2012-05-09T14:00:35-05:00 2011-06-30 EIDE BAILLY LLP 3999 PENNSYLVANIA AVE SUITE 100 DUBUQUE IA 52002 990 2010-07-01 420818642 CENTRAL COMMUNITY HOSPITAL CENT 5632457000 901 DAVIDSON ST NW ELKADER IA 520439015 FRANCES ZICHAL 5632457000 2012-05-08 1 CARMEN KRANTZ 5635561790 2012-05-04 2010 2016-02-24 21:20:13Z FRANCES ZICHAL 901 DAVIDSON ST NW ELKADER IA 520439015 6240173 0 X WWW.CENTRALCOMMUNITYHOSPITAL.COM X 1961 IA PROVIDE HEALTHCARE SERVICES TO THE SURROUNDING COMMUNITY 8 7 81 37 0 0 113245 50569 5722442 5988393 2317 9815 38493 39861 5876497 6088638 7651 0 0 0 2439950 2578432 0 0 47725 3239535 3311943 5687136 5890375 189361 198263 6468661 5897745 1338736 565379 5129925 5332366 X WORKING TOGETHER TO PROVIDE A PERSONALIZED, HEALING EXPERIENCE 0 0 4684959 5988393 CENTRAL COMMUNITY HOSPITAL IS A 25-BED CRITICAL ACCESS HOSPITAL SERVING RESIDENTS OF CLAYTON COUNTY, IOWA. REQUIREMENTS OF THE IRS COMMUNITY BENEFIT STANDARD FOR TAX-EXEMPT ORGANIZATIONS ARE INTEGRAL TO CENTRAL COMMUNITY HOSPITAL'S CHARITABLE MISSION. CENTRAL COMMUNITY HOSPITAL IS GOVERNED BY AN INDEPENDENT BOARD, WHICH INCLUDES COMMUNITY LEADERS, CONSUMER REPRESENTATIVES AND BUSINESS EXPERTS. THE BOARD HAS A HISTORY OF COMMITMENT TO ACTING WITH THE HIGHEST INTEGRITY. DURING THIS YEAR, THE BOARD WORKED WITH MANAGEMENT TO CONTINUE TO MAKE IMPROVEMENTS TO ASSURE THE ORGANIZATION IS IN COMPLIANCE WITH ALL RULES AND REGULATIONS GOVERNING THE HEALTHCARE INDUSTRY AND NON-PROFIT ORGANIZATIONS.CENTRAL COMMUNITY HOSPITAL MAKES CARE ACCESSIBLE TO THE ENTIRE COMMUNITY IT SERVES. CENTRAL COMMUNITY HOSPITAL OPERATES A FULL-TIME EMERGENCY ROOM AND PROVIDES CARE REGARDLESS OF ABILITY TO PAY. CENTRAL COMMUNITY HOSPITAL HAD OVER 2,098 EMERGENCY VISITS THIS YEAR. THE HOSPITAL WORKS WITH THE CITY OF ELKADER TO PROVIDE EMERGENCY RESPONSE AND EMERGENCY TRANSPORT SERVICES FOR THE LOCAL COMMUNITIES. THIS YEAR THE HOSPITAL PROVIDED 542 DAYS OF INPATIENT CARE AND 9,046 OUTPATIENT VISITS TO THE RESIDENTS IN THE SERVICE AREA. CENTRAL COMMUNITY HOSPITAL PROVIDED CARE AT MANY LEVELS INCLUDING SCU, ACUTE, SKILLED, INTERMEDIATE, SAME-DAY-SURGERY, OBSERVATION, OUTPATIENT, AND REHAB SERVICES. IN ADDITION, CENTRAL COMMUNITY HOSPITAL PROVIDES NON-EMERGENCY SERVICES. THESE SERVICES ARE ACCESSIBLE TO THE COMMUNITY THROUGH PARTICIPATION IN GOVERNMENT PROGRAMS LIKE MEDICARE AND MEDICAID. FINANCIAL COUNSELING IS AVAILABLE TO PATIENTS. CENTRAL COMMUNITY HOSPITAL TAKES ITS