CAMBRIDGE MEMORIAL HOSPITAL INC: Form 990, tax year 2009
View the entire original 990 at ProPublica ↗
- Organization
- CAMBRIDGE MEMORIAL HOSPITAL INC (EIN 47-6028103)
- Tax period
- 2009-05-01 to 2010-04-30
- Filed
- 2011-03-14
- IRS object ID
- 201140739349300114
- Schema version
- 2009v1.7
- Source
- Download XML · Original 990 at ProPublica
Every field in the e-filed return. Faint text is the IRS element name, for citing.
Return header ReturnHeader
| Field | Value | IRS element (for citing) |
|---|---|---|
| Timestamp | 2011-03-14T11:01:00-05:00 | Timestamp |
| Tax Period End Date | 2010-04-30 | TaxPeriodEndDate |
Preparer Firm PreparerFirm
Preparer Firm Business Name PreparerFirmBusinessName
| Field | Value | IRS element (for citing) |
|---|---|---|
| Business Name Line1 | EIDE BAILLY LLP | BusinessNameLine1 |
Preparer Firm US Address PreparerFirmUSAddress
| Field | Value | IRS element (for citing) |
|---|---|---|
| Address Line1 | 4310 17TH AVE S PO BOX 2545 | AddressLine1 |
| City | FARGO | City |
| State | ND | State |
| ZIP Code | 581082545 | ZIPCode |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Return Type | 990 | ReturnType |
| Tax Period Begin Date | 2009-05-01 | TaxPeriodBeginDate |
Filer Filer
| Field | Value | IRS element (for citing) |
|---|---|---|
| EIN | 476028103 | EIN |
Name Name
| Field | Value | IRS element (for citing) |
|---|---|---|
| Business Name Line1 | CAMBRIDGE MEMORIAL HOSPITAL | BusinessNameLine1 |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Name Control | CAMB | NameControl |
| Phone | 3086971522 | Phone |
US Address USAddress
| Field | Value | IRS element (for citing) |
|---|---|---|
| Address Line1 | PO BOX 488 | AddressLine1 |
| City | CAMBRIDGE | City |
| State | NE | State |
| ZIP Code | 69022 | ZIPCode |
Officer Officer
| Field | Value | IRS element (for citing) |
|---|---|---|
| Name | Roger Steinkruger | Name |
| Title | Chief Executive Officer | Title |
| Phone | 3086971522 | Phone |
| Date Signed | 2011-03-10 | DateSigned |
| Authorize Third Party | 1 | AuthorizeThirdParty |
Preparer Preparer
| Field | Value | IRS element (for citing) |
|---|---|---|
| Name | LISA CHAFFEE CPA | Name |
| Phone | 7012398500 | Phone |
| Date Prepared | 2011-03-02 | DatePrepared |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Tax Year | 2009 | TaxYear |
| Build TS | 2016-02-24 21:20:13Z | BuildTS |
Form 990 IRS990
Doing Business As DoingBusinessAs
| Field | Value | IRS element (for citing) |
|---|---|---|
| Business Name Line1 | Tri Valley Health System | BusinessNameLine1 |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Name Of Principal Officer Person | Roger Steinkruger | NameOfPrincipalOfficerPerson |
Address Principal Officer US AddressPrincipalOfficerUS
| Field | Value | IRS element (for citing) |
|---|---|---|
| Address Line1 | PO BOX 488 | AddressLine1 |
| City | CAMBRIDGE | City |
| State | NE | State |
| ZIP Code | 69022 | ZIPCode |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Gross Receipts | 14808773 | GrossReceipts |
| Group Return For Affiliates | 0 | GroupReturnForAffiliates |
| Organization501c | X | Organization501c |
| Web Site | www.trivalleyhealth.com | WebSite |
| Type Of Organization Corporation | X | TypeOfOrganizationCorporation |
| Year Formation | 1955 | YearFormation |
| State Legal Domicile | NE | StateLegalDomicile |
| Activity Or Mission Description | Providing quality, compassionate, local healthcare services. | ActivityOrMissionDescription |
| Nbr Voting Members Governing Body | 9 | NbrVotingMembersGoverningBody |
| Nbr Independent Voting Members | 9 | NbrIndependentVotingMembers |
| Total Nbr Employees | 224 | TotalNbrEmployees |
| Total Nbr Volunteers | 188 | TotalNbrVolunteers |
| Total Gross UBI | 10108 | TotalGrossUBI |
| Net Unrelated Business Txbl Income | -35657 | NetUnrelatedBusinessTxblIncome |
| Contributions Grants Prior Year | 69761 | ContributionsGrantsPriorYear |
| Contributions Grants Current Year | 353557 | ContributionsGrantsCurrentYear |
| Program Service Revenue Prior Year | 13393641 | ProgramServiceRevenuePriorYear |
| Program Service Revenue CY | 14437176 | ProgramServiceRevenueCY |
| Investment Income Prior Year | 23614 | InvestmentIncomePriorYear |
| Investment Income Current Year | 18040 | InvestmentIncomeCurrentYear |
| Other Revenue Current Year | 0 | OtherRevenueCurrentYear |
| Total Revenue Prior Year | 13487016 | TotalRevenuePriorYear |
| Total Revenue Current Year | 14808773 | TotalRevenueCurrentYear |
| Grants And Similar Amnts CY | 0 | GrantsAndSimilarAmntsCY |
| Benefits Paid To Members CY | 0 | BenefitsPaidToMembersCY |
| Salaries Etc Prior Year | 7045502 | SalariesEtcPriorYear |
| Salaries Etc Current Year | 7918921 | SalariesEtcCurrentYear |
| Total Prof Fundrsng Exp CY | 0 | TotalProfFundrsngExpCY |
| Total Fundrsng Exp Current Year | 0 | TotalFundrsngExpCurrentYear |
| Other Expense Prior Year | 5944424 | OtherExpensePriorYear |
| Other Expenses Current Year | 5685027 | OtherExpensesCurrentYear |
| Total Expenses Prior Year | 12989926 | TotalExpensesPriorYear |
| Total Expenses Current Year | 13603948 | TotalExpensesCurrentYear |
| Revenues Less Expenses Prior Year | 497090 | RevenuesLessExpensesPriorYear |
| Revenues Less Expenses CY | 1204825 | RevenuesLessExpensesCY |
| Total Assets BOY | 11882511 | TotalAssetsBOY |
| Total Assets EOY | 23211294 | TotalAssetsEOY |
| Total Liabilities BOY | 2172419 | TotalLiabilitiesBOY |
| Total Liabilities EOY | 11855076 | TotalLiabilitiesEOY |
| Net Assets Or Fund Balances BOY | 9710092 | NetAssetsOrFundBalancesBOY |
| Net Assets Or Fund Balances EOY | 11356218 | NetAssetsOrFundBalancesEOY |
| Mission Description | Improve the health of our communities by providing quality, compassionate, local healthcare services. We strive to fulfill this mission by:1. Offering convenient and accessible acute care and senior services that exceed expectations.2. Positively impacting regional economic development.3. Building and reinforcing our sense of community, and4. Referring patients to specialists when necessary. | MissionDescription |
| Significant New Program Services | 0 | SignificantNewProgramServices |
| Significant Change | 0 | SignificantChange |
| Expense | 8183277 | Expense |
| Revenue | 9227106 | Revenue |
