2017-11-15T08:08:56-06:00 2016-12-31 476097913 SEIM JOHNSON LLP 18081 BURT STREET SUITE 200 OMAHA NE 680224722 990 2016-01-01 470408242 CHEYENNE COUNTY HOSPITAL ASSOCIATION INC CHEY 3082545825 1000 POLE CREEK CROSSING SIDNEY NE 69162 JASON PETIK CEO 3082545825 2017-11-14 1 WENDY R COOLEY P01523804 4023302660 209.34.201.180 2017-11-14 14:59:26 CS P E174F7C75A15FCA0AF1E43F729F0FF7E9FDF9AE2 FCEDDD786A52D146CD6D5AF04BB3D8B974087028 2016 2017-02-10 21:41:12Z SIDNEY REGIONAL MEDICAL CENTER JASON PETIK 1000 POLE CREEK CROSSING SIDNEY NE 69162 57136824 0 X WWW.SIDNEYRMC.COM X 1951 NE TO REVOLUTIONIZE HEALTHCARE SERVICES IN THE REGION. 14 12 502 100 0 0 182617 46543 52158301 56805243 -142457 36996 114857 113656 52313318 57002438 76043 40033 0 0 28499642 29070665 0 0 0 19667482 26572885 48243167 55683583 4070151 1318855 88576422 87055366 49324233 46484322 39252189 40571044 X TO REVOLUTIONIZE HEALTHCARE SERVICES IN THE REGION. 0 0 40631893 40033 41416017 SIDNEY REGIONAL MEDICAL CENTER IS A NOT-FOR-PROFIT ACUTE CARE HOSPITAL WHICH PROVIDES INPATIENT, OUTPATIENT AND EMERGENCY ROOM CARE SERVICE TO PATIENTS IN SIDNEY, NEBRASKA. IT ALSO OPERATES LONG-TERM CARE FACILITIES, A HOME HEALTH AGENCY, AND PROVIDER-BASED RURAL HEALTH CLINICS IN SIDNEY, NEBRASKA AND CHAPPELL, NEBRASKA, AS WELL AS A STAND ALONE PRIMARY CARE CLINIC IN SIDNEY, NEBRASKA. 3667536 7028815 IN 2016, THE HOSPITAL NURSING DEPARTMENT PROVIDED 2,023 PATIENT DAYS OF CARE, INCLUDING INPATIENT AND OBSERVATION PATIENTS, AND DELIVERED 69 NEWBORNS FOR THE SEVEN COUNTY AREA THAT SIDNEY REGIONAL MEDICAL CENTER (SRMC) SERVES. SRMC HAD 3,752 PATIENTS SEEK CARE IN THE EMERGENCY DEPARTMENT DURING 2016. 3177496 3934396 THE EXTENDED CARE UNIT PROVIDED CARE FOR AN AVERAGE OF 51 PATIENTS DAILY DURING 2016. SRMC PROVIDED 17,824 PATIENT DAYS OF CARE FOR RESIDENTS IN THE CHEYENNE, DEUEL, KIMBALL AND SURROUNDING AREAS. 2617320 4426015 THE SRMC PHARMACY DEPARTMENT HAS BEEN ACTIVELY INVOLVED WITH THE QUALITY OF CARE PROVIDED TO ALL PATIENTS BOTH IN THE ACUTE AND OUT PATIENT SETTINGS. THE PHARMACY DEPARTMENT HAS HELPED PROVIDE CARE FOR THOSE INDIVIDUALS WITH THE TREATMENT FOR RADIATION OR CHEMOTHERAPY. 2617320 4426015 50094245 1 1 0 1 0 0 0 0 0 0 1 0 0 0 1 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 1 0 0 0 0 0 0 1 0 0 0 1 86 0 1 502 1 0 0 0 0 0 0 0 0 0 0 X 14 12 0 1 0 0 0 0 0 1 1 0 0 1 1 1 1 1 1 1 1 0 X KELLY UTLEY 3082545825 1000 POLE CREEK CROSSING SIDNEY NE 69162 X WILLIAM PILE CHAIRMAN 4.00 0.00 X X 0 0 0 TIM MILLER VICE CHAIRMAN 4.00 0.00 X X 0 0 0 TOM MILLMAN SECRETARY 4.00 0.00 X X 0 0 0 JEFF ELLWANGER TREASURER 4.00 0.00 X X 0 0 0 STAN BELIEU MEMBER 4.00 1.00 X 0 0 0 CLINTON DORWART MD MEMBER - PHYSICIAN AT LARGE 40.00 0.00 X 142082 0 6033 ROBERT GRAVES MD MEMBER - CHIEF OF MEDICAL STAFF 40.00 0.00 X 185102 0 9241 JIM JONES MEMBER 4.00 0.00 X 0 0 0 KATHY NARJES MEMBER 4.00 0.00 X 0 0 0 ROB ROBINSON MEMBER 4.00 0.00 X 0 0 0 DWIGHT SMITH MEMBER 4.00 0.00 X 0 0 0 JULIE WAMSLEY MEMBER 4.00 1.00 X 0 0 0 LAURIE WIDDOWSON MEMBER 4.00 0.00 X 0 0 0 ANNE JOHNSON MEMBER 4.00 0.00 X 0 0 0 JASON PETIK CEO 40.00 0.00 X 0 0 0 KELLY UTLEY CFO 39.00 1.00 X 167994 0 8475 MATTHEW JANSEN DOCTOR 40.00 0.00 X 480279 0 41217 MANDY SHAW MD DOCTOR 40.00 0.00 X 332080 0 10000 REBECCA L ALLARD MD DOCTOR 40.00 0.00 X 340035 0 53144 JAMES THAYER MD DOCTOR 40.00 0.00 X 338149 0 35833 CRAIG SANDBERG CRNA 40.00 0.00 X 285765 0 13250 2271486 0 177193 39 0 1 1 RURAL PARTNERS IN MEDICINE LLC PO BOX 772519 STEAMBOAT SPRINGS CO 80477 PHYSICIAN SERVICES 1987152 BYTES COMPUTER & NETWORK SOLUTIONS INC 1712 AVENUE B SCOTTSBLUFF NE 69361 IT SERVICES 394963 PRIME TIME HEALTHCARE LLC PO BOX 3544 OMAHA NE 68103 TEMPORARY STAFFING 368615 SUNBELT STAFFING