2013-02-08T15:15:19-06:00 2012-09-30 476097913 SEIM JOHNSON LLP 18081 BURT STREET SUITE 200 OMAHA NE 680224722 990 2011-10-01 470468078 JEFFERSON COMMUNITY HEALTH CENTER INC JEFF 4027293351 2200 H STREET PO BOX 277 FAIRBURY NE 68352 CHAD JURGENS 4027293351 2013-02-07 1 JULIE M GERKEN P00400882 4023302660 2011 2016-02-25 16:41:14Z CHAD JURGENS 2200 H STREET PO BOX 277 FAIRBURY NE 68352 16502502 0 X WWW.JCHCHEALTHCARE.ORG X 1960 NE JCHC IS DEVOTED TO PROVIDING APPROPRIATE QUALITY HEALTH SERVICES IN A CARING ENVIRONMENT. 9 8 222 15 0 0 81501 73155 16036870 15683811 109898 77348 101832 411340 16330101 16245654 0 0 0 0 7607171 7950812 0 0 39308 8025900 7270763 15633071 15221575 697030 1024079 16605300 17873822 1732278 1899397 14873022 15974425 JCHC IS DEVOTED TO PROVIDING APPROPRIATE QUALITY HEALTH SERVICES IN A CARING ENVIRONMENT. 0 0 12279588 15076734 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. 1267367 924452 JEFFERSON COMMUNITY HEALTH CENTER OPERATES A 39 BED LONG-TERM CARE FACILITY FOR THE RESIDENTS OF JEFFERSON COUNTY AND THE SURROUNDING AREA. 13546955 1 1 0 1 0 0 0 0 0 1 1 1 0 0 1 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 0 1 5 0 1 222 1 0 0 0 0 0 0 0 0 0 0 X 9 8 0 0 0 0 1 1 1 1 1 0 0 1 1 1 1 1 1 1 0 0 X CHAD JURGENS 4027293351 2200 H STREET PO BOX 277 FAIRBURY NE 68352 DICK HOPPE 1.00 X X 0 0 0 DR CRAIG SHUMARD 1.00 X X 0 0 0 LYMON HAMM 1.00 X X 0 0 0 MARY GLENN 1.00 X 0 0 0 JULIE KNIGGE 1.00 X 0 0 0 RYAN PARKER 1.00 X 0 0 0 TRENA ROGGE 1.00 X 0 0 0 MIKE STEEL 1.00 X 0 0 0 JACK WESCH 1.00 X 0 0 0 WILLIAM WELCH 40.00 X 157396 0 20164 CHAD JURGENS 40.00 X 129847 0 18834 GARY MITCHELL 40.00 X 128570 0 19242 DENNIS RUSSELL 40.00 X 103436 0 17181 519249 0 75421 4 0 1 0 FAIRBURY CLINIC PC 825 22ND STREET FAIRBURY NE 68352 ER COVERAGE 593771 HUSKER REHAB 4911 N 26TH STREET LINCOLN NE 68521 THERAPY SERVICES 459861 SOUTHEAST ANESTHESIA SERVICES 8426 W BIRCH CLATONIA NE 68328 CRNA SERVICES 360000 HEALTHCARE MANAGEMENT SYSTEMS 3102 WEST END AVE STE 400 NASHVILLE TN 37203 HOSPTIAL IT SERVICES 301784 DAVIS DESIGN 211 NORTH 14TH STREET LINCOLN NE 68508 ARCHITECT SERVICES 276743 7 8631 64524 73155 MEDICARE/MEDICAID PAYM 624100 8858191 8858191 PATIENT SERVICE REVENU 624100 4046399 4046399 PHARMACY 446110 986793 986793 LONG TERM CARE REVENUE 623000 924452 924452 LAB 621500 439744 439744 428232 428232 15683811 82358 82358 251838 240197 16651 11641 -16651 -5010 -5010 MISCELLANEOUS INCOME 624100 309174 309174 CAFETERIA 722210 93965 93965 MEDICAL RECORDS 561000 3698 3698 4503 4503 411340 16245654 16001186 0 171313 326241 326241 6090693 5542031 521396 27266 195255 182290 12068 897 890787 799941 90485 361 447836 393399 52591 1846 433 433 41762 41762 11278 11278 1938267 1937454 332 481 51940 19783 31611 546 991029 737897 251027 2105 268986 241668 27318 25126 16751 8337 38 10027 10027 1114348 1001178 113170 108123 108123 MEDICAL SUPPLIES 2351277 2351277 BAD DEBTS EXPENSE 262778 262778 DUES AND SUBSCRIPTIONS 46856 15918 30295 643 OUTSIDE TRAINING 36441 27596 8845 12092 6967 5125 15221575 13546955 1635312 39308 630235 973213 1952245 2789424 321110 321856 157733 152342 18064133 10067693 7966566 7996440 1952896 1970802 