2026-05-12T12:50:17-05:00 2025-06-30 450250958 EIDE BAILLY LLP 18081 BURT ST STE 200 OMAHA NE 680224722 990 2024-07-01 470533373 COMMUNITY HOSPITAL ASSOCIATION OF MCCOOK COMM 3083442650 1301 EAST H STREET PO BOX 1328 MCCOOK NE 69001 SEAN WOLFE CHIEF FINANCIAL OFFICER 3083442650 2026-05-11 1 1 WENDY R COOLEY CPA P01523804 4023302660 2026-05-07 2024 2025-03-06 01:10:19Z SEAN WOLFE 1301 EAST H STREET PO BOX 1328 MCCOOK NE 69001 82517085 0 X WWW.CHMCCOOK.ORG X 1974 NE TO PROVIDE FOR THE HEALTHCARE NEEDS OF OUR REGION. 9 9 381 40 0 0 667289 1653570 63188048 79080538 1268951 1087579 964016 695398 66088304 82517085 416376 468477 0 0 33053335 36611372 0 0 297315 32478343 43716201 65948054 80796050 140250 1721035 91587690 98696906 32519348 37612867 59068342 61084039 X LEADING OUR REGION TO A HEALTHIER FUTURE. 1 0 64997995 468477 79775936 25-BED CRITICAL ACCESS ACUTE CARE HOSPITAL PROVIDING INPATIENT AND OUTPATIENT CARE, DIAGNOSTIC, REHABILITATION, SURGICAL, NURSERY, VISITING MEDICAL SPECIALISTS, HOME HEALTH AND HOSPICE, TWO RURAL HEALTH CLINICS, A PRIMARY CARE CLINIC, AND HEALTH AND EDUCATION PROGRAMS. 64997995 1 1 0 1 0 0 0 0 0 1 1 0 0 1 1 1 0 1 0 0 0 0 0 0 0 0 1 1 1 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 1 1 1 0 0 1 76 0 1 381 1 0 0 0 0 0 0 0 0 0 0 0 0 X 9 9 0 0 0 0 0 0 0 1 0 0 0 1 1 1 1 1 1 1 1 0 X SEAN WOLFE 3083448306 1301 EAST H - PO BOX 1328 MCCOOK NE 69001 RICHARD LAWTON ORTHO PHYSICAN 40.00 0.00 X 728996 0 73868 DOUGLAS TICE ORTHO PHYSICAN 40.00 0.00 X 701358 0 30301 EVAN GEILENKIRCHEN CRNA 40.00 0.00 X 348969 0 58914 TROY BRUNTZ PRESIDENT & CEO 39.00 1.00 X 333968 0 53413 SEAN WOLFE CFO 40.00 0.00 X 232303 0 62516 ANTHONY RODEWALD PHARMACIST 40.00 0.00 X 203660 0 43146 BRUCE MIKESELL EMERGENCY PHYSICIAN 40.00 0.00 X 197298 0 19583 MATTHEW NIELSEN CHAIR 1.00 1.00 X X 0 0 0 KURT VOSBURG VICE CHAIR 1.00 0.00 X X 0 0 0 MICHAEL LORD SECRETARY 1.00 0.00 X X 0 0 0 MATTHEW DAVIDSON TREASURER 1.00 0.00 X X 0 0 0 KAREN CRAW DIRECTOR 0.50 1.00 X 0 0 0 DARREN ESCH DIRECTOR 0.50 0.00 X 0 0 0 JANA KMOCH DIRECTOR 0.50 0.00 X 0 0 0 GRANT NORGAARD DIRECTOR 0.50 0.00 X 0 0 0 ASHLEY VONTZ DIRECTOR 0.50 1.00 X 0 0 0 2746552 0 341741 47 0 1 0 MCCOOK FAMILY MEDICINE 1301 E H ST MCCOOK NE 69001 PROVIDER SERVICES 4464295 RUTTS HEATING & AC 1001 W 1ST ST HASTINGS NE 68901 CONSTRUCTION 2268359 SOUTHWEST NEBRASKA PHYSICAL THERAPY PO BOX 789 MCCOOK NE 69001 PHYSICAL THERAPY SERVICES 1593822 KREWE ANESTHESIA 3915 N ARNOULT RD METAIRE LA 70002 ANESTHESIA SERVICES 995685 PATHOLOGY SERVICES PO BOX 1289 NORTH PLATTE NE 69103 LAB SERVICES 908092 21 461043 142527 1050000 1653570 PATIENT SERVICE REVENUE 621400 77905212 77905212 PHARMACY REVENUE 621400 936100 936100 OUT-SOURCE SERVICES 621400 239226 239226 79080538 1086845 1086845 167429 0 167429 167429 167429 734 0 734 734 734 CAFETERIA/MEALS 900099 320860 320860 HOUSEKEEPING INCOME 900099 76955 76955 130154 130154 527969 82517085 79775936 0 1087579 X 464477 464477 4000 4000 702978 702978 26563182 21466205 4906509 190468 1679795 1360849 306889 12057 5551577 4427638 1084649 39290 2113840 1670146 428898 14796 154012 154012 139835 139835 18231745 14162806 4068939 232742 232742 732112 588513 143581 18 1382965 1382965 48994 34834 14160 823828 453455 363529 6844 1070846 1065960 4886 5376543 4791691 584852 511363 510434 929 MEDICAL SUPPLIES 12036997 12036997 MISCELLANEOUS 2480467 171774 2274851 33842 FOOD 397827 397827 MEMBERSHIPS & DUES 95925 7424 88501 80796050 64997995 15500740 297315 1600 2427 29564598 18475019 9586319 12453679 2165529 2597002 2895604 3053635 117952305 69114487 42438901 48837818 3596728 2224453 660411 705401 0 571958 678000 9775514 91587690 98696906 4262501 9963461 671128 886021 27574730 26740271 10989 23114 32519348 37612867 X 59068342 61084039 59068342 61084039 91587690 98696906 1721035 294662 0 X X 0 1 X 1 1 1 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 0 1 0 0 0 1 5944 0 0 1 20985 26929 0 PART II-B, LINE 1: A PORTION OF DUES PAID TO THE AMERICAN HOSPITAL ASSOCIATION AND NEBRASKA HOSPITAL ASSOCIATION ARE USED FOR LOBBYING AND POLITICAL ACTIVITIES. MANAGEMENT IS ACTIVE IN NEBRASKA HOSPITAL ASSOCIATION'S PAC, AHA'S ADVOCACY DAY, AND OTHER INDUSTRY FUNCTIONS. IN THE CURRENT YEAR, THE ORGANIZATION ALSO SUPPORTED A LOCAL SCHOOL BOND ATTEMPT. 