2019-09-04T08:23:53-05:00 2019-04-30 476097913 SEIM JOHNSON LLP 18081 BURT STREET SUITE 200 OMAHA NE 680224722 990 2018-05-01 470388012 BRODSTONE MEMORIAL HOSPITAL BROD 4028793281 520 EAST 10TH STREET SUPERIOR NE 689781225 TREG VYZOUREK CEO 4028793281 2019-08-28 1 MEGAN L KOZIOL P01544037 4023302660 209.34.201.180 2019-08-28 14:25:53 CD P 4492BEC4F3BAD6652306010BEE5B0619D04D8C2F B319C935D5CD5DD24452FA9CD51ABCBD1A9C8C2C 2018 2019-02-21 02:37:17Z TREG VYZOUREK 520 EAST 10TH STREET SUPERIOR NE 689781225 29320816 0 X WWW.BRODSTONEHOSPITAL.ORG X 1927 NE BRODSTONE MEMORIAL HOSPITAL IS A NOT-FOR-PROFIT CRITICAL ACCESS HOSPITAL DELIVERING INPATIENT, OUTPATIENT AND AMBULATORY CARE. 6 6 218 220 0 0 260928 782555 27340323 28050231 101400 345403 58070 64194 27760721 29242383 0 0 0 0 12795162 13703435 0 0 0 12906456 12465713 25701618 26169148 2059103 3073235 33066255 35421440 8132167 7643741 24934088 27777699 X COMPASSIONATE. DEDICATED. UNIFIED. WE CARE FOR YOU. 0 0 15740107 15481611 ANCILLARY SERVICES - BRODSTONE MEMORIAL HOSPITAL IS A 25 BED CRITICAL ACCESS HOSPITAL. SERVICES PROVIDED BY BRODSTONE INCLUDE ANESTHESIOLOGY, RADIOLOGY, CT SCANS, LABORATORY, BLOOD ADMINISTRATION, INHALATION THERAPY, SLEEP STUDIES, PHYSICAL AND OCCUPATIONAL THERAPY, SPEECH THERAPY, ELECTROCARDIOLOGY AND ECHOCARDIOLOGY, NUCLEAR MEDICINE AND EMERGENCY SERVICES.DURING 2019, BRODSTONE HAD 1,799 EMERGENCY ROOM VISITS AND PERFORMED 520 SURGERIES. THE LABORATORY PERFORMED 48,016 TESTS AND PHYSICAL THERAPY SERVICES PROVIDED 12,206 TREATMENTS. 3313516 3116785 PHYSICIAN' CLINICS - BRODSTONE MEMORIAL HOSPITAL OWNS 3 RURAL HEALTH CLINICS IN SUPERIOR, NELSON, AND EDGAR, NE. THREE BOARD CERTIFIED FAMILY PRACTICE PHYSICIANS, TWO PA-C, AND TWO APRNS SERVE ALL AGES FROM CHILDREN TO SENIOR CITIZENS. IN ADDITION TO DIAGNOSING AND TREATING ILLNESS, THEY ALSO PROVIDE PREVENTIVE CARE, ROUTINE CHECKUPS, IMMUNIZATION AND SCREENING TESTS, AND HOSPITALIZATION AND NURSING HOME CARE, AND OBSTETRICS. THE CLINICS HAD 16,142 VISITS IN 2019. 2605886 2425193 NURSING SERVICES - BRODSTONE MEMORIAL HOSPITAL IS A 25 BED CRITICAL ACCESS HOSPITAL. NURSING SERVICES WORK WITH THE MEDICAL STAFF TO DELIVER QUALITY, AFFORDABLE HEALTH CARE IN A CARING, SAFE AND COMPASSIONATE ENVIRONMENT TO ALL PATIENTS. BRODSTONE PROVIDED 1,195 PATIENT DAYS OF INPATIENT CARE AND 553 PATIENT DAYS OF SWING BED CARE IN 2019. 2065609 7026642 PHARMACY AND INTRAVENOUS THERAPY - BRODSTONE'S PHARMACY DEPARTMENT PREPARES AND DISPENSES MEDICATION BY REVIEWING AND INTERPRETING PHYSICIAN ORDERS. THE PHARMACISTS DETECT THERAPEUTIC INCOMPATIBILITIES, ADVISE INTERVENTIONS, ANSWER QUESTIONS FROM HEALTH PROFESSIONALS, AND COUNSEL PATIENTS ON DRUG THERAPIES. 2065609 7026642 23725118 1 1 0 1 0 0 0 0 0 1 1 0 0 1 1 1 1 0 0 0 0 0 0 0 1 0 1 1 0 0 1 1 0 0 0 0 0 0 1 0 0 0 0 0 0 0 0 1 1 1 0 0 1 34 0 1 218 1 0 0 0 0 0 0 0 0 0 0 0 0 X 6 6 1 0 0 0 0 0 0 1 1 0 0 1 1 1 1 1 1 1 1 0 X SANDRA J BORDEN CFO 4028793281 520 EAST 10TH STREET SUPERIOR NE 68978 PAT MCCORD PRESIDENT 2.00 0.00 X X 0 0 0 JANET EGGERS VICE-PRESIDENT 2.00 0.00 X X 0 0 0 MARLIN MEYER VICE-PRESIDENT THRU 7/18 2.00 0.00 X X 0 0 0 JUDY GROVE SECRETARY 2.00 0.00 X X 0 0 0 JODENE CLABAUGH TREASURER 2.00 0.00 X X 0 0 0 JACKI PORTER DIRECTOR 2.00 0.00 X 0 0 0 BETH SIEBECKER DIRECTOR 2.00 0.00 X 0 0 0 TREG VYZOUREK CEO 40.00 0.00 X 216499 0 31001 SANDRA BORDEN CFO 40.00 0.00 X 174985 0 34438 TIMOTHY BLECHA MD PHYSICIAN 40.00 0.00 X 407901 0 38420 JULIE THEIS MD PHYSICIAN 