Ingham County Medical Care Facility. For the Year Ended December 31, 2011. Financial Statements

Ingham County Medical Care Facility For the Year Ended December 31, 2011 Financial Statements

INGHAM COUNTY MEDICAL CARE FACILITY Table of Contents FINANCIAL SECTION Page Independent Auditors Report 1 Financial Statements for the Year Ended December 31, 2011: Statements of Net Assets 4 Statement of Revenues, Expenses and Changes in Fund Net Assets 5 Statement of Cash Flows 6 Notes to Financial Statements 9 REQUIRED SUPPLEMENTARY INFORMATION Retiree Health Care Plan - Schedules of Funding Progress and Employer Contributions 18 SUPPLEMENTARY FINANCIAL INFORMATION Schedule of Net Patient Revenues Schedule of Operating Expenses Independent Auditors Report on Internal Control over Financial Reporting and on Compliance and Other Matters Based on an Audit of Financial Statements Performed in Accordance with Government Auditing Standards 20 21 23

Rehmann Robson INDEPENDENT AUDITORS' REPORT 675 Robinson Rd. Jackson, MI 49203 Ph: 517.787.6503 Fx: 517.788.8111 www.rehmann.com June 21, 2012 To the Department of Human Services Board of the Ingham County Medical Care Facility Okemos, Michigan We have audited the accompanying financial statements of the Ingham County Medical Care Facility, an enterprise fund of Ingham County, Michigan, as of and for the year ended December 31, 2011, as listed in the table of contents. These financial statements are the responsibility of the Ingham County Medical Care Facility s management. Our responsibility is to express an opinion on these financial statements based on our audit. We conducted our audit in accordance with auditing standards generally accepted in the United States of America and the standards applicable to financial audits contained in Government Auditing Standards, issued by the Comptroller General of the United States. Those standards require that we plan and perform the audit to obtain reasonable assurance about whether the financial statements are free of material misstatement. An audit includes examining, on a test basis, evidence supporting the amounts and disclosures in the financial statements. An audit also includes assessing the accounting principles used and significant estimates made by management, as well as evaluating the overall financial statement presentation. We believe that our audit provides a reasonable basis for our opinion. As discussed in Note 1, the financial statements present only the Ingham County Medical Care Facility and do not purport to, and do not, present fairly the financial position of Ingham County, Michigan, as of December 31, 2011, and the changes in its financial position and its cash flows for the year then ended in conformity with accounting principles generally accepted in the United States of America. In our opinion, the financial statements referred to above present fairly, in all material respects, the financial position of the Ingham County Medical Care Facility as of December 31, 2011, and the changes in its financial position and its cash flows for the year then ended in conformity with accounting principles generally accepted in the United States of America. In accordance with Government Auditing Standards, we have also issued our report dated June 21, 2012, on our consideration of the Ingham County Medical Care Facility s internal control over financial reporting and our tests of its compliance with certain provisions of laws, regulations, contracts, grant agreements and other matters. The purpose of that report is to describe the scope of our testing of internal control over financial reporting and compliance and the results of that testing, and not to provide an opinion on the internal control over financial reporting or on compliance. That report is an integral part of an audit performed in accordance with Government Auditing Standards and should be considered in assessing the results of our audit. 1

Accounting principles generally accepted in the United States of America require that the schedule of funding progress on page 18 be presented to supplement the basic financial statements. Such information, although not a part of the basic financial statements, is required by the Governmental Accounting Standards Board, who considers it to be an essential part of financial reporting for placing the basic financial statements in an appropriate operational, economic, or historical context. We have applied certain limited procedures to the required supplementary information in accordance with auditing standards generally accepted in the United States of America, which consisted of inquiries of management about the methods of preparing the information and comparing the information for consistency with management s responses to our inquiries, the basic financial statements, and other knowledge we obtained during our audit of the basic financial statements. We do not express an opinion or provide any assurance on the information because the limited procedures do not provide us with sufficient evidence to express an opinion or provide assurance. Our audit was conducted for the purpose of forming opinions on the financial statements that collectively comprise the Facility s basic financial statements. The schedules of net patient revenue and operating expenses are presented for purposes of additional analysis and are not a required part of the basic financial statements. Such information is the responsibility of management and was derived from and relates directly to the underlying accounting and other records used to prepare the financial statements. The information has been subjected to the auditing procedures applied in the audit of the financial statements and certain additional procedures, including comparing and reconciling such information directly to the underlying accounting and other records used to prepare the financial statements or to the financial statements themselves, and other additional procedures in accordance with auditing standards generally accepted in the United States of America. In our opinion, the information is fairly stated in all material respects in relation to the financial statements as a whole. 2

