2019-11-14T14:54:41-06:00 2018-12-31 990 2018-01-01 420710268 KEOKUK AREA HOSPITAL KEOK 3195247150 1600 MORGAN STREET KEOKUK IA 52632 MIKE MAHER BOARD MEMBER 3195247150 2019-11-11 205.167.2.34 2019-11-11 16:27:18 CS P 4949FBDB2613D44DD524226BE936F6A9962DEEB1 4949FBDB2613D44DD524226BE936F6A9962DEEB1 2018 2020-03-31 21:24:44Z MIKE MAHER 1600 MORGAN STREET KEOKUK IA 52632 12535784 0 X WWW.UNITYPOINT.ORG/KEOKUK X 1975 IA IMPROVING COMMUNITY HEALTH & ACCESS TO QUALITY HEALTHCARE SERVICES REGARDLESS OF ABILITY TO PAY. 10 9 277 9 0 0 13515 107866 17345146 12329510 -28291 5354 319915 93054 17650285 12535784 0 0 0 0 11917662 11927087 0 0 0 7520084 11216287 19437746 23143374 -1787461 -10607590 13881182 12381657 13244072 22352670 637110 -9971013 IMPROVING COMMUNITY HEALTH AND ENSURING ACCESS TO QUALITY HEALTHCARE SERVICES REGARDLESS OF ABILITY TO PAY. 0 0 17791855 0 12352062 KEOKUK AREA HOSPITAL (KAH) IS A NOT-FOR-PROFIT ACUTE CARE HOSPITAL FULLY ACCREDITED BY THE JOINT COMMISSION. ANNUALLY, KAH SERVICES APPROXIMATELY 1,000 ADMISSIONS, 230,000 OUTPATIENT PROCEDURES AND 12,000 EMERGENCY ROOM VISITS TO THE RESIDENTS OF KEOKUK, IOWA AND SURROUNDING AREAS. KAH ALSO HAS A HOME HEALTH AGENCY THAT SERVICES OVER 7,200 PATIENTS PER YEAR FROM LEE COUNTY, IA AND HANCOCK COUNTY, IL. THE HOSPITAL HAS APPROXIMATELY 120 CREDENTIALED PHYSICIANS ON THE MEDICAL STAFF AND IS GOVERNED BY THE KEOKUK HEALTH SYSTEMS BOARD OF DIRECTORS WHICH IS MADE UP OF LOCAL COMMUNITY MEMBERS. 17791855 1 1 0 0 0 0 0 0 0 0 1 0 0 0 1 1 0 1 0 0 0 0 0 0 0 0 1 1 0 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 1 0 0 0 1 29 0 1 277 1 0 0 0 0 0 0 0 0 0 0 X 10 9 0 0 0 0 1 1 1 1 1 0 0 1 1 1 1 1 1 1 1 0 X X KRIS KARRE DIRECTOR OF FINANCE & ACCOUNTING 3195247150 1600 MORGAN STREET KEOKUK IA 52632 JESSICA BOWMAN BOARD MEMBER (FR 4/18) 1.00 1.00 X 0 0 0 NEVILLE CRENSHAW DO BOARD MEMBER (TO 4/18) 1.00 1.00 X 0 0 0 PAUL EALEY BOARD MEMBER 1.00 1.00 X 0 0 0 CAREY GEHL BOARD MEMBER & UPH EXEC DIR GROWTH 1.00 40.00 X 0 223644 32641 KIRAN KHANOLKAR MD BOARD MEMBER 1.00 1.00 X 0 0 0 MIKE MAHER BOARD MEMBER 1.00 1.00 X 0 0 0 KENT NIXON BOARD VICE CHAIR/TREASURER 1.00 1.00 X X 0 0 0 TOM RICHARDSON BOARD MEMBER 1.00 1.00 X 0 0 0 RON SCOTT BOARD MEMBER 1.00 1.00 X 0 0 0 BARB SMIDT BOARD MEMBER 1.00 1.00 X 0 0 0 JACK SMITH BOARD MEMBER 1.00 1.00 X 0 0 0 WALT STEPHENS BOARD CHAIR 1.00 1.00 X X 0 0 0 WENDY SWANK BOARD SECRETARY 1.00 1.00 X X 0 0 0 ELIZABETH DAVIS PHARMACY DIRECTOR 40.00 0.00 X 122061 0 20145 JAGADAMBA KANTANMENI MD ANESTHESIOLOGIST 40.00 0.00 X 302862 0 1080 DONZA WORDEN CHIEF CLINICAL OFFICER 40.00 0.00 X 192684 0 20857 617607 223644 74723 3 0 1 0 SHARED MEDICAL SERVICES INC 209 LIMESTONE PASS COTTAGE GROVE WI 53527 HEALTHCARE SERVICES 195885 MAYO COLLABORATIVE SERVICES INC 200 SW FIRST STREET ROCHESTER MN 55905 LABORATORY SERVICES 118196 2 35000 72866 107866 NET PATIENT REVENUE 900099 12209011 12209011 RENTAL REVENUE 532000 112957 112957 MGMT & SUPPORT SVCS 561000 108349 108349 MISCELLANEOUS REVENUE 900099 -100807 -100807 12329510 4736 4736 618 0 618 618 618 CAFETERIA/LAUNDRY/MISC 900099 70502 70502 MISCELLANEOUS REVENUE 900099 22552 22552 93054 12535784 12352062 0 75856 X 10035384 7966613 2068771 20920 16607 4313 1272137 1009889 262248 598646 475237 123409 339318 339318 113314 113314 4089721 1560320 2529401 60885 60885 404644 266561 138083 1491786 1491786 674064 662624 11440 47226 37970 9256 1532 1532 550523 550523 815331 815331 68458 68458 MEDICAL SUPPLIES 2528621 2529086 -465 MISCELLANEOUS EXPENSE 30864 30864 23143374 17791855 5351519 0 1763628 1065605 2670174 2434955 4231846 4276797 1009598 949243 