2025-08-14T12:31:40-05:00 2024-09-30 450250958 EIDE BAILLY LLP 18081 BURT ST STE 200 OMAHA NE 680224722 990 2023-10-01 470468078 JEFFERSON COMMUNITY HEALTH CENTER INC JEFF 4027293351 2200 H ST FAIRBURY NE 68352 CHANCE KLASEK CFO 4027293351 2025-08-14 1 1 MEGAN L KOZIOL CPA P01544037 4023302660 2025-08-13 2023 2025-03-06 01:10:19Z JEFFERSON COMMUNITY HEALTH & LIFE CHANCE KLASEK 2200 H ST FAIRBURY NE 68352 35668785 0 X HTTP://WWW.JCHEALTHANDLIFE.ORG X 1960 NE TO OPERATE AN ACUTE CARE CRITICAL ACCESS HOSPITAL IN FAIRBURY, NEBRASKA. 8 7 290 8 0 0 4444716 819603 30805464 33853758 596086 770490 190135 219655 36036401 35663506 5721 6713 0 0 18795995 19750038 0 0 27118 12707169 13591420 31508885 33348171 4527516 2315335 48660085 51704257 19681828 19226488 28978257 32477769 INSPIRING HEALTHY LIVING BY PROVIDING EXCEPTIONAL HEALTH AND LIFE SERVICES FOR EVERY PERSON, EVERY TIME. 0 0 27731320 6713 30432354 JEFFERSON COMMUNITY HEALTH & LIFE OPERATES A 17 BED CRITICAL ACCESS ACUTE CARE HOSPITAL. JEFFERSON COMMUNITY HEALTH & LIFE ALSO OPERATES A FITNESS CENTER, RURAL HEALTH CLINICS, AND PROVIDES HOME HEALTH SERVICES. 2365573 3421404 JEFFERSON COMMUNITY HEALTH & LIFE OPERATES A 40 BED LONG-TERM CARE FACILITY FOR THE RESIDENTS OF JEFFERSON COUNTY AND THE SURROUNDING AREA. 30096893 1 1 0 1 0 0 0 0 0 1 1 0 0 0 1 1 0 1 0 0 0 0 0 0 1 0 1 1 0 0 1 1 0 0 0 0 0 0 0 0 1 0 0 0 0 0 0 1 1 1 0 0 1 7 0 1 290 1 0 0 0 0 0 1 1 0 0 0 0 0 0 X 8 7 0 0 0 0 1 1 1 1 1 0 0 0 1 1 1 1 1 1 1 0 X CHANCE KLASEK 4027296856 2200 H STREET PO BOX 277 FAIRBURY NE 68352 TREVOR STEINMEYER PRESIDENT 1.00 0.00 X X 0 0 0 ROSS BOECKNER VICE PRESIDENT 1.00 1.00 X X 0 0 0 GLENDA AUSTIN SECRETARY/TREASURER 1.00 0.00 X X 0 0 0 CAROLYN SCHERBARTH BOARD MEMBER 1.00 0.00 X 0 0 0 STEVEN SNYDER BOARD MEMBER 1.00 1.00 X 0 0 0 DIANE WELLSANDT BOARD MEMBER 1.00 0.00 X 0 0 0 DALLAS CHRIST BOARD MEMBER 1.00 0.00 X 0 0 0 SARA STEWART BOARD MEMBER 1.00 0.00 X 0 0 0 DR BURKE KLINE CEO (JAN'24 - AUG '24) 40.00 1.00 X 214296 0 34663 BILL WELCH INTERIM CEO (AUG'24 - DEC'24) 40.00 1.00 X 0 0 0 CHANCE KLASEK CFO 40.00 1.00 X 165880 0 41951 CRAIG SHUMARD PHYSICIAN 40.00 0.00 X 421450 0 48400 MADHAV NARAYAN PHYSICIAN 40.00 0.00 X 322680 0 10848 SEAN FLOR PHYSICIAN 40.00 0.00 X 310356 0 34278 REBECCA STROKLUND PHYSICIAN 40.00 0.00 X 301359 0 39029 BRETT WERGIN PHYSICIAN 40.00 0.00 X 301502 0 24995 2037523 0 234164 25 0 1 0 CERNER 2800 ROCK CREEK PKWY KANSAS CITY KS 64117 ELECTRONIC HEALTH RECORD SERVICES 780284 HEARTLAND BUSINESS SYSTEMS 9140 WEST DODGE ROAD SUITE 200 OMAHA NE 68114 INFORMATION TECHNOLOGY SERVICES 377453 RURALMED MANAGEMENT RESOURCES 511 WEST AVE HOLDREGE NE 68949 REVENUE CYCLE SERVICES 253055 BRYAN HEALTH 1600 S 48TH ST LINCOLN NE 68506 MEDICAL SERVICES 251035 HIGH PLAINS ANESTHESIA SERVICES 8426 W BIRCH RD CLATONIA NE 68238 ANESTHESIA SERVICES 180000 11 15424 51537 607192 145450 5580 819603 PATIENT SERVICE REVENUE 624100 30877172 30877172 340B DRUG PRICING PROGRAM 624100 1537040 1537040 CEDARWOOD ASSISTED LIVING SVC FEE 623000 895409 895409 CEDARWOOD: EQUITY IN JT VENTURE 623000 190055 190055 354082 354082 33853758 770490 770490 2320 15424 5279 -2959 -2959 CAFETERIA 722210 222614 222614 222614 35663506 33853758 0 990145 6713 6713 530791 530791 84139 84139 15397426 14731734 640801 24891 464706 464706 2188418 2044334 142263 1821 1084558 1010105 74453 82032 32957 49075 129342 129342 3113593 2385225 728368 137136 20822 116314 1020541 912818 107317 406 554017 498675 55342 78528 66479 12049 157164 106074 51090 489241 452585 36656 2431506 2249328 182178 242036 242036 MEDICAL SUPPLIES 4429439 4429439 FOOD EXPENSE 451310 202927 248383 DUES AND SUBSCRIPTIONS 187382 69885 117497 MISCELLANEOUS EXPENSES 88153 85912 2241 33348171 30096893 3224160 27118 10871578 12078530 8600479 8925672 562966 586307 512900 681175 38682742 19841094 19615173 18841648 6520699 8770393 1348011 1532030 628279 288502 48660085 51704257 3951201 3251089 7214019 6982715 8515754 8414622 854 578062 19681828 19226488 X 28652760 32114646 325497 363123 28978257 32477769 48660085 51704257 2315335 1184177 0 X X 0 1 X 1 0 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 0 0 0 0 0 1 2799 0 0 0 2799 0 PART II-B, LINE 1: JCH&L PAID DUES TO THE NEBRASKA HOSPITAL ASSOCIATION AND THE AMERICAN HOSPITAL ASSOCIATION. A PORTION OF THE DUES WERE USED FOR LOBBYING ACTIVITIES. 