2014-12-11T16:58:45-06:00 2014-04-30 KPMG LLP 1212 North 96th Street Suite 300 Omaha NE 68114 990 2013-05-01 470542043 COLUMBUS COMMUNITY HOSPITAL INC % MIKE ADAMY COLU 4025623357 PO BOX 1800 Suite COLUMBUS NE 68602 MICHAEL T HANSEN CHIEF EXECUTIVE OFFICER 4025623357 2014-12-08 true Donald Neal Jr P00798244 4025623357 2013 2015-11-30 17:44:51Z J Joseph Barbaglia 4600 38th Street Columbus NE 68601 80292003 false X www.columbushosp.org X 1972 NE OUR MISSION IS TO IMPROVE THE HEALTH OF THE COMMUNITIES WE SERVE. 11 11 662 323 18606 -44222 117549 61455 72520573 79026667 321804 364263 1025030 839618 73984956 80292003 1469342 1510490 0 0 33905776 35614672 0 0 0 29781927 31211175 65157045 68336337 8827911 11955666 97892656 108463254 6956170 6261385 90936486 102201869 X OUR MISSION IS TO IMPROVE THE HEALTH OF THE COMMUNITIES WE SERVE. false false 64945322 52500 79576037 General hospital and health care: Columbus Community Hospital ("CCH") is a 47 bed acute care hospital which currently employs over 600 people. It is a significant, positive economic force for the Columbus area, returning dollars into the economy through local purchases by the organization, and salaries that return to the community. It is also a needed asset for the local communities where patients can obtain quality healthcare without the need to drive over 50 miles for care. In providing the care necessary for local communities, CCH has a variety of services. Following is a brief summary of some of the areas of service provided by CCH. a) The main focus is acute care services for patients. All 47 acute care beds at CCH are also certified as swing beds. b) To assist our non-English speaking patients, CCH uses competent, certified, dedicated Medical Interpreters as a liaison between the care providers and the patient. Since this is the interpreters' full time job at the hospital, they are available when needed, in house or on call 24/7. c) To make the patient's stay successful and comfortable, CCH provides ICU, Medical Surgical, OB, and an Orthopedic Service Line along with a variety of complimentary ancillary services (Wound Care, Diabetic Education, Cardiac Rehab) and Clinical Pharmacy Services. CCH uses Bar-Coded Medication Administrated, Smart Pumps, and Computerized Physician Order Entry to enhance safety. d) CCH offers Rehabilitative Services such as Physical Therapy, Speech Therapy, Occupational Therapy and Drivers Rehab Therapy, so patients don't have to travel so far to get adult therapy. Pediatric Physical Therapy, Speech Therapy, and Occupational Therapy are offered at our off-site location, Wiggles & Giggles Therapy (includes Physical, Speech, and Occupational Therapies) for kids. CCH has Physical Therapists, Occupational Therapists and Speech Therapists with specialized certification in cancer rehab. We launched our certified Star Program at Columbus Community Hospital in November of 2012. We are one of only three hospitals in Nebraska to have achieved the star program certification for Cancer Rehabilitation. Star stands for Survivorship Training and Rehab. We have had at least 74 formal Star Program referrals resulting in consultations for potential rehabilitation needs. Many of our Star Program Participants have needed physical therapy, speech therapy or occupational therapy and some have needed nutritional consults as well as psychosocial referrals. Some patients who have participated have had pulmonary concerns and cardiovascular factors. There also have been some Star Program graduates that have transitioned to medical wellness here at CCH. Star Program co-coordinators are Jill Jakub MOTR/L, CLT, and Michell Ruskamp MS, CCC-SLP. They are joined by 23 other clinicians including Physicians, Nurses, Respiratory Therapists, Dieticians, Social Workers, and therapists who are Star Program certified at CCH. The star program cancer rehab certification at CCH is funded by the Columbus Community Hospital Foundation. Our certified Provider Team for the Star Program is made up of 3 physicians, 6 Physical Therapists, 4 Occupational Therapists, 2 Speech Therapists, 5 Nurses, 1 Respiratory Therapist, 2 Social Workers and 2 Nutritionists. CCH has a Specialized Parkinson's Treatment approach which facilitates support groups for Parkinson's, plus a support group for TBI and Stroke Patients. In March 2014 CCH added an Oncology Nurse Specialist who is now also a STAR Certified Clinician. e) Nurses in the Same Day Services Department prepare patients for surgery and, if going home the same day, care for them after surgery. The department oversees several outpatient procedures, including 90 to 100 Endoscopy Procedures each month, blood transfusions, and Chemotherapy Infusions. f) CCH offers some of the most advanced imaging services including MRI, CT, Digital Mammography, Ultrasound, etc. Radiologists are on campus and/or available 24-7 to read the various scans. The dictation used by the Radiologists is voice recognized and becomes part of the digital image. All images are digital, meaning there are no films. g) CCH has an up to date Laboratory which performs over 13,000 tests on average per month, for both Inpatients and Outpatients. h) CCH has highly trained, employed Emergency Physicians and Nurses in their Emergency Department (ED) and offers 24-7 care. The Department includes support from qualified staff in Respiratory Care, Social Work, Laboratory, Medical Interpreting, and Diagnostic Imaging. The ED was designated as a Level III Trauma Center in May, 2006. The Medical Staff and Personnel in the Trauma Center have received specialized training to resuscitate and stabilize trauma patients. The trauma program provides systematic review of the trauma care and participates in injury prevention activities throughout the community. i) CCH opened Wound Care Services in August of 2008. The identified service area includes a 45-mile radius around Columbus. By January, 2009 a second day was added to support the demand. This service has taken off far beyond what was expected. Previously, patients seeking this specialized treatment were required to travel on average 75 miles to see a wound clinic specialist. It was a much needed service for the local communities. Columbus Community Hospital currently sees about 100 patients per month for wound care. j) Centering on services outside the Hospital, the larger services are Home Health and Hospice Services. Home Health is skilled health services for patients at their place of residence. The program is medically directed, therefore, it must be ordered by the attending physician. The Program is Medicare and Medicaid certified and meets the requirements of the Joint Commission. Services provided within the Program are: 1. Supervision and administration of medications 2. Intravenous Therapy 3. Teaching