2012-06-06T13:26:39-05:00 2011-09-30 SEIM JOHNSON LLP 18081 BURT STREET SUITE 200 OMAHA NE 680224722 990 2010-10-01 470468078 JEFFERSON COMMUNITY HEALTH CENTER INC JEFF 4027293351 2200 H STREET PO BOX 277 FAIRBURY NE 68352 CHAD JURGENS CFO 4027293351 2012-05-31 1 JULIE M GERKEN 4023302660 2010 2016-02-24 21:20:13Z CHAD JURGENS 2200 H STREET PO BOX 277 FAIRBURY NE 68352 19150431 0 X WWW.JCHCHEALTHCARE.ORG X 1960 NE JCHC IS DEVOTED TO PROVIDING APPROPRIATE QUALITY HEALTH SERVICES IN A CARING ENVIRONMENT. 9 8 215 15 0 0 526817 81501 14993388 16036870 71276 109898 101622 101832 15693103 16330101 0 0 0 0 7394406 7607171 0 0 38127 7442021 8025900 14836427 15633071 856676 697030 16259616 16605300 2029432 1732278 14230184 14873022 JCHC IS DEVOTED TO PROVIDING APPROPRIATE QUALITY HEALTH SERVICES IN A CARING ENVIRONMENT. 0 0 12851856 13817004 JEFFERSON COMMUNITY HEALTH CENTER OPERATES A 25 BED ACUTE CARE HOSPITAL. JEFFERSON COMMUNITY HEALTH CENTER ALSO OPERATES A WELLNESS CENTER AND PROVIDES HOME HEALTH SERVICES. 1124590 2232799 JEFFERSON COMMUNITY HEALTH CENTER OPERATES A 39 BED LONG-TERM CARE FACILITY FOR THE RESIDENTS OF JEFFERSON COUNTY AND THE SURROUNDING AREA. 13976446 1 1 0 0 0 0 0 0 1 1 1 0 0 1 1 1 0 0 0 0 0 0 0 0 0 1 1 0 0 1 0 0 0 0 0 0 0 1 0 0 0 0 0 0 0 0 0 0 1 6 0 1 215 1 0 0 0 0 0 0 0 0 0 0 X 9 8 0 0 0 0 1 1 1 1 1 0 0 1 1 1 1 1 1 1 0 0 X CHAD JURGENS 4027293351 2200 H STREET PO BOX 277 FAIRBURY NE 68352 DICK HOPPE 1.00 X X 0 0 0 DR CRAIG SHUMARD 1.00 X X 0 0 0 LYMON HAMM 1.00 X X 0 0 0 MARY GLENN 1.00 X 0 0 0 PAUL JUDD 1.00 X 0 0 0 JULIE KNIGGE 1.00 X 0 0 0 RYAN PARKER 1.00 X 0 0 0 TRENA ROGGE 1.00 X 0 0 0 MIKE STEEL 1.00 X 0 0 0 JACK WESCH 1.00 X 0 0 0 CRAIG WHITE 1.00 X 0 0 0 WILLIAM WELCH 40.00 X 150806 0 19592 CHAD JURGENS 40.00 X 126314 0 18398 GARY MITCHELL 40.00 X 122725 0 15652 DENNIS RUSSELL 40.00 X 100194 0 13768 500039 0 67410 4 0 1 0 FAIRBURY CLINIC PC 825 22ND STREET FAIRBURY NE 68352 ER COVERAGE 571740 HUSKER REHAB 4911 N 26TH STREET LINCOLN NE 68521 THERAPY SERVICES 434627 SOUTHEAST ANESTHESIA SERVICES 8426 W BIRCH CLATONIA NE 68328 CRNA SERVICES 360000 HEALTHCARE MANAGEMENT SYSTEMS 3102 WEST END AVE STE 400 NASHVILLE TN 37203 HOSPTIAL IT SERVICES 229943 AUREAUS RADIOLOGY LLC 13609 CALIFORNIA ST OMAHA NE 68103 CONTRACT LAB SERVICES 206311 6 8558 72943 81501 MEDICARE/MEDICAID PAYM 624100 8617229 8617229 PATIENT SERVICE REVENU 624100 4184679 4184679 PHARMACY 446110 1425571 1425571 LONG TERM CARE REVENUE 623000 945871 945871 LAB 621500 472498 472498 391022 391022 16036870 97013 97013 2833215 2820330 12885 12885 12885 CAFETERIA 722210 88899 88899 CENTRAL SUPP - EMPLOYE 624100 5907 5907 MEDICAL RECORDS 561000 3606 3606 3420 3420 101832 16330101 16049803 0 198797 315110 315110 5768987 5215134 525800 28053 187134 173495 12706 933 911905 