53268 89544 27469289 24081074 3988170 3388215 164498 177298 13881182 12381657 4141144 5804226 -189385 4423297 4060547 50000 48152 4629631 12629130 13244072 22352670 X 638706 -9982159 -1596 11146 637110 -9971013 13881182 12381657 X -10607590 -533 X 0 1 X 1 0 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 438675 438675 17122972 15461949 1661023 7363710 6228832 1134878 2543932 2390293 153639 3388215 IOWA HEALTH SYSTEM NOTE PAYABLE 8935683 DUE TO AFFILIATES 3679089 SELF INSURANCE RESERVE 14358 12629130 X 12523000 0 12523000 12784 12784 12535784 21652000 412 412 21651588 1491786 1491786 23143374 PART X, LINE 2: UNITYPOINT HEALTH AND MOST OF ITS SUBSIDIARIES ARE CLASSIFIED AS TAX-EXEMPT ORGANIZATIONS AS DESCRIBED IN SECTIONS 501(C)(3) AND 501(C)(2) OF THE INTERNAL REVENUE CODE (THE CODE). TAX-EXEMPT ORGANIZATIONS ARE NOT SUBJECT TO FEDERAL AND STATE INCOME TAXES ON RELATED INCOME, PURSUANT TO SECTION 501(A) OF THE CODE. THESE ORGANIZATIONS ARE SUBJECT TO FEDERAL AND STATE INCOME TAXES TO THE EXTENT THEY HAVE UNRELATED BUSINESS INCOME AS DESCRIBED UNDER PROVISIONS OF SECTION 511 OF THE CODE. THE SYSTEM FILES FORM 990 FOR SUBSTANTIALLY ALL OF ITS OPERATING ENTITIES IN THE U.S. FEDERAL JURISDICTION AND IS NO LONGER SUBJECT TO EXAMINATION BY TAX AUTHORITIES FOR THE YEARS BEFORE 2015. THE SYSTEM HAS NO MATERIAL UNCERTAIN TAX POSITIONS. CERTAIN SUBSIDIARIES ARE SUBJECT TO FEDERAL AND STATE INCOME TAXES. SOME OF THESE CORPORATIONS HAVE ACCUMULATED NET OPERATING LOSS CARRYFORWARDS THAT ARE AVAILABLE TO OFFSET FUTURE TAXABLE INCOME, IF ANY, DURING THE CARRYFORWARD PERIOD. DEFERRED TAX ASSETS AND LIABILITIES RELATED TO THESE SUBSIDIARIES WERE NOT MATERIAL. PART XI, LINE 4B - OTHER ADJUSTMENTS: REVENUE IN TEMPORARILY FUND BALANCE 12,742. ROUNDING 42. PART XII, LINE 2D - OTHER ADJUSTMENTS: ROUNDING 412. PART XII, LINE 4B - OTHER ADJUSTMENTS: EXPENSES IN TEMPORATILY FUND BALANCE 1,491,786. 1 1 1 X 1 X 600.000000000000 1 1 0 1 1 228512 228512 0.00990 1279482 1279482 0.05530 68920 68920 0.00300 1576914 1576914 0.06820 14961 14961 0.00060 131235 131235 0.00570 20100 20100 0.00090 166296 166296 0.00720 1743210 1743210 0.07540 57643 57643 0.00250 57643 57643 0.00250 1 689858 6997843 9622164 -2624321 X 1 1 1 1 KEOKUK AREA HOSPITAL 1600 MORGAN STREET KEOKUK IA 52632 WWW.KEOKUKHEALTHSYSTEMS.ORG 560054H X X X KEOKUK AREA HOSPITAL 1 0 0 1 X X X X X X X X 16 1 1 1 1 X WWW.UNITYPOINT.ORG/KEOKUK 1 16 1 WWW.UNITYPOINT.ORG/KEOKUK 0 1 X 200.000000000000 600.000000000000 X X X X X X X 1 1 X X X X 1 X WWW.UNITYPOINT.ORG/KEOKUK/FINANCIAL-ASSISTANCE.ASPX X WWW.UNITYPOINT.ORG/KEOKUK/FINANCIAL-ASSISTANCE.ASPX X WWW.UNITYPOINT.ORG/KEOKUK/FINANCIAL-ASSISTANCE.ASPX X X X X X X 1 X 0 X X X X 1 X 0 0 KEOKUK AREA HOSPITAL PART V, SECTION B, LINE 5: KEOKUK AREA HOSPITAL, LEE COUNTY HEALTH DEPARTMENT AND FORT MADISON COMMUNITY HOSPITAL ONCE AGAIN COLLABORATED TO BRING MULTIPLE COMMUNITY MEMBERS AND PARTNERSHIPS TOGETHER TO COMPLETE THE COUNTY'S COMMUNITY HEALTH NEEDS ASSESSMENT. THE PROCESS IDENTIFIED FOUR SPECIFIC HEALTH NEEDS TO ADDRESS IN THE COUNTY'S HEALTH IMPROVEMENT PLAN FOR THE NEXT THREE YEARS. ON SEPTEMBER 22, 2015, 38 REPRESENTATIVES FROM A VARIETY OF COMMUNITY SECTORS MET TO REVIEW AND EVALUATE COUNTY LEVEL DATA/ HEALTH INDICATORS, COMMUNITY-WIDE SURVEY RESULTS, AND DISCUSS COMMUNITY ASSETS AND RESOURCES AVAILABLE TO ADDRESS THE NEEDS OF THE COUNTY. ATTENDEES INCLUDED REPRESENTATIVES FROM KEOKUK AREA HOSPITAL, LEE COUNTY BOARD OF HEALTH, LEE COUNTY HEALTH DEPARTMENT, FORT MADISON COMMUNITY HOSPITAL, CHILDREN FIRST EARLY CHILDHOOD IOWA, LEE COUNTY COMMUNITY SERVICES/SOUTHEAST IOWA