2020-10-13T18:54:58-05:00 2019-12-31 420714325 RSM US LLP 4650 E 53RD ST DAVENPORT IA 528073479 990 2019-01-01 420842204 PELLA REGIONAL HEALTH CENTER PELL 6416283150 404 JEFFERSON STREET PELLA IA 50219 ROBERT KROESE CHIEF EXECUTIVE OFFICER 6416283150 2020-10-07 1 JENIFER L CHASE P01306883 5638884000 2020-10-07 173.20.82.182 2020-10-07 14:39:38 CD P DA39A3EE5E6B4B0D3255BFEF95601890AFD80709 9D8C4631151EF1E1BB3DDB3444689A82E6B5C400 2019 2021-01-29 14:40:06Z ROBERT KROESE 404 JEFFERSON STREET PELLA IA 50219 117780071 0 X HTTPS://WWW.PELLAHEALTH.ORG X 1958 IA TO PROVIDE HEALTHCARE AND HEALING SERVICES WITH CHRISTIAN COMPASSION. 12 8 941 198 45025 0 69724 921184 85394150 90821165 3819561 2843893 9189184 11105576 98472619 105691818 6840 4598 0 0 54266997 55988454 0 0 0 42212255 44380589 96486092 100373641 1986527 5318177 143578323 155992830 51489157 50907871 92089166 105084959 X THE MISSION OF PELLA REGIONAL HEALTH CENTER IS TO PROVIDE HEALTHCARE AND HEALING SERVICES WITH CHRISTIAN COMPASSION. 0 0 85454160 4598 101730877 PELLA REGIONAL HEALTH CENTER (PRHC) IS A 25-BED ACUTE CARE HOSPITAL LOCATED IN PELLA, IOWA. THE HEALTH CENTER ALSO OPERATES CLINICS IN PELLA, SULLY, KNOXVILLE, PRAIRIE CITY, BUSSEY, AND OTTUMWA, IOWA. ANNUALLY, THE HEALTH CENTER HAS OVER 1,400 ADMISSIONS, OVER 600 LIVE BIRTHS, OVER 9,100 EMERGENCY RELATED VISITS, AND PERFORMS OVER 6,100 SURGERIES.PRHC PROVIDES CARE TO PATIENTS WHO MEET CERTAIN CRITERIA UNDER ITS CHARITY CARE POLICY WITHOUT CHARGE OR AT AMOUNTS LESS THAN ESTABLISHED RATES. BECAUSE PRHC DOES NOT PURSUE COLLECTION OF AMOUNTS DETERMINED AS CHARITY CARE, THEY ARE NOT REPORTED AS REVENUE. THE AMOUNT OF CHARGES FOREGONE FOR SERVICES PROVIDED UNDER PRHC'S CHARITY CARE POLICY WAS APPROXIMATELY $823,000 FOR THE YEAR; ENDED DECEMBER 31, 2019. TOTAL DIRECT AND INDIRECT COSTS RELATED TO THESE FORGONE CHARGES WERE $436,000 AT DECEMBER 31, 2019, BASED ON AN AVERAGE RATIO OF COST TO GROSS CHARGES.THE 340B PROGRAM OFFERS ELIGIBLE HEALTH CARE PROVIDERS ACCESS TO LOW-COST MEDICATIONS, WHICH ALLOWS THEM TO EXPAND THE TYPE AND VOLUME OF CARE THEY PROVIDE TO THE MOST VULNERABLE PATIENT POPULATIONS. THE 340B PROGRAM REQUIRES DRUG MANUFACTURERS TO PROVIDE THE OUTPATIENT DRUGS TO ELIGIBLE HEALTH CARE ORGANIZATIONS OR COVERED ENTITIES AT SIGNIFICANTLY REDUCED PRICES. PRHC IS AN ELIGIBLE HEALTH CARE ORGANIZATION AND IS PARTICIPATING IN THE PROGRAM. THE REVENUE GENERATED FROM THE CONTRACTED PHARMACIES UTILIZING THE PROGRAM WAS APPROXIMATELY $6,163,000 AND THE EXPENSES ASSOCIATED WITH THE ADMINISTRATION OF THE PROGRAM AND THE SALE OF THESE DRUGS WHERE APPROXIMATELY $2,896,000 FOR 2019. 85454160 1 1 0 1 0 0 0 0 0 1 1 0 0 0 1 1 0 1 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 1 1 1 0 0 1 52 0 1 941 1 1 1 0 0 0 0 0 0 0 0 0 0 0 X 12 8 0 0 0 0 0 0 0 1 1 0 0 1 1 1 1 1 1 1 0 0 X BRUCE HEIFNER 6416286603 404 JEFFERSON STREET PELLA IA 50219 X DR CRAIG WITTENBERG BOARD MEMBER 40.00 X 642162 0 48266 DR MICHAEL THOMPSON FORMER BOARD MEMBER 40.00 X X 515474 0 45735 DR TEREASA VANZEE - SEIEORE BOARD MEMBER 40.00 X 474755 0 44953 DR RICHARD POSTHUMA BOARD MEMBER 40.00 X 425332 0 45541 JIM BRANDL BOARD MEMBER 0.50 0.20 X 0 0 0 ROD BRAUN TREASURER 0.50 X X 0 0 0 MARY GLENDENING BOARD SECRETARY 0.50 X X 0 0 0 CHAD HUYSER BOARD MEMBER 0.50 X 0 0 0 MIKE LIND BOARD MEMBER 0.50 X 0 0 0 MIKE MORGAN PRESIDENT 0.50 X X 0 0 0 RANDY STRAVERS BOARD MEMBER 0.50 X 0 0 0 TRAVIS TURNBULL BOARD MEMBER 0.50 X 0 0 0 JOHN VANDER WERT VICE PRESIDENT 0.50 X X 0 0 0 ROBERT KROESE CHIEF EXECUTIVE OFFICER 40.00 2.00 X 371812 0 38923 BRUCE HEIFNER CHIEF FINANCIAL OFFICER 40.00 X 180314 0 28976 DAWNETT WILLIS