2018-02-13T13:18:37-06:00 2017-06-30 420714325 RSM US LLP 201 N HARRISON STREET SUITE 300 DAVENPORT IA 528011999 990 2016-07-01 370673506 GRAHAM HOSPITAL ASSOCIATION GRAH 3096475240 210 WEST WALNUT CANTON IL 615202444 ROBERT G SENNEFF PRESIDENT AND CEO 3096475240 2018-01-27 1 JOHN J ROMANO P00227323 5638884000 2016 2022-09-23 18:48:47Z ROBERT G SENNEFF 210 WEST WALNUT CANTON IL 615202444 96507701 0 X WWW.GRAHAMHOSPITAL.ORG X 1905 IL TO PROVIDE COMPASSIONATE, QUALITY HEALTH SERVICES, IN A RESPONSIBLE AND CHARITABLE MANNER, TO THE PEOPLE AND COMMUNITIES WE SERVE. 15 14 808 60 320409 -141191 522416 438864 75838917 83062187 1978191 2506396 1532879 4470143 79872403 90477590 10000 0 0 0 37707781 39668367 0 0 0 40261560 43021827 77979341 82690194 1893062 7787396 154104980 177017784 51415690 58336577 102689290 118681207 X TO PROVIDE COMPASSIONATE, QUALITY HEALTH SERVICES, IN A RESPONSIBLE AND CHARITABLE MANNER, TO THE PEOPLE AND COMMUNITIES WE SERVE. 0 0 44882927 53904970 GRAHAM HOSPITAL IS A PROVIDER OF HEALTHCARE SERVICES IN FULTON COUNTY AND SURROUNDING AREAS. DURING THIS REPORTING PERIOD, 2,597 ADULTS AND CHILDREN WERE ADMITTED AND 241 BABIES WERE BORN. THEY RECEIVED INPATIENT SERVICES IN THE ACUTE CARE FACILITY. 187 PATIENTS WERE ADMITTED FOR 9,382 DAYS OF SERVICE IN THE EXTENDED CARE FACILITY. 104,717 OUTPATIENT SERVICES WERE PROVIDED. 11564631 13964172 GRAHAM MEDICAL GROUP WHICH PROVIDES PHYSICIAN AND PROFESSIONAL HEALTH CARE SERVICES TO THE PATIENTS IN FULTON COUNTY, ILLINOIS. THIS INCLUDES CHARITY CARE TO QUALIFIED INDIVIDUALS AND 96,093 OFFICE VISITS AND 11,275 NURSING HOME AND HOSPITAL VISITS. 10632328 12838426 SURGICAL SERVICES - THE HOSPITAL PERFORMED 804 INPATIENT SURGERIES AND 3,023 OUTPATIENT SURGERIES IN FISCAL YEAR 2017. 5313751 6416300 THE HOSPITAL OPERATES A 24 HOUR EMERGENCY DEPARTMENT WHICH HAD 14,597 PATIENTS REGISTERED TO THE ED IN FISCAL YEAR 2017. 5313751 6416300 72393637 1 1 0 1 0 0 0 0 0 1 1 1 0 0 1 1 1 0 0 0 0 0 0 0 0 0 1 1 0 0 1 1 0 0 0 0 0 0 0 0 0 1 0 0 0 0 0 0 0 0 0 1 70 0 1 808 1 1 1 0 0 0 0 0 0 0 0 0 X 15 14 0 0 0 0 0 0 0 1 1 0 0 1 1 1 1 1 1 1 1 0 IL X ROBERT G SENNEFF 3096475240 210 WEST WALNUT CANTON IL 61520 BRAD ANDERSON TRUSTEE 1.00 X 0 0 0 JANIS BLOUT SECRETARY 2.00 X X 0 0 0 ROBERT BOBELL OD TREASURER 2.00 X X 0 0 0 BILL CARLBERG TRUSTEE 2.00 X 0 0 0 BROOKE DENNISTON TRUSTEE 2.00 X 0 0 0 ALAN DILTS FORMER TRUSTEE 1.00 X 0 0 0 PAULA GRIGSBY TRUSTEE 2.00 X 0 0 0 GORDON JAMES TRUSTEE 1.00 X 0 0 0 JEFF JOCHUMS FORMER TRUSTEE 2.00 X 0 0 0 KENNETH KROCK MD TRUSTEE 2.00 X 0 0 0 MARION KUZNIAR TRUSTEE 1.00 X 0 0 0 KEVIN MEADE TRUSTEE 2.00 X 0 0 0 JOSHUA MILLER TRUSTEE 2.00 X 0 0 0 TERRY MOSS TRUSTEE 2.00 X 0 0 0 MARK PIRTLE CHAIRMAN 2.00 X X 0 0 0 PATRICK RENICK MD TRUSTEE 2.00 X 0 0 0 MIKE RENNER VICE CHAIRMAN 2.00 X X 0 0 0 ERIC FRANZ VP FINANCE/CFO 40.00 X 256757 0 48872 CAROLYN JACOBUS VP CLINIC SERVICES 40.00 X 160128 0 37849 TERESA MCCONKEY VP PATIENT SERVICES 40.00 X 226475 0 32624 JAMES SCHREINER VP INFO SERVICES 40.00 X 203323 0 43097 ROBERT G SENNEFF PRESIDENT AND CEO 40.00 X 467909 0 80142 DWAYNE BERNARD MD MEDICAL DIRECTOR 45.00 X 431063 0 39717 DEVASHISH AGARWAL MD PHYSICIAN 45.00 X 403907 0 37659 JEFFREY HEMP MD PHYSICIAN 45.00 X 348695 