diabetic management 4. Nutritional Assessments 5. Home Health aides 6. Personal Care Services 7. Occupational, Speech and Physical Therapies 8. Hospice services are provided to persons who are no longer receiving curative treatment and whose life expectancy is six months or less. Care is provided by an interdisciplinary team which consists of the Physician, Nurse, Social Worker, Therapist, Home Health Aide, Spiritual Advisor, Volunteer and other health professionals. k) Our local Healthy Family Nebraska program (HFN) targets young, primarily single, pregnant mothers and their families. Our Voluntary HFN Home Visitation Program targets the most vulnerable young women and their families by offering them, intense, in home education, support and resources. This Home Visiting Program covers families in a four county area. The HFN requires each mother/family to actively participate in building an individualized family plan. This strength based approach promotes self- improvement, and enhances self-esteem and independence for our young parents that will help them make better decisions, and break out of destructive cycles. l) CCH's Sleep Lab offers complete Polysomnographic Sleep Testing for the purpose of diagnosing obstructive/central sleep apnea by trained and licensed Sleep Technicians. Both daytime and night sleep studies are performed. m) Occupational Health Services (OHS) offers a menu of health care services designed to prevent and treat injuries in the workplace. Partnering with employers in more than 800 companies and with other health care professionals, OHS provides the Columbus and regional area business and industry with a comprehensive range of services designed to support and maintain a healthy, safe workforce while assisting to meet OSHA and DOT compliance regulations. Their full range of services include: 1. A comprehensive testing procedure called the Physical Capacity Profile (PCP) that matches employees to the job and is designed to accommodate individuals with handicaps. The PCP System was developed by an Orthopedic Physician. Through use of this testing, musculoskeletal imbalances are detected which helps employers place employees in the appropriate job to minimize the potential of injury. 2. Drug and Alcohol Testing Services 24/7 3. DOT Physicals 4. Pre Employment/Post Job Offer Physical Assessments 5. On Site Nursing Services 6. Hearing/Vision Testing 7. Hearing Conservation Program Management 8. Respiratory Fit Testing 9. Respiratory Evaluation Services 10. Flu Shots and Immunization Programs 11. Wellness Programs n) Lifeline, an in home emergency response program, provides the vital safety net that many people need to continue living at home in familiar and comforting surroundings. The program is completely focused on ensuring the patient's independence, safety and well-being in their home. It operates with a bracelet worn by the patient with a button that can be pressed if help is needed. Predetermined responders are summoned to their home or emergency transfer can be called if n 1370490 1370490 0 Charity Care: CCH offers a Charity/Financial Aid Program to provide uncompensated services to people who are unable to pay. CCH Charity/Financial Aid Policy reflects the Mission, Vision and Values of CCH. It is intended to assist low-income, underinsured, and uninsured individuals whose financial status, under the Hospital's qualification criteria, makes it impractical or Impossible to pay for necessary medical services. CCH has a fiduciary responsibility to seek payment for services from those who can pay, and every effort will be made to apply consistent, fair and equitable financial aid practices in a manner consistent with all applicable Federal and State Laws and Regulations. CCH follows the Federal Poverty Guidelines (FPG) to determine both eligibility for free care, 100% of FPG, and discounted care, 200% FPG. CCH also offers Catastrophic Charity Assistance. If the applicant qualifies for partial charity/financial assistance and the total balance after all write-off's is greater than $1,200, an additional write-off will be done as outlined below. Reduce to $1,200; adjustments will be done from oldest to newest. 66315812 true true false true false false false false false true true false false false false true false true false false false false false false false false true true true true true false false false false false false false false false false false false false true true true true false true 32 0 true 662 true true true false false false false false false false false false X 11 11 false false false false false false false true true false false true true true true true true true true false X MIKE ADAMY 4025623382 4600 38TH STREET COLUMBUS NE 68601 X JAMES PILLEN DVM DIRECTOR 1.0 0.0 X 0 0 0 ANTHONY RAIMONDO JR DIRECTOR 1.0 0.0 X 0 0 0 JEFFREY GOTSCHALL MD CHAIR 1.0 0.0 X X 0 0 0 RONALD ERNST MD DIRECTOR 1.0 0.0 X 0 0 0 JOHN C MCCLURE DIRECTOR 1.0 0.0 X 0 0 0 REBECCA RAYMAN DIRECTOR 1.0 0.0 X 0 0 0 BONNIE MCPHILLIPS DIRECTOR 1.0 0.0 X 0 0 0 BRIAN SCHMIDT VICE CHAIR 1.0 0.0 X X 0 0 0 CLARK LEHR TREASURER 1.0 0.0 X X 0 0 0 BETH PRZYMUS DIRECTOR 1.0 0.0 X 0 0 0 KIPTON ANDERSON MD DIRECTOR/MED STAFF PRES 1.0 0.0 X 0 0 0 MICHAEL HANSEN PRESIDENT/CEO/SECRETARY 39.0 1.0 X 353520 0 58664 AMY BLASER VP BUSINESS DEVELOPMENT 40.0 0.0 X 131886 0 34611 J JOSEPH BARBAGLIA VP FINANCE 40.0 0.0 X 201239 0 29975 LINDA WALLINE VP NURSING 40.0 0.0 X 195596 0 27760 JAMES GOULET VP OPERATIONS 40.0 0.0 X 197792 0 29814 ROBERT MILLER MD PHYSICIAN 40.0 0.0 X 289212 0 23698 MICHAEL MCGUIRE MD PHYSICIAN 40.0 0.0 X 574777 0 16882 RICHARD CIMPL MD PHYSICIAN 40.0 0.0 X 647167 0 26164 EDWARD FEHRINGER MD PHYSICIAN 40.0 0.0 X 569295 0 30142 MARK HOWERTER MD PHYSICIAN 40.0 0.0 X 462500 0 30142 3622984 0 307852 22 false true false INPATIENT PHYSICIAN ASSOC 3200 PINE LAKE RD STE A LINCOLN NE 68516 HOSPITALIST SVCS 523246 TSP CONSTRUCTION SERVICES INC 1112 N WEST AVE SIOUX FALLS SD 571041333 CONSTRUCTION SVCS 795668 RENOVO SOLUTIONS LLC 1801 E PARK COURT PLAZA STE 206 SANTA ANA CA 92701 EQUIPMENT MAINT 112698 MCKESSON TECHNOLOGIES INC PO Box 98347 CHICAGO IL 60693 IT Consulting 815109 4 61455 61455 NET PATIENT SVC REVENUE 621110 77687200 77687200 MEANINGFUL USE PAYMENT 900099 1339467 1339467 79026667 284463 284463 0 0 0 0 0 79800 0 79800 79800 79800 0 0 0 MEALS ON WHEELS 900099 56141 56141 CAFETERIA 722100 271642 271642 HEALTH WATCH 900099 56262 56262 455573 436967 18606 839618 80292003 79576037 18606 635905 140000 140000 1370490 1370490 0 0 1080033 1080033 0 28316154 28316154 1053018 1053018 3191396 3191396 1974071 1974071 0 24478 24478 198141 198141 5966 5966 0 0 1407577 1407577 162267 162267 10867164 10624254 242910 1571297 1571297 0 1086641 1086641 197408 197408 0 109322 109322 0 0 4935220 4935220 192756 