2013-09-04T09:33:12-05:00 2013-04-30 476097913 SEIM JOHNSON LLP 18081 BURT STREET SUITE 200 OMAHA NE 680224722 990 2012-05-01 470388012 BRODSTONE MEMORIAL HOSPITAL BROD 4028793281 520 EAST 10TH STREET SUPERIOR NE 689781225 JOHN KEELAN 4028793281 2013-08-28 1 BARBARA J FAJEN P00400874 4023302660 2012 2016-02-24 21:20:13Z JOHN KEELAN 520 EAST 10TH STREET SUPERIOR NE 689781225 22277675 0 X WWW.BRODSTONEHOSPITAL.ORG X 1927 NE BRODSTONE MEMORIAL HOSPITAL IS A NOT-FOR-PROFIT CRITICAL ACCESS HOSPITAL ESTABLISHED TO DELIVER QUALITY, AFFORDABLE HEALTH CARE IN A CARING, SAFE AND COMPASSIONATE ENVIRONMENT TO ALL PERSONS OF SUCH NEED IN A TOTALLY NON-DISCRIMINATORY MANNER. 6 6 216 80 0 0 553137 917518 19052036 21238748 52949 77139 0 38405 19658122 22271810 0 0 0 0 10730012 11318806 0 0 0 7960668 9473148 18690680 20791954 967442 1479856 23510397 26565636 11592140 11619240 11918257 14946396 BRODSTONE MEMORIAL HOSPITAL IS A NOT-FOR-PROFIT CRITICAL ACCESS HOSPITAL ESTABLISHED TO DELIVER QUALITY, AFFORDABLE HEALTH CARE IN A CARING, SAFE AND COMPASSIONATE ENVIRONMENT TO ALL PERSONS OF SUCH NEED IN A TOTALLY NON-DISCRIMINATORY MANNER. 0 0 19198126 21238748 BRODSTONE MEMORIAL HOPSITAL PROVIDES SHORT TERM INPATIENT AND OUTPATIENT SERVICES SUCH AS ACUTE CARE, ICU, OB, AND NURSERY WITHIN THE SCOPE OF ITS HOSPITAL LICENSE TO ALL PATIENTS IN A NON-DISCRIMINATORY MANNER. THE HOSPITAL ALSO OPERATES TWO RURAL HEALTH CLINICS. 19198126 1 1 0 1 0 0 0 0 0 1 1 0 0 1 0 1 1 0 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 0 0 0 0 1 24 0 1 216 1 0 0 0 0 0 0 0 0 0 0 X 6 6 0 0 0 0 0 0 0 1 1 0 0 1 1 1 1 1 1 1 1 0 X SANDRA J BORDEN CFO 4028793281 520 EAST 10TH STREET SUPERIOR NE 68978 PAT MCCORD 2.00 X X 0 0 0 LYNN CULBERTSON 2.00 X X 0 0 0 KATHY ESSINK 2.00 X X 0 0 0 JULIE SIMONSEN 2.00 X X 0 0 0 JUDY GROVE 2.00 X 0 0 0 MARLIN MEYER 2.00 X 0 0 0 JOHN KEELAN 40.00 X 187180 0 27497 SANDRA BORDEN 40.00 X 126019 0 23978 TIMOTHY BLECHA 40.00 X 272621 0 37190 JULIE THEIS 40.00 X 177643 0 33152 ROBERT LEIBEL 40.00 X 170149 0 32382 JASON HASS 40.00 X 118083 0 32572 BRADLEY GARDNER 40.00 X 101345 0 31847 1153040 0 218618 7 0 1 0 CARDINAL HEALTH 21377 NETWORK PLACE CHICAGO IL 60673 PHARMACY MGMT 1185730 CAREFUSION SOL LLC 3750 TORREY VIEW CT SAN DIEGO CA 92130 PYXIS EQUIPMENT/MAINTENANCE 245069 HEALTHLAND 625 S LAKESHORE DR GLENWOOD MN 56334 SOFTWARE MAINTENANCE 198214 GE HEALTHCARE PO BOX 96483 CHICAGO IL 60693 X-RAY EQUIPMENT MAINTENANCE 197403 PRAIRIE WINDS ANESTH LLC 2551 Z ROAD WEBBER KS 66970 CRNA 195206 10 12360 261250 643908 917518 MEDICARE/MEDICAID 621110 11931895 11931895 NET PATIENT SERVICE REVENUE 621110 6687360 6687360 PHARMACY 446110 2478474 2478474 HOME HEALTH CARE 621610 87954 87954 MISCELLANEOUS INCOME 621990 53065 53065 21238748 74905 74905 3526 1292 2234 2234 2234 1872 12360 4573 -2701 -2701 CAFETERIA REVENUE 900099 41106 41106 41106 22271810 21238748 0 115544 364675 