CCMH CORPORATION: Form 990, tax year 2014
View the entire original 990 at ProPublica ↗
- Organization
- CCMH CORPORATION (EIN 61-1297707)
- Tax period
- 2014-01-01 to 2014-12-31
- Filed
- 2015-11-16
- IRS object ID
- 201513209349308366
- Schema version
- 2014v5.0
- Note
- A later return for the same period supersedes this one.
- 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 ReturnHeader
| Field | Value | IRS element (for citing) |
|---|---|---|
| Return | 2015-11-16T13:45:52-06:00 | ReturnTs |
| Tax Period End | 2014-12-31 | TaxPeriodEndDt |
Preparer Firm PreparerFirmGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Preparer Firm EIN | 271235638 | PreparerFirmEIN |
Preparer Firm Name PreparerFirmName
| Field | Value | IRS element (for citing) |
|---|---|---|
| Business Name Line1 | MOUNTJOY CHILTON MEDLEY LLP | BusinessNameLine1Txt |
Preparer US Address PreparerUSAddress
| Field | Value | IRS element (for citing) |
|---|---|---|
| Address Line1 | 462 S FOURTH ST SUITE 2600 | AddressLine1Txt |
| City | LOUISVILLE | CityNm |
| State Abbreviation | KY | StateAbbreviationCd |
| ZIP | 402023445 | ZIPCd |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Return Type | 990 | ReturnTypeCd |
| Tax Period Begin | 2014-01-01 | TaxPeriodBeginDt |
Filer Filer
| Field | Value | IRS element (for citing) |
|---|---|---|
| EIN | 611297707 | EIN |
Business Name BusinessName
| Field | Value | IRS element (for citing) |
|---|---|---|
| Business Name Line1 | CCMH CORPORATION | BusinessNameLine1Txt |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Business Name Control | CCMH | BusinessNameControlTxt |
| Phone | 5027323200 | PhoneNum |
US Address USAddress
| Field | Value | IRS element (for citing) |
|---|---|---|
| Address Line1 | 309 ELEVENTH ST | AddressLine1Txt |
| City | CARROLLTON | CityNm |
| State Abbreviation | KY | StateAbbreviationCd |
| ZIP | 41008 | ZIPCd |
Business Officer BusinessOfficerGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Person | MICHAEL KOZAR | PersonNm |
| Person Title | CEO | PersonTitleTxt |
| Phone | 5027323200 | PhoneNum |
| Signature | 2015-11-16 | SignatureDt |
| Discuss With Paid Preparer | Yes (1) | DiscussWithPaidPreparerInd |
Preparer Person PreparerPersonGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Preparer Person | REBECCA L PHILLIPS CPA | PreparerPersonNm |
| PTIN | P00024055 | PTIN |
| Phone | 5027491900 | PhoneNum |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Tax | 2014 | TaxYr |
| Build TS | 2016-02-25 16:41:14Z | BuildTS |
Form 990 IRS990
| Field | Value | IRS element (for citing) |
|---|---|---|
| Principal Officer | MICHAEL KOZAR | PrincipalOfficerNm |
US Address USAddress
| Field | Value | IRS element (for citing) |
|---|---|---|
| Address Line1 | 309 ELEVENTH ST | AddressLine1Txt |
| City | CARROLLTON | CityNm |
| State Abbreviation | KY | StateAbbreviationCd |
| ZIP | 41008 | ZIPCd |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Gross Receipts | $20,717,539 | GrossReceiptsAmt |
| Group Return For Affiliates | 0 | GroupReturnForAffiliatesInd |
| Organization501c3 | Yes (X) | Organization501c3Ind |
| Website Address | WWW.CCMHOSP.COM | WebsiteAddressTxt |
| Type Of Organization Corp | Yes (X) | TypeOfOrganizationCorpInd |
| Formation | 2007 | FormationYr |
| Legal Domicile State | KY | LegalDomicileStateCd |
| Activity Or Mission | PROVIDE A HEALTHCARE FACILITY OFFERING ACUTE CARE, SKILLED CARE, OUTPATIENT SERVICES, AND EMERGENCY MEDICAL SERVICES TO RESIDENTS OF CARROLL COUNTY, KENTUCKY AND SURROUNDING AREAS. | ActivityOrMissionDesc |
| Voting Members Governing Body | 11 | VotingMembersGoverningBodyCnt |
| Voting Members Independent | 11 | VotingMembersIndependentCnt |
| Total Employee | 221 | TotalEmployeeCnt |
| Total Volunteers | 16 | TotalVolunteersCnt |
| Total Gross UBI | $0 | TotalGrossUBIAmt |
| Net Unrelated Bus Txbl Incm | $0 | NetUnrelatedBusTxblIncmAmt |
| PY Contributions Grants | $298,163 | PYContributionsGrantsAmt |
| CY Contributions Grants | $124,700 | CYContributionsGrantsAmt |
| PY Program Service Revenue | $16,881,156 | PYProgramServiceRevenueAmt |
| CY Program Service Revenue | $19,786,344 | CYProgramServiceRevenueAmt |
| PY Investment Income | $375 | PYInvestmentIncomeAmt |
| CY Investment Income | $105 | CYInvestmentIncomeAmt |
| PY Other Revenue | $1,661,575 | PYOtherRevenueAmt |
| CY Other Revenue | $806,390 | CYOtherRevenueAmt |
| PY Total Revenue | $18,841,269 | PYTotalRevenueAmt |
| CY Total Revenue | $20,717,539 | 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 | $8,416,825 | PYSalariesCompEmpBnftPaidAmt |
| CY Salaries Comp Emp Bnft Paid | $8,749,191 | CYSalariesCompEmpBnftPaidAmt |
| PY Total Prof Fndrsng Expns | $0 | PYTotalProfFndrsngExpnsAmt |
| CY Total Prof Fndrsng Expns | $0 | CYTotalProfFndrsngExpnsAmt |
| CY Total Fundraising Expense | $0 | CYTotalFundraisingExpenseAmt |
| PY Other Expenses | $9,948,450 | PYOtherExpensesAmt |
| CY Other Expenses | $10,488,390 | CYOtherExpensesAmt |
| PY Total Expenses | $18,365,275 | PYTotalExpensesAmt |
| CY Total Expenses | $19,237,581 | CYTotalExpensesAmt |
| PY Revenues Less Expenses | $475,994 | PYRevenuesLessExpensesAmt |
