2024-06-28T11:32:01-05:00 2023-08-31 450250958 EIDE BAILLY LLP 18081 BURT ST STE 200 OMAHA NE 680224722 990 2022-09-01 470537192 NIOBRARA VALLEY HOSPITAL NIOB 4025692451 PO BOX 118 LYNCH NE 68746 KELLY KALKOWSKI ADMINISTRATOR 4025692451 2024-06-26 1 KELLY KALKOWSKI 999009999 1 MEGAN L KOZIOL CPA P01544037 4023302660 2024-06-26 2 AAL1 IAL1 2022 2023-04-26 12:10:37Z KELLY KALKOWSKI PO BOX 118 LYNCH NE 68746 3736713 0 X WWW.NVHCARES.ORG X 1975 NE TO PROVIDE ACUTE HOSPITAL SERVICES. 7 7 38 8 0 0 352975 347212 3162046 3345660 15105 38841 10000 5000 3540126 3736713 985 550 0 0 1516751 1415233 0 0 0 1639037 2093580 3156773 3509363 383353 227350 5150725 5150479 569992 363189 4580733 4787290 X TO DELIVER EXCELLENT, COMPASSIONATE AND PERSONALIZED HEALTHCARE FOR THE PEOPLE WE SERVE. 0 0 2840371 550 3350660 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 69 INPATIENT DAYS, 89 SWING AND RESPITE CARE DAYS AND 582 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. 2840371 1 1 0 1 0 0 0 0 0 0 1 0 0 1 0 1 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 25 0 1 38 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 BREE ALMGREN NURSE PRACTIONER 32.00 X 191187 0 7330 DEBRA HANZLIK DIRECTOR OF NURSING 36.00 X 129929 0 3096 MARTHA NELSON CFO 5.00 X 17790 0 0 TRACY BIRMEIER PRESIDENT 0.30 X X 0 0 0 LINDA SEXTRO VICE PRESIDENT 0.30 X X 0 0 0 LARRY HIATT SECRETARY 0.30 X X 0 0 0 CRAIG BREWSTER TREASURER 0.30 X X 0 0 0 BRAD JERMAN MEMBER 0.30 X 0 0 0 LAREE PRITCHETT MEMBER 0.30 X 0 0 0 WANDA DEKAY MEMBER 0.30 X 0 0 0 CHRIS MINARIK MEMBER THRU 6/2023 0.30 X 0 0 0 KELLY KALKOWSKI ADMINISTRATOR 40.00 X 0 0 0 338906 0 10426 2 0 1 1 READY TECH-GO INC 1005 EAST 23RD STREET SUITE 200 FREMONT NE 68025 IT SERVICES 145330 FAITH REGIONAL HEALTH SERVICES 1500 KOENIGSTEIN AVENUE PO BOX 869 NORFOLK NE 687020869 MANAGEMENT SERVICES 140996 FUSION MEDICAL STAFFING LLC 18881 W DODGE RD STE 300W ELKHORN NE 68022 EMPLOYMENT SERVICES 125281 3 180725 166487 347212 MEDICARE/MEDICAID PAYM 624100 2624240 2624240 PATIENT SERVICE REVENU 624100 700806 700806 OTHER REVENUE 624100 20124 20124 LIFELINE REVENUE 624100 490 490 3345660 38841 38841 5000 0 5000 5000 5000 3736713 3350660 0 38841 X 550 550 17790 17790 1240505 1088919 151586 13287 7130 6157 45942 33280 12662 97709 82992 14717 140996 140996 878 878 55690 55690 1026836 966560 60276 4474 100 4374 321419 164703 156716 101420 92087 9333 12466 12403 63 200570 181439 19131 51299 46380 4919 MEDICAL SUPPLIES 143818 143818 MISCELLANEOUS 22531 13939 8592 DUES & SUBSCRIPTIONS 11183 6071 5112 3509363 2840371 668992 0 250 250 2936119 2719278 277527 279703 54935 54039 6279 33790 4352382 2865331 1462378 1487051 413237 576368 5150725 5150479 267071 363189 302921 0 569992 363189 X 4576789 4783346 3944 3944 4580733 4787290 5150725 5150479 X 227350 -20793 X X 0 1 X 1 0 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 0 0 0 0 0 0 0 0 1 655 655 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 $655. 