2022-02-01T15:12:50-06:00 2021-04-30 450250958 Eide Bailly LLP 800 Nicollet Mall Ste 1300 Minneapolis MN 554027033 990 2020-05-01 476028103 Cambridge Memorial Hospital Inc CAMB 3086973329 1305 W Hwy 6 34 Cambridge NE 69022 Jessica Fisher CEO 3086973329 2022-01-31 1 Jessica Fisher 999009999 Kim Hunwardsen CPA P00484560 6122536500 2022-01-31 2 AAL1 IAL1 2020 2022-09-23 18:48:47Z Tri Valley Health System Jessica Fisher 1305 W Hwy 6 34 Cambridge NE 69022 28879240 0 X www.trivalleyhealth.com X 1955 NE Providing quality, compassionate, local healthcare services. 9 9 194 39 0 0 514422 6247385 20960496 22260328 81333 311029 845805 16643 22402056 28835385 0 0 0 0 10273171 11526797 0 0 0 12544219 11833448 22817390 23360245 -415334 5475140 26374690 31718093 18932225 17619653 7442465 14098440 X To improve the lives we touch by providing care of the highest quality throughout life's journey. 0 0 15352274 18241806 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 1,096 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 Schedule O)Throughout the year, 2,117 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 $113,000 for the year ended April 30, 2021 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. 3346838 3574431 Tri Valley Health System has rural health clinics in Arapahoe, Indianola, and Cambridge, Nebraska. During the year, the clinics had 10,726 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 Schedule 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). 662020 444091 Tri Valley Health System's senior services 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 12 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. 19361132 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 0 0 0 0 0 0 0 0 0 1 57 0 1 194 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 - Treasurer (May-Sep)/President (Oct-Apr) 3.00 X X 0 0 0 Paul Shellabarger President - until Oct 2020 3.00 X X 0 0 0 James Jones Vice President 3.00 X X 0 0 0 Joan Koch Secretary 3.00 X X 0 0 0 Drew Cramer - Trustee May- Sep)/Treasurer (Oct-Apr) 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 - started Aug 2020 3.00 X 0 0 0 James McGowen Trustee - started Aug 2020 3.00 X 0 0 0 Jessica Fisher CEO 40.00 X 172506 0 17288 Diana Swindler CFO 40.00 X 105257 0 13563 Keith Luedders COO - until July 2020 40.00 X 82916 0 3365 Shiuvaun Jaeger MD Family Practice/Obstetrics 40.00 X 314214 0 22580 Rachelle Kaspar-Cope MD Family Practice/Obstetrics 40.00 X 295820 0 36469 Lennie Deaver MD Family Practice/Obstetrics 40.00 X 286788 0 19606 Michael Powell MD Family Practice 40.00 X 296185 0 32895 Holly Lashment CRNA Anesthetist 40.00 X 206615 0 17134 1760301 0 162900 10 0 1 0 Inspire Rehabilitation LLC 8181 Arista Place Ste 100 Broomfield CO 80021 Rehab services 939367 Psychiatric Medical Care LLC PO Box 734606 Dallas TX 75230 Psychiatric services 426043 Avant Healthcare Professionals LLC PO Box 744554 Atlanta GA 303744554 Contract Staffing 340322 Heartland Pain Clinics LLC 603 N Diers Ave Ste 2 Grand Island NE 68803 Medical & Healthcare 314923 Rural Partners in Medicine LLC 8181 Arista Place Ste 100 Broomfield CO 80021 Medical & Healthcare 276408 6 5956966 290419 6247385 Patient & Resident revenue 622110 20586083 20586083 Pharmacy revenue 900099 1468846 1468846 Cafeteria 900099 88796 88796 Wellness & rehab 900099 37658 37658 78945 78945 22260328 291763 291763 16345 0 16345 16345 16345 24200 4934 19266 19266 19266 39219 38921 298 298 28835385 22260328 0 327672 X 386491 386491 74040 74040 8800358 7428164 1372194 312472 264960 47512 1351545 1113583 237962 601891 489271 112620 58250 58250 58185 58185 4726304 4409261 317043 122092 2909 119183 458764 316941 141823 536036 536036 79293 64124 15169 646407 453004 193403 2051141 1545331 505810 343130 343130 Medical supplies 1837117 1837117 Repairs and maintenance 520694 520694 Food costs 134224 134224 261811 171473 90338 23360245 19361132 3999113 0 3227798 4403060 2212337 2893725 119956 84981 432190 493232 191280 215939 38118960 26142620 12033808 11976340 4234197 7329033 138027 138347 3785097 4183436 26374690 31718093 2067663 1957883 101349 365844 14364522 13595926 2398691 0 1700000 18932225 17619653 X 4080201 10433368 3362264 3665072 7442465 14098440 26374690 31718093 X 5475140 664701 516134 X X 0 1 X 1 1 1 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 113289 113289 22671655 15183539 7488116 12681339 9197472 3483867 2652677 1761609 891068 11976340 Other receivables 320331 Interest in Tri Valley Medical Foundation 3660233 Insurance Escrow 202872 4183436 Estimated Third Party Payors 1700000 1700000 X 29500086 664701 664701 28835385 0 28835385 23360245 0 23360245 0 23360245 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 990T) with the IRS. 1 1 X 1 X 1 X 1 1 1 0 0 113000 113000 0.00480 1038432 959229 79203 0.00340 1151432 959229 192203 0.00820 4951026 2872905 2078121 0.08900 4951026 2872905 2078121 0.08900 6102458 3832134 2270324 0.09720 1 610919 67201 10050029 9949828 100201 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 18 1 0 0 1 X See Part V, Section C X 1 18 1 See Part V, Section C 0 1 X 100.000000000000 200.000000000000 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: