH SYSTEM USES SALARY SURVEY INFORMATION FROM THE IOWA HOSPITAL ASSOCIATION TO DETERMINE A REASONABLE RANGE FOR THE CEO'S COMPENSATION. | Explanation |
Schedule K IRS990ScheduleK
Form990 Schedule K Part I Form990ScheduleKPartI (2 entries)
| Bond ReferenceBondReferenceCd | Issuer EINIssuerEIN | CUSIP NumberCUSIPNumber | Date IssuedDateIssued | Issue PriceIssuePrice | Description Of PurposeDescriptionOfPurpose | DefeasedDefeased | On Behalf Of IssuerOnBehalfOfIssuer | Pool FinancingPoolFinancing |
|---|---|---|---|---|---|---|---|---|
| CITY OF SUMNER IOWA | ||||||||
| A | 426005269 | 866450AA7 | 2011-12-08 | 9000000 | CONSTRUCTION AND IMPROVEMENTS TO FACILITIES AND REFUND PRIOR BOND ISSUES | 0 | 0 | 0 |
| CITY OF SUMNER IOWA | ||||||||
| B | 426005269 | 866450AB5 | 2012-01-05 | 9000000 | CONSTRUCTION AND EQUIPMENT TO FACILITIES | 0 | 0 | 0 |
Form990 Schedule K Part II Form990ScheduleKPartII (2 entries)
| Bond ReferenceBondReferenceCd | Total ProceedsTotalProceeds | Capitalized InterestCapitalizedInterest | Issuance Costs From ProceedsIssuanceCostsFromProceeds | Capital ExpendituresCapitalExpenditures | Other Spent ProceedsOtherSpentProceeds | Amount UnspentAmountUnspent | Current RefundingCurrentRefunding | Advance RefundingAdvanceRefunding | Final Allocation MadeFinalAllocationMade | Adequate Books And Recds MaintaindAdequateBooksAndRecdsMaintaind |
|---|---|---|---|---|---|---|---|---|---|---|
| A | 9000357 | 75799 | 137170 | 8058571 | 690586 | 38231 | 1 | 0 | 0 | 1 |
| B | 9000763 | 71665 | 128943 | 3635595 | 5164560 | 0 | 0 | 0 | 1 |
Form990 Schedule K Part III Form990ScheduleKPartIII (2 entries)
| Bond ReferenceBondReferenceCd | Owning Bond Financed PropertyOwningBondFinancedProperty | Any Lease ArrangementsAnyLeaseArrangements | Mngment Cntrct Bond Financd PrprtyMngmentCntrctBondFinancdPrprty | Engage Bond Counsel ContractsEngageBondCounselContracts | Any Research AgreementsAnyResearchAgreements | Bond Iss Meet Prvt Security Pay TestBondIssMeetPrvtSecurityPayTest | Change In Use Bond Financed PropChangeInUseBondFinancedProp | Non Qualified Bond Remed ProcdrsNonQualifiedBondRemedProcdrs | Engage Bond Counsel ResearchEngageBondCounselResearch |
|---|---|---|---|---|---|---|---|---|---|
| A | 0 | 0 | 1 | 1 | 0 | 0 | 0 | 0 | |
| B | 0 | 0 | 0 | 1 | 0 | 0 | 0 | 0 |
Form990 Schedule K Part IV Form990ScheduleKPartIV (2 entries)
| Bond ReferenceBondReferenceCd | Form8038 T FiledForm8038TFiled | Rebate Not Due YetRebateNotDueYet | Exception To RebateExceptionToRebate | No Rebate DueNoRebateDue | Variable Rate IssueVariableRateIssue | Hedge Identified In Books And RecdsHedgeIdentifiedInBooksAndRecds | Gross Proceeds Invested In GICGrossProceedsInvestedInGIC | Gross Proceeds InvestedGrossProceedsInvested | Written Proc To Monitor ReqsWrittenProcToMonitorReqs |
|---|---|---|---|---|---|---|---|---|---|
| A | 0 | 1 | 1 | 0 | 0 | 0 | 0 | 0 | 0 |
