2023-05-04T10:39:42-05:00 2021-06-30 450250958 EIDE BAILLY LLP 200 E 10TH ST STE 500 SIOUX FALLS SD 571046375 990 2020-07-01 420890973 OSCEOLA COMMUNITY HOSPITAL INC OSCE 7127542574 PO BOX 258 SIBLEY IA 51249 BEN DAVIS CEO 7127542574 2023-05-03 1 BEN DAVIS 999009999 LAURIE HANSON CPA P00851848 6053391999 2023-05-03 3 AAL1 IAL1 2020 2023-04-26 12:10:37Z X OSCEOLA REGIONAL HEALTH CENTER BEN DAVIS PO BOX 258 SIBLEY IA 51249 17189590 0 X HTTPS://WWW.OSCEOLARHC.ORG/ X 1960 IA TO PROVIDE HEALTHCARE TO THE CITIZENS OF OSCEOLA COUNTY AND THE SURROUNDING AREA. 9 9 164 221 0 0 536418 4528946 11657315 12335788 160311 178795 162806 146061 12516850 17189590 0 0 0 0 5815033 7391364 0 0 34881 6430513 7149188 12245546 14540552 271304 2649038 24101902 24185263 11188640 7226471 12913262 16958792 IT IS THE MISSION OF THE OSCEOLA COMMUNITY HOSPITAL TO ENHANCE AND IMPROVE THE QUALITY OF LIFE OF THE POPULATION IT SERVES, TO BE THE AREA'S PREMIER HEALTH CARE SERVICE PROVIDER, AND TO HAVE A POSITIVE IMPACT ON THE LIVES OF THE PEOPLE AND COMMUNITY IT SERVES. 0 0 10835084 12335788 OSCEOLA COMMUNITY HOSPITAL PROVIDED NURSING SERVICES, LAB, RADIOLOGY, AND OTHER RELATED HOSPITAL FUNCTIONS TO RESIDENTS OF OSCEOLA COUNTY, IOWA AND NEARBY COUNTIES. IN ADDITION, THE HOSPITAL PROVIDES DAY CARE TO THE COMMUNITY. HEALTH SCREENINGS SUCH AS CHOLESTEROL AND CARDIAC ARE PROVIDED AS WELL. THE HOSPITAL WORKS HARD TO BRING OUTREACH SPECIALISTS TO THE FACILITY TO MAKE THESE SERVICES AVAILABLE TO THOSE THAT FIND IT DIFFICULT TO TRAVEL. THE FACILITY'S WELLNESS CENTER PROVIDES PROGRAMS TO THE LOCAL SCHOOL SYSTEM, NURSING HOME FACILITIES, OUTPATIENTS, AND THE COMMUNITY AT LARGE. DURING THE 12 MONTHS OF 7/01/2020-6/30/2021 THE HOSPITAL PROVIDED $202,000 OF CHARITY CARE CHARGES TO VARIOUS INDIVIDUALS, WITHOUT REIMBURSEMENT. 10835084 1 0 0 0 0 0 0 0 0 0 1 1 0 0 0 1 1 0 0 0 0 0 0 0 0 0 1 1 0 0 1 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 1 1 0 0 1 45 0 1 164 1 0 0 0 0 0 0 0 0 0 0 X 9 9 0 0 0 0 1 1 0 1 1 0 0 1 1 1 1 1 1 1 1 0 X BEN DAVIS 7127542574 600 9TH AVENUE NORTH SIBLEY IA 51249 BEN DAVIS CEO 40.00 0.00 X 160944 0 24776 TODD HELMERS PHYSICAL THERAPIST 40.00 0.00 X 119531 0 18715 WENDY MARCO CNO 40.00 0.00 X 109052 0 25936 CRAIG CARSTENS CFO 40.00 0.00 X 99728 0 25679 ABBY DE ZEEUW PRESIDENT 0.50 0.00 X X 0 0 0 NATHAN ROCKMAN PRESIDENT - ELECT 0.50 0.00 X X 0 0 0 AMBER BOSMA SECRETARY 0.50 0.00 X X 0 0 0 BARB VAN DIEPEN TRUSTEE (UNTIL NOV 2020) 0.50 0.00 X 0 0 0 BRIAN MINO TREASURER 0.50 0.00 X X 0 0 0 KEVIN HERTZ TRUSTEE (UNTIL NOV 2020) 0.50 0.00 X 0 0 0 PEGGI THIES TRUSTEE 0.50 1.00 X 0 0 0 ROSALI ARENDS TRUSTEE 0.50 1.00 X 0 0 0 BRUCE OSTERMAN TRUSTEE 0.50 0.00 X 0 0 0 HOLLY WILSON TRUSTEE (BEG NOV 2020) 0.50 0.00 X 0 0 0 GLORIA TORRES TRUSTEE (BEG JUNE) 0.50 0.00 X 0 0 0 489255 0 95106 3 0 1 0 AVERA MCKENNAN 1325 S CLIFF AVE SIOUX FALLS SD 571175045 PHYSICIAN, IT, ADMIN SERVICES 1690219 AVERA HEALTH 3900 W AVERA DRIVE STE 301 SIOUX FALLS SD 57108 CREDENTIALING, PACS, BILLING SERVICES, C 217504 SANFORD USD MEDICAL CENTER PO BOX 5074 SIOUX FALLS SD 571175074 ANESTHESIA,CRNA CHARGES, LA PRO FEES 122970 3 4431762 97184 4528946 PATIENT REVENUE 621400 11298572 11298572 CHILDCARE SERVICES 621400 453216 453216 584000 584000 12335788 19555 19555 95691 0 95691 95691 95691 159240 0 159240 159240 159240 50370 0 50370 50370 17189590 12335788 0 324856 X 318413 318413 5445668 4544187 880566 20915 89018 74282 14394 342 