2012-05-14T12:02:56-05:00 2011-06-30 SEIM JOHNSON LLP 18081 BURT STREET SUITE 200 OMAHA NE 680224722 990 2010-07-01 470533373 COMMUNITY HOSPITAL ASSOCIATION OF MCCOOK COMM 3083442650 1301 EAST H STREET PO BOX 1328 MCCOOK NE 69001 TROY BRUNTZ 3083442650 2012-05-08 1 JULIE M GERKEN 4023302660 2010 2016-02-24 21:20:13Z TROY BRUNTZ 434 SEMINOLE DRIVE MCCOOK NE 69001 33656253 0 X WWW.CHMCCOOK.ORG X 1974 NE TO PROMOTE PUBLIC HEALTH 9 7 285 25 0 0 112505 154009 30859461 32450816 70023 77835 877596 872351 31919585 33555011 56080 51278 0 0 13029667 14230275 0 0 0 15686083 17673251 28771830 31954804 3147755 1600207 34009223 47715344 11073604 23179518 22935619 24535826 TO EXCEL AT PROVIDING FOR THE HEALTHCARE NEEDS OF OUR REGION THROUGH QUALITY, EFFICIENT AND PATIENT-CENTERED CARE. 0 0 26418634 51278 32874954 CRITICAL ACCESS ACUTE CARE HOSPITAL PROVIDING INPATIENT AND OUTPATIENT CARE, DIAGNOSTIC, REHABILITATION, SURGICAL, NURSERY, VISITING MEDICAL SPECIALISTS, HOME HEALTH AND HOSPICE, TWO RURAL HEALTH CLINICS, AND HEALTH AND EDUCATION PROGRAMS. 26418634 1 1 0 1 0 0 0 0 1 1 0 0 0 0 1 0 1 0 0 0 0 0 0 0 0 1 1 1 0 1 0 0 0 1 0 0 1 1 0 0 0 0 0 1 1 1 0 0 1 48 0 285 1 1 1 0 0 0 0 0 0 0 0 0 X 9 7 0 0 0 0 0 0 0 1 1 0 0 1 1 1 1 1 1 1 1 1 1 X TROY BRUNTZ 3083442650 1301 EAST H - PO BOX 1328 MCCOOK NE 69001 BRIAN ESCH 1.00 X X 0 0 0 JAMES O'DEA 1.00 X X 0 0 0 DORIS FRIEHE 1.00 X X 0 0 0 BRUCE BAIR 1.00 X X 0 0 0 MAX ABERCROMBIE 1.00 X 0 0 0 MARTY CONROY 1.00 X 0 0 0 MARK EILER 1.00 X 0 0 0 DAVE SMITH 1.00 X 0 0 0 CONNIE OLSON 1.00 X 0 0 0 JAMES ULRICH 40.00 X 180022 0 24682 TROY BRUNTZ 40.00 X 112621 0 27668 ANTHONY RODEWALD 40.00 X 131722 0 25670 CHASE CRAWFORD 40.00 X 117362 0 25245 JANET FIDLER 40.00 X 106713 0 24125 TERRY GOURLEY 40.00 X 111056 0 13529 TERESA HODGSON 40.00 X 101255 0 10001 860751 0 150920 9 0 1 0 MCCOOK CLINIC PC 1401 EAST H STREET MCCOOK NE 69001 MEDICAL PROFESSIONAL - PHYSICIANS 998675 SOUTHWEST NEBRASKA PHYSICAL THERAPY PC PO BOX 789 MCCOOK NE 69001 MEDICAL PROFESSIONAL - PHYSICIANS 784460 LAWRENCE FRIESTAD CRNA 901 WEST 7TH MCCOOK NE 69001 MEDICAL PROFESSIONAL - ANESTHESIA 255905 PATHOLOGY SERVICES BOX 1289 NORTH PLATTE NE 69103 MEDICAL PROFESSIONAL - PATHOLOGY 238051 WINTHROP RESOURCES CORPORATION PO BOX 650 HOPKINS MN 55343 RENTS - LEASE/FINANCIAL SERVICES 202820 8 143451 10558 154009 PATIENT SERVICE REVENU 621400 19044263 19044263 MEDICARE/MEDICAID PAYM 621400 13044378 13044378 RECOVERY OF ACCOUNTS 621400 362175 362175 32450816 141417 141417 346123 26360 319763 319763 319763 11300 74882 -63582 -63582 -63582 CAFETERIA/MEALS 900099 104666 104666 HOUSEKEEPING INCOME 900099 80826 80826 PURCHASE DISCOUNTS 621400 28724 28724 338372 314588 23784 