MISSION TO IMPROVE THE HEALTH AND QUALITY OF LIFE OF THE PEOPLE IT SERVES A STEP FURTHER BY REACHING OUT TO MEET THE BROAD HEALTH NEEDS OF THE COMMUNITY. IT STRIVES TO IDENTIFY COMMUNITY NEEDS BEYOND BASIC HEALTHCARE, WORKING COLLABORATIVELY WITH OTHER COMMUNITY ORGANIZATIONS. NEEDS ASSESSMENTS ARE COMPLETED EVERY THREE YEARS AND UPDATED ANNUALLY BY A COUNTY WIDE MULTI-DISCIPLINARY TEAM AND USED TO PRIORITIZE COMMUNITY PROJECTS.THE HOSPITAL MAINTAINS RECORDS TO IDENTIFY AND MONITOR THE LEVEL OF CHARITY CARE IT PROVIDES. THESE RECORDS INCLUDE THE AMOUNT OF CHARGES FORGONE FOR SERVICES AND SUPPLIES FURNISHED UNDER ITS CHARITY CARE POLICY. THE AMOUNTS OF CHARGES FOREGONE WERE $204,722 FOR THE YEAR ENDED JUNE 30, 2011. THE ESTIMATED COSTS OF THE CHARGES FOREGONE, BASED UPON AN OVERALL COST-TO-CHARGE RATIO CALCULATION, FOR THE YEAR ENDED JUNE 30, 2011 WAS $135,000.IN ADDITION, THE HOSPITAL 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 HOSPITAL ALSO COMMITS SIGNIFICANT TIME AND RESOURCES TO ENDEAVORS AND CRITICAL SERVICES WHICH MEET OTHERWISE UNFULFILLED COMMUNITY NEEDS. MANY OF THESE ACTIVITIES ARE SPONSORED WITH THE KNOWLEDGE THAT THEY WILL NOT BE SELF-SUPPORTING OR FINANCIALLY VIABLE. 4684959 1 0 0 0 0 0 0 1 0 1 0 0 0 1 1 1 0 0 0 0 0 0 0 0 0 1 1 0 0 0 0 0 0 0 0 0 1 0 0 0 0 0 0 1 0 0 0 0 1 22 0 1 81 1 0 0 0 0 0 0 0 0 0 0 X 8 7 0 1 0 0 1 1 0 1 1 0 0 1 1 1 1 1 1 1 1 0 IA X PAT BOREL 5632457000 901 DAVIDSON ST NW ELKADER IA 520439015 X ROBERT BODENSTEINER 0.50 X X 0 0 0 HILA GARMS 0.50 X X 0 0 0 TOM NEUHAUS 0.50 X X 0 0 0 RANDALL JOHNSON 0.50 X X 0 0 0 DIANE ERICKSON 0.50 X 0 0 0 DARWIN WINKE 0.50 X 0 0 0 RUSSELL KNIGHT 0.50 X 0 0 0 JENNIFER COWSERT 0.50 X 0 0 0 MARK ZWANZIGER 0.50 X 0 0 0 FRANCES ZICHAL 40.00 X 114434 0 15552 PAT BOREL 40.00 X 0 0 0 LISA MANSON 40.00 X 80445 0 16151 194879 0 31703 1 0 0 0 WAPITI BOX 92 NEWELL SD 57760 ER PHYSICIANS 366607 NORTHERN IOWA THERAPY 1810 4TH ST SW SUITE 103 WAVERLY IA 50677 PT, OT, ST 363752 MERCY MEDICAL CENTER - DUBUQUE 250 MERCY DRIVE DUBUQUE IA 52001 PURCHASED SERVICES 328026 3 37112 13457 50569 PATIENT SERVICE REVENU 622110 5919463 5919463 OTHER SUPPORTING REVEN 900099 34992 34992 LIFELINE REVENUE 900099 33938 33938 5988393 9815 9815 53690 13829 39861 39861 39861 137706 137706 0 0 6088638 5988393 0 49676 229118 229118 44273 44273 1804184 1558427 245757 46630 40262 6368 316207 275886 40321 138020 119553 18467 47391 47391 39238 39238 1723379 