TY 2019 Form 990

(A) Name and title	(B) Average hours per week (list any hours for related organizations below dotted line)	(C) Position (do not check more than one box, unless person is both an officer and a director/trustee)	(E) Reportable compensation from related organizations (W-2/1099-MISC)
(1) KEVIN KENNALLY...................................................................... PHYSICIAN	40.0 ................. 0.0			X	342,692	0	43,381
(2) CHRISTIAN TRAMP...................................................................... PHYSICIAN	40.0 ................. 0.0			X	303,282	0	51,221
(3) JAMES LONGABAUGH...................................................................... PHYSICIAN	40.0 ................. 0.0			X	274,092	0	51,598
(4) GREGG WENGER...................................................................... PHYSICIAN	40.0 ................. 0.0			X	250,943	0	40,956
(5) DAVE DELLASEGA...................................................................... PRESIDENT/CEO/DIRECTOR	2.0 ................. 40.0	X	X		0	208,624	33,481
(6) ELIZABETH KROLL...................................................................... APRN/NP	40.0 ................. 0.0			X	168,786	0	30,257
(7) DURREL KELLEY...................................................................... SENIOR VP OF OPERATIONS	2.25 ................. 40.0		X		0	160,492	32,685
(8) LORA KEY...................................................................... ADMINISTRATOR	40.0 ................. 0.0		X		118,076	0	21,307
(9) DAVE RANKIN...................................................................... CHAIRMAN/DIRECTOR	0.25 ................. 2.25	X	X		0	0	0
(10) JOHN TERRILL...................................................................... VICE PRESIDENT/DIRECTOR	0.25 ................. 2.25	X	X		0	0	0
(11) ROBERT HAMILTON...................................................................... SECRETARY/DIRECTOR	0.25 ................. 2.25	X	X		0	0	0
(12) STEVE CARLSON...................................................................... TREASURER/DIRECTOR	0.25 ................. 2.25	X	X		0	0	0
(13) DR BARBARA BROWN APPL...................................................................... DIRECTOR	0.25 ................. 2.25	X			0	0	0
(14) ART HENRICKSON...................................................................... DIRECTOR	0.25 ................. 2.25	X			0	0	0
(15) CHARLES WESTIN...................................................................... DIRECTOR	0.25 ................. 2.25	X			0	0	0

(A) Name and business address	(B) Description of services	(C) Compensation
GREAT PLAINS HEALTH ALLIANCE, 250 N ROCK ROAD WICHITA,KS67206	MANAGEMENT AND CBO	790,031
STORMONT-VAIL HEALTH, 1500 SW 10TH ST TOPEKA,KS66604	REFERENCE LAB	153,607
SHARED MEDICAL SERVICES, 209 LIMESTONE PASS COTTAGE GROVE,WI53527	MRI SERVICES	129,720
STARS INC, 201 S 4TH ST HIAWATHA,KS66434	PHYSICAL THERAPISTS	114,237

2 Total number of independent contractors (including but not limited to those listed above) who received more than $100,000 of compensation from the organization 4

- TIN:

SCHEDULE A
(Form 990 or 990EZ)

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.
right arrow

Attach to Form 990 or Form 990-EZ.
right arrow

Go to www.irs.gov/Form990 for instructions and the latest information.

OMB No. 1545-0047

2019

Open to Public
Inspection

Name of the organization

GREAT PLAINS OF SABETHA INC

Employer identification number

48-1236156

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 12, check only one box.)

A church, convention of churches, or association of churches described in section 170(b)(1)(A)(i).

A school described in section 170(b)(1)(A)(ii). (Attach Schedule E (Form 990 or 990-EZ).)

A hospital or a cooperative hospital service organization described in section 170(b)(1)(A)(iii).

A medical research organization operated in conjunction with a hospital described in section 170(b)(1)(A)(iii). Enter the hospital's name, city, and state:

An organization operated for the benefit of a college or university owned or operated by a governmental unit described in section 170(b)(1)(A)(iv). (Complete Part II.)

A federal, state, or local government or governmental unit described in section 170(b)(1)(A)(v).

An organization that normally receives a substantial part of its support from a governmental unit or from the general public described in section 170(b)(1)(A)(vi). (Complete Part II.)

A community trust described in section 170(b)(1)(A)(vi). (Complete Part II.)

An agricultural research organization described in 170(b)(1)(A)(ix) operated in conjunction with a land-grant college or university or a non-land grant college of agriculture. See instructions. Enter the name, city, and state of the college or university:

An organization that normally receives: (1) more than 331/3% of its support from contributions, membership fees, and gross 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.)

An organization organized and operated exclusively to test for public safety. See section 509(a)(4).

An organization organized and operated exclusively for the benefit of, to perform the functions of, or to carry out the purposes of one or more publicly supported organizations described in section 509(a)(1) or section 509(a)(2). See section 509(a)(3). Check the box in lines 12a through 12d that describes the type of supporting organization and complete lines 12e, 12f, and 12g.

Type I. A supporting organization operated, supervised, or controlled by its supported organization(s), typically by giving the supported organization(s) the power to regularly appoint or elect a majority of the directors or trustees of the supporting organization. You must complete Part IV, Sections A and B.

Type II. A supporting organization supervised or controlled in connection with its supported organization(s), by having control or management of the supporting organization vested in the same persons that control or manage the supported organization(s). You must complete Part IV, Sections A and C.

Type III functionally integrated. A supporting organization operated in connection with, and functionally integrated with, its supported organization(s) (see instructions). You must complete Part IV, Sections A, D, and E.

Type III non-functionally integrated. A supporting organization operated in connection with its supported organization(s) that is not functionally integrated. The organization generally must satisfy a distribution requirement and an attentiveness requirement (see instructions). You must complete Part IV, Sections A and D, and Part V.

Check this box if the organization received a written determination from the IRS that it is a Type I, Type II, Type III functionally integrated, or Type III non-functionally integrated supporting organization.

Enter the number of supported organizations ...............................

Provide the following information about the supported organization(s).

(i) Name of supported organization	(ii) EIN	(iv) Is the organization listed in your governing document?		(v) Amount of monetary support (see instructions)	(vi) Amount of other support (see instructions)
(i) Name of supported organization	(ii) EIN	Yes	No	(v) Amount of monetary support (see instructions)	(vi) Amount of other support (see instructions)


Total

For Paperwork Reduction Act Notice, see the Instructions for
Form 990 or 990-EZ.

Cat. No. 11285F

Schedule A (Form 990 or 990-EZ) 2019

Page 2

Part II

Support Schedule for Organizations Described in Sections 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 failed to qualify under the tests listed below, please complete Part III.)

Section A. Public Support

Calendar year (or fiscal year beginning in)		(a) 2015	(b) 2016	(c) 2017	(d) 2018	(e) 2019	(f) Total
1	Gifts, grants, contributions, and membership fees received. (Do not include any "unusual grant.") ..
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) 2015	(b) 2016	(c) 2017	(d) 2018	(e) 2019	(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. Do not include gain or loss from the sale of capital assets (Explain in Part VI.)..
11	Total support. Add lines 7 through 10

Gross receipts from related activities, etc. (see instructions) ..................

First five years. If the Form 990 is for the organization's first, second, third, fourth, or fifth tax year as a section 501(c)(3) organization, check this box and stop here........................................ right arrow

Section C. Computation of Public Support Percentage

Public support percentage for 2019 (line 6, column (f) divided by line 11, column (f)) .........

Public support percentage for 2018 Schedule A, Part II, line 14 ...............

16a

33 1/3% support test—2019. 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 ....................... right arrow

33 1/3% support test—2018. If the organization did not check a 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 ..................... right arrow

17a

10%-facts-and-circumstances test—2019. 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 VI how the organization meets the "facts-and-circumstances" test. The organization qualifies as a publicly supported
organization ..................................................... right arrow

10%-facts-and-circumstances test—2018. 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 VI how the organization meets the "facts-and-circumstances" test. The organization qualifies as a publicly
supported organization ................................................ right arrow

Private foundation. If the organization did not check a box on line 13, 16a, 16b, 17a, or 17b, check this box and see
instructions ..................................................... right arrow

Schedule A (Form 990 or 990-EZ) 2019

Page 3

Part III

Support Schedule for Organizations Described in Section 509(a)(2)
(Complete only if you checked the box on line 10 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) 2015	(b) 2016	(c) 2017	(d) 2018	(e) 2019	(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) 2015	(b) 2016	(c) 2017	(d) 2018	(e) 2019	(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 VI.) ..
13	Total support. (Add lines 9, 10c, 11, and 12.)..

First five years. If the Form 990 is for the organization's first, second, third, fourth, or fifth tax year as a section 501(c)(3) organization,
check this box and stop here............................................. right arrow

Section C. Computation of Public Support Percentage

Public support percentage for 2019 (line 8, column (f) divided by line 13, column (f)) .........

Public support percentage from 2018 Schedule A, Part III, line 15 ...............

Section D. Computation of Investment Income Percentage

Investment income percentage for 2019 (line 10c, column (f) divided by line 13, column (f)) ......

Investment income percentage from 2018 Schedule A, Part III, line 17 .............

19a

331/3% support tests—2019. 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 ....... right arrow

33 1/3% support tests—2018. 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 .... right arrow

Private foundation. If the organization did not check a box on line 14, 19a, or 19b, check this box and see instructions .... right arrow

Schedule A (Form 990 or 990-EZ) 2019

Page 4

Part IV

Supporting Organizations

(Complete only if you checked a box on line 12 of Part I. If you checked 12a of Part I, complete Sections A and B. If you checked 12b of Part I, complete Sections A and C. If you checked 12c of Part I, complete Sections A, D, and E. If you checked 12d of Part I, complete Sections A and D, and complete Part V.)

Section A. All Supporting Organizations

Yes

Are all of the organization’s supported organizations listed by name in the organization’s governing documents?
If "No," describe in Part VI how the supported organizations are designated. If designated by class or purpose,
describe the designation. If historic and continuing relationship, explain.

Did the organization have any supported organization that does not have an IRS determination of status under section 509(a)(1) or (2)? If "Yes," explain in Part VI how the organization determined that the supported organization was described in section 509(a)(1) or (2).

Did the organization have a supported organization described in section 501(c)(4), (5), or (6)? If "Yes," answer (b) and (c) below.

Did the organization confirm that each supported organization qualified under section 501(c)(4), (5), or (6) and satisfied the public support tests under section 509(a)(2)? If "Yes," describe in Part VI when and how the organization made the determination.

Did the organization ensure that all support to such organizations was used exclusively for section 170(c)(2)(B) purposes? If "Yes," explain in Part VI what controls the organization put in place to ensure such use.

Was any supported organization not organized in the United States ("foreign supported organization")? If “Yes” and if you checked 12a or 12b in Part I, answer (b) and (c) below.

Did the organization have ultimate control and discretion in deciding whether to make grants to the foreign supported organization? If “Yes,” describe in Part VI how the organization had such control and discretion despite being controlled or supervised by or in connection with its supported organizations.

Did the organization support any foreign supported organization that does not have an IRS determination under sections 501(c)(3) and 509(a)(1) or (2)? If “Yes,” explain in Part VI what controls the organization used to ensure that all support to the foreign supported organization was used exclusively for section 170(c)(2)(B) purposes.

Did the organization add, substitute, or remove any supported organizations during the tax year? If “Yes,” answer (b) and (c) below (if applicable). Also, provide detail in Part VI, including (i) the names and EIN numbers of the supported organizations added, substituted, or removed; (ii) the reasons for each such action; (iii) the authority under the organization's organizing document authorizing such action; and (iv) how the action was accomplished (such as by amendment to the organizing document).

Type I or Type II only. Was any added or substituted supported organization part of a class already designated in the organization's organizing document?

Substitutions only. Was the substitution the result of an event beyond the organization's control?

Did the organization provide support (whether in the form of grants or the provision of services or facilities) to anyone other than (i) its supported organizations, (ii) individuals that are part of the charitable class benefited by one or more of its supported organizations, or (iii) other supporting organizations that also support or benefit one or more of the filing organization’s supported organizations? If “Yes,” provide detail in Part VI.

Did the organization provide a grant, loan, compensation, or other similar payment to a substantial contributor (defined in section 4958(c)(3)(C)), a family member of a substantial contributor, or a 35% controlled entity with regard to a substantial contributor? If “Yes,” complete Part I of Schedule L (Form 990 or 990-EZ) .

Did the organization make a loan to a disqualified person (as defined in section 4958) not described in line 7? If “Yes,” complete Part I of Schedule L (Form 990 or 990-EZ).

Was the organization controlled directly or indirectly at any time during the tax year by one or more disqualified persons as defined in section 4946 (other than foundation managers and organizations described in section 509(a)(1) or (2))? If “Yes,” provide detail in Part VI.

Did one or more disqualified persons (as defined in line 9a) hold a controlling interest in any entity in which the supporting organization had an interest? If “Yes,” provide detail in Part VI.

Did a disqualified person (as defined in line 9a) have an ownership interest in, or derive any personal benefit from, assets in which the supporting organization also had an interest? If “Yes,” provide detail in Part VI.

10a

Was the organization subject to the excess business holdings rules of section 4943 because of section 4943(f) (regarding certain Type II supporting organizations, and all Type III non-functionally integrated supporting organizations)? If “Yes,” answer line 10b below.

10a

Did the organization have any excess business holdings in the tax year? (Use Schedule C, Form 4720, to determine whether the organization had excess business holdings).

10b

Schedule A (Form 990 or 990-EZ) 2019

Page 5

Part IV

Supporting Organizations (continued)

Yes

Has the organization accepted a gift or contribution from any of the following persons?

A person who directly or indirectly controls, either alone or together with persons described in (b) and (c) below, the governing body of a supported organization?

11a

A family member of a person described in (a) above?

11b

A 35% controlled entity of a person described in (a) or (b) above? If “Yes” to a, b, or c, provide detail in Part VI.

11c

Section B. Type I Supporting Organizations

Yes

Did the directors, trustees, or membership of one or more supported organizations have the power to regularly appoint or elect at least a majority of the organization’s directors or trustees at all times during the tax year? If “No,” describe in Part VI how the supported organization(s) effectively operated, supervised, or controlled the organization’s activities. If the organization had more than one supported organization, describe how the powers to appoint and/or remove directors or trustees were allocated among the supported organizations and what conditions or restrictions, if any, applied to such powers during the tax year.

Did the organization operate for the benefit of any supported organization other than the supported organization(s) that operated, supervised, or controlled the supporting organization? If “Yes,” explain in Part VI how providing such benefit carried out the purposes of the supported organization(s) that operated, supervised or controlled the supporting organization.

Section C. Type II Supporting Organizations

Yes

Were a majority of the organization’s directors or trustees during the tax year also a majority of the directors or trustees of each of the organization’s supported organization(s)? If “No,” describe in Part VI how control or management of the supporting organization was vested in the same persons that controlled or managed the supported organization(s).

Section D. All Type III Supporting Organizations

Yes

Did the organization provide to each of its supported organizations, by the last day of the fifth month of the organization’s tax year, (i) a written notice describing the type and amount of support provided during the prior tax year, (ii) a copy of the Form 990 that was most recently filed as of the date of notification, and (iii) copies of the organization’s governing documents in effect on the date of notification, to the extent not previously provided?

Were any of the organization’s officers, directors, or trustees either (i) appointed or elected by the supported organization(s) or (ii) serving on the governing body of a supported organization? If "No," explain in Part VI how the organization maintained a close and continuous working relationship with the supported organization(s).

By reason of the relationship described in (2), did the organization’s supported organizations have a significant voice in the organization’s investment policies and in directing the use of the organization’s income or assets at all times during the tax year? If "Yes," describe in Part VI the role the organization’s supported organizations played in this regard.

Section E. Type III Functionally-Integrated Supporting Organizations

Check the box next to the method that the organization used to satisfy the Integral Part Test during the year (see instructions):

The organization satisfied the Activities Test. Complete line 2 below.

The organization is the parent of each of its supported organizations. Complete line 3 below.

The organization supported a governmental entity. Describe in Part VI how you supported a government entity (see instructions)

Activities Test. Answer (a) and (b) below.

