2022-10-17T11:25:57-05:00 2021-12-31 450250958 EIDE BAILLY LLP 18081 BURT STREET SUITE 200 OMAHA NE 680224722 990 2021-01-01 420860039 STEWART MEMORIAL COMMUNITY HOSPITAL STEW 7124644200 1301 W MAIN LAKE CITY IA 51449 JIM HENKENIUS CHIEF FINANCIAL OFFICER 7124644200 2022-10-17 1 JIM HENKENIUS 999009999 WENDY R COOLEY P01523804 4023302660 2022-10-17 3 AAL1 IAL1 2021 2022-09-23 18:48:47Z JIM HENKENIUS 1301 W MAIN LAKE CITY IA 51449 34740796 0 X WWW.STEWARTMEMORIAL.ORG X 1958 IA TO PROVIDE A COMPLETE CONTINUUM OF HEALTHCARE SERVICES TO THE PEOPLE OF LAKE CITY AND THE SURROUNDING COMMUNITIES WITHOUT REGARD FOR ABILITY TO PAY AND WITHOUT DISCRIMINATION. 9 8 285 30 0 0 3287408 5517883 25921111 28231969 194453 160814 519377 468025 29922349 34378691 0 0 0 0 17349152 18562464 0 0 281376 10406227 11460353 27755379 30022817 2166970 4355874 21974096 35673353 10206028 19311672 11768068 16361681 X STEWART MEMORIAL COMMUNITY HOSPITAL IS COMMITTED TO QUALITY HEALTH AND WELLNESS FOR YOU AND YOUR FAMILY. 0 0 16501576 15110006 STEWART MEMORIAL COMMUNITY HOSPITAL IS A 25 BED CRITICAL ACCESS HOSPITAL THAT ALSO OPERATES 4 RURAL HEALTH CLINICS. STEWART MEMORIAL EMPLOYS 11 FAMILY PRACTICE PROVIDERS, 1 BEHAVIORAL HEALTH PROVIDER, 2 GENERAL SURGEONS AND 2 CRNAS. BESIDES OFFERING 24/7 EMERGENCY ROOM SERVICES, STEWART MEMORIAL ALSO PROVIDES GENERAL RADIOLOGY, CT SCANS, ULTRASOUND, MOBILE MRI, NUCLEAR SCANS, LABORATORY, BLOOD ADMINISTRATION, CARDIAC REHABILITATION, EKGS, RESPIRATORY THERAPY, PHYSICAL THERAPY, OCCUPATIONAL THERAPY, SPEECH THERAPY, OPERATING ROOM, PHARMACY, INFUSIONS AND OBSTETRICS. DURING 2021, STEWART MEMORIAL HAD 1,036 ACUTE PATIENT DAYS, 2,241 EMERGENCY ROOM VISITS, 1,267 OPERATING ROOM PROCEDURES AND 35,176 CLINIC ENCOUNTERS. 6276898 6472774 STEWART MEMORIAL COMMUNITY HOSPITAL OWNS AND OPERATES RURAL HEALTH CLINICS IN THE COMMUNITIES OF LAKE CITY, GOWRIE, LAKE VIEW AND ROCKWELL CITY. WE EMPLOY 14 PROVIDERS WHICH ARE COMPOSED OF PHYSICIANS, PHYSICIAN ASSISTANTS AND NURSE PRACTITIONERS, THEY PROVIDE MEDICAL PROFESSIONAL SERVICES TO MEMBERS OF THESE COMMUNITIES AND SURROUNDING AREAS IN A DESIGNATED HEALTH PROFESSIONAL SHORTAGE AREA. 2263265 4421239 THE LABORATORY DEPARTMENT PROVIDES INPATIENT, OUTPATIENT AND EMERGENCY TESTING FOR PATIENTS OF STEWART MEMORIAL COMMUNITY HOSPITAL. IT ALSO PROVIDE SERVICES TO THE MCCRARY-ROST CLINIC IN LAKE CITY. REAGENT AND SALARY COSTS OF PERSONNEL ACCOUNT FOR THE MAJORITY OF THE DEPARTMENT'S EXPENSES. 1159529 2227950 THE OPERATING AND RECOVERY ROOMS DEPARTMENT PROVIDE GENERAL SURGICAL AND ORTHOPEDIC PROCEDURES ALONG WITH PROCEDURES FOR ENT, CATARACT AND PODIATRY. THE SUPPLIES USED IN SUCH PROCEDURES ACCOUNT FOR A LARGE PORTION OF EXPENSES. 1159529 2227950 26201268 1 1 0 1 0 0 0 0 0 0 1 0 0 1 1 1 1 0 0 0 0 0 0 0 1 0 1 1 0 0 1 1 0 0 0 0 0 0 0 0 1 0 0 0 0 0 0 0 0 0 0 1 33 0 1 285 1 0 0 0 0 0 0 0 0 0 0 0 0 X 9 8 0 1 0 0 0 0 0 1 1 0 0 1 1 1 1 1 1 1 0 0 X JIM HENKENIUS CFO 7124644200 1301 W MAIN STREET LAKE CITY IA 51449 DR MARGARET VITIRITTO-KHAN MEDICAL COUNSEL 40.00 X 341869 0 42239 CHADRIC DIETRICH BOARD CHAIR 2.00 X X 0 0 0 BRADLEY LANE VICE CHAIR 2.00 X X 0 0 0 THERESA HILDRETH SECRETARY 2.00 X X 0 0 0 SCOTT NESBITT TREASURER 2.00 X X 0 0 0 SHEILA BERGER DIRECTOR 1.00 X 0 0 0 