2021-05-12T15:20:24-05:00 2020-06-30 476097913 SEIM JOHNSON LLP 18081 BURT STREET SUITE 200 OMAHA NE 680224722 990 2019-07-01 470544098 WEST HOLT MEMORIAL HOSPITAL WEST 4029252811 406 WEST NEELY STREET ATKINSON NE 68713 JEREMY BAUER CFO 4029252811 2021-05-12 1 WENDY R COOLEY P01523804 4023302660 2019 2022-09-23 18:48:47Z JEREMY BAUER 406 WEST NEELY STREET ATKINSON NE 68713 13285044 0 X WWW.WESTHOLTMED.ORG X 1972 NE CRITICAL ACCESS HOSPITAL AND RURAL HEALTH CLINIC THAT PROVIDES MEDICAL SERVICES. 9 7 127 10 0 0 175109 1106098 12007640 11873186 37095 86743 4906 218388 12224750 13284415 0 0 0 0 5499380 5755284 0 0 39001 6612407 6743073 12111787 12498357 112963 786058 10682608 19756835 3768625 12056794 6913983 7700041 WEST HOLT MEDICAL SERVICES PROVIDES WELL-ROUNDED FAMILY HEALTHCARE WITH RESPECT AND UNDERSTANDING FOR THE PHYSICAL AND EMOTIONAL NEEDS OF OUR NORTH CENTRAL NEBRASKA COMMUNITIES. 0 0 10996578 9627578 WEST HOLT MEMORIAL HOSPITAL (WHMH) IS A 17 BED CRITICAL ACCESS HOSPITAL: SERVICES PROVIDED BY WHMH INCLUDES EMERGENCY SERVICES, LABORATORY, PHYSICAL AND OCCUPATIONAL THERAPY, RESPIRATORY THERAPY, SPEECH THERAPY, DIAGNOSTIC IMAGING TEST, CARDIOLOGY TESTS, EKG, NUCLEAR MEDICINE TESTS, IV THERAPY, SLEEP STUDIES, OP SURGERY, AND A VARIETY OF SPECIALTY CLINICS. DURING 2020, WHMH HAD 468 EMERGENCY ROOM VISITS AND PERFORMED 102 OUTPATIENT SURGERIES. THE LABORATORY PERFORMED 18,163 TESTS, DIAGNOSTIC IMAGING PERFORMED 2,454 TESTS AND PHYSICAL/OCCUPATIONAL/SPEECH THERAPY SERVICES PROVIDED 11,641 TREATMENTS. 10996578 1 1 0 1 0 0 0 0 0 1 1 0 0 0 1 1 1 0 0 0 0 0 0 0 0 0 1 1 0 0 1 0 0 0 0 0 0 1 0 0 0 0 0 0 0 0 0 0 1 15 0 1 127 1 0 0 0 0 0 0 0 0 0 0 0 0 X 9 7 0 0 0 0 1 1 0 1 0 0 0 1 1 1 1 1 1 1 0 0 X JEREMY BAUER 4029252811 406 WEST NEELY STREET ATKINSON NE 68713 JEFFREY HAGEN PHARMACIST 40.00 X 124583 0 31572 NICK KONRAD PHYSICAL THERAPIST 40.00 X 112758 0 39700 AMY KINKENNON PHARMACIST 40.00 X 144644 0 6346 APRIL DEXTER NURSE PRACTITIONER 32.00 X 122760 0 8308 LORRETTA DANIELS PHYSICIAN ASSISTANT 29.00 X 120819 0 427 JEREMY BAUER CFO 40.00 X 75310 0 32189 ASHLEY RIVERA CEO 40.00 X 66579 0 9673 TRENT SCHAAF PRESIDENT 2.00 X X 0 0 0 BRYAN RENTSCHLER FIRST VICE PRESIDENT 1.00 X X 0 0 0 JOHN KRAMER SECOND VICE PRESIDENT 1.00 X X 0 0 0 JACK WOLF SECRETARY THRU 11/19 1.00 X X 0 0 0 JARROD HAMIK SECRETARY 1.00 X X 0 0 0 BRENDAN BORER TREASURER 1.00 X X 0 0 0 LORI OLSON MEMBER 1.00 X 0 0 0 BRETT LIESWALD MEMBER 1.00 X 0 0 0 SUSAN MYERS MEMBER 1.00 X 0 0 0 MARSHA THURLOW MEMBER 1.00 X 0 0 0 767453 0 128215 6 0 1 0 RADEC CONSTRUCTION COMPANY 308 N BROADWAY AVE HARTINGTON NE 68739 CONSTRUCTION SERVICES 1263082 GREATER SANDHILLS FAMILY HEALTHCARE PO BOX 70 STUART NE 68780 PROVIDER ER COVERAGE 324406 FOCUSONE SOLUTIONS 13609 