2026-07-01T06:32:59-05:00 2025-08-31 450250958 EIDE BAILLY LLP 18081 BURT ST STE 200 OMAHA NE 680224722 990 2024-09-01 470537192 NIOBRARA VALLEY HOSPITAL NIOB 4025692451 PO BOX 118 LYNCH NE 68746 KELLY KALKOWSKI CEO 4025692451 2026-06-30 1 1 MEGAN L KOZIOL CPA P01544037 4023302660 2026-06-30 2024 2025-03-06 01:10:19Z KELLY KALKOWSKI PO BOX 118 LYNCH NE 68746 4426836 0 X WWW.NVHCARES.ORG X 1975 NE TO PROVIDE ACUTE HOSPITAL SERVICES. 7 7 40 7 0 0 29762 248596 3729120 4103914 58279 61431 41787 12895 3858948 4426836 1100 0 0 0 1579466 1590541 0 0 0 2485751 2717891 4066317 4308432 -207369 118404 4825497 5061721 266269 412491 4559228 4649230 X TO DELIVER EXCELLENT, COMPASSIONATE AND PERSONALIZED HEALTHCARE FOR THE PEOPLE WE SERVE. 0 0 3344345 4103914 NIOBRARA VALLEY HOSPITAL PROVIDES QUALITY HEALTH CARE REGARDLESS OF RACE, CREED, COLOR, NATIONAL ORIGIN, AGE, SEX, HANDICAP OR ABILITY TO PAY. ALL PERSONS ADMITTED OR TREATED IN THE OUTPATIENT AREA OF THE HOSPITAL SHALL HAVE EQUAL CARE AND TREATMENT AND FULL USE OF ALL HOSPITAL FACILITIES AND SERVICES. REIMBURSEMENT FOR SERVICES RENDERED IS CRITICAL TO THE OPERATION AND STABILITY OF NIOBRARA VALLEY HOSPITAL, BUT IT IS RECOGNIZED THAT NOT ALL INDIVIDUALS POSSESS THE ABILITY TO PURCHASE ESSENTIAL MEDICAL SERVICES. FURTHER, WE STRIVE TO SERVE THE COMMUNITY WITH RESPECT TO PROVIDING HEALTH CARE SERVICES AND HEALTH CARE EDUCATION.THEREFORE, IN KEEPING WITH THIS HOSPITAL'S COMMITMENT TO SERVING ALL MEMBERS OF ITS COMMUNITY: 1.) NIOBRARA VALLEY HOSPITAL MUST BE RESPONSIVE TO THE CHANGING NEEDS OF THE HEALTH CARE INDUSTRY, THE COMMUNITY AND ITS OWN NEEDS. AS NIOBRARA VALLEY HOSPITAL ADAPTS TO THOSE CHANGES, THE HOSPITAL IS DETERMINED TO REMAIN AN INSTITUTION WHERE THE CARE THAT IS RENDERED IS COMPASSIONATE AS WELL AS COMPETENT. 2.) NIOBRARA VALLEY HOSPITAL IS AND SHALL CONTINUE TO BE, A FAMILY CENTERED, COMMUNITY ORIENTED HOSPITAL, OFFERING COMPREHENSIVE MEDICAL SERVICES. 3.) THE STATED PHILOSOPHIES OF NIOBRARA VALLEY HOSPITAL SHALL PERMEATE ALL ACTIVITIES OF THE HOSPITAL AND MOST IMPORTANTLY, THAT OF PATIENT CARE. 4.) THE QUALITY OF PATIENT CARE SHALL CONTINUE TO RECEIVE PRIMARY EMPHASIS AT NIOBRARA VALLEY HOSPITAL. 5.) NIOBRARA VALLEY HOSPITAL SHALL PRUDENTLY UTILIZE ITS RESOURCES THROUGH EFFICIENT AND EFFECTIVE MANAGEMENT; CAREFUL CONSIDERATION SHALL BE GIVEN TO THE COST/BENEFIT RELATIONSHIP OF DELIVERING SERVICES WITHOUT COMPROMISING THE QUALITY OF CARE. 6.) NIOBRARA VALLEY HOSPITAL SHALL PROVIDE AN ATMOSPHERE CONDUCIVE TO THE DEVELOPMENT OF EFFECTIVE WORKING RELATIONSHIPS AMONG THE VARIOUS ELEMENTS NECESSARY BOTH INSIDE AND OUTSIDE THE HOSPITAL FAMILY. THIS FAMILY INCLUDES THE BOARD OF DIRECTORS, MEDICAL STAFF, ADMINISTRATION, EMPLOYEES, THE COMMUNITY, AUXILIARY AND FRIENDS OF THE HOSPITAL. 