2013-11-12T12:05:17-06:00 2012-12-31 476097913 SEIM JOHNSON LLP 18081 BURT STREET SUITE 200 OMAHA NE 680224722 990 2012-01-01 470481628 PHELPS MEMORIAL HEALTH CENTER PHEL 3089952211 1215 TIBBALS HOLDREGE NE 68949 LOREN SCHRODER 3089952211 2013-11-12 1 JULIE M GERKEN P00400882 4023302660 2012 2016-02-24 21:20:13Z MARK HARREL 1215 TIBBALS HOLDREGE NE 68949 30773552 0 X WWW.PHELPSMEMORIAL.COM X 1963 NE PHELPS MEMORIAL HEALTH CENTER IS A PROGRESSIVE FAMILY-CENTERED HEALTH CARE PROVIDER DELIVERING A CONTINUUM OF CARE THAT ENHANCES THE QUALITY OF LIFE FOR PEOPLE WE SERVE. 13 9 263 250 0 0 22699 86559 27281699 30395664 657716 213853 50672 61461 28012786 30757537 31528 187997 0 0 10677047 11763614 0 0 0 12661394 15475064 23369969 27426675 4642817 3330862 52322538 59037639 4196134 7144023 48126404 51893616 X PHELPS MEMORIAL HEALTH CENTER IS A PROGRESSIVE FAMILY-CENTERED HEALTH CARE PROVIDER DELIVERING A CONTINUUM OF CARE THAT ENHANCES THE QUALITY OF LIFE FOR PEOPLE WE SERVE. 0 0 2004190 5354065 PHYSICAL THERAPY - THE THERAPY CENTER INCLUDES A LARGE GYM FOR TRAINING AND REHABILITATION, A WHIRLPOOL ROOM FOR WOUND CARE AND A SPORTS FLOOR FOR ATHLETIC TRAINING. PHYSICAL THERAPY ALLOWS INDIVIDUALS TO DEVELOP, RESTORE AND MAINTAIN MAXIMUM MOVEMENT AND FUNCTIONAL ABILITY THROUGHOUT LIFE. THIS INCLUDES PROVIDING SERVICES IN CIRCUMSTANCES WHERE MOVEMENT AND FUNCTION ARE THREATENED BY AGING, INJURY OR DISEASE. THE HYDROWORX THERAPY POOL HELPS PATIENTS RECOVER FROM SURGERY AND ARTHRITIC SYMPTOMS, AS WELL AS, ATHLETIC REHABILITATION. OCCUPATIONAL THERAPY INCORPORATES MEANINGFUL AND PURPOSEFUL OCCUPATION TO ENABLE PEOPLE WITH LIMITATIONS OR IMPAIRMENTS TO PARTICIPATE IN EVERYDAY LIFE. OCCUPATIONAL THERAPISTS WORK WITH INDIVIDUALS, FAMILIES, GROUPS AND POPULATIONS TO FACILITATE HEALTH AND WELL-BEING THROUGH ENGAGEMENT OR RE-ENGAGEMENT IN OCCUPATIONS AND EVERYDAY ACTIVITIES. OCCUPATIONAL THERAPY MAY INCLUDE RESTORING FUNCTION, ADAPTING THE PATIENT'S ENVIRONMENT, OR EVEN HELPING PATIENTS FIND EQUIPMENT TO HELP THEM PARTICIPATE MORE INDEPENDENTLY IN THEIR EVERYDAY ACTIVITIES. OCCUPATIONAL THERAPY HAS MORE ROOM TO EXPAND THEIR SERVICES AND BETTER SERVE THEIR PATIENTS. SPEECH THERAPY ADDRESSES PEOPLE'S SPEECH PRODUCTION, VOCAL PRODUCTION, SWALLOWING DIFFICULTIES AND LANGUAGE NEEDS. 1170725 11098315 RADIOLOGY - THE RADIOLOGY DEPARTMENT AT PHELPS MEMORIAL HEALTH CENTER IS A PROGRESSIVE IMAGING CENTER. WE ARE A FULLY ACCREDITED IMAGING CENTER WITH STATE OF THE ART EQUIPMENT. FEATURING MRI, CT, GENERAL ULTRASOUND, CARDIOVASCULAR ULTRASOUND, NUCLEAR MEDICINE, MAMMOGRAPHY, AS WELL AS STANDARD X-RAYS. WE ARE A FULLY STAFFED, HIGHLY EDUCATED AND EXPERIENCED DEPARTMENT. OUR STAFF IS NOT ONLY EXPERIENCED BUT FRIENDLY AND WILLING TO SERVE YOU BEYOND YOUR EXPECTATIONS. WE ARE VERY "PATIENT" ORIENTED, FOCUSING ON YOUR NEEDS AS A PATIENT. TRYING TO MAKE YOUR EXPERIENCE AS COMFORTABLE AS POSSIBLE. 