2012-11-15T12:13:24-06:00 2011-12-31 KPMG LLP Two Central Park Plaza Suite 1501 Omaha NE 681021626 990 2011-01-01 470426285 MEMORIAL COMMUNITY HOSPITAL % NICOLE KREITEL MEMO 4024262182 810 NORTH 22ND STREET BLAIR NE 68008 Nicole Kreitel 2012-11-07 true LORRAINE A EGGER 4023481450 2012-11-07 2011 2016-02-24 21:20:13Z NICOLE KREITEL 810 NORTH 22ND STREET BLAIR NE 68008 31399294 false X WWW.MCHHS.ORG X 1956 NE AS AN ENGAGED TEAM OF PHYSICIANS, MEDICAL PROFESSIONALS, AND SUPPORT STAFF WE ARE COMMITTED TO DELIVERING STATE-OF-THE-ART HEALTH CARE TAILORED TO OUR UNIQUE COMMUNITY AND SECOND TO NONE IN THE AREA. 7 5 388 100 93 0 168739 479471 32351438 31546181 27382 30907 -51597 -657265 32495962 31399294 803838 983817 0 0 18276124 18709979 0 0 0 11884286 12386126 30964248 32079922 1531714 -680628 45637482 47908946 26611741 29563833 19025741 18345113 X AS A COMMUNITY HOSPITAL, MEMORIAL COMMUNITY HOSPITAL AND HEALTH SYSTEM OF BLAIR HAS STAYED COMMITTED TO KEEPING RESIDENTS OF WASHINGTON AND BURT COUNTY IN GOOD HEALTH. THROUGH THE YEARS, MEMORIAL COMMUNITY HOSPITAL HAS STRIVED TO IMPROVE THE HEALTH STATUS OF RURAL NEBRASKA RESIDENTS - CHILDREN, TEENS, ADULTS, SENIOR CITIZENS, FRIENDS AND NEIGHBORS THROUGH THE FOLLOWING SERVICES: 24-HOUR EMERGENCY CARE WITH HELIPORT ACCOMMODATIONS, LABOR AND DELIVERY AND CARDIOVASCULAR. CARDIOVASCULAR SERVICES INCLUDE THE FOLLOWING: NON-INVASIVE DIAGNOSTICS STUDIES SUCH AS EKG, TELEMETRY MONITORING, TREADMILL STRESS TESTING, ECHO CARDIOGRAM, AND STRESS ECHO CARDIOGRAM. MEMORIAL COMMUNITY HOSPITAL AND HEALTH SYSTEM PROVIDES A VARIETY OF SPECIALTY CLINICS LOCATED IN BLAIR: ALLERGY/ASTHMA/IMMUNOLOGY, PAIN MANAGEMENT/ANESTHESIA, CARDIOLOGY, ENDOCRINOLOGY, ENT, GENERAL SURGERY, OB/GYN, NEPHROLOGY, NEUROLOGY, NEUROSURGERY, ONCOLOGY, ORTHOPEDICS, ORTHOTICS/PROSTHETICS, PLASTIC SURGERY, DERMATOLOGY, PODIATRY, P false false 25162701 983817 31714983 THE HOSPITAL OPERATES A 21 BED ACUTE CARE HOSPITAL IN BLAIR, NE SERVING THE COMMUNITY FOR INPATIENT & OUTPATIENT SERVICES. ALSO SERVES AS A COMMUNITY RESOURCE FOR HEALTH RELATED PROGRAMS, EDUCATION CLASSES, TRAINING & RECRUITMENT FOR MEDICAL PERSONNEL. 25162701 true true false false false false false false false false true false false false true true false true false false false false false false false false true true false true true true false false false false false false false false false true false false false false false true false false false false true 9 0 true 388 true false false false false false false false false false false X 7 5 false true false false true true false true true false false true true true true false true true true false X NICOLE KREITEL 4024262182 810 NORTH 22ND STREET BLAIR NE 68008 X TERRY DUTTON 1.0 X X 0 0 0 Rod Triplett 1.0 X X 0 0 0 Tim Schnack 1.0 X X 0 0 0 Daniel E Hunt 1.0 X X 0 0 0 Donna Mahlendorf 1.0 X 0 0 0 Ann Schumacher 1.0 X 0 0 0 Brad Sawtelle MD 40.0 X 352480 0 13360 Sally Harvey 40.0 X 0 0 0 Nicole Kreitel 40.0 X 89763 0 6604 Chauncey Wilkins 40.0 X 265354 