2022-11-11T09:00:53-06:00 2021-12-31 450250958 EIDE BAILLY LLP 18081 BURT ST STE 200 OMAHA NE 680224722 990 2021-01-01 480577658 HIAWATHA HOSPITAL ASSOCIATION INC HIAW 9133605584 300 UTAH STREET HIAWATHA KS 66434 JEFF PERRY CEO 9133605584 2022-11-08 1 JEFF PERRY 999009999 WENDY R COOLEY CPA P01523804 4023302660 2022-11-08 0 AAL1 IAL1 2021 2022-09-23 18:48:47Z AMBERWELL HIAWATHA JEFF PERRY 300 UTAH STREET HIAWATHA KS 66434 36634529 0 X HTTPS://WWW.HCH-KS.ORG/ X 1945 KS AS A RURAL COMMUNITY HOSPITAL, HIAWATHA HOSPITAL'S PRIMARY GOAL IS TO PROVIDE MODERN, RELIABLE, AFFORDABLE HEALTH CARE THAT BEST MEETS THE NEEDS OF OUR COMMUNITY. 7 6 291 8 0 0 1248724 6575295 28324725 29968646 -99265 12695 112670 77893 29586854 36634529 3708 10102 0 0 14819362 15845235 0 0 0 13876089 15264673 28699159 31120010 887695 5514519 29553059 31506410 19332005 15126815 10221054 16379595 X THE MISSION AND RESPONSIBILITY OF HIAWATHA HOSPITAL ASSOCIATION, INC. ("HOSPITAL") IS TO PROVIDE QUALITY HEALTH CARE TO OUR PATIENTS THROUGHOUT NORTHEAST KANSAS, IN ACCORDANCE WITH THE CHARTER DOCUMENTS ("ARTICLES OF INCORPORATION") OF THE HOSPITAL AND IN COMPLIANCE WITH APPLICABLE FEDERAL, STATE AND LOCAL LAWS. 0 0 27336865 10102 29968646 HIAWATHA COMMUNITY HOSPITAL'S PRIMARY GOAL IS TO PROVIDE QUALITY, MODERN, AFFORDABLE HEALTHCARE TO OUR COMMUNITY. IN 2021, WE PROVIDED SERVICE FOR 2,784 INPATIENT DAYS, 98 INPATIENT SURGERIES AND 792 OUTPATIENT SURGERIES. WE DELIVERED 68 BABIES AND PROVIDED OUTPATIENT SERVICES TO 45,472 PATIENTS. BY PROVIDING SERVICES LIKE OBSTETRICS AND 24 HOUR EMERGENCY SERVICES THAT NOT ALL SMALL RURAL HOSPITALS PROVIDE, EVEN THOUGH THE PROGRAMS ARE NOT ALWAYS PROFITABLE FOR THE HOSPITAL, WE STRONGLY FEEL THAT THESE SERVICES PROVIDE NECESSARY CARE TO ADDRESS OUR COMMUNITY'S OVERALL HEALTH WHILE PROMOTING OUR MISSION AS A CHARITABLE ORGANIZATION. 27336865 1 1 0 1 0 0 0 0 0 0 1 0 0 0 1 1 1 0 0 0 0 0 0 0 0 0 1 1 1 0 1 1 0 0 0 0 0 0 0 0 1 1 0 0 0 0 0 1 1 0 0 0 1 45 0 1 291 1 0 0 0 0 0 0 0 0 0 0 0 0 X 7 6 0 0 0 0 0 0 0 1 1 0 0 1 1 1 1 1 1 1 1 0 KS X SHARESE MOSER 7857426431 300 UTAH STREET HIAWATHA KS 66434 DR CROSBY GERNON RADIOLOGIST 40.00 0.00 X 400505 0 42787 DR PETER ROSA PHYSICIAN 40.00 0.00 X 383997 0 43187 DR JESSICA JARVIS PHYSICIAN 40.00 0.00 X 329925 0 31915 DR BRYON BIGHAM PHYSICIAN 40.00 0.00 X 313371 0 43135 DUSTIN WILLIAMS APRN 40.00 0.00 X 250216 0 32990 JOHN BROBERG CEO THRU 11/21 40.00 0.00 X 234942 0 0 DANIELLE JAGELS APRN 40.00 0.00 X 173741 0 38937 DR LOWELL SEARIGHT PHYSICIAN 40.00 0.00 X 178642 0 16392 BRETT GLIEM PHYSICIAN ASSISTANT 40.00 0.00 X 144873 0 30700 JODI TWOMBLY PHYSICIAN ASSISTANT 40.00 0.00 X 138799 0 36538 JEAN ABEITA PHARMACIST 40.00 0.00 X 144384 0 23769 ZANE HOFFMAN PHARMACIST 40.00 0.00 X 118464 0 39426 SHARESE MOSER DIRECTOR OF FINANCE 40.00 0.00 X 85500 0 21631 JEFF PERRY CEO 20.00 0.00 X 31150 0 0 GREG RODVELT PRESIDENT 0.50 0.00 X X 