2014-05-01T17:00:08-05:00 2013-09-30 476097913 SEIM JOHNSON LLP 18081 BURT STREET SUITE 200 OMAHA NE 680224722 990 2012-10-01 470468078 JEFFERSON COMMUNITY HEALTH CENTER INC JEFF 4027293351 2200 H STREET PO BOX 277 FAIRBURY NE 68352 CHANCE KLASEK 4027293351 2014-05-01 1 JULIE M GERKEN P00400882 4023302660 2012 2015-11-30 17:44:51Z CHANCE KLASEK 2200 H STREET PO BOX 277 FAIRBURY NE 68352 15499902 0 X WWW.JCHC.US X 1960 NE JCHC WILL PROVIDE AN EXCEPTIONAL HEALTHCARE EXPERIENCE FOR EVERY PATIENT, EVERY TIME. 9 4 229 15 0 0 73155 69131 15683811 14958633 77348 68301 411340 274965 16245654 15371030 0 0 0 0 7950812 8194442 0 0 49671 7270763 7160145 15221575 15354587 1024079 16443 17873822 18395033 1899397 2386539 15974425 16008494 JCHC WILL PROVIDE AN EXCEPTIONAL HEALTHCARE EXPERIENCE FOR EVERY PATIENT, EVERY TIME. 0 0 12245696 12864324 JEFFERSON COMMUNITY HEALTH CENTER OPERATES A 25 BED ACUTE CARE HOSPITAL. JEFFERSON COMMUNITY HEALTH CENTER ALSO OPERATES A WELLNESS CENTER AND PROVIDES HOME HEALTH SERVICES. 1319954 2266543 JEFFERSON COMMUNITY HEALTH CENTER OPERATES A 39 BED LONG-TERM CARE FACILITY FOR THE RESIDENTS OF JEFFERSON COUNTY AND THE SURROUNDING AREA. 13565650 1 0 0 1 0 0 0 0 0 1 1 0 0 0 0 1 1 0 0 0 0 0 0 0 0 0 1 1 0 0 1 0 0 0 0 0 0 0 1 0 0 0 0 0 0 0 0 0 1 5 0 1 229 1 0 0 0 0 0 0 0 0 0 0 X 9 4 0 0 0 0 1 1 1 1 1 0 0 1 1 1 1 1 1 1 0 0 X CHANCE KLASEK 4027296856 2200 H STREET PO BOX 277 FAIRBURY NE 68352 DICK HOPPE 1.00 0.00 X X 0 0 0 DR CRAIG SHUMARD 1.00 0.00 X X 0 0 0 LYMON HAMM 1.00 0.00 X X 0 0 0 MARY GLENN 1.00 0.00 X 0 0 0 JULIE KNIGGE 1.00 0.00 X 0 0 0 RYAN PARKER 1.00 0.00 X 0 0 0 BRIAN SCHEELE 1.00 0.00 X 0 0 0 MIKE STEEL 1.00 0.00 X 0 0 0 JACK WESCH 1.00 0.00 X 0 0 0 TRENA ROGGE 10.00 0.00 X 6103 0 0 WILLIAM WELCH 40.00 0.00 X 163438 0 22607 CHAD JURGENS 40.00 0.00 X 135801 0 21202 CHANCE KLASEK 40.00 0.00 X 0 0 0 GARY MITCHELL 40.00 0.00 X 144215 0 18994 DENNIS RUSSELL 40.00 0.00 X 113014 0 13489 MEGAN LARKINS 40.00 0.00 X 105345 0 10472 667916 0 86764 5 0 1 0 FAIRBURY CLINIC PC 825 22ND STREET FAIRBURY NE 68352 ER COVERAGE 601502 HUSKER REHAB 2320 N 6TH STREET BEATRICE NE 68310 THERAPY SERVICES 404159 SOUTHEAST ANESTHESIA SERVICES 8426 W BIRCH CLATONIA NE 68328 CRNA SERVICES 360000 SYSCO 900 KINGBIRD ROAD LINCOLN NE 68521 FOOD SERVICES 319832 BEATRICE MECHANICAL 2403 CENTENNIAL DRIVE BEATRICE NE 68310 MAINTENANCE SERVICES 310615 13 69131 69131 MEDICARE/MEDICAID PAYMENTS 624100 8564116 8564116 PATIENT SERVICE REVENUE 624100 4521748 4521748 PHARMACY 446110 835086 835086 CEDARWOOD ASSISTED LIVING FEES 561000 441870 441870 LAB 621500 424114 424114 171699 171699 14958633 67173 67173 130000 128872 1128 1128 1128 MISCELLANEOUS INCOME 624100 164070 164070 CAFETERIA 722210 102731 102731 OCCUPATIONAL HEALTH COMMUNITY OUT 624200 3827 3827 4337 4337 274965 15371030 15130867 0 171032 X 349151 349151 192491 192491 6059803 5480380 543117 36306 211368 195768 14347 1253 919982 843528 76444 10 461647 403173 55997 2477 7866 7866 43230 43230 11767 11767 1958339 1957148 710 481 77843 38251 39037 555 977576 720123 254704 2749 270446 241481 28965 26805 18062 8743 4542 4542 1093293 976201 117092 137381 137381 MEDICAL SUPPLIES 2149049 2149049 BAD DEBTS EXPENSE 303229 303229 DUES AND SUBSCRIPTIONS 62049 18863 42688 498 OUTSIDE TRAINING 25639 17612 8027 11091 5749 5342 15354587 13565650 1739266 49671 973213 3758444 2789424 2175713 321856 287419 152342 160644 20228819 10697200 7996440 9531619 1970802 2054053 3500000 0 156491 220317 13254 206824 17873822 18395033 1079832 2001762 435516 384777 384049 0 1899397 2386539 X 15851129 15871588 72542 86152 50754 50754 15974425 16008494 17873822 18395033 16443 17626 0 X X 0 1 X 1 0 X 0 0 0 0 0 0 0 0 1 1561 1561 0 EXPLANATION OF LOBBYING ACTIVITIES: PART II-B, LINE 1: JCHC PAID DUES TO THE NEBRASKA ASSOCIATION OF HOSPITALS AND HEALTH SYSTEMS AND AMERICAN HOSPITAL ASSOCIATION WHICH WERE USED FOR LOBBYING ACTIVITIES. 