3500000 3500000 106559 156491 17956 13254 16605300 17873822 1016858 1079832 611779 435516 103641 384049 1732278 1899397 X 14738677 15851129 83591 72542 50754 50754 14873022 15974425 16605300 17873822 X 1024079 77324 X X 0 1 1 X 0 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 0 0 0 0 0 0 0 0 1 1447 1447 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 250 250 50754 0.00000 1.00000 0.00000 0 0 13943 13943 11630563 5831756 5798807 6004419 4181320 1823099 415208 54617 360591 7996440 REPURCHASE AGREEMENTS 3500000 C 3500000 ESTIMATED THIRD PARTY PAYOR SETTLEMENTS 384049 384049 16245654 15221575 1024079 77324 77324 1101403 16311700 77324 77324 16234376 11278 11278 16245654 15210297 0 15210297 11278 11278 15221575 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: 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, 2012, 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, 2009. 1 1 1 X 1 X 1 1 1 0 1 1 151196 151196 0.01010 775508 601303 174205 0.01160 926704 601303 325401 0.02170 16911 16911 0.00110 2250 2250 0.00020 450018 207917 242101 0.01620 5842 5842 0.00040 475021 207917 267104 0.01790 1401725 809220 592505 0.03960 0 262778 50000 5881164 5822935 58229 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 1 150.000000000000 1 300.000000000000 1 X X X 1 1 X X 1 0 1 X 0 0 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 $262,778. PART I, LINE 7E: A. COMMUNITY HEALTH EDUCATION AND OUTREACH(1) CHILD SAFETY SEAT PROGRAM - JCHC IS A PART OF A CHILD SAFETY SEAT PROJECT 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 133 SEATS WERE CHECKED IN 7 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 2011 WITH 26 ATTENDING THE HALF-DAY SEMINAR. (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. ALSO PARTICIPATED IN THE FIRST-EVER COMMUNITY SAFETY FAIR OFFERED BY LOVELAND INDUSTRIES. (4) SPEAKERS BUREAU - JCHC STAFF MEMBERS PROVIDE EDUCATIONAL PROGRAMS FOR COMMUNITY ORGANIZATIONS ON A VARIETY OF TOPICS. A TOTAL OF 6 PROGRAMS WERE DONE IN FISCAL 2012. JCHC ALSO PARTICIPATES IN A SIXTH GRADE CAREER DAY AT FAIRBURY JUNIOR-SENIOR HIGH SCHOOL. (5) SUPPORT GROUPS - IN 2012, 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 IN THE CONFERENCE ROOM AT JEFFERSON COMMUNITY HEALTH CENTER. TOTAL ATTENDANCE DURING FISCAL 2012 WAS 35. A SUPPORT GROUP FOR CAREGIVER'S OF ALZHEIMER'S PATIENTS MEETS MONTHLY AND HAD ATTENDANCE OF 58 THROUGHOUT THE YEAR. JCHC PROVIDES EDUCATIONAL PROGRAMS FOR EACH OF THESE GROUPS -- INCLUDING SPEAKERS 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. HEALTH TODAY IS A REGULAR MONTHLY PROGRAM WHICH HOSTED 170 PARTICIPANTS IN 2012. (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 2012 AT PARKVIEW MANOR. (2) COMPLETE BLOOD PROFILES - COMPLETE BLOOD PROFILES WERE OFFERED IN THE SPRING AT A REDUCED RATE. A TOTAL OF 100 BLOOD PROFILES WERE OFFERED. (3) IMMUNIZATION CLINICS - JCHC COOPERATES WITH BLUE VALLEY COMMUNITY ACTION 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 "DRIVE THRU BLOOD SCREEN" IN THE FRONT LOBBY. (5) FECAL OCCULT BLOOD SCREENINGS OFFERED - JCHC'S PHARMACY STAFF WORKED THROUGH A GRANT THROUGH PUBLIC HEALTH SOLUTIONS TO OFFER FECAL OCCULT BLOOD SCREENING KITS TO THOSE 50 AND OLDER DURING MARCH 2012. GRANT FUNDING PROVIDED THE KITS. PHARMACY STAFF EXPLAINED THE KITS AND GATHERED INFORMATION FROM THOSE PARTICIPATING. 