2024-11-14T14:44:44-06:00 2023-12-31 450250958 EIDE BAILLY LLP 18081 BURT ST STE 200 OMAHA NE 680224722 990 2023-01-01 480577658 HIAWATHA HOSPITAL ASSOCIATION INC HIAW 9133605584 300 UTAH STREET HIAWATHA KS 66434 CHASE DUDZINSKI CFO 9133605584 2024-11-14 1 1 WENDY R COOLEY CPA P01523804 4023302660 2024-11-13 2023 2024-10-15 13:58:12Z AMBERWELL HIAWATHA JEFFERY PERRY 300 UTAH STREET HIAWATHA KS 66434 29467637 0 X HTTPS://WWW.HCH-KS.ORG/ X 1945 KS PROVIDE MODERN, RELIABLE, AFFORDABLE HEALTH CARE THAT BEST MEETS THE NEEDS OF OUR COMMUNITY. 7 7 318 7 0 0 2788081 161489 27953607 29299685 16004 5298 52644 -6035 30810336 29460437 10834 0 0 0 15804890 19372871 0 0 0 15504050 14531978 31319774 33904849 -509438 -4444412 24339775 20078246 8616967 8677416 15722808 11400830 X AMBERWELL HIAWATHA PROVIDES COMPASSIONATE CARE WITH CLINICAL EXCELLENCE. 0 0 29074033 29299685 HIAWATHA HOSPITAL ASSOCIATION, INC. DBA AMBERWELL HEALTH HIAWATHA IS A CRITICAL ACCESS HOSPITAL (CAH) THAT PROVIDES RELATED INPATIENT, OUTPATIENT, EMERGENCY CARE, AND PHYSICIAN SERVICES TO PATIENTS IN HIAWATHA, KANSAS AND SURROUNDING AREAS. HIAWATHA COMMUNITY HOSPITAL'S PRIMARY GOAL IS TO PROVIDE QUALITY, MODERN, AFFORDABLE HEALTHCARE TO OUR COMMUNITY. IN 2023, WE PROVIDED SERVICE FOR 2,475 INPATIENT DAYS, 181 INPATIENT SURGERIES AND 672 OUTPATIENT SURGERIES. WE DELIVERED 75 BABIES AND PROVIDED OUTPATIENT SERVICES TO 65,037 PATIENTS. (STATEMENT CONTINUED ON SCHEDULE O)BY PROVIDING SERVICES LIKE OBSTETRICS AND 24 HOUR EMERGENCY SERVICES THAT NOT ALL SMALL RURAL HOSPITALS PROVIDE, EVEN THOUGH THE PROGRAMS ARE NOT ALWAYS PROFITABLE FOR THE HOSPITAL, WE STRONGLY FEEL THAT THESE SERVICES PROVIDE NECESSARY CARE TO ADDRESS OUR COMMUNITY'S OVERALL HEALTH WHILE PROMOTING OUR MISSION AS A CHARITABLE ORGANIZATION.THE HOSPITAL MAINTAINS A FINANCIAL ASSISTANCE POLICY FOR PATIENTS WHO ARE FINANCIALLY UNABLE TO PAY FOR THE HEALTHCARE SERVICES THEY RECEIVE. IT IS THE POLICY OF THE HOSPITAL NOT TO PURSUE COLLECTION OF AMOUNTS DETERMINED TO QUALIFY AS PATIENT FINANCIAL ASSISTANCE UNDER THE POLICY. ACCORDINGLY, THE HOSPITAL DOES NOT REPORT THESE AMOUNTS IN PATIENT SERVICE REVENUE. THE HOSPITAL DETERMINES THE COSTS ASSOCIATED WITH PROVIDING CHARITY CARE BY AGGREGATING THE DIRECT AND IN DIRECT COSTS, INCLUDING SALARIES, BENEFITS, SUPPLIES, AND OTHER OPERATING EXPENSES, BASED ON AN OVERALL COST TO CHARGE RATIO. THE COSTS OF CARING FOR THESE PATIENTS FOR THE YEAR ENDED DECEMBER 31, 2023 WAS APPROXIMATELY $67,000. 29074033 1 1 0 1 0 0 0 0 0 0 1 0 0 1 1 1 1 0 0 0 0 0 0 0 0 0 1 1 0 0 1 1 0 0 0 0 0 0 0 0 0 0 1 0 0 0 0 1 1 0 0 0 1 53 0 1 318 1 0 0 0 0 0 0 0 0 0 0 0 0 X 7 7 0 0 0 0 0 0 1 1 0 0 0 1 1 1 1 1 1 1 0 0 X SHARESE MOSER 7857426431 300 UTAH STREET HIAWATHA KS 66434 GREG RODVELT PRESIDENT 0.25 0.00 X X 0 0 0 DEL ELFFNER VICE PRESIDENT 0.25 1.00 X X 0 0 0 JOHN MOORE SECRETARY/TREASURER 0.25 0.00 X X 0 0 0 ERIC INGMIRE DIRECTOR 0.25 0.00 X 0 0 0 WILLIE GEISENDORF DIRECTOR 0.25 0.00 X 0 0 0 HOWARD ELLIOTT DIRECTOR 0.25 0.00 X 0 0 0 JASON SMITH DIRECTOR 0.25 0.00 X 0 0 0 JEFFREY PERRY CEO 20.00 0.00 X 230000 0 0 SHARESE MOSER DIRECTOR OF FINANCE -UNTIL AUGUST 40.00 0.00 X 66093 0 1245 CHASE DUDZINSKI CFO 20.00 0.00 X 250652 0 29813 DR CROSBY GERNON RADIOLOGIST 40.00 0.00 X 398484 0 43754 DR MARIAH KRIWIEL PHYSICIAN 40.00 0.00 X 389419 0 37556 