2016-10-26T12:17:39-05:00 2016-04-30 476097913 SEIM JOHNSON LLP 18081 BURT STREET SUITE 200 OMAHA NE 680224722 990 2015-05-01 470388012 BRODSTONE MEMORIAL HOSPITAL BROD 4028793281 520 EAST 10TH STREET SUPERIOR NE 689781225 SANDRA BORDEN CFO 4028793281 2016-10-25 1 BARBARA J FAJEN P00400874 4023302660 2015 2017-02-10 21:41:12Z SANDRA BORDEN 520 EAST 10TH STREET SUPERIOR NE 689781225 24900509 0 X WWW.BRODSTONEHOSPITAL.ORG X 1927 NE BRODSTONE MEMORIAL HOSPITAL IS A NOT-FOR-PROFIT CRITICAL ACCESS HOSPITAL ESTABLISHED TO DELIVER QUALITY, AFFORDABLE HEALTH CARE IN A CARING, SAFE AND COMPASSIONATE ENVIRONMENT TO ALL PERSONS OF SUCH NEED IN A TOTALLY NON-DISCRIMINATORY MANNER. 6 6 213 217 0 0 380904 182905 23465669 24568140 124999 53540 38079 38033 24009651 24842618 0 0 0 0 10985690 11844691 0 0 0 10755218 11040827 21740908 22885518 2268743 1957100 29563293 29546895 10914340 9219373 18648953 20327522 X BRODSTONE MEMORIAL HOSPITAL IS A NOT-FOR-PROFIT COMMUNITY ACUTE CARE MEDICAL/SURGICAL CRITICAL ACCESS HOSPITAL ESTABLISHED TO DELIVER QUALITY, AFFORDABLE HEALTH CARE IN A CARING, SAFE AND COMPASSIONATE ENVIRONMENT TO ALL PERSONS OF SUCH NEED IN A TOTALLY NON-DISCRIMINATORY MANNER. 0 0 20307063 24568140 BRODSTONE MEMORIAL HOPSITAL PROVIDES SHORT TERM INPATIENT AND OUTPATIENT SERVICES SUCH AS ACUTE CARE, ICU, OB AND NURSERY WITHIN THE SCOPE OF ITS HOSPITAL LICENSE TO ALL PATIENTS IN A NON-DISCRIMINATORY MANNER. THE HOSPITAL ALSO OPERATES TWO RURAL HEALTH CLINICS. 20307063 1 1 0 1 0 0 0 0 0 1 1 0 0 1 1 1 1 0 0 0 0 0 0 0 0 0 1 1 0 0 1 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 1 1 0 0 1 27 0 1 213 1 0 0 0 0 0 0 0 0 0 0 X 6 6 0 0 0 0 0 0 0 1 1 0 0 1 1 1 1 1 1 1 1 0 X SANDRA J BORDEN CFO 4028793281 520 EAST 10TH STREET SUPERIOR NE 68978 PAT MCCORD PRESIDENT 2.00 0.00 X X 0 0 0 MARLIN MEYER VICE-PRESIDENT 2.00 0.00 X X 0 0 0 JUDY GROVE SECRETARY 2.00 0.00 X X 0 0 0 JIM SULLIVAN TREASURER 2.00 0.00 X X 0 0 0 LYNN CULBERTSON MEMBER 2.00 0.00 X 0 0 0 KATHY ESSINK MEMBER 2.00 0.00 X 0 0 0 JOHN KEELAN CEO 40.00 0.00 X 215629 0 30499 SANDRA BORDEN CFO 40.00 0.00 X 153946 0 29283 TIMOTHY BLECHA MD PHYSICIAN 40.00 0.00 X 254588 0 32449 JULIE THEIS MD PHYSICIAN 40.00 0.00 X 194482 0 37835 ROBERT LEIBEL MD PHYSICIAN 40.00 0.00 X 181444 0 36414 JASON HASS PA-C PHYSICIAN ASSISTANT 40.00 0.00 X 120849 0 35547 DENA ALVAREZ COO 40.00 0.00 X 106967 0 27747 1227905 0 229774 8 0 1 0 CARDINAL HEALTH 21377 NETWORK PLACE CHICAGO IL 60673 PHARMACY SERVICES 368849 CG-ID LLC 319 E FRANCIS SUITE 101 NORTH PLATTE NE 69101 ARCHITECT FEES 273339 HEALTHLAND INC 1600 UTICA AVE S STE 300 MINNEAPOLIS MN 55416 MAINTENANCE SERVICES 221061 GE HEALTHCARE (X-RAY) PO BOX 96483 CHICAGO IL 60693 MAINTENANCE SERVICES 196192 PRAIRIE WINDS ANESTHESIA 2551 Z ROAD WEBBER KS 66970 CRNA SERVICES 190000 9 11521 40848 130536 182905 