2019-11-14T10:31:18-06:00 2018-12-31 476097913 SEIM JOHNSON LLP 18081 BURT STREET SUITE 200 OMAHA NE 680224722 990 2018-01-01 911772474 FAITH REGIONAL HEALTH SERVICES FOUNDATION FAIT 4026447301 2700 WEST NORFOLK AVENUE NO 200 NORFOLK NE 68701 JOHN WILKER VP FINANCE 4026447301 2019-11-13 1 WENDY R COOLEY P01523804 4023302660 209.34.201.180 2019-11-13 15:06:27 CS P B319C935D5CD5DD24452FA9CD51ABCBD1A9C8C2C B319C935D5CD5DD24452FA9CD51ABCBD1A9C8C2C 2018 2020-03-31 21:24:44Z JOHN WILKER 2700 WEST NORFOLK AVENUE NO 200 NORFOLK NE 68701 2158903 0 X WWW.FRHS.ORG X 1996 NE TO AID FAITH REGIONAL HEALTH SERVICES (FRHS) BY THE SOLICITATION OF GIFTS, GRANTS, DEVICES AND BEQUESTS EXCLUSIVELY FOR THE USE AND BENEFIT OF FRHS OR ITS PROGRAMS AND SERVICES. 18 17 0 112 0 0 1277722 1246779 0 0 97035 269348 27447 55575 1402204 1571702 72855 184518 0 0 0 0 0 0 13171 31626 34121 104481 218639 1297723 1353063 14515644 15297678 123788 130691 14391856 15166987 TO AID FAITH REGIONAL HEALTH SERVICES (FRHS) BY THE SOLICITATION OF GIFTS, GRANTS, DEVICES AND BEQUESTS EXCLUSIVELY FOR THE USE AND BENEFITS OF FRHS OR ITS PROGRAMS AND SERVICES. 0 0 184518 184518 TO AID FAITH REGIONAL HEALTH SERVICES (FRHS) BY THE SOLICITATION OF GIFTS, GRANTS, DEVICES AND BEQUESTS EXCLUSIVELY FOR THE USE AND BENEFIT OF FRHS OR ITS PROGRAMS AND SERVICES. FRHS PROVIDES ACUTE, PREVENTATIVE AND OTHER HEALTHCARE SERVICES TO THE REGION WHILE ENCOURAGING EDUCATIONAL AND CLINICAL RESEARCH. FRHS SERVES ALL PATIENTS REGARDLESS OF THEIR ABILITY TO PAY AND DOES NOT LIMIT ITS SERVICES OR DISCRIMINATE AGAINST ANYONE ON THE BASIS OF RACE, SEX, NATIONAL ORIGIN, RELIGION OR DIAGNOSIS. 184518 1 1 0 0 0 0 0 0 0 1 0 0 0 0 1 1 0 1 0 0 0 0 0 0 1 0 0 1 0 1 0 0 0 0 0 0 0 0 1 0 0 0 0 1 0 0 0 1 4 0 1 0 0 0 0 0 0 1 1 0 0 0 0 0 0 X 18 17 1 0 0 0 0 1 1 1 1 0 0 1 1 1 1 1 1 0 0 0 X JOHN WILKER 4026447249 2700 WEST NORFOLK AVE STE 200 NORFOLK NE 68701 JACQUE COLLISON PRESIDENT/LCHA BOARD REP 1.00 2.50 X X 0 0 0 JAN EINSPAHR VICE-PRESIDENT 1.00 0.00 X X 0 0 0 BRANDON DOKE PRESIDENT-ELECT 1.00 0.00 X X 0 0 0 TODD WRAGGE PAST PRESIDENT 1.00 0.00 X X 0 0 0 RUSS MCKILLIP SECRETARY/TREASURER 1.00 0.00 X X 0 0 0 DONALD BELL MD MEMBER 1.00 0.00 X 0 0 0 ALAN COLLISON MEMBER 1.00 0.00 X 0 0 0 PAT DELAY MEMBER 1.00 0.00 X 0 0 0 JARED JANSEN MEMBER 1.00 0.00 X 0 0 0 VIRGIL FROEHLICH MEMBER 1.00 0.00 X 0 0 0 DR TRISTAN HARTZELL MEMBER 1.00 40.00 X 