2017-09-27T09:05:47-05:00 2016-12-31 BKD LLP 1201 Walnut Suite 1700 Kansas City MO 641062246 990 2016-01-01 480581968 SUSAN B ALLEN MEMORIAL HOSPITAL % GENE KABERLINE SUSA 3163213300 720 WEST CENTRAL EL DORADO KS 67042 GENE KABERLINE CFO 2017-11-15 true Michael J Engle P00482834 8162216300 64.22.227.161 43372220172705000000 2017-09-27 P 6E878FA6C29EFF3721DC18DF9D0E8A9BE12011F9 60B107EC4821460DA499CE214EC088A36685104E 2016 2021-01-29 14:40:06Z JIM KIRKBRIDE 720 WEST CENTRAL EL DORADO KS 67042 55289042 false X WWW.SBAMH.ORG X 1930 KS THE MISSION OF SUSAN B. ALLEN MEMORIAL HOSPITAL IS TO PROVIDE COMPASSIONATE, PROFESSSIONAL HEALTH CARE TO THE PEOPLE WE SERVE. 12 11 505 120 -1725 -1725 416788 481353 52660093 53214439 1119031 514685 148216 270429 54344128 54480906 24180 19465 0 0 26135674 25699354 0 0 0 28125533 27753821 54285387 53472640 58741 1008266 81259407 82969876 18737315 18733255 62522092 64236621 X TO PROVIDE COMPASSIONATE, PROFESSIONAL HEALTH CARE TO THE PEOPLE WE SERVE. false false 42519020 19465 53214439 SEE SCHEDULE O 42519020 true true false true false false false false false true true false false false false false false true false false true false false false false false true true false true true true false false false false false false false false false true false true false false false true true true true false true 75 0 true 505 true true true false false false false false false false false false X 12 11 true false false false false false false true true false false true true true true true true true true false KS X GENE KABERLINE 3163224559 720 WEST CENTRAL EL DORADO KS 67042 CAMI BAKER SECRETARY/TREASURER 1.0 0.0 X X 0 0 0 MICHAEL CLIFTON TRUSTEE 1.0 0.0 X 0 0 0 CATHY COOPER MD TRUSTEE 1.0 0.0 X 0 0 0 ED GARD CHAIRMAN 1.0 0.0 X X 0 0 0 VINCE HAINES TRUSTEE 1.0 0.0 X 0 0 0 BRANDI LANE TRUSTEE 1.0 0.0 X 0 0 0 SUZIE LOCKE TRUSTEE 1.0 0.0 X 0 0 0 AMY SEEBER MD TRUSTEE 1.0 0.0 X 7569 0 0 MARK UTECH TRUSTEE 1.0 0.0 X 0 0 0 MIKE WHEELER TRUSTEE 1.0 0.0 X 0 0 0 ROD ZIEGLER TRUSTEE 1.0 0.0 X 0 0 0 Greg Joyce Trustee 1.0 0.0 X 0 0 0 JIM KIRKBRIDE PRESIDENT & CEO 40.0 0.0 X 223830 0 16783 EUGENE KABERLINE VICE PRESIDENT & CFO 40.0 0.0 X 128255 0 1076 PATRICK AUMAN INTERIM-CEO 40.0 0.0 X 65722 0 0 ROBERT FISHER INTERIM-CFO 40.0 0.0 X 61289 0 0 ROBIN CRAWFORD VICE PRESIDENT & CFO 40.0 1.0 X 69052 0 3024 CECILIA GOEBEL CHIEF NURSING OFFICER 40.0 0.0 X 148632 0 27548 PAIGE DODSON CHIEF MEDICAL OFFICER 40.0 0.0 X 218264 0 9345 GAY KIMBLE CHIEF HR OFFICER 40.0 0.0 X 112883 0 25651 FRANCIA BIRD CHIEF QUALITY OFFICER 40.0 0.0 X 87591 0 25025 MARK ROOKER CIO & COO 40.0 0.0 X 113182 0 22252 Gerard Librodo MD PHYSICIAN OF ORTHOPEDICS 40.0 0.0 X 654779 0 13658 LAWRENCE SHANK ORTHOPEDIC SURGEON 40.0 0.0 X 221038 0 3069 JASON BRUNTON HOSPITALIST 40.0 0.0 X 231783 0 12415 DR VIKRANT AZAD ORTHO SURGEON 40.0 0.0 X 173181 0 6243 2517050 0 166089 21 false true false FRESENIUS MEDICAL CARE 5215 n oconnor blvd suite 1100 IRVING TX 75039 KIDNEY DIALYSIS 907600 PRISM HEALTHCARE PARTNERS LTD 190 S LA SALLE STREET STE 2900 CHICAGO IL 60603 MEDICAL services 417000 MIDAMERICA ANESTHESIA PROFESSIONALS 700 W CENTRAL SUITE 107 EL DORADO KS 67042 MEDICAL SERVICES 226193 CASCADE HEALTH SERVICES 1045 SWIFT AVENUE N KANSAS CITY MO 64116 MEDICAL SERVICES 190344 DR CHINWE ANTHONIA OKONKWO 700 W CENTRAL SBA MEDICAL CLINIC W EL DORADO KS 67042 MEDICAL SERVICES 177509 12 357220 124133 481353 Patient Service Revenue 621110 53096062 53096062 Meals on Wheels 624200 116337 116337 Screening Program 623990 2040 2040 53214439 532181 532181 127907 127907 322 322 553703 57330 559313 103420 -5610 -46090 -51700 -51700 2202 143201 -2202 -143201 -145403 -145403 0 0 0 0 0 0 0 0 0 Cafeteria 722210 176895 176895 PARTNERSHIP INCOME -1725 -1725 MISCELLANEOUS INCOME 900099 146637 146637 146637 146637 321807 54480906 53214439 -1725 786839 0 19465 19465 0 0 1366973 1366973 12182 12182 18819312 14111438 4707874 465073 348805 116268 3647366 2735525 911841 1388448 1041336 347112 0 0 0 0 0 0 7076908 5307681 1769227 219316 164487 54829 693064 519798 173266 0 0 555001 416251 138750 236940 177705 59235 0 0 363773 295456 68317 0 3888456 2916342 972114 241087 180815 60272 Bad Debt 4405411 4405411 Medical Supplies 9005523 9005523 Repairs & Maint. 