CARROLL COUNTY MEMORIAL HOSPITAL: Form 990, tax year 2010
View the entire original 990 at ProPublica ↗
- Organization
- CARROLL COUNTY MEMORIAL HOSPITAL (EIN 44-0629397)
- Tax period
- 2010-07-01 to 2011-06-30
- Filed
- 2012-05-14
- IRS object ID
- 201201359349302255
- Schema version
- 2010v3.4
- 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) |
|---|---|---|
| Timestamp | 2012-05-14T10:35:58-05:00 | Timestamp |
| Tax Period End Date | 2011-06-30 | TaxPeriodEndDate |
Preparer Firm PreparerFirm
Preparer Firm Business Name PreparerFirmBusinessName
| Field | Value | IRS element (for citing) |
|---|---|---|
| Business Name Line1 | Wendling Noe Nelson & Johnson LLC | BusinessNameLine1 |
Preparer Firm US Address PreparerFirmUSAddress
| Field | Value | IRS element (for citing) |
|---|---|---|
| Address Line1 | 534 S Kansas Ave Suite 1500 | AddressLine1 |
| City | Topeka | City |
| State | KS | State |
| ZIP Code | 666033491 | ZIPCode |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Return Type | 990 | ReturnType |
| Tax Period Begin Date | 2010-07-01 | TaxPeriodBeginDate |
Filer Filer
| Field | Value | IRS element (for citing) |
|---|---|---|
| EIN | 440629397 | EIN |
Name Name
| Field | Value | IRS element (for citing) |
|---|---|---|
| Business Name Line1 | Carroll County Memorial Hospital | BusinessNameLine1 |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Name Control | CARR | NameControl |
| Phone | 6605421695 | Phone |
US Address USAddress
| Field | Value | IRS element (for citing) |
|---|---|---|
| Address Line1 | 1502 N Jefferson St | AddressLine1 |
| City | Carrollton | City |
| State | MO | State |
| ZIP Code | 64633 | ZIPCode |
Officer Officer
| Field | Value | IRS element (for citing) |
|---|---|---|
| Name | Jeff Tindle | Name |
| Title | CEO | Title |
| Phone | 6605421695 | Phone |
| Date Signed | 2012-05-10 | DateSigned |
| Authorize Third Party | 1 | AuthorizeThirdParty |
Preparer Preparer
| Field | Value | IRS element (for citing) |
|---|---|---|
| Name | Gary D Knoll | Name |
| Phone | 7852334226 | Phone |
| Date Prepared | 2012-05-10 | DatePrepared |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Tax Year | 2010 | TaxYear |
| Build TS | 2016-02-24 21:20:13Z | BuildTS |
Form 990 IRS990
| Field | Value | IRS element (for citing) |
|---|---|---|
| Name Of Principal Officer Person | Jeff Tindle | NameOfPrincipalOfficerPerson |
Address Principal Officer US AddressPrincipalOfficerUS
| Field | Value | IRS element (for citing) |
|---|---|---|
| Address Line1 | 1502 N Jefferson St | AddressLine1 |
| City | Carrollton | City |
| State | MO | State |
| ZIP Code | 64633 | ZIPCode |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Gross Receipts | 12653964 | GrossReceipts |
| Group Return For Affiliates | 0 | GroupReturnForAffiliates |
| Organization501c3 | X | Organization501c3 |
| Web Site | N/A | WebSite |
| Type Of Organization Corporation | X | TypeOfOrganizationCorporation |
| Year Formation | 1957 | YearFormation |
| State Legal Domicile | MO | StateLegalDomicile |
| Activity Or Mission Description | Carroll County Memorial Hospital is an acute care hospital providing inpatient and outpatient medical care regardless of ability to pay. | ActivityOrMissionDescription |
| Nbr Voting Members Governing Body | 9 | NbrVotingMembersGoverningBody |
| Nbr Independent Voting Members | 9 | NbrIndependentVotingMembers |
| Total Nbr Employees | 190 | TotalNbrEmployees |
| Total Nbr Volunteers | 0 | TotalNbrVolunteers |
| Total Gross UBI | 0 | TotalGrossUBI |
| Net Unrelated Business Txbl Income | 0 | NetUnrelatedBusinessTxblIncome |
| Contributions Grants Prior Year | 8960 | ContributionsGrantsPriorYear |
| Contributions Grants Current Year | 1740 | ContributionsGrantsCurrentYear |
| Program Service Revenue Prior Year | 12629286 | ProgramServiceRevenuePriorYear |
| Program Service Revenue CY | 12289337 | ProgramServiceRevenueCY |
| Investment Income Prior Year | 224828 | InvestmentIncomePriorYear |
| Investment Income Current Year | 198503 | InvestmentIncomeCurrentYear |
| Other Revenue Prior Year | 121255 | OtherRevenuePriorYear |
| Other Revenue Current Year | 164159 | OtherRevenueCurrentYear |
| Total Revenue Prior Year | 12984329 | TotalRevenuePriorYear |
| Total Revenue Current Year | 12653739 | TotalRevenueCurrentYear |
| Grants And Similar Amnts Prior Year | 0 | GrantsAndSimilarAmntsPriorYear |
| Grants And Similar Amnts CY | 2500 | GrantsAndSimilarAmntsCY |
| Benefits Paid To Members Prior Year | 0 | BenefitsPaidToMembersPriorYear |
| Benefits Paid To Members CY | 0 | BenefitsPaidToMembersCY |
| Salaries Etc Prior Year | 6870281 | SalariesEtcPriorYear |
| Salaries Etc Current Year | 7063626 | SalariesEtcCurrentYear |
| Total Prof Fundrsng Exp Prior Year | 0 | TotalProfFundrsngExpPriorYear |
| Total Prof Fundrsng Exp CY | 0 | TotalProfFundrsngExpCY |
| Total Fundrsng Exp Current Year | 0 | TotalFundrsngExpCurrentYear |
| Other Expense Prior Year | 5387191 | OtherExpensePriorYear |
