2016-05-13T10:59:13-05:00 2015-06-30 410746749 CLIFTONLARSONALLEN LLP 220 SOUTH SIXTH STREET SUITE 300 MINNEAPOLIS MN 55402 990 2014-07-01 420890973 OSCEOLA COMMUNITY HOSPITAL INC OSCE 7127542574 600 9TH AVENUE NORTH SIBLEY IA 51249 JANET DYKSTRA CEO 7127542574 2016-05-13 1 KURT BENNION P01469618 6123764500 2014 2016-08-17 19:52:53Z JANET DYKSTRA 600 9TH AVENUE NORTH SIBLEY IA 51249 11746034 0 X WWW.OSCEOLACOMMUNITYHOSPITAL.ORG X 1960 IA TO PROVIDE HEALTHCARE TO THE CITIZENS OF OSCEOLA COUNTY AND THE SURROUNDING AREA. 9 9 136 193 438442 -163339 154935 267465 10215457 10365448 78823 113780 1014800 998179 11464015 11744872 0 0 0 0 5038808 5585655 0 0 0 6443814 6218777 11482622 11804432 -18607 -59560 20140124 20133437 6533727 6663245 13606397 13470192 IT IS THE MISSION OF THE OSCEOLA COMMUNITY HOSPITAL TO ENHANCE AND IMPROVE THE QUALITY OF LIFE OF THE POPULATION IT SERVES, TO BE THE AREA'S PREMIER HEALTH CARE SERVICE PROVIDER, AND TO HAVE A POSITIVE IMPACT ON THE LIVES OF THE PEOPLE AND COMMUNITY IT SERVES. 0 0 8325243 0 10365448 OSCEOLA COMMUNITY HOSPITAL PROVIDED NURSING SERVICES, LAB, RADIOLOGY AND OTHER RELATED HOSPITAL FUNCTIONS TO RESIDENTS OF OSCEOLA COUNTY, IOWA AND NEARBY COUNTIES. IN ADDITION THE HOSPITAL ALSO PROVIDES HOME HEALTH, INDEPENDANT/ASSISTED LIVING, AND DAY CARE TO THE COMMUNITY. HEALTH SCREENINGS SUCH AS CHOLOSTERAL AND CARDIAC ARE PROVIDED AS WELL. THE HOSPITAL WORKS HARD TO BRING OUTREACH SPECIALISTS TO THE FACILITY TO MAKE THESE SERVICES AVAILABLE TO THOSE THAT FIND IT DIFFICULT TO TRAVEL. THE FACILITY'S WELLNESS CENTER PROVIDES PROGRAMS TO THE LOCAL SCHOOL SYSTEM, NURSING HOME FACILITIES, OUTPAITIENTS, AND THE COMMUNITY AT LARGE. DURING THE 12 MONTHS OF 07/01/14 - 06/30/15 THE HOSPITAL PROVIDED $39,401 OF CHARITY CARE TO VARIOUS INDVIDUALS, WITHOUT REIMBURSEMENT. 8325243 1 1 0 0 0 0 0 0 0 0 1 1 0 0 0 1 0 1 0 0 0 0 0 0 0 0 1 1 0 0 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 1 1 0 0 1 37 0 136 1 1 1 0 0 0 0 0 0 0 0 0 X 9 9 0 0 0 0 1 1 0 1 1 0 0 0 1 1 1 1 1 1 1 0 IA X LORRIE REED 7127542574 600 9TH AVENUE NORTH SIBLEY IA 51249 DARYL BOSMA PRESIDENT (THROUGH AUG 2014) 1.00 1.00 X X 0 0 0 DEB KOHN PRESIDENT 1.00 1.00 X X 0 0 0 JIM BENZ PRESIDENT-ELECT 1.00 0.00 X X 0 0 0 KATI JACOBS SECRETARY 1.00 0.00 X X 0 0 0 STANLEY JOHNSON TREASURER 1.00 1.00 X X 0 0 0 SHIRLEY CHRISTIANS TRUSTEE 1.00 0.00 X 0 0 0 BARB VAN DIEPEN TRUSTEE 1.00 0.00 X 0 0 0 BRIAN DREESSEN TRUSTEE 1.00 0.00 X 0 0 0 KAREN GLADE TRUSTEE 1.00 0.00 X 0 0 0 KEVIN HERTZ TRUSTEE 1.00 0.00 X 0 0 0 DAVID JUNGERS TRUSTEE 1.00 1.00 X 0 0 0 SUE ELLEN SCHUTTE TRUSTEE 1.00 0.00 X 0 0 0 JANET DYKSTRA CEO 50.00 1.00 X 136220 0 9364 JULIE SCHROEDER ASSISTANT ADMINISTRATOR 45.00 0.00 X 80463 0 6995 JERRI PALSROK THROUGH JAN 2015 CFO 45.00 0.00 X 52375 0 6079 LORRIE REED CFO 45.00 0.00 X 32968 0 4890 302026 0 27328 