0 0 0 DEL ELFFNER VICE PRESIDENT 0.30 1.00 X X 0 0 0 JOHN MOORE SECRETARY/TREASURER 0.30 0.00 X X 0 0 0 ANDREA COLLINS-KELLER TRUSTEE 0.30 0.00 X 0 0 0 MANDY GRAHAM TRUSTEE 0.30 0.00 X 0 0 0 WILLIE GEISENDORF TRUSTEE 0.30 0.00 X 0 0 0 HOWARD ELLIOTT TRUSTEE 0.30 0.00 X 0 0 0 JAKE WISDOM TRUSTEE THRU 02/21 0.30 0.00 X 0 0 0 2928509 0 401407 15 0 1 0 STARS INC 201 S 4TH STREET HIAWATHA KS 66434 PT/OT/RT THERAPY SERVICES 652004 STEVEN H GUNNELLS ANESTHESIA 2561 LINDEN AVE HIAWATHA KS 66434 CRNA SERVICES 257469 MIDWEST DATA CENTER PO BOX 39 ROCK PORT MO 64482 IT SERVICES 236817 ANESTHESIA ETC INC PO BOX 95 SENECA KS 66538 CRNA SERVICES 223500 NORTHEASTERN ANESTHESIA SERVICES PA 1706 GRACELAND DR SABETHA KS 66534 CRNA SERVICES 174001 9 146169 6181154 247972 6575295 MEDICARE/MEDICAID PAYMENTS 621400 15862779 15862779 PATIENT REVENUE - PRIVATE PAY 621400 11597805 11597805 340B INCOME 621990 2489568 2489568 18494 18494 29968646 12695 12695 7802 0 7802 7802 7802 CAFETERIA 900099 70091 70091 70091 36634529 29968646 0 90588 X 10102 10102 2209671 1836448 373223 10755574 10291026 464548 373104 355191 17913 1666817 1497964 168853 840069 800482 39587 65726 484 65242 133232 133232 4458539 4303291 155248 62013 56475 5538 222377 171631 50746 155500 109158 46342 1102783 810643 292140 77313 46340 30973 232155 20354 211801 1129935 11071 1118864 653763 156431 497332 MEDICAL SUPPLIES 4801425 4795845 5580 BAD DEBT 1651326 1651326 DUES & SUBSCRIPTIONS 369975 317102 52873 MISC EXPENSE 148611 95501 53110 31120010 27336865 3783145 0 286 366 15892152 13540608 3297690 4737443 656243 813797 221283 182630 33245119 22755470 9485405 10489649 644022 0 1097895 29553059 31506410 2391051 2611680 3576665 4428615 6089841 5955000 420072 124709 2570000 1850582 4284376 156229 19332005 15126815 X 10221054 15735573 644022 10221054 16379595 29553059 31506410 X 5514519 618381 25641 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 5335 5335 0 PART II-B, LINE 1: DUES PAID TO KHA & AHA CONTAIN A PORTION FOR LOBBYING EXPENSES. 784309 784309 18237118 11525925 6711193 11698144 10169776 1528368 2525548 1059769 1465779 10489649 LEASE LIABILITY 156229 156229 X 34983203 0 34983203 1651326 1651326 36634529 29468684 0 29468684 1651326 1651326 31120010 PART X, LINE 2: THE HOSPITAL IS A NOT-FOR-PROFIT CORPORATION AS DESCRIBED IN SECTION 501(C)(3) OF THE INTERNAL REVENUE CODE. THE HOSPITAL HAS RECEIVED A DETERMINATION LETTER INDICATING THAT THEY ARE EXEMPT FROM FEDERAL INCOME TAXES ON RELATED INCOME PURSUANT TO SECTION 501(A) OF THE INTERNAL REVENUE CODE. THE INTERNAL REVENUE SERVICE HAS ESTABLISHED STANDARDS TO BE MET TO MAINTAIN TAX EXEMPT STATUS. THE HOSPITAL ACCOUNTS FOR UNCERTAINTIES IN ACCOUNTING FOR INCOME TAX ASSETS AND LIABILITIES USING GUIDANCE INCLUDED IN 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 4B - OTHER ADJUSTMENTS: BAD DEBT EXPENSE 1,651,326. PART XII, LINE 4B - OTHER ADJUSTMENTS: BAD DEBT EXPENSE 1,651,326. 