2013-11-06T14:01:58-06:00 2012-12-31 KPMG LLP 1212 North 96th Street Suite 300 Omaha NE 68114 990 2012-01-01 470486026 FRANCISCAN CARE SERVICES INC % DENNIS DINSLAGE FRAN 4023722404 430 NORTH MONITOR STREET Suite WEST POINT NE 687881555 RONALD O BRIGGS 4023481450 2013-11-05 true Adam C Stark 4023481450 2012 2016-02-24 21:20:13Z RONALD O BRIGGS 430 NORTH MONITOR STREET WEST POINT NE 687881555 29520570 false 0928 X www.fcswp.org X 1964 NE THE MISSION OF FRANCISCAN CARE SERVICES INC. IS TO LIVE AND TO PROMOTE THE HEALING MISSION OF JESUS CHRIST. 13 8 284 232 -1308 -1308 212443 272049 25097177 28593940 605114 612854 0 -9942 25914734 29468901 0 0 0 0 14439665 16115791 0 0 1848 8500555 10431988 22940220 26547779 2974514 2921122 51314692 59849731 13605330 18414964 37709362 41434767 X THE MISSION OF FRANCISCAN CARE SERVICES INC. IS TO LIVE AND TO PROMOTE THE HEALING MISSION OF JESUS CHRIST BY PROVIDING QUALITY HEALTH CARE AND HEALTH RELATED INPATIENT, OUTPATIENT, HOME HEALTH, PHYSICIAN AND ASSISTED LIVING SERVICES TO ANYONE IN NORTHEAST NEBRASKA, REGARDLESS OF THEIR ABILITY TO PAY. false false 21581892 0 26462176 FRANCISCAN CARE SERVICES MISSION IS TO PROVIDE QUALITY HEALTH CARE AND HEALTH RELATED INPATIENT, OUTPATIENT, HOME HEALTH AND PHYSICIAN SERVICES TO THE PEOPLE OF NORTHEASTERN NEBRASKA. THE CRITICAL ACCESS HOSPITAL PROVIDES A 24 HOUR EMERGENCY ROOM AND DOES NOT DISCRIMINATE AGAINST ANY PATIENT REGARDLESS OF THEIR ABILITY TO PAY. OUR CHARITY CARE POLICY FOLLOWS RECOMMENDED STANDARDS WHICH ARE BASED UPON THE FEDERAL POVERTY GUIDELINES. THIS POLICY IS COMMUNICATED TO OUR PATIENTS ON OUR WEBSITE AND AT OUR REGISTRATION DESKS. PATIENTS SERVED DURING THE YEAR: TOTAL MEDICARE MEDICAID IN-PATIENTS DISCHARGED 473 288 16 PATIENT DAYS - ACUTE 1,688 1,117 49 - SWING BED 1,016 829 16 - NURSERY 111 0 31 OUT-PATIENT & HOME HEALTH 44,447 20,027 924 PHYSICIAN CLINIC VISITS 24,833 9,603 2,031 THE HOSPITAL RECEIVES GENEROUS SUPPORT FROM THE COMMUNITY NOT ONLY FINANCIALLY BUT ALSO FROM ABOUT 182 VOLUNTEERS WHO DONATED APPROXIMATELY 4,420 HOURS OF THEIR VALUABLE TIME. 1905489 0 2121822 ASSISTED LIVING FACILITY FULFILLS THE MISSION OF THE ROMAN CATHOLIC CHURCH BY PROVIDING 84 FRAIL AND ELDERLY PEOPLE WITH ASSISTED LIVING SERVICES REGARDLESS OF THEIR ABILITY TO PAY. A TOTAL OF 17 RESIDENTS RECEIVED $191,171 IN FREE CARE DURING THE YEAR. APPROXIMATELY 50 VOLUNTEERS PROVIDED 3,400 HOURS OF SUPPORT TO THE FACILITY. 23487381 true true false true false false false false false false true false false false false true true true false false false false false false false false true true false false true true false false false false false true false false true false false false false false false true false false false true 43 0 true 284 true false false false false false false false false false false X 13 8 false false true false true true true true true false false true true true true true true true false false X DENNIS DINSLAGE 4023726703 430 NORTH MONITOR STREET WEST POINT NE 687881555 X RONALD O BRIGGS 45.0 0.35 X X 239382 0 33604 SR ROCHELLE KERKHOF 1.0 0.0 X 0 0 0 JAY HANSEN DDS 1.5 0.0 X X 0 0 0 BRIAN REIMERS 1.5 0.0 X X 0 0 0 CONRAD REESON 1.0 0.0 X 0 0 0 SUE STEFFENSMEIER 1.0 0.0 X 0 0 0 SR JO ELLEN KOHLMANN 1.0 0.0 X 0 0 0 STEVE AUSDEMORE 1.5 0.0 X X 0 0 0 BILL KREIKEMEIER 1.5 0.0 X X 0 0 0 JEROME STEFFEN 1.0 0.25 X 0 0 0 CHAD ORTMEIER DDS 1.0 0.25 X 0 0 0 JACKIE RIDDER 1.5 0.0 X X 0 0 0 MARY JANATA 1.0 0.0 X 0 0 0 GARRY CLARK 1.0 0.0 X 0 0 0 DENNIS DINSLAGE 42.0 0.0 X 149509 0 26980 TERRY NELSON 55.0 0.0 X 291057 0 50547 MICHAEL BITTLES MD 40.0 0.0 X 356160 0 35065 SCOTT GREEN MD 44.5 0.0 X 362505 0 36565 RHETT ECKMANN MD 43.3 0.0 X 304440 0 34276 BRIAN HASS MD 43.3 0.0 X 315369 0 32276 KENNETH PITZ MD 40.0 0.0 X 465374 0 32815 2483796 0 282128 14 