364675 8594815 7869237 725578 1803333 1638517 164816 555983 491149 64834 587766 512181 75585 57185 57185 959890 902930 56960 381066 381066 76646 54691 21955 504740 504740 1497683 1497683 156469 156469 MEDICAL SUPPLIES 4419252 4419252 BAD DEBT EXPENSE 691737 691737 MISCELLANEOUS EXPENSE 87167 3645 83522 DUES AND SUBSCRIPTIONS 53547 17644 35903 20791954 19198126 1593828 0 3026962 200 886650 7798627 3610303 2748484 222871 224567 437068 478272 22896555 9836727 13285321 13059828 295370 328242 13718 1745852 1913698 23510397 26565636 1361802 1573379 0 296284 9918868 9749577 311470 0 11592140 11619240 X 11500271 13216233 417986 203314 0 1526849 11918257 14946396 23510397 26565636 X 1479856 21434 1526849 X X 0 1 X 1 0 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 0 0 0 0 0 0 0 0 1 1788 1788 0 EXPLANATION OF LOBBYING ACTIVITIES: PART II-B, LINE 1: PORTION OF NEBRASKA HOSPITAL ASSOCIATION AND AMERICAN HOSPITAL ASSOCIATION DUES ALLOCABLE TO LOBBYING ACTIVITIES. 1395429 85539 104553 39140 19532 1526849 1403603 -8174 1395429 1294935 108665 1403603 1098170 196765 1294935 0.00000 1.00000 0.00000 1 0 117890 117890 14145747 4755219 9390528 8618268 5081508 3536760 14650 14650 13059828 ESTIMATED CONTRACTUAL ESTTLEMENT REC 365000 DEFERRED FINANCING COSTS, NET 21849 BENEFICIAL INTEREST IN TRUSTS 1526849 1913698 X 23824666 21434 1531422 1552856 22271810 0 22271810 20796527 4573 4573 20791954 0 20791954 DESCRIPTION OF INTENDED USE OF ENDOWMENT FUNDS: PART V, LINE 4: INTEREST EARNINGS MAY BE USED FOR OPERATIONS, HOWEVER THE PRINCIPAL IS TO BE MAINTAINED AS A PERMANENT ENDOWMENT. DUE TO INADVERTANT OMISSION OF CERTAIN FUNDS FROM PRESENTATION, CONTRIBUTIONS FOR THE YEAR HAVE BEEN ADJUSTED BY $39,920 TO REFLECT PROPER END OF YEAR BALANCE. DESCRIPTION OF UNCERTAIN TAX POSITIONS UNDER FIN 48: PART X, LINE 2: THE HOSPITAL ACCOUNTS FOR UNCERTAINTIES IN ACCOUNTING FOR INCOME TAX ASSETS AND LIABILITIES USING GUIDANCE INCLUDED IN FASB ASC 740, INCOME TAXES. THE HOSPITAL RECOGNIZES THE EFFECT OF INCOME TAX POSITIONS ONLY IF THOSE POSITIONS ARE MORE LIKELY THAN NOT OF BEING SUSTAINED. AT APRIL 30, 2013 AND 2012, THE HOSPITAL HAD NO UNCERTAIN TAX POSITIONS ACCRUED. WITH FEW EXCEPTIONS, THE HOSPITAL IS NO LONGER SUBJECT TO INCOME TAX EXAMINATIONS BY THE U.S. FEDERAL, STATE OR LOCAL TAX AUTHORITIES FOR YEARS ENDED PRIOR TO APRIL 30, 2010. PART XI, LINE 2D - OTHER ADJUSTMENTS: CHANGE IN BENEFICIAL INTEREST IN TRUSTS 1,526,849. FUNDRAISING EXPENSES 4,573. PART XII, LINE 2D - OTHER ADJUSTMENTS: FUNDRAISING EXPENSES 4,573. 1 1 X 1 X 1 X 1 1 1 0 1 1 279074 279074 0.01390 993546 778493 215053 0.01070 1272620 778493 494127 0.02460 27 2528 361750 51069 310681 0.01550 4 53112 53112 0.00260 7666 7666 0.00040 31 2528 422528 51069 371459 0.01850 31 2528 1695148 829562 865586 0.04310 1 691737 0 10836595 10434507 402088 X 1 1 1 1 BRODSTONE MEMORIAL HOSPITAL

520 E 10TH SUPERIOR NE 68978

