2022-06-29T14:51:14-05:00 2021-08-31 476097913 SEIM JOHNSON LLP 18081 BURT STREET SUITE 200 OMAHA NE 680224722 990 2020-09-01 470537192 NIOBRARA VALLEY HOSPITAL NIOB 4025692451 PO BOX 118 LYNCH NE 68746 KELLY KALKOWSKI ADMINISTRATOR 4025692451 2022-06-29 1 KELLY KALKOWSKI 999009999 MEGAN L KOZIOL P01544037 4023302660 2 AAL1 IAL1 2020 2022-09-23 18:48:47Z KELLY KALKOWSKI PO BOX 118 LYNCH NE 68746 4629640 0 X WWW.NVHCARES.ORG X 1975 NE TO PROVIDE ACUTE HOSPITAL SERVICES. 7 7 33 7 0 0 288289 1637445 2488372 2871920 14134 109275 9800 11000 2800595 4629640 650 1040 0 0 1441473 1511228 0 0 0 1407881 1455193 2850004 2967461 -49409 1662179 5178994 6478410 2689810 2288361 2489184 4190049 X TO DELIVER EXCELLENT, COMPASSIONATE AND PERSONALIZED HEALTHCARE FOR THE PEOPLE WE SERVE. 0 0 2382716 1040 2882920 NIOBRARA VALLEY HOSPITAL PROVIDES QUALITY HEALTH CARE REGARDLESS OF RACE, CREED, COLOR, NATIONAL ORIGIN, AGE, SEX, HANDICAP OR ABILITY TO PAY. ALL PERSONS ADMITTED OR TREATED IN THE OUTPATIENT AREA OF THE HOSPITAL SHALL HAVE EQUAL CARE AND TREATMENT AND FULL USE OF ALL HOSPITAL FACILITIES AND SERVICES. REIMBURSEMENT FOR SERVICES RENDERED IS CRITICAL TO THE OPERATION AND STABILITY OF NIOBRARA VALLEY HOSPITAL, BUT IT IS RECOGNIZED THAT NOT ALL INDIVIDUALS POSSESS THE ABILITY TO PURCHASE ESSENTIAL MEDICAL SERVICES. FURTHER, OUR MISSION IS TO SERVE THE COMMUNITY WITH RESPECT TO PROVIDING HEALTH CARE SERVICES AND HEALTH CARE EDUCATION.THEREFORE, IN KEEPING WITH THIS HOSPITAL'S COMMITMENT TO SERVING ALL MEMBERS OF ITS COMMUNITY: 1.) NIOBRARA VALLEY HOSPITAL MUST BE RESPONSIVE TO THE CHANGING NEEDS OF THE HEALTH CARE INDUSTRY, THE COMMUNITY AND ITS OWN NEEDS. AS NIOBRARA VALLEY HOSPITAL ADAPTS TO THOSE CHANGES, THE HOSPITAL IS DETERMINED TO REMAIN AN INSTITUTION WHERE THE CARE THAT IS RENDERED IS COMPASSIONATE AS WELL AS COMPETENT. 2.) NIOBRARA VALLEY HOSPITAL IS AND SHALL CONTINUE TO BE, A FAMILY CENTERED, COMMUNITY ORIENTED HOSPITAL, OFFERING COMPREHENSIVE MEDICAL SERVICES. 3.) THE STATED PHILOSOPHIES OF NIOBRARA VALLEY HOSPITAL SHALL PERMEATE ALL ACTIVITIES OF THE HOSPITAL AND MOST IMPORTANTLY, THAT OF PATIENT CARE. 4.) THE QUALITY OF PATIENT CARE SHALL CONTINUE TO RECEIVE PRIMARY EMPHASIS AT NIOBRARA VALLEY HOSPITAL. 5.) NIOBRARA VALLEY HOSPITAL SHALL PRUDENTLY UTILIZE ITS RESOURCES THROUGH EFFICIENT AND EFFECTIVE MANAGEMENT; CAREFUL CONSIDERATION SHALL BE GIVEN TO THE COST/BENEFIT RELATIONSHIP OF DELIVERING SERVICES WITHOUT COMPROMISING THE QUALITY OF CARE. 6.) NIOBRARA VALLEY HOSPITAL SHALL PROVIDE AN ATMOSPHERE CONDUCIVE TO THE DEVELOPMENT OF EFFECTIVE WORKING RELATIONSHIPS AMONG THE VARIOUS ELEMENTS NECESSARY BOTH INSIDE AND OUTSIDE THE HOSPITAL FAMILY. THIS FAMILY INCLUDES THE BOARD OF DIRECTORS, MEDICAL STAFF, ADMINISTRATION, EMPLOYEES, THE COMMUNITY, AUXILIARY AND FRIENDS OF THE HOSPITAL. 