| CY Revenues Less Expenses | $1,479,958 | CYRevenuesLessExpensesAmt |
| Total Assets BOY | $7,647,594 | TotalAssetsBOYAmt |
| Total Assets EOY | $7,500,280 | TotalAssetsEOYAmt |
| Total Liabilities BOY | $6,553,345 | TotalLiabilitiesBOYAmt |
| Total Liabilities EOY | $4,926,073 | TotalLiabilitiesEOYAmt |
| Net Assets Or Fund Balances BOY | $1,094,249 | NetAssetsOrFundBalancesBOYAmt |
| Net Assets Or Fund Balances EOY | $2,574,207 | NetAssetsOrFundBalancesEOYAmt |
| Info In Schedule O Part III | Yes (X) | InfoInScheduleOPartIIIInd |
| Mission | PROVIDE A HEALTHCARE FACILITY OFFERING ACUTE CARE, SKILLED CARE, OUTPATIENT SERVICES, AND EMERGENCY MEDICAL SERVICES TO RESIDENTS OF CARROLL COUNTY, KENTUCKY AND SURROUNDING AREAS. | MissionDesc |
| Significant New Program Srvc | Yes (1) | SignificantNewProgramSrvcInd |
| Significant Change | 0 | SignificantChangeInd |
| Expense | $14,417,652 | ExpenseAmt |
| Revenue | $17,904,353 | RevenueAmt |
| Desc | SERVICED 31,380 PATIENTS THIS YEAR. APPROXIMATELY 10,398 PATIENTS WERE SERVICED IN EMERGENCY ROOMS. | Desc |
Prog Srvc Accom Acty2 ProgSrvcAccomActy2Grp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Expense | $1,239,087 | ExpenseAmt |
| Desc | PROVIDED MEDICAL CARE FOR THOSE UNABLE TO PAY | Desc |
Prog Srvc Accom Acty3 ProgSrvcAccomActy3Grp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Expense | $2,334,976 | ExpenseAmt |
| Revenue | $2,528,372 | RevenueAmt |
| Desc | PROVIDED RURAL HEALTH CLINIC TO SERVE THE INDIGENT OF THE COMMUNITY. | Desc |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Program Service Expenses | $17,991,715 | 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 |
| Temp Or Permanent Endowments | 0 | TempOrPermanentEndowmentsInd |
| 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 | Yes (1) | 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 | 0 | BusinessRlnWithFamMemInd |
| Business Rln With Officer Ent | 0 | BusinessRlnWithOfficerEntInd |
| Deductible Non Cash Contri | 0 | 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 | 140 | IRPDocumentCnt |
| IRP Document W2 G | 0 | IRPDocumentW2GCnt |
| Backup Wthld Compliance | Yes (1) | BackupWthldComplianceInd |
| Employee | 221 | 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 |
| Info In Schedule O Part VI | Yes (X) | InfoInScheduleOPartVIInd |
| Governing Body Voting Members | 11 | GoverningBodyVotingMembersCnt |
| Independent Voting Member | 11 | IndependentVotingMemberCnt |
| Family Or Business Rln | 0 | FamilyOrBusinessRlnInd |
| Delegation Of Mgmt Duties | Yes (1) | DelegationOfMgmtDutiesInd |
| Change To Org Documents | 0 | ChangeToOrgDocumentsInd |
| Material Diversion Or Misuse | 0 | MaterialDiversionOrMisuseInd |
| Members Or Stockholders | 0 | MembersOrStockholdersInd |
| Election Of Board Members | 0 | ElectionOfBoardMembersInd |
| Decisions Subject To Approva | 0 | DecisionsSubjectToApprovaInd |
| Minutes Of Governing Body | Yes (1) | MinutesOfGoverningBodyInd |
| Minutes Of Committees | Yes (1) | 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 | Yes (1) | CompensationProcessOtherInd |
| Investment In Joint Venture | 0 | InvestmentInJointVentureInd |
| States Where Copy Of Return Is Fld | KY | StatesWhereCopyOfReturnIsFldCd |
| Upon Request | Yes (X) | UponRequestInd |
Books In Care Of Detail BooksInCareOfDetail
Business Name BusinessName
| Field | Value | IRS element (for citing) |
|---|---|---|
| Business Name Line1 | THE ORGANIZATION | BusinessNameLine1Txt |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Phone | 5027323200 | PhoneNum |
US Address USAddress
| Field | Value | IRS element (for citing) |
|---|---|---|
| Address Line1 | 309 ELEVENTH ST | AddressLine1Txt |
| City | CARROLLTON | CityNm |
| State Abbreviation | KY | StateAbbreviationCd |
| ZIP | 41008 | ZIPCd |
Form990 Part VII Section A Form990PartVIISectionAGrp (22 entries)
| TitleTitleTxt | Average Hours Per WeekAverageHoursPerWeekRt | Individual Trustee Or DirectorIndividualTrusteeOrDirectorInd | Reportable Comp From OrgReportableCompFromOrgAmt | Reportable Comp From Rltd OrgReportableCompFromRltdOrgAmt | Other CompensationOtherCompensationAmt | OfficerOfficerInd | Highest Compensated EmployeeHighestCompensatedEmployeeInd |
|---|---|---|---|---|---|---|---|
| BOBBY LEE WESTRICK | |||||||
| TRUSTEE | 1.00 | Yes (X) | $0 | $0 | $0 | ||
| MIKE NEVIN | |||||||
| TRUSTEE TILL DEC 2014 | 1.00 | Yes (X) | $0 | $0 | $0 | ||
| DENNIS RAISOR | |||||||
| CHAIRMAN | 1.00 | Yes (X) | $0 | $0 | $0 | Yes (X) | |
| DONNA BURNS | |||||||
| TRUSTEE | 1.00 | Yes (X) | $0 | $0 | $0 | ||
| HAROLD TOMLINSON | |||||||
| TRUSTEE TILL DEC 2014 | 1.00 | Yes (X) | $0 | $0 | $0 | ||
| JAMES STEVENSON | |||||||
| VICE CHAIR & SECRETARY | 1.00 | Yes (X) | $0 | $0 | $0 | Yes (X) | |
| LISA JAMES | |||||||
| TRUSTEE | 1.00 | Yes (X) | $0 | $0 | $0 | ||
| IGNACIO PASCUAL | |||||||
| TRUSTEE | 1.00 | Yes (X) | $0 | $0 | $0 | ||
| NICK MARSH | |||||||
| TRUSTEE | 1.00 | Yes (X) | $0 | $0 | $0 | ||
| RUTH BAXTER | |||||||
| TRUSTEE | 1.00 | Yes (X) | $0 | $0 | $0 | ||
| MALCOLM CARRACO | |||||||
| TRUSTEE | 1.00 | Yes (X) | $0 | $0 | $0 | ||
| ROBERT YOWLER | |||||||
| TRUSTEE | 1.00 | Yes (X) | $0 | $0 | $0 | ||