50754 335309 14193 37133 363123 50754 50754 50754 50754 50754 50754 50754 50754 0.00000 0.14010 0.85990 0 0 50943 50943 28167064 13519746 14647318 9387874 6134894 3252980 1076861 186454 890407 18841648 ACCRUED INTEREST 77062 ESTIMATED THIRD-PARTY PAYOR SETTLEMENT 501000 578062 X PART V, LINE 4: THE INTENDED USE OF THE HOSPITAL'S ENDOWMENT FUNDS IS TO PROVIDE NURSING SCHOLARSHIPS AND CAPITAL IMPROVEMENTS. PART X, LINE 2: THE HEALTH CENTER ACCOUNTS FOR UNCERTAINTIES IN ACCOUNTING FOR INCOME TAX ASSETS AND LIABILITIES USING GUIDANCE INCLUDED IN FINANCIAL ACCOUNTING STANDARDS BOARD (FASB) ACCOUNTING STANDARDS CODIFICATION (ASC) 740, INCOME TAXES. THE HEALTH CENTER RECOGNIZES THE EFFECT OF INCOME TAX POSITIONS ONLY IF THOSE POSITIONS ARE MORE LIKELY THAN NOT OF BEING SUSTAINED. AT SEPTEMBER 30, 2024 AND 2023, THE HEALTH CENTER HAD NO UNCERTAIN TAX POSITIONS ACCRUED SCHEDULE D, PART V, LINE COLUMN A: PRIOR TO THE CURRENT YEAR, THE ENDOWMENT FUNDS REPORTED ON SCHEDULE D, PART V DID NOT INCLUDE TEMPORARY ENDOWMENTS. IN THE CURRENT YEAR, THE ORGANIZATION INCLUDED THE TEMPORARY ENDOWMENTS. THE CURRENT YEAR CONTRIBUTION AMOUNT REPORTED IN COLUMN A INCLUDES THE BEGINNING BALANCE OF THE TEMPORARY ENDOWMENTS. GOLF TOURNAMENT 17744 15424 2320 1440 820 1880 607 532 17744 15424 2320 1440 820 1880 607 532 5279 -2959 1 1 X 1 X 1 X 1 1 0 1 1 66000 66000 0.00200 3756040 3514094 241946 0.00730 3822040 3514094 307946 0.00930 74323 74323 0.00220 24100 24100 0.00070 8519123 5575513 2943610 0.08830 10933 10933 0.00030 8628479 5575513 3052966 0.09150 12450519 9089607 3360912 0.10080 275 275 0.00000 275 275 0.00000 1 682097 67528 10513057 10571963 -58906 X 1 1 1 1 JEFFERSON COMMUNITY HEALTH CENTER 2200 H STREET FAIRBURY NE 68352 HTTP://WWW.JCHEALTHANDLIFE.ORG 440001 X X X X JEFFERSON COMMUNITY HEALTH CENTER INC 1 0 0 1 X X X X X X X X X 21 1 0 0 1 X JCHEALTHANDLIFE.ORG/ABOUT/COMMUNITY-HEALTH-NEEDS-ASSESSMENT/ X 1 21 1 JCHEALTHANDLIFE.ORG/ABOUT/COMMUNITY-HEALTH-NEEDS-ASSESSMENT/ 0 1 X 150.000000000000 400.000000000000 X 1 1 X X X 1 X HTTPS://WWW.JCHEALTHANDLIFE.ORG/CARE-SERVICES/PATIENT-RESOURCES/ X HTTPS://WWW.JCHEALTHANDLIFE.ORG/CARE-SERVICES/PATIENT-RESOURCES/ X HTTPS://WWW.JCHEALTHANDLIFE.ORG/CARE-SERVICES/PATIENT-RESOURCES/ X X X X X X 1 X 0 X X X X 1 X 0 0 JEFFERSON COMMUNITY HEALTH CENTER, INC. PART V, SECTION B, LINE 5: JEFFERSON COMMUNITY HEALTH & LIFE BEGAN ITS FOURTH COMMUNITY HEALTH NEEDS ASSESSMENT EARLY IN 2022. JCH&L CONDUCTED FOCUS GROUPS WITH LOCAL ORGANIZATIONS, HELD A COMMUNITY STAKEHOLDERS MEETING AND REVIEWED STATISTICS MADE AVAILABLE THROUGH PUBLIC HEALTH SOLUTIONS, THE STATE OF NEBRASKA, US CENSUS, HEALTHY PEOPLE 2030, AND WEBSITES SUCH AS COUNTY HEALTH RANKINGS AND WORLD LIFE EXPECTANCY.A COMMUNITY HEALTH NEEDS ASSESSMENT STAKEHOLDERS MEETING WAS HELD AT JCH&L WITH REPRESENTATIVES FROM AREA AGENCY PARTNERS, AND FOCUS GROUP MEETINGS WERE CONDUCTED WITH LOCAL COMMUNITY ORGANIZATIONS INCLUDING KIWANIS, ROTARY, OPTIMISTS, SENIOR DINERS AND JCH&L'S DEPARTMENT MANAGERS. A TOTAL OF 84 ATTENDED AND PARTICIPATED IN DISCUSSIONS OF COMMUNITY HEALTH NEEDS. HEALTH CARE PROVIDERS WERE ASKED TO SHARE THEIR CONCERNS AND WHAT THEY SEE AS THE COMMUNITY'S GREATEST NEEDS. JEFFERSON COMMUNITY HEALTH CENTER, INC. PART V, SECTION B, LINE 11: PRIORITIZED NEEDS (AS DETERMINED BY COMMUNITY HEALTH NEEDS ASSESSMENT):1) OBESITY2) NUTRITION/SEDENTARY LIFESTYLE3) CHRONIC DISEASES AFFECTED BY OBESITY AND SEDENTARY LIFESTYLE, INCLUDING DIABETES, HEART DISEASE, STROKE, AND CANCERACTIONS TAKEN IN THIS TAX YEAR TO ADDRESS THESE NEEDS INCLUDE:1. PROMOTING HEALTHY LIFESTYLES AND PHYSICAL ACTIVITY- HOSTED KIDS COOKING CLASSES AND YOUTH SWIM EVENTS, PROMOTING HANDS-ON EDUCATION ABOUT NUTRITION AND FUN PHYSICAL ACTIVITY.- OFFERED FITNESS EDUCATION SESSIONS FOR STUDENTS AT MULTIPLE SCHOOL EVENTS, INCLUDING DILLER-ODELL, FAIRBURY PUBLIC, AND SIXTH GRADE ADVENTURE DAY.- HELD FITNESS IS FUN AND A FUN RUN IN PARTNERSHIP WITH JEFFS GONE MAD.- SPONSORED A WALKING CHALLENGE IN THE NEWLY RENOVATED FAIRBURY COMMUNITY BUILDING WITH PRIZES TIED TO THE SENIOR DINERS PROGRAM.- ADDED THE CIRCL FITNESS CLASS AT BURKLEY FITNESS CENTER AND HOSTED SENIOR HEALTH & FITNESS DAY FEATURING PRESENTATIONS ON NUTRITION AND EXERCISE.- SUPPORTED SAFE TRAVEL FOR ALL CHILDREN THROUGH OCCUPATIONAL THERAPIST TAYLOR ZIMMERMAN, HELPING FAMILIES WITH CHILDREN WHO HAVE SPECIAL MOBILITY NEEDS.- HOSTED COMMUNITY ACTIVITIES THAT ENCOURAGED MOVEMENT AND WELLNESS, SUCH AS THE REINDEER FUN WALK AND PROGRESSIVE AG SAFETY DAY, REACHING NEARLY 100 CHILDREN.2. ADDRESSING CHRONIC DISEASE EDUCATION, SCREENING, AND SUPPORT- OFFERED FREE MEDICARE PART D REVIEWS, WELCOME TO MEDICARE EDUCATION, AND DIABETES EDUCATION BY DR. BRETT WERGIN TO IMPROVE CHRONIC DISEASE MANAGEMENT AMONG SENIORS.- CONTINUED SMART MOVES PARTICIPATION AND CHRONIC CARE COORDINATION PROGRAMMING.- LAUNCHED A WOUND CARE CLINIC, A CRITICAL SERVICE FOR INDIVIDUALS WITH DIABETES AND VASCULAR CONDITIONS.- CONTINUED SUPPORT GROUPS INCLUDING ALZHEIMER'S CAREGIVER SESSIONS, EXPANDING SUPPORT FOR AGING AND CHRONICALLY ILL POPULATIONS.- HOSTED THE BRYAN MOBILE SCREENING UNIT, PROVIDING LOW-COST ACCESS TO SCREENINGS.