0 30782 MATTHEW MCMILLIN MD PHYSICIAN 29.00 X 274199 0 0 JULIO ANTONIO RAMOS MD PHYSICIAN 45.00 X 396287 0 22295 BRENT PARRY MD PODIATRIST 45.00 X 252037 0 7160 3420780 0 380197 29 0 1 0 PJ HOERR INC 107 W COMMERCE PEORIA IL 61604 CONSTRUCTION 8460669 COLEMAN MEDICAL ASSOCIATES 180 SOUTH MAIN STREET CANTON IL 61520 PHYSICIAN SERVICES 7991099 ENDURACARE ACUTE CARE SERVICES LLC PO BOX 654072 DALLAS TX 75265 REHAB SERVICES 1528532 MIDWEST MOBILE ANESTHESIA 4128 W STONEWATER DRIVE PEORIA IL 61615 ANESTHESIA SERVICES 1400000 DIVERSIFIED CLINICAL SERVICES PO BOX 551187 JACKSONVILLE FL 32255 WOUND CLINIC SERVICES 643704 18 438864 438864 PATIENT SERVICES 621110 85855162 85855162 OTHER PROGRAM SERVICE 900099 452321 393704 58617 SCHOOL OF NURSING 611600 417540 417540 LABORATORY SERVICES 621500 209424 209424 LESS: PROVISION FOR UNCOLLECTIBLE 900009 -3872260 -3872260 83062187 1450884 1450884 351736 263683 88053 88053 88053 6806440 15500 5766291 137 1040149 15363 1055512 1055512 340(B) REVENUE 3567213 3567213 CAFETERIA 722210 616117 616117 EMPLOYEE PHARMACY 446110 146392 146392 52368 52368 4382090 90477590 87123868 320409 2594449 X 1692466 882593 809873 25497053 22786643 2710410 647820 562598 85222 9766771 8481929 1284842 2064257 1792699 271558 701870 619856 82014 17473 17473 140999 140999 28060 28060 312712 143 312569 9665845 9665845 190160 7062 183098 10442257 10118375 323882 763087 126252 636835 1151757 922769 228988 44078 28333 15745 1146361 676071 470290 4820846 4301486 519360 1748957 1518878 230079 PURCHASED SERVICES 8898205 7292801 1605404 MEDICAID ASSESSMENT 2085171 2085171 OTHER EXPENSES 287974 223662 64312 PROPERTY TAXES 259562 76816 182746 316453 223655 92798 82690194 72393637 10296557 0 1706810 1451914 2565824 2812137 9830526 13627046 1399058 1564478 1206603 1122084 133465835 63174829 60209209 70291006 65635227 72680361 11285005 12842382 266718 626376 154104980 177017784 8680790 3202557 32078515 40175689 10656385 14958331 51415690 58336577 X 94723166 110239842 261557 322357 7704567 8119008 102689290 118681207 154104980 177017784 X 7787396 5765371 2439150 X X 0 1 X 1 0 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 0 0 0 0 0 0 0 0 1 28060 28060 0 PART II-B, LINE 1: LOBBYING EXPENDITURES RELATED TO MEMBERSHIP DUES INCLUDED: 39% OF MEMBERSHIP DUES PAID TO THE ILLINOIS HOSPITAL ASSOCIATION, OR $19,942; 31% OF MEMBERSHIP DUES PAID TO THE AMERICAN HOSPITAL ASSOCIATION, OR $6,818; 40% OF MEMBERSHIP DUES PAID TO THE ILLINOIS HOME CARE & HOSPICE COUNCIL, OR $1,300. 73601005 131055 8619102 10550 302248 916494 81121870 74358133 292468 -235443 8445 12750 792958 73601005 70323226 2730813 1877809 3050 570665 74358133 63277262 252307 8455919 3300 501000 1157962 70323226 54282312 6002000 4507261 4950 1200000 309361 63277262 0.89590 0.10410 0.00000 1 0 2960957 2960957 75407525 29311276 46096249 42520138 32134566 10385572 12577215 1728987 10848228 70291006 PERPETUAL TRUSTS 8441509 F DEFERRED FINANCING COSTS 463105 F LONG TERM NOTES RECEIVABLE 2067438 C DUE FROM MEDICARE 1870330 C 12842382 ESTIMATED SELF-INSURANCE COSTS 9156463 ASSET RETIREMENT OBLIGATION 266162 FAIR MARKET VALUE OF SWAP OPTION 3720416 DUE TO THIRD PARTY PAYORS 1777058 RECOURSE LIABILITY 38232 14958331 X 98945794 