40.00 0.00 X 309242 0 47984 ROBERT LEIBEL MD PHYSICIAN 40.00 0.00 X 224737 0 44867 JASON HASS PA-C PHYSICIAN ASSISTANT 40.00 0.00 X 193970 0 45278 MATTHEW GATLIN PA-C PHYSICIAN ASSISTANT 40.00 0.00 X 172337 0 42883 1699671 0 284871 12 0 1 0 CARDINAL HEALTH-OWEN 21377 NETWORK PLACE CHICAGO IL 60673 PHARMACY SERVICES 551937 CPSI 6600 WALL ST PO BOX 850309 MOBILE AL 36695 MAINTENANCE SERVICES 283772 RENEE R SINCLAIR 2551 Z ROAD WEBBER KS 66970 CRNA 188873 LORI HARRIS 3207 NORTHWOOD CT NEWTON KS 67114 CRNA 188873 MINDRAY DS USA INC 24312 NETWORK PLACE CHICAGO IL 60673 MAINTENANCE SERVICES 149756 7 38133 243620 500802 782555 ANCILLARY SERVICES 621110 15433713 15433713 PHARMACY & INTRAVENOUS THERAPY 621110 4108736 4108736 PHYSICIAN CLINICS 621110 3116785 3116785 340B PHARMACY REVENUE 446110 2917906 2917906 NURSING SERVICES 621110 2425193 2425193 47898 47898 28050231 229646 229646 157408 8000 49651 0 107757 8000 115757 115757 31169 38133 28782 2387 2387 CAFETERIA REVENUE 900099 61807 61807 61807 29242383 28050231 0 409597 456923 456923 10416007 9827457 588550 2119645 1986987 132658 710860 646885 63975 70472 70472 68330 68330 30022 30022 2559629 2367524 192105 5211 5211 1493136 1244770 248366 475611 432482 43129 281985 251807 30178 112555 76945 35610 171962 146751 25211 2013909 1718659 295250 198934 169769 29165 MEDICAL SUPPLIES 3858665 3858665 BAD DEBT EXPENSE 806578 806578 DIETARY FOOD & SUPPLIES 146334 146334 MISCELLANEOUS EXPENSES 78040 78040 94340 38294 56046 26169148 23725118 2444030 0 200 1821934 5206671 6875696 3089221 3066822 204749 224659 491610 400244 34777998 17168701 18995697 17609297 2306237 3215934 2771870 2206854 33066255 35421440 2238631 2217569 33690 4758 5663983 5179267 195863 242147 8132167 7643741 X 23013924 26009704 201916 232839 1718248 1535156 24934088 27777699 33066255 35421440 X 3073235 -46532 -183092 X X 0 1 X 1 0 X 0 0 0 0 0 0 0 0 1 2358 2358 0 PART II-B, LINE 1: BRODSTONE MEMORIAL HOSPITAL PAID DUES TO THE AMERICAN HOSPITAL ASSOCIATION AND THE NEBRASKA HOSPITAL ASSOCIATION, A PORTION OF THE DUES WERE USED FOR LOBBYING ACTIVITIES. 1718248 68028 221036 30084 1535156 1745868 96344 93784 30180 1718248 1675710 150828 51354 29316 1745868 1773531 -46451 16136 35234 1675710 1642133 80806 99760 17706 31462 1773531 0.00000 1.00000 0.00000 1 0 117890 117890 22667151 8331263 14335888 11495840 8547357 2948483 497117 290081 207036 17609297 BENEFICIAL INTEREST IN TRUSTS 1535156 INTEREST RECEIVABLE 30651 DEFERRED COMPENSATION 242147 ESTIMATED THIRD-PARTY PAYOR SETTLEMENT 398900 2206854 DEFERRED COMPENSATION LIABILITIES 242147 242147 X 27214652 -46532 -108114 -154646 27369298 1873085 1873085 29242383 24324845 28782 28782 24296063 1873085 1873085 26169148 PART V, LINE 4: INTEREST EARNINGS MAY BE USED FOR OPERATIONS, HOWEVER THE PRINCIPAL IS TO BE MAINTAINED AS A PERMANENT ENDOWMENT. PART X, LINE 2: THE HOSPITAL 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 TAX EXEMPT STATUS. IN GENERAL, SUCH STANDARDS REQUIRE THE HOSPITAL TO MEET A COMMUNITY BENEFIT 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 APRIL 30, 2019 AND 2018, THE HOSPITAL HAD NO UNCERTAIN TAX POSITIONS ACCRUED. PART XI, LINE 2D - OTHER ADJUSTMENTS: CHANGE IN BENEFICIAL INTEREST IN TRUSTS -183,092. FUNDRAISING EXPENSES 28,782. ASSETS RELEASED FROM RESTRICTIONS 46,196. PART XI, LINE 4B - OTHER ADJUSTMENTS: PROVISION FOR BAD DEBTS 806,578. 