2024-11-14T17:33:06-06:00 2023-12-31 450250958 EIDE BAILLY LLP 18081 BURT ST STE 200 OMAHA NE 680224722 990 2023-01-01 470796875 FAITH REGIONAL HEALTH SERVICES FAIT 4023714880 1500 KOENIGSTEIN AVENUE PO BOX 869 NORFOLK NE 687020869 BRENDA BAKER VP FINANCE 4023714880 2024-11-14 1 1 MEGAN L KOZIOL CPA P01544037 4023302660 2024-11-14 2023 2024-10-15 13:58:12Z KELLY DRISCOLL 1500 KOENIGSTEIN AVENUE PO BOX 869 NORFOLK NE 687020869 280779635 0 X WWW.FRHS.ORG X 1996 NE TO PROVIDE ACUTE, SKILLED AND OUTPATIENT SERVICES TO INDIVIDUALS IN OUR SERVICE AREA. 15 11 1749 25 248576 207821 3186882 901632 261280318 270022631 1361455 2917598 627270 1506958 266455925 275348819 225961 330441 0 0 147813490 157008079 0 0 257842 118034554 115076744 266074005 272415264 381920 2933555 262709523 266969721 99115717 98020360 163593806 168949361 TO SERVE CHRIST BY PROVIDING ALL PEOPLE WITH EXEMPLARY MEDICAL SERVICES IN AN ENVIRONMENT OF LOVE AND CARE. 0 0 230189280 330441 257163489 FAITH REGIONAL PROVIDES HEALTHCARE TO ALL PEOPLE REGARDLESS OF THEIR ABILITY TO PAY OR THEIR INSURANCE PROVIDER. DURING THE YEAR, FAITH REGIONAL PROVIDED SIGNIFICANT SERVICES FOR MEDICARE AND MEDICAID PATIENTS. 16155527 13367929 MANY SERVICES PROVIDED BY FAITH REGIONAL ARE DONE TO MEET SPECIFIC NEEDS OF THE COMMUNITY BECAUSE NO OTHER SERVICES ARE AVAILABLE. AS A RESULT, THESE SERVICES ARE PROVIDED KNOWING THAT THEY WILL NOT BE FINANCIALLY VIABLE OR SELF-SUPPORTING. THESE SERVICES INCLUDE BEHAVIORAL HEALTH INPATIENT AND OUTPATIENT SERVICES, CHILD ADVOCACY, DIABETIC EDUCATION, DIALYSIS SERVICES, ACUTE REHABILITATIVE SERVICES, HOME HEALTH CARE AND TRANSITIONAL CARE (LONG-TERM REHABILITATION) SERVICES. 458883 0 A SUBSTANTIAL PORTION OF COMMUNITY BENEFITS PROVIDED BY FAITH REGIONAL IS THE PROVISION OF PATIENT CARE SERVICES THAT ARE NOT PAID FOR EITHER BY THE PATIENT OR THIRD PARTY INSURANCE. DURING 2023, FAITH PROVIDED PATIENTS JUST UNDER FIVE HUNDRED THOUSAND DOLLARS IN ASSISTANCE WITH PAYING THEIR HOSPITAL BILLS. 246803690 1 1 0 1 0 0 0 0 0 1 1 0 0 0 1 1 0 1 0 0 0 0 0 0 0 0 1 1 1 0 1 1 0 0 0 0 0 0 0 0 1 0 0 0 0 0 1 1 1 1 0 0 1 62 0 1 1749 1 1 1 0 0 0 0 0 0 0 0 0 0 0 X 15 11 0 0 0 0 1 1 1 1 1 0 0 1 1 1 1 1 1 1 1 1 1 X BRENDA BAKER 4026447248 1500 KOENIGSTEIN AVENUE PO BOX 869 NORFOLK NE 687020869 FADI RZOUQ MD PHYSICIAN 40.00 0.00 X 4831036 0 36247 TRISTAN L HARTZELL MD PHYSICIAN 40.00 1.00 X 3399159 0 714 JOHN LAMMLI MD PHYSICIAN 40.00 0.00 X 1399742 0 36409 BEETHOVEN BROWN MD PHYSICIAN 40.00 0.00 X 1239450 0 13914 NATHAN HERMAN MD PHYSICIAN 40.00 0.00 X 1029265 0 35271 KELLY DRISCOLL CEO 40.00 2.00 X 781144 0 39384 ROBERT PRINCE MD MEMBER - MEDICAL DIRECTOR 40.00 0.00 X 708224 0 5575 LANE HANDKE MD MEMBER - CHIEF OF STAFF 40.00 0.00 X 545247 0 30988 JANNA CLINE VP FINANCE 40.00 2.00 X 272156 0 30551 BRETT JACKSON CHAIR 1.50 2.50 X X 0 0 0 JOHN ROBERTSON VICE CHAIR 1.50 2.50 X X 0 0 0 SUE FUCHTMAN SECRETARY 1.50 0.00 X X 0 0 0 BRAD DINKEL TREASURER 1.50 0.00 X X 0 0 0 STEF LACEY MD MEMBER 1.00 0.00 X 0 0 0 TRAVIS RUTJENS MEMBER 1.00 0.00 X 0 0 0 JACQUE COLLISON MEMBER 1.00 1.00 X 0 0 0 JOSH GOSSMAN MEMBER 1.00 0.00 X 0 0 0 DIANE BECKER MEMBER 1.00 2.50 X 0 0 0 LEON ROSENTHAL MEMBER 1.00 2.50 X 0 0 0 PRESTON SUNDERMAN MEMBER 1.00 2.50 X 0 0 0 REGINA BUSBOOM MEMBER 1.00 2.50 X 0 0 0 TOM SCHUETH MEMBER 1.00 1.00 X 0 0 0 14205423 0 229053 200 0 1 0 PATHOLOGY MEDICAL SERVICE PO BOX 82653 LINCOLN NE 68501 LAB SERVICES 655577 SIOUX CITY NIGHT PATROL PO BOX 3276 SIOUX CITY IA 51102 SECURITY SERVICES 367549 EIDE BAILLY LLP 18081 BURT STREET OMAHA NE 68022 ACCOUNTING SERVICES 227073 NORFOLK CONSTRUCTION CO PO BOX 383 NORFOLK NE 68702 MOWING & SNOW REMOVAL 133038 VIRTUAL RADIOLOGIC CORPORATION 25983 NETWORK PLACE CHICAGO IL 60673 LAB SERVICES 129628 12 47000 517634 307482 29516 901632 NET PATIENT SERVICE REVENUE 621110 169652032 169652032 PATIENT SVC M'CARE/MEDICAID 621110 81177475 81177475 LEASED MEDICAL EMPLOYEES 621110 3365839 3365839 PHYSICIAN CLINICS 621110 985779 985779 14841506 14841506 270022631 2701872 2701872 1399622 819623 579999 579999 579999 4766066 60000 4610340 0 155726 60000 215726 215726 1066 853 213 213 MHR HOME CARE, LLC 456199 248363 248363 678383 508787 169596 926746 275348819 270531418 248576 3667193 330441 