false true false ELKHORN VALLEY ANESTHESIA PC INC 814 VIA LINDA WEST POINT NE 68788 ANESTHESIA SERVICES 595388 MCKESSON TECHNOLOGIES INC 5995 WINDWARD PARKWAY ALPHARETTA GA 30005 IT SOFTWARE SUPPORT 1126299 CYPRESS BENEFIT ADMINISTRATOR PO BOX 7020 APPLETON WI 549127020 HEALTH PLAN ADMIN 388163 IP PATHWAYS LLC 2550 73RD STREET URBANDALE IA 50322 IT SOFTWARE/SUPPORT 436217 MCSBCI CONSTRUCTION 1020 CENTENNIAL RD WEST POINT NE 68788 GENERAL CONSTRUCTION 3259293 13 207717 64332 272049 HOSPITAL/CLINIC HEALTHCARE SERVICES 621110 26379836 26379836 ASSISTED LIVING-ELDER CARE 623000 2114894 2114894 DIETARY/CAFETERIA 721000 99210 99210 28593940 624058 -1308 625366 0 0 0 0 0 9264 20468 -11204 -11204 -11204 0 0 21259 31201 -9942 -9942 0 0 29468901 28583998 -1308 614162 0 0 0 0 795580 709643 85937 0 12017568 10873206 1144362 344789 273564 71225 2181621 1776176 405445 776233 694063 82170 0 16716 16716 76045 76045 2502 2502 0 0 1463951 1243547 220404 116753 115778 975 2018231 1890554 127565 112 416621 337499 79122 0 937516 805987 131529 107783 92430 15353 0 37213 34090 3123 0 0 2471647 2002251 469396 122301 122301 MEDICAL SUPPLIES 2558693 2558693 DUES & SUBSCRIPTIONS 84280 79900 4380 WOMEN'S AUXILIARY SUPPLIES 1736 1736 26547779 23487381 3058550 1848 250 438314 3692484 4547776 0 0 3739182 3405108 0 36667 0 0 57333 6667 476860 507728 165599 173947 56073432 22827472 28436191 33245960 8852017 13512035 5234304 1822887 0 0 0 0 660472 2152642 51314692 59849731 4568798 5103998 22000 10000 0 0 9014532 13300966 0 0 0 0 0 0 0 0 0 0 13605330 18414964 X 37709362 41434767 0 0 0 0 37709362 41434767 51314692 59849731 2921122 804283 X false true X true false X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED false false false false false true 2502 true 0 false false 2502 false PART IV SUPPLEMENTAL INFORMATION PART II-B, LINE F: MEMBERSHIP DUES PAID TO HEALTH CARE ASSOCIATIONS OF WHICH A PERCENTAGE OF THE DUES ARE ALLOCATED TO LOBBYING ACTIVITIES. PART II-B, LINE G: OCCASIONAL PHONE CALL OR EMAIL TO AND FROM OUR REPRESENTATIVES. 367466 367466 20020988 6871874 13149114 30880187 15955598 14924589 4804791 4804791 33245960 0 0 X 30280518 804283 804283 29476235 -7334 -7334 29468901 26546043 26546043 1736 1736 26547779 PART XI, LINE 4B AUXILIARY GIFT SHOP SALES 21,259 AUXILIARY GIFT SHOP COGS (31,201) ------------- NET LOSS FROM SALES ( 9,942) AUXILIARY FUNDS RAISED 7,778 AUXILIARY DONATION TO HOSPITAL -5,170 ------------- TOTAL ( 7,334) PART XII, LINE 4B AUXILIARY OPERATING EXPENSES 1,736 PART X, LINE 2 FIN 48 FOOTNOTE ON AUDITED FINANCIAL STATEMENTS: The organization has evaluated and reviewed uncertain tax positions and found the potential exposure to be insignificant. true true X true X true X true true true false true true 143 331907 0 331907 0.01250 3515 1438873 1316730 122143 0.00460 3658 1770780 1316730 454050 0.01710 6815 149579 14399 135180 0.00510 145 103036 0 103036 0.00390 25111 5013926 4258721 755205 0.02840 7111 47491 3235 44256 0.00170 39182 5314032 4276355 1037677 0.03910 42840 7084812 5593085 1491727 0.05620 1650 1650 0.00010 2031 2031 0.00010 1820 1820 0.00010 1550 1550 7051 7051 0.00030 true 938814 164923 10664281 10721443 -57162 X true true 1 1 ST FRANCIS MEMORIAL HOSPITAL

430 N MONITOR ST WEST POINT NE 68788

X X X X ST FRANCIS MEMORIAL HOSPITAL 1 true true 100 true 200. true X X X X true true X X X X X true false X X true X false false 1 ST JOSEPH'S RETIREMENT COMMUNITY

320 E DECATUR WEST POINT NE 68788