1 1 X 1 X 1 X 1 0 1 1 855478 855478 0.02900 3021898 1858864 1163034 0.03950 3877376 1858864 2018512 0.06850 8047 8047 0.00030 119866 119866 0.00410 152391 141904 10487 0.00040 280304 141904 138400 0.00480 4157680 2000768 2156912 0.07330 1842 1842 0.00010 1842 1842 0.00010 1 1651326 297238 11749097 11288097 461000 X 1 1 1 1 HIAWATHA HOSPITAL ASSOCIATION INC 300 UTAH STREET HIAWATHA KS 66434 HCH-KS.ORG H007001 X X X X HIAWATHA HOSPITAL ASSOCIATION INC 1 0 0 1 X X X X X X X X X 19 1 0 1 1 X HTTPS://WWW.HCH-KS.ORG/GETPAGE.PHP?NAME=COMMUNITY_BENEFITS X 1 19 1 HTTPS://WWW.HCH-KS.ORG/GETPAGE.PHP?NAME=COMMUNITY_BENEFITS 0 1 X 200.000000000000 300.000000000000 X X X X X 1 1 X X X X 1 X HTTPS://WWW.HCH-KS.ORG/GETPAGE.PHP?NAME=FAP X HTTPS://WWW.HCH-KS.ORG/GETPAGE.PHP?NAME=FAP X HTTPS://WWW.HCH-KS.ORG/GETPAGE.PHP?NAME=FAP X X X X X X 1 X 0 X X X X 1 X 0 0 HIAWATHA HOSPITAL ASSOCIATION, INC. PART V, SECTION B, LINE 5: WE CHOSE INDIVIDUALS WHO WOULD HAVE UNIQUE UNDERSTANDING OF THE DIFFERENT POPULATIONS IN OUR COMMUNITY TO BE ON THE COMMITTEE. THE COMMITTEE HELPED FORMULATE THE SURVEY TO TAKE TO OUR COMMUNITY AND GAVE SIGNIFICANT FEEDBACK AND DIRECTION ABOUT WHAT SPECIFIC POPULATION NEEDS WERE.INCLUDED ON THE COMMITTEE:- THE NURSING DIRECTOR FOR BROWN COUNTY HEALTH DEPARTMENT- SUPERINTENDENT OF HIAWATHA USD 415- LOCAL LAW ENFORCEMENT- LOCAL GOVERNMENT- AREA AGENCY ON AGING- KNZA MENTAL HEALTH HIAWATHA HOSPITAL ASSOCIATION, INC. PART V, SECTION B, LINE 6B: BROWN COUNTY HEALTH DEPARTMENT HIAWATHA HOSPITAL ASSOCIATION, INC. PART V, SECTION B, LINE 11: THE HOSPITAL IS ADDRESSING MOST OF THE SIGNIFICANT NEEDS IDENTIFIED IN ITS MOST RECENTLY CONDUCTED CHNA:TO ADDRESS THE SIGNIFICANT NEED OF ADDITIONAL PROVIDERS, THE HOSPITAL WILL CONTINUE TO RECRUIT HCH PROVIDERS TO THE AREA USING NATIONAL RECRUITERS TO FIND QUALITY PROVIDERS. THE HOSPITAL WILL EXPLORE RELATIONSHIPS WITH TERTIARY HOSPITALS TO HAVE VISITING SPECIALIST HOURS AND CREATE AN HCH ON-BOARDING PROGRAM. THE HOSPITAL WILL OFFER COMMUNITY HEALTH FAIRS TO EXPOSE RESIDENTS TO HEALTH CARE PROVIDERS AVAILABLE WITHIN THE AREA. THE HOSPITAL WILL EXPLORE TELEMEDICINE AND TELEHEALTH SERVICES FOR ADDITIONAL PROVIDER SPECIALTY SUPPORT. THE HOSPITAL WILL COMPLETE A DR MANPOWER WORKFORCE NEEDS STUDY IN CONJUNCTION WITH PSA PROVIDERS. IN ADDITION, THE HOSPITAL WILL CREATE A PSA LOCAL COMMUNITY HEALTHCARE RECRUITMENT COMMITTEE WITH A STRATEGY TO GROW PHYSICIAN WORKFORCE AND WILL HOLD UPDATE MEETINGS EVERY QUARTER.TO ADDRESS THE SIGNIFICANT NEED OF THE FINANCIAL HEALTH OF THE LOCAL HOSPITAL, THE HOSPITAL WILL CONTINUE TO EXPLORE THE FUNDING RESOURCES AVAILABLE FROM THE FEDERAL GOVERNMENT / STATE OF KANSAS AND BROWN COUNTY FOR HEALTHCARE SERVICES. THE HOSPITAL WILL CONTINUE TO ADVANCE BROWN COUNTY SALES TAX 2.0 CAMPAIGN AND WILL CONTINUE WITH TAX SUPPORT FUNDING INITIATIVES. THE HOSPITAL WILL CONTINUE TO