DEPT CH 14430 PALATINE IL 60055 TEMPORARY STAFFING 261708 UNIVERSITY OF COLORADO HOSPITAL AUTHORIT PO BOX 733156 DALLAS TX 75373 MANAGEMENT SERVICES 206233 13 7132 27412 11999 46543 NET PATIENT SERVICE REVENUE 621110 33199728 33199728 MEDICARE/MEDICAID 621110 22579039 22579039 340B REVENUE 621110 656224 656224 SCHOOL REHAB REVENUE 621110 70476 70476 299776 299776 56805243 53449 53449 117933 134386 -16453 -16453 -16453 CAFETERIA 722210 106292 106292 PATRONAGE DIVIDEND 900099 7364 7364 113656 57002438 56805243 0 150652 X 40033 40033 518925 342457 176468 97248 97248 22498024 21868008 630016 699767 684067 15700 3674031 3562702 111329 1582670 1489555 93115 206233 206233 66783 66783 82739 82739 7046446 6951898 94548 212212 212212 767940 690654 77286 501700 501700 1161140 1161140 176712 157804 18908 39270 39270 1309193 1309193 5467930 3012272 2455658 338073 338073 MEDICAL SUPPLIES 6586311 6586311 BAD DEBTS 1940282 1940282 FOOD PRODUCTS 404618 404618 DUES AND SUBSCRIPTIONS 145926 79806 66120 119377 70653 48724 55683583 50094245 5589338 0 3036482 3487073 16162753 19412822 7383901 6235226 82808 79808 1225788 1389092 554981 440555 67781720 13648992 58890869 54132728 1238840 1878062 88576422 87055366 9251052 3933611 7192417 9941008 32342914 31966973 537850 642730 49324233 46484322 X 39252189 40571044 39252189 40571044 88576422 87055366 1318855 0 X X 0 1 X 1 1 1 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 0 0 0 0 0 0 0 0 1 6013 6013 0 PART II-B, LINE 1: A PORTION OF THE DUES PAID TO THE AMERICAN HOSPITAL ASSOCIATION (AHA) AND THE NEBRASKA HOSPITAL ASSOCIATION (NHA) ARE USED BY THOSE ORGANIZATIONS FOR LOBBYING ACTIVITIES. 92500 1929968 2022468 48789859 6518525 42271334 21420 21420 15916429 6911240 9005189 1031544 219227 812317 54132728 DEFERRED COMPENSATION PLAN LIABILITY 642147 DUE TO AFFILIATES 583 642730 X PART X, LINE 2: SIDNEY REGIONAL MEDICAL CENTER AND CHEYENNE COUNTY HOSPITAL AND HEALTH CENTER FOUNDATION ARE EXEMPT FROM INCOME TAXES UNDER SECTION 501(A) OF THE CODE AND A SIMILAR PROVISION OF STATE LAW. THE INTERNAL REVENUE SERVICE HAS ESTABLISHED STANDARDS TO BE MET TO MAINTAIN TAX-EXEMPT STATUS. THE SYSTEM ACCOUNTS FOR UNCERTAINTIES IN ACCOUNTING FOR INCOME TAX ASSETS AND LIABILITIES USING GUIDANCE INCLUDED IN FASB ASC 740, INCOME TAXES. THE SYSTEM RECOGNIZES THE EFFECT OF INCOME TAX POSITIONS ONLY IF THOSE POSITIONS ARE MORE LIKELY THAN NOT OF BEING SUSTAINED. AT DECEMBER 31, 2016, THE SYSTEM HAD NO UNCERTAIN TAX POSITIONS ACCRUED. 1 1 1 X 1 X 1 1 1 0 1 1 511569 0 511569 0.00950 3238624 3158412 80212 0.00150 3750193 3158412 591781 0.01100 211285 122809 88476 0.00160 15997 0 15997 0.00030 54548 0 54548 0.00100 281830 122809 159021 0.00290 4032023 3281221 750802 0.01390 96 2621 17684 0 17684 0.00030 7 579 9925 0 9925 0.00020 206 2076 20874 0 20874 0.00040 309 5276 48483 48483 0.00090 1 1940282 679099 16139117 16539443 -400326 X 1 1 1 1 CHEYENNE COUNTY HOSPITAL ASSOCIATION 1000 POLE CREEK CROSSING SIDNEY NE 69162 WWW.SIDNEYRMC.COM 150001 X X X X CHEYENNE COUNTY HOSPITAL ASSOCIATION INC 1 0 0 1 X X X X X X X X X 14 1 1 1 1 X WWW.SIDNEYRMC.COM X WWW.PPHD.ORG X 1 14 1 WWW.SIDNEYRMC.COM 0 1 X 100.000000000000 300.000000000000 X X X X X 0 1 X X 1 X SIDNEYRMC.COM X SIDNEYRMC.COM X SIDNEYRMC.COM X X X X X 1 X 0 X X X X 1 X 0 0 CHEYENNE COUNTY HOSPITAL ASSOCIATION INC PART V, SECTION B, LINE 5: SIDNEY REGIONAL MEDICAL CENTER HOSTED FOCUS GROUPS, COMMUNITY FORUMS AND STAKEHOLDERS MEETINGS FOR THE MEMBERS OF OUR AREA. OF THE THREE FOCUS GROUPS HELD FROM JUNE THROUGH JULY, 2014 THE FIRST GROUP REPRESENTED THE "HEALTHCARE DECISION MAKERS," THE SECOND INCLUDED CHAMBER AND COMMUNITY COLLEGE MEMBERS, AND THE THIRD INVOLVED MEMBERS FROM THE PUBLIC SCHOOLS. THERE