| Description | Tri Valley Health System operates a critical access hospital with an attached long-term care unit, three rural health clinics, an Assisted Living Facility, a Durable Medical Equipment/Supply store and an Independent Retirement Center.The Cambridge Memorial Hospital, a 25 bed critical access hospital, operates a full-time emergency room and provides emergency care regardless of the ability to pay. The emergency room had approximately 1,100 emergency center visits this year. Through its integrated network of providers, Tri Valley Health System provides emergency and non-emergency services to the communities it serves. It makes these services accessible to the communities through participation in government programs like Medicare and Medicaid and by offering assistance through the Tri Valley Health System charity program. The Tri Valley Health System charity program provides discounted and free services to patients who lack the resources to be fully responsible for the health care they receive. The Charity Program is designed to ensure the communities served by Tri Valley Health System have access to needed healthcare services. The Cambridge Memorial Hospital Board of Directors oversees services delivered under the Charity Policy including assessing community needs, approving eligibility criteria and monitoring the effectiveness of the program in providing community access to medical care. Records are maintained to identify and monitor the level of charity care provided. These records include the amount for charges foregone for services and supplies furnished under its Charity Care Policy and equivalent service statistics. The amount of charges foregone during fiscal year ended April 30, 2010, based on established rates was $43,528. | Description |
Activity2 Activity2
| Field | Value | IRS element (for citing) |
|---|---|---|
| Expense | 1820731 | Expense |
| Revenue | 2907982 | Revenue |
| Description | Tri Valley Health System's senior services programs include a Long Term Care Facility, an Assisted Living Facility and an Independent Living Facility. During the fiscal year, Tri Valley averaged over 30 residents a day in the Long Term Care and 14 residents a day in the Assisted Living Facility. By providing a continuum of care from independent, to assisted, to long term care, Tri Valley is encouraging community members to stay as independent as possible and assuring the patients/residents are in the appropriate location based on their level of care needs. Tri Valley launched the "Frog" Program which is a free exercise program for the older generation that meets three times a week. The program is currently offered in Arapahoe and Cambridge and because of the high utilization and by request, Tri Valley is currently looking to offer the program in Indianola as well. | Description |
Activity3 Activity3
| Field | Value | IRS element (for citing) |
|---|---|---|
| Expense | 1761889 | Expense |
| Revenue | 2291980 | Revenue |
| Description | Tri Valley has rural health clinics in Arapahoe, Indianola, and Cambridge, Nebraska. During the year, the clinics had 14,281 visits. The employed physician's are active in the community and provide support services such as attendance at community sport programs and medical directors for EMT groups. They can frequently be seen offering educational programs for the local school systems or healthy living programs for the Healthy in the Heartland programs. Yearly the clinic provides "flu clinics" in which flu vaccinations are provided at reduced rates. Also, the clinics annually offer a "health fair" to the communities they serve. Lab testing completed which normally would cost the patient $400 is reduced to a fee of approximately $35 (depending on tests requested). The results are sent to any physician the patient requests at no additional fee. | Description |
Activity Other ActivityOther
| Field | Value | IRS element (for citing) |
|---|---|---|
| Description | During the fiscal year, Tri Valley Health System has embarked on building a replacement hospital and then renovating the existing hospital to be a "healthy living center". The programs that will be offered in healthy living center include a health club, sleep diagnostic lab services, counseling rooms, nutrition education programs, etc. Tri Valley is committed to promoting through education healthy living to the communities it serves. | Description |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Program Service Expense | 11765897 | TotalProgramServiceExpense |
| Described In501 C3 | 1 | DescribedIn501C3 |
| Schedule B Required | 1 | ScheduleBRequired |
| Political Activities | 0 | PoliticalActivities |
| Lobbying Activities | 0 | LobbyingActivities |
| Donor Advised Funds | 0 | DonorAdvisedFunds |
| Conservation Easements | 0 | ConservationEasements |
| Collections Of Art | 0 | CollectionsOfArt |
| Credit Counseling | 0 | CreditCounseling |
| Term Or Permanent Endowments | 0 | TermOrPermanentEndowments |
| Balance Sheet Amounts Reported | 1 | BalanceSheetAmountsReported |
| Independent Audit Financial Stmt | 1 | IndependentAuditFinancialStmt |
| Consolidated Audit Financial Stmt | 0 | ConsolidatedAuditFinancialStmt |
| School | 0 | School |
| Foreign Office | 0 | ForeignOffice |
| Foreign Activities | 0 | ForeignActivities |
| More Than5000 K To Organizations | 0 | MoreThan5000KToOrganizations |
| More Than5000 K To Individuals | 0 | MoreThan5000KToIndividuals |
| Professional Fundraising | 0 | ProfessionalFundraising |
| Fundraising Activities | 0 | FundraisingActivities |
| Gaming | 0 | Gaming |
| Hospital | 1 | Hospital |
| Grants To Organizations | 0 | GrantsToOrganizations |
| Grants To Individuals | 0 | GrantsToIndividuals |
| Schedule J Required | 1 | ScheduleJRequired |
| Tax Exempt Bonds | 0 | TaxExemptBonds |
| Excess Benefit Transaction | 0 | ExcessBenefitTransaction |
| Prior Excess Benefit Transaction | 0 | PriorExcessBenefitTransaction |
| Loan To Officer Or DQP | 0 | LoanToOfficerOrDQP |
| Grant To Related Person | 0 | GrantToRelatedPerson |
| Bsnss Rltnshp With Organization | 0 | BsnssRltnshpWithOrganization |
| Bsnss Rltnshp Thru Family Member | 0 | BsnssRltnshpThruFamilyMember |
| Officer Entity With Bsnss Rltnshp | 0 | OfficerEntityWithBsnssRltnshp |
| Deductible Non Cash Contributions | 0 | DeductibleNonCashContributions |
| Deductible Contributions Of Art | 0 | DeductibleContributionsOfArt |
| Terminated | 0 | Terminated |
| Partial Liquidation | 0 | PartialLiquidation |
| Disregarded Entity | 0 | DisregardedEntity |
| Related Entity | 0 | RelatedEntity |
| Related Org Controlled Entity | 0 | RelatedOrgControlledEntity |
| Transfers To Exempt Non Chrtbl Org | 0 | TransfersToExemptNonChrtblOrg |
| Activities Conducted Partnership | 0 | ActivitiesConductedPartnership |
| Schedule O Required | 1 | ScheduleORequired |
