2016-11-15T08:53:31-06:00 2015-12-31 476097913 SEIM JOHNSON LLP 18081 BURT STREET SUITE 200 OMAHA NE 680224722 990 2015-01-01 420860039 STEWART MEMORIAL COMMUNITY HOSPITAL STEW 7124644200 1301 W MAIN LAKE CITY IA 51449 JIM HENKENIUS CHIEF FINANCIAL OFFICER 7124644200 2016-11-14 1 WENDY R COOLEY P01523804 4023302660 2015 2017-02-10 21:41:12Z JIM HENKENIUS 1301 W MAIN LAKE CITY IA 51449 30984135 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 8 295 125 5080328 -917433 53713 60066 30466632 30419535 459202 117522 266790 271496 31246337 30868619 0 0 0 0 15352287 15615339 0 0 0 16534276 16237622 31886563 31852961 -640226 -984342 18021265 16694795 8332082 8117476 9689183 8577319 STEWART MEMORIAL COMMUNITY HOSPITAL IS COMMITTED TO PROVIDING QUALITY HEALTHCARE WITH A PERSONAL TOUCH AND RESPONDING TO THE NEEDS OF THE COMMUNITIES AND PEOPLE WE SERVE. 0 0 28837945 25339207 STEWART MEMORIAL COMMUNITY HOSPITAL (SMCH) IS A COMPLETE RURAL HEALTH DELIVERY SYSTEM LOCATED IN LAKE CITY, IOWA. SERVICES PROVIDED INCLUDE INPATIENT, OUTPATIENT, PHYSICIAN CLINIC, HOMECARE, RETAIL PHARMACY, COMMUNITY WELLNESS, AND MANY OTHER RELATED HEALTHCARE PROGRAMS. SMCH IS ALSO AN APPROVED CRITICAL ACCESS HOSPITAL THAT PROVIDES EMERGENCY, OUTPATIENT AND SHORT-TERM INPATIENT SERVICES. 28837945 1 1 0 0 0 0 0 0 0 0 1 0 0 0 1 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 0 0 0 0 0 0 0 0 0 0 0 1 30 0 1 295 1 1 1 0 0 0 0 1 1 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 CHADRIC DIETRICH BOARD CHAIR 2.00 0.00 X X 0 0 0 BRADLEY LANE VICE CHAIR 2.00 0.00 X X 0 0 0 HEATHER MCCLUE SECRETARY 2.00 0.00 X X 0 0 0 SCOTT NESBITT TREASURER 2.00 0.00 X X 0 0 0 DEBRA LIGHTNER DIRECTOR 1.00 0.00 X 0 0 0 MARY WARNER DIRECTOR 1.00 0.00 X 0 0 0 LINDA BETTIN DIRECTOR 1.00 0.00 X 0 0 0 CHARLES SCHMITT DIRECTOR 1.00 0.00 X 0 0 0 DR ADAM SWISHER MEDICAL COUNSEL 40.00 0.00 X 397648 0 30781 HEATHER CAIN CEO 40.00 0.00 X 0 0 0 JIM HENKENIUS CFO 40.00 0.00 X 135613 0 29663 DEREK DUNCAN D.O. 40.00 0.00 X 668162 0 27104 DR DAVID FRATE D.O. 40.00 0.00 X 334032 0 14856 SUSAN HORNBACK D.O. 40.00 0.00 X 608770 0 26157 DANNIELE ANDERSON PA 40.00 0.00 X 315208 0 25427 MARK MORGENSEN PA 40.00 0.00 X 287386 0 27426 2746819 0 181414 21 0 1 1 WESTERN IOWA SURGERY 311 S CLARK STREET SUITE 280 CARROLL IA 51401 GENERAL SURGERY SERVICES 173475 RTG MEDICAL 1005 E 23RD STREET FREMONT NE 68025 CONTRACTED NURSING SERVICES 153103 LOCUM TENENSCOM LLC PO BOX 405547 ATLANTA GA 30384 ER PHYSICIAN LOCUM TENENS 152398 HEALTHNET CONNECT 1776 WEST LAKES PARKWAY SUITE 400 W DES MOINES IA 50266 IT CONTRACTED SERVICES 141735 DES MOINES ORTHOPAEDIC SURGEONS 6001 WESTOWN PARKWAY W DES MOINES IA 50266 ORTHOPAEDIC SURGERY SERVICES 126800 5 41048 19018 60066 MEDICARE/MEDICAID REVENUE 621400 13241486 13241486 PATIENT SERVICE