7.) NIOBRARA VALLEY HOSPITAL SHALL OFFER CONTINUING EDUCATION PROGRAMS AND SERVICES FOR ITS MEDICAL STAFF AND HOSPITAL PERSONNEL. NIOBRARA VALLEY HOSPITAL ALSO SHALL STRIVE TO PROVIDE ITS PATIENTS AND THE COMMUNITY WITH EDUCATION IN HEALTH RELATED MATTERS. 8.) NIOBRARA VALLEY HOSPITAL SHALL PLAN FOR ITS FUTURE. TO THIS END, THE HOSPITAL SHALL COOPERATE WITH OTHER HEALTH CARE PROVIDERS WITHIN THE HEALTH CARE DELIVERY SYSTEM IN A MANNER CONSISTENT WITH ITS STATED PHILOSOPHY. 9.) NIOBRARA VALLEY HOSPITAL SHALL SERVE AS A CATALYST WITHIN THE COMMUNITY TO IDENTIFY THE COMMUNITY'S HEALTH CARE NEEDS, AND SHALL DETERMINE THE LEVEL OF APPROPRIATE PARTICIPATION BY THE HOSPITAL IN MEETING SUCH NEEDS. 10.) NIOBRARA VALLEY HOSPITAL WILL CONSIDER WHERE THE NEED AND/OR THE INDIVIDUAL'S ABILITY TO PAY COEXIST AND OFFER FREE CARE TO THOSE WHO QUALIFY. 11.) NIOBRARA VALLEY HOSPITAL SERVED 100 INPATIENT DAYS, 159 SWING AND RESPITE CARE DAYS AND 215 EMERGENCY ROOM VISITS. 12.) NIOBRARA VALLEY HOSPITAL PROVIDES CARE TO PERSONS COVERED BY GOVERNMENTAL PROGRAMS AT COST. CHARITY CARE IS ALSO PROVIDED THROUGH MANY REDUCED PRICE SERVICES AND FREE PROGRAMS OFFERED THROUGHOUT THE YEAR BASED UPON ACTIVITIES AND SERVICES WHICH NIOBRARA VALLEY HOSPITAL BELIEVES WILL SERVE A BONA FIDE COMMUNITY HEALTH NEED. THESE INCLUDE: 1.) OPERATED A FULL TIME EMERGENCY ROOM THAT PROVIDES MEDICAL SERVICES TO ALL MEMBERS OF THE PUBLIC REGARDLESS OF ABILITY TO PAY. 2.) A VARIETY OF HEALTH CARE MATERIAL WAS DISTRIBUTED TO FOSTER HEALTH EDUCATION IN THE COMMUNITY. 3.) PROVIDED ASSISTANCE TO MEDICARE PATIENTS WITH RESPECT TO THEIR BENEFITS UNDER THE MEDICARE PROGRAM. 4.) EXCESS REVENUE IS REINVESTED IN NEW EQUIPMENT WHICH UPGRADES TECHNOLOGY WHICH WILL ALLOW NIOBRARA VALLEY HOSPITAL TO GUARANTEE THE AVAILABILITY OF AFFORDABLE HEALTH CARE FOR OUR SERVICE AREA. 2382716 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 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 20 0 1 33 1 0 0 0 0 0 0 0 0 0 0 0 0 X 7 7 0 1 0 0 0 0 0 1 1 0 0 1 1 1 1 1 1 1 0 0 X MARTHA NELSON 4025692451 PO BOX 118 LYNCH NE 68746 BREE ALMGREN NURSE PRACTIONER 36.00 X 173080 0 5344 KELLI SMITH NURSE PRACTIONER 36.00 X 159914 0 1012 DEBRA HANZLIK DIRECTOR OF NURSING 40.00 X 115145 0 3015 MARTHA NELSON CFO 5.00 X 17745 0 0 MARY SCHOENEFELD PRESIDENT 0.30 X X 0 0 0 CHRIS MINARIK VICE PRESIDENT 0.30 X X 0 0 