X X X X BRODSTONE MEMORIAL HOSPITAL 1 1 X X X X X X X X X X 12 1 1 1 X X X X X X X 0 0 1 1 100.000000000000 1 200.000000000000 1 X X X X X X 1 1 X X X X X X 1 0 1 X 0 0 2 SUPERIOR FAMILY MEDICAL CENTER

525 E 11TH ST SUPERIOR NE 68978

RURAL HEALTH CLINIC NELSON FAMILY MEDICAL CENTER

76 W 8TH ST NELSON NE 68961

RURAL HEALTH CLINIC PART I, LINE 3C: NOT APPLICABLE: FEDERAL POVERTY GUIDELINES ARE USED TO DETERMINE ELIGIBILITY FOR PROVIDING FREE CARE AND DISCOUNTED CARE TO LOW INCOME INDIVIDUALS. PART I, LINE 6A: BRODSTONE'S COMMUNITY BENEFIT REPORT IS NOT PREPARED BY A RELATED ORGANIZATION. PART I, LINE 7: THE COST TO CHARGE RATIO AS FOLLOWS WAS USED TO DETERMINE CHARITY CARE AND MEANS-TESTED GOVERNMENT PROGRAMS AT COST: (TOTAL EXPENSES - BAD DEBT) / GROSS PATIENT SERVICE REVENUE = PERCENTAGE OF COST TO CHARGE. OTHER COMMUNITY BENEFIT EXPENSES ARE STATED AT COST BASED ON BRODSTONE'S INTERNAL ACCOUNTING RECORDS. PART I, LINE 7G: THERE ARE NO COSTS ATTRIBUTABLE TO A PHYSICIAN CLINIC INCLUDED ON LINE 7G. PART I, LINE 7, COLUMN (F): THE BAD DEBT EXPENSE INCLUDED ON FORM 990, PART IX, LINE 25, COLUMN (A), BUT SUBTRACTED FOR PURPOSES OF CALCULATING THE PERCENTAGE IN THIS COLUMN IS $ 691737. PART II: THERE ARE NO ACTIVITIES REPORTED IN PART II, HOWEVER, BRODSTONE HAS MANY ACTIVITES TO PROMOTE HEALTH IN THE COMMUNITIES SERVED. THESE ACTIVITIES INCLUDE: SPONSOR OF HEALTH FAIR, SUPPORT GROUPS, EDUCATION PROGRAMS, AND MEDICATION ASSISTANCE. THE DONATED SERVICES AND FUNDS HELP FURTHER THE MISSION AND GOALS OF COMMUNITY ORGANIZATIONS WHICH, IN TURN, HELP IMPROVE OVERALL HEALTH STATUS AND QUALITY OF LIFE OF THE COMMUNITIES SERVED. PART III, LINE 4: EXPENSES INCLUDE A PROVISION FOR DOUBTFUL ACCOUNTS BAD DEBTS TO ALLOW FOR ESTIMATED UNCOLLECTIBLE ACCOUNTS. THIS PROVISION IS BASED ON PAST EXPERIENCE AND ON ANALYSIS OF CURRENT ACCOUNTS RECEIVABLE. COLLECTIBILITY ACCOUNTS ARE CONSIDERED DELINQUENT BASED ON PASSAGE OF A SPECIFIED PERIOD OF TIME AND CONSIDERATION OF PAYMENT HISTORY. AS A RESULT, THERE IS AT LEAST A REASONABLE POSSIBILITY THAT RECORDED ESTIMATES WILL CHANGE BY A MATERIAL AMOUNT IN THE NEAR TERM. ACCOUNTS DEEMED UNCOLLECTIBLE ARE CHARGED TO THE ALLOWANCE IN THE YEAR THEY ARE DEEMED UNCOLLECTIBLE. THE COSTING METHODOLOGY FOR LINE 2 IS ACTUAL REVENUE WRITTEN OFF AND SENT TO COLLECTIONS. BRODSTONE'S FINANCIAL STATMENTS DO NOT CONTAIN A SPECIFIC FOOTNOTE DESCRIBING BAD DEBT. HOWEVER, THE FOLLOWING IS THE TEXT OF THE FOOTNOTE TITLED "PATIENT RECEIVABLES, NET" AND "CHARITY CARE":"PATIENT RECEIVABLES, NET"THE HOSPITAL 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 HOSPITAL ANALYZES ITS PAST HISTORY AND IDENTIFIES TRENDS FOR EACH OF ITS MAJOR PAYER SOURCES OF REVENUE TO ESTIMATE THE APPROPRIATE ALLOWANCE FOR DOUBTFUL ACCOUNTS AND PROVISION FOR BAD DEBTS. MANAGEMENT REGULARLY REVIEWS DATA ABOUT THESE MAJOR PAYER SOURCES OF REVENUE IN EVALUATING THE SUFFICIENCY