233243 174932 58311 Recruiting & Retention 236133 177100 59033 598966 508768 90198 53472640 42519020 10953620 0 857874 759552 0 0 0 0 9272381 11674239 0 0 0 0 0 0 1486417 1766090 1802533 1446452 88726710 47480123 42784648 41246587 22778774 23327546 1879425 2124616 120252 381944 0 0 277103 242850 81259407 82969876 3992153 6452778 0 0 0 0 14745162 12280477 0 0 0 0 0 0 0 0 0 0 18737315 18733255 X 59049986 60596483 277731 347420 3194375 3292718 62522092 64236621 81259407 82969876 X 1008266 658668 47595 X false true X true false X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED false false false false false true 11407 false false false 11407 false PART II-B, LINE 1F A PORTION OF THE KANSAS HOSPITAL ASSOCIATION AND AMERICAN HEALTH ASSOCIATION DUES ARE ATTRIBUTED TO LOBBYING EXPENSES. 1568899 220239 105714 7610 1887242 1570557 94805 -15692 73371 7400 1568899 1479284 46819 108550 56867 7229 1570557 1291319 144789 113425 63912 6337 1479284 1170060 92514 82010 47398 5867 1291319 0.74710 0.21350 0.03940 false true true 4104215 4104215 44322756 20258698 24064058 38827859 26056434 12771425 1471880 1164991 306889 41246587 51361360 658668 627197 1285865 50075495 4405411 4405411 54480906 49570174 502945 502945 49067229 4405411 4405411 53472640 SCHEDULE D, PART V, LINE 4 THE ENDOWNMENT FUNDS ARE HELD BY SUSAN B. ALLEN MEMORIAL HOSPITAL FOUNDATION, A RELATED TAX EXEMPT ORGANIZATION. THE EARNINGS FROM THE ENDWOMENT FUNDS ARE USED TO FUND THE PURCHASE OF EQUIPMENT AND PROGRAM SUPPORT FOR SUSAN B. ALLEN MEMORIAL HOSPITAL. SCHEDULE D, PART X, LINE 2 MANAGEMENT HAS EVALUATED THEIR INCOME TAX POSITIONS UNDER THE GUIDANCE INCLUDED IN ASC 740. BASED ON THEIR REVIEW, MANAGEMENT HAS NOT IDENTIFIED ANY MATERIAL UNCERTAIN TAX POSITIONS TO BE RECORDED OR DISCLOSED IN THE FINANCIAL STATEMENTS. SCHEDULE D, PART XI, LINE 2D RELATED ORGANIZATION REVENUE $ 933,465 ELIMINATIONS $ (959,129) RECLASS OF RENTAL EXPENSES $ 662,733 PARTNERSHIP INCOME $ 1,725 ARRA MEANINGFUL USE $ (11,597) ---------- $ 627,197 SCHEDULE D, PART XI, LINE 4b BAD DEBT EXPENSE $ 4,405,411 SCHEDULE D, PART XII, LINE 2D RELATED ORGANIZATION EXPENSE $ 209,029 ELIMINATIONS $ (357,220) RECLASS OF RENTAL EXPENSES $ 662,733 ARRA MEANINGFUL USE $ (11,597) ---------- $ 502,945 SCHEDULE D, PART XII, LINE 4B BAD DEBT EXPENSE $ 4,405,411 false Central America and the Caribbean Investments 855179 855179 855179 false false true true false false true true X true X false true true false true true 761324 455163 306161 0.00630 5501076 5523112 -22036 6262400 5978275 284125 0.00630 162968 43175 119793 0.00250 2500 2500 0.00010 165468 43175 122293 0.00260 6427868 6021450 406418 0.00890 true 4405411 678000 13408875 17703127 -4294252 X true true 1 1 SUSAN B ALLEN MEMORIAL HOSPITAL 720 WEST CENTRAL EL DORADO KS 67042 www.sbamh.org H-008-002 X X X SUSAN B ALLEN MEMORIAL HOSPITAL 1 false false true X X X X X X X X X 16 true false false true X SEE PART V, SECTION C X true 16 true SEE PART V, SECTION C false true X 200. 