3945219 3683 515882 108476 4356308 3660864 3766 446030 165441 3945219 3482371 5110 214711 41328 3660864 3811948 5826 -260507 74896 3482371 3290398 12744 508806 3811948 0.63065 0.36935 0.00000 0 1 1 101803 101803 49846215 42089121 7757094 64242355 23761644 40480711 3761932 3263722 498210 48837818 ESTIMATED THIRD-PARTY PAYOR SETTLEMENTS 9775514 9775514 REFUNDABLE ADVANCES 23114 23114 X PART V, LINE 4: THE ENDOWMENT FUNDS ARE HELD BY THE COMMUNITY HOSPITAL HEALTH FOUNDATION OF MCCOOK (A RELATED PARTY) AND ARE USED IN SUPPORT OF THE HOSPITAL'S PROGRAMS AND PROJECTS, INCLUDING PROPERTY AND EQUIPMENT PURCHASES, SCHOLARSHIPS, HOSPICE PROGRAMS, REHABILITATION SERVICES AND OTHERS. PART X, LINE 2: THE HOSPITAL AND FOUNDATION ACCOUNT FOR UNCERTAINTIES IN ACCOUNTING FOR INCOME TAX ASSETS AND LIABILITIES USING GUIDANCE INCLUDED IN FASB ASC 740, INCOME TAXES. THE HOSPITAL AND FOUNDATION RECOGNIZE THE EFFECT OF INCOME TAX POSITIONS ONLY IF THOSE POSITIONS ARE MORE LIKELY THAN NOT OF BEING SUSTAINED. AT JUNE 30, 2025 AND 2024, THE HOSPITAL AND FOUNDATION HAD NO UNCERTAIN TAX POSITIONS ACCRUED. 1 1 X 1 X 0 1 1 1 0 1 1 1186000 0 1186000 0.01470 7563920 7563920 8749920 7563920 1186000 0.01470 18391 0 18391 0.00020 8535474 5725690 2809784 0.03480 404922 0 404922 0.00500 8958787 5725690 3233097 0.04000 17708707 13289610 4419097 0.05470 1 2918652 437798 27985555 28111021 -125466 X 1 1 1 1 COMMUNITY HOSPITAL ASSOCIATION OF MCCOOK 1301 EAST H STREET - PO BOX 1328 MCCOOK NE 69001 WWW.CHMCCOOK.ORG 320007 X X X X COMMUNITY HOSPITAL ASSOCIATION OF MCCOOK 1 0 0 1 X X X X X X X X X 24 1 0 0 1 X SEE PART V, PAGE 8 X 1 24 1 SEE PART V, PAGE 8 0 1 X 150.000000000000 X X 1 1 X X X 1 X HTTPS://CHMCCOOK.ORG/FOR-PATIENTS/FINANCIAL-ASSISTANCE.HTML X HTTPS://CHMCCOOK.ORG/FOR-PATIENTS/FINANCIAL-ASSISTANCE.HTML X HTTPS://CHMCCOOK.ORG/FOR-PATIENTS/FINANCIAL-ASSISTANCE.HTML X X X X X X X 1 X 0 X X X X 1 X 0 0 COMMUNITY HOSPITAL ASSOCIATION OF MCCOOK PART V, SECTION B, LINE 5: COMMUNITY HOSPITAL WORKED WITH COMMUNITY HOSPITAL CONSULTING TO COLLECT DATA THAT WAS USED TO IDENTIFY THE NEEDS OF OUR REGION. ACCORDING TO THE CHNA PROCESS AND METHODOLOGY, "CHC CONSULTING CONDUCTED THE FOLLOWING RESEARCH: A DEMOGRAPHIC ANALYSIS OF THE STUDY AREA, UTILIZING DEMOGRAPHIC DATA FROM A VARIETY OF SOURCES, A STUDY OF THE MOST RECENT HEALTH DATA AVAILABLE, ONE-ON-ONE PHONE INTERVIEWS WITH INDIVIDUALS WHO HAVE SPECIAL KNOWLEDGE OF THE COMMUNITIES, AND ANALYZED THOSE RESULTS, FACILITATED THE PRIORITIZATION PROCESS UTILIZING A SURVEY OF THE CHNA TEAM. THE CHNA TEAM INCLUDED: TROY BRUNTZ, CEO, MOLLY HERZBERG, CNO, KAREN KLIMENT THOMPSON, VP ANCILLARY SERVICES, LORI BEEBY, VP SUPPORT SERVICES, JESSICA JOHNSON, DIRECTOR OF QUALITY & PATIENT INFORMATION, LEANNE MILLER, DIRECTOR OF HUMAN RESOURCES, KYLE TEEL, CORPORATE CONTROLLER & STRATEGY DIRECTOR, AND BALEIGH ABBOTT, POPULATION HEATH & OUTREACH COORDINATOR."RESOURCES FOR HEALTH DATA WERE COLLECTED FROM SOURCES SUCH AS: THE ROBERT WOOD JOHNSON FOUNDATION, NEBRASKA STATE DEPARTMENT OF HEALTH AND HUMAN SERVICES, THE CARES ENGAGEMENT NETWORK, UNITED STATES CENSUS BUREAU, AND THE CENTERS FOR DISEASE CONTROL AND PREVENTION. FOR THE ONE-ON-ONE INTERVIEWS, ACCORDING TO THE SAME DOCUMENT MENTIONED ABOVE: "CH PROVIDED CHC CONSULTING WITH A LIST OF PERSONS WITH SPECIAL KNOWLEDGE OF PUBLIC HEALTH IN RED WILLOW COUNTY, INCLUDING PUBLIC HEALTH REPRESENTATIVES AND OTHER INDIVIDUALS WHO FOCUS SPECIFICALLY ON UNDERREPRESENTED GROUPS. FROM THAT LIST, SEVENTEEN IN-DEPTH PHONE INTERVIEWS WERE CONDUCTED USING A STRUCTURED INTERVIEW GUIDE. EXTENSIVE NOTES WERE TAKEN DURING EACH INTERVIEW AND THEN QUANTIFIED BASED ON RESPONSES, COMMUNITIES AND POPULATIONS (MINORITY, ELDERLY, UN/UNDERINSURED, ETC.) SERVED, AND PRIORITIES IDENTIFIED BY RESPONDENTS. QUALITATIVE DATA FROM THE INTERVIEWS WAS ALSO ANALYZED AND REPORTED." COMMUNITY HOSPITAL ASSOCIATION OF MCCOOK PART V, SECTION B, LINE 11: THE LIST OF PRIORITIZED NEEDS, IN DESCENDING ORDER, IS LISTED BELOW: 1) CONTINUED EMPHASIS ON RECRUITMENT AND RETENTION OF HEALTHCARE WORKFORCE TO INCREASE ACCESS TO PRIMARY CARE AND SPECIALTY CARE 2) PREVENTION, EDUCATION AND SERVICES TO ADDRESS HIGH MORTALITY RATES, CHRONIC DISEASES, PREVENTABLE CONDITIONS AND UNHEALTHY LIFESTYLES 3) ACCESS TO MENTAL AND BEHAVIORAL HEALTH CARE SERVICES AND PROVIDERS 4) ACCESS TO AFFORDABLE CARE AND REDUCING HEALTH DISPARITIES AMONG SPECIFIC POPULATION. EACH PRIORITY AREA HAS ANYWHERE FROM FOUR TO EIGHT ACTION STEPS IDENTIFIED IN THE CHNA IMPLEMENTATION PLAN TRACKING DOCUMENT AND EACH ACTION STEP HAS AT LEAST ONE RESPONSIBLE LEADER (A CH REPRESENTATIVE WITH OWNERSHIP