COMMUNITY MEMORIAL HOSPITAL ASSOCIATION: Form 990, tax year 2009
View the entire original 990 at ProPublica ↗
- Organization
- COMMUNITY MEMORIAL HOSPITAL ASSOCIATION (EIN 41-0743546)
- Tax period
- 2009-10-01 to 2010-09-30
- Filed
- 2011-07-29
- IRS object ID
- 201122109349300217
- Schema version
- 2009v1.7
- 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 | 2011-07-29T13:05:57-05:00 | Timestamp |
| Tax Period End Date | 2010-09-30 | TaxPeriodEndDate |
Preparer Firm PreparerFirm
Preparer Firm Business Name PreparerFirmBusinessName
| Field | Value | IRS element (for citing) |
|---|---|---|
| Business Name Line1 | RSM McGladrey Inc | BusinessNameLine1 |
Preparer Firm US Address PreparerFirmUSAddress
| Field | Value | IRS element (for citing) |
|---|---|---|
| Address Line1 | 700 Missabe Building | AddressLine1 |
| City | Duluth | City |
| State | MN | State |
| ZIP Code | 55802 | ZIPCode |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Return Type | 990 | ReturnType |
| Tax Period Begin Date | 2009-10-01 | TaxPeriodBeginDate |
Filer Filer
| Field | Value | IRS element (for citing) |
|---|---|---|
| EIN | 410743546 | EIN |
Name Name
| Field | Value | IRS element (for citing) |
|---|---|---|
| Business Name Line1 | COMMUNITY MEMORIAL HOSPITAL ASSOCIATION | BusinessNameLine1 |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Name Control | COMM | NameControl |
| Phone | 2188797027 | Phone |
US Address USAddress
| Field | Value | IRS element (for citing) |
|---|---|---|
| Address Line1 | 512 SKYLINE BLVD | AddressLine1 |
| City | CLOQUET | City |
| State | MN | State |
| ZIP Code | 55720 | ZIPCode |
Officer Officer
| Field | Value | IRS element (for citing) |
|---|---|---|
| Name | BRAD ANDERSON | Name |
| Title | CFO | Title |
| Phone | 2188797027 | Phone |
| Date Signed | 2011-07-21 | DateSigned |
| Authorize Third Party | 1 | AuthorizeThirdParty |
Preparer Preparer
| Field | Value | IRS element (for citing) |
|---|---|---|
| Name | Jennifer Miller | Name |
| Phone | 2187278253 | Phone |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Tax Year | 2009 | TaxYear |
| Build TS | 2016-02-24 21:20:13Z | BuildTS |
Form 990 IRS990
| Field | Value | IRS element (for citing) |
|---|---|---|
| Name Of Principal Officer Person | BRAD ANDERSON | NameOfPrincipalOfficerPerson |
Address Principal Officer US AddressPrincipalOfficerUS
| Field | Value | IRS element (for citing) |
|---|---|---|
| Address Line1 | 512 SKYLINE BLVD | AddressLine1 |
| City | CLOQUET | City |
| State | MN | State |
| ZIP Code | 55720 | ZIPCode |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Gross Receipts | 42403178 | GrossReceipts |
| Group Return For Affiliates | 0 | GroupReturnForAffiliates |
| Organization501c | X | Organization501c |
| Web Site | WWW.CLOQUETHOSPITAL.COM | WebSite |
| Type Of Organization Corporation | X | TypeOfOrganizationCorporation |
| Year Formation | 1954 | YearFormation |
| State Legal Domicile | MN | StateLegalDomicile |
| Activity Or Mission Description | The mission of Community Memorial Hospital is to improve and enhance the health and well-being of individuals and our community through education, prevention, treatment and intervention. | ActivityOrMissionDescription |
| Nbr Voting Members Governing Body | 9 | NbrVotingMembersGoverningBody |
| Nbr Independent Voting Members | 8 | NbrIndependentVotingMembers |
| Total Nbr Employees | 411 | TotalNbrEmployees |
| Total Nbr Volunteers | 117 | TotalNbrVolunteers |
| Total Gross UBI | 10547 | TotalGrossUBI |
| Net Unrelated Business Txbl Income | 0 | NetUnrelatedBusinessTxblIncome |
| Contributions Grants Prior Year | 104340 | ContributionsGrantsPriorYear |
| Contributions Grants Current Year | 263720 | ContributionsGrantsCurrentYear |
| Program Service Revenue Prior Year | 40077345 | ProgramServiceRevenuePriorYear |
| Program Service Revenue CY | 41157389 | ProgramServiceRevenueCY |
| Investment Income Prior Year | 58592 | InvestmentIncomePriorYear |
| Investment Income Current Year | 61630 | InvestmentIncomeCurrentYear |
| Other Revenue Prior Year | 1047548 | OtherRevenuePriorYear |
| Other Revenue Current Year | 920439 | OtherRevenueCurrentYear |
| Total Revenue Prior Year | 41287825 | TotalRevenuePriorYear |
| Total Revenue Current Year | 42403178 | TotalRevenueCurrentYear |
| Grants And Similar Amnts CY | 0 | GrantsAndSimilarAmntsCY |
| Benefits Paid To Members CY | 0 | BenefitsPaidToMembersCY |
| Salaries Etc Prior Year | 23054801 | SalariesEtcPriorYear |
| Salaries Etc Current Year | 25092980 | SalariesEtcCurrentYear |
| Total Prof Fundrsng Exp CY | 0 | TotalProfFundrsngExpCY |
| Total Fundrsng Exp Current Year | 0 | TotalFundrsngExpCurrentYear |
| Other Expense Prior Year | 16815279 | OtherExpensePriorYear |
| Other Expenses Current Year | 16227157 | OtherExpensesCurrentYear |
| Total Expenses Prior Year | 39870080 | TotalExpensesPriorYear |
| Total Expenses Current Year | 41320137 | TotalExpensesCurrentYear |
| Revenues Less Expenses Prior Year | 1417745 | RevenuesLessExpensesPriorYear |
| Revenues Less Expenses CY | 1083041 | RevenuesLessExpensesCY |
| Total Assets BOY | 29832189 | TotalAssetsBOY |
| Total Assets EOY | 31524163 | TotalAssetsEOY |
| Total Liabilities BOY | 14770354 | TotalLiabilitiesBOY |
| Total Liabilities EOY | 15680710 | TotalLiabilitiesEOY |
| Net Assets Or Fund Balances BOY | 15061835 | NetAssetsOrFundBalancesBOY |
| Net Assets Or Fund Balances EOY | 15843453 | NetAssetsOrFundBalancesEOY |
| Mission Description | The mission of Community Memorial Hospital is to improve and enhance the health and well-being of individuals and our community through education, prevention, treatment and intervention. | MissionDescription |