ASSISTED LIVING FACILITY PART I, LINE 3C NOT APPLICABLE PART I, LINE 6A NOT APPLICABLE PART I, LINE 7 A cost-to-charge ratio was used to calculate the cost of community benefit expenses detailed in the table for Part I, line 7(a) - 7(k). The cost-to-charge ratio was derived from Worksheet 2, Ratio of Patient Care Cost-to-Charges. PART I, LINE 7G FRANCISCAN CARE SERVICES, INC. INCLUDED PHYSICIAN CLINIC COSTS OF $755,205 AS SUBSIDIZED HEALTH SERVICES. PART I, LINE 7, COLUMN (F) THE AMOUNT USED TO COMPUTE COLUMN (F) IS FROM THE AMOUNT REPORTED ON FORM 990, PART IX, LINE 25, COLUMN (A). PART II Franciscan Care Services, Inc. currently has involvement in the Elkhorn Logan Valley Public Health Department Board which looks at how the community addresses health and safety issues, the access individuals have to health care services, and the staff necessary to provide healthcare services. We spend a considerable amount of time and effort in educating healthcare professionals. We have many residents and clinical college students on-site throughout the year. We also have a job shadowing program for high school students in the area. We help educate these individuals in the hope that they will come back to the community to provide healthcare services. We provide funds for activities at area schools that provide a safe environment and education for our youth. We help sponsor the local blood drive through the American Red Cross. We donate funds to different organizations to improve the community's health and safety. PART III, LINE 2 The amount reported on line two is taken directly from the general ledger. The amount that is written off to bad debt is the patients account balance when it is determined that the patient will not pay. Therefore, if the patient is self pay and has not paid any of the balance, then 100% of charges are written off. If the patient has commercial insurance and cannot pay the 20% coinsurance that is due after insurance has paid and the contracted discounts have been applied, then only the 20% coinsurance that is owed by the patient is written off to bad debt. PART III, LINE 3 The amount reported on line three is estimated based on an analysis performed by the Patient Accounting Manager and the Patient Financial Counselor. A review of the accounts written off to bad debt is done, taking into consideration the individuals financial situation. During the review, they identify accounts that could have been written off as charity care if sufficient information was received. As a result of the analysis, it was determined that $164,923 would possibly have qualified as charity care. There is a fine line between bad debt and charity care. There are those individuals who just will not pay, but there are a larger number of individuals who cannot pay, but do not want to fill out the paperwork for charity care or do not want to even ask for charity care. We have estimated that $164,923 of our bad debt expense should have been classified as charity care if the appropriate paperwork was received. These are the dollars that should be classified as community benefit. PART III, LINE 4 The accounts receivable footnote from our audited financial statements is as follows: "Accounts receivable for patients, insurance companies, and governmental agencies are based on gross charges. An allowance for uncollectible accounts is established on an aggregate basis by using historical write-off rate factors applied to unpaid accounts based on aging. Loss rate factors are based on historical loss experience and adjusted for economic conditions and other trends affecting the Organization's ability to collect outstanding amounts. Uncollectible amounts are written off against the allowance for doubtful accounts in the period they are determined to be uncollectible." PART III, LINE 8 Total revenue received from Medicare and Medicare allowable costs reported on Part III, lines 5 & 6 were taken directly from the 2012 Medicare cost report. In addition to the revenue received from Medicare and the Medicare allowable costs reported on the Medicare cost report, we also receive part