2022-05-13T16:42:26-05:00 2021-06-30 470617373 COMMONSPIRIT HEALTH 198 INVERNESS DRIVE WEST ENGLEWOOD CO 80112 990 2020-07-01 450226553 MERCY HOSPITAL OF VALLEY CITY MERC 7018456489 570 CHAUTAUQUA BLVD VALLEY CITY ND 58072 BETHANY SMITH VP OF OPERATIONAL FINANCE 7018456489 2022-05-13 1 BETHANY SMITH XXX-XX-XXXX MARK STOCKI P00642127 3032989100 2 AAL1 IAL1 2020 2022-09-23 18:48:47Z CHI MERCY HEALTH BECKI THOMPSON 570 CHAUTAUQUA BLVD VALLEY CITY ND 58072 15239015 0 0928 X WWW.MERCYHOSPITALVALLEYCITY.ORG/ X 1928 ND MERCY HOSPITAL OF VALLEY CITY IS A CRITICAL ACCESS HOSPITAL SERVING A LARGE GEOGRAPHICAL AREA. COMMUNITY BENEFITS INCLUDE: UNCOMPENSATED CARE, MEDICAL EDUCATION AND AWARENESS, SUPPORT SERVICES, AND COMMUNITY OUTREACH. 10 7 100 60 5297 4297 758079 588113 11967656 12446166 1217031 2168799 30682 28788 13973448 15231866 2945 1680 0 0 4503983 4575460 0 0 0 7717516 6968618 12224444 11545758 1749004 3686108 41344654 49620792 9726285 7581678 31618369 42039114 X AS AN AFFILIATE OF COMMONSPIRIT HEALTH, WE MAKE THE HEALING PRESENCE OF GOD KNOWN IN OUR WORLD BY IMPROVING THE HEALTH OF THE PEOPLE WE SERVE, ESPECIALLY THOSE WHO ARE VULNERABLE, WHILE WE ADVANCE SOCIAL JUSTICE FOR ALL. TO FULFILL THIS MISSION, THE CORPORATION, AS A VALUES-BASED ORGANIZATION, WILL ASSURE THE INTEGRITY OF THE MINISTRY IN BOTH CURRENT AND DEVELOPING ORGANIZATIONS AND ACTIVITIES; RESEARCH AND DEVELOP NEW MINISTRIES THAT INTEGRATE HEALTH, EDUCATION, PASTORAL, AND SOCIAL SERVICES; PROMOTE LEADERSHIP DEVELOPMENT AND FORMATION FOR MINISTRY THROUGHOUT THE ENTIRE ORGANIZATION; ADVOCATE FOR SYSTEMIC CHANGES WITH SPECIFIC CONCERN FOR PERSONS WHO ARE POOR, ALIENATED, AND UNDERSERVED; AND STEWARD RESOURCES BY GENERAL OVERSIGHT OF THE ENTIRE ORGANIZATION. 0 0 10793554 1680 12446166 SEE SCHEDULE H 10793554 1 1 0 1 0 0 0 0 0 1 1 1 0 1 1 1 0 1 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 1 1 0 0 0 1 0 0 100 1 1 1 0 0 0 0 0 0 0 0 0 0 0 X 10 7 0 0 0 0 1 1 1 1 1 0 0 1 1 1 1 1 0 0 1 0 ND X BETHANY SMITH 7018456583 570 CHAUTAUQUA BLVD VALLEY CITY ND 58072 CLIFF ROBERTSON MD BOARD MEMBER/CSH SVP DIVISION OFFICER (PARTIAL YEA 1.00 49.00 X 0 2330702 46702 JEFFREY DROP BOARD MEMBER/CSH SVP DIVISION OFFICER (PARTIAL YEA 1.00 49.00 X 0 1263797 34793 JEANETTE WOJTALEWICZ BOARD MEMBER/CSH SVP DIVISION OFFICER (PARTIAL YEA 1.00 49.00 X 0 986312 50266 KEITH HEUSER BOARD MEMBER/PRESIDENT 1.00 40.00 X X 0 276094 33841 CLARK KRUTA CRNA 40.00 0.00 X 227343 0 42067 JOSHUA SENGER FORMER TREASURER/VP, FINANCE 0.00 40.00 X 0 134482 38239 BETH SMITH TREASURER/VP, FINANCE 1.00 39.00 X X 0 113823 33895 CAMILLE SETTELMEYER VP OF CLINICAL SERVICES 0.00 40.00 X 0 127333 18690 AMY NOESKE PHARMACY MANAGER 40.00 0.00 X 112860 0 30727 ROWENA DEPRA RN, MEDICAL-SURGICAL 40.00 0.00 X 106005 0 2065 LISA URBATSCH BOARD SECRETARY 40.00 0.00 X 47163 0 21967 FREDRICK MITZEL MD BOARD MEMBER 1.00 0.00 X 0 0 0 SR STELLA OLSON BOARD MEMBER 1.00 3.00 X 0 0 0 TIM OST BOARD MEMBER 1.00 0.00 X 0 0 0 CASEY STOUDT CHAIR 1.00 0.00 X X 0 0 0 BETTY TYKWINSKI VICE CHAIR 1.00 0.00 X X 0 0 0 PAIGE BJORNSON BOARD MEMBER 1.00 0.00 X 0 0 0 ALAN LAFAVE BOARD MEMBER 1.00 0.00 X 0 0 0 493371 5232543 353252 3 1 1 0 NATIONAL MEDICAL RESOURCES INC 2900 E BROADWAY AVE BISMARCK ND 58540 LOCUM PROVIDERS 1031814 TF POWERS CONSTRUCTION CO 910 6TH AVE N FARGO ND 58102 CONSTRUCTION SERVICES 265111 INTERSTAFF INC PO BOX 4652 DEPT 980 HOUSTON TX 772104652 CONTRACT TRAVELING NURSING LABOR 235269 MEDEFIS INC 2121 N 117TH AVE STE 200 OMAHA NE 68164 VENDOR MANAGEMENT/STAFFING 232478 4 433281 154832 588113 NET PATIENT SERVICES 900099 12441296 12441296 0 0 RENTAL INCOME 900099 4870 4870 12446166 346001 5297 340704 1829887 60 0 7149 1829887 -7089 1822798 1822798 CAFETERIA 722100 24221 0 0 24221 MEDICAL SERVICES 621300 1510 0 0 1510 SERVICES SOLD 900099 616 0 0 616 2441 2441 28788 15231866 12446166 5297 2192290 X 1680 1680 64181 64181 3658718 3444332 214386 181964 166325 15639 405645 392571 13074 264952 243756 21196 13290 13290 2539 2539 3588750 3229875 358875 4747 4747 170807 143478 27329 507528 507528 219399 219399 4484 4304 180 903 903 1211 1211 504708 504708 520813 510397 10416 26892 26892 MEDICAL SUPPLIES 1145615 1145615 0 0 REPAIRS AND MAINTENANCE 160840 160840 0 0 DUES & SUBSCRIPTIONS 61962 61962 0 0 EDUCATION 17665 16782 883 0 16465 13110 3355 11545758 10793554 752204 0 624 625 10546583 11078841 0 2052715 2589987 0 0 0 192564 211112 37738 40806 15591653 11902571 3206766 3689082 0 23470050 29471200 0 0 1837614 2539139 41344654 49620792 4489614 4811387 0 3066291 48582 0 0 0 0 0 2170380 2721709 9726285 7581678 X 31603315 42025360 15054 13754 31618369 42039114 41344654 49620792 X 3686108 3825373 -62203 2971467 X X 0 1 X 1 1 1 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 0 0 0 0 0 1 2539 0 0 0 2539 0 PART II-B, LINE 1: LINE 1F: THE PORTION OF ORGANIZATION DUES THAT ARE RELATED TO LOBBYING ARE AS FOLLOWS: CATHOLIC HEALTH ASSOCIATION - $269 AMERICAN HOSPITAL ASSOCIATION - $507 NORTH DAKOTA HEALTH ASSOCIATION - $1,763 97450 25351 122801 94878 2885 313 97450 89600 5579 301 94878 83074 6733 207 89600 74110 9143 179 83074 0.38610 0.61390 0 1 1 19382 19382 6955588 5926236 1029352 8495030 5874719 2620311 121653 101616 20037 3689082 CSH OPERATING INVESTMENT POOL 29471200 F 29471200 INTERCOMPANY RECEIVABLES 2455017 INVESTMENTST IN UNCONSOLIDATED ORGS 31114 RIGHT OF USE ASSETS 53008 2539139 INTERCOMPANY PAYABLES 2676071 LEASE LIABILITIES 45512 SERVICE FEE LIABILITY 126 2721709 X PART V, LINE 4: WE HAVE TWO ENDOWMENT FUNDS, ONE IS FOR SCHOLARSHIPS AND THE OTHER ONE IS AN EMPLOYEE ENDOWMENT FUND THAT WAS CREATED FOR REMODEL PURPOSES. THE BALANCE OF THE SCHOLARSHIP FUND IS $38,888, AND THE EMPLOYEE ENDOWMENT FUND IS $83,913. PART X, LINE 2: MERCY HOSPITAL OF VALLEY CITY'S FINANCIAL INFORMATION IS INCLUDED IN COMMONSPIRIT HEALTH'S CONSOLIDATED AUDITED FINANCIAL STATEMENTS, WHICH INCLUDES THE FOLLOWING DISCLOSURE: COMMONSPIRIT REVIEWS ITS TAX POSITIONS QUARTERLY AND HAS DETERMINED THAT THERE ARE NO MATERIAL UNCERTAIN TAX POSITIONS THAT REQUIRE RECOGNITION IN THE ACCOMPANYING CONSOLIDATED FINANCIAL STATEMENTS. 1 1 X 1 X 300.000000000000 1 X 1 1 1 0 1 1 186 188287 188287 0.01630 0 0 0 0 186 188287 188287 0.01630 4 12605 33901 33901 0.00290 3 94 7111 7111 0.00060 0 0 0 0 0 0 0 0 0 7 12699 41012 41012 0.00350 7 12885 229299 229299 0.01980 1 625226 0 5085024 4611524 473500 X 1 1 1 1 MERCY HOSPITAL OF VALLEY CITY 570 CHAUTAUQUA BLVD VALLLEY CITY ND 58072 HTTP://WWW.MERCYHOSPITALVALLEYCITY.ORG 5050A X X X X MERCY HOSPITAL OF VALLEY CITY 1 0 0 1 X X X X X X X X X 18 1 0 1 1 X HTTPS://WWW.MERCYHOSPITALVALLEYCITY.ORG/COMMUNITY-BENEFITS/ X 1 19 1 HTTPS://WWW.MERCYHOSPITALVALLEYCITY.ORG/COMMUNITY-BENEFITS/ 0 1 X 300.000000000000 300.000000000000 X X X X 1 1 X X X 1 X HTTPS://WWW.MERCYHOSPITALVALLEYCITY.ORG/FINANCIAL-INFORMATION-DOCUMENTS/ X HTTPS://WWW.MERCYHOSPITALVALLEYCITY.ORG/FINANCIAL-INFORMATION-DOCUMENTS/ X HTTPS://WWW.MERCYHOSPITALVALLEYCITY.ORG/FINANCIAL-INFORMATION-DOCUMENTS/ X X X X X X 1 X 0 X X X X 1 X 0 0 PART V, SECTION B, LINE 3E THE SIGNIFICANT HEALTH NEEDS ARE A PRIORITIZED DESCRIPTION OF THE COMMUNITY'S SIGNIFICANT HEALTH NEEDS IDENTIFIED THROUGH THE CHNA. PART V, SECTION B, LINE 5 A BROAD REPRESENTATION OF THE COMMUNITY WAS INCLUDED IN THE COMMUNITY HEALTH NEEDS ASSESSMENT COALITION. THE INITIATIVE WAS FACILITATED BY LEADERS FROM CITY COUNTY HEALTH DISTRICT AND CHI MERCY HEALTH. ALL COALITION REPRESENTATIVES PARTICIPATED IN DATA REVIEW AND LOCAL CHNA TOOL CONTENT DEVELOPMENT AND DATE COLLECTION. THE MEMBERS THEN PARTICIPATED IN FURTHER DATA REVIEW AND FINALLY IN CONSENSUS PRIORITY SETTING. PART V, SECTION B, LINE 6B THE CHNA WAS CONDUCTED WITH BOTH MERCY HOSPITAL AND CITY-COUNTY HEALTH DISTRICT. PART V, SECTION B, LINE 11 THE FOLLOWING CHNA PRIORITY NEEDS WILL BE ADDRESSED BY CHI MERCY HEALTH IN CONTINUED COLLABORATION WITH CITY-COUNTY HEALTH DISTRICT:- MENTAL HEALTH- SUBSTANCE ABUSE AND MISUSE- ATTRACT AND RETAIN YOUNG FAMILIESHEALTH NEED: MENTAL HEALTHSTRATEGIES:1) EXPANSION* EXPLORE EARLY INTERVENTION OPPORTUNITY THROUGH NURSE FAMILY PARTNERSHIP.