0. X X X true true X X X true X SEE PART V, SECTION C X SEE PART V, SECTION C X SEE PART V, SECTION C X X X X X X true X false X X X X true X false false SCHEDULE H, PART V, SECTION B, LINE 5 Based on data acquired from the 2013 CHNA, Health & Wellness community partners were invited to give input during the 2016 CHNA data collection process and participated in the town hall meeting that followed where gaps in significant needs were identified and prioritized. These partners included but were not limited to: Butler County Health dept, South Central Kansas Mental Health, local school districts, Department of Aging, Members of SBA Medical Staff, Allied Health, Butler Community College School of Nursing, United Way, YMCA, large business owners, clergy, department of human services, etc. SCHEDULE H, PART V, SECTION B, LINE 7A & 10A WWW.SBAMH.ORG/ABOUT_US/COMMUNITY_HEALTH_NEEDS_ASSESSMENT SCHEDULE H, PART V, SECTION B, LINE 11 SBA has adopted a "Population Health" philosophy where Health & Wellness services are developed and delivered to all citizens in our service area. The 2016 CHNA identified three (3) major underserved areas of significant need; mental health/allied health, community awareness/education and child/adult obesity management. SBA has filled vacant Board of Trustee positions based on these gaps and recently hired a community advocate to coordinate with local partners to develop strategies to best deliver the results of the 2016 CHNA to the community. SBA has discussed the need to improve access to dental care with several local dentists. Thus far, the discussion have focused on a hospital based dental clinic where dental hygienists and dentists could practice preventative and routine dental care for the underserved in partnership with the hospital. Initially, there was a dental room planned in the Cancer Center hallway construction project but after further review, it was determined to be too small to accommodate all the needed equipment. Current discussion include offering space in the ENT office that is underutilized and more than adequate for this service. Our next planning meeting will be later this fall. SCHEDULE H, PART V, SECTION B, LINE 16 www.sbamh.org/patients_info/billing_information 4 SBA MEMORIAL HOSPITAL HOME HEALTH 720 W CENTRAL EL DORADO KS 67042 home health agency SUSAN B ALLEN MEMORIAL HOSPITAL DME 720 W CENTRAL EL DORADO KS 67042 DURABLE MEDICAL EQUIPMENT PROVIDER SBA MEMORIAL HOSPITAL DIALYSIS 720 W CENTRAL EL DORADO KS 67042 HEMODIALYSIS SBA MEMORIAL HOSPITAL MEDICAL CLINIC 720 W CENTRAL EL DORADO KS 67042 MEDICAL OFFICE BUILDING SCHEDULE H, PART I, LINE 3C The Hospital also uses medical indigency, asset level, and residency as factors to determine eligibility. Schedule H, Part I, Line 7, Column F THE AMOUNT OF BAD DEBT EXPENSE REMOVED FROM TOTAL EXPENSES FOR CALDULATING THE NET COMMUNITY BENEFIT EXPENSE PERCENTAGE WAS $4,405,411. Schedule H, Part I, Line 7 THE HOSPITAL USES THE COST-TO-CHARGE RATIO. THIS METHOD WAS USED TO CALCULATE THE FIGURES IN THE TABLE AND WAS DETERMINED BY COMPARING PATIENT CARE COST TO PATIENT CARE CHARGES. SCHEDULE H, PART III, SECTION A, LINE 2 NON-MEDICARE/MEDICAID ACCOUNT AGING OVER 180 DAY RESERVES AT 100%. MEDICARE/MEDICAID ACCOUNT AGING OVER 365 DAY RESERVED AT 100%. SCHEDULE H, PART III, SECTION A, LINE 3 ESTIMATED BASED ON US CENSUS BUREAU INDIVIDUALS BELOW POVERTY LEVEL OF 15.4%. SCHEDULE H, PART III, SECTION A, LINE 4 THE BAD DEBT FOOTNOTE IS ON PAGE 8 OF THE AUDITED FINANCIAL STATEMENTS. SCHEDULE H, PART III, SECTION B, LINE 8 SERVING PATIENTS WITH GOVERNMENT HEALTH BENEFITS, SUCH AS MEDICARE, IS A COMPONENT OF THE COMMUNITY BENEFIT STANDARD THAT TAX-EXEMPT HOSPITALS ARE HELD TO. THIS IMPLIES THAT SERVING MEDICARE PATIENTS IS A COMMUNITY BENEFIT AND THAT THE HOSPITAL OPERATES TO PROMOTE THE HEALTH OF THE COMMUNITY. SCHEDULE H, PART III, SECTION C, LINE 9B THE FINANCIAL ASSISTANCE POLICY IS OFFERED AT TIME OF REGISTRATION. NOTIFICATION OF THE FINANCIAL ASSISTANCE POLICY IS AVAILABLE IN MULTIPLE