2012-11-14T07:55:06-06:00 2011-12-31 476097913 SEIM JOHNSON LLP 18081 BURT STREET SUITE 200 OMAHA NE 680224722 990 2011-01-01 470796875 FAITH REGIONAL HEALTH SERVICES FAIT 4023714880 1500 KOENIGSTEIN AVENUE PO BOX 869 NORFOLK NE 687020869 JOHN WILKER 4023713402 2012-11-09 1 P GREG DONDELINGER P00400863 4023302660 2011 2016-02-24 21:20:13Z JAMES J SINEK 1500 KOENIGSTEIN AVENUE PO BOX 869 NORFOLK NE 687020869 152819985 0 X WWW.FRHS.ORG X 1996 NE FAITH REGIONAL HEALTH SERVICES IS A HEALTHCARE ORGANIZATION PROVIDING ACUTE, SKILLED AND OUTPATIENT SERVICES TO INDIVIDUALS IN OUR SERVICE AREA. 15 9 1400 185 259511 188462 1228007 1241736 140448769 148226036 387599 2002325 221862 175877 142286237 151645974 491544 449695 0 0 75834466 71891251 0 0 454476 61532461 74189647 137858471 146530593 4427766 5115381 185782930 188031415 105166197 102340882 80616733 85690533 X FAITH REGIONAL HEALTH SERVICES (FAITH REGIONAL), A NOT-FOR-PROFIT HEALTH CARE FACILITY LOCATED IN NORTHEAST NEBRASKA OPERATES FOR THE BENEFIT OF THE INDIVIDUALS IN ITS SERVICE AREA. FAITH SERVES ALL PATIENTS REGARDLESS OF THEIR ABILITY TO PAY AND DOES NOT LIMIT ITS SERVICES OR DISCRIMINATE AGAINST ANYONE ON THE BASIS OF RACE, COLOR, SEX, NATIONAL ORIGIN, SEXUAL ORIENTATION, RELIGION, AGE, DISABILITY, DISEASE, OR DIAGNOSIS. 0 0 63284326 38891091 FAITH REGIONAL PROVIDES HEALTHCARE TO ALL PEOPLE REGARDLESS OF THEIR ABILITY TO PAY OR THEIR INSURANCE PROVIDER. DURING 2011, FAITH PROVIDED 11,396 PATIENT DAYS TO MEDICARE PATIENTS AND 2,603 PATIENT DAYS TO MEDICAID PATIENTS. 18210715 14574353 MANY SERVICES PROVIDED BY FAITH REGIONAL ARE DONE TO MEET SPECIFIC NEEDS OF THE COMMUNITY BECAUSE NO OTHER SERVICES ARE AVAILABLE. AS A RESULT, THESE SERVICES ARE PROVIDED KNOWING THAT THEY WILL NOT BE FINANCIALLY VIABLE OR SELF-SUPPORTING. THESE SERVICES INCLUDE ACUTE REHABILITATION, BEHAVIORAL HEALTH INPATIENT SERVICES, CARDIOPULMONARY REHABILTIATION SERVICES, DIALYSIS, HOME HEALTH CARE AND TRANSITIONAL CARE (LONG-TERM REHABILITIATION) SERVICES. 5932990 A SUBSTANTIAL PORTION OF COMMUNITY BENEFITS PROVIDED BY FAITH REGIONAL IS THE PROVISION OF PATIENT CARE SERVICES THAT ARE NOT PAID FOR EITHER BY THE PATIENT OR A THIRD PARTY INSURANCE. DURING 2011, FAITH PROVIDED PATIENTS OVER $5 MILLION IN ASSISTANCE WITH PAYING THEIR HOSPITAL BILLS. 39009564 449695 94194560 FAITH REGIONAL IS COMMITTED TO MAINTAINING AND ENHANCING THE QUALITY OF CARE THROUGH THE PROVISION OF EDUCATION TO EMPLOYEES AND MEDICAL STAFF AND THROUGH THE OFFERING OF BENEFITS THAT SUPPORT THIS.BENEFITS TO OUR EMPLOYEES INCLUDE EDUCATIONAL LOANS, TUITION REIMBURSEMENT AND WORKSHOP EXPENSE REIMBURSEMENT. IN 2011, A TOTAL OF 17,000 HOURS OF EDUCATION HOURS WERE PROVIDED TO OUR 1,300 EMPLOYEES AND MEDICAL STAFF MEMBERS. THIS INCLUDED 465 PROGRAMS AND 3,200 HOURS OF CONTINUING EDUCATION FOR HEALTHCARE PROFESSIONALS AND PHYSICIANS. FAITH REGIONAL ALSO HAS E-LEARNING. EMPLOYEES COMPLETED A TOTAL OF 13,000 HOURS OF ONLINE EDUCATION WHICH WAS 330 DIFFERENT COURSES. FAITH REGIONAL ALSO PROMOTES HEALTHCARE CAREERS BY PARTICIPATING AT HIGH SCHOOL CAREER FAIRS, OFFERING STUDENT SHADOWING AND HOSTING MEDICAL EXPLORERS. 39009564 449695 94194560 126437595 1 1 0 1 0 0 0 0 0 1 1 0 0 0 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 1 1 1 0 0 0 0 1 1 1 1 0 0 1 92 0 1 1400 1 1 1 0 0 0 0 0 0 0 0 0 X 15 9 1 0 0 0 1 1 1 1 1 0 0 1 1 1 1 1 1 1 1 1 1 X JOHN WILKER 4026447249 1500 KOENIGSTEIN AVENUE PO BOX 869 NORFOLK NE 687020869 X JIM MILLER 1.00 X X 0 0 0 BERT LAMMLI 1.00 X X 0 0 0 BERNIE AUTEN 1.00 X X 0 0 0 PAUL SANDALL 1.00 X X 0 0 0 ANITA BRENNEMAN 1.00 X 0 0 0 JOHN DINKEL 1.00 X 0 0 0 PHIL ECKSTROM MD 1.00 X 0 0 0 JEFF EISENMENGER 1.00 X 0 0 0 DONNA HERRICK 1.00 X 0 0 0 DAN KARMAZIN DDS 1.00 X 0 0 0 STEFFAN LACEY MD 1.00 X 0 0 0 SCOTT MILLER 1.00 X 0 0 0 JEFF PAPE OD 1.00 X 0 0 0 MARY KAY UHING 1.00 X 0 0 0 TOD VOSS MD 1.00 X 0 0 0 JAMES J SINEK 39.00 X 476500 0 27240 DOUGLAS WISMER 39.00 X 180391 0 14727 LINDA MILLER 40.00 X 133095 0 13231 DEAN FRENCH MD 40.00 X 78850 0 6498 H MICHAEL HAMMOND 40.00 X 149471 0 24194 JANET PINKELMAN 40.00 X 151899 0 10845 PATRICK ROCHE 40.00 X 187005 0 25257 BARRY SPEAR 24.00 X 172013 0 12062 TIMOTHY DAVY MD 40.00 X 46132 0 2102 KELLY DRISCOLL 40.00 X 58381 0 7800 JOSEPH MCCLAIN MD 40.00 X 752161 0 23238 DOUGLAS WELSH MD 40.00 X 668305 0 26816 MOHAMMAD IMRAN MD 40.00 X 595584 0 24682 CHRISTOPHER PRICE MD 40.00 X 553406 0 27044 HAKAM ASAAD MD 40.00 X 539263 0 16990 4742456 0 262726 66 0 1 0 QUAMMEN HEALTH CARE CONSULTANT 552 BRANDIES CIRCLE B4 MURFREESBORO TN 37128 IT CONSULTING 751638 NEBRASKA LAB INC PO BOX 30 BEREA OH 44017 LAB SERVICES 577600 SIOUX CITY NIGHT PATROL PO BOX 3276 SIOUX CITY IA 51102 SECURITY SERVICES 327354 READY TEC-GO INC 1005 E 23RD ST SUITE 200 FREMONT NE 68025 NURSING SERVICES 209102 DUAYNE ALLEN CARLSON 6301 NW 112 ST LINCOLN NE 68524 ORTHOPEDIC SERVICES 191104 10 18000 1089050 134686 1241736 NET PATIENT SERVICE RE 623000 102359846 102359846 MEDICARE/MEDICAID 623000 38795492 38795492 OTHER OPERATING REVENU 900099 5468861 5085951 56550 326360 LEASED MEDICAL EMPLOYE 900099 975237 975237 PHYSICIAN CLINICS 621110 626600 626600 148226036 492985 492985 948166 975250 -27084 -27084 -27084 1708101 198761 1509340 1509340 1509340 MHR HOME CARE LLC 446199 202961 202961 202961 151645974 147843126 259511 2301601 449695 449695 1777693 