CHEYENNE COUNTY HOSPITAL ASSOCIATION INC: Form 990, tax year 2021
View the entire original 990 at ProPublica ↗
- Organization
- CHEYENNE COUNTY HOSPITAL ASSOCIATION INC (EIN 47-0408242)
- Tax period
- 2021-01-01 to 2021-12-31
- Filed
- 2022-11-08
- IRS object ID
- 202203129349304360
- Schema version
- 2021v4.2
- Source
- Download XML · Original 990 at ProPublica
Every field in the e-filed return. Faint text is the IRS element name, for citing.
- Return header
- Form 990
- Schedule A
- Schedule B
- Schedule C
- Schedule D
- Schedule H
- Schedule I
- Schedule J
- Schedule K
- Schedule L
- Schedule O
- Schedule R
Return header ReturnHeader
| Field | Value | IRS element (for citing) |
|---|---|---|
| Return | 2022-11-08T15:37:04-06:00 | ReturnTs |
| Tax Period End | 2021-12-31 | TaxPeriodEndDt |
Preparer Firm PreparerFirmGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Preparer Firm EIN | 450250958 | PreparerFirmEIN |
Preparer Firm Name PreparerFirmName
| Field | Value | IRS element (for citing) |
|---|---|---|
| Business Name Line1 | EIDE BAILLY LLP | BusinessNameLine1Txt |
Preparer US Address PreparerUSAddress
| Field | Value | IRS element (for citing) |
|---|---|---|
| Address Line1 | 18081 BURT ST STE 200 | AddressLine1Txt |
| City | OMAHA | CityNm |
| State Abbreviation | NE | StateAbbreviationCd |
| ZIP | 680224722 | ZIPCd |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Return Type | 990 | ReturnTypeCd |
| Tax Period Begin | 2021-01-01 | TaxPeriodBeginDt |
Filer Filer
| Field | Value | IRS element (for citing) |
|---|---|---|
| EIN | 470408242 | EIN |
Business Name BusinessName
| Field | Value | IRS element (for citing) |
|---|---|---|
| Business Name Line1 | CHEYENNE COUNTY HOSPITAL | BusinessNameLine1Txt |
| Business Name Line2 | ASSOCIATION INC | BusinessNameLine2Txt |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Business Name Control | CHEY | BusinessNameControlTxt |
| Phone | 3082545825 | PhoneNum |
US Address USAddress
| Field | Value | IRS element (for citing) |
|---|---|---|
| Address Line1 | 1000 POLE CREEK CROSSING | AddressLine1Txt |
| City | SIDNEY | CityNm |
| State Abbreviation | NE | StateAbbreviationCd |
| ZIP | 691620000 | ZIPCd |
Business Officer BusinessOfficerGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Person | JASON PETIK | PersonNm |
| Person Title | CEO | PersonTitleTxt |
| Phone | 3082545825 | PhoneNum |
| Signature | 2022-11-07 | SignatureDt |
| Discuss With Paid Preparer | Yes (1) | DiscussWithPaidPreparerInd |
Signing Officer SigningOfficerGrp
Person Full Name PersonFullName
| Field | Value | IRS element (for citing) |
|---|---|---|
| Person First | JASON | PersonFirstNm |
| Person Last | PETIK | PersonLastNm |
| Field | Value | IRS element (for citing) |
|---|---|---|
| SSN | 999009999 | SSN |
Preparer Person PreparerPersonGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Preparer Person | MEGAN L KOZIOL CPA | PreparerPersonNm |
| PTIN | P01544037 | PTIN |
| Phone | 4023302660 | PhoneNum |
| Preparation | 2022-11-07 | PreparationDt |
Additional Filer Information AdditionalFilerInformation
Trusted Customer TrustedCustomerGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Trusted Customer | 3 | TrustedCustomerCd |
| Authentication Assurance Level | AAL1 | AuthenticationAssuranceLevelCd |
| Identity Assurance Level | IAL1 | IdentityAssuranceLevelCd |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Tax | 2021 | TaxYr |
| Build TS | 2022-09-23 18:48:47Z | BuildTS |
Form 990 IRS990
Doing Business As Name DoingBusinessAsName
| Field | Value | IRS element (for citing) |
|---|---|---|
| Business Name Line1 | SIDNEY REGIONAL MEDICAL CENTER | BusinessNameLine1Txt |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Principal Officer | JASON PETIK | PrincipalOfficerNm |
US Address USAddress
| Field | Value | IRS element (for citing) |
|---|---|---|
| Address Line1 | 1000 POLE CREEK CROSSING | AddressLine1Txt |
| City | SIDNEY | CityNm |
| State Abbreviation | NE | StateAbbreviationCd |
| ZIP | 691620000 | ZIPCd |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Gross Receipts | $70,779,074 | GrossReceiptsAmt |
| Group Return For Affiliates | 0 | GroupReturnForAffiliatesInd |
| Organization501c3 | Yes (X) | Organization501c3Ind |
| Website Address | WWW.SIDNEYRMC.COM | WebsiteAddressTxt |
| Type Of Organization Corp | Yes (X) | TypeOfOrganizationCorpInd |
| Formation | 1951 | FormationYr |
| Legal Domicile State | NE | LegalDomicileStateCd |
| Activity Or Mission | TO REVOLUTIONIZE HEALTHCARE SERVICES IN THE REGION. | ActivityOrMissionDesc |
| Voting Members Governing Body | 12 | VotingMembersGoverningBodyCnt |
| Voting Members Independent | 10 | VotingMembersIndependentCnt |
| Total Employee | 479 | TotalEmployeeCnt |
| Total Volunteers | 11 | TotalVolunteersCnt |
| Total Gross UBI | $0 | TotalGrossUBIAmt |
| Net Unrelated Bus Txbl Incm | $0 | NetUnrelatedBusTxblIncmAmt |
| PY Contributions Grants | $5,762,865 | PYContributionsGrantsAmt |
| CY Contributions Grants | $6,348,922 | CYContributionsGrantsAmt |
| PY Program Service Revenue | $55,178,139 | PYProgramServiceRevenueAmt |
| CY Program Service Revenue | $63,840,923 | CYProgramServiceRevenueAmt |
| PY Investment Income | $481,614 | PYInvestmentIncomeAmt |
| CY Investment Income | $467,466 | CYInvestmentIncomeAmt |
| PY Other Revenue | $377,887 | PYOtherRevenueAmt |
| CY Other Revenue | $121,763 | CYOtherRevenueAmt |
| PY Total Revenue | $61,800,505 | PYTotalRevenueAmt |
| CY Total Revenue | $70,779,074 | CYTotalRevenueAmt |
| PY Grants And Similar Paid | $10,200 | PYGrantsAndSimilarPaidAmt |
| CY Grants And Similar Paid | $28,700 | CYGrantsAndSimilarPaidAmt |
| PY Benefits Paid To Members | $0 | PYBenefitsPaidToMembersAmt |
| CY Benefits Paid To Members | $0 | CYBenefitsPaidToMembersAmt |
| PY Salaries Comp Emp Bnft Paid | $34,467,219 | PYSalariesCompEmpBnftPaidAmt |
| CY Salaries Comp Emp Bnft Paid | $36,547,289 | CYSalariesCompEmpBnftPaidAmt |
| PY Total Prof Fndrsng Expns | $0 | PYTotalProfFndrsngExpnsAmt |
| CY Total Prof Fndrsng Expns | $0 | CYTotalProfFndrsngExpnsAmt |
| CY Total Fundraising Expense | $0 | CYTotalFundraisingExpenseAmt |
| PY Other Expenses | $25,990,733 | PYOtherExpensesAmt |
| CY Other Expenses | $25,635,796 | CYOtherExpensesAmt |
| PY Total Expenses | $60,468,152 | PYTotalExpensesAmt |
| CY Total Expenses | $62,211,785 | CYTotalExpensesAmt |
| PY Revenues Less Expenses | $1,332,353 | PYRevenuesLessExpensesAmt |
| CY Revenues Less Expenses | $8,567,289 | CYRevenuesLessExpensesAmt |
| Total Assets BOY | $98,988,154 | TotalAssetsBOYAmt |
| Total Assets EOY | $103,262,011 | TotalAssetsEOYAmt |
| Total Liabilities BOY | $57,308,074 | TotalLiabilitiesBOYAmt |
| Total Liabilities EOY | $52,722,898 | TotalLiabilitiesEOYAmt |
| Net Assets Or Fund Balances BOY | $41,680,080 | NetAssetsOrFundBalancesBOYAmt |
| Net Assets Or Fund Balances EOY | $50,539,113 | NetAssetsOrFundBalancesEOYAmt |
| Mission | TO REVOLUTIONIZE HEALTHCARE SERVICES IN THE REGION. | MissionDesc |
| Significant New Program Srvc | 0 | SignificantNewProgramSrvcInd |
| Significant Change | 0 | SignificantChangeInd |
| Expense | $48,159,663 | ExpenseAmt |
| Grant | $28,700 | GrantAmt |
| Revenue | $46,679,616 | RevenueAmt |
| Desc | SIDNEY REGIONAL MEDICAL CENTER IS A NOT-FOR-PROFIT ACUTE CARE HOSPITAL WHICH PROVIDES INPATIENT, OUTPATIENT AND EMERGENCY ROOM CARE SERVICE TO PATIENTS IN AND AROUND SIDNEY, NEBRASKA AND THE REGION. IT ALSO OPERATES LONG-TERM CARE FACILITIES AND TWO PROVIDER-BASED RURAL HEALTH CLINICS IN SIDNEY, NEBRASKA. | Desc |
Prog Srvc Accom Acty2 ProgSrvcAccomActy2Grp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Expense | $4,982,089 | ExpenseAmt |
| Revenue | $12,625,048 | RevenueAmt |
| Desc | IN 2021, THE HOSPITAL NURSING DEPARTMENT PROVIDED 2,131 PATIENT DAYS OF CARE, INCLUDING GENERAL INPATIENT, ICU PATIENTS AND SWING BED PATIENTS, AND DELIVERED 83 NEWBORNS FOR THE SEVEN COUNTY AREA THAT SIDNEY REGIONAL MEDICAL CENTER (SRMC) SERVES. SRMC HAD 3,663 PATIENTS SEEK CARE IN THE EMERGENCY DEPARTMENT DURING 2021 AND CARED FOR 263 OBSERVATION PATIENTS WHO NEEDED CARE BUT DID NOT QUALIFY FOR INPATIENT SERVICES UNDER CMS RULES. | Desc |
Prog Srvc Accom Acty3 ProgSrvcAccomActy3Grp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Expense | $3,360,209 | ExpenseAmt |
| Revenue | $4,536,259 | RevenueAmt |
| Desc | THE EXTENDED CARE UNIT PROVIDED CARE FOR AN AVERAGE OF 43 PATIENTS DAILY DURING 2021. SRMC PROVIDED 15,467 RESIDENT DAYS OF CARE FOR IT'S RESIDENTS FROM THE CHEYENNE, DEUEL, KIMBALL AND SURROUNDING AREAS. | Desc |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Program Service Expenses | $56,501,961 | TotalProgramServiceExpensesAmt |
| Described In Section501c3 | Yes (1) | DescribedInSection501c3Ind |
| Schedule B Required | Yes (1) | ScheduleBRequiredInd |
| Political Campaign Acty | 0 | PoliticalCampaignActyInd |
| Lobbying Activities | Yes (1) | LobbyingActivitiesInd |
| Subject To Proxy Tax | 0 | SubjectToProxyTaxInd |
| Donor Advised Fund | 0 | DonorAdvisedFundInd |
| Conservation Easements | 0 | ConservationEasementsInd |
| Collections Of Art | 0 | CollectionsOfArtInd |
| Credit Counseling | 0 | CreditCounselingInd |
| Donor Rstr Or Quasi Endowments | 0 | DonorRstrOrQuasiEndowmentsInd |
| Report Land Building Equipment | Yes (1) | ReportLandBuildingEquipmentInd |
| Report Investments Other Sec | 0 | ReportInvestmentsOtherSecInd |
| Report Program Related Invst | 0 | ReportProgramRelatedInvstInd |
| Report Other Assets | 0 | ReportOtherAssetsInd |
| Report Other Liabilities | Yes (1) | ReportOtherLiabilitiesInd |
| Include FIN48 Footnote | Yes (1) | IncludeFIN48FootnoteInd |
| Independent Audit Fincl Stmt | 0 | IndependentAuditFinclStmtInd |
| Consolidated Audit Fincl Stmt | Yes (1) | ConsolidatedAuditFinclStmtInd |
| School Operating | 0 | SchoolOperatingInd |
| Foreign Office | 0 | ForeignOfficeInd |
| Foreign Activities | 0 | ForeignActivitiesInd |
| More Than5000 K To Org | 0 | MoreThan5000KToOrgInd |
| More Than5000 K To Individuals | 0 | MoreThan5000KToIndividualsInd |
| Professional Fundraising | 0 | ProfessionalFundraisingInd |