* WORK WITH COMMUNITY PARTNERS TO ACHIEVE NECESSARY MENTAL HEALTH TRAINING AND RESOURCES IN COMMUNITY.* PROVIDE APPROPRIATE CHI MERCY HEALTH STAFF WITH TRAINING ON MENTAL ILLNESS, INCREASING THEIR UNDERSTANDING OF HOW TO CONNECT PATIENTS TO RESOURCES.2) YOUTH PREVENTION* ADDRESS COLLABORATIVELY WITH COMMUNITY PARTNERS FAMILY EDUCATION AND SUPPORT RESOURCE NEEDS.* SUPPORT CURRENT MENTAL HEALTH AND SUICIDE PREVENTION INITIATIVES IN LOCAL SCHOOLS.* UTILIZE CURRENT NURTURING PARENT PROGRAM AND HEALTHY RELATIONSHIPS CURRICULUM AS MEANS TO REACH FAMILIES WITH MENTAL HEALTH EDUCATION.HEALTH NEED: SUBSTANCE ABUSE AND MISUSESTRATEGIES:1) TREATMENT AND RECOVERY STRATEGIES* CONTRIBUTE TO THE WORK OF COMMUNITY PARTNERS TO DEVELOP A LOCAL ADDICTION RECOVERY PROGRAM BASED ON HOUSING, EMPLOYMENT, PEER SUPPORT AND HEALTHY SOCIALIZATION.* EDUCATE HOSPITAL STAFF ON SUBSTANCE ABUSE DISORDERS.2) NOT IN MY HOUSE* CHANGE THE NORMS OF UNDERAGE DRINKING THROUGH EDUCATION AND COMMUNITY ENGAGEMENT.* REDUCE THE WAY YOUTH CAN ACCESS ALCOHOL.3) LICENSED ADDICTION COUNSELORS* SUPPORT THE WORK OF CITY-COUNTY HEALTH DISTRICT AND SOUTH CENTRAL HUMAN SERVICE CENTER TO ADD THE SERVICES OF LICENSED ADDICTION COUNSELORS TO THE COMMUNITY.HEALTH NEED: ATTRACT AND RETAIN YOUNG FAMILIESSTRATEGIES1) PROMOTION* PARTNER WITH VALLEY CITY - BARNES COUNTY DEVELOPMENT CORPORATION IN THE PROMOTION OF VALLEY CITY TO ACHIEVE QUALITY OF PLACE, WORKFORCE TRAINING AND EDUCATION, AND BUILDING COMMUNITY.* INCREASE COMMUNITY AWARENESS OF HOSPITAL SERVICES, TARGETING YOUNG FAMILIES.2) ENGAGEMENT* ACTIVELY PARTICIPATE IN SELECT COMMUNITY WIDE EVENTS WITH INTENT OF CONTRIBUTING TO A FAMILY FRIENDLY ENVIRONMENT.* PARTNER WITH SCHOOL SYSTEM TO IDENTIFY AND SERVE STUDENT AND FAMILY HEALTH NEEDS.THE HOSPITAL INTENDS TO TAKE ACTIONS TO ADDRESS THE PRIORITIZED SIGNIFICANT HEALTH NEEDS IDENTIFIED THROUGH THE COMMUNITY HEALTH NEEDS ASSESSMENT, BOTH THROUGH ITS OWN PROGRAMS AND SERVICES AND WITH COMMUNITY PARTNERS. THE HOSPITAL HAS CHOSEN NOT TO ADDRESS THE FOLLOWING IDENTIFIED NEEDS SPECIFICALLY WITHIN OUR INITIATIVES. THESE HEALTH CONCERNS ARE EITHER BEYOND OUR CAPACITY, BEING ADDRESSED BY OTHER ORGANIZATIONS AND PROGRAMS, OR ARE CURRENTLY ADDRESSED THROUGH EXISTING HOSPITAL PROGRAMS. FOR EACH ISSUE HOWEVER, WE WILL CONTINUE TO DIALOGUE WITH COMMUNITY PARTNERS:1. PHYSICAL VIOLENCE, DOMESTIC VIOLENCE, SEXUAL ABUSE REMAINS AN ISSUE.2. NOT ENOUGH JOBS WITH LIVABLE WAGES MAKES IT DIFFICULT FOR NEW BUSINESS DEVELOPMENT IN THE COMMUNITY AND TO INCREASE MINIMUM WAGES AND PROVIDE BENEFITS.3. EXTRA HOURS FOR HEALTHCARE APPOINTMENTS IN THE EVENINGS AND ON THE WEEKENDS IS DESIRED TO MAKE CARE MORE ACCESSIBLE.4. ABILITY TO RETAIN PRIMARY CARE PROVIDERS (MD, DO, NP, PA, NURSES) IN THE COMMUNITY.5. NOT HAVING ACCESS TO AFFORDABLE HOUSING HAS CREATED A BARRIER TO MEETING OTHER GENERAL NEEDS OF THE COMMUNITY.OUR BEST-KNOWN, BUT OFTEN LEAST-UTILIZED, COMMUNITY BENEFIT PROGRAM IS THE FINANCIAL ASSISTANCE WE PROVIDE TO PATIENTS WHO CANNOT AFFORD TO PAY FOR THEIR CARE. FINANCIAL ASSISTANCE APPLICATIONS MAY BE OBTAINED AT CHI MERCY HEALTH OR ON THE WEBSITE: WWW.MERCYHOSPITALVALLEYCITY.ORG. THE PROCESS IS COMPLETELY CONFIDENTIAL AND OUR GOAL IS TO AWARD FINANCIAL ASSISTANCE RATHER THAN TURN PATIENTS OVER TO COLLECTION FOR HEALTHCARE BILLS. CHARITY CARE IS FREE OR DISCOUNTED HEALTH AND HEALTH-RELATED SERVICES PROVIDED TO PERSON WHO CANNOT AFFORD TO PAY FOR MEDICALLY NECESSARY HEALTH CARE. ELIGIBILITY IS BASED ON HOUSEHOLD INCOME AS WELL AS OTHER ASSETS. CONSIDERATION IS GIVEN TO A PATIENT WHO HAS SIGNIFICANT OR CATASTROPHIC MEDICAL BILLS AND DOES NOT MEET THE INCOME GUIDELINES. CHARITY CARE IS GIVEN TO UNINSURED, LOW-INCOME PATIENTS WHO ARE NOT EXPECTED TO PAY ALL OR PART OF A BILL, OR WHO ARE ABLE TO PAY ONLY A PORTION USING AN INCOME-RELATED FEE SCHEDULE. COMMUNITY BENEFIT PROGRAMS FOR THE POOR ARE GEARED TO REDUCING MORBIDITY AND MORTALITY IN BENEFICIARIES OF MEDICAID OR STATE OR LOCAL INDIGENT PROGRAMS.III. QUALITATIVE DESCRIPTION OF COMMUNITY BENEFIT COMMUNITY BENEFIT IS THE NAME GIVEN TO THE PROGRAMS WE CREATE IN RESPONSE TO HEALTH NEEDS IN OUR SERVICE AREAS. AN IMPORTANT PART OF OUR MISSION IS BUILDING HEALTHIER COMMUNITIES THROUGH PROGRAMS DESIGNED TO SERVE THE NEEDS OF PEOPLE WHO ARE POOR AND DISADVANTAGED IN OUR COMMUNITY. THIS TYPE OF COMMUNITY BENEFIT HAS THE ADDED, POSITIVE SIDE-EFFECT OF DELIVERING AN IMPROVED QUALITY OF LIFE FOR EVERYONE. COMMUNITY BENEFIT MOST OFTEN TAKES PLACE OUTSIDE THE WALLS OF OUR FACILITIES AND INVOLVES PARTNER ORGANIZATIONS IN THE COMMUNITY. OUR COMMUNITY BENEFIT ACTIVITIES ARE DESIGNED TO:*IDENTIFY AND INCREASE AWARENESS OF HEALTH NEEDS IN BARNES COUNTY.*PROVIDE RESOURCES TO MEET THOSE NEEDS.*CREATE COLLABORATION BETWEEN COMMUNITY ORGANIZATIONS THAT FOCUS ON HEALTH AND WELL-BEING. *TACKLE PROBLEMS SUCH AS POVERTY, HOMELESSNESS, OR BEHAVIORS (SUCH AS CHRONIC DISEASE, DOMESTIC VIOLENCE OR UNDERAGE DRINKING AND ADDICTION) THAT CAN CONTRIBUTE TO POOR HEALTH.COMMUNITY OUTREACH FOR THE POORCHI MERCY HEALTH OUTREACH FOR THE POOR ACTIVITIES INCLUDE: CHARITY CARE/FINANCIAL ASSISTANCE AND UNPAID COST OF MEDICAID. IN ADDITION, WE HAVE ASSISTED IN FUNDRAISING EFFORTS TO PROVIDE OUR SISTER HOSPITAL IN THE PHILIPPINES.COMMUNITY OUTREACH FOR THE BROADER COMMUNITYCHI MERCY HEALTH REACHES THE BROADER COMMUNITY IN MANY WAYS AND MANY ACTIVITIES. THROUGH EDUCATION, PROGRAMS, FUNDRAISERS, BABYSITTING CLASSES, PARADE FLOATS, COMMUNITY SUPPORT, HEALTH FAIRS, WELLNESS DAYS, AND PHONE A NURSE. CHI MERCY HEALTH BELIEVES THEIR ADVOCACY EFFORTS WILL CONTINUE TO IMPROVE HEALTH CARE ACCESS AND QUALITY OF LIFE FOR AREA RESIDENTS. FUNDS AND IN-KIND SERVICES ARE DONATED TO INDIVIDUALS AND/OR THE COMMUNITY AT LARGE. IN-KIND SERVICES ALSO INCLUDE HOURS DONATED BY STAFF TO THE COMMUNITY WHILE ON HEALTH CARE ORGANIZATION WORK TIME SUCH AS BARNES COUNTY'S RELAY FOR LIFE, ADVISORY BOARDS, IN-KIND PRINTING, STUDENT HOUSING, AND MEETING ROOMS FOR COMMUNITY EDUCATION. HEALTH EDUCATION OUTREACH FOR THE COMMUNITY IS REACHED BY ARTICLES WRITTEN FOR "YOUR HEALTH" IN THE WEEKLY NEWSPAPER IN ADDITION TO WEEKLY RADIO