DR JESSICA JARVIS PHYSICIAN 40.00 0.00 X 375771 0 43532 DR ANNA CLELAND-LEIGHTON PHYSICIAN 40.00 0.00 X 274364 0 43359 ROBIN ALEXANDER CRNA 40.00 0.00 X 273014 0 38149 2257797 0 237408 9 0 1 1 GRACE ANESTHESIA SERVICES LLC PO BOX 535 CARROLL IA 51401 ANESTHESIOLOGY SERVICES 605620 MIDWEST DATA CENTER PO BOX 39 ROCK PORT MO 64482 IT SERVICES 294521 MOTHER MOON LLC 22612 LIV 447 CHILICOTHE MO 64601 NURSE 173405 MELANIE HERNANDEZ 2941 WITMORE DRIVE LAWRENCE KS 66046 NURSE 137880 RESTORE 201 S 4TH STREET HIAWATHA KS 66434 THERAPY SERVICES 131540 8 161489 70000 161489 PATIENT SERVICE REVENUE 621110 28586634 28586634 PHARMACY REVENUE 456110 291960 291960 PHYSICAL THERAPY 621110 239190 239190 CAFETERIA 900099 39965 39965 141936 141936 29299685 5298 5298 1165 7200 -6035 -6035 -6035 29460437 29299685 0 -737 X 297339 297339 14533022 13477533 1055489 204592 194443 10149 3303449 3016034 287415 1034469 951470 82999 49388 78 49310 215490 215490 4090 4090 4199488 3286913 912575 125105 14650 110455 1290870 1247427 43443 951995 875562 76433 592529 487310 105219 100557 91306 9251 245272 7492 237780 1983278 1222624 760654 277159 119114 158045 MEDICAL SUPPLIES 2793095 2793086 9 REPAIRS AND MAINTENANCE 1239558 1069546 170012 DUES & SUBSCRIPTIONS 376720 214987 161733 87384 4458 82926 33904849 29074033 4830816 0 565 858 2992962 1386231 5995741 4021764 528780 389495 233271 297111 36732402 25722774 12255863 11009628 679120 678631 261000 43500 1392473 2251028 24339775 20078246 2857358 3418802 5447525 5111959 312084 106898 0 39757 8616967 8677416 X 15226135 10781723 496673 619107 15722808 11400830 24339775 20078246 X -4444412 122434 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 4090 4090 0 PART II-B, LINE 1: A PORTION OF THE DUES PAID TO KANSAS HOSPITAL ASSOCIATION AND AMERICAN HOSPITAL ASSOCIATION ARE ATTRIBUTABLE TO LOBBYING. 784309 784309 20179506 13690264 6489242 14059071 10863793 3195278 1709516 1168717 540799 11009628 EST THIRD-PARTY PAYOR SETTLEMENT 1404461 RIGHT-OF-USE ASSETS OPERATING LEASE 39757 INTEREST IN NET ASSETS OF HIAWATHA COMMUNITY HOSPITAL FOUNDATION 619107 EMPLOYEE ADVANCES, NET 187703 2251028 LEASE LIABILITY 39757 39757 X 29467637 7200 7200 29460437 0 29460437 33912049 7200 7200 33904849 0 33904849 PART X, LINE 2: 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 DECEMBER 31, 2023 AND 2022, THE HOSPITAL HAD NO UNCERTAIN TAX POSITIONS ACCRUED. PART XI, LINE 2D - OTHER ADJUSTMENTS: RENTAL EXPENSE 7,200. PART XII, LINE 2D - OTHER ADJUSTMENTS: RENTAL EXPENSE 7,200. 1 1 X 1 X 1 X 1 0 1 1 67000 67000 0.00200 4812273 2906133 1906140 0.05620 4879273 2906133 1973140 0.05820 784 784 0.00000 170561 170561 0.00500 171345 171345 0.00500 5050618 2906133 2144485 0.06320 784 784 0.00000 784 784 0.00000 1 5030523 467336 11850776 11956341 -105565 X 1 1 1 1 HIAWATHA HOSPITAL ASSOCIATION INC 300 UTAH STREET HIAWATHA KS 66434 WWW.HCH-KS.ORG H007001 X X X X 2 PROVIDER BASED RURAL HEALTH CLINICS HIAWATHA HOSPITAL ASSOCIATION INC 1 0 0 1 X X X X X X X X X 22 1 0 1 1 X PART V, PAGE 8 X 1 22 1 PART V, PAGE 8 0 1 X 200.000000000000 200.000000000000 X X X X X X 1 1 X X X X 1 X HTTPS://AMBERWELLHEALTH.ORG/PATIENT-RESOURCES/FINANCIAL-ASSISTANCE-HIAWATHA X HTTPS://AMBERWELLHEALTH.ORG/PATIENT-RESOURCES/FINANCIAL-ASSISTANCE-HIAWATHA X HTTPS://AMBERWELLHEALTH.ORG/PATIENT-RESOURCES/FINANCIAL-ASSISTANCE-HIAWATHA