2011-02-15T15:03:46-06:00 2010-06-30 SEIM JOHNSON SESTAK & QUIST LLP 8807 INDIAN HILLS DRIVE SUITE 300 OMAHA NE 681144123 990 2009-07-01 470533373 COMMUNITY HOSPITAL ASSOCIATION OF MCCOOK COMM 3083442650 1301 EAST H STREET PO BOX 1328 MCCOOK NE 69001 TROY BRUNTZ 3083442650 2011-02-11 1 Julie M Gerken 4023302660 2009 2016-02-24 21:20:13Z TROY BRUNTZ 434 SEMINOLE DRIVE MCCOOK NE 69001 32014752 0 X www.chmccook.org X 1974 NE TO PROMOTE PUBLIC HEALTH 9 9 290 40 0 0 109021 112505 28057673 30859461 133317 70023 886371 877596 29186382 31919585 56185 56080 0 12425168 13029667 0 0 14766861 15686083 27248214 28771830 1938168 3147755 25471710 34009223 5683846 11073604 19787864 22935619 TO EXCEL AT PROVIDING FOR THE HEALTHCARE NEEDS OF OUR REGION THROUGH QUALITY, EFFICIENT AND PATIENT-CENTERED CARE. 0 0 23822188 56080 31287815 CRITICAL ACCESS ACUTE CARE HOSPITAL PROVIDING INPATIENT AND OUTPATIENT CARE, DIAGNOSTIC, REHABILITATION, SURGICAL, NURSERY, VISITING MEDICAL SPECIALISTS, HOME HEALTH AND HOSPICE, TWO RURAL HEALTH CLINICS, AND HEALTH AND EDUCATION PROGRAMS. 23822188 1 1 0 1 0 0 0 0 1 1 0 1 0 0 0 0 0 0 0 0 1 1 0 1 0 0 0 1 0 0 1 1 0 0 0 0 0 1 1 0 0 1 47 0 1 290 1 1 1 0 0 0 0 0 0 0 0 9 9 0 0 0 0 0 0 0 1 1 0 0 1 1 1 1 1 1 1 1 1 1 X Troy Bruntz 3083442650 1301 EAST H - PO BOX 1328 MCCOOK NE 69001 BRIAN ESCH 1.00 X X 0 0 0 MARC HARPHAM 1.00 X X 0 0 0 DORIS FRIEHE 1.00 X X 0 0 0 JAMES O'DEA 1.00 X X 0 0 0 MARTY CONROY 1.00 X 0 0 0 RICHARD KLUG MD 1.00 X 0 0 0 DAVE SMITH 1.00 X 0 0 0 BRUCE BAIR 1.00 X 0 0 0 MAX ABERCOMBIE 1.00 X 0 0 0 JAMES ULRICH 40.00 X 162182 0 40598 TROY BRUNTZ 40.00 X 105659 0 23244 ANTHONY RODEWALD 40.00 X 114934 0 26744 TERRY GOURLEY 40.00 X 101897 0 10115 ELIZABETH NEAL 40.00 X 108326 0 13392 CHASE CRAWFORD 40.00 X 107288 0 33622 700286 0 147715 6 0 1 0 MCCOOK CLINIC PC 1401 EAST H STREET MCCOOK NE 69001 MEDICAL PROFESSIONAL - PHYSICIANS 969182 SOUTHWEST NEBRASKA PHYSICAL THERAPY PC PO BOX 789 MCCOOK NE 69001 MEDICAL PROFESSIONAL - PHYSICIANS 737283 LAWRENCE FRIESTAD CRNA 901 WEST 7TH MCCOOK NE 69001 MEDICAL PROFESSIONAL - ANESTHESIA 241114 PATHOLOGY SERVICES BOX 1289 NORTH PLATTE NE 69103 MEDICAL PROFESSIONAL - PATHOLOGY 209369 CENTRAL ANESTHESIA LLC 72128 ROAD 401 BARTLEY NE 69020 MEDICAL PROFESSIONAL - ANESTHESIA 160425 8 97101 15404 112505 PATIENT SERVICE REVENU 621400 15806753 15806753 MEDICARE/MEDICAID PAYM 621400 14565797 14565797 RECOVERY OF ACCOUNTS 621400 486911 486911 30859461 117748 117748 351913 17938 333975 333975 333975 29504 77229 -47725 -47725 -47725 CAFETERIA/MEALS 900099 94954 94954 HOUSEKEEPING INCOME 900099 80796 80796 PURCHASE DISCOUNTS 621400 45803 45803 322068 301755 20313 543621 31919585 31287815 0 519265 56080 56080 331683 331683 9834173 7950390 1883783 656103 516360 139743 1373690 1131352 242338 834018 656381 177637 19274 19274 55403 55403 5154636 4235431 919205 186421 186421 4531263 4308326 222937 711431 605939 105492 34141 24110 10031 240963 112347 128616 137409 125931 11478 2058498 1886541 171957 139328 127689 11639 PROVISION FOR BAD DEBTS 1401234 1401234 MISCELLANEOUS 902598 570593 332005 COLLECTION EXPENSE 113484 113484 28771830 23822188 4949642 0 1050 1050 5995021 6276648 3662311 3775575 73 632 69 1111382 1093991 346349 431529 41657101 19972414 14153719 21684687 138344 159442 63461 585600 25471710 34009223 2526381 4320496 