2026-02-02T06:51:03-06:00 2025-04-30 450250958 EIDE BAILLY LLP 18081 BURT ST STE 200 OMAHA NE 680224722 990 2024-05-01 470388012 BRODSTONE MEMORIAL HOSPITAL BROD 4028793281 520 E 10TH ST PO BOX 187 SUPERIOR NE 689781225 TREG VYZOUREK CEO 4028793281 2026-01-30 1 1 MEGAN L KOZIOL CPA P01544037 4023302660 2026-01-30 2024 2025-03-06 01:10:19Z BRODSTONE HEALTHCARE TREG VYZOUREK 520 E 10TH ST PO BOX 187 SUPERIOR NE 689781225 44948902 0 X WWW.BRODSTONEHEALTHCARE.ORG/ X 1927 NE TO DELIVER INPATIENT, OUTPATIENT AND AMBULATORY CARE. 6 6 275 40 0 0 2287066 342961 38761209 43214161 1040031 1153254 82110 68768 42170416 44779144 130178 68848 0 0 21226626 21644444 0 0 49784 16956996 18399421 38313800 40112713 3856616 4666431 70431891 77672236 16650012 18985420 53781879 58686816 X OUR MISSION IS TO PROVIDE EXCEPTIONAL AND PROGRESSIVE HEALTHCARE TO THE COMMUNITIES WE SERVE. 0 0 25251149 68848 24337542 ANCILLARY SERVICES - BRODSTONE MEMORIAL HOSPITAL IS A 25 BED CRITICAL ACCESS HOSPITAL. SERVICES PROVIDED BY BRODSTONE INCLUDE ANESTHESIOLOGY, RADIOLOGY, CT SCANS, LABORATORY, BLOOD ADMINISTRATION, INHALATION THERAPY, SLEEP STUDIES, PHYSICAL AND OCCUPATIONAL THERAPY, SPEECH THERAPY, ELECTROCARDIOLOGY AND ECHOCARDIOLOGY, BEHAVIORAL HEALTH, CHEMOTHERAPY, NUCLEAR MEDICINE AND EMERGENCY SERVICES. 4802166 5026626 PHYSICIAN' CLINICS - BRODSTONE MEMORIAL HOSPITAL OWNS 3 RURAL HEALTH CLINICS IN SUPERIOR, NELSON, AND EDGAR, NE. THREE BOARD CERTIFIED FAMILY PRACTICE PHYSICIANS, FOUR PA-C, AND TWO APRNS SERVE ALL AGES FROM CHILDREN TO SENIOR CITIZENS. ONE APRN IS PSYCHIATRIC-MENTAL HEALTH NP CERTIFIED TO PROVIDE BEHAVIORAL HEALTH SERVICES. IN ADDITION TO DIAGNOSING AND TREATING ILLNESS, THEY ALSO PROVIDE PREVENTIVE CARE, ROUTINE CHECKUPS, IMMUNIZATION AND SCREENING TESTS, AND HOSPITALIZATION AND NURSING HOME CARE, AND OBSTETRICS. 4073373 5015392 NURSING SERVICES - BRODSTONE MEMORIAL HOSPITAL IS A 25 BED CRITICAL ACCESS HOSPITAL, WITH A RECENT 41,900 SQUARE FOOT ADDITION OF AN ER, PATIENT WING, INFUSION SUITES AND HEALING GARDEN. THE NEW SPACE HAS ENHANCED PATIENT SAFETY, SECURITY AND PRIVACY AND FEATURES 17 NEW PATIENT ROOMS INCLUDING AN OB/NURSERY AREA. NURSING SERVICES WORK WITH THE MEDICAL STAFF TO DELIVER QUALITY, AFFORDABLE HEALTH CARE IN A CARING, SAFE AND COMPASSIONATE ENVIRONMENT TO ALL PATIENTS. BRODSTONE PROVIDED 1,351 PATIENT DAYS OF INPATIENT CARE AND 724 PATIENT DAYS OF SWING BED CARE. 2333897 8834601 BRODSTONE'S PHARMACY DEPARTMENT PREPARES AND DISPENSES MEDICATION BY REVIEWING AND INTERPRETING PHYSICIAN ORDERS. THE PHARMACISTS DETECT THERAPEUTIC INCOMPATIBILITIES, ADVISE INTERVENTIONS, ANSWER QUESTIONS FROM HEALTH PROFESSIONALS, AND COUNSEL PATIENTS ON DRUG THERAPIES. 