2022-08-09T15:51:35-05:00 2021-09-30 450250958 EIDE BAILLY LLP 18081 BURT STREET SUITE 200 OMAHA NE 680224722 990 2020-10-01 470468078 JEFFERSON COMMUNITY HEALTH CENTER INC JEFF 4027293351 2200 H STREET PO BOX 277 FAIRBURY NE 68352 CHANCE KLASEK CFO 4027293351 2022-08-05 1 CHANCE KLASEK 999009999 MEGAN L KOZIOL P01544037 4023302660 2022-08-05 3 AAL1 IAL1 2020 2022-09-23 18:48:47Z JEFFERSON COMMUNITY HEALTH & LIFE CHANCE KLASEK 2200 H STREET PO BOX 277 FAIRBURY NE 68352 31212397 0 X HTTP://WWW.JCHEALTHANDLIFE.ORG X 1960 NE INSPIRING HEALTHY LIVING BY PROVIDING EXCEPTIONAL HEALTH AND LIFE SERVICES FOR EVERY PERSON, EVERY TIME. 8 7 295 15 0 0 2396146 4837105 23846246 25932298 247073 132196 164855 145222 26654320 31046821 0 0 0 0 13351917 15149591 0 0 24519 9885858 11986054 23237775 27135645 3416545 3911176 40682105 40230021 16129159 11373908 24552946 28856113 INSPIRING HEALTHY LIVING BY PROVIDING EXCEPTIONAL HEALTH AND LIFE SERVICES FOR EVERY PERSON, EVERY TIME. 0 0 23126446 23422045 JEFFERSON COMMUNITY HEALTH & LIFE OPERATES A 17 BED CRITICAL ACCESS ACUTE CARE HOSPITAL. JEFFERSON COMMUNITY HEALTH & LIFE ALSO OPERATES A FITNESS CENTER, RURAL HEALTH CLINICS, AND PROVIDES HOME HEALTH SERVICES. 1890639 2510253 JEFFERSON COMMUNITY HEALTH & LIFE OPERATES A 40 BED LONG-TERM CARE FACILITY FOR THE RESIDENTS OF JEFFERSON COUNTY AND THE SURROUNDING AREA. 25017085 1 1 0 1 0 0 0 0 0 1 1 0 0 0 1 1 1 0 0 0 0 0 0 0 1 0 1 1 0 0 1 1 0 0 0 0 0 0 0 0 1 0 0 0 0 0 0 0 0 0 0 1 11 0 1 295 1 0 0 0 0 0 1 1 0 0 0 0 0 0 X 8 7 0 0 0 0 1 1 1 1 1 0 0 0 1 1 1 1 1 1 1 0 X CHANCE KLASEK 4027296856 2200 H STREET PO BOX 277 FAIRBURY NE 68352 LINDA BAUER CHAIRMAN 1.00 X X 0 0 0 BRIAN BLOBAUM VICE CHAIRMAN 1.00 X X 0 0 0 SHERI SCHULTIS SECRETARY/TREASURER 1.00 X X 0 0 0 BRIAN SCHEELE MEMBER THRU 12/20 1.00 X 0 0 0 STEPHEN GRIZZLE MEMBER 1.00 X 0 0 0 TREVOR STEINMEYER MEMBER 1.00 X 0 0 0 DR JEFF JOHNSON MEMBER 1.00 X 0 0 0 ROSS BOECKNER MEMBER 1.00 X 0 0 0 GLENDA AUSTIN MEMBER 1.00 X 0 0 0 CHANCE KLASEK CFO 40.00 X 132939 0 24664 BURKE KLINE CEO 40.00 X 109224 0 8400 CRAIG SHUMARD PHYSICIAN 40.00 X 476717 0 41650 RICHARD BLATNY JR PHYSICIAN 40.00 X 452092 0 41650 BRETT WERGIN PHYSICIAN 40.00 X 298991 0 16096 BRANDON BLEICH PHARMACIST 40.00 X 156989 0 21520 REBEKAH KIMBERLIN PHARMACIST 40.00 X 110588 0 19961 1737540 0 173941 15 0 1 1 BECKENHAUER CONSTRUCTION 1901 RIVERSIDE BLVD NORFOLK NE 68701 CONSTRUCTION SERVICES 865508 BRYAN HEALTH 1600 S 48TH STREET LINCOLN NE 68506 MEDICAL SERVICES 391784 CERNER CORPORATION 2800 ROCK CREEK PKWY KANSAS CITY KS 64117 ELECTRONIC HEALTH RECORD SERVICES 391386 MEDHOST 6550 CAROTHERS PARKWAY SUITE 160 FRANKLIN TN 37067 ELECTRONIC HEALTH RECORDS 273110 CHAPPELL ROOFING INC 302 E STREET FAIRBURY NE 68352 CONSTRUCTION SERVICES 194080 13 13293 4662433 161379 4837105 MEDICARE/MEDICAID PAYMENTS 624100 14989266 14989266 PATIENT SERVICE REVENUE 624100 9336977 9336977 340B DRUG PRICING PROGRAM 624100 773403 773403 CEDARWOOD ASSISTED LIVING SVC FEE 623000 540122 540122 CEDARWOOD: EQUITY IN JT VENTURE 623000 217992 217992 74538 74538 25932298 292805 292805 160609 -160609 -160609 -160609 6792 13293 4967 1825 1825 CAFETERIA 722210 143397 143397 143397 31046821 25932298 0 277418 275227 275227 93237 93237 11922138 11338116 564030 19992 399327 379530 19797 1633952 1549154 84798 825710 769207 55047 1456 32666 32666 66778 1897 64881 2441297 2109179 332118 153737 47913 104453 1371 1535155 1427846 106830 479 159814 159814 514774 472910 41864 20078 18839 1239 139577 119582 18774 1221 137118 127442 9676 1542654 1433794 108860 146276 146276 MEDICAL SUPPLIES 3586050 3586050 BAD DEBTS EXPENSE 781984 781984 FOOD EXPENSE 362627 360400 2227 DUES AND SUBSCRIPTIONS 253500 143694 109806 111969 96497 15472 27135645 25017085 2094041 24519 450 450 13526882 7190539 3755258 4148689 407826 399209 347551 144358 34240492 15271882 12383856 18968610 8172221 8043214 1040895 1258887 1047166 76065 40682105 40230021 1913899 2828309 4156049 3917528 1468320 1284781 2308912 0 6281979 3343290 16129159 11373908 X 24336516 28651958 216430 204155 24552946 28856113 40682105 40230021 3911176 391991 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 2044 2044 0 PART II-B, LINE 1: JCH&L PAID DUES TO THE NEBRASKA HOSPITAL ASSOCIATION AND THE AMERICAN HOSPITAL ASSOCIATION. A PORTION OF THE DUES WERE USED FOR LOBBYING ACTIVITIES. 