810495 101360 50 424035 369153 52893 1989 6180 6180 42109 42109 10997 10997 2133951 2132497 539 915 43622 11422 31557 643 3671192 3449917 219022 2253 267708 240520 27188 27902 18140 9750 12 16977 16977 1110353 997588 112765 109836 109836 BAD DEBTS EXPENSE 504626 504626 DUES AND SUBSCRIPTIONS 46391 15770 30181 440 OUTSIDE TRAINING 28750 18245 10505 MISCELLANEOUS 5306 2467 2839 15633071 13976446 1618498 38127 909119 630235 472707 1964127 1952245 341630 321110 151860 157733 17327274 9360708 8455162 7966566 1357212 1952896 2500000 3500000 90842 106559 16957 17956 16259616 16605300 1204351 1016858 781091 611779 43990 103641 2029432 1732278 X 14087276 14738677 92154 83591 50754 50754 14230184 14873022 16259616 16605300 X 697030 -54192 X X 0 1 1 X 0 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 50754 50754 50754 250 250 50754 0.00000 1.00000 0.00000 0 0 13943 13943 11192169 5333084 5859085 5879543 3945664 1933879 241619 81960 159659 7966566 REPURCHASE AGREEMENTS 3500000 C 3500000 ESTIMATED THIRD PARTY PAYOR SETTLEMENTS 103641 103641 16330101 15633071 697030 -54192 -54192 642838 16264912 -54192 -54192 16319104 10997 10997 16330101 15622074 0 15622074 10997 10997 15633071 DESCRIPTION OF INTENDED USE OF ENDOWMENT FUNDS: PART V, LINE 4: THE INTENDED USE OF THE HOSPITAL'S ENDOWMENT FUNDS IS TO PROVIDE NURSING SCHOLARSHIPS AND CAPITAL IMPROVEMENTS. DESCRIPTION OF UNCERTAIN TAX POSITIONS UNDER FIN 48: PART X: THE HEALTH CENTER IS A NOT-FOR-PROFIT CORPORATION AS DESCRIBED IN SECTION 501(C)(3) OF THE INTERNAL REVENUE CODE AND IS 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 THE HEALTH CENTER'S TAX EXEMPT STATUS. IN GENERAL, SUCH STANDARDS REQUIRE THE HEALTH CENTER TO MEET A COMMUNITY BENEFITS STANDARD AND COMPLY WITH VARIOUS LAWS AND REGULATIONS. THE HEALTH CENTER ACCOUNTS FOR UNCERTAINTIES IN ACCOUNTING FOR INCOME TAX ASSETS AND LIABILITIES USING GUIDANCE INCLUDED IN FASB ASC 740, INCOME TAXES. THE HEALTH CENTER RECOGNIZES THE EFFECT OF INCOME TAX POSITIONS ONLY IF THOSE POSITIONS ARE MORE LIKELY THAN NOT OF BEING SUSTAINED. AT SEPTEMBER 30, 2011, THE HEALTH CENTER HAD NO UNCERTAIN TAX POSITIONS ACCRUED. THE HEALTH CENTER IS NO LONGER SUBJECT TO INCOME TAX EXAMINATIONS FOR FISCAL YEARS ENDED PRIOR TO SEPTEMBER 30, 2008. 1 1 1 X 1 X 1 1 1 0 1 1 93326 0 93326 0.00620 827043 754089 72954 0.00480 920369 754089 166280 0.01100 16089 0 16089 0.00110 1700 0 1700 0.00010 468964 207832 261132 0.01730 2609 2609 0.00020 489362 207832 281530 0.01870 1409731 961921 447810 0.02970 0 384424 100000 5721625 5664975 56650 X 1 1 1 1 JEFFERSON COMMUNITY HEALTH CENTER

200 H STREET FAIRBURY NE 68352