Yes

Did substantially all of the organization’s activities during the tax year directly further the exempt purposes of the supported organization(s) to which the organization was responsive? If "Yes," then in Part VI identify those supported organizations and explain how these activities directly furthered their exempt purposes, how the organization was responsive to those supported organizations, and how the organization determined that these activities constituted substantially all of its activities.

Did the activities described in (a) constitute activities that, but for the organization’s involvement, one or more of the organization’s supported organization(s) would have been engaged in? If "Yes," explain in Part VI the reasons for the organization’s position that its supported organization(s) would have engaged in these activities but for the organization’s involvement.

Parent of Supported Organizations. Answer (a) and (b) below.

Did the organization have the power to regularly appoint or elect a majority of the officers, directors, or trustees of each of the supported organizations? Provide details in Part VI.

Did the organization exercise a substantial degree of direction over the policies, programs and activities of each of its supported organizations? If "Yes," describe in Part VI. the role played by the organization in this regard.

Schedule A (Form 990 or 990-EZ) 2019

Page 6

Part V

Type III Non-Functionally Integrated 509(a)(3) Supporting Organizations

Check here if the organization satisfied the Integral Part Test as a qualifying trust on Nov. 20, 1970 (explain in Part VI). See instructions. All other Type III non-functionally integrated supporting organizations must complete Sections A through E.

	Section A - Adjusted Net Income		(A) Prior Year	(B) Current Year (optional)
1	Net short-term capital gain	1
2	Recoveries of prior-year distributions	2
3	Other gross income (see instructions)	3
4	Add lines 1 through 3	4
5	Depreciation and depletion	5
6	Portion of operating expenses paid or incurred for production or collection of gross income or for management, conservation, or maintenance of property held for production of income (see instructions)	6
7	Other expenses (see instructions)	7
8	Adjusted Net Income (subtract lines 5, 6 and 7 from line 4)	8

	Section B - Minimum Asset Amount		(A) Prior Year	(B) Current Year (optional)
1	Aggregate fair market value of all non-exempt-use assets (see instructions for short tax year or assets held for part of year):	1
a	Average monthly value of securities	1a
b	Average monthly cash balances	1b
c	Fair market value of other non-exempt-use assets	1c
d	Total (add lines 1a, 1b, and 1c)	1d
e	Discount claimed for blockage or other factors (explain in detail in Part VI):
2	Acquisition indebtedness applicable to non-exempt use assets	2
3	Subtract line 2 from line 1d	3
4	Cash deemed held for exempt use. Enter 1-1/2% of line 3 (for greater amount, see instructions).	4
5	Net value of non-exempt-use assets (subtract line 4 from line 3)	5
6	Multiply line 5 by .035	6
7	Recoveries of prior-year distributions	7
8	Minimum Asset Amount (add line 7 to line 6)	8

	Section C - Distributable Amount		Current Year
1	Adjusted net income for prior year (from Section A, line 8, Column A)	1
2	Enter 85% of line 1	2
3	Minimum asset amount for prior year (from Section B, line 8, Column A)	3
4	Enter greater of line 2 or line 3	4
5	Income tax imposed in prior year	5
6	Distributable Amount. Subtract line 5 from line 4, unless subject to emergency temporary reduction (see instructions)	6

Check here if the current year is the organization's first as a non-functionally-integrated Type III supporting organization (see instructions)

Schedule A (Form 990 or 990-EZ) 2019

Page 7

Part V

Type III Non-Functionally Integrated 509(a)(3) Supporting Organizations(continued)

Section D - Distributions		Current Year
1 Amounts paid to supported organizations to accomplish exempt purposes
2 Amounts paid to perform activity that directly furthers exempt purposes of supported organizations, in excess of income from activity
3 Administrative expenses paid to accomplish exempt purposes of supported organizations
4 Amounts paid to acquire exempt-use assets
5 Qualified set-aside amounts (prior IRS approval required)
6 Other distributions (describe in Part VI). See instructions
7Total annual distributions. Add lines 1 through 6.
8 Distributions to attentive supported organizations to which the organization is responsive (provide details in Part VI). See instructions
9 Distributable amount for 2019 from Section C, line 6
10 Line 8 amount divided by Line 9 amount

Section E - Distribution Allocations (see instructions)		(i) Excess Distributions	(ii) Underdistributions Pre-2019	(iii) Distributable Amount for 2019
1 Distributable amount for 2019 from Section C, line 6
2 Underdistributions, if any, for years prior to 2019 (reasonable cause required-- explain in Part VI). See instructions.
3 Excess distributions carryover, if any, to 2019:
a From 2014.......
b From 2015.......
c From 2016.......
d From 2017.......
e From 2018.......
fTotal of lines 3a through e
g Applied to underdistributions of prior years
h Applied to 2019 distributable amount
i Carryover from 2014 not applied (see instructions)
j Remainder. Subtract lines 3g, 3h, and 3i from 3f.
4Distributions for 2019 from Section D, line 7:
$
a Applied to underdistributions of prior years
b Applied to 2019 distributable amount
c Remainder. Subtract lines 4a and 4b from 4.
5 Remaining underdistributions for years prior to 2019, if any. Subtract lines 3g and 4a from line 2. If the amount is greater than zero, explain in Part VI. See instructions.
6 Remaining underdistributions for 2019. Subtract lines 3h and 4b from line 1. If the amount is greater than zero, explain in Part VI. See instructions.
7 Excess distributions carryover to 2020. Add lines 3j and 4c.
8 Breakdown of line 7:
a Excess from 2015.....
b Excess from 2016.....
c Excess from 2017.....
d Excess from 2018.....
e Excess from 2019.....

Schedule A (Form 990 or 990-EZ) (2019)

Schedule A (Form 990 or 990-EZ) 2019

Page 8

Part VI

Supplemental Information. Provide the explanations required by Part II, line 10; Part II, line 17a or 17b; Part III, line 12; Part IV, Section A, lines 1, 2, 3b, 3c, 4b, 4c, 5a, 6, 9a, 9b, 9c, 11a, 11b, and 11c; Part IV, Section B, lines 1 and 2; Part IV, Section C, line 1; Part IV, Section D, lines 2 and 3; Part IV, Section E, lines 1c, 2a, 2b, 3a and 3b; Part V, line 1; Part V, Section B, line 1e; Part V Section D, lines 5, 6, and 8; and Part V, Section E, lines 2, 5, and 6. Also complete this part for any additional information. (See instructions).

Facts And Circumstances Test

Return Reference	Explanation

Schedule A (Form 990 or 990-EZ) 2019

Additional Data

Software ID:
Software Version:

- TIN:

Schedule B
(Form 990, 990-EZ,
or 990-PF)

Department of the Treasury
Internal Revenue Service

Schedule of Contributors

Attach to Form 990, 990-EZ, or 990-PF.

Go to www.irs.gov/Form990 for the latest information.

OMB No. 1545-0047

2019

Name of the organization

GREAT PLAINS OF SABETHA INC

Employer identification number

48-1236156

Organization type (check one):

Filers of:

Section:

Form 990 or 990-EZ

501(c)( ) (enter number) organization

4947(a)(1) nonexempt charitable trust not treated as a private foundation

527 political organization

Form 990-PF

501(c)(3) exempt private foundation

4947(a)(1) nonexempt charitable trust treated as a private foundation

501(c)(3) taxable private foundation

Check if your organization is covered by the General Rule or a Special Rule.
Note: Only a section 501(c)(7), (8), or (10) organization can check boxes for both the General Rule and a Special Rule. See instructions.

General Rule

For an organization filing Form 990, 990-EZ, or 990-PF that received, during the year, contributions totaling $5,000 or more (in money or other property) from any one contributor. Complete Parts I and II. See instructions for determining a contributor's total contributions.

Special Rules

For an organization described in section 501(c)(3) filing Form 990 or 990-EZ that met the 33¹/3% support test of the regulations
under sections 509(a)(1) and 170(b)(1)(A)(vi), that checked Schedule A (Form 990 or 990-EZ), Part II, line 13, 16a, or 16b, and that received from any one contributor, during the year, total contributions of the greater of (1) $5,000 or (2) 2% of the amount on (i) Form 990, Part VIII, line 1h, or (ii) Form 990-EZ, line 1. Complete Parts I and II.

For an organization described in section 501(c)(7), (8), or (10) filing Form 990 or 990-EZ that received from any one contributor,
during the year, total contributions of more than $1,000 exclusively for religious, charitable, scientific, literary, or educational purposes, or for the prevention of cruelty to children or animals. Complete Parts I, II, and III.

For an organization described in section 501(c)(7), (8), or (10) filing Form 990 or 990-EZ that received from any one contributor,
during the year, contributions exclusively for religious, charitable, etc., purposes, but no such contributions totaled more than $1,000. If this box is checked, enter here the total contributions that were received during the year for an exclusively religious, charitable, etc., purpose. Don't complete any of the parts unless the General Rule applies to this organization because it received nonexclusively religious, charitable, etc., contributions totaling $5,000 or more during the year ......... Arrow Bullet

Caution: An organization that isn't covered by the General Rule and/or the Special Rules doesn't file Schedule B (Form 990,
990-EZ, or 990-PF), but it must answer “No” on Part IV, line 2, of its Form 990; or check the box on line H of its Form 990-EZ
or on its Form 990PF, Part I, line 2, to certify that it doesn't meet the filing requirements of Schedule B (Form 990,
990-EZ, or 990-PF).

For Paperwork Reduction Act Notice, see the Instructions
for Form 990, 990-EZ, or 990-PF.

Cat. No. 30613XSchedule B (Form 990, 990-EZ, or 990-PF) (2019)

Schedule B (Form 990, 990-EZ, or 990-PF) (2019) Page 2

Name of organization GREAT PLAINS OF SABETHA INC

Part I Contributors	Contributors (see instructions). Use duplicate copies of Part I if additional space is needed.
(a) No.	(b) Name, address, and ZIP + 4	(c) Total contributions	(d) Type of contribution
RESTRICTED	,	$ RESTRICTED	Person Payroll Noncash (Complete Part II for noncash contributions.)
(a) No.	(b) Name, address, and ZIP + 4	(c) Total contributions	(d) Type of contribution
		$	Person Payroll Noncash (Complete Part II for noncash contributions.)
(a) No.	(b) Name, address, and ZIP + 4	(c) Total contributions	(d) Type of contribution
		$	Person Payroll Noncash (Complete Part II for noncash contributions.)
(a) No.	(b) Name, address, and ZIP + 4	(c) Total contributions	(d) Type of contribution
		$	Person Payroll Noncash (Complete Part II for noncash contributions.)
(a) No.	(b) Name, address, and ZIP + 4	(c) Total contributions	(d) Type of contribution
		$	Person Payroll Noncash (Complete Part II for noncash contributions.)
(a) No.	(b) Name, address, and ZIP + 4	(c) Total contributions	(d) Type of contribution
		$	Person Payroll Noncash (Complete Part II for noncash contributions.)
Schedule B (Form 990, 990-EZ, or 990-PF) (2019)

Schedule B (Form 990, 990-EZ, or 990-PF) (2019)

Page 3

Name of organization GREAT PLAINS OF SABETHA INC		Employer identification number 48-1236156

Part II	Noncash Property (see instructions). Use duplicate copies of Part II if additional space is needed.
(a) No. from Part I	(b) Description of noncash property given	(c) FMV (or estimate) (See instructions)	(d) Date received
		$
(a) No. from Part I	(b) Description of noncash property given	(c) FMV (or estimate) (See instructions)	(d) Date received
		$
(a) No. from Part I	(b) Description of noncash property given	(c) FMV (or estimate) (See instructions)	(d) Date received
		$
(a) No. from Part I	(b) Description of noncash property given	(c) FMV (or estimate) (See instructions)	(d) Date received
		$
(a) No. from Part I	(b) Description of noncash property given	(c) FMV (or estimate) (See instructions)	(d) Date received
		$
(a) No. from Part I	(b) Description of noncash property given	(c) FMV (or estimate) (See instructions)	(d) Date received
		$
Schedule B (Form 990, 990-EZ, or 990-PF) (2019)

Schedule B (Form 990, 990-EZ, or 990-PF) (2019)

Page 4


Name of organization GREAT PLAINS OF SABETHA INC			Employer identification number 48-1236156
Part III Exclusively religious, charitable, etc., contributions to organizations described in section 501(c)(7), (8), or (10) that total more than $1,000 for the year from any one contributor. Complete columns (a) through (e) and the following line entry. For organizations completing Part III, enter the total of exclusively religious, charitable, etc., contributions of $1,000 or less for the year. (Enter this information once. See instructions.) $ Use duplicate copies of Part III if additional space is needed.

(a)
No. from Part I

(b) Purpose of gift

(d) Description of how gift is held

(e) Transfer of gift
Transferee's name, address, and ZIP 4	Relationship of transferor to transferee

(a)
No. from Part I

(b) Purpose of gift

(d) Description of how gift is held

(e) Transfer of gift
Transferee's name, address, and ZIP 4	Relationship of transferor to transferee

(a)
No. from Part I

(b) Purpose of gift

(d) Description of how gift is held

(e) Transfer of gift
Transferee's name, address, and ZIP 4	Relationship of transferor to transferee

(a)
No. from Part I

(b) Purpose of gift

(d) Description of how gift is held

(e) Transfer of gift
Transferee's name, address, and ZIP 4	Relationship of transferor to transferee

Schedule B (Form 990, 990-EZ, or 990-PF) (2019)

Additional Data

Software ID:
Software Version:

- TIN:

SCHEDULE C
(Form 990 or 990-EZ)

Department of the Treasury
Internal Revenue Service

Political Campaign and Lobbying Activities

For Organizations Exempt From Income Tax Under section 501(c) and section 527

SchCMd Bullet

Complete if the organization is described below. SchCMd Bullet

Attach to Form 990 or Form 990-EZ.
SchCMd Bullet

Go to www.irs.gov/Form990 for instructions and the latest information.

OMB No. 1545-0047

2019

Open to Public
Inspection

If the organization answered "Yes" on Form 990, Part IV, Line 3, or Form 990-EZ, Part V, line 46 (Political Campaign Activities), then
Round Bullet

Section 501(c)(3) organizations: Complete Parts I-A and B. Do not complete Part I-C.
Round Bullet

Section 501(c) (other than section 501(c)(3)) organizations: Complete Parts I-A and C below. Do not complete Part I-B.
Round Bullet

Section 527 organizations: Complete Part I-A only.
If the organization answered "Yes" on Form 990, Part IV, Line 4, or Form 990-EZ, Part VI, line 47 (Lobbying Activities), then
Round Bullet

Section 501(c)(3) organizations that have filed Form 5768 (election under section 501(h)): Complete Part II-A. Do not complete Part II-B.
Round Bullet

Section 501(c)(3) organizations that have NOT filed Form 5768 (election under section 501(h)): Complete Part II-B. Do not complete Part II-A.
If the organization answered "Yes" on Form 990, Part IV, Line 5 (Proxy Tax) (see separate instructions) or Form 990-EZ, Part V, line 35c (Proxy Tax) (see separate instructions), then
Round Bullet

Section 501(c)(4), (5), or (6) organizations: Complete Part III.

Name of the organization

GREAT PLAINS OF SABETHA INC

Employer identification number

48-1236156

Part I-A

Complete if the organization is exempt under section 501(c) or is a section 527 organization.

Provide a description of the organization’s direct and indirect political campaign activities in Part IV (see instructions for definition of “political campaign activities")

Political campaign activity expenditures (see instructions) .................................................................... SchCMd Bullet

Volunteer hours for political campaign activities (see instructions) ..................................................................

Part I-B

Complete if the organization is exempt under section 501(c)(3).

Enter the amount of any excise tax incurred by the organization under section 4955 ................................ SchCMd Bullet

Enter the amount of any excise tax incurred by organization managers under section 4955 ....................... SchCMd Bullet

If the organization incurred a section 4955 tax, did it file Form 4720 for this year? .........................................

Yes No

Was a correction made? ......................................................................................................................

Yes No

If "Yes," describe in Part IV.

Part I-C

Complete if the organization is exempt under section 501(c), except section 501(c)(3).