1118707 933515 180895 4297 419558 336344 81608 1606 2875 2875 140384 140384 2648705 1984247 664458 181443 1815 179628 437308 268877 167590 841 158573 137514 16446 4613 11079 10785 294 15861 9843 6018 137765 137765 937520 399317 537163 1040 102658 102658 MEDICAL SUPPLIES 1928341 1928052 289 REPAIR AND MAINTENANCE 169124 163443 5681 DUE AND SUBSCRIPTION 14398 1233 13165 263154 41630 220297 1227 14540552 10835084 3670587 34881 2442847 545725 2043012 1261095 1333651 1556497 16404 9792 286277 293727 78166 57476 23460784 16964131 5659882 6496653 9270193 10254354 2386269 2771445 60417 118750 524784 819749 24101902 24185263 955866 1058056 5291330 1837198 3990127 3814672 951317 516545 11188640 7226471 X 12790171 16790368 123091 168424 12913262 16958792 24101902 24185263 X 2649038 1393263 3229 X 0 1 X 1 1 1 X 201490 201490 13511095 9560909 3950186 8637923 6739345 1898578 1110276 663877 446399 6496653 INTEREST IN AVERA HEALTH FOUNDATION 2642304 F CLOSELY-HELD EQUITY INVESTMENTS 129141 F 2771445 X 18540749 1393263 1393263 17147486 42104 42104 17189590 14540552 0 14540552 0 14540552 PART X, LINE 2: THE HEALTH CENTER BELIEVES THAT IT HAS APPROPRIATE SUPPORT FOR ANY TAX POSITIONS TAKEN AFFECTING ITS ANNUAL FILING REQUIREMENTS, AND AS SUCH, DOES NOT HAVE ANY UNCERTAIN TAX POSITIONS THAT ARE MATERIAL TO THE FINANCIAL STATEMENTS. THE HEALTH CENTER WOULD RECOGNIZE FUTURE ACCRUED INTEREST AND PENALTIES RELATED TO UNRECOGNIZED TAX BENEFITS AND LIABILITIES IN INCOME TAX EXPENSE IF SUCH INTEREST AND PENALTIES ARE INCURRED. THE HEALTH CENTER'S TAX RETURNS ARE SUBJECT TO REVIEW AND EXAMINATION BY FEDERAL, STATE, AND LOCAL AUTHORITIES. PART XI, LINE 4B - OTHER ADJUSTMENTS: CONTRIBUTIONS WITH DONOR RESTRICTIONS 42,104. 1 1 X 1 X 1 X 1 1 1 0 1 1 88000 88000 0.00610 992405 891281 101124 0.00700 1080405 891281 189124 0.01310 3014 3014 0.00020 1494704 895823 598881 0.04120 1497718 895823 601895 0.04140 2578123 1787104 791019 0.05450 1 25346 0 6203954 6142529 61425 X 1 1 1 1 OSCEOLA COMMUNITY HOSPITAL 600 NINTH AVENUE NORTH SIBLEY IA 51249 HTTPS://WWW.OSCEOLARHC.ORG/ 720109H X X X X OSCEOLA COMMUNITY HOSPITAL 1 0 0 1 X X X X X X X X X 18 1 0 1 1 X SEE 7D X X 1 18 1 SEE PART V PAGE 8 0 1 X 100.000000000000 200.000000000000 X X 1 1 X X X X 1 X HTTPS://WWW.OSCEOLARHC.ORG/PATIENTS-VISITORS/PAY-MY-BILL/ X HTTPS://WWW.OSCEOLARHC.ORG/PATIENTS-VISITORS/PAY-MY-BILL/ X HTTPS://WWW.OSCEOLARHC.ORG/PATIENTS-VISITORS/PAY-MY-BILL/ X X X X X 1 X 0 X X X X 1 X 0 0 OSCEOLA COMMUNITY HOSPITAL PART V, SECTION B, LINE 5: OSCEOLA COMMUNITY HOSPITAL INC. CONDUCTED FOCUS GROUP MEETINGS AND ALSO CONDUCTED PERSONAL INTERVIEWS. CAREFUL CONSIDERATION WAS GIVEN TO ENSURE INPUT WAS GATHERED FROM PERSONS THAT REPRESENTED THE BROAD INTERESTS OF THE COMMUNITY. THE HOSPITAL ENGAGED THE GENERAL PUBLIC TO INCLUDE VARIOUS AGES, HEALTH STATUS AND INCOME LEVELS, ALONG WITH MEDICAL COMMUNITY AND CIVIC ORGANIZATIONS, BUSINESS OWNERS, PUBLIC HEALTH OFFICIALS, EMERGENCY PERSONNEL, CITY AND COUNTY OFFICIALS, SCHOOL PERSONNEL, MENTAL HEALTH PROVIDERS, MINISTERIAL ASSOCIATION MEMBERS, CHAMBER OF COMMERCE MEMBERS AND OTHERS REPRESENTING THE UNINSURED AND UNDERINSURED POPULATION. OSCEOLA COMMUNITY HOSPITAL PART V, SECTION B, LINE 6B: OSCEOLA PUBLIC HEALTH OSCEOLA COMMUNITY HOSPITAL PART V, SECTION B, LINE 7D: HTTPS://WWW.OSCEOLARHC.ORG/ABOUT/QUALITY-COMMITMENT/ OSCEOLA COMMUNITY HOSPITAL PART V, SECTION B, LINE 11: THE COMMUNITY HEALTH NEEDS ASSESSMENT