2023-11-15T10:22:55-06:00 2022-12-31 390758449 WIPFLI LLP 1502 LONDON ROAD SUITE 200 DULUTH MN 55812 990 2022-01-01 470566524 PROVIDENCE MEDICAL CENTER PROV 4023753800 1200 PROVIDENCE RD WAYNE NE 68787 KIMBERLY HIXSON CFO 4023753800 2023-11-15 1 KIMBERLY HIXSON 999009999 0 MICHAEL J PETERSON CPA P01833529 2187224705 2023-11-15 2 AAL1 IAL1 2022 2023-04-26 12:10:37Z DANIELLE GEARHART 1200 PROVIDENCE RD WAYNE NE 68787 29715692 0 X WWW.PROVIDENCEMEDICAL.COM X 1975 NE SEE SCHEDULE O. 7 7 250 30 0 0 6794741 1206415 27225898 27622182 382088 -24767 176263 180244 34578990 28984074 10493 6723 0 0 13053017 13945826 0 0 0 13762037 14993725 26825547 28946274 7753443 37800 46480888 47729681 14762622 17020880 31718266 30708801 THE MISSION OF PROVIDENCE MEDICAL CENTER IS TO PROVIDE QUALITY HEALTH CARE IN THE SPIRIT OF CHRIST. 0 0 23402942 6723 27622182 PROVIDENCE MEDICAL CENTER IS A NOT-FOR-PROFIT, 21 BED, CRITICAL ACCESS HOSPITAL LOCATED IN WAYNE, NEBRASKA. PROVIDENCE SERVES OVER 15,000 AREA RESIDENTS IN NORTHEAST NEBRASKA AND EMPLOYS OVER 215 PEOPLE. PROVIDENCE OFFERS ACUTE, SKILLED, AND OBSTETRICAL CARE ALONG WITH 24 HOURS A DAY, SEVEN DAYS A WEEK EMERGENCY CARE AND AMBULANCE SERVICES. THE HOSPITAL ALSO PROVIDES DIAGNOSTIC IMAGING, SURGICAL, THERAPY, LABORATORY, ONCOLOGY, RESPIRATORY, HOME HEALTH, BEHAVIORAL HEALTH AND MANY OTHER HEALTH AND WELLNESS SERVICES. THERE ARE OVER 23 SPECIALTY CLINIC DOCTORS OF DIFFERENT SPECIALTIES THAT CONDUCT CLINICS AT THE HOSPITAL IN ORDER TO BRING SPECIALIZED CARE TO THE COMMUNITY. 23402942 1 1 0 1 0 0 0 0 0 1 1 0 0 0 1 0 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 0 0 0 0 0 0 0 0 0 1 50 0 250 1 0 0 0 0 0 0 0 0 0 0 0 0 X 7 7 0 0 0 0 0 0 0 1 1 0 0 0 1 1 1 1 1 1 1 0 NE X KIM HIXSON 4023757673 1200 PROVIDENCE RD WAYNE NE 68787 KRISTINE GIESE COO (THRU DEC 2022) 40.00 X 207856 0 25751 KIMBERLY LUEDERS DIRECTOR OF PHARMACY 40.00 X 163065 0 8957 NICOLE HAGLUND CNO 40.00 X 107653 0 44177 KIMBERLY HIXSON CFO 40.00 X 133912 0 7781 ANDREA BLECKE DIRECTOR OF THERAPY 40.00 X 112994 0 20760 DANIELLE GEARHART CEO 40.00 X 104847 0 7702 MATTHEW LEY CHAIR 1.00 X X 0 0 0 RICHARD BRANDOW VICE CHAIR 1.00 X X 0 0 0 ERIC KNUTSON SECRETARY/TREASURER 1.00 X X 0 0 0 MELISSA GRAHAM DIRECTOR 1.00 X 0 0 0 ROSS HANSEN DIRECTOR 1.00 X 0 0 0 JODI PULFER DIRECTOR 1.00 X 0 0 0 NATHAN RAABE DIRECTOR 1.00 X 0 0 0 830327 0 115128 6 0 1 0 FAITH REGIONAL PHYSICIAN SERVICES LLC 110 NORTH 29TH STREET SUITE 201 NORFOLK NE 68701 ER OB AND C-SECTION DOCTOR COVERAGE 757645 T AND D ANESTHESIA LLC 13606 SOUTH 226TH AVENUE GRETNA NE 68028 CRNA SERVICES 603000 PSYCHIATRIC MEDICAL CARE LLC 8 CADILLAC DRIVE 230 BRENTWOOD TN 37027 SENIOR LIFE PSYCHIATRIC DOCTORS 408756 MEDUIT HEALTH SERVICES 200 14TH AVENUE EAST SARTELL MN 56377 HEALTHCARE REVENUE CYCLE MANAGEMENT 131763 AVEL ECARE LLC 4500 N LEWIS AVENUE SIOUX FALLS SD 57104 PHARMACY & EMERGENCY TELEMEDICINE SERVIC 116446 7 1032482 173933 1206415 PATIENT SERVICE REVENUE 621990 25343618 25343618 PHARMACY 621990 1906006 1906006 FITNESS REVENUE 621990 178893 178893 DIETARY INCOME 900099 44781 44781 LIFELINE 621990 192 192 148692 148692 27622182 196171 