| Significant New Program Services | 0 | SignificantNewProgramServices |
| Significant Change | 0 | SignificantChange |
| Expense | 32213359 | Expense |
| Revenue | 42067281 | Revenue |
| Description | PROVIDE HOSPITAL AND NURSING HOME HEALTHCARE TO COMMUNITY | Description |
| Total Program Service Expense | 32213359 | TotalProgramServiceExpense |
| Described In501 C3 | 1 | DescribedIn501C3 |
| Schedule B Required | 1 | 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 | 1 | CreditCounseling |
| Term Or Permanent Endowments | 1 | TermOrPermanentEndowments |
| Balance Sheet Amounts Reported | 1 | BalanceSheetAmountsReported |
| 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 |
| 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 | 0 | 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 | 1 | RelatedEntity |
| Related Org Controlled Entity | 0 | RelatedOrgControlledEntity |
| Transfers To Exempt Non Chrtbl Org | 0 | TransfersToExemptNonChrtblOrg |
| Activities Conducted Partnership | 0 | ActivitiesConductedPartnership |
| Schedule O Required | 1 | ScheduleORequired |
| Number Forms Transmitted With1096 | 20 | NumberFormsTransmittedWith1096 |
| Number W2 G Included | 0 | NumberW2GIncluded |
| Compliance With Backup Witholding | 1 | ComplianceWithBackupWitholding |
| Number Of Employees | 411 | NumberOfEmployees |
| Employment Tax Returns Filed | 1 | EmploymentTaxReturnsFiled |
| Unrelated Business Income | 1 | UnrelatedBusinessIncome |
| Form990-T Filed | 1 | Form990-TFiled |
| 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 |
| Nbr Voting Governing Body Members | 9 | NbrVotingGoverningBodyMembers |
| Number Independent Voting Members | 8 | 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 | 1 | WhistleblowerPolicy |
| Document Retention Policy | 1 | DocumentRetentionPolicy |
| Compensation Process CEO | 1 | CompensationProcessCEO |
| Compensation Process Other | 1 | CompensationProcessOther |
| Investment In Joint Venture | 1 | InvestmentInJointVenture |
| Written Policy Or Procedure | 1 | WrittenPolicyOrProcedure |
| States Where Copy Of Return Is Filed | MN | StatesWhereCopyOfReturnIsFiled |
| Upon Request | X | UponRequest |
The Books Are In Care Of TheBooksAreInCareOf
Name Business NameBusiness
| Field | Value | IRS element (for citing) |
|---|---|---|
| Business Name Line1 | BRAD ANDERSON | BusinessNameLine1 |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Telephone Number | 2188787027 | TelephoneNumber |
Address US AddressUS
| Field | Value | IRS element (for citing) |
|---|---|---|
| Address Line1 | 512 SKYLINE BLVD | AddressLine1 |
| City | CLOQUET | City |
| State | MN | State |
| ZIP Code | 55720 | ZIPCode |
Form990 Part VII Section A Form990PartVIISectionA (16 entries)
| TitleTitle | Average Hours Per WeekAverageHoursPerWeek | Individual Trustee Or DirectorIndividualTrusteeOrDirector | Reportable Comp From OrganizationReportableCompFromOrganization | Reportable Comp From Related OrgsReportableCompFromRelatedOrgs | Other CompensationOtherCompensation | OfficerOfficer | Highest Compensated EmployeeHighestCompensatedEmployee |
|---|---|---|---|---|---|---|---|
| ROBERT NELSON | |||||||
| DIRECTOR | 2.00 | X | 0 | 0 | 0 | ||
| STEVEN VOPAT | |||||||
| CHAIRMAN | 2.00 | X | 244782 | 0 | 31213 | ||
| NATE SANDMAN | |||||||
| vICE CHAIRMAN | 2.00 | X | 0 | 0 | 0 | ||
| DAVE HALL | |||||||
| SECRETARY | 2.00 | X | 0 | 0 | 0 | ||
| BOB FULGHUM | |||||||
| DIRECTOR | 2.00 | X | 0 | 0 | 0 | ||
| DAVID LUEHR | |||||||
| DIRECTOR | 2.00 | X | 0 | 0 | 0 | ||
| KEVIN TOBOLESKI | |||||||
| DIRECTOR | 2.00 | X | 0 | 0 | 0 | ||
| KELLY JOHNSON | |||||||
| TREASURER | 2.00 | X | 0 | 0 | 0 | ||
| PAM GROVER | |||||||
| DIRECTOR | 2.00 | X | 0 | 0 | 0 | ||
| RICK BREUER | |||||||
| CEO | 40.00 | 181609 | 0 | 26764 | X | ||
| BRAD ANDERSON | |||||||
| CFO | 40.00 | 129659 | 0 | 24167 | X | ||
| SCOTT NIELSEN | |||||||
| PHYSICIAN | 40.00 | 356713 | 0 | 24424 | X | ||
| TIMOTHY MCLEOD | |||||||
| PHYSICIAN | 40.00 | 259044 | 0 | 42598 | X | ||
| PAUL VOLLMAR | |||||||
| PHYSICIAN MDA | 40.00 | 398350 | 0 | 24855 | X | ||
| MATTHEW LEWIS | |||||||
| CRNA | 40.00 | 293370 | 0 | 43060 | X | ||
| CLINTON MOEN | |||||||
| PHYSICIAN | 40.00 | 248783 | 0 | 43245 | X | ||
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Reportable Comp From Org | 2112310 | TotalReportableCompFromOrg |
| Total Reportable Comp Frm Rltd Orgs | 0 | TotalReportableCompFrmRltdOrgs |
| Total Other Compensation | 260326 | TotalOtherCompensation |
| Number Individuals GT100 K | 20 | 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 |
|---|---|---|---|---|---|
| CLOQUET IMAGING SERVICES LLC | |||||
| 512 SKYLINE BLVD | CLOQUET | MN | 55720 | IMAGING SERVICE/EQUIPMENT | 1437120 |
| INOVATIONS IN ARCHETECHTURE | |||||
| 3791 ALDER AVENUE | HERMANTOWN | MN | 55810 | ARCHITECTURAL SERVICES | 1400084 |
| WAPITI MEDICAL GROUP | |||||
| 603 S DAKOTA ST | MILBANK | SD | 57252 | E/R PHYSICIANS | 1106517 |
| CMDI | |||||
| 150 10TH STREET NW | MILACA | MN | 56353 | IMAGING SERVICE/EQUIPMENT | 387920 |
| NORTHERN RESTORATIVE SERVICES | |||||
| 1304 N 19TH AVE E | DULUTH | MN | 55812 | OT SERVICES | 380247 |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Number Of Contractors GT100 K | 11 | NumberOfContractorsGT100K |
| Government Grants | 69166 | GovernmentGrants |
| All Other Contributions | 194554 | AllOtherContributions |
| Total Contributions | 263720 | TotalContributions |
Program Service Revenue ProgramServiceRevenue (2 entries)