| GEORGIA HEISE | |||||||
| TRUSTEE | 1.00 | Yes (X) | $0 | $0 | $0 | ||
| ROBERT MITCHELL | |||||||
| CFO | 40.00 | $13,418 | $0 | $0 | Yes (X) | ||
| CHARLIE HATFIELD | |||||||
| CFO | 40.00 | $42,060 | $0 | $0 | Yes (X) | ||
| MICHAEL KOZAR | |||||||
| CEO | 40.00 | $175,127 | $0 | $1,169 | Yes (X) | ||
| KATHY SHORT | |||||||
| PHYSICIAN | 40.00 | $186,072 | $0 | $9,700 | Yes (X) | ||
| MILAGROS RIVERA | |||||||
| PHYSICIAN | 40.00 | $154,343 | $0 | $0 | Yes (X) | ||
| SHERRELL NUNNELLEY | |||||||
| PHYSICIAN | 40.00 | $240,486 | $0 | $23,000 | Yes (X) | ||
| WINSTON YAP | |||||||
| PHYSICIAN | 40.00 | $194,886 | $0 | $17,500 | Yes (X) | ||
| THOMAS SLONE | |||||||
| CRNA | 40.00 | $166,779 | $0 | $0 | Yes (X) | ||
| FAROOQ MIRZA | |||||||
| PHYSICIAN | 40.00 | $311,846 | $0 | $0 | Yes (X) | ||
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Reportable Comp From Org | $1,485,017 | TotalReportableCompFromOrgAmt |
| Tot Reportable Comp Rltd Org | $0 | TotReportableCompRltdOrgAmt |
| Total Other Compensation | $51,369 | TotalOtherCompensationAmt |
| Indiv Rcvd Greater Than100 K | 7 | 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 |
|---|---|---|---|---|---|
| EMCARE PHYSICIAN SERVICES | |||||
| 7032 COLLECTION CENTER DRIVE | CHICAGO | IL | 60693 | EMERGENCY ROOM PHYSICIANS | $607,852 |
| NUMED INC | |||||
| PO BOX 1098 | DENTON | TX | 76202 | MRI, ULTRASOUND, AND NUC MED SERVICES | $284,539 |
| ALLIANT MANAGEMENT SERVICES | |||||
| 12800 N MERIDIAN STREET SUITE 400 | CARMEL | IN | 46032 | MANAGEMENT SERVICES | $213,498 |
| CARROLLTON INTERNAL MEDICINE | |||||
| 307 11TH STREET | CARROLLTON | KY | 41008 | HOSPITALIST SERVICES | $192,758 |
| CRYSTALINK INC | |||||
| 3007 CHARLESTON CROSSING | NEW ALBANY | IN | 47150 | INFORMATION TECHNOLOGY SERVICES | $162,512 |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Cntrct Rcvd Greater Than100 K | 10 | CntrctRcvdGreaterThan100KCnt |
| Government Grants | $100,000 | GovernmentGrantsAmt |
| All Other Contributions | $24,700 | AllOtherContributionsAmt |
| Total Contributions | $124,700 | TotalContributionsAmt |
Program Service Revenue ProgramServiceRevenueGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Desc | PATIENT SERVICE REVENUE | Desc |
| Business | 621110 | BusinessCd |
| Total Revenue Column | $19,786,344 | TotalRevenueColumnAmt |
| Related Or Exempt Func Income | $19,786,344 | RelatedOrExemptFuncIncomeAmt |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Program Service Revenue | $19,786,344 | TotalProgramServiceRevenueAmt |
Investment Income InvestmentIncomeGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Revenue Column | $105 | TotalRevenueColumnAmt |
| Exclusion | $105 | ExclusionAmt |
Gross Rents GrossRentsGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Real | $135,401 | 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 | $135,401 | RealAmt |
Net Rental Income Or Loss NetRentalIncomeOrLossGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Revenue Column | $135,401 | TotalRevenueColumnAmt |
| Exclusion | $135,401 | ExclusionAmt |
Other Revenue Misc OtherRevenueMiscGrp (3 entries)
| DescDesc | BusinessBusinessCd | Total Revenue ColumnTotalRevenueColumnAmt | Related Or Exempt Func IncomeRelatedOrExemptFuncIncomeAmt | ExclusionExclusionAmt |
|---|---|---|---|---|
| MEDICAID EMR INCENTIVES | 900099 | $507,831 | $507,831 | |
| MISCELLANEOUS | 900099 | $138,550 | $138,550 | |
| CAFETERIA SALES | 722210 | $24,608 | $24,608 |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Other Revenue Total | $670,989 | OtherRevenueTotalAmt |
Total Revenue TotalRevenueGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Revenue Column | $20,717,539 | TotalRevenueColumnAmt |
| Related Or Exempt Func Income | $20,432,725 | RelatedOrExemptFuncIncomeAmt |
| Unrelated Business Revenue | $0 | UnrelatedBusinessRevenueAmt |
| Exclusion | $160,114 | 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 | $231,774 | TotalAmt |
| Program Services | $176,296 | ProgramServicesAmt |
| Management And General | $55,478 | ManagementAndGeneralAmt |
Other Salaries And Wages OtherSalariesAndWagesGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $7,372,876 | TotalAmt |
| Program Services | $7,225,418 | ProgramServicesAmt |
| Management And General | $147,458 | ManagementAndGeneralAmt |
Other Employee Benefits OtherEmployeeBenefitsGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $543,856 | TotalAmt |
| Program Services | $538,406 | ProgramServicesAmt |
| Management And General | $5,450 | ManagementAndGeneralAmt |
Payroll Taxes PayrollTaxesGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $600,685 | TotalAmt |
| Program Services | $570,651 | ProgramServicesAmt |
| Management And General | $30,034 | ManagementAndGeneralAmt |
Fees For Services Management FeesForServicesManagementGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $213,498 | TotalAmt |
| Management And General | $213,498 | ManagementAndGeneralAmt |
Fees For Services Legal FeesForServicesLegalGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $29,478 | TotalAmt |
| Management And General | $29,478 | ManagementAndGeneralAmt |
