2020-08-10T12:04:58-05:00 2019-09-30 476097913 SEIM JOHNSON LLP 18081 BURT STREET SUITE 200 OMAHA NE 680224722 990 2018-10-01 470468078 JEFFERSON COMMUNITY HEALTH CENTER INC JEFF 4027293351 2200 H STREET PO BOX 277 FAIRBURY NE 68352 CHANCE KLASEK CFO 4027293351 2020-08-10 1 MEGAN L KOZIOL P01544037 4023302660 209.34.201.180 2020-08-10 07:35:19 CD P 05D57004E72D560A8AB00D9FF642C8776C6EAF55 C95AA154BB3428A46C5F7CAB7894FBC19C420CF6 2018 2020-09-23 17:36:50Z JEFFERSON COMMUNITY HEALTH & LIFE CHANCE KLASEK 2200 H STREET PO BOX 277 FAIRBURY NE 68352 24324850 0 X HTTP://WWW.JCHEALTHANDLIFE.ORG X 1960 NE INSPIRING HEALTHY LIVING BY PROVIDING EXCEPTIONAL HEALTH AND LIFE SERVICES FOR EVERY PERSON, EVERY TIME. 8 7 297 15 0 0 101000 106625 22519391 23406439 382952 185067 157721 169738 23161064 23867869 0 0 0 0 12890550 13028513 0 0 11386 9346726 9680654 22237276 22709167 923788 1158702 25914225 26913155 6362427 6065906 19551798 20847249 INSPIRING HEALTHY LIVING BY PROVIDING EXCEPTIONAL HEALTH AND LIFE SERVICES FOR EVERY PERSON, EVERY TIME. 0 0 19281981 20763977 JEFFERSON COMMUNITY HEALTH & LIFE OPERATES A 17 BED CRITICAL ACCESS ACUTE CARE HOSPITAL. JEFFERSON COMMUNITY HEALTH & LIFE ALSO OPERATES A FITNESS CENTER, RURAL HEALTH CLINICS, AND PROVIDES HOME HEALTH SERVICES. 1550835 2642462 JEFFERSON COMMUNITY HEALTH & LIFE OPERATES A 40 BED LONG-TERM CARE FACILITY FOR THE RESIDENTS OF JEFFERSON COUNTY AND THE SURROUNDING AREA. 20832816 1 1 0 1 0 0 0 0 0 1 1 0 0 0 1 1 1 0 0 0 0 0 0 0 1 0 1 1 0 0 1 1 0 0 0 0 0 0 0 0 1 0 0 0 0 0 0 0 0 0 0 1 9 0 1 297 1 0 0 0 0 0 1 1 0 0 0 0 0 0 X 8 7 0 0 0 0 1 1 1 1 1 0 0 0 1 1 1 1 1 1 1 0 X CHANCE KLASEK 4027296856 2200 H STREET PO BOX 277 FAIRBURY NE 68352 BRIAN SCHEELE CHAIRMAN 1.00 X X 0 0 0 MARY GLENN VICE CHAIRMAN 1.00 X X 0 0 0 BRIAN BLOBAUM SECRETARY/TREASURER 1.00 X X 0 0 0 LINDA BAUER MEMBER 1.00 X 0 0 0 LOREN DUERKSEN MEMBER 1.00 X 0 0 0 STEPHEN GRIZZLE MEMBER 1.00 X 0 0 0 SHERI SCHULTIS MEMBER 1.00 X 0 0 0 TREVOR STEINMEYER MEMBER 1.00 X 0 0 0 CHAD JURGENS CEO 40.00 X 184966 0 23302 CHANCE KLASEK CFO 40.00 X 114957 0 18241 CRAIG SHUMARD PHYSICIAN 40.00 X 437157 0 37792 RICHARD BLATNY JR PHYSICIAN 40.00 X 392944 0 37792 RICHARD BLATNY SR PHYSICIAN 40.00 X 331101 0 30094 BRANDON BLEICH PHARMACIST 40.00 X 148947 0 17917 DENNIS RUSSELL PHARMACIST 40.00 X 125732 0 20572 1735804 0 185710 13 0 1 0 SOUTHEAST ANESTHSIA SERVICES 8426 W BIRCH CLATONIA NE 68328 CRNA SERVICES 360000 BRYAN MEDICAL CENTER 1600 S 48TH STREET LINCOLN NE 68506 HEALTH SERVICES 317531 MEDHOST 6550 CAROTHERS PKWY FRANKLIN TN 37067 EHR SERVICES 281343 CONVERGEONE NW 5806 MINNEAPOLIS MN 55485 IT SERVICES 143413 CHAPPELL ROOFING INC 302 E ST FAIRBURY NE 68352 ROOFING SERVICES 115400 6 12174 31991 62460 106625 MEDICARE/MEDICAID PAYMENTS 624100 12392372 12392372 PATIENT SERVICE REVENUE 624100 9292585 9292585 340B DRUG PRICING PROGRAM 624100 980190 980190 CEDARWOOD ASSISTED LIVING SVC FEE 623000 569975 569975 CEDARWOOD: EQUITY IN JT VENTURE 623000 156641 156641 14676 14676 23406439 192367 192367 424593 20000 437675 14218 -13082 5782 -7300 -7300 5149 12174 5088 61 61 CAFETERIA 722210 169677 169677 169677 23867869 23406439 0 354805 341466 341466 82660 82660 10249801 9803275 439243 7283 358170 345475 12695 1280826 1204425 76401 715590 666885 48135 570 15289 15289 51149 51149 1600205 1294724 305400 81 93728 17126 75735 867 1213718 1061756 149888 2074 21127 21127 404732 375587 29145 62900 54794 8106 112278 104582 7696 130139 120956 9183 1425367 1324784 100583 101498 2039 99459 MEDICAL SUPPLIES 3334691 3334691 BAD DEBTS EXPENSE 575740 575740 FOOD EXPENSE 386321 386092 229 DUES AND SUBSCRIPTIONS 134210 43516 90183 511 17562 12582 4980 22709167 20832816 1864965 11386 450 450 4593852 5296549 3085923 3544222 381817 432556 308379 331782 26169756 14946686 11525500 11223070 4958727 4965678 715435 872076 344142 246772 25914225 26913155 1638906 1620233 4708050 4435965 5532 9939 9708 6362427 6065906 X 19344987 20656980 156057 139515 50754 50754 19551798 20847249 25914225 26913155 1158702 136749 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 1892 1892 0 PART II-B, LINE 1: JCH&L PAID DUES TO THE NEBRASKA HOSPITAL ASSOCIATION AND THE AMERICAN HOSPITAL ASSOCIATION. A PORTION OF THE DUES WERE USED FOR LOBBYING ACTIVITIES. 