2022-11-11T13:05:16-06:00 2021-12-31 390758449 WIPFLI LLP 1502 LONDON ROAD SUITE 200 DULUTH MN 55812 990 2021-01-01 470566524 PROVIDENCE MEDICAL CENTER PROV 4023753800 1200 PROVIDENCE RD WAYNE NE 68787 DANIELLE GEARHART CEO 4023753800 2022-11-10 1 DANIELLE GEARHART 999009999 MICHAEL J PETERSON CPA P01833529 2187224705 2022-11-10 3 AAL1 IAL1 2021 2022-09-23 18:48:47Z DANIELLE GEARHART 1200 PROVIDENCE RD WAYNE NE 68787 35662753 0 X WWW.PROVIDENCEMEDICAL.COM X 1975 NE SEE SCHEDULE O 7 7 250 28 0 0 3039899 6794741 23903927 27225898 342934 382088 168252 176263 27455012 34578990 5914 10493 0 0 12256617 13053017 0 0 0 13232134 13762037 25494665 26825547 1960347 7753443 46663215 46480888 22906906 14762622 23756309 31718266 THE MISSION OF PROVIDENCE MEDICAL CENTER IS TO PROVIDE QUALITY HEALTH CARE IN THE SPIRIT OF CHRIST. 0 0 21692969 10493 27225898 PROVIDENCE MEDICAL CENTER IS A NOT-FOR-PROFIT, 21 BED, CRITICAL ACCESS HOSPITAL LOCATED IN WAYNE, NEBRASKA. PROVIDENCE SERVES OVER 15,000 AREA RESIDENTS IN NORTHEAST NEBRASKA AND EMPLOYS OVER 200 PEOPLE. PROVIDENCE OFFERS ACUTE, SKILLED, AND OBSTETRICAL CARE ALONG WITH 24 HOURS A DAY, SEVEN DAYS A WEEK EMERGENCY CARE AND AMBULANCE SERVICES. THE HOSPITAL ALSO PROVIDES DIAGNOSTIC IMAGING, SURGICAL, THERAPY, LABORATORY, ONCOLOGY, RESPIRATORY, HOME HEALTH, BEHAVIORAL HEALTH AND MANY OTHER HEALTH AND WELLNESS SERVICES. THERE ARE OVER 23 SPECIALTY CLINIC DOCTORS OF DIFFERENT SPECIALTIES THAT CONDUCT CLINICS AT THE HOSPITAL IN ORDER TO BRING SPECIALIZED CARE TO THE COMMUNITY. 21692969 1 1 0 1 0 0 0 0 0 1 1 0 0 0 1 1 1 0 0 0 0 0 0 0 0 0 1 1 0 0 1 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 50 0 250 1 0 0 0 0 0 0 0 0 0 0 0 0 X 7 7 0 0 0 0 0 0 0 1 1 0 0 1 1 1 1 1 1 1 1 0 NE X KIM HIXSON 4023757673 1200 PROVIDENCE RD WAYNE NE 68787 JAMES FRANK CEO - THRU DECEMBER 40.00 X 194874 0 26754 KRISTINE GIESE COO 40.00 X 158602 0 9364 KIMBERLY LUEDERS DIRECTOR OF PHARMACY 40.00 X 150780 0 11627 KIMBERLY HIXSON CFO 40.00 X 124067 0 7370 DANIELLE GEARHART CEO 40.00 X 0 0 0 MATTHEW LEY CHAIR 1.00 X X 0 0 0 RICHARD BRANDOW VICE CHAIR 1.00 X X 0 0 0 ERIC KNUTSON SECRETARY/TREASURER 1.00 X X 0 0 0 MELISSA GRAHAM DIRECTOR 1.00 X 0 0 0 ROSS HANSEN DIRECTOR 1.00 X 0 0 0 JODI PULFER DIRECTOR 1.00 X 0 0 0 NATHAN RAABE DIRECTOR 1.00 X 0 0 0 628323 0 55115 4 0 1 0 FAITH REGIONAL PHYSICIAN SERVICES LLC 110 NORTH 29TH STREET NORFOLK NE 68701 ER DOCTOR COVERAGE 693499 PSYCHIATRIC MEDICAL CARE LLC 4322 HARDING PIKE 417 NASHVILLE TN 37205 SENIOR LIFE PSYCHIATRIC DOCTORS 423160 HYPNOS ANESHESIA PC 1805 NORTH 145TH STREET OMAHA NE 68154 CRNA SERVICES 406810 ICE TECHNOLOGIES INC 411 SOUTH EAST 9 STREET PELLA IA 50219 IT CONTRACTED LABOR 277574 T AND D ANESTHESIA LLC 13606 SOUTH 