CALIFORNIA ST OMAHA NE 68154 AGENCY NURSING SERVICES 277866 FAITH REGIONAL HEALTH SERVICES 1500 KOENIGSTEIN AVE NORFOLK NE 68701 IT SUPPORT/CNO CONTRACT 189158 BE SMITH LLC PO BOX 74007636 CHICAGO IL 60674 RECRUITMENT SERVICES 109704 5 1017227 88871 1106098 MEDICARE/MEDICAID PAYMENTS 621110 6101862 6101862 PATIENT SERVICE REVENUE 621110 2691693 2691693 RETAIL PHARMACY REVENUE 621110 2458625 2458625 340B PROGRAM REVENUE 621110 605277 605277 15729 15729 11873186 86743 86743 6000 629 5371 5371 5371 INSURANCE PROCEEDS 900099 190999 190999 NET BAD DEBT RECOVERIES 900099 22018 22018 213017 13284415 12086203 0 92114 X 183751 183751 161734 161734 4659606 4067554 562227 29825 91916 81194 9848 874 316624 255336 57158 4130 341653 289675 49943 2035 30284 30284 17379 17379 42140 42140 1527395 1408275 119120 29388 29388 279999 188602 91275 122 191224 159774 30157 1293 144236 136461 7775 18998 15718 3279 1 113688 105218 8470 693962 642260 51702 83459 7920 75539 MEDICAL SUPPLIES 2850781 2850781 MISCELLANEOUS 652275 560828 90726 721 LICENSES & FEES 48687 46070 2617 FOOD 19178 19178 12498357 10996578 1462778 39001 460 460 3364684 11091735 2712419 1538706 486634 587404 88377 50893 15131639 9174451 3804585 5957188 225449 225449 0 305000 10682608 19756835 720083 1083998 2971574 5647196 76968 5325600 3768625 12056794 X 6409117 7361271 504866 338770 6913983 7700041 10682608 19756835 786058 0 X X 0 1 X 1 0 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 0 0 0 0 0 0 0 0 1 475 475 0 PART II-B, LINE 1: WEST HOLT MEMORIAL HOSPITAL PAYS ASSOCATION DUES TO THE NEBRASKA HOSPITAL ASSOCIATION (NHA), OF WHICH A PORTION IS USED BY THE ASSOCIATION FOR LOBBYING PURPOSES. 338770 338770 338770 338770 113321 225449 338770 113321 113321 113321 113321 0.00000 0.00000 1.00000 0 0 39958 39958 6422626 3663480 2759146 6691313 5417545 1273768 1977742 93426 1884316 5957188 CONTRACT LIABILITY - MEDICARE ADVANCE PAYMENTS 2659167 CARES ACT FUNDS 2666433 5325600 X 13285044 629 629 13284415 0 13284415 12498986 629 629 12498357 0 12498357 PART V, LINE 4: THESE FUNDS HAVE BEEN RESTRICTED BY A DONOR FOR SPECIFIC PURPOSES. THE PRINCIPAL CANNOT BE EXPENDED UNTIL 2047. PART X, LINE 2: THE HOSPITAL IS A NOT-FOR-PROFIT CORPORATION AS DESCRIBED IN SECTION 501(C)(3) OF THE CODE AND HAS RECEIVED A DETERMINATION LETTER THAT IT IS EXEMPT FROM FEDERAL INCOME TAXES ON RELATED INCOME PURSUANT TO SECTION 501(A) OF THE CODE. THE INTERNAL REVENUE SERVICE HAS ESTABLISHED STANDARDS TO BE MET TO MAINTAIN THE HOSPITAL'S TAX EXEMPT STATUS. IN GENERAL, SUCH STANDARDS REQUIRE THE HOSPITAL TO MEET A COMMUNITY BENEFITS STANDARD AND COMPLY WITH VARIOUS LAWS AND REGULATIONS. 