50754 50754 50754 50754 50754 50754 50754 50754 50754 50754 0.00000 1.00000 0.00000 0 0 50943 50943 20813390 11939489 8873901 6760422 3212263 3548159 6615737 120130 6495607 18968610 ACCRUED INTEREST 9224 REFUNDABLE ADVANCES 3218897 ESTIMATED THIRD-PARTY PAYOR SETTLEMENTS - MEDICARE AND MEDICAID 115169 3343290 X 30661795 391991 4967 396958 30264837 781984 781984 31046821 26358628 4967 4967 26353661 781984 781984 27135645 PART V, LINE 4: THE INTENDED USE OF THE HOSPITAL'S ENDOWMENT FUNDS IS TO PROVIDE NURSING SCHOLARSHIPS AND CAPITAL IMPROVEMENTS. PART X, LINE 2: THE HEALTH CENTER IS A NOT-FOR-PROFIT CORPORATION AS DESCRIBED IN SECTION 501(C)(3) OF THE INTERNAL REVENUE CODE AND IS EXEMPT FROM FEDERAL INCOME TAXES ON RELATED INCOME PURSUANT TO SECTION 501(A) OF THE CODE. THE INTERNAL REVENUE SERVICE HAS ESTABLISHED STANDARDS TO BE MET TO MAINTAIN THE HEALTH CENTER'S TAX EXEMPT STATUS. IN GENERAL, SUCH STANDARDS REQUIRE THE HEALTH CENTER TO MEET A COMMUNITY BENEFITS STANDARD AND COMPLY WITH VARIOUS LAWS AND REGULATIONS. THE HEALTH CENTER ACCOUNTS FOR UNCERTAINTIES IN ACCOUNTING FOR INCOME TAX ASSETS AND LIABILITIES USING GUIDANCE INCLUDED IN FASB ASC 740, INCOME TAXES. THE HEALTH CENTER RECOGNIZES THE EFFECT OF INCOME TAX POSITIONS ONLY IF THOSE POSITIONS ARE MORE LIKELY THAN NOT OF BEING SUSTAINED. AT SEPTEMBER 30, 2021, THE HEALTH CENTER HAD NO UNCERTAIN TAX POSITIONS ACCRUED. PART XI, LINE 2D - OTHER ADJUSTMENTS: FUNDRAISING EXPENSES 4,967. PART XI, LINE 4B - OTHER ADJUSTMENTS: PROVISION FOR BAD DEBTS 781,984. PART XII, LINE 2D - OTHER ADJUSTMENTS: FUNDRAISING EXPENSES 4,967. PART XII, LINE 4B - OTHER ADJUSTMENTS: PROVISION FOR BAD DEBTS 781,984. GOLF TOURNAMENT 20085 13293 6792 1440 906 1000 717 904 20085 13293 6792 1440 906 1000 717 904 4967 1825 1 1 X 1 X 1 X 0 1 0 1 1 130000 0 130000 0.00490 2922391 2643073 279318 0.01060 3052391 2643073 409318 0.01550 4938 0 4938 0.00020 12000 0 12000 0.00050 4309718 2801368 1508350 0.05720 4144 0 4144 0.00020 4330800 2801368 1529432 0.05810 7383191 5444441 1938750 0.07360 275 0 275 0.00000 500 0 500 0.00000 775 775 0.00000 1 781984 106350 10187254 10258342 -71088 X 1 1 1 1 JEFFERSON COMMUNITY HEALTH CENTER 2200 H STREET FAIRBURY NE 68352 HTTP://WWW.JCHEALTHANDLIFE.ORG 440001 X X X X JEFFERSON COMMUNITY HEALTH CENTER INC 1 0 0 1 X X X X X X X X X 18 1 0 0 1 X JCHEALTHANDLIFE.ORG/ABOUT/COMMUNITY-HEALTH-NEEDS-ASSESSMENT/ X 1 18 1 JCHEALTHANDLIFE.ORG/ABOUT/COMMUNITY-HEALTH-NEEDS-ASSESSMENT/ 0 1 X 150.000000000000 300.000000000000 1 1 X X X 1 X JCHEALTHANDLIFE.ORG/I-WANT-TO/PAY-MY-BILL/FINANCIAL-ASSISTANCE-POLICY X JCHEALTHANDLIFE.ORG/I-WANT-TO/PAY-MY-BILL/FINANCIAL-ASSISTANCE-POLICY X JCHEALTHANDLIFE.ORG/I-WANT-TO/PAY-MY-BILL/FINANCIAL-ASSISTANCE-POLICY X X X X X X 1 X 0 X X X X 1 X 0 0 JEFFERSON COMMUNITY HEALTH CENTER, INC. PART V, SECTION B, LINE 5: JEFFERSON COMMUNITY HEALTH & LIFE BEGAN ITS THIRD COMMUNITY HEALTH NEEDS ASSESSMENT EARLY IN 2019. JCH&L HAS CONDUCTED FOCUS GROUPS WITH LOCAL ORGANIZATIONS, HELD A COMMUNITY STAKEHOLDERS LUNCHEON, AND REVIEWED STATISTICS MADE AVAILABLE THROUGH PUBLIC HEALTH SOLUTIONS, STATE OF NEBRASKA, US CENSUS, HEALTH PEOPLE 2020, AND WEBSITES SUCH AS COUNTY HEALTH RANKINGS AND WORLD LIFE EXPECTANCY.A COMMUNITY HEALTH NEEDS ASSESSMENT MEETING WAS HELD AT JCH&L WITH REPRESENTATIVES FROM AREA AGENCY PARTNERS, AND MEETINGS WERE CONDUCTED WITH LOCAL COMMUNITY ORGANIZATIONS INCLUDING KIWANIS, ROTARY, OPTIMISTS, AND SENIOR DINERS. A TOTAL OF 96 ATTENDED AND PARTICIPATED IN DISCUSSING COMMUNITY HEALTH NEEDS. JEFFERSON COMMUNITY HEALTH CENTER, INC. PART V, SECTION B, LINE 11: PRIORITIZED NEEDS (AS DETERMINED BY COMMUNITY HEALTH NEEDS ASSESSMENT):1) OBESITY2) SEDENTARY LIFESTYLE3) CHRONIC DISEASES AFFECTED BY OBESITY AND SEDENTARY LIFESTYLE, INCLUDING DIABETES, HEART DISEASE, STROKE, AND CANCERTHE HOSPITAL IS DOING THE FOLLOWING TO ADDRESS THESE NEEDS:*THE SMART MOVES PROGRAM OFFERS A YEAR-LONG CLASS TO TEACH THOSE AT RISK FOR DEVELOPING PRE-DIABETES TO MAKE HEALTHY LIFESTYLE CHOICES. CONTINUE TO EXPAND, PROMOTE, AND INCREASE UTILIZATION OF SMART MOVES LIFESTYLE CHANGE PROGRAM (A PROGRAM OF THE NATIONAL DIABETES PREVENTION PROGRAM).*CONTINUE TO BE AN ACTIVE PART OF COMMUNITY PARTNERSHIPS WORKING TO ESTABLISH WALKABLE COMMUNITY AND WALKING/BIKE TRAILS IN FAIRBURY. ESTABLISH HISTORIC TRAIL WALK. ENHANCE COMMUNITY'S SIDEWALKS AND SAFE WALKING/BIKING ROUTES. ENCOURAGE ACTIVITY LIFESTYLES FOR THOSE OF ALL AGES.