1605551 117372 456 1631 1531 100 513217 406724 103597 2896 143254 143254 115574 112862 2712 4703 4703 447238 447238 68280 68280 BAD DEBT EXPENSE 69591 69591 138447 44162 94285 5890375 4684959 1157691 47725 1379378 963865 38091 2665 678978 649038 79287 79182 116444 190154 8138531 4819149 3502618 3319382 529284 536610 144581 154201 0 2648 6468661 5897745 433380 364387 360592 544764 200992 1338736 565379 X 4948503 5140932 181422 191434 5129925 5332366 6468661 5897745 X 198263 4178 X 0 1 1 X 0 X 1 10599 8894 3452 16041 0 26015 26015 3951846 1681831 2270015 4160670 3137318 1023352 3319382 RELATED PARTY PAYABLE 113091 CAPITALIZED LEASE OBLIGATIONS 60901 ESTIMATED THIRD-PARTY PAYOR SETTLEMENTS 27000 200992 6088638 5890375 198263 4178 4178 202441 5976322 -113091 -113091 6089413 -775 -775 6088638 5787661 13829 13829 5773832 116543 116543 5890375 PART IV, LINE 1B: CENTRAL COMMUNITY HOSPITAL AUXILIARY USES THE HOSPITAL'S FEIN BUT HAS ITS OWN CHECKING ACCOUNT. THE AUXILIARY ACCOUNT BALANCES WERE NOT INCLUDED IN THE FINANCIAL STATEMENTS. DESCRIPTION OF UNCERTAIN TAX POSITIONS UNDER FIN 48: PART X: THE HOSPITAL BELIEVES THAT IT HAS APPROPRIATE SUPPORT FOR ANY TAX POSITIONS TAKEN AFFECTING ITS ANNUAL FILING REQUIREMENTS, AND AS SUCH, DOES NOT HAVE ANY UNCERTAIN TAX POSITIONS THAT ARE MATERIAL TO THE FINANCIAL STATEMENTS. THE HOSPITAL WOULD RECOGNIZE FUTURE ACCRUED INTEREST AND PENALTIES RELATED TO UNRECOGNIZED TAX BENEFITS AND LIABILITIES IN INCOME TAX EXPENSE IF SUCH INTEREST AND PENALTIES ARE INCURRED. PART XI, LINE 8 - OTHER ADJUSTMENTS: CHANGE IN INTEREST IN NET ASSETS OF CENTRAL COMMUNITY HOSPITAL FOUNDATION 9,620. CHANGE IN CENTRAL COMMUNITY HOSPITAL AUXILIARY ASSETS -5,442. PART XII, LINE 2D - OTHER ADJUSTMENTS: AFFILIATION AGREEMENT EXPENSE INCLUDED IN REVENUE FOR FINANCIAL STATEMENTS -113,091. PART XII, LINE 4B - OTHER ADJUSTMENTS: CONTRIBUTIONS RECORDED IN FUND BALANCE FOR FINANCIAL STATEMENTS 3,768. MONONA CLINIC RENT EXPENSES INCLUDED IN REVENUE ON FORM 990 -13,829. RESTRICTED DONATIONS RECORDED IN FUND BALANCE FOR FINANCIAL STATEMENTS 392. CENTRAL COMMUNITY HOSPITAL AUXILIARY REVENUE INCLUDED ON FORM 990 8,894. PART XIII, LINE 2D - OTHER ADJUSTMENTS: MONONA CLINIC RENT EXPENSES INCLUDED IN REVENUE ON FORM 990 13,829. PART XIII, LINE 4B - OTHER ADJUSTMENTS: AFFILIATION AGREEMENT EXPENSE INCLUDED IN REVENUE FOR FINANCIAL STATEMENTS 113,091. CENTRAL COMMUNITY HOSPITAL AUXILIARY EXPENSES INCLUDED ON FORM 990 3,452. 