7.) NIOBRARA VALLEY HOSPITAL SHALL OFFER CONTINUING EDUCATION PROGRAMS AND SERVICES FOR ITS MEDICAL STAFF AND HOSPITAL PERSONNEL. NIOBRARA VALLEY HOSPITAL ALSO SHALL STRIVE TO PROVIDE ITS PATIENTS AND THE COMMUNITY WITH EDUCATION IN HEALTH RELATED MATTERS. 8.) NIOBRARA VALLEY HOSPITAL SHALL PLAN FOR ITS FUTURE. TO THIS END, THE HOSPITAL SHALL COOPERATE WITH OTHER HEALTH CARE PROVIDERS WITHIN THE HEALTH CARE DELIVERY SYSTEM IN A MANNER CONSISTENT WITH ITS STATED PHILOSOPHY. 9.) NIOBRARA VALLEY HOSPITAL SHALL SERVE AS A CATALYST WITHIN THE COMMUNITY TO IDENTIFY THE COMMUNITY'S HEALTH CARE NEEDS, AND SHALL DETERMINE THE LEVEL OF APPROPRIATE PARTICIPATION BY THE HOSPITAL IN MEETING SUCH NEEDS. 10.) NIOBRARA VALLEY HOSPITAL WILL CONSIDER WHERE THE NEED AND/OR THE INDIVIDUAL'S ABILITY TO PAY COEXIST AND OFFER FREE CARE TO THOSE WHO QUALIFY. 11.) NIOBRARA VALLEY HOSPITAL SERVED 33 INPATIENT DAYS, 45 SWING AND RESPITE CARE DAYS AND 539 EMERGENCY ROOM VISITS. 12.) NIOBRARA VALLEY HOSPITAL PROVIDES CARE TO PERSONS COVERED BY GOVERNMENTAL PROGRAMS AT COST. CHARITY CARE IS ALSO PROVIDED THROUGH MANY REDUCED PRICE SERVICES AND FREE PROGRAMS OFFERED THROUGHOUT THE YEAR BASED UPON ACTIVITIES AND SERVICES WHICH NIOBRARA VALLEY HOSPITAL BELIEVES WILL SERVE A BONA FIDE COMMUNITY HEALTH NEED. THESE INCLUDE: 1.) OPERATED A FULL TIME EMERGENCY ROOM THAT PROVIDES MEDICAL SERVICES TO ALL MEMBERS OF THE PUBLIC REGARDLESS OF ABILITY TO PAY. 2.) A VARIETY OF HEALTH CARE MATERIAL WAS DISTRIBUTED TO FOSTER HEALTH EDUCATION IN THE COMMUNITY. 3.) PROVIDED ASSISTANCE TO MEDICARE PATIENTS WITH RESPECT TO THEIR BENEFITS UNDER THE MEDICARE PROGRAM. 4.) EXCESS REVENUE IS REINVESTED IN NEW EQUIPMENT WHICH UPGRADES TECHNOLOGY WHICH WILL ALLOW NIOBRARA VALLEY HOSPITAL TO GUARANTEE THE AVAILABILITY OF AFFORDABLE HEALTH CARE FOR OUR SERVICE AREA. 3344345 1 1 0 1 0 0 0 0 0 0 1 0 0 1 1 0 1 0 0 0 0 0 0 0 0 0 1 1 0 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 40 0 1 40 1 0 0 0 0 0 0 0 0 0 0 0 0 X 7 7 0 1 0 0 0 0 0 1 1 0 0 1 1 1 1 1 1 1 0 0 X MARTHA NELSON 4025692451 PO BOX 118 LYNCH NE 68746 TODD HOPE DOCTOR 40.00 X 252140 0 0 DEBRA HANZLIK DIRECTOR OF NURSING 36.00 X 108900 0 1107 KELLY KALKOWSKI CEO 40.00 X 22163 0 0 MARTHA NELSON CFO 5.00 X 13163 0 0 CRAIG BREWSTER PRESIDENT 0.30 X X 0 0 0 TRACY BIRMEIER PRESIDENT THRU 09/24 0.30 X X 0 0 0 LINDA SEXTRO VICE PRESIDENT 0.30 X X 0 0 0 WANDA DEKAY SECRETARY 0.30 X X 0 0 0 LARRY HIATT SECRETARY THRU 09/24 0.30 X X 