REVENUE 621400 9788824 9788824 RETAIL PHARMACY REVENUE 446110 5080328 5080328 340B PROGRAM REVENUE 621400 2174842 2174842 134055 134055 30419535 70519 70519 98820 23989 74831 74831 74831 118370 12700 84067 0 34303 12700 47003 47003 4685 41048 7460 -2775 -2775 CAFETERIA SALES 900099 199440 199440 199440 30868619 25339207 5080328 389018 593705 428429 165276 11821208 10755635 1065573 176019 162104 13915 2277813 2009405 268408 746594 674311 72283 390333 390333 16817 16817 78165 78165 18559 18559 2809605 2597257 212348 154542 104254 50288 1017999 895404 122595 185119 185119 335695 335695 241037 137849 103188 160475 160475 1415400 1284295 131105 162161 162161 RETAIL PHARMACY EXPENSE 5093113 5093113 MEDICAL SUPPLIES 3124323 3124323 BAD DEBT 620147 620147 FOOD 191224 191224 222908 101864 121044 31852961 28837945 3015016 0 72585 346198 1153669 1163427 3947596 3050093 43093 68380 1496427 1480950 80038 35573 29946197 21461991 8484469 8484206 2069922 1894771 673466 171197 18021265 16694795 3637274 3118768 2765000 2425000 1929808 2339814 0 233894 8332082 8117476 X 9689183 8577319 9689183 8577319 18021265 16694795 -984342 -127522 0 X X 0 1 X 1 0 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 171513 171513 5953917 4543545 1410372 21523010 16001302 5521708 2297757 917144 1380613 8484206 ESTIMATED THIRD-PARTY SETTLEMENTS 233894 233894 X 30152399 -127522 31449 -96073 30248472 620147 620147 30868619 31264263 31449 31449 31232814 620147 620147 31852961 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 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, 2015 AND 2014, THE HOSPITAL HAD NO UNCERTAIN TAX POSITIONS ACCRUED. PART XI, LINE 2D - OTHER ADJUSTMENTS: RENTAL EXPENSES 23,989. FUNDRASING EXPENSES 7,460. PART XI, LINE 4B - OTHER ADJUSTMENTS: PROVISION FOR UNCOLLECTIBLE ACCOUNTS 620,147. PART XII, LINE 2D - OTHER ADJUSTMENTS: RENTAL EXPENSES 23,989. FUNDRAISING EXPENSE 7,460. PART XII, LINE 4B - OTHER ADJUSTMENTS: PROVISION FOR UNCOLLECTIBLE ACCOUNTS 620,147. TABLE A FARE 5178 5178 609 72 TRIVIA NIGHT 40555 35870 4685 226 50 3249 400 2854 45733 41048 4685 226 50 3858 400 2926 7460 -2775 1 1 1 X 1 X 100.000000000000 0 1 0 1 1 151 63658 0 63658 0.00200 3612854 2958130 654724 0.02100 151 3676512 2958130 718382 0.02300 12 7394 148530 37750 110780 0.00350 3 16 25403 25403 0.00080 4 285 21736 21736 0.00070 19 7695 195669 37750 157919 0.00500 19 7846 3872181 2995880 876301 0.02800 1 918 0 918 0.00000 1 1655 0 1655 0.00010 1 360 625 625 0.00000 3 360 3198 3198 0.00010 1 620147 0 9758232 10036402 -278170 X 1 0 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 15 1 0 0 1 X WWW.STEWARTMEMORIAL.ORG X 1 15 0 1 0 1 X 200.000000000000 100.000000000000 X 1 1 X X X 1 X WWW.STEWARTMEMORIAL.ORG X WWW.STEWARTMEMORIAL.ORG X WWW.STEWARTMEMORIAL.ORG 