2013-11-04T10:14:40-06:00 2012-12-31 476097913 SEIM JOHNSON LLP 18081 BURT STREET SUITE 200 OMAHA NE 680224722 990 2012-01-01 420670596 SUMNER COMMUNITY CLUB D/B/A COMMUNITY MEMORIAL HOSPITAL SUMN 5635783275 909 W 1ST STREET PO BOX 148 SUMNER IA 506740148 MARY S WELLS 5635783275 2013-10-30 1 BARBARA J FAJEN P00400874 4023302660 2012 2016-02-24 21:20:13Z MARY S WELLS 909 W 1ST STREET PO BOX 148 SUMNER IA 506740148 11390517 0 X WWW.CMHSUMNER.ORG X 1950 IA COMMUNITY MEMORIAL HOSPITAL SERVES THE AREA THROUGH ITS HEALTHCARE AND EDUCATIONAL SERVICES. WE EMPHASIZE CONCERN FOR THE QUALITY OF A PERSON'S LIFE, THROUGH EVERY MEASURE INTENDED TO PRESERVE LIFE WITH DIGNITY AND RESPECT. WE ARE DEDICATED TO CREATING AND MAINTAINING AN ENVIRONMENT SUPPORTING EXCELLENCE IN HEALTHCARE. WE PROVIDE QUALIFIED AND PROPERLY TRAINED PERSONNEL AND MEDICAL STAFF IN AN ATMOSPHERE WHICH INSPIRES A CREATIVE APPROACH TO THE COMPLEX HEALTHCARE CHALLENGES OF TODAY AND TOMORROW. 12 12 0 0 1586 -787 240028 1694875 9454740 9527751 14433 -6172 81493 149207 9790694 11365661 0 0 0 0 4902735 5088957 0 0 0 4468049 4766967 9370784 9855924 419910 1509737 20417085 30929002 11938897 20970674 8478188 9958328 X TO PROVIDE QUALITY HEALTH CARE TO THE PEOPLE OF SUMNER AND SURROUNDING AREAS, WHILE COORDINATING OTHER NEEDED SERVICES. 0 0 1019576 1111830 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. 885088 1783422 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. 880236 358112 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. 5571079 6291173 VARIOUS INPATIENT AND OTHER HEALTH CARE SERVICES. 5571079 6291173 8355979 1 1 0 0 0 0 0 0 0 1 1 1 0 0 1 1 0 1 0 0 0 0 0 0 0 0 1 1 0 0 1 1 0 0 0 0 0 0 0 0 1 1 0 0 0 0 0 1 1 1 0 0 1 11 0 1 0 1 1 0 0 0 0 0 0 0 0 0 X 12 12 0 1 0 0 1 1 1 1 1 0 0 1 1 1 1 1 1 0 0 0 X DAWN EVERDING 5635783275 909 WEST 1ST STREET PO BOX 148 SUMNER IA 50674 PAUL BAHE 1.30 0.80 X X 0 0 0 MIKE MEYER 1.30 0.00 X X 0 0 0 DEB TOENGES 1.30 0.00 X X 0 0 0 DEB BECKNER 0.80 0.00 X 0 0 0 CONNIE LEICHER 0.80 0.00 X 0 0 0 RANDIE MUELLER 0.80 0.00 X 0 0 0 LUARA NECKER 0.80 0.00 X 0 0 0 DIANE PAGEL 0.80 0.00 X 0 0 0 RICK PEDERSON 0.80 0.00 X 0 0 0 BILL SCHWAKE 0.80 0.80 X 0 0 0 DAVE VOSS 0.80 0.00 X 0 0 0 JENNIFER YEAROUS 0.80 0.00 X 0 0 0 MARY WELLS 38.00 2.00 X 148536 0 19895 SARA TRAINOR 39.50 0.50 X 112499 0 28292 LYNNE NIEMANN 39.70 0.30 X 90062 0 15932 TROY BUCHHOLZ 40.00 0.00 X 326865 0 35977 ROBERTA MITTELSTED 40.00 0.00 X 130677 0 25623 808639 0 125719 4 0 1 0 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 10 1604984 17725 72166 1694875 MEDICARE/MEDICAID PAYM 621400 6081673 6081673 PATIENT REVENUE - PRIVATE PAY 621400 3423513 3423513 COMMUNITY WELLNESS 621990 22565 22565 9527751 17884 17884 26768 0 26768 26768 26768 800 24856 -24056 -24056 -24056 AMH OPERATING AGREEMENT INCOME 561000 78978 78978 CAFETERIA EMPLOYEES 900099 25089 25089 MISCELLANEOUS INCOME 900099 16786 16786 1586 1586 122439 11365661 9544537 1586 124663 X 309222 309222 42738 42738 3688045 3103703 584342 696053 586610 109443 352899 282213 70686 60000 60000 113262 113262 2066009 1870591 195418 26290 26290 459642 409239 50403 132819 132819 45483 38314 7169 13514 13514 775698 775698 62039 62039 MEDICAL SUPPLIES 616399 616399 PROVISION FOR BAD DEBT 