2020-11-09T09:53:40-06:00 2019-12-31 476097913 SEIM JOHNSON LLP 18081 BURT STREET SUITE 200 OMAHA NE 680224722 990 2019-01-01 420860039 STEWART MEMORIAL COMMUNITY HOSPITAL STEW 7124644200 1301 W MAIN LAKE CITY IA 51449 JIM HENKENIUS CHIEF FINANCIAL OFFICER 7124644200 2020-11-06 1 WENDY R COOLEY P01523804 4023302660 209.34.201.180 2020-11-06 13:26:29 CS P 0012BF30E53CD086DD430E8C23D72A931157C2A7 5D066E2939FE45487034BD10C4A0DC94BE27FEF9 2019 2021-01-29 14:40:06Z JIM HENKENIUS 1301 W MAIN LAKE CITY IA 51449 33239863 0 X WWW.STEWARTMEMORIAL.ORG X 1958 IA TO PROVIDE A COMPLETE CONTINUUM OF HEALTHCARE SERVICES TO THE PEOPLE OF LAKE CITY AND THE SURROUNDING COMMUNITIES WITHOUT REGARD FOR ABILITY TO PAY AND WITHOUT DISCRIMINATION. 9 8 296 127 2997128 -408576 126803 1115007 31659934 31001161 121316 14705 299603 405702 32207656 32536575 0 0 0 0 16759450 17240302 0 0 0 15231032 13959971 31990482 31200273 217174 1336302 13434280 14985886 5535479 5391725 7898801 9594161 X STEWART MEMORIAL COMMUNITY HOSPITAL IS COMMITTED TO QUALITY HEALTH AND WELLNESS FOR YOU AND YOUR FAMILY. 0 1 18775149 16312317 STEWART MEMORIAL COMMUNITY HOSPITAL IS A 25 BED CRITICAL ACCESS HOSPITAL THAT ALSO OPERATES 4 RURAL HEALTH CLINICS. STEWART MEMORIAL EMPLOYS 11 FAMILY PRACTICE PROVIDERS, 1 GENERAL SURGEON AND 2 CRNAS. BESIDES OFFERING 24/7 EMERGENCY ROOM SERVICES, STEWART MEMORIAL ALSO PROVIDES GENERAL RADIOLOGY, CT SCANS, ULTRASOUND, MOBILE MRI, NUCLEAR SCANS, LABORATORY, BLOOD ADMINISTRATION, CARDIAC REHABILITATION, EKGS, RESPIRATORY THERAPY, PHYSICAL THERAPY, OCCUPATIONAL THERAPY, SPEECH THERAPY, OPERATING ROOM, PHARMACY, INFUSIONS AND OBSTETRICS. DURING 2019, STEWART MEMORIAL HAD 1,006 ACUTE PATIENT DAYS, 2,344 EMERGENCY ROOM VISITS, 984 OPERATING ROOM PROCEDURES AND 33,705 CLINIC ENCOUNTERS. 5932523 5844360 STEWART MEMORIAL COMMUNITY HOSPITAL OWNS AND OPERATES RURAL HEALTH CLINICS IN THE COMMUNITIES OF LAKE CITY, GOWRIE, LAKE VIEW AND ROCKWELL CITY. WE EMPLOY 13 PROVIDERS WHICH ARE COMPOSED OF PHYSICIANS, PHYSICIAN ASSISTANTS AND NURSE PRACTITIONERS, THEY PROVIDE MEDICAL PROFESSIONAL SERVICES TO MEMBERS OF THESE COMMUNITIES AND SURROUNDING AREAS IN A DESIGNATED HEALTH PROFESSIONAL SHORTAGE AREA. 1923625 2081909 THE OPERATING AND RECOVERY ROOMS DEPARTMENT PROVIDE GENERAL SURGICAL AND ORTHOPEDIC PROCEDURES ALONG WITH PROCEDURES FOR ENT, CATARACT AND PODIATRY. THE SUPPLIES USED IN SUCH PROCEDURES ACCOUNT FOR A LARGE PORTION OF EXPENSES. 1471962 3765447 THE LABORATORY DEPARTMENT PROVIDES INPATIENT, OUTPATIENT AND EMERGENCY TESTING FOR PATIENTS OF STEWART MEMORIAL COMMUNITY HOSPITAL. IT ALSO PROVIDE SERVICES TO THE MCCRARY-ROST CLINIC IN LAKE CITY. REAGENT AND SALARY COSTS OF PERSONNEL ACCOUNT FOR THE MAJORITY OF THE DEPARTMENT'S EXPENSES. 