FORMS. SCHEDULE H, PART VI, LINE 2 IN ADDITION TO THE COMMUNITY HEALTH NEEDS ASSESSMENT THAT WAS COMPLETED IN 2016 AS REQUIRED BY 501(R) THE ORGANIZATION HAS A STRATEGIC PLANNING COMMITTEE OF THE BOARD WHO THROUGH A CONSULTANT CONDUCTS A NEEDS SURVEY OF OUR SERVICE AREA. SCHEDULE H, PART VI, LINE 3 ON ADMISSION, PATIENTS ARE GIVEN A BROCHURE DESCRIBING INFORMATION ABOUT THE KANSAS HEALTHWAVE PROGRAM. IT ALSO INCLUDES INFORMATION ABOUT COVENTRY ONE HEALTH INSURANCE AND VALUE BLUE, BOTH ARE LOW COST OR NOCOST INSURANCE PLANS. THE BROCHURE GIVES INFORMATION ABOUT OUR CHARITY CARE PROGRAM. OUR CHARITY CARE PROGRAM INFORMATION IS GIVEN TO OUR MEDICAL STAFF PHYSICIANS FOR DISTRIBUTION TO PATIENTS IN THEIR OFFICES. ALL OF THE BILLING STATEMENTS LIST THAT WE HAVE A CHARITY CARE PROGRAM AND THE WEBSITE URL. THE CHARITY CARE APPLICATION WITH COVER LETTER IS MAILED ALONG WITH THE FIRST STATEMENT SENT TO SELFPAY PATIENTS. THE GUIDELINES ARE INCLUDED WITH THE SECOND STATEMENT AFTER A REVIEW OF THE ACCOUNT INDICATES A NEED FOR FINANCIAL ASSISTANCE. PATIENT ACCOUNT REPRESENTATIVES REVIEW OUR CHARITY CARE PROGRAM WITH PATIENTS WHEN MAKING CALLS. WE ALSO REFER PATIENTS TO THE MIDLAND GROUP TO DETERMINE ELIGIBILITY FOR MEDICAID, OTHER ASSISTANCE PROGRAMS AND OUR CHARITY CARE PROGRAM. THE MIDLAND GROUP ASSISTS PATIENTS IN THE APPLICATION PROCESS TO SEE IF THEY ARE ELIGIBLE FOR STATE ASSISTANCE PROGRAMS. KANSAS MEDICAL ASSISTANCE PROGRAM (KMAP) HEALTHWAVE BROCHURES AND APPLICATIONS ARE PROVIDED TO PATIENTS WHO MAY MEET THE FINANCIAL GUIDELINES OF THE KMAP. SCHEDULE H, PART VI, LINE 4 THE HOSPITAL'S PRIMARY SERVICE AREA CONSISTS OF 6 COMMUNITIES WITHIN BUTLER COUNTY WHICH LIE WITHIN A 15 MILE RADIUS OF THE HOSPITAL. THE POPULATION OF THESE COMMUNITIES IS APPROXIMATELY 37,500 OF WHICH 26% ARE AGE 55 OR OLDER. THE HOSPITAL'S SECONDARY SERVICE AREA CONSISTS OF 13 SMALLER COMMUNITIES LOCATED IN BUTLER, GREENWOOD, ELK, MARION AND COWLEY COUNTIES WITH A COMBINED POPULATION OF JUST OVER 15,000 RESIDENTS OF WHICH 32% ARE AGE 55 OR OLDER. WHILE PART OF THE SERVICE AREA IS IN THE WICHITA METROPOLITAN STATISTICAL AREA, MUCH OF THE SERVICE AREA IS RURAL. SCHEDULE H, PART VI, LINE 5 WE PARTICIPATE IN THE BUTLER COUNTY SENIOR FAIR PROVIDING HEALTH INFORMATION ON VARIOUS HEALTH ISSUES. WE PARTICIPATE IN THE FRONTIER REFINING EMPLOYEE HEALTH FAIR PROVIDING INFORMATION ABOUT VARIOUS HEALTH ISSUES AND OFFER HEALTH TESTING AND SCREENINGS. WE PARTICIPATE IN THE BUTLER COMMUNITY COLLEGE WOMEN'S FAIR PROVIDING INFORMATION ABOUT VARIOUSD IN THE BUTLER COMMUNITY COLLEGE-ANDOVER/SHERWIN WILLIAMS WELLNESS FAIR PROVIDING INFORMATION ABOUT VARIOUS HEALTH ISSUES AND OFFER HEALTH TESTING AND SCREENINGS. WE ARE A SPONSOR OF THE AMERICAN CANCER SOCIETY'S RELAY FOR LIFE IN EL DORADO, KANSAS AND IN EUREKA, KANSAS. WE PROVIDED A PHARMACIST FOR POISON PREVENTION AND SAFETY TO EL DORADO KINDERGARTEN AND 1ST GRADERS. WE PROVIDED MEETING SPACE FOR SEVERAL COMMUNITY HEALTH GROUPS INCLUDING BUTLER COUNTY DIABETES SUPPORT GROUP, THE AMERICAN CANCER SOCIETY, AND THE BUTLER COUNTY MULTIPLE SCLEROSIS SUPPORT GROUP. WE PROVIDE LOW COST SCREENING PROGRAMS FOR CARDIAC HEALTH, OSTEOPOROSIS, HYPERTENSION AND DIABETES. WE PROVIDE FREE INFLUENZA VACCINATIONS TO MEMBERS OF THE COMMUNITY. WE HAVE A VOLUNTEER BOARD OF 12 MEMBERS THAT COME FROM THROUGHOUT OUR SERVICE AREA. FORM 990 DISCLOSURE REQUIRED UNDER REV. PROC. 2015-21 Susan B. Allen Memorial Hospital discovered in November of 2016 that they did not fully comply with 501(r) during a portion of the 2016 calendar year. The client believed they were in compliance until it was discovered during the preparation of their 12/31/2015 tax return. They inadvertently did not include the full version of the Financial Assistance