196171 180244 0 180244 180244 180244 443680 67000 422195 309423 21485 -242423 -220938 -220938 28984074 27622182 0 155477 X 6723 6723 254241 254241 10701158 8981705 1719453 374263 304089 70174 1827661 1472156 355505 788503 631627 156876 10019 5275 4744 57480 57480 3437650 3106583 331067 173537 173537 346030 135313 210717 991999 58620 933379 502816 502790 26 54497 54027 470 105232 73580 31652 284546 207957 76589 2821463 2062029 759434 207272 207272 SUPPLIES AND PHARMACEUT 4166088 4137499 28589 EQUIPMENT RENTAL & MAIN 1027974 871171 156803 PROVISIONS FOR BAD DEBT 769327 769327 37795 22471 15324 28946274 23402942 5543332 0 171811 210428 10101310 3947514 3385642 4133031 719546 732382 378176 336478 53689629 24005369 23115660 29684260 7362220 6507886 288667 290602 957856 1887100 46480888 47729681 2976003 2627823 595180 73410 10010632 14098195 39409 1180807 182043 14762622 17020880 X 30953333 29967124 764933 741677 31718266 30708801 46480888 47729681 X 37800 -1024009 -23256 X 0 1 X 1 1 1 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 0 0 0 0 0 0 0 0 1 2456 2456 0 PART II-B, LINE 1: PROVIDENCE MEDICAL CENTER ("PMC") PAYS ANNUAL ASSOCIATION MEMBERSHIP DUES TO THE NEBRASKA HOSPITAL ASSOCIATION (NHA). THESE DUES ARE PRIMARILY TO ACCESS EDUCATIONAL MATERIALS AND FOR STAFF TRAINING. THE NHA HAS NOTIFIED PMC THAT APPROXIMATELY $2,456 OF THE ANNUAL DUES PAID WERE USED IN CONJUNCTION WITH LOBBYING ACTIVITIES WITH THE GOAL OF IMPROVING THE OVERALL HEALTHCARE ENVIRONMENT. 87009 -4652 82357 77078 9931 87009 74377 2701 77078 64417 9960 74377 66427 2010 64417 0.00000 0.00000 1.00000 1 0 91932 91932 34278585 14801180 19477405 13670568 9204189 4466379 5648544 5648544 29684260 OPERATING LEASE LIABILITIES 148852 DEFERRED COMPENSATION PLAN 33191 182043 27093262 -1024009 -1024009 28117271 866803 866803 28984074 28176947 0 28176947 769327 769327 28946274 PART V, LINE 4: PROVIDENCE MEDICAL CENTER HAS ONE ENDOWMENT FUND HELD BY PROVIDENCE MEDICAL CENTER FOUNDATION. THE ENDOWMENT WAS SET ASIDE BY DONORS TO PROVIDE INVESTMENT INCOME IN WHICH TO PROVIDE FOR FUTURE CAPITAL AND PROGRAM NEEDS OF THE HOSPITAL. PART XI, LINE 4B - OTHER ADJUSTMENTS: PROVISION FOR BAD DEBTS 769,327. FOUNDATION CONTRIBUTION 97,476. PART XII, LINE 4B - OTHER ADJUSTMENTS: PROVISION FOR BAD DEBTS 769,327. 1 1 X 1 X 1 X 1 1 1 0 0 310120 310120 0.01070 2068103 1167828 900275 0.03110 2378223 1167828 1210395 0.04180 519786 262766 257020 0.00890 519786 262766 257020 0.00890 2898009 1430594 1467415 0.05070 0 633270 397472 11566878 11637903 -71025 X 1 1 1 1 PROVIDENCE MEDICAL CENTER 1200 PROVIDENCE ROAD WAYNE NE 68787 WWW.PROVIDENCEMEDICAL.COM 800001 X X X X AMBULANCE SERVICE PROVIDENCE MEDICAL CENTER 1 0 0 1 X X X X X X X X X 22 1 1 1 1 X SEE SUPPLEMENTAL SECTION 1 19 1 SEE SUPPLEMENTAL SECTION 0 1 X 150.000000000000 300.000000000000 X X X X 1 1 X X X X 1 X PFS-0003.04-FINANCIAL-ASSISTANCE-POLICY.PDF (PROVIDENCEMEDICAL.COM) X FINANCIAL-ASSISTANCE-APPLICATION-8-1-21.PDF (PROVIDENCEMEDICAL.COM) X PFS-0003.04-ATTACHMENT-3-PLAIN-LANGUAGE-SUMMARY.PDF (PROVIDENCEMEDICAL.COM) X X X X X X 1 X 0 X X X X 1 X 0 0 PROVIDENCE MEDICAL CENTER PART V, SECTION