1471962 3765447 28103259 1 1 0 1 0 0 0 0 0 0 1 0 0 1 0 1 1 0 0 0 0 0 0 0 1 0 1 1 0 0 1 1 0 0 0 0 0 0 0 0 1 0 1 0 0 0 0 0 0 0 0 1 32 0 1 296 1 1 1 0 0 0 0 0 0 0 0 0 0 0 X 9 8 0 1 0 0 0 0 0 1 1 0 0 1 1 1 1 1 1 1 0 0 X JIM HENKENIUS CFO 7124644200 1301 W MAIN STREET LAKE CITY IA 51449 DEREK DUNCAN MEDICAL COUNSEL 40.00 X 751650 0 58286 SUSAN HORNBACK D.O. 40.00 X 746287 0 57611 RONALD CHENEY D.O. 40.00 X 493036 0 25017 DANNIELE ANDERSON PA 40.00 X 347800 0 55892 MARGARET VITIRITTO-KHAN D.O. 40.00 X 321945 0 46967 MARK MOGENSEN PA 40.00 X 331015 0 60548 JIM HENKENIUS CFO 40.00 X 140829 0 39440 CHADRIC DIETRICH BOARD CHAIR 2.00 X X 0 0 0 BRADLEY LANE VICE CHAIR 2.00 X X 0 0 0 HEATHER MCCLUE SECRETARY THRU 04/19 2.00 X X 0 0 0 THERESA HILDRETH SECRETARY 2.00 X X 0 0 0 SCOTT NESBITT TREASURER 2.00 X X 0 0 0 SHEILA BERGER DIRECTOR 1.00 X 0 0 0 CARMEN HOOD DIRECTOR 1.00 X 0 0 0 SCOTT KLUVER DIRECTOR 1.00 X 0 0 0 JORDAN LIETZ DIRECTOR 1.00 X 0 0 0 CHARLES SCHMITT DIRECTOR THRU 04/19 1.00 X 0 0 0 CYNTHIA CARSTENS CEO 40.00 X 0 0 0 3132562 0 343761 19 0 1 1 CMBA ARCHITECTS 319 SW 5TH ST DES MOINES IA 50309 ARCHITECT SERVICES 988949 BARTON ASSOCIATES 300 JUBILEE DRIVE PEABODY MA 01960 LOCUM TENENS SERVICES 273794 ST ANTHONY REGIONAL HOSPITAL 311 S CLARK ST CARROLL IA 51401 OR CALL COVERAGE 202243 ICE TECHNOLOGIES 411 SE 9TH ST PELLA IA 50219 IT SERVICES 162978 BAIRD HOLM MCEACHEN PEDERSON HAMANN 1500 WOODMEN TOWER OMAHA NE 68102 LEGAL SERVICES 157878 9 74694 1040313 650000 1115007 ANCILLARY SERVICES 621400 14564683 14564683 RURAL HEALTH CLINICS 621400 5844360 5844360 LABORATORY 621400 3765447 3765447 RETAIL PHARMACY REVENUE 446110 2997128 2997128 OPERATING & RECOVERY ROOMS 621400 2081909 2081909 1747634 1747634 31001161 70779 70779 212775 18599 194176 194176 194176 608615 15000 578180 101509 30435 -86509 -56074 -56074 0 74694 5000 -5000 -5000 CAFETERIA SALES 900099 216526 216526 216526 32536575 28004033 2997128 420407 990205 809936 180269 31689 31689 13056247 12140403 915844 304401 279644 24757 1996825 1996825 860935 770828 90107 425573 425573 171471 171471 113012 113012 21408 21408 2952549 2606427 346122 126323 68305 58018 1263563 1150032 113531 427412 389214 38198 362428 360394 2034 144585 112173 32412 91953 22148 69805 1050015 954627 95388 136757 21567 115190 RETAIL PHARMACY EXPENSE 3241186 3241186 MEDICAL SUPPLIES 2556742 2556742 BAD DEBT 506992 506992 MISCELLANEOUS 240557 15915 224642 127445 68212 59233 31200273 28103259 3097014 0 620462 171951 760659 749408 263569 2561451 2605359 192802 209937 931915 324853 57599 99622 31714237 24355495 6063036 7358742 2005381 2434272 240975 768173 13434280 14985886 2545813 3112703 1343383 983759 1519237 1295263 127046 0 5535479 5391725 X 7846706 8592489 52095 1001672 7898801 9594161 13434280 14985886 1336302 359058 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 5568 5568 0 PART II-B, LINE 1: STEWART MEMORIAL COMMUNITY HOSPITAL PAID DUES TO THE AMERICAN HOSPITAL ASSOCIATION AND THE IOWA HOSPITAL ASSOCIATION, A PORTION OF THE DUES WERE USED FOR LOBBYING ACTIVITIES. 