Enter the amount directly expended by the filing organization for section 527 exempt function activities ..... SchCMd Bullet

Enter the amount of the filing organization's funds contributed to other organizations for section 527 exempt function activities ............................................................................................................................ SchCMd Bullet

Total exempt function expenditures. Add lines 1 and 2. Enter here and on Form 1120-POL, line 17b........... SchCMd Bullet

Did the filing organization file Form 1120-POL for this year? ...................................................................

Yes No

Enter the names, addresses and employer identification number (EIN) of all section 527 political organizations to which the filing
organization made payments. For each organization listed, enter the amount paid from the filing organization’s funds. Also enter the amount of political contributions received that were promptly and directly delivered to a separate political organization, such as a separate segregated fund or a political action committee (PAC). If additional space is needed, provide information in Part IV.

(a) Name	(b) Address	(c) EIN	(d) Amount paid from filing organization's funds. If none, enter -0-.	(e) Amount of political contributions received and promptly and directly delivered to a separate political organization. If none, enter -0-.
1
2
3
4
5
6

For Paperwork Reduction Act Notice, see the instructions for Form 990 or 990-EZ.

Cat. No. 50084S

Schedule C (Form 990 or 990-EZ) 2019

Page 2

Part II-A

Complete if the organization is exempt under section 501(c)(3) and filed Form 5768 (election under section 501(h)).

A Check SchCMd Bullet

if the filing organization belongs to an affiliated group (and list in Part IV each affiliated group member's name, address, EIN, expenses, and share of excess lobbying expenditures).
B Check SchCMd Bullet

if the filing organization checked box A and "limited control" provisions apply.

Limits on Lobbying Expenditures (The term "expenditures" means amounts paid or incurred.)		(b) Affiliated group totals
1a	Total lobbying expenditures to influence public opinion (grass roots lobbying) ......................
b	Total lobbying expenditures to influence a legislative body (direct lobbying) ........................
c	Total lobbying expenditures (add lines 1a and 1b) ............................................................
d	Other exempt purpose expenditures ...............................................................................
e	Total exempt purpose expenditures (add lines 1c and 1d) ..................................................
f	Lobbying nontaxable amount. Enter the amount from the following table in both columns.
	If the amount on line 1e, column (a) or (b) is:The lobbying nontaxable amount is:
	Not over $500,00020% of the amount on line 1e.
	Over $500,000 but not over $1,000,000$100,000 plus 15% of the excess over $500,000.
	Over $1,000,000 but not over $1,500,000$175,000 plus 10% of the excess over $1,000,000.
	Over $1,500,000 but not over $17,000,000$225,000 plus 5% of the excess over $1,500,000.
	Over $17,000,000$1,000,000.

g	Grassroots nontaxable amount (enter 25% of line 1f) .................................................
h	Subtract line 1g from line 1a. If zero or less, enter -0-. ................................................
i	Subtract line 1f from line 1c. If zero or less, enter -0-. ................................................
j	If there is an amount other than zero on either line 1h or line 1i, did the organization file Form 4720 reporting section 4911 tax for this year? ...................................................................................................................	Yes No

4-Year Averaging Period Under Section 501(h) (Some organizations that made a section 501(h) election do not have to complete all of the five columns below. See the separate instructions for lines 2a through 2f.)
Lobbying Expenditures During 4-Year Averaging Period
	Calendar year (or fiscal year beginning in)	(a) 2016	(b) 2017	(c) 2018	(d) 2019	(e) Total

2a	Lobbying nontaxable amount

b	Lobbying ceiling amount (150% of line 2a, column(e))

c	Total lobbying expenditures

d	Grassroots nontaxable amount

e	Grassroots ceiling amount (150% of line 2d, column (e))

f	Grassroots lobbying expenditures

Schedule C (Form 990 or 990-EZ) 2019

Page 3

Part II-B

Complete if the organization is exempt under section 501(c)(3) and has NOT filed Form 5768 (election under section 501(h)).

For each "Yes" response on lines 1a through 1i below, provide in Part IV a detailed description of the lobbying activity.

(a)

Yes|No

(b)

Amount

During the year, did the filing organization attempt to influence foreign, national, state or local legislation, including any attempt to influence public opinion on a legislative matter or referendum, through the use of:

Volunteers? ...........................................................................................................

Paid staff or management (include compensation in expenses reported on lines 1c through 1i)? ........

Media advertisements? ...................................................................................................

Mailings to members, legislators, or the public? .............................................................................

Publications, or published or broadcast statements? ...........................................................

Grants to other organizations for lobbying purposes? ..........................................................

Yes

3,061

Direct contact with legislators, their staffs, government officials, or a legislative body? .......................

Rallies, demonstrations, seminars, conventions, speeches, lectures, or any similar means? ..................

Other activities? ...................................................................................................................

Total. Add lines 1c through 1i ....................................................................................................

3,061

Did the activities in line 1 cause the organization to be not described in section 501(c)(3)? .....

If "Yes," enter the amount of any tax incurred under section 4912 ...........................................

If "Yes," enter the amount of any tax incurred by organization managers under section 4912 ...................

If the filing organization incurred a section 4912 tax, did it file Form 4720 for this year? ........................

Part III-A

Complete if the organization is exempt under section 501(c)(4), section 501(c)(5), or section 501(c)(6).

Yes

Were substantially all (90% or more) dues received nondeductible by members? ...............................................

Did the organization make only in-house lobbying expenditures of $2,000 or less? ............................................

Did the organization agree to carry over lobbying and political expenditures from the prior year? .................................

Part III-B

Complete if the organization is exempt under section 501(c)(4), section 501(c)(5), or section 501(c)(6) and if either (a) BOTH Part III-A, lines 1 and 2, are answered "No" OR (b) Part III-A, line 3, is answered “Yes."

Dues, assessments and similar amounts from members ......................................................................

Section 162(e) nondeductible lobbying and political expenditures (do not include amounts of political expenses for which the section 527(f) tax was paid).

Current year .............................................................................................................................

Carryover from last year ............................................................................................................

Total ...........................................................................................................................................

Aggregate amount reported in section 6033(e)(1)(A) notices of nondeductible section 162(e) dues .

If notices were sent and the amount on line 2c exceeds the amount on line 3, what portion of the excess does the organization agree to carryover to the reasonable estimate of nondeductible lobbying and political expenditure next year? ......................................................................................................................

Taxable amount of lobbying and political expenditures (see instructions) .........................................

Part IV

Supplemental Information

Provide the descriptions required for Part l-A, line 1; Part l-B, line 4; Part l-C, line 5; Part II-A (affiliated group list); Part II-A, lines 1 and 2 (see instructions), and Part ll-B, line 1. Also, complete this part for any additional information.

Return Reference	Explanation
SCHEDULE C, PART II-B, LINE 1F	A PORTION OF THE ANNUAL DUES PAID TO KHA AND AHA ARE USED FOR LOBBYING.

Schedule C (Form 990 or 990EZ) 2019

Additional Data

Software ID:
Software Version:

- TIN:

SCHEDULE D
(Form 990)

Department of the Treasury
Internal Revenue Service

Supplemental Financial Statements

Complete if the organization answered "Yes," on Form 990,
Part IV, line 6, 7, 8, 9, 10, 11a, 11b, 11c, 11d, 11e, 11f, 12a, or 12b.
SchDMd Bullet

Attach to Form 990.
SchDMd Bullet

Go to www.irs.gov/Form990 for instructions and the latest information.

OMB No. 1545-0047

2019

Open to Public Inspection

Name of the organization

GREAT PLAINS OF SABETHA INC

Employer identification number

48-1236156

Part I

Organizations Maintaining Donor Advised Funds or Other Similar Funds or Accounts. Complete if the organization answered "Yes" on Form 990, Part IV, line 6.

		(a) Donor advised funds	(b) Funds and other accounts
1	Total number at end of year .........
2	Aggregate value of contributions to (during year)
3	Aggregate value of grants from (during year)
4	Aggregate value at end of year ........

Did the organization inform all donors and donor advisors in writing that the assets held in donor advised funds are the organization’s property, subject to the organization’s exclusive legal control? ............

Yes No

Did the organization inform all grantees, donors, and donor advisors in writing that grant funds can be used only for charitable purposes and not for the benefit of the donor or donor advisor, or for any other purpose conferring impermissible private benefit? ...................................

Yes No

Part II

Conservation Easements.
Complete if the organization answered "Yes" on Form 990, Part IV, line 7.

Purpose(s) of conservation easements held by the organization (check all that apply).

Preservation of land for public use (e.g., recreation or education) Preservation of an historically important land area

Protection of natural habitat Preservation of a certified historic structure

Preservation of open space

Complete lines 2a through 2d if the organization held a qualified conservation contribution in the form of a conservation easement on the last day of the tax year.


a	Total number of conservation easements ......................	2a
b	Total acreage restricted by conservation easements ....................	2b
c	Number of conservation easements on a certified historic structure included in (a) .....	2c
d	Number of conservation easements included in (c) acquired after 7/25/06, and not on a historic structure listed in the National Register ...	2d

Number of conservation easements modified, transferred, released, extinguished, or terminated by the organization during the
tax year SchDMd Bullet

Number of states where property subject to conservation easement is located SchDMd Bullet

Does the organization have a written policy regarding the periodic monitoring, inspection, handling of violations, and enforcement of the conservation easements it holds? ............

Yes No

Staff and volunteer hours devoted to monitoring, inspecting, handling of violations, and enforcing conservation easements during the year
SchDMd Bullet

Amount of expenses incurred in monitoring, inspecting, handling of violations, and enforcing conservation easements during the year
SchDMd Bullet

Does each conservation easement reported on line 2(d) above satisfy the requirements of section 170(h)(4)(B)(i) and section 170(h)(4)(B)(ii)? .............................

Yes No

In Part XIII, describe how the organization reports conservation easements in its revenue and expense statement, and
balance sheet, and include, if applicable, the text of the footnote to the organization’s financial statements that describes
the organization’s accounting for conservation easements.

Part III

Organizations Maintaining Collections of Art, Historical Treasures, or Other Similar Assets.
Complete if the organization answered "Yes" on Form 990, Part IV, line 8.

If the organization elected, as permitted under FASB ASC 958, not to report in its revenue statement and balance sheet works of art, historical treasures, or other similar assets held for public exhibition, education, or research in furtherance of public service, provide, in Part XIII, the text of the footnote to its financial statements that describes these items.

If the organization elected, as permitted under FASB ASC 958, to report in its revenue statement and balance sheet works of art, historical treasures, or other similar assets held for public exhibition, education, or research in furtherance of public service, provide the following amounts relating to these items:

(i)

Revenue included on Form 990, Part VIII, line 1 ......................... SchDMd Bullet

(ii)

Assets included in Form 990, Part X ............................... SchDMd Bullet

If the organization received or held works of art, historical treasures, or other similar assets for financial gain, provide the
following amounts required to be reported under FASB ASC 958 relating to these items:

Revenue included on Form 990, Part VIII, line 1 .......................... SchDMd Bullet

Assets included in Form 990, Part X ............................... SchDMd Bullet

For Paperwork Reduction Act Notice, see the Instructions for Form 990.

Cat. No. 52283D

Schedule D (Form 990) 2019

Page 2

Part III

Organizations Maintaining Collections of Art, Historical Treasures, or Other Similar Assets (continued)

Using the organization’s acquisition, accession, and other records, check any of the following that are a significant use of its collection items (check all that apply):

Public exhibition

Loan or exchange programs

Scholarly research

Other

Preservation for future generations

Provide a description of the organization’s collections and explain how they further the organization’s exempt purpose in
Part XIII.

During the year, did the organization solicit or receive donations of art, historical treasures or other similar
assets to be sold to raise funds rather than to be maintained as part of the organization’s collection?...

Yes No

Part IV

Escrow and Custodial Arrangements. Complete if the organization answered "Yes" on Form 990, Part IV, line 9, or reported an amount on Form 990, Part X, line 21.

Is the organization an agent, trustee, custodian or other intermediary for contributions or other assets not
included on Form 990, Part X? ....................................

Yes No


b	If "Yes," explain the arrangement in Part XIII and complete the following table:		Amount
c	Beginning balance .............................	1c
d	Additions during the year ............................	1d
e	Distributions during the year ..........................	1e
f	Ending balance ................................	1f

Did the organization include an amount on Form 990, Part X, line 21, for escrow or custodial account liability? ...

Yes No

If "Yes," explain the arrangement in Part XIII. Check here if the explanation has been provided in Part XIII ....

Part V

Endowment Funds.
Complete if the organization answered "Yes" on Form 990, Part IV, line 10.

		(a) Current year	(b) Prior year	(c) Two years back	(d) Three years back	(e) Four years back

1a	Beginning of year balance ....
b	Contributions ...
c	Net investment earnings, gains, and losses
d	Grants or scholarships ...
e	Other expenditures for facilities and programs ...
f	Administrative expenses ....
g	End of year balance ......

Provide the estimated percentage of the current year end balance (line 1g, column (a)) held as:

Board designated or quasi-endowment SchDMd Bullet

Permanent endowment SchDMd Bullet

Term endowment SchDMd Bullet

The percentages on lines 2a, 2b, and 2c should equal 100%.

Are there endowment funds not in the possession of the organization that are held and administered for the
organization by:

Yes

(i) Unrelated organizations .................

3a(i)

(ii) Related organizations .................

3a(ii)

If "Yes" on 3a(ii), are the related organizations listed as required on Schedule R? .........

Describe in Part XIII the intended uses of the organization's endowment funds.

Part VI

Land, Buildings, and Equipment.
Complete if the organization answered "Yes" on Form 990, Part IV, line 11a. See Form 990, Part X, line 10.

Description of property		(a) Cost or other basis (investment)	(b) Cost or other basis (other)	(c) Accumulated depreciation	(d) Book value

1a	Land .....	45,460		45,460
b	Buildings ....	6,528,545	5,038,518	1,490,027
c	Leasehold improvements
d	Equipment ....	5,917,541	5,148,056	769,485
e	Other .....	196,874	181,574	15,300
Total. Add lines 1a through 1e. (Column (d) must equal Form 990, Part X, column (B), line 10(c).)..				2,320,272

Schedule D (Form 990) 2019

Page 3

Part VII

InvestmentsOther Securities.
Complete if the organization answered "Yes" on Form 990, Part IV, line 11b. See Form 990, Part X, line 12.

(a) Description of security or category (including name of security)	(b) Book value	(c) Method of valuation: Cost or end-of-year market value
(1) Financial derivatives.........
(2) Closely-held equity interests........
(3)Other
(B)
(C)
(D)
(E)
(F)
(G)
(H)
(I)
Total. (Column (b) must equal Form 990, Part X, col. (B) line 12.)

Part VIII

InvestmentsProgram Related. Complete if the organization answered 'Yes' on Form 990, Part IV, line 11c. See Form 990, Part X, line 13.

(a) Description of investment	(b) Book value	(c) Method of valuation: Cost or end-of-year market value

(2)
(3)
(4)
(5)
(6)
(7)
(8)
(9)
(10)
Total. (Column (b) must equal Form 990, Part X, col.(B) line 13.)

Part IX

Other Assets.
Complete if the organization answered 'Yes' on Form 990, Part IV, line 11d. See Form 990, Part X, line 15.

(a) Description				(b) Book value

(2)
(3)
(4)
(5)
(6)
(7)
(8)
(9)
(10)
Total. (Column (b) must equal Form 990, Part X, col.(B) line 15.)...........

Part X

Other Liabilities.
Complete if the organization answered 'Yes' on Form 990, Part IV, line 11e or 11f. See Form 990, Part X, line 25.