WAS COMPLETED DURING THE 2019 TAX YEAR. THE ONGOING PANDEMIC HAS RESTRICTED OUR ABILITY TO MOVE FORWARD WITH IMPLEMENTATION OF THE INITIATIVES OUTLINED IN THE COMMUNITY HEALTH NEEDS ASSESSMENT. THE FOLLOWING COMMUNITY HEALTH PRIORITY AREAS WERE IDENTIFIED, AND THE FOLLOWING ACTIONS WERE TAKEN BY THE HOSPITAL DURING THE 2021 TAX YEAR.ACCESS TO HEALTH CARE PROVIDERS- IN PARTNERSHIP WITH AVERA MEDICAL GROUP SIBLEY, RECRUITMENT EFFORTS HAVE AND WILL CONTINUE TO BE A MAIN PRIORITY. IN OCTOBER OF 2021, OSCEOLA REGIONAL HEALTH CENTER AND AVERA MEDICAL GROUP SIBLEY WERE ABLE TO RECRUIT A PRIMARY CARE PROVIDER WHO HAS PROVIDED ADDITIONAL ACCESS TO PRIMARY CARE. - OSCEOLA REGIONAL HEALTH CENTER WORKED WITH GENERAL SURGEONS FROM AGENCIES TO ENSURE GENERAL SURGERY SERVICES WERE AVAILABLE 24 HOURS A DAY, 7 DAYS A WEEK. - OSCEOLA REGIONAL HEALTH CENTER RECRUITED A GENERAL SURGEON TO PROVIDE PREVENTATIVE CARE AS WELL AS GENERAL SURGERY SERVICES IN 2022. ACCESS TO MENTAL HEALTH/SUBSTANCE ABUSE SERVICES- OSCEOLA REGIONAL HEALTH CENTER HAS PARTNERED WITH INTERCONNECTIONS THERAPY TO PROVIDE MENTAL HEALTH CLINICS IN THE PUBLIC HEALTH OFFICE AND WILL CONTINUE TO PARTNER WITH THEM TO IMPROVE MENTAL HEALTH SERVICES. - OSCEOLA REGIONAL HEALTH CENTER INTENDS TO PARTNER AND/OR EMPLOY A PSYCHIATRIC NURSE PRACTITIONER FOR MENTAL HEALTH SERVICES, AND TO PARTNER WITH OTHER MENTAL HEALTHCARE ORGANIZATIONS TO PROVIDE MENTAL HEALTH SERVICES.EMERGENCY MANAGEMENT SERVICES- MEETINGS HAVE BEEN HELD WITH THE OSCEOLA REGIONAL HEALTH CENTER, AVERA PHYSICIANS, OSCEOLA BOARD OF SUPERVISORS, EMS AND EMT'S, BOARD OF SUPERVISORS TO ENSURE WE HAVE THE BEST POSSIBLE SERVICE FOR OUR COMMUNITIES. - A TRAUMA/EMERGENCY SERVICES TEAM HAS BEEN ASSEMBLED TO WORK TOWARDS ENSURING A QUALITY SERVICE IS PROVIDED TO THE COMMUNITY. WORKFORCE DEVELOPMENT- OSCEOLA REGIONAL HEALTH CENTER PARTNERED WITH LOCAL SCHOOL DISTRICTS TO PROVIDE SCHOLARSHIPS FOR HIGH SCHOOL GRADUATES TO PURSUE DEGREES IN HEALTHCARE. - ORHC INTENDS TO PARTNER WITH LOCAL SCHOOL DISTRICTS TO CREATE APPRENTICESHIPS AND PRECEPTOR PROGRAMS IN HEALTHCARE.- ORHC HAS PARTNERED WITH COMMUNITY COLLEGES TO PROMOTE HEALTHCARE FIELDS IN POST-SECONDARY EDUCATION.COMMUNITY WELLNESS- OSCEOLA REGIONAL WELLNESS AND REHAB STARTED PHYSICAL ACTIVITY CLASSES WITHIN THE WELLNESS CENTER AS WELL AS HOSTED COMMUNITY EVENTS TO INCLUDE A 5K RUN/WALK. - THE DIABETIC EDUCATION PROGRAM AT OSCEOLA REGIONAL HEALTH CENTER HAS A REGISTERED NURSE (RN) AND A REGISTERED DIETICIAN (RD) THAT PROVIDE COUNSELING SERVICES TO DIABETIC PATIENTS REGARDING KNOWLEDGE OF NUTRITION, EXERCISE, MONITORING, AND MEDICATION. - THE PUBLIC HEALTH OFFICE WHICH IS LOCATED ON THE OSCEOLA REGIONAL HEALTH CENTER CAMPUS PROVIDES IMMUNIZATIONS, PRE/POST-NATAL CARE, FOOT CARE AND THE HOMEMAKER PROGRAM, WHICH ALL SUPPORT COMMUNITY WELLNESS. DAYCARE SERVICES- ORHC WILL WORK WITH THE CITY OF SIBLEY, SIBLEY-OCHEYEDAN SCHOOL DISTRICT, AND THE OSCEOLA COUNTY BOARD OF SUPERVISORS AS WELL AS LOCAL ORGANIZATIONS TO ADDRESS THE NEED FOR ADDITIONAL DAYCARE PROVIDERS AND TO PROMOTE DAYCARE SERVICES.