1 0 0 0 AVERA MCKENNAN HOSPITAL 1325 S CLIFF AVE PO BOX 5045 SIOUX FALLS SD 57117 ADMINISTRATIVE AND MEDICAL SERVICES 760785 GREAT LAKE PHYSICAL THERAPY 2714 CENTER LAKE DRIVE SPIRIT LAKE IA 51360 PHYSICAL THERAPY SERVICES 287185 SANFORD HOSPITAL PO BOX 5074 SIOUX FALLS SD 57117 PATHOLOGY, SPEECH & CRNA SERVICES 198049 ROBERT THORBROGGER 24376 140TH STREET SPIRIT LAKE IA 51360 RADIOLOGY SERVICES 133278 AVERA ECARE 3900 W AVERA DRIVE SUITE 301 SIOUX FALLS SD 57108 EMERGENCY SERVICES 113195 8 121591 145874 267465 PATIENT REVENUE 621400 10271014 10271014 OTHER REVENUE 621400 94434 94434 10365448 13187 13187 86232 0 86232 86232 86232 97355 4400 1162 0 96193 4400 100593 100593 75969 0 75969 75969 DAYCARE REVENUE 624410 369605 369605 340B PROGRAM REVENUE 621400 199401 199401 MISCELLANEOUS INCOME 621400 101509 101509 165463 68837 96626 835978 11744872 10365448 438442 673517 X 342365 342365 3348293 2456814 891479 77282 52126 25156 1559947 862936 697011 257768 168853 88915 10756 10756 98672 98672 2031710 1736193 295517 193573 193573 77521 17879 59642 585561 229521 356040 31172 25997 5175 271346 271346 1121058 1121058 80890 11473 69417 DRUG COST 721122 721122 MEDICAL SUPPLIES 457756 270638 187118 BAD DEBTS EXPENSE 142249 142249 FOOD COST 119322 14662 104660 276069 222376 53693 11804432 8325243 3479189 0 1982713 1152638 1406563 1459831 12071 12071 2277783 3336938 197485 194266 348816 379020 78101 69623 19915250 11608594 9178058 8306656 2692416 3064936 1821015 2025253 145103 132205 20140124 20133437 1038083 1365217 5315644 5154028 180000 144000 6533727 6663245 X 13508616 13330174 97781 140018 13606397 13470192 20140124 20133437 -59560 -76645 0 X 0 1 X 1 0 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 305678 305678 12869221 6261310 6607911 566994 517374 49620 6173357 4829910 1343447 8306656 86198 F AVERA FOUNDATION POOLED INVESTMENT 1939055 F 2025253 X PART X, LINE 2: THE HOSPITAL HAS BEEN GRANTED EXEMPT STATUS RELATIVE TO INTERNAL REVENUE SERVICE CODE SECTION 501(C)(3) OF THE INTERNAL REVENUE CODE, THUS THERE IS NO PROVISION FOR INCOME TAXES AT JUNE 30, 2015 AND 2014. THE HOSPITAL HAS ELECTED TO ADOPT GUIDANCE IN THE INCOME TAX STANDARD REGARDING RECOGNITION AND MEASUREMENT OF UNCERTAIN TAX POSITIONS. THE ADOPTION OF THIS STANDARD HAS NO EFFECT ON THE CONSOLIDATED FINANCIAL STATEMENTS. THE HOSPITAL'S TAX RETURNS ARE SUBJECT TO REVIEW AND EXAMINATION BY FEDERAL, STATE, AND LOCAL AUTHORITIES. 