2217734 1217642 1000092 2128243 1641284 486959 6405 6405 0 1487051 INTEREST - NIOBRARA VALLEY HOSPITAL FOUNDATION 392444 ESTIMATED THIRD-PARTY PAYOR SETTLEMENTS 183924 576368 X 3715920 -20793 -20793 3736713 0 3736713 3509363 0 3509363 0 3509363 PART X, LINE 2: THE HOSPITAL ACCOUNTS FOR UNCERTAINTIES IN ACCOUNTING FOR INCOME TAX ASSETS AND LIABILITIES USING GUIDANCE INCLUDED IN FASB ASC TOPIC 740, INCOME TAXES. THE HOSPITAL RECOGNIZES THE EFFECT OF INCOME TAX POSITIONS ONLY IF THOSE POSITIONS ARE MORE LIKELY THAN NOT OF BEING SUSTAINED. AT AUGUST 31, 2023 AND 2022, THE HOSPITAL HAD NO UNCERTAIN TAX POSITIONS ACCRUED. PART XI, LINE 2D - OTHER ADJUSTMENTS: CHANGE IN INTEREST IN NIOBRARA VALLEY HOSPITAL FOUNDATION -20,793. 1 1 X 1 X 0 0 0 1 1 1048 0 1048 0.00030 405438 218522 186916 0.05330 406486 218522 187964 0.05360 7812 0 7812 0.00220 395158 395158 550 0 550 0.00020 403520 395158 8362 0.00240 810006 613680 196326 0.05600 1 5000 0 2403252 2423722 -20470 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 21 1 1 1 1 X WWW.NVHCARES.ORG/COMMUNITY-HEALTH-NEEDS-ASSESSMENT.HTML X 1 21 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 3J: THROUGH THE PROCESSES OF COMPLETING THE COMMUNITY HEALTH NEEDS ASSESSSMENT AND ASSESSING THE RESOURCES AVAILABLE TO THIS ORGANIZATION AND SURROUNDING COMMUNITIES, IT WAS DETERMINED THAT THE MOST SIGNIFICANT NEED TO BE ADDRESSED BY NIOBRARA VALEY HOSPITAL IS THE CARDIOVASCULAR HEALTH OF THE COMMUNITIES ALONG WITH PROMOTING MENTAL HEALTH, PRIMARILY IN THE AREAS OF BLOOD PRESSURE SCREENINGS AND THE RISKS OF ABNORMAL PRESSURE VALUES AND INCREASING THE AWARENESS OF MENTAL HEALTH AND SUICIDE THROUGH EDUCATIONAL PAMPHLETS AND NEWS OUTLETS. NIOBRARA VALLEY HOSPITAL PART V, SECTION B, LINE 5: NIOBRARA VALLEY HOSPITAL ALONG WITH NORTH CENTRAL DISTRICT HEALTH DEPARTMENT (NCDHD) ADMINISTERED AN ONLINE SURVEY VIA SURVEY MONKEY TO GAIN THE PERSPECTIVE OF THE COMMUNITY REGARDING HEALTH, COMMUNITY HEALTH ISSUES AND QUALITY OF LIFE. A TOTAL OF 18 COMMUNITY MEMBERS 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) COUNSELING & ENRICHMENT CENTER BUILDING BLOCKS REGION 4 BEHAVIORAL HEALTH SYSTEM CENTRAL NEBRASKA COMMUNITY ACTION PARTNERSHIP NORTHEAST NEBRASKA COMMUNITY ACTION PARTNERSHIP VALENTINE COMMUNITY SCHOOL NORTHSTAR SERVICES NORTH CENTRAL COMMUNITY CARE PARTNERSHIP AREA SUBSTANCE ABUSE PREVENTION COALITION PROTEUS CENTRAL NEBRASKA ECONOMIC DEVELOPMENT GOOD SAMARITAN SOCIETY- ATKINSON INDIAN HEALTH SERVICES THE EVERGREEN ASSISTED LIVING FACILITY COTTONWOOD BILLA ASSISTED LIVING FACILITY CALVARY BIBLE CHURCH BROWN-ROCK-KEYA PAHA COUNTY O'NEILL PUBLIC SCHOOL BOARD SANTEE SIOUX NATION UNIVERSITY OF NEBRASKA PUBLIC POLICY CENTER O'NEILL CHAMBER OF COMMERCE ESU 17 / AINSWORTH SCHOOLS HOLT COUNTY ECONOMIC DEVELOPMENT NORTHWEST NEBRASKA COMMUNITY ACTION PARTNERSHIP NIOBRARA VALLEY HOSPITAL PART V, SECTION B, LINE 11: IN REVIEWING THE INFORMATION COLLECTED FROM THE CHA NIOBRARA VALLEY HOSPITAL ADDRESSED THE COMMUNITY NEEDS OF BOTH CARDIOVASCULAR HEALTH AND MENTAL HEALTH. WITH HEART DISEASE BEING THE