OF THE ACTION STEP).PRIORITY #1: CONTINUED EMPHASIS ON RECRUITMENT AND RETENTION OF HEALTHCARE WORKFORCE TO INCREASE ACCESS TO PRIMARY CARE AND SPECIALTY CARE:1.A. COMMUNITY HOSPITAL OFFERS SEVERAL MEDICAL CLINICS OFFERING A VARIETY OF SPECIALTY CARE SERVICES. THE COMMUNITIES OF TRENTON AND CURTIS ARE SERVED BY LOCAL RURAL CLINICS PROVIDED BY COMMUNITY HOSPITAL. ADDITIONALLY, COMMUNITY HOSPITAL WILL ASSESS INFORMATION FROM THE SEMI-ANNUAL MARKET ASSESSMENT AND WILL CONTINUE TO TRACK RECRUITING EFFORTS OF NEW SPECIALISTS THROUGH SERVICE SEED. AS OPPORTUNITIES FOR ADDITIONAL SERVICES ARE EVALUATED, COMMUNITY HOSPITAL WILL ALSO FOCUS ON APPROPRIATE STAFFING FOR THE ADDITION OF SUCH SERVICES.1.B. COMMUNITY HOSPITAL WILL CONTINUE TO OFFER VARIOUS MOBILE SERVICES ON A REGULAR BASIS, SUCH AS PET/CT, CARDIOVASCULAR SCREENINGS, AND NUCLEAR STUDIES.1.C. COMMUNITY HOSPITAL MAINTAINS AN UPDATED CALENDAR OF VISITING SPECIALISTS ON ITS WEBSITE FOR RESIDENTS TO ACCESS AND UTILIZE IN PLANNING HEALTH CARE APPOINTMENTS. ADDITIONALLY, COMMUNITY HOSPITAL WILL CONTINUE TO IMPLEMENT ROTATING FACEBOOK ADVERTISEMENTS FEATURING VISITING SPECIALISTS.1.D. COMMUNITY HOSPITAL WILL CONTINUE TO SERVE AS A TEACHING FACILITY AND ALLOW FOR STUDENTS PURSUING HEALTH-RELATED CAREERS TO ROTATE THROUGH THE FACILITY FOR A VARIETY OF PROGRAMS, INCLUDING, BUT NOT LIMITED TO, THERAPY, PHARMACY, NURSING, AND PUBLIC HEALTH.1.E. THROUGH THE CNA INITIATIVE, COMMUNITY HOSPITAL PARTNERS WITH NURSING HOMES, SCHOOLS AND OTHERS IN THE REGION TO SUPPORT AND ENCOURAGE INTERESTED INDIVIDUALS TO PURSUE OPPORTUNITIES AS A PRACTICING CNA OR RN IN THE COMMUNITY.PRIORITY #2: PREVENTION, EDUCATION AND SERVICES TO ADDRESS HIGH MORTALITY RATES, CHRONIC DISEASES, PREVENTABLE CONDITIONS AND UNHEALTHY LIFESTYLES:2.A. COMMUNITY HOSPITAL WILL CONTINUE TO INCREASE EDUCATIONAL OPPORTUNITIES FOR THE PUBLIC CONCERNING WELLNESS TOPICS AND HEALTH RISK CONCERNS. ADDITIONALLY, COMMUNITY HOSPITAL WILL CONTINUE TO INCREASE AWARENESS OF AND ACCESS TO ITS EDUCATIONAL OFFERINGS.2.B. COMMUNITY HOSPITAL WILL CONTINUE TO HOST AND/OR PARTICIPATE IN LOCAL HEALTH-RELATED EVENTS TO PROMOTE HOSPITAL SERVICES, OFFER A VARIETY OF HEALTH SCREENINGS TO THE COMMUNITY, AND/OR SUPPORT OR PARTNER WITH LOCAL ORGANIZATIONS THAT PROVIDE SERVICES TO VULNERABLE POPULATIONS.2.C. COMMUNITY HOSPITAL WILL CONTINUE TO HOST VARIOUS SUPPORT AND EDUCATIONAL GROUPS AT THE FACILITY.2.D. COMMUNITY HOSPITAL PERSONNEL WILL CONTINUE TO SERVE IN LEADERSHIP ROLES AND AS VOLUNTEERS WITH MANY AGENCIES AND COMMITTEES IN THE COMMUNITY. ADDITIONALLY, COMMUNITY HOSPITAL WILL CONTINUE TO PROVIDE STAFF REPRESENTATION AT VARIOUS CONFERENCES AND IN LOCAL CONSORTIUMS FOCUSED AROUND ITS PATIENT POPULATION'S NEEDS.2.E. COMMUNITY HOSPITAL WILL CONTINUE TO SERVE AS THE BACKBONE ORGANIZATION FOR THE MCCOOK ON THE MOVE INITIATIVE, INCLUDING WELLNESS MCCOOK, IN COLLABORATION WITH SEVERAL LOCAL PARTNER ORGANIZATIONS TO IMPROVE THE OVERALL QUALITY OF LIFE IN THE COMMUNITY.2.F. COMMUNITY HOSPITAL WILL CONTINUE TO INCENTIVIZE EMPLOYEES AND THEIR FAMILIES TO PARTICIPATE IN REGULAR PHYSICAL ACTIVITY THROUGH DISCOUNTED MEMBERSHIPS AT LOCAL GYMS AND RECREATION FACILITIES, AS WELL AS WELLNESS INCENTIVES TOWARDS EMPLOYEE HEALTH INSURANCE PREMIUMS.2.G. COMMUNITY HOSPITAL WILL FOCUS ON VARIOUS PREVENTIVE AND EDUCATION TOPICS IN THE COMMUNITY AS OPPORTUNITIES ARISE.PRIORITY #3: ACCESS TO MENTAL AND BEHAVIORAL HEALTH CARE SERVICES AND PROVIDERS:3.A. COMMUNITY HOSPITAL WILL CONTINUE TO GROW AND EXPAND MENTAL HEALTH SERVICES PROVIDED TO THE COMMUNITY.3.B. COMMUNITY HOSPITAL WILL CONTINUE TO SHARE AN ANNUALLY-UPDATED LIST OF AREA AND TELEHEALTH PROVIDERS FOR MENTAL HEALTH SUPPORT AND COUNSELING SERVICES.3.C. COMMUNITY HOSPITAL WILL CONTINUE TO ADVOCATE AND EXPLORE OPPORTUNITIES TO SUPPORT OTHER OUTLETS IN THE COMMUNITY AND CONNECT PATIENTS WITH MENTAL AND BEHAVIORAL HEALTH RESOURCES AS OPPORTUNITIES ARISE.3.D. COMMUNITY HOSPITAL WILL CONTINUE TO OFFER MENTAL HEALTH SUPPORT TO ITS EMPLOYEES THROUGH THE EMPLOYEE ASSISTANCE PROGRAM (EAP).PRIORITY #4: ACCESS TO AFFORDABLE CARE AND REDUCING HEALTH DISPARITIES AMONG SPECIFIC POPULATIONS:4.A. COMMUNITY HOSPITAL WILL CONTINUE TO HOST AND PARTICIPATE IN DONATION DRIVES AND FUNDRAISING EVENTS TO BENEFIT UNDERSERVED ORGANIZATIONS IN THE COMMUNITY, AS WELL AS EDUCATIONAL EVENTS.4.B. COMMUNITY HOSPITAL WILL CONTINUE TO PROVIDE A LANGUAGE LINE TO OFFER TRANSLATION SERVICES FOR