50754 50754 50754 50754 50754 50754 50754 50754 50754 50754 0.00000 1.00000 0.00000 0 0 50943 50943 19812611 10299593 9513018 5991418 4562764 1428654 314784 84329 230455 11223070 ACCRUED INTEREST 9708 9708 X 23433966 136749 5088 141837 23292129 575740 575740 23867869 22138515 5088 5088 22133427 575740 575740 22709167 PART V, LINE 4: THE INTENDED USE OF THE HOSPITAL'S ENDOWMENT FUNDS IS TO PROVIDE NURSING SCHOLARSHIPS AND CAPITAL IMPROVEMENTS. PART X, LINE 2: THE HEALTH CENTER IS A NOT-FOR-PROFIT CORPORATION AS DESCRIBED IN SECTION 501(C)(3) OF THE INTERNAL REVENUE CODE AND 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 HEALTH CENTER'S TAX EXEMPT STATUS. IN GENERAL, SUCH STANDARDS REQUIRE THE HEALTH CENTER TO MEET A COMMUNITY BENEFITS STANDARD AND COMPLY WITH VARIOUS LAWS AND REGULATIONS. THE HEALTH CENTER ACCOUNTS FOR UNCERTAINTIES IN ACCOUNTING FOR INCOME TAX ASSETS AND LIABILITIES USING GUIDANCE INCLUDED IN FASB ASC 740, INCOME TAXES. THE HEALTH CENTER RECOGNIZES THE EFFECT OF INCOME TAX POSITIONS ONLY IF THOSE POSITIONS ARE MORE LIKELY THAN NOT OF BEING SUSTAINED. AT SEPTEMBER 30, 2019 AND 2018, THE HEALTH CENTER HAD NO UNCERTAIN TAX POSITIONS ACCRUED. PART XI, LINE 2D - OTHER ADJUSTMENTS: FUNDRAISING EXPENSES 5,088. PART XI, LINE 4B - OTHER ADJUSTMENTS: PROVISION FOR BAD DEBTS 575,740. PART XII, LINE 2D - OTHER ADJUSTMENTS: FUNDRAISING EXPENSES 5,088. PART XII, LINE 4B - OTHER ADJUSTMENTS: PROVISION FOR BAD DEBTS 575,740. GOLF TOURNAMENT 17323 12174 5149 1440 889 1000 717 1042 17323 12174 5149 1440 889 1000 717 1042 5088 61 1 1 X 1 X 1 X 1 1 0 1 1 49981 0 49981 0.00230 1715493 1715493 1765474 1715493 49981 0.00230 13628 0 13628 0.00060 12600 0 12600 0.00060 449649 230956 218693 0.00990 7235 0 7235 0.00030 483112 230956 252156 0.01140 2248586 1946449 302137 0.01370 275 275 0.00000 275 275 0.00000 1 575740 78301 9253974 9442415 -188441 X 1 1 1 1 JEFFERSON COMMUNITY HEALTH CENTER 2200 H STREET FAIRBURY NE 68352 HTTP://WWW.JCHEALTHANDLIFE.ORG 440001 X X X X JEFFERSON COMMUNITY HEALTH CENTER INC 1 0 0 1 X X X X X X X X 18 1 0 0 1 X HTTP://JCHEALTHANDLIFE.ORG/ABOUT/COMMUNITY-HEALTH-NEEDS-ASSESSMENT/ X 1 18 1 HTTP://JCHEALTHANDLIFE.ORG/ABOUT/COMMUNITY-HEALTH-NEEDS-ASSESSMENT/ 0 1 X 150.000000000000 300.000000000000 X X X X 1 1 X X X 1 X HTTP://WWW.JCHEALTHANDLIFE.ORG/I-WANT-TO/PAY-MY-BILL/FINANCIAL-ASSISTANCE-P X HTTP://WWW.JCHEALTHANDLIFE.ORG/I-WANT-TO/PAY-MY-BILL/FINANCIAL-ASSISTANCE-P X HTTP://WWW.JCHEALTHANDLIFE.ORG/I-WANT-TO/PAY-MY-BILL/FINANCIAL-ASSISTANCE-P X X X X X X 1 X 0 X X X X 1 X 0 0 JEFFERSON COMMUNITY HEALTH CENTER, INC. PART V, SECTION B, LINE 5: JEFFERSON COMMUNITY HEALTH & LIFE BEGAN ITS THIRD COMMUNITY HEALTH NEEDS ASSESSMENT EARLY IN 2019. JCH&L HAS CONDUCTED FOCUS GROUPS WITH LOCAL ORGANIZATIONS, HELD A COMMUNITY STAKEHOLDERS LUNCHEON, AND REVIEWED STATISTICS MADE AVAILABLE THROUGH PUBLIC HEALTH SOLUTIONS, STATE OF NEBRASKA, US CENSUS, HEALTH PEOPLE 2020, AND WEBSITES SUCH AS COUNTY HEALTH RANKINGS AND WORLD LIFE EXPECTANCY.A COMMUNITY HEALTH NEEDS ASSESSMENT MEETING WAS HELD AT JCH&L WITH REPRESENTATIVES FROM AREA AGENCY PARTNERS, AND MEETINGS WERE CONDUCTED WITH LOCAL COMMUNITY ORGANIZATIONS INCLUDING KIWANIS, ROTARY, OPTIMISTS, AND SENIOR DINERS. A TOTAL OF 96 ATTENDED AND PARTICIPATED IN DISCUSSING COMMUNITY HEALTH NEEDS. JEFFERSON COMMUNITY HEALTH CENTER, INC. PART V, SECTION B, LINE 11: PRIORITIZED NEEDS (AS DETERMINED BY COMMUNITY HEALTH NEEDS ASSESSMENT):1) OBESITY2) SEDENTARY LIFESTYLE3) CHRONIC DISEASES AFFECTED BY OBESITY AND SEDENTARY LIFESTYLE, INCLUDING DIABETES, HEART DISEASE, STROKE, AND CANCERTHE HOSPITAL IS DOING THE FOLLOWING TO ADDRESS THESE NEEDS:*THE SMART MOVES PROGRAM OFFERS A YEAR-LONG CLASS TO TEACH THOSE AT RISK FOR DEVELOPING PRE-DIABETES TO MAKE HEALTHY LIFESTYLE CHOICES. CONTINUE TO EXPAND, PROMOTE, AND INCREASE UTILIZATION OF SMART MOVES LIFESTYLE CHANGE PROGRAM (A PROGRAM OF THE NATIONAL DIABETES PREVENTION PROGRAM).