2012-11-12T10:03:32-06:00 2011-12-31 476097913 SEIM JOHNSON LLP 18081 BURT STREET SUITE 200 OMAHA NE 680224722 990 2011-01-01 470481628 PHELPS MEMORIAL HEALTH CENTER PHEL 3089952211 1215 TIBBALS HOLDREGE NE 68949 MARK HARREL 3089952211 2012-11-06 1 JULIE M GERKEN P00400882 4023302660 2011 2016-02-24 21:20:13Z MARK HARREL 1215 TIBBALS HOLDREGE NE 68949 30344030 0 X WWW.PHELPSMEMORIAL.COM X 1963 NE PHELPS MEMORIAL HEALTH CENTER IS A PROGRESSIVE FAMILY-CENTERED HEALTH CARE PROVIDER DELIVERING A CONTINUUM OF CARE THAT ENHANCES THE QUALITY OF LIFE FOR PEOPLE WE SERVE. 13 8 259 252 0 0 47108 22699 26445560 27281699 503206 657716 55928 50672 27051802 28012786 72715 31528 0 0 10655301 10677047 0 0 0 12539517 12661394 23267533 23369969 3784269 4642817 45433220 52322538 1398603 4196134 44034617 48126404 X PHELPS MEMORIAL HEALTH CENTER IS A PROGRESSIVE FAMILY-CENTERED HEALTH CARE PROVIDER DELIVERING A CONTINUUM OF CARE THAT ENHANCES THE QUALITY OF LIFE FOR PEOPLE WE SERVE. 0 0 727844 3882634 MED/SURG - PHELPS MEMORIAL HEALTH CENTER HAS A LOT TO OFFER YOU AND YOUR FAMILY. WE ARE A 25 BED CRITICAL ACCESS HOSPITAL WITH ALL PRIVATE ROOMS. WE HAVE AN EXPERIENCED SURGICAL TEAM WHICH INCLUDES PHYSICIANS/SURGEONS, NURSE ANESTHETIST (CRNA'S), AND SURGICAL NURSES. WE OFFER A WIDE VARIETY OF SURGICAL SERVICES RANGING FROM MINOR PROCEDURES TO MAJOR SURGERIES. OUR GOALS ARE PATIENT-ORIENTED, FOCUSING ON SAFETY, CARE, AND PAIN MANAGEMENT. OUR NURSES COLLABORATE WITH THE PHYSICIANS AND OTHER DEPARTMENTS TO DELIVER A CONTINUUM OF CARE THAT ENHANCES THE QUALITY OF LIFE FOR OUR PATIENTS AND THEIR FAMILIES. 1856566 4601054 PHYSICAL THERAPY - THE THERAPY CENTER INCLUDES A LARGE GYM FOR TRAINING AND REHABILITATION, A WHIRLPOOL ROOM FOR WOUND CARE AND A SPORTS FLOOR FOR ATHLETIC TRAINING. PHYSICAL THERAPY ALLOWS INDIVIDUALS TO DEVELOP, RESTORE AND MAINTAIN MAXIMUM MOVEMENT AND FUNCTIONAL ABILITY THROUGHOUT LIFE. THIS INCLUDES PROVIDING SERVICES IN CIRCUMSTANCES WHERE MOVEMENT AND FUNCTION ARE THREATENED BY AGING, INJURY OR DISEASE. THE HYDROWORX THERAPY POOL HELPS PATIENTS RECOVER FROM SURGERY AND ARTHRITIC SYMPTOMS, AS WELL AS, ATHLETIC REHABILITATION. OCCUPATIONAL THERAPY INCORPORATES MEANINGFUL AND PURPOSEFUL OCCUPATION TO ENABLE PEOPLE WITH LIMITATIONS OR IMPAIRMENTS TO PARTICIPATE IN EVERYDAY LIFE. OCCUPATIONAL THERAPISTS WORK WITH INDIVIDUALS, FAMILIES, GROUPS AND POPULATIONS TO FACILITATE HEALTH AND WELL-BEING THROUGH ENGAGEMENT OR RE-ENGAGEMENT IN OCCUPATIONS AND EVERYDAY ACTIVITIES. OCCUPATIONAL THERAPY MAY INCLUDE RESTORING FUNCTION, ADAPTING THE PATIENT'S ENVIRONMENT, OR EVEN HELPING PATIENTS FIND EQUIPMENT TO HELP THEM PARTICIPATE MORE INDEPENDENTLY IN THEIR EVERYDAY ACTIVITIES. OCCUPATIONAL THERAPY HAS MORE ROOM TO EXPAND THEIR SERVICES AND BETTER SERVE THEIR PATIENTS. SPEECH THERAPY ADDRESSES PEOPLE'S SPEECH PRODUCTION, VOCAL PRODUCTION, SWALLOWING DIFFICULTIES AND LANGUAGE NEEDS. 