2017-05-12T10:06:59-05:00 2016-06-30 476097913 SEIM JOHNSON LLP 18081 BURT STREET SUITE 200 OMAHA NE 680224722 990 2015-07-01 470533373 COMMUNITY HOSPITAL ASSOCIATION OF MCCOOK COMM 3083442650 1301 EAST H STREET PO BOX 1328 MCCOOK NE 69001 SEAN WOLFE CFO 3083442650 2017-05-08 1 WENDY R COOLEY P01523804 4023302660 2015 2021-01-29 14:40:06Z SEAN WOLFE 1301 EAST H STREET PO BOX 1328 MCCOOK NE 69001 48860010 0 X WWW.CHMCCOOK.ORG X 1974 NE TO EXCEL AT PROVIDING FOR THE HEALTHCARE NEEDS OF OUR REGION THROUGH QUALITY, EFFICIENT AND PATIENT-CENTERED CARE. 10 8 334 0 -313 -313 393937 288218 46713804 47707081 260364 329198 455433 491427 47823538 48815924 122111 92653 0 0 20122655 20756229 0 0 0 24298285 25754444 44543051 46603326 3280487 2212598 67610696 67120803 29283997 26595533 38326699 40525270 REGIONAL HEALTHCARE EXCELLENCE 0 0 38506229 92653 47809986 25-BED CRITICAL ACCESS ACUTE CARE HOSPITAL PROVIDING INPATIENT AND OUTPATIENT CARE, DIAGNOSTIC, REHABILITATION, SURGICAL, NURSERY, VISITING MEDICAL SPECIALISTS, HOME HEALTH AND HOSPICE, TWO RURAL HEALTH CLINICS, AND HEALTH AND EDUCATION PROGRAMS. 38506229 1 1 0 1 0 0 0 0 0 1 1 0 0 0 1 1 0 1 0 0 0 0 0 0 0 0 1 1 1 0 1 0 0 0 0 0 0 1 0 0 0 0 0 0 1 1 1 0 0 1 69 0 1 334 1 0 0 0 0 0 0 0 0 0 0 X 10 8 0 0 0 0 1 1 0 1 1 0 0 1 1 1 1 1 1 1 1 1 1 X SEAN WOLF 3083448306 1301 EAST H - PO BOX 1328 MCCOOK NE 69001 WAYNE WATKINS DVM CHAIRMAN 1.00 0.50 X X 0 0 0 MIKE EILER VICE CHAIRMAN 1.00 0.00 X X 0 0 0 TODD THIESZEN TREASURER 1.00 0.00 X X 0 0 0 MICHAEL LANGAN SECRETARY 1.00 0.00 X X 0 0 0 KRISTI DAUM MEMBER 1.00 0.00 X 0 0 0 WARREN JONES DDS MEMBER 1.00 0.00 X 0 0 0 MIKE LANGAN MEMBER 1.00 0.00 X 0 0 0 CONNIE OLSEN MEMBER 1.00 0.50 X 0 0 0 ROSELYN REMINGTON MD MEMBER 1.00 0.00 X 0 0 0 CURT SWANHORST MEMBER 1.00 0.00 X 0 0 0 BRUCE BAIR MEMBER THRU 12/15 1.00 0.00 X 0 0 0 JAMES ULRICH CEO & PRESIDENT 39.50 0.50 X 245519 0 39326 TROY BRUNTZ CFO & VP OF FINANCE 40.00 0.00 X 172272 0 33891 DR BRENDA KOPRIVA GENERAL SURGEON 40.00 0.00 X 223007 0 28856 BRIAN SMITH DIRECTOR OF ANESTHESIA 40.00 0.00 X 309986 0 40341 CHAD MILLER CRNA ANESTHESIA 40.00 0.00 X 260829 0 39879 EVAN GEILENKIRCHEN CRNA 40.00 0.00 X 264591 0 30597 CHRISTOPHER IHLE ORTHOPEDIC SURGEON 40.00 0.00 X 363956 0 8559 1840160 0 221449 20 0 1 0 MCCOOK CLINIC PC 1401 EAST H STREET MCCOOK NE 69001 MEDICAL PROFESSIONAL - PHYSICIANS 1124777 SOUTHWEST NEBRASKA PHYSICAL THERAPY PC 1301 EAST H STREET MCCOOK NE 69001 PHYSICAL THERAPY SERVICES 1120055 M&B CONSTRUCTION RR1 BOX 88 CULBERTSON NE 68024 CONSTRUCTION SERVICES 391442 PATHOLOGY SERVICES PC BOX 1289 NORTH PLATTE NE 69103 MEDICAL PROFESSIONAL - PATHOLOGY 257517 KEARNEY EYE SURGICAL CENTER 411 W 39TH ST KEARNEY NE 68845 CATARACT SURGICAL SERVICES 192271 13 265696 9392 13130 288218 MEDICARE/MEDICAID PAYMENTS 621400 22933432 22933432 PATIENT SERVICE REVENUE 621400 22199593 22199593 340B PAYMENT 621400 1867453 1867453 EHR INCENTIVE PAYMENT 621400 319970 319970 OUT-SOURCE SERVICES 621400 167569 167569 219064 219064 47707081 357479 357479 249079 3405 245674 245674 245674 12400 40681 -28281 -28281 -28281 CAFETERIA/MEALS 900099 143161 143161 HOUSEKEEPING INCOME 900099 102905 102905 -313 -313 245753 48815924 47809986 -313 718033 X 92653 92653 491008 491008 86642 86642 15374389 12549851 2824538 906299 744358 161941 2587709 2093240 494469 1310182 1042571 267611 40315 40315 94682 94682 6503106 4669235 1833871 230705 25 230680 928981 793281 135700 148445 148445 904768 802415 102353 47145 10101 37044 552206 278703 273503 952133 844422 107711 4696587 4165281 531306 