2011-05-16T09:46:08-05:00 2010-06-30 EIDE BAILLY LLP 401N 31ST ST SUITE 1120 PO BOX 7112 BILLINGS MT 591037112 990 2009-07-01 237169043 Central Montana Medical Facilities Inc CENT 4065357711 408 Wendell Avenue LEWISTOWN MT 59457 Alan R Aldrich 4065386243 2011-05-13 1 Steve Markovich 4068962400 2011-05-13 2009 2016-02-24 21:20:13Z Central Montana Medical Center David Faulkner 408 Wendell Avenue LEWISTOWN MT 59457 25752762 0 X www.cmmccares.com X 1971 MT The mission of CMMC is to be the leader in assuring community based quality healthcare. 13 12 443 350 0 0 89106 62928 25189769 25012193 151398 103817 270526 5130 25700799 25184068 0 0 13971800 14740308 0 36849 11514992 10360013 25486792 25100321 214007 83747 19883188 19912767 5666039 4917200 14217149 14995567 The mission of Central Montana Medical Center is to be the leader in assuring community based quality healthcare. 1 1 3236221 4380892 Skilled Nursing Care/Long-Term Care Rehabilatation or Long-Term Nursing Services:Number of beds: 85Provided 23,316 days of care for a 75.15% occupancy rate. 1599677 2586984 Hospital Inpatient Services:Number of Beds: 25Provided 2,443 Acute Days of Care and 864 Swing Bed Days of Care for a 27% occupancy rate. 1391801 1952875 Emergency Services:Provided for 4,891 Emergency visits.24 hour Physician coverage available. 14180078 16091442 Community care and services are also provided through the many reduced price services and free clinics, fairs, and programs offered throughout the year. These include but are not limited to the following (all costs are estimates): 1. Twenty-seven Foot Clinics were held in 2009-2010 in Denton, Hobson and Lewistown MT. A total of 367 people were served, all received discounted health care. Total Community Benefit Expense of $12,689.2. Two Health Fairs were held in 2009-2010, serving 3,232 people in Fergus and Basin Counties. All received discounted health care. Total Community Benefit Expense of $8,517.3. Three Support Groups met in 2009-2010, serving 106 people. Support Groups included Bereavement/Grief, Cancer and Diabetes Education. Total Community Benefit Expense of $2,076.4. CMMC educated locals with a Baby Sitting Class (20 people served, 1 class offered, total Community Benefit $913), Diabetes Education (6 people served, 6 classes offered, total Community Benefit $353), CPR/First-Aid Classes (Several classes offered, 57 people served, total Community Benefit $1,804), and Lifeguard Training (25 people served, 1 class offered, total Community Benefit $680). CMMC also provided prenatal/family planning, and fitness exercise groups.The facilities maintain records to identify and monitor the level of charity care it provides. These records include the amount of charges foregone for services and supplies furnished under its charity care policy. The amount of charges foregone, based on established rates, was $577,985 for the current year. 14180078 16091442 20407777 1 1 0 0 0 0 0 0 0 1 1 0 0 0 0 0 0 0 1 0 1 0 0 1 1 0 0 0 0 0 0 0 0 1 0 0 0 0 0 0 0 0 0 0 1 38 0 1 443 1 0 0 0 0 0 0 0 0 0 13 12 0 1 0 0 1 1 0 1 1 0 0 1 1 1 1 1 1 0 0 0 X ALAN R ALDRICH CFO 4065357711 408 WENDELL AVENUE LEWISTOWN MT 59457 Wayne Edwards 2.00 X X 0 0 0 Mike Zacher 2.00 X X 0 0 0 Nancy Wilson 2.00 X X 0 0 0 John Jensen 1.00 X 0 0 0 Doug Flament 1.00 X 0 0 0 Alta Pallett 1.00 X 0 0 0 Dave Phillips 1.00 X 0 0 0 Russell Spika CPA 1.00 X 0 0 0 Mike Delaney 1.00 X 0 0 0 Francis Weinheimer 1.00 X 0 0 0 Laura Bennett MD 1.00 X 0 0 0 Christine Volf 1.00 X 0 0 0 Roy Kohler MD 1.00 X 0 0 0 David Faulkner 40.00 X 180503 0 62762 Alan R Aldrich 40.00 X 102447 0 27942 Dianne Scotten 40.00 X 95410 0 12506 Danny Harbour MD 40.00 X 177460 0 32381 James Fox 40.00 X 199738 0 18045 Brian Priest 40.00 X 180608 0 25569 Joan McMahon MD 40.00 X 168280 0 4212 Rene DeGuzman 40.00 X 170017 0 26396 1274463 0 209813 8 0 1 1 quorum Health Resources LLC 105 continential place Brentwood TN 370271018 Facility Management & CEO services 406857 Prairie Travelers 26 Keith Avenue Glasgow MT 59230 Temporary Staffing Services 273399 Delta Flex Travelers po Box 678082 Dallas TX 752678082 Temporary Staffing Services 161970 GE Medical Systems PO Box 843553 Dallas TX 75284 MRI Contract Services 