1 1 X 1 X 1 X 1 1 1 0 1 0 135000 135000 0.02320 346174 346174 481174 346174 135000 0.02320 10453 10453 0.00180 768590 688026 80564 0.01380 779043 688026 91017 0.01560 1260217 1034200 226017 0.03880 2 1568 1568 0.00030 1 6442 6442 0.00110 2 2352 2352 0.00040 5 10362 10362 0.00180 0 41602 11757 2939685 2910580 29105 X 1 1 1 1 CENTRAL COMMUNITY HOSPITAL

901 DAVIDSON ST NW ELKADER IA 520439015

X X X X NOT REQUIRED 1 PART I, LINE 7: CHARITY CARE EXPENSE WAS REPORTED AT COST ON LINE 7A BASED ON AN OVERALL COST-TO-CHARGE RATIO WHICH ADDRESSES ALL PATIENT SEGMENTS. UNREIMBURSED MEDICAID ON LINE 7B WAS CALCULATED USING THE COSTING METHODS TO PREPARE THE COST REPORTS. COMMUNITY HEALTH IMPROVEMENT SERVICES, LINE 7E, WAS REPORTED BASED ON ACTUAL EXPENSES RECORDED IN THE ORGANIZATION'S GENERAL LEDGER. THE COST FOR SUBSIDIZED HEALTH SERVICES ON LINE 7G WAS DETERMINED USING THE MEDICARE COST REPORT. PART I, L7 COL(F): THE AMOUNT OF BAD DEBT EXPENSE BACKED OUT OF TOTAL EXPENSES TO DETERMINE THE PERCENTAGE WAS $69,591. PART II: WE MAKE EVERY EFFORT TO HAVE A CONSTANT PRESENCE AT THE COMMUNITY LEVEL TO PROMOTE HEALTH RELATED ACTIVITIES AND REPORT ON THE VALUE A HOSPITAL BRINGS TO A SMALL COMMUNITY. BASED ON OUR HEALTH NEEDS ASSESSMENT, WE ENCOURAGE THE INVOLVEMENT OF ALL COMMUNITY ORGANIZATIONS IN ACTIVITIES TO PROMOTE BETTER HEALTH FOR OUR SERVICE AREA RESIDENTS. WE HAVE A STRONG PRESENCE IN OUR LOCAL SCHOOL SYSTEMS BY DEVELOPING SCHOOL WELLNESS POLICIES AND TRYING TO PROMOTE GOOD HEALTH HABITS AT AN EARLY AGE. CENTRAL COMMUNITY HOSPITAL IS ALSO INVOLVED IN PUBLIC HEALTH EMERGENCY PREPAREDNESS ACTIVITIES INCLUDING DRILLS AND EXERCISES, MISSION HEALTH DRUG PROGRAM, COMMUNITY HEALTH WORK GROUPS, INFECTION CONTROL MEETINGS ON POLICIES AND PROCEDURES, AND NE IOWA LEADERSHIP AND ECONOMIC DEVELOPMENT MEETINGS TO TRY TO CREATE ADDITIONAL EMPLOYMENT OPPORTUNITIES. WE ARE ALSO ACTIVE IN THE NORTHEAST IOWA FOOD AND FITNESS INITIATIVE. PART III, LINE 4: THE ORGANIZATION'S BAD DEBT EXPENSE AT COST WAS CALCULATED USING THE EXPENSE REPORTED ON THE FINANCIAL STATEMENTS AND APPLYING AN OVERALL COST-TO-CHARGE RATIO CALCULATED FROM WORKSHEET 2.ALL FORMS OF PAYMENT, INCLUDING SELF-PAY, INSURANCE, CONTRACTUAL ALLOWANCES, AND DISCOUNTS, ARE APPLIED TO THE PATIENT'S ACCOUNT BEFORE THE ACCOUNT IS CLASSIFIED AS BAD DEBT. A PAYMENT RECEIVED ON AN ACCOUNT PREVIOUSLY WRITTEN OFF AS BAD DEBT REDUCES BAD DEBT