2019-05-15T11:51:32-05:00 2018-06-30 450250958 EIDE BAILLY LLP 200 EAST 10TH ST PO BOX 5125 SIOUX FALLS SD 571175125 990 2017-07-01 420890973 OSCEOLA COMMUNITY HOSPITAL INC OSCE 7127542574 PO BOX 258 SIBLEY IA 51249 BEN DAVIS CEO 7127542574 2019-05-14 1 LAURIE HANSON P00851848 6053391999 2019-05-14 199.247.43.150 2019-05-14 15:07:14 CD P DB1FD6DC1D5D45D0B5FA61CC16A42C1A816EE75B 401A7809F2AA56B1FE621E55666FA95C3E42E950 2017 2019-02-21 02:37:17Z BEN DAVIS PO BOX 258 SIBLEY IA 51249 15881318 0 X HTTPS://WWW.AVERA.ORG/LOCATIONS/OSCEOLA/ X 1960 IA TO PROVIDE HEALTHCARE TO THE CITIZENS OF OSCEOLA COUNTY AND THE SURROUNDING AREA. 9 9 131 198 0 0 932913 745100 11289537 11015329 216299 133509 953891 220241 13392640 12114179 0 0 0 0 6824032 6112553 0 0 52257 6753814 6809080 13577846 12921633 -185206 -807454 18875085 17695728 5818876 5273843 13056209 12421885 X IT IS THE MISSION OF THE OSCEOLA COMMUNITY HOSPITAL TO ENHANCE AND IMPROVE THE QUALITY OF LIFE OF THE POPULATION IT SERVES, TO BE THE AREA'S PREMIER HEALTH CARE SERVICE PROVIDER, AND TO HAVE A POSITIVE IMPACT ON THE LIVES OF THE PEOPLE AND COMMUNITY IT SERVES. 0 1 11035409 11043657 OSCEOLA COMMUNITY HOSPITAL PROVIDED NURSING SERVICES, LAB, RADIOLOGY, AND OTHER RELATED HOSPITAL FUNCTIONS TO RESIDENTS OF OSCEOLA COUNTY, IOWA AND NEARBY COUNTIES. IN ADDITION, THE HOSPITAL ALSO PROVIDES HOME HEALTH, INDEPENDENT/ASSISTED LIVING, AND DAY CARE TO THE COMMUNITY. HEALTH SCREENINGS SUCH AS CHOLESTEROL AND CARDIAC ARE PROVIDED AS WELL. THE HOSPITAL WORKS HARD TO BRING OUTREACH SPECIALISTS TO THE FACILITY TO MAKE THESE SERVICES AVAILABLE TO THOSE THAT FIND IT DIFFICULT TO TRAVEL. THE FACILITY'S WELLNESS CENTER PROVIDES PROGRAMS TO THE LOCAL SCHOOL SYSTEM, NURSING HOME FACILITIES, OUTPATIENTS, AND THE COMMUNITY AT LARGE. DURING THE 12 MONTHS OF 7/01/2017-6/30/2018 THE HOSPITAL PROVIDED $47,000 OF CHARITY CARE TO VARIOUS INDIVIDUALS, WITHOUT REIMBURSEMENT. 11035409 1 1 0 0 0 0 0 0 0 0 1 1 0 0 0 1 0 1 0 0 0 0 0 0 0 0 1 1 0 0 1 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 0 0 0 1 30 0 1 131 1 0 0 0 0 0 0 0 0 X 9 9 0 0 0 0 1 1 0 1 1 0 0 1 1 1 1 1 1 1 1 0 X CRAIG CARSTENS 7127542574 600 9TH AVENUE NORTH SIBLEY IA 51249 BRUCE OSTERMAN PRESIDENT 1.00 1.00 X X 0 0 0 BARB VAN DIEPEN PRESIDENT ELECT 1.00 0.00 X X 0 0 0 STANLEY JOHNSON TREASURER 1.00 1.00 X X 0 0 0 PEGGI THIES SECRETARY 1.00 0.00 X X 0 0 0 KEVIN HERTZ TRUSTEE 1.00 0.00 X 0 0 0 JIM BENZ TRUSTEE 1.00 0.00 X 0 0 0 BRIAN DREESSEN TRUSTEE 1.00 0.00 X 0 0 0 ROSALIE ARENDS TRUSTEE 1.00 1.00 X 0 0 0 SUE ELLEN SCHUTTE TRUSTEE 1.00 0.00 X 0 0 0 BEN DAVIS CEO 40.00 0.00 X 87501 0 269 LORRIE REED CFO UNTIL 05/2018 40.00 0.00 X 55481 0 1700 CRAIG CARSTENS CFO FROM 05/2018 40.00 0.00 X 0 0 0 JANET DYKSTRA FORMER CEO 0.00 0.00 X 178929 0 7417 321911 0 9386 1 1 1 0 AVERA MCKENNAN 800 E 21ST ST SIOUX FALLS SD 57117 ADMINISTRATIVE AND MEDICAL SERVICES 1593381 CARDINAL HEALTH 7000 CARDINAL PL DUBLIN OH 43017 PHARMACY 467184 GREAT LAKE PHYSICAL THERAPY 3301 BERGQUIST AVE SPIRIT LAKE IA 51360 PHYSICAL THERAPY SERVICES 365530 SIOUX FALLS CONSTRUCTION 4500 W 58TH ST SIOUX FALLS SD 57108 CONSTRUCTION 278835 SANFORD HOSPITAL PO BOX 5074 SIOUX FALLS SD 57117 CRNA COVERAGE, SPEECH THERAPY, LAB 112115 5 45991 