2022-05-12T16:47:05-05:00 2021-06-30 BKD LLP 211 N BROADWAY SUITE 600 ST LOUIS MO 631022733 990 2020-07-01 370661202 Fairfield Memorial Hospital Association % AMY L MARSH FAIR 6188422611 303 NW 11TH STREET FAIRFIELD IL 62837 AMY MARSH CHIEF FINANCIAL OFFI 6188422611 2022-05-15 true KATHERINE BUNTING 999009999 Donna J Larson P00043751 3142315544 2022-05-15 2 2020 2022-09-23 18:48:47Z KATHERINE BUNTING 303 NW 11TH ST FAIRFIELD IL 62837 43663128 false X FAIRFIELDMEMORIAL.ORG X 1948 IL THE MISSION OF FAIRFIELD MEMORIAL HOSPITAL IS TO MAINTAIN AND IMPROVE THE HEALTH OF THE COMMUNITIES WE SERVE. 8 7 423 60 0 3386177 6803262 30561249 36165428 53080 41351 891209 653087 34891715 43663128 35697 0 0 0 19112806 19759501 0 0 0 15454016 17224140 34602519 36983641 289196 6679487 32728614 49011590 15832899 25436388 16895715 23575202 X THE MISSION OF FAIRFIELD MEMORIAL HOSPITAL IS TO MAINTAIN AND IMPROVE THE HEALTH OF THE COMMUNITIES WE SERVE. false false 31351309 36801766 AS A NOT-FOR-PROFIT COMMUNITY HOSPITAL, FAIRFIELD MEMORIAL IS A CHARITABLE ORGANIZATION THAT EXISTS TO ADVANCE THE HEALTH OF THE RESIDENTS OF WAYNE COUNTY AND SURROUNDING COMMUNITIES. FAIRFIELD MEMORIAL HOSPITAL OPERATES A RURAL HEALTHCARE FACILITY WITH 25 ACUTE CARE BEDS AND 30 SKILLED CARE BEDS. IN AUGUST 2008 THE HOSPITAL OPENED AN OUTPATIENT PHYSICIAN CLINIC. FAIRFIELD MEMORIAL HOSPITAL PROVIDES QUALITY MEDICAL HEALTHCARE REGARDLESS OF RACE, CREED, SEX, NATIONAL ORIGIN, HANDICAP, AGE, OR ABILITY TO PAY. ALTHOUGH REIMBURSEMENT FOR SERVICES RENDERED IS CRITICAL TO THE OPERATION AND STABILITY OF FAIRFIELD MEMORIAL HOSPITAL, IT IS RECOGNIZED THAT NOT ALL INDIVIDUALS POSSESS THE ABILITY TO PURCHASE ESSENTIAL MEDICAL SERVICES. THEREFORE, IN KEEPING WITH THIS CORPORATION'S COMMITMENT TO SERVE ALL MEMBERS OF THE COMMUNITIES WE SERVE. THE COMMUNITY, FREE CARE AND/OR SUBSIDIZED CARE, CARE PROVIDED TO PERSONS COVERED BY GOVERNMENTAL PROGRAMS AT BELOW COST, AND HEALTH ACTIVITIES AND PROGRAMS TO SUPPORT THE COMMUNITY WILL BE CONSIDERED WHERE THE NEED AND/OR INDIVIDUALS INABILITY TO PAY COEXISTS. THE COMMUNITY BENEFITS CAN BE MEASURED IN MANY WAYS INCLUDING: DIRECT PATIENT CARE, SCREENINGS, EDUCATION, FUNDRAISING, AND COMMUNITY SERVICE EFFORTS OF OUR COLLEAGUES. THE HOSPITAL PROVIDES CARE TO PERSONS COVERED BY GOVERNMENTAL PROGRAMS, PROVIDING SERVICES TO BOTH MEDICARE AND MEDICAID PATIENTS. CHARITY CARE IS ALSO PROVIDED THROUGH THE HOSPITAL'S INTERNAL POLICY. 