| Other Expenses Current Year | 6015750 | OtherExpensesCurrentYear |
| Total Expenses Prior Year | 12257472 | TotalExpensesPriorYear |
| Total Expenses Current Year | 13081876 | TotalExpensesCurrentYear |
| Revenues Less Expenses Prior Year | 726857 | RevenuesLessExpensesPriorYear |
| Revenues Less Expenses CY | -428137 | RevenuesLessExpensesCY |
| Total Assets BOY | 22779169 | TotalAssetsBOY |
| Total Assets EOY | 23189013 | TotalAssetsEOY |
| Total Liabilities BOY | 1049342 | TotalLiabilitiesBOY |
| Total Liabilities EOY | 1624253 | TotalLiabilitiesEOY |
| Net Assets Or Fund Balances BOY | 21729827 | NetAssetsOrFundBalancesBOY |
| Net Assets Or Fund Balances EOY | 21564760 | NetAssetsOrFundBalancesEOY |
| Mission Description | To improve the health of the community by assuring excellent medical care to our citizens. | MissionDescription |
| Significant New Program Services | 0 | SignificantNewProgramServices |
| Significant Change | 0 | SignificantChange |
| Expense | 10038057 | Expense |
| Revenue | 12289337 | Revenue |
| Description | Acute care hospital organized to provide inpatient and outpatient care to area residents regardless of their ability to pay. | Description |
| Total Program Service Expense | 10038057 | TotalProgramServiceExpense |
| Described In501 C3 | 1 | DescribedIn501C3 |
| Schedule B Required | 0 | ScheduleBRequired |
| Political Activities | 0 | PoliticalActivities |
| Lobbying Activities | 0 | LobbyingActivities |
| Donor Advised Funds | 0 | DonorAdvisedFunds |
| Conservation Easements | 0 | ConservationEasements |
| Collections Of Art | 0 | CollectionsOfArt |
| Credit Counseling | 0 | CreditCounseling |
| Term Or Permanent Endowments | 0 | TermOrPermanentEndowments |
| Report Land Bldg Equip | 1 | ReportLandBldgEquip |
| Report Invest Oth Securities | 1 | ReportInvestOthSecurities |
| Report Prog Rel Invest | 0 | ReportProgRelInvest |
| Report Other Assets | 0 | ReportOtherAssets |
| Report Other Liabilities | 1 | ReportOtherLiabilities |
| Report Fin48 Footnote | 0 | ReportFin48Footnote |
| Independent Audit Financial Stmt | 1 | IndependentAuditFinancialStmt |
| Consolidated Audit Financial Stmt | 0 | ConsolidatedAuditFinancialStmt |
| School | 0 | School |
| Foreign Office | 0 | ForeignOffice |
| Foreign Activities | 0 | ForeignActivities |
| More Than5000 K To Organizations | 0 | MoreThan5000KToOrganizations |
| More Than5000 K To Individuals | 0 | MoreThan5000KToIndividuals |
| Professional Fundraising | 0 | ProfessionalFundraising |
| Fundraising Activities | 0 | FundraisingActivities |
| Gaming | 0 | Gaming |
| Hospital | 1 | Hospital |
| Financial Stmt Attached | 1 | FinancialStmtAttached |
| Grants To Organizations | 0 | GrantsToOrganizations |
| Grants To Individuals | 0 | GrantsToIndividuals |
| Schedule J Required | 1 | ScheduleJRequired |
| Tax Exempt Bonds | 0 | TaxExemptBonds |
| Excess Benefit Transaction | 0 | ExcessBenefitTransaction |
| Prior Excess Benefit Transaction | 0 | PriorExcessBenefitTransaction |
| Loan To Officer Or DQP | 1 | LoanToOfficerOrDQP |
| Grant To Related Person | 0 | GrantToRelatedPerson |
| Bsnss Rltnshp With Organization | 0 | BsnssRltnshpWithOrganization |
| Bsnss Rltnshp Thru Family Member | 0 | BsnssRltnshpThruFamilyMember |
| Officer Entity With Bsnss Rltnshp | 0 | OfficerEntityWithBsnssRltnshp |
| Deductible Non Cash Contributions | 0 | DeductibleNonCashContributions |
| Deductible Contributions Of Art | 0 | DeductibleContributionsOfArt |
| Terminated | 0 | Terminated |
| Partial Liquidation | 0 | PartialLiquidation |
| Disregarded Entity | 0 | DisregardedEntity |
| Related Entity | 0 | RelatedEntity |
| Related Org Controlled Entity | 0 | RelatedOrgControlledEntity |
| Transaction Related Entity | 0 | TransactionRelatedEntity |
| Transfers To Exempt Non Chrtbl Org | 0 | TransfersToExemptNonChrtblOrg |
| Activities Conducted Partnership | 0 | ActivitiesConductedPartnership |
| Schedule O Required | 1 | ScheduleORequired |
| Number Forms Transmitted With1096 | 12 | NumberFormsTransmittedWith1096 |
| Number W2 G Included | 0 | NumberW2GIncluded |
| Compliance With Backup Witholding | 1 | ComplianceWithBackupWitholding |
| Number Of Employees | 190 | NumberOfEmployees |
| Employment Tax Returns Filed | 1 | EmploymentTaxReturnsFiled |
| Unrelated Business Income | 0 | UnrelatedBusinessIncome |
| Foreign Financial Account | 0 | ForeignFinancialAccount |
| Prohibited Tax Shelter Trans | 0 | ProhibitedTaxShelterTrans |
| Taxable Party Notification | 0 | TaxablePartyNotification |
| Non Deductible Contributions | 0 | NonDeductibleContributions |
| Quid Pro Quo Contributions | 0 | QuidProQuoContributions |
| Form8282 Property Disposed Of | 0 | Form8282PropertyDisposedOf |
| Funds To Pay Premiums | 0 | FundsToPayPremiums |
| Premiums Paid | 0 | PremiumsPaid |
| Form8899 Filed | 0 | Form8899Filed |
| Form1098 C Filed | 0 | Form1098CFiled |
| Indoor Tanning Services | 0 | IndoorTanningServices |
