2014-05-09T16:21:56-05:00 2013-06-30 476097913 SEIM JOHNSON LLP 18081 BURT STREET SUITE 200 OMAHA NE 680224722 990 2012-07-01 421087612 KNOXVILLE COMMUNITY HOSPITAL INC KNOX 6418421407 1002 SOUTH LINCOLN KNOXVILLE IA 50138 MAGGIE HAMILTON-BEYER 6418421407 2014-05-08 1 BARBARA J FAJEN P00400874 4023302660 2012 2015-11-30 17:44:51Z MAGGIE HAMILTON-BEYER 1002 SOUTH LINCOLN KNOXVILLE IA 50138 28256137 0 X WWW.KACH.ORG X 1981 IA TO PROVIDE A COMPLETE CONTINUUM OF HEALTHCARE SERVICES TO THE PEOPLE OF KNOXVILLE & SURROUNDING COMMUNITIES WITHOUT REGARD FOR ABILITY TO PAY AND WITHOUT DISCRIMINATION. 9 8 321 2 2383 -8081 67815 50526 26980533 28029305 -99016 64206 102951 111836 27052283 28255873 0 0 0 0 13123922 12989008 0 0 0 13260935 13770660 26384857 26759668 667426 1496205 11226145 14543405 5335823 7128891 5890322 7414514 X THROUGH OUR CARING COMPASSION AND WITH A HEALING SPIRIT, WE PROVIDE EXCEPTIONAL HEALTHCARE SERVICES. WE SERVE THE COMMUNITY WITHOUT REGARD FOR THEIR ABILITY TO PAY, WITHOUT DISCRIMINATION AND TO PROVIDE A COMPLETE CONTINUUM OF HEALTHCARE SERVICES TO THE PEOPLE OF KNOXVILLE AND SURROUNDING AREAS. 0 0 25116860 28030797 KNOXVILLE COMMUNITY HOSPITAL, INC. IS A CRITICAL ACCESS HOSPITAL WITH 25 ACUTE BEDS. THE HOSPITAL PROVIDES ACUTE AND ANCILLARY SERVICES TO INDIVIDUALS IN BOTH INPATIENT AND OUTPATIENT SETTINGS. DURING FISCAL YEAR 2013, THE HOSPITAL PROVIDED 1,458 DAYS OF SKILLED NURSING CARE, 121 NURSERY DAYS, AND 173,518 OUTPATIENT OCCASIONS OF SERVICE. 25116860 1 1 0 1 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 0 1 0 0 0 1 79 0 1 321 1 1 1 0 0 0 0 0 0 0 0 0 X 9 8 0 1 0 0 0 0 0 1 1 0 0 0 1 1 1 1 1 1 1 0 X MAGGIE HAMILTON-BEYER 6418421402 1002 SOUTH LINCOLN KNOXVILLE IA 50138 MEL A SUHR 1.00 0.00 X X 0 0 0 BARRY L GRIFFITH JD 1.00 0.00 X X 0 0 0 MEGAN MCKAY 1.00 0.00 X X 0 0 0 TRESA MOTT 1.00 0.00 X X 0 0 0 STUART L JOB 1.00 0.00 X X 0 0 0 JIM DEVORE 1.00 0.00 X 0 0 0 KARI FROELING 1.00 0.00 X 0 0 0 DANIEL J ROWLEY MD 1.00 0.00 X 219166 0 17385 PATRICK STOCKTON 1.00 0.00 X 0 0 0 KEVIN KINCAID 40.00 0.00 X 161013 0 28403 MAGGIE HAMILTON-BEYER 40.00 0.00 X 109520 0 2350 THOMAS HOEHNS 40.00 0.00 X 240789 0 23913 EARL MCKEEVER 40.00 0.00 X 220666 0 19517 DAVID KERMODE 40.00 0.00 X 205266 0 12321 BYRON SCHAEFFER 40.00 0.00 X 177138 0 22744 BHAMA JAYAVEERAPADIAN 40.00 0.00 X 160583 0 8703 1494141 0 135336 13 0 1 0 DOC EMERGENCY MEDICINE INC 1337 S FOUNTAIN DR OLATHE IA 66061 ER PHYSICIAN COVEREAGE 799607 SQUAREWAVEFORM ANESTHESIOLOGY PO BOX 1192 MARSHALLTOWN IA 50158 ANESTHESIOLOGY COVERAGE 491913 21ST CENTURY REHAB PO BOX 461 NEVADA IA 50201 PT/OT SERVICES 491902 MERCY HEALTH NETWORK INC 1755 59TH PLACE DES MOINES IA 50266 HOSPITAL MANAGEMENT SERVICES 375801 ACUTE CARE INC PO BOX 3288 DES MOINES IA 50316 ER PHYSICIAN COVERAGE 343090 9 31176 18198 1152 50526 MEDICARE 621110 12511269 12511269 NET PATIENT SERVICE REVENUE 621110 10942069 10942069 PHARMACY 621110 2523825 2523825 MEDICAID 621110 1834732 1834732 ELECTRONIC HEALTH