50754 50754 50754 50754 50754 50754 50754 250 250 50754 0.00000 1.00000 0.00000 0 0 13943 13943 12117865 6347264 5770601 5820106 4284623 1535483 2276905 65313 2211592 9531619 X 15376889 17626 17626 15359263 11767 11767 15371030 15342820 0 15342820 11767 11767 15354587 DESCRIPTION OF INTENDED USE OF ENDOWMENT FUNDS: PART V, LINE 4: THE INTENDED USE OF THE HOSPITAL'S ENDOWMENT FUNDS IS TO PROVIDE NURSING SCHOLARSHIPS AND CAPITAL IMPROVEMENTS. DESCRIPTION OF UNCERTAIN TAX POSITIONS UNDER FIN 48: PART X, LINE 2: THE HEALTH CENTER 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 THE HEALTH CENTER'S TAX EXEMPT STATUS. IN GENERAL, SUCH STANDARDS REQUIRE THE HEALTH CENTER TO MEET A COMMUNITY BENEFITS STANDARD AND COMPLY WITH VARIOUS LAWS AND REGULATIONS. THE HEALTH CENTER ACCOUNTS FOR UNCERTAINTIES IN ACCOUNTING FOR INCOME TAX ASSETS AND LIABILITIES USING GUIDANCE INCLUDED IN FASB ASC 740, INCOME TAXES. THE HEALTH CENTER RECOGNIZES THE EFFECT OF INCOME TAX POSITIONS ONLY IF THOSE POSITIONS ARE MORE LIKELY THAN NOT OF BEING SUSTAINED. AT SEPTEMBER 30, 2013, THE HEALTH CENTER HAD NO UNCERTAIN TAX POSITIONS ACCRUED. THE HEALTH CENTER IS NO LONGER SUBJECT TO INCOME TAX EXAMINATIONS FOR FISCAL YEARS ENDED PRIOR TO SEPTEMBER 30, 2010. 1 1 1 X 1 X 1 1 1 0 1 1 129761 129761 0.00860 845706 649545 196161 0.01300 975467 649545 325922 0.02160 19543 19543 0.00130 8040 8040 0.00050 471571 211456 260115 0.01730 7216 7216 0.00050 506370 211456 294914 0.01960 1481837 861001 620836 0.04120 0 303229 50000 6178220 6553140 -374920 X 1 1 1 1 JEFFERSON COMMUNITY HEALTH CENTER

200 H STREET FAIRBURY NE 68352

X X X X JEFFERSON COMMUNITY HEALTH CENTER INC 1 1 X X X X X X X X 12 1 0 1 X X X X X X 0 0 1 1 150.000000000000 1 300.000000000000 1 X X X 1 1 X X 1 0 X X 1 X 0 0 1 GARDENSIDE

200 H STREET FAIRBURY NE 68352

LONG TERM CARE FACILITY PART I, LINE 3C: FEDERAL POVERTY GUIDELINES ARE USED TO DETERMINE ELIGIBILITY FOR PROVIDING FREE AND DISCOUNTED CARE TO LOW INCOME INDIVIDUALS. PART I, LINE 6A: JEFFERSON COMMUNITY HEALTH CENTER PREPARES ITS OWN COMMUNITY BENEFIT REPORT. PART I, LINE 7: THE HOSPITAL USED THE WORKSHEETS PROVIDED IN THE FORM 990 INSTRUCTIONS. PART I, LINE 7G: THERE ARE NO COSTS ATTRIBUTABLE TO A PHYSICIAN CLINIC INCLUDED ON LINE 7G. PART I, L7 COL(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 $303,229. PART I, LINE 7E: A. COMMUNITY HEALTH EDUCATION AND OUTREACH(1) CHILD SAFETY SEAT PROGRAM - JCHC IS A PART OF A CHILD SAFETY SEAT COALITION AND HOLDS CHILD SAFETY SEAT CHECK UP EVENTS DURING THE YEAR, AS WELL AS OFFERING INDIVIDUAL INSTRUCTION IN PROPER USE OF SEATS. A TOTAL OF 61 SEATS WERE CHECKED IN AT CHECK-UP EVENTS AND IN INDIVIDUAL APPOINTMENTS. GRANTS ARE RECEIVED TO PURCHASE SEATS TO HAVE AVAILABLE, BUT STAFF TIME IS DONATED BY JEFFERSON COMMUNITY HEALTH CENTER.