CAMBRIDGE MEMORIAL HOSPITAL INC: Form 990, tax year 2021
View the entire original 990 at ProPublica ↗
- Organization
- CAMBRIDGE MEMORIAL HOSPITAL INC (EIN 47-6028103)
- Tax period
- 2021-05-01 to 2022-04-30
- Filed
- 2023-02-17
- IRS object ID
- 202330489349300433
- Schema version
- 2021v4.2
- 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
- Form 990
- Schedule A
- Schedule B
- Schedule D
- Schedule H
- Schedule J
- Schedule L
- Schedule M
- Schedule O
Return header ReturnHeader
| Field | Value | IRS element (for citing) |
|---|---|---|
| Return | 2023-02-17T12:19:16-06:00 | ReturnTs |
| Tax Period End | 2022-04-30 | TaxPeriodEndDt |
Preparer Firm PreparerFirmGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Preparer Firm EIN | 450250958 | PreparerFirmEIN |
Preparer Firm Name PreparerFirmName
| Field | Value | IRS element (for citing) |
|---|---|---|
| Business Name Line1 | Eide Bailly LLP | BusinessNameLine1Txt |
Preparer US Address PreparerUSAddress
| Field | Value | IRS element (for citing) |
|---|---|---|
| Address Line1 | 800 Nicollet Mall Ste 1300 | AddressLine1Txt |
| City | Minneapolis | CityNm |
| State Abbreviation | MN | StateAbbreviationCd |
| ZIP | 554027033 | ZIPCd |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Return Type | 990 | ReturnTypeCd |
| Tax Period Begin | 2021-05-01 | TaxPeriodBeginDt |
Filer Filer
| Field | Value | IRS element (for citing) |
|---|---|---|
| EIN | 476028103 | EIN |
Business Name BusinessName
| Field | Value | IRS element (for citing) |
|---|---|---|
| Business Name Line1 | Cambridge Memorial Hospital Inc | BusinessNameLine1Txt |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Business Name Control | CAMB | BusinessNameControlTxt |
| Phone | 3086973329 | PhoneNum |
US Address USAddress
| Field | Value | IRS element (for citing) |
|---|---|---|
| Address Line1 | 1305 W Hwy 6 34 | AddressLine1Txt |
| City | Cambridge | CityNm |
| State Abbreviation | NE | StateAbbreviationCd |
| ZIP | 69022 | ZIPCd |
Business Officer BusinessOfficerGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Person | Jessica Fisher | PersonNm |
| Person Title | CEO | PersonTitleTxt |
| Phone | 3086973329 | PhoneNum |
| Signature | 2023-02-10 | SignatureDt |
| Discuss With Paid Preparer | Yes (1) | DiscussWithPaidPreparerInd |
Signing Officer SigningOfficerGrp
Person Full Name PersonFullName
| Field | Value | IRS element (for citing) |
|---|---|---|
| Person First | Jessica | PersonFirstNm |
| Person Last | Fisher | PersonLastNm |
| Field | Value | IRS element (for citing) |
|---|---|---|
| SSN | 999009999 | SSN |
Preparer Person PreparerPersonGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Preparer Person | Kim Hunwardsen CPA | PreparerPersonNm |
| PTIN | P00484560 | PTIN |
| Phone | 6122536500 | PhoneNum |
| Preparation | 2023-02-08 | PreparationDt |
Additional Filer Information AdditionalFilerInformation
Trusted Customer TrustedCustomerGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Trusted Customer | 3 | TrustedCustomerCd |
| Authentication Assurance Level | AAL1 | AuthenticationAssuranceLevelCd |
| Identity Assurance Level | IAL1 | IdentityAssuranceLevelCd |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Tax | 2021 | TaxYr |
| Build TS | 2023-03-07 01:45:13Z | BuildTS |
Form 990 IRS990
Doing Business As Name DoingBusinessAsName
| Field | Value | IRS element (for citing) |
|---|---|---|
| Business Name Line1 | Tri Valley Health System | BusinessNameLine1Txt |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Principal Officer | Jessica Fisher | PrincipalOfficerNm |
US Address USAddress
| Field | Value | IRS element (for citing) |
|---|---|---|
| Address Line1 | 1305 W Hwy 6 34 | AddressLine1Txt |
| City | Cambridge | CityNm |
| State Abbreviation | NE | StateAbbreviationCd |
| ZIP | 69022 | ZIPCd |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Gross Receipts | $26,413,662 | GrossReceiptsAmt |
| Group Return For Affiliates | 0 | GroupReturnForAffiliatesInd |
| Organization501c3 | Yes (X) | Organization501c3Ind |
| Website Address | www.trivalleyhealth.com | WebsiteAddressTxt |
| Type Of Organization Corp | Yes (X) | TypeOfOrganizationCorpInd |
| Formation | 1955 | FormationYr |
| Legal Domicile State | NE | LegalDomicileStateCd |
| Activity Or Mission | Providing quality, compassionate, local healthcare services. | ActivityOrMissionDesc |
| Voting Members Governing Body | 9 | VotingMembersGoverningBodyCnt |
| Voting Members Independent | 9 | VotingMembersIndependentCnt |
| Total Employee | 204 | TotalEmployeeCnt |
| Total Volunteers | 37 | TotalVolunteersCnt |
| Total Gross UBI | $0 | TotalGrossUBIAmt |
| Net Unrelated Bus Txbl Incm | $0 | NetUnrelatedBusTxblIncmAmt |
| PY Contributions Grants | $6,247,385 | PYContributionsGrantsAmt |
| CY Contributions Grants | $462,390 | CYContributionsGrantsAmt |
| PY Program Service Revenue | $22,260,328 | PYProgramServiceRevenueAmt |
| CY Program Service Revenue | $25,441,731 | CYProgramServiceRevenueAmt |
| PY Investment Income | $311,029 | PYInvestmentIncomeAmt |
| CY Investment Income | $427,765 | CYInvestmentIncomeAmt |
| PY Other Revenue | $16,643 | PYOtherRevenueAmt |
| CY Other Revenue | $11,770 | CYOtherRevenueAmt |
| PY Total Revenue | $28,835,385 | PYTotalRevenueAmt |
| CY Total Revenue | $26,343,656 | CYTotalRevenueAmt |
| PY Grants And Similar Paid | $0 | PYGrantsAndSimilarPaidAmt |
| CY Grants And Similar Paid | $0 | CYGrantsAndSimilarPaidAmt |
| PY Benefits Paid To Members | $0 | PYBenefitsPaidToMembersAmt |
| CY Benefits Paid To Members | $0 | CYBenefitsPaidToMembersAmt |
| PY Salaries Comp Emp Bnft Paid | $11,526,797 | PYSalariesCompEmpBnftPaidAmt |
| CY Salaries Comp Emp Bnft Paid | $11,749,284 | CYSalariesCompEmpBnftPaidAmt |
| PY Total Prof Fndrsng Expns | $0 | PYTotalProfFndrsngExpnsAmt |
| CY Total Prof Fndrsng Expns | $0 | CYTotalProfFndrsngExpnsAmt |
| CY Total Fundraising Expense | $0 | CYTotalFundraisingExpenseAmt |
| PY Other Expenses | $11,833,448 | PYOtherExpensesAmt |
| CY Other Expenses | $13,441,941 | CYOtherExpensesAmt |
| PY Total Expenses | $23,360,245 | PYTotalExpensesAmt |
| CY Total Expenses | $25,191,225 | CYTotalExpensesAmt |
| PY Revenues Less Expenses | $5,475,140 | PYRevenuesLessExpensesAmt |
| CY Revenues Less Expenses | $1,152,431 | CYRevenuesLessExpensesAmt |
| Total Assets BOY | $31,718,093 | TotalAssetsBOYAmt |
| Total Assets EOY | $30,986,077 | TotalAssetsEOYAmt |
| Total Liabilities BOY | $17,619,653 | TotalLiabilitiesBOYAmt |
| Total Liabilities EOY | $16,814,339 | TotalLiabilitiesEOYAmt |
| Net Assets Or Fund Balances BOY | $14,098,440 | NetAssetsOrFundBalancesBOYAmt |
| Net Assets Or Fund Balances EOY | $14,171,738 | NetAssetsOrFundBalancesEOYAmt |
| Info In Schedule O Part III | Yes (X) | InfoInScheduleOPartIIIInd |
| Mission | To improve the lives we touch by providing care of the highest quality throughout life's journey. | MissionDesc |
| Significant New Program Srvc | 0 | SignificantNewProgramSrvcInd |
| Significant Change | 0 | SignificantChangeInd |
| Expense | $17,360,661 | ExpenseAmt |
| Revenue | $20,456,612 | RevenueAmt |
| Desc | Cambridge Memorial Hospital, Inc., dba Tri Valley Health System operates a 20-bed critical access hospital located in Cambridge, Nebraska. The hospital provides short-term inpatient and outpatient care. Tri Valley Health System operates a full-time emergency room and provides emergency care regardless of the ability to pay. The emergency room had 1,328 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. Tri Valley Health System initiated a "walk-in" clinic through one of their Rural Health Clinics. (Continued on Sch. O)Throughout the year 2,726 patients were seen through the "walk-in" clinics.Services are 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 Tri Valley Health System Board of Trustees oversees services delivered under the Charity Care 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. The estimated cost of providing these services was $20,000 for the year ended April 30, 2022, calculated by multiplying the ratio of cost to gross charges for the Health System by the gross uncompensated charges associated with providing charity to its patients.In addition, the Health System provides services to other patients under certain government-reimbursed public aid programs. Such programs pay providers amounts which are less than established charges for the services provided to the recipients, and for some services the payments are less than the cost of rendering the services provided.The Health System also commits significant time and resources to endeavors and critical services which meet otherwise unfulfilled community needs. Many of these activities are sponsored with the knowledge that they will not be self-supporting or financially viable. | Desc |
