CAMBRIDGE MEMORIAL HOSPITAL INC: Form 990, tax year 2019
View the entire original 990 at ProPublica ↗
- Organization
- CAMBRIDGE MEMORIAL HOSPITAL INC (EIN 47-6028103)
- Tax period
- 2019-05-01 to 2020-04-30
- Filed
- 2021-03-11
- IRS object ID
- 202140709349301664
- Schema version
- 2019v5.2
- 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 | 2021-03-11T20:12:42-06:00 | ReturnTs |
| Tax Period End | 2020-04-30 | 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 | 2019-05-01 | 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 | 2021-03-10 | SignatureDt |
| Discuss With Paid Preparer | Yes (1) | DiscussWithPaidPreparerInd |
Preparer Person PreparerPersonGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Preparer Person | KIm Hunwardsen CPA | PreparerPersonNm |
| PTIN | P00484560 | PTIN |
| Phone | 6122536500 | PhoneNum |
| Preparation | 2021-03-10 | PreparationDt |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Tax | 2019 | TaxYr |
| Build TS | 2022-09-23 18:48:47Z | BuildTS |
Form 990 IRS990
| Field | Value | IRS element (for citing) |
|---|---|---|
| Address Change | Yes (X) | AddressChangeInd |
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 | $22,443,056 | 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 | 8 | VotingMembersGoverningBodyCnt |
| Voting Members Independent | 8 | VotingMembersIndependentCnt |
| Total Employee | 231 | TotalEmployeeCnt |
| Total Volunteers | 44 | TotalVolunteersCnt |
| Total Gross UBI | $0 | TotalGrossUBIAmt |
| Net Unrelated Bus Txbl Incm | $0 | NetUnrelatedBusTxblIncmAmt |
| PY Contributions Grants | $516,722 | PYContributionsGrantsAmt |
| CY Contributions Grants | $514,422 | CYContributionsGrantsAmt |
| PY Program Service Revenue | $22,225,060 | PYProgramServiceRevenueAmt |
| CY Program Service Revenue | $20,960,496 | CYProgramServiceRevenueAmt |
| PY Investment Income | $62,281 | PYInvestmentIncomeAmt |
| CY Investment Income | $81,333 | CYInvestmentIncomeAmt |
| PY Other Revenue | $535 | PYOtherRevenueAmt |
| CY Other Revenue | $845,805 | CYOtherRevenueAmt |
| PY Total Revenue | $22,804,598 | PYTotalRevenueAmt |
| CY Total Revenue | $22,402,056 | 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 | $10,465,136 | PYSalariesCompEmpBnftPaidAmt |
| CY Salaries Comp Emp Bnft Paid | $10,273,171 | CYSalariesCompEmpBnftPaidAmt |
| PY Total Prof Fndrsng Expns | $0 | PYTotalProfFndrsngExpnsAmt |
| CY Total Prof Fndrsng Expns | $0 | CYTotalProfFndrsngExpnsAmt |
| CY Total Fundraising Expense | $0 | CYTotalFundraisingExpenseAmt |
| PY Other Expenses | $13,471,177 | PYOtherExpensesAmt |
| CY Other Expenses | $12,544,219 | CYOtherExpensesAmt |
| PY Total Expenses | $23,936,313 | PYTotalExpensesAmt |
| CY Total Expenses | $22,817,390 | CYTotalExpensesAmt |
| PY Revenues Less Expenses | -$1,131,715 | PYRevenuesLessExpensesAmt |
| CY Revenues Less Expenses | -$415,334 | CYRevenuesLessExpensesAmt |
| Total Assets BOY | $25,416,084 | TotalAssetsBOYAmt |
| Total Assets EOY | $26,374,690 | TotalAssetsEOYAmt |
| Total Liabilities BOY | $17,305,315 | TotalLiabilitiesBOYAmt |
| Total Liabilities EOY | $18,932,225 | TotalLiabilitiesEOYAmt |
| Net Assets Or Fund Balances BOY | $8,110,769 | NetAssetsOrFundBalancesBOYAmt |
| Net Assets Or Fund Balances EOY | $7,442,465 | 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 | Yes (1) | SignificantChangeInd |
| Expense | $15,443,674 | ExpenseAmt |
| Revenue | $17,961,176 | 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 1,113 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, 2,804 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, 2020 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 | $2,551,525 | ExpenseAmt |
| Revenue | $3,386,012 | RevenueAmt |
| Desc | Tri Valley Health System has rural health clinics in Arapahoe, Indianola, and Cambridge, Nebraska. During the year, the clinics had 11,036 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). | Desc |
Prog Srvc Accom Acty3 ProgSrvcAccomActy3Grp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Expense | $805,518 | ExpenseAmt |