CHIEF OF ANCILLARY SERVICES 40.00 X 176127 0 28873 LEZLIE MORRIS CHIEF OF CLINIC SERVICES 40.00 X 159205 0 14246 SPENCER CARLSTONE MD PHYSICIAN 40.00 X 475412 0 45531 ANNE HELLBUSCH DO PHYSICIAN 40.00 X 443890 0 42962 JEFF HARTUNG DO PHYSICIAN 40.00 X 440566 0 45756 RYAN THORESON DO PHYSICIAN 40.00 X 430273 0 45139 STEPHEN BARNES DO PHYSICIAN 40.00 X 423900 0 48132 5159222 0 523033 76 0 1 0 GRAHAM CONSTRUCTION COMPANY 421 GRAND AVENUE DES MOINES IA 503092309 CONSTRUCTION 2889431 MEDICAL INFORMATION TECHNOLOGY INC PO BOX 74569 CHICAGO IL 60696 EHR SOFTWARE 485147 MEDICAL ONCOLOGY & HEMATOLOGY 1221 PLEASANT STREET DES MOINES IA 50309 PHYSICIAN & NURSE LABOR 460007 CASSLING 13808 F ST OMAHA NE 68137 MEDICAL IMAGING EQUIPMENT & SERVICES 445910 CHANGE HEALTHCARE TECHNOLOGIES PO BOX 98347 CHICAGO IL 60693 INFORMATION TECHNOLOGY AND SERVICES 322560 20 903591 17593 921184 PATIENT SERVICE REVENUE 621110 90821165 90821165 90821165 2302707 2302707 176655 25816 150839 150839 150839 12316378 287245 11823774 238663 492604 48582 541186 541186 OTHER OPERATING REVENUE 900099 6777385 6777385 PHARMACY REVENUE 446110 4177352 4132327 45025 10954737 105691818 101730877 45025 2994732 4598 4598 3240695 2620670 620025 42983287 35984457 6998830 2298785 1841387 457398 4553292 3532897 1020395 2912395 2402615 509780 83511 2646 80865 108222 108222 7843 7843 125438 125438 8811287 6438928 2372359 306214 5595 300619 6299037 5752014 547023 1081058 168790 912268 1219840 1137280 82560 207914 202102 5812 451170 357898 93272 1334635 1334635 7283529 7283529 631676 341353 290323 MEDICAL SUPPLIES 15952690 15952690 FOOD 351876 2555 349321 DUES AND MEMBERSHIPS 113649 76521 37128 EQUIPMENT PARTS AND REP 9656 9656 1344 1344 100373641 85454160 14919481 0 8170493 11850032 13799604 13813002 1076296 1331444 1772216 1670517 130574800 74341119 56985591 56233681 60773702 69918363 17167 983254 1175791 143578323 155992830 8562924 8513692 38663327 36556455 767611 444349 3495295 5393375 51489157 50907871 X 92081666 105077459 7500 7500 92089166 105084959 143578323 155992830 5318177 7677616 0 X X 0 1 X 1 0 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 0 0 0 0 0 0 0 0 1 7843 7843 0 PART II-B, LINE 1: LOBBYING EXPENDITURES RELATED TO MEMBERSHIP DUES INCLUDED: 18.1% OF MEMBERSHIP DUES PAID TO THE IOWA HOSPITAL ASSOCIATION, OR $5,984, AND 18.1% OF MEMBERSHIP DUES PAID TO THE AMERICAN HOSPITAL ASSOCIATION, OR $1,859. 7500 7500 7500 7500 7500 7500 7500 7500 7500 7500 0.00000 1.00000 0.00000 0 0 4125079 4125079 95288797 53272970 42015827 695677 92756 602921 27674911 20116870 7558041 2790336 858523 1931813 56233681 ESTIMATED CLAIMS PAYABLE 2129006 BOND ISSUANCE COSTS -54841 THIRD PARTY SETTLEMENTS 1741099 DEFERRED COMPENSATION 1578111 5393375 X PART V, LINE 4: THE INTENDED USE OF THE ENDOWMENT FUNDS IS TO SERVE THE PURPOSE OF THE RESTRICTIONS PLACED ON THE FUNDS BY THE RESPECTIVE DONORS. PART X, LINE 2: PELLA REGIONAL HEALTH CENTER (THE HEALTH CENTER) AND PELLA HOSPITAL FOUNDATION (THE FOUNDATION) ARE ORGANIZED AS IOWA NONPROFIT CORPORATIONS AND HAVE BEEN RECOGNIZED BY THE INTERNAL REVENUE SERVICE (IRS) AS EXEMPT FROM FEDERAL INCOME TAXES UNDER INTERNAL REVENUE CODE SECTION 501(C)(3). THE HEALTH CENTER AND FOUNDATION ARE EACH ANNUALLY REQUIRED TO FILE A RETURN OF ORGANIZATION EXEMPT FROM INCOME TAX (FORM 990) WITH THE IRS. IN ADDITION, THEY ARE SUBJECT TO INCOME TAX ON NET INCOME THAT IS DERIVED FROM BUSINESS ACTIVITIES THAT ARE UNRELATED TO THEIR EXEMPT PURPOSE. THE HEALTH CENTER AND FOUNDATION BELIEVE THAT THEY HAVE APPROPRIATE SUPPORT FOR ANY TAX POSITIONS TAKEN AFFECTING THEIR ANNUAL FILING REQUIREMENTS, AND AS SUCH, DO NOT HAVE ANY UNCERTAIN TAX POSITIONS THAT ARE MATERIAL TO THE CONSOLIDATED FINANCIAL STATEMENTS. THE HEALTH CENTER AND FOUNDATION WOULD RECOGNIZE FUTURE ACCRUED INTEREST AND PENALTIES RELATED TO UNRECOGNIZED TAX BENEFITS AND LIABILITIES IN INCOME TAX EXPENSE IF SUCH INTEREST AND PENALTIES ARE INCURRED. FORMS 990 AND 990T FILED BY THE HOSPITAL AND FOUNDATION ARE GENERALLY SUBJECT TO EXAMINATION BY THE IRS UP TO THREE YEARS FROM THE EXTENDED DUE DATE OF EACH RETURN. 