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 JUNE 30, 2020 AND 2019, THE HOSPITAL HAD NO UNCERTAIN TAX POSITIONS ACCRUED. PART XI, LINE 2D - OTHER ADJUSTMENTS: RENTAL EXPENSES 629. PART XII, LINE 2D - OTHER ADJUSTMENTS: RENTAL EXPENSES 629. 1 1 X 1 X 110.000000000000 1 X 190.000000000000 1 1 0 1 1 50674 50674 0.00410 443654 185432 258222 0.02070 494328 185432 308896 0.02480 1349 181905 20595 161310 0.01290 2 1000 0 1000 0.00010 1351 182905 20595 162310 0.01300 1351 677233 206027 471206 0.03780 1 110 4399 529 3870 0.00030 8 1349 5072 0 5072 0.00040 9 1459 9471 529 8942 0.00070 1 0 0 5555544 5651981 -96437 X 1 1 1 1 WEST HOLT MEMORIAL HOSPITAL 406 W NEELY ATKINSON NE 68713 WWW.WESTHOLTMED.ORG 410001 X X X X WEST HOLT MEMORIAL HOSPITAL 1 0 0 1 X X X X X X X X X 18 1 1 1 1 X HTTPS://WWW.WESTHOLTMED.ORG/ X HTTP://WWW.NCDHD.ORG/ X 1 18 1 HTTPS://WWW.WESTHOLTMED.ORG/ 0 1 X 110.000000000000 190.000000000000 X 1 1 X X X X 1 X WWW.WESTHOLTMED.ORG X WWW.WESTHOLTMED.ORG X WWW.WESTHOLTMED.ORG X X X X X 1 X 0 X X X X 1 X 0 0 WEST HOLT MEMORIAL HOSPITAL PART V, SECTION B, LINE 5: WEST HOLT MEMORIAL HOSPITAL (WHMH) COLLABORATED WITH NCDHD (NORTH CENTRAL DISTRICT HEALTH DEPARTMENT) AGAIN, ALONG WITH OTHER HOSPITALS IN OUR HEALTH DISTRICT TO COMPLETE THE CHNA. DATA WAS GATHERED THROUGH THE PROCESS OF MOBILIZING FOR ACTION THROUGH PLANNING AND PARTNERSHIPS (MAPP), BEHAVIORAL HEALTH, AND CENSUS DATA. NCDHD CONTRACTED WITH JUAN PAULO RAMIREZ, PH.D. DR. RAMIREZ IS THE OWNER OF GIS AND HUMAN DIMENSIONS, LLC, AND IS AN INDEPENDENT CONTRACTOR. DR. RAMIREZ HAS PREVIOUSLY WORKED FOR THE NEBRASKA DEPARTMENT OF HEALTH AND HUMAN SERVICES COMPILING DIFFERENT DATA SETS FOR THE DIVISION OF PUBLIC HEALTH. BEGINNING IN JULY OF 2018, WHMH WAS A PART OF THE CORE GROUP WHO BEGAN WORKING WITH NCDHD PREPARING FOR THE NEXT ROUND OF CHNA ACTIVITIES. THERE WERE BRAINSTORMING SESSIONS INVOLVING NCDHD STAFF MEMBERS AND NCCCP (NORTH CENTRAL COMMUNITY CARE PARTNERSHIP) MEMBERS, IN ADDITION TO KEY PERSONNEL FROM HOSPITALS WITHIN OUR HEALTH DISTRICT. WE FIRST WORKED TO INCREASE PARTICIPATION FROM THE PUBLIC HEALTH SECTOR BY SENDING EMAILS AND MAKING DIRECT PHONE CALLS. THE ESSENTIAL BUILDING BLOCKS OF MAPP ARE FOUR ASSESSMENTS WHICH PROVIDE CRITICAL INSIGHTS INTO THE HEALTH CHALLENGES AND OPPORTUNITIES CONFRONTING THE COMMUNITY. THESE FOUR ASSESSMENTS AND THE ISSUES THEY ADDRESS ARE DESCRIBED BELOW.THE COMMUNITY THEMES AND STRENGTHS ASSESSMENT IS THE FIRST OF THE FOUR ASSESSMENTS. THIS IS A SUBJECTIVE LOOK AT HOW THE COMMUNITY VIEWS ITS HEALTH TO CAPTURE THE PERCEIVED NEEDS IN THE COMMUNITIES WE SERVE. THIS STEP INCLUDED SURVEYS SUCH AS THE SPECIAL POPULATION NEEDS ASSESSMENT AND THE 2018 COMMUNITY HEALTH ASSESSMENT. ADDITIONAL THEMES AND STRENGTHS WERE IDENTIFIED AT THE DATA PRESENTATION MEETING IN MARCH.THE SECOND ASSESSMENT IS THE FORCES