- A CHILDCARE STRATEGIC PLANNING COMMITTEE WAS CREATED TO ADDRESS THE CHILDCARE SERVICES SHORTAGE. ORHC ACTIVELY PARTICIPATES IN THE PLANNING AND IMPLEMENTATION. MANY OF THESE ACTIVITIES ARE CONTINUATIONS OF ACTIVITIES THE HOSPITAL HAS BEEN CONDUCTING RELATED TO THE PRIOR COMMUNITY HEALTH NEEDS ASSESSMENT. RECREATIONAL ACTIVITIES, PARKS AND TRAILS, AND HOUSING WERE IDENTIFIED AS NEEDS OF THE COMMUNITY. DUE TO LIMITED RESOURCES, THESE NEEDS HAVE NOT BEEN ADDRESSED BY ORHC. OSCEOLA COMMUNITY HOSPITAL PART V, SECTION B, LINE 13B: THE HOSPITAL WILL PRESUMPTIVELY DETERMINE THAT AN INDIVIDUAL QUALIFIES FOR 100% FINANCIAL ASSISTANCE IF THE HOSPITAL OR ITS AGENT OBTAINS EVIDENCE OF ANY OF THE FOLLOWING SITUATIONS. IF A PERSON IS PRESUMPTIVELY DETERMINED TO QUALIFY, THE HOSPITAL WILL SEND A WRITTEN NOTICE INFORMING THE INDIVIDUAL THAT THEIR LIABILITY HAS BEEN FORGIVEN AND NO FURTHER PAYMENTS ARE DUE.-HOMELESSNESS OR RECEIVED CARE FROM A HOMELESS CLINIC;-NO INCOME;-PARTICIPATE IN THE WOMEN'S, INFANT'S, AND CHILDREN'S PROGRAM ("WIC");-ELIGIBLE FOR FOOD STAMPS;-PARTICIPATE IN A SUBSIDIZED SCHOOL LUNCH PROGRAM;-ELIGIBLE FOR OTHER STATE OR LOCAL ASSISTANCE PROGRAMS THAT ARE UNFUNDED, SUCH AS MEDICAID SPEND-DOWN;-FAMILY OR FRIENDS OF THE INDIVIDUAL PROVIDE INFORMATION ESTABLISHING THE INDIVIDUAL'S INABILITY TO PAY;-LOW-INCOME/SUBSIDIZED HOUSING IS PROVIDED AS A VALID ADDRESS;-PATIENT IS DECEASED WITH NO KNOWN ESTATE; OR-PATIENT/GRANTOR IS INCARCERATED, HAS NO ASSETS, AND IS NOT ELIGIBLE FOR PAROLE WITHIN THE NEXT 18 MONTHS. SCHEDULE H, PART V, SECTION B, LINE 10 AVERA.ORG/APP/FILES/PUBLIC/75774/2019-CHNA-OSCEOLA-IMPLEMENTATION-PLAN.PDF PART I, LINE 3C: IN ADDITION TO USING FPG TO DETERMINE ELIGIBILITY FOR FREE OR DISCOUNTED CARE, THE FACILITY USES AN ASSET TEST AND MAY PROVIDE PRESUMPTIVE ELIGIBILITY IF WARRANTED. PART I, LINE 6A: THE HOSPITAL'S COMMUNITY BENEFIT REPORT IS INCLUDED IN A REPORT PREPARED BY THE IOWA HOSPITAL ASSOCIATION, RATHER THAN IN A SEPARATE REPORT PREPARED BY THE ORGANIZATION. THIS REPORT IS MADE AVAILABLE BY THE IOWA HOSPITAL ASSOCIATION TO THE PUBLIC THROUGH THEIR WEBSITE. PART I, LINE 7: CHARITY CARE EXPENSE WAS CONVERTED TO COST ON LINE 7A BASED ON AN OVERALL COST-TO-CHARGE RATIO ADDRESSING ALL PATIENT SEGMENTS. LINES 7B: UNREIMBURSED MEDICAID WAS CALCULATED USING THE COSTING METHODS TO PREPARE THE COST REPORT. ACTUAL COSTS FROM THE GENERAL LEDGER WERE USED FOR LINE 7E.LINE 7G WAS DETERMINED USING THE MEDICARE COST REPORT. PART II, COMMUNITY BUILDING ACTIVITIES: THE ORGANIZATION SUPPORTED THE COMMUNITY THROUGH PROVIDING EMERGENCY PREPAREDNESS, DISEASE SURVEILLANCE AND BEST CARE FOR BETTER BABIES PROGRAMS. 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 4: THE FOOTNOTE THAT DESCRIBES IMPLICIT PRICE CONCESSIONS IS ON PAGE 12 AND 13 OF THE ATTACHED AUDIT REPORT. PART III, LINE 8: MEDICARE ALLOWABLE COST OF CARE WAS CALCULATED FROM THE MEDICARE COST REPORT FOR FISCAL YEAR ENDING 6/30/21. MEDICAL SERVICES ARE PROVIDED TO PATIENTS WITH MEDICARE COVERAGE REGARDLESS OF WHETHER OR NOT A SURPLUS OR DEFICIT IS REALIZED. PROVIDING MEDICARE SERVICES PROMOTES ACCESS TO HEALTHCARE SERVICES WHICH ARE VITALLY NEEDED BY OUR COMMUNITY. THE MEDICARE COST REPORT IS COMPLETED BASED ON THE RULES AND REGULATIONS SET FORTH BY THE CENTERS FOR MEDICARE AND MEDICAID SERVICES. PART III, LINE 9B: IF AN INDIVIDUAL SUBMITS A FINANCIAL ASSISTANCE APPLICATION, THE HOSPITAL WILL CEASE ALL COLLECTION EFFORTS UNTIL A DETERMINATION OF FINANCIAL ASSISTANCE ELIGIBILITY IS MADE.IF THE HOSPITAL OR ANOTHER AUTHORIZED PARTY HAS ALREADY BEGUN AN EXTRAORDINARY COLLECTION ACTION AGAINST AN INDIVIDUAL WHEN THAT INDIVIDUAL SUBMITS A COMPLETE FINANCIAL ASSISTANCE APPLICATION, THE EXTRAORDINARY COLLECTION ACTION WILL BE SUSPENDED. SUSPENDING AN ACTION