1 1 X 1 X 1 X 1 1 1 0 1 1 376358 376358 0.00370 7555609 3770512 3785097 0.03760 7931967 3770512 4161455 0.04130 601630 2167 599463 0.00600 1052355 21100 1031255 0.01020 32097559 21664923 10432636 0.10370 5125 5125 0.00010 33756669 21688190 12068479 0.12000 41688636 25458702 16229934 0.16130 159191 159191 0.00160 159191 159191 0.00160 0 1760367 22859503 23522880 -663377 X 1 1 1 1 PELLA REGIONAL HEALTH CENTER 404 JEFFERSON STREET PELLA IA 50219 WWW.PELLAHEALTH.ORG 630165H X X X X PELLA REGIONAL HEALTH CENTER 1 0 0 1 X X X X X X X X 17 1 0 0 1 X WWW.PELLAHEALTH.ORG/ABOUT-US/COMMUNITY/ X 1 17 1 WWW.PELLAHEALTH.ORG/ABOUT-US/COMMUNITY/ 0 1 X 200.000000000000 200.000000000000 X X X X 1 1 X X X 1 X WWW.PELLAHEALTH.ORG/PATIENTS-VISITORS/BILLING/FINANCIAL-ASSISTANCE/ X WWW.PELLAHEALTH.ORG/PATIENTS-VISITORS/BILLING/FINANCIAL-ASSISTANCE/ X WWW.PELLAHEALTH.ORG/PATIENTS-VISITORS/BILLING/FINANCIAL-ASSISTANCE/ X X X X X X 1 X 0 X X X X 1 X 0 0 PELLA REGIONAL HEALTH CENTER PART V, SECTION B, LINE 5: EACH COMMUNITY HAS A WEALTH OF EXPERTISE TO BE TAPPED FOR CHNA DEVELOPMENT. FOR THIS REASON, A TOWN HALL IS THE PERFECT FORUM TO GATHER COMMUNITY INSIGHT AND PROVIDE AN ATMOSPHERE TO OBJECTIVELY BUILD CONSENSUS AND PRIORITIZE COUNTY HEALTH ISSUES.ALL TOWN HALL PRIORITY-SETTING AND SCORING PROCESSES INVOLVE THE INPUT OF KEY STAKEHOLDERS IN ATTENDANCE. INDIVIDUALS AND ORGANIZATIONS ATTENDING THE TOWN HALLS WERE CRITICALLY IMPORTANT TO THE SUCCESS OF THE CHNA.THE FOLLOWING LIST OUTLINES PARTNERS INVITED TO TOWN HALL: LOCAL HOSPITALS, PUBLIC HEALTH COMMUNITY, MENTAL HEALTH COMMUNITY, FREE CLINICS, COMMUNITY BASED CLINICS, SERVICE PROVIDERS, LOCAL RESIDENTS, COMMUNITY LEADERS, OPINION LEADERS, SCHOOL LEADERS, BUSINESS LEADERS, LOCAL GOVERNMENT, FAITH-BASED ORGANIZATIONS AND PERSONS (OR ORGANIZATIONS SERVING THEM), PEOPLE WITH CHRONIC CONDITIONS, UNINSURED COMMUNITY MEMBERS, LOW INCOME RESIDENTS, AND MINORITY GROUPS. PELLA REGIONAL HEALTH CENTER PART V, SECTION B, LINE 11: THE 2017 IMPLEMENTATION PLAN DESCRIBES THE FOLLOWING NEEDS THAT WILL BE ADDRESSED IN THE FUTURE:1) LACK OF QUALIFIED HEALTHCARE WORKINGS SEEKING EMPLOYMENT. PELLA REGIONAL HEALTH CENTER (PRHC) WILL ENHANCE MARKETING STRATEGIES WITH OUR WEBSITE TO REALLY SHARE OUR STORY AS IT RELATES TO EMPLOYMENT, ENHANCE CONNECTION WITH HIGH SCHOOLS TO EDUCATE ON HEALTHCARE CAREERS, ENHANCE COLLEGE STUDENT CONNECTIONS WITH PRHC TO DRAW POTENTIAL SEEKERS TO PRHC, AND SEEK STRONGER RETENTION MEASURES. 2) MENTAL HEALTH (ACCESS, DIAGNOSIS AND PLACEMENT). PRHC WILL PARTNER WITH PINE REST TO INCREASE PATIENT'S AND PROVIDERS/STAFF KNOWLEDGE/AWARENESS OF AVAILABLE SERVICES WITH THE GOAL OF INCREASE OUTPATIENT SERVICES TO PREVENT THE NEED FOR INPATIENT SERVICES.3) INCREASE MEDICAID REIMBURSEMENT. PRHC WILL MONITOR STATE AND FEDERAL REGULATIONS FOR CHANGES TO LAWS, FOLLOW AHA AND IHA ON MEDICAID REIMBURSEMENT ISSUES, COMMUNICATE WITH LEGISLATORS REGARDING EFFECTS OF BILLS ON MEDICAID PAYMENTS, AND MOBILIZE PELLA REGIONAL CONSTITUENTS TO COMMUNICATE WITH LEGISLATORS REGARDING MEDICAID PAYMENT ISSUES.4) SUBSTANCE ABUSE (METH, MARIJUANA, OPIODS, PRESCRIPTION DRUGS). PRHC WILL LOOK TO INCREASE PATIENTS AND PROVIDERS/STAFF