LINK OF DISABILITY SERVICES, FORT MADISON HY-VEE, THE KENSINGTON, ISU EXTENSION AND OUTREACH, FORT MADISON YMCA, FORT MADISON POLICE DEPARTMENT, LEE COUNTY BENEFITS COORDINATOR, GROUP BENEFIT PARTNERS, CITY OF KEOKUK, LEE COUNTY SHERIFF, COUNSELING ASSOCIATES, COMMUNITY HEALTH CENTERS OF SOUTHEASTERN IOWA, INC., AND FORT MADISON PARTNERS. KEOKUK AREA HOSPITAL PART V, SECTION B, LINE 6A: KEOKUK AREA HOSPITAL'S CHNA WAS PERFORMED WITH FORT MADISON COMMUNITY HOSPITAL. KEOKUK AREA HOSPITAL PART V, SECTION B, LINE 6B: KEOKUK AREA HOSPITAL'S CHNA WAS PERFORMED WITH THE LEE COUNTY HEALTH DEPARTMENT. KEOKUK AREA HOSPITAL PART V, SECTION B, LINE 7D: A COPY OF THE CHNA IS AVAILABLE UPON REQUEST. KEOKUK AREA HOSPITAL PART V, SECTION B, LINE 11: -INCREASED DIABETES EDUCATION AND TEACHING OFFERINGS AND FOCUSED ON PROMOTION TO TARGETED POPULATIONS.-EVALUATED UNIQUE AND INNOVATIVE OPPORTUNITIES TO INCREASE MENTAL HEALTH/BEHAVIORAL HEALTH SERVICES. -PROVIDED HEALTH INFORMATION AND EDUCATION RANGING FROM TRANSPORTATION ASSISTANCE TO HEALTHY FOOD GUIDES TO CUSTOMERS AND COMMUNITY MEMBERS.-ACTIVELY PARTICIPATED WITH THE LIVE HEALTH LEE COUNTY COALITION INITIATIVES TO PROMOTE HEALTHY BEHAVIORS AND RESOURCES.-WERE ACTIVE MEMBERS OF THE KEOKUK DENTAL RECRUITMENT TASK FORCE AND ACTIVELY ENGAGED IN THE KEOKUK CHAMBER OF COMMERCE RECRUITMENT INITIATIVES.SOME OF THE HEALTH NEEDS IDENTIFIED THROUGH THE ASSESSMENT WERE ALREADY BEING ADDRESSED IN THE SERVICE AREA BY THE LEE COUNTY HEALTH DEPARTMENT AND FORT MADISON COMMUNITY HOSPITAL AND COMMUNITY GROUPS THROUGHOUT LEE COUNTY. KEOKUK AREA HOSPITAL PART V, SECTION B, LINE 13H: PATIENTS WHO QUALIFY AND ARE RECEIVING BENEFITS FROM THE FOLLOWING PROGRAMS MAY BE PRESUMED ELIGIBLE FOR 100% FINANCIAL ASSISTANCE: THE US. DEPARTMENT OF AGRICULTURE FOOD AND NUTRITION SERVICE FOOD STAMP PROGRAM; WOMEN, INFANTS & CHILDREN (WIC); AND VARIOUS COUNTY AND STATE RELIEF PROGRAMS. THIRD PARTY AGENCIES ARE USED TO ASSIST WITH COLLECTIONS AND, IF THOSE AGENCIES PROVIDE A STATEMENT REGARDING A PATIENT'S LIKELY INCOME LEVEL, THAT INFORMATION IS USED IN DETERMINING THE ELIGIBILITY STATUS AND THE LEVEL OF DISCOUNT AVAILABLE. 1 1 - TRI-STATE MEDICAL GROUP 1600 MORGAN STREET KEOKUK IA 52632 PRIMARY CARE CLINIC PART I, LINE 6A: KEOKUK AREA HOSPITAL'S COMMUNITY BENEFIT REPORT IS CONTAINED WITHIN THE IOWA HEALTH SYSTEM COMMUNITY BENEFIT REPORT WHICH CAN BE LOCATED AT WWW.UNITYPOINT.ORG. THIS SYSTEM-WIDE REPORT IS COMPLETED IN ADDITION TO THE COMMUNITY BENEFIT REPORT FOR THE HOSPITAL AND ITS REGIONAL AFFILIATES. PART I, LINE 7: A COST-TO-CHARGE RATIO (FROM WORKSHEET 2) IS USED TO CALCULATE THE AMOUNTS ON LINE 7A. THE AMOUNTS ON LINES 7B-7C (UNREIMBURSED MEDICAID AND OTHER MEANS-TESTED GOVERNMENT PROGRAMS) ARE OBTAINED FROM A COST ACCOUNTING SYSTEM OF APPLICABLE PATIENT SEGMENTS. SEGMENTS NOT PASSED TO COST ACCOUNTING SYSTEM USE COST-TO-CHARGE RATIO. THE AMOUNTS FOR LINES 7E, F, H, AND I WOULD COME FROM THE BOOKS AND RECORDS OF SPECIFIC SEGMENTS OF THE ORGANIZATION AND ARE BASED ON COST. THE AMOUNTS ON 7G ARE DERIVED FROM A COST ACCOUNTING SYSTEM OF APPLICABLE PATIENT SEGMENTS. SEGMENTS NOT PASSED TO A COST ACCOUNTING SYSTEM USE THE COST-TO-CHARGE RATIO. PART I, LINE 7G: REPRESENTS THE SUBSIDY TO TRI-STATE MEDICAL GROUP, INC. TO COVER UNCOMPENSATED HEALTHCARE COSTS. PART II, COMMUNITY BUILDING ACTIVITIES: KEOKUK AREA HOSPITAL'S COMMUNITY BUILDING ACTIVITIES PROMOTE THE HEALTH OF THE COMMUNITY THROUGH INCREASED EDUCATION AND TRAINING OF HEALTHCARE RELATED ISSUES AS WELL AS PROMOTING CAREER DEVELOPMENT IN THE HEALTHCARE FIELD. PART III, LINE 4: THE HEALTH SYSTEM