Fees For Services Accounting FeesForServicesAccountingGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $35,869 | TotalAmt |
| Management And General | $35,869 | ManagementAndGeneralAmt |
Fees For Services Other FeesForServicesOtherGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $2,562,741 | TotalAmt |
| Program Services | $1,907,104 | ProgramServicesAmt |
| Management And General | $655,637 | ManagementAndGeneralAmt |
Advertising AdvertisingGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $42,315 | TotalAmt |
| Program Services | $17,349 | ProgramServicesAmt |
| Management And General | $24,966 | ManagementAndGeneralAmt |
Office Expenses OfficeExpensesGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $936,318 | TotalAmt |
| Program Services | $926,955 | ProgramServicesAmt |
| Management And General | $9,363 | ManagementAndGeneralAmt |
Occupancy OccupancyGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $730,442 | TotalAmt |
| Program Services | $730,442 | ProgramServicesAmt |
Travel TravelGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $14,816 | TotalAmt |
| Program Services | $12,742 | ProgramServicesAmt |
| Management And General | $2,074 | ManagementAndGeneralAmt |
Interest InterestGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $72,106 | TotalAmt |
| Program Services | $72,106 | ProgramServicesAmt |
Depreciation Depletion DepreciationDepletionGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $636,757 | TotalAmt |
| Program Services | $636,757 | ProgramServicesAmt |
Insurance InsuranceGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $179,603 | TotalAmt |
| Program Services | $179,603 | ProgramServicesAmt |
Other Expenses OtherExpensesGrp (4 entries)
| DescDesc | TotalTotalAmt | Program ServicesProgramServicesAmt |
|---|---|---|
| BAD DEBT | $3,664,261 | $3,664,261 |
| DRUGS & MEDICAL SUPPLIE | $909,141 | $909,141 |
| PROVIDER TAX | $284,012 | $284,012 |
| FOOD COSTS | $97,419 | $97,419 |
All Other Expenses AllOtherExpensesGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $79,614 | TotalAmt |
| Program Services | $43,053 | ProgramServicesAmt |
| Management And General | $36,561 | ManagementAndGeneralAmt |
Total Functional Expenses TotalFunctionalExpensesGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $19,237,581 | TotalAmt |
| Program Services | $17,991,715 | ProgramServicesAmt |
| Management And General | $1,245,866 | ManagementAndGeneralAmt |
| Fundraising | $0 | FundraisingAmt |
Cash Non Interest Bearing CashNonInterestBearingGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $414,237 | BOYAmt |
| EOY | $598,674 | EOYAmt |
Savings And Temp Cash Invst SavingsAndTempCashInvstGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $50,994 | BOYAmt |
| EOY | $21,718 | EOYAmt |
Accounts Receivable AccountsReceivableGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $2,347,842 | BOYAmt |
| EOY | $3,151,281 | EOYAmt |
Inventories For Sale Or Use InventoriesForSaleOrUseGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $147,299 | BOYAmt |
| EOY | $171,934 | EOYAmt |
Prepaid Expenses Defrd Charges PrepaidExpensesDefrdChargesGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $815,236 | BOYAmt |
| EOY | $158,613 | EOYAmt |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Land Bldg Equip Cost Or Other Bss | $14,874,997 | LandBldgEquipCostOrOtherBssAmt |
| Land Bldg Equip Accum Deprec | $12,137,777 | LandBldgEquipAccumDeprecAmt |
Land Bldg Equip Basis Net LandBldgEquipBasisNetGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $3,211,146 | BOYAmt |
| EOY | $2,737,220 | EOYAmt |
Other Assets Total OtherAssetsTotalGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $660,840 | BOYAmt |
| EOY | $660,840 | EOYAmt |
Total Assets TotalAssetsGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $7,647,594 | BOYAmt |
| EOY | $7,500,280 | EOYAmt |
Accounts Payable Accr Expnss AccountsPayableAccrExpnssGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $2,653,171 | BOYAmt |
| EOY | $2,291,526 | EOYAmt |
Mortg Notes Pybl Scrd Invst Prop MortgNotesPyblScrdInvstPropGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $2,091,157 | BOYAmt |
| EOY | $1,500,162 | EOYAmt |
Unsecured Notes Loans Payable UnsecuredNotesLoansPayableGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $41,121 | BOYAmt |
| EOY | $8,400 | EOYAmt |
Other Liabilities OtherLiabilitiesGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $1,767,896 | BOYAmt |
| EOY | $1,125,985 | EOYAmt |
Total Liabilities TotalLiabilitiesGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $6,553,345 | BOYAmt |
| EOY | $4,926,073 | EOYAmt |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Organization Follows SFAS117 | Yes (X) | OrganizationFollowsSFAS117Ind |
Unrestricted Net Assets UnrestrictedNetAssetsGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $1,094,249 | BOYAmt |
| EOY | $2,537,002 | EOYAmt |
Temporarily Rstr Net Assets TemporarilyRstrNetAssetsGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| EOY | $37,205 | EOYAmt |
Total Net Assets Fund Balance TotalNetAssetsFundBalanceGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $1,094,249 | BOYAmt |
| EOY | $2,574,207 | EOYAmt |