MEANS THAT NO FURTHER STEPS ARE TAKEN ON THAT EXTRAORDINARY COLLECTION ACTION AND NO NEW EXTRAORDINARY COLLECTION ACTIONS ARE INITIATED. THIS SUSPENSION MAY BE LIFTED WHEN THE HOSPITAL DETERMINES THE INDIVIDUAL'S ELIGIBILITY FOR FINANCIAL ASSISTANCE AND NOTIFIES THE INDIVIDUAL AS PRESCRIBED IN THE FINANCIAL ASSISTANCE POLICY.IF THE HOSPITAL OR ANOTHER AUTHORIZED PARTY HAS ALREADY BEGUN AN EXTRAORDINARY COLLECTION ACTION AGAINST AN INDIVIDUAL WHEN THAT INDIVIDUAL IS DETERMINED TO BE ELIGIBLE FOR FINANCIAL ASSISTANCE, THE HOSPITAL AND/OR THE OTHER AUTHORIZED PARTY WILL TAKE ALL REASONABLY AVAILABLE MEASURES TO REVERSE THE EXTRAORDINARY COLLECTION ACTION. SUCH STEPS INCLUDE, BUT ARE NOT LIMITED TO, VACATING A JUDGEMENT AGAINST THE INDIVIDUAL, LIFTING A LEVY OR LIEN ON THE INDIVIDUAL'S PROPERTY, AND REMOVING FROM THE INDIVIDUAL'S CREDIT REPORT ANY ADVERSE INFORMATION THAT WAS REPORTED.IF AN INDIVIDUAL SUBMITS AN INCOMPLETE FINANCIAL ASSISTANCE APPLICATION, THE HOSPITAL WILL SUSPEND ANY EXTRAORDINARY COLLECTION ACTIONS, AND PROVIDE A WRITTEN NOTICE TO THE RESPONSIBLE PARTY THAT INCLUDES THE ADDITIONAL INFORMATION AND/OR DOCUMENTATION THAT MUST BE SUBMITTED, THE PHYSICAL LOCATION AND PHONE NUMBER OF A HOSPITAL EMPLOYEE OR DEPARTMENT THAT CAN PROVIDE INFORMATION ABOUT THE FINANCIAL ASSISTANCE POLICY, THE PHYSICAL LOCATION AND PHONE NUMBER OF AN ORGANIZATION OR HOSPITAL EMPLOYEE/OFFICE/DEPARTMENT THAT CAN PROVIDE ASSISTANCE WITH THE FINANCIAL ASSISTANCE APPLICATION PROCESS. THE HOSPITAL WILL ALLOW A REASONABLE AMOUNT OF TIME FOR THE RESPONSIBLE PARTY TO SUBMIT A COMPLETE FINANCIAL ASSISTANCE APPLICATION. SUCH PERIOD OF TIME WILL BE AT LEAST 30 DAYS FROM THE DATE THE WRITTEN NOTICE IS SENT TO THE RESPONSIBLE PARTY. IF THE RESPONSIBLE PARTY FAILS TO PROVIDE THE REQUESTED INFORMATION WITHIN THE STATED TIME, THE HOSPITAL MAY RENEW THE PREVIOUSLY INITIATED EXTRAORDINARY COLLECTION ACTIONS. IF AN INDIVIDUAL HAS MADE FULL OR PARTIAL PAYMENT, AND THE INDIVIDUAL IS SUBSEQUENTLY DETERMINED TO QUALIFY FOR FINANCIAL ASSISTANCE, ANY PAYMENTS IN EXCESS OF THEIR NEWLY CALCULATED REMAINING LIABILITY WILL BE REFUNDED TO THE PATIENT WITHIN 30 DAYS OF THE FINANCIAL ASSISTANCE ELIGIBILITY DETERMINATION. IF THE REFUNDABLE AMOUNT IS LESS THAN $5.00, IT WILL NOT BE REFUNDED. PART VI, LINE 2: THE HOSPITAL ASSESSES THE HEALTH CARE NEEDS OF THE COMMUNITY THROUGH FORMAL PROCESSES THAT INCLUDE MEETINGS, SURVEY AND COMMUNITY INPUT PRIOR TO UNDERTAKING ANY LARGE PROJECTS. THROUGHOUT THE YEAR, COMMUNITY NEEDS ARE ASSESSED INFORMALLY AT VARIOUS COMMUNITY MEETINGS AND THROUGH PATIENT SURVEYS. THE ORGANIZATION ALSO ASSISTS THE HOME HEALTH DEPARTMENT/PUBLIC HEALTH WITH A COMMUNITY NEEDS ASSESSMENT AND INFORMATION FROM THE CHNA IS UTILIZED TO HELP PLAN SERVICES THE ORGANIZATION OFFERS. PART VI, LINE 3: DURING THE COURSE OF PRE-REGISTRATION A MODE OF PAYMENT IS RECORDED ON THE ADMISSION FORM. IF INSURANCE IS INDICATED, BENEFITS ARE REQUESTED FROM THE INSURANCE COMPANY. IF IT IS NOTED THAT THE ACCOUNT HAS A LARGE DEDUCTIBLE OR IS SELF-PAY, THE INFORMATION IS FORWARDED TO THE COLLECTION STAFF AND SOCIAL SERVICES. OPTIONS FOR HANDLING PAYMENT OF THE ACCOUNT ARE THEN DISCUSSED WITH THE PATIENT OR THE RESPONSIBLE PARTY. IF THE PATIENT OR RESPONSIBLE PARTY IS NOT AVAILABLE AT THE TIME THE INFORMATION IS RECEIVED BY THE BUSINESS OFFICE OR SOCIAL SERVICE STAFF, EFFORTS TO CONTACT THEM INCLUDE PHONE AND WRITTEN CORRESPONDENCE. IF