| Revenue | $458,308 | RevenueAmt |
| Desc | 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 13 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 | $18,800,717 | 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 | 0 | 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 | 76 | IRPDocumentCnt |
| IRP Document W2 G | 0 | IRPDocumentW2GCnt |
| Backup Wthld Compliance | Yes (1) | BackupWthldComplianceInd |
| Employee | 231 | 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 | 8 | GoverningBodyVotingMembersCnt |
| Independent Voting Member | 8 | 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 | Highest Compensated EmployeeHighestCompensatedEmployeeInd | Reportable Comp From OrgReportableCompFromOrgAmt | Reportable Comp From Rltd OrgReportableCompFromRltdOrgAmt | Other CompensationOtherCompensationAmt | OfficerOfficerInd | Individual Trustee Or DirectorIndividualTrusteeOrDirectorInd |
|---|---|---|---|---|---|---|---|
| Rachelle Kaspar-Cope MD | |||||||
| Family Practice/Obstetrics | 40.00 | Yes (X) | $286,350 | $0 | $28,229 | ||
| Lennie Deaver MD | |||||||
| Family Practice/Obstetrics | 40.00 | Yes (X) | $279,860 | $0 | $10,732 | ||
| Shiuvaun Jaeger MD | |||||||
| Family Practice/Obstetrics | 40.00 | Yes (X) | $273,010 | $0 | $28,505 | ||
| Josh Hill CRNA | |||||||
| Anesthetist | 40.00 | Yes (X) | $187,472 | $0 | $31,346 | ||
| Sarah Norton PA-C | |||||||
| Family Practice | 40.00 | Yes (X) | $144,463 | $0 | $28 | ||
| Keith Luedders | |||||||
| COO | 40.00 | $131,592 | $0 | $5,341 | Yes (X) | ||
| Jessica Fisher | |||||||
| CEO | 40.00 | $108,180 | $0 | $10,108 | Yes (X) | ||
| Diana Swindler | |||||||
| CFO | 40.00 | $98,332 | $0 | $14,057 | Yes (X) | ||
| Paul Shellabarger | |||||||
| President | 3.00 | $0 | $0 | $0 | Yes (X) | Yes (X) | |
| James Jones | |||||||
| Vice President | 3.00 | $0 | $0 | $0 | Yes (X) | Yes (X) | |
| Joan Koch | |||||||
| Secretary | 3.00 | $0 | $0 | $0 | Yes (X) | Yes (X) | |
| LaVern Banzhaf | |||||||
| Treasurer | 3.00 | $0 | $0 | $0 | Yes (X) | Yes (X) | |
| John Kutnink | |||||||
| Trustee until 4/22/20 | 3.00 | $0 | $0 | $0 | Yes (X) | ||
| Dale Fohnholz | |||||||
| Trustee as of February 2020 | 3.00 | $0 | $0 | $0 | Yes (X) | ||
| Drew Cramer | |||||||
| Trustee as of March 2020 | 3.00 | $0 | $0 | $0 | Yes (X) | ||
| Ginger tenBensel | |||||||
| Trustee as of March 2020 | 3.00 | $0 | $0 | $0 | Yes (X) | ||
| John Paulsen | |||||||
| Trustee | 3.00 | $0 | $0 | $0 | Yes (X) | ||
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Reportable Comp From Org | $1,509,259 | TotalReportableCompFromOrgAmt |
| Tot Reportable Comp Rltd Org | $0 | TotReportableCompRltdOrgAmt |
| Total Other Compensation | $128,346 | TotalOtherCompensationAmt |
| Indiv Rcvd Greater Than100 K | 10 | 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 | Rehab services | $848,698 |
| Psychiatric Medical Care LLC | |||||
| PO Box 734606 | Dallas | TX | 75230 | Psychiatric services | $456,592 |
| FocusOne Solutions | |||||
| 13609 California Street | Omaha | NE | 68103 | Medical & Healthcare | $324,713 |
| Avant Healthcare Professionals LLC | |||||
| PO Box 744554 | Atlanta | GA | 303744554 | Contract Staffing | $286,994 |
| Rural Partners in Medicine LLC | |||||
| 11880 Airport Way | Broomfield | CO | 80021 | Medical & Healthcare | $279,476 |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Cntrct Rcvd Greater Than100 K | 7 | CntrctRcvdGreaterThan100KCnt |
| Government Grants | $78,489 | GovernmentGrantsAmt |
| All Other Contributions | $435,933 | AllOtherContributionsAmt |
| Noncash Contributions | $68,319 | NoncashContributionsAmt |
| Total Contributions | $514,422 | TotalContributionsAmt |
Program Service Revenue ProgramServiceRevenueGrp (4 entries)
| DescDesc | BusinessBusinessCd | Total Revenue ColumnTotalRevenueColumnAmt | Related Or Exempt Func IncomeRelatedOrExemptFuncIncomeAmt |
|---|---|---|---|
| Patient & Resident revenue | 622110 | $19,156,934 | $19,156,934 |
| Pharmacy revenue | 900099 | $1,557,958 | $1,557,958 |
