2014-05-15T15:13:37-05:00 2013-06-30 BKD LLP 1201 Walnut Suite 1700 Kansas City MO 641062246 990 2012-07-01 440629397 CARROLL COUNTY MEMORIAL HOSPITAL % JEFF TINDLE CARR 6605421695 1502 N JEFFERSON ST Suite CARROLLTON MO 64633 JEFF TINDLE 6605421695 2014-05-15 true Michael J Engle 8162216300 2012 2015-11-30 17:44:51Z JEFF TINDLE 1502 N JEFFERSON ST CARROLLTON MO 64633 15457730 false X CARROLLCOUNTYHOSPITAL.ORG X 1957 MO CARROLL COUNTY MEMORIAL HOSPITAL IS COMMITTED TO MEETING THE CHANGING NEEDS OF OUR COMMUNITY BY PROVIDING COMPREHENSIVE, INNOVATIVE AND PROFESSIONAL QUALITY HEALTHCARE SERVICES. 9 7 177 15 0 0 2265 17685 11417157 14196300 203028 -33883 1243590 431858 12866040 14611960 5000 4966 0 0 6370781 6663126 0 0 0 6111294 8316025 12487075 14984117 378965 -372157 24796834 25902518 2874488 4206204 21922346 21696314 CARROLL COUNTY MEMORIAL HOSPITAL IS COMMITTED TO MEETING THE CHANGING NEEDS OF OUR COMMUNITY BY PROVIDING COMPREHENSIVE, INNOVATIVE AND PROFESSIONAL QUALITY HEALTHCARE SERVICES. false false 11721042 4966 14196300 ACUTE CARE HOSPITAL ORGANIZED TO PROVIDE INPATIENT AND OUTPATIENT CARE TO AREA RESIDENTS REGARDLESS OF THEIR ABILITY TO PAY. 11721042 true false false true false false false false false false true false false false false false true false false false false false false false false false true true false false true false false false false false false true true false false false false false false false false false true 25 0 true 177 true false false false false false false false false false false X 9 7 false false false false false false false true true false false true true true true false true true false false X JEFF TINDLE 6605421695 1502 NORTH JEFFERSON ST CARROLLTON MO 64633 REX BUHRMESTER 1.0 0.0 X X 0 0 0 CAROLYN LOCK 1.0 0.0 X X 0 0 RANDALL BARRY 1.0 0.0 X X 0 0 BEN POLEN 1.0 0.0 X JIM GIBSON 1.0 0.0 X CHARLIE LOCK 1.0 X BLAKE RILEY 1.0 0.0 X LINDA ROSS 1.0 0.0 X DEBBIE MINNICK 1.0 X JEFFREY TINDLE 40.0 0.0 X 153562 0 27867 RICHARD SMITH 40.0 0.0 X 348854 0 36480 TIM REID 40.0 0.0 X 134926 0 44465 JERRY DOVER 0.0 0.0 X 106255 0 15582 743597 0 124394 4 true true false CERNER CORPORATION COMPUTER SYSTEMS 312042 HSMC TECHNOLOGY IT SERVICE 224087 Copland Development Construction 240173 CLINSHARE INC NUCLEAR MEDICINE 232908 Tribridge