USE DATA REVIEW, MANAGER INPUT, AND NATIONAL BENCHMARKS TO SET A STANDARD STAFFING RATIO FOR THE HOSPITAL OVERALL AND FOR EACH DEPARTMENT. THE HOSPITAL WILL RE-EVALUATE THESE STANDARDS ON A ROUTINE BASIS. THE HOSPITAL WILL CONTINUE WORK-PROCESS REDESIGN TO ENSURE FINANCIAL RESPONSIBILITY. HOSPITAL ADMINISTRATION WILL MANAGE STAFFING LEVELS FROM SHIFT TO SHIFT AND CROSS-TRAIN PERSONNEL ACROSS DEPARTMENTS. THE HOSPITAL WILL CONTINUE TO ANALYZE COMPENSATION PRACTICES ACROSS THE ORGANIZATION FOR STANDARDIZATION AND CONSISTENCY. THE HOSPITAL WILL INVESTIGATE & FIND GRANTS TO SUPPORT NON PROFITABLE SERVICES AND APPLY FOR GRANT FUNDING ASSISTANCE. THE HOSPITAL WILL CONTINUE TO SUPPORT MEDICAID EXPANSION, UTILIZE KHA SPEAKERS TO COME TO HCH AT LEAST TWO TIMES PER YEAR.TO ADDRESS THE SIGNIFICANT NEED OF THE COMMUNITY COLLABORATION BETWEEN AGENCIES THE HOSPITAL WILL DEVELOP PARTNER RELATIONSHIPS WITH KEY COMMUNITY MENTAL HEALTH PARTNERS FOR COLLECTIVE IMPACT. THE HOSPITAL WILL CREATE A COLLABORATION AMONG THE FITNESS CENTERS, PARENTS AS TEACHERS, SCHOOLS, SURROUNDING HEALTH DEPARTMENTS, AND FIRE DEPARTMENTS TO ENHANCE PARENTS' HEALTH LITERACY AND PROMOTE CHILDREN'S HEALTHY DEVELOPMENT. THE HOSPITAL WILL CREATE A COMMUNITY / BROWN CO FACEBOOK PAGE (FROM CHAMBER AND HEALTH DEPT PAGES). PROVIDE WEB LINKS TO AREA PROVIDERS, SCHOOLS & CHURCHES TO LIST SERVICES & PROGRAMS. THE HOSPITAL WILL EXPLORE & RELAUNCH HEALTHCARE COMMUNITY COALITION. MEET QUARTERLY TO REVAMP IDEAS AND REVIEW TOP NEEDS FOR BROWN COUNTY SCHOOLS TO HOST THE MEETINGS. THE HOSPITAL WILL EXPAND RELATIONSHIPS WITH CHURCH AND COMMUNITY ORGANIZATIONS THAT OFFER TEEN LIFESTYLE SKILLS TRAINING AND GED PREPARATION TO IDENTIFY SERVICE GAPS AND WAYS TO ENHANCE PARTNERSHIPS (I.E., YOUNG LIFE, 4-H, 5TH QUARTER). CONTINUE TO PROVIDE GED ONLINE CLASSES. THE HOSPITAL WILL HOST COMMUNITY EDUCATION EVENTS IN ORDER TO PROMOTE LOCAL HEALTHCARE / SOCIAL SERVICE PROGRAMS. FOCUS ON COUNTY FAIR, SCHOOL ATHLETES AND WELCOME WAGON. UTILIZE THIS EFFORT WITH AAA. CONTINUE WITH COMMUNITY BABY SHOWERS AT LEAST TWICE PER YEAR THROUGH HD. THE HOSPITAL WILL COLLABORATE WITH KICKAPOO FOR THEIR HEALTH FAIR EFFORTS. THE HOSPITAL WILL COLLABORATE AND HOST LUNCH & LEARNS (MONTHLY) TO EDUCATE COMMUNITY ON HEALTH & WELLNESS PRACTICES / SOCIAL SERVICE PROGRAMS.TO ADDRESS THE SIGNIFICANT NEED OF THE AWARENESS OF SERVICES AMONG THE COMMUNITY THE HOSPITAL WILL CREATE A COLLABORATION AMONGST ALL STAKEHOLDERS IN BROWN COUNTY. HAVE MEETINGS QUARTERLY TO DISCUSS SERVICE OFFERINGS TO THE COMMUNITY. THE HOSPITAL WILL INVESTIGATE OPPORTUNITIES TO CREATE A COMMUNITY FACEBOOK PAGE. PROVIDE WEB LINKS TO AREA PROVIDERS, SCHOOLS & CHURCHES TO LIST SERVICES & PROGRAMS. THE HOSPITAL WILL DEVELOP PARTNER RELATIONSHIPS WITH KEY COMMUNITY PROVIDERS FOR COLLECTIVE IMPACT. UTILIZE NEK MULTI-COUNTY HEALTH DEPARTMENT CONTACTS SUCH AS: DONIPHAN CO HD, AND OTHERS. THE