699109 745100 PATIENT REVENUE 621400 10292042 10292042 CHILDCARE SERVICES 621400 426933 426933 296354 296354 11015329 8511 8511 111597 0 111597 111597 111597 3393251 497200 3266366 499087 126885 -1887 124998 124998 3540 1686 1854 1854 80316 0 80316 80316 A/R INTEREST 900099 26474 26474 26474 12114179 11041803 0 327276 X 349424 349424 3799212 3602157 171332 25723 94399 90239 3872 288 1594622 1341298 239023 14301 274896 241201 31728 1967 7649 7649 123743 123743 2359992 2117900 242011 81 86576 26 86550 263997 182090 81382 525 182897 160961 15813 6123 25178 21277 3901 28378 24575 3803 133782 133782 947810 871056 76592 162 113589 9592 103997 MEDICAL SUPPLIES 1313584 1313584 BAD DEBT EXPENSES 669122 669122 REPAIR AND MAINTENANCE 458937 239319 219303 315 DUES AND SUBSCRIPTIONS 19819 4129 15690 74027 13101 58154 2772 12921633 11035409 1833967 52257 1512794 1987378 1110094 54221 11800 11800 2040007 2101076 71832 8644 386298 369899 69135 54065 20593678 14451690 6616905 6141988 3831892 3968859 2653201 2393454 571127 604344 18875085 17695728 1281476 914121 4465400 4326222 72000 33500 5818876 5273843 X 12471196 12221302 585013 200583 13056209 12421885 18875085 17695728 X -807454 26904 146224 X 0 1 X 1 0 X 201490 201490 12882237 7961347 4920890 672391 633129 39262 6837560 5857214 980346 6141988 INTEREST IN NET ASSETS OF FOUNDATION 2216307 F CLOSELY-HELD EQUITY INVESTMENTS 177147 F 2393454 X PART X, LINE 2: THE HOSPITAL IS ORGANIZED AS AN IOWA NONPROFIT ORGANIZATION AND HAS BEEN RECOGNIZED BY THE INTERNAL REVENUE SERVICE (IRS) AS EXEMPT FROM FEDERAL INCOME TAXES UNDER INTERNAL REVENUE SERVICE CODE SECTION 501(C)(3). THE ENTITY IS ANNUALLY REQUIRED TO FILE A RETURN OF ORGANIZATION EXEMPT FROM INCOME TAX (FORM 990) WITH THE IRS. IN ADDITION, THE ENTITY IS SUBJECT TO INCOME TAX ON NET INCOME THAT IS DERIVED FROM BUSINESS ACTIVITIES THAT ARE UNRELATED TO ITS EXEMPT PURPOSE. MANAGEMENT HAS DETERMINED THAT THE ENTITY IS NOT SUBJECT TO UNRELATED BUSINESS INCOME TAX AND HAS NOT FILED AN EXEMPT ORGANIZATION BUSINESS INCOME TAX RETURN (FORM 990-T) WITH THE IRS. THE HOSPITAL BELIEVES THAT IT HAS APPROPRIATE SUPPORT FOR ANY TAX POSITIONS TAKEN AFFECTING ITS ANNUAL FILING REQUIREMENTS, AND AS SUCH, DOES NOT HAVE ANY UNCERTAIN TAX POSITIONS THAT ARE MATERIAL TO THE FINANCIAL STATEMENTS. THE HOSPITAL WOULD RECOGNIZE FUTURE ACCRUED INTEREST AND PENALTIES RELATED TO UNRECOGNIZED TAX BENEFITS AND LIABILITIES IN INCOME TAX EXPENSE IF SUCH INTEREST AND PENALTIES ARE INCURRED. THE HOSPITAL'S TAX RETURN IS SUBJECT TO REVIEW AND EXAMINATION BY FEDERAL, STATE, AND LOCAL AUTHORITIES. 1 1 X 1 X 1 X 1 1 1 0 1 1 47000 47000 0.00380 741412 658820 82592 0.00670 788412 658820 129592 0.01050 6 1274 3214 3214 0.00030 3 6804 6804 0.00060 1362641 708146 654495 0.05340 1 10000 10000 0.00080 10 1274 1382659 708146 674513 0.05510 10 1274 2171071 1366966 804105 0.06560 3 51957 41720 10237 0.00080 3 51957 41720 10237 0.00080 1 669122 0 4445259 4471502 -26243 X 1 1 1 1 OSCEOLA COMMUNITY HOSPITAL 600 NINTH AVENUE NORTH SIBLEY IA 51249 WWW.OSCEOLACOMMUNITYHOSPITAL.ORG 720109H X X X X OSCEOLA COMMUNITY HOSPITAL 1 0 0 1 X X X X X X X X X 15 1 0 1 1 X HTTPS://WWW.AVERA.ORG/APP/FILES/PUBLIC/64762/20 X 1 15 1 HTTPS://WWW.AVERA.ORG/APP/FILES/PUBLIC/64761/2016-CH 