NIOBRARA VALLEY HOSPITAL CORPORATION: Form 990, tax year 2021
View the entire original 990 at ProPublica ↗
- Organization
- NIOBRARA VALLEY HOSPITAL CORPORATION (EIN 47-0537192)
- Tax period
- 2021-09-01 to 2022-08-31
- Filed
- 2023-07-12
- IRS object ID
- 202311939349300921
- Schema version
- 2021v4.2
- Source
- Download XML · Original 990 at ProPublica
Every field in the e-filed return. Faint text is the IRS element name, for citing.
Return header ReturnHeader
| Field | Value | IRS element (for citing) |
|---|---|---|
| Return | 2023-07-12T09:39:56-05:00 | ReturnTs |
| Tax Period End | 2022-08-31 | TaxPeriodEndDt |
Preparer Firm PreparerFirmGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Preparer Firm EIN | 450250958 | PreparerFirmEIN |
Preparer Firm Name PreparerFirmName
| Field | Value | IRS element (for citing) |
|---|---|---|
| Business Name Line1 | EIDE BAILLY LLP | BusinessNameLine1Txt |
Preparer US Address PreparerUSAddress
| Field | Value | IRS element (for citing) |
|---|---|---|
| Address Line1 | 18081 BURT ST STE 200 | AddressLine1Txt |
| City | OMAHA | CityNm |
| State Abbreviation | NE | StateAbbreviationCd |
| ZIP | 680224722 | ZIPCd |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Return Type | 990 | ReturnTypeCd |
| Tax Period Begin | 2021-09-01 | TaxPeriodBeginDt |
Filer Filer
| Field | Value | IRS element (for citing) |
|---|---|---|
| EIN | 470537192 | EIN |
Business Name BusinessName
| Field | Value | IRS element (for citing) |
|---|---|---|
| Business Name Line1 | NIOBRARA VALLEY HOSPITAL | BusinessNameLine1Txt |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Business Name Control | NIOB | BusinessNameControlTxt |
| Phone | 4025692451 | PhoneNum |
US Address USAddress
| Field | Value | IRS element (for citing) |
|---|---|---|
| Address Line1 | PO BOX 118 | AddressLine1Txt |
| City | LYNCH | CityNm |
| State Abbreviation | NE | StateAbbreviationCd |
| ZIP | 68746 | ZIPCd |
Business Officer BusinessOfficerGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Person | KELLY KALKOWSKI | PersonNm |
| Person Title | ADMINISTRATOR | PersonTitleTxt |
| Phone | 4025692451 | PhoneNum |
| Signature | 2023-07-10 | SignatureDt |
| Discuss With Paid Preparer | Yes (1) | DiscussWithPaidPreparerInd |
Signing Officer SigningOfficerGrp
Person Full Name PersonFullName
| Field | Value | IRS element (for citing) |
|---|---|---|
| Person First | KELLY | PersonFirstNm |
| Person Last | KALKOWSKI | PersonLastNm |
| Field | Value | IRS element (for citing) |
|---|---|---|
| SSN | 999009999 | SSN |
Preparer Person PreparerPersonGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Preparer Person | MEGAN L KOZIOL CPA | PreparerPersonNm |
| PTIN | P01544037 | PTIN |
| Phone | 4023302660 | PhoneNum |
| Preparation | 2023-06-29 | PreparationDt |
Additional Filer Information AdditionalFilerInformation
Trusted Customer TrustedCustomerGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Trusted Customer | 3 | TrustedCustomerCd |
| Authentication Assurance Level | AAL1 | AuthenticationAssuranceLevelCd |
| Identity Assurance Level | IAL1 | IdentityAssuranceLevelCd |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Tax | 2021 | TaxYr |
| Build TS | 2023-04-26 12:10:37Z | BuildTS |
Form 990 IRS990
| Field | Value | IRS element (for citing) |
|---|---|---|
| Principal Officer | KELLY KALKOWSKI | PrincipalOfficerNm |
US Address USAddress
| Field | Value | IRS element (for citing) |
|---|---|---|
| Address Line1 | PO BOX 118 | AddressLine1Txt |
| City | LYNCH | CityNm |
| State Abbreviation | NE | StateAbbreviationCd |
| ZIP | 68746 | ZIPCd |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Gross Receipts | $3,540,126 | GrossReceiptsAmt |
| Group Return For Affiliates | 0 | GroupReturnForAffiliatesInd |
| Organization501c3 | Yes (X) | Organization501c3Ind |
| Website Address | WWW.NVHCARES.ORG | WebsiteAddressTxt |
| Type Of Organization Corp | Yes (X) | TypeOfOrganizationCorpInd |
| Formation | 1975 | FormationYr |
| Legal Domicile State | NE | LegalDomicileStateCd |
| Activity Or Mission | TO PROVIDE ACUTE HOSPITAL SERVICES. | ActivityOrMissionDesc |
| Voting Members Governing Body | 7 | VotingMembersGoverningBodyCnt |
| Voting Members Independent | 7 | VotingMembersIndependentCnt |
| Total Employee | 39 | TotalEmployeeCnt |
| Total Volunteers | 9 | TotalVolunteersCnt |
| Total Gross UBI | $0 | TotalGrossUBIAmt |
| Net Unrelated Bus Txbl Incm | $0 | NetUnrelatedBusTxblIncmAmt |
| PY Contributions Grants | $1,637,445 | PYContributionsGrantsAmt |
| CY Contributions Grants | $352,975 | CYContributionsGrantsAmt |
| PY Program Service Revenue | $2,871,920 | PYProgramServiceRevenueAmt |
| CY Program Service Revenue | $3,162,046 | CYProgramServiceRevenueAmt |
| PY Investment Income | $109,275 | PYInvestmentIncomeAmt |
| CY Investment Income | $15,105 | CYInvestmentIncomeAmt |
| PY Other Revenue | $11,000 | PYOtherRevenueAmt |
| CY Other Revenue | $10,000 | CYOtherRevenueAmt |
| PY Total Revenue | $4,629,640 | PYTotalRevenueAmt |
| CY Total Revenue | $3,540,126 | CYTotalRevenueAmt |
| PY Grants And Similar Paid | $1,040 | PYGrantsAndSimilarPaidAmt |
| CY Grants And Similar Paid | $985 | CYGrantsAndSimilarPaidAmt |
| PY Benefits Paid To Members | $0 | PYBenefitsPaidToMembersAmt |
| CY Benefits Paid To Members | $0 | CYBenefitsPaidToMembersAmt |
| PY Salaries Comp Emp Bnft Paid | $1,511,228 | PYSalariesCompEmpBnftPaidAmt |
| CY Salaries Comp Emp Bnft Paid | $1,516,751 | CYSalariesCompEmpBnftPaidAmt |
| PY Total Prof Fndrsng Expns | $0 | PYTotalProfFndrsngExpnsAmt |