- DISTRIBUTED GAS CARDS TO FAMILIES AFFECTED BY CANCER AND HOSTED AN EDUCATIONAL CANCER SESSION AT FAIRBURY HIGH SCHOOL.3. COMMUNITY ENGAGEMENT AND PARTNERSHIPS- MAINTAINED STRONG COMMUNITY PRESENCE THROUGH PARADES, FAIRS, PRESENTATIONS AT SENIOR DINERS, AND DONATIONS TO LOCAL YOUTH SPORTS PROGRAMS.- PARTNERED WITH FAIRBURY PUBLIC SCHOOLS ON THE HEALTHCARE HEROES LEAGUE FOR THIRD GRADERS AND CAREER DAYS TO FOSTER HEALTH EDUCATION EARLY.- PROVIDED EDUCATION ON VAPING PREVENTION, CPR, AND FIRST AID IN SCHOOLS.- SUPPORTED COMMUNITY WELL-BEING THROUGH EVENTS LIKE TRICK OR TREAT AT GARDENSIDE, CAR SHOWS, GRIEF SUPPORT GROUPS, AND BABYSITTING SAFETY CLASSES.4. ENHANCING ACCESS AND QUALITY OF CARE- EXPANDED CLINIC HOURS AND ADDED EARLY AND AFTERNOON APPOINTMENTS TO IMPROVE ACCESSIBILITY.- RECRUITED AND RETAINED PROVIDERS ACROSS SPECIALTIES INCLUDING BEHAVIORAL HEALTH, VASCULAR SURGERY, AND PAIN MANAGEMENT.- MAINTAINED 5-STAR CMS RATING AT GARDENSIDE AND EARNED MULTIPLE NATIONAL RECOGNITIONS FOR QUALITY, STROKE CARE, AND PATIENT EXPERIENCE.- RE-ACCREDITED THE SLEEP LAB, ADDED NEW DIAGNOSTIC EQUIPMENT, AND MADE FACILITY UPGRADES INCLUDING NEW PARKING, SIDEWALKS, AND ROOFTOP UNITS TO ENHANCE PATIENT CARE.THROUGH THESE INITIATIVES, JCH&L CONTINUED TO MAKE PROGRESS ON ITS 2022 CHNA PRIORITIES. THE CURRENT YEAR'S WORK DEMONSTRATED SUSTAINED COMMITMENT TO PROMOTING HEALTHIER LIFESTYLES, REDUCING CHRONIC DISEASE BURDENS, AND INCREASING ACCESS TO CARE.NEEDS JEFFERSON COMMUNITY HEALTH & LIFE WILL NOT ADDRESS:THERE WERE NEEDS IDENTIFIED THAT JCH&L DID NOT CHOOSE TO ADDRESS. WHILE THESE NEEDS ARE IMPORTANT TO THE COMMUNITY, THEY WERE NOT CHOSEN BASED ON THE PRIORITIZATION PROCESS.NEEDS WHICH WILL NOT BE ADDRESSED SPECIFICALLY BY JCH&L INCLUDE:*MENTAL HEALTH. WE WILL CONTINUE TO WORK TO BE GOOD COMMUNITY PARTNERS IN IMPROVING OUR COMMUNITY'S MENTAL HEALTH. WE CONTINUE TO OFFER A SPECIALTY CLINIC WITH GENESIS PSYCHIATRIC GROUP; WE CONTINUE TO SEEK OTHER POTENTIAL PROVIDERS WHO COULD OFFER SPECIALTY CLINICS AT OUR FACILITY; AND WE CONTINUE TO KEEP UP TO DATE ON WHAT SERVICES ARE AVAILABLE IN OUR COMMUNITY, SO OUR PROVIDERS CAN REFER AS APPROPRIATE. PRIMARY CARE IS OUR PRIME RESPONSIBILITY AND WE WILL CONTINUE TO FOCUS ON PRIMARY CARE FOR OUR AREA RESIDENTS. WE FEEL A MUCH BROADER COMMUNITY APPROACH WILL BE REQUIRED TO BE SUCCESSFUL IN IMPROVING OUR COMMUNITY'S MENTAL HEALTH STATUS.*SUBSTANCE ABUSE. WE WILL CONTINUE TO WORK TO BE GOOD COMMUNITY PARTNERS TO ALL AREA ENTITIES WORKING TO IMPROVE OUR COMMUNITY'S STATUS WITH SUBSTANCE ABUSE. THIS AREA IS ALSO NOT NAMED IN PRIORITIES BECAUSE WE BELIEVE A MUCH BROADER COMMUNITY APPROACH WILL BE REQUIRED TO BESUCCESSFUL IN IMPROVING OUR COMMUNITY'S STATUS WITH SUBSTANCE ABUSE. *SUICIDE. WE WILL CONTINUE TO WORK TO BE GOOD COMMUNITY PARTNERS TO ALL AREA ENTITIES WORKING TOWARD SUICIDE PREVENTION AND ASSISTANCE TO THOSE AFFECTED BY SUICIDE. THIS AREA IS NOT NAMED IN PRIORITIES, BECAUSE A MUCH BROADER COMMUNITY APPROACH WILL BE REQUIRED TO BE SUCCESSFUL IN REDUCING THE NUMBER OF SUICIDES.*ALZHEIMER'S DISEASE. WE WILL CONTINUE TO OFFER AN ALZHEIMER'S CAREGIVER'S SUPPORT GROUP AND WE WILL PROVIDE EDUCATIONAL RESOURCES TO OUR COMMUNITY THROUGH THE ALZHEIMER'S ASSOCIATION. THIS IS THE EXTENT OF WHAT WE FEEL OUR INVOLVEMENT CAN BE AT THIS TIME, SO WE DO NOT INTEND TO NAME THIS AS A MAJOR AREA OF ACTIVITY.*ADDITIONAL SPECIALTIES, ACCESS TO CARE, PREVENTATIVE CARE. JCH&L IS ALWAYS SEEKING POSSIBILITIES FOR ADDITIONAL SPECIALTIES, INCREASED ACCESS TO CARE AND INCREASED PREVENTATIVE CARE TO ADDRESS COMMUNITY NEEDS, AND WILL CONTINUE THIS PROCESS AS A PART OF OUR ONGOING STRATEGIC PLANNINGPROCESS. HOWEVER, IT IS NOT NAMED IN OUR PRIORITIES BECAUSE OF THE NEED FOR PERSONNEL AND RESOURCES TO ADDRESS PRIORITY AREAS, EXCEPT FOR A FEW SELECT AREAS WHICH DIRECTLY AFFECT OUR PRIORITY GOALS FOR THE NEXT THREE YEARS.*BULLYING, DENTAL HEALTH, CHRONIC PAIN. JCH&L WISHES TO BE A GOOD COMMUNITY PARTNER WITH ALL AREA AGENCIES AND PRACTICES WHICH PROVIDE SERVICES IN ALL OF THESE AREAS, WHICH ARE ALL OUTSIDE OF OUR CURRENT OFFERINGS. WE DO NOT INTEND TO NAME THESE AS PRIORITY AREAS AT THE PRESENT TIME.*ECONOMY, HOUSING. THESE ARE ONGOING SOCIETAL ISSUES WHICH AFFECT OUR BUSINESSES AND SERVICES. WE WILL CONTINUE TO BE A GOOD COMMUNITY PARTNER ON DEALING WITH THESE ISSUES IN OUR AREA, BUT WE DO NOT INTEND TO MAKE THESE AREAS OUR PRIORITY AREAS OF FOCUS.