182421 161784 20637 MEDICAL SUPPLIES 8065727 8065727 PROVISION FOR BAD DEBTS 1411283 1411283 MEMBERSHIPS & DUES 42117 42117 953823 652540 301283 46603326 38506229 8097097 0 1685 1765 17442281 18043955 7364053 7292455 1489792 1595088 1006005 952981 70930020 34376188 37809845 36553832 1988610 2275881 312523 383718 195902 21128 67610696 67120803 4061000 3093676 224986 255409 24998011 22448800 0 797648 29283997 26595533 X 38326699 40525270 38326699 40525270 67610696 67120803 X 2212598 -7036 -6991 X X 0 1 X 1 0 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 0 1 0 0 0 0 1 2313 0 1 4065 6378 0 PART II-B, LINE 1: ITEM 1G - JIM ULRICH, CEO, TRAVELED TO WASHINGTON D.C. AND LINCOLN, NE TO ATTEND ADVOCACY EVENTS. ITEM 1I - A PORTION OF DUES PAID TO THE NEBRASKA CHAMBER OF COMMERCE, AMERICAN HOSPITAL ASSOCIATION AND NEBRASKA HOSPITAL ASSOCIATION ARE USED FOR LOBBYING AND POLITICAL ACTIVITIES. MANAGEMENT IS ACTIVE IN NEBRASKA HOSPITAL ASSOCIATION'S PAC, AHA'S ADVOCACY DAY, AND OTHER INDUSTRY FUNCTIONS. 2566458 5544 59250 15224 10534 2633 2602861 2641004 45617 18369 11000 102026 25506 2566458 2419032 5062 359249 113871 28468 2641004 2243200 5955 257537 70128 17532 2419032 2335881 6653 -30823 54809 13702 2243200 0.39220 0.60780 0.00000 0 1 1 76468 76468 25944318 16842663 9101655 42991969 17533525 25458444 1917265 1917265 36553832 ESTIMATED THIRD-PARTY PAYOR SETTLEMENTS 797648 797648 X PART V, LINE 4: THE ENDOWMENT FUNDS ARE HELD BY THE COMMUNITY HOSPITAL HEALTH FOUNDATION OF MCCOOK (A RELATED PARTY) AND ARE USED IN SUPPORT OF THE HOSPITAL'S PROGRAMS AND PROJECTS, INCLUDING PROPERTY AND EQUIPMENT PURCHASES, SCHOLARSHIPS, HOSPICE PROGRAMS, REHABILITATION SERVICES AND OTHERS. PART X, LINE 2: THE HOSPITAL AND FOUNDATION ARE NOT-FOR-PROFIT CORPORATIONS AS DESCRIBED IN SECTION 501(C)(3) OF THE INTERNAL REVENUE CODE AND ARE 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 AND FOUNDATION TO MEET A COMMUNITY BENEFIT STANDARD AND COMPLY WITH VARIOUS LAWS AND REGULATIONS. RED WILLOW IS A FOR-PROFIT CORPORATION. RED WILLOW HAD $17,272 AND $6,741 OF TAXABLE INCOME; INCURRED AND PAID $2,591 AND $1,011 OF FEDERAL INCOME TAX; AND INCURRED AND PAID $964 AND $376 OF STATE INCOME TAX FOR THE FISCAL YEARS ENDING DECEMBER 31, 2015 AND 2014, RESPECTIVELY. AS OF JUNE 30, 2016, RED WILLOW HAD NO TAX LIABILITY. THE HOSPITAL, FOUNDATION AND RED WILLOW ACCOUNT FOR UNCERTAINTIES IN ACCOUNTING FOR INCOME TAX ASSETS AND LIABILITIES USING GUIDANCE INCLUDED IN FASB ASC 740, INCOME TAXES. THE HOSPITAL, FOUNDATION AND RED WILLOW RECOGNIZE THE EFFECT OF INCOME TAX POSITIONS ONLY IF THOSE POSITIONS ARE MORE LIKELY THAN NOT OF BEING SUSTAINED. AT JUNE 30, 2016 AND 2015, THE HOSPITAL, FOUNDATION AND RED WILLOW HAD NO UNCERTAIN TAX POSITIONS ACCRUED. 1 1 1 X 0 1 1 1 0 1 1 898251 898251 0.01990 2240971 2145712 95259 0.00210 3139222 2145712 993510 0.02200 197368 20720 176648 0.00390 558 558 0.00000 107297 107297 0.00240 305223 20720 284503 0.00630 3444445 2166432 1278013 0.02830 0 1411283 211692 20043089 20314292 -271203 X 1 1 1 1 COMMUNITY HOSPITAL ASSOCIATION OF MCCOOK 1301 EAST H STREET - PO BOX 1328 MCCOOK NE 69001 WWW.CHMCCOOK.ORG 320007 X X X X COMMUNITY HOSPITAL ASSOCIATION OF MCCOOK 1 0 0 1 X X X X X X X X X 13 1 0 0 1 X WWW.CHMCCOOK.ORG X 1 13 1 HTTPS://CHMCCOOK.ORG/ABOUT-US/COMMUNITY-HEALTH-NEEDS-ASSESSMENT 0 0 1 X 150.000000000000 X 1 1 X X X 1 X WWW.CHMCCOOK.ORG X X X 1 X 0 X X X X 1 X 0 0 COMMUNITY HOSPITAL ASSOCIATION OF MCCOOK PART V, SECTION B, LINE 5: IN CONDUCTING THE CHNA THE HOSPITAL COLLECTED DATA FROM A VARIETY