*CONTINUE TO BE AN ACTIVE PART OF COMMUNITY PARTNERSHIPS WORKING TO ESTABLISH WALKABLE COMMUNITY AND WALKING/BIKE TRAILS IN FAIRBURY. ESTABLISH HISTORIC TRAIL WALK. ENHANCE COMMUNITY'S SIDEWALKS AND SAFE WALKING/BIKING ROUTES. ENCOURAGE ACTIVITY LIFESTYLES FOR THOSE OF ALL AGES.*CONTINUE TO PARTNER WITH SCHOOLS AND OTHER YOUTH ORGANIZATIONS, OFFER SIDELINES SERVICES FOR ATHLETES, AND OFFER YOUTH EVENTS AT THE BURKLEY FITNESS CENTER, AND PROVIDE EDUCATION AND INFORMATION AS NEEDED BY AREA SCHOOLS.*CONTINUE SUPPORT OF GO RED FOR WOMEN EVENT IN COMMUNITY (SUPPORT OF AMERICAN HEART ASSOCIATION) AND CONTINUE AS HOST OF THIRD ANNUAL WOMEN'S HEALTH FAIR THIS YEAR AND THE EXPANSION OF THE FAIR.*DETERMINE WAY TO REACH MEN WITH SOME TYPE OF MEN'S HEALTH EVENT.*PROVIDE CONTINUED EDUCATION REGARDING AREAS OF INCREASED RISK IN OUR COUNTRY: OBESITY, SEDENTARY LIFESTYLE, TOBACCO USE, CHRONIC HEALTH CONDITIONS, MENTAL HEALTH.*CONTINUE PARTICIPATION IN MEDICARE ACO & BLUE CROSS PATIENT-CENTERED MEDICAL PROGRAM.*ENHANCE USE OF MEDICARE WELLNESS VISIT PROGRAM.*CONTINUE DEVELOPMENT AND EXPANSION OF CHRONIC CARE COORDINATION PROGRAM.*ENHANCE ABILITY TO TRACK COMMUNITY MEDICAL NEEDS BY MOVING TO ELECTRONIC HEALTH RECORD SYSTEM.*CONSIDER ADDITION OF TELEHEALTH SERVICES FOR PULMONOLOGY, ENDOCRINOLOGY, AND NEPHROLOGY (AREAS WHICH WE DO NOT CURRENTLY HAVE SPECIALISTS).*ADD CERTIFIED PERSONAL TRAINERS TO FITNESS CENTER STAFF.*CONTINUE TO PROVIDE FINANCIAL SUPPORT FOR BURKLEY FITNESS CENTER.*CONSIDER ADDING QUALITY INCENTIVES TO PHYSICIAN CONTRACTS TO ADDRESS PRIORITIZED COMMUNITY NEEDS.NEEDS JEFFERSON COMMUNITY HEALTH & LIFE WILL NOT ADDRESS:THERE WERE NEEDS IDENTIFIED THAT JCH&L DID NOT CHOOSE TO ADDRESS. WHILE THESE NEEDS ARE IMPORTANT TO THE COMMUNITY, THEY WERE NOT CHOSEN BASED ON THE PRIORITIZATION PROCESS.NEEDS WHICH WILL NOT BE ADDRESSED SPECIFICALLY BY JCH&L INCLUDE:*MENTAL HEALTH/SUICIDE. WE WILL CONTINUE TO WORK TO BE GOOD COMMUNITY PARTNERS TO ALL AREA ENTITIES WORKING TOWARD IMPROVING OUR COMMUNITY'S MENTAL HEALTH SERVICES AND SUICIDE PREVENTION AND ASSISTANCE TO THOSE AFFECTED BY SUICIDE.*ALZHEIMER'S DISEASE. WE WILL CONTINUE TO OFFER AN ALZHEIMER'S CAREGIVER'S SUPPORT GROUP AND BE A PART OF THE ANNUAL WALK TO END ALZHEIMER'S, AND WE WILL PROVIDE EDUCATIONAL RESOURCES TO OUR COMMUNITY THROUGH THE ALZHEIMER'S ASSOCIATION. THIS IS THE EXTENT OF WHAT WE FEEL OUR INVOLVEMENT CAN BE AT THIS TIME, SO WE DO NOT INTEND TO NAME THIS AS A MAJOR AREA OF ACTIVITY.*ADDITIONAL SPECIALTIES, ACCESS TO CARE, PREVENTATIVE CARE. JCH&L IS ALWAYS SEEKING POSSIBILITIES FOR ADDITIONAL SPECIALTIES, INCREASED ACCESS TO CARE AND INCREASED PREVENTATIVE CARE TO ADDRESS COMMUNITY NEEDS, AND WILL CONTINUE THIS PROCESS AS A PART OF OUR ONGOING STRATEGIC PLANNING PROCESS. HOWEVER, IT IS NOT NAMED IN OUR PRIORITIES BECAUSE OF THE NEED FOR PERSONNEL AND RESOURCES TO ADDRESS PRIORITY AREAS, EXCEPT FOR A FEW SELECT AREAS WHICH DIRECTLY AFFECT OUR PRIORITY GOALS FOR THE NEXT THREE YEARS.*BULLYING, SUICIDE, DENTAL HEALTH, CHRONIC PAIN. JCH&L WISHES TO BE A GOOD COMMUNITY PARTNER WITH ALL AREA AGENCIES AND PRACTICES WHICH PROVIDE SERVICES IN ALL OF THESE AREAS, WHICH ARE ALL OUTSIDE OF OUR CURRENT OFFERINGS. WE DO NOT INTEND TO NAME THESE AS PRIORITY AREAS AT THE PRESENT TIME.*POVERTY, TRANSPORTATION, DECLINING POPULATION, HOUSING. THESE ARE ONGOING SOCIETAL ISSUES WHICH AFFECT OUR BUSINESSES AND SERVICES. WE WILL CONTINUE TO BE A GOOD COMMUNITY PARTNER ON DEALING WITH THESE ISSUES IN OUR AREA, BUT WE DO NOT INTEND TO MAKE THESE AREAS OUR PRIORITY AREAS OF FOCUS.*INSURANCE/UNINSURED/UNDERINSURED. WE CONTINUE TO SEEK WAYS THAT WE AS AN ORGANIZATION CAN BEST SERVE THOSE WHO ARE UNINSURED OR UNDERINSURED, INCLUDING CHARITY CARE. THESE ARE NOT NAMED AS PRIORITY AREAS AT THIS TIME. 3 1 - GARDENSIDE 200 H STREET FAIRBURY NE 68352 LONG TERM CARE FACILITY 2 - FAIRBURY CLINIC 825 22ND STREET FAIRBURY NE 68352 RURAL HEALTH CLINIC 3 - PLYMOUTH CLINIC 316 N MADISON AVE STE 200 PLYMOUTH NE 684144110 RURAL HEALTH CLINIC PART I, LINE 3C: FEDERAL POVERTY GUIDELINES ARE USED TO DETERMINE ELIGIBILITY FOR PROVIDING FREE AND DISCOUNTED CARE TO LOW INCOME INDIVIDUALS. PART I, LINE 6A: JEFFERSON COMMUNITY HEALTH & LIFE PREPARES ITS OWN COMMUNITY BENEFIT REPORT. PART I, LINE 7: THE HOSPITAL USED THE WORKSHEETS PROVIDED IN THE FORM 990 INSTRUCTIONS TO HELP CALCULATE THE FINANCIAL ASSISTANCE AND CERTAIN OTHER COMMUNITY BENEFITS AT COST. 