2013-11-15T13:16:56-06:00 2012-12-31 271235638 MOUNTJOY CHILTON MEDLEY LLP 462 S FOURTH ST SUITE 2600 LOUISVILLE KY 402023445 990 2012-01-01 611297707 CCMH CORPORATION CCMH 5027323200 309 ELEVENTH ST CARROLLTON KY 41008 MICHAEL KOZAR 5027323200 2013-11-15 1 REBECCA L PHILLIPS CPA P00024055 5027491900 2012 2016-03-07 17:11:31Z MICHAEL KOZAR 309 ELEVENTH ST CARROLLTON KY 41008 17529153 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. 10 10 204 15 0 0 149896 47094 16859508 17190867 487 459 197964 290733 17207855 17529153 0 0 0 0 8148608 8101507 0 0 0 9590414 9280587 17739022 17382094 -531167 147059 6882587 6450836 6411391 5832581 471196 618255 PROVIDE A HEALTHCARE FACILITY OFFERING ACUTE CARE, SKILLED CARE, OUTPATIENT SERVICES, AND EMERGENCY MEDICAL SERVICES TO RESIDENTS OF CARROLL COUNTY, KENTUCKY AND SURROUNDING AREAS. 0 0 13350923 16329627 SERVICED 23,311 PATIENTS THIS YEAR. APPROXIMATELY 10,676 PATIENTS WERE SERVICED IN EMERGENCY ROOMS. 2032474 PROVIDED MEDICAL CARE FOR THOSE UNABLE TO PAY 608129 992341 PROVIDED RURAL HEALTH CLINIC TO SERVE THE INDIGENT OF THE COMMUNITY 15991526 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 1 256 0 1 204 1 0 0 0 0 0 0 0 0 0 0 X 10 10 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 JEAN PYLES 1.00 X X 0 0 0 MIKE NEVIN 1.00 X X 0 0 0 DENNIS RAISOR 1.00 X 0 0 0 DONALD GARNER 1.00 X 0 0 0 DONNA BURNS 1.00 X 0 0 0 HAROLD TOMLINSON 1.00 X 0 0 0 JAMES STEVENSON 1.00 X 0 0 0 LISA JAMES 1.00 X 0 0 0 NACHO PASCUAL 1.00 X 0 0 0 NICK MARSH 1.00 X 0 0 0 KANUTE RAREY 40.00 X 150582 0 10458 STEVE EIGLE 40.00 X 94856 0 4847 JEANNINE PERRENOUD 40.00 X 298235 0 15581 KATHY SHORT 40.00 X 263162 0 4948 SHERRELL NUNNELLEY 40.00 X 207450 0 6516 MILAGROS RIVERA 40.00 X 182117 0 4730 WINSTON YAP 40.00 X 282340 0 1289 1478742 0 48369 6 0 1 0 EMCARE PHYSICIAN SERVICES 7032 COLLECTION CENTER DRIVE CHICAGO IL 60693 ER PHYSICIANS 530808 CARROLLTON INTERNAL MEDICINE 307 11TH STREET CARROLLTON KY 41008 HOSPITALISTS 178526 DIAGNOSTIC SHARED SERVICES 2650 EASTPOINT PKWY STE 300 LOUISVILLE KY 40223 MRI SERVICE 162957 HMS DIRECT 2739 MOMENTUM PLACE CHICAGO IL 60689 COMPUTER SERVICES 162300 CREST RESOURCES 735 PLAZA BLVD SUITE 210 COPPELL TX 75019 BIO MEDICAL MAINTENANCE 156301 9 47094 47094 PATIENT SERVICE REVENUE 621110 17190867 17190867 17190867 459 459 128873 0 128873 128873 128873 MEDICAID EMR INCENTIVES 900099 85000 85000 MISCELLANEOUS 900099 46101 46101 CAFETERIA SALES 722210 21523 21523 9236 9236 161860 17529153 17321968 0 160091 X 245438 150582 94856 6793848 6657971 135877 517809 512631 5178 544412 517191 27221 175575 175575 11865 11865 36329 36329 2259331 1405599 853732 13268 5440 7828 945597 936141 9456 724972 724972 19235 16542 2693 101873 101873 566489 566489 259609 259609 BAD DEBT 2823983 2823983 DRUGS & MEDICAL SUPPLIE 880887 880887 PROVIDER TAX 283192 283192 FOOD COSTS 86601 86601 91781 61823 29958 17382094 15991526 1390568 0 97019 264180 200289 499619 2291323 2034388 158027 169658 172904 163824 13591652 10933325 3101895 2658327 861130 660840 6882587 6450836 2010831 1725208 3153853 2216840 69092 90533 1177615 1800000 6411391 5832581 X 471196 618255 471196 618255 6882587 6450836 147059 0 X X 0 1 X 1 0 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 376450 376450 4507132 3964568 542564 1038755 257830 780925 7669315 6710927 958388 2658327 CERTIFICATE OF NEED 660840 660840 ADVANCES FROM CARROLL COUNTY 400000 ESTIMATED THIRD PARTY SETTLEMENTS 1400000 1800000 X 17529153 0 17529153 0 17529153 17382094 0 17382094 0 17382094 DESCRIPTION OF UNCERTAIN TAX POSITIONS UNDER FIN 48: 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 ASC. NO LIABILITY FOR UNCERTAIN TAX POSITIONS HAS BEEN RECORDED IN THE ACCOMPANYING FINANCIAL STATEMENTS. THE HOSPITAL'S 2010-2012 TAX YEARS REMAIN OPEN AND SUBJECT TO EXAMINATION. 1 1 X 1 X 1 X 1 1 0 0 1164392 409996 754396 0.05180 2601878 1852952 748926 0.05140 1105409 1105409 0.07590 4871679 2262948 2608731 0.17910 4871679 2262948 2608731 0.17910 1 2823983 650000 4847733 4804906 42827 X 1 1 1 1 CARROLL COUNTY MEMORIAL HOSPITAL