0 BRAD JERMAN SECRETARY 0.30 X X 0 0 0 STEVE LIEWER TREASURER 0.30 X X 0 0 0 LARRY HIATT MEMBER 0.30 X 0 0 0 LAREE PRITCHETT MEMBER 0.30 X 0 0 0 TRACY BIRMEIER MEMBER 0.30 X 0 0 0 KELLY KALKOWSKI ADMINISTRATOR 40.00 X 0 0 0 465884 0 9371 3 0 1 1 FAITH REGIONAL HEALTH SERVICES 1500 KOENIGSTEIN AVENUE PO BOX 869 NORFOLK NE 687020869 MANAGEMENT SERVICES 106640 FUSION MEDICAL STAFFING 11808 GRANT ST STE 100 OMAHA NE 68164 STAFFING SERVICES 106195 2 1620435 17010 1637445 MEDICARE/MEDICAID PAYM 624100 2193220 2193220 PATIENT SERVICE REVENU 624100 664602 664602 OTHER REVENUE 624100 12719 12719 LIFELINE REVENUE 624100 1379 1379 2871920 14120 14120 11000 0 11000 11000 11000 95155 0 95155 95155 95155 4629640 2882920 0 109275 X 1040 1040 17745 17745 1328817 1206856 121961 9740 8449 1291 53474 39009 14465 101452 90120 11332 103730 103730 511 511 33462 33462 435657 384533 51124 3163 3163 353683 174084 179599 93806 85332 8474 11246 10642 604 542 490 52 109932 99442 10490 41419 37447 3972 MEDICAL SUPPLIES 192456 192456 BAD DEBT 44000 44000 MISCELLANEOUS 20672 7099 13573 DUES & SUBSCRIPTIONS 10914 1717 9197 2967461 2382716 584745 0 250 250 3434191 3874394 140300 506063 52828 59494 13516 12027 4299346 2679070 281116 1620276 1256793 405906 5178994 6478410 217776 459070 300500 2171534 1829291 2689810 2288361 X 2485240 4186105 3944 3944 2489184 4190049 5178994 6478410 X 1662179 38686 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 1 511 511 0 PART II-B, LINE 1: NIOBRARA VALLEY HOSPITAL PAYS MEMBERSHIP DUES TO THE NEBRASKA HOSPITAL ASSOCIATION. THE PORTION OF THE DUES PAID THAT ARE USED FOR LOBBYING PURPOSES IS $511. 2183004 1066822 1116182 2109937 1605843 504094 6405 6405 0 1620276 INTEREST IN NIOBRARA VALLEY HOSPITAL FOUNDATION 405906 405906 REFUNDABLE ADVANCE 776750 ESTIMATED THIRD-PARTY PAYOR SETTLEMENTS 1052541 1829291 X 4624326 38686 38686 4585640 44000 44000 4629640 2923461 0 2923461 44000 44000 2967461 PART X, LINE 2: THE HOSPITAL IS A NOT-FOR-PROFIT CORPORATION AS DESCRIBED IN SECTION 501(C)(3) OF THE INTERNAL REVENUE CODE. THE HOSPITAL HAS RECEIVED A DETERMINATION LETTER THAT IT IS EXEMPT FROM FEDERAL INCOME TAXES ON RELATED INCOME PURSUANT TO SECTION 501(A) OF THE INTERNAL REVENUE CODE. THE INTERNAL REVENUE SERVICE HAS ESTABLISHED STANDARDS TO BE MET TO MAINTAIN TAX EXEMPT STATUS. IN GENERAL, SUCH STANDARDS REQUIRE THE HOSPITAL TO MEET A COMMUNITY BENEFIT STANDARD AND COMPLY WITH VARIOUS LAWS AND REGULATIONS. THE HOSPITAL ACCOUNTS FOR UNCERTAINTIES IN ACCOUNTING FOR INCOME TAX ASSETS AND LIABILITIES USING GUIDANCE INCLUDED IN FASB ASC TOPIC 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 AUGUST 31, 2021, THE HOSPITAL HAD NO UNCERTAIN TAX POSITIONS ACCRUED. PART XI, LINE 2D - OTHER ADJUSTMENTS: CHANGE IN INTEREST IN NIOBRARA VALLEY HOSPITAL FOUNDATION 38,686. PART XI, LINE 4B - OTHER ADJUSTMENTS: PROVISION FOR UNCOLLECTIBLE ACCOUNTS 44,000. PART XII, LINE 4B - OTHER ADJUSTMENTS: PROVISION FOR UNCOLLECTIBLE ACCOUNTS 44,000. 