2333897 8834601 36460585 1 1 0 1 0 0 0 0 0 1 1 0 0 1 1 1 0 1 0 0 0 0 0 0 0 0 1 1 1 0 1 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 1 1 0 0 1 69 32 1 275 1 0 0 0 0 0 0 0 0 0 0 0 0 X 6 6 0 0 0 0 0 0 0 1 0 0 0 1 1 1 1 1 1 1 1 0 X CRYSTAL WYATT 4028793281 520 EAST 10TH STREET SUPERIOR NE 68978 ROYCE SCHOTT PRESIDENT 2.00 0.20 X X 0 0 0 JANET EGGERS VICE-PRESIDENT 2.00 0.00 X X 0 0 0 PIPER HODGE SECRETARY 2.00 0.50 X X 0 0 0 BETH SIEBECKER TREASURER 2.00 0.00 X X 0 0 0 JACKI PORTER DIRECTOR 2.00 0.00 X 0 0 0 SANDY BORDEN DIRECTOR 2.00 0.00 X 0 0 0 TREG VYZOUREK CEO 39.80 0.20 X 399916 0 50593 CRYSTAL WYATT CFO 39.80 0.20 X 128180 0 43958 TIMOTHY BLECHA MD PHYSICIAN 40.00 0.00 X 401631 0 62288 JULIE THEIS MD PHYSICIAN 40.00 0.00 X 376105 0 24298 RAYMOND HELLER MD PHYSICIAN 40.00 0.00 X 321000 0 37252 CHRISTOPHER SOUCHEK CRNA 40.00 0.00 X 262222 0 50667 MATTHEW GATLIN PA-C PHYSICIAN ASSISTANT 40.00 0.00 X 265162 0 40204 2154216 0 309260 24 0 1 0 CARDINAL HEALTH-OWEN PHARMACY SERVICE 21377 NETWORK PLACE CHICAGO IL 60673 MEDICAL SERVICES 2812996 RURAL PARTNERS IN MEDICINE LLC 8181 ARISTA PLACE SUITE 100 BROOMFIELD CO 80021 MEDICAL SERVICES 665457 LYTLE CONSTRUCTION 18505 E 163 ST LAKE WINNEBAGO MO 64034 CONSTRUCTION SERVICES 492519 BD CONSTRUCTION 209 E 6TH STREET KEARNEY NE 68848 CONSTRUCTION SERVICES 368243 LORI G HARRIS CRNA LLC 3207 NORTHWOOD COURT NEWTON KS 67114 MEDICAL SERVICES 266928 12 317785 25176 342961 NET PATIENT SERVICE REVENUE 621110 39039896 39039896 340B PHARMACY REVENUE 456110 3658564 3658564 515701 515701 43214161 1201552 1201552 121460 169758 -48298 -48298 -48298 CAFETERIA REVENUE 900099 68768 68768 68768 44779144 43214161 0 1222022 65848 65848 3000 3000 623251 623251 15601052 14735364 865688 552608 521138 31470 3797438 3526468 270970 1070095 976670 93425 73163 73163 3455999 3195136 257839 3024 100075 608 99467 3576321 2871987 657574 46760 379395 346215 33180 299752 272318 27434 463477 417326 46151 3151051 2837286 313765 430153 387321 42832 PHARMACY EXPENSES 3393435 3393435 MEDICAL SUPPLIES 2651567 2634678 16889 DIETARY FOOD & SUPPLIES 275787 275787 COLLECTIONS EXPENSE 148128 148128 1118 1118 40112713 36460585 3602344 49784 3693878 5414464 19700378 24759794 5766495 8092138 71980 62361 394203 360715 570559 584796 56818430 26990597 31729544 29827833 4187193 4410848 4317661 4159287 70431891 77672236 4263223 3210355 11874912 10725554 511877 5049511 16650012 18985420 X 52127491 56985313 1654388 1701503 53781879 58686816 70431891 77672236 X 4666431 191391 47115 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 3807 3807 0 PART II-B, LINE 1: BRODSTONE MEMORIAL HOSPITAL PAID DUES TO THE AMERICAN HOSPITAL ASSOCIATION AND THE NEBRASKA HOSPITAL ASSOCIATION, A PORTION OF THE DUES WERE USED FOR LOBBYING ACTIVITIES. 1524476 200295 101109 13350 38721 1571591 1452743 227635 100989 26333 28580 1524476 1545374 30725 93698 29658 1452743 1733236 -95776 56892 35193 1545374 1443862 364430 55867 19189 1733236 0.00000 1.00000 0.00000 1 0 117890 117890 40879042 14981796 25897246 15403235 11758484 3644751 418263 250317 167946 29827833 BENEFICIAL INTEREST IN TRUSTS 1571590 DEFERRED COMPENSATION 441416 INTEREST RECEIVABLE 92 RIGHT OF USE ASSETS 2103816 INVESTMENT IN JOINT VENTURES 42373 4159287 DEFERRED COMPENSATION 368977 RIGHT OF USE LIABILITIES 2120796 ESTIMATED THIRD-PARTY PAYOR SETTLEM 2559738 5049511 X PART V, LINE 4: INTEREST EARNINGS MAY BE USED FOR OPERATIONS, HOWEVER THE PRINCIPLE IS TO BE MAINTAINED AS A PERMANENT ENDOWMENT. PART X, LINE 2: THE HOSPITAL ACCOUNTS FOR UNCERTAINTIES IN ACCOUNTING FOR INCOME TAX ASSETS AND LIABILITIES USING GUIDANCE INCLUDED IN FINANCIAL ACCOUNTING STANDARDS BOARD (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, 2025 AND 2024, THE HOSPITAL HAD NO UNCERTAIN TAX POSITIONS ACCRUED. 