0 6532 Garret Shaw 40.0 X 311332 0 13380 Andrea VerMaas 40.0 X 381507 0 6900 Andrew Reynolds 40.0 X 401873 0 18698 JAMES JORDAN 40.0 X 318202 0 10512 2120511 0 75986 25 false true false ALEGENT HEALTH 12809 WEST DODGE ROAD OMAHA NE 68154 MNGMT FEE/HEALTH SRV 719561 CASSLING 13808 F STREET OMAHA NE 68137 HEALTH SERVICES 211814 Graham Construction CO 421 GRAND AVENUE DES MOINES IA 50309 CONSTRUCTION SVCS 926652 PHYSICIANS LABORATORY SERVICES 7441 O STREET 100 LINCOLN NE 68510 LAB SERVICES 127301 KPMG LLP 1501 TWO CENTRAL PARK PLAZA OMAHA NE 68102 PROFESSIONAL SVCS 152657 7 390513 88958 479471 NET PATIENT REVENUE 621110 31546181 31546181 31546181 30907 30907 0 0 0 0 0 0 INTEREST RATE SWAP 900099 -989000 0 0 -989000 OUTPATIENT CLINIC DOCTOR RENT 621400 159802 159802 0 0 DIETARY 621110 73323 0 0 73323 98610 9000 93 89517 -657265 31399294 31714983 93 -795253 0 983817 983817 0 0 442243 352480 89763 0 15178115 11406083 3772032 344690 259473 85217 1759152 1324240 434912 985779 743377 242402 0 0 117625 0 117625 0 0 0 547551 0 547551 71582 71582 0 0 0 0 515389 515389 0 59207 50241 8966 0 102247 102115 132 1240411 1240411 0 0 2621827 2606379 15448 208902 17054 191848 SUPPLIES 3356201 2795262 560939 BAD DEBT 1377711 1377711 0 PURCHASED SERVICES 1028214 496991 531223 EQUIPMENT RENTAL & MAINTENANCE 859910 658542 201368 279349 161554 117795 32079922 25162701 6917221 0 0 0 5127268 6373857 0 0 4581378 4576953 0 0 0 0 0 0 264435 452532 341168 270265 46104054 16359116 30025049 29744938 4000672 6012795 0 0 0 0 0 0 1297512 477606 45637482 47908946 3552192 4168749 0 0 0 0 20736599 19782115 0 0 0 0 0 0 0 0 2322950 5612969 26611741 29563833 X 19025741 18345113 0 0 0 0 19025741 18345113 45637482 47908946 -680628 X false true true X false X false false false RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 663787 663787 18736499 5003195 13733304 2525095 657203 1867892 24178673 10698718 13479955 29744938 0 INTEREST RATE SWAP LIABILITY 2172000 ACCRUED PROFESSIONAL LIABILITY 114115 MRI CAPITAL LEASE 821366 ESTIMATED THIRD PARTY SETTLEMENTS 2505488 5612969 FIN 48 FOOTNOTE SCHEDULE D, PART X, Line 2 In accordance with fasb interpretation no. 48, accounting for uncertainty in income taxes, included in fasb asc subtopic 741-10 - Income taxes - Overall, the hospital recognizes the effect of income tax positions only if those positions are more likely than not of being sustained. Recognized income tax positions are measured at the largest amount that is greater than 50% likely of being realized. Changes in recognition or measurement are reflected in the period in which the change in judgment occurs. In 2011 and 2010 management determined that there are no income tax positions requiring recognition in the consolidated financial statements. true true X false false true true false true true 321 771706 771706 0.02510 321 771706 771706 0.02510 17307 17307 0.00060 17307 17307 0.00060 321 789013 789013 0.02570 true 1080677 11691895 11489041 202854 X true false 1 1 MEMORIAL COMMUNITY HOSPITAL