OF CHANGE. THIS FOCUSES ON IDENTIFYING FORCES SUCH AS SOCIAL, ETHICAL, LEGISLATIVE, TECHNOLOGICAL, ENVIRONMENTAL, LEGAL ISSUES AND OTHER IMPENDING CHANGES WHICH AFFECT THE CONTEXT IN WHICH THE COMMUNITY AND ITS PUBLIC HEALTH SYSTEM OPERATE. THERE WERE FOCUS GROUP MEETINGS HOSTED THROUGHOUT THE DISTRICT.THE THIRD ASSESSMENT IS THE COMMUNITY HEALTH STATUS ASSESSMENT, WHICH IDENTIFIES COMMUNITY HEALTH AND QUALITY OF LIFE ISSUES. THIS CONTAINS A COMPREHENSIVE DATA COLLECTION PROCESS THAT INCLUDES PUBLIC HEALTH DATA COLLECTED BY NEBRASKA DHHS, AS WELL AS DATA FROM BEHAVIORAL RISK FACTOR SURVEILLANCE SYSTEM (BRFSS), YOUTH RISK BEHAVIOR SURVEY (YRBS) AND NEBRASKA RISK AND PROTECTIVE FACTOR STUDENT SURVEY (NRPFSS), AS WELL AS OTHER DATA SOURCES. THE COMMUNITY HEALTH STATUS ASSESSMENT PROVIDES MOST OF THE DATA IN THE REPORT.THE FINAL ASSESSMENT PIECE OF THE MAPP PROCESS IS THE LOCAL AND PUBLIC HEALTH SYSTEM ASSESSMENT. THIS FOCUSES ON ALL OF THE ORGANIZATIONS AND ENTITIES WHICH CONTRIBUTE TO PUBLIC HEALTH. THE LOCAL PUBLIC HEALTH SYSTEM ASSESSMENT (LPHSA) ANSWERS QUESTIONS SUCH AS: "WHAT ARE THE COMPONENTS, ACTIVITIES, COMPETENCIES, AND CAPACITIES OF OUR LOCAL PUBLIC HEALTH SYSTEM? AND "HOW ARE THE ESSENTIAL SERVICES BEING PROVIDED TO OUR COMMUNITIES?" THE TEN ESSENTIAL PUBLIC HEALTH SERVICES WERE REVIEWED AND DISCUSSED.TIMELINE:JULY-SEPTEMBER 2018 - ORGANIZE, COORDINATE PARTICIPANTS AND PREPARE FOR PROCESSOCTOBER 2018-FEBRUARY 2019 - COMMUNITY HEALTH NEEDS ASSESSMENT DATA COLLECTIONFEBRUARY-MARCH 2019 - COMMUNITY THEMES & STRENGTHS, FORCES OF CHANGE, & LOCAL PUBLIC HEALTH SYSTEM ASSESSMENTSMARCH 2019 - COMMUNITY HEALTH NEEDS ASSESSMENT (CHNA) DATA PRESENTATIONAPRIL-MAY 2019 - CHNA REPORT COMPLETED, ADOPTED BY HOSPITAL GROUP AND COMMUNITY PARTNERS, PRIORITY AREAS SELECTED BY PARTNERSHIP MEMBERS, GOALS AND STRATEGIES DEVELOPED FOR COMMUNITY HEALTH IMPROVEMENT PLAN. WEST HOLT MEMORIAL HOSPITAL PART V, SECTION B, LINE 6A: THE FOLLOWING HOSPITALS PARTICIPATED IN THE FACILITIES CHNA:ANTELOPE MEMORIAL HOSPITAL, NELIGH, NE (ANTELOPE COUNTY)AVERA CREIGHTON HOSPITAL, CREIGHTON, NE (KNOX COUNTY)AVERA ST. ANTHONY'S HOSPITAL O'NEILL, NE (HOLT COUNTY)BROWN COUNTY HOSPITAL, AINSWORTH, NE (BROWN COUNTY)CHERRY COUNTY HOSPITAL, VALENTINE, NE (CHERRY COUNTY)NIOBRARA VALLEY HOSPITAL, LYNCH, NE (BOYD COUNTY)OSMOND GENERAL HOSPITAL, OSMOND, NE (PIERCE COUNTY)PLAINVIEW COMMUNITY HOSPITAL, PLAINVIEW, NE (PIERCE COUNTY)ROCK COUNTY HOSPITAL, BASSETT, NE (ROCK COUNTY) WEST HOLT MEMORIAL HOSPITAL PART V, SECTION B, LINE 6B: AREA SUBSTANCE ABUSE AND PREVENTION COALITIONCENTRAL NEBRASKA ECONOMIC DEVELOPMENTCENTRAL NEBRASKA COMMUNITY ACTION PARTNERSHIP NORTH CENTRAL COMMUNITY CARE PARTNERSHIPNORTH CENTRAL DISTRICT HEALTH DEPARTMENT BOARD OF