RECORDS INCENTI 621110 104477 104477 112933 112933 28029305 62620 62620 1850 264 1586 1586 1586 CAFETERIA 900099 110344 2383 107961 MISCELLANEOUS 900099 1492 1492 111836 28255873 28030797 2383 172167 X 527037 236551 290486 10293428 9790516 502912 2168543 2051122 117421 583985 378032 205953 22081 22081 48731 48731 3252 3252 3943717 3826743 116974 154733 154733 766812 556292 210520 250934 194361 56573 1512280 1501677 10603 31417 22014 9403 38766 29812 8954 151865 151865 655803 655803 218454 190354 28100 MEDICAL SUPPLIES 3530787 3530787 BAD DEBTS 1793061 1793061 DUES & LICENSES 58767 48893 9874 SUBSCRIPTIONS & BOOKS 5215 4244 971 26759668 25116860 1642808 0 644542 1238914 385547 1530686 3467137 2748619 382014 603066 390650 468756 101898 104969 16539344 10727942 4449082 5811402 588065 1319013 797328 655842 19882 62138 11226145 14543405 1833063 2139494 3042672 4827248 460088 162149 5335823 7128891 X 5890322 7414514 5890322 7414514 11226145 14543405 1496205 27987 0 X X 0 1 X 1 0 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 0 0 0 0 0 0 0 0 1 3893 3893 0 EXPLANATION OF LOBBYING ACTIVITIES: PART II-B, LINE 1: KNOXVILLE COMMUNITY HOSPITAL, INC. PAYS DUES TO THE IOWA HOSPITAL ASSOCIATION, OF WHICH A PORTION (23.1%) IS USED FOR LOBBYING ACTIVITIES. 252056 252056 8097522 6011646 2085876 5815386 4357205 1458181 2374380 359091 2015289 5811402 ESTIMATED THIRD PARTY PAYOR SETTLEMENTS 115644 CAPITAL LEASES 46505 162149 X 26487547 27987 27987 26459560 3252 1793061 1796313 28255873 24963355 0 24963355 3252 1793061 1796313 26759668 DESCRIPTION OF UNCERTAIN TAX POSITIONS UNDER FIN 48: PART X, LINE 2: THE HOSPITAL IS A NOT-FOR-PROFIT CORPORATION AS DESCRIBED IN SECTION 501(C)(3) OF THE INTERNAL REVENUE CODE. THE HOSPITAL HAS RECEIVED A DETERMINATION LETTER INDICATING THAT IT IS EXEMPT FROM FEDERAL INCOME TAXES ON RELATED INCOME PURSUANT TO SECTION 501(A) OF THE INTERNAL REVENUE CODE. THE HOSPITAL ACCOUNTS FOR UNCERTAINTIES IN ACCOUNTING FOR INCOME TAX ASSETS AND LIABILITIES USING GUIDANCE INCLUDED IN FASB 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 JUNE 30, 2013, THE HOSPITAL HAD NO UNCERTAIN TAX POSITIONS ACCRUED. WITH FEW EXCEPTIONS, THE HOSPITAL IS NO LONGER SUBJECT TO INCOME TAX EXAMINATIONS FOR THE YEAR ENDED PRIOR TO 2010. PART XI, LINE 4B - OTHER ADJUSTMENTS: PROVISION FOR BAD DEBTS 1,793,061. PART XII, LINE 4B - OTHER ADJUSTMENTS: PROVISION FOR BAD DEBTS 1,793,061. 1 1 1 X 1 X 1 1 1 0 1 0 70 127000 127000 0.00510 1879800 596063 1283737 0.05140 450710 256931 193779 0.00780 70 2457510 852994 1604516 0.06430 41272 8843 32429 0.00130 118580 7000 111580 0.00450 43379 0 43379 0.00170 203231 15843 187388 0.00750 70 2660741 868837 1791904 0.07180 902 0 902 0.00000 5083 0 5083 0.00020 17942 360 17582 0.00070 56024 0 56024 0.00220 79951 360 79591 0.00310 1 1793061 0 10051479 9781469 270010 X 0 1 1 KNOXVILLE AREA COMMUNITY HOSPITAL

1002 S LINCOLN STREET KNOXVILLE IA 50138