B, LINE 5: THE REPORT WAS PREPARED BY STAFF OF THE FOLLOWING: NORTHEAST NEBRASKA RURAL HEALTH NETWORK;IN CONJUNCTION WITH VISIONFUSION AND INTERSECTIONS CONSULTING;AND STAFF FROM PARTNER MEMBERS INCLUDING:PENDER COMMUNITY HOSPITAL;PROVIDENCE MEDICAL CENTER;WINNEBAGO PUBLIC HEALTH DEPARTMENT;MIDTOWN HEALTH CENTER;UNIVERSITY OF NEBRASKA MEDICAL CENTER; ANDNORTHEAST NEBRASKA PUBLIC HEALTH DEPARTMENT.THE FOLLOWING AGENCIES PROVIDED INPUT INTO CERTAIN SECTIONS OF THE REPORT: CARL T. CURTIS HEALTH CENTERCEDAR COUNTY TRANSITEDUCATIONAL SERVICE UNIT #1HARTINGTON SENIOR CENTERHAVEN HOUSELA MICHUACANALEAGUE OF HUMAN DIGNITYLUNA'S CAFEMIDTOWN HEALTH CENTERNEBRASKA ASSOCIATION OF LOCAL HEALTH DIRECTORSNEBRASKA DEPARTMENT OF HEALTH AND HUMAN SERVICESNEBRASKA EXTENSIONNORTHEAST NEBRASKA COMMUNITY ACTION PARTNERSHIPNORTHEAST NEBRASKA PUBLIC HEALTH DEPARTMENTPEARL STREET COUNSELINGPENDER MEDICAL CLINICPENDER COMMUNITY HOSPITALPROVIDENCE MEDICAL CENTERRURAL REGION ONE MEDICAL RESPONSE SYSTEMUNIVERSITY OF NEBRASKA COLLEGE OF NURSING NORTHERN DIVISIONUNIVERSITY OF NEBRASKA COLLEGE OF PUBLIC HEALTHWAYNE ASSOCIATION OF CONGREGATIONS AND MINISTERSWAYNE COMMUNITY SCHOOLSWAYNE FAMILY COALITIONWAYNE HERALDWAYNE COMMUNITY HOUSING DEVELOPMENT COMMISSIONWAYNE STATE COLLEGEWINNEBAGO HEALTH DEPARTMENTOVER SIX HUNDRED SURVEYS WERE COLLECTED FROM ACROSS THE HEALTH DISTRICT. LIVE LISTENING SESSIONS WERE CONDUCTED IN CEDAR, DIXON AND WAYNE COUNTIES AND THURSTON COUNTY PARTICIPATED IN A VIRTUAL SESSION. LISTENING SESSIONS WITH THE AREA'S HISPANIC POPULATION, WITH INTERPRETATION BY NNPHD STAFF, WERE FACILITATED BY OUR HEALTH DIRECTOR. THIS LED TO THE FORMATION OF A HEALTH CONSUMER FOCUSED ADVISORY COUNCIL COMPOSED OF MEMBERS OF THE AREA'S LATINO COMMUNITY. A SERIES OF FIVE VIRTUAL CONVERSATIONS WERE HELD TO UPDATE THE FINDINGS OF OUR 2019 LOCAL PUBLIC HEALTH SYSTEM ASSESSMENT USING THE RECENTLY UPDATED 10 ESSENTIAL SERVICES OF PUBLIC HEALTH, AS WELL AS THE LOCAL SYSTEM'S EXPERIENCE WITH THE COVID-19 PANDEMIC. A HEALTH EQUITY ADVISORY COUNCIL WAS STARTED IN DECEMBER 2021 WHICH HAS ALSO GIVEN US FEEDBACK. PROVIDENCE MEDICAL CENTER PART V, SECTION B, LINE 6A: PENDER COMMUNITY HOSPITAL PROVIDENCE MEDICAL CENTER PART V, SECTION B, LINE 6B: NORTHEAST NEBRASKA PUBLIC HEALTH DEPARTMENT WINNEBAGO PUBLIC HEALTH DEPARTMENTMIDTOWN HEALTH CENTERUNIVERSITY OF NEBRASKA MEDICAL CENTERPROVIDENCE MEDICAL CENTER:PART V, SECTION B, LINE 7A: HTTPS://PROVIDENCEMEDICAL.COM/ABOUT-US/COMMUNITY-HEALTH-ASSESSMENT/PROVIDENCE MEDICAL CENTER:PART V, SECTION B, LINE 10A: HTTPS://PROVIDENCEMEDICAL.COM/ABOUT-US/COMMUNITY-HEALTH-ASSESSMENT/ PROVIDENCE MEDICAL CENTER PART V, SECTION B, LINE 11: THE ORGANIZATION COMPLETED A NEW CHNA IN 2022 AND THE ORGANIZATION ALONG WITH THE OTHER PARTICIPANTS IN THE CHNA DETERMINED THE FOLLOWING KEY HEALTH OUTCOMES, KEY HEALTH FACTORS AND KEY DISPARITIES IMPACTING THEM. FINALLY THEY DETERMINED THE TOP CONCERNS AND ACTION ITEMS TOWARD THEM. KEY HEALTH OUTCOMES: HEALTH OUTCOMES WHERE HEALTH DISTRICT AVERAGES, AS WELL AS THOSE OF ONE OR MORE OF OUR COUNTIES, AREWORSE THAN STATE AVERAGES INCLUDE: CANCERCOLON AND RECTUM