1 1 X 1 X 1 X 1 1 1 0 1 1 87 145000 145000 0.00360 3767237 3459335 307902 0.00770 87 3912237 3459335 452902 0.01130 54 100750 100750 0.00250 16690 9417322 5290580 4126742 0.10290 1525 33706 33706 0.00080 18269 9551778 5290580 4261198 0.10620 18356 13464015 8749915 4714100 0.11750 2 1525 49759 49759 0.00120 32 6400 6900 6900 0.00020 15 758 28359 3541 24818 0.00060 49 8683 85018 3541 81477 0.00200 1 586744 70409 11248609 11284339 -35730 X 1 1 1 1 BRODSTONE MEMORIAL HOSPITAL 520 E 10TH SUPERIOR NE 68978 HTTPS://WWW.BRODSTONEHEALTHCARE.ORG/ 570001 X X X X BRODSTONE MEMORIAL HOSPITAL 1 0 0 1 X X X X X X X X X X 24 1 1 1 1 X HTTPS://WWW.BRODSTONEHEALTHCARE.ORG/PATIENTS/COMMUNITY-HEALTH-NEEDS-ASSESSM X 1 24 1 HTTPS://WWW.BRODSTONEHEALTHCARE.ORG/PATIENTS/COMMUNITY-HEALTH-NEEDS-ASSESSM 0 1 X 100.000000000000 200.000000000000 X X 1 1 X X X X X 1 X HTTPS://WWW.BRODSTONEHEALTHCARE.ORG/PATIENTS/FINANCE-SERVICES X HTTPS://WWW.BRODSTONEHEALTHCARE.ORG/PATIENTS/FINANCE-SERVICES X HTTPS://WWW.BRODSTONEHEALTHCARE.ORG/PATIENTS/FINANCE-SERVICES X X X X X 1 X 0 X X X X 1 X 0 0 BRODSTONE MEMORIAL HOSPITAL PART V, SECTION B, LINE 3J: THE REPORT INCLUDES A LIST OF MEASURES IN THE FIVE YEAR PLAN (2025 THROUGH 2030) AND THE COMMUNITY HEALTH IMPROVEMENT PLAN (2025 THROUGH 2030) FIRST YEAR ENDED 4/30/2025. THE PLAN INCLUDES PERFORMANCE MEASURES ALONG WITH STRATEGIES AND ACTIVITIES FOR THE PRIORITY AREAS OF ACCESS TO CARE, MENTAL WELLBEING, CHRONIC DISEASE, AND SENIOR HEALTH. BRODSTONE MEMORIAL HOSPITAL PART V, SECTION B, LINE 5: INCLUDED IN THE REPORT ARE RESULTS FROM A PUBLIC HEALTH SURVEY THAT WAS MADE AVAILABLE OVER A 4 COUNTY AREA (WEBSTER, ADAMS, CLAY AND NUCKOLLS). PUBLICLY AVAILABLE SECONDARY DATA WAS SUPPLEMENTED WITH AN ONLINE COMMUNITY SURVEY AND FIVE FOCUS GROUPS, INCLUDING ONE FOR SPANISH-SPEAKING RESIDENTS. ADDITIONAL, THE ASSESSMENT FOR ADVANCING COMMUNITY TRANSFORMATION (AACT) GATHERED INPUT FROM COMMUNITY ORGANIZATIONS AND STAKEHOLDERS TO IDENTIFY OPPORTUNITIES FOR ADVANCING HEALTH EQUITY. BRODSTONE MEMORIAL HOSPITAL PART V, SECTION B, LINE 6A: BRODSTONE'S CHNA WAS CONDUCTED WITH MARY LANNING HEALTHCARE AND WEBSTER COUNTY COMMUNITY HOSPITAL. BRODSTONE MEMORIAL HOSPITAL PART V, SECTION B, LINE 6B: BRODSTONE'S CHNA WAS CONDUCTED WITH SOUTH HEARTLAND DISTRICT HEALTH DEPARTMENT, CLAY COUNTY HEALTH DEPARTMENT, AND UNITED WAY OF SOUTH-CENTRAL NEBRASKA. BRODSTONE MEMORIAL HOSPITAL PART V, SECTION B, LINE 11: IN THE MOST RECENT CHNA CONDUCTED THE FOLLOWING NEEDS WERE IDENTIFIED: MENTAL HEALTH & WELLBEING, CHRONIC ILLNESS, AND ELDER/SENIOR CARE.MENTAL HEALTH & WELLBEING: -EXPAND ACCESS TO MENTAL HEALTH IN ADOLESCENTS. -RAISE AWARENESS TO REDUCE STIGMA. -CREATE FURTHER ACCESS TO MENTAL HEALTH SUPPORT.CHRONIC ILLNESS: -EXPAND CHRONIC CARE. -CREATE AWARENESS OF HEART DISEASE. -IMPLEMENTATION OF A 3-4-50 PROGRAM. A PUBLIC HEALTH STRATEGY DESIGNED TO HIGHLIGHT THE CONNECTION BETWEEN CERTAIN BEHAVIORS, CHRONIC DISEASES, AND PREMATURE DEATHS (3 BEHAVIORS CONTRIBUTE TO THESE 4 CHRONIC DISEASES, WHICH TOGETHER ACCOUNT FOR MORE THAN 50% OF ALL PREMATURE DEATHS).ELDER/SENIOR CARE: -INCREASE ACCESS BY SUPPORTING TRANSPORTATION OPTIONS.