703375 3825646 MED/SURG - PHELPS MEMORIAL HEALTH CENTER HAS A LOT TO OFFER YOU AND YOUR FAMILY. WE ARE A 25 BED CRITICAL ACCESS HOSPITAL WITH ALL PRIVATE ROOMS. WE HAVE AN EXPERIENCED SURGICAL TEAM WHICH INCLUDES PHYSICIANS/SURGEONS, NURSE ANESTHETIST (CRNA'S), AND SURGICAL NURSES. WE OFFER A WIDE VARIETY OF SURGICAL SERVICES RANGING FROM MINOR PROCEDURES TO MAJOR SURGERIES. OUR GOALS ARE PATIENT-ORIENTED, FOCUSING ON SAFETY, CARE, AND PAIN MANAGEMENT. OUR NURSES COLLABORATE WITH THE PHYSICIANS AND OTHER DEPARTMENTS TO DELIVER A CONTINUUM OF CARE THAT ENHANCES THE QUALITY OF LIFE FOR OUR PATIENTS AND THEIR FAMILIES. 19769389 187997 10117638 OTHER MISCELLANEOUS PROGRAM SERVICES 19769389 187997 10117638 23647679 1 1 0 1 0 0 0 0 0 1 1 0 0 0 1 0 1 0 0 0 0 0 0 0 0 0 1 1 1 0 1 0 0 0 0 0 0 1 1 0 0 0 0 0 0 0 0 0 1 20 0 1 263 1 0 0 0 0 0 0 0 0 0 0 X 13 9 1 1 0 0 1 1 0 1 1 0 0 1 1 1 1 1 1 1 0 0 X LOREN D SCHRODER CFO 3089952211 1215 TIBBALS HOLDREGE NE 68949 CHARLES REESER 2.00 0.00 X X 0 0 0 KATHRYN CANADA 2.00 0.00 X X 0 0 0 DAVID DANNEHL 2.00 0.00 X X 0 0 0 ROGER PETERSON 2.00 0.00 X X 0 0 0 NANCY GARRELTS 2.00 0.00 X 0 0 0 PHIL HINRICHS 2.00 0.00 X 0 0 0 GARY BERGSTEN 2.00 0.00 X 0 0 0 JEFFREY BERNEY MD 2.00 0.00 X 0 0 0 SHERYL MCCLYMONT 2.00 0.00 X 0 0 0 STEVE KNESS 2.00 0.00 X 0 0 0 DAROLD TAGGE 2.00 0.00 X 0 0 0 RONA VANDELL 2.00 0.00 X 0 0 0 LARRY MYERS 2.00 0.00 X 0 0 0 SCOTT EHRESMAN MD 2.00 0.00 X 0 0 0 MARK HARREL 40.00 0.00 X 184498 0 45073 LOREN SCHRODER 40.00 0.00 X 130815 0 34392 ROBERT MILLER 40.00 0.00 X 135238 0 7759 LEORA D SMITH 40.00 0.00 X 130744 0 20708 JERRY L HOWARD II 30.00 0.00 X 159341 0 0 740636 0 107932 5 0 1 1 BRASFIELD & GORRIE LLC PO BOX 11407 BIRMINGHAM AL 35246 CONSTRUCTION 9460323 NEW WEST ORTHOPAEDIC & SPORTS REHAB 3219 CENTRAL AVE STE 104 KEARNEY NE 68847 THERAPY 1978995 QUORUM HEALTH RESOURCES 105 CONTINENTAL PLACE BRENTWOOD TN 37027 MANAGEMENT SERVICE 723756 HOLDREGE MEDICAL CLINIC 516 WEST 14TH AVE HOLDREGE NE 68949 PHYSICIAN ON-CALL 652823 ANESTHESIA SERVICES OF NEBRASKA LLC 113 BENNETT DRIVE LEXINGTON NE 68850 ANESTHESISTS 607754 13 86559 12000 86559 MEDICARE/MEDICAID PAYM 624100 16365597 16365597 NET PATIENT REVENUE 624100 12604158 12604158 EHR INCENTIVE PAYMENT 624100 893976 893976 SUPPLY SALES/MISC OPER 624100 467333 467333 CHILD SERVICES OP OTHE 624100 64600 64600 30395664 224796 224796 72 5000 0 16015 72 -11015 -10943 -10943 CAFETERIA 722210 61461 61461 61461 30757537 30395664 0 275314 X 187997 187997 133368 133368 9099885 7379691 1720194 191649 155944 35705 1713962 1608502 105460 624750 508356 116394 394778 394778 89586 89586 98561 98561 4772265 4622302 149963 78159 78159 1478163 949365 528798 773312 435690 337622 193195 128979 64216 18646 18646 2869768 2869768 105280 105280 MEDICAL SUPPLIES 3348543 3348543 BAD DEBTS 1152887 1152887 DUES AND SUBSCRIPTIONS 101921 42361 59560 27426675 23647679 3778996 0 425 425 11344139 4278419 4832129 5356409 561755 626531 177245 228533 67654364 26318697 28939076 41335667 6036527 5996290 387516 354506 43726 860859 52322538 59037639 3630482 5536120 335652 1527903 230000 80000 4196134 7144023 X 47839632 51587884 86438 95952 200334 209780 48126404 51893616 52322538 59037639 3330862 436350 0 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 1794 1794 0 EXPLANATION OF LOBBYING ACTIVITIES: PART II-B, LINE 1: DUES PAID TO NHA & AHA CONTAIN A PORTION FOR LOBBYING EXPENSES. 