2018-05-03T08:36:12-05:00 2017-06-30 410746749 CLIFTONLARSONALLEN LLP 220 SOUTH SIXTH STREET SUITE 300 MINNEAPOLIS MN 55402 990 2016-07-01 420890973 OSCEOLA COMMUNITY HOSPITAL INC OSCE 7127542574 PO BOX 258 SIBLEY IA 51249 BEN DAVIS CEO 7127542574 2018-04-26 1 KACIE MCEWEN P01599614 6123764500 67.137.57.251 2018-04-26 13:25:51 CD P E5AEBE735E0DF1065458B6EBA0E7D1A366344C92 E698147828662A77FC368A1C9E67113FD81D946A 2016 2021-01-29 14:40:06Z BEN DAVIS PO BOX 258 SIBLEY IA 51249 13394290 0 X WWW.OSCEOLACOMMUNITYHOSPITAL.ORG X 1960 IA TO PROVIDE HEALTHCARE TO THE CITIZENS OF OSCEOLA COUNTY AND THE SURROUNDING AREA. 9 9 137 175 434258 -240610 169434 932913 11855144 11289537 84446 216299 1080002 953891 13189026 13392640 0 5000 0 0 6760531 6824032 0 0 0 6877313 6753814 13637844 13582846 -448818 -190206 19616687 18875085 6654189 5818876 12962498 13056209 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 0 9548820 5000 11289537 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. DURRING THE 12 MONTHS OF 7/01/2016 - 6/30/2017 THE HOSPITAL PROVIDED $67,888.26 OF CHARITY CARE TO VARIOUS INDIVIDUALS, WITHOUT REIMBURSEMENT. 9548820 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 1 0 1 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 1 1 0 0 1 31 0 137 1 1 1 0 0 0 0 0 0 0 0 0 X 9 9 0 0 1 0 1 1 0 1 1 0 0 1 1 1 1 1 1 1 1 0 IA X LORRIE REED 7127542574 600 9TH AVENUE NORTH SIBLEY IA 51249 KEVIN HERTZ PRESIDENT 1.00 0.00 X X 0 0 0 BRUCE OSTERMAN PRESIDENT ELECT 1.00 1.00 X X 0 0 0 BARB VAN DIEPEN SECRETARY 1.00 0.00 X X 0 0 0 STANLEY JOHNSON TREASURER 1.00 1.00 X 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 SHIRLEY CHRISTIANS TRUSTEE 1.00 1.00 X 0 0 0 PEGGI THIES TRUSTEE 1.00 0.00 X 0 0 0 SUE ELLEN SCHUTTE TRUSTEE 1.00 0.00 X 0 0 0 JANET DYKSTRA CEO THRU MARCH 2017 40.00 0.00 X 154780 0 6437 JULIE SCHROEDER ASSISTANT ADMINISTRATOR 1.00 0.00 X 56217 0 2365 DARLENE JURGENS DON 40.00 0.00 X 83544 0 3701 LORRIE REED CFO 40.00 0.00 X 53450 0 2231 347991 0 14734 1 0 1 0 AVERA MCKENNAN 800 E 21ST ST SIOUX FALLS SD 57117 ADMINISTRATIVE AND MEDICAL SERVICES 930812 GREAT LAKE PHYSICAL THERAPY 3301 BERGQUIST AVE SPIRIT LAKE IA 51360 PHYSICAL THERAPY SERVICES 437325 SANFORD HOSPITAL PO BOX 5074 SIOUX FALLS SD 57117 CRNA COVERAGE, SPEECH THERAPY, LAB DIREC 366465 ROBERT THORBROGGER 24376 140TH STREET SPIRIT LAKE IA 51360 RADIOLOGY SERVICES 164135 CLIFTONLARSONALLEN 220 SOUTH 6TH STREET SUITE 300 MINNEAPOLIS MN 55402 ACCOUNTING SERVICES 106911 6 482391 450522 932913 PATIENT REVENUE 621400 11187490 11187490 OTHER REVENUE 621400 102047 102047 11289537 19422 19422 68971 0 68971 68971 68971 194587 2500 0 210 194587 2290 196877 196877 4240 1440 2800 2800 90336 0 90336 90336 DAYCARE REVENUE 624410 388155 388155 340B PROGRAM REVENUE 621400 126003 126003 MEALS AND VENDING REVENUE 621400 105790 105790 171836 46103 125733 791784 13392640 11289537 434258 735932 X 5000 5000 424863 424863 4052223 3043890 1008333 97270 72511 