| DescriptionDescription | Business CodeBusinessCode | Total Revenue ColumnTotalRevenueColumn | Related Or Exempt Function IncomeRelatedOrExemptFunctionIncome | Unrelated Business RevenueUnrelatedBusinessRevenue |
|---|---|---|---|---|
| PATIENT SERVICE REVENU | 621500 | 41146842 | 41146842 | |
| OUTSIDE LAB SALES | 621500 | 10547 | 10547 |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Program Service Revenue | 41157389 | TotalProgramServiceRevenue |
Investment Income InvestmentIncome
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Revenue Column | 61355 | TotalRevenueColumn |
| Exclusion | $61,355 | ExclusionAmount |
Gross Amount Sales Assets GrossAmountSalesAssets
| Field | Value | IRS element (for citing) |
|---|---|---|
| Other | 275 | Other |
Gain Or Loss GainOrLoss
| Field | Value | IRS element (for citing) |
|---|---|---|
| Other | 275 | Other |
Net Gain Or Loss Investments NetGainOrLossInvestments
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Revenue Column | 275 | TotalRevenueColumn |
| Exclusion | $275 | ExclusionAmount |
Other Revenue Misc OtherRevenueMisc (3 entries)
| DescriptionDescription | Business CodeBusinessCode | Total Revenue ColumnTotalRevenueColumn | Related Or Exempt Function IncomeRelatedOrExemptFunctionIncome |
|---|---|---|---|
| EARNINGS IN CMDI | 900099 | 578773 | 578773 |
| EARNINGS IN CLOQUET IM | 900099 | 222882 | 222882 |
| OTHER INCOME | 900099 | 114681 | 114681 |
Miscellaneous Revenue MiscellaneousRevenue
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Revenue Column | 4103 | TotalRevenueColumn |
| Related Or Exempt Function Income | 4103 | RelatedOrExemptFunctionIncome |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Other Revenue | 920439 | TotalOtherRevenue |
Total Revenue TotalRevenue
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Revenue Column | 42403178 | TotalRevenueColumn |
| Related Or Exempt Function Income | 42067281 | RelatedOrExemptFunctionIncome |
| Unrelated Business Revenue | 10547 | UnrelatedBusinessRevenue |
| Exclusion | $61,630 | ExclusionAmount |
Comp Current Officers Directors CompCurrentOfficersDirectors
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | 638194 | Total |
| Program Services | 275995 | ProgramServices |
| Management And General | 362199 | ManagementAndGeneral |
Other Salaries And Wages OtherSalariesAndWages
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | 19898233 | Total |
| Program Services | 18044208 | ProgramServices |
| Management And General | 1854025 | ManagementAndGeneral |
Pension Plan Contributions PensionPlanContributions
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | 844616 | Total |
| Management And General | 844616 | ManagementAndGeneral |
Other Employee Benefits OtherEmployeeBenefits
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | 3711937 | Total |
| Management And General | 3711937 | ManagementAndGeneral |
Interest Interest
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | 658398 | Total |
| Program Services | 658398 | ProgramServices |
Depreciation Depletion DepreciationDepletion
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | 1279734 | Total |
| Program Services | 1279734 | ProgramServices |
Insurance Insurance
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | 87633 | Total |
| Management And General | 87633 | ManagementAndGeneral |
Other Expenses OtherExpenses (5 entries)
| DescriptionDescription | TotalTotal | Program ServicesProgramServices | Management And GeneralManagementAndGeneral |
|---|---|---|---|
| HOSPITAL SUPPLIES & OTH | 6029901 | 6029901 | |
| OTHER NURSING SERVICES | 2277579 | 2277579 | |
| OTHER HOSPITAL SUPPLIES | 1600593 | 1600593 | |
| PROVISION FOR DOUBTFUL | 1398717 | 1398717 | |
| DATA PROCESSING | 633838 | 633838 |
All Other Expenses AllOtherExpenses
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | 2260764 | Total |
| Program Services | 648234 | ProgramServices |
| Management And General | 1612530 | ManagementAndGeneral |
Total Functional Expenses TotalFunctionalExpenses
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | 41320137 | Total |
| Program Services | 32213359 | ProgramServices |
| Management And General | 9106778 | ManagementAndGeneral |
| Fundraising | 0 | Fundraising |
Cash Non Interest Bearing CashNonInterestBearing
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | 4497631 | BOY |
| EOY | 5097073 | EOY |
Savings And Temp Cash Investments SavingsAndTempCashInvestments
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | 1816582 | BOY |
| EOY | 1816582 | EOY |
Pledges And Grants Receivable PledgesAndGrantsReceivable
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | 65745 | BOY |
| EOY | 53489 | EOY |
Accounts Receivable AccountsReceivable
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | 5663762 | BOY |
| EOY | 5616020 | EOY |
Other Notes Loans Receivable Net OtherNotesLoansReceivableNet
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | 196473 | BOY |
| EOY | 137002 | EOY |
Inventories For Sale Or Use InventoriesForSaleOrUse
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | 762189 | BOY |
| EOY | 846997 | EOY |
Prepaid Expenses Deferred Charges PrepaidExpensesDeferredCharges
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | 188026 | BOY |
| EOY | 289830 | EOY |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Land Buildings Equipment Basis | 29737351 | LandBuildingsEquipmentBasis |
| Land Bldg Equipment Accum Deprec | 14768753 | LandBldgEquipmentAccumDeprec |
Land Buildings Equipment Basis Net LandBuildingsEquipmentBasisNet
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | 14302313 | BOY |
| EOY | 14968598 | EOY |
