2014-08-14T09:31:49-05:00 2013-09-30 476097913 SEIM JOHNSON LLP 18081 BURT STREET SUITE 200 OMAHA NE 680224722 990 2012-10-01 470426530 JENNIE M MELHAM MEMORIAL MEDICAL CENTER INC JENN 3088724162 145 EAST MEMORIAL DRIVE BROKEN BOW NE 68822 MICHAEL J STECKLER 3088724162 2014-08-12 1 BARBARA J FAJEN P00400874 4023302660 2012 2015-11-30 17:44:51Z MICHAEL J STECKLER 145 EAST MEMORIAL DRIVE BROKEN BOW NE 68822 17890601 0 X WWW.MELHAM.ORG X 1962 NE THE PRIMARY MISSION AND PURPOSE OF THE JENNIE M. MELHAM MEMORIAL MEDICAL CENTER IS TO IMPROVE THE QUALITY OF LIFE IN ITS SURROUNDING SERVICE AREA BY PROVIDING AN ENVIRONMENT WHICH PROMOTES THE BEST POSSIBLE DELIVERY OF EMERGENCY, INPATIENT, SNF/SWING BED, OUTPATIENT, AMBULATORY CARE, NURSING HOME, DOMICILIARY, AND INDEPENDENT LIVING APARTMENT SERVICES. 5 5 228 159 0 0 50732 37749 16406053 17211850 423468 467795 137695 143046 17017948 17860440 0 0 0 0 8562265 8619970 5685 5411 5411 7483253 7612563 16051203 16237944 966745 1622496 35055536 36011874 1723291 2469706 33332245 33542168 X THE PRIMARY MISSION AND PURPOSE OF THE JENNIE M. MELHAM MEMORIAL MEDICAL CENTER IS TO IMPROVE THE QUALITY OF LIFE IN ITS SURROUNDING SERVICE AREA BY PROVIDING AN ENVIRONMENT WHICH PROMOTES THE BEST POSSIBLE DELIVERY OF EMERGENCY, INPATIENT, SNF/SWING BED, OUTPATIENT, AMBULATORY CARE, NURSING HOME, DOMICILIARY, AND INDEPENDENT LIVING APARTMENT SERVICES. 0 0 15478825 17241203 JMMMC OPERATES AT 23 BED CAH HOSPITAL ALONG WITH AN ATTACHED 50 BED NURSING HOME. IN ADDITION, THERE ARE 20 APARTMENTS DESIGNATED FOR THE ELDERLY AND A 12 BED ASSISTED LIVING CENTER. JMMMC PROVIDES ACUTE CARE, EMERGENCY CARE, LABOR AND DELIVERY SERVICES, OUTPATIENT SPECIALTY CLINICS, SURGERY SERVICES, RADIOLOGY SERVICES INCLUDING MOBILE MRI SERVICES AND INHOUSE CT SERVICES. 15478825 1 1 0 0 0 0 0 0 1 0 1 0 0 0 1 1 0 1 0 0 0 0 0 0 0 0 1 1 0 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 1 1 0 0 0 1 23 0 1 228 1 0 0 0 0 0 0 0 0 0 0 X 5 5 0 0 0 0 0 0 0 1 1 0 0 1 1 1 1 1 1 1 1 0 X MICHAEL J STECKLER CEO 3088724160 145 MEMORIAL DRIVE BROKEN BOW NE 68822 JOHN SMITH 4.00 4.00 X X 0 0 0 DON CANTRELL 4.00 4.00 X X 0 0 0 JOYCE RICHARDSON 4.00 4.00 X X 0 0 0 MIKE FLINT 4.00 4.00 X X 0 0 0 DANIEL ZACH 4.00 4.00 X 0 0 0 MICHAEL J STECKLER 40.00 4.00 X 179419 0 26133 TIMOTHY L SHUCKMAN 40.00 0.00 X 103767 0 24112 MELISSA POLLARD 40.00 0.00 X 118681 0 13346 401867 0 63591 3 0 1 0 SANDHILLS ANESTHESIA SERVICES LLC 79568 SUMNER ROAD BROKEN BOW NE 68822 ANESTHESIA CRNA SERVICES 507877 BRYAN MEDICAL CENTER PO BOX 82557 LINCOLN NE 685012557 MOBILE PATIENT SERVICES 214282 MCMEEN PHYSICAL THERAPY PC PO BOX 435 BROKEN BOW NE 68822 PHYSICAL THERAPY SERVICES 184440 DAVID MINNICK 152 SOUTH E STREET BROKEN BOW NE 68822 PHYSICIAN ER ON CALL SERVICES 114632 ROBERT KAHNK 612 NORTH 12TH AVENUE BROKEN BOW NE 68822 PHYSICIAN ER ON CALL SERVICES 105552 6 23946 13803 37749 PATIENT SERVICE - MEDICARE/MEDICA 621910 9129869 9129869 PATIENT SERVICE - PRIVATE PAY 621910 7360334 7360334 EHR INCENTIVE 621910 624148 624148 WELLNESS CENTER REVENUE 621910 97499 97499 17211850 453147 453147 43710 29559 14151 14151 14151 15250 602 14648 14648 14648 CAFETERIA SALES 900099 99542 99542 OTHER REVENUE 900099 29353 29353 128895 17860440 17241203 0 581488 333431 333431 6628190 6521856 106334 153448 148688 4760 1009468 923650 85818 495433 467912 