KNOWLEDGE/AWARENESS OF AVAILABLE SERVICES, EDUCATE PROVIDERS ON SCREENING QUESTIONS/TOOLS TO EVALUATE PATIENTS, CONTINUE TO MONITOR PRESCRIPTION DRUG ABUSE AND PROVIDE SUPPORT TO PROVIDERS IN DISCOURAGING PRESCRIPTION DRUG ABUSE5) COMMUNITY HEALTH EDUCATION (OWN PERSONAL HEALTH). PRHC WILL PROMOTE WELLNESS EXAMS ANNUALLY, ADD WELLNESS INFORMATION TO WEBSITE, AND UTILIZE HEALTH PARTNERS TO COMMUNICATE WITH CHRONIC ILLNESS PATIENTS REGARDING SCHEDULING OF EXAMS AND TESTING.THE COMMUNITY STILL SENSES A HEALTH NEED TO INCREASE INPATIENT MENTAL HEALTH SERVICES; FIGHT OBESITY BY FOCUSING ON FITNESS, NUTRITION, AND PREVENTION ACTIONS; INCREASE OUTPATIENT MENTAL HEALTH SERVICES; AND PROVIDE MORE AFFORDABLE NURSING HOME CARE OPTIONS. PELLA REGIONAL HEALTH CENTER PART V, SECTION B, LINE 13H: PELLA REGIONAL HEALTH CENTER (HEALTH CENTER) ALSO REVIEWS A PATIENT'S MONTHLY INCOME, EXPENSES, ASSETS, LIABILITIES, PRIOR HEALTH HISTORY, AND TOTAL OUTSTANDING BILLS IN ADDITION TO PROVIDING FREE OR DISCOUNTED CARE BASED ON THE FEDERAL POVERTY GUIDELINES. THE FEDERAL POVERTY GUIDELINES ARE USED AS A STARTING POINT TO DETERMINE FINANCIAL ASSISTANCE, BUT SEVERAL OTHER FACTORS ARE TAKEN INTO CONSIDERATION BEFORE DETERMINING HOW MUCH OF A PATIENT'S BILL WILL BE WRITTEN OFF TO CHARITY CARE IF THE PATIENT'S EARNINGS ARE ABOVE THE 200% FEDERAL POVERTY GUIDELINE BASE AMOUNT.THE HEALTH CENTER ALSO OFFERS UNINSURED PATIENTS A 20% CASH DISCOUNT FOR FINAL BILLS PAID IN FULL WITHIN 60 DAYS. THE HEALTH CENTER DOES NOT CHARGE INTEREST ON UNPAID BALANCES WHEN PAYMENT PLANS ARE SET UP WITHIN 60 DAYS OF PATIENTS RECEIVING THEIR FINAL BILL. PELLA REGIONAL HEALTH CENTER PART V, SECTION B, LINE 20E: IN ADDITION TO THE ACTIONS TAKEN IN PART V, SECTION B, LINE 20A-20D, PELLA REGIONAL HEALTH CENTER SENDS INSUFFICIENT PAYMENT LETTERS TO INDIVIDUALS FOR PAYMENTS NOT MEETING THE HOSPITAL'S MINIMUM PAYMENT REQUIREMENTS. PRHC ALSO SENDS MINIMUM PAYMENTS LETTERS THAT OUTLINED ITS MINIMUM PAYMENT REQUIREMENTS. 14 1 - PELLA MEDICAL CLINIC 405 MONROE PELLA IA 50219 PHYSICIAN CLINIC 2 - OTTUMWA MEDICAL CLINIC 920 N QUINCY AVE OTTUMWA IA 52501 PHYSICIAN CLINIC 3 - PELLA REGIONAL PHARMACY 802 WASHINGTON ST PELLA IA 50219 RETAIL PHARMACY 4 - KNOXVILLE MEDICAL CLINIC 1208 N LINCOLN KNOXVILLE IA 50138 PHYSICIAN CLINIC 5 - PRAIRIE CITY CLINIC 100 E JEFFERSON STREET PRAIRIE IA 50228 PHYSICIAN CLINIC 6 - HOSPICE OF PELLA (COMFORT HOUSE) 505 UNION STREET PELLA IA 50219 HOSPICE 7 - OTTUMWA THERAPY AGENCY 611 NORTH HANCOCK STREET OTTUMWA IA 52501 PHYSICAL AND OCCUPATIONAL THERAPY 8 - HOME HEALTH 1119 E 2ND STREET PELLA IA 50219 HOME HEALTHCARE 9 - PELLA REGIONAL PHARMACY 405 JEFFERSON ST PELLA IA 50219 FIRSTFILL PHARMACY 10 - BUSSEY MEDICAL CLINIC 411 MERRILL STREET BUSSEY IA 50044 PHYSICIAN CLINIC 11 - SULLY CLINIC 704 3RD STREET SULLY IA 50251 PHYSICIAN CLINIC 12 - MONROE CLINIC 100 SHERMAN STREET MONROE IA 50170 PHYSICIAN CLINIC 13 - NEW SHARON MEDICAL CLINIC 302 S PARK AVENUE NEW SHARON IA 50207 PHYSICIAN CLINIC 14 - ALBIA MEDICAL CLINIC (MONROE COUNTY HOSP 6580 165TH STREET ALBIA IA 52531 PHYSICIAN CLINIC PART I, LINE 3C: PELLA REGIONAL HEALTH CENTER (HEALTH CENTER) ALSO REVIEWS A PATIENT'S MONTHLY INCOME, EXPENSES, ASSETS, LIABILITIES, PRIOR HEALTH HISTORY, AND TOTAL OUTSTANDING BILLS IN ADDITION TO PROVIDING FREE OR DISCOUNTED CARE BASED ON THE FEDERAL POVERTY GUIDELINES. THE FEDERAL POVERTY GUIDELINES ARE USED AS A STARTING POINT TO DETERMINE FINANCIAL ASSISTANCE, BUT SEVERAL OTHER FACTORS ARE TAKEN INTO CONSIDERATION BEFORE DETERMINING HOW MUCH OF A PATIENT'S BILL WILL BE WRITTEN OFF TO CHARITY CARE IF THE PATIENT'S EARNINGS ARE