HEALTHO'NEILL CHAMBER OF COMMERCEO'NEILL PUBLIC SCHOOLSCOUNSELING AND ENRICHMENT CENTERBUILDING BLOCKS FOSTER CARE AGENCYUNIVERSITY OF NEBRASKA EXTENSION OFFICE, BROWN-ROCK-KEYA PAHA COUNTYEWING PUBLIC SCHOOLSLYNCH PUBLIC SCHOOLSVALENTINE PUBLIC SCHOOLSO'NEILL LIONS CLUBO'NEILL ROTARY CLUBWEST HOLT HEALTH MINISTRIESHOLT COUNTY ECONOMIC DEVELOPMENTANTELOPE COUNTY ECONOMIC DEVELOPMENTPIERCE COUNTY ECONOMIC DEVELOPMENTBRIGHT HORIZONSWE CARE, INC. WEST HOLT MEMORIAL HOSPITAL PART V, SECTION B, LINE 11: WEST HOLT MEMORIAL HOSPITAL IS ADDRESSING THE SIGNIFICANT NEEDS IDENTIFIED IN ITS MOST RECENTLY CONDUCTED CHNA OF CHRONIC DISEASE DETECTION AND MANAGEMENT AND MENTAL WELLNESS THROUGH PROMOTION OF HEALTH MAINTENANCE WITH HEALTH SCREENINGS AND ADDITIONAL DETECTION CARE MANAGEMENT (BLOOD PRESSURE CHECKS, DEXA SCANS, REDUCED PRICE LABS, AND AN ANNUAL HEALTH FAIR THAT IS FREE TO THE COMMUNITY). WE ALSO ATTEND AN ANNUAL WOMEN'S HEALTH CONFERENCE AND ASSIST WITH THE LOCAL FOOD PANTRY. PHQ9 QUESTIONNAIRE'S ARE OFFERED TO HELP IDENTIFY MENTAL WELL BEING IN PATIENTS THAT MIGHT BE AT RISK. WEST HOLT MEMORIAL HOSPITAL IS ADDRESSING ALL SIGNIFICANT NEEDS IDENTIFIED IN THE MOST RECENTLY CONDUCTED CHNA. 1 1 - WEST HOLT CLINIC 405 WEST PEARL STREET ATKINSON NE 68713 RURAL HEALTH CLINIC PART I, LINE 3C: THE HOSPITAL HAS A POLICY AND USES THE FEDERAL POVERTY GUIDELINES TO DETERMINE ELIGIBILITY. THOSE REQUESTING CHARITY CARE MUST FILL OUT AN APPLICATION. PART I, LINE 6A: THE HOSPITAL PREPARES ITS OWN COMMUNITY BENEFIT REPORT WHICH IS INCLUDED IN THE NEBRASKA HOSPITAL ASSOCIATION ANNUAL COMMUNITY BENEFIT REPORT. PART I, LINE 7G: THERE ARE NO SUBSIDIZED HEALTH SERVICES AT THIS TIME. PART I, LN 7 COL(F): DURING THE YEAR ENDED JUNE 30, 2020, THE BAD DEBT RECOVERIES EXCEEDED THE BAD DEBT EXPENSE. THERE IS NO BAD DEBT EXPENSE INCLUDED ON FORM 990, PART XI, LINE 25. PART II, COMMUNITY BUILDING ACTIVITIES: WEST HOLT MEMORIAL HOSPITAL PROVIDES LAB SCREENING ONCE A YEAR AT A GREATLY REDUCED RATE. THE RESULTS ARE SENT TO THE INDIVIDUALS AT WHICH TIME THEY CAN TAKE TO THEIR PRIMARY PROVIDER AND HAVE THEM REVIEWED. THE HOSPITAL ALSO OFFERS FREE COLORECTAL CANCER SCREENING ONCE A YEAR. WEST HOLT ALSO ARRANGED AN ACTIVE SHOOTER TRAINING WITH CHAD SHEEHAN OF SHEEHAN STRATEGIC SOLUTIONS. THIS LIFE-SAVING TRAINING WAS FREE TO LOCAL BUSINESSES, TEACHERS, EMERGENCY RESPONDERS, AND HEALTHCARE WORKERS. IT FOCUSED ON EDUCATING AND PREPARING ATTENDEES TO SURVIVE WORKPLACE OR SCHOOL VIOLENCE, AND TODAY'S ACTIVE SHOOTER. PART III, LINE 2: IN EVALUATING THE COLLECTIBILITY OF ACCOUNTS RECEIVABLE, THE HOSPITAL ANALYZES ITS PAST HISTORY AND IDENTIFIES TRENDS FOR EACH OF ITS MAJOR PAYER SOURCES OF REVENUE TO ESTIMATE THE APPROPRIATE ALLOWANCE FOR DOUBTFUL