| Fundraising Activities | 0 | FundraisingActivitiesInd |
| Gaming Activities | 0 | GamingActivitiesInd |
| Operate Hospital | Yes (1) | OperateHospitalInd |
| Audited Financial Stmt Att | Yes (1) | AuditedFinancialStmtAttInd |
| Grants To Organizations | Yes (1) | GrantsToOrganizationsInd |
| Grants To Individuals | 0 | GrantsToIndividualsInd |
| Schedule J Required | Yes (1) | ScheduleJRequiredInd |
| Tax Exempt Bonds | Yes (1) | TaxExemptBondsInd |
| Invest Tax Exempt Bonds | 0 | InvestTaxExemptBondsInd |
| Escrow Account | 0 | EscrowAccountInd |
| On Behalf Of Issuer | 0 | OnBehalfOfIssuerInd |
| Engaged In Excess Benefit Trans | 0 | EngagedInExcessBenefitTransInd |
| PY Excess Benefit Trans | 0 | PYExcessBenefitTransInd |
| Loan Outstanding | 0 | LoanOutstandingInd |
| Grant To Related Person | 0 | GrantToRelatedPersonInd |
| Business Rln With Org Mem | 0 | BusinessRlnWithOrgMemInd |
| Business Rln With Fam Mem | Yes (1) | BusinessRlnWithFamMemInd |
| Business Rln With35 Ctrl Ent | 0 | BusinessRlnWith35CtrlEntInd |
| Deductible Non Cash Contri | 0 | DeductibleNonCashContriInd |
| Deductible Art Contribution | 0 | DeductibleArtContributionInd |
| Terminate Operations | 0 | TerminateOperationsInd |
| Partial Liquidation | 0 | PartialLiquidationInd |
| Disregarded Entity | 0 | DisregardedEntityInd |
| Related Entity | Yes (1) | RelatedEntityInd |
| Related Organization Ctrl Ent | 0 | RelatedOrganizationCtrlEntInd |
| Trnsfr Exmpt Non Chrtbl Rltd Org | 0 | TrnsfrExmptNonChrtblRltdOrgInd |
| Activities Conducted Prtshp | 0 | ActivitiesConductedPrtshpInd |
| Schedule O Required | Yes (1) | ScheduleORequiredInd |
| IRP Document | 148 | IRPDocumentCnt |
| IRP Document W2 G | 0 | IRPDocumentW2GCnt |
| Backup Wthld Compliance | Yes (1) | BackupWthldComplianceInd |
| Employee | 479 | EmployeeCnt |
| Employment Tax Returns Filed | Yes (1) | EmploymentTaxReturnsFiledInd |
| Unrelated Bus Incm Over Limit | 0 | UnrelatedBusIncmOverLimitInd |
| Foreign Financial Account | 0 | ForeignFinancialAccountInd |
| Prohibited Tax Shelter Trans | 0 | ProhibitedTaxShelterTransInd |
| Taxable Party Notification | 0 | TaxablePartyNotificationInd |
| Nondeductible Contributions | 0 | NondeductibleContributionsInd |
| Quid Pro Quo Contributions | 0 | QuidProQuoContributionsInd |
| Form8282 Property Disposed Of | 0 | Form8282PropertyDisposedOfInd |
| Rcv Fnds To Pay Prsnl Bnft Cntrct | 0 | RcvFndsToPayPrsnlBnftCntrctInd |
| Pay Premiums Prsnl Bnft Cntrct | 0 | PayPremiumsPrsnlBnftCntrctInd |
| Indoor Tanning Services | 0 | IndoorTanningServicesInd |
| Subj To Tax Rmnrtn Ex Prcht Pymt | 0 | SubjToTaxRmnrtnExPrchtPymtInd |
| Subject To Excs Tax Net Invst Inc | 0 | SubjectToExcsTaxNetInvstIncInd |
| Info In Schedule O Part VI | Yes (X) | InfoInScheduleOPartVIInd |
| Governing Body Voting Members | 12 | GoverningBodyVotingMembersCnt |
| Independent Voting Member | 10 | IndependentVotingMemberCnt |
| Family Or Business Rln | 0 | FamilyOrBusinessRlnInd |
| Delegation Of Mgmt Duties | Yes (1) | DelegationOfMgmtDutiesInd |
| Change To Org Documents | 0 | ChangeToOrgDocumentsInd |
| Material Diversion Or Misuse | 0 | MaterialDiversionOrMisuseInd |
| Members Or Stockholders | 0 | MembersOrStockholdersInd |
| Election Of Board Members | 0 | ElectionOfBoardMembersInd |
| Decisions Subject To Approva | 0 | DecisionsSubjectToApprovaInd |
| Minutes Of Governing Body | Yes (1) | MinutesOfGoverningBodyInd |
| Minutes Of Committees | Yes (1) | MinutesOfCommitteesInd |
| Officer Mailing Address | 0 | OfficerMailingAddressInd |
| Local Chapters | 0 | LocalChaptersInd |
| Form990 Provided To Gvrn Body | 0 | Form990ProvidedToGvrnBodyInd |
| Conflict Of Interest Policy | Yes (1) | ConflictOfInterestPolicyInd |
| Annual Disclosure Covered Prsn | Yes (1) | AnnualDisclosureCoveredPrsnInd |
| Regular Monitoring Enfrc | Yes (1) | RegularMonitoringEnfrcInd |
| Whistleblower Policy | Yes (1) | WhistleblowerPolicyInd |
| Document Retention Policy | Yes (1) | DocumentRetentionPolicyInd |
| Compensation Process CEO | Yes (1) | CompensationProcessCEOInd |
| Compensation Process Other | Yes (1) | CompensationProcessOtherInd |
| Investment In Joint Venture | 0 | InvestmentInJointVentureInd |
| Upon Request | Yes (X) | UponRequestInd |
Books In Care Of Detail BooksInCareOfDetail
Business Name BusinessName
| Field | Value | IRS element (for citing) |
|---|---|---|
| Business Name Line1 | KELLY UTLEY | BusinessNameLine1Txt |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Phone | 3082545825 | PhoneNum |
US Address USAddress
| Field | Value | IRS element (for citing) |
|---|---|---|
| Address Line1 | 1000 POLE CREEK CROSSING | AddressLine1Txt |
| City | SIDNEY | CityNm |
| State Abbreviation | NE | StateAbbreviationCd |
| ZIP | 69162 | ZIPCd |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Info In Schedule O Part VII | Yes (X) | InfoInScheduleOPartVIIInd |
Form990 Part VII Section A Form990PartVIISectionAGrp (20 entries)
| TitleTitleTxt | Average Hours Per WeekAverageHoursPerWeekRt | Average Hours Per Week Rltd OrgAverageHoursPerWeekRltdOrgRt | Individual Trustee Or DirectorIndividualTrusteeOrDirectorInd | Reportable Comp From OrgReportableCompFromOrgAmt | Reportable Comp From Rltd OrgReportableCompFromRltdOrgAmt | Other CompensationOtherCompensationAmt | Highest Compensated EmployeeHighestCompensatedEmployeeInd | OfficerOfficerInd |
|---|---|---|---|---|---|---|---|---|
| REBECCA L ALLARD MD | ||||||||
| CHIEF OF STAFF | 40.00 | 0.00 | Yes (X) | $684,896 | $0 | $50,259 | ||
| MATTHEW JANSEN MD | ||||||||
| DOCTOR | 40.00 | 0.00 | $633,007 | $0 | $50,259 | Yes (X) | ||
| JAMES POPOVICH MD | ||||||||
| DOCTOR | 40.00 | 0.00 | $565,954 | $0 | $50,259 | Yes (X) | ||
| SARA SHOLAR MD | ||||||||
| DOCTOR | 40.00 | 0.00 | $566,053 | $0 | $35,221 | Yes (X) | ||
| KELLY CASEY MD | ||||||||
| DOCTOR | 40.00 | 0.00 | $491,236 | $0 | $40,926 | Yes (X) | ||
| APRIL SMITH MD | ||||||||
| DOCTOR | 40.00 | 0.00 | $399,453 | $0 | $40,646 | Yes (X) | ||
| ROBERT GRAVES MD | ||||||||
| PHYSICIAN AT LARGE | 40.00 | 0.00 | Yes (X) | $347,827 | $0 | $51,815 | ||
| KELLY UTLEY | ||||||||
| CFO | 39.00 | 1.00 | $203,959 | $0 | $19,470 | Yes (X) | ||
| WILLIAM PILE | ||||||||
| CHAIRMAN | 4.00 | 0.00 | Yes (X) | $0 | $0 | $0 | Yes (X) | |
| TIM MILLER | ||||||||
| VICE CHAIRMAN | 4.00 | 0.00 | Yes (X) | $0 | $0 | $0 | Yes (X) | |
| KATHY NARJES | ||||||||
| SECRETARY | 4.00 | 0.00 | Yes (X) | $0 | $0 | $0 | Yes (X) | |
| JEFF ELLWANGER | ||||||||
| TREASURER | 4.00 | 0.00 | Yes (X) | $0 | $0 | $0 | Yes (X) | |
| STAN BELIEU | ||||||||
| MEMBER | 4.00 | 1.00 | Yes (X) | $0 | $0 | $0 | ||
| DWIGHT SMITH | ||||||||
| MEMBER | 4.00 | 0.00 | Yes (X) | $0 | $0 | $0 | ||
| NANCI MCCASLIN | ||||||||
| MEMBER | 4.00 | 1.00 | Yes (X) | $0 | $0 | $0 | ||
| CLEM SCHUMACHER | ||||||||
| MEMBER | 4.00 | 0.00 | Yes (X) | $0 | $0 | $0 | ||
| JEFF HELLER | ||||||||
| MEMBER | 4.00 | 0.00 | Yes (X) | $0 | $0 | $0 | ||
| WILLIAM ROBINSON | ||||||||
| MEMBER | 4.00 | 0.00 | Yes (X) | $0 | $0 | $0 | ||
| JIM JONES | ||||||||
| MEMBER THRU 06/21 | 4.00 | 0.00 | Yes (X) | $0 | $0 | $0 | ||
| JASON PETIK | ||||||||
| CEO | 40.00 | 0.00 | $0 | $0 | $0 | Yes (X) | ||
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Reportable Comp From Org | $3,892,385 | TotalReportableCompFromOrgAmt |
| Tot Reportable Comp Rltd Org | $0 | TotReportableCompRltdOrgAmt |
| Total Other Compensation | $338,855 | TotalOtherCompensationAmt |
| Indiv Rcvd Greater Than100 K | 42 | IndivRcvdGreaterThan100KCnt |
| Former Ofcr Employees Listed | 0 | FormerOfcrEmployeesListedInd |
| Total Comp Greater Than150 K | Yes (1) | TotalCompGreaterThan150KInd |
| Compensation From Other Srcs | Yes (1) | CompensationFromOtherSrcsInd |
Contractor Compensation ContractorCompensationGrp (5 entries)
| Address Line1ContractorAddress/USAddress/AddressLine1Txt | CityContractorAddress/USAddress/CityNm | State AbbreviationContractorAddress/USAddress/StateAbbreviationCd | ZIPContractorAddress/USAddress/ZIPCd | ServicesServicesDesc | CompensationCompensationAmt |
|---|---|---|---|---|---|
| RURAL PARTNERS IN MEDICINE LLC | |||||
| 11880 AIRPORT WAY | BROOMFIELD | CO | 80021 | PHYSICIAN SERVICES | $2,296,422 |
| UNIVERSITY OF COLORADO HEALTH | |||||
| 7901 E LOWRY BLVD SUITE 350 | DENVER | CO | 90230 | SYSTEM SUPPORT | $874,105 |
| GE PRECISION HEALTHCARE LLC | |||||
| PO BOX 96483 | CHICAGO | IL | 60693 | SERVICE CONTRACTS | $748,373 |
| FUSION MEDICAL STAFFING LLC | |||||
| PO BOX 82674 | LINCOLN | NE | 68501 | TEMPORARY STAFFING SERVICES | $704,869 |
| RURAL MEDICAL SOLUTIONS LLC | |||||
| 8181 ARISTA PLACE STE 100 | BROOMFIELD | CO | 80021 | IMPLANT SERVICES | $625,322 |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Cntrct Rcvd Greater Than100 K | 16 | CntrctRcvdGreaterThan100KCnt |
| Government Grants | $6,220,918 | GovernmentGrantsAmt |
| All Other Contributions | $128,004 | AllOtherContributionsAmt |
| Total Contributions | $6,348,922 | TotalContributionsAmt |
Program Service Revenue ProgramServiceRevenueGrp (4 entries)
| DescDesc | BusinessBusinessCd | Total Revenue ColumnTotalRevenueColumnAmt | Related Or Exempt Func IncomeRelatedOrExemptFuncIncomeAmt |
|---|---|---|---|
| NET PATIENT SERVICE REVENUE | 621110 | $36,090,758 | $36,090,758 |
| MEDICARE/MEDICAID | 621110 | $26,482,603 | $26,482,603 |
| 340B REVENUE | 621110 | $1,003,776 | $1,003,776 |
| SCHOOL REHAB REVENUE | 621110 | $144,364 | $144,364 |
Total Oth Program Service Rev TotalOthProgramServiceRevGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Revenue Column | $119,422 | TotalRevenueColumnAmt |
| Related Or Exempt Func Income | $119,422 | RelatedOrExemptFuncIncomeAmt |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Program Service Revenue | $63,840,923 | TotalProgramServiceRevenueAmt |
Investment Income InvestmentIncomeGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Revenue Column | $467,466 | TotalRevenueColumnAmt |
| Exclusion | $467,466 | ExclusionAmt |
Other Revenue Misc OtherRevenueMiscGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Desc | CAFETERIA | Desc |
| Business | 722210 | BusinessCd |