| CY Total Prof Fndrsng Expns | $0 | CYTotalProfFndrsngExpnsAmt |
| CY Total Fundraising Expense | $0 | CYTotalFundraisingExpenseAmt |
| PY Other Expenses | $1,455,193 | PYOtherExpensesAmt |
| CY Other Expenses | $1,639,037 | CYOtherExpensesAmt |
| PY Total Expenses | $2,967,461 | PYTotalExpensesAmt |
| CY Total Expenses | $3,156,773 | CYTotalExpensesAmt |
| PY Revenues Less Expenses | $1,662,179 | PYRevenuesLessExpensesAmt |
| CY Revenues Less Expenses | $383,353 | CYRevenuesLessExpensesAmt |
| Total Assets BOY | $6,478,410 | TotalAssetsBOYAmt |
| Total Assets EOY | $5,150,725 | TotalAssetsEOYAmt |
| Total Liabilities BOY | $2,288,361 | TotalLiabilitiesBOYAmt |
| Total Liabilities EOY | $569,992 | TotalLiabilitiesEOYAmt |
| Net Assets Or Fund Balances BOY | $4,190,049 | NetAssetsOrFundBalancesBOYAmt |
| Net Assets Or Fund Balances EOY | $4,580,733 | NetAssetsOrFundBalancesEOYAmt |
| Info In Schedule O Part III | Yes (X) | InfoInScheduleOPartIIIInd |
| Mission | TO DELIVER EXCELLENT, COMPASSIONATE AND PERSONALIZED HEALTHCARE FOR THE PEOPLE WE SERVE. | MissionDesc |
| Significant New Program Srvc | 0 | SignificantNewProgramSrvcInd |
| Significant Change | 0 | SignificantChangeInd |
| Expense | $2,529,918 | ExpenseAmt |
| Grant | $985 | GrantAmt |
| Revenue | $3,172,046 | RevenueAmt |
| Desc | 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, OUR MISSION IS 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 67 INPATIENT DAYS, 56 SWING AND RESPITE CARE DAYS AND 260 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. | Desc |
| Total Program Service Expenses | $2,529,918 | TotalProgramServiceExpensesAmt |
| Described In Section501c3 | Yes (1) | DescribedInSection501c3Ind |
| Schedule B Required | 0 | ScheduleBRequiredInd |
| Political Campaign Acty | 0 | PoliticalCampaignActyInd |
| Lobbying Activities | Yes (1) | LobbyingActivitiesInd |
| Subject To Proxy Tax | 0 | SubjectToProxyTaxInd |
| Donor Advised Fund | 0 | DonorAdvisedFundInd |
| Conservation Easements | 0 | ConservationEasementsInd |
| Collections Of Art | 0 | CollectionsOfArtInd |
| Credit Counseling | 0 | CreditCounselingInd |
| Donor Rstr Or Quasi Endowments | 0 | DonorRstrOrQuasiEndowmentsInd |
| Report Land Building Equipment | Yes (1) | ReportLandBuildingEquipmentInd |
| Report Investments Other Sec | 0 | ReportInvestmentsOtherSecInd |
| Report Program Related Invst | 0 | ReportProgramRelatedInvstInd |
| Report Other Assets | Yes (1) | ReportOtherAssetsInd |
| Report Other Liabilities | Yes (1) | ReportOtherLiabilitiesInd |
| Include FIN48 Footnote | Yes (1) | IncludeFIN48FootnoteInd |
| Independent Audit Fincl Stmt | Yes (1) | IndependentAuditFinclStmtInd |
| Consolidated Audit Fincl Stmt | 0 | ConsolidatedAuditFinclStmtInd |
| School Operating | 0 | SchoolOperatingInd |
| Foreign Office | 0 | ForeignOfficeInd |
| Foreign Activities | 0 | ForeignActivitiesInd |
| More Than5000 K To Org | 0 | MoreThan5000KToOrgInd |
| More Than5000 K To Individuals | 0 | MoreThan5000KToIndividualsInd |
| Professional Fundraising | 0 | ProfessionalFundraisingInd |
| Fundraising Activities | 0 | FundraisingActivitiesInd |
| Gaming Activities | 0 | GamingActivitiesInd |
| Operate Hospital | Yes (1) | OperateHospitalInd |
| Audited Financial Stmt Att | Yes (1) | AuditedFinancialStmtAttInd |
| Grants To Organizations | 0 | GrantsToOrganizationsInd |
| Grants To Individuals | 0 | GrantsToIndividualsInd |
| Schedule J Required | Yes (1) | ScheduleJRequiredInd |
| Tax Exempt Bonds | 0 | TaxExemptBondsInd |
| Engaged In Excess Benefit Trans | 0 | EngagedInExcessBenefitTransInd |
| PY Excess Benefit Trans | 0 | PYExcessBenefitTransInd |
| Loan Outstanding | 0 | LoanOutstandingInd |
| Grant To Related Person | 0 | GrantToRelatedPersonInd |
| Business Rln With Org Mem | 0 | BusinessRlnWithOrgMemInd |
| Business Rln With Fam Mem | 0 | BusinessRlnWithFamMemInd |
| Business Rln With35 Ctrl Ent | 0 | BusinessRlnWith35CtrlEntInd |
| Deductible Non Cash Contri | 0 | DeductibleNonCashContriInd |
| Deductible Art Contribution | 0 | DeductibleArtContributionInd |
| Terminate Operations | 0 | TerminateOperationsInd |
| Partial Liquidation | 0 | PartialLiquidationInd |
| Disregarded Entity | 0 | DisregardedEntityInd |
| Related Entity | 0 | RelatedEntityInd |
| Related Organization Ctrl Ent | 0 | RelatedOrganizationCtrlEntInd |
| Trnsfr Exmpt Non Chrtbl Rltd Org | 0 | TrnsfrExmptNonChrtblRltdOrgInd |
| Activities Conducted Prtshp | 0 | ActivitiesConductedPrtshpInd |
| Schedule O Required | Yes (1) | ScheduleORequiredInd |
| IRP Document | 24 | IRPDocumentCnt |
| IRP Document W2 G | 0 | IRPDocumentW2GCnt |
| Backup Wthld Compliance | Yes (1) | BackupWthldComplianceInd |
| Employee | 39 | EmployeeCnt |
| Employment Tax Returns Filed | Yes (1) | EmploymentTaxReturnsFiledInd |
| Unrelated Bus Incm Over Limit | 0 | UnrelatedBusIncmOverLimitInd |
| Foreign Financial Account | 0 | ForeignFinancialAccountInd |
| Prohibited Tax Shelter Trans | 0 | ProhibitedTaxShelterTransInd |
| Taxable Party Notification | 0 | TaxablePartyNotificationInd |
| Nondeductible Contributions | 0 | NondeductibleContributionsInd |
| Quid Pro Quo Contributions | 0 | QuidProQuoContributionsInd |
| Form8282 Property Disposed Of | 0 | Form8282PropertyDisposedOfInd |
| Rcv Fnds To Pay Prsnl Bnft Cntrct | 0 | RcvFndsToPayPrsnlBnftCntrctInd |
| Pay Premiums Prsnl Bnft Cntrct | 0 | PayPremiumsPrsnlBnftCntrctInd |
| Indoor Tanning Services | 0 | IndoorTanningServicesInd |
| Subj To Tax Rmnrtn Ex Prcht Pymt | 0 | SubjToTaxRmnrtnExPrchtPymtInd |
| Subject To Excs Tax Net Invst Inc | 0 | SubjectToExcsTaxNetInvstIncInd |