| Info In Schedule O Part VI | X | InfoInScheduleOPartVI |
| Nbr Voting Governing Body Members | 9 | NbrVotingGoverningBodyMembers |
| Number Independent Voting Members | 9 | NumberIndependentVotingMembers |
| Family Or Business Relationship | 0 | FamilyOrBusinessRelationship |
| Delegation Of Management Duties | 0 | DelegationOfManagementDuties |
| Changes To Organizing Docs | 0 | ChangesToOrganizingDocs |
| Material Diversion Or Misuse | 0 | MaterialDiversionOrMisuse |
| Members Or Stockholders | 0 | MembersOrStockholders |
| Election Of Board Members | 0 | ElectionOfBoardMembers |
| Decisions Subject To Approval | 0 | DecisionsSubjectToApproval |
| Minutes Of Governing Body | 1 | MinutesOfGoverningBody |
| Minutes Of Committees | 1 | MinutesOfCommittees |
| Officer Mailing Address | 0 | OfficerMailingAddress |
| Local Chapters | 0 | LocalChapters |
| Form990 Provided To Governing Body | 1 | Form990ProvidedToGoverningBody |
| Conflict Of Interest Policy | 1 | ConflictOfInterestPolicy |
| Annual Disclosure Covered Persons | 1 | AnnualDisclosureCoveredPersons |
| Regular Monitoring Enforcement | 1 | RegularMonitoringEnforcement |
| Whistleblower Policy | 0 | WhistleblowerPolicy |
| Document Retention Policy | 1 | DocumentRetentionPolicy |
| Compensation Process CEO | 1 | CompensationProcessCEO |
| Compensation Process Other | 0 | CompensationProcessOther |
| Investment In Joint Venture | 0 | InvestmentInJointVenture |
| States Where Copy Of Return Is Filed | MO | StatesWhereCopyOfReturnIsFiled |
| Own Website | X | OwnWebsite |
| Other Website | X | OtherWebsite |
| Upon Request | X | UponRequest |
The Books Are In Care Of TheBooksAreInCareOf
Name Business NameBusiness
| Field | Value | IRS element (for citing) |
|---|---|---|
| Business Name Line1 | Jeff Tindle CEO | BusinessNameLine1 |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Telephone Number | 6605421695 | TelephoneNumber |
Address US AddressUS
| Field | Value | IRS element (for citing) |
|---|---|---|
| Address Line1 | 1502 North Jefferson | AddressLine1 |
| City | Carrollton | City |
| State | MO | State |
| ZIP Code | 64633 | ZIPCode |
Form990 Part VII Section A Form990PartVIISectionA (15 entries)
| TitleTitle | Average Hours Per WeekAverageHoursPerWeek | Individual Trustee Or DirectorIndividualTrusteeOrDirector | OfficerOfficer | Reportable Comp From OrganizationReportableCompFromOrganization | Reportable Comp From Related OrgsReportableCompFromRelatedOrgs | Other CompensationOtherCompensation | Highest Compensated EmployeeHighestCompensatedEmployee |
|---|---|---|---|---|---|---|---|
| Edward E Butts | |||||||
| President | 4.00 | X | X | 0 | 0 | 0 | |
| Stanley Kruse | |||||||
| Vice President | 4.00 | X | X | 0 | 0 | 0 | |
| Rex Buhrmester | |||||||
| Secretary | 4.00 | X | X | 0 | 0 | 0 | |
| Carolyn Lock | |||||||
| Director | 4.00 | X | 0 | 0 | 0 | ||
| Linda Ross | |||||||
| Director | 4.00 | X | 0 | 0 | 0 | ||
| Dick Woodward | |||||||
| Director | 4.00 | X | 0 | 0 | 0 | ||
| Donald Kampschmidt | |||||||
| Director | 4.00 | X | 0 | 0 | 0 | ||
| Randall Barry | |||||||
| Director | 4.00 | X | 0 | 0 | 0 | ||
| Debbie Minnick | |||||||
| Director | 4.00 | X | 0 | 0 | 0 | ||
| Jerry Dover | |||||||
| CEO | 40.00 | X | 163733 | 0 | 17894 | ||
| Jeffrey Tindle | |||||||
| CFO | 40.00 | X | 116520 | 0 | 14117 | ||
| Waclaw ADymek | |||||||
| Physician | 40.00 | 173206 | 0 | 18652 | X | ||
| Julie Marvin | |||||||
| Pharmacist | 40.00 | 115680 | 0 | 9254 | X | ||
| Richard Smith | |||||||
| Physician | 40.00 | 173523 | 0 | 25080 | X | ||
| Tim Reid | |||||||
| Physician | 40.00 | 137740 | 0 | 10680 | X | ||
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Reportable Comp From Org | 880402 | TotalReportableCompFromOrg |
| Total Reportable Comp Frm Rltd Orgs | 0 | TotalReportableCompFrmRltdOrgs |
| Total Other Compensation | 95677 | TotalOtherCompensation |
| Number Individuals GT100 K | 6 | NumberIndividualsGT100K |
| Formers Listed | 0 | FormersListed |
| Total Comp GT150 K | 1 | TotalCompGT150K |
| Compensation From Other Sources | 0 | CompensationFromOtherSources |
Contractor Compensation ContractorCompensation (5 entries)
| Address Line1AddressOfContractor/AddressUS/AddressLine1 | CityAddressOfContractor/AddressUS/City | StateAddressOfContractor/AddressUS/State | ZIP CodeAddressOfContractor/AddressUS/ZIPCode | Description Of ServicesDescriptionOfServices | CompensationCompensation |
|---|---|---|---|---|---|
| Clinishare Inc | |||||
| 19600 E 39th Street | Independence | MO | 64057 | Nuclear Medicine | 259334 |
| Cerner Corporation | |||||
| PO Box 412702 | Kansas City | MO | 64141 | Computer Systems | 221280 |
| HSMC Technology Services Inc | |||||
| 3550 NE Ralph Powell Rd | Lees Summit | MO | 64064 | IT Service | 185883 |
| Richard L Smith MD | |||||
| 20644 HWY Z | Chillicothe | MO | 64601 | ER Physician Coverage | 142907 |
| Emcare Physician Services | |||||