Investments Program Related InvestmentsProgramRelated
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | 1568531 | BOY |
| EOY | 1608256 | EOY |
Other Assets Total OtherAssetsTotal
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | 770937 | BOY |
| EOY | 1090316 | EOY |
Total Assets TotalAssets
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | 29832189 | BOY |
| EOY | 31524163 | EOY |
Accounts Payable Accrued Expenses AccountsPayableAccruedExpenses
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | 3847839 | BOY |
| EOY | 4781269 | EOY |
Escrow Account Liability EscrowAccountLiability
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | 14955 | BOY |
| EOY | 15364 | EOY |
Mort Notes Pybl Secured Invest Prop MortNotesPyblSecuredInvestProp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | 9823056 | BOY |
| EOY | 9498150 | EOY |
Other Liabilities OtherLiabilities
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | 1084504 | BOY |
| EOY | 1385927 | EOY |
Total Liabilities TotalLiabilities
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | 14770354 | BOY |
| EOY | 15680710 | EOY |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Follow SFAS117 | X | FollowSFAS117 |
Unrestricted Net Assets UnrestrictedNetAssets
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | 14726185 | BOY |
| EOY | 15497237 | EOY |
Temporarily Restricted Net Assets TemporarilyRestrictedNetAssets
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | 335650 | BOY |
| EOY | 346216 | EOY |
Total Net Assets Fund Balances TotalNetAssetsFundBalances
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | 15061835 | BOY |
| EOY | 15843453 | EOY |
Total Liab Net Assets Fund Balances TotalLiabNetAssetsFundBalances
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | 29832189 | BOY |
| EOY | 31524163 | EOY |
| Field | Value | IRS element (for citing) |
|---|---|---|
| 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 B IRS990ScheduleB
Contributor Info ContributorInfo
| Field | Value | IRS element (for citing) |
|---|---|---|
| Contributor Number | RESTRICTED | ContributorNumber |
Contributor Name Business ContributorNameBusiness
| Field | Value | IRS element (for citing) |
|---|---|---|
| Business Name Line1 | RESTRICTED | BusinessNameLine1 |
Contributor Address US ContributorAddressUS
| Field | Value | IRS element (for citing) |
|---|---|---|
| Address Line1 | RESTRICTED | AddressLine1 |
| Address Line2 | RESTRICTED | AddressLine2 |
| City | RESTRICTED | City |
| State | RESTRICTED | State |
| ZIP Code | RESTRICTED | ZIPCode |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Aggregate Contributions | RESTRICTED | AggregateContributions |
Schedule D IRS990ScheduleD
| Field | Value | IRS element (for citing) |
|---|---|---|
| Agent Trustee Etc | 0 | AgentTrusteeEtc |
| Included On FS | 1 | IncludedOnFS |
Current Year CurrentYear
| Field | Value | IRS element (for citing) |
|---|---|---|
| Beginning Of Year Balance | 335650 | BeginningOfYearBalance |
| Contributions | 173782 | Contributions |
| Investment Earnings Or Losses | 6180 | InvestmentEarningsOrLosses |
| Other Expenditures | 169396 | OtherExpenditures |
| End Of Year Balance | 346216 | EndOfYearBalance |
Current Year Minus1 Year CurrentYearMinus1Year
| Field | Value | IRS element (for citing) |
|---|---|---|
| Beginning Of Year Balance | 329360 | BeginningOfYearBalance |
| Contributions | 30653 | Contributions |
| Investment Earnings Or Losses | 8163 | InvestmentEarningsOrLosses |
| Other Expenditures | 32526 | OtherExpenditures |
| End Of Year Balance | 335650 | EndOfYearBalance |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Board Designated EOY Balance | 1.00000 | BoardDesignatedEOYBalance |
| Endowments Held By Unrelated Orgs | 0 | EndowmentsHeldByUnrelatedOrgs |
| Endowments Held By Related Orgs | 0 | EndowmentsHeldByRelatedOrgs |
Land Land
| Field | Value | IRS element (for citing) |
|---|---|---|
| Other Cost Or Other Basis | 29448 | OtherCostOrOtherBasis |
| Book Value | 29448 | BookValue |
Buildings Buildings
| Field | Value | IRS element (for citing) |
|---|---|---|
| Other Cost Or Other Basis | 20719338 | OtherCostOrOtherBasis |
| Depreciation | 9531836 | Depreciation |
| Book Value | 11187502 | BookValue |
Equipment Equipment
| Field | Value | IRS element (for citing) |
|---|---|---|
| Other Cost Or Other Basis | 6822009 | OtherCostOrOtherBasis |
| Depreciation | 4872772 | Depreciation |
| Book Value | 1949237 | BookValue |
Other Land Buildings OtherLandBuildings
| Field | Value | IRS element (for citing) |
|---|---|---|
| Other Cost Or Other Basis | 2166556 | OtherCostOrOtherBasis |
| Depreciation | 364145 | Depreciation |
| Book Value | 1802411 | BookValue |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Of Book Value Land Buildings | 14968598 | TotalOfBookValueLandBuildings |
Investments Program Related InvestmentsProgramRelated (4 entries)
| DescriptionDescription | Book ValueBookValue | Method Of ValuationMethodOfValuation |
|---|---|---|
| INVESTMENTS IN CENTRAL MINNESOTA DIAGNOSTICS, INC | 1416252 | C |
| INVESTMENTS IN SISU SOLUTIONS, LLC | 55540 | C |
| INVESTMENTS IN CLOQUET IMAGING SERVICES, LLC | 123044 | C |
| INVESTMENTS IN SISU MEDICAL SYSTEMS | 13420 | C |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Of Book Value Program Related | 1608256 | TotalOfBookValueProgramRelated |
Other Liabilities OtherLiabilities
| Field | Value | IRS element (for citing) |
|---|---|---|
| Description | INTEREST SWAP AGREEMENT | Description |
| Amount | $1,385,927 | Amount |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Of Amounts | 1385927 | TotalOfAmounts |