330441 2418081 1291244 1126837 320737 320737 124179759 116204811 7788017 186931 3653759 3239145 409566 5048 19258640 17468696 1787499 2445 7177103 6385717 778128 13258 174096 13415 160681 357260 27528 329732 26022414 24185539 1835080 1795 862124 13095 849029 11400543 10995387 384172 20984 7600832 6569605 1020040 11187 10039193 8283841 1755352 275524 239626 27623 8275 642416 553780 83573 5063 2069366 86869 1982497 13229146 9330974 3898172 1156666 282827 873839 INCOME TAX 51039 51039 MEDICAL SUPPLIES 39544266 39544266 FOOD 911450 908503 2947 DUES & SUBSCRIPTIONS 373578 228669 142053 2856 366831 298975 67856 272415264 246803690 25353732 257842 152063 129051 56344001 64430562 28936969 30789439 2172183 2851575 4469606 4185985 4900162 4666219 305531742 187065878 117333789 118465864 35945553 24680600 3248352 3152503 9206845 13617923 262709523 266969721 31612672 33773534 55940463 50185794 1260526 8118756 10131359 3443826 2669147 99115717 98020360 X 162593806 168949361 1000000 0 163593806 168949361 262709523 266969721 2933555 2422000 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 14066 14066 0 PART II-B, LINE 1: FAITH REGIONAL PAID DUES TO THE NEBRASKA HOSPITAL ASSOCIATION AND THE AMERICAN HOSPITAL ASSOCIATION. A PORTION OF THE DUES WERE USED FOR LOBBYING ACTIVITIES. 6442730 40 91856 6534626 6611965 76 -169311 6442730 5533918 50 1077997 6611965 5523918 10000 1022500 1022500 5533918 8052916 15000 1454367 3998365 5523918 0.00790 0.99210 0.00000 0 1 1 4220548 4220548 139612564 75666928 63945636 145170283 105951737 39218546 16528347 5447213 11081134 118465864 ACCRUED INTEREST RECEIVABLE 133724 OTHER INVESTMENTS 10131359 ESTIMATED THIRD PARTY PAYOR SETTLEMENTS - MEDICARE & MEDICAID 683693 RIGHT OF USE ASSETS 2669147 13617923 LEASE LIABILITY 2669147 2669147 X PART V, LINE 4: CARSON CANCER CENTER ENDOWMENT FUNDS ARE PERMANENTLY SET ASIDE TO GENERATE INVESTMENT EARNINGS TO BE USED TO FUND CAPITAL EQUIPMENT PURCHASES AND/OR OPERATIONS OF THE CARSON REGIONAL CANCER CENTER. INVESTMENT EARNINGS ON THESE FUNDS ARE RESTRICTED AS TO USE. GENERAL ENDOWMENT FUNDS ARE PERMANENTLY SET ASIDE TO GENERATE INVESTMENT EARNINGS. INVESTMENT EARNINGS ON THESE FUNDS ARE NOT RESTRICTED AS TO USE. THE HOSPICE ENDOWMENT FUNDS ARE PERMANENTLY SET ASIDE TO GENERATE INVESTMENT EARNINGS TO BENEFIT THE HOSPICE PROGRAM AND ITS PATIENTS. INVESTMENT INCOME ON THESE FUNDS IS RESTRICTED AS TO USE. THE CARDIAC SERVICES ENDOWMENT FUNDS ARE PERMANENTLY SET ASIDE TO GENERATE INVESTMENT EARNINGS TO FUND FAITH REGIONAL HEALTH SERVICE'S CARDIAC PROGRAM CAPITAL AND/OR OPERATIONAL EXPENSES. THE EDUCATION ENDOWMENT FUNDS ARE PERMANENTLY SET ASIDE TO GENERATE INVESTMENT EARNINGS TO BENEFIT FAITH REGIONAL HEALTH SERVICE'S EDUCATION PROGRAMS AND ITS EFFORTS TO RECRUIT AND RETAIN EMPLOYEES. INVESTMENT INCOME ON THESE FUNDS IS RESTRICTED AS TO USE. ST. JOSEPH'S NURSING HOME/SKYVIEW VILLA ENDOWMENT FUNDS ARE PERMANENTLY SET ASIDE TO GENERATE INVESTMENT EARNINGS TO BE USED TO FUND CAPITAL EQUIPMENT PURCHASES AND/OR OPERATION OF ST. JOSEPH'S NURSING HOME AND SKYVIEW VILLA. INVESTMENT EARNINGS ON THESE FUNDS ARE RESTRICTED AS TO USE. THE PEDIATRIC ENDOWMENT FUNDS ARE PERMANENTLY SET ASIDE TO GENERATE INVESTMENT EARNINGS TO BENEFIT FAITH REGIONAL HEALTH SERVICE'S CHILDREN'S CARE FUND. DONORS MAY SPECIFY CONTRIBUTIONS TO ANY OF THE ENDOWMENT FUNDS. PART X, LINE 2: FAITH REGIONAL HEALTH SERVICES ACCOUNTS FOR UNCERTAINTIES IN ACCOUNTING FOR INCOME TAX ASSETS AND LIABILITIES USING GUIDANCE INCLUDED IN FASB ASC 740, INCOME TAXES. FAITH RECOGNIZES THE EFFECT OF INCOME TAX POSITIONS ONLY IF THOSE POSITIONS ARE MORE LIKELY THAN NOT OF BEING SUSTAINED. AT DECEMBER 31, 2023 AND 2022, FAITH HAD NO UNCERTAIN TAX POSITIONS ACCRUED. 