CANCER-LUNG CANCER-PROSTATE CHRONIC OBSTRUCTIVE PULMONARY DISEASE DIABETES (MEDICARE) HEART DISEASE KIDNEY DISEASE HIGH BLOOD PRESSURE DEATHS OF DESPAIR MORTALITY-CANCER MORTALITY-CORONARY HEART DISEASE MORTALITY-HEART DISEASE MORTALITY-MOTOR VEHICLE CRASH, ALCOHOL-INVOLVED MORTALITY-YEARS OF POTENTIAL LIFE LOST MORTALITY-STROKE MORTALITY-UNINTENTIONAL INJURY-ACCIDENT OBESITYKEY HEALTH FACTORS: HEALTH FACTORS WHERE HEALTH DISTRICT AVERAGES ARE WORSE THAN STATE AVERAGES INCLUDE: LOW PROPORTION OF FOOD BUDGET ON FRUITS AND VEGETABLES HIGH PROPORTION OF FOOD BUDGET SPENT ON SODA PHYSICAL INACTIVITY CURRENT SMOKERS TOBACCO EXPENDITURES HEAVY ALCOHOL CONSUMPTION CHLAMYDIA INCIDENCE KEY DISPARITIES: LANGUAGEOVER 500 OF OUR RESIDENTS ARE NOT PROFICIENT IN ENGLISH. EDUCATION INCOME SCHEDULE OF HEALTH CARE VERSUS JOB SCHEDULE AND TRANSPORTATION OPTIONS LOCATIONS AND TRANSPORTATION OPTIONSTOP CONCERNS AND NEEDS: COVID-19, EVEN IN 2022, WAS EXPRESSED AS A WORRY OF APPROXIMATELY ONE-THIRD OF SURVEY RESPONDENTS AND CITED AS ONE OF THE TOP 3 CONCERNS WHEN ASKED TO PICK FROM A LIST. MENTAL HEALTH REMAINED A TOP WORRY OF SURVEY RESPONDENTS (SIMILAR TO 2019). SOCIAL ISOLATIONWAS IDENTIFIED AS A STRESSOR WHICH CONTRIBUTED TO ANXIETY AND DEPRESSION. CANCER WAS A TOP WORRY OF SURVEY RESPONDENTS, BUT THE AREA HAS BEEN UNDERPERFORMING IN TERMS OF SCREENINGS. WHILE "OBESITY" WAS NOT ONE OF THE CHOICES FOR THE CLOSED ENDED QUESTIONS, RESPONDENTS EXPRESSED CONCERNS ABOUT ACCESS TO HEALTHY AFFORDABLE FOOD, THE NEED TO BE MORE PHYSICALLY ACTIVE AND MAINTAINING A HEALTHY WEIGHT WERE MENTIONED FREQUENTLY IN THE OPEN-ENDED QUESTIONS. AFFORDING OUT-OF-POCKET COSTS FOR MEDICAL CARE, AS WELL AS MAINTAINING INSURANCE, WERE IDENTIFIED AS CONCERNS. BEING ABLE TO GET EMERGENCY OR SPECIALTY CARE AS NEEDED, GIVEN DISTANCES TO FACILITIES, IS A CONCERN. LONG-TERM CARE IS ANOTHER AREA OF CONCERN SINCE A LOCAL FACILITY RECENTLY CLOSED. PROVIDENCE MEDICAL CENTER PART V, SECTION B, LINE 15E: PROVIDENCE MEDICAL CENTER MAY ASSIST PATIENTS IN APPLYING FOR MEDICARE, MEDICAID, AND OTHER GOVERNMENTAL MEDICAL ASSISTANCE PROGRAMS. 2 1 - PROVIDENCE COMMUNITY PHARMACY 803 PROVIDENCE ROAD SUITE 101 WAYNE NE 68787 PHARMACY 2 - PROVIDENCE PERSONAL CARE SERVICES 1200 PROVIDENCE ROAD WAYNE NE 68787 HOME HEALTH PART I, LINE 3C: UNINSURED, UNDERINSURED, AND INDIGENT BY DESIGN PATIENTS WHOSE INCOME/FAMILY INCOME IS GREATER THAN 400% OF THE FEDERAL POVERTY GUIDELINES MAY BE ELIGIBLE FOR DISCOUNTED CARE BASED ON THEIR PARTICULAR CIRCUMSTANCES. SUCH DISCOUNTS ARE AT THE DISCRETION OF THE ORGANIZATION AND WILL NOT BE COUNTED AS CHARITY CARE. PART I, LINE 7: THE COSTING METHODOLOGY USED ON FORM 990 IS BASED ON A COST-TO-CHARGE RATIO WHICH IS DEVELOPED BASED ON THE HOSPITAL'S TOTAL OPERATING EXPENSES LESS THE PROVISION FOR BAD DEBT DIVIDED BY GROSS PATIENT SERVICE REVENUE. THIS COST-TO-CHARGE RATIO IS APPLIED AGAINST VARIOUS REVENUE AND EXPENSE CATEGORIES TO COMPUTE THE ESTIMATED COMMUNITY BENEFIT EXPENSE UNDER IRS SUGGESTED COSTING METHODS FOR THE FORM 990. PART I, LINE 7G: SUBSIDIZED SERVICES INCLUDE HOSPICE AND HOME HEALTH SERVICES. PART