*INSURANCE/UNINSURED/UNDERINSURED. WE CONTINUE TO SEEK WAYS THAT WE AS AN ORGANIZATION CAN BEST SERVE THOSE WHO ARE UNINSURED OR UNDERINSURED, INCLUDING PROVIDING CHARITY CARE. THESE ARE NOT NAMED AS PRIORITY AREAS AT THIS TIME. JEFFERSON COMMUNITY HEALTH CENTER, INC. PART V, SECTION B, LINE 13H: SOME INDIVIDUALS OR GUARANTORS MAY BE ELIGIBLE FOR FINANCIAL ASSISTANCE IN EXCESS OF WHAT WOULD HAVE BEEN GRANTED UNDER THE INCOME CRITERIA IF THEY HAD INCURRED CATASTROPHIC MEDICAL COSTS OR OTHER OBLIGATIONS (PRESENTLY OR ONGOING) THAT HAVE SUBSTANTIALLY REDUCED THEIR ABILITY TO PAY. IN SUCH CASES THE INDIVIDUAL OR GUARANTOR MAY BE DETERMINED BY JEFFERSON COMMUNITY HEALTH & LIFE TO BE MEDICALLY INDIGENT AND MAY, AT JEFFERSON COMMUNITY HEALTH & LIFE'S DISCRETION, BE ELIGIBLE FOR FINANCIAL ASSISTANCE IN THE FORM OF FREE OR DISCOUNTED LIABILITIES. THERE ARE INSTANCES WHEN A PATIENT WILL COMPLETE THE FINANCIAL ASSISTANCE APPLICATION, PROVIDES SUPPORTING DOCUMENTATION AND DOES NOT QUALIFY FOR ASSISTANCE. IF THE PATIENT'S BALANCE EXCEEDS MORE THAN 20% OF THEIR TOTAL INCOME, THIS WILL BE DEEMED A CATASTROPHIC BALANCE. IN THESE INSTANCES, THE CHIEF FINANCIAL OFFICER WILL HAVE THE AUTHORITY TO DETERMINE IF A PORTION OF THE BALANCE SHOULD BE FORGIVEN TO FINANCIAL ASSISTANCE. THIS WILL BE HANDLED ON A CASE-BY-CASE BASIS AND THE TOTALITY OF CIRCUMSTANCES WILL BE UTILIZED IN DETERMINING ELIGIBILITY. THE DISCOUNT SHALL NOT EXCEED 20% OF OUTSTANDING BALANCES. 2 1 - GARDENSIDE 200 H STREET FAIRBURY NE 68352 LONG TERM CARE FACILITY 2 - FAIRBURY CLINIC 825 22ND STREET FAIRBURY NE 68352 RURAL HEALTH CLINIC PART I, LINE 3C: FEDERAL POVERTY GUIDELINES ARE USED TO DETERMINE ELIGIBILITY FOR PROVIDING FREE AND DISCOUNTED CARE TO LOW INCOME INDIVIDUALS. SOME INDIVIDUALS OR GUARANTORS MAY BE ELIGIBLE FOR FINANCIAL ASSISTANCE IN EXCESS OF WHAT WOULD HAVE BEEN GRANTED UNDER THE INCOME CRITERIA IF THEY HAD INCURRED CATASTROPHIC MEDICAL COSTS OR OTHER OBLIGATIONS (PRESENTLY OR ONGOING) THAT HAVE SUBSTANTIALLY REDUCED THEIR ABILITY TO PAY. IN SUCH CASES THE INDIVIDUAL OR GUARANTOR MAY BE DETERMINED BY JEFFERSON COMMUNITY HEALTH & LIFE TO BE MEDICALLY INDIGENT AND MAY, AT JEFFERSON COMMUNITY HEALTH & LIFE'S DISCRETION, BE ELIGIBLE FOR FINANCIAL ASSISTANCE IN THE FORM OF FREE OR DISCOUNTED LIABILITIES. THERE ARE INSTANCES WHEN A PATIENT WILL COMPLETE THE FINANCIAL ASSISTANCE APPLICATION, PROVIDES SUPPORTING DOCUMENTATION AND DOES NOT QUALIFY FOR ASSISTANCE. IF THE PATIENT'S BALANCE EXCEEDS MORE THAN 20% OF THEIR TOTAL INCOME, THIS WILL BE DEEMED A CATASTROPHIC BALANCE. IN THESE INSTANCES, THE CHIEF FINANCIAL OFFICER WILL HAVE THE AUTHORITY TO DETERMINE IF A PORTION OF THE BALANCE SHOULD BE FORGIVEN TO FINANCIAL ASSISTANCE. THIS WILL BE HANDLED ON A CASE-BY-CASE BASIS AND THE TOTALITY OF CIRCUMSTANCES WILL BE UTILIZED IN DETERMINING ELIGIBILITY. THE DISCOUNT SHALL NOT EXCEED 20% OF OUTSTANDING BALANCES. PART I, LINE 6A: JCH&L'S COMMUNITY BENEFIT REPORT IS PREPARED BY THE STAFF OF THE HOSPITAL. PART I, LINE 7: FINANCIAL ASSISTANCE AT COST, LINE 7A, UNREIMBURSED MEDICAID, LINE 7B, AND SUBSIDIZED HEALTH SERVICES, LINE 7G, ARE CALCULATED USING THE COSTING METHODS TO PREPARE THE COST REPORTS. COMMUNITY HEALTH IMPROVEMENT SERVICES, LINE 7E, HEALTH PROFESSIONS EDUCATION, LINE 7F, AND CASH AND IN-KIND CONTRIBUTIONS, LINE 7I, ARE REPORTED BASED ON ACTUAL EXPENSES REPORTED IN THE GENERAL LEDGER. PART I, LINE 7G: THERE ARE COSTS ATTRIBUTABLE TO A PHYSICIAN CLINIC INCLUDED ON LINE 7G. TOTAL REVENUE RECEIVED FROM MEDICARE RELATED TO PHYSICIAN CLINICS INCLUDES $121,849 WITH MEDICARE ESTIMATED COSTS OF CARE RELATING TO PAYMENTS OF $182,066. PART I, LINE 7: JCH&L REACHES OUT TO THE COMMUNITY IN A VARIETY OF WAYS INCLUDING, IN 2024:I. BENEFITS FOR THE POOR/PUBLIC PROGRAMS A. TRADITIONAL CHARITY CARE - JCH&L PROVIDED CHARITY CARE IN FISCAL 2024 FOR ALL JCH&L SERVICES TO THOSE WHO MEET THE FEDERAL POVERTY GUIDELINES. THE HOSPITAL BUSINESS OFFICE STAFF MEMBERS FILE INSURANCE CLAIMS FOR PATIENTS. PATIENTS ASSISTED: 52 VALUE: $66,000 B. IMPLICIT PRICE CONCESSIONS - BESIDES OFFICIAL CHARITY CARE, JCH&L WROTE OFF $682,097 IN IMPLICIT PRICE CONCESSIONS DURING FISCAL 2024. II. COMMUNITY BENEFIT SERVICESA. COMMUNITY HEALTH EDUCATION AND OUTREACH. - HEALTHCARE HEROES PIPELINE JEFFERSON COMMUNITY HEALTH & LIFE HAS PARTNERED WITH THE FAIRBURY PUBLIC SCHOOLS, NEBRASKA HOSPITAL ASSOCIATION AND NEBRASKA HEALTHCARE FOUNDATION TO BRING THE HEALTH CARE HEROES LEAGUE TO FAIRBURY THIRD GRADERS IN THE FALL OF FISCAL 2024. THE PROGRAM IS A COLLABORATIVE EFFORT TO PROVIDE FUN, ENGAGING, AND INNOVATIVE APPROACHES TO TEACH STUDENTS ABOUT A MULTITUDE OF DIFFERENT HEALTH CARE CAREER CHOICES. FOUR JCH&L STAFF MEMBERS WERE TRAINED FOR THE PROGRAM, AND ARE TAKING TURNS WORKING WITH A PE TEACHER IN THE SCHOOL TO OFFER THE PROGRAM. IN AUGUST AND SEPTEMBER 2024, STAFF MEMBERS RECEIVED TRAINING AND BEGAN MEETING WITH SCHOOL CLASSES ON A WEEKLY BASIS. TOTAL INDIVIDUALS REACHED: 69. ESTIMATED COST OF STAFF TIME: $1,650. - HEALTH FAIR JCH&L PROVIDES EDUCATIONAL BOOTHS, FREE HEALTH SCREENINGS, HANDOUTS, INFORMATION, ETC., AT COMMUNITY EVENTS. NO