FINANCIAL STATEMENTS 3

INGHAM COUNTY MEDICAL CARE FACILITY Statement of Net Assets December 31, 2011 Assets Current assets: Pooled cash and investments $ 7,057,922 Pooled cash and investments - restricted 11,268,492 Patient receivables, net 2,663,205 Interest receivable 37,533 Inventory 15,288 Prepaid items 16,505 Total current assets 21,058,945 Capital assets, net 9,832,625 Total assets 30,891,570 Liabilities Current liabilities: Accounts payable 998,100 Accrued expenses 341,643 Compensated absences 233,684 Due to other funds of Ingham County 82,655 Payable from restricted assets - patient trust liability 17,728 Total current liabilities 1,673,810 Noncurrent liabilities: Worker's compensation claims 88,787 Compensated absences, net of current portion 155,790 Provision for contractual losses 531,500 Advances from other funds 324,343 Net other postemployment benefits obligation 1,739,627 Total noncurrent liabilities 2,840,047 Total liabilities 4,513,857 Net assets Invested in capital assets 9,832,625 Restricted 11,250,764 Unrestricted 5,294,324 Total net assets $ 26,377,713 The accompanying notes are an integral part of these financial statements. 4

INGHAM COUNTY MEDICAL CARE FACILITY Statement of Revenues, Expenses and Changes in Fund Net Assets For the Year Ended December 31, 2011 Operating revenues Net patient revenues $ 23,043,336 Other operating revenues 44,305 Total operating revenues 23,087,641 Operating expenses Salaries 10,934,866 Depreciation expense 654,215 Other expenses 9,673,004 Total operating expenses 21,262,085 Operating income 1,825,556 Nonoperating revenues (expenses) Investment earnings 572,726 Provider supplement 1,702,135 Provider tax (1,417,351) Interest expense (4,817) Maintenance of effort payment (37,635) Total nonoperating revenues 815,058 Change in net assets 2,640,614 Net assets, beginning of year 23,737,099 Net assets, end of year $ 26,377,713 The accompanying notes are an integral part of these financial statements. 5

INGHAM COUNTY MEDICAL CARE FACILITY Statement of Cash Flows For the Year Ended December 31, 2011 Cash flows from operating activities Receipts from patients and users $ 23,319,314 Payments to suppliers (8,523,540) Payments to employees (10,931,722) Payments to State of Michigan for maintenance of effort (37,635) Net cash provided by operating activities 3,826,417 Cash flows from noncapital financing activities Principal payment on advance from Ingham County (79,089) Cash flows from capital and related financing activities Acquisition and construction of capital assets (2,395,079) Interest paid on advance from Ingham County (4,817) Net cash used in capital and related financing activities (2,399,896) Cash flows from investing activities Interest received 581,032 Net change in cash and cash equivalents 1,928,464 Cash and cash equivalents, beginning of year 16,397,950 Cash and cash equivalents, end of year $ 18,326,414 Reconciliation to the statement of net assets Pooled cash and investments $ 7,057,922 Pooled cash and investments - restricted 11,268,492 $ 18,326,414 continued 6

INGHAM COUNTY MEDICAL CARE FACILITY Statement of Cash Flows (concluded) For the Year Ended December 31, 2011 Reconciliation of operating income to net cash provided by operating activities Operating income $ 1,825,556 Adjustments to reconcile operating income to net cash provided by operating activities: Depreciation 654,215 Maintenance of effort payments (37,635) Quality assurance supplement 284,784 Change in assets and liabilities: Patient receivables 227,324 Inventory (2,330) Prepaid items 5,914 Accounts payable 294,632 Accrued expenses 17,639 Compensated absences (14,495) Due to other funds of Ingham County 4,349 Patient trust liability 3,404 Worker's compensation claims 50,548 Provision for contractual losses 182,000 Net other postemployment benefits obligation 330,512 Net cash provided by operating activities $ 3,826,417 The accompanying notes are an integral part of these financial statements. 7