EDUCATION SEGMENTS AND PUBLIC SERVICE ANNOUNCEMENTS PREPARED BY HOSPITAL STAFF. CHI MERCY HEALTH ALSO MAILS A QUARTERLY NEWSLETTER TO ALL RESIDENTS OF BARNES COUNTY WITH UP-TO-DATE HEALTHCARE INFORMATION. PART V, SECTION B, LINE 13H THE PATIENT MUST HAVE A MINIMUM ACCOUNT BALANCE OF THIRTY-FIVE DOLLARS ($35.00) WITH THE CHI HOSPITAL ORGANIZATION. MULTIPLE ACCOUNT BALANCES MAY BE COMBINED TO REACH THIS AMOUNT. PATIENTS/GUARANTORS WITH BALANCES BELOW THIRTY-FIVE DOLLARS ($35) MAY CONTACT A FINANCIAL COUNSELOR TO MAKE MONTHLY INSTALLMENT PAYMENT ARRANGEMENTS.THE PATIENT MUST SUBMIT A COMPLETED FINANCIAL ASSISTANCE APPLICATION.PATIENT COOPERATION STANDARDS - A PATIENT MUST EXHAUST ALL OTHER PAYMENT OPTIONS, INCLUDING PRIVATE COVERAGE, FEDERAL, STATE AND LOCAL MEDICAL ASSISTANCE PROGRAMS, AND OTHER FORMS OF ASSISTANCE PROVIDED BY THIRD-PARTIES PRIOR TO BEING APPROVED. AN APPLICANT FOR FINANCIAL ASSISTANCE IS RESPONSIBLE FOR APPLYING TO PUBLIC PROGRAMS FOR AVAILABLE COVERAGE. HE OR SHE IS ALSO EXPECTED TO PURSUE PUBLIC OR PRIVATE HEALTH INSURANCE PAYMENT OPTIONS FOR CARE PROVIDED BY A CHI HOSPITAL ORGANIZATION WITHIN A HOSPITAL FACILITY. A PATIENT'S AND, IF APPLICABLE, ANY GUARANTOR'S COOPERATION IN APPLYING FOR APPLICABLE PROGRAMS AND IDENTIFIABLE FUNDING SOURCES, INCLUDING COBRA COVERAGE (A FEDERAL LAW ALLOWING FOR A TIME-LIMITED EXTENSION OF EMPLOYEE HEALTHCARE BENEFITS), SHALL BE REQUIRED. IF A HOSPITAL FACILITY DETERMINES THAT COBRA COVERAGE IS POTENTIALLY AVAILABLE, AND THAT A PATIENT IS NOT A MEDICARE OR MEDICAID BENEFICIARY, THE PATIENT OR GUARANTOR SHALL PROVIDE THE HOSPITAL FACILITY WITH INFORMATION NECESSARY TO DETERMINE THE MONTHLY COBRA PREMIUM FOR SUCH PATIENT, AND SHALL COOPERATE WITH HOSPITAL FACILITY STAFF TO DETERMINE WHETHER HE OR SHE QUALIFIES FOR HOSPITAL FACILITY COBRA PREMIUM ASSISTANCE, WHICH MAY BE OFFERED FOR A LIMITED TIME TO ASSIST IN SECURING INSURANCE COVERAGE. A HOSPITAL FACILITY SHALL MAKE AFFIRMATIVE EFFORTS TO HELP A PATIENT OR PATIENT'S GUARANTOR APPLY FOR PUBLIC AND PRIVATE PROGRAMS. PART I, LINE 3C: UNLESS ELIGIBLE FOR PRESUMPTIVE FINANCIAL ASSISTANCE, THE FOLLOWING ELIGIBILITY CRITERIA MUST BE MET IN ORDER FOR A PATIENT TO QUALIFY FOR FINANCIAL ASSISTANCE:* THE PATIENT MUST HAVE A MINIMUM ACCOUNT BALANCE OF THIRTY-FIVE DOLLARS ($35.00) WITH THE CHI HOSPITAL ORGANIZATION. MULTIPLE ACCOUNT BALANCES MAY BE COMBINED TO REACH THIS AMOUNT. PATIENTS/GUARANTORS WITH BALANCES BELOW THIRTY-FIVE DOLLARS ($35) MAY CONTACT A FINANCIAL COUNSELOR TO MAKE MONTHLY INSTALLMENT PAYMENT ARRANGEMENTS.* THE PATIENT'S FAMILY INCOME MUST BE AT OR BELOW 300% OF THE FPG.* THE PATIENT MUST COMPLY WITH PATIENT COOPERATION STANDARDS AS DESCRIBED [IN THE FAP].* THE PATIENT MUST SUBMIT A COMPLETED FINANCIAL ASSISTANCE APPLICATION.FOR PATIENTS AND GUARANTORS WHO ARE UNABLE TO PROVIDE REQUIRED DOCUMENTATION, A HOSPITAL FACILITY MAY GRANT PRESUMPTIVE FINANCIAL ASSISTANCE BASED ON INFORMATION OBTAINED FROM OTHER RESOURCES. IN PARTICULAR, PRESUMPTIVE ELIGIBILITY MAY BE DETERMINED ON THE BASIS OF INDIVIDUAL LIFE CIRCUMSTANCES THAT MAY INCLUDE:* RECIPIENT OF STATE-FUNDED PRESCRIPTION PROGRAMS;* HOMELESS OR ONE WHO RECEIVED CARE FROM A HOMELESS CLINIC;* PARTICIPATION IN WOMEN, INFANTS AND CHILDREN PROGRAMS (WIC);* FOOD STAMP ELIGIBILITY;* SUBSIDIZED SCHOOL LUNCH PROGRAM ELIGIBILITY;* ELIGIBILITY FOR OTHER STATE OR LOCAL ASSISTANCE PROGRAMS (E.G., MEDICAID SPEND-DOWN);* LOW INCOME/SUBSIDIZED HOUSING IS PROVIDED AS A VALID ADDRESS; OR* PATIENT IS DECEASED WITH NO KNOWN ESTATE. PART I, LINE 7: THE ORGANIZATION'S COST ACCOUNTING SYSTEM WAS USED TO REPORT FINANCIAL ASSISTANCE AND COMMUNITY BENEFITS IN PART I, LINE 7. THE ORGANIZATION'S COST ACCOUNTING SYSTEM ADDRESSES ALL OF THE PATIENTS SERVED BY MERCY HOSPITAL OF VALLEY CITY. PART III, LINE 2: THE ORGANIZATION HAS REPORTED BAD DEBT EXPENSE AT GROSS CHARGES WRITTEN OFF. THE ORGANIZATION'S BAD DEBT EXPENSE REPRESENTS AMOUNTS BILLED TO PATIENTS THAT WAS DEEMED UNCOLLECTIBLE AND DOES NOT INCLUDE ANY CHARGES THAT WERE ULTIMATELY REIMBURSED OR DISCOUNTED. PATIENT DISCOUNTS ARE RECORDED IN CONTRACTUAL ALLOWANCE OR FINANCIAL ASSISTANCE, AS APPROPRIATE, AS AN OFFSET TO GROSS REVENUE AND ARE NOT INCLUDED IN BAD DEBT EXPENSE. PART III, LINE 3: MERCY HOSPITAL OF VALLEY CITY DOES NOT BELIEVE THAT ANY PORTION OF BAD DEBT EXPENSE COULD REASONABLY BE ATTRIBUTED TO PATIENTS WHO QUALIFY FOR FINANCIAL ASSISTANCE SINCE AMOUNTS DUE FROM THOSE INDIVIDUALS' ACCOUNTS WILL BE RECLASSIFIED FROM BAD DEBT EXPENSE TO CHARITY CARE WITHIN 30 DAYS FOLLOWING THE DATE THAT THE PATIENT IS DETERMINED TO QUALIFY FOR CHARITY CARE. PART III, LINE 4: MERCY HOSPITAL OF VALLEY CITY DOES NOT ISSUE SEPARATE COMPANY AUDITED FINANCIAL STATEMENTS. HOWEVER, THE ORGANIZATION IS INCLUDED IN THE CONSOLIDATED FINANCIAL STATEMENTS OF COMMONSPIRIT HEALTH. THE CONSOLIDATED FOOTNOTE READS AS FOLLOWS:COMMONSPIRIT RELIES ON THE RESULTS OF DETAILED REVIEWS OF HISTORICAL WRITE-OFFS AND COLLECTIONS IN ESTIMATING THE COLLECTABILITY OF ACCOUNTS RECEIVABLE. UPDATES TO THE HINDSIGHT ANALYSIS IS PERFORMED AT LEAST QUARTERLY USING PRIMARILY A ROLLING EIGHTEEN-MONTH COLLECTION HISTORY AND WRITE-OFF DATA. SUBSEQUENT CHANGES TO ESTIMATES OF THE TRANSACTION PRICE ARE GENERALLY RECORDED AS ADJUSTMENTS TO NET PATIENT REVENUE IN THE PERIOD OF CHANGE.SUBSEQUENT CHANGES THAT ARE DETERMINED TO BE THE RESULT OF AN ADVERSE CHANGE IN A THIRD-PARTY PAYOR'S ABILITY TO PAY ARE RECORDED AS BAD DEBT EXPENSE IN PURCHASED SERVICES AND OTHER IN THE ACCOMPANYING CONSOLIDATED STATEMENTS OF OPERATIONS AND CHANGE IN NET ASSETS. BAD DEBT EXPENSE FOR 2021 AND 2020 WAS NOT SIGNIFICANT. PART III, LINE 8: COMMONSPIRIT HEALTH HOSPITALS PREPARE MEDICARE COST REPORTS IN A MANNER THAT COMPORTS WITH PROVIDER REIMBURSEMENT MANUAL (PRM) 15-1 AND PRM 15-2 CHAPTER 40 (TRANSMITTAL 13). AS SUCH, THE FOLLOWING LANGUAGE PER PRM 15-1 DESCRIBES THE COMPUTATION OF COSTS PER THE MEDICARE COST REPORT: TOTAL ALLOWABLE COSTS OF A PROVIDER ARE APPORTIONED BETWEEN PROGRAM BENEFICIARIES AND OTHER PATIENTS SO THAT THE SHARE BORNE BY THE PROGRAM IS BASED UPON ACTUAL SERVICES RECEIVED BY PROGRAM BENEFICIARIES. THE RATIO OF COVERED BENEFICIARY CHARGES TO TOTAL PATIENT CHARGES FOR THE SERVICES OF EACH ANCILLARY DEPARTMENT IS APPLIED TO THE COST OF THE DEPARTMENT. ADDED TO THIS AMOUNT IS THE COST OF ROUTINE SERVICES FOR PROGRAM BENEFICIARIES, DETERMINED ON THE BASIS OF A SEPARATE AVERAGE COST PER DIEM FOR ALL PATIENTS FOR GENERAL ROUTINE PATIENT CARE AREAS. ANOTHER FACTOR CONSIDERED IS A SEPARATE AVERAGE COST PER DIEM FOR EACH INTENSIVE CARE UNIT, CORONARY CARE UNIT, AND OTHER SPECIAL CARE INPATIENT HOSPITAL UNITS. COMMONSPIRIT HEALTH AND ITS SUBORDINATE CORPORATIONS BELIEVE THAT THE ENTIRE MEDICARE SHORTFALL FOR THE CONSOLIDATED ENTITIES, CONSTITUTES COMMUNITY BENEFIT. THE IRS COMMUNITY BENEFIT STANDARD INCLUDES THE PROVISION OF CARE TO THE ELDERLY AND MEDICARE PATIENTS. MEDICARE SHORTFALLS MUST BE ABSORBED BY COMMONSPIRIT HEALTH HOSPITALS IN ORDER TO CONTINUE TREATING THE ELDERLY IN OUR COMMUNITIES. THE HOSPITALS PROVIDE CARE REGARDLESS OF THIS SHORTFALL AND