| Number Forms Transmitted With1096 | 33 | NumberFormsTransmittedWith1096 |
| Number W2 G Included | 0 | NumberW2GIncluded |
| Compliance With Backup Witholding | 1 | ComplianceWithBackupWitholding |
| Number Of Employees | 224 | NumberOfEmployees |
| Employment Tax Returns Filed | 1 | EmploymentTaxReturnsFiled |
| Unrelated Business Income | 1 | UnrelatedBusinessIncome |
| Form990-T Filed | 1 | Form990-TFiled |
| Foreign Financial Account | 0 | ForeignFinancialAccount |
| Prohibited Tax Shelter Trans | 0 | ProhibitedTaxShelterTrans |
| Taxable Party Notification | 0 | TaxablePartyNotification |
| Non Deductible Contributions | 0 | NonDeductibleContributions |
| Quid Pro Quo Contributions | 0 | QuidProQuoContributions |
| Form8282 Property Disposed Of | 0 | Form8282PropertyDisposedOf |
| Funds To Pay Premiums | 0 | FundsToPayPremiums |
| Premiums Paid | 0 | PremiumsPaid |
| Nbr Voting Governing Body Members | 9 | NbrVotingGoverningBodyMembers |
| Number Independent Voting Members | 9 | NumberIndependentVotingMembers |
| Family Or Business Relationship | 0 | FamilyOrBusinessRelationship |
| Delegation Of Management Duties | 1 | DelegationOfManagementDuties |
| Changes To Organizing Docs | 1 | ChangesToOrganizingDocs |
| Material Diversion Or Misuse | 0 | MaterialDiversionOrMisuse |
| Members Or Stockholders | 1 | MembersOrStockholders |
| Election Of Board Members | 1 | ElectionOfBoardMembers |
| Decisions Subject To Approval | 0 | DecisionsSubjectToApproval |
| Minutes Of Governing Body | 1 | MinutesOfGoverningBody |
| Minutes Of Committees | 0 | MinutesOfCommittees |
| Officer Mailing Address | 0 | OfficerMailingAddress |
| Local Chapters | 0 | LocalChapters |
| Form990 Provided To Governing Body | 1 | Form990ProvidedToGoverningBody |
| Conflict Of Interest Policy | 1 | ConflictOfInterestPolicy |
| Annual Disclosure Covered Persons | 1 | AnnualDisclosureCoveredPersons |
| Regular Monitoring Enforcement | 1 | RegularMonitoringEnforcement |
| Whistleblower Policy | 1 | WhistleblowerPolicy |
| Document Retention Policy | 1 | DocumentRetentionPolicy |
| Compensation Process CEO | 0 | CompensationProcessCEO |
| Compensation Process Other | 1 | CompensationProcessOther |
| Investment In Joint Venture | 0 | InvestmentInJointVenture |
| Upon Request | X | UponRequest |
The Books Are In Care Of TheBooksAreInCareOf
Name Business NameBusiness
| Field | Value | IRS element (for citing) |
|---|---|---|
| Business Name Line1 | Diana Rippe | BusinessNameLine1 |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Telephone Number | 3086973329 | TelephoneNumber |
Address US AddressUS
| Field | Value | IRS element (for citing) |
|---|---|---|
| Address Line1 | PO Box 488 | AddressLine1 |
| City | Cambridge | City |
| State | NE | State |
| ZIP Code | 69022 | ZIPCode |
Form990 Part VII Section A Form990PartVIISectionA (16 entries)
| TitleTitle | Average Hours Per WeekAverageHoursPerWeek | Individual Trustee Or DirectorIndividualTrusteeOrDirector | OfficerOfficer | Reportable Comp From OrganizationReportableCompFromOrganization | Reportable Comp From Related OrgsReportableCompFromRelatedOrgs | Other CompensationOtherCompensation | Highest Compensated EmployeeHighestCompensatedEmployee |
|---|---|---|---|---|---|---|---|
| Randy Heitmann | |||||||
| Chairman | 3.00 | X | X | 0 | 0 | 0 | |
| Cathy Kubik | |||||||
| Vice-Chairperson | 3.00 | X | X | 0 | 0 | 0 | |
| Patrick Horwart | |||||||
| Secretary | 3.00 | X | X | 0 | 0 | 0 | |
| Troy Westadt | |||||||
| Treasurer | 3.00 | X | X | 0 | 0 | 0 | |
| Eric Eisenhart | |||||||
| Board Member | 3.00 | X | 0 | 0 | 0 | ||
| Clark Andrews | |||||||
| Board Member | 3.00 | X | 0 | 0 | 0 | ||
| Reginald Warner | |||||||
| Board Member | 3.00 | X | 0 | 0 | 0 | ||
| Bill Minnick | |||||||
| Board Member | 3.00 | X | 0 | 0 | 0 | ||
| Kristy Witte | |||||||
| Board Member | 3.00 | X | 0 | 0 | 0 | ||
| Roger Steinkruger | |||||||
| CEO | 40.00 | X | 127890 | 0 | 45026 | ||
| Diana Rippe | |||||||
| CFO | 40.00 | X | 64103 | 0 | 5720 | ||
| Lennie Deaver MD | |||||||
| Provider | 40.00 | 256894 | 0 | 21699 | X | ||
| Rachelle Kaspar-Cope MD | |||||||
| Provider | 40.00 | 211187 | 0 | 841 | X | ||
| Paul Shellabarger PA | |||||||
| Provider | 40.00 | 167412 | 0 | 17401 | X | ||
| William Malchow PA | |||||||
| Provider | 40.00 | 111114 | 0 | 4807 | X | ||
| Bill Duff | |||||||
| Pharmacist | 40.00 | 150473 | 0 | 10175 | X | ||
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Reportable Comp From Org | 1089073 | TotalReportableCompFromOrg |
| Total Reportable Comp Frm Rltd Orgs | 0 | TotalReportableCompFrmRltdOrgs |
| Total Other Compensation | 105669 | TotalOtherCompensation |
| Number Individuals GT100 K | 5 | NumberIndividualsGT100K |
| Formers Listed | 0 | FormersListed |
| Total Comp GT150 K | 1 | TotalCompGT150K |
| Compensation From Other Sources | 1 | CompensationFromOtherSources |
Contractor Compensation ContractorCompensation (5 entries)
| Address Line1AddressOfContractor/AddressUS/AddressLine1 | CityAddressOfContractor/AddressUS/City | StateAddressOfContractor/AddressUS/State | ZIP CodeAddressOfContractor/AddressUS/ZIPCode | Description Of ServicesDescriptionOfServices | CompensationCompensation |
|---|---|---|---|---|---|
| Neenan Company LLC | |||||
| 2620 E Prospect Rd Ste 100 | Fort Collins | CO | 45263 | Architecture/Construction | 969062 |
| Southwest Nebraska Physical Therapy | |||||
| PO Box 789 | McCook | NE | 69001 | Physical Therapy | 581021 |
| BRIM Healthcare Inc | |||||
| PO Box 636426 | Cincinnati | OH | 45263 | Management Services | 225359 |
| Eide Bailly LLP | |||||
| PO BOX 2545 | Fargo | ND | 58108 | Accounting/Auditing | 134936 |
| Connie Hill CRNA | |||||
| 72195 Cross Creek Rd | Cambridge | NE | 69022 | CRNA | 126325 |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Number Of Contractors GT100 K | 7 | NumberOfContractorsGT100K |
| All Other Contributions | 353557 | AllOtherContributions |
| Total Contributions | 353557 | TotalContributions |
Program Service Revenue ProgramServiceRevenue (3 entries)
| DescriptionDescription | Business CodeBusinessCode | Total Revenue ColumnTotalRevenueColumn | Related Or Exempt Function IncomeRelatedOrExemptFunctionIncome | Unrelated Business RevenueUnrelatedBusinessRevenue |
|---|---|---|---|---|
| Patient Revenue | 900099 | 14366096 | 14366096 | |
| Other Revenue | 900099 | 60972 | 60972 | |
| Medical Spa | 812900 | 10108 | 10108 |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Program Service Revenue | 14437176 | TotalProgramServiceRevenue |