| Cafeteria | 900099 | $104,967 | $104,967 |
| Wellness & rehab | 900099 | $39,462 | $39,462 |
Total Oth Program Service Rev TotalOthProgramServiceRevGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Revenue Column | $101,175 | TotalRevenueColumnAmt |
| Related Or Exempt Func Income | $101,175 | RelatedOrExemptFuncIncomeAmt |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Program Service Revenue | $20,960,496 | TotalProgramServiceRevenueAmt |
Investment Income InvestmentIncomeGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Revenue Column | $72,267 | TotalRevenueColumnAmt |
| Exclusion | $72,267 | ExclusionAmt |
Gross Rents GrossRentsGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Real | $15,434 | 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 | $15,434 | RealAmt |
Net Rental Income Or Loss NetRentalIncomeOrLossGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Revenue Column | $15,434 | TotalRevenueColumnAmt |
| Exclusion | $15,434 | ExclusionAmt |
Gross Amount Sales Assets GrossAmountSalesAssetsGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Other | $9,066 | OtherAmt |
Less Cost Oth Basis Sales Expnss LessCostOthBasisSalesExpnssGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Other | $0 | OtherAmt |
Gain Or Loss GainOrLossGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Other | $9,066 | OtherAmt |
Net Gain Or Loss Investments NetGainOrLossInvestmentsGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Revenue Column | $9,066 | TotalRevenueColumnAmt |
| Exclusion | $9,066 | ExclusionAmt |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Gross Sales Of Inventory | $26,371 | GrossSalesOfInventoryAmt |
| Cost Of Goods Sold | $41,000 | CostOfGoodsSoldAmt |
Net Income Or Loss NetIncomeOrLossGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Revenue Column | -$14,629 | TotalRevenueColumnAmt |
| Exclusion | -$14,629 | ExclusionAmt |
Other Revenue Misc OtherRevenueMiscGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Desc | Settlement proceeds | Desc |
| Business | 900099 | BusinessCd |
| Total Revenue Column | $845,000 | TotalRevenueColumnAmt |
| Related Or Exempt Func Income | $845,000 | RelatedOrExemptFuncIncomeAmt |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Other Revenue Total | $845,000 | OtherRevenueTotalAmt |
Total Revenue TotalRevenueGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Revenue Column | $22,402,056 | TotalRevenueColumnAmt |
| Related Or Exempt Func Income | $21,805,496 | RelatedOrExemptFuncIncomeAmt |
| Unrelated Business Revenue | $0 | UnrelatedBusinessRevenueAmt |
| Exclusion | $82,138 | 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 | $425,237 | TotalAmt |
| Management And General | $425,237 | ManagementAndGeneralAmt |
Comp Disqual Persons CompDisqualPersonsGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $52,655 | TotalAmt |
| Program Services | $52,655 | ProgramServicesAmt |
Other Salaries And Wages OtherSalariesAndWagesGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $7,940,716 | TotalAmt |
| Program Services | $6,628,290 | ProgramServicesAmt |
| Management And General | $1,312,426 | ManagementAndGeneralAmt |
Pension Plan Contributions PensionPlanContributionsGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $282,394 | TotalAmt |
| Program Services | $225,237 | ProgramServicesAmt |
| Management And General | $57,157 | ManagementAndGeneralAmt |
Other Employee Benefits OtherEmployeeBenefitsGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $1,001,956 | TotalAmt |
| Program Services | $770,907 | ProgramServicesAmt |
| Management And General | $231,049 | ManagementAndGeneralAmt |
Payroll Taxes PayrollTaxesGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $570,213 | TotalAmt |
| Program Services | $431,774 | ProgramServicesAmt |
| Management And General | $138,439 | ManagementAndGeneralAmt |
Fees For Services Legal FeesForServicesLegalGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $143,465 | TotalAmt |