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 $575,740. PART I, LINE 7: JCH&L REACHED OUT TO THE COMMUNITY IN A VARIETY OF WAYS IN FISCAL YEAR 2019, INCLUDING:I. BENEFITS FOR THE POOR/PUBLIC PROGRAMSA. TRADITIONAL CHARITY CARE: JCH&L PROVIDED CHARITY CARE IN FISCAL 2019 TO THOSE WHO MEET THE FEDERAL POVERTY GUIDELINES. THE BUSINESS OFFICE STAFF MEMBERS FILE INSURANCE CLAIMS FOR PATIENTS. PATIENTS ASSISTED: 43. VALUE: $48,000.B. UNPAID COSTS OF PUBLIC PROGRAMS: MEDICAID SHORTFALL - SHORTFALL BASED ON COSTS: $0C. BAD DEBT: BESIDES OFFICIAL CHARITY CARE, JCH&L WROTE OFF $575,740 IN BAD DEBT DURING FISCAL 2019. II. COMMUNITY BENEFIT SERVICESA. COMMUNITY HEALTH EDUCATION AND OUTREACH: HEALTH FAIR - JCH&L PROVIDES EDUCATIONAL BOOTHS, FREE HEALTH SCREENINGS, HANDOUTS, INFORMATION, ETC., AT COMMUNITY EVENTS. IN SEPTEMBER JCH&L HOSTED ITS WOMEN'S HEALTH FAIR, WHICH HAD 250 PARTICIPANTS. WE ALSO HAD A BOOTH AT THE JEFFERSON COUNTY FAIR, WHICH ALSO DRAWS SEVERAL HUNDRED PEOPLE. FOR 2019, THE COST OF BOOTHS, GIVEAWAYS, STAFF TIME, ETC., ARE ESTIMATED AT $4,000. ESTIMATED NUMBER REACHED: 500.SPEAKERS BUREAU - JCH&L STAFF MEMBERS PROVIDE EDUCATIONAL PROGRAMS FOR COMMUNITY ORGANIZATIONS ON A VARIETY OF TOPICS. A TOTAL OF 23 PROGRAMS WERE DONE IN FISCAL 2019. TOTAL INDIVIDUALS REACHED: 864. ESTIMATED COST OF STAFF TIME: $650.SUPPORT GROUPS - IN 2019, JCH&L COORDINATED A PARKINSON'S SUPPORT GROUP AND ALZHEIMER'S CAREGIVER'S SUPPORT GROUP. JCH&L STAFF MEMBERS COORDINATED MEETINGS OF THESE SUPPORT GROUPS, OFFERING ASSISTANCE TO ANYONE INTERESTED IN MORE INFORMATION ABOUT THE DISEASES. THE PARKINSON'S SUPPORT GROUP MEETS MONTHLY. TOTAL ATTENDANCE DURING FISCAL 2019 WAS 18. A SUPPORT GROUP FOR CAREGIVER'S OF ALZHEIMER'S PATIENTS MEETS MONTHLY AND HAD ATTENDANCE OF 20 THROUGHOUT THE YEAR. JCH&L PROVIDES EDUCATIONAL PROGRAMS FOR EACH OF THESE GROUPS -- INCLUDING SPEAKER'S FEES OR VIDEO TAPE RENTAL FEES, POSTAGE TO SEND OUT MEETING NOTICES, AND REFRESHMENTS. JCH&L ALSO PROVIDES SPACE FOR A MONTHLY GRIEF SUPPORT GROUP COORDINATED BY ASERACARE HOSPICE. ATTENDANCE DURING THE YEAR IS ESTIMATED AT 30. TOTAL NUMBER REACHED: 68. APPROXIMATE COST OF STAFF TIME SPENT: $1,200. ESTIMATED COST OF POSTAGE: $330. ESTIMATED OTHER COSTS (MATERIALS, SPEAKER FEES, DRINKS, ETC.): $500.HEALTH PROMOTION PROGRAMS - JCH&L OFFERS SMOKING CESSATION INFORMATION TO PATIENTS AND THE PUBLIC. EACH INPATIENT WHO IS A SMOKER IS PROVIDED INFORMATION ON SMOKING CESSATION. ESTIMATED NUMBER REACHED: 89; ESTIMATED COST OF PROMOTIONAL MATERIALS PROVIDED: $453.01. ESTIMATED COST OF STAFF TIME TO PREPARE AND DISTRIBUTE: $375.B. COMMUNITY-BASED CLINICAL SERVICES: SCREENINGS AND ONE-TIME OR OCCASIONALLY HELD CLINICS.COMPLETE BLOOD PROFILES - COMPLETE BLOOD PROFILES WERE OFFERED IN THE SPRING OF 2019 AT A REDUCED RATE. A TOTAL OF 57 BLOOD PROFILES WERE OFFERED. PARTICIPANTS PAID $45, WHICH IS A FRACTION OF THE ESTIMATED VALUE OF THE TESTING. ESTIMATED STAFF TIME: $500.IMMUNIZATION CLINICS - JCH&L COOPERATES WITH BLUE VALLEY COMMUNITY ACTION IN PROVIDING IMMUNIZATION CLINIC FOR CHILDREN TWICE EACH MONTH. JCH&L PROVIDES SPACE WHERE IMMUNIZATIONS ARE DONE, NURSING STAFF, THE PATIENT WAITING AREAS, JANITORIAL AND SUPPORT SERVICES, AND STORAGE OF VACCINES IN OUR PHARMACY. NUMBER OF CHILDREN SERVED: 310. TOTAL OF 892 VACCINATIONS PROVIDED. ESTIMATED COST OF NURSES PROVIDED BY JCH&L TO GIVE SHOTS: $1,620. C. HEALTH CARE SUPPORT SERVICESENROLLMENT ASSISTANCE IN PUBLIC PROGRAMS - JCH&L OFFERED A COMMUNITY PROGRAM ON MEDICARE PART D DRUG PROGRAM PROVIDED BY JCH&L EMPLOYEES TRAINED AS SCHIIP VOLUNTEERS. ESTIMATED NUMBER OF PEOPLE REACHED: 175. ESTIMATED COST OF PROGRAMS, FOOD, AND STAFF TIME: $4,000. III. MEDICAL