2024-05-09T09:21:24-05:00 2023-06-30 410746749 CLIFTONLARSONALLEN LLP 10700 NORTHUP WAY SUITE 200 BELLEVUE WA 98004 990 2022-07-01 862701018 HENRY COUNTY HEALTH CENTER INC HENR 3193853141 407 S WHITE STREET MT PLEASANT IA 52641 JEREMY ALEXANDER CFO 3193853141 2024-05-08 1 JEREMY ALEXANDER XXX-XX-XXXX 1 KURT BENNION CPA P01469618 4252506100 2024-05-08 0 AAL1 IAL1 2022 2023-04-26 12:10:37Z GREAT RIVER HENRY COUNTY HEALTH CENTER TERESA COLGAN 407 S WHITE STREET MT PLEASANT IA 52641 39722831 0 X WWW.GREATRIVERHEALTH.ORG/HENRY-COUNTY-HEALTH-CENT X 2021 IA HENRY COUNTY HEALTH CENTER IS COMMITTED TO ENHANCING THE HEALTH OF INDIVIDUALS AND OUR COMMUNITIES THROUGH HIGH QUALITY, EFFECTIVE AND EFFICIENT SERVICES. 9 8 0 44 0 0 4609874 109625 36067916 39052362 13599 0 2069607 505271 42760996 39667258 0 0 0 0 18430169 15249010 0 0 0 20874232 25239782 39304401 40488792 3456595 -821534 8730020 30966020 3167059 26188284 5562961 4777736 HENRY COUNTY HEALTH CENTER IS COMMITTED TO ENHANCING THE HEALTH OF INDIVIDUALS AND OUR COMMUNITIES THROUGH HIGH QUALITY, EFFECTIVE AND EFFICIENT SERVICES. 0 0 40488792 0 39052362 HENRY COUNTY HEALTH CENTER, INC., HAS ENTERED INTO A HOSPITAL LEASE AGREEMENT WHERE IT LEASES ALL OF THE FACILITIES AND OPERATIONS, EXCEPT THE AMBULANCE SERVICE, OF HENRY COUNTY SOLDIERS AND SAILORS MEMORIAL HOSPITAL, A COUNTY HOSPITAL ORGANIZED UNDER IOWA CODE CHAPTER 347. HENRY COUNTY HEALTH CENTER, INC. MANAGES AND OPERATES HEALTH CARE ORGANIZATIONS, INCLUDING OPERATING THE 74-BED CRITICAL ACCESS HOSPITAL THAT FEATURES 25 ACUTE CARE BEDS ALONG WITH A 49-BED LONG-TERM CARE FACILITY, PARK PLACE. HENRY COUNTY HEALTH CENTER, INC. ALSO MANAGES AND OPERATES A CLINICAL/GROUP PRACTICE LOCATED ON THE GROUNDS OF THE HOSPITAL AND FOUR RURAL HEALTH CLINICS IN THE SURROUNDING RURAL COMMUNITIES AND PROVIDES COMMUNITY HEALTH EDUCATION FOR THE COMMUNITY. 40488792 1 0 0 1 0 0 0 0 0 0 0 0 0 1 1 1 0 1 0 0 0 0 0 0 0 0 1 1 0 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 1 0 0 0 1 10 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 X 9 8 1 1 0 0 1 1 1 1 0 0 0 1 1 1 1 1 1 1 1 0 X CHERYL ALBIN 3197681000 1221 S GEAR AVENUE WEST BURLINGTON IA 52655 MATT WENZEL DIRECTOR (THROUGH 10/12/22) 0.50 42.50 X 0 1122540 53171 DR MICHAEL MCCOY DIRECTOR 0.50 42.50 X 0 624684 51091 ROBB GARDNER CEO (THROUGH JULY 2022) 40.00 0.00 X 0 553735 72309 TERESA COLGAN CEO 40.00 0.00 X 0 494596 49949 DAVID MUHS CFO 40.00 0.00 X 191144 0 51408 DAVID FILE CHAIRPERSON 0.50 0.00 X X 0 0 0 MIKE PATTEN VICE CHAIRMAN & DIRECTOR 0.50 0.00 X X 0 0 0 WHITNEY ROGERS DIRECTOR & VICE CHAIRMAN 0.50 0.00 X X 0 0 0 SARA BETH SCHURR SECRETARY/TREASURER 0.50 0.00 X X 0 0 0 DR DEWAYNE FRAZIER DIRECTOR (THROUGH 3/28/23) 0.50 0.00 X 0 0 0 CHAD HUDSON DIRECTOR 0.50 0.00 X 0 0 0 JEN MOUTRIE DIRECTOR 0.50 0.00 X 0 0 0 DR JOEL RYON DIRECTOR 0.50 0.00 X 0 0 0 DR JOE TANSEY DIRECTOR 0.50 0.00 X 0 