192756 PROVISION FOR BAD DEBTS 5512231 5512231 MINOR EQUIP. & FINANCING AGRMT 1788872 1788872 PURCHASED SERVICES 1605145 1605145 RECRUITING 243212 243212 1303478 1303478 68336337 66315812 2020525 0 1933467 5961224 0 0 0 0 9233671 9015656 0 0 0 0 0 0 1077673 1348807 1512950 1828137 92315034 53664675 37701715 38650359 46218318 51402269 0 0 0 0 0 0 214862 256802 97892656 108463254 6956170 6261385 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 6956170 6261385 X 90936486 102201869 0 0 0 0 90936486 102201869 97892656 108463254 X 11955666 -690283 X false true X true false X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED false false false false false false false false true 5966 5966 false SCHEDULE C, PART II-B, LINE 1I DUES PAID TO AMERICAN HOSPITAL ASSOCIATION ALLOCATED TO LOBBYING $3,108 DUES PAID TO NEBRASKA HOSPITAL ASSOCIATION ALLOCATED TO LOBBYING $2,858 1742125 56121 1798246 1667736 74389 1742125 1573063 94673 1667736 1506660 66403 1573063 1426826 79844 -10 1506660 1.00000 false true true 1279072 1279072 44122186 20225508 23896678 40630741 31491864 9138877 6283035 1947303 4335732 38650359 0 0 X FIN 48 FOOTNOTE SCHEDULE D, PART X The Hospital adopted Financial Accounting Standards Board (FASB) Interpretation No. 48, Accounting for Uncertainty in Income Taxes - an Interpretation of FASB Statement No. 109 (FIN 48). FIN 48 provides specific guidance on how to address uncertainty in accounting for income tax assets and liabilities, prescribing recognition thresholds and measurement attributes. The adoption of FIN 48 by Columbus Community Hospital did not have a material impact on the Hospital's financial position, results of operations, or cash flows. In Fiscal Years Ending 2014 and 2013, management determined that there are no income tax positions requiring recognition in the financial statements. SCHEDULE D, Part V, Line 4 ENDOWMENT FUNDS ARE HELD AND MAINTAINED BY COLUMBUS COMMUNITY HOSPITAL FOUNDATION. THE ENDOWMENT FUNDS EXIST IN SUPPORT OF IMPROVED HEALTH SERVICES BY COLUMBUS COMMUNITY HOSPITAL. true true X true X true X true true false true true 761 761444 761444 0.01210 4775514 1507026 3268488 0.05200 761 5536958 1507026 4029932 0.06410 77619 465978 3550 462428 0.00740 848 804395 10470 793925 0.01260 132 99867 99867 0.00160 78599 1370240 14020 1356220 0.02160 79360 6907198 1521046 5386152 0.08570 1 1950 1950 2360 2360 1560 27531 11959 15572 0.00020 3512 8780 1085 7695 0.00010 5073 40621 13044 27577 0.00030 false 5512231 20400882 21641103 -1240221 X true true HEALTHPARK LLC PROPERTY MANAGEMENT 0.72790 ZARZ LLC PROPERTY MANAGEMENT 0.55550 1 1 Columbus Community Hospital INC 4600 38th Street Columbus NE 686011800 www.columbushosp.org License #: 630001 X X X 47 Bed acute care Hospital w/ 24 HR ER Services COLUMBUS COMMUNITY HOSPITAL INC true X X X X X X X X X 12 true true true X SEE SECTION C X X X X X X X X X false false true true 100 true 200. true X X X X true true X X X X X X X true false true X false false PART V, SECTION B, LINE 3 MOBILIZING FOR ACTION THROUGH PLANNING AND PARTNERSHIP (MAPP) PROCESS WAS DEVELOPED BY AND IS RECOMMENDED FOR COMMUNITY ASSESSMENT BY THE NATIONAL ASSOCIATION OF CITY AND COUNTY HEALTH OFFICIALS (NACCHO) AND CENTER FOR DISEASE CONTROL (CDC). MAPP WAS ALSO A RECOMMENDED COMMUNITY ASSESSMENT BY THE NEBRASKA RURAL HEALTH ASSOCIATION IN ITS "COMMUNITY HEALTH ASSESSMENT COLLABORATIVE PRELIMINARY RECOMMENDATIONS FOR NEBRASKA'S COMMUNITY, NONPROFIT HOSPITALS TO COMPLY WITH NEW REQUIREMENTS FOR TAX EXEMPT STATUS ENACTED BY THE PATIENT PROTECTION AND AFFORDABLE CARE ACT" (SEPTEMBER OF 2011). MAPP allows for input from parties who represent broad interests in the communities. Input from diverse sectors including medically underserved, low-income, minority populations and individuals from diverse age groups was obtained through surveys, targeted focus groups, open public meetings and target invitations to community leaders and agencies. The Hospital's participation in the current MAPP assessment is the most thorough to date with over 100 individuals in the District participating in the process. This does not count the 1,000 individual surveys or focus group participants. PART V, SECTION B, LINE 4 -ALEGENT HEALTH MEMORIAL HOSPITAL, SCHUYLER -GENOA COMMUNITY HOSPITAL -BOONE COUNTY HEALTH CENTER PART V, SECTION B, LINE 5A & 5D THE DETAILED ASSESSMENT AND RELATED COMPONENTS ARE AVAILABLE VIA LINK ON https://www.columbushosp. org/news_events/community_health_needs_assessment_chna.aspx OR AVAILABLE ON REQUEST AND AVAILABLE FOR REVIEW AT COLUMBUS COMMUNITY HOSPITAL. THE IMPLEMENTATION STRATEGY IS AVAILABLE VIA LINK ON https://www.columbushosp.org/news_events/chip_implementation_plan.aspx PART V, SECTION B, LINE 7 We have identified priorities for areas that we are not directly addressing. We will maintain active partnerships with and remain supportive of the lead organizations focused on these priorities. PART V, SECTION B, LINE 14G INFORMATION BROCHURES ON FINANCIAL/CHARITY ASSISTANCE (F/C) ARE AVAILABLE IN KEY AREAS OF THE HOSPITAL. THE CCH WEBSITE HAS INFORMATION REGARDING F/C ASSISTANCE, AS WELL AS APPLICATIONS IN BOTH SPANISH AND ENGLISH. THE PATIENT STATEMENTS HAve INFORMATION REGARDING F/C ASSISTANCE. THE F/C APPLICATIONS ARE AVAILABLE TO ALL STAFF ON THE H DRIVE UNDER FORMS. THE EMERGENCY REGISTRATION, MAIN REGISTRATION, PATIENT ACCOUNTS AND SOCIAL SERVICES DEPARTMENTS HAVE THE F/C APPLICATIONS IN BOTH ENGLISH AND SPANISH AVAILABLE. 9 PREMIER PHYSICAL THERAPY OF CCH US 30 CTR BLDG 3100-23RD st ste 15 COLUMBUS NE 686013161 PHYSICAL & AQUATIC THERAPY, SPORTS TRAINING SERVICES WIGGLES & GIGGLES THERAPY FOR KIDS 2108-13TH STREET COLUMBUS NE 686015100 PEDIATRIC THERAPY SERVICES OCCUPATIONAL HEALTH SERVICES OF CCH 3005-19TH ST SUITE 300 COLUMBUS NE 686014252 EMP. HEALTH CARE SVCS TO PREVENT & TREAT WORK INJURIES WOUND HEALING CENTER 4600-38TH STREET SUITE 165 COLUMBUS NE 68601 WOUND TREATMENT CENTER HUMPHREY CLINIC OF CCH 3003 MAIN STREET HUMPHREY NE 686423155 CLINIC IN SMALL TOWN TO OFFER MEDICAL SVCS TO RESIDENTS HOSPICE OF COLUMBUS COMMUNITY HOSPITAL 3005-19TH STREET SUITE 600 COLUMBUS NE 686014248 HOSPICE SERVICES COLUMBUS COMMUNITY HOSPITAL SLEEP LAB 3020-19TH STREET SUITE 100 COLUMBUS NE 686014252 POLYSOMNOGRAPHIC SLEEP TESTING HOME HEALTH OF COLUMBUS COMMUNITY HOSP 3005-19TH STREET SUITE 600 COLUMBUS NE 686014248 HOME HEALTH SERVICES COLUMBUS ORTHOPEDIC & SPORTS MED CLINIC 4508 38TH STREET STE 133 COLUMBUS NE 686011668 FREE STANDING CLINIC PART I, LINE 3C N/A PART I, LINE 6A A Community Benefit report is included each year in the Hospital's quarterly newsletter "Housecall" with an electronic version of the newsletter housed on the Hospital's website. A separate landing page on the website was also created for the report to provide easy access to the report. PART