2026-08-12T07:40:07-05:00 2025-09-30 423603499 EIDE BAILLY ADVISORY LLC 14010 FNB PKWY STE 600 OMAHA NE 681545206 990 2024-10-01 420738969 COMMUNITY HOSPITAL INC COMM 7123821515 2959 US HIGHWAY 275 HAMBURG IA 516405052 CRISTIN HENDRICKSON CEO 7123821515 2026-08-03 1 1 MEGAN L KOZIOL P01544037 4023302660 2026-08-03 2024 2025-03-06 01:10:19Z GEORGE C GRAPE COMMUNITY HOSPITAL CRISTIN HENDRICKSON 2959 US HIGHWAY 275 HAMBURG IA 516405052 18090076 0 X WWW.GRAPEHOSPITAL.COM X 1955 IA CRITICAL ACCESS HOSPITAL 6 6 136 7 0 0 632696 138158 16412796 17861584 26619 34981 54629 50751 17126740 18085474 0 0 0 0 8079067 8731538 0 0 0 8212784 8832249 16291851 17563787 834889 521687 9111422 8754453 2838429 1846007 6272993 6908446 X GEORGE C. GRAPE COMMUNITY HOSPITAL'S WELL TRAINED MEDICAL STAFF AND HEALTH CARE TEAM WILL STRIVE TO EXCEED PATIENTS' EXPECTATIONS BY PROVIDING CONTINUITY OF PERSONALIZED CARE THROUGH EASY ACCESS TO SERVICES. 0 0 14372290 17861584 GEORGE C. GRAPE COMMUNITY HOSPITAL IS A 25 BED CRITICAL ACCESS HOSPITAL THAT RECEIVED INITIAL CERTIFICATION ON AUGUST 1, 2001. THE HOSPITAL IS OWNED AND OPERATED BY COMMUNITY HOSPITAL INC., DOING BUSINESS AS GEORGE C. GRAPE COMMUNITY HOSPITAL.AS A CRITICAL ACCESS HOSPITAL, GEORGE C. GRAPE COMMUNITY HOSPITAL PERFORMS AN ANNUAL PROGRAM EVALUATION IN ORDER TO DETERMINE WHETHER THE SERVICE IS APPROPRIATE, ADEQUATE, EFFECTIVE AND EFFICIENT. THIS EVALUATION ALSO DETERMINES WHETHER THE UTILIZATION OF SERVICES WAS APPROPRIATE, ESTABLISHED POLICIES WERE FOLLOWED, DETERMINES ANY CHANGES NEEDED AND RECOMMENDS PROJECTS FOR DEVELOPMENT DURING THE NEXT YEAR. STATISTICAL ANALYSIS: 1.) ACUTE CARE- THERE WERE A TOTAL OF 82 INPATIENT ADMISSIONS DURING FISCAL YEAR 2025 COMPARED TO 88 ADMISSIONS DURING FISCAL YEAR 2024.2.) SWING BED- 38 SWING BED ADMISSIONS WERE RECORDED DURING FISCAL YEAR 2025 COMPARED TO 43 ADMISSIONS DURING FISCAL YEAR 2024. 3.) SURGICAL CASES- THERE WERE A TOTAL OF 125 SURGICAL CASES FOR THE 2025 FISCAL YEAR AS COMPARED TO 148 SURGICAL CASES DURING FISCAL YEAR 2024.4.) OUTPATIENT SERVICES- EMERGENCY ROOM SERVICES INCREASED FROM 847 VISITS IN FISCAL YEAR 2024 TO 978 VISITS IN FISCAL YEAR 2025. LABORATORY SERVICES DECREASED FROM 14,149 IN FISCAL YEAR 2024 TO 13,148 IN FISCAL YEAR 2025. RADIOLOGY SERVICES DECREASED FROM 2,218 IN FISCAL YEAR 2024 TO 2,124 IN FISCAL YEAR 2025. ULTRASOUND SERVICES DECREASED FROM 479 IN FISCAL YEAR 2024 TO 359 IN FISCAL YEAR 2025. NUCLEAR MEDICINE SERVICES INCREASED FROM 39 IN FISCAL YEAR 2024 TO 40 IN FISCAL YEAR 2025. 