2011-03-14T11:01:00-05:00 2010-04-30 EIDE BAILLY LLP 4310 17TH AVE S PO BOX 2545 FARGO ND 581082545 990 2009-05-01 476028103 CAMBRIDGE MEMORIAL HOSPITAL CAMB 3086971522 PO BOX 488 CAMBRIDGE NE 69022 Roger Steinkruger 3086971522 2011-03-10 1 LISA CHAFFEE CPA 7012398500 2011-03-02 2009 2016-02-24 21:20:13Z Tri Valley Health System Roger Steinkruger PO BOX 488 CAMBRIDGE NE 69022 14808773 0 X www.trivalleyhealth.com X 1955 NE Providing quality, compassionate, local healthcare services. 9 9 224 188 10108 -35657 69761 353557 13393641 14437176 23614 18040 0 13487016 14808773 0 0 7045502 7918921 0 0 5944424 5685027 12989926 13603948 497090 1204825 11882511 23211294 2172419 11855076 9710092 11356218 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. 0 0 8183277 9227106 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. 1820731 2907982 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. 1761889 2291980 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. 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. 11765897 1 1 0 0 0 0 0 0 0 1 1 0 0 0 0 0 0 0 0 0 1 0 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 33 0 1 224 1 1 1 0 0 0 0 0 0 0 0 9 9 0 1 1 0 1 1 0 1 0 0 0 1 1 1 1 1 1 0 1 0 X Diana Rippe 3086973329 PO Box 488 Cambridge NE 69022 Randy Heitmann 3.00 X X 0 0 0 Cathy Kubik 3.00 X X 0 0 0 Patrick Horwart 3.00 X X 0 0 0 Troy Westadt 3.00 X X 0 0 0 Eric Eisenhart 3.00 X 0 0 0 Clark Andrews 3.00 X 0 0 0 Reginald Warner 3.00 X 0 0 0 Bill Minnick 3.00 X 0 0 0 Kristy Witte 3.00 X 0 0 0 Roger Steinkruger 40.00 X 127890 0 45026 Diana Rippe 40.00 X 64103 0 5720 Lennie Deaver MD 40.00 X 256894 0 21699 Rachelle Kaspar-Cope MD 40.00 X 211187 0 841 Paul Shellabarger PA 40.00 X 167412 0 17401 William Malchow PA 40.00 X 111114 0 4807 Bill Duff 40.00 X 150473 0 10175 1089073 0 105669 5 0 1 1 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 7 353557 353557 Patient Revenue 900099 14366096 14366096 Other Revenue 900099 60972 60972 Medical Spa 812900 10108 10108 14437176 17240 17240 800 800 800 800 14808773 14427068 10108 18040 258862 258862 5999812 5400365 599447 112555 102018 10537 1547692 1376980 170712 301323 301323 4268 4268 59260 59260 1584805 1568883 15922 85806 85806 1777569 1525824 251745 382655 372696 9959 65028 49171 15857 55277 33863 21414 57761 57761 617700 617700 164030 164030 Provision for bad debts 389026 389026 Agency commission 19146 19146 121373 107580 13793 13603948 11765897 1838051 0 1178522 330995 1780999 2207359 283259 298019 60058 74839 24252820 8195529 5384427 16057291 983203 1916138 2092043 2326653 120000 0 11882511 23211294 1726155 5214391 446264 6595685 0 45000 2172419 11855076 X 7616998 9028506 1198751 1433369 894343 894343 9710092 11356218 11882511 23211294 X 0 1 1 X 1 1 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 113289 113289 5813237 3160981 2652256 6421939 4974088 1447851 11904355 60460 11843895 16057291 Interest in Tri Valley Medical Foundation 2326653 F 2326653 Estimated Third Party Payor Settlements 45000 45000 14808773 13603948 1204825 206691 234610 441301 1646126 15015464 206691 206691 14808773 0 14808773 13603948 0 13603948 0 13603948 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. 1 1 X 1 X 1 X 0 1 0 0 22454 22454 0.00170 1206962 1680631 -473669 0.00000 1229416 1680631 -451215 0.00170 5080 5080 0.00040 1008322 481790 526532 0.03980 1013402 481790 531612 0.04020 2242818 2162421 80397 0.04190 0 200679 26891 4638647 4680054 -41407 X 1 1 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

X X X X Long term Care Heritage Plaza

1205 Nelson Street Cambridge NE 69022

Independent Lving Tri Valley Health System Assisted Living

711 Mousel Avenue Cambridge NE 69022

Assisted Living Part I, Line 3c: 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. Part I, Line 7g: Part I, Line 7g includes $1,008,322 of costs from the Arapahoe and Indianola Clinics. Part I, Line 7f: The amount of bad debt expense removed from the denominator is $389,026. 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. 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. 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. 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. 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. 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. Part VI, Line 5: n/a 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. Part VI, Line 7: n/a X X 1 1 0 0 0 1 0 1 0 0 0 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 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. Supplemental Information 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. 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.