Prog Srvc Accom Acty2 ProgSrvcAccomActy2Grp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Expense | $3,654,913 | ExpenseAmt |
| Revenue | $4,438,162 | RevenueAmt |
| Desc | Tri Valley Health System has rural health clinics in Arapahoe, Indianola, and Cambridge, Nebraska. During the year, the clinics had 11,908 visits. The employed physicians are active in the community and provide support services such as attendance at community sport programs and medical directors for EMT groups. They also offer educational programs for the local school systems and people in the community with programs such as "Healthier Me", a diabetes prevention program. Yearly the clinics 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. (Continued on Sch. O)Health fair lab profile testing completed which normally would cost the Health System $665 (based on an average ratio of cost to gross charges) is reduced to a fee of approximately $35 (depending on tests requested). | Desc |
Prog Srvc Accom Acty3 ProgSrvcAccomActy3Grp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Expense | $704,696 | ExpenseAmt |
| Revenue | $546,957 | RevenueAmt |
| Desc | Tri Valley Health System's other programs include an Assisted Living Facility and an Independent Living Facility. Additional services are provided including a home monitoring system, Meals on Wheels, and Public Transportation. During the fiscal year, Tri Valley's Assisted Living Facility averaged 14 residents a day. Tri Valley Health System 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. | Desc |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Program Service Expenses | $21,720,270 | TotalProgramServiceExpensesAmt |
| Described In Section501c3 | Yes (1) | DescribedInSection501c3Ind |
| Schedule B Required | Yes (1) | ScheduleBRequiredInd |
| Political Campaign Acty | 0 | PoliticalCampaignActyInd |
| Lobbying Activities | 0 | LobbyingActivitiesInd |
| Subject To Proxy Tax | 0 | SubjectToProxyTaxInd |
| Donor Advised Fund | 0 | DonorAdvisedFundInd |
| Conservation Easements | 0 | ConservationEasementsInd |
| Collections Of Art | 0 | CollectionsOfArtInd |
| Credit Counseling | 0 | CreditCounselingInd |
| Donor Rstr Or Quasi Endowments | 0 | DonorRstrOrQuasiEndowmentsInd |
| Report Land Building Equipment | Yes (1) | ReportLandBuildingEquipmentInd |
| Report Investments Other Sec | 0 | ReportInvestmentsOtherSecInd |
| Report Program Related Invst | 0 | ReportProgramRelatedInvstInd |
| Report Other Assets | Yes (1) | ReportOtherAssetsInd |
| Report Other Liabilities | Yes (1) | ReportOtherLiabilitiesInd |
| Include FIN48 Footnote | Yes (1) | IncludeFIN48FootnoteInd |
| Independent Audit Fincl Stmt | Yes (1) | IndependentAuditFinclStmtInd |
| Consolidated Audit Fincl Stmt | 0 | ConsolidatedAuditFinclStmtInd |
| School Operating | 0 | SchoolOperatingInd |
| Foreign Office | 0 | ForeignOfficeInd |
| Foreign Activities | 0 | ForeignActivitiesInd |
| More Than5000 K To Org | 0 | MoreThan5000KToOrgInd |
| More Than5000 K To Individuals | 0 | MoreThan5000KToIndividualsInd |
| Professional Fundraising | 0 | ProfessionalFundraisingInd |
| Fundraising Activities | 0 | FundraisingActivitiesInd |
| Gaming Activities | 0 | GamingActivitiesInd |
| Operate Hospital | Yes (1) | OperateHospitalInd |
| Audited Financial Stmt Att | Yes (1) | AuditedFinancialStmtAttInd |
| Grants To Organizations | 0 | GrantsToOrganizationsInd |
| Grants To Individuals | 0 | GrantsToIndividualsInd |
| Schedule J Required | Yes (1) | ScheduleJRequiredInd |
| Tax Exempt Bonds | 0 | TaxExemptBondsInd |
| Engaged In Excess Benefit Trans | 0 | EngagedInExcessBenefitTransInd |
| PY Excess Benefit Trans | 0 | PYExcessBenefitTransInd |
| Loan Outstanding | 0 | LoanOutstandingInd |
| Grant To Related Person | 0 | GrantToRelatedPersonInd |
| Business Rln With Org Mem | 0 | BusinessRlnWithOrgMemInd |
| Business Rln With Fam Mem | Yes (1) | BusinessRlnWithFamMemInd |
| Business Rln With35 Ctrl Ent | 0 | BusinessRlnWith35CtrlEntInd |
| Deductible Non Cash Contri | Yes (1) | DeductibleNonCashContriInd |
| Deductible Art Contribution | 0 | DeductibleArtContributionInd |
| Terminate Operations | 0 | TerminateOperationsInd |
| Partial Liquidation | 0 | PartialLiquidationInd |
| Disregarded Entity | 0 | DisregardedEntityInd |
| Related Entity | 0 | RelatedEntityInd |
| Related Organization Ctrl Ent | 0 | RelatedOrganizationCtrlEntInd |
| Trnsfr Exmpt Non Chrtbl Rltd Org | 0 | TrnsfrExmptNonChrtblRltdOrgInd |
| Activities Conducted Prtshp | 0 | ActivitiesConductedPrtshpInd |
| Schedule O Required | Yes (1) | ScheduleORequiredInd |
| IRP Document | 74 | IRPDocumentCnt |
| IRP Document W2 G | 0 | IRPDocumentW2GCnt |
| Backup Wthld Compliance | Yes (1) | BackupWthldComplianceInd |
| Employee | 204 | EmployeeCnt |
| Employment Tax Returns Filed | Yes (1) | EmploymentTaxReturnsFiledInd |
| Unrelated Bus Incm Over Limit | 0 | UnrelatedBusIncmOverLimitInd |
| Foreign Financial Account | 0 | ForeignFinancialAccountInd |
| Prohibited Tax Shelter Trans | 0 | ProhibitedTaxShelterTransInd |
| Taxable Party Notification | 0 | TaxablePartyNotificationInd |
| Nondeductible Contributions | 0 | NondeductibleContributionsInd |
| Quid Pro Quo Contributions | 0 | QuidProQuoContributionsInd |
| Form8282 Property Disposed Of | 0 | Form8282PropertyDisposedOfInd |
| Rcv Fnds To Pay Prsnl Bnft Cntrct | 0 | RcvFndsToPayPrsnlBnftCntrctInd |
| Pay Premiums Prsnl Bnft Cntrct | 0 | PayPremiumsPrsnlBnftCntrctInd |
| Indoor Tanning Services | 0 | IndoorTanningServicesInd |
| Subj To Tax Rmnrtn Ex Prcht Pymt | 0 | SubjToTaxRmnrtnExPrchtPymtInd |
| Subject To Excs Tax Net Invst Inc | 0 | SubjectToExcsTaxNetInvstIncInd |
| Info In Schedule O Part VI | Yes (X) | InfoInScheduleOPartVIInd |
| Governing Body Voting Members | 9 | GoverningBodyVotingMembersCnt |
| Independent Voting Member | 9 | IndependentVotingMemberCnt |
| Family Or Business Rln | 0 | FamilyOrBusinessRlnInd |
| Delegation Of Mgmt Duties | 0 | DelegationOfMgmtDutiesInd |
| Change To Org Documents | 0 | ChangeToOrgDocumentsInd |
| Material Diversion Or Misuse | 0 | MaterialDiversionOrMisuseInd |
| Members Or Stockholders | Yes (1) | MembersOrStockholdersInd |
| Election Of Board Members | Yes (1) | ElectionOfBoardMembersInd |
| Decisions Subject To Approva | 0 | DecisionsSubjectToApprovaInd |
| Minutes Of Governing Body | Yes (1) | MinutesOfGoverningBodyInd |
| Minutes Of Committees | 0 | MinutesOfCommitteesInd |
| Officer Mailing Address | 0 | OfficerMailingAddressInd |
| Local Chapters | 0 | LocalChaptersInd |
| Form990 Provided To Gvrn Body | Yes (1) | Form990ProvidedToGvrnBodyInd |
| Conflict Of Interest Policy | Yes (1) | ConflictOfInterestPolicyInd |
| Annual Disclosure Covered Prsn | Yes (1) | AnnualDisclosureCoveredPrsnInd |
| Regular Monitoring Enfrc | Yes (1) | RegularMonitoringEnfrcInd |
| Whistleblower Policy | Yes (1) | WhistleblowerPolicyInd |
| Document Retention Policy | Yes (1) | DocumentRetentionPolicyInd |
| Compensation Process CEO | Yes (1) | CompensationProcessCEOInd |
| Compensation Process Other | 0 | CompensationProcessOtherInd |
| Investment In Joint Venture | 0 | InvestmentInJointVentureInd |
| Upon Request | Yes (X) | UponRequestInd |
Books In Care Of Detail BooksInCareOfDetail
Business Name BusinessName
| Field | Value | IRS element (for citing) |