OF THE ALLOWANCE FOR DOUBTFUL ACCOUNTS. FOR RECEIVABLES ASSOCIATED WITH SERVICES PROVIDED TO PATIENTS WHO HAVE THIRD-PARTY COVERAGE, THE HOSPITAL 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 HOSPITAL 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 HOSPITAL ALSO MAINTAINS A CHARITY CARE POLICY AS DESCRIBED IN NOTE 1(O)."CHARIY 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 AS REVENUE IN THE STATEMENTS OF OPERATIONS. MANAGEMENT'S DISCLOSURE OF CHARITY CARE COSTS IS DESCRIBED IN NOTE 3.IN ACCORDANCE WITH ITS MISSION OBJECTIVES, THE HOSPITAL PROVIDES FREE CARE TO PATIENTS WHO LACK FINANCIAL RESOURCES TO PAY FOR THE SERVICES THEY RECEIVE. INCLUDED IN THE PROVISION FOR CONTRACTUAL ALLOWANCES IS THE VALUE (AT STANDARD CHARGES) OF THESE SERVICES TO PATIENTS WHO ARE UNABLE TO PAY, THAT IS ELIMINATED FROM NET PATIENT SERVICE REVENUES WHEN IT IS DETERMINED THEY QUALIFY UNDER THE HOSPITAL'S CHARITY CARE POLICY. THE ESTIMATED COST INCURRED BY THE HOSPITAL TO PROVIDE THESE SERVICES TO PATIENTS WHO ARE UNABLE TO PAY WAS APPROXIMATELY $449,000 AND $314,000 FOR THE YEARS ENDED APRIL 30, 2013 AND 2012, RESPECTIVELY. THE ESTIMATED COST OF THESE CHARITY CARE SERVICES WAS DETERMINED USING A RATIO OF COSTS TO GROSS CHARGES AND APPLYING THAT RATIO TO THE GROSS CHARGES ASSOCIATED WITH PROVIDING CARE TO CHARITY PATIENTS FOR THE PERIOD. GROSS CHARGES ASSOCIATED WITH PROVIDING CARE TO CHARITY PATIENTS INCLUDES ONLY THE RELATED CHARGES FOR THOSE PATIENTS WHO ARE FINANCIALLY UNABLE TO PAY AND QUALIFY UNDER THE HOSPITAL'S CHARITY CARE POLICY AND THAT DO NOT OTHERWISE QUALIFY FOR REIMBURSEMENT FROM A GOVERNMENTAL PROGRAM. DURING THE YEARS ENDED APRIL 30, 2013 AND 2012, THE HOSPITAL RECEIVED NO FUNDS TO HELP DEFRAY THE COSTS OF INDIGENT CARE. PART III, LINE 8: "MEDICARE ALLOWABLE COSTS OF CARE" WAS CALCULATED FROM INFORMATION IN THE MEDICARE COST REPORT D, E, H & M WORKSHEETS, OR PS&R. THESE COSTS ARE MEDICARE REIMBURSABLE COSTS, NOT ALL COSTS. PART III, LINE 9B: PATIENTS WHO QUALIFY FOR MEDICAID WILL AUTOMATICALLY QUALIFY FOR FINANCIAL ASSISTANCE AND MAY QUALIFY FOR MORE IF THEY COMPLETE THE FINANCIAL ASSISTANCE APPLICATION. THESE PATIENTS WILL NOT BE SENT TO COLLECTIONS IF THEY PAY THE AMOUNT FOR WHICH THEY QUALIFY.BRODSTONE'S POLICIES AND PROCEDURES FOR INTERNAL AND EXTERNAL COLLECTION PRACTICES TAKE INTO ACCOUNT THE EXTENT TO WHICH THE PATIENT QUALIFIES FOR CHARITY, A PATIENT'S GOOD FAITH EFFORT TO APPLY FOR A GOVERNMENTAL PROGRAM OR FOR CHARITY FROM THE HOSPITAL, AND A PATIENT'S GOOD FAITH EFFORT TO COMPLY WITH HIS OR HER PAYMENT AGREEMENTS WITH THE HOSPITAL. FOR PATIENTS WHO QUALIFY FOR CHARITY AND WHO ARE COOPERATING IN GOOD FAITH TO RESOLVE THEIR BILLS, BRODSTONE MAY OFFER EXTENDED PAYMENT PLANS TO ELIGIBLE PATIENTS, WILL NOT IMPOSE WAGE GARNISHMENTS OR LIENS, AND WILL NOT SEND UNPAID BILLS TO OUTSIDE COLLECTION AGENCIES AND WILL CEASE ALL COLLECTION