1 1 X 1 X 400.000000000000 1 X 1 1 1 0 1 0 825487 589929 235558 0.00090 16995778 11867793 5127985 0.01880 17821265 12457722 5363543 0.01970 1535175 0 1535175 0.00560 1404710 0 1404710 0.00520 16155527 13367929 2787598 0.01020 330441 0 330441 0.00120 19425853 13367929 6057924 0.02220 37247118 25825651 11421467 0.04190 1770 0 1770 0.00000 121019 0 121019 0.00040 122789 122789 0.00040 1 13692219 1478760 46902445 60881518 -13979073 X 1 1 1 NORTHEAST NE SURGICAL CENTER LLC SURGICAL SERVICES 0.59900 0.00000 0.40100 2 1 FAITH REGIONAL HEALTH SERVICES - WEST 2700 WEST NORFOLK AVENUE NORFOLK NE 68701 WWW.FRHS.ORG 520001 X X X A 2 FAITH REGIONAL HEALTH SERVICES - EAST 1500 KOENIGSTEIN AVENUE NORFOLK NE 68701 WWW.FRHS.ORG 520002 X X A FACILITY REPORTING GROUP - A 0 0 1 X X X X X X X 22 1 1 1 1 X HTTPS://WWW.FRHS.ORG/ABOUT-US/REPORTS/ X 1 22 1 HTTPS://WWW.FRHS.ORG/ABOUT-US/REPORTS/ 0 1 X 400.000000000000 400.000000000000 X X X X X X 1 1 X X X 1 X FRHS.ORG/PATIENTS-VISITORS/BILLING-INSURANCE-FINANCIAL-ASSISTANCE/FINANCIAL X FRHS.ORG/PATIENTS-VISITORS/BILLING-INSURANCE-FINANCIAL-ASSISTANCE/FINANCIAL X FRHS.ORG/PATIENTS-VISITORS/BILLING-INSURANCE-FINANCIAL-ASSISTANCE/FINANCIAL X X X X X X 1 X 0 X X X X 1 X 0 0 PART V, SECTION B FACILITY REPORTING GROUP A FACILITY REPORTING GROUP A CONSISTS OF: - FACILITY 1: FAITH REGIONAL HEALTH SERVICES - WEST, - FACILITY 2: FAITH REGIONAL HEALTH SERVICES - EAST FACILITY REPORTING GROUP - A PART V, SECTION B, LINE 5: THE MULTI-STEP PROCESS BEGAN WITH THE MOBILIZING FOR ACTION THROUGH PLANNING AND PARTNERSHIP (MAPP) PROCESS. A NUMBER OF INDIVIDUALS AND ORGANIZATIONS WITH A COMMON INTEREST IN PUBLIC HEALTH CONTRIBUTED TO IDENTIFYING THE TRENDS, FACTORS, AND EVENTS THAT INFLUENCE THE HEALTH AND QUALITY OF LIFE IN OUR COMMUNITIES AND/OR THE WORK OF THE PUBLIC HEALTH SYSTEM. CONTRIBUTORS REPRESENTED A VARIETY OF ARENAS, SECTORS AND BACKGROUNDS, AND EVERY EFFORT WAS PLACED ON HAVING EQUAL AND FAIR REPRESENTATION ACROSS ALL COUNTIES AND SECTOR FOCUS AREAS. INPUT FROM DIVERSE SECTORS INVOLVED IN PUBLIC HEALTH WAS OBTAINED THROUGH KEY INFORMANT INTERVIEWS FROM THE FOLLOWING GROUPS:-ECONOMIC DEVELOPMENT-CHAMBER OF COMMERCE-FINANCIAL INSTITUTION-HOSPITAL/CLINIC WORKERS-ELVPHD BOARD OF HEALTH-TRAILS COMMITTEE MEMBERS-LONG-TERM CARE-MEDICAL RESPONSE SYSTEMS-NEBRASKA DHHS-VETERAN SERVICE OFFICER-UNL COUNTY EXTENSION-ELECTED OFFICIALS-JUVENILE DIVERSION-LEAGUE OF HUMAN DIGNITY-NORFOLK SAFE COMMUNITIES-BEHAVIORAL HEALTH-HOSPITAL BOARD MEMBERS-NEBRASKA SEE TO LEARN PROGRAM-PUBLIC HEALTH LIAISON/ADVOCATE-SCHOOL NURSES AND SCHOOL ADMINISTRATORS-CENTER FOR RURAL AFFAIRS-CUMING COUNTY PUBLIC POWER DISTRICT-LAW ENFORCEMENT-INSTITUTES OF HIGHER EDUCATION-COMMUNITY-BASED ORGANIZATIONS-CITY EMPLOYEES-NEBRASKA BICYCLING ALLIANCE-AREA AGENCY ON AGING-PONCA TRIBE OF NEBRASKA-FEDERALLY-QUALIFIED HEALTH CENTER-NORFOLK FAMILY COALITION-NEIGHBORING LOCAL PUBLIC HEALTH DEPARTMENTSCOMMUNITY ENGAGEMENT WAS AN OVERARCHING CONCEPT ENCOMPASSING THE COMMUNITY HEALTH NEEDS ASSESSMENT AND FORMATION OF THE COMMUNITY HEALTH IMPROVEMENT PLAN. FACILITY REPORTING GROUP - A PART V, SECTION B, LINE 6A: FAITH REGIONAL HEALTH SERVICES - WEST AND FAITH REGIONAL HEALTH SERVICES - EAST PARTNERED WITH THE ELKHORN LOGAN VALLEY PUBLIC HEALTH DEPARTMENT (ELVPHD) AND ITS RESPECTIVE DISTRICT HOSPITALS TO COMPLETE THE CHNA, THOSE HOSPITALS ARE AS FOLLOWS:-FRANCISCAN HEALTHCARE, WEST POINT, NE (CUMING COUNTY) FACILITY REPORTING GROUP - A PART V, SECTION B, LINE 6B: FAITH REGIONAL HEALTH SERVICES PARTNERED WITH ITS LOCAL HEALTH DEPARTMENT, ELKHORN LOGAN VALLEY PUBLIC HEALTH DEPARTMENT TO COMPLETE THE CHNA. FACILITY REPORTING GROUP - A PART V, SECTION B, LINE 11: FAITH REGIONAL HEALTH SERVICES HAS IDENTIFIED TWO PRIORITY AREAS IN THE CHNA: CANCER PREVENTION AND SCREENING AND BEHAVIORAL/MENTAL HEALTH. FOR EACH OF THESE AREAS, GOALS AND IMPLEMENTATION STRATEGIES ARE IDENTIFIED IN THE HOSPITAL COMMUNITY HEALTH IMPLEMENTATION PLAN.THE GOALS FOCUSED ON CANCER PREVENTION AND SCREENING INCLUDE THE FOLLOWING: 1) INCREASE CANCER SCREENING AND PREVENTION IN OUR SERVICE AREA. 2) INCREASING PATIENT AND PROVIDER COMMUNICATION ABOUT SCREENINGS UTILIZING ELECTRONIC HEALTH RECORD (EHR) EPIC. 3) DECREASED THE BURDEN OF OBESITY IN THE ELVPHD DISTRICT AS A SIGNIFICANT RISK FACTOR FOR CANCER.THE GOALS FOCUSED ON BEHAVIORAL/MENTAL HEALTH INCLUDE THE FOLLOWING: 1) INCREASE INTERNSHIP AND PRECEPTORSHIP OPPORTUNITIES IN THE INPATIENT OR OUTPATIENT SETTINGS FOR MENTAL HEALTH NURSING, MENTAL HEALTH THERAPISTS AND SOCIAL WORK DEGREES. 2) INCREASE TELEHEALTH ENCOUNTERS IN THE OUTPATIENT CLINIC IN BOTH MED MANAGEMENT AND THERAPY ENCOUNTERS. 3) DECREASE FINANCIAL BARRIERS TO INDIVIDUALS RECEIVING MENTAL HEALTH SERVICES, INPATIENT AND OUTPATIENT THROUGH USE OF REGION IV FUNDING. 