III, LINE 2: THE COSTING METHODOLOGY USED ON FORM 990 IS BASED ON A COST-TO-CHARGE RATIO, WHICH IS DEVELOPED BASED ON THE HOSPITAL'S TOTAL OPERATING EXPENSES EXCLUDING THE PROVISION FOR BAD DEBT, DIVIDED BY GROSS PATIENT SERVICE REVENUE. THIS COST-TO-CHARGE RATIO IS APPLIED AGAINST THE TOTAL CHARGES THAT ARE WRITTEN OFF DURING THE YEAR TO ESTIMATE THE COST OF CARE OF PATIENTS WHO HAVE ACCOUNTS THAT ARE DEEMED TO BE BAD DEBTS TO THE HOSPITAL. THE HOSPITAL ALSO RECOGNIZES THAT IT ALSO PROVIDES A DISCOUNT TO SELF-PAY OR UNINSURED PATIENTS. THESE AMOUNTS ARE EXCLUDED FROM GROSS PATIENT SERVICE REVENUE ON THE FINANCIAL STATEMENTS AND ARE NOT INCLUDED IN THE RATIO AS DESCRIBED ABOVE AND APPROVED BY THE IRS FOR USE ON FORM 990. IF CONSIDERED, THESE ADDITIONAL WRITE-OFF AMOUNTS TO UNINSURED ACCOUNTS WOULD ALSO INCREASE THE ESTIMATED BAD DEBT EXPENSE AMOUNT ASSOCIATED WITH THESE UNCOLLECTIBLE ACCOUNTS TO THE HOSPITAL. PART III, LINE 3: MANAGEMENT PROVIDES FOR PROBABLE UNCOLLECTIBLE AMOUNTS, PRIMARILY UNINSURED PATIENTS AND AMOUNTS PATIENTS ARE PERSONALLY RESPONSIBLE FOR, THROUGH A CHARGE TO OPERATIONS AND A CREDIT TO A VALUATION ALLOWANCE BASED ON ITS ASSESSMENT OF HISTORICAL COLLECTION LIKELIHOOD AND THE CURRENT STATUS OF INDIVIDUAL ACCOUNTS. BALANCES THAT ARE STILL OUTSTANDING AFTER THE HOSPITAL HAS USED REASONABLE COLLECTION EFFORTS ARE WRITTEN OFF THROUGH A CHARGE TO THE VALUATION ALLOWANCE AND A CREDIT TO ACCOUNTS RECEIVABLE. PART III, LINE 4: IN EVALUATING THE COLLECTABILITY OF ACCOUNTS RECEIVABLE, THE HOSPITAL ANALYZES PAST RESULTS AND IDENTIFIES TRENDS FOR EACH OF ITS MAJOR PAYOR SOURCES OF REVENUE TO ESTIMATE THE APPROPRIATE ALLOWANCE FOR UNCOLLECTIBLE ACCOUNTS AND PROVISION FOR BAD DEBTS. MANAGEMENT REGULARLY REVIEWS DATA ABOUT THESE MAJOR PAYOR SOURCES OF REVENUE IN EVALUATING THE SUFFICIENCY OF THE ALLOWANCE FOR UNCOLLECTIBLE ACCOUNTS. SPECIFICALLY, FOR RECEIVABLES ASSOCIATED WITH SERVICES PROVIDED TO PATIENTS WHO HAVE THIRD-PARTY COVERAGE, THE HOSPITAL ANALYZES CONTRACTUALLY DUE AMOUNTS AND PROVIDES AN ALLOWANCE FOR UNCOLLECTIBLE ACCOUNTS AND A PROVISION FOR BAD DEBTS FOR EXPECTED UNCOLLECTIBLE DEDUCTIBLES AND COPAYMENTS ON ACCOUNTS FOR WHICH THE THIRD-PARTY PAYOR HAS NOT YET PAID, OR FOR PAYORS AND PATIENTS WHO ARE KNOWN TO BE HAVING FINANCIAL DIFFICULTIES THAT MAKE THE REALIZATION OF AMOUNTS DUE UNLIKELY. FOR RECEIVABLES ASSOCIATED WITH SELF-PAY PATIENTS (WHICH INCLUDES BOTH PATIENTS WITHOUT INSURANCE AND PATIENTS WITH DEDUCTIBLE AND COPAYMENT BALANCES DUE FOR WHICH THIRD-PARTY COVERAGE EXISTS FOR PART OF THE BILL), THE HOSPITAL RECORDS A SIGNIFICANT PROVISION FOR BAD DEBTS IN THE PERIOD OF SERVICE ON THE BASIS OF ITS PAST EXPERIENCE, WHICH INDICATES THAT MANY PATIENTS ARE UNABLE OR UNWILLING TO PAY THE PORTION OF THEIR BILL FOR WHICH THEY ARE FINANCIALLY RESPONSIBLE. THE DIFFERENCE BETWEEN THE STANDARD RATES (OR THE DISCOUNTED RATES, IF NEGOTIATED) AND THE AMOUNTS COLLECTED AFTER ALL REASONABLE COLLECTION EFFORTS HAVE BEEN EXHAUSTED IS CHARGED OFF AGAINST THE ALLOWANCE FOR UNCOLLECTIBLE ACCOUNTS. THE AUDITED FINANCIAL STATEMENTS DO NOT CONTAIN A SEPARATE FOOTNOTE REGARDING BAD