552588 33555011 32874954 0 526048 51278 51278 344993 344993 10711456 8687896 2023560 710809 561194 149615 1608953 1311624 297329 854064 674296 179768 27071 27071 78552 78552 5443463 4484678 958785 262543 262543 5011684 4696458 315226 806300 704455 101845 35325 19638 15687 269715 157749 111966 503836 469460 34376 2765928 2577211 188717 156018 145373 10645 MISCELLANEOUS 1299960 864468 435492 PROVISION FOR BAD DEBTS 927986 927986 COLLECTION EXPENSE 84870 84870 31954804 26418634 5536170 0 1050 1385 6276648 7793287 3775575 4526320 632 678 69 1093991 1195440 431529 677999 53291816 21028463 21684687 32263353 159442 178001 585600 1078881 34009223 47715344 4320496 3864544 2697569 19314974 4055539 11073604 23179518 X 22935619 24535826 22935619 24535826 34009223 47715344 1600207 0 X X 0 1 1 X 0 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 0 0 0 0 0 0 1 0 1 2861 2861 0 EXPLANATION OF OTHER LOBBYING ACTIVITIES: PART II-B, LINE 1I: ITEM 1G - JAMES ULRICH, CEO AND PRESIDENT, TRAVELED TO WASHINGTON, D.C. TO PARTICIPATE IN "ADVOCACY DAY". MR. ULRICH MADE THIS TRIP AS A REPRESENTATIVE OF COMMUNITY HOSPITAL ASSOCIATION OF MCCOOK, AND AS A REPRESENTATIVE OF AHA AND NHA. AS AN "ADVOCACY DAY" PARTICIPANT, MR. ULRICH SPOKE WITH REPRESENTATIVES AND SENATORS REGARDING HEALTH CARE PROVIDER CONCERNS. ITEM 1I - A PORTION OF DUES PAID TO FRIENDS OF NEBRASKA NONPROFIT HOSPITALS, AMERICAN HOSPITAL ASSOCIATION AND NEBRASKA HOSPITAL ASSOCIATION IS USED BY THOSE ORGANIZATIONS TO INFLUENCE LEGISLATION. 2095101 11236 408161 142894 35723 2335881 1545264 441506 165360 45171 11858 2095101 1852460 42818 -288173 47008 14833 1545264 0.35200 0.64800 0 1 1 133878 133878 18402016 10025623 8376393 28710223 10554862 18155361 6045699 447978 5597721 32263353 33555011 31954804 1600207 0 1600207 33581371 26360 26360 33555011 0 33555011 31981164 26360 26360 31954804 0 31954804 DESCRIPTION OF INTENDED USE OF ENDOWMENT FUNDS: PART V, LINE 4: THE ENDOWMENT FUNDS ARE HELD BY THE COMMUNITY HOSPITAL HEALTH FOUNDATION OF MCCOOK (A RELATED PARTY) AND ARE USED IN SUPPORT OF THE HOSPITAL'S PROGRAMS AND PROJECTS, INCLUDING PROPERTY AND EQUIPMENT PURCHASES, SCHOLARSHIPS, HOSPICE PROGRAMS, REHABILITATION SERVICES AND OTHERS. DESCRIPTION OF UNCERTAIN TAX POSITIONS UNDER FIN 48: PART X: THE HOSPITAL AND FOUNDATION ARE NOT-FOR-PROFIT CORPORATIONS AS DESCRIBED IN SECTION 501(C)(3) OF THE INTERNAL REVENUE CODE AND ARE EXEMPT FROM FEDERAL INCOME TAXES ON RELATED INCOME PURSUANT TO SECTION 501(A) OF THE CODE. THE INTERNAL REVENUE SERVICE HAS ESTABLISHED STANDARDS TO BE MET TO MAINTAIN TAX-EXEMPT STATUS. IN GENERAL, SUCH STANDARDS REQUIRE THE HOSPITAL AND FOUNDATION TO MEET A COMMUNITY BENEFIT STANDARD