PRIMARY CAUSE OF DEATH FOR THE NCDHD RESIDENTS WE DEEMED THIS A WORTHY CAUSE TO ADDRESS BY PROMOTING BLOOD PRESSURE SCREENINGS, HEALTH SCREENING BLOOD DRAWS, PROMOTING AWARENESS OF THE RISKS OF ABNORMAL BLOOD PRESSURES AND EXPLORING AVENUES FOR PHYSICAL ACTIVITY IN THE COUNTY. MENTAL HEALTH WAS ALSO ONE OF THE TOP CONCERNS IDENTIFIED BY NCDHD CHA RESPONDENTS. THE AVERAGE VALUES ACROSS NCDHD WAS 12.1% FOR FREQUENT MENTAL DISTRESS, COMPARED TO OVERALL NEBRASKA VALUES OF 11.3%. IT WAS ALSO IDENTIFIED THAT ABOUT ONE THIRD OF ELDERLY RESIDENTS SURVEYED REPORTED NOT FEELING LONELY OR DISCONNECTED FROM OTHERS (69.6%). FROM THIS NIOBRARA VALLEY HOSPITAL WILL UTILIZE MEDIA OUTLETS TO INCREASE THE AWARENESS OF MENTAL HEALTH AND SUICIDE AND BRING IN MORE OPTIONS FOR TELE-PSYCHIATRY TO THE AREA. DURING THE FISCAL YEAR ENDING 08/31/23 NIOBRARA VALLEY HOSPITAL HELD TWO DIFFERENT HEALTH FAIRS ON MAY 18TH AND 25TH WHERE A BLOOD PANEL WAS PROVIDED THAT HELPED DIAGNOSE CARDIOVASCULAR ISSUES AND BLOOD PRESSURES WERE PERFORMED. EDUCATIONAL PAMPHLETS WERE HANDED OUT SHOWING PROPER BLOOD PRESSURE AWARENESS ALONG WITH MENTAL HEALTH INFORMATION TO HELP PROMOTE THE AWARENESS OF MENTAL HEALTH AND SUICIDE.OTHER NEEDS IDENTIFIED BY THE CHNA THAT ARE NOT ADDRESSED IN NIOBRARA VALLEY HOSPITAL'S IMPLEMENTATION STRATEGY ARE: 1.) AGING POPULATION & RELATED ISSUES, 2.) SUBSTANCE ABUSE. NIOBRARA VALLEY HOSPITAL DOES NOT POSSESS THE NECESSARY RESOURCES AND/OR EXPERTISE TO ADDRESS THESE NEEDS. THESE NEEDS WILL BE ADDRESSED BY EXISTING COMMUNITY ASSETS THAT HAVE BEEN IDENTIFIED IN THE LOCAL HEALTH DEPARTMENT PLAN. 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. PART I, LINE 6A: NIOBRARA VALLEY HOSPITAL'S COMMUNITY BENEFIT REPORT IS PREPARED BY THE STAFF OF NIOBRARA VALLEY HOSPITAL. PART I, LINE 7G: THERE ARE NO COSTS ATTRIBUTABLE TO A PHYSICIAN CLINIC INCLUDED ON LINE 7G. PART II, COMMUNITY BUILDING ACTIVITIES: NIOBRARA VALLEY HOSPITAL DOES NOT HAVE ANY COMMUNITY BUILDING ACTIVITIES. PART III, LINE 2: THE HOSPITAL DETERMINES THE TRANSACTION PRICE BASED ON STANDARD CHARGES FOR GOODS AND SERVICES PROVIDED, REDUCED BY CONTRACTUAL ADJUSTMENTS PROVIDED TO THIRD-PARTY PAYORS, DISCOUNTS PROVIDED TO UNINSURED PATIENTS IN ACCORDANCE WITH THE HOSPITAL'S POLICY, AND OR IMPLICIT PRICE CONCESSIONS PROVIDED TO UNINSURED PATIENTS. THE HOSPITAL DETERMINES ITS ESTIMATES OF CONTRACTUAL ADJUSTMENTS AND DISCOUNTS BASED ON CONTRACTUAL AGREEMENTS, ITS DISCOUNT POLICIES AND HISTORICAL EXPERIENCE. THE HOSPITAL DETERMINES ITS ESTIMATE OF IMPLICIT PRICE CONCESSIONS BASED ON HISTORICAL COLLECTION EXPERIENCE WITH VARIOUS CLASSES OF PATIENTS. PART III, LINE 3: NIOBRARA PROVIDES PATIENT FINANCIAL ASSISTANCE TO PATIENTS WHO ARE FINANCIALLY UNABLE TO PAY FOR THE HEALTHCARE SERVICES THEY RECEIVE. IT IS THE POLICY OF NIOBRARA NOT TO PURSUE COLLECTION OF AMOUNTS DETERMINED TO QUALIFY AS PATIENT FINANCIAL ASSISTANCE. ACCORDINGLY, NIOBRARA DOES NOT REPORT THESE AMOUNTS IN PATIENT SERVICE REVENUE. PART III, LINE 4: THE HOSPITAL'S