X X X X KNOXVILLE COMMUNITY HOSPITAL INC 1 1 X X X X X X X X X X 12 1 0 1 X X X X X X X 1 0 1 1 100.000000000000 1 300.000000000000 1 X X X X 1 1 X X 0 0 X X X 1 X 0 0 4 KNOXVILLE AREA COMMUNITY HOSPITAL CLINIC

1202 WEST HOWARD STREET KNOXVILLE IA 50138

PHYSICIAN CLINIC MELCHER PHYSICIANS CLINIC

113 NORTH MAIN STREET MELCHER IA 50163

PHYSICIAN CLINIC PLEASANTVILLE PHYSICIAN CLINIC

104 NORTH WASHINGTON STREET PLEASANTVILLE IA 50225

PHYSICIAN CLINIC BELL AVENUE CLINIC

1008 BELL AVENUE SUITE 104 KNOXVILLE IA 50138

WOMEN'S CLINIC PART I, LINE 3C: NOT APPLICABLE: FEDERAL POVERTY GUIDELINES ARE USED TO DETERMINE ELIGIBILITY FOR PROVIDING FREE CARE OR DISCOUNTED CARE TO LOW INCOME INDIVIDUALS. PART I, LINE 6A: KNOXVILLE COMMUNITY HOSPITAL, INC.'S COMMUNITY BENEFIT REPORT IS NOT PREPARED BY A RELATED ORGANIZATION. THE MANAGEMENT OF KNOXVILLE COMMUNITY HOSPITAL PREPARES THE COMMUNITY BENEFIT REPORT. PART I, LINE 7: THE COST TO CHARGE RATIO AS FOLLOWS WAS USED TO DETERMINE CHARITY CARE AND MEANS-TESTED GOVERNMENT PROGRAMS AT COST: (TOTAL EXPENSES - BAD DEBT) / (GROSS PATIENT SERVICE REVENUE + OTHER REVENUE) = PERCENTAGE OF COST TO CHARGE. OTHER COMMUNITY BENEFIT EXPENSES ARE STATED AT COST BASED ON KNOXVILLE COMMUNITY HOSPITAL INC.'S INTERNAL ACCOUNTING RECORDS. PART I, LINE 7G: THERE ARE NO COSTS ATTRIBUTABLE TO A PHYSICIAN CLINIC INCLUDED ON LINE 7G. 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 $ 1793061. PART II: COMMUNITY SERVICE PROJECTS: EMPLOYEES PARTICIPATED IN THE "ACTS FOR SERVICE" EVENT WHICH INVOLVES HELPING COMMUNITY MEMBERS WITH HOME IMPROVEMENTS. WE ALSO HAD LEADERS GO TO A HABITAT HOUSE AND ASSIST FOR A DAY AS A COMMUNITY SERVICE PROJECT. DEPARTMENT LEADERS PERFORM ANNUAL SERVICE PROJECTS AT HELPING HANDS FOOD PANTRY. ECONOMIC DEVELOPMENT: A DEPARTMENT LEADER IS ON THE INDUSTRIAL DEVELOPMENT COUNCIL AND LOCAL CHAMBER SO SHE ATTENDS MEETINGS AND EVENTS DURING THE DAY. ONE OF OUR LEADERS IS ALSO PRESIDENT OF THE LOCAL ROTARY CLUB AND FUNDED DAY CARE BOARD. DEPARTMENT LEADERS PERFORMED A SERVICE PROJECT IN THE LOCAL LIBRARY RENOVATION. THE CEO AND ADMINISTRATIVE ASSISTANT ARE ON THE CHAMBER BOARD.COMMUNITY SUPPORT: WE DONATE FUNDS FOR VARIOUS COMMUNITY ACTIVITIES SUCH AS CANCER RUNS, POST-PROM SAFETY EVENTS, ETC. WE ALSO HAVE DEPARTMENT LEADERS ON BOARDS FOR OUR MARKET COMMUNITIES. WE HAVE DEPARTMENT LEADERS AND EMPLOYEES WHO SIT ON LOCAL SCHOOL BOARDS. EMPLOYEES ARE INVOLVED IN LOCAL COMMUNITY THEATER PRODUCTIONS.ENVIRONMENTAL IMPROVEMENTS: EMPLOYEES PARTICIPATE IN PARK CLEAN UP AND IMPROVEMENT PROJECTS. KNOXVILLE COMMUNITY HOSPITAL, INC. MADE FINANCIAL DONATIONS TO COMMUNITY IMPROVEMENT PROJECTS. COALITION BUILDING: WE GIVE FINANCIAL AND ADMINISTRATIVE SUPPORT TO AREA NON-PROFITS, SCHOOL PROJECTS, AND YOUTH SPORTS. WE ALLOW USE OF OUR FACILITY FOR COMMUNITY MEETINGS. VARIOUS EMPLOYEES PRESENT AT LOCAL SCHOOL CAREER DAYS.COMMUNITY HEALTH IMPROVEMENT ADVOCACY: WE PARTICIPATE IN THE LOCAL HEALTH FAIR AS A SPONSOR, PROVIDING FLU SHOTS AND SPORTS PHYSICALS. ALL THE PROCEEDS ARE DONATED. WE