2016-03-21T13:44:29-05:00 2015-06-30 450250958 EIDE BAILLY LLP 1545 ASSOCIATES DR STE 101 DUBUQUE IA 52002 990 2014-07-01 420818642 Central Community Hospital CENT 5632457000 901 Davidson St NW Elkader IA 520439015 Rebecca Johnson Revenue Cycle Manager 5632457000 2016-03-17 1 Carmen Krantz P00031958 5635561790 2016-03-03 2014 2016-08-17 19:52:53Z Fran Zichal 901 Davidson St NW Elkader IA 520439015 6425775 0 X www.centralcommunityhospital.com X 1961 IA Provide healthcare services to the surrounding community 7 7 91 35 0 0 37399 38635 5931226 6323207 7231 7015 42961 42740 6018817 6411597 46258 400 0 0 2714454 2552801 0 0 19598 3289471 3563392 6050183 6116593 -31366 295004 6287458 7464631 698041 1566429 5589417 5898202 X Every patient matters. 0 0 4661591 400 6323207 Central Community Hospital is a 25-Bed Critical Access Hospital serving residents of Clayton County, Iowa. Requirements of the IRS community benefit standard for tax-exempt organizations are integral to Central Community Hospital's charitable mission. Central Community Hospital is governed by an independent Board, which includes community leaders, consumer representatives and business experts. The Board has a history of commitment to acting with the highest integrity. During this year, the Board worked with management to continue to make improvements to assure the organization is in compliance with all rules and regulations governing the healthcare industry and non-profit organizations.Program A: ERCentral Community Hospital makes care accessible to the entire community it serves. Central Community Hospital operates a full-time emergency room and provides care regardless of ability to pay. Central Community Hospital had 894 emergency visits this year and 86 continued care in Observation. The Hospital works with the City of Elkader to provide emergency response and emergency transport services for the local communities. The city purchases the new ambulances, provides maintenance and tires on the vehicles and purchases 50% of the gas to run the ambulance. CCH pays 50% of the gas and employs the EMS personnel. The CCH Auxiliary paid for the airway trainer and infusion pumps both used by CCH staff and EMS staff. CCH assures all providers are current in ACLS, ATLS and PALS. CCH also assures Registered Nurses are current with ACLS, NRP, TNCC and PALS. This year the Hospital provided 788 days of inpatient care and 5,746 outpatient visits to the residents in the service area. Central Community Hospital provided care at many levels including SCU, Acute, Skilled, Intermediate, Same-Day-Surgery, Observation Care, Outpatient, and Rehab services. In addition, Central Community Hospital provides non-emergency services. These services are accessible to the community through participation in government programs like Medicare and Medicaid. Financial counseling is available to patients. Central Community Hospital takes its mission to improve the health and quality of life of the people it serves a step further by reaching out to meet the broad health needs of the community. It strives to identify community needs beyond basic healthcare, working collaboratively with other community organizations. Needs assessments are completed every three years and updated annually by a county wide multi-disciplinary team and used to prioritize community projects.The Hospital provides care to patients who meet certain criteria under its charity care policy without charge or at amounts less than established rates. Because the Hospital does not pursue collection of amounts determined to qualify as charity care, they are not reported as revenue. The amount of charges foregone for services provided under the Hospital's charity care policy were $114,721 for the year ended June 30, 2015. The direct and indirect costs related to these forgone charges were $75,000 at June 30, 2015, based on an average ratio of costs to gross charges.In addition, the Hospital 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 Hospital 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. 15904 Program B: Community Health and EducationThe committee that oversees community health and education is the AIM committee (A-align with community needs; I-inspire staff to improve health of community and M-manage those needs to best capability of CCH. The annual goals are set primarily through the health needs assessment AIM offers classes in the community including schools, Corporate Wellness targeting businesses wanting to improve health of their employees and participation in public awareness activities (Clayton County Fair, Community Parades and Blood Drives. CCH offers assistance to patients who qualify for reduced cost of medication through drug companies. Two volunteers counsel Medicare Part D