CARMEN HOOD DIRECTOR 1.00 X 0 0 0 SCOTT KLUVER DIRECTOR 1.00 X 0 0 0 JORDAN LIETZ DIRECTOR 1.00 X 0 0 0 JIM HENKENIUS CFO 40.00 X 162447 0 38436 CYNTHIA CARSTENS CEO 40.00 X 0 0 0 DEREK DUNCAN D.O. 40.00 X 748140 0 44654 SUSAN HORNBACK D.O. 40.00 X 927161 0 33971 RONALD CHENEY D.O. 40.00 X 450472 0 44404 JOSH SMITH D.O. 40.00 X 375781 0 1000 TONJA PETERSEN-ANDERSON ARNP 40.00 X 230271 0 5996 3236141 0 210700 24 0 1 1 SHARED MEDICAL SERVICES INC 209 LIMESTONE PASS COTTAGE GROVE WI 53551 MOBILE MRI SERVICES 166950 BARTON & ASSOCIATES INC 300 JUBILEE DRIVE BOSTON MA 01960 OB NURSING & RHC PROVIDERS COVERAGE 161161 LOCUM TENENSCOM LLC 2575 NORTHWINDS PARKWAY ALPHARETTA GA 30009 ER & OBSTETRICS COVERAGE 157225 WAPITI MEDICAL STAFFING 107 FLYNN DRIVE SUITE 600 MILBANK SD 57252 ER COVERAGE 129833 FOCUSONE SOLUTIONS LLC PO BOX 850861 MINNEAPOLIS MN 55485 OB NURSING COVERAGE 127010 5 40812 2319465 3157606 5517883 ANCILLARY SERVICES 621400 14356245 14356245 RURAL HEALTH CLINICS 621400 6472774 6472774 LABORATORY 621400 4421239 4421239 OPERATING & RECOVERY ROOMS 621400 2227950 2227950 340B PROGRAM REVENUE 621400 434286 434286 319475 319475 28231969 71540 71540 246074 106 245968 245968 245968 447273 500 358499 0 88774 500 89274 89274 2500 40812 3500 -1000 -1000 CAFETERIA SALES 900099 223057 223057 223057 34378691 28231969 0 628839 584991 384108 200883 37871 37871 14683062 13315229 1156231 211602 270063 246370 23693 2040449 1742010 298266 173 946028 803882 127082 15064 474949 474949 91236 91236 75210 75210 22590 22590 2782197 2335021 430649 16527 127768 90317 5340 32111 1431450 1387141 40545 3764 608220 558764 49456 401796 398626 3170 110496 75647 34709 140 79921 6757 73164 1100310 1010856 89454 206703 27769 178934 MEDICAL SUPPLIES 3032932 3032932 BAD DEBT 614114 614114 MISCELLANEOUS 169609 44828 124100 681 DUES & SUBSCRIPTIONS 130852 89026 40512 1314 30022817 26201268 3540173 281376 3984165 2852583 1129837 2487581 449226 300861 2336965 2958069 123364 96351 372658 417595 231410 44361 47018311 25293884 8709352 21724427 2613498 2301498 2023621 2490027 21974096 35673353 2623013 3980235 619136 240000 1677333 1228856 5237745 12306187 48801 1556394 10206028 19311672 X 10119122 14481898 1648946 1879783 11768068 16361681 21974096 35673353 4355874 237739 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 5741 5741 0 PART II-B, LINE 1: STEWART MEMORIAL COMMUNITY HOSPITAL PAID DUES TO THE AMERICAN HOSPITAL ASSOCATION AND THE IOWA HOSPITAL ASSOCIATION. A PORTION OF THE DUES WERE USED FOR LOBBYING ACTIVITIES. 146413 146413 6135551 4600349 1535202 25630395 20446078 5184317 15105952 247457 14858495 21724427 OTHER RECEIVABLE 2411254 INVESTMENT IN CAPTIVE 78773 2490027 DEFERRED COMPENSATION LIABILITIES 145864 ESTIMATED THIRD-PARTY PAYOR SETTLEMENTS 1410530 1556394 X 34005922 237739 3606 241345 33764577 614114 614114 34378691 29412309 3606 3606 29408703 614114 614114 30022817 PART X, LINE 2: THE HOSPITAL IS A NOT-FOR-PROFIT CORPORATION AS DESCRIBED IN SECTION 501(C)(3) OF THE CODE AND HAS RECEIVED A DETERMINATION LETTER THAT IT 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 HOSPITAL'S TAX EXEMPT STATUS. IN GENERAL, SUCH STANDARDS REQUIRE THE HOSPITAL TO MEET A COMMUNITY BENEFITS STANDARD AND COMPLY WITH VARIOUS LAWS