| Management And General | $143,465 | ManagementAndGeneralAmt |
Fees For Services Accounting FeesForServicesAccountingGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $59,725 | TotalAmt |
| Management And General | $59,725 | ManagementAndGeneralAmt |
Fees For Services Other FeesForServicesOtherGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $5,287,282 | TotalAmt |
| Program Services | $4,828,822 | ProgramServicesAmt |
| Management And General | $458,460 | ManagementAndGeneralAmt |
Advertising AdvertisingGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $149,419 | TotalAmt |
| Program Services | $2,487 | ProgramServicesAmt |
| Management And General | $146,932 | ManagementAndGeneralAmt |
Office Expenses OfficeExpensesGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $418,239 | TotalAmt |
| Program Services | $290,313 | ProgramServicesAmt |
| Management And General | $127,926 | ManagementAndGeneralAmt |
Occupancy OccupancyGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $514,981 | TotalAmt |
| Program Services | $514,981 | ProgramServicesAmt |
Travel TravelGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $102,548 | TotalAmt |
| Program Services | $71,605 | ProgramServicesAmt |
| Management And General | $30,943 | ManagementAndGeneralAmt |
Interest InterestGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $683,110 | TotalAmt |
| Program Services | $577,842 | ProgramServicesAmt |
| Management And General | $105,268 | ManagementAndGeneralAmt |
Depreciation Depletion DepreciationDepletionGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $2,224,317 | TotalAmt |
| Program Services | $1,881,548 | ProgramServicesAmt |
| Management And General | $342,769 | ManagementAndGeneralAmt |
Insurance InsuranceGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $348,635 | TotalAmt |
| Management And General | $348,635 | ManagementAndGeneralAmt |
Other Expenses OtherExpensesGrp (3 entries)
| DescDesc | TotalTotalAmt | Program ServicesProgramServicesAmt |
|---|---|---|
| Medical supplies | $1,652,664 | $1,652,664 |
| Repairs and maintenance | $530,396 | $530,396 |
| Food costs | $154,330 | $154,330 |
All Other Expenses AllOtherExpensesGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $275,108 | TotalAmt |
| Program Services | $186,866 | ProgramServicesAmt |
| Management And General | $88,242 | ManagementAndGeneralAmt |
Total Functional Expenses TotalFunctionalExpensesGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $22,817,390 | TotalAmt |
| Program Services | $18,800,717 | ProgramServicesAmt |
| Management And General | $4,016,673 | ManagementAndGeneralAmt |
| Fundraising | $0 | FundraisingAmt |
Savings And Temp Cash Invst SavingsAndTempCashInvstGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $1,039,685 | BOYAmt |
| EOY | $3,227,798 | EOYAmt |
Accounts Receivable AccountsReceivableGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $2,911,366 | BOYAmt |
| EOY | $2,212,337 | EOYAmt |
Oth Notes Loans Receivable Net OthNotesLoansReceivableNetGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $55,500 | BOYAmt |
| EOY | $119,956 | EOYAmt |
Inventories For Sale Or Use InventoriesForSaleOrUseGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $374,601 | BOYAmt |
| EOY | $432,190 | EOYAmt |
Prepaid Expenses Defrd Charges PrepaidExpensesDefrdChargesGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $279,679 | BOYAmt |
| EOY | $191,280 | EOYAmt |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Land Bldg Equip Cost Or Other Bss | $36,866,526 | LandBldgEquipCostOrOtherBssAmt |
| Land Bldg Equip Accum Deprec | $24,832,718 | LandBldgEquipAccumDeprecAmt |
Land Bldg Equip Basis Net LandBldgEquipBasisNetGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $13,463,750 | BOYAmt |
| EOY | $12,033,808 | EOYAmt |
Investments Pub Traded Sec InvestmentsPubTradedSecGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $3,253,404 | BOYAmt |
| EOY | $4,234,197 | EOYAmt |
Investments Program Related InvestmentsProgramRelatedGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $153,573 | BOYAmt |