31351309 true true false false false false false false false false true false false false true true true false false false false false false false false false true true false false true false false false false false false true false false false false false false true false false false true 22 0 423 true false false false false false false false false false false false false X 8 7 false false false false false false false true true false false true true true true true true true false false IL X AMY L MARSH 6188478260 303 NW 11TH FAIRFIELD IL 62837 WESLEY THOMPSON PHYSICIAN 40.0 0.0 X 367609 0 27815 CHRISTOPHER BALLARD PHYSICIAN 40.0 0.0 X 339375 0 28155 KATHERINE BUNTING CHIEF EXECUTIVE OFFICER 40.0 0.0 X 324830 0 12451 MARLA LAFIKES PHYSICIAN 40.0 0.0 X 276206 0 28741 ALEXIS KING CRNA 40.0 0.0 X 255644 0 12488 CAROLINE NEFF PHYSICIAN 40.0 0.0 X 257279 0 5060 AMY MARSH CHIEF FINANCIAL OFFICER 40.0 0.0 X 121038 0 6295 DANA TAYLOR CHIEF OPERATING OFFICER 40.0 0.0 X 116242 0 9716 CHRISTINA BAKER CHIEF NURSING OFFICER 40.0 0.0 X 97499 0 6295 PATRICK MOLT MD PRESIDENT 1.75 0.0 X 0 0 0 JOSEPH HUNGERFORD VICE PRESIDENT 1.75 0.0 X 0 0 0 ANITA POND SECRETARY/TREASURER 1.75 0.0 X 0 0 0 DONNA MASTERSON TRUSTEE 1.25 0.0 X 0 0 0 DOUG WILSON TRUSTEE 1.25 0.0 X 0 0 0 JAMIE POLLARD TRUSTEE 1.25 0.0 X 0 0 0 JARED VAUGHN TRUSTEE 1.25 0.0 X 0 0 0 TOBY HUCKER TRUSTEE 1.25 0.0 X 0 0 0 CLARK GRIFFITH TRUSTEE 1.25 0.0 X 0 0 0 2155722 0 137016 17 false true false THE HASKELL COMPANY 111 RIVERSIDE AVE JACKSONVILLE FL 32202 DESIGN CONTRACT 5323451 DR DOUGLAS FRANKEL 407 S MARKET MARION IL 62959 ER PHYSICIAN 464937 DR MICHELLE O'NEILL 10345 WILMINGTON DR EVANSVILLE IN 47577 ER PHYSICIAN 244929 DR RODNEY BEELER 2142 KETTLE HILL CT EVANSVILLE IN 47725 ER PHYSICIAN 403477 DR MARK ROTICH 1401 DANIELLE CT MARION IL 62959 ER PHYSICIAN 218221 10 113220 5421852 1268190 6803262 NET PATIENT SERVICE REVENUE 621110 36165428 36165428 36165428 41351 41351 0 0 237073 237073 0 237073 237073 0 0 0 0 0 0 0 0 0 0 304B REBATE 900099 187253 187253 CAFETERIA 722514 16749 16749 ALL OTHER REVENUE 900099 212012 212012 416014 43663128 36801766 58100 X 0 0 0 0 694366 621023 73343 0 14556134 13018623 1537511 167019 149377 17642 3290080 2942561 347519 1051902 940794 111108 0 15120 15120 69232 69232 0 0 0 5340569 4112364 1228205 290344 92751 197593 2772725 2589053 183672 0 0 1266242 1266242 103416 33036 70380 0 0 398786 281291 117495 0 1378754 1378754 217239 217239 DRUGS 1352293 1352293 BED AND PROVIDER TAX 960210 960210 REPAIRS AND MAINTANENCE 731237 531622 199615 MEDICAL SUPPLIES 496129 496129 1831844 585186 1246658 36983641 31351309 5632332 0 1229 1432 7498663 9756584 0 0 4011296 5223700 0 0 0 0 1121253 1056562 688554 649434 708089 956292 59856527 29229312 18057466 30627215 0 0 800 800 0 0 0 0 641264 739571 32728614 49011590 8164185 6363876 0 0 0 0 0 0 0 0 0 0 5798034 17938643 755330 515260 1115350 618609 15832899 25436388 X 16604705 22952422 291010 622780 16895715 23575202 32728614 49011590 6679487 X false true X true true true X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 449428 449428 20875516 12514737 8360779 19922227 16714575 3207652 18609356 18609356 30627215 0 DUE TO THIRD PARTIES 618609 618609 43663128 43663128 43663128 36983641 36983641 36983641 true true X true X true X true true