2012-03-15T16:42:01-05:00 2011-07-31 DOHMAN AKERLUND & EDDY LLC PO BOX 470 AURORA NE 688180470 990 2010-08-01 470421272 COMMUNITY MEDICAL CENTER INC COMM 4022456501 3307 BARADA STREET FALLS CITY NE 68355 SCOTT L SAWYER 4022456501 2012-03-15 true TIMOTHY J COUFAL 4026946404 2012-03-15 2010 2016-02-24 21:20:13Z RYAN LARSEN SAME AS ABOVE FALLS CITY NE 68355 18258516 false X HTTP://CMCFC.ORG X 1995 NE TO OFFER GENERAL HEALTHCARE SERVICES WITHIN THE SCOPE OF ITS LICENSE AND CAPABILITIES; TO RENDER HEALTHCARE TO ALL PERSONS WITHOUT RESPECT TO RACE, RELIGIOUS BELIEFS OR FINANCIAL STANDING. 8 8 208 0 128051 219218 16957330 18026525 -2282000 -58647 0 14803381 18187096 0 0 8547567 8265693 0 0 8357305 9143655 16904872 17409348 -2101491 777748 33807196 33958439 21676433 21049928 12130763 12908511 TO OFFER GENERAL HEALTHCARE SERVICES WITHIN THE SCOPE OF ITS LICENSE AND CAPABILITIES; TO RENDER HEALTHCARE TO ALL PERSONS WITHOUT RESPECT TO RACE, RELIGIOUS BELIEFS OR FINANCIAL STANDING. false false 13928928 COMMUNITY MEDICAL CENTER PROVIDES MEDICAL SERVICES TO MEET THE NEEDS OF THE PEOPLE OF RICHARDSON COUNTY AND THE SURROUNDING COMMUNITIES. COMMUNITY MEDICAL CENTER PROVIDED 2,226 INPATIENT DAYS, 2,128 SWING-BED DAYS, 116 NURSERY DAYS, 12,013 CLINIC VISITS AND NUMEREOUS OUTPATIENT SERVICES DURING THE YEAR. COMMUNITY BENEFITS INCLUDE 427,903 OF SUBSIDIZED HEALTH SERVICES, 294,909 OF TRADITIONAL CHARITY CARE, 218,055 OF BAD DEBT AND 5,000 OF HEALTH EDUCATION. 13928928 true true false false false false false false false true true false false false true false true false false false false false false false false false true true false false true false false false false false false false false false false false false false false false false false false true 48 0 true 208 true false false false false false false X 8 8 false false false false false false false true true false false false true true true false true true false false X SCOTT L SAWYER 4022456501 3307 BARADA STREET FALLS CITY NE 68355 RODGER MERZ 1.00 X 0 0 0 RENIE GERWECK 1.00 X 0 0 0 STEVE SEVERIN 1.00 X 0 0 0 DANA RATHJE 1.00 X 0 0 0 LAURIE KIMBROUGH 1.00 X 0 0 0 CHUCK HUNZEKER 1.00 X 0 0 0 KENT BIEKER 1.00 X 0 0 0 DIRCK CLARK 1.00 X 0 0 0 RYAN LARSEN 40.00 X 196240 0 35571 SCOTT SAWYER 40.00 X 104075 0 21971 BARBARA HOWARD 40.00 X 88217 0 12516 DAVID BORG 40.00 X 405773 0 58590 HONG CUI 40.00 X 200558 0 14671 SANDRA CATLIN 40.00 X 157798 0 23655 CHARLES HAGEDORN 40.00 X 157516 0 6498 1310177 173472 6 false true false PTRS-NACHTIGAL LLC 700 OREGON STREET HIAWATHA KS 66434 PT/OT SERVICES 544113 CARDINAL HEALTH 21337 NETWORK PLACE CHICAGO IL 60673 PHARMACY SVCS 268536 NHI OUTREACH CLINICAL SERVICES 7440 S 91ST STREET LINCOLN NE 68501 NM & ECHO SERV 110189 SHARED MEDICAL SERVICES PO BOX 330 COTTAGE GROVE WI 53527 MRI SERVICES 103810 4 165666 53552 6762 219218 NET PATIENT SERVICE REVENUE 622110 17779847 17779847 MISCELLANEOUS HOPSITAL REV 622110 86261 86261 CAFETERIA 722310 64737 64737 PHARMACY 900099 60780 60780 LIFELINE 900099 34900 34900 18026525 9923 9923 2850 71420 -68570 -68570 -68570 18187096 17957955 9923 388532 