27521 3260 3260 60765 60765 5411 5411 1877517 1877517 1104696 1053077 51619 323675 323675 14175 1684 12491 28611 18048 10563 1732655 1732655 186169 134568 51601 MEDICAL SUPPLIES 945539 945539 OTHER DIRECT EXPENSES 735720 735720 BAD DEBT 553098 553098 DUES AND SUBSCRIPTIONS 34622 34622 12061 6516 5545 16237944 15478825 753708 5411 2195 115 3013236 2071473 2376962 2433389 147245 7864 366302 446215 240051 214782 30276541 14366156 17265617 15910385 11643928 13917288 0 1010363 35055536 36011874 1650439 1754278 28429 0 44423 715428 1723291 2469706 X 33332245 33542168 33332245 33542168 35055536 36011874 1622496 -1412573 0 X X 0 1 X 1 0 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 1 543 3511 3248 806 0 74192 74192 22200543 8564830 13635713 7387050 5673061 1713989 614756 128265 486491 15910385 ESTIMATED THIRD-PARTY PAYOR SETTLEMENTS 715428 715428 X PART IV, LINE 1B: JENNIE M. MELHAM MEMORIAL MEDICAL CENTER MANAGES A RESIDENT ACCOUNT TRUST FOR RESIDENTS IN THE LONGTERM CARE UNIT. DESCRIPTION OF UNCERTAIN TAX POSITIONS UNDER FIN 48: PART X, LINE 2: THE HOSPITAL AND FOUNDATION ARE NOT-FOR-PROFIT CORPORATIONS AS DESCRIBED IN SECTION 501(C)(3) OF THE CODE AND HAVE RECEIVED DETERMINATION LETTERS THAT THEY ARE 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 MEDICAL CENTER'S TAX EXEMPT STATUS. IN GENERAL, SUCH STANDARDS REQUIRE THE MEDICAL CENTER TO MEET A COMMUNITY BENEFITS STANDARD AND COMPLY WITH VARIOUS LAWS AND REGULATIONS. THE MEDICAL CENTER ACCOUNTS FOR UNCERTAINTIES IN ACCOUNTING FOR INCOME TAX ASSETS AND LIABILITIES USING GUIDANCE INCLUDED IN FASB ASC 740, INCOME TAXES. THE MEDICAL 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 MEDICAL CENTER HAD NO UNCERTAIN TAX POSITIONS ACCRUED. THE MEDICAL 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 0 1 1 50831 50831 0.00320 50831 50831 0.00320 42380 42380 0.00270 213221 213221 0.01360 44455 44455 0.00280 300056 300056 0.01910 350887 350887 0.02230 2635 2635 0.00020 6426 6426 0.00040 1371 1371 0.00010 1702 1702 0.00010 30000 30000 0.00190 42134 42134 0.00270 0 553098 0 6641482 6575725 65757 X 1 0 1 1 JENNIE M MELHAM MEMORIAL MEDICAL CENTER

145 MEMORIAL DRIVE BROKEN BOW NE 68822

X X X X LONGTERM CARE UNIT, ASSISTED LIVING, AND APARTMENTS JENNIE M MELHAM MEMORIAL MED CTR INC 1 1 X X X X X X X X X 12 1 0 1 X X X X X X 0 0 1 1 100.000000000000 1 200.000000000000 0 1 1 X X 0 0 X 1 X 0 0 3 HERITAGE HALL

145 MEMORIAL DRIVE BROKEN BOW NE 68822

50-BED LONG TERM CARE CENTER INDEPENDENCE HALL

145 MEMORIAL DRIVE BROKEN BOW NE 68822

12-BED ASSISTED LIVING CENTER LIBERTY SQUARE APARTMENTS

145 MEMORIAL DRIVE BROKEN BOW NE 68822

SENIOR INDEPENDENT LIVING APARTMENT COMPLEX PART I, LINE 3C: PATIENTS MAY COMPLETE AN APPLICATION FOR CHARITY CARE ASSISTANCE. THE APPLICATION IS REVIEWED, VERIFIED, THEN PRESENTED TO THE BOARD OF DIRECTORS FOR A DECISION. ELIGIBILITY IS MAINLY BASED UPON FEDERAL POVERTY GUIDELINES, HOWEVER, OTHER FACTORS WILL COME INTO THE DECISION MAKING PROCESS. THESE FACTORS INCLUDE AGE, EXISTING MEDICAL DEBT, EXISTING NON-MEDICAL DEBT, ASSET OWNERSHIP, INVESTMENTS AND ANY OTHER PERTINENT INFORMATION. THE INCOME GUIDELINES ALLOW FOR ASSISTANCE, BASED UPON A SLIDING SCALE, WHERE INCOME IS FROM ANYWHERE FROM 100% TO 200% OF FEDERAL POVERTY GUIDLINES. PART I, LINE 6A: JMMMMC'S COMMUNITY BENEFIT REPORT IS NOT PREPARED BY A