4) MAINTAIN RELATIONSHIPS WITH REGION IV COORDINATOR AND REGION IV LAW ENFORCEMENT TO IMPROVE EASE OF ACCESS FOR REGIONAL CARE.THERE WERE NOT ANY NEEDS IDENTIFIED IN THE CHNA THAT ARE NOT BEING ADDRESSED BY THE HOSPITAL. FACILITY REPORTING GROUP - A PART V, SECTION B, LINE 13B: FOR MEDICARE PATIENTS, THE HOSPITAL MAY USE THE ORIGINAL DETERMINATION AMOUNT. FACILITY REPORTING GROUP - A PART V, SECTION B, LINE 13H: CHARITY CARE MAY BE AUTHORIZED FOR FINANCIALLY RESPONSIBLE PARTIES WITH INCOME LEVELS EXCEEDING 400% FPG IN THE CASE OF UNUSUAL, SPECIAL AND/OR EXTENUATING CIRCUMSTANCES. THESE INSTANCES ARE GENERALLY DUE TO MEDICAL CATASTROPHE SITUATIONS. 2 1 - NORTHEAST NE SURGERY CENTER LLC 301 NORTH 27TH ST STE 3 NORFOLK NE 68701 SURGERY CENTER 3 - ST JOSEPH REHABILITATION & CARE CTR 401 N 18TH STREET NORFOLK NE 68701 SKILLED NURSING FACILITY PART I, LINE 3C: IN ADDITION TO FEDERAL POVERTY GUIDELINES, FAITH REGIONAL USES ASSET LEVEL, MEDICAL INDIGENCY, INSURANCE STATUS, UNDERINSURANCE STATUS AND FOR MEDICARE PATIENTS, THE HOSPITAL MAY USE THE ORIGINAL DETERMINATION AMOUNT, TO DETERMINE ELIGIBILITY FOR FREE OR DISCOUNTED CARE. FAMILY SIZE AND INCOME LEVEL ARE USED TO DETERMINE WHERE THE PATIENT FALLS IN RELATION TO RECEIVING FREE CARE OR DISCOUNTED CARE.CHARITY CARE MAY BE AUTHORIZED FOR FINANCIALLY RESPONSIBLE PARTIES WITH INCOME LEVELS EXCEEDING 400% FPG IN THE CASE OF UNUSUAL, SPECIAL AND/OR EXTENUATING CIRCUMSTANCES. THESE INSTANCES ARE GENERALLY DUE TO MEDICAL CATASTROPHE SITUATIONS. PART I, LINE 6A: FAITH REGIONAL'S ANNUAL COMMUNITY BENEFIT REPORT IS NOT PREPARED BY A RELATED ORGANIZATION. PART I, LINE 7: FAITH REGIONAL USES A COST ACCOUNTING SYSTEM TO DETERMINE COSTS REPORTABLE ON PART I, LINE 7 (AND ELSEWHERE ON SCHEDULE H). THE FIRST STEP IN THE COST ACCOUNTING PROCESS IS TO ALLOCATE THE OVERHEAD EXPENSES (ADMINISTRATION AND GENERAL, PLANT, ETC) TO THE REVENUE PRODUCING DEPARTMENTS (OPERATING ROOM, IMAGING, ONCOLOGY, ETC). THIS IS DONE SIMILAR TO THE MEDICARE COST REPORT USING A SINGLE STEP DOWN METHOD TO ALLOCATE THE COSTS USING APPLICABLE STATISTICS. FOR EXAMPLE: PLANT EXPENSES ARE ALLOCATED DOWN TO THE OTHER DEPARTMENTS USING CURRENT SQUARE FOOTAGE SO DEPARTMENTS WITH MORE SQUARE FOOTAGE WILL BE ALLOCATED MORE PLANT EXPENSES; DIETARY EXPENSES ARE ALLOCATED BASED ON MEALS SERVED; EMPLOYEE BENEFITS ARE ALLOCATED BASED ON SALARIES; ADMINISTRATIVE AND GENERAL EXPENSES ARE ALLOCATED BASED ON ACCUMULATED COSTS; AND SO ON. ONCE ALL THE OVERHEAD EXPENSES ARE ALLOCATED TO THE REVENUE PRODUCING DEPARTMENTS THE COSTS ARE FURTHER ALLOCATED DOWN TO THE CHARGE CODE LEVEL. IN ORDER TO DO THIS, TWO DIFFERENT METHODS ARE USED DEPENDING ON THE DEPARTMENT. SPECIFIC DEPARTMENTS USE A RVU (RELATIVE VALUE UNIT) ALLOCATION WHERE EACH PROCEDURE IS WEIGHTED BY THE INTENSITY OF THE SERVICE AND IS THEN ALLOCATED COST BASED ON THAT LEVEL OF INTENSITY. FOR EXAMPLE AN XRAY WITH SEDATION IS MORE COMPLICATED AND TIME INTENSIVE THAN A SIMPLE CHEST XRAY SO IT WOULD HAVE A HIGHER RVU VALUE AND, IN TURN, A HIGHER COST ALLOCATED TO IT. THE DEPARTMENTS USING THIS ALLOCATION METHOD ARE IMAGING, CARDIAC CATH, CT, MRI, ULTRASOUND, NUCLEAR MEDICINE, RADIATION ONCOLOGY, AND REHAB (PHYSICAL, OCCUPATIONAL AND SPEECH THERAPY).THE OTHER DEPARTMENTS USE A RATIO OF COST TO CHARGE METHOD TO ALLOCATE THE COSTS DOWN TO THE CHARGE CODE LEVEL.AFTER ALL THE COSTS HAVE BEEN ALLOCATED TO THE CHARGE CODES THE COSTING IS APPLIED TO ALL PATIENT ACCOUNTS BASED ON THEIR CHARGES TO DETERMINE THE COST OF THEIR ENCOUNTER AND THEN REPORTS CAN BE RUN TO DETERMINE THE PROFITABILITY OF CERTAIN PAYORS, SERVICE LINES OR DEPARTMENTS. PART I, LINE 7G: MANY SERVICES PROVIDED BY FAITH REGIONAL ARE DONE SO TO MEET SPECIFIC NEEDS OF THE COMMUNITY BECAUSE NO OTHER SERVICES ARE AVAILABLE. AS A RESULT, THESE SERVICES ARE PROVIDED KNOWING THAT THEY WILL NOT BE FINANCIALLY VIABLE OR SELF-SUPPORTING. FAITH REGIONAL DID NOT INCLUDE ANY PHYSICIAN CLINIC EXPENSES AS SUBSIDIZED HEALTH SERVICES. PART II, COMMUNITY BUILDING ACTIVITIES: COMMUNITY BUILDING ACTIVITIES DURING THE YEAR INCLUDED EXPENSES FOR THE NORFOLK AREA BIG GIVE, AS WELL AS CARDBOARD RECYCLING. PART III, LINE 2: THE AMOUNT ON LINE 2 REPRESENTS IMPLICIT PRICE CONCESSIONS. FAITH 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 10.8% 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 PAGE 14 OF THE ATTACHED FINANCIAL STATEMENTS. PART III, LINE 8: THE ENTIRE MEDICARE SHORTFALL IS CONSIDERED A COMMUNITY BENEFIT. 