1232453 11203434 RADIOLOGY - THE RADIOLOGY DEPARTMENT AT PHELPS MEMORIAL HEALTH CENTER IS A PROGRESSIVE IMAGING CENTER. WE ARE A FULLY ACCREDITED IMAGING CENTER WITH STATE OF THE ART EQUIPMENT. FEATURING MRI, CT, GENERAL ULTRASOUND, CARDIOVASCULAR ULTRASOUND, NUCLEAR MEDICINE, MAMMOGRAPHY, AS WELL AS STANDARD X-RAYS. WE ARE A FULLY STAFFED, HIGHLY EDUCATED AND EXPERIENCED DEPARTMENT. OUR STAFF IS NOT ONLY EXPERIENCED BUT FRIENDLY AND WILLING TO SERVE YOU BEYOND YOUR EXPECTATIONS. WE ARE VERY "PATIENT" ORIENTED, FOCUSING ON YOUR NEEDS AS A PATIENT. TRYING TO MAKE YOUR EXPERIENCE AS COMFORTABLE AS POSSIBLE. 16184948 31528 7594577 OTHER MISCELLANEOUS PROGRAM SERVICES 16184948 31528 7594577 20001811 1 1 0 1 0 0 0 0 0 1 1 0 0 0 1 1 1 0 0 0 0 0 0 0 0 0 1 1 1 0 1 0 0 0 0 0 0 1 1 0 0 0 0 0 0 0 0 0 0 1 18 0 1 259 1 0 0 0 0 0 0 0 0 0 0 X 13 8 1 1 0 0 1 1 0 1 1 0 0 1 1 1 1 1 1 1 0 0 X LOREN D SCHRODER CFO 3089952211 1215 TIBBALS HOLDREGE NE 68949 CHARLES REESER 2.00 X X 0 0 0 KATHRYN CANADA 2.00 X X 0 0 0 DAVID DANNEHL 2.00 X X 0 0 0 ROGER PETERSON 2.00 X X 0 0 0 NANCY GARRELTS 2.00 X 0 0 0 DAVID ROSENTHAL 2.00 X 0 0 0 GARY BERGSTEN 2.00 X 0 0 0 JEFFREY BERNEY MD 2.00 X 0 0 0 DOUGLAS HOHMAN 2.00 X 0 0 0 SHERYL MCCLYMONT 2.00 X 0 0 0 STEVE KNESS 2.00 X 0 0 0 DAROLD TAGGE 2.00 X 0 0 0 RONA VANDELL 2.00 X 0 0 0 LARRY MYERS 2.00 X 0 0 0 THOMAS SMITH MD 2.00 X 0 0 0 MARK HARREL 40.00 X 184181 0 42589 LOREN SCHRODER 40.00 X 123933 0 31969 ROBERT MILLER 40.00 X 130720 0 3898 LEORA D SMITH 40.00 X 103629 0 17969 542463 0 96425 4 0 1 1 BRASFIELD & GORRIE LLC PO BOX 11407 BIRMINGHAM AL 35246 CONSTRUCTION 8546962 NEW WEST ORTHOPAEDIC & SPORTS REHAB 3219 CENTRAL AVE STE 104 KEARNEY NE 68847 THERAPY 1765515 QUORUM HEALTH RESOURCES 105 CONTINENTAL PLACE BRENTWOOD TN 37027 MANAGEMENT SERVICE 694982 ANESTHESIA SERVICES OF NEBRASKA LLC 113 BENNETT DRIVE LEXINGTON NE 68850 ANESTHESIA 603163 HOLDREGE MEDICAL CLINIC 516 WEST 14TH AVE HOLDREGE NE 68949 PHYSICIAN ON-CALL 542349 9 22699 22699 NET PATIENT REVENUE 624100 15813666 15813666 MEDICARE/MEDICAID PAYM 624100 10942044 10942044 SUPPLY SALES/MISC OPER 624100 424989 424989 CHILD SERVICES OP OTHE 624100 101000 101000 27281699 350158 350158 2638502 300 2317988 13256 320514 -12956 307558 307558 CAFETERIA 722210 50672 50672 50672 28012786 27281699 0 708388 31528 31528 382672 382672 8123696 6763403 1360293 184074 149505 34569 1412754 1385294 27460 573851 460303 113548 72111 72111 74455 74455 4455645 3977325 478320 67840 67840 1520722 975130 545592 485099 389622 95477 190907 118585 72322 6122 6122 1985854 1985854 122889 122889 MEDICAL SUPPLIES 2910070 2910070 BAD DEBTS 695004 695004 DUES AND SUBSCRIPTIONS 74676 31177 43499 23369969 20001811 3368158 