2011-01-28T13:23:56-06:00 2010-06-30 EIDE BAILLY LLP 3999 PENNSYLVANIA AVE SUITE 100 DUBUQUE IA 52002 990 2009-07-01 420818642 Central Community Hospital CENT 5632457000 901 Davidson St NW Elkader IA 520439015 Frances Zichal 5632457000 2011-01-25 1 Carmen Krantz 5635561790 2009 2016-02-24 21:20:13Z Frances Zichal 901 Davidson St NW Elkader IA 520439015 5898901 0 X www.centralcommunityhospital.com X 1961 IA Provide healthcare services to the surrounding community 8 7 83 12 0 0 325576 113245 5898256 5722442 8463 2317 42875 38493 6275170 5876497 7651 0 2565936 2439950 0 0 3207690 3239535 5773626 5687136 501544 189361 6034279 6468661 1096350 1338736 4937929 5129925 Working together to provide a personalized, healing experience 1 0 4572340 7651 5722442 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 1300 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 1,291 days of inpatient care and 14,204 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's Charity Care Program provides discounted and free services to patients who lack the resources to be fully responsible for the health care they receive. The Charity Care Policy is designed to ensure the entire community served by Central Community Hospital has access to needed healthcare services. Eligibility is based on income levels and family size. Generally, individuals earning income of up to 200% of the Federal Policy Income Guidelines are eligible for varying levels of discounts, including full discounts. Applications for the Charity Care Program are available from Financial Services or by calling (563) 245-7000.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 four years and updated annually by a county wide multi-disciplinary team and used to prioritize community projects. Financial Summary: Charity Care (at cost) $ 98,000 Bad Debt (at cost) 104,000 Community Benefit Programs: Community Health Improvement Services 12,605 Financial and in-kind contributions 7,651 Community Building Activities 3,818 Subsidized Health Services 107,551 Total Community Benefits $ 333,625 4572340 1 1 0 0 0 0 0 0 0 1 1 0 0 0 0 0 0 0 0 0 1 1 0 1 0 0 0 0 0 0 1 0 0 0 0 0 0 1 0 0 0 1 22 0 1 83 1 0 0 0 0 0 0 0 0 0 8 7 0 1 0 0 1 1 0 1 1 0 0 1 1 1 1 1 1 1 1 0 IA X Lisa Manson 5632457000 901 Davidson St NW Elkader IA 520439015 Robert Bodensteiner 0.50 X X 0 0 0 Mark Zwanziger 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 Hila Garms 0.50 X 0 0 0 Darwin Winke 0.50 X 0 0 0 Russell Knight 0.50 X 0 0 0 Frances Zichal 40.00 X 118464 0 7878 Lisa Manson 40.00 X 83851 0 13452 202315 0 21330 1 0 0 1 Mercy Medical Center - Dubuque 250 Mercy Drive Dubuque IA 52001 Purchased Services 614969 Wapiti Box 92 Newell SD 57760 ER Physicians 281320 Northern Iowa Therapy 1810 4th St SW Suite 103 Waverly IA 50677 PT, OT, ST 269672 Dick Beinborn CRNA 62598 Bluffs of Wildernest Prairie Du Chien WI 53821 Anesthesia 101060 4 10051 80764 22430 113245 Patient Service Revenu 622110 5647474 5647474 Other Supporting Reven 900099 41761 41761 Lifeline Revenue 900099 33207 33207 5722442 9785 9785 53429 14936 38493 38493 38493 7468 -7468 -7468 -7468 5876497 5722442 0 40810 7651 7651 218356 218356 37489 37489 1703248 1466442 236806 41727 35902 5825 308570 284339 24231 130560 112444 18116 49247 49247 30061 30061 1475796 1368419 107377 1552 1552 515204 399917 115287 151987 151987 180534 109700 70834 27488 27488 530011 530011 Bad Debt Expense 148341 148341 Miscellaneous Expense 129314 44197 85117 5687136 4572340 1114796 0 1431150 1379378 15124 38091 750580 678978 71581 79287 94658 116444 7860701 4358083 3439206 3502618 27901 529284 204079 144581 6034279 6468661 454704 433380 415267 360592 226379 544764 1096350 1338736 X 4784071 4948503 153858 181422 4937929 5129925 6034279 6468661 X 0 1 1 X 0 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 1 11536 9052 9989 10599 26015 26015 3918621 1526816 2391805 3916065 2831267 1084798 3502618 Accounts payable - Mercy Medical Center-Dubuque 50284 Capitalized lease obligations 83480 Estimated third-party payor settlements 411000 544764 5876497 5687136 189361 2635 2635 191996 5809157 -50284 -50284 5859441 17056 17056 5876497 5641799 14936 14936 5626863 60273 60273 5687136 Part IV, Line 1b: Central Community Hospital Auxiliary uses the Hospital's FEIN but has its own checking account. The Auxiliary accounts balances were not included in the financial statements. Part X: Description of Uncertain Tax Positions Under FIN 48: The Hospital has adopted the provisions of FASB Accounting Standards Codification Topic ASC 740-10 (previously Financial Interpretation No. 48, Accounting for Uncertainty in Income Taxes) on July 1, 2009. The implementation of this standard had no impact on the financial statements. Due to the nature of the Hospital, as of both the date of adoption, and as of June 30, 2010, there is no unrecognized tax benefit/liability accrual. If incurred, the Hospital will recognize future accrued interest and penalties related to the unrecognized tax liabilities in income tax expense. The Hospital is no longer subject to Federal or state tax examinations by tax authorities for years before 2006. Part XI, Line 8 - Other Adjustments: Change in interest in net assets of Central Community Hospital Foundation: 18624. Auxiliary beginning of year cash balance reclassified to custodial account: -16926. Change in Central Community Hospital Auxiliary assets: 937. Part XII, Line 2d - Other Adjustments: Affiliation agreement expense included in revenue for financial statements: -50284. Part XII, Line 4b - Other Adjustments: Contributions recorded in fund balance for financial statements: 14000. Monona Clinic rent expenses included in revenue on Form 990: -14936. Restricted donations recorded in fund balance for financial statements: 8940. Central Community Hospital Auxiliary revenue included on Form 990: 9052. Part XIII, Line 2d - Other Adjustments: Monona Clinic rent expenses included in revenue on Form 990: 14936. Part XIII, Line 4b - Other Adjustments: Affiliation agreement expense included in revenue for financial statements: 50284. Central Community Hospital Auxiliary expenses included on Form 990: 9989. 1 1 X 1 X 1 X 1 1 0 1 1 176 98000 98000 0.01780 136301 136301 176 234301 136301 98000 0.01780 2283 12605 12605 0.00230 500315 392764 107551 0.01960 260 7651 7651 0.00140 2543 520571 392764 127807 0.02330 2719 754872 529065 225807 0.04110 154 2108 2108 0.00040 89 1574 1574 0.00030 136 136 0.00000 243 3818 3818 0.00070 0 104000 1966 3093655 3143464 -49809 X 1 1 Central Community Hospital

