Acquisition of Intra-facility Call Light System · If the physical address of your organization is different than the mailing address, ... Acquisition of Intra-facility Call Light

Niceta Farber Sheridan County Hospital

Printed On: 21 December 2017 Requests of more than $5,000 1

Acquisition of Intra-facility Call Light SystemRequests of more than $5,000

Sheridan County HospitalMs. Niceta Farber 826 18th StreetP. O. Box 167Hoxie, KS 67740

O: 785-675-3281M: 785-675-3281

Ms. Niceta Farber 826 18th StreetP. O. Box 167Hoxie, KS 67740

[email protected]: 785-675-3281M: 785-675-3281



Application Form

Organization InformationVerification of tax-exempt status* Organization is:

501(c)(3) public charity

Verification of status Please note: Applications from public charities (501(c)3 organizations) are required to attach verification of charitable status in order to be considered. A state sales tax exemption DOES NOT complete this requirement. Applications from churches and/or government entities are not required to attach a verification document.

Physical Address If the physical address of your organization is different than the mailing address, please enter your physical address below.

Our address is the same as above

Project InformationProject Name* Name of Project.

Acquisition of Intra-facility Call Light System

Amount requested* $86,478.00

Primary objectives* The Foundation has six primary objectives. Which of these does your program or project best addresses:

Health Care

County or Counties Served* Please check the primary county served by the program/project for which you are requesting funds.



DecaturGoveGrahamSheridan

Communities Served* Please list the primary community served by the program/project for which you are requesting funds.

The communities of Decatur, Gove, Graham, and Sheridan will be primarily served by this project.

Strategic Doing Project* Was this application generated through the Strategic Doing initiative?

No

Target Population* Please check one or more populations served by the program/project for which you are requesting funds.

All

Project Description* Briefly describe the program/project for which you are requesting funds.

The goal of this submission is to acquire a Tek-Tone 400 P5 call light system. Like many items in our building, the current call light system was implemented in the 1980’s and is no longer meeting the safety and care needs of our patients and residents. The call light system is now obsolete in the production world, which has left us scouring eBay and third party vendors for parts to repair the current system. We have maintained our current system for the last several years by salvaging unused parts from the existing system and repurposing them to the failed areas. Most recently, we experienced a complete call light failure that affected our thirty-two bed Long Term Care Facility. When this occurred, it put our residents’ safety in immediate jeopardy. In implementing this new system, we are able to create a more patient and resident friendly atmosphere with fewer sounding alarms, better connectivity, and more adaptability to the system. With the new call light system, we are able to easily replace portions of the system by simply unplugging a failed piece and plugging in a replacement. This process would be similar to unplugging a landline phone and plugging in a new one. Our current system requires electrical wiring similar to rewiring a light in your home in order to replace failing portions of it. The Tek-Tone system is backed up onto a master system and can be re-routed to other areas of the Complex to ensure no call light ever goes unanswered. In using the master system, we can also track how long an alarm sounded prior to being answered and log what kind of alarm was pushed. Our current system does not place code blue buttons in any room in the hospital. This inhibits response time to critical events that require immediate attention. The new system would place a “Code Blue” alarm in all areas that provide patient/resident care. In the event we would update the facility or ever move to a new site, this system is easily transferable.

Grant Request Description* If funded, how will you specifically use the Dane G. Hansen funds?



In 2016, we had 6,588 patient days, 570 ER encounters, 1325 outpatient encounters, 25 long term care residents and 8 assisted living residents. For 2017, we've had 6,570 patient days, 474 ER encounters, 843 outpatient encounters, an average of 27 long term care residents, and 10 assisted living residents. Adding a full-time physician to our staff, we have seen encounters increase. If awarded, the new call light system will be ordered immediately. We have begun preparations for the implementation of the system by pulling the necessary wiring and assessing all patient/resident areas. Marketing on social media, our website and in print material recognizing the Dane G. Hansen Foundation’s contribution to this project will take place when notification of the award is received. Preserving our patients and residents’ well-being and maintaining their safety is our highest priority.