AND COMPLY WITH VARIOUS LAWS AND REGULATIONS. RED WILLOW IS A FOR-PROFIT CORPORATION. RED WILLOW HAD $14,509 AND $14,398 OF TAXABLE INCOME; INCURRED AND PAID $2,176 AND $2,160 OF FEDERAL INCOME TAX; AND INCURRED AND PAID $810 AND $803 OF STATE INCOME TAX FOR THE FISCAL YEARS ENDING DECEMBER 31, 2010 AND 2009, RESPECTIVELY. AS OF JUNE 30, 2011, RED WILLOW HAD NO TAX LIABILITY. THE HOSPITAL, FOUNDATION AND RED WILLOW ACCOUNT FOR UNCERTAINTIES IN ACCOUNTING FOR INCOME TAX ASSETS AND LIABILITIES USING GUIDANCE INCLUDED IN FASB ASC 740, INCOME TAXES. THE HOSPITAL, FOUNDATION AND RED WILLOW RECOGNIZE THE EFFECT OF INCOME TAX POSITIONS ONLY IF THOSE POSITIONS ARE MORE LIKELY THAN NOT OF BEING SUSTAINED. AT JUNE 30, 2011 AND 2010, THE HOSPITAL, FOUNDATION AND RED WILLOW HAD NO UNCERTAIN TAX POSITIONS ACCRUED. PART XII, LINE 2D - OTHER ADJUSTMENTS: RENTAL EXPENSES INCLUDED ON FORM 990, PART VIII, LINE 6B: 26,360. PART XIII, LINE 2D - OTHER ADJUSTMENTS: RENTAL EXPENSES INCLUDED ON FORM 990, PART VIII, LINE 6B: 26,360. 1 1 1 X 150.000000000000 0 1 1 1 0 1 1 640526 640526 0.02060 2207331 2209441 -2110 0.00000 2847857 2209441 638416 0.02060 102233 17325 84908 0.00270 3548 3548 0.00010 14791 14791 0.00050 120572 17325 103247 0.00330 2968429 2226766 741663 0.02390 39077 39077 0.00130 19278 19278 0.00060 58355 58355 0.00190 0 631958 110193 14609474 14524604 84870 X 1 1 1 1 COMMUNITY HOSPITAL ASSN OF MCCOOK

1301 EAST H STREET - PO BOX 1328 MCCOOK NE 69001

X X X X NOT APPLICABLE 1 5 COMMUNITY HEALTHCARE & HOSPICE

407 WEST 5TH STREET MCCOOK NE 69001

HOME HEALTH AND HOSPICE SERVICES COMMUNITY HOSPITAL SLEEP LAB

801 WEST C STREET SUITE 3B MCCOOK NE 69001

OUTPATIENT SLEEP SERVICES CURTIS MEDICAL CENTER

302 EAST 6TH STREET CURTIS NE 69025

RURAL HEALTH CLINIC-OUTPATIENT SERVICES TRENTON MEDICAL CLINIC

406 EAST 1ST STREET TRENTON NE 69044

RURAL HEALTH CLINIC-OUTPATIENT SERVICES COMMUNITY HOSPITAL - OUTPATIENT SERVICES

104 NORTH 3RD STREET INDIANOLA NE 69034

OUTPATIENT SERVICES PART I, LINE 3C: CHARITY CARE IS GRANTED TO ALL INDIVIDUALS WHOSE HOUSEHOLD INCOME IS BELOW 150% OF THE FEDERAL POVERTY GUIDELINE AT THE 100% WRITE-OFF LEVEL. DISCOUNTING OR 100% WRITE-OFF TO CHARITY CARE IS ALLOWED ABOVE 150% OF THE FEDERAL POVERTY GUIDELINE BASED ON AN ANALYSIS OF INDIVIDUAL NEED AND DETERMINATION OF THE PATIENT BEING MEDICALLY INDIGENT; THIS ANALYSIS INCLUDES FACTORS SUCH AS INCOME, ACCESSIBLE ASSETS, MEDICAL OR/AND OTHER DEBTS, THE LIKELIHOOD OF ONGOING MEDICAL CARE AND THE INDIVIDUAL'S OVERALL ABILITY TO PAY. PART I, LINE 6A: THE COMMUNITY BENEFIT REPORT IS PREPARED BY THE STAFF OF COMMUNITY HOSPITAL ASSOCIATION OF MCCOOK. PART I, LINE 7: THE ORGANIZATION