EFFORTS. BRODSTONE MEMORIAL HOSPITAL PART V, SECTION B, LINE 1J: COMMUNITY HEALTH NEEDS ASSESSMENT SOUTH HEARTLAND'S PROCESSTHE SHDHD MAPP/CHIP PROCESS BEGAN WITH IDENTIFICATION OF CORE PLANNING TEAM MEMBERS WHOSE RESPONSIBILITIES WERE TO REVIEW THE MAPP PROCESS, COMPLETE A READINESS ASSESSMENT, DISCUSS AND DEFINE "COMMUNITY" FOR EACH HOSPITAL, REVIEW STAKEHOLDER CATEGORIES, IDENTIFY STAKEHOLDERS, DETERMINE TIMELINES AND DISCUSS RESOURCES TO IMPLEMENT THE PROCESS. ALL THREE HOSPITALS IN THE DISTRICT COMMITTED TO PARTICIPATE WITH SHDHD IN MAPP AND SIGNED MEMORANDA OF UNDERSTANDING OUTLINING THEIR CONTRIBUTIONS INCLUDING RESOURCES. HOSPITAL ADMINISTRATORS IDENTIFIED STAFF MEMBERS TO PARTICIPATE IN THE CORE TEAM. THIS TEAM WAS ALSO RESPONSIBLE FOR OVERSEEING THE IMPLEMENTATION AND MANAGEMENT OF THE PROCESS. THE CORE TEAM INCLUDED EIGHT MEMBERS: HOSPITAL ADMINISTRATORS AND/OR APPOINTED STAFF FROM BRODSTONE MEMORIAL HOSPITAL, MARY LANNING HEALTHCARE, WEBSTER COUNTY COMMUNITY HOSPITAL, CLAY COUNTY HEALTH DEPARTMENT DIRECTOR, SHDHD BOARD OF HEALTH PRESIDENT, AND SHDHD DIRECTOR. THE FIRST PLANNING MEETING WAS HELD SEPTEMBER 2, 2011. THE ASSESSMENT PHASE CONSISTED OF IMPLEMENTING ALL FOUR OF THE MAPP ASSESSMENTS AND WAS CARRIED OUT, WITH ASSISTANCE FROM A CONTRACTED FACILITATOR, DURING THE PERIOD OF OCTOBER 1, 2011 AUGUST 30, 2012. FOLLOWING THE ASSESSMENT PHASE, THE COMMUNITY (VIA STAKEHOLDER WORK GROUPS) IDENTIFIED STRATEGIC ISSUES AND FORMULATED GOALS AND STRATEGIES FOR ADDRESSING EACH ISSUE. COMMUNITY STAKEHOLDERS COLLABORATED IN A FACILITATED DEVELOPMENT OF A COMMUNITY (DISTRICT-WIDE) HEALTH IMPROVEMENT PLAN (CHIP). IN 2013 AND BEYOND, WORK GROUPS FOR EACH PRIORITY WILL MOVE THE PLAN COMPONENTS INTO THE ACTION PHASE (CHIP IMPLEMENTATION), WITH OVERSIGHT AND EVALUATION PLANNING FROM THE MAPP/CHIP CORE TEAM, WHICH WILL CONTINUE TO MEET 1-2 TIMES A YEAR FOR THE DURATION OF THE CHIP. BRODSTONE SELECTED A CORE TEAM TO BE INVOLVED WITH THE PROCESS. KAREN TINKHAM, ADMINISTRATIVE ASSISTANT, KORI FIELD, DIRECTOR OF NURSING AND MICHELL HARRIS, REGISTERED NURSE, WERE SELECTED AS BRODSTONE'S REPRESENTATIVES. THESE REPRESENTATIVES REPORTED DIRECTLY TO BRODSTONE'S ADMINISTRATIVE TEAM, THE TEAM RESPONSIBLE FOR THE NEEDS ASSESSMENT AND THE IMPLEMENTATION STRATEGY.THE CHNA ALSO INCLUDED BRODSTONE MEMORIAL HOSPITAL'S ACTION PLAN ALONG WITH THE IMPLEMENTATION STRATEGY, TIME FRAME, AND RESPONSIBLE PARTY. BRODSTONE MEMORIAL HOSPITAL PART V, SECTION B, LINE 3: MOBILIZING FOR ACTION THROUGH PLANNING AND PARTNERSHIPS (MAPP) IS A STRATEGIC APPROACH TO COMMUNITY HEALTH IMPROVEMENT. SOUTH HEARTLAND DISTRICT HEALTH DEPARTMENT (SHDHD) USED THIS TOOL TO FACILITATE THE 4-COUNTY HEALTH DISTRICT IN EFFORTS TO IMPROVE HEALTH AND QUALITY OF LIFE THROUGH COMMUNITY-WIDE AND COMMUNITY-DRIVEN STRATEGIC PLANNING. THIS PROCESS HELPED THE DISTRICT IDENTIFY AND PLAN THE USE OF RESOURCES TAKING