ACCOUNTS AND PROVISION FOR BAD DEBTS. MANAGEMENT REGULARLY REVIEWS DATA ABOUT THESE MAJOR PAYER SOURCES OF REVENUE IN EVALUATING THE SUFFICIENCY OF THE ALLOWANCE FOR DOUBTFUL ACCOUNTS. FOR RECEIVABLES ASSOCIATED WITH SERVICES PROVIDED TO PATIENTS WHO HAVE THIRD-PARTY COVERAGE, THE HOSPITAL ANALYZES CONTRACTUALLY DUE AMOUNTS AND PROVIDES AN ALLOWANCE FOR DOUBTFUL ACCOUNTS AND A PROVISION FOR BAD DEBTS FOR THOSE ACCOUNTS OVER A CERTAIN AGE BASED ON DISCHARGE THAT MAKE THE REALIZATION OF AMOUNTS DUE UNLIKELY. FOR RECEIVABLES ASSOCIATED WITH SELF-PAY PATIENTS (WHICH INCLUDES BOTH PATIENTS WITHOUT INSURANCE AND PATIENTS WITH DEDUCTIBLE AND COPAYMENT BALANCES DUE FOR WHICH THIRD-PARTY COVERAGE EXISTS FOR PART OF THE BILL), THE HOSPITAL RECORDS A SIGNIFICANT PROVISION FOR BAD DEBTS IN THE PERIOD OF SERVICE ON THE BASIS OF ITS PAST EXPERIENCE, WHICH INDICATES THAT MANY PATIENTS ARE UNABLE OR UNWILLING TO PAY THE PORTION OF THEIR BILL FOR WHICH THEY ARE FINANCIALLY RESPONSIBLE. THE DIFFERENCE BETWEEN THE STANDARD RATES (OR THE DISCOUNTED RATES IF NEGOTIATED) AND THE AMOUNTS ACTUALLY COLLECTED AFTER ALL REASONABLE COLLECTION EFFORTS HAVE BEEN EXHAUSTED IS CHARGED OFF AGAINST THE ALLOWANCE FOR DOUBTFUL ACCOUNTS. PART III, LINE 3: DURING THE YEAR ENDED JUNE 30, 2020, THE BAD DEBT RECOVERIES EXCEEDED THE BAD DEBT EXPENSE AND THUS NO PORTION IS ATTRIBUTABLE TO PATIENTS ELIGIBLE UNDER THE ORGANIZATION'S FINANCIAL ASSISTANCE POLICY. PART III, LINE 4: THE HOSPITAL'S FINANCIAL STATEMENTS DO NOT CONTAIN A SPECIFIC FOOTNOTE DESCRIBING BAD DEBT. HOWEVER, PAGES 8, 10 AND 11 OF THE ATTACHED AUDITED FINANCIAL STATEMENTS INCLUDE FOOTNOTES TITLED "PATIENT RECEIVABLES, NET," "NET PATIENT SERVICE REVENUE, AND "CHARITY CARE". PART III, LINE 8: THE COMMUNITY DOES BENEFIT BECAUSE THE HOSPITAL APPLIES OTHER REVENUES TO COVER THE COSTS OF CARING FOR MEDICARE PATIENTS.THE COSTING METHODOLOGY USED FOR PART III, SECTION B, LINE 6 IS THE COSTS TAKEN DIRECTLY FROM THE MEDICARE COST REPORT WHICH ARE ASSOCIATED WITH THE TOTAL REVENUE REPORTED IN LINE 5. NO MEDICARE SHORTFALL IS TREATED AS COMMUNITY BENEFITS. PART III, LINE 9B: FOR PATIENTS WITH EXCEPTIONALLY LARGE MEDICAL BILLS OR WHOSE PERSONAL CIRCUMSTANCES ARE SUCH THAT THE PAYMENT OPTIONS ARE NEITHER REALISTIC NOR AFFORDABLE, THE FINANCIAL ADVISOR SHALL ATTEMPT TO DETERMINE THE PATIENT'S ABILITIES TO PAY WHILE VISITING WITH THE PATIENT. THE FINANCIAL ADVISOR, CFO OR CEO WILL HAVE THE FULL AUTHORITY TO MAKE AND APPROVE PAYMENT ARRANGEMENTS. PART VI, LINE 2: THE ORGANIZATION ASSESSES THE HEALTH CARE NEEDS OF THE COMMUNITY IT SERVES THROUGH ROUTINE COLLECTION OF INFORMATION ABOUT IMPORTANT ASPECTS OF PATIENT CARE PROVIDED IN THE HOSPITAL AND ABOUT THE CLINICAL PERFORMANCE OF ALL INDIVIDUALS