0 1 X 100.000000000000 200.000000000000 X X 1 1 X X X X 1 X HTTPS://WWW.AVERA.ORG/APP/FILES/PUBLIC/65614/OSCEOLA-FAP.PDF X SEE PART V SECTION C X HTTPS://WWW.AVERA.ORG/APP/FILES/PUBLIC/65615/OSCEOLA-PLAIN-LANGUAGE-FAP.PDF X X X X X X 1 X 0 X X X X 1 X 0 0 OSCEOLA COMMUNITY HOSPITAL PART V, SECTION B, LINE 5: THE ASSESSMENT WAS CONDUCTED BY OSCEOLA COMMUNITY HOSPITAL AND OSCEOLA COMMUNITY HEALTH SERVICES, WHICH ALSO PROVIDED THE FINANCIAL AID AND IN-KIND SUPPORT FOR THE ASSESSMENT PROCESS. SINCE THE GREATEST PORTION OF THE ORGANIZATION'S PATIENTS AND CUSTOMERS RESIDE IN OSCEOLA AND LYON COUNTIES, FOCUS GROUPS AND PAPER SURVEYS WERE TAKEN TO SIX SURROUNDING TOWNS OF HARRIS, MELVIN, OCHEYEDAN, ASHTON, LITTLE ROCK AND GEORGE, ALL IN IOWA. A PAPER SURVEY WAS HANDED OUT TO PARTICIPANTS AT THE HOSPITAL AND VARIOUS CONGREGATE PLACES, AND FOCUS GROUPS WERE CONDUCTED IN EACH COMMUNITY. FOR THE 2015-2016 COMMUNITY NEEDS ASSESSMENT THERE WERE SEVENTEEN FOCUS GROUPS AND A TOTAL OF 190 SURVEYS COMPLETED. SPECIAL ATTENTION WAS TAKEN THROUGHOUT THE PRIMARY DATA COLLECTION PROCESS TO ENSURE THE HOSPITAL'S ASSESSMENT TOOK INTO ACCOUNT INPUT FROM PERSONS WHO REPRESENTED THE BROAD INTERESTS OF THE COMMUNITY, INCLUDING THOSE WITH SPECIAL KNOWLEDGE AND EXPERTISE IN PUBLIC HEALTH.THE FOCUS GROUP PARTICIPANTS INCLUDED REPRESENTATIVES FROM THE MEDICAL COMMUNITY AND CIVIC ORGANIZATIONS, BUSINESS OWNERS, FARMERS, PUBLIC HEALTH OFFICIALS, EMTS, FIREFIGHTERS, CITY AND COUNTY OFFICIALS, SIBLEY-OCHEYEDAN SCHOOL PERSONNEL, MENTAL HEALTH PROVIDERS, OSCEOLA COUNTY SHERIFF'S OFFICE PERSONNEL, DOMESTIC ABUSE COUNSELORS, SUBSTANCE ABUSE AND MENTAL HEALTH COUNSELORS, MINISTERIAL ASSOCIATION MEMBERS, BOARD OF TRUSTEE MEMBERS, PATIENTS, AND PEOPLE REPRESENTING THE UNINSURED AND UNDERINSURED POPULATION. IN ADDITION, A FOCUS GROUP WAS HELD FOR STAFF FROM OSCEOLA ECONOMIC SERVICES. THIS SERVICE CARES FOR PEOPLE LIVING WITH DISABILITIES. MANY OF THE CLIENTS WERE UNABLE TO READ THE SURVEY. ONE ON ONE CONVERSATIONS WERE CONDUCTED WITH TWELVE INDIVIDUALS, WHICH PROVIDED VALUABLE INPUT AND INFORMATION FROM THE DISABLED MEMBERS OF THE COMMUNITY. ALL AGE GROUPS WERE REPRESENTED IN THE FOCUS GROUPS.OSCEOLA COMMUNITY HOSPITAL REACHED OUT TO A GROWING HISPANIC POPULATION WITH SURVEYS AND FOCUS GROUP REPRESENTATION. OSCEOLA COMMUNITY HOSPITAL PART V, SECTION B, LINE 6B: CHNA WAS CONDUCTED IN CONNECTION WITH OSCEOLA PUBLIC HEALTH. OSCEOLA COMMUNITY HOSPITAL PART V, SECTION B, LINE 11: DURING THE 2015 COMMUNITY HEALTH NEEDS ASSESSMENT, THE SIGNIFICANT HEALTH NEEDS WERE IDENTIFIED AS ACCESS TO HEALTH CARE (MENTAL HEALTH AND DENTAL), HEALTH IMPROVEMENT AND PROMOTION, MEMORY CARE, AND TRANSPORTATION. THE FOLLOWING ACTIONS WERE TAKEN BY OSCEOLA COMMUNITY HOSPITAL TO ADDRESS THESE SIGNIFICANT HEALTH NEEDS.ACCESS TO HEALTH CAREIN PARTNERSHIP WITH AVERA MEDICAL GROUP SIBLEY, WE RECRUITED A PHYSICIAN TO SERVE THE RESIDENTS OF OSCEOLA COUNTY AND SURROUNDING AREAS MAKING ACCESS TO PRIMARY CARE RELIABLE FOR COMMUNITY MEMBERS. WE HAVE ALSO RECRUITED A PODIATRIST AND ORTHOPEDIC SURGEON TO ENSURE PATIENT RECEIVE CARE CLOSE TO HOME.MENTAL HEALTH SERVICEOSCEOLA COMMUNITY HOSPITAL PARTNERED WITH SEASONS CENTER FOR BEHAVIORAL