(2) DIABETES CONFERENCE - A DIABETES CONFERENCE WAS HELD FOR THE COMMUNITY IN NOVEMBER 2012 WITH 36 ATTENDING THE HALF-DAY SEMINAR. THE COST OF $10 FOR PARTICIPANTS IN ADDITION TO SPONSORSHIP RECEIVED HELPED TO OFFSET THE COST OF SPEAKERS AND SUPPLIES. (3) HEALTH FAIR - JCHC PROVIDES EDUCATIONAL BOOTHS, FREE HEALTH SCREENINGS, HANDOUTS, INFORMATION, ETC., AT THE JEFFERSON COUNTY HOME AND GARDEN SHOW AND THE JEFFERSON COUNTY FAIR. AN ESTIMATED 500 TOOK PART IN OFFERINGS FROM JCHC AT THESE EVENTS. JCHC ALSO PARTICIPATED IN THE SECOND COMMUNITY SAFETY FAIR OFFERED BY LOVELAND INDUSTRIES. THE COMMUNITY SAFETY FAIR WAS ATTENDED BY ABOUT 200 PEOPLE.(4) SPEAKERS BUREAU - JCHC STAFF MEMBERS PROVIDE EDUCATIONAL PROGRAMS FOR COMMUNITY ORGANIZATIONS ON A VARIETY OF TOPICS. A TOTAL OF 11 PROGRAMS WERE DONE IN FISCAL 2013. (5) SUPPORT GROUPS - IN 2013, JCHC COORDINATED A PARKINSON'S SUPPORT GROUP AND ALZHEIMER'S CAREGIVER'S SUPPORT GROUP. JCHC STAFF MEMBERS COORDINATED MEETINGS OF THESE SUPPORT GROUPS, OFFERING ASSISTANCE TO ANYONE INTERESTED IN MORE INFORMATION ABOUT THE DISEASES. THE PARKINSON'S SUPPORT GROUP MEETS MONTHLY. TOTAL ATTENDANCE DURING FISCAL 2013 WAS 35. A SUPPORT GROUP FOR CAREGIVER'S OF ALZHEIMER'S PATIENTS MEETS MONTHLY AND HAD ATTENDANCE OF 57 THROUGHOUT THE YEAR. JCHC PROVIDES EDUCATIONAL PROGRAMS FOR EACH OF THESE GROUPS -- INCLUDING SPEAKER'S FEES OR VIDEO TAPE RENTAL FEES, POSTAGE TO SEND OUT MEETING NOTICES AND REFRESHMENTS.(6) EDUCATIONAL PROGRAMS - JEFFERSON COMMUNITY HEALTH CENTER OFFERS EDUCATIONAL PROGRAMS TO THE COMMUNITY AT BREAK-EVEN PRICES. HEALTH TODAY WAS HELD IN OCTOBER, NOVEMBER AND DECEMBER 2012, WITH A TOTAL OF 51 ATTENDING.(7) HEALTH PROMOTION PROGRAMS - JCHC OFFERS SMOKING CESSATION INFORMATION TO PATIENTS AND THE PUBLIC. EACH INPATIENT WHO IS A SMOKER IS PROVIDED INFORMATION ON SMOKING CESSATION.B. COMMUNITY-BASED CLINICAL SERVICES (SCREENINGS AND ONE-TIME OR OCCASIONALLY HELD CLINICS.)(1) BLOOD PRESSURE CLINICS - HOME HEALTH OFFERED COMMUNITY BLOOD PRESSURE SCREENING 4 TIMES IN 2013 AT PARKVIEW MANOR. (2) COMPLETE BLOOD PROFILES - COMPLETE BLOOD PROFILES WERE OFFERED IN THE SPRING AT A REDUCED RATE. A TOTAL OF 90 BLOOD PROFILES WERE OFFERED. PARTICIPANTS PAID $45 WHICH IS A FRACTION OF THE ESTIMATED VALUE OF THE TESTING. (3) IMMUNIZATION CLINICS - JCHC COOPERATES WITH BLUE VALLEY COMMUNITY ACTION AND PUBLIC HEALTH SOLUTIONS IN PROVIDING IMMUNIZATION CLINIC FOR CHILDREN TWICE EACH MONTH. JCHC PROVIDES SPACE WHERE IMMUNIZATIONS ARE DONE, NURSING STAFF, THE PATIENT WAITING AREAS, JANITORIAL AND SUPPORT SERVICES AND STORAGE OF VACCINES IN OUR PHARMACY. (4) DIABETES ALERT DAY SCREENINGS - OFFERED FREE BLOOD SUGAR SCREENINGS ON DIABETES ALERT DAY IN MARCH WITH A "DIABETES ON THE SQUARE" EVENT IN DOWNTOWN FAIRBURY. C. HEALTH CARE SUPPORT SERVICES(1) ENROLLMENT ASSISTANCE IN PUBLIC PROGRAMS - JCHC OFFERED A COMMUNITY EDUCATION PROGRAM ON MEDICARE PART D DRUG PROGRAM PROVIDED BY JCHC EMPLOYEES TRAINED AS SCHIIP VOLUNTEERS (350) AND PRENATAL CLASSES (20). PART I, LINE 7F: A. SCHOLARSHIP FUNDING FOR HEALTH PROFESSIONS.(1) PHYSICIAN/MEDICAL STUDENTS, NURSES/NURSING STUDENTS, TECHNICIANS AND OTHER HEALTH PROFESSIONALS - JCHC WORKS WITH SOUTHEAST COMMUNITY COLLEGE IN BEATRICE AS A SITE FOR LPN PRACTICAL NURSING TRAINING. AN ESTIMATED 60 STUDENTS LEARNED IN OUR FACILITY IN 2013. NURSING STUDENTS UTILIZE MEETING ROOM SPACE AT JCHC, AS WELL AS TAKE PART IN CLINICAL PRACTICE. MEDICAL STUDENTS COME REGULARLY FOR RURAL ROTATIONS TO LEARN FROM LOCAL PHYSICIANS. JCHC PROVIDES A ROOM FOR THE MEDICAL STUDENTS TO STAY IN DURING THEIR TIME IN FAIRBURY AND ALSO PROVIDES THEM USE OF OUR WELLNESS CENTER DURING THEIR STAY. THREE MEDICAL STUDENTS UTILIZED OUR FACILITY IN 2013. JCHC OFFERS