NOTES TO FINANCIAL STATEMENTS 8

INGHAM COUNTY MEDICAL CARE FACILITY Notes To Financial Statements 1. SUMMARY OF SIGNIFICANT ACCOUNTING POLICIES The financial statements of the Ingham County Medical Care Facility (ICMCF) have been prepared in conformity with generally accepted accounting principles (GAAP) as applied to governmental units. The Governmental Accounting Standards Board (GASB) is the accepted standard setting body for establishing governmental accounting and financial reporting principles. The more significant of the ICMCF s accounting policies are described below. Reporting Entity The ICMCF is an enterprise fund of Ingham County, Michigan (the County ) that provides long-term skilled care to residents of the County. A three-member board is responsible for establishing policies and oversight. The County appoints two board members and the State of Michigan appoints the third. An administrator manages the ICMCF s daily operations. Measurement Focus, Basis of Accounting, and Financial Statement Presentation The ICMCF uses a fund (i.e., a separate accounting entity with a self balancing set of accounts) to report its financial position and the changes in financial position. Fund accounting is designed to demonstrate legal compliance and to aid financial management by segregating transactions related to certain governmental functions and activities. The ICMCF is operated as an enterprise fund, a proprietary fund type, which is used to account for operations that are financed and operated in a manner similar to private business. Proprietary funds are accounted for on the flow of economic resources measurement focus and use the accrual basis of accounting. Under this method, revenues are recorded when earned and expenses are recorded at the time liabilities are incurred. Proprietary funds distinguish operating revenues and expenses from nonoperating items. Operating revenues and expenses generally result from providing services and producing and delivering goods in connection with a proprietary fund s principal ongoing operations. The principal operating revenues of the ICMCF are charges to patients for services. Operating expenses for enterprise funds include the cost of sales and services, administrative expenses, and depreciation on capital assets. All revenues and expenses not meeting this definition are reported as nonoperating revenues and expenses. Assets, liabilities and equity Deposits and Investments The ICMCF s pooled cash and investments include cash on hand, demand deposits and deposits in the Ingham County Treasurer s cash management pool. The Treasurer s cash management pool has the general characteristics of a demand deposit in that deposits and withdrawals may be made at any time without prior notice or penalty. State statutes authorize the ICMCF and the County to deposit in the accounts of federally insured banks, credit unions and savings and loan associations and to invest in obligations of the United States, certain commercial paper, repurchase agreements, bankers acceptances and mutual funds composed of otherwise legal investments. 9

INGHAM COUNTY MEDICAL CARE FACILITY Notes To Financial Statements Receivables Patient receivables are shown net of Medicaid advance payments and an allowance for uncollectible accounts. Approximately 87% of patient revenues are generated from services to patients covered by Medicare and Medicaid. Retroactive adjustments to the per diem rates established under those programs and by other third party payors are accrued on an estimated basis in the period the related services are rendered and adjusted in future periods as final settlements are determined. Interfund Receivables/Payables During the course of operations, numerous transactions occur between the ICMCF and Ingham County for goods provided or services rendered. Such transactions that are representative of lending/borrowing arrangements outstanding at year-end are referred to as advances to/from other funds. All other outstanding balances between funds including the current portion of any advances are reported as due to/from other funds on the statement of net assets. Inventory and Prepaid Items Inventory is valued at cost using the first in/first out (FIFO) method. Certain payments to vendors reflect costs applicable to future accounting periods and are recorded as prepaid items. Restricted Assets Certain assets are classified as restricted assets on the statement of net assets because their use is limited to specific purposes as mandated by the State of Michigan or other third parties. These purposes include capital acquisitions and improvements, donations and patient trust monies. Capital Assets Capital assets, which include property and equipment, are recorded at cost. Capital assets are defined by the ICMCF as assets with an individual cost of more than $5,000 and an estimated useful life in excess of two years. Donated property and equipment are recorded at their estimated fair value at the date of donation. Property and equipment are depreciated using the straight-line method over the estimated useful lives of the assets. The cost of normal maintenance and repairs that do not add to the value of the assets or materially extend their lives are charged to expense when incurred. Years Land improvements 5-40 Building 40 Equipment 5-20 10

INGHAM COUNTY MEDICAL CARE FACILITY Notes To Financial Statements Compensated Absences ICMCF employees are granted paid time off (PTO) in varying amounts based on length of service and are permitted to accumulate such earned but unused leave time subject to certain limitations. Patient Trust Liability The Michigan Department of Treasury requires facilities such as the ICMCF to administer and account for certain patient monies. Accordingly, the patient trust liability recorded in the statement of net assets represents those patient monies on deposit with the ICMCF at year-end. Net Assets Restricted net assets are entirely restricted for capital improvements. 2. DEPOSITS At December 31, 2011, the carrying amount of the ICMCF s pooled cash and investments were composed of the following: Current Assets Restricted Assets Total On deposit with the County $ 7,052,578 $ 11,250,764 $ 18,303,342 On deposit with bank 4,594 17,128 21,722 Cash on hand 750 600 1,350 Total deposits $ 7,057,922 $ 11,268,492 $ 18,326,414 As of year end, $588,906 of the Facility s bank balance of $855,482 (book balance of $21,722) was exposed to custodial credit risk because it was uninsured and uncollateralized. The bank balance and federal deposit insurance coverage, if any, of the funds on deposit with County are not readily determinable inasmuch as those funds are deposited in the Ingham County Treasurer s cash management pool. 3. PATIENT RECEIVABLES The details of patient receivables are as follows at December 31, 2011: Patient receivables $ 2,967,168 Adjust: Allowances for uncollectible accounts (300,000) Medicaid interim payments (3,963) Patient receivables, net $ 2,663,205 11