HEALTH TO PROVIDE OUTPATIENT MENTAL HEALTH COUNSELING SERVICES AT OSCEOLA COMMUNITY HOSPITAL. OSCEOLA COMMUNITY HOSPITAL ALSO PARTNERS WITH AVERA EEMERGENCY TO PROVIDE MENTAL HEALTH ASSESSMENTS IN THE EMERGENCY ROOM VIA TELEMEDICINE. THE HOSPITAL CONTINUES TO PARTNER WITH THE NORTHWEST IOWA CARE CONNECTIONS MENTAL HEALTH AND DISABILITY SERVICE, AVERA BEHAVIORAL HEALTH, CREATIVE LIVING CENTER, HOPE HAVEN AND THE SIBLEY-OCHEYEDAN SCHOOL DISTRICT TO PROMOTE MENTAL HEALTH SERVICES AND COUNSELING IN OUR REGION. HEALTH IMPROVEMENT AND PROMOTIONOSCEOLA COMMUNITY HOSPITAL PLANS TO UPDATE THE WELLNESS CENTER TO PROVIDE NEW EQUIPMENT AND 24-HOUR ACCESS TO RESOURCES IN THE WELLNESS CENTER. THE OSCEOLA COMMUNITY HOSPITAL WILL OFFER EDUCATION PROGRAMS FOR THE COMMUNITY ON HEALTHY EATING AND GOOD NUTRITION AND EDUCATION ON STAYING FIT. IN PARTNERSHIP WITH AVERA MEDICAL GROUP SIBLEY, THE PRIMARY CARE PROVIDERS ARE PROMOTING HEALTH IMPROVEMENT, EDUCATION AND PROMOTION.MEMORY CAREOSCEOLA COMMUNITY HOSPITAL IS A COMMUNITY PARTNER IN WORKING WITH LOCAL AND REGIONAL ENTITIES TO ADDRESS DEMENTIA CARE INCLUDING LOCAL NURSING HOMES. TRANSPORTATIONIN PARTNERSHIP WITH LOCAL ORGANIZATIONS, THE COMMUNITY EXPRESS BUS OFFERS TRANSPORTATION NEEDS TO COMMUNITY MEMBERS. OSCEOLA COMMUNITY HOSPITAL PARTICIPATES IN FUNDING THE BUS AND HAS A REPRESENTATIVE ON THE BOARD. THIS HAS BEEN A SUCCESSFUL VENTURE FOR ALL ORGANIZATIONS INVOLVED. OSCEOLA COMMUNITY HOSPITAL PART V, SECTION B, LINE 13B: THE HOSPITAL WILL PRESUMPTIVELY DETERMINE THAT AN INDIVIDUAL QUALIFIES FOR 100% FINANCIAL ASSISTANCE IF THE HOSPITAL OR ITS AGENT OBTAINS EVIDENCE OF ANY OF THE FOLLOWING SITUATIONS. IF A PERSON IS PRESUMPTIVELY DETERMINED TO QUALIFY, THE HOSPITAL WILL SEND A WRITTEN NOTICE INFORMING THE INDIVIDUAL THAT THEIR LIABILITY HAS BEEN FORGIVEN AND NO FURTHER PAYMENTS ARE DUE.-HOMELESSNESS OR RECEIVED CARE FROM A HOMELESS CLINIC;-NO INCOME;-PARTICIPATE IN THE WOMEN'S, INFANT'S, AND CHILDREN'S PROGRAM ("WIC");-ELIGIBLE FOR FOOD STAMPS;-PARTICIPATE IN A SUBSIDIZED SCHOOL LUNCH PROGRAM;-ELIGIBLE FOR OTHER STATE OR LOCAL ASSISTANCE PROGRAMS THAT ARE UNFUNDED, SUCH AS MEDICAID SPEND-DOWN;-FAMILY OR FRIENDS OF THE INDIVIDUAL PROVIDE INFORMATION ESTABLISHING THE INDIVIDUAL'S INABILITY TO PAY;-LOW-INCOME/SUBSIDIZED HOUSING IS PROVIDED AS A VALID ADDRESS;-PATIENT IS DECEASED WITH NO KNOWN ESTATE; OR-PATIENT/GRANTOR IS INCARCERATED, HAS NO ASSETS, AND IS NOT ELIGIBLE FOR PAROLE WITHIN THE NEXT 18 MONTHS. PART V, LINE 16B, HTTPS://WWW.AVERA.ORG/APP/FILES/PUBLIC/65613/OSCEOLA-CHARITY-CARE-APPLICATION.PDF PART I, LINE 3C: IN ADDITION TO USING FPG TO DETERMINE ELIGIBILITY FOR FREE OR DISCOUNTED CARE, THE FACILITY USES AN ASSET TEST AND MAY PROVIDE PRESUMPTIVE ELIGIBILITY IF WARRANTED. PART I, LINE 6A: THE HOSPITAL'S COMMUNITY BENEFIT REPORT IS INCLUDED IN A REPORT PREPARED BY THE IOWA HOSPITAL ASSOCIATION, RATHER THAN IN A SEPARATE REPORT PREPARED BY THE ORGANIZATION. THIS REPORT IS MADE AVAILABLE BY THE IOWA HOSPITAL ASSOCIATION TO THE PUBLIC THROUGH THEIR WEBSITE. PART I, LINE 7: CHARITY CARE EXPENSE WAS CONVERTED TO COST ON LINE 7A BASED ON AN OVERALL COST-TO-CHARGE RATIO ADDRESSING ALL PATIENT SEGMENTS. LINES 7B: UNREIMBURSED MEDICAID WAS CALCULATED