Holdings LLC COMPUTER SYSTEMS 198786 13 17685 17685 NET PATIENT SERVICE REVENUE 621990 14196300 14196300 14196300 123280 123280 0 0 345688 345688 0 345688 345688 685054 3553 839065 6705 -154011 -3152 -157163 -157163 0 0 0 MISCELLANEOUS INCOME 900099 86170 86170 86170 14611960 14196300 397975 2566 2566 2400 2400 0 0 158559 0 158559 0 71434 71434 5304643 5063797 240846 273507 253769 19738 484847 246909 237938 370136 343425 26711 0 8305 8305 42614 42614 0 0 130 130 1988243 1479890 508353 0 114058 15209 98849 987746 584005 403741 747757 436385 311372 0 496073 462655 33418 74693 65543 9150 0 0 49022 9663 39359 0 1442538 847958 594580 523857 8036 515821 MEDICAL SUPPLIES 785506 785506 MEDICAL EQUIPMENT LEASES 58336 58336 BAD DEBT EXPENSE 931914 931914 MISCELLANEOUS EXPENSES 65233 51642 13591 14984117 11721042 3263075 0 0 0 7058597 9427632 0 0 3645265 2092723 0 0 0 0 0 0 123491 160533 69670 70505 24165203 11660858 12026667 12504345 1773144 1521444 0 0 0 0 0 0 100000 125336 24796834 25902518 1093625 1689223 0 0 0 0 0 0 0 0 0 0 1780863 2516981 0 0 0 0 2874488 4206204 X 21922346 21690978 0 5336 0 0 21922346 21696314 24796834 25902518 X -372157 140789 5336 X false true X true false X X true false false false false false true 2870 false false false 2870 false false 251007 251007 18472949 8302324 10170625 5295993 3294057 2001936 145254 64477 80777 12504345 13820835 140789 140789 13680046 931914 931914 14611960 14052203 14052203 931914 931914 14984117 UNCERTAIN TAX POSITIONS DISCLOSURE SCHEDULE D, PART X, LINE 2 MANAGEMENT HAS EVALUATED THEIR INCOME TAX POSITIONS UNDER THE GUIDANCE INCLUDED IN ASC 740. BASED ON THEIR REVIEW, MANAGEMENT HAS NOT IDENTIFIED ANY MATERIAL UNCERTAIN TAX POSITIONS TO BE RECORDED OR DISCLOSED IN THE FINANCIAL STATEMENTS. RECONCILIATION OF REVENUE PER AUDITED FINANCIAL STATEMENTS SCHEDULE D, PART XI, LINE 4B BAD DEBT EXPENSE $ 931,914 RECONCILIATION OF EXPENSES PER AUDITED FINANCIAL STATEMENTS SCHEDULE D, PART XII, LINE 4B BAD DEBT EXPENSE $ 931,914 true true true X true X true false true true 55344 55344 0.00390 1642403 1488307 154096 0.01100 1697747 1488307 209440 0.01490 551664 551664 0.03930 551664 551664 0.03930 2249411 1488307 761104 0.05420 false 931914 205021 6634451 6713713 -79262 X true true NONE 1 1 CARROLL COUNTY MEMORIAL HOSPITAL