ALSO SPONSOR BACK PACK BUDDIES AND MEALS ON WHEELS. WE MAKE FINANCIAL DONATIONS TO LOCAL HEALTH-RELATED NON-PROFITS. FURTHERMORE, WE SPONSOR UNREIMBURSED PRESCRIPTION DRUGS, HEALTH SCREENING DISCOUNTS, FREE CPR AND BLS EDUCATION CLASSES. WE OFFER NURSING ED ROTATIONS, HIGH SCHOOL HEALTH CLASSROOMS AND PROVIDE INSTRUCTORS AT NO CHARGE TO THE SCHOOLS AND THE PUBLIC. WE SPONSORED PUBLIC VIEWING OF THE MERCY HELICOPTER NOW LOCATED IN KNOXVILLE. THE FOOD SERVICE DEPARTMENT PARTICIPATES IN THE LOCAL FARMERS' MARKET AND OFFERS HEALTHY COOKING CLASSES TO THE PUBLIC. DOCTORS, NURSES, AND CLERKS WORK AT THE LOCAL FREE CLINIC AT NO CHARGE. PHYSICIANS PARTICIPATE IN LOCAL HEALTH BOARDS AND CONSULT FREE OF CHARGE TO THE OTHER ORGANIZATIONS.OTHER: WE PROVIDE CAB FARE FROM THE EMERGENCY ROOM FOR INDIGENTS AND USE OF OUR ROOMS FOR LOCAL CLUBS AND COMMUNITY MEETINGS. WE OFFER ADMINISTRATIVE ASSISTANCE TO VARIOUS ORGANIZATIONS. WE SPONSOR LOCAL SUN AND BIKE SAFETY PRESENTATIONS ANNUALLY. MANY EMPLOYEES COACH AND TEACH IN LOCAL PROGRAMS. PART III, LINE 4: THE COSTING METHODOLOGY USED TO DETERMINE THE BAD DEBT EXPENSE INCLUDED (1) CALCULATING THE TOTAL ESTIMATE BASED ON THE AGING TRIAL BALANCE REPORT, THEN, (2) ADJUSTING FOR ALLOWANCES, RECOVERIES, OTHER CHANGES IN ACCOUNTS RECEIVABLE AND CHANGES TO REFUNDS CLEARING. WHEN CALCULATING BAD DEBT, ANY INSURANCE DISCOUNTS AND PATIENT PAYMENTS HAVE BEEN REMOVED FROM THE ACCOUNT BALANCES. THE BALANCE OF THE ACCOUNT IS USED TO CALCULATE THE BAD DEBT ESTIMATE.THE HOSPITAL'S FINANCIAL STATEMENTS DO NOT CONTAIN A SPECIFIC FOOTNOTE DESCRIBING BAD DEBT. HOWEVER, THE FOLLOWING IS TEXT OF THE FOOTNOTES TITLED "PATIENT ACCOUNTS RECEIVABLES, NET" AND "CHARITY CARE":"PATIENT ACCOUNTS RECEIVABLES, NET"NET PATIENT RECEIVABLES CONSIST OF UNCOLLATERALIZED PATIENT AND THIRD-PARTY OBLIGATIONS. THE HOSPITAL REPORTS PATIENT ACCOUNTS RECEIVABLE FOR SERVICES RENDERED AT NET REALIZABLE AMOUNTS FROM THIRD-PARTY PAYORS, PATIENTS AND OTHERS. ACCOUNTS RECEIVABLE ARE REDUCED BY AN ALLOWANCE FOR DOUBTFUL ACCOUNTS. IN EVALUATING THE COLLECTIBILITY OF ACCOUNTS RECEIVABLE, THE HOSPITAL ANALYZES ITS PAST HISTORY AND IDENTIFIES TRENDS FOR EACH OF ITS MAJOR PAYOR SOURCES OF REVENUE TO ESTIMATE THE APPROPRIATE ALLOWANCE FOR DOUBTFUL ACCOUNTS AND PROVISION FOR BAD DEBTS. MANAGEMENT REGULARLY REVIEWS DATA ABOUT THESE MAJOR PAYOR SOURCES OF REVENUE IN EVALUATING THE SUFFICIENCY OF THE ALLOWANCE FOR DOUBTFUL ACCOUNTS. FOR RECEIVABLES ASSOCIATED WITH SERVICES PROVIDED TO PATIENTS WHO HAVE THIRD-PARTY COVERAGE, THE HOSPITAL ANALYZES CONTRACTUALLY DUE AMOUNTS AND PROVIDES AN ALLOWANCE FOR DOUBTFUL ACCOUNTS AND A PROVISION FOR BAD DEBTS FOR THOSE ACCOUNTS OVER A CERTAIN AGE BASED ON DISCHARGE THAT MAKE THE REALIZATION OF AMOUNTS DUE UNLIKELY. FOR RECEIVABLES ASSOCIATED WITH SELF-PAY PATIENTS (WHICH INCLUDES BOTH PATIENTS WITHOUT INSURANCE AND PATIENTS WITH DEDUCTIBLE AND COPAYMENT BALANCES DUE FOR WHICH THIRD-PARTY COVERAGE EXISTS FOR PART OF THE BILL), THE