Tot Liab Net Assets Fund Balance TotLiabNetAssetsFundBalanceGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $7,647,594 | BOYAmt |
| EOY | $7,500,280 | EOYAmt |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Reconcilation Revenue Expnss | $1,479,958 | ReconcilationRevenueExpnssAmt |
| Other Changes In Net Assets | $0 | 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 | $376,450 | OtherCostOrOtherBasisAmt |
| Book Value | $376,450 | BookValueAmt |
Buildings BuildingsGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Other Cost Or Other Basis | $4,507,132 | OtherCostOrOtherBasisAmt |
| Depreciation | $4,020,047 | DepreciationAmt |
| Book Value | $487,085 | BookValueAmt |
Leasehold Improvements LeaseholdImprovementsGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Other Cost Or Other Basis | $1,123,379 | OtherCostOrOtherBasisAmt |
| Depreciation | $394,505 | DepreciationAmt |
| Book Value | $728,874 | BookValueAmt |
Equipment EquipmentGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Other Cost Or Other Basis | $8,868,036 | OtherCostOrOtherBasisAmt |
| Depreciation | $7,723,225 | DepreciationAmt |
| Book Value | $1,144,811 | BookValueAmt |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Book Value Land Buildings | $2,737,220 | TotalBookValueLandBuildingsAmt |
Other Assets Org OtherAssetsOrgGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Desc | CERTIFICATE OF NEED | Desc |
| Book Value | $660,840 | BookValueAmt |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Book Value Other Assets | $660,840 | TotalBookValueOtherAssetsAmt |
Other Liabilities Org OtherLiabilitiesOrgGrp (2 entries)
| DescDesc | AmtAmt |
|---|---|
| ADVANCES FROM CARROLL COUNTY | $200,000 |
| ESTIMATED THIRD PARTY SETTLEMENTS | $925,985 |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Liability | $1,125,985 | TotalLiabilityAmt |
| Footnote Text | Yes (X) | FootnoteTextInd |
| Total Rev Etc Audited Fincl Stmt | $17,053,278 | TotalRevEtcAuditedFinclStmtAmt |
| Revenue Not Reported | $0 | RevenueNotReportedAmt |
| Revenue Subtotal | $17,053,278 | RevenueSubtotalAmt |
| Other Revenues Not Included | $3,664,261 | OtherRevenuesNotIncludedAmt |
| Revenue Not Reported Fincl Stmt | $3,664,261 | RevenueNotReportedFinclStmtAmt |
| Total Revenue Per Form990 | $20,717,539 | TotalRevenuePerForm990Amt |
| Tot Expns Etc Audited Fincl Stmt | $15,573,320 | TotExpnsEtcAuditedFinclStmtAmt |
| Expenses Not Reported | $0 | ExpensesNotReportedAmt |
| Expenses Subtotal | $15,573,320 | ExpensesSubtotalAmt |
| Other Expenses Not Included | $3,664,261 | OtherExpensesNotIncludedAmt |
| Expenses Not Rpt Fincl Stmt | $3,664,261 | ExpensesNotRptFinclStmtAmt |
| Total Expenses Per Form990 | $19,237,581 | TotalExpensesPerForm990Amt |
Supplemental Information Detail SupplementalInformationDetail (3 entries)
| Form And Line ReferenceFormAndLineReferenceDesc | ExplanationExplanationTxt |
|---|---|
| PART X, LINE 2: | THE HOSPITAL IS A NOT-FOR-PROFIT CORPORATION AND HAS BEEN RECOGNIZED AS A TAX-EXEMPT PURSUANT TO SECTION 501(C)(3) OF THE INTERNAL REVENUE CODE. THE HOSPITAL RECOGNIZES UNCERTAIN TAX POSITIONS USING THE "MORE LIKELY-THAN-NOT" APPROACH AS DEFINED IN THE ACCOUNTING STANDARDS CODIFICATION. NO LIABILITY FOR UNCERTAIN TAX POSITIONS HAS BEEN RECORDED IN THE ACCOMPANYING FINANCIAL STATEMENTS. THE HOSPITAL'S 2011-2013 TAX YEARS REMAIN OPEN AND SUBJECT TO EXAMINATION. |
| PART XI, LINE 4B - OTHER ADJUSTMENTS: | BAD DEBT EXPENSE 3,664,261. |
| PART XII, LINE 4B - OTHER ADJUSTMENTS: | BAD DEBT EXPENSE 3,664,261. |
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 | Yes (1) | FreeCareMedicallyIndigentInd |
| Financial Assistance Budget | Yes (1) | FinancialAssistanceBudgetInd |
| Expenses Exceed Budget | 0 | ExpensesExceedBudgetInd |
| Annual Community Bnft Report | Yes (1) | AnnualCommunityBnftReportInd |
| Report Publically Available | Yes (1) | ReportPublicallyAvailableInd |
Financial Assistance At Cost Typ FinancialAssistanceAtCostTyp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Community Benefit Expns | $1,855,869 | TotalCommunityBenefitExpnsAmt |
| Direct Offsetting Revenue | $411,914 | DirectOffsettingRevenueAmt |
| Net Community Benefit Expns | $1,443,955 | NetCommunityBenefitExpnsAmt |
| Total Expense | 0.09270 | TotalExpensePct |
Unreimbursed Medicaid UnreimbursedMedicaidGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Community Benefit Expns | $2,375,828 | TotalCommunityBenefitExpnsAmt |
| Direct Offsetting Revenue | $2,087,855 | DirectOffsettingRevenueAmt |
| Net Community Benefit Expns | $287,973 | NetCommunityBenefitExpnsAmt |
| Total Expense | 0.01850 | TotalExpensePct |
Total Financial Assistance Typ TotalFinancialAssistanceTyp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Community Benefit Expns | $4,231,697 | TotalCommunityBenefitExpnsAmt |
| Direct Offsetting Revenue | $2,499,769 | DirectOffsettingRevenueAmt |
| Net Community Benefit Expns | $1,731,928 | NetCommunityBenefitExpnsAmt |
| Total Expense | 0.11120 | TotalExpensePct |
Total Community Benefits TotalCommunityBenefitsGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Community Benefit Expns | $4,231,697 | TotalCommunityBenefitExpnsAmt |