OF SOURCES, INCLUDING CENSUS DATA AND HEALTH DATA FROM OTHER AGENCIES TO BEGIN THE BASIS OF OUR ASSESSMENT. WE THEN FORMULATED A STUDY DESIGNED SPECIFICALLY TO DRAW TO THE SURFACE OUR AREA'S NEEDS ACCORDING TO ITS COMMUNITY MEMBERS, HEALTHCARE PROVIDERS AND PARTNERS, WHICH INCLUDED A TELEPHONE SURVEY, FOCUS GROUPS FOR BOTH COMMUNITY MEMBERS AND THE HEALTHCARE COMMUNITY, ALONG WITH KEY INFORMANT INTERVIEWS OF COMMUNITY LEADERS. COMMUNITY HOSPITAL ASSOCIATION OF MCCOOK PART V, SECTION B, LINE 11: PRIORITY 1: INCREASED AVAILABILITY OF SPECIALTY DOCTORS, INCLUDING THE AVAILABILITY OF A FULL-TIME ORTHOPEDIC SURGEON. THE IMPACT OF THIS PRIORITY WOULD CREATE AN INCREASED AWARENESS OF COMMUNITY HOSPITAL'S SPECIALISTS, ESPECIALLY FOR THOSE WHO ARE UNDERSERVED IN OUR COMMUNITY. DURING THIS FISCAL YEAR, IN ORDER TO MEET THE NEEDS OF THIS SPECIFICALLY IDENTIFIED NEED WE BEGAN BY INCREASING EFFORTS FOR AWARENESS OF AVAILABLE SPECIALISTS. TO BETTER UNDERSTAND THE REACH OF OUR MARKETING TOOLS BY TRACKING HITS TO OUR SPECIALISTS PAGE ON OUR WEBSITE THROUGH GOOGLE ANALYTICS. WE ALSO HAD AN AD THAT SHOWCASES OUR VISITING SPECIALISTS REGULARLY PRINTED IN ALL AREA NEWSPAPER, ONE TIME EACH QUARTER. NEW COMERS TO THE AREA ALSO RECEIVED A PRINTED VERSION OF THIS ADVERTISEMENT. A SIGNIFICANT ACCOMPLISHMENT FOR THIS FISCAL YEAR WAS THE RECRUITMENT OF AND ONBOARDING OF A FULL-TIME ON-SITE ORTHOPEDIC SURGEON, DR. CHRISTOPHER IHLE. OUR SPECIALIST LIST CONTINUED TO GROW AND INCLUDED THE FOLLOWING SPECIALTIES: CARDIOLOGY DERMATOLOGY EAR, NOSE, AN THROAT GASTROENTEROLOGY OBSTETRICS AND GYNECOLOGY OPTHAMOLOGY ORTHOPEDICS PODIATRY PROSTHETICS AND ORTHOTICS ONCOLOGY, BOTH MEDICAL AND RADIATION UROLOGYPRIORITY 2: WELLNESS EDUCATION AND SERVICES, INCLUDING EXERCISE, NUTRITION, AND WEIGHT MANAGEMENT PROGRAMS. THE IMPACT OF THIS PRIORITY WOULD ENGAGE OUR COMMUNITY IN A CULTURE OF WELLNESS THROUGH WELLNESS-CENTERED ACTIVITIES, SPONSORSHIPS, CLASSES AND EDUCATIONAL MATERIALS, ESPECIALLY THOSE INDIVIDUALS WHO ARE UNDERSERVED IN OUR COMMUNITY. DURING THIS FISCAL YEAR WE BEGAN TO ROLL-OUT A WELLNESS PROGRAM TAILORED TO THE NEEDS OF OUR AREA SMALL BUSINESSES. UTILIZING THE MAILING LIST FROM THE LOCAL AREA CHAMBER OF COMMERCE INVITATIONS WERE SENT TO PARTICIPATE IN VARIOUS WELLNESS-BASED CHALLENGES, SUCH AS WALKING MONTH WHICH WAS SPONSORED BY THE AMERICAN HEART ASSOCIATION. OVER 100 PARTICIPANTS TOOK PART IN THE CHALLENGE AND WON WELLNESS FOR LIFE SHIRTS FOR COMPLETING THE REQUIREMENTS OF 150 MINUTES OF EXERCISE EACH WEEK. THE PUBLIC, INCLUDING THESE SMALL BUSINESSES, WERE INVITED TO JOIN COMMUNITY HOSPITAL IN THEIR CELEBRATION OF WELLNESS WEEK BY ATTENDING EDUCATIONAL CLASSES ABOUT NUTRITION, WEIGHT MANAGEMENT, AND STRESS REDUCTION, AS WELL AS GROUP EXERCISE CLASSES. THE FROG (FITNESS REACHING OLDER GENERATIONS) PROGRAM CONTINUED TO GROW WITH THE FINANCIAL AND EMPLOYEE SUPPORT OF COMMUNITY HOSPITAL. WITH NINE AREA LOCATIONS AND AN ESTIMATED 90+ PARTICIPANTS EACH WEEK THE PROGRAM HELPS PARTICIPANTS TO MAINTAIN MUSCLE MASS, REDUCE THEIR RISK OF FALLS, AND INCREASE OVERALL WELLNESS. DURING THIS FISCAL YEAR A NEW FITNESS SERIES WAS CREATED CALL THE REPUBLICAN RIVER FITNESS SERIES. COMMUNITY HOSPITAL IS A PREMIERE SPONSOR OF THE SERIES WHICH PROMOTES PHYSICAL ACTIVITY AND OVERALL WELLNESS. THE SERIES PUTS TOGETHER TEN WALKING AND/OR RUNNING ACTIVITIES RANGING FROM 5KS TO HALF MARATHONS. PRIORITY 3: CARE FOR THE ELDERLY IN OUR COMMUNITY, SPECIFICALLY IN-HOME CARE. THE IMPACT OF THIS PRIORITY WOULD POTENTIALLY HELP TO FILL THE NEED