| Total Revenue Column | $121,763 | TotalRevenueColumnAmt |
| Exclusion | $121,763 | ExclusionAmt |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Other Revenue Total | $121,763 | OtherRevenueTotalAmt |
Total Revenue TotalRevenueGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Revenue Column | $70,779,074 | TotalRevenueColumnAmt |
| Related Or Exempt Func Income | $63,840,923 | RelatedOrExemptFuncIncomeAmt |
| Unrelated Business Revenue | $0 | UnrelatedBusinessRevenueAmt |
| Exclusion | $589,229 | ExclusionAmt |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Info In Schedule O Part IX | Yes (X) | InfoInScheduleOPartIXInd |
Grants To Domestic Orgs GrantsToDomesticOrgsGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $28,700 | TotalAmt |
| Program Services | $28,700 | ProgramServicesAmt |
Comp Current Ofcr Directors CompCurrentOfcrDirectorsGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $1,358,226 | TotalAmt |
| Program Services | $1,134,797 | ProgramServicesAmt |
| Management And General | $223,429 | ManagementAndGeneralAmt |
Comp Disqual Persons CompDisqualPersonsGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $186,196 | TotalAmt |
| Program Services | $95,006 | ProgramServicesAmt |
| Management And General | $91,190 | ManagementAndGeneralAmt |
Other Salaries And Wages OtherSalariesAndWagesGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $25,512,245 | TotalAmt |
| Program Services | $23,514,624 | ProgramServicesAmt |
| Management And General | $1,997,621 | ManagementAndGeneralAmt |
Pension Plan Contributions PensionPlanContributionsGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $798,683 | TotalAmt |
| Program Services | $717,326 | ProgramServicesAmt |
| Management And General | $81,357 | ManagementAndGeneralAmt |
Other Employee Benefits OtherEmployeeBenefitsGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $8,691,939 | TotalAmt |
| Program Services | $8,181,829 | ProgramServicesAmt |
| Management And General | $510,110 | ManagementAndGeneralAmt |
Fees For Services Management FeesForServicesManagementGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $289,740 | TotalAmt |
| Management And General | $289,740 | ManagementAndGeneralAmt |
Fees For Services Legal FeesForServicesLegalGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $24,124 | TotalAmt |
| Management And General | $24,124 | ManagementAndGeneralAmt |
Fees For Services Accounting FeesForServicesAccountingGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $40,673 | TotalAmt |
| Management And General | $40,673 | ManagementAndGeneralAmt |
Fees For Services Other FeesForServicesOtherGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $7,416,809 | TotalAmt |
| Program Services | $6,813,620 | ProgramServicesAmt |
| Management And General | $603,189 | ManagementAndGeneralAmt |
Office Expenses OfficeExpensesGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $1,251,053 | TotalAmt |
| Program Services | $1,141,668 | ProgramServicesAmt |
| Management And General | $109,385 | ManagementAndGeneralAmt |
Information Technology InformationTechnologyGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $1,246,771 | TotalAmt |
| Program Services | $1,113,985 | ProgramServicesAmt |
| Management And General | $132,786 | ManagementAndGeneralAmt |
Occupancy OccupancyGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $1,198,634 | TotalAmt |
| Program Services | $1,025,172 | ProgramServicesAmt |
| Management And General | $173,462 | ManagementAndGeneralAmt |
Travel TravelGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $85,704 | TotalAmt |
| Program Services | $82,592 | ProgramServicesAmt |
| Management And General | $3,112 | ManagementAndGeneralAmt |
Conferences Meetings ConferencesMeetingsGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $120,239 | TotalAmt |
| Program Services | $49,185 | ProgramServicesAmt |
| Management And General | $71,054 | ManagementAndGeneralAmt |
Interest InterestGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $1,213,302 | TotalAmt |
| Program Services | $1,100,304 | ProgramServicesAmt |
| Management And General | $112,998 | ManagementAndGeneralAmt |
Depreciation Depletion DepreciationDepletionGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $3,780,846 | TotalAmt |
| Program Services | $3,503,003 | ProgramServicesAmt |
| Management And General | $277,843 | ManagementAndGeneralAmt |
Insurance InsuranceGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $746,478 | TotalAmt |
| Management And General | $746,478 | ManagementAndGeneralAmt |
Other Expenses OtherExpensesGrp (4 entries)
| DescDesc | TotalTotalAmt | Program ServicesProgramServicesAmt | Management And GeneralManagementAndGeneralAmt |
|---|---|---|---|
| MEDICAL SUPPLIES | $6,817,060 | $6,817,060 | |
| RECRUITING FEES | $420,640 | $397,800 | $22,840 |
| FOOD PRODUCTS | $329,149 | $329,149 | |
| BAD DEBTS | $272,535 | $272,535 |
All Other Expenses AllOtherExpensesGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $382,039 | TotalAmt |
| Program Services | $183,606 | ProgramServicesAmt |
| Management And General | $198,433 | ManagementAndGeneralAmt |
Total Functional Expenses TotalFunctionalExpensesGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $62,211,785 | TotalAmt |
| Program Services | $56,501,961 | ProgramServicesAmt |
| Management And General | $5,709,824 | ManagementAndGeneralAmt |
| Fundraising | $0 | FundraisingAmt |
Cash Non Interest Bearing CashNonInterestBearingGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $843,641 | BOYAmt |
| EOY | $361,790 | EOYAmt |
Savings And Temp Cash Invst SavingsAndTempCashInvstGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $33,791,429 | BOYAmt |
| EOY | $41,877,043 | EOYAmt |
Accounts Receivable AccountsReceivableGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $8,758,247 | BOYAmt |
| EOY | $9,892,268 | EOYAmt |
Oth Notes Loans Receivable Net OthNotesLoansReceivableNetGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $380,342 | BOYAmt |
| EOY | $462,821 | EOYAmt |
Inventories For Sale Or Use InventoriesForSaleOrUseGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $1,715,762 | BOYAmt |
| EOY | $1,698,330 | EOYAmt |
Prepaid Expenses Defrd Charges PrepaidExpensesDefrdChargesGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $671,809 | BOYAmt |
| EOY | $871,738 | EOYAmt |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Land Bldg Equip Cost Or Other Bss | $73,642,467 | LandBldgEquipCostOrOtherBssAmt |
| Land Bldg Equip Accum Deprec | $36,192,320 | LandBldgEquipAccumDeprecAmt |
Land Bldg Equip Basis Net LandBldgEquipBasisNetGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $38,971,017 | BOYAmt |
| EOY | $37,450,147 | EOYAmt |
Investments Pub Traded Sec InvestmentsPubTradedSecGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $11,364,478 | BOYAmt |
| EOY | $9,258,356 | EOYAmt |
Other Assets Total OtherAssetsTotalGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $2,491,429 | BOYAmt |
| EOY | $1,389,518 | EOYAmt |
Total Assets TotalAssetsGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $98,988,154 | BOYAmt |
| EOY | $103,262,011 | EOYAmt |
Accounts Payable Accr Expnss AccountsPayableAccrExpnssGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $4,880,207 | BOYAmt |
| EOY | $6,063,295 | EOYAmt |
Deferred Revenue DeferredRevenueGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $8,600,000 | BOYAmt |
| EOY | $4,312,837 | EOYAmt |
Tax Exempt Bond Liabilities TaxExemptBondLiabilitiesGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $8,322,558 | BOYAmt |
| EOY | $7,901,171 | EOYAmt |
Mortg Notes Pybl Scrd Invst Prop MortgNotesPyblScrdInvstPropGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $29,930,604 | BOYAmt |
| EOY | $29,414,730 | EOYAmt |
Unsecured Notes Loans Payable UnsecuredNotesLoansPayableGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $4,276,950 | BOYAmt |
| EOY | $0 | EOYAmt |
Other Liabilities OtherLiabilitiesGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $1,297,755 | BOYAmt |
| EOY | $5,030,865 | EOYAmt |
Total Liabilities TotalLiabilitiesGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $57,308,074 | BOYAmt |
| EOY | $52,722,898 | EOYAmt |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Organization Follows FASB117 | Yes (X) | OrganizationFollowsFASB117Ind |
No Donor Restriction Net Assets NoDonorRestrictionNetAssetsGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $41,680,080 | BOYAmt |
| EOY | $50,539,113 | EOYAmt |
Total Net Assets Fund Balance TotalNetAssetsFundBalanceGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $41,680,080 | BOYAmt |
| EOY | $50,539,113 | EOYAmt |
Tot Liab Net Assets Fund Balance TotLiabNetAssetsFundBalanceGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $98,988,154 | BOYAmt |
| EOY | $103,262,011 | EOYAmt |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Reconcilation Revenue Expnss | $8,567,289 | ReconcilationRevenueExpnssAmt |
| Net Unrlzd Gains Losses Invst | $291,744 | NetUnrlzdGainsLossesInvstAmt |
| Other Changes In Net Assets | $0 | OtherChangesInNetAssetsAmt |
| Info In Schedule O Part XII | Yes (X) | InfoInScheduleOPartXIIInd |
| Method Of Accounting Accrual | Yes (X) | MethodOfAccountingAccrualInd |
| Accountant Compile Or Review | 0 | AccountantCompileOrReviewInd |
| FS Audited | Yes (1) | FSAuditedInd |
FS Audited Basis FSAuditedBasisGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Consolidated Basis Fincl Stmt | Yes (X) | ConsolidatedBasisFinclStmtInd |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Audit Committee | Yes (1) | AuditCommitteeInd |
| Federal Grant Audit Required | Yes (1) | FederalGrantAuditRequiredInd |
| Federal Grant Audit Performed | Yes (1) | FederalGrantAuditPerformedInd |
Schedule A IRS990ScheduleA
| Field | Value | IRS element (for citing) |
|---|---|---|
| Hospital | Yes (X) | HospitalInd |
Schedule B IRS990ScheduleB
Contributor Information ContributorInformationGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Contributor | RESTRICTED | ContributorNum |
Contributor Business Name ContributorBusinessName