1777693 243563 243563 55344350 49883539 5194625 266186 2612450 2333719 266309 12422 8137861 7207016 892483 38362 3775334 3306276 451459 17599 338602 338602 224351 224351 168348 168348 16873006 11317846 5489390 65770 54225 39220 13648 1357 5640971 3301711 2302718 36542 2586052 541267 2041402 3383 3295951 3020268 275683 86961 58712 26273 1976 4487667 4487667 10802729 10759751 42978 793645 789014 4631 MEDICAL SUPPLIES 22234402 22234402 BAD DEBT 6371281 6371281 DUES & SUBSCRIPTIONS 213509 75185 127445 10879 LICENSES 17463 17463 484 484 146530593 126437595 19638522 454476 73 213 20380825 34071093 18245967 17107418 782142 1647453 4083846 3841458 1139734 1178593 192368599 77204440 122146086 115164159 13126141 9004798 25302 15302 2028769 1902408 3824045 4098520 185782930 188031415 13599377 14251628 75508998 72855943 15134135 12769181 923687 2464130 105166197 102340882 X 80588488 85662070 28245 28463 80616733 85690533 185782930 188031415 X 5115381 -41581 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 7524 7524 0 EXPLANATION OF LOBBYING ACTIVITIES: PART II-B, LINE 1: FAITH REGIONAL PAID DUES TO THE NEBRASKA ASSOCIATION OF HOSPITALS AND HEALTH SYSTEMS, AMERICAN HOSPITAL ASSOCIATION AND NEBRASKA ASSOCIATION OF HOME AND COMMUNITY HEALTH AGENCIES DUES WHICH WERE USED FOR LOBBYING ACTIVITIES. THE AMOUNT OF DUES PAID WERE $3,657, $3,730 AND $137, RESPECTIVELY. 5670101 13321 -38571 66738 5578113 5188508 2727 517780 38914 5670101 4493972 6814 721427 33705 5188508 5706317 4188 -1146496 71037 4492972 0.00000 1.00000 0.00000 0 1 1 1006212 1006212 7149316 85955630 35994435 57110511 176685 94379922 39663458 54893149 3700834 1546547 2154287 115164159 ESTIMATED THIRD PARTY PAYOR SETTLEMENTS - MEDICARE & MEDICAID 588463 DEFERRED COMP INVESTMENT 1875667 2464130 151645974 146530593 5115381 -41581 -41581 5073800 152579643 -41581 975250 933669 151645974 0 151645974 147505843 975250 975250 146530593 0 146530593 DESCRIPTION OF INTENDED USE OF ENDOWMENT FUNDS: PART V, LINE 4: CARSON CANCER CENTER ENDOWMENT FUNDS ARE PERMANENTLY SET ASIDE TO GENERATE INVESTMENT EARNINGS TO BE USED TO FUND CAPITAL EQUIPMENT PURCHASES AND/OR OPERATIONS OF THE CARSON REGIONAL CANCER CENTER. INVESTMENT EARNINGS ON THESE FUNDS ARE TEMPORARILY RESTRICTED AS TO USE. GENERAL ENDOWMENT FUNDS ARE PERMANENTLY SET ASIDE TO GENERATE INVESTMENT EARNINGS. INVESTMENT EARNINGS ON THESE FUNDS ARE NOT RESTRICTED AS TO USE. THE HOSPICE ENDOWMENT FUNDS ARE PERMANENTLY SET ASIDE TO GENERATE INVESTMENT EARNINGS TO BENEFIT THE HOSPICE PROGRAM AND ITS PATIENTS. INVESTMENT INCOME ON THESE FUNDS ARE TEMPORARILY RESTRICTED AS TO USE. THE CARDIAC SERVICES ENDOWMENT FUNDS ARE PERMANENTLY SET ASIDE TO GENERATE INVESTMENT EARNINGS TO FUND FAITH REGIONAL HEALTH SERVICE'S CARDIAC PROGRAM CAPITAL AND/OR OPERATIONAL EXPENSES. THE EDUCATION ENDOWMENT FUNDS ARE PERMANENTLY SET ASIDE TO GENERATE INVESTMENT EARNINGS TO BENEFIT FAITH REGIONAL HEALTH SERVICE'S EDUCATION PROGRAMS AND ITS EFFORTS TO RECRUIT AND RETAIN EMPLOYEES. INVESTMENT INCOME ON THESE FUNDS ARE TEMPORARILY RESTRICTED AS TO USE. ST. JOSEPH'S NURSING HOME/SKYVIEW VILLA ENDOWMENT FUNDS ARE PERMANENTLY SET ASIDE TO GENERATE INVESTMENT EARNINGS TO BE USED TO FUND CAPITAL EQUIPMENT PURCHASES AND/OR OPERATION OF ST. JOSEPH'S NURSING HOME AND SKYVIEW VILLA. INVESTMENT EARNINGS ON THESE FUNDS ARE TEMPORARILY RESTRICTED AS TO USE. THE PEDIATRIC ENDOWMENT FUNDS ARE PERMANENTLY SET ASIDE TO GENERATE INVESTMENT EARNINGS TO BENEFIT FAITH REGIONAL HEALTH SERVICE'S CHILDREN'S CARE FUND. DONORS CAN SPECIFY CONTRIBUTIONS TO ANY OF THE ENDOWMENT FUNDS. DESCRIPTION OF UNCERTAIN TAX POSITIONS UNDER FIN 48: PART X: FRHS AND THE FOUNDATION ARE NOT-FOR-PROFIT CORPORATIONS AS DESCRIBED IN SECTION 501(C) (3) OF THE INTERNAL REVENUE CODE AND ARE EXEMPT FROM FEDERAL AND NEBRASKA STATE INCOME TAXES ON RELATED INCOME PURSUANT TO SECTION 501(A) OF THE CODE. FRPS IS A LIMITED LIABILITY COMPANY WHOLLY OWNED BY FAITH. THE INTERNAL REVENUE SERVICE HAS ESTABLISHED STANDARDS TO BE MET TO MAINTAIN TAX-EXEMPT STATUS. IN GENERAL, SUCH STANDARDS REQUIRE FRHS AND THE FOUNDATION TO MEET A COMMUNITY BENEFIT STANDARD AND COMPLY WITH VARIOUS LAWS AND REGULATIONS. FRHS ACCOUNTS FOR UNCERTAINTIES IN ACCOUNTING FOR INCOME TAX ASSETS AND LIABILITIES USING GUIDANCE INCLUDED IN FASB ASC 740, INCOME TAXES. FAITH RECOGNIZES THE EFFECT OF INCOME TAX POSITIONS ONLY IF THOSE POSITIONS ARE MORE LIKELY THAN NOT OF BEING SUSTAINED. AT DECEMBER 31, 2011 AND 2010, FAITH HAD NO UNCERTAIN TAX POSITIONS ACCRUED. OPEN TAX YEARS FOR FAITH INCLUDE 2011, 2010 AND 2009. PART XII, LINE 2D - OTHER ADJUSTMENTS: RENTAL EXPENSES 975,250. PART XIII, LINE 2D - OTHER ADJUSTMENTS: RENTAL EXPENSES 975,250. 1 1 X 1 X 400.000000000000 1 X 1 1 1 0 1 1 2450325 2450325 0.01750 9656885 6912675 2744210 0.01960 12107210 6912675 5194535 0.03710 810643 61678 748965 0.00530 18210715 14574353 3636362 0.02590 363618 363618 0.00260 19384976 14636031 4748945 0.03380 31492186 21548706 9943480 0.07090 1 2632308 110640 33601076 43021167 -9420091 X 1 1 1 NORTHEAST NE IMAGING CENTER LLC IMAGING SERVICES 0.25000 0.00000 0.75000 2 1 FAITH REGIONAL HEALTH SERVICES - WEST

2700 NORFOLK AVENUE NORFOLK NE 68701

X X X 2 FAITH REGIONAL HEALTH SERVICES - EAST

1500 KOENIGSTEIN AVE NORFOLK NE 68701