AND REGULATIONS. THE HOSPITAL ACCOUNTS FOR UNCERTAINTIES IN ACCOUNTING FOR INCOME TAX ASSETS AND LIABILITIES USING GUIDANCE INCLUDED IN FINANCIAL ACCOUNTING STANDARDS BOARD (FASB) ASC 740, INCOME TAXES. THE HOSPITAL RECOGNIZES THE EFFECT OF INCOME TAX POSITIONS ONLY IF THOSE POSITIONS ARE MORE LIKELY THAN NOT OF BEING SUSTAINED. AT DECEMBER 31, 2021 AND 2020, THE HOSPITAL HAD NO UNCERTAIN TAX POSITIONS ACCRUED. PART XI, LINE 2D - OTHER ADJUSTMENTS: RENTAL EXPENSES 106. FUNDRAISING EXPENSES 3,500. PART XI, LINE 4B - OTHER ADJUSTMENTS: PROVISION FOR UNCOLLECTIBLE ACCOUNTS 614,114. PART XII, LINE 2D - OTHER ADJUSTMENTS: RENTAL EXPENSES 106. FUNDRAISING EXPENSES 3,500. PART XII, LINE 4B - OTHER ADJUSTMENTS: PROVISION FOR UNCOLLECTIBLE ACCOUNTS 614,114. TRIVIA ON THE GREENS 43312 40812 2500 250 1500 750 500 500 43312 40812 2500 250 1500 750 500 500 3500 -1000 1 1 X 1 X 1 X 100.000000000000 0 1 0 1 1 165 245143 0 245143 0.00830 3706191 3449941 256250 0.00870 165 3951334 3449941 501393 0.01700 11 4957 94434 12322 82112 0.00280 4 14 127620 0 127620 0.00430 5 41 18757 0 18757 0.00060 20 5012 240811 12322 228489 0.00770 20 5177 4192145 3462263 729882 0.02470 1 3585 0 3585 0.00010 1 2055 0 2055 0.00010 2 5640 5640 0.00020 1 614114 0 9338613 9040299 298314 X 1 1 1 1 STEWART MEMORIAL COMMUNITY HOSPITAL 1301 WEST MAIN STREET LAKE CITY IA 51449 WWW.STEWARTMEMORIAL.ORG 130029H X X X X STEWART MEMORIAL COMMUNITY HOSPITAL 1 0 0 1 X X X X X X X X 21 1 0 1 1 X WWW.STEWARTMEMORIAL.ORG X X 1 21 1 WWW.STEWARTMEMORIAL.ORG 0 1 X 200.000000000000 100.000000000000 X X X 1 1 X X X 1 X WWW.STEWARTMEMORIAL.ORG X WWW.STEWARTMEMORIAL.ORG X WWW.STEWARTMEMORIAL.ORG X X X X X X 1 X 0 X X X X 1 X 0 0 STEWART MEMORIAL COMMUNITY HOSPITAL PART V, SECTION B, LINE 5: STEWART MEMORIAL COMMUNITY HOSPITAL, IN CONJUNCTION WITH CALHOUN COUNTY PUBLIC HEALTH DEVELOPED A SURVEY MONKEY QUESTIONNAIRE TO GET INPUT FROM COMMUNITY MEMBERS. THE QUESTIONNAIRE WAS DISTRIBUTED THROUGHOUT THE SMCH SERVICE AREA TO VARIOUS ORGANIZATIONS INCLUDING PUBLIC HEALTH, SCHOOLS, OTHER HEALTH CARE PROVIDERS AND LOCAL BUSINESSES ALONG WITH EMPLOYEES OF THE HOSPITAL AND ITS AUXILIARY. STEWART MEMORIAL COMMUNITY HOSPITAL PART V, SECTION B, LINE 6B: CALHOUN COUNTY PUBLIC HEALTH STEWART MEMORIAL COMMUNITY HOSPITAL PART V, SECTION B, LINE 7D: A HARD COPY OF THE SURVEY WAS PRINTED AND DISTRIBUTED THROUGHOUT OUR SERVICE AREA INCLUDING THE LOCAL LIBRARY. STEWART MEMORIAL COMMUNITY HOSPITAL PART V, SECTION B, LINE 11: FOUR TOPICS WERE IDENTIFIED IN THE ASSESSMENT - 1) IMPROVE ACCESS TO QUALITY HEALTH SERVICES & SUPPORTS; 2) HEALTH EDUCATION AND INFORMATION RESOURCES; 3) HEALTHY LIVING; 4) HEALTH EQUITY AND SOCIAL DETERMINANTS OF HEALTH. THE FIRST TOPIC HAD 6 GOALS AND A FEW OBJECTIVES UNDER EACH. THE GOALS ARE TO REDUCE THE RATE OF CANCER DIAGNOSIS IN CALHOUN COUNTY, INCREASE THE USE OF CARE COORDINATION TO ASSIST WITH NAVIGATION THROUGH HEALTH CARE INFORMATION AND SERVICES, INCREASE ACCESS AND REFERRALS TO SHELTER SERVICES FOR VICTIMS OF ABUSE, VIOLENCE, OR SEX; INCLUDING INDIVIDUALS WITH DISABILITIES, REDUCE THE NUMBER OF REPORTED POOR MENTAL HEALTH DAYS TO IMPROVE QUALITY OF LIFE FOR CALHOUN COUNTY INDIVIDUALS AND FAMILIES, INCREASE AVAILABLE AND AFFORDABLE TRANSPORTATION