1502 NORTH JEFFERSON ST CARROLLTON MO 64633

X X X X PHYSICIAN CLINICS CARROLL COUNTY MEMORIAL HOSPITAL 1 true X X X X X X X X X 12 true false true X X X X X X X true false true true 100 true 200. true X true true X true false X X X true X false false 5 JEFFERSON MEDICAL GROUP - CARROLLTON

1403 JEFFERSON CARROLLTON MO 64633

RURAL HEALTH CLINIC JEFFERSON MEDICAL GROUP - NORBONNE

105 EAST 2ND STREET NORBONNE MO 64668

RURAL HEALTH CLINIC JEFFERSON MEDICAL GROUP - HALE

321 ELM STREET HALE MO 64643

RURAL HEALTH CLINIC REID MEDICAL GROUP

1401 N JEFFERSON CARROLLTON MO 64633

RURAL HEALTH CLINIC CCMH HOME HEALTH

1502 N JEFFERSON ST CARROLLTON MO 64633

HOME HEALTH AGENCY SCHEDULE H, PART I, LINE 7 THE COSTING METHODOLOGY USED TO CALCULATE THE AMOUNTS REPORTED IN THE TABLE WAS THE COST TO CHARGE RATIO DERIVED FROM WORKSHEET 2. SCHEDULE H, PART I, LINE 7, COLUMN F THE AMOUNT OF BAD DEBT EXPESNE INCLUDED ON FORM 990, PART IX, LINE 25 COLUMN (A) BUT SUBTRACTED FOR PURPOSES OF CALCULATING THE PERCENTAGE IN THIS COLUMN IS $931,914. SCHEDULE H, PART I, LINE 7G NO PHYSICIAN CLINIC COSTS ARE INCLUDED. BAD DEBT EXPENSE SCHEDULE H, PART III, LINES 2 & 3 LINE 2: THE HOSPITAL ESTIMATES THIS ALLOWANCE BASED ON THE AGING OF EACH TYPE OF PAYOR. THE HOSPITAL'S BAD DEBT AT COST WAS DETERMINED BY APPLYING AN OVERALL RATIO OF COST TO CHARGES. LINE 3: THE AMOUNT OF BAD DEBT ATTRIBUTABLE TO PATIENTS ELIGIBLE FOR CHARITY CARE IS BASED ON SELF-PAY ONLY PATIENTS COVERED BY MEDICAID. BAD DEBT EXPENSE SCHEDULE H, PART III, LINE 4 THE FOOTNOTE THAT DESCRIBES BAD DEBT EXPENSE CAN BE FOUND ON PAGE 7 OF THE ATTACHED FINANCIAL STATEMENTS. MEDICARE SCHEDULE H, PART III, LINE 8 THE MEDICARE ALLOWABLE FAILS TO COVER COST. NON-PAYMENT BY MEDICARE RECIPIENTS FOR THEIR DEDUCTIBLE AND COINSURANCE AMOUNTS INCREASES FINANCIAL ASSISTANCE AND BAD DEBT. THESE SHORTFALLS DECREASE THE ORGANIZATION'S POOL OF ASSETS AND IT'S ABILITY TO SUCCESSFULLY ATTRACT HIGHLY-TRAINED STAFF AND INVEST IN MEDICAL TECHNOLOGY. IF SERVICES ARE TO BE MAINTAINED, THEN THE COSTS WILL HAVE TO BE COVERED BY THOSE WHO PAY. THE COSTING METHODOLGY USED WAS THE COST TO CHARGE METHOD, USING THE COST TO CHARGE % FROM WORKSHEET 2. COLLECTION PRACTICES SCHEDULE H, PART III, LINE 9B EACH PATIENT IS PROVIDED WITH PAYMENT INFORMATION IN CLEAR, EASY-TO-UNDERSTAND LANGUAGE. CCMH CHECKS ON PUBLIC-ASSISTANCE PROGRAMS TO SEE IF THE PATIENT QUALIFIES. THE HOSPITAL OFFERS DISCOUNTS ON CHARGES TO UNDERINSURED AND UNINSURED PATIENTS WHEN POSSIBLE. SCHEDULE H, PART V, LINE 3 Stakeholder and local business owners/community leaders were interviewed to discuss the future of CCMH and what they saw as a health need for the community. A local physician was interviewed to gather his thoughts of the health of the community. An RN from the Carroll County Health