14372290 1 1 0 0 0 0 0 0 0 0 1 0 0 0 1 1 0 1 0 0 0 0 0 0 0 0 1 1 0 0 1 0 0 0 0 0 0 0 0 0 0 0 0 1 1 0 0 0 1 31 0 1 136 1 0 0 0 0 0 0 0 0 0 0 0 0 X 6 6 0 0 0 0 1 1 0 1 0 0 0 1 1 1 1 1 1 1 1 0 X DOUG BRANDT 7123821515 2959 US HWY 275 HAMBURG IA 51640 DR THOMAS LARGEN PRESIDENT 1.00 X X 0 0 0 TROY HENDRICKSON VICE PRESIDENT 1.00 X X 0 0 0 KENT CLAIBORNE SECRETARY/TREASURER 1.00 X X 0 0 0 DANNY OSBORN DIRECTOR 1.00 X 0 0 0 MELISSA TRAVIS DIRECTOR 1.00 X 0 0 0 ANGIE ETTLEMAN DIRECTOR 1.00 X 0 0 0 DR MICHAEL WELLS DIRECTOR THRU 7/2025 1.00 X 0 0 0 CRISTIN HENDRICKSON CEO 40.00 X 189322 0 8883 DOUGLAS BRANDT CFO 40.00 X 127434 0 17722 MICHAEL OURADA PROVIDER 40.00 X 251963 0 0 JAYLENE ZANKER PROVIDER 40.00 X 191588 0 0 KELLI WOLTEMATH PROVIDER 40.00 X 143110 0 26861 ANGELA MALLAS LAB TECH 40.00 X 140000 0 0 JAMIE HUTT RADIOLOGY SUPERVISOR 40.00 X 123440 0 5556 1166857 0 59022 9 0 1 0 INSPIRE 100 TECHNOLOGY DRIVE BROOMFIELD CO 80021 PHYSICAL/OCCUPATIONAL THERAPY 592644 ANDERSON AND ASSOCIATES 1231 20TH STREET SHENANDOAH IA 51601 ANESTHESIOLOGY 233286 MEDICAL SOLUTIONS PO BOX 850737 MINNEAPOLIS MN 68103 TRAVELING PERSONNEL 139347 FUSION MEDICAL STAFFING LLC PO BOX 30131 OMAHA NE 68103 TRAVELING PERSONNEL 114370 RCM PROFESSIONALS LLC PO BOX 1860 BENTON AR 72018 TRAVELING PERSONNEL 109992 7 36511 60706 40941 138158 PATIENT SERVICE REVENUE 624100 17647346 17647346 AMBULANCE SERVICES 624100 83430 83430 CONTRACT SERVICES 624100 77323 77323 53485 53485 17861584 30083 30083 7200 0 7200 7200 7200 9500 4602 4898 4898 4898 CAFETERIA 624200 43551 43551 43551 18085474 17861584 0 85732 X 376500 376500 6904216 5598572 1305644 154362 101222 53140 772556 566850 205706 523904 423858 100046 5580 5580 19725 19725 191265 191265 3487149 3045661 441488 29285 6976 22309 382586 331790 50796 87414 87414 338175 237832 100343 9122 6930 2192 20898 13930 6968 64705 64705 649996 520321 129675 183483 78264 105219 MEDICAL SUPPLIES 3320287 3320287 DUES & SUBSCRIPTIONS 32028 21832 10196 10551 10551 17563787 14372290 3191497 0 218760 93162 701420 618797 1366595 1439647 170324 4297 447932 565508 57551 17788 16928755 11449751 5910944 5479004 225426 339192 12470 197058 9111422 8754453 1075650 1112576 23504 23504 869972 703856 869303 6071 2838429 1846007 X 6272993 6908446 6272993 6908446 9111422 8754453 521687 113766 0 X X 0 1 X 1 0 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 98000 98000 7125066 4028255 3096811 9349598 7151184 2198414 356091 270312 85779 5479004 CAPITAL LEASE OBLIGATIONS 6071 6071 X PART X, LINE 2: THE HOSPITAL ACCOUNTS FOR UNCERTAINTIES IN ACCOUNTING FOR INCOME TAX ASSETS AND LIABILITIES USING GUIDANCE INCLUDED IN FINANCIAL ACCOUNTING STANDARDS BOARD (FASB) ACCOUNTING STANDARDS CODIFICATION (ASC) 740, INCOME TAXES. THE HOSPITAL RECOGNIZES THE EFFECT OF INCOME TAX POSITIONS ONLY IF THOSE POSITIONS ARE MORE LIKELY THAN NOT OF BEING SUSTAINED. AT SEPTEMBER 30, 2025 AND 2024, THE HOSPITAL HAD NO UNCERTAIN TAX POSITIONS ACCRUED. 