INGHAM COUNTY MEDICAL CARE FACILITY Notes To Financial Statements 4. CAPITAL ASSETS Changes in the components of the capital assets are summarized as follows: Beginning Balance Additions Disposals Ending Balance Capital assets, not being depreciated: Land $ 132,832 $ - $ - $ 132,832 Construction in progress 840,104 1,152,817 (840,104) 1,152,817 972,936 1,152,817 (840,104) 1,285,649 Capital assets, being depreciated: Land improvements 309,509 10,326-319,835 Buildings 15,168,951 1,918,363 (53,975) 17,033,339 Equipment 586,110 153,677 (45,713) 694,074 16,064,570 2,082,366 (99,688) 18,047,248 Less accumulated depreciation for: Land improvements (243,435) (6,250) - (249,685) Buildings (8,353,997) (573,312) 53,975 (8,873,334) Equipment (348,313) (74,653) 45,713 (377,253) (8,945,745) (654,215) 99,688 (9,500,272) Total capital assets being depreciated, net 7,118,825 1,428,151-8,546,976 Capital assets, net $ 8,091,761 $ 2,580,968 $ (840,104) $ 9,832,625 5. RISK MANAGEMENT Through the County, the ICMCF is self-insured for workers compensation claims up to $300,000 per occurrence and insured for the amount of claims in excess of that limitation up to a maximum of $5 million. The change in the worker s compensation liability amount for the last two years is as follows: 2011 2010 Claims liability at beginning of fiscal year $ 38,239 $ 61,836 Claims and changes in estimates 185,407 117,207 Claim payments (134,859) (140,804) Claims liability at end of year $ 88,787 $ 38,239 12

INGHAM COUNTY MEDICAL CARE FACILITY Notes To Financial Statements Also through the County, the ICMCF participates in the Michigan Municipal Risk Management Authority (MMRMA) for general and automobile liability, motor vehicle physical damage and property coverage. Under most circumstances, the maximum loss retention per occurrence is as follows: Type of Risk General and automobile liability Motor vehicle physical damage Property coverage Maximum Retention per Occurrence $150,000 $16,000 per vehicle; $31,000 per occurrence $11,000 Further information and disclosures regarding risk management is provided in the County s comprehensive annual financial report. 6. MAINTENANCE OF EFFORT Each month the ICMCF is billed by the State of Michigan for maintenance of effort in an amount equal to a specified rate times the number of Medicaid patient days approved by the State for that month. 7. CONTINGENT LIABILITIES Amounts received or receivable from third party payors, in particular Medicare and Medicaid, are subject to audit and adjustment by various intermediaries. The amount of such adjustments cannot be determined at this time although the ICMCF expects such amounts, if any, to be immaterial. In 1978, the ICMCF received a federal grant under the Hill Burton Act to help finance construction of the facility. A provision of the grant is that the facility provide free of charge care to qualifying individuals in a total cumulative amount equal to the original grant amount adjusted for inflation. Through December 31, 2011, the ICMCF has not yet satisfied the charitable care obligations of the Hill Burton Act. 8. EMPLOYEE RETIREMENT SYSTEM ICMCF employees participate, along with other Ingham County employees, in the Michigan Municipal Employees Retirement System (MERS). The plan is a multiple employer defined benefit plan administered by MERS. During 2011, employer contributions of $667,975 were made by the ICMCF in accordance with contribution requirements determined by an actuarial valuation of the plan as of December 31, 2010. Further information regarding the Ingham County plan including detailed trend information is presented in the County s 2011 comprehensive annual financial report, which is available to the public. 13