THEREBY RELIEVE THE FEDERAL GOVERNMENT OF THE BURDEN OF PAYING THE FULL COST FOR MEDICARE BENEFICIARIES. MERCY HOSPITAL OF VALLEY CITY'S SURPLUS, AS REPORTED ON PART III, SECTION B, LINE 7, OF $473,500 REPRESENTS THE FILING ORGANIZATION'S MEDICARE COST REPORTS. PART III, LINE 9B: THE ORGANIZATION'S BILLING AND COLLECTIONS POLICY APPLIES TO ALL INDIVIDUALS PRESENTING FOR EMERGENCY OR OTHER MEDICALLY NECESSARY CARE. THE POLICY CONTAINS PROVISIONS FOR COLLECTING AMOUNTS DUE FROM THOSE PATIENTS WHO THE ORGANIZATION KNOWS TO QUALIFY FOR FINANCIAL ASSISTANCE EITHER THROUGH THE TRADITIONAL FINANCIAL ASSISTANCE APPLICATION PROCESS OR THROUGH PRESUMPTIVE ELIGIBILITY PROCESSES. BEFORE ENGAGING IN EXTRAORDINARY COLLECTION ACTIONS (ECAS) TO OBTAIN PAYMENT FOR EMCARE, HOSPITAL FACILITIES MUST MAKE REASONABLE EFFORTS THROUGH ITS BILLING AND COLLECTIONS PROCESSES, PURSUANT TO TREAS. REG. 1.501(R)-6(C), TO DETERMINE WHETHER AN INDIVIDUAL IS ELIGIBLE FOR FINANCIAL ASSISTANCE. IN NO EVENT WILL AN ECA BE INITIATED PRIOR TO 120 DAYS FROM THE DATE THE FACILITY PROVIDES THE FIRST POST-DISCHARGE BILLING STATEMENT (I.E., DURING THE NOTIFICATION PERIOD) UNLESS ALL REASONABLE EFFORTS HAVE BEEN MADE.HOSPITAL FACILITIES WILL NOT REFER ACCOUNTS FOR COLLECTION WHERE THE PATIENT HAS INITIALLY APPLIED FOR FINANCIAL ASSISTANCE, AND THE HOSPITAL FACILITY HAS NOT YET MADE REASONABLE EFFORTS WITH RESPECT TO THE ACCOUNT.FOR PATIENTS AND GUARANTORS WHO ARE UNABLE TO PROVIDE REQUIRED DOCUMENTATION, A HOSPITAL FACILITY MAY GRANT PRESUMPTIVE FINANCIAL ASSISTANCE BASED ON INFORMATION OBTAINED FROM OTHER RESOURCES.PATIENTS WHO QUALIFY FOR MEDICAID ARE PRESUMED TO QUALIFY FOR FULL CHARITY WRITE OFF. ANY CHARGES FOR DAYS OR SERVICES WRITTEN OFF (EXCLUDING MEDICAID DENIALS RELATED TO TIMELINESS OF BILLING, INSUFFICIENT MEDICAL RECORD DOCUMENTATION, MISSING INVOICES, AUTHORIZATION, OR ELIGIBILITY ISSUES) AS A RESULT OF A MEDICAID ARE BOOKED AS CHARITY.SOME MEDICAID PLANS OFFER COVERAGE FOR A LIMITED OR RESTRICTED LIST OF SERVICES. IF A PATIENT IS ELIGIBLE FOR MEDICAID, ANY CHARGES FOR DAYS OR SERVICES NOT COVERED BY THE PATIENT'S COVERAGE MAY BE WRITTEN OFF TO CHARITY WITHOUT A COMPLETED APPLICATION. THIS DOES NOT INCLUDE ANY SHARE OF COST (SOC) OR OTHER PATIENT COST-SHARING AMOUNTS SUCH AS DEDUCTIBLES OR COPAYMENTS, AS SUCH COSTS ARE DETERMINED BY THE STATE TO BE AN AMOUNT THAT THE PATIENT MUST PAY BEFORE THE PATIENT IS ELIGIBLE FOR MEDICAID. HEALTH AND HUMAN SERVICES (HSS) USES THE TERM "SPEND DOWN" INSTEAD OF SHARE OF COST.ALL COLLECTION ACTIVITIES CONDUCTED BY THE FACILITY, A DESIGNATED SUPPLIER, OR ITS THIRD-PARTY COLLECTION AGENTS WILL BE IN CONFORMANCE WITH ALL FEDERAL AND STATE LAWS GOVERNING DEBT COLLECTION PRACTICES. ALL THIRD-PARTY AGREEMENTS GOVERNING COLLECTION AND RECOVERY ACTIVITIES MUST INCLUDE A PROVISION REQUIRING COMPLIANCE WITH THE HOSPITAL FACILITIES' FINANCIAL ASSISTANCE AND BILLING AND COLLECTIONS POLICY AND INDEMNIFICATION FOR FAILURES AS A RESULT OF ITS NONCOMPLIANCE. THIS INCLUDES, BUT IS NOT LIMITED TO, AGREEMENTS BETWEEN THIRD PARTIES WHO SUBSEQUENTLY SELL OR REFER DEBT OF THE HOSPITAL FACILITY. PART VI, LINE 2: ORGANIZATION'S MISSION, VISION, AND TAX-EXEMPT PURPOSECHI MERCY HEALTH WAS FOUNDED TO ALLEVIATE A SHORTAGE OF HOSPITAL BEDS IN THE COMMUNITY AND OPENED ON MAY 15, 1928. AS THE FIRST CATHOLIC HOSPITAL TO SERVE THE COMMUNITY, CHI MERCY HEALTH EMBRACED THE MISSION OF THE FOUNDING CONGREGATION, THE SISTERS OF MERCY, WHICH JOINED WITH OTHER CONGREGATIONS IN 1996 TO FORM CATHOLIC HEALTH INITIATIVES.THE MISSION OF CHI MERCY HEALTH OF VALLEY CITY AND COMMONSPIRIT HEALTH IS "WE MAKE THE HEALING PRESENCE OF GOD KNOWN IN OUR WORLD BY IMPROVING THE HEALTH OF THE PEOPLE WE SERVE, ESPECIALLY THOSE WHO ARE VULNERABLE, WHILE WE ADVANCE SOCIAL JUSTICE FOR ALL."COMMONSPIRIT HEALTH'S VISION IS "A HEALTHIER FUTURE FOR ALL - INSPIRED BY FAITH, DRIVEN BY INNOVATION, AND POWERED BY OUR HUMANITY. OUR CORE VALUES "COMPASSION, INCLUSION, INTEGRITY, EXCELLENCE, AND COLLABORATION", ARE THE GUIDING PRINCIPLES THAT PROVIDE FOCUS, DIRECTION AND ACCOUNTABILITY. THE CORE VALUES PLAY A VITAL ROLE IN CREATING IDENTITY, SPIRIT AND CONNECTION WITH ONE ANOTHER IN COMMON SPIRIT HEALTH.THE PRIMARY EXEMPT PURPOSE OF CHI MERCY HEALTH OF VALLEY CITY IS TO PROVIDE HEALTHCARE SERVICES TO RESIDENTS IN THE COMMUNITY AND SURROUNDING AREA REGARDLESS OF THEIR ABILITY TO PAY.AT CHI MERCY HEALTH, YOU'LL FIND DEDICATED, COMMITTED, HIGHLY QUALIFIED INDIVIDUALS WHO CAN MEET YOUR ROUTINE AND NOT-SO-ROUTINE HEALTH CARE NEEDS 365 DAYS OF THE YEAR WITHOUT THE INCONVENIENCE OF A 60-MILE DRIVE. SERVICES AVAILABLE AT CHI MERCY HEALTH INCLUDE: ACUTE CARE & SWING BED, AMBULATORY CARE, CARDIAC REHAB, HEALTH EDUCATION, TRAUMA 5 EMERGENCY ROOM, LABORATORY, OCCUPATIONAL THERAPY, PHYSICAL THERAPY, RADIOLOGY, RESPIRATORY THERAPY, RESPITE CARE, SAME DAY SURGERY, SLEEP STUDIES, SOCIAL & BEHAVIORAL SERVICES, COUNSELING SERVICES, SPIRITUAL SERVICES, STRESS TESTING, MAMMOGRAPHY, AND PAIN MANAGEMENT INJECTIONS.CHI MERCY HEALTH ASSISTS IN ADDRESSING THE PHYSICAL, SPIRITUAL, AND EMOTIONAL NEEDS OF VALLEY CITY AND PORTIONS OF SIX SURROUNDING COUNTIES. THE MISSION DEPARTMENT, SPIRITUAL CARE AND THE SOCIAL SERVICES DEPARTMENT PROVIDE ASSISTANCE FOR THOSE NEEDING GUIDANCE AND HELP.THE CHI MERCY HEALTH BOARD OF DIRECTORS CONSISTS OF SIX MEMBERS REPRESENTING A CROSS SECTION OF LOCAL RESIDENTS, WOMEN RELIGIOUS, AND COMMONSPIRIT HEALTH. THE BOARD HAS FIDUCIARY RESPONSIBILITY FOR THE QUALITY, LEGAL COMPLIANCE AND FINANCIAL/BUSINESS PERFORMANCE OF THE HOSPITAL AS WELL AS FOR HIRING THE HOSPITAL ADMINISTRATOR. THEY MEET FOUR TIMES PER YEAR, OR MORE AS NEEDED, TO ASSESS STRATEGIC DIRECTION, MISSION COMPLIANCE, AND MONTHLY PERFORMANCE AS COMPARED TO ESTABLISHED BENCHMARKS. THEY ALSO ROUTINELY EVALUATE LEGAL COMPLIANCE, HUMAN RESOURCES MANAGEMENT, MEDICAL STAFF RELATIONS, COMMUNITY NEEDS, AND NEW BUSINESS LINES.THE LAST COMMUNITY HEALTH NEEDS ASSESSMENT WAS CONDUCTED IN THE FALL OF 2018 AND WAS ADOPTED IN APRIL OF 2019. A BROAD REPRESENTATION OF THE COMMUNITY WAS INCLUDED IN THE COMMUNITY HEALTH NEEDS ASSESSMENT COALITION. THE INITIATIVE WAS FACILITATED BY LEADERS FROM CITY COUNTY HEALTH DISTRICT AND CHI MERCY HEALTH. ALL COALITION REPRESENTATIVES PARTICIPATED IN DATA REVIEW AND LOCAL CHNA TOOL CONTENT DEVELOPMENT AND DATE COLLECTION. THE MEMBERS THEN PARTICIPATED IN FURTHER DATA REVIEW AND FINALLY IN CONSENSUS PRIORITY SETTING.USING DATA FROM THE INITIAL PRESENTATION AND CHNA, THE COALITION IDENTIFIED PRIORITY AREAS. THE PROCESS THAT WAS USED FOR PRIORITIZATION INCLUDED STRUCTURED BRAINSTORMING TO CREATE THE LIST OF PERTINENT ISSUES. THIS WAS THEN FOLLOWED WITH A MULTI-VOTING PRIORITY PROCESS, WHEREAS THE MEMBERS IDENTIFIED THE PRIORITIES FOR THE POPULATION THEY REPRESENTED. THE PRIORITY AREAS IDENTIFIED BY THE COALITION ARE:* SUBSTANCE ABUSE/ADDICTION (ALCOHOL AND DRUGS)* ATTRACTING AND RETAINING YOUNG FAMILIES* AVAILABILITY OF SUBSTANCE ABUSE/TREATMENT SERVICES* DEPRESSION AND ANXIETYTHE 2019 CHNA AND IMPLEMENTATION STRATEGY PLAN CAN BE LOCATED ON:WWW.MERCYHOSPITALVALLEYCITY.ORG