1 1 X 1 X 0 0 0 1 1 691 691 0.00020 147079 122081 24998 0.00860 147770 122081 25689 0.00880 5380 1495 3885 0.00130 1089160 545567 543593 0.18590 1040 1040 0.00040 1095580 547062 548518 0.18760 1243350 669143 574207 0.19640 1 44000 0 1994994 1975241 19753 X 1 1 1 1 NIOBRARA VALLEY HOSPITAL PO BOX 118 LYNCH NE 68746 WWW.NVHCARES.ORG 050001 X X X NIOBRARA VALLEY HOSPITAL 1 0 0 1 X X X X X X X X 18 1 1 1 1 X WWW.NVHCARES.ORG/COMMUNITY-HEALTH-NEEDS-ASSESSMENT.HTML X 1 18 1 WWW.NVHCARES.ORG/COMMUNITY-HEALTH-IMPROVEMENT-PLAN.HTML 0 1 X 100.000000000000 X X 1 1 X X X X 1 X WWW.NVHCARES.ORG/FINANCIAL-ASSISTANCE.HTML X WWW.NVHCARES.ORG/FINANCIAL-ASSISTANCE.HTML X WWW.NVHCARES.ORG/FINANCIAL-ASSISTANCE.HTML X X X X X X 1 X 0 X X X X 1 X 0 0 NIOBRARA VALLEY HOSPITAL PART V, SECTION B, LINE 3J: THROUGH THE PROCESSES OF COMPLETING THE COMMUNITY HEALTH NEEDS ASSESSMENT AND ASSESSING THE RESOURCES AVAILABLE TO THIS ORGANIZATION AND SURROUNDING COMMUNITIES, IT WAS DETERMINED THAT THE MOST SIGNIFICANT NEED TO BE ADDRESSED BY NIOBRARA VALLEY HOSPITAL IS THE PHYSICAL WELLNESS OF THE COMMUNITIES, PRIMARILY IN THE AREAS OF DIABETES AND BLOOD PRESSURE. BY ADDRESSING THESE TWO HEALTH ISSUES, NIOBRARA VALLEY HOSPITAL HAS THE OPPORTUNITY TO VASTLY DECREASE THE DEATH RATE ATTRIBUTED TO HEART DISEASE. NIOBRARA VALLEY HOSPITAL PART V, SECTION B, LINE 5: THE NORTH CENTRAL DISTRICT HEALTH DEPARTMENT (NCDHD) ADMINISTERED AN ONLINE SURVEY VIA SURVEY MONKEY TO GAIN THE PERSPECTIVE OF THE NCDHD COMMUNITY REGARDING HEALTH, COMMUNITY HEALTH ISSUES, AND QUALITY OF LIFE. A TOTAL OF 16 COMMUNITY MEMBERS PARTICIPATED IN THIS SURVEY REPRESENTING THE COMMUNITY. NIOBRARA VALLEY HOSPITAL PART V, SECTION B, LINE 6A: ANTELOPE MEMORIAL HOSPITAL, NELIGH, NE (ANTELOPE COUNTY) AVERA CREIGHTON HOSPITAL, CREIGHTON, NE (KNOX COUNTY) AVERA SAINT ANTHONY'S HOSPITAL, O'NEILL, NE (HOLT COUNTY) OSMOND GENERAL HOSPITAL, OSMOND, NE (PIERCE COUNTY) PLAINVIEW COMMUNITY HOSPITAL, PLAINVIEW, NE (PIERCE COUNTY) WEST HOLT MEMORIAL HOSPITAL, ATKINSON, NE (HOLT COUNTY) BROWN COUNTY HOSPITAL, AINSWORTH, NE (BROWN COUNTY) CHERRY COUNTY HOSPITAL, VALENTINE, NE (CHERRY COUNTY) ROCK COUNTY HOSPITAL, BASSETT, NE (BROWN COUNTY) NIOBRARA VALLEY HOSPITAL PART