participants on the program and recommend best insurance company for the individuals. Rehab staff offer services to Central Community School athletes. Each month therapists calculate value to the students. CCH EMS personnel attend local school football games to provide emergency assistance to athletes, coaches and/or fans.The value of these programs:1. Athletic Program at Central Community School: $1,4162. Blood Drive: $9593. Coalition Building: $2884. CCH and County Health Needs Assessment: $3305. CPR/First Aid Classes for community: $1,5046. Prescription Drug Program for those meeting criteria: $4,0807. Triage Telephone Advice by Nurses: $7058. Community Education including Schools, Public Awareness, Medical Care at Community events; $6,622 4677495 1 0 0 0 0 0 0 0 0 0 1 0 0 0 1 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 36 0 1 91 1 0 0 0 0 0 0 0 0 0 0 X 7 7 1 0 0 0 1 1 0 1 0 0 0 1 1 1 1 1 1 1 1 0 X Rebecca Johnson 5632457000 901 Davidson St NW Elkader IA 520439015 Robert Bodensteiner President 0.50 X X 0 0 0 Jennifer Cowsert Vice President 0.50 X X 0 0 0 Tom Neuhaus Treasurer 0.50 X X 0 0 0 Kevin Ihde Secretary 0.50 X X 0 0 0 Darwin Winke Member 0.50 X 0 0 0 Russell Knight Member 0.50 X 0 0 0 William Reimer Member 0.50 X 0 0 0 Fran Zichal CEO 40.00 X 164534 0 4698 Pat Borel CFO 40.00 X 87279 0 6959 251813 0 11657 1 0 1 0 Cerner Healthcare Solutions Inc 1300 Godward Street NE Suite 4100 Minneapolis MN 55413 Consulting & software 970161 Wapiti Medical Group 107 Flynn Drive Suite 600 Milbank SD 57252 ER physicians 465947 Northern Iowa Therapy 1810 4th St SW Suite 103 Waverly IA 50677 Contracted services 438472 Mercy Medical Center - Dubuque 250 Mercy Drive Dubuque IA 52001 Purchased services & management fee 235204 Siemens Medical Solutions PO Box 121102 Dallas TX 735121102 Diagnostic services 176805 6 23448 15187 38635 Patient service revenu 622110 6048811 6048811 Electronic health reco 900099 267826 267826 Supporting revenue 900099 6570 6570 6323207 7015 7015 56918 14178 42740 42740 42740 6411597 6323207 0 49755 X 400 400 238798 238798 1913650 1667693 226506 19451 32337 24639 7698 222208 174284 47924 145808 111222 34586 49455 49455 2185724 1555699 630025 15773 15773 144470 96061 48262 147 101793 98431 3362 42651 14190 28461 8599 8599 504944 504944 76334 76334 Medical supplies 266292 266292 Bad debt 114044 114044 Food 24607 24607 Community benefits 5228 4957 271 23478 11433 12045 6116593 4677495 1419500 19598 606366 3176156 2765 890201 753090 81151 72484 50872 62388 9793774 6581991 3591200 3211783 654954 172301 186082 237648 2648 6287458 7464631 624344 336815 858862 73697 56752 0 314000 698041 1566429 X 5405268 5700272 184149 197930 5589417 5898202 6287458 7464631 X 295004 13781 X 0 1 X 1 0 X 26015 26015 4039909 2290402 1749507 5727850 4291589 1436261 3211783 Estimated third-party payor settlements 314000 314000 X 6311731 -114044 -114044 6425775 -14178 -14178 6411597 6016727 -99866 -99866 6116593 0 6116593 Part X, Line 2: The Hospital is organized as an Iowa nonprofit corporation and has been recognized by the Internal Revenue Service (IRS) as exempt from federal income taxes under Interanl Revenue Code Section 501(c)(3). The Hospital is annually required to file a Return of Organization Exempt from Income Tax (Form 990) with the IRS. In addition, the Hospital is subject to income tax on net income that is derived from business activities that are unrelated to its exempt purpose. The Hospital has determined that 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. The Hospital 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 Hospital 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. Part XI, Line 2d - Other Adjustments: Bad debt expense included in expenses on Form 990 -114,044. Part XI, Line 4b - Other Adjustments: Rent expenses included in revenue on Form 990 -14,178. Part XII, Line 2d - Other Adjustments: Monona Clinic rent expenses included in revenue on Form 990 14,178. Bad debt expense included in expenses on Form 990 -114,044. 1 1 X 1 X 1 X 0 1 1 0 1 1 75000 75000 0.01250 75000 75000 0.01250 6 8994 8994 0.00150 1 972680 680939 291741 0.04860 7 981674 680939 300735 0.05010 7 1056674 680939 375735 0.06260 1 288 288 0.00000 1 6622 6622 0.00110 2 6910 6910 0.00110 1 114044 5930 2983643 3010669 -27026 X 1 1 1 1 Central Community Hospital 901 Davidson St NW Elkader IA 520439015 www.centralcommunityhospital.com 220051H X X X X Central Community Hospital 1 0 0 1 X X X X X X X X X 12 1 1 1 1 X www.centralcommunityhospital.com/patient-info/community-assessment/ X 1 12 1 www.centralcommunityhospital.com/patient-info/community-assessment/ 0 0 1 X 150.000000000000 200.000000000000 X X X 1 1 X X X X 1 X www.centralcommunityhospital.com X www.centralcommunityhospital.com X X X X X X 1 