1.(a) Description of liability	(b) Book value
(1) Federal income taxes

(2)
(3)
(4)
(5)
(6)
(7)
(8)
(9)
Total. (Column (b) must equal Form 990, Part X, col.(B) line 25.)
2. Liability for uncertain tax positions. In Part XIII, provide the text of the footnote to the organization's financial statements that reports the organization's liability for uncertain tax positions under FIN 48 (ASC 740). Check here if the text of the footnote has been provided in Part XIII

Schedule D (Form 990) 2019

Page 4

Part XI Reconciliation of Revenue per Audited Financial Statements With Revenue per Return. Complete if the organization answered 'Yes' on Form 990, Part IV, line 12a.
1	Total revenue, gains, and other support per audited financial statements .......			1	13,217,175
2	Amounts included on line 1 but not on Form 990, Part VIII, line 12:
a	Net unrealized gains (losses) on investments ....	2a
b	Donated services and use of facilities .........	2b
c	Recoveries of prior year grants ...........	2c
d	Other (Describe in Part XIII.) ............	2d	-319,481
e	Add lines 2a through 2d .....................			2e	-319,481
3	Subtract line 2e from line 1..................			3	13,536,656
4	Amounts included on Form 990, Part VIII, line 12, but not on line 1:
a	Investment expenses not included on Form 990, Part VIII, line 7b .	4a
b	Other (Describe in Part XIII.) ...........	4b
c	Add lines 4a and 4b....................			4c
5	Total revenue. Add lines 3 and 4c. (This must equal Form 990, Part I, line 12.) ......			5	13,536,656

Part XII Reconciliation of Expenses per Audited Financial Statements With Expenses per Return. Complete if the organization answered 'Yes' on Form 990, Part IV, line 12a.
1	Total expenses and losses per audited financial statements ...........			1	13,135,371
2	Amounts included on line 1 but not on Form 990, Part IX, line 25:
a	Donated services and use of facilities .........	2a
b	Prior year adjustments ............	2b
c	Other losses ................	2c
d	Other (Describe in Part XIII.) ............	2d	4,239
e	Add lines 2a through 2d....................			2e	4,239
3	Subtract line 2e from line 1...................			3	13,131,132
4	Amounts included on Form 990, Part IX, line 25, but not on line 1:
a	Investment expenses not included on Form 990, Part VIII, line 7b ..	4a
b	Other (Describe in Part XIII.) ............	4b	331,655
c	Add lines 4a and 4b.....................			4c	331,655
5	Total expenses. Add lines 3 and 4c. (This must equal Form 990, Part I, line 18.) ......			5	13,462,787

Part XIII

Supplemental Information

Provide the descriptions required for Part II, lines 3, 5, and 9; Part III, lines 1a and 4; Part lV, lines 1b and 2b; Part V, line 4; Part X, line 2; Part XI, lines 2d and 4b; and Part XII, lines 2d and 4b. Also complete this part to provide any additional information.

Return Reference	Explanation
SCHEDULE D, PART X, LINE 2	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 FINANCIAL STATEMENTS.
SCHEDULE D, PART XI, LINE 2D	EQUITY IN EARNINGS SABETHA HEALTHCARE, INC. 7,935 SPECIAL EVENT EXPENSES 4,239 PROVISION FOR UNCOLLECTIBLE ACCOUNTS (331,655) ------------ TOTAL (319,481)
SCHEDULE D, PART XII, LINE 2D	SPECIAL EVENT EXPENSES 4,239
SCHEDULE D, PART XII, LINE 4B	PROVISION FOR UNCOLLECTIBLE ACCOUNTS 331,655

Schedule D (Form 990) 2019

Additional Data

Software ID:
Software Version:

- TIN:

SCHEDULE G (Form 990 or 990-EZ)

Department of the Treasury
Internal Revenue Service

Supplemental Information Regarding
Fundraising or Gaming Activities

Complete if the organization answered "Yes" on Form 990, Part IV, lines 17, 18, or 19, or if the organization entered more than $15,000 on Form 990-EZ, line 6a. right arrow

Attach to Form 990 or Form 990-EZ.
right arrow

Go to www.irs.gov/Form990 for instructions and the latest information.

OMB No. 1545-0047

2019

Open to Public Inspection

Name of the organization
GREAT PLAINS OF SABETHA INC

Employer identification number

48-1236156

Part I

Fundraising Activities.Complete if the organization answered "Yes" on Form 990, Part IV, line 17.

Form 990-EZ filers are not required to complete this part.

Indicate whether the organization raised funds through any of the following activities. Check all that apply.

a	Mail solicitations	e	Solicitation of non-government grants
b	Internet and email solicitations	f	Solicitation of government grants
c	Phone solicitations	g	Special fundraising events
d	In-person solicitations

Did the organization have a written or oral agreement with any individual (including officers, directors, trustees

or key employees listed in Form 990, Part VII) or entity in connection with professional fundraising services?

YesNo

If "Yes," list the 10 highest paid individuals or entities (fundraisers) pursuant to agreements under which the fundraiser is
to be compensated at least $5,000 by the organization.

(i) Name and address of individual or entity (fundraiser)	(iii) Did fundraiser have custody or control of contributions?
	Yes	No










Total . . . . . . . . . . . . . . . . . . . .

List all states in which the organization is registered or licensed to solicit contributions or has been notified it is exempt from registration or licensing.

For Paperwork Reduction Act Notice, see the Instructions for Form 990 or 990-EZ.

Cat. No. 50083H

Schedule G (Form 990 or 990-EZ) 2019

Page 2

Part II

Fundraising Events. Complete if the organization answered "Yes" on Form 990, Part IV, line 18, or reported more than $15,000 of fundraising event contributions and gross income on Form 990-EZ, lines 1 and 6b. List events with gross receipts greater than $5,000.

		(a) Event #1 GOLF TOURNAMENT (event type)	(d) Total events (add col. (a) through col. (c))
1	Gross receipts . . . . .	16,503	16,503
2	Less: Contributions . . . .	14,088	14,088
3	Gross income (line 1 minus line 2) . . . . . .	2,415	2,415

4	Cash prizes . . . . .	990	990
5	Noncash prizes . . . .	1,654	1,654
6	Rent/facility costs . . . .	0	0
7	Food and beverages . . .	528	528
8	Entertainment . . . .	0	0
9	Other direct expenses . . .	1,067	1,067
10	Direct expense summary. Add lines 4 through 9 in column (d) . . . . . . . . . .		4,239
11	Net income summary. Subtract line 10 from line 3, column (d). . . . . . . . . .		-1,824

Part III

Gaming. Complete if the organization answered "Yes" on Form 990, Part IV, line 19, or reported more than $15,000 on Form 990-EZ, line 6a.

		(a) Bingo	(b) Pull tabs/Instant bingo/progressive bingo	(c) Other gaming	(d) Total gaming (add col.(a) through col.(c))
1	Gross revenue . . . . .

2	Cash prizes . . . . .
3	Noncash prizes . . . .
4	Rent/facility costs . . . .
5	Other direct expenses . . .

Volunteer labor . . . .

	Yes %
	No

	Yes %
	No

	Yes %
	No

Direct expense summary. Add lines 2 through 5 in column (d) . . . . . . . . . . right arrow

Net gaming income summary. Subtract line 7 from line 1, column (d). . . . . . . . . right arrow

Enter the state(s) in which the organization conducts gaming activities:

Is the organization licensed to conduct gaming activities in each of these states? . . . . . . . .

YesNo

If "No," explain:

10a

Were any of the organization's gaming licenses revoked, suspended or terminated during the tax year? . . .

YesNo

If "Yes," explain:

Schedule G (Form 990 or 990-EZ) 2019

Page 3

Does the organization conduct gaming activities with nonmembers? . . . . . . . . . . .

YesNo

Is the organization a grantor, beneficiary or trustee of a trust or a member of a partnership or other entity

formed to administer charitable gaming? . . . . . . . . . . . . . . . . .

YesNo

Indicate the percentage of gaming activity conducted in:

The organization's facility . . . . . . . . . . . . . . . . . .

13a

An outside facility . . . . . . . . . . . . . . . . . . . .

13b

Enter the name and address of the person who prepares the organization's gaming/special events books and records:

Name

Address

15a

Does the organization have a contract with a third party from whom the organization receives gaming

revenue? . . . . . . . . . . . . . . . . . . . . . . . .

YesNo

If "Yes," enter the amount of gaming revenue received by the organization right arrow

$ and the

amount of gaming revenue retained by the third party right arrow

$ .

If "Yes," enter name and address of the third party:

Name

Address

Gaming manager information:

Name

Gaming manager compensation right arrow

Description of services provided right arrow

Director/officer Employee Independent contractor

Mandatory distributions:

Is the organization required under state law to make charitable distributions from the gaming proceeds to

retain the state gaming license? . . . . . . . . . . . . . . . . . . .

YesNo

Enter the amount of distributions required under state law distributed to other exempt organizations or spent

in the organization's own exempt activities during the tax year right arrow

Part IV

Supplemental Information. Provide the explanations required by Part I, line 2b, columns (iii) and (v); and Part III, lines 9, 9b, 10b, 15b, 15c, 16, and 17b, as applicable. Also provide any additional information. See instructions.

Return Reference	Explanation

Schedule G (Form 990 or 990-EZ) 2019

Additional Data

Software ID:
Software Version:

- TIN:

SCHEDULE H
(Form 990)

Department of the Treasury
Internal Revenue Service

Hospitals

Complete if the organization answered "Yes" on Form 990, Part IV, question 20.
MediumBullet

Attach to Form 990.
MediumBullet

Go to www.irs.gov/Form990EZ for instructions and the latest information.

OMB No. 1545-0047

2019

Open to Public Inspection

Name of the organization

GREAT PLAINS OF SABETHA INC

Employer identification number

48-1236156

Part I

Financial Assistance and Certain Other Community Benefits at Cost

Yes

Did the organization have a financial assistance policy during the tax year? If "No," skip to question 6a . . . .

Yes

If "Yes," was it a written policy? ......................

Yes

If the organization had multiple hospital facilities, indicate which of the following best describes application of the financial assistance policy to its various hospital facilities during the tax year.

Applied uniformly to all hospital facilities Applied uniformly to most hospital facilities Generally tailored to individual hospital facilities

Answer the following based on the financial assistance eligibility criteria that applied to the largest number of the organization's patients during the tax year.

Did the organization use Federal Poverty Guidelines (FPG) as a factor in determining eligibility for providing free care?

If "Yes," indicate which of the following was the FPG family income limit for eligibility for free care:

Yes

100% 150% 200% Other %

Did the organization use FPG as a factor in determining eligibility for providing discounted care? If "Yes," indicate

which of the following was the family income limit for eligibility for discounted care: . . . . . . . .

200% 250% 300% 350% 400% Other %

If the organization used factors other than FPG in determining eligibility, describe in Part VI the criteria used for determining eligibility for free or discounted care. Include in the description whether the organization used an asset test or other threshold, regardless of income, as a factor in determining eligibility for free or discounted care.

Did the organization's financial assistance policy that applied to the largest number of its patients during the tax year provide for free or discounted care to the "medically indigent"? . . . . . . . . . . . . .

Yes

Did the organization budget amounts for free or discounted care provided under its financial assistance policy during
the tax year? . . . . . . . . . . . . . . . . . . . . . . .

Yes

If "Yes," did the organization's financial assistance expenses exceed the budgeted amount? . . . . . .

If "Yes" to line 5b, as a result of budget considerations, was the organization unable to provide free or discountedcare to a patient who was eligibile for free or discounted care? . . . . . . . . . . . . .

Did the organization prepare a community benefit report during the tax year? . . . . . . . . .

Yes

If "Yes," did the organization make it available to the public? . . . . . . . . . . . . .

Yes

Complete the following table using the worksheets provided in the Schedule H instructions. Do not submit these worksheets with the Schedule H.

Financial Assistance and Certain Other Community Benefits at Cost

Financial Assistance and Means-Tested Government Programs		(c) Total community benefit expense	(d) Direct offsetting revenue	(e) Net community benefit expense	(f) Percent of total expense
a	Financial Assistance at cost (from Worksheet 1) . . .	26,058		26,058	0.200 %
b	Medicaid (from Worksheet 3, column a) . . . . .	429,554	190,362	239,192	1.820 %
c	Costs of other means-tested government programs (from Worksheet 3, column b) . .
d	Total Financial Assistance and Means-Tested Government Programs . . . . .	455,612	190,362	265,250	2.020 %
Other Benefits
e	Community health improvement services and community benefit operations (from Worksheet 4).	65,066	12,272	52,794	0.400 %
f	Health professions education (from Worksheet 5) . . .
g	Subsidized health services (from Worksheet 6) . . . .
h	Research (from Worksheet 7) .
i	Cash and in-kind contributions for community benefit (from Worksheet 8) . . . .	3,733		3,733	0.030 %
j	Total. Other Benefits . .	68,799	12,272	56,527	0.430 %
k	Total. Add lines 7d and 7j .	524,411	202,634	321,777	2.450 %

For Paperwork Reduction Act Notice, see the Instructions for Form 990. Cat. No. 50192T Schedule H (Form 990) 2019

Schedule H (Form 990) 2019

Page

Part II

Community Building Activities Complete this table if the organization conducted any community building activities during the tax year, and describe in Part VI how its community building activities promoted the health of the communities it serves.

		(a) Number of activities or programs (optional)	(b) Persons served (optional)	(c) Total community building expense	(d) Direct offsetting revenue	(e) Net community building expense	(f) Percent of total expense
1	Physical improvements and housing
2	Economic development
3	Community support
4	Environmental improvements
5	Leadership development and training for community members
6	Coalition building
7	Community health improvement advocacy
8	Workforce development
9	Other
10	Total

Part III

Bad Debt, Medicare, & Collection Practices

Section A. Bad Debt Expense

Yes

Did the organization report bad debt expense in accordance with Healthcare Financial Management Association Statement No. 15? ..........................

Enter the amount of the organization's bad debt expense. Explain in Part VI the methodology used by the organization to estimate this amount. ......

331,655

Enter the estimated amount of the organization's bad debt expense attributable to patients eligible under the organization's financial assistance policy. Explain in Part VI the methodology used by the organization to estimate this amount and the rationale, if any, for including this portion of bad debt as community benefit. ......

Provide in Part VI the text of the footnote to the organization’s financial statements that describes bad debt expense or the page number on which this footnote is contained in the attached financial statements.

Section B. Medicare

Enter total revenue received from Medicare (including DSH and IME).....

5,171,424

Enter Medicare allowable costs of care relating to payments on line 5.....

5,171,424

Subtract line 6 from line 5. This is the surplus (or shortfall)........

Describe in Part VI the extent to which any shortfall reported in line 7 should be treated as community benefit.Also describe in Part VI the costing methodology or source used to determine the amount reported on line 6.Check the box that describes the method used:

Cost accounting system Cost to charge ratio Other

Section C. Collection Practices

Did the organization have a written debt collection policy during the tax year? ..........

Yes

If "Yes," did the organization’s collection policy that applied to the largest number of its patients during the tax year
contain provisions on the collection practices to be followed for patients who are known to qualify for financial assistance? Describe in Part VI .........................

Yes

Part IV

Management Companies and Joint Ventures(owned 10% or more by officers, directors, trustees, key employees, and physicians—see instructions)

(a) Name of entity	(b) Description of primary activity of entity	(c) Organization's profit % or stock ownership %	(d) Officers, directors, trustees, or key employees' profit % or stock ownership %	(e) Physicians' profit % or stock ownership %
1
2
3
4
5
6
7
8
9
10
11
12
13

Schedule H (Form 990) 2019

Page

Part VFacility Information

Section A. Hospital Facilities (list in order of size from largest to smallest—see instructions)How many hospital facilities did the organization operate during the tax year?1Name, address, primary website address, and state license number (and if a group return, the name and EIN of the subordinate hospital organization that operates the hospital facility)
1	SABETHA COMMUNITY HOSPITAL 14TH OREGON PO BOX 229 SABETHA,KS66534 WWW.SABETHAHOSPITAL.ORG H066002	X	X	X	X

Schedule H (Form 990) 2019

Page 4

Part VFacility Information (continued)

Section B. Facility Policies and Practices

(Complete a separate Section B for each of the hospital facilities or facility reporting groups listed in Part V, Section A)

	SABETHA COMMUNITY HOSPITAL
Name of hospital facility or letter of facility reporting group

Line number of hospital facility, or line numbers of hospital facilities in a facility
reporting group (from Part V, Section A):

Yes

Community Health Needs Assessment

Was the hospital facility first licensed, registered, or similarly recognized by a state as a hospital facility in the current tax year or the immediately preceding tax year?........................

Was the hospital facility acquired or placed into service as a tax-exempt hospital in the current tax year or the immediately preceding tax year? If “Yes,” provide details of the acquisition in Section C...............

During the tax year or either of the two immediately preceding tax years, did the hospital facility conduct a community health needs assessment (CHNA)? If "No," skip to line 12......................