V, SECTION B, LINE 6B: NORTH CENTRAL DISTRICT HEALTH DEPARTMENT (NCDHD) THE EVERGREEN ASSISTED LIVING FACILITY COTTONWOOD VILLA ASSISTED LIVING FACILITY GOOD SAMARITAN SOCIETY - ATKINSON PREGANCY RESOURCE CENTER FINISH LINE CHIROPRACTIC COUNSELING AND ENRICHMENT CENTER / BUILDING BLOCKS REGION 4 BEHAVIORAL HEALTH SYSTEM CENTRAL NEBRASKA COMMUNITY ACTION PARTNERSHIP NORTHEAST NEBRASKA COMMUNITY ACTION PARTNERSHIP NORTHWEST NEBRASKA COMMUNITY ACTION PARTNERSHIP NORTHSTAR SERVICES NCDHD BOARD OF HEALTH NORTH CENTRAL COMMUNITY CARE PARTNERSHIP AREA SUBSTANCE ABUSE PREVENTION COALITION O'NEILL CHAMBER OF COMMERCE CENTRAL NEBRASKA ECONOMIC DEVELOPMENT HOLT COUNTY ECONOMIC DEVELOPMENT KNOX COUNTY ECONOMIC DEVELOPMENT NELIGH ECONOMIC DEVELOPMENT PIERCE COUNTY ECONOMIC DEVELOPMENT UNIVERSITY OF NEBRASKA LINCOLN EXTENSION OFFICE, BROWN-ROCK-KEYA -PAHA COUNTY EWING PUBLIC SCHOOL LYNCH PUBLIC SCHOOL O'NEILL PUBLIC SCHOOL BOARD O'NEILL MINISTERIAL ASSOCATION WEST HOLT HEALTH MINISTRIES O'NEILL LIONS CLUB O'NEILL ROTARY CLUB MITCHELL EQUIPMENT - O'NEILL, NE FAMILY SERVICE CHILD CARE FOOD PROGRAM NIOBRARA VALLEY HOSPITAL PART V, SECTION B, LINE 11: NIOBRARA VALLEY HOSPITAL ADDRESSED THE COMMUNITY NEEDS OF PHYSICAL WELLNESS OF THOSE PATIENTS DIAGNOSED WITH DIABETES BY INCREASING THE NUMBER OF PEOPLE WHO ARE GETTING SCREENED FOR DIABETES. NIOBRARA VALLEY HOSPITAL ADDRESSED THE COMMUNITY NEEDS OF PHYSICAL WELLNESS OF THOSE PATIENT DIAGNOSED WITH HIGH BLOOD PRESSURE BY INCREASING THE PROPORTION OF ADULTS WHO HAVE HAD THEIR BLOOD PRESSURE MEASURED.OTHER NEEDS IDENTIFIED BY THE CHNA THAT ARE NOT ADDRESSED IN NIOBRARA VALLEY HOSPITAL'S IMPLEMENTATION STRATEGY ARE: 1.) AGING POPULATION & RELATED ISSUES, 2.) MENTAL WELLNESS AND 3.) SUBSTANCE ABUSE. NIOBRARA VALLEY HOSPITAL DOES NOT POSSESS THE NECESSARY RESOURCES AND/OR EXPERTISE TO ADDRESS THESE NEEDS. THESE NEEDS WILL BE ADDRESSED BY EXISTING COMMUNITY ASSETS THAT HAVE BEEN IDENTIFIED IN THE LOCAL HEALTH DEPARTMENT PLAN. NIOBRARA VALLEY HOSPITAL PART V, SECTION B, LINE 15E: THE FINANCIAL ASSISTANCE POLICY STATES THE FOLLOWING: PATIENTS WHO BELIEVE THEY MAY QUALIFY FOR FINANCIAL ASSISTANCE UNDER THIS POLICY ARE REQUIRED TO SUBMIT AN APPLICATION ON THE HOSPITAL'S FINANCIAL ASSISTANCE APPLICATION FORM DURING THE APPLICATION PERIOD. NIOBRARA VALLEY HOSPITAL PART V, SECTION B, LINE 16J: THE FINANCIAL ASSISTANCE PROGRAM IS PUBLICIZED ON THE MONTHLY STATEMENTS SENT TO ALL PATIENTS. IT IS ALSO INCLUDED ON THE PAYMENT POLICY WHICH IS SENT TO ALL PATIENTS WITH THEIR FIRST BILLING STATEMENT. THE FINANCIAL ASSISTANCE POLICY SUMMARY IS SENT TO THOSE PATIENTS WHOSE ACCOUNTS ARE NOT CURRENT. 