X X FAITH REGIONAL HEALTH SERVICES - WEST 1 1 1 400.000000000000 1 400.000000000000 1 X X X X X X X X 1 1 X 0 0 1 X 0 0 FAITH REGIONAL HEALTH SERVICES - EAST 2 1 1 400.000000000000 1 400.000000000000 1 X X X X X X X X 1 1 X 0 0 1 X 0 0 3 ST JOSEPH REHABILITIATION & CARE CTR

401 N 18TH STREET NORFOLK NE 68701

SKILLED NURSING FACILITY NORTHEAST NE SURGERY CENTER LLC

301 NORTH 27TH ST STE 3 NORFOLK NE 68701

SURGERY CENTER NORTHEAST NE IMAGING CENTER LLC

301 NORTH 27TH ST STE 15 NORFOLK NE 68701

IMAGING CENTER PART I, LINE 3C: FAITH REGIONAL USES THE FEDERAL POVERTY GUIDELINES TO DETERMINE ELIGIBILITY FOR DISCOUNTED CARE. FINANCIALLY RESPONSIBLE PARTIES WHO SUBMIT A COMPLETE, VERIFIABLE APPLICATION FOR FINANCIAL ASSISTANCE WILL BE CONSIDERED FOR FREE OR REDUCED "CHARITY CARE" FINANCIAL ASSISTANCE ON THE BASIS OF THE FEDERAL POVERTY GUIDELINES (400% FPG LIMIT).ELIGIBILITY FOR THIS PROGRAM WILL BE DETERMINED BY FAMILY SIZE, GROSS INCOME BASED ON THE FEDERAL POVERY GUIDELINES AND AN ASSET TEST. THE GROSS INCOME LEVELS ARE UPDATED EACH YEAR AS THE FEDERAL POVERTY GUIDELINES ARE UPDATED.CHARITY CARE MAY BE GRANTED WITH RESPECT TO ANY DOLLARS OWED BY A FINANCIALLY RESPONSIBLE PARTY, INCLUDING, BUT NOT LIMITED TO, DEDUCTIBLE, COINSURANCE AND COPAYMENT AMOUNTS; CHARGES FOR NON-COVERED SERVICES AND MEDICAID COST OF SHARE AMOUNTS.CHARITY CARE MAY BE AUTHORIZED FOR FINANCIALLY RESPONSIBLE PARTIES WITH INCOME LEVELS EXCEEDING 400% FPG IN THE CASE OF UNUSUAL, SPECIAL AND/OR EXTENUATING CIRCUMSTANCES. THESE INSTANCES ARE GENERALLY DUE TO MEDICAL CATASTROPHE SITUATIONS. PART I, LINE 7: FAITH REGIONAL USES A COST ACCOUNTING SYSTEM TO DETERMINE COSTS REPORTABLE ON PART I, LINE 7 (AND ELSEWHERE ON SCHEDULE H). THE FIRST STEP IN THE COST ACCOUNTING PROCESS IS TO ALLOCATE THE OVERHEAD EXPENSES (ADMINISTRATION AND GENERAL, PLANT, ETC) TO THE REVENUE PRODUCING DEPARTMENTS (OPERATING ROOM, IMAGING, ONCOLOGY, ETC). THIS IS DONE SIMILAR TO THE MEDICARE COST REPORT USING A SINGLE STEP DOWN METHOD TO ALLOCATE THE COSTS USING APPLICABLE STATISTICS. FOR EXAMPLE: PLANT EXPENSES ARE ALLOCATED DOWN TO THE OTHER DEPARTMENTS USING CURRENT SQUARE FOOTAGE SO DEPARTMENTS WITH MORE SQUARE FOOTAGE WILL BE ALLOCATED MORE PLANT EXPENSES; DIETARY EXPENSES ARE ALLOCATED BASED ON MEALS SERVED; EMPLOYEE BENEFITS ARE ALLOCATED BASED ON SALARIES; ADMINISTRATIVE AND GENERAL EXPENSES ARE ALLOCATED BASED ON ACCUMULATED COSTS; AND SO ON. ONCE ALL THE OVERHEAD EXPENSES ARE ALLOCATED TO THE REVENUE PRODUCING DEPARTMENTS THE COSTS ARE FURTHER ALLOCATED DOWN TO THE CHARGE CODE LEVEL. IN ORDER TO DO THIS WE USE TWO DIFFERENT METHODS DEPENDING ON THE DEPARTMENT. FOR SPECIFIC DEPARTMENTS WE USE A RVU (RELATIVE VALUE UNIT) ALLOCATION WHERE EACH PROCEDURE IS WEIGHTED BY THE INTENSITY OF THE SERVICE AND IS THEN ALLOCATED COST BASED ON THAT LEVEL OF INTENSITY. FOR EXAMPLE AN XRAY WITH SEDATION IS MORE COMPLICATED AND TIME INTENSIVE THAN A SIMPLE CHEST XRAY SO IT WOULD HAVE A HIGHER RVU VALUE AND, IN TURN, A HIGHER COST ALLOCATED TO IT. THE DEPARTMENTS USING THIS ALLOCATION METHOD ARE IMAGING, CARDIAC CATH, CT, MRI, ULTRASOUND, NUCLEAR MEDICINE, RADIATION ONCOLOGY, AND REHAB (PHYSICAL, OCCUPATIONAL AND SPEECH THERAPY).FOR THE OTHER DEPARTMENTS WE USE A RATIO OF COST TO CHARGE METHOD TO ALLOCATE THE COSTS DOWN TO THE CHARGE CODE LEVEL.AFTER ALL THE COSTS HAVE BEEN ALLOCATED TO THE CHARGE CODES THE COSTING IS APPLIED TO ALL PATIENT ACCOUNTS BASED ON THEIR CHARGES TO DETERMINE THE COST OF THEIR ENCOUNTER AND THEN REPORTS CAN BE RUN TO DETERMINE THE PROFITABILITY OF CERTAIN PAYORS, SERVICE LINES OR DEPARTMENTS. FOR SCHEDULE H PART III, LINE 2, BAD DEBT EXPENSE (AT COST) WAS DETERMINED BY TAKING THE 2011 BAD DEBT PROVISION AND MULTIPYING THIS BY THE COST TO CHARGE RATION FROM THE 2011 COST REPORT. PART I, LINE 7G: MANY SERVICES PROVIDED BY FAITH REGIONAL ARE DONE SO TO MEET SPECIFIC NEEDS OF THE COMMUNITY BECAUSE NO OTHER SERVICES ARE AVAILABLE. AS A RESULT, THESE SERVICES ARE PROVIDED KNOWING THAT THEY WILL NOT BE FINANCIALLY VIABLE OR SELF-SUPPORTING. FAITH REGIONAL DID NOT INCLUDE COSTS ATTRIBUTABLE TO PHYSICIAN CLINICS AS SUBSIDIZED SERVICES.A SUBSIDIZED HEALTH SERVICE BENEFIT WAS CALCULATED FOR THE ACUTE REHABILITIATION, BEHAVIORAL HEALTH INPATIENT SERVICES, CARDIOPULMONARY REHABILITATION, DIALYSIS, HOME HEALTH CARE, TRANSITIONAL CARE (LONG-TERM REHABILITATION) AND SKILLED NURSING CARE DEPARTMENTS TO RECOGNIZE THAT THESE AREAS OPERATE AT A NEGATIVE MARGIN WHEN THE INDIRECT COSTS ARE CONSIDERED.THE REPORTED SUBSIDIZED LOSS REPRESENTS THE DIFFERENCE IN NET REVENUE RECEIVED FROM ALL PAYORS IN ADDITION TO ANY MISCELLANEOUS OPERATING REVENUE REPORTED BY THE DEPARTMENT LESS TOTAL OPERATING EXPENSES (DIRECT + INDIRECT COSTS INCLUDED) APPLICABLE TO EACH DEPARTMENT. PART I, L7 COL(F): FAITH REGIONAL ACCOUNTS FOR DISCOUNTS OR PAYMENTS ON PATIENT ACCOUNTS PREVIOUSLY DETERMINED AS BAD DEBT BY CREDITING THE BAD DEBT EXPENSE ACCOUNT. PART I, LINE 6A: FAITH REGIONAL'S COMMUNITY BENEFIT REPORT IS FILED WITH THE NEBRASKA HOSPITAL ASSOCIATION AND IS AVAILABLE TO THE PUBLIC ON OUR WEBSITE: WWW.FRHS.ORG PART II: NONE PART III, LINE 4: THE AUDITED FINANCIAL STATEMENT FOOTNOTES FOR FAITH REGIONAL DO NOT CONTAIN A FOOTNOTE RELATED TO BAD DEBT EXPENSE. BAD DEBT EXPENSE IS IDENTIFIED ON THE CONSOLIDATED STATEMENT OF OPERATIONS WHICH IS CONSISTENT WITH THE REPORTING PRACTICE OF OTHER HEALTH CARE ORGANIZATIONS.DESCRIBE THE COSTING