1 1 X 1 X 133.000000000000 1 X 185.000000000000 1 1 1 0 1 0 39401 39401 0.00340 785004 494898 290106 0.02490 824405 494898 329507 0.02830 388267 13750 374517 0.03210 23852 23852 0.00200 78495 78495 0.00670 490614 13750 476864 0.04080 1315019 508648 806371 0.06910 158775 158775 0.01360 11609 11609 0.00100 8186 8186 0.00070 43166 43166 0.00370 221736 221736 0.01900 1 142249 71125 5045110 5356845 -311735 X 1 1 1 1 OSCEOLA COMMUNITY HOSPITAL 600 NINTH AVENUE NORTH SIBLEY IA 51249 WWW.OSCEOLACOMMUNITYHOSPITAL.ORG 720109H X X X X OSCEOLA COMMUNITY HOSPITAL 1 0 0 1 X X X X X X X X X 12 1 0 0 1 X WWW.AVERA.ORG/APP/FILES/PUBLIC/12221/2013-CHNA-OSCEOLA X 1 12 0 0 0 1 X 133.000000000000 185.000000000000 X X X X X 1 1 1 X X 1 X 0 X X X 1 X 0 0 OSCEOLA COMMUNITY HOSPITAL PART V, SECTION B, LINE 5: THE 2012 OSCEOLA COMMUNITY HOSPITAL HEALTH NEEDS ASSESSMENT REPRESENTS A COMBINATION OF QUANTITATIVE AND QUALITATIVE INFORMATION BASED ON CENSUS DATA, TECHNICAL DATA AND FOCUS GROUP FEEDBACK FROM COMMUNITY ORGANIZATIONS, LEADERS, CONSUMERS AND HEALTH PROFESSIONALS. LOCAL DATA WAS COMPARED TO STATE, NATIONAL AND BENCHMARK INFORMATION. THE RESULTS OF THE COMMUNITY HEALTH NEEDS ASSESSMENT SURVEYS WERE REVIEWED AND TABULATED. TWELVE FOCUS GROUPS WERE GIVEN THE SURVEYS WITH 263 PEOPLE RESPONDING TO THE QUESTIONNAIRE, 37 PEOPLE RESPONDED FROM THE HEALTH FAIR AND 10 OTHER PEOPLE FROM THE COMMUNITY ALSO RESPONDED TO THE SURVEY. THIS GAVE US A TOTAL OF 310 PEOPLE WHO PARTICIPATED IN THE 2012 COMMUNITY NEEDS ASSESSMENT. SINCE THE GREATEST PORTION OF THE ORGANIZATION'S PATIENT AND CUSTOMERS RESIDE IN OSCEOLA AND LYON COUNTIES, FOCUS GROUPS AND PAPER SURVEYS WERE TAKEN TO SIX SURROUNDING TOWNS OF HARRIS, MELVIN, OCHEYEDAN, ASHTON, LITTLE ROCK AND GEORGE, ALL IN IOWA. A PAPER SURVEY WAS HANDED OUT TO PARTICIPANTS AT THE HOSPITAL AND VARIOUS CONGREGATE PLACES, AND FOCUS GROUPS WERE CONDUCTED IN EACH COMMUNITY. SPECIAL ATTENTION WAS TAKEN THROUGHOUT THE PRIMARY DATA COLLECTION PROCESS TO ENSURE THE HOSPITAL'S ASSESSMENT TOOK INTO ACCOUNT INPUT FROM PERSONS WHO REPRESENTED THE BROAD INTERESTS OF THE COMMUNITY, INCLUDING THOSE WITH SPECIAL KNOWLEDGE AND EXPERTISE IN PUBLIC HEALTH.THE FOCUS GROUP MEMBERS INCLUDED REPRESENTATIVES FROM THE MEDICAL COMMUNITY AND CIVIC ORGANIZATIONS, BUSINESS OWNERS, FARMERS, PUBLIC HEALTH OFFICIALS, EMTS, FIREFIGHTERS, CITY AND COUNTY OFFICIALS, SIBLEY-OCHEYEDAN SCHOOL PERSONNEL, MENTAL HEALTH PROVIDERS, OSCEOLA COUNTY SHERRIFF'S OFFICE PERSONNEL, DOMESTIC ABUSE COUNSELORS, SUBSTANCE ABUSE AND MENTAL HEALTH COUNSELORS, MINISTERIAL ASSOCIATION MEMBERS, BOARD OF TRUSTEE MEMBERS, PATIENTS, AND PEOPLE REPRESENTING THE UNINSURED AND UNDERINSURED POPULATION. ALL AGE GROUPS WERE REPRESENTED IN THE FOCUS GROUPS.OSCEOLA COMMUNITY HOSPITAL REACHED OUT TO A GROWING HISPANIC POPULATION WITH SURVEYS AND FOCUS GROUP REPRESENTATION. OSCEOLA COMMUNITY HOSPITAL PART V, SECTION B, LINE 11: DURING THE 2012 COMMUNITY HEALTH NEEDS ASSESSMENT, THE SIGNIFICANT HEALTH NEEDS WERE IDENTIFIED AS ACCESS TO HEALTH CARE, MENTAL HEALTH, AND HEALTH IMPROVEMENT AND PROMOTION. DURING THE FISCAL YEAR ENDED 6/30/2015, THE FOLLOWING ACTIONS WERE TAKEN BY OSCEOLA COMMUNITY HOSPITAL TO ADDRESS THOSE SIGNIFICANT HEALTH NEEDS.ACCESS TO HEALTH