b payments (fee schedule) from Medicare for certain lab, radiology, rehabilitation and physician services. These amounts are not included on the Medicare cost report. The revenue received from Medicare for our part b services was $511,032 while the associated costs were $644,165 for a shortfall of ($133,133). The costs for the services reimbursed on a fee schedule methodology were calculated based on the cost to charge ratio from the cost report for that department. The shortfall reported on Part III, line 7 of ($57,162) and the medicare part b shortfall of ($133,133) for a total shortfall of ($190,295) should be treated as a community benefit because these are costs over and above the amount that Medicare pays us. These services are integral services to the community and would not be available to the community if they were not provided by our facility. PART III, LINE 9B In our collection policy there is a section on financial assistance. It states: "Franciscan Care Services has a Financial Assistance program to assist patients that are financially burdened and unable to pay for their medical expenses. An assistance application must be completed and turned into the Financial Counselor. A copy of the most current tax information must accompany the application. A determination of approval or denial is made from this application and is based upon hospital established guidelines." PART V, SECTION B - ST. FRANCIS MEMORIAL HOSPITAL (1) 1. Lines 1 - 7 Not applicable for 2012. 2. Lines 10 11 - Not applicable. 3. Line 12 Other factors that we use in determining eligibility for any discounts include eligibility for Medicaid or other assistance and a bank loan. 4. Line 14g - The policy is attached to the billing statement after contact has been made by the Financial Counselor. 5. Lines 16e 22 Not applicable. NEEDS ASSESSMENT The health care needs of the communities we serve are assessed in many different ways. We work closely with the local area public health department who surveys the area population to ascertain health disparities, collaborate on health screenings, and determine areas of need. As our physicians and other health care workers see patients they discuss their current status and what else we can do for them. Also, our board members and employees who are in the public advise us as to what health care needs are in the community that we do not currently address. Many of our employees are involved in state and national organizations that keep us up-to-date on the current trends in health care that are brought back to our community. Through strategic planning with the physicians, board of directors, and hospital leaders, we look at what the needs of the community are and how we can address them. All of these groups work together with Administration to continue to address the health care needs of the community. PATIENT EDUCATION OF ELIGIBILITY FOR ASSISTANCE On the Conditions of Admission and Consent for Treatment form that is signed by each patient of the hospital, there is a financial agreement section that states "If you have limited insurance or do not have insurance, you may request to meet with our Financial Counselor to set up a payment plan or to determine if you are eligible for charity care." The collection policy is posted at the Hospital and Clinic entrance and also at the Emergency Room entrance. Also, if the Financial Counselor contacts a patient regarding payment of a bill, a letter and a copy of the collection policy is sent to them which states that if they are unable to pay they may be eligible for the charitable care program that we offer. Lastly, on our website www.fcswp.org there is a section on Patient Financial Information. In this section there is information on our charity care policy and who to contact