| 7032 Collection Center Dr | Chicago | IL | 60693 | ER Physician Coverage | 137099 |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Number Of Contractors GT100 K | 6 | NumberOfContractorsGT100K |
| All Other Contributions | 1740 | AllOtherContributions |
| Total Contributions | 1740 | TotalContributions |
Program Service Revenue ProgramServiceRevenue
| Field | Value | IRS element (for citing) |
|---|---|---|
| Description | Net Patient service re | Description |
| Business Code | 621990 | BusinessCode |
| Total Revenue Column | 12289337 | TotalRevenueColumn |
| Related Or Exempt Function Income | 12289337 | RelatedOrExemptFunctionIncome |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Program Service Revenue | 12289337 | TotalProgramServiceRevenue |
Investment Income InvestmentIncome
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Revenue Column | 198728 | TotalRevenueColumn |
| Exclusion | $198,728 | ExclusionAmount |
Gross Rents GrossRents
| Field | Value | IRS element (for citing) |
|---|---|---|
| Real | 60000 | Real |
Rental Income Or Loss RentalIncomeOrLoss
| Field | Value | IRS element (for citing) |
|---|---|---|
| Real | 60000 | Real |
Net Rental Income Or Loss NetRentalIncomeOrLoss
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Revenue Column | 60000 | TotalRevenueColumn |
| Exclusion | $60,000 | ExclusionAmount |
Less Cost Oth Basis Sales Expenses LessCostOthBasisSalesExpenses
| Field | Value | IRS element (for citing) |
|---|---|---|
| Securities | 225 | Securities |
Gain Or Loss GainOrLoss
| Field | Value | IRS element (for citing) |
|---|---|---|
| Securities | -225 | Securities |
Net Gain Or Loss Investments NetGainOrLossInvestments
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Revenue Column | -225 | TotalRevenueColumn |
| Exclusion | -$225 | ExclusionAmount |
Other Revenue Misc OtherRevenueMisc (3 entries)
| DescriptionDescription | Business CodeBusinessCode | Total Revenue ColumnTotalRevenueColumn | ExclusionExclusionAmount |
|---|---|---|---|
| Other income | 900099 | 86606 | $86,606 |
| Vending | 900099 | 7928 | $7,928 |
| Medical record fees | 621990 | 5168 | $5,168 |
Miscellaneous Revenue MiscellaneousRevenue
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Revenue Column | 4457 | TotalRevenueColumn |
| Exclusion | $4,457 | ExclusionAmount |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Other Revenue | 104159 | TotalOtherRevenue |
Total Revenue TotalRevenue
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Revenue Column | 12653739 | TotalRevenueColumn |
| Related Or Exempt Function Income | 12289337 | RelatedOrExemptFunctionIncome |
| Unrelated Business Revenue | 0 | UnrelatedBusinessRevenue |
| Exclusion | $362,662 | ExclusionAmount |
Grants To Domestic Individuals GrantsToDomesticIndividuals
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | 2500 | Total |
| Program Services | 2500 | ProgramServices |
Comp Current Officers Directors CompCurrentOfficersDirectors
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | 329346 | Total |
| Management And General | 329346 | ManagementAndGeneral |
Other Salaries And Wages OtherSalariesAndWages
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | 5396414 | Total |
| Program Services | 4565141 | ProgramServices |
| Management And General | 831273 | ManagementAndGeneral |
Pension Plan Contributions PensionPlanContributions
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | 308865 | Total |
| Program Services | 266687 | ProgramServices |
| Management And General | 42178 | ManagementAndGeneral |
Other Employee Benefits OtherEmployeeBenefits
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | 636971 | Total |
| Program Services | 518772 | ProgramServices |
| Management And General | 118199 | ManagementAndGeneral |
Payroll Taxes PayrollTaxes
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | 392030 | Total |
| Program Services | 313636 | ProgramServices |
| Management And General | 78394 | ManagementAndGeneral |
Fees For Services Legal FeesForServicesLegal
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | 9000 | Total |
| Program Services | 14 | ProgramServices |
| Management And General | 8986 | ManagementAndGeneral |
Fees For Services Other FeesForServicesOther
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | 954882 | Total |
| Program Services | 898447 | ProgramServices |
| Management And General | 56435 | ManagementAndGeneral |
Advertising Advertising
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | 19753 | Total |
| Program Services | 7876 | ProgramServices |
| Management And General | 11877 | ManagementAndGeneral |
Office Expenses OfficeExpenses
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | 31188 | Total |
| Program Services | 31188 | ProgramServices |
Information Technology InformationTechnology
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | 42850 | Total |
| Program Services | 5574 | ProgramServices |
| Management And General | 37276 | ManagementAndGeneral |