Project Objectives* What do you hope to achieve and how will it benefit the people of Northwest Kansas?

Sheridan County Health Complex (SCHC), located in Hoxie, KS, is a Critical Access Hospital serving as the sole medical provider in a rural Medically Underserved Area. We employ 161 individuals at SCHC and strive to stay up to date with technology, specialists, and services as they evolve in the medical field. Our clinic is both a Federally Qualified Health Center and a Safety Net Clinic providing care to the uninsured and underinsured. We also offer Long Term Care and Assisted Living areas. The entire county of Sheridan has been recognized by both Federal and State entities as a Frontier Count designation. Our Mission at SCHC is “to excel at providing quality healthcare close to home.” Without an updated call light system, we fail to meet required safety regulations, which prevent us from admitting residents into our LTC. When we can’t admit patients/residents, we fail to uphold our organizations Mission. We provide care to anyone seeking assistance, and we pride ourselves on meeting the needs of all individuals regardless of their ability to pay. We do this by signing them up for financial assistance plans and government applications through our in-house social services designee. We have partaken in competitive bidding and have found the Tek-Tone system is the best for our facility. Our objectives include implementing a higher quality system that is easier to maintain, has excellent service assistance for our area, and allows the highest patient/resident safety. The proposed call light system will be installed by a company out of WaKeeney, KS and will be maintained by this same company. Until the call light system is up and running, we, with the guidance of governing agencies, have chosen not to admit residents due to the potential patient/resident safety risks. In not being able to admit patients/residents, we lose the opportunity to provide safe care and housing for those individuals who most desperately need our services.

Timetable for the Project* When is the project projected to begin and end? For ongoing projects, when will the Dane G. Hansen funds be utilized?

If our application is awarded the funding, we will put the monies towards our new call light system in its entirety. We have secured support from the Board of Trustees due to the risk that is poses the residents of the facility.

Additional Support Describe additional sources of support (if any) that have been secured or that will be pursued for this project.

We have not pursued other avenues of funding outside of our Organization. Due to the necessity of the system, one will have to be installed regardless of whether the grant is awarded or not. Our hope is to secure these funds through this grant and use Board funds to purchase and implement other quality and safety measures that need installed in our aging facility.



Evaluation* How will you evaluate the success of the project/program? Be specific. (If funded, this will be helpful when completing the final grant report.)

This call light system will be implemented and copious training will be provided to staff. Since this is a life safety code item, the facility will continually assess whether the placement, location, and set up is adequate to care for all patients and residents. With the decrease is sounding alarms, we predict the well-being of our patients and their comfort level will increase exponentially. The push in Long Term Care facilities is to make it a resident centered and as "home-like" as possible. Decreasing unnecessary clamor promotes this type of environment.

Sustainability* How will the project/program be sustained in the future? (For capital projects, how will you maintain or operate the item or facility?)

This project is a crucial part of our infrastructure and an imperative system to keep our patients and residents safe. We expect to have this system as long as we did the old system. With the ease of it, we can change parts, big and small, by simply unplugging on piece and plugging in a new one. The company and system are reputable and will provide service for years to come. Implementing this call light system, we have to ability to upgrade and update the system as our needs grow and change.

Supporting DocumentsProposal Budget* Complete the budget form attached on the Grant Criteria page under document requirements and upload here.

Sheridan County - Nurse Call System (DGH - Budget).xlsx

Balance Sheet* A detailed financial statement is required. Please do not attach your entire audit report. An example can be found on the Grant Criteria page, under document requirements.

Sep 2017 - SCHC BS (Final).pdf

Income Statement* A detailed financial statement is required. Please do not attach your entire audit report. An example can be found on the Grant Criteria page, under document requirements.