HOSPITAL RECORDS A SIGNIFICANT PROVISION FOR BAD DEBTS IN THE PERIOD OF SERVICE ON THE BASIS OF ITS PAST EXPERIENCE, WHICH INDICATES THAT MANY PATIENTS ARE UNABLE OR UNWILLING TO PAY THE PORTION OF THEIR BILL FOR WHICH THEY ARE FINANCIALLY RESPONSIBLE. THE DIFFERENCE BETWEEN THE STANDARD RATES (OR THE DISCOUNTED RATES IF NEGOTIATED) AND THE AMOUNTS ACTUALLY COLLECTED AFTER ALL REASONABLE COLLECTION EFFORTS HAVE BEEN EXHAUSTED IS CHARGED OFF AGAINST THE ALLOWANCE FOR DOUBTFUL ACCOUNTS."CHARITY CARE"THE HOSPITAL 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 HOSPITAL DOES NOT PURSUE COLLECTION OF AMOUNTS DETERMINED TO QUALIFY AS CHARITY CARE, THEY ARE NOT REPORTED AS REVENUE. MANAGEMENT'S DISCLOSURE OF CHARITY CARE COSTS ARE DESCRIBED IN NOTE 3.THE HOSPITAL IS DEDICATED TO PROVIDING COMPREHENSIVE HEALTH CARE SERVICES TO ALL SEGMENTS OF SOCIETY, INCLUDING THE AGED AND OTHERWISE ECONOMICALLY DISADVANTAGED. IN ADDITION, THE HOSPITAL PROVIDES A VARIETY OF COMMUNITY HEALTH SERVICES AT OR BELOW COST. THE HOSPITAL PROVIDES CHARITY CARE TO PATIENTS WHO ARE FINANCIALLY UNABLE TO PAY FOR THE HEALTH CARE SERVICES THEY RECEIVE. PATIENTS WHO QUALIFY FOR CHARITY CARE ARE GIVEN A PERCENTAGE DISCOUNT FROM ESTABLISHED CHARGES BASED ON A SLIDING SCALE USING POVERTY GUIDELINES. IT IS THE POLICY OF THE HOSPITAL NOT TO PURSUE COLLECTION OF AMOUNTS DETERMINED TO QUALIFY AS CHARITY CARE. ACCORDINGLY, THE HOSPITAL DOES NOT REPORT THESE AMOUNTS IN NET OPERATING REVENUE OR IN THE ALLOWANCE FOR DOUBTFUL ACCOUNTS. THE HOSPITAL DETERMINES THE COSTS ASSOCIATED WITH PROVIDING CHARITY CARE BY AGGREGATING THE DIRECT AND INDIRECT COSTS, INCLUDING SALARIES, BENEFITS, SUPPLIES, AND OTHER OPERATING EXPENSES, BASED ON THE OVERALL COST TO CHARGE RATIO FOR THE HOSPITAL. THE COSTS OF CARING FOR CHARITY CARE PATIENTS FOR THE YEARS ENDED JUNE 30, 2013 AND 2012 WERE APPROXIMATELY $127,000 AND $78,000, RESPECTIVELY. PART III, LINE 8: "MEDICARE ALLOWABLE COSTS OF CARE" WAS CALCULATED FROM INFORMATION IN THE MEDICARE COST REPORT D, E, H & M WORKSHEETS, OR PS&R. BECAUSE KNOXVILLE COMMUNITY HOSPITAL IS A CRITICAL ACCESS HOSPITAL, MEDICARE ALLOWABLE COSTS ARE REIMBURSED AT 101%, HOWEVER MEDICARE ALLOWABLE COSTS DOES NOT INCLUDE ALL THE COSTS OF CARING FOR PATIENTS. IF ALL OF THE COSTS WERE INCLUDED, THE AMOUNT BY WHICH REVENUES EXCEED COSTS WOULD BE LESS, OR THERE MAY BE A SHORTFALL. THE COMMUNITY BENEFITS FROM THE HOSPITAL'S CARE OF MEDICARE PATIENTS BECAUSE THE HOSPITAL APPLIES OTHER REVENUES TO COVER THE COSTS OF CARING FOR THOSE PATIENTS. PART III, LINE 9B: ALTHOUGH THE HOSPITAL DOES NOT HAVE A WRITTEN DEBT COLLECTION POLICY, IT DOES HAVE ESTABLISHED PRACTICES AND PROCEDURES. THE HOSPITAL CONTRACTS WITH MARS, A SELF-PAY EARLY OUT COMPANY. MARS MAKES TELEPHONE CALLS TO PATIENTS TO FOLLOW UP ON BALANCES DUE TO THE HOSPITAL. IF A PATIENT DOES NOT PAY AFTER RECEIVING A CALL, THEN THE ACCOUNT IS REFERRED TO A COLLECTION AGENCY. NO FURTHER ACTION IS TAKEN IF A PATIENT IS KNOWN TO