X 0 X X X X 1 X 0 1 Central Community Hospital Part V, Section B, Line 5: The following individuals and groups were consulted as individuals representing the community interests: Elkader Care Center, HAWK Partnership for Children, Clayton County VNA, Child Health Specialty Clinics, Community Circle of Care, Central Community Hospital, Central Community Hospital Foundation, Northland Agency on Aging, Clayton County WIC, Clayton County Substance Abuse Services, Guttenberg Municipal Hospital, Northeast Iowa Community Action and Central Community School. A Wipfli consultant conducted two focus groups with community members providing input on healthcare needs of Central Community Hospital's service area. Central Community Hospital Part V, Section B, Line 6a: The community health needs assessment was conducted with Guttenberg Municipal Hospital in Guttenberg, Iowa. Central Community Hospital Part V, Section B, Line 6b: The CHNA was conducted with Clayton County Public Health. Central Community Hospital Part V, Section B, Line 11: Lead poisoning was a health need found in the Community Health Needs Assessment (CHNA) but was not addressed as existing health care facilities and resources within the community are better able to respond to that need.Actions to prevent an increase in obesity in Clayton County children and adults is ongoing with the Hospital establishing wellness meetings and activities.Actions to prevent further increase in substance abuse among Clayton County children and adults is ongoing as the Hospital works with area agencies to support local efforts and classes to adults and high school students. Preventing an increase in number of falls among older adults in Clayton County is still being addressed as the Hospital implements classes.Increasing nurses' understanding of mental health issues and techniques to decrease patient stress is ongoing with nurses receiving mental health first aid classes, community education and security and safety policies.Improving care coordination in the county is ongoing as the Hospital continues work of the Elkader Healthcare Coalition, participates in Clayton County Healthcare Coalition activities and assures EMR improvement of QI indicators related to care coordination. Central Community Hospital Part V, Section B, Line 13h: There are instances when a patient may appear eligible for financial discounts, but there is no financial assistance form on file or a lack of supporting documentation. Central Community Hospital may use outside agencies to determine eligibility. These resources may use demographic and household information and/or credit scoring technology to determine eligibility. Patients who meet presumptive eligibility criteria may be granted financial assistance without completing the application. Presumptive eligibility awards must be 100% discounts. Other forms of presumptive eligibility include: Eligible for the Iowa Cares Program, bankruptcy, death with no estate resources, and Title XIX eligible and receiving non-covered services. Central Community Hospital Part V, Section B, Line 16i: At the time of registrations, CCH staff makes every effort to determine if a patient may possibly need or qualify for any financial assistance. We notify patients of the availability of these programs by posting information in our registration and emergency room areas. We offer a private meeting with a financial counselor. Inpatients are offered an opportunity to meet with the counselor upon discharge. Financial assistance information is provided in all correspondence regarding patient bills. Our financial counselor attempts phone contact whenever possible. We do an annual article about the service in our newsletter. Central Community Hospital Part V, Section B, Line 24: All individuals eligible under the hospital financial assistance policy are provided a discount for emergency and other medically necessary care. The financial assistance policy does not apply to elective procedures. Therefore, FAP-eligible patients without insurance may be charged gross charges on elective procedures. Part V, Section B, Line 16 Financial Assistance Policy Website Availability Central Community Hospital Part V, Section B, line 16a website: www.centralcommunityhospital.com Central Community Hospital Part V, Section B, line 16b website: www.centralcommunityhospital.com Part I, Line 3c: Income Criteria as a % of US Government poverty income guidelines:Less than or equal to 150% 0% paid by patient151% - 175% 0% paid by patient176% - 200% 0% paid by patientGreater than 200% 100% paid by patientThere are instances when a patient may appear eligible for financial discounts, but there is no financial assistance form on file or a lack of supporting documentation. Central Community Hospital