THE LILLIAN HANSEN REESMAN RN MEMORIAL NURSES SCHOLARSHIP FUND. SCHOLARSHIPS ARE OFFERED FROM THIS FUND ESTABLISHED IN 1980. ONLY INTEREST IS USED FROM THIS $10,000 PERPETUAL FUND, DONATED BY THE REESMAN FAMILY, TO PROVIDE NURSING SCHOLARSHIPS. SCHOLARSHIPS ARE PROVIDED AS INTEREST FUNDS ARE AVAILABLE. ONE $500 SCHOLARSHIP WAS AWARDED IN FISCAL 2013. THE JCHC AUXILIARY PROVIDES A SCHOLARSHIP FOR STUDENTS PURSUING AN EDUCATION IN MEDICAL FIELDS. THE $400 SCHOLARSHIP IS GIVEN FROM THE AUXILIARY'S FUNDS, AND THE NUMBER OF SCHOLARSHIPS GIVEN EACH YEAR IS BASED ON THE AUXILIARY'S FUNDING AVAILABILITY AND THE NUMBER OF REQUESTS. ONE SCHOLARSHIP WAS AWARDED IN 2013. B. OTHER (1) JOB SHADOWING - JCHC HOSTS JOB SHADOW STUDENTS THROUGH FAIRBURY HIGH SCHOOL'S ANATOMY AND PHYSIOLOGY CLASS, THROUGH THE SOUTHEAST COMMUNITY COLLEGE-FAIRBURY HIGH SCHOOL CAREER ACADEMY PROGRAM AND FOR INTERESTED INDIVIDUALS. THIS YEAR, SHADOWING OPPORTUNITIES WERE ALSO ARRANGED FOR STUDENTS AS A PART OF THE SCC CAREER ACADEMY AND OTHER INDIVIDUALS WHO WERE INTERESTED. A TOTAL OF 28 STUDENTS PARTICIPATED IN SHADOWING OPPORTUNITIES IN FISCAL 2013. (2) VIDEOCONFERENCE - JCHC CONTINUED TO OFFER VIDEOCONFERENCING CAPABILITIES INCLUDING POSSIBLE PROGRAMS FOR PROFESSIONALS IN THE COMMUNITY. AVAILABILITY COSTS $100 PER MONTH. A TOTAL OF 56 EDUCATIONAL AND ADMINISTRATIVE PROGRAMS WERE OFFERED IN 2013. THIS INCLUDED A NUMBER OF OPPORTUNITIES FOR STAFF AND COMMUNITY EDUCATION, MEETINGS AND CLINICAL VISITS. PART I, LINE 7G: WELLNESS CENTER SUPPORT - JEFFERSON COMMUNITY HEALTH CENTER HAS OPERATED THE BOB AND WAUNETA BURKLEY WELLNESS CENTER AS A COMMUNITY WELLNESS CENTER SINCE IT OPENED IN 1996. JCHC PAYS THE WELLNESS CENTER'S OPERATING EXPENSES THAT EXCEED REVENUES. BECAUSE OF THE HEALTH CENTER'S SUPPORT OF THE WELLNESS CENTER'S CASH FLOW, PRICES FOR MEMBERSHIPS AND SERVICES CAN REMAIN REASONABLE FOR COMMUNITY RESIDENTS. IF THE WELLNESS CENTER WERE A STAND-ALONE OPERATION, PRICES WOULD HAVE TO RISE CONSIDERABLY TO PAY ALL EXPENSES. PART I, LINE 7I: A. CASH DONATIONS - JCHC MAKES DONATIONS TO VARIOUS CHARITABLE CAUSES, INCLUDING GIRL SCOUT AND BOY SCOUT FIRST AID KITS, 4-H FIRST AID PROJECT, FREE LOAN OF HOME BILLIRUBEN BLANKET, SPONSORSHIP OF BASEBALL AND SOFTBALL TEAMS, GOLF TOURNAMENTS, AREA HIGH SCHOOL POST PROM ACTIVITIES, AN AREA COMMUNITY PICNIC, A LOCAL DANCE RECITAL, AN AREA RODEO, EMT TRAINING CONFERENCE, CHAMBER OF COMMERCE BANQUET, CHAMBER OF COMMERCE NEW TEACHER WELCOME, CHAMBER OF COMMERCE TEACHER RECOGNITION, LOANING OUT CPR MANNEQUINS, ETC. JCHC ALSO CONTRIBUTES ITEMS SUCH AS WELLNESS CENTER PASSES, JCHC GLASSES AND DUFFLE BAGS, ETC., TO COMMUNITY EVENTS AS DOOR PRIZES. THESE TOTALED $646.39. USE OF A BILIBLANKET WAS DONATED FOR NEWBORNS WITH JAUNDICE FOR 33 DAYS OF IN-KIND USE FOR A VALUE OF $3,630. B. IN-KIND DONATIONS. (1) WALK TO END ALZHEIMER'S - JEFFERSON COMMUNITY HEALTH CENTER SUPPORTS THE ANNUAL WALK TO END ALZHEIMER'S BY PROVIDING STAFF TIME AND POSTAGE TO SEND OUT SPONSORSHIP LETTERS AND NEWS RELEASES PROMOTING THE EVENT STAFF TIME TO ASSIST IN PLANNING THE EVENT AND STAFF TIME THE DAY OF THE EVENT. A TOTAL OF 19 WALKERS PARTICIPATED AND THE EVENT RAISED $3,800 FOR THE ALZHEIMER'S ASSOCIATION. (2) SAFE KIDS CHAPTER - THE LEAD AGENCY FOR SAFE KIDS WAS CHANGED TO PUBLIC HEALTH SOLUTIONS IN 2013, BUT JEFFERSON COMMUNITY HEALTH CENTER CONTINUES TO BE INVOLVED. FOUR JCHC STAFF MEMBERS PARTICIPATE IN THE ORGANIZATION. THEY ARE JOINED BY A VARIETY OF OUTSIDE