Policy on their website. SBAMH corrected this in November of 2016 by adding the full version of the Financial Assistance Policy on their website. SBAMH also added a translated version of the Financial Assistance Policy on their website in December of 2016 even though it is not required. SBAMH does have someone visiting the homes of people that have not completed the Financial Application Policy, but are presumed to qualify, to encourage them to complete the application. It was discovered in July of 2017 from an IRS letter that the listing of covered and non-covered providers was not posted on the website and the CHNA posted on the website did not include managements action plan. These items were corrected upon receiving the letter. true ADULT DIABETES EDUCATION PROGRAM 2 1504 BOOK EDUCATION PUBLIC INFLUENZA VACCINATIONS 918 17961 BOOK VACCINATIONS SCHEDULE I, PART I, LINE 2 THE PUBLIC INFLUENZA VACCINATIONS ARE GIVEN TO ALL WHO SHOW UP AT THE TWO CLINICY. THE ADULT DIABETES EDUCATION PROGRAM GRANTS ARE GIVEN TO THOSE WHO APPLY AND MEET THE FINANCIAL NEED CRITERIA. X X X X false false false false false true false false false JIM KIRKBRIDE PRESIDENT & CEO 191965 0 30000 0 1865 0 1711 0 15072 0 240613 0 0 0 Gerard Librodo MD PHYSICIAN OF ORTHOPEDICS 460983 0 192716 0 1080 0 2880 0 10778 0 668437 0 0 0 LAWRENCE SHANK ORTHOPEDIC SURGEON 220255 0 0 0 783 0 2207 0 862 0 224107 0 0 0 JASON BRUNTON HOSPITALIST 230786 0 0 0 997 0 2327 0 10088 0 244198 0 0 0 DR VIKRANT AZAD ORTHO SURGEON 173181 0 0 0 0 0 22 0 6221 0 179424 0 0 0 CECILIA GOEBEL CHIEF NURSING OFFICER 147027 0 0 0 1605 0 6688 0 20860 0 176180 0 0 0 PAIGE DODSON CHIEF MEDICAL OFFICER 191528 25000 1736 1907 7438 227609 0 SCHEDULE J, PART I, LINE 6A MANAGEMENT INCENTIVE PLAN BASED ON CRITERIA OF CONTRIBUTION MARGIN PERCENTAGE AFTER MEETING ACCREDITATION STANDARDS AND QUALITY STANDARDS. A BUTLER COUNTY KANSAS 486035405 12343PAA3 2012-04-30 14500000 SEE PART VI false false false B BUTLER COUNTY KANSAS 486035405 2014-12-16 6500000 SEE PART VI false false false A 7500364 0 14500655 0 24 0 0 0 0 3607315 10893316 0 2013 true true true true B 1220145 0 6502044 0 0 0 110354 0 0 5302497 0 1089193 2017 false false false true A false false false false 0 false false false true B false false false false 0 false false false true A false true false false 0 false 0 false true B false true false false 0 false 0 false true A true B true Part I, Line A, Column (f) Improve and equip hospital facilities; Refund Series 1998Z Bonds (issued 12/22/1998); Refund Series 2002Q Bonds (issued 12/17/2002). PART I, LINE B, COLUMN (F) RENOVATIONS TO AND EQUIPMENT FOR HOSPITAL FACILITIES. Part II, Line 3, Column A Amount does not equal issue price due to investment earnings earned in the project fund during the project period. Part II, Line 3, Column B Amount does not equal issue price due to investment earnings earned in the project fund during the project period. Part II, Line 11, Column A This amount was expended to redeem the refunded bonds on May 1, 2012 and December 15, 2012. Part II, Line 12, Column B Amount represents $1,089,193 of Bond proceeds remaining in the project fund as of the fiscal year end. Part II, Line 13 and Line 16, Column B The project was completed after the fiscal year end. The Institution is in the process of completing the Final Allocation for the Bonds. Part II, Line 15, Column A The bond issue constitutes an "advance refunding issue" under U.S. Treasury Regs 1.150-1(d), but no bond that is part of the bond issue is an "advance refunding bond" under I.R.C. 149(d). The bonds were issued as a "draw-down loan" within meaning of U.S. Treasury Regs 1.150(1)(c)(4)(i). The first draw/advance on the bonds was made April 30, 2012 (i.e., the issue date