| Total Revenue | 42403178 | TotalRevenue |
| Total Expenses | 41320137 | TotalExpenses |
| Excess Or Deficit For Year | 1083041 | ExcessOrDeficitForYear |
| Other | -$301,423 | OtherAmount |
| Total Adjustments | -301423 | TotalAdjustments |
| Excess Or Deficit Per FS | 781618 | ExcessOrDeficitPerFS |
| Tot Revenue Etc Audited Fincl Stmt | 42101480 | TotRevenueEtcAuditedFinclStmt |
| Revenue Not Rptd F990 | 0 | RevenueNotRptdF990 |
| Revenue Subtotal | 42101480 | RevenueSubtotal |
| Other Revenues Not Included | 301698 | OtherRevenuesNotIncluded |
| Revenue Not Rptd On Fin Stmt | 301698 | RevenueNotRptdOnFinStmt |
| Total Revenue Per Form990 | 42403178 | TotalRevenuePerForm990 |
| Tot Expenses Etc Audited Fincl Stmt | 41319862 | TotExpensesEtcAuditedFinclStmt |
| Expenses Not Rptd F990 | 0 | ExpensesNotRptdF990 |
| Expenses Subtotal | 41319862 | ExpensesSubtotal |
| Other Expenses Not Included | 275 | OtherExpensesNotIncluded |
| Expenses Not Rptd On Fin Stmt | 275 | ExpensesNotRptdOnFinStmt |
| Total Expenses Per Form990 | 41320137 | TotalExpensesPerForm990 |
Form990 Schedule D Part XIV Form990ScheduleDPartXIV (5 entries)
| IdentifierIdentifier | ExplanationExplanation | Return ReferenceReturnReference |
|---|---|---|
| Part IV, Line 2b: | the hospital is the custodian of funds for residents of the nursing home. the hospital holds these funds for purchases made by the residents. | |
| Part X: | Management evaluated the Association's tax positions and concluded that the Association had taken no uncertain tax positions that require adjustment to the financial statements. | Description of Uncertain Tax Positions Under FIN 48: |
| Part XI, Line 8 - Other Adjustments: | CHANGE IN FAIR VALUE OF INTEREST RATE SWAP AGREEMENT: -301423. | |
| Part XII, Line 4b - Other Adjustments: | CHANGE IN FAIR VALUE OF INTEREST SWAP AGREEMENT: 301423. GAIN ON DISPOSAL OF FIXED ASSETS: 275. | |
| Part XIII, Line 4b - Other Adjustments: | GAIN ON DISPOSAL OF FIXED ASSETS: 275. |
Schedule H IRS990ScheduleH
| Field | Value | IRS element (for citing) |
|---|---|---|
| Charity Care Policy | 1 | CharityCarePolicy |
| Written Policy | 1 | WrittenPolicy |
| FPG Reference Free Care | 1 | FPGReferenceFreeCare |
| Pcent200 | X | Pcent200 |
| FPG Reference Discounted Care | 1 | FPGReferenceDiscountedCare |
| Pcent250 | X | Pcent250 |
| Free Disc Care Medically Indigent | 1 | FreeDiscCareMedicallyIndigent |
| Amounts Budgeted For Charity Care | 1 | AmountsBudgetedForCharityCare |
| Expenses Exceeded Budget | 1 | ExpensesExceededBudget |
| Unable To Provide Care | 0 | UnableToProvideCare |
| 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 | 215836 | TotalCommunityBenefitExpense |
| Net Community Benefit Expense | 215836 | NetCommunityBenefitExpense |
| Percent Of Total Expense | 0.00540 | PercentOfTotalExpense |
Unreimbursed Medicaid UnreimbursedMedicaid
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Community Benefit Expense | 8857289 | TotalCommunityBenefitExpense |
| Direct Offsetting Revenue | 7093550 | DirectOffsettingRevenue |
| Net Community Benefit Expense | 1763739 | NetCommunityBenefitExpense |
| Percent Of Total Expense | 0.04420 | PercentOfTotalExpense |
Unreimbursed Costs UnreimbursedCosts
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Community Benefit Expense | 1689510 | TotalCommunityBenefitExpense |
| Direct Offsetting Revenue | 1498939 | DirectOffsettingRevenue |
| Net Community Benefit Expense | 190571 | NetCommunityBenefitExpense |
| Percent Of Total Expense | 0.00480 | PercentOfTotalExpense |
Total Charity Care TotalCharityCare
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Community Benefit Expense | 10762635 | TotalCommunityBenefitExpense |
| Direct Offsetting Revenue | 8592489 | DirectOffsettingRevenue |
| Net Community Benefit Expense | 2170146 | NetCommunityBenefitExpense |
| Percent Of Total Expense | 0.05440 | PercentOfTotalExpense |
Community Health Services CommunityHealthServices
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Community Benefit Expense | 35962 | TotalCommunityBenefitExpense |
| Net Community Benefit Expense | 35962 | NetCommunityBenefitExpense |
| Percent Of Total Expense | 0.00090 | PercentOfTotalExpense |
Cash And In Kind Contributions CashAndInKindContributions
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Community Benefit Expense | 13220 | TotalCommunityBenefitExpense |
| Net Community Benefit Expense | 13220 | NetCommunityBenefitExpense |
| Percent Of Total Expense | 0.00030 | PercentOfTotalExpense |
Total Other Benefits TotalOtherBenefits
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Community Benefit Expense | 49182 | TotalCommunityBenefitExpense |
| Net Community Benefit Expense | 49182 | NetCommunityBenefitExpense |
| Percent Of Total Expense | 0.00120 | PercentOfTotalExpense |
Total Community Benefits TotalCommunityBenefits
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Community Benefit Expense | 10811817 | TotalCommunityBenefitExpense |
| Direct Offsetting Revenue | 8592489 | DirectOffsettingRevenue |
| Net Community Benefit Expense | 2219328 | NetCommunityBenefitExpense |
| Percent Of Total Expense | 0.05560 | PercentOfTotalExpense |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Bad Debt Expense Reported | 1 | BadDebtExpenseReported |
| Bad Debt Expense | $754,753 | BadDebtExpenseAmount |
| Amount Attributable To | 27671 | AmountAttributableTo |
| Amount Reimbursed By Medicare | 10203204 | AmountReimbursedByMedicare |
| Cost Of Care Reimbursed By Medicare | 10156442 | CostOfCareReimbursedByMedicare |
| Medicare Surplus Or Shortfall | 46762 | MedicareSurplusOrShortfall |
