2015-05-14T16:00:05-05:00 2014-06-30 470617373 CATHOLIC HEALTH INITIATIVES 198 INVERNESS DRIVE WEST ENGLEWOOD CO 80112 990 2013-07-01 470379755 GOOD SAMARITAN HOSPITAL GOOD 3088657900 PO Box 1990 Kearney NE 68848 JEANETTE WOJTALEWICZ CFO CHI HEALTH 2014-05-13 true ANGELA LEA P01051055 3032989100 2013 2016-03-07 17:11:31Z CHI GOOD SAMARITAN CLIFF ROBERTSON 12809 West Dodge Road Omaha NE 68154 238117698 false 0928 X WWW.GSHS.ORG X 1924 NE THE MISSION OF THE CORPORATION IS TO NURTURE THE HEALING MINISTRY OF THE CHURCH, SUPPORTED BY EDUCATION AND RESEARCH. 11 8 1731 200 106288 55893 3037646 1573697 210414933 225923071 10339862 7294212 3934031 3294449 227726472 238085429 553988 763350 0 0 75045752 73105351 0 0 0 132117856 139500619 207717596 213369320 20008876 24716109 368225432 408846427 43638201 42046369 324587231 366800058 X SEE SCHEDULE O false false 183367173 763350 225873793 SEE SCHEDULE H 183367173 true true false true false false false false false true true false false true true false true false false false false false false false false true true true true true false false false false false false false false false false false false false true true true false false true 4 0 true 1731 true true true false false false false false false false false false X 11 8 false false true false true true true true true false false true true true true true true false true true false NE X Jeanette Wojtalewicz 4023434671 12809 West Dodge Road Omaha NE 68154 CLIFF ROBERTSON Board Member/CEO CHI Health 1.00 59.00 X X 0 761591 100446 MICHAEL DEFREECE Secretary/Treasurer 1.00 11.00 X X 0 0 0 RICHARD HACHTEN II Chair/ACH President & CEO 1.00 48.00 X X 0 4316298 67124 RICHARD HERINK BOARD CHAIR 1.00 11.00 X X 0 0 0 RICHARD J VIERK Vice Chair 1.00 11.00 X X 0 0 0 BARRY SANDSTROM Board Member 1.00 12.00 X 0 0 0 DR MARYANNE STEVENS RSM Board Member 1.00 11.00 X 0 0 0 FR JAMES CLIFTON SJ Board Member 1.00 11.00 X 0 0 0 GREGORY HEIDRICK Board Member 1.00 12.00 X 0 0 0 H KEITH SCHMODE Board Member 1.00 11.00 X 0 0 0 LARRY BUTLER Board Member 1.00 11.00 X 0 0 0 MARTIN M MANCUSO MD Board Member 1.00 59.00 X 0 416092 25222 MICHAEL ROWAN FACHE Board member/CHI EVP & COO 1.00 59.00 X 0 2769716 258055 PAUL EDGETT III Board Member/CHI SVP 1.00 59.00 X 0 1126594 94198 ROBERT LANIK BOARD MEMBER/CHI NE President/CEO 2.00 58.00 X 0 1314093 48200 SISTER NADINE HEIMANN Board Member 1.00 11.00 X 0 0 0 GEORGE HARMS VICE PRESIDENT OF FINANCE 55.00 5.00 X 240572 0 42504 JEANETTE WOJTALEWICZ CFO, CHI HEALTH 1.00 59.00 X 0 499985 59878 MICHAEL SCHNIEDERS PRESIDENT GSH 55.00 5.00 X 0 495769 75511 AMY HATCHER VP Divisional Finance 1.00 0 X 0 0 0 CAROL WAHL VP PATIENT SERVICES 60.00 0 X 237918 0 36771 DENNIS EDWARDS VP MEDICAL AFFAIRS 40.00 10.00 X 0 391777 41950 LISA WEBB VP of Finance 1.00 46.00 X 17044 218584 16004 ROBERT CUNNINGHAM VP ANCILLARY SUPPORT 60.00 0 X 217173 0 38252 DAVID HUEBNER MD Board Member/PRESIDENT MEDICAL STAFF 55.00 0 X 384598 0 0 MICHAEL BIBLER Physician 0.00 60.00 X 427296 456769 31870 NICKI L BOHL DIRECTOR PHARMACY 45.00 0 X 139145 0 26855 RICHARD HRANAC BOARD MEMBER/Physician 2.00 0.00 X 45157 117989 15529 TODD STOVER DIRECTOR PERFUSION 45.00 0 X 144695 0 34682 CLARESSA L MILLSAP DIRECTOR CARDIOVASCULAR 45.00 0.00 X 23827 102638 33294 ELIZABETH TAYLOR-TRUJILLO DIRECTOR BEHAVIORAL HEALTH 45.00 0 X 115458 0 13174 FISHEL LIBERMAN FORMER PHYSICIAN 0.00 60.00 X 0 747024 44500 HUGO GONZALEZ NIETO FORMER PHYSICIAN 0.00 60.00 X 0 312689 38896 LAWRENCE A SURMEIER DIRECTOR FACILITY OPERATIONS 45.00 0 X 113597 0 13123 LEIGH BERTHOLF Former VP & CRO 0.00 60.00 X 0 337725 49840 STEPHEN LEURCK FORMER INTERIM CAO 0.00 40.00 X 0 298799 0 2106480 14684132 1205878 30 true true false WPS TRICARE FOR LIFE PO BOX 7928 MADISON WI 537077928 PHYSICIANS SERVICES SUPPORT 1435573 RODGERS HELICOPTER SERVICES 4965 AIRPORT ROAD KEARNEY NE 688473372 AIRCARE FLIGHT SERVICES 782687 SORENSEN GROUP INC 1400 W 22ND STREET KEARNEY NE 68845 GENERAL CONTRACTORS 568856 SULLIVAN HEALTHCARE CONSULTING 900VICTORS WAY ANN ARBOR MI 48108 CONSULTING 520466 ALL ABOUT STAFFING INC 10020 NORTH RODNEY PARHAM RD LITTLE ROCK AR 72227 STAFFING SERVICES 509661 55 1036554 347831 189312 1573697 PATIENT SERVICES 900099 223768632 223768632 EQUITY CHANGES OF UNCONSOLIDATED ORGS 900099 1208185 1158907 49278 RENTAL INCOME 900099 946254 946254 0 0 0 0 0 0 225923071 3924997 -11100 3936097 0 0 0 0 0 0 0 3398593 2891 32269 3398593 -29378 3369215 3369215 0 0 0 SERVICES SOLD 900099 1228916 5669 1223247 CAFETERIA 722100 928010 1208 926802 CHILD CARE 624410 447389 447389 690134 0 61233 628901 3294449 238085429 225873793 106288 10531651 X 763350 763350 0 0 0 793252 339303 453949 0 54688048 53611308 1076740 2984085 2765376 218709 10673143 10669298 3845 3966823 3890261 76562 0 348168 348168 0 0 0 0 35420689 21332159 14088530 0 588296 583913 4383 5553954 5527560 26394 10407913 9844029 563884 0 3149899 2804839 345060 450609 428631 21978 0 55088 54242 846 918482 918482 16354584 3841155 12513429 11166862 11152578 14284 635584 601149 34435 MEDICAL SUPLIES 37850460 37850460 BAD DEBTS 9913454 9913454 REPAIRS AND MAINTENANCE 3405967 3400667 5300 UNRELATED BUSINESS TAXES 13855 13855 3266755 3074959 191796 0 213369320 183367173 30002147 0 0 4950 5050 17677778 27955800 29972633 39148867 0 0 0 0 87755 307681 7293623 7315265 334670 429150 271777684 148906765 129982925 122870919 710 611 173091551 202971746 0 0 2301156 2301156 7477681 5540182 368225432 408846427 15006987 18823804 68445 0 0 28631214 23154120 43638201 42046369 X 324587231 366800058 0 0 0 0 324587231 366800058 368225432 408846427 X 24716109 17178058 318660 X false true X true true true X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED false false false false false true 9843 false false false 9843 false Schedule C, Part II-B, Line 1, Description of the activities reported on Lines 1a through 1i LINE 1F: THE PORTION OF ORGANIZATION DUES THAT ARE RELATED TO LOBBYING ARE AS FOLLOWS; NEBRASKA HOSPITAL ASSOCIATION $6,343, CATHOLIC HEALTH ASSOCIATION $2,601, AND AMERICAN HOSPITAL ASSOCIATION $899. 8318547 8318547 112502994 42708829 69794165 0 138439670 99582747 38856923 12516473 6615189 5901284 122870919 0 0 CHI OIP - FIXED INCOME 98876209 F CHI OIP - EQUITY SECURITIES 104095537 F 202971746 0 INTERCOMPANY PAYABLES 22882713 UNCLAIMED PROPERTY 15994 PHYSICIAN GUARANTEE 255413 23154120 X Schedule D, Part X, Line 2, FIN 48 (ASC 740) footnote GOOD SAMARITAN HOSPITAL'S FINANCIAL INFORMATION IS INCLUDED IN THE CONSOLIDATED AUDITED FINANCIAL STATEMENTS OF CATHOLIC HEALTH INITIATIVES, A RELATED ORGANIZATION. CHI'S FIN 48 (ASC740) FOOTNOTE FOR THE YEAR ENDED JUNE 30, 2014 READS AS FOLLOWS: "CHI IS A TAX-EXEMPT COLORADO CORPORATION AND HAS BEEN GRANTED AN EXEMPTION FROM FEDERAL INCOME TAX UNDER SECTION 501(C)(3) OF THE INTERNAL REVENUE CODE. CHI OWNS CERTAIN TAXABLE SUBSIDIARIES AND ENGAGES IN CERTAIN ACTIVITIES THAT ARE UNRELATED TO ITS EXEMPT PURPOSE AND THEREFORE SUBJECT TO INCOME TAX. MANAGEMENT REVIEWS ITS TAX POSITIONS ANNUALLY AND HAS DETERMINED THAT THERE ARE NO MATERIAL UNCERTAIN TAX POSITIONS THAT REQUIRE RECOGNITION IN THE ACCOMPANYING CONSOLIDATED FINANCIAL STATEMENTS." true true X false false true true true false true true 3509 3905132 3905132 0.01920 8559 17301464 12388107 4913357 0.02410 196992 523335 -326343 0.00000 0 12068 21403588 12911442 8492146 0.04330 42 248408 963548 42302 921246 0.00450 29 2595 569997 35695 534302 0.00260 0 0.00000 3 311534 311534 0.00150 19 30502 513519 513519 0.00250 93 281505 2358598 77997 2280601 0.01110 93 293573 23762186 12989439 10772747 0.05440 0 0.00000 0 0.00000 2 13548 13548 0.00000 0 0.00000 0 0.00000 0 0.00000 1 1076 1076 0.00000 1 699878 699878 0.00320 0 0.00000 4 0 714502 0 714502 0.00330 true 9913454 0 82444848 107580000 -25135152 X true true KEARNEY AMBULATORY SURGICAL CENTER SURGERY 0.2462 0 0.7538 3 1 GOOD SAMARITAN HOSPITAL 10 EAST 31ST STREET PO BOX 1990 KEARNEY NE 68848 WWW.GSHS.ORG 070001 X X X ACUTE HOSPITAL A 2 RICHARD YOUNG BEHAVIORAL HEALTH CENTER 1755 PRAIRIE VIEW PL KEARNEY NE 68847 WWW.GSHS.ORG X PSYCHIATRIC HOSPITAL A 3 GOOD SAMARITAN HOSPITAL LTC 10 EAST 31ST STREET PO BOX 1990 KEARNEY NE 68848 WWW.GSHS.ORG X LONG TERM CARE A A 1 true X X X X X X X X X 12 true false true X www.chihealthgoodsamaritan.org X www.whychihealth.org X X X X X X X X X true false true false false true X X X X true true X X X X true false true X false false Schedule H, Part V Sec B, Line 3, Community Served by Needs Assessment (1) A - GROUP A: GOOD SAMARITAN HOSPITAL HOLDS A PERMANENT SEAT ON THE BOARD OF BUFFALO COUNTY COMMUNITY PARTNERS, PROVIDING SIGNIFICANT FINANCIAL AND IN-KIND SUPPORT, AS WELL AS HOSPITAL STAFF PARTICIPATION ON THE BOARD AND VARIOUS COALITIONS AND COMMITTEES. THIS ASSESSMENT REPORT IS A SUMMARY OF THE CONTINUOUS ASSESSMENTS AND PRIORITIZATION ACTIVITIES THAT ARE CONDUCTED BY BUFFALO COUNTY COMMUNITY PARTNERS SINCE 2009. THE BOARD OF BUFFALO COUNTY COMMUNITY PARTNERS INCLUDES A WIDE RANGE OF INDIVIDUALS REPRESENTING PUBLIC HEALTH, LOCAL GOVERNMENT, EDUCATION, SOCIAL SERVICE AGENCIES, BUSINESS, THE FAITH COMMUNITY, AND HEALTH CARE PROVIDERS. ADDITIONALLY THERE ARE ISSUE SPECIFIC COALITIONS AND COMMITTEES THAT FURTHER EXPAND COMMUNITY INVOLVEMENT IN OUR ONGOING ASSESSMENT ACTIVITIES. ADDITIONALLY, TOWN HALL MEETINGS WERE HELD IN EVERY CITY IN THE COUNTY, FOCUS GROUPS, DOOR TO DOOR SURVEYS, AS WELL AS NUMEROUS OTHER SURVEYS CONDUCTED IN THE SCHOOLS AND WITH THE ADULT POPULATION. COMMUNITY PARTICIPANTS INCLUDED: *DENISE ZWIENER, DIRECTOR, BUFFALO COUNTY COMMUNITY PARTNERS *SUE REIBER AREA REPRESENTATIVE *KATHY GOSCH, PARISH NURSING *PROGRAM ADMINISTRATOR, REGION 3, BEHAVIORAL HEALTH SERVICES *ISMAEL TORRES, HEALTH, EDUCATION