119355 4 25307 33782 3839 62928 Net Patient Revenue 622110 23927470 23927470 Special Programs 900099 915287 915287 Cafeteria 722210 119694 119694 Casualty Relief Servic 900099 44348 44348 5394 5394 25012193 142583 142583 295820 290690 5130 5130 5130 227861 50 263144 3533 -35283 -3483 -38766 -38766 11327 25307 11327 0 25184068 25012193 0 108947 232967 106560 126407 11882450 9505960 2366947 9543 241369 195100 45983 286 1546630 1252237 291639 2754 836892 669514 166765 613 471292 282775 188517 36323 36323 30690 30690 65976 32988 15675 17313 58362 21225 36477 660 994049 767976 224273 1800 54218 50694 3524 85917 55881 30036 169602 132290 37312 1158586 869734 288695 157 607356 577549 29807 Supplies 3395421 3149449 245401 571 Bad Debt Allowance 743242 743242 Service Contracts 581115 375598 202365 3152 Medical Professional Fe 385622 385622 Equipment Rental and Ma 244462 211159 33303 1277780 1022224 255556 25100321 20407777 4655695 36849 1378361 1570599 3566394 3479999 57048 50238 498983 442033 103217 144993 28259558 20164117 8981135 8095441 3182114 3616602 2115936 2512862 19883188 19912767 2108960 2125546 1647060 1147968 1910019 1643686 5666039 4917200 X 12836575 13271811 768206 931428 612368 792328 14217149 14995567 19883188 19912767 X 0 1 1 X 0 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 1 6132 11760 11632 6260 103009 103009 16260128 10586443 5673685 763781 569518 194263 11132640 9008156 2124484 8095441 Long-Term Prepaid Expenses 172683 Due from Foundation 1723756 Other Receivables 384450 3rd Party Payor Settlements 231973 2512862 25184068 25100321 83747 351489 343182 694671 778418 25437137 0 25437137 -253069 -253069 25184068 25391011 0 25391011 -290690 -290690 25100321 Part IV, Line 1b: Nursing Home trust account. These funds belong to our residents. We have deposited them in trust for various small expenses incurred by the individuals. Part X: Description of Uncertain Tax Positions Under FIN 48: The Facilities undergo an annual analysis of its various tax positions, assessing the likelihood of those positions being upheld upon examination with relevant tax authorities. As of June 30, 2010 and 2009, the unrecognized tax benefit accrual is zero. Part XI, Line 8 - Other Adjustments: Interest in Central Montana Foundation: 343182. Part XII, Line 4b - Other Adjustments: Contributions for specific purposes recorded in fund balance for f/s: 37621. Rental expenses recorded in expenses for financial statements: -290690. Part XIII, Line 4b - Other Adjustments: Rental expenses recorded in expenses for financial statements: -290690. Hospice Auction & Home Tours 17067 11116 5951 3250 2702 Golf Tourney 12403 8271 4132 512 3113 506 1 7164 5920 1244 1244 36634 25307 11327 512 6363 4452 11327 0 1 1 X 1 X 1 X 1 1 1 0 0 371531 371531 0.01530 1575105 1827806 -252701 0.00000 110578 120082 -9504 0.00000 2057214 1947888 109326 0.01530 36921 4139 32782 0.00130 3401133 2518434 882699 0.03620 23405 23405 0.00100 3461459 2522573 938886 0.03850 5518673 4470461 1048212 0.05380 3 1516 10785 10785 0.00040 3 1516 10785 10785 0.00040 0 477758 8434 5686044 5618388 67656 X 1 0 Central Montana Medical Center

408 Wendall Avenue Lewistown MT 59457

X X X X Home Health / Hospice Skilled Nursing Center Central Montana Medical Center - DME

202 4th Avenue South Lewistown MT 59457

HME/DME Services Basin Medical Center

76 Central Avenue Stanford MT 59479

Rural Health Clinic Part I, Line 3c: Eligibility is based on patient's family size, family gross income, personal assets, and other medical debts. Part I, Line 7: Charity care was converted to cost using the cost-to-charge ratio derived from Worksheet 2. Unreimbursed Medicaid and Unreimbursed costs - other means-tested gov't programs were converted to cost using the cost-to-charge ratio derived from Worksheet 2. Community health improvement services and cash and in-kind contributions were based on expenses recorded in the general ledger. Subsidized health services are reported according to costs allocated to the relevant cost centers on the Medicare cost report. Part I, Line 7g: $306,806 of costs are attributable to a physician clinic. Part I, Line 7f: The amount of bad debt expense removed from the denominator of the