Oct - SCHC IS (Final).pdf

http://danehansenfoundation.org/?page_id=988





Board of Directors* Please attach a list of your board members. (Name and title, no biographies.)

2017 Board of Trustees Information.docx

Bid or Quote A copy of the bid or quote is required for a capital project or purchase.

Nurse Call System REVISED Nov 2017.pdf

Letter of Support 1 A letter of support may be attached, but is not required.

HARRY JO PRATT SUPPORT LETTER.pdf

Letter of Support 2 A second letter of support may be attached, but is not required.

Annette Follis Letter of Support.pdf

Letter of Support 3 A third letter of support may be attached, but is not required.

JAMES PEMBERTON SUPPORT LETTER.pdf

Additional Documents If there are additional documents that are critical to the trustees’ understanding of your proposal, upload them here.

Electronic SignatureSignature of Applicant* By entering my full legal name here, I warrant the truthfulness of the information provided in this application.

Hannah Elise Schoendaler

Title of Applicant* Chief Nursing Officer of Acute Care Services



Signature of Principal or College President (if required) By entering my full legal name here, I warrant that I have read and support this application.

Hannah Elise Nemechek

Title of Principal or College President

Signature of CEO, Director, Mayor, etc. If this request is for a City, 501 (c)(3) Organization, Government Entity, etc., the signature of the CEO, Director, Mayor, etc., is required.

By entering my full legal name here, I warrant that I have read and support this application.

Niceta Beth Farber

Title of CEO, Director, Mayor, etc. Chief Executive Officer

InternalTracking Number*

2018-1-1

501c3* Yes



File Attachment SummaryApplicant File Uploads• Sheridan County - Nurse Call System (DGH - Budget).xlsx• Sep 2017 - SCHC BS (Final).pdf• Oct - SCHC IS (Final).pdf• 2017 Board of Trustees Information.docx• Nurse Call System REVISED Nov 2017.pdf• HARRY JO PRATT SUPPORT LETTER.pdf• Annette Follis Letter of Support.pdf• JAMES PEMBERTON SUPPORT LETTER.pdf

Dane G. Hansen Project Budget FormOrganization: Sheridan County Health ComplexProject name: Nurse Call System

List project expenses (be specific) $0.00Nurse Call System (Fire Alarm Specialist, Inc.) Components listed below $123,987.00

Qty 1 - Master Station Touch (Acute) $0.00Qty 2 - Master Station Bridge (LTC) $0.00Qty 64 - Patient Dome Light $0.00Qty 10 - Hall Dome Light $0.00Qty 46 - Code Blue $0.00Qty 48 - Emergency Bath Station $0.00Qty 64 - Patient Single Station $0.00Qty 3 - Patient Double Station $0.00Qty 47 - Patient Call Cord $0.00Qty 70 - Break Away Extention $0.00Qty 50 - Staff Assist Station $0.00Qty 3 - Power Supply $0.00Qty 3 - Battery Back up $0.00Qty 2 - Network Switch - 5 port $0.00Qty 1 - Tekbridge $0.00Qty 1 - License $0.00Qty 1 - Transmitter $0.00Qty 4 - Repeater $0.00Qty 16 - Pager $0.00Qty 1 - Telligence Station Gatewar - C300 $0.00Qty 1 - Telligence Power Switch $0.00Qty 1 - Latest Software $0.00Qty 9 - Batteries $0.00Qty 23 - Pillow Speakers $0.00Truck Cable $0.00Commercial Grade Cable $0.00Conduit (Boxes, Pipe, Misc. Connectors) $0.00

$0.00*Total Project Expenses $123,987.00

Project Revenue Secured Applied-for Earned

In-kind donations can be included- provide equitable dollar amount. Budgeted funds,gifts received, etc

(Grants, Pendingdonations)

(Fees, ticketsales, etc)

Dane G. Hansen Foundation Request $0.00 $86,478.00Insurance Proceeds $32,509.00 $0.00Insurance Deductible $5,000.00 $0.00

$0.00 $0.00 $0.00$0.00 $0.00 $0.00

$0.00 $0.00 $0.00$0.00 $0.00 $0.00$0.00 $0.00 $0.00$0.00 $0.00 $0.00$0.00 $0.00 $0.00$0.00 $0.00 $0.00

TOTALS $0.00 $123,987.00 $0.00

*Total Project Revenue $123,987.00

*Revenue and Expense totals should be the same.