| B | 0 | 1 | 0 | 0 | 0 | 0 | 0 | 0 | 0 |
Form990 Schedule K Part VI Form990ScheduleKPartVI (2 entries)
| IdentifierIdentifier | Return ReferenceReturnReference | ExplanationExplanation |
|---|---|---|
| FORM 990, SCHEDULE K, PART III, LINE 3(A) | MANAGEMENT OR SERVICE CONTRACTS | THE ORGANIZATION HAS DETERMINED THAT THE SERVICE CONTRACTS ARE QUALIFIED CONTRACTS MEETING THE SAFE HARBOR AVAILABLE UNDER REVENUE PROCEDURE 97-13 AND DO NOT RESULT IN PRIVATE USE. |
| FORM 990, SCHEDULE K, PART II, LINE 3 | THE TOTAL PROCEEDS DO NOT AGREE TO THE ISSUE PRICE IN PART I, COLUMN (E) DUE TO INVESTMENT EARNINGS. |
Schedule L IRS990ScheduleL
Form990 Schedule L Part IV Form990ScheduleLPartIV
Name Of Interested Person NameOfInterestedPerson
| Field | Value | IRS element (for citing) |
|---|---|---|
| Name Person | JUSTIN TRAINOR | NamePerson |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Relationship | SPOUSE OF CFO | Relationship |
| Amount Of Transaction | 402502 | AmountOfTransaction |
| Description Of Transaction | PERFORMANCE REHAB IS 40% OWNED BY JUSTIN TRAINOR, THE SPOUSE OF SARA TRAINOR, CFO. THE ENTITY PROVIDES PHYSICAL AND OCCUPATIONAL THERAPIES AT CMH. PERFORMANCE REHAB'S COMPENSATION FROM CMH IS CALCULATED AS A PERCENTAGE OF CMH'S NET REIMBURSEMENT FOR THERAPY SERVICES. | DescriptionOfTransaction |
| Sharing Of Revenues | 1 | SharingOfRevenues |
Schedule O IRS990ScheduleO
General Explanation GeneralExplanation (11 entries)
| Return ReferenceReturnReference | ExplanationExplanation | IdentifierIdentifier |
|---|---|---|
| FORM 990, PART VI, SECTION A, LINE 3 | THE ORGANIZATION HAS A MANAGEMENT CONTRACT WITH ALLEN HEALTH SYSTEMS. | |
| FORM 990, PART VI, SECTION A, LINE 6 | THE ORGANIZATION'S ARTICLES OF INCORPORATION PROVIDE THAT THE CORPORATION "HAS NO CAPITAL STOCK AND THE CAPITAL OF THIS ASSOCIATION SHALL BE THE MEMBERSHIP FEES . . . FIXED BY THE BOARD OF DIRECTORS". ANYONE IN THE COMMUNITY MAY BE A MEMBER OF THE CORPORATION UPON PAYMENT OF THE $1 MEMBERSHIP FEE, AS FIXED BY THE BOARD OF DIRECTORS ACCORDING TO THE BYLAWS. THE ORGANIZATION'S MEMBERS ELECT THE BOARD OF DIRECTORS. | |
| FORM 990, PART VI, SECTION A, LINE 7A | EACH BOARD OF DIRECTOR SHALL BE ELECTED BY THE LARGEST VOTE CAST BY THE MEMBERS PRESENT AT THE ANNUAL MEETING. ABSENTEE BALLOTS WILL BE ALLOWED FOR EMPLOYEES WORKING AT COMMUNITY MEMORIAL HOSPITAL DURING THE ACTUAL HOURS OF THE ANNUAL MEETING. | |
| FORM 990, PART VI, SECTION A, LINE 7B | IN 2003, COMMUNITY MEMORIAL HOSPITAL (CMH) ENTERED INTO AN OPERATING AGREEMENT WITH ALLEN HEALTH SYSTEM (AHS). UNDER THE TERMS OF THAT AGREEMENT, A JOINT GOVERNANCE STRUCTURE WAS ESTABLISHED, WHEREBY AHS AND THE BOARD OF DIRECTORS OF CMH EXERCISE JOINT AUTHORITY FOR THE OPERATION OF THE HOSPITAL. WHILE AHS HAS DAY-TO-DAY OPERATIONAL CONTROL, CERTAIN GOVERNANCE AUTHORITY ACTIONS REQUIRE THE PARTICIPATION OF BOTH AHS AND CMH'S BOARD OF DIRECTORS. | |