Department was consulted to help with reports regarding public health. SCHEDULE H, PART V, LINE 20D THE HOSPITAL UTILIZES A STANDARDIZED CHARGE RATE FOR EACH PROCEDURE AND SUPPLY CHARGED TO PATIENTS REGARDLESS OF PAYOR TYPE OR ABILITY TO PAY. NEEDS ASSESSMENT SCHEDULE H, PART VI, LINE 2 CARROLL COUNTY MEMORIAL HOSPITAL RELIES ON INTERACTION WITH LOCAL HEALTH CARE AGENCIES AS WELL AS FEEDBACK FROM PATIENTS AND PRIMARY SERVICE AREA RESIDENTS TO ASSESS THE HEALTH CARE NEEDS OF THE COMMUNITY. PATIENT EDUCATION OF ELIGIBILITY FOR ASSISTANCE SCHEDULE H, PART VI, LINE 3 CARROLL COUNTY MEMORIAL HOSPITAL PROVIDES EACH PATIENT WITH A LETTER THAT CLEARLY STATES PAYMENT INFORMATION IN AN EASY-TO-UNDERSTAND LANGUAGE. THE HOSPITAL INFORMS PATIENTS PROMPTLY ABOUT THE CHARGE FOR ANY ITEM OR SERVICE PROVIDED. THE LETTER INFORMS THE PATIENT THAT IF THEY ARE NOT ABLE TO PAY THEIR HOSPITAL BILL THERE ARE PROGRAMS THAT MAY HELP ALLEVIATE THE BURDEN. IF THE HOSPITAL IS PROMPTED IT WILL CHECK FOR PUBLIC-ASSISSTANCE OR CHARITY CARE PROGRAMS TO SEE IF THE PATIENT QUALIFIES. COMMUNITY INFORMATION SCHEDULE H, PART VI, LINE 3 CARROLL COUNTY MEMORIAL HOSPITAL IS LOCATED IN CARROLLTON, MISSOURI. THE HOSPITALS PRIMARY SERVICE AREA CONSISTS OF CARROLLTON AND THE SURRONDING AREAS OF CARROLL COUNTY. CARROLL COUNTY MEMORIAL HOSPITAL OPERATES TWO SATELLITE CLINICS LOCATED IN HALE AND NORBORNE. CARROLL COUNTY HAS A POPULATION OF APPROXIMATELY 9,300 RESIDENTS, WITH 35% OF THE RESIDENTS LIVING IN URBAN AREAS AND 65% LIVING IN RURAL AREAS. THE MEDIAN ANNUAL HOUSEHOLD INCOME FOR CARROLL COUNTY IS APPROXIMATELY $36,500. APPROXIMATELY 13.7% OF CARROLL COUNTY RESIDENTS HAVE ANNUAL INCOME BELOW THE FEDERAL POVERTY LEVEL, AND 4.5% OF CARROLL COUNTY RESIDENTS HAVE ANNUAL INCOME BELOW 50% OF THE FEDERAL POVERTY LEVEL. THE CLOSEST HOSPITALS ARE LOCATED IN MARSHALL, LEXINGTON, AND RICHMOND. THE DISTANCE BETWEEN CARROLL COUNTY MEMORIAL HOSPITAL AND THESE FACILITIES IS APPROXIMATELY 20, 25, AND 27 MILES. PROMOTION OF COMMUNITY HEALTH SCHEDULE H, PART VI, LINE 4 THE HOSPITALS BOARD OF DIRECTORS IS ELECTED FROM THE LOCAL COMMUNITY AND SURROUNDING AREA THAT COMPRISES THE LOCAL SERVICE AREA. THE HOSPITAL'S ACTIVE MEDICAL STAFF MEMBERS ARE RESIDENTS OF THE COUNTY. CCMH SPONSORS COMMUNITY HEALTH FAIRS AND EDUCATION CLASSES IN MANY AREAS. ANY SURPLUS IN FUNDS ARE REINVESTED IN THE HOSPITAL'S FACILITIES AND PATIENT SERVICE PROGRAMS. CCMH HAS INVESTED OVER $15 MILLION IN PATIENT CARE IMPROVEMENTS OVER THE PAST 8 YEARS. X true true X X false false false true false false false false false JEFFREY TINDLE 142047 0 0 0 11515 0 12285 0 15582 0 181429 0 0 0 RICHARD SMITH 334125 0 0 0 14729 0 14400 0 22080 0 385334 0 0 0 TIM REID 131618 0 0 0 3308 0 11385 0 33080 0 179391 0 0 0 JERRY DOVER 105697 0 0 0 558 0 0 0 15582 0 121837 0 0 0 