2012-10-18T11:17:36-05:00 2011-12-31 476097913 SEIM JOHNSON LLP 18081 BURT STREET SUITE 200 OMAHA NE 680224722 990 2011-01-01 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 2012-10-08 1 BARBARA J FAJEN P00400874 4023302660 2011 2016-02-24 21:20:13Z MARY S WELLS 909 W 1ST STREET PO BOX 148 SUMNER IA 506740148 9790694 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. 13 13 0 0 1259 -193 591026 240028 9081554 9454740 16459 14433 146051 81493 9835090 9790694 0 0 0 0 4714193 4902735 0 0 0 4146237 4468049 8860430 9370784 974660 419910 11272413 20417085 2454855 11938897 8817558 8478188 X TO PROVIDE QUALITY HEALTH CARE TO THE PEOPLE OF SUMNER AND SURROUNDING AREAS, WHILE COORDINATING OTHER NEEDED SERVICES. 1 0 811126 1683242 CMH MEDICAL CLINIC HAS CONTINUED TO SERVE SUMNER AND THE SURROUNDING AREA IN THE YEAR 2011. WE CONTINUED TO BE STAFFED WITH THREE PROVIDERS THROUGH JULY 2011 CONSISTING OF TWO PHYSICIANS AND ONE NURSE PRACTITIONER AND THEN WENT TO TWO PROVIDERS WITH ONE PHYSICIAN AND ONE NURSE PRACTITIONER. A VARIETY OF 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 7,709 FOR 2011. 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 FIREFIGHTER 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 OF 2011. CLINIC STAFF WENT TO AN AREA BANK THE FIRST TUESDAY OF EACH MONTH AND OFFERED FREE BLOOD PRESSURE CHECKS TO ANYONE ON A WALK-IN BASIS. PROVIDERS AVIDLY PRECEPT FOR STUDENTS FROM VARIOUS PROGRAMS WITH ALLEN COLLEGE IN WATERLOO TAKING ADVANTAGE OF THIS IN 2011. THE CLINIC HOURS ARE MONDAY THROUGH FRIDAY STARTING AT 7 AM AND ENDING AT 5 PM. 910340 533523 ACUTE NURSING HAD 190 ADMISSIONS IN 2011. CMH UTILIZES A COMPANY CALLED EXECUTIVE HEALTH RESOURCES (EHR) TO PROVIDE SECONDARY REFERENCE FOR ACUTE ADMISSIONS TO VERIFY ADMISSION TO THE APPROPRIATE LEVEL OF CARE. INTERQUAL TOO IS UTILIZED TO PLAN THE PATHWAY OF CARE, QUALIFICATION OF INPATIENT, AND DISCHARGE TIMELINESS. THE USE OF BOTH THESE TOOLS ARE TO MEET ADMISSION AND CONTINUED STAY COMPLIANCE FOR INSURANCES AND MEDICARE. 876362 1113529 THE CMH EMERGENCY DEPARTMENT SERVED A TOTAL OF 1,240 PATIENTS IN 2011. THIS IS AN INCREASE IN VOLUME OF 38 PATIENT VISITS COMPARED TO 1,202 VISITS IN 2010. HOURS SPENT PROVIDING CARE TO PATIENTS IN THE ED BY THE PROVIDERS WERE 2,210 HOURS IN 2010 AND 2,490 HOURS IN 2011. THIS WAS AN INCREASE OF 280 HOURS IN THE YEAR 2011. CQI PROJECTS THAT WERE IMPLEMENTED IN 2011 INCLUDED ADMISSIONS TO THE EMERGENCY DEPARTMENT WITHIN ONE MONTH FOLLOWING AN EMERGENCY DEPARTMENT/OUTPATIENT TREATMENT OF SIMILAR SYMPTOMS, MONITORING THE COMPLETENESS OF EMERGENCY TRANSFER FORMS TO ENSURE RESPONSIBILITY OF THE TRANSFERRING HOSPITAL HAS BEEN MET, DOCUMENTATION OF THE GCS PRE/POST VISIT, COMPLETITION OF THE IDPH TRANSFER FORMS AND THE TRAUMA ADMIT FORMS PER PROTOCOL, IV STARTS FOR CT COMPLETED BY NURSING, AND PEDIATRIC HEIGHT AND WEIGHT DOCUMENTED.EDUCATIONAL HIGHLIGHTS FOCUSED ON TRAUMA COMPETENCIES, COURT COMMITTAL PROCESS, HAZMAT COMMUNITY WIDE DRILL, TRIAGING PROCESS, PROCEDURAL CHARTING, MEANINGFUL USE GUIDELINES AND CHARTING, OB DELIVERIES, AND MOCK CODE DRILLS. 