| Direct Offsetting Revenue | $2,499,769 | DirectOffsettingRevenueAmt |
| Net Community Benefit Expns | $1,731,928 | NetCommunityBenefitExpnsAmt |
| Total Expense | 0.11120 | TotalExpensePct |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Bad Debt Expense Reported | Yes (1) | BadDebtExpenseReportedInd |
| Bad Debt Expense | $3,664,261 | BadDebtExpenseAmt |
| Bad Debt Expense Attributable | $450,000 | BadDebtExpenseAttributableAmt |
| Reimbursed By Medicare | $4,423,772 | ReimbursedByMedicareAmt |
| Cost Of Care Reimbursed By Medcr | $4,468,457 | CostOfCareReimbursedByMedcrAmt |
| Medicare Surplus Or Shortfall | -$44,685 | MedicareSurplusOrShortfallAmt |
Costing Methodology Used CostingMethodologyUsedGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Cost To Charge Ratio | Yes (X) | CostToChargeRatioInd |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Written Debt Collection Policy | Yes (1) | WrittenDebtCollectionPolicyInd |
| Financial Assistance Prvsn | Yes (1) | FinancialAssistancePrvsnInd |
Management Co And Jnt Ventures ManagementCoAndJntVenturesGrp (2 entries)
| Primary ActivitiesPrimaryActivitiesTxt | Org Profit Or OwnershipOrgProfitOrOwnershipPct | Ofcr Etc Profit Or OwnershipOfcrEtcProfitOrOwnershipPct | Physicians Profit Or OwnershipPhysiciansProfitOrOwnershipPct |
|---|---|---|---|
| 1 ALLIANT MANAGEMENT | |||
| MANAGEMENT CONSULTING | 0.00000 | 0.00000 | 0.00000 |
| 2 UTRA GROUP | |||
| GERI PHYSCH PROGRAM | 0.00000 | 0.00000 | 0.00000 |
| Field | Value | IRS element (for citing) |
|---|---|---|
| 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 | CARROLL COUNTY MEMORIAL HOSPITAL | BusinessNameLine1Txt |
US Address USAddress
| Field | Value | IRS element (for citing) |
|---|---|---|
| Address Line1 | 309 ELEVENTH ST | AddressLine1Txt |
| City | CARROLLTON | CityNm |
| State Abbreviation | KY | StateAbbreviationCd |
| ZIP | 41008 | ZIPCd |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Licensed Hospital | Yes (X) | LicensedHospitalInd |
| General Medical And Surgical | Yes (X) | GeneralMedicalAndSurgicalInd |
| Critical Access Hospital | Yes (X) | CriticalAccessHospitalInd |
| Emergency Room24 Hrs | Yes (X) | EmergencyRoom24HrsInd |
Hospital Fclty Policies Prctc HospitalFcltyPoliciesPrctcGrp
Hospital Facility Name HospitalFacilityName
| Field | Value | IRS element (for citing) |
|---|---|---|
| Business Name Line1 | CARROLL COUNTY MEMORIAL HOSPITAL | 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 |
| CHNA Conducted | 13 | 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 | WWW.CCMHOSP.COM | OwnWebsiteURLTxt |
| Paper Copy Public Inspection | Yes (X) | PaperCopyPublicInspectionInd |
| Implementation Strategy Adopt | Yes (1) | ImplementationStrategyAdoptInd |
| Implementation Strategy Adpt | 13 | ImplementationStrategyAdptYr |
| Strategy Posted Website | Yes (1) | StrategyPostedWebsiteInd |
| Strategy Website URL | WWW.CCMHOSP.COM | StrategyWebsiteURLTxt |
| Strategy Attached | 0 | StrategyAttachedInd |
| 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 |
| Income Level Criteria | Yes (X) | IncomeLevelCriteriaInd |
| Insurance Status Criteria | Yes (X) | InsuranceStatusCriteriaInd |
| Explained Basis | Yes (1) | ExplainedBasisInd |
| App Financial Asst Expln | Yes (1) | AppFinancialAsstExplnInd |
| Includes Publicity Measures | Yes (1) | IncludesPublicityMeasuresInd |
| FAP Available On Website | Yes (X) | FAPAvailableOnWebsiteInd |
| FAP Actions On Nonpayment | Yes (1) | FAPActionsOnNonpaymentInd |
| Collection Activities | 0 | CollectionActivitiesInd |
| FAP Notified Upon Admission | Yes (X) | FAPNotifiedUponAdmissionInd |
| FAP Notified Before Discharge | Yes (X) | FAPNotifiedBeforeDischargeInd |
| FAP Notified All Patients | Yes (X) | FAPNotifiedAllPatientsInd |
| Documented Elig Determination | Yes (X) | DocumentedEligDeterminationInd |
| Nondis Emergency Care Policy | Yes (1) | NondisEmergencyCarePolicyInd |
| Other Method Used | Yes (X) | OtherMethodUsedInd |
| Amounts Generally Billed | 0 | AmountsGenerallyBilledInd |
| Gross Charges | 0 | GrossChargesInd |
Supplemental Information SupplementalInformationGrp (5 entries)
| Form And Line ReferenceFormAndLineReferenceDesc | ExplanationExplanationTxt |
|---|---|
| CARROLL COUNTY MEMORIAL HOSPITAL | PART V, SECTION B, LINE 5: THE COMMUNITY STEERING COMMITTEE IS A VITAL PART TO THE CHNA PROCESS. THESE INDIVIDUALS REPRESENT ORGANIZATIONS AND AGENCIES FROM THE SERVICE AREA AND IN PARTICULAR, THE INDIVIDUALS WHO WERE WILLING TO VOLUNTEER ENABLED THE HOSPITAL TO GET INPUT FROM POPULATIONS THAT WERE OFTEN NOT ENGAGED IN CONVERSATIONS ABOUT THEIR HEALTH NEEDS. CEDIK PROVIDED A LIST OF POTENTIAL AGENCIES AND ORGANIZATIONS THAT WOULD FACILITATE BROAD INPUT. THE COMMUNITY STEERING COMMITTEE MET TWICE AS A GROUP AND EACH TIME A HOSPITAL REPRESENTATIVE WELCOMED AND THANKED THE INDIVIDUALS FOR ASSISTING IN THE PROCESS AND THEN EXCUSED THEMSELVES IF FOCUS GROUP DISCUSSION WAS BEING CONDUCTED. CEDIK ASKED THE HOSPITAL REPRESENTATIVES NOT BE PRESENT DURING ANY FOCUS GROUP DISCUSSIONS OR DEBRIEFING WITH THE COMMUNITY STEERING COMMITTEE.COMMUNITY STEERING COMITTEE MEMBERS:FLOYD BOWLING OF MAGISTRATERAY CLEM OF HOUSING AUTHORITYGREG GOFF OF FIRST NATIONAL BANKBILL HOGAN OF CARROLL COUNTY SCHOOOL SYSTEMTRACY MILES OF GALLATIN COUNTY CLERK'S OFFICEJEFF MOORE OF NEWS DEMOCRATSDANA NEW OF INTERIM HOME HEALTHVICKY RAND OF ALL STATE INSURANCE AGENCYBECKY WILSON OF THREE RIVERS DISTRICT HEALTH DEPARTMENT |