650000 146413 796413 5620063 4445491 1174572 22627992 19029105 3598887 2669769 880899 1788870 7358742 OTHER RECEIVABLE 385502 INVESTMENT IN CAPTIVE 78773 ESTIMATED THIRD-PARTY PAYOR SETTLEMENTS 303898 768173 X 32412240 359058 23599 382657 32029583 506992 506992 32536575 30716880 23599 23599 30693281 506992 506992 31200273 PART X, LINE 2: THE HOSPITAL IS A NOT-FOR-PROFIT CORPORATION AS DESCRIBED IN SECTION 501(C)(3) OF THE CODE AND HAS RECEIVED A DETERMINATION LETTER THAT IT IS EXEMPT FROM FEDERAL INCOME TAXES ON RELATED INCOME PURSUANT TO SECTION 501(A) OF THE CODE. THE INTERNAL REVENUE SERVICE HAS ESTABLISHED STANDARDS TO BE MET TO MAINTAIN THE HOSPITAL'S TAX EXEMPT STATUS. IN GENERAL, SUCH STANDARDS REQUIRE THE HOSPITAL TO MEET A COMMUNITY BENEFITS STANDARD AND COMPLY WITH VARIOUS LAWS AND REGULATIONS. THE HOSPITAL ACCOUNTS FOR UNCERTAINTIES IN ACCOUNTING FOR INCOME TAX ASSETS AND LIABILITIES USING GUIDANCE INCLUDED IN FINANCIAL ACCOUNTING STANDARDS BOARD (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, 2019 AND 2018, THE HOSPITAL HAD NO UNCERTAIN TAX POSITIONS ACCRUED. PART XI, LINE 2D - OTHER ADJUSTMENTS: RENTAL EXPENSES 18,599. FUNDRAISING EXPENSES 5,000. PART XI, LINE 4B - OTHER ADJUSTMENTS: PROVISION FOR UNCOLLECTIBLE ACCOUNTS 506,992. PART XII, LINE 2D - OTHER ADJUSTMENTS: RENTAL EXPENSES 18,599. FUNDRAISING EXPENSES 5,000. PART XII, LINE 4B - OTHER ADJUSTMENTS: PROVISION FOR UNCOLLECTIBLE ACCOUNTS 506,992. TRIVIA NIGHT 74694 74694 120 500 3500 400 480 74694 74694 120 500 3500 400 480 5000 -5000 1 1 X 1 X 1 X 100.000000000000 0 1 0 1 1 182 80524 80524 0.00260 1548 4304765 3595781 708984 0.02310 1730 4385289 3595781 789508 0.02570 15 4507 98565 16100 82465 0.00270 4 50 133887 133887 0.00440 5 42 18660 18660 0.00060 24 4599 251112 16100 235012 0.00770 24 6329 4636401 3611881 1024520 0.03340 1 12 4732 1975 2757 0.00010 1 4435 0 4435 0.00010 1 1901 0 1901 0.00010 3 12 11068 1975 9093 0.00030 1 506992 0 10557969 10589810 -31841 X 1 1 1 1 STEWART MEMORIAL COMMUNITY HOSPITAL 1301 WEST MAIN STREET LAKE CITY IA 51449 WWW.STEWARTMEMORIAL.ORG 130029H X X X X STEWART MEMORIAL COMMUNITY HOSPITAL 1 0 0 1 X X X X X X X X 18 1 0 1 1 X WWW.STEWARTMEMORIAL.ORG X X 1 18 1 WWW.STEWARTMEMORIAL.ORG 0 1 X 200.000000000000 100.000000000000 X X X 1 1 X X X 1 X WWW.STEWARTMEMORIAL.ORG X WWW.STEWARTMEMORIAL.ORG X WWW.STEWARTMEMORIAL.ORG X X X X X X 1 X 0 X X X X 1 X 0 0 STEWART MEMORIAL COMMUNITY HOSPITAL PART V, SECTION B, LINE 5: STEWART MEMORIAL COMMUNITY HOSPITAL (SMCH) CREATED A COMMUNITY NEEDS ASSESSMENT SURVEY. THE SURVEY WAS DISTRIBUTED THROUGHOUT THE SMCH SERVICE AREA TO VARIOUS ORGANIZATIONS INCLUDING PUBLIC HEALTH, SCHOOLS, OTHER HEALTH CARE PROVIDERS AND LOCAL BUSINESSES ALONG WITH EMPLOYEES OF THE HOSPITAL AND ITS AUXILIARY. A COMMUNITY FORUM WAS HELD TO DISCUSS THE RESULTS OF THE ASSESSMENT AND TO DEVELOP A PLAN TO ADDRESS THE PRIORITIES IDENTIFIED. THOSE INVITED INCLUDED MEMBERS OF THE HOSPITAL, CALHOUN COUNTY PUBLIC HEALTH, OTHER HEALTH CARE PROVIDERS INCLUDING NURSING HOMES, OPTOMETRIST, DENTISTS AND ICF/ID PROVIDER, INSURANCE AGENTS, SCHOOL REPRESENTATIVES AND COMMUNITY MEMBERS. STEWART MEMORIAL COMMUNITY HOSPITAL PART V, SECTION B, LINE 6B: CALHOUN COUNTY PUBLIC HEALTH STEWART MEMORIAL COMMUNITY HOSPITAL PART V, SECTION