|---|---|---|
| Business Name Line1 | Diana Swindler | BusinessNameLine1Txt |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Phone | 3086973329 | PhoneNum |
US Address USAddress
| Field | Value | IRS element (for citing) |
|---|---|---|
| Address Line1 | 1305 W Hwy 6 34 | AddressLine1Txt |
| City | Cambridge | CityNm |
| State Abbreviation | NE | StateAbbreviationCd |
| ZIP | 69022 | ZIPCd |
Form990 Part VII Section A Form990PartVIISectionAGrp (17 entries)
| TitleTitleTxt | Average Hours Per WeekAverageHoursPerWeekRt | Individual Trustee Or DirectorIndividualTrusteeOrDirectorInd | OfficerOfficerInd | Reportable Comp From OrgReportableCompFromOrgAmt | Reportable Comp From Rltd OrgReportableCompFromRltdOrgAmt | Other CompensationOtherCompensationAmt | Highest Compensated EmployeeHighestCompensatedEmployeeInd |
|---|---|---|---|---|---|---|---|
| LaVern Banzhaf | |||||||
| President | 3.00 | Yes (X) | Yes (X) | $0 | $0 | $0 | |
| James Jones | |||||||
| Vice President | 3.00 | Yes (X) | Yes (X) | $0 | $0 | $0 | |
| Joan Koch | |||||||
| Secretary (thru Oct 2021) | 3.00 | Yes (X) | Yes (X) | $0 | $0 | $0 | |
| James McGowen Trustee thru | |||||||
| Oct 2021)/Secretary (as of Nov) | 3.00 | Yes (X) | Yes (X) | $0 | $0 | $0 | |
| Drew Cramer | |||||||
| Treasurer | 3.00 | Yes (X) | Yes (X) | $0 | $0 | $0 | |
| Ginger tenBensel | |||||||
| Trustee | 3.00 | Yes (X) | $0 | $0 | $0 | ||
| Dale Fohnholz | |||||||
| Trustee | 3.00 | Yes (X) | $0 | $0 | $0 | ||
| John Paulsen | |||||||
| Trustee | 3.00 | Yes (X) | $0 | $0 | $0 | ||
| Logan Baker | |||||||
| Trustee | 3.00 | Yes (X) | $0 | $0 | $0 | ||
| Nanette Witte | |||||||
| Trustee (as of Nov 2021) | 3.00 | Yes (X) | $0 | $0 | $0 | ||
| Jessica Fisher | |||||||
| CEO | 40.00 | Yes (X) | $182,328 | $0 | $17,663 | ||
| Diana Swindler | |||||||
| CFO | 40.00 | Yes (X) | $111,299 | $0 | $16,318 | ||
| Lennie Deaver MD | |||||||
| Family Practice/Obstetrics | 40.00 | $367,691 | $0 | $11,632 | Yes (X) | ||
| Shiuvaun Jaeger MD | |||||||
| Family Practice/Obstetrics | 40.00 | $346,922 | $0 | $44,955 | Yes (X) | ||
| Rachelle Kaspar-Cope MD | |||||||
| Family Practice/Obstetrics | 40.00 | $364,028 | $0 | $40,898 | Yes (X) | ||
| Holly Lashment CRNA | |||||||
| Anesthetist | 40.00 | $222,752 | $0 | $20,710 | Yes (X) | ||
| Michael Powell MD | |||||||
| Family Practice | 40.00 | $264,424 | $0 | $44,744 | Yes (X) | ||
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Reportable Comp From Org | $1,859,444 | TotalReportableCompFromOrgAmt |
| Tot Reportable Comp Rltd Org | $0 | TotReportableCompRltdOrgAmt |
| Total Other Compensation | $196,920 | TotalOtherCompensationAmt |
| Indiv Rcvd Greater Than100 K | 14 | IndivRcvdGreaterThan100KCnt |
| Former Ofcr Employees Listed | 0 | FormerOfcrEmployeesListedInd |
| Total Comp Greater Than150 K | Yes (1) | TotalCompGreaterThan150KInd |
| Compensation From Other Srcs | 0 | CompensationFromOtherSrcsInd |
Contractor Compensation ContractorCompensationGrp (5 entries)
| Address Line1ContractorAddress/USAddress/AddressLine1Txt | CityContractorAddress/USAddress/CityNm | State AbbreviationContractorAddress/USAddress/StateAbbreviationCd | ZIPContractorAddress/USAddress/ZIPCd | ServicesServicesDesc | CompensationCompensationAmt |
|---|---|---|---|---|---|
| Inspire Rehabilitation LLC | |||||
| 8181 Arista Place Ste 100 | Broomfield | CO | 80021 | Rehabilitation services | $935,863 |
| Focusone Solutions | |||||
| PO Box 850861 | Minneapolis | MN | 55485 | Contract services | $521,739 |
| Psychiatric Medical Care LLC | |||||
| PO Box 734606 | Dallas | TX | 75373 | Behavioral health services | $428,279 |
| Rural Partners in Medicine LLC | |||||
| 8181 Arista Place Ste 100 | Broomfield | CO | 80021 | Specialty health services | $281,615 |
| Med-Care Inc | |||||
| 152 Ponderosa Court | Grand Island | NE | 68803 | Pain management services | $160,650 |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Cntrct Rcvd Greater Than100 K | 8 | CntrctRcvdGreaterThan100KCnt |
| Government Grants | $392,728 | GovernmentGrantsAmt |
| All Other Contributions | $69,662 | AllOtherContributionsAmt |
| Noncash Contributions | $41,480 | NoncashContributionsAmt |
| Total Contributions | $462,390 | TotalContributionsAmt |
Program Service Revenue ProgramServiceRevenueGrp (4 entries)
| DescDesc | BusinessBusinessCd | Total Revenue ColumnTotalRevenueColumnAmt | Related Or Exempt Func IncomeRelatedOrExemptFuncIncomeAmt |
|---|---|---|---|
| Patient & Resident Revenue | 622110 | $24,082,106 | $24,082,106 |
| Pharmacy Revenue | 900099 | $1,095,238 | $1,095,238 |
| Cafeteria Revenue | 900099 | $96,794 | $96,794 |
| Wellness & Rehab | 900099 | $42,435 | $42,435 |
Total Oth Program Service Rev TotalOthProgramServiceRevGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Revenue Column | $125,158 | TotalRevenueColumnAmt |
| Related Or Exempt Func Income | $125,158 | RelatedOrExemptFuncIncomeAmt |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Program Service Revenue | $25,441,731 | TotalProgramServiceRevenueAmt |
Investment Income InvestmentIncomeGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Revenue Column | $425,875 | TotalRevenueColumnAmt |
| Exclusion | $425,875 | ExclusionAmt |
Gross Rents GrossRentsGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Real | $19,632 | RealAmt |
Less Rental Expenses LessRentalExpensesGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Real | $0 | RealAmt |
Rental Income Or Loss RentalIncomeOrLossGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Real | $19,632 | RealAmt |
Net Rental Income Or Loss NetRentalIncomeOrLossGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Revenue Column | $19,632 | TotalRevenueColumnAmt |
| Exclusion | $19,632 | ExclusionAmt |
Gross Amount Sales Assets GrossAmountSalesAssetsGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Other | $10,130 | OtherAmt |
Less Cost Oth Basis Sales Expnss LessCostOthBasisSalesExpnssGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Other | $8,240 | OtherAmt |
Gain Or Loss GainOrLossGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Other | $1,890 | OtherAmt |
Net Gain Or Loss Investments NetGainOrLossInvestmentsGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Revenue Column | $1,890 | TotalRevenueColumnAmt |
| Exclusion | $1,890 | ExclusionAmt |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Gross Sales Of Inventory | $53,904 | GrossSalesOfInventoryAmt |
| Cost Of Goods Sold | $61,766 | CostOfGoodsSoldAmt |
Net Income Or Loss NetIncomeOrLossGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Revenue Column | -$7,862 | TotalRevenueColumnAmt |
| Exclusion | -$7,862 | ExclusionAmt |
Total Revenue TotalRevenueGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Revenue Column | $26,343,656 | TotalRevenueColumnAmt |
| Related Or Exempt Func Income | $25,441,731 | RelatedOrExemptFuncIncomeAmt |
| Unrelated Business Revenue | $0 | UnrelatedBusinessRevenueAmt |
| Exclusion | $439,535 | ExclusionAmt |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Info In Schedule O Part IX | Yes (X) | InfoInScheduleOPartIXInd |
Comp Current Ofcr Directors CompCurrentOfcrDirectorsGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $383,370 | TotalAmt |
| Management And General | $383,370 | ManagementAndGeneralAmt |
Comp Disqual Persons CompDisqualPersonsGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $76,375 | TotalAmt |
| Program Services | $76,375 | ProgramServicesAmt |
Other Salaries And Wages OtherSalariesAndWagesGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $8,985,672 | TotalAmt |
| Program Services | $7,650,867 | ProgramServicesAmt |
| Management And General | $1,334,805 | ManagementAndGeneralAmt |
Pension Plan Contributions PensionPlanContributionsGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $319,280 | TotalAmt |
| Program Services | $273,059 | ProgramServicesAmt |
| Management And General | $46,221 | ManagementAndGeneralAmt |
Other Employee Benefits OtherEmployeeBenefitsGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $1,361,188 | TotalAmt |