| Info In Schedule O Part VI | Yes (X) | InfoInScheduleOPartVIInd |
| Governing Body Voting Members | 7 | GoverningBodyVotingMembersCnt |
| Independent Voting Member | 7 | IndependentVotingMemberCnt |
| Family Or Business Rln | 0 | FamilyOrBusinessRlnInd |
| Delegation Of Mgmt Duties | Yes (1) | DelegationOfMgmtDutiesInd |
| Change To Org Documents | 0 | ChangeToOrgDocumentsInd |
| Material Diversion Or Misuse | 0 | MaterialDiversionOrMisuseInd |
| Members Or Stockholders | 0 | MembersOrStockholdersInd |
| Election Of Board Members | 0 | ElectionOfBoardMembersInd |
| Decisions Subject To Approva | 0 | DecisionsSubjectToApprovaInd |
| Minutes Of Governing Body | Yes (1) | MinutesOfGoverningBodyInd |
| Minutes Of Committees | Yes (1) | MinutesOfCommitteesInd |
| Officer Mailing Address | 0 | OfficerMailingAddressInd |
| Local Chapters | 0 | LocalChaptersInd |
| Form990 Provided To Gvrn Body | Yes (1) | Form990ProvidedToGvrnBodyInd |
| Conflict Of Interest Policy | Yes (1) | ConflictOfInterestPolicyInd |
| Annual Disclosure Covered Prsn | Yes (1) | AnnualDisclosureCoveredPrsnInd |
| Regular Monitoring Enfrc | Yes (1) | RegularMonitoringEnfrcInd |
| Whistleblower Policy | Yes (1) | WhistleblowerPolicyInd |
| Document Retention Policy | Yes (1) | DocumentRetentionPolicyInd |
| Compensation Process CEO | Yes (1) | CompensationProcessCEOInd |
| Compensation Process Other | 0 | CompensationProcessOtherInd |
| Investment In Joint Venture | 0 | InvestmentInJointVentureInd |
| Upon Request | Yes (X) | UponRequestInd |
Books In Care Of Detail BooksInCareOfDetail
| Field | Value | IRS element (for citing) |
|---|---|---|
| Person | MARTHA NELSON | PersonNm |
| Phone | 4025692451 | PhoneNum |
US Address USAddress
| Field | Value | IRS element (for citing) |
|---|---|---|
| Address Line1 | PO BOX 118 | AddressLine1Txt |
| City | LYNCH | CityNm |
| State Abbreviation | NE | StateAbbreviationCd |
| ZIP | 68746 | ZIPCd |
Form990 Part VII Section A Form990PartVIISectionAGrp (14 entries)
| TitleTitleTxt | Average Hours Per WeekAverageHoursPerWeekRt | Highest Compensated EmployeeHighestCompensatedEmployeeInd | Reportable Comp From OrgReportableCompFromOrgAmt | Reportable Comp From Rltd OrgReportableCompFromRltdOrgAmt | Other CompensationOtherCompensationAmt | OfficerOfficerInd | Individual Trustee Or DirectorIndividualTrusteeOrDirectorInd |
|---|---|---|---|---|---|---|---|
| BREE ALMGREN | |||||||
| NURSE PRACTIONER | 36.00 | Yes (X) | $147,477 | $0 | $6,997 | ||
| KELLI SMITH | |||||||
| NURSE PRACTIONER | 36.00 | Yes (X) | $134,974 | $0 | $1,460 | ||
| DEBRA HANZLIK | |||||||
| DIRECTOR OF NURSING | 40.00 | Yes (X) | $121,181 | $0 | $3,070 | ||
| MARTHA NELSON | |||||||
| CFO | 5.00 | $18,555 | $0 | $0 | Yes (X) | ||
| TRACY BIRMEIER | |||||||
| PRESIDENT | 0.30 | $0 | $0 | $0 | Yes (X) | Yes (X) | |
| MARY SCHOENEFELD | |||||||
| PRESIDENT THRU 11/21 | 0.30 | $0 | $0 | $0 | Yes (X) | Yes (X) | |
| LINDA SEXTRO | |||||||
| VICE PRESIDENT | 0.30 | $0 | $0 | $0 | Yes (X) | Yes (X) | |
| LARRY HIATT | |||||||
| SECRETARY | 0.30 | $0 | $0 | $0 | Yes (X) | Yes (X) | |
| CRAIG BREWSTER | |||||||
| TREASURER | 0.30 | $0 | $0 | $0 | Yes (X) | Yes (X) | |
| STEVE LIEWER | |||||||
| TREASURER THRU 11/21 | 0.30 | $0 | $0 | $0 | Yes (X) | Yes (X) | |
| CHRIS MINARIK | |||||||
| MEMBER | 0.30 | $0 | $0 | $0 | Yes (X) | ||
| BRAD JERMAN | |||||||
| MEMBER | 0.30 | $0 | $0 | $0 | Yes (X) | ||
| LAREE PRITCHETT | |||||||
| MEMBER | 0.30 | $0 | $0 | $0 | Yes (X) | ||
| KELLY KALKOWSKI | |||||||
| ADMINISTRATOR | 40.00 | $0 | $0 | $0 | Yes (X) | ||
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Reportable Comp From Org | $422,187 | TotalReportableCompFromOrgAmt |
| Tot Reportable Comp Rltd Org | $0 | TotReportableCompRltdOrgAmt |
| Total Other Compensation | $11,527 | TotalOtherCompensationAmt |
| Indiv Rcvd Greater Than100 K | 3 | IndivRcvdGreaterThan100KCnt |
| Former Ofcr Employees Listed | 0 | FormerOfcrEmployeesListedInd |
| Total Comp Greater Than150 K | Yes (1) | TotalCompGreaterThan150KInd |
| Compensation From Other Srcs | Yes (1) | CompensationFromOtherSrcsInd |
Contractor Compensation ContractorCompensationGrp
Contractor Name ContractorName
Business Name BusinessName
| Field | Value | IRS element (for citing) |
|---|---|---|
| Business Name Line1 | FAITH REGIONAL HEALTH SERVICES | BusinessNameLine1Txt |
Contractor Address ContractorAddress
US Address USAddress
| Field | Value | IRS element (for citing) |
|---|---|---|
| Address Line1 | 1500 KOENIGSTEIN AVENUE PO BOX 869 | AddressLine1Txt |
| City | NORFOLK | CityNm |
| State Abbreviation | NE | StateAbbreviationCd |
| ZIP | 687020869 | ZIPCd |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Services | MANAGEMENT SERVICES | ServicesDesc |
| Compensation | $111,156 | CompensationAmt |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Cntrct Rcvd Greater Than100 K | 1 | CntrctRcvdGreaterThan100KCnt |
| Government Grants | $341,801 | GovernmentGrantsAmt |
| All Other Contributions | $11,174 | AllOtherContributionsAmt |
| Total Contributions | $352,975 | TotalContributionsAmt |
Program Service Revenue ProgramServiceRevenueGrp (4 entries)
| DescDesc | BusinessBusinessCd | Total Revenue ColumnTotalRevenueColumnAmt | Related Or Exempt Func IncomeRelatedOrExemptFuncIncomeAmt |
|---|---|---|---|
| MEDICARE/MEDICAID PAYM | 624100 | $2,266,952 | $2,266,952 |
| PATIENT SERVICE REVENU | 624100 | $880,349 | $880,349 |
| OTHER REVENUE | 624100 | $13,722 | $13,722 |