340B CONTRACTED SERVICES EXPENSE 1,066,507. PART XII, LINE 2D - OTHER ADJUSTMENTS: FUNDRAISING EXPENSES 28,782. PART XII, LINE 4B - OTHER ADJUSTMENTS: PROVISION FOR BAD DEBTS 806,578. 340B CONTRACTED SERVICES EXPENSE 1,066,507. HARVEST MOON GALA 57190 28645 28545 2754 5529 8575 5560 3666 SUPERIOR GOLF TOURNAMENT 12112 9488 2624 1280 450 894 74 69302 38133 31169 1280 3204 5529 9469 5560 3740 28782 2387 1 1 X 1 X 1 X 1 1 1 0 1 1 266758 266758 0.01050 1375816 1128986 246830 0.00970 1642574 1128986 513588 0.02020 771 168160 165340 2820 0.00010 1109 151795 39296 112499 0.00440 125 8560 0 8560 0.00030 2005 328515 204636 123879 0.00480 2005 1971089 1333622 637467 0.02500 18990 0 18990 0.00070 20272 0 20272 0.00080 39262 39262 0.00150 1 806578 0 13665625 13760451 -94826 X 1 1 1 1 BRODSTONE MEMORIAL HOSPITAL 520 E 10TH SUPERIOR NE 68978 HTTPS://WWW.BRODSTONEHOSPITAL.ORG 570001 X X X X BRODSTONE MEMORIAL HOSPITAL 1 0 0 1 X X X X X X X X X X 18 1 1 1 1 X HTTPS://WWW.BRODSTONEHOSPITAL.ORG/PATIENTS-AND-VISITORS/COMMUNITY_HEALTH_NE X 1 18 1 HTTPS://WWW.BRODSTONEHOSPITAL.ORG/PATIENTS-AND-VISITORS/COMMUNITY_HEALTH_NE 0 1 X 100.000000000000 200.000000000000 X X X X X X 1 1 X X X X X 1 X HTTPS://WWW.BRODSTONEHOSPITAL.ORG/PATIENTS-AND-VISITORS/FINANCE-SERVICES/FI X HTTPS://WWW.BRODSTONEHOSPITAL.ORG/PATIENTS-AND-VISITORS/FINANCE-SERVICES/FI X HTTPS://WWW.BRODSTONEHOSPITAL.ORG/PATIENTS-AND-VISITORS/FINANCE-SERVICES/FI X X X X X 1 X 0 X X X X 1 X 0 0 BRODSTONE MEMORIAL HOSPITAL PART V, SECTION B, LINE 3J: THE REPORT INCLUDES A LIST OF MEASURES IN THE THREE YEAR PLAN (2018 THROUGH 2021) AND A COMMUNITY HEALTH IMPROVEMENT PLAN FOR THE DISTRICT. THE PLAN INCLUDES PERFORMANCE MEASURES ALONG WITH STRATEGIES AND ACTIVITIES FOR THE PRIORITY AREAS OF ACCESS TO CARE, MENTAL HEALTH, SUBSTANCE MISUSE, OBESITY & RELATED HEALTH CONDITIONS, AND CANCER. BRODSTONE MEMORIAL HOSPITAL PART V, SECTION B, LINE 5: INCLUDED IN THE REPORT ARE RESULTS FROM A PUBLIC HEALTH SURVEY THAT WAS MADE AVAILABLE OVER A 4 COUNTY AREA (WEBSTER, ADAMS, CLAY AND NUCKOLLS), FOLLOWED BY A BROAD SPECTRUM OF STAKEHOLDERS THAT PARTICIPATED IN FOCUS GROUPS AND CONTRIBUTED TO EACH ASSESSMENT, DATA REVIEW, PRIORITY SETTING, AND STRATEGY MEETINGS. ITEMS FOR DISCUSSION WERE GAPS IN SERVICES, WHERE COMMUNITY MEMBERS GO FOR HEALTHCARE, WHERE DO THEY GET THEIR HEALTH INFORMATION, THEIR BIGGEST HEATHCARE CONCERNS, AND WHAT HEALTHCARE SERVICES ARE USED (OR NOT USED) BY THE PEOPLE THEY KNOW. ALSO DISCUSSED WERE THE STRENGTHS OF LOCAL HEALTHCARE AND FUTURE DEMANDS.THIS WAS A 7 MONTH PROCESS CONDUCTED APRIL THROUGH OCTOBER, 2018. THE SOUTH HEARTLAND DISTRICT HEALTH DEPARTMENT SPEARHEADED THE ASSESSMENT IN PARTNERSHIP WITH MARY LANNING HEALTHCARE IN HASTINGS, WEBSTER COUNTY HOSPITAL IN RED CLOUD, CLAY COUNTY HEALTH DEPARTMENT IN CLAY COUNTY AND BRODSTONE MEMORIAL HOSPITAL IN SUPERIOR. INPUT WAS SOUGHT AND RECEIVED BY THE LOCAL PUBLIC HEALTH SYSTEM AND ALL OF THE ENTITIES THAT CONTRIBUTE TO THE DELIVERY OF PUBLIC HEALTH SERVICES IN OUR COMMUNITY. THIS INCLUDES PUBLIC, PRIVATE ENTITIES, CIVIC AND FAITH-BASED ORGANIZATIONS, INDIVIDUALS AND INFORMAL ASSOCIATIONS, FRONT-LINE AND GRASSROOTS WORKERS, AND POLICY MAKERS. ALSO INCLUDED AND NOT LIMITED TO EMS, SCHOOLS, NEIGHBORHOOD ORGANIZATIONS, NURSING HOMES, COMMUNITY CENTERS, HOSPITALS, DRUG TREATMENT CENTERS, HOME HEALTH, LABORATORIES, HEALTHCARE PROVIDERS, LAW ENFORCEMENT, EMPLOYERS, CORRECTIONS, ELECTED OFFICIALS, FIRE, TRANSIT AGENCIES, MENTAL HEALTH PROVIDERS, AND TRIBAL HEALTH. BRODSTONE MEMORIAL HOSPITAL PART