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 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 3 GOALS. THE PRIORITIES ARE CHRONIC DISEASE PREVENTION & SCREENING, ADDICTIVE BEHAVIORS IN ADULTS AND ADDICTIVE BEHAVIORS IN CHILDREN. THE GOALS ARE 1) REDUCE THE NUMBER OF NEWLY DIAGNOSED CASES OF DIABETES IN THE POPULATION; 2) REDUCE ILLNESS, DISABILITY AND DEATH RELATED TO TOBACCO PRODUCTS AND SECOND-HAND SMOKE EXPOSURE; 3) REDUCE ALCOHOL 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 A HEALTHY LIVING ENVIRONMENT, 2ND IS SURFACE & GROUND WATER QUALITY AND 3RD IS FOOD SAFETY & HAZARDOUS WASTE DISPOSAL. THE GOALS ARE SAFE AND HEALTHY HOUSING FOR ALL 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 FIRST GOAL FOR IMMUNIZATION RATES IS TO ACHIEVE IMMUNIZATION COVERAGE FOR ALL UNIVERSALLY RECOMMENDED VACCINES BY INCREASING THE RECOMMENDED VACCINE LEVELS FOR CHILDREN AND ADULTS. THE SECOND GOAL IS TO REDUCE THE OUTBREAK RATES OF PREVENTABLE INFECTIOUS DISEASES. THE 2 OBJECTIVES ARE TO 1)DECREASE THE PROPORTION OF SEXUALLY ACTIVE PERSONS 24 YEARS AND YOUNGER DIAGNOSED WITH GENITAL CHLAMYDIA & GONORRHEA AND 2) REDUCE THE NUMBER OF IDSS CASES OF FOOD AND WATERBORNE DISEASES. 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 GOAL IS 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, HAS 3 PRIORITIES OF ITS OWN. 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. 4 GOALS HAVE BEEN DEVELOPED UNDER THESE PRIORITIES AND THEY AS FOLLOWS - 1) IMPROVE ACCESS TO QUALITY HEALTH SERVICES AND SUPPORT. THE OBJECT 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 WITH 3 OBJECTIVES - 1) INCREASE THE PROPORTION OF CHILDREN & YOUTH WHO HAVE A SPECIFIC SOURCE OF ON-GOING CARE THAT FOLLOWS MEDICAID EARLY & PERIODIC SCREENING, DIAGNOSIS AND TREATMENT (EPSDT) RECOMMENDATIONS; 2) INCREASE THE PROPORTION OF ADULTS WHO HAVE A SPECIFIC SOURCE OF ON-GOING CARE THAT FOLLOWS THE COMMUNITY GUIDE/HEALTH INSURANCE COVERAGE WELLNESS SCREENING RECOMMENDATIONS; 3) INCREASE THE PROPORTION OF ADULTS WHO HAVE A SPECIFIC SOURCE OF ON-GOING CARE THAT FOLLOWS MEDICARE WELLNESS SCREENING RECOMMENDATIONS. THE 3RD GOAL IS TO ACHIEVE ACCREDITATION-LEVELS, STANDARDS DEVELOPMENT OR STRATEGIC PLANNING FOR PROGRAMS & SERVICES BY PURSUING PUBLIC HEALTH ACCREDITATION BOARD QUALITY INDICATORS FOR DOMAIN STANDARDS & PERFORMANCE MEASURES. THE LAST GOAL IS COMMUNITY-WIDE AWARENESS OF EMERGING STRATEGIES TO ADDRESS SOCIAL DETERMINANTS OF HEALTH THAT KEEP PEOPLE IN POVERTY. WE WILL ORGANIZE A COUNTY AND/OR REGIONAL "COALITION" DEDICATED TO COMPREHENSIVE STRATEGIES THAT WILL INCREASE UNDERSTANDING OF COLLABORATIVE ACTION TO ADDRESS INEQUITABLE SOCIAL DETERMINANTS OF HEALTH. THERE WAS 1 PRIORITY IDENTIFIED THAT WAS NOT ADDRESSED AND THAT WAS FOOD SAFETY AND HAZARDOUS WASTE DISPOSAL. AN EXISTING PROGRAM ALREADY EXISTS TO ADDRESS THE PROBLEM. BUENA VISTA COUNTY ASSUMED ALL FOOD INSPECTIONS FOR CALHOUN COUNTY IN 2015. CALHOUN COUNTY EH MAINTAINS A HOUSEHOLD HAZARDOUS WASTE SITE IN COLLABORATION WITH METRO WASTE AUTHORITY. 