COORDINATOR, UNIVERSITY OF NEBRASKA AT KEARNEY *MATHEW MIMS, ASSISTANT PROFESSOR, COUNSELOR EDUCATION, UNIVERSITY OF NEBRASKA AT KEARNEY *MICHELLE REED, FAITH UNITED METHODIST CHURCH *EPHRAIM VALENZUELA, SERGEANT, BUFFALO COUNTY SHERIFF'S OFFICE *LISA REESE PARISH, EXECUTIVE DIRECTOR, UNITED WAY *SUZANNE BRODINE, ASSISTANT TO THE CITY MANAGER, CITY OF KEARNEY *DAVE GLOVER, OFFICE MANAGER, FAMILY PRACTICE ASSOCIATES *JANA PETERSON, FACILITY ADMINISTRATOR, YRTC-K *BOB HUDDLESTON, WELLS FARGO *SCOTT ANDERSON, NEW YORK LIFE, INSURANCE COMPANY *ELNIDA CHANDLER, CROSSROADS CENTER, RESCUE MISSION *NIKKI GAUSMAN, EXECUTIVE DIRECTOR, SAFE CENTER *CRYSTAL WINFIELD, EXECUTIVE DIRECTOR, SENTINEL HEALTH CARE *JULIE WEIR, DIRECTOR OF HEALTH SERVICES COMMUNITY ACTION PARTNERSHIP *ROBERT SMOOT, VP OF MISSION INTEGRATION, GOOD SAMARITAN HEALTH SYSTEMS *CAROL SCHWARZ, EXTENSION EDUCATOR, BUFFALO COUNTY EXTENSION SERVICE *TERRY KROHN, TWO RIVERS PUBLIC HEALTH DEPARTMENT *DR. LEANN OBRECHT, DIRECTOR COUNSELING AND HEALTH CARE, UNIVERSITY OF NEBRASKA AT KEARNEY *CORTNEY GEISLER, APRN, PLATTE VALLEY MEDICAL GROUP *CAROL RENNER, ASSOCIATE SUPERINTENDENT, KEARNEY PUBLIC SCHOOLS *ANDREA RABE, CENTRAL HEALTH CENTER THIS PUBLIC INPUT PROCESS WAS USED TO VALIDATE THE LOCAL HEALTH ISSUE DATA, AND TO SELECT PRIORITY HEALTH NEEDS FOR GOOD SAMARITAN HOSPITAL AND THE GREATER KEARNEY AREA TO ADDRESS TOGETHER.; Schedule H, Part V Sec B, Line 10, Used federal poverty guidelines (FPG) to determine eligibility (1) A - GROUP A: HUD LOW INCOME GUIDELINES USED; Schedule H, Part V Sec B, Line 11, Eligibility for Discounted Care (1) A - GROUP A: HUD LOW INCOME GUIDELINES USED; Schedule H, Part V Sec B, Line 14g, Other ways hospital publicized Financial Assistance Policy (1) A - : INFORMATION FOR OUR FINANCIAL ASSISTANCE PROGRAM, INCLUDING THE APPLICATION PROCESS, IS PROVIDED TO PATIENTS IN VARYING FORMATS AND PROCESSES (E.G. PATIENT BROCHURES, GUEST INFORMATION GUIDE, SIGNAGE, SELF-PAY PACKETS, COMMUNITY BENEFIT TAB ON WEBSITE, ETC).; Schedule H, Part V Sec B, Line 20d, How amounts charged to FAP-eligible patients were determined (1) A - : THE AVERAGE MANAGED CARE CONTRACTUAL ALLOWANCES RATE SHALL BE DEVELOPED ANNUALLY BY GOOD SAMARITAN HOSPITAL AND APPLIED TO ALL UNINSURED PATIENTS DEEMED ELIGIBLE FOR THIS DISCOUNT. THE DISCOUNT SHALL BE CALCULATED BY EACH SEPARATE ENTITY WITHIN GOOD SAMARITAN HOSPITAL BY DIVIDING THE TOTAL AMOUNT OF MANAGED CARE CONTRACTUAL ALLOWANCES, FOR THE MOST RECENT FISCAL YEAR, BY THE TOTAL GROSS CHARGES FOR THOSE MANAGED CARE PLANS TO DETERMINE A DISCOUNT RATE THAT SHALL BE USED FOR THE CURRENT FISCAL YEAR, AS FOLLOWS: DISCOUNT PERCENTAGE = TOTAL MANAGED CARE CONTRACTUAL ALLOWANCES / TOTAL MANAGED CARE GROSS CHARGES. FEDERAL, STATE, LOCAL AND COUNTY ENTITLEMENT PROGRAMS SHALL BE EXCLUDED FROM THE ABOVE CALCULATION (I.E., DISREGARD THE DISCOUNTS AND CHARGES FROM SUCH PLANS). ; Schedule H, Part I, Line 3c, Eligibility criteria for free or discounted care WHEN CATHOLIC HEALTH INITIATIVES (THE ULTIMATE PARENT ORGANIZATION TO GOOD SAMARITAN HOSPITAL) ESTABLISHED ITS CHARITY CARE POLICY IT WAS DETERMINED THAT ESTABLISHING A HOUSEHOLD INCOME SCALE BASED ON THE HUD VERY LOW INCOME GUIDELINES MORE ACCURATELY REFLECTS THE SOCIOECONOMIC DISPERSIONS AMONG URBAN AND RURAL COMMUNITIES IN 17 STATES SERVED BY CHI HOSPITALS AND HEALTH CARE FACILITIES. IN COMPARING HUD GUIDELINES TO THE FEDERAL POVERTY GUIDELINES ("FPG"), WE FIND THAT ON AVERAGE HUD GUIDELINES COMPUTE TO APPROXIMATELY 200% TO 250% (AND SOMETIMES 300%) OF FPG. ELIGIBILITY FOR CHARITY CARE DISCOUNTS SHALL BE DETERMINED BASED ON 130% OF THE ANNUALLY UPDATED HUD GEOGRAPHIC VERY-LOW INCOME GUIDELINES FOR THE APPLICANT'S COUNTY OF RESIDENCE, (REFERENCED LATER IN THIS DOCUMENT), AVAILABLE ASSETS AND ANY EXTENUATING CIRCUMSTANCES. THUS, THE STANDARDS OF ELIGIBILITY FOR THE APPLICATION OF CHARITY DISCOUNTS MUST CONSIDER ASSETS, AS WELL AS INCOME. IN ADDITION, THE NEED FOR FUTURE SERVICES REQUIRING FINANCIAL ASSISTANCE SHALL BE ASSESSED. SEPARATE DETERMINATIONS OF ELIGIBILITY FOR CHARITY CARE DISCOUNTS SHALL BE MADE FOR EACH DATE OF SERVICE. CONFIRMATION OF CONTINUED ELIGIBILITY SHALL BE UPDATED EVERY 90 DAYS FOR PATIENTS WHO REQUIRE ONGOING HEALTH CARE SERVICES. AN INDIVIDUAL'S OCCUPATION MAY BE INDICATIVE OF ELIGIBILITY FOR A CHARITY CARE DISCOUNT. EXAMPLES OF LOW-PAYING JOBS MIGHT INCLUDE DAY LABORER, FARM WORKER, MIGRANT WORKER AND FOOD SERVICE ASSOCIATE. Schedule H, Part I, Line 7, Costing Methodology used to calculate financial assistance A COST ACCOUNTING SYSTEM WAS NOT USED TO COMPUTE AMOUNTS IN THE TABLE; RATHER COSTS IN THE TABLE WERE COMPUTED USING THE ORGANIZATION'S COST-TO-CHARGE RATIO. THE COST-TO-CHARGE RATIO COVERS ALL PATIENT SEGMENTS. THE COST-TO-CHARGE RATIO FOR THE YEAR ENDED 6/30/14 WAS COMPUTED USING THE FOLLOWING FORMULA: OPERATING EXPENSE (BEFORE RESTRUCTURING, IMPAIRMENT AND OTHER LOSSES) DIVIDED BY GROSS PATIENT REVENUE. BASED ON THAT FORMULA, $17,541,578/$39,366,244 RESULTS IN A 37.26% COST-TO-CHARGE RATIO. WORKSHEET 2 WAS NOT USED TO DERIVE THE COST-TO-CHARGE RATIO. Schedule H, Part I, Line 7, col(f), Bad Debt Expense excluded from financial assistance calculation 9,913,454 Schedule H, Part I, Line 7g, Subsidized Health Services THERE ARE NO PHYSICIAN CLINICS INCLUDED IN SUBSIDIZED HEALTH SERVICES. Schedule H, Part III, Line 2, Bad debt expense - methodology used to estimate amount COSTING METHODOLOGY FOR AMOUNTS REPORTED ON LINE 2 IS DETERMINED USING THE ORGANIZATION'S COST/CHARGE RATIO OF 37.26%. WHEN DISCOUNTS ARE EXTENDED TO SELF-PAY PATIENTS, THESE PATIENT ACCOUNT DISCOUNTS ARE RECORDED AS A REDUCTION IN REVENUE, NOT AS BAD DEBT EXPENSE. Schedule H, Part III, Line 3, Bad Debt Expense Methodology GOOD SAMARITAN HOSPITAL DOES NOT BELIEVE THAT ANY PORTION OF BAD DEBT EXPENSE COULD REASONABLY BE ATTRIBUTED TO PATIENTS WHO QUALIFY FOR FINANCIAL ASSISTANCE SINCE AMOUNTS DUE FROM THOSE INDIVIDUALS' ACCOUNTS WILL BE RECLASSIFIED FROM BAD DEBT EXPENSE TO CHARITY CARE WITHIN 30 DAYS FOLLOWING THE DATE THAT THE PATIENT IS DETERMINED TO QUALIFY FOR CHARITY CARE. Schedule H, Part III, Line 4, Bad debt expense - financial statement footnote GOOD SAMARITAN HOSPITAL DOES NOT ISSUE SEPARATE COMPANY AUDITED FINANCIAL STATEMENTS. HOWEVER, THE ORGANIZATION IS INCLUDED IN THE CONSOLIDATED FINANCIAL STATEMENTS OF CATHOLIC HEALTH INITIATIVES. THE CONSOLIDATED FOOTNOTE READS AS FOLLOWS: "THE PROVISION FOR BAD DEBTS IS BASED UPON MANAGEMENT'S ASSESSMENT OF HISTORICAL AND EXPECTED NET COLLECTIONS, TAKING INTO CONSIDERATION HISTORICAL BUSINESS AND ECONOMIC CONDITIONS, TRENDS IN HEALTH CARE COVERAGE AND OTHER COLLECTION INDICATORS. MANAGEMENT ROUTINELY ASSESSES THE ADEQUACY OF THE ALLOWANCES FOR UNCOLLECTIBLE ACCOUNTS BASED UPON HISTORICAL WRITE-OFF EXPERIENCE BY PAYOR CATEGORY. THE RESULTS OF THESE REVIEWS ARE USED TO MODIFY, AS NECESSARY, THE PROVISION FOR BAD DEBTS AND TO ESTABLISH APPROPRIATE ALLOWANCES FOR UNCOLLECTIBLE NET PATIENT ACCOUNTS RECEIVABLE. AFTER SATISFACTION OF AMOUNTS DUE FROM INSURANCE, CHI FOLLOWS ESTABLISHED GUIDELINES FOR PLACING CERTAIN PATIENT BALANCES WITH COLLECTION AGENCIES, SUBJECT TO THE TERMS OF CERTAIN RESTRICTIONS ON COLLECTION EFFORTS AS DETERMINED BY EACH FACILITY. IN ACCORDANCE WITH ACCOUNTING STANDARDS UPDATE (ASU) NO. 2011-07, PRESENTATION AND DISCLOSURE OF PATIENT SERVICES REVENUE, PROVISION FOR BAD DEBTS, AND ALLOWANCES FOR DOUBTFUL ACCOUNTS FOR CERTAIN HEALTH ENTITIES, THE PROVISION FOR BAD DEBTS IS PRESENTED ON THE CONSOLIDATED STATEMENT OF OPERATIONS AS A DEDUCTION FROM PATIENT SERVICES REVENUES (NET OF CONTRACTUAL ALLOWANCES AND DISCOUNTS) SINCE CHI ACCEPTS AND TREATS ALL PATIENTS WITHOUT REGARD TO THE ABILITY TO PAY." Schedule H, Part III, Line 8, Community benefit & methodology for determining medicare costs USING ESSENTIALLY THE SAME MEDICARE COST REPORT PRINCIPLES AS TO THE ALLOCATION OF GENERAL SERVICES COSTS AND "APPORTIONMENT" METHODS, THE"CHI WORKBOOK" CALCULATES A PAYERS' GROSS ALLOWABLE COSTS BY SERVICE (SO AS TO FACILITATE A CORRESPONDING COMPARISON BETWEEN GROSS ALLOWABLE COSTS AND ULTIMATE PAYMENTS RECEIVED). THE TERM "GROSS ALLOWABLE COSTS" MEANS COSTS BEFORE ANY DEDUCTIBLES OR CO-INSURANCE ARE SUBTRACTED. GOOD SAMARITAN HOSPITAL'S ULTIMATE REIMBURSEMENT WILL BE REDUCED BY ANY APPLICABLE COPAYMENT/ DEDUCTIBLE. WHERE MEDICARE IS THE SECONDARY INSURER, AMOUNTS DUE FROM THE INSURED'S PRIMARY PAYER WERE NOT SUBTRACTED FROM MEDICARE ALLOWABLE COSTS BECAUSE THE AMOUNTS ARE TYPICALLY IMMATERIAL. ALTHOUGH NOT PRESENTED ON THE MEDICARE COST REPORT, IN ORDER TO FACILITATE A MORE ACCURATE UNDERSTANDING OF THE "TRUE" COST OF SERVICES (FOR "SHORTFALL" PURPOSES) THE CHI WORKBOOK ALLOWS A HEALTH CARE FACILITY NOT TO OFFSET COSTS THAT MEDICARE CONSIDERS TO BE NON-ALLOWABLE, BUT FOR WHICH THE FACILITY CAN LEGITIMATELY ARGUE ARE RELATED TO THE CARE OF THE FACILITY'S PATIENTS. IN ADDITION, ALTHOUGH NOT REPORTABLE ON THE MEDICARE COST REPORT, THE CHI WORKBOOK INCLUDES THE COST OF SERVICES THAT ARE PAID VIA A SET FEE-SCHEDULE RATHER THAN BEING REIMBURSED BASED ON COSTS (E.G. OUTPATIENT CLINICAL LABORATORY). FINALLY, THE CHI WORKBOOK ALLOWS A FACILITY TO INCLUDE OTHER HEALTH CARE SERVICES PERFORMED BY A SEPARATE FACILITY (SUCH AS A PHYSICIAN PRACTICE) THAT ARE MAINTAINED ON SEPARATE BOOKS AND RECORDS (AS OPPOSED TO THE MAIN FACILITY'S BOOKS AND RECORDS WHICH HAS ITS COSTS OF SERVICE INCLUDED WITHIN A COST REPORT). TRUE COSTS OF MEDICARE COMPUTED USING THIS METHODOLOGY: TOTAL MEDICARE REVENUE: $ 82,444,848 TOTAL MEDICARE COSTS: $ 107,580,000 SURPLUS OF SHORTFALL $ (25,135,152) GOOD SAMARITAN HOSPITAL BELIEVES THAT EXCLUDING MEDICARE LOSSES FROM COMMUNITY BENEFIT MAKES THE OVERALL COMMUNITY