226TH AVENUE GRETNA NE 68028 CRNA SERVICES 252000 8 6284135 510606 4360 6794741 PATIENT SERVICE REVENUE 621990 25494739 25494739 PHARMACY 621990 1361222 1361222 FITNESS REVENUE 621990 195915 195915 DIETARY INCOME 722210 43486 43486 LIFELINE 621990 910 910 129626 129626 27225898 140562 140562 176263 0 176263 176263 176263 1323189 2100 1045909 37854 277280 -35754 241526 241526 34578990 27225898 0 558351 X 10493 10493 352465 352465 9743130 8190580 1552550 343410 282584 60826 1893760 1516360 377400 720252 570615 149637 43904 43904 44947 2760 42187 3043628 2717216 326412 149778 149778 225098 125839 99259 894901 84257 810644 462716 462687 29 58601 58289 312 86456 71821 14635 268642 195622 73020 2556214 1861410 694804 183780 183780 SUPPLIES AND PHARMACEUT 3785054 3766221 18833 PROVISIONS FOR BAD DEBT 1078780 929103 149677 EQUIPMENT RENTAL & MAIN 814786 814786 64752 32326 32426 26825547 21692969 5132578 0 394404 171811 15940074 10101310 88385 0 3516313 3385642 682968 719546 304663 378176 45737890 22622230 17903251 23115660 6544691 7362220 285576 288667 1002890 957856 46663215 46480888 1583357 2976003 2238972 595180 7028391 10010632 3615706 8440480 1180807 22906906 14762622 X 22796295 30953333 960014 764933 23756309 31718266 46663215 46480888 X 7753443 315210 -106696 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 2812 2812 0 PART II-B, LINE 1: PROVIDENCE MEDICAL CENTER ("PMC") PAYS ANNUAL ASSOCIATION MEMBERSHIP DUES TO THE NEBRASKA HOSPITAL ASSOCIATION (NHA). THESE DUES ARE PRIMARILY TO ACCESS EDUCATIONAL MATERIALS AND FOR STAFF TRAINING. THE NHA HAS NOTIFIED PMC THAT APPROXIMATELY $2,812 OF THE ANNUAL DUES PAID WERE USED IN CONJUNCTION WITH LOBBYING ACTIVITIES WITH THE GOAL OF IMPROVING THE OVERALL HEALTHCARE ENVIRONMENT. 77078 9931 87009 74377 2701 77078 64417 9960 74377 66427 2010 64417 58983 7444 66427 0.00000 0.00000 1.00000 1 0 91932 91932 26133959 13075450 13058509 12020330 9546780 2473550 7491669 7491669 23115660 THIRD-PARTY REIMBURSEMENT PROGRAMS 1039350 OPERATING LEASE LIABILITIES 98543 DEFERRED COMPENSATION PLAN 42914 1180807 X 33763195 315210 315210 33447985 1131005 1131005 34578990 26010761 0 26010761 814786 814786 26825547 PART V, LINE 4: PROVIDENCE MEDICAL CENTER HAS ONE ENDOWMENT FUND HELD BY PROVIDENCE MEDICAL CENTER FOUNDATION. THE ENDOWMENT WAS SET ASIDE BY DONORS TO PROVIDE INVESTMENT INCOME IN WHICH TO PROVIDE FOR FUTURE CAPITAL AND PROGRAM NEEDS OF THE HOSPITAL. PART X, LINE 2: PROVIDENCE MEDICAL CENTER HAS BEEN GRANTED TAX-EXEMPT STATUS UNDER SECTION 501(C)(3) OF THE INTERNAL REVENUE CODE AND WISCONSIN STATUTE. IT HAS BEEN CLASSIFIED AS AN ORGANIZATION THAT IS NOT A PRIVATE FOUNDATION UNDER THE INTERNAL REVENUE CODE AND CHARITABLE CONTRIBUTIONS BY DONORS ARE TAX DEDUCTIBLE. PROVIDENCE MEDICAL CENTER HAS EVALUATED ITS TAX POSITIONS AND DETERMINED IT HAS NO UNCERTAIN TAX POSITIONS AS OF DECEMBER 31, 2021. PART XI, LINE 4B - OTHER ADJUSTMENTS: PROVISION FOR BAD DEBTS 814,786. CONTRIBUTIONS TO RESTRICTED NET ASSETS: 11,615. FOUNDATION CONTRIBUTION 304,604. PART XII, LINE 4B - OTHER ADJUSTMENTS: PROVISION FOR BAD DEBTS 814,786. 