ABOVE THE 200% FEDERAL POVERTY GUIDELINE BASE AMOUNT. THE HEALTH CENTER ALSO OFFERS UNINSURED PATIENTS A 20% CASH DISCOUNT FOR FINAL BILLS PAID IN FULL WITHIN 60 DAYS. THE HEALTH CENTER DOES NOT CHARGE INTEREST ON UNPAID BALANCES WHEN PAYMENT PLANS ARE SET UP WITHIN 60 DAYS OF PATIENTS RECEIVING THEIR FINAL BILL. PART I, LINE 6A: NOT APPLICABLE PART I, LINE 7: CHARITY CARE EXPENSE WAS CONVERTED TO COST ON LINE 7A BASED ON AN OVERALL COST-TO-CHARGE RATIO ADDRESSING ALL PATIENT SEGMENTS. UNREIMBURSED MEDICAID ON LINE 7B WAS CALCULATED USING THE COSTING METHODS USED 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 EXPENSE AND REVENUE AMOUNTS RECORDED FROM THE EVENTS IN THE GENERAL LEDGER. THE COST FOR SUBSIDIZED HEALTH SERVICES REPORTED ON LINE 7G WAS DETERMINED USING THE MEDICARE COST REPORT. PART I, LINE 7G: THE ORGANIZATION USED THE MEDICARE COST REPORT AS WELL AS INTERNAL FINANCIAL STATEMENTS TO CALCULATE A COST-TO-CHARGE RATIO FOR EACH DEPARTMENT THAT CONSTITUTES A SUBSIDIZED HEALTH SERVICE ACTIVITY. THE FOLLOWING PHYSICIAN CLINIC COSTS WERE INCLUDED IN COMMUNITY BENEFIT EXPENSE: PELLA MEDICAL CLINIC - $22,402,044, MONROE CLINIC - $383,385, SULLY CLINIC - $574,618, OTTUMWA CLINIC - $4,018,701, BUSSEY AND PRAIRIE CITY CLINIC - $2,635,386, AND NEW SHARON CLINIC - $279,948. PART II, COMMUNITY BUILDING ACTIVITIES: INFECTION CONTROL SERVES AS A COMMUNITY BENEFIT AS IT TRACKS INFECTIONS THROUGHOUT THE WORLD, NATION, AND LOCAL AREA IN AN EFFORT TO REDUCE OR PREVENT INCIDENCE OR LOCAL OCCURENCE. ALSO, IT HELPS TO PREPARE FOR THE EVENTUALITY OF INFECTION ISSUES WITHIN THE COMMUNITY AND AT OUR FACILITY. PART III, LINE 2: PATIENT ACCOUNTS ARE WRITTEN OFF TO BAD DEBT AFTER EVERY EFFORT IS MADE TO COLLECT THE BALANCE AND PATIENTS ARE GIVEN OPPORTUNITIES TO COMPLETE CHARITY CARE APPLICATIONS OR SET UP PAYMENT PLANS. ALL DISCOUNTS AND CONTRACTUAL ADJUSTMENTS ARE APPLIED TO ACCOUNTS BEFORE THEY ARE WRITTEN OFF TO BAD DEBT. CURRENT PAYMENTS ON ACCOUNTS PREVIOUSLY WRITTEN OFF AS BAD DEBT REDUCES BAD DEBT EXPENSE.BAD DEBT EXPENSE ON LINE 2 IS REPORTED AT CHARGES AS PRESENTED ON THE FINANCIAL STATEMENTS. PART III, LINE 3: NOT APPLICABLE PART III, LINE 4: THE FOOTNOTE TO THE ORGANIZATION'S FINANCIAL STATEMENTS CAN BE FOUND ON PAGE 10 OF THE ATTACHED AUDITED FINANCIAL STATEMENTS. PART III, LINE 8: THE ENTIRE MEDICARE SHORTFALL IS CONSIDERED A COMMUNITY BENEFIT. PELLA REGIONAL HEALTH CENTER PROVIDES SERVICES TO PATIENTS UNDER THE MEDICARE PROGRAM KNOWING THAT THEY WILL NOT RECOVER ALL OF THE COSTS ASSOCIATED WITH PROVIDING THESE SERVICES. PROVIDING THESE SERVICES IS ESSENTIAL TO THESE PATIENTS AND THE COMMUNITY AND INCREASES THEIR ACCESS TO HEALTHCARE. THE ORGANIZATION REPORTED ONLY THOSE ALLOWABLE COSTS AND MEDICARE REIMBURSEMENTS REPORTED IN THE MEDICARE COST REPORT FOR THE YEAR.TOTAL REVENUE RECEIVED FROM MEDICARE (INCLUDING DSH AND IME) IS THE GROSS REIMBURSEMENT PLUS SETTLEMENT (INCLUDING LSA). BOTH THE 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 THE CENTERS FOR MEDICARE AND MEDICAID SERVICES. PART III, LINE 9B: PELLA REGIONAL HEALTH CENTER'S COLLECTION POLICY HAS PROVISONS FOR PATIENTS THAT QUALIFY FOR FINANCIAL ASSISTANCE OR CHARITY CARE AND FOR PATIENTS IN THE PROCESS OF APPLYING FOR ASSISTANCE. PELLA REGIONAL HEALTH CENTER DOES NOT PURSUE COLLECTION EFFORTS WHILE A PATIENT IS IN THE PROCESS OF APPLYING FOR ANY TYPE OF ASSISTANCE OR FOR ANY PORTION OF A PATIENT'S BILL CONSIDERED CHARITY CARE. AFTER ASSISTANCE IS DETERMINED, ANY PERSONAL PORTION DUE WOULD FOLLOW THE SAME COLLECTION PROCEDURES AS OTHER PATIENTS. IF A PAYMENT PLAN IS ESTABLISHED AND THE PATIENT DEFAULTS, THEIR