BENEFIT REPORT MORE CREDIBLE FOR THESE REASONS: UNLIKE SUBSIDIZED AREAS SUCH AS BURN UNITS OR BEHAVIORAL-HEALTH SERVICES, MEDICARE IS NOT A DIFFERENTIATING FEATURE OF TAX-EXEMPT HEALTH CARE ORGANIZATIONS. IN FACT, FOR-PROFIT HOSPITALS FOCUS ON ATTRACTING PATIENTS WITH MEDICARE COVERAGE, ESPECIALLY IN THE CASE OF WELL-PAID SERVICES THAT INCLUDE CARDIAC AND ORTHOPEDICS. SIGNIFICANT EFFORT AND RESOURCES ARE DEVOTED TO ENSURING THAT HOSPITALS ARE REIMBURSED APPROPRIATELY BY THE MEDICARE PROGRAM. THE MEDICARE PAYMENT ADVISORY COMMISSION (MEDPAC), AN INDEPENDENT CONGRESSIONAL AGENCY, CAREFULLY STUDIES MEDICARE PAYMENT AND THE ACCESS TO CARE THAT MEDICARE BENEFICIARIES RECEIVE. THE COMMISSION RECOMMENDS PAYMENT ADJUSTMENTS TO CONGRESS ACCORDINGLY. THOUGH MEDICARE LOSSES ARE NOT INCLUDED BY CATHOLIC HOSPITALS AS COMMUNITY BENEFIT, THE CATHOLIC HEALTH ASSOCIATION GUIDELINES ALLOW HOSPITALS TO COUNT AS COMMUNITY BENEFIT SOME PROGRAMS THAT SPECIFICALLY SERVE THE MEDICARE POPULATION. FOR INSTANCE, IF HOSPITALS OPERATE PROGRAMS FOR PATIENTS WITH MEDICARE BENEFITS THAT RESPOND TO IDENTIFIED COMMUNITY NEEDS, GENERATE LOSSES FOR THE HOSPITAL, AND MEET OTHER CRITERIA, THESE PROGRAMS CAN BE INCLUDED IN THE CHA FRAMEWORK IN CATEGORY C AS "SUBSIDIZED HEALTH SERVICES." MEDICARE LOSSES ARE DIFFERENT FROM MEDICAID LOSSES, WHICH ARE COUNTED IN THE CHA COMMUNITY BENEFIT FRAMEWORK, BECAUSE MEDICAID REIMBURSEMENTS GENERALLY DO NOT RECEIVE THE LEVEL OF ATTENTION PAID TO MEDICARE REIMBURSEMENT. MEDICAID PAYMENT IS LARGELY DRIVEN BY WHAT STATES CAN AFFORD TO PAY, AND IS TYPICALLY SUBSTANTIALLY LESS THAN WHAT MEDICARE PAYS. Schedule H, Part III, Line 9b, Collection practices for patients eligible for financial assistance GOOD SAMARITAN HOSPITAL'S DEBT COLLECTION POLICY PROVIDES THAT GOOD SAMARITAN HOSPITAL WILL PERFORM A REASONABLE REVIEW OF EACH INPATIENT ACCOUNT PRIOR TO TURNING AN ACCOUNT OVER TO A THIRD-PARTY COLLECTION AGENT AND PRIOR TO INSTITUTING ANY LEGAL ACTION FOR NON-PAYMENT, TO ASSURE THAT THE PATIENT AND PATIENT GUARANTOR ARE NOT ELIGIBLE FOR ANY ASSISTANCE PROGRAM (E.G. MEDICAID) AND DO NOT QUALIFY FOR COVERAGE THROUGH GOOD SAMARITAN HOSPITAL COMMUNITY ASSISTANCE POLICY. AFTER HAVING BEEN TURNED OVER TO A THIRD-PARTY COLLECTION AGENT, ANY PATIENT ACCOUNT THAT IS SUBSEQUENTLY DETERMINED TO MEET THE GOOD SAMARITAN HOSPITAL COMMUNITY ASSISTANCE POLICY IS REQUIRED TO BE RETURNED IMMEDIATELY BY THE THIRD-PARTY COLLECTION AGENT TO GOOD SAMARITAN HOSPITAL FOR APPROPRIATE FOLLOW-UP. GOOD SAMARITAN HOSPITAL REQUIRES ITS THIRD-PARTY COLLECTION AGENTS TO INCLUDE A MESSAGE ON ALL STATEMENTS INDICATING THAT IF A PATIENT OR PATIENT GUARANTOR MEETS CERTAIN STIPULATED INCOME REQUIREMENTS, THE PATIENT OR PATIENT GUARANTOR MAY BE ELIGIBLE FOR FINANCIAL ASSISTANCE. ALL OF CATHOLIC HEALTH INITIATIVES' HOSPITALS' CONTRACTS WITH THIRD PARTY COLLECTION AGENCIES INCLUDE THE FOLLOWING STANDARDS: *NEITHER CHI HOSPITALS NOR THEIR COLLECTION AGENCIES WILL REQUEST BENCH OR ARREST WARRANTS AS A RESULT OF NON-PAYMENT; *NEITHER CHI HOSPITALS NOR THEIR COLLECTION AGENCIES WILL SEEK LIENS THAT WOULD REQUIRE THE SALE OR FORECLOSURE OF A PRIMARY RESIDENCE; AND *NO CATHOLIC HEALTH INITIATIVES' COLLECTION AGENCY MAY SEEK COURT ACTION WITHOUT HOSPITAL APPROVAL. FINALLY, COLLECTION AGENCIES ARE TRAINED ON THE CATHOLIC HEALTH INITIATIVES MISSION, CORE VALUES AND STANDARD OF CONDUCT TO MAKE SURE ALL PATIENTS ARE TREATED WITH DIGNITY AND RESPECT. SCHEDULE H, PART VI, LINES 2, 4 AND 5 - NEEDS ASSESSMENT AND COMMUNITY INFORMATION IN 2010, THE KEARNEY COMMUNITY BEGAN THEIR COMMUNITY HEALTH NEEDS ASSESSMENT BY WORKING PRIMARILY THROUGH OUR COMMUNITY WIDE COALITION, WHICH WAS ESTABLISHED TO IMPROVE THE HEALTH STATUS OF THE RESIDENTS OF BUFFALO COUNTY. THE ASSESSMENT INCLUDED A REVIEW OF PUBLIC HEALTH DATA OVER SEVERAL YEARS, YOUTH RISK AND PROTECTION FACTOR SURVEY IN 2010, THE ADULT BEHAVIORAL RISK FACTOR SURVEY IN 2010, AND THE MINORITY BEHAVIORAL RISK FACTOR SURVEY IN 2009. ADDITIONALLY, IN 2009, TOWN HALL MEETINGS WERE CONDUCTED IN EACH OF THE CITIES IN BUFFALO COUNTY. INSTEAD OF AN INSULATED AND INTERNAL PROCESS OF PRIORITIZATION WITHIN THE HOSPITAL, THE HOSPITAL AND ITS PARTNERS CONDUCT THE PRIORITIZATION OF HEALTH NEEDS IN OUR COMMUNITY COLLABORATIVELY. THROUGH THE COALITION'S. "PLANNING AND MEASUREMENT COMMITTEE" WE CONDUCTED A DETAILED REVIEW OF THE RESULTS OF THE VARIOUS SURVEYS, TOWN HALL MEETINGS AND OTHER FOCUS GROUPS MENTIONED ABOVE. THIS PROCESS OF REVIEW RESULTED IN A SET OF RECOMMENDATIONS TO THE LARGER COALITION BOARD THAT THEN APPROVED THE PRIORITIES. GOOD SAMARITAN HOSPITAL'S EXECUTIVE TEAM AND BOARD OF DIRECTORS REVIEWED THESE PRIORITIES AND AFFIRMED THEM AS THE PRIORITY AREAS THAT WOULD GUIDE OUR OWN COMMUNITY HEALTH STRATEGY. THE ASSESSMENT PROCESS IS A FLUID PROCESS THAT IS COORDINATED BY THE BOARD'S PLANNING AND MEASUREMENT COMMITTEE. THE COMMITTEE HAS OUTLINED STEPS BELOW THAT ARE FOLLOWED TO ENSURE A CONSISTENT AND LIVING ASSESSMENT PROCESS. IN 2008-2010, THE COMMUNITY PARTNERS CONDUCTED A COUNTYWIDE ASSESSMENT TO DETERMINE WHICH PRIORITY HEALTH GOALS SHOULD BE ATTAINED BY 2020. ASSESSMENT TOOLS USED FOR THE COUNTY WIDE ASSESSMENT INCLUDE; BEHAVIORAL RISK FACTOR SURVEYS FOR ADULTS, MINORITY AND YOUTH IN BUFFALO COUNTY (THESE SURVEYS ARE LINKED IN THE SECTION ABOVE). TO SECURE THE QUALITATIVE DATA THE PARTNERS CONDUCTED A FOCUS GROUP PROCESS CALLED MINI-TOWN HALL MEETINGS IN EACH BUFFALO COUNTY COMMUNITY NETWORKING WITH 300 RESIDENTS INCLUDING YOUTH AND MINORITIES. THE MOST RECENT TOWN HALL MEETING REPORT IS LINKED IN THE SECTION ABOVE. FIVE AREAS OF NEED WERE PRIORITIZED AND SELECTED BY GOOD SAMARITAN HOSPITAL AS ALIGNED HEALTH NEEDS AND ARE NOW PART OF THE IMPLEMENTATION PLAN SHARED BY THE HOSPITAL. HIGH IMPACT PREVENTION SERVICES - A REVIEW OF THE DATA SHOWS OUR COMMUNITY HAS OPPORTUNITY TO DECREASE UNDERAGE AND BINGE DRINKING, TOBACCO AND MARIJUANA USE, TO WORK TOWARD EARLIER DETECTION AND BETTER COMMUNITY RESPONSE TO ALZHEIMER'S AND DEMENTIA, AND TO INCREASE THE NUMBER OF TEENS REPORTING THEY ARE NOT SEXUALLY ACTIVE. GOOD SAMARITAN HOSPITAL AFFIRMS THE COMMUNITY'S PRIORITIZATION OF THESE EFFORTS. ELIMINATE HEALTH DISPARITIES -A REVIEW OF THE DATA SHOWS THAT OUR COMMUNITY HAS OPPORTUNITY TO INCREASE THE NUMBER OF ADULTS WITH HEALTH INSURANCE, DECREASE THE NUMBER OF MINORITY RESIDENTS REPORTING BARRIERS TO HEALTH CARE, AND INCREASE THE NUMBER OF ADULTS REPORTING HEALTHY DAYS. GOOD SAMARITAN HOSPITAL AFFIRMS THE COMMUNITY'S PRIORITIZATION OF THESE EFFORTS. HEALTHY EATING & ACTIVE LIVING -A REVIEW OF THE DATA SHOWS THAT OUR COMMUNITY HAS OPPORTUNITY TO INCREASE PHYSICAL ACTIVITY BY ADULTS AND YOUTH, INCREASE CONSUMPTION OF FRUITS AND VEGETABLES BY ADULTS AND YOUTH, AND TO DECREASE THE BMI REPORTED BY ADULTS AND YOUTH. GOOD SAMARITAN HOSPITAL AFFIRMS THE COMMUNITY'S PRIORITIZATION OF THESE EFFORTS INJURY-FREE LIVING -A REVIEW OF THE DATA INDICATES OUR COMMUNITY HAS OPPORTUNITY TO INCREASE SEAT BELT USE AMONG ADULTS AND YOUTH, TO INCREASE REPORTING OF SUBSTANTIATED CASES OF CHILD ABUSE, TO INCREASE REPORTING OF CASES OF DOMESTIC VIOLENCE, AND TO DECREASE YOUTH SUICIDE AND THOUGHTS OF SUICIDE. GOOD SAMARITAN HOSPITAL AFFIRMS THE COMMUNITY'S PRIORITIZATION OF THESE EFFORTS. SCHEDULE H, PART VI, LINES 2,4 AND 5 - NEEDS ASSESSMENT AND COMMUNITY INFORMATION FOR PURPOSES OF THE CHNA GOOD SAMARITAN DEFINES BUFFALO COUNTY AS THE COMMUNITY WE SERVE. WHILE WE CERTAINLY SERVE PEOPLE IN A BROADER AREA, BUFFALO COUNTY REPRESENTS THE SINGLE LARGEST BLOCK OF PATIENTS WE SERVE. THE SURROUNDING COUNTIES EACH HAVE THEIR CRITICAL ACCESS HOSPITALS WITHIN THEIR BORDERS THAT ARE BETTER SUITED TO ADDRESS LOCAL CONCERNS. THE POPULATION OF BUFFALO COUNTY ACCORDING TO THE 2010 CENSUS IS 46,102, CLASSIFYING BUFFALO COUNTY AS RURAL. ECONOMY - MAJOR INDUSTRIES/EMPLOYERS: MANUFACTURING, WHOLESALE TRADE, RETAIL TRADE, INFORMATION, REAL ESTATE/RENTAL & LEASING, PROFESSIONAL/SCIENTIFIC/TECH. SERVICES , ADMINISTRATIVE/SUPPORT & WASTE MANAGEMENT, EDUCATION SERVICES, HEALTH CARE & SOCIAL ASSISTANCE, ARTS/ENTERTAINMENT/RECREATION, ACCOMMODATION & FOOD SERVICES, OTHER SERVICES (NON-GOVERNMENTAL) MAJOR NON-MANUFACTURING EMPLOYERS INCLUDE: GOOD SAMARITAN HOSPITAL 1,000+, UNIVERSITY OF NE AT KEARNEY 1000+, KEARNEY PUBLIC SCHOOLS 750-1000, THE BUCKLE 500-750, WAL-MART STORES, INC. 500-750, CABELA'S 250-500, CASH-WA 250-500, CITY OF KEARNEY 250-500. MAJOR MANUFACTURING EMPLOYERS INCLUDE: BALDWIN FILTERS OIL, AIR, FUEL FILTERS 750-1000, EATON CORPORATION AUTO VALVES & FORGED GEARS 250-500, WEST PHARM. SERVICES PHARM. STOPPERS & CLOSURES 250-500. INCOME LEVELS: MEDIAN HOUSEHOLD INCOME IS $46,762; PER CAPITA INCOME $22,787 DEMOGRAPHICS: PERSONS UNDER 5 YEARS, PERCENT, 2011 7.1% PERSONS UNDER 18 YEARS, PERCENT, 2011 23.6% PERSONS 65 YEARS AND OVER, PERCENT, 2011 12.1% FEMALE PERSONS, PERCENT, 2011 50.4% WHITE PERSONS, PERCENT, 2011 (A) 96.1% BLACK PERSONS, PERCENT, 2011 (A) 1.0% AMERICAN INDIAN AND ALASKA NATIVE PERSONS, PERCENT, 2011 (A) 0.4% ASIAN PERSONS, PERCENT, 2011 (A) 1.3% NATIVE HAWAIIAN AND OTHER PACIFIC ISLANDER PERSONS, PERCENT, 2011 (A) 0.1% PERSONS REPORTING TWO OR MORE RACES, PERCENT, 2011 1.2% PERSONS OF HISPANIC OR LATINO ORIGIN, PERCENT, 2011 (B) 7.6% WHITE PERSONS NOT HISPANIC, PERCENT, 2011 89.1% LIVING IN SAME HOUSE 1 YEAR & OVER, 2006-2010 79.3% FOREIGN BORN PERSONS, PERCENT, 2006-2010 3.7% LANGUAGE OTHER THAN ENGLISH SPOKEN AT HOME, PCT AGE 5+, 2006-2010 6.5% HIGH SCHOOL GRADUATES, PERCENT OF PERSONS AGE 25+, 2006-2010 92.1% BACHELOR'S DEGREE OR HIGHER, PCT OF PERSONS AGE 25+, 2006-2010 32.0% VETERANS, 2006-2010 3,102 MEAN TRAVEL TIME TO WORK (MINUTES), WORKERS AGE 16+, 2006-2010 14.7 SCHEDULE H, PART