| LIFELINE REVENUE | 624100 | $1,023 | $1,023 |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Program Service Revenue | $3,162,046 | TotalProgramServiceRevenueAmt |
Investment Income InvestmentIncomeGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Revenue Column | $13,905 | TotalRevenueColumnAmt |
| Exclusion | $13,905 | ExclusionAmt |
Gross Rents GrossRentsGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Real | $10,000 | RealAmt |
Less Rental Expenses LessRentalExpensesGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Real | $0 | RealAmt |
Rental Income Or Loss RentalIncomeOrLossGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Real | $10,000 | RealAmt |
Net Rental Income Or Loss NetRentalIncomeOrLossGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Revenue Column | $10,000 | TotalRevenueColumnAmt |
| Related Or Exempt Func Income | $10,000 | RelatedOrExemptFuncIncomeAmt |
Gross Amount Sales Assets GrossAmountSalesAssetsGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Other | $1,200 | OtherAmt |
Less Cost Oth Basis Sales Expnss LessCostOthBasisSalesExpnssGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Other | $0 | OtherAmt |
Gain Or Loss GainOrLossGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Other | $1,200 | OtherAmt |
Net Gain Or Loss Investments NetGainOrLossInvestmentsGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Revenue Column | $1,200 | TotalRevenueColumnAmt |
| Exclusion | $1,200 | ExclusionAmt |
Total Revenue TotalRevenueGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Revenue Column | $3,540,126 | TotalRevenueColumnAmt |
| Related Or Exempt Func Income | $3,172,046 | RelatedOrExemptFuncIncomeAmt |
| Unrelated Business Revenue | $0 | UnrelatedBusinessRevenueAmt |
| Exclusion | $15,105 | ExclusionAmt |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Info In Schedule O Part IX | Yes (X) | InfoInScheduleOPartIXInd |
Grants To Domestic Orgs GrantsToDomesticOrgsGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $985 | TotalAmt |
| Program Services | $985 | ProgramServicesAmt |
Comp Current Ofcr Directors CompCurrentOfcrDirectorsGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $18,555 | TotalAmt |
| Management And General | $18,555 | ManagementAndGeneralAmt |
Other Salaries And Wages OtherSalariesAndWagesGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $1,338,862 | TotalAmt |
| Program Services | $1,202,712 | ProgramServicesAmt |
| Management And General | $136,150 | ManagementAndGeneralAmt |
Pension Plan Contributions PensionPlanContributionsGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $9,332 | TotalAmt |
| Program Services | $8,323 | ProgramServicesAmt |
| Management And General | $1,009 | ManagementAndGeneralAmt |
Other Employee Benefits OtherEmployeeBenefitsGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $45,058 | TotalAmt |
| Program Services | $30,895 | ProgramServicesAmt |
| Management And General | $14,163 | ManagementAndGeneralAmt |
Payroll Taxes PayrollTaxesGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $104,944 | TotalAmt |
| Program Services | $92,320 | ProgramServicesAmt |
| Management And General | $12,624 | ManagementAndGeneralAmt |
Fees For Services Management FeesForServicesManagementGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $111,156 | TotalAmt |
| Management And General | $111,156 | ManagementAndGeneralAmt |
Fees For Services Legal FeesForServicesLegalGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $1,128 | TotalAmt |
| Management And General | $1,128 | ManagementAndGeneralAmt |
Fees For Services Accounting FeesForServicesAccountingGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $45,552 | TotalAmt |
| Management And General | $45,552 | ManagementAndGeneralAmt |
Fees For Services Other FeesForServicesOtherGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $550,038 | TotalAmt |
| Program Services | $479,538 | ProgramServicesAmt |
| Management And General | $70,500 | ManagementAndGeneralAmt |
Advertising AdvertisingGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $3,561 | TotalAmt |
| Program Services | $250 | ProgramServicesAmt |
| Management And General | $3,311 | ManagementAndGeneralAmt |
Office Expenses OfficeExpensesGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $253,501 | TotalAmt |
| Program Services | $97,194 | ProgramServicesAmt |
| Management And General | $156,307 | ManagementAndGeneralAmt |
Occupancy OccupancyGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $107,183 | TotalAmt |
| Program Services | $97,450 | ProgramServicesAmt |
| Management And General | $9,733 | ManagementAndGeneralAmt |
Travel TravelGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $11,243 | TotalAmt |
| Program Services | $9,996 | ProgramServicesAmt |
| Management And General | $1,247 | ManagementAndGeneralAmt |
Depreciation Depletion DepreciationDepletionGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $192,012 | TotalAmt |
| Program Services | $173,657 | ProgramServicesAmt |
| Management And General | $18,355 | ManagementAndGeneralAmt |
Insurance InsuranceGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $44,095 | TotalAmt |
| Program Services | $39,867 | ProgramServicesAmt |
| Management And General | $4,228 | ManagementAndGeneralAmt |
Other Expenses OtherExpensesGrp (4 entries)
| DescDesc | TotalTotalAmt | Program ServicesProgramServicesAmt | Management And GeneralManagementAndGeneralAmt |
|---|---|---|---|
| MEDICAL SUPPLIES | $216,998 | $216,998 | |
| BAD DEBT | $59,000 | $59,000 | |
| MISCELLANEOUS | $26,676 | $16,238 | $10,438 |
| DUES & SUBSCRIPTIONS | $16,894 | $4,495 | $12,399 |