I, LINE 7B The revenue generated by Medicaid patients is multiplied by the cost to charge ratio developed in worksheet 2. The remaining product is the calculated cost associated with the charges from Medicaid patients. These costs are reduced by the reimbursements collected for the Medicaid charges. The remaining number is the net community benefit expense. Part I, Line 7e Expenses represent wages along with services and supplies purchased by the Hospital. Direct offsetting revenues represent cash collected for these services. Part I, Line 7f Expenses represent wages along with services and supplies purchased by the Hospital. Direct offsetting revenues represent cash collected for these services. Part I, Line 7i Cash donations represent the majority of these donations, the largest amount, $87,500, going to the East Central District Health Department to support Community Health Programs. Other cash donations were made to smaller organizations for programs or events relating to health. The in-kind donations, $369, were items like boxes of gloves, bottles of hand sanitizer to Special Olympics Teams, etc. Part I, Line 7, Column (f) The amount of 62,824,106 used as the denominator to compute Column (f) is calculated by taking total functional expenses of 68,336,337 minus Bad Debt expense of 5,512,231. PART II COMMUNITY BUILDING ACTIVITIES - The Hospital continues to collaborate with the local Chamber of Commerce to recruit skilled professionals to fill job openings in the community. The Hospital also provides support and staff time to assist in highlighting the healthcare community, providing specific department or Hospital tours in order to recruit skilled professionals to live and work here in the community. - The Hospital donated land to the City of Columbus providing space for a twelve-acre urban lake and 20 acres of land for a future fire station on this property. The urban lake is equipped with a nice wooden dock making it very accessible for strollers, wheelchairs and other assistive devices to fish or watch the water fowl on the lake. Local assisted living and nursing care centers can drive to the accessible dock, allowing their residents to have convenient access to the lake as well. This urban lake, waterfowl area provides a community space within the City limits for the whole community, young and old alike. - The Hospital continues to partner with our local District Public Health Department and Community Health Center (CHC) on several projects and community disease prevention initiatives. The Hospital provides financial support and professional staff time as liaisons to these community partnerships throughout the year working on multiple chronic disease and accident prevention strategies. Some of these community initiatives include Type II Diabetes, Hypertension and Heart Disease, Pre and Post Natal Newborn care, Physical Activity and Exercise, Colon Cancer Prevention and Early Detection as well as Community Preparedness to natural and manmade disasters. Several other initiatives are addressed throughout the year as community health issues arise. Thousands of community members are reached with these community initiative campaigns each year and making a real difference in the lives of people living with chronic health issues. The Hospital also provides free flu shots to residents of Harbor of Hope, a homeless shelter. - Additionally, CCH participates in over a dozen community health fairs/community events each year, providing medical screenings and information for all community members. - CCH also partners with local day cares, schools and colleges to provide speakers and hands on learning events for students to encourage entry into the medical professions. Additionally, the CCH Board has approved the construction of a day care center that will provide not only day care, but pre-school learning using the Educare Model. - The CCH Board of Directors has approved the construction of a $21.0 million, 85,723 square feet Community Wellness Facility that will be leased, below fair market value, to the YMCA. The Wellness Center will be available for use by the entire community and include 2 gyms, pool, weights and exercise equipment, all in 62,397 square feet. Classes for wellness and fitness will be provided by healthcare professionals from the Hospital and YMCA staff. The facility will also house the Hospital's Adult Therapies and Pediatric Therapy in separate areas. PART III, Section A, LINE 2 The methodology used to estimate the bad debt expense is to take the private pay write-offs for the year and divide them by the total revenue generated from self-pay patients and multiply the product by the self-pay accounts receivable. This gives the amount of reserve necessary to cover the potential bad debt in current self-pay accounts receivable. Bad debt expense for the fiscal year is the amount of additional expense necessary to bring that reserve account to the calculated (estimated) balance. Part III, Section A, Line 3 N/A Part III, Section A, Line 4 Financial statements do not include any text for bad debt. The amount in Line 2 is the book bad debt amount. Charity care is kept separate from bad debt. PART III, Section B, LINE 8 In accordance with 42 CFR 413.24, Columbus Community Hospital uses the "step-down method" as its costing methodology. Departments within a provider are usually divided into two types: 1) those that produce patient care revenue (e.g., routing services, radiology), and 2) those that do not directly generate patient care revenue, but are utilized as a service by other departments (e.g., laundry and linen, dietary). The two types of departments are commonly referred to as "revenue-producing cost centers" and "nonrevenue-producing cost centers", respectively. Although nonrevenue-producing cost centers do not directly produce patient care revenue, they contribute indirectly to patient care revenue generated by "serving" as a service to the revenue-producing centers and also to other nonrevenue-producing centers. Therefore, for the purpose of proper matching of revenue and expenses, the cost of the revenue-producing centers should include both its direct expenses and its proportionate share of the costs of each nonrevenue-producing center (indirect costs) based on the amount of services received. The process of allocating the cost of a particular nonrevenue-producing center to other nonrevenue-producing centers and revenue-producing centers is performed by utilizing a set of statistics (e.g., pounds of laundry for allocating "laundry and linen" costs, square feet for allocating "depreciation building" costs). Every nonrevenue-producing cost center has the potential of being allocated to every other nonrevenue-producing cost centers in addition to the revenue-producing cost