0 0 0 CINDY NOLAN TREASURER 0.30 X X 0 0 0 DARIN RIHANEK MEMBER 0.30 X 0 0 0 COREY FINNAGAN MEMBER 0.30 X 0 0 0 JEANNE SINCLAIR MEMBER 0.30 X 0 0 0 396366 0 1107 2 0 1 1 ALTERNALIVE HEALTH LLC 2116 S CYPRESS ST SIOUX CITY IA 51106 STAFFING SERVICES 177538 A STAFFING 3626 N HALL ST STE 620 DALLAS TX 75219 EMPLOYMENT SERVICES 156325 FUSION MEDICAL STAFFING LLC 18881 W DODGE RD STE 300W ELKHORN NE 68022 EMPLOYMENT SERVICES 143355 READY TECH-GO INC RTG MEDICAL 4611 EAST 22ND ST FREMONT NE 68025 STAFFING SERVICES 111486 VENTURA MEDSTAFF LLC PO BOX 8637 OMAHA NE 68108 EMPLOYMENT SERVICES 103701 5 15332 233264 248596 PATIENT SERVICE REVENU 624100 4090503 4090503 OTHER REVENUE 624100 12096 12096 LIFELINE REVENUE 624100 1315 1315 4103914 53131 53131 991 0 991 991 991 8300 0 8300 8300 8300 CAFETERIA 722514 11904 11904 11904 4426836 4103914 0 74326 X 13163 13163 1433623 1242325 191298 10234 3758 6476 26359 16705 9654 107162 87955 19207 131149 131149 5398 5398 74098 74098 1511702 1299626 212076 7530 230 7300 207141 151781 55360 101103 92221 8882 22806 21809 997 233307 210936 22371 74075 66972 7103 DUES & SUBSCRIPTIONS 122287 289 121998 MEDICAL SUPPLIES 120190 120190 MISCELLANEOUS 107105 29548 77557 4308432 3344345 964087 0 250 580219 2497670 1433800 232037 235520 58827 63001 57639 6786 4461222 3247175 1294667 1214047 684407 1528348 4825497 5061721 266269 346341 0 66150 266269 412491 X 4555284 4636948 3944 12282 4559228 4649230 4825497 5061721 X 118404 -28402 X X 0 1 X 1 0 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 0 0 0 0 0 0 0 0 1 651 651 0 PART II-B, LINE 1: NIOBRARA VALLEY HOSPITAL PAYS MEMBERSHIP DUES TO THE NEBRASKA HOSPITAL ASSOCIATION. THE PORTION OF THE DUES PAID THAT ARE USED FOR LOBBYING PURPOSES IS $651. 1000 1000 2245662 1368112 877550 2208155 1872658 335497 6405 6405 0 1214047 INTEREST - NIOBRARA VALLEY HOSPITAL FOUNDATION 343348 ESTIMATED THIRD-PARTY PAYOR SETTLEMENTS 1185000 1528348 ESTIMATED THIRD-PARTY PAYOR SETTLEM 66150 66150 4398434 -28402 -28402 4426836 0 4426836 4308432 0 4308432 0 4308432 PART XI, LINE 2D - OTHER ADJUSTMENTS: CHANGE IN INTEREST IN NIOBRARA VALLEY HOSPITAL FOUNDATION -28,402. 1 1 X 1 X 0 0 1 0 1 1 447904 151437 296467 0.06880 447904 151437 296467 0.06880 911892 508071 403821 0.09370 1080 1080 0.00030 912972 508071 404901 0.09400 1360876 659508 701368 0.16280 1 30000 3930 765987 770093 -4106 X 1 1 1 1 NIOBRARA VALLEY HOSPITAL PO BOX 118 LYNCH NE 68746 WWW.NVHCARES.ORG 050001 X X X NIOBRARA VALLEY HOSPITAL 1 0 0 1 X X X X X X X X X 24 1 1 1 1 X WWW.NVHCARES.ORG/COMMUNITY-HEALTH-NEEDS-ASSESSMENT.HTML X 1 24 1 WWW.NVHCARES.ORG/COMMUNITY-HEALTH-IMPROVEMENT-PLAN.HTML 