Total Functional Expenses TotalFunctionalExpensesGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $3,156,773 | TotalAmt |
| Program Services | $2,529,918 | ProgramServicesAmt |
| Management And General | $626,855 | ManagementAndGeneralAmt |
| Fundraising | $0 | FundraisingAmt |
Cash Non Interest Bearing CashNonInterestBearingGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $250 | BOYAmt |
| EOY | $250 | EOYAmt |
Savings And Temp Cash Invst SavingsAndTempCashInvstGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $3,874,394 | BOYAmt |
| EOY | $2,936,119 | EOYAmt |
Accounts Receivable AccountsReceivableGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $506,063 | BOYAmt |
| EOY | $277,527 | EOYAmt |
Inventories For Sale Or Use InventoriesForSaleOrUseGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $59,494 | BOYAmt |
| EOY | $54,935 | EOYAmt |
Prepaid Expenses Defrd Charges PrepaidExpensesDefrdChargesGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $12,027 | BOYAmt |
| EOY | $6,279 | EOYAmt |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Land Bldg Equip Cost Or Other Bss | $4,325,269 | LandBldgEquipCostOrOtherBssAmt |
| Land Bldg Equip Accum Deprec | $2,862,891 | LandBldgEquipAccumDeprecAmt |
Land Bldg Equip Basis Net LandBldgEquipBasisNetGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $1,620,276 | BOYAmt |
| EOY | $1,462,378 | EOYAmt |
Other Assets Total OtherAssetsTotalGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $405,906 | BOYAmt |
| EOY | $413,237 | EOYAmt |
Total Assets TotalAssetsGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $6,478,410 | BOYAmt |
| EOY | $5,150,725 | EOYAmt |
Accounts Payable Accr Expnss AccountsPayableAccrExpnssGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $459,070 | BOYAmt |
| EOY | $267,071 | EOYAmt |
Other Liabilities OtherLiabilitiesGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $1,829,291 | BOYAmt |
| EOY | $302,921 | EOYAmt |
Total Liabilities TotalLiabilitiesGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $2,288,361 | BOYAmt |
| EOY | $569,992 | EOYAmt |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Organization Follows FASB117 | Yes (X) | OrganizationFollowsFASB117Ind |
No Donor Restriction Net Assets NoDonorRestrictionNetAssetsGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $4,186,105 | BOYAmt |
| EOY | $4,576,789 | EOYAmt |
Donor Restriction Net Assets DonorRestrictionNetAssetsGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $3,944 | BOYAmt |
| EOY | $3,944 | EOYAmt |
Total Net Assets Fund Balance TotalNetAssetsFundBalanceGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $4,190,049 | BOYAmt |
| EOY | $4,580,733 | EOYAmt |
Tot Liab Net Assets Fund Balance TotLiabNetAssetsFundBalanceGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $6,478,410 | BOYAmt |
| EOY | $5,150,725 | EOYAmt |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Info In Schedule O Part XI | Yes (X) | InfoInScheduleOPartXIInd |
| Reconcilation Revenue Expnss | $383,353 | ReconcilationRevenueExpnssAmt |
| Other Changes In Net Assets | $7,331 | OtherChangesInNetAssetsAmt |
| Info In Schedule O Part XII | Yes (X) | InfoInScheduleOPartXIIInd |
| Method Of Accounting Accrual | Yes (X) | MethodOfAccountingAccrualInd |
| Accountant Compile Or Review | 0 | AccountantCompileOrReviewInd |
| FS Audited | Yes (1) | FSAuditedInd |
FS Audited Basis FSAuditedBasisGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Separate Basis Fincl Stmt | Yes (X) | SeparateBasisFinclStmtInd |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Audit Committee | Yes (1) | AuditCommitteeInd |
| Federal Grant Audit Required | 0 | FederalGrantAuditRequiredInd |
Schedule A IRS990ScheduleA
| Field | Value | IRS element (for citing) |
|---|---|---|
| Hospital | Yes (X) | HospitalInd |
Schedule C IRS990ScheduleC
| Field | Value | IRS element (for citing) |
|---|---|---|
| Volunteers | 0 | VolunteersInd |
| Paid Staff Or Management | 0 | PaidStaffOrManagementInd |
| Media Advertisements | 0 | MediaAdvertisementsInd |
| Mailings Members | 0 | MailingsMembersInd |
| Publications Or Broadcast | 0 | PublicationsOrBroadcastInd |
| Grants Other Organizations | 0 | GrantsOtherOrganizationsInd |
| Direct Contact Legislators | 0 | DirectContactLegislatorsInd |
| Rallies Demonstrations | 0 | RalliesDemonstrationsInd |
| Other Activities | Yes (1) | OtherActivitiesInd |
| Other Activities | $540 | OtherActivitiesAmt |
| Total Lobbying Expenditures | $540 | TotalLobbyingExpendituresAmt |
| Not Described Section501c3 | 0 | NotDescribedSection501c3Ind |
Supplemental Information Detail SupplementalInformationDetail
| Field | Value | IRS element (for citing) |
|---|---|---|
| Form And Line Reference | PART II-B, LINE 1: | FormAndLineReferenceDesc |
| Explanation | NIOBRARA VALLEY HOSPITAL PAYS MEMBERSHIP DUES TO THE NEBRASKA HOSPITAL ASSOCIATION. THE PORTION OF THE DUES PAID THAT ARE USED FOR LOBBYING PURPOSES IS $540. | ExplanationTxt |
Schedule D IRS990ScheduleD
Buildings BuildingsGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Other Cost Or Other Basis | $2,193,395 | OtherCostOrOtherBasisAmt |
| Depreciation | $1,141,741 | DepreciationAmt |
| Book Value | $1,051,654 | BookValueAmt |
Equipment EquipmentGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Other Cost Or Other Basis | $2,125,469 | OtherCostOrOtherBasisAmt |
| Depreciation | $1,714,745 | DepreciationAmt |
| Book Value | $410,724 | BookValueAmt |
Other Land Buildings OtherLandBuildingsGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Other Cost Or Other Basis | $6,405 | OtherCostOrOtherBasisAmt |