5765371 2439150 8204521 90741273 -263683 -263683 90477590 82953877 263683 263683 82690194 0 82690194 PART V, LINE 4: THE INTENDED USE OF THE ORGANIZATION'S ENDOWMENT FUNDS IS TO PROVIDE SCHOLARSHIPS BASED ON STUDENT NEEDS FROM THE INCOME OF THE DONOR-RESTRICTED ENDOWMENT FUNDS. THE PERMANENT ENDOWMENT IS USED FOR THE PURCHASE OF PROPERTY AND EQUIPMENT. PART X, LINE 2: THE HOSPITAL IS EXEMPT FROM INCOME TAXES UNDER SECTION 501(C)(3) OF THE INTERNAL REVENUE CODE. THE HOSPITAL FILES A FORM 990 (RETURN OF ORGANIZATION EXEMPT FROM INCOME TAX) ANNUALLY. WHEN THE RETURNS ARE FILED, IT IS HIGHLY CERTAIN THAT SOME POSITIONS TAKEN WOULD BE SUSTAINED UPON EXAMINATION BY TAXING AUTHORITIES, WHILE OTHERS ARE SUBJECT TO UNCERTAINTY ABOUT THE MERITS OF THE TAX POSITION TAKEN OR THE AMOUNT OF THE POSITION THAT WOULD ULTIMATELY BE SUSTAINED. EXAMPLES OF TAX POSITIONS COMMON TO NONPROFIT ORGANIZATIONS INCLUDE SUCH MATTERS AS THE FOLLOWING: THE TAX EXEMPT STATUS OF EACH ENTITY AND VARIOUS POSITIONS RELATIVE TO POTENTIAL SOURCES OF UNRELATED BUSINESS INCOME (UBI). UBI IS REPORTED ON FORM 990-T, AS APPROPRIATE. THE BENEFIT OF A TAX POSITION IS RECOGNIZED IN THE FINANCIAL STATEMENTS IN THE PERIOD DURING WHICH, BASED ON ALL AVAILABLE EVIDENCE, MANAGEMENT BELIEVES THAT IT IS MORE LIKELY THAN NOT THAT THE POSITION WILL BE SUSTAINED UPON EXAMINATION, INCLUDING THE RESOLUTION OF APPEALS OR LITIGATION PROCESS, IF ANY. TAX POSITIONS ARE OFFSET OR AGGREGATED WITH OTHER POSITIONS. TAX POSITIONS THAT MEET THE "MORE LIKELY THAN NOT" RECOGNITION THRESHOLD ARE MEASURED AS THE LARGEST AMOUNT OF TAX BENEFIT THAT IS MORE THAN 50% LIKELY TO BE REALIZED ON SETTLEMENT WITH THE APPLICABLE TAXING AUTHORITY. THE PORTION OF THE BENEFITS ASSOCIATED WITH TAX POSITIONS TAKEN THAT EXCEEDS THE AMOUNT MEASURED AS DESCRIBED ABOVE IS REFLECTED AS A LIABILITY FOR UNCERTAIN TAX BENEFITS IN THE ACCOMPANYING BALANCE SHEETS ALONG WITH ANY ASSOCIATED INTEREST AND PENALTIES THAT WOULD BE PAYABLE TO THE TAXING AUTHORITIES UPON EXAMINATION. AS OF JUNE 30, 2017 AND 2016, THERE WERE NO UNRECOGNIZED TAX BENEFITS IDENTIFIED OR RECORDED AS A LIABILITY. FORMS 990 FILED BY THE HOSPITAL ARE SUBJECT TO EXAMINATION BY THE INTERNAL REVENUE SERVICE (IRS) UP TO THREE YEARS FROM THE EXTENDED DUE DATE OF EACH RETURN. FORMS 990 FILED BY THE HOSPITAL ARE GENERALLY NO LONGER SUBJECT TO EXAMINATION FOR THE YEARS ENDED JUNE 30, 2013 AND PRIOR. PART XI, LINE 2D - OTHER ADJUSTMENTS: CHANGE IN FAIR VALUE OF INTEREST RATE SWAP AGREEMENT 1,963,909. CHANGE IN INTEREST IN NET ASSETS OF THE FOUNDATION 60,800. CHANGE IN BENEFICIAL INTEREST IN PERPETUAL TRUSTS 414,441. PART XI, LINE 4B - OTHER ADJUSTMENTS: RENTAL EXPENSES INCLUDED WITH REVENUE ON RETURN -263,683. PART XII, LINE 2D - OTHER ADJUSTMENTS: RENTAL EXPENSES INCLUDED WITH REVENUE ON RETURN 263,683. 