810 NORTH 22ND STREET BLAIR NE 68008

X X X X MEMORIAL COMMUNITY HOSPITAL 1 true false false true X X X true true X X X X true X X true X X X X X X true X false true 4 BLAIR CLINIC

812 NORTH 22ND STREET BLAIR NE 68008

PRIMARY CARE CLINIC FORT CALHOUN CLINIC

1420 CLARK STREET FORT CALHOUN NE 68023

PRIMARY CARE CLINIC COTTONWOOD CLINIC

120 SOUTH 9TH STREET TEKAMAH NE 68061

PRIMARY CARE CLINIC BURT-WASHINGTON HOME HEALTH & HOSPICE

670 SOUTH 19TH STREET BLAIR NE 68008

HOME HEALTH AND HOSPICE AGENCY Part I, line 3c The amount of financial assistance write-off for Memorial Community Hospital and Health System is based on a financial assistance sliding fee schedule utilizing a derivative of the current US Department of Housing and Urban Development (HUD) very low income guidelines, which are updated annually. Designees of MCH help patients seek reimbursement from local, state, and federal programs at no charge to the patient when there is no other source of payment. After these efforts/resources have been exhausted, patients are assisted in the application process for financial assistance. The application process includes completing a personal financial application and providing verification documents. These verification documents may include, but are not limited to, receiving a copy of the applicant's federal tax return, pay stub, bank statements, a call to employers, or a credit report; the applicant's net worth and/or liquid assets; and reasonable household or business expenses. Financial assistance may also be granted in certain circumstances involving a catastrophic occurrence resulting in medical bills grossly exceeding the patient's ability to pay and in these situations, the patient's responsibility will be limited to 30% of the family's gross annual income. Part I, line 6a Memorial Community Hospital produces a Community Benefit Report that is sent to the Nebraska Hospital Association for data collection purposes. Part I, line 7g Memorial Community Hospital does not provide subsidized health services. Part I, line 7, column (f) BAD DEBT OF $1,377,711 INCLUDED IN FUNCTIONAL EXPENSE TOTAL PART IX LINE 25 IS NOT INCLUDED IN THE TOTAL OPERATING EXPENSE $32,079,920 USED TO CALCULATE THE TABLE 7 PERCENTAGES. Part I, line 7 The costing methodology used to calculate the amounts reported in the table were worksheets within the Schedule H instructions. The cost to charge ratio used in the calculations was derived from the as filed 2011 cost report. Part III, line 4 THE AUDITED FOOTNOTES FOR MEMORIAL COMMUNITY HOSPITAL AND MEDICAL CENTER DO NOT CONTAIN FOOTNOTES RELATED TO BAD DEBT EXPENSE. BAD DEBT EXPENSE IS IDENTIFIED ON THE CONSOLIDATED STATEMENT OF OPERATIONS WHICH IS CONSISTENT WITH THE REPORTING PRACTICE OF OTHER HEALTH CARE ORGANIZATIONS. BAD DEBT EXPENSE AT 100% CHARGE VALUE WAS MULTIPLIED BY THE RATIO DERIVED FROM THE SCHEDULE H WORKSHEETS IN THE SCHEDULE H INSTRUCTIONS TO ARRIVE AT AN APPROXIMATE COST VALUE. Part III, line 8 The Medicare charges reported on Line 5 and Line 6 are from the 2011 filed cost report which used a cost to charge ratio. Part III, line 9b MEMORIAL COMMUNITY HOSPITAL'S collection policy does not contain provisions on the collection practices to be followed for patients who are known to qualify for charity care or financial assistance. Needs assessment MEMORIAL COMMUNITY HOSPITAL assesses the health care needs of the communities it serves through multiple channels including community health fairs, wellness programs, providing occupational health services, listening to patient and community voices as well as watching national trends. Patient education of eligibility for assistance There are several financial assistance access points throughout a patient's care cycle. Bills contain financial assistance verbiage; brochures are available in clinics and the hospital, and there is information on financial assistance