SHERIDAN COUNTY HEALTH COMPLEX10/23/17 12:26 PM BALANCE SHEET FOR THE MONTH ENDING: 09/30/17 Current Year Prior Year Net Change ASSETS CURRENT ASSETS CASH - OPERATING 725,770 1,036,255 (310,485) CASH - CLINIC 200,326 123,540 76,785 CASH - FQHC BOARD FUNDS 250,056 250,056 CASH - CAH BOARD FUNDS 2,013,509 1,577,695 435,814 CASH - WELLNESS CENTER 24,585 18,633 5,952 CASH - AUXILIARY 2,923 4,022 (1,099) CASH - HELPING HANDS 1,471 1,471 PATIENT ACCOUNTS REC - HOSP 1,343,030 1,275,172 67,858 PATIENT ACCOUNTS REC - FQHC 236,914 281,397 (44,483) PHARMACY ACCOUNTS REC 248,209 248,209 ALLOWANCE FOR PHARMACY (230,888) (230,888) ALLOWANCE FOR DOUBTFUL ACCOUNTS (749,400) (649,922) (99,477) NONCAPITAL APPROPRIATIONS (175,422) (14,251) (161,171) ESTIMATED RECEIVABLE - MEDICARE 46,800 (46,800) ESTIMATED RECEIVABLE - MEDICAID 89,814 11,835 77,979 GRANTS RECEIVABLE 176,091 82,455 93,635 NON-PATIENT RECEIVABLE 32,882 32,882 INVENTORY 196,501 117,491 79,010 PREPAID EXPENSES AND OTHER 146,063 32,811 113,251 ----------------- ----------------- ----------------- TOTAL CURRENT ASSETS 4,532,441 3,943,937 588,504 CAPITAL ASSETS PROPERTY PLANT & EQUIPMENT 9,281,601 8,762,632 518,968 ACCUM DEPR PP&E (6,549,958) (6,019,542) (530,416) CONSTRUCTION IN PROGRESS 41,392 41,392 ----------------- ----------------- ----------------- NET CAPITAL ASSETS 2,773,035 2,743,090 29,944 ----------------- ----------------- ----------------- TOTAL ASSETS 7,305,477 6,687,028 618,448 ================= ================= =================

SHERIDAN COUNTY HEALTH COMPLEX10/23/17 12:26 PM BALANCE SHEET FOR THE MONTH ENDING: 09/30/17 Current Year Prior Year Net Change LIABILITIES CURRENT LIABILITIES ACCOUNTS PAYABLE 252,995 31,988 221,007 MEDICARE COST REPORT PAYABLE 175,083 175,083 ACCRUED PAYROLL TAXES/BENEFITS 37,705 31,375 6,330 ACCRUED PAYROLL 409,978 351,963 58,014 OTHER PAYABLES 143,214 15,077 128,136 DEFERRED REVENUE 58,350 40,342 18,007 CURRENT PORTION OF LONG TERM DEBT 92,562 152,968 (60,405) ----------------- ----------------- ----------------- TOTAL CURRENT LIABILITIES 1,169,890 623,715 546,175 LONG TERM LIABILITIES LEASE PAYABLE 8,940 17,880 (8,940) LONG TERM DEBT 607,544 637,724 (30,179) ----------------- ----------------- ----------------- TOTAL LONG TERM LIABILITIES 616,484 655,604 (39,119) TOTAL LIABILITIES 1,786,374 1,279,319 507,055 FUND BALANCE BEGINNING FUND BALANCE 5,552,515 3,789,969 1,762,546 NET INCOME (33,412) 1,617,740 (1,651,152) ----------------- ----------------- ----------------- TOTAL FUND BALANCE 5,519,102 5,407,709 111,393 ----------------- ----------------- ----------------- TOTAL LIABILITIES AND FUND BALANCE 7,305,477 6,687,028 618,448 ================= ================= =================