centers. This precludes a simple allocation of the direct expense of the nonrevenue-producing cost center because the indirect costs derived from allocation of other nonrevenue-producing cost centers must be computed in determining the "full cost" (direct and indirect costs) of the nonrevenue-producing cost center being allocated. The "step-down method" recognizes that services furnished by certain nonrevenue-producing departments are utilized by certain other nonrevenue-producing centers as well as by the revenue-producing centers. All costs of nonrevenue-producing centers are allocated to all centers that they serve, regardless of whether or not these centers produce revenue. The cost of the nonrevenue-producing center serving the greatest number of other centers, while receiving benefits from the least number of centers, is apportioned first. Following the apportionment of the cost of the nonrevenue-producing center, that center will be considered "closed" and no further costs are apportioned to that center. This applies even though it may have received some service from a center whose cost is apportioned later. Generally, if two centers furnish services to an equal number of centers while receiving benefits from an equal number, that center which has the greatest amount of expense should be allocated first. PART III, Section C, LINE 9B Charity (financial aid) program policy/procedure Columbus Community Hospital (CCH) offers a charity/financial aid program to provide uncompensated services to people who are unable to pay. CCH charity/financial aid policy reflects the mission, vision and values of CCH. It is intended to assist low-income, underinsured and uninsured individuals whose financial status, under the Hospital's qualification criteria, makes it impractical or impossible to pay for necessary medical services. CCH has a fiduciary responsibility to seek payment for services from those who can pay, and every effort will be made to apply consistent, fair and equitable financial aid practices in a manner consistent with all applicable Federal and State laws and regulations. 1. Charity Policy A. Our charity/financial aid policy does not eliminate the personal responsibility and financial discounts are always secondary to other Government-sponsored programs. However, CCH is committed serving those without the means to pay and works with Good Neighbor Community Health Center and Medicaid services to provide services to this segment. 2. Health Insurance A. If a patient or guarantor has access to employer-based or Government-sponsored health insurance, yet elected not to enroll or failed to maintain eligibility, they may be considered. They will be encouraged to obtain coverage at the next eligible period. B. If a patient or guarantor has a medical savings account, this must be expended before they are eligible for assistance. C."Presumptive" financial assistance may be taken into consideration when a patient has expired and there is no estate. An incomplete financial assistance form may be on file because documentation was lacking that would support the provision of financial aid. In this case: I. A family member is contacted to ensure no estate exists. II. A family member may be asked to sign and date a statement to the effect that no estate exists. III. The County in which the deceased patient resided in is contacted to verify that no estate exists. D. CCH's charity/financial aid is not a substitute for employer-sponsored, public or individually-purchased insurance, nor is CCH's financial aid policy a substitute for the responsibility of Government and employers to expand access to healthcare coverage for all persons. 3. Accounts with a balance A. Charity/financial aid may apply to balances due from insured patients for deductibles, co-payments, or co-insurance, or other types of patient payment responsibility. 4. Receiving an application A. CCH is diligent in its efforts to determine, at the earliest point in time, the patient's ability to pay. Information on charity/financial assistance is available in key areas of the Hospital and how to apply or obtain further information, as well as information on the Hospital website and patient statements. I. Hospital staff who work closely with patients are well educated on communicating financial aid availability and how to direct patients to staff responsible for the financial aid application process. II. Staff members are trained to treat financial aid applicants with courtesy, confidentiality and cultural sensitivity. III. These principles and guidelines are for those patients who truly cannot afford healthcare services. B. Any person requesting financial aid information is directed to the Patient Accounts or Social Services departments. An application for the charity/financial aid program is completed prior to making an eligibility determination. The application is also available in Spanish. Once the application is submitted with written proof of income, a determination is made in a timely manner. One of more of the following is required as verification of income. I. A letter or rejection from the Department of Social Services (Medicaid) if applicable. II. Signed copy of previous year's tax return III. Copy of most recent pay stub, with accumulative earnings. IV. Copy of recent three months of bank statements with an explanation of all deposits. V. Copy of any compensation received, e.g., unemployment, if applicable VI. Social Security determination if applicable. C. A family is defined as anyone living together in a household; this will include college students who received financial support from their parents, regardless of their residence. 5. Review process A. All completed applications are reviewed and approved by the Patient Financial Services Director and overseen by the Vice-President of Finance. B. Any applications that are in need of further assistance are taken to the Vice-President of Finance. C. All write-offs greater than $5,000 are reviewed by the Vice-President of Finance. D. The Vice-President of Finance oversees the charity and Medicare bad debt statistical reports on a monthly basis. E. If the applicant's income is above poverty guidelines, but is still in need of assistance, a sliding scale is used. This scale is adjusted according to the current year's poverty guidelines. If the applicant qualifies for partial charity/financial assistance, acceptable monthly payment arrangements must be agreed upon. F. If the applicant qualifies for partial charity/financial assistance and the total balance, after all write-off's, is $1,200 or greater, an additional write-off will be done as outlined below. - Reduce to $1,200; adjustments will be done from the oldest to the newest. G. A letter will be sent to the guarantor informing them of the