0 425 425 11984060 11344139 3682479 4832129 515572 561755 251140 177245 52555135 23616059 18985871 28939076 8762674 6036527 1171112 387516 79887 43726 45433220 52322538 1379302 3630482 19301 335652 0 230000 1398603 4196134 X 43759209 47839632 76395 86438 199013 200334 44034617 48126404 45433220 52322538 X 4642817 -551030 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 1606 1606 0 EXPLANATION OF LOBBYING ACTIVITIES: PART II-B, LINE 1: DUES PAID TO NHA & AHA CONTAIN A PORTION FOR LOBBYING EXPENSES. 401558 15661 417219 383151 18407 401558 368643 100 14408 383151 345888 6296 16459 368643 0.51000 0.49000 0 0 246511 246511 23733578 11825838 11907740 14144561 11554352 2590209 14430485 235869 14194616 28939076 3RD PARTY PAYABLE 230000 230000 28012786 23369969 4642817 -551030 -551030 4091787 27461756 -551030 -551030 28012786 0 28012786 23369969 0 23369969 0 23369969 DESCRIPTION OF INTENDED USE OF ENDOWMENT FUNDS: PART V, LINE 4: THE INTENDED USES FOR THE ENDOWMENT FUNDS ARE HEALTH CARE SCHOLARSHIPS, CHILD HEALTHCARE AND UNUSUAL HARDSHIP COSTS. 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. THE HEALTH CENTER RECEIVED A DETERMINATION LETTER THAT IT IS EXEMPT FROM FEDERAL INCOME TAXES ON RELATED INCOME PURSUANT TO SECTION 501(A) OF THE INTERNAL REVENUE CODE. THE INTERNAL REVENUE SERVICE HAS ESTABLISHED STANDARDS TO BE MET TO MAINTAIN TAX-EXEMPT STATUS. IN GENERAL, SUCH STANDARDS REQUIRE THE HEALTH CENTER TO MEET A COMMUNITY BENEFIT 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 DECEMBER 31, 2011, THE HEALTH CENTER HAD NO UNCERTAIN TAX POSITIONS ACCRUED. OPEN TAX YEARS FOR THE HEALTH CENTER INCLUDE 2010, 2009, AND 2008. 1 1 1 X 1 X 1 1 0 1 1 245862 245862 0.01080 245862 245862 0.01080 39633 2650 36983 0.00160 36130 36130 0.00160 303358 142233 161125 0.00710 48242 48242 0.00210 427363 144883 282480 0.01240 673225 144883 528342 0.02320 6286 0 6286 0.00030 6286 6286 0.00030 0 695004 271989 10489251 10178803 310448 X 1 0 1 1 PHELPS MEMORIAL HEALTH CENTER

1215 TIBBALS HOLDREGE NE 68949

X X X X PHELPS MEMORIAL HEALTH CENTER 1 1 1 100.000000000000 1 200.000000000000 0 1 1 X 1 X 0 1 X 0 0 PART I, LINE 3C: PHELPS MEMORIAL HEALTH CENTER (PMHC) USES FEDERAL POVERTY GUIDELINES TO DETERMINE ELIGIBILITY FOR PROVIDING FREE AND DISCOUNTED CARE. PART I, LINE 6A: THE COMMUNITY BENEFIT REPORT IS PREPARED BY THE STAFF AT PMHC. PART I, LINE 7: THE COSTING METHODOLOGY USED TO CALCULATE THE AMOUNTS REPORTED IN THE TABLE WAS A COST-TO-CHARGE RATIO. THE RATIO WAS DERIVED FROM THE COST REPORT FOR FINANCIAL ASSISTANCE. PART I, LINE 7G: NO COSTS ASSOCIATED WITH PHYSICIAN CLINICS WERE INCLUDED AS SUBSIDIZED HEALTH SERVICES. PART I, LINE 7, COLUMN (F): THE BAD DEBT EXPENSE INCLUDED ON FORM 990, PART IX, LINE 25, COLUMN (A), BUT SUBTRACTED FOR PURPOSES OF CALCULATING THE PERCENTAGE