2024-02-27T13:45:45-06:00 2023-06-30 450250958 EIDE BAILLY LLP 18081 BURT ST STE 200 OMAHA NE 680224722 990 2022-07-01 470544098 WEST HOLT MEMORIAL HOSPITAL WEST 4029252811 406 WEST NEELY STREET ATKINSON NE 68713 JEREMY BAUER CEO 4029252811 2024-02-27 1 JEREMY BAUER 999009999 1 WENDY R COOLEY CPA P01523804 4023302660 2024-02-27 2 AAL1 IAL1 2022 2023-04-26 12:10:37Z JEREMY BAUER 406 WEST NEELY STREET ATKINSON NE 68713 16881222 0 X WWW.WESTHOLTMED.ORG X 1972 NE CRITICAL ACCESS HOSPITAL AND RURAL HEALTH CLINIC THAT PROVIDES MEDICAL SERVICES. 8 6 139 10 0 0 487718 552265 16133214 16197491 46515 116276 5321 6341 16672768 16872373 0 0 0 0 7025996 6759407 0 0 8497 9637732 10465252 16663728 17224659 9040 -352286 19610827 18920606 8956894 8607510 10653933 10313096 WEST HOLT MEDICAL SERVICES PROVIDES WELL-ROUNDED FAMILY HEALTHCARE WITH RESPECT AND UNDERSTANDING FOR THE PHYSICAL AND EMOTIONAL NEEDS OF OUR NORTH CENTRAL NEBRASKA COMMUNITIES. 0 0 15346332 16197491 WEST HOLT MEMORIAL HOSPITAL (WHMH) IS A 15 BED CRITICAL ACCESS HOSPITAL: SERVICES PROVIDED BY WHMH INCLUDES EMERGENCY SERVICES, LABORATORY, PHYSICAL AND OCCUPATIONAL THERAPY, RESPIRATORY THERAPY, SPEECH THERAPY, DIAGNOSTIC IMAGING TEST, CARDIOLOGY TESTS, EKG, NUCLEAR MEDICINE TESTS, IV THERAPY, SLEEP STUDIES, OP SURGERY, AND A VARIETY OF SPECIALTY CLINICS. DURING 2023, WHMH HAD 609 EMERGENCY ROOM VISITS AND PERFORMED 166 OUTPATIENT SURGERIES. THE LABORATORY PERFORMED 29,838 TESTS, DIAGNOSTIC IMAGING PERFORMED 3,710 TESTS AND PHYSICAL/OCCUPATIONAL/SPEECH THERAPY SERVICES PROVIDED 11,869 TREATMENTS. 15346332 1 1 0 1 0 0 0 0 0 1 1 0 0 0 1 1 1 0 0 0 0 0 0 0 0 0 1 1 0 0 1 0 0 0 0 0 0 1 0 0 0 0 0 0 0 0 0 0 1 14 0 1 139 1 0 0 0 0 0 0 0 0 0 0 0 0 X 8 6 0 0 0 0 1 1 0 1 0 0 0 1 1 1 1 1 1 1 0 0 X TAYLOR MCCORMICK 4029252811 406 WEST NEELY STREET ATKINSON NE 68713 TRENT SCHAAF PRESIDENT 2.00 X X 0 0 0 BRYAN RENTSCHLER FIRST VICE PRESIDENT 1.00 X X 0 0 0 TOM DVORAK SECOND VICE PRESIDENT 1.00 X X 0 0 0 MARSHA THURLOW SECRETARY 1.00 X X 0 0 0 BRETT LIESWALD TREASURER 1.00 X X 0 0 0 LORI OLSON MEMBER 1.00 X 0 0 0 SUSAN MYERS MEMBER 1.00 X 0 0 0 MICHAEL PEEK MEMBER 1.00 X 0 0 0 AUSTIN HAMM MEMBER (THRU 3/2023) 1.00 X 0 0 0 BRIAN MARTIN CEO (THRU 7/2022) 40.00 X 164383 0 5555 JEREMY BAUER CEO 40.00 X 150806 0 44449 TAYLOR MCCORMICK CFO 40.00 X 19231 0 0 SAMANTHA SHOLES PHYSICIAN 40.00 X 217564 0 52375 NICK KONRAD PHYSICAL THERAPIST 40.00 X 121960 0 36987 LORRETTA DANIELS PHYSICIAN