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. PART III, LINE 9B: FRHS WILL NOT ENGAGE IN ECAS, EITHER DIRECTLY OR BY ANY DEBT COLLECTION AGENCY OR OTHER PARTY TO WHICH THE HOSPITAL HAS REFERRED THE PATIENT'S DEBT, BEFORE REASONABLE EFFORTS ARE MADE TO DETERMINE WHETHER A RESPONSIBLE INDIVIDUAL(S) IS ELIGIBLE FOR ASSISTANCE UNDER THE FAP.AT LEAST THREE SEPARATE STATEMENTS FOR COLLECTIONS OF SELF-PAY ACCOUNTS SHALL BE MAILED TO THE LAST KNOWN ADDRESS OF EACH RESPONSIBLE INDIVIDUAL(S); PROVIDED, HOWEVER, THAT NO ADDITIONAL STATEMENTS NEED BE SENT AFTER A RESPONSIBLE INDIVIDUAL(S) SUBMITS A COMPLETE APPLICATION FOR FINANCIAL ASSISTANCE UNDER THE FAP OR HAS PAID IN-FULL. AT LEAST 120 DAYS MUST LAPSED BETWEEN THE FIRST AND LAST OF THESE REQUIRED THREE MAILINGS.AT LEAST ONE OF THE STATEMENTS MAILED OR EMAILED WILL INCLUDE WRITTEN NOTICE THAT INFORMS THE RESPONSIBLE INDIVIDUAL(S) ABOUT THE ECAS THAT ARE INTENDED TO BE TAKEN IF THE RESPONSIBLE INDIVIDUAL(S) DOES NOT APPLY FOR FINANCIAL ASSISTANCE UNDER THE FAP GUIDELINES OR PAY THE AMOUNT DUE BY THE BILLING DEADLINE. SUCH STATEMENT MUST BE PROVIDED TO THE RESPONSIBLE INDIVIDUAL(S) AT LEAST 30 DAYS BEFORE THE DEADLINE SPECIFIED IN THE STATEMENT.PRIOR TO INITIATION OF ANY ECAS, AN ORAL ATTEMPT WILL BE MADE TO CONTACT RESPONSIBLE INDIVIDUAL(S) BY TELEPHONE AT THE LAST KNOWN TELEPHONE NUMBER, IF ANY, AT LEAST ONCE DURING THE SERIES OF MAILED STATEMENTS IF THE ACCOUNT REMAINS UNPAID. DURING ALL CONVERSATION, THE PATIENT OR RESPONSIBLE INDIVIDUAL(S) WILL BE INFORMED ABOUT THE FINANCIAL ASSISTANCE THAT MAY BE AVAILABLE UNDER THE FAP. IF AN APPLICATION, COMPLETE OR INCOMPLETE, FOR FINANCIAL ASSISTANCE UNDER THE FAP IS SUBMITTED BY A RESPONSIBLE INDIVIDUAL(S), AT ANY TIME PRIOR TO THE APPLICATION DEADLINE, FRHS WILL SUSPEND ECAS WHILE SUCH FINANCIAL ASSISTANCE APPLICATION IS PENDING. THIS WILL INCLUDE ANY CURRENT ACCOUNTS AND BAD DEBT ACCOUNTS GOING BACK 240 DAYS FROM THE DATE OF THE FIRST STATEMENT ON THE ACCOUNT. PART VI, LINE 2: FAITH REGIONAL CHOSE TO PARTNER WITH THE ELKHORN LOGAN VALLEY PUBLIC HEALTH DEPARTMENT (ELVPHD) AND ITS RESPECTIVE DISTRICT HOSPITALS TO COMPLETE THE JOINT COMMUNITY HEALTH NEEDS ASSESSMENT (CHNA) IN 2022. IN ADDITION TO THE PUBLIC HEALTH DEPARTMENT'S ASSESSMENT, FAITH REGIONAL IS INTIMATELY INVOLVED IN THE ELKHORN ECONOMIC DEVELOPMENT ASSOCIATION, BOTH ON THE BOARD AND THROUGH FINANCIAL SUPPORT. THAT INVOLVEMENT IS INTENDED TO FACILITATE COMMUNITY GROWTH, JOB DEVELOPMENT, INFRASTRUCTURE DEVELOPMENT AND BUSINESS EDUCATION/TRAINING. FAITH REGIONAL IS ALSO A MEMBER OF THE NORFOLK CHAMBER OF COMMERCE WHICH IS INVOLVED IN BUSINESS RETAIL DEVELOPMENT AND SUPPORT AS WELL AS THE COMMUNITY IMPROVEMENT PROJECTS. FAITH ALSO WORKS WITH ORGANIZATIONS LIKE THE ORPHAN GRAIN TRAIN IN PROVIDING MEDICINE AND MEDICAL EQUIPMENT/SUPPLIES TO OTHER NATIONS IN NEED. PART VI, LINE 3: PATIENTS RECEIVING CARE ARE GIVEN INFORMATION REGARDING FAITH REGIONAL'S FINANCIAL ASSISTANCE PROGRAM THROUGH THE USE OF BROCHURES HANDED OUT BY REGISTRATION, HOSPITAL SOCIAL SERVICES, M.A.S.H. (MEDICAL ADVOCACY SERVICES FOR HEALTHCARE) PERSONNEL AND BY PATIENT ACCOUNTS STAFF. ANY PATIENT OR FAMILY MEMBER THAT EXPRESSES CONCERN REGARDING ABILITY TO PAY FOR SERVICES WILL BE DIRECTED TO A SOCIAL WORKER, REGISTRATION CLERK, CASHIER OR FINANCIAL SERVICES REPRESENTATIVE WHO WILL THEN GIVE THEM AN APPLICATION FOR PATIENT FINANCIAL ASSISTANCE ALONG WITH A BROCHURE EXPLAINING HOW TO COMPLETE THE APPLICATION. PART VI, LINE 4: FAITH REGIONAL'S PRIMARY SERVICE AREA CONSISTS OF ANTELOPE, BOONE, HOLT, KNOX, MADISON, PIERCE, PLATTE, STANTON AND WAYNE COUNTIES IN NEBRASKA. THE HOSPITAL'S SECONDARY SERVICE AREA CONSISTS OF CEDAR, COLFAX, CUMING AND DIXON COUNTIES IN NEBRASKA. FAITH REGIONAL ALSO HAS A TERTIARY SERVICE AREA OF BOYD, BROWN, BURT, CHERRY, DAKOTA, GARFIELD, KEYA PAHA, NANCE, ROCK, THURSTON AND WHEELER COUNTIES IN NEBRASKA.BASED ON U.S. CENSUS INFORMATION, THE