Costing Methodology Used CostingMethodologyUsed
| Field | Value | IRS element (for citing) |
|---|---|---|
| Cost To Charge Ratio | X | CostToChargeRatio |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Written Debt Collection Policy | 1 | WrittenDebtCollectionPolicy |
| Provision For Charity Care | 1 | ProvisionForCharityCare |
Form990 Schedule H Part IV Form990ScheduleHPartIV
Name Of Entity NameOfEntity
| Field | Value | IRS element (for citing) |
|---|---|---|
| Business Name Line1 | CLOQUET IMAGING INC | BusinessNameLine1 |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Description Ent Primary Activity | IMAGING SERVICES/EQUIPMENT | DescriptionEntPrimaryActivity |
| Organization Profit Or Ownership | 0.50000 | OrganizationProfitOrOwnership |
| Officers Etc Profit Or Ownership | 0.00000 | OfficersEtcProfitOrOwnership |
| Physicans Profit Or Ownership | 0.50000 | PhysicansProfitOrOwnership |
Form990 Schedule H Part V Form990ScheduleHPartV
Name Name
| Field | Value | IRS element (for citing) |
|---|---|---|
| Business Name Line1 | COMMUNITY MEMORIAL HOSPITAL | BusinessNameLine1 |
Address Address
| Field | Value | IRS element (for citing) |
|---|---|---|
| Address Line1 | 512 SKYLINE BLVD | AddressLine1 |
| City | CLOQUET | City |
| State | MN | State |
| ZIP Code | 55720 | 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 |
Form990 Schedule H Part VI Form990ScheduleHPartVI
| Field | Value | IRS element (for citing) |
|---|---|---|
| Costing Method Used | Part I, Line 7: Costs are calculated using financial data and the Cost to Charge Ratio from the as filed 2010 Medicare Cost Report (lines 7a, 7b, 7c). Lines 7e and 7i are listed as actual with the exception of an estimate for space utilization for various community programs. | CostingMethodUsed |
| Percent Of Total Expense Expln | Part I, Line 7f: Bad debt expense from financial statements IS $1,398,717. | PercentOfTotalExpenseExpln |
| Bad Debt Footnote | Part III, Line 4: CMH records bad debt expense as an estimate of uncollectible accounts receivable based on aging and historical trends and actual bankruptcy write-offs. The Medicare Cost Report (MCR) cost to charge ratio is then applied to these items to determine Part III, section A, line 2 cost. The estimate of bad debt cost due to charity care patients is based on the total number of charity care applications distributed (requested) vs. the actual number completed and returned. The MCR cost to charge ratio is also applied to this estimate to determine Part III, section A, line 3 cost. Selfpay discounts are applied immediately to all Selfpay accounts receivable. From financial statement footnote "...Management determines the allowance for doubtful accounts by identifying troubled accounts and by using historical experience applied to an aging of accounts. Patient receivables are written off when deemed uncollectible. Recoveries of receivables previously written off are recorded when received." | BadDebtFootnote |
| Shortfall As Community Benefit | Part III, Line 8: The hospital is a critical access hospital and thus is reimbursed at 101% of cost. The medicare fees for reimbursed services resulted in net revenue of 470,807 and allowable costs of 1,289,325 resulting in a shortfall of 818,518. The shortfall is the result of unreimbursed Professional care. Our community is enhanced by the Hospital's ability to provide 24 hour Emergency, Obstetrics, Ambulatory Surgery and other convenient professional services. These benefits to the Community have great importance, as travel to neighboring providers is distant, dangerous during long winters and primarily, could have negative health outcomes.The hospital followed Medicare's prescribed methods of determining costs payable under title XVIII (Medicare) in completing its annual Medicare cost report (cost report) using data available from the institution's basic accounts, as usually maintained, to arrive at equitable and proper payment for services. The cost report was completed using the hospital's trial balance of expenses, as well as other statistical and financial records maintained by the hospital. As required by Medicare regulations, certain reclassifications and adjustments to costs were included in the cost report to determine Medicare allowable costs.After Medicare allowable costs are determined, the cost report provides for the step down method of cost finding. This method provides for allocating the cost of services rendered by each general service cost center to other cost centers, which utilize the services. Once the costs of a general service cost center have been allocated, that cost center is considered closed. Once closed, it does not receive any of the costs subsequently allocated from the remaining general service cost centers. After all costs of the general service cost centers have been allocated to the remaining cost centers, the total costs of these remaining cost centers are further distributed to the departmental classification to which they pertain, e.g., hospital general inpatient routine, subprovider, ancillary, etc.After the step-down process, the cost report provides for the apportionment of costs to the Medicare program based on a number of different methodologies including per patient day, per visit, and percentage of charges, as most prevalent. Medicare costs as determined by the cost report methodologies described previously were utilized to complete the applicable Medicare allowable costs of care for Schedule H (Form 990) Part III Section B Line 6. | ShortfallAsCommunityBenefit |