| Field | Value | IRS element (for citing) |
|---|---|---|
| Business Name Line1 | RESTRICTED | BusinessNameLine1 |
Contributor US Address ContributorUSAddress
| Field | Value | IRS element (for citing) |
|---|---|---|
| Address Line1 | RESTRICTED | AddressLine1 |
| Address Line2 | RESTRICTED | AddressLine2 |
| City | RESTRICTED | City |
| State | RESTRICTED | State |
| ZIP Code | RESTRICTED | ZIPCode |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Contributions | RESTRICTED | TotalContributionsAmt |
Schedule C IRS990ScheduleC
| Field | Value | IRS element (for citing) |
|---|---|---|
| Volunteers | 0 | VolunteersInd |
| Paid Staff Or Management | 0 | PaidStaffOrManagementInd |
| Media Advertisements | 0 | MediaAdvertisementsInd |
| Mailings Members | 0 | MailingsMembersInd |
| Publications Or Broadcast | 0 | PublicationsOrBroadcastInd |
| Grants Other Organizations | 0 | GrantsOtherOrganizationsInd |
| Direct Contact Legislators | 0 | DirectContactLegislatorsInd |
| Rallies Demonstrations | 0 | RalliesDemonstrationsInd |
| Other Activities | Yes (1) | OtherActivitiesInd |
| Other Activities | $6,880 | OtherActivitiesAmt |
| Total Lobbying Expenditures | $6,880 | TotalLobbyingExpendituresAmt |
| Not Described Section501c3 | 0 | NotDescribedSection501c3Ind |
Supplemental Information Detail SupplementalInformationDetail
| Field | Value | IRS element (for citing) |
|---|---|---|
| Form And Line Reference | PART II-B, LINE 1: | FormAndLineReferenceDesc |
| Explanation | A PORTION OF THE DUES PAID TO THE AMERICAN HOSPITAL ASSOCIATION (AHA) AND THE NEBRASKA HOSPITAL ASSOCIATION (NHA) ARE USED BY THOSE ORGANIZATIONS FOR LOBBYING ACTIVITIES. | ExplanationTxt |
Schedule D IRS990ScheduleD
Land LandGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Investment Cost Or Other Basis | $92,500 | InvestmentCostOrOtherBasisAmt |
| Other Cost Or Other Basis | $1,947,968 | OtherCostOrOtherBasisAmt |
| Book Value | $2,040,468 | BookValueAmt |
Buildings BuildingsGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Other Cost Or Other Basis | $49,728,330 | OtherCostOrOtherBasisAmt |
| Depreciation | $20,797,812 | DepreciationAmt |
| Book Value | $28,930,518 | BookValueAmt |
Equipment EquipmentGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Other Cost Or Other Basis | $19,840,368 | OtherCostOrOtherBasisAmt |
| Depreciation | $14,750,010 | DepreciationAmt |
| Book Value | $5,090,358 | BookValueAmt |
Other Land Buildings OtherLandBuildingsGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Other Cost Or Other Basis | $2,033,301 | OtherCostOrOtherBasisAmt |
| Depreciation | $644,498 | DepreciationAmt |
| Book Value | $1,388,803 | BookValueAmt |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Book Value Land Buildings | $37,450,147 | TotalBookValueLandBuildingsAmt |
Other Liabilities Org OtherLiabilitiesOrgGrp (2 entries)
| DescDesc | AmtAmt |
|---|---|
| DEFERRED COMPENSATION PLAN LIABILITY | $1,389,518 |
| ESTIMATED THIRD-PARTY PAYOR SETTLEMENTS | $3,641,347 |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Liability | $5,030,865 | TotalLiabilityAmt |
| Footnote Text | Yes (X) | FootnoteTextInd |
Supplemental Information Detail SupplementalInformationDetail
| Field | Value | IRS element (for citing) |
|---|---|---|
| Form And Line Reference | PART X, LINE 2: | FormAndLineReferenceDesc |
| Explanation | SRMC AND THE FOUNDATION ARE EXEMPT FROM FEDERAL INCOME TAXES ON RELATED INCOME PURSUANT TO SECTION 501(A) OF THE INTERNAL REVENUE CODE AND A SIMILAR PROVISION OF STATE LAW. THE INTERNAL REVENUE SERVICE HAS ESTABLISHED STANDARDS TO BE MET TO MAINTAIN TAX-EXEMPT STATUS. THE ORGANIZATION ACCOUNTS FOR UNCERTAINTIES IN ACCOUNTING FOR INCOME TAX ASSETS AND LIABILITIES USING GUIDANCE INCLUDED IN FASB ASC 740, INCOME TAXES. THE ORGANIZATION RECOGNIZES THE EFFECT OF INCOME TAX POSITIONS ONLY IF THOSE `POSITIONS ARE MORE LIKELY THAN NOT OF BEING SUSTAINED. AT DECEMBER 31, 2021, THE SYSTEM HAD NO UNCERTAIN TAX POSITIONS ACCRUED. | ExplanationTxt |
Schedule H IRS990ScheduleH
| Field | Value | IRS element (for citing) |
|---|---|---|
| Financial Assistance Policy | Yes (1) | FinancialAssistancePolicyInd |
| Written Policy | Yes (1) | WrittenPolicyInd |
| All Hospitals Policy | Yes (X) | AllHospitalsPolicyInd |
| FPG Reference Free Care | Yes (1) | FPGReferenceFreeCareInd |
| Percent100 | Yes (X) | Percent100Ind |
| FPG Reference Discounted Care | Yes (1) | FPGReferenceDiscountedCareInd |
| Percent300 | Yes (X) | Percent300Ind |
| Free Care Medically Indigent | Yes (1) | FreeCareMedicallyIndigentInd |
| Financial Assistance Budget | Yes (1) | FinancialAssistanceBudgetInd |
| Expenses Exceed Budget | 0 | ExpensesExceedBudgetInd |
| Annual Community Bnft Report | 0 | AnnualCommunityBnftReportInd |
Financial Assistance At Cost Typ FinancialAssistanceAtCostTyp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Community Benefit Expns | $229,981 | TotalCommunityBenefitExpnsAmt |
| Direct Offsetting Revenue | $0 | DirectOffsettingRevenueAmt |
| Net Community Benefit Expns | $229,981 | NetCommunityBenefitExpnsAmt |
| Total Expense | 0.00370 | TotalExpensePct |
Unreimbursed Medicaid UnreimbursedMedicaidGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Community Benefit Expns | $5,563,990 | TotalCommunityBenefitExpnsAmt |
| Direct Offsetting Revenue | $1,397,467 | DirectOffsettingRevenueAmt |
| Net Community Benefit Expns | $4,166,523 | NetCommunityBenefitExpnsAmt |
| Total Expense | 0.06730 | TotalExpensePct |
Total Financial Assistance Typ TotalFinancialAssistanceTyp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Community Benefit Expns | $5,793,971 | TotalCommunityBenefitExpnsAmt |
| Direct Offsetting Revenue | $1,397,467 | DirectOffsettingRevenueAmt |
| Net Community Benefit Expns | $4,396,504 | NetCommunityBenefitExpnsAmt |
| Total Expense | 0.07100 | TotalExpensePct |
Community Health Services CommunityHealthServicesGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Community Benefit Expns | $90,602 | TotalCommunityBenefitExpnsAmt |
| Direct Offsetting Revenue | $43,233 | DirectOffsettingRevenueAmt |
| Net Community Benefit Expns | $47,369 | NetCommunityBenefitExpnsAmt |
| Total Expense | 0.00080 | TotalExpensePct |
Health Professions Education HealthProfessionsEducationGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Community Benefit Expns | $10,657 | TotalCommunityBenefitExpnsAmt |
| Direct Offsetting Revenue | $0 | DirectOffsettingRevenueAmt |
| Net Community Benefit Expns | $10,657 | NetCommunityBenefitExpnsAmt |
| Total Expense | 0.00020 | TotalExpensePct |
Subsidized Health Services SubsidizedHealthServicesGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Community Benefit Expns | $1,254,675 | TotalCommunityBenefitExpnsAmt |
| Net Community Benefit Expns | $1,254,675 | NetCommunityBenefitExpnsAmt |
| Total Expense | 0.02030 | TotalExpensePct |
Cash And In Kind Contributions CashAndInKindContributionsGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Community Benefit Expns | $63,473 | TotalCommunityBenefitExpnsAmt |
| Direct Offsetting Revenue | $0 | DirectOffsettingRevenueAmt |
| Net Community Benefit Expns | $63,473 | NetCommunityBenefitExpnsAmt |
| Total Expense | 0.00100 | TotalExpensePct |
Total Other Benefits TotalOtherBenefitsGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Community Benefit Expns | $1,419,407 | TotalCommunityBenefitExpnsAmt |
| Direct Offsetting Revenue | $43,233 | DirectOffsettingRevenueAmt |
| Net Community Benefit Expns | $1,376,174 | NetCommunityBenefitExpnsAmt |
| Total Expense | 0.02230 | TotalExpensePct |
Total Community Benefits TotalCommunityBenefitsGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Community Benefit Expns | $7,213,378 | TotalCommunityBenefitExpnsAmt |
| Direct Offsetting Revenue | $1,440,700 | DirectOffsettingRevenueAmt |
| Net Community Benefit Expns | $5,772,678 | NetCommunityBenefitExpnsAmt |
| Total Expense | 0.09330 | TotalExpensePct |
Community Support CommunitySupportGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Activities Or Programs | 40 | ActivitiesOrProgramsCnt |
| Persons Served | 884 | PersonsServedCnt |
| Total Community Benefit Expns | $1,847 | TotalCommunityBenefitExpnsAmt |
| Direct Offsetting Revenue | $0 | DirectOffsettingRevenueAmt |
| Net Community Benefit Expns | $1,847 | NetCommunityBenefitExpnsAmt |
| Total Expense | 0.00000 | TotalExpensePct |
Other Communtity Building Acty OtherCommuntityBuildingActyGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Activities Or Programs | 93 | ActivitiesOrProgramsCnt |
| Persons Served | 432 | PersonsServedCnt |
| Total Community Benefit Expns | $8,475 | TotalCommunityBenefitExpnsAmt |
| Direct Offsetting Revenue | $0 | DirectOffsettingRevenueAmt |
| Net Community Benefit Expns | $8,475 | NetCommunityBenefitExpnsAmt |
| Total Expense | 0.00010 | TotalExpensePct |
Total Communtity Building Acty TotalCommuntityBuildingActyGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Activities Or Programs | 133 | ActivitiesOrProgramsCnt |
| Persons Served | 1316 | PersonsServedCnt |
| Total Community Benefit Expns | $10,322 | TotalCommunityBenefitExpnsAmt |
| Net Community Benefit Expns | $10,322 | NetCommunityBenefitExpnsAmt |
| Total Expense | 0.00010 | TotalExpensePct |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Bad Debt Expense Reported | Yes (1) | BadDebtExpenseReportedInd |
| Bad Debt Expense | $272,535 | BadDebtExpenseAmt |
| Bad Debt Expense Attributable | $0 | BadDebtExpenseAttributableAmt |
| Reimbursed By Medicare | $20,901,469 | ReimbursedByMedicareAmt |
| Cost Of Care Reimbursed By Medcr | $20,922,913 | CostOfCareReimbursedByMedcrAmt |
| Medicare Surplus Or Shortfall | -$21,444 | MedicareSurplusOrShortfallAmt |
Costing Methodology Used CostingMethodologyUsedGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Cost To Charge Ratio | Yes (X) | CostToChargeRatioInd |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Written Debt Collection Policy | Yes (1) | WrittenDebtCollectionPolicyInd |
| Financial Assistance Prvsn | Yes (1) | FinancialAssistancePrvsnInd |
| Hospital Facilities | 1 | HospitalFacilitiesCnt |