THE PARTY DOES NOT RESPOND, THE ACCOUNT IS HANDED OVER TO THE COLLECTION AREA. THIS PROCESS OFTEN REQUIRES A COMBINATION OF BUSINESS OFFICE AND SOCIAL SERVICE STAFF WORKING TOGETHER.OPTIONS FOR ANY SELF-PAY OBLIGATIONS INCLUDE PAYMENT IN FULL, PAYMENT PLANS, VARIOUS ASSISTANCE PROGRAMS, AND THE FINANCIAL ASSISTANCE OFFERED BY OSCEOLA COMMUNITY HOSPITAL'S CHARITY CARE. INFORMATION REGARDING THESE OPTIONS IS MADE AVAILABLE AT THIS TIME.DURING THE DISCUSSIONS, INFORMATION IS REQUESTED TO ASSESS AND APPROVE FINANCIAL STATUS IF PAYMENTS, PROGRAM APPLICATION, OR CHARITY ARE INDICATED. ASSISTANCE IS OFFERED FOR COMPLETION OF APPLICATIONS AND INSTRUCTIONS ARE GIVEN FOR COMPLETION OF FINANCIAL ASSESSMENTS. PARTICULAR ACCOUNTS MAY ALSO BE BROUGHT TO THE ATTENTION OF THE BUSINESS OFFICE OR SOCIAL SERVICES BY THE COLLECTIONS STAFF, PATIENTS THEMSELVES, OR RELATIVES OF PATIENTS. THIS USUALLY OCCURS WHEN THE CIRCUMSTANCES OF THE PATIENT CHANGES AFTER A TIME PERIOD HAS PASSED. WHEN NOTIFICATION IS RECEIVED, THESE CASES ARE REASSESSED. PART VI, LINE 4: DURING FISCAL YEAR 2019 A COMMUNITY HEALTH NEEDS ASSESSMENT (CHNA) WAS CONDUCTED BY OSCEOLA COMMUNITY HOSPITAL FOR THE APPROXIMATELY 12,000 PEOPLE RESIDING IN THE HOSPITAL'S PRIMARY SERVICE AREA. IN DEFINING COMMUNITY, OSCEOLA COMMUNITY HOSPITAL HAS TAKEN IN TO CONSIDERATION ALL MEMBERS OF OSCEOLA COUNTY AND OUR LARGER SERVICE AREA (LYON, O'BRIEN, DICKINSON AND NOBLES, MN COUNTIES) REGARDLESS OF SOCIO-ECONOMIC STATUS. OSCEOLA COMMUNITY HOSPITAL IS COMMITTED TO MEETING THE NEEDS OF ALL WHO NEED CARE REGARDLESS OF THEIR ABILITY TO PAY. THE COMMUNITIES LOCATED IN THIS GEOGRAPHIC AREA INCLUDE BUT ARE NOT LIMITED TO: ASHTON, BOYDEN, GEORGE, HARRIS, LAKE PARK, LITTLE ROCK, MELVIN, OCHEYEDAN, SHELDON, AND SIBLEY IN IOWA, AND BIGELOW, RUSHMORE, AND WORTHINGTON IN MINNESOTA.THE CURRENT POPULATION IN SIBLEY IS 2475, IT HAS DECREASED 11.54% SINCE 2010. THE MEDIAN AGE OF THE POPULATION IS 42 AND 94.68% BEING CAUCASIAN. THE AVERAGE HOUSEHOLD INCOME IS $70,682 AND A POVERTY RATE OF 12.99%. THE AVERAGE HOUSEHOLD SIZE IS 2.28. PART VI, LINE 6: OSCEOLA COMMUNITY HOSPITAL IS A MANAGED FACILITY OF AVERA HEALTH. AVERA HEALTH AND OSCEOLA COMMUNITY HOSPITAL WORK COOPERATIVELY TO ENHANCE HEALTHCARE THROUGHOUT THE COMMUNITY SERVED BY THE HOSPITAL. OSCEOLA COMMUNITY HOSPITAL ALSO HAS ACCESS TO "BACK OFFICE" SUPPORT SERVICES, SUCH AS LEGAL CONSULTATION, QUALITY BENCHMARKING, CODING, COMPUTER SERVICES, CONTRACT NEGOTIATIONS, ADMINISTRATIVE CONSULTATION, GROUP PURCHASING, HUMAN RESOURCE ASSISTANCE AND MANY OTHER SERVICES. AVERA HEALTH IS ABLE TO PROVIDE THESE SERVICES TO THE HOSPITAL AT A COST BELOW THAT WHICH OSCEOLA COMMUNITY HOSPITAL COULD OTHERWISE ACHIEVE. IN TURN, LOCAL CAREGIVERS ARE ABLE TO DEVOTE MORE RESOURCES TO PATIENT AND RESIDENT CARE. AVERA HEALTH AND OSCEOLA COMMUNITY HOSPITAL DEDICATE RESOURCES TO ENDEAVORS THAT MAKE A POSITIVE DIFFERENCE TO IMPROVE THE HEALTH OF THE COMMUNITIES THEY SERVE. THESE ACTIVITIES INCLUDE LEADERSHIP DEVELOPMENT AND TRAINING FOR COMMUNITY MEMBERS, ECONOMIC DEVELOPMENT, PHYSICAL IMPROVEMENTS IN THE COMMUNITY, CONTRIBUTIONS TO NONPROFIT COMMUNITY ORGANIZATIONS, NONPROFIT EVENT SPONSORSHIPS, DONATED MEDICAL SUPPLIES, COMMUNITY HEALTH EDUCATION AND SUPPORT GROUPS, HEALTH SCREENINGS, FLU-SHOT CLINICS, COMMUNITY HEALTH EDUCATION AND VARIOUS OTHER ACTIVITIES. X X X 0 0 0 0 0 0 0 0 0 BEN DAVIS CEO 160944 0 0 0 0 0 5304 0 25733 0 