MEDICARE/MEDICAID 621110 13837106 13837106 COMMERCIAL INS & SELF-PAY 621110 8207914 8207914 PHARMACY 446110 2479110 2479110 44010 44010 24568140 97130 97130 9000 52590 -43590 -43590 -43590 1704 11521 5301 -3597 -3597 CAFETERIA REVENUE 900099 41630 41630 41630 24842618 24568140 0 91573 429357 429357 8642005 8048300 593705 2164119 1986180 177939 609210 544089 65121 29734 29734 67236 67236 1920780 1790800 129980 5940 5940 1259069 1069869 189200 503360 503360 258900 258900 96980 64140 32840 217180 188479 28701 1647348 1429646 217702 192340 192340 MEDICAL SUPPLIES 3561420 3561420 BAD DEBT EXPENSE 640210 640210 PHARMACY EXPENSES 378270 378270 DIETARY FOOD & SUPPLIES 139360 139360 122700 9120 113580 22885518 20307063 2578455 0 200 200 7037686 9004353 5430080 2785030 229180 250450 566813 605230 24815003 11989718 12215162 12825285 2155620 2045167 1928552 2031180 29563293 29546895 1936907 2103403 483265 281150 7173353 6722530 1320815 112290 10914340 9219373 X 16696801 18454122 178621 197690 1773531 1675710 18648953 20327522 29563293 29546895 X 1957100 -180710 -97821 X X 0 1 X 1 0 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 0 0 0 0 0 0 0 0 1 2175 2175 0 PART II-B, LINE 1: BRODSTONE MEMORIAL HOSPITAL PAID DUES TO THE AMERICAN HOSPITAL ASSOCIATION AND THE NEBRASKA HOSPITAL ASSOCIATION, A PORTION OF THE DUES WERE USED FOR LOBBYING ACTIVITIES. 1773531 -46451 16136 35234 1675710 1642133 80806 99760 17706 31462 1773531 1526849 156146 23337 17525 1642133 1395429 85539 104553 39140 19532 1526849 1403603 -8174 1395429 0.00000 1.00000 0.00000 1 0 117890 117890 14194740 5826060 8368680 8962603 5900198 3062405 1539770 263460 1276310 12825285 DEFERRED FINANCING COSTS, NET 135690 BENEFICIAL INTEREST IN TRUSTS 1675710 INTEREST RECEIVABLE 8730 ESTIMATED THIRD-PARTY PAYOR SETTLEMENT 98760 DEFERRED COMPENSATION 112290 2031180 DEFERRED COMPENSATION LIABILITIES 112290 112290 X 23957938 -180710 -63760 -244470 24202408 640210 640210 24842618 22250609 5301 5301 22245308 640210 640210 22885518 PART V, LINE 4: INTEREST EARNINGS MAY BE USED FOR OPERATIONS, HOWEVER THE PRINCIPAL IS TO BE MAINTAINED AS A PERMANENT ENDOWMENT. PART X, LINE 2: THE HOSPITAL IS A NOT-FOR-PROFIT CORPORATION AS DESCRIBED IN SECTION 501(C)(3) OF THE INTERNAL REVENUE CODE AND IS EXEMPT FROM FEDERAL INCOME TAXES ON RELATED INCOME PURSUANT TO SECTION 501(A) OF THE CODE. THE INTERNAL REVENUE SERVICE HAS ESTABLISHED STANDARDS TO BE MET TO MAINTAIN TAX EXEMPT STATUS. IN GENERAL, SUCH STANDARDS REQUIRE THE HOSPITAL TO MEET A COMMUNITY BENEFIT STANDARD AND COMPLY WITH VARIOUS LAWS AND REGULATIONS. THE HOSPITAL ACCOUNTS FOR UNCERTAINTIES IN ACCOUNTING FOR INCOME TAX ASSETS AND LIABILITIES USING GUIDANCE INCLUDED IN FASB ASC 740, INCOME TAXES. THE HOSPITAL RECOGNIZES THE EFFECT OF INCOME TAX POSITIONS ONLY IF THOSE POSITIONS ARE MORE LIKELY THAN NOT