2023-10-26T13:17:34-05:00 2022-12-31 450250958 EIDE BAILLY LLP 18081 BURT ST STE 200 OMAHA NE 680224722 990 2022-01-01 470796875 FAITH REGIONAL HEALTH SERVICES FAIT 4023714880 1500 KOENIGSTEIN AVENUE PO BOX 869 NORFOLK NE 687020869 JANNA CLINE CFO 4023714880 2023-10-26 1 JANNA CLINE 999009999 1 MEGAN L KOZIOL CPA P01544037 4023302660 2023-10-24 2 AAL1 IAL1 2022 2023-04-26 12:10:37Z KELLY DRISCOLL 1500 KOENIGSTEIN AVENUE PO BOX 869 NORFOLK NE 687020869 268655031 0 X WWW.FRHS.ORG X 1996 NE TO PROVIDE ACUTE, SKILLED AND OUTPATIENT SERVICES TO INDIVIDUALS IN OUR SERVICE AREA. 14 9 1998 28 273423 243043 5365427 3186882 292707231 261280318 1263698 1361455 887256 627270 300223612 266455925 324099 225961 0 0 144821895 147813490 0 0 273925 146770510 118034554 291916504 266074005 8307108 381920 286490479 262709523 118741263 99115717 167749216 163593806 TO SERVE CHRIST BY PROVIDING ALL PEOPLE WITH EXEMPLARY MEDICAL SERVICES IN AN ENVIRONMENT OF LOVE AND CARE. 0 0 224774327 225961 249189482 FAITH REGIONAL PROVIDES HEALTHCARE TO ALL PEOPLE REGARDLESS OF THEIR ABILITY TO PAY OR THEIR INSURANCE PROVIDER. DURING THE YEAR, FAITH REGIONAL PROVIDED SIGNIFICANT SERVICES FOR MEDICARE AND MEDICAID PATIENTS. 15892054 12474313 MANY SERVICES PROVIDED BY FAITH REGIONAL ARE DONE TO MEET SPECIFIC NEEDS OF THE COMMUNITY BECAUSE NO OTHER SERVICES ARE AVAILABLE. AS A RESULT, THESE SERVICES ARE PROVIDED KNOWING THAT THEY WILL NOT BE FINANCIALLY VIABLE OR SELF-SUPPORTING. THESE SERVICES INCLUDE BEHAVIORAL HEALTH INPATIENT AND OUTPATIENT SERVICES, CHILD ADVOCACY, DIABETIC EDUCATION, DIALYSIS SERVICES, ACUTE REHABILITATIVE SERVICES, HOME HEALTH CARE AND TRANSITIONAL CARE (LONG-TERM REHABILITATION) SERVICES. 679266 0 A SUBSTANTIAL PORTION OF COMMUNITY BENEFITS PROVIDED BY FAITH REGIONAL IS THE PROVISION OF PATIENT CARE SERVICES THAT ARE NOT PAID FOR EITHER BY THE PATIENT OR THIRD PARTY INSURANCE. DURING 2022, FAITH PROVIDED PATIENTS JUST UNDER SEVEN HUNDRED THOUSAND DOLLARS IN ASSISTANCE WITH PAYING THEIR HOSPITAL BILLS. 241345647 1 1 0 1 0 0 0 0 0 1 1 0 0 0 1 1 0 1 0 0 0 0 0 0 0 0 1 1 1 0 1 1 0 0 0 0 0 0 0 0 1 0 0 0 0 0 1 1 1 1 0 0 1 101 0 1 1998 1 1 1 0 0 0 0 0 0 0 0 0 0 0 X 14 9 0 0 0 0 1 1 1 1 1 0 0 1 1 1 1 1 1 1 1 1 1 X JANNA CLINE 4026447249 1500 KOENIGSTEIN AVENUE PO BOX 869 NORFOLK NE 687020869 FADI RZOUQ MD PHYSICIAN 40.00 0.00 X 4373512 0 48874 TRISTAN L HARTZELL MD PHYSICIAN 40.00 1.00 X 3680758 0 1398 JOHN LAMMLI MD PHYSICIAN 40.00 0.00 X 1198372 0 46296 NATHAN HERMAN MD PHYSICIAN 40.00 0.00 X 1162323 0 49556 BEETHOVEN BROWN MD PHYSICIAN 40.00 0.00 X 1177611 0 11083 KELLY DRISCOLL CEO 39.00 2.00 X 758697 0 48857 ROBERT PRINCE MD MEMBER - MEDICAL DIRECTOR 40.00 0.00 X 744111 0 45021 LANE HANDKE MD MEMBER - CHIEF OF STAFF 40.00 0.00 X 549044 0 42370 JANNA CLINE VP FINANCE 39.00 2.00 X 238398 0 30149 LINDA MILLER RN CHAIR 1.50 0.00 X X 0 0 0 BRETT JACKSON VICE CHAIR 1.50 0.00 X X 0 0 0 SUE FUCHTMAN SECRETARY 1.50 0.00 X X 0 0 0 JOHN ROBERTSON TREASURER 1.00 2.50 X X 0 0 0 STEF LACEY MD MEMBER 1.00 0.00 X 0 0 0 TRAVIS RUTJENS MEMBER 1.00 0.00 X 0 0 0 JACQUE COLLISON MEMBER 1.00 3.50 X 0 0 0 JOSH GOSSMAN MEMBER 1.00 0.00 X 0 0 0 DIANE BECKER MEMBER 1.00 2.50 X 0 0 0 BRAD DINKEL MEMBER 1.00 0.00 X 0 0 0 LEON ROSENTHAL MEMBER 1.00 2.50 X 0 0 0 PRESTON SUNDERMAN MEMBER 1.00 2.50 X 0 0 0 CORY SHAW MEMBER (THRU 10/2022) 1.00 0.00 X 0 0 0 13882826 0 323604 117 0 1 0 PATHOLOGY MEDICAL SERVICE PO BOX 82653 LINCOLN NE 68501 LAB SERVICES 542000 SIOUX CITY NIGHT PATROL PO BOX 3276 SIOUX CITY IA 51102 SECURITY SERVICES 352630 BROGAN & LAMMLI 3204 W BENJAMIN AVE NORFOLK NE 68701 LEGAL SERVICES 179676 EIDE BAILLY LLP 18081 BURT STREET OMAHA NE 68022 ACCOUNTING SERVICES 137787 VIRTUAL RADIOLOGIC CORPORATION 25983 NETWORK PLACE CHICAGO IL 60673 LAB SERVICES 124259 10 47000 2767691 372191 3186882 NET PATIENT SERVICE REVENUE 621110 167486899 167486899 PATIENT SVC M'CARE/MEDICAID 621110 80116636 80116636 LEASED MEDICAL EMPLOYEES 621110 2869379 2869379 PHYSICIAN CLINICS 621110 1149995 1149995 9657409 9657409 261280318 1277080 1277080 661971 819427 -157456 -157456 -157456 1305185 151419 1286633 85596 18552 65823 84375 84375 9312 7450 1862 1862 MHR HOME CARE, LLC 456199 271561 271561 511303 383477 127826 782864 266455925 261663795 273423 1331825 225961 225961 2456647 1380546 1076101 524109 524109 120602670 111559381 8838556 204733 3514981 3256829 252679 5473 13369820 11863944 1501547 4329 7345263 6780882 548316 16065 431554 8403 423151 212013 4128 207885 25009760 25008861 899 907829 7167 900662 10404718 9409992 986091 8635 8619112 7320878 1287271 10963 7065114 6692739 372375 253863 227672 20850 