X X X X NOT REQUIRED 1 PART I, LINE 3C: FEDERAL POVERTY GUIDELINES ARE USED TO DETERMINE ELIGIBILITY FOR PROVIDING FREE AND DISCOUNTED CARE TO LOW INCOME INDIVIDUALS. PART I, LINE 6A: JEFFERSON COMMUNITY HEALTH CENTER PREPARES ITS OWN COMMUNITY BENEFIT REPORT. PART I, LINE 7: THE HOSPITAL USED THE WORKSHEETS PROVIDED IN THE FORM 990 INSTRUCTIONS. PART I, LINE 7G: THERE ARE NO COSTS ATTRIBUTABLE TO A PHYSICIAN CLINIC INCLUDED ON LINE 7G. PART I, L7 COL(F): THE BAD DEBT EXPENSE INCLUDED ON FORM 990, PART IX, LINCE 25, COLUMN (A) BUT SUBTRACTED FOR PURPOSES OF CALCULATING THE PERCENTAGE IN THIS COLUMN IS $504,626. PART II: CURRENTLY, THERE ARE NO COMMUNITY BUILDING ACTIVITIES CONDUCTED BY JCHC. PART III, LINE 4: JCHC'S FINANCIAL STATEMENTS DO NOT CONTAIN A SPECIFIC FOOTNOTE DESCRIBING BAD DEBT EXPENSE. HOWEVER, THE FOLLOWING IS TEXT OF THE FOOTNOTES TITLED "PATIENT ACCOUNTS RECEIVABLE" AND "CHARITY CARE":PATIENT ACCOUNTS RECEIVABLE:THE HEALTH CENTER REPORTS PATIENT ACCOUNTS RECEIVABLE FOR SERVICES RENDERED AT NET REALIZABLE AMOUNTS FROM THIRD-PARTY PAYORS, PATIENTS AND OTHERS. THE HEALTH CENTER PROVIDES AN ALLOWANCE FOR DOUBTFUL ACCOUNTS BASED UPON A REVIEW OF OUTSTANDING RECEIVABLES, HISTORICAL COLLECTION INFORMATION AND EXISTING ECONOMIC CONDITIONS.CHARITY CARE:THE HEALTH CENTER PROVIDES CARE TO PATIENTS WHO MEET CERTAIN CRITERIA UNDER ITS CHARITY CARE POLICY WITHOUT CHARGE OR AT AMOUNTS LESS THAN ITS ESTABLISHED RATES. BECAUSE THE HEALTH CENTER DOES NOT PURSUE COLLECTION OF AMOUNTS DETERMINED TO QUALIFY AS CHARITY CARE, THEY ARE NOT REPORTED AS REVENUE.THE HEALTH CENTER IS DEDICATED TO PROVIDING COMPREHENSIVE HEALTHCARE SERVICES TO ALL SEGMENTS OF SOCIETY, INCLUDING THE AGED AND OTHERWISE ECONOMICALLY DISADVANTAGED. IN ADDITION, THE HEALTH CENTER PROVIDES A VARIETY OF COMMUNITY HEALTH SERVICES AT OR BELOW COST.THE HEALTH CENTER USED THE RATIO OF COST TO CHARGES FROM WORKSHEET 2 OF THE SCHEDULE H INSTRUCTIONS. THE ESTIMATED AMOUNT OF BAD DEBT EXPENSE ATTRIBUTABLE TO PATIENTS ELIGIBLE UNDER THE ORGANIZATION'S CHARITY CARE POLICY IS CONSERVATIVELY BASED ON THE BELIEF THAT MANY POTENTIALLY ELIGIBLE PATIENTS DID NOT TAKE THE TIME OR EFFORT TO COMPLETE AN APPLICATION FOR CHARITY CARE. PART III, LINE 8: THE HOSPITAL CALCULATED THE MEDICARE ALLOWABLE COSTS BY ADDING THE INPATIENT, SWING BED AND OUTPATIENT COSTS AS FOUND ON THE MEDICARE COST REPORT (WORKSHEET D) FOR SEPTEMBER 30, 2011. PART III, LINE 9B: ONCE IT IS DETERMINED THAT A PATIENT MAY NOT HAVE THE MEANS TO PAY, AN ASSISTANCE APPLICATION SHOULD BE PROVIDED. IN ADDITION, ALL ACCOUNTS THAT OUR SELF-PAY RECEIVABLE VENDOR DID NOT RECEIVE PAYMENT ON AFTER 75 DAYS WILL BE RUN THROUGH A PRESUMPTIVE CHARITY CRITERIA PROCESS. THIS PROCESS ASSISTS IN THE DETERMINATION OF FINANCIAL ASSISTANCE ELIGIBILITY. JCHC STAFF WILL APPLY THE RECOMMENDED PERCENTAGE DISCOUNT TO THE PATIENT'S ACCOUNT. PART V, SECTION B: NOT REQUIRED IN THE CURRENT YEAR. PART VI, LINE 2: JCHC ASSESSES