IN THIS COLUMN IS $ 695004. PART II: ONE OF THE MAJOR COMMUNITY BUILDING ACTIVITIES THAT PMHC HELPS LEAD IS THE SAFE COMMUNITIES COALITION. PMHC EMPLOYEES THREE COALITION MEMBERS, INCLUDING THE COALITION COORDINATOR WHO IS RESPONSIBLE FOR THE DAY TO DAY ORGANIZATIONAL RESPONSIBILITIES, MINUTES, AGENDAS, AND PROGRAM AND EVENT COORDINATION. SAFE COMMUNITIES COALITION IS A GROUP OF REPRESENTATIVES FROM SEVERAL COMMUNITY AGENCIES, INCLUDING PHELPS MEMORIAL HEALTH CENTER, HOLDREGE POLICE DEPARTMENT, PHELPS COUNTY SHERIFF'S DEPARTMENT, NEBRASKA STATE PATROL, YMCA OF THE PRAIRIE, AMERICAN FAMILY INSURANCE, SAFE CENTER, TWO RIVERS PUBLIC HEALTH DEPARTMENT, HOLDREGE, LOOMIS, AND BERTRAND SCHOOLS, AND OTHERS. PART III, LINE 4: THE ORGANIZATION'S FINANCIAL STATEMENTS DO NOT CONTAIN A SPECIFIC FOOTNOTE DESCRIBING BAD DEBT. HOWEVER, THE FOLLOWING IS THE TEXT OF THE FOOTNOTES TITLED "PATIENT RECEIVABLE, NET," "NET PATIENT SERVICE REVENUE," AND "CHARITY CARE":THE HEALTH CENTER REPORTS PATIENT RECEIVABLES FOR SERVICES RENDERED AT NET REALIZABLE AMOUNTS AFTER DETERMINING THE ESTIMATED ALLOWANCE FOR DOUBTFUL ACCOUNTS AND CONTRACTUAL ADJUSTMENTS FROM THIRD-PARTY PAYORS. MANAGEMENT REVIEWS PATIENT RECEIVABLES BY PAYOR CLASS AND APPLIES PERCENTAGES RELATIVE TO ACCOUNT AGE AND HISTORICAL COLLECTION INFORMATION TO DETERMINE AN ESTIMATED BAD DEBT PROVISION. MANAGEMENT UTILIZES CALCULATION ESTIMATES BASED ON APPLICABLE THIRD-PARTY REIMBURSEMENT METHODOLOGIES TO DETERMINE CONTRACTUAL ADJUSTMENTS.THE HEALTH CENTER HAS AGREEMENTS WITH THIRD-PARTY PAYORS THAT PROVIDE FOR PAYMENTS TO THE HEALTH CENTER AT AMOUNTS DIFFERENT FROM ITS ESTABLISHED RATES. PAYMENT ARRANGEMENTS INCLUDE PROSPECTIVELY DETERMINED RATES PER DISCHARGE, REIMBURSED COSTS, DISCOUNTED CHARGES, AND PER DIEM PAYMENTS. NET PATIENT SERVICE REVENUE IS REPORTED AT THE ESTIMATED NET REALIZABLE AMOUNTS FROM PATIENTS, THIRD-PARTY PAYORS, AND OTHERS FOR SERVICES RENDERED, INCLUDING ESTIMATED RETROACTIVE ADJUSTMENTS UNDER REIMBURSEMENT AGREEMENTS WITH THIRD-PARTY PAYORS. RETROACTIVE ADJUSTMENTS ARE ACCRUED ON AN ESTIMATED BASIS IN THE PERIOD THE RELATED SERVICES ARE RENDERED AND ADJUSTED IN FUTURE PERIODS AS FINAL SETTLEMENTS ARE DETERMINED.THE HEALTH CENTER PROVIDES CARE TO PATIENTS WHO MEET CERTAIN CRITERIA UNDER ITS CHARITY CARE POLICY WITHOUT CHARGE OR AT AMOUNTS LESS THAN ITS ESTABLISHED RATES. BECAUSE THE HEALTH CENTER DOES NOT PURSUE COLLECTION OF AMOUNTS DETERMINED TO QUALIFY AS CHARITY CARE, THEY ARE NOT REPORTED IN THE STATEMENTS OF OPERATIONS.THE HEALTH CENTER IS DEDICATED TO PROVIDING COMPREHENSIVE HEALTHCARE SERVICES TO ALL SEGMENTS OF SOCIETY, INCLUDING THE AGED AND OTHERWISE ECONOMICALLY DISADVANTAGED. IN ADDITION, THE HEALTH CENTER PROVIDES A VARIETY OF COMMUNITY HEALTH SERVICES AT OR BELOW COST.ESTIMATED BAD DEBT