X X X X X X 1 X 0 X X X X 1 X 0 0 HIAWATHA HOSPITAL ASSOCIATION, INC. PART V, SECTION B, LINE 5: WE CHOSE INDIVIDUALS WHO WOULD HAVE UNIQUE UNDERSTANDING OF THE DIFFERENT POPULATIONS IN OUR COMMUNITY TO BE ON THE COMMITTEE. THE COMMITTEE HELPED FORMULATE THE SURVEY TO TAKE TO OUR COMMUNITY AND GAVE SIGNIFICANT FEEDBACK AND DIRECTION ABOUT WHAT SPECIFIC POPULATION NEEDS WERE.INCLUDED ON THE COMMITTEE:AMBERWELL HIAWATHAKANZA MENTAL HEALTHHORIZON THERAPYNEK AREA AGENCY ON AGINGAMBERWELL HEALTHGN BANKNEK MULTICOUNTY HEALTH DEPARTMENTSCITY OF HIAWATHAHIAWATHA FUMC HIAWATHA HOSPITAL ASSOCIATION, INC. PART V, SECTION B, LINE 6B: BROWN COUNTY HEALTH DEPARTMENT HIAWATHA HOSPITAL ASSOCIATION, INC. PART V, SECTION B, LINE 11: THE HOSPITAL COMPLETED ITS COMMUNITY HEALTH NEEDS ASSESSMENT IN 2022. THE FOLLOWING NEEDS WERE IDENTIFIED AND WILL BE ADDRESSED OVER THE NEXT 3 YEARS.PRIMARY CARE / MENTAL HEALTH CARE INTEGRATED DELIVERY1. ASSESS PCP COMFORT AND INVOLVEMENT IN DIAGNOSING AND TREATING COMMON MENTAL HEALTH CONDITIONS.2. EXPLORE INTEGRATED BEHAVIORAL CARE MODELS AND EVALUATE COMMUNITY RESOURCES REQUIRED TO IMPLEMENT.3. RESEARCH GRANTS FOR PRIMARY CARE PRACTICES TO HIRE BEHAVIORAL HEALTH PROVIDERS OR OTHERWISE FACILITATE THE ADOPTION OF MODELS TO INTEGRATE BEHAVIORAL HEALTH AND PRIMARY CARE.MENTAL HEALTH (DIAGNOSIS, PLACEMENT, AFTERCARE, AWARENESS, AND PROVIDERS)1. MAINTAIN A COMMUNITY INVENTORY OF SERVICES TO DOCUMENT THE AVAILABILITY OF MENTAL HEALTH RESOURCES, INCLUDING HOURS OF SERVICE. MAKE THE INVENTORY AVAILABLE TO THE PUBLIC AS NEEDED. DOCUMENT MENTAL HEALTH SERVICES BY AGE CATEGORIES.2. INCREASE DEPRESSION SCREENINGS BY PRIMARY CARE PROVIDERS. 3. EXPAND MENTAL HEALTH TRAINING AND CREATE EDUCATION (MATERIALS / PRESENTATIONS) IN SCHOOLS AND COMMUNITY PROGRAMS TO DESTIGMATIZE MENTAL HEALTH ISSUES. EXPAND ACCESS TO MENTAL HEALTH THROUGH ADDING ADDITIONAL MENTAL HEALTH PROFESSIONALS TO SERVE THE COMMUNITY. 4. INVESTIGATE GRANT WRITING TO FUND MENTAL HEALTH EDUCATION AND SERVICES. IF AVAILABLE, DESIGNATE COMMUNITY LEAD TO ATTAIN THE NECESSARY GRANT. 5. PROMOTE EXISTING MENTAL HEALTH SERVICES, FACILITIES, AND PROVIDERS. EDUCATE COMMUNITY ON PLACEMENT PROCESS AND OPTIONS THROUGH HOSPITAL PHYSICIANS, CLINICS, AND E.R. 6. ESTABLISH SUPPORT GROUPS (SUCH AS FAMILIES WITH MENTAL HEALTH CRISES, GRIEF GROUP) LED BY A SOCIAL WORKER.CHRONIC DISEASE MANAGEMENT (DIABETIC)1. CONTINUE DIABETES PREVENTION LIFESTYLE CHANGE PROGRAM WITH SELF-MANAGEMENT EDUCATION AND MEDICAL NUTRITION THERAPY FOR THOSE WITH DIABETES OR PRE-DIABETES.2. EXPLORE OFFERING MOBILE OR OFFSITE DIABETIC SCREENINGS IN COMMUNITY.3. OFFER EXERCISE CLASSES AND FITNESS PROGRAM SUPPORT IN COMMUNITY.4. SUPPORT TEMPORARY PROGRAMS THAT WORK TO ENERGIZE PARTICIPANTS TO LOSE WEIGHT VIA PRIZES, OFTEN COMBINED WITH EDUCATION, WEIGHT STATUS AND FOOD INTAKE TRACKING, REGULAR CHECK-INS, AND GROUP SUPPORT.5. BUILD, STRENGTHEN, AND MAINTAIN SOCIAL NETWORKS THAT PROVIDE SUPPORTIVE RELATIONSHIPS FOR BEHAVIOR CHANGE THROUGH WALKING GROUPS OR OTHER COMMUNITY-BASED INTERVENTIONS.A SENIOR LIFE SOLUTIONS PROGRAM WAS IMPLEMENTED IN 2023 TO HELP WITH PRIMARY CARE AND MENTAL HEALTH WITHIN THE COMMUNITY.HEALTHCARE TRANSPORTATION ARE NEEDS IDENTIFIED THAT THE HOSPITAL IS NOT ABLE TO ADDRESS EITHER BECAUSE IT IS OUT OF THEIR JURISDICTION