1 1 X 1 X 1 X 1 1 1 0 0 305066 305066 0.01140 1815641 1613728 201913 0.00750 2120707 1613728 506979 0.01890 571102 368683 202419 0.00750 571102 368683 202419 0.00750 2691809 1982411 709398 0.02640 0 545077 342118 11000966 10845726 155240 X 1 1 1 1 PROVIDENCE MEDICAL CENTER 1200 PROVIDENCE ROAD WAYNE NE 68787 WWW.PROVIDENCEMEDICAL.COM 800001 X X X X AMBULANCE SERVICE PROVIDENCE MEDICAL CENTER 1 0 0 1 X X X X X X X X X 19 1 1 1 1 X SEE SUPPLEMENTAL SECTION 1 19 1 SEE SUPPLEMENTAL SECTION 0 1 X 150.000000000000 300.000000000000 X X X X 1 1 X X X X 1 X PFS-0003.04-FINANCIAL-ASSISTANCE-POLICY.PDF (PROVIDENCEMEDICAL.COM) X FINANCIAL-ASSISTANCE-APPLICATION-8-1-21.PDF (PROVIDENCEMEDICAL.COM) X PFS-0003.04-ATTACHMENT-3-PLAIN-LANGUAGE-SUMMARY.PDF (PROVIDENCEMEDICAL.COM) X X X X X X 1 X 0 X X X 1 X 0 0 PROVIDENCE MEDICAL CENTER PART V, SECTION B, LINE 5: THE HEALTH OF THE COMMUNITY IS INFLUENCED BY MANY DIFFERENT AGENCIES AND COMMUNITY SECTORS AND NOT JUST THE PUBLIC HEALTH DEPARTMENT. THE 45 PARTICIPANTS WHO ATTENDED THE MAY 21ST, 2019 INITIAL CHIP MEETING HELD VIRTUALLY ON ADOBE CONNECT WERE ASKED TO RECORD WHAT COMMUNITY SECTOR THEY REPRESENTED WITHIN THE PUBLIC HEALTH SYSTEM. THE FOLLOWING COMMUNITY SECTORS WERE PRESENT AT THE MEETING. HOSPITALS HEALTH CARE PROVIDERS FEDERALLY QUALIFIED HEALTH CENTER LOCAL PUBLIC HEALTH DEPARTMENT FAITH COMMUNITY ACADEMIC INSTITUTION SCHOOL COMMUNITY NOT FOR PROFIT CIVIC GROUP / CLUB CHAMBER OF COMMERCE LOCAL BUSINESS LAW ENFORCEMENT EMS FOUNDATION / PHILANTHROPISTS BEHAVIORAL HEALTH PRIVATE CITIZEN HISPANIC POPULATION PROVIDENCE MEDICAL CENTER PART V, SECTION B, LINE 6A: PENDER COMMUNITY HOSPITAL PROVIDENCE MEDICAL CENTER PART V, SECTION B, LINE 6B: NORTHEAST NEBRASKA PUBLIC HEALTH DEPARTMENT PROVIDENCE MEDICAL CENTER:PART V, SECTION B, LINE 7A: HTTPS://PROVIDENCEMEDICAL.COM/WP-CONTENT/UPLOADS/2021/02/2019-NNPHD-CHA-COMMUNITY-HEALTH-ASSESSMENT-FINAL1.PDFPROVIDENCE MEDICAL CENTER:PART V, SECTION B, LINE 10A: HTTPS://PROVIDENCEMEDICAL.COM/WP-CONTENT/UPLOADS/2021/02/2020-2022-PMC-CHNA-ACTION-PLAN.PDF PROVIDENCE MEDICAL CENTER PART V, SECTION B, LINE 11: WITH THE COMPLETION OF THE COMMUNITY HEALTH NEEDS ASSESSMENT (CHNA) AND IN CONJUNCTION WITH NORTHEAST NEBRASKA PUBLIC HEALTH DEPARTMENT (NNPHD), PENDER COMMUNITY HOSPITAL, AND COMMUNITY FOCUS GROUPS, THE HEALTH CONCERNS WERE PRIORITIZED, AND STRATEGIES