INGHAM COUNTY MEDICAL CARE FACILITY Notes To Financial Statements 9. POSTEMPLOYMENT BENEFITS OTHER THAN PENSIONS ICMCF employees participate in a single employer defined benefit healthcare plan.. The Plan provides postemployment healthcare and life insurance benefits to eligible retirees in accordance with labor contracts and personnel policies. Funding Policy. The contribution requirements of plan members and the Facility are established and may be amended by the County Board of Commissioners, subject to applicable labor contracts. Plan members are not required to contribute; however, plan members receiving healthcare benefits pay for half of the health care insurance premium over an annually established level (which was approximately $365 per month for 2011) and for 100% of the additional premium cost for spousal and dependent coverage. The Facility may contribute the annual required contribution (ARC), an amount actuarially determined in accordance with the parameters of GASB Statement 45, Accounting and Financial Reporting by Employers for Postemployment Benefits Other Than Pensions. The ARC represents a level of funding that, if paid on an ongoing basis, is projected to cover the normal cost each year and amortize any unfunded actuarial liabilities (or funding excess) over a period not to exceed thirty years. Annual OPEB Cost and Net OPEB Obligation. For 2011, the components of the ICMCF s annual OPEB (other postemployment benefit) cost for the year, the amount actually contributed to the Plan, and changes in the ICMCF s net OPEB obligation to the Plan are as follows: Annual required contribution $ 505,629 Interest on net OPEB obligation 84,547 Adjustment to annual required contribution (62,383) Net OPEB cost 527,793 Contributions made (197,281) Increase in net OPEB obligation 330,512 Net OPEB obligation, beginning of year 1,409,115 Net OPEB obligation, end of year $ 1,739,627 The Facility s annual OPEB cost, the percentage of annual OPEB cost contributed to the plan, and the net OPEB obligation for the last three years were as follows: Year Ended Three-Year Trend Information Annual OPEB Cost Percentage of Annual OPEB Cost Contributed Net OPEB Obligation 2009 $ 277,620 57% $ 1,284,044 2010 292,326 57% 1,409,115 2011 527,793 37% 1,739,627 14

INGHAM COUNTY MEDICAL CARE FACILITY Notes To Financial Statements Funded Status and Funding Progress. The funded status of the Plan as of December 31, 2010, the date of the most recent actuarial valuation, is as follows: Actuarial accrued liability (AAL) (1) $ 5,655,037 Actuarial value of assets (2) - Unfunded AAL (UAAL) (3) $ 5,655,037 (1) - (2) Funded ratio (4) 0.0% (2) / (1) Covered payroll (5) 9,517,974 UAAL as % of covered payroll (6) 59.4% (3) / (5) The schedule of funding progress, presented as required supplementary information following the notes to the financial statements, present multiyear trend information about whether the actuarial values of plan assets are increasing or decreasing over time relative to the actuarial accrued liabilities for benefits. The accompanying schedule of employer contributions present trend information about the amounts contributed to the plan by employers in comparison with the ARC, an amount that is actuarially determined in accordance with the parameters of GASB Statement 43. The ARC represents a level of funding that, if paid on an ongoing basis, is projected to cover normal cost for each year and amortize any unfunded actuarial liabilities (or funding excess) over a period not to exceed 30 years. Actuarial Methods and Assumptions. Actuarial valuations of an ongoing plan involve estimates of the value of reported amounts and assumptions about the probability of potential occurrences of certain events in the future. Examples include assumption about future employment, mortality, healthcare costs trends, inflation, etc. Amounts determined regarding the funded status of the plan and the annual required contributions of the Facility are subject to constant changes and modifications as actual results are compared with past expectations and new estimates and assumptions are formed regarding the future. Projections of retiree benefits for financial reporting purposes are based on current plan activities as it is handled by the Facility and the benefits are received by the eligible plan members and include the types of benefits provided at the time of each valuation and the historical pattern of sharing of benefit costs between the Facility and plan members. The actuarial methods and assumptions used include techniques that are designed to reduce the effects of short-term volatility in actuarial accrued liabilities and the actuarial value of assets, consistent with the long-term perspective of the calculations. In the December 31, 2010, actuarial valuation, the individual entry age normal actuarial cost method was used. The actuarial assumptions include a 6.0% a year rate of investment return, compounded annually net after investment expense, which is the expected long-term investment return on plan assets, and a base payroll growth rate of 4.5%. There were also merit and seniority salary rate increase assumptions taken into consideration and those are detailed in the actuarial study and are based on age, along with an inflationary rate assumption factored into the calculation. Per the actuarial study, the assumed rate ranges from 9.0% in the short-term to 4.5% in the long-term for health care related costs. The UAAL is being amortized as a level percentage of active member payroll over a period of 28 years on an open basis. 15