determination for charity/financial assistance along with a monthly payment agreement for those who qualified for partial approval or denied applicants. This agreement is signed and returned to the Patient Accounts Department within 10 days. 6. Documentation of processed accounts A. The Patient Financial Services Director will maintain an annual log of all applicants. Documentation is also maintained for those accounts which have been approved or written off. 7. Archived applications A. All charity applications are scanned into MPF under document type `Charity Applications`. NEEDS ASSESSMENT In 2010, Columbus Community Hospital began implementing a five year strategic plan. The plan includes a thorough assessment of the organization's external environment in terms of opportunities and threats, as well as an assessment of the organizations internal strengths and weaknesses. The plan also includes strategic issues, goals, and related strategies for future organizational effectiveness. Six organizational pillars were identified: Quality, Culture, People, Service, Facilities and Finance. 1)Quality - Quality efforts have been focused on Evidence Based Processes (EBP) and educating staff on the importance of using and integrating these processes in daily operations. CCH has implemented an electronic medical record to afford ease of information access and communication across the continuum of care. The Clinical Leadership Group for Nursing and Respiratory Therapy have initiated a review of how to integrate EBP into the clinical areas and will be starting classes to educate staff within and outside nursing. 2)Culture - In an effort to achieve a high performance organization, CCH is in the process of implementing a 4-part culture improvement initiative including TeamSTEPPS, Just Culture, Studer and Lean/Six Sigma Process Improvement. The Hospital continues to work with the Studer Group to hardwire appropriate tools, focusing on improving patient outcomes and creating a culture/environment where staff want to work and physicians want to bring their patients. 3)People - CCH has continued to be aggressive in its recruitment efforts to attract and retain the workforce needed to support strategic growth initiatives across all service lines. CCH is initiating a new onboarding process for new employees. In addition, nursing has updated their orientation program and has trained preceptors and nurse mentors/coaches. 4)Services - CCH performs an annual, comprehensive program review of existing and new services and has ranked priority service line development to begin in the areas of hospital medicine, orthopedics, cardiology, cancer and rehab services. 5)Facilities - CCH has developed a comprehensive master facilities plan that can adapt to current and future patient care needs. An emergency department expansion was completed in 2012 and we now are in the process of building a new Medical Office Building which will house our Visiting Physicians and W.O.C. Health Center (Wound, Ostomy and Continence Care). 6)Finance - CCH will work diligently to maintain financial stability. Their approach includes: work to extend the Demonstration Project with a plan in place if the program is discontinued, maintain a conservative successful investment strategy and grow the CCH Foundation/Auxiliary. PATIENT EDUCATION OF ELIGIBILITY FOR ASSISTANCE Here is a sample of what is available on our CCH web site with detailed links. A hard copy with information is also available in a special wall unit located inside each patient room as well as in brochures located in outpatient areas. There is also a tutorial listing each step and letting the patient know what they will need to bring along or have available for copying purposes. A) Monthly Payment Option 1. If you are unable to pay your balance in full, please call the Patient Accounts Department to set up an acceptable payment arrangement. B) Patient Charity/Financial Assistance Program 1. If you feel your income is not sufficient to pay for your services at Columbus Community Hospital, please contact the Patient Accounts Department and/or Social Workers for information regarding charity/financial assistance. 2. Further information about Medicare/Medicaid/Charity Care is provided in both English and Spanish. The State has Medicaid applications available online. Our Patient Accounts and Social Services staff have financial/charity applications available in both English and Spanish to provide to our patients. 3. Additionally, signage is posted directing patients to call as needed for financial help, and referrals are built into the medical admission software, so if patients voice concerns about the cost, or their lack of coverage a referral is generated to Social Services staff who will see patients individually and counsel on specific circumstances. 4. Monthly statements have the following information on them: a. Payment Plans b. Charity/Financial Assistance Program c. 27/7 online business office, which includes information on payment plans, charity/financial assistance, and downloadable financial/charity applications (available in English and Spanish). COMMUNITY INFORMATION The local economy- Columbus Community Hospital is located in Columbus, Nebraska, which is the largest city in Platte County. With a growing population of 33,066, Platte County is the largest county of the seven county service areas. From July 31, 2013 to July 31, 2014, unemployment in the City of Columbus decreased slightly from 3.9% rate or 756 and Jobless to 3.3% rate or 610 jobless. During this same period of time, the Nebraska jobless rate was 3.6% and the National average was reported at 6.2%. As reported in Money Magazine, Columbus is listed as the third best place in the U.S. to find employment and in the "Top 100 best small towns to live". Three counties in Nebraska were listed in the top ten counties in the U.S. to live and work, including Platte, Madison (which is contiguous to Platte County) and Sarpy County near Lincoln, Nebraska. Our local economy is based on agriculture and manufacturing, with many industrial companies attracted by plentiful, low-priced hydroelectric power. Among the major employers are Archer Daniels Midland (ADM), an ethanol manufacturing company; Flex-Con; Central Confinement Service; Pillen Family Farms; Vishay; BD Medical Plants, a medical equipment company; Behlen Manufacturing, which manufactures steel buildings; and Nebraska Public Power, with headquarters located in Columbus. Due to successful economic and industrial development in our area, this large manufacturing base remains intact. A hard-working, well-educated workforce, low energy costs and a local environment friendly to business, provide encouragement for strong economic and industrial development within our service