-DEVELOP AN AGE-FRIENDLY COMMUNITY (NEBRASKA HOSPITAL ASSOCIATION/AMERICAN HOSPITAL ASSOCIATION PROGRAM)-PROVIDE EDUCATION AND TRAININGS FOR THE COMMUNITY ON CYBERSECURITY AND SCAM PREVENTION.THE FACILITY CONDUCTED A NEW CHNA IN THE CURRENT TAX YEAR AND HASN'T HAD THE OPPORTUNITY TO ADDRESS ALL AREAS YET. HOWEVER, WE HAVE BEEN ABLE TO ADDRESS A FEW AREAS. BRODSTONE IS CONTINUOUSLY WORKING ON ACCESS TO CARE. BRODSTONE IS NOW ABOUT TO SEND OUT AUTOMATED TEXT MESSAGE APPOINTMENT REMINDERS. BRODSTONE HAS PARTNERED WITH A COMPANY TO PROVIDE TELE-STROKE PROVIDERS FOR ER COVERAGE FOR SIGNIFICANT NEUROLOGICAL SITUATIONS. IN ADDITION, WE WERE ABLE TO ADD UROLOGY TO THE MONTHLY SPECIALISTS THAT COME TO BRODSTONE. WE ADDED AN ADDITIONAL DAY EACH MONTH FOR PODIATRY SERVICES. BRODSTONE CONTINUES TO PROVIDE BASELINE CONCUSSION TESTING FOR AREA SCHOOLS INCLUDING: SUPERIOR, LAWRENCE/NELSON, AND SANDY CREEK. HOSTED A HEALTH & WELLNESS EXPO OFFERING SKIN CHECKS, FLU SHOTS, WATER TESTING KITS, CPR DEMONSTRATIONS, INSURANCE EDUCATION, AND CYBER-SECURITY AWARENESS. CONTINUE TO PROVIDE A WALKING CLUB 3 DAYS A WEEK FOR INDOOR ACTIVITY YEAR ROUND ENGAGING THE COMMUNITY OF SUPERIOR. IN ADDITION, FITNESS CLASSES ARE OFFERED 3 DAYS A WEEK EARLIER IN THE DAY FOR THOSE WORKING DURING WALKING CLUB HOURS. TAI CHI CLASSES WERE OFFERED TO HELP WITH MOBILITY ISSUES. MENTAL HEALTH WAS A HEALTH PRIORITY GOAL LAST YEAR AND THIS YEAR. IN THE CURRENT YEAR, THE FACILITY HAD AN EMPLOYEE WHO COMPLETED EDUCATION FOR CERTIFIED PLAY THERAPY AND LMHP (LICENSED MENTAL HEALTH PRACTITIONER) TO BE ABLE TO PROVIDE IN-PERSON SERVICES FOR ADOLESCENT POPULATIONS. IN ADDITION, THE EMPLOYEE WILL BE WORKING MORE HOURS TO PROVIDE MORE OPENINGS FOR THE ADOLESCENT POPULATION. TO ADDRESS THE CHRONIC ILLNESS NEED, BRODSTONE HAS PARTNERED WITH CHARTSPAN TO ENHANCE THE CARE PROVIDED TO MEDICARE PATIENTS THROUGH A COMPREHENSIVE CARE MANAGEMENT PROGRAM TO HELP REDUCE CHRONIC ILLNESS. THIS INITIATIVE WILL SIGNIFICANTLY IMPROVE PATIENT SUPPORT AND ACCESS TO HEALTHCARE RESOURCES. ELIGIBLE PATIENTS WILL RECEIVE CORRESPONDENCE, INCLUDING PHONE CALLS, LETTERS, OR EMAILS REGARDING ENROLLMENT IN THE PROGRAM.BRODSTONE WILL CONTINUE TO PROVIDE WELLNESS ACTIVITIES FOR THE COMMUNITY TO GET PEOPLE ACTIVE. WE HOSTED THE ANNUAL FIREKRACKER RUN OFFERING A 1 MILE PREDICT, 2 MILE WALK/RUN, AND A 5K WALK/RUN FOR PARTICIPANTS. SEATED YOGA WAS OFFERED FOR 4 MONTHS ALONG WITH TAI CHI FOR 7 MONTHS WITH 2 SEPARATE SESSIONS. A GROCERY STORE TOUR WAS OFFERED WITH HOW TO EAT HEALTHY ON A BUDGET. 