false true true 244761 244761 0.00700 7476062 3919393 3556669 0.09600 7720823 3919393 3801430 0.10300 6080 6080 140212 140212 0.00400 146292 146292 0.00400 7867115 3919393 3947722 0.10700 true 1126591 281647 12286837 15922282 -3635445 X true true 1 1 FAIRFIELD MEMORIAL HOSPITAL 303 NW 11TH STREET FAIRFIELD IL 62837 WWW.FAIRFIELDMEMORIAL.ORG 320005545 X X X X FAIRFIELD MEMORIAL HOSPITAL false false true X X X X X X X X X 19 true false false true X SEE SUPPLEMENTAL STATEMENT X true 19 true SEE SUPPLEMENTAL STATEMENT false true X 200. 400. X X true true X X X true X 0 X 0 X X X X X X X true X false X X X X true X false false SCHEDULE H, PART V, SECTION B, LINE 5 THE HOSPITAL TOOK INTO ACCOUNT INPUT FROM PERSONS WHO REPRESENT THE BROAD INTERESTS OF THE COMMUNITY SERVED BY THE HOSPITAL. THESE , INCLUDED THOSE WITH SPECIAL KNOWLEDGE OF, OR EXPERTISE IN PUBLIC HEALTH (LOCAL, REGIONAL, STATE AND/OR TRIBAL), MEMBERS OF THE MEDICALLY UNDERSERVED, LOW-INCOME, AND MINORITY POPULATIONS SERVED BY THE HOSPITAL AND/OR INDIVIDUALS OR ORGANIZATIONS REPRESENTING THE INTERESTS OF SUCH POPULATIONS. THE MEDICALLY UNDERSERVED ARE MEMBERS OF A POPULATION WHO EXPERIENCE HEALTH DISPARITIES, ARE AT RISK OF NOT RECEIVING ADEQUATE MEDICAL CARE AS A RESULT OF BEING UNINSURED OR UNDERINSURED, AND /OR EXPERIENCING BARRIERS TO HEALTHCARE DUE TO GEOGRAPHIC, LANGUAGE, FINANCIAL, AND OTHER BARRIERS. MEMBERS OF THE CHNA STEERING COMMITTEE, ALONG WITH THOSE WHO PARTICIPATED IN FOCUS GROUPS, AND THE NEEDS INDENTIFICATION AND PRIORITIZATION PROCESS, WERE CHOSEN BASED ON THEIR UNIQUE EXPERTISE AND EXPERIENCE, INFORMED PERSPECTIVE, AND INVOLVEMENT WITH THE COMMUNITY. THE CHNA STEERING COMMITTEE MEMBERS INCLUDED: -A GROCERY STORE MANAGER -A PUBLIC TRANSPORTATION MANAGER -A SCHOOL ADMINISTRATOR -A PHYSICIAN/SURGEON -A COUNTY HEALTH DEPARTMENT ADMINISTRATOR -A PHARMACIST FROM THE COMMUNITY -A FAMILY PRACTICE PHYSICIAN -A BEHAVIORAL THERAPIST SCHEDULE H, PART V, SECTION B, LINES 7A AND 10A WWW.FAIRFIELDMEMORIAL.ORG/RESOURCES/COMMUNITY-REPORTS/ SCHEDULE H, PART V, SECTION B, LINE 11 THE FACILITY'S IMPLEMENTATION STRATEGY PRIORITIZED FOUR NEEDS AS FOLLOWS: PRORITY #1 - REDUCE OBESITY - THE FACILITY WILL EXPLORE PROVIDING COMMUNITY EDUCATION PROGRAMS FROM THE NUTRITIONIST - THE FACILITY WILL EXPLORE YOUTH EDUCATION AND AWARENESS PROGRAMS - THE FACILITY WILL REESTABLISH A WEIGHT LOSS CLINIC - THE FACILITY WILL OFFER COMMUNITY EDUCATION THROUGH SOCIAL MEDIA ABOUT SEDENTARY LIFESTYLES - THE FACILITY WILL OFFER COMMUNITY EDUCATION THROUGH SOCIAL MEDIA ABOUT FAST FOODS AND HEALTHY DIETS -THE FACILITY WILL OFFER COMMUNITY EDUCATION THROUGH SOCIAL MEDIA ABOUT THE IMPORTANCE OF PHYSICAL ACTIVITY AND RECREATION AND WHERE OPPORTUNITIES FOR BOTH CAN BE FOUND IN THE COMMUNITY THE FACILITY PLANS TO DEDICATE VARIOUS PROGRAMS/RESOURCES TO ADDRESS THESE NEEDS INCLUDING ADMINISTRATION, A