FOR PATIENTS ELIGIBLE FOR CHARITY CARE WAS DETERMINED BY APPLYING CHARITY CARE GUIDELINES BASED ON AVERAGE PER HOUSEHOLD INCOME FOR PHELPS COUNTY. THE HEALTH CENTER PROVIDES CARE TO PATIENTS WHO MEET CERTAIN CRITERIA UNDER ITS CHARITY CARE POLICY WITHOUT CHARGE OR AT AMOUNTS LESS THAN ITS ESTABLISHED RATES. BECAUSE THE HEALTH CENTER DOES NOT PURSUE COLLECTION OF AMOUNTS DETERMINED TO QUALIFY AS CHARITY CARE, THEY ARE NOT REPORTED IN THE STATEMENTS OF OPERATIONS. PART III, LINE 8: THE ORGANIZATION USED THE MEDICARE COST REPORT FOR FISCAL YEAR 2011 TO REPORT THE AMOUNTS OF TOTAL REVENUE RECEIVED FROM MEDICARE AND RELATED MEDICARE ALLOWABLE COSTS. PART III, LINE 9B: IF A PATIENT IS UNABLE TO MAKE FULL PAYMENT OF THE PATIENT BALANCE WHEN DUE, PERIODIC, PARTIAL PAYMENTS MAY BE APPROVED IN ACCORDANCE WITH CREDIT AND COLLECTION PROCEDURES, AS AUTHORIZED BY THE CHIEF FINANCIAL OFFICER. A PATIENT FINANCIAL STATEMENT MAY BE REQUESTED TO DETERMINE APPROPRIATE PAYMENT ARRANGEMENTS.IF A PATIENT IS DETERMINED TO BE FINANCIALLY INDIGENT, THE PATIENT FINANCIAL SERVICES DEPARTMENT WILL ASSIST THE PATIENT IN APPLYING FOR OTHER FINANCIAL ASSISTANCE. IF NO SOURCE OF FINANCIAL ASSISTANCE IS AVAILABLE, THE HOSPITAL WILL REVIEW THE ACCOUNT FOR CHARITY CARE ALLOWANCE. ALL CHARITY CARE ALLOWANCE MUST BE APPROVED BY THE CHIEF FINANCIAL OFFICER AND PATIENT FINANCIAL SEVICES LEADER.IF PAYMENT ARRANGEMENTS HAVE NOT BEEN MADE AFTER 120 DAYS THE FIRST NOTICE IS RECEIVED, THE PATIENT IS SENT A LETTER STATING THAT THE ACCOUNT IS BEING FORWARDED TO A COLLECTION AGENCY. PART VI, LINE 2: PHELPS MEMORIAL HEALTH CENTER MANAGEMENT, BOARD OF DIRECTORS AND MEDICAL STAFF MEET EVERY 3 TO 5 YEARS FOR A MAJOR STRATEGIC PLANNING AGENDA THAT INCLUDES ASSESSMENT OF THE HEALTH CARE NEEDS OF THE COMMUNITY. OUTSIDE RESOURCES ARE UTILIZED TO IDENTIFY THE CURRENT PATIENT DEMOGRAPHIC TRENDS, HEALTH CARE CONCERNS IN OUR COUNTY AND STATE, PHYSICIAN NEED, ETC. EVERY YEAR MANAGEMENT, BOARD OF DIRECTORS AND MEDICAL STAFF MEET TO DISCUSS AND ASSESS THE ONGOING HEALTH CARE NEEDS OF THE COMMUNITY AND DEVELOP AN ANNUAL BUSINESS PLAN TO ADDRESS THESE NEEDS IN THE UPCOMING YEAR. PART VI, LINE 3: PHELPS MEMORIAL HEALTH CENTER SOCIAL SERVICES DEPARTMENT MONITORS PATIENTS WITHIN THE HOSPITAL AND INDENTIFIES POSSIBLE PATIENTS THAT COULD QUALIFY FOR ASSISTANCE UNDER FEDERAL, STATE OR LOCAL GOVERNMENT. A REPRESENTATIVE OF SOCIAL SERVICES THEN MEETS WITH THE PATIENT TO ASSIST IN REGISTERING FOR SUCH ASSISTANCE. EVERY PATIENT REGISTERING AT PHELPS MEMORIAL HEALTH CENTER IS GIVEN A BILLING PAMPLET THAT EXPLAINS THE FINANCIAL ASSISTANCE PROGRAM. ATTACHED TO EVERY STATEMENT THERE IS A PAYMENT OPTIONS LETTER THAT ALLOWS PATIENTS TO INQUIRE ABOUT THE FINANCIAL ASSISTANCE PROGRAM. EVERY PATIENT WITH A SELF PAY BALANCE IS SENT A LETTER