INTO ACCOUNT THE UNIQUE CIRCUMSTANCES AND NEEDS OF THE DISTRICT AND THE INDIVIDUAL COMPONENT COUNTIES. IT ALSO PROMOTED NEW AND SOLIDIFIED EXISTING PARTNERSHIPS IN OUR COMMUNITIES AND ACROSS THE DISTRICT. THE MAPP ASSESSMENT PROCESS LEADS TO THE DEVELOPMENT OF A COMMUNITY-WIDE HEALTH IMPROVEMENT PLAN (CHIP), WHICH CAN ONLY BE ADOPTED AND REALISTICALLY IMPLEMENTED IF THE COMMUNITY HAS CONTRIBUTED TO THE PLAN DEVELOPMENT. SHDHD WORKED TO ENSURE PARTICIPATION BY A BROAD CROSS SECTION OF THE DISTRICT INVITING REPRESENTATIVES FROM MANY SECTORS OF OUR COMMUNITIES. IN ADDITION, MAPP ALSO SUPPORTS ORGANIZATIONAL ACTION PLAN DEVELOPMENT BY EACH OF THE PARTICIPATING ENTITIES INCLUDING THE KEY HOSPITAL PARTNERS FOR THEIR SERVICE AREAS.THROUGH THE MAPP PROCESS, THE SOUTH HEARTLAND DISTRICT CONTINUED TO STRENGTHEN THE LOCAL PUBLIC HEALTH SYSTEM. WE DEFINED THE LOCAL PUBLIC HEALTH SYSTEM AS ALL OF THE ENTITIES THAT CONTRIBUTE TO THE DELIVERY OF PUBLIC HEALTH SERVICES WITHIN OUR COMMUNITIES. THIS INCLUDED PUBLIC AND PRIVATE ENTITIES, CIVIC AND FAITH-BASED ORGANIZATIONS, INDIVIDUALS, INFORMAL ASSOCIATIONS, FRONT-LINE AND GRASSROOTS WORKERS AND POLICY MAKERS. USING MAPP AS THE FRAMEWORK FOR THE COMMUNITY NEEDS ASSESSMENT ALLOWED SHDHD TO FOCUS ON THE 10 ESSENTIAL SERVICES OF PUBLIC HEALTH TO DEFINE WHO IS RESPONSIBLE FOR THE COMMUNITY'S HEALTH AND WELL-BEING.THE 10 ESSENTIAL PUBLIC HEALTH SERVICES ARE:1. MONITOR HEALTH STATUS TO IDENTIFY COMMUNITY HEALTH PROBLEMS. 2. DIAGNOSE AND INVESTIGATE HEALTH PROBLEMS AND HEALTH HAZARDS IN THE COMMUNITY.3. INFORM, EDUCATE, AND EMPOWER PEOPLE ABOUT HEALTH ISSUES.4. MOBILIZE COMMUNITY PARTNERSHIPS TO IDENTIFY AND SOLVE HEALTH PROBLEMS.5. DEVELOP POLICIES AND PLANS THAT SUPPORT INDIVIDUAL AND COMMUNITY HEALTH EFFORTS.6. ENFORCE LAWS AND REGULATIONS THAT PROTECT HEALTH AND ENSURE SAFETY.7. LINK PEOPLE TO NEEDED PERSONAL HEALTH SERVICES AND ASSURE THE PROVISION OF HEALTH CARE WHEN OTHERWISE UNAVAILABLE.8. ASSURE A COMPETENT PUBLIC HEALTH AND PERSONAL HEALTH CARE WORKFORCE.9. EVALUATE EFFECTIVENESS, ACCESSIBILITY, AND QUALITY OF PERSONAL AND POPULATION-BASED HEALTH SERVICES.10. RESEARCH FOR NEW INSIGHTS AND INNOVATIVE SOLUTIONS TO HEALTH PROBLEMS.IN THIS MODEL, THE PHASES OF THE PROCESS ARE DIAGRAMED IN THE CENTER. THE ENTIRE PROCESS IS INFORMED BY DATA AND THE FOUR ASSESSMENTS THAT PRODUCE THESE DATA ARE SHOWN IN THE ARROWS AROUND THE OUTSIDE. THE PHASES OF THE MAPP PROCESS ARE: ORGANIZING/PARTNERSHIP DEVELOPMENT, VISIONING, ASSESSMENT, IDENTIFYING STRATEGIC ISSUES, FORMULATING GOALS AND STRATEGIES, AND THE ACTION CYCLE FOR THE RESULTING COMMUNITY HEALTH IMPROVEMENT PLAN (CHIP). BRODSTONE MEMORIAL HOSPITAL PART V, SECTION B, LINE 4: BRODSTONE'S CHNA WAS CONDUCTED WITH WEBSTER COUNTY COMMUNITY HOSPITAL AND MARY LANNING MEMORIAL HEALTHCARE. BRODSTONE MEMORIAL HOSPITAL PART V, SECTION B, LINE 5C: COPIES OF THE CHNA REPORT IS