Department of the Treasury Internal Revenue Service
Public Charity Status and Public Support
Complete if the organization is a section 501(c)(3) organization or a section
4947(a)(1) nonexempt charitable trust.
Attach to Form 990 or Form 990-EZ. See separate instructions.
OMB No. 1545-0047
2010
Open to Public Inspection
Name of the organization
NORTH PLATTE NE HOSPITAL CORP DBA GREAT PLAINS REGIONAL MEDICAL CENTER
Employer identification number
47-0662290
Part I
Reason for Public Charity Status
(All organizations must complete this part.) See instructions
The organization is not a private foundation because it is: (For lines 1 through 11, check only one box.)
1
2
3
4
5
section 170(b)(1)(A)(iv). (Complete Part II.)
6
7
8
9
receipts from activities related to its exempt functions—subject to certain exceptions, and (2) no more than 331/3% of
its support from gross investment income and unrelated business taxable income (less section 511 tax) from businesses
acquired by the organization after June 30, 1975. See section 509(a)(2). (Complete Part III.)
10
11
e
By checking this box, I certify that the organization is not controlled directly or indirectly by one or more disqualified persons other than foundation managers and other than one or more publicly supported organizations described in section 509(a)(1) or section 509(a)(2).
f
If the organization received a written determination from the IRS that it is a Type I, Type II or Type III supporting organization, check this box
..................................................
g
Since August 17, 2006, has the organization accepted any gift or contribution from any of the following persons?
(i) a person who directly or indirectly controls, either alone or together with persons described in (ii)
Yes
No
and (iii) below, the governing body of the the supported organization?
................
11g(i)
(ii)
a family member of a person described in (i) above?
......................
11g(ii)
(iii)
a 35% controlled entity of a person described in (i) or (ii) above?
................
11g(iii)
h
Provide the following information about the supported organization(s).
(i) Name of supported organization
(ii) EIN
(iii) Type of organization (described on lines 1- 9 above or IRC section (see instructions))
(iv) Is the organization in col. (i) listed in your governing document?
(v) Did you notify the organization in col. (i) of your support?
(vi) Is the organization in col. (i) organized in the U.S.?
(vii) Amount of support?
Yes
No
Yes
No
Yes
No
Total
For Paperwork Reduction Act Notice, see the Instructions for Form 990.
Cat. No. 11285F
Schedule A (Form 990 or 990-EZ) 2010
Schedule A (Form 990 or 990-EZ) 2010
Page 2
Part II
Support Schedule for Organizations Described in IRC 170(b)(1)(A)(iv) and 170(b)(1)(A)(vi) (Complete only if you checked the box on line 5, 7, or 8 of Part I or if the
organization failed to qualify under Part III. If the organization fails to
qualify under the tests listed below, please complete Part III.)
Section A. Public Support
Calendar year(or fiscal year beginning in)
(a) 2006
(b) 2007
(c) 2008
(d) 2009
(e) 2010
(f) Total
1
Gifts, grants, contributions, and membership fees received. (Do not include any "unusual grants.") ....
2
Tax revenues levied for the organization's benefit and either paid to or expended on its behalf.......
3
The value of services or facilities furnished by a governmental unit to the organization without charge..
4
Total. Add lines 1 through 3..
5
The portion of total contributions by each person (other than a governmental unit or publicly supported organization) included
on line 1 that exceeds 2% of the amount shown on line 11, column (f)..
6
Public Support. Subtract line 5 from line 4.
Section B. Total Support
Calendar year(or fiscal year beginning in)
(a) 2006
(b) 2007
(c) 2008
(d) 2009
(e) 2010
(f) Total
7
Amounts from line 4..
8
Gross income from interest, dividends, payments received on securities loans, rents, royalties and income from similar sources..
9
Net income from unrelated business activities, whether or not the business is regularly carried on..
10
Other income. (Explain in Part IV.) Do not include gain or loss from the sale of capital assets..
11
Total support (Add lines 7 through 10).
12
Gross receipts from related activities, etc. (See instructions.)
..................
12
13
First Five Years
If the Form 990 is for the organization's first, second, third, fourth, or fifth tax year as a 501(c)(3) organization,
check this box and stop here..........................................
Section C. Computation of Public Support Percentage
14
Public Support Percentage for 2010 (line 6 column (f) divided by line 11 column (f))
.........
14
15
Public Support Percentage for 2009 Schedule A, Part II, line 14
...............
15
16a
33 1/3% support test—2010.
If the organization did not check the box on line 13, and line 14 is 33 1/3% or more, check this box
and stop here. The organization qualifies as a publicly supported organization
......................
b
33 1/3% support test—2009.