FOR IN-HOME CARE, ESPECIALLY FOR THOSE WHO ARE UNDERSERVED IN OUR COMMUNITY. IT WOULD ALSO OPEN THE COMMUNICATION TO ACCESSIBILITY TO THESE TYPES OF SERVICES TO OUR COMMUNITY AT-LARGE. DURING THE FISCAL YEAR THE HOME HEALTH & HOSPICE STAFF WORKED TO CREATE A DATABASE OF PROVIDERS IN THE SURROUNDING AREAS WHO PROVIDE SERVICES RANGING FROM DAILY ERRANDS TO MEAL PREPARATION TO BATHING AND CLEANING. THE LIST WAS THEN PUBLISHED ON COMMUNITY HOSPITAL'S WEBSITE FOR THE PUBLIC TO ACCESS. OTHER AREA PROVIDERS WERE GIVEN ACCESS TO THIS INFORMATION AS WELL TO INCREASE THE AWARENESS OF THE SERVICES.THROUGHOUT THE PROCESS OF COLLECTING DATA FOR THE COMMUNITY HEALTH NEEDS ASSESSMENT, AND THROUGHOUT THE FISCAL YEAR, THE NEED FOR ADDITIONAL SERVICES IN THE AREAS OF BEHAVIORAL AND MENTAL HEALTH CONTINUED TO ARISE. THIS IS A CONCERN AREA FOR OUR COMMUNITY, AND OUR STATE OF NEBRASKA. THE NUMBER OF PROVIDERS AND AVAILABILITY OF INPATIENT CARE IS EXTREMELY LIMITED. COMMUNITY HOSPITAL CONTINUES TO BE A STRONG ADVOCATE FOR THIS ISSUE AT THE STATE AND NATIONAL LEVEL. THROUGH THE NEBRASKA HOSPITAL ASSOCIATION POLITICAL ACTION COMMITTEE (NHA PAC) WE DONATE DOLLARS FOR TIME TO ADVOCATE FOR ISSUES, SUCH AS THIS. OUR CEO, JIM ULRICH, ALSO ADVOCATES AT THE NATIONAL LEVEL AT AMERICAN HOSPITAL ASSOCIATION FUNCTIONS IN WASHINGTON D.C. COMMUNITY HOSPITAL ASSOCIATION OF MCCOOK PART V, SECTION B, LINE 16I: THE HOSPITAL PUBLICIZED THE FINANCIAL ASSISTANCE POLICY ON BILLING INVOICES, ON POSTERS IN THE ER AND WAITING ROOMS, AT THE ADMISSIONS DESKS, INCLUDING UPON ADMISSIONS WITH SUMMARY NOTICES OF THE POLICIES. THE COMPLETE POLICY WAS AVAILABLE ON THE HOSPITAL'S WEBSITE AND UPON REQUEST. THE HOSPITAL ALSO PUBLICIZED THE POLICY THROUGH REFERRALS BY CLINICAL, SOCIAL WORKERS, AND OTHER STAFF TO THE HOSPITALS FINANCIAL COUNSELORS. COMMUNITY HOSPITAL ASSOCIATION OF MCCOOK PART V, SECTION B, LINE 22D: THE HOSPITAL GRANTED 100% FREE CARE TO FAP ELIGIBLE INDIVIDUALS. 3 1 - COMMUNITY HEALTHCARE & HOSPICE 407 WEST 5TH STREET MCCOOK NE 69001 HOME HEALTH AND HOSPICE SERVICES 3 - CURTIS MEDICAL CENTER 302 EAST 6TH STREET CURTIS NE 69025 RURAL HEALTH CLINIC-OUTPATIENT SERVICES 4 - TRENTON MEDICAL CLINIC 406 EAST 1ST STREET TRENTON NE 69044 RURAL HEALTH CLINIC-OUTPATIENT SERVICES PART I, LINE 3C: CHARITY CARE IS GRANTED TO ALL INDIVIDUALS WHOSE HOUSEHOLD INCOME IS BELOW 150% OF THE FEDERAL POVERTY GUIDELINE AT THE 100% WRITE-OFF LEVEL. DISCOUNTING OR 100% WRITE-OFF TO CHARITY CARE IS ALLOWED ABOVE 150% OF THE FEDERAL POVERTY GUIDELINE BASED ON AN ANALYSIS OF INDIVIDUAL NEED AND DETERMINATION OF THE PATIENT BEING MEDICALLY INDIGENT; THIS ANALYSIS INCLUDES FACTORS SUCH AS INCOME, ACCESSIBLE ASSETS, MEDICAL OR/AND OTHER DEBTS, THE LIKELIHOOD OF ONGOING MEDICAL CARE AND THE INDIVIDUAL'S OVERALL ABILITY TO PAY. PART I, LINE 6A: THE COMMUNITY BENEFIT REPORT IS PREPARED BY THE STAFF OF COMMUNITY HOSPITAL ASSOCIATION OF MCCOOK. PART I, LN 7 COL(F): THE BAD DEBT EXPENSE INCLUDED IN FORM 990, PART IX, LINE 25 BUT NOT INCLUDED IN SCHEDULE H, PART I, LINE 7, COLUMN (F) IS $1,411,283. PART II, COMMUNITY BUILDING ACTIVITIES: COMMUNITY HOSPITAL SUPPORTS VARIOUS COMMUNITY BUILDING ACTIVITIES, PRIMARILY THROUGH MONETARY SUPPORT. EXAMPLES INCLUDE SUPPORT TO THE ECONOMIC DEVELOPMENT CORPORATION, THE LOCAL COMMUNITY COLLEGE AND INVEST NEBRASKA. THESE PROGRAMS DIRECTLY IMPACT THE HEALTH OF OUR COMMUNITY BY DEVELOPMENT OF EMPLOYMENT OPPORTUNITIES AND A MORE EMPLOYABLE WORKFORCE. MEMBERS OF OUR COMMUNITY WITH GOOD EMPLOYMENT HAVE ACCESS TO HEALTH INSURANCE AND ARE GENERALLY ABLE TO LIVE HEALTHIER LIVES. 