QUALIFY FOR FINANCIAL ASSISTANCE. IF THE COLLECTION AGENCY IS NOT SUCCESSFUL, THE HOSPITAL MAY TAKE LEGAL ACTION IF IT BELIEVES THE PATIENT HAS THE ABILITY TO PAY. KNOXVILLE COMMUNITY HOSPITAL, INC. PART V, SECTION B, LINE 1J: HEALTH ACCESS, TRANSPORTATION, BEDS, EDUCATION, WELLNESS EDUCATION, SUBSTANCE ABUSE TREATMENT AND PREVENTION, FAMILY PLANNING IN HIGH SCHOOL FOR BIRTH CONTROL, TRAILS AND SIDEWALKS, SPECIALTY SERVICES LIKE PSYCHIATRY, ORTHOPEDICS, G.I., COMMUNITY PERCEPTION AND COMMUNICATION, COMMUNITY BUY-IN FOR PREVENTIVE HEALTHCARE, CANCER, ADULT DAY CARE, UNINSURED DENTAL CARE, URGENT CARE, ECONOMIC DEVELOPMENT, WEEKEND HOSPITAL SERVICE, OCCUPATIONAL HEALTH PROVIDERS, BETTER COORDINATION AMOUNG PROVIDERS, MAMMOGRAPHY, ER DOCTORS, EXPAND MEDICAID, VETERANS CARE. KNOXVILLE COMMUNITY HOSPITAL, INC. PART V, SECTION B, LINE 3: RESEARCH WAS PERFORMED AND DATA WAS COLLECTED TO ENSURE PROPER TOWN HALL REPRESENTATION AND TO DETERMINE THE PRIMARY SERVICE AREA. PR STORY WAS PREPARED AND SENT TO LOCAL MEDIA TO PUBLISH AND ANNOUNCE UPCOMING CHNA WORK AND REQUEST PUBLIC SURVEY PARTICIPATION. A PAPER SURVEY WAS USED WITH AN ONLINE LINK TO PSA RESIDENTS. THE SURVEY WAS SENT TO 1000 PARTICIPANTS WITH ANTICIPATION OF RECEIVING 250 RETURNS. WE PREPARED AND PUBLISHED A TOWN HALL INVITATION TO THE PUBLIC AND COLLABORATING PARTIES SUCH AS PUBLIC HEALTH, SCHOOL LEADERS, FAITH-BASED LEADERS, PHYSICIANS AND OTHER CARE PROVIDERS, MENTAL HEALTH COMMUNITY, FREE CLINICS, LOCAL RESIDENTS, COMMUNITY LEADERS, BUSINESS LEADERS, LOCAL GOVERNMENT, PEOPLE WITH CHRONIC CONDITIONS, UNINSURED COMMUNITY MEMBERS, LOW INCOME RESIDENTS, AND MINORITY GROUPS ALONG WITH KNOXVILLE HOSPITAL AND CLINICS. WE PREPARED A BRIEF OF GOALS, OBJECTIVES, PURPOSE, OUTCOME, ROLES, AND COMMUNITY INVOLVEMENT AND HELD A KICK-OFF MEETING. COMMUNITY HEALTH FACTS AND PRACTICE DATA WERE COLLECTED AND PUBLISHED. A SECOND ROUND TABLE WAS THEN HELD TO REVIEW THE RESEARCH GATHERED, OPINIONS GIVEN, AND NEEDS IDENTIFIED. COMMUNITY OPINIONS WERE COLLECTED ON HEALTH NEEDS, PRACTICES, AND PHYSICIAN AND CARE PROVIDER MANPOWER AVAILABILITY. THE COMMUNITY HEALTH NEEDS REPORT WAS THEN PREPARED AND PRESENTED TO COMMUNITY LEADERS WITH RECOMMENDED ACTIONS. AT THE TOWN HALL MEETING THE DISCUSSION INCLUDED PURPOSE, ROLES, REIVIEW OF HISTORICAL DATA, PARTICIPANT DISCUSSIONS TALLY AND RANKING OF HEALTH CONCERNS, AND REFLECTION ON THE HEALTH NEEDS OF THE COMMUNITY. THE MEETING CLOSED WITH INFORMATION ABOUT THE NEXT STEPS. THE COMMUNITY WAS ENCOURAGED TO CONTINUE TO PARTICIPATE BY CONTRIBUTING IDEAS TO THE HOSPITAL AND HEALTH DEPARTMENT VIA EMAIL OR PERSONAL CONVERSATIONS. IN ADDITION, OTHER MEETINGS, INTERVIEWS, AND FOCUS GROUPS WERE HELD. KNOXVILLE COMMUNITY HOSPITAL, INC. PART V, SECTION B, LINE 5C: HTTP://KNOXVILLEHOSPITAL.ORG/WP-CONTENT/UPLOADS/2013/12/MARIONSKINNY.PDF KNOXVILLE COMMUNITY HOSPITAL, INC. PART V, SECTION B, LINE 20D: WE USE A SLIDING SCALE TO DISCOUNT FEES FOR INDIVIDUALS AT 100% OF THE FEDERAL