| EOY | $138,027 | EOYAmt |
Other Assets Total OtherAssetsTotalGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $3,884,526 | BOYAmt |
| EOY | $3,785,097 | EOYAmt |
Total Assets TotalAssetsGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $25,416,084 | BOYAmt |
| EOY | $26,374,690 | EOYAmt |
Accounts Payable Accr Expnss AccountsPayableAccrExpnssGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $2,163,241 | BOYAmt |
| EOY | $2,067,663 | EOYAmt |
Deferred Revenue DeferredRevenueGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $46,289 | BOYAmt |
| EOY | $101,349 | EOYAmt |
Mortg Notes Pybl Scrd Invst Prop MortgNotesPyblScrdInvstPropGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $15,095,785 | BOYAmt |
| EOY | $14,364,522 | EOYAmt |
Unsecured Notes Loans Payable UnsecuredNotesLoansPayableGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $0 | BOYAmt |
| EOY | $2,398,691 | EOYAmt |
Total Liabilities TotalLiabilitiesGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $17,305,315 | BOYAmt |
| EOY | $18,932,225 | 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 | $4,729,729 | BOYAmt |
| EOY | $4,080,201 | EOYAmt |
Donor Restriction Net Assets DonorRestrictionNetAssetsGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $3,381,040 | BOYAmt |
| EOY | $3,362,264 | EOYAmt |
Total Net Assets Fund Balance TotalNetAssetsFundBalanceGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $8,110,769 | BOYAmt |
| EOY | $7,442,465 | EOYAmt |
Tot Liab Net Assets Fund Balance TotLiabNetAssetsFundBalanceGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $25,416,084 | BOYAmt |
| EOY | $26,374,690 | EOYAmt |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Info In Schedule O Part XI | Yes (X) | InfoInScheduleOPartXIInd |
| Reconcilation Revenue Expnss | -$415,334 | ReconcilationRevenueExpnssAmt |
| Net Unrlzd Gains Losses Invst | -$18,837 | NetUnrlzdGainsLossesInvstAmt |
| Other Changes In Net Assets | -$234,133 | 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 | 0 | FederalGrantAuditRequiredInd |
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 | $22,280,571 | OtherCostOrOtherBasisAmt |
| Depreciation | $14,212,910 | DepreciationAmt |
| Book Value | $8,067,661 | BookValueAmt |
Equipment EquipmentGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Other Cost Or Other Basis | $11,868,866 | OtherCostOrOtherBasisAmt |
| Depreciation | $9,011,254 | DepreciationAmt |
| Book Value | $2,857,612 | BookValueAmt |
Other Land Buildings OtherLandBuildingsGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Other Cost Or Other Basis | $2,603,800 | OtherCostOrOtherBasisAmt |
| Depreciation | $1,608,554 | DepreciationAmt |
| Book Value | $995,246 | BookValueAmt |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Book Value Land Buildings | $12,033,808 | TotalBookValueLandBuildingsAmt |
Other Assets Org OtherAssetsOrgGrp (4 entries)
| DescDesc | Book ValueBookValueAmt |
|---|---|
| Other receivables | $363,318 |
| Estimated third-party payor settlements | $75,000 |
| Interest in Tri Valley Medical Foundation | $3,144,099 |
| Insurance Escrow | $202,680 |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Book Value Other Assets | $3,785,097 | TotalBookValueOtherAssetsAmt |
| Footnote Text | Yes (X) | FootnoteTextInd |
| Total Rev Etc Audited Fincl Stmt | $22,383,219 | TotalRevEtcAuditedFinclStmtAmt |
| Net Unrealized Gains Invst | -$18,837 | NetUnrealizedGainsInvstAmt |
| Revenue Not Reported | -$18,837 | RevenueNotReportedAmt |
| Revenue Subtotal | $22,402,056 | RevenueSubtotalAmt |
| Revenue Not Reported Fincl Stmt | $0 | RevenueNotReportedFinclStmtAmt |
| Total Revenue Per Form990 | $22,402,056 | TotalRevenuePerForm990Amt |
| Tot Expns Etc Audited Fincl Stmt | $22,817,390 | TotExpnsEtcAuditedFinclStmtAmt |
| Expenses Not Reported | $0 | ExpensesNotReportedAmt |
| Expenses Subtotal | $22,817,390 | ExpensesSubtotalAmt |
| Expenses Not Rpt Fincl Stmt | $0 | ExpensesNotRptFinclStmtAmt |