HOSPITALS WILL HOST LUNCH & LEARNS (AT LEAST QUARTERLY) TO EDUCATE COMMUNITY ON HEALTH & WELLNESS PRACTICES / SOCIAL SERVICE PROGRAMS. THE HOSPITAL WILL MAINTAIN A COMMUNITY INVENTORY OF HEALTHCARE SERVICES IN THE AREA, INCLUDING HOURS OF SERVICE. MAKE INVENTORY AVAILABLE TO THE PUBLIC, AS NEEDED. THE HOSPITAL WILL CONTINUE TO OFFER COMMUNITY HEALTH FAIRS TO EXPOSE RESIDENTS TO HEALTH CARE AVAILABILITY. ASK THREE PSA SCHOOLS TO ASSIST AND HOST AT LEAST TWICE PER YEAR. THE HOSPITAL WILL PROVIDE PSA CONSUMER REPORTS TO COMMUNITY. THE HOSPITAL WILL CONTINUE SHARING THE HCH CALENDAR OF EVENTS WITH THE COMMUNITY. CREATE A HEALTH DEPT EVENT CALENDAR AND MAKE IT AVAILABLE TO THE COMMUNITY. THE HOSPITAL WILL UTILIZE BROWN CO FB PAGE TO POST.THE FOLLOWING STRATEGIES WERE PUT ON HOLD DUE TO THE PANDEMIC AND THE AMOUNT OF TIME THE HOSPITAL WAS FOCUSING ON HOW TO RESPOND AND CONTINUE TO PROVIDE CARE TO OUR PATIENTS AND COMMUNITY. WE PROVIDE MEDICALLY-RELATED TRANSPORTATION AT NO COST TO THE PUBLIC, PROVIDE MENTAL HEALTH SCREENINGS AND PROMOTE THE LOCAL PARKS AND REC AND WALKING TRAILS. WE WORK ON OBTAINING COMMUNITY-WIDE GRANTS TO IMPROVE LOCAL HABITS THAT RESULT IN HEALTHY OUTCOMES. 2 1 - HIAWATHA COMM HOSP FAM PRACTICE CLINIC 300 OREGON STREET 2ND FLOOR HIAWATHA KS 66434 RURAL HEALTH CLINIC 2 - HIAWATHA COMM HOSPITAL HIGHLAND CLINIC 415 S MAIN STREET HIAWATHA KS 66434 RURAL HEALTH CLINIC PART I, LINE 3C: IN ADDITION TO FPG, THE ORGANIZATION USES ASSET LEVEL, INSURANCE STATUS, RESIDENCY, MEDICAL INDIGENCY, AND UNDERINSURANCE STATUS AS FACTORS IN DETERMINING ELIGIBILITY FOR FREE OR DISCOUNTED CARE. PART I, LINE 6A: THE COMMUNITY BENEFIT REPORT IS PREPARED BY VVV CONSULTING AND IS POSTED ON THE HOSPITAL'S WEBSITE. PART I, LINE 7: THE HOSPITAL USES THE COST-TO-CHARGE RATIO. THIS METHOD WAS USED TO CALCULATE THE FIGURES IN THE TABLE AND WAS DETERMINED BY COMPARING PATIENT CARE COST TO PATIENT CARE CHARGES. PART I, LN 7 COL(F): THE AMOUNT OF BAD DEBT EXPENSE REMOVED FROM TOTAL EXPENSES FOR CALCULATING THE NET COMMUNITY BENEFIT EXPENSE PERCENTAGE WAS $1,651,326. PART II, COMMUNITY BUILDING ACTIVITIES: LITTLE HANDS DAYCARE IS A NOT FOR PROFIT DAYCARE THAT PROVIDES LICENSED, RELIABLE, QUALITY DAYCARE AND EDUCATION TO CHILDREN IN THE COMMUNITY. ONE OF THE ISSUES CITED BY LOCAL EMPLOYERS WHEN RECRUITING WORK WAS A LACK OF OPENINGS WITH LOCAL DAYCARE PROVIDERS. LITTLE HANDS WAS STARTED TO ADDRESS THAT NEED. HIAWATHA HOSPITAL'S CONTRIBUTIONS IN TIME AND SUPPLIES HAS HELPED THEM TO BE ABLE TO PROVIDE QUALITY SERVICES WHILE OPERATING ON MINIMAL MARGINS. PART III, LINE 2: GENERALLY, PATIENTS WHO ARE COVERED BY THIRD-PARTY PAYORS ARE RESPONSIBLE FOR RELATED DEDUCTIBLES AND COINSURANCE, WHICH VARY IN AMOUNT. THE HOSPITAL PROVIDES SERVICES TO UNINSURED PATIENTS, AND OFFERS THOSE UNINSURED PATIENTS A DISCOUNT, EITHER BY POLICY OR LAW, FROM STANDARD CHARGES. THE HOSPITAL ESTIMATES