USING THE COSTING METHODS TO PREPARE THE COST REPORT. ACTUAL COSTS FROM THE GENERAL LEDGER WERE USED FOR LINES 7E, 7F AND 7I.LINE 7G WAS DETERMINED USING THE MEDICARE COST REPORT. PART I, LN 7 COL(F): BAD DEBT EXPENSE OF $669,122 WAS SUBTRACTED FROM TOTAL OPERATING EXPENSE. PART II, COMMUNITY BUILDING ACTIVITIES: THE ORGANIZATION SUPPORTED THE COMMUNITY THROUGH PROVIDING EMERGENCY PREPAREDNESS, DISEASE SURVEILLANCE AND BEST CARE FOR BETTER BABIES PROGRAMS. PART III, LINE 2: IN EVALUATING THE COLLECTABILITY OF PATIENT ACCOUNTS RECEIVABLE, THE HOSPITAL 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. 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, IF NECESSARY.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 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 4: THE FOOTNOTE THAT DESCRIBES BAD DEBT EXPENSE IS ON PAGE 8-9 OF THE ATTACHED AUDIT REPORT. PART III, LINE 8: MEDICARE ALLOWABLE COST OF CARE WAS CALCULATED FROM THE MEDICARE COST REPORT FOR FISCAL YEAR ENDING 6/30/18. MEDICAL SERVICES ARE PROVIDED TO PATIENTS WITH MEDICARE COVERAGE REGARDLESS OF WHETHER OR NOT A SURPLUS OR DEFICIT IS REALIZED. PROVIDING MEDICARE SERVICES PROMOTES ACCESS TO HEALTHCARE SERVICES WHICH ARE VITALLY NEEDED BY OUR COMMUNITY. THE MEDICARE COST REPORT IS COMPLETED BASED ON THE RULES AND REGULATIONS SET FORTH BY THE CENTERS FOR MEDICARE AND MEDICAID SERVICES. PART III, LINE 9B: IF AN INDIVIDUAL SUBMITS A FINANCIAL ASSISTANCE APPLICATION, THE HOSPITAL WILL CEASE ALL COLLECTION EFFORTS UNTIL A DETERMINATION OF FINANCIAL ASSISTANCE ELIGIBILITY IS MADE. IF THE HOSPITAL OR ANOTHER AUTHORIZED PARTY HAS ALREADY BEGUN AN EXTRAORDINARY COLLECTION ACTION AGAINST AN INDIVIDUAL WHEN THAT INDIVIDUAL SUBMITS A COMPLETE FINANCIAL ASSISTANCE APPLICATION, THE EXTRAORDINARY COLLECTION ACTION WILL BE SUSPENDED. SUSPENDING AN ACTION MEANS THAT NO FURTHER STEPS ARE TAKEN ON THAT EXTRAORDINARY COLLECTION ACTION AND NO NEW EXTRAORDINARY COLLECTION ACTIONS ARE INITIATED. THIS SUSPENSION MAY BE LIFTED WHEN THE HOSPITAL DETERMINES THE INDIVIDUAL'S ELIGIBILITY FOR FINANCIAL ASSISTANCE AND NOTIFIES THE INDIVIDUAL AS PRESCRIBED IN THE FINANCIAL ASSISTANCE POLICY. IF THE HOSPITAL OR ANOTHER AUTHORIZED PARTY HAS ALREADY BEGUN AN EXTRAORDINARY COLLECTION ACTION AGAINST AN INDIVIDUAL WHEN THAT INDIVIDUAL IS DETERMINED TO BE ELIGIBLE FOR FINANCIAL ASSISTANCE, THE HOSPITAL AND/OR THE OTHER AUTHORIZED PARTY WILL TAKE ALL REASONABLY AVAILABLE MEASURES TO REVERSE THE EXTRAORDINARY COLLECTION ACTION. SUCH STEPS INCLUDE, BUT ARE NOT LIMITED TO, VACATING A JUDGEMENT AGAINST THE INDIVIDUAL, LIFTING A LEVY OR LIEN ON THE INDIVIDUAL'S PROPERTY, AND REMOVING FROM THE INDIVIDUAL'S CREDIT REPORT ANY ADVERSE INFORMATION THAT WAS REPORTED.IF AN INDIVIDUAL SUBMITS AN INCOMPLETE FINANCIAL ASSISTANCE APPLICATION, HOSPITAL WILL TAKE THE FOLLOWING STEPS TO ENCOURAGE THEM TO COMPLETE THE APPLICATION. -SUSPEND ANY EXTRAORDINARY COLLECTION ACTIONS TO OBTAIN PAYMENT FOR THE CARE. -PROVIDE A WRITTEN NOTICE TO THE RESPONSIBLE PARTY THAT INCLUDES THE FOLLOWING INFORMATION. -THE ADDITIONAL INFORMATION AND/OR DOCUMENTATION THAT MUST BE SUBMITTED. -THE PHYSICAL LOCATION AND PHONE NUMBER OF A HOSPITAL EMPLOYEE OR DEPARTMENT THAT CAN PROVIDE