AVAILABLE AT ADMISSIONS. BRODSTONE MEMORIAL HOSPITAL PART V, SECTION B, LINE 7: THE MAJORITY OF THE ACTION NEEDED TO BE ADDRESSED IN THE CATEGORIES OF CANCER, MENTAL HEALTH AND SUBSTANCE ABUSE FALL OUT OF THE SCOPE OF EXPERTISE AND RESOURCES OF THE HOSPITAL. BRODSTONE MEMORIAL HOSPITAL PART V, SECTION B, LINE 10: BRODSTONE MEMORIAL HOSPITAL REQUIRES A FINANCIAL ASSISTANCE FORM TO BE COMPLETED BEFORE DETERMINING THE AMOUNT OF ASSISTANCE FOR WHICH THE PERSON IS ELIGIBLE. THE HOUSEHOLD INCOME AND NET WORTH ARE USED TO DETERMINE THE AMOUNT USING FEDERAL POVERTY GUIDELINES. PATIENTS ARE ELIGIBLE FOR 100% FREE CARE IF AT OR BELOW THE FEDERAL POVERTY LEVEL. BRODSTONE MEMORIAL HOSPITAL PART V, SECTION B, LINE 11: BRODSTONE MEMORIAL HOSPITAL REQUIRES A FINANCIAL ASSISTANCE FORM BE COMPLETED BEFORE DETERMING THE AMOUNT OF ASSISTANCE FOR WHICH THE PERSON IS ELIGIBLE. THE HOUSEHOLD INCOME AND NET WORTH ARE USED TO DETERMINE THE AMOUNT OF DISCOUNTED CARE USING THE FEDERAL POVERTY GUIDELINES. PATIENTS ARE ELIGIBLE FOR UP TO 80% DISCOUNTED CARE AT 200% OF THE FEDERAL POVERTY LEVEL. BRODSTONE MEMORIAL HOSPITAL PART V, SECTION B, LINE 12H: BRODSTONE MEMORIAL HOSPITAL USES THE COST OF SUPPLIES, SALARIES, AND OTHER EXPENSES TO DETERMINE BRODESTONE'S CHARGES TO PATIENTS. BRODSTONE PERIODICALLY USES CHARGEMASTER REVIEWS FOR REVIEW OF CHARGES. BRODSTONE MEMORIAL HOSPITAL PART V, SECTION B, LINE 14G: BRODSTONE MEMORIAL HOSPITAL POSTS THE WRITTEN FINANCIAL ASSISTANCE POLICY ON ITS WEBSITE, HAS BROCHURES AVAILABLE WHERE PATIENTS ARE ADMITTED, INCLUDES THE POLICY IN PATIENT HANDBOOKS, AND SENDS THE POLICY TO PATIENTS UPON REQUEST. PART VI, LINE 2: BRODSTONE ASSESSES THE HEALTH CARE NEEDS OF THE COMMUNITY IT SERVES THROUGH A SURVEY. THE BUDGETING PROCESS PUBLISHES SUGGESTIONS AND STRATEGIC PLANNING. HOSPITAL STAFF ALSO NETWORKS WITH OTHER HEALTH CARE ORGANIZATIONS TO DEVELOP IDEAS OF WHAT WE CAN DO TO IMPROVE THE AVAILABILITY OF SERVICES IN OUR COMMUNITY. PART VI, LINE 3: BRODSTONE HAS A BROCHURE CALLED CHARITY POLICY THAT ADDRESSESS OUR FINANCIAL ASSISTANCE AVAILABILITY. IT IS POSTED AT OUR ADMISSIONS AREAS AND EMERGENCY ROOM. THE CHARITY POLICY IS DISCUSSED WHEN MAKING PAYMENT ARRANGEMENTS. PART VI, LINE 4: SUPERIOR HAS A POPULATION OF 1,959 AND IS LOCATED ON THE NEBRASKA-KANSAS BORDER. BRODSTONE'S SERVICE AREA COVERS ALL OF NUCKOLLS COUNTY AND PARTS OF 2 OTHER COUNTIES IN NEBRASKA AND 3 COUNTIES IN KANSAS. THE MEDIAN HOUSEHOLD INCOME FOR NUCKOLLS COUNTY IS $27,948 COMPARED TO THE U.S. AVERAGE AT $50,221 AND THE NEBRASKA AVERAGE OF $47,357. THE AREA POPULATION IS PREDOMINATELY WHITE ELDERLY AND LOW INCOME. 