of the bond issue), in part, to refund and redeem a prior series of 1998Z bonds on May 1, 2013; the second draw/advance on the Bonds was made December 14, 2012, in part, to refund and redeem a prior series of 2002Q bonds on December 15, 2012. Therefore, there are no advance refunding bonds, because no bond proceeds were used to pay debt service on a prior series of bonds more than 90 days after the issue date of that bond. Part III, Column A The bonds were issued for three separate purposes: (1) to currently refund a prior series of 1998Z bonds (issued December 22, 1998), (2) to currently refund a period series of 2002Q bonds (issued December 17, 2002) and (3) to finance new-money projects. In accordance with the Instructions for Schedule K (Form 990), the organization is completing this Part III (Private Business Use) only with respect to the portion of the bonds financing the new-money projects, because both prior series of refunded bonds were issued prior to January 1, 2003. Part IV, Line 2c, Column A Arbitrage Computation completed as of 1/1/2014. SEE SCHEDULE L PART V SCHEDULE L, PART IV (A) KACEY CARLSON (B) DAUGHTER OF EDWIN GARD, TRUSTEE/VICE CHAIRPERSON OF SUSAN B. ALLEN MEMORIAL HOSPITAL. (C) $12,182 (D) KACEY CARLSON IS AN EMPLOYEE AT SUSAN B. ALLEN MEMORIAL HOSPITAL. (E) NO X 1 2000 ACCRUED false false false Sch. M, Part I, Line 1, Column B The amount in column B represents the number of items contributed. FORM 990, PART III, LINE 4A COMMUNITY SERVICES - SUSAN B. ALLEN MEMORIAL HOSPITAL OFFERS A NUMBER OF PROGRAMS AND SERVICES IN OUR COMMUNITY AT MINIMAL OR NO COST IN ORDER TO PROMOTE HEALTH AND WELLNESS. ACTUAL COSTS FOR THESE SERVICES ARE NOT SEPARATELY IDENTIFIABLE, AND ARE INCLUDED AS PART OF THE PATIENT SERVICES COST. 1. PARTICIPATED IN THE BUTLER COUNTY SENIOR FAIR, HELD IN EL DORADO, DISPLAYING AND PROVIDING INFORMATION REGARDING OUR DIABETES EDUCATION PROGRAM (INCLUDING BLOOD GLUCOSE SCREENINGS), HOME HEALTH SERVICES (INCLUDING BALANCE SCREENING, BLOOD PRESSURE TESTING, 02 SATURATIONS), HOME MEDICAL EQUIPMENT SERVICES, OSTEOPOROSIS INFORMATION (INCLUDING SCREENING), NUTRITION SERVICES, ENT INFORMATION (INCLUDING AUDIOLOGY TESTING), AND PHYSICAL REHABILITATION AT NOCHARGE. 2. PARTICIPATED IN THE FRONTIER REFINING EMPLOYEE HEALTH FAIR PROVIDING INFORMATION ON DIABETIC FOOT CARE, CARDIAC HEALTH, DIETARY EDUCATION, ORTHOPAEDIC ISSUES, PHYSICAL THERAPY ISSUES, HEARING SCREENINGS, BONE DENSITY TESTING AND BLOOD WORK (INCLUDING LIPID, PSA AND HEMOGLOBIN A1C TESTING). 3. BEGAN SERVING AS A PROJECT SEARCH HOST SITE. PROJECT SEARCH IS A HIGH SCHOOL TO WORK TRANSITION PROGRAM SERVING STUDENTS WITH DISABILITIES BETWEEN THE AGES OF 18-21. 4. PROVIDED A REGISTERED PHARMACIST TO THE EL DORADO SCHOOL DISTRICT FOR POISON PREVENTION AND SAFETY TALKS FOR ALL KINDERGARTEN AND FIRST GRADE STUDENTS AT THE ELEMENTARY SCHOOLS IN TOWN (APPROXIMATELY 300 STUDENTS). 5. PROVIDED A NUMBER OF DIRECTORS AND STAFF TO SPEAK AT LOCAL SCHOOL DISTRICT CAREER FAIR EVENTS INCLUDING PHYSICAL REHABILITATION, DIAGNOSTIC IMAGING, ATHLETIC TRAINING, AND ORTHOPEDIC SURGERY. 6. ADMINISTRATIVE PERSONNEL (4) ARE SUPPORTING THE EL DORADO VISION 2020 PROGRAM, PROVIDING MENTORING AT A LOCAL SCHOOL ONE HOUR PER WEEK. 7. PROVIDED OVER 200 FREE DARI (MOTION ANALYSIS) SCREENINGS FOR HIGH SCHOOL AND COMMUNITY COLLEGE ATHLETES. 8. SPONSORED THE AMERICAN CANCER SOCIETY'S RELAY FOR LIFE IN EL DORADO WITH A $1,000 SPONSORSHIP. THE HOSPITAL ALSO SUPPORTED THE GREENWOOD COUNTY (EUREKA, KANSAS) RELAY FOR LIFE WITH A $500 SPONSORSHIP. 9. MADE AVAILABLE A "SPEAKERS BUREAU" TO OUR COMMUNITY. HOSPITAL PERSONNEL SPOKE TO VARIOUS CIVIC GROUPS AND ORGANIZATIONS ON NUMEROUS OCCASIONS. 10. HOSPITAL EMPLOYEES DONATED OVER $15,305 IN SUPPORT OF THE EL DORADO UNITED WAY PROGRAM. 