2025-07-14T13:39:18-05:00 2024-08-31 450250958 EIDE BAILLY LLP 18081 BURT ST STE 200 OMAHA NE 680224722 990 2023-09-01 470537192 NIOBRARA VALLEY HOSPITAL NIOB 4025692451 PO BOX 118 LYNCH NE 68746 KELLY KALKOWSKI ADMINISTRATOR 4025692451 2025-07-11 1 1 MEGAN L KOZIOL CPA P01544037 4023302660 2025-07-11 2023 2025-03-06 01:10:19Z KELLY KALKOWSKI PO BOX 118 LYNCH NE 68746 3858948 0 X WWW.NVHCARES.ORG X 1975 NE TO PROVIDE ACUTE HOSPITAL SERVICES. 7 7 37 7 0 0 347212 29762 3345660 3729120 38841 58279 5000 41787 3736713 3858948 550 1100 0 0 1415233 1579466 0 0 0 2093580 2485751 3509363 4066317 227350 -207369 5150479 4825497 363189 266269 4787290 4559228 X TO DELIVER EXCELLENT, COMPASSIONATE AND PERSONALIZED HEALTHCARE FOR THE PEOPLE WE SERVE. 0 0 3288183 1100 3754354 NIOBRARA VALLEY HOSPITAL PROVIDES QUALITY HEALTH CARE REGARDLESS OF RACE, CREED, COLOR, NATIONAL ORIGIN, AGE, SEX, HANDICAP OR ABILITY TO PAY. ALL PERSONS ADMITTED OR TREATED IN THE OUTPATIENT AREA OF THE HOSPITAL SHALL HAVE EQUAL CARE AND TREATMENT AND FULL USE OF ALL HOSPITAL FACILITIES AND SERVICES. REIMBURSEMENT FOR SERVICES RENDERED IS CRITICAL TO THE OPERATION AND STABILITY OF NIOBRARA VALLEY HOSPITAL, BUT IT IS RECOGNIZED THAT NOT ALL INDIVIDUALS POSSESS THE ABILITY TO PURCHASE ESSENTIAL MEDICAL SERVICES. FURTHER, WE STRIVE TO SERVE THE COMMUNITY WITH RESPECT TO PROVIDING HEALTH CARE SERVICES AND HEALTH CARE EDUCATION.THEREFORE, IN KEEPING WITH THIS HOSPITAL'S COMMITMENT TO SERVING ALL MEMBERS OF ITS COMMUNITY: 1.) NIOBRARA VALLEY HOSPITAL MUST BE RESPONSIVE TO THE CHANGING NEEDS OF THE HEALTH CARE INDUSTRY, THE COMMUNITY AND ITS OWN NEEDS. AS NIOBRARA VALLEY HOSPITAL ADAPTS TO THOSE CHANGES, THE HOSPITAL IS DETERMINED TO REMAIN AN INSTITUTION WHERE THE CARE THAT IS RENDERED IS COMPASSIONATE AS WELL AS COMPETENT. 2.) NIOBRARA VALLEY HOSPITAL IS AND SHALL CONTINUE TO BE, A FAMILY CENTERED, COMMUNITY ORIENTED HOSPITAL, OFFERING COMPREHENSIVE MEDICAL SERVICES. 3.) THE STATED PHILOSOPHIES OF NIOBRARA VALLEY HOSPITAL SHALL PERMEATE ALL ACTIVITIES OF THE HOSPITAL AND MOST IMPORTANTLY, THAT OF PATIENT CARE. 4.) THE QUALITY OF PATIENT CARE SHALL CONTINUE TO RECEIVE PRIMARY EMPHASIS AT NIOBRARA VALLEY HOSPITAL. 