*CONTINUE TO PARTNER WITH SCHOOLS AND OTHER YOUTH ORGANIZATIONS, OFFER SIDELINES SERVICES FOR ATHLETES, AND OFFER YOUTH EVENTS AT THE BURKLEY FITNESS CENTER, AND PROVIDE EDUCATION AND INFORMATION AS NEEDED BY AREA SCHOOLS.*CONTINUE SUPPORT OF GO RED FOR WOMEN EVENT IN COMMUNITY (SUPPORT OF AMERICAN HEART ASSOCIATION) AND CONTINUE AS HOST OF THIRD ANNUAL WOMEN'S HEALTH FAIR THIS YEAR AND THE EXPANSION OF THE FAIR.*DETERMINE WAY TO REACH MEN WITH SOME TYPE OF MEN'S HEALTH EVENT.*PROVIDE CONTINUED EDUCATION REGARDING AREAS OF INCREASED RISK IN OUR COUNTRY: OBESITY, SEDENTARY LIFESTYLE, TOBACCO USE, CHRONIC HEALTH CONDITIONS, MENTAL HEALTH.*CONTINUE PARTICIPATION IN MEDICARE ACO & BLUE CROSS PATIENT-CENTERED MEDICAL PROGRAM.*ENHANCE USE OF MEDICARE WELLNESS VISIT PROGRAM.*CONTINUE DEVELOPMENT AND EXPANSION OF CHRONIC CARE COORDINATION PROGRAM.*ENHANCE ABILITY TO TRACK COMMUNITY MEDICAL NEEDS BY MOVING TO ELECTRONIC HEALTH RECORD SYSTEM.*CONSIDER ADDITION OF TELEHEALTH SERVICES FOR PULMONOLOGY, ENDOCRINOLOGY, AND NEPHROLOGY (AREAS WHICH WE DO NOT CURRENTLY HAVE SPECIALISTS).*ADD CERTIFIED PERSONAL TRAINERS TO FITNESS CENTER STAFF.*CONTINUE TO PROVIDE FINANCIAL SUPPORT FOR BURKLEY FITNESS CENTER.*CONSIDER ADDING QUALITY INCENTIVES TO PHYSICIAN CONTRACTS TO ADDRESS PRIORITIZED COMMUNITY NEEDS.NEEDS JEFFERSON COMMUNITY HEALTH & LIFE WILL NOT ADDRESS:THERE WERE NEEDS IDENTIFIED THAT JCH&L DID NOT CHOOSE TO ADDRESS. WHILE THESE NEEDS ARE IMPORTANT TO THE COMMUNITY, THEY WERE NOT CHOSEN BASED ON THE PRIORITIZATION PROCESS.NEEDS WHICH WILL NOT BE ADDRESSED SPECIFICALLY BY JCH&L INCLUDE:*MENTAL HEALTH/SUICIDE. WE WILL CONTINUE TO WORK TO BE GOOD COMMUNITY PARTNERS TO ALL AREA ENTITIES WORKING TOWARD IMPROVING OUR COMMUNITY'S MENTAL HEALTH SERVICES AND SUICIDE PREVENTION AND ASSISTANCE TO THOSE AFFECTED BY SUICIDE.*ALZHEIMER'S DISEASE. WE WILL CONTINUE TO OFFER AN ALZHEIMER'S CAREGIVER'S SUPPORT GROUP AND BE A PART OF THE ANNUAL WALK TO END ALZHEIMER'S, AND WE WILL PROVIDE EDUCATIONAL RESOURCES TO OUR COMMUNITY THROUGH THE ALZHEIMER'S ASSOCIATION. THIS IS THE EXTENT OF WHAT WE FEEL OUR INVOLVEMENT CAN BE AT THIS TIME, SO WE DO NOT INTEND TO NAME THIS AS A MAJOR AREA OF ACTIVITY.*ADDITIONAL SPECIALTIES, ACCESS TO CARE, PREVENTATIVE CARE. JCH&L IS ALWAYS SEEKING POSSIBILITIES FOR ADDITIONAL SPECIALTIES, INCREASED ACCESS TO CARE AND INCREASED PREVENTATIVE CARE TO ADDRESS COMMUNITY NEEDS, AND WILL CONTINUE THIS PROCESS AS A PART OF OUR ONGOING STRATEGIC PLANNING PROCESS. HOWEVER, IT IS NOT NAMED IN OUR PRIORITIES BECAUSE OF THE NEED FOR PERSONNEL AND RESOURCES TO ADDRESS PRIORITY AREAS, EXCEPT FOR A FEW SELECT AREAS WHICH DIRECTLY AFFECT OUR PRIORITY GOALS FOR THE NEXT THREE YEARS.*BULLYING, SUICIDE, DENTAL HEALTH, CHRONIC PAIN. JCH&L WISHES TO BE A GOOD COMMUNITY PARTNER WITH ALL AREA AGENCIES AND PRACTICES WHICH PROVIDE SERVICES IN ALL OF THESE AREAS, WHICH ARE ALL OUTSIDE OF OUR CURRENT OFFERINGS. WE DO NOT INTEND TO NAME THESE AS PRIORITY AREAS AT THE PRESENT TIME.*POVERTY, TRANSPORTATION, DECLINING POPULATION, HOUSING. THESE ARE ONGOING SOCIETAL ISSUES WHICH AFFECT OUR BUSINESSES AND SERVICES. WE WILL CONTINUE TO BE A GOOD COMMUNITY PARTNER ON DEALING WITH THESE ISSUES IN OUR AREA, BUT WE DO NOT INTEND TO MAKE THESE AREAS OUR PRIORITY AREAS OF FOCUS.*INSURANCE/UNINSURED/UNDERINSURED. WE CONTINUE TO SEEK WAYS THAT WE AS AN ORGANIZATION CAN BEST SERVE THOSE WHO ARE UNINSURED OR UNDERINSURED, INCLUDING CHARITY CARE. THESE ARE NOT NAMED AS PRIORITY AREAS AT THIS TIME. 3 1 - GARDENSIDE 200 H STREET FAIRBURY NE 68352 LONG TERM CARE FACILITY 2 - FAIRBURY CLINIC 825 22ND STREET FAIRBURY NE 68352 RURAL HEALTH CLINIC 3 - PLYMOUTH CLINIC 316 N MADISON AVE STE 200 PLYMOUTH NE 684144110 RURAL HEALTH CLINIC PART I, LINE 3C: FEDERAL POVERTY GUIDELINES ARE USED TO DETERMINE ELIGIBILITY FOR PROVIDING FREE AND DISCOUNTED CARE TO LOW INCOME INDIVIDUALS. PART I, LINE 6A: JEFFERSON COMMUNITY HEALTH & LIFE PREPARES ITS OWN COMMUNITY BENEFIT REPORT. PART I, LINE 7: THE HOSPITAL USED THE WORKSHEETS PROVIDED IN THE FORM 990 INSTRUCTIONS TO HELP CALCULATE THE FINANCIAL ASSISTANCE AND CERTAIN OTHER COMMUNITY BENEFITS AT COST. 