Investment Income InvestmentIncome
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Revenue Column | 17240 | TotalRevenueColumn |
| Exclusion | $17,240 | ExclusionAmount |
Gross Amount Sales Assets GrossAmountSalesAssets
| Field | Value | IRS element (for citing) |
|---|---|---|
| Other | 800 | Other |
Gain Or Loss GainOrLoss
| Field | Value | IRS element (for citing) |
|---|---|---|
| Other | 800 | Other |
Net Gain Or Loss Investments NetGainOrLossInvestments
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Revenue Column | 800 | TotalRevenueColumn |
| Exclusion | $800 | ExclusionAmount |
Total Revenue TotalRevenue
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Revenue Column | 14808773 | TotalRevenueColumn |
| Related Or Exempt Function Income | 14427068 | RelatedOrExemptFunctionIncome |
| Unrelated Business Revenue | 10108 | UnrelatedBusinessRevenue |
| Exclusion | $18,040 | ExclusionAmount |
Comp Current Officers Directors CompCurrentOfficersDirectors
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | 258862 | Total |
| Management And General | 258862 | ManagementAndGeneral |
Other Salaries And Wages OtherSalariesAndWages
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | 5999812 | Total |
| Program Services | 5400365 | ProgramServices |
| Management And General | 599447 | ManagementAndGeneral |
Pension Plan Contributions PensionPlanContributions
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | 112555 | Total |
| Program Services | 102018 | ProgramServices |
| Management And General | 10537 | ManagementAndGeneral |
Other Employee Benefits OtherEmployeeBenefits
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | 1547692 | Total |
| Program Services | 1376980 | ProgramServices |
| Management And General | 170712 | ManagementAndGeneral |
Fees For Services Management FeesForServicesManagement
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | 301323 | Total |
| Management And General | 301323 | ManagementAndGeneral |
Fees For Services Legal FeesForServicesLegal
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | 4268 | Total |
| Management And General | 4268 | ManagementAndGeneral |
Fees For Services Accounting FeesForServicesAccounting
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | 59260 | Total |
| Management And General | 59260 | ManagementAndGeneral |
Fees For Services Other FeesForServicesOther
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | 1584805 | Total |
| Program Services | 1568883 | ProgramServices |
| Management And General | 15922 | ManagementAndGeneral |
Advertising Advertising
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | 85806 | Total |
| Management And General | 85806 | ManagementAndGeneral |
Office Expenses OfficeExpenses
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | 1777569 | Total |
| Program Services | 1525824 | ProgramServices |
| Management And General | 251745 | ManagementAndGeneral |
Occupancy Occupancy
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | 382655 | Total |
| Program Services | 372696 | ProgramServices |
| Management And General | 9959 | ManagementAndGeneral |
Travel Travel
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | 65028 | Total |
| Program Services | 49171 | ProgramServices |
| Management And General | 15857 | ManagementAndGeneral |
Conferences Meetings ConferencesMeetings
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | 55277 | Total |
| Program Services | 33863 | ProgramServices |
| Management And General | 21414 | ManagementAndGeneral |
Interest Interest
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | 57761 | Total |
| Program Services | 57761 | ProgramServices |
Depreciation Depletion DepreciationDepletion
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | 617700 | Total |
| Program Services | 617700 | ProgramServices |
Insurance Insurance
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | 164030 | Total |
| Program Services | 164030 | ProgramServices |
Other Expenses OtherExpenses (2 entries)
| DescriptionDescription | TotalTotal | Program ServicesProgramServices | Management And GeneralManagementAndGeneral |
|---|---|---|---|
| Provision for bad debts | 389026 | 389026 | |
| Agency commission | 19146 | 19146 |
All Other Expenses AllOtherExpenses
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | 121373 | Total |
| Program Services | 107580 | ProgramServices |
| Management And General | 13793 | ManagementAndGeneral |
Total Functional Expenses TotalFunctionalExpenses
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | 13603948 | Total |
| Program Services | 11765897 | ProgramServices |
| Management And General | 1838051 | ManagementAndGeneral |
| Fundraising | 0 | Fundraising |
Savings And Temp Cash Investments SavingsAndTempCashInvestments
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | 1178522 | BOY |
| EOY | 330995 | EOY |
Accounts Receivable AccountsReceivable
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | 1780999 | BOY |
| EOY | 2207359 | EOY |
Inventories For Sale Or Use InventoriesForSaleOrUse
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | 283259 | BOY |
| EOY | 298019 | EOY |
Prepaid Expenses Deferred Charges PrepaidExpensesDeferredCharges
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | 60058 | BOY |
| EOY | 74839 | EOY |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Land Buildings Equipment Basis | 24252820 | LandBuildingsEquipmentBasis |
| Land Bldg Equipment Accum Deprec | 8195529 | LandBldgEquipmentAccumDeprec |
Land Buildings Equipment Basis Net LandBuildingsEquipmentBasisNet
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | 5384427 | BOY |
| EOY | 16057291 | EOY |
Investments Pub Traded Securities InvestmentsPubTradedSecurities
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | 983203 | BOY |
| EOY | 1916138 | EOY |
Investments Other Securities InvestmentsOtherSecurities
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | 2092043 | BOY |
| EOY | 2326653 | EOY |
Other Assets Total OtherAssetsTotal
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | 120000 | BOY |
| EOY | 0 | EOY |
Total Assets TotalAssets
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | 11882511 | BOY |
| EOY | 23211294 | EOY |
Accounts Payable Accrued Expenses AccountsPayableAccruedExpenses
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | 1726155 | BOY |
| EOY | 5214391 | EOY |
Mort Notes Pybl Secured Invest Prop MortNotesPyblSecuredInvestProp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | 446264 | BOY |
| EOY | 6595685 | EOY |