calculation was $743,242. Part III, Line 4: Bad debt expense was converted to cost using the cost-to-charge ratio derived from Worksheet 2. The estimated amount of bad debt expense attributable to patients eligible under the organization's charity care policy is calculated by using charity care as a % of gross patient services revenue. As a portion of revenue is considered charity care, it is assumed that a percentage of bad debt expense would also be considered charity care.Bad debt expense is reported net of discounts and contractual allowances. A payment on an account previously written off reduces bad debt expense in the current year.Financial Statement Note: The carrying amount of patient and resident receivables is reduced by a valuation allowance that reflects management's best estimate of amounts that will not be collected from patients, residents and third party payors. Management reviews patient and resident receivables by payor class and applies percentages to determine estimated amounts that will not be collected from third parties under contractual agreements and amounts that will not be collected from patients and residents due to bad debts. Management considers historical write off and recovery information in determining the bad debt provision. Part III, Line 8: Medicare allowable costs of care are based on the Medicare cost report. The Medicare cost report is completed based on the rules and regulations set forth by CMS. Part III, Line 9b: Patients deemed unable to pay by CMMC at any time during the revenue cycle may be eligible to receive available financial assistance. Patients must complete an application. Our collection practice is to refrain from collection efforts until financial assistance is determined. Normal collection efforts would resume if the application is not returned timely or after the write-off is complete and the patient owes a balance. Our policies will note our current procedure for the year ending 6/30/2011. Part V: The organization operates 2 clinics that provide therapy services and are not required to have a separate license in the state of Montana. Part VI, Line 2: Currently, CMMC assesses the health care needs of the community by the number of responses to ads and articles released through the local media. CMMC monitors the attendance at annual events such as health fairs. Also tracked were the kinds of support requested of CMMC such as children's safety, wellness initiatives and healthcare assessments. In the past, CMMC completed an official Community Needs Assessment with the help of Montana State University. Mail and phone surveys were completed and "town hall" type meetings were held in Lewistown as well as most of the surrounding smaller communities. CMMC will be doing another Community Needs Assessment in the next year or so. Part VI, Line 3: CMMC has financial assistance signage posted in the admissions areas and the ER waiting area. A pamphlet explaining our financial assistance program, the application process and contact information is available at all hospital registration areas. The Charity Care policy and application along with a checklist and contact information is posted on our website on the internet. Prior to discharge someone from discharge planning discusses with the patient the availability of various government benefits, such as Medicaid, and assists the patient with qualifications for such programs, where applicable. Assistance with filling out the Charity Care application is also provided at this time. Private Pay in-patients are informed of Charity Care either prior to scheduled admission by physician referral or prior to discharge from the facility. We also send out information with first time statements. All other patients are informed upon inquiry. Part VI, Line 4: Lewistown is an agricultural community and the county seat for Fergus County Montana. Lewistown is located in the center of Montana and is surrounded by five mountain ranges: the Snowies, the Judiths, the Moccasins, the Belts and the Highwoods. The city of Lewistown and the surrounding rural towns are supported by one hospital, Central Montana Medical Center. Fergus County has a Primary Care Low Income HPSA