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: BASED ON A COMBINATION OF PAST EXPERIENCE AND CENSUS DATA AVAILABLE, THE HOSPITAL ESTIMATES 15% OF BAD DEBT IS ATTRIBUTABLE TO PATIENTS ELIGIBLE UNDER THE HOSPITAL'S FINANCIAL ASSISTANCE POLICY. IN ACCORDANCE WITH ITS MISSION OBJECTIVES, THE HOSPITAL PROVIDES FINANCIAL ASSISTANCE TO PATIENTS WHO LACK FINANCIAL RESOURCES TO PAY FOR THE SERVICES THEY RECEIVE, AND THE HOSPITAL RECOGNIZES THE SPECIAL CONCERNS OF INDIVIDUALS AND HOUSEHOLDS WITH LIMITED FINANCIAL RESOURCES OR WHO ARE OTHERWISE VULNERABLE WITHIN THE COMMUNITY THE HOSPITAL SERVICES. FINANCIAL ASSISTANCE IS PROVIDED TO PATIENTS WITH DEMONSTRATED INABILITY TO PAY AS CONTRASTED WITH BAD DEBT THAT RESULTS FROM AN UNWILLINGNESS TO PAY; THUS, CHARITY CARE DOES NOT INCLUDE BAD DEBT. PART III, LINE 4: THE ORGANIZATION'S FINANCIAL STATEMENTS DO NOT CONTAIN A SPECIFIC FOOTNOTE DESCRIBING BAD DEBT. HOWEVER, PAGES 9 AND 11 OF THE ATTACHED AUDITED FINANCIAL STATEMENTS INCLUDE FOOTNOTES TITLED "PATIENT RECEIVABLES, NET," "NET PATIENT SERVICE REVENUE, AND "CHARITY CARE". PART III, LINE 8: THE SOURCE USED TO DETERMINE THE AMOUNT REPORTED ON LINE 6 WAS THE MEDICARE COST REPORT. NO MEDICARE SHORTFALL IS TREATED AS COMMUNITY BENEFITS. PART III, LINE 9B: COMMUNITY HOSPITAL GRANTS 100% CHARITY CARE FOR PATIENTS KNOWN TO QUALIFY FOR FINANCIAL ASSISTANCE. OUR CHARITY CARE POLICY IS SET AT 150% OF THE FEDERAL POVERTY GUIDELINE BASED FAMILY SIZE. FOR PATIENTS THAT EXCEED THE INCOME THRESHOLD OF THE CHARITY CARE POLICY, OUR MEDICALLY INDIGENT FINANCIAL ASSISTANCE IS AVAILABLE FOR PATIENTS THAT HAVE INCURRED CATASTROPHIC MEDICAL COSTS OR OTHER OBLIGATIONS (PRESENTLY OR ONGOING) THAT HAVE SUBSTANTIALLY REDUCED THEIR ABILITY TO PAY. IN SUCH CASES, THE INDIVIDUAL OR GUARANTOR MAY BE DETERMINED BY THE HOSPITAL TO BE MEDICALLY INDIGENT AND MAY, AT THE HOSPITAL'S DISCRETION, BE ELIGIBLE FOR FINANCIAL ASSISTANCE IN THE FORM OF FREE OR DISCOUNTED LIABILITIES.CERTAIN CLASSES OF PATIENTS ARE DEEMED TO HAVE QUALIFIED FOR CHARITY CARE WITHOUT AN APPLICATION. ACCOUNTS THAT MAY QUALIFY FOR FINANCIAL ASSISTANCE WITHOUT A COMPLETED APPLICATION INCLUDE:1. MEDICAID SHARE OF COST PORTIONS.2. MEDICAID APPLICATIONS APPROVED FOR SUBSEQUENT CARE (NOT RETROACTIVE TO THE LIABILITY).3. PATIENTS OR GUARANTORS WHO HAVE DECLARED BANKRUPTCY.4. PATIENTS OR GUARANTORS WHO ARE DECEASED WITH NO ESTATE IN PROBATE AND FOR WHOM NO ONE ELSE (SUCH AS A SPOUSE OR LEGAL GUARDIAN) IS LEGALLY RESPONSIBLE FOR THE LIABILITY.5. PATIENTS OR GUARANTORS DETERMINED TO BE HOMELESS. PART VI, LINE 2: COMMUNITY HOSPITAL HAS COMPLETED A COMMUNITY HEALTH NEEDS ASSESSMENT. ACTION PLANS ARE IN PLACE TO ADDRESS SEVERAL OF THE IDENTIFIED NEEDS IN THE REPORT. PART VI, LINE 3: IDENTIFICATION OF PATIENTS WITH A POTENTIAL NEED FOR FINANCIAL ASSISTANCE WILL BE ACCOMPLISHED BY BOTH AN OPEN AND PUBLICIZED APPLICATION PROCESS AND A VARIETY OF SCREENING OPPORTUNITIES INCLUDING:A. ADMISSIONS/REGISTRATION PERSONNEL BASED UPON INFORMATION RECEIVED DURING THE REGISTRATION PROCESS.B. SOCIAL SERVICES PERSONNEL BASED UPON INFORMATION DURING THE INITIAL VISIT AND DISCHARGE PLANNING.C. NURSING STAFF BASED UPON INFORMATION RECEIVED DURING DISCUSSIONS WITH FAMILY AND/OR PATIENT.D. BUSINESS OFFICE PERSONNEL BASED UPON STATUS OF ACCOUNTS AND DISCUSSIONS WITH RESPONSIBLE PARTY.E. ACCOUNTS RECEIVABLE REPORTS.HOSPITAL STAFF OR THE NOTIFIED PATIENT ADVOCATE WILL EDUCATE THE PATIENT OR GUARANTOR ABOUT THE FINANCIAL ASSISTANCE POLICY AND WILL