VI, LINES 2,4 AND 5 - NEEDS ASSESSMENT AND COMMUNITY INFORMATION ORGANIZATION'S MISSION, VISION, AND TAX-EXEMPT PURPOSE THE MISSION OF GOOD SAMARITAN HOSPITAL IS TO NURTURE THE HEALING MINISTRY OF THE CHURCH BY BRINGING IT NEW LIFE, ENERGY AND VIABILITY IN THE 21ST CENTURY. FIDELITY TO THE GOSPEL URGES US TO EMPHASIZE HUMAN DIGNITY AND SOCIAL JUSTICE AS WE MOVE TOWARD THE CREATION OF HEALTHIER COMMUNITIES. HONORING OUR CATHOLIC HERITAGE, GOOD SAMARITAN HOSPITAL IS RECOGNIZED FOR EXCELLENCE IN REGIONAL HEALTHCARE THROUGH VALUES-BASED LEADERSHIP. THE PRIMARY TAX-EXEMPT PURPOSE IS TO SUPPORT THE COMMUNITY BY PROMOTING AND PROVIDING HEALTH CARE SERVICES IN ACCORDANCE WITH THE NEEDS OF A COMMUNITY IN THE ABSENCE OF PRIVATE BENEFIT. GOOD SAMARITAN HOSPITAL SERVES BOTH THE UNDERINSURED AND UNINSURED IN KEARNEY, NE AND THE SURROUNDING COMMUNITIES. GOOD SAMARITAN HOSPITAL (GSH) HAS ALWAYS BEEN INTIMATELY INVOLVED IN COMMUNITY HEALTH COLLABORATION. IN THE EARLY 1990S GOOD SAMARITAN HOSPITAL PROVIDED A GRANT TO HELP ESTABLISH WHAT IS TODAY BUFFALO COUNTY COMMUNITY PARTNERS, WHOSE MISSION IS TO ASSESS, STRENGTHEN AND PROMOTE THE HEALTH OF BUFFALO COUNTY. GSH HOLDS A PERMANENT SEAT ON THE BOARD OF BUFFALO COUNTY COMMUNITY PARTNERS, PROVIDING SIGNIFICANT FINANCIAL AND IN-KIND SUPPORT, AS WELL AS HOSPITAL STAFF PARTICIPATION ON THE BOARD AND VARIOUS COALITIONS AND COMMITTEES. GSH HAS A HISTORY OF TARGETED COMMUNITY BENEFIT INVESTMENTS AND COMMUNITY PARTNERSHIPS THAT ADDRESS COMMUNITY HEALTH NEEDS WHICH INCLUDE COMMUNITY BUILDING SUCH AS: *COMMUNITY HEALTH ACCESS TEAM (CHAT) - THE COMMUNITY HEALTH ACCESS TEAM IS A TEAM OF INDIVIDUALS REPRESENTING 14 DIFFERENT ORGANIZATIONS AND AGENCIES WHOSE MISSION IS: EVERYONE WITH A POINT OF ENTRY TO SERVICE IN BUFFALO COUNTY WILL HAVE ACCESS TO, REGULARLY USE, AND BE SATISFIED WITH COMPREHENSIVE, COST EFFECTIVE, HIGH QUALITY, PRIMARY HEALTH SERVICES THAT SUPPORT OPTIMAL QUALITY OF LIFE. CHAT'S GOAL IS TO REACH 100 PERCENT ACCESS TO PRIMARY HEALTHCARE SERVICES FOR ALL WITH ZERO RACIAL AND ETHNIC DISPARITY. DIFFERENCES BETWEEN PEOPLE, SUCH AS CULTURE, CLASS, EDUCATIONAL ATTAINMENT, EMPLOYMENT STATUS AND ABILITY TO PAY, WILL NO LONGER BE ASSOCIATED WITH DIFFERENTIAL HEALTH OUTCOMES. *24-HOUR EMERGENCY ROOM *OPEN MEDICAL STAFF *PROVIDE CRITICAL SPECIALTY SERVICES AND ADDITIONAL RURAL OUTREACH, WHICH IS OTHERWISE UNAVAILABLE TO SURROUNDING COUNTIES INCLUDING: NEUROLOGY, CARDIOVASCULAR SERVICES, ONCOLOGY, ETC. IN CONCERT WITH GOOD SAMARITAN HOSPITAL, THE MEDICAL STAFF HAS ESTABLISHED CLINICS IN SEVERAL SPECIALTY AREAS ALLOWING RESIDENTS IN RURAL COMMUNITIES TO RECEIVE CARE CLOSE TO HOME. THESE SPECIALTY AREAS INCLUDE: OBSTETRICS AND GYNECOLOGY, HEMATOLOGY AND ONCOLOGY, SPORTS MEDICINE, OPHTHALMOLOGY, UROLOGY, NEUROSURGERY, CARDIOLOGY, PODIATRY, SPINE AND ORTHOPEDICS, NEUROLOGY, NEPHROLOGY, PULMONOLOGY, RHEUMATOLOGY, BEHAVIORAL HEALTH AND VASCULAR SURGERY *LIVING WELL CLASS - OFFERED TO THE COMMUNITY THREE TIMES A YEAR, WHICH IS AN EVIDENCE-BASED CHRONIC DISEASE SELF-MANAGEMENT PROGRAM DEVELOPED BY STANFORD UNIVERSITY. *MEDICATION ACCESS PROGRAM - FUNDED SENTINEL HEALTH CARE'S MEDICATION ACCESS PROGRAM WHICH PROVIDED AID IN OBTAINING 4,899 PRESCRIPTIONS IN FY14. *AMERICAN RED CROSS BLOOD COLLECTION CENTER - COLLABORATED WITH THE AMERICAN RED CROSS TO CONNECT THE FT. KEARNEY CHAPTER OF THE AMERICAN RED CROSS AND THE AMERICAN RED CROSS MIDWEST BLOOD REGION, A NEW BLOOD COLLECTION CENTER TO MAXIMIZE DONATION LOCATION IN THE AREA. *ANNUAL SIMPLY PINK BREAST CANCER AWARENESS STYLE SHOW - RAISE AWARENESS AND TO HONOR BREAST CANCER SURVIVORS. THE EVENT IS FREE, HOWEVER; FREE WILL DONATIONS ARE RECEIVED. THIS YEAR THE DONATIONS WILL BE USED TO HELP FUND THE HEALING GARDEN. *GOOD SAMARITAN CANCER CENTER - PROVIDES VARIOUS SUPPORT GROUPS TO AID PATIENTS AND FAMILIES DURING DIAGNOSIS, TREATMENT AND RECOVERY. *CENTRAL NEBRASKA AREA HEALTH EDUCATION CENTER (CN-AHEC) -PROVIDE SUPPORT FINANCIAL AND IN-KIND SUPPORT TO ELIMINATE DISPARITIES IN HEALTH AND HEALTH CARE, ESPECIALLY IN UNDERSERVED COMMUNITIES. *LOW-COST AND WIDELY ACCESSIBLE CANCER SCREENINGS *IN-KIND SPACE PROVIDED TO MORE THAN 25,000 PARTICIPANTS VIA THE GSH CONFERENCE CENTER *CRITICAL ACCESS HOSPITAL (CAH) NETWORK - VISION OF THE GOOD SAMARITAN CAH NETWORK IS TO UTILIZE A COLLABORATIVE APPROACH TO IMPROVE PROCESSES OF COMMUNICATION, QUALITY ASSURANCE, PEER REVIEW AND CREDENTIALING SO THAT CARE IS OPTIMIZED WITHIN EACH HOSPITAL IN THE NETWORK AS WELL AS WHEN PATIENTS ARE TRANSFERRED FROM CRITICAL ACCESS HOSPITALS TO THE TERTIARY CARE HOSPITAL. AS A NETWORK, WE WILL LOOK FOR WAYS TO SUPPORT THE NETWORK WHILE STRENGTHENING INDIVIDUAL MEMBERS AND THE COMMUNITIES THEY SERVE. *EN CARE PROGRAM (EMERGENCY NURSES' CARE)- DELIVERS EN CARE PROGRAMS FOR CHILDREN, TEENS, YOUNG ADULTS AND SENIOR CITIZENS INCLUDING; FALL PREVENTION, ALCOHOL/DRUG/TOBACCO PREVENTION PROGRAM, AND BIKE SAFETY. *ENHANCED ACCESS TO RICHARD YOUNG BEHAVIORAL HEALTH CENTER- PROVIDE FREE INITIAL ASSESSMENTS BY LICENSED MENTAL HEALTH PROFESSIONALS SCHEDULE H, PART VI, LINES 2,4 AND 5 - NEEDS ASSESMENT AND COMMUNITY INFORMATION *FAMILY ADVOCACY NETWORK (FAN) - IN-KIND OFFICE SPACE FOR THIS ORGANIZATION THAT CONNECTS ALL AGENCIES AND THE FAMILY TO PROVIDE AN EXPERIENCED, MULTIDISCIPLINARY RESPONSE TO ABUSE AND SEXUAL ASSAULT. *FEETLOOSE WITH SAM THE MOOSE - GSH LED ACTIVE LIVING CAMPAIGN FOR FAMILIES; NEARLY 1,000 PEOPLE PARTICIPATED IN THE FEETLOOSE ECHALLENGE AND POSTED COMMENTS, PHOTOS AND MORE ON THE DAILY CHALLENGES. *HEALTH CARE SCIENCES II CLASS - GOOD SAMARITAN HOSPITAL PARTNERS WITH KEARNEY HIGH SCHOOL TO OFFER THE HEALTH CARE SCIENCES II CLASS. THIS CLASS MEETS AT GOOD SAMARITAN HOSPITAL FOUR DAYS A WEEK AND PROVIDES REAL HANDS-ON LEARNING EXPERIENCES FOR STUDENTS INTERESTED IN HEALTHCARE CAREERS. EXPERTS IN THEIR FIELDS, DIFFERENT HOSPITAL REPRESENTATIVES MEET WITH THE STUDENTS OVER THE COURSE OF 8 WEEKS TO PROVIDE INFORMATION ABOUT THEIR INDUSTRY, THE SPECIFIC ASPECTS OF THE CARE THEY PROVIDE, AND VARIOUS CAREER OPPORTUNITIES WITHIN HEALTHCARE. THE PROGRAM IS DIVIDED INTO FIVE HEALTH SCIENCES CAREER PATHWAYS, MODELED AFTER THE NEBRASKA DEPARTMENT OF EDUCATION'S CAREER FIELDS AND CLUSTER MODEL: DIAGNOSTIC SERVICES, SUPPORT SERVICES, BIOTECHNOLOGY RESEARCH AND DEVELOPMENT, THERAPEUTIC SERVICES AND HEALTH INFORMATICS. *MIDWEST TELEHEALTH NETWORK - THE MIDWEST TELEHEALTH NETWORK BECAME OPERATIONAL IN 1995 WITH FIVE RURAL SITES AND GOOD SAMARITAN HOSPITAL AS THE HUB FACILITY. SINCE THEN, THE TELEHEALTH NETWORK HAS GROWN TO NOW INCLUDE TWENTY-THREE RURAL SITES FROM BOTH NEBRASKA AND KANSAS. *GOOD SAMARITAN HOSPITAL HAS DEVELOPED AND IMPLEMENTED SEVERAL COLLABORATIVE PROJECTS TO ASSIST FAMILIES, TEENS AND ADULTS. THESE PROJECTS HAVE BEEN DEVELOPED FROM GRANT FUNDS OBTAINED BY THE GOOD SAMARITAN HOSPITAL FOUNDATION. THEY INCLUDE: *EARLY DEVELOPMENT NETWORK - PROVIDES SERVICES COORDINATION TO FAMILIES WHO HAVE CHILDREN 0-3 YEARS OF AGE WHO HAVE A VERIFIED DISABILITY PER NE RULE 51 (SPECIAL EDUCATION LAW). THIS MEANS THAT THE PROGRAM IS AN ONGOING CENTRAL ACCESS POINT FOR FAMILIES TO HELP CONNECT THEM WITH SERVICES IN THEIR COMMUNITY THAT WILL HELP THEM CARE FOR THEIR CHILDREN AND ENSURE THE FREE AND APPROPRIATE EDUCATION GUARANTEED TO ALL CHILDREN AGES BIRTH TO 21 IN THE STATE OF NEBRASKA. *INJURY PREVENTION - TRAUMA DEPARTMENT: -POISON PREVENTION POSTER CONTEST ENTRY WITH EDUCATIONAL MATERIALS WAS DISTRIBUTED TO ALL ELEMENTARY AGE SCHOOL CHILDREN IN THE KEARNEY PUBLIC SCHOOL SYSTEM. THE WINNING ENTRY WAS PRINTED ON HIGHWAY 30 JUST OUTSIDE OF KEARNEY. -THE FIRST ANNUAL KIDS SAFETY DAY; MORE THAN 200 CHILDREN ATTENDED AND LEARNED SAFETY ADVICE FOR VARIOUS ACTIVITIES, INCLUDING BIKE SAFETY, WATER SAFETY, FIRE SAFETY, ATV SAFETY, AND MUCH MORE. CHILD PASSENGER SAFETY INSPECTION STATIONS WERE SET UP TO PROPERLY FIT CAR SEATS IN VEHICLES. -A "SLOW DOWN IN OUR NEIGHBORHOOD" YARD SIGN CONTEST WAS IMPLEMENTED AT THE BEGINNING OF THE NEW SCHOOL YEAR. -OVER 400 THIRD GRADE STUDENTS HEARD THE MESSAGE "WHY I WON'T USE DRUGS" DURING RED RIBBON WEEK FROM THE INJURY PREVENTION NURSE COORDINATOR AND THE CANCER PREVENTION NURSE. THE EFFECTS OF ALCOHOL, DRUGS AND TOBACCO ON THE BODY, BRAIN AND LUNGS WERE DISCUSSED AND ALSO DEMONSTRATED WITH A BRAIN MODEL, REAL PIG LUNGS AND MR. GROSS MOUTH. -TRAUMA OUTREACH HEADED A NEW PROGRAM FOR CONCUSSION AWARENESS AND PREVENTION IN OUR REGION. GOOD SAMARITAN HOSPITAL PARTNERED WITH NEBRASKA SPORTS CONCUSSION NETWORK AND AREA SPORTS TRAINERS TO PROVIDE CONCUSSION TRAINING TO OVER 100 AREA COACHES; REACHING 2000 STUDENTS IN 30 AREA HIGH SCHOOLS. TRAINING AND PRECONCUSSION NEUROCOGNITIVE TESTING WERE COMPLETED AT THE EXPENSE OF GOOD SAMARITAN HOSPITAL. -THE SAFE TEEN DRIVING SCHOLARSHIP PROGRAM AWARDED SEVERAL KIDS SCHOLARSHIPS RANGING FROM $50-$150 FOR A TOTAL OF $2000 TO ASSIST WITH THE COST OF DRIVER'S EDUCATION CLASSES. -SAFE KIDS PLATTE VALLEY - GSH IS THE LEAD AGENCY FOR THIS INJURY PREVENTION COALITION -MONTHLY CHILD PASSENGER SAFETY FITTING STATIONS IN KEARNEY AND NORTH PLATTE. ASSISTING NEBRASKA OFFICE OF HIGHWAY SAFETY AND SAFE KIDS NEBRASKA WITH NEBRASKA CHILD PASSENGER SAFETY TECHNICAL UPDATE -TEEN NET (PRENATAL AND PARENTING PROGRAM FOR TEENS) - TEEN PARENTING PROGRAM; FUNDING THROUGH GOOD SAMARITAN HOSPITAL AND KEARNEY PUBLIC SCHOOLS -PROJECT SEARCH - HIGH SCHOOL TRANSITION PROGRAM THAT ASSISTS STUDENTS WITH DISABILITIES WITH A CONNECTION TO EMPLOYMENT. GSH HOSTS THE PROGRAM ON-SITE AT NO COST TO THE PROGRAM. *MEDICAL EDUCATION - GOOD SAMARITAN HOSPITAL SUPPORTS THE EDUCATION OF MEDICAL STUDENTS BY PROVIDING SPECIALTY SPECIFIC PHYSICIAN-SUPERVISED ROTATIONS IN CONJUNCTION WITH MEDICAL SCHOOLS. OTHER