OF BEING SUSTAINED. AT APRIL 30, 2016 AND 2015, THE HOSPITAL HAD NO UNCERTAIN TAX POSITIONS ACCRUED. PART XI, LINE 2D - OTHER ADJUSTMENTS: CHANGE IN BENEFICIAL INTEREST IN TRUSTS -97,821. FUNDRAISING EXPENSES 5,301. ASSETS RELEASED FROM RESTRICTIONS 28,760. PART XI, LINE 4B - OTHER ADJUSTMENTS: PROVISION FOR BAD DEBTS 640,210. PART XII, LINE 2D - OTHER ADJUSTMENTS: FUNDRAISING EXPENSES 5,301. PART XII, LINE 4B - OTHER ADJUSTMENTS: PROVISION FOR BAD DEBTS 640,210. 1 1 X 1 X 1 X 1 1 0 1 1 187460 0 187460 0.00840 1170564 1021966 148598 0.00670 1358024 1021966 336058 0.01510 463747 35813 427934 0.01920 55180 55180 0.00250 6106 6106 0.00030 525033 35813 489220 0.02200 1883057 1057779 825278 0.03710 2 3300 0 3300 0.00010 18 1706 0 1706 0.00010 6 7720 0 7720 0.00030 26 12726 12726 0.00050 1 640210 0 11882804 12000448 -117644 X 1 1 1 1 BRODSTONE MEMORIAL HOSPITAL 520 E 10TH SUPERIOR NE 68978 HTTP://WWW.BRODSTONEHOSPITAL.ORG/ 570001 X X X X BRODSTONE MEMORIAL HOSPITAL 1 0 0 1 X X X X X X X X X X 15 1 1 1 1 X HTTP://WWW.BRODSTONEHOSPITAL.ORG X 1 15 1 HTTP://WWW.BRODSTONEHOSPITAL.ORG 0 0 1 X 100.000000000000 200.000000000000 X X X X 1 1 X X X X 1 X HTTP://WWW.BRODSTONEHOSPITAL.ORG X HTTP://WWW.BRODSTONEHOSPITAL.ORG X HTTP://WWW.BRODSTONEHOSPITAL.ORG X X X X X 1 X X 0 X X X X 1 X 0 0 BRODSTONE MEMORIAL HOSPITAL PART V, SECTION B, LINE 3J: THE REPORT INCLUDES AN UPDATE OF PERFORMANCE MEASURES INCLUDED IN THE SIX-YEAR (2013 THROUGH 2018) COMMUNITY HEALTHIMPROVEMENT PLAN FOR THE DISTRICT. THE PLAN INCLUDES PERFORMANCE MEASURES ALONG WITH STRATEGIES AND ACTIVITIES UNDER THE PRIORITY AREAS OF OBESITY, CANCER, MENTAL HEALTH, SUBSTANCE ABUSE, AND ACCESS TO HEALTH CARE.INCLUDED IN THE REPORT ARE RESULTS FROM A PUBLIC HEALTH SURVEY COVERING A BROAD RANGE OF PUBLIC HEALTH AND COMMUNITY ISSUES IN THE AREAS OF THE HEALTHCARE SYSTEM, SUPPORTS FOR RAISING CHILDREN, SUPPORTS FOR OLDER ADULTS, RECREATIONAL AND LEISURE OPTIONS, JOBS AND THE ECONOMY, HOUSING, SAFETY AND SOCIAL SUPPORT, HEALTH ISSUES AND RISKY BEHAVIORS, AND ALCOHOL USE AND PREVENTION.THERE ARE ALSO RESULTS FROM THREE FOCUS GROUPS CONDUCTED IN THE DISTRICT FOCUSING ON COMMUNITY HEALTH. TOPICS OF DISCUSSION INCLUDED EXERCISE AND RECREATION OPPORTUNITIES, WORKSITE WELLNESS, COMMUNICATING WITH DOCTORS, BARRIERS TO RECEIVING HEALTH CARE, HEALTH SCREENINGS, BEHAVIORAL HEALTH, AND OTHER RELATED TOPICS.A REVIEW WAS CONDUCTED OF THE COUNTY HEALTH RANKINGS WHICH PROVIDES RANKINGS ON HEALTH OUTCOMES (LENGTH AND QUALITY OF LIFE) AND HEALTH FACTORS (HEALTH BEHAVIORS, CLINICAL CARE, SOCIAL AND ECONOMIC FACTORS, AND THE PHYSICAL ENVIRONMENT). RANKINGS FOR BOTH HEALTH OUTCOMES AND HEALTH FACTORS FROM THE LAST FOUR YEARS ARE INCLUDED IN THE REPORT, AS WELL AS SUPPORTING DATA FROM THE 2015 RANKINGS. BRODSTONE MEMORIAL HOSPITAL PART V, SECTION B, LINE 5: A COMMUNITY