5341 602747 542069 52664 8014 2200220 86868 2113352 13519066 8938650 4580416 1266650 216326 1050324 INCOME TAX 34531 34531 MEDICAL SUPPLIES 42899781 42899781 MISCELLANEOUS 3378738 3372173 604 5961 FOOD 865910 865327 583 362948 118430 241006 3512 266074005 241345647 24454433 273925 190982 152063 67375791 56344001 25084865 28936969 2926393 2172183 4776453 4469606 5089469 4900162 305935597 188601808 122461782 117333789 42861644 35945553 3338141 3248352 12384959 9206845 286490479 262709523 32966356 31612672 61787203 55940463 9866670 8118756 14121034 3443826 118741263 99115717 X 167749216 162593806 0 1000000 167749216 163593806 286490479 262709523 381920 -4537330 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 13254 13254 0 PART II-B, LINE 1: FAITH REGIONAL PAID DUES TO THE NEBRASKA HOSPITAL ASSOCIATION AND THE AMERICAN HOSPITAL ASSOCIATION. A PORTION OF THE DUES WERE USED FOR LOBBYING ACTIVITIES. 6611965 76 -169311 6442730 5533918 50 1077997 6611965 5523918 10000 1022500 1022500 5533918 8052916 15000 1454367 3998365 5523918 8361450 50 -308584 8052916 0.00800 0.99200 0.00000 0 1 1 4220548 4220548 132660891 71510896 61149995 154590228 112030705 42559523 14463930 5060207 9403723 117333789 ESTIMATED THIRD PARTY PAYOR SETTLEMENTS - MEDICARE & MEDICAID 969000 LEASE LIABILITY 2474826 3443826 X PART V, LINE 4: CARSON CANCER CENTER ENDOWMENT FUNDS ARE PERMANENTLY SET ASIDE TO GENERATE INVESTMENT EARNINGS TO BE USED TO FUND CAPITAL EQUIPMENT PURCHASES AND/OR OPERATIONS OF THE CARSON REGIONAL CANCER CENTER. INVESTMENT EARNINGS ON THESE FUNDS ARE RESTRICTED AS TO USE. GENERAL ENDOWMENT FUNDS ARE PERMANENTLY SET ASIDE TO GENERATE INVESTMENT EARNINGS. INVESTMENT EARNINGS ON THESE FUNDS ARE NOT RESTRICTED AS TO USE. THE HOSPICE ENDOWMENT FUNDS ARE PERMANENTLY SET ASIDE TO GENERATE INVESTMENT EARNINGS TO BENEFIT THE HOSPICE PROGRAM AND ITS PATIENTS. INVESTMENT INCOME ON THESE FUNDS IS RESTRICTED AS TO USE. THE CARDIAC SERVICES ENDOWMENT FUNDS ARE PERMANENTLY SET ASIDE TO GENERATE INVESTMENT EARNINGS TO FUND FAITH REGIONAL HEALTH SERVICE'S CARDIAC PROGRAM CAPITAL AND/OR OPERATIONAL EXPENSES. THE EDUCATION ENDOWMENT FUNDS ARE PERMANENTLY SET ASIDE TO GENERATE INVESTMENT EARNINGS TO BENEFIT FAITH REGIONAL HEALTH SERVICE'S EDUCATION PROGRAMS AND ITS EFFORTS TO RECRUIT AND RETAIN EMPLOYEES. INVESTMENT INCOME ON THESE FUNDS IS RESTRICTED AS TO USE. ST. JOSEPH'S NURSING HOME/SKYVIEW VILLA ENDOWMENT FUNDS ARE PERMANENTLY SET ASIDE TO GENERATE INVESTMENT EARNINGS TO BE USED TO FUND CAPITAL EQUIPMENT PURCHASES AND/OR OPERATION OF ST. JOSEPH'S NURSING HOME AND SKYVIEW VILLA. INVESTMENT EARNINGS ON THESE FUNDS ARE RESTRICTED AS TO USE. THE PEDIATRIC ENDOWMENT FUNDS ARE PERMANENTLY SET ASIDE TO GENERATE INVESTMENT EARNINGS TO BENEFIT FAITH REGIONAL HEALTH SERVICE'S CHILDREN'S CARE FUND. DONORS MAY SPECIFY CONTRIBUTIONS TO ANY OF THE ENDOWMENT FUNDS. PART X, LINE 2: FAITH REGIONAL HEALTH SERVICES ACCOUNTS FOR UNCERTAINTIES IN ACCOUNTING FOR INCOME TAX ASSETS AND LIABILITIES USING GUIDANCE INCLUDED IN FASB ASC 740, INCOME TAXES. FAITH RECOGNIZES THE EFFECT OF INCOME TAX POSITIONS ONLY IF THOSE POSITIONS ARE MORE LIKELY THAN NOT OF BEING SUSTAINED. AT DECEMBER 31, 2022 AND 2021, FAITH HAD NO UNCERTAIN TAX POSITIONS ACCRUED. 1 1 X 1 X 400.000000000000 1 X 1 1 1 0 1 0 198 584566 415738 168828 0.00060 9208 16204239 11730665 4473574 0.01680 9406 16788805 12146403 4642402 0.01740 2686066 0 2686066 0.01010 1444370 0 1444370 0.00540 3417740 0 3417740 0.01280 352541 0 352541 0.00130 7900717 7900717 0.02960 9406 24689522 12146403 12543119 0.04700 1 11613088 0 46746527 61921882 -15175355 X 1 1 1 NORTHEAST NE SURGICAL CENTER LLC SURGICAL SERVICES 0.60420 0.00000 0.39580 2 1 FAITH REGIONAL HEALTH SERVICES - WEST 2700 WEST NORFOLK AVENUE NORFOLK NE 68701 WWW.FRHS.ORG 520001 X X X A 2 FAITH REGIONAL HEALTH SERVICES - EAST 1500 KOENIGSTEIN AVENUE NORFOLK NE 68701 WWW.FRHS.ORG 520002 X X A FACILITY REPORTING GROUP - A 0 0 1 X X X X X X X 22 1 1 1 1 X HTTPS://WWW.FRHS.ORG/ABOUT-US/REPORTS/ X 1 22 1 HTTPS://WWW.FRHS.ORG/ABOUT-US/REPORTS/ 0 1 X 400.000000000000 400.000000000000 X X X X X 1 1 X X X 1 X FRHS.ORG/PATIENTS-VISITORS/BILLING-INSURANCE-FINANCIAL-ASSISTANCE/FINANCIAL X FRHS.ORG/PATIENTS-VISITORS/BILLING-INSURANCE-FINANCIAL-ASSISTANCE/FINANCIAL X FRHS.ORG/PATIENTS-VISITORS/BILLING-INSURANCE-FINANCIAL-ASSISTANCE/FINANCIAL X X X X X X 1 X 0 X X X X 1 X 0 0 PART V, SECTION B FACILITY REPORTING GROUP A FACILITY REPORTING GROUP A CONSISTS OF: - FACILITY 1: FAITH REGIONAL HEALTH SERVICES - WEST, - FACILITY 2: FAITH REGIONAL HEALTH SERVICES - EAST FACILITY REPORTING GROUP - A PART V, SECTION