EXPENSE. CENTRAL COMMUNITY HOSPITAL DOES NOT REFUSE SERVICES TO PATIENTS THAT GENERATE BAD DEBT.THE ESTIMATED AMOUNT OF THE ORGANIZATION'S BAD DEBT EXPENSE ATTRIBUTABLE TO PATIENTS ELIGIBLE UNDER THE ORGANIZATION'S CHARITY CARE POLICY IS CALCULATED BASED ON THE PERCENTAGE OF INCOMPLETE APPLICATIONS. OF THE 46 TOTAL CHARITY CARE APPLICATIONS, 13 WERE NOT COMPLETED AND THEREFORE THE ACCOUNTS WERE WRITTEN OFF TO BAD DEBT. FINANCIAL STATEMENT FOOTNOTE: THE CARRYING AMOUNT OF PATIENT RECEIVABLES IS REDUCED BY A VALUATION ALLOWANCE THAT REFLECTS MANAGEMENT'S ESTIMATE OF AMOUNTS THAT WILL NOT BE COLLECTED FROM PATIENTS AND THIRD-PARTY PAYORS. MANAGEMENT REVIEWS PATIENT RECEIVABLES BY PAYOR CLASS AND APPLIES PERCENTAGES TO DETERMINE ESTIMATED AMOUNTS THAT WILL NOT BE COLLECTED FROMTHIRD PARTIES UNDER CONTRACTUAL AGREEMENTS AND AMOUNTS THAT WILL NOT BE COLLECTED FROM PATIENTS DUE TO BAD DEBTS. MANAGEMENT CONSIDERS HISTORICAL WRITE OFF AND RECOVERY INFORMATION IN DETERMINING THE ESTIMATED BAD DEBT PROVISION. MANAGEMENT ALSO REVIEWS ACCOUNTS TO DETERMINE IF CLASSIFICATION AS CHARITY CARE IS APPROPRIATE. PART III, LINE 8: TOTAL REVENUE RECEIVED FROM MEDICARE IS THE GROSS REIMBURSEMENT PLUS SETTLEMENT. BOTH TOTAL REVENUE RECEIVED FROM MEDICARE AND THE MEDICARE ALLOWABLE COSTS ARE REPORTED FROM THE MEDICARE COST REPORT. PART III, LINE 9B: IF A PATIENT CANNOT PAY THEIR BALANCE IN FULL IN 30 DAYS, A FINANCIAL COUNSELOR IS AVAILABLE TO DISCUSS PAYMENT OPTIONS. AFTER FINANCIAL ASSISTANCE IS DETERMINED, ANY PERSONAL PORTION DUE FOLLOWS THE SAME DEBT COLLECTION POLICY AS OTHER PATIENTS WITHOUT FINANCIAL ASSISTANCE. IF A BANKRUPTCY NOTICE IS RECEIVED ON ANY ACCOUNT, ALL COLLECTION ACTIVITIES WILL CEASE IMMEDIATELY. CENTRAL COMMUNITY HOSPITAL WILL NOT HARASS A PATIENT FOR THEIR PAST DUE ACCOUNT, NOR MAKE FALSE STATEMENTS TO GET THE PATIENT TO PAY THEIR ACCOUNT. PART VI, LINE 2: CENTRAL COMMUNITY HOSPITAL MEETS EVERY SIX MONTHS WITH ALL HEALTH CARE PROVIDERS IN CLAYTON COUNTY TO PREPARE A COUNTY-WIDE HEALTH NEEDS ASSESSMENT, CREATE A PLAN OF ACTION, AND MONITOR IMPLEMENTATION. THIS DOCUMENT IS REVIEWED ANNUALLY AND REWRITTEN EVERY FIVE YEARS. THE NEEDS ASSESSMENT IS UTILIZED BY ALL CLAYTON COUNTY PROVIDERS TO PLAN COMMUNITY PROGRAMS AND LOOK FOR OPPORTUNITIES TO OFFER PROGRAMS FOCUSED ON THE COUNTY-WIDE NEEDS. PART VI, LINE 3: AT THE TIME OF REGISTRATIONS, CCH STAFF MAKES EVERY EFFORT TO DETERMINE IF A PATIENT