Designation with a score of 16. Fergus County is located in a federally designated medically underserved area. As of 2009, there were 5,933 people residing in the city. The population density was 3,055.3 people per square mile. Also 13.9% of the residents were below the poverty level and 6.3% of the residents were 50% of the poverty level.The racial makeup of the city was 96.53% White, 0.07% African American, 1.41% Native American, 0.34% Asian, 0.14% from other races and 1.51% from two or more races. Hispanic or Lantino of any race were 0.72% of the population.There were 2,954 households out of which 26.1% had children under the age of 18 living with them, 46.5% were married couples living together, 8.6% had a female householder with no husband present and 41.9% were non-families. 37.7% of all households were made up of individuals and 18.4% had someone living alone who were 65 years of age or older. The average household size was 2.18 and the average family size was 2.88.In the city, the population spread was 23.6% under the age of 18, 6.8% from 18 to 24, 23.2% from 25 to 44, 23.6% from 45 to 64 and 22.8% were 65 years of age or older. The median age was 43 years. For every 100 females there were 87.5 males. For every 100 females age 18 and over there were 84.4 males. The median income for a household in the city was $28,949 and the median income for a family was $36,888. Males had a median income of $30,231 versus $20,019 for females. The per capita income for the city was $16,817. About 9.0% of families and 13.6% of the population were below the poverty line, including 17.3% of those under the age of 18 and 12.0% of those age 65 and over. Part VI, Line 5: CMMC promotes the health of the community by serving on several different community boards and through several community events. Several of the organization department managers serve on community boards such as Relay for Life, Kiwanis, Transportation Advisory Board, Community Health Steering Committee, Head Start Advisory Board and the Local Emergency Planning Committee. CMMC promotes health through several community events such as the Blood Pressure booth at the Central Montana Fair, HRDC Kids Fair, Diabetes Educational Presentations, local Community Health Fair and Fergus High School Career Fair.CMMC is involved in providing information to surrounding communities through First Aid and CPR training for Volunteer Emergency Response personnel and Health Fairs. Part VI, Line 6: The CMMC Governing Board consists of 13 volunteer community members including residents from Grass Range, Stanford, Denton and Judith Gap. CMMC extends medical staff privileges to qualified physicians based upon community needs.Surplus funds, when available, are applied to patient care needs, equipment and building maintenance and medical education requirements. The expenditure of these funds are approved by the Governing Board which meets on a monthly basis. Part VI, Line 7: N/A X 0 0 0 0 0 0 0 0 0 David Faulkner 180503 0 0 0 0 0 0 0 62762 0 243265 0 0 0 Danny Harbour MD 177460 0 0 0 0 0 23820 0 8560 0 209840 0 0 0 James Fox 199738 0 0 0 0 0 18045 0 1109 0 218892 0 0 0 Brian Priest 180608 0 0 0 0 0 14696 0 10873 0 206177 0 0 0 Joan McMahon MD 168280 0 0 0 0 0 0 0 4212 0 172492 0 0 0 Rene DeGuzman 170017 0 0 0 0 0 11039 0 16372 0 197428 0 0 0 Supplemental Information Part III Part I, Question 3: The organization does not pay compensation to the CEO directly. The CEO is compensated by an unrelated management company. The Board of Directors approves the contract with the management company. Part II: The CEO, David Faulkner, is compensated by an unrelated management company, Quorum health resources LLC. He is compensated for services provided to C.M. Medical Facilities, Inc. The management company bases the CEO's salary on compensation surveys for the area. The board of directors approves the salary or makes recommendations back to the management company. Fergus County Montana 816001358 2003-07-31 1980000 Refund old bonds 0 0 Fergus County Montana 816001358 2006-08-25 1529611 MRI system project 0 0 Fergus County Montana 816001358 2003-04-30 525000 construct/equipment addition 0 0 1980000 1980000 2003 1 0 1 1 1529611 29611 1500000 2006 0 0 1 1 525000 2800 522200 2003 0 0 1 1 0 0 0 0 0 0.00000 0.00000 0.00000 1 0 0 0 0 0 0.00000 0.00000 0.00000 1 0 0 0 0 0 1 0 0 0 0 0 1 0 0 0 0 0 1 Annie Davis Family of Board Member 48894 Payment of Compensation 0 0 Form 990, Part III, line 2 New Program Services 1. Opening of Basin Therapy in Stanford, MT - January 2010 2. Implementation of SBIRT (Screening, Brief Intervention and Refer to Treatment) Program - May 2010. 