THE HEALTH CARE NEEDS OF THE COMMUNITY JCHC SERVES IN SEVERAL WAYS. JCHC UTILIZES SURVEYS BY PUBLIC HEALTH SOLUTIONS OF THE HEALTH CARE NEEDS FOR RESIDENTS OF JEFFERSON COUNTY AND THE SURROUNDING COMMUNITY. JCHC VISITS LOCAL COMMUNITY SERVICE ORGANIZATIONS AND SEEKS INPUT ON NEEDS. JCHC CONDUCTED A COMMUNITY PERCEPTION SURVEY IN 2006, WHICH INCLUDES QUESTIONS ON COMMUNITY HEALTH NEEDS. JCHC REVIEWS SURVEYS DONE BY THE STATE AND OTHER ORGANIZATIONS ON THE HEALTH CARE NEEDS FOR RESIDENTS OF JEFFERSON COUNTY AND THE SURROUNDING AREA. PART VI, LINE 3: JCHC INFORMS AND EDUCATES PATIENTS ABOUT ELIGIBILITY FOR ASSISTANCE ON AN INDIVIDUAL BASIS WHEN QUESTIONS ARISE. THE PATIENT BOOKLET THAT IS HANDED OUT EXPLAINS WHO IN THE BUSINESS OFFICE TO CONTACT IF THE PATIENT HAS QUESTIONS ABOUT THEIR BILL. THE SELF-PAY BILLING VENDOR JCHC USES NOW HAS A SET OF CRITERIA IT ASSESSES TO DETERMINE IF A PATIENT MIGHT BE ELIGIBLE FOR ASSISTANCE PROGRAMS THE PATIENT IS NOT ALREADY UTILIZING, OR IF THEY MIGHT QUALIFY FOR JCHC'S CHARITY CARE. PART VI, LINE 4: JCHC SERVES JEFFERSON COUNTY AND PARTS OF THAYER, FILLMORE, SALINE AND GAGE COUNTIES, ALL IN NEBRASKA; AND PARTS OF WASHINGTON AND MARSHALL COUNTIES IN KANSAS. THE POPULATION OF THE SERVICE AREA IS ESTIMATED AT ABOUT 18,000. REVENUE FROM MEDICARE PATIENTS IS OVER 50% ON AVERAGE, AND REVENUE FROM MEDICAID CLIENTS IS OVER 10% ON AVERAGE. PART VI, LINE 6: JCHC OPERATES IN JEFFERSON COUNTY WITH A COMMUNITY BOARD AND OPEN MEDICAL STAFF. ALL SURPLUS FUNDS ARE REINVESTED BACK INTO THE FACILITY THROUGH BUILDING CONSTRUCTION, EQUIPMENT PURCHASES, OR COMMUNITY PROGRAMS PROVIDED. JCHC PROMOTES THE HEALTH OF THE COMMUNITY BY OFFERING A COMMUNITY WELLNESS CENTER AT A REASONABLE RATE AND OFFERING SCHOLARSHIPS FOR THE COMMUNITY'S YOUTH WHO HAVE FINANCIAL NEED. THE NET COMMUNITY BENEFIT REPORTED IN PART I RELATING TO THE WELLNESS CENTER WAS $261,132. JCHC PROMOTES THE HEALTH OF THE COMMUNITY BY PROMOTING COMMUNITY WIDE PROGRAMS SUCH AS LIVE HEALTHY NEBRASKA AND STEP 2 IT (PROGRAMS WHICH ENCOURAGE INCREASING ACTIVITY AND LOSING WEIGHT.) JCHC IS ALSO INVOLVED IN CAR SAFETY SEAT CHECKS, PROGRESSIVE AG SAFETY DAY, AND WORKING WITH BLUE VALLEY COMMUNITY ACTION TO OFFER IMMUNIZATIONS TO AREA CHILDREN. JCHC PROMOTES THE HEALTH OF THE COMMUNITY BY OFFERING PROGRAMS, TOURS, SPEAKERS, AND EDUCATION - INCLUDING SUPPORT GROUPS, EDUCATIONAL PROGRAMS, AND PROGRAMS FOR LOCAL ORGANIZATIONS. PART VI, LINE 7: JCHC IS NOT PART OF AN AFFILIATED HEALTH CARE SYSTEM BUT DOES WORK TO BE A LEADER IN PROMOTING THE HEALTH OF THE COMMUNITIES IT SERVES. JCHC PARTNERS WITH MANY OTHER AREA ORGANIZATIONS - PUBLIC HEALTH SOLUTIONS, FARM SAFETY 4 JUST KIDS, NEBRASKA SAFE KIDS, JEFFERSON COUNTY EXTENSION, BLUE VALLEY COMMUNITY ACTION, FAIRBURY CHAMBER OF COMMERCE, FAIRBURY