0 3318312 11000 RICK HIGGINS MEMBER 1.00 0.00 X 0 0 0 PAT HUGHES MEMBER 1.00 0.00 X 0 0 0 GORDON ADAMS MD MEMBER 1.00 0.00 X 0 0 0 JIM SCHEER FRHS BOARD REPRESENTATIVE 1.00 0.50 X 0 0 0 TOM SCHUETH MEMBER 1.00 0.00 X 0 0 0 HARRIET STUDEBAKER MEMBER 1.00 0.00 X 0 0 0 TIMOTHY TIGHE MEMBER 1.00 0.00 X 0 0 0 MARK KLOSTERMAN CEO THRU 7/2018 1.00 40.00 X 0 662852 8250 JOHNATHAN WILKER VP FINANCE 1.00 40.00 X 0 262421 35873 JAKE CLAUSSEN FOUNDATION DIRECTOR 20.00 20.00 X 0 112174 27475 KELLY DRISCOLL CEO 1.00 40.00 X 0 376263 40319 0 4732022 122917 0 0 1 0 0 228321 28500 989958 71941 1246779 267856 267856 452403 450911 1492 1492 1492 191865 228321 136290 55575 55575 1571702 0 0 324923 184518 184518 20950 20950 11408 11408 ANNUITY PAYMENTS 1369 1369 FUNDRAISING EXPENSES 394 394 218639 184518 20950 13171 2516 15546 6518018 7951961 207885 7995110 7122286 14515644 15297678 1346 9319 122442 121372 123788 130691 X 1793677 1896975 7140869 7812652 5457310 5457360 14391856 15166987 14515644 15297678 1353063 -577932 0 X X 0 1 X 1 0 X X 1 FAITH REGIONAL HEALTH SERVICES 470796875 3 1 184518 0 1 184518 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 0 RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 8361450 50 -308584 8052916 7601924 10000 749526 8361450 7172111 10010 419803 7601924 7388088 11370 -209870 17477 7172111 7065293 12155 310640 166091 7221997 0.00640 0.67770 0.31590 0 0 0 ANNUITY PAYABLE 121372 121372 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 TEMPORARILY 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 TEMPORARILY RESTRICTED AS TO USE. THE CARDIAC SERVICES ENDOWMENT FUNDS ARE PERMANENTLY SET ASIDE TO GENERATE INVESTMENT EARNINGS TO FUND FAITH REGIONAL HEALTH SERVICE'S (FRHS) CARDIAC PROGRAM CAPITAL AND/OR OPERATIONAL EXPENSES. THE EDUCATION ENDOWMENT FUNDS ARE PERMANENTLY SET ASIDE TO GENERATE INVESTMENT EARNINGS TO BENEFIT FRHS'S EDUCATION PROGRAMS AND ITS EFFORTS TO RECRUIT AND RETAIN EMPLOYEES. INVESTMENT INCOME ON THESE FUNDS IS TEMPORARILY 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 TEMPORARILY RESTRICTED AS TO USE. THE PEDIATRIC ENDOWMENT FUNDS ARE PERMANENTLY SET ASIDE TO GENERATE INVESTMENT EARNINGS TO BENEFIT FRHS'S CHILDREN'S CARE FUND. DONORS MAY SPECIFY CONTRIBUTIONS TO ANY OF THE ENDOWMENT FUNDS. PART X, LINE 2: FAITH REGIONAL HEALTH SERVICES (FRHS) AND FAITH REGIONAL HEALTH SERVICES FOUNDATION (THE FOUNDATION) ARE