WERE ALSO THREE COMMUNITY FORUMS THAT WERE OVERSEEN BY PANHANDLE PUBLIC HEALTH DISTRICT AND THEY INCLUDE A COMMUNITY GROUP FROM SIDNEY, SECOND SMALLER GROUP REPRESENTING THE 6% OF THE COUNTY'S HISPANIC POPULATION. THE THIRD GROUP REPRESENTED CHAPPELL, NEBRASKA IN DEUEL COUNTY LOCATED APPROXIMATELY 20 MILES EAST OF SIDNEY. A STAKEHOLDER MEETING WAS HELD TO ESTABLISH AN OUTREACH VISION FOR THE COMMUNITY/COUNTY. PARTICIPANTS INCLUDED REPRESENTATIVES FROM THE HOSPITAL, PUBLIC SCHOOL SYSTEM, MEDIA GROUPS, CHAMBER OF COMMERCE, LOCAL BUSINESSES, NON-PROFIT AND SERVICE ORGANIZATIONS, FAITH BASED ORGANIZATIONS, LAW ENFORCEMENT AND CITY OF SIDNEY. OVER THE COURSE OF THE MEETING THE PARTICIPANTS WERE PRESENTED WITH HEALTH DATA, SOCIOECONOMIC DATA, LEADING CAUSES OF DEATH FOR THE PANHANDLE COMPARED TO THE REST OF THE STATE, THE IMPACT OF ADVERSE CHILDHOOD EXPERIENCES (ACE) AND CHILD WELL BEING DATA. PRESENTERS ALSO GAVE AN OUTLINE OF THE CURRENT PRIORITY AREAS OF THE PANHANDLE HEALTH IMPROVEMENT PLAN. THE RESULTS OF THE STAKEHOLDER MEETING, THE FOCUS GROUPS AND THE HEALTH DATA AS WELL AS THE RESULTS FROM THE COMMUNITY HEALTH NEEDS ASSESSMENT SURVEY WERE PRESENTED TO A SMALLER COMMITTEE OF SRMC STAFF IN NOVEMBER 2014 TO DETERMINE PRIORITY AREAS. CHEYENNE COUNTY HOSPITAL ASSOCIATION INC PART V, SECTION B, LINE 6A: THE FOLLOWING IS A LIST OF HOSPITALS THAT PARTICIPATED IN THE CHNA:-BOX BUTTE GENERAL HOSPITAL, ALLIANCE, NE-MORRILL COUNTY HOSPITAL, BRIDGEPORT, NE-REGIONAL WEST MEDICAL CENTER, SCOTTSBLUFF, NE-CHADRON COMMUNITY HOSPITAL, CHADRON, NE-GARDEN COUNTY HEALTH SERVICES, OSHKOSH, NE-GORDON MEMORIAL HOSPITAL, GORDON, NE-KIMBALL HEALTH SERVICES, KIMBALL, NE-SCOTTSBLUFF COUNTY HEALTH DEPARTMENT, SCOTTSBLUFF, NE-SIDNEY REGIONAL MEDICAL CENTER, SIDNEY, NE CHEYENNE COUNTY HOSPITAL ASSOCIATION INC PART V, SECTION B, LINE 6B: PANHANDLE PUBLIC HEALTH DEPARTMENT CHEYENNE COUNTY HOSPITAL ASSOCIATION INC PART V, SECTION B, LINE 11: 2016 ACTIVITIES TO ADDRESS THE SIGNIFICANT NEEDS IDENTIFIED IN THE MOST RECENTLY CONDUCTED CHNA:NUTRITION AND WEIGHT STATUS: 1. THE HOSPITAL PARTNERED WITH THE LOCAL GROCERY STORE AND CONDUCTED DIETICIAN GUIDED TOURS OF THE STORE AND EDUCATION TO COMMUNITY MEMBERS ATTENDING. 2. RADIO SPOTS WERE AIRED WITH THE DIETICIAN AND RADIO HOST IN DIALOGUE REGARDING NUTRITION NEEDS AND WEIGHT MANAGEMENT. 3. SRMC DIETICIAN SPOKE AT THE WOMEN IN AG CONFERENCE ON "HEALTHY EATING AS WE AGE".4. DR. JENNIFER BROWN PRESENTED THE MONTHLY NUTRITION TALK "ALL ABOUT FOOD" FOR COMMUNITY MEMBERS AS AN OPEN FORUM/DISCUSSION ON HIGH CHOLESTEROL AND HIGH BLOOD PRESSURE/HEART HEALTHY FOOD CHOICES. 5. KIDS HEALTH ADVENTURE WAS HELD AT CCCC AND SRMC PROVIDED FREE HEIGHT, WEIGHT BMI AND BLOOD PRESSURE SCREENINGS, WITH A PROVIDER ON SITE TO ANSWER ANY QUESTIONS FROM PARENTS REGARDING THEIR CHILD AND WHERE THEY FELL IN TO THE GROWTH CHART. PHYSICAL ACTIVITY:1. SRMC PARTNERED WITH THE PANHANDLE PUBIC HEALTH DISTRICT AND OTHER LOCAL BUSINESSES TO SUPPORT THE WALKABILITY/BIKE-ABILITY PROJECT TO "ACTIVATE SIDNEY" BY PROMOTING A HEALTHY AND ACTIVE LIFESTYLE AND BIKING ON THE TRAIL, FOR ALL AGES WITHIN OUR COMMUNITY. SRMC ENCOURAGED LOCAL BUSINESSES TO SUPPORT WORKSITE WELLNESS/WALKABILITY FOR THEIR EMPLOYEES DURING THEIR BREAKS.2. SRMC PROMOTED AND COORDINATED THE TEACHING OF A 16-WEEK PROGRAM FOR WEIGHT LOSS AND BECOMING MORE PHYSICALLY ACTIVE WITH 9 MEMBERS DOING 13,320 MINUTES OF EXERCISE FOR THE FINAL 10 WEEKS.3. KYLE BROWN PA-C GAVE A LUNCH AND LEARN PRESENTATION ON BACK SAFETY/PHYSICAL ACTIVITY TO A GROUP AT CABELA'S DISTRIBUTION CENTER.4. SRMC'S DASH FOR THE SPLASH TRIATHLON WAS HELD FOR THE COMMUNITY AND SURROUNDING AREA WITH A TOTAL OF 174 PARTICIPANTS.5. SRMC HELD THE OCTOBERFEST 5K RUN/WALK AND 10K RUN FOR THE COMMUNITY FOR BOTH ADULTS AND KIDS FOR A TOTAL OF 101 PARTICIPANTS. 