METHOD USED TO DETERMINE AMOUNTS REPORTED IN LINES 2 & 3:FAITH REGIONAL USES A COST ACCOUNTING SYSTEM TO DETERMINE COSTS REPORTABLE ON LINES 2 & 3 (AND ELSEWHERE ON SCHEDULE H). THE FIRST STEP IN THE COST ACCOUNTING PROCESS IS TO ALLOCATE THE OVERHEAD EXPENSES (ADMINISTRATION AND GENERAL, PLANT, ETC) TO THE REVENUE PRODUCING DEPARTMENTS (OPERATING ROOM, IMAGING, ONCOLOGY, ETC). THIS IS DONE SIMILAR TO THE MEDICARE COST REPORT USING A SINGLE STEP DOWN METHOD TO ALLOCATE THE COSTS USING APPLICABLE STATISTICS. FOR EXAMPLE: PLANT EXPENSES ARE ALLOCATED DOWN TO THE OTHER DEPARTMENTS USING CURRENT SQUARE FOOTAGE SO DEPARTMENTS WITH MORE SQUARE FOOTAGE WILL BE ALLOCATED MORE PLANT EXPENSES; DIETARY EXPENSES ARE ALLOCATED BASED ON MEALS SERVED; EMPLOYEE BENEFITS ARE ALLOCATED BASED ON SALARIES; ADMINISTRATIVE AND GENERAL EXPENSES ARE ALLOCATED BASED ON ACCUMULATED COSTS; AND SO ON. ONCE ALL THE OVERHEAD EXPENSES ARE ALLOCATED TO THE REVENUE PRODUCING DEPARTMENTS THE COSTS ARE FURTHER ALLOCATED DOWN TO THE CHARGE CODE LEVEL. IN ORDER TO DO THIS WE USE 2 DIFFERENT METHODS DEPENDING ON THE DEPARTMENT. FOR SPECIFIC DEPARTMENTS WE USE A RVU (RELATIVE VALUE UNIT) ALLOCATION WHERE EACH PROCEDURE IS WEIGHTED BY THE INTENSITY OF THE SERVICE AND IS THEN ALLOCATED COST BASED ON THAT LEVEL OF INTENSITY. FOR EXAMPLE, AN XRAY WITH SEDATION IS MORE COMPLICATED AND TIME INTENSIVE THAN A SIMPLE CHEST XRAY SO IT WOULD HAVE A HIGHER RVU VALUE AND IN-TURN A HIGHER COST ALLOCATED TO IT. THE DEPARTMENTS USING THIS ALLOCATION METHOD ARE IMAGING, CARDIAC CATH, CT, MRI, ULTRASOUND, NUCLEAR MEDICINE, RADIATION ONCOLOGY, AND REHAB (PHYSICAL, OCCUPATIONAL AND SPEECH THERAPY). FOR THE OTHER DEPARTMENTS WE USE A RATIO OF COST TO CHARGE METHOD TO ALLOCATE THE COSTS DOWN TO THE CHARGE CODE LEVEL.AFTER ALL THE COSTS HAVE BEEN ALLOCATED TO THE CHARGE CODES, THE COSTING IS APPLIED TO ALL PATIENT ACCOUNTS BASED ON THEIR CHARGES TO DETERMINE THE COST OF THEIR ENCOUNTER AND THEN REPORTS CAN BE RUN TO DETERMINE THE PROFITABILITY OF CERTAIN PAYORS, SERVICE LINES OR DEPARTMENTS. FOR SCHEDULE H PART III, LINE 2, BAD DEBT DURING 2011 WAS MULTIPLIED BY THE RATIO COST TO CHARGES. TO DETERMINE THE AMOUNT TO REPORT ON LINE 3 (ESTIMATED BAD DEBTS THAT COULD BE ATTRIBUTED TO THE PATIENTS ELIGIBLE UNDER THE CHARITY CARE POLICY); WE DIVIDED TOTAL CHARITY CARE FOR 2011 BY TOTAL NET PATIENT REVENUE AND MULITPLIED THIS RESULTING PERCENTAGE (4.20%) BY BAD DEBT EXPENSE (AT COST). FAITH REGIONAL ACCOUNTS FOR DISCOUNTS OR PAYMENTS ON PATIENT ACCOUNTS PREVIOUSLY DETERMINED AS BAD DEBT BY CREDITING THE BAD DEBT EXPENSE ACCOUNT. PART III, LINE 8: FAITH REGIONAL USES A COST ACCOUNTING SYSTEM TO DETERMINE COSTS TO BE REPORTED IN SCHEDULE H. THE MEDICARE COSTS WERE DETERMINED BY RUNNING A REPORT SHOWING ALL MEDICARE ACCOUNTS DURING 2011 AND REPORTING ALL PAYMENTS RECEVIED ON LINE 5 AND THE TOTAL COSTS (DIRECT AND INDIRECT) ASSOCIATED WITH THOSE ACCOUNTS ON LINE 6. PART III, LINE 9B: THROUGHOUT THE COLLECTION PROCESS EACH ACCOUNT IS ALSO CONSIDERED FOR FINANCIAL ASSISTANCE FOR THOSE GUARANTORS THAT ARE FINANCIALLY UNABLE TO PAY OR EXPRESS INABILITY TO PAY. ALL CORRESPONDENCE, INCLUDING STATEMENTS AND COLLECTION LETTERS INCLUDE A STATEMENT THAT "FINANCIAL ASSISTANCE MAY BE AVAILABLE." ACCOUNTS THAT ARE NOT SUCCESSFULLY RESOLVED ARE CONSIDERED FOR REFERRAL TO OUTSIDE COLLECTION AGENCIES. THE PATIENT ACCOUNTS' STAFF MEMBER WILL REVIEW THE ACCOUNT TO INSURE ALL PROCESSES ARE COMPLETE, AND THEN FLAG THE ACCOUNT TO BE SENT TO OUTSIDE COLLECTION AGENCIES. THE COLLECTION AGENCIES WE UTILIZE ALSO HAVE COPIES OF OUR FINANCIAL ASSISTANCE POLICY AND APPLICATION IF THE NEED ARISES. FAITH REGIONAL HEALTH SERVICES - WEST PART V, SECTION B, LINE 11H: OTHER BASIS FOR CALCULATING AMOUNTS CHARGED TO PATIENTS INCLUDE FEDERAL POVERTY GUIDELINES SCALE AND APPLICATION. FAITH REGIONAL HEALTH SERVICES - EAST PART V, SECTION B, LINE 11H: OTHER BASIS FOR CALCULATING AMOUNTS CHARGED TO PATIENTS INCLUDE FEDERAL POVERTY GUIDELINES SCALE AND APPLICATION. FAITH REGIONAL HEALTH SERVICES - WEST PART V, SECTION B, LINE 19D: USES FEDERAL POVERTY GUIDELINES TO DETERMINE MAXIMUM AMOUNTS. FAITH REGIONAL HEALTH SERVICES - EAST PART V, SECTION B, LINE 19D: USES FEDERAL POVERTY GUIDELINES TO DETERMINE MAXIMUM AMOUNTS. PART VI, LINE 2: FAITH REGIONAL DOES NOT COMPLETE A FORMAL NEEDS ASSESSMENT AT THIS TIME AS THE PUBLIC HEALTH DEPARTMENT HAS DONE SEVERAL IN THE PAST COUPLE OF YEARS AND FAITH HAS CHOSEN NOT TO DUPLICATE THE WORK AS THE HEALTH DEPARTMENT DOES A COMPLETE REPORT. IN ADDITION TO THE PUBLIC HEALTH DEPARTMENT'S ASSESSMENT, FAITH REGIONAL IS INTIMATELY INVOLVED IN THE ELKHORN ECONOMIC DEVELOPMENT ASSOCIATION, BOTH ON THE BOARD AND THROUGH FINANCIAL SUPPORT. THAT INVOLVMENT IS INTENDED TO FACILITATE COMMUNITY GROWTH, JOB DEVELOPMENT, INFRASTRUCTURE DEVELOPMENT AND BUSINESS EDUCATION/TRAINING. FAITH REGIONAL IS ALSO A MEMBER OF THE NORFOLK CHAMBER OF COMMERCE WHICH IS INVOLVED IN BUSINESS RETAIL DEVELOPMENT AND SUPPORT AS WELL AS THE COMMUNITY IMPROVEMENT PROJECTS. FAITH ALSO WORKS WITH ORGANIZATIONS LIKE THE ORPHAN GRAIN TRAIN IN PROVIDING MEDICINE AND MEDICAL EQUIPMENT/SUPPLIES TO OTHER NATIONS IN NEED. PART VI, LINE 3: PATIENTS RECEIVING CARE ARE GIVEN INFORMATION REGARDING FAITH REGIONAL'S FINANCIAL ASSISTANCE PROGRAM THROUGH THE USE OF BROCHURES HANDED OUT BY