2017-03-24T14:35:24-05:00 2016-06-30 410746749 CLIFTONLARSONALLEN LLP 114 E EVERETT DIXON IL 61021 990 2015-07-01 370661215 KIRBY MEDICAL CENTER KIRB 2177622115 1000 MEDICAL CENTER DRIVE MONTICELLO IL 61856 MR STEVEN TENHOUSE CHIEF EXECUTIVE OFFICER 2177622115 2017-03-21 1 TODD M ETHERIDGE P00233050 8152859300 2015 2021-01-29 14:40:06Z MR STEVEN TENHOUSE 1000 MEDICAL CENTER DRIVE MONTICELLO IL 61856 34522206 0 X WWW.KIRBYHEALTH.ORG X 1939 IL KIRBY MEDICAL CENTER IS COMMITTED TO PROVIDING QUALITY AND COMPASSIONATE CARE TO ALL. 9 8 298 241 0 0 175130 167887 30742045 31705584 495813 300289 813509 1004106 32226497 33177866 61145 33130 0 0 12908541 13466162 0 0 0 14821828 15468404 27791514 28967696 4434983 4210170 76436390 78547366 32913324 31241684 43523066 47305682 X KIRBY MEDICAL CENTER IS COMMITTED TO PROVIDING QUALITY AND COMPASSIONATE CARE TO ALL. 1 0 19969873 33130 31705584 THE HOSPITAL PROVIDES QUALITY INPATIENT AND OUTPATIENT SERVICES TO ITS COMMUNITY. FREE, SUBSIDIZED, AND GOVERNMENT ASSISTED CARE ARE PROVIDED AT A REDUCED RATE WHEN NEEDED. SERVICES PROVIDED DURING THE YEAR INCLUDE APPROXIMATELY 21,455 PATIENT VISITS THROUGH THE KIRBY MEDICAL CLINIC, 2,060 NURSING CARE INPATIENT DAYS, AND 77,965 LABORATORY PROCEDURES. 19969873 1 1 0 1 0 0 0 0 0 0 1 1 0 0 1 1 0 1 0 0 0 0 0 0 0 0 1 1 1 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 1 1 1 0 0 1 44 0 298 1 0 0 0 0 0 0 0 0 0 0 X 9 8 0 0 0 0 0 0 0 1 1 0 0 1 1 1 1 1 1 1 0 0 IL X MR STEVEN TENHOUSE 2177622115 1000 MEDICAL CENTER DRIVE MONTICELLO IL 61856 CRAIG WEBB CHAIRMAN 3.50 0.00 X X 18000 0 0 GARY HUISINGA VICE CHAIRMAN 1.80 0.00 X X 9300 0 0 JAMES BALLSRUD TREASURER 1.90 0.00 X X 9900 0 0 STEPHEN AYERS BOARD MEMBER 1.10 0.00 X 5550 0 0 EDWARD EWALD BOARD MEMBER 1.00 0.50 X 4800 0 0 DYKE PIATT BOARD MEMBER 1.00 0.50 X 6300 0 0 WILLIAM TRACY II BOARD MEMBER 0.90 0.00 X 4500 0 0 KARLA BRADLEY BOARD MEMBER 1.00 0.00 X 5400 0 0 STEVE MILLS BOARD MEMBER 1.20 0.00 X 6450 0 0 STEVEN TENHOUSE SECRETARY & CEO 40.00 0.50 X 198483 0 42388 DR NARAIN MANDHAN CHIEF MEDICAL OFFICER 40.00 0.00 X 269471 0 39128 ALEXANDER NAZARIAN CHIEF FINANCIAL OFFICER 40.00 0.00 X 111086 0 14594 JENNIFER MOSS CHIEF CLINICAL OFFICER 40.00 0.00 X 107269 0 18618 MARK FRED CHIEF OPERATING OFFICER 40.00 0.00 X 120604 0 30526 ANDREW BUFFENBARGER CHIEF COMPLIANCE OFFICER 40.00 0.00 X 92595 0 29649 JOSEPH LAMB PHYSICIAN'S ASSISTANT 40.00 0.00 X 100388 0 32801 DR JAMES MANINT PHYSICIAN 40.00 0.00 X 159590 0 11436 1229686 0 219140 7 0 1 0 CARLE PHYSICIAN GROUP 611 W PARK STREET URBANA IL 61801 PHYSICIAN SERVICES 2492453 PETRY-KUHNE COMPANY PO BOX 3757 CHAMPAIGN IL 61826 GENERAL CONTRACTOR 1175287 CARLE FOUNDATION HOSPITAL 611 W PARK STREET URBANA IL 61801 PHYSICIAN SERVICES 770631 QUEST DIAGNOSTICS INC 7937 COLLECTION CENTER DR PO BOX 1 CHICAGO IL 60693 LAB CONTRACTED SERVICES 