PROVIDES AN ALLOWANCE FOR DOUBTFUL ACCOUNTS BASED UPON A REVIEW OF OUTSTANDING RECEIVABLES, HISTORICAL COLLECTION INFORMATION AND EXISTING ECONOMIC CONDITIONS. AS A SERVICE TO THE PATIENT, THE HEALTH SYSTEM BILLS THIRD-PARTY PAYERS DIRECTLY AND BILLS THE PATIENT WHEN THE PATIENT'S LIABILITY IS DETERMINED. PATIENT ACCOUNTS RECEIVABLE ARE DUE IN FULL WHEN BILLED. ACCOUNTS ARE CONSIDERED DELINQUENT AND SUBSEQUENTLY WRITTEN OFF AS BAD DEBTS BASED ON INDIVIDUAL CREDIT EVALUATION AND SPECIFIC CIRCUMSTANCES OF THE ACCOUNT.THE AMOUNT REPORTED ON LINE 2 WAS CALCULATED USING IRS WORKSHEET 2 'RATIO OF PATIENT CARE COST TO CHARGES' TO CALCULATE THE COST TO CHARGE RATIO FOR ALLEN MEMORIAL HOSPITAL. THIS RATIO WAS THEN APPLIED AGAINST THE BAD DEBT ATTRIBUTABLE TO PATIENT ACCOUNTS USING IRS WORKSHEET A TO ARRIVE AT THE BAD DEBT EXPENSE AT COST REPORTED ON LINE 2. PART III, LINE 8: AMOUNTS ON LINE 6 WERE CALCULATED USING IRS WORKSHEET B 'TOTAL MEDICARE ALLOWABLE COSTS.' THE MEDICARE ALLOWABLE COSTS WERE OBTAINED FROM THE MEDICARE COST REPORTS AND THEN REDUCED BY ANY AMOUNTS ALREADY CAPTURED IN COMMUNITY BENEFIT EXPENSE IN PART I ABOVE.THE METHODOLOGY DESCRIBED IN THE INSTRUCTIONS TO SCHEDULE H, PART III SECTION B, LINE 6 DOES NOT TAKE INTO ACCOUNT ALL COSTS INCURRED BY THE HOSPITAL AND DOES NOT REPRESENT THE TOTAL COMMUNITY BENEFIT CONFERRED IN THIS AREA. THE MEDICARE SURPLUS REFLECTED ON SCHEDULE H, PART III, SECTION B WAS DETERMINED USING INFORMATION FROM THE ORGANIZATION'S MEDICARE COST REPORT. HOWEVER THE MEDICARE COST REPORT DISALLOWS CERTAIN ITEMS THAT WE BELIEVE ARE LEGITIMATE EXPENSES INCURRED IN THE PROCESS OF CARING FOR OUR MEDICARE PATIENTS. EXAMPLES OF THESE ITEMS INCLUDE PROVIDER BASED PHYSICIAN EXPENSE, SELF INSURANCE EXPENSE, HOME OFFICE EXPENSE AND THE SHORTFALL FROM FEE SCHEDULE PAYMENTS. THE HOSPITAL BELIEVES THE ENTIRE AMOUNT OF THE MEDICARE SHORTFALL SHOULD BE TREATED AS COMMUNITY BENEFIT, MORE SPECIFICALLY, AS CHARITY CARE. THE ELDERLY CONSTITUTE A CLEARLY-RECOGNIZED CHARITABLE CLASS, AND MANY MEDICARE BENEFICIARIES, LIKE THEIR MEDICAID COUNTERPARTS, ARE POOR AND THUS WOULD HAVE QUALIFIED FOR THE HOSPITAL'S CHARITY CARE PROGRAM, MEDICAID OR OTHER NEEDS-BASED GOVERNMENT PROGRAMS ABSENT THE MEDICARE PROGRAM. BY ACCEPTING PAYMENT BELOW COST TO TREAT THESE INDIVIDUALS, THE BURDENS OF GOVERNMENT ARE RELIEVED WITH RESPECT TO THESE INDIVIDUALS. ADDITIONALLY, THERE IS A SIGNIFICANT POSSIBILITY THAT CONTINUED REDUCTION IN REIMBURSEMENT MAY ACTUALLY CREATE DIFFICULTIES IN ACCESS FOR THESE INDIVIDUALS. FINALLY, THE AMOUNT SPENT TO COVER THE MEDICARE SHORTFALL IS MONEY NOT AVAILABLE TO COVER CHARITY CARE AND OTHER COMMUNITY BENEFIT NEEDS. PART III, LINE 9B: AFTER THE PATIENT MEETS THE QUALIFICATIONS FOR FINANCIAL ASSISTANCE, THE ACCOUNT BALANCE IS PARTIALLY OR ENTIRELY WRITTEN OFF, AS APPROPRIATE. ANY REMAINING BALANCE, IF ANY, WOULD BE COLLECTED UNDER THE NORMAL DEBT COLLECTION POLICY. PART VI, LINE 2: KEOKUK AREA HOSPITAL PARTICIPATES WITH MANY HEALTH RELATED ORGANIZATIONS TO ASSESS HEALTHCARE NEEDS IN LEE COUNTY, IOWA AND SHARES THE RESULTS IN A WRITTEN COMMUNITY HEALTH NEEDS ASSESSMENT WHICH IS AVAILABLE ON THE WEBSITE OR BY REQUEST. PART VI, LINE 3: THE HOSPITAL COMMUNICATES THE AVAILABILITY OF FINANCIAL ASSISTANCE TO ALL PATIENTS AND WITHIN THE COMMUNITY. COPIES OF THE FINANCIAL ASSISTANCE POLICY, FINANCIAL ASSISTANCE APPLICATION AND PLAIN LANGUAGE SUMMARY ARE AVAILABLE BY MAIL, ON EACH HOSPITAL'S WEBSITE, AND IN PERSON AT EACH HOSPITAL. THE CENTRAL BILLING OFFICE IS AVAILABLE BY PHONE TO ANSWER QUESTIONS ABOUT THE POLICY, OR PATIENTS SHOULD GO TO