19 INDIVIDUALS PARTICIPATED IN THE FACILITY'S HEALTHY LIVING PROGRAM. PRESENTATIONS WERE PRESENTED ON THE TOPICS OF HIDDEN SUGARS, MENTAL HEALTH, AND VAPING IN A LOCAL SCHOOL TO STUDENTS IN A HEALTH CLASS. WE ARE EVALUATING HOW TO INCREASE ACCESS FOR ELDER/SENIOR CARE BY SUPPORTING TRANSPORTATION OPTIONS. THERE WERE NO SIGNIFICANT NEEDS IDENTIFIED THAT ARE NOT BEING ADDRESSED. BRODSTONE MEMORIAL HOSPITAL PART V, SECTION B, LINE 13H: IN INSTANCES WHEN A PATIENT MAY APPEAR ELIGIBLE FOR FINANCIAL ASSISTANCE, BUT THERE IS NO FINANCIAL APPLICATION FORM ON FILE DUE TO A LACK OF SUPPORTING DOCUMENTATION, FINANCIAL ASSISTANCE MAY STILL BE GRANTED IN CERTAIN SITUATIONS BASED ON PRESUMPTIVE CIRCUMSTANCES. OFTEN THERE IS ADEQUATE INFORMATION PROVIDED BY THE PATIENT OR THROUGH OTHER SOURCES, WHICH COULD PROVIDE SUFFICIENT EVIDENCE TO PROVIDE THE PATIENT WITH FINANCIAL ASSISTANCE. IN THE EVENT THERE IS NO EVIDENCE TO SUPPORT A PATIENT'S ELIGIBILITY FOR FINANCIAL ASSISTANCE, BRODSTONE COULD USE OUTSIDE AGENCIES IN DETERMINING ESTIMATED INCOME AMOUNTS FOR THE BASIS OF DETERMINING FINANCIAL ASSISTANCE ELIGIBILITY AND POTENTIAL DISCOUNT AMOUNTS. PRESUMPTIVE ELIGIBILITY MAY BE DETERMINED IN CERTAIN SITUATIONS, AND BASED ON THE APPROVAL OF BRODSTONE'S MANAGEMENT, ON THE BASIS OF INDIVIDUAL LIFE CIRCUMSTANCES THAT MAY INCLUDE:A) STATE-FUNDED PRESCRIPTION PROGRAMS;B) TRANSIENT, HOMELESS OR RECEIVED CARE FROM A HOMELESS CLINIC, OR UNIDENTIFIED PERSONS;C) PARTICIPATION IN WOMEN, INFANTS AND CHILDREN PROGRAMS (WIC);D) FOOD STAMP ELIGIBILITY;E) ELIGIBILITY FOR OTHER STATE OR LOCAL ASSISTANCE PROGRAMS THAT ARE UNFUNDED (E.G., MEDICAID SPEND-DOWN);F) CRIME VICTIMS BILLED CHARGES AFTER STATE OR FEDERAL FUNDS HAVE PAID OR ARE EXHAUSTED;G) LOW INCOME/SUBSIDIZED HOUSING IS PROVIDED AS A VALID ADDRESS;H) PATIENT IS DECEASED WITH NO KNOWN ESTATE OR RESPONSIBLE PARTY; ANDI) PERSONS WHO INCOME IS AT OR BELOW 100% OF THE CURRENT POVERTY LEVEL. BRODSTONE MEMORIAL HOSPITAL PART V, SECTION B, LINE 15E: PATIENTS MAY APPLY FOR ASSISTANCE BY CALLING BRODSTONE MEMORIAL HOSPITAL AT 402-207-1539 AND REQUESTING A FINANCIAL ASSISTANCE APPLICATION; OR BY REQUESTING AN APPLICATION IN PERSON FROM REGISTRATION OR THE BUSINESS OFFICE. AN APPLICATION MAY BE DOWNLOADED FROM THE HOSPITAL'S WEBSITE. 3 1 - SUPERIOR FAMILY MEDICAL CENTER 525 E 11TH ST SUPERIOR NE 68978 RURAL HEALTH CLINIC 2 - NELSON FAMILY MEDICAL CENTER 76 W 8TH ST NELSON NE 68961 RURAL HEALTH CLINIC 3 - EDGAR MEDICAL CLINIC 315 N C ST EDGAR NE 68935 RURAL HEALTH CLINIC PART I, LINE 3C: IN ADDITION TO FEDERAL POVERTY GUIDELINES, THE HOSPITAL ALSO USES MEDICAL INDIGENCY TO DETERMINE ELIGIBILITY OF FREE OR DISCOUNTED CARE. IN INSTANCES WHEN A PATIENT MAY APPEAR ELIGIBLE FOR FINANCIAL ASSISTANCE, BUT THERE IS NO FINANCIAL APPLICATION FORM ON FILE DUE TO A LACK OF SUPPORTING DOCUMENTATION, FINANCIAL ASSISTANCE MAY STILL BE GRANTED IN CERTAIN SITUATIONS BASED ON PRESUMPTIVE CIRCUMSTANCES. OFTEN THERE IS ADEQUATE INFORMATION PROVIDED BY THE PATIENT OR THROUGH OTHER SOURCES, WHICH COULD PROVIDE SUFFICIENT EVIDENCE TO PROVIDE THE PATIENT WITH FINANCIAL ASSISTANCE. IN THE EVENT THERE IS NO EVIDENCE TO SUPPORT A PATIENT'S ELIGIBILITY FOR FINANCIAL ASSISTANCE, BRODSTONE COULD USE OUTSIDE AGENCIES IN DETERMINING ESTIMATED INCOME AMOUNTS FOR THE BASIS OF DETERMINING FINANCIAL ASSISTANCE ELIGIBILITY AND POTENTIAL DISCOUNT AMOUNTS. PRESUMPTIVE ELIGIBILITY MAY BE DETERMINED IN CERTAIN SITUATIONS, AND BASED ON THE APPROVAL OF BRODSTONE'S MANAGEMENT, ON THE BASIS OF INDIVIDUAL LIFE CIRCUMSTANCES THAT MAY INCLUDE:A) STATE-FUNDED PRESCRIPTION PROGRAMS;B) TRANSIENT, HOMELESS