OR DUE TO LACK OF FUNDING.THE ORGANIZATION WILL NOT ADDRESS THE FOLLOWING NEEDS IDENTIFIED SINCE THEY ARE NOT PART OF THE HOSPITAL'S MISSION OF CRITICAL OPERATIONS. WE WILL PARTNER WITH OTHERS AS APPROPRIATE.1. HOUSING2. FOOD INSECURITY3. POVERTY HIAWATHA HOSPITAL ASSOCIATION, INC. PART V, SECTION B, LINE 13H: IN ADDITION TO FEDERAL POVERTY GUIDELINES, THE ORGANIZATION USES ASSET LEVEL, INSURANCE STATUS, RESIDENCY, MEDICAL INDIGENCY, AND UNDERINSURANCE STATUS AS FACTORS IN DETERMINING ELIGIBILITY FOR FREE OR DISCOUNTED CARE.PRESUMPTIVE FINANCIAL ASSISTANCE ELIGIBILITY1. THERE ARE INSTANCES WHEN A PATIENT MAY APPEAR ELIGIBLE FOR FINANCIAL DISCOUNTS, BUT THERE IS NO FINANCIAL ASSISTANCE FORM ON FILE OR A LACK OF SUPPORTING DOCUMENTATION. IN THE EVENT THERE IS NO EVIDENCE TO SUPPORT A PATIENT'S ELIGIBILITY FOR FINANCIAL ASSISTANCE, AMBERWELL HIAWATHA MAY USE OUTSIDE AGENCIES OR VENDORS IN DETERMINING ELIGIBILITY AND POTENTIAL DISCOUNT AMOUNTS. THESE RESOURCES MAY USE DEMOGRAPHIC AND HOUSEHOLD INFORMATION AND/OR CREDIT SCORING TECHNOLOGY TO DETERMINE THE PERCENT OF ASSISTANCE TO APPLY TO THE PATIENT'S ACCOUNT.2. PATIENTS WHO MEET PRESUMPTIVE ELIGIBILITY CRITERIA MAY BE GRANTED FINANCIAL ASSISTANCE WITHOUT COMPLETING THE APPLICATION. SCHEDULE H, PART V, SECTION B, LINE 7A AND 10A: COMMUNITY HEALTH NEEDS ASSESSMENT AND IMPLEMENTATIONSTRATEGY WEBSITE:HTTPS://AMBERWELLHEALTH.ORG/COMMUNITY-HEALTH-NEEDS-ASSESSMENT/ PART I, LINE 3C: IN ADDITION TO FEDERAL POVERTY GUIDELINES, THE ORGANIZATION USES ASSET LEVEL, INSURANCE STATUS, RESIDENCY, MEDICAL INDIGENCY, AND UNDERINSURANCE STATUS AS FACTORS IN DETERMINING ELIGIBILITY FOR FREE OR DISCOUNTED CARE.PRESUMPTIVE FINANCIAL ASSISTANCE ELIGIBILITY1. THERE ARE INSTANCES WHEN A PATIENT MAY APPEAR ELIGIBLE FOR FINANCIAL DISCOUNTS, BUT THERE IS NO FINANCIAL ASSISTANCE FORM ON FILE OR A LACK OF SUPPORTING DOCUMENTATION. IN THE EVENT THERE IS NO EVIDENCE TO SUPPORT A PATIENT'S ELIGIBILITY FOR FINANCIAL ASSISTANCE, AMBERWELL HIAWATHA MAY USE OUTSIDE AGENCIES OR VENDORS IN DETERMINING ELIGIBILITY AND POTENTIAL DISCOUNT AMOUNTS. THESE RESOURCES MAY USE DEMOGRAPHIC AND HOUSEHOLD INFORMATION AND/OR CREDIT SCORING TECHNOLOGY TO DETERMINE THE PERCENT OF ASSISTANCE TO APPLY TO THE PATIENT'S ACCOUNT.2. PATIENTS WHO MEET PRESUMPTIVE ELIGIBILITY CRITERIA MAY BE GRANTED FINANCIAL ASSISTANCE WITHOUT COMPLETING THE APPLICATION. PART I, LINE 6A: THE COMMUNITY BENEFIT REPORT IS PREPARED BY VVV CONSULTING AND IS POSTED ON THE HOSPITAL'S WEBSITE. 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 COST-TO-CHARGE RATIO DERIVED FROM WORKSHEET 2. COMMUNITY HEALTH IMPROVEMENT SERVICES, LINE 7E, AND HEALTH PROFESSIONS EDUCATION, LINE 7F, ARE REPORTED BASED ON ACTUAL EXPENSES RECORDED FROM THE EVENTS IN THE GENERAL LEDGER. PART II, COMMUNITY BUILDING ACTIVITIES: LITTLE HANDS DAYCARE IS A NOT FOR PROFIT DAYCARE THAT PROVIDES LICENSED, RELIABLE, QUALITY DAYCARE AND EDUCATION TO CHILDREN IN THE COMMUNITY. ONE OF THE ISSUES CITED BY LOCAL EMPLOYERS WHEN RECRUITING WORK WAS A LACK OF OPENINGS WITH LOCAL DAYCARE PROVIDERS. LITTLE HANDS WAS STARTED TO ADDRESS THAT NEED. HIAWATHA HOSPITAL'S CONTRIBUTIONS IN TIME AND SUPPLIES HAS HELPED THEM TO BE ABLE TO PROVIDE QUALITY SERVICES WHILE OPERATING ON MINIMAL MARGINS. PART III, LINE 2: THE AMOUNT REPORTED ON LINE 2 REPRESENTS