2023-10-12T09:22:35-05:00 2022-12-31 450250958 EIDE BAILLY LLP 18081 BURT ST STE 200 OMAHA NE 680224722 990 2022-01-01 420843389 IDA COUNTY IOWA COMMUNITY HOSPITAL INC IDAC 7123643311 701 EAST 2ND STREET IDA GROVE IA 51445 GLEN WINEKAUF CEO 7123643311 2023-10-09 1 GLEN WINEKAUF 999009999 1 MEGAN L KOZIOL CPA P01544037 4023302660 2023-10-06 2 AAL1 IAL1 2022 2023-04-26 12:10:37Z HORN MEMORIAL HOSPITAL GLEN WINEKAUF 701 EAST 2ND STREET IDA GROVE IA 51445 27385713 0 X WWW.HORNMEMORIALHOSPITAL.ORG X 1966 IA TO PROVIDE HEALTHCARE SERVICES TO THE RESIDENTS OF IDA GROVE & THE SURROUNDING COMMUNITIES. 9 9 247 60 0 0 203623 1737904 23679468 25368481 205817 111654 178192 164561 24267100 27382600 0 0 0 0 13066111 13537932 0 0 0 10867129 12843821 23933240 26381753 333860 1000847 36282126 34695468 12466197 10475409 23815929 24220059 TO PROVIDE QUALITY CARE AND EDUCATION AS A PARTNER IN YOUR HEALTH AND WELLNESS. 0 0 24336958 25368481 IDA COUNTY, IOWA COMMUNITY HOSPITAL, INC. D/B/A HORN MEMORIAL HOSPITAL IS A NOT-FOR-PROFIT ACUTE CARE HOSPITAL WHICH PROVIDES INPATIENT, OUTPATIENT AND EMERGENCY CARE SERVICE TO PATIENTS IN THE AREA OF IDA GROVE, IOWA. IT ALSO OPERATES HOME HEALTH AND HOSPICE AGENCIES, PROVIDER-BASED RURAL HEALTH CLINICS IN IDA GROVE, IOWA AND SURROUNDING COMMUNITIES, AND OTHER HEALTHCARE SERVICES.HEALTHCARE SERVICES PROVIDED TO PATIENTS: 693 ACUTE PATIENT DAYS, 873 SKILLED PATIENT DAYS, 32 INTERMEDIATE DAYS, 22,676 OUTPATIENT OCCASIONS OF SERVICE, 2,787 HOME HEALTH VISITS. 24336958 1 1 0 1 0 0 0 0 0 0 1 0 0 0 1 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 0 0 0 1 28 0 1 247 1 0 0 0 0 0 0 0 0 0 0 0 0 X 9 9 0 0 0 0 1 1 0 1 0 0 0 1 1 1 1 1 1 1 1 0 X JONI SCHUMANN 7123643311 701 EAST 2ND STREET IDA GROVE IA 51445 ALBERT VELTRI PHYSICIAN 40.00 0.00 X 388362 0 64498 MAX DELANEY CRNA 40.00 0.00 X 230308 0 53949 SHARON VANDEVEGTE PHYSICIAN 32.00 0.00 X 225607 0 53327 CURTIS HESSE PHYSICIAN 40.00 0.00 X 217005 0 24811 GLEN WINEKAUF CEO 40.00 1.00 X 190859 0 46691 JOEY HOEFLING ARNP 40.00 0.00 X 156004 0 7597 JONI SCHUMANN CFO 40.00 1.00 X 123602 0 23992 JEAN BURNS CHAIR 0.50 0.00 X X 0 0 0 DAVID FORBES VICE CHAIR 0.50 0.00 X X 0 0 0 KELLI BOYLE SECRETARY 0.50 0.00 X X 0 0 0 KEITH ROBINSON SECRETARY THRU 04/22 0.50 0.00 X X 0 0 0 COLE BOGER TREASURER 0.50 1.00 X X 0 0 0 PETER GOLDSMITH DIRECTOR 0.50 0.00 X 0 0 0 CHRISTINA HANSON DIRECTOR 0.50 0.00 X 0 0 0 VANCE LUNDELL DIRECTOR 0.50 0.00 X 0 0 0 ROB PAULSEN DIRECTOR 0.50 0.00 X 0 0 0 KRIS GUNDERSON DIRECTOR 0.50 0.00 X 0 0 0 