OR RECEIVED CARE FROM A HOMELESS CLINIC, OR UNIDENTIFIED PERSONS;C) PARTICIPATION IN WOMEN, INFANTS AND CHILDREN PROGRAMS (WIC);D) FOOD STAMP ELIGIBILITY;E) ELIGIBILITY FOR OTHER STATE OR LOCAL ASSISTANCE PROGRAMS THAT ARE UNFUNDED (E.G., MEDICAID SPEND-DOWN);F) CRIME VICTIMS BILLED CHARGES AFTER STATE OR FEDERAL FUNDS HAVE PAID OR ARE EXHAUSTED;G) LOW INCOME/SUBSIDIZED HOUSING IS PROVIDED AS A VALID ADDRESS;H) PATIENT IS DECEASED WITH NO KNOWN ESTATE OR RESPONSIBLE PARTY; ANDI) PERSONS WHO INCOME IS AT OR BELOW 100% OF THE CURRENT POVERTY LEVEL. PART I, LINE 7: CHARITY CARE EXPENSE WAS CONVERTED TO COST ON LINE 7A BASED ON AN OVERALL COST-TO-CHARGE RATIO ADDRESSING ALL PATIENT SEGMENTS. UNREIMBURSED MEDICAID ON LINE 7B, AND SUBSIDIZED HEALTH SERVICES, LINE 7G, WERE CALCULATED USING THE COSTING METHODS TO PREPARE THE COST REPORTS. HEALTH PROFESSIONS EDUCATION, LINE 7F, AND IN-KIND CONTRIBUTIONS FOR COMMUNITY BENEFIT, LINE 7I, ARE REPORTED BASED ON ACTUAL EXPENSES REPORTED IN THE GENERAL LEDGER. PART II, COMMUNITY BUILDING ACTIVITIES: THE COMMUNITY BUILDING ACTIVITIES PROMOTED THE HEALTH OF THE COMMUNITIES ITS SERVES THROUGH SEVERAL DIFFERENT AREAS. SEVERAL MEMBERS OF THE SR. LEADERSHIP MEETING SAT IN ON THE DEVELOPMENT OF THE CITY'S COMPREHENSIVE 10 YEAR PLAN. THIS INCLUDED ECONOMIC DEVELOPMENT IDEAS AND WAYS TO IMPROVE SUPERIOR. THE HOSPITAL HAS PARTNERED WITH THE NC3 DAYCARE TO PROVIDE ADDITIONAL OPPORTUNITIES FOR CHILD CARE IN THE AREA. THERE HAS BEEN A SHORTAGE AND HAS CREATED STAFFING ISSUES DUE TO NO DAYCARE. BRODSTONE CONTINUES TO PROVIDE HAMBURGERS AND HOTDOGS FOR NON-PROFIT COMMUNITY ORGANIZATIONS TO HELP RAISE FUNDS FOR THEIR SPECIFIC AREAS; SEVERAL HAVE BEEN SUPPORTING LOCAL SCHOOLS. BRODSTONE'S COMMUNITY WELLNESS HAS PROVIDED WALKING SCHOOL BUS FOR SCHOOL AGE KIDS, MORNING FITNESS CLASSES AND WALKING CLUBS INSIDE SO INDIVIDUALS HAVE A SAFE PLACE TO WALK YEAR AROUND. BIKE RODEO WAS CONDUCTED TO PROVIDE EDUCATION AROUND BIKE SAFETY, HELMET FITTINGS, AND SAFETY CHECKS. THE FIREKRACKER RUN IS AN ANNUAL EVENT CONDUCTED TO PROMOTE WELLNESS WITHIN INDIVIDUALS. TAI CHI IS DONE TO HELP PROMOTE BALANCE IN THE ELDERLY POPULATION ALONG WITH SEATED YOGA. A GROCERY STORE TOUR WAS CONDUCTED TO HELP EDUCATE THE PUBLIC ON HOW TO EAT HEALTHY ON A BUDGET WITH DIFFERENT IDEAS. PART III, LINE 2: THE AMOUNT ON LINE 2 REPRESENTS IMPLICIT PRICE CONCESSIONS. THE ORGANIZATION DETERMINES ITS ESTIMATE OF IMPLICIT PRICE CONCESSION BASED ON ITS HISTORICAL COLLECTION EXPERIENCE WITH THIS CLASS OF PATIENTS. PART III, LINE 3: THE ESTIMATED AMOUNT OF THE ORGANIZATION'S IMPLICIT PRICE CONCESSIONS ATTRIBUTABLE TO PATIENTS ELIGIBLE UNDER THE ORGANIZATION'S CHARITY CARE POLICY IS CALCULATED BASED ON AN APPROXIMATE 12.0% OF INDIVIDUALS LIVING BELOW THE POVERTY LEVEL IN THE SERVICE AREA. PART III, LINE 4: THE FOOTNOTE TO THE ORGANIZATION'S FINANCIAL STATEMENTS THAT DESCRIBES IMPLICIT PRICE CONCESSIONS IS LOCATED IN FOOTNOTE 1 ON PAGES 13 THROUGH 14 OF THE ATTACHED FINANCIAL STATEMENTS. PART III, LINE 8: THE ENTIRE MEDICARE SHORTFALL IS CONSIDERED A COMMUNITY BENEFIT. SERVICES ARE PROVIDED TO PATIENTS UNDER THE MEDICARE PROGRAM EVEN