Yes

If "Yes," indicate what the CHNA report describes (check all that apply):

A definition of the community served by the hospital facility

Demographics of the community

Existing health care facilities and resources within the community that are available to respond to the health needs of the community

How data was obtained

The significant health needs of the community

Primary and chronic disease needs and other health issues of uninsured persons, low-income persons, and minority groups

The process for identifying and prioritizing community health needs and services to meet the community health needs

The process for consulting with persons representing the community’s interests

The impact of any actions taken to address the significant health needs identified in the hospital facility's prior CHNA(s)

Other (describe in Section C)

Indicate the tax year the hospital facility last conducted a CHNA: 20 18

In conducting its most recent CHNA, did the hospital facility take into account input from persons who represent the broad interests of the community served by the hospital facility, including those with special knowledge of or expertise in public health? If "Yes," describe in Section C how the hospital facility took into account input from persons who represent the community, and identify the persons the hospital facility consulted .................

Yes

6 a

Was the hospital facility’s CHNA conducted with one or more other hospital facilities? If "Yes," list the other hospital facilities in Section C..................................

Yes

Was the hospital facility’s CHNA conducted with one or more organizations other than hospital facilities?” If “Yes,” list the other organizations in Section C. ............................

Did the hospital facility make its CHNA report widely available to the public?..............

Yes

If "Yes," indicate how the CHNA report was made widely available (check all that apply):

Hospital facility’s website (list url): SEE SCHEDULE H, PART V, SECTION C

Other website (list url):

Made a paper copy available for public inspection without charge at the hospital facility

Other (describe in Section C)

Did the hospital facility adopt an implementation strategy to meet the significant community health needs
identified through its most recently conducted CHNA? If "No," skip to line 11. ..............

Yes

Indicate the tax year the hospital facility last adopted an implementation strategy: 20 18

Is the hospital facility's most recently adopted implementation strategy posted on a website?.........

Yes

If "Yes" (list url): SEE SCHEDULE H, PART V, SECTION C

If "No," is the hospital facility’s most recently adopted implementation strategy attached to this return? ......

10b

Describe in Section C how the hospital facility is addressing the significant needs identified in its most recently conducted CHNA and any such needs that are not being addressed together with the reasons why such needs are not being addressed.

12a

Did the organization incur an excise tax under section 4959 for the hospital facility's failure to conduct a CHNA as required by section 501(r)(3)?...............................

12a

If "Yes" on line 12a, did the organization file Form 4720 to report the section 4959 excise tax?........

12b

If "Yes" on line 12b, what is the total amount of section 4959 excise tax the organization reported on Form 4720 for all of its hospital facilities? $

Schedule H (Form 990) 2019

Page 5

Part VFacility Information (continued)

Financial Assistance Policy (FAP)

	SABETHA COMMUNITY HOSPITAL
Name of hospital facility or letter of facility reporting group

Yes

Did the hospital facility have in place during the tax year a written financial assistance policy that:

Explained eligibility criteria for financial assistance, and whether such assistance included free or discounted care?

Yes

If “Yes,” indicate the eligibility criteria explained in the FAP:

Federal poverty guidelines (FPG), with FPG family income limit for eligibility for free care of 200.%
and FPG family income limit for eligibility for discounted care of 0.%

Income level other than FPG (describe in Section C)

Asset level

Medical indigency

Insurance status

Underinsurance discount

Residency

Other (describe in Section C)

Explained the basis for calculating amounts charged to patients?.................

Yes

Explained the method for applying for financial assistance?...................

Yes

If “Yes,” indicate how the hospital facility’s FAP or FAP application form (including accompanying instructions) explained the method for applying for financial assistance (check all that apply):

Described the information the hospital facility may require an individual to provide as part of his or her application

Described the supporting documentation the hospital facility may require an individual to submit as part of his or
her application

Provided the contact information of hospital facility staff who can provide an individual with information about the
FAP and FAP application process

Provided the contact information of nonprofit organizations or government agencies that may be sources of
assistance with FAP applications

Other (describe in Section C)

Was widely publicized within the community served by the hospital facility?........

Yes

If "Yes," indicate how the hospital facility publicized the policy (check all that apply):

The FAP was widely available on a website (list url):

SEE SCHEDULE H, PART V, SECTION C

The FAP application form was widely available on a website (list url):

SEE SCHEDULE H, PART V, SECTION C

A plain language summary of the FAP was widely available on a website (list url):
SEE SCH H, PART V, SECTION C

The FAP was available upon request and without charge (in public locations in the hospital facility and by mail)

The FAP application form was available upon request and without charge (in public locations in the hospital facility
and by mail)

A plain language summary of the FAP was available upon request and without charge (in public locations in the
hospital facility and by mail)

Individuals were notified about the FAP by being offered a paper copy of the plain language summary of the FAP, by
receiving a conspicuous written notice about the FAP on their billing statements, and via conspicuous public displays or
other measures reasonably calculated to attract patients' attention

Notified members of the community who are most likely to require financial assistance about availability of the FAP

The FAP, FAP application form, and plain language summary of the FAP were translated into the primary language(s)
spoken by LEP populations

Other (describe in Section C)

Schedule H (Form 990) 2019

Page 6

Part VFacility Information (continued)

Billing and Collections

	SABETHA COMMUNITY HOSPITAL
Name of hospital facility or letter of facility reporting group

Yes

Did the hospital facility have in place during the tax year a separate billing and collections policy, or a written financial assistance policy (FAP) that explained all of the actions the hospital facility or other authorized party may take upon nonpayment?..................................

Yes

Check all of the following actions against an individual that were permitted under the hospital facility's policies during the tax year before making reasonable efforts to determine the individual’s eligibility under the facility’s FAP:

Reporting to credit agency(ies)

Selling an individual’s debt to another party

Deferring, denying, or requiring a payment before providing medically necessary care due to nonpayment of a previous
bill for care covered under the hospital facility's FAP

Actions that require a legal or judicial process

Other similar actions (describe in Section C)

None of these actions or other similar actions were permitted

Did the hospital facility or other authorized party perform any of the following actions during the tax year before making reasonable efforts to determine the individual’s eligibility under the facility’s FAP?............

If "Yes," check all actions in which the hospital facility or a third party engaged:

Reporting to credit agency(ies)

Selling an individual’s debt to another party

Deferring , denying, or requiring a payment before providing medically necessary care due to nonpayment of a previous
bill for care covered under the hospital facility's FAP

Actions that require a legal or judicial process

Other similar actions (describe in Section C)

Indicate which efforts the hospital facility or other authorized party made before initiating any of the actions listed (whether or not checked) in line 19. (check all that apply):

Provided a written notice about upcoming ECAs (Extraordinary Collection Action) and a plain language summary of the
FAP at least 30 days before initiating those ECAs (if not, describe in Section C)

Made a reasonable effort to orally notify individuals about the FAP and FAP application process (if not, describe in
Section C)

Processed incomplete and complete FAP applications (if not, describe in Section C)

Made presumptive eligibility determinations (if not, describe in Section C)

Other (describe in Section C)

None of these efforts were made

Policy Relating to Emergency Medical Care

Did the hospital facility have in place during the tax year a written policy relating to emergency medical care that required the hospital facility to provide, without discrimination, care for emergency medical conditions to individuals regardless of their eligibility under the hospital facility’s financial assistance policy?..................

Yes

If "No," indicate why:

The hospital facility did not provide care for any emergency medical conditions

The hospital facility’s policy was not in writing

The hospital facility limited who was eligible to receive care for emergency medical conditions (describe in Section C)

Other (describe in Section C)

Schedule H (Form 990) 2019

Page 7

Part VFacility Information (continued)

Charges to Individuals Eligible for Assistance Under the FAP (FAP-Eligible Individuals)

	SABETHA COMMUNITY HOSPITAL
Name of hospital facility or letter of facility reporting group

Yes

Indicate how the hospital facility determined, during the tax year, the maximum amounts that can be charged to FAP-eligible individuals for emergency or other medically necessary care.

The hospital facility used a look-back method based on claims allowed by Medicare fee-for-service during a prior 12-month period

The hospital facility used a look-back method based on claims allowed by Medicare fee-for-service and all private health insurers that pay claims to the hospital facility during a prior 12-month period

The hospital facility used a look-back method based on claims allowed by Medicaid, either alone or in combination with
Medicare fee-for-service and all private health insurers that pay claims to the hospital facility during a prior 12-month
period

The hospital facility used a prospective Medicare or Medicaid method

During the tax year, did the hospital facility charge any FAP-eligible individual to whom the hospital facility provided emergency or other medically necessary services more than the amounts generally billed to individuals who had insurance covering such care? ...............................

If "Yes," explain in Section C.

During the tax year, did the hospital facility charge any FAP-eligible individual an amount equal to the gross charge for any service provided to that individual? ...........................

If "Yes," explain in Section C.

Schedule H (Form 990) 2019

Page 8

Part V

Facility Information (continued)

Section C. Supplemental Information for Part V, Section B. Provide descriptions required for Part V, Section B, lines 2, 3j, 5, 6a, 6b, 7d, 11, 13b, 13h, 15e, 16j, 18e, 19e, 20a, 20b, 20c, 20d, 20e, 21c, 21d, 23, and 24. If applicable, provide separate descriptions for each hospital facility in a facility reporting group, designated by facility reporting group letter and hospital facility line number from Part V, Section A (“A, 1,” “A, 4,” “B, 2,” “B, 3,” etc.) and name of hospital facility.
Form and Line Reference	Explanation
SCHEDULE H, PART V, SECTION B, LINE 5	A PRIORITY OF THE PROGRAM IS TO SOLICIT INPUT FROM A BROAD CROSS SECTION OF THE COMMUNITY, NOT SIMPLY MEMBERS OF THE LOCAL HEALTHCARE SECTOR. THE MEETING PARTICIPANTS INCLUDED COMMUNITY RESIDENTS AND GOVERNMENTAL AND BUSINESS LEADERS WITHIN THE COMMUNITY.
SCHEDULE H, PART V, SECTION B, LINE 6A	NEMAHA VALLEY COMMUNITY HOSPITAL
SCHEDULE H, PART V, LINE 7A	http://www.sabethahospital.com/getpage.php?name=chna
SCHEDULE H, PART V, LINE 10A	http://www.sabethahospital.com/getpage.php?name=chna
SCHEDULE H, PART V, LINE 11	Sabetha Community Hospital's Community Health Needs Assessment identified three focused areas. Priority #1 was to promote health, wellness, and chronic disease prevention especially in the areas of hypertension, diabetes, smoking cessation and increased seatbelt usage. The hospital accomplished this goal by partnering with the City of Sabetha on a health and wellness center. The Health and Wellness Center opened on July 1, 2019. The center provides exercise classes in cardio fitness and aquatic therapy. Physical Therapy as well Cardiac Rehab Phase III programs transition patients who have completed their care to an exercise program at the Health and Wellness Center. Sabetha Community Hospital is a Certified Diabetic Education Facility and employs a Certified Diabetic educator who works with the current diabetes patients. The diabetic educator not only conducts education classes but works alongside the dietician in conducting the SMART program which holds the diabetic accountable for their own care. The hospital conducts low dose CT for lung cancer screening and partners with the local Community Health agency to direct patients to a smoking cessation class. The hospital now employs two certified seatbelt technician who do car seat safety checks for newborn babes leaving the hospital and car seat safety checks in the community as well. Monthly publications are sent out to the community and surrounding region on related health topics as mentioned above. This information is posted on the hospital website and Facebook page. Pre-natal classes are conducted quarterly throughout the year. SCH partners with the local health department to provide breastfeeding services through a certified lactation consultant. This consultant works with the pre-natal instructor to provide information to expectant mothers. The two hospitals in the county work together to provide supplies to newborn babes and families. The Level IV Trauma committee remains active in the community by giving scholarships to community children for swimming lessons offered at the public pool. Stop the Bleed instructors also provide that education to the community. Priority #2 identified improving access to mental health services. The local community mental health center provides access to mental health services through a clinic setting and some telehealth. The hospital does use Avera e-care within the ER setting to help with mental health issues. Resources and the availability of mental health professionals are limited in this rural area. The hospital continues to provide assistance to the community to those who seek help enrolling in Medicaid, Medicare and third-party payers as well as the drug prescription program. A local community group through the library, daycare, parents as teachers, and other organizations meet monthly to remain updated on community resources and needs. The hospital social worker and public relations coordinator attend to share hospital resources back to the group. In addition, a resource directory is attached to the community health needs assessment on the SCH website. In mid-year of 2019, the hospital updated the revenue cycle to a Cerner product. This entailed educating the community on new bill types due to the combining of the physician clinic and the hospital billing statements. Patients continue to be educated on accessing the Cerner patient portal to access their medical records. The Care Transitions Committee continued to meet through 2019 to better enhance patients' transitions for acute care to post-acute care. Transition of care reports generated by Cerner upon patients' discharge is used to enhance follow up of the patient from the emergency room, inpatient or OBs back to the physician's office. assessment on the SCH website. For the first six months of 2019, city officials and the hospital CEO and staff engaged in numerous meetings regarding the building of the community health and wellness center. This project was complete by July 1, 2019. The staff of the health and wellness center focuses on cardio fitness and aquatic therapy. As a community benefit to local industries, the hospital provides wellness checks which include blood pressure checks, BMI, and blood work and, if requested, educational sessions. Another service to the local businesses is the provision of occupational assessment testing along with hearing screens. The OAS testing and hearing screens are done by certified hospital staff. The hospital offers public flu immunization clinics at the local grocery store as well as providing immunization clinics to the local industries. Wellness is promoted among SCH employees by providing a corporate membership to the community fitness center. Hospital staff is also encouraged to donate blood during the quarterly blood drives. CPR training for professionals in the area are conducted. The hospital provides prenatal classes including CPR training, breastfeeding and care of a newborn infant on a quarterly basis for expectant parents. Cardiac Rehab Phase III is open to the community to offer support in an exercise program, especially for those patients who have graduated from the Cardiac Rehab Phase II program. This program is above and beyond use of the Health and Wellness Center. Social Services aids those in the community who request assistance and need resources for items such as meals on wheels, transportation, etc. Social Service and swingbed director coordinate transfer of patients to the local dialysis center. Medical Director for the city owned ambulance service is a hospital employed physician and the hospital provides RNs as needed for emergency indicated transfers to the local tertiary center. The four family practice physicians serve as medical directors for the Home Health and Hospice Agency. The Chief Executive Officer of Sabetha Community Hospital serves on the Health Innovations Network of Kansas Board, and the Governors KanCare Advisory Group. Hospital staff serves on various committees for the Kansas Hospital Association, and also, local civic groups. Sabetha Community Hospital takes its commitment to the community very seriously and participates in emergency drills, always monitoring patient and employee safety, educating staff on risk management, quality assurance, infection control issues, bloodborn pathogens, HIPAA and Corporate Compliance. The hospital provides an avenue for nursing students to do rotations through the hospital with its affiliation with Highland Community College and Southeast Community College, Beatrice, Nebraska. Medical students in the rural residency program at Kansas University School of Medicine are able to do clinical rotations with the family physicians. Physical therapy students through affiliation with Kansas City Kansas Community College and Indian Hills Community College, occupational therapy students through Washburn University affiliation, and social service students from Kansas State University all do clinical rotations at the hospital as well. Hospital Administration works closely with the High School counselor in the administration of local scholarships to nursing students and to those who are going into a healthcare career. Hospital staff participate in Senior Career Day at the local high school and every year middle school and high school student's job shadow at the hospital to encourage careers in healthcare.
SCHEDULE H, PART V, LINE 16A	http://www.sabethahospital.com/getpage.php?name=Financial_Assistance
SCHEDULE H, PART V, LINE 16B	http://www.sabethahospital.com/getpage.php?name=Financial_Assistance
SCHEDULE H, PART V, LINE 16C	http://www.sabethahospital.com/getpage.php?name=Financial_Assistance

Schedule H (Form 990) 2019

Page 9

Part VFacility Information (continued)

Section D. Other Health Care Facilities That Are Not Licensed, Registered, or Similarly Recognized as a Hospital Facility (list in order of size, from largest to smallest) How many non-hospital health care facilities did the organization operate during the tax year?1
Name and address		Type of Facility (describe)
1	SABETHA FAMILY PRACTICE 1115 MAIN STREET SABETHA,KS66534	FAMILY CLINIC
2
3
4
5
6
7
8
9
10

Schedule H (Form 990) 2019

Page 10

Part VI

Supplemental Information

Provide the following information.