24759 1945209 1147593 797616 304467 196545 107922 34150 34150 103330 103330 2313809 1966584 347225 145515 145515 100705 37312 63393 646123 255901 390222 36983 26071 10912 127946 127946 971109 971109 92254 12142 80112 MEDICAL SUPPLIES 710158 438454 271704 DRUG COST 667287 667307 -20 BAD DEBTS EXPENSE 295227 295227 FOOD COST 120571 17963 102608 388647 267265 121382 13582846 9548820 4034026 0 2221411 1512794 983053 1110094 36383 11800 2943208 2040007 0 151857 71832 505729 386298 92967 69135 20117307 13500402 7426217 6616905 3134206 3831892 2010330 2653201 111326 0 571127 19616687 18875085 1351266 1281476 4738738 4465400 564185 72000 0 6654189 5818876 X 12813153 12471196 149345 585013 12962498 13056209 19616687 18875085 -190206 283917 0 X 0 1 X 1 0 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 305678 305678 12866355 7372807 5493548 571386 597427 -26041 6373888 5530168 843720 6616905 91026 F AVERA FOUNDATION POOLED INVESTMENT 2562175 F 2653201 X PART X, LINE 2: THE HOSPITAL HAS BEEN GRANTED EXEMPT STATUS RELATIVE TO INTERNAL REVENUE SERVICE CODE SECTION 501(C)(3) OF THE INTERNAL REVENUE CODE, THUS THERE IS NO PROVISION FOR INCOME TAXES AT JUNE 30, 2017 AND 2016. THE HOSPITAL HAS ELECTED TO ADOPT GUIDANCE IN THE INCOME TAX STANDARD REGARDING RECOGNITION AND MEASUREMENT OF UNCERTAIN TAX POSITIONS. THE ADOPTION OF THIS STANDARD HAS NO EFFECT ON THE CONSOLIDATED FINANCIAL STATEMENTS. THE HOSPITAL'S TAX RETURNS ARE SUBJECT TO REVIEW AND EXAMINATION BY FEDERAL, STATE, AND LOCAL AUTHORITIES. 1 1 X 1 X 1 X 1 1 1 0 1 1 43003 43003 0.00320 891062 737249 153813 0.01160 934065 737249 196816 0.01480 216874 216874 0.01630 9893 9893 0.00070 119691 119691 0.00900 346458 346458 0.02600 1280523 737249 543274 0.04080 4452 4452 0.00030 248532 248532 0.01870 6430 6430 0.00050 4712 4712 0.00040 47068 47068 0.00350 311194 311194 0.02340 1 295227 4047866 5573278 -1525412 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/64762/2016-CHNA-OSCEOLA-COMMUNITY-HO X 1 15 1 HTTPS://WWW.AVERA.ORG/APP/FILES/PUBLIC/64761/2016-CHNA-IMPLEMENTATION-PLAN- 0 1 X 100.000000000000 200.000000000000 X X 1 1 X X X 1 X HTTPS://WWW.AVERA.ORG/APP/FILES/PUBLIC/65614/OSCEOLA-FAP.PDF X HTTPS://WWW.AVERA.ORG/APP/FILES/PUBLIC/65613/OSCEOLA-CHARITY-CARE-APPLICATI 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 AND IN-KIND SUPPORT FOR THE ASSESSMENT PROCESS. SINCE THE GREATEST PORTION OF THE ORGANIZATION'S PATIENT 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 SHERRIFF'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 CONVERSATION WERE CONDUCTED WITH TWELVE INDIVIDUALS, WHICH PROVIDED VALUABLE INPUT AND INFORMATION FROM THE DISABLE 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 CAREWE CONTINUE TO HAVE ONGOING EFFORTS TO RECRUIT ANOTHER FAMILY PHYSICIAN. A NURSE PRACTITIONER WAS HIRED BY AVERA MEDICAL GROUP. THE GENERAL SURGEON HAS ADDED ANOTHER DAY SO HE WILL DO MORE PROCEDURES IN SIBLEY. AN OPHTHALMOLOGIST DOES OUTREACH AT OUR