HEALTH FAIR WAS HELD IN 2024. - SPEAKERS BUREAU. JCH&L STAFF MEMBERS PROVIDE EDUCATIONAL PROGRAMS FOR COMMUNITY ORGANIZATIONS ON A VARIETY OF TOPICS. A TOTAL OF 21 PROGRAMS WERE DONE IN FISCAL 2024. TOTAL INDIVIDUALS REACHED: 1,063. ESTIMATED COST OF STAFF TIME: $1050. - SUPPORT GROUPS - ALZHEIMER'S ASSOCIATION CAREGIVERS SUPPORT GROUP RESUMED IN FISCAL 2023 AFTER BEING OFF BECAUSE OF COVID. JCH&L STAFF COORDINATE MEETINGS, OFFERING ASSISTANCE TO ANYONE INTERESTED IN MORE INFORMATION ABOUT ALZHEIMER'S AND BEING A CAREGIVER. JCH&L PROVIDES EDUCATIONAL PROGRAMS FOR THE GROUP -- INCLUDING SPEAKER'S FEES IF NEEDED, POSTAGE TO SEND OUT MEETING NOTICES, AND REFRESHMENTS. WE ALSO PROVIDE MEETING SPACE AND DRINKS FOR A GRIEF SUPPORT GROUP COORDINATED BY COTTONWOOD HOSPICE. TOTAL NUMBER REACHED: 60. APPROXIMATE COST OF STAFF TIME SPENT: $1,650. ESTIMATED COST OF POSTAGE: $200 (MEETING NOTICES) ESTIMATED OTHER COSTS (MATERIALS, SPEAKER FEES, REFRESHMENTS): $450. B. COMMUNITY-BASED CLINICAL SERVICES SCREENINGS AND ONE-TIME OR OCCASIONALLY HELD CLINICS. - COMPLETE BLOOD PROFILES IN THE FALL OF 2021, JCH&L BEGAN OFFERING WELLNESS WEDNESDAYS AND FASTING FRIDAYS, OFFERING PATIENT-REQUESTED BLOOD SCREENINGS FOR THOSE WITH HIGH DEDUCTIBLES OR WHO WOULD LIKE RESULTS MORE OFTEN THAN THEY CAN GET THEM THROUGH INSURANCE COVERAGE. THIS WAS TO TAKE THE PLACE OF COMPLETE BLOOD PROFILES PREVIOUSLY OFFERED TO OUR COMMUNITY AT A REDUCED RATE EACH SPRING. SEVERAL TYPES OF SCREENINGS ARE OFFERED WEEKLY AT A REDUCED RATE. DURING THE FISCAL YEAR WE DID 563 SCREENINGS, AND BROUGHT IN $10,250 IN PAYMENTS FOR THE SERVICE. WHEN COMPARED AGAINST TYPICAL CHARGES THE TOTAL COMMUNITY BENEFIT WAS MORE THAN $44,000. ESTIMATED NUMBER REACHED: 563 VALUE OF ESTIMATED STAFF TIME: $22,201.79. ESTIMATED VALUE OF COMMUNITY BENEFIT: $44,821. - IMMUNIZATION CLINICS. JCH&L COOPERATES WITH BLUE VALLEY COMMUNITY ACTION IN PROVIDING IMMUNIZATION CLINIC FOR CHILDREN TWICE EACH MONTH. JCHC PROVIDES SPACE WHERE IMMUNIZATIONS ARE DONE, NURSING STAFF, THE PATIENT WAITING AREAS, AND JANITORIAL AND SUPPORT SERVICES. NUMBER OF PATIENTS SERVED: 164. TOTAL OF 413 VACCINATIONS PROVIDED. ESTIMATED COST OF NURSES PROVIDED BY JCH&L TO GIVE SHOTS: $2,300.III. MEDICAL EDUCATION A. SCHOLARSHIP FUNDING FOR HEALTH PROFESSIONS. - PHYSICIAN/MEDICAL STUDENTS, NURSES/NURSING STUDENTS, TECHNICIANS AND OTHER HEALTH PROFESSIONALS. MEDICAL STUDENTS COME REGULARLY FOR RURAL ROTATIONS TO LEARN FROM LOCAL PHYSICIANS. JCH&L PROVIDES AN APARTMENT FOR THE MEDICAL STUDENTS TO STAY IN DURING THEIR TIME IN FAIRBURY, AND ALSO PROVIDES THEM USE OF OUR FITNESS CENTER DURING THEIR STAY. A TOTAL OF 7 PHYSICIAN STUDENTS, 5 PA STUDENTS, 3 NURSE PRACTITIONER STUDENTS, AND 1 PHARMACY STUDENT LEARNED AT OUR FACILITY IN FISCAL 2024. JCH&L IS A PARTNER IN OFFERING THE LILLIAN HANSEN REESMAN RN MEMORIAL NURSES SCHOLARSHIP FUND. SCHOLARSHIPS ARE OFFERED FROM THIS FUND, ESTABLISHED IN 1980. ONLY INTEREST IS USED FROM THIS $10,000 PERPETUAL FUND, DONATED BY THE REESMAN FAMILY, TO PROVIDE NURSING SCHOLARSHIPS. SCHOLARSHIPS ARE PROVIDED AS INTEREST FUNDS ARE AVAILABLE. ONE $500 SCHOLARSHIP WAS AWARDED IN FISCAL 2024. THE JCH&L AUXILIARY PROVIDES A SCHOLARSHIP FOR STUDENTS PURSUING AN EDUCATION IN MEDICAL FIELDS. THE $400 SCHOLARSHIP IS GIVEN FROM THE AUXILIARY'S FUNDS, AND THE NUMBER OF SCHOLARSHIPS GIVEN EACH YEAR IS BASED ON THE AUXILIARY'S FUNDING AVAILABILITY AND THE NUMBER OF REQUESTS. ONE SCHOLARSHIP WAS AWARDED IN 2024. ESTIMATED NUMBER REACHED: 16. JCH&L COST (APARTMENT RENT, STAFF TIME, ETC.): $20,000. B. OTHER - JOB SHADOWING. JCH&L TYPICALLY HOSTS JOB SHADOW STUDENTS THROUGH FAIRBURY HIGH SCHOOL'S ANATOMY AND PHYSIOLOGY CLASS, THROUGH THE SOUTHEAST COMMUNITY COLLEGE-FAIRBURY HIGH SCHOOL CAREER ACADEMY PROGRAM, AND FOR INTERESTED INDIVIDUALS. NUMBER REACHED: 41. ESTIMATED COST OF STAFF TIME: $4,100.IV. SUBDIZED HEALTH SERVICES - WELLNESS CENTER SUPPORT. JEFFERSON COMMUNITY HEALTH & LIFE HAS OPERATED THE BURKLEY FITNESS CENTER AS A COMMUNITY FITNESS/WELLNESS CENTER SINCE IT OPENED IN 1996. JCH&L PAYS THE WELLNESS CENTER'S OPERATING EXPENSES THAT EXCEED REVENUES. BECAUSE OF THE HEALTH CENTER'S SUPPORT OF THE FITNESS CENTER'S CASH FLOW, PRICES FOR MEMBERSHIPS AND SERVICES CAN REMAIN REASONABLE FOR COMMUNITY RESIDENTS. IF THE FITNESS CENTER WERE A STAND-ALONE OPERATION, PRICES WOULD HAVE TO RISE CONSIDERABLY TO PAY ALL EXPENSES. TOTAL VISITS FOR FISCAL 2024: 54,045. ESTIMATED AMOUNT OF WELLNESS CENTER SUPPORT: $49,156. - HOME HEALTH SUPPORT. JEFFERSON COMMUNITY HEALTH & LIFE HAS OPERATED A HOME HEALTH AGENCY SINCE 1984. JCH&L PAYS THE AGENCY'S OPERATING EXPENSES THAT EXCEED REVENUES. THE HEALTH CENTER'S SUPPORT MAKES IT POSSIBLE FOR THE HOME HEALTH AGENCY TO CONTINUE TO PROVIDE SKILLED