THEMES AND STRENGTHS ASSESSMENT WAS MADE USING A FOCUS GROUP/WORKSHOP APPROACH TO IDENTIFYING THE PERCEIVED QUALITY OF LIFE IN THE COMMUNITY. STRENGTHS AND AREAS OF NEED WERE IDENTIFIED ACROSS THE SPECTRUM OF PUBLIC HEALTH AND COMMUNITY SERVICES.ANOTHER TOOL USED TO AID IN THE ASSESSMENT WAS THE SOUTH HEARTLAND DISTRICT HEALTH DEPARTMENT COMMUNITY SURVEY, WHICH IS A BROAD SURVEY COVERING NUMEROUS PUBLIC HEALTH AND COMMUNITY ISSUES IN THE AREAS OF THE HEALTHCARE SYSTEM, SUPPORTS FOR RAISING CHILDREN, SUPPORTS FOR OLDER ADULTS, RECREATIONAL AND LEISURE OPTIONS, JOBS AND THE ECONOMY, HOUSING, SAFETY AND SOCIAL SUPPORT, HEALTH ISSUES AND RISKY BEHAVIORS, AND ALCOHOL USE AND PREVENTION. RESULTS FROM THE SURVEY WILL BE USED TO GAUGE COMMUNITY NEEDS AND WILL HELP SET PRIORITIES FOR IMPROVING THE OVERALL HEALTH OF THE POPULATION WITHIN THE DISTRICT.THE COMMUNITY SURVEY WAS DISTRIBUTED ACROSS THE FOUR COUNTIES WITHIN THE DISTRICT (WEBSTER, ADAMS, NUCKOLLS, AND CLAY). THE SURVEY WAS CONDUCTED ON LINE VIA SURVEY MONKEY AND WAS PROMOTED BY VARIOUS HEALTH CLINICS AND HOSPITALS.THREE COMMUNITY FOCUS GROUPS WERE CONDUCTED ON DECEMBER 22, 2015 WITH PARTICIPANTS RECRUITED TO FIT A CERTAIN SUB-POPULATION OF THE SHDHD SERVICE AREA. THE FOCUS GROUPS WERE CONDUCTED BY JOYCE SCHMEECKLE, PHD OF SCHMEECKLE RESEARCH. ONE WAS LOCATED IN SUPERIOR WITH LOW INCOME INDIVIDUALS OF RURAL/AGRICULTURAL BACKGROUND, AND ANOTHER WAS LOCATED IN HASTINGS WITH INDIVIDUALS OF LOW INCOME BACKGROUND LIVING IN HASTINGS.USING THE RESULTS OF THE SURVEY, THE ASSESSMENT AND THE FOCUS GROUPS, BRODSTONE FORMED TEAMS OF 4 TO 5 STAFF MEMBERS TO ADDRESS THE NEEDS OF THE COMMUNITY AND TO FORM A PLAN ADDRESSING THOSE NEEDS. BRODSTONE MEMORIAL HOSPITAL PART V, SECTION B, LINE 6A: BRODSTONE'S CHNA WAS CONDUCTED WITH WEBSTER COUNTY COMMUNITY HOSPITAL AND MARY LANNING MEMORIAL HEALTHCARE. BRODSTONE MEMORIAL HOSPITAL PART V, SECTION B, LINE 6B: BRODSTONE'S CHNA WAS CONDUCTED WITH SOUTH HEARTLAND DISTRICT HEALTH DEPARTMENT. BRODSTONE MEMORIAL HOSPITAL PART V, SECTION B, LINE 11: THE MAJORITY OF THE ACTION NEEDING TO BE ADDRESSED IN THE CATEGORIES OF CANCER, MENTAL HEALTH AND SUBSTANCE ABUSE FALL OUT OF THE SCOPE OF EXPERTISE AND RESOURCES OF THE HOSPITAL. BRODSTONE MEMORIAL HOSPITAL PART V, SECTION B, LINE 13B: PATIENTS WHOSE FAMILY INCOME EXCEEDS 200% OF THE FPL MAY BE ELIGIBLE TO RECEIVE DISCOUNTED RATES ON A CASE-BY-CASE BASIS BASED ON THEIR SPECIFIC CIRCUMSTANCES, SUCH AS CATASTROPHIC ILLNESS OR MEDICAL INDIGENCE, AT THE DISCRETION OF BRODSTONE MEMORIAL HOSPITAL. BRODSTONE MEMORIAL HOSPITAL PART V, SECTION B, LINE 15E: PATIENTS MAY APPLY FOR ASSISTANCE BY CALLING BRODSTONE MEMORIAL HOSPITAL AT 402-879-3281 EXT. 115 AND REQUESTING A FINANCIAL ASSISTANCE APPLICATION; OR BY REQUESTING AN APPLICATION IN PERSON FROM REGISTRATION OR THE BUSINESS OFFICE. AN APPLICATION MAY BE DOWNLOADED FROM THE HOSPITAL'S WEBSITE. 