PART VI, LINE 3: NOTIFICATION ABOUT THE AVAILABILITY OF FINANCIAL ASSISTANCE FROM CHI HOSPITAL ORGANIZATIONS SHALL BE DISSEMINATED BY VARIOUS MEANS, WHICH MAY INCLUDE, BUT NOT BE LIMITED TO: - CONSPICUOUS PUBLICATION OF NOTICES IN PATIENT BILLS; - NOTICES POSTED IN EMERGENCY ROOMS, URGENT CARE CENTERS, ADMITTING/REGISTRATION DEPARTMENTS, BUSINESS OFFICES, AND AT OTHER PUBLIC PLACES AS A HOSPITAL FACILITY MAY ELECT; AND - PUBLICATION OF A SUMMARY OF THIS POLICY ON THE HOSPITAL FACILITY'S WEBSITE AND AT OTHER PLACES WITHIN THE COMMUNITIES SERVED BY THE HOSPITAL FACILITY AS IT MAY ELECT. SUCH NOTICES AND SUMMARY INFORMATION SHALL INCLUDE A CONTACT NUMBER AND SHALL BE PROVIDED IN ENGLISH, SPANISH, AND OTHER PRIMARY LANGUAGES SPOKEN BY THE POPULATION SERVED BY AN INDIVIDUAL HOSPITAL FACILITY, AS APPLICABLE. REFERRAL OF PATIENTS FOR FINANCIAL ASSISTANCE MAY BE MADE BY ANY MEMBER OF THE CHI HOSPITAL ORGANIZATION NON-MEDICAL OR MEDICAL STAFF, INCLUDING PHYSICIANS, NURSES, FINANCIAL COUNSELORS, SOCIAL WORKERS, CASE MANAGERS, CHAPLAINS, AND RELIGIOUS SPONSORS. A REQUEST FOR ASSISTANCE MAY BE MADE BY THE PATIENT OR A FAMILY MEMBER, CLOSE FRIEND, OR ASSOCIATE OF THE PATIENT, SUBJECT TO APPLICABLE PRIVACY LAWS.IN ADDITION, HOSPITAL REGISTRATION CLERKS ARE TRAINED TO PROVIDE CONSULTATION TO THOSE WHO HAVE NO INSURANCE OR POTENTIALLY INADEQUATE INSURANCE CONCERNING THEIR FINANCIAL OPTIONS INCLUDING APPLICATION FOR MEDICAID AND FOR ASSISTANCE UNDER THE FINANCIAL ASSISTANCE POLICY. COUNSELORS ASSIST MEDICARE ELIGIBLE PATIENTS IN ENROLLMENT BY PROVIDING REFERRALS TO THE APPROPRIATE GOVERNMENT AGENCIES. ONCE IT IS DETERMINED THAT THE PATIENT DOES NOT QUALIFY FOR ANY THIRD PARTY FUNDING, THE PATIENT IS VERBALLY NOTIFIED ABOUT THE EXISTENCE OF FINANCIAL ASSISTANCE APPLICATION AND ADDITIONAL SCREENING TAKES PLACE BY A HOSPITAL EMPLOYEE TO DETERMINE IF THE PATIENT IS ELIGIBLE FOR CHARITY SERVICE PRIOR TO DISCHARGE. UPON REGISTRATION (AND ONCE ALL EMTALA REQUIREMENTS ARE MET), PATIENTS WHO ARE IDENTIFIED AS UNINSURED (AND NOT COVERED BY MEDICARE OR MEDICAID) ARE PROVIDED WITH A PACKET OF INFORMATION THAT ADDRESSES THE FINANCIAL ASSISTANCE POLICY, THE PLAIN LANGUAGE SUMMARY OF THAT POLICY, AND AN APPLICATION FOR ASSISTANCE. HOSPITAL REGISTRATION CLERKS READ THE ORGANIZATION'S MEDICAL ASSISTANCE POLICY TO THOSE WHO APPEAR TO BE INCAPABLE OF READING, AND PROVIDE TRANSLATORS FOR NON-ENGLISH-SPEAKING INDIVIDUALS. PATIENTS THAT HAVE BEEN DISCHARGED PRIOR TO CHARITY SCREENING, SUCH AS EMERGENCY ROOM PATIENTS, RECEIVE A WRITTEN NOTIFICATION OF POSSIBLE ELIGIBILITY FOR SERVICES. IF THE PATIENT IS DETERMINED NOT TO BE ELIGIBLE FOR GOVERNMENT ASSISTANCE, HE/SHE MAY NOTIFY THE HOSPITAL THAT THEY SEEK CHARITY ASSISTANCE. THE APPROPRIATE CHARITY FORM IS SENT TO THE PATIENT/GUARANTOR FOR COMPLETION AND THEN RETURNED TO THE HOSPITAL FOR EVALUATION AND QUALIFICATION. ONCE DETERMINATION OF ELIGIBILITY IS MADE, THE PATIENT IS SENT A NOTICE INFORMING HIM/HER IF THEY QUALIFY FOR FULL, PARTIAL, OR NO CHARITY CARE SERVICES.HOSPITAL FACILITIES MUST MAKE REASONABLE EFFORTS THROUGH ITS BILLING AND COLLECTIONS PROCESSES, PURSUANT TO TREAS. REG. 1.501(R)-6(C), TO DETERMINE WHETHER ANY INDIVIDUAL IS ELIGIBLE FOR FINANCIAL ASSISTANCE. PART VI, LINE 4: CHI MERCY HEALTH IS LOCATED IN VALLEY CITY, BARNES COUNTY, NORTH DAKOTA. BARNES COUNTY IS THE PRIMARY SERVICE AREA WITH CLOSE TO 90% OF THE PATIENT'S VISITS AND ALMOST 72% COME FROM VALLEY CITY ALONE. SERVICE AREA POPULATION WAS ESTIMATED BY THE US CENSUS BUREAU IN 2019 TO BE AT 10,706 FOR BARNES COUNTYWHICH HAS A TOTAL AREA OF 1,492 SQUARE MILES. THIS DATA SHOWS THERE WAS A 3.3% DECREASE IN POPULATION IN BARNES COUNTY. CHILDREN UNDER THE AGE OF 18 ROSE TO 22.1% AND SOMEONE OVER 65 YEARS OF AGE ROSE TO 29.7%. THE MEDIAN INCOME FOR A HOUSEHOLD HAS INCREASED TO $57,064. THE POPULATION LIVING BELOW THE POVERTY LINE INCREASED FROM 9.3% (2013 ESTIMATE) TO 10.5%. THE RACIAL MAKEUP OF THE COUNTY WAS 92.8% WHITE. CHI MERCY HEALTH SERVICE AREA ALSO INCLUDES PORTIONS OF THE FOLLOWING COUNTIES: CASS, LAMOURE, RANSOM, STUTSMAN, GRIGGS, AND STEELE - SOME OF THESE COUNTIES ARE LESS THAN TENTHS OF A PERCENT SERVED BY CHI MERCY HEALTH. PART VI, LINE 5: COLLABORATIVE EFFORTS TO IMPROVE COMMUNITY HEALTHCOLLABORATIVE EFFORTS TO IMPROVE COMMUNITY HEALTH HAS BEEN GOING STRONG FOR SEVERAL YEARS IN BARNES COUNTY BY PROVIDING EDUCATIONAL CLASSES TO IMPROVE HEALTH ARE CARDIAC REHAB, COMMUNITY AND BUSINESS CPR CLASSES, LABORATORY EDUCATION TO VCSU STUDENTS, SOCIAL & BEHAVIORAL SERVICES, ADVANCED DIRECTIVE EDUCATION AND ASSISTANCE, EDUCATIONAL OPPORTUNITIES ENCOMPASS A WIDE SPAN OF PATIENT TYPES. EDUCATION INCLUDES LECTURES, PRESENTATIONS, AND OTHER PROGRAMS AND ACTIVITIES PROVIDED TO GROUPS WITHOUT PROVIDING CLINICAL OR DIAGNOSTIC SERVICES.CARDIAC SUPPORT GROUP AND BEHAVIORAL SERVICES COMMUNITY BASED CLINICAL SERVICES AND HEALTH CARE SUPPORT SERVICES: ARE PROVIDED TO THE COMMUNITY SUCH AS CARDIAC REHAB - PHASE III WHICH IS OUTPATIENT SUPERVISED EXTENDED EXERCISE FOR CARDIAC PATIENTS. MEMORY SCREENINGS BY SOCIAL SERVICES. HOSPITAL NURSES ALSO ANSWER CALLS FOR THE ABUSED PERSONS OUTREACH CENTER AND PAGES THE OUTREACH CENTER'S ON-CALL STAFF; SOCIAL SERVICE ASSISTANCE FOR PUBLIC PROGRAMS, CO-LEAD THE BARNES COUNTY BEHAVIORAL HEALTH COALITION, RUN A DOMESTIC VIOLENCE PREVENTION TEAM FOR COMMUNITY OUTREACH AND HEALTHY RELATIONSHIP TRAINING, AS WELL AS ENVIRONMENTAL IMPROVEMENT ACTIVITIES IS THE COMMUNITY SHARPS DISPOSAL PROGRAM.HEALTH PROFESSIONS EDUCATION:CHI MERCY HEALTH PLACES A HIGH PRIORITY ON PROVIDING EDUCATION AND SUPPORT OF INDIVIDUALS PURSUING CAREERS IN THE HEALTH CARE FIELD. CHI MERCY HEALTH HAS A NURSE INTERNSHIP PROGRAM WHERE INDIVIDUALS ARE PAID TO WORK, ONE-ON-ONE, ALONGSIDE A REGISTERED NURSE TO OBTAIN CLINICAL EXPERIENCE WHILE IN NURSING SCHOOL. WE ALSO PROVIDED SUPERVISION AND GUIDANCE FOR THE FOLLOWING STUDENTS LAB STUDENT ROTATION PROGRAM; PHARMACY STUDENT ONSITE; AND PHYSICAL THERAPY STUDENTS. WE SUPPORT OUR LOCAL HIGH SCHOOL HEALTH CAREERS JOB SHADOW PROGRAM. WE PROVIDE INTEREST-FREE LOANS TO HEALTH CAREER STUDENTS WHILE THEY ARE IN SCHOOL. DONATIONS AND FREE TEACHING SPACE ARE MADE TO DAKOTA NURSING PROGRAM AND WE PROVIDE BOTH NURSING SCHOLARSHIPS AND GENERAL MEDICAL SCHOLARSHIPS TO LOCAL YOUTH PURSUING A CAREER IN THE HEALTHCARE FIELD. CHI MERCY HEALTH REACHES OUT TO STUDENTS NOT ONLY TO OUR LOCAL ELEMENTARY AND HIGH SCHOOL STUDENTS, BUT ALSO TO VALLEY CITY STATE UNIVERSITY, VO TECH HIGH SCHOOL, NDSU, NDSCS, AND LRSC.COMMUNITY-BUILDING ACTIVITIESCOMMUNITY-BUILDING ACTIVITIES INCLUDE CASH, IN-KIND DONATIONS AND BUDGETED EXPENDITURES FOR THE DEVELOPMENT OF COMMUNITY HEALTH PROGRAMS AND PARTNERSHIPS. CHI MERCY HEALTH IS INVOLVED IN SEVERAL COLLABORATIVE EFFORTS TO IMPROVE OUR COMMUNITY AND IS FORTUNATE TO HAVE DEDICATED STAFF THAT SUPPORTS THE HOSPITAL EFFORTS IN COMMUNITY PROJECTS: BARNES COUNTY BEHAVIORAL HEALTH COALITION, HEALTHY COMMUNITY COALITION/COMMUNITY RESOURCE COLLABORATION; VIOLENCE PREVENTION; ALSO MEMBERSHIP IN THE VALLEY CITY AREA CHAMBER OF COMMERCE, NORTH DAKOTA WINTER