if the patient would like more information. COMMUNITY INFORMATION Franciscan Care Services, Inc. is located in a rural area, predominantly agricultural based. The population of the five county service area is approximately 18,000 people. The median household income is approximately $35,500. The population is predominantly Caucasian, high-school educated, and geriatric in nature. There is a small population of Hispanic descent. PROMOTION OF COMMUNITY HEALTH The board of directors is comprised of persons from the surrounding communities. The board members are diverse in background ranging from Sisters from our sponsor, a nurse, dentist, a school guidance counselor, bankers, and business owners, to farmers who are neither employees (except CEO), contractors, or family members. We hope the diverse backgrounds of our board members give us the insight we need to fulfill the needs of the community. Franciscan Care Services, Inc. has an open medical staff that includes one general surgeon, one orthopaedic surgeon, five family practice physicians, three physician assistants, and one nurse practitioner. There are also a number of specialists that come in from the nearby communities of Norfolk, Fremont, and Omaha to meet the health needs of the community. Specialists that see patients in our Outpatient Clinic include Audiology, Cardiology, ENT, Nephrology, Neurology, Obstetrics/Gynecology, Oncology, Ophthalmology, Pain, Podiatry, Urology, and Vascular. There are many different programs that we are able to offer due to surplus funds from operations. Our clinics provide disease management through the use of health coaches to help patients manage chronic health conditions such as diabetes, hypertension, COPD, clotting, and osteoporosis. This is a program that is good for our patients even though we receive little to no reimbursement for providing this service. During 2012, we initiated an e-ICU program with Alegent Health in Omaha, NE. This program allows an intensivist at Omaha's Lakeside Hospital to follow our most critical patients without transferring the patient to Omaha. We also began offering a free in-home monitoring service to our patients for 60-days after discharge through our Home Health Department. We provide free sport screens to area athletes who think they may have been injured at a practice or game. We offer reduced-cost screens and health education for businesses in our service area to reach out to those individuals who do not take the time to come to our facility to see us. AFFILIATED HEALTH CARE SYSTEM Franciscan Care Services, Inc. is a part of the Franciscan Sisters of Christian Charity Sponsored Ministries, a not-for-profit system of acute and long-term health care facilities and a liberal arts college located in Wisconsin, Nebraska and Ohio. Each organization within the Ministry is responsible for carrying out the healing and education mission of the Catholic Church according to the needs of their community. STATE FILING OF COMMUNITY BENEFIT REPORT The community benefit report is filed with the Nebraska Hospital Association. The report is also sent to our local mayor and our state and congressional representatives. X X X X false true false true false false false false false RONALD O BRIGGS 176275 0 35442 0 27665 0 11712 0 23812 0 274906 0 0 0 DENNIS DINSLAGE 120339 0 21724 0 7446 0 8184 0 19912 0 177605 0 0 0 TERRY NELSON 167451 0 123192 0 414 0 30250 0 21762 0 343069 0 0 0 MICHAEL BITTLES MD 346730 0 200 0 9230 0 13000 0 23761 0 392921 0 0 0 SCOTT GREEN MD 252248 0 97121 0 13136 0 14500 0 23761 0 400766 0 0 0 RHETT ECKMANN MD 237096 0 58844 0 8500 0 12211 0 23761 0 340412 0 0 0 BRIAN HASS MD 240231 0 62873 0 12265 0 12211 0 21761 0 349341 0 0 0 KENNETH PITZ MD 431480 0 7620 0 26274 0 12500 0 22011 0 499885 0 0 0 