NONENGLISH SPEAKING PATIENTS AND FAMILIES AS NEEDED.4.C. COMMUNITY HOSPITAL WILL CONTINUE TO OFFER FINANCIAL ASSISTANCE AND PAYMENT PLAN EDUCATION TO PATIENTS WHO HAVE AN ECONOMIC NEED AND MEET THE QUALIFICATIONS OF THE FINANCIAL ASSISTANCE POLICY. IF FINANCIAL ASSISTANCE IS NEEDED, COMMUNITY HOSPITAL ENCOURAGES PATIENTS TO COMPLETE AN APPLICATION TO SEE IF THEY QUALIFY.4.D. IN CONJUNCTION WITH THE COMMUNITIES OF EXCELLENCE PROGRAM, COMMUNITY HOSPITAL WILL EXPLORE INCREASING ACCESS TO TRANSPORTATION SERVICES IN THE COMMUNITY.4.E. COMMUNITY HOSPITAL WILL CONTINUE TO INCREASE ACCESS TO CARE THROUGH THE PROVISION OF TELEHEALTH SERVICES TO APPLICABLE PATIENTS AND EXPLORE EXPANSION OF TELEHEALTH SERVICES AS OPPORTUNITIES ARISE.4.F. COMMUNITY HOSPITAL WILL CONTINUE TO PROVIDE HOME HEALTH, HOSPICE, AND PALLIATIVE CARE SERVICES FOR APPLICABLE RESIDENTS. FURTHERMORE, COMMUNITY HOSPITAL WILL CONTINUE TO FOCUS ON THE PATIENT'S FAMILY WELLBEING BY PROVIDING RESPITE CARE IN ORDER TO REDUCE CAREGIVER BURNOUT.4.G. COMMUNITY HOSPITAL WILL CONTINUE TO MEET WITH LOCAL NURSING HOMES AND ASSISTED LIVING FACILITIES ON A QUARTERLY BASIS AND COMPREHENSIVELY DISCUSS ANY EMERGING ISSUES IN THE AREA AND HOW TO ADDRESS SUCH ISSUES TO IMPROVE QUALITY AND EFFICIENCY OF CARE FOR PATIENTS.4.H. COMMUNITY HOSPITAL STAFF MEMBERS REGULARLY VOLUNTEER AT THE LOCAL MEALS ON WHEELS AND SENIOR CENTER ORGANIZATIONS TO SUPPORT THE NEEDS OF ELDERLY RESIDENTS IN THE COMMUNITY.ALL IDENTIFIED COMMUNITY HEALTH NEEDS ARE INCLUDED AND ADDRESSED IN THE FOUR PRIORITY AREAS INCLUDED IN THE CHNA AND RELATED ACTION PLANS. ACCORDINGLY, THERE CURRENTLY ARE NOT ANY IDENTIFIED NEEDS THAT ARE NOT BEING ADDRESSED AS PART OF THE PLAN.THE HOSPITAL CONTINUES TO PARTICIPATE IN FUNDRAISING EFFORTS FOR VARIOUS COMMUNITY ORGANIZATIONS INCLUDING THE BACKPACK EVENT FOR SCHOOL CHILDREN AND JEANS DAY FUNDRAISERS FOR A ROTATING LIST OF COMMUNITY BENEFIT PROGRAMS (4A). OCT 1ST COMMUNITY HOSPITAL WENT LIVE WITH AN ONLINE SYSTEM FOR FINANCIAL ASSISTANCE PROGRAM APPLICATIONS, STREAMLINING THE PROCESS TO EASE THE BURDEN ON PATIENTS WITH ECONOMIC NEED (4C) AND HOSTED THE BRIDGES TO MENTAL HEALTH EDUCATIONAL EVENT ON THE HOSPITAL'S CAMPUS (3C).COMMUNITY HOSPITAL ALSO MAINTAINED ARRANGEMENTS WITH MULTIPLE MOBILE IMAGING SERVICES TO BOLSTER ACCESS TO CARE IN OUR RURAL COMMUNITY (1B). COMMUNITY HOSPITAL ASSOCIATION OF MCCOOK PART V, SECTION B, LINE 13B: DISCOUNTING OR 100% WRITE-OFF TO CHARITY CARE IS ALLOWED ABOVE 150% OF THE FEDERAL POVERTY GUIDELINE BASED ON AN ANALYSIS OF INDIVIDUAL NEED AND DETERMINATION OF THE PATIENT BEING MEDICALLY INDIGENT; THIS ANALYSIS INCLUDES FACTORS SUCH AS INCOME, ACCESSIBLE ASSETS, MEDICAL AND/OR OTHER DEBTS, THE LIKELIHOOD OF ONGOING MEDICAL CARE AND THE INDIVIDUAL'S OVERALL ABILITY TO PAY.PATIENTS WHO QUALIFY FOR FINANCIAL ASSISTANCE AS MEDICALLY INDIGENT WILL BE RESPONSIBLE FOR THEIR MEDICAL BILLS UP TO A PERCENT OF THE GREATER OF THEIR HOUSEHOLD INCOME OR NET WORTH BASED ON AMOUNTS PROVIDED IN THE FINANCIAL ASSISTANCE POLICY. THERE IS NO LIMIT TO THE FPG INCOME, BUT PATIENTS OVER 501% OF FEDERAL POVERTY GUIDELINES MAY RECEIVE A DISCOUNT IF THEIR FAMILY'S MEDICAL BILLS AND RELATED DEBT ARE NO MORE THAN THE GREATER OF 20% OF HOUSEHOLD INCOME OR 10% OF NET WORTH.THE HOSPITAL MAY USE PRESUMPTIVE ELIGIBILITY AND PREVIOUS FINANCIAL ASSISTANCE DETERMINATIONS TO PROVIDE FINANCIAL ASSISTANCE IN CERTAIN CIRCUMSTANCES WHEN A PATIENT FAILS TO SUPPLY SUFFICIENT INFORMATION TO SUPPORT ELIGIBILITY. COMMUNITY HOSPITAL ASSOCIATION OF MCCOOK PART V, SECTION B, LINE 16J: THE HOSPITAL PUBLICIZED THE FINANCIAL ASSISTANCE POLICY ON BILLING INVOICES, ON POSTERS IN THE ER AND WAITING ROOMS, AT THE ADMISSIONS DESKS, INCLUDING UPON ADMISSIONS WITH SUMMARY NOTICES OF THE POLICIES. THE COMPLETE POLICY WAS AVAILABLE ON THE HOSPITAL'S WEBSITE AND UPON REQUEST. THE HOSPITAL ALSO PUBLICIZED THE POLICY THROUGH REFERRALS BY CLINICAL, SOCIAL WORKERS, AND OTHER STAFF TO THE HOSPITAL'S FINANCIAL COUNSELORS. COMMUNITY HOSPITAL ASSOCIATION OF MCCOOK DOES NOT HAVE AN LEP POPULATION OF A SINGLE PRIMARY LANGUAGE THAT REACHES 1,000 INDIVIDUALS OR 5% OF THE COMMUNITY SERVED BY THE HOSPITAL. HOWEVER, WITH SPANISH AS THE PREDOMINANT NON-ENGLISH LANGUAGE WE HAVE OPTED TO OFFER A FAP APPLICATION FORM IN THAT LANGUAGE FOR OUR PATIENTS' CONVENIENCE. SCHEDULE H, PART V, SECTION B, LINE 7A AND 10A: COMMUNITY HEALTH NEEDS ASSESSMENT AND IMPLEMENTATION STRATEGY