THE TRANSACTION PRICE FOR PATIENTS WITH DEDUCTIBLES AND COINSURANCE AND FROM THOSE WHO ARE UNINSURED BASED ON HISTORICAL EXPERIENCE AND CURRENT MARKET CONDITIONS. THE INITIAL ESTIMATE OF THE TRANSACTION PRICE IS DETERMINED BY REDUCING THE STANDARD CHARGE BY ANY CONTRACTUAL ADJUSTMENTS, DISCOUNTS AND IMPLICIT PRICE CONCESSIONS. SUBSEQUENT CHANGES TO THE ESTIMATE OF THE TRANSACTION PRICE ARE RECORDED AS ADJUSTMENTS TO PATIENT SERVICE REVENUE IN THE PERIOD OF CHANGE. SUBSEQUENT CHANGES THAT ARE DETERMINED TO BE THE RESULT OF AN ADVERSE CHANGE IN THE PATIENT'S ABILITY TO PAY ARE RECORDED AS BAD DEBT EXPENSE. PART III, LINE 3: BEFORE MAKING ACCOUNTS ELIGIBLE FOR BAD DEBT, WE RUN ALL ACCOUNTS THROUGH A COMPANY TO CHECK TO SEE IF THEY WOULD LIKELY BE ELIGIBLE FOR FINANCIAL ASSISTANCE. THOSE WHO COME BACK AS PROBABLE ARE CONTACTED AND ASKED AGAIN TO COMPLETE A FAP APPLICATION. MANY INDIVIDUALS ARE NOT WILLING TO COMPLETE THE APPLICATION. AT THAT POINT THEY ARE GRANTED PRESUMPTIVE FINANCIAL ASSISTANCE STATUS AND THEIR BALANCES ARE WRITTEN OFF TO CHARITY CARE INSTEAD OF BAD DEBT. WHILE WE FEEL THAT WE WORK VERY DILIGENTLY TO PROVIDE FINANCIAL ASSISTANCE TO THOSE WHO QUALIFY, WE CANNOT GUARANTEE A PERFECT SYSTEM. SO THE ABOVE FIGURE IS AN ESTIMATION OF THE BALANCES THAT MAY HAVE NOT BEEN CAUGHT BY OUR SYSTEM. PART III, LINE 4: THE ORGANIZATION'S FINANCIAL STATEMENTS DO NOT CONTAIN A SPECIFIC FOOTNOTE DESCRIBING BAD DEBT. HOWEVER, PAGES 8, 10 AND 11 OF THE ATTACHED AUDITED FINANCIAL STATEMENTS INCLUDE FOOTNOTES TITLED "PATIENT ACCOUNTS RECEIVABLE" "PATIENT SERVICE REVENUE", AND "PATIENT FINANCIAL ASSISTANCE". PART III, LINE 8: THERE IS NO SHORTFALL REPORTED IN THE CURRENT YEAR. PART III, LINE 9B: CHARITY CARE APPLICATIONS ARE MADE AVAILABLE TO ALL PATIENTS AT THE TIME OF REGISTRATION, ON STATEMENTS, AND ON THE WEBSITE. 120 DAYS AFTER THE FIRST POST DISCHARGE STATEMENT IS MADE ON AN ACCOUNT, IF PAYMENT ISN'T MADE AND A CHARITY CARE APPLICATION ISN'T COMPLETED THE PATIENT'S NAME IS RUN THROUGH A COMPANY TO CHECK FOR PRESUMPTIVE CHARITY CARE. IF THEY QUALIFY, THEY ARE OFFERED AN APPLICATION AGAIN. IF THEY FAIL TO COMPLETE THE APPLICATION, THEY ARE WRITTEN OFF TO CHARITY CARE UNDER OUR PRESUMPTIVE CHARITY CARE PROGRAM. IF THEY DO NOT QUALIFY FOR CHARITY CARE, AND HAVE NOT RESPONDED TO OUR REQUESTS FOR PAYMENTS FOR 120 DAYS, THEN THE ACCOUNT IS GRANTED APPROVAL BY THE BOARD OF TRUSTEES. ONCE AN ACCOUNT IS GRANTED APPROVAL BY THE BOARD, IT IS SENT TO THE COLLECTION AGENCY. WE GIVE THE COLLECTION AGENCY SEVERAL MONTHS TO COLLECT THE DEBT. IF THEY ARE UNSUCCESSFUL, THE ACCOUNT IS RETURNED TO THE HOSPITAL AND WRITTEN OFF. PART VI, LINE 2: NOT ONLY DID WE SEEK FEEDBACK FROM COMMITTEE MEMBERS REPRESENTING LESSER-HEARD VOICES FROM OUR COMMUNITY, BUT WE MADE AN ONLINE SURVEY AVAILABLE, WE PUT HARD COPIES OF THE SURVEY IN MULTIPLE PLACES INCLUDING ALL OF THE TOWNS IN OUR SERVICE