2011-07-29T13:05:57-05:00 2010-09-30 RSM McGladrey Inc 700 Missabe Building Duluth MN 55802 990 2009-10-01 410743546 COMMUNITY MEMORIAL HOSPITAL ASSOCIATION COMM 2188797027 512 SKYLINE BLVD CLOQUET MN 55720 BRAD ANDERSON 2188797027 2011-07-21 1 Jennifer Miller 2187278253 2009 2016-02-24 21:20:13Z BRAD ANDERSON 512 SKYLINE BLVD CLOQUET MN 55720 42403178 0 X WWW.CLOQUETHOSPITAL.COM X 1954 MN 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. 9 8 411 117 10547 0 104340 263720 40077345 41157389 58592 61630 1047548 920439 41287825 42403178 0 0 23054801 25092980 0 0 16815279 16227157 39870080 41320137 1417745 1083041 29832189 31524163 14770354 15680710 15061835 15843453 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. 0 0 32213359 42067281 PROVIDE HOSPITAL AND NURSING HOME HEALTHCARE TO COMMUNITY 32213359 1 1 0 0 0 0 0 1 1 1 1 0 0 0 0 0 0 0 0 0 1 0 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 1 0 0 0 1 20 0 1 411 1 1 1 0 0 0 0 0 0 0 0 9 8 0 0 0 0 0 0 0 1 1 0 0 1 1 1 1 1 1 1 1 1 1 MN X BRAD ANDERSON 2188787027 512 SKYLINE BLVD CLOQUET MN 55720 ROBERT NELSON 2.00 X 0 0 0 STEVEN VOPAT 2.00 X 244782 0 31213 NATE SANDMAN 2.00 X 0 0 0 DAVE HALL 2.00 X 0 0 0 BOB FULGHUM 2.00 X 0 0 0 DAVID LUEHR 2.00 X 0 0 0 KEVIN TOBOLESKI 2.00 X 0 0 0 KELLY JOHNSON 2.00 X 0 0 0 PAM GROVER 2.00 X 0 0 0 RICK BREUER 40.00 X 181609 0 26764 BRAD ANDERSON 40.00 X 129659 0 24167 SCOTT NIELSEN 40.00 X 356713 0 24424 TIMOTHY MCLEOD 40.00 X 259044 0 42598 PAUL VOLLMAR 40.00 X 398350 0 24855 MATTHEW LEWIS 40.00 X 293370 0 43060 CLINTON MOEN 40.00 X 248783 0 43245 2112310 0 260326 20 0 1 0 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 11 69166 194554 263720 PATIENT SERVICE REVENU 621500 41146842 41146842 OUTSIDE LAB SALES 621500 10547 10547 41157389 61355 61355 275 275 275 275 EARNINGS IN CMDI 900099 578773 578773 EARNINGS IN CLOQUET IM 900099 222882 222882 OTHER INCOME 900099 114681 114681 4103 4103 920439 42403178 42067281 10547 61630 638194 275995 362199 19898233 18044208 1854025 844616 844616 3711937 3711937 658398 658398 1279734 1279734 87633 87633 HOSPITAL SUPPLIES & OTH 6029901 6029901 OTHER NURSING SERVICES 2277579 2277579 OTHER HOSPITAL SUPPLIES 1600593 1600593 PROVISION FOR DOUBTFUL 1398717 1398717 DATA PROCESSING 633838 633838 2260764 648234 1612530 41320137 32213359 9106778 0 4497631 5097073 1816582 1816582 65745 53489 5663762 5616020 196473 137002 762189 846997 188026 289830 29737351 14768753 14302313 14968598 1568531 1608256 770937 1090316 29832189 31524163 3847839 4781269 14955 15364 9823056 9498150 1084504 1385927 14770354 15680710 X 14726185 15497237 335650 346216 15061835 15843453 29832189 31524163 X 0 1 1 X 0 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 0 1 335650 173782 6180 169396 346216 329360 30653 8163 32526 335650 1.00000 0 0 29448 29448 20719338 9531836 11187502 6822009 4872772 1949237 2166556 364145 1802411 14968598 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 1608256 INTEREST SWAP AGREEMENT 1385927 1385927 42403178 41320137 1083041 -301423 -301423 781618 42101480 0 42101480 301698 301698 42403178 41319862 0 41319862 275 275 41320137 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: Description of Uncertain Tax Positions Under FIN 48: 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. 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. 1 1 1 X 1 X 1 1 1 0 1 1 215836 215836 0.00540 8857289 7093550 1763739 0.04420 1689510 1498939 190571 0.00480 10762635 8592489 2170146 0.05440 35962 35962 0.00090 13220 13220 0.00030 49182 49182 0.00120 10811817 8592489 2219328 0.05560 1 754753 27671 10203204 10156442 46762 X 1 1 CLOQUET IMAGING INC IMAGING SERVICES/EQUIPMENT 0.50000 0.00000 0.50000 COMMUNITY MEMORIAL HOSPITAL

512 SKYLINE BLVD CLOQUET MN 55720

X X X X 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. Part I, Line 7f: Bad debt expense from financial statements IS $1,398,717. 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." 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. 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. 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. 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." 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. 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. Part VI, Line 5: N/A 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. Part VI, Line 7: N/A MN X X X 0 0 0 0 0 0 0 0 0 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 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. CLOQUET COMMUNITY MEMORIAL HOSPITAL FOUNDATION 512 SKYLINE BLVD CLOQUET MN 55720 363588501 SUPPORT MN 501(C)(3) 509(A)(3) N/A CLOQUET IMAGING SERVICES LLC 512 SKYLINE BOULEVARD CLOQUET MN 55720 208847722 MEDICAL IMAGING MN N/A RELATED 154123 414600 0 0 0 0 1 0 0 0 0 0 0 0 0 0 1 1 0 0 0 0