B, LINE 5: THE MULTI-STEP PROCESS BEGAN WITH THE MOBILIZING FOR ACTION THROUGH PLANNING AND PARTNERSHIP (MAPP) PROCESS. A NUMBER OF INDIVIDUALS AND ORGANIZATIONS WITH A COMMON INTEREST IN PUBLIC HEALTH CONTRIBUTED TO IDENTIFYING THE TRENDS, FACTORS, AND EVENTS THAT INFLUENCE THE HEALTH AND QUALITY OF LIFE IN OUR COMMUNITIES AND/OR THE WORK OF THE PUBLIC HEALTH SYSTEM. CONTRIBUTORS REPRESENTED A VARIETY OF ARENAS, SECTORS AND BACKGROUNDS, AND EVERY EFFORT WAS PLACED ON HAVING EQUAL AND FAIR REPRESENTATION ACROSS ALL COUNTIES AND SECTOR FOCUS AREAS. INPUT FROM DIVERSE SECTORS INVOLVED IN PUBLIC HEALTH WAS OBTAINED THROUGH KEY INFORMANT INTERVIEWS FROM THE FOLLOWING GROUPS:-ECONOMIC DEVELOPMENT-CHAMBER OF COMMERCE-FINANCIAL INSTITUTION-HOSPITAL/CLINIC WORKERS-ELVPHD BOARD OF HEALTH-TRAILS COMMITTEE MEMBERS-LONG-TERM CARE-MEDICAL RESPONSE SYSTEMS-NEBRASKA DHHS-VETERAN SERVICE OFFICER-UNL COUNTY EXTENSION-ELECTED OFFICIALS-JUVENILE DIVERSION-LEAGUE OF HUMAN DIGNITY-NORFOLK SAFE COMMUNITIES-BEHAVIORAL HEALTH-HOSPITAL BOARD MEMBERS-NEBRASKA SEE TO LEARN PROGRAM-PUBLIC HEALTH LIAISON/ADVOCATE-SCHOOL NURSES AND SCHOOL ADMINISTRATORS-CENTER FOR RURAL AFFAIRS-CUMING COUNTY PUBLIC POWER DISTRICT-LAW ENFORCEMENT-INSTITUTES OF HIGHER EDUCATION-COMMUNITY-BASED ORGANIZATIONS-CITY EMPLOYEES-NEBRASKA BICYCLING ALLIANCE-AREA AGENCY ON AGING-PONCA TRIBE OF NEBRASKA-FEDERALLY-QUALIFIED HEALTH CENTER-NORFOLK FAMILY COALITION-NEIGHBORING LOCAL PUBLIC HEALTH DEPARTMENTSCOMMUNITY ENGAGEMENT WAS AN OVERARCHING CONCEPT ENCOMPASSING THE COMMUNITY HEALTH NEEDS ASSESSMENT AND FORMATION OF THE COMMUNITY HEALTH IMPROVEMENT PLAN. FACILITY REPORTING GROUP - A PART V, SECTION B, LINE 6A: FAITH REGIONAL HEALTH SERVICES - WEST AND FAITH REGIONAL HEALTH SERVICES - EAST PARTNERED WITH THE ELKHORN LOGAN VALLEY PUBLIC HEALTH DEPARTMENT (ELVPHD) AND ITS RESPECTIVE DISTRICT HOSPITALS TO COMPLETE THE CHNA, THOSE HOSPITALS ARE AS FOLLOWS:-ST. FRANCIS MEMORIAL HOSPITAL, WEST POINT, NE (CUMING COUNTY) FACILITY REPORTING GROUP - A PART V, SECTION B, LINE 6B: FAITH REGIONAL HEALTH SERVICES PARTNERED WITH ITS LOCAL HEALTH DEPARTMENT, ELKHORN LOGAN VALLEY PUBLIC HEALTH DEPARTMENT TO COMPLETE THE CHNA. FACILITY REPORTING GROUP - A PART V, SECTION B, LINE 11: FAITH REGIONAL HEALTH SERVICES HAS IDENTIFIED TWO PRIORITY AREAS IN THE CHNA: CANCER PREVENTION AND SCREENING AND BEHAVIORAL/MENTAL HEALTH. FOR EACH OF THESE AREAS, GOALS AND IMPLEMENTATION STRATEGIES ARE IDENTIFIED IN THE HOSPITAL COMMUNITY HEALTH IMPLEMENTATION PLAN.THE GOALS FOCUSED ON CANCER PREVENTION AND SCREENING INCLUDE THE FOLLOWING: 1) INCREASE CANCER SCREENING AND PREVENTION IN OUR SERVICE AREA. 2) INCREASING PATIENT AND PROVIDER COMMUNICATION ABOUT SCREENINGS UTILIZING ELECTRONIC HEALTH RECORD (HER) EPIC. 3) DECREASED THE BURDEN OF OBESITY IN THE ELVPHD DISTRICT AS A SIGNIFICANT RISK FACTOR FOR CANCER.THE GOALS FOCUSED ON BEHAVIORAL/MENTAL HEALTH INCLUDE THE FOLLOWING: 1) INCREASE INTERNSHIP AND PRECEPTORSHIP OPPORTUNITIES IN THE INPATIENT OR OUTPATIENT SETTINGS FOR MENTAL HEALTH NURSING, MENTAL HEALTH THERAPISTS AND SOCIAL WORK DEGREES. 2) INCREASE TELEHEALTH ENCOUNTERS IN THE OUTPATIENT CLINIC IN BOTH MED MANAGEMENT AND THERAPY ENCOUNTERS. 3) DECREASE FINANCIAL BARRIERS TO INDIVIDUALS RECEIVING MENTAL HEALTH SERVICES, INPATIENT AND OUTPATIENT THROUGH USE OF REGION IV FUNDING.THERE WERE NOT ANY NEEDS IDENTIFIED IN THE CHNA THAT ARE NOT BEING ADDRESSED BY THE HOSPITAL. FACILITY REPORTING GROUP - A PART V, SECTION B, LINE 13B: FOR MEDICARE PATIENTS, THE HOSPITAL MAY USE THE ORIGINAL DETERMINATION AMOUNT. 2 1 - NORTHEAST NE SURGERY CENTER LLC 301 NORTH 27TH ST STE 3 NORFOLK NE 68701 SURGERY CENTER 3 - ST JOSEPH REHABILITATION & CARE CTR 401 N 18TH STREET NORFOLK NE 68701 SKILLED NURSING FACILITY PART I, LINE 3C: FAITH REGIONAL USES THE FEDERAL POVERTY GUIDELINES TO DETERMINE ELIGIBILITY FOR DISCOUNTED CARE. FINANCIALLY RESPONSIBLE PARTIES WHO SUBMIT A COMPLETE, VERIFIABLE APPLICATION FOR FINANCIAL ASSISTANCE WILL BE CONSIDERED FOR FREE OR REDUCED "CHARITY CARE" FINANCIAL ASSISTANCE ON THE BASIS OF THE FEDERAL POVERTY GUIDELINES (400% FPG LIMIT).ELIGIBILITY FOR THIS PROGRAM WILL BE DETERMINED BY FAMILY SIZE, GROSS INCOME BASED ON THE FEDERAL POVERY GUIDELINES AND AN ASSET TEST. THE GROSS INCOME LEVELS ARE UPDATED EACH YEAR AS THE FEDERAL POVERTY GUIDELINES ARE UPDATED.CHARITY CARE MAY BE GRANTED WITH RESPECT TO ANY DOLLARS OWED BY A FINANCIALLY RESPONSIBLE PARTY, INCLUDING, BUT NOT LIMITED TO, DEDUCTIBLE, COINSURANCE AND COPAYMENT AMOUNTS; CHARGES FOR NON-COVERED SERVICES AND MEDICAID COST OF SHARE AMOUNTS.CHARITY CARE MAY BE