6. ON 12/29/2016 THE NATIONAL DIABETES PREVENTION PROGRAM (GROUP # 7) FINISHED THEIR 16-WEEK CLASS WITH 7 PARTICIPANTS LOGGING 7,255 MINUTES OF EXERCISE.SUBSTANCE ABUSE EDUCATION AND HAND HYGIENE:1. KIDS HEALTH ADVENTURE, SRMC PHARMACY STAFF PARTICIPATING WITH A KIDS ACTIVITY WHERE THE KIDS HAD TO "GUESS" CANDY OR PILLS ON A LARGE TAG BOARD.2. ANNIE MCCARTNEY RN, INFECTION CONTROL NURSE AT SRMC, DISCUSSED THE IMPORTANCE OF HAND HYGIENE AND COVERING THOSE SNEEZES AND COUGHS WITH FLU SEASON UPON US, TO THE KSID LISTENERS ON TUESDAY MORNING SEGMENT = 2000+ LISTENERS.3. ANNUAL KIDS HEALTH ADVENTURE WAS HELD AT CHEYENNE COUNTY COMMUNITY CENTER AND ANNIE MCCARTNEY RN, INFECTION CONTROL NURSE AT SRMC, DEMONSTRATED AND HAD AN ACTIVITY FOR THE KIDS AND THEIR PARENTS ON HOW GERMS ARE SPREAD USING GLITTER = 140 PARTICIPANTS.BREAST FEEDING PROMOTION AND EDUCATION:1. SRMC SPECIFICALLY BUILT A NEW BREAST FEEDING ROOM FOR EMPLOYEES AND PATIENTS OR VISITORS IN THE HOSPITAL.2. OB NURSE, MARION ABBOTT, PROVIDES EDUCATION AND ASSISTANCE AFTER DELIVERY BOTH IN THE HOSPITAL AND DURING HOME VISITS FOR MOTHERS WHO MAY HAVE DELIVERED AT A DIFFERENT HOSPITAL OR AT HOME.CANCER PREVENTION:1. THE HOSPITAL CONTINUES TO BE A NON-SMOKING CAMPUS2. THE HOSPITAL PROVIDES FREE NICOTINE PATCHES FOR EMPLOYEES WHO WOULD LIKE TO STOP USING TOBACCOMENTAL AND EMOTIONAL WELL BEING:1. SRMC DID NOT HAVE THE RESOURCES TO INCLUDE MENTAL AND EMOTIONAL WELLBEING INTO ITS COMMUNITY HEALTH DURING THIS TIME PERIOD. CHEYENNE COUNTY HOSPITAL ASSOCIATION INC PART V, SECTION B, LINE 13B: SPECIFICALLY IDENTIFIED CASES MAY BE PRESUMED ELIGIBLE FOR CHARITABLE ASSISTANCE WITHOUT A COMPLETED APPLICATION OR ASSESSMENT OF POVERTY LEVELS. EXAMPLES OF THESE CASES ARE: 1) DECEASED PATIENTS WITH NO KNOWN ESTATE OR SPOUSE, 2) PATIENTS WITH CURRENT ELIGIBILITY UNDER COUNTY OR STATE MEDICAL INDIGENT SERVICES ADMINISTERED BY COUNTY OR STATE FACILITIES, OR 3) A PATIENT HOMELESS OR WITHOUT RESOURCES. PERCENT OF CHARITY WILL BE BASED ON HOUSEHOLD INCOME AND SIZE, REAL ESTATE OWNERSHIP EQUITY, PERSONAL PROPERTY OWNERSHIP EQUITY AND INVESTMENT EQUITY, WITH CREDIT GIVEN FOR ALREADY EXISTING MEDICAL LOANS AND FOR INCOME EARNED BY FULL-TIME STUDENTS RESIDING IN THE HOUSEHOLD IN COMPARISON TO THE CURRENT YEAR FEDERAL POVERTY GUIDELINES. CHEYENNE COUNTY HOSPITAL ASSOCIATION INC PART V, SECTION B, LINE 16J: THE POLICY IS REFERENCED IN BILLING STATEMENTS AND IS ORALLY COMMUNICATED DURING REGISTRATION OR ADMISSIONS AND THROUGH THE PATIENT FINANCIAL SERVICES FOLLOW UP PROCESSES, INCLUDING PATIENT ADVOCACY CONVERSATIONS. THE POLICY IS AVAILABLE IN THE WAITING ROOMS AT THE HOSPITAL. ADDITIONALLY, FINANCIAL SERVICE REPRESENTATIVES ACTIVELY SCAN FOR ACCOUNTS WHICH COULD QUALIFY FOR CHARITY CARE AND OFFER IT WITH OTHER OPTIONS FOR PAYMENT DURING THEIR CONVERSATIONS WITH PATIENTS. A HARDCOPY OF THE POLICY IS OFFERED BY THE PATIENT ADVOCATE/FINANCIAL COUNSELOR DURING MEETINGS WITH PATIENTS. THE CHARITY CARE POLICY IS ALSO MAILED TO EVERY GUARANTOR PRIOR TO EXTRAORDINARY COLLECTION ACTIONS. CHEYENNE COUNTY HOSPITAL ASSOCIATION INC PART V, SECTION B, LINE 20E: PROVIDED WRITTEN NOTICE OF UPCOMING ECAS AND PROVIDED WRITTEN NOTIFICATION OF HOSPITAL FINANCIAL ASSISTANCE AVAILABILITY. 