2 1 - SUPERIOR FAMILY MEDICAL CENTER 525 E 11TH ST SUPERIOR NE 68978 RURAL HEALTH CLINIC 2 - NELSON FAMILY MEDICAL CENTER 76 W 8TH ST NELSON NE 68961 RURAL HEALTH CLINIC PART I, LINE 3C: NOT APPLICABLE: FEDERAL POVERTY GUIDELINES ARE USED TO DETERMINE ELIGIBILITY FOR PROVIDING FREE CARE AND DISCOUNTED CARE TO LOW INCOME INDIVIDUALS. PART I, LINE 6A: BRODSTONE'S COMMUNITY BENEFIT REPORT IS NOT PREPARED BY A RELATED ORGANIZATION. PART I, LINE 7: THE COST TO CHARGE RATIO AS FOLLOWS WAS USED TO DETERMINE CHARITY CARE AND MEANS-TESTED GOVERNMENT PROGRAMS AT COST: (TOTAL EXPENSES - BAD DEBT) / GROSS PATIENT SERVICE REVENUE = PERCENTAGE OF COST TO CHARGE. OTHER COMMUNITY BENEFIT EXPENSES ARE STATED AT COST BASED ON BRODSTONE'S INTERNAL ACCOUNTING RECORDS. PART I, LINE 7G: THERE ARE NO COSTS ATTRIBUTABLE TO A PHYSICIAN CLINIC INCLUDED ON LINE 7G. PART I, LINE 7, COLUMN (F): THE BAD DEBT EXPENSE INCLUDED ON FORM 990, PART IX, LINE 25, COLUMN (A), BUT SUBTRACTED FOR PURPOSES OF CALCULATING THE PERCENTAGE IN THIS COLUMN IS $ 640,210. PART II, COMMUNITY BUILDING ACTIVITIES: BRODSTONE HAS MANY ACTIVITIES TO PROMOTE HEALTH IN THE COMMUNITIES SERVED. THESE ACTIVITIES INCLUDE: SPONSOR OF HEALTH FAIR, SUPPORT GROUPS, EDUCATION PROGRAMS AND MEDICATION ASSISTANCE. THE DONATED SERVICES AND FUNDS HELP FURTHER THE MISSION AND GOALS OF COMMUNITY ORGANIZATIONS WHICH, IN TURN, HELP IMPROVE OVERALL HEALTH STATUS AND QUALITY OF LIFE OF THE COMMUNITIES SERVED. PART III, LINE 2: IN EVALUATING THE COLLECTIBILITY OF ACCOUNTS RECEIVABLE, THE HOSPITAL ANALYZES ITS PAST HISTORY AND IDENTIFIES TRENDS FOR EACH OF ITS MAJOR PAYOR SOURCES OF REVENUE TO ESTIMATE THE APPROPRIATE ALLOWANCE FOR DOUBTFUL ACCOUNTS AND PROVISION FOR BAD DEBTS. MANAGEMENT REGULARLY REVIEWS DATA ABOUT THESE MAJOR PAYOR SOURCES OF REVENUE IN EVALUATING THE SUFFICIENCY OF THE ALLOWANCE FOR DOUBTFUL ACCOUNTS. FOR RECEIVABLES ASSOCIATED WITH SERVICES PROVIDED TO PATIENTS WHO HAVE THIRD-PARTY COVERAGE, THE HOSPITAL ANALYZES CONTRACTUALLY DUE AMOUNTS AND PROVIDES AN ALLOWANCE FOR DOUBTFUL ACCOUNTS AND A PROVISION FOR BAD DEBTS FOR THOSE ACCOUNTS OVER A CERTAIN AGE BASED ON DISCHARGE THAT MAKE THE REALIZATION OF AMOUNTS DUE UNLIKELY. FOR RECEIVABLES ASSOCIATED WITH SELF-PAY PATIENTS (WHICH INCLUDES BOTH PATIENTS WITHOUT INSURANCE AND PATIENTS WITH DEDUCTIBLE AND COPAYMENT BALANCES DUE FOR WHICH THIRD-PARTY COVERAGE EXISTS FOR PART OF THE BILL), THE HOSPITAL RECORDS A SIGNIFICANT PROVISION FOR BAD DEBTS IN THE PERIOD OF SERVICE ON THE BASIS OF ITS PAST EXPERIENCE, WHICH INDICATES THAT MANY PATIENTS ARE UNABLE OR UNWILLING TO PAY THE PORTION OF THEIR BILL FOR WHICH THEY ARE FINANCIALLY RESPONSIBLE. THE DIFFERENCE BETWEEN THE STANDARD RATES (OR THE DISCOUNTED RATES IF NEGOTIATED) AND