AGENCIES IN THE COMMUNITY WHO BELIEVE STRONGLY IN CHILDHOOD SAFETY. IN ADDITION TO SAFETY SEAT CHECK UP EVENTS, OTHER SAFETY PROMOTIONS WERE OFFERED. (3) BLOOD DRIVE SUPPORT - JCHC ASSISTS NEBRASKA COMMUNITY BLOOD BANK BY SCHEDULING APPOINTMENTS FOR SIX BLOOD DRIVES EACH YEAR. THE BLOOD PRODUCTS ULTIMATELY HELP OUR COMMUNITY AS NEBRASKA COMMUNITY BLOOD BANK IS JCHC'S SUPPLIER OF BLOOD AND BLOOD PRODUCTS. (4) SAFETY DAY FOR KIDS - JCHC WAS ONE OF THE CO-SPONSORS FOR THE ANNUAL SAFETY DAY FOR KIDS IN JEFFERSON COUNTY. A TOTAL OF 67 KIDS AGES KINDERGARTEN THROUGH SIXTH GRADES ATTENDED. STAFF MEMBERS ASSISTED IN PLANNING THE EVENT AND ASSISTED IN COORDINATING AND INSTRUCTING ON THE DAY OF THE CAMP. PART II: JEFFERSON COMMUNITY HEALTH CENTER IS ACTIVE IN LOCAL ECONOMIC DEVELOPMENT ACTIVITIES. JCHC IS A MEMBER OF THE FAIRBURY CHAMBER OF COMMERCE. JCHC SEEKS OPPORTUNITIES TO OFFER TOURS, HEALTH CARE INFORMATION ON COMMUNITY WEBSITES, ETC. IN ADDITION TO THESE DIRECT PROGRAMS AND SERVICES, THE EMPLOYEES OF JEFFERSON COMMUNITY HEALTH CENTER SERVE THEIR COMMUNITY IN MANY WAYS INCLUDING SERVING IN THEIR CHURCHES AS GIRL AND BOY SCOUT LEADERS, AS 4-H LEADERS, AS LEADERS IN CIVIC ORGANIZATIONS, AS YOUTH GROUP LEADERS, AS CITY GOVERNMENT MEMBERS, ON COMMUNITY DEVELOPMENT BOARDS, FOR EMERGENCY RESPONSE ORGANIZATIONS AND OTHERS. JCHC STAFF MEMBERS ARE A RESOURCE AS COMMUNITY ROLE MODELS.JCHC IS PROUD OF ITS CONTRIBUTIONS TO THE CITIZENS OF JEFFERSON COUNTY AND THE SURROUNDING AREA. THE CITIZENS OF THIS AREA ALSO HIGHLY REGARD JCHC'S CONTRIBUTIONS TO THE COMMUNITY.THE GOAL OF THE JCHC BOARD OF DIRECTORS, ADMINISTRATION AND STAFF IS TO EXPAND THAT PARTNERSHIP WITH AREA RESIDENTS AND FIND MORE WAYS TO SERVE AS A RESOURCE FOR HEALTH AND WELLNESS INFORMATION. PART III, LINE 4: BAD DEBT INCLUDES PATIENT ACCOUNTS SENT TO THE COLLECTION AGENCY AFTER BEING RETURNED AS UNCOLLECTABLE FROM THE HOSPITAL'S "EARLY OUT" COLLECTION VENDOR. BAD DEBT EXPENSE IS ADJUSTED FOR ALLOWANCES AND RECOVERIES. ANY DISCOUNTS PROVIDED OR PAYMENTS MADE TO A PARTICULAR PATIENT ACCOUNT ARE APPLIED TO THE PATIENT ACCOUNTS PRIOR TO ANY BAD DEBT WRITE-OFF AND THUS ARE NOT INCLUDED IN BAD DEBT EXPENSE.JCHC'S FINANCIAL STATEMENTS DO NOT CONTAIN A SPECIFIC FOOTNOTE DESCRIBING BAD DEBT EXPENSE. HOWEVER, THE FOLLOWING IS TEXT OF THE FOOTNOTES TITLED "PATIENT ACCOUNTS RECEIVABLE" AND "CHARITY CARE":PATIENT ACCOUNTS RECEIVABLE:THE HEALTH CENTER REPORTS PATIENT ACCOUNTS RECEIVABLE FOR SERVICES RENDERED AT NET REALIZABLE AMOUNTS FROM THIRD-PARTY PAYERS, PATIENTS, AND OTHERS. ACCOUNTS RECEIVABLE ARE REDUCED BY AN ALLOWANCE FOR DOUBTFUL ACCOUNTS. IN EVALUATING THE COLLECTIBILITY OF ACCOUNTS RECEIVABLE, THE HEALTH CENTER ANALYZES ITS PAST HISTORY AND IDENTIFIES TRENDS FOR EACH OF ITS MAJOR PAYER SOURCES OF REVENUE TO ESTIMATE THE APPROPRIATE ALLOWANCE FOR DOUBTFUL ACCOUNTS AND PROVISION FOR BAD DEBTS. MANAGEMENT REGULARLY REVIEWS DATA ABOUT THESE MAJOR PAYER SOURCES OF REVENUE IN EVALUATING THE SUFFICIENCY OF THE ALLOWANCE FOR DOUBTFUL ACCOUNTS. FOR RECEIVABLES ASSOCIATED WITH SERVICES PROVIDED TO PATIENTS WHO HAVE THIRD-PARTY COVERAGE, THE HEALTH CENTER 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 HEALTH CENTER 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.CHARITY CARE:THE HEALTH CENTER PROVIDES CARE TO PATIENTS WHO MEET CERTAIN CRITERIA UNDER ITS CHARITY CARE POLICY WITHOUT CHARGE OR AT AMOUNTS LESS THAN ITS ESTABLISHED RATES. BECAUSE THE HEALTH CENTER DOES NOT PURSUE