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 $781,984. PART I, LINE 7: JCH&L REACHED OUT TO THE COMMUNITY IN A VARIETY OF WAYS IN FISCAL YEAR 2021, INCLUDING:I. BENEFITS FOR THE POOR/PUBLIC PROGRAMSA. JCH&L PROVIDED CHARITY CARE IN FISCAL 2021 FOR ALL JCH&L SERVICES TO THOSE WHO MEET THE FEDERAL POVERTY GUIDELINES. THE HOSPITAL BUSINESS OFFICE STAFF MEMBERS FILE INSURANCE CLAIMS FOR PATIENTS. PATIENTS ASSISTED: 35 VALUE: $130,000B. . UNPAID COSTS OF PUBLIC PROGRAMS. MEDICAID SHORTFALL - SHORTFALL BASED ON COSTS: $ 279,318.45C. BAD DEBT: BESIDES OFFICIAL CHARITY CARE, JCH&L WROTE OFF $ 781,984 IN BAD DEBT DURING FISCAL 2021. II. COMMUNITY BENEFIT SERVICESA. COMMUNITY HEALTH EDUCATION AND OUTREACH: HEALTH FAIR - JCH&L PROVIDES EDUCATIONAL BOOTHS, FREE HEALTH SCREENINGS, HANDOUTS, INFORMATION, ETC., AT COMMUNITY EVENTS. IN 2021, WE WERE NOT ABLE TO HOLD A HEALTH FAIR BECAUSE OF COVID-19.SPEAKERS BUREAU - JCH&L STAFF MEMBERS PROVIDE EDUCATIONAL PROGRAMS FOR COMMUNITY ORGANIZATIONS ON A VARIETY OF TOPICS. A TOTAL OF 9 PROGRAMS WERE DONE IN FISCAL 2021. TOTAL INDIVIDUALS REACHED: 375. ESTIMATED COST OF STAFF TIME: $300.SUPPORT GROUPS - JCH&L'S PARKINSON'S SUPPORT GROUP AND ALZHEIMER'S CAREGIVER'S SUPPORT GROUP WERE PUT ON HOLD IN 2020 BECAUSE OF COVID AND WERE NOT RESTARTED PRIOR TO THE END OF FISCAL 2021. IN PREVIOUS YEARS, JCH&L STAFF MEMBERS COORDINATED MEETINGS OF THESE SUPPORT GROUPS, OFFERING ASSISTANCE TO ANYONE INTERESTED IN MORE INFORMATION ABOUT THE DISEASES. JCH&L PROVIDES EDUCATIONAL PROGRAMS FOR EACH OF THESE GROUPS -- INCLUDING SPEAKER'S FEES OR VIDEO TAPE RENTAL FEES, POSTAGE TO SEND OUT MEETING NOTICES, AND REFRESHMENTS. TOTAL NUMBER REACHED: 0. APPROXIMATE COST OF STAFF TIME SPENT: $0. ESTIMATED COST OF POSTAGE: $25 (TO NOTIFY THOSE INTERESTED THAT MEETINGS WERE STILL SUSPENDED.) ESTIMATED OTHER COSTS (MATERIALS, SPEAKER FEES): $0.HEALTH PROMOTION PROGRAMS - JCH&L OFFERS SMOKING CESSATION INFORMATION TO PATIENTS AND THE PUBLIC. EACH INPATIENT WHO IS A SMOKER IS PROVIDED INFORMATION ON SMOKING CESSATION. ESTIMATED NUMBER REACHED: 30; ESTIMATED COST OF PROMOTIONAL MATERIALS PROVIDED: $152.69. ESTIMATED COST OF STAFF TIME TO PREPARE AND DISTRIBUTE: $250.B. COMMUNITY-BASED CLINICAL SERVICES: SCREENINGS AND ONE-TIME OR OCCASIONALLY HELD CLINICS.COMPLETE BLOOD PROFILES - COMPLETE BLOOD PROFILES WERE OFFERED TO OUR COMMUNITY AT A REDUCED RATE IN THE SPRING OF 2021. STAFF TIME IS INCLUDED FOR THE PLANNING, SCHEDULING AND PUBLICIZING, IN ADDITION TO REGISTRATION AND BLOOD DRAW. BLOOD DRAWS ARE OFFERED FOR $45, WHICH IS A TREMENDOUS DISCOUNT FROM THE NORMAL PRICE. ESTIMATED NUMBER REACHED: 55 VALUE OF ESTIMATED STAFF TIME: $750IMMUNIZATION CLINICS - JCH&L COOPERATES WITH BLUE VALLEY COMMUNITY ACTION IN PROVIDING IMMUNIZATION CLINIC FOR CHILDREN TWICE EACH MONTH. JCHC PROVIDES SPACE WHERE IMMUNIZATIONS ARE DONE, NURSING STAFF, THE PATIENT WAITING AREAS, JANITORIAL AND SUPPORT SERVICES, AND STORAGE OF VACCINES IN OUR PHARMACY. NUMBER OF PATIENTS SERVED: 617. TOTAL OF 1,544 VACCINATIONS PROVIDED. ESTIMATED COST OF NURSES PROVIDED BY JCH&L TO GIVE SHOTS: $1,460. C. HEALTH CARE SUPPORT SERVICESCOVID MASKS - OFFERED FREE CLOTH MASKS TO THE COMMUNITY DURING COVID. ESTIMATED COST: $2,000.COVID TESTING - OFFERED FREE COVID TESTING THROUGH TESTNEBRASKA, AT VARIOUS INTERVALS DEPENDING ON THE COMMUNITY NEED (SOMETIMES MONTHLY, WEEKLY, OR TWICE WEEKLY.) WE WERE REIMBURSED FOR STAFF TIME THROUGH TESTNEBRASKA. COST OF STAFF TIME AFTER REIMBURSEMENT FROM TESTNEBRASKA: $0.COVID CLINICS AND BOOSTER CLINICS - JCH&L OFFERED COVID VACCINE CLINICS EVERY FRIDAY FROM FEB. 5 THROUGH APRIL 23. WE OFFERED SCHOOL-AGE CLINICS ON TWO FRIDAYS IN AUGUST AND SEPTEMBER. WE RECEIVED AN ADMINISTRATION FEE THROUGH INSURANCE FOR MOST OF THE VACCINES GIVEN. COST OF STAFF TIME AFTER ADMINISTRATION FEES: $0III. MEDICAL EDUCATIONA. SCHOLARSHIP FUNDING FOR HEALTH PROFESSIONS.PHYSICIAN/MEDICAL STUDENTS, NURSES/NURSING STUDENTS, TECHNICIANS AND OTHER HEALTH PROFESSIONALS. JCH&L WORKS WITH SOUTHEAST COMMUNITY COLLEGE IN BEATRICE AS A SITE FOR LPN PRACTICAL NURSING TRAINING. NORMALLY, NURSING STUDENTS UTILIZE MEETING ROOM SPACE AT JCH&L, AS WELL AS TAKE PART IN CLINICAL PRACTICE. THIS WAS NOT OFFERED IN FISCAL 2021 BECAUSE OF COVID. JCH&L SPORTS MEDICINE AND REHAB SERVICES HOSTED 2 THERAPY STUDENTS. THERAPY STUDENTS ARE TYPICALLY HOUSED IN A PATIENT ROOM DURING THEIR STAY. MEDICAL STUDENTS COME REGULARLY FOR