5392915 6157538 VARIOUS INPATIENT AND OTHER HEALTH CARE SERVICES. 5392915 6157538 7990743 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 0 0 0 1 9 0 1 0 1 1 0 0 0 0 0 0 0 0 0 X 13 13 0 1 0 0 1 1 1 1 1 0 0 1 1 1 1 1 1 0 0 0 IA X SARA TRAINOR 5635783275 909 WEST 1ST STREET PO BOX 148 SUMNER IA 50674 X PAUL BAHE 1.30 X X 0 0 0 MIKE MEYER 1.30 X X 0 0 0 DEB TOENGES 1.30 X X 0 0 0 DEB BECKNER 0.80 X 0 0 0 LUARA NECKER 0.80 X 0 0 0 DAVE VOSS 0.80 X 0 0 0 JAMES LAHMANN 0.80 X 0 0 0 CONNIE LEICHER 0.80 X 0 0 0 RANDIE MUELLER 0.80 X 0 0 0 RICK PEDERSON 0.80 X 0 0 0 JENNIFER YEAROUS 0.80 X 0 0 0 BILL SCHWAKE 0.80 X 0 0 0 DIANE PAGEL 0.80 X 0 0 0 MARY WELLS 38.00 X 157915 0 20737 SARA TRAINOR 39.50 X 115249 0 31043 LYNNE NIEMANN 40.00 X 91762 0 16780 TROY BUCHHOLZ 40.00 X 325592 0 35187 TED SAI SCHWARM 40.00 X 132001 0 16784 822519 0 120531 4 0 1 0 GRAHAM CONSTRUCTION 421 GRAND AVENUE DES MOINES IA 50309 CONSTRUCTION SERVICES 1054602 INVISION ARCHITECTURE 501 SYCAMORE ST SUITE 101 WATERLOO IA 50704 ARCHITECTURAL SERVICES 792220 PERFORMANCE REHAB LLC 909 W 1ST ST SUMNER IA 50674 REHAB SERVICES 373593 EMERGENCY PRACTICE ASSOCIATES INC PO BOX 1260 WATERLOO IA 50704 ED COVERAGE 289815 DR JAYASWAL 8315 W 119TH TERRACE OVERLAND KS 66213 ED COVERAGE 146950 8 21 101118 138889 240028 MEDICARE/MEDICAID PAYM 621400 5248949 5248949 PATIENT REVENUE - PRIV 621400 4185501 4185501 COMMUNITY WELLNESS 621990 20290 20290 9454740 14433 14433 22945 0 22945 22945 22945 MISCELLANEOUS INCOME 900099 33092 33092 CAFETERIA EMPLOYEES 900099 24197 24197 CATERING 722320 1259 1259 58548 9790694 9487832 1259 61575 943050 618106 324944 46482 46482 2929597 2442395 487202 778399 650213 128186 205207 166135 39072 64801 64801 67657 67657 1878358 1651664 226694 19666 19666 416293 380168 36125 127284 127284 37278 31918 5360 95342 95342 645318 645318 65455 65455 MEDICAL SUPPLIES 626852 626852 PROVISION FOR BAD DEBT 274590 274590 DUES AND SUBSCRIPTIONS 119473 119473 MISC. EXPENSES 29682 29682 9370784 7990743 1380041 0 100 100 3052573 2766551 527182 545171 1397780 1611764 101814 110936 88005 72771 9542872 5385407 2963546 4157465 279574 7434698 2684825 3544459 177014 173170 11272413 20417085 1063355 2128931 1055000 9000000 336500 185706 0 624260 2454855 11938897 X 5808829 4571957 387171 425039 2621558 3481192 8817558 8478188 11272413 20417085 X 419910 -759280 X X 0 1 1 X 1 1 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 2684825 1033086 173452 3544459 2638298 110582 64055 2684825 2634633 58750 55085 