AUTHORIZED FOR FINANCIALLY RESPONSIBLE PARTIES WITH INCOME LEVELS EXCEEDING 400% FPG IN THE CASE OF UNUSUAL, SPECIAL AND/OR EXTENUATING CIRCUMSTANCES. THESE INSTANCES ARE GENERALLY DUE TO MEDICAL CATASTROPHE SITUATIONS. PART I, LINE 6A: FAITH REGIONAL'S ANNUAL COMMUNITY BENEFIT REPORT IS NOT PREPARED BY A RELATED ORGANIZATION. PART I, LINE 7: FAITH REGIONAL USES A COST ACCOUNTING SYSTEM TO DETERMINE COSTS REPORTABLE ON PART I, LINE 7 (AND ELSEWHERE ON SCHEDULE H). THE FIRST STEP IN THE COST ACCOUNTING PROCESS IS TO ALLOCATE THE OVERHEAD EXPENSES (ADMINISTRATION AND GENERAL, PLANT, ETC) TO THE REVENUE PRODUCING DEPARTMENTS (OPERATING ROOM, IMAGING, ONCOLOGY, ETC). THIS IS DONE SIMILAR TO THE MEDICARE COST REPORT USING A SINGLE STEP DOWN METHOD TO ALLOCATE THE COSTS USING APPLICABLE STATISTICS. FOR EXAMPLE: PLANT EXPENSES ARE ALLOCATED DOWN TO THE OTHER DEPARTMENTS USING CURRENT SQUARE FOOTAGE SO DEPARTMENTS WITH MORE SQUARE FOOTAGE WILL BE ALLOCATED MORE PLANT EXPENSES; DIETARY EXPENSES ARE ALLOCATED BASED ON MEALS SERVED; EMPLOYEE BENEFITS ARE ALLOCATED BASED ON SALARIES; ADMINISTRATIVE AND GENERAL EXPENSES ARE ALLOCATED BASED ON ACCUMULATED COSTS; AND SO ON. ONCE ALL THE OVERHEAD EXPENSES ARE ALLOCATED TO THE REVENUE PRODUCING DEPARTMENTS THE COSTS ARE FURTHER ALLOCATED DOWN TO THE CHARGE CODE LEVEL. IN ORDER TO DO THIS, TWO DIFFERENT METHODS ARE USED DEPENDING ON THE DEPARTMENT. SPECIFIC DEPARTMENTS USE A RVU (RELATIVE VALUE UNIT) ALLOCATION WHERE EACH PROCEDURE IS WEIGHTED BY THE INTENSITY OF THE SERVICE AND IS THEN ALLOCATED COST BASED ON THAT LEVEL OF INTENSITY. FOR EXAMPLE AN XRAY WITH SEDATION IS MORE COMPLICATED AND TIME INTENSIVE THAN A SIMPLE CHEST XRAY SO IT WOULD HAVE A HIGHER RVU VALUE AND, IN TURN, A HIGHER COST ALLOCATED TO IT. THE DEPARTMENTS USING THIS ALLOCATION METHOD ARE IMAGING, CARDIAC CATH, CT, MRI, ULTRASOUND, NUCLEAR MEDICINE, RADIATION ONCOLOGY, AND REHAB (PHYSICAL, OCCUPATIONAL AND SPEECH THERAPY).THE OTHER DEPARTMENTS USE A RATIO OF COST TO CHARGE METHOD TO ALLOCATE THE COSTS DOWN TO THE CHARGE CODE LEVEL.AFTER ALL THE COSTS HAVE BEEN ALLOCATED TO THE CHARGE CODES THE COSTING IS APPLIED TO ALL PATIENT ACCOUNTS BASED ON THEIR CHARGES TO DETERMINE THE COST OF THEIR ENCOUNTER AND THEN REPORTS CAN BE RUN TO DETERMINE THE PROFITABILITY OF CERTAIN PAYORS, SERVICE LINES OR DEPARTMENTS. PART I, LINE 7G: MANY SERVICES PROVIDED BY FAITH REGIONAL ARE DONE SO TO MEET SPECIFIC NEEDS OF THE COMMUNITY BECAUSE NO OTHER SERVICES ARE AVAILABLE. AS A RESULT, THESE SERVICES ARE PROVIDED KNOWING THAT THEY WILL NOT BE FINANCIALLY VIABLE OR SELF-SUPPORTING. FAITH REGIONAL DID NOT INCLUDE ANY PHYSICIAN CLINIC EXPENSES AS SUBSIDIZED HEALTH SERVICES. PART II, COMMUNITY BUILDING ACTIVITIES: THE ORGANIZATION DID NOT HAVE ANY COMMUNITY BUILDING ACTIVITIES DURING THE YEAR. PART III, LINE 2: CONSISTENT WITH FAITH'S MISSION, CARE IS PROVIDED TO PATIENTS REGARDLESS OF THEIR ABILITY TO PAY. THEREFORE, FAITH HAS DETERMINED IT 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 FAITH EXPECTS TO COLLECT BASED ON COLLECTION HISTORY WITH THOSE PATIENTS. PART III, LINE 3: FAITH PROVIDES PATIENT FINANCIAL ASSISTANCE TO PATIENTS WHO ARE FINANCIALLY UNABLE TO PAY FOR THE HEALTHCARE SERVICES THEY RECEIVE. IT IS THE POLICY OF FAITH NOT TO PURSUE COLLECTION OF AMOUNTS DETERMINED TO QUALIFY AS PATIENT FINANCIAL ASSISTANCE. ACCORDINGLY, FAITH DOES NOT REPORT THESE AMOUNTS IN OPERATING REVENUE. PART III, LINE 4: THE ORGANIZATION'S FINANCIAL STATEMENTS DO NOT CONTAIN A SPECIFIC FOOTNOTE DESCRIBING BAD DEBT. BAD DEBT EXPENSE IS IDENTIFIED ON THE CONSOLIDATED STATEMENT OF OPERATIONS WHICH IS CONSISTENT WITH THE REPORTING PRACTICE OF OTHER HEALTH CARE ORGANIZATIONS. HOWEVER, THE FOOTNOTES TITLED "PATIENT RECEIVABLES" "PATIENT SERVICE REVENUE AND "PATIENT FINANCIAL ASSISTANCE" CAN BE FOUND ON PAGES 8, 10, 11, AND 12 OF THE ATTACHED AUDITED FINANCIAL STATEMENTS. PART III, LINE 8: "MEDICARE ALLOWABLE COSTS OF CARE" WAS CALCULATED FROM INFORMATION IN THE MEDICARE COST REPORT D, E & H WORKSHEETS. IT DOES NOT INCLUDE ALL OF THE MEDICARE REVENUES AND COSTS. IF ALL OF THE MEDICARE REVENUES AND COSTS WERE INCLUDED, THE SHORTFALL WOULD BE GREATER THAN THAT SHOWN ON LINE 7. THE SHORTFALL REPRESENTS ACTUAL UNREIMBURSED COSTS INCURRED BY FAITH REGIONAL HEALTH SERVICES 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: THROUGHOUT THE COLLECTION PROCESS EACH ACCOUNT IS ALSO CONSIDERED FOR FINANCIAL ASSISTANCE FOR THOSE GUARANTORS THAT ARE FINANCIALLY UNABLE TO PAY OR EXPRESS INABILITY TO PAY. ALL CORRESPONDENCE, INCLUDING STATEMENTS AND COLLECTION LETTERS INCLUDE A STATEMENT THAT "FINANCIAL ASSISTANCE MAY BE AVAILABLE." ACCOUNTS THAT ARE NOT SUCCESSFULLY RESOLVED ARE CONSIDERED FOR REFERRAL TO OUTSIDE COLLECTION AGENCIES. THE PATIENT ACCOUNTS' STAFF MEMBER WILL REVIEW THE ACCOUNT TO INSURE ALL PROCESSES ARE COMPLETE, AND THEN FLAG THE ACCOUNT TO BE SENT TO OUTSIDE COLLECTION AGENCIES. THE COLLECTION AGENCIES UTILIZED ALSO HAVE COPIES OF THE FINANCIAL ASSISTANCE POLICY AND APPLICATION IF THE NEED ARISES. PART VI, LINE 2: FAITH REGIONAL CHOSE TO PARTNER WITH THE ELKHORN LOGAN VALLEY PUBLIC HEALTH DEPARTMENT (ELVPHD) AND ITS RESPECTIVE DISTRICT HOSPITALS TO COMPLETE THE JOINT COMMUNITY HEALTH NEEDS ASSESSMENT (CHNA) IN 2022. IN ADDITION TO THE PUBLIC HEALTH DEPARTMENT'S ASSESSMENT, FAITH REGIONAL IS INTIMATELY INVOLVED IN THE ELKHORN ECONOMIC DEVELOPMENT ASSOCIATION, BOTH ON THE BOARD AND THROUGH FINANCIAL SUPPORT. THAT INVOLVEMENT IS INTENDED TO FACILITATE COMMUNITY GROWTH, JOB DEVELOPMENT, INFRASTRUCTURE DEVELOPMENT AND BUSINESS EDUCATION/TRAINING. FAITH REGIONAL IS ALSO A MEMBER OF THE NORFOLK CHAMBER OF COMMERCE WHICH IS INVOLVED IN BUSINESS RETAIL DEVELOPMENT AND SUPPORT AS WELL AS THE COMMUNITY IMPROVEMENT PROJECTS. FAITH ALSO WORKS WITH ORGANIZATIONS LIKE THE ORPHAN GRAIN TRAIN IN PROVIDING MEDICINE AND MEDICAL EQUIPMENT/SUPPLIES TO OTHER NATIONS IN NEED. PART VI, LINE 3: PATIENTS RECEIVING CARE ARE GIVEN INFORMATION REGARDING FAITH REGIONAL'S FINANCIAL ASSISTANCE PROGRAM THROUGH THE USE OF BROCHURES HANDED OUT BY REGISTRATION, HOSPITAL SOCIAL SERVICES, M.A.S.H. (MEDICAL ADVOCACY SERVICES FOR HEALTHCARE) PERSONNEL AND BY PATIENT ACCOUNTS STAFF. ANY PATIENT OR FAMILY MEMBER THAT EXPRESSES CONCERN REGARDING ABILITY TO PAY FOR SERVICES WILL BE DIRECTED TO A SOCIAL WORKER, REGISTRATION CLERK, CASHIER OR FINANCIAL SERVICES REPRESENTATIVE WHO WILL THEN GIVE THEM AN APPLICATION FOR PATIENT FINANCIAL ASSISTANCE ALONG WITH A BROCHURE EXPLAINING HOW TO COMPLETE THE APPLICATION. THE APPLICATION WILL NEED TO BE SUBMITTED ALONG WITH PROOF OF THEIR GROSS INCOME FOR THE PRECEDING THREE MONTHS. THIS CAN BE ACCOMPLISHED BY PROVIDING CHECK STUBS FOR THE PRECEDING THREE MONTHS, PROVIDING THE MOST RECENTLY FILED STATE AND FEDERAL TAX RETURNS, PROVIDING A PROFIT AND LOSS STATEMENT IF SELF-EMPLOYED OR BY PRESENTING A STATEMENT FROM THEIR EMPLOYER (ON COMPANY LETTERHEAD) INDICATING GROSS INCOME FOR EACH OF THE PREVIOUS THREE MONTHS. MEDICARE PATIENTS MAY SHOW THEIR ORIGINAL DETERMINATION AMOUNT, A PHOTOCOPY OF A MONTHLY CHECK OR A COPY OF THEIR BANK STATEMENT.THE FINANCIAL SERVICES REPRESENTATIVE WILL THEN MULTIPLY THE GROSS INCOME FOR THE THREE MONTHS BY FOUR TO GET AN ANNUAL GROSS INCOME. THE FINANCIAL SERVICE REPRESENTATIVE WILL ALSO REVIEW THE PATIENT'S ASSETS TO SEE IF THERE IS SUFFICIENT EQUITY TO HELP PAY FOR HEALTH SERVICES. THE EQUITY OF ASSETS WILL BE DETERMINED AS FOLLOWS: REAL ESTATE - WE WILL EXCLUDE THE PRIMARY RESIDENCE ALONG WITH UP TO 1 ACRE OF LAND THAT THE RESIDENCE IS ON; WE WILL INCLUDE RENTAL PROPERTIES, ALL HOMES OR REAL PROPERTY ABOVE AND BEYOND THE PRIMARY RESIDENCE, CABINS, RECREATIONAL PROPERTY, ETC., AS WELL AS REAL ESTATE OWNED FOR BUSINESS PURPOSES.PERSONAL PROPERTY - WE WILL EXCLUDE ONE VEHICLE PER WAGE EARNER (OR SOCIAL SECURITY OR DISABILITY RECIPIENT); WE WILL CONSIDER THE EQUITY IN MOTOR VEHICLES (MOTORCYCLES, MOTOR HOMES, BOATS, BOAT TRAILERS AND ATVS).OTHER PERSONAL PROPERTY WILL INCLUDE STOCKS, BONDS, CDS, FUTURES, ANTIQUE COLLECTIBLES AND ANY OTHER COLLECTIONS OF VALUE.THE HOUSEHOLD SIZE WILL BE DETERMINED USING THE FEDERAL HOUSEHOLD DEFINITIONS.IF THERE IS AN OMISSION OF INFORMATION ON THE APPLICATIONS OR INFORMATION PROVIDED APPEARS TO BE INCORRECT, A LETTER WILL BE SENT TO THE PATIENT REQUESTING THE MISSING INFORMATION OR REQUESTING CLARIFICATION OF THE INFORMATION. THE DATE THAT THE LETTER IS SENT WILL BE DOCUMENTED ON A LOG OF PENDING APPLICATIONS. IF THE REQUESTED DOCUMENTATION IS NOT RETURNED IN NINE WORKING DAYS, THE APPLICATION WILL BE DENIED.FINANCIAL SERVICES WILL REVIEW THE APPLICATION AND ASSETS AND MAKE A DETERMINATION WITHIN 10 DAYS OF THE RECEIPT OF A COMPLETE APPLICATION. THE FINANCIAL COUNSELOR WILL THEN NOTIFY (BY LETTER) THE PATIENT INDICATING THAT THE APPLICATION HAS BEEN APPROVED OR DENIED. IF THE APPLICATION IS DENIED THE PATIENT MAY APPLY AGAIN IF THEIR FINANCIAL CIRCUMSTANCES CHANGE FOR SERVICES NOT PREVIOUSLY IN COLLECTIONS AND NO FURTHER BACK THAN SIX MONTHS FROM THE DATE OF APPLICATION FOR ACTIVE ACCOUNTS. PART VI, LINE 4: FAITH REGIONAL'S PRIMARY SERVICE AREA CONSISTS OF ANTELOPE, BOONE, HOLT, KNOX, MADISON, PIERCE, PLATTE, STANTON AND WAYNE COUNTIES IN NEBRASKA REPRESENTING