INFORMATION ABOUT THE FINANCIAL ASSISTANCE POLICY. - THE PHYSICAL LOCATION AND PHONE NUMBER OF AN ORGANIZATION OR HOSPITAL EMPLOYEE/OFFICE/DEPARTMENT THAT CAN PROVIDE ASSISTANCE WITH THE FINANCIAL ASSISTANCE APPLICATION PROCESS. -ALLOW A REASONABLE AMOUNT OF TIME FOR THE RESPONSIBLE PARTY TO SUBMIT A COMPLETE FINANCIAL ASSISTANCE APPLICATION. SUCH PERIOD OF TIME WILL BE AT LEAST 30 DAYS FROM THE DATE THE WRITTEN NOTICE IS SENT TO THE RESPONSIBLE PARTY. IF THE RESPONSIBLE PARTY FAILS TO PROVIDE THE REQUESTED INFORMATION WITHIN THE STATED TIME, HOSPITAL MAY RENEW THE PREVIOUSLY INITIATED EXTRAORDINARY COLLECTION ACTIONS. IF AN INDIVIDUAL HAS MADE FULL OR PARTIAL PAYMENT, AND THE INDIVIDUAL IS SUBSEQUENTLY DETERMINED TO QUALIFY FOR FINANCIAL ASSISTANCE, ANY PAYMENTS IN EXCESS OF THEIR NEWLY CALCULATED REMAINING LIABILITY WILL BE REFUNDED TO THE PATIENT WITHIN 30 DAYS OF THE FINANCIAL ASSISTANCE ELIGIBILITY DETERMINATION. IF THE REFUNDABLE AMOUNT IS LESS THAN $5.00, IT WILL NOT BE REFUNDED. PART VI, LINE 2: THE HOSPITAL ASSESSES THE HEALTH CARE NEEDS OF THE COMMUNITY THROUGH FORMAL PROCESSES THAT INCLUDE MEETINGS, SURVEY AND COMMUNITY INPUT PRIOR TO UNDERTAKING ANY LARGE PROJECTS. THROUGHOUT THE YEAR, COMMUNITY NEEDS ARE ASSESSED INFORMALLY AT VARIOUS COMMUNITY MEETINGS AND THROUGH PATIENT SURVEYS. THE ORGANIZATION ALSO ASSISTS THE HOME HEALTH DEPARTMENT/PUBLIC HEALTH WITH A COMMUNITY NEEDS ASSESSMENT AND INFORMATION FROM THE CHNA IS UTILIZED TO HELP PLAN SERVICES THE ORGANIZATION OFFERS. PART VI, LINE 3: DURING THE COURSE OF PRE-REGISTRATION A MODE OF PAYMENT IS RECORDED ON THE ADMISSION FORM. IF INSURANCE IS INDICATED, BENEFITS ARE REQUESTED FROM THE INSURANCE COMPANY. IF IT IS NOTED THAT THE ACCOUNT HAS A LARGE DEDUCTIBLE OR IS SELF-PAY, THE INFORMATION IS FORWARDED TO THE COLLECTION STAFF AND SOCIAL SERVICES. OPTIONS FOR HANDLING PAYMENT OF THE ACCOUNT ARE THEN DISCUSSED WITH THE PATIENT OR THE RESPONSIBLE PARTY. IF THE PATIENT OR RESPONSIBLE PARTY IS NOT AVAILABLE AT THE TIME THE INFORMATION IS RECEIVED BY THE BUSINESS OFFICE OR SOCIAL SERVICE STAFF, EFFORTS TO CONTACT THEM INCLUDE PHONE AND WRITTEN CORRESPONDENCE. IF THE PARTY DOES NOT RESPOND, THE ACCOUNT IS HANDED OVER TO THE COLLECTION AREA. THIS PROCESS OFTEN REQUIRES A COMBINATION OF BUSINESS OFFICE AND SOCIAL SERVICE STAFF WORKING TOGETHER.OPTIONS FOR ANY SELF-PAY OBLIGATIONS INCLUDE PAYMENT IN FULL, PAYMENT PLANS, VARIOUS ASSISTANCE PROGRAMS, AND THE FINANCIAL ASSISTANCE OFFERED BY OSCEOLA COMMUNITY HOSPITAL'S CHARITY CARE. INFORMATION REGARDING THESE OPTIONS IS MADE AVAILABLE AT THIS TIME.DURING THE DISCUSSIONS, INFORMATION IS REQUESTED TO ASSESS AND APPROVE FINANCIAL STATUS IF PAYMENTS, PROGRAM APPLICATION, OR CHARITY ARE INDICATED. ASSISTANCE IS OFFERED FOR COMPLETION OF APPLICATIONS AND INSTRUCTIONS ARE GIVEN FOR COMPLETION OF FINANCIAL ASSESSMENTS. PARTICULAR ACCOUNTS MAY ALSO BE BROUGHT TO THE ATTENTION OF THE BUSINESS OFFICE OR SOCIAL SERVICES BY THE COLLECTIONS STAFF, PATIENTS THEMSELVES, OR RELATIVES OF PATIENTS. THIS USUALLY OCCURS WHEN THE CIRCUMSTANCES OF THE PATIENT CHANGES AFTER A TIME PERIOD HAS PASSED. WHEN NOTIFICATION IS RECEIVED, THESE CASES ARE REASSESSED. PART VI, LINE 4: OSCEOLA COMMUNITY HOSPITAL'S