417219 14848 432067 401558 15661 417219 383151 18407 401558 368643 100 14408 383151 345888 6296 16459 368643 0.51000 0.49000 0.00000 0 0 246511 246511 38005643 13557784 24447859 16841840 12486525 4355315 12560370 274388 12285982 41335667 PLEDGE PAYABLE - PHELPS COUNTY DEVELOPMENT CORP 80000 80000 31193887 436350 436350 30757537 0 30757537 27426675 0 27426675 0 27426675 DESCRIPTION OF INTENDED USE OF ENDOWMENT FUNDS: PART V, LINE 4: THE INTENDED USES FOR THE ENDOWMENT FUNDS ARE HEALTH CARE SCHOLARSHIPS, CHILD HEALTHCARE AND UNUSUAL HARDSHIP COSTS. 1 1 1 X 125.000000000000 1 X 1 1 1 0 1 1 324593 324593 0.01180 324593 324593 0.01180 26380 8 26372 0.00100 48770 48770 0.00180 1841484 959955 881529 0.03210 248633 248633 0.00910 2165267 959963 1205304 0.04400 2489860 959963 1529897 0.05580 4510 4510 0.00020 4510 4510 0.00020 0 1152887 451182 12042883 12028615 14268 X 1 0 1 1 PHELPS MEMORIAL HEALTH CENTER

1215 TIBBALS HOLDREGE NE 68949

X X X X PHELPS MEMORIAL HEALTH CENTER 1 1 1 125.000000000000 1 250.000000000000 0 1 1 X 1 0 X X X 1 X 0 0 PART I, LINE 3C: PHELPS MEMORIAL HEALTH CENTER (PMHC) USES FEDERAL POVERTY GUIDELINES TO DETERMINE ELIGIBILITY FOR PROVIDING FREE AND DISCOUNTED CARE. PART I, LINE 6A: THE COMMUNITY BENEFIT REPORT IS PREPARED BY THE STAFF AT PMHC. PART I, LINE 7: THE COSTING METHODOLOGY USED TO CALCULATE THE AMOUNTS REPORTED IN THE TABLE WAS A COST-TO-CHARGE RATIO. THE RATIO WAS DERIVED FROM THE COST REPORT FOR FINANCIAL ASSISTANCE. PART I, LINE 7G: NO COSTS ASSOCIATED WITH PHYSICIAN CLINICS WERE INCLUDED AS SUBSIDIZED HEALTH SERVICES. 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 $1,152,887. PART II: ONE OF THE MAJOR COMMUNITY BUILDING ACTIVITIES THAT PMHC HELPS LEAD IS THE SAFE COMMUNITIES COALITION. PMHC EMPLOYEES THREE COALITION MEMBERS, INCLUDING THE COALITION COORDINATOR WHO IS RESPONSIBLE FOR THE DAY TO DAY ORGANIZATIONAL RESPONSIBILITIES, MINUTES, AGENDAS, AND PROGRAM AND EVENT COORDINATION. SAFE COMMUNITIES COALITION IS A GROUP OF REPRESENTATIVES FROM SEVERAL COMMUNITY AGENCIES, INCLUDING PHELPS MEMORIAL HEALTH CENTER, HOLDREGE POLICE DEPARTMENT, PHELPS COUNTY SHERIFF'S DEPARTMENT, NEBRASKA STATE PATROL, YMCA OF THE PRAIRIE, AMERICAN FAMILY INSURANCE, SAFE CENTER, TWO RIVERS PUBLIC HEALTH DEPARTMENT, HOLDREGE, LOOMIS, AND BERTRAND SCHOOLS, AND OTHERS. METHODOLOGY USED BY THE ORGANIZATION TO ESTIMATE BAD DEBT EXPENSE: PART III, LINE 2: IN EVALUATING THE COLLECTIBILITY OF ACCOUNTS RECEIVABLE, THE HEALTH CENTER ANALYZES ITS PAST HISTORY AND IDENTIFIES TRENDS FOR EACH OF ITS MAJOR PAYER SOURCES OF REVENUE TO ESTIMATE THE APPROPRIATE ALLOWANCE FOR DOUBTFUL ACCOUNTS AND PROVISION FOR BAD DEBTS. MANAGEMENT REGULARLY REVIEWS DATA ABOUT THESE MAJOR PAYER SOURCES OF REVENUE IN EVALUATING THE SUFFICIENCY OF THE ALLOWANCE FOR DOUBTFUL ACCOUNTS. FOR RECEIVABLES ASSOCIATED WITH SERVICES PROVIDED TO PATIENTS WHO HAVE THIRD-PARTY COVERAGE, THE HEALTH CENTER ANALYZES CONTRACTUALLY DUE AMOUNTS AND PROVIDES AN ALLOWANCE FOR DOUBTFUL ACCOUNTS AND A PROVISION FOR BAD DEBTS FOR THOSE ACCOUNTS OVER A CERTAIN AGE BASED ON DISCHARGE THAT MAKE THE REALIZATION OF AMOUNTS DUE UNLIKELY. FOR RECEIVABLES ASSOCIATED WITH SELF-PAY PATIENTS (WHICH INCLUDES BOTH PATIENTS WITHOUT INSURANCE