INFORMING THEM PHELPS MEMORIAL HEALTH CENTER HAS A FINANCIAL ASSISTANCE PROGRAM THAT THEY MAY APPLY FOR. PART VI, LINE 4: PHELPS COUNTY NEBRASKA IS LOCATED ON THE HIGH PLAINS IN RURAL NEBRASKSA. THE PRIMARY INDUSTRY IS AGRICULTURE INCLUDING CROPS AND LIVESTOCK. ADDITIONAL INDUSTRY INCLUDES MANUFACTURING. PMHC'S PRIMARY SERVICE AREA IS THE COUNTY OF PHELPS AND PORTIONS OF SURROUNDING COUNTIES WITH A TOTAL SERVICE POPULATION OF APPROXIMATELY 20,000. PART VI, LINE 5: PHELPS MEMORIAL HEALTH CENTER IS THE LEADING ENTITY FOR HEALTH PROMOTION IN THE COMMUNITY IN PARTNERSHIP WITH LOCAL PHYSICIANS, OTHER HEALTH CARE PROFESSIONALS AND THE LOCAL PUBLIC HEALTH DEPARTMENT. THE HOSPITAL IS GOVERNED BY A VOLUNTEER GROUP OF LOCAL CITIZENS REPRESENTING ALL ASPECTS OF THE COMMUNITY. THE MEDICAL STAFF IS OPEN TO ALL PHYSICIANS AND MEDICAL STAFF PROFESSIONALS THAT MEET CREDENTIALING CRITERIA. PHELPS MEMORIAL HEALTH CENTER MAINTAINS A PERMANENT SUB-COMMITTEE OF THE BOARD THAT SUPPORTS AND PROMOTES COMMUNITY HEALTH PROJECTS THROUGH GRANT FUNDING AND OTHER ASSISTANCE. IN ADDITION, THE HOSPITAL PROVIDES MULTIPLE HEALTH RELATED ANNUAL EVENTS TO THE PUBLIC AT NO CHARGE THAT ADDRESS HEALTH CARE NEEDS AND RISKS OF THE COMMUNITY. PART VI, LINE 6: PMHC IS NOT PART OF AN AFFILIATED HEALTH CARE SYSTEM. REPORTS FILED WITH STATES PART VI, LINE 7 NE 1 HOLDREGE BOY SCOUT TROOP 216 HOLDREGE UNITED METHODIST CHURCH 604 WEST AVENUE HOLDREGE NE 68949 470402819 501(C)(3) 5500 BUS FOR BOY SCOUTS CASA (COURT APPOINTED SPECIAL ADVOCATES) CO PHELPS COUNTY GOVERNMENT 715 5TH AVE HOLDREGE NE 68949 476006496 GOV ENTITY 10000 HELP SUPPORT CASA PROGRAM (CASA IMPROVES THE QUALITY OF REPRESENTATION PROVIDED TO CHILD VICTIMS OF ABUSE AND NEGLECT) EDUCATIONAL SERVICE UNIT 412 W 14TH AVENUE HOLDREGE NE 68949 470522576 SCHOOL 5528 AEDS PURCHASED LOOMIS PUBLIC SCHOOL 101 BRYAN STREET LOOMIS NE 68958 476004726 SCHOOL 6000 PLAYGROUND EQUIPMENT PROJECT 4 PROCEDURE FOR MONITORING GRANTS IN THE U.S.: PART I, LINE 2: SCHEDULE I, PART I, LINE 2: ALL GRANTS MADE TO LOCAL ORGANIZATIONS IN PHELPS COUNTY AND SURROUNDING COUNTIES. CRITERIA IN PLACE TO ENSURE GRANTS ARE AWARDED TO ORGANIZATION MEETING FOUNDATION GUIDELINES. X 0 1 X X 0 0 0 0 0 0 0 0 0 MARK HARREL 167621 0 16560 0 0 0 2763 0 39826 0 226770 0 0 0 LOREN SCHRODER 122477 0 1456 0 0 0 1859 0 30110 0 155902 0 0 0 PART I, LINE 1A PHELPS MEMORIAL HEALTH CENTER PROVIDES A MEMBERSHIP TO A COUNTRY CLUB FOR THE CEO OF THE ORGANIZATION. THE MEMBERSHIP ALLOWS THE CEO AND OTHER MEMBERS OF THE STAFF TO TAKE EMPLOYEES, CLIENTS AND VENDORS OUT TO THE COUNTRY CLUB. FURTHERMORE, THE ORGANIZATION UTILIZES THE COUNTRY CLUB'S FACILITY FOR MEETINGS AND OTHER EVENTS. SUPPLEMENTAL INFORMATION PART III MARK HARREL AND LOREN SCHRODER RECEIVE COMPENSATION FROM QUORUM HEALTH RESOURCES, AN UNRELATED