SERVICES IN CALHOUN COUNTY, INCREASE THE AVAILABILITY OF SUBSTANCE ABUSE SUPPORT GROUPS FOR INDIVIDUALS AND FAMILIES. THE FIRST GOAL, REDUCE THE RATE OF CANCER DIAGNOSIS IN CALHOUN COUNTY, HAS 1 OBJECTIVE. THE OBJECTIVE IS TO INCREASE PREVENTATIVE BEHAVIORS IN PERSONS AT HIGH RISK FOR CANCER TO REDUCE CANCER RELATED DEATHS FROM 25 IN 2020 TO 15 IN 2025THE SECOND GOAL, INCREASE THE USE OF CARE COORDINATION TO ASSIST WITH NAVIGATION THROUGH HEALTH CARE INFORMATION AND SERVICES HAS 2 OBJECTIVES - INCREASE IDENTIFICATION OF INDIVIDUALS WITH MULTIPLE CARE CONDITIONS NEEDING REFERRAL FOR CARE COORDINATION TO INCREASE ACCESS AND FOLLOW UP FOR NEEDED SERVICES FROM CARE COORDINATION REFERRALS AND TO DEVELOP A TOOL TO TRACK HOME CARE REFERRALS AND FOLLOW UP. THE TARGET VALUE OF THE 1ST OBJECTIVE IS 50 INDIVIDUALS. THE 2ND OBJECTIVE IS TO DEVELOP A TOOL TO TRACK HOME CARE REFERRALS AND FOLLOW UP FROM THE BASELINE VALUE OF 0% TO 100%.THE 3RD GOAL, INCREASE ACCESS AND REFERRALS TO SHELTER SERVICES FOR VICTIMS OF ABUSE, VIOLENCE OR SEX; INCLUDING INDIVIDUALS WITH DISABILITIES HAS ONE OBJECTIVE AND ONE STRATEGY. THE OBJECTIVE IS TO INCREASE THE IDENTIFICATION OF VICTIMS OF INTIMATE PARTNER VIOLENCE WITH REFERRALS TO COMMUNITY SERVICES. CURRENT VALUE IS 46 WITH A TARGET OF 60 BY 2025.THE 4TH GOAL, REDUCE THE NUMBER OF REPORTED POOR MENTAL HEALTH DAYS TO IMPROVE QUALITY OF LIFE FOR CALHOUN COUNTY INDIVIDUALS HAS 1 OBJECTIVE. THE OBJECTIVE IS TO INCREASE KNOWLEDGE AND THE BENEFITS OF MENTAL HEALTH SERVICES FOR INDIVIDUALS WITH MENTAL HEALTH ISSUES AND THEIR FAMILIES SO THEY CAN MANAGE THEIR MENTAL HEALTH ON A DAILY BASIS AND RECEIVE APPROPRIATE SUPPORT DECREASING THE NUMBER OF REPORTED POOR MENTAL HEALTH DAYS. CURRENT BASELINE VALUE IS 3.6 DAYS, AND THE TARGET IS <3 DAYS BY 2025.THE FIFTH GOAL, INCREASE AVAILABLE AND AFFORDABLE TRANSPORTATION SERVICES IN CALHOUN COUNTY HAS ONE OBJECTIVE. THE OBJECTIVE IS TO INCREASE THE NUMBER OF RESOURCES FROM 2 (MIDAS AND MCO MEDICAL TRANSPORTATION) TO A MINIMUM OF 3 RESOURCES BY 2025. THE SIXTH GOAL FOR IMPROVE ACCESS TO QUALITY HEALTH SERVICES AND SUPPORTS IS TO INCREASE THE AVAILABILITY OF SUBSTANCE ABUSE SUPPORT GROUPS FOR INDIVIDUALS AND FAMILIES. THE OBJECTIVE IS TO INCREASE THE NUMBER OF AA/ALANON/NA GROUPS FROM 2 IN 2020 TO 4 IN 2025. THE SECOND TOPIC, HEALTH EDUCATION AND INFORMATION RESOURCES HAS 4 GOALS. THE GOALS ARE TO REDUCE THE STD RATES IN CALHOUN COUNTY, INCREASE THE NUMBER OF FAMILIES RECEIVING FAMILY FOUNDATION SERVICES, IMPROVE ACCESS TO QUALITY HEALTH SERVICES AND SUPPORTS AND TO DECREASE THE PERCENTAGE OF FOOD INSECURITY IN CALHOUN COUNTY.THE OBJECTIVE OF THE FIRST GOAL, REDUCE STD RATES IN CALHOUN COUNTY, IS TO INCREASE KNOWLEDGE OF PREVENTATIVE BEHAVIORS RELATED TO SEXUALLY TRANSMITTED INFECTIONS TO REDUCE THE NUMBER OF INFECTIONS FROM 236 IN 2020 TO 200 IN 2025. THE 2ND GOAL, INCREASE THE NUMBER OF FAMILIES RECEIVING FAMILY FOUNDATION SERVICES HAS ONE OBJECTIVE WITH FIVE STRATEGIES. THE OBJECTIVE IS TO INCREASE THE NUMBER OF FAMILIES AT 125% OF THE POVERTY RATE OR HIGHER. THE BASELINE VALUE IS 68% WITH A TARGET VALUE OF 78%. THE THIRD GOAL, IMPROVE ACCESS TO QUALITY HEALTH SERVICE AND SUPPORTS, HAS 1 OBJECTIVE. THE OBJECTIVE IS TO REDUCE THE NUMBER OF PERSONS