2018-03-13T10:00:09-05:00 2017-04-30 450250958 EIDE BAILLY LLP 1545 ASSOCIATES DR STE 101 DUBUQUE IA 52002 990 2016-05-01 476028103 Cambridge Memorial Hospital Inc CAMB 3086971522 PO Box 488 Cambridge NE 69022 Deborah Herzberg CEO 3086971522 2018-03-12 1 Carmen Krantz P00031958 5635561790 2018-03-08 74.84.124.22 2018-03-12 11:55:01 CD P 330E77A2EC15986A2DC713C7FDB26B906589BB96 330E77A2EC15986A2DC713C7FDB26B906589BB96 2016 2021-01-29 14:40:06Z Tri Valley Health System Deborah Herzberg PO Box 488 Cambridge NE 69022 20372071 0 X www.trivalleyhealth.com X 1955 NE Providing quality, compassionate, local healthcare services. 9 9 259 57 0 0 691245 448968 20559419 19833359 20752 62758 13707 3900 21285123 20348985 0 0 0 0 10204555 10457906 0 0 0 11520678 11201120 21725233 21659026 -440110 -1310041 30820949 28851468 19709609 18746383 11111340 10105085 X To improve the lives we touch by providing care of the highest quality throughout life's journey. 0 0 13568109 13999031 Tri Valley Health System operates a 20-bed critical access hospital and a 34-bed nursing facility located in Cambridge, Nebraska, which provides short-term inpatient and outpatient care as well as long-term intermediate care. The Cambridge Memorial Hospital operates a full-time emergency room and provides emergency care regardless of the ability to pay. The emergency room had 1,172 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. Continued on Schedule O.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 Directors 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. These records include the amount of charges foregone for services and supplies furnished under its Charity Care Policy and equivalent service statistics. The amount of charges foregone for services provided under the Health System's charity care policy was approximately $51,000 for the year ended April 30, 2017. Total direct and indirect costs related to these foregone charges were approximately $39,000 at April 30, 2017, based on an average ratio of cost to gross charges.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. 2841077 3693604 Tri Valley has rural health clinics in Arapahoe, Indianola, and Cambridge, Nebraska. During the year, the clinics had 12,680 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 our Healthy in the Heartland programs. Yearly the clinic provides "flu clinics" in which flu vaccinations are provided at reduced rates. Also, the clinics annually offer a "health fair" to the communities they serve. Health fair lab testing completed which normally would cost the patient $800 is reduced to a fee of approximately $30 (depending on tests requested). 2096242 2140724 Tri Valley Health System's senior services programs include a Long Term Care Facility, an Assisted Living Facility and an Independent Living Facility. During the fiscal year, Tri Valley averaged over 23 residents a day in the Long Term Care and 14 residents a day in the Assisted Living Facility. By providing a continuum of care from independent, to assisted, to long term care, Tri Valley is encouraging community members to stay as independent as possible and assuring the patients/residents are in the appropriate location based on their level of care needs. Tri Valley continues to offer a "Frog" Program which is a free exercise program for the older generation that meets three times a week. The program is currently offered in Cambridge. 18505428 1 1 0 0 0 0 0 0 0 0 1 1 0 0 0 1 1 0 0 0 0 0 0 0 0 0 1 1 0 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 52 0 1 259 1 0 0 0 0 0 0 0 0 0 0 X 9 9 1 1 0 0 1 1 0 1 0 0 0 1 1 1 1 1 1 1 0 0 X Diana Rippe 3086973329 PO Box 488 Cambridge NE 69022 Randy Heitmann President 3.00 X X 0 0 0 Patrick Horwart Vice President 3.00 X X 0 0 0 Kristy Witte Secretary 3.00 X X 0 0 0 Troy Westadt Treasurer 3.00 X X 0 0 0 Eric Eisenhart Director 3.00 X 0 0 0 Clark Andrews Director 3.00 X 0 0 0 Reginald Warner Director 3.00 X 0 0 0 Bill Minnick Director 3.00 X 0 0 0 Cathy Kubik Director 3.00 X 0 0 0 Deb Herzberg CEO 40.00 X 98503 0 4344 Diana Swindler CFO 40.00 X 99955 0 5862 Constance Hill CRNA Anesthetist 40.00 X 184094 0 8056 Josh Hill CRNA Anesthetist 40.00 X 180204 0 4364 Shiuvaun Jaeger MD Family Practice/Obstetrics 40.00 X 316747 0 11368 Lennie Deaver MD Family Practice/Obstetrics 40.00 X 285538 0 12701 Rachelle Kaspar-Cope MD Family