AND PATIENTS WITH DEDUCTIBLE AND COPAYMENT BALANCES DUE FOR WHICH THIRD-PARTY COVERAGE EXISTS FOR PART OF THE BILL), THE HEALTH CENTER RECORDS A SIGNIFICANT PROVISION FOR BAD DEBTS IN THE PERIOD OF SERVICE ON THE BASIS OF ITS PAST EXPERIENCE, WHICH INDICATES THAT MANY PATIENTS ARE UNABLE OR UNWILLING TO PAY THE PORTION OF THEIR BILL FOR WHICH THEY ARE FINANCIALLY RESPONSIBLE. THE DIFFERENCE BETWEEN THE STANDARD RATES (OR THE DISCOUNTED RATES IF NEGOTIATED) AND THE AMOUNTS ACTUALLY COLLECTED AFTER ALL REASONABLE COLLECTION EFFORTS HAVE BEEN EXHAUSTED IS CHARGED OFF AGAINST THE ALLOWANCE FOR DOUBTFUL ACCOUNTS. PART III, LINE 4: THE ORGANIZATION'S FINANCIAL STATEMENTS DO NOT CONTAIN A SPECIFIC FOOTNOTE DESCRIBING BAD DEBT. HOWEVER, THE FOLLOWING IS THE TEXT OF THE FOOTNOTES TITLED "PATIENT ACCOUNTS RECEIVABLE, NET," "NET PATIENT SERVICE REVENUE," AND "CHARITY CARE":PATIENT ACCOUNTS RECEIVABLE, NET:THE HEALTH CENTER REPORTS PATIENT ACCOUNTS RECEIVABLE FOR SERVICES RENDERED AT NET REALIZABLE AMOUNTS FROM THIRD-PARTY PAYERS, PATIENTS AND OTHERS. ACCOUNTS RECEIVABLE ARE REDUCED BY AN ALLOWANCE FOR DOUBTFUL ACCOUNTS. IN EVALUATING THE COLLECTIBILITY OF ACCOUNTS RECEIVABLE, THE HEALTH CENTER ANALYZES ITS PAST HISTORY AND IDENTIFIES TRENDS FOR EACH OF ITS MAJOR PAYER SOURCES OF REVENUE TO ESTIMATE THE APPROPRIATE ALLOWANCE FOR DOUBTFUL ACCOUNTS AND PROVISION FOR BAD DEBTS. MANAGEMENT REGULARLY REVIEWS DATA ABOUT THESE MAJOR PAYER SOURCES OF REVENUE IN EVALUATING THE SUFFICIENCY OF THE ALLOWANCE FOR DOUBTFUL ACCOUNTS. FOR RECEIVABLES ASSOCIATED WITH SERVICES PROVIDED TO PATIENTS WHO HAVE THIRD-PARTY COVERAGE, THE HEALTH CENTER ANALYZES CONTRACTUALLY DUE AMOUNTS AND PROVIDES AN ALLOWANCE FOR DOUBTFUL ACCOUNTS AND A PROVISION FOR BAD DEBTS FOR THOSE ACCOUNTS OVER A CERTAIN AGE BASED ON DISCHARGE THAT MAKE THE REALIZATION OF AMOUNTS DUE UNLIKELY. FOR RECEIVABLES ASSOCIATED WITH SELF-PAY PATIENTS (WHICH INCLUDES BOTH PATIENTS WITHOUT INSURANCE AND PATIENTS WITH DEDUCTIBLE AND COPAYMENT BALANCES DUE FOR WHICH THIRD-PARTY COVERAGE EXISTS FOR PART OF THE BILL), THE HEALTH CENTER RECORDS A SIGNIFICANT PROVISION FOR BAD DEBTS IN THE PERIOD OF SERVICE ON THE BASIS OF ITS PAST EXPERIENCE, WHICH INDICATES THAT MANY PATIENTS ARE UNABLE OR UNWILLING TO PAY THE PORTION OF THEIR BILL FOR WHICH THEY ARE FINANCIALLY RESPONSIBLE. THE DIFFERENCE BETWEEN THE STANDARD RATES (OR THE DISCOUNTED RATES IF NEGOTIATED) AND THE AMOUNTS ACTUALLY COLLECTED AFTER ALL REASONABLE COLLECTION EFFORTS HAVE BEEN EXHAUSTED IS CHARGED OFF AGAINST THE ALLOWANCE FOR DOUBTFUL ACCOUNTS.NET PATIENT SERVICE REVENUE:NET PATIENT SERVICE REVENUE IS REPORTED AT THE ESTIMATED NET REALIZABLE AMOUNTS FROM PATIENTS, THIRD-PARTY PAYERS, AND OTHERS FOR SERVICES RENDERED AND INCLUDES ESTIMATED RETROACTIVE REVENUE ADJUSTMENTS DUE TO FUTURE AUDITS, REVIEWS, AND INVESTIGATIONS. RETROACTIVE ADJUSTMENTS ARE CONSIDERED IN THE RECOGNITION OF REVENUE ON AN ESTIMATED BASIS IN THE PERIOD THE RELATED SERVICES ARE RENDERED AND SUCH AMOUNTS ARE ADJUSTED IN FUTURE PERIODS AS ADJUSTMENTS BECOME KNOWN OR AS YEARS ARE NO LONGER SUBJECT TO SUCH AUDITS, REVIEWS, AND INVESTIGATIONS.