PROVIDE THEM AN APPLICATION FOR FINANCIAL ASSISTANCE. IF NECESSARY, THE PATIENT FINANCIAL COUNSELOR OR OTHER HOSPITAL STAFF MAY ASSIST THE PATIENT IN COMPLETING THE APPLICATION; HOWEVER, THE COMPLETION OF AN APPLICATION AND PROVIDING ALL NECESSARY SUPPORTING DOCUMENTATION IS THE PATIENT'S RESPONSIBILITY. PATIENTS MAY ALSO REQUEST AN APPLICATION OR ADDITIONAL INFORMATION IN PERSON AT THE ADMISSIONS OFFICE OR BY CALLING OR WRITING THE PATIENT FINANCIAL COUNSELOR AND AN APPLICATION WILL BE MAILED. PART VI, LINE 4: COMMUNITY HOSPITAL SERVES A PRIMARY MARKET OF RED WILLOW COUNTY, WHICH IS LOCATED ON THE SOUTHERN BORDER OF NEBRASKA. IT IS 717 SQUARE MILES AND HAS APPROXIMATELY 15.0 PEOPLE PER SQUARE MILE. MCCOOK IS THE COUNTY SEAT. COMMUNITY HOSPITAL ALSO SERVES A SECONDARY MARKET INCLUDING NORTHERN KANSAS AND SOUTHWEST NEBRASKA, WHICH CONSISTS OF FURNAS, NE, HITCHCOCK, NE, DECATUR, KS, CHEYENNE, KS, FRONTIER, NE, RAWLINS, KS AND HAYES, NE. THE TOTAL ESTIMATED POPULATION FOR COMMUNITY HOSPITAL'S SERVICE AREA IS APPROXIMATELY 30,348. RED WILLOW COUNTY HAS A POPULATION OF APPROXIMATELY 10,747. THE GROUP OF COUNTIES WHICH MAKE UP THE SECONDARY MARKET FOR COMMUNITY HOSPITAL HAVE A POPULATION OF APPROXIMATELY 19,601. THE HOUSEHOLD INCOME AVERAGES FOR THESE AREAS ARE AS FOLLOWS:14.3% $0 - 15K11.4% $15K - 25K30.5% $25K - 50K19.1% $50K - 75K9.5% $75K - 100K15.3% $100K+ PART VI, LINE 5: COMMUNITY HOSPITAL IS THE LARGEST HOSPITAL WITHIN AN HOUR TRAVEL TIME FOR MOST OF THE COMMUNITY SERVED. THE HOSPITAL PROVIDES THE PHYSICIANS OF MCCOOK A HOSPITAL IN WHICH TO PRACTICE MEDICINE. WITHOUT THE HOSPITAL OUR PATIENTS WOULD HAVE EXTREMELY LONG DISTANCES TO TRAVEL FOR EVERYTHING FROM EMERGENCY TO ROUTINE CARE. OUR HOSPITAL IS OVERSEEN BY A NON-COMPENSATED BOARD OF INDEPENDENT COMMUNITY MEMBERS. ANY PROFITS FROM THE OPERATION OF THE HOSPITAL ARE REINVESTED BACK INTO THE FACILITIES, EQUIPMENT AND STAFF TO PROVIDE OUR COMMUNITY WITH CURRENT AND HIGH QUALITY MEDICAL SERVICES CLOSE TO HOME. PART VI, LINE 6: N/A PART VI, LINE 7, REPORTS FILED WITH STATES NE 1 RED WILLOW COUNTY FAIR BOARD 1412 WEST 5TH STREET MCCOOK NE 69001 476006500 GOVERNMENT 15000 SPONSORSHIP OF THE CONCERT AT THE COUNTY FAIR. MAKE A WISH NEBRASKA 11836 ARBOR STREET OMAHA NE 68144 470671096 501(C)(3) 5000 SUPPORT THE MAKE-A-WISH PROGRAM IN NEBRASKA. NEBRASKA COMMUNITY FOUNDATION PO BOX 36 MCCOOK NE 69001 470769903 501(C)(3) 9750 TO SUPPORT ECONOMIC DEVELOPMENT ACTIVES WITHIN THE COMMUNITY CAMPAIGN. MCCOOK ECONOMIC DEVELOPMENT CORPORATION 301 NORRIS AVE STE 200 MCCOOK NE 69001 470685662 501(C)(4) 12000 PROMOTE ECONOMIC DEVELOPMENT ACTIVES THAT RECRUIT, STRENGTH AND EXPAND AREA BUSINESSES THAT ARE VITAL TO OUR COMMUNITY'S LONG TERM SUCCESS. ROCKY MOUNTAIN PERFORMANCE EXCELLENCE 4100 JACKSON STREET DENVER CO 80216 841543649 501(C)(3) 10000 RMPEX GUIDES ORGANIZATIONS AND VOLUNTEERS TO PERFORMANCE EXCELLENCE BY PROVIDING EDUCATION, TRAINING, NETWORKING, AND SHARING OF BEST PRACTICES LEADING TO ASSESSMENT AND FEEDBACK, WHICH RESULT IN CONTINUOUS IMPROVEMENT, RECOGNITION, AND AWARDS. COMMUNITY HOSPITAL HEALTH FOUNDATION PO BOX 1328 MCCOOK NE 69001 470693261 501(C)(3) 12050 TO SUPPORT THE MISSION OF THE FOUNDATION 5 1 PART I, LINE 2: GRANTS ARE MADE ONLY TO SELECTED CHARITABLE OR OTHER EXEMPT ORGANIZATIONS. COMMUNITY HOSPITAL ASSOCIATION ENTERS INTO AGREEMENTS WITH GRANTEES THAT GRANT FUNDS WILL BE RESTRICTED TO SPECIFIED EXEMPT PURPOSES. X X X X 0 0 0 0 0 0 0 0 0 JAMES ULRICH CEO & PRESIDENT 244709 0 0 0 810 0 17535 0 21791 0 284845 0 0 0 TROY BRUNTZ CFO & VP OF FINANCE 171494 0 0 0 778 0 12473 0 21418 0 206163 0 0 0 DR BRENDA KOPRIVA GENERAL SURGEON 222691 0 0 0 316 0 16173 0 12683 0 251863 0 0 0 BRIAN SMITH DIRECTOR OF ANESTHESIA 309500 0 0 0 486 0 18550 0 21791 0 350327 0 0 0 CHAD MILLER CRNA ANESTHESIA 260343 0 0 0 486 0 18088 0 21791 0 300708 0 0 0 EVAN GEILENKIRCHEN CRNA 263625 0 0 0 966 0 9640 0 20957 0 295188 0 0 0 CHRISTOPHER IHLE ORTHOPEDIC SURGEON 363956 0 0 0 0 0 0 0 8559 0 372515 0 0 0 JESSICA JOHNSON JESSICA JOHNSON IS THE DAUGHTER OF WAYNE WATKINS, BOARD MEMBER 50689 EMPLOYEE W-2 WAGES 0 HANNAH SWANHORST HANNAH SWANHOSRT IS THE DAUGHTER OF CURT SWANHORST, BOARD MEMBER 35953 EMPLOYEE W-2 WAGES 0 FORM 990, PART VI, SECTION A, LINE 6 THE MEMBERS CONSIST OF ALL PERSONS WHO CONTRIBUTE TO THE BUILDING AND IMPROVEMENT FUND OF THE CORPORATION, AT ANY TIME DURING THE EXISTENCE OF THE CORPORATION, NOT LESS THAN THE SUM OF $100. FORM 990, PART VI, SECTION A, LINE 7A THE MEMBERS ELECT THE BOARD OF DIRECTORS AT THE ANNUAL MEETING EACH YEAR. FORM 990, PART VI, SECTION B, LINE 11 COMMUNITY HOSPITAL'S FORM 990, 990-T AND NEBRASKA INCOME TAX FORMS ARE PREPARED BY THE PUBLIC ACCOUNTING FIRM SEIM JOHNSON. MANAGEMENT RECEIVES DRAFT COPIES OF THE COMPLETED FORMS FOR REVIEW. AFTER HOSPITAL MANAGEMENT HAS REVIEWED THE RETURNS, COMPLETE COPIES ARE DISTRIBUTED TO ALL MEMBERS OF THE BOARD OF DIRECTORS OF THE COMMUNITY HOSPITAL ASSOCIATION AND THE RETURNS ARE APPROVED FOR FILING BY THE BUDGET & FINANCE COMMITTEE OF THE BOARD (A STANDING COMMITTEE WITH RESPONSIBILITY TO OVERSEE FINANCIAL, AUDIT, TAXATION AND BUDGET MATTERS OF THE HOSPITAL). BOARD COMMITTEE APPROVAL IS REQUIRED PRIOR TO SIGNATURE AND SUBMISSION OF THE RETURNS TO THE IRS AND STATE TAXING AUTHORITIES. FORM 990, PART VI, SECTION B, LINE 12C THE COMMUNITY HOSPITAL ASSOCIATION'S CODE OF CONDUCT REQUIRES ALL EMPLOYEES, CONTRACTORS, AND AGENTS TO REPORT ANY CONFLICTS OF INTEREST THAT ARISE. IN ADDITION, THE ASSOCIATION HAS A CONFLICT OF INTEREST POLICY APPLICABLE TO DIRECTORS, OFFICERS, MEMBERS OF COMMITTEES AND SUBCOMMITTEES WITH BOARD-DELEGATED POWERS, AND KEY EMPLOYEES THAT REQUIRES, AMONG OTHER THINGS, ALL APPLICABLE PERSONS DISCLOSE ANY RELATIONSHIPS THAT MAY CREATE A CONFLICT OF INTEREST AND ARE REQUIRED TO COMPLETE AN ANNUAL DISCLOSURE OF ALL SUCH RELATIONSHIPS. ALL SUCH RELATIONSHIPS ARE DISCLOSED TO THE ENTIRE BOARD AND SENIOR MANAGEMENT, AND ANY AND ALL CONFLICTS OR POTENTIAL CONFLICTS ARE MONITORED BY SENIOR MANAGEMENT AND THE ASSOCIATION'S COMPLIANCE FUNCTION. FORM 990, PART VI, SECTION B, LINE 15 COMMUNITY HOSPITAL'S PROCESS FOR DETERMINING THE COMPENSATION OF THE CEO IS AS FOLLOWS: THE EXECUTIVE COMMITTEE OF THE BOARD OF DIRECTORS IS RESPONSIBLE FOR SETTING THE SALARY OF THE CEO. ANNUALLY, THE COMMITTEE CONDUCTS A REVIEW OF THE CEO'S PERFORMANCE, ABILITIES, AND OVERALL EFFECTIVENESS. THE COMMITTEE IS PRESENTED WITH SALARY AND COMPENSATION SURVEY DATA THAT IS COMPILED BY THE CEO AND THE HUMAN RESOURCE DEPARTMENT AND THE ACCURACY OF WHICH IS ATTESTED TO BY THE CFO. MULTIPLE SOURCES OF SURVEY DATA ARE USED, INCLUDING INFORMATION FROM THE NEBRASKA AND IOWA HOSPITAL ASSOCIATIONS, WHICH IS BROKEN DOWN TO SIMILARLY QUALIFIED PERSONS IN COMPARABLE POSITIONS AT SIMILARLY SIZED AND SITUATED ORGANIZATIONS. ALL SOURCE DOCUMENTATION IS GIVEN TO THE COMMITTEE AS WELL AS SUMMARIES PROVIDED FOR EASE OF REFERENCE. THE EXECUTIVE COMMITTEE CONDUCTS THE PERFORMANCE REVIEW WITH THE CEO; THEN MEETS IN PRIVATE CHAMBERS TO DISCUSS THE REVIEW AND TO DELIBERATE ANY AND ALL CHANGES TO THE EMPLOYMENT