THOUGH THE HOSPITAL KNOWS THEY WILL NOT RECOVER ALL OF THE COSTS FROM PROVIDING THE SERVICES. THIS PROGRAM IS CONSIDERED SUBSIDIZED BY THE HOSPITAL AND OTHER PAYORS. PATIENTS RELY ON THESE SERVICES FOR THEIR HEALTH AND WELL-BEING AND ARE ESSENTIAL FOR THEIR ACCESS TO HEALTHCARE. TOTAL REVENUE RECEIVED FROM MEDICARE IS THE GROSS REIMBURSEMENT PLUS SETTLEMENT. BOTH TOTAL REVENUE RECEIVED FROM MEDICARE AND THE MEDICARE ALLOWABLE COSTS ARE REPORTED FROM THE MEDICARE COST REPORT. THE MEDICARE COST REPORT IS COMPLETED BASED ON THE RULES AND REGULATIONS SET FORTH BY CENTERS FOR MEDICARE AND MEDICAID SERVICES.HOSPITAL SERVICES RENDERED ON A FEE SCHEDULE ARE NOT INCLUDED IN THE MEDICARE CALCULATIONS PER THE 990 INSTRUCTIONS. HAD THIS BEEN REPORTED THE HOSPITAL WOULD HAVE HAD A GREATER LOSS FROM MEDICARE SERVICES OF $162,312.MEDICARE FEE SCHEDULE REVENUE $288,251MEDICARE ESTIMATED COSTS OF CARE RELATING TO PAYMENTS $450,563NET (SHORTAGE) $(162,312) 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, WILL NOT SEND UNPAID BILLS TO OUTSIDE COLLECTION AGENCIES AND WILL CEASE ALL COLLECTION EFFORTS. PART VI, LINE 2: BRODSTONE ASSESSES THE HEALTH CARE NEEDS OF THE COMMUNITY IT SERVES THROUGH A SURVEY, AND PUBLISHES SUGGESTIONS AND STRATEGIC PLANNING RESULTS. HOSPITAL STAFF ALSO NETWORK WITH OTHER HEALTH CARE ORGANIZATIONS TO DEVELOP IDEAS OF WHAT CAN BE DONE TO IMPROVE THE AVAILABILITY OF SERVICES IN THE COMMUNITY. PART VI, LINE 3: BRODSTONE HAS A BROCHURE CALLED CHARITY POLICY THAT ADDRESSESS THE FINANCIAL ASSISTANCE AVAILABILITY. IT IS POSTED AT THE ADMISSIONS AREAS AND EMERGENCY ROOM. THE CHARITY POLICY IS DISCUSSED WHEN MAKING PAYMENT ARRANGEMENTS. THIS POLICY IS ALSO AVAILABLE ON THE HOSPITAL'S WEBSITE. PART VI, LINE 4: SUPERIOR HAS A POPULATION OF 1,826 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 $69,323 COMPARED TO THE U.S. AVERAGE AT $77,719 AND THE NEBRASKA AVERAGE OF $82,485. THE AREA POPULATION IS PREDOMINATELY WHITE ELDERLY AND LOW INCOME. 49.6% OF THE HOSPITAL'S PATIENTS ARE MEDICARE PATIENTS. PART VI, LINE 5: BRODSTONE'S GOVERNING BODY CONSISTS OF INDIVIDUALS WITH NO IMMEDIATE FAMILY TIES TO ANY EMPLOYEE NOR ARE THEY CONTRACTORS OF THE ORGANIZATION. ALL BOARD MEMBERS HAVE SUPERIOR NEBRASKA ADDRESSES BUT 2 MEMBERS LIVE IN JEWELL COUNTY, KANSAS. ALL FAMILY PRACTICE PHYSICIANS AND MIDLEVELS IN THE AREA WHO HAVE REQUESTED MEDICAL STAFF PRIVILEGES AND MEET THE REQUIREMENTS HAVE PRIVILEGES AT THE HOSPITAL. ONE DENTIST HAS COURTESY PRIVELEGES. ALL SURPLUS FUNDS OF THE ORGANIZATION ARE USED TO FUND THE BUDGET FOR THE COMING YEARS OR SET ASIDE FOR FUTURE PROJECTS. 1 BRODSTONE MEMORIAL HOSPITAL FOUNDATION 520 EAST 10TH STREET SUPERIOR NE 68978 851276014 501(C)(3) 65848 0 REIMBURSE FOUNDATION FOR FUNDRAISING EXPENSES AND CONTRIBUTE FUNDS FOR PROGRAM SUPPORT. 