| Program Services | $1,133,402 | ProgramServicesAmt |
| Management And General | $227,786 | ManagementAndGeneralAmt |
Payroll Taxes PayrollTaxesGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $623,399 | TotalAmt |
| Program Services | $511,783 | ProgramServicesAmt |
| Management And General | $111,616 | ManagementAndGeneralAmt |
Fees For Services Legal FeesForServicesLegalGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $77,908 | TotalAmt |
| Management And General | $77,908 | ManagementAndGeneralAmt |
Fees For Services Accounting FeesForServicesAccountingGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $55,250 | TotalAmt |
| Management And General | $55,250 | ManagementAndGeneralAmt |
Fees For Services Other FeesForServicesOtherGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $5,459,376 | TotalAmt |
| Program Services | $5,195,896 | ProgramServicesAmt |
| Management And General | $263,480 | ManagementAndGeneralAmt |
Advertising AdvertisingGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $160,390 | TotalAmt |
| Program Services | $3,263 | ProgramServicesAmt |
| Management And General | $157,127 | ManagementAndGeneralAmt |
Office Expenses OfficeExpensesGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $392,079 | TotalAmt |
| Program Services | $287,387 | ProgramServicesAmt |
| Management And General | $104,692 | ManagementAndGeneralAmt |
Occupancy OccupancyGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $519,207 | TotalAmt |
| Program Services | $519,207 | ProgramServicesAmt |
Travel TravelGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $99,247 | TotalAmt |
| Program Services | $89,148 | ProgramServicesAmt |
| Management And General | $10,099 | ManagementAndGeneralAmt |
Interest InterestGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $604,552 | TotalAmt |
| Program Services | $507,306 | ProgramServicesAmt |
| Management And General | $97,246 | ManagementAndGeneralAmt |
Depreciation Depletion DepreciationDepletionGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $1,925,687 | TotalAmt |
| Program Services | $1,752,364 | ProgramServicesAmt |
| Management And General | $173,323 | ManagementAndGeneralAmt |
Insurance InsuranceGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $347,502 | TotalAmt |
| Management And General | $347,502 | ManagementAndGeneralAmt |
Other Expenses OtherExpensesGrp (3 entries)
| DescDesc | TotalTotalAmt | Program ServicesProgramServicesAmt |
|---|---|---|
| Medical Supplies | $2,813,644 | $2,813,644 |
| Repairs and Maintenance | $534,879 | $534,879 |
| Food Costs | $149,863 | $149,863 |
All Other Expenses AllOtherExpensesGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $302,357 | TotalAmt |
| Program Services | $221,827 | ProgramServicesAmt |
| Management And General | $80,530 | ManagementAndGeneralAmt |
Total Functional Expenses TotalFunctionalExpensesGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $25,191,225 | TotalAmt |
| Program Services | $21,720,270 | ProgramServicesAmt |
| Management And General | $3,470,955 | ManagementAndGeneralAmt |
| Fundraising | $0 | FundraisingAmt |
Savings And Temp Cash Invst SavingsAndTempCashInvstGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $4,403,060 | BOYAmt |
| EOY | $5,239,696 | EOYAmt |
Accounts Receivable AccountsReceivableGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $2,893,725 | BOYAmt |
| EOY | $2,733,847 | EOYAmt |
Oth Notes Loans Receivable Net OthNotesLoansReceivableNetGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $84,981 | BOYAmt |
| EOY | $60,205 | EOYAmt |
Inventories For Sale Or Use InventoriesForSaleOrUseGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $493,232 | BOYAmt |
| EOY | $517,201 | EOYAmt |
Prepaid Expenses Defrd Charges PrepaidExpensesDefrdChargesGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $215,939 | BOYAmt |
| EOY | $305,963 | EOYAmt |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Land Bldg Equip Cost Or Other Bss | $38,674,135 | LandBldgEquipCostOrOtherBssAmt |
| Land Bldg Equip Accum Deprec | $27,582,101 | LandBldgEquipAccumDeprecAmt |
Land Bldg Equip Basis Net LandBldgEquipBasisNetGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $11,976,340 | BOYAmt |
| EOY | $11,092,034 | EOYAmt |
Investments Pub Traded Sec InvestmentsPubTradedSecGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $7,329,033 | BOYAmt |
| EOY | $6,715,063 | EOYAmt |
Investments Program Related InvestmentsProgramRelatedGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $138,347 | BOYAmt |
| EOY | $130,147 | EOYAmt |
Other Assets Total OtherAssetsTotalGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $4,183,436 | BOYAmt |
| EOY | $4,191,921 | EOYAmt |
Total Assets TotalAssetsGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $31,718,093 | BOYAmt |
| EOY | $30,986,077 | EOYAmt |
Accounts Payable Accr Expnss AccountsPayableAccrExpnssGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $1,957,883 | BOYAmt |
| EOY | $2,242,091 | EOYAmt |
Deferred Revenue DeferredRevenueGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $365,844 | BOYAmt |
| EOY | $356,804 | EOYAmt |
Mortg Notes Pybl Scrd Invst Prop MortgNotesPyblScrdInvstPropGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $13,595,926 | BOYAmt |
| EOY | $12,885,444 | EOYAmt |
Other Liabilities OtherLiabilitiesGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $1,700,000 | BOYAmt |
| EOY | $1,330,000 | EOYAmt |
Total Liabilities TotalLiabilitiesGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $17,619,653 | BOYAmt |
| EOY | $16,814,339 | EOYAmt |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Organization Follows FASB117 | Yes (X) | OrganizationFollowsFASB117Ind |
No Donor Restriction Net Assets NoDonorRestrictionNetAssetsGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $10,433,368 | BOYAmt |
| EOY | $10,611,434 | EOYAmt |
Donor Restriction Net Assets DonorRestrictionNetAssetsGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $3,665,072 | BOYAmt |
| EOY | $3,560,304 | EOYAmt |
Total Net Assets Fund Balance TotalNetAssetsFundBalanceGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $14,098,440 | BOYAmt |
| EOY | $14,171,738 | EOYAmt |
Tot Liab Net Assets Fund Balance TotLiabNetAssetsFundBalanceGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $31,718,093 | BOYAmt |
| EOY | $30,986,077 | EOYAmt |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Info In Schedule O Part XI | Yes (X) | InfoInScheduleOPartXIInd |
| Reconcilation Revenue Expnss | $1,152,431 | ReconcilationRevenueExpnssAmt |
| Net Unrlzd Gains Losses Invst | -$976,361 | NetUnrlzdGainsLossesInvstAmt |
| Other Changes In Net Assets | -$102,772 | OtherChangesInNetAssetsAmt |
| Info In Schedule O Part XII | Yes (X) | InfoInScheduleOPartXIIInd |
| Method Of Accounting Accrual | Yes (X) | MethodOfAccountingAccrualInd |
| Accountant Compile Or Review | 0 | AccountantCompileOrReviewInd |
| FS Audited | Yes (1) | FSAuditedInd |
FS Audited Basis FSAuditedBasisGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Separate Basis Fincl Stmt | Yes (X) | SeparateBasisFinclStmtInd |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Audit Committee | Yes (1) | AuditCommitteeInd |
| Federal Grant Audit Required | Yes (1) | FederalGrantAuditRequiredInd |
| Federal Grant Audit Performed | Yes (1) | FederalGrantAuditPerformedInd |
Schedule A IRS990ScheduleA
| Field | Value | IRS element (for citing) |
|---|---|---|
| Hospital | Yes (X) | HospitalInd |
Schedule B IRS990ScheduleB
Contributor Information ContributorInformationGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Contributor | RESTRICTED | ContributorNum |
Contributor Business Name ContributorBusinessName
| Field | Value | IRS element (for citing) |
|---|---|---|
| Business Name Line1 | RESTRICTED | BusinessNameLine1 |
Contributor US Address ContributorUSAddress
| 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) |
|---|---|---|
| Total Contributions | RESTRICTED | TotalContributionsAmt |
Schedule D IRS990ScheduleD