POVERTY LEVEL BASED ON THEIR INCOME AND ASSETS. THE DISCOUNT IS LOWERED TO ZERO WHEN INCOME IS MORE THAN 300% OF THE NATIONAL POVERTY LEVEL. PART VI, LINE 2: DURING FISCAL YEAR 2013, KNOXVILLE COMMUNITY HOSPITAL, INC. AND CLINICS (KHC), IN COLLABORATION WITH MARION COUNTY PUBLIC HEALTH, HELD TOWN HALL MEETINGS TO DEVELOP A COMMUNITY HEALTH NEEDS ASSESSMENT TO SET HEALTH GOALS AND PROGRAMS TO ADDRESS THE HEALTH NEEDS AND DESIRES OF THE COMMUNITY CAPTURED IN KHC'S ANNUAL COMMUNITY BENEFIT REPORT. ALSO, KHC ALWAYS UTILIZES INPUT FROM MEDICAL STAFF, THE BOARD OF DIRECTORS AND VARIOUS HOSPITAL ADMINISTRATIVE STAFF WHO REGULARLY REVIEW THE TREATMENT OF PATIENTS TO ENSURE MEDICAL NECESSITY AND APPROPRIATE LEVELS OF CARE ARE CONSISTENTLY PROVIDED TO THE PATIENTS OF KHC. PART VI, LINE 3: PATIENTS ARE MADE AWARE OF KNOXVILLE COMMUNITY HOSPITAL, INC AND CLINIC'S (KHC) FINANCIAL ASSISTANCE PROGRAM UPON ADMISSION TO THE HOSPITAL FOR INPATIENT, OUTPATIENT AND CLINIC SERVICES. DURING THE ADMITTING PROCESS THE CLERK BECOMES AWARE OF PATIENTS WITHOUT INSURANCE. AT THAT TIME, THE CLERK CONTACTS CUSTOMER SERVICE STAFF, WHO VISIT WITH THE PATIENT AND ASSIST THEM WITH THE PROCESS. ALSO, KHC HAS CONTRACTED WITH A SELF-PAY EARLY OUT VENDOR FOR SOME BILLING AND COLLECTIONS FUNCTIONS. ONE FUNCTION THIS VENDOR PERFORMS IS TO CONTACT FORMER PATIENTS BY TELEPHONE AND MAKE PATIENTS AWARE OF THE FINANCIAL ASSISTANCE PROGRAM. PART VI, LINE 4: KNOXVILLE COMMUNITY HOSPITAL, INC. PRIMARY SERVICE AREA INCLUDES THE FOLLOWING CITIES IN MARION COUNTY: KNOXVILLE (POP. 11,583), PLEASANTVILLE (POP. 2,954), AND MELCHER/DALLAS (POP. 1,625). THE KNOXVILLE COMMUNITY IS 40 MILES SOUTHEAST OF DES MOINES, IOWA. PART VI, LINE 5: KNOXVILLE COMMUNITY HOSPITAL, INC. AND CLINICS PROVIDES NUMEROUS OUTPATIENT SPECIALTY PROVIDER CLINICS SUCH AS PODIATRY, ORTHOPAEDICS, CARDIOLOGY, UROLOGY, DERMATOLOGY, AND EMG TESTING. PROVIDERS AND STAFF PROVIDE VARIOUS FREE EDUCATIONAL/WELLNESS PROGRAMS FOR THE COMMUNITY/SCHOOLS. THE HOSPITAL IS ADDING TO SPECIALTIES YEARLY, HOSTING ANNUAL PUBLIC PRESENTATIONS ON SUN AND BIKE SAFETY, AND OFFERING SAFE SITTER AND PRENATAL EVENTS. THESE ARE PUBLISHED IN LOCAL NEWSPAPERS. PART VI, LINE 6: DURING FISCAL YEAR 2013, KNOXVILLE COMMUNTY HOSPITAL, INC. AND CLINICS WAS AN AFFILIATED MEMBER OF MERCY HEALTH NETWORK - CENTRAL IOWA THROUGH MERCY HOSPITAL - DES MOINES, IOWA. MERCY HEALTH NETWORK - CENTRAL IOWA INCLUDES 16 CAH/TWEENER HOSPITALS ALL LOCATED IN CENTRAL IOWA. BENEFITS OF THE AFFILIATION ARE NUMEROUS AND INCLUDE: A. SHARING OF BEST PRACTICES B. SAVINGS ON GROUP PURCHASING AGREEMENTS C. SAVINGS THROUGH GROUP CONTRACTING FOR NUMEROUS SERVICES D. ACCESS TO NUMEROUS HEALTH CARE EXPERTS E. ACCESS TO PROVIDERS OF ALL TYPES AND SPECIALTIES REPORTS FILED WITH STATES PART VI, LINE 7 IA X X 0 0 0 0 0 0 0 0 0 DANIEL J ROWLEY MD 168853 0 49263 0 1050 0 0 0 17385 0 236551 0 0 0 KEVIN KINCAID 161013 0 0 0 0 0 10815 0 17588 0 189416 0 0 0 THOMAS HOEHNS 212739 0 27000 0 1050 0 