B, LINE 7D: A HARD COPY OF THE SURVEY WAS PRINTED AND DISTRIBUTED THROUGHOUT OUR SERVICE AREA INCLUDING THE LOCAL LIBRARY. STEWART MEMORIAL COMMUNITY HOSPITAL PART V, SECTION B, LINE 11: THERE WERE 6 PRIORITY AREAS IDENTIFIED IN THE ASSESSMENT - 1) PROMOTE HEALTHY LIVING; 2) PREVENT INJURIES & VIOLENCE; 3) PROTECT AGAINST ENVIRONMENTAL HAZARDS; 4) PREVENT EPIDEMICS & THE SPREAD OF DISEASE; 5) PREPARE FOR, RESPOND TO, & RECOVER FROM PUBLIC HEALTH EMERGENCIES; 6) STRENGTHEN THE HEALTH INFRASTRUCTURE. THE 1ST PRIORITY, PROMOTE HEALTHY LIVING HAS 3 PRIORITIES OF ITS OWN AND 2 GOALS. THE PRIORITIES ARE CHRONIC DISEASES PREVENTION & SCREENING, ADDICTIVE BEHAVIORS IN ADULTS, AND ADDICTIVE BEHAVIORS IN YOUTH. THE GOALS ARE 1) REDUCE ILLNESS, DISABILITY AND DEATH RELATED TO TOBACCO PRODUCTS AND SECOND-HAND SMOKE EXPOSURE; 2) REDUCE SUBSTANCE ABUSE TO PROTECT THE HEALTH SAFETY AND QUALITY OF LIFE FOR ALL, ESPECIALLY CHILDREN. THE 2ND PRIORITY, PREVENT INJURIES & VIOLENCE HAS 4 PRIORITIES LISTED IN THE CHNA. THE PRIORITIES ARE 1) UNINTENTIONAL INJURY RATES FOR ADULTS; 2) UNINTENTIONAL INJURY RATES FOR CHILDREN; 3) CHILD ABUSE & NEGLECT RATES; 4) BULLYING. THE GOAL IS TO PREVENT UNINTENTIONAL INJURIES, DEATHS, AND VIOLENCE AND REDUCE THEIR CONSEQUENCES. THE 1ST OBJECTIVE IS TO REDUCE MOTOR VEHICLE CRASH DEATHS WITH ALCOHOL INVOLVEMENT, THE 2ND OBJECTIVE IS TO DECREASE THE LOCAL INJURY RATE, THE 3RD OBJECTIVE IS TO REDUCE CONFIRMED OR FOUNDED EVENTS OF CHILD ABUSE AND NEGLECT, AND THE 4TH OBJECTIVE IS TO REDUCE THE PERCENT OF 6TH - 11TH GRADE STUDENTS WHO REPORT BEING BULLIED. THE 3RD PRIORITY, PROTECT AGAINST ENVIRONMENTAL HAZARDS HAS 3 PRIORITIES AND 2 GOALS UNDER IT. THE FIRST IS HEALTHY LIVING ENVIRONMENT, THE 2ND IS SURFACE & GROUND WATER QUALITY AND THE 3RD IS FOOD SAFETY AND HAZARDOUS WASTE DISPOSAL. THE GOALS ARE TO PROMOTE HEALTH FOR ALL THROUGH A HEALTHY ENVIRONMENT AND SURFACE & GROUND WATER QUALITY. THE 4TH PRIORITY, PREVENT EPIDEMICS & THE SPREAD OF DISEASE HAS 2 MAIN PRIORITIES LISTED UNDER IT - 1) IMMUNIZATION RATES; 2) INFECTIOUS DISEASE. THE 5TH PRIORITY, PREPARE FOR, RESPOND TO, & RECOVER FROM PUBLIC HEALTH EMERGENCIES IS BEING ADDRESSED UNDER 3 PRIORITIES - 1) HUMAN RESOURCE CAPACITY; 2) PLANNING; 3) TECHNICAL & COMMUNICATION CAPACITY. THE GOALS ARE TO SUPPORT A SYSTEM OF PUBLIC & PRIVATE PARTNERS THAT PREPARE FOR, RESPOND TO AND RECOVER FROM EVENTS THAT EXCEED INDIVIDUAL CAPACITIES. THE OBJECTIVE IS TO MAINTAIN CURRENT RECORDS OF COMPLETED CERTIFICATES OF BASIC INCIDENT COMMAND SYSTEM TRAINING REQUIREMENTS. THE LAST AND 6TH PRIORITY, STRENGTHEN THE HEALTH INFRASTRUCTURE ADDRESSES 3 PRIORITIES. THE 1ST PRIORITY IS ACCESS TO QUALITY HEALTH SERVICES AND SUPPORT, THE 2ND IS ACCREDITATION AND STANDARDIZATION OF HEALTH PROGRAMS & SERVICES AND THE 3RD IS POVERTY. 