| Total Expenses Per Form990 | $22,817,390 | 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 990T) 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 | 0 | 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 | $113,000 | TotalCommunityBenefitExpnsAmt |
| Net Community Benefit Expns | $113,000 | NetCommunityBenefitExpnsAmt |
| Total Expense | 0.00500 | TotalExpensePct |
Unreimbursed Medicaid UnreimbursedMedicaidGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Community Benefit Expns | $1,158,169 | TotalCommunityBenefitExpnsAmt |
| Direct Offsetting Revenue | $1,075,073 | DirectOffsettingRevenueAmt |
| Net Community Benefit Expns | $83,096 | NetCommunityBenefitExpnsAmt |
| Total Expense | 0.00360 | TotalExpensePct |
Total Financial Assistance Typ TotalFinancialAssistanceTyp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Community Benefit Expns | $1,271,169 | TotalCommunityBenefitExpnsAmt |
| Direct Offsetting Revenue | $1,075,073 | DirectOffsettingRevenueAmt |
| Net Community Benefit Expns | $196,096 | NetCommunityBenefitExpnsAmt |
| Total Expense | 0.00860 | TotalExpensePct |
Subsidized Health Services SubsidizedHealthServicesGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Community Benefit Expns | $6,059,470 | TotalCommunityBenefitExpnsAmt |
| Direct Offsetting Revenue | $3,680,342 | DirectOffsettingRevenueAmt |
| Net Community Benefit Expns | $2,379,128 | NetCommunityBenefitExpnsAmt |
| Total Expense | 0.10430 | TotalExpensePct |
Total Other Benefits TotalOtherBenefitsGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Community Benefit Expns | $6,059,470 | TotalCommunityBenefitExpnsAmt |
| Direct Offsetting Revenue | $3,680,342 | DirectOffsettingRevenueAmt |
| Net Community Benefit Expns | $2,379,128 | NetCommunityBenefitExpnsAmt |
| Total Expense | 0.10430 | TotalExpensePct |
Total Community Benefits TotalCommunityBenefitsGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Community Benefit Expns | $7,330,639 | TotalCommunityBenefitExpnsAmt |
| Direct Offsetting Revenue | $4,755,415 | DirectOffsettingRevenueAmt |
| Net Community Benefit Expns | $2,575,224 | NetCommunityBenefitExpnsAmt |
| Total Expense | 0.11290 | TotalExpensePct |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Bad Debt Expense Reported | Yes (1) | BadDebtExpenseReportedInd |
| Bad Debt Expense | $1,024,935 | BadDebtExpenseAmt |
| Bad Debt Expense Attributable | $111,718 | BadDebtExpenseAttributableAmt |
| Reimbursed By Medicare | $9,524,217 | ReimbursedByMedicareAmt |
| Cost Of Care Reimbursed By Medcr | $9,596,031 | CostOfCareReimbursedByMedcrAmt |
| Medicare Surplus Or Shortfall | -$71,814 | 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 | 18 | CHNAConductedYr |
| Take Into Account Others Input | Yes (1) | TakeIntoAccountOthersInputInd |
| CHNA Conducted With Other Fclts | 0 | CHNAConductedWithOtherFcltsInd |
| CHNA Conducted With Non Fclts | 0 | 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 | 18 | 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 |
| 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 (4 entries)
| Form And Line ReferenceFormAndLineReferenceDesc | ExplanationExplanationTxt |
|---|---|
| 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 include:(1) Recruitment/Add Visiting Specialists. Work/contract with area specialists to provide specialty services in TVHS Specialty Clinic. Current relationship with Platte Valley Medical Group in Kearney, NE, Rural Partners in Medicine in Steamboat, CO and other various medical groups in the state who can provide specialized services. TVHS will network with other neighboring Specialty Clinics to share services (if able). TVHS recruited the following specialists/providers in FY2020: APRN Wound Care; APRN Family Practice; MD Family Practice; and CRNA.(2) Healthcare Staffing Shortages. Through Workforce Connections Program, TVHS will continue to work on selecting and supporting non-traditional students in the pursuit of furthering their education to meet our staffing needs. During FY2020, TVHS supported four (4) Workforce Connection students. (3) Aging Nursing Home Facilities. The Board of Trustees made a decision to close the Nursing Home.