1 1 X 1 X 1 X 1 1 0 1 1 33000 33000 0.00190 1345101 1345101 1378101 1345101 33000 0.00190 24941 24941 0.00140 1169756 855290 314466 0.01790 1194697 855290 339407 0.01930 2572798 2200391 372407 0.02120 1 271399 27683 8573530 8620708 -47178 X 1 1 1 1 COMMUNITY HOSPITAL INC 2959 US HWY 275 HAMBURG IA 51640 WWW.GRAPEHOSPITAL.COM 360067H X X X X GEORGE C GRAPE COMMUNITY HOSPITAL 1 0 0 1 X X X X X X X X X 24 1 0 0 1 X HTTPS://WWW.GRAPEHOSPITAL.COM/GETPAGE.PHP?NAME=NEWS_CHNA2025 X 1 24 1 HTTPS://WWW.GRAPEHOSPITAL.COM/GETPAGE.PHP?NAME=NEWS_CHNA2025 0 1 X 200.000000000000 400.000000000000 X X X X 1 1 X X X 1 X HTTPS://WWW.GRAPEHOSPITAL.COM/DOCS/FINANCIAL_ASSISTANCE_POLICY.PDF X HTTPS://WWW.GRAPEHOSPITAL.COM/DOCS/FAP_WEB_APPLICATION.PDF X HTTPS://WWW.GRAPEHOSPITAL.COM/DOCS/PLAIN_LANGUAGE_SUMMARY.PDF X X X X X 1 X 0 X X X X 1 X 0 0 GEORGE C. GRAPE COMMUNITY HOSPITAL PART V, SECTION B, LINE 5: CHNA ASSESSMENT BEGAN IN AUGUST OF 2024 AND WAS FACILITATED / CREATED BY GEORGE C. GRAPE COMMUNITY HOSPITAL'S CHNA BOARD. CREATING HEALTHY COMMUNITIES REQUIRES A HIGH LEVEL OF MUTUAL UNDERSTANDING AND COLLABORATION AMONG COMMUNITY LEADERS. THE DEVELOPMENT OF THE ASSESSMENT BROUGHT TOGETHER COMMUNITY HEALTH LEADERS AND PROVIDERS, ALONG WITH THE RESIDENTS, TO RESEARCH AND PRIORITIZE COUNTY HEALTH NEEDS AND DOCUMENT COMMUNITY HEALTH DELIVERY SUCCESS. AREA STAKEHOLDERS HELD A COMMUNITY CONVERSATION TO REVIEW, DISCUSS AND PRIORITIZE HEALTH DELIVERY. COMMUNITY FEEDBACK FROM RESIDENTS, COMMUNITY LEADERS AND PROVIDERS WAS OBTAINED USING AN ONLINE PERCEPTION SURVEY. GEORGE C. GRAPE COMMUNITY HOSPITAL PART V, SECTION B, LINE 11: IN THE 2024-2025 FISCAL YEAR, GEORGE C. GRAPE COMMUNITY HOSPITAL (THE HOSPITAL) ADDRESSED THE NEEDS OF THE COMMUNITY (AS IDENTIFIED IN THE PRIOR COMMUNITY HEALTH NEEDS ASSESSMENT REPORT DUE TO TIMING OF THE NEW CHNA).SPECIFIC NEEDS TO BE ADDRESSED INCLUDED MENTAL HEALTH, PRIMARY CARE, FOOD INSECURITY, VISITING SPECIALISTS, SENIOR ACTIVITIES, ADEQUATE HEALTHCARE STAFFING, AND SUBSTANCE ABUSE.THE FACILITY HAS HOSTED MANY CLASSES FOR THE COMMUNITY IN THE CURRENT TAX YEAR, AS WELL AS HOSTING A BLOOD DRIVE. THE HOSPITAL CONTINUED TO EDUCATE ER STAFF REGARDING MENTAL HEALTH DELIVERY