2638298 2889909 -246778 8498 2634633 1.00000 1 0 100421 100421 3106895 2747780 359115 3218226 2461681 756545 3117330 175946 2941384 4157465 PERPETUAL TRUST 3544459 F 3544459 ESTIMATED THIRD-PARTY PAYOR SETTLEMENTS - MEDICARE AND MEDICAID 624260 624260 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. DESCRIPTION OF UNCERTAIN TAX POSITIONS UNDER FIN 48: PART X: 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, 2011 AND 2010, 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, 2008. 1 1 1 X 125.000000000000 1 X 1 1 0 1 0 54793 54793 0.00600 379109 290435 88674 0.00970 433902 290435 143467 0.01570 19261 1878 17383 0.00190 59778 100 59678 0.00660 244672 25215 219457 0.02410 27519 27519 0.00300 351230 27193 324037 0.03560 785132 317628 467504 0.05130 1 203663 53847 4638111 4592189 45922 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: NOT APPLICABLE 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): BAD DEBT EXPENSE OF $274,590 WAS DEDUCTED FROM TOTAL EXPENSES (PART IX, LINE 25) OF $9,417,638. THE RESULT, $9,143,048, WAS USED AS THE DENOMINATOR IN COMPUTING SCHEDULE H, PART I, LINE 7A THROUGH K, COLUMN (F).PERCENTAGES BASED ON COLUMN (C), TOTAL COMMUNITY BENEFIT EXPENSE, ARE AS FOLLOWS:CHARITY CARE AT COST - .60%MEDICAID AT COST - .97%COMMUNITY HEALTH IMPROVEMENT SERVICES - .19%HEALTH PROFESSIONALS EDUCATION - .66%SUBSIDIZED HEALTH SERVICES - 2.41%CASH & IN-KIND CONTRIBUTIONS - .30%TOTAL OTHER BENEFITS - 3.56%TOTAL - 5.13% PART II: NOT APPLICABLE PART III, LINE 4: 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. BAD DEBT EXPENSE IS NOT INCLUDED WITH COMMUNITY BENEFITS.LINE 2 WAS CALCULATED AS FOLLOWS: BAD DEBT EXPENSE PER FINANCIAL STATEMENTS X COST TO CHARGE RATIO AS CALCULATED IN IRS WORKSHEET 2AND LINE 3 WAS CALCULATED AS FOLLOWS: COST TO CHARGE RATIO AS CALCULATED IN IRS WORKSHEET 2 X CHARITY CARE EXPENSEALL AMOUNTS ARE PER THE AUDITED FINANCIAL STATEMENTS. BAD DEBT EXPENSE IS NOT INCLUDED WITH COMMUNITY BENEFITS. PART III, LINE 8: THIS IS NOT APPLICABLE, AS THERE WAS AN OVERAGE RATHER THAN A SHORTFALL. THE COSTING METHODOLOGY IS BASED ON A COST TO CHARGE RATIO AS WE ARE A CRITICAL ACCESS HOSPITAL. MEDICARE COST REPORT FIGURES WERE USED TO DETERMINE THE AMOUNTS REPORTED AS MEDICARE ALLOWABLE COSTS. 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 19D: 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 INSURACE. 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 DID A STRATEGIC PLANNING RETREAT WITH THE BOARD OF DIRECTORS IN LATE OCTOBER 2011. THIS PLANNING SESSION WAS FOCUSED ON ALL COMPONENTS FOR FUTURE GOAL SETTING WHICH INCLUDED NOT ONLY FINANCIAL FORECASTING AND DIRECTION BUT LOOKING TO THE HEALTH NEEDS OF THE COMMUNITY. 