WEBSITE:HTTPS://CHMCCOOK.ORG/ABOUT/COMMUNITY-HEALTH-NEEDS-ASSESSMENT.HTML 3 1 - COMMUNITY HEALTHCARE & HOSPICE 407 WEST 5TH STREET MCCOOK NE 69001 HOME HEALTH AND HOSPICE SERVICES 2 - CURTIS MEDICAL CENTER 302 EAST 6TH STREET CURTIS NE 69025 RURAL HEALTH CLINIC-OUTPATIENT SERVICES 3 - TRENTON MEDICAL CLINIC 406 EAST 1ST STREET TRENTON NE 69044 RURAL HEALTH CLINIC-OUTPATIENT SERVICES PART I, LINE 3C: CHARITY CARE IS GRANTED TO ALL INDIVIDUALS WHOSE HOUSEHOLD INCOME IS BELOW 150% OF THE FEDERAL POVERTY GUIDELINE AT THE 100% WRITE-OFF LEVEL. DISCOUNTING OR 100% WRITE-OFF TO CHARITY CARE IS ALLOWED ABOVE 150% OF THE FEDERAL POVERTY GUIDELINE BASED ON AN ANALYSIS OF INDIVIDUAL NEED AND DETERMINATION OF THE PATIENT BEING MEDICALLY INDIGENT; THIS ANALYSIS INCLUDES FACTORS SUCH AS INCOME, ACCESSIBLE ASSETS, MEDICAL OR/AND OTHER DEBTS, THE LIKELIHOOD OF ONGOING MEDICAL CARE AND THE INDIVIDUAL'S OVERALL ABILITY TO PAY.PATIENTS WHO QUALIFY FOR FINANCIAL ASSISTANCE AS MEDICALLY INDIGENT WILL BE RESPONSIBLE FOR THEIR MEDICAL BILLS UP TO A PERCENT OF THE GREATER OF THEIR HOUSEHOLD INCOME OR NET WORTH BASED ON AMOUNTS PROVIDED IN THE FINANCIAL ASSISTANCE POLICY. THERE IS NO LIMIT TO THE FPG INCOME, BUT PATIENTS OVER 501% OF FEDERAL POVERTY GUIDELINES MAY RECEIVE A DISCOUNT IF THEIR FAMILY'S MEDICAL BILLS AND RELATED DEBT ARE NO MORE THAN THE GREATER OF 20% OF HOUSEHOLD INCOME OR 10% OF NET WORTH.THE HOSPITAL MAY USE PRESUMPTIVE ELIGIBILITY AND PREVIOUS FINANCIAL ASSISTANCE DETERMINATIONS TO PROVIDE FINANCIAL ASSISTANCE IN CERTAIN CIRCUMSTANCES WHEN A PATIENT FAILS TO SUPPLY SUFFICIENT INFORMATION TO SUPPORT ELIGIBILITY. 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 ON LINE 7B WAS CALCULATED USING THE COSTING METHODS TO PREPARE THE COST REPORTS. COMMUNITY HEALTH IMPROVEMENT SERVICES, LINE 7E, AND CASH AND IN-KIND CONTRIBUTIONS, LINE 7I, ARE REPORTED BASED ON ACTUAL EXPENSES REPORTED IN THE GENERAL LEDGER. THE COST FOR SUBSIDIZED HEALTH SERVICES ON LINE 7G WAS DETERMINED USING THE MEDICARE COST REPORT. PART III, LINE 2: THE AMOUNT ON LINE 2 REPRESENTS IMPLICIT PRICE CONCESSIONS. THE ORGANIZATION DETERMINES ITS ESTIMATE OF IMPLICIT PRICE CONCESSION BASED ON ITS HISTORICAL COLLECTION EXPERIENCE WITH THIS CLASS OF PATIENTS. FOR THE FISCAL YEAR, THE AMOUNT OF IMPLICIT PRICE CONCESSIONS REPORTED IS $2,918,652. PART III, LINE 3: BASED ON A COMBINATION OF PAST EXPERIENCE AND CENSUS DATA AVAILABLE, THE HOSPITAL ESTIMATES 15% OF THE PATIENT IMPLICIT PRICE CONCESSIONS IS ATTRIBUTABLE TO PATIENTS ELIGIBLE UNDER THE HOSPITAL'S FINANCIAL ASSISTANCE POLICY. IN ACCORDANCE WITH ITS MISSION OBJECTIVES, THE HOSPITAL PROVIDES FINANCIAL ASSISTANCE TO PATIENTS WHO LACK FINANCIAL RESOURCES TO PAY FOR THE SERVICES THEY RECEIVE, AND THE HOSPITAL RECOGNIZES THE SPECIAL CONCERNS OF INDIVIDUALS AND HOUSEHOLDS WITH LIMITED FINANCIAL RESOURCES OR WHO ARE OTHERWISE VULNERABLE WITHIN THE COMMUNITY THE HOSPITAL SERVICES. PART III, LINE 4: THE FOOTNOTE TO THE ORGANIZATION'S FINANCIAL STATEMENTS THAT DESCRIBES IMPLICIT PRICE CONCESSIONS IS LOCATED ON PAGES 14 AND 15 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.HOSPITAL SERVICES REIMBURSED ON A FEE SCHEDULE ARE NOT INCLUDED IN THE MEDICARE CALCULATION PER THE 990 INSTRUCTIONS. HAD THIS BEEN REPORTED, THE TOTAL LOSS FROM MEDICARE SERVICES WOULD HAVE INCREASED BY $924,379. MEDICARE FEE SCHEDULE REVENUE WAS $1,157,225 AND THE MEDICARE ESTIMATED COSTS OF CARE RELATING TO PAYMENTS WAS $2,081,604 RESULTING IN A NET SHORTAGE OF $924,379. PART III, LINE 9B: THE HOSPITAL WILL NOT TAKE EXTRAORDINARY COLLECTION ACTIVITIES (ECAS) AGAINST A PATIENT OR ANY OTHER INDIVIDUAL WHO HAS ACCEPTED OR IS REQUIRED TO ACCEPT FINANCIAL RESPONSIBILITY FOR A PATIENT UNLESS AND UNTIL THE HOSPITAL HAS MADE "REASONABLE EFFORTS" TO DETERMINE WHETHER THE PATIENT IS ELIGIBLE FOR FINANCIAL ASSISTANCE UNDER THIS POLICY. PATIENT FINANCIAL COUNSELING IS RESPONSIBLE TO DETERMINE WHETHER THE HOSPITAL HAS ENGAGED IN REASONABLE EFFORTS TO DETERMINE WHETHER A PATIENT IS ELIGIBLE FOR FINANCIAL ASSISTANCE.THE HOSPITAL DOES NOT TAKE ECAS AGAINST THE PATIENTS FOR AT LEAST 120 DAYS FROM THE DATE THE HOSPITAL PROVIDES THE PATIENT WITH THE FIRST POST-DISCHARGE BILL FOR CARE. A WRITTEN NOTICE IS SENT TO THE PATIENT AT LEAST 30 DAYS PRIOR TO ANY ECAS. THE NOTICE CONTAINS THE FOLLOWING INFORMATION:1. NOTIFIES THE PATIENT OF THE AVAILABILITY OF FINANCIAL ASSISTANCE,2. IDENTIFIES THE SPECIFIC ECA(S) THE HOSPITAL INTENDS