THAT ARE UNABLE TO OBTAIN OR DELAY OBTAINING NECESSARY PRIMARY CARE OR MENTAL HEALTH CARE BY 5% BY 2025 FROM THE BASELINE VALUE OF 24%. THE FINAL GOAL IN THIS TOPIC, DECREASE THE PERCENTAGE OF FOOD INSECURITY IN CALHOUN COUNTY, ALSO HAS 1 OBJECTIVE. THE OBJECTIVE IS TO DISSEMINATE INFORMATION TO COMMUNITIES HOW TO ACCESS EMERGENCY FEEDING SITES/FOOD AND NUTRITION SITES TO REDUCE FOOD INSECURITY. THE CURRENT BASELINE VALUE IS 12% WITH A TARGET VALUE OF 6% BY 2025. THE THIRD TOPIC, HEALTHY LIVING, HAS 2 GOALS AND 2 OBJECTIVES. THE GOALS ARE TO REDUCE ADULT OBESITY RATES IN CALHOUN COUNTY AND INCREASE ACCESS TO EXERCISE OPPORTUNITIES IN CALHOUN COUNTY.THE OBJECTIVE OF GOAL 1, REDUCE ADULT OBESITY RATES IN CALHOUN COUNTY, IS TO INCREASE EDUCATIONAL AND SUPPORT PROGRAMS AVAILABLE IN CALHOUN COUNTY TO ADDRESS ADULT OBESITY AND REDUCE THE RATE. THERE IS A TARGET VALUE OF 30% FOR THIS OBJECTIVE. THE SECOND GOAL, INCREASE ACCESS TO EXERCISE OPPORTUNITIES IN CALHOUN COUNTY, HAS 1 OBJECTIVE. THE OBJECTIVE IS TO INCREASE ACCESS TO LOCATIONS OR PROGRAMS THAT SUPPORT INCREASE PHYSICAL ACTIVITY FOR CALHOUN COUNTY RESIDENTS. THE FOURTH AND FINAL TOPIC, HEALTH EQUITY AND SOCIAL DETERMINANTS OF HEALTH, HAS 2 GOALS. THESE GOALS ARE TO IMPROVE INCOME AND INCOME DISTRIBUTION AND TO IMPROVE HOUSING OPTIONS IN CALHOUN COUNTY.THE FIRST GOAL, IMPROVE INCOME AND INCOME DISTRIBUTION, HAS 1 OBJECTIVE - TO DECREASE INCOME INEQUALITY. BASED ON THE 2020 BASELINE YEAR, THE BASELINE VALUE IS 0.45 (GINI INDEX) WITH A TARGET VALUE OF 0.3 IN 2025. THE SECOND GOAL, IMPROVE HOUSING OPTIONS IN CALHOUN COUNTY, HAS 1 OBJECTIVE, THE OBJECTIVE IS TO DECREASE THE PERCENTAGE OF INDIVIDUALS LIVING IN INADEQUATE HOUSING. THE GOAL IS TO DECREASE TO A VALUE OF 15%. STEWART MEMORIAL COMMUNITY HOSPITAL PART V, SECTION B, LINE 13H: STEWART MEMORIAL COMMUNITY HOSPITAL IS COMMITTED TO PROVIDING NECESSARY HOSPITAL CARE AND TREATMENT TO ALL PATIENTS REGARDLESS OF THEIR ABILITY TO PAY. ANY PATIENT WHO HAS RECEIVED SERVICES AND WHO FALLS BELOW CERTAIN INCOME AND ASSET LIMITS MAY BE ELIGIBLE FOR HOSPITAL CARE FREE OF CHARGE, OR AT A REDUCTION OF OUR ESTABLISHED CHARGES.THE HOSPITAL USES THE POVERTY INCOME GUIDELINES ISSUED BY THE COMMUNITY SERVICE ADMINISTRATION AS A BASIS FOR ELIGIBILITY CRITERIA FOR DISCOUNTED CARE. THESE GUIDELINES ARE ADJUSTED ANNUALLY BASED ON INCREASES IN THE CONSUMER PRICE INDEX. SUPPORT TO GRANT FINANCIAL ASSISTANCE MUST BE FULLY DOCUMENTED IN OUR FILES. SMCH HAS A SPREADSHEET BASED ON THE FEDERAL POVERTY GUIDELINES TO DETERMINE DISCOUNTED CARE. THE SPREADSHEET ALSO ACCOUNTS FOR THE FAMILY SIZE IN DETERMINING ELIGIBILITY. FOR THOSE APPLYING, IF THEIR INCOME FALLS BETWEEN 225-250% OF THE GUIDELINES, 75% OF THE PATIENT'S BILL IS FORGIVEN; IF THE INCOME IS BETWEEN 300-400% OF THE GUIDELINES, 50% IS FORGIVEN; IF THE INCOME AT 450% OF THE GUIDELINES, 35% IS FORGIVEN; IF THE INCOME IS AT 500% OF THE GUIDELINES, 25% IS FORGIVEN. THE NEW 501(R) REGULATIONS AND POLICIES THAT TOOK EFFECT JANUARY 1, 2016 WILL BE MADE AVAILABLE TO EVERY PATIENT AND ALSO MADE AVAILABLE ON OUR WEBSITE. 