0 1 X 100.000000000000 X X 1 1 X X X X 1 X WWW.NVHCARES.ORG/FINANCIAL-ASSISTANCE.HTML X WWW.NVHCARES.ORG/FINANCIAL-ASSISTANCE.HTML X WWW.NVHCARES.ORG/FINANCIAL-ASSISTANCE.HTML X X X X X X 1 X 0 X X X X 1 X 0 0 NIOBRARA VALLEY HOSPITAL PART V, SECTION B, LINE 5: NIOBRARA VALLEY HOSPITAL ALONG WITH NORTH CENTRAL DISTRICT HEALTH DEPARTMENT (NCDHD) AND OTHER HOSPITALS ADMINISTERED A COMMUNITY HEALTH SURVEY TO CAPTURE A BROAD RANGE OF PERSPECTIVES AND LIVED EXPERIENCES RELATED TO HEALTH BEHAVIORS AND OUTCOMES. MORE THAN 330 RESPONDENTS PARTICIPATED IN THIS SURVEY REPRESENTING THE COMMUNITY. NIOBRARA VALLEY HOSPITAL PART V, SECTION B, LINE 6A: ANTELOPE MEMORIAL HOSPITAL, NELIGH, NE (ANTELOPE COUNTY) AVERA CREIGHTON HOSPITAL, CREIGHTON, NE (KNOX COUNTY) AVERA SAINT ANTHONY'S HOSPITAL, O'NEILL, NE (HOLT COUNTY) BROWN COUNTY HOSPITAL, AINSWORTH, NE (BROWN COUNTY) OSMOND GENERAL HOSPITAL, OSMOND, NE (PIERCE COUNTY) PLAINVIEW COMMUNITY HOSPITAL, PLAINVIEW, NE (PIERCE COUNTY) WEST HOLT MEMORIAL HOSPITAL, ATKINSON, NE (HOLT COUNTY) CHERRY COUNTY HOSPITAL, VALENTINE, NE (CHERRY COUNTY) ROCK COUNTY HOSPITAL, BASSETT, NE (BROWN COUNTY) NIOBRARA VALLEY HOSPITAL PART V, SECTION B, LINE 6B: NORTH CENTRAL DISTRICT HEALTH DEPARTMENT (NCDHD) NIOBRARA VALLEY HOSPITAL PART V, SECTION B, LINE 11: IN REVIEWING THE INFORMATION COLLECTED FROM THE CHNA, NIOBRARA VALLEY HOSPITAL ADDRESSED THE COMMUNITY NEEDS OF LIFESTYLE CHANGES, SOCIOECONOMIC STABILITY, AND ACCESS TO CARE. 1) LIFESTYLE CHANGES: THE CHNA/CHIP GROUP IDENTIFIED MENTAL HEALTH AND SUBSTANCE ABUSE AND CHRONIC DISEASE AND DISEASE PREVENTION TO BE TWO PRIORITY AREAS ON MARCH 25TH, 2025. IN DEVELOPING THE CHIP, IT WAS DETERMINED THAT LIFESTYLE CHANGES LEAD TO THE GREATEST CHANGES IN BOTH THESE PRIORITY AREAS. TO IMPROVE MENTAL HEALTH, SUBSTANCE USE, AND CHRONIC DISEASE, THE GROUP DECIDED TO WORK TO IMPROVE LIFESTYLE CHOICE IN THE DISTRICT BY RUNNING MORE EDUCATIONAL PROMOTIONS CONCERNING HEALTHY AND PROPER DIABETIC EATING AND INCREASING IN THE NUMBER OF MEALS DELIVERED TO LOCAL PATRONS TO PROVIDE A QUALITY MEAL THROUGHOUT THE WEEK.2) SOCIOECONOMIC STABILITY: A HOUSEHOLD'S INCOME LEVEL DETERMINES WHAT TYPES OF HEALTH-RELATED CHOICES ARE AVAILABLE. THOSE WITH LOWER LEVELS OF INCOME OFTEN HAVE LOWER ACCESS TO HEALTHY FOODS, PREVENTATIVE HEALTH CARE, AND EDUCATIONAL OPPORTUNITIES AND ARE ALSO ASSOCIATED WITH POORER PHYSICAL AND MENTAL HEALTH OUTCOMES (BRAVEMAN, EGERTER, & BARCLAY, 2011). A LACK OF FINANCIAL RESOURCES CAN MAKE ENGAGING IN HEALTHY BEHAVIORS DIFFICULT, OFTEN LEADING TO POOR HEALTH BEHAVIORS AND OUTCOMES. POOR PHYSICAL