PRIMARY SERVICE AREA INCLUDES THE CITIZENS OF OSCEOLA COUNTY, IOWA. THE SECONDARY SERVICE AREA INCLUDES THE SURROUNDING COUNTIES OF NOBLES (MN), JACKSON (MN), DICKINSON (IA), O'BRIEN (IA), AND LYON (IA).ACCORDING TO THE 2000 AND 2010 CENSUS, THE POPULATION HAS DECREASED 8% OVER THE PREVIOUS 10 YEARS. THE MEDIAN AGE OF THE POPULATION WAS 40 AND WAS MADE UP OF 98% CAUCASIANS. THE MEDIAN HOUSEHOLD INCOME WAS $34,274 WITH AN AVERAGE HOUSEHOLD OF 2.5. PART VI, LINE 6: OSCEOLA COMMUNITY HOSPITAL IS A MANAGED FACILITY OF AVERA HEALTH. AVERA HEALTH AND OSCEOLA COMMUNITY HOSPITAL WORK COOPERATIVELY TO ENHANCE HEALTHCARE THROUGHOUT THE COMMUNITY SERVED BY THE HOSPITAL. AS A MANAGED FACILITY, OSCEOLA COMMUNITY HOSPITAL IS ABLE TO PARTICIPATE IN AVERA E-CARE SERVICES. THESE SERVICES INCLUDE AVERA E-EMERGENCY, E-PHARMACY AND E-CONSULT. THESE SERVICES ALLOW RURAL PATIENTS TO BE CARED FOR AT THEIR LOCAL HOSPITALS, PROVIDE RURAL HOSPITALS ACCESS TO IMMEDIATE SPECIALTY CARE AND SUPPORT, AND HELP REDUCE HEALTH CARE COSTS AND TRAVEL.OSCEOLA COMMUNITY HOSPITAL ALSO HAS ACCESS TO "BACK OFFICE" SUPPORT SERVICES, SUCH AS LEGAL CONSULTATION, QUALITY BENCHMARKING, CODING, COMPUTER SERVICES, CONTRACT NEGOTIATIONS, ADMINISTRATIVE CONSULTATION, GROUP PURCHASING, HUMAN RESOURCE ASSISTANCE AND MANY OTHER SERVICES. AVERA HEALTH IS ABLE TO PROVIDE THESE SERVICES TO THE HOSPITAL AT A COST BELOW THAT WHICH OSCEOLA COMMUNITY HOSPITAL COULD OTHERWISE ACHIEVE. IN TURN, LOCAL CAREGIVERS ARE ABLE TO DEVOTE MORE RESOURCES TO PATIENT AND RESIDENT CARE. AVERA HEALTH AND OSCEOLA COMMUNITY HOSPITAL DEDICATE RESOURCES TO ENDEAVORS THAT MAKE A POSITIVE DIFFERENCE TO IMPROVE THE HEALTH OF THE COMMUNITIES THEY SERVE. THESE ACTIVITIES INCLUDE LEADERSHIP DEVELOPMENT AND TRAINING FOR COMMUNITY MEMBERS, ECONOMIC DEVELOPMENT, PHYSICAL IMPROVEMENTS IN THE COMMUNITY, CONTRIBUTIONS TO NONPROFIT COMMUNITY ORGANIZATIONS, NONPROFIT EVENT SPONSORSHIPS, DONATED MEDICAL SUPPLIES, COMMUNITY HEALTH EDUCATION AND SUPPORT GROUPS, HEALTH SCREENINGS, FLU-SHOT CLINICS, COMMUNITY HEALTH EDUCATION AND VARIOUS OTHER ACTIVITIES. X X 1 0 0 0 0 0 0 0 0 JANET DYKSTRA FORMER CEO 52711 0 0 0 126218 0 7417 0 0 0 186346 0 0 0 PART I, LINE 4A FORMER CEO, JANET DYKSTRA, RECEIVED SEVERANCE PAY OF $126,218 DURING 2017. A CITY OF SIBLEYIA 426005203 2016-02-24 4776000 TO REFINANCE SERIES 2001 AND 2007 BONDS 0 0 0 A 365003 4776000 95520 4680101 1 0 1 1 A 0 0 0 0 0.00000 0.00000 0.00000 0 0 1 A 0 0 0 0 1 0 0 0 1 A 1 FORM 990, PART III, LINE 3 WE STOPPED PROVIDING OB SERVICES IN FEBRUARY 2018. FORM 990, PART VI, SECTION A, LINE 1 THE EXECUTIVE COMMITTEE CONSISTS OF THE OFFICERS OF THE ORGANIZATION. THE PRESIDENT SHALL SERVE AS THE CHAIR OF THE COMMITTEE. THE EXECUTIVE COMMITTEE SHALL HAVE POWER TO TRANSACT ALL REGULAR BUSINESS OF THE ORGANIZATION DURING THE INTERIM BETWEEN THE MEETINGS OF THE BOARD OF TRUSTEES, PROVIDED THAT ANY ACTION WHICH IT MAY TAKE SHALL NOT CONFLICT WITH THE POLICIES AND EXPRESSED WISHES OF THE BOARD OF TRUSTEES, AND THAT IT SHALL REFER ALL MATTERS OF MAJOR IMPORTANCE TO THE BOARD OF TRUSTEES. FORM 990, PART VI, SECTION A, LINE 6 REGULAR MEMBERS ARE THOSE PERSONS, CORPORATIONS, ASSOCIATIONS OR PARTNERSHIPS WHO HAVE CONTRIBUTED AND PAID INTO THE