CHARITY CARE STATUS IS REVOKED AND THE REMAINING BALANCE IS SENT TO COLLECTIONS. PART VI, LINE 2: PELLA REGIONAL HEALTH CENTER PARTICIPATED IN A COMMUNITY ENGAGEMENT PROJECT IN 2017. THIS PROJECT INCLUDED A COMMUNITY HEALTH NEEDS ASSESSMENT, KEY INFORMANT INTERVIEWS, AND SECONDARY DATA ANALYSIS ADMINISTERED BY THE VVV MARKETING & DEVELOPMENT INC. OF OLATHE, KANSAS. THE HEALTH IMPLEMENTATION PLAN (HIP) FROM THE 2017 CHNA WILL BE CLOSED AS OF DECEMBER 31, 2017. CREATING HEALTHY COMMUNITIES REQUIRES A HIGH LEVEL OF MUTUAL UNDERSTANDING AND COLLABORATION AMONG COMMUNITY LEADERS. THE DEVELOPMENT OF THIS ASSESSMENT BRINGS TOGETHER COMMUNITY HEALTH LEADERS AND PROVIDERS, ALONG WITH LOCAL RESIDENTS, TO RESEARCH AND PRIORITIZE COUNTY HEALTH NEEDS AND DOCUMENT COMMUNITY HEALTH DELIVERY SUCCESSES. THIS HEALTH ASSESSMENT WILL SERVE AS THE FOUNDATION FOR COMMUNITY HEALTH IMPROVEMENT EFFORTS FOR THE NEXT THREE YEARS. THE LAST CHNA FOR PELLA REGIONAL HEALTH CENTER (PRIMARY SERVICE AREA) WAS PUBLISHED IN OCTOBER 2014. THE PATIENT PROTECTION AND AFFORDABLE CARE ACT (ACA) REQUIRES NOT-FOR-PROFIT HOSPITALS TO CONDUCT A CHNA EVERY THREE YEARS AND ADOPT AN IMPLEMENTATION STRATEGY TO MEET THE NEEDS IDENTIFIED BY THE CHNA. THIS ASSESSMENT WAS COORDINATED AND PRODUCED BY VVV CONSULTANTS LLC (OLATHE, KANSAS) UNDER THE DIRECTION OF VINCE VANDEHAAR, MBA. A CHNA PROVIDES BENEFITS TO LOCAL HEALTH SERVICE ORGANIZATIONS, THE HOSPITAL, THE PUBLIC HEALTH DEPARTMENT, AS WELL AS OTHER COMMUNITY PROVIDERS AND STAKEHOLDERS IN THE FOLLOWING WAYS: 1) INCREASES KNOWLEDGE OF COMMUNITY HEALTH NEEDS AND RESOURCES; 2) CREATES A COMMON UNDERSTANDING OF THE PRIORITIES OF THE COMMUNITY'S HEALTH NEEDS; 3) ENHANCES RELATIONSHIPS AND MUTUAL UNDERSTANDING BETWEEN AND AMONG STAKEHOLDERS; 4) PROVIDES A BASIS UPON WHICH COMMUNITY STAKEHOLDERS CAN MAKE DECISIONS ABOUT HOW THEY CAN CONTRIBUTE TO IMPROVING THE HEALTH OF THE COMMUNITY; 5) PROVIDES RATIONALE FOR CURRENT AND POTENTIAL FUNDERS TO SUPPORT EFFORTS TO IMPROVE THE HEALTH OF THE COMMUNITY; 6) CREATES OPPORTUNITIES FOR COLLABORATION IN DELIVERY OF SERVICES TO THE COMMUNITY; AND 7) PROVIDES GUIDANCE TO THE HOSPITAL AND LOCAL HEALTH DEPARTMENT FOR HOW THEY CAN ALIGN THEIR SERVICES AND COMMUNITY BENEFIT PROGRAMS TO BEST MEET NEEDS.IN MAY 2017, PELLA REGIONAL BEGAN ITS THIRD COMMUNITY HEALTH NEEDS ASSESSMENT PROCESS. OVER THE SUMMER, A RANDOM, STRATIFIED SAMPLE OF 1,000 RESIDENTS WITHIN PELLA REGIONAL'S SERVICE AREA WAS SURVEYED, AND 219 SURVEYS WERE RETURNED PROVIDING A 21.9 PERCENT RESPONSE RATE. IN ADDITION, A FOCUS GROUP WITH 50 COMMUNITY LEADERS INCLUDING SENIOR CITIZENS, CONSUMERS, HEALTH CARE PROVIDERS/CLINICIANS, EDUCATORS, BUSINESS OWNERS, CLERGY, AND LAW ENFORCEMENT OFFERED QUALITATIVE INFORMATION TO SUPPLEMENT THE SURVEY.THE COMMUNITY HEALTH NEEDS ASSESSMENT IDENTIFIED COMMUNITY HEALTH STRENGTHS AND WEAKNESSES. OUR FORMAL COMMUNITY HEALTH NEEDS ASSESSMENT AND HEALTH IMPLEMENTATION PLAN WAS POSTED TO OUR WEBSITE IN DECEMBER 2017. PART VI, LINE 3: PELLA REGIONAL HEALTH CENTER'S PATIENT ADVOCATES ARE AVAILABLE TO WORK WITH PATIENTS PRIOR TO NON-EMERGENCY SERVICES TO REVIEW SPECIFIC INSURANCE SITUATIONS AND THE DOCTOR'S RECOMMENDED SERVICE FOR THE PATIENT. THE ADVOCATE ESTIMATES EACH PATIENT'S ACTUAL COST AND WORKS WITH THEM TO FIND THE BEST METHOD OF PAYMENT, OR HELP DETERMINE ELIGIBILITY FOR CHARITY CARE FROM PELLA REGIONAL HEALTH CENTER OR THROUGH GOVERNMENT PROGRAMS. PART VI, LINE 4: PELLA REGIONAL HEALTH CENTER (PRHC) IS A CRITICAL ACCESS HOSPITAL THAT OFFERS A LARGE ARRAY OF BOTH INPATIENT AND OUTPATIENT SERVICES. PRHC HAS A RACIALLY HOMOGENOUS SERVICE AREA THAT COVERS