DEBT EXPENSE. PART III, LINE 8: THE SHORTFALL SHOULD BE TREATED AS A COMMUNITY BENEFITS EXPENSE BECAUSE PROVIDING MEDICAL CARE AT A SHORTFALL IMPACTS THE HOSPITAL'S OPERATIONS AND GROWTH. THE CARE IS PROVIDED BECAUSE THERE IS A NEED AND A DESIRE TO PROVIDE MEDICAL CARE IN THIS COMMUNITY.THE COSTING METHOD USED ABOVE FOR IRS FORM 990 COMPLIANCE REPORTING IS ALSO BASED ON AN OVERALL AVERAGE COST-TO-CHARGE RATIO AND DOES NOT CONSIDER MEDICARE NON-ALLOWABLE EXPENSES AS IT IS BASED ON TOTAL HOSPITAL PATIENT SERVICE REVENUE (IGNORING CONTRACTUAL ADJUSTMENTS ON FEE SCHEDULE REIMBURSED ITEMS AND NON-ALLOWABLE MEDICARE EXPENSES AS NOTED ABOVE) DIVIDED BY TOTAL OPERATING EXPENSES LESS THE PROVISION FOR BAD DEBT EXPENSE. THIS RATIO IS THEN MULTIPLIED BY THE TOTAL MEDICARE SERVICES WHICH ARE REIMBURSED ON A COST METHODOLOGY EXCLUDING THE FEE SCHEDULE ITEMS LIKE PHYSICIAN SERVICES AND THE HOSPITAL WOULD SHOW A LARGE LOSS ON THESE SERVICES.WHETHER THERE IS A SHORTFALL OR SURPLUS FROM SERVICES PROVIDED TO MEDICARE BENEFICIARIES, THESE PEOPLE, WHO ARE TYPICALLY ELDERLY MEMBERS OF THE COMMUNITY, ARE AN UNDERSERVED POPULATION WHO EXPERIENCE ISSUES WITH ACCESS TO HEALTHCARE SERVICES. WITHOUT TAX-EXEMPT HOSPITALS PROVIDING MEDICARE PATIENT SERVICES, THE CENTERS FOR MEDICARE AND MEDICAID (CMS) WOULD BEAR THE BURDEN OF DIRECTLY PROVIDING SERVICES TO THE ELDERLY AND DISABLED MEMBERS OF THE COMMUNITY. PART III, LINE 9B: PROVIDENCE MEDICAL CENTER HAS A STRONG COMMITMENT TO THE COMMUNITY AND TO THE PATIENTS THAT WE SERVE. MEDICAL TREATMENT IS PROVIDED TO ALL PATIENTS REGARDLESS OF THEIR ABILITY TO PAY. IN DOING SO, WE SHALL: INFORM THE PUBLIC OF THE AVAILABILITY OF ALTERNATIVE PAYMENT ARRANGEMENTS, INCLUDING PAYMENT PLANS AND FINANCIAL ASSISTANCE PROGRAMS; PROVIDE FINANCIAL COUNSELING TO PATIENTS ABOUT THEIR HOSPITAL BILLS; RESPOND PROMPTLY TO PATIENTS' QUESTIONS ABOUT THEIR BILLS AND REQUESTS FOR FINANCIAL HELP THROUGH AN ACCEPTABLE PAYMENT PLAN AND/OR THROUGH FINANCIAL ASSISTANCE; AND PURSUE COLLECTION OF ACCOUNTS FAIRLY AND CONSISTENTLY AND WITHIN OUR WRITTEN GUIDELINES AND ENSURE THAT AGENCIES ACTING ON OUR BEHALF IN THE COLLECTION OF DEBT ALSO ACT IN ACCORDANCE WITH OUR MISSION AND GUIDELINES. PART VI, LINE 2: PMC WORKS WITH THE STATE OF NEBRASKA AND THE NEBRASKA HOSPITAL ASSOCIATION TO REVIEW PATIENT DATA AND OUTCOMES. ONE OF THE PRODUCTS USED IS COMS (CLINICAL OUTCOMES MEASUREMENT SYSTEM) WHICH GIVES OUTCOME DATA FOR MORBIDITY AND MORTALITY FOR THE STATE OF NEBRASKA AND OUR SERVICE AREA. PMC ALSO HAS WORKED WITH THE NORTHEAST NEBRASKA PUBLIC HEALTH DEPARTMENT WITH MAPP WHICH IS "MOBILIZING FOR ACTION THROUGH PLANNING AND PARTNERSHIP," WHICH IDENTIFIES PUBLIC HEALTH ISSUES AND FINDS RESOURCES TO ADDRESS THEM. PART VI, LINE 3: PAYMENT POLICIES AND FINANCIAL ASSISTANCE INSTRUCTIONS ARE GIVEN WITH ADMISSION DOCUMENTS, INCLUDED WITH EACH BILL, UPLOADED ON PMC'S WEBSITE, AND POSTED THROUGHOUT PMC'S FACILITIES. PART VI, LINE 4: THE HEALTHCARE FACILITY IS LOCATED IN WAYNE, NEBRASKA WHERE IT SERVES RESIDENTS OF NORTHEASTERN NEBRASKA. THE POPULATION BASE FROM THE NEARBY COMMUNITIES IS APPROXIMATELY 9,600 WITH