SHOW, ROTARY, BARNES COUNTY MINISTERIAL ASSOCIATION, AND ND APIC AND COMMUNITY HEALTH IMPROVEMENT ADVOCACY.COMMUNITY BENEFIT OPERATIONS:COMMUNITY BENEFIT OPERATIONS INCLUDE COSTS ASSOCIATED WITH DEDICATED STAFF, COMMUNITY HEALTH NEEDS AND/OR ASSETS ASSESSMENT, AND OTHER COSTS ASSOCIATED WITH COMMUNITY BENEFIT STRATEGY AND OPERATIONS. DEDICATED STAFF HOURS ARE COUNTED FOR THE WORK ON CHARITY CARE ASSISTING THE PATIENTS THAT ARE UNDERINSURED OR UNINSURED. CHI MERCY HEALTH AS A NONPROFIT, TAX-EXEMPT FACILITY CONTINUES TO TAKE THE NECESSARY MEASURES TO BE COMPLIANT WITH NEW LEGISLATION RESULTING FROM HEALTHCARE REFORM IN DETERMINING WHAT TO REPORT, HOW TO REPORT, AND ALSO IMPLEMENTING STRATEGIES IN RESPONSE FROM THE COMMUNITY NEEDS ASSESSMENT. PART VI, LINE 6: THE ORGANIZATION IS AFFILIATED WITH COMMONSPIRIT HEALTH. COMMONSPIRIT HEALTH WAS CREATED BY THE ALIGNMENT OF CATHOLIC HEALTH INITIATIVES AND DIGNITY HEALTH IN EARLY 2019. COMMONSPIRIT HEALTH, A NONPROFIT, FAITH-BASED HEALTH SYSTEM IS COMMITTED TO BUILDING HEALTHIER COMMUNITIES, ADVOCATING FOR THOSE WHO ARE POOR AND VULNERABLE, AND INNOVATING HOW AND WHERE HEALING CAN HAPPEN BOTH INSIDE ITS HOSPITALS AND OUT IN THE COMMUNITY. COMMONSPIRIT HEALTH OWNS AND OPERATES HEALTH CARE FACILITIES IN 21 STATES AND IS THE SOLE CORPORATE MEMBER (PARENT CORPORATION) OF OTHER PRIMARILY NONPROFIT CORPORATIONS THAT ARE EXEMPT FROM FEDERAL AND STATE INCOME TAXES. COMMONSPIRIT HEALTH IS COMPRISED OF MORE THAN 1,500 CARE SITES, CONSISTING OF 140 HOSPITALS, INCLUDING ACADEMIC HEALTH CENTERS, MAJOR TEACHING HOSPITALS, AND CRITICAL ACCESS FACILITIES, COMMUNITY HEALTH SERVICES ORGANIZATIONS, ACCREDITED NURSING COLLEGES, HOME HEALTH AGENCIES, LIVING COMMUNITIES, A MEDICAL FOUNDATION AND OTHER AFFILIATED MEDICAL GROUPS, AND OTHER FACILITIES AND SERVICES THAT SPAN THE INPATIENT AND OUTPATIENT CONTINUUM OF CARE. IN FISCAL YEAR 2021, COMMONSPIRIT HEALTH PROVIDED MORE THAN $2.5 BILLION IN FINANCIAL ASSISTANCE AND COMMUNITY BENEFIT FOR PROGRAMS AND SERVICES FOR THE POOR, FREE CLINICS, EDUCATION AND RESEARCH. FINANCIAL ASSISTANCE AND COMMUNITY BENEFIT TOTALED MORE THAN $5.1 BILLION WITH THE INCLUSION OF THE UNPAID COSTS OF MEDICARE. THE HEALTH SYSTEM, WHICH GENERATED OPERATING REVENUES OF $33.25 BILLION IN FISCAL YEAR 2021, HAS TOTAL ASSETS OF APPROXIMATELY $54.87 BILLION.COMMONSPIRIT HEALTH PROVIDES STRATEGIC PLANNING AND MANAGEMENT SERVICES AS WELL AS CENTRALIZED SERVICES FOR ITS DIVISIONS. THE PROVISION OF CENTRALIZED MANAGEMENT AND SHARED SERVICES INCLUDING AREAS SUCH AS ACCOUNTING, HUMAN RESOURCES, PAYROLL AND SUPPLY CHAIN PROVIDES ECONOMIES OF SCALE AND PURCHASING POWER TO THE DIVISIONS. THE COST SAVINGS ACHIEVED THROUGH COMMONSPIRIT HEALTH'S CENTRALIZATION ENABLE DIVISIONS TO DEDICATE ADDITIONAL RESOURCES TO HIGH-QUALITY HEALTH CARE AND COMMUNITY OUTREACH SERVICES TO THE MOST VULNERABLE MEMBERS OF OUR SOCIETY. PART VI, LINE 7, REPORTS FILED WITH STATES ND 0 1 0 0 0 0 0 0 0 CLIFF ROBERTSON MD BOARD MEMBER/CSH SVP DIVISION OFFICE 0 1011674 0 921351 0 397677 0 16975 0 29727 0 2377404 0 157178 JEFFREY DROP BOARD MEMBER/CSH SVP DIVISION OFFICE 0 692085 0 430582 0 141130 0 16844 0 17949 0 1298590 0 0 JEANETTE WOJTALEWICZ BOARD MEMBER/CSH SVP DIVISION OFFICE 0 553985 0 277663 0 154664 0 17649 0 32617 0 1036578 0 49946 KEITH HEUSER BOARD MEMBER/PRESIDENT 0 231874 0 24821 0 19399 0 16460 0 17381 0 309935 0 0 CLARK KRUTA CRNA 215223 0 0 0 12120 0 11722 0 30345 0 269410 0 0 0 JOSHUA SENGER FORMER TREASURER/VP, FINANCE 0 128810 0 5426 0 246 0 8941 0 29298 0 172721 0 0 CAMILLE SETTELMEYER VP OF CLINICAL SERVICES 0 126327 0 100 0 906 0 8709 0 9981 0 146023 0 0 PART I, LINE 3 DURING THE CALENDAR YEAR 2020, COMPENSATION FOR THE TOP MANAGEMENT OFFICIAL WAS ESTABLISHED AND PAID BY COMMONSPIRIT HEALTH, A RELATED ORGANIZATION. COMMONSPIRIT HEALTH USED THE FOLLOWING TO ESTABLISH THE TOP MANAGEMENT OFFICIAL'S COMPENSATION: (1) COMPENSATION COMMITTEE; (2) INDEPENDENT COMPENSATION CONSULTANT; (3) COMPENSATION SURVEY OR STUDY; (4) APPROVAL BY THE BOARD OR COMPENSATION COMMITTEE. PART 1, LINE 4A: FOR REPORTABLE INDIVIDUALS EMPLOYED PRIOR TO 2019, POST-TERMINATION PAYMENTS ARE ADDRESSED IN EXECUTIVE EMPLOYMENT AGREEMENTS FOR EMPLOYEES AT THE LEVEL OF VICE PRESIDENT AND ABOVE. THESE EMPLOYMENT AGREEMENTS REQUIRE THAT IN ORDER FOR THE EXECUTIVE TO RECEIVE POST-TERMINATION PAYMENTS, THESE INDIVIDUALS MUST EXECUTE A GENERAL RELEASE AND SETTLEMENT AGREEMENT. POST-TERMINATION PAYMENT ARRANGEMENTS ARE PERIODICALLY REVIEWED FOR OVERALL REASONABLENESS IN LIGHT OF THE EXECUTIVE'S OVERALL COMPENSATION PACKAGE. OFFICERS, KEY EMPLOYEES AND CERTAIN HIGHLY COMPENSATED EMPLOYEES WHO BEGAN EMPLOYMENT AFTER NOVEMBER 1ST OF 2019 ARE COVERED BY THE COMMONSPIRIT HEALTH EXECUTIVE SEVERANCE POLICY. THIS POLICY PROVIDES FOR SEVERANCE PAY WHICH VARIES BASED UPON THE EXECUTIVE'S POSITION LEVEL, IN THE EVENT OF A POSITION ELIMINATION OR OTHER QUALIFYING EVENT, IN ACCORDANCE WITH THE GUIDELINES OF THE EXECUTIVE SEVERANCE POLICY. AN EXECUTIVE'S WRITTEN EMPLOYMENT OR SEVERANCE AGREEMENT SHALL CONTROL WHERE THE SEVERANCE PAY AMOUNTS IN THE POLICY CONFLICT WITH THE EXECUTIVE'S WRITTEN EMPLOYMENT OR SEVERANCE AGREEMENT. IN ORDER FOR THE EXECUTIVE TO RECEIVE POST-TERMINATION PAYMENTS, THESE INDIVIDUALS MUST EXECUTE A GENERAL RELEASE AND SETTLEMENT OF CLAIMS. POST-TERMINATION PAYMENT ARRANGEMENTS ARE PERIODICALLY REVIEWED FOR OVERALL REASONABLENESS IN LIGHT OF THE EXECUTIVE'S OVERALL COMPENSATION PACKAGE. PART 1, LINE 4B: DURING THE 2020 CALENDAR YEAR, COMMONSPIRIT HEALTH ("COMMONSPIRIT") MAINTAINED A SUPPLEMENTAL NON-QUALIFIED DEFERRED COMPENSATION PLAN FOR DIVISION CEOS/PRESIDENTS AND OTHER DESIGNATED COMMONSPIRIT EXECUTIVES AT THE LEVEL OF SENIOR VICE PRESIDENT AND ABOVE. DURING 2020 THE FOLLOWING DISTRIBUTIONS WERE MADE BY COMMONSPIRIT FROM THE DEFERRED COMPENSATION PLAN: CLIFF ROBERTSON, $186,901; JEANETTE WOJTALEWICZ, $71,692. DUE TO THE "SUPER" VESTING RULES UNDER COMMONSPIRIT'S DEFERRED COMPENSATION PLAN, PARTICIPANTS WHO HAVE MET CERTAIN REQUIREMENTS SUCH AS INVOLUNTARY TERMINATION WITHOUT CAUSE, AGE, AGE AND YEARS OF SERVICE, OR MORE THAN 5 YEARS OF PLAN PARTICIPATION ARE ELIGIBLE TO RECEIVE THEIR 2020 CONTRIBUTIONS IN CASH. THESE CASH PAYOUTS ARE INCLUDED IN THE PARTICIPANT'S REPORTABLE COMPENSATION IN COLUMN (III) OTHER REPORTABLE COMPENSATION ON SCHEDULE J PART II. DURING 2020, THE FOLLOWING PAYMENTS WERE MADE PURSUANT TO THE SUPER VESTING RULES: CLIFF ROBERTSON, $195,187; JEFFREY DROP, $113,534; JEANETTE WOJTALEWICZ, $77,144, KEITH HEUSER, $13,971. FORM 990, PART VI, SECTION A, LINE 1 PURSUANT TO SECTION 8.6 OF THE BYLAWS OF MERCY HOSPITAL OF VALLEY CITY, THE EXECUTIVE COMMITTEE SHALL CONSIST OF ONLY DIRECTORS OF THE CORPORATION. THE EXECUTIVE COMMITTEE HAS THE POWER TO TRANSACT THE ROUTINE BUSINESS OF THE CORPORATION IN THE INTERIM PERIODS BETWEEN REGULARLY SCHEDULED MEETINGS OF THE BOARD OF DIRECTORS, PROVIDED THAT THEIR ACTIONS ARE CONSISTENT WITH ANY ACTIONS OR POLICIES OF THE BOARD OR THE CORPORATE MEMBER. ALL ACTIONS TAKEN ARE CONTEMPORANEOUSLY DOCUMENTED AND REPORTED TO THE BOARD AT THE EARLIEST MEETING. FORM 