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 IN THE STATEMENTS OF OPERATIONS. 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.ESTIMATED BAD DEBT FOR PATIENTS ELIGIBLE FOR CHARITY CARE WAS DETERMINED BY APPLYING CHARITY CARE GUIDELINES BASED ON AVERAGE PER HOUSEHOLD INCOME FOR PHELPS COUNTY. 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 IN THE STATEMENTS OF OPERATIONS. PART III, LINE 8: THE ORGANIZATION USED THE MEDICARE COST REPORT FOR FISCAL YEAR 2012 TO REPORT THE AMOUNTS OF TOTAL REVENUE RECEIVED FROM MEDICARE AND RELATED MEDICARE ALLOWABLE COSTS. PART III, LINE 9B: IF A PATIENT IS UNABLE TO MAKE FULL PAYMENT OF THE PATIENT BALANCE WHEN DUE, PERIODIC, PARTIAL PAYMENTS MAY BE APPROVED IN ACCORDANCE WITH CREDIT AND COLLECTION PROCEDURES, AS AUTHORIZED BY THE CHIEF FINANCIAL OFFICER. A PATIENT FINANCIAL STATEMENT MAY BE REQUESTED TO DETERMINE APPROPRIATE PAYMENT ARRANGEMENTS.IF A PATIENT IS DETERMINED TO BE FINANCIALLY INDIGENT, THE PATIENT FINANCIAL SERVICES DEPARTMENT WILL ASSIST THE PATIENT IN APPLYING FOR OTHER FINANCIAL ASSISTANCE. IF NO SOURCE OF FINANCIAL ASSISTANCE IS AVAILABLE, THE HOSPITAL WILL REVIEW THE ACCOUNT FOR CHARITY CARE ALLOWANCE. ALL CHARITY CARE ALLOWANCE MUST BE APPROVED BY THE CHIEF FINANCIAL OFFICER AND PATIENT FINANCIAL SEVICES LEADER.IF PAYMENT ARRANGEMENTS HAVE NOT BEEN MADE AFTER 120 DAYS THE FIRST NOTICE IS RECEIVED, THE PATIENT IS SENT A LETTER STATING THAT THE ACCOUNT IS BEING FORWARDED TO A COLLECTION AGENCY. PART VI, LINE 2: PHELPS MEMORIAL HEALTH CENTER MANAGEMENT, BOARD OF DIRECTORS AND MEDICAL STAFF MEET EVERY 3 TO 5 YEARS FOR A MAJOR STRATEGIC PLANNING AGENDA THAT INCLUDES ASSESSMENT OF THE HEALTH CARE NEEDS OF THE COMMUNITY. OUTSIDE RESOURCES ARE UTILIZED TO IDENTIFY THE CURRENT PATIENT DEMOGRAPHIC TRENDS, HEALTH CARE CONCERNS IN OUR COUNTY AND STATE, PHYSICIAN NEED, ETC. EVERY YEAR MANAGEMENT, BOARD OF DIRECTORS AND MEDICAL STAFF MEET TO DISCUSS AND ASSESS THE ONGOING HEALTH CARE NEEDS OF THE COMMUNITY AND DEVELOP AN ANNUAL BUSINESS PLAN TO ADDRESS THESE NEEDS IN THE UPCOMING YEAR. PART VI, LINE 3: PHELPS MEMORIAL HEALTH CENTER SOCIAL SERVICES DEPARTMENT MONITORS PATIENTS WITHIN THE HOSPITAL AND INDENTIFIES POSSIBLE PATIENTS THAT COULD QUALIFY FOR ASSISTANCE UNDER FEDERAL, STATE OR LOCAL GOVERNMENT. A REPRESENTATIVE OF SOCIAL SERVICES THEN MEETS WITH THE PATIENT TO ASSIST IN REGISTERING FOR SUCH ASSISTANCE. EVERY PATIENT REGISTERING AT PHELPS MEMORIAL HEALTH CENTER IS GIVEN A BILLING PAMPLET THAT EXPLAINS THE FINANCIAL ASSISTANCE PROGRAM. ATTACHED TO EVERY STATEMENT THERE IS A PAYMENT OPTIONS LETTER THAT ALLOWS PATIENTS TO INQUIRE ABOUT THE FINANCIAL ASSISTANCE PROGRAM. EVERY PATIENT WITH A SELF PAY BALANCE IS SENT A LETTER INFORMING THEM PHELPS MEMORIAL HEALTH CENTER HAS A FINANCIAL ASSISTANCE PROGRAM THAT THEY MAY APPLY FOR. PART VI, LINE 4: PHELPS COUNTY NEBRASKA IS LOCATED ON THE HIGH PLAINS IN RURAL NEBRASKSA. THE PRIMARY INDUSTRY IS AGRICULTURE INCLUDING CROPS AND LIVESTOCK. ADDITIONAL INDUSTRY INCLUDES MANUFACTURING. PMHC'S PRIMARY SERVICE AREA IS THE COUNTY OF PHELPS AND PORTIONS OF SURROUNDING COUNTIES WITH A TOTAL SERVICE POPULATION OF APPROXIMATELY 20,000. PART VI, LINE 5: PHELPS