2023-11-10T08:34:21-06:00 2022-12-31 450250958 EIDE BAILLY LLP 18081 BURT ST STE 200 OMAHA NE 680224722 990 2022-01-01 420860039 STEWART MEMORIAL COMMUNITY HOSPITAL STEW 7124644200 1301 W MAIN LAKE CITY IA 51449 JIM HENKENIUS CHIEF FINANCIAL OFFICER 7124644200 2023-11-09 1 JIM HENKENIUS 999009999 1 WENDY R COOLEY CPA P01523804 4023302660 2023-11-08 2 AAL1 IAL1 2022 2023-04-26 12:10:37Z JIM HENKENIUS 1301 W MAIN LAKE CITY IA 51449 33385706 0 X WWW.STEWARTMEMORIAL.ORG X 1958 IA TO PROVIDE A COMPLETE CONTINUUM OF HEALTHCARE SERVICES TO THE PEOPLE OF LAKE CITY AND THE SURROUNDING COMMUNITIES WITHOUT REGARD FOR ABILITY TO PAY AND WITHOUT DISCRIMINATION. 9 8 295 25 0 0 5517883 1570104 28231969 30859895 160814 122303 468025 527477 34378691 33079779 0 0 0 0 18562464 19632256 0 0 265930 11460353 12550524 30022817 32182780 4355874 896999 35673353 46408156 19311672 29542013 16361681 16866143 X STEWART MEMORIAL COMMUNITY HOSPITAL IS COMMITTED TO QUALITY HEALTH AND WELLNESS FOR YOU AND YOUR FAMILY. 0 0 18032844 16212544 STEWART MEMORIAL COMMUNITY HOSPITAL IS A 25 BED CRITICAL ACCESS HOSPITAL THAT ALSO OPERATES 4 RURAL HEALTH CLINICS. STEWART MEMORIAL EMPLOYS 12 FAMILY PRACTICE PROVIDERS, 1 BEHAVIORAL HEALTH PROVIDER, 2 GENERAL SURGEONS AND 2 CRNAS. BESIDES OFFERING 24/7 EMERGENCY ROOM SERVICES, STEWART MEMORIAL ALSO PROVIDES GENERAL RADIOLOGY, CT SCANS, ULTRASOUND, MOBILE MRI, NUCLEAR SCANS, LABORATORY, BLOOD ADMINISTRATION, CARDIAC REHABILITATION, EKGS, RESPIRATORY THERAPY, PHYSICAL THERAPY, OCCUPATIONAL THERAPY, SPEECH THERAPY, OPERATING ROOM, PHARMACY, INFUSIONS AND OBSTETRICS. DURING 2022, STEWART MEMORIAL HAD 1,006 ACUTE PATIENT DAYS, 2,328 EMERGENCY ROOM VISITS, 1,410 OPERATING ROOM PROCEDURES AND 35,923 CLINIC ENCOUNTERS. 6588642 7251946 STEWART MEMORIAL COMMUNITY HOSPITAL OWNS AND OPERATES RURAL HEALTH CLINICS IN THE COMMUNITIES OF LAKE CITY, GOWRIE, LAKE VIEW AND ROCKWELL CITY. WE EMPLOY 15 PROVIDERS WHICH ARE COMPOSED OF PHYSICIANS, PHYSICIAN ASSISTANTS AND NURSE PRACTITIONERS, THEY PROVIDE MEDICAL PROFESSIONAL SERVICES TO MEMBERS OF THESE COMMUNITIES AND SURROUNDING AREAS IN A DESIGNATED HEALTH PROFESSIONAL SHORTAGE AREA. 2038853 4502641 THE LABORATORY DEPARTMENT PROVIDES INPATIENT, OUTPATIENT AND EMERGENCY TESTING FOR PATIENTS OF STEWART MEMORIAL COMMUNITY HOSPITAL. IT ALSO PROVIDE SERVICES TO THE MCCRARY-ROST CLINIC IN LAKE CITY. REAGENT AND SALARY COSTS OF PERSONNEL ACCOUNT FOR THE MAJORITY OF THE DEPARTMENT'S EXPENSES. 1397443 2892764 THE OPERATING AND RECOVERY ROOMS DEPARTMENT PROVIDE GENERAL SURGICAL AND ORTHOPEDIC PROCEDURES ALONG WITH PROCEDURES FOR ENT, CATARACT AND PODIATRY. THE SUPPLIES USED IN SUCH PROCEDURES ACCOUNT FOR A LARGE PORTION OF EXPENSES. 1397443 2892764 28057782 1 1 0 1 0 0 0 0 0 0 1 0 0 1 1 1 1 0 0 0 0 0 0 0 1 0 1 1 0 0 1 0 0 0 0 0 0 1 0 0 0 0 0 0 0 0 0 0 1 36 0 1 295 1 0 0 0 0 0 0 0 0 0 0 0 0 X 9 8 0 1 0 0 1 1 1 1 1 0 0 1 1 1 1 1 1 1 0 0 X JIM HENKENIUS CFO 7124644200 1301 W MAIN STREET LAKE CITY IA 51449 DR SUSAN HORNBACK MEDICAL COUNSEL 40.00 X 946422 0 34329 DEREK DUNCAN D.O. 40.00 X 754255 0 41494 JOSH SMITH D.O. 40.00 X 572416 0 20085 RONALD CHENEY D.O. 40.00 X 478404 0 40521 JAMES LEWIS D.O. 40.00 X 236957 0 36340 JEREMY JOHNSON ARNP 40.00 X 228031 0 14650 JIM HENKENIUS