CAREA FEMALE FPOB PHYSICIAN WAS RECRUITED. SHE BEGAN HER PRACTICE WITH THE AVERA MEDICAL GROUP SIBLEY IN OCTOBER OF 2014. EFFORTS CONTINUE TO RECRUIT ANOTHER FAMILY PRACTICE PHYSICIAN. A GENERAL SURGEON WAS RECRUITED AND STARTED PRACTICE IN THE SPRING OF 2015.MENTAL HEALTH SERVICES COUNSELINGONGOING MEETINGS WERE HELD BETWEEN AVERA PHYSICIANS, OSCEOLA COMMUNITY HOSPITAL STAFF, SEASONS COUNSELING SERVICES, AND SPENCER HOSPITAL MENTAL HEALTH SERVICES REGARDING THE NEED FOR INCREASED MENTAL HEALTH SERVICES. WE PARTNERED WITH THE NORTHWEST IOWA CARE CONNECTIONS MHDS REGION TO ADDRESS THE NEEDS OF INDIVIDUALS IN OUR AREA. THESE MEETINGS ARE ONGOING.TELE-PSYCHOLOGY SERVICES WERE SET UP WITH SEASONS MENTAL HEALTH CENTER AND OCCURRED AT OUR HOSPITAL. THIS INCREASED THE ACCESS FOR OUTPATIENT MENTAL HEALTH SERVICES.WE DID PSYCH SCREENINGS VIA EEMERGENCY THROUGH AVERA HOSPITAL, SIOUX FALLS, SD. THE BEHAVIORAL HEALTH HOSPITAL IN SIOUX FALLS NOW CAN TAKE IOWA MEDICAID PATIENTS. THIS HAS MADE PLACEMENT EASIER AT TIMES.HEALTH IMPROVEMENT AND PROMOTIONHEART DISEASE IS THE #1 RANKED CAUSE OF DEATH IN OSCEOLA COUNTY AND WE CONTINUE TO DO EDUCATION IN THE COUNTY AND SURROUNDING AREAS. AN INFLATABLE MEGA HEART WAS ON DISPLAY AT THE FARM & HOME SHOW, OSCEOLA COUNTY FAIR AND SIBLEY OCHEYEDAN SCHOOL. EDUCATION WAS DONE REGARDING THE IMPORTANCE OF TAKING CARE OF YOUR HEART AND THE FUNCTION OF THE HEART. WE HAD LUNCH AND LEARNS ON EXERCISE TRAINING, HEALTHY NUTRITION AND PREVENTION OF HEART DISEASE. WE DID MONTHLY BLOOD PRESSURE CHECKS AT OUR WELLNESS CENTER. OSCEOLA COMMUNITY HOSPITAL PART V, SECTION B, LINE 16I: IF THE PATIENTS ARE UNINSURED, THE HOSPITAL CONTACTS THEM VIA PHONE OR LETTER TO INFORM THEM OF THE FINANCIAL ASSISTANCE POLICY. OSCEOLA COMMUNITY HOSPITAL PART V, SECTION B, LINE 22D: THE HOSPITAL CALCULATES AMOUNTS GENERALLY BILLED AS THE AVERAGE CONTRACTUAL DISCOUNT GIVEN TO COMMERCIAL PAYERS, EXCLUDING BLUE CROSS. THIS CONTRACTUAL DISCOUNT IS LESS THAN THE SMALLEST POSSIBLE DISCOUNT UNDER THE HOSPITAL'S FINANCIAL ASSISTANCE POLICY. PART I, LINE 3C: OSCEOLA COMMUNITY HOSPITAL UTILIZES FEDERAL POVERTY GUIDELINES TO DETERMINE HOSPITAL ASSISTANCE ELIGIBILITY BASED ON THE HOUSEHOLD YEARLY GROSS INCOME. TO BE ELIGIBLE TO RECEIVE UNCOMPENSATED CARE, THE PATIENT MUST HAVE BEEN AN OSCEOLA COUNTY RESIDENT FOR A CONTINUOUS TWELVE MONTH PERIOD. PROOF OF RESIDENCY MUST BE PROVIDED UPON REQUEST. OSCEOLA COMMUNITY HOSPITAL WILL NOT EXTEND HOSPITAL ASSISTANCE TO CASES DEEMED AS COSMETIC. PART I, LINE 6A: THE HOSPITAL'S COMMUNITY BENEFIT REPORT IS INCLUDED IN A REPORT PREPARED BY THE IOWA HOSPITAL ASSOCIATION, RATHER THAN IN A SEPARATE REPORT PREPARED BY THE ORGANIZATION. THIS REPORT IS MADE AVAILABLE BY THE IOWA HOSPITAL ASSOCIATION TO THE PUBLIC THROUGH THIER WEBSITE. PART I, LINE 7: COSTING METHODOLOGY:THE AMOUNTS