THE AMOUNTS ACTUALLY COLLECTED AFTER ALL REASONABLE COLLECTION EFFORTS HAVE BEEN EXHAUSTED IS CHARGED OFF AGAINST THE ALLOWANCE FOR DOUBTFUL ACCOUNTS. PART III, LINE 3: IN ACCORDANCE WITH ITS MISSION OBJECTIVES, THE HOSPITAL PROVIDES FREE CARE TO PATIENTS WHO LACK FINANCIAL RESOURCES TO PAY FOR THE SERVICES THEY RECEIVE. INCLUDED IN THE PROVISION FOR CONTRACTUAL ALLOWANCES IS THE VALUE (AT STANDARD CHARGES) OF THESE SERVICES TO PATIENTS WHO ARE UNABLE TO PAY, THAT IS ELIMINATED FROM NET PATIENT SERVICE REVENUES WHEN IT IS DETERMINED THEY QUALIFY UNDER THE HOSPITAL'S CHARITY CARE POLICY. THE ESTIMATED COST INCURRED BY THE HOSPITAL TO PROVIDE THESE SERVICES TO PATIENTS WHO ARE UNABLE TO PAY WAS APPROXIMATELY $192,000 AND $194,000 FOR THE YEARS ENDED APRIL 30, 2016 AND 2015, RESPECTIVELY. THE ESTIMATED COST OF THESE CHARITY CARE SERVICES WAS DETERMINED USING A RATIO OF COSTS TO GROSS CHARGES AND APPLYING THAT RATIO TO THE GROSS CHARGES ASSOCIATED WITH PROVIDING CARE TO CHARITY PATIENTS FOR THE PERIOD. GROSS CHARGES ASSOCIATED WITH PROVIDING CARE TO CHARITY PATIENTS INCLUDES ONLY THE RELATED CHARGES FOR THOSE PATIENTS WHO ARE FINANCIALLY UNABLE TO PAY AND QUALIFY UNDER THE HOSPITAL'S CHARITY CARE POLICY AND THAT DO NOT OTHERWISE QUALIFY FOR REIMBURSEMENT FROM A GOVERNMENTAL PROGRAM. DURING THE YEARS ENDED APRIL 30, 2016 AND 2015, THE HOSPITAL RECEIVED NO FUNDS TO HELP DEFRAY THE COSTS OF INDIGENT CARE. PART III, LINE 4: THE HOSPITAL'S FINANCIAL STATMENTS DO NOT CONTAIN A SPECIFIC FOOTNOTE DESCRIBING BAD DEBT. HOWEVER, PAGES 8 AND 10 OF THE ATTACHED AUDITED FINANCIAL STATEMENTS INCLUDE FOOTNOTES TITLED "PATIENT RECEIVABLES, NET", "NET PATIENT SERVICE REVENUE AND "CHARITY CARE". PART III, LINE 8: "MEDICARE ALLOWABLE COSTS OF CARE" WAS CALCULATED FROM INFORMATION IN THE MEDICARE COST REPORT D, E, H & M WORKSHEETS, OR PS&R. THESE COSTS ARE MEDICARE REIMBURSABLE COSTS, NOT ALL COSTS. NO MEDICARE SHORTFALL IS TREATED AS COMMUNITY BENEFIT. PART III, LINE 9B: PATIENTS WHO QUALIFY FOR MEDICAID WILL AUTOMATICALLY QUALIFY FOR FINANCIAL ASSISTANCE AND MAY QUALIFY FOR MORE IF THEY COMPLETE THE FINANCIAL ASSISTANCE APPLICATION. THESE PATIENTS WILL NOT BE SENT TO COLLECTIONS IF THEY PAY THE AMOUNT FOR WHICH THEY QUALIFY.BRODSTONE'S POLICIES AND PROCEDURES FOR INTERNAL AND EXTERNAL COLLECTION PRACTICES TAKE INTO ACCOUNT THE EXTENT TO WHICH THE PATIENT QUALIFIES FOR CHARITY, A PATIENT'S GOOD FAITH EFFORT TO APPLY FOR A GOVERNMENTAL PROGRAM OR FOR CHARITY FROM THE HOSPITAL AND A PATIENT'S GOOD FAITH EFFORT TO COMPLY WITH HIS OR HER PAYMENT AGREEMENTS WITH THE HOSPITAL. FOR PATIENTS WHO QUALIFY FOR CHARITY AND WHO ARE COOPERATING IN GOOD FAITH TO RESOLVE THEIR BILLS, BRODSTONE MAY OFFER EXTENDED PAYMENT PLANS TO ELIGIBLE PATIENTS, WILL NOT IMPOSE WAGE GARNISHMENTS OR LIENS, WILL NOT SEND UNPAID BILLS TO