CFO 40.00 X 167968 0 39291 CHADRIC DIETRICH BOARD CHAIR 2.00 X X 0 0 0 THERESA HILDRETH VICE CHAIR 2.00 X X 0 0 0 BRADLEY LANE VICE CHAIR THRU 04/22 2.00 X X 0 0 0 JORDAN LIETZ SECRETARY 2.00 X X 0 0 0 SCOTT KLUVER TREASURER 2.00 X X 0 0 0 JENNIFER LANE DIRECTOR 1.00 X 0 0 0 SCOTT NESBITT DIRECTOR 1.00 X 0 0 0 MARY LAUVER DIRECTOR 1.00 X 0 0 0 STACY COREY DIRECTOR 1.00 X 0 0 0 SHEILA BERGER DIRECTOR THRU 04/22 1.00 X 0 0 0 CARMEN HOOD DIRECTOR THRU 04/22 1.00 X 0 0 0 CYNTHIA CARSTENS CEO 40.00 X 0 0 0 3384453 0 226710 21 0 1 1 MEDICAL SOLUTIONS LLC 13609 CALIFORNIA STREET OMAHA NE 68154 STAFFING SERVICES 304065 WAPITI MEDICAL STAFFING 107 FLYNN DRIVE SUITE 600 MILBANK SD 57252 ER COVERAGE 259210 SHARED MEDICAL SERVICES INC 209 LIMESTONE PASS COTTAGE GROVE WI 53551 MOBILE MRI SERVICES 205215 LOCUM TENENSCOM LLC 2575 NORTHWINDS PARKWAY ALPHARETTA GA 30009 ER & OBSTETRICS COVERAGE 200736 BARTON & ASSOCIATES INC 300 JUBILEE DRIVE BOSTON MA 01960 OB NURSING & RHC PROVIDERS COVERAGE 178388 6 38585 1479876 51643 1570104 ANCILLARY SERVICES 621400 15582948 15582948 RURAL HEALTH CLINICS 621400 7251946 7251946 LABORATORY 621400 4502641 4502641 OPERATING & RECOVERY ROOMS 621400 2892764 2892764 340B PROGRAM REVENUE 621400 367682 367682 261914 261914 30859895 74673 74673 313711 0 313711 313711 313711 350747 293438 9679 57309 -9679 47630 47630 2310 38585 2810 -500 -500 CAFETERIA SALES 900099 214266 214266 214266 33079779 30859895 0 649780 X 1188010 980751 207259 39277 39277 14754303 13282401 1279852 192050 338402 306466 31936 2351203 1886697 453041 11465 961061 856292 91007 13762 454160 454160 108052 108052 107747 107747 22180 22180 3497705 3010342 472645 14718 133441 108712 5161 19568 1356759 1283623 70322 2814 728385 669174 59211 418485 418485 154982 111667 43204 111 40007 2605 37402 1556394 1429873 126521 183191 31204 151987 MEDICAL SUPPLIES 3117232 3117232 BAD DEBT 431549 431549 MISCELLANEOUS 145797 40519 94746 10532 DUES & SUBSCRIPTIONS 94458 50913 42635 910 32182780 28057782 3859068 265930 2852583 142413 2487581 1831007 300861 225492 2958069 2631291 96351 93334 417595 438443 44361 42962 59245658 25101733 21724427 34143925 2301498 2811562 2490027 4047727 35673353 46408156 3980235 5194132 240000 1228856 12306187 24162571 1556394 185310 19311672 29542013 X 14481898 14909428 1879783 1956715 16361681 16866143 35673353 46408156 896999 -392537 0 X 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 3957 3957 0 PART II-B, LINE 1: STEWART MEMORIAL COMMUNITY HOSPITAL PAID DUES TO THE AMERICAN HOSPITAL ASSOCATION AND THE IOWA HOSPITAL ASSOCIATION. A PORTION OF THE DUES WERE USED FOR LOBBYING ACTIVITIES. 123913 123913 14452672 4673934 9778738 35002858 20427799 14575059 9666215 9666215 34143925 OTHER RECEIVABLE 3682815 INVESTMENT IN CAPTIVE 78773 ESTIMATED 3RD PARTY SETTLEMENTS 286139 4047727 DEFERRED COMPENSATION LIABILITIES 185310 185310 X 32258503 -392537 2810 -389727 32648230 431549 431549 33079779 31754041 2810 2810 31751231 431549 431549 32182780 PART X, LINE 2: THE HOSPITAL ACCOUNTS FOR UNCERTAINTIES IN ACCOUNTING FOR INCOME TAX ASSETS AND LIABILITIES USING GUIDANCE INCLUDED IN FINANCIAL ACCOUNTING STANDARDS BOARD (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, 2022 AND 2021, THE HOSPITAL HAD NO UNCERTAIN