TO INITIATE AGAINST THE PATIENT,3. STATES A DEADLINE AFTER WHICH ECAS MAY BE INITIATED THAT IS NO EARLIER THAN 30 DAYS AFTER THE DATE THE NOTICE IS PROVIDED TO THE PATIENT;5. PROVIDES A PLAIN LANGUAGE SUMMARY OF THE FINANCIAL ASSISTANCE POLICY WITH THE AFOREMENTIONED NOTICE; ANDMAKES A REASONABLE EFFORT TO ORALLY NOTIFY THE PATIENT ABOUT THE POTENTIAL AVAILABILITY OF FINANCIAL ASSISTANCE AT LEAST 30 DAYS PRIOR TO INITIATING ECAS AGAINST THE PATIENT DESCRIBING HOW THE INDIVIDUAL MAY OBTAIN ASSISTANCE WITH THE FINANCIAL ASSISTANCE APPLICATION PROCESS. PART VI, LINE 2: IN ADDITION TO THE CHNA, COMMUNITY HOSPITAL CONTINUES TO ASSESS THE HEALTH NEEDS OF THE COMMUNITY THROUGH A VARIETY OF WAYS, INCLUDING (BUT NOT LIMITED TO) THE FOLLOWING:1) COMMUNITY HOSPITAL IS A KEY MEMBER OF MCCOOK ON THE MOVE INITIATIVE. THIS INCLUDES FOUR KEY COMMUNITY GROUPS THAT MEET REGULARLY AND LEAD/COORDINATE ACTIVITIES WITHIN THE COMMUNITY, WHICH INCLUDE THE FAMILY, EDUCATION, HEALTH, AND ECONOMIC DEVELOPMENT PILLARS. THE HEALTH PILLAR ATTEMPTS TO BRING TOGETHER ALL THE MAJOR HEALTHCARE PROVIDERS AND PUBLIC HEALTH AGENCIES QUARTERLY TO MAINTAIN AWARENESS AND WORK WITH EACH OTHER TO ADDRESS ISSUES AS THEY EMERGE. THE HEALTH PILLAR ALSO FOCUSES ON PROJECTS THAT PROMOTE A HEALTHY LIFESTYLE. 2) COMMUNITY HOSPITAL REGULARLY SCREENS PATIENTS FOR SOCIAL DETERMINANTS OF HEALTH; INCLUDING FINANCIAL, TRANSPORTATION CONCERNS, ISSUES RELATED TO LIVING ALONE, AND OTHER SOCIAL AND FINANCIAL ISSUES THAT IMPACT THE PATIENT'S HEALTH. WE HAVE PUT VARIOUS PROCESSES IN PLACE TO HELP THESE PATIENTS ADDRESS THESE CONCERNS AND ISSUES AS THEY ARE IDENTIFIED.3) COMMUNITY HOSPITAL REGULARLY MEETS WITH OUR NURSING HOMES AND OTHER LONG TERM ASSISTED CARE FACILITIES AS WELL AS OTHER PROVIDERS IN THE REGION TO ASSURE THAT THE CONTINUUM OF CARE FOR PATIENTS ARE WELL MET AND THAT WE ARE AWARE OF AND CAN ADDRESS ANY CONCERNS AS THEY COME TO OUR ATTENTION. PART VI, LINE 3: IDENTIFICATION OF PATIENTS WITH A POTENTIAL NEED FOR FINANCIAL ASSISTANCE WILL BE ACCOMPLISHED BY BOTH AN OPEN AND PUBLICIZED APPLICATION PROCESS AND A VARIETY OF SCREENING OPPORTUNITIES INCLUDING:A. ADMISSIONS/REGISTRATION PERSONNEL BASED UPON INFORMATION RECEIVED DURING THE REGISTRATION PROCESS.B. SOCIAL SERVICES PERSONNEL BASED UPON INFORMATION DURING THE INITIAL VISIT AND DISCHARGE PLANNING.C. NURSING STAFF BASED UPON INFORMATION RECEIVED DURING DISCUSSIONS WITH FAMILY AND/OR PATIENT.D. BUSINESS OFFICE PERSONNEL BASED UPON STATUS OF ACCOUNTS AND DISCUSSIONS WITH RESPONSIBLE PARTY.E. ACCOUNTS RECEIVABLE REPORTS.HOSPITAL STAFF OR THE NOTIFIED PATIENT ADVOCATE WILL EDUCATE THE PATIENT OR GUARANTOR ABOUT THE FINANCIAL ASSISTANCE POLICY AND WILL PROVIDE THEM AN APPLICATION FOR FINANCIAL ASSISTANCE. IF NECESSARY, THE PATIENT FINANCIAL COUNSELOR OR OTHER HOSPITAL STAFF MAY ASSIST THE PATIENT IN COMPLETING THE APPLICATION; HOWEVER, THE COMPLETION OF AN APPLICATION AND PROVIDING ALL NECESSARY SUPPORTING DOCUMENTATION IS THE PATIENT'S RESPONSIBILITY. PATIENTS MAY ALSO REQUEST AN APPLICATION OR ADDITIONAL INFORMATION IN PERSON AT THE ADMISSIONS OFFICE OR BY CALLING OR WRITING THE PATIENT FINANCIAL COUNSELOR AND AN APPLICATION WILL BE MAILED.IF A PATIENT SUBMITS A COMPLETED FINANCIAL ASSISTANCE APPLICATION DURING THE APPLICATION PERIOD AND THE HOSPITAL DETERMINES THAT THE PATIENT MAY BE ELIGIBLE FOR PARTICIPATION IN MEDICAID, THE HOSPITAL WILL NOTIFY THE PATIENT IN WRITING OF SUCH POTENTIAL ELIGIBILITY AND REQUEST THAT THE PATIENT TAKE STEPS NECESSARY TO ENROLL IN SUCH PROGRAM. IN SUCH CIRCUMSTANCES THE HOSPITAL WILL DELAY THE PROCESSING OF THE PATIENT'S FINANCIAL ASSISTANCE APPLICATION UNTIL THE PATIENT'S APPLICATION FOR MEDICAID IS COMPLETED, SUBMITTED TO THE REQUISITE GOVERNMENTAL AUTHORITY, AND A DETERMINATION HAS BEEN MADE. PART VI, LINE 4: COMMUNITY HOSPITAL SERVES A PRIMARY MARKET OF RED WILLOW COUNTY, WHICH IS LOCATED ON THE SOUTHERN BORDER OF NEBRASKA. IT IS 717 SQUARE MILES AND HAS APPROXIMATELY 15.0 PEOPLE PER SQUARE MILE. MCCOOK IS THE COUNTY SEAT. COMMUNITY HOSPITAL ALSO SERVES A SECONDARY MARKET INCLUDING NORTHERN KANSAS AND SOUTHWEST NEBRASKA, WHICH CONSISTS OF FURNAS, NE, HITCHCOCK, NE, DECATUR, KS, CHEYENNE, KS, FRONTIER, NE, RAWLINS, KS AND HAYES, NE. THE TOTAL ESTIMATED POPULATION FOR COMMUNITY HOSPITAL'S SERVICE AREA IS APPROXIMATELY 30,348. RED WILLOW COUNTY HAS A POPULATION OF APPROXIMATELY 10,337. THE GROUP OF COUNTIES WHICH MAKE UP THE