V, SECTION B, LINE 6A: BRODSTONE'S CHNA WAS CONDUCTED WITH WEBSTER COUNTY COMMUNITY HOSPITAL AND MARY LANNING HEALTHCARE. BRODSTONE MEMORIAL HOSPITAL PART V, SECTION B, LINE 6B: BRODSTONE'S CHNA WAS CONDUCTED WITH SOUTH HEARTLAND DISTRICT HEALTH DEPARTMENT AND THE CLAY COUNTY HEALTH DEPARTMENT AS THAT COUNTY DOES NOT HAVE A HOSPITAL. BRODSTONE MEMORIAL HOSPITAL PART V, SECTION B, LINE 11: THE STRATEGIES THAT WERE SCHEDULED FOR THIS YEAR ON OUR COMMUNITY HEALTH IMPROVEMENT PLAN THAT WERE ACCOMPLISHED ARE AS FOLLOWS:ACCESS TO CARE:RECRUIT PROVIDERS FOR OUR SPECIALTY CLINIC. OUR GOAL WAS TO RECRUIT 3 ADDITIONAL PROVIDERS. IN THE LAST FISCAL WE RECRUITED A UROLOGIST, A MENTAL HEALTH PROVIDER VIA TELEHEALTH, AND A PODIATRIST. WE CONTINUE TO SEARCH FOR A FAMILY PRACTICE PHYSICIAN. WE JOINED A GROUP TO HAVE A RESIDENCY PROGRAM AND THAT IS SLOWLY BUILDING, ALTHOUGH, WE HAVE YET TO HAVE A CANDIDATE.THE PROMOTION OF THE USE OF BALANCE ASSESSMENT EQUIPMENT HAS BEEN DELAYED UNTIL THE NEXT FISCAL YEAR. A CONTRACT IS BEING SOUGHT WITH 3 AREA SCHOOLS TO PROVIDE THERAPY SERVICES AND THE BALANCE ASSESSMENT EQUIPMENT WILL BE USED WITH THE SCHOOL SYSTEM ONCE WE HAVE THE CONTRACT SIGNED.THE HANDY BUS IS CONTROLLED BY ANOTHER ENTITY AND WE ARE NOT ABLE TO PROMOTE THAT AS PLANNED.OUR HEALTH LIVING PROGRAM IS ONGOING. WE CONTINUE TO MAINTAIN THE NUMBER OF PARTICIPANTS.WE CONTINUE TO PROMOTE OUR DIABETES SUPPORT GROUP, HOWEVER ATTENDANCE HAS BEEN MAINTAINED, WITH NO INCREASE. WE ALWAYS SEND A FLYER TO ALL PARTICIPANTS THAT DESIRE AN INVITATION, WHICH IS APPROXIMATELY 165 COMMUNITY MEMBERS. THE FLYER INCLUDES TIPS FOR A HEALTHY LIFESTYLE AND EVEN THOUGH THEY ARE NOT ABLE TO ATTEND THE SUPPORT GROUPS, THEY ARE PROVIDED EDUCATIONAL MATERIALS.BECAUSE OF STAFFING WE WERE NOT ABLE TO IMPLEMENT AN ALZHEIMER'S/DEMENTIA SUPPORT GROUP.CANCER:DUE TO STAFFING ISSUES, WE HAVE BEEN UNABLE TO IMPLEMENT A "TIME TO HEAL" PROGRAM.WE HAVE USED RADIO, NEWSPAPER AND SOCIAL MEDIA TO EDUCATE THE COMMUNITY ON THE SCREENINGS AVAILABLE FOR CANCER PREVENTION. THIS WAS ALSO DONE AT THE ANNUAL HEALTH FAIR.WE DID NOT PROCEED WITH OUR PLANS TO HAVE A "PINK NIGHT" FOR EDUCATIONAL PURPOSES, HOWEVER WE HAVE BEEN FUND RAISING AND WORKING ON EDUCATING STAFF TO BE ABLE TO PROVIDE CHEMOTHERAPY AT OUR FACILITY.BRODSTONE EMPLOYEES DONATED $741.19 TO THE NUCKOLLS COUNTY CANCER STOMP IN THE LAST FISCAL YEAR.BRODSTONE DONATED TO THE GOLF TOURNAMENT RALLY FOR A CURE.TWELVE NUCKOLLS COUNTY RESIDENTS WERE REFERRED TO THE NUCKOLLS COUNTY CANCER STOMP.MENTAL HEALTH:IN THE LAST FISCAL YEAR, OUR BEHAVIORAL HEALTH PROVIDER HAS INCREASED HER ON SITE DAYS FROM THREE TIME A MONTH TO FOUR TIMES A MONTH. WE HAVE ALSO ADDED THE AVAILABILITY OF COUNSELING VIA TELEHEALTH EVERY WEEKDAY. THE LANNING CENTER FROM HASTINGS IS ALSO PROVIDING COUNSELING SERVICES 2 DAYS A MONTH VIA TELEHEALTH.OBESITY:BRODSTONE WAS PROVIDING SPACE FOR OVEREATERS ANONYMOUS HOWEVER THE GROUP DISBANDED DUE TO LACK OF PARTICIPATION.A WALK/RUN WAS HELD IN MAY WITH 150 PARTICIPANTS.THE FIRECRACKER RUN WAS HELD IN JULY. BRODSTONE MAKES A MONETARY DONATION TO THIS EVENT AND A LARGE NUMBER OF EMPLOYEES HELP WITH THE EVENT AND/OR PARTICIPATE.A WALKING CHALLENGE WAS HELD IN MAY/JUNE WITH 167 PARTICIPANTS. THIS IS A 6 WEEK CHALLENGE AND TEAMS ARE FORMED AT THE HOSPITAL AND FROM THE COMMUNITY.A WALKING SCHOOL BUS PROGRAM WAS DEVELOPED WITH ADULTS ORGANIZING WALKING WEDNESDAYS FROM THE CITY PARK TO THE SCHOOL. PARTICIPATION