74 OF THE HOSPITAL'S PATIENTS ARE MEDICARE PATIENTS. PART VI, LINE 5: BRODSTONE'S GOVERNING BODY CONSISTS OF 2 MEN AND 4 WOMEN WITH NO IMMEDIATE FAMILY TIES TO ANY EMPLOYEE NOR ARE THEY CONTRACTORS OF OUR ORGANIZATION. ALL BOARD MEMBERS ARE RESIDENTS OF NUCKOLLS COUNTY, NE. ALL FAMILY PRACTICE PHYSIANS AND MIDLEVELS IN OUR AREA WHO HAVE REQUESTED MEDICAL STAFF PRIVILEGES AND MEET THE REQUIREMENTS HAVE PRIVILIGES AT THE HOSPITAL. TWO DENTISTS HAVE COURTESY PRIVELEGES. ALL SURPLUS FUNDS OF THE ORGANIZATION ARE USED TO FUND THE BUDGET FOR THE COMING YEARS OR SET ASIDE FOR FUTURE PROJECTS. PART VI, LINE 6: BRODESTONE MEMORIAL HOSPITAL IS NOT PART OF AN AFFILIATED HEALTH CARE SYSTEM. PART VI, LINE 7: BRODSTONE DOES NOT FILE A COMMUNITY BENEFIT REPORT WITH ANY STATE. X 1 1 X X X 0 0 0 1 0 0 0 0 0 JOHN KEELAN 183680 0 3500 0 0 0 5798 0 21699 0 214677 0 0 0 TIMOTHY BLECHA 188618 0 84003 0 0 0 7500 0 29690 0 309811 0 0 0 JULIE THEIS 177643 0 0 0 0 0 5628 0 27524 0 210795 0 0 0 ROBERT LEIBEL 170149 0 0 0 0 0 5296 0 27086 0 202531 0 0 0 JASON HASS 112021 0 6062 0 0 0 3794 0 28778 0 150655 0 0 0 PART I, LINE 1A JOHN KEELAN, CEO, IS PROVIDED THE LOCAL COUNTRY CLUB MEMBERSHIP PART I, LINE 5 IN ACCORDANCE WITH RELATED EMPLOYMENT CONTRACTS, ADDITIONAL COMPENSATION IS PAID BASED ON REVENUES GENERATED BY EACH MEDICAL PROVIDER, AS DEFINED. THESE ADDITIONAL AMOUNTS HAVE BEEN LISTED AS INCENTIVE COMPENSATION IN PART II OF THIS SCHEDULE FORM 990, PART VI, SECTION B, LINE 11 THE FORM 990 IS PREPARED BY AN OUTSIDE ACCOUNTING FIRM. BEFORE IT IS FILED, IT IS GIVEN A DETAILED REVIEW BY MANAGEMENT AND THEN A GENERAL REVIEW BY THE BOARD OF DIRECTORS AT A REGULARLY SCHEDULED BOARD MEETING. A FINAL COPY OF THE FORM 990 WILL BE ELECTRONICALLY FILED AFTER APPROVAL. FORM 990, PART VI, SECTION B, LINE 12C BOARD MEMBERS WHO HAVE A CONFLICT OF INTEREST WOULD REFRAIN FROM DISCUSSION AND VOTING ON THOSE MATTERS. THERE IS AN ANNUAL BOARD MEMBER TRAINING THAT COVERS THIS POLICY. ADDITIONALLY, ALL BOARD MEMBERS ARE WELL ACQUAINTED WITH EACH OTHER SO IF THERE WAS A CONFLICT OF INTEREST AND THE BOARD MEMBER DID NOT DISCLOSE, THE OTHER BOARD MEMBERS WOULD BRING IT TO THE BOARD'S ATTENTION. FORM 990, PART VI, SECTION B, LINE 15 THE HR DIRECTOR PREPARES A SALARY SURVEY ANNUALLY FOR ALL JOBS DESCRIPTIONS WITH HOSPITALS OF SIMILAR SIZE AND REVENUES. THE BOARD OF DIRECTORS REVIEWS THE SURVEY AND PRIOR SALARY INCREASES FOR THE CEO BEFORE GRANTING PAY INCREASES. THE HR DIRECTOR AND CFO MAKE RECOMMENDATIONS TO THE CEO FOR OTHER EMPLOYEES. THE CEO REVIEWS THE SURVEY, PRIOR SALARY INCREASES, AND RECOMMENDATIONS BEFORE APPROVING PAY INCREASES FOR EMPLOYEES. THE PAY INCREASES ARE APPROVED BY THE BOARD OF DIRECTORS DURING THE BUDGET PROCESS. FORM 990, PART VI, SECTION C, LINE 19 GOVERNING DOCUMENTS AND CONFLICT OF INTEREST POLICY ARE NOT MADE AVAILABLE TO THE PUBLIC. CHANGES IN NET ASSETS OR FUND BALANCES: FORM 990, PART XI, LINE 9: CHANGE IN BENEFICIAL INTEREST IN TRUSTS 1,526,849. FORM 990, PART XII, LINE 2C: THE BOARD OF DIRECTORS IS RESPONSIBLE FOR THE OVERSIGHT OF THE AUDIT AND THE SELECTION OF THE INDEPENDENT AUDITOR. THIS PROCESS HAS NOT CHANGED FROM THE PRIOR YEAR.