| Depreciation | $6,405 | DepreciationAmt |
| Book Value | $0 | BookValueAmt |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Book Value Land Buildings | $1,462,378 | TotalBookValueLandBuildingsAmt |
Other Assets Org OtherAssetsOrgGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Desc | INTEREST IN NIOBRARA VALLEY HOSPITAL FOUNDATION | Desc |
| Book Value | $413,237 | BookValueAmt |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Book Value Other Assets | $413,237 | TotalBookValueOtherAssetsAmt |
Other Liabilities Org OtherLiabilitiesOrgGrp (2 entries)
| DescDesc | AmtAmt |
|---|---|
| REFUNDABLE ADVANCE | $165,732 |
| ESTIMATED THIRD-PARTY PAYOR SETTLEMENTS | $137,189 |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Liability | $302,921 | TotalLiabilityAmt |
| Footnote Text | Yes (X) | FootnoteTextInd |
| Total Rev Etc Audited Fincl Stmt | $3,488,457 | TotalRevEtcAuditedFinclStmtAmt |
| Other Revenue | $7,331 | OtherRevenueAmt |
| Revenue Not Reported | $7,331 | RevenueNotReportedAmt |
| Revenue Subtotal | $3,481,126 | RevenueSubtotalAmt |
| Other Revenues Not Included | $59,000 | OtherRevenuesNotIncludedAmt |
| Revenue Not Reported Fincl Stmt | $59,000 | RevenueNotReportedFinclStmtAmt |
| Total Revenue Per Form990 | $3,540,126 | TotalRevenuePerForm990Amt |
| Tot Expns Etc Audited Fincl Stmt | $3,097,773 | TotExpnsEtcAuditedFinclStmtAmt |
| Expenses Not Reported | $0 | ExpensesNotReportedAmt |
| Expenses Subtotal | $3,097,773 | ExpensesSubtotalAmt |
| Other Expenses Not Included | $59,000 | OtherExpensesNotIncludedAmt |
| Expenses Not Rpt Fincl Stmt | $59,000 | ExpensesNotRptFinclStmtAmt |
| Total Expenses Per Form990 | $3,156,773 | TotalExpensesPerForm990Amt |
Supplemental Information Detail SupplementalInformationDetail (4 entries)
| Form And Line ReferenceFormAndLineReferenceDesc | ExplanationExplanationTxt |
|---|---|
| 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, 2022 AND 2021, THE HOSPITAL HAD NO UNCERTAIN TAX POSITIONS ACCRUED. |
| PART XI, LINE 2D - OTHER ADJUSTMENTS: | CHANGE IN INTEREST IN NIOBRARA VALLEY HOSPITAL FOUNDATION 7,331. |
| PART XI, LINE 4B - OTHER ADJUSTMENTS: | PROVISION FOR UNCOLLECTIBLE ACCOUNTS 59,000. |
| PART XII, LINE 4B - OTHER ADJUSTMENTS: | PROVISION FOR UNCOLLECTIBLE ACCOUNTS 59,000. |
Schedule H IRS990ScheduleH
| Field | Value | IRS element (for citing) |
|---|---|---|
| Financial Assistance Policy | Yes (1) | FinancialAssistancePolicyInd |
| Written Policy | Yes (1) | WrittenPolicyInd |
| All Hospitals Policy | Yes (X) | AllHospitalsPolicyInd |
| FPG Reference Free Care | Yes (1) | FPGReferenceFreeCareInd |
| Percent100 | Yes (X) | Percent100Ind |
| FPG Reference Discounted Care | 0 | FPGReferenceDiscountedCareInd |
| Free Care Medically Indigent | 0 | FreeCareMedicallyIndigentInd |
| Financial Assistance Budget | 0 | FinancialAssistanceBudgetInd |
| Annual Community Bnft Report | Yes (1) | AnnualCommunityBnftReportInd |
| Report Publically Available | Yes (1) | ReportPublicallyAvailableInd |
Unreimbursed Medicaid UnreimbursedMedicaidGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Community Benefit Expns | $252,264 | TotalCommunityBenefitExpnsAmt |
| Direct Offsetting Revenue | $235,174 | DirectOffsettingRevenueAmt |
| Net Community Benefit Expns | $17,090 | NetCommunityBenefitExpnsAmt |
| Total Expense | 0.00550 | TotalExpensePct |
Total Financial Assistance Typ TotalFinancialAssistanceTyp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Community Benefit Expns | $252,264 | TotalCommunityBenefitExpnsAmt |
| Direct Offsetting Revenue | $235,174 | DirectOffsettingRevenueAmt |
| Net Community Benefit Expns | $17,090 | NetCommunityBenefitExpnsAmt |
| Total Expense | 0.00550 | TotalExpensePct |
Community Health Services CommunityHealthServicesGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Community Benefit Expns | $4,710 | TotalCommunityBenefitExpnsAmt |
| Direct Offsetting Revenue | $1,320 | DirectOffsettingRevenueAmt |
| Net Community Benefit Expns | $3,390 | NetCommunityBenefitExpnsAmt |
| Total Expense | 0.00110 | TotalExpensePct |
Subsidized Health Services SubsidizedHealthServicesGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Community Benefit Expns | $1,242,118 | TotalCommunityBenefitExpnsAmt |
| Direct Offsetting Revenue | $1,242,118 | DirectOffsettingRevenueAmt |
Cash And In Kind Contributions CashAndInKindContributionsGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Community Benefit Expns | $985 | TotalCommunityBenefitExpnsAmt |
| Net Community Benefit Expns | $985 | NetCommunityBenefitExpnsAmt |
| Total Expense | 0.00030 | TotalExpensePct |
Total Other Benefits TotalOtherBenefitsGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Community Benefit Expns | $1,247,813 | TotalCommunityBenefitExpnsAmt |
| Direct Offsetting Revenue | $1,243,438 | DirectOffsettingRevenueAmt |
| Net Community Benefit Expns | $4,375 | NetCommunityBenefitExpnsAmt |
| Total Expense | 0.00140 | TotalExpensePct |
Total Community Benefits TotalCommunityBenefitsGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Community Benefit Expns | $1,500,077 | TotalCommunityBenefitExpnsAmt |
| Direct Offsetting Revenue | $1,478,612 | DirectOffsettingRevenueAmt |
| Net Community Benefit Expns | $21,465 | NetCommunityBenefitExpnsAmt |
| Total Expense | 0.00690 | TotalExpensePct |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Bad Debt Expense Reported | Yes (1) | BadDebtExpenseReportedInd |
| Bad Debt Expense | $59,000 | BadDebtExpenseAmt |