Hospital Facilities HospitalFacilitiesGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Facility | 1 | FacilityNum |
Business Name BusinessName
| Field | Value | IRS element (for citing) |
|---|---|---|
| Business Name Line1 | CHEYENNE COUNTY HOSPITAL ASSOCIATION | BusinessNameLine1Txt |
US Address USAddress
| Field | Value | IRS element (for citing) |
|---|---|---|
| Address Line1 | 1000 POLE CREEK CROSSING | AddressLine1Txt |
| City | SIDNEY | CityNm |
| State Abbreviation | NE | StateAbbreviationCd |
| ZIP | 69162 | ZIPCd |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Website Address | WWW.SIDNEYRMC.COM | WebsiteAddressTxt |
| State License | 150001 | StateLicenseNum |
| Licensed Hospital | Yes (X) | LicensedHospitalInd |
| General Medical And Surgical | Yes (X) | GeneralMedicalAndSurgicalInd |
| Critical Access Hospital | Yes (X) | CriticalAccessHospitalInd |
| Emergency Room24 Hrs | Yes (X) | EmergencyRoom24HrsInd |
Hospital Fclty Policies Prctc HospitalFcltyPoliciesPrctcGrp
Hospital Facility Name HospitalFacilityName
| Field | Value | IRS element (for citing) |
|---|---|---|
| Business Name Line1 | CHEYENNE COUNTY HOSPITAL ASSOCIATION INC | BusinessNameLine1Txt |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Facility | 1 | FacilityNum |
| First Licensed CY Or PY | 0 | FirstLicensedCYOrPYInd |
| Tax Exempt Hospital CY Or PY | 0 | TaxExemptHospitalCYOrPYInd |
| CHNA Conducted | Yes (1) | CHNAConductedInd |
| Community Definition | Yes (X) | CommunityDefinitionInd |
| Community Demographics | Yes (X) | CommunityDemographicsInd |
| Existing Resources | Yes (X) | ExistingResourcesInd |
| How Data Obtained | Yes (X) | HowDataObtainedInd |
| Community Health Needs | Yes (X) | CommunityHealthNeedsInd |
| Other Health Issues | Yes (X) | OtherHealthIssuesInd |
| Community Hlth Needs Id Process | Yes (X) | CommunityHlthNeedsIdProcessInd |
| Consulting Process | Yes (X) | ConsultingProcessInd |
| Prior CHNA Impact | Yes (X) | PriorCHNAImpactInd |
| CHNA Conducted | 20 | CHNAConductedYr |
| Take Into Account Others Input | Yes (1) | TakeIntoAccountOthersInputInd |
| CHNA Conducted With Other Fclts | Yes (1) | CHNAConductedWithOtherFcltsInd |
| CHNA Conducted With Non Fclts | Yes (1) | CHNAConductedWithNonFcltsInd |
| CHNA Report Widely Available | Yes (1) | CHNAReportWidelyAvailableInd |
| Rpt Available On Own Website | Yes (X) | RptAvailableOnOwnWebsiteInd |
| Own Website URL | WWW.SIDNEYRMC.COM/501R | OwnWebsiteURLTxt |
| Other Website | Yes (X) | OtherWebsiteInd |
| Other Website URL | WWW.PPHD.ORG/PAGES/CHIP.HTML | OtherWebsiteURLTxt |
| Paper Copy Public Inspection | Yes (X) | PaperCopyPublicInspectionInd |
| Implementation Strategy Adopt | Yes (1) | ImplementationStrategyAdoptInd |
| Implementation Strategy Adpt | 20 | ImplementationStrategyAdptYr |
| Strategy Posted Website | Yes (1) | StrategyPostedWebsiteInd |
| Strategy Website URL | WWW.SIDNEYRMC.COM/501R | StrategyWebsiteURLTxt |
| Organization Incur Excise Tax | 0 | OrganizationIncurExciseTaxInd |
| Elig Criteria Explained | Yes (1) | EligCriteriaExplainedInd |
| FPG Family Incm Lmt Free Dscnt | Yes (X) | FPGFamilyIncmLmtFreeDscntInd |
| FPG Family Incm Lmt Free Care | 100.000000000000 | FPGFamilyIncmLmtFreeCarePct |
| FPG Family Incm Lmt Dscnt Care | 300.000000000000 | FPGFamilyIncmLmtDscntCarePct |
| Income Level Criteria | Yes (X) | IncomeLevelCriteriaInd |
| Asset Level Criteria | Yes (X) | AssetLevelCriteriaInd |
| Medical Indigency Criteria | Yes (X) | MedicalIndigencyCriteriaInd |
| Underinsurance Stat Criteria | Yes (X) | UnderinsuranceStatCriteriaInd |
| Residency Criteria | Yes (X) | ResidencyCriteriaInd |
| Explained Basis | Yes (1) | ExplainedBasisInd |
| App Financial Asst Expln | Yes (1) | AppFinancialAsstExplnInd |
| Described Info | Yes (X) | DescribedInfoInd |
| Described Suprt Doc | Yes (X) | DescribedSuprtDocInd |
| Provided Hospital Contact | Yes (X) | ProvidedHospitalContactInd |
| Provided Nonprofit Contact | Yes (X) | ProvidedNonprofitContactInd |
| Includes Publicity Measures | Yes (1) | IncludesPublicityMeasuresInd |
| FAP Available On Website | Yes (X) | FAPAvailableOnWebsiteInd |
| FAP Available On Website URL | SIDNEYRMC.COM/501R | FAPAvailableOnWebsiteURLTxt |
| FAP App Available On Website | Yes (X) | FAPAppAvailableOnWebsiteInd |
| FAP App Available On Website URL | SIDNEYRMC.COM/501R | FAPAppAvailableOnWebsiteURLTxt |
| FAP Summary On Website | Yes (X) | FAPSummaryOnWebsiteInd |
| FAP Summary On Website URL | SIDNEYRMC.COM/501R | FAPSummaryOnWebsiteURLTxt |
| FAP Avlbl On Request No Charge | Yes (X) | FAPAvlblOnRequestNoChargeInd |
| FAP App Avlbl On Request No Chrg | Yes (X) | FAPAppAvlblOnRequestNoChrgInd |
| FAP Sum Avlbl On Request No Chrg | Yes (X) | FAPSumAvlblOnRequestNoChrgInd |
| Notified FAP Copy Bill Display | Yes (X) | NotifiedFAPCopyBillDisplayInd |
| Communtity Notified FAP | Yes (X) | CommuntityNotifiedFAPInd |
| Other Publicity | Yes (X) | OtherPublicityInd |
| FAP Actions On Nonpayment | Yes (1) | FAPActionsOnNonpaymentInd |
| Permit No Actions | Yes (X) | PermitNoActionsInd |
| Collection Activities | 0 | CollectionActivitiesInd |
| Provided Written Notice | Yes (X) | ProvidedWrittenNoticeInd |
| Made Effort Orally Notify | Yes (X) | MadeEffortOrallyNotifyInd |
| Processed FAP Application | Yes (X) | ProcessedFAPApplicationInd |
| Made Presumptive Elig Determ | Yes (X) | MadePresumptiveEligDetermInd |
| Other Actions Taken | Yes (X) | OtherActionsTakenInd |
| Nondis Emergency Care Policy | Yes (1) | NondisEmergencyCarePolicyInd |
| Look Back Medicare Private | Yes (X) | LookBackMedicarePrivateInd |
| Amounts Generally Billed | 0 | AmountsGenerallyBilledInd |
| Gross Charges | 0 | GrossChargesInd |
Supplemental Information SupplementalInformationGrp (7 entries)
| Form And Line ReferenceFormAndLineReferenceDesc | ExplanationExplanationTxt |
|---|---|
| CHEYENNE COUNTY HOSPITAL ASSOCIATION INC | PART V, SECTION B, LINE 5: A MAPP STEERING COMMITTEE WAS FORMED IN 2014, MADE UP OF REPRESENTATIVES FROM EACH OF THE NINE RURAL NEBRASKA HEALTH NETWORK HOSPITALS (SEE LIST OF MEMBERS IN LINE 6A). COMMITTEE MEMBERS PROVIDE GUIDANCE THROUGHOUT THE MAPP PROCESS AND ARE CHARGED WITH REVIEWING DATA AND PROGRESS ON THE CHOSEN PRIORITY AREAS, USING QUALITY IMPROVEMENT TO MODIFY IMPLEMENTATION PLANS AS NEEDED, AND SHARING RESULTS WITH STAKEHOLDERS. TWO NEW REPRESENTATIVES JOINED THE COMMITTEE IN 2017: A REPRESENTATIVE FROM THE PANHANDLE PARTNERSHIP, SERVING AS A REPRESENTATIVE OF A VARIETY OF COMMUNITY-BASED ORGANIZATIONS, AND A REPRESENTATIVE FROM THE LOCAL ECONOMIC DEVELOPMENT DISTRICT, PANHANDLE AREA DEVELOPMENT DISTRICT (PADD). EACH HOSPITAL FACILITATED AT LEAST ONE FOCUS GROUP WITH LOCAL OR AREA RESIDENTS IN THEIR SERVICE AREA. HOSPITALS WITH A GREATER THAN 50% MINORITY POPULATION MADE A CONCERTED EFFORT TO INCLUDE PEOPLE REPRESENTATIVE OF THE MINORITY POPULATION IN THE FOCUS GROUPS. GROUPS WERE INTENDED TO BE MADE UP OF 8-10 PEOPLE, ALTHOUGH THERE MAY BE SOME VARIANCE. HOSPITAL REPRESENTATIVES IDENTIFIED POTENTIAL FOCUS GROUP PARTICIPANTS AND REACHED OUT VIA PHONE CALLS, E-MAILS AND SOCIAL MEDIA TO INVITE THEM TO ATTEND A FOCUS GROUP SESSION. A TOTAL OF 16 FOCUS GROUP SESSIONS, INVOLVING APPROXIMATELY 142 NEBRASKA PANHANDLE RESIDENTS WERE COMPLETED. FOCUS GROUPS WERE LARGELY CONDUCTED IN THE SPRING OF 2020. BECAUSE OF THE COVID-19 PANDEMIC, A HANDFUL OF FOCUS GROUPS WERE COMPLETED VIA OPEN ENDED SURVEY RATHER THAN IN PERSON. |
| CHEYENNE COUNTY HOSPITAL ASSOCIATION INC | PART V, SECTION B, LINE 6A: THE FOLLOWING IS A LIST OF HOSPITALS THAT PARTICIPATED IN THE CHNA:-BOX BUTTE GENERAL HOSPITAL, ALLIANCE, NE-MORRILL COUNTY HOSPITAL, BRIDGEPORT, NE-REGIONAL WEST MEDICAL CENTER, SCOTTSBLUFF, NE-CHADRON COMMUNITY HOSPITAL, CHADRON, NE-REGIONAL WEST GARDEN COUNTY, OSHKOSH, NE-GORDON MEMORIAL HOSPITAL, GORDON, NE-KIMBALL HEALTH SERVICES, KIMBALL, NE-PERKINS COUNTY HEALTH SERVICES, GRANT, NE-SIDNEY REGIONAL MEDICAL CENTER, SIDNEY, NE |
| CHEYENNE COUNTY HOSPITAL ASSOCIATION INC | PART V, SECTION B, LINE 6B: PANHANDLE PUBLIC HEALTH DISTRICT |
| CHEYENNE COUNTY HOSPITAL ASSOCIATION INC | PART V, SECTION B, LINE 11: FROM FOCUS GROUPS, FEED BACK FROM SURVEYS, AND OTHER REGIONAL ANALYTICS, SRMC DETERMINED THE FOLLOWING POINTS WERE TO BE ADDRESSED FOR THE CHIP 2021-2023. GOALS AND STRATEGIES FOR PRIORITY AREAS ARE AS FOLLOWS:FOCUS AREA 1: BEHAVIORAL HEALTH 1. WEEKLY VISITS TO SCHOOL COUNSELORS TO IDENTIFY INDIVIDUALS WITH NEEDS AND PROACTIVELY DESIGN PLAN OF CARE. 2. MONTHLY ARTICLES, TIPS AND TECHNIQUES ABOUT MENTAL HEALTH ISSUES IN AREA MEDIA VENDORS. 3. RAISE AWARENESS FOR BEHAVIORAL HEALTH AND SENIOR LIFE SOLUTIONS AT SRMC. 4. OFFER AN ANNUAL SURVEY TO ACCESS PROGRESS AND AREAS OF NEED.SRMC WILL HOLD A "MENTAL HEALTH IN THE WORKPLACE" FOR A GROUP OF AG WORKERS CALLED "GEEPS" IN FEBRUARY 2021.FOCUS AREA 2: CHRONIC CARE 1. PROMOTE CHRONIC CARE MANAGEMENT (CCM) "PROGRAM INSERTS" TO COMMUNITY VIA SOCIAL MEDIA/WEBSITE WITH E-MAIL SIGN-UP FOR FREE DOWNLOAD. 2. RESEARCH THE VIABILITY AND USAGE FOR THE LIVING WELL ONLINE PROGRAM AVAILABLE THROUGH PPHD. 3. DETERMINE THREE KEY AREAS FOR CURRENT CCM PARTICIPANTS TO TRACK IMPROVEMENTS. 4. PROMOTE DIRECT CCESS TESTING. CHRONIC CARE MANAGEMENT IS CURRENTLY AVAILABLE FOR THOSE WHO ARE 65 AND OLDER ON MEDICARE, WITH 2 OR MORE CHRONIC ILLNESSES. REQUIRED ELIGIBILITY THROUGH THE ACO-PROGRAM REQUIRES 65+, TWO CHRONIC DISEASES AND SEEING A PROVIDER THAT WILL ENROLL THEM IF THEY QUALIFY. FOCUS AREA 3: END OF LIFE 1. CREATE ANNUAL SENIOR LIFE HEALTH FAIR PROMOTING AREA AVAILABLE RESOURCES. 2. OFFER DOULA TRAINING TO DEVELOP AN END OF LIFE VOLUNTEER SUPPORT SYSTEM. 