STUDENTS FROM VARIOUS PROGRAMS AND COLLEGES ARE PROVIDED EDUCATIONAL EXPERIENCES AT GOOD SAMARITAN HOSPITAL. APRNS, RNS, LPNS, PSYCH STUDENTS, MASTER'S LEVEL COUNSELING STUDENTS, AND RECREATIONAL THERAPISTS ARE PROVIDED A BROAD RANGE OF EDUCATIONAL EXPERIENCES FROM FIELD EXPERIENCES TO INTERNSHIPS. Schedule H, Part VI, Line 3, Patient education of eligibility for assistance. GOOD SAMARITAN HOSPITAL INCLUDES INFORMATION CONCERNING ITS FINANCIAL ASSISTANCE POLICY ON ITS WEBSITE. IN ADDITION, GOOD SAMARITAN HOSPITAL PROMINENTLY DISPLAYS ITS FINANCIAL ASSISTANCE POLICY IN BOTH ENGLISH AND SPANISH IN OBVIOUS LOCATIONS THROUGHOUT THE HOSPITALS, INCLUDING THE EMERGENCY ROOMS AND OTHER PATIENT INTAKE AREAS, AS WELL AS IN GOOD SAMARITAN HOSPITAL OUTPATIENT FACILITIES. IN ADDITION, GOOD SAMARITAN HOSPITAL REGISTRATION CLERKS ARE TRAINED TO PROVIDE CONSULTATION TO THOSE WHO HAVE NO INSURANCE OR POTENTIALLY INADEQUATE INSURANCE CONCERNING THEIR FINANCIAL OPTIONS INCLUDING APPLICATION FOR MEDICAID AND FOR FINANCIAL ASSISTANCE UNDER GOOD SAMARITAN HOSPITAL'S FINANCIAL ASSISTANCE POLICY. UPON REGISTRATION (AND ONCE ALL EMTALA REQUIREMENTS ARE MET), PATIENTS WHO ARE IDENTIFIED AS UNINSURED (AND NOT COVERED BY MEDICARE OR MEDICAID) ARE PROVIDED WITH A PACKET OF INFORMATION THAT ADDRESSES THE FINANCIAL ASSISTANCE POLICY AND PROCEDURES INCLUDING AN APPLICATION FOR ASSISTANCE. GOOD SAMARITAN HOSPITAL REGISTRATION CLERKS READ THE ORGANIZATION'S MEDICAL ASSISTANCE POLICY TO THOSE WHO APPEAR TO BE INCAPABLE OF READING, AND PROVIDE TRANSLATORS FOR NON-ENGLISH-SPEAKING INDIVIDUALS. GOOD SAMARITAN HOSPITAL'S STAFF WILL ALSO ASSIST THE PATIENT/GUARANTOR WITH APPLYING FOR OTHER AVAILABLE COVERAGE (SUCH AS MEDICAID), IF NECESSARY. COUNSELORS ASSIST MEDICARE ELIGIBLE PATIENTS IN ENROLLMENT BY PROVIDING REFERRALS TO THE APPROPRIATE GOVERNMENT AGENCIES. Schedule H, Part VI, Line 6, Affiliated health care system GOOD SAMARITAN HOSPITAL ALONG WITH ITS AFFILIATED OUTPATIENT FACILITIES, ARE PART OF CATHOLIC HEALTH INITIATIVES. CATHOLIC HEALTH INITIATIVES (CHI) IS A NATIONAL FAITH-BASED NONPROFIT HEALTH CARE ORGANIZATION WITH HEADQUARTERS IN ENGLEWOOD, COLORADO. CHI'S EXEMPT PURPOSE IS TO SERVE AS AN INTEGRAL PART OF ITS NATIONAL SYSTEM OF HOSPITALS AND OTHER CHARITABLE ENTITIES, WHICH ARE DESCRIBED AS MARKET-BASED ORGANIZATIONS, OR MBOS. AN MBO IS A DIRECT PROVIDER OF CARE OR SERVICES WITHIN A DEFINED MARKET AREA THAT MAY BE AN INTEGRATED HEALTH SYSTEM AND/OR A STAND-ALONE HOSPITAL OR OTHER FACILITY OR SERVICE PROVIDER. CHI SERVES AS THE PARENT CORPORATION OF ITS MBOS WHICH ARE COMPRISED OF 92 HOSPITALS, INCLUDING FOUR ACADEMIC MEDICAL CENTERS, AND 24 CRITICAL ACCESS FACILITIES; COMMUNITY HEALTH SERVICE ORGANIZATIONS; ACCREDITED NURSING COLLEGES; HOME HEALTH AGENCIES; AND OTHER FACILITIES THAT SPAN THE INPATIENT AND OUTPATIENT CONTINUUM OF CARE. TOGETHER, THESE FACILITIES PROVIDED $910 MILLION IN CHARITY CARE AND COMMUNITY BENEFIT IN THE 2014 FISCAL YEAR, INCLUDING SERVICES FOR THE POOR, FREE CLINICS, EDUCATION AND RESEARCH. CHI PROVIDES STRATEGIC PLANNING AND MANAGEMENT SERVICES AS WELL AS CENTRALIZED "SHARED SERVICES" FOR THE MBOS. THE PROVISION OF CENTRALIZED MANAGEMENT AND SHARED SERVICES - INCLUDING AREAS SUCH AS ACCOUNTING, HUMAN RESOURCES, PAYROLL AND SUPPLY CHAIN -- PROVIDES ECONOMIES OF SCALE AND PURCHASING POWER TO THE MBOS. THE COST SAVINGS ACHIEVED THROUGH CHI'S CENTRALIZATION ENABLE MBOS TO DEDICATE ADDITIONAL RESOURCES TO HIGH-QUALITY HEALTH CARE AND COMMUNITY OUTREACH SERVICES TO THE MOST VULNERABLE MEMBERS OF OUR SOCIETY. GOOD SAMARITAN HOSPITAL OPERATES WITH ITS WHOLLY OWNED AFFILIATES AND COMMUNITY PARTNERS, ALONG WITH ITS FUNDRAISING ARM, THE [GOOD SAMARITAN HOSPITAL FOUNDATION, TO SERVE THE HEALTH CARE NEEDS OF THE KEARNEY, NEBRASKA COMMUNITIES. Schedule H, Part VI, Line 7, State filing of community benefit report NE true KEARNEY PUBLIC SCHOOLS 310 W 24TH STREET KEARNEY NE 68845 476001393 N/A 50000 PROGRAM SUPPORT BUFFALO COUNTY COMMUNITY HEALTH PARTNERS INC 1755 PRAIRIE VIEW PLACE KEARNEY NE 68845 205852415 501(C)(3) 35000 PROGRAM SUPPORT UNIVERSITY OF NEBRASKA FOUNDATION 1010 LINCOLN MALL SUITE 300 LINCOLN NE 68501 470049123 501(C)(3) 250000 PROGRAM SUPPORT KEARNEY CATHOLIC FOUNDATION PO BOX 1261 KEARNEY NE 68848 363157461 501(C)(3) 20000 PROGRAM SUPPORT AMERICAN HEART ASSOCIATION 7272 GREENVILLE AVE DALLAS TX 75231 135613797 501(C)(3) 12500 PROGRAM SUPPORT GOOD SAMARITAN HOSPITAL FOUNDATION 111 WEST 31ST STREET KEARNEY NE 68847 476059443 501(C)(3) 350000 PROGRAM SUPPORT 5 1 Schedule I, Part I, Line 2, Procedures for monitoring use of grant funds MOST DISBURSEMENTS IN FURTHERANCE OF THE ORGANIZATION'S EXEMPT PROGRAMS ARE MADE DIRECTLY IN THE ACTIVE CONDUCT OF THE ACTIVITIES CONSTITUTING THE EXEMPT PURPOSE OR FUNCTION OF THE ORGANIZATION. OTHERWISE, DISTRIBUTIONS IN FURTHERANCE OF THE INSTITUTION'S EXEMPT PROGRAMS ARE MADE IN ACCORDANCE WITH PROCEDURES SUBJECT TO CONDITIONS ESTABLISHED BY THE INSTITUTION'S GOVERNING BOARD OR MANAGEMENT DESIGNED TO ENSURE THAT RECIPIENTS OF SUCH DISBURSEMENTS FROM THE ORGANIZATION ARE ADEQUATELY INVESTIGATED AND GRANTED TO QUALIFIED RECIPIENTS. X X true true false true false false false false false false false RICHARD HACHTEN II CHAIR/ACH PRESIDENT & CEO 0 1002940 0 3138518 0 174840 0 53071 0 14053 0 4383422 0 155803 CLIFF ROBERTSON BOARD MEMBER/CEO CHI HEALTH 0 575759 0 114665 0 71167 0 77744 0 22702 0 862037 0 48435 PAUL EDGETT III BOARD MEMBER/CHI SVP 0 496880 0 515695 0 114019 0 72192 0 22006 0 1220792 0 92265 ROBERT LANIK BOARD MEMBER/CHI NE PRESIDENT/CEO 0 650100 0 502592 0 161401 0 33702 0 14498 0 1362293 0 28040 MARTIN M MANCUSO MD BOARD MEMBER 0 368040 0 0 0 48052 0 7500 0 17722 0 441314 0 0 MICHAEL ROWAN FACHE BOARD MEMBER/CHI EVP & COO 0 1098277 0 1471311 0 200128 0 238353 0 19702 0 3027771 0 175028 LEIGH BERTHOLF FORMER VP & CRO 0 232348 0 18808 0 86569 0 31152 0 18688 0 387565 0 0 STEPHEN LEURCK FORMER INTERIM CAO 0 298799 0 0 0 0 0 0 0 0 0 298799 0 0 JEANETTE WOJTALEWICZ CFO, CHI HEALTH 0 426811 0 51596 0 21578 0 39641 0 20237 0 559863 0 0 MICHAEL SCHNIEDERS PRESIDENT GSH 0 377773 0 68850 0 49146 0 55377 0 20134 0 571280 0 18011 GEORGE HARMS VICE PRESIDENT OF FINANCE 215002 0 16263 0 9307 0 22736 0 19768 0 283076 0 0 0 LISA WEBB VP OF FINANCE 17044 193775 0 15980 0 8829 0 0 0 16004 17044 234588 0 0 ROBERT CUNNINGHAM VP ANCILLARY SUPPORT 194175 0 14389 0 8609 0 19846 0 18406 0 255425 0 0 0 CAROL WAHL VP PATIENT SERVICES 212594 0 15579 0 9745 0 28969 0 7802 0 274689 0 0 0 DENNIS EDWARDS VP MEDICAL AFFAIRS 0 384900 0 1500 0 5377 0 20952 0 20998 0 433727 0 0 CLARESSA L MILLSAP DIRECTOR CARDIOVASCULAR 23827 100070 0 2353 0 215 0 13761 1845 17688 25672 134087 0 0 ELIZABETH TAYLOR-TRUJILLO DIRECTOR BEHAVIORAL HEALTH 98884 0 1869 0 14705 0 0 0 13174 0 128632 0 0 0 LAWRENCE A SURMEIER DIRECTOR FACILITY OPERATIONS 111712 0 1738 0 147 0 0 0 13123 0 126720 0 0 0 HUGO GONZALEZ NIETO FORMER PHYSICIAN 0 234138 0 75530 0 3021 0 23502 0 15394 0 351585 0 0 FISHEL LIBERMAN FORMER PHYSICIAN 0 589697 0 150290 0 7037 0 23502 0 20998 0 791524 0 0 RICHARD HRANAC BOARD MEMBER/PHYSICIAN 45157 107856 0 0 0 10133 0 6549 0 8980 45157 133518 0 0 DAVID HUEBNER MD BOARD MEMBER/PRESIDENT MEDICAL STAFF 384598 0 0 0 0 0 0 0 0 0 384598 0 0 0 MICHAEL BIBLER PHYSICIAN 427296 444384 0 0 0 12385 0 23502 0 8368 427296 488639 0 0 TODD STOVER DIRECTOR PERFUSION 136617 0 2264 0 5814 0 15138 0 19544 0 179377 0 0 0 NICKI L BOHL DIRECTOR PHARMACY 136882 0 2125 0 138 0 12667 0 14188 0 166000 0 0 0 Schedule J, Part I, Line 1a, Travel for companions GOOD SAMARITAN HOSPITAL PROVIDES FOR COMPANION TRAVEL FOR ITS BOARD MEMBERS WHEN DEEMED APPROPRIATE. THESE BENEFITS ARE PAID AND GROSSED-UP PURSUANT TO A WRITTEN POLICY. ALL SUCH BENEFITS ARE INCLUDED IN THE INDIVIDUAL'S FORM W-2. Schedule J, Part I, Line 1a, Tax indemnification and gross-up payments GOOD SAMARITAN HOSPITAL PROVIDES FOR COMPANION TRAVEL FOR ITS BOARD MEMBERS WHEN DEEMED APPROPRIATE. THESE BENEFITS ARE PAID AND GROSSED-UP PURSUANT TO A WRITTEN POLICY. ALL SUCH BENEFITS ARE INCLUDED IN THE INDIVIDUAL'S FORM W-2. Schedule J, Part I, Line 3, Arrangement used to establish the top management official's compensation COMPENSATION FOR THE TOP MANAGEMENT OFFICIAL WAS ESTABLISHED AND PAID BY CATHOLIC HEALTH INITIATIVES (CHI), A RELATED ORGANIZATION. CHI USED THE FOLLOWING TO ESTABLISH THE TOP MANAGEMENT OFFICIAL'S COMPENSATION: (1) COMPENSATION COMMITTEE; (2) INDEPENDENT COMPENSATION CONSULTANT; (3) WRITTEN EMPLOYMENT CONTRACTS; (4) COMPENSATION SURVEY OR STUDY; (5) APPROVAL BY THE BOARD OR COMPENSATION COMMITTEE. SCHEDULE J, PART I, LINE 4A, SEVERANCE POST-TERMINATION PAYMENTS ARE ADDRESSED IN EXECUTIVE EMPLOYMENT AGREEMENTS FOR CATHOLIC HEALTH INITIATIVES ("CHI") AND RELATED ORGANIZATIONS' EMPLOYEES AT THE LEVEL OF VICE PRESIDENT AND ABOVE, INCLUDING THE MBO CEOS. THESE EMPLOYMENT AGREEMENTS REQUIRE THAT IN ORDER FOR THE EXECUTIVE TO RECEIVE POST-TERMINATION PAYMENTS, THESE INDIVIDUALS MUST EXECUTE A GENERAL RELEASE AND SETTLEMENT AGREEMENT. POST-TERMINATION PAYMENT ARRANGEMENTS ARE PERIODICALLY REVIEWED FOR OVERALL REASONABLENESS IN LIGHT OF THE EXECUTIVE'S OVERALL COMPENSATION PACKAGE. NO REPORTABLE INDIVIDUALS RECEIVED SEVERANCE PAYMENTS IN CALENDAR YEAR 2013. Schedule J, Part I, Line 4b, Supplemental nonqualified retirement plan DURING THE 2013 CALENDAR YEAR CATHOLIC HEALTH INITIATIVES ("CHI"), A RELATED ORGANIZATION, MAINTAINED A SUPPLEMENTAL NON-QUALIFIED DEFERRED COMPENSATION PLAN FOR MBO CEOS AND OTHER CHI EMPLOYEES AT THE LEVEL OF SENIOR VICE PRESIDENT AND ABOVE. THE FOLLOWING REPORTABLE INDIVIDUALS WERE ELIGIBLE TO PARTICIPATE IN THAT PLAN: MICHAEL SCHNIEDERS, ROBERT LANIK, PAUL EDGETT, CLIFF