area. According to the Nebraska Department of Labor, Columbus is considered a major hub for the manufacturing industry and has a greater share of manufacturing employment than other Nebraska metropolitan areas. We continue to see an influx of single and young families moving into our area seeking employment. Our community growth correlates to our continuing increase in Hospital outpatient visits. Outpatient visits reached 44,613 visits for the fiscal year ending April 2014. In 2005, our outpatient visits over a twelve month period totaled 38,129. This 17% increase in our outpatient visits over the past nine years is a reflection of the significant impact the Demonstration Project has had on our Hospital. SERVICE CAPACITY: The W.O.C. Health Center opened August of 2008. It has grown to 1,107 patients/visits as of April 30, 2014. The identified service area includes a 45-mile radius around Columbus. The W.O.C. Health Center is located in the Visiting Physician office suite of the attached medical office building. The Center has scheduled visits two days per week. Additional nurse staff time is spent each week assisting outpatient clients with wound applications, as well as assisting with applications of wound vacs in surgery or on our medical floor, scheduling appointments and other responsibilities such as ordering supplies and maintaining compliance with National Standards. Previously, patients seeking this specialized treatment were required to travel on average 75 miles to see a Wound Center Specialist. The volume we are seeing at this W.O.C. Health Center reinforces the amount of community need that existed for this service and has greatly increased the local access to for so many of our higher acuity patients and their families. Our nurses are WCOM certified, so in addition to wound care, our patients who have challenges with ostomy appliances and continence problems can be addressed. CCH installed a new CT Scanner, new Radiologic/Fluoroscopy System and Nuclear Medicine Camera. These replaced existing systems. We recently opened a Women's Imaging Area within the Hospital which is separate from the Radiology Department. A new registration area recently opened which provides patient privacy. We reduced our Mammography procedure pricing 21% on February 8, 2012 and sought and received a Susan G. Komen Grant, which the Hospital Foundation matched, to promote mammography screening for women in the community. In 2010 we changed our Bone Density Service from contracting with a mobile service unit to purchasing our own Bone Density stationary equipment, the necessary support equipment and trained staff. The benefits to the community include increased access for patients and providers who no longer have to wait diagnosis with the mobile units' intermittent service. This is another new program made possible by the Demonstration Project that increases access and eliminates the need to travel to out of town for prompt diagnosis. Columbus Community Hospital is a 47 bed, acute care hospital serving needs offering a variety of surgical procedures and short term hospitalizations. All 47 beds are licensed for either acute care or swing bed patients. In addition, we provide comprehensive outpatient Laboratory, Radiology, Respiratory and Rehabilitative services. We also provide free interpreter services 24/7. Our facility offers comprehensive care, including Intensive Care, Medical-Surgical Care, Inpatient and Outpatient Surgical Procedures (General, ENT, Urology, Podiatry, Orthopedic), as well as other complimentary ancillary services including Respiratory, Wound Care, Diabetes Education, Endoscopies and Cardiopulmonary Rehabilitation. In 2006, the Hospital's Emergency Department was designated as a Level III Trauma Center with nurses certified in TNCC, ACLS and PALS. Eight of the Emergency Department nurses are also certified in ENPC. A 30,000 square foot, addition in 2012 provided the Emergency Department with expanded space. The ED added two trauma bays, a two-bay ambulance garage, a dedicated decontamination area, a dedicated family grief and counseling room, covered drive-up access and a negative air-pressure room, which allows patients with communicable diseases to be treated while protecting other patients and staff. Our Home Health/Hospice Interdisciplinary Services are provided to patients within a 30 mile radius of Columbus and can provide in home telehealth monitoring. The Hospital's Sleep Lab provides Polysomnographic Sleep Testing. In addition, we have available both daytime and home sleep tests. In January 2010, the Hospital hired a fulltime RN as the Orthopedic Service Line Coordinator. A multi-disciplinary team was organized to review, standardize and improve the patient's Total Joint Process from diagnosis to post-surgical recovery and in November. In March, 2012 the Hospital acquired Columbus Orthopedic and Sports Medicine Clinic, enabling the Hospital to expand the service line and ensure the community's aging population Orthopedic Services close to home. In May 2013, we expanded the RN Coordinators responsibility into case management in the Transitional Care Department. This expansion of her duties enables us to plan for continuity of care post hospitalization. Three Cardiologists have relocated to Columbus, providing full time Cardiology Services to the area. Since 2010, 63 Physicians in total have been recruited to service the needs of our Primary and Secondary Service Areas to include 55 MDs, 1 DPM and 7 Midlevels, 34 are full time providers and the other 29 are serving the community is a visiting capacity. The Hospital has completed construction on three road projects on and around the campus to increase access to the facility. Two clinic buildings, one for a Family Practice Group and one for a Pharmacy have been completed as well. The Hospital's Board of Directors has authorized the construction of a $21.0 million, 85,723 square feet Community Wellness Center for use by the entire community. The facility will be leased to the YMCA, with 62,397 square feet containing 2 gyms, pool, weights and exercise equipment promoting exercise and wellness in our community. The facility will also house the Hospital's adult therapies and pediatric therapy. PROMOTION OF COMMUNITY HEALTH -THE HOSPITAL REINVESTS CAPITAL TO IMPROVE PATIENT CARE, ATTRACT THE BEST QUALIFIED STAFF TO PROVIDE QUALITY CARE FOR OUR PATIENTS, PROVIDE MEDICAL EDUCATION AND PREVENTION ACTIVITIES IN THE COMMUNITY. -OUR HOSPITAL IS LIVING OUR MISSION AND VISION WITHIN THE COMMUNITY: *OUR MISSION IS TO IMPROVE THE HEALTH OF THE COMMUNITIES WE SERVE *OUR VISION IS TO COMPASSIONATELY DELIVER THE STATE'S HIGHEST QUALITY PATIENT CARE -CORE VALUES CCH CORE VALUES ARE: *INTEGRITY *COMPASSION (CHANGED FROM "COMMITMENT" AS PART OF THE