PART I, LINE 4B QUESTIONS REGARDING COMPENSATION DURING 2012, FRANCISCAN CARE SERVICES INC. CONTRIBUTED FUNDS TO AN IRC SECTION 457(F) PLAN FOR THE FOLLOWING INDIVIDUALS: DR. BITTLES $13,000 DR. GREEN $ 4,000 DR. ECKMANN $ 4,321 DR. HASS $ 4,321 DR. PITZ $12,500 MR. NELSON $16,500 PART I, LINE 5A QUESTIONS REGARDING COMPENSATION AT THE BEGINNING OF THE CALENDAR YEAR, THERE WAS A WRITTEN AGREEMENT ESTABLISHED REGARDING THE POTENTIAL AMOUNT OF SUPPLEMENTAL INCOME THAT CERTAIN PHYSICIANS MAY RECEIVE DURING THE YEAR BASED ON THEIR INDIVIDUAL PRODUCTIVITY. EACH OF THESE PHYSICIANS IS PAID A BASE SALARY AS AN EMPLOYED PHYSICIAN OF THE ORGANIZATION. IN ADDITION, THE PHYSICIAN MAY EARN ADDITIONAL COMPENSATION BASED ON A PRE-DETERMINED CALCULATED FORMULA AS STIPULATED IN THE WRITTEN AGREEMENT. THE FORMULA IN SUMMARY IS CALCULATED BY TAKING THE INDIVIDUAL'S PRODUCTIVITY REVENUE FOR THE CALENDAR YEAR LESS ANY CONTRACTUAL ADJUSTMENTS OR WRITE-OFFS AND THEN MULTIPLYING THAT NET AMOUNT BY A PRE-DETERMINED PERCENTAGE. IF THIS CALCULATED AMOUNT EXCEEDS THEIR BASE SALARY, THE PHYSICIAN IS PAID THE VARIANCE. DURING THE YEAR, DRS. GREEN, ECKMANN AND HASS RECEIVED A PAYMENT. TERRY NELSON, REHAB MANAGER, ALSO HAD A WRITTEN AGREEMENT AT THE BEGINNING OF THE CALENDAR YEAR WHICH ALLOWED FOR INCENTIVE COMPENSATION TO BE EARNED BASED UPON A PRE-DETERMINED FORMULA. IN SUMMARY, THE FORMULA TO CALCULATE HIS INCENTIVE COMPENSATION IS BASED ON THE NET COLLECTED REVENUE OF HIS DEPARTMENT LESS WAGE EXPENSE MULTIPLIED BY FIVE PERCENT. DURING THE YEAR, TERRY NELSON RECEIVED A PAYMENT. A HOSPITAL AUTHORITY NO 1 OF CUMING COUNTY NE 470762878 2010-07-27 12000000 SEE SCHEDULE K, PART VI false false false B HOSPITAL AUTHORITY NO 1 OF CUMING COUNTY NE 470762878 2009-03-31 2200000 SEE SCHEDULE K, PART VI false false false A 192867 0 12000000 0 0 0 0 0 0 12000000 0 0 2012 false false true true B 706167 0 2200000 0 0 0 0 0 0 0 0 0 1999 true false true true A false false false false 0.00000 0.00000 0.00000 false false false true B 0 A false true true false 0 false 0 false true B false true false false 0 false 0 false true A true B true SCHEDULE K, PART 1, LINE A, COLUMN F: 0 THE 2010 PROJECT CONSISTS OF A THREE STORY PATIENT BED ADDITION TO AND RELATED FIXED EQUIPMENT FOR THE EXISTING HOSPITAL FACILITY. THE 2010 PROJECT DOES NOT INCLUDE CERTAIN SPACE ON THE FIRST FLOOR NOT EXCEEDING 650 SQUARE FEET OF SPACE WITH ALLOCATED COSTS NOT IN EXCESS OF $250,000, WHICH IS TO BE UNFINISHED AND IS EXPECTED TO BE USED FOR STORAGE BUT WHICH MAY BE ALLOCATED TO AND SUBSEQUENTLY UTILIZED FOR PRIVATE OR UNRELATED BUSINESS ACTIVITY SUCH AS FOR A RETAIL PHARMACY. SCHEDULE K, PART I, LINE B, COLUMN F: 0 REVENUE REFUNDING BONDS ISSUED TO REFUND THE SERIES 1999 BONDS ISSUED IN THE ORIGINAL AMOUNT OF $4,250,000. THE SERIES 1999 BONDS WERE ISSUED TO REFINANCE THE COST OF CONSTRUCTION AND ACQUIRING A RESIDENTIAL CARE FACILITY AND REFINANCE THE COSTS OF CONSTRUCTION AND ACQUIRING ADDITIONS AND IMPROVEMENTS TO THE EXISTING HOSPITAL FACILITIES. NA KENNETH PITZMD HIGHEST COMPENSATION RELOCATION X 22000 14667 false true true KENNETH PITZMD HIGHEST COMPENSATION RELOCATION X 22000 22000 false true true 36667 AGNES DINSLAGE SEE PART V 23858 EMPLOYMENT false NANCY NELSON SEE PART V 37610 EMPLOYMENT false CHERI DOESCHER SEE PART V 27687 EMPLOYMENT false BARBARA STEFFEN SEE PART V 20492 EMPLOYMENT false DAVID RIDDER SEE PART V 78200 EMPLOYMENT false TERRI RIDDER SEE PART V 80023 EMPLOYMENT false DOROTHY BURGER SEE PART V 37409 EMPLOYMENT false ANGELA WEGNER SEE PART V 30004 EMPLOYMENT false ERIN RIDDER SEE PART V 13530 EMPLOYMENT false DAN HAKEL SEE PART V 98761 EMPLOYMENT false BRENDA WISNIESKI SEE PART V 37258 EMPLOYMENT false SCHEDULE L, PART IV DAVID RIDDER IS A FAMILY MEMBER OF JACKIE RIDDER, TRUSTEE