COLLECTION OF AMOUNTS DETERMINED TO QUALIFY AS CHARITY CARE, THEY ARE NOT REPORTED AS REVENUE.THE HEALTH CENTER IS DEDICATED TO PROVIDING COMPREHENSIVE HEALTHCARE SERVICES TO ALL SEGMENTS OF SOCIETY, INCLUDING THE AGED AND OTHERWISE ECONOMICALLY DISADVANTAGED. IN ADDITION, THE HEALTH CENTER PROVIDES A VARIETY OF COMMUNITY HEALTH SERVICES AT OR BELOW COST.THE HEALTH CENTER PROVIDES CHARITY CARE TO PATIENTS WHO ARE FINANCIALLY UNABLE TO PAY FOR THE HEALTHCARE SERVICES THEY RECEIVE. IT IS THE POLICY OF THE HEALTH CENTER NOT TO PURSUE COLLECTION OF AMOUNTS DETERMINED TO QUALIFY AS CHARITY CARE. ACCORDINGLY, THE HEALTH CENTER DOES NOT REPORT THESE AMOUNTS IN NET OPERATING REVENUE OR IN THE ALLOWANCE FOR DOUBTFUL ACCOUNTS. THE HEALTH CENTER DETERMINES THE COSTS ASSOCIATED WITH PROVIDING CHARITY CARE BY AGGREGATING THE DIRECT AND INDIRECT COSTS, INCLUDING SALARIES, BENEFITS, SUPPLIES, AND OTHER OPERATING EXPENSES, BASED ON AN OVERALL COST TO CHARGE RATIO. THE COSTS OF CARING FOR THESE PATIENTS FOR THE YEARS ENDED SEPTEMBER 30, 2013 AND 2012 WERE APPROXIMATELY $134,000 AND $157,000, RESPECTIVELY.THE ESTIMATED AMOUNT OF BAD DEBT EXPENSE ATTRIBUTABLE TO PATIENTS ELIGIBLE UNDER THE ORGANIZATION'S CHARITY CARE POLICY IS CONSERVATIVELY BASED ON THE BELIEF THAT MANY POTENTIALLY ELIGIBLE PATIENTS DID NOT TAKE THE TIME OR EFFORT TO COMPLETE AN APPLICATION FOR CHARITY CARE. NO PORTION OF BAD DEBT IS INCLUDED AS A COMMUNITY BENEFIT. PART III, LINE 8: THE HOSPITAL CALCULATED THE MEDICARE ALLOWABLE COSTS BY ADDING THE INPATIENT, SWING BED AND OUTPATIENT COSTS AS FOUND ON THE MEDICARE COST REPORT (WORKSHEET D) FOR SEPTEMBER 30, 2013. PART III, LINE 9B: ONCE IT IS DETERMINED THAT A PATIENT MAY NOT HAVE THE MEANS TO PAY, AN ASSISTANCE APPLICATION SHOULD BE PROVIDED. IN ADDITION, ALL ACCOUNTS THAT OUR SELF-PAY RECEIVABLE VENDOR DID NOT RECEIVE PAYMENT ON AFTER 75 DAYS WILL BE RUN THROUGH A PRESUMPTIVE CHARITY CRITERIA PROCESS. THIS PROCESS ASSISTS IN THE DETERMINATION OF FINANCIAL ASSISTANCE ELIGIBILITY. JCHC STAFF WILL APPLY THE RECOMMENDED PERCENTAGE DISCOUNT TO THE PATIENT'S ACCOUNT. JEFFERSON COMMUNITY HEALTH CENTER, INC. PART V, SECTION B, LINE 1J: OTHER ITEMS ADDRESSED IN THE NEEDS ASSESSMENT ARE IMPLEMENTATION STRATEGY AND NEEDS THAT WILL NOT BE ADDRESSED BY JCHC. JEFFERSON COMMUNITY HEALTH CENTER, INC. PART V, SECTION B, LINE 3: JEFFERSON COMMUNITY HEALTH CENTER BEGAN ITS HEALTH NEEDS ASSESSMENT IN DECEMBER 2012 AND WORKED WITH PUBLIC HEALTH SOLUTIONS DISTRICT HEALTH DEPARTMENT, REVIEWED INTERVIEWS CONDUCTED BY PUBLIC HEALTH SOLUTIONS, CONDUCTED INTERVIEWS WITH LOCAL ORGANIZATIONS, CONDUCTED INTERVIEWS WITH JCHC STAFF AND REVIEWED STATISTICS MADE AVAILABLE THROUGH PUBLIC HEALTH SOLUTIONS AND THE STATE OF NEBRASKA. MEETINGS WERE CONDUCTED WITH LOCAL COMMUNITY ORGANIZATIONS INCLUDING KIWANIS, ROTARY, AGRICULTURE REPRESENTATIVES AND SENIOR DINERS. A TOTAL OF 83 ATTENDED AND PARTICIPATED. IN ADDITION, MEETINGS WERE HELD WITH JEFFERSON COMMUNITY HEALTH CENTER STAFF WHO ALSO REPRESENT THE AREA IN WHICH THEY LIVE. A TOTAL OF 71 JCHC STAFF MEMBERS ALSO PARTICIPATED.PUBLIC HEALTH SOLUTIONS DISTRICT HEALTH DEPARTMENT CONDUCTED ITS COMMUNITY HEALTH IMPROVEMENT PLAN STUDY OF ALL FIVE COUNTIES WITH THE ASSISTANCE OF LANE GEWECKE CONSULTING IN NOVEMBER 2012. JEFFERSON COMMUNITY HEALTH CENTER, INC. PART V, SECTION B, LINE 7: THERE WERE NEEDS IDENTIFIED THAT JCHC DID NOT CHOOSE TO ADDRESS. WHILE THESE NEEDS ARE IMPORTANT TO THE COMMUNITY, THEY WERE NOT CHOSEN BASED