3 1 - SIDNEY REG'L MEDICAL CTR EXTENDED CARE 549 KELLER DRIVE SIDNEY NE 69162 LONG TERM CARE FACILITY 2 - SLOAN ESTATES ASSISTED LIVING 2550 CRAIG AVENUE SIDNEY NE 69162 ASSISTED LIVING 3 - SIDNEY REG'L MEDICAL CTR WALK IN CLINIC 1625 DORWART DRIVE SIDNEY NE 69162 WALK IN CLINIC PART I, LINE 3C: THE CALCULATION FOR ELIGIBILITY IS BASED ON ALL INCOME PER HOUSEHOLD WITH EXCEPTIONS MADE FOR WAGE EARNERS WHO ARE STUDENTS. OTHER MEDICAL PAYMENTS ALREADY BEING MADE ARE CONSIDERED IN THE CALCUATION. INCOME IS COMPARED TO THE NATIONAL POVERTY GUIDELINES AND A DETERMINATION OF REDUCTION IS MADE BASED ON THE ADJUSTED INCOME LEVEL. THE WRITE OFF AMOUNT MAY BE REDUCED FOR EQUITY IN ASSETS, IF ANY, ABOVE EXEMPTION THRESHOLDS FOR HOMES AND VEHICLES. THERE IS NO EXEMPTION FOR INVESTMENTS OR OTHER ASSETS HELD. PART I, LINE 6A: THE COMMUNITY BENEFIT REPORT IS PREPARED BY THE STAFF OF SIDNEY REGIONAL MEDICAL CENTER. PART I, LINE 7: THE COST TO CHARGE RATIO IS DETERMINED AS FOLLOWS: (TOTAL EXPENSES - BAD DEBT)/GROSS PATIENT SERVICE REVENUE = PERCENTAGE OF COST TO CHARGE. PART I, LINE 7G: THERE ARE NO SUBSIDIZED HEALTH SERVICES. PART I, LN 7 COL(F): BAD DEBT EXPENSE OF $1,940,282 HAS BEEN EXCLUDED FROM THE DENOMINATOR IN THE CALCULATION OF THE PERCENTAGES IN LINE 7, COLUMN F. PART II, COMMUNITY BUILDING ACTIVITIES: COMMUNITY SUPPORT INCLUDES ACTIVITIES SUCH AS THERAPISTS AVAILABLE AT GAMES AND AT THE COMMUNITY CENTER AND WELLNESS CAMPAIGNS IN COOPERATION WITH THE COMMUNITY CENTER. COMMUNITY HEALTH IMPROVEMENT INCLUDES COMMUNITY BLOOD DRAWS, HEALTH FAIR, BLOOD PRESSURE SCREENINGS, DIABETES PREVENTION PROGRAMS, AND MULTIPLE SMALLER COMMUNITY EDUCATION PROGRAMS THROUGH RADIO INTERVIEWS WITH HEALTH PROFESSIONALS. PART III, LINE 2: IN EVALUATING THE COLLECTIBILITY OF ACCOUNTS RECEIVABLE, THE SYSTEM ANALYZES ITS PAST HISTORY AND IDENTIFIES TRENDS FOR EACH OF ITS MAJOR PAYER SOURCES OF REVENUE TO ESTIMATE THE APPROPRIATE ALLOWANCE FOR DOUBTFUL ACCOUNTS AND PROVISION FOR BAD DEBTS. MANAGEMENT REGULARLY REVIEWS DATA ABOUT THESE MAJOR PAYER SOURCES OF REVENUE IN EVALUATING THE SUFFICIENCY OF THE ALLOWANCE FOR DOUBTFUL ACCOUNTS. THE SYSTEM 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: SIDNEY REGIONAL MEDICAL CENTER HAS ESTIMATED THE AMOUNT OF BAD DEBT EXPENSE ATTRIBUTABLE TO PATIENTS WHO MAY HAVE BEEN ELIGIBLE UNDER THE ORGANIZATION'S FINANCIAL ASSISTANCE POLICY AT 35%. THIS ESTIMATE IS BASED ON A RECOVERY RATE FROM THE COLLECTION AGENCY FOR 2016 ACCOUNTS OF APPROXIMATELY 30%. THEORETICALLY, THE NEARLY 30% WHICH HAS BEEN RECOVERED IS BEING RECOVERED FROM PEOPLE WHO COULD PAY BUT DIDN'T. WHEN ESTIMATING THAT POSSIBLY HALF OF THE REMAINING 70% OF THE BAD DEBT WAS ATTRIBUTABLE TO PATIENTS WHO HAD NO MEANS OF PAYMENT RATHER THAN MEANS BUT NO INTENT, THIS ESTIMATE OF FAP AMOUNTS IN BAD DEBT WOULD TOTAL APPROXIMATELY 35%. PART III, LINE 4: THE HOSPITAL'S FINANCIAL STATMENTS DO NOT CONTAIN A SPECIFIC FOOTNOTE DESCRIBING BAD DEBT. HOWEVER, PAGES 8, 9, 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: THE ORGANIZATION USED THE MEDICARE COST REPORT FOR FISCAL YEAR 2016 TO REPORT THE AMOUNTS OF TOTAL REVENUE RECEIVED FROM MEDICARE AND RELATED MEDICARE ALLOWABLE COSTS. MEDICARE PAYS THE HOSPITAL'S RURAL HEALTH CLINICS (RHC) AT COST SUBJECT TO CERTAIN LIMITS. THE MEDICARE SHORTFALL IN PAYMENTS SHOULD BE CONSIDERED A COMMUNITY BENEFIT AS IT IS PART OF THE HOSPITAL'S MISSION TO PROVIDE THESE SERVICES EVEN IF MEDICARE REIMBURSEMENT IS BELOW COST. PART III, LINE 9B: THE CHARITY CARE POLICY ALLOWS FOR PROACTIVE WRITE OFF TO ALLOWANCE FOR CHARITY CARE OF ANY BALANCE OWED BY A PATIENT KNOWN TO QUALIFY FOR CHARITY CARE UNDER THE FINANCIAL ASSISTANCE POLICY. COLLECTION PROCEDURES DO NOT ENSUE ON ANY ACCOUNTS ELIGIBLE FOR FINANCIAL ASSISTANCE. PART VI, LINE 2: NEEDS ASSESSMENTS ARE DETERMINED THROUGH SCIENTIFIC, AS WELL AS UNSCIENTIFIC METHODS. EVERY 2 TO 3 YEARS A MARKET ASSESSMENT IS COMPLETED USING CLAIMS DATA WHICH REVEALS THE NEEDS OF COMMUNITY MEMBERS BEING MET ELSEWHERE DUE TO EITHER UNAVAILABILITY OF SERVICE OR PATIENT CHOICE. THIS