(4) Healthcare Insurance Options. TVHS will perform annual due diligence to evaluate health insurance providers as well as self-insurance options to provide affordable coverage options to employees. During FY2020, TVHS added a 3rd insurance option for employees. Also, TVHS switched retirement plan administrators to increase employee satisfaction.(5) Build Community Awareness/Support. TVHS will develop and implement a marketing plan focused on increasing awareness of healthcare services offered. TVHS will partner with Nex-Tech Marketing to provide assistance with a marketing plan and an upgraded and regularly updated website. TVHS will also use social media for marketing purposes. Although TVHS ended the contract with Nex-Tech during FY20, TVHS implemented "The Beat" which is a CEO weekly/bi-weekly Facebook video post to share updates. A quarterly newsletter by using direct mail services called "The Pulse" was implemented. "The Pulse" is now sent out quarterly. (6) Drugs (Opioids, Meth, Marjuana). TVHS will collaborate with schools, law enforcement, pharmacies, and neighboring agencies to prevent the unauthorized usage of prescription and illicit substances within our communities. Furthermore, TVHS will work with TVHS providers to prescribe and dispense substances in accordance with the Opioid Stewardship initiative to reduce the prevalence of drug abuse in our community. During FY2020, e-Prescribe went live and is currently used by TVHS providers. |
| 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. 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 assinged to a collection agency in the current year.In Furnas County, Nebraska, the percentage of residents that are at or below poverty level is 10.9%. 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, 2020 and 2019 was not significant. |
| Part III, Line 8: | Even though Tri Valley Health System has a Medicare shortfall patients with Medicare coverage are accepted regardless of whether or not a surplus or deficit is realized from providing the services. The Hospital provides services to these patients because access to healthcare is important to the Hospital. This is a key advantage to the community and therefore the shortfall is considered a community benefit.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. |
| Part III, Line 9b: | If an individual submits an incomplete application during the Application Period, the Hospital will:1. Suspend any extraordinary collection actions, 2. Provide written notice that contains a summary of the Policy and that describes the additional information or documentation required under the Policy or in the application to complete the application; and3. Provide at least one written notice that informs the individual about the extraordinary collection actions the Hospital may take or reinstate if the individual does not complete an application or pay the amount due by a date that is not earlier than the last day of the Application Period and thirty (30) days of the date of the notice.If an individual submits a completed application during the Application Period, the Hospital will:1. Suspend any extraordinary collection actions;2. Determine and document whether the individual is an individual who qualifies for financial assistance under the Policy;3. Notify the individual in writing of the determination and the basis for the determination; and4. If the individual is an individual who qualifies for assistance under the Policy, provide the individual with a billing statement that indicates the amount the individual owes as adjusted under the Policy and how the Hospital determined the amount the individual owes. The Hospital will also refund any excess payments made by the individual and take reasonable measures to reverse any extraordinary collection action taken against the individual.The Application Period begins on the date the care is provided to the individual and ends on the 240th day after the Hospital provides the individual with the first bill for care provided.Extraordinary collection actions do not include deferring or denying care based on a pattern of nonpayment, requiring deposits before providing care or charging interest, to the extent that such practices are not prohibited with respect to the Hospital's obligation to provide emergency medical care (MSE and any necessary stabilizing treatment as required by EMTALA). |