3. DETERMINE IF PARTNERING WITH HOSPICE OF THE PLAINS AS A HOSPICE PROVIDER IS POSSIBLE.OTHER AREA NEEDS THAT ARE NOT BEING ADDRESSED AT THIS TIME ARE: 1. NOT ENOUGH HEALTH INSURANCE/NO HEALTH INSURANCE2. POVERTY3. CHILD ABUSE/NEGLECTSRMC DOES NOT HAVE THE RESOURCES TO ADDRESS THESE NEEDS AT THIS TIME. THE FOLLOWING IS A QUARTERLY RECAP OF 2021:1ST QUARTER: WITH COVID-19 PANDEMIC, THERE HAVE BEEN NO ON-SITE BLOOD DRIVES THIS QUARTER. WE HAVE HELD 52 COVID CLINICS (JANUARY 5TH THROUGH MARCH 31ST) FOR THE COMMUNITY OFFERING THE MODERNA VACCINE. WE GAVE A TOTAL OF 3501 VACCINATIONS DURING THIS TIME FRAME, FOLLOWING THE GUIDELINES/TIMELINES OF THE CDC AND PPHD GIVEN VACCINE TO AGE GROUPS AS WERE RECOMMENDED. DIRECT ACCESS TESTING CONTINUES TO BE UTILIZED ON WEDNESDAYS BY OUR COMMUNITY. NUMBERS ARE NOT AVAILABLE TO REPORT AT THIS TIME DUE TO REPORTING TOOL NOT WORKING. OFF-SITE COMMUNITY BLOOD PRESSURE SCREENINGS HAVE ALSO BEEN ON HOLD THIS QUARTER.2ND QUARTER:NO BLOOD DRIVES HELD VIA THE DONOR CENTER OUT OF SCOTTSBLUFF THIS 2ND QUARTER DUE TO THEIR LIMITED STAFFING ISSUES, AND SOME NEW OSHA REGULATIONS FOR MOBILE DRIVES. SRMC HELD 30 FREE COVID CLINICS THIS QUARTER, ALONG WITH THE ABILITY TO SEE A PROVIDER AND GET VACCINATED AT THEIR VISIT AS WELL. WE GAVE A TOTAL OF 1803 COVID VACCINES THIS QUARTER. THE RHC OFFERED UP FREE SPORTS PHYSICALS TO SCHOOL AGE KIDS AND DID 15 OF THEM. WELLNESS WEDNESDAYS OR DIRECT ACCESS TESTING CONTINUES TO BE UTILIZED BY COMMUNITY MEMBERS. WE JUST DO NOT CURRENTLY HAVE THE TOOLS TO GATHER THE TOTAL NUMBERS DONE FOR THIS QUARTER. HOPEFULLY SOON THIS WILL BE FIXED SO WE CAN AGAIN REPORT THEM. OFF-SITE BLOOD PRESSURE SCREENINGS AT AREA BUSINESSES AND SURROUNDING COMMUNITIES WERE ON HOLD FOR THE 2ND QUARTER ALSO. SEVERAL BEHAVIOR HEALTH EVENTS TOOK PLACE SUCH AS THE NATIONAL STRESS DAY OPEN HOUSE IN APRIL WITH ABOUT 20 PARTICIPANTS, THE SPRING EXPO IN APRIL WE PROVIDED COMMUNITY EDUCATION ABOUT OUR BEHAVIORAL HEALTH SERVICES. THE AMERICAN FOUNDATION FOR SUICIDE PREVENTION ACTIVITIES WERE APRIL 19TH AND 20TH AND EDUCATION WAS PROVIDED ABOUT SUICIDE PREVENTION. IN JUNE, EDUCATION WAS PROVIDED ABOUT STRESS MANAGEMENT IN AGRICULTURAL SETTINGS FOR THE AG SAFETY MANAGERS AND SUPERVISORS OF NE. SENIOR LIFE SOLUTIONS IS NOW UP AND GOING AS OF MAY 13TH. THEY CURRENTLY HAVE 5 PATIENTS WHO MEET TOGETHER IN A GROUP SETTING THREE TIMES A WEEK FOR 3 HOURS EACH TIME. THE PROGRAM IS GOING WELL.3RD QUARTER:NO BLOOD DRIVES AGAIN IN THE 3RD QUARTER DUE TO CONTINUED STAFF SHORTAGES WITH THE DONOR CENTER OUT OF SCOTTSBLUFF. THEY ARE UNABLE TO SUPPORT MOBILE BLOOD DRIVES AT THIS TIME. SRMC, THROUGH THE RHC, ADMINISTERED A TOTAL OF 350 FREE COVID-19 VACCINATIONS DURING THE 3RD QUARTER. THE RHC OFFERED REDUCED COST SPORTS PHYSICALS TO SCHOOL AGED KIDS THIS QUARTER AND THE REPORT PULLED PER MANDI RAFFELSON SHOWS 320 SPORTS PHYSICALS WERE DONE. WELLNESS WEDNESDAYS (DIRECT ACCESS TESTING) INCREASED THEIR HOURS OF OPERATIONS THIS QUARTER FROM 7 AM TO 4 PM EVERY WEDNESDAY. THIS SERVICE CONTINUES TO BE UTILIZED BY OUR COMMUNITY MEMBERS AS WELL AS SURROUNDING COMMUNITIES. THERE WERE A TOTAL OF 350 COMMUNITY MEMBERS THAT USED THIS REDUCED COST LAB TESTING SERVICE. ON-SITE FREE BLOOD PRESSURE SCREENINGS AND EDUCATION RESUMED FOR AREA BUSINESSES AND SURROUNDING COMMUNITIES THIS 3RD QUARTER. KRISTEN ROSE, BEHAVIORAL THERAPIST, DID EDUCATION ON EATING DISORDERS IN THE MILITARY FOR THE NATIONAL ASSOCIATION OF SOCIAL WORKERS NE CHAPTER AT THEIR ANNUAL CONFERENCE. SHE ALSO HAD A BOOTH AT THE AMERICAN FOUNDATION FOR SUICIDE PREVENTION AWARENESS WALK. IN JULY OF 2021 DURING THE Q3 CHEYENNE COUNTY FAIR, THE FORMER COVID TRAILER WAS USED AS A PLACE FOR FIRST AID OR A NEED FOR WATER. IT WAS STAFFED BY A PROVIDER AND A NURSE FROM THE RHC.4TH QUARTER:THIS 4TH QUARTER WE WERE ABLE TO HOST OUR FIRST BLOOD DRIVE IN TWO YEARS. WE HAD A MIXTURE OF EMPLOYEES AND COMMUNITY MEMBERS WHO DONATED 43 UNITS. THE METHODIST CHURCH ALSO HOSTED A BLOOD DRIVE IN NOVEMBER AND COLLECTED 33 UNITS OF BLOOD. SRMC, VIA THE RHC GAVE 884 FREE COVID-19 VACCINATIONS AND BOOSTERS IN THE 4TH QUARTER 2021. THE RHC OFFERED REDUCED COST SPORTS PHYSICALS AGAIN DURING THE 4TH QUARTER AND THERE WERE 13 COMPLETED. WELLNESS WEDNESDAYS (DIRECT ACCESS TESTING) IS THE REDUCED COST LABS WITHOUT A DOCTOR'S ORDER THAT COMMUNITY MEMBERS AND EMPLOYEES UTILIZEHERE IN OUR LAB DEPARTMENT AND HAPPENS EVERY WEDNESDAY. WE HAD 211 PEOPLE USE THIS SERVICE DURING THE 4TH QUARTER, WHICH IS DOWN FROM THE PREVIOUS QUARTER. FREE BLOOD PRESSURE SCREENINGS AND EDUCATION WERE PROVIDED TO VARIOUS BUSINESSES AND COMMUNITIES ON A MONTHLY BASIS DURING THE 4TH QUARTER. REGARDING BEHAVIORAL HEALTH, KRISTIN ROSE DID A PRESENTATION ON EATING DISORDERS FOR PANHANDLE PUBLIC HEALTH DISTRICTS WORKSITE WELLNESS PROGRAM IN OCTOBER. IN NOVEMBER, KRISTIN DID THE SAME PRESENTATION, VIRTUALLY, FOR THE NE COUNSELING ASSOCIATION. |
| CHEYENNE COUNTY HOSPITAL ASSOCIATION INC | PART V, SECTION B, LINE 13B: PATIENTS MAY BE CONSIDERED FOR CHARITY CARE FOR MEDICALLY NECESSARY SERVICES. WHEN IN QUESTION, MEDICALLY NECESSARY SERVICES SHALL BE DETERMINED BY THE EXAMINING PHYSICIAN. PATIENTS MUST BE RESIDENTS OF CHEYENNE OR DEUEL COUNTY AND/OR A 20 MILE RADIUS OF SIDNEY REGIONAL MEDICAL CENTER. THIS MAY BE WAIVED FOR PATIENTS ADMITTED VIA THE EMERGENCY DEPARTMENT OR AT THE DISCRETION OF ADMINISTRATION.SPECIFICALLY IDENTIFIED CASES MAY BE PRESUMED ELIGIBLE FOR CHARITABLE ASSISTANCE AND CLASSIFIED WITHOUT A COMPLETED APPLICATION OR ASSESSMENT. EXAMPLES OF THESE CASES ARE: PATIENT IS DECEASED WITH NO KNOWN ESTATE OR SPOUSE; PATIENTS WITH CURRENT ELIGIBILITY UNDER COUNTY OR STATE MEDICAL INDIGENT SERVICES ADMINISTERED BY COUNTY OR STATE FACILITIES; PATIENT IS HOMELESS OR HAS BEEN IDENTIFIED AS BEING WITHOUT RESOURCES BASED ON PREVIOUS ACCOUNT ACTION AND CONTACT WITH THE SRMC STAFF.PERCENT OF CHARITY WILL BE BASED ON HOUSEHOLD INCOME AND SIZE, REAL ESTATE, PERSONAL PROPERTY AND INVESTMENT EQUITY, WITH CREDIT TO BE GIVEN FOR ALREADY EXISTING MEDICAL LOANS, IN COMPARISON TO THE CURRENT YEAR FEDERAL POVERTY GUIDELINES. THE HHS POVERTY GUIDELINES ARE PUBLISHED EACH YEAR IN THE FEDERAL REGISTER. FREE CARE WILL BE GIVEN TO HOUSEHOLDS THAT ARE AT 100% OF THE POVERTY LEVEL. DISCOUNTED CARE WILL BE GIVEN AT UP TO 300% OF THE POVERTY LEVEL. |
| CHEYENNE COUNTY HOSPITAL ASSOCIATION INC | PART V, SECTION B, LINE 16J: THE POLICY IS REFERENCED IN BILLING LETTERS AND IS ORALLY COMMUNICATED DURING REGISTRATION OR ADMISSIONS AND THROUGH THE PATIENT FINANCIAL SERVICES FOLLOW UP PROCESSES, INCLUDING PATIENT ADVOCACY CONVERSATIONS. THE POLICY IS AVAILABLE IN ADMISSIONS AND WAITING AREAS AT THE HOSPITAL. SIGNAGE IS POSTED IN WAITING AREAS REFERRING PATIENTS TO THE WEBSITE TO VIEW THE POLICY. ADDITIONALLY, PLAIN LANGUAGE SUMMARY IS INCLUDED IN ALL DISCHARGE PACKETS WITH REFERENCE TO THE WEBSITE OR FINANCIAL SERVICES TO OBTAIN THE ENTIRE POLICY. |
| CHEYENNE COUNTY HOSPITAL ASSOCIATION INC | PART V, SECTION B, LINE 20E: SRMC ATTEMPTS OTHER NON-EXTRAORDINARY COLLECTION EFFORTS SUCH AS: SUBSEQUENT MONTHLY BILLINGS, COLLECTION LETTERS AND/OR TELEPHONE CALLS CONSTITUTING A GENUINE EFFORT TO HELP OUR PATIENTS TO ARRANGE FOR PAYMENT IF THEY CAN AFFORD IT. DOCUMENTATION OF THESE EFFORTS WILL BE MADE BY NOTATING PATIENT ACCOUNTS AND DOCUMENTING STATEMENTS AND REPORTS OF TELEPHONE CALLS AND PERSONAL CONTACTS. FOR ELECTIVE PROCEDURES, PATIENTS ARE ASKED TO MEET WITH A FINANCIAL COUNSELOR BEFORE THE PROCEDURE TO SET UP PAYMENT ARRANGEMENTS. SRMC DOES OFFER LOANS TO PATIENTS WITH NO COLLATERAL FROM THE PATIENTS. SRMC ALSO SECURES FINANCING FOR THE PATIENTS IF THEY DO NOT QUALIFY FOR CHARITY CARE. SRMC DOES NOT REQUIRE PATIENTS WHO QUALIFY FOR CHARITY CARE UNDER THE FINANCIAL ASSISTANCE POLICY TO OBTAIN A LOAN TO PAY THE ACCOUNT. |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Facility | 3 | FacilityNum |
Oth Hlth Care Fclts Not Hospital OthHlthCareFcltsNotHospitalGrp
Oth Hlth Care Fclts OthHlthCareFcltsGrp (3 entries)
| Address Line1USAddress/AddressLine1Txt | CityUSAddress/CityNm | State AbbreviationUSAddress/StateAbbreviationCd | ZIPUSAddress/ZIPCd | FacilityFacilityTxt |
|---|---|---|---|---|
| 1 - SIDNEY REG'L MEDICAL CTR EXTENDED CARE | ||||
| 549 KELLER DRIVE | SIDNEY | NE | 69162 | LONG TERM CARE FACILITY |
| 2 - SLOAN ESTATES ASSISTED LIVING | ||||
| 2550 CRAIG AVENUE | SIDNEY | NE | 69162 | ASSISTED LIVING |
| 3 - SIDNEY REG'L MEDICAL CTR WALK IN CLINIC | ||||
| 610 GROVER ROAD SUITE 4 | SIDNEY | NE | 69162 | WALK IN CLINIC |
Supplemental Information Detail SupplementalInformationDetail (16 entries)
| Form And Line ReferenceFormAndLineReferenceDesc | ExplanationExplanationTxt |
|---|---|
| PART I, LINE 3C: | THE CALCULATION FOR ELIGIBILITY IS BASED ON ALL INCOME PER HOUSEHOLD WITH EXCEPTIONS MADE FOR WAGE EARNERS WHO ARE STUDENTS. OTHER MEDICAL PAYMENTS ALREADY BEING MADE ARE CONSIDERED IN THE CALCUATION. INCOME IS COMPARED TO THE NATIONAL POVERTY GUIDELINES AND A DETERMINATION OF REDUCTION IS MADE BASED ON THE ADJUSTED INCOME LEVEL. THE WRITE OFF AMOUNT MAY BE REDUCED FOR EQUITY IN ASSETS, IF ANY, ABOVE EXEMPTION THRESHOLDS FOR HOMES AND VEHICLES. THERE IS NO EXEMPTION FOR INVESTMENTS OR OTHER ASSETS HELD. |
| PART I, LINE 6A: | THE COMMUNITY BENEFIT REPORT WAS NOT PREPARED IN THE CURRENT YEAR. |
| PART I, LINE 7: | THE COST TO CHARGE RATIO IS DETERMINED AS FOLLOWS: (TOTAL EXPENSES - BAD DEBT)/GROSS PATIENT SERVICE REVENUE = PERCENTAGE OF COST TO CHARGE. |
| PART I, LINE 7G: | THERE ARE NO COSTS ASSOCIATED WITH PHYSICIAN CLINICS INCLUDED AS SUBSIDIZED HEALTH SERVICES. |
| PART I, LN 7 COL(F): | BAD DEBT EXPENSE OF $272,535 HAS BEEN EXCLUDED FROM THE DENOMINATOR IN THE CALCULATION OF THE PERCENTAGES IN LINE 7, COLUMN F. |
| PART II, COMMUNITY BUILDING ACTIVITIES: | COMMUNITY SUPPORT INCLUDES ACTIVITIES SUCH AS THERAPISTS AVAILABLE AT GAMES AND AT THE COMMUNITY CENTER AND WELLNESS CAMPAIGNS IN COOPERATION WITH THE COMMUNITY CENTER. OTHER ACTIVITIES INCLUDE COMMUNITY BLOOD DRAWS, HEALTH FAIR, BLOOD PRESSURE SCREENINGS, DIABETES PREVENTION PROGRAMS, AND MULTIPLE SMALLER COMMUNITY EDUCATION PROGRAMS THROUGH RADIO INTERVIEWS WITH HEALTH PROFESSIONALS. |
| PART III, LINE 2: | BAD DEBTS RESULT WHEN A PATIENT WHO HAS BEEN DETERMINED TO HAVE THE FINANCIAL CAPACITY TO PAY FOR HEALTHCARE SERVICES IS UNWILLING TO SETTLE THE CLAIM. DUE TO A COMPLIANCE WITH FASB TOPIC 606 CONCERNING REVENUE RECOGNITION, BAD DEBT EXPENSE HAS BEEN GREATLY REDUCED AS THE RECOGNITION OF BAD DEBT IS AN EXPENSE ASSOCIATED WITH SPECIFIC ACCOUNTS RATHER THAN AN ALLOWANCE FOR DOUBTFUL ACCOUNTS WHICH ARE UNSPECIFIC AND CLASSIFIED AS AN IMPLICIT PRICE CONCESSION REDUCING REVENUE ON THE OPERATING STATEMENT. |