170551 MEDICAL INFORMATION TECHNOLOGY PO BOX 74569 CHICAGO IL 60696 OPERATING SYSTEM SUPPORT 160496 9 1346 114443 14730 37368 167887 NET PATIENT SERVICE REVENUE 621110 31287626 31287626 PHARMACY INCOME 621110 184851 184851 PHYSICAL THERAPY INCOME 621110 98137 98137 EMR INCENTIVE REIMBURSEMENT 621110 71615 71615 AMBULANCE SERVICE INCOME 621910 57460 57460 5895 5895 31705584 305700 305700 863312 84959 778353 778353 778353 1249970 4000 1209806 49575 40164 -45575 -5411 -5411 CAFETERIA INCOME 722210 161821 161821 MISCELLANEOUS INC 621110 63932 63932 225753 33177866 31705584 0 1304395 X 33130 33130 1302704 1302704 9728407 7345841 2382566 463353 327086 136267 1213424 873777 339647 758274 519255 239019 5323 5323 39684 39684 3859426 3374162 485264 171582 171582 698151 587287 110864 98380 98380 363689 346231 17458 91707 47000 44707 121431 57373 64058 1611910 1611910 2975034 2975034 724699 724699 MEDICAL SUPPLIES 1315452 1252157 63295 BAD DEBT 1047105 1047105 REPAIRS AND MAINTENANCE 773099 524191 248908 IDPA ASSESSMENT 250735 250735 1320997 660244 660753 28967696 19969873 8997823 0 24396 52635 6731627 6778646 4786155 4585266 207812 235863 1129888 1128201 46666949 15286612 31169232 31380337 10733856 13135418 20863317 20807588 790107 443412 76436390 78547366 3574570 3404591 28434403 27598029 904351 239064 32913324 31241684 X 22659749 26498094 20863317 20807588 43523066 47305682 76436390 78547366 X 4210170 -401825 -25729 X X 0 1 X 1 1 1 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 0 0 0 0 0 0 0 0 1 8057 8057 0 PART II-B, LINE 1: LOBBYING EXPENSES ARE ALLOCATED THROUGH MEMBERSHIP DUES WITH THE ILLINOIS AND AMERICAN HOSPITAL ASSOCIATION. NO OTHER LOBBYING ACTIVITIES WERE CONDUCTED. 2455305 349650 2804955 788640 16726258 4393359 13121539 20465417 9544943 10920474 5881679 1348310 4533369 31380337 BENEFICIAL INTEREST IN TRUSTS 20807588 C 20807588 DUE TO MEDICARE 239064 239064 X PART X, LINE 2: KMC IS A NOT-FOR-PROFIT CORPORATIONS AND HAVE BEEN RECOGNIZED AS TAX-EXEMPT PURSUANT TO SEC. 501(C)(3) OF THE INTERNAL REVENUE CODE AND HAVE BEEN CLASSIFIED AS OTHER THAN A PRIVATE FOUNDATION. KMC FILES FORM 990 (RETURN OF ORGANIZATION EXEMPT FROM INCOME TAX) ANNUALLY. WHEN THESE RETURNS ARE FILED, IT IS HIGHLY CERTAIN THAT SOME POSITIONS TAKEN WOULD BE SUSTAINED UPON EXAMINATION BY THE TAXING AUTHORITIES, WHILE OTHERS ARE SUBJECT TO UNCERTAINTY ABOUT THE MERITS OF THE POSITION TAKEN OR THE AMOUNT OF THE POSITION THAT WOULD ULTIMATELY BE SUSTAINED. EXAMPLES OF TAX POSITIONS INCLUDE SUCH MATTERS AS THE FOLLOWING: THE TAX EXEMPT STATUS OF THE ENTITY AND VARIOUS POSITIONS RELATIVE TO POTENTIAL SOURCES OF UNRELATED BUSINESS TAXABLE INCOME (UBIT). UBIT IS REPORTED ON FORM 990T, 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 PROCESSES, IF ANY. TAX POSITIONS ARE NOT 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 