NOT-FOR-PROFIT CORPORATIONS AS DESCRIBED IN SECTION 501(C)(3) OF THE INTERNAL REVENUE CODE AND ARE EXEMPT FROM FEDERAL AND NEBRASKA STATE INCOME TAXES ON RELATED INCOME PURSUANT TO SECTION 501(A) OF THE CODE. FAITH REGIONAL PHYSICIAN SERVICES (FRPS) IS A LIMITED LIABILITY COMPANY WHOLLY OWNED BY FRHS. THE INTERNAL REVENUE SERVICE HAS ESTABLISHED STANDARDS TO BE MET TO MAINTAIN TAX-EXEMPT STATUS. FAITH 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, 2018 AND 2017, FAITH HAD NO UNCERTAIN TAX POSITIONS ACCRUED. GOLF TOURNAMENT 57097 27175 29922 150 24743 4895 WINTER GALA 286192 152620 133572 1500 60522 14804 2 76897 48526 28371 2486 11502 8972 6716 420186 228321 191865 1500 63158 51049 8972 11611 136290 55575 1 FAITH REGIONAL HEALTH SERVICES 2700 WEST NORFOLK AVENUE NORFOLK NE 68701 470796875 501(C)(3) 184518 FUNDING FOR HOSPITAL OPERATIONS AND PROJECTS 1 0 PART I, LINE 2: FAITH REGIONAL HEALTH SERVICES FOUNDATION PROVIDES GRANT MONEY TO FAITH REGIONAL HEALTH SERVICES, A RELATED 501(C)(3) ORGANIZATION. FAITH REGIONAL HEALTH SERVICES PROVIDES HEALTH CARE SERVICES TO INDIVIDUALS IN NORTHEAST NEBRASKA. 1 0 0 0 0 0 0 0 0 DR TRISTAN HARTZELL MEMBER 0 990787 0 2326967 0 558 0 11000 0 0 0 3329312 0 0 MARK KLOSTERMAN CEO THRU 7/2018 0 626999 0 25000 0 10853 0 8250 0 0 0 671102 0 0 JOHNATHAN WILKER VP FINANCE 0 260598 0 0 0 1823 0 7550 0 28323 0 298294 0 0 KELLY DRISCOLL CEO 0 373581 0 0 0 2682 0 11000 0 29319 0 416582 0 0 PART I, LINE 4A MARK KLOSTERMAN, OFFICER AND CEO THROUGH JULY 2018, RECEIVED A SEVERANCE PAYMENT OF $210,030 FROM FAITH REGIONAL HEATLH SERVICES, A RELATED ORGANIZATION, DURING 2018. SCHEDULE J, PART II: FAITH REGIONAL HEALTH SERVICES FOUNDATION DOES NOT COMPENSATE ANY OFFICERS, DIRECTORS, OR KEY EMPLOYEES. THE COMPENSATION LISTED IN SCHEDULE J IS PAID BY FAITH REGIONAL HEALTH SERVICES (FRHS), A RELATED ENTITY. THEIR COMPENSATION IS DETERMINED BY GATHERING DATA FROM EXTERNAL SURVEYS AND FORM 990 DATA PROVIDED BY COMPARABLE FACILITIES. FACILITIES USED ARE SIMILAR IN SIZE OF HOSPITAL, REVENUE, AND NUMBER OF FTES. WAGES ARE GATHERED AND COMPARED BY TITLE, RESPONSIBILITIES AND YEARS OF EXPERIENCE. THE SALARY RECOMMENDATIONS ARE MADE BY THE FRHS HUMAN RESOURCES DEPARTMENT. THE FRHS GOVENING 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. X 3 6116 FMV X 11659 FMV X 1 2350 FMV X 6 1765 FMV X EQUIPMENT 1 13500 FMV X RECREATION TRIPS 11 