INGHAM COUNTY MEDICAL CARE FACILITY Notes To Financial Statements 10. ADVANCES PAYABLE TO INGHAM COUNTY In 1996, ICMCF borrowed $1.5 million from the County for a capital expansion and renovation project. The loan agreement provides for repayment of the advance over 20 years with interest at one percent (1%) per annum on the outstanding principal balance. Repayment requirements to maturity are as follows: Year Ending December 31, Principal Interest Total 2012 $ 79,089 $ 4,034 $ 83,123 2013 79,880 3,243 83,123 2014 80,678 2,445 83,123 2015 81,485 1,638 83,123 2016 82,300 823 83,123 $ 403,432 $ 12,183 $ 415,615 The principal amount due in 2012 ($79,089) is reported in the statement of net assets with the amounts due to other funds of Ingham County. The remaining principal balance of $324,343 is reported in the noncurrent liabilities under advances from other funds of Ingham County. 11. COMPENSATED ABSENCES Changes in compensated absences for the year ended December 31, 2011, were as follows: Beginning Balance Additions Deductions Ending Balance Due Within One Year Compensated absences $ 403,969 $ 740,952 $ (755,447) $ 389,474 $ 233,684 12. CONSTRUCTION COMMITMENT The Facility has an active construction project as of December 31, 2011 with a remaining contractual commitment of $262,380. The Facility expects the project to be completed during 2012. 16

REQUIRED SUPPLEMENTARY INFORMATION 17

INGHAM COUNTY MEDICAL CARE FACILITY Required Supplementary Information Retiree Health Care Plan Schedule of Funding Progress Actuarial Accrued UAAL as a Actuarial Liability Unfunded Percentage Actuarial Value of (AAL) - AAL Funded Covered of Covered Valuation Assets Entry Age (UAAL) Ratio Payroll Payroll Date (a) (b) (b-a) (a / b) (c) ((b-a) / c) 12/31/2006 $ - $ 9,268,458 $ 9,268,458 0.0% $ 7,287,609 127.2% 12/31/2008-4,290,944 4,290,944 0.0% 8,953,011 47.9% 12/31/2010-5,655,037 5,655,037 0.0% 9,517,974 59.4% Schedule of Employer Contributions Annual Year Ended Required Percentage December 31, Contributions Contributed 2008 $ 850,595 26.3% 2009 266,815 58.9% 2010 278,821 60.0% 2011 505,629 39.0% 18

SUPPLEMENTARY FINANCIAL INFORMATION 19

INGHAM COUNTY MEDICAL CARE FACILITY Schedule of Net Patient Revenues For the Year Ended December 31, 2011 Daily Room Services Medicaid $ 10,285,063 Medicare 9,230,813 Other 2,805,619 Total daily room services 22,321,495 Ancillary Services Pharmacy and IV 1,183,055 Physical therapy 1,555,642 Occupational therapy 1,598,968 Speech therapy 359,317 Medical supplies 143,768 Total ancillary services 4,840,750 Total patient revenue 27,162,245 Revenue deductions Provision for contractual discounts (4,118,909) Net patient revenues $ 23,043,336 20

INGHAM COUNTY MEDICAL CARE FACILITY Schedule of Operating Expenses For the Year Ended December 31, 2011 Salaries Other Total Administration $ 401,856 $ 530,670 $ 932,526 Human resources 160,058 73,128 233,186 Maintenance 181,955 731,893 913,848 Laundry 196,377 100,620 296,997 Housekeeping 398,972 161,901 560,873 Dietary 798,307 804,374 1,602,681 Central supply 54,653 470 55,123 Pharmacy - 906,704 906,704 Nursing 7,859,193 822,672 8,681,865 Physical therapy - 994,080 994,080 Occupational therapy - 882,427 882,427 Psychosocial services 579,607 52,255 631,862 Admissions and marketing 153,450 13,670 167,120 Vehicles - 1,667 1,667 Physician services - 54,875 54,875 Nurse aide training 92,402 18,428 110,830 In-service education 58,036 1,492 59,528 Speech therapy - 157,259 157,259 Fringe benefits - 3,363,404 3,363,404 Depreciation - 654,215 654,215 Prior year cost settlement - 1,015 1,015 Total expenses $ 10,934,866 $ 10,327,219 $ 21,262,085 21