MARION, MAHASKA, JASPER, AND WAPELLO COUNTIES IN IOWA. PELLA IS A THRIVING COMMUNITY APPROXIMATELY 40 MILES SOUTHEAST OF DES MOINES, IOWA AND IS HOME TO NOT ONLY PRHC BUT ALSO THE CORPORATE HEADQUARTERS FOR PELLA CORP, A LARGE MANUFACTURER OF WINDOWS AND DOORS, AND VERMEER CORPORATION, THE MANUFACTURER OF INDUSTRIAL AND AGRICULTURAL EQUIPMENT. BOTH COMPANIES ARE KNOWN WORLDWIDE. PELLA IS VERY FORTUNATE TO HAVE THIS TYPE OF INDUSTRIAL AND FINANCIAL BASE. THE POPULATION IN PELLA, IA FOR 2019 WAS 10,237. MEDIAN HOUSEHOLD INCOME IN 2018 WAS $64,770 AND THERE WERE 7.7% OF PEOPLE LIVING IN POVERTY. UNDER HEALTH, PERSONS WITH A DISABILITY, UNDER 65 YEARS WAS 8.8%, 2014-2018 AND PERSONS WITHOUT HEALTH INSURANCE UNDER AGE 65 YEARS WAS 3.2%. THIS INFORMATION WAS OBTAINED FROM HTTPS://WWW.CENSUS.GOV/QUICKFACTS/PELLACITYIOWA. PART VI, LINE 5: THE BOARD MEMBERS ALL RESIDE IN THE SERVICE AREA. A MAJORITY OF THE BOARD MEMBERS ARE NOT EMPLOYED BY PELLA AND NONE ARE FAMILY MEMBERS. PHYSICIANS ARE ENCOURAGED TO PARTICIPATE ON THE BOARD AS THEY HAVE DIRECT CONTACT WITH OUR PATIENTS AND KNOW FIRSTHAND THE NEEDS OF THE COMMUNITY. PELLA REGIONAL HEALTH CENTER EXTENDS MEDICAL STAFF PRIVILEGES TO ALL QUALIFIED PHYSICIANS IN THE COMMUNITY EXCEPT FOR PHYSICIANS WITH PENDING QUALITY ISSUES. THE ORGANIZATION APPLIES SURPLUS FUNDS TO IMPROVE PATIENT CARE, MEDICAL EDUCATION, AND RESEARCH THROUGH THE NORMAL BUDGET AND CAPITAL BUDGET PROCESSES. ALSO, PELLA REGIONAL HEALTH CENTER PROMOTES THE HEALTH OF THE COMMUNITY BY OPERATING AN EMERGENCY ROOM AVAILABLE TO ALL REGARDLESS OF ABILITY TO PAY, PARTICIPATING IN GOVERNMENT-SPONSORED HEALTH PROGRAMS AND VOLUNTEERING IN THE COMMUNITY. PART VI, LINE 7, REPORTS FILED WITH STATES IA X X X 0 1 0 0 0 0 0 0 0 DR CRAIG WITTENBERG BOARD MEMBER 642162 0 0 0 0 0 16800 0 31466 0 690428 0 0 0 DR MICHAEL THOMPSON FORMER BOARD MEMBER 515474 0 0 0 0 0 16800 0 28935 0 561209 0 0 0 DR TEREASA VANZEE - SEIEORE BOARD MEMBER 474755 0 0 0 0 0 16800 0 28153 0 519708 0 0 0 DR RICHARD POSTHUMA BOARD MEMBER 425332 0 0 0 0 0 16800 0 28741 0 470873 0 0 0 ROBERT KROESE CHIEF EXECUTIVE OFFICER 371812 0 0 0 0 0 16800 0 22123 0 410735 0 0 0 BRUCE HEIFNER CHIEF FINANCIAL OFFICER 180314 0 0 0 0 0 11163 0 17813 0 209290 0 0 0 DAWNETT WILLIS CHIEF OF ANCILLARY SERVICES 176127 0 0 0 0 0 8232 0 20641 0 205000 0 0 0 LEZLIE MORRIS CHIEF OF CLINIC SERVICES 159205 0 0 0 0 0 9696 0 4550 0 173451 0 0 0 SPENCER CARLSTONE MD PHYSICIAN 475412 0 0 0 0 0 16800 0 28731 0 520943 0 0 0 ANNE HELLBUSCH DO PHYSICIAN 443890 0 0 0 0 0 16800 0 26162 0 486852 0 0 0 JEFF HARTUNG DO PHYSICIAN 440566 0 0 0 0 0 16800 0 28956 0 486322 0 0 0 RYAN THORESON DO PHYSICIAN 430273 0 0 0 0 0 16800 0 28339 0 475412 0 0 0 STEPHEN BARNES DO PHYSICIAN 423900 0 0 0 0 0 16800 0 31332 0 472032 0 0 0 PART I, LINE 4B THE FOLLOWING INDIVIDUAL PARTICIPATED IN A SUPPLEMENTAL NONQUALIFIED RETIREMENT PLAN IN 2019 SPONSORED BY PELLA REGIONAL HEALTH CENTER (PRHC): ROBERT KROESE. ON DECEMBER 31, 2019, THE ACCOUNT BALANCE WAS $122,650, WHERE $40,000 REPRESENTS THE CURRENT YEAR CONTRIBUTION MADE BY PRHC ON BEHALF OF THE INDIVIDUAL TO THE PLAN. ROBERT KROESE ALSO RECEIVED A 50% DISTRIBUTION FROM THIS NONQUALIFIED RETIREMENT PLAN ON HIS VESTING DATE OF JANUARY 2, 2019, PER HIS CONTRACT WITH PRHC. A HEALTH FACILITIES REVENUE REFUNDING BOND 521699886 NONEAVAIL 2017-06-08 41734118 REFUND BONDS ISSUED 09/28/06 0 1 0 A 41734118 3836530 703275 44867373 2009 1 0 1 1 A 0 0 0 0 0.00000 0.00000 0.00000 0 0 1 A 0 0 0 1 1 1 PCBB 15.000000000000 0 0 0 0 0 A 0 DATE REBATE COMPUTATION PERFORMED ISSUER NAME: HEALTH FACILITIES REVENUE REFUNDING BOND DATE THE REBATE