0 0 191144 2795555 277928 1 0 1 1 WAPITI MEDICAL GROUP 107 FLYNN DRIVE SUITE 600 MILBANK SD 57252 EMERGENCY ROOM SERVICES 1496046 LOCUM TENENS PO BOX 405547 ATLANTA GA 30384 CONTRACTED LABOR 627108 MEDICAL SOLUTIONS 1010 N 102ND STREET SUITE 300 OMAHA NE 68114 CONTRACTED LABOR 536248 PSYCHIATRIC MEDICAL CARE PO BOX 734606 DALLAS TX 75373 CONTRACTED LABOR 486549 ABC STAFFING 3451 S MERCY ROAD SUITE 102 GILBERT AZ 85297 CONTRACTED LABOR 331266 9 109625 109625 NET PATIENT REVENUE 621400 38356566 38356566 PARTNERSHIP INCOME 621400 425000 425000 OTHER OPERATING INCOME 621400 270796 270796 39052362 370664 55573 315091 315091 315091 CAFETERIA 900099 141952 141952 MISCELLANEOUS INCOME 900099 48228 48228 190180 39667258 39052362 0 505271 X 13071740 13071740 2177270 2177270 17324617 17324617 360638 360638 950720 950720 378174 378174 MEDICAL SUPPLIES 5334645 5334645 BAD DEBT EXPENSE 890988 890988 40488792 40488792 0 0 2476 2121696 525226 3944436 5121452 947715 881989 248524 1162525 1465173 23274828 8730020 30966020 1395954 2913458 1771105 23274826 3167059 26188284 X 5562961 4777736 5562961 4777736 8730020 30966020 -821534 36309 0 X X 0 1 X 1 0 X 0 0 0 0 0 0 0 0 1 7847 7847 0 PART II-B, LINE 1: HENRY COUNTY HEALTH CENTER PAYS ASSOCIATION DUES TO THE IOWA HOSPITAL ASSOCIATION (IHA) AND AMERICAN HOSPITAL ASSOCIATION (AHA). PORTIONS OF THE ASSOCIATION DUES ARE EXPENDED BY THE ASSOCIATIONS FOR LOBBYING PURPOSES. 0 RIGHT-OF-USE LEASE ASSETS 23274828 23274828 RIGHT-OF-USE LEASE LIABILITIES 23274826 23274826 X PART X, LINE 2: THE ORGANIZATION IS EXEMPT FROM INCOME TAXES UNDER SECTION 501(C)(3) OF THE INTERNAL REVENUE CODE. HOWEVER, THE ORGANIZATION IS SUBJECT TO FEDERAL INCOME TAX ON ANY UNRELATED BUSINESS TAXABLE INCOME. MANAGEMENT HAS EVALUATED THEIR INCOME TAX POSITIONS UNDER THE GUIDANCE INCLUDED IN ASC 740. BASED ON THEIR REVIEW, MANAGEMENT HAS NOT IDENTIFIED ANY MATERIAL UNCERTAIN TAX POSITIONS TO BE RECORDED OR DISCLOSED IN THE CONSOLIDATED FINANCIAL STATEMENTS. 1 1 X 1 X 1 X 1 1 0 1 1 77892 77892 0.00200 131419 113757 17662 0.00040 209311 113757 95554 0.00240 95624 95624 0.00240 95624 95624 0.00240 304935 113757 191178 0.00480 1 890988 91771 14141158 14344218 -203060 X 1 1 1 1 HENRY COUNTY HEALTH CENTER 407 SOUTH WHITE STREET MT PLEASANT IA 52641 WWW.GREATRIVERHEALTH.ORG/HENRY-COUNTY- 440047H X X X X HENRY COUNTY HEALTH CENTER 1 0 1 0 0 1 X 200.000000000000 300.000000000000 X X X 1 1 X X X X 1 X SEE LINE 16J X SEE LINE 16J X SEE LINE 16J X X X X X X X 1 X 0 X X X X X 1 X 0 0 HENRY COUNTY HEALTH CENTER PART V, SECTION B, LINE 2: HENRY COUNTY HEALTH CENTER, INC., RECEIVED TAX EXEMPT STATUS AS A 501(C)(3) IN MARCH 2021 AND ENTERED INTO A HOSPITAL LEASE AGREEMENT WHERE IT LEASES ALL OF THE FACILITIES AND OPERATIONS, EXCEPT THE AMBULANCE SERVICE, OF HENRY COUNTY SOLDIERS AND SAILORS MEMORIAL HOSPITAL, A COUNTY HOSPITAL ORGANIZED UNDER IOWA CODE