TERRI RIDDER IS A FAMILY MEMBER OF JACKIE RIDDER, TRUSTEE DOROTHY BURGER IS A FAMILY MEMBER OF JACKIE RIDDER, TRUSTEE ANGELA WEGNER IS A FAMILY MEMBER OF JACKIE RIDDER, TRUSTEE ERIN RIDDER IS A FAMILY MEMBER OF JACKIE RIDDER, TRUSTEE BARBARA STEFFEN IS A FAMILY MEMBER OF JEROME STEFFEN, TRUSTEE DAN HAKEL IS A FAMILY MEMBER OF CHAD ORTMEIER, TRUSTEE BRENDA WISNIESKI IS A FAMILY MEMBER OF MARY JANATA, TRUSTEE AGNES DINSLAGE IS A FAMILY MEMBER OF DENNIS DINSLAGE, OFFICER NANCY NELSON IS A FAMILY MEMBER OF TERRY NELSON, KEY EMPLOYEE CHERI DOESCHER IS A FAMILY MEMBER OF TERRY NELSON, KEY EMPLOYEE PART VI SECTION A, LINE 7A & 7B The Franciscan sisters of Christian charity sponsored ministries, inc. a Wisconsin non-stock, not for profit corporation has the following reserved powers over Franciscan care services inc.: A) approval of the philosophy, mission and values statements of the corporation. B) Amendment of articles of incorporation and by-laws of the corporation. C) Appointment and removal of members to the board of directors. d) Approval of the creation and dissolution of this corporation or any subsidiary corporations, as well as approval of any merger, consolidation, affiliation, joint venture or other form of corporate reorganization of this corporation or any subsidiary of which this corporation is the member or controlling shareholder. E) Appointment, evaluation and discharge of the president of the corporation. F) Approval of borrowing in excess of the limit established by the member. G) Approval of purchase, mortgage or sale of real estate, or lease of real estate, by or to the corporation for longer than one year. H) Implementation of sponsor appointment, salary negotiation, and reassignment processes for Franciscan sister personnel within this corporation. I) Approval of capital and operating budgets. J) Requirement of a certified audit of corporate funds at any time and approval of the fiscal auditor of the corporation annually. K) Approval of all insurance carriers and insurance coverage for the corporation. L)Approval of long-range or strategic plans of the corporation. PART VI, SECTION A, LINE 6 THE ORGANIZATION IS A NOT-FOR-PROFIT CORPORATION WHOSE MEMBER IS FRANCISCAN SISTERS OF CHRISTIAN CHARITY SPONSORED MINISTRIES,INC. PART VI, SECTION B, LINE 11B Form 990 is reviewed prior to submission by the member (Franciscan sisters of Christian charity sponsored ministries, inc.) and the finance committee of the Franciscan care services, inc. board of directors. A copy of form 990 will be available for all board members to review at their monthly board meeting before the 990 is filed. Form 990 is made available in the administrative office for any individual requesting to inspect it as required by internal revenue code section 6104. PART VI, SECTION B, LINE 12C The corporate compliance officer (cco) and several members of the corporate compliance committee attend board, administrative, and department manager meetings. The cco ensures that all board, medical staff, administration staff, department managers, and individuals who have purchasing authority review the conflict of interest policy annually and disclose any conflicts that might exist. Each individual is also asked to identify any family members that are an employee of FCS, inc. or employed by a business with which fcs conducts business. Any new conflicts that arise during the year need to be reported to the compliance officer immediately. If a conflict exists at the board level, the person or the cco or committee member identifies that the conflict exists and then the board determines if the person can take part in the deliberations or needs to leave the room. The person would not be able to vote and it is identified in the minutes of the meeting. At the