JEN CONOVER DIRECTOR THRU 04/22 0.50 0.00 X 0 0 0 1531747 0 274865 12 0 1 0 WMG RED HAWTHORNE LLC 107 FLYNN DRIVE SUITE 600 MILBANK SD 57252 ER PHYSICIAN SERVICES 1374321 SPORTS REHAB & PHYSICAL THERAPY CENTER 315 W 5TH ST STORM LAKE IA 50588 REHAB SERVICES 1057543 FUSION MEDICAL STAFFING LLC PO BOX 850781 MINNEAPOLIS MN 55485 CONTRACTED STAFFING 486753 SANFORD LABORATORIES PO BOX 5056 SIOUX FALLS SD 57117 LAB SERVICES 212154 CASSLING 13810 FNB PKWY SUITE 200 OMAHA NE 68154 CT, DRX, RADIOLOGY SERVICES 168379 9 70000 1105833 562071 1737904 MEDICARE/MEDICAID PAYMENTS 624100 17686892 17686892 PATIENT SERVICE REVENUE 624100 6738096 6738096 340B REVENUE 624100 747621 747621 195872 195872 25368481 111654 111654 71680 0 71680 71680 71680 8173 3113 5060 5060 CAFETERIA/DIETARY 722210 87821 87821 87821 27382600 25368481 0 276215 X 385144 385144 10205562 9483272 722290 347777 323588 24189 1879103 1716881 162222 720346 639740 80606 138617 138617 24495 24495 5441579 5367601 73978 65016 57008 8008 558331 489560 68771 1267024 1110961 156063 158736 139184 19552 31071 27244 3827 252754 250961 1793 1676547 1578912 97635 130543 114464 16079 MEDICAL SUPPLIES 2305979 2305979 0 DUES AND SUBSCRIPTIONS 321159 281601 39558 BAD DEBT EXPENSE 293627 293627 0 MISCELLANEOUS 119151 104474 14677 59192 51901 7291 26381753 24336958 2044795 0 20141 13872 12643988 10760743 34999 305374 3527074 3267778 533143 530148 209710 73555 37061091 21429741 15707491 15631350 2966693 2454613 581233 449633 57654 1208402 36282126 34695468 1643751 1857698 9585813 8275769 1236633 341942 12466197 10475409 X 23815929 23751859 0 468200 23815929 24220059 36282126 34695468 1000847 -587594 -9123 0 X X 0 1 X 1 1 1 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 0 0 0 0 0 0 0 0 1 3122 3122 0 PART II-B, LINE 1: THE HOSPITAL PAYS DUES TO THE IOWA HOSPITAL ASSOCIATION, A PORTION OF WHICH ARE ATTRIBUTABLE TO LOBBYING. 253789 253789 22148477 12322950 9825527 9730458 7458906 2271552 4928367 1647885 3280482 15631350 RIGHT OF USE ASSET - FINANCING LEASE (NET) 341942 341942 X 26501379 -587594 -587594 27088973 293627 293627 27382600 26088126 0 26088126 293627 293627 26381753 PART X, LINE 2: THE HOSPITAL ACCOUNTS FOR UNCERTAINTIES IN ACCOUNTING FOR INCOME TAX ASSETS AND LIABILITIES USING GUIDANCE INCLUDED IN FASB ASC 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 DECEMBER 31, 2022, THE HOSPITAL HAD NO UNCERTAIN TAX POSITIONS ACCRUED. PART XI, LINE 4B - OTHER ADJUSTMENTS: BAD DEBT EXPENSE 293,627. PART XII, LINE 4B - OTHER ADJUSTMENTS: BAD DEBT EXPENSE 293,627. 