Land LandGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Other Cost Or Other Basis | $113,289 | OtherCostOrOtherBasisAmt |
| Book Value | $113,289 | BookValueAmt |
Buildings BuildingsGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Other Cost Or Other Basis | $22,643,132 | OtherCostOrOtherBasisAmt |
| Depreciation | $15,828,343 | DepreciationAmt |
| Book Value | $6,814,789 | BookValueAmt |
Equipment EquipmentGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Other Cost Or Other Basis | $12,977,335 | OtherCostOrOtherBasisAmt |
| Depreciation | $9,857,728 | DepreciationAmt |
| Book Value | $3,119,607 | BookValueAmt |
Other Land Buildings OtherLandBuildingsGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Other Cost Or Other Basis | $2,940,379 | OtherCostOrOtherBasisAmt |
| Depreciation | $1,896,030 | DepreciationAmt |
| Book Value | $1,044,349 | BookValueAmt |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Book Value Land Buildings | $11,092,034 | TotalBookValueLandBuildingsAmt |
Other Assets Org OtherAssetsOrgGrp (3 entries)
| DescDesc | Book ValueBookValueAmt |
|---|---|
| Other receivables | $378,798 |
| Interest in Tri Valley Medical Foundation | $3,557,461 |
| Insurance Escrow | $255,662 |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Book Value Other Assets | $4,191,921 | TotalBookValueOtherAssetsAmt |
Other Liabilities Org OtherLiabilitiesOrgGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Desc | Estimated Third Party Payors | Desc |
| Amt | $1,330,000 | Amt |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Liability | $1,330,000 | TotalLiabilityAmt |
| Footnote Text | Yes (X) | FootnoteTextInd |
| Total Rev Etc Audited Fincl Stmt | $25,367,295 | TotalRevEtcAuditedFinclStmtAmt |
| Net Unrealized Gains Invst | -$976,361 | NetUnrealizedGainsInvstAmt |
| Revenue Not Reported | -$976,361 | RevenueNotReportedAmt |
| Revenue Subtotal | $26,343,656 | RevenueSubtotalAmt |
| Revenue Not Reported Fincl Stmt | $0 | RevenueNotReportedFinclStmtAmt |
| Total Revenue Per Form990 | $26,343,656 | TotalRevenuePerForm990Amt |
| Tot Expns Etc Audited Fincl Stmt | $25,191,225 | TotExpnsEtcAuditedFinclStmtAmt |
| Expenses Not Reported | $0 | ExpensesNotReportedAmt |
| Expenses Subtotal | $25,191,225 | ExpensesSubtotalAmt |
| Expenses Not Rpt Fincl Stmt | $0 | ExpensesNotRptFinclStmtAmt |
| Total Expenses Per Form990 | $25,191,225 | TotalExpensesPerForm990Amt |
Supplemental Information Detail SupplementalInformationDetail
| Field | Value | IRS element (for citing) |
|---|---|---|
| Form And Line Reference | Part X, Line 2: | FormAndLineReferenceDesc |
| Explanation | The Health System believes that it has appropriate support for any tax positions taken affecting its annual filing requirements, and as such, does not have any uncertain tax positions that are material to the financial statements. The Health System would recognize future accrued interest and penalties related to unrecognized tax benefits and liabilities in income tax expense, if such interest and penalties are incurred. The Health System has determined it is not subject to unrelated business income tax and has not filed an Exempt Organization Business Income Tax Return (Form 990-T) with the IRS. | ExplanationTxt |
Schedule H IRS990ScheduleH
| Field | Value | IRS element (for citing) |
|---|---|---|
| Financial Assistance Policy | Yes (1) | FinancialAssistancePolicyInd |
| Written Policy | Yes (1) | WrittenPolicyInd |
| All Hospitals Policy | Yes (X) | AllHospitalsPolicyInd |
| FPG Reference Free Care | Yes (1) | FPGReferenceFreeCareInd |
| Percent100 | Yes (X) | Percent100Ind |
| FPG Reference Discounted Care | Yes (1) | FPGReferenceDiscountedCareInd |
| Percent200 D | Yes (X) | Percent200DInd |
| Free Care Medically Indigent | Yes (1) | FreeCareMedicallyIndigentInd |
| Financial Assistance Budget | Yes (1) | FinancialAssistanceBudgetInd |
| Expenses Exceed Budget | 0 | ExpensesExceedBudgetInd |
| Annual Community Bnft Report | 0 | AnnualCommunityBnftReportInd |
Financial Assistance At Cost Typ FinancialAssistanceAtCostTyp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Community Benefit Expns | $20,000 | TotalCommunityBenefitExpnsAmt |
| Direct Offsetting Revenue | $0 | DirectOffsettingRevenueAmt |
| Net Community Benefit Expns | $20,000 | NetCommunityBenefitExpnsAmt |
| Total Expense | 0.00080 | TotalExpensePct |
Total Financial Assistance Typ TotalFinancialAssistanceTyp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Community Benefit Expns | $20,000 | TotalCommunityBenefitExpnsAmt |
| Net Community Benefit Expns | $20,000 | NetCommunityBenefitExpnsAmt |
| Total Expense | 0.00080 | TotalExpensePct |
Subsidized Health Services SubsidizedHealthServicesGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Community Benefit Expns | $5,264,018 | TotalCommunityBenefitExpnsAmt |
| Direct Offsetting Revenue | $3,491,559 | DirectOffsettingRevenueAmt |
| Net Community Benefit Expns | $1,772,459 | NetCommunityBenefitExpnsAmt |
| Total Expense | 0.07040 | TotalExpensePct |
Total Other Benefits TotalOtherBenefitsGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Community Benefit Expns | $5,264,018 | TotalCommunityBenefitExpnsAmt |
| Direct Offsetting Revenue | $3,491,559 | DirectOffsettingRevenueAmt |
| Net Community Benefit Expns | $1,772,459 | NetCommunityBenefitExpnsAmt |
| Total Expense | 0.07040 | TotalExpensePct |
Total Community Benefits TotalCommunityBenefitsGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Community Benefit Expns | $5,284,018 | TotalCommunityBenefitExpnsAmt |
| Direct Offsetting Revenue | $3,491,559 | DirectOffsettingRevenueAmt |
| Net Community Benefit Expns | $1,792,459 | NetCommunityBenefitExpnsAmt |
| Total Expense | 0.07120 | TotalExpensePct |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Bad Debt Expense Reported | Yes (1) | BadDebtExpenseReportedInd |
| Bad Debt Expense | $725,134 | BadDebtExpenseAmt |
| Bad Debt Expense Attributable | $63,957 | BadDebtExpenseAttributableAmt |
| Reimbursed By Medicare | $8,842,836 | ReimbursedByMedicareAmt |
| Cost Of Care Reimbursed By Medcr | $8,760,852 | CostOfCareReimbursedByMedcrAmt |
| Medicare Surplus Or Shortfall | $81,984 | MedicareSurplusOrShortfallAmt |
Costing Methodology Used CostingMethodologyUsedGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Other | Yes (X) | OtherInd |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Written Debt Collection Policy | Yes (1) | WrittenDebtCollectionPolicyInd |
| Financial Assistance Prvsn | Yes (1) | FinancialAssistancePrvsnInd |
| Hospital Facilities | 1 | HospitalFacilitiesCnt |
Hospital Facilities HospitalFacilitiesGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Facility | 1 | FacilityNum |
Business Name BusinessName
| Field | Value | IRS element (for citing) |
|---|---|---|
| Business Name Line1 | Cambridge Memorial Hospital Inc | BusinessNameLine1Txt |
US Address USAddress
| Field | Value | IRS element (for citing) |
|---|---|---|
| Address Line1 | 1305 W Hwy 6 34 | AddressLine1Txt |
| City | Cambridge | CityNm |
| State Abbreviation | NE | StateAbbreviationCd |
| ZIP | 69022 | ZIPCd |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Website Address | www.trivalleyhealth.com | WebsiteAddressTxt |
| State License | 310001 | StateLicenseNum |
| Licensed Hospital | Yes (X) | LicensedHospitalInd |
| General Medical And Surgical | Yes (X) | GeneralMedicalAndSurgicalInd |
| Critical Access Hospital | Yes (X) | CriticalAccessHospitalInd |
| Emergency Room24 Hrs | Yes (X) | EmergencyRoom24HrsInd |
| Other | 3 provider based rural health clinics | OtherDesc |
Hospital Fclty Policies Prctc HospitalFcltyPoliciesPrctcGrp
Hospital Facility Name HospitalFacilityName
| Field | Value | IRS element (for citing) |
|---|---|---|
| Business Name Line1 | Cambridge Memorial Hospital Inc | BusinessNameLine1Txt |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Facility | 1 | FacilityNum |
| First Licensed CY Or PY | 0 | FirstLicensedCYOrPYInd |
| Tax Exempt Hospital CY Or PY | 0 | TaxExemptHospitalCYOrPYInd |