IMPLICIT PRICE CONCESSIONS. THE HOSPITAL DETERMINES ITS ESTIMATE OF IMPLICIT PRICE CONCESSIONS BASED ON ITS HISTORICAL COLLECTION EXPERIENCE WITH THIS CLASS OF PATIENTS. PART III, LINE 3: APPROXIMATELY 9.29% OF THE HOSPITAL'S IMPLICIT PRICE CONCESSIONS IS ATTRIBUTABLE TO PATIENTS ELIGIBLE UNDER THE ORGANIZATION'S FINANCIAL ASSISTANCE POLICY. THIS IS THE APPROXIMATE PERCENTAGE OF APPLICATIONS DENIED OR NOT RETURNED DUE TO INSUFFICIENT INFORMATION. PART III, LINE 4: THE FOOTNOTE TO THE ORGANIZATION'S FINANCIAL STATEMENTS CAN BE FOUND ON PAGES 12 AND 13 OF THE ATTACHED AUDITED FINANCIAL STATEMENTS. PART III, LINE 8: HIAWATHA HOSPITAL ASSOCIATION, INC. PROVIDES SERVICES TO PATIENTS UNDER THE MEDICARE PROGRAM KNOWING THEY WILL NOT RECOVER ALL THE COSTS ASSOCIATED WITH PROVIDING THESE SERVICES. PROVIDING THESE SERVICES IS ESSENTIAL TO THESE PATIENTS AND THE COMMUNITY AND INCREASES THEIR ACCESS TO HEALTHCARE SERVICES. THEREFORE, THE MEDICARE SHORTFALL IS CONSIDERED A COMMUNITY BENEFIT.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 THE CENTERS FOR MEDICARE AND MEDICAID SERVICES. PART III, LINE 9B: FINANCIAL ASSISTANCE MAY BE APPLIED ON ANY ACCOUNT(S) THAT HAS BEEN ASSIGNED TO AN OUTSIDE COLLECTION AGENCY. AMBERWELL HIAWATHA CAN PLACE ACCOUNTS WITH A COLLECTION AGENCY WITHIN 120 DAYS, HOWEVER, THE COLLECTION AGENCY CANNOT BEGIN ANY EXTRAORDINARY COLLECTION ACTIONS AS DEFINED BY THE PATIENT PROTECTION AND AFFORDABLE CARE ACT SUBSECTION 501(R) SUCH AS LEGAL PROCESS, SELLING DEBT, REPORTING ADVERSE INFORMATION ON CREDIT BUREAUS, COMMENCE CIVIL ACTION, GARNISH WAGES, COMPLETE A LIEN OR CAUSE AN ARREST BEFORE THE FIRST 240 DAYS FROM THE DATE OF THE FIRST STATEMENT. ACCOUNTS ASSIGNED TO AN OUTSIDE AGENCY WILL BE REVIEWED ON A CASE-BY-CASE BASIS. PART VI, LINE 2: NOT ONLY DID WE SEEK FEEDBACK FROM COMMITTEE MEMBERS REPRESENTING LESSER-HEARD VOICES FROM OUR COMMUNITY, BUT WE MADE AN ONLINE SURVEY AVAILABLE, WE PUT HARD COPIES OF THE SURVEY IN MULTIPLE PLACES INCLUDING ALL OF THE TOWNS IN OUR SERVICE AREA. WE COMBINED THAT FEEDBACK WITH STATISTICAL INFORMATION FROM RELIABLE SOURCES TO IDENTIFY PRIORITIES. PART VI, LINE 3: WE POST INFORMATION ABOUT OUR FINANCIAL ASSISTANCE POLICY IN PROMINENT LOCATIONS. WE MAKE COPIES OF THE FINANCIAL ASSISTANCE POLICY AVAILABLE DURING REGISTRATION, IN INPATIENT ROOMS, ONLINE, AND ON OUR BILLING CORRESPONDENCE. PART VI, LINE 4: THE HOSPITAL SERVES A GEOGRAPHIC AREA THAT ENCOMPASSES ATCHISON, BROWN, DONIPHAN, JACKSON AND NEMAHA COUNTIES IN KANSAS, AND RICHARDSON COUNTY IN NEBRASKA. OF THOSE PATIENTS, 85% ARE FROM BROWN AND DONIPHAN COUNTIES. THESE ARE MOSTLY RURAL COMMUNITIES. 88% OF THE POPULATION OF THE BROWN AND DONIPHAN COUNTIES THAT IS 25 YEARS OR OLDER HAS A MINIMUM OF A HIGH SCHOOL DIPLOMA, 16% HAS A BACHELORS DEGREE OR HIGHER. THE AVERAGE MEDIAN HOUSEHOLD INCOME IS $41,300 COMPARED TO THE STATE WIDE MEDIAN HOUSEHOLD INCOME OF $50,594. 16% OF THE POPULATION LIVES IN POVERTY; 19% FOR BROWN COUNTY ALONE. 