RELATED ORGANIZATION. PART I, LINE 7: JMMMMC USED THE SEPTEMBER 30, 2013 COST REPORT AND AUDITED FINANCIAL STATEMENTS TO CALCULATE THE AMOUNT REPORTED ON PART I, LINE 7. JMMMMC TOOK CHARITY CARE CHARGES FROM THE AUDITED FINANCIAL STATMENTS THEN REDUCED THOSE NUMBER TO A COST BASIS USING A COST-TO-CHARGE RATIO. PART I, LINE 7G: THE COSTS ATTRIBUTABLE TO A PHYSICIAN CLINIC AS SUBSIDIZED HEALTH SERVICES ON PART I, LINE 7G IS $6,112. PART I, L7 COL(F): THE BAD DEBT THAT HAS BEEN SUBTRACTED FROM TOTAL EXPENSES TO DETERMINE THE DENOMINATOR IN THE PERCENTAGES FOR COLUMN (F) IS $553,098. PART II: JMMMMC'S COMMUNITY BUILDING ACTIVITIES INCLUDE FAMILY PRACTICE DOCTOR RECRUITING EXPENSES. THE RECRUITING ALLOWS THE HIRING OF PRIMARY CARE PHYSICIANS FOR THE LOCAL COMMUNITY ALLOWING ACCESS TO LOCAL HEALTHCARE SERVICES. HAVING THE AVAILABILITY OF LOCAL HEALTH CARE STRENGTHENS THE COMMUNITY AS A WHOLE, ALLOWING THE BROKEN BOW AND THE SURROUNDING AREA TO BE A VIBRANT COMMUNITY. METHODOLOGY USED BY THE ORGANIZATION TO ESTIMATE BAD DEBT EXPENSE: PART III, LINE 2: IN EVALUATING THE COLLECTIBILITY OF ACCOUNTS RECEIVABLE, THE MEDICAL CENTER ANALYZES ITS HISTORICAL COLLECTIONS 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 MEDICAL 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 MEDICAL 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. PART III, LINE 4: THERE IS NO FOOTNOTE TO JMMMMC'S FINANCIAL STATEMENTS THAT DESCRIBES BAD DEBT. HOWEVER, THE FOLLOWING IS THE TEXT OF THE FOOTNOTES TITLED "PATIENT RECEIVABLES, NET," "NET PATIENT SERVICE REVENUE," AND "CHARITY CARE":THE MEDICAL 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 MEDICAL CENTER ANALYZES ITS HISTORICAL COLLECTIONS 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 MEDICAL 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 MEDICAL 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.THE FOLLOWING IS THE TEXT OF THE FOOTNOTE TITLED "NET PATIENT SERVICE REVENUE":THE HOSPITAL HAS AGREEMENTS WITH THIRD-PARTY PAYORS THAT PROVIDE FOR PAYMENTS TO THE HOSPITAL AT AMOUNTS DIFFERENT FROM ITS ESTABLISHED RATES. PAYMENT ARRANGEMENTS INCLUDE PROSPECTIVELY DETERMINED RATES PER DISCHARGE, REIMBURSED COSTS, DISCOUNTED CHARGES AND PER DIEM PAYMENTS. NET PATIENT SERVICE REVENUE IS REPORTED AT THE ESTIMATED NET REALIZABLE AMOUNTS FROM PATIENTS, THIRD-PARTY PAYORS, AND OTHERS FOR SERVICES RENDERED, INCLUDING ESTIMATED RETROACTIVE ADJUSTMENTS UNDER REIMBURSEMENT AGREEMENTS WITH THIRD-PARTY PAYORS. RETROACTIVE ADJUSTMENTS ARE ACCRUED ON AN ESTIMATED BASIS IN THE PERIOD THE RELATED SERVICES ARE RENDERED AND ADJUSTED IN FUTURE PERIODS AS FINAL SETTLEMENTS ARE DETERMINED.THE FOLLOWING IS THE TEXT OF THE FOOTNOTE TITLED "CHARITY CARE":THE HOSPITAL 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 HOSPITAL DOES NOT PURSUE COLLECTION OF AMOUNTS DETERMINED TO QUALIFY AS CHARITY CARE, THEY ARE NOT REPORTED IN THE STATEMENTS OF OPERATIONS.THE HOSPITAL IS DEDICATED TO PROVIDING COMPREHENSIVE HEALTHCARE SERVICES TO ALL SEGMENTS OF SOCIETY, INCLUDING THE AGED AND OTHERWISE ECONOMICALLY DISADVANTAGED. IN ADDITION, THE HOSPITAL PROVIDES A VARIETY OF COMMUNITY HEALTH SERVICES AT OR BELOW COST.THE FACILITY'S OVERALL COST TO CHARGE RATIO WAS APPLIED TO THE AMOUNT OF BAD DEBT LISTED IN MELHAM MEDICAL CENTER'S YEAR-END AUDITED FINANCIAL STATEMENTS. CURRENTLY