EDUCATIONA. SCHOLARSHIP FUNDING FOR HEALTH PROFESSIONS.PHYSICIAN/MEDICAL STUDENTS, NURSES/NURSING STUDENTS, TECHNICIANS AND OTHER HEALTH PROFESSIONALS. JCH&L WORKS WITH SOUTHEAST COMMUNITY COLLEGE IN BEATRICE AS A SITE FOR LPN PRACTICAL NURSING TRAINING. A TOTAL OF 16 STUDENTS LEARNED IN OUR FACILITY IN FISCAL 2019. NURSING STUDENTS UTILIZE MEETING ROOM SPACE AT JCH&L, AS WELL AS TAKE PART IN CLINICAL PRACTICE. MEDICAL STUDENTS COME REGULARLY FOR RURAL ROTATIONS TO LEARN FROM LOCAL PHYSICIANS. JCH&L PROVIDES AN APARTMENT FOR THE MEDICAL STUDENTS TO STAY IN DURING THEIR TIME IN FAIRBURY, AND ALSO PROVIDES THEM USE OF OUR FITNESS CENTER DURING THEIR STAY. A TOTAL OF 6 PHYSICIAN STUDENTS UTILIZED OUR FACILITY IN 2019. JCH&L OFFERS THE LILLIAN HANSEN REESMAN RN MEMORIAL NURSES SCHOLARSHIP FUND. SCHOLARSHIPS ARE OFFERED FROM THIS FUND, ESTABLISHED IN 1980. ONLY INTEREST IS USED FROM THIS $10,000 PERPETUAL FUND, DONATED BY THE REESMAN FAMILY, TO PROVIDE NURSING SCHOLARSHIPS. SCHOLARSHIPS ARE PROVIDED AS INTEREST FUNDS ARE AVAILABLE. TWO $500 SCHOLARSHIPS WERE AWARDED IN FISCAL 2019. THE JCH&L AUXILIARY PROVIDES A SCHOLARSHIP FOR STUDENTS PURSUING AN EDUCATION IN MEDICAL FIELDS. THE $400 SCHOLARSHIP IS GIVEN FROM THE AUXILIARY'S FUNDS, AND THE NUMBER OF SCHOLARSHIPS GIVEN EACH YEAR IS BASED ON THE AUXILIARY'S FUNDING AVAILABILITY AND THE NUMBER OF REQUESTS. NO SCHOLARSHIPS WERE AWARDED IN 2019. ESTIMATED NUMBER REACHED: 24. JCH&L (APARTMENT RENT, STAFF TIME, ETC.): $12,000.B. OTHER: JOB SHADOWING- JCH&L HOSTS JOB SHADOW STUDENTS THROUGH FAIRBURY HIGH SCHOOL'S ANATOMY AND PHYSIOLOGY CLASS, THROUGH THE SOUTHEAST COMMUNITY COLLEGE-FAIRBURY HIGH SCHOOL CAREER ACADEMY PROGRAM, AND FOR INTERESTED INDIVIDUALS. A TOTAL OF 24 STUDENTS PARTICIPATED IN SHADOWING OPPORTUNITIES IN FISCAL 2019. NUMBER REACHED: 24. ESTIMATED COST OF STAFF TIME: $600.IV. SUBSIDIZED HEALTH SERVICESWELLNESS CENTER SUPPORT - JEFFERSON COMMUNITY HEALTH & LIFE HAS OPERATED THE BURKLEY FITNESS CENTER AS A COMMUNITY FITNESS/WELLNESS CENTER SINCE IT OPENED IN 1996. JCH&L PAYS THE WELLNESS CENTER'S OPERATING EXPENSES THAT EXCEED REVENUES. BECAUSE OF THE HEALTH CENTER'S SUPPORT OF THE FITNESS CENTER'S CASH FLOW, PRICES FOR MEMBERSHIPS AND SERVICES CAN REMAIN REASONABLE FOR COMMUNITY RESIDENTS. IF THE FITNESS CENTER WERE A STAND-ALONE OPERATION, PRICES WOULD HAVE TO RISE CONSIDERABLY TO PAY ALL EXPENSES. MEMBERSHIPS: 654 (TOTAL MEMBERSHIPS AS OF FISCAL YEAR-END 2019. THIS INCLUDES FAMILY MEMBERSHIPS WITH MULTIPLE PERSONS ON MEMBERSHIP). TOTAL VISITS FOR FISCAL 2019: 49,270. ESTIMATED AMOUNT OF WELLNESS CENTER SUPPORT: $218,693V. RESEARCH.NO RESEARCH DOLLARS EXPENDED.VI. CASH AND IN-KIND DONATIONS.A. CASH DONATIONS:JCH&L MAKES DONATIONS TO VARIOUS CHARITABLE CAUSES, INCLUDING GIRL SCOUTS, BOY SCOUTS, SOFTBALL, BASEBALL AND CHURCH CAMP FIRST AID KITS, SPONSORSHIP OF BASEBALL AND SOFTBALL TEAMS, GOLF TOURNAMENTS, AREA HIGH SCHOOL POST PROM ACTIVITIES, AREA COMMUNITY CELEBRATIONS, DANCE RECITAL, AN AREA RODEO, CHAMBER OF COMMERCE BANQUET, CHAMBER OF COMMERCE NEW TEACHER WELCOME, CHAMBER OF COMMERCE TEACHER RECOGNITION, LOANING OUT CPR MANNEQUINS, DONATION TO AN AREA COMMUNITY'S NEW FITNESS ROOM AT THEIR SCHOOL, AND DONATIONS TO RELAY FOR LIFE, TEAMMATES, GO RED FOR WOMEN, CATTLEMAN'S BALL, FAIRBURY HIGH SCHOOL GRAY OUT, ETC. THESE TOTALED $3,285.05. JCH&L ALSO CONTRIBUTES ITEMS -- SUCH AS FITNESS CENTER PASSES, JCH&L ITEMS, ETC., TO COMMUNITY EVENTS AS DOOR PRIZES. THESE TOTALED AN ESTIMATED $500. DONATIONS DURING FISCAL 2019 TOTALED $3,785.05. PART I, LINE 7 (CONTINUED): B. IN-KIND DONATIONS:SAFE KIDS CHAPTER - JEFFERSON COMMUNITY HEALTH & LIFE IS A MEMBER OF THE SAFE KIDS COALITION. THREE JCHC STAFF MEMBERS PARTICIPATE IN THE ORGANIZATION. THEY ARE JOINED BY A VARIETY OF OUTSIDE AGENCIES IN THE COMMUNITY WHO BELIEVE STRONGLY IN CHILDHOOD SAFETY. SAFE KIDS OFFERS SAFETY SEAT CHECK UP EVENTS AND OTHER SAFETY PROMOTIONS. ONE SAFETY SEAT EVENT WAS HELD IN FISCAL 2019, CHECKING SEATS FOR 7 CHILDREN. ESTIMATED STAFF TIME: $800.BLOOD DRIVE SUPPORT - JCH&L ASSISTS