COMMUNICATION OF THIS STRATEGIC PLAN) *ACCOUNTABILITY *RESPECT *EXCELLENCE -THE HOSPITAL HAS PRIORITIZED OUR CAPITAL REINVESTMENT BY ALIGNING IT TO THE STRATEGIC PLAN. OUR PLAN CONSISTS OF SIX ORGANIZATIONAL PILLARS WITH GOALS AND STRATEGIES ASSOCIATED WITH EACH. THE SIX PILLARS OF EXCELLENCE CONSIST OF: *QUALITY *CULTURE *PEOPLE *SERVICES *FACILITIES *FINANCE MEASUREMENT OF ONGOING OPERATIONAL PERFORMANCE IS ORGANIZED AROUND THESE PILLARS OF EXCELLENCE. THESE PILLARS WERE STRATEGICALLY IDENTIFIED AS COMMON MEASURES AROUND WHICH OPERATIONAL PERFORMANCE IS ORGANIZED IN MANY HEALTH CARE INSTITUTIONS AND ADAPTED FOR CCH. COLUMBUS COMMUNITY HOSPITAL HAS AN INDEPENDENT BOARD OF DIRECTORS MADE UP OF COMMUNITY LEADERS WITH DIVERSE BACKGROUNDS. COLUMBUS COMMUNITY HOSPITAL HAS AN OPEN EMERGENCY ROOM AVAILABLE TO ALL IN NEED NO MATTER OF RACE, CREED, AGE, OR ABILITY TO PAY. THE HOSPITAL ALSO HAS AN OPEN MEDICAL STAFF. AFFILIATED HEALTH CARE SYSTEM N/A STATE FILING OF COMMUNITY BENEFIT REPORT NONE true East Central District HEALTH DEpt 1453 29th AVENUE COLUMBUS NE 68601 470835183 87500 Support Community COLUMBUS COMMUNITY HOSPITAL FOUNDATION 4600 38TH STREET COLUMBUS NE 68601 470836747 501(C)(3) 52500 TO SUPPORT EXEMPT 1 0 CHARITY CARE TO PATIENTS 761 1370490 BOOK WRITE-OFF OF MED EXP GENERAL INFORMATION ON GRANTS AND ASSISTANCE Schedule I, Part I, Line 2 COLUMBUS COMMUNITY HOSPITAL DOES NOT TYPICALLY GIVE OUT DONATIONS, BUT OCCASIONALLY A REQUEST IS BROUGHT FORWARD AND THE BOARD DETERMINES THAT IT IS IN THE BEST INTEREST OF THE COMMUNITY TO PROVIDE A PARTICULAR GRANT. PRIOR TO PROVIDING THE GRANT, THE HOSPITAL DETERMINES THAT THE ORGANIZATION IT GIVES TO IS A 501(C)(3) ORGANIZATION OR A GOVERNMENT AGENCY. THE HOSPITAL WILL ALSO MAKE GRANTS TO THEIR RELATED ORGANIZATIONS AS NECESSARY TO SUPPORT THEIR EXEMPT PURPOSE. X true true X X X X X X false true false false false true false false false MICHAEL HANSEN PRESIDENT/CEO/SECRETARY 298520 0 37500 0 17500 0 42700 0 21013 0 417233 0 0 0 AMY BLASER VP BUSINESS DEVELOPMENT 120317 0 11569 0 0 0 14669 0 21958 0 168513 0 0 0 J JOSEPH BARBAGLIA VP FINANCE 165866 0 17873 0 17500 0 10033 0 22946 0 234218 0 0 0 LINDA WALLINE VP NURSING 150978 0 27118 0 17500 0 7818 0 22495 0 225909 0 0 0 JAMES GOULET VP OPERATIONS 133731 0 29563 0 34498 0 9872 0 22726 0 230390 0 0 0 ROBERT MILLER MD PHYSICIAN 289212 0 0 0 0 0 9034 0 18516 0 316762 0 0 0 MICHAEL MCGUIRE MD PHYSICIAN 574777 0 0 0 0 0 10200 0 13377 0 598354 0 0 0 RICHARD CIMPL MD PHYSICIAN 629667 0 0 0 17500 0 10200 0 22716 0 680083 0 0 0 EDWARD FEHRINGER MD PHYSICIAN 551795 0 0 0 17500 0 10200 0 27444 0 606939 0 0 0 MARK HOWERTER MD PHYSICIAN 462500 0 0 0 0 0 10200 0 25645 0 498345 0 0 0 QUESTIONS REGARDING COMPENSATION PART I, LINE 1A THE ORGANIZATION PAID FOR SOCIAL AND HEALTH CLUB DUES AS PART OF THE CEO'S EMPLOYMENT AGREEMENT. These amounts were reflected on the CEO's W-2. PART I, LINE 4B The following reportable individuals participated in a supplemental nonqualified retirement plan during the 2013 calendar year. Amounts deferred from the plan were included in Column C of the Schedule J: Michael Hansen - $32,500 Amy Blaser - $9,440 PART I, LINE 6A WITH THE ASSISTANCE OF IHSTRATEGIES, EXECUTIVE COMPENSATION CONSULTANTS, THE BOARD AUTHORIZED PAYING AN INCENTIVE TO THE EXECUTIVES FOR MEETING SPECIFIC BOARD- ESTABLISHED DIRECTIVES. THE BOARD AUTHORIZED PAYING 25% OF BASE COMPENSATION FOR Michael Hansen and 20% FOR THE following VPS: JOSEPH BARBAGLIA JIM GOULET LINDA WALLINE AMY BLASER THE INCENTIVE IS BASED ON GOALS ESTABLISHED BY THE BOARD WHICH ARE NOW REVIEWED ANNUALLY. ONE OF THE GOALS IS THE HOSPITALS OPERATING MARGIN. THE BOARD DETERMINES THE ASSOCIATED METRICS FOR EACH INDIVIDUAL GOAL. EACH OF THE GOALS IS THEN ASSIGNED A WEIGHT BASED ON THE LEVEL OF IMPORTANCE, AS DETERMINED BY THE BOARD. THE RESULTS ARE ENTERED AND THE METRIC IS TABULATED. THAT NUMBER IS MULTIPLIED BY THE CORRESPONDING WEIGHT. ONCE WEIGHTED, THE FIGURES ARE ADDED IN TOTAL TO ESTABLISH A SCORE BETWEEN 1-5. NO INCENTIVE IS PAID IF THE HOSPITALS OPERATING MARGIN FALLS BELOW 5.0%, REGARDLESS OF THE OUTCOMES OF THE OTHER MEASURES. THE INCENTIVES WERE PAID IN THIS FISCAL YEAR FOR WORK DONE IN THE PREVIOUS FISCAL YEAR. THE BONUSES PAID WERE: MICHAEL HANSEN - $37,500 JOE BARBAGLIA - $17,873 JIM GOULET - $29,563 LINDA WALLINE - $27,118 AMY BLASER - $11,569 GOVERNANCE, MANAGEMENT AND DISCLOSURE PART VI, LINE 11B The form 990 will be available for all members of the Finance Committee to review. Upon Committee review, the 990 will then be submitted to the Board for review and the Board will make any corrections if applicable. Form 990, Part VI, Line 12C Columbus Community Hospital monitors any conflict of interest based on their conflict of interest policy. Employees and Volunteers are required to fully disclose any conflict of interest that may exist or appears to exist. Hospital reviews any of these conflicts and works with the Vice President or CEO to determine if a conflict exists. If one does exist, the hospital initiates actions to manage, reduce, or eliminate the conflict. FORM 990, PART VI, LINE 15 The Hospital's Executive Compensation Committee, made up of independent Hospital Board members, reviews the CEO's compensation annually. The wage range is compared to information provided by third party consultants. Decisions are documented. Form 990, Part VI, Line 19 At Columbus Community Hospital, a 3-ring binder exists in the Executive Assistant's office labeled "For Public Disclosure" which includes the most current of the following: a) Governing documents which are the hospital bylaws b) Conflict of interest policy c) Audited financial statements d) Forms 990 and 990-t RECONCILIATION OF NET ASSETS PART XI, LINE 9 CHANGE IN INTEREST IN HEALTHPARK LLC & ZARZ LLC (690,283) COLUMBUS COMMUNITY HOSPITAL FOUNDATION 4600 38TH STREET COLUMBUS NE 68601 470836747 FUNDRAISING NE 501(c)(3) LINE 11, I CCH true HEALTHPARK TITLE CO 4600 38TH STREET COLUMBUS NE 68601 470830945 HOLDING CO. NE 501(c)(2) N/A CCH true ZARZ LLC PO BOX 1800 COLUMBUS NE 68602 273676428 PROPERTY MGMT NE HLTHPK TITLE CO RELATED 0 0 false 0 false 0.44450 HEALTHPARK LLC PO BOX 1800 COLUMBUS NE 68602 470836733 PROPERTY MGMT NE HLTHPK TITLE CO RELATED 0 0 false 0 false 0.27210 false true true false true false false false false true true false true true true false true false false COLUMBUS COMMUNITY HOSPITAL FOUNDATION b 52500 Cash COLUMBUS COMMUNITY HOSPITAL FOUNDATION c 61455 cash COLUMBUS COMMUNITY HOSPITAL FOUNDATION e 94809 BOOK HEALTHPARK TITLE COMPANY k 295772 BOOK Part V, Line 2 (3) COLUMBUS COMMUNITY HOSPITAL FOUNDATION IS LISTED AS BACKING THE COLUMBUS COMMUNITY HOSPITAL, INC.'S TAX EXEMPT BOND. THIS IS COVERED WITH THE FOUNDATION'S NON-ENDOWED FUNDS. The bonds were paid off In January, 2013.