ON THE PRIORITIZATION PROCESS. THESE NEEDS INCLUDE: ALZHEIMER'S DISEASE, UNINTENTIONAL INJURIES, HEALTH CARE PROVIDER COVERAGE WHEN EXISTING PHYSICIANS RETIRE, FUTURE OF HEALTH CARE, WEAKENING FAMILY STRUCTURE/PARENTING, LACK OF DOCTORS/HEALTH CARE, DRUG/ALCOHOL USE AND THE AGING POPULATION. PART V, SECTION B, LINE 5A: JCHS'S COMMUNITY HEALTH NEEDS ASSESSMENT CAN BE FOUND AT HTTP://JCHC.US/WP-CONTENT/UPLOADS/2014/01/2013-JCHC-COMMUNITY-HEALTH- NEEDS-ASSESSMENT.DOCX. PART VI, LINE 2: JCHC ASSESSES THE HEALTH CARE NEEDS OF THE COMMUNITY JCHC SERVES IN SEVERAL WAYS. JCHC UTILIZES SURVEYS BY PUBLIC HEALTH SOLUTIONS OF THE HEALTH CARE NEEDS FOR RESIDENTS OF JEFFERSON COUNTY AND THE SURROUNDING COMMUNITY. JCHC VISITS LOCAL COMMUNITY SERVICE ORGANIZATIONS AND SEEKS INPUT ON NEEDS. JCHC CONDUCTED A COMMUNITY PERCEPTION SURVEY IN 2006, WHICH INCLUDES QUESTIONS ON COMMUNITY HEALTH NEEDS. JCHC REVIEWS SURVEYS DONE BY THE STATE AND OTHER ORGANIZATIONS ON THE HEALTH CARE NEEDS FOR RESIDENTS OF JEFFERSON COUNTY AND THE SURROUNDING AREA. PART VI, LINE 3: JCHC INFORMS AND EDUCATES PATIENTS ABOUT ELIGIBILITY FOR ASSISTANCE ON AN INDIVIDUAL BASIS WHEN QUESTIONS ARISE. THE PATIENT BOOKLET THAT IS HANDED OUT EXPLAINS WHO IN THE BUSINESS OFFICE TO CONTACT IF THE PATIENT HAS QUESTIONS ABOUT THEIR BILL. THE SELF-PAY BILLING VENDOR JCHC USES NOW HAS A SET OF CRITERIA IT ASSESSES TO DETERMINE IF A PATIENT MIGHT BE ELIGIBLE FOR ASSISTANCE PROGRAMS THE PATIENT IS NOT ALREADY UTILIZING, OR IF THEY MIGHT QUALIFY FOR JCHC'S CHARITY CARE. PART VI, LINE 4: JCHC SERVES JEFFERSON COUNTY AND PARTS OF THAYER, FILLMORE, SALINE AND GAGE COUNTIES, ALL IN NEBRASKA; AND PARTS OF WASHINGTON AND MARSHALL COUNTIES IN KANSAS. THE POPULATION OF THE SERVICE AREA IS ESTIMATED AT ABOUT 18,000. REVENUE FROM MEDICARE PATIENTS IS OVER 50% ON AVERAGE, AND REVENUE FROM MEDICAID CLIENTS IS OVER 10% ON AVERAGE. PART VI, LINE 5: JCHC OPERATES IN JEFFERSON COUNTY WITH A COMMUNITY BOARD AND OPEN MEDICAL STAFF. ALL SURPLUS FUNDS ARE REINVESTED BACK INTO THE FACILITY THROUGH BUILDING CONSTRUCTION, EQUIPMENT PURCHASES, OR COMMUNITY PROGRAMS PROVIDED. JCHC PROMOTES THE HEALTH OF THE COMMUNITY BY OFFERING A COMMUNITY WELLNESS CENTER AT A REASONABLE RATE AND OFFERING SCHOLARSHIPS FOR THE COMMUNITY'S YOUTH WHO HAVE FINANCIAL NEED. THE NET COMMUNITY BENEFIT REPORTED IN PART I RELATING TO THE WELLNESS CENTER WAS $242,101. JCHC PROMOTES THE HEALTH OF THE COMMUNITY BY PROMOTING COMMUNITY WIDE PROGRAMS SUCH AS LIVE HEALTHY NEBRASKA AND STEP 2 IT (PROGRAMS WHICH ENCOURAGE INCREASING ACTIVITY AND LOSING WEIGHT.) JCHC IS ALSO INVOLVED IN CAR SAFETY SEAT CHECKS, PROGRESSIVE AG SAFETY DAY, AND WORKING WITH BLUE VALLEY COMMUNITY ACTION TO OFFER IMMUNIZATIONS TO AREA CHILDREN. JCHC PROMOTES THE HEALTH OF THE COMMUNITY BY OFFERING PROGRAMS, TOURS, SPEAKERS, AND EDUCATION - INCLUDING SUPPORT GROUPS, EDUCATIONAL PROGRAMS AND PROGRAMS FOR LOCAL ORGANIZATIONS. PART VI, LINE 6: JCHC IS NOT PART OF AN AFFILIATED HEALTH CARE SYSTEM BUT DOES WORK TO BE A LEADER IN PROMOTING THE HEALTH OF THE COMMUNITIES IT SERVES. JCHC PARTNERS WITH MANY OTHER AREA ORGANIZATIONS - PUBLIC HEALTH SOLUTIONS, FARM SAFETY 4 JUST KIDS, NEBRASKA SAFE KIDS, JEFFERSON COUNTY EXTENSION, BLUE VALLEY COMMUNITY ACTION, FAIRBURY CHAMBER OF COMMERCE, FAIRBURY PUBLIC SCHOOLS, FAIRBURY CLINIC, NEBRASKA COMMUNITY BLOOD BANK, RURAL COMPREHENSIVE CARE NETWORK, BLUE RIVER VALLEY NETWORK, HEARTLAND HEALTH ALLIANCE, AND OTHERS. DEPENDING ON THE ACTIVITY, JCHC