1	Required descriptions. Provide the descriptions required for Part I, lines 3c, 6a, and 7; Part II and Part III, lines 2, 3, 4, 8 and 9b.
2	Needs assessment. Describe how the organization assesses the health care needs of the communities it serves, in addition to any CHNAs reported in Part V, Section B.
3	Patient education of eligibility for assistance. Describe how the organization informs and educates patients and persons who may be billed for patient care about their eligibility for assistance under federal, state, or local government programs or under the organization’s financial assistance policy.
4	Community information. Describe the community the organization serves, taking into account the geographic area and demographic constituents it serves.
5	Promotion of community health. Provide any other information important to describing how the organization’s hospital facilities or other health care facilities further its exempt purpose by promoting the health of the community (e.g., open medical staff, community board, use of surplus funds, etc.).
6	Affiliated health care system. If the organization is part of an affiliated health care system, describe the respective roles of the organization and its affiliates in promoting the health of the communities served.
7	State filing of community benefit report. If applicable, identify all states with which the organization, or a related organization, files a community benefit report.

Form and Line Reference	Explanation
SCHEDULE H, PART I, LINE 3C	THE ORGANIZATION USED THE FOLLOWING CRITERIA TO DETERMINE ELIGIBILITY FOR FINANCIAL ASSISTANCE: ASSET LEVEL, MEDICAL INDIGENCY, INSURANCE STATUS, AND UNDERINSURANCE STATUS. SCHEDULE H, PART I, LINE 7 THE COSTING METHODOLOGY USED TO CALCULATE THE AMOUNTS CONTAINED IN THE TABLE OF PART I, LINE 7, OF SCHEDULE H, IS A COST TO CHARGE RATIO. SCHEDULE H, PART I, LINE 7, COLUMN F THE BAD DEBT EXPENSE INCLUDED ON FORM 990, PART IX, LINE 25, COLUMN (A), BUT SUBTRACTED FOR PURPOSES OF CALCULATING THE PERCENTAGE IN THIS COLUMN IS $331,655. SCHEDULE H, PART III, LINE 2 HOSPITAL CHARGES THAT ARE NOT COLLECTED AND ARE NOT APPROVED FOR FINANCIAL ASSISTANCE ARE CLASSIFIED AS BAD DEBTS FROM PATIENTS WHO WILL NOT PAY.
SCHEDULE H, PART III, LINE 3	THE COSTING METHODOLOGY IS BASED ON THE ORGANIZATION'S MEDICARE COST-TO-CHARGE RATIO. WHILE WE RECOGNIZE THAT THERE WOULD BE SOME BAD DEBT EXPENSE ATTRIBUTABLE TO PATIENTS ELIGIBLE UNDER THE ORGANIZATION'S CHARITY CARE POLICY, WE HAVE NO REASONABLE BASIS FOR ESTIMATING THIS FIGURE. IF ELIGIBILITY IS KNOWN, THE AMOUNT WOULD FALL UNDER CHARITY CARE AND NOT BAD DEBT.
SCHEDULE H, PART III, LINE 4	SEE PAGE 7 OF THE AUDITED FINANCIALS UNDER NOTE 1.
SCHEDULE H, PART III, LINE 8	THE COSTING METHODOLOGY USED TO CALCULATE THE AMOUNT ON LINE 6 IS A COST TO CHARGE RATIO.
SCHEDULE H, PART III, LINE 9B	ALL CHARITY CARE CHARGES AND CHARGES NOT TO BE COLLECTED DUE TO FINANCIAL ASSISTANCE COMPUTATIONS ARE EXEMPTED FROM COLLECTION POLICIES AND PRACTICES. THOSE ACCOUNTS ARE REMOVED FROM THE COLLECTION CYCLE.
SCHEDULE H, PART VI, LINE 2	Sabetha Community Hospital's Community Health Needs Assessment identified three focused areas. Priority #1 was to promote health, wellness, and chronic disease prevention especially in the areas of hypertension, diabetes, smoking cessation and increased seatbelt usage. The hospital accomplished this goal by partnering with the City of Sabetha on a health and wellness center. The Health and Wellness Center opened on July 1, 2019. The center provides exercise classes in cardio fitness and aquatic therapy. Physical Therapy as well Cardiac Rehab Phase III programs transition patients who have completed their care to an exercise program at the Health and Wellness Center. Sabetha Community Hospital is a Certified Diabetic Education Facility and employs a Certified Diabetic educator who works with the current diabetes patients. The diabetic educator not only conducts education classes but works alongside the dietician in conducting the SMART program which holds the diabetic accountable for their own care. The hospital conducts low dose CT for lung cancer screening and partners with the local Community Health agency to direct patients to a smoking cessation class. The hospital now employs two certified seatbelt technician who do car seat safety checks for newborn babes leaving the hospital and car seat safety checks in the community as well. Monthly publications are sent out to the community and surrounding region on related health topics as mentioned above. This information is posted on the hospital website and Facebook page. Pre-natal classes are conducted quarterly throughout the year. SCH partners with the local health department to provide breastfeeding services through a certified lactation consultant. This consultant works with the pre-natal instructor to provide information to expectant mothers. The two hospitals in the county work together to provide supplies to newborn babes and families. The Level IV Trauma committee remains active in the community by giving scholarships to community children for swimming lessons offered at the public pool. Stop the Bleed instructors also provide that education to the community. Priority #2 identified improving access to mental health services. The local community mental health center provides access to mental health services through a clinic setting and some telehealth. The hospital does use Avera e-care within the ER setting to help with mental health issues. Resources and the availability of mental health professionals are limited in this rural area. The hospital continues to provide assistance to the community to those who seek help enrolling in Medicaid, Medicare and third-party payers as well as the drug prescription program. A local community group through the library, daycare, parents as teachers, and other organizations meet monthly to remain updated on community resources and needs. The hospital social worker and public relations coordinator attend to share hospital resources back to the group. In addition, a resource directory is attached to the community health needs assessment on the SCH website. In mid-year of 2019, the hospital updated the revenue cycle to a Cerner product. This entailed educating the community on new bill types due to the combining of the physician clinic and the hospital billing statements. Patients continue to be educated on accessing the Cerner patient portal to access their medical records. The Care Transitions Committee continued to meet through 2019 to better enhance patients' transitions for acute care to post-acute care. Transition of care reports generated by Cerner upon patients' discharge is used to enhance follow up of the patient from the emergency room, inpatient or OBs back to the physician's office. assessment on the SCH website.
SCHEDULE H, PART VI, LINE 3	The following measures are used to publicize the program to the community and patients: 1. Posting the Financial Assistance Program, Financial Assistance Application and a summary of the Policy on the Sabetha Community Hospital website at the following location: www.sabethahospital.com 2. Providing paper copies of the Program, application and summary of the Program upon request in admissions and patient financial services at Sabetha Community Hospital. 3. Posting notices about the Program in the emergency department, admitting areas, Clinic lobby and business office of Sabetha Community Hospital. 4. Distributing a plain language summary of the Program and offering a Financial Assistance application to patients before discharge from the hospital. 5. Informing patients about the Program in person or during billing and customer service phone contacts. 6. Providing notification of the Program in the patients' monthly billing statement which provides information and resources on how to apply for financial assistance. The Financial Assistance Program employs a sliding scale discount that takes into consideration a patient's household income and qualifying assets. The Financial Counselor consults with private pay patients to see if they qualify for the Hospital's financial assistance policy. If discovered during the accounts receivable collection process that a patient is having trouble paying bills, both the hospital and the clinic will inform the patient that financial assistance is available. As part of the financial assistance program all applicants must apply for Medicaid. To determine if the patient may qualify for financial assistance, the financial counselor gives patient forms to complete and asks to see bank statements, tax returns, etc. Computations based on current Federal Poverty Level Guidelines are completed to see if qualifications is appropriate and the percentage of charges to be written off is determined, based on family size and household income. All instances of financial assistance are approved by upper management of the Hospital. Information about Financial Assistance is posted on the hospital website and the Financial Assistance form can be downloaded from www.sabethehospital.com
SCHEDULE H, PART VI, LINE 4	Sabetha Community Hospital is a 25 bed Critical Access Hospital located in the city of Sabetha, Nemaha County Kansas. Currently, the population of the City of Sabetha is estimated at 2584. The primary service area for Sabetha Community Hospital includes portions of Nemaha, Brown and Jackson County, Kansas and several counties in Nebraska. For Nemaha County in 2017 there were 599 of inpatient discharges. Estimated population for Nemaha County is 10,241 according to the United States Census Bureau. People age 65 and over make up 27% of the county's total population. The racial and ethnic composition of Nemaha County is mostly white which is at 96.9%, Native American .6%, African Americans .8%, Asians .3% and Hispanics were 1.7% of the population.
SCHEDULE H, PART VI, LINE 5	For the first six months of 2019, city officials and the hospital CEO and staff engaged in numerous meetings regarding the building of the community health and wellness center. This project was complete by July 1, 2019. The staff of the health and wellness center focuses on cardio fitness and aquatic therapy. As a community benefit to local industries, the hospital provides wellness checks which include blood pressure checks, BMI, and blood work and, if requested, educational sessions. Another service to the local businesses is the provision of occupational assessment testing along with hearing screens. The OAS testing and hearing screens are done by certified hospital staff. The hospital offers public flu immunization clinics at the local grocery store as well as providing immunization clinics to the local industries. Wellness is promoted among SCH employees by providing a corporate membership to the community fitness center. Hospital staff is also encouraged to donate blood during the quarterly blood drives. CPR training for professionals in the area are conducted. The hospital provides prenatal classes including CPR training, breastfeeding and care of a newborn infant on a quarterly basis for expectant parents. Cardiac Rehab Phase III is open to the community to offer support in an exercise program, especially for those patients who have graduated from the Cardiac Rehab Phase II program. This program is above and beyond use of the Health and Wellness Center. Social Services aids those in the community who request assistance and need resources for items such as meals on wheels, transportation, etc. Social Service and swingbed director coordinate transfer of patients to the local dialysis center. Medical Director for the city owned ambulance service is a hospital employed physician and the hospital provides RNs as needed for emergency indicated transfers to the local tertiary center. The four family practice physicians serve as medical directors for the Home Health and Hospice Agency. The Chief Executive Officer of Sabetha Community Hospital serves on the Health Innovations Network of Kansas Board, and the Governors KanCare Advisory Group. Hospital staff serves on various committees for the Kansas Hospital Association, and also, local civic groups. Sabetha Community Hospital takes its commitment to the community very seriously and participates in emergency drills, always monitoring patient and employee safety, educating staff on risk management, quality assurance, infection control issues, bloodborn pathogens, HIPAA and Corporate Compliance. The hospital provides an avenue for nursing students to do rotations through the hospital with its affiliation with Highland Community College and Southeast Community College, Beatrice, Nebraska. Medical students in the rural residency program at Kansas University School of Medicine are able to do clinical rotations with the family physicians. Physical therapy students through affiliation with Kansas City Kansas Community College and Indian Hills Community College, occupational therapy students through Washburn University affiliation, and social service students from Kansas State University all do clinical rotations at the hospital as well. Hospital Administration works closely with the High School counselor in the administration of local scholarships to nursing students and to those who are going into a healthcare career. Hospital staff participate in Senior Career Day at the local high school and every year middle school and high school student's job shadow at the hospital to encourage careers in healthcare.
SCHEDULE H, PART VI, LINE 6	Organization is affiliated with Great Plains Health Alliance, Inc. (GPHA), a non-profit 501(c)(3) organization which provides management services and operational, finance and accounting support to the Hospital. GPHA does not provide services directly to patients, but does provide access to professionals that may not be affordable to the normal critical access hospital. GPHA provides education and assistance in areas such as HIPAA, Medicare reimbursement, meaningful use requirements for computer systems, etc. GPHA is an affiliation of Critical Access hospitals in Kansas and Nebraska that provides networking opportunities with other rural hospital, communities and leaders. GPHA provides policies and guidance to its Critical Access facilities regarding financial assistance, conflicts of interest, corporate compliance, HIPAA Privacy and Security and many other areas. GPHA also provides educational sessions for Board Members, Business Office Mangers, Billers, Medical Records personnel, Director of Nursing and Administrators. GPHA is a vital link in allowing CAH hospitals to operate at a high quality within the cash constraints imposed by the Critical Access program.
SCHEDULE H, PART VI, LINE 7	N/A

Schedule H (Form 990) 2019

Additional Data

Software ID:
Software Version:

- TIN:

Schedule J
(Form 990)

Department of the Treasury
Internal Revenue Service

Compensation Information

For certain Officers, Directors, Trustees, Key Employees, and Highest
Compensated Employees
SchJMediumBullet

Complete if the organization answered "Yes" on Form 990, Part IV, line 23.
SchJMediumBullet

Attach to Form 990.
SchJMediumBullet

Go to www.irs.gov/Form990 for instructions and the latest information.

OMB No. 1545-0047

2019

Open to Public Inspection

Name of the organization

GREAT PLAINS OF SABETHA INC

Employer identification number

48-1236156

Part I

Questions Regarding Compensation

Yes

Check the appropiate box(es) if the organization provided any of the following to or for a person listed on Form
990, Part VII, Section A, line 1a. Complete Part III to provide any relevant information regarding these items.

First-class or charter travel Housing allowance or residence for personal use

Travel for companions Payments for business use of personal residence

Tax idemnification and gross-up payments Health or social club dues or initiation fees

Discretionary spending account Personal services (e.g., maid, chauffeur, chef)

If any of the boxes on Line 1a are checked, did the organization follow a written policy regarding payment or reimbursement or provision of all of the expenses described above? If "No," complete Part III to explain .........

Did the organization require substantiation prior to reimbursing or allowing expenses incurred by all
directors, trustees, officers, including the CEO/Executive Director, regarding the items checked on Line 1a? ..

Indicate which, if any, of the following the filing organization used to establish the compensation of the
organization's CEO/Executive Director. Check all that apply. Do not check any boxes for methods
used by a related organization to establish compensation of the CEO/Executive Director, but explain in Part III.

Compensation committee Written employment contract

Independent compensation consultant Compensation survey or study

Form 990 of other organizations Approval by the board or compensation committee

During the year, did any person listed on Form 990, Part VII, Section A, line 1a, with respect to the filing organization or a related organization:

Receive a severance payment or change-of-control payment? .............

Participate in, or receive payment from, a supplemental nonqualified retirement plan? .........

Participate in, or receive payment from, an equity-based compensation arrangement? .........

If "Yes" to any of lines 4a-c, list the persons and provide the applicable amounts for each item in Part III.

Only 501(c)(3), 501(c)(4), and 501(c)(29) organizations must complete lines 5-9.

For persons listed on Form 990, Part VII, Section A, line 1a, did the organization pay or accrue any
compensation contingent on the revenues of:

The organization? ....................

Any related organization? .......................

If "Yes," on line 5a or 5b, describe in Part III.

For persons listed on Form 990, Part VII, Section A, line 1a, did the organization pay or accrue any
compensation contingent on the net earnings of:

The organization? ..................

Any related organization? ......................

If "Yes," on line 6a or 6b, describe in Part III.

For persons listed on Form 990, Part VII, Section A, line 1a, did the organization provide any nonfixed
payments not described in lines 5 and 6? If "Yes," describe in Part III ............

Were any amounts reported on Form 990, Part VII, paid or accured pursuant to a contract that was
subject to the initial contract exception described in Regulations section 53.4958-4(a)(3)? If "Yes," describe
in Part III ..........................

If "Yes" on line 8, did the organization also follow the rebuttable presumption procedure described in Regulations section 53.4958-6(c)? .........................

For Paperwork Reduction Act Notice, see the Instructions for Form 990.

Cat. No. 50053T

Schedule J (Form 990) 2019

Page 2

Part II

Officers, Directors, Trustees, Key Employees, and Highest Compensated Employees. Use duplicate copies if additional space is needed.