HEALTH AND MENTAL HEALTH ARE ALL MORE COMMON AMONG PEOPLE MAKING LESS MONEY IN THEIR HOUSEHOLD. IMPROVEMENTS BEING MADE IN THIS AREA INCLUDE STARTING A LOCAL FOOD PANTRY AND INCREASING THE NUMBER OF PROMOTIONS TO THE PUBLIC SO THEY ARE AWARE OF THE OFFERINGS WITHIN THEIR COMMUNITY.3) ACCESS TO CARE: SEVERAL BARRIERS WERE REPORTED THAT LIMITED ACCESS TO CARE. AMONG THE MOST COMMON WERE COST, LACK OF AVAILABLE HEALTHCARE PROFESSIONALS, LACK OF CHILD CARE, AND LACK OF TRANSPORTATION. NIOBRARA VALLEY HOSPITAL PARTNERED WITH AVELECARE TO OFFER BEHAVIORAL HEALTH SPECIALISTS TO PATIENTS IN NEED, AND A NEW CLINIC WAS OPENED IN AN ADJACENT COMMUNITY. ADDITIONAL DAYS WERE ALSO ADDED TO CURRENT CLINICS TO GIVE PATRONS MULTIPLE OPTIONS FOR THEIR HEALTHCARE NEEDS TO BE ADDRESSED.NIOBRARA VALLEY HOSPITAL WAS ABLE TO ADDRESS ALL OF THE NEEDS BY COMBINING THE TWO PRIORITY AREAS OF "MENTAL HEALTH & SUBSTANCE ABUSE PREVENTION AND "CHRONIC DISEASE & DISEASE PREVENTION" INTO LIFESTYLE CHANGES" AS MOST DISEASE AND HEALTH ISSUES ARE A DIRECT RESULT OF THE LIFESTYLE CHOICES PEOPLE MAKE, AND THEY MAKE THE BIGGEST IMPACT ON PHYSICAL AND MENTAL HEALTH. NIOBRARA VALLEY HOSPITAL PART V, SECTION B, LINE 15E: THE FINANCIAL ASSISTANCE POLICY STATES THE FOLLOWING: PATIENTS WHO BELIEVE THEY MAY QUALIFY FOR FINANCIAL ASSISTANCE UNDER THIS POLICY ARE REQUIRED TO SUBMIT AN APPLICATION ON THE HOSPITAL'S FINANCIAL ASSISTANCE APPLICATION FORM DURING THE APPLICATION PERIOD. NIOBRARA VALLEY HOSPITAL PART V, SECTION B, LINE 16J: THE FINANCIAL ASSISTANCE PROGRAM IS PUBLICIZED ON THE MONTHLY STATEMENTS SENT TO ALL PATIENTS. IT IS ALSO INCLUDED ON THE PAYMENT POLICY WHICH IS SENT TO ALL PATIENTS WITH THEIR FIRST BILLING STATEMENT. THE FINANCIAL ASSISTANCE POLICY SUMMARY IS SENT TO THOSE PATIENTS WHOSE ACCOUNTS ARE NOT CURRENT. 1 1 - NVMC - SPENCER 108 WEST EVANS STREET SPENCER NE 68777 CLINIC PART I, LINE 3C: AT NIOBRARA VALLEY HOSPITAL, THERE IS NO DISCOUNTED CARE. EITHER THE PATIENT QUALIFIES FOR FREE CARE OR HE/SHE DOES NOT. ELIGIBILITY FOR FREE CARE IS BASED OFF 100% OF FEDERAL POVERTY GUIDELINES. OTHER FACTORS USED TO DETERMINE FREE CARE INCLUDE INSURANCE AND UNINSURANCE STATUS. PART I, LINE 7: UNREIMBURSED MEDICAID, LINE 7B, AND SUBSIDIZED HEALTH SERVICES, LINE 7G, ARE CALCULATED USING THE COSTING METHODS TO PREPARE THE COST REPORTS. CASH AND IN-KIND CONTRIBUTIONS, LINE 7I, ARE REPORTED BASED ON ACTUAL EXPENSES REPORTED IN THE GENERAL LEDGER. PART I, LINE 7G: THERE ARE COSTS ATTRIBUTABLE TO A PHYSICIAN CLINIC INCLUDED ON LINE 7G. TOTAL REVENUE RECEIVED FROM MEDICARE RELATED TO PHYSICIAN CLINICS INCLUDES $22,987 WITH