5.) NIOBRARA VALLEY HOSPITAL SHALL PRUDENTLY UTILIZE ITS RESOURCES THROUGH EFFICIENT AND EFFECTIVE MANAGEMENT; CAREFUL CONSIDERATION SHALL BE GIVEN TO THE COST/BENEFIT RELATIONSHIP OF DELIVERING SERVICES WITHOUT COMPROMISING THE QUALITY OF CARE. 6.) NIOBRARA VALLEY HOSPITAL SHALL PROVIDE AN ATMOSPHERE CONDUCIVE TO THE DEVELOPMENT OF EFFECTIVE WORKING RELATIONSHIPS AMONG THE VARIOUS ELEMENTS NECESSARY BOTH INSIDE AND OUTSIDE THE HOSPITAL FAMILY. THIS FAMILY INCLUDES THE BOARD OF DIRECTORS, MEDICAL STAFF, ADMINISTRATION, EMPLOYEES, THE COMMUNITY, AUXILIARY AND FRIENDS OF THE HOSPITAL. 7.) NIOBRARA VALLEY HOSPITAL SHALL OFFER CONTINUING EDUCATION PROGRAMS AND SERVICES FOR ITS MEDICAL STAFF AND HOSPITAL PERSONNEL. NIOBRARA VALLEY HOSPITAL ALSO SHALL STRIVE TO PROVIDE ITS PATIENTS AND THE COMMUNITY WITH EDUCATION IN HEALTH RELATED MATTERS. 8.) NIOBRARA VALLEY HOSPITAL SHALL PLAN FOR ITS FUTURE. TO THIS END, THE HOSPITAL SHALL COOPERATE WITH OTHER HEALTH CARE PROVIDERS WITHIN THE HEALTH CARE DELIVERY SYSTEM IN A MANNER CONSISTENT WITH ITS STATED PHILOSOPHY. 9.) NIOBRARA VALLEY HOSPITAL SHALL SERVE AS A CATALYST WITHIN THE COMMUNITY TO IDENTIFY THE COMMUNITY'S HEALTH CARE NEEDS, AND SHALL DETERMINE THE LEVEL OF APPROPRIATE PARTICIPATION BY THE HOSPITAL IN MEETING SUCH NEEDS. 10.) NIOBRARA VALLEY HOSPITAL WILL CONSIDER WHERE THE NEED AND/OR THE INDIVIDUAL'S ABILITY TO PAY COEXIST AND OFFER FREE CARE TO THOSE WHO QUALIFY. 11.) NIOBRARA VALLEY HOSPITAL SERVED 60 INPATIENT DAYS, 101 SWING AND RESPITE CARE DAYS AND 442 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. 3288183 1 1 0 1 0 0 0 0 0 0 1 0 0 1 0 1 1 0 0 0 0 0 0 0 0 0 1 1 0 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 33 0 1 37 1 0 0 0 0 0 0 0 0 0 0 0 0 X 7 7 0 1 0 0 0 0 0 1 1 0 0 1 1 1 1 1 1 1 0 0 X MARTHA NELSON 4025692451 PO BOX 118 LYNCH NE 68746 TRACY BIRMEIER PRESIDENT 0.30 X X 0 0 0 LINDA SEXTRO VICE PRESIDENT 0.30 X X 0 0 0 LARRY HIATT SECRETARY 0.30 X X 0 0 0 CRAIG BREWSTER TREASURER 0.30 X X 0 0 0 WANDA DEKAY MEMBER 0.30 X 0 0 0 CINDY NOLAN MEMBER 0.30 X 0 0 0 DARIN RIHANEK MEMBER 0.30 X 0 0 0 MARTHA NELSON CFO 5.00 X 22894 0 0 KELLY KALKOWSKI ADMINISTRATOR 40.00 X 19548 0 0 BREE ALMGREN NURSE PRACTIONER 32.00 X 201956 0 2256 TODD HOPE DOCTOR 40.00 X 108069 0 0 352467 0 2256 2 0 1 1 GRAPETREE MEDICAL STAFFING LLC 2501 BOJI BEND DR STE 10 MILFORD IA 51351 EMPLOYMENT SERVICES 291953 VENTURA MEDSTAFF LLC 2909 N 118TH ST STE 200 OMAHA NE 68164 EMPLOYMENT SERVICES 168160 FAITH REGIONAL HEALTH SERVICES 1500 KOENIGSTEIN AVENUE PO BOX 869 NORFOLK NE 687020869 MANAGEMENT SERVICES 115322 3 15012 14750 29762 PATIENT SERVICE REVENU 624100 3717744 3717744 OTHER REVENUE 624100 10579 10579 LIFELINE REVENUE 624100 797 797 3729120 58279 58279 3450 0 3450 3450 3450 INSURANCE PROCEEDS 624100 25234 25234 CAFETERIA 722514 13103 13103 38337 3858948 3754354 0 74832 X 1100 1100 22894 22894 1395614 1246249 149365 11011 4055 6956 47683 30827 16856 102264 88603 13661 123747 123747 571 571 57630 57630 1285118 1194522 90596 3967 3967 404800 204642 200158 97195 88611 8584 23455 22134 1321 227407 205750 21657 59261 53579 5682 MEDICAL SUPPLIES 128575 128575 MISCELLANEOUS 64532 19120 45412 DUES & SUBSCRIPTIONS 9493 416 9077 4066317 3288183 778134 0 250 250 2719278 2497670 279703 232037 54039 58827 33790 57639 4387403 3092736 1487051 1294667 576368 684407 5150479 4825497 363189 266269 363189 266269 X 4783346 4555284 3944 3944 4787290 4559228 5150479 4825497 X -207369 -20693 X X 0 1 X 1 0 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 0 0 0 0 0 0 0 0 1 654 654 0 PART II-B, LINE 1: NIOBRARA VALLEY HOSPITAL PAYS MEMBERSHIP DUES TO THE NEBRASKA HOSPITAL ASSOCIATION. THE PORTION OF THE DUES PAID THAT ARE USED FOR LOBBYING PURPOSES IS $654. 1000 1000 2245662 1293507 952155 2134336 1792824 341512 6405 6405 0 1294667 INTEREST - NIOBRARA VALLEY HOSPITAL FOUNDATION 371751 ESTIMATED THIRD-PARTY PAYOR SETTLEMENTS 312656 684407 X 3838255 -20693 -20693 3858948 0 3858948 4066317 0 4066317 0 4066317 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, 2024 AND 2023, THE HOSPITAL HAD NO UNCERTAIN TAX POSITIONS ACCRUED. PART XI, LINE 2D - OTHER ADJUSTMENTS: CHANGE IN INTEREST IN NIOBRARA VALLEY HOSPITAL FOUNDATION -20,693. 1 1 X 1 X 0 0 1 0 1 1 460528 221487 239041 0.05880 460528 221487 239041 0.05880 5680 0 5680 0.00140 2697260 562990 2134270 0.52490 1100 0 1100 0.00030 2704040 562990 2141050 0.52660 3164568 784477 2380091 0.58540 1 42000 5082 696479 699203 -2724 X 1 1 1 1 NIOBRARA VALLEY HOSPITAL PO BOX 118 LYNCH NE 68746 WWW.NVHCARES.ORG 050001 X X X NIOBRARA VALLEY HOSPITAL 1 0 0 1 X X X X X X X X X 21 1 1 1 1 X WWW.NVHCARES.ORG/COMMUNITY-HEALTH-NEEDS-ASSESSMENT.HTML X 1 21 1 WWW.NVHCARES.ORG/COMMUNITY-HEALTH-IMPROVEMENT-PLAN.HTML 0 1 X 100.000000000000 X X 1 1 X X X X 1 X WWW.NVHCARES.ORG/FINANCIAL-ASSISTANCE.HTML X WWW.NVHCARES.ORG/FINANCIAL-ASSISTANCE.HTML X