ASSISTANT 29.00 X 166019 0 13835 AMY KINKENNON PHARMACIST 40.00 X 148737 0 7883 APRIL DEXTER NURSE PRACTITIONER 32.00 X 135382 0 5737 1124082 0 166821 11 0 1 0 FOCUSONE SOLUTIONS 13609 CALIFORNIA ST OMAHA NE 68154 AGENCY NURSING SERVICES 1231116 MERIT MECHANICAL 707 SOUTH CENTER STREET TILDEN NE 68781 CONSTRUCTION SERVICES 976264 GREATER SANDHILLS FAMILY HEALTHCARE PO BOX 70 STUART NE 68780 PROVIDER ER COVERAGE 255322 FAITH REGIONAL HEALTH SERVICES 1500 KOENIGSTEIN AVE NORFOLK NE 68701 AGENCY CNO & IT 161050 SILVERHAWK AVIATION 1751 WEST KEARNEY AVE LINCOLN NE 68524 TRAVEL SERVICES 115000 5 533812 18453 552265 MEDICARE/MEDICAID PAYMENTS 621110 8279289 8279289 PATIENT SERVICE REVENUE 621110 3980379 3980379 RETAIL PHARMACY REVENUE 621110 3123057 3123057 340B PROGRAM REVENUE 621110 789943 789943 24823 24823 16197491 122966 122966 7000 659 6341 6341 6341 1500 8190 -6690 -6690 -6690 16872373 16197491 0 122617 X 359671 359671 189996 189996 5031604 4537757 487276 6571 164902 148962 15715 225 631620 531025 100385 210 381614 325564 55553 497 33007 33007 80958 80958 3382018 3259791 122227 55799 55799 529251 453962 74745 544 62779 51858 10831 90 135947 118881 17066 71241 22515 48726 312 312 177965 165961 12004 1140519 1063590 76929 92404 4029 88375 MEDICAL SUPPLIES 4295285 4186401 108524 360 MISCELLANEOUS 325709 212344 113365 LICENSES & FEES 82058 73696 8362 17224659 15346332 1869830 8497 360 485 5607172 6931643 4352002 2742232 667766 700546 149842 202120 19459636 11399767 8561423 8059869 272262 283711 19610827 18920606 1246223 1237332 6349318 6153474 1361353 1216704 8956894 8607510 X 10322835 9854155 331098 458941 10653933 10313096 19610827 18920606 X -352286 11449 X X 0 1 X 1 0 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 0 0 0 0 0 0 0 0 1 686 686 0 PART II-B, LINE 1: WEST HOLT MEMORIAL HOSPITAL PAYS ASSOCATION DUES TO THE NEBRASKA HOSPITAL ASSOCIATION (NHA), OF WHICH A PORTION IS USED BY THE ASSOCIATION FOR LOBBYING PURPOSES. 272262 31374 16101 3824 283711 338770 -64255 2253 272262 338770 338770 338770 338770 338770 338770 0.00000 0.00000 1.00000 0 0 39958 39958 11014446 4982049 6032397 8106165 6304956 1801209 299067 112762 186305 8059869 ESTIMATED THIRD-PARTY PAYOR SETTLEMENTS 1216704 1216704 X 16884481 12108 12108 16872373 0 16872373 17225318 659 659 17224659 0 17224659 PART V, LINE 4: THESE FUNDS HAVE BEEN RESTRICTED BY A DONOR FOR SPECIFIC PURPOSES. THE PRINCIPAL CANNOT BE EXPENDED UNTIL 2047. A CORRECTION