2015-11-16T13:45:52-06:00 2014-12-31 271235638 MOUNTJOY CHILTON MEDLEY LLP 462 S FOURTH ST SUITE 2600 LOUISVILLE KY 402023445 990 2014-01-01 611297707 CCMH CORPORATION CCMH 5027323200 309 ELEVENTH ST CARROLLTON KY 41008 MICHAEL KOZAR CEO 5027323200 2015-11-16 1 REBECCA L PHILLIPS CPA P00024055 5027491900 2014 2016-02-25 16:41:14Z MICHAEL KOZAR 309 ELEVENTH ST CARROLLTON KY 41008 20717539 0 X WWW.CCMHOSP.COM X 2007 KY PROVIDE A HEALTHCARE FACILITY OFFERING ACUTE CARE, SKILLED CARE, OUTPATIENT SERVICES, AND EMERGENCY MEDICAL SERVICES TO RESIDENTS OF CARROLL COUNTY, KENTUCKY AND SURROUNDING AREAS. 11 11 221 16 0 0 298163 124700 16881156 19786344 375 105 1661575 806390 18841269 20717539 0 0 0 0 8416825 8749191 0 0 0 9948450 10488390 18365275 19237581 475994 1479958 7647594 7500280 6553345 4926073 1094249 2574207 X PROVIDE A HEALTHCARE FACILITY OFFERING ACUTE CARE, SKILLED CARE, OUTPATIENT SERVICES, AND EMERGENCY MEDICAL SERVICES TO RESIDENTS OF CARROLL COUNTY, KENTUCKY AND SURROUNDING AREAS. 1 0 14417652 17904353 SERVICED 31,380 PATIENTS THIS YEAR. APPROXIMATELY 10,398 PATIENTS WERE SERVICED IN EMERGENCY ROOMS. 1239087 PROVIDED MEDICAL CARE FOR THOSE UNABLE TO PAY 2334976 2528372 PROVIDED RURAL HEALTH CLINIC TO SERVE THE INDIGENT OF THE COMMUNITY. 17991715 1 1 0 0 0 0 0 0 0 0 1 0 0 1 1 1 1 0 0 0 0 0 0 0 0 0 1 1 0 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 140 0 1 221 1 0 0 0 0 0 0 0 0 0 0 X 11 11 0 1 0 0 0 0 0 1 1 0 0 1 1 1 1 1 1 1 1 0 KY X THE ORGANIZATION 5027323200 309 ELEVENTH ST CARROLLTON KY 41008 BOBBY LEE WESTRICK TRUSTEE 1.00 X 0 0 0 MIKE NEVIN TRUSTEE TILL DEC 2014 1.00 X 0 0 0 DENNIS RAISOR CHAIRMAN 1.00 X X 0 0 0 DONNA BURNS TRUSTEE 1.00 X 0 0 0 HAROLD TOMLINSON TRUSTEE TILL DEC 2014 1.00 X 0 0 0 JAMES STEVENSON VICE CHAIR & SECRETARY 1.00 X X 0 0 0 LISA JAMES TRUSTEE 1.00 X 0 0 0 IGNACIO PASCUAL TRUSTEE 1.00 X 0 0 0 NICK MARSH TRUSTEE 1.00 X 0 0 0 RUTH BAXTER TRUSTEE 1.00 X 0 0 0 MALCOLM CARRACO TRUSTEE 1.00 X 0 0 0 ROBERT YOWLER TRUSTEE 1.00 X 0 0 0 GEORGIA HEISE TRUSTEE 1.00 X 0 0 0 ROBERT MITCHELL CFO 40.00 X 13418 0 0 CHARLIE HATFIELD CFO 40.00 X 42060 0 0 MICHAEL KOZAR CEO 40.00 X 175127 0 1169 KATHY SHORT PHYSICIAN 40.00 X 186072 0 9700 MILAGROS RIVERA PHYSICIAN 40.00 X 154343 0 0 SHERRELL NUNNELLEY PHYSICIAN 40.00 X 240486 0 23000 WINSTON YAP PHYSICIAN 40.00 X 194886 0 17500 THOMAS SLONE CRNA 40.00 X 166779 0 0 FAROOQ MIRZA PHYSICIAN 40.00 X 311846 0 0 1485017 0 51369 7 0 1 0 EMCARE PHYSICIAN SERVICES 7032 COLLECTION CENTER DRIVE CHICAGO IL 60693 EMERGENCY ROOM PHYSICIANS 607852 NUMED INC PO BOX 1098 DENTON TX 76202 MRI, ULTRASOUND, AND NUC MED SERVICES 284539 ALLIANT MANAGEMENT SERVICES 12800 N MERIDIAN STREET SUITE 400 CARMEL IN 46032 MANAGEMENT SERVICES 213498 CARROLLTON INTERNAL MEDICINE 307 11TH STREET CARROLLTON