JMMMMC DOES NOT HAVE A MECHANISM TO ESTIMATE THE AMOUNT OF CHARITY CARE THAT MAY EXIST IN THE BAD DEBT EXPENSE. EFFORTS ARE MADE PRIOR TO THE CLASSIFICATION OF PATIENT ACCOUNTS TO BAD DEBT STATUS TO ASCERTAIN WHETHER OR NOT INDIVIDUALS WOULD QUALIFY FOR THE CHARITY CARE PROGRAM. PART III, LINE 8: JMMMMC USED THE SEPTEMBER 30, 2013 COST REPORT TO CALCULATE THE AMOUNT REPORTED ON PART III, LINE 6. THERE IS NO SHORTFALL REPORTED ON PART III, LINE 7. PART III, LINE 9B: IF A PATIENT IS IDENTIFIED THAT IS KNOWN TO QUALIFY FOR FINANCIAL ASSISTANCE, EFFORTS TO REACH OUT TO THIS INDIVIDUAL OR THE INDIVIDUAL'S FAMILY ARE MADE. THE PATIENT OR FAMILY IS REQUESTED TO COMPLETE A CHARITY CARE APPLICATION TO FORMALIZE THE PROCESS. AT THE TIME A COMPLETED APPLICATION IS RECEIVED, ALL COLLECTION EFFORTS ARE CEASED UNTIL A DETERMINATION IS MADE TO THE QUALIFICATION OF THE INDIVIDUAL. JENNIE M. MELHAM MEMORIAL MED. CTR. INC. PART V, SECTION B, LINE 3: TO PREPARE FOR DEVELOPMENT OF THE CHNA, THE MEDICAL CENTER'S ADMINISTRATION COLLECTED AND ANALYZED COMMUNITY AND COUNTY POPULATION DEMOGRAPHICS, VITAL STATISTICS, ALONG WITH THE MOST RECENT 2010 MOBILIZING FOR ACTION THROUGH PLANNING AND PARTNERSHIPS (MAPP) AND THE 2011 PUBLIC HEALTH AGENCY OF NEBRASKA (PHAN) DOCUMENTS PROVIDED BY THE LOUP BASIN PUBLIC HEALTH DEPARTMENT. OTHER FEDERAL, STATE AND LOCAL DATA BASES WERE USED AS SOURCES OF INFORMATION FOR THIS REPORT. THIS IS ALL PUBLIC INFORMATION AND THIS DOCUMENTATION CAN BE FOUND IN PUBLIC SOURCES.A MEETING WAS CONVENED ON AUGUST 30, 2013, AT 9 A.M. IN THE MEDICAL CENTER'S CONFERENCE ROOM WITH MEMBERS OF THE CUSTER COUNTY HEALTHCARE COALITION. THE COALITION IS A GROUP OF AREA HEALTH CARE SERVICE PROVIDERS, REGIONAL SOCIAL SERVICE ORGANIZATIONS, REGIONAL PUBLIC HEALTH STAFF, NE DEPARTMENT OF HEALTH STAFF, AREA COMMUNITY SERVICES STAFF AND MEMBERS OF THE UNIVERSITY OF NE EXTENSION SERVICE UNIT, WHO BEGAN GETTING TOGETHER THIRTEEN YEARS AGO TO DISCUSS THE HEALTH AND SOCIAL SERVICE NEEDS OF THE COMMUNITY. THIS VOLUNTARY GROUP REVIEWED AND DISCUSSED AVAILABLE SERVICES, COMMUNITY NEEDS, CHALLENGES, OPPORTUNITIES AND WAYS TO SHARE RESOURCES FOR THE BETTERMENT OF THE COMMUNITY'S HEALTH.THE COALITION MEMBERSHIP ASSISTED IN DEVELOPMENT OF THE HOSPITAL'S COMMUNITY HEALTH NEEDS ASSESSMENT. THE GROUP REVIEWED AND DISCUSSED THE MEDICAL CENTER'S NEED FOR A CHNA, THEY DISCUSSED THE CHNA DEVELOPMENT PROCESS AND HOW THE MEDICAL CENTER'S CHNA COULD POTENTIALLY AFFECT THE COMMUNITY'S HEALTH.IMPORTANT INFORMATION, IDEAS AND OPINIONS WERE GATHERED FROM THE MEMBERS TO BE USED IN THE CHNA DEVELOPMENT PROCESS. THE COALITION MEMBER'S INSIGHTS INTO THE PUBLIC HEALTH NEEDS OF THE COMMUNITY WERE VERY DETAILED AND USEFUL. THE COALITION MEMBERS REVIEWED AND DISCUSSED A LIST OF POSSIBLE HEALTH ISSUES AND HEALTH NEEDS IN THE COMMUNITY. THE GROUP WAS THEN ASKED TO ADD TO THE LIST BY IDENTIFYING ANY ADDITIONAL ISSUES OR NEEDS THAT THEY FELT SHOULD BE ADDED TO THE LIST OF COMMUNITY HEALTH NEEDS FOR THE PURPOSES OF THIS ASSESSMENT. ONCE THE GROUP FELT THE LIST WAS COMPLETE, THE COALITION MEMBERS WERE THEN ASKED TO GO THROUGH A GROUP PROCESS OF IDENTIFYING THE TOP FOUR HEALTH NEEDS IN THE COMMUNITY THAT IS SERVED BY THE MEDICAL CENTER. THROUGH A PROCESS OF OPEN DISCUSSION THESE ITEMS WERE THEN PRIORITIZED BY THE MEMBERS PRESENT. THE RESULT OF THIS