Occupancy Occupancy
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | 441690 | Total |
| Program Services | 141368 | ProgramServices |
| Management And General | 300322 | ManagementAndGeneral |
Travel Travel
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | 57280 | Total |
| Program Services | 51314 | ProgramServices |
| Management And General | 5966 | ManagementAndGeneral |
Depreciation Depletion DepreciationDepletion
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | 1236938 | Total |
| Program Services | 1236938 | ProgramServices |
Insurance Insurance
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | 161810 | Total |
| Management And General | 161810 | ManagementAndGeneral |
Other Expenses OtherExpenses (5 entries)
| DescriptionDescription | TotalTotal | Program ServicesProgramServices | Management And GeneralManagementAndGeneral |
|---|---|---|---|
| Collection fees and bad | 979766 | 979766 | |
| Medicaid FRA Tax | 422016 | 422016 | |
| Supplies | 407033 | 344490 | 62543 |
| Pharmaceuticals | 341998 | 341998 | |
| Repairs and maintenance | 186372 | 113852 | 72520 |
All Other Expenses AllOtherExpenses
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | 723174 | Total |
| Program Services | 218496 | ProgramServices |
| Management And General | 504678 | ManagementAndGeneral |
Total Functional Expenses TotalFunctionalExpenses
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | 13081876 | Total |
| Program Services | 10038057 | ProgramServices |
| Management And General | 3043819 | ManagementAndGeneral |
| Fundraising | 0 | Fundraising |
Savings And Temp Cash Investments SavingsAndTempCashInvestments
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | 7533874 | BOY |
| EOY | 8223551 | EOY |
Accounts Receivable AccountsReceivable
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | 1596950 | BOY |
| EOY | 1186139 | EOY |
Inventories For Sale Or Use InventoriesForSaleOrUse
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | 117529 | BOY |
| EOY | 119724 | EOY |
Prepaid Expenses Deferred Charges PrepaidExpensesDeferredCharges
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | 101789 | BOY |
| EOY | 90850 | EOY |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Land Buildings Equipment Basis | 19456734 | LandBuildingsEquipmentBasis |
| Land Bldg Equipment Accum Deprec | 9008657 | LandBldgEquipmentAccumDeprec |
Land Buildings Equipment Basis Net LandBuildingsEquipmentBasisNet
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | 10566312 | BOY |
| EOY | 10448077 | EOY |
Investments Other Securities InvestmentsOtherSecurities
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | 2306776 | BOY |
| EOY | 1969846 | EOY |
Other Assets Total OtherAssetsTotal
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | 555939 | BOY |
| EOY | 1150826 | EOY |
Total Assets TotalAssets
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | 22779169 | BOY |
| EOY | 23189013 | EOY |
Accounts Payable Accrued Expenses AccountsPayableAccruedExpenses
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | 1026725 | BOY |
| EOY | 1157222 | EOY |
Other Liabilities OtherLiabilities
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | 22617 | BOY |
| EOY | 467031 | EOY |
Total Liabilities TotalLiabilities
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | 1049342 | BOY |
| EOY | 1624253 | EOY |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Follow SFAS117 | X | FollowSFAS117 |
Unrestricted Net Assets UnrestrictedNetAssets
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | 21729827 | BOY |
| EOY | 21564760 | EOY |
Total Net Assets Fund Balances TotalNetAssetsFundBalances
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | 21729827 | BOY |
| EOY | 21564760 | EOY |
Total Liab Net Assets Fund Balances TotalLiabNetAssetsFundBalances
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | 22779169 | BOY |
| EOY | 23189013 | EOY |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Info In Schedule O Part XI | X | InfoInScheduleOPartXI |
| Reconcilation Revenue Expenses | -428137 | ReconcilationRevenueExpenses |
| Reconcilation Other Changes | 263070 | ReconcilationOtherChanges |
| Info In Schedule O Part XII | X | InfoInScheduleOPartXII |
| Method Of Accounting Accrual | X | MethodOfAccountingAccrual |
| Accountant Compile Or Review | 0 | AccountantCompileOrReview |
| FS Audited | 1 | FSAudited |
| Audit Committee | 1 | AuditCommittee |
| Financial Statement Separate | X | FinancialStatementSeparate |
| Federal Grant Audit Required | 0 | FederalGrantAuditRequired |
Schedule A IRS990ScheduleA
| Field | Value | IRS element (for citing) |
|---|---|---|
| Hospital170b1 Aiii | X | Hospital170b1Aiii |
Schedule D IRS990ScheduleD
Other Land Buildings OtherLandBuildings
| Field | Value | IRS element (for citing) |
|---|---|---|
| Other Cost Or Other Basis | 19456734 | OtherCostOrOtherBasis |
| Depreciation | 9008657 | Depreciation |