AREA. WE COMBINED THAT FEEDBACK WITH STATISTICAL INFORMATION FROM RELIABLE SOURCES TO IDENTIFY PRIORITIES. PART VI, LINE 3: WE POST INFORMATION ABOUT OUR FAPS EXISTENCE IN PROMINENT LOCATIONS. WE MAKE COPIES OF THE FAP AVAILABLE DURING REGISTRATION, IN INPATIENT ROOMS, ONLINE, AND ON OUR BILLING CORRESPONDENCE. PART VI, LINE 4: THE HOSPITAL SERVES A GEOGRAPHIC AREA THAT ENCOMPASSES ATCHISON, BROWN, DONIPHAN, JACKSON AND NEMAHA COUNTIES IN KANSAS, AND RICHARDSON COUNTY IN NEBRASKA. OF THOSE PATIENTS, 85% ARE FROM BROWN AND DONIPHAN COUNTIES. THESE ARE MOSTLY RURAL COMMUNITIES. 88% OF THE POPULATION OF THE BROWN AND DONIPHAN COUNTIES THAT IS 25 YEARS OR OLDER HAS A MINIMUM OF A HIGH SCHOOL DIPLOMA, 16% HAS A BACHELORS DEGREE OR HIGHER. THE AVERAGE MEDIAN HOUSEHOLD INCOME IS $41,300 COMPARED TO THE STATE WIDE MEDIAN HOUSEHOLD INCOME OF $50,594. 16% OF THE POPULATION LIVES IN POVERTY; 19% FOR BROWN COUNTY ALONE. 16% OF THE POPULATION IN BROWN AND DONIPHAN COUNTIES DOES NOT HAVE HEALTH INSURANCE. PART VI, LINE 5: WE SUPPORT A WIDE ARRAY OF PROGRAMS AND PROJECTS IN OUR COMMUNITY. MANY OF OUR KEY EMPLOYEES SERVE ON MULTIPLE BOARDS THAT HAVE A POSITIVE IMPACT ON VARIOUS ASPECTS OF THE COMMUNITY. WE PROVIDE DONATIONS OF BOTH TIME AND MONEY TO VARIOUS SERVICE ORGANIZATIONS. PART VI, LINE 6: THE HOSPITAL IS PART OF AN AFFILIATED HEALTH CARE SYSTEM WITH AMBERWELL ATCHISON ASSOCIATION. PART VI, LINE 7, REPORTS FILED WITH STATES KS 0 TOWN AND COUNTRY EMS LLC PO BOX 296 708 N 1ST HIAWATHA KS 66434 454148768 6205 0 SUPPORT AMBULANCE SERVICES 0 1 X 1 1 X X X 0 0 0 1 0 0 0 0 0 DR CROSBY GERNON RADIOLOGIST 399954 0 500 0 51 0 9000 0 33787 0 443292 0 0 0 DR PETER ROSA PHYSICIAN 297998 0 85948 0 51 0 6706 0 36481 0 427184 0 0 0 DR JESSICA JARVIS PHYSICIAN 295678 0 34196 0 51 0 0 0 31915 0 361840 0 0 0 DR BRYON BIGHAM PHYSICIAN 300125 0 13195 0 51 0 6812 0 36323 0 356506 0 0 0 DUSTIN WILLIAMS APRN 233625 0 16540 0 51 0 0 0 32990 0 283206 0 0 0 JOHN BROBERG CEO THRU 11/21 234942 0 0 0 0 0 0 0 0 0 234942 0 0 0 DANIELLE JAGELS APRN 135279 0 38411 0 51 0 6683 0 32254 0 212678 0 0 0 DR LOWELL SEARIGHT PHYSICIAN 169091 0 9500 0 51 0 3806 0 12586 0 195034 0 0 0 BRETT GLIEM PHYSICIAN ASSISTANT 112589 0 32233 0 51 0 2534 0 28166 0 175573 0 0 0 JODI TWOMBLY PHYSICIAN ASSISTANT 122208 0 16540 0 51 0 2751 0 33787 0 175337 0 0 0 JEAN ABEITA PHARMACIST 143833 0 500 0 51 0 3223 0 20546 0 168153 0 0 0 ZANE HOFFMAN PHARMACIST 117913 0 500 0 51 0 2639 0 36787 0 157890 0 0 0 PART I, LINE 1A JOHN BROBERG, CEO THRU NOVEMBER OF 2021, RECEIVED COMPENSATION FOR HOUSING THE AMOUNT OF $4,600 AS A TAXABLE BENEFIT. THE AMOUNT WAS INCLUDED ON THE 1099. PART I, LINE 5 THE PROVIDERS ARE PAID A PERFORMANCE BONUS BASED ON PRODUCTIVITY AND CONSIDERATION OF REVENUES. A CITY OF HIAWATHA KANSAS 486025665 428545CY1 2020-03-31 6295000 SEE PART VI 0 0 0 A 340000 6295000 300000 125900 1899946 4169100 100054 1 0 