THE CASHIER'S OFFICE AT THE HOSPITAL TO OBTAIN THIS INFORMATION. THE PLAIN LANGUAGE SUMMARY IS OFFERED AS PART OF THE PATIENT INTAKE AND/OR DISCHARGE PROCESS AND INCLUDED WHEN A PATIENT IS SENT WRITTEN NOTICE THAT EXTRAORDINARY COLLECTION ACTIONS MAY BE TAKEN AGAINST HIM/HER. THE FINANCIAL ASSISTANCE POLICY, THE PLAIN LANGUAGE SUMMARY, AND ALL FINANCIAL ASSISTANCE FORMS ARE AVAILABLE IN ENGLISH AND IN ANY OTHER LANGUAGE IN WHICH LIMITED ENGLISH PROFICIENCY (LEP) POPULATIONS CONSTITUTE THE LESSER OF 1,000 PERSONS OR MORE THAN 5% OF THE COMMUNITY SERVED BY THE HOSPITAL. THESE TRANSLATED DOCUMENTS WILL BE AVAILABLE BY MAIL, ON EACH HOSPITAL'S WEBSITE, AND IN PERSON AT EACH HOSPITAL. PART VI, LINE 4: KEOKUK HOSPITAL IS A 49 BED COMMUNITY HOSPITAL SERVING THE MIDWEST REGION. KEOKUK HOSPITAL IS NONDENOMINATIONAL AND SERVES ALL WHO COME HERE, REGARDLESS OF REASON OR CIRCUMSTANCE.90% OF KEOKUK HOSPITAL MARKET RESIDENTS LIVE WITHIN THE IOWA COUNTIY OF LEE. KEOKUK HOSPITAL ADMITS APPROXIMATELY 530 INPATIENTS AND CARES FOR 10,000 EMERGENCY PATIENTS PER YEAR. MEDIAN HOUSEHOLD INCOME IS $54,605 AND THE AVERAGE POVERTY RATE IS 12.2%.69.4% OF KEOKUK HOSPITAL'S INPATIENTS ARE ELIGIBLE FOR MEDICARE OR MEDICAID. PART VI, LINE 5: KEOKUK AREA HOSPITAL HAS AN ALL VOLUNTEER BOARD OF DIRECTORS MADE UP OF LOCAL COMMUNITY MEMBERS WHO SERVE WITHOUT COMPENSATION. THE MEDICAL STAFF IS OPEN TO ALL INTERESTED PROVIDERS WHO ARE APPROPRIATELY CREDENTIALED. ALL FUNDS GENERATED BY THE HOSPITAL ARE UTILIZED FOR PATIENT RELATED SERVICES AND TO ENSURE THAT ALL PATIENTS IN THE MARKET HAVE ACCESS TO QUALITY HEALTHCARE SERVICES REGARDLESS OF ABILITY TO PAY. PART VI, LINE 6: THE HOSPITAL IS PART OF IOWA HEALTH SYSTEM (D/B/A UNITYPOINT HEALTH). THROUGH RELATIONSHIPS WITH 36 HOSPITALS IN METROPOLITAN AND RURAL COMMUNITIES AND MORE THAN 280 PHYSICIAN CLINICS, UNITYPOINT HEALTH PROVIDES CARE THROUGHOUT IOWA, WESTERN ILLINOIS, AND SOUTHERN WISCONSIN.UNITYPOINT HEALTH ENTITIES EMPLOY A LARGE NONPROFIT WORKFORCE, WITH MORE THAN 30,000 EMPLOYEES WORKING TOWARD INNOVATIVE ADVANCEMENTS TO DELIVER THE BEST OUTCOME FOR EVERY PATIENT EVERY TIME. EACH YEAR, THROUGH MORE THAN 6.5 MILLION PATIENT VISITS, UNITYPOINT HEALTH HOSPITALS AND CLINICS PROVIDE A FULL RANGE OF CARE TO PATIENTS AND FAMILIES. WITH ANNUAL REVENUES OF $4.4 BILLION, UNITYPOINT HEALTH IS THE FIFTH LARGEST NONDENOMINATIONAL HEALTH SYSTEM IN AMERICA AND PROVIDES COMMUNITY BENEFIT PROGRAMS AND SERVICES TO IMPROVE THE HEALTH OF PEOPLE IN ITS COMMUNITIES. UNITYPOINT HEALTH AND ITS AFFILIATES ENGAGE IN COMMUNITY HEALTH PROGRAMS AND SERVICES THROUGHOUT IOWA, AND WORK WITH VOLUNTEER AND CIVIC ORGANIZATIONS, SCHOOLS, BUSINESSES, INSURERS AND INDIVIDUALS TO SUPPORT ACTIVITIES THAT BENEFIT PEOPLE THROUGHOUT THE STATE. IN 2018, UNITYPOINT HEALTH AND ITS AFFILIATES PROVIDED MORE THAN $559 MILLION OF COMMUNITY BENEFIT. THE CONTRIBUTIONS TO THEIR COMMUNITIES BY UNITYPOINT HEALTH AND ITS AFFILIATES ARE REPORTED IN DETAIL IN STATEMENT OF PROGRAM SERVICE ACCOMPLISHMENTS (PART III) OF THE IRS FORM 990 OF THOSE AFFILIATES. PART VI, LINE 7, REPORTS FILED WITH STATES IA X X X X 0 0 0 0 0 0 0 0 0 CAREY GEHL BOARD MEMBER & UPH EXEC DIR GROWTH 0 188633 0 22596 0 12415 0 11254 0 21387 0 256285 0 0 JAGADAMBA KANTANMENI MD ANESTHESIOLOGIST 302283 0 0 0 579 0 0 0 1080 0 303942 0 0 0 DONZA WORDEN CHIEF CLINICAL OFFICER 192105 0 0 0 579 0 0 0 20857 0 213541 0 0 0 PART I, LINE 3 CEO/EXECUTIVE SALARY IS APPROVED BY THE BOARD OF DIRECTORS AFTER REVIEW BY EXECUTIVE COMMITTEE USING VARIOUS BENCHMARK DATA, INCLUDING 990 DATA OF SIMILAR HOSPITALS, IOWA HOSPITAL ASSOCIATION SALARY