CHAPTER 347. HENRY COUNTY HEALTH CENTER, INC. MANAGES AND OPERATES HEALTH CARE ORGANIZATIONS. THIS INCLUDES OPERATING THE 74-BED CRITICAL ACCESS HOSPITAL THAT FEATURES 25 ACUTE CARE BEDS ALONG WITH A 49-BED LONG TERM CARE FACILITY, PARK PLACE. HENRY COUNTY HEALTH CENTER, INC. ALSO MANAGES AND OPERATES A CLINICAL/GROUP PRACTICE LOCATED ON THE GROUNDS OF THE HOSPITAL AND FOUR RURAL HEALTH CLINICS IN THE SURROUNDING RURAL COMMUNITIES AND PROVIDES COMMUNITY HEALTH EDUCATION FOR THE COMMUNITY. HENRY COUNTY HEALTH CENTER PART V, SECTION B, LINE 16J: THE FINANCIAL ASSISTANCE POLICY, PLAIN LANGUAGE SUMMARY AND FINANCIAL ASSISTANCE APPLICATION ARE AVAILABLE ONLINE AT WWW.GREATRIVERHEALTH.ORG/PATIENTS-VISITORS/BILLING-FINANCIAL-SERVICES/. HENRY COUNTY HEALTH CENTER PART V, SECTION B, LINE 20E: HCHC USES AN OUTSIDE SOURCE TO SCREEN PATIENTS TO SEE IF THEY COULD BE ELIGIBLE FOR FINANCIAL ASSISTANCE. THE HOSPITAL GETS NOTIFICATION BACK AS TO HOW MUCH OF A FINANCIAL ASSISTANCE DISCOUNT THEY WOULD BE ELIGIBLE FOR. IF THE PATIENT DOESN'T RESPOND TO PHONE CALLS REGARDING THE FINANCIAL ASSISTANCE APPLICATION OR THEY DON'T COMPLETE THE APPLICATION, THE HOSPITAL MAY STILL DISCOUNT THE PATIENT'S CHARGES UNDER THEIR PRESUMPTIVE CHARITY POLICY. THE HOSPITAL'S PRESUMPTIVE CHARITY PROGRAM GIVES THE HOSPITAL THE OPPORTUNITY TO DISCOUNT PATIENT ACCOUNTS BASED ON INFORMATION IT MAY HAVE REGARDING A PATIENT BEING HOMELESS OR UNEMPLOYED. 5 1 - PARK PLACE ELDER LIVING 401 S VAN BUREN STREET MT PLEASANT IA 52641 NURSING HOME CARE 2 - HCHC - MT PLEASANT CLINIC 407 S WHITE STREET SUITE 103 MT PLEASANT IA 52641 PROVIDER HEALTH CLINIC 3 - HCHC - WINFIELD CLINIC 110 W PINE STREET WINFIELD IA 52659 PROVIDER HEALTH CLINIC 4 - HCHC - WAYLAND CLINIC 227 W MAIN STREET WAYLAND IA 52654 PROVIDER HEALTH CLINIC 5 - HCHC - NEW LONDON CLINIC 111 W WASHINGTON STREET NEW LONDON IA 52645 PROVIDER HEALTH CLINIC PART I, LINE 3C: HENRY COUNTY HEALTH CENTER (HCHC) USES THE FPG TO DETERMINE FREE OR DISCOUNTED CARE. INDIVIDUALS WHO ARE BELOW 200% OF THE FPG QUALIFY FOR FREE CARE. IN MOST INSTANCES, THEY HAVE TO PROVIDE FINANCIAL DOCUMENTATION AND FILL OUT A CHARITY CARE APPLICATION. THE HOSPITAL ALSO USES A PRESUMPTIVE CHARITY CARE PROGRAM THAT ANALYZES PUBLIC AND PRIVATE DATABASES TO HELP DETERMINE ELIGIBILITY FOR CHARITY CARE. THESE INDIVIDUALS DO NOT HAVE ANY OTHER DOCUMENTATION TO PROVIDE. THIS PROGRAM IS USED AFTER COLLECTION ATTEMPTS HAVE BEEN DISCONTINUED. EXTRAORDINARY ASSETS ARE TAKEN INTO CONSIDERATION WHEN DETERMINING CHARITY CARE ELIGIBILITY. MEDICALLY INDIGENT INDIVIDUALS ARE COVERED UNDER THE SAME CHARITY CARE POLICY. INDIVIDUALS BETWEEN 200% AND 300% OF THE FEDERAL POVERTY LIMITS ARE GRANTED CHARITY ON A SLIDING SCALE. PART I, LINE 7: THE AMOUNTS INCLUDED IN PART I, LINES 7A-7D WERE CALCULATED USING COST TO CHARGE RATIO DERIVED FROM WORKSHEET 2 OF THE IRS SCHEDULE H