| Bad Debt Expense Attributable | $0 | BadDebtExpenseAttributableAmt |
| Reimbursed By Medicare | $1,891,126 | ReimbursedByMedicareAmt |
| Cost Of Care Reimbursed By Medcr | $1,882,085 | CostOfCareReimbursedByMedcrAmt |
| Medicare Surplus Or Shortfall | $9,041 | MedicareSurplusOrShortfallAmt |
Costing Methodology Used CostingMethodologyUsedGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Cost To Charge Ratio | Yes (X) | CostToChargeRatioInd |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Written Debt Collection Policy | Yes (1) | WrittenDebtCollectionPolicyInd |
| Financial Assistance Prvsn | Yes (1) | FinancialAssistancePrvsnInd |
| Hospital Facilities | 1 | HospitalFacilitiesCnt |
Hospital Facilities HospitalFacilitiesGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Facility | 1 | FacilityNum |
Business Name BusinessName
| Field | Value | IRS element (for citing) |
|---|---|---|
| Business Name Line1 | NIOBRARA VALLEY HOSPITAL | BusinessNameLine1Txt |
US Address USAddress
| Field | Value | IRS element (for citing) |
|---|---|---|
| Address Line1 | PO BOX 118 | AddressLine1Txt |
| City | LYNCH | CityNm |
| State Abbreviation | NE | StateAbbreviationCd |
| ZIP | 68746 | ZIPCd |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Website Address | WWW.NVHCARES.ORG | WebsiteAddressTxt |
| State License | 050001 | StateLicenseNum |
| Licensed Hospital | Yes (X) | LicensedHospitalInd |
| Critical Access Hospital | Yes (X) | CriticalAccessHospitalInd |
| Emergency Room24 Hrs | Yes (X) | EmergencyRoom24HrsInd |
Hospital Fclty Policies Prctc HospitalFcltyPoliciesPrctcGrp
Hospital Facility Name HospitalFacilityName
| Field | Value | IRS element (for citing) |
|---|---|---|
| Business Name Line1 | NIOBRARA VALLEY HOSPITAL | BusinessNameLine1Txt |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Facility | 1 | FacilityNum |
| First Licensed CY Or PY | 0 | FirstLicensedCYOrPYInd |
| Tax Exempt Hospital CY Or PY | 0 | TaxExemptHospitalCYOrPYInd |
| CHNA Conducted | Yes (1) | CHNAConductedInd |
| Community Definition | Yes (X) | CommunityDefinitionInd |
| Community Demographics | Yes (X) | CommunityDemographicsInd |
| Existing Resources | Yes (X) | ExistingResourcesInd |
| How Data Obtained | Yes (X) | HowDataObtainedInd |
| Community Health Needs | Yes (X) | CommunityHealthNeedsInd |
| Community Hlth Needs Id Process | Yes (X) | CommunityHlthNeedsIdProcessInd |
| Consulting Process | Yes (X) | ConsultingProcessInd |
| Other | Yes (X) | OtherInd |
| CHNA Conducted | 21 | CHNAConductedYr |
| Take Into Account Others Input | Yes (1) | TakeIntoAccountOthersInputInd |
| CHNA Conducted With Other Fclts | Yes (1) | CHNAConductedWithOtherFcltsInd |
| CHNA Conducted With Non Fclts | Yes (1) | CHNAConductedWithNonFcltsInd |
| CHNA Report Widely Available | Yes (1) | CHNAReportWidelyAvailableInd |
| Rpt Available On Own Website | Yes (X) | RptAvailableOnOwnWebsiteInd |
| Own Website URL | WWW.NVHCARES.ORG/COMMUNITY-HEALTH-NEEDS-ASSESSMENT.HTML | OwnWebsiteURLTxt |
| Paper Copy Public Inspection | Yes (X) | PaperCopyPublicInspectionInd |
| Implementation Strategy Adopt | Yes (1) | ImplementationStrategyAdoptInd |
| Implementation Strategy Adpt | 21 | ImplementationStrategyAdptYr |
| Strategy Posted Website | Yes (1) | StrategyPostedWebsiteInd |
| Strategy Website URL | WWW.NVHCARES.ORG/COMMUNITY-HEALTH-IMPROVEMENT-PLAN.HTML | StrategyWebsiteURLTxt |
| Organization Incur Excise Tax | 0 | OrganizationIncurExciseTaxInd |
| Elig Criteria Explained | Yes (1) | EligCriteriaExplainedInd |
| FPG Family Incm Lmt Free Dscnt | Yes (X) | FPGFamilyIncmLmtFreeDscntInd |
| FPG Family Incm Lmt Free Care | 100.000000000000 | FPGFamilyIncmLmtFreeCarePct |
| Insurance Status Criteria | Yes (X) | InsuranceStatusCriteriaInd |
| Underinsurance Stat Criteria | Yes (X) | UnderinsuranceStatCriteriaInd |
| Explained Basis | Yes (1) | ExplainedBasisInd |
| App Financial Asst Expln | Yes (1) | AppFinancialAsstExplnInd |
| Described Info | Yes (X) | DescribedInfoInd |
| Described Suprt Doc | Yes (X) | DescribedSuprtDocInd |
| Provided Hospital Contact | Yes (X) | ProvidedHospitalContactInd |
| Other Method | Yes (X) | OtherMethodInd |
| Includes Publicity Measures | Yes (1) | IncludesPublicityMeasuresInd |
| FAP Available On Website | Yes (X) | FAPAvailableOnWebsiteInd |
| FAP Available On Website URL | WWW.NVHCARES.ORG/FINANCIAL-ASSISTANCE.HTML | FAPAvailableOnWebsiteURLTxt |
| FAP App Available On Website | Yes (X) | FAPAppAvailableOnWebsiteInd |
| FAP App Available On Website URL | WWW.NVHCARES.ORG/FINANCIAL-ASSISTANCE.HTML | FAPAppAvailableOnWebsiteURLTxt |
| FAP Summary On Website | Yes (X) | FAPSummaryOnWebsiteInd |
| FAP Summary On Website URL | WWW.NVHCARES.ORG/FINANCIAL-ASSISTANCE.HTML | FAPSummaryOnWebsiteURLTxt |
| FAP Avlbl On Request No Charge | Yes (X) | FAPAvlblOnRequestNoChargeInd |
| FAP App Avlbl On Request No Chrg | Yes (X) | FAPAppAvlblOnRequestNoChrgInd |
| FAP Sum Avlbl On Request No Chrg | Yes (X) | FAPSumAvlblOnRequestNoChrgInd |
| Notified FAP Copy Bill Display | Yes (X) | NotifiedFAPCopyBillDisplayInd |
| Communtity Notified FAP | Yes (X) | CommuntityNotifiedFAPInd |
| Other Publicity | Yes (X) | OtherPublicityInd |
| FAP Actions On Nonpayment | Yes (1) | FAPActionsOnNonpaymentInd |
| Permit No Actions | Yes (X) | PermitNoActionsInd |
| Collection Activities | 0 | CollectionActivitiesInd |
| Provided Written Notice | Yes (X) | ProvidedWrittenNoticeInd |
| Made Effort Orally Notify | Yes (X) | MadeEffortOrallyNotifyInd |
| Processed FAP Application | Yes (X) | ProcessedFAPApplicationInd |