0 1 A 0 0 1 1 0 0.00000 0.00000 0.00000 0 0 1 A 0 1 0 0 0 0 0 0 1 A 1 PART I, LINE A, COLUMN F THE BONDS WERE ISSUED TO (1) REFUND THE SERIES 2014 BONDS (ISSUED 9/29/2014) AND (2) MAKE CAPITAL IMPROVEMENTS INCLUDING STRUCTURAL IMPROVEMENTS AND THE ACQUISITION OF CAPITAL ASSETS TO IMPROVE HOSPITAL SERVICES. PART II, LINE 13, COLUMN A THE PROJECT IS STILL IN PROGRESS MANDY GRAHAM MANDY GRAHAM, TRUSTEE, AND A GREATER THAN 35% OWNER OF RESTORE. 161000 THE HOSPITAL PAID RESTORE $161,000 FOR SPEECH THERAPY. 0 FORM 990, PART VI, SECTION B, LINE 11B AN INDEPENDENT ACCOUNTING FIRM PREPARES AND REVIEWS THE 990. THE 990 IS THEN REVIEWED BY THE ORGANIZATION'S OFFICERS AND ACCOUNTING PERSONNEL. ANY QUESTIONS OR CONCERNS THE ORGANIZATION'S OFFICERS AND ACCOUNTING PERSONNEL HAVE ARE ADDRESSED AND ANY CORRECTIONS OR CLARIFICATIONS THAT NEED TO BE MADE ARE MADE. THE FINAL FORM 990 WITH ALL REQUIRED SCHEDULES IS THEN PROVIDED TO ALL VOTING MEMBERS OF THE BOARD PRIOR TO FILING. FORM 990, PART VI, SECTION B, LINE 12C ALL EMPLOYEES AND DECISION MAKERS FOR THE HOSPITAL ARE COVERED UNDER THIS POLICY. CONFLICTS ARE EITHER REVIEWED BY THE CORPORATE COMPLIANCE OFFICER OR THE BOARD PRESIDENT. AT BOARD MEETINGS, THE BOARD CHAIR IS APPRAISED OF ALL CONFLICTS OF INTEREST AND THEN ASKS THE MEMBER TO ABSTAIN FROM DISCUSSING AND VOTING ON TOPICS OF CONFLICT. FORM 990, PART VI, SECTION B, LINE 15 HUMAN RESOURCES PERIODICALLY PROVIDES THE PRESIDENT OF THE BOARD OF DIRECTORS WITH A COMPENSATION SURVEY COMPILED BY THE KANSAS HOSPITAL ASSOCIATION. THE SURVEY DELINEATES COMPENSATION PACKAGES FOR ADMINISTRATORS AT HOSPITALS THAT ARE SIMILAR TO HIAWATHA. BASED ON THAT SURVEY, THE ADMINISTRATOR'S PERFORMANCE, AND THE PERFORMANCE OF THE HOSPITAL, THE BOARD SETS THE ADMINISTRATOR'S SALARY. THE LAST EVALUATION WAS GIVEN IN 2021 WHILE HIRING OUR CURRENT CEO. FORM 990, PART VI, SECTION C, LINE 19 THE ORGANIZATION MAKES ITS GOVERNING DOCUMENTS, CONFLICT OF INTEREST POLICY, AND FINANCIAL STATEMENTS AVAILABLE TO THE PUBLIC UPON REQUEST. FORM 990, PART IX, LINE 11G OTHER SERVICE FEES: PROGRAM SERVICE EXPENSES 4,303,291. MANAGEMENT AND GENERAL EXPENSES 155,248. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 4,458,539. FORM 990, PART XI, LINE 9: CHANGE IN INTEREST IN FOUNDATION 25,641. FORM 990, PAGE 12, PART XII, LINE 2C: THE BOARD OF DIRECTORS HAS THE RESPONSIBILITY OF SELECTING THE INDEPENDENT ACCOUNTANT TO COMPLETE THE AUDIT WORK. THE FINANCE COMMITTEE OF THE BOARD OF DIRECTORS HAS THE RESPONSIBILITY FOR THE OVERSIGHT OF THE AUDIT. UPON CONCLUSION OF THE AUDIT, THE AUDITING FIRM PRESENTS THE RESULTS AND FINDINGS TO THE BOARD OF DIRECTORS. THIS PROCESS HAS NOT CHANGED FROM THE PRIOR YEAR. HIAWATHA COMMUNITY HOSPITAL FOUNDATION 300 UTAH STREET HIAWATHA KS 66434 481223766 FUNDRAISING KS 501(C)(3) LINE 12D, III-O 0 CHARITABLE REMAINDER TRUST (1) TRUST KS HHA T 1 0 0 1 0 0 0 0 0 0 0 0 0 0 1 1 0 0 0 0