MEMORIAL HEALTH CENTER IS THE LEADING ENTITY FOR HEALTH PROMOTION IN THE COMMUNITY IN PARTNERSHIP WITH LOCAL PHYSICIANS, OTHER HEALTH CARE PROFESSIONALS AND THE LOCAL PUBLIC HEALTH DEPARTMENT. THE HOSPITAL IS GOVERNED BY A VOLUNTEER GROUP OF LOCAL CITIZENS REPRESENTING ALL ASPECTS OF THE COMMUNITY. THE MEDICAL STAFF IS OPEN TO ALL PHYSICIANS AND MEDICAL STAFF PROFESSIONALS THAT MEET CREDENTIALING CRITERIA. PHELPS MEMORIAL HEALTH CENTER MAINTAINS A PERMANENT SUB-COMMITTEE OF THE BOARD THAT SUPPORTS AND PROMOTES COMMUNITY HEALTH PROJECTS THROUGH GRANT FUNDING AND OTHER ASSISTANCE. IN ADDITION, THE HOSPITAL PROVIDES MULTIPLE HEALTH RELATED ANNUAL EVENTS TO THE PUBLIC AT NO CHARGE THAT ADDRESS HEALTH CARE NEEDS AND RISKS OF THE COMMUNITY. PART VI, LINE 6: PMHC IS NOT PART OF AN AFFILIATED HEALTH CARE SYSTEM. REPORTS FILED WITH STATES PART VI, LINE 7 NE 1 BERTRAND COMMUNITY SCHOOL 503 SCHOOL STREET BERTRAND NE 68927 476004725 SCHOOL 5000 SAFETY COMMITTEE CITY OF HOLDREGE 502 EAST AVE HOLDREGE NE 68949 476006232 GOV ENTITY 9461 FOR THE PURCHASE OF AED'S (AUTOMATED EXTERNAL DEFIBRILLATOR) HOLDREGE AREA PUBLIC LIBRARY 604 EAST AVE HOLDREGE NE 68949 470523813 GOV ENTITY 18900 FOR THE PURCHASE OF AN ELEVATOR BERTRAND RESCUE SQUAD MINOR AVE BERTRAND NE 68927 476006103 GOV ENTITY 15000 FOR THE PURCHASE OF AN AMBULANCE COURT APPOINTED SPECIAL ADVOCATES (CASA) 715 5TH AVE HOLDREGE NE 68949 476006496 GOV ENTITY 9000 HELP SUPPORT CASA PROGRAM (CASA IMPROVES THE QUALITY OF REPRESENTATION PROVIDED TO CHILD VICTIMS OF ABUSE AND NEGLECT. CHRISTIAN HOMES 1923 WEST 4TH HOLDREGE NE 68949 470378776 501(C)(3) 9602 FOR THE PURCHASE OF A BUS YMCA 1415 BROADWAY STREET HOLDREGE NE 68949 470807617 501(C)(3) 7219 FOR THE PURCHASE OF A POOL SALT SYSTEM CHRISTIAN CHARITY FUND PHELPS CO MINISTERIAL ASSOCIATION 1419 EAST AVE HOLDREGE NE 68949 201308219 CHURCH 8115 FUNDS DISPENSED TO THOSE IN NEED OF FINANCIAL AID PHELPS COUNTY DEVELOPMENT CORPORATION PO BOX 522 HOLDREGE NE 68949 470814669 501(C)(6) 100000 ECONOMIC DEVELOPMENT IN PHELPS COUNTY 8 1 PROCEDURE FOR MONITORING GRANTS IN THE U.S.: PART I, LINE 2: SCHEDULE I, PART I, LINE 2: ALL GRANTS MADE TO LOCAL ORGANIZATIONS IN PHELPS COUNTY AND SURROUNDING COUNTIES. THERE IS CRITERIA IN PLACE TO ENSURE GRANTS ARE AWARDED TO ORGANIZATION MEETING FOUNDATION GUIDELINES. X 0 1 X X 0 0 0 0 0 0 0 0 0 MARK HARREL 172834 0 11664 0 0 0 2767 0 42306 0 229571 0 0 0 LOREN SCHRODER 129151 0 1664 0 0 0 1962 0 32430 0 165207 0 0 0 LEORA D SMITH 116849 0 13895 0 0 0 18014 0 2694 0 151452 0 0 0 JERRY L HOWARD II 159341 0 0 0 0 0 0 0 0 0 159341 0 0 0 PART I, LINE 1A PHELPS MEMORIAL HEALTH CENTER PROVIDES A MEMBERSHIP TO A COUNTRY CLUB FOR THE CEO OF THE ORGANIZATION. THE MEMBERSHIP ALLOWS THE CEO AND OTHER MEMBERS OF THE STAFF TO TAKE EMPLOYEES, CLIENTS AND VENDORS OUT TO THE COUNTRY CLUB. FURTHERMORE, THE ORGANIZATION UTILIZES THE COUNTRY CLUB'S FACILITY FOR MEETINGS AND OTHER EVENTS. SUPPLEMENTAL INFORMATION PART III MARK HARREL AND LOREN SCHRODER RECEIVE COMPENSATION FROM QUORUM HEALTH RESOURCES, AN UNRELATED ENTITY, WHICH PROVIDES MANAGEMENT SERVICES TO ITS CLIENTS. THE PHELPS MEMORIAL HEALTH CENTER BOARD OF DIRECTORS SETS THE