2022-02-02T16:50:46-06:00 2020-06-30 BKD LLP 211 N BROADWAY SUITE 600 ST LOUIS MO 631022733 990 2019-07-01 370661202 Fairfield Memorial Hospital Association % AMY L MARSH FAIR 6188422611 303 NW 11th Street Fairfield IL 62837 KATHERINE BUNTING CHIEF EXECUTIVE OFFI 6188422611 2022-02-15 true Donna J Larson P00043751 3142315544 2022-02-15 2019 2022-09-23 18:48:47Z X FAIRFIELD MEMORIAL HOSPITAL KATHERINE BUNTING 303 NW 11TH FAIRFIELD IL 62837 34891715 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. 9 7 424 60 0 34952 3386177 31311387 30561249 100076 53080 1141496 891209 32587911 34891715 0 35697 0 0 17271959 19112806 0 0 0 14760020 15454016 32031979 34602519 555932 289196 24318933 32728614 7712428 15832899 16606505 16895715 X THE MISSION OF FAIRFIELD MEMORIAL HOSPITAL IS TO MAINTAIN AND IMPROVE THE HEALTH OF THE COMMUNITIES WE SERVE. false false 28808786 35697 31291475 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. 28808786 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 true true false false false false false false true false false false true 28 0 424 true false false false false false false false false false false false false X 9 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 405171 0 18214 CHRISTOPHER BALLARD PHYSICIAN 40.0 0.0 X 284398 0 10299 KATHERINE BUNTING CHIEF EXECUTIVE OFFICER 40.0 0.0 X 269590 0 8484 MARLA LAFIKES PHYSICIAN 40.0 0.0 X 264607 0 9903 ALEXIS KING CRNA 40.0 0.0 X 255501 0 9721 NICOLE FYIE PHYSICIAN 40.0 0.0 X 213798 0 14637 DANA TAYLOR CHIEF OPERATING OFFICER 40.0 0.0 X 111041 0 2106 AMY MARSH CHIEF FINANCIAL OFFICER 40.0 0.0 X 111350 0 0 PATRICK MOLT MD PRESIDENT 1.75 0.0 X 69913 0 0 CHRISTINA BAKER CHIEF NURSING OFFICER 40.0 0.0 X 56828 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 CLARK GRIFFITH TRUSTEE 1.25 0.0 X 0 0 0 DONNA MASTERSON TRUSTEE 1.25 0.0 X 0 0 0 JAMIE POLLARD TRUSTEE 1.25 0.0 X 0 0 0 TOBY HUCKER TRUSTEE 1.25 0.0 X 0 0 0 JARED VAUGHN TRUSTEE 1.75 0.0 X 0 0 0 DOUG WILSON TRUSTEE 1.25 0.0 X 0 0 0 2042197 0 73364 14 false true false THE HASKELL COMPANY 111 RIVERSIDE AVE JACKSONVILLE FL 32202 DESIGN CONTRACT 192526 DR RODNEY BEELER 2142 KETTLE HILL CT EVANSVILLE IN 47725 ER PHYSICIAN 395798 DR DOUGLAS FRANKEL 407 S MARKET ST MARION IL 62959 ER PHYSICIAN 430930 DR MICHELLE O'NEAL 10345 WILMINGTON DR EVANSVILLE IN 47577 ER PHYSICIAN 315173 DR SCOTT RUSTIO 8422 BROESWOOD ESTATES DR OFALLON IL 62269 ER PHYSICIAN 216385 7 2782399 603778 3386177 NET PATIENT SERVICE REVENUE 621110 30561249 30561249 30561249 53080 53080 0 0 247285 247285 0 247285 247285 0 0 0 0 0 0 0 0 0 0 304B REBATE 900099 463518 463518 CAFETERIA 722514 160983 160983 ALL OTHER REVENUE 900099 19423 19423 643924 34891715 31291475 214063 X 35697 35697 0 0 0 629312 558404 70908 0 14519657 12883638 1636019 143897 127683 16214 2792044 2477447 314597 1027896 912077 115819 0 59722 59722 51600 51600 0 0 0 5320694 4690548 630146 252407 80624 171783 2887344 2696080 191264 0 0 1208040 549759 658281 155523 49677 105846 0 0 369167 281922 87245 0 1281008 1281008 240821 240821 DRUGS 996188 996188 BED AND PROVIDER TAX 845579 845579 REPAIRS AND MAINTANENCE 709241 513977 195264 MEDICAL SUPPLIES 485091 485091 591591 188966 402625 34602519 28808786 5793733 0 1928 1229 2674059 7498663 0 0 4111807 4011296 0 0 0 0 1107571 1121253 582776 688554 583853 708089 45908024 27850558 14501333 18057466 0 0 800 800 0 0 0 0 754806 641264 24318933 32728614 1883356 8164185 0 0 0 0 0 0 0 0 0 0 5092506 5798034 736566 755330 0 1115350 7712428 15832899 X 16507527 16604705 98978 291010 16606505 16895715 24318933 32728614 289196 14 X false true X true false X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 449428 449428 20568782 11911006 8657776 19431841 15939552 3492289 5457973 5457973 18057466 0 DUE TO THIRD PARTIES 1115350 1115350 34860833 