IS BASED ON WEATHER CONDITIONS WITH ANYWHERE FROM 6 TO 12 CHILDREN WALKING TO SCHOOL. THIS IS DONE FOR 6 WEEKS IN THE FALL AND 4 WEEKS IN THE SPRING.THE HOSPITAL HAS BEEN WORKING WITH A COALITION TO PROMOTE WALKING ON A TEMPORARY PATH THAT WAS PAINTED ALONG 6TH STREET FROM THE CITY PARK TO THE SCHOOL. FACEBOOK POSTS, NEWSPAPER STORIES AND THE WALKING SCHOOL BUS HAVE ALL HELPED TO PROMOTE THIS PATH.BRODSTONE HAS BEEN WORKING WITH THE VENDING MACHINE COMPANY TO HAVE HEALTHIER CHOICES IN THE MACHINES. FRUIT IS NOW AVAILABLE IN THE DINING ROOM THROUGHOUT THE DAY. A HEALTHY MEAL OPTION IS NOW OFFERED 5 DAYS A WEEK.BRODSTONE STAFF DONATED 6,035 POUNDS OF FOOD TO THE NUCKOLLS COUNTY FOOD PANTRY.SUBSTANCE ABUSE:DUE TO STAFF CHANGES, THE SMOKING CESSATION CLASSES WERE ON HOLD UNTIL A NEW INSTRUCTOR WAS EDUCATED. WE INTEND TO OFFER THOSE CLASSES AGAIN IN THE FUTURE. COACHES ARE BEING SOUGHT. AN EDUCATIONAL BROCHURE WILL BE DEVELOPED WHEN A NEW INSTRUCTOR HAS BEEN EDUCATED.DISPOSAL OF NARCOTICS AND OTHER MEDICATIONS IS AVAILABLE AT THE LOCAL PHARMACY ON A DAILY BASIS. THE PHARMACY HAS BEEN PROMOTING THAT INFORMATION. INFORMATION IS ALSO AVAILABLE AT THE ANNUAL HEALTH FAIR.THE "LIFE OF AN ATHLETE" PROGRAM EDUCATION IS BEING PROVIDED BY OUR LOCAL HEALTH DEPARTMENT. WE ARE ON THE LIST TO PARTICIPATE WHEN THAT EDUCATION IS AGAIN AVAILABLE.BECAUSE OF A STAFFING CHANGE, MARIJUANA EDUCATION HAS BEEN POSTPONED. BRODSTONE MEMORIAL HOSPITAL PART V, SECTION B, LINE 13B: PATIENTS WHOSE FAMILY INCOME EXCEEDS 200% OF THE FPL MAY BE ELIGIBLE TO RECEIVE DISCOUNTED RATES ON A CASE-BY-CASE BASIS BASED ON THEIR SPECIFIC CIRCUMSTANCES, SUCH AS CATASTROPHIC ILLNESS OR MEDICAL INDIGENCE, AT THE DISCRETION OF BRODSTONE MEMORIAL HOSPITAL. BRODSTONE MEMORIAL HOSPITAL PART V, SECTION B, LINE 13H: IN INSTANCES WHEN A PATIENT MAY APPEAR ELIGIBLE FOR FINANCIAL ASSISTANCE, BUT THERE IS NO FINANCIAL APPLICATION FORM ON FILE DUE TO A LACK OF SUPPORTING DOCUMENTATION, FINANCIAL ASSISTANCE MAY STILL BE GRANTED IN CERTAIN SITUATIONS BASED ON PRESUMPTIVE CIRCUMSTANCES. OFTEN THERE IS ADEQUATE INFORMATION PROVIDED BY THE PATIENT OR THROUGH OTHER SOURCES, WHICH COULD PROVIDE SUFFICIENT EVIDENCE TO PROVIDE THE PATIENT WITH FINANCIAL ASSISTANCE. IN THE EVENT THERE IS NO EVIDENCE TO SUPPORT A PATIENT'S ELIGIBILITY FOR FINANCIAL ASSISTANCE, BRODSTONE COULD USE OUTSIDE AGENCIES IN DETERMINING ESTIMATED INCOME AMOUNTS FOR THE BASIS OF DETERMINING FINANCIAL ASSISTANCE ELIGIBILITY AND POTENTIAL DISCOUNT AMOUNTS. PRESUMPTIVE ELIGIBILITY MAY BE DETERMINED IN CERTAIN SITUATIONS, AND BASED ON THE APPROVAL OF BRODSTONE'S MANAGEMENT, ON THE BASIS OF INDIVIDUAL LIFE CIRCUMSTANCES THAT MAY INCLUDE:A) STATE-FUNDED PRESCRIPTION PROGRAMS;B) TRANSIENT, HOMELESS OR RECEIVED CARE FROM A HOMELESS CLINIC, OR UNIDENTIFIED PERSONS;C) PARTICIPATION IN WOMEN, INFANTS AND CHILDREN PROGRAMS (WIC);D) FOOD STAMP ELIGIBILITY;E) ELIGIBILITY FOR OTHER STATE OR LOCAL ASSISTANCE PROGRAMS THAT ARE UNFUNDED (E.G., MEDICAID SPEND-DOWN);F) CRIME VICTIMS BILLED CHARGES AFTER STATE OR FEDERAL FUNDS HAVE PAID OR ARE EXHAUSTED;G) LOW INCOME/SUBSIDIZED HOUSING IS PROVIDED AS A VALID ADDRESS;H) PATIENT IS DECEASED WITH NO KNOWN ESTATE OR RESPONSIBLE PARTY; ANDI) PERSONS WHO INCOME IS AT OR BELOW 100% OF THE CURRENT POVERTY LEVEL. BRODSTONE MEMORIAL HOSPITAL PART V, SECTION B, LINE 15E: PATIENTS MAY APPLY FOR ASSISTANCE BY CALLING BRODSTONE MEMORIAL HOSPITAL AT 402-879-3281 EXT. 5115 AND REQUESTING A FINANCIAL ASSISTANCE APPLICATION; OR BY REQUESTING AN APPLICATION IN PERSON FROM REGISTRATION OR THE BUSINESS OFFICE. AN APPLICATION MAY BE DOWNLOADED FROM THE HOSPITAL'S WEBSITE. 