88217 300315 6106860 5187457 919403 253688 193441 60247 1078206 890300 187906 438407 353648 84759 44710 44710 33000 33000 2595482 2395531 199951 20800 4458 16342 140151 77974 62177 367400 5335 362065 25685 15899 9786 27600 19292 8308 945800 677354 268446 1560302 1117488 442814 72309 12386 59923 PHARMACY 984127 984127 CENTRAL SUPPLY 385150 385150 REPAIR AND MAINTENANCE 358385 253914 104471 PROVISION FOR BAD DEBTS 296136 296136 EQUIPMENT RENTAL 268574 248913 19661 1018044 1018044 17409348 13928928 3480420 0 5118584 6320809 2057340 2066194 424759 254822 2325439 3109352 194203 82502 53186 48650 417251 280321 25537066 4695193 22026745 20841873 13772 14355 485917 459561 690000 480000 33807196 33958439 1460180 1206342 18047208 17737886 2169045 2105700 21676433 21049928 X 12130763 12908511 12130763 12908511 33807196 33958439 777748 X false true true X false X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED false false false false false false false 979328 791570 1275 778715 993457 561962 11553894 3723 11140251 979328 1.00000 false false false 1352420 1352420 17513170 1613358 15899812 1680612 167627 1512985 4990864 2914208 2076656 20841873 CONDITIONAL CONTRIBUTION 2000000 EST THIRD-PARTY PAYOR SETTLEMENTS 60000 DEFERRED COMPENSATION 45700 2105700 18187096 17409348 777748 777748 18187096 18187096 18187096 17409348 17409348 17409348 INTENDED USES FOR ENDOWMENT FUNDS SCHEDULE D, PAGE 2, PART V, LINE 4 THE FUNDS INCLUDE 5,490 DESIGNATED BY THE BOARD FOR CAPITAL IMPROVEMENTS, 109,919 DESIGNATED BY BOARD FOR DEFERRED COMPENSATION, 166,860 DESIGNATED BY A LONG-TERM DEBT COVENANT ON THE USDA LOAN, 230,253 DESIGNATED LOAN PROCEEDS TO BE USED FOR EQUIPMENT, AND 480,935 DESIGNATED AS A DEBT SINKING FUND. true true X true X true X false true false false 294909 294909 0.01720 294909 294909 0.01720 6851 6851 0.00040 5000 5000 0.00030 449617 21713 427904 0.02500 461468 21713 439755 0.02570 756377 21713 734664 0.04290 true 218055 21806 9897810 9782571 115239 X true false 1 1 COMMUNITY MEDICAL CENTER

3307 BARADA STREET FALLS CITY NE 68355

X X X X COMMUNITY MEDICAL CENTER 1 true true 200.0 true 300.0 true X true true X X X true true X X X X X true X false true 2 FAMILY MEDICINE

3307 BARADA STREET FALLS CITY NE 68355

RURAL HEALTH CLINIC HUMBOLDT FAMILY MEDICINE

1120 GRAND AVENUE HUMBOLDT NE 68376

RURAL HEALTH CLINIC EXCLUSIONS FROM PERCENT OF TOTAL EXPENSE PART I LINE 7 COLUMN F 296136 COSTING METHODOLOGY EXPLANATION PART I LINE 7 THE COSTING METHODOLOGY USED TO CALCULATE THE AMOUNTS REPORTED IN THE TABLE WAS A COST TO CHARGE RATIO COMMUNITY BUILDING ACTIVITIES PART II ALTHOUGH NO COMMUNITY BUILDING ACTIVITIES WERE REPORTED IN PART II THE ORGANIZATION WORKS CLOSELY WITH OTHERS IN THE COMMUNITY TO IMPROVE THE HEALTH AND WELFARE OF COMMUNITY MEMBERS THE ORGANIZATION HAS RECENTLY MOVED INTO A NEW HOSPITAL FACILITY TO PROVIDE THE BEST POSSIBLE CARE TO PATIENTS IT SERVES ALSO AS THE LARGEST EMPLOYER IN FALLS CITY THE NEW FACILITY PROVIDES A BETTER WORK ENVIRONMENT FOR THE ORGANIZATIONS WORKFORCE BAD DEBT EXPENSE EXPLANATION PART III LINE 4 FINANCIAL STATEMENT FOOTNOTE EXPENSES