OTHER COMPENSATION SCHEDULE J, PART I, LINE 1A ALL STAFF RECEIVE MEMBERSHIP TO LIFESTYLE FITNESS. LIONS AND KIWANIS CLUB MEMBERSHIPS ARE PAID FOR JEFFERY TINDLE & JERRY DOVER, THE MEMBERSHIPS WERE USED ONLY FOR BUSINESS PURPOSES, THEREFORE THE AMOUNT OF THE DUES WERE NOT INCLUDED IN HIS W-2. COUNTRY CLUB DUES WERE PAID FOR JEFFERY TINDLE & JERRY DOVER, THE AMOUNT OF THE DUES WAS NOT INCLUDED IN HIS W-2. COMPENSATION CONTINGENT ON REVENUES SCHEDULE J, PART I, LINE 5 PHYSICIAN BONUSES WERE CALCULATED QUARTERLY USING A % OF GROSS CHARGES. SEE SCHEDULE L PART V BUSINESS TRANSACTIONS INVOLVING INTERESTED PERSONS SCHEDULE L, PART IV, LINE 1 (A) MARVIN ROSS (B) SPOUSE OF BOARD MEMBER, LINDA ROSS (C) $46,153.86 (D) EMPLOYED PHYSICIAN OF CARROLL COUNTY MEMORIAL HOSPITAL (E) NO (A) SUSAN STARK (B) SISTER OF BOARD MEMBER, RANDALL BARRY (C) $25,279.86 (D) EMPLOYED REGISTERED NURSE OF CARROLL COUNTY MEMORIAL HOSPITAL (E) NO FORM 990 REVIEW PROCESS Form 990, Part VI, SECTION B, LINE 11B AN INDEPENDENT ACCOUNTING FIRM PREPARES AND REVIEWS THE 990. THE 990 IS THEN REVIEWED BY THE ORGANIZATION'S OFFICERS AND ACCOUNTING PERSONNEL. ANY QUESTIONS AND CONCERNS THE ORGANIZATION'S OFFICERS AND ACCOUNTING PERSONNEL HAVE ARE ADDRESSED AND ANY CORRECTIONS OR CLARIFICATIONS THAT NEED TO BE MADE ARE MADE. THE FINAL FORM 990 WITH ALL REQUIRED SCHEDULES IS THEN PROVIDED TO ALL VOTING MEMBERS OF THE BOARD PRIOR TO FILING THE 990. MONITORING OF CONFLICT OF INTEREST POLICY Form 990, Part VI, SECTION B, LINE 12C THE BOARD SETS POLICY AND ADMINISTRATION IS CHARGED WITH ASSURING THAT COMPLIANCE IS MAINTAINED. Conflict of interest is reviewed annually and each board member signs a conflict of interest disclosure form. IF A CONFLICT ARISES THE CONFLICTED PERSON DOES NOT TAKE PART IN THE VOTE ON THE ISSUE. COMPENSATION REVIEW Form 990, Part VI, SECTION B, LINES 15A & 15B LINE 15A: THE CEO IS HIRED, REVIEWED AND COMPENSATION IS SET BY THE BOARD. COMPENSATION REVIEWS OCCUR ANNUALLY WITH THE LAST ONE BEING CONDUCTED IN DECEMBER OF 2012. LINE 15B: ALL OTHER MANAGEMENT POSITIONS ARE HIRED, REVIEWED, AND MONITORED BY THE CEO, CNO AND COO. COMPENSATION REVIEWS OCCUR ANNUALLY. AVAILABILITY OF DOCUMENTS Form 990, Part VI, SECTION C, LINE 19 THE ORGANIZATIONS GOVERNING DOCUMENTS, CONFLICT OF INTEREST POLICY, AND FINANCIAL STATEMENTS ARE AVAILABLE UPON REQUEST. RECONCILIATION OF NET ASSETS FORM 990, PART XI, LINE 9 CHANGE IN BENEFICIAL INTEREST IN FOUNDATION $ 5,336 OTHER FEES FOR SERVICES FOR NON-EMPLOYEES FORM 990 PART IX LINE 11G DESCRIPTION:ER PHYSICIAN FEES TOTAL FEES:537985 OTHER FEES FOR SERVICES FOR NON-EMPLOYEES FORM 990 PART IX LINE 11G DESCRIPTION:MEDICAID ADMINISRATION TOTAL FEES:486135 OTHER FEES FOR SERVICES FOR NON-EMPLOYEES FORM 990 PART IX LINE 11G DESCRIPTION:OTHER CONTRACT SERVICES TOTAL FEES:964123