USES A COST-TO-CHARGE RATIO METHODOLOGY DERIVED FROM WORKSHEET #2 OF THE FORM 990 INSTRUCTIONS. PART I, L7 COL(F): THE BAD DEBT EXPENSE INCLUDED IN FORM 990, PART IX, LINE 25 BUT NOT INCLUDED IN SCHEDULE H, PART I, LINE 7, COLUMN (F) IS $927,986. PART II: COMMUNITY HOSPITAL SUPPORTS VARIOUS COMMUNITY BUILDING ACTIVITIES, PRIMARILY THROUGH MONETARY SUPPORT. EXAMPLES INCLUDE SUPPORT TO THE ECONOMIC DEVELOPMENT CORPORATION, THE LOCAL COMMUNITY COLLEGE AND INVEST NEBRASKA. THESE PROGRAMS DIRECTLY IMPACT THE HEALTH OF OUR COMMUNITY BY DEVELOPMENT OF EMPLOYMENT OPPORTUNITIES AND A MORE EMPLOYABLE WORKFORCE. MEMBERS OF OUR COMMUNITY WITH GOOD EMPLOYMENT HAVE ACCESS TO HEALTH INSURANCE AND ARE GENERALLY ABLE TO LIVE HEALTHIER LIVES. PART III, LINE 4: COMMUNITY HOSPITAL'S BAD DEBT EXPENSE IS RECORDED AT GROSS REVENUE VALUE ON THE HOSPITALS BOOKS BASED ON ACTUAL BAD DEBT INCURRED DURING THE FISCAL YEAR AND AN ESTIMATE AMOUNT OF ACCOUNTS RECEIVABLE AT YEAR END, THAT BASED ON HISTORICAL TRENDS, ARE PROJECTED TO BE UNCOLLECTABLE FROM PATIENTS AND/OR THIRD PARTY PAYORS. BAD DEBT EXPENSE DOES NOT INCLUDE ANY AMOUNTS ATTRIBUTABLE TO PATIENTS THAT ARE KNOWN BY THE HOSPITAL TO QUALIFY FOR THE CHARITY CARE PROGRAM, NOR DOES IT INCLUDE ANY AMOUNTS WRITTEN OFF DUE TO CONTRACTUAL RELATIONSHIPS WITH THIRD PARTY PAYORS. THE COST OF BAD DEBT ON LINE 2 WAS CALCULATED USING THE OVERALL COST TO CHARGE RATIO FROM WORKSHEET #2 IN THE FORM 990 INSTRUCTIONS. LINE 3 WAS ESTIMATED USING BOTH QUANTITATIVE AND QUALITATIVE SOURCES. THE QUANTITATIVE WAS AN ANALYTICAL ANALYSIS OF THE AMOUNT OF CHARITY CARE GIVEN BY COMMUNITY HOSPITAL COMPARED TO THE LOCAL DEMOGRAPHICS FOR POVERTY BASED ON US CENSUS DATA. ONE OF THE ASSUMPTIONS MADE WAS THAT MOST INDIVIDUALS THAT WOULD HAVE QUALIFIED FOR CHARITY CARE BUT WOULD NOT APPLY ENDED UP AS BAD DEBT WRITE-OFFS OF THE HOSPITAL. THIS ANALYSIS SHOWED THAT APPROXIMATELY 17.4% OF THE BAD DEBT EXPENSE WAS LIKELY TO HAVE CAME FROM INDIVIDUALS THAT WOULD HAVE QUALIFIED FOR CHARITY CARE HAD THEY APPLIED. THE QUALITATIVE SOURCE WE EMPLOYED WAS TO ASK OUR STAFF THAT ROUTINELY HANDLE CHARITY CARE APPLICATIONS AND BAD DEBT DETERMINATIONS, WHAT PERCENTAGE, IN THEIR PROFESSIONAL OPINION, OF BAD DEBT WAS FROM INDIVIDUALS THAT WOULD HAVE LIKELY QUALIFIED FOR THE CHARITY CARE PROGRAM HAD THE PATIENT APPLIED FOR ASSISTANCE. THE ESTIMATE WE RECEIVED WAS 15%-20% OF ACCOUNTS TURNED OVER AS BAD DEBT, IN THEIR OPINION, LIKELY WOULD HAVE QUALIFIED FOR CHARITY ASSISTANCE HAD THE PATIENT BEEN COOPERATIVE IN THE PROCESS AND APPLIED FOR CHARITY CARE. AFTER ANALYSIS OF THESE FACTORS, THE HOSPITAL IS RECORDING 17.4% OF ITS BAD DEBT COSTS ON LINE 3. PART III, LINE 8: THE