WWW.NVHCARES.ORG/FINANCIAL-ASSISTANCE.HTML X X X X X X 1 X 0 X X X X 1 X 0 0 NIOBRARA VALLEY HOSPITAL PART V, SECTION B, LINE 3J: THROUGH THE PROCESSES OF COMPLETING THE COMMUNITY HEALTH NEEDS ASSESSSMENT AND ASSESSING THE RESOURCES AVAILABLE TO THIS ORGANIZATION AND SURROUNDING COMMUNITIES, IT WAS DETERMINED THAT THE MOST SIGNIFICANT NEED TO BE ADDRESSED BY NIOBRARA VALEY HOSPITAL IS THE CARDIOVASCULAR HEALTH OF THE COMMUNITIES ALONG WITH PROMOTING MENTAL HEALTH, PRIMARILY IN THE AREAS OF BLOOD PRESSURE SCREENINGS AND THE RISKS OF ABNORMAL PRESSURE VALUES AND INCREASING THE AWARENESS OF MENTAL HEALTH AND SUICIDE THROUGH EDUCATIONAL PAMPHLETS AND NEWS OUTLETS. NIOBRARA VALLEY HOSPITAL PART V, SECTION B, LINE 5: NIOBRARA VALLEY HOSPITAL ALONG WITH NORTH CENTRAL DISTRICT HEALTH DEPARTMENT (NCDHD) ADMINISTERED AN ONLINE SURVEY VIA SURVEY MONKEY TO GAIN THE PERSPECTIVE OF THE COMMUNITY REGARDING HEALTH, COMMUNITY HEALTH ISSUES AND QUALITY OF LIFE. A TOTAL OF 18 COMMUNITY MEMBERS PARTICIPATED IN THIS SURVEY REPRESENTING THE COMMUNITY. NIOBRARA VALLEY HOSPITAL PART V, SECTION B, LINE 6A: ANTELOPE MEMORIAL HOSPITAL, NELIGH, NE (ANTELOPE COUNTY) AVERA CREIGHTON HOSPITAL, CREIGHTON, NE (KNOX COUNTY) AVERA SAINT ANTHONY'S HOSPITAL, O'NEILL, NE (HOLT COUNTY) BROWN COUNTY HOSPITAL, AINSWORTH, NE (BROWN COUNTY) OSMOND GENERAL HOSPITAL, OSMOND, NE (PIERCE COUNTY) PLAINVIEW COMMUNITY HOSPITAL, PLAINVIEW, NE (PIERCE COUNTY) WEST HOLT MEMORIAL HOSPITAL, ATKINSON, NE (HOLT COUNTY) CHERRY COUNTY HOSPITAL, VALENTINE, NE (CHERRY COUNTY) ROCK COUNTY HOSPITAL, BASSETT, NE (BROWN COUNTY) NIOBRARA VALLEY HOSPITAL PART V, SECTION B, LINE 6B: NORTH CENTRAL DISTRICT HEALTH DEPARTMENT (NCDHD) COUNSELING & ENRICHMENT CENTER BUILDING BLOCKS REGION 4 BEHAVIORAL HEALTH SYSTEM CENTRAL NEBRASKA COMMUNITY ACTION PARTNERSHIP NORTHEAST NEBRASKA COMMUNITY ACTION PARTNERSHIP VALENTINE COMMUNITY SCHOOL NORTHSTAR SERVICES NORTH CENTRAL COMMUNITY CARE PARTNERSHIP AREA SUBSTANCE ABUSE PREVENTION COALITION PROTEUS CENTRAL NEBRASKA ECONOMIC DEVELOPMENT GOOD SAMARITAN SOCIETY- ATKINSON INDIAN HEALTH SERVICES THE EVERGREEN ASSISTED LIVING FACILITY COTTONWOOD BILLA ASSISTED LIVING FACILITY CALVARY BIBLE CHURCH BROWN-ROCK-KEYA PAHA COUNTY O'NEILL PUBLIC SCHOOL BOARD SANTEE SIOUX NATION UNIVERSITY OF NEBRASKA PUBLIC POLICY CENTER O'NEILL CHAMBER OF COMMERCE ESU 17 / AINSWORTH SCHOOLS HOLT COUNTY