3. VA Contract for the Skilled Nursing Center - May 2010 4. Implementation of the PadNet Service - 2009 Form 990, Part III, line 3 Changes in Program Services 1. Dr. Kohler became Board Certified in Sleep Studies, therefore able to interpret Sleep Studies internally - February 2010 2. Sleep Lab accreditation - February 2010 3. Eight EMT's became certified as I-99 EMT's - (May 2009, March 2010) Form 990, Part VI, Section A, line 3 The organization delegated control over management duties customarily performed by or under direct supervision of officers, directors, trustees, or key employees to the CEO who is employed by a management company, Quorum Health Resources LLC (QHR). QHR assists with the management and supervision of the organization under the policies and direction of the governing board. Form 990, Part VI, Section A, line 6 The organization members consist of residents of the Central Montana area who are at least 18 years of age and who have or shall indicate their interest in the maintenance of adequate medical facilities and high standards of medical care in the area. Members of the organization must attend and sign the register at the organization's annual meeting. Form 990, Part VI, Section A, line 7a Members of the organization may vote on matters being addressed at the annual meetings. Each member is entitled to one vote on any question or action with the exception of the election of Directors of the corporation. For the election of Directors, the members shall vote for one nominee for each vacant board position. Form 990, Part VI, Section B, line 11 Draft copy of Form 990 is reviewed by the CFO and Board of Directors prior to its filing. Form 990, Part VI, Section B, line 12c The organization regularly and consistently monitors and enforces compliance with the conflict of interest policy by discussing at the Board of Director Meetings and obtaining signed statements from members. All officers, board members, and key employees are covered by the policy. The board determines whether conflicts exist and all potential conflicts are reviewed by the board. Any persons with a conflict are not allowed to vote on conflicted issues. Form 990, Part VI, section B, line 15a: The CEO is employed by Quorum Health Resources LLC (QHR), a hospital management corporation. QHR determines the CEO's compensation based on independent data and comparisons. The information is then presented to the board of directors for review and approval. This process is completed on an annual basis and was completed in fiscal year ending 6/30/10. Form 990, Part VI, Section C, line 19 The organization makes its governing documents, conflict of interest policy and financial statements available to the public upon request. A copy may be requested by calling, emailing, walk-in or via mail. Form 990, Part III, Line 1 Organization Vision Statement Our Vision is to be the healthcare provider for our region; Dedicate ourselves to innovative excellence in care; Collaborate care for economical services with other agencies; Be the leader in providing health education, prevention, and wellness services to promote individual responsibility for health outcomes; Provide financial stewardship for economic health care; Create an environment in which all participants feel valued and respected; Embrace change while exploring tomorrows needs today. Our Values are the intrinsic forces behind our mission and vision, and describe how our actions will be guided. We believe in Compassion: We will be aware and respectful of the life situation of others and treat them with compassion and consideration, Accountability: With integrity, knowledge, action and trust, Respect: For dignity, care, and concern for all, Excellence: As a team in all we do.