ROBERTSON, MICHAEL ROWAN, RICHARD HACHTEN, JEANETTE WOJTALEWICZ DURING 2013 THE FOLLOWING CONTRIBUTIONS WERE MADE BY CHI TO THE DEFERRED COMPENSATION PLAN: MICHAEL SCHNIEDERS $34,425 PAUL EDGETT $43,590 CLIFF ROBERTSON $49,142 MICHAEL ROWAN $214,851 JEANETTE WOJTALEWICZ $13,589 DURING 2013 THE FOLLOWING DISTRIBUTIONS WERE MADE BY CHI FROM THE DEFERRED COMPENSATION PLAN: MICHAEL SCHNIEDERS $18,011 ROBERT LANIK $28,040 PAUL EDGETT $92,265 CLIFF ROBERTSON $48,435 MICHAEL ROWAN $175,028 DUE TO THE "SUPER" VESTING RULES UNDER THE CHI DEFERRED COMPENSATION PLAN, PARTICIPANTS WHO HAVE MET CERTAIN REQUIREMENTS SUCH AS TERMINATION, AGE, OR YEARS OF SERVICE ARE ELIGIBLE TO RECEIVE THEIR 2013 CONTRIBUTIONS IN CASH. THESE CASH PAYOUTS ARE INCLUDED IN THE PARTICIPANT'S REPORTABLE COMPENSATION IN COLUMN (III) OTHER REPORTABLE COMPENSATION ON SCHEDULE J PART II. DURING 2013, THE FOLLOWING CONTRIBUTIONS THAT WOULD HAVE BEEN MADE BY CHI TO THE DEFERRED COMPENSATION PLAN WERE PAID IN CASH: ROBERT LANIK $101,293 RICHARCD HACHTEN $133,616 SCHEDULE J, PART I, LINE 7, NON-FIXED PAYMENTS CATHOLIC HEALTH INITIATIVES (CHI) MAINTAINS A VARIABLE PAY PROGRAM FOR MANAGERS AND ABOVE THAT PUTS A CERTAIN AMOUNT OF COMPENSATION AT RISK. AWARDS OF INCENTIVE COMPENSATION UNDER THE VARIABLE PAY PROGRAM ARE MADE BASED UPON ACHIEVEMENT OF ORGANIZATIONAL OBJECTIVES INCLUDING FINANCIAL OUTCOMES, QUALITY IMPROVEMENT, AND OTHER MEASURES AS DETERMINED ANNUALLY BY THE BOARD OF STEWARDSHIP TRUSTEES. HOWEVER, ELIGIBLE AWARDS PAYABLE UNDER THIS PROGRAM ARE DEPENDENT ON HITTING MINIMUM LEVELS OF OPERATING MARGIN AND CHARITY CARE LEVELS, UNLESS THE HR COMMITTEE OF THE BOARD OF STEWARDSHIP TRUSTEES USES THEIR DISCRETION TO APPROVE AN EXCEPTION. FORM 990, PART III, LINE 1, ORGANIZATION'S MISSION THE MISSION OF THE CORPORATION IS TO NURTURE THE HEALING MINISTRY OF THE CHURCH, SUPPORTED BY EDUCATION AND RESEARCH. FIDELITY TO THE GOSPEL URGES THE CORPORATION TO EMPHASIZE HUMAN DIGNITY AND SOCIAL JUSTICE AS IT CREATES HEALTHIER COMMUNITIES. THE CORPORATION, SPONSORED BY A LAY-RELIGIOUS PARTNERSHIP, CALLS OTHER CATHOLIC SPONSORS AND SYSTEMS TO UNITE TO ENSURE THE FUTURE OF CATHOLIC HEALTH CARE. TO FULFILL THIS MISSION, THE CORPORATION, AS A VALUES-BASED ORGANIZATION, WILL ASSURE THE INTEGRITY OF THE MINISTRY IN BOTH CURRENT AND DEVELOPING ORGANIZATIONS AND ACTIVITIES; RESEARCH AND DEVELOP NEW MINISTRIES THAT INTEGRATE HEALTH, EDUCATION, PASTORAL, AND SOCIAL SERVICES; PROMOTE LEADERSHIP DEVELOPMENT AND FORMATION FOR MINISTRY THROUGHOUT THE ENTIRE ORGANIZATION; ADVOCATE FOR SYSTEMIC CHANGES WITH SPECIFIC CONCERN FOR PERSONS WHO ARE POOR, ALIENATED, AND UNDERSERVED; AND STEWARD RESOURCES BY GENERAL OVERSIGHT OF THE ENTIRE ORGANIZATION. Form 990, Part VI, Sec A, Line 1a, Delegate broad authority to a committee PURSUANT TO SECTION 8.1 OF THE CORPORATION'S BYLAWS, COMMITTEES, SUCH AS THE EXECUTIVE COMMITTEE, THAT ARE GRANTED THE AUTHORITY TO ACT ON BEHALF OF THE BOARD OF DIRECTORS MAY INCLUDE ONLY DIRECTORS OF THE CORPORATION. Form 990, Part VI, Sec A, Line 4, Significant changes to organizational documents GOOD SAMRITAN HOSPITAL AMENDED ITS BYLAWS ON OCTOBER 1, 2013. SIGNIFICANT CHANGES INCLUDE AN INCREASE IN THE MINIMUM NUMBER OF BOARD MEMBER FROM 9 TO 11 AND A DECREASE IN THE MAXIMUM NUMBER OF BOARD MEMBERS FROM 21 TO 15. FURTHERMORE, THE CHIEF EXECUTIVE OFFICER AND THE EXECUTIVE VICE PRESIDENT AND CHIEF OPERATING OFFICER OR OTHER DESIGNEE SHALL EACH SERVE AS AN EX OFFICIO VOTING MEMBER OF THE BOARD. ADDITIONAL CHANGES MADE INCLUDE REMOVING THE REQUIREMENTS THAT THE PRESIDENT OF THE MEDICAL STAFF SHALL REPORT TO THE BOARD ON MATTERS RELATING TO THE MEDICAL STAFF AND THE CHAIRPERSON OF THE FOUNDATION SHALL NO LONGER BE REQUESTED TO ATTEND MEETINGS AT LEAST QUARTERLY. Form 990, Part VI, Sec A, Line 6, Classes of members or stockholders THE SOLE MEMBER OF THE CORPORATION IS CHI NEBRASKA, A NEBRASKA NONPROFIT CORPORATION. Form 990, Part VI, Sec A, Line 7a, Members or stockholders electing members of governing body CHI NEBRASKA HAS THE POWER TO APPOINT, REMOVE OR REPLACE THE MEMBERS OF THE BOARD OF DIRECTORS. Form 990, Part VI, Sec A, Line 7b, Decisions requiring approval by members or stockholders THE ORGANIZATION'S CORPORATE MEMBER IS CHI NEBRASKA. PURSUANT TO SECTION 5.1 OF THE ORGANIZATION'S BYLAWS, THE CORPORATE MEMBER SHALL HAVE THE SPECIFIC RIGHTS SET FORTH IN THE GOVERNANCE MATRIX. PURSUANT TO THE GOVERNANCE MATRIX THE FOLLOWING RIGHTS ARE RESERVED TO THE CHI NEBRASKA BOARD DIRECTLY OR THROUGH POWERS DELEGATED TO THE CHI NEBRASKA CHIEF EXECUTIVE OFFICER: -APPROVE MEMBERS OF THE GOOD SAMARITAN HOSPITAL BOARD -AMENDMENT OF THE CORPORATE DOCUMENTS OF THE GOOD SAMARITAN HOSPITAL -APPROVE REMOVAL OF A MEMBER OF THE GOVERNING BODY OF THE GOOD SAMARITAN HOSPITAL -ADOPTION OF LONG RANGE AND STRATEGIC PLANS FOR THE GOOD SAMARITAN HOSPITAL -SUBSTANTIAL CHANGE IN THE MISSION OR PHILOSOPHY OF THE GOOD SAMARITAN HOSPITAL -REMOVAL OF A MEMBER OF THE GOVERNING BODY OF THE GOOD SAMARITAN HOSPITAL -APPROVAL OF ISSUANCE OF DEBT BY GOOD SAMARITAN HOSPITAL -APPROVAL OF PARTICIPATION OF GOOD SAMARITAN HOSPITAL IN A JOINT VENTURE -APPROVAL OF FORMATION OF A NEW CORPORATION BY GOOD SAMARITAN HOSPITAL -APPROVAL OF A MERGER INVOLVING THE GOOD SAMARITAN HOSPITAL -APPROVAL OF THE SALE OF ALL OR SUBSTANTIALLY ALL OF THE ASSETS OF THE GOOD SAMARITAN HOSPITAL -TO REQUIRE THE TRANSFER OF ASSETS BY THE GOOD SAMARITAN HOSPITAL TO CHI TO ACCOMPLISH CHI'S GOALS AND OBJECTIVES, AND TO SATISFY CHI DEBTS. PURSUANT TO SECTION 5.2 OF THE ORGANIZATION'S BYLAWS, GOOD SAMARITAN HOSPITAL OR CHI NEBRASKA MAY, IN EXERCISE OF THEIR APPROVAL POWERS, GRANT OR WITHHOLD APPROVAL IN WHOLE OR IN PART, OR MAY, IN ITS COMPLETE DISCRETION, AFTER CONSULTATION WITH THE BOARD AND ITS PRESIDENT AND THE CHIEF EXECUTIVE OFFICER OF THE ORGANIZATION, RECOMMEND SUCH OTHER OR DIFFERENT ACTIONS AS IT DEEMS APPROPRIATE. Form 990, Part VI, Sec B, Line 11b, Review of form 990 by governing body FOLLOWING THE PREPARATION OF THE FORM 990 BY TAX ANALYSTS OF CATHOLIC HEALTH INITIATIVES, A RELATED ORGANIZATION, THE RETURN IS REVIEWED BY THE CHI TAX DIRECTOR AND THE LOCAL CHIEF FINANCIAL OFFICER. AFTER INCORPORATION OF ANY CHANGES RESULTING FROM THIS REVIEW, THE FORM 990 IS PROVIDED TO THE BOARD OF DIRECTORS AND MEMBERS OF THE FINANCE COMMITTEE OF THE BOARD A WEEK IN ADVANCE OF THE FINANCE COMMITTEE MEETING. THE FORM 990 IS REVIEWED AT THE FINANCE COMMITTEE MEETING AND THE CHIEF FINANCIAL OFFICER AND CHI TAX DIRECTOR ARE PRESENT AT THE MEETING TO ANSWER QUESTIONS. ADDITIONALLY, THE BOARD OF DIRECTORS ARE PROVIDED THE FINAL FORM 990 AND RELATED SCHEDULES TO REVIEW AND ARE ABLE TO ASK THE CHIEF FINANCIAL OFFICER AND TAX DIRECTOR QUESTIONS PRIOR TO FILING WITH THE IRS. UPON CHIEF FINANCIAL OFFICER APPROVAL AND SIGNATURE, THE TAX DIRECTOR FILES THE FINAL FORM 990 AS PRESENTED TO THE BOARD AND FINANCE COMMITTEE, MAKING ANY NON-SUBSTANTIVE CHANGES NECESSARY IN ORDER TO EFFECT E-FILING. ANY SUCH CHANGES ARE NOT RE-SUBMITTED TO THE BOARD. Form 990, Part VI, Sec B, Line 12c, Conflict of interest policy GOOD SAMARITAN HOSPITAL HAS ADOPTED THE CONFLICT OF INTEREST POLICY AND CONFLICT INVESTIGATION PROCESS OF CATHOLIC HEALTH INITIATIVES, A RELATED ORGANIZATION. ALL OFFICERS, TRUSTEES AND EMPLOYEES ARE COVERED BY A CONFLIC T OF INTEREST POLICY. ADDITIONALLY, ALL OFFICERS, TRUSTEES AND EMPLOYEES ARE REQUIRED TO ACT IN ACCORDANCE WITH CHI'S STATNDARDS OF CONDUCT, WHICH INCLUDE THE AVOIDANCE OF CONFLICTS OF INTEREST OR THE APPEARANCE OF CONFLICTS. THE CHI CONFLICT OF INTEREST POLICY PROVIDES THAT ALL MEMBERS OF THE BOARD OF DIRECTORS AND OF ANY BOARD COMMITTEE ARE REQUIRED TO PROMPTLY AND FULLY DISCLOSE TO THE BOARD CHAIR SITUATIONS THAT MAY CREATE A CONFLICT OF INTEREST WHEN THEY BECOME AWARE OF THE SITUATION. IN ADDITIONAL, ALL MEMBERS OF THE BOARD ARE REQUIRED TO ANNUALLY DISCLOSE ANY CONFLICTS OF INTEREST VIA COMPLETION OF THE CONFLICT OF INTEREST DISCLOSURE FORM WHICH IS REVIEWED BY THE SENIOR VICE PRESIDENT LEGAL SERVICES AND GENERAL COUNSEL. ANY IDENTIFIED POTENTIAL CONFLICTS ARE REPORTED TO THE BOARD CHARE, WHO IS CHARGED WITH FURTHER INVESTIGATION OF THE CONFLICT(S). AS HE OR SHE DEEMS APPROPRIATE: DOCUMENTATION OF CONCLUSIONS WITH RESPECT TO THE EXISTENCE OF A CONFLICT (INCLUDING RELEVANT FACTS AND CIRCUMSTANCES); AND REPORTING TO THE BOARD EXECUTIVE COMMITTEE CONCERNING THE REVIEW, EVALUATION AND CONFLICT DETERMINATION. TO THE EXTENT THAT THE BOARD CHAIR AND ANY OTHER TRUSTEE DISAGREE AS TO WHETHER A CIRCUMSTANCE GIVES RISE TO A CONFLICT, THE BOARD EXECUTIVE COMMITTEE MAKES THE FINAL DETERMINATION AS TO THE EXISTENCE OF A CONFLICT. THE CONFLICTED TRUSTEE IS EXCLUDED FROM VOTING AS TO THE EXISTENCE OF A CONFLICT, AND IS EXCUSED FROM THE ROOM WHILE VOTING CONCERNING THE MATTER IS CONDUCTED. IN ANY CIRCUMSTANCE WHERE A TRUSTEE HAS BEEN IDENTIFIED AS HAVING A CONFLICT OF INTEREST WITH RESPECT TO A PARTICULAR TRANSACTION, THAT TRUSTEE IS ALSO EXCLUDED FROM VOTING WITH RESPECT THAT PARTICULAR TRANSACTION. THE CONFLICT OF INTEREST POLICY WITH RESPECT TO EMPLOYEES REQUIRES THAT ALL EMPLOYEES COMPLETE AND SIGN A CONFLICT OF INTEREST DISCLOSURE FORM AT THE TIME OF HIRING. THEREAFTER, DIRECTOR LEVEL AND ABOVE EMPLOYEES MYST ANNUALLY CERTIFY AS PART OF THE PERFORMANCE EVALUATION PROCESS THAT THEY HAVE NO CONFLICTS OF INTEREST. FURTHER, ALL EMPLOYEES, REGARDLESS OF EMPLOYMENT LEVEL, ARE SUBJECT TO A GENERAL OBLIGATION TO DISCLOSE TO THEIR SUPERVISOR ANY CONFLICTS THAT ARISE DURING THE YEAR. FAILURE TO DISCLOSE ACTUAL OR POTENTIAL CONFLICTS MAY RESULT IN DISCIPLINARY ACTION. FORM 990, PART VI, LINE 15A, PROCESS USED TO ESTABLISH COMPENSATION OF TOP MANAGEMENT OFFICIAL CERTAIN EXECUTIVES AND