TAX POSITIONS ACCRUED. PART XI, LINE 2D - OTHER ADJUSTMENTS: FUNDRAISING EXPENSES 2,810. PART XI, LINE 4B - OTHER ADJUSTMENTS: PROVISION FOR UNCOLLECTIBLE ACCOUNTS 431,549. PART XII, LINE 2D - OTHER ADJUSTMENTS: FUNDRAISING EXPENSES 2,810. PART XII, LINE 4B - OTHER ADJUSTMENTS: PROVISION FOR UNCOLLECTIBLE ACCOUNTS 431,549. TRIVIA ON THE GREENS 40895 38585 2310 300 500 960 550 500 40895 38585 2310 300 500 960 550 500 2810 -500 1 1 X 1 X 1 X 100.000000000000 0 1 0 1 1 177 77991 0 77991 0.00250 4072958 3972736 100222 0.00320 177 4150949 3972736 178213 0.00570 11 4846 83747 13122 70625 0.00220 4 20 154290 0 154290 0.00490 5 45 18987 0 18987 0.00060 20 4911 257024 13122 243902 0.00770 20 5088 4407973 3985858 422115 0.01340 1 3589 0 3589 0.00010 1 2210 0 2210 0.00010 2 5799 5799 0.00020 1 431549 0 11266917 11214742 52175 X 1 1 1 1 STEWART MEMORIAL COMMUNITY HOSPITAL 1301 WEST MAIN STREET LAKE CITY IA 51449 WWW.STEWARTMEMORIAL.ORG 130029H X X X X STEWART MEMORIAL COMMUNITY HOSPITAL 1 0 0 1 X X X X X X X X 21 1 0 1 1 X WWW.STEWARTMEMORIAL.ORG X X 1 21 1 WWW.STEWARTMEMORIAL.ORG 0 1 X 200.000000000000 100.000000000000 X X X 1 1 X X X 1 X WWW.STEWARTMEMORIAL.ORG X WWW.STEWARTMEMORIAL.ORG X WWW.STEWARTMEMORIAL.ORG X X X X X X 1 X 0 X X X X 1 X 0 0 STEWART MEMORIAL COMMUNITY HOSPITAL PART V, SECTION B, LINE 5: STEWART MEMORIAL COMMUNITY HOSPITAL, IN CONJUNCTION WITH CALHOUN COUNTY PUBLIC HEALTH DEVELOPED A SURVEY MONKEY QUESTIONNAIRE TO GET INPUT FROM COMMUNITY MEMBERS. THE QUESTIONNAIRE WAS DISTRIBUTED THROUGHOUT THE SMCH SERVICE AREA TO VARIOUS ORGANIZATIONS INCLUDING PUBLIC HEALTH, SCHOOLS, OTHER HEALTH CARE PROVIDERS AND LOCAL BUSINESSES ALONG WITH EMPLOYEES OF THE HOSPITAL AND ITS AUXILIARY. STEWART MEMORIAL COMMUNITY HOSPITAL PART V, SECTION B, LINE 6B: CALHOUN COUNTY PUBLIC HEALTH STEWART MEMORIAL COMMUNITY HOSPITAL PART V, SECTION B, LINE 7D: A HARD COPY OF THE SURVEY WAS PRINTED AND DISTRIBUTED THROUGHOUT OUR SERVICE AREA INCLUDING THE LOCAL LIBRARY. STEWART MEMORIAL COMMUNITY HOSPITAL PART V, SECTION B, LINE 11: FOUR TOPICS WERE IDENTIFIED IN THE ASSESSMENT - 1) IMPROVE ACCESS TO QUALITY HEALTH SERVICES & SUPPORTS; 2) HEALTH EDUCATION AND INFORMATION RESOURCES; 3) HEALTHY LIVING; 4) HEALTH EQUITY AND SOCIAL DETERMINANTS OF HEALTH. THE FIRST TOPIC HAD 6 GOALS AND A FEW OBJECTIVES UNDER EACH. THE GOALS ARE TO REDUCE THE RATE OF CANCER DIAGNOSIS IN CALHOUN COUNTY, INCREASE THE USE OF CARE COORDINATION TO ASSIST WITH NAVIGATION THROUGH HEALTH CARE INFORMATION AND SERVICES, INCREASE ACCESS AND REFERRALS TO SHELTER SERVICES FOR VICTIMS OF ABUSE, VIOLENCE, OR SEX; INCLUDING INDIVIDUALS WITH DISABILITIES, REDUCE THE NUMBER OF REPORTED POOR MENTAL HEALTH DAYS TO IMPROVE QUALITY OF LIFE FOR CALHOUN COUNTY INDIVIDUALS AND FAMILIES, INCREASE AVAILABLE AND AFFORDABLE TRANSPORTATION SERVICES IN CALHOUN COUNTY, AND INCREASE THE AVAILABILITY OF SUBSTANCE ABUSE SUPPORT GROUPS FOR INDIVIDUALS AND FAMILIES. THE FIRST GOAL, REDUCE THE RATE OF CANCER DIAGNOSIS IN CALHOUN COUNTY, HAS 1 OBJECTIVE. THE OBJECTIVE IS TO INCREASE PREVENTATIVE BEHAVIORS IN PERSONS AT HIGH RISK FOR CANCER TO REDUCE CANCER RELATED DEATHS FROM 25 IN 2020 TO 15 IN 2025.THE SECOND GOAL, INCREASE THE USE OF CARE COORDINATION TO ASSIST WITH NAVIGATION