ABOVE COUNTIES IN THE FRHS PRIMARY AND SECONDARY SERVICE AREAS REPRESENT A TOTAL POPULATION OF 209,753. THE RACIAL MAKEUP OF THE SERVICE AREA POPULATION IS MAJORITY WHITE WITH 92.6% IDENTIFYING AS WHITE ALONE AND 7.4% IDENTIFYING AS NON-WHITE. THE SERVICE AREA'S MOST SIGNIFICANT RACIAL MINORITY IS HISPANIC WITH AN AVERAGE 8.5% PERCENT HISPANIC/LATINO POPULATION.THE MEDIAN HOUSEHOLD INCOME OF OUR SERVICE AREA IS $55,451 AND THE PER CAPITA INCOME IS $29,078, COMPARED TO THE MEDIAN HOUSEHOLD INCOME FOR NEBRASKA AT $50,695 AND THE PER CAPITA INCOME AT $26,113. AN AVERAGE OF 10.8% OF THE FRHS SERVICE AREA LIVES IN POVERTY, AND AN AVERAGE 9% DO NOT HAVE HEALTH INSURANCE. PART VI, LINE 5: FAITH REGIONAL, A NOT-FOR-PROFIT HEALTH CARE FACILITY, LOCATED IN NORTHEAST NEBRASKA, OPERATES FOR THE BENEFIT OF THE INDIVIDUALS IN THE SERVICE AREA. FAITH REGIONAL SERVES ALL PATIENTS REGARDLESS OF THEIR ABILITY TO PAY AND DOES NOT LIMIT ITS SERVICES OR DISCRIMINATE AGAINST ANYONE ON THE BASIS OF RACE, COLOR, SEX, NATIONAL ORIGIN, SEXUAL ORIENTATION, RELIGION, AGE, DISABILITY, DISEASE OR DIAGNOSIS. FAITH REGIONAL ALSO PROVIDES COMMUNICATIONS SERVICES (E.G. BILINGUAL STAFF AND INTERPRETERS, SIGN LANGUAGE INTERPRETERS, TDD SERVICES, ETC) FOR SENSORY IMPAIRED INDIVIDUALS. FAITH REGIONAL EVALUATES ITSELF ON ITS EFFECTIVENESS ANNUALLY BY EXAMINING ITS ABILITY TO FULFILL ITS MISSION, ACCOMPLISH ITS VISION, PROVIDE SERVICE AND MAINTAIN ITS VALUES. FAITH REGIONAL'S MISSION, VISION, SERVICE AND VALUES ARE: THE MISSION: THE MISSION IS TO SERVE CHRIST BY PROVIDING ALL PEOPLE WITH EXEMPLARY MEDICAL SERVICES IN AN ENVIRONMENT OF LOVE AND CARE.THE VISION: THE VISION OF FAITH REGIONAL HEALTH SERVICES IS TO BECOME A REGIONAL REFERRAL CENTER BY PROVIDING THE MOST COMPREHENSIVE, HIGH QUALITY HEALTH SERVICES TO THE RESIDENTS OF NORTHEAST NEBRASKA. THE VALUES:-SPIRITUALITY-EXCELLENCE-INTEGRITY-COMPASSION-RESPECT-STEWARDSHIPFAITH REGIONAL'S PROGRAM SERVICE ACCOMPLISHMENTS ARE BASED ON THE COMMUNITY ACCOUNTABILITY STANDARDS DEVELOPED BY THE VOLUNTARY HOSPITALS OF AMERICA (VHA). THESE FOUR STANDARDS ARE:1) DEMONSTRATE LEADERSHIP AS A CHARITABLE INSTITUTION.2) PROVIDING ESSENTIAL HEALTH CARE SERVICES.3) BEING ACCOUNTABLE TO THE COMMUNITY.4) MAINTAINING EVIDENCE OF COMMITMENT TO COMMUNITY BENEFIT.FAITH REGIONAL RECOGNIZES ITS OBLIGATION TO DEMONSTRATE LEADERSHIP AS A CHARITABLE ORGANIZATION BY PROVIDING A FULL RANGE OF HEALTH CARE, HEALTH EDUCATION AND WELLNESS RELATED SERVICES TO THE COMMUNITY, AND PARTICIPATING IN FEDERAL, STATE AND LOCAL PROGRAMS TO PROVIDE HEALTH BENEFITS TO THOSE IN NEED. FAITH REGIONAL FINANCIALLY SUPPORTS VARIOUS OUTREACH ACTIVITIES IN WHICH HOSPITAL PROVIDERS TRAVEL OUT TO SURROUNDING COMMUNITIES TO PROVIDE SERVICES WHICH MAY OTHERWISE NOT BE AVAILABLE. FAITH REGIONAL PROVIDES TRANSPORTATION SERVICES PRIMARILY TO RADIATION ONCOLOGY PATIENTS AT NO CHARGE.FAITH REGIONAL REMAINS ACCOUNTABLE TO THE COMMUNITY BY WORKING WITH A VOLUNTEER GOVERNING BOARD THAT IS REPRESENTATIVE OF THE COMMUNITY IT SERVES. COOPERATION WITH COMMUNITY BASED HEALTH ORGANIZATIONS IDENTIFY PERTINENT ISSUES RELATED TO ESSENTIAL SERVICES, CHARITY CARE, HEALTH CARE COST CONTAINMENT, COMMUNITY BENEFIT ACTIVITIES AND OTHERS AS APPROPRIATE. FAITH REGIONAL CONTINUES TO OPERATE UNDER A VOLUNTEER GOVERNING BOARD AND REMAINS ACTIVELY INVOLVED IN ADVOCATING PUBLIC AWARENESS OF HEALTH CARE AND HEALTH CARE POLICY ISSUES. DISCLOSURES OF COMMUNITY BENEFIT INFORMATION AND ADVOCACY ISSUES ARE PROVIDED THROUGH A VARIETY OF MEDIA INCLUDING MEDIA RELEASES AND ITS INTERNET WEBSITE: WWW.FRHS.ORG.FAITH REGIONAL'S CONTRIBUTION TO THE COMMUNITY NOT ONLY INCLUDES COMPENSATED AND DONATED TIME BUT ALSO EQUIPMENT, MATERIALS AND SPACE. MEETING ROOMS ARE PROVIDED AS NEEDED AND EQUIPMENT AND MATERIALS (E.G. COMPUTERS, COPIER, FAXES, TELEPHONES, CHILDBIRTH PROPS, PROJECTORS, MANNEQUINS, HEARING BOOTH, AUDIOMETERS, BEDS, MONITORS, WARMING UNITS, MINOR INSTRUMENTS, ETC.) ARE PROVIDED AT NO CHARGE. A MAJOR CONCERN IN HEALTH CARE THAT CAN SOMETIMES BE "HIDDEN" IS THAT OF SEXUAL ABUSE AND NEGLECT IN CHILDREN. THE NORTHEAST NEBRASKA CHILD ADVOCACY PROGRAM AT FAITH REGIONAL PROVIDES A SAFE, NON THREATENING ENVIRONMENT WHERE CHILDREN (AGES INFANT TO 18) WHO ARE VICTIMS OF ABUSE RECEIVE IMMEDIATE MEDICAL CARE AND FORENSIC INTERVIEWS FROM VARIOUS AGENCIES WORKING TOGETHER. ALL OF THESE SERVICES ARE AVAILABLE FREE TO FAMILIES WITHIN A 24-COUNTY AREA. PART VI, LINE 6: FAITH REGIONAL IS NOT PART OF AN AFFILIATED HEALTH CARE SYSTEM. 