Other Liabilities OtherLiabilities
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | 0 | BOY |
| EOY | 45000 | EOY |
Total Liabilities TotalLiabilities
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | 2172419 | BOY |
| EOY | 11855076 | EOY |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Follow SFAS117 | X | FollowSFAS117 |
Unrestricted Net Assets UnrestrictedNetAssets
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | 7616998 | BOY |
| EOY | 9028506 | EOY |
Temporarily Restricted Net Assets TemporarilyRestrictedNetAssets
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | 1198751 | BOY |
| EOY | 1433369 | EOY |
Permanently Restricted Net Assets PermanentlyRestrictedNetAssets
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | 894343 | BOY |
| EOY | 894343 | EOY |
Total Net Assets Fund Balances TotalNetAssetsFundBalances
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | 9710092 | BOY |
| EOY | 11356218 | EOY |
Total Liab Net Assets Fund Balances TotalLiabNetAssetsFundBalances
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | 11882511 | BOY |
| EOY | 23211294 | EOY |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Method Of Accounting Accrual | X | MethodOfAccountingAccrual |
| Accountant Compile Or Review | 0 | AccountantCompileOrReview |
| FS Audited | 1 | FSAudited |
| Audit Committee | 1 | AuditCommittee |
| Financial Statement Separate | X | FinancialStatementSeparate |
| Federal Grant Audit Required | 1 | FederalGrantAuditRequired |
| Federal Grant Audit Performed | 1 | FederalGrantAuditPerformed |
Schedule A IRS990ScheduleA
| Field | Value | IRS element (for citing) |
|---|---|---|
| Hospital170b1 Aiii | X | Hospital170b1Aiii |
Schedule B IRS990ScheduleB
Contributor Info ContributorInfo
| Field | Value | IRS element (for citing) |
|---|---|---|
| Contributor Number | RESTRICTED | ContributorNumber |
Contributor Name Business ContributorNameBusiness
| Field | Value | IRS element (for citing) |
|---|---|---|
| Business Name Line1 | RESTRICTED | BusinessNameLine1 |
Contributor Address US ContributorAddressUS
| Field | Value | IRS element (for citing) |
|---|---|---|
| Address Line1 | RESTRICTED | AddressLine1 |
| Address Line2 | RESTRICTED | AddressLine2 |
| City | RESTRICTED | City |
| State | RESTRICTED | State |
| ZIP Code | RESTRICTED | ZIPCode |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Aggregate Contributions | RESTRICTED | AggregateContributions |
Schedule D IRS990ScheduleD
Land Land
| Field | Value | IRS element (for citing) |
|---|---|---|
| Other Cost Or Other Basis | 113289 | OtherCostOrOtherBasis |
| Book Value | 113289 | BookValue |
Buildings Buildings
| Field | Value | IRS element (for citing) |
|---|---|---|
| Other Cost Or Other Basis | 5813237 | OtherCostOrOtherBasis |
| Depreciation | 3160981 | Depreciation |
| Book Value | 2652256 | BookValue |
Equipment Equipment
| Field | Value | IRS element (for citing) |
|---|---|---|
| Other Cost Or Other Basis | 6421939 | OtherCostOrOtherBasis |
| Depreciation | 4974088 | Depreciation |
| Book Value | 1447851 | BookValue |
Other Land Buildings OtherLandBuildings
| Field | Value | IRS element (for citing) |
|---|---|---|
| Other Cost Or Other Basis | 11904355 | OtherCostOrOtherBasis |
| Depreciation | 60460 | Depreciation |
| Book Value | 11843895 | BookValue |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Of Book Value Land Buildings | 16057291 | TotalOfBookValueLandBuildings |
Other Securities OtherSecurities
| Field | Value | IRS element (for citing) |
|---|---|---|
| Description | Interest in Tri Valley Medical Foundation | Description |
| Book Value | 2326653 | BookValue |
| Method Of Valuation | F | MethodOfValuation |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Of Book Value Securities | 2326653 | TotalOfBookValueSecurities |
Other Liabilities OtherLiabilities
| Field | Value | IRS element (for citing) |
|---|---|---|
| Description | Estimated Third Party Payor Settlements | Description |
| Amount | $45,000 | Amount |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Of Amounts | 45000 | TotalOfAmounts |
| Total Revenue | 14808773 | TotalRevenue |
| Total Expenses | 13603948 | TotalExpenses |
| Excess Or Deficit For Year | 1204825 | ExcessOrDeficitForYear |
| Net Unrealized GL On Investments | 206691 | NetUnrealizedGLOnInvestments |
| Other | $234,610 | OtherAmount |
| Total Adjustments | 441301 | TotalAdjustments |
| Excess Or Deficit Per FS | 1646126 | ExcessOrDeficitPerFS |
| Tot Revenue Etc Audited Fincl Stmt | 15015464 | TotRevenueEtcAuditedFinclStmt |
| Net Unrealized Gains Investments | 206691 | NetUnrealizedGainsInvestments |
| Revenue Not Rptd F990 | 206691 | RevenueNotRptdF990 |
| Revenue Subtotal | 14808773 | RevenueSubtotal |
| Revenue Not Rptd On Fin Stmt | 0 | RevenueNotRptdOnFinStmt |
| Total Revenue Per Form990 | 14808773 | TotalRevenuePerForm990 |
| Tot Expenses Etc Audited Fincl Stmt | 13603948 | TotExpensesEtcAuditedFinclStmt |
| Expenses Not Rptd F990 | 0 | ExpensesNotRptdF990 |
| Expenses Subtotal | 13603948 | ExpensesSubtotal |
| Expenses Not Rptd On Fin Stmt | 0 | ExpensesNotRptdOnFinStmt |
| Total Expenses Per Form990 | 13603948 | TotalExpensesPerForm990 |
Form990 Schedule D Part XIV Form990ScheduleDPartXIV (2 entries)
| IdentifierIdentifier | Return ReferenceReturnReference | ExplanationExplanation |
|---|---|---|
| Part X: | Description of Uncertain Tax Positions Under FIN 48: | The Health System is organized as a Nebraska nonprofit corporation and has been recognized by the Internal Revenue Service as exempt from federal income taxes under Internal Revenue Code Section 501(c)(3). During 2010, the Health System adopted the provisions of Accounting Standards Codification (ASC) 740-10 (previously Financial Interpretation No. 48, Accounting for Uncertainty in Income Taxes). The Health System undergoes an annual analysis of its various tax positions, assessing the likelihood of those positions being upheld upon examination with relevant tax authorities. The implementation of this standard had no material impact on the financial statements. As of both the date of adoption and as of April 30, 2010, no amounts were recorded as a result of this analysis. The Health System is no longer subject to Federal or state tax examinations by tax authorities for years before 2007. |
| Part XI, Line 8 - Other Adjustments: | Change in Interest in net assets of Tri Valley Medical Foundation: 234610. |
Schedule H IRS990ScheduleH
| Field | Value | IRS element (for citing) |
|---|---|---|
| Charity Care Policy | 1 | CharityCarePolicy |