Tri Valley Health System held a town hall meeting and invited members of the community which includes local hospital, public health community, mental health community, service providers, local residents, community leaders, school leaders, business leaders, local government, faith-based organizations and person with chronic conditions, uninsured community members, low income residents and minority groups. VVV Consultants, LLC was the principal consultant. Tri Valley Health System also completed an online survey which was widely published as well as individual letters sent to community members requesting the survey be completed. Cambridge Memorial Hospital, Inc. Part V, Section B, Line 11: 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. The areas being addressed and FY2021 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. (2) Healthcare Staffing Shortages. Tri Valley Health System addresses healthcare staffing shortages by utilizing a Workforce Connections Program that selects and supports non-traditional students in the pursuit of furthering their education to meet their staffing needs. (3) Aging Nursing Home Facilities. The Board of Trustees made a decision to close the Nursing Home.(4) Healthcare Insurance Options. Tri Valley Health System completes annual due diligence evaluations on health insurance providers as well as self-insurance options to provide affordable coverage options. (5) Build Community Awareness/Support. Tri Valley Health System builds community awareness and support by developing and implementing a marketing plan focused on increasing awareness of healthcare services offered. Tri Valley Health System partnered with Nex-Tech Marketing to provide assistance with a marketing plan and upgrade the website. TVHS increased their use of social media marketing, radio advertising, regular advertisement, and press releases. (6) Drugs (Opioids, Meth, Marijuana). Tri Valley Health System collaborates with schools, law enforcement, pharmacies, and neighboring agencies to prevent the unauthorized usage of prescription and illicit substances within our community. Tri Valley Health System providers prescribe and dispense substances in accordance with the Opioid Stewardship initiative to reduce the prevalence of drug abuse in our community. 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. Unreimbursed Medicaid on line 7b was calculated using the costing methods to prepare the cost reports. 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 11%. 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 ability to estimate the collectability of uninsured and other self-pay patients or residents is contingent on the patient's or resident's ability or willingness to pay for the services provided. Subsequent changes that are determined to be the result of an adverse change in the patient's or resident's ability to pay are recorded as bad debt expense. Bad debt expense for the years ended April 30, 2021 and 2020 was not significant. 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 $296,964.Medicare fee schedule revenue $ 201,837Medicare estimated costs of care relating to payments (498,801)Net (Shortage) $ (296,964) Part III, Line 9b: If the account is over 120 days old with no payments from 1st statement and there is no response to inquiries for information, failure to complete Medicaid application and/or financial assistance application, the accounts will be deemed as bad debt. 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 $48,838 in 2019. These income values are below the median and average for both the state of Nebraska and the United States. About 11% of the population were below the poverty level.Unemployment rate for the service area for 2020 was 2.7%.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 Shiuvaun Jaeger MD Family Practice/Obstetrics 314214 0 0 0 0 0 11290 0 12085 0 337589 0 0 0 Rachelle Kaspar-Cope MD Family Practice/Obstetrics 295820 0 0 0 0 0 11400 0 25873 0 333093 0 0 0 Michael Powell MD Family Practice 296185 0 0 0 0 0 7826 0 25858 0 329869 0 0 0 Lennie Deaver MD Family Practice/Obstetrics 286788 0 0 0 0 0 10488 0 9907 0 307183 0 0 0 Holly Lashment CRNA Anesthetist 206615 0 0 0 0 0 8016 0 9886 0 224517 0 0 0 Jessica Fisher CEO 172506 0 0 0 0 0 6970 0 11076 0 190552 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 74040 Employee Compensation 0 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 2,890,389. Management and general expenses 0. Fundraising expenses 0. Total expenses 2,890,389. Purchased services: Program service expenses 892,878. Management and general expenses 247,391. Fundraising expenses 0. Total expenses 1,140,269. Pharmacy Fees: Program service expenses 625,994. Management and general expenses 0. Fundraising expenses 0. Total expenses 625,994. Other Fees: Program service expenses 0. Management and general expenses 69,652. Fundraising expenses 0. Total expenses 69,652. Form 990, Part XI, line 9: Change in interest in net assets of Tri Valley Medical Foundation 516,134. Form 990, Part XII, Line 2c: The Board of Trustees assumes responsibility for oversight of the audit and selection of an independent accountant.