REGISTRATION, HOSPITAL SOCIAL SERVICES, M.A.S.H. (MEDICAL ADVOCACY SERVICES FOR HEALTHCARE) PERSONNEL, AND BY PATIENT ACCOUNTS STAFF. ANY PATIENT OR FAMILY MEMBER THAT EXPRESSES CONCERN REGARDING ABILITY TO PAY FOR SERVICES WILL BE DIRECTED TO A SOCIAL WORKER, REGISTRATION CLERK, CASHIER, OR FINANCIAL SERVICES REPRESENTATIVE WHO WILL THEN GIVE THEM AN APPLICATION FOR PATIENT FINANCIAL ASSISTANCE ALONG WITH A BROCHURE EXPLAINING HOW TO COMPLETE THE APPLICATION. THE APPLICATION WILL NEED TO BE SUBMITTED ALONG WITH PROOF OF THEIR GROSS INCOME FOR THE PRECEDING THREE MONTHS. THIS CAN BE ACCOMPLISHED BY PROVIDING CHECK STUBS FOR THE PRECEDING THREE MONTHS, PROVIDING THE MOST RECENTLY FILED TAX RETURN, PROVIDING A PROFIT AND LOSS STATEMENT IF SELF-EMPLOYED, OR BY PRESENTING A STATEMENT FROM THEIR EMPLOYER (ON COMPANY LETTERHEAD) INDICATING GROSS INCOME FOR EACH OF THE PREVIOUS THREE MONTHS. MEDICARE PATIENTS MAY SHOW THEIR ORIGINAL DETERMINATION AMOUNT, A PHOTOCOPY OF A MONTHLY CHECK, OR A COPY OF THEIR BANK STATEMENT.THE FINANCIAL SERVICES REPRESENTATIVE WILL THEN MULTIPLY THE GROSS INCOME FOR THE THREE MONTHS BY FOUR TO GET AN ANNUAL GROSS INCOME. THE FINANCIAL SERVICE REPRESENTATIVE WILL ALSO REVIEW THE PATIENT'S ASSETS TO SEE IF THERE IS SUFFICIENT EQUITY TO HELP PAY FOR HEALTH SERVICES. THE EQUITY OF ASSETS WILL BE DETERMINED AS FOLLOWS: REAL ESTATE - WE WILL EXCLUDE THE PRIMARY RESIDENCE ALONG WITH UP TO 1 ACRE OF LAND THAT THE RESIDENCE IS ON; WE WILL INCLUDE RENTAL PROPERTIES, ALL HOMES OR REAL PROPERTY ABOVE AND BEYOND THE PRIMARY RESIDENCE, CABINS, RECREATIONAL PROPERTY, ETC., AS WELL AS REAL ESTATE OWNED FOR BUSINESS PURPOSES.PERSONAL PROPERTY - WE WILL EXCLUDE ONE VEHICLE PER WAGE EARNER (OR SOCIAL SECURITY OR DISABILITY RECIPIENT); WE WILL CONSIDER THE EQUITY IN MOTOR VEHICLES (MOTORCYCLES, MOTOR HOMES, BOATS, BOAT TRAILERS, AND ATVS).OTHER PERSONAL PROPERTY WILL INCLUDE STOCKS, BONDS, CDS, FUTURES, ANTIQUE COLLECTIBLES, AND ANY OTHER COLLECTIONS OF VALUE.THE HOUSEHOLD SIZE WILL BE DETERMINED USING THE FEDERAL HOUSEHOLD DEFINITIONS.IF THERE IS AN OMISSION OF INFORMATION ON THE APPLICATIONS OR INFORMATION PROVIDED APPEARS TO BE INCORRECT, A LETTER WILL BE SENT TO THE PATIENT REQUESTING THE MISSING INFORMATION OR REQUESTING CLARIFICATION OF THE INFORMATION. THE DATE THAT THE LETTER IS SENT WILL BE DOCUMENTED ON A LOG OF PENDING APPLICATIONS. IF THE REQUESTED DOCUMENTATION IS NOT RETURNED IN NINE WORKING DAYS, THE APPLICATION WILL BE DENIED.THE TEAM LEADER FOR THE PATIENT FINANCIAL SERVICES REPRESENTATIVES WILL REVIEW THE APPLICATION AND ASSETS AND MAKE A DETERMINIATION WITHIN 10 DAYS OF THE RECEIPT OF A COMPLETE APPLICATION. THE TEAM LEADER WILL THEN NOTIFY (BY LETTER) THE PATIENT INDICATING THAT THE APPLCIATION HAS BEEN APPROVED OR DENIED. IF THE APPLICATION IS DENIED THE PATIENT MAY APPLY AGAIN IF THEIR FINANCIAL CIRCUMSTANCES CHANGE FOR SERVICES NOT PREVIOUSLY IN COLLECTIONS AND NO FURTHER BACK THAN SIX MONTHS FROM THE DATE OF APPLICATION. PART VI, LINE 4: FAITH REGIONAL'S PRIMARY SERVICE AREA CONSISTS OF ANTELOPE, HOLT, KNOX, MADISON, PIERCE, PLATTE, STANTON AND WAYNE COUNTIES IN NEBRASKA REPRESENTING A POPULATION OF APPROXIMATELY 116,000 PEOPLE. THE HOSPITAL'S SECONDARY SERVICE AREA CONSISTS OF BOONE, CEDAR, COLFAX, CUMING AND DIXON COUNTIES IN NEBRASKA REPRESENTING APPROXIMATELY 40,000 PEOPLE. FAITH REGIONAL ALSO HAS A TERTIARY SERVICE AREA OF CHERRY, BROWN, KEYA PAHA, ROCK, BOYD, GARFIELD, WHEELER, GREELEY, NANCE, DAKOTA, THURSTON AND BURT COUNTIES IN NEBRASKA WITH APPROXIMATELY A POPULATION OF 57,400.FOR THE YEAR ENDED DECEMBER 31, 2011, 91% OF FAITH REGIONAL'S DISCHARGES WERE FROM PATIENTS RESIDING IN THE PRIMARY SERVICE AREA; 5% FROM THE SECONDARY; AND 1% FROM THE TERTIARY SERVICE AREAS. THE REMAINING 3% OF DISCHARGES WERE FROM PATIENTS RESIDING OUTSIDE OF THE DEFINED SERVICE AREA.DEMOGRAPHIC SURVEY (SOURCE: US CENSUS BUREAU 2010 CENSUS)MADISON COUNTY:TOTAL POPULATION: 34,876AVERAGE INCOME: $42,911"PERCENT OF INDIVIDUALS BELOW POVERTY LEVEL": 12%BREAKOUT OF POPULATION BY AGE:AGE POPULATION % OF TOTALLESS THAN 19 9,911 28.4%20 - 24 2,458 7.1%25 - 44 8,037 23.0%45 - 64 9,346 26.8%65+ 5,124 14.7%TOTAL 34,876 100.0%BREAKOUT OF POPULATION BY RACE:RACE POPULATION % OF TOTALWHITE 30,752 88.2%BLACK/AFRICAN AMERICAN 444 1.3%AMERICAN INDIAN 401 1.1%ASIAN/PACIFIC ISLANDER 183 0.5%OTHER 3,096 8.9%TOTAL 34,876 100.0% PART VI, LINE 5: FAITH REGIONAL, A NOT-FOR-PROFIT HEALTH CARE FACILITY, LOCATED IN NORTHEAST NEBRASKA, OPERATES FOR THE BENEFIT OF THE INDIVIDUALS IN THE SERVICE AREA. FAITH REGIONAL SERVES ALL PATIENTS REGARDLESS OF THEIR ABILITY TO PAY AND DOES NOT LIMIT ITS SERVICES OR DISCRIMINATE AGAINST ANYONE ON THE BASIS OF RACE, COLOR, SEX, NATIONAL ORIGIN, SEXUAL ORIENTATION, RELIGION, AGE, DISABILITY, DISEASE, OR DIAGNOSIS. FAITH REGIONAL ALSO PROVIDES COMMUNICATIONS SERVICES (E.G. BILINGUAL STAFF AND INTERPRETERS, SIGN LANGUAGE INTERPRETERS, TDD SERVICES, ETC) FOR SENSORY IMPAIRED INDIVIDUALS. FAITH REGIONAL EVALUATES ITSELF ON ITS EFFECTIVENESS ANNUALLY BY EXAMINING ITS ABILITY TO FULFILL ITS MISSION, ACCOMPLISH ITS VISION, PROVIDE SERVICE, AND MAINTAIN ITS VALUES. FAITH REGIONAL'S MISSION, VISION, SERVICE, AND VALUES ARE: THE MISSION: THE MISSION IS TO SERVE CHRIST BY PROVIDING ALL PEOPLE WITH EXEMPLARY MEDICAL SERVICES IN AN ENVIRONMENT OF LOVE