1 1 1 X 180.000000000000 1 X 1 1 0 1 0 1449716 1449716 0.01750 19585141 14279081 5306060 0.06420 21034857 14279081 6755776 0.08170 62806 62806 0.00080 86388 86388 0.00100 149194 149194 0.00180 21184051 14279081 6904970 0.08350 5000 5000 0.00010 5000 5000 0.00010 34000 34000 0.00040 5000 5000 0.00010 49000 49000 0.00070 1 3872260 19832365 21790223 -1957858 X 1 1 1 1 GRAHAM HOSPITAL ASSOCIATION 210 WEST WALNUT STREET CANTON IL 61520 WWW.GRAHAMHEALTHSYSTEM.ORG 0000869 X X GRAHAM HOSPITAL ASSOCIATION 1 0 0 1 X X X X X X X X X 15 1 0 0 1 X WWW.GRAHAMHEALTHSYSTEM.ORG X 1 15 1 WWW.GRAHAMHEALTHSYSTEM.ORG 0 1 X 180.000000000000 300.000000000000 1 1 X X X 1 X WWW.GRAHAMHEALTHSYSTEM.ORG/PATIENTS-VISITORS/BILLING-FINANCIAL-ASSISTANCE X WWW.GRAHAMHEALTHSYSTEM.ORG/PATIENTS-VISITORS/BILLING-FINANCIAL-ASSISTANCE X WWW.GRAHAMHEALTHSYSTEM.ORG/PATIENTS-VISITORS/BILLING-FINANCIAL-ASSISTANCE X X X X 1 X 0 X X X X 1 X 0 0 GRAHAM HOSPITAL ASSOCIATION PART V, SECTION B, LINE 5: GRAHAM HOSPITAL ASSOCIATION CREATED THE FOLLOWING FOCUS GROUPS TO GATHER INPUT FOR THE COMMUNITY HEALTH NEEDS ASSESSMENT:THE COMMUNITY MEMBERS FOCUS GROUP INCLUDED THE MAYOR OF CANTON, A REPRESENTATIVE OF A LOCAL FOOD PANTRY, AND THE DIRECTOR OF COMMUNITY WELLNESS CLINIC (WHICH IS A CLINIC THAT PROVIDES ASSISTANCE IN ACCESS TO CARE FOR THE UNDERINSURED AND UNINSURED RESIDENTS OF THE COMMUNITY) THEY MET ON JANUARY 5, 2016.THE MEDICAL PROFESSIONALS AND PARTNERS GROUP INCLUDED FOUR PHYSICIANS, THE ADMINISTRATOR OF THE COUNTY HEALTH DEPARTMENT, AND OTHER HEALTH PROFESSIONALS. THEY MET ON JANUARY 5, 2016. GRAHAM HOSPITAL ASSOCIATION PART V, SECTION B, LINE 11: GRAHAM HOSPITAL REVIEWED THE NEEDS IDENTIFIED IN THE COMMUNITY HEALTH NEEDS ASSESSMENT THAT WAS COMPLETED IN FISCAL YEAR 2016, AND PRIORITIZED THE NEEDS ACCORDINGLY. SIX NEEDS WERE IDENTIFIED AND AN IMPLEMENTATION STRATEGY WAS DEVELOPED TO ADDRESS THOSE NEEDS. THE IMPLEMENTATION STRATEGY INDENTIFIES ACTIONS THE HOSPITAL INTENDS TO TAKE ALONG WITH THE ANTICIPATED IMPACT OF THE OTHER ACTIONS, THE RESOURCES THE HOSPITAL INTENDS TO COMMIT TO THE ACTIONS, AND THE EXTERNAL COLLABORATORS THE HOSPITAL PLANS TO COOPERATE WITH TO ADDRESS THE NEED. THE PLAN WILL BE EVALUATED BY PERIODIC REVIEW OF MEASURABLE OUTCOME INDICIATORS IN CONJUNCTION WITH ANNUAL REVIEW AND REPORTING. THE IMPLEMENTATION STRATEGY ALSO EXPLAINS REASONS GRAHAM WILL NOT ADDRESS ALL NEEDS IDENTIFIED, AND THAT IT WILL CONTINUE TO SUPPORT OTHER ORGANIZATIONS THAT ARE ALREADY COMMITTED TO ADDRESSING THOSE NEEDS. 10 1 - GRAHAM MEDICAL GROUP 180 SOUTH MAIN STREET CANTON IL 61520 MULTI-SPECIALTY OUTPATIENT PHYSICIAN CLINIC 2 - GRAHAM HOSPITAL PHARMACY 210 WEST WALNUT STREET CANTON IL 61520 PHARMACY FOR PATIENTS & RETAIL FOR EMPLOYEES 3 - GRAHAM MEDICAL GROUP - LEWISTOWN 408 SOUTH MAIN STREET LEWISTOWN IL 61542 MULTI-SPECIALTY OUTPATIENT PHYSICIAN CLINIC 4 - GRAHAM MEDICAL GROUP - FARMINGTON 601 EAST FORT STREET FARMINGTON IL 61531 MULTI-SPECIALTY OUTPATIENT PHYSICIAN CLINIC 5 - GRAHAM HOSPITAL EXTENDED CARE UNIT 210 WEST WALNUT STREET CANTON IL 61520 SKILLED NURSING & LONG TERM CARE UNITS 6 - GHA HOME MEDICAL EQUIPMENT STORE 101 SOUTH MAIN STREET CANTON IL 61520 HOME MEDICAL EQUIPMENT RETAIL STORE 7 - GRAHAM HOSPITAL HOME HEALTHHOSPICE 225 WEST WALNUT CANTON IL 61520 HOME HEALTH AND HOSPICE PROVIDER 8 - GRAHAM HOSPITAL SCHOOL OF NURSING 210 WEST WALNUT STREET CANTON IL 61520 SCHOOL OF NURSING 9 - GRAHAM CARDIAC REHABILITATION 235 WEST WALNUT CANTON IL 61520 CARDIAC REHAB SERVICES 10 - GRAHAM MEDICAL GROUP - CUBA 114 SOUTH 4TH STREET CUBA IL 61427 OUTPATIENT PHYSICIAN CLINIC PART I, LINE 3C: NOT APPLICABLE PART I, LINE 6A: NOT