1 1 X 1 X 1 X 1 1 0 1 1 62 21919 0 21919 0.00080 2024 2842351 2226787 615564 0.02360 97 388 0 388 0.00000 2183 2864658 2226787 637871 0.02440 35358 35085 15377 19708 0.00080 62 33423 0 33423 0.00130 422 25393 25393 24300 86023 0 86023 0.00330 60142 179924 40770 139154 0.00540 62325 3044582 2267557 777025 0.02980 1 293627 0 11930525 12083909 -153384 X 1 1 1 1 HORN MEMORIAL HOSPITAL 701 EAST 2ND STREET IDA GROVE IA 51445 HORNMEMORIALHOSPITAL.ORG 470061H X X X X IDA COUNTY IOWA COMMUNITY HOSPITAL INC 1 0 0 1 X X X X X X X X X 22 1 0 0 1 X WWW.HORNMEMORIALHOSPITAL.ORG/GETPAGE.PHP?NAME=COMMUNITY_HEALTH_NEEDS X 1 22 1 WWW.HORNMEMORIALHOSPITAL.ORG/GETPAGE.PHP?NAME=COMMUNITY_HEALTH_NEEDS 0 1 X 100.000000000000 400.000000000000 X X X X 1 1 X X X 1 X WWW.HORNMEMORIALHOSPITAL.ORG/GETPAGE.PHP?NAME=PAYMENT_ARRANGEMENTS X WWW.HORNMEMORIALHOSPITAL.ORG/GETPAGE.PHP?NAME=PAYMENT_ARRANGEMENTS X WWW.HORNMEMORIALHOSPITAL.ORG/GETPAGE.PHP?NAME=PAYMENT_ARRANGEMENTS X X X X X X 1 X 0 X X X X 1 X 0 0 IDA COUNTY, IOWA COMMUNITY HOSPITAL, INC PART V, SECTION B, LINE 5: PARTICIPANTS VIA ONLINE SURVEY INCLUDED 19 HEALTH PROVIDERS, 1 SOCIAL SERVICES PROVIDER, AND 26 OTHER COMMUNITY LEADERS. MULTIPLE OTHER DATA SOURCES WERE ALSO CONSULTED TO COMPLEMENT THE RESEARCH QUALITY OF THE CHNA. WRITTEN COMMENTS AND FEEDBACK WERE ALSO REQUESTED THROUGH HORN'S WEBSITE. COMMUNITY DEFINED FOR THE CHNA INCLUDED THE THREE COUNTIES OF IDA, MONONA, AND SAC BASED ON THE AREAS OF RESIDENCE OF MOST RECENT PATIENTS OF HORN MEMORIAL HOSPITAL. IDA COUNTY, IOWA COMMUNITY HOSPITAL, INC PART V, SECTION B, LINE 11: HORN'S COMMITTEE OF NINE MEMBERS MET TO DISCUSS AND PRIORITIZE THE TOP HEALTH NEEDS IDENTIFIED FROM THE CHNA. THE BOARD OF TRUSTEES OFFICIALLY REVIEWED AND APPROVED THE FOUR PRIORITIZED SIGNIFICANT COMMUNITY NEEDS AND INITIATIVES RELATED TO THESE AREAS:1) MENTAL HEALTH - INCREASE AWARENESS AND ACCESS TO MENTAL HEALTH SERVICES.2) HEART DISEASE & STROKE - INCREASE ACCESS AND AWARENESS OF HEART DISEASE AND STROKE RESOURCES.3) CANCER - PROMOTE/ENCOURAGE REFERRALS FOR PREVENTABLE CANCER SCREENINGS.4) ACCESS TO HEALTHCARE - INCREASE ACCESS TO HEALTHCARE SERVICES IN OUR SERVICE AREA AND INCREASE COMMUNITY AWARENESS OF SERVICES AVAILABLE FOR HORN.HORN IS NOT ADDRESSING THE FOLLOWING NEEDS IDENTIFIED: 1) SUBSTANCE ABUSE - OTHER FACILITIES OR ORGANIZATIONS IN THE COMMUNITY ARE ADDRESSING THE NEED.2) RESPIRATORY DISEASE - DUE TO RESOURCE CONSTRAINTS.3) ORAL HEALTH - DUE TO THE RELATIVELY LOW PRIORITY ASSIGNED TO THE NEED.4) INJURY & VIOLENCE - DUE TO THE RELATIVELY LOW PRIORITY ASSIGNED TO THE NEED. IDA COUNTY, IOWA COMMUNITY HOSPITAL, INC PART V, SECTION B, LINE 13B: DISCOUNTS FOR PATIENTS WITH NO INSURANCE AND PROMPT PAYMENT ARE NOT BASED ON ANY INCOME LEVEL. 