If the organization did not check the box on line 13 or 16a, and line 15 is 33 1/3% or more, check this
box and stop here. The organization qualifies as a publicly supported organization
.....................
17a
10%-facts-and-circumstances test—2010.
If the organization did not check a box on line 13, 16a, or 16b and line 14
is 10% or more, and if the organization meets the "facts and circumstances" test, check this box and stop here. Explain
in Part IV how the organization meets the "facts and circumstances" test. The organization qualifies as a publicly supported
organization
..................................................
b
10%-facts-and-circumstances test—2009.
If the organization did not check a box on line 13, 16a, 16b, or 17a and line
15 is 10% or more, and if the organization meets the "facts and circumstances" test, check this box and stop here.
Explain in Part IV how the organization meets the "facts and circumstances" test. The organization qualifies as a publicly supported organization
..............................................
18
Private Foundation
If the organization did not check a box on line 13, 16a, 16b, 17a or 17b, check this box and see
instructions
...................................................
Schedule A (Form 990 or 990-EZ) 2010
Schedule A (Form 990 or 990-EZ) 2010
Page 3
Part III
Support Schedule for Organizations Described in IRC 509(a)(2) (Complete only if you checked the box on line 9 of Part I or if the organization
failed to qualify under Part II. If the organization fails to qualify under
the tests listed below, please complete Part II.)
Section A. Public Support
Calendar year(or fiscal year beginning in)
(a) 2006
(b) 2007
(c) 2008
(d) 2009
(e) 2010
(f) Total
1
Gifts, grants, contributions, and membership fees received. (Do not include any "unusual grants.") .
2
Gross receipts from admissions, merchandise sold or services performed, or facilities furnished in any activity that is related to the organization's tax-exempt purpose......
3
Gross receipts from activities that are not an unrelated trade or business under section 513..
4
Tax revenues levied for the organization's benefit and either paid to or expended on its behalf...
5
The value of services or facilities furnished by a governmental unit to the organization without charge..
6
Total. Add lines 1 through 5.
7a
Amounts included on lines 1, 2, and 3 received from disqualified persons...
b
Amounts included on lines 2 and 3 received from other than disqualified persons that exceed the greater of $5,000 or 1% of the amount on line 13 for the year.
c
Add lines 7a and 7b..
8
Public Support (Subtract line 7c from line 6.)
Section B. Total Support
Calendar year (or fiscal year beginning in)
(a) 2006
(b) 2007
(c) 2008
(d) 2009
(e) 2010
(f) Total
9
Amounts from line 6...
10a
Gross income from interest, dividends, payments received on securities loans, rents, royalties and income from similar sources..
b
Unrelated business taxable income (less section 511 taxes) from businesses acquired after June 30, 1975.
c
Add lines 10a and 10b.
11
Net income from unrelated business activities not included in line 10b, whether or not the business is regularly carried on.
12
Other income. Do not include gain or loss from the sale of capital assets (Explain in Part IV.)
13
Total support (Add lines 9, 10c, 11 and 12.).
14
First Five Years
If the Form 990 is for the organization's first, second, third, fourth, or fifth tax year as a 501(c)(3) organization,
check this box and stop here.............................................
Section C. Computation of Public Support Percentage
15
Public Support Percentage for 2010 (line 8 column (f) divided by line 13 column (f))
.........
15
16
Public support percentage from 2009 Schedule A, Part III, line 15
...............
16
Section D. Computation of Investment Income Percentage
17
Investment income percentage for 2010 (line 10c column (f) divided by line 13 column (f))
......
17
18
Investment income percentage from 2009 Schedule A, Part III, line 17
.............
18
19a
33 1/3% support tests—2010.
If the organization did not check the box on line 14, and line 15 is more than 33 1/3% and line 17 is not more than 33 1/3%, check this box and stop here. The organization qualifies as a publicly supported organization
..........
b
33 1/3% support tests—2009.
If the organization did not check a box on line 14 or line 19a, and line 16 is more than 33 1/3% and line 18 is not more than 33 1/3%, check this box and stop here. The organization qualifies as a publicly supported organization
....
20
Private Foundation
If the organization did not check a box on line 14, 19a or 19b, check this box and see instructions
.....
Schedule A (Form 990 or 990-EZ) 2010
Schedule A (Form 990 or 990-EZ) 2010
Page 4
Part IV
Supplemental Information.
Supplemental Information. Complete this part to provide the explanation required by Part II, line 10; Part II, line 17a or 17b; or Part III, line 12. Also complete this part for any additional information. (See instructions).