901 Davidson St NW Elkader IA 520439015

X X X X 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 and cash and in-kind contributions to community groups, lines 7e and 7i, are 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.Total community benefit expense as a percentage of total expenses is 13.27%. Part I, Line 7g: The organization did not include as subsidized health services any costs attributable to a physician clinic. Part I, Line 7f: The amount of bad debt expense backed out of total expenses to determine the percentage was $148,341. Part III, Line 4: The organization's bad debt expense was converted to cost using the cost to charge ratio derived 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 an estimate of charity care to gross charges.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: Central Community Hospital provides services to Medicare patients understanding there will be write-offs and knowing the organization will not recover the costs of the services provided. Providing these services is essential to the community and therefore increases access to healthcare services, which is a community benefit.Total revenue received from Medicare is the gross reimbursement plus settlement. The costing methodology used is the cost accounting system. 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 there is no payment on an account after 30 days the account is sent to HR Pre-Collect. The patient will have 30 days to correct this before being sent to regular collections. Before an account is turned over to the collection agency, approval must be obtained from the Financial Services Manager. Legal suits may be instructed by the collection agency in accordance with standard collection practices and good business ethics. Once a bankruptcy notice has been received, 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 quarterly with all health care providers in Clayton County to prepare a county-wide health needs assessment, creative plan of action, and monitor implementation. This document is reviewed annually and rewritten every three 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 frequent articles 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. Part VI, Line 5: 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, trying to promote good health habits at an early age. Central Community Hospital is also involved in public health emergency readiness, 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. 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. IA 1 X Procedure for Monitoring Grants in the U.S.: Part I, Line 2: Schedule I, Part I, Line 2: Central Community Hospital provides cash donations and in-kind contributions to local organizations in need of medical supplies. The Hospital maintains records of who receives the support. X X X X 0 0 0 0 0 0 0 0 0 Frances Zichal 117576 0 0 0 888 0 4297 0 3581 0 126342 0 0 0 Lisa Manson 83630 0 0 0 221 0 3279 0 10173 0 97303 0 0 0 Supplemental Information Part III Part I, Question 3: Central Community Hospital does not pay compensation to the CEO and CFO directly. The CEO and CFO are compensated by an unrelated mangagement company. The Hospital board of directors uses the processes described in Part I, Question 3 to help determine appropriate compensation for the CEO and CFO. The board of directors also approves the organization's contract with the Management Company. Supplemental Information Part III Part II: Frances Zichal, CEO, and Lisa Manson, CFO are compensated by Mercy Medical Center - Dubuque, an unrelated management company, for services provided to Central Community Hospital. Haleisa Johnson Wife of board member of organization 37489 Salary and benefits as an employee 0 Form 990, Part III, line 2 New Program Services Reclast Clinic was offered for patients to receive an osteoporosis drug and education. Service began in May, 2010. Form 990, Part VI, Section A, line 3 The CEO and CFO of Central Community Hospital 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. 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 e-mailed to all board members and presented by the accounting firm at the annual board meeting. The CEO and CFO review and approve the 990 before it is filed. 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 is based on salary adjustment recommendations based on annual evaluations, wage scales, committee approval (Board Chair and Mercy Medical Center - Dubuque 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 and CFO. The process was last undertaken in fiscal year 2010. Form 990, Part VI, Section C, line 19 The organization's governing documents, conflict of interest policy, and financial statements are available upon written request. Form 990, Part VI, Section A, Line 1a: 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 VII, Section A The following individual devoted time providing services to Central Community Hospital Foundation, a related organization. Frances Zichal 1 hour Central Community Hospital Foundation 901 Davidson St NW Elkader IA 52043 421239401 To support Central Community Hospital and health education IA 501(c)(3) 7 N/A 0 0 1 0 0 0 0 0 0 0 0 1 1 1 0 0 0 0