| Book Value | 10448077 | BookValue |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Of Book Value Land Buildings | 10448077 | TotalOfBookValueLandBuildings |
Other Securities OtherSecurities (2 entries)
| DescriptionDescription | Book ValueBookValue | Method Of ValuationMethodOfValuation |
|---|---|---|
| Equity securities | 1173194 | F |
| Corporate bonds | 796652 | F |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Of Book Value Securities | 1969846 | TotalOfBookValueSecurities |
Other Liabilities OtherLiabilities (2 entries)
| DescriptionDescription | AmountAmount |
|---|---|
| Property and equipment purchases payable | $84,815 |
| Purchase agreement | $382,216 |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Of Amounts | 467031 | TotalOfAmounts |
| Total Revenue | 12653739 | TotalRevenue |
| Total Expenses | 13081876 | TotalExpenses |
| Excess Or Deficit For Year | -428137 | ExcessOrDeficitForYear |
| Net Unrealized GL On Investments | 263070 | NetUnrealizedGLOnInvestments |
| Total Adjustments | 263070 | TotalAdjustments |
| Excess Or Deficit Per FS | -165067 | ExcessOrDeficitPerFS |
| Tot Revenue Etc Audited Fincl Stmt | 12653739 | TotRevenueEtcAuditedFinclStmt |
| Revenue Not Rptd F990 | 0 | RevenueNotRptdF990 |
| Revenue Subtotal | 12653739 | RevenueSubtotal |
| Revenue Not Rptd On Fin Stmt | 0 | RevenueNotRptdOnFinStmt |
| Total Revenue Per Form990 | 12653739 | TotalRevenuePerForm990 |
| Tot Expenses Etc Audited Fincl Stmt | 13081876 | TotExpensesEtcAuditedFinclStmt |
| Expenses Not Rptd F990 | 0 | ExpensesNotRptdF990 |
| Expenses Subtotal | 13081876 | ExpensesSubtotal |
| Expenses Not Rptd On Fin Stmt | 0 | ExpensesNotRptdOnFinStmt |
| Total Expenses Per Form990 | 13081876 | TotalExpensesPerForm990 |
Schedule H IRS990ScheduleH
| Field | Value | IRS element (for citing) |
|---|---|---|
| Charity Care Policy | 1 | CharityCarePolicy |
| Written Policy | 1 | WrittenPolicy |
| FPG Reference Free Care | 1 | FPGReferenceFreeCare |
| Pcent100 | X | Pcent100 |
| FPG Reference Discounted Care | 1 | FPGReferenceDiscountedCare |
| Pcent200 D | X | Pcent200D |
| Free Disc Care Medically Indigent | 1 | FreeDiscCareMedicallyIndigent |
| Amounts Budgeted For Charity Care | 0 | AmountsBudgetedForCharityCare |
| Annual Community Benefit Report | 1 | AnnualCommunityBenefitReport |
| Report Publically Available | 1 | ReportPublicallyAvailable |
Charity Care At Cost CharityCareAtCost
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Community Benefit Expense | 159734 | TotalCommunityBenefitExpense |
| Direct Offsetting Revenue | 84845 | DirectOffsettingRevenue |
| Net Community Benefit Expense | 74889 | NetCommunityBenefitExpense |
| Percent Of Total Expense | 0.00620 | PercentOfTotalExpense |
Unreimbursed Medicaid UnreimbursedMedicaid
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Community Benefit Expense | 1726095 | TotalCommunityBenefitExpense |
| Direct Offsetting Revenue | 1132030 | DirectOffsettingRevenue |
| Net Community Benefit Expense | 594065 | NetCommunityBenefitExpense |
| Percent Of Total Expense | 0.04900 | PercentOfTotalExpense |
Total Charity Care TotalCharityCare
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Community Benefit Expense | 1885829 | TotalCommunityBenefitExpense |
| Direct Offsetting Revenue | 1216875 | DirectOffsettingRevenue |
| Net Community Benefit Expense | 668954 | NetCommunityBenefitExpense |
| Percent Of Total Expense | 0.05520 | PercentOfTotalExpense |
Community Health Services CommunityHealthServices
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Community Benefit Expense | 5000 | TotalCommunityBenefitExpense |
| Net Community Benefit Expense | 5000 | NetCommunityBenefitExpense |
| Percent Of Total Expense | 0.00040 | PercentOfTotalExpense |
Health Professions Education HealthProfessionsEducation
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Community Benefit Expense | 1000 | TotalCommunityBenefitExpense |
| Net Community Benefit Expense | 1000 | NetCommunityBenefitExpense |
| Percent Of Total Expense | 0.00010 | PercentOfTotalExpense |
Subsidized Health Services SubsidizedHealthServices
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Community Benefit Expense | 3894892 | TotalCommunityBenefitExpense |
| Direct Offsetting Revenue | 2459290 | DirectOffsettingRevenue |
| Net Community Benefit Expense | 1435602 | NetCommunityBenefitExpense |
| Percent Of Total Expense | 0.11850 | PercentOfTotalExpense |
Cash And In Kind Contributions CashAndInKindContributions
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Community Benefit Expense | 935 | TotalCommunityBenefitExpense |
| Net Community Benefit Expense | 935 | NetCommunityBenefitExpense |
| Percent Of Total Expense | 0.00010 | PercentOfTotalExpense |
Total Other Benefits TotalOtherBenefits
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Community Benefit Expense | 3901827 | TotalCommunityBenefitExpense |
| Direct Offsetting Revenue | 2459290 | DirectOffsettingRevenue |