MAY POSSIBLY NEED OR QUALIFY FOR ANY FINANCIAL ASSISTANCE. WE NOTIFY PATIENTS OF THE AVAILABILITY OF THESE PROGRAMS BY POSTING INFORMATION IN OUR REGISTRATION AND EMERGENCY ROOM AREAS. WE OFFER A PRIVATE MEETING WITH A FINANCIAL COUNSELOR. INPATIENTS ARE OFFERED AN OPPORTUNITY TO MEET WITH THE COUNSELOR UPON DISCHARGE. FINANCIAL ASSISTANCE INFORMATION IS PROVIDED IN ALL CORRESPONDENCE REGARDING PATIENT BILLS. OUR FINANCIAL COUNSELOR ATTEMPTS PHONE CONTACT WHENEVER POSSIBLE. OUR "MISSION HEALTH" CHARITY PROGRAM INFORMATION IS AVAILABLE ON OUR WEBSITE. WE DO AN ANNUAL ARTICLE ABOUT THE SERVICE IN OUR NEWSLETTER. OUR FINANCIAL COUNSELOR WILL ALSO ASSIST WITH ENROLLMENT IN EXTERNAL PROGRAMS. PART VI, LINE 4: CENTRAL COMMUNITY HOSPITAL SERVES THE RESIDENTS OF CLAYTON COUNTY. IT IS A RURAL, AGRICULTURAL COMMUNITY. EMPLOYERS IN THE AREA ARE GENERALLY SMALL AND OFTEN DO NOT OFFER EMPLOYEE HEALTH BENEFITS. THE COUNTY HAS ONE OF THE LOWEST INCOME PER CAPITA LEVELS IN THE STATE. RESIDENTS WOULD HAVE TO TRAVEL APPROX. 70 TO 90 MILES TO REACH A LARGER HEALTH FACILITY. THE AREA IS ACCESSED VIA STATE AND COUNTY TWO-LANE ROADS, OFTEN DIFFICULT TO TRAVEL IN THE WINTER.THE 2010 POPULATION FOR CLAYTON COUNTY WAS 18,129. THE 2009 MEDIAN HOUSEHOLD INCOME WAS $43,387 AND 11.3% OF PEOPLE WERE BELOW THE POVERTY LEVEL. PART VI, LINE 6: OUR ORGANIZATION HAS A BOARD OF DIRECTORS REPRESENTING THE ENTIRE SERVICE AREA AND WITH VARIED BACKGROUNDS. WE HAVE AN OPEN MEDICAL STAFF. IN ADDITION TO OUR LOCAL PHYSICIANS, WE ENCOURAGE SPECIALTY PHYSICIANS TO HOLD CLINICS AT OUR FACILITY TO IMPROVE ACCESS TO OUR LOCAL RESIDENTS. WE HAVE MADE GREAT EFFORTS TO MINIMIZE LONG-TERM DEBT AND INSTEAD TAKE THE APPROACH OF REINVESTING CASH FLOW BACK INTO THE ORGANIZATION. PART VI, LINE 7: CENTRAL COMMUNITY HOSPITAL IS AFFILIATED WITH MERCY MEDICAL CENTER - DUBUQUE, A PRIVATE, NON-PROFIT ORGANIZATION. THE HOSPITAL ENTERED INTO A MASTER AFFILIATION AGREEMENT WITH MERCY MEDICAL CENTER - DUBUQUE TO PROVIDE HOSPITAL, PHYSICIAN, AND OTHER HEALTH CARE SERVICES IN ELKADER, IOWA. MERCY IS COMMITTED TO SUPPORTING HEALTH CARE IN RURAL AREAS, AS DEMONSTRATED BY THEIR JOINT OPERATIONS AND SUBSIDY OF MEDICAL CLINICS AS WELL AS THEIR RURAL OUTREACH PROGRAMS. REPORTS FILED WITH STATES PART VI, LINE 7 IA HALEISA JOHNSON WIFE OF BOARD MEMBER OF ORGANIZATION 44273 SALARY AND BENEFITS AS AN EMPLOYEE 0 FORM 990, PART VI, SECTION A, LINE 1 THE EXECUTIVE COMMITTEE