NEBRASKA COMMUNITY BLOOD BANK BY SCHEDULING APPOINTMENTS FOR SIX BLOOD DRIVES EACH YEAR. THE BLOOD PRODUCTS ULTIMATELY HELP OUR COMMUNITY, AS NEBRASKA COMMUNITY BLOOD BANK IS JCH&L'S SUPPLIER OF BLOOD AND BLOOD PRODUCTS. ESTIMATED STAFF TIME: $250.SAFETY DAY FOR KIDS - JCHC WAS ONE OF THE CO-SPONSORS FOR THE ANNUAL SAFETY DAY FOR KIDS IN JEFFERSON COUNTY. A TOTAL OF 90 KIDS --AGES KINDERGARTEN THROUGH SIXTH GRADES-- ATTENDED. STAFF MEMBERS ASSISTED IN PLANNING THE EVENT AND ASSISTED IN COORDINATING AND INSTRUCTING ON THE DAY OF THE CAMP. THE COST OF STAFF TIME DONATED IS ESTIMATED AT $1,150. TOTAL COST OF SUPPLIES FURNISHED WAS $250. GO RED FOR WOMEN - JCH&L STAFF ORGANIZED THE ANNUAL GO RED FOR WOMEN FUNDRAISING EVENT FOR THE AMERICAN CANCER SOCIETY IN 2019. THE EVENT RAISED MORE THAN $16,000 FOR THE AMERICAN CANCER SOCIETY. COST OF STAFF TIME DONATED IS ESTIMATED AT: $1,000. NUMBER ATTENDING EVENT: 175. PART II, COMMUNITY BUILDING ACTIVITIES: JEFFERSON COMMUNITY HEALTH & LIFE IS ACTIVE IN LOCAL ECONOMIC DEVELOPMENT ACTIVITIES. JCH&L IS A MEMBER OF THE FAIRBURY CHAMBER OF COMMERCE. JCH&L SEEKS OPPORTUNITIES TO OFFER TOURS, HEALTH CARE INFORMATION ON COMMUNITY WEBSITES, ETC. COST OF CHAMBER MEMBERSHIP: $275. IN ADDITION TO THESE DIRECT PROGRAMS AND SERVICES, THE EMPLOYEES OF JEFFERSON COMMUNITY HEALTH & LIFE SERVE THEIR COMMUNITY IN MANY WAYS INCLUDING SERVING IN THEIR CHURCHES, AS GIRL AND BOY SCOUT LEADERS, AS 4-H LEADERS, FFA ALUMNI, AS LEADERS IN CIVIC ORGANIZATIONS, AS YOUTH GROUP LEADERS, AS CITY GOVERNMENT MEMBERS, ON COMMUNITY DEVELOPMENT BOARDS, FOR EMERGENCY RESPONSE ORGANIZATIONS AND OTHERS. JCH&L STAFF MEMBERS ARE A RESOURCE AS COMMUNITY ROLE MODELS.JCH&L IS PROUD OF ITS CONTRIBUTIONS TO THE CITIZENS OF JEFFERSON COUNTY AND THE SURROUNDING AREA. THE CITIZENS OF THIS AREA ALSO HIGHLY REGARD JCH&L'S CONTRIBUTIONS TO THE COMMUNITY.THE GOAL OF THE JCH&L BOARD OF DIRECTORS, ADMINISTRATION AND STAFF IS TO EXPAND THAT PARTNERSHIP WITH AREA RESIDENTS AND FIND MORE WAYS TO SERVE AS A RESOURCE FOR HEALTH AND WELLNESS INFORMATION. PART III, LINE 2: IN EVALUATING THE COLLECTIBILITY OF ACCOUNTS RECEIVABLE, THE HEALTH CENTER ANALYZES ITS PAST HISTORY AND IDENTIFIES TRENDS FOR EACH OF ITS MAJOR PAYOR SOURCES OF REVENUE TO ESTIMATE THE APPROPRIATE ALLOWANCE FOR DOUBTFUL ACCOUNTS AND PROVISION FOR BAD DEBTS. MANAGEMENT REGULARLY REVIEWS DATA ABOUT THESE MAJOR PAYOR SOURCES OF REVENUE IN EVALUATING THE SUFFICIENCY OF THE ALLOWANCE FOR DOUBTFUL ACCOUNTS. FOR RECEIVABLES ASSOCIATED WITH SERVICES PROVIDED TO PATIENTS WHO HAVE THIRD-PARTYCOVERAGE, THE HEALTH CENTER 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 HEALTH CENTER 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: AS PART OF OUR COMMUNITY NEEDS ASSESSMENT, WE GATHERED INFORMATION ON THE INCOME CHARACTERISTICS OF THE UNINSURED POPULATION. USING THAT DATA, WE ANALYZED WHAT PORTION OF UNINSURED INDIVIDUALS IN THE HOSPITAL'S SERVICE AREA WOULD BE ELIGIBLE FOR THE HOSPITAL'S FINANCIAL ASSISTANCE POLICY. THIS PERCENTAGE WAS APPLIED TO THE TOTAL AMOUNT OF BAD DEBT FOR SELF-PAY PATIENTS TO ESTIMATE THE PORTION OF SELF-PAY BAD DEBT THAT WAS LIKELY ATTRIBUTABLE TO INDIVIDUALS ELIGIBLE FOR THE HOSPITAL'S FINANCIAL ASSISTANCE POLICY. PART III, LINE 4: JCH&L'S FINANCIAL STATEMENTS DO NOT CONTAIN A SPECIFIC FOOTNOTE DESCRIBING BAD DEBT EXPENSE. HOWEVER, PAGES 8 AND 9 OF THE ATTACHED FINANCIAL STATEMENTS INCLUDE FOOTNOTES TITLED "PATIENT ACCOUNTS RECEIVABLE, NET," "NET PATIENT SERVICE REVENUE AND "FINANCIAL ASSISTANCE/CHARITY CARE". PART III, LINE 8: THE HOSPITAL CALCULATED THE MEDICARE ALLOWABLE COSTS BY ADDING THE INPATIENT, SWING BED AND OUTPATIENT COSTS AS FOUND ON THE MEDICARE COST REPORT FOR SEPTEMBER 30, 2019. NO SHORTFALL IS TREATED AS COMMUNITY BENEFIT. PART III, LINE 9B: ONCE IT IS DETERMINED THAT A PATIENT MAY NOT HAVE THE MEANS TO PAY, AN ASSISTANCE APPLICATION IS PROVIDED. IN ADDITION, ALL ACCOUNTS THAT OUR SELF-PAY RECEIVABLE VENDOR DID NOT RECEIVE PAYMENT ON/AFTER 75 DAYS WILL BE RUN THROUGH A PRESUMPTIVE CHARITY CRITERIA PROCESS. THIS PROCESS ASSISTS IN