11. THE HOSPITAL DONATED $2,500 IN GIFT CARDS TO RESIDENTS OF EUREKA, KANSAS FOLLOWING A TORNADO EVENT IN THEIR COMMUNITY IN JULY. GIFT CARDS FROM A HOME/LUMBER SUPPLY BUSINESS WERE DISTRIBUTED TO RESIDENTS IDENTIFIED BY THE AMERICAN RED CROSS AND LOCAL LAW ENFORCEMENT. 12. PROVIDED MEETING ROOM SPACE FOR OTHER ORGANIZATIONS SERVING THE COMMUNITY, SUCH AS THE BUTLER COUNTY DIABETES SUPPORT GROUP, THE AMERICAN CANCER SOCIETY, THE ARC OF BUTLER (SPECIAL NEEDS AND DISABILITIES), BUTLER COUNTY ALZHEIMER'S SUPPORT GROUP, AND THE BUTLER COUNTY MULTIPLE SCLEROSIS SUPPORT GROUP. 13. PROVIDED FACILITIES AND MEALS FOR A BUTLER/GREENWOOD COUNTY MEDICAL SOCIETY MEETING. 14. STAFF MEMBERS FROM THE EMERGENCY DEPARTMENT (CHEST PAIN CENTER), RESPIRATORY CARE DEPARTMENT, AND PHYSICAL REHABILITATION DEPARTMENT ATTENDED THE BUTLER COMMUNITY COLLEGE "CAMP MED" PROGRAM FOR YOUTH FROM THROUGHOUT BUTLER COUNTY. 15. PROVIDE PERSONNEL AND FACILITIES FOR LOCAL EMERGENCY PLANNING COMMITTEE MEETINGS. 16. PROVIDE ONCE-A-MONTH FREE CHILDBIRTH EDUCATION CLASSES FOR NEW MOMS AND SIGNIFICANT OTHERS, REGARDLESS OF WHERE THEY WILL BE DELIVERING. OBSTETRICS STAFF PROVIDE EDUCATION AND INFORMATION ABOUT LABOR AND DELIVERY, COMFORT MEASURES, PAIN MANAGEMENT, NEWBORN CARE, RECOVERY AND DISCHARGE. 17. PROVIDED A LOW-COST SCREENING PROGRAM FOR CARDIAC HEALTH, OSTEOPOROSIS, HYPERTENSION, AND DIABETES TWO TIMES DURING THE YEAR IN FOR THE COMMUNITY HERE AT SUSAN B. ALLEN. 18. PROVIDED FREE OSTEOPOROSIS SCREENINGS IN THE PHYSICAL REHABILITATION DEPARTMENT ONE-HALF DAY EACH MONTH. 19. PROVIDE FREE HEARING SCREENINGS IN THE EL DORADO EAR, NOSE AND THROAT OFFICES ONE-HALF DAY EACH WEEK. 20. PARTNERED WITH USD 490 AND THE EL DORADO YMCA TO CREATE A MIDDLE SCHOOL AFTER-SCHOOL PROGRAM PROVIDING HEALTHY ACTIVITY, NUTRITION EDUCATION AND HEALTY LIFESTYLE EDUCATION TO STUDENTS AT NO COST. 21. PROVIDED A FREE INFLUENZA VACCINATION PROGRAM FOR MEMBERS OF OUR COMMUNITY. LARGE CLINICS WERE HELD FOR THE GENERAL PUBLIC - 1 IN EL DORADO AND 1 IN AUGUSTA - AS WELL AS SMALLER CLINICS LOCATED HERE AT THE HOSPITAL. IN TOTAL, 1,240 DOSES WERE GIVEN TO COMMUNITY MEMBERS AT NO COST. 22. ADMINISTRATIVE AND MANAGEMENT STAFF SERVE ON A VARIETY OF BOARDS AND COMMITTEES, INCLUDING THE EL DORADO YMCA, CHAMBER OF COMMERCE, EL DORADO INC., KANSAS HOSPITAL ASSOCIATION BOARD OF DIRECTORS EXECUTIVE COMMITTEE, CLINICAL LABORATORY MANAGERS ASSOCIATION - WHEATLAND CHAPTER, MEDICAL LABORATORY TECHNOLOGY PROGRAM ADVISORY COMMITTEE FOR SEWARD, BARTON COMMUNITY, AND MANHATTAN TECHNICAL COLLEGES, WICHITA STATE UNIVERSITY CLINICAL SCIENCE PROGRAM ADVISORY COMMITTEE, STATE OF KANSAS LABORATORY EMERGENCY PREPAREDNESS COMMITTEE, QUALITY CARE SERVICES, ASSOCIATION OF PROFESSIONAL INFECTION CONTROL AND EPIDEMIOLOGY, CENTRAL PLAINS EXPO, KANSAS SPORTS CONCUSSION PARTNERSHIP COMMITTEE, AMERICAN CANCER SOCIETY RELAY FOR LIFE, BLUESTEM COMMUNITY CREDIT UNION, EMPAC, BUTLER COMMUNITY COLLEGE NURSING ADVISORY BOARD, ASSOCIATION OF FUNDRAISING PROFESSIONALS BOARD, WICHITA STATE UNIVERSITY INSTITUTIONAL REVIEW BOARD, EL DORADO MINISTERIAL ALLIANCE, EL DORADO ARC OF BUTLER BOARD, THE KANSAS DIABETES ADVISORY COUNCIL, SOUTH CENTRAL KANSAS REGIONAL HOSPITAL EMERGENCY PLANNING GROUP, AND THE LOCAL EMERGENCY PLANNING COMMITTEE. 23. SPONSORED THE EL DORADO YMCA STRONG KIDS CAMPAIGN WITH A $1,000 DONATION. 24. ACT AS A CLINICAL SITE FOR TRAINING OF HEALTHCARE PROFESSIONALS INCLUDING MEDICAL STUDENTS, NURSING STUDENTS, RADIOLOGY, LAB, MEDICAL TECHNOLOGISTS, RESPIRATORY THERAPISTS, DIETITIANS, PHYSICAL, OCCUPATIONAL AND SPEECH THERAPISTS, ATHLETIC TRAINING STUDENTS, CRNA STUDENTS, PHYSICIAN ASSISTANT STUDENTS, APRN STUDENTS, AND PHARMACY STUDENTS. 