KY 41008 HOSPITALIST SERVICES 192758 CRYSTALINK INC 3007 CHARLESTON CROSSING NEW ALBANY IN 47150 INFORMATION TECHNOLOGY SERVICES 162512 10 100000 24700 124700 PATIENT SERVICE REVENUE 621110 19786344 19786344 19786344 105 105 135401 0 135401 135401 135401 MEDICAID EMR INCENTIVES 900099 507831 507831 MISCELLANEOUS 900099 138550 138550 CAFETERIA SALES 722210 24608 24608 670989 20717539 20432725 0 160114 X 231774 176296 55478 7372876 7225418 147458 543856 538406 5450 600685 570651 30034 213498 213498 29478 29478 35869 35869 2562741 1907104 655637 42315 17349 24966 936318 926955 9363 730442 730442 14816 12742 2074 72106 72106 636757 636757 179603 179603 BAD DEBT 3664261 3664261 DRUGS & MEDICAL SUPPLIE 909141 909141 PROVIDER TAX 284012 284012 FOOD COSTS 97419 97419 79614 43053 36561 19237581 17991715 1245866 0 414237 598674 50994 21718 2347842 3151281 147299 171934 815236 158613 14874997 12137777 3211146 2737220 660840 660840 7647594 7500280 2653171 2291526 2091157 1500162 41121 8400 1767896 1125985 6553345 4926073 X 1094249 2537002 37205 1094249 2574207 7647594 7500280 1479958 0 X X 0 1 X 1 0 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 376450 376450 4507132 4020047 487085 1123379 394505 728874 8868036 7723225 1144811 2737220 CERTIFICATE OF NEED 660840 660840 ADVANCES FROM CARROLL COUNTY 200000 ESTIMATED THIRD PARTY SETTLEMENTS 925985 1125985 X 17053278 0 17053278 3664261 3664261 20717539 15573320 0 15573320 3664261 3664261 19237581 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. 1 1 X 1 X 1 X 1 1 0 1 1 1855869 411914 1443955 0.09270 2375828 2087855 287973 0.01850 4231697 2499769 1731928 0.11120 4231697 2499769 1731928 0.11120 1 3664261 450000 4423772 4468457 -44685 X 1 1 1 ALLIANT MANAGEMENT MANAGEMENT CONSULTING 0.00000 0.00000 0.00000 2 UTRA GROUP GERI PHYSCH PROGRAM 0.00000 0.00000 0.00000 1 1 CARROLL COUNTY MEMORIAL HOSPITAL 309 ELEVENTH ST CARROLLTON KY 41008 X X X X CARROLL COUNTY MEMORIAL HOSPITAL 1 0 0 1 X X X X X X X X 13 1 0 0 1 X WWW.CCMHOSP.COM X 1 13 1 WWW.CCMHOSP.COM 0 0 1 X 100.000000000000 200.000000000000 X X 1 1 1 X 1 0 X X X X 1 X 0 0 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/ 3 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 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. 1 X X X 0 0 0 0 0 0 0 0 0 MICHAEL KOZAR CEO 175127 0 0 0 0 0 1169 0 0 0 176296 0 0 0 KATHY SHORT PHYSICIAN 186072 0 0 0 0 0 9700 0 0 0 195772 0 0 0 MILAGROS RIVERA PHYSICIAN 154343 0 0 0 0 0 0 0 0 0 154343 0 0 0 SHERRELL NUNNELLEY PHYSICIAN 240486 0 0 0 0 0 23000 0 0 0 263486 0 0 0 WINSTON YAP PHYSICIAN 194886 0 0 0 0 0 17500 0 0 0 212386 0 0 0 THOMAS SLONE CRNA 166779 0 0 0 0 0 0 0 0 0 166779 0 0 0 FAROOQ MIRZA PHYSICIAN 311846 0 0 0 0 0 0 0 0 0 311846 0 0 0 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.