posted at registration points throughout clinics and the hospital. Information on the MCH financial assistance policies is located at WWW.MCHHS.ORG. Designees such as financial counselors of MCH help patients seek reimbursement from local, state and federal programs at no charge to the patient, when there is no other source of payment. After these efforts/resources have been exhausted, patients are assisted in the application process for financial assistance. Community information MEMORIAL COMMUNITY HOSPITAL AND HEALTH SYSTEMS OF BLAIR, NE SERVES BOTH WASHINGTON AND BURT COUNTIES IN NEBRASKA. WASHINGTON COUNTY NEBRASKA HAS AN ESTIMATED POPULATION OF 20,234. CENSUS ESTIMATES SHOW THAT WASHINGTON COUNTY'S RACIAL AND ETHNIC MAKE UP IS 97.2% WHITE 0.9% SOME OTHER RACE ALONE 0.6% TWO OR MORE RACES 1.3% HISPANIC OR LATINO. ITS MEDIAN HOUSEHOLD INCOME IS $59,181 COMPARED TO $47,470 FOR THE STATE OF NEBRASKA. APPROXIMATELY 15% OF THE STUDENTS IN WASHINGTON COUNTY RECEIVE FREE OR REDUCED LUNCH. BURT COUNTY HAS AN ESTIMATED POPULATION OF 6,858. CENSUS ESTIMATES SHOW THAT BURT COUNTY'S RACIAL AND ETHNIC MAKE UP IS 95.9% WHITE 1.1% SOME OTHER RACE ALONE 1.2% TWO OR MORE RACES 1.8% HISPANIC OR LATINO. ITS MEDIAN HOUSEHOLD INCOME IS $42,242 COMPARED TO $47,470 FOR THE STATE OF NEBRASKA. APPROXIMATELY ONE THIRD OF THE STUDENTS IN EACH OF THE SCHOOL DISTRICTS RECEIVE FREE OR REDUCED LUNCH. PART II Community building activities MEMORIAL COMMUNITY HOSPITAL DID NOT ENAGE IN ANY COMMUNITY BUILDING ACTIVITIES IN 2011. Promotion of community health MCH&HS promotes the health of its community through financial and in-kind donations. Other information required Board of Directors - The Board of Directors manage the affairs of Memorial Community Hospital in Blair, NE. There are seven directors who serve on the Board: 3 members from the community, 3 members from Alegent Health and 1 member from the MCH&HS Medical Staff. The Board of Directors is compromised of individuals who are leaders in the fields of business, healthcare, accounting and medicine and understand their role in providing strong corporate governance. Emergency Department - Memorial Community Health has a full-time emergency department that is open to the public and provides medical screening examinations and stabilizing treatment within the capabilities and capacities of the hospital regardless of but not limited to the patient's race, color, sex, age and/or ability to pay. MCH&HS is in compliance with the Federal EMTALA guidelines. Medical Staff - MCHHS maintains an open medical staff. All qualified MDs, Dos, Other healthcare practitioners, and Mid-level practitioners are eligible to apply for privileges at the Hospital. MCH&HS policy on physician credentialing is that no individual is to be denied medical staff appointment based on sex, race, creed, color or national origin. The standards a physician must meet for appointment relate to (1) educational qualifications and licensing; (2) professional competence, (3) character, (4) ethical standing, and (5) ability to relate to and work with others. Applications are reviewed at several levels within the organization. Physicians who have been granted staff privileges automatically become members of the medical staff at the hospital for which privileges have been granted. Affiliated health care system SEE BOARD OF DIRECTORS NARRATIVE ABOVE PART VI, LINE 7: STATES WHERE ORGANIZATION FILES COMMUNITY BENEFITS REPORT: NONE false CHARITY CARE 321 0 983817 BOOK MEDICAL CARE MONITORING OF GRANT FUNDS SCHEDULE I, PART I, LINE 2 Memorial Community Hospital does not give out any grants. Instead, it does provide financial assistance to those patients in need that qualify under the Hospital's Charity Care Policy. X X X false false false false false false false false false Chauncey Wilkins 127986 120638 16730 5513 1019 271886 0 Garret Shaw 257458 25966 27908 6000 7380 324712 