IS BEING MADE TO CORRECTLY REFLECT THE ENDOWMENT BALANCE AS OF 06/30/22 UNDER PART V COLUMN (B). PART X, LINE 2: THE HOSPITAL ACCOUNTS FOR UNCERTAINTIES IN ACCOUNTING FOR INCOME TAX ASSETS AND LIABILITIES USING GUIDANCE INCLUDED IN FASB ASC 740, INCOME TAXES. THE HOSPITAL RECOGNIZES THE EFFECT OF INCOME TAX POSITIONS ONLY IF THOSE POSITIONS ARE MORE LIKELY THAN NOT OF BEING SUSTAINED. AT JUNE 30, 2023 AND 2022, THE HOSPITAL HAD NO UNCERTAIN TAX POSITIONS ACCRUED. PART XI, LINE 2D - OTHER ADJUSTMENTS: RENTAL EXPENSES 659. CHANGE IN BENEFICIAL INTEREST IN TRUSTS 11,449. PART XII, LINE 2D - OTHER ADJUSTMENTS: RENTAL EXPENSES 659. 1 1 X 1 X 110.000000000000 1 X 1 1 0 1 1 156702 121030 35672 0.00210 929846 631026 298820 0.01730 1086548 752056 334492 0.01940 1326 219372 41390 177982 0.01030 2 1000 0 1000 0.00010 1328 220372 41390 178982 0.01040 1328 1306920 793446 513474 0.02980 1 29943 2994 7405557 7449233 -43676 X 1 1 1 1 WEST HOLT MEMORIAL HOSPITAL 406 W NEELY ATKINSON NE 68713 WWW.WESTHOLTMED.ORG 410001 X X X X WEST HOLT MEMORIAL HOSPITAL 1 0 0 1 X X X X X X X X X 21 1 1 1 1 X HTTPS://WWW.WESTHOLTMED.ORG/ X HTTP://WWW.NCDHD.ORG/ X 1 21 1 HTTPS://WWW.WESTHOLTMED.ORG/ 0 1 X 110.000000000000 200.000000000000 X 1 1 X X X X 1 X WWW.WESTHOLTMED.ORG X WWW.WESTHOLTMED.ORG X WWW.WESTHOLTMED.ORG X X X X X 1 X 0 X X X X 1 X 0 0 WEST HOLT MEMORIAL HOSPITAL PART V, SECTION B, LINE 5: WEST HOLT MEMORIAL HOSPITAL (WHMH) COLLABORATED WITH NCDHD (NORTH CENTRAL DISTRICT HEALTH DEPARTMENT) AGAIN, ALONG WITH OTHER HOSPITALS IN OUR HEALTH DISTRICT TO COMPLETE THE CHNA. THE UNIVERSITY OF NEBRASKA PUBLIC POLICY CENTER (NUPPC) ASSEMBLED THIS DATA, WORKING WITH THE NCDHD. MUCH OF THE PUBLIC HEALTH AND COMMUNITY WELL-BEING DATA WAS COLLECTED BY THE NORTH CENTRAL DISTRICT HEALTH DEPARTMENT, THROUGH MOBILIZING FOR ACTION THROUGH PLANNING AND PARTNERSHIPS (MAPP) PROCESS, AS WELL AS OTHER SOURCES OF BEHAVIORAL HEALTH AND HEALTH DATA, AND U.S. CENSUS DATA.AUGUST - SEPTEMBER 2021: ORGANIZE, COORDINATE PARTICIPANTS, IDENTIFY KEY STAKEHOLDERS AND PREPARE FOR MAPP PROCESS.OCTOBER 2021: DETERMINE THE VISION, IDENTIFY QUESTIONS FOR THE COMMUNITY HEALTH STATUS ASSESSMENT, AND OUTLINE THE FOCUS OF THE GROUP. NOVEMBER 2021: FEBRUARY 2022: GATHER DATA AND PREPARE CHNA.FEBRUARY 2022: DRAFT CHNA DOCUMENT FOR RELEASE.MARCH 2022: PRESENT CHNA TO COMMUNITY MEMBERS. WEST HOLT MEMORIAL HOSPITAL PART V, SECTION B, LINE 6A: THE FOLLOWING HOSPITALS PARTICIPATED