SOURCE USED TO DETERMINE THE AMOUNT REPORTED ON LINE 6 WAS THE MEDICARE COST REPORT. PART III, LINE 9B: COMMUNITY HOSPITAL GRANTS 100% CHARITY CARE FOR PATIENTS KNOWN TO QUALIFY FOR FINANCIAL ASSISTANCE. OUR CHARITY CARE POLICY IS SET AT 150% OF THE FEDERAL POVERTY GUIDELINE BASED FAMILY SIZE. FOR PATIENTS THAT EXCEED THE INCOME THRESHHOLD OF THE CHARITY CARE POLICY, OUR MEDICALLY INDIGENT FINANCIAL ASSISTANCE IS AVAILABLE FOR PATIENTS THAT HAVE INCURRED CATASTROPHIC MEDICAL COSTS OR OTHER OBLIGATIONS (PRESENTLY OR ONGOING) THAT HAVE SUBSTANTIALLY REDUCED THEIR ABILITY TO PAY. IN SUCH CASES, THE INDIVIDUAL OR GUARANTOR MAY BE DETERMINED BY THE HOSPITAL TO BE MEDICALLY INDIGENT AND MAY, AT THE HOSPITAL'S DISCRETION, BE ELIGIBLE FOR FINANCIAL ASSISTANCE IN THE FORM OF FREE OR DISCOUNTED LIABILITIES.CERTAIN CLASSES OF PATIENTS ARE DEEMED TO HAVE QUALIFIED FOR CHARITY CARE WITHOUT AN APPLICATION. ACCOUNTS THAT MAY QUALIFY FOR FINANCIAL ASSISTANCE WITHOUT A COMPLETED APPLICATION INCLUDE:1. MEDICAID SHARE OF COST PORTIONS.2. MEDICAID APPLICATIONS APPROVED FOR SUBSEQUENT CARE (NOT RETROACTIVE TO THE LIABILITY).3. PATIENTS OR GUARANTORS WHO HAVE DECLARED BANKRUPTCY.4. PATIENTS OR GUARANTORS WHO ARE DECEASED WITH NO ESTATE IN PROBATE AND FOR WHOM NO ONE ELSE (SUCH AS A SPOUSE OR LEGAL GUARDIAN) IS LEGALLY RESPONSIBLE FOR THE LIABILITY.5. PATIENTS OR GUARANTORS DETERMINED TO BE HOMELESS. PART VI, LINE 2: COMMUNITY HOSPITAL HAS COMPLETED A COMMUNITY HEALTH NEEDS ASSESSMENT. ACTION PLANS ARE IN PLACE TO ADDRESS SEVERAL OF THE IDENTIFIED NEEDS IN THE REPORT. PART VI, LINE 3: IDENTIFICATION OF PATIENTS WITH A POTENTIAL NEED FOR FINANCIAL ASSISTANCE WILL BE ACCOMPLISHED BY BOTH AN OPEN AND PUBLICIZED APPLICATION PROCESS AND A VARIETY OF SCREENING OPPORTUNITIES INCLUDING:A. ADMISSIONS/REGISTRATION PERSONNEL BASED UPON INFORMATION RECEIVED DURING THE REGISTRATION PROCESS.B. SOCIAL SERVICES PERSONNEL BASED UPON INFORMATION DURING THE INITIAL VISIT AND DISCHARGE PLANNING.C. NURSING STAFF BASED UPON INFORMATION RECEIVED DURING DISCUSSIONS WITH FAMILY AND/OR PATIENT.D. BUSINESS OFFICE PERSONNEL BASED UPON STATUS OF ACCOUNTS AND DISCUSSIONS WITH RESPONSIBLE PARTY.E. ACCOUNTS RECEIVABLE REPORTS.HOSPITAL STAFF OR THE NOTIFIED PATIENT ADVOCATE WILL EDUCATE THE PATIENT OR GUARANTOR ABOUT THE FINANCIAL ASSISTANCE POLICY AND WILL PROVIDE THEM AN APPLICATION FOR FINANCIAL ASSISTANCE. IF NECESSARY, THE PATIENT FINANCIAL COUNSELOR OR OTHER HOSPITAL STAFF MAY ASSIST THE PATIENT IN COMPLETING THE APPLICATION; HOWEVER, THE COMPLETION OF AN APPLICATION AND PROVIDING ALL NECESSARY SUPPORTING DOCUMENTATION IS THE PATIENT'S RESPONSIBILITY. PATIENTS MAY ALSO REQUEST AN APPLICATION