191981 0 0 0 A CITY OF SIBLEYIA 426005203 2016-02-24 4776000 TO REFINANCE SERIES 2001 AND 2007 BONDS 0 0 0 A 890882 4776000 95520 4680101 1 0 1 1 A 0 0 0 0 0.00000 0.00000 0.00000 0 0 1 A 0 0 1 0 1 0 0 0 1 A 1 FORM 990, PART VI, SECTION A, LINE 1 THE EXECUTIVE COMMITTEE CONSISTS OF THE OFFICERS OF THE ORGANIZATION. THE PRESIDENT SHALL SERVE AS THE CHAIR OF THE COMMITTEE. THE EXECUTIVE COMMITTEE SHALL HAVE POWER TO TRANSACT ALL REGULAR BUSINESS OF THE ORGANIZATION DURING THE INTERIM BETWEEN THE MEETINGS OF THE BOARD OF TRUSTEES, PROVIDED THAT ANY ACTION WHICH IT MAY TAKE SHALL NOT CONFLICT WITH THE POLICIES AND EXPRESSED WISHES OF THE BOARD OF TRUSTEES, AND THAT IT SHALL REFER ALL MATTERS OF MAJOR IMPORTANCE TO THE BOARD OF TRUSTEES. FORM 990, PART VI, SECTION A, LINE 6 REGULAR MEMBERS ARE THOSE PERSONS, CORPORATIONS, ASSOCIATIONS OR PARTNERSHIPS WHO HAVE CONTRIBUTED AND PAID INTO THE CORPORATION A MINIMUM OF $75 OR MORE TO FURTHER THE OBJECTIVES OF THE CORPORATION. MEMBERSHIP SHALL BE LIFELONG AND NONTRANSFERABLE. EACH MEMBER WHOSE NAME IS ENDORSED ON THE MEMBERSHIP CERTIFICATES SHALL BE QUALIFIED TO ORIGINATE AND TAKE PART IN THE DISCUSSION OF ANY SUBJECT THAT MAY PROPERLY COME BEFORE THE ANNUAL MEETING OF THE CORPORATION, TO VOTE ON SUCH SUBJECTS, AND TO HOLD ANY OFFICE TO WHICH THE MEMBER MAY TO ELECTED OR APPOINTED. NO EMPLOYEE OR EMPLOYEE'S SPOUSE OF THE CORPORATION MAY BE ELECTED TO THE BOARD OF TRUSTEES. FORM 990, PART VI, SECTION A, LINE 7A TRUSTEES ARE ELECTED TO THE BOARD OF TRUSTEES FROM THE MEMBERS AT THE ANNUAL MEETING OF THE ORGANIZATION. FORM 990, PART VI, SECTION B, LINE 11B THE FORM 990 WAS REVIEWED IN DETAIL BY MANAGEMENT OF THE HOSPITAL. UPON APPROVAL, THE FORM 990 WAS THEN PRESENTED TO THE BOARD MEMBERS AT A REGULARLY SCHEDULED BOARD MEETING PRIOR TO FILING WITH THE IRS. FORM 990, PART VI, SECTION B, LINE 12C EACH DIRECTOR/TRUSTEE, PRINCIPAL OFFICER, AND MEMBER OF A COMMITTEE WITH BOARD-DELEGATED POWERS SHALL ANNUALLY SIGN A CONFLICT OF INTEREST STATEMENT. IN CONNECTION WITH ANY ACTUAL OR POSSIBLE CONFLICT OF INTEREST, AN INTERESTED PERSON MUST DISCLOSE THE EXISTENCE OF A FINANCIAL INTEREST AND ALL MATERIAL FACTS TO THE DIRECTORS/TRUSTEES AND MEMBERS OF COMMITTEES WITH BOARD DELEGATED POWERS CONSIDERING THE PROPOSED TRANSACTION OR ARRANGEMENT. AFTER THE INTERESTED PERSON LEAVES THE MEETING, THE REMAINING BOARD OR COMMITTEE MEMBERS WILL DISCUSS AND VOTE UPON WHETHER A CONFLICT OF INTEREST EXISTS. ALSO, IF THE BOARD OR COMMITTEE HAS REASONABLE CAUSE TO BELIEVE A DIRECTOR, TRUSTEE, OR MEMBER HAS FAILED TO DISCLOSE ACTUAL OR POSSIBLE CONFLICTS OF INTEREST, IT SHALL INFORM SUCH PERSON OF THE BASIS FOR SUCH BELIEF AND AFFORD THE PERSON AN OPPORTUNITY TO EXPLAIN THE ALLEGED FAILURE TO DISCLOSE. APPROPRIATE DISCIPLINARY AND CORRECTIVE ACTION SHALL BE TAKEN IF NECESSARY. FORM 990, PART VI, SECTION B, LINE 15 A COMPENSATION SPECIALIST FROM AN AFFILIATE ORGANIZATION REVIEWS THE COMPENSATION WITH THE BOARD OF TRUSTEES SEMI-ANNUALLY. THE SPECIALIST REVIEWS MARKET VALUE AND PRESENTS A RECOMMENDATION TO THE BOARD OF TRUSTEES. THE BOARD MAKES THEIR DECISION ON THE INFORMATION PRESENTED. THE COMPENSATION REVIEW PROCESS IS COMPLETED ANNUALLY FOR ALL OFFICERS AND TOP MANAGEMENT. FORM 990, PART VI, SECTION C, LINE 19 THE ORGANIZATION DOES NOT MAKE ITS GOVERNING DOCUMENTS OR CONFLICT OF INTEREST POLICY AVAILABLE TO THE PUBLIC. THE FINANCIAL STATEMENTS ARE MADE AVAILABLE UPON REQUEST AND THE FORM 990 IS AVAILABLE AT THE ANNUAL MEETING AND UPON REQUEST. FORM 990, PART IX, LINE 11G MEDICAL PROF FEE: PROGRAM SERVICE EXPENSES 1,200,733. MANAGEMENT AND GENERAL EXPENSES 0. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 1,200,733. PURCHASE SERVICES: PROGRAM SERVICE EXPENSES 783,514. MANAGEMENT AND GENERAL EXPENSES 664,458. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 1,447,972. FORM 990, PART XI, LINE 9: CHANGE IN INTEREST IN NET ASSETS OF FOUNDATION 12,729. NET ASSETS RELEASED FROM RESTRICTIONS -9,500. OTHER CHANGE IN NET ASSETS AMENDED RETURN THE FY 2021 990 RETURN WAS AMENDED TO ATTACH THE AUDITED FINANCIAL STATEMENT AND REPORT CHANGES TO FORM 990, PARTS VIII, IX, X, AND XI AS A RESULT OF CHANGES MADE TO THE FINANCIAL STATEMENT UPON COMPLETION OF THE AUDIT. THE CHANGES ARE AS FOLLOWS: PART VIII STATEMENT OF REVENUE: LINE 1E CHANGED FROM $4,530,704 TO $4,431,762. LINE 1F CHANGED FROM $97,185 TO $97,184. LINE 1G CHANGED FROM $4,627,889 TO $4,528,946. LINE 2A CHANGED FROM $11,395,900 TO $11,298,572. LINE 2F CHANGED FROM $748,249 TO $584,000. LINE 2G CHANGED FROM $12,597,365 TO $12,335,788. LINE 12 COLUMN A CHANGED FROM $17,550,110 TO $17,189,590. LINE 12 COLUMN B CHANGED FROM $12,597,365 TO $12,335,788. PART IX STATEMENT OF FUNCTIONAL EXPENSES: LINE 11G COLUMN A CHANGED FROM $2,743,985 TO $2,648,705. LINE 11G COLUMN B CHANGED FROM $2,079,527 TO $1,984,247. LINE 13 COLUMN A CHANGED FROM $443,117 TO $437,308. LINE 13 COLUMN B CHANGED FROM $274,686 TO $268,877. LINE 20 COLUMN A & C CHANGED FROM $114,327 TO $ 137,765. LINE 22 COLUMN A CHANGED FROM $851,343 TO $937,520. LINE 22 COLUMN B CHANGED FROM $313,140 TO $399,317. LINE 25 COLUMN A CHANGED FROM $14,532,026 TO $14,540,552. LINE 25 COLUMN B CHANGED FROM $10,849,996 TO $10,835,084. LINE 25 COLUMN C CHANGED FROM $3,647,149 TO $3,670,587. PART X BALANCE SHEET: LINE 1 CHANGED FROM $545,650 TO $545,725. LINE 2 CHANGED FROM $1,261,170 TO $1,261,095. LINE 4 CHANGED FROM $1,556,496 TO $1,556,497. LINE 10A CHANGED FROM $22,866,588 TO $23,460,784. LINE 10B CHANGED FROM $16,890,771 TO $16,964,131. LINE 10C CHANGED FROM $5,975,817 TO $6,496,653. LINE 16 CHANGED FROM $23,664,426 TO 24,185,263. LINE 17 CHANGED FROM $1,090,409 TO $1,058,056. LINE 19 CHANGED FROM $1,770,640 TO $1,837,198. LINE 24 CHANGED FROM $0 TO $516,545. LINE 26 CHANGED FROM $6,675,721 TO $7,226,471. LINE 27 CHANGED FROM $16,846,005 TO $16,790,368. LINE 28 CHANGED FROM $142,700 TO $168,424. LINE 32 CHANGED FROM $16,988,705 TO $16,958,792. LINE 33 CHANGED FROM $23,664,426 TO $24,185,263. PART XI RECONCILIATION OF NET ASSETS: LINE 1 CHANGED FROM $17,550,110 TO $17,189,590. LINE 2 CHANGED FROM $14,532,026 TO $14,540,552. LINE 3 CHANGED FROM $3,018,084 TO $2,649,038. LINE 5 CHANGED FROM $1,013,740 TO $1,393,263. LINE 9 CHANGED FROM $43,619 TO $3,229. LINE 10 CHANGED FROM $16,988,705 TO $16,958,792. SCHEDULE D PART VI: LINE 1D COLUMN B CHANGED FROM $8,043,727 TO $8,637,923. LINE 1D COLUMN C CHANGED FROM $6,665,985 TO $6,739,345. LINE 1D COLUMN D CHANGED FROM $1,377,742 TO $1,898,578. SCHEDULE D PART XI: ADDED LINE 1 OF $18,540,749. ADDED LINE 2A OF $1,393,263. ADDED LINE 4B OF $42,104. SCHEDULE D PART XII: ADDED LINE 1 OF $14,540,552. HEARTWOOD HEIGHTS 409 9TH AVE NORTH SIBLEY IA 51249 421495686 INDEPENDENT;ASSISTED LIVING IA 501(C)(3) PF OSCEOLA COMMUNITY HOSPITAL 1 0 0 0 0 0 0 0 0 0 0 0 1 0 0 1 0 1 0 0 HEARTWOOD HEIGHTS O 336131 ACTUAL COST