WITH CLINICAL PRIVILEGES. THIS INFORMATION IS COLLECTED THROUGH ACTIVITIES OF THE MEDICAL STAFF COMMITTEES, THE OVERALL QUALITY ASSURANCE PROGRAM, AND THROUGH THE MEDICAL STAFF MONITORING ACTIVITIES. THROUGH THIS COLLECTION OF INFORMATION, PERIODIC ASSESSMENTS ARE CONDUCTED TO IDENTIFY OPPORTUNITIES TO IMPROVE PATIENT CARE AND THE PROBLEMS THAT NEED RESOLUTIONS. PART VI, LINE 3: ALL NEW PATIENTS ARE GIVEN A "NEW PATIENT PACKET" THAT CONTAINS WEST HOLT MEDICAL SERVICES BILLING AND COLLECTION POLICY WHICH OUTLINES PATIENT ELIGIBILITY FOR FINANCIAL ASSISTANCE. THERE IS ALSO A FINANCIAL ASSISTANCE SECTION ON WESTHOLTMED.ORG UNDER PATIENT RESOURCES THAT INCLUDES OUR COMPREHENSIVE CHARITY CARE POLICY AND FINANCIAL ASSISTANCE POLICY (ALSO A PLAIN LANGUAGE SUMMARY VERSION). THESE RESOURCES ARE ALSO MADE AVAILABLE FOR ALL PATIENTS IN THE REGISTRATION AREAS OF THE FACILITY. PATIENTS ARE ENCOURAGED TO SPEAK WITH OUR FINANCIAL COUNSELOR AND SOCIAL SERVICES WORKER TO FURTHER EDUCATE THEMSELVES ON ALL AVENUES FOR FINANCIAL ASSISTANCE. PART VI, LINE 4: WEST HOLT MEMORIAL HOSPITAL IS IN THE NORTH CENTRAL DISTRICT HEALTH DEPARTMENT AREA WHICH CONSISTS OF 9 COUNTIES IN NORTH CENTRAL NEBRASKA. RESIDENTS BETWEEN THE AGE OF 18-65 ACCOUNT FOR 58.50%, OVER THE AGE OF 65 ACCOUNT FOR 22.3%, AND 19.2% OF THE POPULATION IS UNDER THE AGE OF 18. THE POPULATION DENSITY IN THE AREA IS 4.2 PEOPLE PER SQUARE MILE AS COMPARED TO THE NEBRASKA RATE OF 24.5 PEOPLE PER SQUARE MILE. THE PERCENT OF THE POPULATION WITH INCOMES BELOW 100% OF THE FEDERAL POVERTY LEVEL IS 10.3%, WHILE THE STATE PERCENTAGE IS 12.0%. THE AREA FACES AN ACUTE SHORTAGE OF PHYSICIANS IN NEARLY EVERY SPECIALTY AREA. GIVEN THE VASTNESS OF THE REGION AND SPARSE POPULATION DENSITY, IT IS NOT UNCOMMON FOR RESIDENTS TO LIVE MANY MILES FROM THE NEAREST HEALTH CARE PROVIDER. PART VI, LINE 5: THE HOSPITAL HAS THE AUTHORITY FOR A 40 MEMBER COMMUNITY BOARD WITH 17 MEMBERS CURRENTLY SERVING. FROM THIS GROUP, 9 MEMBERS SERVE AS THE HOSPITAL BOARD. ONE THIRD OF THE MEMBERS ARE ELECTED EVERY YEAR AT THE ANNUAL MEETING. THIS MEETING IS HELD THE FOURTH MONDAY OF OCTOBER AND IS OPEN TO THE COMMUNITY. THOSE ATTENDING ARE INVITED TO ASK QUESTIONS AND VOICE ANY CONCERNS THEY MAY HAVE. THE HOSPITAL HOSTS A HEALTH FAIR EVERY YEAR. LAB TESTS ARE OFFERED AT A REDUCED RATE AND OUTSIDE VENDORS OFFER INFORMATION FOR THE PARTICIPANTS. THE HOSPITAL OFFERS REDUCED PRICED LAB TESTS AND FREE COLORECTAL CANCER TESTS. PART VI, LINE 6: THE HOSPITAL IS NOT PART OF AN AFFILIATED HEALTH CARE SYSTEM. X X 0 0 0 0 0 0 0 0 0 JEFFREY HAGEN PHARMACIST 124583 0 0 0 0 0 4222 0 27350 0 156155 0 0 0 NICK KONRAD PHYSICAL THERAPIST 112758 0 0 0 0 0 3952 0 35748 0 152458 0 0 0 AMY KINKENNON PHARMACIST 144644 0 0 0 0 0 