INSTRUCTIONS. PART I, LINES 7E-7J ARE ACTUAL COSTS. PART I, LN 7 COL(F): BAD DEBT EXPENSES OF $890,988 WERE SUBTRACTED FROM THE TOTAL EXPENSES IN CALCULATING THE PERCENTAGES IN PART I, LINE 7, COLUMN F. PART III, LINE 2: THE HEALTH CENTER DETERMINES THE TRANSACTION PRICE BASED ON STANDARD CHARGES FOR GOODS AND SERVICES PROVIDED, REDUCED BY CONTRACTUAL ADJUSTMENTS PROVIDED TO THIRD PARTY PAYORS, DISCOUNTS PROVIDED TO UNINSURED PATIENTS IN ACCORDANCE WITH THE HEALTH CENTER'S POLICY, AND OR IMPLICIT PRICE CONCESSIONS PROVIDED TO UNINSURED PATIENTS. THE HEALTH CENTER DETERMINES ITS ESTIMATES OF CONTRACTUAL ADJUSTMENTS AND DISCOUNTS BASED ON CONTRACTUAL AGREEMENTS, ITS DISCOUNT POLICIES AND HISTORICAL EXPERIENCE. THE HEALTH CENTER DETERMINES ITS ESTIMATE OF IMPLICIT PRICE CONCESSIONS BASED ON HISTORICAL COLLECTION EXPERIENCE WITH VARIOUS CLASSES OF PATIENTS. PART III, LINE 3: THE ESTIMATED AMOUNT OF THE ORGANIZATION'S IMPLICIT PRICE CONCESSIONS ATTRIBUTABLE TO PATIENTS ELIGIBLE UNDER THE ORGANIZATION'S CHARITY CARE POLICY IS CALCULATED BASED ON THE PERCENTAGE OF INDIVIDUALS LIVING BELOW THE POVERTY LEVEL. 10.3% CAN REASONABLY BE CONSIDERED A COMMUNITY BENEFIT AS IT WOULD HAVE BEEN WRITTEN OFF TO CHARITY CARE. PART III, LINE 4: SEE THE "PATIENTS RECEIVABLES" PARAGRAPH IN NOTE 1 ON PAGE 10 OF THE ATTACHED AUDITED FINANCIAL STATEMENTS FOR A DESCRIPTION OF BAD DEBT EXPENSE. PART III, LINE 8: THE ORGANIZATION DERIVED ITS COSTING METHODOLOGY USED TO DETERMINE THE MEDICARE ALLOWABLE COSTS REPORTED IN THE ORGANIZATION'S MEDICARE COST REPORT BY USING COST REPORT WORKSHEETS. MEDICARE COSTS ARE DETERMINED THROUGH THE MEDICARE COST FINDING PROCESS WHICH ALLOCATES GENERAL SERVICE CENTER COSTS TO REVENUE DEPARTMENTS. THE METHODOLOGY DESCRIBED IN THE INSTRUCTIONS TO SCHEDULE H, PART III, SECTION B, LINE 6 DOES NOT TAKE INTO ACCOUNT ALL COSTS INCURRED BY THE HOSPITAL AND DOES NOT REPRESENT THE TOTAL COMMUNITY BENEFIT CONFERRED IN THIS AREA. THE REASONS MEDICARE SHORTFALL SHOULD BE TREATED AS A COMMUNITY BENEFIT ARE (A) ABSENT THE MEDICARE PROGRAM, IT IS LIKELY MANY OF THE INDIVIDUALS WOULD QUALIFY FOR FINANCIAL ASSISTANCE OR OTHER NEEDS-BASED GOVERNMENT PROGRAMS; (B) BY ACCEPTING PAYMENT BELOW COST TO TREAT THESE INDIVIDUALS, THE BURDENS OF GOVERNMENT ARE RELIEVED WITH RESPECT TO THESE INDIVIDUALS; AND (C) THERE IS A SIGNIFICANT POSSIBILITY THAT CONTINUED REDUCTION IN REIMBURSEMENT MAY ACTUALLY CREATE DIFFICULTIES IN ACCESS FOR THESE INDIVIDUALS, AND THE AMOUNT SPENT TO COVER MEDICARE SHORTFALL IS MONEY NOT AVAILABLE TO COVER FINANCIAL ASSISTANCE AND OTHER COMMUNITY BENEFIT NEEDS. PART III, LINE 9B: EACH PATIENT RECEIVES CARE REGARD LESS OF THE ABILITY TO PAY. ANY PATIENT CAN APPLY FOR FINANCIAL ASSISTANCE PRIOR TOO RAFTER RECEIVING A STATEMENT FOR SERVICES. THERE ARE NO COLLECTION EFFORTS WHILE AN INDIVIDUAL IS IN THE PROCESS OF APPLYING FOR FINANCIAL