IN THE FACILITY'S CHNA:ANTELOPE MEMORIAL HOSPITAL, NELIGH, NE (ANTELOPE COUNTY)AVERA CREIGHTON HOSPITAL, CREIGHTON, NE (KNOX COUNTY)AVERA ST. ANTHONY'S HOSPITAL O'NEILL, NE (HOLT COUNTY)BROWN COUNTY HOSPITAL, AINSWORTH, NE (BROWN COUNTY)CHERRY COUNTY HOSPITAL, VALENTINE, NE (CHERRY COUNTY)NIOBRARA VALLEY HOSPITAL, LYNCH, NE (BOYD COUNTY)OSMOND GENERAL HOSPITAL, OSMOND, NE (PIERCE COUNTY)CHI HEALTH PLAINVIEW HOSPITAL, PLAINVIEW, NE (PIERCE COUNTY)ROCK COUNTY HOSPITAL, BASSETT, NE (ROCK COUNTY) WEST HOLT MEMORIAL HOSPITAL PART V, SECTION B, LINE 6B: AREA SUBSTANCE ABUSE AND PREVENTION COALITIONCENTRAL NEBRASKA ECONOMIC DEVELOPMENTCENTRAL NEBRASKA COMMUNITY ACTION PARTNERSHIP NORTH CENTRAL COMMUNITY CARE PARTNERSHIPNORTH CENTRAL DISTRICT HEALTH DEPARTMENT BOARD OF HEALTHO'NEILL CHAMBER OF COMMERCEO'NEILL PUBLIC SCHOOLSCOUNSELING AND ENRICHMENT CENTERBUILDING BLOCKS FOSTER CARE AGENCYUNIVERSITY OF NEBRASKA EXTENSION OFFICE, BROWN-ROCK-KEYA PAHA COUNTYEWING PUBLIC SCHOOLSLYNCH PUBLIC SCHOOLSVALENTINE PUBLIC SCHOOLSO'NEILL LIONS CLUBO'NEILL ROTARY CLUBWEST HOLT HEALTH MINISTRIESHOLT COUNTY ECONOMIC DEVELOPMENTANTELOPE COUNTY ECONOMIC DEVELOPMENTPIERCE COUNTY ECONOMIC DEVELOPMENTBRIGHT HORIZONSWE CARE, INC.REGION 4 BEHAVIORAL HEALTH SYSTEMNORTHEAST NEBRASKA COMMUNITY ACTION PARTNERSHIPNORTHSTAR SERVICESAREA SUBSTANCE ABUSE PREVENTION COALITIONPROTEUSCENTRAL NEBRASKA ECONOMIC DEVELOPMENTGOOD SAMARITAN SOCIETY ATKINSONINDIAN HEALTH SERVICESTHE EVERGREEN ASSISTED LIVING FACILITYCOTTONWOOD VILLA ASSISTED LIVING FACILITYCALVARY BIBLE CHURCHBROWN-ROCK-KEYA PAHA COUNTIESO'NEILL PUBLIC SCHOOL BOARDO'NEILL MINISTERIAL ASSOCIATIONLEGAL AID OF NEBRASKASANTEE SIOUX NATIONUNIVERSITY OF NEBRASKA PUBLIC POLICY CENTERESU 17 / AINSWORTH SCHOOLSNORTHWEST NEBRASKA COMMUNITY ACTION PARTNERSHIP WEST HOLT MEMORIAL HOSPITAL PART V, SECTION B, LINE 11: WEST HOLT MEMORIAL HOSPITAL IS ADDRESSING THE SIGNIFICANT NEEDS IDENTIFIED IN ITS MOST RECENTLY CONDUCTED CHNA OF CHRONIC DISEASE DETECTION AND MANAGEMENT AND MENTAL WELLNESS THROUGH PROMOTION OF HEALTH MAINTENANCE WITH HEALTH SCREENINGS AND ADDITIONAL DETECTION CARE MANAGEMENT (BLOOD PRESSURE CHECKS, DEXA SCANS, REDUCED PRICE LABS, AND ATTENDANCE AT LOCAL VENDOR FAIRS SHARING HEALTH EDUCATION THAT IS FREE TO THE COMMUNITY). WE ALSO ATTEND AN ANNUAL WOMEN'S HEALTH CONFERENCE AND ASSIST WITH THE LOCAL FOOD PANTRY. BLOOD PRESSURE CHECKS ARE DONE AT THE LOCAL NURSING HOMES WEEKLY AND AVAILABLE