2 GOALS HAVE BEEN DEVELOPED UNDER THESE PRIORITIES AND THEY ARE AS FOLLOWS - 1) IMPROVE ACCESS TO QUALITY HEALTH SERVICES AND SUPPORT. THE OBJECTIVE IS TO REDUCE THE NUMBER OF PERSONS WHO ARE UNABLE TO OBTAIN OR DELAY OBTAINING NECESSARY MEDICAL CARE. GOAL 2 IS TO EXPAND DEVELOPMENT OF PATIENT-CENTERED MEDICAL HOME CONCEPT FOR ALL AGES. ITS OBJECTIVE IS TO INCREASE THE PROPORTION OF CHILDREN AND YOUTH WHO HAVE A SPECIFIC SOURCE OF ON-GOING CARE THAT FOLLOWS WELL-CHILD SCREENINGS FROM 0-5 YEARS TO AGES 6-18 YEARS.THERE WERE 2 PRIORITIES IDENTIFIED THAT WERE NOT ADDRESSED AND THEY WERE ADDICTIVE BEHAVIORS IN CHILDREN AND UNINTENTIONAL INJURY RATES FOR ADULTS.ADDICTIVE BEHAVIORS IN CHILDREN: THE FOCUS HAS CHANGED TO THE OPIOD CRISIS FROM OTHER ADDICTIVE BEHAVIORS. SMCH HAS FOCUSED ON THE OPIOID CRISIS THIS PAST YEAR THROUGH PARTICIPATION IN THE OPIOID TASK FORCE RATHER THAN LOOKING AT SPECIFIC ADDICTIVE BEHAVIORS SUCH AS ILLEGAL DRUGS, ALCOHOL ABUSE OR GAMBLING. SMCH IS STARTING TO IMPLEMENT PROCESSES THAT REQUIRE PROVIDER TO CHECK PRESCRIPTION DRUG MONITORING. SMCH SHARED A PRESCRIPTION DRUG SAFETY EDUCATION WEBINAR SERIES WITH CALHOUN COUNTY SCHOOLS FROM UNITY POINT.UNINTENTIONAL INJURY RATES FOR ADULTS: SMCH IS ADDRESSING THE UNINTENTIONAL FALL RATES BY PARTNERING WITH CALHOUN COUNTY PUBLIC HEALTH TO OFFER MATTER OF BALANCE CLASSES. SMCH CONTINUED TO OFFER THE SENIOR STRONG CLASS IN THE WINTER, SPRING AND FALL OF 2019 WITH 10 PARTICIPANTS PER CLASS AND 2 CLASS TIMES TYPICALLY. TAI CHI CLASSES ARE ALSO OFFERED TO MEMBERS OF OUR COMMUNITY. THE ONE ISSUE SMCH HAS NOT ADDRESSED IS HOW TO REDUCE THE NUMBER OF MOTOR VEHICLE ACCIDENTS RELATED TO ALCOHOL. SMCH HAS NOT ADDRESSED HOW TO REDUCE THE UNINTENTIONAL INJURY RATES FOR CHILDREN OTHER THAN HAVING AN EMPLOYEE THAT IS CERTIFIED IN THE PROPER INSTALLATION AND EVALUATION OF CAR SEATS. STEWART MEMORIAL COMMUNITY HOSPITAL PART V, SECTION B, LINE 13H: STEWART MEMORIAL COMMUNITY HOSPITAL IS COMMITTED TO PROVIDING NECESSARY HOSPITAL CARE AND TREATMENT TO ALL PATIENTS REGARDLESS OF THEIR ABILITY TO PAY. ANY PATIENT WHO HAS RECEIVED SERVICES AND WHO FALLS BELOW CERTAIN INCOME AND ASSET LIMITS MAY BE ELIGIBLE FOR HOSPITAL CARE FREE OF CHARGE, OR AT A REDUCTION OF OUR ESTABLISHED CHARGES.THE HOSPITAL USES THE POVERTY INCOME GUIDELINES ISSUED BY THE COMMUNITY SERVICE ADMINISTRATION AS A BASIS FOR ELIGIBILITY CRITERIA FOR DISCOUNTED CARE. THESE GUIDELINES ARE ADJUSTED ANNUALLY BASED ON INCREASES IN THE CONSUMER PRICE INDEX. SUPPORT TO GRANT FINANCIAL ASSISTANCE MUST BE FULLY DOCUMENTED IN OUR FILES. SMCH HAS A SPREADSHEET BASED ON THE FEDERAL POVERTY GUIDELINES TO DETERMINE DISCOUNTED CARE. THE SPREADSHEET ALSO ACCOUNTS FOR THE FAMILY SIZE IN DETERMINING ELIGIBILITY. FOR THOSE APPLYING, IF THEIR INCOME FALLS BETWEEN 225-250% OF THE GUIDELINES, 75% OF THE PATIENT'S BILL IS FORGIVEN; IF THE INCOME IS BETWEEN 300-400% OF THE GUIDELINES, 50% IS FORGIVEN; IF THE INCOME AT 450% OF THE GUIDELINES, 35% IS FORGIVEN; IF THE INCOME IS AT 500% OF THE GUIDELINES, 25% IS FORGIVEN. THE NEW 501(R) REGULATIONS AND POLICIES THAT TOOK EFFECT JANUARY 1, 2016 WILL BE MADE AVAILABLE TO EVERY PATIENT AND ALSO MADE AVAILABLE ON OUR WEBSITE. 