4 1 - HORN PHYSICIANS CLINIC IDA GROVE 700 EAST 2ND STREET IDA GROVE IA 51445 PHYSICIAN CLINIC 2 - HORN PHYSICIANS CLINIC ODEBOLT 300 SOUTH MAPLE STREET ODEBOLT IA 51458 PHYSICIAN CLINIC 3 - HORN PHYSICIANS CLINIC MAPLETON 412 MAIN STREET MAPLETON IA 51034 PHYSICIAN CLINIC 4 - HORN PHYSICIANS CLINIC HOLSTEIN 1400 SOUTH KIEL STREET HOLSTEIN IA 51025 PHYSICIAN CLINIC PART I, LINE 3C: FOR PATIENTS WITH THE ABILITY TO PAY, A 5% DISCOUNT IS OFFERED ON HOSPITAL SERVICES, WHICH APPLIES ONLY IF THE BALANCE IS PAID IN FULL WITHIN THIRTY DAYS FROM THE RECEIPT OF THE FIRST PRIVATE PAY STATEMENT. THIS DISCOUNT DOES NOT APPLY TO ANY CLINIC OR PUBLIC HEALTH CHARGES. A $4.00 DISCOUNT IS OFFERED TO PATIENTS AT THE TIME OF SERVICE IN THE CLINICS IF THE HOUSEHOLD INCOME IT AT OR BELOW 400% OF THE FEDERAL POVERTY GUIDELINES.FOR COLLECTION PURPOSES, PATIENTS WITH NO INSURANCE AS GIVEN A 20% DISCOUNT ON HOSPITAL SERVICES. PART I, LINE 6A: THE COMMUNITY BENEFIT REPORT WAS NOT PREPARED BY A RELATED PARTY. PART I, LINE 7: THE HOSPITAL USES AN OVERALL COST TO CHARGE RATIO (TOTAL EXPENSES - BAD DEBT) / GROSS PATIENT SERVICE REVENUE = PERCENTAGE OF COST TO CHARGE. PART I, LINE 7G: SUBSIDIZED HEALTH SERVICES REPORTED ON LINE 7G INCLUDE WELLNESS CHECKS AND FOOT CLINICS. FOOT CLINICS ACCOUNT FOR $3,300 OF EXPENSES AND $2,725 OF OFFSETTING REVENUE. 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 $293,627. PART II, COMMUNITY BUILDING ACTIVITIES: THE HOSPITAL DOES NOT REPORT ANY COMMUNITY BUILDING ACTIVITIES. PART III, LINE 2: CONSISTENT WITH THE HOSPITAL'S MISSION, CARE IS PROVIDED TO PATIENTS REGARDLESS OF THEIR ABILITY TO PAY. THEREFORE, THE HOSPITAL HAS PROVIDED IMPLICIT PRICE CONCESSIONS TO UNINSURED PATIENTS AND PATIENTS WITH UNINSURED BALANCES (COPAYS AND DEDUCTIBLES). THE IMPLICIT PRICE CONCESSIONS INCLUDED IN ESTIMATING TRANSACTION PRICE REPRESENT THE DIFFERENCE BETWEEN AMOUNTS BILLED TO PATIENTS AND THE AMOUNTS THE HOSPITAL EXPECTS TO COLLECT BASED ON COLLECTION HISTORY WITH THOSE PATIENTS. PART III, LINE 3: THE HOSPITAL PROVIDES PATIENT FINANCIAL ASSISTANCE TO PATIENTS WHO ARE FINANCIALLY UNABLE TO PAY FOR THE HEALTH CARE SERVICES THEY RECEIVE. IT IS THE POLICY OF THE HOSPITAL NOT TO PURSUE COLLECTION OF AMOUNTS DETERMINED TO QUALIFY