NUTRITIONIST, MARKETING, PHYSICAL THERAPY, PHYSICIAN ASSISTANT AND FUNDS. THE FACILITY WILL COLLABORATE WITH OTHER ORGANIZATIONS - SCHOOLS, PUBLIC HEALTH, PARK DISTRICT, AND GYMS AND OTHER EXERCISE AND RECREATION FACILITIES. PRIORITY #2 - ADDRESS SUBSTANCE ABUSE THROUGH EXPANDED PREVENTION EDUCATION AT YOUNG AGES - THE FACILITY WILL EXPLORE FORMATION OF A SADD PROGRAM OR SIMILAR YOUTH PREVENTION EFFORT WITH HIGH SCHOOL STUDENTS - THE FACILITY WILL COLLABORATE WITH SCHOOLS TO BRING APPROPRIATE SUBSTANCE ABUSE PREVENTION PROGRAMS TO STUDENTS. THE FACILITY PLANS TO DEDICATE VARIOUS PROGRAMS/RESOURCES TO ADDRESS THESE NEEDS INCLUDING ADMINISTRATION, BEHAVIORAL HEALTH AND FUNDS. THE FACILITY WILL COLLABORATE WITH OTHER ORGANIZATIONS - SCHOOL ADMINISTRATORS, PERSONS WITH EXPERTISE IN YOUTH ORGANIZING AND PROGRAMMING, LAW ENFORCEMENT, AND PUBLIC HEALTH. PRIORITY #3 - EXPANDED ACCESS TO DETOXIFICATION -THE FACILTY WILL EXPLORE THE FEASIBILITY OF LOCAL INPATIENT DETOXIFICATION -THE FACILITY WILL EXPLORE AVAILABLE PARTNERS FOR A DETOXIFICATION CENTER FOR TRANSFERS THE FACILITY PLANS TO DEDICATE VARIOUS PROGRAMS/RESOURCES TO ADDRESS THESE NEEDS INCLUDING ADMINISTRATION, PHYSICIANS AND FUNDS. THE FACILITY WILL COLLABORATE WITH OTHER ORGANIZATIONS - REGIONAL PARTNERS PRIORITY #4 - EXPAND LOCAL SERVICES FOR SUICIDE AND OTHER MENTAL HEALTH CRISES -THE FACILITY WILL BUILD A NEW EMERGENCY ROOM WITH TWO DEDICATED PSYCHIATRIC USE ROOMS -THE FACILITY WILL HIRE A CRISIS INTERVENTIONIST THE FACILITY PLANS TO DEDICATE VARIOUS PROGRAMS/RESOURCES TO ADDRESS THESE NEEDS INCLUDING ADMINISTRATION, SOCIAL SERVICES, EMERGENCY PHYSICIANS AND FUNDS. THE FACILITY WILL COLLABORATE WITH OTHER ORGANIZATIONS - LAW ENFORCEMENT AND REGIONAL MENTAL HEALTH SERVICES. ALL NEEDS IDENTIFIED BY THE STEERING GROUP WERE ADDRESSED IN THE IMPLEMENTATION STRATEGY. SCHEDULE H, PART V, SECTION B, LINE 16J THE POLICY IS VERBALLY DISCUSSED WITH ALL SELF-PAY PATIENTS. 1 HORIZON HEALTHCARE 213 NW 10TH STREET SUITE A FAIRFIELD IL 62837 OUTPATIENT PHYSICIAN CLINIC SCHEDULE H, PART I, LINE 7 THE FAIRFIELD MEMORIAL HOSPITAL ASSOCIATION USED A COST TO CHARGE RATIO AS CALCULATED FROM WORKSHEET 2, RATIO OF PATIENT CARE COST-TO-CHARGES, INCLUDED IN THE SCHEDULE H INSTRUCTIONS TO DETERMINE THE AMOUNTS ON LINE 7 OF PART I OF SCHEDULE H. SCHEDULE H, PART III, SECTION A, LINE 2 THE HOSPITAL CALCULATED BAD DEBT EXPENSE AT COST USING THE COST TO CHARGE RATIO AS CALCULATED USING WORKSHEET 2 OF THE SCHEDULE H INSTRUCTIONS. PATIENT ACCOUNTS ARE WRITTEN OFF TO BAD DEBT ONLY AFTER ALL COLLECTION PROCEDURES HAVE BEEN EXHAUSTED AS OUTLINED IN SCHEDULE H, PART III, LINE 9B. PATIENT ACCOUNTS ARE WRITTEN OFF TO BAD DEBT AFTER ALL DISCOUNTS AND PAYMENTS HAVE BEEN APPLIED. SCHEDULE H, PART III, SECTION A, LINE 3 BASED ON THE HOSPITAL'S EXPERIENCE WITH ALL ITS PATIENTS, THEY ESTIMATE THAT IT IS LIKELY THAT