AND CARE.THE VISION: THE VISION OF FAITH REGIONAL HEALTH SERVICES IS TO BECOME A REGIONAL REFERRAL CENTER BY PROVIDING THE MOST COMPREHENSIVE, HIGH QUALITY HEALTH SERVICES TO THE RESIDENTS OF NORTHEAST NEBRASKA. THE VALUES:SPIRITUALITYEXCELLENCEINTEGRITYCOMPASSIONRESPECTSTEWARDSHIPFAITH REGIONAL'S PROGRAM SERVICE ACCOMPLISHMENTS ARE BASED ON THE COMMUNITY ACCOUNTABILITY STANDARDS DEVELOPED BY THE VOLUNTARY HOSPITALS OF AMERICA (VHA). THESE FOUR STANDARDS ARE:1) DEMONSTRATE LEADERSHIP AS A CHARITABLE INSTITUTION . "ORGANIZATIONS SHOULD ACTIVELY PURSUE AN UNDERSTANDING OF THEIR COMMUNITIES' NEEDS AND FULFILL THEM TO THE BEST OF THEIR ABILITY. THIS INCLUDES REACHING OUT WITH PREVENTATIVE AND OTHER HEALTHCARE, PARTICIPATING IN MEDICARE, MEDICAID AND OTHER REIMBURSEMENT PROGRAMS FOR THE NEEDY, AND SOLICITING AND DONATING FUNDS TO HELP THOSE IN NEED."2) PROVIDING ESSENTIAL HEALTH CARE SERVICES - "ORGANIZATIONS SHOULD ASSESS THEIR COMMUNITIES' HEALTH NEEDS AND WORK TO MEET THEM AS NECESSARY, INCLUDING COOPERATING WITH OTHER COMMUNITY HEALTH CARE PROVIDERS TO PROVIDE THE BEST CARE POSSIBLE AND OFFERING 24-HOUR EMERGENCY SERVICES."3) BEING ACCOUNTABLE TO THE COMMUNITY. "ORGANIZATIONS SHOULD WORK WITH A VOLUNTEER GOVERNING BOARD THAT IS REPRESENTATIVE OF THE COMMUNITY. ORGANIZATIONS ARE ALSO ENCOURAGED TO VOLUNTARILY DISCLOSE INFORMATION ABOUT FINANCIAL STATUS, COMMUNITIY BENEFIT ACTIVITIES, SERVICES AND CHARITY CARE, AND TO ADVOCATE HEALTH CARE COST CONTAINMENT AND OTHER ISSUES AS APPROPRIATE."4) MAINTAING EVIDENCE OF COMMITMENT TO COMMUNITY BENEFIT. "ORGANIZATIONS SHOULD EMBRACE A MISSION STATEMENT AND BYLAWS REFLECTING A COMMITMENT TO THE GOOD OF THE COMMUNITY AND SHOULD ACT AS LEADERS IN ORGANIZING COMMUNITY BENEFIT ACTIVITIES, BASED ON COMMUNITY NEEDS, SHOULD BE PART OF A STRATEGIC PLAN, AND EMPLOYEES AND MEDICAL STAFF SHOULD BE EDUCATED AND INVOLVED IN THESE ACTIVITIES."FAITH REGIONAL REGOGNIZES ITS OBLIGATION TO DEMONSTRATE LEADERSHIP AS A CHARITABLE ORGANIZATION BY PROVIDING A FULL RANGE OF HEALTH CARE, HEALTH EDUCATION AND WELLNESS RELATED SERVICES TO THE COMMUNITY, AND PARTICIPATING IN FEDERAL, STATE AND LOCAL PROGRAMS TO PROVIDE HEALTH BENEFITS TO THOSE IN NEED.DURING 2011, FAITH REGIONAL PARTICIPATED IN A VARIETY OF PROGRAMS INTENDED TO BENEFIT THE ELDERLY AND NEEDY POPULATIONS WITHIN, AND THOSE INDIVIDUALS ENTERING, ITS SERVICE AREA. THESE INCLUDE MEDICARE, MEDICAID, CHAMPUS, WORKERS COMPENSATION, AND OTHER DISCOUNTED HEALTH INSURANCE PROGRAMS. FAITH IS ALSO A PARTICIPATING PROVIDER WITH SEVERAL COMMERCIAL INSURANCE COMPANIES PROVIDING MANAGED CARE TO EMPLOYERS IN OUR COMMUNITIES. THIS PARTICIPATION PROVIDES INDIVIDUALS WITH ACCESS TO A LOCAL HEALTH CARE PROVIDER. IN ADDITION, FAITH PROVIDES CHARITY CARE FOR THOSE INDIVIDUALS, WHEN IDENTIFIED, WHO ARE FOUND TO BE UNABLE TO PAY FOR SERVICES RENDERED. BECAUSE OF ITS PARTICIPATATION IN VARIOUS HEALTH INSURANCE AND CHARITY PROGRAMS, FAITH REGIONAL ACCEPTS CONTRACTUALLY DISCOUNTED PAYMENTS AS PAYMENT IN FULL. THIS DISCOUNTED PAYMENT VARIES WITH THE TYPE OF THIRD PARTY PAYOR. THESE AMOUNTS, CONTRACTUAL ADJUSTMENTS, ARE DISCOUNTED FROM NORMAL CHARGES. IN ADDITION TO PROVIDING UNCOMPENSATED MEDICAL CARE, DURING 2011, FAITH REGIONAL ALSO PROVIDED CASH AND IN-KIND CONTRIBUTIONS TO VARIOUS COMMUNITY ORGANIZATIONS TO FURTHER THE MISSION OF THOSE ORGANIZATIONS AND IMPROVE OVERALL AWARENESS OF HEALTHCARE RELATED ISSUES IN OUR COMMUNITIES. ORGANIZATIONS RECEIVING CASH OR IN-KIND CONTRIBUTIONS FROM FAITH INCLUDE:THE AMERICAN RED CROSS, AMERICAN HEART ASSOCIATION, CITY OF NORFOLK, BIRTHRIGHT OF NORFOLK, PLANNED APPROACH TO COMMUNITY HEALTH (PATCH), AND NORFOLK AREA CHAMBER OF COMMERCE. ALSO DURING 2011, FAITH CONTRIBUTED FINANCIAL SUPPORT FOR A NEW 4-YEAR NURSING SCHOOL IN NORFOLK, NE THROUGH COLLABORATION BETWEEN NORTHEAST COMMUNITY COLLEGE AND THE UNIVERSITY OF NEBRASKA.FAITH REGIONAL ALSO FINANCIALLY SUPPORTS THE NORFOLK COMMUNITY "FREE CLINIC" THROUGH PHYSICIAN RECRUITMENT AND CLINIC SPACE DONATION. FAITH REGIONAL PROVIDES TRANSPORTATION SERVICES PRIMARILY TO RADIATION ONCOLOGY AND RENAL DIALYSIS PATIENTS AT NO CHARGE.FAITH REGIONAL REMAINS ACCOUNTABLE TO THE COMMUNITY BY WORKING WITH A VOLUNTEER GOVERNING BOARD THAT IS REPRESENTATIVE OF THE COMMUNITY IT SERVES. COOPERATION WITH COMMUNITY BASED HEALTH ORGANIZATIONS IDENTIFY PERTINENT ISSUES RELATED TO ESSENTIAL SERVICES, CHARITY CARE, HEALTH CARE COST CONTAINMENT, COMMUNITY BENEFIT ACTIVITIES AND OTHERS AS APPROPRIATE. FAITH REGIONAL CONTINUES TO OPERATE UNDER A VOLUNTEER GOVERNING BOARD AND REMAINS ACTIVELY INVOLVED IN ADVOCATING PUBLIC AWARENESS OF HEALTH CARE AND HEALTH CARE POLICY ISSUES. DISCLOSURES OF FINANCIAL INFORMATION, COMMUNITY BENEFIT INFORMATION AND ADVOCACY ISSUES IS PROVIDED THROUGH A VARIETY OF MEDIA INCLUDING AN ANNUAL REPORT TO THE COMMUNITY, MEDIA RELEASES, AND ITS INTERNET WEBSITE: WWW.FRHS.ORGFAITH REGIONAL'S CONTRIBUTION TO THE COMMUNITY NOT ONLY INCLUDES COMPENSATED AND DONATED TIME BUT ALSO EQUIPMENT, MATERIALS AND SPACE. MEETING ROOMS ARE PROVIDED AS NEEDED AND EQUIPMENT AND MATERIALS (E.G. COMPUTERS, COPIER,FAXES, TELEPHONES, CHILDBIRTH PROPS, PROJECTORS, MANNEQUINS, HEARING BOOTH, AUDIOMETERS, BEDS, MONITORS, WARMING UNITS, MINOR INSTRUMENTS, ETC) ARE PROVIDED AT NO CHARGE. A MAJOR CONCERN IN HEALTH CARE THAT CAN SOMETIMES BE "HIDDEN" IS THAT