| Net Community Benefit Expense | 1442537 | NetCommunityBenefitExpense |
| Percent Of Total Expense | 0.11910 | PercentOfTotalExpense |
Total Community Benefits TotalCommunityBenefits
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Community Benefit Expense | 5787656 | TotalCommunityBenefitExpense |
| Direct Offsetting Revenue | 3676165 | DirectOffsettingRevenue |
| Net Community Benefit Expense | 2111491 | NetCommunityBenefitExpense |
| Percent Of Total Expense | 0.17430 | PercentOfTotalExpense |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Bad Debt Expense Reported | 1 | BadDebtExpenseReported |
| Bad Debt Expense | $593,481 | BadDebtExpenseAmount |
| Amount Attributable To | 392469 | AmountAttributableTo |
| Amount Reimbursed By Medicare | 4719487 | AmountReimbursedByMedicare |
| Cost Of Care Reimbursed By Medicare | 4673659 | CostOfCareReimbursedByMedicare |
| Medicare Surplus Or Shortfall | 45828 | MedicareSurplusOrShortfall |
Costing Methodology Used CostingMethodologyUsed
| Field | Value | IRS element (for citing) |
|---|---|---|
| Other | X | Other |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Written Debt Collection Policy | 1 | WrittenDebtCollectionPolicy |
| Provision For Charity Care | 1 | ProvisionForCharityCare |
| Number Of Hospital Facilities | 1 | NumberOfHospitalFacilities |
Form990 Schedule H Part V Section A Form990ScheduleHPartVSectionA
| Field | Value | IRS element (for citing) |
|---|---|---|
| Facility Number | 1 | FacilityNumber |
Name Name
| Field | Value | IRS element (for citing) |
|---|---|---|
| Business Name Line1 | Carroll County Memorial Hospital | BusinessNameLine1 |
Address Address
| Field | Value | IRS element (for citing) |
|---|---|---|
| Address Line1 | 1502 North Jefferson | AddressLine1 |
| City | Carrollton | City |
| State | MO | State |
| ZIP Code | 64633 | ZIPCode |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Licensed Hospital | X | LicensedHospital |
| General Medical And Surgical | X | GeneralMedicalAndSurgical |
| Critical Access Hospital | X | CriticalAccessHospital |
| Er24 Hours | X | Er24Hours |
| Other | Physician clinics | Other |
Form990 Schedule H Part V Section B Form990ScheduleHPartVSectionB
Hospital Facility Name HospitalFacilityName
| Field | Value | IRS element (for citing) |
|---|---|---|
| Business Name Line1 | Carroll County Memorial Hospital | BusinessNameLine1 |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Hospital Facility Number | 1 | HospitalFacilityNumber |
| CHNA Conducted | 1 | CHNAConducted |
| Take Into Account | 0 | TakeIntoAccount |
| Other Facilities | 0 | OtherFacilities |
| CHNA Widely Available | 0 | CHNAWidelyAvailable |
| All Needs Addressed | 1 | AllNeedsAddressed |
| Eligibility Criteria Explained | 1 | EligibilityCriteriaExplained |
| Uses FPG Free | 1 | UsesFPGFree |
| FPG Free Percent | 100.000000000000 | FPGFreePercent |
| Uses FPG Discounted | 1 | UsesFPGDiscounted |
| FPG Discount Percent | 200.000000000000 | FPGDiscountPercent |
| Explains Basis | 1 | ExplainsBasis |
| Income Level | X | IncomeLevel |
| Medical Indigency | X | MedicalIndigency |
| Uninsured Discount | X | UninsuredDiscount |
| Includes Publicity Measures | 1 | IncludesPublicityMeasures |
| Provided On Admission | X | ProvidedOnAdmission |
| Available On Request | X | AvailableOnRequest |
| Actions On Nonpayment | 1 | ActionsOnNonpayment |
| Permit Report To Credit Agency | X | PermitReportToCreditAgency |
| Permit Lawsuit | X | PermitLawsuit |
| Permit Lien On Residence | X | PermitLienOnResidence |
| Collection Activities | 1 | CollectionActivities |
| Report To Credit Agency | X | ReportToCreditAgency |
| Lawsuit | X | Lawsuit |
| Lien On Residence | X | LienOnResidence |
| Notify Upon Admission | X | NotifyUponAdmission |
| Notify Before Discharge | X | NotifyBeforeDischarge |
| Notified All Patients | X | NotifiedAllPatients |
| Documented Determination | X | DocumentedDetermination |
| Other Actions Taken | X | OtherActionsTaken |
| Nondiscrim Emergency Care Policy | 1 | NondiscrimEmergencyCarePolicy |
| Used Other Method | X | UsedOtherMethod |
Form990 Schedule H Part VI Form990ScheduleHPartVI (10 entries)
| ExplanationExplanation | IdentifierIdentifier |
|---|---|
| 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 $ 967527. | |
| Part III, Line 4: The Hospital provides for accounts receivable that could become uncollectible in the future by establishing an allowance to reduce the carrying value of such receivables to their estimated net realizable value. 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. The amount of bad debt attributable to patients eligible for charity care is based on self-pay only patients and patients covered by Medicaid. | |
| Part III, Line 8: Amounts were obtained from the cost report filed with Medicare for the period ending June 30, 2011. | |
| 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. | |