34860833 30882 30882 34891715 34571637 34571637 30882 30882 34602519 SCHEDULE D, PART XI, LINE 4b Rebate income reclassified from expenses. SCHEDULE D, PART XII, LINE 4b Rebate income reclassified from expenses. true true X true X true X true true false true true 207194 207194 0.00600 6193028 4545199 1647829 0.04760 6400222 4545199 1855023 0.05360 4100 4100 0.00010 66860 66860 0.00190 35697 35697 0.00100 106657 106657 0.00300 6506879 4545199 1961680 0.05660 true 3287948 821987 12460931 13544631 -1083700 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 1 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. 300. X X true true X X X true X 0 X 0 X 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: PRIORITY #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 NOTE S - UNCOMPENSATED CARE AND COMMUNITY BENEFIT IN SUPPORT OF ITS MISSION, THE HOSPITAL VOLUNTARILY PROVIDES CARE TO PATIENTS AT LESS THAN ITS ESTABLISHED CHARGES FOR PATIENTS THAT MEET THE HOSPITAL'S CHARITY CARE CRITERIA. BECAUSE THE HOSPITAL DOES NOT PURSUE COLLECTION OF AMOUNTS DETERMINED TO QUALIFY AS CHARITY CARE, THEY ARE NOT REPORTED IN NET PATIENT SERVICES REVENUE. IN ADDITION, THE HOSPITAL PROVIDES SERVICES TO OTHER MEDICALLY INDIGENT PATIENTS UNDER CERTAIN GOVERNMENT-REIMBURSED PUBLIC AID PROGRAMS. SUCH PROGRAMS PAY PROVIDERS AMOUNTS WHICH ARE LESS THAN ESTABLISHED CHARGES FOR THE SERVICES PROVIDED TO THE RECIPIENTS AND MANY TIMES THE PAYMENTS ARE LESS THAN THE COST OF RENDERING THE SERVICES PROVIDED. THE HOSPITAL'S TOTAL COST OF UNCOMPENSATED CARE RELATING TO THESE SERVICES AND OTHER SERVICES ARE AS FOLLOWS: CHARITY CARE $207,194 STATE MEDICAID AND OTHER PUBLIC PROGRAMS $1,760,714 UNCOLLECTIBLE ACCOUNTS $1,024,532 THE UNCOMPENSATED CARE COST OF STATE MEDICAID AND OTHER PUBLIC AID PROGRAMS IS DETERMINED BY COMPUTING THE COST OF PROVIDING THAT CARE LESS AMOUNTS PAID BY THE PROGRAM. IN ADDITION TO THE ABOVE COST OF UNCOMPENSATED CARE, THE HOSPITAL ALSO COMMITS SIGNIFICANT TIME AND RESOURCES TO ENDEAVORS AND CRITICAL SERVICES WHICH MEET OTHERWISE UNFULFILLED COMMUNITY NEEDS. MANY OF THESE ACTIVITIES ARE SPONSORED WITH KNOWLEDGE THAT THEY WILL NOT BE SELF-SUPPORTING OR FINANCIALLY VIABLE. 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, 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 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 269590 0 0 0 0 0 5392 0 3092 0 278074 0 ALEXIS KING CRNA 255501 0 0 0 0 0 4730 0 4991 0 265222 0 CHRISTOPHER BALLARD PHYSICIAN 271991 0 0 0 12407 0 5308 0 4991 0 294697 0 NICOLE FYIE PHYSICIAN 209325 0 0 0 4473 0 3896 0 10741 0 228435 0 MARLA LAFIKES PHYSICIAN 258131 0 0 0 6476 0 4912 0 4991 0 274510 0 WESLEY THOMPSON PHYSICIAN 390971 0 0 0 14200 0 7723 0 10491 0 423385 0 PATRICK MOLT SURGEON AND BOARD CHAIR 69912 CALL COVERAGE false NICOLE FYIE WIFE OF BOARD MEMBER 213798 EMPLOYED PHYSICIAN false 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. 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. Amended return FORM 990 IS BEING AMENDED BASED UPON COMPLETION OF THE ORGANIZATION'S AUDIT REPORT, WHICH WAS STILL OUTSTANDING AT THE TIME FORM 990 WAS REQUIRED TO BE FILED. THE FOLLOWING SECTIONS OF FORM 990 HAVE BEEN CHANGED: PART III, LINE 4A, PART VIII, PART IX, PART X, PART XI, SCHEDULE D, PARTS XI AND XII, SCHEDULE H, PART I, LINE 7, SCHEDULE H, PART III, LINES 2 & 3, AND SCHEDULE H, PART VI NOTE FOR PART III, LINE 4. FORM 990, PART VI, SECTION B, LINE 11B THE FORM 990 WAS REVIEWED BY CFO AND DISCUSSED WITH CPA FIRM REGARDING QUESTIONS; TAKEN TO FULL BOARD MEETING FOR APPROVAL; REVIEWED AND SIGNED BY CEO. FORM 990 PART IX LINE 11G DESCRIPTION:PURCHASED SERVICES TOTAL FEES:3401916 FORM 990 PART IX LINE 11G DESCRIPTION:PHYSICIAN SERVICES TOTAL FEES:1918778 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