230818 230818 DUES AND SUBSCRIPTIONS 141137 141137 MISC. EXPENSES 23857 23857 9855924 8355979 1499945 0 100 100 2766551 3435704 545171 1611764 1301417 110936 108269 72771 302422 21472222 5422436 4157465 16049786 7434698 5204499 3544459 4171601 173170 355204 20417085 30929002 2070548 2885944 9000000 18000000 185706 62978 682643 21752 11938897 20970674 X 4571957 5786727 425039 0 3481192 4171601 8478188 9958328 20417085 30929002 X 1509737 627142 -545172 -111567 X X 0 1 X 1 1 1 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 3544459 858953 231811 4171601 2684825 1033086 173452 3544459 2638298 110582 64055 2684825 2634633 58750 55085 2638298 2889909 -246778 8498 2634633 1.00000 1 0 100421 100421 2684715 2689573 -4858 3980405 2649518 1330887 14706681 83345 14623336 16049786 PERPETUAL TRUST 4171601 F 4171601 CAPITALIZED LEASE OBLIGATIONS 21752 21752 X 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. 1 1 1 X 125.000000000000 1 X 1 1 0 1 0 50414 0 50414 0.00520 515923 515080 843 0.00010 566337 515080 51257 0.00530 22304 3127 19177 0.00200 94461 0 94461 0.00980 238971 30720 208251 0.02160 0 0 16086 0 16086 0.00170 371822 33847 337975 0.03510 938159 548927 389232 0.04040 1 230818 51000 4790858 4743424 47434 X 1 1 1 1 SUMNER COMMUNITY CLUB DBA COMMUNITY

MEMORIAL HOSP 909 W 1ST ST PO BOX 148 SUMNER IA 50674

X X X PROVIDER-BASED MEDICAL CLINIC COMMUNITY MEMORIAL HOSPITAL 1 1 1 125.000000000000 1 300.000000000000 0 1 1 X 1 0 1 X 0 0 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." COMMUNITY MEMORIAL HOSPITAL 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. 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. REPORTS FILED WITH STATES PART VI, LINE 7 IA X 0 0 0 0 0 0 0 0 0 MARY WELLS 132049 0 16487 0 0 0 7591 0 12304 0 168431 0 0 0 TROY BUCHHOLZ 182537 0 55500 0 88828 0 12500 0 23477 0 362842 0 0 0 ROBERTA MITTELSTED 90563 0 34750 0 5364 0 6776 0 18847 0 156300 0 0 0 PART I, LINE 3 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. A CITY OF SUMNER IOWA 426005269 866450AA7 2011-12-08 9000000 CONSTRUCTION AND IMPROVEMENTS TO FACILITIES AND REFUND PRIOR BOND ISSUES 0 0 0 B CITY OF SUMNER IOWA 426005269 866450AB5 2012-01-05 9000000 CONSTRUCTION AND EQUIPMENT TO FACILITIES 0 0 0 A 9000357 75799 137170 8058571 690586 38231 1 0 0 1 B 9000763 71665 128943 3635595 5164560 0 0 0 1 A 0 0 1 1 0 0 0 0 B 0 0 0 1 0 0 0 0 A 0 1 1 0 0 0 0 0 0 B 0 1 0 0 0 0 0 0 0 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. JUSTIN TRAINOR SPOUSE OF CFO 402502 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. 1 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. OTHER FEES 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. CHANGES IN NET ASSETS OR FUND BALANCES: FORM 990, PART XI, LINE 9: IMPAIREMENT LOSS ON PROPERTY & EQUIPMENT -111,567. COMMITTEE WITH OVERSIGHT OF THE AUDIT 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. PROCESS FOR DETERMINING COMPENSATION 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. FRIENDS OF CMH SUMNER COMMUNITY MEMORIAL HOSPITAL FOUNDATION 909 W 1ST STREET SUMNER IA 50674 421408693 HOSPITAL FOUNDATION IA 501(C)(3) 7 SUMNER COMMUNITY CLUB 1 0 0 1 0 0 0 0 0 0 0 0 0 1 1 1 0 1 0 0 FRIENDS OF CMH SUMNER COMMUNITY MEMORIAL HOSPITAL FOUNDATION C 1604984