AS PATIENT FINANCIAL ASSISTANCE. ACCORDINGLY, THE HOSPITAL DOES NOT REPORT THESE AMOUNTS IN THE STATEMENTS OF OPERATIONS. THE HOSPITAL DETERMINES THE COSTS ASSOCIATED WITH PROVIDING PATIENT FINANCIAL ASSISTANCE BY AGGREGATING THE DIRECT AND INDIRECT COSTS, INCLUDING SALARIES, BENEFITS, SUPPLIES, AND OTHER OPERATING EXPENSES, BASED ON THE OVERALL COST TO CHARGE RATIO. THE COSTS OF CARING FOR PATIENT FINANCIAL ASSISTANCE PATIENTS FOR THE YEARS ENDED DECEMBER 31, 2022 AND 2021 WERE APPROXIMATELY $14,900 AND $20,800, RESPECTIVELY. PART III, LINE 4: THE COSTING METHODOLOGY USED IN DETERMINING THE BAD DEBT EXPENSES INCLUDES CALCULATING ON A MONTHLY BASIS THE TOTAL ESTIMATED AMOUNTS BASED ON HISTORICAL WRITE OFFS.THE ORGANIZATION'S FINANCIAL STATEMENTS DO NOT CONTAIN A SPECIFIC FOOTNOTE DESCRIBING BAD DEBT. FOOTNOTES TITLED "PATIENT RECEIVABLES," "PATIENT SERVICE REVENUE, AND "PATIENT FINANCIAL ASSISTANCE" CAN BE FOUND ON PAGES 8, 10, 11, & 14 OF THE ATTACHED AUDITED FINANCIAL STATEMENTS. PART III, LINE 8: THESE COSTS ARE MEDICARE REIMBURSABLE COSTS, NOT ALL COSTS. THESE MEDICARE REIMBURSABLE COSTS SHOULD BE TREATED AS A COMMUNITY BENEFIT TO THE EXTENT THAT MEDICARE REVENUES DO NOT COVER THE COSTS. WE DO NOT USE ANY NEGOTIATION TOOL WITH MEDICARE FOR OUR RATES; THE RATES THAT WE ARE PAID ARE MANDATED. HENCE, THIS DOES NOT GIVE US THE ABILITY AS A PROVIDER TO RECEIVE SUFFICIENT REVENUES TO COVER THE MEDICARE COSTS. AS A FACILITY WE ARE WORKING TOWARD COSTS SAVINGS. PART III, LINE 9B: ONCE A PATIENT HAS BEEN DETERMINED TO BE ELIGIBLE FOR FINANCIAL ASSISTANCE, A PAYMENT PLAN IS ESTABLISHED. IF THEY DEFAULT, AFTER TWO MONTHS OUR BAD DEBT COLLECTION POLICIES ARE ENACTED AND FOLLOWED. PART VI, LINE 2: COMMUNITY NEEDS ARE ASSESSED REGULARLY THROUGH FEEDBACK FROM PATIENT SURVEYS, OUR MEDICAL STAFF (MANY OF WHOM ARE COMMUNITY RESIDENTS) AND EMPLOYEES, AS WELL AS OUR BOARD OF TRUSTEES WHO LIVE IN AND REPRESENT THECOMMUNITIES WE SERVE. A COMMUNITY HEALTH NEEDS ASSESSMENT (CHNA) IS CONDUCTED EVERY THREE YEARS TO EVALUATE OUR ONGOING SERVICE REQUIREMENTS, IDENTIFY NEW SIGNIFICANT HEALTH NEEDS, AND IMPLEMENT STRATEGIES TO ADDRESS THEM. PART VI, LINE 3: OUR CONSENT TO TREATMENT FORM INCLUDES LANGUAGE REGARDING FINANCIAL ASSISTANCE AND CONTACT INFORMATION. THIS IS ALSO PRINTED AT THE REGISTRATION DESKS. IN ADDITION, OUR FINANCIAL ASSISTANCE POLICY IS POSTED IN REGISTRATION AREAS OF BOTH THE HOSPITAL AND ITS CLINICS. OUR HOSPITAL WEBSITE OFFERS ADDITIONAL INFORMATION UNDER THE PATIENTS AND