may use outside agencies to determine eligibility. These resources may use demographic and household information and/or credit scoring technology to determine eligibility. Patients who meet presumptive eligibility criteria may be granted financial assistance without completing the application. Presumptive eligibility awards must be 100% discounts. Other forms of presumptive eligibility include: Eligible for Bankruptcy, death with no estate resources, and Title XIX eligible and receiving non-covered services. Part I, Line 6a: The community benefit report is available on the Hospital's website and upon request. Part I, Line 7: Charity care expense was reported at cost on line 7a based on an overall cost-to-charge ratio which addresses all patient segments. Medicaid is cost reimbursed therefore there is no community benefit expense reported. Community health improvement services, line 7e is reported based on actual expenses recorded in the Organization's general ledger. The cost for subsidized health services 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 $114,044. Part II, Community Building Activities: We make every effort to have a constant presence at the community level to promote health related activities and report on the value a hospital brings to a small community. Based on our health needs assessment, we encourage the involvement of all community organizations in activities to promote better health for our service area residents. We offer assistance to patients who qualify for reduced cost of medication through the drug companies. This ensures these individuals receive the prescriptions they need. Two individuals counsel Medicare Part D participants on the program and annually review the participant's choice to assure the most appropriate insurance program is selected. The Hospital's EMTs attend the Central Community School football games to provide immediate assistance to athletes, coaches and fans. Part III, Line 2: All forms of payment, including self-pay, insurance, contractual allowances, and discounts, are applied to the patient's account before the account is classified as bad debt. A payment received on an account previously written off as bad debt reduces bad debt expense. Central Community Hospital does not refuse services to patients that generate bad debt.Bad debt expense on line 2 is reported at charges as presented on the financial statements. Part III, Line 3: A reasonable estimate of the Hospital's bad debt expense attributable to patients eligible under the charity care policy is 5.2% of bad debt expense. This is based on the percentage of individuals below the poverty level in the area. Part III, Line 4: The footnote to the Organization's financial statements can be found on pages 8 and 9 of the attached audited financial statements. Part III, Line 8: Central Community Hospital has a Medicare shortfall and considers this a community benefit. The Hospital provides services to Medicare patients regardless of the shortfall because access to healthcare and individual's health is important. Total revenue received from Medicare is the gross reimbursement plus settlement. Both total revenue received from Medicare and the Medicare allowable costs are reported from the Medicare Cost Report. The Medicare Cost Report is completed based on the rules and regulations set forth by Centers for Medicare and Medicaid Services. Part III, Line 9b: We make every effort to determine if a patient is eligible for financial assistance. If a patient cannot pay their balance in full in 30 days, a financial counselor is available to discuss payment options. After financial assistance is determined, any personal portion due follows the same debt collection policy as other patients without financial assistance. If a bankruptcy notice is received on any account, all collection activities will cease immediately. Central Community Hospital will not harass a patient for their past due account, nor make false statements to get the patient to pay their account. There are instances when a patient may appear eligible for financial discounts, but there is no financial assistance form on file or a lack of supporting documentation. Central Community Hospital may use outside agencies to determine eligibility. These resources may use demographic and household information and/or credit scoring technology to determine eligibility. Patients who meet presumptive eligibility criteria may be granted financial assistance without completing the application. Presumptive eligibility awards must be 100% discount. Other forms of presumptive eligibility include: eligible for the Iowa Cares Program, bankruptcy, death with no estate resources, and Title XIX eligible and receiving non-covered services (reviewed case by