SECONDARY MARKET FOR COMMUNITY HOSPITAL HAVE A POPULATION OF APPROXIMATELY 19,601. THE HOUSEHOLD INCOME AVERAGES FOR THESE AREAS ARE AS FOLLOWS:17% $0 - 25K25% $25K - 50K30% $50K - 100K22% $100K - 200K6% $200K+ PART VI, LINE 5: COMMUNITY HOSPITAL IS THE LARGEST HOSPITAL WITHIN AN HOUR TRAVEL TIME FOR MOST OF THE COMMUNITY SERVED. THE HOSPITAL PROVIDES THE PHYSICIANS OF MCCOOK A HOSPITAL IN WHICH TO PRACTICE MEDICINE. WITHOUT THE HOSPITAL OUR PATIENTS WOULD HAVE EXTREMELY LONG DISTANCES TO TRAVEL FOR EVERYTHING FROM EMERGENCY TO ROUTINE CARE. OUR HOSPITAL IS OVERSEEN BY A NON-COMPENSATED BOARD OF INDEPENDENT COMMUNITY MEMBERS. ANY PROFITS FROM THE OPERATION OF THE HOSPITAL ARE REINVESTED BACK INTO THE FACILITIES, EQUIPMENT AND STAFF TO PROVIDE OUR COMMUNITY WITH CURRENT AND HIGH QUALITY MEDICAL SERVICES CLOSE TO HOME. PART VI, LINE 7, REPORTS FILED WITH STATES NE 1 COMMUNITY HOSPITAL HEALTH FOUNDATION 1301 E H ST MCCOOK NE 69001 470693261 501(C)(3) 103332 0 TO SUPPORT THE MISSION OF THE FOUNDATION MCCOOK COLLEGE FOUNDATION 1205 EAST 1ST ST MCCOOK NE 69001 476089800 501(C)(3) 55000 0 PLEDGE FOR HEALTH SCIENCES CENTER AND NURSE AID SCHOLARSHIPS UNIVERSITY OF NEBRASKA FOUNDATION 1010 LINCOLN MALL SUITE 300 LINCOLN NE 68508 470379839 501(C)(3) 30000 0 DONATION TO SUPPORT THE HEALTH SCIENCES PROGRAM (KHOP) YMCA OF MCCOOK PO BOX 408 MCCOOK NE 69001 470377999 501(C)(3) 152625 0 PLEDGE ON REMODEL CAMPAIGN AND VARIOUS TEAM SPONSORSHIPS NORTH PLATTE COMMUNITY COLLEGE FOUNDATION 601 WEST STATE FARM RD NORTH PLATTE NE 69101 202459157 501(C)(3) 10000 0 PLEDGE FOR HEALTH SCIENCES BUILDING MCCOOK ECONOMIC DEVELOPMENT CORP 402 NORRIS AVE SUITE 301 MCCOOK NE 69001 470685662 501(C)(6) 19520 0 SPONSORING VARIOUS COMMUNITY DEVELOPMENT PROJECTS MCCOOK AREA CHAMBER OF COMMERCE 402 NORRIS AVE SUITE 316 MCCOOK NE 69101 470233780 501(C)(6) 9000 0 SPONSORSHIP RED WILLOW CO FAIR BOARD PO BOX 876 MCCOOK NE 69001 GOVERNMENTAL 15000 0 FAIR SPONSOR CITY OF MCCOOK 505 WEST C STREET MCCOOK NE 69001 GOVERNMENTAL 70000 0 INCLUSIVE PLAYGROUND AND MATCHING FUNDS FOR CCCFF GRANT 7 2 PART I, LINE 2: GRANTS ARE MADE ONLY TO SELECTED CHARITABLE OR OTHER EXEMPT ORGANIZATIONS. COMMUNITY HOSPITAL ASSOCIATION ENTERS INTO AGREEMENTS WITH GRANTEES THAT GRANT FUNDS WILL BE RESTRICTED TO SPECIFIED EXEMPT PURPOSES. X X X X 0 0 0 0 0 0 0 0 0 RICHARD LAWTON ORTHO PHYSICAN 725257 0 175 0 3564 0 24150 0 50780 0 803926 0 0 0 DOUGLAS TICE ORTHO PHYSICAN 698566 0 50 0 2742 0 0 0 31839 0 733197 0 0 0 EVAN GEILENKIRCHEN CRNA 344970 0 435 0 3564 0 24150 0 36449 0 409568 0 0 0 TROY BRUNTZ PRESIDENT & CEO 331396 0 250 0 2322 0 23945 0 31153 0 389066 0 0 0 SEAN WOLFE CFO 231513 0 250 0 540 0 17202 0 47255 0 296760 0 0 0 ANTHONY RODEWALD PHARMACIST 202425 0 425 0 810 0 0 0 45224 0 248884 0 0 0 BRUCE MIKESELL EMERGENCY PHYSICIAN 194322 0 75 0 2901 0 0 0 20468 0 217766 0 0 0 FORM 990, PART III, LINE 2 ADDED A PRIMARY CARE CLINIC (MCCOOK CLINIC) AS OF JANUARY 1, 2025. FORM 990, PART VI, SECTION A, LINE 8B THERE IS NO COMMITTEE WITH AUTHORITY TO ACT ON BEHALF OF THE GOVERNING BODY. FORM 990, PART VI, SECTION B, LINE 11B COMMUNITY HOSPITAL'S FORM 990 & 990-T ARE PREPARED BY THE PUBLIC ACCOUNTING FIRM EIDE BAILLY. MANAGEMENT RECEIVES DRAFT COPIES OF THE COMPLETED FORMS FOR REVIEW. AFTER HOSPITAL MANAGEMENT HAS REVIEWED THE RETURNS, COMPLETE COPIES ARE DISTRIBUTED TO ALL MEMBERS OF THE BOARD OF DIRECTORS OF THE COMMUNITY HOSPITAL ASSOCIATION. FORM 990, PART VI, SECTION B, LINE 12C THE COMMUNITY HOSPITAL ASSOCIATION'S CODE OF CONDUCT REQUIRES ALL EMPLOYEES, CONTRACTORS, AND AGENTS TO REPORT ANY CONFLICTS OF INTEREST THAT ARISE. IN ADDITION, THE ASSOCIATION HAS A CONFLICT OF INTEREST POLICY APPLICABLE TO DIRECTORS, OFFICERS, MEMBERS OF COMMITTEES AND SUBCOMMITTEES WITH BOARD-DELEGATED POWERS, AND KEY EMPLOYEES THAT REQUIRES, AMONG OTHER THINGS, ALL APPLICABLE PERSONS DISCLOSE ANY RELATIONSHIPS THAT MAY CREATE A CONFLICT OF INTEREST AND ARE REQUIRED TO COMPLETE AN ANNUAL DISCLOSURE OF ALL SUCH RELATIONSHIPS. ALL SUCH RELATIONSHIPS ARE DISCLOSED TO THE ENTIRE BOARD AND SENIOR MANAGEMENT, AND ANY AND ALL CONFLICTS OR POTENTIAL CONFLICTS ARE MONITORED BY SENIOR MANAGEMENT AND THE ASSOCIATION'S COMPLIANCE FUNCTION. FORM 990, PART VI, SECTION B, LINE 15 COMMUNITY HOSPITAL'S PROCESS FOR DETERMINING THE COMPENSATION OF THE CEO IS AS FOLLOWS: THE EXECUTIVE COMMITTEE OF THE BOARD OF DIRECTORS IS RESPONSIBLE FOR SETTING THE SALARY OF THE CEO. ANNUALLY, THE