UP TO ONE FOURTH OF THE PATIENT ACCOUNTS WRITTEN OFF TO BAD DEBTS MAY QUALIFY FOR CHARITY CARE OR OTHER ASSISTANCE BUT CHOSE NOT TO APPLY. THEREFORE, 25% OF THE BAD DEBT EXPENSE WAS INCLUDED ON PART III, LINE 3 AT COST. SCHEDULE H, PART III, SECTION A, LINE 4 Patient accounts receivable are reduced by an allowance for doubtful accounts. In evaluating the collectability of accounts receivable, the Hospital analyzes it's history and identifies trends for each of its major payer sources of revenue to estimate the appropriate allowance for doubtful accounts and provision for uncollectible accounts. Management regularly reviews data about these major payer sources of revenue in evaluating the sufficiency of the allowance for doubtful accounts. For receivables associated with services provided to patients who have third-party coverage, the Hospital analyzes contractually due amounts and provides an allowance for doubtful accounts and a provision for uncollectible accounts, if necessary (for example, for expected uncollectible deductibles and copayments on accounts for which the third-party payer has not yet paid, or for payers who are known to be having financial difficulties that make the realization of amounts due unlikely. For receivables associated with self-pay patients (which includes both patients without insurance and patients with deductible and copayment balances due for which third-part coverage exists for part of the bill), the Hospital records a significant provision for uncollectible accounts in the period of service on the basis of its past experience, which indicates that many patients are unable or unwilling to pay the portion of their bill for which they are financially responsible. The difference between the standard rates (or the discounted rates if negotiated or provided by policy) and the amounts actually collected after all reasonable collection efforts have been exhausted is charged off against the allowance for doubtful accounts. SCHEDULE H, PART III, SECTION B, LINE 8 UNPAID COST OF MEDICARE REPRESENTS THE COST (DETERMINED USING THE OVERALL COST TO CHARGE RATIO) OF PROVIDING SERVICES TO PRIMARILY ELDERLY BENEFICIARIES OF THE MEDICARE PROGRAM, IN EXCESS OF PAYMENTS FOR THOSE SERVICES. IRS REVENUE RULING 69-545, WHICH ESTABLISHED THE COMMUNITY BENEFIT STANDARD FOR NONPROFIT HOSPITALS, STATES THAT IF A HOSPITAL SERVES PATIENTS WITH GOVERNMENT HEALTH BENEFTIS, INCLUDING MEDICARE, THEN THIS IS AN INDICATION THAT THE HOSPITAL OPERATES TO PROMOTE THE HEALTH OF THE COMMUNITY. THIS IMPLIES THAT TREATING MEDICARE PATIENTS IS A COMMUNITY BENEFIT. SCHEDULE H, PART III, SECTION C, LINE 9B FAIRFIELD MEMORIAL HOSPITAL APPLIES ITS COLLECTION PRACTICES EQUALLY TO ALL PATIENTS, BOTH CHARITY CARE ELIGIBLE AND NON CHARITY CARE ELIGIBLE. THE PROCEDURE FOR COLLECTION ON PATIENT ACCOUNTS IS AS FOLLOWS: SELF-PAY ACCOUNTS AND