4 1 - MCCRARY-ROST CLINIC 1351 WEST MAIN STREET LAKE CITY IA 51449 HEALTH CLINIC 2 - GOWRIE CLINIC 1800 MAIN GOWRIE IA 50543 HEALTH CLINIC 3 - LAKE VIEW CLINIC 1160 3RD STREET LAKE VIEW IA 51540 HEALTH CLINIC 4 - ROCKWELL CITY CLINIC 505 EAST LAKE STREET ROCKWELL CITY IA 50579 HEALTH CLINIC PART I, LINE 3C: NOT APPLICABLE PART I, LINE 6A: STEWART MEMORIAL COMMUNITY HOSPITAL'S COMMUNITY BENEFIT REPORT IS NOT PREPARED BY A RELATED ORGANIZATION. PART I, LINE 7: STEWART MEMORIAL COMMUNITY HOSPITAL USED THE WORKSHEETS PROVIDED IN THE IRS INSTRUCTIONS FOR SCHEDULE H IN ADDITION TO THE INTERNAL COST ACCOUNTING SYSTEM. PART I, LINE 7G: THERE ARE NO COSTS ATTRIBUTABLE TO A PHYSICIAN CLINIC INCLUDED ON LINE 7G. PART I, LN 7 COL(F): THE BAD DEBT EXPENSE INCLUDED ON FORM 990, PART IX, LINE 25, COLUMN (A), BUT SUBTRACTED FOR PURPOSES OF CALCULATING THE PERCENTAGE IN THIS COLUMN IS $614,114. PART II, COMMUNITY BUILDING ACTIVITIES: ONE MEMBER OF THE ORGANIZATION IS A VOLUNTEER MEMBER ON THE LOCAL BETTERMENT ORGANIZATION. AT THE MONTHLY MEETINGS, THEY USE THEIR TIME TO PROMOTE THE SERVICES AND WELLNESS ACTIVITIES THE HOSPITAL PROVIDES. CURRENT AND PROSPECTIVE BUSINESSES UNDERSTAND THE VARIOUS HEALTH SERVICES THAT ARE MADE AVAILABLE TO THEM AND THEIR EMPLOYEES. OTHER STAFF MEMBERS SERVE ON VARIOUS PROJECT TEAMS IN OUR SURROUNDING COMMUNITIES TO REPRESENT THE HOSPITAL AND BUILD COMMUNITY AWARENESS. THE COO AND AN EMPLOYED PHYSICIAN ARE MEMBERS OF THE CALHOUN COUNTY BOARD OF HEALTH. STEWART MEMORIAL COMMUNITY HOSPITAL WORKED IN CONJUNCTION WITH CALHOUN COUNTY PUBLIC HEALTH TO COMPLETE A COMMUNITY NEEDS ASSESSMENT AND DEVELOP A HEALTH IMPROVEMENT PROGRAM. PART III, LINE 2: IN EVALUATING THE COLLECTIBILITY OF ACCOUNTS RECEIVABLE, THE HOSPITAL ANALYZES ITS PAST HISTORY AND IDENTIFIES TRENDS FOR EACH OF ITS MAJOR PAYOR SOURCES OF REVENUE TO ESTIMATE THE APPROPRIATE ALLOWANCE FOR DOUBTFUL ACCOUNTS AND PROVISION FOR BAD DEBTS. MANAGEMENT REGULARLY REVIEWS DATA ABOUT THESE MAJOR PAYOR SOURCES OF REVENUE IN EVALUATING THE SUFFICIENCY OF THE ALLOWANCE FOR DOUBTFUL ACCOUNTS. FOR RECEIVABLES ASSOCIATED WITH SERVICES PROVIDED TO PATIENTS WHO HAVE THIRD-PARTY COVERAGE, THE HOSPITAL ANALYZES CONTRACTUALLY DUE AMOUNTS AND ESTIMATES A PERCENTAGE OF THOSE ACCOUNTS THAT WILL TRANSITION TO SELF-PAY PATIENTS BASED ON HISTORICAL ANALYSIS. THE ESTIMATED PERCENTAGE OF THOSE TRANSITION ACCOUNTS ARE ADDED TO RECEIVABLES ASSOCIATED WITH SELF-PAY PATIENTS (WHICH INCLUDES BOTH PATIENTS WITHOUT INSURANCE AND PATIENTS WITH DEDUCTIBLE AND COPAYMENT BALANCES DUE FOR WHICH THIRD-PARTY COVERAGE EXISTS FOR PART OF THE BILL). THE HOSPITAL RECORDS A SIGNIFICANT PROVISION FOR BAD DEBTS IN THE PERIOD OF SERVICE ON THE BASIS OF ITS PAST EXPERIENCE, WHICH INDICATES THAT MANY PATIENTS ARE UNABLE OR UNWILLING TO PAY THE PORTION OF THEIR BILL FOR WHICH THEY ARE FINANCIALLY RESPONSIBLE. THE DIFFERENCE BETWEEN THE STANDARD RATES (OR THE DISCOUNTED RATES IF NEGOTIATED) AND THE AMOUNTS ACTUALLY COLLECTED AFTER ALL REASONABLE COLLECTION EFFORTS HAVE BEEN EXHAUSTED IS CHARGED OFF AGAINST THE ALLOWANCE FOR DOUBTFUL ACCOUNTS. PART III, LINE 4: THE ORGANIZATION'S FINANCIAL STATEMENTS DO NOT CONTAIN A SPECIFIC FOOTNOTE DESCRIBING BAD DEBT. HOWEVER, PAGES 8 THROUGH 11 OF THE ATTACHED AUDITED FINANCIAL STATEMENTS INCLUDE FOOTNOTES TITLED "PATIENT RECEIVABLES" "PATIENT SERVICE REVENUE, AND "CHARITY CARE." PART III, LINE 8: SINCE