APPLICABLE PART I, LINE 7: GRAHAM HOSPITAL ASSOCIATION UTILIZED WORKSHEET 2 TO CALCULATE ITS COST-TO-CHARGE RATIO. TOTAL EXPENSES REPORTED IN THE FINANCIAL REPORT FOR THE YEAR ENDED 06/30/17 OF $82,953,877 LESS NONPATIENT CARE ACTIVITIES OF $3,971,213, THE MEDICAID ASSESSMENT PROVIDER TAX OF $2,085,171, TOTAL COMMUNITY BUILDING EXPENSE OF $15,000 AND THE COMMUNITY BENEFIT EXPENSES FOR VARIOUS PROGRAMS OF $149,194 ARE DIVIDED BY GROSS PATIENT CHARGES OF $221,193,984 TO REACH A COST TO CHARGE RATIO OF 34.69%.DURING EACH FISCAL YEAR VARIOUS COMMUNITY HEALTH IMPROVEMENT SERVICES ARE HELD AT A FACILITY OWNED BY GRAHAM HOSPITAL ASSOCIATION OR GRAHAM HOSPITAL ASSOCIATION EMPLOYEES ASSIST WITH SERVICES HELD AT VARIOUS LOCATIONS WITHIN THE CATCHMENT AREA. AN ACTUAL COUNT OF COMMUNITY MEMBERS SERVED IS RECORDED IF AVAILABLE OR ESTIMATED IF NOT AVAILABLE. COST FOR EACH ACTIVITY IS RECORDED AT THE ACTUAL COST OF SUPPLIES, AND STAFF TIME IS CALCULATED USING ACTUAL TIME SPENT MULTIPLIED BY AVERAGE WAGES FOR THE EMPLOYEES INVOLVED. ANY OFFSETTING REVENUE IS SUBTRACTED FROM THE COST OF THE ACTIVITY TO REACH A NET COST OF EACH EVENT. WHEN COMMUNITY GROUPS USE A ROOM IN ONE OF THE GRAHAM HOSPITAL ASSOCIATION FACILITIES, THERE IS NO CHARGE FOR THE COMMUNITY GROUP AND THE COST OF THE ROOM USE IS ESTIMATED AT A NOMINAL FLAT RATE FEE AND RECORDED HERE AS AN IN-KIND CONTRIBUTION. THESE ACTIVITES REPRESNT THE COMMUNITY BENEFIT EXPENSES NOTED ABOVE. PART I, LINE 7G: NOT APPLICABLE PART I, LN 7 COL(F): NO BAD DEBT EXPENSE WAS INCLUDED IN THE DENOMINATOR BECAUSE BAD DEBT WAS REPORTED IN LINE 2E OF PART VIII, STATEMENT OF REVENUE. THE ORGANIZATION'S TOTAL COMMUNITY BENEFIT EXPENSE AS A PERCENTAGE OF TOTAL EXPENSES IS 25.62%, AND THE PERCENTAGE INCREASES TO 51.97% IF MEDICARE ALLOWABLE COSTS ARE INCLUDED IN TOTAL COMMUNITY BENEFIT EXPENSE. PART II, COMMUNITY BUILDING ACTIVITIES: A DONATION OF $5,000 WAS MADE TO THE SPOON RIVER PARTNERSHIP FOR ECONOMIC DEVELOPMENT. THIS ORGANIZATION FOCUSES ON BUILDING IN THE LOCAL COMMUNITY THROUGH ECONOMIC GROWTH, WHICH IMPROVES OPPORTUNITIES FOR JOBS AND INSURANCE WITHIN THE COMMUNITY. A DONATION OF $5,000 WAS MADE TO THE CITY OF CANTON DISASTER RECOVERY FUND AFTER A GAS EXPLOSION HIT DOWNTOWN. THIS DONATION HELPED SUPPORT THE LOCAL ECONOMY BY HELPING SMALL BUSINESSES REBUILD. A DONATION OF $5,000 WAS MADE TO THE UNIVERSITY OF ILLINOIS FAMILY MEDICINE RURAL STUDENT PHYSICIAN PROGRAM. THIS DONATION WILL HELP GIVE OPPORTUNITY TO PHYSICIANS WHO WANT TO WORK IN RURAL HOSPITALS LIKE GRAHAM. A MONTHLY DONATION OF $3,000 WAS MADE TO THE FULTON COUNTY FREE HEALTH AND WELLNESS CLINIC. THIS CLINIC IS CONSISTENT WITH AND SUPPORTIVE OF GRAHAM'S MISSION OF PROVIDING CHARITY CARE AND HEALTH IMPROVEMENT SERVICES TO THOSE IN NEED. PART III, LINE 2: PATIENT RECEIVABLES ARE WRITTEN OFF AS BAD DEBT EXPENSE BASED ON INDIVIDUAL CREDIT EVALUATION AND SPECIFIC CIRCUMSTANCES OF THE ACCOUNT. RECOVERIES OF RECEIVABLES PREVIOUSLY WRITTEN OFF ARE RECORDED AS A REDUCTION OF BAD DEBT EXPENSE WHEN RECEIVED. PART III, LINE 3: NOT APPLICABLE PART III, LINE 4: PATIENT RECEIVABLES DUE DIRECTLY FROM THE PATIENTS ARE CARRIED AT THE ORIGINAL CHARGE FOR THE SERVICE PROVIDED LESS AN ESTIMATED ALLOWANCE FOR