COMMITTEE CONDUCTS A REVIEW OF THE CEO'S PERFORMANCE, ABILITIES, AND OVERALL EFFECTIVENESS. THE COMMITTEE IS PRESENTED WITH SALARY AND COMPENSATION SURVEY DATA THAT IS COMPILED BY THE CEO AND THE HUMAN RESOURCE DEPARTMENT AND THE ACCURACY OF WHICH IS ATTESTED TO BY THE CFO. MULTIPLE SOURCES OF SURVEY DATA ARE USED, INCLUDING INFORMATION FROM THE NEBRASKA AND IOWA HOSPITAL ASSOCIATIONS, WHICH IS BROKEN DOWN TO SIMILARLY QUALIFIED PERSONS IN COMPARABLE POSITIONS AT SIMILARLY SIZED AND SITUATED ORGANIZATIONS. ALL SOURCE DOCUMENTATION IS GIVEN TO THE COMMITTEE AS WELL AS SUMMARIES PROVIDED FOR EASE OF REFERENCE. THE EXECUTIVE COMMITTEE CONDUCTS THE PERFORMANCE REVIEW WITH THE CEO; THEN MEETS IN PRIVATE CHAMBERS TO DISCUSS THE REVIEW AND TO DELIBERATE ANY AND ALL CHANGES TO THE EMPLOYMENT AGREEMENT, INCLUDING COMPENSATION, AND GOALS FOR THE FOLLOWING YEAR. CONTEMPORANEOUS RECORDS ARE KEPT OF ALL SURVEY AND COMPARABILITY DATA USED, AND THE RESULTS AND DECISIONS OF THE EXECUTIVE COMMITTEES MEETING ON COMPENSATION. COMPENSATION OF EMPLOYEES BELOW THE ROLE OF CEO ARE DETERMINED THROUGH THE USE OF SURVEY INFORMATION OF SIMILARLY QUALIFIED PERSONS IN COMPARABLE POSITIONS AT SIMILARLY SIZED AND SITUATED ORGANIZATIONS. THE CEO SETS THE COMPENSATION OF SENIOR MANAGEMENT BASED ON THOSE SURVEYS, TAKING IN CONSIDERATION PERFORMANCE AND EXPERIENCE OF EACH INDIVIDUAL. COMPENSATION RANGES OF EMPLOYEES BELOW SENIOR MANAGEMENT ARE SET BY HUMAN RESOURCES BASED ON MARKET WAGE RATES FOR SIMILARLY QUALIFIED PERSONS IN COMPARABLE POSITIONS AT SIMILARLY SIZED AND SITUATED ORGANIZATIONS. ALL EMPLOYEES HAVE AN ANNUAL REVIEW BY THEIR SUPERVISOR, WHICH DETERMINE WHERE IN THE SALARY RANGE AN EMPLOYEE WILL FALL. ALL SALARY RANGES, INCLUDING THOSE OF SENIOR MANAGEMENT, ARE ULTIMATELY APPROVED BY THE BOARD OF DIRECTORS DURING THE APPROVAL OF THE ANNUAL OPERATING BUDGET. FORM 990, PART VI, SECTION C, LINE 19 COMMUNITY HOSPITAL MAKES ITS GOVERNING DOCUMENTS, CONFLICT OF INTEREST POLICY, FORM 990 & 990-T (CURRENT AND PAST YEARS AS REQUIRED BY LAW) AND FINANCIAL STATEMENTS AVAILABLE TO THE PUBLIC UPON REQUEST. ANY INDIVIDUAL WHO WOULD LIKE A COPY OF ANY OF THE ABOVE MENTIONED DOCUMENTS MAY INSPECT THOSE DOCUMENTS IN PERSON AT THE HOSPITAL DURING NORMAL BUSINESS HOURS, OR REQUEST A COPY OF ANY OF THE ABOVE INFORMATION IN PERSON, BY PHONE, OR BY MAIL, AND WE WILL PROVIDE A COPY FREE OF CHARGE. FORM 990, PART IX, LINE 11G MISCELLANEOUS FEES FOR SERVICE: PROGRAM SERVICE EXPENSES 2,323,122. MANAGEMENT AND GENERAL EXPENSES 574,937. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 2,898,059. PHYSICIAN FEES: PROGRAM SERVICE EXPENSES 7,249,225. MANAGEMENT AND GENERAL EXPENSES 0. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 7,249,225. MAINTENANCE CONTRACTS: PROGRAM SERVICE EXPENSES 3,142,881. MANAGEMENT AND GENERAL EXPENSES 0. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 3,142,881. PT CONTRACT SERVICES: PROGRAM SERVICE EXPENSES 1,447,578. MANAGEMENT AND GENERAL EXPENSES 0. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 1,447,578. COLLECTION FEES: PROGRAM SERVICE EXPENSES 0. MANAGEMENT AND GENERAL EXPENSES 148,648. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 148,648. MEDICAID PROVIDER ASSESSMENT: PROGRAM SERVICE EXPENSES 0. MANAGEMENT AND GENERAL EXPENSES 3,345,354. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 3,345,354. FORM 990, PART XII, LINE 2C COMMUNITY HOSPITAL HAS A STANDING BOARD COMMITTEE, THE BUDGET AND FINANCE COMMITTEE, WHICH HAS THE AUTHORITY AND ASSUMES THE RESPONSIBILITY FOR THE SELECTION OF THE INDEPENDENT ACCOUNTING FIRM AND ALL RELATED OVERSIGHT, COMMUNICATION, AND REPORTING. THIS COMMITTEE APPROVES ALL ENGAGEMENT LETTERS AND RECEIVES ALL BOARD DIRECTED COMMUNICATION FROM THE INDEPENDENT ACCOUNTING FIRM. COPIES OF RECEIVED LETTERS/COMMUNICATIONS AND REPORTS ARE DISTRIBUTED TO ALL MEMBERS OF THE BOARD OF DIRECTORS IN ADDITION TO THE COMMITTEE MEMBERS. WHILE THE MEMBERS OF THE COMMITTEE HAVE CHANGED, THE PROCESS DESCRIBED HAS NOT CHANGED FROM THE PREVIOUS YEAR. COMMUNITY HOSPITAL HEALTH FOUNDATION 801 WEST C STREET PO BOX 1328 MCCOOK NE 69001 470693261 SUPPORTING ORGANIZATION PROVIDES FUNDRAISING FOR THE HOSPITAL NE 501(C)(3) LINE 12A, I COMMUNITY HOSPITAL ASSOCIATION OF MCCOOK 1 0 1 1 0 0 0 0 0 0 0 1 0 1 1 1 1 1 0 0 COMMUNITY HOSPITAL HEALTH FOUNDATION C 461043 CASH TRANSFERRED EQUALS FMV COMMUNITY HOSPITAL HEALTH FOUNDATION B 103332 CASH TRANSFERRED EQUALS FMV