1 0 PART I, LINE 2: THE HOSPITAL ONLY GRANTS FUNDS TO ITS RELATED FOUNDATION. THEREFORE, IT IS ABLE TO MONITOR THE USE OF THE GRANT FUNDS. X X X X 0 0 0 1 0 0 0 0 0 TIMOTHY BLECHA MD PHYSICIAN 275065 0 126566 0 0 0 35422 0 26866 0 463919 0 0 0 TREG VYZOUREK CEO 399916 0 0 0 0 0 13800 0 36793 0 450509 0 0 0 JULIE THEIS MD PHYSICIAN 294845 0 81260 0 0 0 12993 0 11305 0 400403 0 0 0 RAYMOND HELLER MD PHYSICIAN 280255 0 40745 0 0 0 9602 0 27650 0 358252 0 0 0 CHRISTOPHER SOUCHEK CRNA 262222 0 0 0 0 0 10420 0 40247 0 312889 0 0 0 MATTHEW GATLIN PA-C PHYSICIAN ASSISTANT 213100 0 52062 0 0 0 10844 0 29360 0 305366 0 0 0 CRYSTAL WYATT CFO 125103 0 3077 0 0 0 5442 0 38516 0 172138 0 0 0 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. A THE CITY OF SUPERIOR NEBRASKA 476006376 2013-05-22 4000000 REFUND ISSUES (9/9/03, 9/10/09, 9/10/09) 0 0 0 B THE COUNTY OF NUCKOLLS NEBRASKA 476006492 2013-05-22 4000000 REFUND ISSUES (9/9/03, 9/10/09, 9/10/09) 0 0 0 C CITY OF SUPERIOR NEBRASKA 476006376 2019-12-12 10000000 CONSTRUCT AND EQUIP FACILITY 0 0 0 A 2999993 4000000 4000000 2010 1 0 1 1 B 2999993 4000000 4000000 2010 1 0 1 1 C 1076330 10000000 10000000 2024 0 0 1 1 A 0 0 0 0 0.00000 0.00000 0.00000 0 0 1 B 0 0 0 0 0.00000 0.00000 0.00000 0 0 1 C 0 0 0 0 0.00000 0.00000 0.00000 0 0 1 A 0 0 0 1 0 0 0 0 1 B 0 0 0 1 0 0 0 0 1 C 0 0 0 1 1 0 0 0 1 A 1 B 1 C 1 SCHEDULE K, PART IV, LINE 2C: (A) ISSUER NAME: CITY OF SUPERIOR, NEBRASKA DATE THE REBATE COMPUTATION WAS PERFORMED: 08/07/2020 (B) ISSUER NAME: THE COUNTY OF NUCKOLLS, NEBRASKA DATE THE REBATE COMPUTATION WAS PERFORMED: 08/07/2020 (C) ISSUER NAME: CITY OF SUPERIOR, NEBRASKA DATE THE REBATE COMPUTATION WAS PERFORMED: 03/31/2024 NOTE REGARDING THE 8/7/2020 REBATE COMPUTATIONS: SINCE THE BOND PROCEEDS WERE SPENT ON THE ISSUE DATE, A SPENDING EXCEPTION WAS MET, AND THE DEBT SERVICE FUND WAS OPERATED ON A BONA FIDE BASIS, NO FURTHER REBATE CALCULATIONS ARE NECESSARY. NOTE REGARDING THE 3/31/2024 REBATE COMPUTATION: SINCE THE BOND PROCEEDS ARE SPENT AND THE DEBT SERVICE FUND WAS OPERATED ON A BONA FIDE BASIS, NO FURTHER REBATE CALCULATIONS ARE NECESSARY. FORM 990, PART VI, SECTION A, LINE 8B THERE ARE NO COMMITTEES WITH AUTHORITY TO ACT ON BEHALF OF THE GOVERNING BODY. FORM 990, PART VI, SECTION B, LINE 11B 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 HUMAN RESOURCE 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 HUMAN RESOURCE 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 THE ORGANIZATION DOES NOT MAKE ITS GOVERNING DOCUMENTS AND CONFLICT OF INTEREST POLICY AVAILABLE TO THE PUBLIC, BUT FINANCIAL STATEMENTS ARE AVAILABLE UPON REQUEST. FORM 990, PART XI, LINE 9: CHANGE IN BENEFICIAL INTEREST IN TRUSTS 47,115. FORM 990, PART XII, LINE 2C: THE BOARD OF DIRECTORS ASSUMES THE RESPONSIBILITY FOR OVERSIGHT OF THE AUDIT OF ITS FINANCIAL STATEMENTS AND THE SELECTION OF AN INDEPENDENT ACCOUNTANT. THIS PROCESS HAS NOT CHANGED FROM THE PRIOR YEAR. PNC VESTEY TRUST UA UNB & NORTHERN CO SUCC BENEFIT BRODSTONE MEM HOSP 116 ALLEGHENY CENTER MALL PITTSBURGH PA 15212 226023351 ASSISTING IN THE OPERATIONS OF BRODSTONE MEMORIAL HOSPITAL PA 4947(A)(1) PF BRODSTONE MEMORIAL HOSPITAL 1 BRODSTONE MEMORIAL HOSPITAL FOUNDATION 520 EAST 10TH STREET SUPERIOR NE 68978 851276014 TO SUPPORT BRODSTONE MEMORIAL HOSPITAL NE 501(C)(3) LINE 12A, I BRODSTONE MEMORIAL HOSPITAL 1 0 1 1 0 0 0 0 0 0 0 0 0 1 1 1 1 1 0 0 PNC VESTEY TRUST C 57109 FMV BRODSTONE MEMORIAL HOSPITAL FOUNDATION B 65848 FMV BRODSTONE MEMORIAL HOSPITAL FOUNDATION C 260676 FMV