case). Part VI, Line 2: The Community Health Needs Assessment was completed and posted to the website on June 30, 2013. The assessment was conducted with the help of Guttenberg Municipal Hospital in Guttenberg, Iowa (located in Clayton County). Representatives of 18 organizations compiled Clayton County data on their services and populations served. Six priorities for health care needs were established for the county. When Central Community Hospital (CCH) created their Action Plan, they selected five of the priorities. CCH addressed the five priorities completing a quarterly report that was posted to the website and distributed internally. CCH established three action steps to be taken under each of the five priorities. The needs assessment will be conducted again in fiscal year 2016. Quarterly reports will continue through the next fiscal year. Part VI, Line 3: At the time of registrations, CCH staff makes every effort to determine if a patient may possibly need or qualify for any financial assistance. We notify patients of the availability of these programs by posting information in our registration and emergency room areas. We offer a private meeting with a financial counselor. Inpatients are offered an opportunity to meet with the counselor upon discharge. Financial assistance information is provided in all correspondence regarding patient bills. Our financial counselor attempts phone contact whenever possible. Our charity program information is available on our website. We do an annual article about the service in our newsletter. Our financial counselor will also assist with enrollment in external programs. Part VI, Line 4: Central Community Hospital serves the residents of the central part of Clayton County into the northeast section of the county. It is a rural, agricultural area. The geographic area of Clayton County is 778.54 square miles. The nearest larger city is Dubuque, Iowa, which is 72 miles from Elkader, the county seat. With 17,773 people, Clayton County is the 39th most populated county in the state of 99 counties. The population saw a 1.4% decline from 2008-2012. In 2012, the median household income of Clayton County residents was $46,617. 12.9% of Clayton County residents live in poverty. The median age for Clayton County residents is 44.7 years young. The largest Clayton County racial/ethnic groups are White (96.9%) followed by Hispanic (1.7%) and Other (0.9%). Part VI, Line 5: Central Community Hospital's board members reside in the primary service area except for one who lives in Dubuque, IA. None of the board members are employed by the Hospital nor are they contractors of the Hospital. None of the board members have family members employed by Central Community Hospital. Central Community Hospital extends hospital privileges to all qualified physicians in our service area extending to Dubuque, Iowa, where specialists serve our area. CCH encourages specialists to offer clinics in our facility to improve access for our local residents. Many of CCH older patients are apprehensive to drive 72 miles one-way to a large city to see a specialist. When the Hospital creates its budget, efforts are made by the Administrative Team to allocate funds to improve patient care through updating equipment, expanding supplies or hiring staff. Each year dollars are allocated to improve services based on recommendations submitted by department managers.Central Community Hospital (CCH) works with the city of Elkader to assure tax dollars are collected to purchase ambulances when needed, provide annual maintenance and tires for the vehicles and purchase 50% of the gas consumed. CCH pays the other 50% of the gas bill. The committee that oversees community health and education is the AIM committee, whose purpose is to align with the community needs with hospital goals, inspire staff to cooperatively improve the health of the community and manage those needs to best capability of CCH. Their annual goals are set primarily by the community health needs assessment plan and the needs determined by CCH staff. AIM offers classes at schools and in the community, Corporate Wellness program targeting businesses looking for opportunities to improve the health of their employees and participation in public awareness activities. Part VI, Line 6: Central Community Hospital is affiliated with Mercy Health Network, Des Moines, IA. Mercy Health Network provides 29 affinity meetings on a regular basis covering all aspects of services in the hospital (administrative, clinical, supportive). The staff is available daily to answer questions, provide assistance with policies and procedures and assign experts to offer classes, webinars, written materials and telephone conferences. They offer additional services that include