DAILY IN OUR FACILITIES, FREE OF CHARGE TO THE COMMUNITY. PHQ9 QUESTIONNAIRE'S ARE OFFERED TO HELP IDENTIFY MENTAL WELL BEING IN PATIENTS THAT MIGHT BE AT RISK. WEST HOLT MEMORIAL HOSPITAL IS ADDRESSING ALL SIGNIFICANT NEEDS IDENTIFIED IN THE MOST RECENTLY CONDUCTED CHNA. 2 1 - WEST HOLT CLINIC 405 WEST PEARL STREET ATKINSON NE 68713 RURAL HEALTH CLINIC 2 - WEST HOLT PHARMACY 313 W PEARL ST ATKINSON NE 68713 RETAIL PHARMACY PART I, LINE 3C: THE HOSPITAL HAS A POLICY AND USES THE FEDERAL POVERTY GUIDELINES TO DETERMINE ELIGIBILITY. THOSE REQUESTING CHARITY CARE MUST FILL OUT AN APPLICATION. PART I, LINE 6A: THE HOSPITAL PREPARES ITS OWN COMMUNITY BENEFIT REPORT WHICH IS INCLUDED IN THE NEBRASKA HOSPITAL ASSOCIATION ANNUAL COMMUNITY BENEFIT REPORT. 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: THERE ARE NO SUBSIDIZED HEALTH SERVICES AT THIS TIME. PART II, COMMUNITY BUILDING ACTIVITIES: WEST HOLT MEMORIAL HOSPITAL PROVIDES LAB SCREENING AT VARIOUS DESIGNATED TIMES THROUGHOUT THE YEAR AT A GREATLY REDUCED RATE. THE RESULTS ARE SENT TO THE INDIVIDUALS AT WHICH TIME THEY CAN TAKE TO THEIR PRIMARY PROVIDER AND HAVE THEM REVIEWED FOR GENERAL HEALTH ABNORMALITIES, GENERAL METABOLIC DISORDERS, AND OTHER ILLNESSES. THE HOSPITAL ALSO OFFERS FREE COLORECTAL CANCER SCREENING ONCE A YEAR. SCHOOL PHYSICAL EXAMS, BLOOD PRESSURE CHECKS AT THE SENIOR CENTER, AND FLU SHOTS FOR THE AREA EMS VOLUNTEER PERSONNEL ARE ALSO SERVICES PERFORMED BY WEST HOLT IN THE COMMUNITY. PART III, LINE 2: THE AMOUNT ON LINE 2 REPRESENTS IMPLICIT PRICE CONCESSIONS. THE ORGANIZATION DETERMINES ITS ESTIMATE OF IMPLICIT PRICE CONCESSION BASED ON ITS HISTORICAL COLLECTION EXPERIENCE WITH THIS CLASS OF PATIENTS. PART III, LINE 3: THE PATIENT FINANCIAL ADVISOR AND CFO REVIEWED THE PATIENT IMPLICIT PRICE CONCESSIONS AND NOTES FROM CREDIT MANAGEMENT. WITH THIS INFORMATION, THEY DETERMINED THAT APPROXIMATELY 10% RESULTED FROM CHARGES TO PATIENTS WHO WOULD QUALIFY FOR CHARITY CARE. PART III, LINE 4: THE HOSPITAL'S FINANCIAL STATEMENTS PAGES 10, 13 AND 14 OF THE ATTACHED AUDITED FINANCIAL STATEMENTS INCLUDE FOOTNOTES TITLED "PATIENT RECEIVABLES", "PATIENT SERVICE REVENUE, AND "PATIENT FINANCIAL ASSISTANCE" THAT DESCRIBES IMPLICIT PRICE CONCESSIONS. PART III, LINE 8: THE COMMUNITY DOES BENEFIT BECAUSE THE HOSPITAL APPLIES OTHER REVENUES TO COVER THE COSTS OF CARING FOR MEDICARE PATIENTS.THE COSTING METHODOLOGY USED FOR PART III, SECTION B, LINE 6 IS