COMPUTATION WAS PERFORMED: 10/03/2017 FORM 990, PART VI, SECTION A, LINE 1 THE EXECUTIVE COMMITTEE IS COMPOSED OF THE PRESIDENT, VICE PRESIDENT, SECRETARY, AND TREASURER. THE COMMITTEE ACTS FOR THE BOARD OF TRUSTEES AND DIRECTS AND CONTROLS THE AFFAIRS OF THE CORPORATION DURING THE INTERIM BETWEEN BOARD MEETINGS BUT IS SUBJECT TO THE SUPERVISION OF THE BOARD AND PROVIDED ANY ACTION TAKEN DOES NOT CONFLICT WITH THE POLICIES AND EXPRESSED WISHES OF THE BOARD. THE EXECUTIVE COMMITTEE KEEPS AN ACCURATE AND COMPLETE RECORD OF ALL OF ITS PROCEEDINGS AND THE RECORD MUST BE SUBMITTED FOR CONFIRMATION TO THE BOARD OF TRUSTEES AT THE BOARD'S NEXT MEETING AND MADE A PART OF THE MINUTES. THE EXECUTIVE COMMITTEE HAS THE RIGHT TO APPROVE OR REJECT THE CEO'S RECOMMENDATIONS ON EMPLOYMENT OF PERSONNEL, PLAN OF INTERNAL ORGANIZATION OF THE CORPORATION, AND RULES AND REGULATIONS DEFINING DUTIES, HOURS AND INTERDEPARTMENTAL RELATIONSHIPS OF PERSONNEL. FORM 990, PART VI, SECTION B, LINE 11B THE FORM 990 IS DISTRIBUTED TO THE BOARD'S FINANCE COMMITTEE AND PROVIDED TO ALL BOARD MEMBERS PRIOR TO FILING. IT IS ALSO REVIEWED BY THE CEO AND CFO. FORM 990, PART VI, SECTION B, LINE 12C PELLA REGIONAL HEALTH CENTER HAS CONFLICT OF INTEREST POLICIES COMPLETED EACH YEAR BY ALL BOARD MEMBERS AND OFFICERS THUS MONITORING ANY POTENTIAL CONFLICTS OF INTEREST. THE CEO AND CFO REVIEW THE COMPLETED STATEMENTS. IF A POTENTIAL CONFLICT IS IDENTIFIED, THE CEO FOLLOWS UP. ANY ACTUAL OR POTENTIAL DUALITY OR CONFLICT OF INTEREST, INCLUDING BUT NOT LIMITED TO, OWNERSHIP OR CONTROL OF ANY ENTITY THAT CONTRACTS WITH PELLA REGIONAL HEALTH CENTER FOR ANY PRODUCTS OR SERVICES MUST BE DISCLOSED TO THE OTHER MEMBERS OF THE BOARD AND MADE A MATTER OF RECORD IN THE MINUTES WHEN THE SUBJECT OF SUCH INTEREST BECOMES A MATTER OF BOARD ACTION. WHEN CONFLICT ARISES, THE MEMBER IS ASKED TO BE EXCUSED FROM THE MEETING. FORM 990, PART VI, SECTION B, LINE 15A THE CEO'S COMPENSATION IS SET BY THE EXECUTIVE COMMITTEE OF THE BOARD WITH SALARY ADJUSTMENT RECOMMENDATIONS BASED ON AN ANNUAL EVALUATION AND INPUT FROM HUMAN RESOURCES. THE COMPENSATION FOR OTHER OFFICERS AND KEY EMPLOYEES IS SET BY THE CEO WITH SALARY ADJUSTMENTS BASED ON ANNUAL EVALUATIONS AND DIRECTION FROM HUMAN RESOURCES. COMPARABILITY DATA IS USED TO DETERMINE COMPENSATION FOR TOP MANAGEMENT OFFICIALS, OFFICERS, AND EMPLOYEES IN NON-MANAGEMENT POSITIONS. SEVERAL SURVEYS ARE USED FOR COMPARABILITY INCLUDING THE IOWA HOSPITAL ASSOCIATION, IOWA HEALTH SYSTEM, IOWA INTEGRATED HEALTHCARE STRATEGIES, COMPDATA SURVEYS, IOWA ASSOCIATION OF HOMES AND SERVICES FOR THE AGING, IOWA MEDICAL GROUP MANAGEMENT ASSOCIATION, AND SOUTHEAST IOWA COMP CLUB. THE ORGANIZATION DOCUMENTS AND PROVIDES SUBSTANTIATION FOR ITS COMPENSATION PROCESS FOR ALL EMPLOYEES. THIS PROCESS WAS LAST UNDERTAKEN IN 2019. FORM 990, PART VI, SECTION C, LINE 19 THE GOVERNING DOCUMENTS AND CONFLICT OF INTEREST POLICY ARE AVAILABLE TO THE PUBLIC UPON WRITTEN REQUEST. FINANCIAL STATEMENTS ARE AVAILABLE TO THE PUBLIC AS THEY ARE ATTACHED TO THE FORM 990. FORM 990, PART VII, SECTION A: THE PHYSICIANS/DIRECTORS ARE COMPENSATED FOR THEIR SERVICES AS PHYSICIANS. THEIR TIME SERVED AS BOARD MEMBERS IS ON A VOLUNTEER BASIS AND NO COMPENSATION IS RECEIVED FOR THOSE SERVICES. FORM 990, PART XII, LINE 2C: THE OVERSIGHT AND SELECTION PROCESS HAS NOT CHANGED FROM PRIOR TAX YEARS. PELLA HOSPITAL FOUNDATION 404 JEFFERSON STREET PELLA IA 50219 421430122 SOLICIT FUNDS AND SUPPORT PELLA REGIONAL HEALTH CENTER IA 501(C)(3) LINE 7 PELLA REGIONAL HEALTH CENTER 1 0 0 1 0 0 0 0 0 0 0 0 1 0 1 1 0 1 0 1 PELLA HOSPITAL FOUNDATION C 903591 FAIR MARKET VALUE