IDENTIFICATION AND PRIORITIZATION PROCESS WAS THE BASIS OF THE HOSPITAL'S CHNA. JENNIE M. MELHAM MEMORIAL MED. CTR. INC. PART V, SECTION B, LINE 7: IMPORTANT COMMUNITY INPUT WAS OBTAINED DURING DEVELOPMENT OF THE HOSPITAL'S CHNA. FOUR KEY HEALTH ISSUES WERE IDENTIFIED AND PRIORITIZED BY THE GROUP OF HEALTH CARE PROVIDERS, EDUCATORS, AND PUBLIC HEALTH AGENCIES THAT PARTICIPATED IN THE CHNA PROCESS. THESE WERE AS FOLLOWS: 1. ACCESS TO HEALTH SCREENING SERVICES AND HEALTH EDUCATION SERVICES IN THE COMMUNITY 2. ADEQUATE NUTRITION PROGRAMS FOR RESIDENTS OF THE COMMUNITY 3. OBESITY/PHYSICAL ACTIVITY/EXERCISE AND WEIGHT LOSS 4. ACCESS TO MENTAL HEALTH SERVICESBASED UPON THE INPUT OF THE GROUPS INVOLVED IN DEVELOPING THE ASSESSMENT, THE FOLLOWING ACTION PLANS WERE DEVELOPED TO ADDRESS EACH OF THE HEALTH ISSUES/NEEDS IDENTIFIED FOR THE COMMUNITY. NOT ALL OF THESE HEALTH ISSUES COULD BE ADDRESSED DURING THE FIRST YEAR OF COMMUNITY HEALTH PLAN IMPLEMENTATION. THE HOSPITAL ACHIEVED MANY, BUT NOT ALL, GOALS. IT SHOULD BE REMINDED THAT THIS IS A THREE YEAR PLAN AND THAT NOT ALL GOALS WERE EXPECTED TO BE ACHIEVED IN THE FIRST YEAR. BELOW IS A SUMMARY OF THOSE GOALS THAT HAVE NOT BEEN ACHIEVED AND EXPLANATION OF THE REASONS THEY WERE NOT ACHIEVED. THEY ARE AS FOLLOWS:1) ACCESS TO HEALTH SCREENING SERVICES AND HEALTH EDUCATION SERVICES IN THE COMMUNITY.IMPROVE ACCESS TO HEALTH SCREENING SERVICES IN THE COMMUNITY BY WORKING WITH OTHER AREA ORGANIZATIONS TO PROVIDE LOCAL HEALTH SCREENING OPPORTUNITIES TO HELP COMMUNITY RESIDENTS DETERMINE PERSONAL HEALTH ISSUES. -STROKE AWARENESS - WORK WITH BRYAN HEALTH SERVICES TO PROVIDE A LOW COST MOBILE PERIPHERAL ARTERY/VASCULAR SCREENING SERVICE IN THE COMMUNITY. THIS ISSUE HAS NOT BEEN ADDRESSED AS OF YET DUE TO TIMING OF OBTAINING THESE SERVICES IN THE COMMUNITY FROM A THIRD PARTY VENDOR. THESE ISSUES WILL BE ACCOMPLISHED IN 2015-2016. -BREAST CANCER - IMPLEMENT AN ANNUAL MAMMOGRAPHY SCREENING PROMOTION BY PROVIDING A DISCOUNT PROGRAM FOR FIRST TIME PATIENTS IN THE COMMUNITY WHO WISH TO HAVE A SCREENING MAMMOGRAPHY. THIS ISSUE WILL BE ADDRESSED IN OCTOBER 2014 WITH A SPECIAL EDUCATION AND PROMOTION PROGRAM IN THE COMMUNITY.2) OBESITY/PHYSICAL ACTIVITY/EXERCISE AND WEIGHT LOSSWORK WITH OTHERS IN THE COMMUNITY TO DEVELOP AND IMPLEMENT EDUCATIONAL PROGRAMS TARGETED AT TEACHING COMMUNITY MEMBERS APPROPRIATE EXERCISE TECHNIQUES. WE HAVE MADE SOME PROGRESS ON THIS SET OF TARGETS/GOALS. WE ARE CONTINUING TO WORK WITH OTHERS IN THE REGION TO ORGANIZE AND IMPLEMENT A COMMUNITY FITNESS CHALLENGE AND HEALTH EDUCATION PROGRAMS. THERE ARE NOT MANY READILY AVAILABLE RESOURCES OR PEOPLE WITH SKILLS IN OUR SMALL RURAL COMMUNITY TO COMPLETE SOME OF THESE SPECIAL GOALS. WE HAVE IDENTIFIED COMMUNITY GROUPS AND AGENCIES THAT HAVE AGREED TO PUSH THROUGH COORDINATION ISSUES TO ACCOMPLISH OUR STATED GOALS IN THE COMING YEAR. THE HOSPITAL HAS DEVELOPED A NEW WELLNESS/TENNIS CENTER FOR THE COMMUNITY WHICH NOW HAS 950 PARTICIPATING MEMBERS. MEMBERSHIP FEES HAVE BEEN KEPT LOWER THAN COMPARABLE RATES IN THE STATE AND REGION TO ENCOURAGE MEMBERSHIP.3) ACCESS TO MENTAL HEALTH SERVICESWHILE THIS COMMUNITY NEED WAS NOTED BY THE PARTICIPANTS IN THE ASSESSMENT PROCESS, IT SHOULD BE NOTED THAT THIS IS NOT AN AREA OF EXPERTISE HELD BY THE MEDICAL CENTER. THE MEDICAL CENTER IS NOT PREPARED TO TAKE