| PART III, LINE 3: | GENERALLY, PATIENTS WHO ARE COVERED BY THIRD-PARTY PAYORS ARE RESPONSIBLE FOR RELATED DEDUCTIBLES AND COINSURANCE, WHICH VARY IN AMOUNT. THE ORGANIZATION PROVIDES SERVICES TO UNINSURED PATIENTS, AND OFFERS THOSE UNINSURED PATIENTS A DISCOUNT, EITHER BY POLICY OR LAW, FROM STANDARD CHARGES. THE ORGANIZATION 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. FOR THE YEARS ENDED DECEMBER 31, 2021 AND 2020, 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 TO THE ESTIMATE OF THE TRANSACTION PRICE ARE RECORDED AS ADJUSTMENTS TO PATIENT SERVICE REVENUE IN THE PERIOD OF CHANGE. 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. NONE OF THE AMOUNT IS INCLUDED AS COMMUNITY BENEFIT. |
| PART III, LINE 4: | THE HOSPITAL'S FINANCIAL STATMENTS DO NOT CONTAIN A SPECIFIC FOOTNOTE DESCRIBING BAD DEBT. HOWEVER, PAGES 8, 10, 11, AND 12 OF THE ATTACHED AUDITED FINANCIAL STATEMENTS INCLUDE FOOTNOTES TITLED "PATIENT RECEIVABLES", "PATIENT SERVICE REVENUE AND "PATIENT FINANCIAL ASSISTANCE". |
| PART III, LINE 8: | THE ORGANIZATION USED THE MEDICARE COST REPORT FOR FISCAL YEAR 2021 TO REPORT THE AMOUNTS OF TOTAL REVENUE RECEIVED FROM MEDICARE AND RELATED MEDICARE ALLOWABLE COSTS. MEDICARE PAYS THE HOSPITAL'S RURAL HEALTH CLINICS (RHC) AT COST SUBJECT TO CERTAIN LIMITS. THE MEDICARE SHORTFALL IN PAYMENTS SHOULD BE CONSIDERED A COMMUNITY BENEFIT AS IT IS PART OF THE HOSPITAL'S MISSION TO PROVIDE THESE SERVICES EVEN IF MEDICARE REIMBURSEMENT IS BELOW COST. |
| PART III, LINE 9B: | THE CHARITY CARE POLICY ALLOWS FOR PROACTIVE WRITE OFF TO ALLOWANCE FOR CHARITY CARE OF ANY BALANCE OWED BY A PATIENT KNOWN TO QUALIFY FOR CHARITY CARE UNDER THE FINANCIAL ASSISTANCE POLICY. COLLECTION PROCEDURES DO NOT ENSUE ON ANY ACCOUNTS ELIGIBLE FOR FINANCIAL ASSISTANCE. |
| PART VI, LINE 2: | NEEDS ASSESSMENTS ARE DETERMINED THROUGH SCIENTIFIC, AS WELL AS UNSCIENTIFIC METHODS. EVERY 3 YEARS A MARKET ASSESSMENT IS COMPLETED USING CLAIMS DATA WHICH REVEALS THE NEEDS OF COMMUNITY MEMBERS BEING MET ELSEWHERE DUE TO EITHER UNAVAILABILITY OF SERVICE OR PATIENT CHOICE. THIS ASSESSMENT INCLUDES THE DEMOGRAPHICS OF THE AREA WHICH SHOW AN AGING AND MODERATE INCOME POPULATION. THESE FACTS ARE THEN USED TO DETERMINE THE NEEDS OF THE COMMUNITY AS WELL AS THE FUTURE NEEDS BASED ON HISTORICAL DATA. ADDITIONALLY, COMMUNITY NEEDS ARE DETERMINED USING PUBLIC OPINION, PATIENT SATISFACTION RECOMMENDATIONS, BOARD AND LEADERSHIP EXPERIENCE, COMMUNICATIONS WITH COMMUNITY MEMBERS, AND PHYSICIAN INPUT. FUTURE MEASUREMENTS OF HEALTH DATA MINED FROM CLAIMS SUBMISSIONS WILL BE USED TO FURTHER ANALYZE THE NEEDS OF THE COMMUNITY. |
| PART VI, LINE 3: | AT THE POINT OF REGISTRATION, A PATIENT'S INSURED STATUS IS DETERMINED. PATIENTS WHO ARE UNDERINSURED OR UNINSURED RECEIVE COUNSELING THROUGH THE HOSPITAL'S PATIENT ADVOCATE AND/OR A MEMBER OF THE FINANCIAL SERVICES OR REGISTRATION STAFF SERVING AS A FINANCIAL COUNSELOR. INFORMATION IS CONVEYED TO THE PATIENT OR THE GUARANTOR REGARDING MEDICAID AND MEDICARE, AS WELL AS CHARITY CARE PROVIDED BY THE HOSPITAL. ADDITIONAL COUNSELING IS PROVIDED AFTER DISMISSAL WHEN THE PROACTIVE APPROACH WAS UNSUCCESSFUL. ADDITIONALLY, SOCIAL SERVICES PERSONNEL AND PATIENT FINANCIAL COUNSELORS MEET WITH PATIENTS INDIVIDUALLY WHEN NEEDED REGARDING THEIR COVERAGE IN AN ATTEMPT TO DETERMINE ELIGIBILITY FOR FINANCIAL ASSISTANCE AND OTHER MEANS FOR THE INDIVIDUALS. |
| PART VI, LINE 4: | MOST OF THE AREA THAT THE HOSPITAL SERVES IS LOCATED IN CHEYENNE COUNTY, NEBRASKA WHICH HAS A POPULATION OF APPROXIMATELY 9,529 PEOPLE. THE CITIES OF SIDNEY, LODGEPOLE, POTTER, DALTON, GURLEY, AND SUNOL ARE LOCATED WITHIN THE COUNTY AND ARE GENERALLY WITHIN APPROXIMATELY 30 MILES FROM THE HOSPITAL. ACCORDING TO THE US CENSUS BUREAU, THE 2021 DEMOGRAPHIC IS AROUND 94.9% CAUCASIAN. THE AVERAGE HOUSEHOLD INCOME IN CHEYENNE COUNTY IS $52,270 WITH A POVERTY RATE OF 10.0%. |
| PART VI, LINE 5: | IN ADDITION TO ACTIVITIES ADDRESSED IN THE CHNA REPORT, THE HOSPITAL NORMALLY HOLDS AN ANNUAL HEALTH FAIR AND AN ANNUAL CHILDREN'S HEALTH FAIR, 10K RACES, TRIATHLON RACES, PROVIDES OUTREACH SERVICE TO LOCAL BUSINESSES TO ASSURE FLU SHOTS AND IMMUNIZATIONS ARE UP TO DATE AS WELL AS DOING BLOOD PRESSURE SCREENINGS. THE HOSPITAL WAS UNABLE TO DO MANY THINGS IN 2021 DUE TO THE COVID-19 PANDEMIC. SRMC ALSO CONDUCTS DIABETES EDUCATION CLASSES AND A DIABETES HEALTH FAIR DURING THE YEAR. SRMC OFFERS IN-HOME FOLLOW UP VISITS TO ANY MOTHERS WITH NEW BABIES NO MATTER WHERE THEY DELIVERED THEIR BABY, AND COLLABORATES WITH THE SCHOOL TO PROVIDE FOLLOWUP THERAPY CONSULTATIONS AFTER SPORTING EVENTS. THE HOSPITAL CONTINUES TO PROVIDE OB AND DELIVERY SERVICES EVEN THOUGH MANY SMALLER HOSPITALS HAVE DISCONTINUED SUPPORT OF THEIR COMMUNITIES IN THIS ARENA. COMMUNITY EDUCATION IS PROVIDED THRU RADIO BROADCASTS EACH WEEK WITH VARYING TOPICS. |
| PART VI, LINE 6: | SIDNEY REGIONAL MEDICAL CENTER IS NOT PART OF AN AFFILIATED HEALTH CARE ORGANIZATION. |
Schedule I IRS990ScheduleI
| Field | Value | IRS element (for citing) |
|---|---|---|
| Grant Records Maintained | Yes (1) | GrantRecordsMaintainedInd |
Recipient Table RecipientTable (2 entries)
| Address Line1USAddress/AddressLine1Txt | CityUSAddress/CityNm | State AbbreviationUSAddress/StateAbbreviationCd | ZIPUSAddress/ZIPCd | Recipient EINRecipientEIN | IRC SectionIRCSectionDesc | Cash GrantCashGrantAmt | Non Cash AssistanceNonCashAssistanceAmt | Purpose Of GrantPurposeOfGrantTxt |
|---|---|---|---|---|---|---|---|---|
| DICKEY AND ASSOCIATES AUCTIONEERS | ||||||||
| 1616 BIRCH STREET | SIDNEY | NE | 69162 | 822544780 | 501(C)(3) | $11,200 | $0 | YOUTH LIVESTOCK SPONSORSHIP |
| KIDS PLUS INC | ||||||||
| PO BOX 296 | SIDNEY | NE | 69162 | 470715249 | 501(C)(3) | $12,500 | $0 | SIDNEY PARK PROJECT |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total501c3 Org | 2 | Total501c3OrgCnt |
| Total Other Org | 0 | TotalOtherOrgCnt |
Supplemental Information Detail SupplementalInformationDetail
| Field | Value | IRS element (for citing) |
|---|---|---|
| Form And Line Reference | PART I, LINE 2: | FormAndLineReferenceDesc |
| Explanation | IF THE DONEE ORGANIZATION IS NOT A GOVERNMENTAL ENTITY OR IDENTIFIED AS A CHARITABLE ORGANIZATION ON GUIDESTAR, THE DONEE ORGANIZATION IS RESEARCHED TO ASSURE THEIR NOT-FOR-PROFIT STATUS. THE DONEE ORGANIZATION'S MISSION INFORMATION, THEIR FINANCIAL DATA AND THEIR FORM 990 (IF AVAILABLE) IS REVIEWED AND CONSIDERED BY THE BOARD OF DIRECTORS. THE BOARD OF DIRECTORS MUST APPROVE, BY A MAJORITY VOTE OF THE QUORUM IN ATTENDANCE, THE DONATION TO THE ORGANIZATION OR GOVERNMENTAL ENTITY. DURING THE FOLLOWING 12 TO 24 MONTHS AFTER THE DONATION IS DISTRIBUTED, CONTINUED MONITORING OF THE PROJECT OR DONATION RESTRICTIONS, IF APPLICABLE, SHALL BE REPORTED TO THE BOARD OF DIRECTORS. THE DONEE ORGANIZATION'S FORM 990 (IF AVAILABLE) FOR THE YEAR OF THE DONATION AND ANY OTHER SUBSEQUENT YEARS REQUESTED SHALL BE MADE AVAILABLE TO THE BOARD MEMBERS FOR FOLLOW UP REVIEW. | ExplanationTxt |
Schedule J IRS990ScheduleJ
| Field | Value | IRS element (for citing) |
|---|---|---|
| Compensation Committee | Yes (X) | CompensationCommitteeInd |
| Written Employment Contract | Yes (X) | WrittenEmploymentContractInd |
| Compensation Survey | Yes (X) | CompensationSurveyInd |
| Board Or Committee Approval | Yes (X) | BoardOrCommitteeApprovalInd |
| Severance Payment | 0 | SeverancePaymentInd |
| Supplemental Nonqual Rtr Plan | 0 | SupplementalNonqualRtrPlanInd |
| Equity Based Comp Arrngm | 0 | EquityBasedCompArrngmInd |
| Comp Based On Revenue Of Flng Org | 0 | CompBasedOnRevenueOfFlngOrgInd |
| Comp Bsd On Rev Related Orgs | 0 | CompBsdOnRevRelatedOrgsInd |
| Comp Bsd Net Earns Flng Org | 0 | CompBsdNetEarnsFlngOrgInd |
| Comp Bsd Net Earns Rltd Orgs | 0 | CompBsdNetEarnsRltdOrgsInd |
| Any Non Fixed Payments | 0 | AnyNonFixedPaymentsInd |
| Initial Contract Exception | 0 | InitialContractExceptionInd |
Rltd Org Officer Trst Key Empl RltdOrgOfficerTrstKeyEmplGrp (8 entries)
| TitleTitleTxt | Base Compensation Filing OrgBaseCompensationFilingOrgAmt | Compensation Based On Rltd OrgsCompensationBasedOnRltdOrgsAmt | Bonus Filing OrganizationBonusFilingOrganizationAmount | Bonus Related OrganizationsBonusRelatedOrganizationsAmt | Other Compensation Filing OrgOtherCompensationFilingOrgAmt | Other Compensation Rltd OrgsOtherCompensationRltdOrgsAmt | Deferred Compensation Flng OrgDeferredCompensationFlngOrgAmt | Deferred Comp Rltd OrgsDeferredCompRltdOrgsAmt | Nontaxable Benefits Filing OrgNontaxableBenefitsFilingOrgAmt | Nontaxable Benefits Rltd OrgsNontaxableBenefitsRltdOrgsAmt | Total Compensation Filing OrgTotalCompensationFilingOrgAmt | Total Compensation Rltd OrgsTotalCompensationRltdOrgsAmt | Comp Report Prior990 Filing OrgCompReportPrior990FilingOrgAmt | Comp Report Prior990 Rltd OrgsCompReportPrior990RltdOrgsAmt |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| REBECCA L ALLARD MD | ||||||||||||||
| CHIEF OF STAFF | $657,276 | $0 | $27,500 | $0 | $120 | $0 | $14,500 | $0 | $35,759 | $0 | $735,155 | $0 | $0 | $0 |
| MATTHEW JANSEN MD | ||||||||||||||
| DOCTOR | $630,399 | $0 | $2,500 | $0 | $108 | $0 | $14,500 | $0 | $35,759 | $0 | $683,266 | $0 | $0 | $0 |
| JAMES POPOVICH MD | ||||||||||||||
| DOCTOR | $563,346 | $0 | $2,500 | $0 | $108 | $0 | $14,500 | $0 | $35,759 | $0 | $616,213 | $0 | $0 | $0 |
| SARA SHOLAR MD | ||||||||||||||
| DOCTOR | $563,457 | $0 | $2,500 | $0 | $96 | $0 | $11,307 | $0 | $23,914 | $0 | $601,274 | $0 | $0 | $0 |
| KELLY CASEY MD | ||||||||||||||
| DOCTOR | $488,460 | $0 | $2,500 | $0 | $276 | $0 | $2,417 | $0 | $38,509 | $0 | $532,162 | $0 | $0 | $0 |
| APRIL SMITH MD | ||||||||||||||
| DOCTOR | $396,845 | $0 | $2,500 | $0 | $108 | $0 | $14,500 | $0 | $26,146 | $0 | $440,099 | $0 | $0 | $0 |
| ROBERT GRAVES MD | ||||||||||||||
| PHYSICIAN AT LARGE | $343,803 | $0 | $2,500 | $0 | $1,524 | $0 | $14,444 | $0 | $37,371 | $0 | $399,642 | $0 | $0 | $0 |
| KELLY UTLEY | ||||||||||||||