THROUGH HEALTH CARE INFORMATION AND SERVICES, HAS 2 OBJECTIVES - INCREASE IDENTIFICATION OF INDIVIDUALS WITH MULTIPLE CARE CONDITIONS NEEDING REFERRAL FOR CARE COORDINATION TO INCREASE ACCESS AND FOLLOW UP FOR NEEDED SERVICES FROM CARE COORDINATION REFERRALS AND TO DEVELOP A TOOL TO TRACK HOME CARE REFERRALS AND FOLLOW UP. THE TARGET VALUE OF THE 1ST OBJECTIVE IS 50 INDIVIDUALS. THE 2ND OBJECTIVE IS TO DEVELOP A TOOL TO TRACK HOME CARE REFERRALS AND FOLLOW UP FROM THE BASELINE VALUE OF 0% TO 100%.THE 3RD GOAL, INCREASE ACCESS AND REFERRALS TO SHELTER SERVICES FOR VICTIMS OF ABUSE, VIOLENCE OR SEX; INCLUDING INDIVIDUALS WITH DISABILITIES, HAS ONE OBJECTIVE AND ONE STRATEGY. THE OBJECTIVE IS TO INCREASE THE IDENTIFICATION OF VICTIMS OF INTIMATE PARTNER VIOLENCE WITH REFERRALS TO COMMUNITY SERVICES. CURRENT VALUE IS 46 WITH A TARGET OF 60 BY 2025.THE 4TH GOAL, REDUCE THE NUMBER OF REPORTED POOR MENTAL HEALTH DAYS TO IMPROVE QUALITY OF LIFE FOR CALHOUN COUNTY INDIVIDUALS, HAS 1 OBJECTIVE. THE OBJECTIVE IS TO INCREASE KNOWLEDGE AND THE BENEFITS OF MENTAL HEALTH SERVICES FOR INDIVIDUALS WITH MENTAL HEALTH ISSUES AND THEIR FAMILIES SO THEY CAN MANAGE THEIR MENTAL HEALTH ON A DAILY BASIS AND RECEIVE APPROPRIATE SUPPORT DECREASING THE NUMBER OF REPORTED POOR MENTAL HEALTH DAYS. CURRENT BASELINE VALUE IS 3.6 DAYS, AND THE TARGET IS <3 DAYS BY 2025.THE FIFTH GOAL, INCREASE AVAILABLE AND AFFORDABLE TRANSPORTATION SERVICES IN CALHOUN COUNTY, HAS ONE OBJECTIVE. THE OBJECTIVE IS TO INCREASE THE NUMBER OF RESOURCES FROM 2 (MIDAS AND MCO MEDICAL TRANSPORTATION) TO A MINIMUM OF 3 RESOURCES BY 2025. THE SIXTH GOAL FOR IMPROVING ACCESS TO QUALITY HEALTH SERVICES AND SUPPORTS IS TO INCREASE THE AVAILABILITY OF SUBSTANCE ABUSE SUPPORT GROUPS FOR INDIVIDUALS AND FAMILIES. THE OBJECTIVE IS TO INCREASE THE NUMBER OF AA/ALANON/NA GROUPS FROM 2 IN 2020 TO 4 IN 2025. THE SECOND TOPIC, HEALTH EDUCATION AND INFORMATION RESOURCES HAS 4 GOALS. THE GOALS ARE TO REDUCE THE STD RATES IN CALHOUN COUNTY, INCREASE THE NUMBER OF FAMILIES RECEIVING FAMILY FOUNDATION SERVICES, IMPROVE ACCESS TO QUALITY HEALTH SERVICES AND SUPPORTS AND TO DECREASE THE PERCENTAGE OF FOOD INSECURITY IN CALHOUN COUNTY.THE OBJECTIVE OF THE FIRST GOAL, REDUCE STD RATES IN CALHOUN COUNTY, IS TO INCREASE KNOWLEDGE OF PREVENTATIVE BEHAVIORS RELATED TO SEXUALLY TRANSMITTED INFECTIONS TO REDUCE THE NUMBER OF INFECTIONS FROM 236 IN 2020 TO 200 IN 2025. THE 2ND GOAL, INCREASE THE NUMBER OF FAMILIES RECEIVING FAMILY FOUNDATION SERVICES, HAS ONE OBJECTIVE WITH FIVE STRATEGIES. THE OBJECTIVE IS TO INCREASE THE NUMBER OF FAMILIES AT 125% OF THE POVERTY RATE OR HIGHER. THE BASELINE VALUE IS 68% WITH A TARGET VALUE OF 78%. THE THIRD GOAL, IMPROVE ACCESS TO QUALITY HEALTH SERVICE AND SUPPORTS, HAS 1 OBJECTIVE. THE OBJECTIVE IS TO REDUCE THE NUMBER OF PERSONS THAT ARE UNABLE TO OBTAIN OR DELAY OBTAINING NECESSARY PRIMARY CARE OR MENTAL HEALTH CARE BY 5% BY 2025 FROM THE BASELINE VALUE OF 24%. THE FINAL GOAL IN THIS TOPIC, DECREASE THE PERCENTAGE OF FOOD INSECURITY IN CALHOUN COUNTY, ALSO HAS 1 OBJECTIVE. THE OBJECTIVE IS TO DISSEMINATE INFORMATION TO COMMUNITIES HOW TO ACCESS EMERGENCY FEEDING SITES/FOOD AND NUTRITION SITES TO REDUCE FOOD INSECURITY. THE CURRENT BASELINE VALUE