CONSISTS OF THE OFFICERS OF THE BOARD. THE PRESIDENT OF THE BOARD CHAIRS THE COMMITTEE. THE COMMITTEE HAS AND MAY EXERCISE THE POWER AND AUTHORITY OF THE BOARD WHEN NECESSARY OR ADVISABLE BETWEEN THE MEETINGS OF THE BOARD. THE COMMITTEE REPORTS ALL OF ITS ACTIONS TO THE BOARD AT THE NEXT REGULAR OR SPECIAL MEETING OF THE BOARD, AND SUCH ACTIONS ARE SUBJECT TO REVISION AND ALTERATION BY THE BOARD AT SUCH MEETING; PROVIDED HOWEVER, THAT THE RIGHTS OF THIRD PARTIES ARE NOT AFFECTED BY ANY SUCH REVISION OR ALTERATION. FORM 990, PART VI, SECTION A, LINE 3 FRAN ZICHAL, CEO AND LISA MANSON, CFO (UNTIL 4/14/11) ARE EMPLOYED BY MERCY MEDICAL CENTER - DUBUQUE. CENTRAL COMMUNITY HOSPITAL HAS A MASTER AFFILIATION AGREEMENT WITH MERCY MEDICAL CENTER - DUBUQUE. DAILY MANAGEMENT IS THE RESPONSIBILITY OF MERCY MEDICAL CENTER - DUBUQUE THROUGH DELEGATION OF DUTIES TO THE CEO AND CFO. THE BOARD OF DIRECTORS OF THE REPORTING ORGANIZATION RETAINS ALL AUTHORITY OVER DECISIONS MADE. THE CURRENT CFO, PAT BOREL, IS A DIRECT EMPLOYEE OF CENTRAL COMMUNITY HOSPITAL. FORM 990, PART VI, SECTION A, LINE 6 THE ORGANIZATION HAS MEMBERS, ALL OF ONE CLASS AND ARE RESIDENT CITIZENS OF THE CENTRAL COMMUNITY HOSPITAL SERVICE AREA. FORM 990, PART VI, SECTION A, LINE 7A MEMBERS OF THE BOARD ARE ELECTED BY THE RESIDENT CITIZENS OF THE CENTRAL COMMUNITY HOSPITAL SERVICE AREA AT THE ANNUAL MEETING TO SERVE FOR A TERM OF FOUR YEARS. FORM 990, PART VI, SECTION B, LINE 11 A COPY OF THE FORM 990 IS MADE AVAILABLE TO ALL BOARD MEMBERS BEFORE IT IS FILED. THE CEO AND CFO REVIEW AND APPROVE THE 990. FORM 990, PART VI, SECTION B, LINE 12C ANY DUALITY OF INTEREST OR POSSIBLE CONFLICT OF INTEREST ON THE PART OF ANY BOARD MEMBER AND OFFICER IS DISCLOSED TO THE OTHER MEMBERS OF THE BOARD AND MADE A MATTER OF RECORD THROUGH AN ANNUAL PROCEDURE AND ALSO WHEN THE INTEREST BECOMES A MATTER OF BOARD ACTION. ANY INDIVIDUAL HAVING A DUALITY OF INTEREST OR POSSIBLE CONFLICT OF INTEREST ON ANY MATTER SHOULD NOT VOTE OR USE HIS OR HER PERSONAL INFLUENCE ON THE MATTER, AND SHOULD NOT BE COUNTED IN DETERMINING THE QUORUM FOR THE MEETING, EVEN WHERE PERMITTED BY LAW. THE MINUTES OF THE MEETING REFLECT THE DISCLOSURE, THE ABSTENTION FROM VOTING, AND THE QUORUM SITUATION. ANY NEW MEMBER OF THE BOARD WILL BE ADVISED OF THIS POLICY UPON ENTERING ON THE DUTIES OF OFFICE. THE GOVERNING BOARD, CEO AND CFO COMPLETE AND SIGN THE CONFLICT OF INTEREST FORM