REPORTED IN PART I, LINE 7 WERE CALCULATED BY USING THE COST-TO-CHARGE RATIO DERIVED FROM WORKSHEET 2 OF THE IRS SCHEDULE H INSTRUCTIONS. PART I, LINE 7, COLUMN (F): THE BAD DEBT EXPENSE INCLUDED ON FORM 990, PART IX, LINE 25, COLUMN (A), BUT SUBTRACTED FOR PURPOSES OF CALCULATING THE PERCENTAGE IN THIS COLUMN IS $ 146,212. PART III, LINE 2: IN EVALUATING THE COLLECTABILITY OF PATIENT ACCOUNTS RECEIVABLE, THE HOSPITAL ANALYZES ITS PAST HISTORY AND IDENTIFIES TRENDS FOR EACH OF ITS MAJOR PAYOR SOURCES OF REVENUE TO ESTIMATE THE APPROPRIATE ALLOWANCE FOR DOUBTFUL ACCOUNTS AND PROVISION FOR BAD DEBTS. FOR RECEIVABLES ASSOCIATED WITH SERVICES PROVIDED TO PATIENTS WHO HAVE THIRD-PARTY COVERAGE, THE HOSPITAL ANALYZES CONTRACTUALLY DUE AMOUNTS AND PROVIDES AN ALLOWANCE FOR DOUBTFUL ACCOUNTS AND A PROVISION FOR BAD DEBTS, IF NECESSARY. FOR RECEIVABLES ASSOCIATED WITH SELF-PAY PATIENTS (WHICH INCLUDES BOTH PATIENTS WITHOUT INSURANCE AND PATIENTS WITH DEDUCTIBLE AND COPAYMENT BALANCES DUE FOR WHICH THIRD-PARTY COVERAGE EXISTS FOR PART OF THE BILL), THE HOSPITAL RECORDS A PROVISION FOR BAD DEBTS IN THE PERIOD OF SERVICE ON THE BASIS OF ITS PAST EXPERIENCE, WHICH INDICATES THAT MANY PATIENTS ARE UNABLE OR UNWILLING TO PAY THE PORTION OF THEIR BILL FOR WHICH THEY ARE FINANCIALLY RESPONSIBLE. THE DIFFERENCE BETWEEN THE STANDARD RATES (OR THE DISCOUNTED RATES IF NEGOTIATED) AND THE AMOUNTS ACTUALLY COLLECTED AFTER ALL REASONABLE COLLECTION EFFORTS HAVE BEEN EXHAUSTED IS CHARGED OFF AGAINST THE ALLOWANCE FOR DOUBTFUL ACCOUNTS. PART III, LINE 3: THE ESTIMATED AMOUNT OF THE ORGANIZATION'S BAD DEBT EXPENSE ATTRIBUTABLE TO PATIENTS ELIGIBLE UNDER THE ORGANIZATION'S CHARITY CARE POLICY IS 50%. THIS IS BASED ON RECORD REVIEWS AND ANALYSIS OF DEMOGRAPHICS. PART III, LINE 4: FOR A DESCRIPTION OF THE ORGANIZATION'S BAD DEBT EXPENSE, SEE THE "PATIENT RECEIVABLES, NET" SECTION OF NOTE 1 TO THE FINANCIAL STATEMENTS ON PAGES 8-9 OF THE ATTACHED FINANCIAL STATEMENTS. PART III, LINE 8: THE ORGANIZATION IS A CRITICAL ACCESS HOSPITAL AND IS NORMALLY REIMBURSED AT 101% OF COST. HOWEVER, BECAUSE OF THE FEDERAL GOVERNMENT'S SEQUESTRATION IN THE SUMMER OF 2015, THE ORGANIZATION IS REPORTING A SMALL SHORTFALL FOR THE YEAR ENDED JUNE 30, 2015.THE MEDICARE ALLOWABLE COSTS INCLUDED IN PART III, LINE 6 WERE DERIVED FROM THE 2015 FILED MEDICARE COST REPORT. PART III, LINE 9B: EMERGENT PATIENTS THAT ARE KNOWN TO QUALIFY FOR FINANCIAL ASSISTANCE ARE CONTACTED AS SOON AS POSSIBLE AFTER THEIR SERVICE IN ORDER TO PROVIDE THEM WITH THE INFORMATION CONCERNING THE TYPE OF ASSISTANCE WE BELIEVE THEM TO QUALIFY FOR. THEY ARE SUPPLIED FORMS AND ASSISTANCE IN COMPLETION OF THE FORMS IF NECESSARY. NON-EMERGENT PATIENTS ARE QUESTIONED PRIOR TO RECEIVING THE SERVICE AND GIVEN INFORMATION ON STATE ASSISTANCE PROGRAMS THAT THEY MIGHT QUALIFY FOR. WE