IS 12% WITH A TARGET VALUE OF 6% BY 2025. THE THIRD TOPIC, HEALTHY LIVING, HAS 2 GOALS AND 2 OBJECTIVES. THE GOALS ARE TO REDUCE ADULT OBESITY RATES IN CALHOUN COUNTY AND INCREASE ACCESS TO EXERCISE OPPORTUNITIES IN CALHOUN COUNTY.THE OBJECTIVE OF GOAL 1, REDUCE ADULT OBESITY RATES IN CALHOUN COUNTY, IS TO INCREASE EDUCATIONAL AND SUPPORT PROGRAMS AVAILABLE IN CALHOUN COUNTY TO ADDRESS ADULT OBESITY AND REDUCE THE RATE. THERE IS A TARGET VALUE OF 30% FOR THIS OBJECTIVE. THE SECOND GOAL, INCREASE ACCESS TO EXERCISE OPPORTUNITIES IN CALHOUN COUNTY, HAS 1 OBJECTIVE. THE OBJECTIVE IS TO INCREASE ACCESS TO LOCATIONS OR PROGRAMS THAT SUPPORT INCREASE PHYSICAL ACTIVITY FOR CALHOUN COUNTY RESIDENTS. THE FOURTH AND FINAL TOPIC, HEALTH EQUITY AND SOCIAL DETERMINANTS OF HEALTH, HAS 2 GOALS. THESE GOALS ARE TO IMPROVE INCOME AND INCOME DISTRIBUTION AND TO IMPROVE HOUSING OPTIONS IN CALHOUN COUNTY.THE FIRST GOAL, IMPROVE INCOME AND INCOME DISTRIBUTION, HAS 1 OBJECTIVE - TO DECREASE INCOME INEQUALITY. BASED ON THE 2020 BASELINE YEAR, THE BASELINE VALUE IS 0.45 (GINI INDEX) WITH A TARGET VALUE OF 0.3 IN 2025. THE SECOND GOAL, IMPROVE HOUSING OPTIONS IN CALHOUN COUNTY, HAS 1 OBJECTIVE, THE OBJECTIVE IS TO DECREASE THE PERCENTAGE OF INDIVIDUALS LIVING IN INADEQUATE HOUSING. THE GOAL IS TO DECREASE TO A VALUE OF 15%. STEWART MEMORIAL COMMUNITY HOSPITAL PART V, SECTION B, LINE 13H: STEWART MEMORIAL COMMUNITY HOSPITAL IS COMMITTED TO PROVIDING NECESSARY HOSPITAL CARE AND TREATMENT TO ALL PATIENTS REGARDLESS OF THEIR ABILITY TO PAY. ANY PATIENT WHO HAS RECEIVED SERVICES AND WHO FALLS BELOW CERTAIN INCOME AND ASSET LIMITS MAY BE ELIGIBLE FOR HOSPITAL CARE FREE OF CHARGE, OR AT A REDUCTION OF OUR ESTABLISHED CHARGES.THE HOSPITAL USES THE POVERTY INCOME GUIDELINES ISSUED BY THE COMMUNITY SERVICE ADMINISTRATION AS A BASIS FOR ELIGIBILITY CRITERIA FOR DISCOUNTED CARE. THESE GUIDELINES ARE ADJUSTED ANNUALLY BASED ON INCREASES IN THE CONSUMER PRICE INDEX. SUPPORT TO GRANT FINANCIAL ASSISTANCE MUST BE FULLY DOCUMENTED IN OUR FILES. SMCH HAS A SPREADSHEET BASED ON THE FEDERAL POVERTY GUIDELINES TO DETERMINE DISCOUNTED CARE. THE SPREADSHEET ALSO ACCOUNTS FOR THE FAMILY SIZE IN DETERMINING ELIGIBILITY. FOR THOSE APPLYING, IF THEIR INCOME FALLS BETWEEN 225-250% OF THE GUIDELINES, 75% OF THE PATIENT'S BILL IS FORGIVEN; IF THE INCOME IS BETWEEN 300-400% OF THE GUIDELINES, 50% IS FORGIVEN; IF THE INCOME AT 450% OF THE GUIDELINES, 35% IS FORGIVEN; IF THE INCOME IS AT 500% OF THE GUIDELINES, 25% IS FORGIVEN. THE NEW 501(R) REGULATIONS AND POLICIES THAT TOOK EFFECT JANUARY 1, 2016 WILL BE MADE AVAILABLE TO EVERY PATIENT AND ALSO MADE AVAILABLE ON OUR WEBSITE. 4 1 - MCCRARY-ROST CLINIC 1351 WEST MAIN STREET LAKE CITY IA 51449 HEALTH CLINIC 2 - GOWRIE CLINIC 1800 MAIN GOWRIE IA 50543 HEALTH CLINIC 3 - LAKE VIEW CLINIC 1160 3RD STREET LAKE VIEW IA 51540 HEALTH CLINIC 4 - ROCKWELL CITY CLINIC 505 EAST LAKE STREET ROCKWELL CITY IA 50579 HEALTH CLINIC PART I, LINE 3C: NOT APPLICABLE PART I, LINE 6A: STEWART MEMORIAL COMMUNITY HOSPITAL'S COMMUNITY BENEFIT REPORT IS NOT PREPARED BY A RELATED ORGANIZATION. PART I, LINE 7: STEWART MEMORIAL COMMUNITY HOSPITAL USED THE WORKSHEETS PROVIDED IN THE IRS INSTRUCTIONS FOR SCHEDULE H IN ADDITION TO THE