143474 3013991 2697569 4055539 5683846 11073604 X 19787864 22935619 19787864 22935619 25471710 34009223 X 0 1 1 X 0 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 0 0 0 0 0 0 1 0 1 3067 3067 0 Part II-B, Line 1i: Explanation of Other Lobbying Activities: ITEM 1G - JAMES ULRICH, CEO AND PRESIDENT, TRAVELED TO WASHINGTON, D.C. TO PARTICIPATE IN "ADVOCACY DAY". MR. ULRICH MADE THIS TRIP AS A REPRESENTATIVE OF COMMUNITY HOSPITAL ASSOCIATION OF MCCOOK, AND AS A REPRESENTATIVE OF AHA AND NHA. AS AN "ADVOCACY DAY" PARTICIPANT, MR. ULRICH SPOKE WITH REPRESENTATIVES AND SENATORS REGARDING HEALTH CARE PROVIDER CONCERNS. ITEM 1I - A PORTION OF DUES PAID TO FRIENDS OF NEBRASKA NONPROFIT HOSPITALS, AMERICAN HOSPITAL ASSOCIATION AND NEBRASKA HOSPITAL ASSOCIATION IS USED BY THOSE ORGANIZATIONS TO INFLUENCE LEGISLATION. 1545264 441506 165360 45171 11858 2095101 1852460 42818 -288173 47008 14833 1545264 0.28310 0.71690 0 1 1 133878 133878 12895630 9964625 2931005 18561881 9604611 8957270 10065712 403178 9662534 21684687 31919585 28771830 3147755 0 3147755 31937523 17938 17938 31919585 0 31919585 28789768 17938 17938 28771830 0 28771830 Part V, Line 4: Description of Intended Use of Endowment Funds: THE ENDOWMENT FUNDS ARE HELD BY THE COMMUNITY HOSPITAL HEALTH FOUNDATION OF MCCOOK (A RELATED PARTY) AND ARE USED IN SUPPORT OF THE HOSPITAL'S PROGRAMS AND PROJECTS, INCLUDING PROPERTY AND EQUIPMENT PURCHASES, SCHOLARSHIPS, HOSPICE PROGRAMS, REHABILITATION SERVICES AND OTHERS. Part X: Description of Uncertain Tax Positions Under FIN 48: The Hospital and Foundation are not-for-profit corporations as described in Section 501(c)(3) of the Internal Revenue Code and are exempt from federal income taxes on related income pursuant to Section 501(a) of the Code. The Internal Revenue Service has established standards to be met to maintain tax-exempt status. In general, such standards require the Hospital and Foundation to meet a community benefit standard and comply with various laws and regulations. Red Willow is a for-profit corporation. Red Willow had $14,398 and $9,188 of taxable income; incurred and paid $2,160 and $1,378 of federal income tax; and incurred and paid $803 and $513 of state income tax for the fiscal years ending December 31, 2009 and 2008, respectively. As of June 30, 2010, Red Willow had no tax liability. The Hospital, Foundation and Red Willow account for uncertainties in accounting for income tax assets and liabilities using guidance included in FASB ASC 740, Income Taxes. The Hospital, Foundation and Red Willow recognize the effect of income tax positions only if those positions are more likely than not of being sustained. At June 30, 2010 and 2009, the Hospital, Foundation and Red Willow had no uncertain tax positions accrued. Part XII, Line 2d - Other Adjustments: RENTAL EXPENSES INCLUDED ON FORM 990, PART VIII, LINE 6B:: 17938. Part XIII, Line 2d - Other Adjustments: RENTAL EXPENSES INCLUDED ON FORM 990, PART VIII, LINE 6B:: 17938. 1 1 1 X 125.000000000000 0 1 1 0 1 1 393824 393824 0.01440 1969828 1968413 1415 0.00010 2363652 1968413 395239 0.01450 54435 54435 0.00200 54435 54435 0.00200 2418087 1968413 449674 0.01650 102468 19145 83323 0.00300 5496 5496 0.00020 107964 19145 88819 0.00320 0 844482 126600 12226135 12208854 17281 X 1 1 COMMUNITY HOSPITAL ASSN OF MCCOOK