HOSPITAL AND DOES CATARACT SURGERIES ON A MONTHLY BASIS. WE ALSO HAVE AN UROLOGIST DOING MONTHLY CLINICS IN SIBLEY.HEALTH IMPROVEMENT AND PROMOTIONWE CONTINUE TO EDUCATE THE RESIDENTS IN THE COMMUNITIES ABOUT HEART DISEASE AND PREVENTION OF HEART DISEASE. AN INFLATABLE MEGA HEART WAS ON DISPLAY AT THE COMMUNITY EVENTS. EDUCATIONAL INFORMATION WAS GIVEN OUT REGARDING PREVENTION OF HEART DISEASE. WE CONTINUE TO PROVIDE EDUCATION ON A HEALTHY LIFESTYLE. WE OFFER PROGRAMS AT OUR WELLNESS CENTER. MONTHLY BLOOD PRESSURE SCREENINGS ARE DONE AT THE WELLNESS CENTER.MENTAL HEALTH SERVICEWE CONTINUE TO PARTNER WITH NORTHWEST IOWA CARE CONNECTIONS TO ADDRESS THE NEEDS OF INDIVIDUALS IN OUR AREA. WE CURRENTLY HAVE TWO PROVIDERS COMING TO OUR COMMUNITY ONE DAY A WEEK TO SEE PATIENTS. WE ARE IN DISCUSSION WITH TWO OTHER PROVIDERS TO ADD MORE SERVICES. WE HAVE BEEN ABLE TO OFFER SUPPORT CLASSES AND ALSO MEDITATION CLASSES TO OUR RESIDENTS.TRANSPORTATIONA JOINT EFFORT BETWEEN THE OSCEOLA COMMUNITY HOSPITAL, CITY OF SIBLEY AND TWO NURSING HOMES ADDRESSED THE NEED FOR TRANSPORTATION IN OUR COMMUNITY AND COUNTY. A 14 PASSENGER BUS WAS PURCHASED AND BEGAN OPERATING MONDAY THROUGH FRIDAY. THE BUS TRANSPORTS ALL AGES IN SIBLEY. THIS SERVICE WILL BE EXPANDED TO INCLUDE TOWNS IN OUR COUNTY.DURING THE 2012 COMMUNITY HEALTH NEEDS ASSESSMENT, THE SIGNIFICANT HEALTH NEEDS WERE IDENTIFIED AS ACCESS TO HEALTH CARE, MENTAL HEALTH, AND HEALTH IMPROVEMENT AND PROMOTION. THE FOLLOWING ACTIONS WERE TAKEN BY OSCEOLA COMMUNITY HOSPITAL TO ADDRESS THESE SIGNIFICANT HEALTH NEEDS.ACTIONS SINCE THE 2012 CHNA OSCEOLA COMMUNITY HOSPITAL HAS SUCCESSFULLY RECRUITED HEALTH CARE PROVIDERS. OUR FAMILY PRACTICE PROVIDERS JOINED THE AVERA MEDICAL GROUP; ONE GENERAL SURGEON WAS RECRUITED AS WELL AS AN OPHTHALMOLOGIST AND UROLOGIST. THE FAMILY PRACTICE PROVIDER HAS INCREASED ACCESS TO PRIMARY CARE IN OUR COMMUNITY. SINCE THE SURGEON JOINED THE STAFF OUR INPATIENT AND OUTPATIENT SURGERIES HAVE INCREASED AND THE NUMBER OF COLONOSCOPIES WE PERFORM. NEW PROCEDURES HAVE ALSO BEEN ADDED TO THE SURGERY SCHEDULE. FOR EXAMPLE THE OPHTHALMOLOGY CLINIC ALLOWS PATIENTS TO BE SEEN IN OUR COMMUNITY AND HAVE THEIR CATARACT SURGERY DONE HERE. HEALTH IMPROVEMENT AND PROMOTION WAS A GOAL SET FORTH IN 2013 CHNA. IN OSCEOLA COUNTY HEART DISEASE WAS THE NUMBER ONE CAUSE OF DEATH. WE DID EDUCATION AND BLOOD PRESSURE SCREENINGS IN ALL THE COMMUNITIES WE SERVE. WE CONTINUE TO DO MONTHLY BLOOD PRESSURE SCREENINGS AT THE WELLNESS CENTER. WE HAVE HAD EDUCATION FOR THE PUBLIC ON RISK FACTORS OF HEART DISEASE, SYMPTOMS OF A HEART ATTACK, NUTRITION, EXERCISE, AND DIABETES. WE WILL CONTINUE WITH THIS IN THE FUTURE. MENTAL HEALTH SERVICES WE CONTINUE TO WORK WITH MENTAL HEALTH PROVIDERS IN THE AREA TO INCREASE ACCESS AND IMPROVE SERVICES. THIS WILL BE AN ONGOING PROJECT FOR US. OSCEOLA COMMUNITY HOSPITAL PART V, SECTION B, LINE 13H: HOSPITAL WILL PRESUMPTIVELY DETERMINE THAT AN INDIVIDUAL