THE DETERMINATION OF FINANCIAL ASSISTANCE ELIGIBILITY. JCH&L STAFF WILL APPLY THE RECOMMENDED PERCENTAGE DISCOUNT TO THE PATIENT'S ACCOUNT. PART VI, LINE 2: JCH&L ASSESSES THE HEALTH CARE NEEDS OF THE COMMUNITY JCH&L SERVES IN SEVERAL WAYS. JCH&L UTILIZES SURVEYS BY PUBLIC HEALTH SOLUTIONS OF THE HEALTH CARE NEEDS FOR RESIDENTS OF JEFFERSON COUNTY AND THE SURROUNDING COMMUNITY. JCH&L VISITS LOCAL COMMUNITY SERVICE ORGANIZATIONS AND SEEKS INPUT ON NEEDS. JCH&L CONDUCTED A COMMUNITY PERCEPTION SURVEY IN 2015, WHICH INCLUDES QUESTIONS ON COMMUNITY HEALTH NEEDS. JCH&L REVIEWS SURVEYS DONE BY THE STATE AND OTHER ORGANIZATIONS ON THE HEALTH CARE NEEDS FOR RESIDENTS OF JEFFERSON COUNTY AND THE SURROUNDING AREA. PART VI, LINE 3: JCH&L INFORMS AND EDUCATES PATIENTS ABOUT ELIGIBILITY FOR ASSISTANCE ON AN INDIVIDUAL BASIS WHEN QUESTIONS ARISE. THE PATIENT BOOKLET PROVIDES BUSINESS OFFICE CONTACT INFORMATION FOR PATIENT QUESTIONS ABOUT THEIR BILL. THE SELF-PAY BILLING VENDOR ENGAGED BY JCH&L HAS A SET OF CRITERIA IT USES TO ASSESS WHETHER A PATIENT IS ELIGIBLE FOR ASSISTANCE PROGRAMS, OR IF THEY QUALIFY FOR JCH&L'S CHARITY CARE PROGRAM. PART VI, LINE 4: JCH&L SERVES JEFFERSON COUNTY AND PARTS OF THAYER, FILLMORE, SALINE AND GAGE COUNTIES, ALL IN NEBRASKA; AND PARTS OF WASHINGTON AND MARSHALL COUNTIES IN KANSAS. THE POPULATION OF THE SERVICE AREA IS ESTIMATED AT ABOUT 18,000. REVENUE FROM MEDICARE PATIENTS AVERAGES APPROXIMATELY 50%, AND REVENUE FROM MEDICAID CLIENTS AVERAGES APPROXIMATELY 10%. PART VI, LINE 5: JCH&L OPERATES IN JEFFERSON COUNTY WITH A COMMUNITY BOARD AND OPEN MEDICAL STAFF. ALL SURPLUS FUNDS ARE REINVESTED BACK INTO THE FACILITY THROUGH BUILDING CONSTRUCTION, EQUIPMENT PURCHASES, OR COMMUNITY PROGRAMS PROVIDED. JCH&L PROMOTES THE HEALTH OF THE COMMUNITY BY OFFERING A COMMUNITY FITNESS CENTER AT A REASONABLE RATE AND OFFERING SCHOLARSHIPS FOR THE COMMUNITY'S YOUTH WHO HAVE FINANCIAL NEED. THE NET COMMUNITY BENEFIT REPORTED IN PART I RELATING TO THE FITNESS CENTER WAS APPROXIMATELY $218,000. JCH&L PROMOTES THE HEALTH OF THE COMMUNITY BY PROMOTING COMMUNITY-WIDE PROGRAMS SUCH AS LIVE HEALTHY NEBRASKA AND STEP-2-IT (PROGRAMS WHICH ENCOURAGE INCREASING ACTIVITY AND LOSING WEIGHT.) JCH&L IS ALSO INVOLVED IN CAR SAFETY SEAT CHECKS, PROGRESSIVE AG SAFETY DAY, AND WORKING WITH BLUE VALLEY COMMUNITY ACTION TO OFFER IMMUNIZATIONS TO AREA CHILDREN. JCH&L PROMOTES THE HEALTH OF THE COMMUNITY BY OFFERING PROGRAMS, TOURS, SPEAKERS, AND EDUCATION, INCLUDING SUPPORT GROUPS, EDUCATIONAL PROGRAMS AND PROGRAMS FOR LOCAL ORGANIZATIONS. PART VI, LINE 6: JCH&L IS NOT PART OF AN AFFILIATED HEALTH CARE SYSTEM BUT DOES WORK TO BE A LEADER IN PROMOTING THE HEALTH OF THE COMMUNITIES IT SERVES. JCH&L PARTNERS WITH MANY OTHER AREA ORGANIZATIONS, INCLUDING PUBLIC HEALTH SOLUTIONS, FARM SAFETY 4 JUST KIDS, NEBRASKA SAFE KIDS, JEFFERSON COUNTY EXTENSION, BLUE VALLEY COMMUNITY ACTION, FAIRBURY CHAMBER OF COMMERCE, FAIRBURY PUBLIC SCHOOLS, FAIRBURY CLINIC, NEBRASKA COMMUNITY BLOOD BANK, RURAL COMPREHENSIVE CARE NETWORK, BLUE RIVER VALLEY NETWORK, HEARTLAND HEALTH ALLIANCE, AND OTHERS. DEPENDING ON THE ACTIVITY, JCH&L MAY BE THE LEAD ORGANIZATION, OR AN ORGANIZATION PROVIDING HELP AND ASSISTANCE. PART VI, LINE 7: JCH&L DOES NOT FILE A COMMUNITY BENEFIT REPORT WITH ANY STATES. X 0 0 X X X X 0 0 0 1 0 0 0 1 0 CHAD JURGENS CEO 184966 0 0 0 0 0 9260 0 14042 0 208268 0 0 0 CRAIG SHUMARD PHYSICIAN 324877 0 112280 0 0 0 23750 0 14042 0 474949 0 0 0 RICHARD BLATNY JR PHYSICIAN 226650 0 166294 0 0 0 23750 0 14042 0 430736 0 0 0 RICHARD BLATNY SR PHYSICIAN 246686 0 84415 0 0 0 23750 0 6344 0 361195 0 0 0 BRANDON BLEICH PHARMACIST 148947 0 0 0 0 0 3875 0 14042 0 166864 0 0 0 PART I, LINE 1A JCH&L PROVIDES DISCOUNTED OR FREE FITNESS CENTER MEMBERSHIPS TO ITS EMPLOYEES AND PHYSICIANS. PART I, LINE 5 PHYSICIANS RECEIVE INCENTIVE COMPENSATION BASED ON PHYSICIAN'S NET COLLECTIONS IN EXCESS OF THE MONTHLY THRESHOLDS SET PER CONTRACT. "NET COLLECTIONS" MEANS CASH ACTUALLY RECEIVED FROM PATIENTS OR THIRD PARTY PAYORS FOR PERSONALLY PERFORMED PROFESSIONAL SERVICES OF