| Written Policy | 1 | WrittenPolicy |
| Policy Applied To All Hospitals | X | PolicyAppliedToAllHospitals |
| FPG Reference Free Care | 1 | FPGReferenceFreeCare |
| Pcent100 | X | Pcent100 |
| FPG Reference Discounted Care | 1 | FPGReferenceDiscountedCare |
| Pcent200 D | X | Pcent200D |
| Free Disc Care Medically Indigent | 0 | FreeDiscCareMedicallyIndigent |
| Amounts Budgeted For Charity Care | 1 | AmountsBudgetedForCharityCare |
| Expenses Exceeded Budget | 0 | ExpensesExceededBudget |
| Annual Community Benefit Report | 0 | AnnualCommunityBenefitReport |
Charity Care At Cost CharityCareAtCost
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Community Benefit Expense | 22454 | TotalCommunityBenefitExpense |
| Net Community Benefit Expense | 22454 | NetCommunityBenefitExpense |
| Percent Of Total Expense | 0.00170 | PercentOfTotalExpense |
Unreimbursed Medicaid UnreimbursedMedicaid
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Community Benefit Expense | 1206962 | TotalCommunityBenefitExpense |
| Direct Offsetting Revenue | 1680631 | DirectOffsettingRevenue |
| Net Community Benefit Expense | -473669 | NetCommunityBenefitExpense |
| Percent Of Total Expense | 0.00000 | PercentOfTotalExpense |
Total Charity Care TotalCharityCare
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Community Benefit Expense | 1229416 | TotalCommunityBenefitExpense |
| Direct Offsetting Revenue | 1680631 | DirectOffsettingRevenue |
| Net Community Benefit Expense | -451215 | NetCommunityBenefitExpense |
| Percent Of Total Expense | 0.00170 | PercentOfTotalExpense |
Community Health Services CommunityHealthServices
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Community Benefit Expense | 5080 | TotalCommunityBenefitExpense |
| Net Community Benefit Expense | 5080 | NetCommunityBenefitExpense |
| Percent Of Total Expense | 0.00040 | PercentOfTotalExpense |
Subsidized Health Services SubsidizedHealthServices
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Community Benefit Expense | 1008322 | TotalCommunityBenefitExpense |
| Direct Offsetting Revenue | 481790 | DirectOffsettingRevenue |
| Net Community Benefit Expense | 526532 | NetCommunityBenefitExpense |
| Percent Of Total Expense | 0.03980 | PercentOfTotalExpense |
Total Other Benefits TotalOtherBenefits
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Community Benefit Expense | 1013402 | TotalCommunityBenefitExpense |
| Direct Offsetting Revenue | 481790 | DirectOffsettingRevenue |
| Net Community Benefit Expense | 531612 | NetCommunityBenefitExpense |
| Percent Of Total Expense | 0.04020 | PercentOfTotalExpense |
Total Community Benefits TotalCommunityBenefits
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Community Benefit Expense | 2242818 | TotalCommunityBenefitExpense |
| Direct Offsetting Revenue | 2162421 | DirectOffsettingRevenue |
| Net Community Benefit Expense | 80397 | NetCommunityBenefitExpense |
| Percent Of Total Expense | 0.04190 | PercentOfTotalExpense |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Bad Debt Expense Reported | 0 | BadDebtExpenseReported |
| Bad Debt Expense | $200,679 | BadDebtExpenseAmount |
| Amount Attributable To | 26891 | AmountAttributableTo |
| Amount Reimbursed By Medicare | 4638647 | AmountReimbursedByMedicare |
| Cost Of Care Reimbursed By Medicare | 4680054 | CostOfCareReimbursedByMedicare |
| Medicare Surplus Or Shortfall | -41407 | MedicareSurplusOrShortfall |
Costing Methodology Used CostingMethodologyUsed
| Field | Value | IRS element (for citing) |
|---|---|---|
| Other | X | Other |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Written Debt Collection Policy | 1 | WrittenDebtCollectionPolicy |
| Provision For Charity Care | 1 | ProvisionForCharityCare |
Form990 Schedule H Part V Form990ScheduleHPartV (6 entries)
| Address Line1Address/AddressLine1 | CityAddress/City | StateAddress/State | ZIP CodeAddress/ZIPCode | OtherOther | Licensed HospitalLicensedHospital | General Medical And SurgicalGeneralMedicalAndSurgical | Critical Access HospitalCriticalAccessHospital | Er24 HoursEr24Hours |
|---|---|---|---|---|---|---|---|---|
| Arapahoe Clinic | ||||||||
| 305 Nebraska Ave | Arapahoe | NE | 68922 | Physician Clinic | ||||
| Cambridge Clinic | ||||||||
| 309 Nelson Street | Cambridge | NE | 69022 | Physician Clinic | ||||
| Indianola Clinic | ||||||||
| 119 S 4th Street | Indianola | NE | 69034 | Physician Clinic | ||||
| Cambridge Memorial Hospital | ||||||||
| 1305 W Hwy 6 34 PO BOX 488 | Cambridge | NE | 69022 | Long term Care | X | X | X | X |
| Heritage Plaza | ||||||||
| 1205 Nelson Street | Cambridge | NE | 69022 | Independent Lving | ||||
| Tri Valley Health System Assisted Living | ||||||||
| 711 Mousel Avenue | Cambridge | NE | 69022 | Assisted Living | ||||
Form990 Schedule H Part VI Form990ScheduleHPartVI
| Field | Value | IRS element (for citing) |
|---|---|---|
| Income Based Criteria | Part I, Line 3c: | IncomeBasedCriteria |
| Costing Method Used | Part I, Line 7: The organization used Worksheet 2 to determine the cost for Part I, Line 7, Rows a. It includes all patient segments of inpatient, outpatient, emergency room, private insurance, Medicaid, uninsured and self pay. For Row b, worksheet 2 was used to bring gross hospital Medicaid patient revenues to cost and Medicaid revenues less adjustments were backed out of this figure. Actual expenses were tracked for the programs included in Part I, Line 7, Row e. The community health improvement program was a Healthy Women in the Heartland program and educational programs offered throughout the year and the "FROG" program which is an exercise program free of charge to older generations. Row g was determined from costs in the Medicare Cost report. | CostingMethodUsed |
| Subsidized Health Services Expln | Part I, Line 7g: Part I, Line 7g includes $1,008,322 of costs from the Arapahoe and Indianola Clinics. | SubsidizedHealthServicesExpln |
| Percent Of Total Expense Expln | Part I, Line 7f: The amount of bad debt expense removed from the denominator is $389,026. | PercentOfTotalExpenseExpln |