SHERIDAN COUNTY HEALTH COMPLEX COMPARATIVE INCOME STATEMENT 11/16/17 04:51 PM FOR THE 10 MONTHS ENDING 10/31/17 ----------------- M O N T H ----------------- ---------- Y E A R T O D A T E ------------ ACTUAL BUDGET VARIANCE ACTUAL BUDGET VARIANCE OPERATING REVENUE 168,715 137,250 31,465 INPATIENT 1,400,940 1,372,500 28,440 316,006 243,812 72,194 OUTPATIENT 2,832,126 2,438,120 394,006 390,968 247,328 143,640 SWING BED 2,395,791 2,473,280 (77,488) 45,535 38,086 7,449 EMER ROOM 384,498 380,860 3,638 4,340 4,350 (10) NIGHT CARE 42,560 43,500 (940) 197,100 157,057 40,043 CLINIC (FQHC) 1,658,280 1,570,570 87,710 185,816 180,027 5,789 LONG TERM CARE 1,774,742 1,800,270 (25,527) 20,225 13,986 6,239 ASSISTED LIVING 162,963 139,860 23,103 ------------ ------------ ------------ ------------ ------------ ------------ 1,328,708 1,021,896 306,812 GROSS REVENUE 10,651,903 10,218,960 432,943 (266,009) (165,492) (100,517) CONTR ALLOW-MEDICARE (1,909,200) (1,654,912) (254,288) (200,798) (75,240) (125,558) CONTR ALLOW - OTHER (925,407) (752,400) (173,007) (101,077) (51,500) (49,577) CONTR ALLOW - CLINIC (645,426) (515,000) (130,426) (287) (8,337) 8,049 CHARITY CARE (100,246) (83,370) (16,876) (3,733) (8,826) 5,092 BAD DEBT (73,158) (88,251) 15,092 ------------ ------------ ------------ ------------ ------------ ------------ 756,801 712,501 44,300 NET REVENUE 6,998,464 7,125,027 (126,562) OPERATING EXPENSES 488,054 481,761 (6,293) SALARIES & WAGES 4,721,505 4,817,610 96,104 149,264 101,186 (48,078) FICA & BENEFITS 1,062,275 1,011,860 (50,415) 38,063 51,181 13,117 SUPPLIES 393,522 511,810 118,287 6,342 4,172 (2,170) SMALL EQUIPMENT 54,817 41,720 (13,097) 43,218 20,338 (22,880) DRUGS 304,000 203,380 (100,620) 3,454 6,611 3,156 MAINTENANCE 42,332 66,110 23,777 23,797 12,305 (11,492) MAINTENANCE CONTRACT 158,533 123,050 (35,483) 8,803 8,099 (704) HARDWARE/SOFTWARE 74,839 80,990 6,150 16,694 13,801 (2,893) FOOD 155,598 138,018 (17,580) 6,674 6,499 (175) TRAVEL & EDUC 52,168 64,997 12,828 (79) 19,608 19,687 OTHER EXPENSES 184,209 196,089 11,879 595 3,855 3,259 EQUIP & PROPERTY RENT 39,481 38,550 (931) 130,270 116,301 (13,969) SPECIALIST FEES 1,031,081 1,162,992 131,910 14,405 13,722 (683) UTILITIES 156,370 137,220 (19,150) 713 9,375 8,661 ACCOUNTING FEES 86,273 93,750 7,476 43,556 59,831 16,274 DEPRECIATION 408,174 598,310 190,135 ------------ ------------ ------------ ------------ ------------ ------------ 973,829 928,645 (45,184) TOTAL OPERATING EXPENS 8,925,184 9,286,456 361,271 (217,028) (216,144) (884) OPERATING INCOME/(LOSS) (1,926,720) (2,161,429) 234,708 NON OPERATING REVENUES 41,960 41,960 0 PROPERTY TAX REVENUE 419,601 419,600 1 31,655 32,675 (1,020) SALES TAX REVENUE 317,714 326,750 (9,035) 5,635 16,424 (10,788) NONCAPITAL GRANTS AND GIFTS 175,517 164,240 11,277 95,013 70,889 24,124 NONCAPITAL GRANTS CLINIC 788,453 708,890 79,563 0 33,209 (33,208) 340B DRUG REVENUE (NET) (122,821) 332,090 (454,911) 9,826 11,131 (1,304) OTHER REVENUE 192,090 111,310 80,780 9,979 9,979 0 EHR INCENTIVE 99,794 99,790 4 ------------ ------------ ------------ ------------ ------------ ------------ 194,070 216,267 (22,196) TOTAL NONOPERATING REV 1,870,350 2,162,670 (292,319) (22,957) 123 (23,080) INCREASE IN NET POSITION (56,370) 1,241 (57,611)