THERE IS NO MEDICARE SHORTFALL CALCULATED FOR 2021, THERE IS NO SHORTFALL THAT IS TREATED AS COMMUNITY BENEFIT. THE 2021 FILED MEDICARE COST REPORT WAS USED TO DETERMINE THE ALLOWABLE COSTS. PART III, LINE 9B: COLLECTION POLICY:PATIENTS ARE ADMITTED INTO THE HOSPITAL COMPUTER SYSTEM WITH APPROPRIATE FINANCIAL INFORMATION INCLUDING INSURANCE INFORMATION AND ARE ASSIGNED A FINANCIAL CLASS (F/C) USED TO SEGREGATE ACCOUNTS IN ACCOUNTS RECEIVABLE (A/R) BY PAYER TYPE. PATIENTS WHO ARE MINORS ARE ADMITTED WITH THE PARENT WHO CARRIES THE INSURANCE COVERAGE AS THE RESPONSIBLE PARTY OR IF NO INSURANCE, THE PARENT WHO BROUGHT THE CHILD IN FOR CARE IS LISTED AS GUARANTOR.THE BUSINESS OFFICE WILL SEND AN ITEMIZED STATEMENT OF CHARGES TO ALL PATIENTS WHO REQUEST A COPY. INSURANCE COMPANIES ARE BILLED ELECTRONICALLY THROUGH THE USE OF EMDEON SOFTWARE WHENEVER POSSIBLE. ONCE THE INSURANCE COMPANY HAS PROCESSED THE CLAIM AND PAID ITS ENTIRE SHARE OR IF THE PATIENT DOESN'T HAVE INSURANCE, THEY WILL BE ASSIGNED A FINANCIAL CLASS OF SELF-PAY. SMCH ALLOWS PATIENTS TO SET UP PAYMENT ARRANGEMENTS FOLLOWING THIS SCHEDULE USING CHECK, MONEY ORDER, MASTERCARD OR VISA:BALANCE IS: MINIMUM PAYMENT:UNDER $250 $ 25.00 $251-$500 $ 50.00$501-$1000 $ 100.00$1001 - ABOVE $ 150.00THESE LIMITS ARE SET TO INSURE BALANCES ARE PAID IN FULL WITH 18 MONTHS IF AT ALL POSSIBLE. WHEN THE PATIENT IS ASSIGNED A FINANCIAL CLASS OF P, THE ACCOUNT IS SENT TO MED-PLAN FOR EARLY OUT PRE-COLLECT PROCESSING. THE FIRST STATEMENT FROM MED-PLAN IS MAILED OUT ON DAY 1 WHEN THEY RECEIVE THE ACCOUNT AND THEN AGAIN AT 30 DAYS. ACCOUNTS THAT DO NOT MAKE PAYMENT ARRANGEMENTS OR MAKE PAYMENTS FROM THE LETTER CAMPAIGN AFTER 45 DAYS ARE MOVED INTO A TELEPHONE CAMPAIGN. THE TELEPHONE CAMPAIGN MAKES 3 ATTEMPTS OVER 15 DAYS TO SECURE PAYMENT IN FULL OR A SCHEDULED PAYMENT PLAN. IF RESOLUTION ATTEMPTS FAIL AND MED-PLAN IS UNABLE TO RESOLVE AN ACCOUNT BECAUSE (1) IT IS IMPOSSIBLE TO REACH A PATIENT BY TELEPHONE, OR (2) THE PATIENT HAS FAILED TO COOPERATE IN ESTABLISHING A PAYMENT PLAN, OR (3) THE PATIENT HAS FAILED TO HONOR AN ESTABLISHED PLAN BY NOT MAKING SATISFACTORY PAYMENT WITHIN 60-90 DAYS, A FINAL NOTICE WILL BE SENT TO THE PATIENT. ACCOUNTS UNPAID OR ARRANGEMENTS NOT MADE AT THIS POINT IN THE BILLING PROCESS ARE DETERMINED UNCOLLECTIBLE. IF NO PAYMENT IN ALLOWABLE TIME IS RECEIVED, ACCOUNTS ARE ELECTRONICALLY SENT TO A COLLECTION AGENCY. IN THE EVENT OF PARTIAL PAYMENT, A DETERMINATION ON AN INDIVIDUAL BASIS IS MADE AS TO STOP OR PROCEED WITH THE COLLECTION AGENCY. PART VI, LINE 2: SMCH COLLABORATES WITH THE COUNTY HEALTH DEPARTMENT IN ASSESSING THE HEALTH CARE NEEDS OF THE COMMUNITIES THEY SERVE. SMCH ALSO EVALUATES USAGE DATA THROUGH THE IOWA HOSPITAL ASSOCIATION TO SEE THE PRIMARY MEDICAL DIAGNOSIS IN THEIR COMMUNITIES. PART VI, LINE 3: SMCH HAS A PATIENT ACCOUNTS MANAGER AS WELL AS A SOCIAL WORKER ON STAFF THAT IDENTIFY PATIENTS THAT MAY BE ELIGIBLE FOR ASSISTANCE OR QUALIFY FOR CHARITY CARE. THEY ASSIST THE PATIENT WITH AVAILABLE OPTIONS AND/OR THE NECESSARY PAPERWORK. PART VI, LINE 4: THE SERVICE AREA IS A 35 MILE RADIUS SURROUNDING THE SMCH COMMUNITY. THIS AREA CONSISTS OF MANY SMALL, RURAL COMMUNITIES THAT ARE AGRICULTURAL BASED. THE PATIENT BASE