1301 EAST H STREET - PO BOX 1328 MCCOOK NE 69001

X X X X COMMUNITY HEALTHCARE & HOSPICE

407 WEST 5TH STREET MCCOOK NE 69001

HOME HEALTH AND HOSPICE SERVICES COMMUNITY HOSPITAL SLEEP LAB

801 WEST C STREET SUITE 3B MCCOOK NE 69001

OUTPATIENT SLEEP SERVICES CURTIS MEDICAL CENTER

302 EAST 6TH STREET CURTIS NE 69025

RURAL HEALTH CLINIC-OUTPATIENT SERVICES TRENTON MEDICAL CLINIC

406 EAST 1ST STREET TRENTON NE 69044

RURAL HEALTH CLINIC-OUTPATIENT SERVICES COMMUNITY HOSPITAL - OUTPATIENT SERVICES

104 NORTH 3RD STREET INDIANOLA NE 69034

OUTPATIENT SERVICES Part I, Line 3c: Charity Care is granted to all individuals whose household income is below 125% of the federal poverty guideline at the 100% write-off level. Discounting or 100% write-off to charity care is allowed above 125% of the federal poverty guideline based on an analysis of individual need and determination of the patient being medically indigent; this analysis includes factors such as income, accessible assets, medical or/and other debts, the likelihood of ongoing medical care and the individual's overall ability to pay. Part I, Line 7: The organization uses a cost-to-charge ratio methodology derived from worksheet #2 of the form 990 instructiions. Part I, Line 7f: the bad debt expense included in form 990, part ix, line 25 but not included in Schedule h, part i, line 7, column (f) is $1,401,234. Part III, Line 4: Community Hospital's bad debt expense is recorded at gross revenue value on the Hospital's books based on actual bad debt incurred during the fiscal year and an estimate amount of accounts receivable at year end that, based on historical trends, are projected to be uncollectible from patients and/or third party Payors. Bad debt expense does not include any amounts attributable to patients that are known by the Hospital to qualify for the charity care program, nor does it include any amounts written off due to contractual relationships with third party Payors. The Cost of bad debt on line 2 was calculated using the overall cost-to-charge ratio from worksheet #2 in the Form 990 instructions. Line 3 was estimated using both quantitative and qualitative sources. The quantitative source was an analytical analysis of the amount of charity care given by Community Hospital compared to the local demographics for poverty based on US Census data. One of the assumptions made was that most individuals that would have qualified for charity care but would not apply ended up as bad debt write-offs of the Hospital. This analysis showed that approximately 5% of the bad debt expense was likely to have come from individuals that would have qualified for charity care had they applied. The qualitative source we employed was to ask our staff that routinely handle charity care applications and bad debt determinations, what percentage, in their professional opinion, of bad debt was from individuals that would have likely qualified for the charity care program had the patient applied for assistance. The estimate we received was 15%-20% of accounts turned over as bad debt, in their opinion, likely would have qualified for charity assistance had the patient been cooperative in the process and applied for charity care. After analysis of these factors, the Hospital is recording 15% of its bad debt costs on Line 3. Part III, Line 8: THE SOURCE USED TO DETERMINE THE AMOUNT REPORTED ON LINE 6 WAS THE MEDICARE COST REPORT. Part III, Line 9b: Community Hospital will adhere to hospital policies regarding Charity Care and grant a 100% Charity Care write-off for all patients known to qualify for Charity Care. Part VI, Line 2: Community Hospital conducts a community health needs assessment (CHNA) and has an implementation strategy to meet the community health needs identified through such assessment. The CHNA uses input from persons who represented the broad interests of the community served by Community Hospital, including community members, physicians, nurses, clinicians and leaders from other organizations dedicated to public health and welfare. Part VI, Line 3: Community Hospital works with patients identified as possibly qualifying for federal or state programs (i.e. Medicaid or Medicare) in applying for those programs. Community Hospital uses multiple communication channels and opportunities to communicate our charity policy to our patients, both at the time of service