| Debt Collection Policy | Part III, Line 9b: Community Memorial Hospital has both Self-pay Collections and Community Care Program (Charity Care) policies that are utilized and applied fluidly. Self-pay (Minnesota Attorney General) discounts are applied immediately to a self-pay patients' liability. All inpatient and outpatient accounts are eligible for charity care. All patients are advised of this program and applications are made readily available. Eligibility is determined by the applicants income (federal tax return and other financial disclosures) compared to the Federal Poverty Guidelines. Qualifying patients can receive a partial sliding scale reduction up to 100%. Patients who may qualify but do not complete the Community Care application would be moved to our Self-pay collection policy. This policy outlines the series of statement mailings, 30-60-90 day letters, courtesy calls as well as the availability of Community Care. This cycle is pursued rather than the account being considered for bad debt collection. | DebtCollectionPolicy |
| General Explanation | PART I, LINE 6A: The Organization prepares and publishes and annual report to the Community. This publication reports sources and uses of funds, statistical volumes and calculated Community Benefits. These are mailed to members of the community and all patients. | GeneralExplanation |
| Needs Assessment | Part VI, Line 2: "We are a sponsor of the Bridge to Health survey instrument. The survey is designed to gather population-based health status data on residents in a nine-county region in northeastern Minnesota and northwestern Wisconsin. The survey is a collaborative effort involving representatives from over 60 health-related organizations. We utilize the information gathered from this survey broken down to our specific service area to identify unmet needs and opportunities for community health improvement." | NeedsAssessment |
| Patient Education Assistance | Part VI, Line 3: Self Pay patients are informed at the time of service that we can provide community care services and provide a form. We advise the patient to apply for Medical Assistance to the Minnesota County Human Services office where they reside so that they can apply for assistance. Community Care (charity care) applications are provided in our registration offices, waiting rooms and on our website. The organization also sends information to patients with their itemized bills. We request that patients call us with questions or for help regarding medical assistance or our Community Care Program. | PatientEducationAssistance |
| Community Information | Part VI, Line 4: Commumity Memorial Hospital (CMH) meets the State of Minnesota's criteria of a rural hospital and has been granted Necessary Provider status as a critical access hospital. CMH is located in Cloquet Minnesota, which is in Carlton County a northeastern county in Minnesota, approximately 25 miles from Duluth Minnesota and Lake Superior. CMH serves primarily an eleven zip code area with 85% of its patients residing in Carlton County. Carlton County's 2010 census estimated at 34,000. While 42% of the population is 45 and older, 19 % of the residents are female age 15-44. Growth is projected over the next five plus years. Median household income for the area is $48,000 which is 18% lower than the Minnesota average. The economy of the service area is mixed and includes manufacturing, educational services, recreational casino-resort and healthcare services. This mix has had a stabilizing effect on unemployment. While being generally higher than the Minnesota average, this measure has not seen large swings that the nation has seen. | CommunityInformation |
| Community Building Activities | Part VI, Line 5: N/A | CommunityBuildingActivities |
| Other Information | Part VI, Line 6: Community Memorial Hospital (CMH) continues to have a strong economic impact on our service region. We know we could not be successful without the support of our community. Our Board of Directors are comprised of community members with diverse backgrounds and interests. We have an open medical staff policy that shares our interest of providing quality health care locally. We take "community" in our name seriously. CMH reaches out by offering screenings, education groups and other connections to improve the health of our citizens. Educational seminars include: Dizziness, diabetes, childbirth and urinary incontinence. Ongoing Stroke and Grief support groups help families dealing with these issues. CMH hosts exercise programs in Arthritis care and Pilates. Many consulting services are offered through our Occupational Therapy Department. We can assist in designing and performing employment screenings, functional job descriptions, work-site evaluations, worker education etc. Community Memorial Hospital goes out into the area to conduct health fairs and expos providing screenings for vision, blood glucose, blood pressure, grip strength as well as body fat analysis. Community Memorial Hospital will continue to grow the promotion of health in the community and further its purpose as a exempt organization. | OtherInformation |
| Affiliated Health Care System | Part VI, Line 7: N/A | AffiliatedHealthCareSystem |
| Reports Filed With States | MN | ReportsFiledWithStates |
Schedule J IRS990ScheduleJ
| Field | Value | IRS element (for citing) |
|---|---|---|
| Written Employment Contract | X | WrittenEmploymentContract |
| Compensation Survey | X | CompensationSurvey |
| Board Or Committee Approval | X | BoardOrCommitteeApproval |
| 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 (8 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 |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| STEVEN VOPAT | |||||||||||||