ASSISTANCE. THE HOSPITAL WILL NOT PURSUE EXTRAORDINARY COLLECTION ACTIVITIES ON PATIENTS FOR AT LEAST 120 DAYS FROM THE DATE OF THE FIRST STATEMENT AND PROVIDES PATIENTS 240 DAYS TO APPLY FOR ASSISTANCE. PART VI, LINE 2: HENRY COUNTY HEALTH CENTER, INC., RECEIVED TAX EXEMPT STATUS AS A 501(C)(3) IN MARCH 2021 AND ENTERED INTO A HOSPITAL LEASE AGREEMENT WHERE IT LEASES ALL OF THE FACILITIES AND OPERATIONS, EXCEPT THE AMBULANCE SERVICE, OF HENRY COUNTY SOLDIERS AND SAILORS MEMORIAL HOSPITAL, A COUNTY HOSPITAL ORGANIZED UNDER IOWA CODE CHAPTER 347. HENRY COUNTY HEALTH CENTER, INC. MANAGES AND OPERATES HEALTH CARE ORGANIZATIONS. THIS INCLUDES OPERATING THE 74-BED CRITICAL ACCESS HOSPITAL THAT FEATURES 25 ACUTE CARE BEDS ALONG WITH A 49-BED LONG TERM CARE FACILITY, PARK PLACE. HENRY COUNTY HEALTH CENTER, INC. ALSO MANAGES AND OPERATES A CLINICAL/GROUP PRACTICE LOCATED ON THE GROUNDS OF THE HOSPITAL AND FOUR RURAL HEALTH CLINICS IN THE SURROUNDING RURAL COMMUNITIES AND PROVIDES COMMUNITY HEALTH EDUCATION FOR THE COMMUNITY. PART VI, LINE 3: NOTIFICATION ABOUT GOVERNMENT PROGRAM AND/OR FINANCIAL ASSISTANCE FROM HCHC IS DISSEMINATED BY VARIOUS MEANS AT HCHC, WHICH INCLUDES PUBLICATION OF NOTICES IN PATIENT BILLS AND POSTED NOTICES IN THE EMERGENCY ROOMS, ADMISSION FORMS, ADMITTING AND REGISTRATION DEPARTMENT, HOSPITAL BUSINESS OFFICES, AND THE FINANCIAL SERVICES OFFICE ON THE FACILITY CAMPUS. HCHC ALSO POSTS AT THE LOCAL DEPARTMENT OF HEALTH SERVICES OFFICE. HCHC ALSO PUBLISHES AND WIDELY PUBLICIZES A SUMMARY OF THE ASSISTANCE OPTIONS ON THE FACILITY WEBSITE AND IN BROCHURES AVAILABLE IN PATIENT ACCESS SITES. REFERRAL OF PATIENTS FOR CHARITY MAY BE MADE BY ANY MEMBER OF THE SEIRMC STAFF. ALSO REQUESTS FOR CHARITY MAY BE MADE BY THE PATIENT OR A FAMILY MEMBER, CLOSE FRIEND, OR ASSOCIATE OF THE PATIENT, SUBJECT TO APPLICABLE PRIVACY LAWS. FINANCIAL COUNSELORS MEET WITH PATIENTS TO ASSIST IN COMPLETING A QUESTIONNAIRE THAT HELPS THEM DETERMINE IF THE PATIENT QUALIFIES FOR A GOVERNMENT PROGRAM. PART VI, LINE 4: LOCATED IN SOUTHEAST IOWA, MOUNT PLEASANT IS AT THE CROSSROADS OF U.S. HIGHWAY 218 AND U.S. 34. HENRY COUNTY HAS 11 CITIES AND MORE THAN 20,000 PEOPLE. THE MEDIAN HOUSEHOLD INCOME IN HENRY COUNTY IS $62,365. THIS IS LOWER THAN THE STATE MEDIAN ($69,588) AND NATIONAL MEDIAN ($74,755). ELEVEN PERCENT OF ALL RESIDENTS AND 15% OF CHILDREN UNDER THE AGE OF 18 LIVE IN HOUSEHOLDS EARNING LESS THAN THE FEDERAL POVERTY LEVEL. THE STATE POVERTY LEVEL IS 11% FOR ALL RESIDENTS AND 12.2% FOR CHILDERN UNDER THE AGE OF 18. THE FEDERAL LEVEL IS 12.6% FOR ALL RESIDENTS AND 16.3% FOR CHILDERN UNDER THE AGE OF 18. 