and in the collection process. Our patients are provided information by signs posted in the facility, through literature available in the community and at the facility, at the time of registration and on each billing that is mailed. Part VI, Line 4: Community Hospital serves a rural population of approximately 29,700 people living in an area of 717 square miles. Approximately 19% of the population is elderly (over 65). Over one half of the households have annual incomes of $40,000 or less and 81% have annual incomes of $60,000 or less; the median household income is $33,000. The number of families living below the federal poverty level is higher than the nebraska state average. Part VI, Line 5: Community Hospital supports various community building activities, primarily through monetary support. Examples include support to: the Economic Development Corporation, the local Community College and Invest Nebraska. These programs directly impact the health of our community by development of employment opportunities and a more employable workforce. Members of our community with good employment have access to health insurance and are generally able to live healthier lives. Part VI, Line 6: Community Hospital is the largest hospital within an hour travel time for most of the community served. The Hospital provides the physicians of McCook a Hospital to practice medicine. without the Hospital our patients would have extremely long distances to travel for everything from emergency to routine care. Our Hospital is overseen by a non-compensated board of independent community members. Any profits from the operation of the hospital are reinvested back into the facilities, equipment and staff to provide our community with current and high quality medical services close to home. Part VI, Line 7: N/A NE 1 INVEST NEBRASKA CORPORATION 4701 INNOVATION DR LINCOLN NE 68521 460469145 501(c)(3) 6667 TO SUPPORT ECONOMIC DEVELOPMENT IN OUR COMMUNITY. MCCOOK COLLEGE FOUNDATION PO BOX 195 MCCOOK NE 69001 476089800 501(c)(3) 20000 SUPPORT FOR THE CONSTRUCTION OF THE MCC EVENT CENTER WHICH PROMOTES HEALTH AND WELLNESS CURRICULUM AND ACTIVITIES IN THE MCCOOK COMMUNITY. MCCOOK ECONOMIC DEVELOPMENT CORPORATION 301 NORRIS AVE SUITE 200 - PO BOX 626 MCCOOK NE 69001 470685662 501(c)(4) 14000 TO RECRUIT, STRENGTHEN AND EXPAND THE BUSINESSES THAT ARE THE FOUNDATION TO OUR LOCAL ECONOMY. 2 1 Procedure for Monitoring Grants in the U.S.: Part I, Line 2: Schedule I, Part I, Line 2: GRANTS ARE MADE ONLY TO SELECTED CHARITABLE OR OTHER EXEMPT ORGANIATIONS. COMMUNITY HOSPITAL ASSOCIATION ENTERS INTO AGREEMENTS WITH GRANTEES THAT GRANT FUNDS WILL BE RESTRICTED TO SPECIFIED EXEMPT PURPOSES. X X X X 0 0 0 0 0 0 0 0 0 JAMES ULRICH 162182 0 0 0 0 0 11536 0 29062 0 202780 0 0 0 TROY BRUNTZ CFO EMPLOYEE COMPUTER PURCHASE X 1087 632 0 0 1 SUZANNE ABERCROMBIE EMPLOYEE COMPUTER PURCHASE X 717 69 0 0 1 701 MARTY CONROY JOYCE CONROY MR. CONROY: BOARD OF DIRECTORS - MEMBER, JOYCE CONROY: SPOUSE 19635 MRS. CONROY IS EMPLOYED BY THE HOSPITAL. 0 MAX ABERCROMBIE SUZANNE ABERCROMB MAX ABERCROMBIE: BOARD OF DIRECTORS - MEMBER, SUZANNE ABERCROMBIE: SPOUSE 17432 MRS. ABERCROMBIE IS EMPLOYED BY THE HOSPITAL. 0 MCCOOK CLINIC PC RICHARD KLUG,MD: BOARD OF DIRECTORS-MEMBER, and PARTNER IN MCCOOK CLINIC,PC 1265852 THE HOSPITAL PAID THE CLINIC $963,600 AND $32,244 FOR EMERGENCY ROOM COVERAGE AND RURAL HEALTH CLINIC COVERAGE, RESPECTIVELY. THE CLINIC PAID THE HOSPITAL $215,421 FOR RENT OF THE BUILDING AND $54,587 FOR ENVIRONMENTAL SERVICES IN THE BUILDING. 0 Form 990, Part VI, Section B, line 11 Community Hospital's Form 990, 990-T and Nebraska form 1120N are compiled by the PUBLIC ACCOUNTING firm Seim Johnson. Management receives draft copies of the completed forms for review. After Hospital management has reviewed the returns, members of the Board of Directors of the Community Hospital Association REVIEW THE RETURNS. FINALLY, THE RETURNS ARe approved for filing by the Budget & Finance Committee of the Board (a standing committee with responsibility to oversee financial, audit, taxation and budget matters of the Hospital). Board Committee approval is required prior to signature and submission of the returns to the IRS and STATE TAXING AUTHORITIES. Form 990, Part VI, Section B, line 12c The Community Hospital Association's Code of Conduct requires all employees, contractors, and agents