DEVELOPED BY A CORE GROUP OF HOSPITAL ADMINISTRATIVE MEMBERS AND COMMUNITY PARTNERS. THE IMPLEMENTATION STRATEGIES WERE BROUGHT BEFORE THE PROVIDENCE MEDICAL CENTER BOARD OF DIRECTORS FOR APPROVAL AND ADOPTION. PRIORITIZED LIST OF SIGNIFICANT HEALTH NEEDS IDENTIFIED IN THE CHNATHROUGH THE DISCUSSION AND CONSENSUS VOTING, THE FOLLOWING COMMUNITY HEALTH PRIORITY AREAS WERE FINALIZED:PRIORITY 1: BEHAVIORAL HEALTH PRIORITY 2: OVERWEIGHT/OBESITYPRIORITY 3: CHRONIC DISEASE DETECTION AND MANAGEMENTTHE IMPACT OF ADDRESSING THESE CONCERNS WOULD OFFER THE FOLLOWING: IMPROVE ACCESS TO CARE MANAGEMENT ENHANCE POPULATION HEALTH OF THE COMMUNITY ADVANCE KNOWLEDGE OF DISEASE PROCESS AND MENTAL WELLNESSADDRESSING THESE NEEDS WILL BENEFIT OUR COMMUNITY AND RESULT IN MEASURABLE EXPENSE TO PROVIDENCE MEDICAL CENTER.RESOURCES COMMITTED WILL INVOLVE FINANCIAL SUPPORT OF ORGANIZATIONAL/ACTIVITY EXPENSE, EMPLOYEE WAGE, USE OF MEDICAL EQUIPMENT AND CLERICAL ITEMS. PROVIDENCE MEDICAL CENTER PART V, SECTION B, LINE 15E: PROVIDENCE MEDICAL CENTER MAY ASSIST PATIENTS IN APPLYING FOR MEDICARE, MEDICAID, AND OTHER GOVERNMENTAL MEDICAL ASSISTANCE PROGRAMS. 2 1 - PROVIDENCE COMMUNITY PHARMACY 803 PROVIDENCE ROAD SUITE 101 WAYNE NE 68787 PHARMACY 2 - PROVIDENCE PERSONAL CARE SERVICES 1200 PROVIDENCE ROAD WAYNE NE 68787 HOME HEALTH PART I, LINE 3C: UNINSURED, UNDERINSURED, AND INDIGENT BY DESIGN PATIENTS WHOSE INCOME/FAMILY INCOME IS GREATER THAN 400% OF THE FEDERAL POVERTY GUIDELINES MAY BE ELIGIBLE FOR DISCOUNTED CARE BASED ON THEIR PARTICULAR CIRCUMSTANCES. SUCH DISCOUNTS ARE AT THE DISCRETION OF THE ORGANIZATION AND WILL NOT BE COUNTED AS CHARITY CARE. PART I, LINE 7: THE COSTING METHODOLOGY USED ON FORM 990 IS BASED ON A COST-TO-CHARGE RATIO WHICH IS DEVELOPED BASED ON THE HOSPITAL'S TOTAL OPERATING EXPENSES LESS THE PROVISION FOR BAD DEBT DIVIDED BY GROSS PATIENT SERVICE REVENUE. THIS COST-TO-CHARGE RATIO IS APPLIED AGAINST VARIOUS REVENUE AND EXPENSE CATEGORIES TO COMPUTE THE ESTIMATED COMMUNITY BENEFIT EXPENSE UNDER IRS SUGGESTED COSTING METHODS FOR THE FORM 990. PART III, LINE 2: THE COSTING METHODOLOGY USED ON FORM 990 IS BASED ON A COST-TO-CHARGE RATIO, WHICH IS DEVELOPED BASED ON THE HOSPITAL'S TOTAL OPERATING EXPENSES EXCLUDING THE PROVISION FOR BAD DEBT, DIVIDED BY GROSS PATIENT SERVICE REVENUE. THIS COST-TO-CHARGE RATIO IS APPLIED AGAINST THE TOTAL CHARGES THAT ARE WRITTEN OFF DURING THE YEAR TO ESTIMATE THE COST OF CARE OF PATIENTS WHO HAVE ACCOUNTS THAT ARE DEEMED TO BE BAD DEBTS TO THE HOSPITAL. THE HOSPITAL ALSO RECOGNIZES THAT IT ALSO PROVIDES A DISCOUNT TO SELF-PAY OR UNINSURED PATIENTS. THESE AMOUNTS ARE EXCLUDED FROM GROSS PATIENT SERVICE REVENUE ON THE FINANCIAL STATEMENTS AND ARE NOT INCLUDED