16% OF THE POPULATION IN BROWN AND DONIPHAN COUNTIES DOES NOT HAVE HEALTH INSURANCE. PART VI, LINE 5: A MAJORITY OF THE HOSPITAL'S BOARD OF DIRECTORS ARE COMPRISED OF PERSONS WHO RESIDE IN THE HOSPITAL'S PRIMARY SERVICE AREA AND ARE NEITHER EMPLOYEES OR CONTRACTORS OF THE HOSPITAL OR FAMILY MEMBERS THEREOF. THE HOSPITAL ALLOWS OTHER COMMUNITY PHYSICIANS (NOT EMPLOYED BY HIAWATHA) TO APPY FOR AND BE GRANTED PRIVILEGES. ANY SURPLUS FUNDS FOR THE HOSPITAL ARE USED FOR CAPITAL INITIATIVES. EACH BUDGET MANAGER SUBMITS THEIR YEARLY BUDGETS TO THE ADMIN TEAM. ONCE THE SURPLUS AMOUNT IS CALCULATED, THE ADMIN TEAM WILL DISCUSS/APPROVE WHICH CAPITAL PROJECTS ARE PRIORITY FOR THE HOSPITAL'S CURRENT SITUATION AND FUTURE GROWTH.WE SUPPORT A WIDE ARRAY OF PROGRAMS AND PROJECTS IN OUR COMMUNITY. MANY OF OUR KEY EMPLOYEES SERVE ON MULTIPLE BOARDS THAT HAVE A POSITIVE IMPACT ON VARIOUS ASPECTS OF THE COMMUNITY. WE PROVIDE DONATIONS OF BOTH TIME AND MONEY TO VARIOUS SERVICE ORGANIZATIONS. PART VI, LINE 6: THE HOSPITAL IS PART OF AN AFFILIATED HEALTH CARE SYSTEM WITH AMBERWELL ATCHISON ASSOCIATION. X X 0 0 0 1 0 0 0 0 0 DR CROSBY GERNON RADIOLOGIST 398484 0 0 0 0 0 6525 0 37978 0 442987 0 0 0 DR MARIAH KRIWIEL PHYSICIAN 387419 0 2000 0 0 0 326 0 37978 0 427723 0 0 0 DR JESSICA JARVIS PHYSICIAN 364862 0 10909 0 0 0 6280 0 38001 0 420052 0 0 0 DR ANNA CLELAND-LEIGHTON PHYSICIAN 266364 0 8000 0 0 0 6129 0 37978 0 318471 0 0 0 ROBIN ALEXANDER CRNA 270931 0 2083 0 0 0 935 0 37964 0 311913 0 0 0 CHASE DUDZINSKI CFO 244568 0 6084 0 0 0 7672 0 22491 0 280815 0 0 0 JEFFREY PERRY CEO 230000 0 0 0 0 0 0 0 0 0 230000 0 0 0 PART I, LINE 5 THE PROVIDERS ARE PAID A PERFORMANCE BONUS BASED ON PRODUCTIVITY AND CONSIDERATION OF REVENUES. FORM 990, SCHEDULE J, PART II UNRELATED ORGANIZATION COMPENSATION: CHASE DUDZINSKI IS THE CFO FOR HIAWATHA HOSPITAL ASSOCIATION AND AMBERWELL HEALTH ASSOCIATION, AN UNRELATED ORGANIZATION. AMBERWELL HEALTH ASSOCIATION ISSUES THE W-2 FOR THE CFO. COMPENSATION AND BENEFITS ARE PAID FOR SERVICES TO BOTH HOSPITALS. HIAWATHA HOSPITAL ASSOCIATION REIMBURSES AMBERWELL HEALTH ASSOCIATION 30% OF CHASE'S COMPENSATION AND BENEFITS. A CITY OF HIAWATHA KANSAS 486025665 428545CY1 2020-03-31 6295000 SEE PART VI 0 0 0 A 1040000 6295000 125900 2000000 4169100 2022 1 0 1 1 A 0 0 0 0 0.00000 0.00000 0.00000 0 0 1 A 0 0 0 0 0 0 0 0 1 A 1 PART I, LINE A, COLUMN F THE BONDS WERE ISSUED TO (1) REFUND THE SERIES 2014 BONDS (ISSUED 9/29/2014) AND (2) MAKE CAPITAL IMPROVEMENTS INCLUDING STRUCTURAL IMPROVEMENTS AND THE ACQUISITION OF CAPITAL ASSETS TO IMPROVE HOSPITAL SERVICES. X MAMMOMAT INSPIRATION 3D UNIT 1 70000 FMV 0 0 0 0 PART I, COLUMN (B): THE ORGANIZATION IS REPORTING IN PART I, COLUMN (B) THE NUMBER OF ITEMS RECEIVED. FORM 990, PART VI, SECTION A, LINE 7B THE GOVERNING BOARD SHALL HAVE RESPONSIBILITY FOR THE MANAGEMENT AND OPERATION OF THE HOSPITAL ACTIVITIES SUBJECT TO THE RATIFICATION RIGHTS OF THE HEALTH SYSTEM SET FORTH IN THE AFFILIATION AGREEMENT, WHICH INCLUDES: A. THE HEALTH SYSTEM'S RIGHT TO RATIFY THE APPOINTMENT AND RETENTION OF DIRECTORS OF THE GOVERNING BOARD, WHICH, APPROVAL MAY ONLY BE WITHHELD BY THE HEALTH SYSTEM DUE TO A CANDIDATE'S CONFLICT OF INTEREST OR FAILURE TO MEET BEST PRACTICES FOR HOSPITAL GOVERNANCE; B. THE HEALTH SYSTEM'S RIGHT TO EXERCISE REASONABLY NECESSARY MANAGEMENT AUTHORITY IN ORDER FOR THE HEALTH SYSTEM TO PROVIDE SERVICES AS A "HOME OFFICE" ON BEHALF OF THE HOSPITAL WHICH, PURSUANT TO 42 CFR PART 485 AND THE REGULATIONS PROMULGATED BY THE LICENSING AUTHORITY OF THE STATE OF KANSAS, MAY BE DELEGATED TO A MANAGEMENT COMPANY BY A STATE LICENSED CRITICAL ACCESS HOSPITAL, EXCLUDING THOSE