11540 FMV X TICKETS 28 10386 FMV X OTHER MISCELLANEOUS ITEMS 37 5650 FMV X SPORTING EQUIPMENT 5 4560 FMV X ELECTRONICS 4 2600 FMV X GIFT BASKETS 12 1815 FMV 0 1 0 FORM 990, PART VI, SECTION A, LINE 2 JACQUE COLLISON AND ALAN COLLISON, BOTH BOARD MEMBERS, HAVE A FAMILY RELATIONSHIP. FORM 990, PART VI, SECTION A, LINE 7A FAITH REGIONAL HEALTH SERVICES FOUNDATION'S BYLAWS STATE ALL DIRECTORS SHALL BE APPOINTED BY THE FAITH REGIONAL HEALTH SERVICES BOARD OF DIRECTORS. FORM 990, PART VI, SECTION A, LINE 7B BOARD MEMBER APPOINTMENT AND RETENTION DECISIONS MADE BY THE FOUNDATION BOARD ARE APPROVED BY THE FAITH REGIONAL HEALTH SERVICES BOARD OF DIRECTORS. FORM 990, PART VI, SECTION B, LINE 11B THE FORM 990 AND ALL APPLICABLE SCHEDULES WERE PREPARED AND SIGNED BY SEIM JOHNSON, LLP IN OMAHA, NEBRASKA. COPIES OF THE COMPLETED RETURN WERE DISTRIBUTED TO THE BOARD MEMBERS FOR REVIEW PRIOR TO SUBMISSION TO THE IRS. FORM 990, PART VI, SECTION B, LINE 12C FAITH REGIONAL HEALTH SERVICES FOUNDATION BOARD MEMBERS COMPLETE A CONFLICT OF INTEREST STATEMENT AND DISCLOSURE ANNUALLY. THESE STATEMENTS ARE REVIEWED BY A DIRECTOR OF THE FOUNDATION. FORM 990, PART VI, SECTION C, LINE 19 FAITH REGIONAL HEALTH SERVICES FOUNDATION DOES NOT MAKE ITS GOVERNING DOCUMENTS, CONFLICT OF INTEREST STATEMENT, OR FINANCIAL STATEMENTS AVAILABLE TO THE PUBLIC. FORM 990, PART VI, SECTION B, LINE 15: FAITH REGIONAL HEALTH SERVICES FOUNDATION DOES NOT PAY COMPENSATION TO A CEO, EXECUTIVE DIRECTOR, TOP MANAGEMENT OFFICIAL, OFFICERS OR KEY EMPLOYESS OF THE ORGANIZATION. THEREFORE, QUESTION 15A AND 15B ARE ANSWERED NO. FORM 990, PART XII, LINE 2C: FAITH REGIONAL HEALTH SERVICES FOUNDATION HAS AN AUDIT COMPLETED ON A CONSOLIDATED BASIS WITH FAITH REGIONAL HEALTH SERVICES AND FAITH REGIONAL PHYSICIAN SERVICES, LLC. THE BOARD OF DIRECTORS OF FAITH REGIONAL HEALTH SERVICES ASSUMES RESPONSIBILITY FOR THE OVERSIGHT OF THE AUDIT AND THE SELECTION OF AN INDEPENDENT ACCOUNTANT. THERE HAVE BEEN NO CHANGES IN THIS PROCESS FROM PRIOR YEARS. FAITH REGIONAL HEALTH SERVICES 2700 W NORFOLK AVE NORFOLK NE 68701 470769875 PROVIDE HEALTHCARE SERVICES TO THE NORTHEAST NEBRASKA REGION NE 501(C)(3) 3 LUTHERAN COMMUNITY HOSPITAL ASSOCIATION 0 LUTHERAN COMMUNITY HOSPITAL ASSOCIATION 2700 W NORFOLK AVE NORFOLK NE 68701 470396139 SUPPORT FAITH REGIONAL HEALTH SERVICES NE 501(C)(3) 3 N/A 0 0 1 1 0 0 0 0 0 0 0 0 1 0 1 1 0 0 0 0