Practice/Obstetrics 40.00 X 275937 0 13192 1440978 0 59887 11 0 1 0 Inspire Rehabilitation LLC 2810 W 35th Street Kearney NE 68845 Rehap services 804208 MedHost of Tennessee Inc 2739 Momentum Place Chicago IL 606895327 Software and support 244505 Medical Staffing Network Inc PO Box 840292 Dallas TX 752840292 Staffing agency 171895 HealthTechS3 5110 Maryland Way Brentwood TN 37027 Management services 163665 4 9020 439948 448968 Patient & Resident revenue 622110 18559587 18559587 Pharmacy revenue 900099 881696 881696 EHR incentive payment 900099 179087 179087 Cafeteria 900099 73260 73260 Wellness & rehab 900099 37521 37521 102208 102208 19833359 62758 62758 26986 23086 3900 3900 20348985 19833359 0 66658 X 280153 280153 8723571 7703998 1019573 253250 225390 27860 515611 446502 69109 685321 587045 98276 99682 99682 30100 30100 48560 48560 2795892 2302195 493697 190082 190082 752955 415689 337266 545537 531563 13974 46629 37683 8946 555144 547547 7597 761035 761035 2259087 2259087 317954 1326 316628 Medical supplies 1624800 1624800 Repairs and maintenance 480235 455232 25003 Bad debt expense 381465 381465 Food costs 224871 224871 87092 87092 21659026 18505428 3153598 0 885 2744193 2035984 2361791 2378564 15000 42500 325069 376468 266694 417667 34366092 18510947 17717986 15855145 2290209 3929189 3008753 3280020 185412 145685 1904957 390246 30820949 28851468 1756944 1918221 602343 198485 17350322 16629677 19709609 18746383 X 8024888 6824273 2192109 2386469 894343 894343 11111340 10105085 30820949 28851468 X -1310041 109426 194360 X X 0 1 X 1 1 1 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 113289 113289 22158149 10749532 11408617 9630290 6668112 2962178 2464364 1093303 1371061 15855145 Interest in Tri Valley Medical Foundation 3280020 F 3280020 X 19765540 109426 -381465 -272039 20037579 311406 311406 20348985 21277561 0 21277561 381465 381465 21659026 Part X, Line 2: The Health System is organized as a Nebraska nonprofit corporation and has been recognized by the Internal Revenue Service (IRS) as exempt from federal income taxes under Internal Revenue Code Section 501(c)(3). The Health System is required annually to file a Return of Organization Exempt from Income Tax (Form 990) with the IRS. In addition, the Health System is subject to income tax on net income that is derived from business activities that are unrelated to its exempt purpose, if applicable. 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's federal Form 990T filings are no longer subject to federal tax examinations by tax authorities for years before 2012. 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. Part XI, Line 2d - Other Adjustments: Provision for bad debts included in revenue for financial statements -381,465. Part XI, Line 4b - Other Adjustments: Contributions for long-lived assets incl in fund balance for financial stmts 311,406. Part XII, Line 4b - Other Adjustments: Provision for bad debts included in revenue for financial statements 381,465. 1 1 X 1 X 1 X 0 1 0 0 39000 39000 0.00180 609823 416115 193708 0.00910 648823 416115 232708 0.01090 131513 17550 113963 0.00540 4311223 3115547 1195676 0.05620 4442736 3133097 1309639 0.06160 5091559 3549212 1542347 0.07250 0 381465 65612 7561854 7628100 -66246 X 1 1 1 1 Cambridge Memorial Hospital dba Tri Valley Health System 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 15 1 0 0 1 X www.trivalleyhealth.com X 1 15 1 www.trivalleyhealth.com 0 1 X 100.000000000000 200.000000000000 X X 1 1 X X X X 1 X www.trivalleyhealth.com/financialassistance.aspx X www.trivalleyhealth.com/financialassistance.axpx X www.trivalleyhealth.com/financialassistance.axpx X X X X X X 1 X 0 X X X 1 X 0 0 Cambridge Memorial Hospital, Inc. Part V, Section B, Line 5: Tri Valley 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 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 2016. Tri Valley Health System approved an implementation plan to address all nine (9) needs identified in the CHNA. (1) The uninsured adult population rate in Furnas County is 14%, higher than the rural Nebraska norm of 13.7%. With Tri Valley being the largest employer in the county, the community feedback conclusion was Tri Valley needed to provide affordable health insurance options to employees. In calendar year 2017, Tri Valley was able to offer insurance to employees. Tri Valley