AUTHORITIES WHICH, PURSUANT TO THE FOREGOING REGULATIONS OR THE EXPRESS TERMS OF THE AFFILIATION AGREEMENT ARE RETAINED BY THE HOSPITAL'S GOVERNING BOARD; C. THE HEALTH SYSTEM'S RIGHT TO FACILITATE THE ADOPTION OF THE ANNUAL CAPITAL AND OPERATING BUDGETS AS FOLLOWS. THE HEALTH SYSTEM SHALL HAVE AUTHORITY AND RESPONSIBILITY FOR CREATING A HOSPITAL BUDGET PROCESS WHICH WILL HAVE THE FOLLOWING CONDITIONS: I. THE HEALTH SYSTEM WILL ANNUALLY PROVIDE THE PROTOCOLS FOR THE HOSPITAL BUDGET PROCESS WHICH THE HOSPITAL MUST FOLLOW IN CREATING THE HOSPITAL BUDGET; II. THE HOSPITAL'S CHIEF EXECUTIVE OFFICER AND CHIEF FINANCIAL OFFICER WILL ANNUALLY IMPLEMENT THE HOSPITAL BUDGET PROCESS WITH THE ASSISTANCE OF THE HEALTH SYSTEM, TO INCLUDE HOSPITALS' DEPARTMENT MANAGERS; III. ANNUALLY, THE HOSPITAL'S GOVERNING BOARD WILL SUBMIT A HOSPITAL BUDGET TO THE HEALTH SYSTEM DIRECTORS WHO MAY EITHER A) APPROVE; OR, B) REJECT AND SEND BACK TO THE HOSPITAL'S GOVERNING BOARD WITH RECOMMENDED CHANGES. THE HOSPITAL'S GOVERNING BOARD WILL BE REQUIRED TO SEND A REVISED HOSPITAL BUDGET TO THE HEALTH SYSTEM DIRECTORS WHO MAY THEREAFTER EITHER APPROVE OR MODIFY THE HOSPITAL BUDGET, WHICH THE HOSPITAL'S GOVERNING BOARD SHALL ADOPT; AND IV. THE ANNUAL HOSPITAL BUDGET WILL INCLUDE PROVISIONS THAT AUTHORIZE DISCRETIONARY SPENDING BY THE HOSPITAL'S GOVERNING BOARD WITHIN THE HOSPITAL'S BUDGET AND STRATEGIC PLAN DURING THE HOSPITAL'S FISCAL YEAR. D. THE HEALTH SYSTEM'S RIGHT TO APPROVE OF ANY STRATEGIC PLANS OR MATERIAL NONCLINICAL PROGRAMING AND MARKETING PLANS, INCLUDING MATERIAL MODIFICATIONS THEREOF; E. THE HEALTH SYSTEM'S PRE-AUTHORIZATION OF DEBT INCURRED, ASSUMED, OR GUARANTEED BY THE HOSPITAL OTHER THAN AS PROVIDED FOR IN ANY APPROVED ANNUAL CAPITAL OR OPERATING BUDGET; F. THE HEALTH SYSTEM'S PRE-AUTHORIZATION OF ANY MATERIAL ACQUISITION, DISPOSITION, FORMATION, ORGANIZATION OR INVESTMENT BY THE HOSPITAL OF OR IN ANY OTHER CORPORATION, PARTNERSHIP, LIMITED LIABILITY COMPANY, OTHER ENTITY OR JOINT VENTURE; G. THE HEALTH SYSTEM'S PRE-AUTHORIZATION OF THE SALE, DISPOSITION, MORTGAGE, OR ENCUMBRANCE OF ANY ASSETS DEDICATED TO THE OPERATIONS OF THE HOSPITAL; H. THE HEALTH SYSTEM'S PRE-AUTHORIZATION OF THE HOSPITAL TO ENTER INTO ANY MERGER, CONSOLIDATION OR JOINT VENTURE; OR TO SELL OR DISPOSE OF SUBSTANTIALLY ALL OF THE ASSETS OF THE HOSPITAL OR ANY OF ITS RESPECTIVE SUBSIDIARIES; OR TO CREATE OR ACQUIRE ANY SUBSIDIARY ORGANIZATION; I. THE HEALTH SYSTEM'S PRE-AUTHORIZATION OF THE HOSPITAL TO INSTITUTE ANY BANKRUPTCY, INSOLVENCY OR REORGANIZATION PROCEEDINGS FOR ITSELF OR ANY SUBSIDIARY; J. THE HEALTH SYSTEM'S PRE-AUTHORIZATION OF A CAPITAL INVESTMENT BY THE HOSPITAL OR ANY OF ITS SUBSIDIARIES IN ANY INDIVIDUAL ENTITY OR PROJECT IN THE FORM OF CASH OR EITHER TANGIBLE OR INTANGIBLE PROPERTY, EXCEPT AS PROVIDED IN ANY APPROVED ANNUAL CAPITAL OR OPERATING BUDGET; K. THE HEALTH SYSTEM'S PRE-AUTHORIZATION TO DEVELOP, IMPLEMENT OR APPROVE THE TERMINATION OF A SERVICE LINE BY THE HOSPITAL OR ITS SUBSIDIARIES; L. THE HEALTH SYSTEM'S PRE-AUTHORIZATION OF ANY AMENDMENT OF THE ARTICLES OF INCORPORATION OR BYLAWS OF THE HOSPITAL OR ITS SUBSIDIARIES TO THE EXTENT THAT IT WOULD A) IMPACT THE RESERVED POWERS SET FORTH IN THE AFFILIATION AGREEMENT; OR B) REASONABLY BE EXPECTED TO HAVE A MATERIAL STRATEGIC, COMPETITIVE OR