SURVEYS AND EXPERIENCE LEVEL OF CANDIDATE. FORM 990, PART VI, SECTION A, LINE 6 KEOKUK HEALTH SYSTEMS INC., A TAX-EXEMPT IOWA NONPROFIT CORPORATION, IS THE SOLE MEMBER. FORM 990, PART VI, SECTION A, LINE 7A THE SOLE MEMBER, KEOKUK HEALTH SYSTEMS, INC., HAS THE POWER TO NOMINATE AND APPOINT BOARD OF DIRECTORS. FORM 990, PART VI, SECTION A, LINE 7B THE SOLE MEMBER, KEOKUK HEALTH SYSTEMS, INC., HAS THE POWER TO APPROVE CHANGES IN ARTICLES AND BYLAWS, DISSOLUTIONS OR MERGER, AND APPOINT BOARD OF DIRECTORS. IN ADDITION, AT LEAST TWO BOARD MEMBERS MUST ALSO BE BOARD MEMBERS OF KEOKUK HEALTH SYSTEMS, INC. FORM 990, PART VI, SECTION B, LINE 11B THE FORM 990 IS PREPARED INTERNALLY BY THE IOWA HEALTH SYSTEM TAX DEPARTMENT USING INFORMATION GATHERED FROM VARIOUS FUNCTIONAL AREAS OF THE ORGANIZATION. EACH SECTION OF THE RETURN IS REVIEWED BY THE RESPONSIBLE FUNCTIONAL AREA ALONG WITH THE TAX DEPARTMENT. A DRAFT COPY OF THE RETURN IS PROVIDED TO THE CFO FOR REVIEW. A FULL COPY OF THE FORM 990 IS PROVIDED TO THE BOARD OF DIRECTORS PRIOR TO FILING WITH THE IRS. FORM 990, PART VI, SECTION B, LINE 12C THE ORGANIZATION HAS A CONFLICT OF INTEREST POLICY. ANNUALLY ALL OFFICERS, DIRECTORS, KEY EMPLOYEES AND REPORTING PHYSICIANS ARE REQUESTED TO COMPLETE A QUESTIONNAIRE TO REPORT POTENTIAL CONFLICTS OF INTEREST. PERSONS WHO HAVE NOT RETURNED QUESTIONNAIRES ARE CONTACTED ADDITIONAL TIMES IN AN EFFORT TO RECEIVE COMPLETE AND ACCURATE RESPONSES FROM ALL PERSONS. THE ANNUAL QUESTIONNAIRES INCLUDE AN ACKNOWLEDGEMENT THAT THE OFFICER, DIRECTOR, KEY EMPLOYEE OR REPORTING PHYSICIAN: 1) HAS ACCESS TO A COPY OF THE CONFLICT OF INTEREST POLICY; 2) HAS READ AND UNDERSTANDS THE POLICY; 3) AGREES TO COMPLY WITH THE POLICY; 4) UNDERSTANDS THAT THE POLICY APPLIES TO ALL COMMITTEES AND SUBCOMMITTEES HAVING BOARD-DELEGATED POWERS; AND 5) UNDERSTANDS THAT THE ORGANIZATION IS A CHARITABLE ORGANIZATION AND THAT IN ORDER TO MAINTAIN ITS TAX-EXEMPT STATUS, IT MUST CONTINUOUSLY ENGAGE PRIMARILY IN ACTIVITIES WHICH ACCOMPLISH ONE OR MORE OF ITS TAX-EXEMPT PURPOSES. SENIOR ADMINISTRATIVE STAFF AT ALL RELATED ORGANIZATIONS PROVIDE INFORMATION TO A CENTRAL COORDINATOR RELATED TO THE IDENTIFICATION OF WHICH INDIVIDUALS SHOULD RECEIVE THE QUESTIONNAIRE FOR COMPLETION. THE RESULTS ARE COMPILED CENTRALLY AND REVIEWED BY THE IOWA HEALTH SYSTEM COMPLIANCE OFFICER AND DIRECTOR OF INTERNAL AUDIT. THE DETAIL RESULTS ARE REPORTED TO A COMMITTEE OF THE SYSTEM BOARD. THE RESULTS RELATED TO SPECIFIC REGIONAL PARENT COMPANIES, THEIR HOSPITALS AND RELATED ORGANIZATIONS, ARE DISTRIBUTED IN DETAIL TO THE CHAIRPERSON OF THE REGIONAL PARENT ORGANIZATION, THE CHIEF EXECUTIVE OFFICER, CHIEF FINANCIAL OFFICER AND COMPLIANCE MANAGER. THESE INDIVIDUALS ARE ALSO REMINDED OF THE APPROPRIATE PROCESS TO BE FOLLOWED DURING THE YEAR TO ADDRESS POTENTIAL CONFLICTS OF INTEREST THAT RELATE TO MATTERS THAT ARE BROUGHT TO THE BOARD OF DIRECTORS FOR ACTION. THE INFORMATION DISCLOSED IS USED TO IDENTIFY POTENTIAL CONFLICTS OF INTEREST AND TO ASSIST IN COMPLETING IRS AND MEDICAID QUESTIONNAIRES. ANY DUALITY OF INTEREST OR POSSIBLE CONFLICT OF INTEREST ON THE PART OF ANY ORGANIZATIONAL OFFICER, DIRECTOR, KEY EMPLOYEE OR REPORTING PHYSICIAN TOGETHER WITH ALL MATERIAL FACTS, SHOULD BE DISCLOSED TO THE BOARD OF DIRECTORS AND MADE A MATTER OF RECORD, EITHER THROUGH AN ANNUAL PROCEDURE OR WHEN THE INTEREST OCCURS OR BECOMES A MATTER OF BOARD ACTION. ANY ORGANIZATIONAL OFFICER, DIRECTOR, KEY EMPLOYEE OR REPORTING PHYSICIAN HAVING A CONFLICT OF INTEREST IN ANY MATTER SHOULD NOT BE PRESENT DURING GENERAL DISCUSSION NOR VOTE OR USE HIS OR HER