MEDICARE ESTIMATED COSTS OF CARE RELATING TO PAYMENTS OF $212,871. PART III, LINE 2: THE AMOUNT ON LINE 2 REPRESENTS IMPLICIT PRICE CONCESSIONS. THE ORGANIZATION DETERMINES ITS ESTIMATE OF IMPLICIT PRICE CONCESSION BASED ON ITS HISTORICAL COLLECTION EXPERIENCE WITH THIS CLASS OF PATIENTS. PART III, LINE 3: THE ESTIMATED AMOUNT OF THE ORGANIZATION'S IMPLICIT PRICE CONCESSIONS ATTRIBUTABLE TO PATIENTS ELIGIBLE UNDER THE ORGANIZATION'S CHARITY CARE POLICY IS CALCULATED BASED ON AN APPROXIMATE 13.1% OF INDIVIDUALS LIVING BELOW THE POVERTY LEVEL IN THE SERVICE AREA. PART III, LINE 4: THE FOOTNOTE TO THE ORGANIZATION'S FINANCIAL STATEMENTS THAT DESCRIBES IMPLICIT PRICE CONCESSIONS IS LOCATED IN FOOTNOTE 1 ON PAGES 12 AND 13 OF THE ATTACHED FINANCIAL STATEMENTS. PART III, LINE 8: THE ENTIRE MEDICARE SHORTFALL IS CONSIDERED A COMMUNITY BENEFIT. SERVICES ARE PROVIDED TO PATIENTS UNDER THE MEDICARE PROGRAM EVEN THOUGH THE HOSPITAL KNOWS THEY WILL NOT RECOVER ALL OF THE COSTS FROM PROVIDING THE SERVICES. THIS PROGRAM IS CONSIDERED SUBSIDIZED BY THE HOSPITAL AND OTHER PAYORS. PATIENTS RELY ON THESE SERVICES FOR THEIR HEALTH AND WELL-BEING AND ARE ESSENTIAL FOR THEIR ACCESS TO HEALTHCARE. TOTAL REVENUE RECEIVED FROM MEDICARE IS THE GROSS REIMBURSEMENT PLUS SETTLEMENT. BOTH TOTAL REVENUE RECEIVED FROM MEDICARE AND THE MEDICARE ALLOWABLE COSTS ARE REPORTED FROM THE MEDICARE COST REPORT. THE MEDICARE COST REPORT IS COMPLETED BASED ON THE RULES AND REGULATIONS SET FORTH BY CENTERS FOR MEDICARE AND MEDICAID SERVICES.HOSPITAL SERVICES RENDERED ON A FEE SCHEDULE ARE NOT INCLUDED IN THE MEDICARE CALCULATIONS PER THE 990 INSTRUCTIONS. HAD THIS BEEN REPORTED THE HOSPITAL WOULD HAVE HAD A GREATER LOSS FROM MEDICARE SERVICES OF $46,776.MEDICARE FEE SCHEDULE REVENUE $41,969MEDICARE ESTIMATED COSTS OF CARE RELATING TO PAYMENTS $88,745NET (SHORTAGE) $(46,776) PART III, LINE 9B: IF A PERSON APPLIES FOR FINANCIAL ASSISTANCE IN ACCORDANCE WITH THE FINANCIAL ASSISTANCE POLICY ALL COLLECTION EFFORTS WILL STOP UNTIL THE DETERMINATION OF ELIGIBILITY FOR FINANCIAL ASSISTANCE IS MADE. IF THE PERSON QUALIFIES FOR FINANCIAL ASSISTANCE, THE HOSPITAL WILL TAKE STEPS TO REVERSE COLLECTIONS ACTION, REPORTS AND OTHER ACTIONS THAT HAVE BEEN TAKEN TO OBTAIN PAYMENT. PART VI, LINE 2: NIOBRARA VALLEY HOSPITAL PARTNERED WITH NORTH CENTRAL DISTRICT HEALTH DEPARTMENT TO GATHER INFORMATION ON THE COMMUNITY NEEDS. IONA RESEARCH WAS HIRED TO TABULATE THE RESULTS. PART VI, LINE 3: AT THE POINT OF ADMISSION, A PATIENT'S INSURED STATUS IS DETERMINED. WHEN BILLING STATEMENTS ARE MAILED, THE COLLECTION POLICY OF NIOBRARA VALLEY HOSPITAL IS