DOUBTFUL RECEIVABLES BASED ON A REVIEW OF ALL OUTSTANDING AMOUNTS ON A MONTHLY BASIS. THE HOSPITAL DOES NOT CHARGE INTEREST ON RECEIVABLES. PATIENT ACCOUNTS RECEIVABLE ARE DUE IN FULL WHEN BILLED. ACCOUNTS ARE CONSIDERED PAST DUE WHEN AN AMOUNT IS PAST DUE ACCORDING TO THE PAYOR'S AGREED-UPON TERMS. PATIENT RECEIVABLES ARE WRITTEN OFF AS BAD DEBT EXPENSE BASED ON INDIVIDUAL CREDIT EVALUATION AND SPECIFIC CIRCUMSTANCES OF THE ACCOUNT. RECOVERIES OF RECEIVABLES PREVIOUSLY WRITTEN OFF ARE RECORDED AS A REDUCTION OF BAD DEBT EXPENSE WHEN RECEIVED. PART III, LINE 8: MEDICARE ALLOWABLE COSTS ARE TAKEN FROM WORKSHEET D-1 AS REPORTED IN THE FILED MEDICARE COST REPORT FOR THE YEAR ENDED 6/30/2017. PART III, LINE 9B: THE COLLECTION POLICY DESCRIBES THE STEPS TAKEN TO COLLECT SELF PAY BALANCES OUTSTANDING INCLUDING NOTIFICATIONS TO THE PATIENT THROUGH STATEMENTS, FOLLOW-UP PHONE CALLS, VERIFICATION OF INSURANCE ELIGIBILITY AND ULTIMATELY AT WHAT POINT THE UNPAID BALANCE IS WRITTEN OFF AS UNCOLLECTIBLE. IN PRACTICE, WHEN A PATIENT IS IDENTIFIED AS QUALIFYING FOR FINANCIAL ASSISTANCE, A SEARCH OF ACCOUNTS WRITTEN OFF AS UNCOLLECTIBLE IS DONE AND THOSE ACCOUNTS ARE REPROCESSED. PART VI, LINE 2: IN ADDITION TO THE COMMUNITY HEALTH NEEDS ASSESSMENT IMPLEMENTED DURING FISCAL YEAR 2016 (TAX YEAR 2015), A PHYSICIAN NEEDS ASSESSMENT IS DONE TO IDENTIFY NEEDS FOR SPECIFIC SPECIALTY SERVICES BASED ON THE SIZE OF THE CATCHMENT AREA, DATA IS ANALYZED TO IDENTIFY SERVICES THAT ARE PROVIDED TO COUNTY RESIDENTS BY OTHER FACILITIES THAT WOULD BE MORE ACCESSIBLE TO PATIENTS IF PROVIDED AT GRAHAM HOSPITAL. INPUT IS GAINED FROM PHYSICIANS AND OTHER HEALTHCARE WORKERS PROVIDING SERVICE IN THE AREA ALONG WITH INPUT PROVIDED BY THE BOARD OF DIRECTORS WHO REPRESENT THE COMMUNITY AND PROVIDE A COMMUNICATION LINK BETWEEN GRAHAM HOSPITAL AND THE COMMUNITIES WE SERVE. PART VI, LINE 3: THE CHARITY CARE/FINANCIAL ASSISTANCE PROGRAM IS MADE AVAILABLE TO PATIENTS UPON REGISTRATION. FINANCIAL ASSISTANCE APPLICATIONS ARE AVAILABLE TO PATIENTS UPON REGISTRATION OR TO ANYONE REQUESTING THE APPLICATION AT ANYTIME FOR CLAIMS EXCEEDING $300. THE APPLICATIONS ARE AVAILABLE ON GRAHAM HEALTH SYSTEM'S WEBSITE AT WWW.GRAHAMHEALTHSYSTEM.ORG/PATIENTS-VISITORS/BILLING-FINANCIAL-ASSISTANCE. APPOINTMENTS MAY BE MADE WITH A FINANCIAL ADVOCATE IF ASSISTANCE IS NEEDED. MEDICAID SERVICES APPLICATION ASSISTANCE IS AVAILABLE. PART VI, LINE 4: THE GRAHAM HOSPITAL ASSOCIATION PRIMARY CATCHMENT AREA IS LOCATED PRIMARILY IN FULTON COUNTY AND INCLUDES ALL OR PORTIONS OF THE TOWNS OF CANTON, LEWISTOWN, CUBA, FARMINGTON, HAVANA, ST. DAVID, ASTORIA, DUNFERMLINE AND BRYANT. THE RACE AND ETHNICITY MAKEUP ARE TYPICAL OF RURAL ILLINOIS BASED ON US CENSUS BUREAU DATA AND INCLUDES 92.5% WHITE, 3.7% BLACK, 2.6% HISPANIC ORIGIN, AND 1.2% OTHER. ACCORDING TO THE US CENSUS BUREAU MEDIAN HOUSEHOLD INCOME 2012 WAS $41,899. FULTON COUNTY'S NOV 2014 UNEMPLOYMENT RATE WAS 7.3%. PART VI, LINE 5: DURING EACH FISCAL YEAR VARIOUS COMMUNITY HEALTH IMPROVEMENT SERVICES ARE HELD AT A FACILITY OWNED BY GRAHAM HOSPITAL ASSOCIATION OR GRAHAM HOSPITAL ASSOCIATION EMPLOYEES ASSIST WITH SERVIES HELD AT VARIOUS LOCATIONS WITHIN THE CATCHMENT AREA. EXAMPLES OF THESE ACTIVITIES