ALSO GIVE INFORMATION ON OUR FACILITY PAYMENT PLANS AND OUR ASSISTANCE POLICY. IF THE PATIENT QUALIFIES FOR THE ORGANIZATION'S FINANCIAL ASSISTANCE POLICY FOR LOW-INCOME, UNINSURED PATIENTS AND IS COOPERATING WITH THE ORGANIZATION WITH REGARD TO EFFORTS TO SETTLE AN OUTSTANDING BILL WITHIN A REASONABLE TIME PERIOD, THE ORGANIZATION OR IT'S AGENT SHALL NOT SEND, NOR INTIMATE THAT IT WILL SEND, THE UNPAID BILL TO ANY OUTSIDE AGENCY IF DOING SO MAY NEGATIVELY IMPACT A PATIENT'S CREDIT. AT SUCH TIME AS THE ORGANIZATION SENDS THE UNCOLLECTED ACCOUNT TO AN OUTSIDE COLLECTION AGENCY, THE AMOUNT REFERRED TO THE AGENCY SHALL REFLECT THE REDUCED-PAYMENT LEVEL FOR WHICH THE PATIENT WAS ELIGIBLE UNDER THE ORGANIZATION'S FINANCIAL ASSISTANCE POLICY FOR LOW-INCOME UNINSURED PATIENTS.ANY EXTENDED PAYMENT PLANS OFFERED BY THE ORGANIZATION IN SETTLING THE OUTSTANDING BILLS OF LOW INCOME, UNINSURED PATIENTS WHO QUALIFY FOR FINANCIAL ASSISTANCE SHALL BE INTEREST-FREE SO LONG AS THE REPAYMENT SCHEDULE IS MET. PART VI, LINE 2: THE HOSPITAL ASSESSES THE HEALTH CARE NEEDS OF THE COMMUNITY THROUGH FORMAL PROCESSES THAT INCLUDE, MEETINGS, SURVEY AND COMMUNITY INPUT PRIOR TO UNDERTAKING ANY LARGE PROJECTS. THROUGHOUT THE YEAR, COMMUNITY NEEDS ARE ASSESSED INFORMALLY AT VARIOUS COMMUNITY MEETINGS AND THROUGH PATIENT SURVEYS. THE ORGANIZATION ALSO ASSISTS THE HOME HEALTH DEPARTMENT/PUBLIC HEALTH WITH A COMMUNITY NEEDS ASSESSMENT INFORMATION FROM THE CHNA IS UTILIZED TO HELP PLAN SERVICES THE ORGANIZATION OFFERS. PART VI, LINE 3: DURING THE COURSE OF PRE-REGISTRATION A MODE OF PAYMENT IS RECORDED ON THE ADMISSION FORM. IF INSURANCE IS INDICATED, BENEFITS ARE REQUEST FROM THE INSURANCE COMPANY. IF IT IS NOTED THAT THE ACCOUNT HAS A LARGE DEDUCTIBLE OR IS SELF PAY, THE INFORMATION IS FORWARDED TO THE COLLECTION STAFF AND SOCIAL SERVICES. OPTIONS FOR HANDLING PAYMENT OF THE ACCOUNT ARE THEN DISCUSSED WITH THE PATIENT OR THE RESPONSIBLE PARTY. IF THE PATIENT OR RESPONSIBLE PARTY IS NOT AVAILABLE AT THE TIME THE INFORMATION IS RECEIVED BY THE BUSINESS OFFICE OR SOCIAL SERVICE STAFF, EFFORTS TO CONTACT THEM INCLUDE PHONE AND WRITTEN CORRESPONDENCE. IF THE PARTY DOES NOT RESPOND, THE ACCOUNT IS HANDED OVER TO THE COLLECTION AREA. THIS PROCESS OFTEN REQUIRES A COMBINATION OF BUSINESS OFFICE AND SOCIAL SERVICE STAFF WORKING TOGETHER. OPTIONS FOR ANY SELF PAY OBLIGATIONS INCLUDE PAYMENT IN FULL, PAYMENT PLANS, VARIOUS ASSISTANCE PROGRAMS, AND THE FINANCIAL ASSISTANCE OFFERED BY OSCEOLA COMMUNITY HOSPITAL'S CHARITY CARE. INFORMATION REGARDING THESE OPTIONS IS MADE AVAILABLE AT THIS TIME. DURING THE DISCUSSIONS, INFORMATION IS REQUESTED TO ASSESS AND PROVE FINANCIAL STATUS IF PAYMENTS, PROGRAM APPLICATION, OR CHARITY ARE INDICATED. ASSISTANCE IS OFFERED FOR COMPLETION OF APPLICATIONS AND INSTRUCTIONS ARE GIVEN FOR COMPLETION OF FINANCIAL