INCLUDE A PROVISION FOR DOUBTFUL ACCOUNTS TO ALLOW FOR ESTIMATED UNCOLLECTIBLE ACCOUNTS THIS PROVISION IS BASED ON PAST EXPERIENCE AND ON ANALYSIS OF CURRENT ACCOUNTS RECEIVABLE COLLECTIBILITY ACCOUNTS ARE CONSIDERED DELINQUENT BASED ON PASSAGE OF A SPECIFIED PERIOD OF TIME AND CONSIDERATION OF PAYMENT HISTORY ACCOUNTS DEEMED UNCOLLECTIBLE ARE CHARGED TO THE ALLOWANCE IN THE YEAR THEY ARE DEEMED UNCOLLECTIBLE AS A RESULT THERE IS AT LEAST A REASONABLE POSSIBILITY THAT RECORDED ESTIMATES WILL CHANGE BY A MATERIAL AMOUNT IN THE NEAR TERM THE ALLOWANCE FOR DOUBTFUL ACCOUNTS WAS 434000 AND 465000 AT JULY 31 2011 AND 2010 RESPECTIVELY COSTING METHODOLOGY FOR LINE 2 OVERALL COST TO CHARGE RATIO WAS USED TO DETERMINE AMOUNTS REPORTED ON SCHEDULE H PART III LINE 2 BAD DEBT EXPENSE REPORTED ON FORM 990 PART IX LINE 25 WAS 296136 COSTING METHODOLOGY FOR LINE 3 AFTER REVIEW OF BAD DEBTS WRITTEN OFF IT WAS DETERMINED APPROXIMATELY 10 OF BAD DEBT ACCOUNTS WRITTEN OFF WOULD HAVE QUALIFIED FOR CHARITY CARE IF THE INDIVIDUALS WOULD HAVE COMPLETED THE APPLICATION PROCESS RATIONALE FOR INCLUDED BAD DEBT AS A COMMUNITY BENEFIT BY LAW THE ORGANIZATION CANNOT REFUSE CERTAIN SERVICES TO PATIENTS REGARDLESS OF THEIR ABILITY TO PAY THUS BAD DEBT SHOULD BE INCLUDED AS A COMMUNITY BENEFIT MEDICARE EXPLANATION PART III LINE 8 THE MEDICARE COST REPORT WAS USED TO DETERMINE THE AMOUNTS REPORTED ON LINE 6 NEEDS ASSESSMENT PART VI THE ORGANIZATION ASSESSES THE NEEDS OF THE COMMUNITIES IS SERVICES BY MONITORING THE UTILIZATION OF SERVICES OFFERED AND EVALUATING NEW SERVICES WHICH COULD BE OFFERED TO IMPROVE THE HEALTH AND WELFARE OF THE CITIZENS IN THE COMMUNITIES IT SERVES STARTING IN 2012 THE ORGANIZATION WILL CONDUCT A COMMUNITY NEEDS ASSESSMENT EVERY 3 YEARS AND EXECUTE AGAINST IT PATIENT EDUCATION OF ELIGIBILITY FOR ASSISTANCE PART VI THE ORGANIZATION INFORMS AND EDUCATES PATIENTS AND PERSONS WHO MAY BE BILLED FOR PATIENT CARE ABOUT THEIR ELIGIBILITY FOR ASSISTANCE UNDER THE ORGANIZATIONS HELPFUL OPTIONS FOR PATIENT EXPENSES HOPE PROGRAM OR FINANCIAL ASSISTANCE POLICY BY HAVING THE INFORMATION AVAILABLE ON THEIR WEBSITE PROVIDING THE INFORMATION TO ALL WHO INQUIRE ABOUT OBTAINING FINANCIAL ASSISTANCE AND BY REFERRING THOSE KNOWN TO BE UNINSURED ANDOR TO HAVE LOW INCOME TO FINANCIAL COUNSELORS WHO WILL DISCUSS THE POLICY COMMUNITY INFORMATION PART VI RICHARDSON COUNTY NEBRASKA IS PRIMARILY RURAL AND INCLUDES THE CITIES OF BARADA DAWSON FALLS CITY HUMBOLDT PRESTON RULO SALEM SHUBERT STELLA AND VERDON IT IS LOCATED IN THE SOUTHEAST CORNER OF NEBRASKA POPULATION ACCORDING TO THE 2010 CENSUS IS 8363 DECLINING 123 FROM 2000 PERSONS 65 YEARS AND OLDER IS 229 WHILE PERSONS 18 AND YOUNGER IS 215 ETHNIC BACKGROUDS BY PERCENT INCLUDE WHITE 943 AMERICAN INDIAN AND ALASKA NATIVE PERSONS 30 WITH ALL OTHERS REPORTING LESS THAN 2 THERE ARE 3862 HOUSEHOLDS WITH AN AVERAGE OF 219 PERSONS PER HOUSEHOLD MEDIAN HOUSEHOLD INCOME IS 35165 WITH 142 OF PERSONS BELOW THE POVERTY LEVEL THERE ARE 55184 TOTAL SQUARE MILES AND 152 PERSON PER SQUARE MILE HEALTH OF COMMUNITY IN RELATION TO EXEMPT PURPOSE PART VI THE