ACCOUNTS WITH BALANCES AFTER INSURANCE ARE SENT A LETTER REQUESTING PAYMENT. IF NO RESPONSE IS RECEIVED WITHIN 35 DAYS, THE ACCOUNT IS TRANSFERRED TO EARLY-OUT DEPARTMENT FOR A FOLLOW UP STATEMENT/PHONE CALL TO THE PATIENT. THE HOSPITAL OFFERS THE PATIENTS SEVERAL PAYMENT ALTERNATIVES, INCLUDING CASH/CHECK FOR THE FULL AMOUNT, CREDIT CARD, SHORT TERM MONTHLY INSTALLMENTS BASED ON OUTSTANDING BALANCE. SPECIAL PAYMENT ARRANGEMENTS CAN BE MADE UPON REQUEST AND COMPLETION OF A CREDIT APPLICATION WHICH WILL BE VERIFIED AND APPROVED BY THE BUSINESS OFFICE DIRECTOR. IF PAYMENT OR SATISFCTORY PAYMENT ARRANGEMENTS AS OUTLINED ABOVE ARE NOT MADE, THE ACCOUNT WILL PROCEED THROUGH A COLLECTION PROCESS AS FOLLOWS: DAY 1 1ST NOTICE DAY 7-14 FIRST PHONE CALL IS MADE; AT LEAST ONE PHONE CALL OR NOTICE PER WEEK FOR THE REMAINDER OF THE EARLY OUT 90 DAYS DAY 75 DEMAND NOTICE DAY 90 ACCOUNT IS SENT TO COLLECTIONS. ANY ACCOUNT THAT IS SENT TO COLLECTIONS MAY BE TURNED OVER TO AN ATTORNEY, AND ADDITIONAL COSTS ASSOCIATED WITH COLLECTIONS WILL BE ADDED TO THE ACCOUNT. SCHEDULE H, PART VI, LINE 2 THE DETERMINATION OF CURRENT AND FUTURE HEALTHCARE NEEDS OF THE COMMUNITY OR COMMUNITIES SERVED BY FAIRFIELD MEMORIAL HOSPITAL IS BASED ON ALL OR A COMBINATION OF THE FOLLOWING FACTORS: EXISTENCE OR NON EXISTENCE OF SERVICES, OPPORTUNITY, SUPPLY, DEMONSTRATED NEED, "VOICE OF THE CUSTOMER",COLLABORATIVE EFFORTS WITH OUTSIDE ENTITIES, COMMUNITY BASED NEEDS ASSESSMENT, GOVERNMENT AGENCIES, OTHER HEALTHCARE PROVIDERS THAT WOULD ENABLE THE FILLING OF A NEED OR ENHANCE AND COMPLIMENT AN ALREADY EXISTING SERVICE. DATA IS GATHERED CONSTANTLY THROUGH BENCHMARKING, MARKET RESEARCH, CUSTOMER SURVEYS, PHYSICIAN INPUT, AND THROUGH CONSTANT MONITORING OF STATE AND FEDERAL GUIDELINES. THIS INFORMATION IS REVIEWED AND ANALYZED BY THE HOSPITAL'S SENIOR LEADERSHIP AND INCORPORATED INTO THE STRATEGIC PLANNING PROCESS. SCHEDULE H, PART VI, LINE 3 SIGNS ARE POSTED IN THE FACILITY. THE PATIENT'S BILL INFORMS THEM OF FINANCIAL ASSISTANCE PROGRAM. THE HOSPITAL WEBSITE HAS A LINK TO THE FINANCIAL ASSISTANCE APPLICATION. THE SOCIAL SERVICES DEPARTMENT SPEAKS TO ALL INPATIENTS ABOUT THE PROGRAM. SCHEDULE H, PART VI, LINE 4 FAIRFIELD MEMORIAL HOSPITAL SERVES THE POPULATION OF WAYNE COUNTY AND THE SURROUNDING COMMUNITIES WITHOUT REGARD TO AGE, GENDER, INCOME, ETHNIC ORIGIN, INSURANCE COVERAGE, OR ABILITY TO PAY. WAYNE COUNTY IS A RURAL AREA WITH AN ESTIMATED POPULATION OF 16,495. THE MEDIAN INCOME IN 2018 WAS 46,405, WHICH WAS 75.8% OF ILLINOIS' AVERAGE. THE PERCENT OF INDIVIDUALS BELOW POVERTY WAS 14%. SCHEDULE H, PART VI, LINE 5 FAIRFIELD MEMORIAL HOSPITAL HAS A COMMUNITY BOARD, MADE UP OF MEMBERS FROM DIFFERENT OCCUPATIONS IN THE COMMUNITY, INCLUDING MEDICAL, EDUCATION, LOCAL BUSINESSES, FARMING INDUSTRY AND BANKING. SCHEDULE H, PART VI, LINE 6 N/A SCHEDULE H, PART VI, LINE 7 LIST OF