ASSESSMENTS. ATTENTION TO PARTICULAR ACCOUNTS MAY ALSO BE BROUGHT TO THE ATTENTION OF THE BUSINESS OFFICE OR SOCIAL SERVICES BY THE COLLECTIONS STAFF, PATIENTS THEMSELVES, OR RELATIVES OF PATIENTS. THIS USUALLY OCCURS WHEN THE CIRCUMSTANCES OF THE PATIENT CHANGES AFTER A TIME PERIOD HAS PASSED. WHEN NOTIFICATION IS RECEIVED, THESE CASES ARE REASSESSED. PART VI, LINE 4: OSCEOLA COMMUNITY HOSPITAL'S PRIMARY SERVICE AREA INCLUDES THE CITIZENS OF OSCEOLA COUNTY, IOWA. THE SECONDARY SERVICE AREA INCLUDES THE SURROUNDING COUNTIES OF NOBLES (MN), JACKSON (MN), DICKINSON (IA), O'BRIEN (IA), AND LYON (IA). ACCORDING TO THE 2000 AND 2010 CENSUS, THE POPULATION HAS DECREASED 8% OVER THE PREVIOUS 10 YEARS. THE MEDIAN AGE OF THE POPULATION WAS 40 AND WAS MADE UP OF 98% CAUCASIANS. THE MEDIAN HOUSEHOLD INCOME WAS $34,274 WITH AN AVERAGE HOUSEHOLD OF 2.5. PART VI, LINE 6: THE HOSPITAL IS A MEMBER OF AVERA HEALTH. A CITY OF SIBLEY IOWA 426005203 825759AM5 2007-12-01 4800000 CAPITAL PROJECTS 0 0 0 B CITY OF SIBLEY IOWA 426005203 2007-12-14 1000000 CAPITAL PROJECTS 0 0 0 A 375000 4800000 88603 142554 4657446 2010 0 0 1 1 B 270972 1000000 21463 978537 2010 0 0 1 1 A 0 0 0 0 0 0 1 B 0 0 0 0 0 0 1 A 0 0 0 1 1 0 0 0 0 B 0 0 1 0 1 0 0 0 0 A 0 B 0 DATE REBATE COMPUTATION PERFORMED ISSUER NAME: CITY OF SIBLEY, IOWA DATE THE REBATE COMPUTATION WAS PERFORMED: 12/13/2012 PART I, COLUMN F DESCRIPTION OF PROJECT: EACH PROJECT CONSISTED OF EXPANDING AND RENOVATING BORROWER'S EXISTING HOSPITAL FACILITIES, AND ACQUIRING MAJOR MEDICAL EQUIPMENT, INCLUDING WITHOUT LIMITAION, A NEW OPERATING ROOM, NEW PATIENT ROOMS, A RENOVATED AND EXPANDED EMERGENCY ROOM, AN EXPANDED WELLNESS AREA, NEW EXAM ROOMS, NEW SUPPORT AREAS, A NEW NURSING STATION, AND NEW NURSERY OBSTETRICAL SUITES FOR USE AT THE BORROWER'S EXISTING HOSPITAL FACILITIES AT 600 9TH AVENUE NORTH IN SIBLEY, IOWA. FORM 990, PART VI, SECTION A, LINE 1 THE EXECUTIVE COMMITTEE CONSISTS OF THE OFFICERS OF THE ORGANIZATION. THE PRESIDENT SHALL SERVE AS THE CHAIR OF THE COMMITTEE. THE EXECUTIVE COMMITTEE SHALL HAVE POWER TO TRANSACT ALL REGULAR BUSINSS OF THE ORGANIZATION DURING THE INTERIM BETWEEN THE MEETINGS OF THE BOARD OF TRUSTEES, PROVIDED THAT ANY ACTION WHICH IT MAY TAKE SHALL NOT CONFLICT WITH THE POLICIES AND EXPRESSED WISHES OF THE BOARD OF TRUSTEES, AND THAT IT SHALL REFER ALL MATTERS OF MAJOR IMPORTANCE TO THE BOARD OF TRUSTEES. FORM 990, PART VI, SECTION A, LINE 6 REGULAR MEMBERS ARE THOSE PERSONS, CORPORATIONS, ASSOCIATIONS OR PARTNERSHIPS WHO HAVE CONTRIBUTED AND PAID INTO THE CORPORATION A MINIMUM OF $75 OR MORE TO FURTHER THE OBJECTIVES OF THE CORPORATION. MEMBERSHIP SHALL BE LIFELONG AND NONTRANSFERABLE. EACH MEMBER WHOSE NAME IS ENDORSED ON THE MEMBERSHIP CERTIFICATES SHALL BE QUALIFIED TO ORIGINATE AND TAKE PART IN THE DISCUSSION OF ANY SUBJECT THAT MAY