RURAL ROTATIONS TO LEARN FROM LOCAL PHYSICIANS. JCH&L PROVIDES AN APARTMENT FOR THE MEDICAL STUDENTS TO STAY IN DURING THEIR TIME IN FAIRBURY, AND ALSO PROVIDES THEM USE OF OUR FITNESS CENTER DURING THEIR STAY. A TOTAL OF 5 PHYSICIAN STUDENTS AND 2 PA STUDENTS UTILIZED OUR FACILITY IN FISCAL 2021. JCH&L IS A PARTNER IN OFFERING THE LILLIAN HANSEN REESMAN RN MEMORIAL NURSES SCHOLARSHIP FUND. SCHOLARSHIPS ARE OFFERED FROM THIS FUND, ESTABLISHED IN 1980. ONLY INTEREST IS USED FROM THIS $10,000 PERPETUAL FUND, DONATED BY THE REESMAN FAMILY, TO PROVIDE NURSING SCHOLARSHIPS. SCHOLARSHIPS ARE PROVIDED AS INTEREST FUNDS ARE AVAILABLE. ONE $500 SCHOLARSHIP WAS AWARDED IN FISCAL 2021. THE JCH&L AUXILIARY PROVIDES A SCHOLARSHIP FOR STUDENTS PURSUING AN EDUCATION IN MEDICAL FIELDS. THE $400 SCHOLARSHIP IS GIVEN FROM THE AUXILIARY'S FUNDS, AND THE NUMBER OF SCHOLARSHIPS GIVEN EACH YEAR IS BASED ON THE AUXILIARY'S FUNDING AVAILABILITY AND THE NUMBER OF REQUESTS. NO SCHOLARSHIPS WERE AWARDED IN 2021. ESTIMATED NUMBER REACHED: 10. JCH&L COST (APARTMENT RENT, STAFF TIME, ETC.): $12,000.B. OTHER: JOB SHADOWING - JCH&L TYPICALLY HOSTS JOB SHADOW STUDENTS THROUGH FAIRBURY HIGH SCHOOL'S ANATOMY AND PHYSIOLOGY CLASS, THROUGH THE SOUTHEAST COMMUNITY COLLEGE-FAIRBURY HIGH SCHOOL CAREER ACADEMY PROGRAM, AND FOR INTERESTED INDIVIDUALS. DURING FISCAL 2021 WE WERE NOT ALLOW JOB SHADOWS BECAUSE OF COVID. WE RESUMED JOB SHADOWING IN EARLY 2022, WITH THE REQUIREMENT THAT ALL STUDENTS BE VACCINATED FOR COVID (PER CMS REQUIREMENTS.) NUMBER REACHED: 0. ESTIMATED COST OF STAFF TIME: $0.IV. SUBSIDIZED HEALTH SERVICESWELLNESS CENTER SUPPORT - JEFFERSON COMMUNITY HEALTH & LIFE HAS OPERATED THE BURKLEY FITNESS CENTER AS A COMMUNITY FITNESS/WELLNESS CENTER SINCE IT OPENED IN 1996. JCH&L PAYS THE WELLNESS CENTER'S OPERATING EXPENSES THAT EXCEED REVENUES. BECAUSE OF THE HEALTH CENTER'S SUPPORT OF THE FITNESS CENTER'S CASH FLOW, PRICES FOR MEMBERSHIPS AND SERVICES CAN REMAIN REASONABLE FOR COMMUNITY RESIDENTS. IF THE FITNESS CENTER WERE A STAND-ALONE OPERATION, PRICES WOULD HAVE TO RISE CONSIDERABLY TO PAY ALL EXPENSES. IN FISCAL 2020, THE FITNESS CENTER WAS CLOSED FOR SEVERAL MONTHS, AND OPERATED WITH LIMITED NUMBERS AND WITHOUT GROUP FITNESS CLASSES CLASS FOR SEVERAL MORE MONTHS. TOTAL VISITS FOR FISCAL 2021: 28,736. ESTIMATED AMOUNT OF WELLNESS CENTER SUPPORT: $254,646. HOME HEALTH SUPPORT - JEFFERSON COMMUNITY HEALTH & LIFE HAS OPERATED A HOME HEALTH AGENCY SINCE 1984. JCH&L PAYS THE AGENCY'S OPERATING EXPENSES THAT EXCEED REVENUES. THE HEALTH CENTER'S SUPPORT MAKES IT POSSIBLE FOR THE HOME HEALTH AGENCY TO CONTINUE TO PROVIDE SKILLED CARE IN THE HOMES OF AREA RESIDENTS. INCOME: $148,547. EXPENSES: $431,986.GARDENSIDE LONG-TERM CARE - JEFFERSON COMMUNITY HEALTH & LIFE HAS OPERATED GARDENSIDE LONG-TERM CARE SINCE OPENING IN 1963. GARDENSIDE PROVIDES A HOME (SHORT-TERM FOR SKILLED CARE OR LONG-TERM FOR THOSE UNABLE TO LIVE IN THEIR OWN HOME INDEPENDENTLY) FOR UP TO 40 INDIVIDUALS. MOST ARE FROM THIS AREA AND HAVING A LONG-TERM CARE FACILITY NEAR THEIR HOMES AND FAMILIES IS A GREAT BENEFIT TO OUR RESIDENTS, AS WELL AS TO THEIR FAMILIES. INCOME: $2,534,650. EXPENSES: $3,494,878.V. RESEARCH.NO RESEARCH DOLLARS EXPENDED. PART I, LINE 7 (CONTINUED): VI. CASH AND IN-KIND DONATIONSA. CASH DONATIONS:JCH&L MAKES DONATIONS TO VARIOUS CHARITABLE CAUSES, INCLUDING GIRL SCOUT, SOFTBALL, BASEBALL AND CHURCH CAMP FIRST AID KITS, SPONSORSHIP OF BASEBALL AND SOFTBALL TEAMS, GOLF TOURNAMENTS, AREA HIGH SCHOOL POST PROM ACTIVITIES, AREA COMMUNITY CELEBRATIONS, AN AREA RODEO, CHAMBER OF COMMERCE BANQUET, CHAMBER OF COMMERCE NEW TEACHER WELCOME, CHAMBER OF COMMERCE TEACHER RECOGNITION, AND DONATIONS TO TEAMMATES, LIGHT IT UP BLUE, FIVE STAR BIBLE CAMP, RURAL FIRE TRAINING, STATEBOUND ATHLETES FROM JEFFERSON COUNTY SCHOOLS, BONHAM THEATRE, ROTARY TANK PAINTING PROJECT, AREA POST PROMS, KGMT-KUTT ANNUAL THANKSGIVING MEAL, BLUE VALLEY COMMUNITY ACTION, AREA COMMUNITIES' EVENTS, AND AREA WRESTLING PROGRAMS, ETC. THESE TOTALED $2,894.48 JCH&L ALSO CONTRIBUTES ITEMS -- SUCH AS FITNESS CENTER PASSES, JCH&L ITEMS, ETC., TO COMMUNITY EVENTS AS DOOR PRIZES. THESE TOTALED AN ESTIMATED $1,000. DONATIONS DURING FISCAL 2021 TOTALED $3,894.48. B. IN-KIND DONATIONS: SAFE KIDS CHAPTER - JCH&L IS A MEMBER OF THE SAFE KIDS COALITION. SAFE KIDS OFFERS SAFETY