ISSUES AND HOW TO ADDRESS THEM, AS WELL AS PROVIDED CONTINUING EDUCATION COURSES TO KEEP THE STAFF CURRENT IN TERMS OF TREATING MENTAL HEALTH ISSUES AND TRAINING STAFF TO WORK WITH HEARTLAND FAMILY SERVICES. EXISTING MENTAL HEALTH SERVICES, FACILITIES AND PROVIDERS WERE PROMOTED DURING THE YEAR.THE HOSPITAL CONTINUED TO RECRUIT PROVIDERS TO THE AREA AND SOUGHT ADDITIONAL FEDERAL AND STATE GRANT MONEY TO SUPPORT ADDITIONAL PROVIDER COVERAGE.THE HOSPITAL OFFERED "AWARENESS PROGRAM" TO EDUCATE ELEMENTARY/MIDDLE SCHOOL STUDENTS AND THEIR FAMILIES ABOUT NUTRITION AND LOCAL PROGRAMS AVAILABLE, AS WELL AS PROVIDED NUTRITION EDUCATION AT FAIRS AND OTHER EDUCATIONAL PROGRAMS THROUGHOUT THE YEAR.DURING THE YEAR, THE HOSPITAL DEVELOPED PARTNER RELATIONSHIPS WITH AREA PROVIDERS TO COLLECTIVELY RECRUIT VISITING SPECIALISTS AND IDENTIFIED KEY COLLABORATIVE PARTNERS TO POSSIBLY SHARE OFFICE SPACE, WORKFORCE AND EQUIPMENT.THE HOSPITAL UPDATED THE COMMUNITY FACEBOOK PAGE THROUGHOUT THE YEAR TO PROMOTE COMMUNITY ACTIVITIES FOR FAMILIES AND SENIORS, AND PROVIDED WEB LINKS TO AREA PROVIDERS, SCHOOLS, CHURCHES, AND COMMUNITY PROGRAMS TO ENCOURAGE THESE ENTITIES TO ADD HEALTH INFORMATION TO THEIR PAGES.THE HOSPITAL ALSO SUPPLIED VARIOUS EDUCATIONAL HANDOUTS FOR MEDICAL PROVIDERS TO DISTRIBUTE TO PATIENTS WHEN PRESCRIBING SCHEDULE II DRUGS, AS WELL AS SUPPLIED EDUCATION REGARDING SUBSTANCE ABUSE FOR PATIENTS AND STUDENTS THROUGH THEIR SOCIAL MEDIA PLATFORMS.THE HOSPITAL WILL BE ADDRESSING ALL NEEDS THAT WERE BROUGHT UP IN THE MOST RECENT CHNA IN THE FUTURE. THESE NEEDS INCLUDE MENTAL HEALTH, NUTRITION, EXERCISE, OBESITY AND WELLNESS EDUCATION, POVERTY, SENIOR CARE/SUPPORT, DRUG/SUBSTANCE ABUSE, AWARENESS OF HEALTHCARE SERVICES, AND PRENATAL CARE. 4 1 - SOUTHWEST IOWA HOME HEALTH 803 INDIANA STREET SIDNEY IA 51652 HOME HEALTH/PUBLIC HEALTH AGENCY 2 - HAMBURG MEDICAL CLINIC 1219 MAIN STREET HAMBURG IA 51640 RURAL HEALTH CLINIC 3 - SIDNEY MEDICAL CLINIC 313 MAIN STREET SIDNEY IA 51652 RURAL HEALTH CLINIC 4 - TABOR MEDICAL CLINIC 710 CENTER STREET TABOR IA 51653 RURAL HEALTH CLINIC PART I, LINE 3C: ASSET LEVEL, MEDICAL INDIGENCY, INSURANCE STATUS AND UNDERINSURANCE STATUS ARE USED, ALONG WITH FEDERAL POVERTY GUIDELINES, TO DETERMINE ELIGIBILITY FOR PROVIDING FREE AND DISCOUNTED CARE TO LOW INCOME INDIVIDUALS. PART I, LINE 7: CHARITY CARE EXPENSE WAS CONVERTED TO COST ON LINE 7A BASED ON AN OVERALL COST-TO-CHARGE RATIO ADDRESSING ALL PATIENT SEGMENTS. UNREIMBURSED MEDICAID, LINE 7B, AND SUBSIDIZED HEALTH SERVICES, LINE 7G, WERE CALCULATED