PHYSICIAN. NET COLLECTIONS SHALL BE ADJUSTED BY ANY REDUCTIONS FOR PATIENT ACCOUNT ADJUSTMENTS, RECOVERED OVERPAYMENTS, OFFSETS AND ANY FEES EXPENDED ON AMOUNTS RECOVERED THROUGH COLLECTION AGENCIES. NET COLLECTIONS SHALL NOT INCLUDE THE TECHNICAL FEES ASSOCIATED WITH ANY COLLECTIONS FOR LAB, X-RAY, ANCILLARY SERVICES, DESIGNATED HEALTH SERVICES UNDER STARK, ANY SERVICES NOT RENDERED PERSONALLY BY PHYSICIAN, OR THE TECHNICAL COMPONENT OF ANY OTHER SERVICES. WHEN A GLOBAL PAYMENT IS RECEIVED THAT INCLUDES PROFESSIONAL SERVICES AND ANY SUCH EXCLUDED SERVICES, HOSPITAL SHALL MAKE A REASONABLE ALLOCATION OF SUCH RECEIPT BETWEEN SUCH CATEGORIES. PART I, LINE 7 UPON COMPLETION OF EACH CONTRACT YEAR, THE HOSPITAL SHALL DETERMINE PHYSICIAN'S QUALIFICATION TO RECEIVE QUALITY INCENTIVE COMPENSATION BASED ON ANNUAL GOALS ESTABLISHED AT THE BEGINNING OF THE CONTRACT YEAR. IN ORDER TO QUALIFY TO RECEIVE QUALITY INCENTIVE COMPENSATION, PHYSICIAN SHALL REMAIN EMPLOYED IN GOOD STANDING AT THE END OF THE CONTRACT YEAR. THE QUALITY INCENTIVE COMPENSATION SHALL NOT EXCEED FIVE PERCENT (5%) OF BASE SALARY. A HOSPITAL AUTHORITY NO 1 OF JEFFERSON COUNTY NE 611683496 2012-12-18 5800000 CONSTRUCTION AND RENOVATION OF FACILITIES 0 0 0 A 1261147 5800000 50001 5749999 2015 0 0 1 1 A 0 0 0 0 0.00000 0.00000 0.00000 0 0 0 A 0 0 0 1 0 0 0 0 1 A 1 PART IV, COLUMN A, LINE 2C: THE REBATE COMPUTATION WAS PERFORMED ON JANUARY 19, 2016. THIS DEBT WAS ISSUED ON A DRAW-DOWN BASIS AND AMOUNTS WERE DRAWN AS PROJECT COSTS WERE INCURRED. AS NO REBATABLE ARBITRAGE WAS EARNED AND THE DEBT SERVICE FUND WAS OPERATED ON A BONA FIDE BASIS, NO FURTHER REBATE ANALYSIS IS NECESSARY. CAROL BLOBAUM EMPLOYEE OF THE HOSPITAL AND SPOUSE OF BRIAN BLOBAUM, SECRETARY/TREASURER 82660 EMPLOYEE COMPENSATION 0 FORM 990, PART VI, SECTION A, LINE 6 JEFFERSON COMMUNITY HEALTH & LIFE HAS MEMBERS. ANY PERSON, CORPORATION OR OTHER ENTITY MAY BECOME A LIFETIME MEMBER IF A CONTRIBUTION OF $100 OR MORE IS MADE TO THE CORPORATION. FORM 990, PART VI, SECTION A, LINE 7A VACANCIES, OCCURRING ON THE BOARD BY EXPIRATION, SHALL BE FILLED THROUGH ELECTION BY THE MEMBERS AT THE ANNUAL MEETING OF THE MEMBERS. THE BOARD DEVELOPMENT COMMITTEE SHALL SUBMIT A SLATE OF PROSPECTIVE CANDIDATES TO THE BOARD OF DIRECTORS AT THEIR MEETING PRIOR TO THE ANNUAL MEETING WHICH WILL THEN BE PRESENTED AT THE ANNUAL MEETING FOR CONSIDERATION FOR ELECTION TO THE BOARD. IN ADDITION, MEMBERS OF THE CORPORATION MAY MAKE NOMINATIONS FROM THE FLOOR. FORM 990, PART VI, SECTION A, LINE 7B EACH MEMBER SHALL BE ENTITLED TO ONE VOTE ON EACH MATTER SUBMITTED TO THE VOTE OF THE MEMBERS. FORM 990, PART VI, SECTION B, LINE 11B THE BOARD WILL REVIEW THE FORM 990 AT A REGULARLY SCHEDULED BOARD MEETING, WHICH DOES NOT NECESSARILY OCCUR PRIOR TO THE FILING OF FORM 990. FORM 990 IS REVIEWED BY MR. CHANCE KLASEK, CFO, PRIOR TO FILING. FORM 990, PART VI, SECTION B, LINE 12C BOARD MEMBERS ARE REQUIRED, BY THE ARTICLES AND BYLAWS, TO REVIEW THE CONFLICT OF INTEREST POLICY ANNUALLY. A BOARD MEMBER WITH A CONFLICT OF INTEREST IS REQUIRED TO ABSTAIN FROM VOTING ON ANY MOTION FOR WHICH HE HAS A CONFLICT OF INTEREST. BOARD MEMBERS ARE WELL ACQUAINTED WITH EACH OTHER AND WOULD BE AWARE OF ANY PERSONAL CONFLICTS OF INTEREST. FORM 990, PART VI, SECTION B, LINE 15 THE HOSPITAL PARTICIPATES IN THE NEBRASKA COMPDATA SALARY SURVEYS FOR ALL POSITIONS. THE CEO SURVEY DATA IS GIVEN TO THE BOARD TO REVIEW, AND THE BOARD APPROVES THE CEO'S SALARY ON AN ANNUAL BASIS. OTHER OFFICER COMPENSATION IS REVIEWED AND APPROVED BY THE CEO AND HR DIRECTOR. FORM 990, PART VI, SECTION C, LINE 19 THE ORGANIZATION'S GOVERNING DOCUMENTS, CONFLICT OF INTEREST POLICY AND FINANCIAL STATEMENTS ARE AVAILABLE TO THE PUBLIC UPON REQUEST. FORM 990, PAGE 11, PART XI, LINE 2C: THE FINANCE COMMITTEE OF THE BOARD OF DIRECTORS SELECTS THE INDEPENDENT ACCOUNTANT AND HAS THE RESPONSIBILITY FOR OVERSIGHT OF THE AUDIT. UPON CONCLUSION OF THE AUDIT, THE AUDITING FIRM PRESENTS THE RESULTS AND FINDINGS TO THE FINANCE COMMITTEE. THERE HAVE BEEN NO CHANGES TO THIS PROCESS FROM THE PRIOR YEAR.