PUBLIC SCHOOLS, FAIRBURY CLINIC, NEBRASKA COMMUNITY BLOOD BANK, RURAL COMPREHENSIVE CARE NETWORK, BLUE RIVER VALLEY NETWORK, HEARTLAND HEALTH ALLIANCE, AND OTHERS. DEPENDING ON THE ACTIVITY, JCHC MAY BE THE LEAD ORGANIZATION, OR AN ORGANIZATION PROVIDING HELP AND ASSISTANCE. PART VI, LINE 7: JCHC DOES NOT FILE A COMMUNITY BENEFIT REPORT WITH ANY STATES. X X 0 0 0 0 0 0 0 0 0 WILLIAM WELCH 150806 0 0 0 0 0 7600 0 11992 0 170398 0 0 0 FAIRBURY CLINIC PC DR. CRAIG SHUMARD, BOARD MEMBER, OWNS MORE THAN 5% OF FAIRBURY CLINIC P.C. 571740 FAIRBURY CLINIC P.C. PROVIDED EMERGENCY ROOM COVERAGE SERVICES TO JEFFERSON COMMUNTIY HEALTH CENTER. 0 FORM 990, PART VI, SECTION A, LINE 6 JEFFERSON COMMUNITY HEALTH CENTER HAS MEMBERS. ANY PERSON, CORPORATION OR OTHER ENTITY MAY BECOME A LIFETIME MEMBER IF A CONTRIBUTION OF $100 OR MORE IS MADE TO THE CORPORATION. FORM 990, PART VI, SECTION A, LINE 7A VACANCIES, OCCURRING ON THE BOARD BY EXPIRATION, SHALL BE FILLED THROUGH ELECTION BY THE MEMBERS AT THE ANNUAL MEETING OF THE MEMBERS. THE BOARD DEVELOPMENT COMMITTEE SHALL SUBMIT A SLATE OF PROSPECTIVE CANDIDATES TO THE BOARD OF DIRECTORS AT THEIR MEETING PRIOR TO THE ANNUAL MEETING WHICH WILL THEN BE PRESENTED AT THE ANNUAL MEETING FOR CONSIDERATION FOR ELECTION TO THE BOARD. IN ADDITION, MEMBERS OF THE CORPORATION MAY MAKE NOMINATIONS FROM THE FLOOR. FORM 990, PART VI, SECTION A, LINE 7B EACH MEMBER SHALL BE ENTITLED TO ONE VOTE ON EACH MATTER SUBMITTED TO THE VOTE OF THE MEMBERS. FORM 990, PART VI, SECTION B, LINE 11 THE 990 IS REVIEWED AT THE REGULAR BOARD MEETING. FORM 990, PART VI, SECTION B, LINE 12C BOARD MEMBERS ARE REQUIRED, BY THE ARTICLES AND BYLAWS, TO REVIEW THE CONFLICT OF INTEREST POLICY ANNUALLY. A BOARD MEMBER WITH A CONFLICT OF INTEREST IS REQUIRED TO ABSTAIN FROM VOTING ON ANY MOTION REGARDING DISCLOSED CONFLICT OF INTEREST. BOARD MEMBERS ARE WELL ACQUAINTED AND WOULD BE AWARE OF ANY PERSONAL CONFLICTS OF INTEREST. FORM 990, PART VI, SECTION B, LINE 15A THE HOSPITAL PARTICIPATES IN THE NEBRASKA COMPDATA SALARY SURVEYS FOR ALL POSITIONS. THE CEO SURVEY DATA IS GIVEN TO THE BOARD TO REVIEW AND APPROVE THE CEO SALARY ON AN ANNUAL BASIS. FORM 990, PART VI, SECTION C, LINE 19 THE ORGANIZATIONS GOVERNING DOCUMENTS, CONFLICT OF INTEREST POLICY, AND FINANCIAL STATEMENTS ARE AVAILABLE TO THE PUBLIC UPON REQUEST. CHANGES IN NET ASSETS OR FUND BALANCES: FORM 990, PART XI, LINE 5: NET UNREALIZED LOSSES ON INVESTMENTS: -54,192. FORM 990, PAGE 11, PART XI, LINE 2C: THERE HAVE BEEN NO CHANGES FROM THE PRIOR YEAR. THE FINANCE COMMITTEE OF THE BOARD OF DIRECTORS SELECTS THE INDEPENDENT ACCOUNTANT AND HAS THE RESPONSIBILITY FOR OVERSIGHT OF THE AUDIT. UPON CONCLUSION OF THE AUDIT, THE AUDITING FIRM PRESENTS THE RESULTS AND FINDINGS TO THE FINANCE COMMITTEE.