4 1 - MCCRARY-ROST CLINIC 1351 WEST MAIN STREET LAKE CITY IA 51449 HEALTH CLINIC 2 - GOWRIE CLINIC 1800 MAIN GOWRIE IA 50543 HEALTH CLINIC 3 - LAKE VIEW CLINIC 1160 3RD STREET LAKE VIEW IA 51540 HEALTH CLINIC 4 - ROCKWELL CITY CLINIC 505 EAST LAKE STREET ROCKWELL CITY IA 50579 HEALTH CLINIC PART I, LINE 3C: NOT APPLICABLE PART I, LINE 6A: STEWART MEMORIAL COMMUNTIY HOSPITAL'S COMMUNITY BENEFIT REPORT IS NOT PREPARED BY A RELATED ORGANIZATION. PART I, LINE 7: STEWART MEMORIAL COMMUNITY HOSPITAL USED THE WORKSHEETS PROVIDED IN THE IRS INSTRUCTIONS FOR SCHEDULE H IN ADDITION TO THE INTERNAL COST ACCOUNTING SYSTEM. PART I, LINE 7G: THERE ARE NO COSTS ATTRIBUTABLE TO A PHYSICIAN CLINIC INCLUDED ON LINE 7G. PART I, LN 7 COL(F): THE BAD DEBT EXPENSE INCLUDED ON FORM 990, PART IX, LINE 25, COLUMN (A), BUT SUBTRACTED FOR PURPOSES OF CALCULATING THE PERCENTAGE IN THIS COLUMN IS $506,992. PART II, COMMUNITY BUILDING ACTIVITIES: ONE MEMBER OF THE ORGANIZATION IS A VOLUNTEER MEMBER ON THE LOCAL BETTERMENT ORGANIZATION. AT THE MONTHLY MEETINGS, THEY USE THEIR TIME TO PROMOTE THE SERVICES AND WELLNESS ACTIVITIES THE HOSPITAL PROVIDES. CURRENT AND PROSPECTIVE BUSINESSES UNDERSTAND THE VARIOUS HEALTH SERVICES THAT ARE MADE AVAILABLE TO THEM AND THEIR EMPLOYEES. OTHER STAFF MEMBERS SERVE ON VARIOUS PROJECT TEAMS IN OUR SURROUNDING COMMUNITIES TO REPRESENT THE HOSPITAL AND BUILD COMMUNITY AWARENESS. THE COO AND AN EMPLOYED PHYSICIAN ARE MEMBERS OF THE CALHOUN COUNTY BOARD OF HEALTH. STEWART MEMORIAL COMMUNITY HOSPITAL WORKED IN CONJUNCTION WITH CALHOUN COUNTY PUBLIC HEALTH TO COMPLETE A COMMUNITY NEEDS ASSESSMENT AND DEVELOP A HEALTH IMPROVEMENT PROGRAM. PART III, LINE 2: IN EVALUATING THE COLLECTIBILITY OF ACCOUNTS RECEIVABLE, THE HOSPITAL ANALYZES ITS PAST HISTORY AND IDENTIFIES TRENDS FOR EACH OF ITS MAJOR PAYOR SOURCES OF REVENUE TO ESTIMATE THE APPROPRIATE ALLOWANCE FOR DOUBTFUL 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 DOUBTFUL ACCOUNTS. FOR RECEIVABLES ASSOCIATED WITH SERVICES PROVIDED TO PATIENTS WHO HAVE THIRD-PARTY COVERAGE, THE HOSPITAL ANALYZES CONTRACTUALLY DUE AMOUNTS AND ESTIMATES A PERCENTAGE OF THOSE ACCOUNTS THAT WILL TRANSITION TO SELF-PAY PATIENTS BASED ON HISTORICAL ANALYSIS. THE ESTIMATED PERCENTAGE OF THOSE TRANSITION ACCOUNTS ARE ADDED TO 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 DOUBTFUL ACCOUNTS. PART III, LINE 4: THE ORGANIZATION'S FINANCIAL STATEMENTS DO NOT CONTAIN A SPECIFIC FOOTNOTE DESCRIBING BAD DEBT. HOWEVER, PAGES 8 THROUGH 11 OF THE ATTACHED AUDITED FINANCIAL STATEMENTS INCLUDE FOOTNOTES TITLED "PATIENT RECEIVABLES" "PATIENT SERVICE REVENUE, AND "CHARITY CARE." PART III, LINE 8: NO MEDICARE SHORTFALL IS TREATED AS COMMUNITY BENEFIT. THE 2019 FILED MEDICARE COST REPORT WAS USED TO DETERMINE THE ALLOWABLE COSTS. PART III, LINE 9B: COLLECTION POLICY:PATIENTS ARE ADMITTED INTO THE HOSPITAL COMPUTER SYSTEM WITH APPROPRIATE FINANCIAL INFORMATION INCLUDING INSURANCE INFORMATION AND ARE ASSIGNED A FINANCIAL CLASS (F/C) USED TO SEGREGATE ACCOUNTS IN ACCOUNTS RECEIVABLE (A/R) BY PAYER