SALARY AND BENEFITS FOR MR. HARREL AND MR. SCHRODER. QUORUM HEALTH RESOURCES CHARGES PHELPS MEMORIAL HEALTH CENTER FOR THE SERVICES MR. HARREL AND MR. SCHRODER PROVIDE TO THE ORGANIZATION. SHERYL MCCLYMONT SISTER IS AN EMPLOYEE 55272 EMPLOYEE WAGES 0 RONA VANDELL SISTER-IN-LAW IS AN EMPLOYEE 66307 EMPLOYEE WAGES 0 SCOTT EHRESMAN MD PARTNERSHIP MORE THAN 5% OWNED BY SCOTT EHRESMAN, CURRENT BOARD MEMBER 652823 PAID FAMILY MEDICAL SPECIALTIES FOR EMERGENCY ROOM, CARDIAC REHABILITIATION, AND RESPIRATORY REHABILITATION COVERAGE 0 JEFFREY R BERNEY MD PARTNERSHIP MORE THAN 5% OWNED BY JEFFREY R. BERNEY, CURRENT BOARD MEMBER 652823 PAID FAMILY MEDICAL SPECIALTIES FOR EMERGENCY ROOM, CARDIAC REHABILITATION, AND RESPIRATORY REHABILITATION COVERAGE 0 DAROLD TAGGE GRANDDAUGHTER IS AN EMPLOYEE 11789 EMPLOYEE WAGES 0 SCOTT EHRESMAN MD PARTNERSHIP MORE THAN 5% OWNED BY SCOTT EHRESMAN, CURRENT BOARD MEMBER 345796 RENT RECEIVED FROM FAMILY MEDICAL SPECIALTIES 0 JEFFREY R BERNEY MD PARTNERSHIP MORE THAN 5% OWNED BY JEFFREY R. BERNEY, CURRENT BOARD MEMBER 345796 RENT RECEIVED FROM FAMILY MEDICAL SPECIALTIES 0 FORM 990, PART VI, SECTION A, LINE 2 JEFF BERNEY, MD AND THOMAS SMITH, MD BOTH OFFICERS ON THE BOARD, HAVE A BUSINESS RELATIONSHIP. FORM 990, PART VI, SECTION A, LINE 3 QUORUM HEALTH RESOURCES, LLC ("QHR") AND PHELPS MEMORIAL HEALTH CENTER ("PMHC") HAVE AN AGREEMENT IN PLACE FOR ADMINISTRATIVE SERVICES. QHR PROVIDES THE HOSPITAL THE SERVICES OF INDIVIDUALS TO SERVE AS THE CEO & CFO AT PMHC. THE CEO & CFO SHALL OVERSEE THE EXECUTION AND PERFORMANCE OF THE ADMINISTRATIVE FUNCTIONS OF PMHC AND COMMUNICATE THE BUSINESS AND OPERATIONAL ACTIVITY OF PMHC WITH THE BOARD OR BOARD REPRESENTATIVE ROUTINELY. THE CFO REPORTS TO THE CEO, AND THE CEO IS ACCOUNTABLE AND REPORTS DIRECTLY TO THE BOARD. FORM 990, PART VI, SECTION A, LINE 6 EVERY DONOR OF A GIFT OF $100 OR MORE TO PHELPS COUNTY MEMORIAL HOSPITAL ASSOCIATION SHALL BE A MEMBER OF PHELPS MEMORIAL HEALTH CENTER. FORM 990, PART VI, SECTION A, LINE 7A EACH MEMBER OF PHELPS MEMORIAL HEALTH CENTER HAS ONE VOTE IN THE ELECTION OF DIRECTORS. FORM 990, PART VI, SECTION B, LINE 11 YES, A COPY OF THE FORM 990 WILL BE DISTRIBUTED TO THE BOARD OF DIRECTORS A WEEK BEFORE THE MEETING. DURING THE BOARD OF DIRECTORS MEETING THE FORM 990 WILL BE THOROUGHLY REVIEWED AND DISCUSSED IN ORDER TO ADDRESS ANY QUESTIONS PRIOR TO SUBMISSION. FORM 990, PART VI, SECTION B, LINE 12C PMHC BOARD OF TRUSTEES DISCLOSE CONFLICTS OF INTEREST ON AN ANNUAL BASIS BY SIGNING A CONFLICT OF INTEREST STATEMENT. ALL MEMBERS OF THE BOARD OF DIRECTORS, THE TOP MANAGEMENT OFFICIAL (CEO) AND THE TOP FINANCIAL OFFICIAL (CFO) ARE REQUIRED TO DISCLOSE, ON AN ANNUAL BASIS, ALL INTERESTS THAT COULD GIVE RISE TO A CONFLICT OF INTEREST. THESE DISCLOSURES ARE REVIEWED BY THE BOARD OF DIRECTORS, THE CEO AND THE ORGANIZATION'S COMPLIANCE OFFICER. ACTUAL CONFLICTS ARE ALSO REVIEWED BY THE ENTIRE BOARD OF DIRECTORS. UPON A DIRECTOR'S DISCLOSURE OF A CONFLICT OF INTEREST, THAT DIRECTOR WITHDRAWS FROM BOARD CONSIDERATION AND DISCUSSION, DOES NOT PARTICIPATE IN THE VOTING OR DECISION-MAKING AND, AT THE REQUEST OF THE PRESIDENT, IS EXCUSED FROM THE BOARD