FINANCIAL IMPACT ON THE HEALTH SYSTEM OR ANY OF ITS AFFILIATES; AND M. THE HEALTH SYSTEM'S COLLABORATION WITH THE HOSPITAL'S GOVERNING BOARD'S APPOINTMENT OR REAPPOINTMENT OF A CHIEF EXECUTIVE OFFICER IN A PROCESS DESCRIBED IN THE AFFILIATION AGREEMENT. FORM 990, PART VI, SECTION A, LINE 8B THE HEALTH SYSTEM DOES NOT HAVE A COMMITTEE THAT ACTS ON BEHALF OF THE GOVERNING BOARD. FORM 990, PART VI, SECTION B, LINE 11B AN INDEPENDENT ACCOUNTING FIRM PREPARES AND REVIEWS THE 990. THE 990 IS THEN REVIEWED BY THE ORGANIZATION'S OFFICERS AND ACCOUNTING PERSONNEL. ANY QUESTIONS OR CONCERNS THE ORGANIZATION'S OFFICERS AND ACCOUNTING PERSONNEL HAVE ARE ADDRESSED AND ANY CORRECTIONS OR CLARIFICATIONS THAT NEED TO BE MADE ARE MADE. THE FINAL FORM 990 WITH ALL REQUIRED SCHEDULES IS THEN PROVIDED TO ALL VOTING MEMBERS OF THE BOARD PRIOR TO FILING. FORM 990, PART VI, SECTION B, LINE 12C ALL EMPLOYEES AND DECISION MAKERS FOR THE HOSPITAL ARE COVERED UNDER THIS POLICY. CONFLICTS ARE EITHER REVIEWED BY THE CORPORATE COMPLIANCE OFFICER OR THE BOARD PRESIDENT. AT BOARD MEETINGS, THE BOARD CHAIR IS APPRAISED OF ALL CONFLICTS OF INTEREST AND THEN ASKS THE MEMBER TO ABSTAIN FROM DISCUSSING AND VOTING ON TOPICS OF CONFLICT. FORM 990, PART VI, SECTION B, LINE 15A HUMAN RESOURCES PERIODICALLY PROVIDES THE PRESIDENT OF THE BOARD OF DIRECTORS WITH A COMPENSATION SURVEY COMPILED BY THE KANSAS HOSPITAL ASSOCIATION. THE SURVEY DELINEATES COMPENSATION PACKAGES FOR ADMINISTRATORS AT HOSPITALS THAT ARE SIMILAR TO HIAWATHA. BASED ON THAT SURVEY, THE CEO'S PERFORMANCE, AND THE PERFORMANCE OF THE HOSPITAL, THE BOARD SETS THE CEO'S SALARY. THE LAST EVALUATION OF THE CEO'S COMPENSATION WAS COMPLETED IN 2023. COMPENSATION FOR THE CFO AND KEY EMPLOYEES IS BASED ON COMPARISON OF SIMILAR HOSPITALS AND POSITIONS IN THE AREA. FORM 990, PART VI, SECTION C, LINE 19 THE ORGANIZATION MAKES ITS GOVERNING DOCUMENTS, CONFLICT OF INTEREST POLICY, AND FINANCIAL STATEMENTS AVAILABLE TO THE PUBLIC UPON REQUEST. FORM 990, PART IX, LINE 11G OTHER SERVICE FEES: PROGRAM SERVICE EXPENSES 374,279. MANAGEMENT AND GENERAL EXPENSES 494,304. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 868,583. PURCHASED SERVICES: PROGRAM SERVICE EXPENSES 320,737. MANAGEMENT AND GENERAL EXPENSES 94,342. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 415,079. LEASED EMPLOYEES: PROGRAM SERVICE EXPENSES 2,265,202. MANAGEMENT AND GENERAL EXPENSES 0. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 2,265,202. SHARED EMPLOYEE: PROGRAM SERVICE EXPENSES 326,695. MANAGEMENT AND GENERAL EXPENSES 323,929. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 650,624. FORM 990, PART XI, LINE 9: CHANGE IN INTEREST IN FOUNDATION 122,434. FORM 990, PAGE 12, PART XII, LINE 2C: THE BOARD OF DIRECTORS HAS THE RESPONSIBILITY OF SELECTING THE INDEPENDENT ACCOUNTANT TO COMPLETE THE AUDIT WORK. THE FINANCE COMMITTEE OF THE BOARD OF DIRECTORS HAS THE RESPONSIBILITY FOR THE OVERSIGHT OF THE AUDIT. UPON CONCLUSION OF THE AUDIT, THE AUDITING FIRM PRESENTS THE RESULTS AND FINDINGS TO THE BOARD OF DIRECTORS. THIS PROCESS HAS NOT CHANGED FROM THE PRIOR YEAR. HIAWATHA COMMUNITY HOSPITAL FOUNDATION 300 UTAH STREET HIAWATHA KS 66434 481223766 FUNDRAISING KS 501(C)(3) LINE 12D, III-O 0 CHARITABLE REMAINDER TRUST (1) TRUST KS HHA T 1 0 0 1 0 0 0 0 0 0 0 0 0 1 1 1 0 0 0 0