THE COSTS TAKEN DIRECTLY FROM THE MEDICARE COST REPORT WHICH ARE ASSOCIATED WITH THE TOTAL REVENUE REPORTED IN LINE 5. PART III, LINE 9B: FOR PATIENTS WITH EXCEPTIONALLY LARGE MEDICAL BILLS OR WHOSE PERSONAL CIRCUMSTANCES ARE SUCH THAT THE PAYMENT OPTIONS ARE NEITHER REALISTIC NOR AFFORDABLE, THE FINANCIAL ADVISOR SHALL ATTEMPT TO DETERMINE THE PATIENT'S ABILITIES TO PAY WHILE VISITING WITH THE PATIENT. THE FINANCIAL ADVISOR, CFO OR CEO WILL HAVE THE FULL AUTHORITY TO MAKE AND APPROVE PAYMENT ARRANGEMENTS. PART VI, LINE 2: THE ORGANIZATION ASSESSES THE HEALTH CARE NEEDS OF THE COMMUNITY IT SERVES THROUGH ROUTINE COLLECTION OF INFORMATION ABOUT IMPORTANT ASPECTS OF PATIENT CARE PROVIDED IN THE HOSPITAL AND ABOUT THE CLINICAL PERFORMANCE OF ALL INDIVIDUALS WITH CLINICAL PRIVILEGES. THIS INFORMATION IS COLLECTED THROUGH ACTIVITIES OF THE MEDICAL STAFF COMMITTEES, THE OVERALL QUALITY ASSURANCE PROGRAM, AND THROUGH THE MEDICAL STAFF MONITORING ACTIVITIES. THROUGH THIS COLLECTION OF INFORMATION, PERIODIC ASSESSMENTS ARE CONDUCTED TO IDENTIFY OPPORTUNITIES TO IMPROVE PATIENT CARE AND THE PROBLEMS THAT NEED RESOLUTIONS. PART VI, LINE 3: ALL NEW PATIENTS ARE GIVEN A "NEW PATIENT PACKET" THAT CONTAINS WEST HOLT MEDICAL SERVICES BILLING AND COLLECTION POLICY WHICH OUTLINES PATIENT ELIGIBILITY FOR FINANCIAL ASSISTANCE. THERE IS ALSO A FINANCIAL ASSISTANCE SECTION ON WESTHOLTMED.ORG UNDER PATIENT RESOURCES THAT INCLUDES OUR COMPREHENSIVE CHARITY CARE POLICY AND FINANCIAL ASSISTANCE POLICY (ALSO A PLAIN LANGUAGE SUMMARY VERSION). THESE RESOURCES ARE ALSO MADE AVAILABLE FOR ALL PATIENTS IN THE REGISTRATION AREAS OF THE FACILITY. PATIENTS ARE ENCOURAGED TO SPEAK WITH OUR FINANCIAL COUNSELOR AND SOCIAL SERVICES WORKER TO FURTHER EDUCATE THEMSELVES ON ALL AVENUES FOR FINANCIAL ASSISTANCE. PART VI, LINE 4: WEST HOLT MEMORIAL HOSPITAL IS IN THE NORTH CENTRAL DISTRICT HEALTH DEPARTMENT AREA WHICH CONSISTS OF 9 COUNTIES IN NORTH CENTRAL NEBRASKA. RESIDENTS BETWEEN THE AGE OF 18-65 ACCOUNT FOR 51.70%, OVER THE AGE OF 65 ACCOUNT FOR 23.7, AND 24.6% OF THE POPULATION IS UNDER THE AGE OF 18. THE POPULATION DENSITY IN THE AREA IS 6.0 PEOPLE PER SQUARE MILE AS COMPARED TO THE NEBRASKA RATE OF 25.5 PEOPLE PER SQUARE MILE. THE PERCENT OF THE POPULATION WITH INCOMES BELOW 100% OF THE FEDERAL POVERTY LEVEL IS 12.1%, WHILE THE STATE PERCENTAGE IS 11.5%. THE AREA FACES AN ACUTE SHORTAGE OF PHYSICIANS IN NEARLY EVERY SPECIALTY AREA. GIVEN THE