FINANCIAL STATEMENTS DO NOT CONTAIN A SPECIFIC FOOTNOTE DESCRIBING BAD DEBT. HOWEVER, PAGES 8, 11 AND 12 OF THE ATTACHED FINANCIAL STATEMENTS INCLUDE FOOTNOTES TITLED "PATIENT RECEIVABLES," "PATIENT SERVICE REVENUE AND "PATIENT FINANCIAL ASSISTANCE." PART III, LINE 8: NIOBRARA VALLEY HOSPITAL USED THE AUGUST 31, 2023 MEDICARE COST REPORT TO ARRIVE AT MEDICARE ALLOWABLE COSTS. NVH USED WORKSHEETS D-1, D-3, E, E-2 AND E-3 OF THE COST REPORT. IT DOES NOT INCLUDE ALL OF THE MEDICARE REVENUES AND COSTS. IF ALL OF THE MEDICARE REVENUES AND COSTS WERE INCLUDED, THERE WOULD BE A SHORTFALL ON LINE 7. THE SHORTFALL WOULD REPRESENT ACTUAL UNREIMBURSED COSTS INCURRED BY NIOBRARA VALLEY HOSPITAL IN PROVIDING SERVICES TO INDIVIDUALS ELIGIBLE FOR MEDICARE. THE COMMUNITY BENEFITS BECAUSE THE HOSPITAL APPLIES OTHER REVENUES TO COVER THE COSTS OF CARING FOR MEDICARE PATIENTS. PART III, LINE 9B: THE COLLECTION POLICY INCLUDES AN EXPLANATION OF NVH'S CHARITY CARE PROGRAM. THE PROGRAM IS CONSIDERED A "LAST RESORT" FOR PATIENTS MAKING A GENUINE EFFORT TO PAY THEIR BILLS. ALL OTHER AVENUES FOR PAYMENT MUST BE EXHAUSTED (SUCH AS MEDICAID, DISABILITY, KID'S CONNECTION) BEFORE THIS PROGRAM APPLIES. REGULAR COLLECTION EFFORTS WILL BE FOLLOWED UNTIL A DETERMINATION IS MADE FROM A COMPLETED ASSISTANCE APPLICATION THAT A PATIENT QUALIFIES FOR FINANCIAL ASSISTANCE. 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 SPONSORS EDUCATIONAL SPEAKERS FOR COMMUNITY GROUPS. NIOBRARA VALLEY HOSPITAL OFFERS FREE BLOOD PRESSURE CHECKS AND PROVIDES PERSONNEL FOR COMMUNITY HEALTH SCREENINGS. PART VI, LINE 6: NIOBRARA VALLEY HOSPITAL IS NOT PART OF AN AFFILIATED HEALTH CARE SYSTEM. PART VI, LINE 7 NIOBRARA VALLEY HOSPITAL DOES NOT FILE A COMMUNITY BENEFIT REPORT WITH ANY STATES. 0 0 0 0 0 0 0 0 0 BREE ALMGREN NURSE PRACTIONER 191187 0 0 0 0 0 4393 0 2937 0 198517 0 0 0 PART I, LINE 3 MR. KALKOWSKI WAS PAID BY AN UNRELATED ORGANIZATION, FAITH REGIONAL HEALTH SERVICES, FOR HIS POSITION AS ADMINISTRATOR. 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 ADMINISTRATOR. TOTAL COMPENSATION AND BENEFITS PAID TO MR. KALKOWSKI FOR 2022 WERE $140,996. 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 THE NEBRASKA HOSPITAL ASSOCIATION SALARY SURVEY WAS USED FOR COMPARISON. 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 162,329. MANAGEMENT AND GENERAL EXPENSES 36,893. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 199,222. EMERGENCY ROOM PHYSICIANS: PROGRAM SERVICE EXPENSES 236,547. MANAGEMENT AND GENERAL EXPENSES 0. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 236,547. CONSULTING SERVICES: PROGRAM SERVICE EXPENSES 529,119. MANAGEMENT AND GENERAL EXPENSES 23,063. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 552,182. RECRUITMENT FEES: PROGRAM SERVICE EXPENSES 38,565. MANAGEMENT AND GENERAL EXPENSES 320. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 38,885. 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 -20,793. 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.