will continue to provide affordable hospital enrollment assistance education and services for Medicare/Medicaid and other third party payors. (2) The second need identified was an awareness of the aging primary care providers. Tri Valley works with multiple sources to get mid-level candidates hired. Tri Valley is working with a physician recruitment firm to hire an internal medicine or primary care provider. Tri Valley will solidify and implement the on-boarding process for new providers when hired as well as complete a provider satisfaction survey. Additionally, Tri Valley has partnered with local schools to educate high school students on health care career options. (3) The number of poor mental health days in Furnas County is 2.8, higher than the rural Nebraska norm of 2.7. The community feedback conclusion was mental health services (diagnosis and placement) needs improvement. While Tri Valley already offers mental health services, the implementation plan is to encourage and increase depression screenings by primary care physicians. Tri Valley will be opening a program called Senior Life Solutions which is for mental health services for the elderly population. Tri Valley will also be completing an evaluations to determine the appropriate specialties to add to our specialty clinic which will include evaluating the need for urgent care services, cancer services, child care, chiropractors, optometrist, family planning services, home health and school nurses. (4) The need to increase awareness of health care services offered was identified in the CHNA. Tri Valley developed a marketing plan focused to increase awareness of healthcare services offered. (5) The aging of nursing home facilities in our community was identified as a need. Tri Valley addressed this by completing an analysis of the senior services currently offered and the financial impact for continuing to offer these services. Tri Valley will engage an outside vendor to evaluate the current facilities and costs associated with the improvements needed. Tri Valley will then recommend an alternative way to manage senior services to the Board of Directors. (6) Nursing shortage was identified in the assessment. Tri Valley redefined behavioral standards through development of frontline staff and senior team led committee. Tri Valley developed a communication plan and communicated employee standards, hardwired rounding on every employee every month, developed and implemented peer interview processes, developed and implemented a new employee onboarding process as well as an employee satisfaction survey. Tri Valley will partner with local schools to educate students on health care career options and offer on-site experiences. (7) The assessment identified drug abuse. Tri Valley will establish a community task force to explore how to stop black market sales of prescription meds and set up a program to monitor prescription drug abuse. Tri Valley will develop education handouts for medical providers to distribute to patients when prescribing schedule II drugs. Tri Valley will continue to promote a drug drop program twice a year through a DEA sponsored national medication take-back initiative. Tri Valley will partner with the schools to increase and train school-based programs regarding substance abuse. Tri Valley will also evaluate a need for a chronic pain clinic. (8) The number of mothers who began prenatal care in the first trimester in Furnas County is 159, lower than the rural Nebraska norm of 393. Tri Valley addressed this by implementing a system to ensure all pregnant women presenting to the Emergency Room are scheduled for an OB appointment with their choice of provider before discharge. Tri Valley will promoted OB provider adherence to ACOG guidelines pertaining to first trimester entry to prenatal care. Tri Valley also educates the community on availability of prenatal care resources and other support services through Tri Valley. (9) The adult obesity rate in Furnas County is 33%, higher than the rural Nebraska norm of 31.3%. Also, the percent of diabetic monitoring is lower than the rural Nebraska norm of 84.2%. Furnas County residents also identified a limited access to healthy foods. Tri Valley continues to promote fitness and healthy lifestyles focusing on promoting walking trails, restaurant healthy meals and health fairs, classes and speakers. Furthermore, Tri Valley promotes a community farmer's market and Tri Valley started a community wide fitness challenge initiative focusing on fitness, nutrition and physical activity. The program is called "Healthier Me". 