| FORM 990, PART VI, SECTION B, LINE 11 | THE IRS FORM 990 IS PRESENTED TO THE CMH BOARD OF DIRECTORS AT A REGULARLY SCHEDULED MONTHLY MEETING FOR REVIEW. IT WILL BE NOTED AS AN AGENDA ITEM UNDER "NEW BUSINESS" AND REQUIRES THE PROPER APPROVAL FROM THE BOARD PRIOR TO BEING SUBMITTED TO IRS. | |
| FORM 990, PART VI, SECTION B, LINE 12C | THE BOARD OF DIRECTORS AND KEY EMPLOYEES ARE REQUIRED TO ANNUALLY COMPLETE A CONFLICT OF INTEREST DISCLOSURE/QUESTIONNAIRE. THESE ARE REVIEWED BY THE CEO AND BOARD CHAIR. EACH MONTH THERE IS AN AGENDA ITEM AT THE BOARD MEETING FOR ANY CONFLICTS RELATED TO THE REST OF THE AGENDA TO BE DISCLOSED. IF NONE ARE NOTED, BUT THE BOARD CHAIR FEELS ONE EXISTS, IT IS THE CHAIR'S RESPONSIBILITY TO INQUIRE ABOUT IT BEFORE PROCEEDING. WHEN THERE IS A CONFLICT OF INTEREST, THE PERSON WITH THE CONFLICT ABSTAINS FROM VOTING. | |
| FORM 990, PART VI, SECTION C, LINE 19 | THE ORGANIZATION DOES NOT MAKE ITS GOVERNING DOCUMENTS, CONFLICT OF INTEREST POLICY, AND FINANCIAL STATEMENTS AVAILABLE TO THE PUBLIC. HOWEVER, FINANCIAL STATEMENTS ARE MADE AVAILABLE AT THE SUMNER COMMUNITY CLUB MEETING AND A PERSON MAY BECOME A MEMBER OF THE SUMNER COMMUNITY CLUB BY PAYING THE $1.00 MEMBERSHIP FEE. | |
| FORM 990, PART IX, LINE 11G | OUTSIDE SERVICES: PROGRAM SERVICE EXPENSES 718,223. MANAGEMENT AND GENERAL EXPENSES 195,418. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 913,641. EMERGENCY ROOM SPECIALIST FEES: PROGRAM SERVICE EXPENSES 776,005. MANAGEMENT AND GENERAL EXPENSES 0. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 776,005. PHARMACY SPECIALIST FEES: PROGRAM SERVICE EXPENSES 376,363. MANAGEMENT AND GENERAL EXPENSES 0. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 376,363. | OTHER FEES |
| FORM 990, PART XI, LINE 9: | IMPAIREMENT LOSS ON PROPERTY & EQUIPMENT -111,567. | CHANGES IN NET ASSETS OR FUND BALANCES: |
| FORM 990, PAGE 12, PART XII, LINE 2C: | THERE HAVE BEEN NO CHANGES FROM THE PRIOR YEAR. THE BOARD OF DIRECTORS HAS THE RESPONSIBILITY OF SELECTING THE INDEPENDENT ACCOUNTANT. THE FINANCE COMMITTEE OF THE BOARD OF DIRECTORS HAS THE RESPONSIBILITY FOR THE OVERSIGHT OF THE AUDIT. UPON CONCLUSION OF THE AUDIT, THE AUDITING FIRM PRESENTS THE RESULTS AND FINDINGS TO THE BOARD OF DIRECTORS. | COMMITTEE WITH OVERSIGHT OF THE AUDIT |
| FORM 990, PAGE 6, PART VI, SECTION B, LINE 15 | THE ORGANIZATION IS JOINTLY OPERATED WITH ALLEN HEALTH SYSTEM. A CEO OF ALLEN HEALTH SYSTEM IS RESPONSIBLE FOR SETTING THE SALARY FOR MARY WELLS, CEO OF CMH. THE CEO OF ALLEN HEALTH SYSTEM USES SALARY SURVEY INFORMATION FROM THE IOWA HOSPITAL ASSOCIATION TO DETERMINE A REASONABLE RANGE FOR THE CEO'S COMPENSATION. THE CMH CEO IS RESPONSIBLE FOR SETTING THE SALARIES OF SARA TRAINOR, CFO AND LYNNE NIEMANN, DIRECTOR OF NURSING (BOTH ARE OFFICERS). COMPARABILITY DATA IS ALSO USED IN SETTING THE OFFICERS' COMPENSATION. | PROCESS FOR DETERMINING COMPENSATION |