OUTSIDE COLLECTION AGENCIES AND WILL CEASE ALL COLLECTION EFFORTS. PART VI, LINE 2: BRODSTONE ASSESSES THE HEALTH CARE NEEDS OF THE COMMUNITY IT SERVES THROUGH A SURVEY. THE BUDGETING PROCESS PUBLISHES SUGGESTIONS AND STRATEGIC PLANNING. HOSPITAL STAFF ALSO NETWORKS WITH OTHER HEALTH CARE ORGANIZATIONS TO DEVELOP IDEAS OF WHAT CAN BE DONE TO IMPROVE THE AVAILABILITY OF SERVICES IN THE COMMUNITY. PART VI, LINE 3: BRODSTONE HAS A BROCHURE CALLED CHARITY POLICY THAT ADDRESSESS THE FINANCIAL ASSISTANCE AVAILABILITY. IT IS POSTED AT THE ADMISSIONS AREAS AND EMERGENCY ROOM. THE CHARITY POLICY IS DISCUSSED WHEN MAKING PAYMENT ARRANGEMENTS. THIS POLICY IS ALSO AVAILABLE ON THE HOSPITAL'S WEBSITE. PART VI, LINE 4: SUPERIOR HAS A POPULATION OF 1,933 AND IS LOCATED ON THE NEBRASKA-KANSAS BORDER. BRODSTONE'S SERVICE AREA COVERS ALL OF NUCKOLLS COUNTY AND PARTS OF 2 OTHER COUNTIES IN NEBRASKA AND 3 COUNTIES IN KANSAS. THE MEDIAN HOUSEHOLD INCOME FOR NUCKOLLS COUNTY IS $33,875 COMPARED TO THE U.S. AVERAGE AT $51,324 AND THE NEBRASKA AVERAGE OF $51,381. THE AREA POPULATION IS PREDOMINATELY WHITE ELDERLY AND LOW INCOME. 58% OF THE HOSPITAL'S PATIENTS ARE MEDICARE PATIENTS. PART VI, LINE 5: BRODSTONE'S GOVERNING BODY CONSISTS OF 2 MEN AND 4 WOMEN WITH NO IMMEDIATE FAMILY TIES TO ANY EMPLOYEE NOR ARE THEY CONTRACTORS OF THE ORGANIZATION. ALL BOARD MEMBERS ARE RESIDENTS OF NUCKOLLS COUNTY, NE. ALL FAMILY PRACTICE PHYSIANS AND MIDLEVELS IN THE AREA WHO HAVE REQUESTED MEDICAL STAFF PRIVILEGES AND MEET THE REQUIREMENTS HAVE PRIVILIGES AT THE HOSPITAL. ONE DENTIST HAS COURTESY PRIVELEGES. ALL SURPLUS FUNDS OF THE ORGANIZATION ARE USED TO FUND THE BUDGET FOR THE COMING YEARS OR SET ASIDE FOR FUTURE PROJECTS. PART VI, LINE 6: BRODSTONE MEMORIAL HOSPITAL IS NOT PART OF AN AFFILIATED HEALTH CARE SYSTEM. PART VI, LINE 7: BRODSTONE DOES NOT FILE A COMMUNITY BENEFIT REPORT WITH ANY STATE. X 1 1 X X X X 0 0 0 1 0 0 0 0 0 JOHN KEELAN CEO 215629 0 0 0 0 0 6630 0 23869 0 246128 0 0 0 SANDRA BORDEN CFO 153946 0 0 0 0 0 4817 0 24466 0 183229 0 0 0 TIMOTHY BLECHA MD PHYSICIAN 201994 0 52594 0 0 0 7834 0 24615 0 287037 0 0 0 JULIE THEIS MD PHYSICIAN 194482 0 0 0 0 0 6062 0 31773 0 232317 0 0 0 ROBERT LEIBEL MD PHYSICIAN 181444 0 0 0 0 0 5641 0 30773 0 217858 0 0 0 JASON HASS PA-C PHYSICIAN ASSISTANT 120849 0 0 0 0 0 3853 0 31694 0 156396 0 0 0 PART I, LINE 1A JOHN KEELAN, CEO, IS PROVIDED THE LOCAL COUNTRY CLUB MEMBERSHIP. PART I, LINE 5 IN ACCORDANCE WITH RELATED EMPLOYMENT CONTRACTS, ADDITIONAL COMPENSATION IS PAID BASED ON REVENUES GENERATED BY EACH MEDICAL PROVIDER, AS DEFINED. THESE ADDITIONAL AMOUNTS HAVE BEEN LISTED AS INCENTIVE COMPENSATION IN PART II OF THIS SCHEDULE. A THE CITY OF SUPERIOR NEBRASKA 476006376 2013-05-22 4000000 REFUND ISSUES (9/9/03, 9/10/09, 9/10/09) 0 0 0 B THE COUNTY OF NUCKOLLS NEBRASKA 476006492 