309 ELEVENTH ST CARROLLTON KY 41008

X X X X CARROLL COUNTY MEMORIAL HOSPITAL 1 1 1 100.000000000000 1 236.000000000000 1 X X 1 1 X 1 0 X X X X 1 X 0 0 3 BEDFORD FAMILY PRACTICE

470 HIGHWAY 421 NORTH BEDFORD KY 40006

PHYSICIAN OFFICE WARSAW FAMILY PRACTICE

302 W MAIN ST WARSAW KY 41095

PHYSICIAN OFFICE CARROLL COUNTY RURAL HEALTH CLINIC

309 ELEVENTH ST CARROLLTON KY 41008

RURAL 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 $ 2823983. 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 28.5%. PART III, LINE 9B: THE ORGANIZATION'S COLLECTION POLICY STATES THAT ANY PERSON INDICATING AN INABILITY TO PAY WILL BE SCREENED FOR FINANCIAL ASSISTANCE. CARROLL COUNTY MEMORIAL HOSPITAL PART V, SECTION B, LINE 20D: A 40% DISCOUNT IS OFFERRED TO ALL SELF-PAY PATIENTS. 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. X 1 1 X X X 0 0 0 0 0 0 0 0 0 KANUTE RAREY 150582 0 0 0 0 0 0 0 10458 0 161040 0 0 0 JEANNINE PERRENOUD 298235 0 0 0 0 0 0 0 15581 0 313816 0 0 0 KATHY SHORT 248162 0 0 0 15000 0 0 0 4948 0 268110 0 0 0 SHERRELL NUNNELLEY 207450 0 0 0 0 0 0 0 6516 0 213966 0 0 0 MILAGROS RIVERA 182117 0 0 0 0 0 0 0 4730 0 186847 0 0 0 WINSTON YAP 179787 0 102553 0 0 0 0 0 1289 0 283629 0 0 0 FORM 990, PART VI, SECTION A, LINE 3 ALLIANT MANAGEMENT SERVICES OVERSEES OPERATION OF THE HOSPITAL. THE COMPANY REPORTS TO THE BOARD OF DIRECTORS AND SERVES AT THEIR DIRECTION. 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 THE ORGANIZATION REGULARLY AND CONSISTENTLY MONITORS AND ENFORCES COMPLIANCE WITH THE CONFLICT OF INTEREST POLICY BY HAVING BOARD MEMBERS COMPLETE A FORM EACH YEAR. 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. OTHER FEES FORM 990, PART IX, LINE 11G COLLECTION FEES: PROGRAM SERVICE EXPENSES 55,116. MANAGEMENT AND GENERAL EXPENSES 31,003. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 86,119. PHYSICIAN FEES: PROGRAM SERVICE EXPENSES 465,551. MANAGEMENT AND GENERAL EXPENSES 261,872. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 727,423. LAUNDRY SERVICE: PROGRAM SERVICE EXPENSES 50,181. MANAGEMENT AND GENERAL EXPENSES 28,227. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 78,408. REFUSE SERVICES: PROGRAM SERVICE EXPENSES 6,465. MANAGEMENT AND GENERAL EXPENSES 3,637. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 10,102. AMBULANCE SERVICES: PROGRAM SERVICE EXPENSES 2,948. MANAGEMENT AND GENERAL EXPENSES 1,658. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 4,606. OTHER FEES: PROGRAM SERVICE EXPENSES 825,338. MANAGEMENT AND GENERAL EXPENSES 527,335. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 1,352,673. 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.