ON THE RESPONSIBILITY FOR DEVELOPMENT OF A MENTAL HEALTH PROGRAM FOR THE COMMUNITY. THE MEDICAL CENTER HAS MANY OTHER FINANCIAL COMMITMENTS TO ENSURE PROVISION OF THE MEDICAL CARE NEEDS IN THE COMMUNITY. THERE ARE ALREADY PROVIDERS IN THE COMMUNITY WHO ARE WORKING ON MENTAL HEALTH ISSUES. THE MEDICAL CENTER DOES NOT WANT TO EXPEND RESOURCES TO DEVELOP DUPLICATIVE SERVICES IN THE COMMUNITY THAT WOULD COMPETE WITH EXISTING SERVICES AND THEIR UTILIZATION BASED FUNDING.4) ADEQUATE NUTRITION PROGRAMS FOR RESIDENTS OF THE COMMUNITYTHIS COMMUNITY NEED WAS ALSO NOTED BY THE PARTICIPANTS IN THE ASSESSMENT PROCESS, IT SHOULD BE NOTED THAT THIS IS NOT AN AREA OF EXPERTISE HELD BY THE MEDICAL CENTER. THE MEDICAL CENTER IS NOT PREPARED TO TAKE ON THE RESPONSIBILITY FOR DEVELOPMENT OF A NUTRITION PROGRAM FOR THE COMMUNITY. THE MEDICAL CENTER HAS MANY OTHER FINANCIAL COMMITMENTS TO PROVISION OF THE MEDICAL CARE IN THE COMMUNITY. IT IS FELT THAT THERE ARE A NUMBER OF SERVICES IN THE COMMUNITY ALREADY WORKING ON NUTRITION ISSUES IN THE COMMUNITY. THERE IS NO NEED FOR THE MEDICAL CENTER TO TRY TO DEVELOP DUPLICATIVE SERVICES IN THE COMMUNITY TO COMPETE WITH EXISTING SERVICES THAT ARE WORKING ON NUTRITION NEEDS FOR THE COMMUNITY AND HAVE FUNDING SOURCES THAT ARE UTILIZATION BASED.THERE WERE MANY LESSONS LEARNED DURING THE FIRST YEAR OF THE CHNA IMPLEMENTATION THAT WILL HELP TO IMPROVE FUTURE GOAL ACHIEVMENT AND COMMUNITY HEALTH NEEDS ASSESSMENT PLANNING. JMMMC IS BUDGETING ADDITIONAL FUNDS IN THE 2015 OPERATING BUDGET TO HELP WITH IMPLEMENTATION OF MANY OF THE GOALS WHICH COULD NOT BE ACCOMPLISHED IN THE PAST YEAR DUE TO FUNDING ISSUES. A SUMMARY REPORT ON THE GOALS MET WILL BE DEVELOPED IN 2015 AND THE NEW CHNA/CHIP DOCUMENT WILL BE DEVELOPED AND PUBLISHED BY SEPTEMBER 2016. JENNIE M. MELHAM MEMORIAL MED. CTR. INC. PART V, SECTION B, LINE 18E: THE MEDICAL CENTER MADE NO SUCH EFFORTS. JENNIE M. MELHAM MEMORIAL MED. CTR. INC. PART V, SECTION B, LINE 20D: JMMMC CHARGES THE SAME AMOUNT FOR ALL PATIENTS. PATIENTS FAP-ELIGIBLE HAVE ACCOUNTS ADJUSTED AS A PERCENT OF CHARGES UP TO 100% OF CHARGES BASED UPON A SLIDING SCALE OF ASSISTANCE. THE FAP AND THE SLIDING SCALE OF ASSISTANCE IS BASED ON FEDERAL POVERY GUIDELINES. PART VI, LINE 2: THERE IS NO FORMAL POLICY TO ASSESS THE HEALTH CARE NEEDS OF THE COMMUNITY JMMMMC SERVES IN ADDITION TO THE NEEDS ASSESSMENT THAT WAS CONDUCTED IN 2012. PART VI, LINE 3: ALL PRIVATE PAY PATIENT ACCOUNTS ARE REVIEWED BY THE BILLING STAFF. DURING THE REVIEW PROCESS, PATIENTS THAT ARE IDENTIFIED AS POTENTIAL CANDIDATES FOR ELIGIBILTY AND ASSISTANCE ARE CONTACTED BY THE BILLING STAFF. THE BILLING STAFF ENCOURAGES THE PATIENTS TO CONTACT THE APPROPRIATE AGENCY, MAINLY THE STATE MEDICAID PROGRAM, IN ORDER FOR THEM TO ASCERTAIN THEIR ELIGIBILITY. KNOWN INDIGENT PATIENTS ARE ENCOURAGED TO COMPLETE A CHARITY CARE APPLICATION. PART VI, LINE 4: JENNIE M. MELHAM MEMORIAL MEDICAL CENTER SERVES THE PEOPLE OF CENTRAL NEBRASKA. LOCATED IN BROKEN BOW, THE COUNTY SEAT, THE PRIMARY SERVICE AREA ENCOMPASSES CUSTER COUNTY, BLAINE COUNTY, THOMAS COUNTY, LOUP COUNTY AND PARTS OF SHERMAN COUNTY. THE SERVICE AREA IS A VERY RURAL BASED AREA. SOME COUNTIES OR PARTS THEREOF SERVED ARE AMONG THE SPARCEST POPULATED AREAS IN THE UNITED STATES. THE PRIMARY SERVICE AREA CONSISTS OF A POPULATION BASIS OF APPROXIMATELY 