SEAT CHECK UP EVENTS AND OTHER SAFETY PROMOTIONS. NO SAFETY SEAT EVENTS WERE HELD IN FISCAL 2021. ESTIMATED STAFF TIME: $0. BLOOD DRIVE SUPPORT - JCH&L ASSISTS NEBRASKA COMMUNITY BLOOD BANK BY SCHEDULING APPOINTMENTS FOR SIX BLOOD DRIVES EACH YEAR. THE BLOOD PRODUCTS ULTIMATELY HELP OUR COMMUNITY, AS NEBRASKA COMMUNITY BLOOD BANK IS JCH&L'S SUPPLIER OF BLOOD AND BLOOD PRODUCTS. ESTIMATED STAFF TIME: $250.SAFETY DAY FOR KIDS - JCH&L IS TYPICALLY ONE OF THE COSPONSORS OF THE ANNUAL SAFETY DAY FOR KIDS IN JEFFERSON COUNTY. THE EVENT WAS NOT HELD IN 2021 BECAUSE OF COVID. VII. COMMUNITY BUILDING ACTIVITIES:ECONOMIC DEVELOPMENT - JEFFERSON COMMUNITY HEALTH & LIFE IS ACTIVE IN LOCAL ECONOMIC DEVELOPMENT ACTIVITIES. JCH&L IS A MEMBER OF THE FAIRBURY CHAMBER OF COMMERCE. WE SEEK OPPORTUNITIES TO OFFER TOURS, HEALTH CARE INFORMATION ON COMMUNITY WEBSITES, ETC. COST OF CHAMBER MEMBERSHIP: $275. PARK IMPROVEMENT - JCH&L WORKED WITH JEFFCO ON THE MOVE AND MANY OTHER ORGANIZATIONS TO UPDATE THE ISAAC OUTDOOR GAME CENTER IN THE FAIRBURY CITY PARK. THE PROJECT WAS SUBSTANTIALLY COMPLETED IN JULY; A RIBBON CUTTING WAS HELD IN OCTOBER. JCH&L STAFF MEMBER EMCEED THE GRAND OPENING. ESTIMATED COST OF STAFF TIME INVOLVED: $500IN ADDITION TO THESE DIRECT PROGRAMS AND SERVICES, THE EMPLOYEES OF JEFFERSON COMMUNITY HEALTH & LIFE SERVE THEIR COMMUNITY IN MANY WAYS INCLUDING SERVING IN THEIR CHURCHES, AS GIRL AND BOY SCOUT LEADERS, 4-H LEADERS, AS LEADERS IN CIVIC ORGANIZATIONS, AS YOUTH GROUP LEADERS, AS CITY GOVERNMENT MEMBERS, ON COMMUNITY DEVELOPMENT BOARDS, FOR EMERGENCY RESPONSE ORGANIZATIONS, AND OTHERS. JCH&L STAFF MEMBERS ARE A RESOURCE AS COMMUNITY ROLE MODELS.JCH&L IS PROUD OF ITS CONTRIBUTIONS TO THE CITIZENS OF JEFFERSON COUNTY AND THE SURROUNDING AREA. THE CITIZENS OF THIS AREA ALSO HIGHLY REGARD JCH&L'S CONTRIBUTIONS TO THE COMMUNITY.THE GOAL OF THE JCH&L BOARD OF DIRECTORS, ADMINISTRATION AND STAFF IS TO EXPAND THAT PARTNERSHIP WITH AREA RESIDENTS AND FIND MORE WAYS TO SERVE AS A RESOURCE FOR HEALTH AND WELLNESS INFORMATION. PART II, COMMUNITY BUILDING ACTIVITIES: JEFFERSON COMMUNITY HEALTH & LIFE IS ACTIVE IN LOCAL ECONOMIC DEVELOPMENT ACTIVITIES. JCH&L IS A MEMBER OF THE FAIRBURY CHAMBER OF COMMERCE. WE SEEK OPPORTUNITIES TO OFFER TOURS, HEALTH CARE INFORMATION ON COMMUNITY WEBSITES, ETC. COST OF CHAMBER MEMBERSHIP: $275. IN ADDITION TO THESE DIRECT PROGRAMS AND SERVICES, THE EMPLOYEES OF JEFFERSON COMMUNITY HEALTH & LIFE SERVE THEIR COMMUNITY IN MANY WAYS INCLUDING SERVING IN THEIR CHURCHES, AS GIRL AND BOY SCOUT LEADERS, 4-H LEADERS, AS LEADERS IN CIVIC ORGANIZATIONS, AS YOUTH GROUP LEADERS, AS CITY GOVERNMENT MEMBERS, ON COMMUNITY DEVELOPMENT BOARDS, FOR EMERGENCY RESPONSE ORGANIZATIONS, AND OTHERS. JCH&L STAFF MEMBERS ARE A RESOURCE AS COMMUNITY ROLE MODELS.JCH&L IS PROUD OF ITS CONTRIBUTIONS TO THE CITIZENS OF JEFFERSON COUNTY AND THE SURROUNDING AREA. THE CITIZENS OF THIS AREA ALSO HIGHLY REGARD JCH&L'S CONTRIBUTIONS TO THE COMMUNITY.THE GOAL OF THE JCH&L BOARD OF DIRECTORS, ADMINISTRATION AND STAFF IS TO EXPAND THAT PARTNERSHIP WITH AREA RESIDENTS AND FIND MORE WAYS TO SERVE AS A RESOURCE FOR HEALTH AND WELLNESS INFORMATION. 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 HEALTH CENTER PROVIDES SERVICES TO UNINSURED PATIENTS, AND OFFERS THOSE UNINSURED PATIENTS A DISCOUNT, EITHER BY POLICY OR LAW, FROM STANDARD CHARGES. THE HEALTH CENTER 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 SEPTEMBER 30, 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: AS PART OF OUR COMMUNITY NEEDS ASSESSMENT, WE GATHERED INFORMATION ON THE INCOME CHARACTERISTICS OF THE UNINSURED POPULATION. USING THAT DATA, WE ANALYZED WHAT PORTION OF UNINSURED INDIVIDUALS IN THE HOSPITAL'S SERVICE AREA WOULD BE ELIGIBLE FOR THE HOSPITAL'S FINANCIAL ASSISTANCE POLICY. THIS PERCENTAGE WAS APPLIED TO THE TOTAL AMOUNT OF BAD DEBT FOR SELF-PAY PATIENTS TO ESTIMATE THE PORTION OF SELF-PAY BAD DEBT THAT WAS LIKELY ATTRIBUTABLE TO INDIVIDUALS ELIGIBLE FOR THE HOSPITAL'S FINANCIAL ASSISTANCE POLICY. PART III, LINE 4: JCH&L'S FINANCIAL STATEMENTS DO NOT CONTAIN A SPECIFIC FOOTNOTE DESCRIBING BAD DEBT EXPENSE. HOWEVER, PAGES 8, 10 AND 11 OF THE ATTACHED FINANCIAL STATEMENTS INCLUDE FOOTNOTES TITLED "PATIENT RECEIVABLE," "PATIENT SERVICE REVENUE AND "FINANCIAL ASSISTANCE/CHARITY CARE". PART III, LINE 8: THE HOSPITAL CALCULATED THE MEDICARE ALLOWABLE COSTS BY ADDING THE INPATIENT, SWING BED AND OUTPATIENT COSTS AS FOUND ON THE MEDICARE COST REPORT FOR SEPTEMBER 30, 2021. NO SHORTFALL IS TREATED AS COMMUNITY BENEFIT. PART III, LINE 9B: ONCE IT IS DETERMINED THAT A PATIENT MAY NOT HAVE THE MEANS TO PAY, AN ASSISTANCE APPLICATION IS PROVIDED. JCH&L STAFF WILL APPLY THE RECOMMENDED PERCENTAGE DISCOUNT TO THE PATIENT'S ACCOUNT. PART VI, LINE 2: JCH&L ASSESSES THE HEALTH CARE NEEDS OF THE COMMUNITY JCH&L SERVES IN SEVERAL WAYS. JCH&L UTILIZES SURVEYS BY PUBLIC HEALTH SOLUTIONS OF THE HEALTH CARE NEEDS FOR RESIDENTS OF JEFFERSON COUNTY AND THE SURROUNDING COMMUNITY. JCH&L VISITS LOCAL COMMUNITY SERVICE ORGANIZATIONS AND SEEKS INPUT ON NEEDS. JCH&L CONDUCTED A COMMUNITY PERCEPTION SURVEY IN 2015, WHICH INCLUDES QUESTIONS ON COMMUNITY HEALTH NEEDS. JCH&L REVIEWS SURVEYS DONE BY THE STATE AND OTHER ORGANIZATIONS ON THE HEALTH CARE NEEDS FOR RESIDENTS OF JEFFERSON COUNTY AND THE SURROUNDING AREA. PART VI, LINE 3: JCH&L INFORMS AND EDUCATES PATIENTS ABOUT ELIGIBILITY FOR ASSISTANCE ON AN INDIVIDUAL BASIS WHEN QUESTIONS ARISE. THE PATIENT BOOKLET PROVIDES BUSINESS OFFICE CONTACT INFORMATION FOR PATIENT QUESTIONS ABOUT THEIR BILL. THE SELF-PAY BILLING VENDOR ENGAGED BY JCH&L HAS A SET OF CRITERIA IT USES TO ASSESS WHETHER A PATIENT IS ELIGIBLE FOR ASSISTANCE PROGRAMS, OR IF THEY QUALIFY FOR JCH&L'S CHARITY CARE PROGRAM. PART VI, LINE 4: JCH&L SERVES JEFFERSON COUNTY AND PARTS OF THAYER, FILLMORE, SALINE AND GAGE COUNTIES, ALL IN NEBRASKA; AND PARTS OF WASHINGTON AND MARSHALL COUNTIES IN KANSAS. THE POPULATION OF THE SERVICE AREA IS ESTIMATED AT ABOUT 18,000. REVENUE FROM MEDICARE PATIENTS AVERAGES APPROXIMATELY 50%, AND REVENUE FROM MEDICAID CLIENTS AVERAGES APPROXIMATELY 10%. PART VI, LINE 5: JCH&L OPERATES IN JEFFERSON COUNTY WITH A COMMUNITY BOARD AND OPEN MEDICAL STAFF. ALL SURPLUS FUNDS ARE REINVESTED BACK INTO THE FACILITY THROUGH BUILDING CONSTRUCTION, EQUIPMENT PURCHASES, OR COMMUNITY PROGRAMS PROVIDED. JCH&L PROMOTES THE HEALTH OF THE COMMUNITY BY OFFERING A COMMUNITY FITNESS CENTER AT A REASONABLE RATE AND OFFERING SCHOLARSHIPS FOR THE COMMUNITY'S YOUTH WHO HAVE FINANCIAL NEED. THE NET COMMUNITY BENEFIT REPORTED IN PART I RELATING TO THE FITNESS CENTER WAS APPROXIMATELY $255,000. JCH&L PROMOTES THE HEALTH OF THE COMMUNITY BY PROMOTING COMMUNITY-WIDE PROGRAMS SUCH AS LIVE HEALTHY NEBRASKA AND STEP-2-IT (PROGRAMS WHICH ENCOURAGE INCREASING ACTIVITY AND LOSING WEIGHT.) JCH&L IS ALSO INVOLVED IN CAR SAFETY SEAT CHECKS, PROGRESSIVE AG SAFETY DAY, AND WORKING WITH BLUE VALLEY COMMUNITY ACTION TO OFFER IMMUNIZATIONS TO AREA CHILDREN. JCH&L PROMOTES THE HEALTH OF THE COMMUNITY BY OFFERING PROGRAMS, TOURS, SPEAKERS, AND EDUCATION, INCLUDING SUPPORT GROUPS, EDUCATIONAL PROGRAMS AND PROGRAMS FOR LOCAL ORGANIZATIONS. PART VI, LINE 6: JCH&L IS NOT PART OF AN AFFILIATED HEALTH CARE SYSTEM BUT DOES WORK TO BE A LEADER IN PROMOTING THE HEALTH OF THE COMMUNITIES IT SERVES. JCH&L PARTNERS WITH MANY OTHER AREA ORGANIZATIONS, INCLUDING PUBLIC HEALTH SOLUTIONS, FARM SAFETY 4 JUST KIDS, NEBRASKA SAFE KIDS, JEFFERSON COUNTY EXTENSION, BLUE VALLEY COMMUNITY ACTION, FAIRBURY CHAMBER OF COMMERCE, FAIRBURY PUBLIC SCHOOLS, NEBRASKA COMMUNITY BLOOD BANK, RURAL COMPREHENSIVE CARE NETWORK, BLUE RIVER VALLEY NETWORK, HEARTLAND HEALTH ALLIANCE, AND OTHERS. DEPENDING ON THE ACTIVITY, JCH&L MAY BE THE LEAD ORGANIZATION, OR AN ORGANIZATION PROVIDING HELP AND ASSISTANCE. PART VI, LINE 7: JCH&L DOES NOT FILE A COMMUNITY BENEFIT REPORT WITH ANY STATES. X 1 1 X X X X 0 0 0 1 0 0 0 1 0 CRAIG SHUMARD PHYSICIAN 331475 0 145242 0 0 0 24250 0 17400 0 518367 0 0 0 RICHARD BLATNY JR PHYSICIAN 322150 0 129942 0 0 0 24250 0 17400 0 493742 0 0 0 BRETT WERGIN PHYSICIAN 271484 0 27507 0 0 0 7096 0 9000 0 315087 0 0 0 BRANDON BLEICH PHARMACIST 156989 0 0 0 0 0 4120 0 17400 0 178509 0 0 0 CHANCE KLASEK CFO 132939 0 0 0 0 0 7264 0 17400 0 157603 0 0 0 PART I, LINE 1A JCH&L PROVIDES DISCOUNTED OR FREE FITNESS CENTER MEMBERSHIPS TO ITS EMPLOYEES AND PHYSICIANS. PART I, LINE 5 PHYSICIANS RECEIVE INCENTIVE COMPENSATION BASED ON PHYSICIAN'S NET COLLECTIONS IN EXCESS OF THE MONTHLY THRESHOLDS SET PER CONTRACT. "NET COLLECTIONS" MEANS CASH ACTUALLY RECEIVED FROM PATIENTS OR THIRD PARTY PAYORS FOR PERSONALLY PERFORMED PROFESSIONAL SERVICES