administrative level, the staff member identifies the conflict and the administrative team determines if the person can take part in the discussion or needs to leave the room. This is also the policy at the medical staff and manager meetings. PART VI, SECTION B, LINE 15A & 15B Franciscan care services, inc. strives to provide a fair and competitive compensation package for its executive. This package shall include, but is not limited to salary, incentive bonus, life insurance, health benefits, and a matching defined contribution to a 403(B) retirement plan. The salary range and total compensations shall be based upon surveys of the geographic west north central states average for the position as reported by an independent executive compensation market analysis for liked sized organizations and the executive compensation survey for Nebraska hospitals provided by the Nebraska hospital association. Bonuses are given based upon achievement of strategic goals agreed upon by the Franciscan care services board of directors and the president of the Franciscan sisters of Christian charity sponsored ministries, inc. these bonuses are based upon a percentage of salary and are not to exceed 25%. The president/ceo's compensation is set by the executive committee of the board of directors and the sponsored ministries president after a performance appraisal conducted by the executive committee of the fcs board (serving as the compensation committee) and the president of Franciscan sisters of Christian charity sponsored ministries, inc. all members of the board provide their input through a written appraisal presented to the compensation committee. Minutes of the meeting are kept by the sponsored ministries president. All other executives are reviewed by the Franciscan care services, inc president/ceo, who sets their compensation based upon the above surveys and principles. PART VI, SECTION C, LINE 19 NO DOCUMENTS AVAILABLE TO THE PUBLIC Part IV, Line 12a Checklist of Required Schedules The organization's financial statements were audited on a separate basis but also consolidated at the organization's parent level. The organization uses the separate audited financial statements for tax return purposes. FORM 990, PART VI, LINE 4 THE NAME OF THE SOLE MEMBER OF FRANCISCAN CARE SERVICES INC. WAS CHANGED FROM FRANCISCAN SISTERS OF CHRISTIAN CHARITY HEALTHCARE MINISTRY, INC. TO THE FRANCISCAN SISTERS OF CHRISTIAN CHARITY SPONSORED MINISTRIES, INC. HOLY FAMILY CONVENT FRANCISCAN SISTERS 2409 SOUTH ALVERNO ROAD MANITOWOC WI 54220 390808523 RELIGION WI 501(C)(3) LINE 1 NA false FRANCISCAN SISTERS OF CHRISTIAN CHARITY 1415 SOUTH RAPIDS ROAD MANITOWOC WI 54220 391530622 EDU/HLTHCARE WI 501(C)(3) LINE 1 SEE LINE 1 false ST FRANCIS MEMORIAL HOSPITAL FOUNDATION 430 N MONITOR ST WEST POINT NE 68788 470629079 FUNDRAISING NE 501(C)(3) 11A TYPE I NA false ST JOSEPHS RETIREMENT COMMUNITY FDN PO BOX 65 WEST POINT NE 68788 470790644 FUNDRAISING NE 501(C)(3) 11A TYPE I NA false HOLY FAMILY MEMORIAL INC 2300 WESTERN AVE PO BOX 1450 MANITOWOC WI 54221 390806395 HEALTHCARE WI 501(C)(3) Line 3 SEE LINE 2 false ST PAUL ELDER SERVICES INC 316 EAST 14TH STREET KAUKAUNA WI 54130 391029149 ELDER CARE WI 501(C)(3) LINE 1 SEE LINE 2 false GOOD SAMARITAN MEDICAL CENTER 800 FOREST AVENUE ZANESVILLE OH 43701 314379479 HOLDING CO. OH 501(C)(3) 11A TYPE I SEE LINE 2 false SILVER LAKE COLLEGE OF HOLY FAMILY INC 2406 SOUTH ALVERNO ROAD MANITOWOC WI 54220 390980974 HIGHER EDUCAT WI 501(C)(3) LINE 2 SEE LINE 2 false NONE HOLY FAMILY HEALTH SERVICES 3310 CALUMET AVENUE MANITOWOC WI 54220 391572253 PHARMACY WI See Pt II Ln 5 C CORP false false false true true true false false false false false false false true false false true true false true ALL TRANSACTIONS WERE BETWEEN 501(c)(3) ORGS