2023-02-17T12:19:16-06:00 2022-04-30 450250958 Eide Bailly LLP 800 Nicollet Mall Ste 1300 Minneapolis MN 554027033 990 2021-05-01 476028103 Cambridge Memorial Hospital Inc CAMB 3086973329 1305 W Hwy 6 34 Cambridge NE 69022 Jessica Fisher CEO 3086973329 2023-02-10 1 Jessica Fisher 999009999 Kim Hunwardsen CPA P00484560 6122536500 2023-02-08 3 AAL1 IAL1 2021 2023-03-07 01:45:13Z Tri Valley Health System Jessica Fisher 1305 W Hwy 6 34 Cambridge NE 69022 26413662 0 X www.trivalleyhealth.com X 1955 NE Providing quality, compassionate, local healthcare services. 9 9 204 37 0 0 6247385 462390 22260328 25441731 311029 427765 16643 11770 28835385 26343656 0 0 0 0 11526797 11749284 0 0 0 11833448 13441941 23360245 25191225 5475140 1152431 31718093 30986077 17619653 16814339 14098440 14171738 X To improve the lives we touch by providing care of the highest quality throughout life's journey. 0 0 17360661 20456612 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. 3654913 4438162 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). 704696 546957 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. 21720270 1 1 0 0 0 0 0 0 0 0 1 0 0 1 1 1 1 0 0 0 0 0 0 0 0 0 1 1 0 0 1 0 0 0 0 0 0 1 0 1 0 0 0 0 0 0 0 0 1 74 0 1 204 1 0 0 0 0 0 0 0 0 0 0 0 0 X 9 9 0 0 0 0 1 1 0 1 0 0 0 1 1 1 1 1 1 1 0 0 X Diana Swindler 3086973329 1305 W Hwy 6 34 Cambridge NE 69022 LaVern Banzhaf President 3.00 X X 0 0 0 James Jones Vice President 3.00 X X 0 0 0 Joan Koch Secretary (thru Oct 2021) 3.00 X X 0 0 0 James McGowen Trustee thru Oct 2021)/Secretary (as of Nov) 3.00 X X 0 0 0 Drew Cramer Treasurer 3.00 X X 0 0 0 Ginger tenBensel Trustee 3.00 X 0 0 0 Dale Fohnholz Trustee 3.00 X 0 0 0 John Paulsen Trustee 3.00 X 0 0 0 Logan Baker Trustee 3.00 X 0 0 0 Nanette Witte Trustee (as of Nov 2021) 3.00 X 0 0 0 Jessica Fisher CEO 40.00 X 182328 0 17663 Diana Swindler CFO 40.00 X 111299 0 16318 Lennie Deaver MD Family Practice/Obstetrics 40.00 X 367691 0 11632 Shiuvaun Jaeger MD Family Practice/Obstetrics 40.00 X 346922 0 44955 Rachelle Kaspar-Cope MD Family Practice/Obstetrics 40.00 X 364028 0 40898 Holly Lashment CRNA Anesthetist 40.00 X 222752 0 20710 Michael Powell MD Family Practice 40.00 X 264424 0 44744 1859444 0 196920 14 0 1 0 Inspire Rehabilitation LLC 8181 Arista Place Ste 100 Broomfield CO 80021 Rehabilitation services 935863 Focusone Solutions PO Box 850861 Minneapolis MN 55485 Contract services 521739 Psychiatric Medical Care LLC PO Box 734606 Dallas TX 75373 Behavioral health services 428279 Rural Partners in Medicine LLC 8181 Arista Place Ste 100 Broomfield CO 80021 Specialty health services 281615 Med-Care Inc 152 Ponderosa Court Grand Island NE 68803 Pain management services 160650 8 392728 69662 41480 462390 Patient & Resident Revenue 622110 24082106 24082106 Pharmacy Revenue 900099 1095238 1095238 Cafeteria Revenue 900099 96794 96794 Wellness & Rehab 900099 42435 42435 125158 125158 25441731 425875 425875 19632 0 19632 19632 19632 10130 8240 1890 1890 1890 53904 61766 -7862 -7862 26343656 25441731 0 439535 