IN THE RATIO AS DESCRIBED ABOVE AND APPROVED BY THE IRS FOR USE ON FORM 990. IF CONSIDERED, THESE ADDITIONAL WRITE-OFF AMOUNTS TO UNINSURED ACCOUNTS WOULD ALSO INCREASE THE ESTIMATED BAD DEBT EXPENSE AMOUNT ASSOCIATED WITH THESE UNCOLLECTIBLE ACCOUNTS TO THE HOSPITAL. PART III, LINE 4: IN EVALUATING THE COLLECTABILITY OF ACCOUNTS RECEIVABLE, THE HOSPITAL ANALYZES PAST RESULTS AND IDENTIFIES TRENDS FOR EACH OF ITS MAJOR PAYOR SOURCES OF REVENUE TO ESTIMATE THE APPROPRIATE ALLOWANCE FOR UNCOLLECTIBLE ACCOUNTS AND PROVISION FOR BAD DEBTS. MANAGEMENT REGULARLY REVIEWS DATA ABOUT THESE MAJOR PAYOR SOURCES OF REVENUE IN EVALUATING THE SUFFICIENCY OF THE ALLOWANCE FOR UNCOLLECTIBLE ACCOUNTS. SPECIFICALLY, FOR RECEIVABLES ASSOCIATED WITH SERVICES PROVIDED TO PATIENTS WHO HAVE THIRD-PARTY COVERAGE, THE HOSPITAL ANALYZES CONTRACTUALLY DUE AMOUNTS AND PROVIDES AN ALLOWANCE FOR UNCOLLECTIBLE ACCOUNTS AND A PROVISION FOR BAD DEBTS FOR EXPECTED UNCOLLECTIBLE DEDUCTIBLES AND COPAYMENTS ON ACCOUNTS FOR WHICH THE THIRD-PARTY PAYOR HAS NOT YET PAID, OR FOR PAYORS AND PATIENTS WHO ARE KNOWN TO BE HAVING FINANCIAL DIFFICULTIES THAT MAKE THE REALIZATION OF AMOUNTS DUE UNLIKELY. FOR RECEIVABLES ASSOCIATED WITH SELF-PAY PATIENTS (WHICH INCLUDES BOTH PATIENTS WITHOUT INSURANCE AND PATIENTS WITH DEDUCTIBLE AND COPAYMENT BALANCES DUE FOR WHICH THIRD-PARTY COVERAGE EXISTS FOR PART OF THE BILL), THE HOSPITAL RECORDS A SIGNIFICANT PROVISION FOR BAD DEBTS IN THE PERIOD OF SERVICE ON THE BASIS OF ITS PAST EXPERIENCE, WHICH INDICATES THAT MANY PATIENTS ARE UNABLE OR UNWILLING TO PAY THE PORTION OF THEIR BILL FOR WHICH THEY ARE FINANCIALLY RESPONSIBLE. THE DIFFERENCE BETWEEN THE STANDARD RATES (OR THE DISCOUNTED RATES, IF NEGOTIATED) AND THE AMOUNTS ACTUALLY COLLECTED AFTER ALL REASONABLE COLLECTION EFFORTS HAVE BEEN EXHAUSTED IS CHARGED OFF AGAINST THE ALLOWANCE FOR UNCOLLECTIBLE ACCOUNTS. THE AUDITED FINANCIAL STATEMENTS DO NOT CONTAIN A SEPARATE FOOTNOTE REGARDING BAD DEBT EXPENSE. PART III, LINE 8: THE SHORTFALL SHOULD BE TREATED AS A COMMUNITY BENEFITS EXPENSE BECAUSEPROVIDING MEDICAL CARE AT A SHORTFALL IMPACTS THE HOSPITAL'S OPERATIONSAND GROWTH. THE CARE IS PROVIDED BECAUSE THERE IS A NEED AND A DESIRE TOPROVIDE MEDICAL CARE IN THIS COMMUNITY.THE COSTING METHOD USED ABOVE FOR IRS FORM 990 COMPLIANCE REPORTING IS ALSO BASED ON AN OVERALL AVERAGE COST-TO-CHARGE RATIO AND DOES NOT CONSIDER MEDICARE NON-ALLOWABLE EXPENSES AS IT IS BASED ON TOTAL HOSPITAL PATIENT SERVICE REVENUE (IGNORING CONTRACTUAL ADJUSTMENTS ON FEE SCHEDULE REIMBURSED ITEMS AND NON-ALLOWABLE MEDICARE EXPENSES AS NOTED ABOVE) DIVIDED BY TOTAL OPERATING EXPENSES LESS THE PROVISION FOR BAD DEBT EXPENSE. THIS RATIO IS THEN MULTIPLIED BY THE TOTAL