CARE IN THE HOMES OF AREA RESIDENTS. INCOME: $189,237. EXPENSES: $506,157. NET LOSS: $316,920. - GARDENSIDE LONG-TERM CARE. JEFFERSON COMMUNITY HEALTH & LIFE HAS OPERATED GARDENSIDE LONG-TERM CARE SINCE OPENING IN 1963. GARDENSIDE PROVIDES A HOME (SHORT-TERM FOR SKILLED CARE OR LONG-TERM FOR THOSE UNABLE TO LIVE IN THEIR OWN HOME INDEPENDENTLY) FOR UP TO 40 INDIVIDUALS. MOST ARE FROM THIS AREA AND HAVING A LONG-TERM CARE FACILITY NEAR THEIR HOMES AND FAMILIES IS A GREAT BENEFIT TO OUR RESIDENTS, AS WELL AS TO THEIR FAMILIES. INCOME: $ 3,383,759. EXPENSES: $4,245,233. NET LOSS: $ 861,474.V. RESEARCH. NO RESEARCH DOLLARS EXPENDED.VI. CASH AND IN-KIND DONATIONS.A. CASH DONATIONS. JCH&L MAKES DONATIONS TO VARIOUS CHARITABLE CAUSES, INCLUDING GIRL SCOUTS, SOFTBALL, BASEBALL AND CHURCH CAMP FIRST AID KITS; SPONSORSHIP OF BASEBALL AND SOFTBALL TEAMS; GOLF TOURNAMENTS, AREA HIGH SCHOOL POST PROM ACTIVITIES; AREA COMMUNITY CELEBRATIONS; CHAMBER OF COMMERCE BANQUET, CHAMBER OF COMMERCE NEW TEACHER WELCOME, CHAMBER OF COMMERCE TEACHER RECOGNITION; AND DONATIONS TO TEAMMATES, LIGHT IT UP BLUE, FIVE STAR BIBLE CAMP; STATEBOUND ATHLETES FROM JEFFERSON COUNTY SCHOOLS; BONHAM THEATRE; ROTARY FUND-RAISERS; KGMT-KUTT ANNUAL THANKSGIVING MEAL; BLUE VALLEY COMMUNITY ACTION; BLUE RIVERS AREA AGENCY ON AGING; AND AREA SCHOOLS' WRESTLING PROGRAMS. THESE TOTALED $6,383. JCH&L ALSO CONTRIBUTES ITEMS -- SUCH AS FITNESS CENTER PASSES, JCH&L ITEMS, ETC., TO COMMUNITY EVENTS AS DOOR PRIZES. THESE TOTALED AN ESTIMATED $1,000. DONATIONS DURING FISCAL 2024 TOTALED $7,383. B. IN-KIND DONATIONS. - BLOOD DRIVE SUPPORT JCH&L ASSISTS NEBRASKA COMMUNITY BLOOD BANK BY SCHEDULING APPOINTMENTS FOR SIX BLOOD DRIVES EACH YEAR. THE BLOOD PRODUCTS ULTIMATELY HELP OUR COMMUNITY, AS NEBRASKA COMMUNITY BLOOD BANK IS JCH&L'S SUPPLIER OF BLOOD AND BLOOD PRODUCTS. ESTIMATED STAFF TIME: $500. - SAFETY DAY FOR KIDS. JCHL IS ONE OF THE COSPONSORS OF THE ANNUAL SAFETY DAY FOR KIDS IN JEFFERSON COUNTY. A TOTAL OF 98 KIDS -- AGES KINDERGARTEN THROUGH SIXTH GRADES ATTENDED THE AUGUST 2024 EVENT. STAFF MEMBERS ASSISTED IN PLANNING THE EVENT AND ASSISTED IN COORDINATING AND INSTRUCTING ON THE DAY OF THE CAMP. THE COST OF STAFF TIME DONATED IS ESTIMATED AT: $2,550. TOTAL COST OF SUPPLIES FURNISHED WAS $500. PART II, COMMUNITY BUILDING ACTIVITIES: ECONOMIC DEVELOPMENT. JEFFERSON COMMUNITY HEALTH & LIFE IS ACTIVE IN LOCAL ECONOMIC DEVELOPMENT ACTIVITIES. JCH&L IS A MEMBER OF THE FAIRBURY CHAMBER OF COMMERCE. WE SEEK OPPORTUNITIES TO OFFER TOURS, HEALTH CARE INFORMATION ON COMMUNITY WEBSITES, ETC. COST OF CHAMBER MEMBERSHIP: $275. IN ADDITION TO THESE DIRECT PROGRAMS AND SERVICES, THE EMPLOYEES OF JEFFERSON COMMUNITY HEALTH & LIFE SERVE THEIR COMMUNITY IN MANY WAYS INCLUDING SERVING IN THEIR CHURCHES, AS GIRL AND BOY SCOUT LEADERS, 4-H LEADERS, AS LEADERS IN CIVIC ORGANIZATIONS, AS YOUTH GROUP LEADERS, AS CITY GOVERNMENT MEMBERS, ON COMMUNITY DEVELOPMENT BOARDS, FOR EMERGENCY RESPONSE ORGANIZATIONS, AND OTHERS. JCH&L STAFF MEMBERS ARE A RESOURCE AS COMMUNITY ROLE MODELS.JCH&L IS PROUD OF ITS CONTRIBUTIONS TO THE CITIZENS OF JEFFERSON COUNTY AND THE SURROUNDING AREA. THE CITIZENS OF THIS AREA ALSO HIGHLY REGARD JCH&L'S CONTRIBUTIONS TO THE COMMUNITY.THE GOAL OF THE JCH&L BOARD OF DIRECTORS, ADMINISTRATION AND STAFF IS TO EXPAND THAT PARTNERSHIP WITH AREA RESIDENTS AND FIND MORE WAYS TO SERVE AS A RESOURCE FOR HEALTH AND WELLNESS INFORMATION. PART III, LINE 2: THE AMOUNT ON LINE 2 REPRESENTS IMPLICIT PRICE CONCESSIONS. THE ORGANIZATION DETERMINES ITS ESTIMATE OF IMPLICIT PRICE CONCESSION BASED ON ITS HISTORICAL COLLECTION EXPERIENCE WITH THIS CLASS OF PATIENTS. PART III, LINE 3: THE ESTIMATED AMOUNT OF THE ORGANIZATION'S IMPLICIT PRICE CONCESSIONS ATTRIBUTABLE TO PATIENTS ELIGIBLE UNDER THE ORGANIZATION'S CHARITY CARE POLICY IS CALCULATED BASED ON AN APPROXIMATE 9.9% OF INDIVIDUALS LIVING BELOW THE POVERTY LEVEL IN THE SERVICE AREA. PART III, LINE 4: THE FOOTNOTE TO THE ORGANIZATION'S FINANCIAL STATEMENTS THAT DESCRIBES IMPLICIT PRICE CONCESSIONS IS LOCATED IN FOOTNOTE 1 ON PAGES 12 AND 13 OF THE ATTACHED FINANCIAL STATEMENTS. PART III, LINE 8: THE ENTIRE MEDICARE SHORTFALL IS CONSIDERED A COMMUNITY BENEFIT. SERVICES ARE PROVIDED TO PATIENTS UNDER THE MEDICARE PROGRAM EVEN THOUGH THE HOSPITAL KNOWS THEY WILL NOT RECOVER ALL OF THE COSTS FROM PROVIDING THE SERVICES. THIS PROGRAM IS CONSIDERED SUBSIDIZED BY THE HOSPITAL AND OTHER PAYORS. PATIENTS RELY ON THESE SERVICES FOR THEIR HEALTH AND WELL-BEING AND ARE ESSENTIAL FOR THEIR ACCESS TO HEALTHCARE. TOTAL REVENUE RECEIVED FROM MEDICARE IS THE GROSS REIMBURSEMENT PLUS SETTLEMENT. BOTH TOTAL REVENUE RECEIVED FROM MEDICARE AND THE MEDICARE ALLOWABLE COSTS ARE REPORTED FROM THE MEDICARE COST REPORT. THE