VASTNESS OF THE REGION AND SPARSE POPULATION DENSITY, IT IS NOT UNCOMMON FOR RESIDENTS TO LIVE MANY MILES FROM THE NEAREST HEALTH CARE PROVIDER. PART VI, LINE 5: THE HOSPITAL HAS THE AUTHORITY FOR A 40 MEMBER COMMUNITY BOARD WITH 17 MEMBERS CURRENTLY SERVING. FROM THIS GROUP, 9 MEMBERS SERVE AS THE HOSPITAL BOARD. ONE THIRD OF THE MEMBERS ARE ELECTED EVERY YEAR AT THE ANNUAL MEETING. THIS MEETING IS HELD THE FOURTH MONDAY OF OCTOBER AND IS OPEN TO THE COMMUNITY. THOSE ATTENDING ARE INVITED TO ASK QUESTIONS AND VOICE ANY CONCERNS THEY MAY HAVE. THE HOSPITAL HOSTS A HEALTH FAIR EVERY YEAR. LAB TESTS ARE OFFERED AT A REDUCED RATE AND OUTSIDE VENDORS OFFER INFORMATION FOR THE PARTICIPANTS. THE HOSPITAL OFFERS REDUCED PRICED LAB TESTS AND FREE COLORECTAL CANCER TESTS. PART VI, LINE 6: THE HOSPITAL IS NOT PART OF AN AFFILIATED HEALTH CARE SYSTEM. X X 1 0 0 0 0 0 0 0 0 SAMANTHA SHOLES PHYSICIAN 217564 0 0 0 0 0 9635 0 42740 0 269939 0 0 0 JEREMY BAUER CEO 150806 0 0 0 0 0 6699 0 37750 0 195255 0 0 0 LORRETTA DANIELS PHYSICIAN ASSISTANT 166019 0 0 0 0 0 6646 0 7189 0 179854 0 0 0 BRIAN MARTIN CEO (THRU 7/2022) 164383 0 0 0 0 0 5216 0 339 0 169938 0 0 0 NICK KONRAD PHYSICAL THERAPIST 121960 0 0 0 0 0 5577 0 31410 0 158947 0 0 0 AMY KINKENNON PHARMACIST 148737 0 0 0 0 0 6014 0 1869 0 156620 0 0 0 PART I, LINE 4A BRIAN MARTIN RECEIVED A SEVERANCE PAYMENT OF $34,034. AMY RENTSCHLER EMPLOYEE OF HOSPITAL AND SPOUSE OF BRYAN RENTSCHLER, BOARD VICE PRESIDENT 137629 EMPLOYEE W-2 WAGES 0 AMANDA SCHAAF EMPLOYEE OF HOSPITAL AND DAUGHTER OF BOARD MEMBER MARSHA THURLOW 53857 EMPLOYEE W-2 WAGES 0 FORM 990, PART VI, SECTION A, LINE 6 WEST HOLT MEMORIAL HOSPITAL SHALL HAVE ONE CLASS OF MEMBERS, CONSISTING OF FORTY INDIVIDUALS, OR FEWER IF THERE ARE LESS THAN 40 QUALIFIED INDIVIDUALS WILLING TO SERVE. MEMBERS MUST BE CITIZENS OF THE UNITED STATES, RESIDENTS OF HOLT COUNTY, NEBRASKA OR AN ADJOINING COUNTY, AND HAVE ATTAINED THE AGE OF MAJORITY. FORM 990, PART VI, SECTION A, LINE 7A THE MEMBERS OF WEST HOLT MEMORIAL HOSPITAL HAVE THE POWER TO ELECT AND REMOVE INDIVIDUALS TO MEMBERSHIP, ELECT THE DIRECTORS OF THE BOARD OF DIRECTORS, AND MAKE RECOMMENDATIONS TO THE BOARD ON OTHER MATTERS. EACH MEMBER SHALL HAVE ONE VOTE ON EACH MATTER SUBMITTED TO A VOTE OF THE MEMBERS. FORM 990, PART VI, SECTION A, LINE 8B THERE ARE NO COMMITTEES WITH AUTHORITY TO ACT ON BEHALF OF THE BOARD OF DIRECTORS. FORM 990, PART VI, SECTION B, LINE 11B THE CEO AND CFO