| Made Presumptive Elig Determ | Yes (X) | MadePresumptiveEligDetermInd |
| Nondis Emergency Care Policy | Yes (1) | NondisEmergencyCarePolicyInd |
| Prospective Medicare Medicaid | Yes (X) | ProspectiveMedicareMedicaidInd |
| Amounts Generally Billed | 0 | AmountsGenerallyBilledInd |
| Gross Charges | 0 | GrossChargesInd |
Supplemental Information SupplementalInformationGrp (7 entries)
| Form And Line ReferenceFormAndLineReferenceDesc | ExplanationExplanationTxt |
|---|---|
| NIOBRARA VALLEY HOSPITAL | PART V, SECTION B, LINE 3J: THROUGH THE PROCESSES OF COMPLETING THE COMMUNITY HEALTH NEEDS ASSESSMENT AND ASSESSING THE RESOURCES AVAILABLE TO THIS ORGANIZATION AND SURROUNDING COMMUNITIES, IT WAS DETERMINED THAT THE MOST SIGNIFICANT NEED TO BE ADDRESSED BY NIOBRARA VALLEY HOSPITAL IS THE PHYSICAL WELLNESS OF THE COMMUNITIES, PRIMARILY IN THE AREAS OF DIABETES AND BLOOD PRESSURE. BY ADDRESSING THESE TWO HEALTH ISSUES, NIOBRARA VALLEY HOSPITAL HAS THE OPPORTUNITY TO VASTLY DECREASE THE DEATH RATE ATTRIBUTED TO HEART DISEASE. |
| 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. 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. |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Facility | 1 | FacilityNum |
Oth Hlth Care Fclts Not Hospital OthHlthCareFcltsNotHospitalGrp
Oth Hlth Care Fclts OthHlthCareFcltsGrp
Business Name BusinessName
| Field | Value | IRS element (for citing) |
|---|---|---|
| Business Name Line1 | 1 - NVMC - SPENCER | BusinessNameLine1Txt |
US Address USAddress
| Field | Value | IRS element (for citing) |
|---|---|---|
| Address Line1 | 108 WEST EVANS STREET | AddressLine1Txt |
| City | SPENCER | CityNm |
| State Abbreviation | NE | StateAbbreviationCd |
| ZIP | 68777 | ZIPCd |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Facility | CLINIC | FacilityTxt |
Supplemental Information Detail SupplementalInformationDetail (16 entries)
| Form And Line ReferenceFormAndLineReferenceDesc | ExplanationExplanationTxt |
|---|---|
| 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 I, LN 7 COL(F): | THE BAD DEBT EXPENSE INCLUDED ON FORM 990, PART IX, LINE 25, COLUMN (A), BUT SUBTRACTED FOR PURPOSES OF CALCULATING THE PERCENTAGE IN THIS COLUMN IS $59,000. |
| 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 7, 9 AND 10 OF THE ATTACHED FINANCIAL STATEMENTS INCLUDE FOOTNOTES TITLED "PATIENT ACCOUNTS RECEIVABLE," "PATIENT SERVICE REVENUE AND "PATIENT FINANCIAL ASSISTANCE." |
| PART III, LINE 8: | NIOBRARA VALLEY HOSPITAL USED THE AUGUST 31, 2022 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. |
Schedule J IRS990ScheduleJ
| Field | Value | IRS element (for citing) |
|---|---|---|
| Severance Payment | 0 | SeverancePaymentInd |
| Supplemental Nonqual Rtr Plan | 0 | SupplementalNonqualRtrPlanInd |
| Equity Based Comp Arrngm | 0 | EquityBasedCompArrngmInd |
| Comp Based On Revenue Of Flng Org | 0 | CompBasedOnRevenueOfFlngOrgInd |
| Comp Bsd On Rev Related Orgs | 0 | CompBsdOnRevRelatedOrgsInd |
| Comp Bsd Net Earns Flng Org | 0 | CompBsdNetEarnsFlngOrgInd |
| Comp Bsd Net Earns Rltd Orgs | 0 | CompBsdNetEarnsRltdOrgsInd |
| Any Non Fixed Payments | 0 | AnyNonFixedPaymentsInd |
| Initial Contract Exception | 0 | InitialContractExceptionInd |
Rltd Org Officer Trst Key Empl RltdOrgOfficerTrstKeyEmplGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Person | BREE ALMGREN | PersonNm |
| Title | NURSE PRACTIONER | TitleTxt |
| Base Compensation Filing Org | $147,477 | BaseCompensationFilingOrgAmt |
| Compensation Based On Rltd Orgs | $0 | CompensationBasedOnRltdOrgsAmt |
| Bonus Filing Organization | $0 | BonusFilingOrganizationAmount |
| Bonus Related Organizations | $0 | BonusRelatedOrganizationsAmt |
| Other Compensation Filing Org | $0 | OtherCompensationFilingOrgAmt |
| Other Compensation Rltd Orgs | $0 | OtherCompensationRltdOrgsAmt |
| Deferred Compensation Flng Org | $4,060 | DeferredCompensationFlngOrgAmt |
| Deferred Comp Rltd Orgs | $0 | DeferredCompRltdOrgsAmt |
| Nontaxable Benefits Filing Org | $2,937 | NontaxableBenefitsFilingOrgAmt |
| Nontaxable Benefits Rltd Orgs | $0 | NontaxableBenefitsRltdOrgsAmt |
| Total Compensation Filing Org | $154,474 | TotalCompensationFilingOrgAmt |
| Total Compensation Rltd Orgs | $0 | TotalCompensationRltdOrgsAmt |
| Comp Report Prior990 Filing Org | $0 | CompReportPrior990FilingOrgAmt |
| Comp Report Prior990 Rltd Orgs | $0 | CompReportPrior990RltdOrgsAmt |
Supplemental Information Detail SupplementalInformationDetail (2 entries)
| Form And Line ReferenceFormAndLineReferenceDesc | ExplanationExplanationTxt |
|---|---|
| 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 2021 WERE $111,156. |
Schedule O IRS990ScheduleO
Supplemental Information Detail SupplementalInformationDetail (10 entries)
| Form And Line ReferenceFormAndLineReferenceDesc | ExplanationExplanationTxt |
|---|---|
| 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 125,287. MANAGEMENT AND GENERAL EXPENSES 37,793. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 163,080. EMERGENCY ROOM PHYSICIANS: PROGRAM SERVICE EXPENSES 88,730. MANAGEMENT AND GENERAL EXPENSES 0. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 88,730. CONSULTING SERVICES: PROGRAM SERVICE EXPENSES 265,104. MANAGEMENT AND GENERAL EXPENSES 25,573. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 290,677. RECRUITMENT FEES: PROGRAM SERVICE EXPENSES 417. MANAGEMENT AND GENERAL EXPENSES 7,134. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 7,551. |
| 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 7,331. |
| 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. |
Comments