ENTITY, WHICH PROVIDES MANAGEMENT SERVICES TO ITS CLIENTS. THE PHELPS MEMORIAL HEALTH CENTER BOARD OF DIRECTORS SETS THE SALARY AND BENEFITS FOR MR. HARREL AND MR. SCHRODER. QUORUM HEALTH RESOURCES CHARGES PHELPS MEMORIAL HEALTH CENTER FOR THE SERVICES MR. HARREL AND MR. SCHRODER PROVIDE TO THE ORGANIZATION. SHERYL MCCLYMONT SISTER IS AN EMPLOYEE 57226 EMPLOYEE WAGES 0 RONA VANDELL SISTER-IN-LAW IS AN EMPLOYEE 75202 EMPLOYEE WAGES 0 THOMAS SMITH MD PARTNERSHIP MORE THAN 5% OWNED BY THOMAS SMITH, CURRENT BOARD MEMBER 542349 PAID FAMILY MEDICAL SPECIALTIES FOR EMERGENCY ROOM, CARDIAC REHABILITATION, AND RESPIRATORY REHABILITATION COVERAGE 0 JEFFREY R BERNEY MD PARTNERSHIP MORE THAN 5% OWNED BY JEFFREY R. BERNEY, CURRENT BOARD MEMBER 542349 PAID FAMILY MEDICAL SPECIALTIES FOR EMERGENCY ROOM, CARDIAC REHABILITATION, AND RESPIRATORY REHABILITATION COVERAGE 0 DAROLD TAGGE GRANDDAUGHTER IS AN EMPLOYEE 13495 EMPLOYEE WAGES 0 THOMAS SMITH MD PARTNERSHIP MORE THAN 5% OWNED BY THOMAS SMITH, CURRENT BOARD MEMBER 318687 RENT RECEIVED FROM FAMILY MEDICAL SPECIALTIES 0 JEFFREY R BERNEY MD PARTNERSHIP MORE THAN 5% OWNED BY JEFFREY R. BERNEY, CURRENT BOARD MEMBER 318687 RENT RECEIVED FROM FAMILY MEDICAL SPECIALTIES 0 0 FORM 990, PART VI, SECTION A, LINE 2 JEFF BERNEY, MD AND THOMAS SMITH, MD BOTH OFFICERS ON THE BOARD, HAVE A BUSINESS RELATIONSHIP. FORM 990, PART VI, SECTION A, LINE 3 QUORUM HEALTH RESOURCES, LLC ("QHR") AND PHELPS MEMORIAL HEALTH CENTER ("PMHC") HAVE AN AGREEMENT IN PLACE FOR ADMINISTRATIVE SERVICES. QHR PROVIDES THE HOSPITAL THE SERVICES OF INDIVIDUALS TO SERVE AS THE CEO & CFO AT PMHC. THE CEO & CFO SHALL OVERSEE THE EXECUTION AND PERFORMANCE OF THE ADMINISTRATIVE FUNCTIONS OF PMHC AND COMMUNICATE THE BUSINESS AND OPERATIONAL ACTIVITY OF PMHC WITH THE BOARD OR BOARD REPRESENTATIVE ROUTINELY. THE CFO REPORTS TO THE CEO, AND THE CEO IS ACCOUNTABLE AND REPORTS DIRECTLY TO THE BOARD. FORM 990, PART VI, SECTION A, LINE 6 EVERY DONOR OF A GIFT OF $100 OR MORE TO PHELPS COUNTY MEMORIAL HOSPITAL ASSOCIATION SHALL BE A MEMBER OF PHELPS MEMORIAL HEALTH CENTER. FORM 990, PART VI, SECTION A, LINE 7A EACH MEMBER OF PHELPS MEMORIAL HEALTH CENTER HAS ONE VOTE IN THE ELECTION OF DIRECTORS. FORM 990, PART VI, SECTION B, LINE 11 YES, A COPY OF THE FORM 990 WILL BE DISTRIBUTED TO THE BOARD OF DIRECTORS A WEEK BEFORE THE MEETING. DURING THE BOARD OF DIRECTORS MEETING THE FORM 990 WILL BE THOROUGHLY REVIEWED AND DISCUSSED IN ORDER TO ADDRESS ANY QUESTIONS PRIOR TO SUBMISSION. FORM 990, PART VI, SECTION B, LINE 12C PMHC BOARD OF TRUSTEES DISCLOSE CONFLICTS OF INTEREST ON AN ANNUAL BASIS BY SIGNING A CONFLICT OF INTEREST STATEMENT. ALL MEMBERS OF THE BOARD OF DIRECTORS, THE TOP MANAGEMENT OFFICIAL (CEO) AND THE TOP FINANCIAL OFFICIAL (CFO) ARE REQUIRED TO DISCLOSE, ON AN ANNUAL