4386 0 1960 0 150990 0 0 0 KRISTI TIELKE EMPLOYEE OF HOSPITAL AND SISTER OF LORI OLSON, BOARD MEMBER 52291 EMPLOYEE W-2 WAGES 0 AMY RENTSCHLER EMPLOYEE OF HOSPITAL AND SPOUSE OF BRYAN RENTSCHLER, BOARD VICE PRESIDENT 109443 EMPLOYEE W-2 WAGES 0 FORM 990, PART VI, SECTION A, LINE 6 WEST HOLT MEMORIAL HOSPITAL SHALL HAVE ONE CLASS OF MEMBERS, CONSISTING OF FORTY INDIVIDUALS, OR FEWER IF THERE ARE LESS THAN 40 QUALIFIED INDIVIDUALS WILLING TO SERVE. MEMBERS MUST BE CITIZENS OF THE UNITED STATES, RESIDENTS OF HOLT COUNTY, NEBRASKA OR AN ADJOINING COUNTY, AND HAVE ATTAINED THE AGE OF MAJORITY. FORM 990, PART VI, SECTION A, LINE 7A THE MEMBERS OF WEST HOLT MEMORIAL HOSPITAL HAVE THE POWER TO ELECT AND REMOVE INDIVIDUALS TO MEMBERSHIP, ELECT THE DIRECTORS OF THE BOARD OF DIRECTORS, AND MAKE RECOMMENDATIONS TO THE BOARD ON OTHER MATTERS. EACH MEMBER SHALL HAVE ONE VOTE ON EACH MATTER SUBMITTED TO A VOTE OF THE MEMBERS. FORM 990, PART VI, SECTION A, LINE 8B THERE ARE NO COMMITTEES WITH AUTHORITY TO ACT ON BEHALF OF THE BOARD OF DIRECTORS. EACH COMMITTEE NEEDS APPROVAL FROM THE BOARD OF DIRECTORS. FORM 990, PART VI, SECTION B, LINE 11B THE CEO AND CFO WILL REVIEW THE FORM 990 PRIOR TO SUBMISSION TO THE IRS. THE BOARD OF DIRECTORS WILL BE PROVIDED THE FORM 990 PRIOR TO FILING. FORM 990, PART VI, SECTION B, LINE 12C FOLLOWING THE ELECTION OF THE BOARD OF DIRECTORS, EACH MEMBER IS REQUIRED TO SIGN THE CONFLICT OF INTEREST POLICY AND REFRAIN FROM THOSE SITUATIONS THAT MAY CAUSE NON-COMPLIANCE. FORM 990, PART VI, SECTION B, LINE 15A COMPDATA CONSULTING AND THE NEBRASKA HOSPITAL ASSOCIATION ARE CONTACTED WITH SALARY RANGES FOR THESE POSITIONS. THE CEO'S SALARY IS SET BY THE BOARD OF DIRECTORS. FORM 990, PART VI, SECTION C, LINE 19 THE PUBLIC IS WELCOME TO COME TO THE FACILITY TO VIEW THE GOVERNING DOCUMENTS, CONFLICT OF INTEREST POLICY OR FINANCIAL STATEMENTS AT ANYTIME. FORM 990, PART IX, LINE 11G MACHINE SERVICE FEES: PROGRAM SERVICE EXPENSES 329,263. MANAGEMENT AND GENERAL EXPENSES 76,719. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 405,982. PHYSICIAN FEES: PROGRAM SERVICE EXPENSES 582,559. MANAGEMENT AND GENERAL EXPENSES 0. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 582,559. CONSULTING FEES: PROGRAM SERVICE EXPENSES 129,992. MANAGEMENT AND GENERAL EXPENSES 0. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 129,992. OTHER FEES FOR SERVICE: PROGRAM SERVICE EXPENSES 366,461. MANAGEMENT AND GENERAL EXPENSES 42,401. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 408,862. FORM 990, PART XI, LINE 2C: THE BOARD OF DIRECTORS ASSUMES RESPONSIBILITY FOR OVERSIGHT OF THE AUDIT OF ITS FINANCIAL STATEMENTS AND SELECTION OF AN INDEPENDENT ACCOUNTANT. THIS PROCESS HAS NOT CHANGED SINCE THE PRIOR YEAR.