27.0% OF THE POPULATION IS 65 YEARS OR OLDER WHICH IS HIGHER THAN IOWA'S OVERALL RATE OF 18.4%. THERE IS A LOWER PERCENTAGE OF YOUNG PEOPLE UNDER THE AGE OF 30 LIVING IN HENRY COUNTY (37.5%) COMPARED TO IOWA (38.7%). ACCORDING TO THE U.S. CENSUS 2020 ESTIMATES, HENRY COUNTY IS 87.8% WHITE, 2.5% BLACK OR AFRICAN AMERICAN, 0.4% AMERICAN INDIAN AND ALASKA NATIVE, 2.2% ASIAN, AND 4.8% TWO OR MORE RACES. PART VI, LINE 5: THE BOARD MEMBERS LIVE IN THE HOSPITAL SERVICE AREA AND USE THE FACILITY. THE HOSPITAL EXTENDS MEDICAL STAFF PRIVILEGES TO ALL QUALIFIED PHYSICIANS IN THE COMMUNITY. HENRY COUNTY HEALTH CENTER USES SURPLUS FUNDS TO INVEST IN HOSPITAL EQUIPMENT AND IMPROVEMENTS. PART VI, LINE 6: HENRY COUNTY HEALTH CENTER IS PART OF GREAT RIVER HEALTH SYSTEM.GREAT RIVER HEALTH SYSTEM CONSISTS OF TWO HOSPITALS, A HOSPICE HOUSE, HOME HEALTH SERVICES, AMBULANCE SERVICES, THREE PHARMACIES, A DURABLE MEDICAL EQUIPMENT COMPANY, A LONG-TERM CARE NURSING HOME, ABOUT 25 PRIMARY-CARE AND SPECIALTY PHYSICIAN CLINICS, AND IS AFFILIATED WITH AN OUTPATIENT RENAL DIALYSIS CENTER.THE NON-HOSPITAL HEALTH CARE FACILITIES THAT ARE OPERATED BY ORGANIZATIONS RELATED TO THE HOSPITAL ARE: GREAT RIVER HEALTH SYSTEM-ANESTHESIA; GREAT RIVER HEALTH SYSTEM-AUDIOLOGY; GREAT RIVER HEALTH SYSTEM-BUSINESS HEALTH; GREAT RIVER HEALTH SYSTEM-CANCER CENTER; GREAT RIVER HEALTH SYSTEM-CARDIOLOGY; GREAT RIVER HEALTH SYSTEM-DIABETIC FOOT CLINIC; GREAT RIVER HEALTH SYSTEM-EYE SPECIALISTS; GREAT RIVER HEALTH SYSTEM-FAMILY MEDICINE; GREAT RIVER HEALTH SYSTEM-FAMILY MEDICINE, MERCY PLAZA; GREAT RIVER HEALTH SYSTEM-GASTROENTEROLOGY; GREAT RIVER HEALTH SYSTEM-HEALTHY LIVING; GREAT RIVER HEALTH SYSTEM-HERITAGE FAMILY PHARMACY; GREAT RIVER HEALTH SYSTEM-HERITAGE MEDICAL EQUIPMENT AND SUPPLIES; GREAT RIVER HEALTH SYSTEM-HERITAGE PARK PHARMACY; GREAT RIVER HEALTH SYSTEM-HERITAGE PARTNERS PHARMACY; GREAT RIVER HEALTH SYSTEM-KEOKUK; GREAT RIVER HEALTH SYSTEM-MEDIAPOLIS; GREAT RIVER HEALTH SYSTEM-MEDICINE SPECIALISTS; GREAT RIVER HEALTH SYSTEM-MENTAL HEALTH; GREAT RIVER HEALTH SYSTEM-NEPHROLOGY; GREAT RIVER HEALTH SYSTEM-ORTHOPAEDIC SPECIALISTS; GREAT RIVER HEALTH SYSTEM-PULMONOLOGY; GREAT RIVER HEALTH SYSTEM-QUICK CARE; GREAT RIVER HEALTH SYSTEM-SURGEONS; GREAT RIVER HEALTH SYSTEM-UROLOGY; GREAT RIVER HEALTH SYSTEM-WAPELLO; GREAT RIVER HEALTH SYSTEM-WEST POINT; GREAT RIVER HEALTH SYSTEM-WOMEN'S HEALTH; GREAT RIVER HEALTH SYSTEM-WOUND AND HYPERBARIC; SOUTHEASTERN RENAL DIALYSIS. PART VI, LINE 7: HCHC DOES NOT FILE A COMMUNITY BENEFIT REPORT WITH THE STATE OF IOWA. HOWEVER, COMMUNITY BENEFIT INFORMATION IS PROVIDED TO THE IOWA HOSPITAL ASSOCIATION. 1 0 0 0 0 0 0 0 0 MATT WENZEL DIRECTOR (THROUGH 10/12/22) 0 740784 0 213774 0 167982 0 15250 0 37921 0 1175711 0 0 DR MICHAEL MCCOY DIRECTOR 0 532528 0 80672 0 11484 0 15250 0 35841 0 675775 0 0 ROBB GARDNER CEO (THROUGH JULY 2022) 0 219407 0 43750 0 290578 0 15250 0 57059 0 626044 0 0 TERESA COLGAN CEO 0 421350 0 65421 0 7825 0 15250 0 34699 0 544545 0 0 DAVID MUHS CFO 191144 0 0 0 0 0 0 0 51408 0 242552 0 0 0 PART I, LINE 4A MATT WENZEL RECEIVED A SEVERANCE PAYMENT OF $164,442. THIS