For each individual whose compensation must be reported on Schedule J, report compensation from the organization on row (i) and from related organizations, described in the
instructions, on row (ii). Do not list any individuals that are not listed on Form 990, Part VII.
Note. The sum of columns (B)(i)-(iii) for each listed individual must equal the total amount of Form 990, Part VII, Section A, line 1a, applicable column (D) and (E) amounts for that individual.

(A) Name and Title		(B) Breakdown of W-2 and/or 1099-MISC compensation			(C) Retirement and other deferred compensation	(D) Nontaxable benefits	(E) Total of columns (B)(i)-(D)	(F) Compensation in column (B) reported as deferred on prior Form 990
(A) Name and Title		(i) Base compensation	(ii) Bonus & incentive compensation	(iii) Other reportable compensation	(C) Retirement and other deferred compensation	(D) Nontaxable benefits	(E) Total of columns (B)(i)-(D)
1DAVE DELLASEGA PRESIDENT/CEO/DIRECTOR	(i) (ii)	0 ------------- 208,541	0 ------------- 0	0 ------------- 83	0 ------------- 20,484	0 ------------- 12,997	0 ------------- 242,105	0 ------------- 0
2DURREL KELLEY SENIOR VP OF OPERATIONS	(i) (ii)	0 ------------- 160,275	0 ------------- 0	0 ------------- 217	0 ------------- 15,277	0 ------------- 17,408	0 ------------- 193,177	0 ------------- 0
3KEVIN KENNALLY PHYSICIAN	(i) (ii)	339,635 ------------- 0	0 ------------- 0	3,057 ------------- 0	27,200 ------------- 0	16,181 ------------- 0	386,073 ------------- 0	0 ------------- 0
4ELIZABETH KROLL APRN/NP	(i) (ii)	167,151 ------------- 0	0 ------------- 0	1,635 ------------- 0	7,159 ------------- 0	23,098 ------------- 0	199,043 ------------- 0	0 ------------- 0
5GREGG WENGER PHYSICIAN	(i) (ii)	248,881 ------------- 0	0 ------------- 0	2,062 ------------- 0	25,317 ------------- 0	15,639 ------------- 0	291,899 ------------- 0	0 ------------- 0
6JAMES LONGABAUGH PHYSICIAN	(i) (ii)	271,585 ------------- 0	0 ------------- 0	2,507 ------------- 0	27,200 ------------- 0	24,398 ------------- 0	325,690 ------------- 0	0 ------------- 0
7CHRISTIAN TRAMP PHYSICIAN	(i) (ii)	300,807 ------------- 0	0 ------------- 0	2,475 ------------- 0	27,200 ------------- 0	24,021 ------------- 0	354,503 ------------- 0	0 ------------- 0

Schedule J (Form 990) 2019

Page 3

Part III

Supplemental Information

Provide the information, explanation, or descriptions required for Part I, lines 1a, 1b, 3, 4a, 4b, 4c, 5a, 5b, 6a, 6b, 7, and 8, and for Part II. Also complete this part for any additional information.

Return Reference

Explanation

FORM 990, PART VII; SCHEDULE J, PART I, LINE 3

COMPENSATION FOR DURREL KELLEY AND DAVE DELLASEGA IS PROVIDED BY GREAT PLAINS HEALTH ALLIANCE, A RELATED ORGANIZATION. GREAT PLAINS HEALTH ALLIANCE'S BOARD OF DIRECTORS ANNUALLY APPROVE THE COMPENSATION FOR MR. KELLEY AND MR. DELLASEGA. THE AMERICAN COLLEGE HEALTHCARE EXECUTIVES AND THE KANSAS HOSPITAL ASSOCIATION ALSO HAVE COMPARABLE COMPENSATION DATA THAT CAN BE USED BY THE BOARD. A COMPENSATION REVIEW WAS DONE WHEN DAVE DELLASEGA TOOK OVER AS CEO AND WAS CONDUCTED BY THE BOARD, BUT SINCE THAT TIME THERE HAS BEEN NO FORMAL COMPENSATION REVIEW.

Schedule J (Form 990) 2019

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 990-EZ or to provide any additional information.
MediumBullet

Attach to Form 990 or 990-EZ.
MediumBullet

Go to www.irs.gov/Form990 for the latest information.

OMB No. 1545-0047

2019

Open to Public
Inspection

Name of the organization

GREAT PLAINS OF SABETHA INC

Employer identification number

48-1236156

Return Reference	Explanation
FORM 990, PART III, LINE 4A	Addressing the needs of mental health among the elderly population as well as youth continues to be a priority but problematic due to the lack of mental health providers. The hospital partners with the regional Community Mental Health Center to provide access to mental health services whether it be in a clinic setting or through telehealth services. Again, addressing mental health is as important as promoting physical health within a community, and Sabetha Hospital recognizes that importance. Another large program the hospital provides is community support and mentoring. Outreach education is a priority to the hospital by participating in the Middle School and High School job shadowing days for these students. Several departments of the hospital participate in the high school work study program where students go into the workplace as part of their curriculum. Pre-natal classes and breastfeeding support is offered to expectant moms whether they are a first-time mom or have multiple children already. Another important factor in babes care is also a properly fitted car seat. The hospital provides a certified car seat specialist to make sure the baby is safe when leaving the hospital. The hospital has two technicians that will conduct car seat safety checks for the community as well. Stop the Bleed instructors conduct classes for the EMS technicians and various local industries. The hospital diabetic educator conducts the SMART program with diabetic patients which holds them accountable for their diabetic health. Hospital department heads present education on hospital services to the Hospital Guild which meets on a monthly basis. Staff provides presentations for local civic groups to create healthcare awareness on topics such as obesity, stroke/heart attacks, and diabetes. The next largest program that the hospital provides to the Sabetha Community is enrollment assistance for public medical programs such as Medicaid, Medicare, and Medicare Part D. Two hospital staff are dedicated to this program during the open enrollment periods. The hospital social worker takes the lead on this project and is helped by a staff member. After the open enrollment periods are closed the Social Worker is still available to the community to help with any assistance needed to for first time enrollees in Medicare or the Medicaid programs. The Social Worker also will assistance community members with needed information and resources, and work with the local pharmacies regarding prescription drug programs if the community member is unable to afford a needed medication. Quality healthcare is important to Sabetha Community Hospital and the hospital continues to participate in the Kansas Health Care Collaborative HIIN as well as reporting to the Medicare Beneficiary Quality Improvement Program. HCAHPS scores are monitored and used to keep staff informed of patient satisfaction and evaluate areas for needed improvement. SCH's mission remains to provide quality of health and care given in our communities. FORM 990, PART VI, SECTION A, LINE 2 DAVE DELLASEGA AND DURREL KELLEY HAVE A BUSINESS RELATIONSHIP. THEY ARE BOTH EMPLOYED BY, AND ALSO OFFICERS OF, A RELATED 501(C)(3) ORGANIZATION, GREAT PLAINS HEALTH ALLIANCE. FORM 990, PART VI, SECTION A, LINE 6 GREAT PLAINS HEALTH ALLIANCE, INC., A NOT-FOR-PROFIT, 501(C)(3) ORGANIZATION, IS THE SOLE MEMBER OF GREAT PLAINS OF SABETHA, INC. FORM 990, PART VI, SECTION A, LINE 7A GREAT PLAINS HEALTH ALLIANCE, INC., BEING THE SOLE MEMBER, HAS THE RIGHT TO ELECT AND APPROVE ALL THE BOARD MEMBERS.
FORM 990, PART VI, SECTION A, LINE 7B	GREAT PLAINS HEALTH ALLIANCE, INC. (GPHA) IS THE SOLE MEMBER AND HAS THE AUTHORITY TO APPROVE THE ARTICLES OF INCORPORATION, BYLAWS, ELECTION TO OR REMOVAL FROM THE BOARD OF DIRECTORS, THE ANNUAL OPERATING AND CAPITAL BUDGETS, AND THE LONG RANGE OR STRATEGIC PLANS.
FORM 990, PART VI, SECTION B, LINE 11B	THE 990 IS PREPARED AND REVIEWED BY AN INDEPENDENT ACCOUNTING FIRM. THE 990 IS THEN PROVIDED TO THE CHIEF EXECUTIVE OFFICER FOR REVIEW AND APPROVAL. AN ELECTRONIC DRAFT OF THE 990 WITH ALL REQUIRED SCHEDULES IS THEN PROVIDED TO THE FULL BOARD FOR REVIEW PRIOR TO FILING THE 990 WITH THE IRS.
FORM 990, PART VI, SECTION B, LINE 12C	THE ORGANIZATION IS REQUIRED TO ADOPT GPHA'S CONFLICT OF INTEREST POLICY. ALL BOARD MEMBERS, OFFICERS AND EMPLOYEES ARE SUBJECT TO THE CONFLICT OF INTEREST POLICY AND SIGN AN ANNUAL ACKNOWLEDGEMENT THAT THEY HAVE READ, UNDERSTAND AND COMPLIED WITH THE GPHA CONFLICT OF INTEREST POLICY. UNDER THE POLICY, ANY MEMBER WHO HAS A DIRECT OR INDIRECT (VIA FAMILY) FINANCIAL INTEREST IS CHARACTERIZED AS AN INTERESTED PERSON. INTERESTED PERSONS ARE REQUIRED TO DISCLOSE FINANCIAL INTERESTS WITH COMPANIES DOING BUSINESS WITH GPHA. THE INTERESTED PERSON MUST RECUSE THEMSELVES FROM FURTHER DISCUSSIONS OF THE TRANSACTION AND LEAVE THE ROOM. THE REMAINING NON-INTERESTED MEMBERS DECIDE IF A CONFLICT OF INTEREST EXISTS. THE BOARD CHAIR MAY APPOINT ANOTHER DISINTERESTED PARTY TO DISCUSS THE TRANSACTION OR THE REMAINING BOARD MEMBERS MAY VOTE TO ENTER INTO OR ABSTAIN FROM THE SUSPECT TRANSACTION. FAILURE TO DISCLOSE FINANCIAL INTERESTS BY INTERESTED BOARD MEMBERS WILL RESULT IN DISCIPLINARY ACTION, INCLUDING SANCTIONING BY BOARD. ALL CONFLICTS OF INTEREST AND THEIR ULTIMATE RESOLUTION ARE DOCUMENTED IN THE BOARD MINUTES. THE BOARD CONDUCTS PERIODIC REVIEWS TO DETERMINE THAT CONFLICTS ARE BEING IDENTIFIED AND RESOLVED ACCORDING TO POLICY DOCUMENTATION. REVIEWS BY OUTSIDE EXPERTS ARE PERMITTED, BUT NOT REQUIRED. FORM 990, PART VI, SECTION B, LINES 15A & B THE CEO AND COO ARE COMPENSATED BY GREAT PLAINS HEALTH ALLIANCE, A RELATED ORGANIZATION. GPHA'S BOARD USES COMPARABILITY DATA IN SETTING THEIR SALARIES, AND DOCUMENTATION IS RETAINED OF THE BOARD'S DELIBERATIONS AND DECISIONS. FORM 990, PART VI, SECTION C, LINE 19 THE ORGANIZATION'S GOVERNING DOCUMENTS, CONFLICT OF INTEREST POLICY AND FINANCIAL STATEMENTS ARE AVAILABLE TO THE PUBLIC UPON REQUEST. THE COMPANY'S KANSAS ANNUAL REPORT IS ALSO AVAILABLE UPON REQUEST FROM THE KANSAS SECRETARY OF STATE.
FORM 990, PART XI, LINE 9	EQUITY IN EARNINGS SABETHA HEALTHCARE, INC. 7,935
FORM 990 PART IX LINE 11G	DESCRIPTION:CONTRACTED MEDICAL STAFF TOTAL FEES:1135948
FORM 990 PART IX LINE 11G	DESCRIPTION:BILLING/COLLECTIONS TOTAL FEES:152131
FORM 990 PART IX LINE 11G	DESCRIPTION:LAB SERVICES TOTAL FEES:170126
FORM 990 PART IX LINE 11G	DESCRIPTION:PHARMACY SERVICES TOTAL FEES:140905
FORM 990 PART IX LINE 11G	DESCRIPTION:ADMINISTRATION/HUMAN RESOURCES TOTAL FEES:177758
FORM 990 PART IX LINE 11G	DESCRIPTION:MAINTENANCE/HOUSEKEEPING TOTAL FEES:9989

For Paperwork Reduction Act Notice, see the Instructions for Form 990 or 990-EZ.

Cat. No. 51056K

Schedule O (Form 990 or 990-EZ) 2019

Additional Data

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- TIN:

SCHEDULE R
(Form 990)

Department of the Treasury
Internal Revenue Service

Related Organizations and Unrelated Partnerships

Complete if the organization answered "Yes" on Form 990, Part IV, line 33, 34, 35b, 36, or 37.
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Attach to Form 990.
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Go to www.irs.gov/Form990 for instructions and the latest information.

OMB No. 1545-0047

2019

Open to Public Inspection

Name of the organization

GREAT PLAINS OF SABETHA INC

Employer identification number

48-1236156

Part I

Identification of Disregarded Entities. Complete if the organization answered "Yes" on Form 990, Part IV, line 33.

(a) Name, address, and EIN (if applicable) of disregarded entity	(b) Primary activity	(c) Legal domicile (state or foreign country)	(d) Total income	(e) End-of-year assets	(f) Direct controlling entity

Part II

Identification of Related Tax-Exempt Organizations. Complete if the organization answered "Yes" on Form 990, Part IV, line 34 because it had one or more related tax-exempt organizations during the tax year.

(a) Name, address, and EIN of related organization	(b) Primary activity	(c) Legal domicile (state or foreign country)	(d) Exempt Code section	(e) Public charity status (if section 501(c)(3))	(f) Direct controlling entity	(g) Section 512(b)(13) controlled entity?
(a) Name, address, and EIN of related organization	(b) Primary activity	(c) Legal domicile (state or foreign country)	(d) Exempt Code section	(e) Public charity status (if section 501(c)(3))	(f) Direct controlling entity	Yes	No
(1)GREAT PLAINS HEALTH CARE FOUNDATION INC 250 NORTH ROCK ROAD STE 160 WICHITA,KS67206 48-0955870	SUPPORT	KS	501(C)(3)	10	GPHA INC	Yes
(2)GREAT PLAINS OF CHEYENNE COUNTY INC 250 NORTH ROCK ROAD STE 160 WICHITA,KS67206 48-1226831	HOSPITAL	KS	501(C)(3)	3	GPHA INC	Yes
(3)GREAT PLAINS OF ELLINWOOD INC 250 NORTH ROCK ROAD STE 160 WICHITA,KS67206 48-1226976	HOSPITAL	KS	501(C)(3)	3	GPHA INC	Yes
(4)GREAT PLAINS OF KIOWA COUNTY INC 250 NORTH ROCK ROAD STE 160 WICHITA,KS67206 48-1226833	HOSPITAL	KS	501(C)(3)	3	GPHA INC	Yes
(5)GREAT PLAINS OF OTTAWA COUNTY INC 250 NORTH ROCK ROAD STE 160 WICHITA,KS67206 48-1226856	HOSPITAL	KS	501(C)(3)	3	GPHA INC	Yes
(6)GREAT PLAINS OF REPUBLIC COUNTY INC 250 NORTH ROCK ROAD STE 160 WICHITA,KS67206 48-1226977	HOSPITAL	KS	501(C)(3)	3	GPHA INC	Yes
(7)GREAT PLAINS OF SMITH COUNTY INC 250 NORTH ROCK ROAD STE 160 WICHITA,KS67206 48-1226830	HOSPITAL	KS	501(C)(3)	3	GPHA INC	Yes
(8)GREAT PLAINS HEALTH ALLIANCE INC 250 N ROCK ROAD STE 160 WICHITA,KS67206 48-0617739	MANAGEMENT	KS	501(C)(3)	3	NA		No
(9)GREAT PLAINS EMPLOYEE BENEFITS TRUST 250 NORTH ROCK ROAD STE 160 WICHITA,KS67206 47-6918582	HEALTH PLAN	KS	501(C)(9)		GPHA INC	Yes

For Paperwork Reduction Act Notice, see the Instructions for Form 990.