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INDEPENDENT AUDITORS' REPORT ON INTERNAL CONTROL OVER FINANCIAL REPORTING AND ON COMPLIANCE AND OTHER MATTERS BASED ON AN AUDIT OF FINANCIAL STATEMENTS PERFORMED IN ACCORDANCE WITH GOVERNMENT AUDITING STANDARDS Rehmann Robson 675 Robinson Rd. Jackson, MI 49203 Ph: 517.787.6503 Fx: 517.788.8111 www.rehmann.com To the Department of Human Services Board of the Ingham County Medical Care Facility Okemos, Michigan June 21, 2012 We have audited the financial statements of the Ingham County Medical Care Facility (the Facility ), an enterprise fund of Ingham County, Michigan, as of and for the year ended December 31, 2011, and have issued our report thereon dated June 21, 2012. We conducted our audit in accordance with auditing standards generally accepted in the United States of America and the standards applicable to financial audits contained in Government Auditing Standards, issued by the Comptroller General of the United States. Internal Control Over Financial Reporting Management of the Facility is responsible for establishing and maintaining effective internal control over financial reporting. In planning and performing our audit, we considered the Facility s internal control over financial reporting as a basis for designing our auditing procedures for the purpose of expressing our opinions on the financial statements, but not for the purpose of expressing an opinion on the effectiveness of the Facility s internal control over financial reporting. Accordingly, we do not express an opinion on the effectiveness of the Facility s internal control over financial reporting. A deficiency in internal control exists when the design or operation of a control does not allow management or employees, in the normal course of performing their assigned functions, to prevent, or detect and correct misstatements on a timely basis. A material weakness is a deficiency, or a combination of deficiencies, in internal control such that there is a reasonable possibility that a material misstatement of the entity s financial statements will not be prevented, or detected and corrected on a timely basis. Our consideration of internal control over financial reporting was for the limited purpose described in the first paragraph of this section and was not designed to identify all deficiencies in internal control over financial reporting that might be deficiencies, significant deficiencies or material weaknesses. We did not identify any deficiencies in internal control over financial reporting that we consider to be material weaknesses, as defined above. 23

Compliance and Other Matters As part of obtaining reasonable assurance about whether the Facility s financial statements are free of material misstatement, we performed tests of its compliance with certain provisions of laws, regulations, contracts, and grant agreements, noncompliance with which could have a direct and material effect on the determination of financial statement amounts. However, providing an opinion on compliance with those provisions was not an objective of our audit, and accordingly, we do not express such an opinion. The results of our tests disclosed no instances of noncompliance or other matters that are required to be reported under Government Auditing Standards. In addition, we noted certain other matters that we reported to management of the Facility in a separate letter dated June 21, 2012. This report is intended solely for the information and use of management, the Department of Human Services Board, and others within the entity and is not intended to be and should not be used by anyone other than these specified parties. 24

Rehmann Robson 675 Robinson Rd. Jackson, MI 49203 Ph: 517.787.6503 Fx: 517.788.8111 www.rehmann.com June 21, 2012 To the Department of Human Services Board of the Ingham County Medical Care Facility We have audited the financial statements of the INGHAM COUNTY MEDICAL CARE FACILITY (the Facility ) as of and for the year ended December 31, 2011, and have issued our report thereon dated June 21, 2012. Professional standards require that we provide you with the following information related to our audit. Our Responsibility Under Auditing Standards Generally Accepted in the United States of America and Government Auditing Standards As stated in our engagement letter dated December 20, 2011, our responsibility, as described by professional standards, is to express an opinion about whether the financial statements prepared by management with your oversight are fairly presented, in all material respects, in conformity with accounting principles generally accepted in the United States of America. Our audit of the financial statements does not relieve you or management of your responsibilities. As part of our audit, we considered the internal control of the Facility. Such considerations were solely for the purpose of determining our audit procedures and not to provide any assurance concerning such internal control. As part of obtaining reasonable assurance about whether the financial statements are free of material misstatement, we performed tests of Facility s compliance with certain provisions of laws, regulations, contracts and grants. However, the objective of our tests was not to provide an opinion on compliance with such provisions. Other Information in Documents Containing Audited Financial Statements Our responsibility for the supplementary information accompanying the financial statements, as described by professional standards, is to evaluate the presentation of the supplementary information in relation to the financial statements as a whole and to report on whether the supplementary information is fairly stated, in all material respects, in relation to the financial statements as a whole. We made certain inquiries of management and evaluated the form, content, and methods of preparing the information to determine that the information complies with accounting principles generally accepted in the United States of America, the method of preparing it has not changed from the prior period, and the information is appropriate and complete in relation to our audit of the financial statements. We compared and reconciled the supplementary information to the underlying accounting records used to prepare the financial statements or to the financial statements themselves. Planned Scope and Timing of the Audit We performed the audit according to the planned scope and timing previously communicated to you in our engagement letter and our meeting about planning matters on April 30, 2012.