990, PART VI, SECTION A, LINE 6 ACCORDING TO THE BYLAWS OF MERCY HOSPITAL OF VALLEY CITY, THE ENTITY'S SOLE MEMBER IS COMMONSPIRIT HEALTH, A COLORADO NONPROFIT ORGANIZATION. FORM 990, PART VI, SECTION A, LINE 7A ACCORDING TO THE ORGANIZATION'S BYLAWS, DIRECTORS SHALL BE APPOINTED OR REFUSED BY THE CORPORATE MEMBER. THE CORPORATE MEMBER MAY APPOINT ONE OR MORE INDIVIDUALS TO THE BOARD OF DIRECTORS, AND MAY AT ANY TIME REMOVE, WITH OR WITHOUT CAUSE, ANY MEMBER OF THE BOARD OF DIRECTORS. ACCORDING TO THE ORGANIZATION'S BYLAWS, DIRECTORS OF THE CORPORATION SHALL BE APPOINTED BY THE CORPORATE MEMBER NO LATER THAN JUNE 30 OF EACH YEAR. THE NAMES AND QUALIFICATIONS OF EACH INDIVIDUAL ACCEPTED BY THE BOARD OF DIRECTORS SHALL BE SUBMITTED TO THE CORPORATE MEMBER, WHO SHALL APPOINT OR REFUSE EACH NOMINEE IN ACCORDANCE WITH THE CORPORATE MEMBER'S BYLAWS AND WITH ENDORSEMENT OF THE SENIOR VICE PRESIDENT OF OPERATIONS. THE CORPORATE MEMBER MAY UNILATERALLY APPOINT ONE OR MORE INDIVIDUALS TO THE BOARD OF DIRECTORS SHOULD THE BOARD FAIL TO FURNISH THE CORPORATE MEMBER WITH A LIST OF INDIVIDUALS QUALIFIED TO SERVE ON THE BOARD OF DIRECTORS OF THE CORPORATION. (CHCF RESERVED RIGHTS) EXCEPT AS OTHERWISE PROVIDED IN THE CORPORATION'S ARTICLES OF INCORPORATION OR THE LAWS OF THE STATE OF ORGANIZATION, CATHOLIC HEALTH CARE FEDERATION ("CHCF") SHALL HAVE SUCH RIGHTS AS ARE RESERVED TO THE CORPORATE MEMBER, ACTING IN ITS CAPACITY AS THE MEMBERSHIP BODY OF CHCF, UNDER THE GOVERNANCE MATRIX. FORM 990, PART VI, SECTION A, LINE 7B THE ORGANIZATION'S CORPORATE MEMBER IS COMMONSPIRIT HEALTH. PURSUANT TO SECTION 5.4 OF THE ORGANIZATION'S BYLAWS, THE CORPORATE MEMBER SHALL HAVE THE SPECIFIC RIGHTS SET FORTH IN THE GOVERNANCE MATRIX. PURSUANT TO THE GOVERNANCE MATRIX THE FOLLOWING RIGHTS ARE RESERVED TO THE COMMONSPIRIT HEALTH BOARD DIRECTLY OR THROUGH POWERS DELEGATED TO THE COMMONSPIRIT HEALTH CHIEF EXECUTIVE OFFICER: * SUBSTANTIAL CHANGE IN THE MISSION OR PHILOSOPHY OF MERCY HOSPITAL OF VALLEY CITY * AMENDMENT OF THE CORPORATE DOCUMENTS OF MERCY HOSPITAL OF VALLEY CITY * APPROVE MEMBERS OF MERCY HOSPITAL OF VALLEY CITY'S BOARD * REMOVAL OF A MEMBER OF THE GOVERNING BODY OF MERCY HOSPITAL OF VALLEY CITY * APPROVAL OF ISSUANCE OF DEBT BY MERCY HOSPITAL OF VALLEY CITY * APPROVAL OF PARTICIPATION OF MERCY HOSPITAL OF VALLEY CITY IN A JOINT VENTURE * APPROVAL OF FORMATION OF A NEW CORPORATION BY MERCY HOSPITAL OF VALLEY CITY * APPROVAL OF A MERGER INVOLVING MERCY HOSPITAL OF VALLEY CITY * APPROVAL OF THE SALE OF ALL OR SUBSTANTIALLY ALL OF THE ASSETS OF MERCY HOSPITAL OF VALLEY CITY * TO REQUIRE THE TRANSFER OF ASSETS BY MERCY HOSPITAL OF VALLEY CITY TO COMMONSPIRIT HEALTH TO ACCOMPLISH COMMONSPIRIT HEALTH'S GOALS AND OBJECTIVES, AND TO SATISFY COMMONSPIRIT HEALTH DEBTS. * ADOPTION OF LONG RANGE AND STRATEGIC PLANS FOR MERCY HOSPITAL OF VALLEY CITY PURSUANT TO SECTION 5.5 OF THE ORGANIZATION'S BYLAWS, COMMONSPIRIT HEALTH MAY, IN EXERCISE OF ITS APPROVAL POWERS, GRANT OR WITHHOLD APPROVAL IN WHOLE OR IN PART, OR MAY, IN ITS COMPLETE DISCRETION, AFTER CONSULTATION WITH THE BOARD AND THE PRESIDENT AND CHIEF EXECUTIVE OFFICER OF THE ORGANIZATION, RECOMMEND SUCH OTHER OR DIFFERENT ACTIONS AS IT DEEMS APPROPRIATE." EXCEPT AS OTHERWISE PROVIDED IN THE CORPORATION'S ARTICLES OF INCORPORATION OR THE LAWS OF THE STATE OF ORGANIZATION, CATHOLIC HEALTH CARE FEDERATION ("CHCF") SHALL HAVE SUCH RIGHTS AS ARE RESERVED TO THE CORPORATE MEMBER, ACTING IN ITS CAPACITY AS THE MEMBERSHIP BODY OF CHCF, UNDER THE GOVERNANCE MATRIX. FORM 990, PART VI, SECTION B, LINE 11B ONCE THE RETURN IS PREPARED, THE RETURN IS PRESENTED TO THE BOARD AT A BOARD MEETING OR AN ELECTRONIC COPY OF THE RETURN IS SENT TO EACH BOARD MEMBER BY EMAIL FOR THEIR REVIEW. SUBSEQUENT TO PROVIDING THE RETURN TO THE BOARD, THE COMMONSPIRIT HEALTH TAX DEPARTMENT FILES THE RETURN WITH THE APPROPRIATE FEDERAL AND STATE AGENCIES, MAKING ANY NONSUBSTANTIVE CHANGES NECESSARY TO EFFECT E-FILING. ANY SUCH CHANGES ARE NOT RESUBMITTED TO THE BOARD FORM 990, PART VI, SECTION B, LINE 12C THE ORGANIZATION HAS A CONFLICTS OF INTEREST ("COI") POLICY (THE "POLICY") IN PLACE TO PROTECT THE INTERESTS OF COMMONSPIRIT HEALTH ("COMMONSPIRIT") IN CIRCUMSTANCES THAT MAY RESULT IN A CONFLICT BETWEEN PERSONAL INTERESTS OF A PERSON AND THE INTERESTS OF THE ORGANIZATION AND THOSE IT SERVES. THE POLICY WAS LAST UPDATED DURING THE TAX YEAR ENDED 6/30/2021. COMMONSPIRIT'S COI POLICY APPLIES TO COMMONSPIRIT, ITS DIRECT AFFILIATES AND SUBSIDIARIES AND ANY RELATED ENTITY THE GOVERNING DOCUMENTS OF WHICH REQUIRE THE ENTITY TO COMPLY WITH COMMONSPIRIT POLICY (COLLECTIVELY THE "SYSTEM ENTITIES"). THE FOLLOWING PERSONS ARE REQUIRED TO DISCLOSE ACTUAL OR POTENTIAL CONFLICTS OF INTEREST AT LEAST ANNUALLY (VIA A FORMAL SYSTEM-ADMINISTERED SURVEY) IF THE PERSON'S AFFILIATION WITH COMMONSPIRIT CONTINUES: - MEMBERS OF CORPORATE AND COMMUNITY BOARDS OF SYSTEM ENTITIES - MEMBERS OF COMMITTEES OF CORPORATE AND COMMUNITY BOARDS OF SYSTEM ENTITIES - MEMBERS OF THE EXECUTIVE LEADERSHIP TEAM ("ELT") OF COMMONSPIRIT - CORPORATE OFFICERS OF SYSTEM ENTITIES - KEY EMPLOYEES AND HIGHEST COMPENSATED EMPLOYEES AS SPECIFIED BY THE INTERNAL REVENUE SERVICE FOR FORM 990 PURPOSES WHO ARE NOT OTHERWISE INCLUDED IN THE CATEGORIES ABOVE - EMPLOYEES OF SYSTEM ENTITIES AT THE VICE PRESIDENT LEVEL AND ABOVE - ALL INDIVIDUALS ENGAGED IN RESEARCH AT INSTITUTIONS OWNED OR OPERATED BY A SYSTEM ENTITY - SELECT EMPLOYEES AS DETERMINED FROM TIME TO TIME BY LEADERSHIP DISCLOSURE, REVIEW, AND MANAGEMENT OF PERCEIVED, POTENTIAL, OR ACTUAL CONFLICTS OF INTEREST ARE ACCOMPLISHED THROUGH A DEFINED COI DISCLOSURE REVIEW PROCESS. EACH PERSON IS REQUIRED TO PROMPTLY AND FULLY DISCLOSE ANY SITUATION OR CIRCUMSTANCE THAT MAY CREATE A CONFLICT OF INTEREST AS SOON AS SHE/HE BECOMES AWARE OF IT. IN ADDITION, AT THE INCEPTION OF AN INDIVIDUAL'S RELATIONSHIP WITH COMMONSPIRIT (E.G. HIRING, BOARD APPOINTMENT), AND FOR CERTAIN POSITIONS, ANNUALLY THEREAFTER, WRITTEN CONFLICT OF INTEREST DISCLOSURE FORMS MUST BE COMPLETED. A FAILURE TO DISCLOSE MAY RESULT IN DISCIPLINARY OR CORRECTIVE ACTIONS. REPORTED POTENTIAL OR ACTUAL CONFLICTS OF INTEREST ARE INITIALLY REVIEWED BY LEGAL, CORPORATE RESPONSIBILITY OR RESEARCH INTEGRITY STAFF. IF NECESSARY, A CONFLICT OF INTEREST MANAGEMENT PLAN IS DEVELOPED, WHICH PLAN SHALL BE SUBJECT TO ACCEPTANCE BY THE APPROPRIATE DIRECT MANAGER, SUPERVISOR, MEDICAL STAFF OFFICE, BOARD OR BOARD COMMITTEE (FOR BOARD, BOARD COMMITTEE, ELT OR CORPORATE OFFICER CONFLICTS), OR OTHER APPROPRIATE INDIVIDUAL OR BODY. ONCE ACCEPTED, THE CONFLICT OF INTEREST MANAGEMENT PLAN IS COMMUNICATED TO THE PERSON WITH THE ACTUAL OR POTENTIAL CONFLICT AND THE INDIVIDUAL MUST CONDUCT THEMSELVES IN CONFORMITY WITH THE PLAN. IN THE EVENT THAT A TRANSACTIONAL CONFLICT INTEREST ARISES IN CONNECTION WITH A SYSTEM ENTITY BOARD MEETING, THE CONFLICTED INDIVIDUAL MUST DISCLOSE THAT CONFLICT PRIOR TO OR AT THE BEGINNING OF THE MEETING IN WHICH THE MATTER IS TO BE CONSIDERED. THE CONFLICTED INDIVIDUAL IS EXCLUDED FROM VOTING ON THE TRANSACTION AND IS PROHIBITED