| 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.In March, 2019, round three of the Community Health Needs Assessment (CHNA) was conducted by Tri Valley Health System for the approximately 21,000 residents in their designated service area. To ensure input from persons with broad knowledge of the community, a Community Advisory Committee was organized with specific individuals from the community served. Personal invitations were sent to individuals representing various community, business, and educational groups throughout the four-county area along with representatives from Tri Valley Health System.The community health needs assessment and implementation strategy are posted to the Hospital's website at www.trivalleyhealth.com. |
| 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 $48,977 in 2018. These income values are below the median and average for both the state of Nebraska and the United States. About 10.9% of the population were below the poverty level.Unemployment rates for the service area for 2019 range from 2.6% (Gosper), 2.7% (Frontier), 2.6% (Red Willow) to 2.7% (Furnas). These rates compare favorably to the state of Nebraska and the United States.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. In 2011, Tri Valley Health System opened 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. In 2016, the Health System started 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 (4 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 | $286,350 | $0 | $0 | $0 | $0 | $0 | $0 | $0 | $28,808 | $0 | $315,158 | $0 | $0 | $0 |
| Lennie Deaver MD | ||||||||||||||
| Family Practice/Obstetrics | $279,860 | $0 | $0 | $0 | $0 | $0 | $0 | $0 | $12,198 | $0 | $292,058 | $0 | $0 | $0 |
| Shiuvaun Jaeger MD | ||||||||||||||
| Family Practice/Obstetrics | $273,010 | $0 | $0 | $0 | $0 | $0 | $0 | $0 | $28,856 | $0 | $301,866 | $0 | $0 | $0 |
| Josh Hill CRNA | ||||||||||||||
| Anesthetist | $187,472 | $0 | $0 | $0 | $0 | $0 | $0 | $0 | $31,591 | $0 | $219,063 | $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 | $52,655 | TransactionAmt |
| Transaction | Employee Compensation | 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 | 2 | ContributionCnt |
| Noncash Contributions Rpt F990 | $68,319 | NoncashContributionsRptF990Amt |
| Method Of Determining Revenues | Cost | 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 | Part I, column (b) is the number of items received. | ExplanationTxt |
Schedule O IRS990ScheduleO
Supplemental Information Detail SupplementalInformationDetail (11 entries)
| Form And Line ReferenceFormAndLineReferenceDesc | ExplanationExplanationTxt |
|---|---|
| Form 990, Part III, line 3 | The Cambridge Manor long-term care facility closed May 1, 2019. |
| 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 2,782,063. Management and general expenses 0. Fundraising expenses 0. Total expenses 2,782,063. Purchased services: Program service expenses 1,417,354. Management and general expenses 350,889. Fundraising expenses 0. Total expenses 1,768,243. Pharmacy Fees: Program service expenses 629,405. Management and general expenses 0. Fundraising expenses 0. Total expenses 629,405. Other Fees: Program service expenses 0. Management and general expenses 107,571. Fundraising expenses 0. Total expenses 107,571. |
| Form 990, Part XI, line 9: | Change in interest in net assets of Tri Valley Medical Foundation -234,133. |
| Form 990, Part XII, Line 2c: | The Board of Trustees assumes responsibility for oversight of the audit and selection of an independent accountant. |