| 244782 | 0 | 0 | 0 | 0 | 0 | 11779 | 0 | 19434 | 0 | 275995 | 0 | 0 | 0 |
| RICK BREUER | |||||||||||||
| 181609 | 0 | 0 | 0 | 0 | 0 | 9080 | 0 | 17684 | 0 | 208373 | 0 | 0 | 0 |
| BRAD ANDERSON | |||||||||||||
| 129659 | 0 | 0 | 0 | 0 | 0 | 6483 | 0 | 17684 | 0 | 153826 | 0 | 0 | 0 |
| SCOTT NIELSEN | |||||||||||||
| 356713 | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 24424 | 0 | 381137 | 0 | 0 | 0 |
| TIMOTHY MCLEOD | |||||||||||||
| 259044 | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 42598 | 0 | 301642 | 0 | 0 | 0 |
| PAUL VOLLMAR | |||||||||||||
| 398350 | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 24855 | 0 | 423205 | 0 | 0 | 0 |
| MATTHEW LEWIS | |||||||||||||
| 293370 | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 43060 | 0 | 336430 | 0 | 0 | 0 |
| CLINTON MOEN | |||||||||||||
| 248783 | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 43245 | 0 | 292028 | 0 | 0 | 0 |
Schedule O IRS990ScheduleO
General Explanation GeneralExplanation (6 entries)
| IdentifierIdentifier | ExplanationExplanation |
|---|---|
| Form 990, Part VI, Section B, line 11 | 990 is completed by an independent CPA firm, reviewed by Administration and Finance for accuracy and presented to the Board of Directors. |
| Form 990, Part VI, Section B, line 12c | Education is done on a yearly basis to Physicians, Dept Directors and the Board of Directors. Conflict of Interest statements are given to those individuals. Items listed on those statements are reviewed by the CEO, Compliance Officer and/or the Chairman of the Board to see if conflicts exist. |
| Form 990, Part VI, Section B, line 15 | An organizational policy "Salary Administration Policy - Non Contract Employees" is followed. Annually an industry salary survey is completed and results are used to set wage scales for positions by job code. Any changes to wage scales are presented the Human Resources Committee of the Board of Directors which reviews and makes recommendations to the Board of Directors for approval. |
| Form 990, Part VI, Section C, line 18 | All such documents are kept on-site for review by the public during normal business hours. |
| Form 990, Part VI, Section C, line 19 | All such documents are kept on-site for review by the public during normal business hours. |
| FORM 990, PART XI , LINE 2C: | THE ORGANIZATION HAS A COMMITTEE THAT OVERSEES THE AUDIT AND SELECTS AN INDEPENDENT ACCOUNTANT. |
Schedule R IRS990ScheduleR
Form990 Schedule R Part II Form990ScheduleRPartII
Name Of Disregarded Entity NameOfDisregardedEntity
| Field | Value | IRS element (for citing) |
|---|---|---|
| Business Name Line1 | CLOQUET COMMUNITY MEMORIAL HOSPITAL FOUNDATION | BusinessNameLine1 |
Address US AddressUS
| Field | Value | IRS element (for citing) |
|---|---|---|
| Address Line1 | 512 SKYLINE BLVD | AddressLine1 |
| City | CLOQUET | City |
| State | MN | State |
| ZIP Code | 55720 | ZIPCode |
| Field | Value | IRS element (for citing) |
|---|---|---|
| EIN | 363588501 | EIN |
| Primary Activities | SUPPORT | PrimaryActivities |
| Legal Domicile State | MN | LegalDomicileState |
| Exempt Code Section | 501(C)(3) | ExemptCodeSection |
| Public Charity Status | 509(A)(3) | PublicCharityStatus |
| Direct Controlling Entity NA | N/A | DirectControllingEntityNA |
Form990 Schedule R Part III Form990ScheduleRPartIII
Name Of Related Org NameOfRelatedOrg
| Field | Value | IRS element (for citing) |
|---|---|---|
| Business Name Line1 | CLOQUET IMAGING SERVICES LLC | BusinessNameLine1 |
Address US AddressUS
| Field | Value | IRS element (for citing) |
|---|---|---|
| Address Line1 | 512 SKYLINE BOULEVARD | AddressLine1 |
| City | CLOQUET | City |
| State | MN | State |
| ZIP Code | 55720 | ZIPCode |
| Field | Value | IRS element (for citing) |
|---|---|---|
| EIN | 208847722 | EIN |
| Primary Activity | MEDICAL IMAGING | PrimaryActivity |
| Legal Domicile State | MN | LegalDomicileState |
| Direct Controlling Entity NA | N/A | DirectControllingEntityNA |
| Predominant Income Type | RELATED | PredominantIncomeType |
| Share Of Total Income | 154123 | ShareOfTotalIncome |
| Share Of EOY Assets | 414600 | ShareOfEOYAssets |
| Disproportionate Allocations | 0 | DisproportionateAllocations |
| General Or Managing Partner | 0 | GeneralOrManagingPartner |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Receipt Of Int Ann Rents Royalties | 0 | ReceiptOfIntAnnRentsRoyalties |
| Gift Grant Or Cap Contr To Other Org | 0 | GiftGrantOrCapContrToOtherOrg |
| Gift Grant Or Cap Contr Fr Other Org | 1 | GiftGrantOrCapContrFrOtherOrg |
| Loans Or Guarantees To Other Org | 0 | LoansOrGuaranteesToOtherOrg |
| Loans Or Guarantees From Other Org | 0 | LoansOrGuaranteesFromOtherOrg |
| Sale Of Assets To Other Org | 0 | SaleOfAssetsToOtherOrg |
| Purchase Of Assets From Other Org | 0 | PurchaseOfAssetsFromOtherOrg |
| Exchange Of Assets | 0 | ExchangeOfAssets |
| Rental Of Facilities To Other Orgs | 0 | RentalOfFacilitiesToOtherOrgs |
| Rental Of Facilities Fr Other Orgs | 0 | RentalOfFacilitiesFrOtherOrgs |
| Perform Of Services For Other Orgs | 0 | PerformOfServicesForOtherOrgs |
| Perform Of Services By Other Orgs | 0 | PerformOfServicesByOtherOrgs |
| Sharing Of Facilities | 1 | SharingOfFacilities |
| Sharing Of Paid Employees | 1 | SharingOfPaidEmployees |
| Reimbursement Paid To Other Org | 0 | ReimbursementPaidToOtherOrg |
| Reimbursement Paid By Other Org | 0 | ReimbursementPaidByOtherOrg |
| Other Transfer To Other Org | 0 | OtherTransferToOtherOrg |
| Other Transfer From Other Org | 0 | OtherTransferFromOtherOrg |