BASIS, ALL INTERESTS THAT COULD GIVE RISE TO A CONFLICT OF INTEREST. THESE DISCLOSURES ARE REVIEWED BY THE BOARD OF DIRECTORS, THE CEO AND THE ORGANIZATION'S COMPLIANCE OFFICER. ACTUAL CONFLICTS ARE ALSO REVIEWED BY THE ENTIRE BOARD OF DIRECTORS. UPON A DIRECTOR'S DISCLOSURE OF A CONFLICT OF INTEREST, THAT DIRECTOR WITHDRAWS FROM BOARD CONSIDERATION AND DISCUSSION, DOES NOT PARTICIPATE IN THE VOTING OR DECISION-MAKING AND, AT THE REQUEST OF THE PRESIDENT, IS EXCUSED FROM THE BOARD MEETING DURING DISCUSSION AND VOTING. ALL EMPLOYEES, INCLUDING SENIOR LEADERSHIP AND DEPARTMENT LEADERS ALSO DISCLOSE AND SIGN A CONFLICT OF INTEREST STATEMENT DURING THEIR ANNUAL REVIEWS. FORM 990, PART VI, SECTION B, LINE 15A QUORUM HEALTH RESOURCES, LLC ("QHR") PROVIDES ADMINISTRATIVE SERVICES TO PHELPS MEMORIAL HEALTH CENTER ("PMHC"). THIS INCLUDES THE HOSPITAL'S CHIEF EXECUTIVE OFFICER AND THE HOSPITAL'S CHIEF FINANCIAL OFFICER. THE BOARD OF DIRECTORS CONDUCTS AN ANNUAL EVALUATION FOR THE CEO AND CFO. A NATIONAL COMPARATIVE BENCHMARK FROM QHR IS PRESENTED TO THE BOARD OF DIRECTORS. THIS COMPARATIVE DATA IS BASED ON SIMILAR HOSPITAL SIZE AND SIMILAR ANNUAL NET REVENUE. THIS DATA IS UTILIZED BY THE BOARD OF DIRECTORS IN ADDITION TO THE ANNUAL PERFORMANCE OF THE CEO AND CFO TO DETERMINE COMPENSATION. MARKET ADJUSTMENTS ARE DETERMINED ANNUALLY BY THE HR LEADER, CEO AND CFO WITH APPROPRIATE DEPARTMENT LEADERS. PAY INCREASES SHALL BE DETERMINED BY THE PERFORMANCE APPRAISAL OVERALL SCORE. ANNUAL PAY INCREASES ARE EFFECTIVE ON THE SECOND PAY PERIOD IN AUGUST EACH YEAR PROVIDED AN ANNUAL PERFORMANCE APPRAISAL HAS BEEN COMPLETED ELECTRONICALLY. THE HUMAN RESOURCE LEADER AND CEO SHALL BE RESPONSIBLE FOR COMPLETION OF AN ANNUAL COMPETENCY REPORT TO BE SUBMITTED TO THE BOARD OF DIRECTORS. THIS REPORT SHALL INCLUDE COMPETENCY OF ALL HOSPITAL EMPLOYEES. FORM 990, PART VI, SECTION C, LINE 19 PMHC DOES NOT MAKE ITS GOVERNING DOCUMENTS, CONFLICT OF INTEREST POLICY OR FINANCIAL STATEMENTS AVAILABLE TO THE PUBLIC. CHANGES IN NET ASSETS OR FUND BALANCES: FORM 990, PART XI, LINE 5: NET UNREALIZED LOSSES ON INVESTMENTS: -551,030. FORM 990, PART XII, LINE 2C: PHELPS MEMORIAL HEALTH CENTER HAS A BOARD OF DIRECTORS THAT IS ORGANIZED INTO SIX STANDING COMMITTEES: EXECUTIVE COMMITTEE; FINANCE COMMITTEE; QUALITY & COMMUNITY HEALTH COMMITTEE; GOVERNANCE COMMITTEE; SPECIALTY RECRUITMENT COMMITTEE; AND FOUNDATION COMMITTEE. IT IS THE FINANCE COMMITTEE'S DUTY TO PROVIDE INPUT INTO THE ANNUAL BUDGET PREPARATION, THE THREE YEAR CAPITAL AND LAND USE PROJECTIONS, MONITOR INVESTMENT FUNDS, PROVIDE FOR AN ANNUAL OUTSIDE AUDIT AND IN GENERAL SEE TO THE OVERALL FINANCIAL WELL BEING OF THE FACILITY. THE OVERSIGHT PROCESS OF THE AUDIT AND THE SELECTION PROCESS OF AN INDEPENDENT ACCOUNTANT HAS NOT CHANGED FROM THE PRIOR YEAR.