12,000. A LARGE PORTION OF THE POPULATION SERVED IS OVER AGE 65, RESULTING IN A LARGE NUMBER OF PATIENTS SEEN AT THE MEDICAL CENTER BEING COVERED BY THE MEDICARE PROGRAM. OVER 51% OF GROSS PATIENT REVENUE GENERATED AT THE MEDICAL CENTER IS MEDICARE. ADDITIONALLY, 11% OF GROSS PATIENT REVENUE IS RECEIVED FROM THE MEDICAID PROGRAM. PART VI, LINE 5: JMMMMC FURTHER PROMOTES THE HEALTH OF THE COMMUNITY BY THE FOLLOWING ACTIONS AND INITIATIVES:JMMMMC PARTICIPATES WITH AREA COMMUNITY COLLEGES BY SERVING AS A CLINICAL ROTATION SITE FOR PHYSICIAN, PHYSICIAN ASSISTANT, PHARMACY, MEDICAL TECHNOLOGY, LPN, RN, MEDICAL TRANSCRIPTIONIST, PHYSICAL THERAPIST AND RADIOLOGY TECHNOLOGY STUDENTS. SPACE AND STAFF OVERSIGHT IS PROVIDED AT NO COST TO THE COLLEGE OR THE STUDENT. JMMMMC ALSO OWNS A RESIDENTIAL HOUSE THAT IS USED TO MAKE FREE HOUSING AVAILABLE TO MANY OF THE STUDENTS WHO COME FROM OUT OF TOWN TO PARTICIPATE IN THE ABOVE STATED TRAINING PROGRAMS. JMMMMC COVERS THE COSTS RELATED TO MAINTENANCE, HEATING, COOLING, LIGHTING, LAUNDRY/LINEN, INTERNET, ETC. FOR THIS HOUSE.JMMMMC ASSISTS WITH LOCAL ECONOMIC DEVELOPMENT CORPORATION PROGRAMS THAT ARE DESIGNED TO PROMOTE INTEREST IN HEALTH CARE CAREERS. IT IS JMMMMC'S HOPE THAT BY CREATING LOCAL INTEREST IN HEALTH CARE CAREERS JMMMMC WILL INSPIRE LOCAL RESIDENTS TO SEEK OUT TRAINING AND THEN RETURN TO THE COMMUNITY TO PURSUE A CAREER IN HEALTH CARE. JMMMMC ALSO PARTNERS WITH LOCAL HIGH SCHOOLS TO PROMOTE HEALTHCARE CAREERS TO LOCAL STUDENTS. A LOCAL "HOME GROWN" WORKFORCE IS ESSENTIAL TO THE OPERATIONS OF JMMMMC AND THUS THE DELIVERY OF HEALTHCARE IN THE AREA. JMMMMC PROVIDES SPEAKERS TO LOCAL SCHOOLS ABOUT HEALTHCARE CAREERS AND PROVIDES TOURS, AS REQUESTED. IN THIS WAY, THE MEDICAL CENTER PROMOTES HEALTH CARE TO A FUTURE WORKFORCE TO CONTINUE LOCAL HEALTHCARE OPERATIONS.NOT ALL PATIENTS HAVE AN ABILITY TO PAY AT TIME OF SERVICE. THEREFORE, JMMMMC HAS DEVELOPED FAIRLY LIBERAL CREDIT GUIDELINES. THESE GUIDELINES DO NOT REQUIRE PAYMENT IN FULL AT TIME OF SERVICE FOR EMERGENT, URGENT OR ELECTIVE SERVICES AND ALLOWS FOR EXTENDED PERIODS OF TIME FOR PAYMENT OF THE DEBT AND NO INTEREST CHARGES ARE INCURRED. EVERY EFFORT IS MADE BY JMMMMC TO KEEP HEALTHCARE AFFORDABLE FOR AREA PATIENTS.MEDICAL CENTER MEETING ROOMS ARE PROVIDED FREE OF CHARGE TO OUTSIDE COMMUNITY SERVICE ORGANIZATIONS WHO ARE PROMOTING HEALTHY LIFESTYLES AND WELLNESS PROMOTION.FREE BROADBAND ACCESS AND COMPUTER RESOURCES ARE PROVIDED FREE OF CHARGE TO LOCAL EMT VOLUNTEERS ALLOWING THEM TO BE MORE EFFICIENT IN THEIR DUTIES. THIS ALLOWS FOR BETTER PARTICIPATION IN THE EMT PROGRAM, THUS EXTENDING EMERGENCY TRANSFER SERVICES TO LOCAL RESIDENTS AND VISITORS. TELEVIDEO EQUIPMENT IS PROVIDED FREE OF CHARGE TO AREA EMT VOLUNTEERS. THIS ALLOWS FOR QUARTERLY TRAINING TO BE PROVIDED LOCALLY THAT IS REQUIRED TO MEET THEIR CONTINUING EDUCATION REQUIREMENTS AND MAINTAIN THEIR CERTIFICATION. THE AVAILABILITY OF THIS SERVICE FOR THE EMTS RESULTS IN SIGNIFICANT SAVINGS IN TERMS OF TRAVEL COSTS AND TRAVEL TIME, HELPING BOOST MORALE AND ENCOURAGING PARTICIPATION OF THIS EXTREMELY IMPORTANT SERVICE. IN THIS RURAL COMMUNITY, THERE IS NO OTHER EMERGENCY AMBULANCE SERVICE OTHER THAN THE LOCAL VOLUNTEERS. LOCAL LAW ENFORCEMENT, THE COUNTY ATTORNEY AND HEALTH DEPARTMENTS ALSO MAKE USE OF THE TELEVIDEO EQUIPMENT TO