ECONOMIC DEVELOPMENT NORTHWEST NEBRASKA COMMUNITY ACTION PARTNERSHIP NIOBRARA VALLEY HOSPITAL PART V, SECTION B, LINE 11: IN REVIEWING THE INFORMATION COLLECTED FROM THE CHA NIOBRARA VALLEY HOSPITAL ADDRESSED THE COMMUNITY NEEDS OF BOTH CARDIOVASCULAR HEALTH AND MENTAL HEALTH. WITH HEART DISEASE BEING THE PRIMARY CAUSE OF DEATH FOR THE NCDHD RESIDENTS WE DEEMED THIS A WORTHY CAUSE TO ADDRESS BY PROMOTING BLOOD PRESSURE SCREENINGS, HEALTH SCREENING BLOOD DRAWS, PROMOTING AWARENESS OF THE RISKS OF ABNORMAL BLOOD PRESSURES AND EXPLORING AVENUES FOR PHYSICAL ACTIVITY IN THE COUNTY. MENTAL HEALTH WAS ALSO ONE OF THE TOP CONCERNS IDENTIFIED BY NCDHD CHA RESPONDENTS. THE AVERAGE VALUES ACROSS NCDHD WAS 12.1% FOR FREQUENT MENTAL DISTRESS, COMPARED TO OVERALL NEBRASKA VALUES OF 11.3%. IT WAS ALSO IDENTIFIED THAT ABOUT TWO-THIRDS OF ELDERLY RESIDENTS SURVEYED REPORTED FEELING LONELY OR DISCONNECTED FROM OTHERS (69.6%). FROM THIS NIOBRARA VALLEY HOSPITAL WILL UTILIZE MEDIA OUTLETS TO INCREASE THE AWARENESS OF MENTAL HEALTH AND SUICIDE AND BRING IN MORE OPTIONS FOR TELE-PSYCHIATRY TO THE AREA. DURING THE FISCAL YEAR ENDING 08/31/24 NIOBRARA VALLEY HOSPITAL CONTINUED TO OFFER FREE BLOOD PRESSURE SCREENINGS IN ALL THREE OF OUR CLINICS ON A DAILY BASIS. EDUCATIONAL PAMPHLETS WERE HANDED OUT SHOWING PROPER BLOOD PRESSURE AWARENESS ALONG WITH MENTAL HEALTH INFORMATION TO HELP PROMOTE THE AWARENESS OF MENTAL HEALTH AND SUICIDE.OTHER NEEDS IDENTIFIED BY THE CHNA THAT ARE NOT ADDRESSED IN NIOBRARA VALLEY HOSPITAL'S IMPLEMENTATION STRATEGY ARE: 1.) AGING POPULATION & RELATED ISSUES, 2.) SUBSTANCE ABUSE. NIOBRARA VALLEY HOSPITAL DOES NOT POSSESS THE NECESSARY RESOURCES AND/OR EXPERTISE TO ADDRESS THESE NEEDS. THESE NEEDS WILL BE ADDRESSED BY EXISTING COMMUNITY ASSETS THAT HAVE BEEN IDENTIFIED IN THE LOCAL HEALTH DEPARTMENT PLAN. NIOBRARA VALLEY HOSPITAL PART V, SECTION B, LINE 15E: THE FINANCIAL ASSISTANCE POLICY STATES THE FOLLOWING: PATIENTS WHO BELIEVE THEY MAY QUALIFY FOR FINANCIAL ASSISTANCE UNDER THIS POLICY ARE REQUIRED TO SUBMIT AN APPLICATION ON THE HOSPITAL'S FINANCIAL ASSISTANCE APPLICATION FORM DURING THE APPLICATION PERIOD. NIOBRARA VALLEY HOSPITAL PART V, SECTION B, LINE 16J: THE FINANCIAL ASSISTANCE PROGRAM IS PUBLICIZED ON THE MONTHLY STATEMENTS SENT TO ALL PATIENTS. IT IS ALSO INCLUDED ON THE PAYMENT POLICY WHICH IS SENT TO ALL PATIENTS WITH THEIR FIRST BILLING STATEMENT. THE FINANCIAL ASSISTANCE POLICY SUMMARY IS SENT TO THOSE PATIENTS WHOSE ACCOUNTS ARE NOT CURRENT. 