VISITORS, PAYMENT ARRANGEMENTS SECTION REGARDING OUR PAYMENT REQUIREMENTS, FINANCIAL ASSISTANCE POLICY, SLIDING FEE SCALES, AND THE APPLICATION FORM FOR FINANCIAL ASSISTANCE. MAIL AND PHONE INQUIRIES REGARDING PATIENT INVOICES OR PAYMENT ARRANGEMENTS ARE REFERRED TO OUR FINANCIAL COUNSELOR FOR ASSISTANCE. PART VI, LINE 4: THE HOSPITAL SERVES THE COUNTIES OF IDA, MONONA AND SAC IN THE STATE OF IOWA. THE POPULATION OF THIS AREA IS OVER 25,000 RESIDENTS. IN THE TOTAL SERVICE AREA, 21.8% OF THE POPULATION ARE CHILDREN AGE 0-17; ANOTHER 55.4%ARE AGE 18 TO 64, WHILE 22.8% ARE AGE 65 AND OLDER. THE PROPORTION OF OLDER ADULTS (AGE 65+) IS SIGNIFICANTLY ABOVE THAT SEEN STATEWIDE OR (ESPECIALLY) NATIONALLY. PART VI, LINE 5: AS A PRIVATE, NON-PROFIT CRITICAL ACCESS HOSPITAL, HORN MEMORIAL HOSPITAL AND ITS CLINICS ARE ABLE TO IMPROVE ACCESS TO HEALTHCARE TO THOSE AT RISK BECAUSE OF FINANCIAL ABILITY, LACK OF ADEQUATE INSURANCE, MINORITY, OR OTHER BARRIERS, THROUGH OUR FOUR LOCATIONS WITHIN THREE RURAL COUNTIES.WE OFFER A VARIETY OF SPECIALTY CLINICS TO MEET THE NEEDS OF THE COMMUNITIES WE SERVE, AND MAINTAIN FOUR RURAL HEALTH CLINICS, A 24 HOUR EMERGENCY DEPARTMENT AND A 20 BED INPATIENT WING. THE HOSPITAL SPONSORS WEEKLY RADIO BROADCASTS ADDRESSING A WIDE VARIETY OF HEALTHCARE SERVICES AND ISSUES/CONCERNS. A MONTHLY NEWSLETTER IS ALSO PUBLISHED WHICH INCLUDES INFORMATION REGARDING SCHEDULED SPECIALTY CLINICS AND OTHER TIMELY CONCERNS OR INFORMATION FOR OUR READERSHIP. WE PROVIDE TRANSLATION SERVICES AT ALL LOCATIONS. WE PARTNER THROUGH LOCAL, COUNTY, AND STATE AGENCIES TO PROVIDE PUBLIC HEALTH SERVICES TO OUR COMMUNITIES. PART VI, LINE 6: THE HOSPITAL IS NOT PART OF AN AFFILIATED HEALTH CARE SYSTEM. PART VI, LINE 7, REPORTS FILED WITH STATES IA X X X X 0 0 0 0 0 0 0 0 0 ALBERT VELTRI PHYSICIAN 387862 0 500 0 0 0 20157 0 44341 0 452860 0 0 0 MAX DELANEY CRNA 229808 0 500 0 0 0 12144 0 41805 0 284257 0 0 0 SHARON VANDEVEGTE PHYSICIAN 225357 0 250 0 0 0 11891 0 41436 0 278934 0 0 0 CURTIS HESSE PHYSICIAN 216505 0 500 0 0 0 10959 0 13852 0 241816 0 0 0 GLEN WINEKAUF CEO 189749 0 500 0 610 0 10014 0 36677 0 237550 0 0 0 JOEY HOEFLING ARNP 155504 0 500 0 0 0 4068 0 3529 0 163601 0 0 0 A CITY OF IDA GROVE IOWA 426004785 NONEAVAIL 2016-08-08 7457000 REFUND PRIOR ISSUES (SERIES 2004) 0 0 0 B CITY OF IDA GROVE IOWA 426004785 NONEAVAIL 2016-08-08 4843000 REFUND PRIOR ISSUES (SERIES 2004) 0 0 0 A 7457000 7457000 2016 1 0 1 1 B 3883242 4843000 92 4842908 2016 1 0 1 1 A 0 0 0 0 0.00000 0.00000 0.00000 0 0 