MEMBERS OF MANAGEMENT WERE PAID BY CHI, A RELATED ORGANIZATION, DURING CALENDAR YEAR 2013. FOR THOSE PAID BY CHI, COMPENSATION WAS DETERMINED UNDER THE COMPENSATION PHILOSOPHY OF CHI. UNDER CHI'S PHILOSOPHY, BOTH THE EXECUTIVE AND NON-EXECUTIVE COMPENSATION STRUCTURES AND RANGES ARE REVIEWED ANNUALLY IN COMPARISON TO MARKET DATA. CHI USES THE HAY GROUP AS THE INDEPENDENT THIRD PARTY TO ASSESS EXECUTIVE COMPENSATION PROGRAMS AND TO ENSURE THE REASONABLENESS OF ACTUAL SALARIES AND TOTAL COMPENSATION PACKAGES. COMPENSATION OF THE SENIOR MOST EXECUTIVES IS REVIEWED ANNUALLY. THE HAY GROUP REVIEWS BOTH CASH AND TOTAL COMPENSATION FOR OVERALL REASONABLENESS, FOR ADHERENCE TO CHI'S COMPENSATION PHILOSOPHY, AND FOR COMPARABILITY TO THE NOT-FOR-PROFIT HEALTHCARE MARKET. THIS INDEPENDENT REVIEW IS DELIVEREC BY THE HAY GROUP TO THE HR COMMITTEE OF THE CHI BOARD OF STEWARDSHIP TRUSTEES ANNUALLY AT THEIR SEPTEMBER MEETING AND MINUTES ARE SHARED WITH THE FULL BOARD AT THE DECEMBER MEETING. IN ADDITION, THE HAY GROUP COMPLETES A COMPREHENSIVE ANNUAL REVIEW OF ALL CHI POSITIONS AT THE LEVEL OF VICE PRESIDENT AND ABOVE. THESE COMPENSATION LEVELS ARE REVISED ANNUALLY BASED ON MARKET DATA, WHERE APPLICABLE. FOR OTHER MEMBERS OF MANAGEMENT WHO WERE PAID UNDER ALEGENT CREIGHTON HEALTH FOR CALENDAR YEAR 2013, ALEGENT CREIGHTON HEALTH HUMAN RESOURCES COMPLETES A COMPENSATION MARKET STUDY TO DETERMINE SALARY. Form 990, Part VI, Sec B, Line 15b, Process to establish compensation of other employees HR ADVANTAGE HAS SERVED AS THE INDEPENDENT COMPENSATION CONSULTANT FOR THE NEBRASKA FACILITIES IN 2012-2014. HR ADVANTAGE REVIEWED ALL NEBRASKA MINISTRIES' VP AND EXECUTIVE DIRECTORS COMPENSATION LEVELS AND PROVIDED A REPORT WITH COMPARABILITY DATA TO CHI NEBRASKA HR LEADERS TO REVIEW WITH LOCAL CEOS, CONFIRMING THE REASONABLENESS OF MBO EXECUTIVE'S COMPENSATION AND PHILOSOPHY. COMPENSATION PACKAGE AND BONUS POTENTIAL FOR EXECUTIVE LEADERS IS APPROVED BY EACH MINISTRIES LOCAL BOARDS. THE HIGHEST PAID EMPLOYEES ARE DIRECTORS. FORM 990, PART VI, LINE 16B, FORMAL POLICIES CONCERNING PARTICIPATION IN JOINT VENTURES GOOD SAMARITAN HOSPITAL HAS NOT FORMALLY ADOPTED A WRITTEN POLICY OR WRITTEN PROCEDURE REGARDING JOINT VENTURES. HOWEVER,CHI'S SYSTEM WIDE JOINT VENTURE MODEL OPERATING AGREEMENT INCORPORATES CONTROLS OVER THE VENTURE SUFFICIENT TO ENSURE THAT (1) THE EXEMPT ORGANIZATION AT ALL TIMES RETAINS CONTROL OVER THE VENTURE SUFFICIENT TO ENSURE THAT THE PARTNERSHIP FURTHERS THE EXEMPT PURPOSE OF THE ORGANIZATION; (2) IN ANY PARTNERSHIP IN WHICH THE EXEMPT ORGANIZATION IS A PARTNER, ACHIEVEMENT OF EXEMPT PURPOSES IS PRIORITIZED OVER MAXIMIZATION OF PROFITS FOR THE PARTNERS; (3) THE PARTNERSHIP DOES NOT ENGAGE IN ANY ACTIVITIES THAT WOULD JEOPARDIZE THE EXEMPT ORGANIZATION'S EXEMPTION; (4) RETURNS OF CAPITAL, ALLOCATIONS AND DISTRIBUTIONS MUST BE MADE IN PROPORTION TO THE PARTNERS' RESPECTIVE OWNERSHIP INTERESTS; AND (5) ALL CONTRACTS ENTERED INTO BY THE PARTNERSHIP WITH THE EXEMPT ORGANIZATION MUST BE AT ARM'S-LENGTH, WITH PRICES SET AT FAIR MARKET VALUE. ANY JOINT VENTURE AGREEMENTS THAT DO NOT CONFORM TO THE MODEL AGREEMENT ARE GENERALLY REVIEWED BY COUNSEL. Form 990, Part VI, Sec C, Line 19, Required documents available to the public THE ORGANIZATION'S GOVERNING DOCUMENTS AND CONFLICT OF INTEREST POLICY ARE AVAILABLE UPON REQUEST FROM THE ADMINISTRATION DEPARTMENT. IN ADDITION, THE ARTICLES OF INCORPORATION ARE AVAILABLE FROM THE NEBRASKA (IOWA) SCRETARY OF STATE WEBSITE (HTTP://WWW.SOS.NE.GOV/BUSINESS OR IOWA'S WEBSITE FROM PRIOR YEAR) THE ORGANIZATION'S FINANCIAL STATEMENTS ARE INCLUDED IN CATHOLIC HEALTH INITIATIVES' CONSOLIDATED AUDITED FINANCIAL STATEMENTS THAT ARE AVAILABLE AT WWW.CATHOLICHEALTHINIT.ORG OR AT WWW.DACBOND.ORG. Form 990, Part IX, Line 11g, Other Expenses CONTRACT SERVICES - TOTAL EXPENSE: 21542853, PROGRAM SERVICE EXPENSE: 10081211, MANAGEMENT AND GENERAL EXPENSES: 11461642, FUNDRAISING EXPENSES: ; CONTRACT LABOR - TOTAL EXPENSE: 3174024, PROGRAM SERVICE EXPENSE: 2825832, MANAGEMENT AND GENERAL EXPENSES: 348192, FUNDRAISING EXPENSES: ; CONTRACTED PROFESSIONALS - TOTAL EXPENSE: 4425933, PROGRAM SERVICE EXPENSE: 3783413, MANAGEMENT AND GENERAL EXPENSES: 642520, FUNDRAISING EXPENSES: ; OTHER FEES FOR SERVICES - TOTAL EXPENSE: 6277879, PROGRAM SERVICE EXPENSE: 4641703, MANAGEMENT AND GENERAL EXPENSES: 1636176, FUNDRAISING EXPENSES: ; Form 990 , Part XI, Line 9, Other changes in net assets or fund balances DONATED EQUIPMENT - 318660; ALEGENT CREIGHTON CLINIC 12809 W DODGE RD OMAHA NE 68154 470765154 HEALTHCARE NE 501(C)(3) 3 ACH true ALEGENT CREIGHTON HEALTH 12809 W DODGE RD OMAHA NE 68154 470757164 HEALTHCARE NE 501(C)(3) 3 CHI NEBRASKA true ALEGENT CREIGHTON HEALTH FOUNDATION 12809 W DODGE RD OMAHA NE 68154 470648586 FUNDRAISING NE 501(C)(3) 7 ACH true ALEGENT HEALTH - BERGAN MERCY HEALTH SYSTEM 7500 MERCY RD OMAHA NE 68124 470484764 HEALTHCARE NE 501(C)(3) 3 CHI NEBRASKA true ALEGENT HEALTH - COMMUNITY MEMORIAL HOSPITAL OF MISSOURI VALLEY IA 631 N 8TH ST MISSOURI VALLEY IA 51555 420776568 HEALTHCARE IA 501(C)(3) 3 CHI NEBRASKA true ALEGENT HEALTH - IMMANUEL MEDICAL CENTER 6901 N 72ND ST OMAHA NE 68122 470376615 HEALTHCARE NE 501(C)(3) 3 CHI NEBRASKA true ALEGENT HEALTH - MEMORIAL HOSPITAL SCHUYLER 104 W 17TH ST SCHUYLER NE 68661 470399853 HEALTHCARE NE 501(C)(3) 3 CHI NEBRASKA true ALEGENT HEALTH - MERCY HOSPITAL CORNING IOWA PO BOX 368 CORNING IA 50841 420782518 HEALTHCARE IA 501(C)(3) 3 CHI NEBRASKA true ALVERNA APARTMENTS 300 SE 8TH AVE LITTLE FALLS MN 56345 411351177 LTERM CARE MN 501(C)(3) 9 CHI true APPLETREE COURT 601 OAK ST BRECKENRIDGE MN 56520 411850500 SENIOR LIVING MN 501(C)(3) 9 SFH true BISHOP DRUMM RETIREMENT CENTER 1111 6TH AVE DES MOINES IA 50314 420725196 LTERM CARE IA 501(C)(3) 9 CHI-IA CORP true BORNEMANN HEALTHCARE CORPORATION 2500 BERNVILLE RD PO BOX 316 READING PA 19603 232187242 HEALTHCARE PA 501(C)(3) 11 - Type I CHI true CARRINGTON HEALTH CENTER 800 N 4TH ST CARRINGTON ND 58421 450227311 HEALTHCARE ND 501(C)(3) 3 CHI true CATHOLIC HEALTH INITIATIVES 198 INVERNESS DRIVE WEST ENGLEWOOD CO 80112 470617373 HEALTHCARE CO 501(C)(3) 9 NA true CATHOLIC HEALTH INITIATIVES - COLORADO 188 INVERNESS DRIVE WEST STE 500 ENGLEWOOD CO 80112 840405257 HEALTHCARE CO 501(C)(3) 3 CHI true CATHOLIC HEALTH INITIATIVES - IOWA CORP 1111 6TH AVE DES MOINES IA 50314 420680448 HEALTHCARE IA 501(C)(3) 3 CHI true CATHOLIC HEALTH INITIATIVES COLORADO FOUNDATION 6385 CORPORATE DR STE 301 COLORADO SPRINGS CO 80919 840902211 FUNDRAISING CO 501(C)(3) 7 CHIC true CATHOLIC HEALTH INITIATIVES NATIONAL FOUNDATION 6385 CORPORATE DR COLORADO SPRINGS CO 80919 270930004 FUNDRAISING CO 501(C)(3) 11 - Type I CHI true CATHOLIC HEALTH INITIATIVES VIRTUAL HEALTH SERVICES 198 INVERNESS DRIVE WEST ENGLEWOOD CO 80112 460992796 HEALTHCARE CO 501(C)(3) 11 - Type I CHINS true CENTENNIAL MEDICAL GROUP INC 2700 STEWART PKWY ROSEBURG OR 97471 263946191 PHYSICIANS OR 501(C)(3) 9 MMC true CENTRAL KANSAS MEDICAL CENTER 3515 BROADWAY GREAT BEND KS 67530 480543724 SURGERY CENTER KS 501(C)(3) 3 CHI true CHI HEALTH CONNECT AT HOME - FARGO 4816 AMBER VALLEY PKWY S FARGO ND 58104 271966847 HEALTHCARE MN 501(C)(3) 9 CHI true CHI INSTITUTE FOR RESEARCH AND INNOVATION 198 INVERNESS DRIVE WEST ENGLEWOOD CO 80112 271050565 HEALTHCARE CO 501(C)(3) 11 - Type I CHI true CHI KENTUCKY INC 3900 OLYMPIC BLVD STE 400 ERLANGER KY 41018 202741651 HEALTHCARE KY 501(C)(3) 11 - Type I CHI true CHI NATIONAL HOME CARE 198 INVERNESS DRIVE WEST ENGLEWOOD CO 80112 451261716 HEALTHCARE CO 501(C)(3) 9 CHI NS true CHI NATIONAL SERVICES 198 INVERNESS DRIVE WEST ENGLEWOOD CO 80112 452532084 HEALTHCARE CO 501(C)(3) 11 - Type I CHI true CHI NEBRASKA 6940 O ST STE 200 LINCOLN NE 68510 363233121 HEALTHCARE NE 501(C)(3) 11 - Type III - FI CHI true CHI ST LUKE'S HEALTH BAYLOR COLLEGE OF MEDICINE MEDICAL CENTER 6624 FANNIN ST HOUSTON TX 77030 741161938 HEALTHCARE TX 501(C)(3) 3 SLHS true CHI ST VINCENT HOSPITAL HOT SPRINGS 300 WERNER ST HOT SPRINGS AR 71913 710236913 HEALTHCARE AR 501(C)(3) 3 CHISVHS true CHI ST VINCENT HOT SPRINGS 300 WERNER ST HOT SPRINGS AR 71913 261125064 HOLDING CO AR 501(C)(3) 11 - Type II SVIMC true CHI ST VINCENT MEDICAL GROUP HOT SPRINGS 1 MERCY LANE STE 201 HOT SPRINGS AR 71913 261125131 HEALTHCARE AR 501(C)(3) 3 CHISVHS true COMMUNITY LIMITED CARE DIALYSIS CENTER 619 OAK ST ACCOUNTING-3 W CINCINNATI OH 45206 237419853 HOLDING CO OH 501(C)(2) N/A GSH true COMMUNITY MEMORIAL HOSPITAL MEDICAL SERVICE FOUNDATION 631 N 8TH ST MISSOURI VALLEY IA 51555 421294399 FUNDRAISING IA 501(C)(3) 11 - Type I AH-CMHMV true CONTINUING CARE HOSPITAL 150 NORTH EAGLE CREEK DR LEXINGTON KY 40509 611400619 LT ACH KY 501(C)(3) 3 SJHS true COVENANT HOME CARE 198 INVERNESS DRIVE WEST ENGLEWOOD CO 80112 232028429 HOME HEALTH PA 501(C)(3) 11 - Type II CHI NHC true ENUMCLAW REGIONAL HOSPITAL ASSOCIATION 1450 BATTERSBY AVE ENUMCLAW WA 98022 910715805 HEALTHCARE WA 501(C)(3) 3 FHS true FLAGET HEALTHCARE INC 4305 NEW SHEPHERDSVILLE RD BARDSTOWN KY 40004 611345363 HEALTHCARE KY 501(C)(3) 3 KOH true FLAGET MEMORIAL HOSPITAL FOUNDATION INC 4305 NEW SHEPHERDSVILLE RD BARDSTOWN KY 40004 562351341 FUNDRAISING KY 501(C)(3) 11 - Type I FH true FRANCISCAN FOUNDATION 1717 SOUTH J ST TACOMA WA 98405 911145592 FUNDRAISING WA 501(C)(3) 9 FHS true FRANCISCAN HEALTH SYSTEM 1717 SOUTH J ST TACOMA WA 98405 910564491 HEALTHCARE WA 501(C)(3) 3 CHI true FRANCISCAN HEALTH VENTURES FKA SJMGROUP TACOMA FNC CTR BLDG 1145 BROADWAY TACOMA WA 98402 431882377 PHYSICIANS MO 501(C)(3) 9 CHI true FRANCISCAN MEDICAL GROUP 1313 BROADWAY STE 200 TACOMA WA 98402 911939739 HEALTHCARE WA 501(C)(3) 9 FHS true FRANCISCAN VILLA OF SOUTH MILWAUKEE INC 3601 S CHICAGO AVE