STATES RECEIVING COMMUNITY BENEFIT REPORT: ILLINOIS X X X X false false false false false false false false KATHERINE BUNTING CHIEF EXECUTIVE OFFICER 324830 0 0 0 0 0 5142 0 7309 0 337281 0 WESLEY THOMPSON PHYSICIAN 359937 0 0 0 7672 0 5700 0 22115 0 395424 0 CHRISTOPHER BALLARD PHYSICIAN 325147 0 0 0 14228 0 5103 0 23052 0 367530 0 MARLA LAFIKES PHYSICIAN 270250 0 0 0 5956 0 5689 0 23052 0 304947 0 CAROLINE NEFF PHYSICIAN 219120 0 0 0 38159 0 0 0 5060 0 262339 0 ALEXIS KING CRNA 255644 0 0 0 0 0 5179 0 7309 0 268132 0 NICOLE FYIE WIFE OF BOARD MEMBER 218371 EMPLOYED PHYSICIAN false FORM 990, PART VI, SECTION B, LINE 11B THE CFO REVIEWS THE 990 AFTER IT IS COMPLETED BY BKD, PRIOR TO BEING FINALIZED. ONCE REVIEWED, IT IS GIVEN TO CEO, FOR REVIEW. AT THE NEXT BOARD MEETING, AFTER THE DOCUMENT IS REVIEWED BY CEO, THE DOCUMENT IS AVAILABLE TO FOR THE BOARD TO REVIEW. THE CFO/CEO ADDRESS ANY COMMENTS OR QUESTIONS FROM THE BOARD DURING THE BOARD MEETING. THE 990 PREPARERS (BKD) ARE NOTIFIED THAT THE DOCUMENT IS APPROVED BY THE HOSPITAL. FORM 990, PART VI, SECTION B, LINE 12C ANNUALLY EACH BOARD MEMBER RECEIVES THE CORPORATE COMPLIANCE POLICY WHICH INCLUDES CONFLICT OF INTEREST POLICY, TO REVIEW AND SIGN STATING THEY HAVE READ, AND DISCLOSED ANY CONFLICT OF INTERESTS; ALL SIGNED DOCUMENTS ARE KEPT ON FILE IN ADMINISTRATION OFFICE. FORM 990, PART VI, SECTION B, LINE 15A FALL 2019; SEVERAL MARKET REPORTS WERE COMPILED AND REVIEWED, INCLUDING BECKERS HOSPITAL REVIEW, CEO COMPENSATION REPORT. THE CFO REQUESTED AND WAS PROVIDED DATA FROM THE AUDIT FIRM, WHO PROVIDED DATA OF CEO COMPENSATION BY SIZE OF HOSPITAL AND REGION. ALL REPORTS WERE PROVIDED BY CFO TO THE BOARD PRESIDENT FOR REVIEW. THE BOARD PRESIDENT THEN SUPPLIED THE DOCUMENTS TO THE COMPENSATION COMMITTEE OF THE BOARD, WHO REVIEWED THE DOCUMENTS, AND ESTABLISHED A RATE FOR THE CEO. THE COMPENSATION COMMITTEE PRESENTED THE RATE TO THE FULL BOARD FOR APPROVAL. THE CEO'S CONTRACT IS IN EFFECT FOR 5 YEARS. FORM 990, PART VI, SECTION C, LINE 19 COPIES OF THE ORGANIZATIONS GOVERNING DOCUMENTS, CONFLICT OF INTEREST POLICIES, FINANCIAL STATEMENTS AND THE FEDERAL FORM 990 TAX RETURNS ARE AVAILABLE UPON REQUEST FROM THE ADMINISTRATIVE OFFICES. FORM 990, PART IV, LINE 20B AS OF THE DATE OF THE FILING OF FORM 990, THE AUDIT OF THE FINANCIAL STATEMENTS WAS NOT COMPLETE. THEREFORE, A COPY OF THE PRIOR YEAR AUDITED FINANCIAL STATEMENTS WAS ATTACHED TO THE RETURN. FORM 990 PART IX LINE 11G DESCRIPTION:PURCHASED SERVICES TOTAL FEES:3422365 FORM 990 PART IX LINE 11G DESCRIPTION:PHYSICIAN SERVICES TOTAL FEES:1918204 FAIRFIELD MEMORIAL HOSPITAL FOUNDATION 303 NW 11TH ST FAIRFIELD IL 62837 371185754 SUPPORT IL 501(C)(3) 12B NA false false false true false false false false false false false false false false false false false false false false FAIRFIELD MEMORIAL HOSPITAL FOUNDATION C 113220 CASH