INCLUDE SPONSORSHIP OF AN ANNUAL WOMEN'S HEALTH FAIR HELD IN THE HOSPITAL FACILITY THAT IS OPEN TO THE PUBLIC WHERE EDUCATIONAL BOOTHS, FREE HEALTH SCREENINGS, HEALTHY LUNCHES, PRESENTATIONS BY LOCAL PHYSICIANS ARE AVAILABLE TO ATTENDEES DURING THE DAY; ANNUAL SPONSORSHIP OF A COMMUNITY TALK AND DINNER THAT IS FREE TO THE PUBLIC COVERING HEART HEALTH; FREE BLOOD PRESSURE CLINICS OFFERED THROUGHOUT THE COUNTY ON A REGULAR BASIS. GRAHAM HOSPITAL PROVIDES THE SPACE FOR OPERATION OF AN OUTPATIENT CLINIC THAT PROVIDES FREE HEALTHCARE SERVICES TO FULTON COUNTY RESIDENTS. CLINIC SERVICES ARE PROVIDED BY COMMUNITY VOLUNTEERS. PART VI, LINE 6: NOT APPLICABLE X X X 0 1 0 0 0 0 0 1 0 ERIC FRANZ VP FINANCE/CFO 216504 0 34020 0 6233 0 30088 0 18784 0 305629 0 0 0 CAROLYN JACOBUS VP CLINIC SERVICES 142873 0 15638 0 1617 0 19648 0 18201 0 197977 0 0 0 TERESA MCCONKEY VP PATIENT SERVICES 201278 0 24570 0 627 0 23115 0 9509 0 259099 0 43181 0 JAMES SCHREINER VP INFO SERVICES 181987 0 20475 0 861 0 20534 0 22563 0 246420 0 28145 0 ROBERT G SENNEFF PRESIDENT AND CEO 409232 0 57487 0 1190 0 69370 0 10772 0 548051 0 0 0 DWAYNE BERNARD MD MEDICAL DIRECTOR 429022 0 310 0 1731 0 7950 0 31767 0 470780 0 0 0 DEVASHISH AGARWAL MD PHYSICIAN 403387 0 310 0 210 0 7950 0 29709 0 441566 0 0 0 JEFFREY HEMP MD PHYSICIAN 345728 0 310 0 2657 0 7950 0 22832 0 379477 0 0 0 MATTHEW MCMILLIN MD PHYSICIAN 273558 0 465 0 176 0 0 0 0 0 274199 0 0 0 JULIO ANTONIO RAMOS MD PHYSICIAN 392758 0 310 0 3219 0 7950 0 14345 0 418582 0 0 0 BRENT PARRY MD PODIATRIST 182524 0 69072 0 441 0 4635 0 2525 0 259197 0 0 0 PART I, LINE 4B THE FOLLOWING INDIVIDUALS PARTICIPATED IN A 457(F) PLAN IN 2016 SPONSORED BY GRAHAM HOSPITAL ASSOCIATION: CAROLYN JACOBUS - $14,700, TERESA MCCONKEY - $16,200, JAMES SCHREINER - $14,250, ROBERT G. SENNEFF - $61,420, AND ERIC FRANZ - $22,201. THE DOLLAR AMOUNT REPRESENTS THE CURRENT YEAR CONTRIBUTION MADE BY GRAHAM HOSPITAL ASSOCIATION ON BEHALF OF THE INDIVIDUALS TO THE PLAN IN 2016. THIS INFORMATION IS INCLUDED IN DEFERRED COMPENSATION ON THE FORM 990, PART VII AND SCHEDULE J, PART II. THE FOLLOWING INDIVIDUALS PARTICIPATED IN A 457(F) PLAN IN 2016 SPONSORED BY GRAHAM HOSPITAL ASSOCIATION: TERESA MCCONKEY - $42,645 AND JAMES SCHREINER - $36,503. THE DOLLAR AMOUNT REPRESENTS THE CURRENT YEAR DISTRIBUTION FROM THE PLAN IN 2016. THIS INFORMATION IS INCLUDED IN REPORTABLE COMPENSATION ON THE FORM 990, PART VII AND SCHEDULE K, PART II. PART I, LINE 7 INCENTIVE AWARDS ARE BASED ON THE ATTAINMENT OF HOSPITAL AND INDIVIDUAL TARGETS AND ARE CALCULATED AS A PERCENTAGE OF WAGES. PAYMENT OF INCENTIVE AWARDS IS DEPENDENT ON THE ACHIEVEMENT OF ORGANIZATIONAL KEY INDICATORS. FORM 990, SCHEDULE J, PART II, COLUMN F: THE FOLLOWING INDIVIDUALS ALSO PARTICIPATED IN A SUPPLEMENTAL EXECUTIVE RETIREMENT PLAN IN 2009-2016 SPONSORED BY GRAHAM HOSPITAL ASSOCIATION: TERESA MCCONKEY - $43,181 AND JAMES SCHREINER - $28,145. THE DOLLAR AMOUNT REPRESENTS PRIOR YEAR CONTRIBUTIONS MADE BY GRAHAM HOSPITAL ASSOCIATION ON BEHALF OF THE INDIVIDUALS TO THE PLAN IN 2009-2015. THIS INFORMATION WAS INCLUDED IN DEFERRED COMPENSATION ON THE PRIOR YEARS' FORM 990, PART VII AND SCHEDULE J, PART II. THESE INDIVIDUALS REACHED A SPECIFIED LEVEL