PROPERLY COME BEFORE THE ANNUAL MEETING OF THE CORPORATION, TO VOTE ON SUCH SUBJECTS, AND TO HOLD ANY OFFICE TO WHICH THE MEMBER MAY BE ELECTED OR APPOINTED. NO EMPLOYEE OR EMPLOYEE'S SPOUSE OF THE CORPORATION MAY BE ELECTED TO THE BOARD OF TRUSTEES. FORM 990, PART VI, SECTION A, LINE 7A TRUSTEES ARE ELECTED TO THE BOARD OF TRUSTEES FROM THE MEMBERS AT THE ANNUAL MEETING OF THE ORGANIZATION. FORM 990, PART VI, SECTION B, LINE 11 THE MANAGEMENT OF THE ORGANIZATION REVIEWS THE FORM 990 PRIOR TO FILING. THE BOARD OF DIRECTORS REVIEW THE 990 SUBSEQUENT TO FILING. FORM 990, PART VI, SECTION B, LINE 12C EACH DIRECTOR/TRUSTEE, PRINCIPAL OFFICER AND MEMBER OF A COMMITTEE WITH BOARD-DELEGATED POWERS SHALL ANNUALLY SIGN A CONFLICT OF INTEREST STATEMENT. IN CONNECTION WITH ANY ACTUAL OR POSSIBLE CONFLICT OF INTEREST, AN INTERESTED PERSON MUST DISCLOSE THE EXISTENCE OF A FINANCIAL INTEREST AND ALL MATERIAL FACTS TO THE DIRECTORS/TRUSTEES AND MEMBERS OF COMMITTEES WITH BOARD DELEGATED POWERS CONSIDERING THE PROPOSED TRANSACTION OR ARRANGEMENT. AFTER THE INTERESTED PERSON LEAVES THE MEETING, THE REMAINING BOARD OR COMMITTEE MEMBERS WILL DISCUSS AND VOTE UPON WHETHER A CONFLICT OF INTEREST EXISTS. ALSO, IF THE BOARD OR COMMITTEE HAS REASONABLE CAUSE TO BELIEVE A DIRECTOR, TRUSTEE, OR MEMBER HAS FAILED TO DISCLOSE ACTUAL OR POSSIBLE CONFLICT OF INTEREST, IT SHALL INFORM SUCH PERSON OF THE BASIS FOR SUCH BELIEF AND AFFORD THE PERSON AN OPPORTUNITY TO EXPLAIN THE ALLEGED FAILURE TO DISCLOSE. APPROPRIATE DISCIPLINARY AND CORRECTIVE ACTION SHALL BE TAKEN IF NECESSARY. FORM 990, PART VI, SECTION B, LINE 15 A COMPENSATION SPECIALIST FROM AN AFFILIATE ORGANIZATION REVIEWS THE COMPENSATION WITH THE BOARD OF TRUSTEES SEMI ANNUALLY. THE SPECIALIST REVIEWS MARKET VALUE AND PRESENTS A RECOMMENDATION TO THE BOARD OF TRUSTEES. THE BOARD MAKES THEIR DECISION ON THE INFORMATION PRESENTED. THE MOST RECENT PROCESS WAS COMPLETED IN 2015 FOR ALL OFFICERS AND TOP MANAGEMENT. FORM 990, PART VI, SECTION C, LINE 19 THE ORGANIZATION DOES NOT MAKE ITS GOVERNING DOCUMENTS OR CONFLICT OF INTEREST POLICY AVAILABLE TO THE PUBLIC. THE FINANCIAL STATEMENTS ARE MADE AVAILABLE UPON REQUEST AND THE FORM 990 AND 990T ARE AVAILABLE AT THE ANNUAL MEETING AND UPON REQUEST. FORM 990, PART IX, LINE 11G PROFESSIONAL FEES: PROGRAM SERVICE EXPENSES 1,167,605. MANAGEMENT AND GENERAL EXPENSES 1,560. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 1,169,165. PURCHASED SERVICES: PROGRAM SERVICE EXPENSES 568,588. MANAGEMENT AND GENERAL EXPENSES 293,957. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 862,545. HEARTWOOD HEIGHTS 409 9TH AVE NORTH SIBLEY IA 51249 421495686 INDEPENDENT/ASSISTED LIVING COMPLEX IA 501(C)(3) PF OSCEOLA COMMUNITY HOSPITAL 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 0 0 0 0 HEARTWOOD HEIGHTS O 162013 ACTUAL COST