OR ADDITIONAL INFORMATION IN PERSON AT THE ADMISSIONS OFFICE OR BY CALLING OR WRITING THE PATIENT FINANCIAL COUNSELOR AND AN APPLICATION WILL BE MAILED. PART VI, LINE 4: COMMUNITY HOSPITAL SERVES A RURAL POPULATION IN SOUTHWEST NEBRASKA. THE NEXT CLOSEST HOSPITAL FROM THE CITY OF MCCOOK IS 24 MILES AWAY AND THE NEXT LARGER HOSPITAL IS OVER 70 MILES AWAY. ACCORDING TO THE US CENSUS BUREAU, IN 2010 RED WILLOW COUNTY HAD A POPULATION OF 11,055; 18.7% OF WHICH WAS 65 YEARS OF AGE OR OLDER AND 12.3% WHICH LIVE BELOW THE FEDERAL POVERTY LEVEL. MEDIAN HOUSEHOLD INCOME WAS $40,572; 14.5% BELOW THE NEBRASKA MEDIAN OF $47,470 AND MORE THAN 60% OF HOUSEHOLDS LIVING ON LESS THAN $50,000 PER YEAR. PART VI, LINE 6: COMMUNITY HOSPITAL IS THE LARGEST HOSPITAL WITHIN AN HOUR TRAVEL TIME FOR MOST OF THE COMMUNITY SERVED. THE HOSPITAL PROVIDES THE PHYSICIANS OF MCCOOK A HOSPITAL TO PRACTICE MEDICINE. WITHOUT THE HOSPITAL OUR PATIENTS WOULD HAVE EXTREMELY LONG DISTANCES TO TRAVEL FOR EVERYTHING FROM EMERGENCY TO ROUTINE CARE. OUR HOSPITAL IS OVERSEEN BY A NON-COMPENSATED BOARD OF INDEPENDENT COMMUNITY MEMBERS. ANY PROFITS FROM THE OPERATION OF THE HOSPITAL ARE REINVESTED BACK INTO THE FACILITIES, EQUIPMENT AND STAFF TO PROVIDE OUR COMMUNITY WITH CURRENT AND HIGH QUALITY MEDICAL SERVICES CLOSE TO HOME. PART VI, LINE 7: N/A REPORTS FILED WITH STATES PART VI, LINE 7 NE 1 INVEST NEBRASKA CORPORATION 4701 INNOVATION DR LINCOLN NE 68521 460469145 501(C)(3) 6667 TO SUPPORT ECONOMIC DEVELOPMENT IN OUR COMMUNITY. MCCOOK COLLEGE FOUNDATION PO BOX 195 MCCOOK NE 69001 476089800 501(C)(3) 20000 SUPPORT FOR THE CONSTRUCTION OF THE MCC EVENT CENTER WHICH PROMOTES HEALTH AND WELLNESS CURRICULUM AND ACTIVITIES IN THE MCCOOK COMMUNITY. MCCOOK ECONOMIC DEVELOPMENT CORPORATION 301 NORRIS AVE SUITE 200 - PO BOX 626 MCCOOK NE 69001 470685662 501(C)(4) 14000 TO RECRUIT, STRENGTHEN AND EXPAND THE BUSINESSES THAT ARE THE FOUNDATION TO OUR LOCAL ECONOMY. 2 1 PROCEDURE FOR MONITORING GRANTS IN THE U.S.: PART I, LINE 2: SCHEDULE I, PART I, LINE 2: GRANTS ARE MADE ONLY TO SELECTED CHARITABLE OR OTHER EXEMPT ORGANIATIONS. COMMUNITY HOSPITAL ASSOCIATION ENTERS INTO AGREEMENTS WITH GRANTEES THAT GRANT FUNDS WILL BE RESTRICTED TO SPECIFIED EXEMPT PURPOSES. X X X X 0 0 0 0 0 0 0 0 0 JAMES ULRICH 180022 0 0 0 0 0 12682 0 12000 0 204704 0 0 0 ANTHONY RODEWALD 131722 0 0 0 0 0 9508 0 16162 0 157392 0 0 0 TROY BRUNTZ CFO EMPLOYEE COMPUTER PURCHASE X 2076 678 0 0 1 678 MARTY CONROY JOYCE CONROY MR. CONROY: BOARD OF DIRECTORS - MEMBER, JOYCE CONROY: SPOUSE 33014 MRS. CONROY IS EMPLOYED BY THE HOSPITAL. 0 MAX ABERCROMBIE SUZANNE ABERCROMB MAX ABERCROMBIE: BOARD OF DIRECTORS - MEMBER, SUZANNE ABERCROMBIE: SPOUSE 35796 MRS. ABERCROMBIE IS EMPLOYED BY THE HOSPITAL. 