PROMOTE HEALTH AND SAFETY IN THE COMMUNITY. JMMMMC PROVIDES SPACE FREE OF CHARGE TO THE CUSTER COUNTY COMMUNICATIONS DEPARTMENT. THIS COMMUNICATION CENTER HANDLES ALL RADIO COMMUNICATION BETWEEN THE LAW ENFORCEMENT AGENCIES, FIRE DEPARTMENTS AND EMERGENCY RESPONDERS FOR CUSTER COUNTY. THIS SPACE HOUSES EQUIPMENT THAT SERVES AS A BACKUP TO THEIR PRIMARY COMMUNICATION EQUIPMENT. IN SITUATIONS WHERE THE PRIMARY EQUIPMENT FAILS, THIS ALLOWS THE CUSTER COUNTY TO HAVE EMERGENCY BACKUP EQUIPMENT TO CONTINUE TO PROVIDE THE CRITICAL COMMUNICATION NEEDS OF CUSTER COUNTY.JMMMMC'S EMERGENCY ROOM SERVICES ARE PROVIDED 24 HOURS PER DAY, 7 DAYS PER WEEK. THIS DEPARTMENT OPERATES AT A SIGNIFICANT LOSS BUT ENSURES THAT PATIENTS HAVE ACCESS TO EMERGENCY HEALTHCARE AT ALL TIMES. THE ER IS CERTIFIED AS A LEVEL I TRAUMA CENTER AND THE SERVICE AREA EXTENDS APPROXIMATELY 100 MILES EAST TO WEST ALONG THE HIGHWAY 2 CORRIDOR. THIS IS THE MAIN HIGHWAY HORIZONTALLY BISECTING NEBRASKA AND IS USED BY MANY TRAVELERS AND VACATIONERS, GIVING THEM ACCESS TO EMERGENCY AND TRAUMA CARE. JMMMMC'S EMERGENCY ROOM PROVIDES AROUND 2,600 EMERGENCY ROOM VISITS PER YEAR. THE MEDICAL CENTER PAYS LOCAL PHYSICIANS TO CARRY A PAGER AND BE AVAILABLE TO PROVIDE EMERGENCY ROOMS SERVICES 24 HOURS PER DAY, 365 DAYS PER YEAR. PART VI, LINE 6: JMMMMC IS NOT PART OF AN AFFILIATED HEALTH CARE SYSTEM. X X 0 0 0 0 0 0 0 0 0 MICHAEL J STECKLER 179419 0 0 0 0 0 6584 0 19549 0 205552 0 0 0 FORM 990, PART VI, SECTION B, LINE 11 THE FORM 990 WILL BE PRESENTED TO THE BOARD OF DIRECTORS AT A REGULARLY SCHEDULED BOARD MEETING PRIOR TO FILING THE FORM 990. DIRECTORS WILL BE ALLOWED TO REVIEW THE FORM AT THE MEETING. IF ADDITIONAL TIME IS NEEDED ON THEIR PART FOR REVIEW, NECESSARY TIME WILL BE ALLOTTED TO THEM TO REVIEW THE DOCUMENT PRIOR TO FILING. FORM 990, PART VI, SECTION B, LINE 12C THE CONFLICT OF INTEREST POLICY IS PRESENTED ANNUALLY TO THE BOARD OF DIRECTORS. THIS FORM IS REVIEWED AND DISCUSSED WITH THEM. THE BOARD MEMBERS ARE REQUIRED TO SIGN A CONFLICT OF INTEREST DISCLOSURE FORM. THE CHAIRMAN CAN POINT OUT ANY KNOWN CONFLICTS OF INTEREST. INDIVIDUAL BOARD MEMBERS ARE ALSO RESPONSIBLE FOR DELCARING CONFLICTS AND UPON A CONFLICT, THEY ARE EXCLUDED FROM THE VOTE BUT NOT FROM THE DISCUSSION. FORM 990, PART VI, SECTION B, LINE 15 THE BOARD OF DIRECTORS IS PRESENTED WITH COMPARITIVE INFORMATION FROM WAGE STUDIES PERFORMED BY THE NEBRASKA HOSPITAL ASSOCIATION. NHA GATHERS THE WAGE INFORMATION ANNUALY FROM MOST, IF NOT ALL, OF THE HOSPITALS IN THE STATE. THE DATA CAN BE ANALYZED IN A VARIETY OF FORMATS, ALLOWING FOR EXCELLENT WAGE COMPARISON. THE BOARD SETS THE CEO SALARY BASED UPON THIS INFORMATION. FORM 990, PART VI, SECTION C, LINE 19 JENNIE M. MELHAM MEMORIAL MEDICAL CENTER DOES NOT MAKE ITS GOVERNING DOCUMENTS, CONFLICT OF INTEREST POLICY, OR FINANCIAL STATEMENTS AVAILABLE TO THE PUBLIC. FORM 990, PART XI, LINE 2C: THE BOARD OF DIRECTORS ASSUMES RESPONSIBILITY FOR OVERSIGHT OF THE AUDIT OF ITS FINANCIAL STATEMENTS AND SELECTION OF AN INDEPENDENT ACCOUNTANT. THIS PROCESS HAS NOT CHANGED FROM THE PRIOR YEAR. THE MELHAM MEDICAL CENTER FOUNDATION INC 145 MEMORIAL DRIVE BROKEN BOW NE 68822 470795995 SUPPORTING THE OPERATIONS OF A CRITICAL ACCESS HOSPITAL NE 501(C)(3) 11B JENNIE M MELHAM MEMORIAL MEDICAL CENTER INC 1 0 0 1 0 0 0 0 0 0 0 0 0 0 1 0 0 0 0 0