AN AVERAGE INCOME OF APPROXIMATELY $45,000. PART VI, LINE 5: THE HOSPITAL HAS A COMMUNITY BOARD WITH MEMBERS THAT REPRESENT DIFFERENT TOWNS IN OUR SERVICE AREA. WE STRIVE TO INVEST OUR FUNDS IN BANKS WITHIN OUR SERVICE AREA. ALSO THE HOSPITAL'S ADMITTING PHYSICIANS ARE PRIMARILY PRACTITIONERS IN THE LOCAL AREA. PART VI, LINE 6: THE HOSPITAL IS NOT AFFILIATED WITH ANY OTHER HEALTH SYSTEMS. PART VI, LINE 7, REPORTS FILED WITH STATES NE X X 0 0 0 0 0 0 0 0 0 KRISTINE GIESE COO (THRU DEC 2022) 202731 0 5000 0 125 0 8698 0 17053 0 233607 0 0 0 KIMBERLY LUEDERS DIRECTOR OF PHARMACY 157040 0 5300 0 725 0 6488 0 2469 0 172022 0 0 0 NICOLE HAGLUND CNO 102528 0 5000 0 125 0 4997 0 39180 0 151830 0 0 0 A THE COUNTY OF WAYNE IN THE STATE OF NEBRASKA 476006517 NONEAVAIL 2015-07-31 8400000 TO CONSTRUCT AND EQUIP HOSPITAL FACILITY 0 0 0 B THE COUNTY OF WAYNE IN THE STATE OF NEBRASKA 476006517 NONEAVAIL 2016-03-08 4100000 TO CONSTRUCT AND EQUIP HOSPITAL FACILITY 0 0 0 C THE COUNTY OF WAYNE IN THE STATE OF NEBRASKA 476006517 NONEAVAIL 2021-06-22 6988641 TO CONSTRUCT AND EQUIP HOSPITAL FACILITY 0 0 0 A 1059815 8400000 264021 297702 8400000 2017 0 0 1 0 B 174565 4100000 264021 32759 4100000 2017 0 0 1 0 C 6988641 134839 106524 6988641 2022 0 0 1 0 A 0 0 0 0 0 0 0 B 0 0 0 0 0 0 0 C 0 0 0 0 0 0 0 A 0 0 1 0 0 0 0 0 1 B 0 0 1 0 0 0 0 0 1 C 0 1 0 0 0 0 0 0 1 A 1 B 1 C 1 FORM 990, PART I, LINE 1, DESCRIPTION OF ORGANIZATION MISSION: WE BELIEVE THAT THE PATIENT IS THE MOST IMPORTANT PERSON IN OUR MEDICAL CENTER, THAT LIFE IS A GIFT FROM GOD, AND THAT ALL PERSONS ARE CREATED EQUAL. WE BELIEVE THAT EVERY PATIENT HAS A RIGHT TO BE ADMITTED WHEN IN NEED OF SERVICES WHICH OUR FACILITY IS EQUIPPED TO PROVIDE, PRIVACY, PROFESSIONAL DISCRETION, CONSENT TO OR REFUSAL OF TREATMENT AND MAY REQUEST THE MINISTER OF HIS/HER CHOICE. WE BELIEVE THAT OUR MEDICAL CENTER HAS THE RESPONSIBILITY TO PROVIDE ADEQUATE AND COMPETENT STAFF AND DIAGNOSTIC, PREVENTATIVE AND THERAPEUTIC FACILITIES TO ENSURE HIGH QUALITY MEDICAL CARE TO THE PATIENT, AND THAT THIS CAN ONLY BE ACHIEVED THROUGH COOPERATION AND SUPPORT AMONG THE STAFF AND COMMUNITY. WE BELIEVE THAT THE EMPLOYEES ARE ENTITLED TO JUST WAGES FOR HONEST WORK AND TO OPPORTUNITIES FOR PERSONAL AND PROFESSIONAL GROWTH. WE BELIEVE THAT OUR MEDICAL CENTER NEEDS TO PARTICIPATE ACTIVELY IN COMMUNITY PLANNING OF HEALTH AND MEDICAL CARE FACILITIES AND OPERATE IN ACCORDANCE WITH THE NEEDS OF THE CIVIC COMMUNITY. FORM 990, PART VI, SECTION B, LINE 11B THE FORM 990 IS REVIEWED AND APPROVED BY THE HOSPITAL CEO AND CFO PRIOR TO FILING. ALSO, THE FORM 990 IS DISTRIBUTED TO THE BOARD OF DIRECTORS AFTER FILING. FORM 990, PART VI, SECTION B, LINE 12C PMC'S BOARD AND ADMINISTRATIVE MEMBERS ARE REQUIRED TO SIGN A NEW CONFLICT OF INTEREST STATEMENT AND DISCLOSURE ANNUALLY. ANY CONFLICTS ARE REVIEWED BY THE BOARD. AFTER EXERCISING DUE DILIGENCE, WHICH MAY INCLUDE INVESTIGATING ALTERNATIVES THAT PRESENT NO CONFLICT, THE BOARD SHALL DETERMINE WHETHER THE TRANSACTION IS IN THE ORGANIZATION'S BEST INTEREST, FOR ITS OWN BENEFIT, AND WHETHER IT IS JUST AND REASONABLE TO THE ORGANIZATION. THE TRANSACTION