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 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. 2 1 - Heritage Plaza 1205 Nelson Street Cambridge NE 69022 Independent living 2 - Tri Valley Health System Assisted Living 711 Mousel Ave Cambridge NE 69022 Assisted 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. Community health improvement services on line 7e are reported based on revenues and expenses for each event. The cost for subsidized health services reported on line 7g was determined using the Medicare Cost Report. Part I, Ln 7 Col(f): The amount of bad debt expense removed from total expenses to determine the percentage was 381,465. Part III, Line 2: The reserve for doubtful accounts is determined by a percentage of the remaining account receivables after discounts and payments are applied based on the age of the account. Payments received on accounts previously written off to bad debt reduces bad debt expense in the current year.Bad debt expense on line 2 is reported at charges as presented on the financial statements. Part III, Line 3: In Furnas County, Nebraska, the percentage of residents that are at or below poverty level is 17.2%. We can assume that the same percentage of patients would be eligible for charity care, however either did not apply or were denied charity care based on lack of information. Bad debt expense was $381,465. We can assume that 17.2%, or $64,468, of this bad debt was attributable to patients who were eligible for the charity care program. Part III, Line 4: The footnote to the Organization's financial statements can be found on page 9 of the attached audited financial statements. 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 April, 2016, round two 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 $39,934 as of 2015. These income values are below the median and average for both the state of Nebraska and the United States.Unemployment rates for the service area for 2016 range from 2.2% (Gosper), 2.8% (Frontier), 2.5% (Red Willow) to 2.7% (Furnas). These rates compare favorably to the state of Nebraska and the United States. Part VI, Line 5: Tri Valley Health System is governed by a nine person Board of Directors whose members reside within the system's primary service area and have no immediate family ties to any employees. These individuals also do not benefit financially through their businesses by means of contracts or other agreements. Surplus funds, if available, are used to purchase equipment or are re-invested in the facility to improve patient care. Tri Valley Health System extends medical staff privileges to all qualified physicians in the community. Throughout Tri Valley Health System's fiscal year, strides were made to increase the community outreach and education as well as the health of the communities. In 2011 Tri Valley 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. Healthy Women in the Heartland program provides monthly newsletters and quarterly educational programs at no cost to the members. The programs offered include everything from healthy eating by the Hospital's dietician to foot care by a podiatrist. Annually the Hospital promotes a Women's Day of Health which includes a full day of activities and educational programs to encourage and educate women on healthy living. During the year, In 2016, the 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 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 also provided baseline trauma testing to football players in all the schools in the communities they serve as well as offering an athletic trainers to the schools systems at no cost. As a critical access hospital, Tri Valley Health System's Cambridge Memorial Hospital invites specialists throughout the state to conduct weekly or monthly clinics in the specialty clinic. Services offered to patients during the fiscal year were cardiology, general surgery, mental health, obstetrics/gynecology, orthopedics, ophthalmology, otolaryngology, podiatry, pulmonology, and urology. Tri Valley Health System is also a member of the Nebraska Telehealth