| CFO | $200,943 | $0 | $2,500 | $0 | $516 | $0 | $9,774 | $0 | $9,696 | $0 | $223,429 | $0 | $0 | $0 |
Supplemental Information Detail SupplementalInformationDetail
| Field | Value | IRS element (for citing) |
|---|---|---|
| Form And Line Reference | SCHEDULE J, PART III: | FormAndLineReferenceDesc |
| Explanation | JASON PETIK, CEO, RECEIVES COMPENSATION FROM POUDRE VALLEY MEDICAL GROUP, AN UNRELATED ENTITY. POUDRE VALLEY MEDICAL GROUP PROVIDES MANAGEMENT SERVICES TO ITS CLIENTS, INCLUDING THE SIDNEY REGIONAL MEDICAL CENTER. THE SIDNEY REGIONAL MEDICAL CENTER'S BOARD OF DIRECTORS SETS THE COMPENSATION FOR MR. PETIK. MR. PETIK RECEIVED TOTAL COMPENSATION OF $289,740. MR. PETIK'S COMPENSATION IS REFLECTED IN PART IX, LINE 11A. | ExplanationTxt |
Schedule K IRS990ScheduleK
Tax Exempt Bonds Issues TaxExemptBondsIssuesGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Bond Reference | A | BondReferenceCd |
Issuer Name IssuerName
| Field | Value | IRS element (for citing) |
|---|---|---|
| Business Name Line1 | THE COUNTY OF DEUEL NEBRASKA | BusinessNameLine1Txt |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Bond Issuer EIN | 476006452 | BondIssuerEIN |
| CUSIP | 251476AA5 | CUSIPNum |
| Bond Issued | 2014-10-16 | BondIssuedDt |
| Issue Price | $10,000,000 | IssuePriceAmt |
| Purpose | CONSTRUCT HOSPITAL | PurposeDesc |
| Defeased | 0 | DefeasedInd |
| On Behalf Of Issuer | 0 | OnBehalfOfIssuerInd |
| Pool Financing | 0 | PoolFinancingInd |
Tax Exempt Bonds Proceeds TaxExemptBondsProceedsGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Bond Reference | A | BondReferenceCd |
| Retired | $2,098,829 | RetiredAmt |
| Total Proceeds | $10,000,000 | TotalProceedsAmt |
| Capital Expenditures | $10,000,000 | CapitalExpendituresAmt |
| Substantial Completion | 2015 | SubstantialCompletionYr |
| Refunding Tax Exempt Bonds | 0 | RefundingTaxExemptBondsInd |
| Refunding Taxable Bonds | 0 | RefundingTaxableBondsInd |
| Final Allocation Made | Yes (1) | FinalAllocationMadeInd |
| Adequate Books And Rec Maint | Yes (1) | AdequateBooksAndRecMaintInd |
Tax Exempt Bonds Private Bus Use TaxExemptBondsPrivateBusUseGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Bond Reference | A | BondReferenceCd |
| Owning Bond Financed Property | 0 | OwningBondFinancedPropertyInd |
| Any Lease Arrangements | 0 | AnyLeaseArrangementsInd |
| Mgmt Contract Bond Fincd Prop | 0 | MgmtContractBondFincdPropInd |
| Any Research Agreements | 0 | AnyResearchAgreementsInd |
| Private Bus Use By Others | 0.00000 | PrivateBusUseByOthersPct |
| Private Bus Concerning UBI | 0.00000 | PrivateBusConcerningUBIPct |
| Total Private Business Use | 0.00000 | TotalPrivateBusinessUsePct |
| Bond Iss Meet Prvt Sec Pymt Test | 0 | BondIssMeetPrvtSecPymtTestInd |
| Change In Use Bond Financed Prop | 0 | ChangeInUseBondFinancedPropInd |
| Procs Nonqualified Bond Remdtd | Yes (1) | ProcsNonqualifiedBondRemdtdInd |
Tax Exempt Bonds Arbitrage TaxExemptBondsArbitrageGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Bond Reference | A | BondReferenceCd |
| Form8038 T Filed | 0 | Form8038TFiledInd |
| Rebate Not Due Yet | 0 | RebateNotDueYetInd |
| Exception To Rebate | Yes (1) | ExceptionToRebateInd |
| No Rebate Due | 0 | NoRebateDueInd |
| Variable Rate Issue | Yes (1) | VariableRateIssueInd |
| Hedge Identified In Bks And Rec | 0 | HedgeIdentifiedInBksAndRecInd |
| Gross Proceeds Invested In GIC | 0 | GrossProceedsInvestedInGICInd |
| Gross Proceeds Invested | 0 | GrossProceedsInvestedInd |
| Written Proc To Monitor Reqs | Yes (1) | WrittenProcToMonitorReqsInd |
Procedures Corrective Action ProceduresCorrectiveActionGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Bond Reference | A | BondReferenceCd |
| Procedures Corrective Action | Yes (1) | ProceduresCorrectiveActionInd |
Schedule L IRS990ScheduleL
Bus Tr Involve Interested Prsn BusTrInvolveInterestedPrsnGrp (2 entries)
| Relationship DescriptionRelationshipDescriptionTxt | TransactionTransactionAmt | TransactionTransactionDesc | Sharing Of RevenuesSharingOfRevenuesInd |
|---|---|---|---|
| KEVIN UTLEY | |||
| EMPLOYEE OF ORGANIZATION AND SPOUSE OF KELLY UTLEY, CFO | $91,190 | EMPLOYEE COMPENSATION | 0 |
| SUSAN PETIK | |||
| EMPLOYEE OF ORGANIZATION AND SPOUSE OF JASON PETIK, CEO | $95,006 | EMPLOYEE COMPENSATION | 0 |
Schedule O IRS990ScheduleO
Supplemental Information Detail SupplementalInformationDetail (8 entries)
| Form And Line ReferenceFormAndLineReferenceDesc | ExplanationExplanationTxt |
|---|---|
| FORM 990, PART VI, SECTION A, LINE 3 | POUDRE VALLEY MEDICAL GROUP CURRENTLY EMPLOYS THE CHIEF EXECUTIVE OFFICER FOR SIDNEY REGIONAL MEDICAL CENTER. |
| FORM 990, PART VI, SECTION B, LINE 11B | THE ORGANIZATION'S ACCOUNTING DEPARTMENT PROVIDES DOCUMENTATION TO THE INDEPENDENT ACCOUNTING FIRM FOR THE PREPARATION OF THE FORM 990. COMMUNICATIONS BETWEEN THE ACCOUNTING FIRM AND THE ACCOUNTING DEPARTMENT FINALIZE THE PREPARATION OF THE FORM 990. THE CEO AND CFO THEN REVIEW THE FORM 990 AND E-MAIL THE PUBLIC DISCLOSURE COPY TO ALL MEMBERS OF THE BOARD OF DIRECTORS FOR THEIR REVIEW. ONCE THE 990 RETURN HAS BEEN APPROVED BY ALL PARTIES IT IS SUBMITTED TO THE IRS ON OR BEFORE THE REGULAR OR EXTENDED DUE DATE. |
| FORM 990, PART VI, SECTION B, LINE 12C | EACH YEAR ALL BOARD MEMBERS ARE REQUIRED TO DISCLOSE ANY CONFLICTS OF INTEREST. ANY DUALITY OF INTEREST OR POTENTIAL CONFLICT OF INTEREST ON THE PART OF ANY OFFICER, DIRECTOR, COMMITTEE MEMBER, OR ANY KEY EMPLOYEE IS DISCLOSED TO THE BOARD OF DIRECTORS AND MADE A MATTER OF RECORD WHENEVER IT ARISES. WHENEVER IT INVOLVES A MATTER OF BOARD ACTION, ANY OFFICER, DIRECTOR, COMMITTEE MEMBER, OR KEY EMPLOYEE HAVING A DUALITY OF INTEREST OR A POSSIBLE CONFLICT OF INTEREST IN ANY MATTER DOES NOT VOTE OR ABSTAINS FROM THE VOTE, IF PRESENT IN THE ROOM. OFTEN THE BOARD MEMBER IS ASKED TO LEAVE THE MEETING DURING DISCUSSION PERIODS AND FOR THE VOTE ON ISSUES FOR WHICH CONFLICT EXISTS. THESE INDIVIDUALS DO NOT USE THEIR PERSONAL INFLUENCE ON THE MATTERS. |
| FORM 990, PART VI, SECTION B, LINE 15 | POUDRE VALLEY MEDICAL GROUP PROVIDES ADMINISTRATIVE SERVICES TO SIDNEY REGIONAL MEDICAL CENTER (SRMC). THIS INCLUDES PROVIDING THE HOSPITAL'S CHIEF EXECUTIVE OFFICER. SRMC'S METHOD TO DETERMINE EXECUTIVE SALARY RANGES IS TO ANNUALLY PULL SALARY RANGES FROM NO LESS THAN TWO SURVEY SOURCES (THREE WHEN POSSIBLE) TO DETERMINE THE AVERAGE SALARY RANGE FOR EACH EXECUTIVE POSITION BY GEOGRAPHICAL REGION. THESE ARE REVIEWED AND PRESENTED TO THE HUMAN RESOURCE COMMITTEE OF THE BOARD OF DIRECTORS FOR REVIEW AND APPROVAL/RECOMMENDATIONS. |
| FORM 990, PART VI, SECTION C, LINE 19 | THE GOVERNING DOCUMENTS, CONFLICT OF INTEREST POLICY AND FINANCIAL STATEMENTS ARE MADE AVAILABLE UPON REQUEST. ALSO, THE FINANCIAL STATEMENTS ARE SENT ANNUALLY TO COMMUNITY LEADERS. |
| FORM 990, PART VII, SECTION A, LINE 5: | JASON PETIK RECEIVES COMPENSATION FROM AN UNRELATED ORGANIZATION, POUDRE VALLEY MEDICAL GROUP, WHICH PROVIDES MANAGEMENT SERVICES TO SIDNEY REGIONAL MEDICAL CENTER. |
| FORM 990, PART IX, LINE 11G | PROFESSIONAL FEES - OTHER: PROGRAM SERVICE EXPENSES 4,148,288. MANAGEMENT AND GENERAL EXPENSES 603,189. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 4,751,477. CONTRACT SERVICES - SURGERY PROFESSIONALS: PROGRAM SERVICE EXPENSES 2,380,393. MANAGEMENT AND GENERAL EXPENSES 0. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 2,380,393. CONTRACT SERVICES - ANESTHESIA PROFESSIONALS: PROGRAM SERVICE EXPENSES 284,939. MANAGEMENT AND GENERAL EXPENSES 0. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 284,939. |
| FORM 990, PART XI, LINE 2C: | THE BOARD OF DIRECTORS ASSUMES THE RESPONSIBILITY FOR OVERSIGHT OF THE AUDIT OF SRMC'S FINANCIAL STATEMENTS AND SELECTION OF AN INDEPENDENT ACCOUNTANT. THIS PROCESS HAS NOT CHANGED SINCE THE PRIOR YEAR. |
Schedule R IRS990ScheduleR
Id Related Tax Exempt Org IdRelatedTaxExemptOrgGrp
Disregarded Entity Name DisregardedEntityName
| Field | Value | IRS element (for citing) |
|---|---|---|
| Business Name Line1 | CHEYENNE COUNTY HOSPITAL AND HEALTH CENTER FOUNDATION | BusinessNameLine1Txt |
US Address USAddress
| Field | Value | IRS element (for citing) |
|---|---|---|
| Address Line1 | 1000 POLE CREEK CROSSING | AddressLine1Txt |
| City | SIDNEY | CityNm |
| State Abbreviation | NE | StateAbbreviationCd |
| ZIP | 69162 | ZIPCd |
| Field | Value | IRS element (for citing) |
|---|---|---|
| EIN | 470686476 | EIN |
| Primary Activities | SUPPORT SIDNEY REGIONAL MEDICAL CENTER | PrimaryActivitiesTxt |
| Legal Domicile State | NE | LegalDomicileStateCd |
| Exempt Code Section | 501(C)(3) | ExemptCodeSectionTxt |
| Public Charity Status | LINE 12C, III-FI | PublicCharityStatusTxt |
| Direct Controlling NA | N/A | DirectControllingNACd |
| Controlled Organization | 0 | ControlledOrganizationInd |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Receipt Of Int Annts Rnts Rylts | 0 | ReceiptOfIntAnntsRntsRyltsInd |
| Gift Grnt Or Cap Contri To Oth Org | Yes (1) | GiftGrntOrCapContriToOthOrgInd |
| Gift Grnt Cap Contri From Oth Org | 0 | GiftGrntCapContriFromOthOrgInd |
| Loans Or Guarantees To Other Org | 0 | LoansOrGuaranteesToOtherOrgInd |
| Loans Or Guarantees From Oth Org | 0 | LoansOrGuaranteesFromOthOrgInd |
| Div Related Organization | 0 | DivRelatedOrganizationInd |
| Asset Sale To Other Org | 0 | AssetSaleToOtherOrgInd |
| Asset Purchase From Other Org | 0 | AssetPurchaseFromOtherOrgInd |
| Asset Exchange | 0 | AssetExchangeInd |
| Rental Of Facilities To Oth Org | 0 | RentalOfFacilitiesToOthOrgInd |
| Rental Of Fclts From Oth Org | 0 | RentalOfFcltsFromOthOrgInd |
| Perform Of Services For Oth Org | 0 | PerformOfServicesForOthOrgInd |
| Perform Of Services By Other Org | Yes (1) | PerformOfServicesByOtherOrgInd |
| Sharing Of Facilities | Yes (1) | SharingOfFacilitiesInd |
| Paid Employees Sharing | Yes (1) | PaidEmployeesSharingInd |
| Reimbursement Paid To Other Org | Yes (1) | ReimbursementPaidToOtherOrgInd |
| Reimbursement Paid By Other Org | Yes (1) | ReimbursementPaidByOtherOrgInd |
| Transfer To Other Org | 0 | TransferToOtherOrgInd |
| Transfer From Other Org | 0 | TransferFromOtherOrgInd |