OF PHYSICIAN. NET COLLECTIONS SHALL BE ADJUSTED BY ANY REDUCTIONS FOR PATIENT ACCOUNT ADJUSTMENTS, RECOVERED OVERPAYMENTS, OFFSETS AND ANY FEES EXPENDED ON AMOUNTS RECOVERED THROUGH COLLECTION AGENCIES. NET COLLECTIONS SHALL NOT INCLUDE THE TECHNICAL FEES ASSOCIATED WITH ANY COLLECTIONS FOR LAB, X-RAY, ANCILLARY SERVICES, DESIGNATED HEALTH SERVICES UNDER STARK, ANY SERVICES NOT RENDERED PERSONALLY BY PHYSICIAN, OR THE TECHNICAL COMPONENT OF ANY OTHER SERVICES. WHEN A GLOBAL PAYMENT IS RECEIVED THAT INCLUDES PROFESSIONAL SERVICES AND ANY SUCH EXCLUDED SERVICES, HOSPITAL SHALL MAKE A REASONABLE ALLOCATION OF SUCH RECEIPT BETWEEN SUCH CATEGORIES. PART I, LINE 7 UPON COMPLETION OF EACH CONTRACT YEAR, THE HOSPITAL SHALL DETERMINE PHYSICIAN'S QUALIFICATION TO RECEIVE QUALITY INCENTIVE COMPENSATION BASED ON ANNUAL GOALS ESTABLISHED AT THE BEGINNING OF THE CONTRACT YEAR. IN ORDER TO QUALIFY TO RECEIVE QUALITY INCENTIVE COMPENSATION, PHYSICIAN SHALL REMAIN EMPLOYED IN GOOD STANDING AT THE END OF THE CONTRACT YEAR. THE QUALITY INCENTIVE COMPENSATION SHALL NOT EXCEED FIVE PERCENT (5%) OF BASE SALARY. SCHEDULE J, PART II VIC LEE, INTERIM CEO THRU MAY OF 2020 WAS PAID BY AN UNRELATED ORGANIZATION, BRYAN HEALTH. TOTAL COMPENSATION AND BENEFITS PAID TO MR. LEE FOR 2020 WERE $102,000. A HOSPITAL AUTHORITY NO 1 OF JEFFERSON COUNTY NE 611683496 2020-12-18 8291780 RENOVATE FACILITY & REF BOND ISSUE (12/18/12) 0 0 0 A 225000 4266989 4266989 1 0 0 1 A 0 0 0 0 0.00000 0.00000 0.00000 0 0 0 A 0 1 1 0 1 0 0 0 1 A 1 PART II, LINE 3: THE TOTAL PROCEEDS DO NOT AGREE TO THE ISSUE PRICE IN PART I, COLUMN (E) AS THIS DEBT WAS ISSUED ON A DRAW-DOWN BASIS AND THE TOTAL PRINCIPAL AVAILABLE HAS NOT YET BEEN DRAWN CAROL BLOBAUM EMPLOYEE OF THE HOSPITAL AND SPOUSE OF BRIAN BLOBAUM, VICE CHAIRMAN 93237 EMPLOYEE COMPENSATION 0 FORM 990, PART VI, SECTION A, LINE 6 JEFFERSON COMMUNITY HEALTH & LIFE HAS MEMBERS. ANY PERSON, CORPORATION OR OTHER ENTITY MAY BECOME A LIFETIME MEMBER IF A CONTRIBUTION OF $100 OR MORE IS MADE TO THE CORPORATION. FORM 990, PART VI, SECTION A, LINE 7A VACANCIES, OCCURRING ON THE BOARD BY EXPIRATION, SHALL BE FILLED THROUGH ELECTION BY THE MEMBERS AT THE ANNUAL MEETING OF THE MEMBERS. THE BOARD DEVELOPMENT COMMITTEE SHALL SUBMIT A SLATE OF PROSPECTIVE CANDIDATES TO THE BOARD OF DIRECTORS AT THEIR MEETING PRIOR TO THE ANNUAL MEETING WHICH WILL THEN BE PRESENTED AT THE ANNUAL MEETING FOR CONSIDERATION FOR ELECTION TO THE BOARD. IN ADDITION, MEMBERS OF THE CORPORATION MAY MAKE NOMINATIONS FROM THE FLOOR. FORM 990, PART VI, SECTION A, LINE 7B EACH MEMBER SHALL BE ENTITLED TO ONE VOTE ON EACH MATTER SUBMITTED TO THE VOTE OF THE MEMBERS. FORM 990, PART VI, SECTION B, LINE 11B THE BOARD WILL REVIEW THE FORM 990 AT A REGULARLY SCHEDULED BOARD MEETING, WHICH DOES NOT NECESSARILY OCCUR PRIOR TO THE FILING OF FORM 990. FORM 990 IS REVIEWED BY MR. CHANCE KLASEK, CFO, PRIOR TO FILING. FORM 990, PART VI, SECTION B, LINE 12C BOARD MEMBERS ARE REQUIRED, BY THE ARTICLES AND BYLAWS, TO REVIEW THE CONFLICT OF INTEREST POLICY ANNUALLY. A BOARD MEMBER WITH A CONFLICT OF INTEREST IS REQUIRED TO ABSTAIN FROM VOTING ON ANY MOTION FOR WHICH HE HAS A CONFLICT OF INTEREST. BOARD MEMBERS ARE WELL ACQUAINTED WITH EACH OTHER AND WOULD BE AWARE OF ANY PERSONAL CONFLICTS OF INTEREST. FORM 990, PART VI, SECTION B, LINE 15 THE HOSPITAL PARTICIPATES IN THE NEBRASKA COMPDATA SALARY SURVEYS FOR ALL POSITIONS. THE CEO SURVEY DATA IS GIVEN TO THE BOARD TO REVIEW, AND THE BOARD APPROVES THE CEO'S SALARY ON AN ANNUAL BASIS. OTHER OFFICER COMPENSATION IS REVIEWED AND APPROVED BY THE CEO AND HR DIRECTOR. THE BOARD OF DIRECTORS REVIEWS COMPENSATION RANGES PROPOSED BY OR THROUGH THE CEO FOR JCH&L'S OFFICERS AND KEY EMPLOYEES AND DETERMINES THAT SUCH COMPENSATION RANGES ARE REASONABLE AND CONSISTENT WITH FAIR MARKET VALUE. FORM 990, PART VI, SECTION C, LINE 19 THE ORGANIZATION'S GOVERNING DOCUMENTS, CONFLICT OF INTEREST POLICY AND FINANCIAL STATEMENTS ARE AVAILABLE TO THE PUBLIC UPON REQUEST. FORM 990, PAGE 11, PART XI, LINE 2C: THE FINANCE COMMITTEE OF THE BOARD OF DIRECTORS SELECTS THE INDEPENDENT ACCOUNTANT AND HAS THE RESPONSIBILITY FOR OVERSIGHT OF THE AUDIT. UPON CONCLUSION OF THE AUDIT, THE AUDITING FIRM PRESENTS THE RESULTS AND FINDINGS TO THE FINANCE COMMITTEE. THERE HAVE BEEN NO CHANGES TO THIS PROCESS FROM THE PRIOR YEAR.