USING THE COSTING METHODS TO PREPARE THE COST REPORTS. COMMUNITY HEALTH IMPROVEMENT SERVICES, LINE 7E, IS REPORTED BASED ON ACTUAL EXPENSES REPORTED IN THE GENERAL LEDGER. PART III, LINE 2: THE AMOUNT ON LINE 2 REFLECTS IMPLICIT PRICE CONCESSIONS. THE HOSPITAL DETERMINES ITS ESTIMATE OF IMPLICIT PRICE CONCESSIONS BASED ON HISTORICAL COLLECTION EXPERIENCE WITH VARIOUS CLASSES OF PATIENTS. PART III, LINE 3: THE ESTIMATED AMOUNT OF THE ORGANIZATION'S IMPLICIT PRICE CONCESSIONS ATTRIBUTABLE TO PATIENTS ELIGIBLE UNDER THE ORGANIZATION'S CHARITY CARE POLICY IS CALCULATED BASED ON AN APPROXIMATE 10.2% OF INDIVIDUALS LIVING BELOW THE POVERTY LEVEL IN THE SERVICE AREA. PART III, LINE 4: THE FOOTNOTE TO THE ORGANIZATION'S FINANCIAL STATEMENTS THAT DESCRIBES IMPLICIT PRICE CONCESSIONS IS LOCATED IN FOOTNOTE 1 ON PAGES 11 AND 12 OF THE ATTACHED FINANCIAL STATEMENTS. PART III, LINE 8: SERVICES ARE PROVIDED TO PATIENTS UNDER THE MEDICARE PROGRAM EVEN THOUGH THE HOSPITAL KNOWS THEY WILL NOT RECOVER ALL OF THE COSTS FROM PROVIDING THE SERVICES. THIS PROGRAM IS CONSIDERED SUBSIDIZED BY THE HOSPITAL AND OTHER PAYORS. PATIENTS RELY ON THESE SERVICES FOR THEIR HEALTH AND WELL-BEING AND ARE ESSENTIAL FOR THEIR ACCESS TO HEALTHCARE. TOTAL REVENUE RECEIVED FROM MEDICARE IS THE GROSS REIMBURSEMENT PLUS SETTLEMENT. BOTH TOTAL REVENUE RECEIVED FROM MEDICARE AND THE MEDICARE ALLOWABLE COSTS ARE REPORTED FROM THE MEDICARE COST REPORT. THE MEDICARE COST REPORT IS COMPLETED BASED ON THE RULES AND REGULATIONS SET FORTH BY CENTERS FOR MEDICARE AND MEDICAID SERVICES. THERE IS NO SHORTFALL IN THE CURRENT YEAR.HOSPITAL SERVICES RENDERED ON A FEE SCHEDULE ARE NOT INCLUDED IN THE MEDICARE CALCULATIONS PER THE 990 INSTRUCTIONS. HAD THIS BEEN REPORTED THE HOSPITAL WOULD HAVE HAD A GREATER LOSS FROM MEDICARE SERVICES OF $72,220.MEDICARE FEE SCHEDULE REVENUE $21,552MEDICARE ESTIMATED COSTS OF CARE RELATING TO PAYMENTS $93,772NET (SHORTAGE) $(72,220) PART III, LINE 9B: THE COLLECTIONS/CHARITY WRITE-OFF POLICY PROVIDES THAT ONCE THE PATIENT/GUARANTOR QUALIFIES FOR CHARITY CARE HE/SHE WILL BE NOTIFIED OF THE AMOUNT OF FREE CARE AND THE NON-CHARITY AMOUNT. PAYMENT ARRANGEMENTS WILL BE MADE FOR THE NON-CHARITY AMOUNT AT THE TIME OF NOTIFICATION. NO ACTIONS ARE TAKEN ON ACCOUNTS UNTIL REASONABLE EFFORTS ARE MADE TO DETERMINE IF A PATIENT QUALIFIES FOR FINANCIAL ASSISTANCE. COLLECTION ACTIONS ARE THE SAME FOR THE NON-CHARITY AMOUNT AS OTHER PATIENTS. PART VI, LINE 2: AT GEORGE C. GRAPE HOSPITAL, WE EMPLOY SEVERAL STRATEGIES IN ADDITION TO THE COMMUNITY HEALTH NEEDS