3 1 - SUPERIOR FAMILY MEDICAL CENTER 525 E 11TH ST SUPERIOR NE 68978 RURAL HEALTH CLINIC 2 - NELSON FAMILY MEDICAL CENTER 76 W 8TH ST NELSON NE 68961 RURAL HEALTH CLINIC 3 - EDGAR MEDICAL CLINIC 315 N C ST EDGAR NE 68935 RURAL HEALTH CLINIC PART I, LINE 3C: NOT APPLICABLE: FEDERAL POVERTY GUIDELINES ARE USED TO DETERMINE ELIGIBILITY FOR PROVIDING FREE CARE AND DISCOUNTED CARE TO LOW INCOME INDIVIDUALS. PART I, LINE 6A: BRODSTONE'S COMMUNITY BENEFIT REPORT IS NOT PREPARED BY A RELATED ORGANIZATION. PART I, LINE 7: THE COST TO CHARGE RATIO AS FOLLOWS WAS USED TO DETERMINE CHARITY CARE AND MEANS-TESTED GOVERNMENT PROGRAMS AT COST: (TOTAL EXPENSES - BAD DEBT) / GROSS PATIENT SERVICE REVENUE = PERCENTAGE OF COST TO CHARGE. OTHER COMMUNITY BENEFIT EXPENSES ARE STATED AT COST BASED ON BRODSTONE'S INTERNAL ACCOUNTING RECORDS. PART I, LINE 7G: THERE ARE NO COSTS ATTRIBUTABLE TO A PHYSICIAN CLINIC INCLUDED ON LINE 7G. PART I, LINE 7, COLUMN (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 $ 806,578. PART II, COMMUNITY BUILDING ACTIVITIES: BRODSTONE HAS MANY ACTIVITIES TO PROMOTE HEALTH IN THE COMMUNITIES SERVED. THESE ACTIVITIES INCLUDE: SPONSOR OF HEALTH FAIR, SUPPORT GROUPS, EDUCATION PROGRAMS AND MEDICATION ASSISTANCE. THE DONATED SERVICES AND FUNDS HELP FURTHER THE MISSION AND GOALS OF COMMUNITY ORGANIZATIONS WHICH, IN TURN, HELP IMPROVE OVERALL HEALTH STATUS AND QUALITY OF LIFE OF THE COMMUNITIES SERVED. 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 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-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: IN ACCORDANCE WITH ITS MISSION OBJECTIVES, THE HOSPITAL PROVIDES FREE CARE TO PATIENTS WHO LACK FINANCIAL RESOURCES TO PAY FOR THE SERVICES THEY RECEIVE. INCLUDED IN THE PROVISION FOR CONTRACTUAL ALLOWANCES IS THE VALUE (AT STANDARD CHARGES) OF THESE SERVICES TO PATIENTS WHO ARE UNABLE TO PAY, THAT IS ELIMINATED FROM NET PATIENT SERVICE REVENUES WHEN IT IS DETERMINED THEY QUALIFY UNDER THE HOSPITAL'S CHARITY CARE POLICY. THE ESTIMATED COST INCURRED BY THE HOSPITAL TO PROVIDE THESE SERVICES TO PATIENTS WHO ARE UNABLE TO PAY WAS APPROXIMATELY $245,000 AND $206,000 FOR THE YEARS ENDED APRIL 30, 2019 AND 2018, RESPECTIVELY. THE ESTIMATED COST OF THESE CHARITY CARE SERVICES WAS DETERMINED USING A RATIO OF COSTS TO GROSS CHARGES AND APPLYING THAT RATIO TO THE GROSS CHARGES ASSOCIATED WITH PROVIDING CARE TO CHARITY PATIENTS FOR THE PERIOD. GROSS CHARGES ASSOCIATED WITH PROVIDING CARE TO CHARITY PATIENTS INCLUDES ONLY THE RELATED CHARGES FOR THOSE PATIENTS WHO ARE FINANCIALLY UNABLE TO PAY AND QUALIFY UNDER THE HOSPITAL'S CHARITY CARE POLICY AND THAT DO NOT OTHERWISE QUALIFY FOR REIMBURSEMENT FROM A GOVERNMENTAL PROGRAM. DURING THE YEARS ENDED APRIL 30, 2019 AND 2018, THE HOSPITAL RECEIVED NO FUNDS TO HELP DEFRAY THE COSTS OF INDIGENT CARE. PART III, LINE 4: THE HOSPITAL'S FINANCIAL STATMENTS DO NOT CONTAIN A SPECIFIC FOOTNOTE DESCRIBING BAD DEBT. HOWEVER, PAGES 8 AND 10 OF THE ATTACHED AUDITED FINANCIAL STATEMENTS INCLUDE FOOTNOTES TITLED "PATIENT RECEIVABLES, NET", "NET PATIENT SERVICE REVENUE AND "CHARITY CARE". PART III, LINE 8: "MEDICARE ALLOWABLE COSTS OF CARE" WAS CALCULATED FROM INFORMATION IN THE MEDICARE COST REPORT D, E, H & M WORKSHEETS, OR PS&R. THESE COSTS