2013-05-22 4000000 REFUND ISSUES (9/9/03, 9/10/09, 9/10/09) 0 0 0 A 638736 4000000 4000000 2010 1 0 1 1 B 638736 4000000 4000000 2010 1 0 1 1 A 0 0 0 0 0 0 1 B 0 0 0 0 0 0 1 A 0 0 1 1 0 0 0 0 1 B 0 0 1 1 0 0 0 0 1 A 1 B 1 SCHEDULE K, PART IV, LINE 2C: (A) ISSUER NAME: CITY OF SUPERIOR, NEBRASKA DATE THE REBATE COMPUTATION WAS PERFORMED: 05/22/2013 (B) ISSUER NAME: THE COUNTY OF NUCKOLLS, NEBRASKA DATE THE REBATE COMPUTATION WAS PERFORMED: 05/22/2013 NOTE REGARDING THE REBATE COMPUTATIONS: SINCE THE BOND PROCEEDS WERE SPENT ON THE ISSUE DATE, A SPENDING EXCEPTION WAS MET, AND THE DEBT SERVICE FUND WAS OPERATED ON A BONA FIDE BASIS, NO FURTHER REBATE CALCULATIONS ARE NECESSARY. FORM 990, PART VI, SECTION B, LINE 11 THE FORM 990 IS PREPARED BY AN OUTSIDE ACCOUNTING FIRM. BEFORE IT IS FILED, IT IS GIVEN A DETAILED REVIEW BY MANAGEMENT AND THEN A GENERAL REVIEW BY THE BOARD OF DIRECTORS AT A REGULARLY SCHEDULED BOARD MEETING. A FINAL COPY OF THE FORM 990 WILL BE ELECTRONICALLY FILED AFTER APPROVAL. FORM 990, PART VI, SECTION B, LINE 12C BOARD MEMBERS WHO HAVE A CONFLICT OF INTEREST WOULD REFRAIN FROM DISCUSSION AND VOTING ON THOSE MATTERS. THERE IS AN ANNUAL BOARD MEMBER TRAINING THAT COVERS THIS POLICY. ADDITIONALLY, ALL BOARD MEMBERS ARE WELL ACQUAINTED WITH EACH OTHER SO IF THERE WAS A CONFLICT OF INTEREST AND THE BOARD MEMBER DID NOT DISCLOSE, THE OTHER BOARD MEMBERS WOULD BRING IT TO THE BOARD'S ATTENTION. FORM 990, PART VI, SECTION B, LINE 15 THE HUMAN RESOURCE DIRECTOR PREPARES A SALARY SURVEY ANNUALLY FOR ALL JOBS DESCRIPTIONS WITH HOSPITALS OF SIMILAR SIZE AND REVENUES. THE BOARD OF DIRECTORS REVIEWS THE SURVEY AND PRIOR SALARY INCREASES FOR THE CEO BEFORE GRANTING PAY INCREASES. THE HUMAN RESOURCE DIRECTOR AND CFO MAKE RECOMMENDATIONS TO THE CEO FOR OTHER EMPLOYEES. THE CEO REVIEWS THE SURVEY, PRIOR SALARY INCREASES, AND RECOMMENDATIONS BEFORE APPROVING PAY INCREASES FOR EMPLOYEES. THE PAY INCREASES ARE APPROVED BY THE BOARD OF DIRECTORS DURING THE BUDGET PROCESS. FORM 990, PART VI, SECTION C, LINE 19 THE ORGANIZATION DOES NOT MAKE ITS GOVERNING DOCUMENTS AND CONFLICT OF INTEREST POLICY AVAILABLE TO THE PUBLIC, BUT FINANCIAL STATEMENTS ARE AVAILABLE UPON REQUEST. FORM 990, PART XI, LINE 9: CHANGE IN BENEFICIAL INTEREST IN TRUSTS -97,821. FORM 990, PART XII, LINE 2C: THE BOARD OF DIRECTORS ASSUMES THE RESPONSIBILITY FOR OVERSIGHT OF THE AUDIT OF ITS FINANCIAL STATEMENTS AND THE SELECTION OF AN INDEPENDENT ACCOUNTANT. THIS PROCESS HAS NOT CHANGED FROM THE PRIOR YEAR. E B VESTEY TRUST UA UNB & NORTHERN CO SUCC BENEFIT BRODSTONE MEM HOSP 620 LIBERTY AVE 10 FLR UNB PITTSBURGH PA 15222 226023351 ASSISTING IN THE OPERATIONS OF BRODSTONE MEMORIAL HOSPITAL PA 4947(A)(1) PF BRODSTONE MEMORIAL HOSPITAL 1 0 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 E B VESTEY TRUST C 40848 FMV