AMOUNT WAS INCLUDED IN W-2 WAGES. ROBB GARDNER RECEIVED A SEVERANCE PAYMENT OF $250,000. THIS AMOUNT WAS INCLUDED IN W-2 WAGES. FORM 990, PART VII, SECTION A, LINE 5: DAVID MUHS IS EMPLOYED BY HENRY COUNTY SOLDIERS & SAILORS MEMORIAL HOSPITAL. THE EMPLOYEES FROM THAT HOSPITAL ARE LEASED TO HENRY COUNTY HEALTH CENTER INC. FORM 990, PART VI, SECTION A, LINE 2 DR. MICHAEL MCCOY, MATT WENZEL AND JEREMY ALEXANDER HAVE BUSINESS RELATIONSHIPS BY SERVING AS OFFICERS AND/OR BOARD MEMBERS OF FOR-PROFIT SUBSIDIARIES OF GREAT RIVER HEALTH SYSTEM. FORM 990, PART VI, SECTION A, LINE 3 EXECUTIVES AND EMPLOYEES OF GREAT RIVER HEALTH SYSTEM, INC., MANAGE THE ACTIVITIES OF THE HENRY COUNTY HEALTH CENTER, INC. THE CFO IS AN EMPLOYEE OF HENRY COUNTY SOLDIERS AND SAILORS MEMORIAL HOSPITAL AND PROVIDES SERVICES THROUGH A SERVICES AGREEMENT WITH THAT ORGANIZATION. FORM 990, PART VI, SECTION A, LINE 6 GREAT RIVER HEALTH SYSTEM, INC., AN IOWA NONPROFIT CORPORATION, IS THE SOLE MEMBER OF HENRY COUNTY HEALTH CENTER, INC. FORM 990, PART VI, SECTION A, LINE 7A THE SOLE MEMBER, GREAT RIVER HEALTH SYSTEM, INC (GRHS), HAS THE SOLE POWER TO ELECT OR REMOVE ALL BOARD MEMBERS OF HENRY COUNTY HEALTH CENTER. THE NOMINATING COMMITTEE SHALL PRESENT A RECOMMENDATION FOR THE ELECTION OF DIRECTORS TO THE BOARD, WHICH UPON APPROVAL OF THE BOARD AND THE SUBSEQUENT APPROVAL OF GRHS, SHALL BE ELECTED TO THE BOARD. FORM 990, PART VI, SECTION A, LINE 7B THE GRHS BOARD OF DIRECTORS HAS THE FOLLOWING SPECIFIC POWERS RELATED TO ALL SUBSIDIARY CORPORATIONS AND AFFILIATED ORGANIZATIONS: 1. ELECT OR REMOVE THE BOARD OF DIRECTORS, OR ANY OTHER MEMBER OF THE BOARD OF DIRECTORS; 2. AMEND THE ARTICLES OF INCORPORATION OR THE BYLAWS; 3. DISSOLVE OR APPROVE MERGER WITH ANY OTHER CORPORATE ENTITY; 4. APPROVE STRATEGIC OR OTHER BUSINESS PLANS; 5. APPROVE CAPITAL AND OPERATING BUDGETS; 6. APPROVAL OF ANY INDEBTEDNESS INCURRED; 7. TRANSFER, SELL OR CLOSE ANY FACILITY, DEPARTMENT OR FUNCTION; 8. APPROVE ANY CHARITABLE DISBURSEMENTS, WHETHER INTERNAL OR EXTERNAL, IN EXCESS OF ONE HUNDRED THOUSAND DOLLARS ($100,000.00) IN THE AGGREGATE DURING ANY FISCAL YEAR; 9. THE SALE, DISPOSITION OR ANY ENCUMBRANCE (OTHER THAN ROUTINE LEASE TRANSACTIONS) OF ANY REAL ESTATE; 10. ADOPT, AMEND, OR TERMINATE EMPLOYEE BENEFIT PROGRAMS OR PLANS; 11. APPOINT OR TERMINATE THE CHIEF EXECUTIVE OFFICER; 12. APPROVE THE ELECTION OF ANY OFFICER OR CHAIRPERSON OF THE BOARD OF DIRECTORS; AND 13. TO TAKE ANY OTHER ACTION NECESSARY DEEMED IN THE BEST INTERESTS OF GRHS. FORM 990, PART VI, SECTION A, LINE 8B THERE ARE NO COMMITTEES WITH AUTHORITY TO ACT ON BEHALF OF THE GOVERNING BODY. FORM 990, PART VI, SECTION B, LINE 11B THE FORM 990 WAS PREPARED BY AN EXTERNAL ACCOUNTANT. A DRAFT OF THE FORM 990 WAS REVIEWED IN DETAIL BY A MEMBER OF THE ACCOUNTING DEPARTMENT, DIRECTOR OF FINANCE AND CFO. ANY NECESSARY ADJUSTMENTS WERE