1 1 - NVMC - SPENCER 108 WEST EVANS STREET SPENCER NE 68777 CLINIC PART I, LINE 3C: AT NIOBRARA VALLEY HOSPITAL, THERE IS NO DISCOUNTED CARE. EITHER THE PATIENT QUALIFIES FOR FREE CARE OR HE/SHE DOES NOT. ELIGIBILITY FOR FREE CARE IS BASED OFF 100% OF FEDERAL POVERTY GUIDELINES. OTHER FACTORS USED TO DETERMINE FREE CARE INCLUDE INSURANCE AND UNINSURANCE STATUS. PART I, LINE 6A: NIOBRARA VALLEY HOSPITAL'S COMMUNITY BENEFIT REPORT IS PREPARED BY THE STAFF OF NIOBRARA VALLEY HOSPITAL. PART I, LINE 7: UNREIMBURSED MEDICAID, LINE 7B, AND SUBSIDIZED HEALTH SERVICES, LINE 7G, ARE CALCULATED USING THE COSTING METHODS TO PREPARE THE COST REPORTS. COMMUNITY HEALTH IMPROVEMENT SERVICES, LINE 7E, AND CASH AND IN-KIND CONTRIBUTIONS, LINE 7I, ARE REPORTED BASED ON ACTUAL EXPENSES REPORTED IN THE GENERAL LEDGER. PART I, LINE 7G: THERE ARE COSTS ATTRIBUTABLE TO A PHYSICIAN CLINIC INCLUDED ON LINE 7G. TOTAL REVENUE RECEIVED FROM MEDICARE RELATED TO PHYSICIAN CLINICS INCLUDES $30,079 WITH MEDICARE ESTIMATED COSTS OF CARE RELATING TO PAYMENTS OF $58,079. PART III, LINE 2: THE AMOUNT ON LINE 2 REPRESENTS IMPLICIT PRICE CONCESSIONS. THE ORGANIZATION DETERMINES ITS ESTIMATE OF IMPLICIT PRICE CONCESSION BASED ON ITS HISTORICAL COLLECTION EXPERIENCE WITH THIS CLASS OF PATIENTS. PART III, LINE 3: THE ESTIMATED AMOUNT OF THE ORGANIZATION'S IMPLICIT PRICE CONCESSIONS ATTRIBUTABLE TO PATIENTS ELIGIBLE UNDER THE ORGANIZATION'S CHARITY CARE POLICY IS CALCULATED BASED ON AN APPROXIMATE 12.1% OF INDIVIDUALS LIVING BELOW THE POVERTY LEVEL IN THE SERVICE AREA. PART III, LINE 4: THE FOOTNOTE TO THE ORGANIZATION'S FINANCIAL STATEMENTS THAT DESCRIBES IMPLICIT PRICE CONCESSIONS IS LOCATED IN FOOTNOTE 1 ON PAGES 11 AND 12 OF THE ATTACHED FINANCIAL STATEMENTS. PART III, LINE 8: THE ENTIRE MEDICARE SHORTFALL IS CONSIDERED A COMMUNITY BENEFIT. SERVICES ARE PROVIDED TO PATIENTS UNDER THE MEDICARE PROGRAM EVEN THOUGH THE HOSPITAL KNOWS THEY WILL NOT RECOVER ALL OF THE COSTS FROM PROVIDING THE SERVICES. THIS PROGRAM IS CONSIDERED SUBSIDIZED BY THE HOSPITAL AND OTHER PAYORS. PATIENTS RELY ON THESE SERVICES FOR THEIR HEALTH AND WELL-BEING AND ARE ESSENTIAL FOR THEIR ACCESS TO HEALTHCARE. TOTAL REVENUE RECEIVED FROM MEDICARE IS THE GROSS