MEDICARE COST REPORT IS COMPLETED BASED ON THE RULES AND REGULATIONS SET FORTH BY CENTERS FOR MEDICARE AND MEDICAID SERVICES. PART III, LINE 9B: IF A PATIENT IS GRANTED FINANCIAL ASSISTANCE THAT IS FREE CARE, THE WRITTEN NOTICE TO THE PATIENT SHALL SO STATE AND REASONABLE MEASURES SHALL BE TAKEN TO ENSURE THAT ALL ECAS ARE REVERSED. IN ADDITION, ANY AMOUNTS PAID BY THE PATIENT IN EXCESS OF $5 SHALL BE REFUNDED. IF THE PATIENT IS GRANTED FINANCIAL ASSISTANCE THAT IS OTHER THAN FREE CARE,JCH&L WILL:1. PROVIDE THE PATIENT WITH A REVISED BILL SETTING FORTH: (I) THE AMOUNT THE PATIENT OWES FOR CARE PROVIDED AFTER FINANCIAL ASSISTANCE, (II) HOW THE REVISED AMOUNT WAS DETERMINED; AND (III) EITHER THE AGB FOR THE CARE PROVIDED OR INSTRUCTIONS ON HOW THE PATIENT CAN OBTAIN INFORMATION REGARDING THE AGB FOR THE CARE PROVIDED;2. PROVIDE THE PATIENT WITH A REFUND FOR ANY AMOUNT THE PATIENT HAS PAID IN EXCESS OF THE AMOUNT OWED TO JCH&L(UNLESS SUCH AMOUNT IS LESS THAN $5); AND3. TAKE REASONABLE MEASURES TO REVERSE ANY ECAS TAKEN AGAINST THE PATIENT. PART VI, LINE 2: JCH&L ASSESSES THE HEALTH CARE NEEDS OF THE COMMUNITY JCH&L SERVES IN SEVERAL WAYS. JCH&L UTILIZES SURVEYS BY PUBLIC HEALTH SOLUTIONS OF THE HEALTH CARE NEEDS FOR RESIDENTS OF JEFFERSON COUNTY AND THE SURROUNDING COMMUNITY. JCH&L VISITS LOCAL COMMUNITY SERVICE ORGANIZATIONS AND SEEKS INPUT ON NEEDS. JCH&L REVIEWS SURVEYS DONE BY THE STATE AND OTHER ORGANIZATIONS ON THE HEALTH CARE NEEDS FOR RESIDENTS OF JEFFERSON COUNTY AND THE SURROUNDING AREA. PART VI, LINE 3: JCH&L INFORMS AND EDUCATES PATIENTS ABOUT ELIGIBILITY FOR ASSISTANCE ON AN INDIVIDUAL BASIS WHEN QUESTIONS ARISE. THE PATIENT BOOKLET PROVIDES BUSINESS OFFICE CONTACT INFORMATION FOR PATIENT QUESTIONS ABOUT THEIR BILL. THE SELF-PAY BILLING VENDOR ENGAGED BY JCH&L HAS A SET OF CRITERIA IT USES TO ASSESS WHETHER A PATIENT IS ELIGIBLE FOR ASSISTANCE PROGRAMS, OR IF THEY QUALIFY FOR JCH&L'S CHARITY CARE PROGRAM. PART VI, LINE 4: JCH&L SERVES JEFFERSON COUNTY AND PARTS OF THAYER, FILLMORE, SALINE AND GAGE COUNTIES, ALL IN NEBRASKA; AND PARTS OF WASHINGTON AND MARSHALL COUNTIES IN KANSAS. THE POPULATION OF THE SERVICE AREA IS ESTIMATED AT ABOUT 18,000. REVENUE FROM MEDICARE PATIENTS AVERAGES APPROXIMATELY 50%, AND REVENUE FROM MEDICAID CLIENTS AVERAGES APPROXIMATELY 10%. PART VI, LINE 5: JCH&L OPERATES IN JEFFERSON COUNTY WITH A COMMUNITY BOARD AND OPEN MEDICAL STAFF. ALL SURPLUS FUNDS ARE REINVESTED BACK INTO THE FACILITY THROUGH BUILDING CONSTRUCTION, EQUIPMENT PURCHASES, OR COMMUNITY PROGRAMS PROVIDED. JCH&L PROMOTES THE HEALTH OF THE COMMUNITY BY OFFERING A COMMUNITY FITNESS CENTER AT A REASONABLE RATE AND OFFERING SCHOLARSHIPS FOR THE COMMUNITY'S YOUTH WHO HAVE FINANCIAL NEED. THE NET COMMUNITY BENEFIT REPORTED IN PART I RELATING TO THE FITNESS CENTER WAS APPROXIMATELY $143,000. JCH&L PROMOTES THE HEALTH OF THE COMMUNITY BY PROMOTING COMMUNITY-WIDE PROGRAMS SUCH AS LIVE HEALTHY NEBRASKA AND STEP-2-IT (PROGRAMS WHICH ENCOURAGE INCREASING ACTIVITY AND LOSING WEIGHT.) JCH&L IS ALSO INVOLVED IN PROGRESSIVE AG SAFETY DAY AND WORKING WITH BLUE VALLEY COMMUNITY ACTION TO OFFER IMMUNIZATIONS TO AREA CHILDREN. JCH&L PROMOTES THE HEALTH OF THE COMMUNITY BY OFFERING PROGRAMS, TOURS, SPEAKERS, AND EDUCATION, INCLUDING SUPPORT GROUPS, EDUCATIONAL PROGRAMS AND PROGRAMS FOR LOCAL ORGANIZATIONS. PART VI, LINE 6: JCH&L IS NOT PART OF AN AFFILIATED HEALTH CARE SYSTEM BUT DOES WORK TO BE A LEADER IN PROMOTING THE HEALTH OF THE COMMUNITIES IT SERVES. JCH&L PARTNERS WITH MANY OTHER AREA ORGANIZATIONS, INCLUDING PUBLIC HEALTH SOLUTIONS, FARM SAFETY 4 JUST KIDS, NEBRASKA SAFE KIDS, JEFFERSON COUNTY EXTENSION, BLUE VALLEY COMMUNITY ACTION, FAIRBURY CHAMBER OF COMMERCE, FAIRBURY PUBLIC SCHOOLS, NEBRASKA COMMUNITY BLOOD BANK, RURAL COMPREHENSIVE CARE NETWORK, BLUE RIVER VALLEY NETWORK, HEARTLAND HEALTH ALLIANCE, AND OTHERS. DEPENDING ON THE ACTIVITY, JCH&L MAY BE THE LEAD ORGANIZATION, OR AN ORGANIZATION PROVIDING HELP AND ASSISTANCE. X X X X X 1 0 0 1 0 0 0 0 0 CRAIG SHUMARD PHYSICIAN 299558 0 121892 0 0 0 24263 0 24137 0 469850 0 0 0 SEAN FLOR PHYSICIAN 270746 0 39610 0 0 0 20720 0 13558 0 344634 0 0 0 REBECCA STROKLUND PHYSICIAN 274801 0 26558 0 0 0 7911 0 31118 0 340388 0 0 0 MADHAV NARAYAN PHYSICIAN 271780 0 50900 0 0 0 720 0 10128 0 333528 0 0 0 BRETT WERGIN PHYSICIAN 272789 0 28713 0 0 0 11275 0 13720 0 326497 0 0 0 DR BURKE KLINE CEO (JAN'24 - AUG '24) 213130 0 1166 0 0 0 5655 0 29008 0 248959 0 0 0 CHANCE KLASEK CFO 165230 0 650 0 0 0 9609 0 32342 0 207831 0 0 0 PART I, LINE 4A DURING THE YEAR, A SEVERANCE PAYMENT WAS MADE TO BURKE N. KLINE, A FORMER EMPLOYEE OF THE ORGANIZATION. UNDER A SEPARATION AGREEMENT AND RELEASE, THE ORGANIZATION AGREED TO PAY SEVERANCE COMPENSATION IN THE TOTAL GROSS