OF SEXUAL ABUSE AND NEGLECT IN CHILDREN. THE NORTHEAST NEBRASKA CHILD ADVOCACY PROGRAM AT FAITH REGIONAL PROVIDES A SAFE, NON THREATENING ENVIRONMENT WHERE CHILDREN (AGES INFANT TO 18) WHO ARE VICTIMS OF ABUSE RECEIVE IMMEDIATE MEDICAL CARE AND FORENSIC INTERVIEWS FROM VARIOUS AGENCIES WORKING TOGETHER. ALL OF THESE SERVICES ARE AVAILABLE FREE TO FAMILIES WITHIN A 24-COUNTY AREA. PART VI, LINE 6: N/A PART VI, LINE 7: N/A 1 THE AMERICAN RED CROSS 3838 DEWEY AVENUE OMAHA NE 68105 530196605 501(C)(3) 17232 FMV IN-KIND RENT DEFRAY OPERATING COSTS NORTHEAST NEBRASKA AREA HEALTH EDUCATION CENTER (AHEC) 110 NORTH 16TH STREET SUITE 2 NORFOLK NE 68701 223867376 501(C)(3) 25908 FMV IN-KIND RENT DEFRAY OPERATING COSTS NORFOLK COMMUNITY HEALTHCARE CLINIC INC 110 NORTH 16TH STREET SUITE 16 NORFOLK NE 68701 470833378 501(C)(3) 38856 FMV IN-KIND RENT DEFRAY OPERATING COSTS UNIVERSITY OF NE - UNMC COLLEGE OF NURSING 3838 HOLDREGE STREET LINCOLN NE 68503 470049123 501(C)(3) 250000 HELP FUND NEW NURSING COLLEGE LOCATION IN NORFOLK, NE AMERICAN HEART ASSOCIATION 460 N LINDBERGH BLVD ST LOUIS MO 63141 135613797 501(C)(3) 10500 GO RED FOR WOMEN EVENT NORFOLK CHAMBER OF COMMERCE 609 W NORFOLK AVE NORFOLK NE 68701 271441871 5000 CHAMBER BUIDLING FUND 5 1 PROCEDURE FOR MONITORING GRANTS IN THE U.S.: PART I, LINE 2: SCHEDULE I, PART I, LINE 2: IN-KIND DONATIONS OF RENT ARE MADE TO 501(C)(3) ORGANIZATIONS. THESE DONATIONS HELP THE DONEE ORGANIZATIONS MINIMIZE CASH NEEDED FOR OPERATING COSTS AND ALLOW THE ORGANIZATIONS TO USE THEIR AVAILABLE FUNDS IN FURTHERANCE OF THEIR MISSIONS. CASH DONATIONS ARE ALSO MADE TO 501(C)(3) ORGANIZATIONS, MANY OF WHICH HAVE HEALTH CARE OR SOCIAL SERVICES MISSIONS. THESE DONATIONS ARE SOMETIME RESTRICTED FOR A SPECIFIC USE OR ACTIVITY. 501(C)(3) ORGANIZATIONS ARE BOUND BY THEIR ARTICLES OF ORGANIZATION AND STATED MISSIONS TO CONDUCTING ACTIVITIES STRICTLY FOR CHARITABLE PURPOSES. FAITH REGIONAL DOES NOT REQUEST GRANT REPORTS FROM DONEE CHARITABLE ORGANIZATIONS. X X X X 1 1 X X X X X 0 0 0 0 0 0 0 0 0 JAMES J SINEK 457978 0 0 0 18522 0 7350 0 19890 0 503740 0 0 0 DOUGLAS WISMER 166600 0 0 0 13791 0 6701 0 8026 0 195118 0 0 0 H MICHAEL HAMMOND 131451 0 0 0 18020 0 6893 0 17301 0 173665 0 0 0 JANET PINKELMAN 143382 0 0 0 8517 0 7285 0 3560 0 162744 0 0 0 PATRICK ROCHE 166648 0 0 0 20357 0 8577 0 16680 0 212262 0 0 0 BARRY SPEAR 161231 0 0 0 10782 0 4875 0 7187 0 184075 0 0 0 JOSEPH MCCLAIN MD 712002 0 0 0 40159 0 7350 0 15888 0 775399 0 0 0 DOUGLAS WELSH MD 625531 0 0 0 42774 0 9800 0 17016 0 695121 0 0 0 MOHAMMAD IMRAN MD 556265 0 0 0 39319 0 7350 0 17332 0 620266 0 0 0 CHRISTOPHER PRICE MD 512361 0 0 0 41045 0 9800 0 17244 0 580450 0 0 0 HAKAM ASAAD MD 508331 0 0 0 30932 0 0 0 16990 0 556253 0 0 0 PART I, LINE 1A JAMES J. SINEK'S YMCA MEMBERSHIP AND COUNTRY CLUB DUES ARE PAID BY FAITH REGIONAL. THE AMOUNTS PAID FOR THESE ITEMS ARE ADDED TO MR. SINEK'S W-2 AS WAGES. BARRY SPEAR'S YMCA MEMBERSHIP AND COUNTRY CLUB DUES ARE PAID BY FAITH REGIONAL HEALTH SERVICES. THE AMOUNT PAID FOR THIS ITEM IS ADDED TO MR. SPEAR'S W-2 AS WAGES. KELLY DRISCOLL'S HOUSING ALLOWANCE IS PAID BY FAITH REGIONAL HEALTH SERVICES. THE AMOUNT PAID FOR THIS ITEM IS ADDED TO MS. DRISCOLL'S W-2 AS WAGES. HOSPITAL AUTHORITY #1 OF MADISON COUNTY NEBRASKA 521357975 557463DR9 2008-07-10 65501382 FUND NEW BED TOWER AND REIMBURSE PRIOR CAPITAL, REFUND PRIOR ISSUES 0 0 0 HOSPITAL AUTHORITY #1 OF MADISON COUNTY NEBRASKA 521357975 557352EF4 2008-11-20 15000000 CONSTRUCTION OF TOWER 0 0 0 7840000 67165524 5752316 113793 9935269 38580806 12783340 2010 1 1 1 1 15039468 22833 15016635 2010 0 0 1 1 0 0 1 1 0 0.00000 0.00000 0.00000 0 0 0 1 1 0 0.00000 0.00000 0.00000 0 0 0 0 0 0 1 0 1 0 0 0 1 SCHEDULE K SUPPLENTAL INFORMATION SCHEDULE K, PART II, LINE 3: THE TOTAL PROCEEDS DO NOT AGREE TO THE ISSUE PRICE IN PART I, COLUMN (E) DUE TO INVESTMENT EARNINGS. PART III, LINE 7: DURING THE APPLICABLE TAX YEAR, THE ORGANIZATION CONSIDERED ITS TAX-EXEMPT BOND TRANSCRIPTS AND RELATED DOCUMENTATION AS ITS PRACTICES AND PROCEDURES FOR POST-ISSUANCE COMPLIANCE. AS OF THE DATE OF FILING, THE ORGANIZATION IS ACTIVELY PROCEEDING TOWARD THE ADOPTION OF A FORMAL POLICY AND PROCEDURES TO ADDRESS POST-ISSUANCE COMPLIANCE OF ITS TAX-EXEMPT BOND LIABILITIES. PART V: DURING THE APPLICABLE TAX YEAR, THE ORGANIZATION CONSIDERED ITS TAX-EXEMPT BOND TRANSCRIPTS AND RELATED DOCUMENTATION AS ITS PRACTICES AND PROCEDURES FOR POST-ISSUANCE COMPLIANCE, INCLUDING IDENTIFICATION AND CORRECTION OF OF VIOLATIONS. AS OF THE DATE OF FILING, THE ORGANIZATION IS ACTIVELY PROCEEDING TOWARD THE ADOPTION OF A FORMAL POLICY AND PROCEDURES TO ADDRESS POST-ISSUANCE COMPLIANCE OF ITS TAX-EXEMPT BOND LIABILITIES AND THE TIMELY IDENTIFICATION AND CORRECTION OF VIOLATIONS. PAMELA PILE PAMELA'S BROTHER IS JOHN DINKEL, BOARD MEMBER. 43959 PAMELA IS AN EMPLOYEE OF FAITH REGIONAL HEALTH SERVICES. 0 LORI KNAPP LORI'S BROTHER-IN-LAW IS SCOTT MILLER, A BOARD MEMBER. 40663 LORI IS AN EMPLOYEE OF FAITH REGIONAL HEALTH SERVICES. 0 DANIELLE FREUDENBURG DANIELLE'S BROTHER-IN-LAW IS SCOTT MILLER, A BOARD MEMBER. 39633 DANIELLE IS AN EMPLOYEE OF FAITH REGIONAL HEALTH SERVICES. 0 PATHOLOGY MEDICAL SERVICES PC DR. LACY SERVES AS A DIRECTOR, AND HE IS A SHAREHOLDER OF THE COMPANY 119308 PATHOLOGY MEDICAL SERVICES PC PROVIDES SERVICES TO FAITH REGIONAL HEALTH SERVICES. 