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 SENIOR HEALTH INSURANCE INFORMATION PROGRAM (SHIIP) VOLUNTEERS (300), 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 2012. 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 2012. 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 2012. 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 2012. B. OTHER (1) JOB SHADOWING - JCHC HOSTS JOB SHADOW STUDENTS THROUGH FAIRBURY HIGH SCHOOLS ANATOMY AND PHYSIOLOGY CLASS TWICE A YEAR. 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 15 STUDENTS PARTICIPATED IN SHADOWING OPPORTUNITIES IN FISCAL 2012. (2) VIDEOCONFERENCE - CONTINUED OFFERING VIDEOCONFERENCING CAPABILITIES, INCLUDING POSSIBLE PROGRAMS FOR PROFESSIONALS IN THE COMMUNITY. AVAILABILITY COSTS $100 PER MONTH. A TOTAL OF 43 EDUCATIONAL AND ADMINISTRATIVE PROGRAMS WERE OFFERED IN 2012. THIS INCLUDED A NUMBER OF OPPORTUNITIES FOR STAFF AND COMMUNITY EDUCATION, MEETINGS, AND CLINICAL VISITS. (3) EMT TRAINING - EMT TRAINING HELD AT JCHC WITH SPEAKER JILL DUIS. JCHC PROVIDED A MEAL FOR THE 17 EMT PARTICIPANTS FROM AREA COMMUNITIES. 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. USE OF A BILIBLANKET WAS DONATED FOR NEWBORNS WITH JAUNDICE FOR 33 DAYS OF IN-KIND USE, FOR A VALUE OF $1,980. 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 25 WALKERS PARTICIPATED AND THE EVENT RAISED $4,400 FOR THE ALZHEIMER'S ASSOCIATION. (2) FORMATION OF SAFE KIDS CHAPTER - JEFFERSON COMMUNITY HEALTH CENTER IS THE LEAD AGENCY IN A NEW SAFE KIDS FILLMORE, JEFFERSON AND SALINE COUNTIES. REPRESENTING JCHC IN THIS ORGANIZATION WHICH PROMOTES SAFETY FOR OUR AREA'S CHILDREN ARE: SHARON VANDEGRIFT, COORDINATOR; LANA LIKENS, PR; DEBBIE HELLBUSCH, HOME HEALTH; CARRIE BRANSON, SAFETY SEAT TECHNICIAN. 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. 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, 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. 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 PAYORS, PATIENTS AND OTHERS. THE HEALTH CENTER PROVIDES AN ALLOWANCE FOR DOUBTFUL ACCOUNTS BASED UPON A REVIEW OF OUTSTANDING RECEIVABLES, HISTORICAL COLLECTION INFORMATION AND EXISTING ECONOMIC CONDITIONS.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, 2012 AND 2011 WERE APPROXIMATELY $160,000 AND $98,000, 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. 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, 2012. 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. 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 157396 0 0 0 0 0 7930 0 12234 0 177560 0 0 0 FAIRBURY CLINIC PC DR. CRAIG SHUMARD, BOARD MEMBER, OWNS MORE THAN 5% OF FAIRBURY CLINIC P.C. 593771 FAIRBURY CLINIC P.C. PROVIDED EMERGENCY ROOM COVERAGE SERVICES TO JEFFERSON COMMUNTIY HEALTH CENTER. 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. CHANGES IN NET ASSETS OR FUND BALANCES: FORM 990, PART XI, LINE 5: NET UNREALIZED GAINS ON INVESTMENTS: 77,324. 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.