0 0 FORM 990, PART VI, SECTION B, LINE 11 COMMUNITY HOSPITAL'S FORM 990, 990-T AND NEBRASKA AND IOWA INCOME TAX FORMS ARE COMPILED BY THE PUBLIC ACCOUNTING FIRM SEIM JOHNSON. MANAGEMENT RECEIVES DRAFT COPIES OF THE COMPLETED FORMS FOR REVIEW. AFTER HOSPITAL MANAGEMENT HAS REVIEWED THE RETURNS, COMPLETE COPIES ARE DISTRIBUTED TO ALL MEMBERS OF THE BOARD OF DIRECTORS OF THE COMMUNITY HOSPITAL ASSOCIATION AND THE RETURNS ARE APPROVED FOR FILING BY THE BUDGET & FINANCE COMMITTEE OF THE BOARD (A STANDING COMMITTEE WITH RESPONSIBILITY TO OVERSEE FINANCIAL, AUDIT, TAXATION AND BUDGET MATTERS OF THE HOSPITAL). BOARD COMMITTEE APPROVAL IS REQUIRED PRIOR TO SIGNATURE AND SUBMISSION OF THE RETURNS TO THE IRS AND STATE TAXING AUTHORITIES. FORM 990, PART VI, SECTION B, LINE 12C THE COMMUNITY HOSPITAL ASSOCIATION'S CODE OF CONDUCT REQUIRES ALL EMPLOYEES, CONTRACTORS, AND AGENTS TO REPORT ANY CONFLICTS OF INTEREST THAT ARISE. IN ADDITION, THE ASSOCIATION HAS A CONFLICT OF INTEREST POLICY THAT IS APPLICABLE TO DIRECTORS, OFFICERS, MEMBERS OF COMMITTEES AND SUBCOMMITTEES WITH BOARD-DELEGATED POWERS, AND KEY EMPLOYEES THAT REQUIRES, AMONG OTHER THINGS, ALL APPLICABLE PERSONS DISCLOSE ANY RELATIONSHIPS THAT MAY CREATE A CONFLICT OF INTEREST AND ARE REQUIRED TO COMPLETE AN ANNUAL DISCLOSURE OF ALL SUCH RELATIONSHIPS. ALL SUCH RELATIONSHIPS ARE DISCLOSED TO THE ENTIRE BOARD AND SENIOR MANAGEMENT, AND ANY AND ALL CONFLICTS OR POTENTIAL CONFLICTS ARE MONITORED BY SENIOR MANAGEMENT AND THE ASSOCIATION'S COMPLIANCE FUNCTION. FORM 990, PART VI, SECTION B, LINE 15 COMMUNITY HOSPITALS PROCESS FOR DETERMINING THE COMPENSATION OF THE CEO IS AS FOLLOWS: THE EXECUTIVE COMMITTEE OF THE BOARD OF DIRECTORS IS RESPONSIBLE FOR SETTING THE SALARY OF THE CEO. ANNUALLY, THE COMMITTEE CONDUCTS A REVIEW OF THE CEO'S PERFORMANCE, ABILITIES, AND OVERALL EFFECTIVENESS. THE COMMITTEE IS PRESENTED WITH SALARY AND COMPENSATION SURVEY DATA THAT IS COMPILED BY THE CEO AND THE HUMAN RESOURCE DEPARTMENT AND THE ACCURACY OF WHICH IS ATTESTED TO BY THE CFO. MULTIPLE SOURCES OF SURVEY DATA ARE USED, INCLUDING INFORMATION FROM THE NEBRASKA AND IOWA HOSPITAL ASSOCIATIONS, WHICH IS BROKEN DOWN TO SIMILARLY QUALIFIED PERSONS IN COMPARABLE POSITIONS AT SIMILARLY SIZED AND SITUATED ORGANIZATIONS. ALL SOURCE DOCUMENTATION IS GIVEN TO THE COMMITTEE AS WELL AS SUMMARIES PROVIDED FOR EASE OF REFERENCE. THE EXECUTIVE COMMITTEE CONDUCTS THE PERFORMANCE REVIEW WITH THE CEO; THEN MEETS IN PRIVATE CHAMBERS TO DISCUSS THE REVIEW AND TO DELIBERATE ANY AND ALL CHANGES TO THE EMPLOYMENT AGREEMENT, INCLUDING COMPENSATION, AND GOALS FOR THE FOLLOWING