0 Andrea VerMaas 180464 182227 18816 6900 0 388407 0 Andrew Reynolds 314077 72259 15537 11118 7580 420571 0 Brad Sawtelle MD 151047 0 185510 0 15923 0 5980 0 7380 0 365840 0 0 0 JAMES JORDAN 147904 146322 23976 5952 5514 329668 0 Hospital Auth #1 of Washington Cnty NE 521441599 000000000 2007-06-19 9250000 Constuction of Facility false false false Hospital Auth #1 of Washington Cnty NE 521441599 000000000 2008-05-22 8000000 Constuction of Facility false false false Hospital Auth #1 of Washington Cnty NE 521441599 000000000 2009-02-12 3950000 Constuction of Facility false false false 420094 0 9493722 0 0 0 173747 0 0 9319975 0 0 2008 false false true true 316593 0 8059333 0 0 0 65000 0 0 7994333 0 0 2008 false false true true 462559 0 0 3953609 0 0 11450 0 0 3942159 0 0 false false true true 0 0 0 false false false 0 false 0 false true false true true FNB of Omaha 20.1 true false false 0 false true false true false 0 false 0 false true 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. TERRY DUTTON CHAIRMAN WASH CO. BANK PRESIDENT 1194144 INTEREST EXPENSE false DISCLOSURE TO THE PUBLIC 990, PART VI, SECTION C, LINE 19 MEMORIAL COMMUNITY HOSPITAL'S AUDIT REPORT IS MADE AVAILABLE TO THE PUBLIC. THE CONFLICT OF INTEREST POLICY AND GOVERNING DOCUMENTS ARE NOT AVAILABLE TO THE PUBLIC. CONFLICT OF INTEREST POLICY 990, PART VI, SECTION B, LINE 12C Each board member annually signs a conflict of interest statement and is given a copy of the conflict of interest policy. The chairman of the board reviews these statements and ensures that board members excuse themselves from discussions at board meetings on topics where they have a conflict of interest. COMPENSATION 990, PART VI, SECTION B, LINE 15A & 15B The officers of the board are not compensated for their duties. They are volunteers. The officers of the corporation (the executives) are compensated based on recommendations of the compensation committee of the board. The compensation committee looks at comparative hospital and industry salary information in setting base salaries, and reviews and approves the individual goals proposed by the executive team for incentive compensation. MEMBER RIGHTS 990, PART VI, SECTION A, LINE 6 and 7a Memorial Community Hospital Corporation ("Hospital") has two members - Memorial Community Health System, Inc. ("MCHS") and Alegent Health - Immanuel Medical Center ("Immanuel"). The Hospital has a seven member board of directors. MCHS appoints three of these board members, Immanuel appoints three, and the medical staff appoints one member which is always the medical staff president. All official actions of the board require an affirmative vote of two-thirds of the entire Board of Directors. A simple majority of the Board of Directors constitutes a quorum for the transaction of business. BOARD APPROVAL OF 990 PART VI, SECTION B, LINE 11B THE BOARD MEMBERS RECEIVED A COPY OF THE FINAL 990 VIA EMAIL PRIOR TO FILING. DELEGATION OF MANAGEMENT DUTIES 990, PART VI, SECTION A, LINE 3 The ceo of memorial community hospital corporation (hospital) is provided by one of its members (Alegent health). The ceo is an employee of Alegent health, and the hospital reimburses the member for the ceo's compensation and benefits. The Hospital pays Alegent health a management fee equal to the direct cost of the ceo's compensation and benefits plus 5.5% of earnings before interest, depreciation, and amortization for Alegent Health's support. MEMORIAL COMMUNITY HOSPITAL FOUNDATION 810 N 22ND STREET BLAIR NE 68008 113660156 SUPPORT NE 501(c)(3) Line 11(C) MCHS false MEMORIAL COMMUNITY HEALTH SYSTEM 810 NORTH 22ND STREET BLAIR NE 68008 470718840 HEALTH SYS. NE 501(c)(3) LINE 7 NA false MCH AUXILIARY THRIFT SHOP 810 NORTH 22ND STREET BLAIR NE 68008 470748162 AUXILIARY NE 501(c)(3) LINE 7 MCHS false false false true false false false false false false false false true false true false true false false