ASSESSMENT (CHNA) TO ASSESS THE HEALTH CARE NEEDS OF OUR COMMUNITY:1. PATIENT FEEDBACK AND SURVEYS: WE REGULARLY COLLECT AND ANALYZE FEEDBACK FROM OUR PATIENTS THROUGH SATISFACTION SURVEYS, SUGGESTION BOXES, AND DIRECT PATIENT INTERVIEWS. THIS HELPS US UNDERSTAND THEIR EXPERIENCES, IDENTIFY GAPS IN SERVICES, AND MAKE NECESSARY IMPROVEMENTS.2. COLLABORATION WITH LOCAL HEALTH ORGANIZATIONS: WE PARTNER WITH LOCAL PUBLIC HEALTH DEPARTMENTS, CLINICS, AND COMMUNITY ORGANIZATIONS SUCH AS FREMONT COUNTY PUBLIC HEALTH AND IOWA STATE UNIVERSITY EXTENSION AND OUTREACH OFFICE TO SHARE INFORMATION AND INSIGHTS. THIS COLLABORATIVE APPROACH ALLOWS US TO GAIN A COMPREHENSIVE UNDERSTANDING OF COMMUNITY HEALTH TRENDS AND NEEDS.3. HEALTH DATA ANALYSIS: WE REVIEW AND ANALYZE HEALTH DATA FROM VARIOUS SOURCES, INCLUDING THE CDC, STATE HEALTH DEPARTMENTS, AND LOCAL HEALTH STATISTICS. THIS DATA HELPS US IDENTIFY PREVALENT HEALTH ISSUES, EMERGING HEALTH TRENDS, AND AREAS REQUIRING FOCUSED ATTENTION.4. EMERGENCY DEPARTMENT AND CLINIC UTILIZATION REPORTS: BY ANALYZING THE UTILIZATION PATTERNS OF OUR EMERGENCY DEPARTMENT AND CLINICS, WE CAN IDENTIFY COMMON HEALTH ISSUES AND UNMET NEEDS IN THE COMMUNITY. THIS HELPS US TAILOR OUR SERVICES TO ADDRESS THESE SPECIFIC NEEDS.5. HEALTH SCREENINGS AND OUTREACH PROGRAMS: OUR HOSPITAL CONDUCTS REGULAR HEALTH SCREENINGS AND OUTREACH PROGRAMS IN VARIOUS COMMUNITY SETTINGS. THESE INITIATIVES NOT ONLY PROVIDE DIRECT HEALTH SERVICES BUT ALSO OFFER INSIGHTS INTO THE HEALTH STATUS AND NEEDS OF DIFFERENT POPULATION GROUPS WITHIN OUR COMMUNITY.6. ENGAGEMENT WITH HEALTHCARE PROVIDERS: WE MAINTAIN REGULAR COMMUNICATION WITH OUR NETWORK OF HEALTHCARE PROVIDERS, INCLUDING PRIMARY CARE PHYSICIANS, SPECIALISTS, AND ALLIED HEALTH PROFESSIONALS. THEIR FIRSTHAND EXPERIENCES AND OBSERVATIONS PROVIDE VALUABLE INFORMATION ABOUT THE HEALTH NEEDS AND CHALLENGES FACED BY THEIR PATIENTS.BY COMBINING THESE METHODS, WE CAN GAIN A UNDERSTANDING OF THE HEALTH CARE NEEDS OF OUR COMMUNITY AND ENSURE THAT OUR SERVICES ARE ALIGNED WITH THOSE NEEDS, ULTIMATELY ENHANCING THE OVERALL HEALTH AND WELL-BEING OF THE RESIDENTS WE SERVE. PART VI, LINE 3: THE HOSPITAL COMMUNICATES VIA MAIL WITH EACH PATIENT. THE ON STAFF FINANCIAL COUNSELOR ASSISTS PATIENTS IN COMPLETING THE FINANCIAL ASSISTANCE APPLICATION WHEN NECESSARY. PATIENTS WILL RECEIVE STATEMENTS OF ACCOUNT VIA MAIL WITH FINANCIAL ASSISTANCE POLICY INFORMATION INCLUDED. WHEN POSSIBLE, THE FINANCIAL COUNSELOR WILL SPEAK WITH PATIENTS PERSONALLY BEFORE BEING DISCHARGED TO DISCUSS THEIR CHARITY