PERSONAL INFLUENCE ON THE MATTER, AND HE OR SHE SHOULD NOT BE COUNTED IN DETERMINING THE EXISTENCE OF A QUORUM FOR PURPOSES OF THE MATTER OR ITEM AS TO WHICH A CONFLICT EXISTS. THE BOARD SHOULD EXCLUDE THE INDIVIDUAL FROM ANY DISCUSSION OR VOTE IN WHICH THE BOARD DECIDES WHETHER OR NOT A CONFLICT OF INTEREST EXISTS. IN CASES IN WHICH AN OFFICER, DIRECTOR, KEY EMPLOYEE, REPORTING PHYSICIAN OR THE INDIVIDUAL'S HOUSEHOLD MEMBER HAS A CONFLICT OF INTEREST IN AN ARRANGEMENT OR TRANSACTION, THE FOLLOWING ADDITIONAL STEPS MAY BE TAKEN AT THE DIRECTION OF THE BOARD OF DIRECTORS: 1) AFTER DISCLOSURE OF THE FINANCIAL INTEREST AND ALL MATERIAL FACTS, AND AFTER ANY DISCUSSION WITH THE INTERESTED PERSON, HE OR SHE SHALL LEAVE THE BOARD OR COMMITTEE MEETING WHILE THE DETERMINATION OF A CONFLICT OF INTEREST IS DISCUSSED AND VOTED UPON. THE REMAINING BOARD OR COMMITTEE MEMBERS SHALL 1) DECIDE IF A CONFLICT OF INTEREST EXISTS, 2) A DISINTERESTED PERSON OR COMMITTEE MAY BE APPOINTED TO INVESTIGATE ALTERNATIVES TO THE PROPOSED ARRANGEMENT OR TRANSACTION; 3) IN ORDER TO APPROVE THE ARRANGEMENT OR TRANSACTION, THE BOARD MUST FIRST FIND, BY MAJORITY VOTE OF DISINTERESTED MEMBERS, THAT THE ARRANGEMENT OR TRANSACTION IS IN THE ORGANIZATION'S BEST INTEREST, IS FAIR AND REASONABLE TO THE ORGANIZATION, AND, AFTER REASONABLE INVESTIGATION, THE DISINTERESTED MEMBERS HAVE DETERMINED THAT A MORE ADVANTAGEOUS TRANSACTION OR ARRANGEMENT CANNOT BE OBTAINED WITH REASONABLE EFFORTS UNDER THE CIRCUMSTANCES; THE MINUTES OF THE BOARD AND ALL COMMITTEES WITH BOARD-DELEGATED POWERS SHALL CONTAIN: 1) THE NAMES OF THE PERSONS WHO DISCLOSED OR OTHERWISE WERE FOUND TO HAVE A FINANCIAL INTEREST IN CONNECTION WITH AN ACTUAL OR POSSIBLE CONFLICT OF INTEREST, THE NATURE OF THE FINANCIAL INTEREST, ANY ACTION TAKEN TO DETERMINE WHETHER A CONFLICT OF INTEREST WAS PRESENT, AND THE BOARD'S OR COMMITTEE'S DECISION AS TO WHETHER A CONFLICT OF INTEREST IN FACT EXISTED; 2) THE NAMES OF THE PERSONS WHO WERE PRESENT FOR DISCUSSIONS AND VOTES RELATING TO THE TRANSACTION OR ARRANGEMENT, THE CONTENT OF THE DISCUSSION, INCLUDING ANY ALTERNATIVES TO THE PROPOSED TRANSACTION OR ARRANGEMENT, AND A RECORD OF ANY VOTES TAKEN IN CONNECTION THEREWITH; IN ORDER TO PROTECT THE ORGANIZATION'S BEST INTERESTS, APPROPRIATE DISCIPLINARY ACTION MAY BE TAKEN WITH RESPECT TO AN OFFICER, DIRECTOR, KEY EMPLOYEE OR REPORTING PHYSICIAN WHO VIOLATES THE CONFLICT OF INTEREST POLICY. FORM 990, PART VI, SECTION B, LINE 15 THE BOARD OF DIRECTORS REVIEWS ALL COMPENSATION ARRANGEMENTS WITH HIGHLY PAID EMPLOYEES UTILIZING BENCHMARK DATA FROM VARIOUS SOURCES INCLUDING THE IOWA HOSPITAL ASSOCIATION WAGE AND SALARY SURVEYS AND PHYSICIAN COMPENSATION SURVEYS. FORM 990, PART VI, SECTION C, LINE 19 THE ORGANIZATION'S GOVERNING DOCUMENTS ARE AVAILABLE UPON REQUEST THROUGH THE IOWA HEALTH SYSTEM, OUR PARENT ORGANIZATION, LEGAL DEPARTMENT. THE ORGANIZATION'S CONFLICT OF INTEREST POLICY AND FINANCIAL STATEMENTS ARE PUBLICLY AVAILABLE ON THE IOWA HEALTH SYSTEM WEBSITE, WWW.UNITYPOINT.ORG. FORM 990, PART IX, LINE 11G HEALTHCARE PROFESSIONALS : PROGRAM SERVICE EXPENSES 414,717. MANAGEMENT AND GENERAL EXPENSES 0. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 414,717. PURCHASED HOUSEKEEPING AND LAUNDRY : PROGRAM SERVICE EXPENSES 98,051. MANAGEMENT AND GENERAL EXPENSES 0. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 98,051. MISC PURCHASED SERVICES : PROGRAM SERVICE EXPENSES 1,047,552. MANAGEMENT AND GENERAL EXPENSES 2,529,401. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 3,576,953. FORM 990, PART XI, LINE 9: ROUNDING -533. 