| CHNA Conducted | Yes (1) | CHNAConductedInd |
| Community Definition | Yes (X) | CommunityDefinitionInd |
| Community Demographics | Yes (X) | CommunityDemographicsInd |
| Existing Resources | Yes (X) | ExistingResourcesInd |
| How Data Obtained | Yes (X) | HowDataObtainedInd |
| Community Health Needs | Yes (X) | CommunityHealthNeedsInd |
| Other Health Issues | Yes (X) | OtherHealthIssuesInd |
| Community Hlth Needs Id Process | Yes (X) | CommunityHlthNeedsIdProcessInd |
| Consulting Process | Yes (X) | ConsultingProcessInd |
| Prior CHNA Impact | Yes (X) | PriorCHNAImpactInd |
| CHNA Conducted | 21 | CHNAConductedYr |
| Take Into Account Others Input | Yes (1) | TakeIntoAccountOthersInputInd |
| CHNA Conducted With Other Fclts | 0 | CHNAConductedWithOtherFcltsInd |
| CHNA Conducted With Non Fclts | Yes (1) | CHNAConductedWithNonFcltsInd |
| CHNA Report Widely Available | Yes (1) | CHNAReportWidelyAvailableInd |
| Rpt Available On Own Website | Yes (X) | RptAvailableOnOwnWebsiteInd |
| Own Website URL | See Part V, Section C | OwnWebsiteURLTxt |
| Paper Copy Public Inspection | Yes (X) | PaperCopyPublicInspectionInd |
| Implementation Strategy Adopt | Yes (1) | ImplementationStrategyAdoptInd |
| Implementation Strategy Adpt | 21 | ImplementationStrategyAdptYr |
| Strategy Posted Website | Yes (1) | StrategyPostedWebsiteInd |
| Strategy Website URL | See Part V, Section C | StrategyWebsiteURLTxt |
| Organization Incur Excise Tax | 0 | OrganizationIncurExciseTaxInd |
| Elig Criteria Explained | Yes (1) | EligCriteriaExplainedInd |
| FPG Family Incm Lmt Free Dscnt | Yes (X) | FPGFamilyIncmLmtFreeDscntInd |
| FPG Family Incm Lmt Free Care | 100.000000000000 | FPGFamilyIncmLmtFreeCarePct |
| FPG Family Incm Lmt Dscnt Care | 200.000000000000 | FPGFamilyIncmLmtDscntCarePct |
| Asset Level Criteria | Yes (X) | AssetLevelCriteriaInd |
| Medical Indigency Criteria | Yes (X) | MedicalIndigencyCriteriaInd |
| Insurance Status Criteria | Yes (X) | InsuranceStatusCriteriaInd |
| Explained Basis | Yes (1) | ExplainedBasisInd |
| App Financial Asst Expln | Yes (1) | AppFinancialAsstExplnInd |
| Described Info | Yes (X) | DescribedInfoInd |
| Described Suprt Doc | Yes (X) | DescribedSuprtDocInd |
| Provided Hospital Contact | Yes (X) | ProvidedHospitalContactInd |
| Provided Nonprofit Contact | Yes (X) | ProvidedNonprofitContactInd |
| Includes Publicity Measures | Yes (1) | IncludesPublicityMeasuresInd |
| FAP Available On Website | Yes (X) | FAPAvailableOnWebsiteInd |
| FAP Available On Website URL | https://www.trivalleyhealth.com/financial-assistance.html | FAPAvailableOnWebsiteURLTxt |
| FAP App Available On Website | Yes (X) | FAPAppAvailableOnWebsiteInd |
| FAP App Available On Website URL | https://www.trivalleyhealth.com/financial-assistance.html | FAPAppAvailableOnWebsiteURLTxt |
| FAP Summary On Website | Yes (X) | FAPSummaryOnWebsiteInd |
| FAP Summary On Website URL | https://www.trivalleyhealth.com/financial-assistance.html | FAPSummaryOnWebsiteURLTxt |
| FAP Avlbl On Request No Charge | Yes (X) | FAPAvlblOnRequestNoChargeInd |
| FAP App Avlbl On Request No Chrg | Yes (X) | FAPAppAvlblOnRequestNoChrgInd |
| FAP Sum Avlbl On Request No Chrg | Yes (X) | FAPSumAvlblOnRequestNoChrgInd |
| Notified FAP Copy Bill Display | Yes (X) | NotifiedFAPCopyBillDisplayInd |
| Communtity Notified FAP | Yes (X) | CommuntityNotifiedFAPInd |
| Other Publicity | Yes (X) | OtherPublicityInd |
| FAP Actions On Nonpayment | Yes (1) | FAPActionsOnNonpaymentInd |
| Permit No Actions | Yes (X) | PermitNoActionsInd |
| Collection Activities | 0 | CollectionActivitiesInd |
| Provided Written Notice | Yes (X) | ProvidedWrittenNoticeInd |
| Made Effort Orally Notify | Yes (X) | MadeEffortOrallyNotifyInd |
| Processed FAP Application | Yes (X) | ProcessedFAPApplicationInd |
| Made Presumptive Elig Determ | Yes (X) | MadePresumptiveEligDetermInd |
| Nondis Emergency Care Policy | Yes (1) | NondisEmergencyCarePolicyInd |
| Look Back Medicaid Medcr Prvt | Yes (X) | LookBackMedicaidMedcrPrvtInd |
| Amounts Generally Billed | 0 | AmountsGenerallyBilledInd |
| Gross Charges | 0 | GrossChargesInd |
Supplemental Information SupplementalInformationGrp (5 entries)
| Form And Line ReferenceFormAndLineReferenceDesc | ExplanationExplanationTxt |
|---|---|
| Cambridge Memorial Hospital, Inc. | Part V, Section B, Line 5: Phase I Discovery: Conducted a 30-minute conference call with the CHNA county health department and hospital clients.Phase II Conducted secondary research to uncover the historical community health status for the primary service area.Phase III Conducted a 90-minute Town Hall meeting with required community primary service area residents. |
| Cambridge Memorial Hospital, Inc. | Part V, Section B, Line 6b: Collaborated with Southwest Nebraska Public Health Department and VVV Consultants. |
| Cambridge Memorial Hospital, Inc. | Part V, Section B, Line 11: The most recent Community Health Needs Assessment was completed in March 2022. The following needs were identified. Due to timing of the completion of the CHNA the needs will be addressed over the next three years. (1) Senior Health (2) Awareness of Healthcare ServicesSeveral areas identified were not part of the hospitals mission of critical operations. These needs include Mental Health (Diagnosis, Placement, Aftercare, and Providers), Child Care, Uninsured/Underinsured, Dental Services taking Medicaid, Housing, Healthy Food Nutrition and School Health. A Community Health Needs Assessment was completed in the first quarter of 2019. Tri Valley Health System approved an implementation plan to address six of the eight needs identified in the plan. Tri Valley Health System chose not to address the need of Child Care Services or Housing as they are not part of Tri Valley Health System's mission of critical operations. FY2022 updates include:(1) Recruitment/Add Visiting Specialists. Tri Valley Health System contracts with visiting specialists to provide specialty services in TVHS Specialty Clinic. Current relationships with Platte Valley Medical Group, Kearney, NE, Rural Partners in Medicine in Steamboat, CO, and other various medical groups in the state who can provide specialized services. If able, TVHS works with neighboring Specialty Clinics to share services. Throughout the three-year period, TVHS was able to recruit two Urologists, a full-time and a part-time APRN, a full-time Family Practice physician, and a full-time and part-time CRNA.(2) Healthcare Staffing Shortages. Tri Valley Health System continued to support the Workforce Connections Program that selects and supports non-traditional students in the pursuit of furthering their education to meet their staffing needs. At the end of the three-year period, TVHS continued to promote and support one student.(3) Aging Nursing Home Facilities. The Board of Trustees made a decision to close the Nursing Home in June 2019.(4) Healthcare Insurance Options. Throughout the three years, TVHS performed annual due diligence to evaluate health insurance providers as well as self-insurance options to provide affordable coverage options to employees. Three insurance options are provided to employees annual for their selection.(5) Build Community Awareness/Support. A number of steps were taken to provide community awareness and support. "The Beat" was implemented by the CEO which provides weekly/bi-weekly Facebook video posts to share update. A quarterly newsletter was implemented that provides information to approximately 17,000 people in the primary and secondary market area. (6) Drugs (Opioids, Meth, Marijuana). TVHS provided "Dispose RX" to the community as a method to educate patients and community members on how to dispose of their controlled medications. E-Prescribe was implemented on the EMR system for providers to use the functionality. Drug take-back bags were distributed which can be mailed with a prepaid envelope to the facility to be disposed of. |