Page 2 Significant Results of the Audit Qualitative Aspects of Accounting Practices Management is responsible for the selection and use of appropriate accounting policies. In accordance with the terms of our engagement letter, we will advise management about the appropriateness of accounting policies and their application. The significant accounting policies used by the Facility are described in Note 1 to the financial statements. No new accounting policies were adopted and the application of existing policies was not changed during the year. We noted no transactions entered into by the Facility during the year for which there is a lack of authoritative guidance or consensus. There are no significant transactions that have been recognized in the financial statements in a different period than when the transaction occurred. Accounting estimates are an integral part of the financial statements prepared by management and are based on management s knowledge and experience about past and current events and assumptions about future events. Certain accounting estimates are particularly sensitive because of their significance to the financial statements and because of the possibility that future events affecting them may differ significantly from those expected. The most sensitive estimates affecting the financial statements were: Management s estimate of the useful lives of depreciable capital assets is based on the length of time it is believed that those assets will provide some economic benefit in the future. Management s estimate of the liability for uninsured risks, including incurred but not reported claims, for self-insured workers compensation coverage. We relied upon the work of a third-party administrator and the analysis of the County in determining that the liability is reasonable in relation to the financial statements taken as a whole. Management s estimate of the collectability of patient receivables from first and third party payers. We evaluated the key factors and assumptions used to develop the allowances for uncollectable accounts in determining that they are reasonable in relation to the basic financial statements taken as a whole. Management s estimate of other postemployment benefits and pension contributions are based on current covered payroll. We evaluated the key factors and assumptions used to develop these estimates in determining that they are reasonable in relation to the financial statements taken as a whole. Difficulties Encountered in Performing the Audit We encountered no significant difficulties in dealing with management in performing and completing our audit. Corrected and Uncorrected Misstatements Professional standards require us to accumulate all known and likely misstatements identified during the audit, other than those that are trivial, and communicate them to the appropriate level of management. Management has corrected all such misstatements.

In addition, none of the misstatements detected as a result of audit procedures and corrected by management were material, either individually or in the aggregate, to the financial statements taken as a whole. Disagreements with Management For purposes of this letter, professional standards define a disagreement with management as a financial accounting, reporting, or auditing matter, whether or not resolved to our satisfaction, that could be significant to the financial statements or the auditor s report. We are pleased to report that no such disagreements arose during the course of our audit. Management Representations We have requested certain representations from management that are included in the attached management representation letter dated June 21, 2012. Management Consultations with Other Independent Accountants In some cases, management may decide to consult with other accountants about auditing and accounting matters, similar to obtaining a second opinion on certain situations. If a consultation involves application of an accounting principle to the entity s financial statements or a determination of the type of auditor s opinion that may be expressed on those statements, our professional standards require the consulting accountant to check with us to determine that the consultant has all the relevant facts. To our knowledge, there were no such consultations with other accountants. Other Audit Findings or Issues We generally discuss a variety of matters, including the application of accounting principles and auditing standards, with management each year prior to retention as the governmental unit s auditors. However, these discussions occurred in the normal course of our professional relationship and our responses were not a condition to our retention. This information is intended solely for the use of the governing body and management of the Ingham County Medical Care Facility and is not intended to be and should not be used by anyone other than these specified parties. Very truly yours, Page 3

Ingham County Medical Care Facility Attachment A - Consideration of Internal Control Over Financial Reporting For the December 31, 2011 Audit We have audited the financial statements of the INGHAM COUNTY MEDICAL CARE FACILITY (the Facility ) for the year ended December 31, 2011, and have issued our report thereon dated June 21, 2012. In planning and performing our audit in accordance with auditing standards generally accepted in the United States of America, we considered the Facility s internal control over financial reporting (internal control) as a basis for designing our auditing procedures for the purpose of expressing our opinion on the financial statements, but not for the purpose of expressing an opinion on the effectiveness of the Facility s internal control. Accordingly, we do not express an opinion on the effectiveness of the Facility s internal control. A deficiency in internal control exists when the design or operation of a control does not allow management or employees, in the normal course of performing their assigned functions, to prevent, or detect and correct misstatements on a timely basis. A material weakness is a deficiency, or combination of deficiencies in internal control, such that there is a reasonable possibility that a material misstatement of the entity s financial statements will not be prevented, or detected and corrected on a timely basis. Our consideration of internal control was for the limited purpose described in the first paragraph and was not designed to identify all deficiencies in internal control that might be significant deficiencies or material weaknesses and, therefore, there can be no assurance that all such deficiencies have been identified. We did not identify any deficiencies in internal control that we consider to be material weaknesses. Other Matters Cash Receipting Process. During the audit we considered the internal controls relating to cash receipting. From our procedures, we noted that in the prior year the same individual was involved throughout the entire cash receipting process. In the current year, in an effort to segregate cash receipting duties, an individual independent of the cash receipting process began taking the deposit to the bank, however, they do not perform a review of the deposit. We recommend that the individual taking the deposit to the bank perform a review of the deposit, and sign off noting their review, prior to taking it to the bank. Information Technology controls. During the audit we considered the internal controls relating to the Facility s information technology systems. We noted that system backups are performed daily, however, the backups are not stored off-site. It is our recommendation that the Facility develop a procedure in which the backups are periodically taken off-site for storage. A1