A POPULATION OF APPROXIMATELY 90,000 PEOPLE. THE HOSPITAL'S SECONDARY SERVICE AREA CONSISTS OF CEDAR, COLFAX, CUMING AND DIXON COUNTIES IN NEBRASKA REPRESENTING APPROXIMATELY 35,000 PEOPLE. FAITH REGIONAL ALSO HAS A TERTIARY SERVICE AREA OF BOYD, BROWN, BURT, CHERRY, DAKOTA, GARFIELD, KAYA PAHA, NANCE, ROCK, THURSTON AND WHEELER COUNTIES IN NEBRASKA WITH APPROXIMATELY A POPULATION OF 57,400.BASED ON THE 2015 U.S. CENSUS INFORMATION, THE ABOVE COUNTIES IN THE FRHS PRIMARY AND SECONDARY SERVICE AREAS REPRESENT A TOTAL POPULATION OF 155,935. THE AVERAGE AGE IS 41.1 YEARS AND CONSISTS MOSTLY OF WHITE AT 92.7%, HISPANIC OR LATINO AT 8.2% AND BLACK OR AFRICAN AMERICAN AT .4%.THE MEDIAN HOUSEHOLD INCOME OF OUR SERVICE AREA IS $45,527 AND THE PER CAPITA INCOME IS $22,551, COMPARED TO THE MEDIAN HOUSEHOLD INCOME FOR NEBRASKA AT $50,695 AND THE PER CAPITA INCOME AT $26,113. PART VI, LINE 5: FAITH REGIONAL, A NOT-FOR-PROFIT HEALTH CARE FACILITY, LOCATED IN NORTHEAST NEBRASKA, OPERATES FOR THE BENEFIT OF THE INDIVIDUALS IN THE SERVICE AREA. FAITH REGIONAL SERVES ALL PATIENTS REGARDLESS OF THEIR ABILITY TO PAY AND DOES NOT LIMIT ITS SERVICES OR DISCRIMINATE AGAINST ANYONE ON THE BASIS OF RACE, COLOR, SEX, NATIONAL ORIGIN, SEXUAL ORIENTATION, RELIGION, AGE, DISABILITY, DISEASE OR DIAGNOSIS. FAITH REGIONAL ALSO PROVIDES COMMUNICATIONS SERVICES (E.G. BILINGUAL STAFF AND INTERPRETERS, SIGN LANGUAGE INTERPRETERS, TDD SERVICES, ETC) FOR SENSORY IMPAIRED INDIVIDUALS. FAITH REGIONAL EVALUATES ITSELF ON ITS EFFECTIVENESS ANNUALLY BY EXAMINING ITS ABILITY TO FULFILL ITS MISSION, ACCOMPLISH ITS VISION, PROVIDE SERVICE AND MAINTAIN ITS VALUES. FAITH REGIONAL'S MISSION, VISION, SERVICE AND VALUES ARE: THE MISSION: THE MISSION IS TO SERVE CHRIST BY PROVIDING ALL PEOPLE WITH EXEMPLARY MEDICAL SERVICES IN AN ENVIRONMENT OF LOVE AND CARE.THE VISION: THE VISION OF FAITH REGIONAL HEALTH SERVICES IS TO BECOME A REGIONAL REFERRAL CENTER BY PROVIDING THE MOST COMPREHENSIVE, HIGH QUALITY HEALTH SERVICES TO THE RESIDENTS OF NORTHEAST NEBRASKA. THE VALUES:-SPIRITUALITY-EXCELLENCE-INTEGRITY-COMPASSION-RESPECT-STEWARDSHIPFAITH REGIONAL'S PROGRAM SERVICE ACCOMPLISHMENTS ARE BASED ON THE COMMUNITY ACCOUNTABILITY STANDARDS DEVELOPED BY THE VOLUNTARY HOSPITALS OF AMERICA (VHA). THESE FOUR STANDARDS ARE:1) DEMONSTRATE LEADERSHIP AS A CHARITABLE INSTITUTION.2) PROVIDING ESSENTIAL HEALTH CARE SERVICES.3) BEING ACCOUNTABLE TO THE COMMUNITY.4) MAINTAINING EVIDENCE OF COMMITMENT TO COMMUNITY BENEFIT.FAITH REGIONAL RECOGNIZES ITS OBLIGATION TO DEMONSTRATE LEADERSHIP AS A CHARITABLE ORGANIZATION BY PROVIDING A FULL RANGE OF HEALTH CARE, HEALTH EDUCATION AND WELLNESS RELATED SERVICES TO THE COMMUNITY, AND PARTICIPATING IN FEDERAL, STATE AND LOCAL PROGRAMS TO PROVIDE HEALTH BENEFITS TO THOSE IN NEED. FAITH REGIONAL FINANCIALLY SUPPORTS VARIOUS OUTREACH ACTIVITIES IN WHICH HOSPITAL PROVIDERS TRAVEL OUT TO SURROUNDING COMMUNITIES TO PROVIDE SERVICES WHICH MAY OTHERWISE NOT BE AVAILABLE. FAITH REGIONAL PROVIDES TRANSPORTATION SERVICES PRIMARILY TO RADIATION ONCOLOGY PATIENTS AT NO CHARGE.FAITH REGIONAL REMAINS ACCOUNTABLE TO THE COMMUNITY BY WORKING WITH A VOLUNTEER GOVERNING BOARD THAT IS REPRESENTATIVE OF THE COMMUNITY IT SERVES. COOPERATION WITH COMMUNITY BASED HEALTH ORGANIZATIONS IDENTIFY PERTINENT ISSUES RELATED TO ESSENTIAL SERVICES, CHARITY CARE, HEALTH CARE COST CONTAINMENT, COMMUNITY BENEFIT ACTIVITIES AND OTHERS AS APPROPRIATE. FAITH REGIONAL CONTINUES TO OPERATE UNDER A VOLUNTEER GOVERNING BOARD AND REMAINS ACTIVELY INVOLVED IN ADVOCATING PUBLIC AWARENESS OF HEALTH CARE AND HEALTH CARE POLICY ISSUES. DISCLOSURES OF COMMUNITY BENEFIT INFORMATION AND ADVOCACY ISSUES ARE PROVIDED THROUGH A VARIETY OF MEDIA INCLUDING MEDIA RELEASES AND ITS INTERNET WEBSITE: WWW.FRHS.ORG.FAITH REGIONAL'S CONTRIBUTION TO THE COMMUNITY NOT ONLY INCLUDES COMPENSATED AND DONATED TIME BUT ALSO EQUIPMENT, MATERIALS AND SPACE. MEETING ROOMS ARE PROVIDED AS NEEDED AND EQUIPMENT AND MATERIALS (E.G. COMPUTERS, COPIER, FAXES, TELEPHONES, CHILDBIRTH PROPS, PROJECTORS, MANNEQUINS, HEARING BOOTH, AUDIOMETERS, BEDS, MONITORS, WARMING UNITS, MINOR INSTRUMENTS, ETC.) ARE PROVIDED AT NO CHARGE. A MAJOR CONCERN IN HEALTH CARE THAT CAN SOMETIMES BE "HIDDEN" IS THAT OF SEXUAL ABUSE AND NEGLECT IN CHILDREN. THE NORTHEAST NEBRASKA CHILD ADVOCACY PROGRAM AT FAITH REGIONAL PROVIDES A SAFE, NON THREATENING ENVIRONMENT WHERE CHILDREN (AGES INFANT TO 18) WHO ARE VICTIMS OF ABUSE RECEIVE IMMEDIATE MEDICAL CARE AND FORENSIC INTERVIEWS FROM VARIOUS AGENCIES WORKING TOGETHER. ALL OF THESE SERVICES ARE AVAILABLE FREE TO FAMILIES WITHIN A 