MADE PRIOR TO FINALIZING THE FORM. A COPY OF THE FINAL FORM 990 WAS MADE AVAILABLE TO THE BOARD MEMBERS FOR THEIR REVIEW PRIOR TO FILING WITH THE IRS. ANY QUESTIONS OF THE BOARD MEMBERS WERE ADDRESSED THROUGH THE ACCOUNTING DEPARTMENT. FORM 990, PART VI, SECTION B, LINE 12C BOTH CORPORATE AND SUBSIDIARY BOARD MEMBERS ARE PROVIDED EDUCATION REGARDING CONFLICTS OF INTEREST. THIS EDUCATION IS PROVIDED BY THE CHIEF COMPLIANCE OFFICER. ALL BOARD MEMBERS ARE REQUIRED TO COMPLETE A CONFLICT OF INTEREST DISCLOSURE FORM. RELATIONSHIPS NOTED ON THIS FORM MAY BE DISCUSSED WITH THE RESPECTIVE BOARD MEMBER IF THERE ARE QUESTIONS. IF AN INDIVIDUAL HAS A CONFLICT OF INTEREST, THEY MAY NOT PARTICIPATE IN DISCUSSIONS RELATING TO THE TRANSACTION IN QUESTION AND MAY NOT VOTE ON MATTERS RELATED TO THE TRANSACTION. CONFLICT OF INTEREST PROCEEDINGS ARISING FROM CONFLICTS OF INTEREST ARE DOCUMENTED IN THE BOARD MINUTES. FORM 990, PART VI, SECTION B, LINE 15 COMPENSATION OF OFFICERS IS PAID BY A RELATED FOR-PROFIT SUBSIDIARY. THE COMPENSATION FOR THE CEO AND OTHER OFFICERS IS DETERMINED BY THE EXECUTIVE COMPENSATION COMMITTEE OF GREAT RIVER HEALTH SYSTEM, INC. THE ROLE OF THE COMPENSATION COMMITTEE IS TO ACT ON BEHALF OF THE CORPORATE BOARD OF DIRECTORS IN ADOPTING, REVIEWING AND MAINTAINING AN EXECUTIVE COMPENSATION PHILOSOPHY. THE COMPENSATION COMMITTEE IS COMPRISED OF THREE BOARD MEMBERS, ALL OF WHOM ARE INDEPENDENT FROM THE CEO AND OTHER OFFICERS. THE COMPENSATION COMMITTEE REVIEWS THE COMPENSATION OF THE CEO AND OTHER OFFICERS ON AN ANNUAL BASIS. THE DELIBERATIONS AND DECISIONS ARE DOCUMENTED IN MINUTES TAKEN AT THE MEETINGS. GREAT RIVER HEALTH SYSTEM, INC. PARTICIPATES IN AND UTILIZES EXECUTIVE SALARY SURVEYS TO DETERMINE COMPENSATION RANGES. THE COMMITTEE REVIEWS PREVAILING MARKET DATA TO ENSURE CONTINUED MARKET COMPETITIVENESS. THE COMPENSATION COMMITTEE ALSO ENGAGES AN INDEPENDENT THIRD PARTY COMPENSATION CONSULTING GROUP BIENNIALLY TO ASSESS AND VALIDATE THE ENTIRETY OF EXECUTIVE COMPENSATION AND BENEFITS PACKAGES TO ENSURE REGULATORY COMPLIANCE, EXTERNAL COMPETITIVENESS, AND INTERNAL EQUITY. THE MOST RECENT YEAR OF AN INDEPENDENT THIRD PARTY REVIEW WAS 2023. FORM 990, PART VI, SECTION C, LINE 19 HENRY COUNTY HEALTH CENTER MAKES ITS GOVERNING DOCUMENTS, CONFLICT OF INTEREST POLICY, AND FINANCIAL STATEMENTS AVAILABLE UPON REQUEST. FORM 990, PART IX, LINE 11G OTHER FEES: PROGRAM SERVICE EXPENSES 40,300. MANAGEMENT AND GENERAL EXPENSES 0. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 40,300. MEDICAL PROFESSIONAL FEES: PROGRAM SERVICE EXPENSES 17,284,317. MANAGEMENT AND GENERAL EXPENSES 0. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 17,284,317. FORM 990, PART XII, LINE 2C: THE PROCESS FOR OVERSIGHT AND SELECTION OF AN INDEPENDENT ACCOUNTANT HAS NOT CHANGED FROM THE PRIOR YEAR. 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