CARE NEEDS. PART VI, LINE 4: OUR PRIMARY SERVICE AREA INCLUDES FREMONT COUNTY. THE NORTHERN PART OF THE COUNTY IS BEGINNING TO GROW AT A SLOW PACE. THE MIDDLE AND SOUTHERN PART OF THE COUNTY IS EITHER DECLINING OR MAINTAINING THEIR POPULATIONS. THE SOUTHERN PART OF THE COUNTY ALSO HAS A HIGH POVERTY RATE. THIS SERVICE AREA HAS A POPULATION OF 7,147. OUR SECONDARY SERVICE AREA INCLUDES THREE SURROUNDING COUNTIES IN IOWA, TWO IN MISSOURI, AND TWO IN NEBRASKA WHICH HAVE AN ESTIMATED POPULATION OF 93,000. THE HOSPITAL DOES SERVE SOME PATIENTS IN THE SECONDARY SERVICE AREA, BUT THE MAJORITY OF THE PATIENTS COME FROM THE PRIMARY SERVICE AREA. PART VI, LINE 5: WE PROMOTE HEALTH TO THE COMMUNITY BY PROVIDING INFORMATION VIA OUR SOCIAL MEDIA OUTLETS, SCHEDULED CLASSES, AND COMMUNITY ACTIVITIES. A MAJORITY OF THE GOVERNING BODY IS COMPRISED OF INDIVIDUALS WHO RESIDE IN THE ORGANIZATION'S PRIMARY SERVICE AREA AND ARE NOT EMPLOYEES OR CONTRACTORS OF THE ORGANIZATION, NOR ARE THEY RELATED TO ANY INDIVIDUALS WHO ARE EMPLOYEES OR CONTRACTORS OF THE ORGANIZATION. THE HOSPITAL EXTENDS MEDICAL STAFF PRIVILEGES TO ALL QUALIFIED PHYSICIANS IN ITS COMMUNITY FOR SOME OR ALL OF ITS DEPARTMENTS. IF THERE ARE SURPLUS FUNDS, THE HOSPITAL WILL USE THE FUNDS TO UPDATE EQUIPMENT TO PROVIDE MEANINGFUL IMPROVEMENTS FOR PATIENTS, NOT JUST OPERATIONALLY, BUT IN SAFETY, OUTCOMES, EXPERIENCES, AND ACCESS TO CARE. PART VI, LINE 7, REPORTS FILED WITH STATES IA X X 0 0 0 0 0 0 0 0 0 MICHAEL OURADA PROVIDER 251963 0 0 0 0 0 0 0 0 0 251963 0 0 0 CRISTIN HENDRICKSON CEO 189322 0 0 0 0 0 7593 0 1983 0 198898 0 0 0 JAYLENE ZANKER PROVIDER 191588 0 0 0 0 0 0 0 0 0 191588 0 0 0 KELLI WOLTEMATH PROVIDER 143110 0 0 0 0 0 3783 0 23998 0 170891 0 0 0 FORM 990, PART VI, SECTION A, LINE 6 GRAPE COMMUNITY HOSPITAL IS A CORPORATION THAT HAS MEMBERS. MEMBERSHIP IN THE CORPORATION SHALL CONSIST OF THE PERSONS, CORPORATIONS OR ASSOCIATIONS WHO SUBSCRIBED AS INCORPORATORS AND SUCH OTHER PERSONS, CORPORATIONS OR ASSOCIATIONS WHO HAVE CONTRIBUTED $100 OR MORE TO THE CORPORATION IN CASH, PROPERTY OR VOLUNTEER SERVICES RENDERED TO THE CORPORATION. FORM 990, PART VI, SECTION A, LINE 7A THE INDIVIDUAL MEMBERS (NOT CORPORATE OR ASSOCIATION MEMBERS) OF GRAPE COMMUNITY HOSPITAL (AS DESCRIBED ON FORM 990, PART VI, SECTION A, LINE 6) SHALL ELECT, AT THE ANNUAL MEETING, THE BOARD OF DIRECTORS. FORM 990, PART VI, SECTION A, LINE 8B THERE IS NO COMMITTEE WITH THE AUTHORITY TO ACT ON BEHALF OF THE GOVERNING BODY. FORM 990, PART VI, SECTION B, LINE 11B THE CEO AND DIRECTOR OF FINANCE