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IA N/A C 0 DELHI POINT CONDO ASSOCIATION 350 N GRANDVIEW DUBUQUE IA 52001 421467002 REAL ESTATE MANAGEMENT IA N/A C 0 HCP CORPORATION 202 SOUTH PARK STREET MADISON WI 53715 391177562 REAL ESTATE RENTAL WI N/A C 0 HANCOCK AREA MEDICAL SUPPLY INC 1204 BUCHANAN ST CARTHAGE IL 62321 371180373 RETAIL HOME HEALTH MEDICAL EQUIPMENT IL N/A C 0 HANSEN CHARITABLE REMAINDER ANNUITY TRUST 210 FOURTH AVENUE GRINNELL IA 50112 396770806 INVESTMENT IA N/A T 0 HANSEN CHARITABLE REMAINDER UNITRUST 210 FOURTH AVENUE GRINNELL IA 50112 396770807 INVESTMENT IA N/A T 0 HEALTH ADVANTAGE PLUS INC 210 4TH AVENUE GRINNELL IA 50112 421436490 PHYSICAL THERAPY IA N/A C 0 HEALTH PLUS INC 5409 N KNOXVILLE AVE PEORIA IL 61614 371295532 MANAGED CARE ADMINISTRATION IL N/A C 0 HNC SERVICES 1776 WEST LAKES PKWY 400 WEST DES MOINES IA 50266 270987243 FIBER OPTIC NETWORK SERVICES IA N/A C 0 HOME HEALTH PLUS SERVICES INC PO BOX 87 PEORIA IL 61650 364053068 HOME HEALTH SERVICES IL N/A C 0 KEOKUK AREA MEDICAL EQUIPMENT AND SUPPLY INC 420 NORTH 17TH STREET KEOKUK IA 52632 421237312 RETAIL DURABLE MEDICAL EQUIPMENT IA N/A C 0 MARIGOLD CITY LAND TRUST NO ONE 2956 COURT STREET PEKIN IL 61554 272750273 PROPERTY MANAGEMENT IL N/A T 0 MEDIMORE INC 1776 WEST LAKES PKWY 400 WEST DES MOINES IA 50266 421414390 MANAGED CARE IA N/A C 0 MERITER HEALTH ENTERPRISES INC 202 SOUTH PARK STREET MADISON WI 53715 391293620 MANAGEMENT SERVICES WI N/A C 0 MERITER MANAGEMENT SERVICES INC 202 SOUTH PARK STREET MADISON WI 53715 391458235 ADMINISTRATIVE SERVICES WI N/A C 0 METHODIST HEALTH VENTURES INC PO BOX 87 PEORIA IL 61650 371140939 PHARMACY/OFFICE STAFFING IL N/A C 0 METHODIST PHYSICIAN SERVICES INC PO BOX 87 PEORIA IL 61650 363858550 MEDICAL SERVICES IL N/A C 0 OPTIMUM HEALTH SOLUTIONS INC 221 NORTHEAST GLEN OAK AVE PEORIA IL 61636 205430137 HEALTH & WELLNESS CONSULTING IA N/A C 0 PEKIN PROHEALTH INC 600 SOUTH 13TH STREET PEKIN IL 61554 371117052 CLINIC IL N/A C 0 PRECEDENCE INC 4622 PROGRESS DRIVE STE A DAVENPORT IA 52807 371288604 MANAGED MENTAL CARE IA N/A C 0 PROVIDER RESOURCE MANAGEMENT INC PO BOX 87 PEORIA IL 61650 371223550 RESOURCE MANAGEMENT IL N/A C 0 STL HEALTH RESOURCES CO 1026 A AVE NE CEDAR RAPIDS IA 52402 421193499 PHYSICIAN OFFICE RENTAL IA N/A C 0 TRINITY HEALTH ENTERPRISES INC 2701 17TH ST ROCK ISLAND IL 61201 363320141 RETAIL DURABLE MEDICAL EQUIPMENT & PHARMACY IL N/A C 0 TRINITY PHYSICIAN HOSPITAL ORGANIZATION LTD 4622 PROGRESS DRIVE STE A DAVENPORT IA 52807 363924720 MANAGED HEALTH CARE IA N/A C 0 0 0 1 0 0 0 0 0 0 0 0 0 0 1 1 0 0 1 1 SCHEDULE R, PARTS I - IV: OWA HEALTH SYSTEM AND SUBSIDIARIES (D/B/A UNITYPOINT HEALTH) IOWA HEALTH SYSTEM IS AN IOWA NONPROFIT CORPORATION FORMED IN DECEMBER 1994. IOWA HEALTH SYSTEM AND ITS SUBSIDIARIES PROVIDE INPATIENT AND OUTPATIENT CARE AND PHYSICIAN SERVICES FROM 36 HOSPITAL FACILITIES AND OVER 400 OUTPATIENT SITES IN IOWA, ILLINOIS AND WISCONSIN. PRIMARY, SECONDARY AND TERTIARY CARE SERVICES ARE PROVIDED TO RESIDENTS OF IOWA, ILLINOIS, WISCONSIN AND ADJACENT STATES. ON APRIL 16, 2013, IOWA HEALTH SYSTEM BEGAN BEING PUBLICLY KNOWN AS UNITYPOINT HEALTH (THE SYSTEM). THIS NAME CHANGE REFLECTS THE TRANSFORMATION OF CLINICAL PROCESSES UNDERWAY WITHIN THE SYSTEM AND THE ADAPTATION TO BETTER ADDRESS THE HEALTH CARE NEEDS OF COMMUNITIES, INCLUDING BUILDING A MODEL OF DELIVERING HEALTH CARE THAT COORDINATES CARE AROUND THE PATIENT WHILE FOCUSING ON IMPROVING THE QUALITY OF CARE AND REDUCING COSTS. THE LEGAL NAME OF THE PARENT REMAINS IOWA HEALTH SYSTEM, WITH THE UNITYPOINT HEALTH NAME REFLECTING A DOING BUSINESS AS (D/B/A).