| CARROLL COUNTY MEMORIAL HOSPITAL | PART V, SECTION B, LINE 11: PHYSICIAN BEDSIDE MANNER - WE CURRENTY HAVE A PROCESS IN PLACE TO FOLLOW-UP AND ADDRESS NEGATIVE SURVEYS AND COMPLAINTS IN REGARDS TO ER PHYSICIANS. WE ARE IN CONSTANT COMMUNICATION WITH THE ER PHYSICIAN GROUP ABOUT CONCERNS. A MAJORITY OF OUR PATIENT SATISFACTION SURVEYS ARE FROM THE ER AND WE HAVE ABOUT 96% APPROVAL RATE.EMERGENCY ROOM WAIT TIME - WE WILL CONTINUE TO MONITOR WAIT TIMES, CURRENTLY CCMH ER WAIT TIMES ARE AVERAGING BETWEEN 84-89 MINUTES, WHICH IS BELOW THE NATIONAL AVERAGE OF 120 MINUTES.PATIENT CHECKLIST - WE WILL BETTER INFORM THE COMMUNITY OF WHAT PROCESSES ARE CURRENTLY IN PLACE. EXAMPLE: EACH PATIENT IS GIVEN DISCHARGE INSTRUCTIONS THAT ARE DISCUSSED WITH THE PATIENT/FAMILY; STAFF CALLS THE PATIENT 24-72 HOURS AFTER DISCHARGE TO MAKE SURE THE PATIENT DOESN'T HAVE ANY QUESTIONS; EACH PATIENT'S FOLLOW UP APPOINTMENT WITH ANY PHYSICIAN IS MADE BEFORE THE PATIENT IS DISCHARGED UNLESS REFUSED BY THE PATIENT. |
| CARROLL COUNTY MEMORIAL HOSPITAL | PART V, SECTION B, LINE 22D: A 40% DISCOUNT IS OFFERRED TO ALL SELF-PAY PATIENTS. |
| PART V, SECTION B, LINE 16 | FINANCIAL ASSISTANCE POLICY WEBSITE AVAILABILITY |
| CARROLL COUNTY MEMORIAL HOSPITAL PART V, SECTION B, LINE 16A WEBSITE: | HTTP://WWW.CCMHOSP.COM/FINANCIAL-INFORMATION/ |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Facility | 3 | FacilityNum |
Oth Hlth Care Fclts Not Hospital OthHlthCareFcltsNotHospitalGrp
Oth Hlth Care Fclts OthHlthCareFcltsGrp (3 entries)
| Address Line1USAddress/AddressLine1Txt | CityUSAddress/CityNm | State AbbreviationUSAddress/StateAbbreviationCd | ZIPUSAddress/ZIPCd | FacilityFacilityTxt |
|---|---|---|---|---|
| BEDFORD FAMILY PRACTICE | ||||
| 470 HIGHWAY 421 NORTH | BEDFORD | KY | 40006 | PROVIDER BASED RURAL HEALTH CLINIC |
| WARSAW FAMILY PRACTICE | ||||
| 302 W MAIN ST | WARSAW | KY | 40006 | PROVIDER BASED RURAL HEALTH CLINIC |
| CARROLL COUNTY RURAL HEALTH CLINIC | ||||
| 309 ELEVENTH ST | CARROLLTON | KY | 41008 | PROVIDER BASED RURAL HEALTH CLINIC |
Supplemental Information Detail SupplementalInformationDetail (10 entries)
| Form And Line ReferenceFormAndLineReferenceDesc | ExplanationExplanationTxt |
|---|---|
| PART I, LINE 7: | THE ORGANIZATION USED THE MEDICARE COST TO CHARGE RATIO TO COMPLETE PART I, LINE 7. |
| PART I, LINE 7, COLUMN (F): | THE BAD DEBT EXPENSE INCLUDED ON FORM 990, PART IX, LINE 25, COLUMN (A), BUT SUBTRACTED FOR PURPOSES OF CALCULATING THE PERCENTAGE IN THIS COLUMN IS $ 3,664,261. |
| PART III, LINE 2: | IN DETERMINING THE AMOUNT OF BAD DEBT AT COST, THE ORGANIZATION USED THE MEDICARE COST REPORT (MCR), COST TO CHARGE RATIO OF 28%. |
| PART III, LINE 3: | PATIENT ACCOUNTS RECEIVABLE ARE STATED AT NET REALIZABLE AMOUNTS FROM PATIENTS, THIRD-PARTY PAYORS AND OTHERS FOR SERVICES RENDERED. THE HOSPITAL PROVIDES AN ALLOWANCE FOR DOUBTFUL ACCOUNTS, WHICH IS MANAGEMENT'S ESTIMATE BASED UPON HISTORICAL COLLECTION INFORMATION AND OTHER INDUSTRY TRENDS. PATIENT ACCOUNTS RECEIVABLE ARE BILLED UPON DISCHARGE AND ARE ORDINARILY DUE WITHIN 30 DAYS OF BILLING. BALANCES MORE THAN 120 DAYS PAST DUE ARE CONSIDERED DELINQUENT. DELINQUENT RECEIVABLES ARE TURNED OVER TO A COLLECTION AGENCY. |
| PART III, LINE 4: | A SEPARATE FOOTNOTE FOR BAD DEBT EXPENSE IS NOT INCLUDED IN THE AUDITED FINANCIAL STATEMENTS.PATIENT ACCOUNTS RECEIVABLE ARE STATED AT NET REALIZABLE AMOUNTS FROM PATIENTS, THIRD-PARTY PAYORS AND OTHERS FOR SERVICES RENDERED. THE HOSPITAL PROVIDES AN ALLOWANCE FOR DOUBTFUL ACCOUNTS, WHICH IS MANAGEMENT'S ESTIMATE BASED UPON HISTORICAL COLLECTION INFORMATION AND OTHER INDUSTRY TRENDS. PATIENT ACCOUNTS RECEIVABLE ARE BILLED UPON DISCHARGE AND ARE ORDINARILY DUE WITHIN 30 DAYS OF BILLING. BALANCES MORE THAN 120 DAYS PAST DUE ARE CONSIDERED DELINQUENT. DELINQUENT RECEIVABLES ARE TURNED OVER TO A COLLECTION AGENCY. IN DETERMINING THE AMOUNT OF BAD DEBT AT COST, THE ORGANIZATION USED THE MEDICARE COST REPORT (MCR), COST TO CHARGE RATIO OF 28%. |
| PART III, LINE 9B: | THE ORGANIZATION'S COLLECTION POLICY STATES THAT ANY PERSON INDICATING AN INABILITY TO PAY WILL BE SCREENED FOR FINANCIAL ASSISTANCE. |
| PART VI, LINE 2: | INPUT FROM COMMUNITY LEADERS, BOARD MEMBERS, EMPLOYEES AND PATIENTS. CEO IS MEMBER OF SEVERAL LOCAL ORGANIZATIONS (ROTARY, ECONOMIC DEVELOPMENT, ETC.). |
| PART VI, LINE 3: | FINANCIAL COUNSELORS ASSIST THOSE WITHOUT INSURANCE INCLUDING THOSE WITH INSURANCE THAT EXPRESS A NEED FOR FINANCIAL ASSISTANCE. |
| PART VI, LINE 4: | THE ORGANIZATION SERVES A LARGELY RURAL POPULATION. COMMERCE IS CENTERED AROUND THE OHIO RIVER AND INDUSTRIES RELATED TO SUCH. THE POPULATION IS GENERALLY POORER THAN THE STATE AVERAGE WITH HIGHER THAN AVERAGE UNEMPLOYMENT. |
| PART VI, LINE 5: | HOSPITAL SPONSORED COMMUNITY HEALTH FAIR OFFERING SCREENINGS, PREVENTATIVE EDUCATION, AND INFORMATION TO PROMOTE GOOD HEALTH.BOARD OF DIRECTORS REPRESENT THE ENTIRE COMMUNITY AND WORK WITH THE HOSPITAL TO PROMOTE AND PROVIDE HEALTHY COMMUNITY BENEFITS.HOSPITAL WORKS WITH COUNTY HEALTH DEPARTMENT TO PROMOTE HEALTHY LIVING AND PREVENTION. |