24-COUNTY AREA. PART VI, LINE 6: FAITH REGIONAL IS NOT PART OF AN AFFILIATED HEALTH CARE SYSTEM. PART VI, LINE 7: NOT APPLICABLE 1 NE NEBRASKA ALL STAR CLASSIC 309 N 5TH ST NORFOLK NE 68701 461257935 501(C)(3) 20000 0 SPONSORSHIPS FOR THE GIRLS NORFOLK PO BOX 1124 NORFOLK NE 68702 460972709 501(C)(3) 7500 0 SPONSORSHIPS NORFOLK AREA UNITED WAY PO BOX 1041 NORFOLK NE 68702 470492054 501(C)(3) 6000 0 ANNUAL GIVING/CAPITAL CAMPAIGN NORFOLK FAMILY YMCA 301 W BENJAMIN AVE NORFOLK NE 68701 465709553 501(C)(3) 105000 0 FACILITY EXPANSION AND ROUNDTABLE EVENT GREATER NORFOLK ECONOMIC DEVELOPMENT FOUNDATION 609 W NORFOLK AVE NORFOLK NE 68701 363441719 501(C)(3) 50000 0 TO PROVIDE TRANSPORTATION FOR EMPLOYEES TO AND FROM WORK. KNIGHTS OF AKSARBEN FOUNDATION 2120 SOUTH 72ND ST STE 800 OMAHA NE 68124 470447496 501(C)(3) 10000 0 SPONSORSHIPS 6 0 PART I, LINE 2: CASH DONATIONS ARE MADE TO ORGANIZATIONS, MANY OF WHICH HAVE HEALTH CARE OR SOCIAL SERVICES MISSIONS. THESE DONATIONS ARE SOMETIMES RESTRICTED FOR A SPECIFIC USE OR ACTIVITY. 501(C)(3) ORGANIZATIONS ARE BOUND BY THEIR ARTICLES OF ORGANIZATION AND STATED MISSIONS TO CONDUCT ACTIVITIES STRICTLY FOR CHARITABLE PURPOSES. FAITH REGIONAL DOES NOT REQUEST GRANT REPORTS FROM DONEE CHARITABLE ORGANIZATIONS. X X X X 0 0 0 0 0 0 0 1 0 FADI RZOUQ MD PHYSICIAN 963601 0 3409371 0 540 0 12200 0 36674 0 4422386 0 0 0 TRISTAN L HARTZELL MD PHYSICIAN 1079338 0 2600880 0 540 0 0 0 1398 0 3682156 0 0 0 JOHN LAMMLI MD PHYSICIAN 703770 0 494062 0 540 0 12200 0 34096 0 1244668 0 0 0 NATHAN HERMAN MD PHYSICIAN 510317 0 651702 0 304 0 12200 0 37356 0 1211879 0 0 0 BEETHOVEN BROWN MD PHYSICIAN 1169513 0 0 0 8098 0 9324 0 1759 0 1188694 0 0 0 KELLY DRISCOLL CEO 685108 0 60829 0 12760 0 12200 0 36657 0 807554 0 0 0 ROBERT PRINCE MD MEMBER - MEDICAL DIRECTOR 676614 0 63933 0 3564 0 9150 0 35871 0 789132 0 0 0 LANE HANDKE MD MEMBER - CHIEF OF STAFF 547335 0 0 0 1709 0 15016 0 27354 0 591414 0 0 0 JANNA CLINE VP FINANCE 237122 0 500 0 776 0 7277 0 22872 0 268547 0 0 0 PART I, LINE 7 PHYSICIANS HAVE AN OPPORTUNITY TO EARN PRODUCTION BONUSES IF THE PROVIDER REACHES ABOVE RELATIVE VALUE UNIT AMOUNTS. PAYOUTS ARE DEPENDENT ON THEIR BASE SALARY PERCENTILE. PHYSICIANS ALSO HAVE AN OPPORTUNITY TO EARN A QUALITY BONUS IF THEY MEET CERTAIN CRITERIA THROUGHOUT THE YEAR WHICH INCLUDES MIPS-QPP TARGETS, MEETING ATTENDANCE, COMMUNITY SERVICE, AND EVENT SPONSORSHIPS. PHYSICIANS RECEIVING THESE BONUSES DURING THE YEAR INCLUDE THE FOLLOWING: TRISTAN HARTZELL, M.D. FADI RZOUQ, M.D. NATHAN HERMAN, M.D. JOHN LAMMLI, M.D. ROBERT PRINCE, M.D. A HOSPITAL AUTHORITY #1 OF MADISON COUNTY NEBRASKA 521357975 557352EX5 2017-08-17 44772246 REFUND PRIOR ISSUES (07/10/08 & 11/20/08) 0 0 0 B HOSPITAL AUTHORITY #1 OF MADISON COUNTY NEBRASKA 521357975 2018-01-01 12075000 REFUND PRIOR ISSUES (8/17/17) 0 0 0 C HOSPITAL AUTHORITY #1 OF MADISON COUNTY NEBRASKA 521357975 557352FQ9 2018-05-10 32483481 CONSTRUCT FACILITY 0 0 0 A 19545000 45107444 712032 44395412 2010 1 1 1 1 B 6175000 12075000 12075000 2010 1 0 1 1 C 3920000 32804303 22597 580862 32200844 2019 0 0 1 1 A 0 0 0 0 0.00540 0.00000 0.00540 0 0 0 B 0 0 0 0 0.00540 0.00000 0.00540 0 0 0 C 0 0 0 0 0.00000 0.00000 0.00000 0 0 0 A 0 0 0 1 0 0 0 0 1 B 0 0 0 1 0 0 0 0 1 C 0 0 0 1 0 0 0 0 1 A 1 B 1 C 1 DATE REBATE COMPUTATION PERFORMED ISSUER NAME: HOSPITAL AUTHORITY #1 OF MADISON COUNTY NEBRASKA DATE THE REBATE COMPUTATION WAS PERFORMED: 07/01/2018 ISSUER NAME: HOSPITAL AUTHORITY #1 OF MADISON COUNTY NEBRASKA DATE THE REBATE COMPUTATION WAS PERFORMED: 07/01/2018 ISSUER NAME: HOSPITAL AUTHORITY #1 OF MADISON COUNTY NEBRASKA DATE THE REBATE COMPUTATION WAS PERFORMED: 12/31/2019 SCHEDULE K SUPPLENTAL INFORMATION SCHEDULE K, PART II, LINE 3: THE TOTAL PROCEEDS DO NOT AGREE TO THE ISSUE PRICE IN PART I, COLUMN (E) DUE TO INVESTMENT EARNINGS. SCHEDULE K, PART IV, ARBITRAGE, LINC 2C: NOTE REGARDING THE FIRST REBATE COMPUTATION ON 7/1/18: AS NO REBATABLE ARBITRAGE WAS EARNED ON THE ADVANCE REFUNDING ESCROW AND THE DEBT SERVICE FUND WAS OPERATED ON A BONA RIDE BASIS, NO FURTHER REBATE ANALYSIS IS NECESSARY. NOTE REGARDING THE SECOND REBATE COMPUTATION ON 7/1/18: SINCE THE BOND PROCEEDS HAVE BEEN SPENT, A SPENDING EXCEPTION WAS MET, AND THE DEBT SERVICE FUND WAS OPERATED ON A BONA FIDE BASIS, NO FURTHER REBATE CALCULATIONS ARE NECESSARY. NOTE REGARDING THE COMPUTATION ON 12/31/19: SINCE THE BOND PROCEEDS HAVE BEEN SPENT AND THE DEBT SERVICE FUND WAS OPERATED ON A BONA FIDE BASIS, NO FURTHER REBATE CALCULATIONS ARE NECESSARY. TRACY COLLISON DAUGHTER-IN-LAW OF JACQUE COLLISON, A BOARD MEMBER 140958 TRACY IS AN EMPLOYEE OF FAITH REGIONAL HEALTH SERVICES. 