TYPE. PATIENTS WHO ARE MINORS ARE ADMITTED WITH THE PARENT WHO CARRIES THE INSURANCE COVERAGE AS THE RESPONSIBLE PARTY OR IF NO INSURANCE, THE PARENT WHO BROUGHT THE CHILD IN FOR CARE IS LISTED AS GUARANTOR.THE BUSINESS OFFICE WILL SEND AN ITEMIZED STATEMENT OF CHARGES TO ALL PATIENTS WHO REQUEST A COPY. INSURANCE COMPANIES ARE BILLED ELECTRONICALLY THROUGH THE USE OF EMDEON SOFTWARE WHENEVER POSSIBLE. ONCE THE INSURANCE COMPANY HAS PROCESSED THE CLAIM AND PAID ITS ENTIRE SHARE OR IF THE PATIENT DOESN'T HAVE INSURANCE, THEY WILL BE ASSIGNED A FINANCIAL CLASS OF SELF-PAY. SMCH ALLOWS PATIENTS TO SET UP PAYMENT ARRANGEMENTS FOLLOWING THIS SCHEDULE USING CHECK, MONEY ORDER, MASTERCARD OR VISA:BALANCE IS: MINIMUM PAYMENT:UNDER $250 $ 25.00 $251-$500 $ 50.00$501-$1000 $ 100.00$1001 - ABOVE $ 150.00THESE LIMITS ARE SET TO INSURE BALANCES ARE PAID IN FULL WITH 18 MONTHS IF AT ALL POSSIBLE. WHEN THE PATIENT IS ASSIGNED A FINANCIAL CLASS OF P, THE ACCOUNT IS SENT TO MED-PLAN FOR EARLY OUT PRE-COLLECT PROCESSING. THE FIRST STATEMENT FROM MED-PLAN IS MAILED OUT ON DAY 1 WHEN THEY RECEIVE THE ACCOUNT AND THEN AGAIN AT 30 DAYS. ACCOUNTS THAT DO NOT MAKE PAYMENT ARRANGEMENTS OR MAKE PAYMENTS FROM THE LETTER CAMPAIGN AFTER 45 DAYS ARE MOVED INTO A TELEPHONE CAMPAIGN. THE TELEPHONE CAMPAIGN MAKES 3 ATTEMPTS OVER 15 DAYS TO SECURE PAYMENT IN FULL OR A SCHEDULED PAYMENT PLAN. IF RESOLUTION ATTEMPTS FAIL AND MED-PLAN IS UNABLE TO RESOLVE AN ACCOUNT BECAUSE (1) IT IS IMPOSSIBLE TO REACH A PATIENT BY TELEPHONE, OR (2) THE PATIENT HAS FAILED TO COOPERATE IN ESTABLISHING A PAYMENT PLAN, OR (3) THE PATIENT HAS FAILED TO HONOR AN ESTABLISHED PLAN BY NOT MAKING SATISFACTORY PAYMENT WITHIN 60-90 DAYS, A FINAL NOTICE WILL BE SENT TO THE PATIENT. ACCOUNTS UNPAID OR ARRANGEMENTS NOT MADE AT THIS POINT IN THE BILLING PROCESS ARE DETERMINED UNCOLLECTIBLE. IF NO PAYMENT IN ALLOWABLE TIME IS RECEIVED, ACCOUNTS ARE ELECTRONICALLY SENT TO A COLLECTION AGENCY. IN THE EVENT OF PARTIAL PAYMENT, A DETERMINATION ON AN INDIVIDUAL BASIS IS MADE AS TO STOP OR PROCEED WITH THE COLLECTION AGENCY. PART VI, LINE 2: SMCH COLLABORATES WITH THE COUNTY HEALTH DEPARTMENT IN ASSESSING THE HEALTH CARE NEEDS OF THE COMMUNITIES THEY SERVE. SMCH ALSO EVALUATES USAGE DATA THROUGH THE IOWA HOSPITAL ASSOCIATION TO SEE THE PRIMARY MEDICAL DIAGNOSIS IN THEIR COMMUNITIES. PART VI, LINE 3: SMCH HAS A PATIENT ACCOUNTS MANAGER AS WELL AS A SOCIAL WORKER ON STAFF THAT IDENTIFY PATIENTS THAT MAY BE ELIGIBLE FOR ASSISTANCE OR QUALIFY FOR CHARITY CARE. THEY ASSIST THE PATIENT WITH AVAILABLE OPTIONS AND/OR THE NECESSARY PAPERWORK. PART VI, LINE 4: THE SERVICE AREA IS A 35 MILE RADIUS SURROUNDING THE SMCH COMMUNITY. THIS AREA CONSISTS OF MANY SMALL, RURAL COMMUNITIES THAT ARE AGRICULTURAL BASED. THE PATIENT BASE CONSISTS OF A LARGE MEDICARE POPULATION. PART VI, LINE 5: SMCH PROVIDES THE COMMUNITIES WITH LABORATORY WELLNESS TESTING AND EDUCATIONAL PROGRAMS ON PROMOTING HEALTHY LIFESTYLES. THEY PROVIDE CARE TO THE INDIGENT REGARDLESS OF THEIR ABILITY TO