FROM USING PERSONAL INFLUENCE WITH RESPECT TO THE MATTER, BUT IS NOT PROHIBITED FROM PROVIDING INPUT IF REQUESTED TO DO SO. FORM 990, PART VI, SECTION B, LINE 15B THE ORGANIZATION'S TOP MANAGEMENT OFFICIAL'S COMPENSATION WAS PAID BY COMMONSPIRIT HEALTH, A RELATED ORGANIZATION. THE COMMONSPIRIT HEALTH BOARD OF STEWARDSHIP TRUSTEES APPOINTS A HUMAN RESOURCES AND COMPENSATION COMMITTEE, COMPRISED EXCLUSIVELY OF INDEPENDENT DIRECTORS, WHO ARE ACCOUNTABLE FOR APPROVING REASONABLE COMPENSATION PACKAGES FOR EACH OFFICER AND CERTAIN KEY EMPLOYEES (INCLUDING THE PRESIDENT/CEO). THE HUMAN RESOURCES AND COMPENSATION COMMITTEE APPROVES, CONSISTENT WITH THE ORGANIZATION'S PHILOSOPHY AND PRINCIPLES, THE ANNUAL PERFORMANCE GOALS AND CRITERIA TO BE USED IN DETERMINING MERIT INCREASES AND VARIABLE COMPENSATION CRITERIA FOR OFFICERS AND KEY EXECUTIVES. THE HUMAN RESOURCES AND COMPENSATION COMMITTEE ALSO ENGAGES OUTSIDE LEGAL COUNSEL AS NECESSARY AND QUALIFIED INDEPENDENT COMPENSATION AND BENEFITS SPECIALISTS (INDEPENDENT EXPERTS) TO REVIEW, ANALYZE AND PROVIDE BENCHMARKING DATA FOR THE TOTAL COMPENSATION AND BENEFITS PACKAGES OF OFFICERS AND KEY EXECUTIVES. APPROPRIATE COMPARABLE DATA IS OBTAINED FROM THE INDEPENDENT EXPERTS, (E.G., TOTAL ECONOMIC BENEFITS PAID BY SIMILARLY SITUATED ORGANIZATIONS, BOTH TAXABLE AND TAX-EXEMPT, FOR SIMILAR JOB RESPONSIBILITIES). KEY DELIBERATIONS OF THE COMMITTEE ARE DOCUMENTED IN MEETING MINUTES WHICH ARE APPROVED AT THE NEXT COMMITTEE MEETING AND PROVIDED TO THE BOARD OF STEWARDSHIP TRUSTEES. THE DOCUMENTATION OF THE DELIBERATIONS INCLUDES (A) THE TERMS OF THE AGREEMENT APPROVED AND THE DATE APPROVED; (B) THE MEMBERS OF THE COMMITTEE WHO WERE PRESENT DURING DISCUSSION OF THE APPROVED AGREEMENT AND THOSE WHO VOTED ON IT; AND (C) THE COMPARABILITY DATA OBTAINED AND RELIED UPON BY THE COMMITTEE AND HOW THE DATA WAS OBTAINED. DURING THE TAX YEAR ENDED 6/30/2021, ANY EXECUTIVE COMPENSATION PAID TO OFFICERS, DIRECTORS OR TRUSTEES WAS REVIEWED AND APPROVED BY THE BOARD UTILIZING COMPARABILITY STUDIES TO DETERMINE COMPENSATION AND WAS CONTEMPORANEOUSLY DOCUMENTED. FORM 990, PART VI, SECTION C, LINE 19 THE ORGANIZATION'S FINANCIAL STATEMENTS, CONFLICT OF INTEREST POLICY AND GOVERNING DOCUMENTS ARE AVAILABLE TO THE PUBLIC UPON REQUEST. THE ORGANIZATION'S FINANCIAL STATEMENTS ARE INCLUDED IN COMMONSPIRIT HEALTH'S CONSOLIDATED AUDITED FINANCIAL STATEMENTS THAT ARE AVAILABLE AT WWW.COMMONSPIRITHEALTH.ORG. FORM 990, PART VI, LINE 14 THE DOCUMENT RETENTION AND DESTRUCTION POLICY IS MORE OF AN OPERATIONAL POLICY. THESE TYPES OF POLICIES USUALLY DO NOT GO TO THE BOARD OF DIRECTORS. THIS HAS NOT BEEN ADOPTED BY THE BOARD OF DIRECTORS. FORM 990, PART IX, LINE 11G OTHER FEES: PROGRAM SERVICE EXPENSES 930,900. MANAGEMENT AND GENERAL EXPENSES 103,433. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 1,034,333. CONSULTING: PROGRAM SERVICE EXPENSES 13. MANAGEMENT AND GENERAL EXPENSES 1. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 14. CONTRACT SERVICES: PROGRAM SERVICE EXPENSES 570,857. MANAGEMENT AND GENERAL EXPENSES 63,429. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 634,286. CONTRACT LABOR: PROGRAM SERVICE EXPENSES 1,193,840. MANAGEMENT AND GENERAL EXPENSES 132,649. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 1,326,489. PURCHASED SERVICES: PROGRAM SERVICE EXPENSES 534,265. MANAGEMENT AND GENERAL EXPENSES 59,363. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 593,628. FORM 990, PART XI, LINE 9: REALLOCATION OF CARES ACT REVENUE 3,006,849. EQUITY CHANGES OF UNCONSOLIDATED ORGS -35,382. FORM 990, PART XI, LINE 8: PRIOR PERIOD ADJUSTMENT: CENTRALIZED TRANSACTIONS: TRANSFERS FOR JOURNAL ENTRIES RECORDED CENTRALLY AT COMMONSPIRIT TO STANDARDIZE CONTRACTUAL ALLOWANCE METHODOLOGY ACROSS ALL COMMONSPIRIT AFFILIATES AND SUBSIDIARIES. RECORDED CENTRALLY AT YEAR END AND TRANSFERRED TO FACILITIES IN THE FOLLOWING YEAR. 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BRECKENRIDGE MN 56520 411850500 SENIOR LIVING MN 501(C)(3) LINE 10 SFH 0 ARROYO GRANDE COMMUNITY HOSPITAL FOUNDATION 345 S HALCYON RD ARROYO GRANDE CA 93420 203256066 FUNDRAISING FOUNDATION CA 501(C)(3) LINE 12A, I DH 0 BAKERSFIELD MEMORIAL HOSPITAL 420 34TH STREET BAKERSFIELD CA 93301 951802779 HOSPITAL CA 501(C)(3) LINE 3 DCC 0 BARROW NEUROLOGICAL FOUNDATION 350 WEST THOMAS ROAD PHOENIX AZ 85013 860174371 FUNDRAISING FOUNDATION AZ 501(C)(3) LINE 7 DH 0 BAYLOR ST LUKE'S HEALTH VENTURES 17200 ST LUKES WAY STE 170 THE WOODLANDS TX 77384 274499340 PHYSICIANS TX 501(C)(3) LINE 12A, I SLHS 0 BAYLOR ST LUKE'S MEDICAL GROUP 6624 FANNIN ST STE 1100 HOUSTON TX 77030 760458535 PHYSICIANS TX 501(C)(3) LINE 3 BSLHV 0 BORNEMANN HEALTHCARE CORPORATION 198 INVERNESS DRIVE WEST ENGLEWOOD CO 80112 232187242 INACTIVE PA 501(C)(3) LINE 12A, I CSH 0 BRAZOSPORT HEALTH FOUNDATION INC 1 WEST WAY CT LAKE JACKSON TX 77566 760080110 FUNDRAISING FOUNDATION TX 501(C)(3) LINE 12A, I TCHB 0 BRAZOSPORT REGIONAL 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KY 501(C)(3) LINE 12A, I CSH 0 CHI LIVING COMMUNITIES 5942 RENAISSANCE PLACE STE A TOLEDO OH 43623 341892096 SENIOR LIVING OH 501(C)(3) LINE 12A, I SFH-OH 0 CHI MEMORIAL HOSPITAL - GEORGIA 100 GROSS CRESCENT CIRCLE FORT OGLETHORPE GA 30742 822748395 HOSPITAL GA 501(C)(3) LINE 3 MHCS 0 CHI NATIONAL HOME CARE 198 INVERNESS DRIVE WEST ENGLEWOOD CO 80112 451261716 HOME HEALTH CO 501(C)(3) LINE 10 CHI NS 0 CHI NATIONAL SERVICES 198 INVERNESS DRIVE WEST ENGLEWOOD CO 80112 452532084 HOLDING CO CO 501(C)(3) LINE 12A, I CSH 0 CHI NEBRASKA 12809 WEST DODGE ROAD OMAHA NE 68510 363233121 HOLDING CO NE 501(C)(3) LINE 12A, I CSH 0 CHI ST JOSEPH CHILDREN'S HEALTH 1929 LINCOLN HWY E STE 150 LANCASTER PA 17602 232342997 HEALTHCARE PA 501(C)(3) LINE 12A, I CSH 0 CHI ST JOSEPH'S CHILDREN 1516 5TH ST NW ALBUQUERQUE NM 87102 710897107 COMMUNITY NM 501(C)(3) LINE 12A, I CSH 0 CHI ST VINCENT HOSPITAL HOT SPRINGS 300 WERNER ST HOT SPRINGS AR 71913 710236913 HOSPITAL AR 501(C)(3) LINE 3 CHISVHS 0 CHI ST 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SOUTH DOBSON ROAD CHANDLER AZ 85224 742418514 FUNDRAISING FOUNDATION AZ 501(C)(3) LINE 12A, I DH 0 DIGNITY HEALTH HPL SELF-INSURANCE TRUST 185 BERRY STREET STE 200 SAN FRANCISCO CA 94107 943006034 SELF INSURANCE CA 501(C)(3) LINE 12A, I DH 0 DIGNITY HEALTH INSURANCE NEVADA LTD 185 BERRY STREET STE 200 SAN FRANCISCO CA 94107 813800752 SELF INSURANCE NV 501(C)(3) LINE 12A, I DH 0 DIGNITY HEALTH MEDICAL FOUNDATION 3400 DATA DRIVE RANCHO CORDOVA CA 95670 680220314 MULTI-SPECIALTY OUTPATIENT MEDICAL CLINIC CA 501(C)(3) LINE 12A, I DCC 0 DIGNITY HEALTH WORKERS COMP SELF-INSURANCE TRUST 185 BERRY STREET STE 200 SAN FRANCISCO CA 94107 946612446 SELF INSURANCE CA 501(C)(3) LINE 12A, I DH 0 DOMINICAN HEALTH SERVICES 1555 SOQUEL DRIVE SANTA CRUZ CA 95065 770056778 COMMUNITY HEALTH SYSTEM CA 501(C)(3) LINE 12A, I DH 0 DOMINICAN HOSPITAL FOUNDATION 1555 SOQUEL DRIVE SANTA CRUZ CA 95065 942450442 FUNDRAISING FOUNDATION CA 501(C)(3) LINE 12A, I DH 0 DOMINICAN OAKS CORPORATION 1555 SOQUEL DRIVE SANTA 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