0 CHRISTINE PRINCE WIFE OF ROBERT PRINCE, A BOARD MEMBER 129904 CHRISTINE IS AN EMPLOYEE OF FAITH REGIONAL HEALTH SERVICES. 0 SHARON GOSSMAN MOTHER OF JOSH GOSSMAN, A BOARD MEMBER 186765 SHARON IS AN EMPLOYEE OF FAITH REGIONAL HEALTH SERVICES. 0 KENDRA MITTEIS SISTER OF BRAD DINKEL, A BOARD MEMBER 66482 KENDRA IS AN EMPLOYEE OF FAITH REGIONAL HEALTH SERVICES. 0 FORM 990, PART VI, SECTION A, LINE 1A THE EXECUTIVE COMMITTEE, CONSISTING OF THE IMMEDIATE PAST CHAIR, THE CHAIR, THE VICE CHAIR, THE SECRETARY, THE TREASURER, AND ONE PHYSICIAN BOARD MEMBER, HAS AUTHORITY TO ACT ON BEHALF OF THE GOVERNING BODY. IF THE IMMEDIATE PAST CHAIR IS NO LONGER A VOTING DIRECTOR, HE OR SHE SHALL NEVERTHELESS SERVE IN A VOTING CAPACITY ON THE EXECUTIVE COMMITTEE. FORM 990, PART VI, SECTION A, LINE 6 FAITH REGIONAL HAS ONE NONPROFIT 501(C)(3) CORPORATE MEMBER, LUTHERAN COMMUNITY HOSPITAL ASSOCIATION, A RELATED ORGANIZATION. FORM 990, PART VI, SECTION A, LINE 7A THE SOLE CORPORATE MEMBER, LUTHERAN COMMUNITY HOSPITAL ASSOCIATION, APPOINTS 13 VOTING MEMBERS OF THE BOARD OF DIRECTORS OF FAITH REGIONAL HEALTH SERVICES. FORM 990, PART VI, SECTION A, LINE 7B CERTAIN POWERS ARE RESERVED TO ITS SOLE MEMBER, LUTHERAN COMMUNITY HOSPITAL ASSOCIATION. THERE ARE 13 RESERVED POWERS, INCLUDING APPOINTMENT AND REMOVAL OF DIRECTORS, OTHER THAN CHIEF OF STAFF AND THE PHYSICIAN SERVICES MEDICAL DIRECTOR, AMENDMENT OF THE ARTICLES OF INCORPORATION AND BYLAWS, AMENDMENT OF THE MISSION, VISION AND VALUE STATEMENTS, AMONG OTHERS. FORM 990, PART VI, SECTION B, LINE 11B FORM 990 INFORMATION SCHEDULES ARE COMPLETED IN-HOUSE BY THE REIMBURSEMENT ACCOUNTANT AND REVIEWED BY THE CONTROLLER AND CFO. THE INFORMATION IS PROVIDED FOR RETURN PREPARATION AND SIGNATURE. FORM 990 IS REVIEWED AND DISCUSSED WITH THE CFO AND COPIES OF THE COMPLETED RETURN ARE DISTRIBUTED TO THE BOARD MEMBERS FOR REVIEW PRIOR TO SUBMISSION TO THE IRS. FORM 990, PART VI, SECTION B, LINE 12C FAITH REGIONAL'S BOARD MEMBERS ARE REQUIRED TO SIGN A CONFLICT OF INTEREST STATEMENT AND DISCLOSURE ANNUALLY. ANY CONFLICTS ARE REVIEWED BY BOTH THE GOVERNANCE COMMITTEE AND INDEPENDENT LEGAL COUNSEL. THE GOVERNANCE COMMITTEE PRESENTS RECOMMENDATIONS TO THE FULL BOARD. A MEMBER WITH A CONFLICT IS EXCUSED FROM THE BOARD DELIBERATIONS AND ACTION. FORM 990, PART VI, SECTION B, LINE 15 DETERMINATION OF COMPENSATION FOR THE CEO AND OTHER OFFICERS IS MADE BY GATHERING DATA FROM EXTERNAL SURVEYS AND THE FORM 990 DATA PROVIDED BY COMPARABLE FACILITIES. FACILITIES USED ARE DETERMINED BY SIMILAR BED SIZE, NET REVENUES AND NUMBER OF FTES. WAGES ARE GATHERED AND COMPARED BY TITLE, RESPONSIBILITIES AND YEARS OF EXPERIENCE. THE SALARY RECOMMENDATIONS ARE MADE BY THE HUMAN RESOURCE DEPARTMENT. THE GOVERNING BOARD APPROVES THE SALARY RECOMMENDATIONS FOR THE CEO; THE CEO APPROVES THE RECOMMENDATIONS FOR THE OTHER OFFICERS AND VICE-PRESIDENTS; AND THE VICE-PRESIDENTS APPROVE THE RECOMMENDATIONS FOR THE DIRECTORS OF VARIOUS HOSPITAL DEPARTMENTS. FORM 990, PART VI, SECTION C, LINE 19 FAITH REGIONAL DOES NOT MAKE ITS GOVERNING DOCUMENTS, CONFLICT OF INTEREST POLICY OR FINANCIAL STATEMENTS AVAILABLE TO THE PUBLIC. FORM 990, PART XII, LINE 2C: THE FINANCE/AUDIT COMMITTEE OF THE BOARD OF DIRECTORS ASSUMES RESPONSBILITY FOR OVERSIGHT OF THE AUDIT AND SELECTION OF AN INDEPENDENT ACCOUNTANT. THIS PROCESS HAS NOT CHANGED FROM THE PRIOR YEAR. FAITH REGIONAL PHYSICIAN SERVICES LLC 2700 WEST NORFOLK AVENUE NORFOLK NE 68701 421629846 PHYSICIAN SERVICES NE 46612728 25277471 FAITH REGIONAL HEALTH SERVICES FAITH REGIONAL HEALTH SERVICES PHO INC 2700 WEST NORFOLK AVENUE NORFOLK NE 68701 IMPROVE HEALTHCARE SERVICES NE 0 0 FAITH REGIONAL HEALTH SERVICES ST JOSEPH'S REHABILITATION AND CARE CENTER 401 N 18TH ST NORFOLK NE 68701 470796875 NURSING HOME NE 5970364 6138626 FAITH REGIONAL HEALTH SERVICES LUTHERAN COMMUNITY HOSPITAL ASSOCIATION 2700 W NORFOLK AVE NORFOLK NE 68701 470396139 SUPPORT FAITH REGIONAL HEALTH SERVICES NE 501(C)(3) LINE 3 N/A 0 FAITH REGIONAL HEALTH SERVICES FOUNDATION 2700 W NORFOLK AVE NORFOLK NE 68701 911772474 SUPPORT FAITH REGIONAL HEALTH SERVICES NE 501(C)(3) LINE 12A, I FAITH REGIONAL HEALTH SERVICES 1 NORTHEAST NEBRASKA SURGERY CENTER 301 N 27TH STREET NORFOLK NE 68701 470819088 OUTPATIENT SURGERY NE N/A RELATED 1123094 3045291 0 0 0.60420 0 0 1 1 1 0 0 0 0 1 0 0 1 1 1 0 0 0 0 NORTHEAST NEBRASKA SURGERY CENTER O 2649838 FAIR MARKET VALUE NORTHEAST NEBRASKA SURGERY CENTER J 625585 FAIR MARKET VALUE FAITH REGIONAL HEALTH SERVICES FOUNDATION C 2767691 FAIR MARKET VALUE NORTHEAST NEBRASKA SURGERY CENTER D 425138 FAIR MARKET VALUE