Schedule R IRS990ScheduleR
Form990 Schedule R Part II Form990ScheduleRPartII
Name Of Disregarded Entity NameOfDisregardedEntity
| Field | Value | IRS element (for citing) |
|---|---|---|
| Business Name Line1 | FRIENDS OF CMH SUMNER COMMUNITY MEMORIAL HOSPITAL FOUNDATION | BusinessNameLine1 |
Address US AddressUS
| Field | Value | IRS element (for citing) |
|---|---|---|
| Address Line1 | 909 W 1ST STREET | AddressLine1 |
| City | SUMNER | City |
| State | IA | State |
| ZIP Code | 50674 | ZIPCode |
| Field | Value | IRS element (for citing) |
|---|---|---|
| EIN | 421408693 | EIN |
| Primary Activities | HOSPITAL FOUNDATION | PrimaryActivities |
| Legal Domicile State | IA | LegalDomicileState |
| Exempt Code Section | 501(C)(3) | ExemptCodeSection |
| Public Charity Status | 7 | PublicCharityStatus |
Direct Controlling Entity Name DirectControllingEntityName
| Field | Value | IRS element (for citing) |
|---|---|---|
| Business Name Line1 | SUMNER COMMUNITY CLUB | BusinessNameLine1 |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Controlled Org | 1 | ControlledOrg |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Receipt Of Int Ann Rents Royalties | 0 | ReceiptOfIntAnnRentsRoyalties |
| Gift Grant Or Cap Contr To Other Org | 0 | GiftGrantOrCapContrToOtherOrg |
| Gift Grant Or Cap Contr Fr Other Org | 1 | GiftGrantOrCapContrFrOtherOrg |
| Loans Or Guarantees To Other Org | 0 | LoansOrGuaranteesToOtherOrg |
| Loans Or Guarantees From Other Org | 0 | LoansOrGuaranteesFromOtherOrg |
| Dividends Related Organization | 0 | DividendsRelatedOrganization |
| Sale Of Assets To Other Org | 0 | SaleOfAssetsToOtherOrg |
| Purchase Of Assets From Other Org | 0 | PurchaseOfAssetsFromOtherOrg |
| Exchange Of Assets | 0 | ExchangeOfAssets |
| Rental Of Facilities To Other Orgs | 0 | RentalOfFacilitiesToOtherOrgs |
| Rental Of Facilities Fr Other Orgs | 0 | RentalOfFacilitiesFrOtherOrgs |
| Perform Of Services For Other Orgs | 0 | PerformOfServicesForOtherOrgs |
| Perform Of Services By Other Orgs | 1 | PerformOfServicesByOtherOrgs |
| Sharing Of Facilities | 1 | SharingOfFacilities |
| Sharing Of Paid Employees | 1 | SharingOfPaidEmployees |
| Reimbursement Paid To Other Org | 0 | ReimbursementPaidToOtherOrg |
| Reimbursement Paid By Other Org | 1 | ReimbursementPaidByOtherOrg |
| Other Transfer To Other Org | 0 | OtherTransferToOtherOrg |
| Other Transfer From Other Org | 0 | OtherTransferFromOtherOrg |
Transactions Related Orgs Table TransactionsRelatedOrgsTable
Name Of Other Organization NameOfOtherOrganization
| Field | Value | IRS element (for citing) |
|---|---|---|
| Business Name Line1 | FRIENDS OF CMH SUMNER COMMUNITY MEMORIAL HOSPITAL FOUNDATION | BusinessNameLine1 |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Transaction Type | C | TransactionType |
| Amount Involved | 1604984 | AmountInvolved |
Comments