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 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 PRESENTS 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 FOR THE 2012 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: NOT APPLICABLE PART VI, LINE 6: NOT APPLICABLE X 0 0 0 0 0 0 0 0 0 MARY WELLS 120365 0 37500 0 50 0 7870 0 12867 0 178652 0 0 0 TROY BUCHHOLZ 181207 0 26500 0 117885 0 11873 0 23314 0 360779 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. CITY OF SUMNER IOWA 426005269 866450AA7 2011-12-08 9000000 CONSTRUCTION AND IMPROVEMENTS TO FACILITIES AND REFUND PRIOR BOND ISSUES 0 0 0 9000000 136670 738045 690586 7434699 1 0 0 1 0 0 1 1 0 0.00000 0.00000 0.00000 1 0 0 0 0 0 1 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. JUSTIN TRAINOR SPOUSE OF CFO 373593 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 NEW PROGRAM SERVICES FORM 990, PART III, LINE 2 CMH OPENED AN ANTICOAGULATION CLINIC IN 2011. THE ANTICOAGULATION CLINIC IS A SERVICE DESIGNED TO HELP A PERSON TAKING THE PILL FORM OF BLOOD THINNER KNOWN AS WARFARIN (GENERIC NAME) OR COUMADIN (BRAND NAME) STAY WITHIN THEIR SET INR RANGE. USING A FINGER-STICK METHOD FOR CHECKING INR AND MEETING EACH TIME WITH A SPECIALLY TRAINED REGISTERED NURSE, THE CLINIC CLOSELY MONITORS PEOPLE AND ADJUSTS BLOOD THINNER DOSES IN ORDER TO MAXIMIZE THE BENEFITS AND REDUCE THE RISKS RELATED TO BLOOD THINNER USE. THE REGISTERED NURSE WORKS CLOSELY WITH THE PERSON'S OWN HEALTH CARE PROVIDER AND UNDER THE GUIDANCE OF A MEDICAL DIRECTOR. 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 IN 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 WILL BE 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. 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. AVERAGE HOURS PER WEEK DEVOTED TO RELATED ORGANIZATION FORM 990, PAGE 7, PART VII, SECTION A, LINE 1A PAUL BAHE, BOARD CHAIR, DEVOTES AN AVERAGE OF .8 HOURS PER WEEK TO FRIENDS OF COMMUNITY MEMORIAL HOSPITAL, A RELATED ORGANIZATION. JAMES LAHMANN, BOARD MEMBER, DEVOTES AN AVERAGE OF .8 HOURS PER WEEK TO FRIENDS OF COMMUNITY MEMORIAL HOSPITAL, A RELATED ORGANIZATION. BILL SCHWAKE, BOARD MEMBER, DEVOTES AN AVERAGE OF .8 HOURS PER WEEK TO FRIENDS OF COMMUNITY MEMORIAL HOSPITAL, A RELATED ORGANIZATION. MARY WELLS, CEO, DEVOTES AN AVERAGE OF 2.0 HOURS PER WEEK TO FRIENDS OF COMMUNITY MEMORIAL HOSPITAL, A RELATED ORGANIZATION. SARA TRAINOR, CFO, DEVOTES AN AVERAGE OF .5 HOURS PER WEEK TO FRIENDS OF COMMUNITY MEMORIAL HOSPITAL, A RELATED ORGANIZATION. CHANGES IN NET ASSETS OR FUND BALANCES: FORM 990, PART XI, LINE 5: NET UNREALIZED GAINS ON INVESTMENTS: 859,635. IMPAIREMENT LOSS ON PROPERTY & EQUIPMENT -1,618,915. TOTAL TO FORM 990, PART XI, LINE 5: -759,280. COMMITTEE WITH OVERSIGHT OF THE AUDIT FORM 990, PAGE 12, PART XI, 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 N/A 1 0 0 1 0 0 0 0 0 0 0 0 1 1 1 0 1 0 0