Facts And Circumstances Test
Explanation
Schedule A (Form 990 or 990-EZ) 2010
Additional Data
Software ID:
Software Version:
-
TIN:
SCHEDULE O (Form 990 or 990-EZ)
Department of the Treasury Internal Revenue Service
Supplemental Information to Form 990 or 990-EZ
Complete to provide information for responses to specific questions on
Form 990 or to provide any additional information.
Attach to Form 990 or 990-EZ.
OMB No. 1545-0047
2010
Open to Public Inspection
Name of the organization
NORTH PLATTE NE HOSPITAL CORP DBA GREAT PLAINS REGIONAL MEDICAL CENTER
Employer identification number
47-0662290
Identifier
Return Reference
Explanation
NEW PROGRAM SERVICES
FORM 990, PART III, LINE 2
WEIGHT LOSS MANAGEMENT PROGRAM IS DEDICATED TO HELPING INDIVIDUALS MAKE INFORMED DECISIONS ABOUT WEIGHT LOSS, WHICH INCLUDES SURGICAL AND NON-SURGICAL OPTIONS. THE NON-SURGICAL PROVIDES NUTRITION COUNSELING, DIETARY CLASSES AND EXERCISE MANAGEMENT. THE SURGICAL PROGRAM OFFERS GASTRIC BANDING WITH NUTRITUION/DIETARY MANAGEMENT. IMPLEMENTATION OF MDT (MAGGOT DEBRIDEMENT THERAPY) TO DIABETIC PATIENTS. MIDWEST MEDICAL TRANSPORT LAUNCHED IT NEW HELICOPTER SERVICE. PATIENT COORDINATED CARE - THE INTERDISCIPLINARY PLAN OF CARE FOR PATIENTS AND MONITORING PATIENTS STATUS TOWARD THE OUTCOMES OF CARE. PATIENT SATISFACTION SURVEY THAT USES VOICE RECOGNITION TECHNOLOGY. CONDUCT PHYSICIAN FORUMS THAT PROVIDES FOR THE EXCHANGE OF CLINICAL INFORMATION ACROSS THE STATE AND OFFER MEDICAL PROVIDERS EDUCATIONAL WORKSHOPS TO MEET THEIR CME REQUIREMENTS. PARTNERING WITH THE MID-PLAINS COMMUNITY COLLEGE IN THE IMPLEMENTATION AND DEVELOPMENT OF THE CENTER FOR ENTERPRISE LEARNING. ALSO DURING 2010, THE RAPID RESPONSE TEAM WAS AVAILABLE 24 HOURS PER DAY TEAM TO ASSIST NURSING STAFF AND OTHER MEMBERS OF THE INTERDISCIPLINARY TEAM, PATIENTS, AND FAMILIES WITH CONCERNS REGARDING PEDIATRIC AND ADULT PATIENTS, TO REDUCE THE NUMBER OF CODES OCCURRING OUTSIDE THE ICU AND NUMBER OF EMERGENT TRANSFERS INTO THE ICU, AND TO IDENTIFY AND INITIATE TIMELY TREATMENT OF STROKE AND SEPSIS PATIENTS.
FORM 990, PART VI, SECTION A, LINE 2
DIANN KOLKMAN AND JAMES E. SMITH HAVE A BUSINESS RELATIONSHIP.
FORM 990, PART VI, SECTION A, LINE 3
QUORUM HEALTH RESOURCES (QHR) WAS THE MANAGEMENT COMPANY FOR THE HOSPITAL FROM JANUARY 2010 TO MARCH 2010; THIS RELATIONSHIP WAS TERMINATED. COMMUNITY HOSPITAL CORPORATION (CHC), A CONSULTING FIRM, WAS HIRED IN AN ADVISORY CAPACITY FOR THE BOARD OF DIRECTORS.
FORM 990, PART VI, SECTION B, LINE 11
COPIES OF THE FORM 990 ARE DISTRIBUTED TO THE AUDIT COMMITTEE OF THE BOARD FOR REVIEW. THIS IS DONE VIA THE BOARD PORTAL; FOLLOW UP IS DISCUSSED AT THE NEXT MEETING FOLLOWING THE FILING OF THE FORM 990.
FORM 990, PART VI, SECTION B, LINE 12C
GPRMC PROVIDES A CONFLICT OF INTEREST QUESTIONNAIRE TO EACH OFFICER AND DIRECTOR. THE CONFLICT OF INTEREST QUESTIONNAIRE IS FILLED OUT AND RETURNED ANNUALLY. ANY QUESTIONABLE SITUATION IS DISCLOSED ON THE QUESTIONNAIRE. FURTHERMORE, ANY POTENTIAL CONFLICTS ARISING DURING THE YEAR ARE TO BE REPORTED TO ADMINISTRATION. THERE HAS BEEN A COMMITTEE FORMED CALLED THE CONFLICTS REVIEW COMMITTEE. THE COMMITTEE REVIEWS TRANSACTIONS THAT MAY BE CONSIDERED TO HAVE A CONFLICT OF INTEREST.