YEARLY. THE FORMS ARE REVIEWED BY THE BOARD PRESIDENT AND IF A POTENTIAL CONFLICT IS IDENTIFIED THE BOARD PRESIDENT FOLLOWS UP. FORM 990, PART VI, SECTION B, LINE 15 THE PROCESS FOR DETERMINING COMPENSATION FOR THE CEO IS BASED ON SALARY ADJUSTMENT RECOMMENDATIONS BASED ON AN ANNUAL EVALUATION, USE OF WAGE SCALES, COMMITTEE APPROVAL (BOARD CHAIR AND MERCY MEDICAL CENTER - DUBUQUE'S CEO), AND BOARD APPROVAL. ALSO, MERCY MEDICAL CENTER - DUBUQUE'S COMPENSATION SYSTEM IS UTILIZED. THIS INCLUDES REVIEW OF WAGES IN COMPARISON TO COMPARABLE POSITIONS. THE ORGANIZATION DOCUMENTS AND PROVIDES SUBSTANTIATION FOR THEIR COMPENSATION PROCESS FOR THE CEO. THE PROCESS WAS LAST UNDERTAKEN IN FISCAL YEAR 2011. THE PROCESS FOR DETERMINING COMPENSATION FOR THE CFO WAS BASED ON SALARY ADJUSTMENT RECOMMENDATIONS BASED ON AN ANNUAL EVALUATION, USE OF WAGE SCALES, COMMITTEE APPROVAL (BOARD CHAIR AND MERCY MEDICAL CENTER - DUBUQUE'S CEO), AND BOARD APPROVAL. ALSO, MERCY MEDICAL CENTER - DUBUQUE'S COMPENSATION SYSTEM WAS UTILIZED. THIS INCLUDED A REVIEW OF WAGES IN COMPARISON TO COMPARABLE POSITIONS. THE ORGANIZATION DOCUMENTED AND PROVIDED SUBSTANTIATION FOR THEIR COMPENSATION PROCESS FOR THE CFO. THIS WAS THE PROCESS UNTIL THE NEW CFO WAS HIRED ON 5/31/11. THE CURRENT CFO IS COMPENSATED DIRECTLY BY THE HOSPITAL AND NOT MERCY MEDICAL CENTER - DUBUQUE, THE MANAGEMENT COMPANY. THE HOSPITAL'S BOARD DETERMINES COMPENSATION FOR THE CFO THROUGH AN ANNUAL EVALUATION AND USE OF WAGE SCALES. THE PROCESS IS DOCUMENTED AND WAS LAST UNDERTAKEN IN FY 2011. FORM 990, PART VI, SECTION C, LINE 19 THE ORGANIZATION'S GOVERNING DOCUMENTS AND CONFLICT OF INTEREST POLICY ARE AVAILABLE UPON WRITTEN REQUEST. THE FINANCIAL STATEMENTS ARE ATTACHED TO THE FORM 990 AND THEREFORE AVAILABLE FOR PUBLIC INSPECTION. FORM 990, PART VII, SECTION A: THE FOLLOWING INDIVIDUAL DEVOTED TIME PROVIDING SERVICES TO CENTRAL COMMUNITY HOSPITAL FOUNDATION, A RELATED ORGANIZATION. FRANCES ZICHAL 10 HOURS PER WEEK CHANGES IN NET ASSETS OR FUND BALANCES: FORM 990, PART XI, LINE 5: CHANGE IN INTEREST IN NET ASSETS OF CENTRAL COMMUNITY HOSPITAL FOUNDATION 9,620. CHANGE IN CENTRAL COMMUNITY HOSPITAL AUXILIARY ASSETS -5,442. TOTAL TO FORM 990, PART XI, LINE 5: 4,178. CENTRAL COMMUNITY HOSPITAL FOUNDATION 901 DAVIDSON ST NW ELKADER IA 52043 421239401 TO SUPPORT CENTRAL COMMUNITY HOSPITAL AND HEALTH EDUCATION IA 501(C)(3) LINE 7 N/A 0 0 0 1 0 0 0 0 0 0 0 0 1 1 1 0 0 0 0