AMOUNT OF $123,760, EQUIVALENT TO 26 WEEKS OF BASE SALARY, FOLLOWING HIS SEPARATION FROM EMPLOYMENT. IN ADDITION, IF THE EMPLOYEE ELECTED COBRA CONTINUATION COVERAGE, THE EMPLOYER AGREED TO CONTRIBUTE TO HEALTH INSURANCE PREMIUMS AT THE SAME LEVEL AS EXISTING EMPLOYEES THROUGH DECEMBER 2024. THE SEVERANCE PAYMENT WAS MADE IN ACCORDANCE WITH THE TERMS OUTLINED IN THE AGREEMENT AND WAS SUBJECT TO STANDARD PAYROLL DEDUCTIONS. THE AGREEMENT INCLUDED CONFIDENTIALITY, NON-DISPARAGEMENT, AND RELEASE OF CLAIMS PROVISIONS. PART I, LINE 5 THE ORGANIZATION PROVIDES INCENTIVE COMPENSATION TO CERTAIN EMPLOYED PHYSICIANS AND ADVANCED PRACTICE PROVIDERS BASED ON INDIVIDUAL PRODUCTIVITY AS MEASURED BY WORK RELATIVE VALUE UNITS (WRVUS). PROVIDERS RECEIVE A BASE SALARY AND ARE ELIGIBLE FOR ADDITIONAL INCENTIVE COMPENSATION FOR WRVUS PERFORMED IN EXCESS OF AN ESTABLISHED THRESHOLD. THE INCENTIVE COMPENSATION IS CALCULATED QUARTERLY AT A FIXED WRVU CONVERSION FACTOR AND RECONCILED AGAINST A BI-WEEKLY DRAW SYSTEM. THIS INCENTIVE STRUCTURE IS BASED ON INDIVIDUAL PHYSICIAN PRODUCTIVITY AND NOT DIRECTLY ON THE OVERALL REVENUES OF THE ORGANIZATION OR ANY RELATED ENTITY. A HOSPITAL AUTHORITY NO 1 OF JEFFERSON COUNTY NE 611683496 2021-12-18 8291780 RENOVATE FACILITY & REF BOND ISSUE (12/18/12) 0 0 0 A 1218164 8291780 4024791 4266989 2022 1 0 1 1 A 0 0 0 0 0.00000 0.00000 0.00000 0 0 0 A 0 0 0 1 1 0 0 0 1 A 1 DATE THE REBATE COMPUTATION WAS PERFORMED: 03/31/2022 NOTE REGARDING THE REBATE COMPUTATION: SINCE THE BOND PROCEEDS HAVE BEEN SPENT AND THE DEBT SERVICE FUND WAS OPERATED ON A BONA FIDE BASIS, NO FURTHER REBATE CALCULATIONS ARE NECESSARY. PATRICIA SNYDER EMPLOYEE OF THE HOSPITAL AND SPOUSE OF STEVEN SNYDER, BOARD OF DIRECTOR 84139 EMPLOYEE COMPENSATION 0 FORM 990, PART VI, SECTION A, LINE 1A THE EXECUTIVE COMMITTEE, COMPRISED OF THE BOARD PRESIDENT, VICE PRESIDENT, SECRETARY/TREASURER AND ONE OTHER APPOINTED MEMBER OF THE BOARD, HAS THE AUTHORITY TO ACT ON BEHALF OF THE GOVERNING BODY. FORM 990, PART VI, SECTION A, LINE 6 JEFFERSON COMMUNITY HEALTH & LIFE HAS MEMBERS. ANY PERSON, CORPORATION OR OTHER ENTITY MAY BECOME A LIFETIME MEMBER IF A CONTRIBUTION OF $100 OR MORE IS MADE TO THE CORPORATION. FORM 990, PART VI, SECTION A, LINE 7A VACANCIES, OCCURRING ON THE BOARD BY EXPIRATION, SHALL BE FILLED THROUGH ELECTION BY THE MEMBERS AT THE ANNUAL MEETING OF THE MEMBERS. THE BOARD DEVELOPMENT COMMITTEE SHALL SUBMIT A SLATE OF PROSPECTIVE CANDIDATES TO THE BOARD OF DIRECTORS AT THEIR MEETING PRIOR TO THE ANNUAL MEETING WHICH WILL THEN BE PRESENTED AT THE ANNUAL MEETING FOR CONSIDERATION FOR ELECTION TO THE BOARD. IN ADDITION, MEMBERS OF THE CORPORATION MAY MAKE NOMINATIONS FROM THE FLOOR. FORM 990, PART VI, SECTION A, LINE 7B EACH MEMBER SHALL BE ENTITLED TO ONE VOTE ON EACH MATTER SUBMITTED TO THE VOTE OF THE MEMBERS. FORM 990, PART VI, SECTION B, LINE 11B THE BOARD WILL REVIEW THE FORM 990 AT A REGULARLY SCHEDULED BOARD MEETING, WHICH DOES NOT NECESSARILY OCCUR PRIOR TO THE FILING OF FORM 990. FORM 990 IS REVIEWED BY MR. CHANCE KLASEK, CFO, PRIOR TO FILING. FORM 990, PART VI, SECTION B, LINE 12C BOARD MEMBERS ARE REQUIRED, BY THE ARTICLES AND BYLAWS, TO REVIEW THE CONFLICT OF INTEREST POLICY ANNUALLY. A BOARD MEMBER WITH A CONFLICT OF INTEREST IS REQUIRED TO ABSTAIN FROM VOTING ON ANY MOTION FOR WHICH HE HAS A CONFLICT OF INTEREST. BOARD MEMBERS ARE WELL ACQUAINTED WITH EACH OTHER AND WOULD BE AWARE OF ANY PERSONAL CONFLICTS OF INTEREST. FORM 990, PART VI, SECTION B, LINE 15 THE HOSPITAL PARTICIPATES IN THE NEBRASKA COMPDATA SALARY SURVEYS FOR ALL POSITIONS. THE CEO SURVEY DATA IS GIVEN TO THE BOARD TO REVIEW, AND THE BOARD APPROVES THE CEO'S SALARY ON AN ANNUAL BASIS. OTHER OFFICER COMPENSATION IS REVIEWED AND APPROVED BY THE CEO AND HR DIRECTOR. THE BOARD OF DIRECTORS REVIEWS COMPENSATION RANGES PROPOSED BY OR THROUGH THE CEO FOR JCH&L'S OFFICERS AND KEY EMPLOYEES AND DETERMINES THAT SUCH COMPENSATION RANGES ARE REASONABLE AND CONSISTENT WITH FAIR MARKET VALUE. FORM 990, PART VI, SECTION C, LINE 19 THE ORGANIZATION'S GOVERNING DOCUMENTS, CONFLICT OF INTEREST POLICY AND FINANCIAL STATEMENTS ARE AVAILABLE TO THE PUBLIC UPON REQUEST. FORM 990, PAGE 11, PART XI, LINE 2C: THE FINANCE COMMITTEE OF THE BOARD OF DIRECTORS SELECTS THE INDEPENDENT ACCOUNTANT AND HAS THE RESPONSIBILITY FOR OVERSIGHT OF THE AUDIT. UPON CONCLUSION OF THE AUDIT, THE AUDITING FIRM PRESENTS THE RESULTS AND FINDINGS TO THE FINANCE COMMITTEE. THERE HAVE BEEN NO CHANGES TO THIS PROCESS FROM THE PRIOR YEAR. JCHC REAL ESTATE INC 2200 H STREET FAIRBURY NE 68352 881755265 REAL ESTATE HOLDINGS NE 501(C)(3) LINE 12C, III-FI JEFFERSON COMMUNITY HEALTH CENTER INC 1 0 0 1 0 0 0 0 0 0 0 0 0 0 1 1 0 0 0 0 JCHC REAL ESTATE INC C 51537 FAIR MARKET VALUE