Sheridan County Health Complex 2017 Board of Trustees InformationJoy Bretz, Chairman790 S. Road 148EHoxie, KS 67740

(Home) 785-627-4575(Cell) 785-627-6326

[email protected](Elected in 2015)

Lucille Heim, Vice-ChairmanPO Box 234

Hoxie, KS 67740(Cell) 785-675-1615

(Home) [email protected]

(Elected in 2014)

Leanna Sloan, Executive SecretaryPO Box 408

Hoxie, KS 67740(Home) 785-675-3209(Cell) [email protected]

(Elected in 2015)

Ken Eland, TreasurerPO Box 565Hoxie, KS 67740

(Cell) 785-675-8321(Work) [email protected]

(Elected in 2016)

Michael L. Mullins1408 Trail Ave.

PO Box 441Hoxie, KS 67740

(Home) 785-675-1482(Cell) 785-675-1138

[email protected] (Elected in 2016)

mailto:[email protected]





Fire Alarm Specialist, Inc.

29073 S Road, WaKeeney, KS 67672

phone (785) 743-5287 fax (785) 743-5286

e-mail [email protected]

Prompt and Courteous Service Guaranteed!

Sheridan County Hospital November 6, 2017

Hoxie, KS Attn: James

Job: Nurse Call System

Item Description Quantity

TT-MS Master Station Touch (Acute) 1

TTMSB Master Station Bridge (LTC) 1

TT-Dome Patient Dome Light 64

TT-Zone Hall Dome Light 10

TT-CB-WP Code Blue 46

TT-B-WP Emergency Bath Station 48

TT-B-S Patient Single Station 64

TT-B-D Patient Double Station 3

TT-CC Patient Call Cord 47

TT-BAC Break Away Extention 70

TT-SA Staff Assist Station 50

250 Power Supply 3

UPS Battery Back up 3

554 Network Switch – 5 port 2

TB747 TekBridge 1

LIC License 1

54 Transmitter 1

T113 Repeater 4

PGR Pager 16

TT-Gwy Telligence Station Gatewar-C300 1

TT-P-S Telligence Power Switch 1

TT-1251-17 Latest Software 1

12v Batteries 9

TTPS Pillow Speakers 23

Truck Cable

Comm Grade Cable

Conduit

-boxes

-pipe

-misc. connectors

Quote: $123,987.00

Comments: This quote includes equipment, installation, test and certify. Valid for 90

days. Customer is responsible for supplying stamped plans and code footprint, if

required.

Signature: PO#