Cat. No. 50135Y

Schedule R (Form 990) 2019

Page 2

Part III

Identification of Related Organizations Taxable as a Partnership. Complete if the organization answered "Yes" on Form 990, Part IV, line 34, because it had one or more related organizations treated as a partnership during the tax year.

(a) Name, address, and EIN of related organization	(b) Primary activity	(c) Legal domicile (state or foreign country)	(d) Direct controlling entity	(f) Share of total income	(g) Share of end-of-year assets	(h) Disproprtionate allocations?		(i) Code V-UBI amount in box 20 of Schedule K-1 (Form 1065)	(j) General or managing partner?
(a) Name, address, and EIN of related organization	(b) Primary activity	(c) Legal domicile (state or foreign country)	(d) Direct controlling entity	(f) Share of total income	(g) Share of end-of-year assets	Yes	No	(i) Code V-UBI amount in box 20 of Schedule K-1 (Form 1065)	Yes	No

Part IV

Identification of Related Organizations Taxable as a Corporation or Trust. Complete if the organization answered "Yes" on Form 990, Part IV, line 34 because it had one or more related organizations treated as a corporation or trust during the tax year.

(a) Name, address, and EIN of related organization	(b) Primary activity	(c) Legal domicile (state or foreign country)	(d) Direct controlling entity	(e) Type of entity (C corp, S corp, or trust)	(f) Share of total income	(g) Share of end-of-year assets	(i) Section 512(b)(13) controlled entity?
(a) Name, address, and EIN of related organization	(b) Primary activity	(c) Legal domicile (state or foreign country)	(d) Direct controlling entity	(e) Type of entity (C corp, S corp, or trust)	(f) Share of total income	(g) Share of end-of-year assets	Yes	No

Schedule R (Form 990) 2019

Page 3

Part V

Transactions With Related Organizations. Complete if the organization answered "Yes" on Form 990, Part IV, line 34, 35b, or 36.

Note. Complete line 1 if any entity is listed in Parts II, III, or IV of this schedule.

Yes

1 During the tax year, did the orgranization engage in any of the following transactions with one or more related organizations listed in Parts II-IV?

a Receipt of (i) interest, (ii) annuities, (iii) royalties, or (iv) rent from a controlled entity .....................

b Gift, grant, or capital contribution to related organization(s) ............................

c Gift, grant, or capital contribution from related organization(s) ............................

d Loans or loan guarantees to or for related organization(s) ............................

e Loans or loan guarantees by related organization(s) ............................

f Dividends from related organization(s) ............................

g Sale of assets to related organization(s) ............................

h Purchase of assets from related organization(s) ............................

i Exchange of assets with related organization(s) ............................

j Lease of facilities, equipment, or other assets to related organization(s) .......................

k Lease of facilities, equipment, or other assets from related organization(s) ......................

l Performance of services or membership or fundraising solicitations for related organization(s) .....................

m Performance of services or membership or fundraising solicitations by related organization(s) .................

Yes

n Sharing of facilities, equipment, mailing lists, or other assets with related organization(s) ...................

o Sharing of paid employees with related organization(s) ............................

Yes

p Reimbursement paid to related organization(s) for expenses ............................

q Reimbursement paid by related organization(s) for expenses ............................

r Other transfer of cash or property to related organization(s) ............................

Yes

s Other transfer of cash or property from related organization(s) ............................

If the answer to any of the above is "Yes," see the instructions for information on who must complete this line, including covered relationships and transaction thresholds.

(a) Name of related organization	(b) Transaction type (a-s)	(c) Amount involved	(d) Method of determining amount involved
(1) GPHA EMPLOYEE BENEFITS TRUST	R	570,910	ACTUAL

Schedule R (Form 990) 2019

Page 4

Part VI

Unrelated Organizations Taxable as a Partnership. Complete if the organization answered "Yes" on Form 990, Part IV, line 37.

Provide the following information for each entity taxed as a partnership through which the organization conducted more than five percent of its activities (measured by total assets or gross revenue) that was not a related organization. See instructions regarding exclusion for certain investment partnerships.

(a) Name, address, and EIN of entity	(b) Primary activity	(c) Legal domicile (state or foreign country)	(e) Are all partners section 501(c)(3) organizations?		(f) Share of total income	(g) Share of end-of-year assets	(h) Disproprtionate allocations?		(i) Code V-UBI amount in box 20 of Schedule K-1 (Form 1065)	(j) General or managing partner?
(a) Name, address, and EIN of entity	(b) Primary activity	(c) Legal domicile (state or foreign country)	Yes	No	(f) Share of total income	(g) Share of end-of-year assets	Yes	No	(i) Code V-UBI amount in box 20 of Schedule K-1 (Form 1065)	Yes	No

Schedule R (Form 990) 2019

Page 5

Part VII

Supplemental Information

Provide additional information for responses to questions on Schedule R. (see instructions).

Return Reference	Explanation

Schedule R (Form 990) 2019

Additional Data

Software ID:
Software Version:

1	Briefly describe the organization’s mission or most significant activities: ACUTE CARE HOSPITAL THAT PROVIDES MEDICAL CARE TO THE GENERAL PUBLIC IN SABETHA, KANSAS AND SURROUNDING RURAL COMMUNITIES.
2	Check this box
3	Number of voting members of the governing body (Part VI, line 1a) ........	3	8
4	Number of independent voting members of the governing body (Part VI, line 1b) .....	4	7
5	Total number of individuals employed in calendar year 2019 (Part V, line 2a) ......	5	161
6	Total number of volunteers (estimate if necessary) .............	6	73
7a	Total unrelated business revenue from Part VIII, column (C), line 12 ........	7a	0
b	Net unrelated business taxable income from Form 990-T, line 39 .........	7b

		Prior Year	Current Year
8	Contributions and grants (Part VIII, line 1h) .........	517,141	478,097
9	Program service revenue (Part VIII, line 2g) .........	12,621,943	12,677,224
10	Investment income (Part VIII, column (A), lines 3, 4, and 7d ) ....	31,124	41,967
11	Other revenue (Part VIII, column (A), lines 5, 6d, 8c, 9c, 10c, and 11e)	136,886	339,368
12	Total revenue—add lines 8 through 11 (must equal Part VIII, column (A), line 12)	13,307,094	13,536,656
13	Grants and similar amounts paid (Part IX, column (A), lines 1–3 )...	0	0
14	Benefits paid to or for members (Part IX, column (A), line 4).....	0	0
15	Salaries, other compensation, employee benefits (Part IX, column (A), lines 5–10)	7,505,644	7,889,131
16a	Professional fundraising fees (Part IX, column (A), line 11e) .....	0	0
b	Total fundraising expenses (Part IX, column (D), line 25) 0
17	Other expenses (Part IX, column (A), lines 11a–11d, 11f–24e)....	5,438,989	5,573,656
18	Total expenses. Add lines 13–17 (must equal Part IX, column (A), line 25)	12,944,633	13,462,787
19	Revenue less expenses. Subtract line 18 from line 12.......	362,461	73,869
		Beginning of Current Year	End of Year
20	Total assets (Part X, line 16).............	6,512,326	7,062,735
21	Total liabilities (Part X, line 26).............	1,461,268	1,929,873
22	Net assets or fund balances. Subtract line 21 from line 20.....	5,051,058	5,132,862

Sign Here

	Signature of officer	Date

	Type or print name and title


4a	(Code: ) (Expenses $ 11,535,951 including grants of $ 0 ) (Revenue $ 12,677,224 )
	One of the largest programs Sabetha Community Hospital provides to community is the Cardiac Rehab Phase III program. Community members are able to come to the hospital and for reduced session fees utilizing cardio pulmonary exercise equipment. This program addresses the importance of continual exercise and the health benefits associated but brings with it a social aspect to those community members who participate providing much needed social interaction within the elderly population. This was evidenced when this program was thought to be discontinued due to the establishment of the health and wellness center. SEE SCHEDULE O FOR CONTINUATION.

4b	(Code: ) (Expenses $ including grants of $ ) (Revenue $ )












4c	(Code: ) (Expenses $ including grants of $ ) (Revenue $ )












4d	Other program services (Describe in Schedule O.)
	(Expenses $ including grants of $ ) (Revenue $ )
4e	Total program service expenses11,535,951

1b	Sub-Total................
c	Total from continuation sheets to Part VII, Section A....
d	Total (add lines 1b and 1c)...........	1,457,871	369,116	304,886

1a	Federated campaigns..		1a
b	Membership dues..		1b
c	Fundraising events..		1c	14,088
d	Related organizations		1d
e	Government grants (contributions)		1e	370,650

f	All other contributions, gifts, grants, and similar amounts not included above		1f	93,359

g	Noncash contributions included in lines 1a - 1f:$		1g	1,654

h Total. Add lines 1a-1f.......		478,097

		Business Code
2a	NET PATIENT SERVICE REVENUE	621300	11,820,519	11,820,519
b	340(b) Pharmacy Revenue	621300	856,705	856,705
c
d
e
f	All other program service revenue.
g	Total. Add lines 2a–2f .....		12,677,224

3 Investment income (including dividends, interest, and othersimilar amounts) ......			41,967			41,967
4 Income from investment of tax-exempt bond proceeds			0
5 Royalties...........			0
		(ii) Personal	(i) Real
6a	Gross rents		14,100	6a
b	Less: rental expenses			6b
c	Rental income or (loss)	0	14,100	6c
d	Net rental income or (loss).......			14,100			14,100
		(ii) Other	(i) Securities
7a	Gross amount from sales of assets other than inventory			7a
b	Less: cost or other basis and sales expenses			7b
c	Gain or (loss)			7c
d	Net gain or (loss).........			0			0
8a	Gross income from fundraising events (not including $ 14,088of contributions reported on line 1c). See Part IV, line 18 ....
			8a	2,415
b	Less: direct expenses ...		8b	4,239
c	Net income or (loss) from fundraising events..			-1,824			-1,824
9a	Gross income from gaming activities. See Part IV, line 19 ...
			9a	0
b	Less: direct expenses ...		9b	0
c	Net income or (loss) from gaming activities..			0
10a	Gross sales of inventory, less returns and allowances ..
			10a	0
b	Less: cost of goods sold ..		10b	0
c	Net income or (loss) from sales of inventory..			0
Business Code			Miscellaneous Revenue
11a	EMPLOYEE/GUEST MEALS		722513	17,082			17,082
b	OUTSIDE SERVICES		621300	19,306			19,306
c	WELLNESS CENTER		900099	254,241			254,241
d	All other revenue ....			36,463			36,463
e	Total. Add lines 11a–11d ......			327,092
12	Total revenue. See instructions.....			13,536,656	12,677,224		381,335

1	Grants and other assistance to domestic organizations and domestic governments. See Part IV, line 21 ....	0
2	Grants and other assistance to domestic individuals. See Part IV, line 22 ...........	0
3	Grants and other assistance to foreign organizations, foreign governments, and foreign individuals. See Part IV, lines 15 and 16. .............	0
4	Benefits paid to or for members .......	0
5	Compensation of current officers, directors, trustees, and key employees ...........	139,383		139,383
6	Compensation not included above, to disqualified persons (as defined under section 4958(f)(1)) and persons described in section 4958(c)(3)(B) .........	0
7	Other salaries and wages........	6,209,501	5,526,978	682,523
8	Pension plan accruals and contributions (include section 401(k) and 403(b) employer contributions) ....	470,348	402,490	67,858
9	Other employee benefits .......	647,671	531,833	115,838
10	Payroll taxes ...........	422,228	359,167	63,061
11	Fees for services (non-employees):
a	Management ......	128,146		128,146
b	Legal .........	12,948		12,948
c	Accounting ...........	38,044		38,044
d	Lobbying ...........	3,061		3,061
e	Professional fundraising services. See Part IV, line 17	0
f	Investment management fees ......	0
g	Other (If line 11g amount exceeds 10% of line 25, column (A) amount, list line 11g expenses on Schedule O)	1,786,857	1,455,966	330,891	0
12	Advertising and promotion ....	47,223	28,297	18,926
13	Office expenses .......	177,229	123,670	53,559
14	Information technology ......	6,353	99	6,254
15	Royalties ..	0
16	Occupancy ...........	332,125	318,776	13,349
17	Travel ............	15,529	4,851	10,678
18	Payments of travel or entertainment expenses for any federal, state, or local public officials .	0
19	Conferences, conventions, and meetings ....	53,699	44,061	9,638
20	Interest ...........	10,892	9,473	1,419
21	Payments to affiliates .......	0
22	Depreciation, depletion, and amortization ..	299,604	250,944	48,660
23	Insurance ...	129,842	37,583	92,259
24	Other expenses. Itemize expenses not covered above (List miscellaneous expenses in line 24e. If line 24e amount exceeds 10% of line 25, column (A) amount, list line 24e expenses on Schedule O.)
a	MEDICAL SUPPLIES & DRUGS	1,636,367	1,636,367
b	RENTAL EQUIPMENT & REPAIRS	363,180	345,751	17,429
c	BAD DEBT EXPENSE	331,655	331,655
d	DUES & SUBSCRIPTIONS	56,025	15,550	40,475
e	All other expenses	144,877	112,440	32,437
25	Total functional expenses. Add lines 1 through 24e	13,462,787	11,535,951	1,926,836	0
26	Joint costs. Complete this line only if the organization reported in column (B) joint costs from a combined educational campaign and fundraising solicitation. Check here if following SOP 98-2 (ASC 958-720).

1	Cash–non-interest-bearing ........			35,482	1	9,860
2	Savings and temporary cash investments .........			2,036,880	2	2,223,602
3	Pledges and grants receivable, net ......			99,575	3	100,640
4	Accounts receivable, net .............			1,424,776	4	1,818,244
5	Loans and other payables to any current or former officer, director, trustee, key employee, creator or founder, substantial contributor, or 35% controlled entity or family member of any of these persons .......
				0	5	0
6	Loans and other receivables from other disqualified persons (as defined under section 4958(f)(1)), and persons described in section 4958(c)(3)(B) ...
				0	6	0
7	Notes and loans receivable, net ...........			0	7	0
8	Inventories for sale or use ............			189,291	8	162,242
9	Prepaid expenses and deferred charges ......			113,002	9	120,280
10a	Land, buildings, and equipment: cost or other basis. Complete Part VI of Schedule D	10a	12,688,420
b	Less: accumulated depreciation	10b	10,368,148	2,155,776	10c	2,320,272
11	Investments—publicly traded securities .			0	11	0
12	Investments—other securities. See Part IV, line 11 .....			256,046	12	247,894
13	Investments—program-related. See Part IV, line 11 ..			0	13	0
14	Intangible assets ...............			0	14	0
15	Other assets. See Part IV, line 11 ...........			201,498	15	59,701
16	Total assets. Add lines 1 through 15 (must equal line 33)...			6,512,326	16	7,062,735

17	Accounts payable and accrued expenses .....	1,346,553	17	1,582,700
18	Grants payable ...	0	18	0
19	Deferred revenue .........	9,321	19	40,102
20	Tax-exempt bond liabilities .........	0	20	0
21	Escrow or custodial account liability. Complete Part IV of Schedule D	0	21	0
22	Loans and other payables to any current or former officer, director, trustee, key employee, creator or founder, substantial contributor, or 35% controlled entity or family member of any of these persons .........
		0	22	0
23	Secured mortgages and notes payable to unrelated third parties ..	105,394	23	307,071
24	Unsecured notes and loans payable to unrelated third parties ..	0	24	0
25	Other liabilities (including federal income tax, payables to related third parties, and other liabilities not included on lines 17 - 24). Complete Part X of Schedule D	0	25	0
26	Total liabilities. Add lines 17 through 25..	1,461,268	26	1,929,873

	Organizations that follow FASB ASC 958, check here and complete lines 27, 28, 32, and 33.
27	Net assets without donor restrictions ..........	5,015,796	27	5,123,222
28	Net assets with donor restrictions ...........	35,262	28	9,640
	Organizations that do not follow FASB ASC 958, check here and complete lines 29 through 33.
29	Capital stock or trust principal, or current funds .....		29
30	Paid-in or capital surplus, or land, building or equipment fund ...		30
31	Retained earnings, endowment, accumulated income, or other funds		31
32	Total net assets or fund balances ...........	5,051,058	32	5,132,862
33	Total liabilities and net assets/fund balances ........	6,512,326	33	7,062,735