| Part V, Section B, Line 17e: Financial counseling with self-pay patients. | Carroll County Memorial Hospital |
| Part V, Section B, Line 19d: Patient visits with a financial counselor to determine payment ability. | Carroll County Memorial Hospital |
| 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. | |
| 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 that there are programs that may help alleviate the burden. If the Hospital is prompted it will check for public-assistance or charity care programs to see if the patient qualifies. | |
| Part VI, Line 4: Carroll County Memorial Hospital is located in Carrollton, Missouri. The Hospital's primary service area consists of Carrollton and the surrounding areas in Carroll County. Carroll County Memorial Hospital operates two satellite clinics located in Hale and Norborne. Carroll County has a population of approximately 9,500 residents, with 35% of the residents living in urban areas and 65 % living rural 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 Chillicothe, Marshall, Lexington, and Richmond. The distance between Carroll County Memorial Hospital and all of these facilities are approximately 30 miles. | |
| Part VI, Line 6: The Hospital's 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. |
Schedule J IRS990ScheduleJ
| Field | Value | IRS element (for citing) |
|---|---|---|
| Severance Payment | 0 | SeverancePayment |
| Supplemental Nonqual Retire Plan | 0 | SupplementalNonqualRetirePlan |
| Equity Based Comp Arrangement | 0 | EquityBasedCompArrangement |
| Comp Based On Revenue Of Filing Org | 0 | CompBasedOnRevenueOfFilingOrg |
| Comp Based On Revenue Related Orgs | 0 | CompBasedOnRevenueRelatedOrgs |
| Comp Based Net Earnings Filing Org | 0 | CompBasedNetEarningsFilingOrg |
| Comp Based Net Earnings Relate Orgs | 0 | CompBasedNetEarningsRelateOrgs |
| Any Non Fixed Payments | 0 | AnyNonFixedPayments |
| Initial Contract Exception | 0 | InitialContractException |
Form990 Schedule J Part II Form990ScheduleJPartII (3 entries)
| Base Compensation Filing OrgBaseCompensationFilingOrg | Comp Based On Related OrgsCompBasedOnRelatedOrgs | Bonus Filing OrgBonusFilingOrg | Bonus Related OrgsBonusRelatedOrgs | Other Compensation Filing OrgOtherCompensationFilingOrg | Other Compensation Related OrgsOtherCompensationRelatedOrgs | Deferred Comp Filing OrgDeferredCompFilingOrg | Deferred Comp Related OrgsDeferredCompRelatedOrgs | Nontaxable Benefits Filing OrgNontaxableBenefitsFilingOrg | Nontaxable Benefits Related OrgsNontaxableBenefitsRelatedOrgs | Total Compensation Filing OrgTotalCompensationFilingOrg | Total Compensation Related OrgsTotalCompensationRelatedOrgs | Comp Report Prior990 Filing OrgCompReportPrior990FilingOrg | Comp Report Prior990 Related OrgsCompReportPrior990RelatedOrgs |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Jerry Dover | |||||||||||||
| 163733 | 0 | 0 | 0 | 0 | 0 | 13214 | 0 | 4680 | 0 | 181627 | 0 | 84492 | 0 |
| Waclaw ADymek | |||||||||||||
| 173206 | 0 | 0 | 0 | 0 | 0 | 13972 | 0 | 4680 | 0 | 191858 | 0 | 81911 | 0 |
| Richard Smith | |||||||||||||
| 173523 | 0 | 0 | 0 | 0 | 0 | 14400 | 0 | 10680 | 0 | 198603 | 0 | 94525 | 0 |
Schedule L IRS990ScheduleL
Loan Table LoanTable
| Field | Value | IRS element (for citing) |
|---|---|---|
| Name Person | Andrew Horine | NamePerson |
| Purpose Of Loan | Medical School | PurposeOfLoan |
| Loan From Organization | X | LoanFromOrganization |
| Original Principal | $60,000 | OriginalPrincipalAmount |
| Balance Due | 60000 | BalanceDue |
| Default | 0 | Default |
| Approved By Board | 1 | ApprovedByBoard |
| Written Agreement | 1 | WrittenAgreement |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Balance Due | 60000 | TotalBalanceDue |
Schedule O IRS990ScheduleO
General Explanation GeneralExplanation (6 entries)
| IdentifierIdentifier | ExplanationExplanation | Return ReferenceReturnReference |
|---|---|---|
| Form 990, Part VI, Section B, line 11 | A copy of the Form 990 is provided to members of the Board of Directors prior to filling. | |
| The Board sets policy and administration is charged with assuring that compliance is maintained. In 2011 a Director of Compliance was hired and oversees all compliance matters. | Form 990, Part VI, Section B, line 12c | |
| The CEO is hired, reviewed and compensation is set by the Board. All other management positions are hired, reviewed and monitored by the CEO, CNO and CFO. | Form 990, Part VI, Section B, line 15a | |
| As a private not for profit we do not fall under the same rules of open meeting, however we do post our meetings in the local newspaper and would honor a request for review/discussion of our financials. | Form 990, Part VI, Section C, line 19 | |
| Changes in Net Assets or Fund Balances: | Net unrealized gains on investments: 263,070. | Form 990, Part XI, line 5: |
| Financial Statements | The Carrol County Memorial Hospital Board along with Administration assumes responsibility. | FORM 990, PART XII, LINE 2c |