OF VESTING IN 2016, SO THE DOLLAR AMOUNT WAS INCLUDED IN REPORTABLE COMPENSATION ON THE 2016 FORM 990, PART VII AND SCHEDULE J, PART II. THE DOLLAR AMOUNT IS ALSO LISTED AS COMPENSATION REPORTED IN A PRIOR FORM 990 ON THE CURRENT YEAR FORM 990, SCHEDULE J, PART II. A CITY OF CANTON IL 376000876 2015-11-04 48540000 REFUND PRIOR ISSUE AND FUND BUILDING PROJECTS 0 0 0 A 48540000 26755000 488550 14697139 6599311 1 0 0 1 A 0 1 0 0 0.15000 0.00000 0.15000 1 0 1 A 1 1 1 MORGAN STANLEY & BMO HARRIS NA 25.000000000000 0 0 0 0 0 A 0 MIDAMERICA NATIONAL BANK SEE BELOW FOR DESCRIPTION OF RELATIONSHIP 27878 INTEREST, DIVIDENDS, AND REALIZED GAINS (LOSSES) EARNED ON THE ORGANIZATION'S INVESTMENTS WITH MIDAMERICA NATIONAL BANK. 0 MIDAMERICA NATIONAL BANK SEE BELOW FOR DESCRIPTION OF RELATIONSHIP 14706 BANK FEES PAID BY THE ORGANIZATION TO MIDAMERICA NATIONAL BANK 0 FORM 990, SCHEDULE L, PART IV RELATIONSHIP BETWEEN INTEREST PERSON AND THE ORGANIZATION:ROBERT BOBELL, O.D., AN OFFICER OF GRAHAM HOSPITAL ASSOCIATION, IS A DIRECTOR ON THE BOARD OF MIDAMERICA NATIONAL BANK. FORM 990, PART I, LINE 6: THE GRAHAM HOSPITAL SERVICE LEAGUE VOLUNTEERS OPERATE AND MANAGE THEIR OWN GIFT SHOP WHICH IS LOCATED WITHIN GRAHAM HOSPITAL. A PORTION OF THE PROCEEDS FROM THE GIFT SHOP AND ALL OTHER FUNDRAISING EVENTS IS GIVEN TO THE HOSPITAL ANNUALLY TO PROVIDE FOR MUCH NEEDED MEDICAL EQUIPMENT. VOLUNTEERS ALSO PERFORM VARIOUS OTHER SERVICES WITHIN THE HOSPITAL; SURGERY HOSTESS, INFORMATION DESK, AND MAINTENANCE OF ATRIUM PLANTS. FORM 990, PART VI, SECTION B, LINE 11B THE PREPARED FORM 990 IS REVIEWED BY THE CFO, DIRECTOR OF ACCOUNTING, AND SENIOR ACCOUNTANT BEFORE FILING WITH THE IRS. BEFORE FILING, THE INDEPENDENT ACCOUNTANT PRESENTS THE FORM 990 TO THE ORGANIZATION'S BOARD OF DIRECTORS. FORM 990, PART VI, SECTION B, LINE 12C GRAHAM HOSPITAL REQUIRES THAT ALL TRUSTEES AND ADMINISTRATIVE OFFICERS KEEP THE BOARD OF TRUSTEES INFORMED OF POTENTIAL CONFLICTS OF INTEREST, AND THAT EACH PERSON MAKE AN ANNUAL DECLARATION OF SUCH INTEREST. A CONFLICT OF INTEREST MIGHT EXIST WHEN ORGANIZATIONS IN WHICH TRUSTEES OR OFFICERS HAVE A MATERIAL FINANCIAL INTEREST ARE EITHER DOING BUSINESS WITH, COMPETING WITH, OR HAVE A FINANCIAL INTEREST IN GRAHAM HOSPITAL. FORM 990, PART VI, SECTION B, LINE 15 THE COMPENSATION OF THE ADMINISTRATIVE OFFICERS IS REVIEWED ANNUALLY BY THE EXECUTIVE COMPENSATION COMMITTEE OF THE BOARD OF TRUSTEES. THE ORGANIZATION UTILIZES AN OUTSIDE FIRM, SULLIVAN, COTTER AND ASSOCIATES, INC. TO PROVIDE OUTSIDE EXECUTIVE COMPENSATION INFORMATION. THE LAST REVIEW WAS COMPLETED IN MAY 23, 2016. FORM 990, PART VI, SECTION C, LINE 19 THE GOVERNING DOCUMENTS, CONFLICT OF INTEREST POLICY, AND FINANCIAL STATEMENTS ARE NOT MADE AVAILABLE TO THE PUBLIC. FORM 990, PART IX, LINE 11G OTHER FEES: PROGRAM SERVICE EXPENSES 9,665,845. MANAGEMENT AND GENERAL EXPENSES 0. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 9,665,845. FORM 990, PART XI, LINE 9: CHANGE IN FAIR VALUE OF SWAP OPTION 1,963,909. CHANGE IN NET ASSETS OF GRAHAM HOSPITAL FOUNDATION 60,800. CHANGE IN BENEFICIAL INTEREST IN PERPETUAL TRUSTS 414,441. FORM 990, PART XII, LINE 2C THE OVERSIGHT AND SELECTION PROCESS HAS NOT CHANGED FROM THE PRIOR TAX YEAR.