5100 0 18813 0 264702 0 0 0 EARL MCKEEVER 199689 0 19927 0 1050 0 4649 0 14868 0 240183 0 0 0 DAVID KERMODE 205266 0 0 0 0 0 5100 0 7221 0 217587 0 0 0 BYRON SCHAEFFER 162961 0 13127 0 1050 0 4019 0 18725 0 199882 0 0 0 BHAMA JAYAVEERAPADIAN 136694 0 22839 0 1050 0 3234 0 5469 0 169286 0 0 0 SUPPLEMENTAL INFORMATION PART III SCHEDULE J, PART II: KEVIN KINCAID WAS PAID BY AN UNRELATED ORGANIZATION, MERCY MEDICAL CENTER - DES MOINES. MERCY MEDICAL CENTER HAS A MANAGEMENT AGREEMENT WITH KNOXVILLE COMMUNITY HOSPITAL INC. KNOXVILLE COMMUNITY HOSPITAL PAYS MERCY MEDICAL CENTER FOR THE COMPENSATION OF THE CEO/ADMINISTRATOR. MERCY MEDICAL CENTER IS PART OF CATHOLIC HEALTH INITIATIVES. FORM 990, PART VI, SECTION A, LINE 3 KNOXVILLE COMMUNITY HOSPITAL CONTRACTS WITH MERCY MEDICAL CENTER - DES MOINES FOR OVERSIGHT OF MANAGEMENT SERVICES. MERCY MEDICAL CENTER PROVIDES A FULL-TIME HOSPITAL CHIEF EXECUTIVE OFFICER/ADMINISTRATOR TO PROVIDE MANAGEMENT SERVICES AND ADMINISTRATIVE DIRECTION. KNOXVILLE COMMUNITY HOSPITAL PAYS MERCY MEDICAL CENTER FOR THE COMPENSATION OF THE CEO/ADMINISTRATOR. FORM 990, PART VI, SECTION B, LINE 11 THE FORM 990 IS REVIEWED BY THE CFO AND CEO PRIOR TO BEING FILED, IT IS REVIEWED BY THE BOARD OF DIRECTORS AT THE NEXT BOARD MEETING, WHICH MAY OCCUR AFTER FORM 990 HAS BEEN FILED WITH IRS. FORM 990, PART VI, SECTION B, LINE 12C THE COMPLIANCE OFFICER REVIEWS THE POLICIES AND UPDATES THEM ANNUALLY. THE COMPLIANCE TEAM MEETS QUARTERLY TO REVIEW ALL COMPLIANCE AREAS AND CONFLICT OF INTEREST IS ONE OF THOSE AREAS. THE COMPLIANCE OFFICER ATTENDS BOARD MEETINGS AND MEMBERS DO NOT VOTE ON AREAS OF CONFLICT. FORM 990, PART VI, SECTION B, LINE 15 PER HUMAN RESOURCE POLICIES, KNOXVILLE COMMUNITY HOSPITAL UTILIZES THE IHA WAGE SURVEY AND COMPARATIVE ANALYSIS AND MARKET RATES. MOST WAGES ARE ADJUSTED WHEN THE BOARD OF DIRECTORS APPROVES PAY INCREASE PERCENTAGES. KNOXVILLE COMMUNITY HOSPITAL HOPES TO INSTITUTE A NEW PAY FOR PERFORMANCE PLAN IN FISCAL YEAR 2014. FORM 990, PART VI, SECTION C, LINE 19 KNOXVILLE COMMUNITY HOSPITAL'S GOVERNING DOCUMENTS, CONFLICT OF INTEREST POLICY AND FINANCIAL STATEMENTS ARE MADE AVAILABLE TO THE PUBLIC BY REQUEST AT ORGANIZATION'S ADMINISTRATIVE OFFICES DURING NORMAL BUSINESS HOURS. OTHER FEES FORM 990, PART IX, LINE 11G CONTRACT SERVICES: PROGRAM SERVICE EXPENSES 122,198. MANAGEMENT AND GENERAL EXPENSES 116,974. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 239,172. OUTSIDE MEDICAL SERVICES: PROGRAM SERVICE EXPENSES 3,704,545. MANAGEMENT AND GENERAL EXPENSES 0. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 3,704,545. FORM 990, PART XII, LINE 2C: THE BOARD OF DIRECTORS ASSUMES RESPONSIBILITY FOR THE OVERSIGHT OF THE AUDIT AND THE SELECTION OF AN INDEPENDENT ACCOUNTANT. THIS PROCESS HAS NOT CHANGED DURING THE CURENT YEAR. KNOXVILLE HOSPITAL FOUNDATION 1002 SOUTH LINCOLN KNOXVILLE IA 50138 900126510 SUPPORT FOR KNOXVILLE COMMUNITY HOSPITAL IA 501(C)(3) LINE 7 N/A 0 0 0 1 0 0 0 0 0 0 0 0 0 0 1 1 0 0 0 0