1 B 0 0 0 0 0.00000 0.00000 0.00000 0 0 1 A 0 0 1 0 0 0 0 0 1 B 0 0 1 0 0 0 0 0 1 A 1 B 1 FORM 990, PART VI, SECTION A, LINE 6 MEMBERS OF THE ORGANIZATION SHALL BE THOSE PERSONS WHO SHALL CONTRIBUTE NOT LESS THAN $10.00 PER PERSON OR $20.00 PER FAMILY ANNUALLY. FORM 990, PART VI, SECTION A, LINE 7A THE ORGANIZATION'S MEMBERS ELECT THE BOARD OF DIRECTORS. FORM 990, PART VI, SECTION A, LINE 8B THERE ARE NO COMMITTEES WITH AUTHORITY TO ACT ON BEHALF OF THE GOVERNING BODY. FORM 990, PART VI, SECTION B, LINE 11B THE 990 IS REVIEWED BY THE ORGANIZATION'S CEO AND CFO AND A COPY IS PROVIDED TO ALL BOARD MEMBERS BEFORE FILING. FORM 990, PART VI, SECTION B, LINE 12C CONFLICT OF INTEREST STATEMENTS ARE SIGNED ANNUALLY BY EACH BOARD MEMBER. IF A POSSIBLE CONFLICT EXISTS, A BOARD MEMBER ABSTAINS FROM VOTING ON THE MATTER. COMPLIANCE WITH THE POLICY IS MONITORED BY THE ADMINISTRATION AND THE BOARD MEMBERS. FORM 990, PART VI, SECTION B, LINE 15 SALARY CHANGES FOR THE CEO OCCUR EACH JANUARY. CHANGES ARE BASED ON SEVERAL FACTORS WHICH ARE PROVIDED TO THE BOARD CHAIR UPON REQUEST; AFTER BOARD REVIEW AND APPROVAL, THE CHANGE IS COMMUNICATED TO THE CFO. COMPENSATION FOR ALL OTHER EMPLOYEES USES SIMILAR DATA, AND IS REVIEWED AND APPROVED BY THE CEO. FORM 990, PART VI, SECTION C, LINE 19 THE ORGANIZATION MAKES ITS GOVERNING DOCUMENTS, CONFLICT OF INTEREST POLICY, AND FINANCIAL STATEMENTS AVAILABLE UPON REQUEST. FINANCIAL STATEMENTS ARE ALSO DISCLOSED AT THE ANNUAL MEETING WHICH IS OPEN TO THE PUBLIC. FORM 990, PART IX, LINE 11G PURCHASED SERVICES: PROGRAM SERVICE EXPENSES 1,901,653. MANAGEMENT AND GENERAL EXPENSES 73,978. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 1,975,631. SURGERY SERVICES: PROGRAM SERVICE EXPENSES 1,364,600. MANAGEMENT AND GENERAL EXPENSES 0. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 1,364,600. PHYSICIAN SERVICES: PROGRAM SERVICE EXPENSES 1,307,522. MANAGEMENT AND GENERAL EXPENSES 0. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 1,307,522. PHYSICAL THERAPY SERVICES: PROGRAM SERVICE EXPENSES 793,826. MANAGEMENT AND GENERAL EXPENSES 0. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 793,826. FORM 990, PART XII, LINE 2C: THE BOARD OF DIRECTORS ASSUMES RESPONSIBILITY FOR OVERSIGHT OF THE AUDIT AND SELECTION OF THE INDEPENDENT ACCOUNTANT. THIS PROCESS HAS NOT CHANGED FROM THE PRIOR YEAR. HORN MEMORIAL HOSPITAL FOUNDATION 701 EAST 2ND STREET IDA GROVE IA 51445 421478302 FUNDRAISING IA 501(C)(3) LINE 12B, II N/A 0 0 0 1 0 0 0 0 0 0 0 0 0 1 1 1 0 0 0 0