25. SPONSORED THE BUTLER COUNTY 4-H PROGRAM WITH A $700 DONATION DURING THE ANNUAL LIVESTOCK AUCTION. 26. MADE AVAILABLE SCHOLARSHIP MONEY FOR PATIENTS TO GO THROUGH THE SBA ADULT DIABETES EDUCATION PROGRAM. IN ADDITION TO THE ACTUAL CLASS COSTS, ADDITIONAL LAB WORK WAS ALSO WRITTEN OFF FOR THESE PATIENTS. IN TOTAL, $2,123 WAS PROVIDED FOR FOUR PATIENTS WHO ATTENDED THE CLASS. FORM 990, PART VI, SECTION A, LINE 2 CATHY N COOPER MD AND MICHAEL K WHEELER HAVE A BUSINESS RELATIONSHIP. FORM 990, PART VI, SECTION B, LINE 11B AN INDEPENDENT ACCOUNTING FIRM PREPARES AND REVIEWS THE 990. THE 990 IS THEN REVIEWED BY THE HOSPITAL'S OFFICERS AND THE ACCOUNTING STAFF. ANY QUESTIONS OR CONCERNS THE HOSPITAL'S OFFICERS OR ACCOUNTING STAFF HAVE ARE ADDRESSED AND ANY CLARIFICATION OR CORRECTIONS THAT NEED TO BE MADE ARE MADE. THE 990 IS THEN PRESENTED TO THE BOARD OF TRUSTEES FOR THEIR REVIEW AND COMMENT. ANY QUESTIONS OR CONCERNS THE BOARD OF TRUSTEES HAVE ARE ADDRESSED AND ANY CORRECTIONS OR CLARIFICATIONS THAT ARE NEEDED ARE MADE. THE FINAL 990 WITH ALL REQUIRED SCHEDULES ARE APPROVED BY THE BOARD OF TRUSTEES AND FILED. IF THE 990 IS FILED PRIOR TO BOARD APPROVAL AND CHANGES ARE NEEDED AN AMENDED RETURN IS FILED. FORM 990, PART VI, SECTION B, LINE 12C AT THE TIME OF HIRE OR ELECTION IN THE CASE OF BOARD MEMBERS, AND ANNUALLY THEREAFTER, THE PRESIDENT AND CEO OR THEIR DESIGNEE SHALL PROVIDE TO THE BOARD, EXECUTIVE OFFICERS AND DEPARTMENT DIRECTORS, A COPY OF THE CONFLICT OF INTEREST POLICY AND THE CONFLICT OF INTEREST DISCLOSURE STATEMENT WHICH WILL BE COMPLETED TO IDENTIFY ANY RELATIONSHIPS, POSITIONS OR CIRCUMSTANCES WITH RESPECT IT IS BELIEVED A CONFLICT MAY ARISE. THE ANNUAL REVIEW AND MONITORING IS A PART OF THE HOSPITAL'S CORPORATE COMPLIANCE PLAN. A REPORT SHALL BE MADE TO THE BOARD OF TRUSTEES OF ITEMS DISCLOSED. EACH MEMBER OF THE BOARD OF TRUSTEES OR MANAGEMENT SHALL DISCLOSE FULLY AND FRANKLY ANY AND ALL POTENTIAL CONFLICTS OF INTEREST WHICH MAY EXIST OR APPEAR TO EXIST. FORM 990, PART VI, SECTION B, LINE 15A & 15B THE HOSPITAL PARTICIPATES IN AN EXTERNAL SALARY SURVEY FOR ALL EXECUTIVE POSITIONS. THE PRESIDENT AND CEO REVIEWS THE SURVEY RESULTS, AND PRESENTS THEM TO THE COMPENSATION COMMITTEE OF THE BOARD WITH RECOMMENDATIONS FOR THE VICE PRESIDENTS. THE COMPENSATION COMMITTEE OF THE BOARD MAKES RECOMMENDATIONS TO THE FULL BOARD FOR APPROVAL. IN ADDITION, THE COMPENSATION COMMITTEE MAKES A RECOMMENDATION FOR THE PRESIDENT AND CEO SALARY TO THE FULL BOARD FOR APPROVAL. THE REVIEW IS DONE ANNUALLY BY THE COMPENSATION COMMITTEE AND THE BOARD. FORM 990, PART VI, SECTION C, LINE 19 THE GOVERING DOCUMENTS, CONFLICT OF INTEREST POLICY, AND FINANCIAL STATEMENTS ARE NOT MADE AVAILABLE TO THE PUBLIC. FORM 990, PART VII AMY SEEBER IS COMPENSATED BY THE HOSPITAL FOR HER SERVICES PROVIDING A PHYSICIAN INTERPRETATION OF ELECTROCARDIOGRAMS. FORM 990, PART XI, LINE 9 CHANGE IN BENEFICIAL INTEREST IN PERPETUAL TRUSTS $ (76,658) CHANGE IN INTEREST IN THE NET ASSETS OF SBAMHF $ 245,191 Contributed personnel services from affiliate $ (122,664) Partnership Income $ 1,725 ---------- $ 47,595 SUSAN B ALLEN MEMORIAL HOSPITAL FDN 720 WEST CENTRAL EL DORADO KS 67042 480862732 SUPPORT ORG KS 501(C)(3) 12A SBA HOSPITAL true SBAMH EMPLOYEE GROUP BENEFIT TRUST 720 WEST CENTRAL EL DORADO KS 67042 481105047 VEBA KS 501(C)(9) SBA HOSPITAL true FS ALLEN 720 WEST CENTRAL EL DORADO KS 67042 486103710 GRANTOR TRUST KS NA TRUST -76391 2811055 1.00000 true false false true false false false false false false false false true false true true true true true true SUSAN B ALLEN MEMORIAL HOSPITAL FDN C 357220 cash SUSAN B ALLEN MEMORIAL HOSPITAL FDN L 122664 FMV SBAMH EMPLOYEE GROUP BENEFIT TRUST R 3278934 cash SUSAN B ALLEN MEMORIAL HOSPITAL FDN S 77724 FMV