Network providing additional services such as neurology and psychiatry. X X 1 1 X X 0 0 0 0 0 0 0 0 0 Constance Hill CRNA Anesthetist 183001 0 0 0 1093 0 6552 0 1968 0 192614 0 0 0 Josh Hill CRNA Anesthetist 180141 0 0 0 63 0 0 0 4827 0 185031 0 0 0 Shiuvaun Jaeger MD Family Practice/Obstetrics 228814 0 62483 0 25450 0 8775 0 3315 0 328837 0 0 0 Lennie Deaver MD Family Practice/Obstetrics 226985 0 56118 0 2435 0 9681 0 3758 0 298977 0 0 0 Rachelle Kaspar-Cope MD Family Practice/Obstetrics 229185 0 44270 0 2482 0 10971 0 2836 0 289744 0 0 0 Part I, Line 1a Spouses of board members attend one conference up to a maximum of $600. Providers can choose to belong to either a health club or a golf club. Payments are made directly to the health club or golf club. This is reported as income on the provider's W-2. Schedule J, Part I, Line 3: Tri Valley Health System did not pay compensation to the CEO directly. The CEO was compensated by HealthTechS3, an unrelated management company for 5/1/16 thru 6/30/16 and was considered a common law employee of the management company. Tri Valley Health System had a written contract with HealthTechS3 that terminated 6/30/16. Effective 7/1/16, the Board of Directors hired Deborah Herzberg as CEO and an employee of Tri Valley Health System. Form 990, Part VI, Section A, line 2 Randy Heitmann and Bill Minnick serve together as board members of a separate organization. Form 990, Part VI, Section A, line 3 Deb Herzberg, CEO for Tri Valley Health System, was an employee of HealthTechS3, an unrelated management company, from 5/1/16 through 6/30/16 at which time Tri Valley Health System ended the contract with HealthTechS3. Effective 7/1/16, the Board of Directors hired Deborah Herzberg as CEO and an employee of Tri Valley Health System. The CEO was considered a common law employee of HealthTechS3 until 6/30/16. Calendar year 2016 compensation from the management company for supervising the management, administration and operation of Tri Valley Health System was $34,282. Form 990, Part VI, Section A, line 6 Members pay a $5 fee to become a lifetime member. Form 990, Part VI, Section A, line 7a Members select the Board of Directors at the annual meeting. All members have the same voting rights. Form 990, Part VI, Section A, line 8b There are no 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 Members prior to it being filed. Form 990, Part VI, Section B, line 12c At the October board meeting all board members complete an annual disclosure. The policy covers the board of directors. The CEO reviews the disclosures. Anyone with a conflict must abstain from voting on the issue and is not able to participate in discussions regarding the issue. Form 990, Part VI, Section B, line 15a The CEO's compensation was determined by HealthTechS3, an unrelated management company, as the CEO was considered a common law employee of HealthTechS3. Annually, the Regional Vice-President from HealthTechS3 provided a CEO evaluation form to each Board member to complete. After completing the form, the Board members returned it directly to the Regional Vice-President. The Regional Vice-President also met with the Board in a private meeting to review the evaluations and approve the compensation. The full authority and ultimate control of the Health System remained exclusively with the Board. Effective 1/1/17, the CEO became an employee of Tri Valley Health System and the Board of Directors determines compensation and benefits 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. 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 done annually. Market Wage Adjustments are made on an as-needed basis to adjust salaries that fall outside the survey guidelines. Form 990, Part VI, Section C, line 19 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 341,722. Management and general expenses 68,988. Fundraising expenses 0. Total expenses 410,710. Purchased services: Program service expenses 1,960,473. Management and general expenses 424,709. Fundraising expenses 0. Total expenses 2,385,182. Form 990, Part XI, line 9: Change in interest in net assets of Tri Valley Medical Foundation 271,267. Net assets released from restrictions -76,907. Form 990, Part XII, Line 2c: The Board of Trustees assumes responsibility for oversight of the audit and selection of an independent accountant.