QUALIFIES FOR 100% FINANCIAL ASSISTANCE IF HOSPITAL OR ITS AGENT OBTAINS EVIDENCE OF ANY OF THE FOLLOWING SITUATIONS. IF A PERSON IS PRESUMPTIVELY DETERMINED TO QUALIFY, HOSPITAL WILL SEND A WRITTEN NOTICE INFORMING THE INDIVIDUAL THAT THEIR LIABILITY HAS BEEN FORGIVEN AND NO FURTHER PAYMENTS ARE DUE. - HOMELESSNESS ORE 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 VALED 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 I, LINE 3C: OSCEOLA COMMUNITY HOSPITAL UTILIZES FEDERAL POVERTY GUIDELINES TO DETERMINE HOSPITAL ASSISTANCE ELIGIBILITY BASED ON THE HOUSEHOLD YEARLY GROSS INCOME.TOTAL INCOME: THE ESTIMATED TOTAL INCOME OF AN INDIVIDUAL AND ALL WORKING ADULTS WHO RESIDE WITH THEM. ESTIMATED TOTAL INCOME IS BASED ON TOTAL INCOME FROM A PERSON'S MOST RECENT TAX RETURN OR THE ANNUALIZED INCOME AS CALCULATED FROM THEIR TWO MOST RECENT PAY STUBS. IF THOSE TWO SOURCES HAVE A SIGNIFICANT DIFFERENCE, THE PAY STUBS WILL BE USED TO DETERMINE TOTAL INCOME. HOSPITAL RESERVES THE RIGHT TO ADJUST THIS CALCULATION IF HOSPITAL OBTAINS EVIDENCE THAT AN INDIVIDUAL'S CURRENT AND FUTURE INCOME IS SUBSTANTIALLY DIFFERENT THAN INDICATED IN THOSE DOCUMENTS.(A) FOR AN EMPLOYED INDIVIDUAL, THE AMOUNT REPORTED IN FORM 1040, LINE 22.(B) FOR A FARMER, INCOME IS TOTAL INCOME FROM FORM 1040, LINE 22 PLUS ANY DEPRECIATION CLAIMED IN FORM 1040, SCHEDULE F.(C) FOR A SELF-EMPLOYED INDIVIDUAL, INCOME IS TOTAL INCOME FROM FORM 1040, LINE 22 PLUS ANY DEPRECIATION CLAIMED IN FORM 1040, SCHEDULE C.IF AN INDIVIDUAL'S HOUSEHOLD OWNS RECREATIONAL VEHICLES THAT DO NOT HAVE A BUSINESS PURPOSE, THE HOUSEHOLD MAY BE REQUIRED TO SELL THE RECREATIONAL VEHICLES TO PAY THE INDIVIDUAL'S MEDICAL LIABILITY TO HOSPITAL BEFORE THE INDIVIDUAL WILL QUALIFY FOR FINANCIAL ASSISTANCE. RECREATIONAL VEHICLES INCLUDE, BUT ARE NOT LIMITED TO, MOTOR HOMES, ALL-TERRAIN VEHICLES ("ATV'S"), SNOWMOBILES, MOTORCYCLES, BOATS, AND JET SKIS. HOSPITAL MAY REQUIRE EVIDENCE OF A VALID BUSINESS PURPOSE FOR EACH RECREATIONAL VEHICLE. HOSPTIAL WILL NOT REQUIRE A RECREATIONAL VEHICLE TO BE SOLD IF THE OUTSTANDING DEBTS ON A VEHICLE ARE GREATER THAN ITS FAIR MARKET VALUE.HOSPITAL WILL PRESUMPTIVELY DETERMINE THAT AN INDIVIDUAL QUALIFIES FOR 100% FINANCIAL ASSISTANCE IF HOSPITAL OR ITS AGENT OBTAINS EVIDENCE OF ANY OF THE FOLLOWING SITUATIONS. IF A PERSON IS PRESUMPTIVELY DETERMINED TO QUALIFY, HOSPITAL WILL SEND A WRITTEN NOTICE INFORMING THE INDIVIDUAL THAT THEIR LIABILITY HAS BEEN FORGIVEN AND NO FURTHER PAYMENTS ARE DUE. - HOMELESSNESS ORE 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 VALED 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 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 THIER WEBSITE. PART I, LINE 7: COSTING METHODOLOGY:THE AMOUNTS REPORTED IN PART I, LINE 7 WERE CALCULATED BY USING THE COST-TO-CHARGE RATIO DERIVED FROM WORKSHEET 2 OF THE IRS SCHEDULE H INSTRUCTIONS. 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 $ 295,227. 