| Bad Debt Footnote | Part III, Line 4: Financial Statement Bad Debt Expense Footnote:The carrying amount of patient and resident receivables is reduced by a valuation allowance that reflects management's 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 estimated bad debt provision.The reserve for doubtful accounts is determined by a percentage of the remaining account receivables after discounts and payments are applied based on the age of the account.In Furnas County, Nebraska, the percentage of residents that are at or below poverty level is 13.4%. We can assume that the same percentage of patients would either be eligible for charity care or either did not apply or were denied charity care based on lack of information. Net patient revenue was $14,376,204. Bad debt expense at cost is $200,679. We can assume that 13.4%, or $26,891, of this bad debt was attributable to patients who were eligible for the charity care program. | BadDebtFootnote |
| Shortfall As Community Benefit | Part III, Line 8: The Medicare shortfall should be treated as a community benefit because Tri Valley has a higher level of Medicare patients in the area compared to the state averages and due to our higher poverty levels compared to the state averages, a large majority of these individuals are lower income.Medicare allowable costs were obtained from the 2009 Medicare Cost Report. | ShortfallAsCommunityBenefit |
| Debt Collection Policy | Part III, Line 9b: When self pay balances are determined the accounts are subjected to three policies: The Collection Policy, Budget Pay Policy and the Charity Care policy. All self pay balances are due within 30 days or an acceptable budget or payment plan has been established. At the time the budget payment plan is being established accounts are evaluated for eligibility for Charity Care. If payment in full or payment arrangements are not made then after 90 days or three statements, the accounts are referred to the collection agency. In these processes the patient receives our normal monthly statements, two letters (slow pay and final demand) plus we contact them by phone prior to sending them to collections. | DebtCollectionPolicy |
| Needs Assessment | Part VI, Line 2: In former years, Brim Healthcare assisted Tri Valley Health System (TVHS) in completing a strategic planning session which included Board of Trustees, and Leadership and Department Directors to determine the health care needs of the communities. Statistics were the basis on determining the needs in the community. TVHS is currently planning a community needs assessment that will be completed by TVHS Business Development Executive. | NeedsAssessment |
| Patient Education Assistance | Part VI, Line 3: Education on eligibility for available assistance programs is usually communicated on an individual basis. Social services staff will discuss with patients the availability of state programs (i.e. Medicaid) and they will assist them with the necessary paperwork. This is usually done primarily for inpatients and nursing home residents. Social Services will contact patient accounting staff about any other individuals in need of our Charity care program. We have financial brochures available for all patients. The same financial brochure information is posted on our website and we ask all patients having financial hardships to please contact our patient accounting office. After self pay accounts generate a patient statement, they are reviewed by self pay patient accounting staff. When deemed appropriate, an explanatory letter and financial application are mailed to the patient. We provide them with all the necessary contact information and documentation requirements. Numerous attempts are made to obtain the needed information to qualify our patients for either charity care and/or Medicaid, if appropriate. | PatientEducationAssistance |
| Community Information | Part VI, Line 4: Tri Valley Health System's primary service area is in Furnas County, Nebraska. In 2009, the US Census Bureau estimated the population at 4,556. This was a decline from 2000 of 14.4%. 23.2% of the population is over 65 years old. In 2008, 13.4% of the persons in Furnas County were below poverty level. There are no other hospitals in Furnas County. | CommunityInformation |
| Community Building Activities | Part VI, Line 5: n/a | CommunityBuildingActivities |
| Other Information | Part VI, Line 6: Tri Valley Health System is governed by a nine person Board of Trustees whose members reside within the system's primary service area and have no immediate family ties to any employees. These individuals also do not benefit financially through their businesses by means of contracts or other agreements. Surplus funds, if available, are used to purchase equipment or are re-invested in the facility to improve patient care. Tri Valley Health System extends medical staff privileges to all qualified physicians in the community. Throughout Tri Valley Health System's 2009-2010 fiscal year, strides were made to increase the community outreach and education. Every day, people with chronic disease such as diabetes and heart failure are being monitored, educated, and cared for by dedicated health care professionals who help them enjoy the best quality of life possible. During the fiscal year, the hospital hired a dietician to provide programs such as diabetes and nutrition education to not only patients of the hospital, but also to members in the community. Healthy Women in the Heartland program was launched which provides monthly newsletters and quarterly educational programs at no cost to the members. The programs offered included everything from healthy eating by the hospital's dietician to foot care by a podiatrist. Annually the hospital promotes a Women's Day of Health which includes a full day of activities and educational programs to encourage and educate Women on healthy living. The hospital opens its doors to the community to use conference areas for groups such as alcohol anonymous, ministerial associations and community volunteer emergency medical technician training. Other improvements to community outreach and education were accomplished through more frequent Healthy Living Lunch lectures, and the development of Fitness Reaching Older Generations (FROG) classes within three communities of the primary service area.As a Critical Access Hospital, Tri Valley Health System's Cambridge Memorial Hospital invites specialists throughout the state to conduct weekly or monthly clinics in the Specialty Clinic. Services offered to patients during the 2009-2010 fiscal year were Cardiology, General Surgery, Mental Health, Obstetrics/Gynecology, Orthopedics, Ophthalmology, Otolaryngology, Podiatry, Pulmonology, and Urology. Tri Valley Health System is also a member of the Nebraska Telehealth Network providing additional services such as neurology and psychiatry. | OtherInformation |
| Affiliated Health Care System | Part VI, Line 7: n/a | AffiliatedHealthCareSystem |