ALSO SENT. THE COLLECTION POLICY INCLUDES INFORMATION ON CHARITY CARE AND DETAILS CHARITY CARE APPLICATION INSTRUCTIONS. PART VI, LINE 4: THE FACILITY SERVES BOYD COUNTY AND PORTIONS OF KNOX AND HOLT COUNTIES. THE POPULATION OF THIS AREA IS APPROXIMATELY 2,500 WITH A HIGH CONCENTRATION OF ELDERLY AND LOW INCOME FAMILIES. PART VI, LINE 5: NIOBRARA VALLEY HOSPITAL SUPPORTS THE HEALTH OF ITS SERVICE AREA THROUGH A VARIETY OF COMMUNITY BENEFIT ACTIVITIES. THE HOSPITAL PROVIDES FREE BLOOD PRESSURE SCREENINGS TO THE PUBLIC DURING CLINIC HOURS AND, DURING THE CURRENT FISCAL YEAR, IMPLEMENTED A COMMUNITY HEALTH SCREENING PROGRAM OFFERING PERIODIC BLOOD DRAWS AND RELATED SERVICES. THE HOSPITAL ALSO SPONSORS EDUCATIONAL SPEAKERS FOR COMMUNITY GROUPS AND PROMOTES PUBLIC HEALTH INITIATIVES THROUGH LOCAL MEDIA OUTREACH, INCLUDING SOCIAL MEDIA, NEWSPAPER ARTICLES, AND RADIO ANNOUNCEMENTS.GOVERNANCE AND COMMUNITY REPRESENTATION ARE MAINTAINED THROUGH A BOARD OF DIRECTORS COMPRISED OF LOCAL RESIDENTS FROM THE HOSPITAL'S SERVICE AREA. THE HOSPITAL EXTENDS MEDICAL STAFF PRIVILEGES TO QUALIFIED PROVIDERS IN THE REGION TO ENHANCE ACCESS TO CARE. HOSPITAL LEADERSHIP CONTINUOUSLY EVALUATES OPPORTUNITIES TO IMPROVE PATIENT CARE AND COMMUNITY HEALTH, PRIORITIZING QUALITY IMPROVEMENT INITIATIVES AND REINVESTING SURPLUS RESOURCES INTO PATIENT CARE ENHANCEMENTS AND COMMUNITY BENEFIT PROGRAMS WHILE MAINTAINING FINANCIAL STABILITY. 0 0 0 0 0 0 0 0 0 TODD HOPE DOCTOR 252140 0 0 0 0 0 0 0 0 0 252140 0 0 0 PART I, LINE 3 MR. KALKOWSKI WAS PAID BY AN UNRELATED ORGANIZATION, FAITH REGIONAL HEALTH SERVICES, FOR HIS POSITION AS CEO. FAITH REGIONAL HEALTH SERVICES USES AN INDEPENDENT COMPENSATION CONSULTANT, FORM 990 OF OTHER ORGANIZATIONS, WRITTEN EMPLOYMENT CONTRACT, COMPENSATION SURVEY AND APPROVAL BY THE BOARD IN DETERMINING HIS COMPENSATION. SCHEDULE J, PART II MR. KALKOWSKI WAS PAID BY AN UNRELATED ORGANIZATION, FAITH REGIONAL HEALTH SERVICES, FOR HIS POSITION AS CEO. TOTAL COMPENSATION AND BENEFITS PAID TO MR. KALKOWSKI FOR 2024 WERE $150,695. FORM 990, PART VI, SECTION A, LINE 1A THE EXECUTIVE COMMITTEE, CONSISTING OF THE PRESIDENT AND AT LEAST THREE OTHER DESIGNATED BOARD MEMBERS, HAS THE ABILITY TO ACT ON BEHALF OF THE GOVERNING BODY. FORM 990, PART VI, SECTION A, LINE 3 NIOBRARA VALLEY HOSPITAL HAS A SERVICE CONTRACT WITH FAITH REGIONAL HEALTH SERVICES FOR MANAGEMENT SERVICES. FORM 990, PART VI, SECTION B, LINE 11B THE GOVERNING BOARD REVIEWS THE FORM 990 AND RELATED SCHEDULES BEFORE THE FORM IS SUBMITTED TO THE IRS. THE FORM 990 IS ALSO REVIEWED BY THE ADMINISTRATOR AND THE CFO. FORM 990, PART VI, SECTION