1 FOR THE GIRLS NORFOLK PO BOX 1124 NORFOLK NE 68702 460972709 501(C)(3) 7500 0 SPONSORSHIPS NORFOLK AREA UNITED WAY PO BOX 1041 NORFOLK NE 68702 470492054 501(C)(3) 6000 0 ANNUAL GIVING/CAPITAL CAMPAIGN NORFOLK FAMILY YMCA 301 W BENJAMIN AVE NORFOLK NE 68701 465709553 501(C)(3) 105000 0 FACILITY EXPANSION AND ROUNDTABLE EVENT GREATER NORFOLK ECONOMIC DEVELOPMENT FOUNDATION 609 W NORFOLK AVE NORFOLK NE 68701 363441719 501(C)(3) 50000 0 TO PROVIDE TRANSPORTATION FOR EMPLOYEES TO AND FROM WORK. NORTH FORK AREA TRANSIT 222 N 4TH ST NORFOLK NE 68701 237207097 501(C)(3) 50000 0 TO PROVIDE TRANSPORTATION FOR EMPLOYEES TO AND FROM WORK. 5 0 PART I, LINE 2: CASH DONATIONS ARE MADE TO ORGANIZATIONS, MANY OF WHICH HAVE HEALTH CARE OR SOCIAL SERVICES MISSIONS. THESE DONATIONS ARE SOMETIMES RESTRICTED FOR A SPECIFIC USE OR ACTIVITY. 501(C)(3) ORGANIZATIONS ARE BOUND BY THEIR ARTICLES OF ORGANIZATION AND STATED MISSIONS TO CONDUCT ACTIVITIES STRICTLY FOR CHARITABLE PURPOSES. FAITH REGIONAL DOES NOT REQUEST GRANT REPORTS FROM DONEE CHARITABLE ORGANIZATIONS. X X X X 0 0 0 0 0 0 0 1 0 FADI RZOUQ MD PHYSICIAN 1010067 0 3820969 0 0 0 13200 0 24445 0 4868681 0 0 0 TRISTAN L HARTZELL MD PHYSICIAN 1115995 0 2283164 0 0 0 0 0 2112 0 3401271 0 0 0 JOHN LAMMLI MD PHYSICIAN 777721 0 622021 0 0 0 13200 0 24607 0 1437549 0 0 0 BEETHOVEN BROWN MD PHYSICIAN 1239400 0 50 0 0 0 13200 0 1913 0 1254563 0 0 0 NATHAN HERMAN MD PHYSICIAN 480969 0 548296 0 0 0 13200 0 23307 0 1065772 0 0 0 KELLY DRISCOLL CEO 696897 0 72772 0 11475 0 16500 0 25083 0 822727 0 0 0 ROBERT PRINCE MD MEMBER - MEDICAL DIRECTOR 708174 0 50 0 0 0 279 0 5304 0 713807 0 0 0 LANE HANDKE MD MEMBER - CHIEF OF STAFF 330405 0 214842 0 0 0 9167 0 23025 0 577439 0 0 0 JANNA CLINE VP FINANCE 272106 0 50 0 0 0 8317 0 23637 0 304110 0 0 0 PART I, LINE 7 PHYSICIANS HAVE AN OPPORTUNITY TO EARN PRODUCTION BONUSES IF THE PROVIDER REACHES ABOVE RELATIVE VALUE UNIT AMOUNTS. PAYOUTS ARE DEPENDENT ON THEIR BASE SALARY PERCENTILE. PHYSICIANS ALSO HAVE AN OPPORTUNITY TO EARN A QUALITY BONUS IF THEY MEET CERTAIN CRITERIA THROUGHOUT THE YEAR WHICH INCLUDES MIPS-QPP TARGETS, MEETING ATTENDANCE, COMMUNITY SERVICE, AND EVENT SPONSORSHIPS. PHYSICIANS RECEIVING THESE BONUSES DURING THE YEAR INCLUDE THE FOLLOWING: TRISTAN HARTZELL, M.D. FADI RZOUQ, M.D. NATHAN HERMAN, M.D. JOHN LAMMLI, M.D. LANE HANDKE, M.D. A HOSPITAL AUTHORITY #1 OF MADISON COUNTY NEBRASKA 521357975 557352EX5 2017-08-17 44772246 REFUND PRIOR ISSUES (07/10/08 & 11/20/08) 0 0 0 B HOSPITAL AUTHORITY #1 OF MADISON COUNTY NEBRASKA 521357975 557352FQ9 2018-05-10 32483418 CONSTRUCT FACILITY 0 0 0 A 23429132 44772246 712032 44060214 1 1 1 1 B 6786500 32483418 2577140 580862 29325416 2019 0 0 1 1 A 0 0 0 0 0.00540 0.00000 0.00540 0 0 1 B 0 0 0 0 0.00000 0.00000 0.00000 0 0 0 A 0 0 0 1 0 0 0 0 1 B 0 0 0 1 0 0 0 0 1 A 1 B 1 DATE REBATE COMPUTATION PERFORMED ISSUER NAME: HOSPITAL AUTHORITY #1 OF MADISON COUNTY NEBRASKA DATE THE REBATE COMPUTATION WAS PERFORMED: 07/01/2018 ISSUER NAME: HOSPITAL AUTHORITY #1 OF MADISON COUNTY NEBRASKA DATE THE REBATE COMPUTATION WAS PERFORMED: 12/31/2019 SCHEDULE K, PART IV, ARBITRAGE, LINC 2C: NOTE REGARDING THE FIRST REBATE COMPUTATION ON 7/1/18: AS NO REBATABLE ARBITRAGE WAS EARNED ON THE ADVANCE REFUNDING ESCROW AND THE DEBT SERVICE FUND WAS OPERATED ON A BONA RIDE BASIS, NO FURTHER REBATE ANALYSIS IS NECESSARY. NOTE REGARDING THE COMPUTATION ON 12/31/19: SINCE THE BOND PROCEEDS HAVE BEEN SPENT AND THE DEBT SERVICE FUND WAS OPERATED ON A BONA FIDE BASIS, NO FURTHER REBATE CALCULATIONS ARE NECESSARY. TRACY COLLISON DAUGHTER-IN-LAW OF JACQUE COLLISON, A BOARD MEMBER 85689 TRACY IS AN EMPLOYEE OF FAITH REGIONAL HEALTH SERVICES. 0 CHRISTINE PRINCE WIFE OF ROBERT PRINCE, A BOARD MEMBER 96371 CHRISTINE IS AN EMPLOYEE OF FAITH REGIONAL HEALTH SERVICES. 0 SHARON GOSSMAN MOTHER OF JOSH GOSSMAN, A BOARD MEMBER 138677 SHARON IS AN EMPLOYEE OF FAITH REGIONAL HEALTH SERVICES. 