ASSESSMENT INCLUDES THE DEMOGRAPHICS OF THE AREA WHICH SHOW AN AGING AND MODERATE INCOME POPULATION. THESE FACTS ARE THEN USED TO DETERMINE THE NEEDS OF THE COMMUNITY AS WELL AS THE FUTURE NEEDS BASED ON HISTORICAL DATA. ADDITIONALLY, COMMUNITY NEEDS ARE DETERMINED USING PUBLIC OPINION, PATIENT SATISFACTION RECOMMENDATIONS, BOARD AND LEADERSHIP EXPERIENCE, COMMUNICATIONS WITH COMMUNITY MEMBERS, AND PHYSICIAN INPUT. FUTURE MEASUREMENTS OF HEALTH DATA MINED FROM CLAIMS SUBMISSIONS WILL BE USED TO FURTHER ANALYZE THE NEEDS OF THE COMMUNITY. PART VI, LINE 3: AT THE POINT OF ADMISSION, A PATIENT'S INSURED STATUS IS DETERMINED. PATIENTS WHO ARE UNDERINSURED OR UNINSURED RECEIVE COUNSELING THROUGH THE HOSPITAL'S PATIENT ADVOCATE AND/OR A MEMBER OF THE FINANCIAL SERVICES STAFF SERVING AS A FINANCIAL COUNSELOR. INFORMATION IS CONVEYED TO THE PATIENT OR THE GUARANTOR REGARDING MEDICAID AND MEDICARE, AS WELL AS CHARITY CARE PROVIDED BY THE HOSPITAL. ADDITIONAL COUNSELING IS PROVIDED AFTER DISMISSAL WHEN THE PROACTIVE APPROACH WAS UNSUCCESSFUL. ADDITIONALLY, SOCIAL SERVICES PERSONNEL HOLD WORKSHOPS AND MEETINGS WITH PATIENTS INDIVIDUALLY REGARDING THEIR COVERAGE IN AN ATTEMPT TO DETERMINE ELIGIBILITY FOR FINANCIAL ASSISTANCE AND OTHER MEANS FOR THE INDIVIDUALS. PART VI, LINE 4: MOST OF THE AREA THAT THE HOSPITAL SERVES IS LOCATED IN CHEYENNE COUNTY, NEBRASKA WHICH HAS A POPULATION OF APPROXIMATELY 10,000 PEOPLE. THE CITIES OF SIDNEY, LODGEPOLE, POTTER, DALTON, GURLEY, AND SUNOL ARE LOCATED WITHIN THE COUNTY AND ARE GENERALLY WITHIN APPROXIMATELY 30 MILES FROM THE HOSPITAL. ACCORDING TO THE US CENSUS BUREAU, THE 2016 DEMOGRAPHIC IS AROUND 96% CAUCASIAN AND THE AVERAGE HOUSEHOLD SIZE IS 2.27 PEOPLE PER HOUSEHOLD. LESS THAN 7% OF PEOPLE ARE WITHOUT HEALTH INSURANCE OF THE TOTAL POPULATION OVER 16 YEARS OF AGE, 73.1% ARE ACTIVELY IN THE LABOR FORCE. PERSONS UNDER 18 AND OVER 65 YEARS OLD TOTALED JUST UNDER 30%. PART VI, LINE 5: IN ADDITIONAL TO ACTIVITIES ADDRESSED IN THE CHNA REPORT, THE HOSPITAL HOLDS AN ANNUAL HEALTH FAIR AND AN ANNUAL CHILDREN'S HEALTH FAIR, 10K RACES, TRIATHLON RACES, PROVIDES OUTREACH SERVICE TO LOCAL BUSINESSES TO ASSURE FLU SHOTS AND IMMUNIZATIONS ARE UP TO DATE AS WELL AS DOING BLOOD PRESSURE SCREENINGS. SRMC ALSO CONDUCTS DIABETES EDUCATION CLASSES AND A DIABETES HEALTH FAIR DURING THE YEAR. SRMC OFFERS IN-HOME FOLLOW UP VISITS TO ANY MOTHERS WITH NEW BABIES NO MATTER WHERE THEY DELIVERED THEIR BABY, AND COLLABORATES WITH THE SCHOOL TO PROVIDE FOLLOWUP THERAPY CONSULTATIONS AFTER SPORTING EVENTS. THE HOSPITAL CONTINUES TO PROVIDE OB AND DELIVERY SERVICES EVEN THOUGH MANY SMALLER HOSPITALS HAVE DISCONTINUED SUPPORT OF THEIR COMMUNITIES IN THIS ARENA. COMMUNITY EDUCATION IS PROVIDED THRU RADIO BROADCASTS EACH WEEK WITH VARYING TOPICS. PART VI, LINE 6: SIDNEY REGIONAL MEDICAL CENTER IS NOT PART OF AN AFFILIATED HEALTH CARE ORGANIZATION. REQUIRED DISCLOSURE IN ACCORDANCE WITH SEC. 7 OF REV. PROC. 2015-21: THE HOSPITAL'S FINANCIAL ASSISTANCE POLICY AS IT EXISTED PRIOR TO 01/01/17 DID NOT ADDRESS IN WRITING THE BASIS FOR CALCULATING AMOUNTS CHARGED TO PATIENTS WHO WERE ELIGIBLE FOR FINANCIAL ASSISTANCE. THE LACK OF THIS LANGUAGE IN THE POLICY WAS AN INADVERTENT ERROR BECAUSE THE HOSPITAL WAS NEVERTHELESS APPLYING DISCOUNTS TO THE AMOUNTS GENERALLY BILLED BY THE HOSPITAL EVEN THOUGH THE REQUIREMENT TO DO SO WAS MISSING IN THE WRITTEN POLICY. CONSEQUENTLY, THERE WERE NO ADVERSE EFFECTS AGAINST ANY INDIVIDUAL PATIENTS. THE HOSPITAL WAS IN THE PROCESS OF REVISING THE FINANCIAL ASSISTANCE POLICY DURING THE 2016 TAX YEAR AND THE ISSUE WAS CORRECTED WHEN THE HOSPITAL'S BOARD OF DIRECTORS ADOPTED ITS CURRENT FINANCIAL ASSISTANCE POLICY WITH AN OFFICIAL APPROVAL DATE OF 11/01/17. 