YEAR. CONTEMPORANEOUS RECORDS ARE KEPT OF ALL SURVEY AND COMPARABILITY DATA USED, AND THE RESULTS AND DECISIONS OF THE EXECUTIVE COMMITTEES MEETING ON COMPENSATION. COMPENSATION OF EMPLOYEES BELOW THE ROLE OF CEO ARE DETERMINED THROUGH THE USE OF SURVEY INFORMATION OF SIMILARLY QUALIFIED PERSONS IN COMPARABLE POSITIONS AT SIMILARLY SIZED AND SITUATED ORGANIZATIONS. THE CEO SETS THE COMPENSATION OF SENIOR MANAGEMENT BASED ON THOSE SURVEYS, TAKING IN CONSIDERATION PERFORMANCE AND EXPERIENCE OF EACH INDIVIDUAL. COMPENSATION RANGES OF EMPLOYEES BELOW SENIOR MANAGEMENT ARE SET BY HUMAN RESOURCES BASED ON MARKET WAGE RATES FOR SIMILARLY QUALIFIED PERSONS IN COMPARABLE POSITIONS AT SIMILARLY SIZED AND SITUATED ORGANIZATIONS. ALL EMPLOYEES HAVE AN ANNUAL REVIEW BY THEIR SUPERVISOR, WHICH DETERMINE WHERE IN THE SALARY RANGE AN EMPLOYEE WILL FALL. ALL SALARY RANGES, INCLUDING THOSE OF SENIOR MANAGEMENT, ARE ULTIMATELY APPROVED BY THE BOARD OF DIRECTORS DURING THE APPROVAL OF THE ANNUAL OPERATING BUDGET. FORM 990, PART VI, SECTION C, LINE 19 COMMUNITY HOSPITAL MAKES ITS GOVERNING DOCUMENTS, CONFLICT OF INTEREST POLICY, FORM 990 & 990-T (CURRENT AND PAST YEARS AS REQUIRED BY LAW) AND FINANCIAL STATEMENTS AVAILABLE TO THE PUBLIC UPON REQUEST. ANY INDIVIDUAL WHO WOULD LIKE A COPY OF ANY OF THE ABOVE MENTIONED DOCUMENTS CAN INSPECT THOSE DOCUMENTS IN PERSON AT THE HOSPITAL DURING NORMAL BUSINESS HOURS, OR REQUEST A COPY OF ANY OF THE ABOVE INFORMATION IN PERSON, BY PHONE, OR BY MAIL, AND WE WILL PROVIDE A COPY FREE OF CHARGE. FORM 990, PART XII, LINE 2C COMMUNITY HOSPITAL HAS A STANDING BOARD COMMITTEE, THE BUDGET AND FINANCE COMMITTEE, WHICH HAS THE AUTHORITY AND ASSUMES THE RESPONSIBILITY FOR THE SELECTION OF THE INDEPENDENT ACCOUNTING FIRM AND ALL RELATED OVERSIGHT, COMMUNICATION, AND REPORTING. THIS COMMITTEE APPROVES ALL ENGAGEMENT LETTERS AND RECEIVES ALL BOARD DIRECTED COMMUNICATION FROM THE INDEPENDENT ACCOUNTING FIRM. COPIES OF RECEIVED LETTERS/COMMUNICATIONS AND REPORTS ARE DISTRIBUTED TO ALL MEMBERS OF THE BOARD OF DIRECTORS IN ADDITION TO THE COMMITTEE MEMBERS. WHILE THE MEMBERS OF THE COMMITTEE HAVE CHANGED, THE PROCESS DESCRIBED HAS NOT CHANGED FROM THE PREVIOUS YEAR. COMMUNITY HOSPITAL HEALTH FOUNDATION 801 WEST C STREET PO BOX 1328 MCCOOK NE 69001 470693261 SUPPORTING ORGANIZATION PROVIDES FUNDRAISING FOR THE HOSPITAL NE 501(C)(3) 11C, TYPE III-FI N/A 1 RED WILLOW HOLDING COMPANY 1301 EASH H STREET MCCOOK NE 69001 470628195 RENTAL REAL ESTATE - CLINIC BUILDING NE N/A C 50322 124028 1.00000 0 1 1 0 0 0 0 0 0 1 0 1 1 0 1 1 0 0 RED WILLOW MEDICAL HOLDING J 50261 CASH PAYMENTS=FMV COMMUNITY HOSPITAL HEALTH FOUNDATION C 143451 CASH RECEIVED=FMV