CONSISTS OF A LARGE MEDICARE POPULATION. PART VI, LINE 5: SMCH PROVIDES THE COMMUNITIES WITH LABORATORY WELLNESS TESTING AND EDUCATIONAL PROGRAMS ON PROMOTING HEALTHY LIFESTYLES. THEY PROVIDE CARE TO THE INDIGENT REGARDLESS OF THEIR ABILITY TO PAY. THE BOARD OF DIRECTORS ARE REPRESENTED BY THE VARIOUS COMMUNITIES THEY SERVE.THE HOSPITAL HAS ALSO JOINED WITH THE COUNTY DEPARTMENT OF HEALTH IN ESTABLISHING A PROGRAM CALLED "CARING HANDS CLOSET." CARING HANDS CLOSET IS A PROGRAM FOR EXPECTING MOTHERS AND NEW MOTHERS TO EARN POINTS TOWARDS BABY ITEMS BY ATTENDING THEIR DOCTOR APPOINTMENTS AND/OR EDUCATIONAL PROGRAMS. SMCH PROVIDES MONTHLY LABORATORY WELLNESS TESTING AND EDUCATIONAL PROGRAMS BI-MONTHLY. PART VI, LINE 6: SMCH IS NOT PART OF AN AFFILIATED HEALTH CARE SYSTEM. PART VI, LINE 7, REPORTS FILED WITH STATES IA X X X 0 0 0 0 0 0 0 0 0 SUSAN HORNBACK D.O. 814714 0 112057 0 390 0 8700 0 25271 0 961132 0 0 0 DEREK DUNCAN D.O. 593779 0 154107 0 254 0 8700 0 35954 0 792794 0 0 0 RONALD CHENEY D.O. 449742 0 0 0 730 0 8700 0 35704 0 494876 0 0 0 DR MARGARET VITIRITTO-KHAN MEDICAL COUNSEL 341623 0 0 0 246 0 8700 0 33539 0 384108 0 0 0 JOSH SMITH D.O. 375007 0 0 0 774 0 0 0 1000 0 376781 0 0 0 TONJA PETERSEN-ANDERSON ARNP 124840 0 105042 0 389 0 4996 0 1000 0 236267 0 0 0 JIM HENKENIUS CFO 161721 0 0 0 726 0 5153 0 33283 0 200883 0 0 0 FORM 990, PART VII, LINE 5: CYNTHIA CARSTENS, CEO, RECEIVED COMPENSATION FROM UNITYPOINT HEALTH, AN UNRELATED ENTITY, WHICH PROVIDES MANAGEMENT SERVICES TO ITS CLIENTS. MS. CARSTENS RECEIVED COMPENSATION AND BENEFITS IN THE AMOUNT OF $239,648 FOR HER SERVICES DURING THE CALENDAR YEAR 2021. HER COMPENSATION IS REPORTED IN PART IX, LINE 11A. A CITY OF LAKE CITY IOWA 426004850 508021AQ5 2016-10-24 1440000 CAPITAL IMPROVEMENTS 0 0 0 A 1440000 1440000 72000 1368000 2016 0 0 1 1 A 0 0 0 0 0.00000 0.00000 0.00000 0 0 0 A 0 0 1 1 0 0 0 0 0 A 0 SCHEDULE K, PART IV, LINE 2C: THE FINAL ARBITRAGE REBATE COMPUTATION WAS COMPLETED ON 09/16/2021. JODI HENKENIUS ORGANIZATION'S EMPLOYEE & SPOUSE OF JIM HENKENIUS, CFO 37871 EMPLOYEE WAGES 0 FORM 990, PART VI, SECTION A, LINE 3 UNITYPOINT HEALTH AND STEWART MEMORIAL COMMUNITY HOSPITAL HAVE AN AGREEMENT FOR ADMINISTRATIVE SERVICES. UNITYPOINT HEALTH PROVIDED THE SERVICES OF CYNTHIA CARSTENS, CEO. FORM 990, PART VI, SECTION B, LINE 11B THE FORM 990 WILL BE PROVIDED ELECTRONICALLY TO THE BOARD OF DIRECTORS AND REVIEWED BY THE CEO AND CFO PRIOR TO SUBMISSION. FORM 990, PART VI, SECTION B, LINE 12C EACH BOARD MEMBER SIGNS A CONFLICT OF INTEREST FORM ANNUALLY STATING THAT THEY WILL ABSTAIN FROM VOTING AND DISCUSSING ITEMS FOR WHICH THEY HAVE A CONFLICT OF INTEREST. FORM 990, PART VI, SECTION B, LINE 15A THE BOARD OF DIRECTORS MEET ANNUALLY TO DISCUSS THE TERMS OF THE CEO'S CONTRACT. THEY USE DATA FROM THE LATEST IOWA HOSPITAL ASSOCIATION SALARY SURVEY. FORM 990, PART VI, SECTION C, LINE 19 THE ORGANIZATION DOES NOT MAKE ITS GOVERNING DOCUMENTS, CONFLICT OF INTEREST POLICY, OR FINANCIAL STATEMENTS AVAILABLE TO THE PUBLIC. FORM 990, PART XII, LINE 2C: THE BOARD OF DIRECTORS ASSUMES THE RESPONSIBILITY FOR OVERSIGHT OF THE AUDIT OF THE FINANCIAL STATEMENTS AND SELECTION OF THE INDEPENDENT ACCOUNTANT. THIS PROCESS HAS NOT CHANGED FROM THE PREVIOUS YEAR.