INTERNAL COST ACCOUNTING SYSTEM. PART I, LINE 7G: THERE ARE NO COSTS ATTRIBUTABLE TO A PHYSICIAN CLINIC INCLUDED ON LINE 7G. PART I, LN 7 COL(F): THE BAD DEBT EXPENSE INCLUDED ON FORM 990, PART IX, LINE 25, COLUMN (A), BUT SUBTRACTED FOR PURPOSES OF CALCULATING THE PERCENTAGE IN THIS COLUMN IS $431,549. PART II, COMMUNITY BUILDING ACTIVITIES: ONE MEMBER OF THE ORGANIZATION IS A VOLUNTEER MEMBER ON THE LOCAL BETTERMENT ORGANIZATION. AT THE MONTHLY MEETINGS, THEY USE THEIR TIME TO PROMOTE THE SERVICES AND WELLNESS ACTIVITIES THE HOSPITAL PROVIDES. CURRENT AND PROSPECTIVE BUSINESSES UNDERSTAND THE VARIOUS HEALTH SERVICES THAT ARE MADE AVAILABLE TO THEM AND THEIR EMPLOYEES. OTHER STAFF MEMBERS SERVE ON VARIOUS PROJECT TEAMS IN OUR SURROUNDING COMMUNITIES TO REPRESENT THE HOSPITAL AND BUILD COMMUNITY AWARENESS. THE COO AND AN EMPLOYED PHYSICIAN ARE MEMBERS OF THE CALHOUN COUNTY BOARD OF HEALTH. STEWART MEMORIAL COMMUNITY HOSPITAL WORKED IN CONJUNCTION WITH CALHOUN COUNTY PUBLIC HEALTH TO COMPLETE A COMMUNITY NEEDS ASSESSMENT AND DEVELOP A HEALTH IMPROVEMENT PROGRAM. PART III, LINE 2: CONSISTENT WITH THE HOSPITAL'S MISSION, CARE IS PROVIDED TO PATIENTS REGARDLESS OF THEIR ABILITY TO PAY. THEREFORE, THE HOSPITAL HAS DETERMINED IT HAS PROVIDED IMPLICIT PRICE CONCESSIONS TO UNINSURED PATIENTS AND PATIENTS WITH UNINSURED BALANCES (DEDUCTIBLES AND COINSURANCE). THE IMPLICIT PRICE CONCESSIONS INCLUDED IN ESTIMATING THE TRANSACTION PRICE REPRESENT THE DIFFERENCE BETWEEN AMOUNTS BILLED TO PATIENTS AND THE AMOUNTS THE HOSPITAL EXPECTS TO COLLECT BASED ON COLLECTION HISTORY WITH THOSE PATIENTS. PART III, LINE 4: THE ORGANIZATION'S FINANCIAL STATEMENTS DO NOT CONTAIN A SPECIFIC FOOTNOTE DESCRIBING BAD DEBT. HOWEVER, PAGES 9 THROUGH 12 OF THE ATTACHED AUDITED FINANCIAL STATEMENTS INCLUDE FOOTNOTES TITLED "PATIENT RECEIVABLES" "PATIENT SERVICE REVENUE, AND "CHARITY CARE." PART III, LINE 8: SINCE THERE IS NO MEDICARE SHORTFALL CALCULATED FOR 2022, THERE IS NO SHORTFALL THAT IS TREATED AS COMMUNITY BENEFIT. THE 2022 FILED MEDICARE COST REPORT WAS USED TO DETERMINE THE ALLOWABLE COSTS. PART III, LINE 9B: COLLECTION POLICY:PATIENTS ARE ADMITTED INTO THE HOSPITAL COMPUTER SYSTEM WITH APPROPRIATE FINANCIAL INFORMATION INCLUDING INSURANCE INFORMATION AND ARE ASSIGNED A FINANCIAL CLASS (F/C) USED TO SEGREGATE ACCOUNTS IN ACCOUNTS RECEIVABLE (A/R) BY PAYER TYPE. PATIENTS WHO ARE MINORS ARE ADMITTED WITH THE PARENT WHO CARRIES THE INSURANCE COVERAGE AS THE RESPONSIBLE PARTY OR IF NO INSURANCE, THE PARENT WHO BROUGHT THE CHILD IN FOR CARE IS LISTED AS GUARANTOR.THE BUSINESS OFFICE WILL SEND AN ITEMIZED STATEMENT OF CHARGES TO ALL PATIENTS WHO REQUEST A COPY. INSURANCE COMPANIES ARE BILLED ELECTRONICALLY THROUGH THE USE OF EMDEON SOFTWARE WHENEVER POSSIBLE. ONCE THE INSURANCE COMPANY HAS PROCESSED THE CLAIM AND PAID ITS ENTIRE SHARE OR IF THE PATIENT DOESN'T HAVE INSURANCE, THEY WILL BE ASSIGNED A FINANCIAL CLASS OF SELF-PAY. SMCH ALLOWS PATIENTS TO SET UP PAYMENT ARRANGEMENTS FOLLOWING THIS SCHEDULE USING CHECK, MONEY ORDER, MASTERCARD OR VISA:BALANCE IS: MINIMUM PAYMENT:UNDER $250 $ 25.00$251-$500 $ 50.00$501-$1000 $ 100.00$1001 - ABOVE $ 150.00THESE LIMITS ARE SET TO INSURE BALANCES ARE PAID IN FULL WITH 18 MONTHS IF AT ALL