B, LINE 12C UPON COMPLETION OF EACH FISCAL YEAR, DIRECTORS AND MANAGEMENT EMPLOYEES (RESPONSIBLE PERSONS) ARE REQUIRED TO SUBMIT A SIGNED CONFLICT OF INTEREST DISCLOSURE STATEMENT. RESPONSIBLE PERSONS ARE ALSO REQUIRED TO SUBMIT WRITTEN SIGNED ACKNOWLEDGEMENT AFFIRMING THAT HE OR SHE: 1) HAS RECEIVED AND READ A COPY OF THE CONFLICT OF INTEREST POLICY, 2) AGREES TO COMPLY WITH THIS POLICY AND 3) UNDERSTANDS THAT NIOBRARA VALLEY HOSPITAL IS A CHARITABLE ORGANIZATION. IN ADDITION TO THE ANNUAL DISCLOSURE PROCESS, ALL RESPONSIBLE PERSONS HAVE A DUTY TO IMMEDIATELY DISCLOSE ANY NEW OR MODIFIED FINANCIAL INTEREST OR RELATIONSHIP IN WRITING TO THE EXECUTIVE COMMITTEE CHAIR OR THE ADMINISTRATOR. DISCLOSURES MADE UNDER THIS SHALL BE FORWARDED TO THE EXECUTIVE COMMITTEE FOR EVALUATION AND DECISION REGARDING THE POTENTIAL EXISTENCE OF A CONFLICT OF INTEREST. FORM 990, PART VI, SECTION B, LINE 15A FAITH REGIONAL HEALTH SERVICES, AN UNRELATED ORGANIZATION, DETERMINES COMPENSATION FOR THE ORGANIZATION'S TOP MANAGEMENT OFFICIAL. FAITH REGIONAL HEALTH SERVICES USES AN INDEPENDENT COMPENSATION CONSULTANT, FORM 990 OF OTHER ORGANIZATIONS, WRITTEN EMPLOYMENT CONTRACT, COMPENSATION SURVEY AND APPROVAL BY THE BOARD IN DETERMINING COMPENSATION. FORM 990, PART VI, SECTION C, LINE 19 THE ORGANIZATION DOES NOT MAKE ITS GOVERNING DOCUMENTS, CONFLICT OF INTEREST POLICY OR FINANCIAL STATEMENTS AVAILABLE TO THE PUBLIC. FORM 990, PART IX, LINE 11G OTHER FEES FOR SERVICE: PROGRAM SERVICE EXPENSES 127,594. MANAGEMENT AND GENERAL EXPENSES 163,169. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 290,763. EMERGENCY ROOM PHYSICIANS: PROGRAM SERVICE EXPENSES 166,367. MANAGEMENT AND GENERAL EXPENSES 0. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 166,367. CONSULTING SERVICES: PROGRAM SERVICE EXPENSES 1,003,165. MANAGEMENT AND GENERAL EXPENSES 31,407. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 1,034,572. RECRUITMENT FEES: PROGRAM SERVICE EXPENSES 2,500. MANAGEMENT AND GENERAL EXPENSES 17,500. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 20,000. FORM 990, PART IX, LINE 5: THE HOSPITAL ADMINISTRATOR IS PAID BY FAITH REGIONAL HEALTH SERVICES, AN UNRELATED ENTITY. THE COMPENSATION FOR THIS INDIVIDUAL IS REPORTED ON PART IX, LINE 11A, COLUMN C. FORM 990, PART XI, LINE 9: CHANGE IN INTEREST IN NIOBRARA VALLEY HOSPITAL FOUNDATION -28,402. FORM 990, PART XII, LINE 2C: THE BOARD OF DIRECTORS OF NIOBRARA VALLEY HOSPITAL ASSUMES RESPONSIBILITY FOR OVERSIGHT OF THE AUDIT OF THE FINANCIAL STATEMENTS AND THE SELECTION OF THE INDEPENDENT ACCOUNTANT. THIS PROCESS HAS NOT CHANGED FROM THE PRIOR YEAR.