1 1 - NVMC - SPENCER 108 WEST EVANS STREET SPENCER NE 68777 CLINIC PART I, LINE 3C: AT NIOBRARA VALLEY HOSPITAL, THERE IS NO DISCOUNTED CARE. EITHER THE PATIENT QUALIFIES FOR FREE CARE OR HE/SHE DOES NOT. ELIGIBILITY FOR FREE CARE IS BASED OFF 100% OF FEDERAL POVERTY GUIDELINES. PART I, LINE 6A: NIOBRARA VALLEY HOSPITAL'S COMMUNITY BENEFIT REPORT IS PREPARED BY THE STAFF OF NIOBRARA VALLEY HOSPITAL. 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 $44,000. PART II, COMMUNITY BUILDING ACTIVITIES: NIOBRARA VALLEY HOSPITAL DOES NOT HAVE ANY COMMUNITY BUILDING ACTIVITIES. PART III, LINE 2: GENERALLY, PATIENTS WHO ARE COVERED BY THIRD-PARTY PAYORS ARE RESPONSIBLE FOR RELATED DEDUCTIBLES AND COINSURANCE, WHICH VARY IN AMOUNT. THE HOSPITAL PROVIDES SERVICES TO UNINSURED PATIENTS, AND OFFERS THOSE UNINSURED PATIENTS A DISCOUNT, EITHER BY POLICY OR LAW, FROM STANDARD CHARGES. THE HOSPITAL ESTIMATES THE TRANSACTION PRICE FOR PATIENTS WITH DEDUCTIBLES AND COINSURANCE AND FROM THOSE WHO ARE UNINSURED BASED ON HISTORICAL EXPERIENCE AND CURRENT MARKET CONDITIONS. THE INITIAL ESTIMATE OF THE TRANSACTION PRICE IS DETERMINED BY REDUCING THE STANDARD CHARGE BY ANY CONTRACTUAL ADJUSTMENTS, DISCOUNTS AND IMPLICIT PRICE CONCESSIONS. SUBSEQUENT CHANGES TO THE ESTIMATE OF THE TRANSACTION PRICE ARE RECORDED AS ADJUSTMENTS TO PATIENT SERVICE REVENUE IN THE PERIOD OF CHANGE. FOR THE YEAR ENDED AUGUST 31, 2021, NO SIGNIFICANT ADJUSTMENTS TO REVENUE WERE RECOGNIZED DUE TO CHANGES IN ESTIMATES OF IMPLICIT PRICE CONCESSIONS FOR PERFORMANCE OBLIGATIONS SATISFIED IN PRIOR YEARS. SUBSEQUENT CHANGES THAT ARE DETERMINED TO BE THE RESULT OF AN ADVERSE CHANGE IN THE PATIENT'S ABILITY TO PAY ARE RECORDED AS BAD DEBT EXPENSE. PART III, LINE 3: NIOBRARA PROVIDES PATIENT FINANCIAL ASSISTANCE TO PATIENTS WHO ARE FINANCIALLY UNABLE TO PAY FOR THE HEALTHCARE SERVICES THEY RECEIVE. IT IS THE POLICY OF NIOBRARA NOT TO PURSUE COLLECTION OF AMOUNTS DETERMINED TO QUALIFY AS PATIENT FINANCIAL ASSISTANCE. ACCORDINGLY, NIOBRARA DOES NOT REPORT THESE AMOUNTS IN NET PATIENT SERVICE REVENUE OR IN THE PROVISION FOR BAD DEBTS. PART III, LINE 4: THE HOSPITAL'S FINANCIAL STATEMENTS DO NOT CONTAIN A SPECIFIC FOOTNOTE DESCRIBING BAD DEBT. HOWEVER, PAGES 7, 9, AND 10 OF THE ATTACHED FINANCIAL STATEMENTS INCLUDE FOOTNOTES TITLED "PATIENT ACCOUNTS RECEIVABLE, NET", "PATIENT SERVICE REVENUE AND "CHARITY CARE". PART III, LINE 8: NIOBRARA VALLEY HOSPITAL USED THE AUGUST 31, 2021 MEDICARE COST REPORT TO ARRIVE AT MEDICARE ALLOWABLE COSTS. NVH USED WORKSHEETS