POSSIBLE. WHEN THE PATIENT IS ASSIGNED A FINANCIAL CLASS OF P, THE ACCOUNT IS SENT TO MED-PLAN FOR EARLY OUT PRE-COLLECT PROCESSING. THE FIRST STATEMENT FROM MED-PLAN IS MAILED OUT ON DAY 1 WHEN THEY RECEIVE THE ACCOUNT AND THEN AGAIN AT 30 DAYS. ACCOUNTS THAT DO NOT MAKE PAYMENT ARRANGEMENTS OR MAKE PAYMENTS FROM THE LETTER CAMPAIGN AFTER 45 DAYS ARE MOVED INTO A TELEPHONE CAMPAIGN. THE TELEPHONE CAMPAIGN MAKES 3 ATTEMPTS OVER 15 DAYS TO SECURE PAYMENT IN FULL OR A SCHEDULED PAYMENT PLAN. IF RESOLUTION ATTEMPTS FAIL AND MED-PLAN IS UNABLE TO RESOLVE AN ACCOUNT BECAUSE (1) IT IS IMPOSSIBLE TO REACH A PATIENT BY TELEPHONE, OR (2) THE PATIENT HAS FAILED TO COOPERATE IN ESTABLISHING A PAYMENT PLAN, OR (3) THE PATIENT HAS FAILED TO HONOR AN ESTABLISHED PLAN BY NOT MAKING SATISFACTORY PAYMENT WITHIN 60-90 DAYS, A FINAL NOTICE WILL BE SENT TO THE PATIENT. ACCOUNTS UNPAID OR ARRANGEMENTS NOT MADE AT THIS POINT IN THE BILLING PROCESS ARE DETERMINED UNCOLLECTIBLE. IF NO PAYMENT IN ALLOWABLE TIME IS RECEIVED, ACCOUNTS ARE ELECTRONICALLY SENT TO A COLLECTION AGENCY. IN THE EVENT OF PARTIAL PAYMENT, A DETERMINATION ON AN INDIVIDUAL BASIS IS MADE AS TO STOP OR PROCEED WITH THE COLLECTION AGENCY. PART VI, LINE 2: SMCH COLLABORATES WITH THE COUNTY HEALTH DEPARTMENT IN ASSESSING THE HEALTH CARE NEEDS OF THE COMMUNITIES THEY SERVE. SMCH ALSO EVALUATES USAGE DATA THROUGH THE IOWA HOSPITAL ASSOCIATION TO SEE THE PRIMARY MEDICAL DIAGNOSIS IN THEIR COMMUNITIES. PART VI, LINE 3: SMCH HAS A PATIENT ACCOUNTS MANAGER AS WELL AS A SOCIAL WORKER ON STAFF THAT IDENTIFY PATIENTS THAT MAY BE ELIGIBLE FOR ASSISTANCE OR QUALIFY FOR CHARITY CARE. THEY ASSIST THE PATIENT WITH AVAILABLE OPTIONS AND/OR THE NECESSARY PAPERWORK. PART VI, LINE 4: THE SERVICE AREA IS A 35 MILE RADIUS SURROUNDING THE SMCH COMMUNITY. THIS AREA CONSISTS OF MANY SMALL, RURAL COMMUNITIES THAT ARE AGRICULTURAL BASED. THE PATIENT BASE CONSISTS OF A LARGE MEDICARE POPULATION. PART VI, LINE 5: SMCH PROVIDES THE COMMUNITIES WITH LABORATORY WELLNESS TESTING AND EDUCATIONAL PROGRAMS ON PROMOTING HEALTHY LIFESTYLES. THEY PROVIDE CARE TO THE INDIGENT REGARDLESS OF THEIR ABILITY TO PAY. THE BOARD OF DIRECTORS ARE REPRESENTED BY THE VARIOUS COMMUNITIES THEY SERVE.THE HOSPITAL HAS ALSO JOINED WITH THE COUNTY DEPARTMENT OF HEALTH IN ESTABLISHING A PROGRAM CALLED "CARING HANDS CLOSET." CARING HANDS CLOSET IS A PROGRAM FOR EXPECTING MOTHERS AND NEW MOTHERS TO EARN POINTS TOWARDS BABY ITEMS BY ATTENDING THEIR DOCTOR APPOINTMENTS AND/OR EDUCATIONAL PROGRAMS. SMCH PROVIDES MONTHLY LABORATORY WELLNESS TESTING AND EDUCATIONAL PROGRAMS BI-MONTHLY. PART VI, LINE 6: SMCH IS NOT PART OF AN AFFILIATED HEALTH CARE SYSTEM. PART VI, LINE 7, REPORTS FILED WITH STATES IA X X X 0 0 0 0 0 0 0 0 0 DR SUSAN HORNBACK MEDICAL COUNSEL 786068 0 159640 0 714 0 8933 0 25396 0 980751 0 0 0 DEREK DUNCAN D.O. 628456 0 125417 0 382 0 6214 0 35280 0 795749 0 0 0 JOSH SMITH D.O. 551041 0 21375 0 0 0 0 0 20085 0 592501 0 0 0 RONALD CHENEY D.O. 477690 0 0 0 714 0 5441 0 35080 0 518925 0 0 0 JAMES LEWIS D.O. 236957 0 0 0 0 0 3818 0 32522 0 273297 0 0 0 JEREMY JOHNSON ARNP 227782 0 0 0 249 0 6900 0 7750 0 242681 0 0 0 JIM HENKENIUS CFO 167254 0 0 0 714 0 4711 0 34580 0 207259 0 0 0 FORM 990, PART VII, LINE 5: CYNTHIA