CAN BE APPROVED BY THE BOARD BY MAJORITY VOTE OF THOSE PRESENT AT A MEETING FOR WHICH QUORUM REQUIREMENTS HAVE BEEN MET, WITHOUT COUNTING THE VOTE OF ANY DISQUALIFIED DIRECTORS. FORM 990, PART VI, SECTION B, LINE 15 COMPENSATION PROCESS FOR OFFICERS' SALARIES AND FOR ALL EMPLOYEES ARE BASED ON THE NEBRASKA HOSPITAL ASSOCIATION'S (NHA) ANNUAL SALARY SURVEY. THE SURVEY IS CATEGORIZED BY JOB TITLES AND DETAILED BY HOURLY SALARY RANGES. NHA IS AN EXEMPT ORGANIZATION UNDER SECTION 501(C)(6) OF THE INTERNAL REVENUE CODE (TRADE ASSOCIATION), WITH ITS MEMBERS BEING THE HOSPITALS IN THE STATE OF NEBRASKA. EXECUTIVE WAGES OR SALARIES ARE NOT EVALUATED ANY DIFFERENTLY THAN OTHER EMPLOYEES. THEY RECEIVE NO PREFERENTIAL TREATMENT UNLESS THE GOVERNING BOARD MAKES A SPECIAL RECOMMENDATION. THE GUIDELINES INCLUDE: 1. A DETERMINATION OF THE FEASIBILITY OF BONUSES BASED ON AVAILABILITY OF CASH FLOW AND EXCESS REVENUE FOR THE CURRENT FISCAL YEAR, 2. DETERMINATION OF PMC'S OVERALL WAGE LEVELS BASED ON AN ANALYSIS OF WAGES AGAINST THE NHA'S SALARY SURVEY AND EMPLOYEE TIME OF SERVICE, 3. HOURLY WAGE INCREASES MAY ALSO BE GIVEN IF NEEDED TO BE COMPATIBLE OR TO COMPENSATE FOR A CHANGE IN JOB DESCRIPTIONS, AND 4. THE GOVERNING BOARD MAKES FINAL APPROVAL OF THE BUDGET WHICH WOULD INCLUDE ALL SALARIES AND BONUSES. FORM 990, PART VI, SECTION C, LINE 19 PROVIDENCE MEDICAL CENTER MAKES ITS GOVERNING DOCUMENTS, CONFLICT OF INTEREST POLICY, AND FINANCIAL STATEMENTS AVAILABLE TO THE PUBLIC UPON REQUEST AT ITS HOSPITAL BUSINESS LOCATION DURING NORMAL BUSINESS HOURS. FORM 990, PART IX, LINE 11G LABORATORY PURCHASED SERVICES: PROGRAM SERVICE EXPENSES 92,565. MANAGEMENT AND GENERAL EXPENSES 0. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 92,565. ANESTHESIA SERVICES PROFESSIONAL FEES: PROGRAM SERVICE EXPENSES 459,000. MANAGEMENT AND GENERAL EXPENSES 0. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 459,000. EMERGENCY SERVICES: PROGRAM SERVICE EXPENSES 880,257. MANAGEMENT AND GENERAL EXPENSES 0. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 880,257. HOSPICE PURCHASED SERVICES: PROGRAM SERVICE EXPENSES 102,580. MANAGEMENT AND GENERAL EXPENSES 0. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 102,580. RADIOLOGY PURCHASED SERVICES: PROGRAM SERVICE EXPENSES 206,136. MANAGEMENT AND GENERAL EXPENSES 0. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 206,136. WOUND CARE PURCHASED SERVICES: PROGRAM SERVICE EXPENSES 78,563. MANAGEMENT AND GENERAL EXPENSES 0. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 78,563. PATIENT FINANCIAL SERVICES: PROGRAM SERVICE EXPENSES 0. MANAGEMENT AND GENERAL EXPENSES 250,203. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 250,203. QUALITY ASSURANCE PURCHASED SERVICES: PROGRAM SERVICE EXPENSES 86,147. MANAGEMENT AND GENERAL EXPENSES 0. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 86,147. OTHER PROFESSIONAL FEES: PROGRAM SERVICE EXPENSES 1,201,335. MANAGEMENT AND GENERAL EXPENSES 80,864. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 1,282,199. FORM 990, PART XI, LINE 9: NET CHANGE IN TEMPORARILY RESTRICTED NET ASSETS OF FOUNDATION -23,256.