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 TAKE EFFECT JANUARY 1, 2016 WILL BE MADE AVAILABLE TO EVERY PATIENT AND ALSO MADE AVAILABLE ON OUR WEBSITE. STEWART MEMORIAL COMMUNITY HOSPITAL PART V, SECTION B, LINE 22D: IT IS THE POLICY OF THE HOSPITAL TO DETERMINE ELIGIBILITY FOR THE FINANCIAL ASSISTANCE PROGRAM AFTER CARE IS ADMINISTERED. 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 $620,147. 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 AND 9 OF THE ATTACHED AUDITED FINANCIAL STATEMENTS INCLUDE FOOTNOTES TITLED "PATIENT RECEIVABLES, NET," "NET PATIENT SERVICE REVENUE, AND "CHARITY CARE." PART III, LINE 8: NO MEDICARE SHORTFALL IS TREATED AS COMMUNITY BENEFIT. THE 2015 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. PART VI, LINE 6: THE HOSPITAL HAS 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 7, REPORTS FILED WITH STATES IA X X X 0 0 0 0 0 0 0 0 0 DR ADAM SWISHER MEDICAL COUNSEL 385186 0 12318 0 144 0 7077 0 23704 0 428429 0 0 0 JIM HENKENIUS CFO 135460 0 0 0 153 0 4305 0 25358 0 165276 0 0 0 DEREK DUNCAN D.O. 517982 0 150000 0 180 0 5220 0 21884 0 695266 0 0 0 DR DAVID FRATE D.O. 286264 0 47663 0 105 0 4403 0 10453 0 348888 0 0 0 SUSAN HORNBACK D.O. 518500 0 90000 0 270 0 7063 0 19094 0 634927 0 0 0 DANNIELE ANDERSON PA 305161 0 0 0 10047 0 7525 0 17902 0 340635 0 0 0 MARK MORGENSEN PA 277224 0 0 0 10162 0 3944 0 23482 0 314812 0 0 0 FORM 990, PART VII, LINE 5: HEATHER CAIN, CEO, RECEIVED COMPENSATION FROM TRINITY HEALTH SYSTEMS, AN UNRELATED ENTITY, WHICH PROVIDES MANAGEMENT SERVICES TO ITS CLIENTS. MS. CAIN RECEIVED A BASE COMPENSATION OF $156,560 FOR HER SERVICES DURING THE CALENDAR YEAR 2015. HER COMPENSATION IS REPORTED IN PART IX, LINE 11A. A CITY OF LAKE CITY IOWA 426004850 508021AQ5 2006-02-08 5000000 CAPITAL IMPROVEMENTS 0 0 0 A 2575000 5142886 484047 4658839 2008 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 PART II, LINE 3: THE TOTAL PROCEEDS DO NOT AGREE TO THE ISSUE PRICE IN PART I, COLUMN (E) DUE TO INVESTMENT EARNINGS. PART IV, ARBITRAGE, LINE 2C: (A) ISSUER NAME: CITY OF LAKE CITY, IA DATE THE REBATE COMPUTATION WAS PERFORMED: 01/31/2011 PART V STEWART MEMORIAL COMMUNITY HOSPITAL IS IN THE PROCESS OF ADOPTING VCAP PROCEDURES. FORM 990, PART VI, SECTION A, LINE 3 TRINITY HEALTH SYSTEMS AND STEWART MEMORIAL COMMUNITY HOSPITAL HAVE AN AGREEMENT FOR ADMINISTRATIVE SERVICES. TRINITY HEALTH SYSTEMS PROVIDED THE SERVICES OF HEATHER CAIN, CEO SINCE 01/01/14. FORM 990, PART VI, SECTION B, LINE 11 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.