0 FORM 990, PART VI, SECTION A, LINE 1A THE EXECUTIVE COMMITTEE, CONSISTING OF THE IMMEDIATE PAST CHAIR, THE CHAIR, THE VICE CHAIR, THE SECRETARY, THE TREASURER, AND ONE PHYSICIAN BOARD MEMBER, HAS AUTHORITY TO ACT ON BEHALF OF THE GOVERNING BODY. IF THE IMMEDIATE PAST CHAIR IS NO LONGER A VOTING DIRECTOR, HE OR SHE SHALL NEVERTHELESS SERVE IN A VOTING CAPACITY ON THE EXECUTIVE COMMITTEE. FORM 990, PART VI, SECTION A, LINE 6 FAITH REGIONAL HAS ONE NONPROFIT 501(C)(3) CORPORATE MEMBER, LUTHERAN COMMUNITY HOSPITAL ASSOCIATION, A RELATED ORGANIZATION. FORM 990, PART VI, SECTION A, LINE 7A THE SOLE CORPORATE MEMBER, LUTHERAN COMMUNITY HOSPITAL ASSOCIATION, APPOINTS 13 VOTING MEMBERS OF THE BOARD OF DIRECTORS OF FAITH REGIONAL HEALTH SERVICES. FORM 990, PART VI, SECTION A, LINE 7B CERTAIN POWERS ARE RESERVED TO ITS SOLE MEMBER, LUTHERAN COMMUNITY HOSPITAL ASSOCIATION. THERE ARE 13 RESERVED POWERS, INCLUDING APPOINTMENT AND REMOVAL OF DIRECTORS, OTHER THAN CHIEF OF STAFF AND THE PHYSICIAN SERVICES MEDICAL DIRECTOR, AMENDMENT OF THE ARTICLES OF INCORPORATION AND BYLAWS, AMENDMENT OF THE MISSION, VISION AND VALUE STATEMENTS, AMONG OTHERS. FORM 990, PART VI, SECTION B, LINE 11B FORM 990 INFORMATION SCHEDULES ARE COMPLETED IN-HOUSE BY THE REIMBURSEMENT ACCOUNTANT AND REVIEWED BY THE CONTROLLER AND CFO. THE INFORMATION IS PROVIDED FOR RETURN PREPARATION AND SIGNATURE. FORM 990 IS REVIEWED AND DISCUSSED WITH THE CFO AND COPIES OF THE COMPLETED RETURN ARE DISTRIBUTED TO THE BOARD MEMBERS FOR REVIEW PRIOR TO SUBMISSION TO THE IRS. FORM 990, PART VI, SECTION B, LINE 12C FAITH REGIONAL'S BOARD MEMBERS ARE REQUIRED TO SIGN A CONFLICT OF INTEREST STATEMENT AND DISCLOSURE ANNUALLY. ANY CONFLICTS ARE REVIEWED BY BOTH THE GOVERNANCE COMMITTEE AND INDEPENDENT LEGAL COUNSEL. THE GOVERNANCE COMMITTEE PRESENTS RECOMMENDATIONS TO THE FULL BOARD. A MEMBER WITH A CONFLICT IS EXCUSED FROM THE BOARD DELIBERATIONS AND ACTION. FORM 990, PART VI, SECTION B, LINE 15 DETERMINATION OF COMPENSATION FOR THE CEO AND OTHER OFFICERS IS MADE BY GATHERING DATA FROM EXTERNAL SURVEYS AND THE FORM 990 DATA PROVIDED BY COMPARABLE FACILITIES. FACILITIES USED ARE DETERMINED BY SIMILAR BED SIZE, NET REVENUES AND NUMBER OF FTES. WAGES ARE GATHERED AND COMPARED BY TITLE, RESPONSIBILITIES AND YEARS OF EXPERIENCE. THE SALARY RECOMMENDATIONS ARE MADE BY THE HUMAN RESOURCE DEPARTMENT. THE GOVERNING BOARD APPROVES THE SALARY RECOMMENDATIONS FOR THE CEO; THE CEO APPROVES THE RECOMMENDATIONS FOR THE OTHER OFFICERS AND VICE-PRESIDENTS; AND THE VICE-PRESIDENTS APPROVE THE RECOMMENDATIONS FOR THE DIRECTORS OF VARIOUS HOSPITAL DEPARTMENTS. FORM 990, PART VI, SECTION C, LINE 19 FAITH REGIONAL DOES NOT MAKE ITS GOVERNING DOCUMENTS, CONFLICT OF INTEREST POLICY OR FINANCIAL STATEMENTS AVAILABLE TO THE PUBLIC. FORM 990, PART XII, LINE 2C: THE FINANCE/AUDIT COMMITTEE OF THE BOARD OF DIRECTORS ASSUMES RESPONSBILITY FOR OVERSIGHT OF THE AUDIT AND SELECTION OF AN INDEPENDENT ACCOUNTANT. THIS PROCESS HAS NOT CHANGED FROM THE PRIOR YEAR. FAITH REGIONAL PHYSICIAN SERVICES LLC 2700 WEST NORFOLK AVENUE NORFOLK NE 68701 421629846 PHYSICIAN SERVICES NE 51514303 23534826 FAITH REGIONAL HEALTH SERVICES FAITH REGIONAL HEALTH SERVICES PHO INC 2700 WEST NORFOLK AVENUE NORFOLK NE 68701 IMPROVE HEALTHCARE SERVICES NE 0 0 FAITH REGIONAL HEALTH SERVICES ST JOSEPH'S REHABILITATION AND CARE CENTER 401 N 18TH ST NORFOLK NE 68701 470796875 NURSING HOME NE 6160249 3536616 FAITH REGIONAL HEALTH SERVICES LUTHERAN COMMUNITY HOSPITAL ASSOCIATION 2700 W NORFOLK AVE NORFOLK NE 68701 470396139 SUPPORT FAITH REGIONAL HEALTH SERVICES NE 501(C)(3) LINE 3 N/A 0 FAITH REGIONAL HEALTH SERVICES FOUNDATION 2700 W NORFOLK AVE NORFOLK NE 68701 911772474 SUPPORT FAITH REGIONAL HEALTH SERVICES NE 501(C)(3) LINE 12A, I FAITH REGIONAL HEALTH SERVICES 1 NORTHEAST NEBRASKA SURGERY CENTER 301 N 27TH STREET NORFOLK NE 68701 470819088 OUTPATIENT SURGERY NE FAITH REGIONAL HEALTH SERVICES RELATED 782391 2821432 0 0 0.59900 0 0 1 1 1 0 0 0 0 1 0 0 1 1 1 0 0 0 0 NORTHEAST NEBRASKA SURGERY CENTER O 2937632 FAIR MARKET VALUE NORTHEAST NEBRASKA SURGERY CENTER J 647521 FAIR MARKET VALUE FAITH REGIONAL HEALTH SERVICES FOUNDATION C 517634 FAIR MARKET VALUE NORTHEAST NEBRASKA SURGERY CENTER D 180065 FAIR MARKET VALUE