CARSTENS, CEO, RECEIVED COMPENSATION FROM UNITYPOINT HEALTH, AN UNRELATED ENTITY, WHICH PROVIDES MANAGEMENT SERVICES TO ITS CLIENTS. MS. CARSTENS RECEIVED COMPENSATION AND BENEFITS IN THE AMOUNT OF $226,681 FOR HER SERVICES DURING THE CALENDAR YEAR 2022. HER COMPENSATION IS REPORTED IN PART IX, LINE 11A. JODI HENKENIUS ORGANIZATION'S EMPLOYEE & SPOUSE OF JIM HENKENIUS, CFO 39277 EMPLOYEE WAGES 0 FORM 990, PART VI, SECTION A, LINE 1A THE EXECUTIVE COMMITTEE SHALL HAVE POWER TO TRANSACT ALL REGULAR BUSINESS OF THE CORPORATION DURING THE INTERIM BETWEEN MEETINGS OF THE BOARD, PROVIDED THAT ANY ACTION WHICH IT MAY TAKE SHALL NOT CONFLICT WITH THE POLICIES AND EXPRESS WISHES OF THE BOARD. FORM 990, PART VI, SECTION A, LINE 3 UNITYPOINT HEALTH AND STEWART MEMORIAL COMMUNITY HOSPITAL HAVE AN AGREEMENT FOR ADMINISTRATIVE SERVICES. UNITYPOINT HEALTH PROVIDED THE SERVICES OF CYNTHIA CARSTENS, CEO. FORM 990, PART VI, SECTION A, LINE 6 MEMBERS OF THE CORPORATION SHALL BE THOSE PERSONS, CORPORATIONS, OR ASSOCIATIONS WHO HAVE CONTRIBUTED THE SUM OF ONE HUNDRED DOLLARS ($100) OR MORE TO THE CORPORATION TO FURTHER THE OBJECTIVES OF THE CORPORATION, WHICH MEMBERSHIP SHALL BE LIFELONG AND NON-TRANSFERABLE. FORM 990, PART VI, SECTION A, LINE 7A MEMBERS SHALL HAVE THE RIGHTS TO ELECT AND REMOVE DIRECTORS. FORM 990, PART VI, SECTION A, LINE 7B MEMBERS SHALL HAVE THE RIGHTS TO APPROVE AMENDMENTS TO THE ARTICLES OF INCORPORATION, APPROVE ANY MERGER, CONSOLIDATION, OR DISSOLUTION OF THE CORPORATION, TO VOTE ON ANY OTHER MATTER SUBMITTED TO THE MEMBERS BY THE BOARD OF DIRECTORS, AND TO VOTE ON ANY MATTER THAT IS REQUIRED TO RECEIVE MEMBER APPROVAL UNDER IOWA LAW. FORM 990, PART VI, SECTION B, LINE 11B THE FORM 990 WILL BE PROVIDED ELECTRONICALLY TO THE BOARD OF DIRECTORS AND REVIEWED BY THE CEO AND CFO PRIOR TO SUBMISSION. FORM 990, PART VI, SECTION B, LINE 12C EACH BOARD MEMBER SIGNS A CONFLICT OF INTEREST FORM ANNUALLY STATING THAT THEY WILL ABSTAIN FROM VOTING AND DISCUSSING ITEMS FOR WHICH THEY HAVE A CONFLICT OF INTEREST. FORM 990, PART VI, SECTION B, LINE 15A THE BOARD OF DIRECTORS MEET ANNUALLY TO DISCUSS THE TERMS OF THE CEO'S CONTRACT. THEY USE DATA FROM THE LATEST IOWA HOSPITAL ASSOCIATION SALARY SURVEY. FORM 990, PART VI, SECTION C, LINE 19 THE ORGANIZATION DOES NOT MAKE ITS GOVERNING DOCUMENTS, CONFLICT OF INTEREST POLICY, OR FINANCIAL STATEMENTS AVAILABLE TO THE PUBLIC. FORM 990, PART IX, LINE 11G ONCOLOGY FEES: PROGRAM SERVICE EXPENSES 493. MANAGEMENT AND GENERAL EXPENSES 0. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 493. RADIOLOGIST FEES: PROGRAM SERVICE EXPENSES 576,762. MANAGEMENT AND GENERAL EXPENSES 0. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 576,762. EMERGENCY ROOM FEES: PROGRAM SERVICE EXPENSES 561,640. MANAGEMENT AND GENERAL EXPENSES 0. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 561,640. OTHER FEES FOR SERVICES: PROGRAM SERVICE EXPENSES 1,871,447. MANAGEMENT AND GENERAL EXPENSES 472,645. FUNDRAISING EXPENSES 14,718. TOTAL EXPENSES 2,358,810. FORM 990, PART XII, LINE 2C: THE BOARD OF DIRECTORS ASSUMES THE RESPONSIBILITY FOR OVERSIGHT OF THE AUDIT OF THE FINANCIAL STATEMENTS AND SELECTION OF THE INDEPENDENT ACCOUNTANT. THIS PROCESS HAS NOT CHANGED FROM THE PREVIOUS YEAR.