Schedule J IRS990ScheduleJ
| Field | Value | IRS element (for citing) |
|---|---|---|
| Travel For Companions | X | TravelForCompanions |
| Club Dues Or Fees | X | ClubDuesOrFees |
| Written Policy Re T And E Expenses | 1 | WrittenPolicyReTAndEExpenses |
| Substantiation Required | 1 | SubstantiationRequired |
| Severance Payment | 0 | SeverancePayment |
| Supplemental Nonqual Retire Plan | 0 | SupplementalNonqualRetirePlan |
| Equity Based Comp Arrangement | 0 | EquityBasedCompArrangement |
| Comp Based On Revenue Of Filing Org | 1 | CompBasedOnRevenueOfFilingOrg |
| Comp Based On Revenue Related Orgs | 0 | CompBasedOnRevenueRelatedOrgs |
| Comp Based Net Earnings Filing Org | 1 | CompBasedNetEarningsFilingOrg |
| Comp Based Net Earnings Relate Orgs | 0 | CompBasedNetEarningsRelateOrgs |
| Any Non Fixed Payments | 0 | AnyNonFixedPayments |
| Initial Contract Exception | 0 | InitialContractException |
Form990 Schedule J Part II Form990ScheduleJPartII (5 entries)
| Base Compensation Filing OrgBaseCompensationFilingOrg | Comp Based On Related OrgsCompBasedOnRelatedOrgs | Bonus Filing OrgBonusFilingOrg | Bonus Related OrgsBonusRelatedOrgs | Other Compensation Filing OrgOtherCompensationFilingOrg | Other Compensation Related OrgsOtherCompensationRelatedOrgs | Deferred Comp Filing OrgDeferredCompFilingOrg | Deferred Comp Related OrgsDeferredCompRelatedOrgs | Nontaxable Benefits Filing OrgNontaxableBenefitsFilingOrg | Nontaxable Benefits Related OrgsNontaxableBenefitsRelatedOrgs | Total Compensation Filing OrgTotalCompensationFilingOrg | Total Compensation Related OrgsTotalCompensationRelatedOrgs | Comp Report Prior990 Filing OrgCompReportPrior990FilingOrg | Comp Report Prior990 Related OrgsCompReportPrior990RelatedOrgs |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Roger Steinkruger | |||||||||||||
| 127890 | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 45026 | 0 | 172916 | 0 | 0 | 0 |
| Lennie Deaver MD | |||||||||||||
| 177502 | 0 | 78871 | 0 | 521 | 0 | 15740 | 0 | 5959 | 0 | 278593 | 0 | 0 | 0 |
| Rachelle Kaspar-Cope MD | |||||||||||||
| 168861 | 0 | 41659 | 0 | 667 | 0 | 0 | 0 | 841 | 0 | 212028 | 0 | 0 | 0 |
| Paul Shellabarger PA | |||||||||||||
| 89307 | 0 | 77640 | 0 | 465 | 0 | 13207 | 0 | 4193 | 0 | 184812 | 0 | 0 | 0 |
| Bill Duff | |||||||||||||
| 149825 | 0 | 545 | 0 | 103 | 0 | 0 | 0 | 10175 | 0 | 160648 | 0 | 0 | 0 |
Form990 Schedule J Part III Form990ScheduleJPartIII (4 entries)
| Return ReferenceReturnReference | ExplanationExplanation | IdentifierIdentifier |
|---|---|---|
| Part I, Line 1a | Spouses of board members attend one conference up to a maximum of $600. Providers can choose to belong to either a health club or a golf club. Payments are made directly to the health club or golf club. | |
| Part I, Line 5 | The Brim Healthcare contract has a set of goals that they give to the CEO. If the goals are met Brim approaches the Tri-Valley Health System board and asks that the bonus be paid to Brim. Each provider has an incentive payment schedule written in their contract. Incentive bonus is paid out monthly based on services performed. | |
| Part I, Line 6 | The CFO is under the employee bonus program offered to all employees which allows for bonuses based on financial indicators and quality indicators. | |
| Part III | Part I, Line 3: The compensation paid to the CEO is set by Brim Healthcare an unrelated management company. Cambridge Memorial Hospital has a written contract with Brim Healthcare that is reviewed and approved by the board. Roger Steinkruger was contracted as CEO during calendar year 2010. Amounts reported are based on the monthly contract fee assuming 70% compensation and benefits of 22.35%. Assumed payroll taxes of 7.65% are not included in the reported amounts. | Supplemental Information |
Schedule O IRS990ScheduleO
General Explanation GeneralExplanation (10 entries)
| IdentifierIdentifier | ExplanationExplanation |
|---|---|
| Form 990, Part VI, Section A, line 3 | The CEO is employed by Brim Healthcare. |
| Form 990, Part VI, Section A, line 4 | So long as a mortgage on the Corporation's property is insured or held by the Secretary of Housing and Urban Development, the Articles of Incorporation may not be amended without the prior written approval of the Secretary of Housing and Urban Development. |
| Form 990, Part VI, Section A, line 6 | Members pay a $5 fee to become a lifetime member. |
| Form 990, Part VI, Section A, line 7a | Members select the board of directors at the annual meeting. All members have the same voting rights. |
| Form 990, Part VI, Section A, line 8b | There are no committes with the authority to act on behalf of the governing body. |
| Form 990, Part VI, Section B, line 11 | The CEO and CFO will review the Form 990. The 990 will then be electronically distributed to the Board Members prior to it being filed. |
| Form 990, Part VI, Section B, line 12c | At the October board meeting all board members complete an annual disclosure. The policy covers the board of directors. The CEO reviews the disclosures. Anyone with a conflict must abstain from voting on the issue and is not able to participate in discussions regarding the issue. |
| Form 990, Part VI, Section B, line 15b | The CEO's compensation is set by Brim Healthcare. Annually, the Regional Vice-President from Brim Healthcare provides a CEO evaluation form to each Board member to complete. After completing the form the Board members return it directly to the Regional Vice-President. He also meets with the Board in a private meeting to review the evaluations and review the compensation. For the CFO , the Human Resources department participates in the Nebraska Hospital Association Compensation Survey on an annual basis. Once the results are received, they review the staff's years of experience as well as their position responsibilities to determine if othe salary range is appropriate. A wage range is recommended to the CEO and the CEO determines the final wage for the CFO. This process is done annually. Market Wage Adjustments are made on an as-needed basis to adjust salaries that fall outside the survey guidelines. |
| Form 990, Part VI, Section C, line 19 | These documents are available upon request. |
| Form 990, Part XI, Line 2c: Financial statements and independent accountant: There is a financial committee that is responsible for overseeing the audit of the financial statements and the selection of an independent accountant. This process has not changed from last year. |
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