SOUTH MILWAUKEE WI 53172 391093829 HEALTHCARE WI 501(C)(3) 9 CHI true GLOBAL HEALTH INITIATIVES 198 INVERNESS DRIVE WEST ENGLEWOOD CO 80112 201536108 MINISTRIES CO 501(C)(3) 11 - Type I CHI true GOOD SAMARITAN COLLEGE OF NURSING & HEALTH SCIENCE 619 OAK ST ACCOUNTING-3 W CINCINNATI OH 45206 311778403 EDUCATION OH 501(C)(3) 2 GSH true GOOD SAMARITAN FOUNDATION OF CINCINNATI INC 619 OAK ST ACCOUNTING-3 W CINCINNATI OH 45206 311206047 FUNDRAISING OH 501(C)(3) 11 - Type I GSH true GOOD SAMARITAN HOSPITAL PO BOX 1990 KEARNEY NE 68848 470379755 HEALTHCARE NE 501(C)(3) 3 CHI NEBRASKA true GOOD SAMARITAN HOSPITAL FOUNDATION 111 W 31ST ST KEARNEY NE 68847 470659443 FUNDRAISING NE 501(C)(3) 7 GSH true GOOD SAMARITAN HOSPITAL FOUNDATION - DAYTON 110 N MAIN ST STE 500 DAYTON OH 45402 237296923 FUNDRAISING OH 501(C)(3) 7 SHP true HARRISON MEDICAL CENTER 2520 CHERRY AVE BREMERTON WA 98310 910565546 HEALTHCARE WA 501(C)(3) 3 FHS true HARRISON MEDICAL CENTER FOUNDATION 2520 CHERRY AVE BREMERTON WA 98310 911197626 FUNDRAISING WA 501(C)(3) 7 HMC true HEALTH SET 2420 W 26TH AVE STE 460D DENVER CO 80211 841102943 LOW INC CARE CO 501(C)(3) 7 CHIC true HEALTHCARE AND WELLNESS FOUNDATION 2400 ST FRANCIS DR BRECKENRIDGE MN 56520 760761782 FUNDRAISING MN 501(C)(3) 11 - Type I SFMC true HIGHLINE MEDICAL CENTER 16251 SYLVESTER RD SW BURIEN WA 98166 910712166 HEALTHCARE WA 501(C)(3) 3 FHS true HOUSE OF MERCY 1111 6TH AVE DES MOINES IA 50314 421323808 SHELTER IA 501(C)(3) 7 CHI-IA CORP true JEWISH HOSPITAL AND ST MARY'S HEALTHCARE INC 539 S 4TH ST LOUISVILLE KY 40202 611029768 HEALTHCARE KY 501(C)(3) 3 KOH true KENTUCKYONE HEALTH MEDICAL GROUP INC 539 S 4TH ST LOUISVILLE KY 40202 611352729 HEALTHCARE KY 501(C)(3) 9 JHSMH true KENTUCKYONE HEALTH INC 200 ABRAHAM FLEXNER WAY LOUISVILLE KY 40202 611029769 HEALTHCARE KY 501(C)(3) 9 CHI true LAKEWOOD HEALTH CENTER 600 MAIN AVE S BAUDETTE MN 56623 410758434 HEALTHCARE MN 501(C)(3) 3 CHI true LINUS OAKES INC 2700 STEWART PKWY ROSEBURG OR 97471 930821381 SENIOR LIVING OR 501(C)(3) 9 MMC true LISBON AREA HEALTH SERVICES 905 MAIN ST LISBON ND 58054 820558836 HEALTHCARE ND 501(C)(3) 3 CHI true LUFKIN VISION ACQUISITIONS PO BOX 1447 LUFKIN TX 75901 820563768 PROPERTY MGMT TX 501(C)(3) 11 - Type III - FI MHSET true MEMORIAL HEALTH CARE SYSTEM FOUNDATION INC 2525 DE SALES AVE CHATTANOOGA TN 37404 621839548 FUNDRAISING TN 501(C)(3) 7 MHCS true MEMORIAL HEALTH CARE SYSTEM INC 2525 DE SALES AVE CHATTANOOGA TN 37404 620532345 HEALTHCARE TN 501(C)(3) 3 CHI true MEMORIAL HEALTH PARTNERS FOUNDATION INC 5600 BRAINERD RD STE 500 CHATTANOOGA TN 37411 030417049 HEALTHCARE TN 501(C)(3) 9 MHCS true MEMORIAL HEALTH SYSTEM OF EAST TEXAS PO BOX 1447 LUFKIN TX 75902 750755367 HEALTHCARE TX 501(C)(3) 3 CHI true MEMORIAL MEDICAL CENTER - LIVINGSTON PO BOX 1447 LUFKIN TX 75902 760436439 HEALTHCARE TX 501(C)(3) 3 MHSET true MEMORIAL MEDICAL CENTER - SAN AUGUSTINE PO BOX 1447 LUFKIN TX 75902 752663904 HEALTHCARE TX 501(C)(3) 3 MHSET true MEMORIAL MULTISPECIALTY ASSOCIATES 1201 FRANK AVE LUFKIN TX 95904 752721155 PHYSICIANS TX 501(C)(3) 11 - Type III - FI MHSET true MEMORIAL SPECIALTY HOSPITAL PO BOX 1447 LUFKIN TX 95902 752492741 HEALTHCARE TX 501(C)(3) 3 MHSET true MERCY AUXILIARY OF CENTRAL IOWA 1111 6TH AVE DES MOINES IA 50314 426076069 AUXILIARY IA 501(C)(3) 11 - Type I MF-DM IA true MERCY CLINICS INC 1111 6TH AVE DES MOINES IA 50314 421193699 PHYSICIANS IA 501(C)(3) 9 CHI-IA CORP true MERCY COLLEGE OF HEALTH SCIENCES 1111 6TH AVE DES MOINES IA 50314 421511682 EDUCATION IA 501(C)(3) 2 CHI-IA CORP true MERCY FOUNDATION OF DES MOINES IA 1111 6TH AVE DES MOINES IA 50314 237358794 FUNDRAISING IA 501(C)(3) 7 CHI-IA CORP true MERCY FOUNDATION INC 2700 STEWART PKWY ROSEBURG OR 97471 936088946 FUNDRAISING OR 501(C)(3) 7 MMC true MERCY HEALTH CARE FOUNDATION PO BOX 368 CORNING IA 50841 421461064 FUNDRAISING IA 501(C)(3) 11 - Type I AHMH-CORNING true MERCY HEALTHCARE FOUNDATION 570 CHAUTAUQUA BLVD VALLEY CITY ND 58072 450435338 FUNDRAISING ND 501(C)(3) 11 - Type III - FI MHVC true MERCY HOSPITAL FOUNDATION COUNCIL BLUFFS 800 MERCY DR COUNCIL BLUFFS IA 51503 421178204 FUNDRAISING IA 501(C)(3) 11 - Type I AHBMHS true MERCY HOSPITAL OF DEVILS LAKE 1031 7TH ST NE DEVILS LAKE ND 58301 450227012 HEALTHCARE ND 501(C)(3) 3 CHI true MERCY HOSPITAL OF DEVILS LAKE FOUNDATION 1031 7TH ST NE DEVILS LAKE ND 58301 352367360 FUNDRAISING ND 501(C)(3) 7 MHDL true MERCY HOSPITAL OF VALLEY CITY 570 CHAUTAUQUA BLVD VALLEY CITY ND 58072 450226553 HEALTHCARE ND 501(C)(3) 3 CHI true MERCY MEDICAL CENTER 1301 15TH AVE WEST WILLISTON ND 58801 450231183 HEALTHCARE ND 501(C)(3) 3 CHI true MERCY MEDICAL CENTER - CENTERVILLE ONE ST JOSEPHS DRIVE CENTERVILLE IA 52544 420680308 HEALTHCARE IA 501(C)(3) 3 CHI-IA CORP true MERCY MEDICAL CENTER INC 2700 STEWART PKWY ROSEBURG OR 97471 930386868 HEALTHCARE OR 501(C)(3) 3 CHI true MERCY MEDICAL FOUNDATION 1301 15TH AVE WEST WILLISTON ND 58801 450381803 FUNDRAISING ND 501(C)(3) 11 - Type I MMC true MERCY PROFESSIONAL PRACTICE ASSOCIATES INC 1111 6TH AVE DES MOINES IA 50314 421470935 PHYSICIANS IA 501(C)(3) 9 CHI-IA CORP true NEBRASKA HEART HOSPITAL 7500 S 91ST ST LINCOLN NE 68526 392031968 HEALTHCARE NE 501(C)(3) 3 CHI NEBRASKA true OAKES COMMUNITY HOSPITAL 1200 N 7TH ST OAKES ND 58474 450231675 HEALTHCARE ND 501(C)(3) 3 CHI true OAKES COMMUNITY HOSPITAL FOUNDATION 1200 N 7TH ST OAKES ND 58474 710966606 FUNDRAISING ND 501(C)(3) 11 - Type I OCH true PINEYWOODS MEDICAL DEVELOPMENT CORP PO BOX 1447 LUFKIN TX 75902 752493116 PROPERTY MGMT TX 501(C)(3) 11 - Type III - FI MHSET true PUEBLO STEPUP 1925 E ORMAN AVE STE G52 PUEBLO CO 81004 841234295 COMMUNITY CO 501(C)(3) 7 CHIC true REGIONAL HOSPITAL FOR RESPIRATORY AND COMPLEX CARE 12844 MILITARY RD S TUKWILA WA 98168 911170040 HEALTHCARE WA 501(C)(3) 3 FHS true SET OF COLORADO SPRINGS INC 2864 S CIRCLE DR STE 450 COLORADO SPRINGS CO 80906 841183335 LTERM CARE CO 501(C)(3) 7 CHIC true SAINT CLARE'S COMMUNITY CARE INC 25 POCONO RD DENVILLE NJ 07834 222876836 HEALTHCARE NJ 501(C)(3) 11 - Type II SCHS true SAINT CLARE'S FOUNDATION INC 25 POCONO RD DENVILLE NJ 07834 222502997 FUNDRAISING NJ 501(C)(3) 7 SCHS true SAINT CLARE'S HEALTH SERVICES INC 25 POCONO RD DENVILLE NJ 07834 223639733 MANAGEMENT NJ 501(C)(3) 11 - Type II CHI true SAINT CLARE'S HOSPITAL INC 25 POCONO RD DENVILLE NJ 07834 223319886 HEALTHCARE NJ 501(C)(3) 3 SCHS true SAINT ELIZABETH FOUNDATION 555 S 70TH ST LINCOLN NE 68510 470625523 FUNDRAISING NE 501(C)(3) 7 SERMC true SAINT ELIZABETH HEALTH SERVICES 555 S 70TH ST LINCOLN NE 68510 363233120 HEALTHCARE NE 501(C)(3) 3 SERMC true SAINT ELIZABETH REGIONAL MEDICAL CENTER 555 S 70TH ST LINCOLN NE 68510 470379836 HEALTHCARE NE 501(C)(3) 3 CHI NEBRASKA true SAINT FRANCIS MEDICAL CENTER 2620 W FAIDLEY GRAND ISLAND NE 68803 470376601 HEALTHCARE NE 501(C)(3) 3 CHI NEBRASKA true SAINT FRANCIS MEDICAL CENTER FOUNDATION PO BOX 9804 GRAND ISLAND NE 68802 470630267 FUNDRAISING NE 501(C)(3) 7 SFMC true SAINT JOSEPH BEREA HOSPITAL FOUNDATION INC 305 ESTILL ST BEREA KY 40403 260152877 FUNDRAISING KY 501(C)(3) 7 SJHS true SAINT JOSEPH HEALTH SYSTEM INC 424 LEWIS HARGETT CIRCLE STE 160 LEXINGTON KY 40503 611334601 HEALTHCARE KY 501(C)(3) 3 KOH true SAINT JOSEPH HOSPITAL FOUNDATION INC ONE SAINT JOSEPH DRIVE LEXINGTON KY 40504 611159649 FUNDRAISING KY 501(C)(3) 11 - Type I SJHS true SAINT JOSEPH LONDON FOUNDATION INC 1001 SAINT JOSEPH LANE LONDON KY 40741 260438748 FUNDRAISING KY 501(C)(3) 7 SJHS true SAINT JOSEPH MEDICAL FOUNDATION INC 200 ABRAHAM FLEXNER WAY LOUISVILLE KY 40202 311539059 PHYSICIANS KY 501(C)(3) 3 SJHS true SAINT JOSEPH MOUNT STERLING FOUNDATION INC 225 FALCON DR MOUNT STERLING KY 40353 272884584 FUNDRAISING KY 501(C)(3) 7 SJHS true SAINT JOSEPH'S HOSPITAL FOUNDATION 30 WEST 7TH ST DICKINSON ND 58601 363418207 FUNDRAISING ND 501(C)(3) 11 - Type I SJHHC true SAMARITAN BEHAVIORAL HEALTH INC 601 S EDWIN C MOSES BLVD DAYTON OH 45417 020633634 HEALTHCARE OH 501(C)(3) 7 SHP true SAMARITAN HEALTH PARTNERS 110 N MAIN ST STE 500 DAYTON OH 45402 311107411 HEALTHCARE OH 501(C)(3) 11 - Type I CHI true SCHUYLER MEMORIAL HOSPITAL FOUNDATION INC 104 W 17TH ST SCHUYLER NE 68661 363630014 FUNDRAISING NE 501(C)(3) 11 - Type I AHMHS true SJRMC JOPLIN MISSOURI 198 INVERNESS DRIVE WEST ENGLEWOOD CO 80112 440545809 HEALTHCARE MO 501(C)(3) 3 CHI true SL AUGUSTA CORP PO BOX 20269 HOUSTON TX 77225 760226623 TITLE HOLDING TX 501(C)(2) N/A SLPC true ST ANTHONY HOSPITAL 1601 SE COURT AVE PENDLETON OR 97801 930391614 HEALTHCARE OR 501(C)(3) 3 CHI true ST ANTHONY HOSPITAL FOUNDATION 1601 SE COURT AVE PENDLETON OR 97801 930992727 FUNDRAISING OR 501(C)(3) 11 - Type I SAH true ST ANTHONY'S HOSPITAL ASSOCIATION FOUR HOSPITAL DR MORRILTON AR 72110 710245507 HEALTHCARE AR 501(C)(3) 3 SVIMC true ST CATHERINE HOSPITAL 401 EAST SPRUCE ST GARDEN CITY KS 67846 480543721 HEALTHCARE KS 501(C)(3) 3 CHI true ST CATHERINE HOSPITAL DEVELOPMENT FOUNDATION 401 EAST SPRUCE ST GARDEN CITY KS 67846 200598702 FUNDRAISING KS 501(C)(3) 11 - Type I SCH true ST DOMINIC OF ONTARIO OREGON 198 INVERNESS DRIVE WEST ENGLEWOOD CO 80112 930433692 HEALTHCARE OR 501(C)(4) N/A CHI true ST FRANCIS HOME 2400 ST FRANCIS DR BRECKENRIDGE MN 56520 410729978 LTERM CARE MN 501(C)(3) 9 CHI true ST FRANCIS LIFE CARE CORPORATION 19 POCONO RD DENVILLE NJ 07834 222536017 ELDERLY CARE NJ 501(C)(3) 9 SCHS true ST FRANCIS MEDICAL CENTER 2400 ST FRANCIS DR BRECKENRIDGE MN 56520 410695598 HEALTHCARE MN 501(C)(3) 3 CHI true ST FRANCIS OF BAKER CITY 198 INVERNESS DRIVE WEST ENGLEWOOD CO 80112 930412495 HEALTHCARE OR 501(C)(3) 3 CHI true ST JOSEPH COMMUNITY HEALTH 1516 5TH ST NW ALBUQUERQUE NM 87102 710897107 COMMUNITY NM 501(C)(3) 11 - 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