MEDICARE SERVICES WHICH ARE REIMBURSED ON A COST METHODOLOGY EXCLUDING THE FEE SCHEDULE ITEMS LIKE PHYSICIAN SERVICES AND THE HOSPITAL WOULD SHOW A LARGE LOSS ON THESE SERVICES.WHETHER THERE IS A SHORTFALL OR SURPLUS FROM SERVICES PROVIDED TO MEDICARE BENEFICIARIES, THESE PEOPLE, WHO ARE TYPICALLY ELDERLY MEMBERS OF THE COMMUNITY, ARE AN UNDERSERVED POPULATION WHO EXPERIENCE ISSUES WITH ACCESS TO HEALTHCARE SERVICES. WITHOUT TAX-EXEMPT HOSPITALS PROVIDING MEDICARE PATIENT SERVICES, THE CENTERS FOR MEDICARE AND MEDICAID (CMS) WOULD BEAR THE BURDEN OF DIRECTLY PROVIDING SERVICES TO THE ELDERLY AND DISABLED MEMBERS OF THE COMMUNITY. PART III, LINE 9B: PROVIDENCE MEDICAL CENTER HAS A STRONG COMMITMENT TO THE COMMUNITY AND TO THE PATIENTS THAT WE SERVE. MEDICAL TREATMENT IS PROVIDED TO ALL PATIENTS REGARDLESS OF THEIR ABILITY TO PAY. IN DOING SO, WE SHALL: INFORM THE PUBLIC OF THE AVAILABILITY OF ALTERNATIVE PAYMENT ARRANGEMENTS, INCLUDING PAYMENT PLANS AND FINANCIAL ASSISTANCE PROGRAMS; PROVIDE FINANCIAL COUNSELING TO PATIENTS ABOUT THEIR HOSPITAL BILLS; RESPOND PROMPTLY TO PATIENTS' QUESTIONS ABOUT THEIR BILLS AND REQUESTS FOR FINANCIAL HELP THROUGH AN ACCEPTABLE PAYMENT PLAN AND/OR THROUGH FINANCIAL ASSISTANCE; AND PURSUE COLLECTION OF ACCOUNTS FAIRLY AND CONSISTENTLY AND WITHIN OUR WRITTEN GUIDELINES AND ENSURE THAT AGENCIES ACTING ON OUR BEHALF IN THE COLLECTION OF DEBT ALSO ACT IN ACCORDANCE WITH OUR MISSION AND GUIDELINES. PART VI, LINE 2: PMC WORKS WITH THE STATE OF NEBRASKA AND THE NEBRASKA HOSPITAL ASSOCIATION TO REVIEW PATIENT DATA AND OUTCOMES. ONE OF THE PRODUCTS USED IS COMS (CLINICAL OUTCOMES MEASUREMENT SYSTEM) WHICH GIVES OUTCOME DATA FOR MORBIDITY AND MORTALITY FOR THE STATE OF NEBRASKA AND OUR SERVICE AREA. PMC ALSO HAS WORKED WITH THE NORTHEAST NEBRASKA PUBLIC HEALTH DEPARTMENT WITH MAPP WHICH IS "MOBILIZING FOR ACTION THROUGH PLANNING AND PARTNERSHIP," WHICH IDENTIFIES PUBLIC HEALTH ISSUES AND FINDS RESOURCES TO ADDRESS THEM. PART VI, LINE 3: PAYMENT POLICIES AND FINANCIAL ASSISTANCE INSTRUCTIONS ARE GIVEN WITH ADMISSION DOCUMENTS, INCLUDED WITH EACH BILL, UPLOADED ON PMC'S WEBSITE, AND POSTED THROUGHOUT PMC'S FACILITIES. PART VI, LINE 4: THE HEALTHCARE FACILITY IS LOCATED IN WAYNE, NEBRASKA WHERE IT SERVES RESIDENTS OF NORTHEASTERN NEBRASKA. THE POPULATION BASE FROM THE NEARBY COMMUNITIES IS APPROXIMATELY 9,600 WITH AN AVERAGE INCOME OF APPROXIMATELY $45,000. PART VI, LINE 5: THE HOSPITAL HAS A COMMUNITY BOARD WITH MEMBERS THAT REPRESENT DIFFERENT TOWNS IN OUR SERVICE AREA. WE STRIVE TO INVEST OUR FUNDS IN BANKS WITHIN OUR SERVICE AREA. ALSO THE HOSPITAL'S ADMITTING PHYSICIANS ARE PRIMARILY PRACTITIONERS IN THE LOCAL AREA. PART VI, LINE 6: THE HOSPITAL IS NOT AFFILIATED