provider recruitment, legal services and administrative support for major decision-making projects including major construction, adding service line or addressing new regulatory mandates. CCH also has a Critical Access Network Agreement with Mercy Medical Center, Dubuque, IA to meet the regulations regarding support for critical access including transportation, communication, quality and credentialing. Mercy Medical Center is committed to supporting health care in rural areas as demonstrated by their joint operations and subsidy of the Elkader Medical Clinic. X X 0 0 0 0 0 0 0 0 0 Fran Zichal CEO 162871 0 0 0 1663 0 3983 0 1456 0 169973 0 0 0 Form 990, Part VI, Section A, line 1 The Executive Committee consists of the officers of the Board. The President of the Board chairs the Committee. The Committee has the power to exercise authority of the Board when necessary or advisable between meetings of the Board. The Committee reports all of its actions to the Board at the next regular or special meeting of the Board, and such actions are subject to revision and alteration by the Board; provided however, that the rights of third parties are not affected by any revision or alteration. The Committee has the duty of reviewing the Bylaws of the Board at least annually and recommending to the Board the amendment of the Bylaws of the Hospital. The Executive Committee oversees compliance of the Hospital with requirements of regulatory bodies and meets on the call of the President. Minutes are kept of all meetings. Form 990, Part VI, Section A, line 2 Fran Zichal, CEO, and Russel Knight, Board member, have a business relationship. Form 990, Part VI, Section A, line 6 The Organization has members who are all of one class and resident citizens of the Central Community Hospital service area. Form 990, Part VI, Section A, line 7a Members of the Board are elected by the resident citizens of the Central Community Hospital service area at the annual meeting to serve for a term of four years. Form 990, Part VI, Section A, line 8b The Executive Committee did not meet during FY 2015. Form 990, Part VI, Section B, line 11 The Form 990 is made available to all Board Members before it is filed. The CEO and CFO review and approve the 990. Form 990, Part VI, Section B, line 12c Any duality of interest or possible conflict of interest on the part of any Board member and officer is disclosed to the other members of the Board and made a matter of record through an annual procedure and also when the interest becomes a matter of Board action. Any individual having a duality of interest or possible conflict of interest on any matter should not vote or use his or her personal influence on the matter, and should not be counted in determining the quorum for the meeting, even where permitted by law. The minutes of the meeting reflect the disclosure, the abstention from voting, and the quorum situation. Any new member of the Board will be advised of this policy upon entering on the duties of office. The governing board, CEO and CFO complete and sign the conflict of interest form yearly. The forms are reviewed by the Board President, and if a potential conflict is identified the Board President follows up. Form 990, Part VI, Section B, line 15 The process for determining compensation for the CEO is based on salary adjustment recommendations based on an annual evaluation, use of wage scales, committee approval (Board Chair and Mercy Medical Center - Dubuque's CEO), and Board approval. Also, Mercy Medical Center - Dubuque's compensation system is utilized. This includes review of wages in comparison to comparable positions. The organization documents and provides substantiation for their compensation process for the CEO. The process was last undertaken in FY 2014. The Hospital's Board determines compensation for the CFO through an annual evaluation and use of wage scales. The process is documented and was last undertaken in FY 2015. Form 990, Part VI, Section C, line 19 The Organization's governing documents and conflict of interest policy are available upon written request. The financial statements are attached to the Form 990 and therefore available for public inspection. Form 990, Part IX, line 11g Purchased services: Program service expenses 1,213,395. Management and general expenses 362,068. Fundraising expenses 0. Total expenses 1,575,463. Repairs and maintenance: Program service expenses 230,618. Management and general expenses 255,803. Fundraising expenses 0. Total expenses 486,421. Professional fees: Program service expenses 111,686. Management and general expenses 12,154. Fundraising expenses 0. Total expenses 123,840. Form 990, Part XI, line 9: Change in interest in net assets of Central Community Hospital Foundation 13,781.