REIMBURSEMENT PLUS SETTLEMENT. BOTH TOTAL REVENUE RECEIVED FROM MEDICARE AND THE MEDICARE ALLOWABLE COSTS ARE REPORTED FROM THE MEDICARE COST REPORT. THE MEDICARE COST REPORT IS COMPLETED BASED ON THE RULES AND REGULATIONS SET FORTH BY CENTERS FOR MEDICARE AND MEDICAID SERVICES. PART III, LINE 9B: IF A PERSON APPLIES FOR FINANCIAL ASSISTANCE IN ACCORDANCE WITH THE FINANCIAL ASSISTANCE POLICY ALL COLLECTION EFFORTS WILL STOP UNTIL THE DETERMINATION OF ELIGIBILITY FOR FINANCIAL ASSISTANCE IS MADE. IF THE PERSON QUALIFIES FOR FINANCIAL ASSISTANCE, THE HOSPITAL WILL TAKE STEPS TO REVERSE COLLECTIONS ACTION, REPORTS AND OTHER ACTIONS THAT HAVE BEEN TAKEN TO OBTAIN PAYMENT. 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. 0 0 0 0 0 0 0 0 0 BREE ALMGREN NURSE PRACTIONER 201956 0 0 0 0 0 2256 0 5279 0 209491 0 0 0 PART I, LINE 3 MR. KALKOWSKI WAS PAID BY AN UNRELATED ORGANIZATION, FAITH REGIONAL HEALTH SERVICES, FOR HIS POSITION AS ADMINISTRATOR. FAITH REGIONAL HEALTH SERVICES USES AN INDEPENDENT COMPENSATION CONSULTANT, FORM 990 OF OTHER ORGANIZATIONS, WRITTEN EMPLOYMENT CONTRACT, COMPENSATION SURVEY AND APPROVAL BY THE BOARD IN DETERMINING HIS COMPENSATION. SCHEDULE J, PART II MR. KALKOWSKI WAS PAID BY AN UNRELATED ORGANIZATION, FAITH REGIONAL HEALTH SERVICES, FOR HIS POSITION AS ADMINISTRATOR. TOTAL COMPENSATION AND BENEFITS PAID TO MR. KALKOWSKI FOR 2023 WERE $144,893. 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 197,656. MANAGEMENT AND GENERAL EXPENSES 58,238. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 255,894. EMERGENCY ROOM PHYSICIANS: PROGRAM SERVICE EXPENSES 122,306. MANAGEMENT AND GENERAL EXPENSES 0. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 122,306. CONSULTING SERVICES: PROGRAM SERVICE EXPENSES 872,060. MANAGEMENT AND GENERAL EXPENSES 19,219. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 891,279. RECRUITMENT FEES: PROGRAM SERVICE EXPENSES 2,500. MANAGEMENT AND GENERAL EXPENSES 13,139. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 15,639. FORM 990, PART IX, LINE 5: THE HOSPITAL ADMINISTRATOR IS PAID BY FAITH REGIONAL HEALTH SERVICES, AN UNRELATED ENTITY. THE COMPENSATION FOR THIS INDIVIDUAL IS REPORTED ON PART IX, LINE 11A, COLUMN C. FORM 990, PART XI, LINE 9: CHANGE IN INTEREST IN NIOBRARA VALLEY HOSPITAL FOUNDATION -20,693. 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.