FORM 990, PART VI, SECTION B, LINE 15
THE GREAT PLAINS REGIONAL MEDICAL CENTER (GPRMC) BOARD OF DIRECTORS STRIVE TO COMPENSATE OFFICERS AND KEY EMPLOYEES AT LEVELS THAT ARE COMPETITIVE IN THE MARKETPLACE, COST EFFECTIVE AND, AS MUCH AS POSSIBLE, INTERNALLY EQUITABLE. THE EXECUTIVE COMMITTEE FOR THE BOARD OF TRUSTEES MEETS NO LESS THAN ANNUALLY TO REVIEW COMPENSATION PACKAGES FOR GPRMC'S PRESIDENT, OFFICERS, AND KEY EMPLOYEES. COMPENSATION DATA IS GATHERED BY AN INDEPENDENT EXECUTIVE COMPENSATION CONSULTANT BY SURVEY OF COMPARABLE POSITIONS AT PEER INSTITUTIONS ENSURE THAT COMPENSATION PACKAGES ARE MEETING FAIR MARKET VALLEY. A COMPLETE ANALYSIS OF DATA IS REQUESTED AT LEAST EVERY FOUR YEARS. THE INDEPENDENT EXECUTIVE COMPENSATION CONSULTANT IS ULTIMATELY ACCOUNTABLE TO THE EXECUTIVE COMMITTEE AND THE BOARD. THE EXECUTIVE COMMITTEE ANNUALLY RECOMMEND TO THE BOARD THE SELECTION/RETENTION OF THE INDEPENDENT EXECUTIVE COMPENSATION; REVIEWS COMPENSATION RECOMMENDATIONS; AND DETERMINES THOSE OFFICERS AND KEY EMPLOYEES FOR WHOM WRITTEN EMPLOYMENT CONTRACTS WILL BE WRITTEN. THE BOARD OF DIRECTORS HAS THE AUTHORITY TO ANNUALLY AUTHORIZE MANAGEMENT TO PROCEED WITH IMPLEMENTATION OF PROPOSED COMPENSATION OF OFFICERS AND KEY EMPLOYEES.
FORM 990, PART VI, SECTION C, LINE 19
GREAT PLAINS REGIONAL MEDICAL CENTER DOES NOT MAKE ITS CONFLICT OF INTEREST POLICY AND FINANCIAL STATEMENTS AVAILABLE TO THE PUBLIC. UPON WRITTEN REQUEST TO THE CHIEF FINANCIAL OFFICER, GOVERNING DOCUMENTS WILL BE MADE AVAILABLE TO THE PUBLIC FOR REVIEW AT THE HOSPITAL'S ADMINSTRATIVE OFFICE.
FORM 990, PART VII, SECTION A, LINE 1A:
THE BOARD MEMBERS OF GREAT PLAINS REGIONAL MEDICAL CENTER ARE ALSO BOARD MEMBERS FOR GREAT PLAINS MEDICAL ARTS BUILDING, INC. RORIC PAULMAN, DIRECTOR, SERVES ON THE BOARD OF REGENCY RETIREMENT RESIDENCE OF NORTH PLATTE. GREGORY A. NIELSEN, CEO/PRESIDENT, AND LANA WEBSTER, CFO, ALSO SERVE AS CEO/PRESIDENT AND CFO, RESPECTIVELY, FOR GREAT PLAINS MEDICAL ARTS BUILDING, INC.
CHANGES IN NET ASSETS OR FUND BALANCES:
FORM 990, PART XI, LINE 5:
NET UNREALIZED LOSSES ON INVESTMENTS: -265,344. CHANGE IN INTEREST IN GREAT PLAINS HEALTH CARE FOUNDATION 276,810. TRANSFER OF EQUITY FROM AFFILIATE 3,500,000. TOTAL TO FORM 990, PART XI, LINE 5: 3,511,466.
FORM 990, PART XI, LINE 2C:
THE BOARD OF DIRECTORS OF GREAT PLAINS REGIONAL MEDICAL CENTER ASSUMES RESPONSIBILITY FOR OVERSIGHT OF THE AUDIT OF ITS FINANCIAL STATEMENTS AND SELECTION OF AN INDEPENDENT ACCOUNTANT. THIS PROCESS HAS NOT CHANGED FROM PRIOR YEARS.
For Paperwork Reduction Act Notice, see the Instructions for Form 990 or 990-EZ.