Schedule J IRS990ScheduleJ
| Field | Value | IRS element (for citing) |
|---|---|---|
| Substantiation Required | Yes (1) | SubstantiationRequiredInd |
| Written Employment Contract | Yes (X) | WrittenEmploymentContractInd |
| 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 (7 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 |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| MICHAEL KOZAR | ||||||||||||||
| CEO | $175,127 | $0 | $0 | $0 | $0 | $0 | $1,169 | $0 | $0 | $0 | $176,296 | $0 | $0 | $0 |
| KATHY SHORT | ||||||||||||||
| PHYSICIAN | $186,072 | $0 | $0 | $0 | $0 | $0 | $9,700 | $0 | $0 | $0 | $195,772 | $0 | $0 | $0 |
| MILAGROS RIVERA | ||||||||||||||
| PHYSICIAN | $154,343 | $0 | $0 | $0 | $0 | $0 | $0 | $0 | $0 | $0 | $154,343 | $0 | $0 | $0 |
| SHERRELL NUNNELLEY | ||||||||||||||
| PHYSICIAN | $240,486 | $0 | $0 | $0 | $0 | $0 | $23,000 | $0 | $0 | $0 | $263,486 | $0 | $0 | $0 |
| WINSTON YAP | ||||||||||||||
| PHYSICIAN | $194,886 | $0 | $0 | $0 | $0 | $0 | $17,500 | $0 | $0 | $0 | $212,386 | $0 | $0 | $0 |
| THOMAS SLONE | ||||||||||||||
| CRNA | $166,779 | $0 | $0 | $0 | $0 | $0 | $0 | $0 | $0 | $0 | $166,779 | $0 | $0 | $0 |
| FAROOQ MIRZA | ||||||||||||||
| PHYSICIAN | $311,846 | $0 | $0 | $0 | $0 | $0 | $0 | $0 | $0 | $0 | $311,846 | $0 | $0 | $0 |
Schedule O IRS990ScheduleO
Supplemental Information Detail SupplementalInformationDetail (8 entries)
| Form And Line ReferenceFormAndLineReferenceDesc | ExplanationExplanationTxt |
|---|---|
| FORM 990, PART III, LINE 2 | A PEDIATRICS CLINIC WAS OPENED IN CARROLLTON, KENTUCKY AS PART OF CARROLL COUNTY FAMILY PRACTICE. |
| FORM 990, PART VI, SECTION A, LINE 3 | ALLIANT MANAGEMENT SERVICES PROVIDES MANAGEMENT GUIDANCE. |
| FORM 990, PART VI, SECTION B, LINE 11 | THE CFO REVIEWS THE 990 AND THEN THE 990 IS DISTRIBUTED TO THE GOVERNING BODY PRIOR TO ITS FILING. |
| FORM 990, PART VI, SECTION B, LINE 12C | CARROLL COUNTY MEMORIAL HOSPITAL'S ADVISORY BOARD; CCMH CORPORATION; OWE A DUTY OF CARE AND A DUTY OF LOYALTY TO CARROLL COUNTY MEMORIAL HOSPITAL, WHICH REQUIRE EACH DIRECTOR TO ACT IN GOOD FAITH, ON AN INFORMED BASIS, AND IN A MANNER THAT THE DIRECTOR HONESTLY BELIEVES TO BE IN THE BEST INTEREST OF CARROLL COUNTY MEMORIAL HOSPITAL. EACH MEMBER OF THE ADVISORY BOARD OF CARROLL COUNTY MEMORIAL HOSPITAL AND ITS AFFILIATED ORGANIZATIONS, CARROLL COUNTY MEMORIAL HOSPITAL OR SUBCOMMITTEES OF THESE BOARDS THAT HAVE BOARD DELEGATED POWERS SHALL FULLY AND ACCURATELY COMPLETE CARROLL COUNTY MEMORIAL HOSPITAL'S CONFLICT OF INTEREST DISCLOSURE FORM. THE FORM IS COMPLETED ANNUALLY. |
| FORM 990, PART VI, SECTION B, LINE 15 | THE COMPENSATION OF THE CEO IS REVIEWED, DETERMINED AND APPROVED BY THE CCMH BOARD OF DIRECTORS. IT IS PART OF AN EMPLOYMENT CONTRACT FOR THE CEO. COMPARATIVE DATA FOR A HOSPITAL OF THIS SIZE AND IN THIS GEOGRAPHIC AREA ARE USED AMONG OTHER FACTORS. SALARY ADJUSTMENT IS REVIEWED ANNUALLY BY THE BOARD. THE CONTRACT IS REVIEWED EVERY TWO YEARS. COMPENSATION FOR THE CFO, CNO, AND DEPARTMENT MANAGER SALARY AND WAGES ARE BASED ON A SALARY SCALE CONSIDERING YEARS OF EXPERIENCE AND YEARS OF SERVICE AT THE HOSPITAL. ANNUAL INCREASES ARE REVIEWED AND APPROVED BY THE CCMH BOARD AS PART OF THE BUDGETARY PROCESS AND AT THE TIME OF THE SALARY AND WAGE INCREASE. THE SALARY SCALE IS REVIEWED ANNUALLY THROUGH A MARKET ANALYSIS WITH COMPARATIVE DATA FOR HOSPITALS OF THIS SIZE IN THE GEOGRAPHIC AREA. |
| FORM 990, PART VI, SECTION C, LINE 19 | THE ORGANIZATION MAKES ITS GOVERNING DOCUMENTS, CONFLICT OF INTEREST POLICY, AND FINANCIAL STATEMENTS AVAILABLE TO THE PUBLIC UPON REQUEST. |
| FORM 990, PART IX, LINE 11G | COLLECTION FEES: PROGRAM SERVICE EXPENSES 73,553. MANAGEMENT AND GENERAL EXPENSES 41,373. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 114,926. PHYSICIAN FEES: PROGRAM SERVICE EXPENSES 533,503. MANAGEMENT AND GENERAL EXPENSES 300,095. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 833,598. LAUNDRY SERVICE: PROGRAM SERVICE EXPENSES 44,591. MANAGEMENT AND GENERAL EXPENSES 25,083. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 69,674. REFUSE SERVICES: PROGRAM SERVICE EXPENSES 7,094. MANAGEMENT AND GENERAL EXPENSES 3,990. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 11,084. AMBULANCE SERVICES: PROGRAM SERVICE EXPENSES 823. MANAGEMENT AND GENERAL EXPENSES 463. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 1,286. OUTSIDE GROUNDS SERVICES: PROGRAM SERVICE EXPENSES 4,671. MANAGEMENT AND GENERAL EXPENSES 2,628. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 7,299. OTHER FEES: PROGRAM SERVICE EXPENSES 1,242,869. MANAGEMENT AND GENERAL EXPENSES 282,005. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 1,524,874. |
| FORM 990, PART XII, LINE 2C: | THE PROCESS HAS NOT CHANGED FROM PRIOR YEAR. THE ORGANIZATION HAS A FINANCE COMMITTEE THAT OVERSEES THE AUDIT OF THE FINANCIAL STATEMENTS AND SELECTION OF AN INDEPENDENT AUDITOR. THE INDEPENDENT AUDITOR MEETS WITH THE FINANCE COMMITTEE AT THE CONCLUSION OF THE AUDIT. |