WILL REVIEW THE FORM 990 PRIOR TO SUBMISSION TO THE IRS. THE BOARD OF DIRECTORS WILL BE PROVIDED THE FORM 990 PRIOR TO FILING. FORM 990, PART VI, SECTION B, LINE 12C FOLLOWING THE ELECTION OF THE BOARD OF DIRECTORS, EACH MEMBER IS REQUIRED TO SIGN THE CONFLICT OF INTEREST POLICY AND REFRAIN FROM THOSE SITUATIONS THAT MAY CAUSE NON-COMPLIANCE. ANY DUALITY OF INTEREST OR POTENTIAL CONFLICT OF INTEREST ON THE PART OF ANY OFFICER, DIRECTOR, COMMITTEE MEMBER, OR KEY EMPLOYEE SHOULD BE DISCLOSED TO THE BOARD OF DIRECTORS AND MADE A MATTER OF RECORD WHENEVER IT ARISES, OR WHENEVER IT INVOLVES A MATTER OF BOARD ACTION. ANY OFFICER, DIRECTOR, COMMITTEE MEMBER, OR KEY EMPLOYEE HAVING A DUALITY OF INTEREST OR A POSSIBLE CONFLICT OF INTEREST IN ANY MATTER SHOULD NOT VOTE OR USE HIS OR HER PERSONAL INFLUENCE ON THE MATTER. FORM 990, PART VI, SECTION B, LINE 15A COMPDATA CONSULTING AND THE NEBRASKA HOSPITAL ASSOCIATION ARE CONTACTED WITH SALARY RANGES FOR THESE POSITIONS. THE CEO'S SALARY IS SET BY THE BOARD OF DIRECTORS. FORM 990, PART VI, SECTION C, LINE 19 THE PUBLIC IS WELCOME TO COME TO THE FACILITY TO VIEW THE GOVERNING DOCUMENTS, CONFLICT OF INTEREST POLICY OR FINANCIAL STATEMENTS AT ANYTIME. FORM 990, PART IX, LINE 11G MACHINE SERVICE FEES: PROGRAM SERVICE EXPENSES 387,770. MANAGEMENT AND GENERAL EXPENSES 54,589. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 442,359. ANESTHESIOLOGY FEES: PROGRAM SERVICE EXPENSES 138,280. MANAGEMENT AND GENERAL EXPENSES 0. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 138,280. EMERGENCY ROOM COVERAGE FEES: PROGRAM SERVICE EXPENSES 363,912. MANAGEMENT AND GENERAL EXPENSES 0. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 363,912. OTHER FEES FOR SERVICE: PROGRAM SERVICE EXPENSES 823,856. MANAGEMENT AND GENERAL EXPENSES 67,638. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 891,494. LAB FEES: PROGRAM SERVICE EXPENSES 195,974. MANAGEMENT AND GENERAL EXPENSES 0. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 195,974. NURSING FEES: PROGRAM SERVICE EXPENSES 1,349,999. MANAGEMENT AND GENERAL EXPENSES 0. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 1,349,999. FORM 990, PART XI, LINE 9: CHANGE IN BENEFICIAL INTEREST IN TRUSTS 11,449. FORM 990, PART XI, LINE 2C: THE BOARD OF DIRECTORS ASSUMES RESPONSIBILITY FOR OVERSIGHT OF THE AUDIT OF ITS FINANCIAL STATEMENTS AND SELECTION OF AN INDEPENDENT ACCOUNTANT. THIS PROCESS HAS NOT CHANGED SINCE THE PRIOR YEAR.