AGREEMENT, INCLUDING COMPENSATION, AND GOALS FOR THE FOLLOWING YEAR. CONTEMPORANEOUS RECORDS ARE KEPT OF ALL SURVEY AND COMPARABILITY DATA USED, AND THE RESULTS AND DECISIONS OF THE EXECUTIVE COMMITTEES MEETING ON COMPENSATION. COMPENSATION OF EMPLOYEES BELOW THE ROLE OF CEO ARE DETERMINED THROUGH THE USE OF SURVEY INFORMATION OF SIMILARLY QUALIFIED PERSONS IN COMPARABLE POSITIONS AT SIMILARLY SIZED AND SITUATED ORGANIZATIONS. THE CEO SETS THE COMPENSATION OF SENIOR MANAGEMENT BASED ON THOSE SURVEYS, TAKING IN CONSIDERATION PERFORMANCE AND EXPERIENCE OF EACH INDIVIDUAL. COMPENSATION RANGES OF EMPLOYEES BELOW SENIOR MANAGEMENT ARE SET BY HUMAN RESOURCES BASED ON MARKET WAGE RATES FOR SIMILARLY QUALIFIED PERSONS IN COMPARABLE POSITIONS AT SIMILARLY SIZED AND SITUATED ORGANIZATIONS. ALL EMPLOYEES HAVE AN ANNUAL REVIEW BY THEIR SUPERVISOR, WHICH DETERMINE WHERE IN THE SALARY RANGE AN EMPLOYEE WILL FALL. ALL SALARY RANGES, INCLUDING THOSE OF SENIOR MANAGEMENT, ARE ULTIMATELY APPROVED BY THE BOARD OF DIRECTORS DURING THE APPROVAL OF THE ANNUAL OPERATING BUDGET. FORM 990, PART VI, SECTION C, LINE 19 COMMUNITY HOSPITAL MAKES ITS GOVERNING DOCUMENTS, CONFLICT OF INTEREST POLICY, FORM 990 & 990-T (CURRENT AND PAST YEARS AS REQUIRED BY LAW) AND FINANCIAL STATEMENTS AVAILABLE TO THE PUBLIC UPON REQUEST. ANY INDIVIDUAL WHO WOULD LIKE A COPY OF ANY OF THE ABOVE MENTIONED DOCUMENTS MAY INSPECT THOSE DOCUMENTS IN PERSON AT THE HOSPITAL DURING NORMAL BUSINESS HOURS, OR REQUEST A COPY OF ANY OF THE ABOVE INFORMATION IN PERSON, BY PHONE, OR BY MAIL, AND WE WILL PROVIDE A COPY FREE OF CHARGE. FORM 990, PART IX, LINE 11G MISCELLANEOUS FEES FOR SERVICE: PROGRAM SERVICE EXPENSES 1,167,017. MANAGEMENT AND GENERAL EXPENSES 973,868. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 2,140,885. PHYSICIAN FEES: PROGRAM SERVICE EXPENSES 1,624,615. MANAGEMENT AND GENERAL EXPENSES 0. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 1,624,615. MAINTENANCE CONTRACTS: PROGRAM SERVICE EXPENSES 799,851. MANAGEMENT AND GENERAL EXPENSES 860,003. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 1,659,854. PT CONTRACT SERVICES: PROGRAM SERVICE EXPENSES 1,077,752. MANAGEMENT AND GENERAL EXPENSES 0. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 1,077,752. FORM 990, PART XI, LINE 9: GAIN/LOSS ON JOINT VENTURE -8,173. BOOK/TAX DIFFERENCE ON PARTNERSHIP INTEREST 1,182. FORM 990, PART XII, LINE 2C COMMUNITY HOSPITAL HAS A STANDING BOARD COMMITTEE, THE BUDGET AND FINANCE COMMITTEE, WHICH HAS THE AUTHORITY AND ASSUMES THE RESPONSIBILITY FOR THE SELECTION OF THE INDEPENDENT ACCOUNTING FIRM AND ALL RELATED OVERSIGHT, COMMUNICATION, AND REPORTING. THIS COMMITTEE APPROVES ALL ENGAGEMENT LETTERS AND RECEIVES ALL BOARD DIRECTED COMMUNICATION FROM THE INDEPENDENT ACCOUNTING FIRM. COPIES OF RECEIVED LETTERS/COMMUNICATIONS AND REPORTS ARE DISTRIBUTED TO ALL MEMBERS OF THE BOARD OF DIRECTORS IN ADDITION TO THE COMMITTEE MEMBERS. WHILE THE MEMBERS OF THE COMMITTEE HAVE CHANGED, THE PROCESS DESCRIBED HAS NOT CHANGED FROM THE PREVIOUS YEAR. COMMUNITY HOSPITAL HEALTH FOUNDATION 801 WEST C STREET PO BOX 1328 MCCOOK NE 69001 470693261 SUPPORTING ORGANIZATION PROVIDES FUNDRAISING FOR THE HOSPITAL NE 501(C)(3) LINE 11A, I COMMUNITY HOSPITAL ASSOCIATION OF MCCOOK 1 RED WILLOW HOLDING COMPANY PO BOX 1328 MCCOOK NE 69001 470628195 RENTAL REAL ESTATE - CLINIC BUILDING NE COMMUNITY HOSPITAL ASSOCIATION OF MCCOOK C 53079 169581 1.00000 1 0 1 1 0 0 0 0 0 0 0 1 0 1 1 1 1 1 0 0 COMMUNITY HOSPITAL HEALTH FOUNDATION C 265696 CASH RECEIVED=FMV