X 383370 383370 76375 76375 8985672 7650867 1334805 319280 273059 46221 1361188 1133402 227786 623399 511783 111616 77908 77908 55250 55250 5459376 5195896 263480 160390 3263 157127 392079 287387 104692 519207 519207 99247 89148 10099 604552 507306 97246 1925687 1752364 173323 347502 347502 Medical Supplies 2813644 2813644 Repairs and Maintenance 534879 534879 Food Costs 149863 149863 302357 221827 80530 25191225 21720270 3470955 0 4403060 5239696 2893725 2733847 84981 60205 493232 517201 215939 305963 38674135 27582101 11976340 11092034 7329033 6715063 138347 130147 4183436 4191921 31718093 30986077 1957883 2242091 365844 356804 13595926 12885444 1700000 1330000 17619653 16814339 X 10433368 10611434 3665072 3560304 14098440 14171738 31718093 30986077 X 1152431 -976361 -102772 X X 0 1 X 1 1 1 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 113289 113289 22643132 15828343 6814789 12977335 9857728 3119607 2940379 1896030 1044349 11092034 Other receivables 378798 Interest in Tri Valley Medical Foundation 3557461 Insurance Escrow 255662 4191921 Estimated Third Party Payors 1330000 1330000 X 25367295 -976361 -976361 26343656 0 26343656 25191225 0 25191225 0 25191225 Part X, Line 2: 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. 1 1 X 1 X 1 X 1 1 0 0 20000 0 20000 0.00080 20000 20000 0.00080 5264018 3491559 1772459 0.07040 5264018 3491559 1772459 0.07040 5284018 3491559 1792459 0.07120 1 725134 63957 8842836 8760852 81984 X 1 1 1 1 Cambridge Memorial Hospital Inc 1305 W Hwy 6 34 Cambridge NE 69022 www.trivalleyhealth.com 310001 X X X X 3 provider based rural health clinics Cambridge Memorial Hospital Inc 1 0 0 1 X X X X X X X X X 21 1 0 1 1 X See Part V, Section C X 1 21 1 See Part V, Section C 0 1 X 100.000000000000 200.000000000000 X X X 1 1 X X X X 1 X https://www.trivalleyhealth.com/financial-assistance.html X https://www.trivalleyhealth.com/financial-assistance.html X https://www.trivalleyhealth.com/financial-assistance.html X X X X X X 1 X 0 X X X X 1 X 0 0 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 1 1 - Heritage Plaza 1205 Nelson Street Cambridge NE 69022 Independent living 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. X X 1 1 X X 0 0 0 0 0 0 0 0 0 Rachelle Kaspar-Cope MD Family Practice/Obstetrics 364028 0 0 0 0 0 11600 0 30120 0 405748 0 0 0 Shiuvaun Jaeger MD Family Practice/Obstetrics 346922 0 0 0 0 0 11600 0 35404 0 393926 0 0 0 Lennie Deaver MD Family Practice/Obstetrics 367691 0 0 0 0 0 0 0 13675 0 381366 0 0 0 Michael Powell MD Family Practice 264424 0 0 0 0 0 7996 0 37531 0 309951 0 0 0 Holly Lashment CRNA Anesthetist 222752 0 0 0 0 0 9079 0 13618 0 245449 0 0 0 Jessica Fisher CEO 182328 0 0 0 0 0 7431 0 10514 0 200273 0 0 0 Part I, Line 1a 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. Maranda Lee Family member of Diana Swindler, CFO 76375 Compensation and benefits as employee 0 X 1 41480 FMV 0 0 0 0 Part I, Column (b): The amount in column (b) is the number of contributions. 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.