MAY BE THE LEAD ORGANIZATION, OR AN ORGANIZATION PROVIDING HELP AND ASSISTANCE. PART VI, LINE 7: JCHC DOES NOT FILE A COMMUNITY BENEFIT REPORT WITH ANY STATES. X X 0 0 0 0 0 0 0 0 0 WILLIAM WELCH 163438 0 0 0 0 0 8169 0 14438 0 186045 0 0 0 CHAD JURGENS 135801 0 0 0 0 0 6764 0 14438 0 157003 0 0 0 GARY MITCHELL 144215 0 0 0 0 0 7209 0 11785 0 163209 0 0 0 FAIRBURY CLINIC PC DR. CRAIG SHUMARD, BOARD MEMBER, OWNS MORE THAN 5% OF FAIRBURY CLINIC P.C. 601502 FAIRBURY CLINIC P.C. PROVIDED EMERGENCY ROOM COVERAGE SERVICES TO JEFFERSON COMMUNITY HEALTH CENTER. 0 MARY HOPPE EMPLOYEE OF ORGANIZATION AND SPOUSE OF DICK HOPPE, CHAIRMAN OF THE BOARD 79656 EMPLOYEE'S W-2 WAGES 0 STACY SHUMARD EMPLOYEE OF ORGANIZATION AND SPOUSE OF DR. CRAIG SHUMARD, BOARD MEMBER 33980 EMPLOYEE'S W-2 WAGES 0 SANDRA SCHEELE EMPLOYEE OF ORGANIZATION AND SPOUSE OF BRIAN SCHEELE, BOARD MEMBER 11923 EMPLOYEE'S W-2 WAGES 0 JANET STEELE EMPLOYEE OF ORGANIZATION AND SPOUSE OF MIKE STEELE, BOARD MEMBER 42473 EMPLOYEE'S W-2 WAGES 0 JACQUELINE WESCH EMPLOYEE OF ORGANIZATION AND SPOUSE OF JACK WESCH, BOARD MEMBER 24459 EMPLOYEE'S W-2 WAGES 0 FORM 990, PART VI, SECTION A, LINE 6 JEFFERSON COMMUNITY HEALTH CENTER HAS MEMBERS. ANY PERSON, CORPORATION OR OTHER ENTITY MAY BECOME A LIFETIME MEMBER IF A CONTRIBUTION OF $100 OR MORE IS MADE TO THE CORPORATION. FORM 990, PART VI, SECTION A, LINE 7A VACANCIES, OCCURRING ON THE BOARD BY EXPIRATION, SHALL BE FILLED THROUGH ELECTION BY THE MEMBERS AT THE ANNUAL MEETING OF THE MEMBERS. THE BOARD DEVELOPMENT COMMITTEE SHALL SUBMIT A SLATE OF PROSPECTIVE CANDIDATES TO THE BOARD OF DIRECTORS AT THEIR MEETING PRIOR TO THE ANNUAL MEETING WHICH WILL THEN BE PRESENTED AT THE ANNUAL MEETING FOR CONSIDERATION FOR ELECTION TO THE BOARD. IN ADDITION, MEMBERS OF THE CORPORATION MAY MAKE NOMINATIONS FROM THE FLOOR. FORM 990, PART VI, SECTION A, LINE 7B EACH MEMBER SHALL BE ENTITLED TO ONE VOTE ON EACH MATTER SUBMITTED TO THE VOTE OF THE MEMBERS. FORM 990, PART VI, SECTION B, LINE 11 THE 990 IS REVIEWED AT THE REGULAR BOARD MEETING. FORM 990, PART VI, SECTION B, LINE 12C BOARD MEMBERS ARE REQUIRED, BY THE ARTICLES AND BYLAWS, TO REVIEW THE CONFLICT OF INTEREST POLICY ANNUALLY. A BOARD MEMBER WITH A CONFLICT OF INTEREST IS REQUIRED TO ABSTAIN FROM VOTING ON ANY MOTION REGARDING DISCLOSED CONFLICT OF INTEREST. BOARD MEMBERS ARE WELL ACQUAINTED AND WOULD BE AWARE OF ANY PERSONAL CONFLICTS OF INTEREST. FORM 990, PART VI, SECTION B, LINE 15A THE HOSPITAL PARTICIPATES IN THE NEBRASKA COMPDATA SALARY SURVEYS FOR ALL POSITIONS. THE CEO SURVEY DATA IS GIVEN TO THE BOARD TO REVIEW AND APPROVE THE CEO SALARY ON AN ANNUAL BASIS. FORM 990, PART VI, SECTION C, LINE 19 THE ORGANIZATIONS GOVERNING DOCUMENTS, CONFLICT OF INTEREST POLICY, AND FINANCIAL STATEMENTS ARE AVAILABLE TO THE PUBLIC UPON REQUEST. OTHER FEES FORM 990, PART IX, LINE 11G PURCHASED SERVICES: PROGRAM SERVICE EXPENSES 1,354,548. MANAGEMENT AND GENERAL EXPENSES 710. FUNDRAISING EXPENSES 481. TOTAL EXPENSES 1,355,739. EMERGENCY ROOM PHYSICIANS: PROGRAM SERVICE EXPENSES 602,600. MANAGEMENT AND GENERAL EXPENSES 0. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 602,600. FORM 990, PAGE 11, PART XI, LINE 2C: THERE HAVE BEEN NO CHANGES FROM THE PRIOR YEAR. THE FINANCE COMMITTEE OF THE BOARD OF DIRECTORS SELECTS THE INDEPENDENT ACCOUNTANT AND HAS THE RESPONSIBILITY FOR OVERSIGHT OF THE AUDIT. UPON CONCLUSION OF THE AUDIT, THE AUDITING FIRM PRESENTS THE RESULTS AND FINDINGS TO THE FINANCE COMMITTEE.