MEETING DURING DISCUSSION AND VOTING. ALL EMPLOYEES, INCLUDING SENIOR LEADERSHIP AND DEPARTMENT LEADERS ALSO DISCLOSE AND SIGN A CONFLICT OF INTEREST STATEMENT DURING THEIR ANNUAL REVIEWS. FORM 990, PART VI, SECTION B, LINE 15A QUORUM HEALTH RESOURCES, LLC ("QHR") PROVIDES ADMINISTRATIVE SERVICES TO PHELPS MEMORIAL HEALTH CENTER ("PMHC"). THIS INCLUDES THE HOSPITAL'S CHIEF EXECUTIVE OFFICER AND THE HOSPITAL'S CHIEF FINANCIAL OFFICER. THE BOARD OF DIRECTORS CONDUCTS AN ANNUAL EVALUATION FOR THE CEO AND CFO. A NATIONAL COMPARATIVE BENCHMARK FROM QHR IS PRESENTED TO THE BOARD OF DIRECTORS. THIS COMPARATIVE DATA IS BASED ON SIMILAR HOSPITAL SIZE AND SIMILAR ANNUAL NET REVENUE. THIS DATA IS UTILIZED BY THE BOARD OF DIRECTORS IN ADDITION TO THE ANNUAL PERFORMANCE OF THE CEO AND CFO TO DETERMINE COMPENSATION. MARKET ADJUSTMENTS ARE DETERMINED ANNUALLY BY THE HR LEADER, CEO AND CFO WITH APPROPRIATE DEPARTMENT LEADERS. PAY INCREASES SHALL BE DETERMINED BY THE PERFORMANCE APPRAISAL OVERALL SCORE. ANNUAL PAY INCREASES ARE EFFECTIVE ON THE SECOND PAY PERIOD IN AUGUST EACH YEAR PROVIDED AN ANNUAL PERFORMANCE APPRAISAL HAS BEEN COMPLETED ELECTRONICALLY. THE HUMAN RESOURCE LEADER AND CEO SHALL BE RESPONSIBLE FOR COMPLETION OF AN ANNUAL COMPETENCY REPORT TO BE SUBMITTED TO THE BOARD OF DIRECTORS. THIS REPORT SHALL INCLUDE COMPETENCY OF ALL HOSPITAL EMPLOYEES. FORM 990, PART VI, SECTION C, LINE 19 PMHC DOES NOT MAKE ITS GOVERNING DOCUMENTS, CONFLICT OF INTEREST POLICY OR FINANCIAL STATEMENTS AVAILABLE TO THE PUBLIC. OTHER FEES FORM 990, PART IX, LINE 11G PHYSICIAN FEES: PROGRAM SERVICE EXPENSES 1,086,221. MANAGEMENT AND GENERAL EXPENSES 0. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 1,086,221. OUTSIDE PHYSICAL AND OCCUPATIONAL THERAPY FEES: PROGRAM SERVICE EXPENSES 1,936,496. MANAGEMENT AND GENERAL EXPENSES 0. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 1,936,496. ANESTEHESIOLOGY FEES: PROGRAM SERVICE EXPENSES 598,954. MANAGEMENT AND GENERAL EXPENSES 0. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 598,954. OTHER FEES FOR SERVICE: PROGRAM SERVICE EXPENSES 1,000,631. MANAGEMENT AND GENERAL EXPENSES 149,963. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 1,150,594. FORM 990, PART IX, LINE 5: THE CEO AND CFO OF PHELPS MEMORIAL HEALTH CENTER ARE PAID BY QUORUM HEALTH RESOURCES, LLC, AN UNRELATED ENTITY THAT IS PAID TO PROVIDE ADMINSTRATIVE SERVICES TO THE HEALTH CENTER. THE COMPENSATION FOR THESE INDIVIDUALS ARE REPORTED ON LINE 11A, COLUMN C. FORM 990, PART XII, LINE 2C: PHELPS MEMORIAL HEALTH CENTER HAS A BOARD OF DIRECTORS THAT IS ORGANIZED INTO SIX STANDING COMMITTEES: EXECUTIVE COMMITTEE; FINANCE COMMITTEE; QUALITY & COMMUNITY HEALTH COMMITTEE; GOVERNANCE COMMITTEE; SPECIALTY RECRUITMENT COMMITTEE; AND FOUNDATION COMMITTEE. IT IS THE FINANCE COMMITTEE'S DUTY TO PROVIDE INPUT INTO THE ANNUAL BUDGET PREPARATION, THE THREE YEAR CAPITAL AND LAND USE PROJECTIONS, MONITOR INVESTMENT FUNDS, PROVIDE FOR AN ANNUAL OUTSIDE AUDIT AND IN GENERAL SEE TO THE OVERALL FINANCIAL WELL BEING OF THE FACILITY. THE OVERSIGHT PROCESS OF THE AUDIT AND THE SELECTION PROCESS OF AN INDEPENDENT ACCOUNTANT HAS NOT CHANGED FROM THE PRIOR YEAR.