0 FORM 990, PART VI, SECTION A, LINE 2 JOHN DINKEL AND MARY KAY UHING HAVE A FAMILY RELATIONSHIP. FORM 990, PART VI, SECTION A, LINE 6 FAITH REGIONAL HAS ONE NONPROFIT 501(C)(3) CORPORATE MEMBER, LUTHERAN COMMUNITY HOSPITAL ASSOCIATION. FORM 990, PART VI, SECTION A, LINE 7A PURSUANT TO FAITH REGIONAL'S 2008 RESTATED BYLAWS, THE SOLE CORPORATE MEMBER, LUTHERAN COMMUNITY HOSPITAL ASSOCIATION, APPOINTS 14 OF THE 15 VOTING MEMBERS OF THE BOARD OF DIRECTORS OF FAITH REGIONAL HEALTH SERVICES. FORM 990, PART VI, SECTION A, LINE 7B FAITH REGIONAL'S RESTATED BYLAWS RESERVE CERTAIN POWERS TO ITS SOLE MEMBER, LUTHERAN COMMUNITY HOSPITAL ASSOCIATION. THERE ARE 13 RESERVED POWERS, INCLUDING APPOINTMENT AND REMOVAL OF DIRECTORS, OTHER THAN CHIEF OF STAFF, AMENDMENT OF THE ARTICLES OF INCORPORATION AND BYLAWS, AMENDMENT OF THE MISSION, VISION AND VALUE STATEMENTS, AMONG OTHERS. FORM 990, PART VI, SECTION B, LINE 11 THE FORM 990 AND ALL APPLICABLE SCHEDULES ARE COMPLETED IN-HOUSE BY THE REIMBURSEMENT ACCOUNTANT AND REVIEWED BY THE CFO. ONCE THE FORMS ARE COMPLETED THEY ARE REVIEWED AND SIGNED BY SEIM JOHNSON, LLP IN OMAHA, NE. POST-AUDIT REVIEW, FORM 990 AND SCHEDULES ARE MAILED TO EACH BOARD MEMBER. FORM 990 IS REVIEWED AND DISCUSSED AT THE SCHEDULED BOARD MEETING PRIOR TO SUBMISSION TO IRS. FORM 990, PART VI, SECTION B, LINE 12C FAITH REGIONAL'S BOARD MEMBERS ARE REQUIRED TO SIGN A NEW CONFLICT OF INTEREST STATEMENT AND DISCLOSURE ANNUALLY. ANY CONFLICTS ARE REVIEWED BY THE BOARD. A MEMBER WITH A CONFLICT IS EXCUSED FROM THE BOARD DELIBERATIONS AND ACTION. FORM 990, PART VI, SECTION B, LINE 15 DETERMINATION OF COMPENSATION FOR THE CEO AND OTHER OFFICERS AND KEY EMPLOYEES IS MADE BY GATHERING DATA FROM EXTERNAL SURVEYS AND THE FORM 990 DATA PROVIDED BY COMPARABLE FACILITIES. FACILITIES USED ARE DETERMINED BY SIMILAR BED SIZE, NET REVENUES AND NUMBER OF FTES. WAGES ARE GATHERED AND COMPARED BY TITLE, RESPONSIBILITIES, AND YEARS OF EXPERIENCE. THE SALARY RECOMMENDATIONS ARE MADE BY THE HUMAN RESOURCE DEPARTMENT. THE GOVERNING BOARD APPROVES THE SALARY RECOMMENDATIONS FOR THE CEO; THE CEO APPROVES THE RECOMMENDATIONS FOR THE OTHER OFFICERS AND VICE-PRESIDENTS; AND THE VICE-PRESIDENTS APPROVE THE RECOMMENDATIONS FOR THE "DIRECTORS" OF VARIOUS HOSPITAL DEPARTMENTS. FORM 990, PART VI, SECTION C, LINE 19 FAITH REGIONAL DOES NOT MAKE ITS GOVERNING DOCUMENTS, CONFLICT OF INTEREST POLICY OR FINANCIAL STATEMENTS AVAILABLE TO THE PUBLIC. FORM 990, PART VII, SECTION A, LINE 1A: JAMES SINEK, CEO, DEVOTES AN AVERAGE OF 1.00 HOUR PER WEEK TO FAITH REGIONAL HEALTH SERVICES FOUNDATION, A RELATED ORGANIZATION. DOUGLAS WISMER, CFO, DEVOTES AN AVERAGE OF 1.00 HOUR PER WEEK TO FAITH REGIONAL HEALTH SERVICES FOUNDATION, A RELATED ORGANIZATION. BARRY SPEAR, VP GROWTH & DEVELOPMENT, DEVOTED AN AVERAGE OF 16.00 HOURS PER WEEK TO FAITH REGIONAL HEALTH SERVICES FOUNDATION, A RELATED ORGANIZATION. DONNA HERRICK, FAITH REGIONAL BOARD REPRESENTATIVE, DEVOTES AN AVERAGE OF 1.00 HOUR PER WEEK TO FAITH REGIONAL HEALTH SERVICES FOUNDATION, A RELATED ORGANIZATION. CHANGES IN NET ASSETS OR FUND BALANCES: FORM 990, PART XI, LINE 5: NET UNREALIZED LOSSES ON INVESTMENTS: -41,581. FORM 990, PART XII, LINE 2C: THE FINANCE/AUDIT COMMITTEE MEETS MONTHLY TO REVIEW OUR UNAUDITED FINANCIAL STATEMENTS. IN NOVEMBER OF EACH YEAR THEY MEET TO APPROVE OUR ANNUAL BUDGET AND FIVE-YEAR STRATEGIC FINANCIAL PLAN. IN DECEMBER THEY WILL REVIEW AND APPROVE THE ENGAGEMENT LETTER PREPARED BY OUR EXTERNAL AUDITORS, SEIM JOHNSON, LLP, WHICH OUTLINES THE SCOPE OF THEIR AUDIT AND THEIR FEES AND EXPENSES. AT THE CLOSE OF THE AUDIT THEY MEET WITH THE FAITH REGIONAL EXECUTIVE TEAM AND SEIM JOHNSON, LLP REPRESENTATIVES TO DISCUSS ANY AUDIT ISSUES. IN MID TO LATE MARCH THEY THEN MEET AGAIN WITH SEIM JOHNSON, LLP REPRESENTATIVES TO DISCUSS THE DRAFT AND FINAL AUDITED FINANCIAL STATEMENTS INCLUDING THEIR OPINION. REGARDING THE SELECTION OF AN EXTERNAL AUDITOR, THE COMMITTEE HAS IN THE PAST SELECTED UP TO THREE REGIONAL CPA FIRMS SPECIALIZING IN HEALTHCARE AUDITS TO SEND RFPS TO AND THEN REVIEW THE RFPS AT A LATER DATE. THE LAST TIME THIS WAS DONE THEY REAFFIRMED THE RETENTION OF SEIM JOHNSON, LLP AS THE EXTERNAL AUDITOR. EACH FIVE YEARS, ALTHOUGH NOT REQUIRED BY THE SARBANES-OXLEY LEGISLATION, SEIM JOHNSON, LLP ROTATES ONE OF THEIR PARTNERS TO THE FAITH REGIONAL ENGAGEMENT. THIS PROCESS HAS NOT CHANGED FROM THE PRIOR YEAR. FAITH REGIONAL PHYSICIAN SERVICES LLC 2700 WEST NORFOLK AVENUE NORFOLK NE 68701 421629846 PHYSICIAN SERVICES NE 13496754 4238559 FAITH REGIONAL HEALTH SERVICES LUTHERAN COMMUNITY HOSPITAL ASSOCIATION 2700 W NORFOLK AVE NORFOLK NE 68701 470396139 SUPPORT FAITH REGIONAL HEALTH SERVICES NE 501(C)(3) 3 N/A 0 FAITH REGIONAL HEALTH SERVICES FOUNDATION 1500 KOENIGSTEIN AVE NORFOLK NE 68701 911772474 SUPPORT FAITH REGIONAL HEALTH SERVICES NE 501(C)(3) 11A FAITH REGIONAL HEALTH SERVICES 1 NORTHEAST NEBRASKA SURGERY CENTER 301 N 27TH STREET NORFOLK NE 68701 470819088 OUTPATIENT SURGERY NE FAITH REGIONAL HEALTH SERVICES RELATED 79271 1902576 0 0 0.94200 1 0 1 0 0 0 0 0 1 1 0 1 1 1 0 0 0 1 FAITH REGIONAL HEALTH SERVICES FOUNDATION C 1089050 FAIR MARKET VALUE NORTHEAST NEBRASKA SURGERY CENTER N 974185 FAIR MARKET VALUE NORTHEAST NEBRASKA SURGERY CENTER A 265069 FAIR MARKET VALUE NORTHEAST NEBRASKA SURGERY CENTER R 147253 FAIR MARKET VALUE