D-1, D-3, E, E-2 AND E-3 OF THE COST REPORT. IT DOES NOT INCLUDE ALL OF THE MEDICARE REVENUES AND COSTS. IF ALL OF THE MEDICARE REVENUES AND COSTS WERE INCLUDED, THERE WOULD BE A SHORTFALL ON LINE 7. THE SHORTFALL WOULD REPRESENT ACTUAL UNREIMBURSED COSTS INCURRED BY NIOBRARA VALLEY HOSPITAL IN PROVIDING SERVICES TO INDIVIDUALS ELIGIBLE FOR MEDICARE. THE COMMUNITY BENEFITS BECAUSE THE HOSPITAL APPLIES OTHER REVENUES TO COVER THE COSTS OF CARING FOR MEDICARE PATIENTS. PART III, LINE 9B: THE COLLECTION POLICY INCLUDES AN EXPLANATION OF NVH'S CHARITY CARE PROGRAM. THE PROGRAM IS CONSIDERED A "LAST RESORT" FOR PATIENTS MAKING A GENUINE EFFORT TO PAY THEIR BILLS. ALL OTHER AVENUES FOR PAYMENT MUST BE EXHAUSTED (SUCH AS MEDICAID, DISABILITY, KID'S CONNECTION) BEFORE THIS PROGRAM APPLIES. REGULAR COLLECTION EFFORTS WILL BE FOLLOWED UNTIL A DETERMINATION IS MADE FROM A COMPLETED ASSISTANCE APPLICATION THAT A PATIENT QUALIFIES FOR FINANCIAL ASSISTANCE. PART VI, LINE 2: NIOBRARA VALLEY HOSPITAL PARTNERED WITH NORTH CENTRAL DISTRICT HEALTH DEPARTMENT TO GATHER INFORMATION ON THE COMMUNITY NEEDS. IONA RESEARCH WAS HIRED TO TABULATE THE RESULTS. PART VI, LINE 3: AT THE POINT OF ADMISSION, A PATIENT'S INSURED STATUS IS DETERMINED. WHEN BILLING STATEMENTS ARE MAILED, THE COLLECTION POLICY OF NIOBRARA VALLEY HOSPITAL IS ALSO SENT. THE COLLECTION POLICY INCLUDES INFORMATION ON CHARITY CARE AND DETAILS CHARITY CARE APPLICATION INSTRUCTIONS. PART VI, LINE 4: THE FACILITY SERVES BOYD COUNTY AND PORTIONS OF KNOX AND HOLT COUNTIES. THE POPULATION OF THIS AREA IS APPROXIMATELY 2,500 WITH A HIGH CONCENTRATION OF ELDERLY AND LOW INCOME FAMILIES. PART VI, LINE 5: NIOBRARA VALLEY HOSPITAL SPONSORS EDUCATIONAL SPEAKERS FOR COMMUNITY GROUPS. NIOBRARA VALLEY HOSPITAL OFFERS FREE BLOOD PRESSURE CHECKS AND PROVIDES PERSONNEL FOR COMMUNITY HEALTH SCREENINGS. PART VI, LINE 6: NIOBRARA VALLEY HOSPITAL IS NOT PART OF AN AFFILIATED HEALTH CARE SYSTEM. PART VI, LINE 7 NIOBRARA VALLEY HOSPITAL DOES NOT FILE A COMMUNITY BENEFIT REPORT WITH ANY STATES. 0 0 0 0 0 0 0 0 0 BREE ALMGREN NURSE PRACTIONER 172330 0 750 0 0 0 2407 0 2937 0 178424 0 0 0 KELLI SMITH NURSE PRACTIONER 159164 0 750 0 0 0 0 0 1012 0 160926 0 0 0 PART I, LINE 3 MR. KALKOWSKI WAS PAID BY AN UNRELATED ORGANIZATION, FAITH REGIONAL HEALTH SERVICES, FOR HIS POSITION AS ADMINISTRATOR. FAITH REGIONAL HEALTH SERVICES USES AN INDEPENDENT COMPENSATION CONSULTANT, FORM 990 OF OTHER ORGANIZATIONS, WRITTEN EMPLOYMENT CONTRACT, COMPENSATION SURVEY AND APPROVAL BY THE BOARD IN DETERMINING HIS COMPENSATION. SCHEDULE J, PART II MR. KALKOWSKI WAS PAID