PAY. THE BOARD OF DIRECTORS ARE REPRESENTED BY THE VARIOUS COMMUNITIES THEY SERVE.THE HOSPITAL HAS ALSO JOINED WITH THE COUNTY DEPARTMENT OF HEALTH IN ESTABLISHING A PROGRAM CALLED "CARING HANDS CLOSET." CARING HANDS CLOSET IS A PROGRAM FOR EXPECTING MOTHERS AND NEW MOTHERS TO EARN POINTS TOWARDS BABY ITEMS BY ATTENDING THEIR DOCTOR APPOINTMENTS AND/OR EDUCATIONAL PROGRAMS. SMCH PROVIDES MONTHLY LABORATORY WELLNESS TESTING AND EDUCATIONAL PROGRAMS BI-MONTHLY. PART VI, LINE 6: SMCH IS NOT PART OF AN AFFILIATED HEALTH CARE SYSTEM. PART VI, LINE 7, REPORTS FILED WITH STATES IA X X X 0 0 0 0 0 0 0 0 0 DEREK DUNCAN MEDICAL COUNSEL 621345 0 130035 0 270 0 7138 0 51148 0 809936 0 0 0 SUSAN HORNBACK D.O. 655873 0 90000 0 414 0 8206 0 49405 0 803898 0 0 0 RONALD CHENEY D.O. 493036 0 0 0 0 0 0 0 25017 0 518053 0 0 0 DANNIELE ANDERSON PA 347688 0 0 0 112 0 8178 0 47714 0 403692 0 0 0 MARGARET VITIRITTO-KHAN D.O. 321675 0 0 0 270 0 7726 0 39241 0 368912 0 0 0 MARK MOGENSEN PA 329145 0 1600 0 270 0 8400 0 52148 0 391563 0 0 0 JIM HENKENIUS CFO 140415 0 0 0 414 0 4487 0 34953 0 180269 0 0 0 FORM 990, PART VII, LINE 5: CYNTHIA CARSTENS, CEO, RECEIVED COMPENSATION FROM UNITYPOINT HEALTH, AN UNRELATED ENTITY, WHICH PROVIDES MANAGEMENT SERVICES TO ITS CLIENTS. MS. CARSTENS RECEIVED A BASE COMPENSATION OF $185,286 FOR HER SERVICES DURING THE CALENDAR YEAR 2019. HER COMPENSATION IS REPORTED IN PART IX, LINE 11A. A CITY OF LAKE CITY IOWA 426004850 508021AQ5 2016-10-24 1440000 CAPITAL IMPROVEMENTS 0 0 0 A 765000 1440000 72000 1368000 2016 0 0 1 1 A 0 0 0 0 0.00000 0.00000 0.00000 0 0 0 A 0 0 1 1 0 0 0 0 0 A 0 JODI HENKENIUS ORGANIZATION'S EMPLOYEE & SPOUSE OF JIM HENKENIUS, CFO 31689 EMPLOYEE WAGES 0 X 1 650000 FAIR MARKET VALUE 0 0 1 0 FORM 990, PART III, LINE 3 ON JUNE 30, 2019, THE HOSPITAL SOLD ITS RETAIL PHARMACY OPERATIONS TO AN UNRELATED PARTY. FORM 990, PART VI, SECTION A, LINE 3 UNITYPOINT HEALTH AND STEWART MEMORIAL COMMUNITY HOSPITAL HAVE AN AGREEMENT FOR ADMINISTRATIVE SERVICES. UNITYPOINT HEALTH PROVIDED THE SERVICES OF CYNTHIA CARSTENS, CEO. FORM 990, PART VI, SECTION B, LINE 11B THE FORM 990 WILL BE PROVIDED ELECTRONICALLY TO THE BOARD OF DIRECTORS AND REVIEWED BY THE CEO AND CFO PRIOR TO SUBMISSION. FORM 990, PART VI, SECTION B, LINE 12C EACH BOARD MEMBER SIGNS A CONFLICT OF INTEREST FORM ANNUALLY STATING THAT THEY WILL ABSTAIN FROM VOTING AND DISCUSSING ITEMS FOR WHICH THEY HAVE A CONFLICT OF INTEREST. FORM 990, PART VI, SECTION B, LINE 15A THE BOARD OF DIRECTORS MEET ANNUALLY TO DISCUSS THE TERMS OF THE CEO'S CONTRACT. THEY USE DATA FROM THE LATEST IOWA HOSPITAL ASSOCIATION SALARY SURVEY. FORM 990, PART VI, SECTION C, LINE 19 THE ORGANIZATION DOES NOT MAKE ITS GOVERNING DOCUMENTS, CONFLICT OF INTEREST POLICY, OR FINANCIAL STATEMENTS AVAILABLE TO THE PUBLIC. FORM 990, PART XII, LINE 2C: THE BOARD OF DIRECTORS ASSUMES THE RESPONSIBILITY FOR OVERSIGHT OF THE AUDIT OF THE FINANCIAL STATEMENTS AND SELECTION OF THE INDEPENDENT ACCOUNTANT. THIS PROCESS HAS NOT CHANGED FROM THE PREVIOUS YEAR.