1 MAKE A WISH FOUNDATION NEBRASKA 8 WEST 56TH STREET STE B-2 NORTH KEARNEY NE 68847 470671096 501(C)(3) 10000 MAKE A WISH PLEDGE FOR A COMMUNITY CHILD CHEYENNE COUNTY HOSPITAL AND HEALTH CENTER FOUNDATION 1000 POLE CREEK CROSSING SIDNEY NE 69162 470686476 501(C)(3) 7510 SPONSORSHIP OF FUNDRAISING ACTIVITIES 2 0 PART I, LINE 2: IF THE DONEE ORGANIZATION IS NOT A GOVERNMENTAL ENTITY OR IDENTIFIED AS A CHARITABLE ORGANIZATION ON GUIDESTAR, THE DONEE ORGANIZATION IS RESEARCHED TO ASSURE THEIR NOT-FOR-PROFIT STATUS. THE DONEE ORGANIZATION'S MISSION INFORMATION, THEIR FINANCIAL DATA AND THEIR FORM 990 (IF AVAILABLE) IS REVIEWED AND CONSIDERED BY THE BOARD OF DIRECTORS. THE BOARD OF DIRECTORS MUST APPROVE, BY A MAJORITY VOTE OF THE QUORUM IN ATTENDANCE, THE DONATION TO THE ORGANIZATION OR GOVERNMENTAL ENTITY. DURING THE FOLLOWING 12 TO 24 MONTHS AFTER THE DONATION IS DISTRIBUTED, CONTINUED MONITORING OF THE PROJECT OR DONATION RESTRICTIONS, IF APPLICABLE, SHALL BE REPORTED TO THE BOARD OF DIRECTORS. THE DONEE ORGANIZATION'S FORM 990 (IF AVAILABLE) FOR THE YEAR OF THE DONATION AND ANY OTHER SUBSEQUENT YEARS REQUESTED SHALL BE MADE AVAILABLE TO THE BOARD MEMBERS FOR FOLLOW UP REVIEW. X X X X 0 0 0 1 0 0 0 0 0 ROBERT GRAVES MD MEMBER - CHIEF OF MEDICAL STAFF 184262 0 0 0 840 0 9241 0 0 0 194343 0 0 0 KELLY UTLEY CFO 167689 0 0 0 305 0 8475 0 0 0 176469 0 0 0 MATTHEW JANSEN DOCTOR 479943 0 0 0 336 0 1323 0 39894 0 521496 0 0 0 MANDY SHAW MD DOCTOR 331875 0 0 0 205 0 10000 0 0 0 342080 0 0 0 REBECCA L ALLARD MD DOCTOR 339781 0 0 0 254 0 13250 0 39894 0 393179 0 0 0 JAMES THAYER MD DOCTOR 295803 0 40683 0 1663 0 8121 0 27712 0 373982 0 0 0 CRAIG SANDBERG CRNA 253258 0 32350 0 157 0 13250 0 0 0 299015 0 0 0 PART I, LINE 5 DR. JAMES THAYER RECEIVES DRAW ON HIS SALARY BASED ON HIS GROSS CHARGES. THE DRAW IS CALCULATED BY MULTIPLYING THE GROSS CHARGES BY 33% AND SUBTRACTING OFF HIS BASE BIWEEKLY SALARY OF $10,000. ADDITIONALY, HE HAS THE OPPORTUNITY TO EARN A BONUS BASED UPON QUALITY INDICATORS, MEDICAL RECORDS COMPLETION, ETC. SCHEDULE J, PART III: JASON PETIK, CEO, RECEIVES COMPENSATION FROM THE UNIVERSITY OF COLORADO HOSPITAL AUTHORITY, AN UNRELATED ENTITY. THE UNIVERSITY OF COLORADO HOSPITAL AUTHORITY PROVIDES MANAGEMENT SERVICES TO ITS CLIENTS, INCLUDING THE SIDNEY REGIONAL MEDICAL CENTER. THE SIDNEY REGIONAL MEDICAL CENTER'S BOARD OF DIRECTORS SETS THE SALARY AND BENEFITS FOR MR. PETIK. MR. PETIK RECEIVED A SALARY OF $218,578, RETIREMENT BENEFITS OF $7,347, AND NONTAXABLE BENEFITS OF $9,672. MR. PETIK'S SALARY IS REFLECTED IN PART IX, LINE 11A. A THE COUNTY OF DEUEL NEBRASKA 476006452 251476AA5 2014-10-16 10000000 CONSTRUCT HOSPITAL 0 0 0 B THE COUNTY OF CHEYENNE NEBRASKA 476006443 1668ATAA7 2014-09-30 32000000 CONSTRUCT HOSPITAL 0 0 0 A 10000000 10000000 2015 0 0 1 1 B 32000056 212500 31787552 2015 0 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 0 1 0 0 0 1 B 0 0 1 0 0 0 0 0 1 A 1 B 1 PART II, LINE 3, COLUMN B: THE TOTAL PROCEEDS DO NOT AGREE TO THE ISSUE PRICE IN PART I, COLUMN E DUE TO INVESTMENT EARNINGS. KEVIN UTLEY EMPLOYEE OF ORGANIZATION AND SPOUSE OF KELLY UTLEY, CFO 97248 EMPLOYEE COMPENSATION 0 0 FORM 990, PART VI, SECTION A, LINE 3 THE UNIVERSITY OF COLORADO HOSPITAL AUTHORITY CURRENTLY EMPLOYS THE CHIEF EXECUTIVE OFFICER FOR SIDNEY REGIONAL MEDICAL CENTER. EACH MONTH, SRMC PROVIDES THE UNIVERSITY OF COLORADO HOSPITAL AUTHORITY WITH DATA ON SERVICES PROVIDED TO THE COMMUNITY FOR COMPARISON DATA PURPOSES. FORM 990, PART VI, SECTION B, LINE 11B THE ORGANIZATION'S ACCOUNTING DEPARTMENT PROVIDES DOCUMENTATION TO THE INDEPENDENT ACCOUNTING FIRM FOR THE PREPARATION OF THE FORM 990. COMMUNICATIONS BETWEEN THE ACCOUNTING FIRM