WILL REVIEW THE 990 PRIOR TO SUBMISSION. THE 990 WILL BE PRESENTED TO THE BOARD OF DIRECTORS FOR REVIEW PRIOR TO SUBMISSION. FORM 990, PART VI, SECTION B, LINE 12C ALL DIRECTORS AND KEY EMPLOYEES WILL BE REQUIRED TO ANNUALLY COMPLETE THE "CONFLICT OF INTERESTS STATEMENT". THIS POLICY IS REVIEWED BY THE BOARD OF DIRECTORS ANNUALLY AND GIVEN TO EACH NEW DIRECTOR FOR SIGNATURE DURING ORIENTATION. ANY CONFLICTS THAT ARISE DURING THE YEAR ARE DISCLOSED TO THE BOARD OF DIRECTORS AND APPROPRIATELY DOCUMENTED. SHOULD ANY CONFLICT REQUIRE BOARD ACTION, THE DIRECTORS SHALL HOLD A MEETING TO VOTE ON THE MATTER. FORM 990, PART VI, SECTION B, LINE 15 THE CEO'S SALARY WAS DETERMINED BY USING THE IOWA HOSPITAL ASSOCIATION (IHA) SALARY SURVEY. IT WAS DISCUSSED BY INDEPENDENT BOARD MEMBERS AND REVIEWED BY LEGAL COUNSEL. THIS PROCESS HAS BEEN IN PLACE SINCE 2008. ALL OTHER SALARIES, REGARDLESS OF THE POSITION, ARE COMPARED TO THE IHA SALARY SURVEY WITH YEARS OF EXPERIENCE TAKEN INTO CONSIDERATION AS WELL. THE HOSPITAL HAS SENIOR ADMINISTRATION THAT ARE INVOLVED IN THE HIRING OF MANAGEMENT, INCLUDING THE CEO. FORM 990, PART VI, SECTION C, LINE 19 THE GOVERNING DOCUMENTS, FINANCIAL STATEMENTS AND CONFLICT OF INTEREST POLICY ARE AVAILABLE TO THE PUBLIC UPON REQUEST. FORM 990, PART IX, LINE 11G OTHER FEES FOR SERVICE: PROGRAM SERVICE EXPENSES 1,518,438. MANAGEMENT AND GENERAL EXPENSES 441,488. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 1,959,926. NURSING SERVICES: PROGRAM SERVICE EXPENSES 1,000,591. MANAGEMENT AND GENERAL EXPENSES 0. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 1,000,591. ANESTHESIA SERVICES: PROGRAM SERVICE EXPENSES 197,527. MANAGEMENT AND GENERAL EXPENSES 0. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 197,527. LAB SERVICES: PROGRAM SERVICE EXPENSES 204,760. MANAGEMENT AND GENERAL EXPENSES 0. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 204,760. RADIOLOGY SERVICES: PROGRAM SERVICE EXPENSES 124,345. MANAGEMENT AND GENERAL EXPENSES 0. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 124,345. FORM 990, PART XII, LINE 2C: THE BOARD OF DIRECTORS ASSUMES RESPONSIBILITY FOR OVERSIGHT OF THE AUDIT AND SELECTION OF AN INDEPENDENT ACCOUNTANT. THIS PROCESS HAS NOT CHANGED FROM THE PRIOR YEAR. MEDICAL CLINIC INC 1219 MAIN ST HAMBURG IA 51640 420994017 MEDICAL CLINIC IA 1918115 566387 COMMUNITY HOSPITAL INC GRAPE HOSPITAL FOUNDATION PO BOX 9 HAMBURG IA 51640 421335348 FUNDRAISING AND SUPPORT OF GEORGE C. GRAPE COMMUNITY HOSPITAL IA 501(C)(3) LINE 12B, II N/A 0 0 0 1 0 0 0 0 0 0 0 0 0 1 1 0 0 0 0 0