ORGANIZATIONS BOARD OF DIRECTORS IS COMPRISED OF PERSONS WHO RESIDE IN THE ORGANIZATIONS PRIMARY SERVICE AREA WHO ARE NEITHER EMPLOYEES NOR CONTRACTORS OF THE ORGANIZATION NOR FAMILY MEMBERS THEREOF THE ORGANIZATION EXTENDS MEDICAL STAFF PRIVALEDGES TO ALL QUALIFIED PHYSICIANS IN ITS COMMUNITY IN ADDITION THE ORGANIZATION CONTINUALLY APPLIES SURPLUS FUNDS TOWARD THE IMPROVEMENT OF PATIENT CARE SUCH AS NEW FACILITIES AND THE PURCHASE OF NEWUPDATED MEDICAL EQUIPMENT COMMUNITY MEDICAL CENTER LINE NUMBER 1 PART V LINE 13G PART V LINE 13G REGISTRATION PERSONNEL REFERRED UNINSURED ANDOR LOW INCOME PATIENTS TO FINANCIAL COUNSELORS TO DISCUSS THE POLICY COMMUNITY MEDICAL CENTER LINE NUMBER 1 PART V LINE 19D PART V LINE 19D THE HOSPITAL FACILITY CHARGES PATIENTS WITHOUT INSURANCE THE SAME RATES AS PATIENTS WHO HAVE INSURANCE FOR THOSE SERVICES AT THE HOSPITAL FACILITY PATIENTS THAT QUALIFY FOR FINANCIAL ASSISTANCE ARE GIVEN A MINIMUM OF 25 DISCOUNT ON SERVICES COMMUNITY MEDICAL CENTER LINE NUMBER 1 PART V LINE 21 PART V LINE 21 THE HOSPITAL FACILITY CHARGES PATIENTS WITHOUT INSURANCE THE SAME RATES AS PATIENTS WHO HAVE INSURANCE FOR THOSE SERVICES AT THE HOSPITAL FACILITY PATIENTS THAT QUALIFY FOR FINANCIAL ASSISTANCE ARE GIVEN A MINIMUM OF 25 DISCOUNT ON SERVICES X true true X X X false false false true false false false false false RYAN LARSEN 136240 60000 19912 15659 231811 DAVID BORG 155002 221588 29183 42884 15706 464363 HONG CUI 156917 10000 33641 1578 13093 215229 SANDRA CATLIN 57826 82894 17078 7949 15706 181453 CHARLES HAGEDORN 150016 7500 6498 164014 FRINGE OR EXPENSE EXPLANATION SCHEDULE J, PAGE 1, PART I, LINE 1A RYAN LARSEN, CEO - LIONS CLUB DUES 146.50, FALL CITY ROTARY CLUB 100.00 COMPENSATION CONTINGENT UPON REVENUES OF ORGANIZATION SCHEDULE J, PAGE 1, PART I, LINE 5A PROVIDER PRODUCTIVITY BONUSES ARE CALCULATED BASED ON RURAL HEALTH CLINIC REVENUES. OTHER ADDITIONAL INFORMATION SCHEDULE J, PART III PRODUCTIVITY BONUSES BASED ON REVENUES: DAVID BORG 107,380 SANDRA CATLIN 81,057 ORGANIZATION'S PROCESS USED TO REVIEW FORM 990 FORM 990, PAGE 6, PART VI, LINE 11B THE FORM 990 IS REVIEWED BY THE CFO AND IS PRESENTED TO THE FINANCE COMMITTEE OF THE BOARD OF DIRECTORS FOR APPROVAL PRIOR TO FILING THE RETURN. ENFORCEMENT OF CONFLICTS POLICY FORM 990, PAGE 6, PART VI, LINE 12C MANAGEMENT CONTINUALLY REVIEWS OFFICERS, DIRECTORS, TRUSTEES AND KEY EMPLOYEES ANNUAL DISCLOSURES AND RELATIONSHIPS WITH COMMUNITY MEDICAL CENTER TO IDENTIFY POSSIBLE CONFLICTS OF INTEREST. ONCE A CONFLICT OF INTEREST IS IDENTIFIED, THE CONFLICT WOULD BE DOCUMENTED AND MONITORED TO ENSURE APPROPRIATE ACTION IS TAKEN BASED ON THE SITUATION. COMPENSATION PROCESS FOR TOP OFFICIAL FORM 990, PAGE 6, PART VI, LINE 15A COMPENSATION FOR THE CEO IS DETERMINED BY THE BOARD OF DIRECTORS. THE BOARD OF DIRECTORS UTILIZE INDEPENDENT PARTIES OR STUDIES OCCASIONALLY. GOVERNING DOCUMENTS DISCLOSURE EXPLANATION FORM 990, PAGE 6, PART VI, LINE 19 GOVERNING DOCUMENTS, CONFLICTS OF INTEREST STATEMENTS, AND FINANCIAL STATEMETNS ARE NOT MADE AVAILABLE TO THE PUBLIC WITHOUT APPROVAL BY THE BOARD OF DIRECTORS.