ARE MEDICARE REIMBURSABLE COSTS, NOT ALL COSTS. NO MEDICARE SHORTFALL IS TREATED AS COMMUNITY BENEFIT. PART III, LINE 9B: PATIENTS WHO QUALIFY FOR MEDICAID WILL AUTOMATICALLY QUALIFY FOR FINANCIAL ASSISTANCE AND MAY QUALIFY FOR MORE IF THEY COMPLETE THE FINANCIAL ASSISTANCE APPLICATION. THESE PATIENTS WILL NOT BE SENT TO COLLECTIONS IF THEY PAY THE AMOUNT FOR WHICH THEY QUALIFY.BRODSTONE'S POLICIES AND PROCEDURES FOR INTERNAL AND EXTERNAL COLLECTION PRACTICES TAKE INTO ACCOUNT THE EXTENT TO WHICH THE PATIENT QUALIFIES FOR CHARITY, A PATIENT'S GOOD FAITH EFFORT TO APPLY FOR A GOVERNMENTAL PROGRAM OR FOR CHARITY FROM THE HOSPITAL AND A PATIENT'S GOOD FAITH EFFORT TO COMPLY WITH HIS OR HER PAYMENT AGREEMENTS WITH THE HOSPITAL. FOR PATIENTS WHO QUALIFY FOR CHARITY AND WHO ARE COOPERATING IN GOOD FAITH TO RESOLVE THEIR BILLS, BRODSTONE MAY OFFER EXTENDED PAYMENT PLANS TO ELIGIBLE PATIENTS, WILL NOT IMPOSE WAGE GARNISHMENTS OR LIENS, WILL NOT SEND UNPAID BILLS TO OUTSIDE COLLECTION AGENCIES AND WILL CEASE ALL COLLECTION EFFORTS. PART VI, LINE 2: BRODSTONE ASSESSES THE HEALTH CARE NEEDS OF THE COMMUNITY IT SERVES THROUGH A SURVEY. THE BUDGETING PROCESS PUBLISHES SUGGESTIONS AND STRATEGIC PLANNING. HOSPITAL STAFF ALSO NETWORKS WITH OTHER HEALTH CARE ORGANIZATIONS TO DEVELOP IDEAS OF WHAT CAN BE DONE TO IMPROVE THE AVAILABILITY OF SERVICES IN THE COMMUNITY. PART VI, LINE 3: BRODSTONE HAS A BROCHURE CALLED CHARITY POLICY THAT ADDRESSESS THE FINANCIAL ASSISTANCE AVAILABILITY. IT IS POSTED AT THE ADMISSIONS AREAS AND EMERGENCY ROOM. THE CHARITY POLICY IS DISCUSSED WHEN MAKING PAYMENT ARRANGEMENTS. THIS POLICY IS ALSO AVAILABLE ON THE HOSPITAL'S WEBSITE. PART VI, LINE 4: SUPERIOR HAS A POPULATION OF 1,933 AND IS LOCATED ON THE NEBRASKA-KANSAS BORDER. BRODSTONE'S SERVICE AREA COVERS ALL OF NUCKOLLS COUNTY AND PARTS OF 2 OTHER COUNTIES IN NEBRASKA AND 3 COUNTIES IN KANSAS. THE MEDIAN HOUSEHOLD INCOME FOR NUCKOLLS COUNTY IS $41,576 COMPARED TO THE U.S. AVERAGE AT $61,372 AND THE NEBRASKA AVERAGE OF $56,927. THE AREA POPULATION IS PREDOMINATELY WHITE ELDERLY AND LOW INCOME. 49.7% OF THE HOSPITAL'S PATIENTS ARE MEDICARE PATIENTS. PART VI, LINE 5: BRODSTONE'S GOVERNING BODY CONSISTS OF FEMALES WITH NO IMMEDIATE FAMILY TIES TO ANY EMPLOYEE NOR ARE THEY CONTRACTORS OF THE ORGANIZATION. ALL BOARD MEMBERS HAVE SUPERIOR NEBRASKA ADDRESSES BUT 2 MEMBERS LIVE IN JEWELL COUNTY, KANSAS. ALL FAMILY PRACTICE PHYSIANS AND MIDLEVELS IN THE AREA WHO HAVE REQUESTED MEDICAL STAFF PRIVILEGES AND MEET THE REQUIREMENTS HAVE PRIVILEGES AT THE HOSPITAL. ONE DENTIST HAS COURTESY PRIVELEGES. ALL SURPLUS FUNDS OF THE ORGANIZATION ARE USED TO FUND THE BUDGET FOR THE COMING YEARS OR SET ASIDE FOR FUTURE PROJECTS. PART VI, LINE 6: BRODSTONE MEMORIAL HOSPITAL IS NOT PART OF AN AFFILIATED HEALTH CARE SYSTEM. PART VI, LINE 7: BRODSTONE DOES NOT FILE A COMMUNITY BENEFIT REPORT WITH ANY STATE. X X X X 0 0 0 1 0 0 0 0 0 TREG VYZOUREK CEO 216499 0 0 0 0 0 0 0 31001 0 247500 0 0 0 SANDRA BORDEN CFO 174985 0 0 0 0 0 5428 0 29010 0 209423 0 0 0 TIMOTHY BLECHA MD PHYSICIAN 264056 0 143845 0 0 0 8250 0 30170 0 446321 0 0 0 JULIE THEIS MD PHYSICIAN 266360 0 42882 0 0 0 8250 0 39734 0 357226 0 0 0 ROBERT LEIBEL MD PHYSICIAN 224737 0 0 0 0 0 6961 0 37906 0 269604 0 0 0 JASON HASS PA-C PHYSICIAN ASSISTANT 193970 0 0 0 0 0 6077 0 39201 0 239248 0 0 0 MATTHEW GATLIN PA-C PHYSICIAN ASSISTANT 155772 0 16565 0 0 0 5377 0 37506 0 215220 0 0 0 PART I, LINE 5 IN ACCORDANCE