BY AN UNRELATED ORGANIZATION, FAITH REGIONAL HEALTH SERVICES, FOR HIS POSITION AS ADMINISTRATOR. TOTAL COMPENSATION AND BENEFITS PAID TO MR. KALKOWSKI FOR 2020 WERE $103,730. FORM 990, PART VI, SECTION A, LINE 3 NIOBRARA VALLEY HOSPITAL HAS A SERVICE CONTRACT WITH FAITH REGIONAL HEALTH SERVICES FOR MANAGEMENT SERVICES. FORM 990, PART VI, SECTION B, LINE 11B THE GOVERNING BOARD REVIEWS THE FORM 990 AND RELATED SCHEDULES BEFORE THE FORM IS SUBMITTED TO THE IRS. THE FORM 990 IS ALSO REVIEWED BY THE ADMINISTRATOR AND THE CFO. FORM 990, PART VI, SECTION B, LINE 12C UPON COMPLETION OF EACH FISCAL YEAR, DIRECTORS AND MANAGEMENT EMPLOYEES (RESPONSIBLE PERSONS) ARE REQUIRED TO SUBMIT A SIGNED CONFLICT OF INTEREST DISCLOSURE STATEMENT. RESPONSIBLE PERSONS ARE ALSO REQUIRED TO SUBMIT WRITTEN SIGNED ACKNOWLEDGEMENT AFFIRMING THAT HE OR SHE: 1) HAS RECEIVED AND READ A COPY OF THE CONFLICT OF INTEREST POLICY, 2) AGREES TO COMPLY WITH THIS POLICY AND 3) UNDERSTANDS THAT NIOBRARA VALLEY HOSPITAL IS A CHARITABLE ORGANIZATION. IN ADDITION TO THE ANNUAL DISCLOSURE PROCESS, ALL RESPONSIBLE PERSONS HAVE A DUTY TO IMMEDIATELY DISCLOSE ANY NEW OR MODIFIED FINANCIAL INTEREST OR RELATIONSHIP IN WRITING TO THE EXECUTIVE COMMITTEE CHAIR OR THE ADMINISTRATOR. DISCLOSURES MADE UNDER THIS SHALL BE FORWARDED TO THE EXECUTIVE COMMITTEE FOR EVALUATION AND DECISION REGARDING THE POTENTIAL EXISTENCE OF A CONFLICT OF INTEREST. FORM 990, PART VI, SECTION B, LINE 15A THE NEBRASKA HOSPITAL ASSOCIATION SALARY SURVEY WAS USED FOR COMPARISON. 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 OTHER FEES FOR SERVICE: PROGRAM SERVICE EXPENSES 172,824. MANAGEMENT AND GENERAL EXPENSES 41,219. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 214,043. EMERGENCY ROOM PHYSICIANS: PROGRAM SERVICE EXPENSES 61,575. MANAGEMENT AND GENERAL EXPENSES 0. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 61,575. CONSULTING SERVICES: PROGRAM SERVICE EXPENSES 150,134. MANAGEMENT AND GENERAL EXPENSES 9,905. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 160,039. FORM 990, PART IX, LINE 5: THE HOSPITAL ADMINISTRATOR IS PAID BY FAITH REGIONAL HEALTH SERVICES, AN UNRELATED ENTITY. THE COMPENSATION FOR THIS INDIVIDUAL IS REPORTED ON PART IX, LINE 11A, COLUMN C. FORM 990, PART XI, LINE 9: CHANGE IN INTEREST IN NIOBRARA VALLEY HOSPITAL FOUNDATION 38,686. FORM 990, PART XII, LINE 2C: THE BOARD OF DIRECTORS OF NIOBRARA VALLEY HOSPITAL ASSUMES RESPONSIBILITY FOR OVERSIGHT OF THE AUDIT OF THE FINANCIAL STATEMENTS AND THE SELECTION OF THE INDEPENDENT ACCOUNTANT. THIS PROCESS HAS NOT CHANGED FROM THE PRIOR YEAR.