to report any conflicts of interest that arise. In addition, the Association has a conflict of interest policy that is applicable to directors, officers, members of committees and subcommittees with board-delegated powers, and key employees that requires, among other things, all applicable persons disclose any relationships that may create a conflict of interest and are required to complete an annual disclosure of all such relationships. All such relationships are disclosed to the entire board and senior management, and any and all conflicts or potential conflicts are monitored by senior management and the Association's compliance function. Form 990, Part VI, Section B, line 15 Community Hospitals process for determining the compensation of the CEO is as follows: The Executive Committee of the Board of Directors is responsible for setting the salary of the CEO. Annually, the Committee conducts a review of the CEO's performance, abilities, and overall effectiveness. The Committee is presented with salary and compensation survey data that is compiled by the CEO and the human resource department and the accuracy of which is attested to by the CFO. Multiple sources of survey data are used, including information from the Nebraska and Iowa Hospital Associations, which is broken down to similarly qualified persons in comparable positions at similarly sized and situated organizations. All source documentation is given to the Committee as well as summaries provided for ease of reference. The Executive Committee conducts the performance review with the CEO; then meetS in private chambers to discuss the review and to deliberate any and all changes to the employment agreement, including compensation, and goals for the following year. Contemporaneous records are kept of all survey and comparability data used, and the results and decisions of the Executive Committees meeting on compensation. Compensation of Employees below the role of CEO are determined through the use of survey information of similarly qualified persons in comparable positions at similarly sized and situated organizations. The CEO sets the compensation of senior management based on those surveys, taking in consideration performance and experience of each individual. Compensation ranges of employees below senior management are set by human resources based on market wage rates for similarly qualified persons in comparable positions at similarly sized and situated organizations. All employees have an annual review by their supervisor, which determine where in the salary range an employee will fall. All salary ranges, including those of senior management, are ultimately approved by the Board of Directors during the approval of the annual operating budget. Form 990, Part VI, Section C, line 19 Community Hospital makes its governing documents, conflict of interest policy, Form 990 & 990-T (current and past years as required by law) and financial statements available to the public upon request. Any individual who would like a copy of any of the above mentioned documents can inspect those documents in person at the Hospital during normal business hours, or request a copy of any of the above information in person, by phone, or by mail, and we will provide a copy free of charge. FORM 990, PART XI, LINE 2C Community Hospital has a standing Board Committee, the Budget and Finance Committee, which has the authority and assumes the responsibility for the selection of the independent accounting firm and all related oversight, communication, and reporting. This committee approves all engagement letters and receives all board directed communication from the independent accounting firm. Copies of received letters/communications and reports are distributed to all members of the Board of Directors in addition to the committee members. While the members of the committee have changed, the process described has not changed from the previous year. COMMUNITY HOSPITAL HEALTH FOUNDATION 801 WEST C STREET PO BOX 1328 MCCOOK NE 69001 470693261 SUPPORTING ORGANIZATION PROVIDES FUNDRAISING FOR THE HOSPITAL NE 501(C)(3) 11C, TYPE III-FI N/A RED WILLOW HOLDING COMPANY 1301 EASH H STREET MCCOOK NE 69001 470628195 RENTAL REAL ESTATE - CLINIC BUILDING NE N/A C 50779 112481 1.00000 0 1 1 0 0 0 0 0 0 1 0 1 1 0 1 1 0 0 RED WILLOW MEDICAL HOLDING J 50261 COMMUNITY HOSPITAL HEALTH FOUNDATION C 97101