WITH RELATED EMPLOYMENT CONTRACTS, ADDITIONAL COMPENSATION IS PAID BASED ON REVENUES GENERATED BY EACH MEDICAL PROVIDER, AS DEFINED. THESE ADDITIONAL AMOUNTS HAVE BEEN LISTED AS INCENTIVE COMPENSATION IN PART II OF THIS SCHEDULE. A THE CITY OF SUPERIOR NEBRASKA 476006376 2013-05-22 4000000 REFUND ISSUES (9/9/03, 9/10/09, 9/10/09) 0 0 0 B THE COUNTY OF NUCKOLLS NEBRASKA 476006492 2013-05-22 4000000 REFUND ISSUES (9/9/03, 9/10/09, 9/10/09) 0 0 0 A 871555 4000000 4000000 2010 1 0 1 1 B 871555 4000000 4000000 2010 1 0 1 1 A 0 0 0 0 0.00000 0.00000 0.00000 0 0 1 B 0 0 0 0 0.00000 0.00000 0.00000 0 0 1 A 0 0 1 1 0 0 0 0 1 B 0 0 1 1 0 0 0 0 1 A 1 B 1 SCHEDULE K, PART IV, LINE 2C: (A) ISSUER NAME: CITY OF SUPERIOR, NEBRASKA DATE THE REBATE COMPUTATION WAS PERFORMED: 05/22/2013 (B) ISSUER NAME: THE COUNTY OF NUCKOLLS, NEBRASKA DATE THE REBATE COMPUTATION WAS PERFORMED: 05/22/2013 NOTE REGARDING THE REBATE COMPUTATIONS: SINCE THE BOND PROCEEDS WERE SPENT ON THE ISSUE DATE, A SPENDING EXCEPTION WAS MET, AND THE DEBT SERVICE FUND WAS OPERATED ON A BONA FIDE BASIS, NO FURTHER REBATE CALCULATIONS ARE NECESSARY. BEN VYZOUREK BEN IS THE SON OF THE CEO, TREG VYZOUREK. 1000 CASH GRANT HEALTH CAREER EDUCATION FORM 990, PART VI, SECTION A, LINE 2 DIRECTORS JUDY GROVE AND JACKI PORTER HAVE A FAMILY RELATIONSHIP. FORM 990, PART VI, SECTION B, LINE 11B THE FORM 990 IS PREPARED BY AN OUTSIDE ACCOUNTING FIRM. BEFORE IT IS FILED, IT IS GIVEN A DETAILED REVIEW BY MANAGEMENT AND THEN A GENERAL REVIEW BY THE BOARD OF DIRECTORS AT A REGULARLY SCHEDULED BOARD MEETING. A FINAL COPY OF THE FORM 990 WILL BE ELECTRONICALLY FILED AFTER APPROVAL. FORM 990, PART VI, SECTION B, LINE 12C BOARD MEMBERS WHO HAVE A CONFLICT OF INTEREST WOULD REFRAIN FROM DISCUSSION AND VOTING ON THOSE MATTERS. THERE IS AN ANNUAL BOARD MEMBER TRAINING THAT COVERS THIS POLICY. ADDITIONALLY, ALL BOARD MEMBERS ARE WELL ACQUAINTED WITH EACH OTHER SO IF THERE WAS A CONFLICT OF INTEREST AND THE BOARD MEMBER DID NOT DISCLOSE, THE OTHER BOARD MEMBERS WOULD BRING IT TO THE BOARD'S ATTENTION. FORM 990, PART VI, SECTION B, LINE 15 THE HUMAN RESOURCE DIRECTOR PREPARES A SALARY SURVEY ANNUALLY FOR ALL JOBS DESCRIPTIONS WITH HOSPITALS OF SIMILAR SIZE AND REVENUES. THE BOARD OF DIRECTORS REVIEWS THE SURVEY AND PRIOR SALARY INCREASES FOR THE CEO BEFORE GRANTING PAY INCREASES. THE HUMAN RESOURCE DIRECTOR AND CFO MAKE RECOMMENDATIONS TO THE CEO FOR OTHER EMPLOYEES. THE CEO REVIEWS THE SURVEY, PRIOR SALARY INCREASES, AND RECOMMENDATIONS BEFORE APPROVING PAY INCREASES FOR EMPLOYEES. THE PAY INCREASES ARE APPROVED BY THE BOARD OF DIRECTORS DURING THE BUDGET PROCESS. FORM 990, PART VI, SECTION C, LINE 19 THE ORGANIZATION DOES NOT MAKE ITS GOVERNING DOCUMENTS AND CONFLICT OF INTEREST POLICY AVAILABLE TO THE PUBLIC, BUT FINANCIAL STATEMENTS ARE AVAILABLE UPON REQUEST. FORM 990, PART XI, LINE 9: CHANGE IN BENEFICIAL INTEREST IN TRUSTS -183,092. FORM 990, PART XII, LINE 2C: THE BOARD OF DIRECTORS ASSUMES THE RESPONSIBILITY FOR OVERSIGHT OF THE AUDIT OF ITS FINANCIAL STATEMENTS AND THE SELECTION OF AN INDEPENDENT ACCOUNTANT. THIS PROCESS HAS NOT CHANGED FROM THE PRIOR YEAR. PNC VESTEY TRUST UA UNB & NORTHERN CO SUCC BENEFIT BRODSTONE MEM HOSP 116 ALLEGHENY CENTER MALL PITTSBURGH PA 15212 226023351 ASSISTING IN THE OPERATIONS OF BRODSTONE MEMORIAL HOSPITAL PA 4947(A)(1) PF BRODSTONE MEMORIAL HOSPITAL 1 0 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 PNC VESTEY TRUST C 243620 FMV