| Cambridge Memorial Hospital, Inc. | Part V, Section B, Line 16j: A plain language summary is conspicuously displayed in Hospital patient waiting areas and in the Patient Accounting Department in a manner that is reasonably calculated to attract visitors' attention. A plain language summary of this Policy and a copy of the financial assistance application will be included in all admission packets provided to inpatients upon admission to the Hospital. A plain language summary of this policy will be offered to all outpatients registering for services. The Hospital publishes the plain language summary of the Policy in the local newspaper on at least an annual basis and may publicize the Policy using other media at the option of Hospital administration. |
| Schedule H, Part V, Section B, Line 7a and 10a: | https://www.trivalleyhealth.com/community-health-needs.html |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Facility | 1 | FacilityNum |
Oth Hlth Care Fclts Not Hospital OthHlthCareFcltsNotHospitalGrp
Oth Hlth Care Fclts OthHlthCareFcltsGrp
Business Name BusinessName
| Field | Value | IRS element (for citing) |
|---|---|---|
| Business Name Line1 | 1 - Heritage Plaza | BusinessNameLine1Txt |
US Address USAddress
| Field | Value | IRS element (for citing) |
|---|---|---|
| Address Line1 | 1205 Nelson Street | AddressLine1Txt |
| City | Cambridge | CityNm |
| State Abbreviation | NE | StateAbbreviationCd |
| ZIP | 69022 | ZIPCd |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Facility | Independent living | FacilityTxt |
Supplemental Information Detail SupplementalInformationDetail (10 entries)
| Form And Line ReferenceFormAndLineReferenceDesc | ExplanationExplanationTxt |
|---|---|
| Part I, Line 7: | Charity care expense was converted to cost on line 7a based on an overall cost-to-charge ratio addressing all payor segments. The cost for subsidized health services reported on line 7g was determined using the Medicare Cost Report. |
| Part III, Line 2: | The amount reported on line 2 represents implicit price concessions. The Health System determines its estimate of implicit price concessions based on its historical collection experience with this class of patients and residents. |
| Part III, Line 3: | The Hospital reasonably estimates the portion of implicit price concessions that could have qualified for charity care by identifying the uninsured, underinsured, and account balances assigned to a collection agency in the current year.In Furnas County, Nebraska, the percentage of residents that are at or below poverty level is 8.82%. We can assume that the same percentage of implicit price concessions are attributable to patients potentially eligible for charity care. |
| Part III, Line 4: | The footnote to the Organization's financial statements can be found on page 11 of the attached audited financial statements. |
| Part III, Line 8: | Tri Valley Health System had a Medicare surplus. The Health System provides care to patients with Medicare coverage regardless of whether or not a surplus or deficit is realized from providing the services. The Hospital provides services to Medicare patients because access to healthcare is important to the Hospital. This is a key advantage to the community. Medicare allowable costs of care are based on the Medicare cost report. The Medicare cost report is completed based on the rules and regulations set forth by the Centers for Medicare and Medicaid Services.Hospital services reimbursed on a fee schedule are not included in the Medicare calculation per the 990 instructions. Had this been reported the total loss from Medicare services would have been $214,611.Medicare fee schedule revenue $ 217,461Medicare estimated costs of care relating to payments (432,072)Net (Shortage) $ (214,611) |
| Part III, Line 9b: | Incomplete applications will receive a written notice providing the patient with at least 30 days to provide the required information. The policy further states the hospital may refer a patient's bill to a collection agency 120 days from the date the first bill for care was provided to the patient.The application period for applying for financial assistance begins on the date care is provided to the patient and ends on the later of the 240th day after the date of the first post-discharge billing statement is provided to the patient or not less than 30 days after the date the hospital provides the patient the requisite final notice to commence extraordinary collection actions. |
| Part VI, Line 2: | In addition to the community health needs assessment, the Hospital assesses the health care needs of the community it serves through patient feedback using various surveys. The surveys are provided by an outside vendor for inpatient care, Emergency Department, and Rural Health Clinics. In-house surveys are completed by various departments. |
| Part VI, Line 3: | The Financial Assistance Policy, an application, a plain language summary of the Policy, and any notices or publications regarding the Policy will be made available on the Hospital's website. The Policy, applications, and plain language summaries are available upon request, without charge at the Patient Accounting Department and by mail.A plain language summary is conspicuously displayed in Hospital patient waiting areas and in the Patient Accounting Department in a manner that is reasonably calculated to attract visitors' attention. A plain language summary of the Policy and a copy of the Financial Assistance Application will be included in all admission packets provided to inpatients upon admission to the Hospital. A plain language summary of the Policy is offered to all outpatients registering for services.The Hospital will publish the plain language summary of the Policy in the local newspaper on at least an annual basis and may publicize the Policy using other media at the option of Hospital Administration.Social services staff discusses with patients the availability of state programs (i.e. Medicaid), and assists them with the necessary paperwork. This is usually done primarily for inpatients and nursing home residents. Social Services contacts patient accounting staff about any other individuals in need of our Charity Care Program. 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 service area includes the southwest Nebraska counties of Furnas, Frontier, Gosper, and Red Willow. Median household income in the service area was $60,938 in 2021. These income values are below the median and average for both the state of Nebraska and the United States. About 8.82% of the population were below the poverty level.Unemployment rate for the service area of 2021 was 1.7%.The largest industries in Cambridge, NE are health care and social assistance, educational services, and manufacturing |
| Part VI, Line 5: | Tri Valley Health System is governed by a Board of Trustees whose members reside within the Health 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 fiscal year, strides were made to increase the community outreach and education as well as the health of the communities. Tri Valley Health System operates the Healthy Living Center which includes a Wellness and Rehab Center. Every day people with chronic diseases, such as diabetes and heart failure, are monitored, educated, and cared for by dedicated health care professionals who help them enjoy the best quality of life possible. The Health System has a "Healthy Living" program directed toward diabetes and obesity through the Nutrition Education Department. The Hospital opens its doors to the community to use conference areas for groups such as Alcohol Anonymous, ministerial associations, Weight Watchers, 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 the Cambridge Community. Tri Valley Health System is reaching out to the communities through the school system and providing education to students in topics such as smoking cessation, bone health, spinal trauma and thyroid issues. Tri Valley Health System also provided baseline trauma testing to football players in all the schools in the communities they serve as well as offering athletic trainers to the school systems at no cost. As a critical access hospital, Tri Valley Health System invites specialists throughout the state to conduct weekly or monthly clinics in the specialty clinic. Services offered to patients during the fiscal year were cardiology, general surgery, mental health, obstetrics/gynecology, orthopedics, ophthalmology, otolaryngology, podiatry, pulmonology, and urology. Tri Valley Health System also offers telehealth psychiatric services. |