CORPORATION A MINIMUM OF $75 OR MORE TO FURTHER THE OBJECTIVES OF THE CORPORATION. MEMBERSHIP SHALL BE LIFELONG AND NONTRANSFERABLE. EACH MEMBER WHOSE NAME IS ENDORSED ON THE MEMBERSHIP CERTIFICATES SHALL BE QUALIFIED TO ORIGINATE AND TAKE PART IN THE DISCUSSION OF ANY SUBJECT THAT MAY PROPERLY COME BEFORE THE ANNUAL MEETING OF THE CORPORATION, TO VOTE ON SUCH SUBJECTS, AND TO HOLD ANY OFFICE TO WHICH THE MEMBER MAY TO ELECTED OR APPOINTED. NO EMPLOYEE OR EMPLOYEE'S SPOUSE OF THE CORPORATION MAY BE ELECTED TO THE BOARD OF TRUSTEES. FORM 990, PART VI, SECTION A, LINE 7A TRUSTEES ARE ELECTED TO THE BOARD OF TRUSTEES FROM THE MEMBERS AT THE ANNUAL MEETING OF THE ORGANIZATION. FORM 990, PART VI, SECTION B, LINE 11B THE FORM 990 WAS REVIEWED IN DETAIL BY MANAGEMENT OF THE HOSPITAL. UPON APPROVAL, THE FORM 990 WAS THEN PRESENTED TO THE BOARD MEMBERS AT A REGULARLY SCHEDULED BOARD MEETING PRIOR TO FILING WITH THE IRS. FORM 990, PART VI, SECTION B, LINE 12C EACH DIRECTOR/TRUSTEE, PRINCIPAL OFFICER, AND MEMBER OF A COMMITTEE WITH BOARD-DELEGATED POWERS SHALL ANNUALLY SIGN A CONFLICT OF INTEREST STATEMENT. IN CONNECTION WITH ANY ACTUAL OR POSSIBLE CONFLICT OF INTEREST, AN INTERESTED PERSON MUST DISCLOSE THE EXISTENCE OF A FINANCIAL INTEREST AND ALL MATERIAL FACTS TO THE DIRECTORS/TRUSTEES AND MEMBERS OF COMMITTEES WITH BOARD DELEGATED POWERS CONSIDERING THE PROPOSED TRANSACTION OR ARRANGEMENT. AFTER THE INTERESTED PERSON LEAVES THE MEETING, THE REMAINING BOARD OR COMMITTEE MEMBERS WILL DISCUSS AND VOTE UPON WHETHER A CONFLICT OF INTEREST EXISTS. ALSO, IF THE BOARD OR COMMITTEE HAS REASONABLE CAUSE TO BELIEVE A DIRECTOR, TRUSTEE, OR MEMBER HAS FAILED TO DISCLOSE ACTUAL OR POSSIBLE CONFLICTS OF INTEREST, IT SHALL INFORM SUCH PERSON OF THE BASIS FOR SUCH BELIEF AND AFFORD THE PERSON AN OPPORTUNITY TO EXPLAIN THE ALLEGED FAILURE TO DISCLOSE. APPROPRIATE DISCIPLINARY AND CORRECTIVE ACTION SHALL BE TAKEN IF NECESSARY. FORM 990, PART VI, SECTION B, LINE 15 A COMPENSATION SPECIALIST FROM AN AFFILIATE ORGANIZATION REVIEWS THE COMPENSATION WITH THE BOARD OF TRUSTEES SEMI-ANNUALLY. THE SPECIALIST REVIEWS MARKET VALUE AND PRESENTS A RECOMMENDATION TO THE BOARD OF TRUSTEES. THE BOARD MAKES THEIR DECISION ON THE INFORMATION PRESENTED. THE MOST RECENT PROCESS WAS COMPLETED IN 2017 FOR ALL OFFICERS AND TOP MANAGEMENT. FORM 990, PART VI, SECTION C, LINE 19 THE ORGANIZATION DOES NOT MAKE ITS GOVERNING DOCUMENTS OR CONFLICT OF INTEREST POLICY AVAILABLE TO THE PUBLIC. THE FINANCIAL STATEMENTS ARE MADE AVAILABLE UPON REQUEST AND THE FORM 990 IS AVAILABLE AT THE ANNUAL MEETING AND UPON REQUEST. FORM 990, PART IX, LINE 11G PURCHASED SERVICES: PROGRAM SERVICE EXPENSES 630,141. MANAGEMENT AND GENERAL EXPENSES 242,011. FUNDRAISING EXPENSES 81. TOTAL EXPENSES 872,233. MEDICAL PROFESSIONAL FEES: PROGRAM SERVICE EXPENSES 1,487,759. MANAGEMENT AND GENERAL EXPENSES 0. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 1,487,759. FORM 990, PART XI, LINE 9: CHANGE IN INTEREST IN NET ASSETS OF FOUNDATION 146,224. HEARTWOOD HEIGHTS 409 9TH AVE NORTH SIBLEY IA 51249 421495686 INDEPENDENT;ASSISTED LIVING IA 501(C)(3) PF OSCEOLA COMMUNITY HOSPITAL 1 0 0 0 0 0 0 0 0 0 0 0 1 0 0 1 0 1 0 0 HEARTWOOD HEIGHTS O 155599 ACTUAL COST