WITH ANY OTHER HEALTH SYSTEMS. PART VI, LINE 7, REPORTS FILED WITH STATES NE X X 0 0 0 0 0 0 0 0 0 JAMES FRANK CEO - THRU DECEMBER 194749 0 0 0 125 0 8320 0 18434 0 221628 0 0 0 KRISTINE GIESE COO 155710 0 1000 0 1892 0 7924 0 1440 0 167966 0 0 0 KIMBERLY LUEDERS DIRECTOR OF PHARMACY 145779 0 1000 0 4001 0 6123 0 5504 0 162407 0 0 0 A THE COUNTY OF WAYNE IN THE STATE OF NEBRASKA 476006517 NONEAVAIL 2015-07-31 8400000 TO CONSTRUCT AND EQUIP HOSPITAL FACILITY 0 0 0 A 528974 8400000 264021 263936 7872043 2017 0 0 1 0 A 0 0 0 0 0 0 0 A 0 0 1 0 0 0 0 0 1 A 1 FORM 990, PART I, LINE 1, DESCRIPTION OF ORGANIZATION MISSION: WE BELIEVE THAT THE PATIENT IS THE MOST IMPORTANT PERSON IN OUR MEDICAL CENTER, THAT LIFE IS A GIFT FROM GOD, AND THAT ALL PERSONS ARE CREATED EQUAL. WE BELIEVE THAT EVERY PATIENT HAS A RIGHT TO BE ADMITTED WHEN IN NEED OF SERVICES WHICH OUR FACILITY IS EQUIPPED TO PROVIDE, PRIVACY, PROFESSIONAL DISCRETION, CONSENT TO OR REFUSAL OF TREATMENT AND MAY REQUEST THE MINISTER OF HIS/HER CHOICE. WE BELIEVE THAT OUR MEDICAL CENTER HAS THE RESPONSIBILITY TO PROVIDE ADEQUATE AND COMPETENT STAFF AND DIAGNOSTIC, PREVENTATIVE AND THERAPEUTIC FACILITIES TO ENSURE HIGH QUALITY MEDICAL CARE TO THE PATIENT, AND THAT THIS CAN ONLY BE ACHIEVED THROUGH COOPERATION AND SUPPORT AMONG THE STAFF AND COMMUNITY. WE BELIEVE THAT THE EMPLOYEES ARE ENTITLED TO JUST WAGES FOR HONEST WORK AND TO OPPORTUNITIES FOR PERSONAL AND PROFESSIONAL GROWTH. WE BELIEVE THAT OUR MEDICAL CENTER NEEDS TO PARTICIPATE ACTIVELY IN COMMUNITY PLANNING OF HEALTH AND MEDICAL CARE FACILITIES AND OPERATE IN ACCORDANCE WITH THE NEEDS OF THE CIVIC COMMUNITY. FORM 990, PART VI, SECTION B, LINE 11B THE FORM 990 IS REVIEWED AND APPROVED BY THE HOSPITAL CEO AND CFO PRIOR TO FILING. ALSO, THE FORM 990 IS DISTRIBUTED TO THE BOARD OF DIRECTORS PRIOR TO FILING. FORM 990, PART VI, SECTION B, LINE 12C PMC'S BOARD AND ADMINISTRATIVE MEMBERS ARE REQUIRED TO SIGN A NEW CONFLICT OF INTEREST STATEMENT AND DISCLOSURE ANNUALLY. ANY CONFLICTS ARE REVIEWED BY THE BOARD. AFTER EXERCISING DUE DILIGENCE, WHICH MAY INCLUDE INVESTIGATING ALTERNATIVES THAT PRESENT NO CONFLICT, THE BOARD SHALL DETERMINE WHETHER THE TRANSACTION IS IN THE ORGANIZATION'S BEST INTEREST, FOR ITS OWN BENEFIT, AND WHETHER IT IS JUST AND REASONABLE TO THE ORGANIZATION. THE TRANSACTION CAN BE APPROVED BY THE BOARD BY MAJORITY VOTE OF THOSE PRESENT AT A MEETING FOR WHICH QUORUM REQUIREMENTS HAVE BEEN MET, WITHOUT COUNTING THE VOTE OF ANY DISQUALIFIED DIRECTORS. FORM 990, PART VI, SECTION B, LINE 15 COMPENSATION PROCESS FOR OFFICERS' SALARIES AND FOR ALL EMPLOYEES ARE BASED ON THE NEBRASKA HOSPITAL ASSOCIATION'S (NHA) ANNUAL SALARY SURVEY. THE SURVEY IS CATEGORIZED BY JOB TITLES