Schedule J IRS990ScheduleJ
| Field | Value | IRS element (for citing) |
|---|---|---|
| Travel For Companions | Yes (X) | TravelForCompanionsInd |
| Club Dues Or Fees | Yes (X) | ClubDuesOrFeesInd |
| Written Policy Ref T And E Expnss | Yes (1) | WrittenPolicyRefTAndEExpnssInd |
| Substantiation Required | Yes (1) | SubstantiationRequiredInd |
| Compensation Survey | Yes (X) | CompensationSurveyInd |
| Board Or Committee Approval | Yes (X) | BoardOrCommitteeApprovalInd |
| Severance Payment | 0 | SeverancePaymentInd |
| Supplemental Nonqual Rtr Plan | 0 | SupplementalNonqualRtrPlanInd |
| Equity Based Comp Arrngm | 0 | EquityBasedCompArrngmInd |
| Comp Based On Revenue Of Flng Org | 0 | CompBasedOnRevenueOfFlngOrgInd |
| Comp Bsd On Rev Related Orgs | 0 | CompBsdOnRevRelatedOrgsInd |
| Comp Bsd Net Earns Flng Org | 0 | CompBsdNetEarnsFlngOrgInd |
| Comp Bsd Net Earns Rltd Orgs | 0 | CompBsdNetEarnsRltdOrgsInd |
| Any Non Fixed Payments | 0 | AnyNonFixedPaymentsInd |
| Initial Contract Exception | 0 | InitialContractExceptionInd |
Rltd Org Officer Trst Key Empl RltdOrgOfficerTrstKeyEmplGrp (6 entries)
| TitleTitleTxt | Base Compensation Filing OrgBaseCompensationFilingOrgAmt | Compensation Based On Rltd OrgsCompensationBasedOnRltdOrgsAmt | Bonus Filing OrganizationBonusFilingOrganizationAmount | Bonus Related OrganizationsBonusRelatedOrganizationsAmt | Other Compensation Filing OrgOtherCompensationFilingOrgAmt | Other Compensation Rltd OrgsOtherCompensationRltdOrgsAmt | Deferred Compensation Flng OrgDeferredCompensationFlngOrgAmt | Deferred Comp Rltd OrgsDeferredCompRltdOrgsAmt | Nontaxable Benefits Filing OrgNontaxableBenefitsFilingOrgAmt | Nontaxable Benefits Rltd OrgsNontaxableBenefitsRltdOrgsAmt | Total Compensation Filing OrgTotalCompensationFilingOrgAmt | Total Compensation Rltd OrgsTotalCompensationRltdOrgsAmt | Comp Report Prior990 Filing OrgCompReportPrior990FilingOrgAmt | Comp Report Prior990 Rltd OrgsCompReportPrior990RltdOrgsAmt |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Rachelle Kaspar-Cope MD | ||||||||||||||
| Family Practice/Obstetrics | $364,028 | $0 | $0 | $0 | $0 | $0 | $11,600 | $0 | $30,120 | $0 | $405,748 | $0 | $0 | $0 |
| Shiuvaun Jaeger MD | ||||||||||||||
| Family Practice/Obstetrics | $346,922 | $0 | $0 | $0 | $0 | $0 | $11,600 | $0 | $35,404 | $0 | $393,926 | $0 | $0 | $0 |
| Lennie Deaver MD | ||||||||||||||
| Family Practice/Obstetrics | $367,691 | $0 | $0 | $0 | $0 | $0 | $0 | $0 | $13,675 | $0 | $381,366 | $0 | $0 | $0 |
| Michael Powell MD | ||||||||||||||
| Family Practice | $264,424 | $0 | $0 | $0 | $0 | $0 | $7,996 | $0 | $37,531 | $0 | $309,951 | $0 | $0 | $0 |
| Holly Lashment CRNA | ||||||||||||||
| Anesthetist | $222,752 | $0 | $0 | $0 | $0 | $0 | $9,079 | $0 | $13,618 | $0 | $245,449 | $0 | $0 | $0 |
| Jessica Fisher | ||||||||||||||
| CEO | $182,328 | $0 | $0 | $0 | $0 | $0 | $7,431 | $0 | $10,514 | $0 | $200,273 | $0 | $0 | $0 |
Supplemental Information Detail SupplementalInformationDetail
| Field | Value | IRS element (for citing) |
|---|---|---|
| Form And Line Reference | Part I, Line 1a | FormAndLineReferenceDesc |
| Explanation | Spouses of board members attend one conference up to a maximum of $600. Providers & CEO choose to belong to either a health club or a golf club. Payments are made directly to the health club or golf club. This is reported as income on the providers and CEO's W-2. | ExplanationTxt |
Schedule L IRS990ScheduleL
Bus Tr Involve Interested Prsn BusTrInvolveInterestedPrsnGrp
Name Of Interested NameOfInterested
| Field | Value | IRS element (for citing) |
|---|---|---|
| Person | Maranda Lee | PersonNm |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Relationship Description | Family member of Diana Swindler, CFO | RelationshipDescriptionTxt |
| Transaction | $76,375 | TransactionAmt |
| Transaction | Compensation and benefits as employee | TransactionDesc |
| Sharing Of Revenues | 0 | SharingOfRevenuesInd |
Schedule M IRS990ScheduleM
Cars And Other Vehicles CarsAndOtherVehiclesGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Non Cash Checkbox | Yes (X) | NonCashCheckboxInd |
| Contribution | 1 | ContributionCnt |
| Noncash Contributions Rpt F990 | $41,480 | NoncashContributionsRptF990Amt |
| Method Of Determining Revenues | FMV | MethodOfDeterminingRevenuesTxt |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Form8283 Received | 0 | Form8283ReceivedCnt |
| Any Property That Must Be Held | 0 | AnyPropertyThatMustBeHeldInd |
| Review Process Unusual NC Gifts | 0 | ReviewProcessUnusualNCGiftsInd |
| Third Parties Used | 0 | ThirdPartiesUsedInd |
Supplemental Information Detail SupplementalInformationDetail
| Field | Value | IRS element (for citing) |
|---|---|---|
| Form And Line Reference | Part I, Column (b): | FormAndLineReferenceDesc |
| Explanation | The amount in column (b) is the number of contributions. | ExplanationTxt |
Schedule O IRS990ScheduleO
Supplemental Information Detail SupplementalInformationDetail (10 entries)
| Form And Line ReferenceFormAndLineReferenceDesc | ExplanationExplanationTxt |
|---|---|
| Form 990, Part VI, Section A, line 6 | Members pay an annual membership fee of $10. |
| Form 990, Part VI, Section A, line 7a | Members select the Board of Trustees at the annual meeting. All members have the same voting rights. |
| Form 990, Part VI, Section A, line 8b | There are no committees with the authority to act on behalf of the governing body. |
| Form 990, Part VI, Section B, line 11b | The CEO and CFO will review the Form 990. The 990 will then be electronically distributed to the Board Trustees prior to it being filed. |
| Form 990, Part VI, Section B, line 12c | At the November board meeting the newly elected Board of Trustees complete an annual disclosure. At the January board meeting all Board of Trustees, CEO, and CFO complete an annual disclosure. 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 15a | The Board of Trustees determines compensation and benefits for the CEO through an employment contract. Review and determination of compensation is done on an annual basis using the Nebraska Hospital Association Compensation Survey as comparability data. Documentation is provided in the CEO's personnel file. 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 staffs' years of experience as well as their position responsibilities to determine if the 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 completed on an annual basis and documentation is made in the CFO's personnel file. 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 | The governing documents, conflict of interest policy and financial statements are available upon request. The financial statements are also attached to the Form 990. |
| Form 990, Part IX, line 11g | Professional Fees: Program service expenses 3,056,793. Management and general expenses 0. Fundraising expenses 0. Total expenses 3,056,793. Purchased Services: Program service expenses 1,583,110. Management and general expenses 156,302. Fundraising expenses 0. Total expenses 1,739,412. Pharmacy Fees: Program service expenses 555,993. Management and general expenses 0. Fundraising expenses 0. Total expenses 555,993. Other Fees: Program service expenses 0. Management and general expenses 107,178. Fundraising expenses 0. Total expenses 107,178. |
| Form 990, Part XI, line 9: | Change in interest in net assets of Tri Valley Medical Foundation -102,772. |
| Form 990, Part XII, Line 2c: | The Board of Trustees assumes responsibility for oversight of the audit and selection of an independent accountant. |