AND THE ACCOUNTING DEPARTMENT FINALIZE THE PREPARATION OF THE FORM 990. THE CEO AND CFO THEN REVIEW THE FORM 990 AND E-MAIL IT TO ALL MEMBERS OF THE BOARD OF DIRECTORS FOR THEIR REVIEW. ONCE THE 990 RETURN HAS BEEN APPROVED BY ALL PARTIES IT IS SUBMITTED TO THE IRS ON OR BEFORE THE REGULAR OR EXTENDED DUE DATE. FORM 990, PART VI, SECTION B, LINE 12C EACH YEAR ALL BOARD MEMBERS ARE REQUIRED TO DISCLOSE ANY CONFLICTS OF INTEREST. ANY DUALITY OF INTEREST OR POTENTIAL CONFLICT OF INTEREST ON THE PART OF ANY OFFICER, DIRECTOR, COMMITTEE MEMBER, OR ANY KEY EMPLOYEE IS DISCLOSED TO THE BOARD OF DIRECTORS AND MADE A MATTER OF RECORD WHENEVER IT ARISES. WHENEVER IT INVOLVES A MATTER OF BOARD ACTION, ANY OFFICER, DIRECTOR, COMMITTEE MEMBER, OR KEY EMPLOYEE HAVING A DUALITY OF INTEREST OR A POSSIBLE CONFLICT OF INTEREST IN ANY MATTER DOES NOT VOTE OR ABSTAINS FROM THE VOTE, IF PRESENT IN THE ROOM. OFTEN THE BOARD MEMBER IS ASKED TO LEAVE THE MEETING DURING DISCUSSION PERIODS AND FOR THE VOTE ON ISSUES FOR WHICH CONFLICT EXISTS. THESE INDIVIDUALS DO NOT USE THEIR PERSONAL INFLUENCE ON THE MATTERS. FORM 990, PART VI, SECTION B, LINE 15 THE UNIVERSITY OF COLORADO HOSPITAL AUTHORITY PROVIDES ADMINISTRATIVE SERVICES TO SIDNEY REGIONAL MEDICAL CENTER (SRMC). THIS INCLUDES PROVIDING THE HOSPITAL'S CHIEF EXECUTIVE OFFICER. SRMC'S METHOD TO DETERMINE EXECUTIVE SALARY RANGES IS TO ANNUALLY PULL SALARY RANGES FROM NO LESS THAN TWO SURVEY SOURCES (THREE WHEN POSSIBLE) TO DETERMINE THE AVERAGE SALARY RANGE FOR EACH EXECUTIVE POSITION BY GEOGRAPHICAL REGION. THESE ARE REVIEWED AND PRESENTED TO THE HUMAN RESOURCE COMMITTEE OF THE BOARD OF DIRECTORS FOR REVIEW AND APPROVAL/RECOMMENDATIONS. FORM 990, PART VI, SECTION C, LINE 19 THE GOVERNING DOCUMENTS, CONFLICT OF INTEREST POLICY AND FINANCIAL STATEMENTS ARE MADE AVAILABLE UPON REQUEST. ALSO, THE FINANCIAL STATEMENTS ARE SENT ANNUALLY TO COMMUNITY LEADERS. FORM 990, PART VII, SECTION A, LINE 5: JASON PETIK RECEIVES COMPENSATION FROM AN UNRELATED ORGANIZATION, THE UNIVERSITY OF COLORADO HOSPITAL AUTHORITY, WHICH PROVIDES MANAGEMENT SERVICES TO SIDNEY REGIONAL MEDICAL CENTER. FORM 990, PART VII, SECTION A, LINE 1A: ROBERT GRAVES, MD AND CLINTON DORWART, MD ARE PHYSICIANS OF SIDNEY REGIONAL MEDICAL CENTER AND ARE COMPENSATED FOR THE MEDICAL SERVICES THEY PROVIDE. NEITHER IS PAID BY THE HOSPITAL FOR THEIR SERVICE ON THE BOARD OF DIRECTORS. FORM 990, PART IX, LINE 11G PROFESSIONAL FEES - OTHER: PROGRAM SERVICE EXPENSES 4,912,196. MANAGEMENT AND GENERAL EXPENSES 94,548. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 5,006,744. CONTRACT SERVICES - SURGERY PROFESSIONALS: PROGRAM SERVICE EXPENSES 710,713. MANAGEMENT AND GENERAL EXPENSES 0. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 710,713. CONTRACT SERVICES - ANESTHESIA PROFESSIONALS: PROGRAM SERVICE EXPENSES 412,547. MANAGEMENT AND GENERAL EXPENSES 0. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 412,547. RECRUITING FEES: PROGRAM SERVICE EXPENSES 424,145. MANAGEMENT AND GENERAL EXPENSES 0. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 424,145. CONTRACT SERVICES - RADIOLOGY PROFESSIONALS: PROGRAM SERVICE EXPENSES 492,297. MANAGEMENT AND GENERAL EXPENSES 0. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 492,297. FORM 990, PART XI, LINE 2C: THE BOARD OF DIRECTORS ASSUMES THE RESPONSIBILITY FOR OVERSIGHT OF THE AUDIT OF SRMC'S FINANCIAL STATEMENTS AND SELECTION OF AN INDEPENDENT ACCOUNTANT. THIS PROCESS HAS NOT CHANGED SINCE THE PRIOR YEAR. CHEYENNE COUNTY HOSPITAL AND HEALTH CENTER FOUNDATION 1000 POLE CREEK CROSSING SIDNEY NE 69162 470686476 SUPPORT SIDNEY REGIONAL MEDICAL CENTER NE 501(C)(3) LINE 12C, III-FI N/A 0 0 1 1 1 1 0 0 0 0 1 0 0 0 1 1 1 1 0 0