AND DETAILED BY HOURLY SALARY RANGES. NHA IS AN EXEMPT ORGANIZATION UNDER SECTION 501(C)(6) OF THE INTERNAL REVENUE CODE (TRADE ASSOCIATION), WITH ITS MEMBERS BEING THE HOSPITALS IN THE STATE OF NEBRASKA. EXECUTIVE WAGES OR SALARIES ARE NOT EVALUATED ANY DIFFERENTLY THAN OTHER EMPLOYEES. THEY RECEIVE NO PREFERENTIAL TREATMENT UNLESS THE GOVERNING BOARD MAKES A SPECIAL RECOMMENDATION. THE GUIDELINES INCLUDE: 1. A DETERMINATION OF THE FEASIBILITY OF BONUSES BASED ON AVAILABILITY OF CASH FLOW AND EXCESS REVENUE FOR THE CURRENT FISCAL YEAR, 2. DETERMINATION OF PMC'S OVERALL WAGE LEVELS BASED ON AN ANALYSIS OF WAGES AGAINST THE NHA'S SALARY SURVEY AND EMPLOYEE TIME OF SERVICE, 3. HOURLY WAGE INCREASES MAY ALSO BE GIVEN IF NEEDED TO BE COMPATIBLE OR TO COMPENSATE FOR A CHANGE IN JOB DESCRIPTIONS, AND 4. THE GOVERNING BOARD MAKES FINAL APPROVAL OF THE BUDGET WHICH WOULD INCLUDE ALL SALARIES AND BONUSES. FORM 990, PART VI, SECTION C, LINE 19 PROVIDENCE MEDICAL CENTER MAKES ITS GOVERNING DOCUMENTS, CONFLICT OF INTEREST POLICY, AND FINANCIAL STATEMENTS AVAILABLE TO THE PUBLIC UPON REQUEST AT ITS HOSPITAL BUSINESS LOCATION DURING NORMAL BUSINESS HOURS. FORM 990, PART IX, LINE 11G LABORATORY PURCHASED SERVICES: PROGRAM SERVICE EXPENSES 132,528. MANAGEMENT AND GENERAL EXPENSES 0. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 132,528. ANESTHESIA SERVICES PROFESSIONAL FEES: PROGRAM SERVICE EXPENSES 578,810. MANAGEMENT AND GENERAL EXPENSES 0. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 578,810. EMERGENCY SERVICES: PROGRAM SERVICE EXPENSES 733,696. MANAGEMENT AND GENERAL EXPENSES 0. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 733,696. HOSPICE PURCHASED SERVICES: PROGRAM SERVICE EXPENSES 47,349. MANAGEMENT AND GENERAL EXPENSES 0. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 47,349. RADIOLOGY PURCHASED SERVICES: PROGRAM SERVICE EXPENSES 75,230. MANAGEMENT AND GENERAL EXPENSES 0. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 75,230. WOUND CARE PURCHASED SERVICES: PROGRAM SERVICE EXPENSES 76,908. MANAGEMENT AND GENERAL EXPENSES 0. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 76,908. PATIENT FINANCIAL SERVICES: PROGRAM SERVICE EXPENSES 0. MANAGEMENT AND GENERAL EXPENSES 238,064. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 238,064. QUALITY ASSURANCE PURCHASED SERVICES: PROGRAM SERVICE EXPENSES 88,577. MANAGEMENT AND GENERAL EXPENSES 0. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 88,577. OTHER PROFESSIONAL FEES: PROGRAM SERVICE EXPENSES 984,118. MANAGEMENT AND GENERAL EXPENSES 88,348. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 1,072,466. FORM 990, PART XI, LINE 9: NET CHANGE IN TEMPORARILY RESTRICTED NET ASSETS OF FOUNDATION -106,696.