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: FOR A DESCRIPTION OF THE ORGANIZATION'S BAD DEBT EXPENSE, SEE THE "PATIENT RECEIVABLES, NET" SECTION OF NOTE 1 TO THE FINANCIAL STATEMENTS ON PAGES 8-9 OF THE ATTACHED FINANCIAL STATEMENTS. PART III, LINE 8: THE MEDICARE SHORTFALL OF $1,525,413 IS MADE UP MOSTLY OF PATIENT DEDUCTIBLES AND COINSURANCE. IF WE BACK THESE AMOUNTS OUT OF THE SHORTFALL, WE ARE LEFT WITH A TRUE SHORTFALL OF $82,609. THIS AMOUNT IS A RESULT OF THE FEDERAL GOVERNMENT'S SEQUESTRATION IMPLEMENTED BACK IN THE SUMMER OF 2016. THE MEDICARE ALLOWABLE COSTS INCLUDED IN PART III, LINE 6 WERE DERIVED FROM THE 2017 FILED MEDICARE COST REPORT. PART III, LINE 9B: IF AN INDIVIDUAL SUBMITS A FINANCIAL ASSISTANCE APPLICATION, HOSPITAL WILL CEASE ALL COLLECTION EFFORTS UNTIL A DETERMINATION OF FINANCIAL ASSISTANCE ELIGIBILITY IS MADE.IF 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 HOSPITAL DETERMINES THE INDIVIDUAL'S ELIGIBILITY FOR FINANCIAL ASSISTANCE AND NOTIFIES THE INDIVIDUAL AS PRESCRIBED IN THE FINANCIAL ASSISTANCE POLICY.IF 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, 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 REQUEST 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 PROVE 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. ATTENTION TO 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: THE HOSPITAL IS A MEMBER OF AVERA HEALTH. 0 OSCEOLA COUNTY AMBULANCE SERVICE 309 6TH ST SIBLEY IA 51249 426005204 501(C)(3) 5000 DONATION TO PROJECT LIFEPAK. 1 0 X X 0 0 0 0 0 0 0 0 0 JANET DYKSTRA CEO THRU MARCH 2017 154780 0 0 0 0 0 4789 0 1648 0 161217 0 0 0 A CITY OF SIBLEY IOWA 426005203 2016-02-24 4776000 TO REFINANCE SERIES 2001 AND 2007 BONDS 0 0 0 A 212550 4776000 4680101 95520 379 2010 1 0 1 1 A 0 0 0 0 0 0 1 A 0 1 0 0 1 0 0 0 1 A 0 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 4 THE FOLLOWING PARTS OF THE BYLAWS OF OCH WERE AMENDED: SECTION 5, LIMITATION OF TERMS: NO TRUSTEE SHALL SERVE MORE THAN TWO CONSECUTIVE THREE-YEAR TERMS WITHOUT A ONE TIME ONE YEAR ABSENCE FROM THE BOARD. PREVIOUSLY, A TRUSTEE WAS REQUIRED TO TAKE A THREE-YEAR ABSENCE BETWEEN TERMS. 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 BE 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 CONFLICT 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 2016 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 AND 990-T ARE AVAILABLE AT THE ANNUAL MEETING AND UPON REQUEST. FORM 990, PART IX, LINE 11G PROFESSIONAL FEES: PROGRAM SERVICE EXPENSES 1,450,041. MANAGEMENT AND GENERAL EXPENSES 0. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 1,450,041. PURCHASED SERVICES: PROGRAM SERVICE EXPENSES 516,543. MANAGEMENT AND GENERAL EXPENSES 347,225. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 863,768. HEARTWOOD HEIGHTS 409 9TH AVE NORTH SIBLEY IA 51249 421495686 INDEPENDENT/ASSISTED LIVING COMPLEX 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 162123 ACTUAL COST