UNRECOGNIZED TAX BENEFITS IN THE ACCOMPANYING STATEMENTS OF FINANCIAL POSITION ALONG WITH ANY ASSOCIATED INTEREST AND PENALTIES THAT WOULD BE PAYABLE TO THE TAXING AUTHORITIES UPON EXAMINATION. PRESENTLY, THERE ARE NO ONGOING INCOME TAX AUDITS OR UNRESOLVED DISPUTES WITH TAX AUTHORITIES THAT THE MEDICAL CENTER CURRENTLY FILES OR HAS FILED WITH. PART V UPON FURTHER REVIEW OF THE PREVIOUSLY REPORTED ENDOWMENT FUNDS, IT HAS BEEN DETERMINED THAT THERE WAS NOT ACTUALLY AN ENDOWMENT FUND TO REPORT ON SCHEDULE D BECAUSE THE PREVIOUSLY REPORTED FUNDS DID NOT MEET THE SFAS 117 DEFINITION. AS A RESULT, THE ENDOWMENT FUND HAS BEEN REMOVED FROM THE 2015 FORM 990. 1 1 X 1 X 1 X 280.000000000000 1 1 1 0 1 1 625008 625008 0.02240 3508651 2600286 908365 0.03250 4133659 2600286 1533373 0.05490 18152 130 18022 0.00060 961352 887968 73384 0.00260 34379 34379 0.00120 1013883 888098 125785 0.00440 5147542 3488384 1659158 0.05930 1642 1642 0.00010 92 92 0.00000 21 21 0.00000 196 196 0.00000 1951 1951 0.00010 1 1047105 0 7371071 7383029 -11958 X 1 1 1 1 KIRBY MEDICAL CENTER 1000 MEDICAL CENTER DRIVE MONTICELLO IL 61856 WWW.KIRBYHOSPITAL.ORG 5785 X X X X KIRBY MEDICAL CENTER 1 0 0 1 X X X X X X X X X 15 1 0 1 1 X WWW.KIRBYHOSPITAL.ORG X 1 15 1 HTTP://KIRBYHEALTH.ORG/FILES/2016_KIRBY_MEDICAL_CENTER_CHNA-LOGO.PDF 0 0 1 X 150.000000000000 280.000000000000 X X X X X X 1 1 X X X 1 X HTTP://KIRBYHEALTH.ORG/PATIENTS_VISITORS/KIRBY_CARE.PHP X HTTPS://WWW.KIRBYHEALTH.ORG/PDF/KIRBY-FINANCIAL-ASSITANCE-APPLICATION.PDF X HTTPS://WWW.KIRBYHEALTH.ORG/PDF/PLAIN-LANGUAGE-SUMMERY.PDF X X X X X X 1 X 0 X X X X X 1 X 0 0 KIRBY MEDICAL CENTER PART V, SECTION B, LINE 5: A FOCUS GROUP COMPRISED OF COMMUNITY REPRESENTATIVES MET ON JANUARY 13, 2016. ANOTHER FOCUS GROUP COMPRISED OF MEDICAL PROFESSIONALS AND PARTNERS GROUP MET ON JANUARY 24, 2016. A THIRD FOCUS GROUP COMPRISED OF MEMBERS OR REPRESENTATIVES OF THE FOCUS GROUPS MET ON FEBRUARY 23, 2016. THESE FOCUS GROUPS WERE COMPRISED OF AREA HEALTHCARE PROVIDERS, PARTNERS, AND PERSONS WHO REPRESENT THE BROAD INTERESTS OF THE COMMUNITY SERVED BY THE HOSPITAL, INCLUDING THOSE WITH SPECIAL KNOWLEDGE OF, OR EXPERTISE IN PUBLIC HEALTH. KIRBY MEDICAL CENTER PART V, SECTION B, LINE 6B: ILLINOIS CRITICAL ACCESS HOSPITAL NETWORK KIRBY MEDICAL CENTER PART V, SECTION B, LINE 11: THE LATEST CHNA WAS ADOPTED TWO MONTHS PRIOR TO THE END OF THE TAX YEAR. WE HAVE IMMEDIATE SUCCESS STORIES FOR MENTAL HEALTH AND CHRONIC DISEASE MANAGEMENT AS THESE ARE THE TWO MOST IMPORTANT NEEDS THAT WE HAVE IDENTIFIED. TO ADDRESS THE MENTAL HEALTH NEEDS, WE HAVE HIRED A FULL TIME SOCIAL WORKER TO COUNSEL PATIENTS WITH MENTAL HEALTH NEEDS. WE HAVE PARTNERED WITH THE PIATT COUNTY MENTAL HEALTH TO PROVIDE LICENSED CLINICAL SOCIAL WORKER (LCSW) SERVICES WITHIN THE KIRBY MEDICAL GROUP RURAL HEALTH CLINICS IN MONTICELLO AND ATWOOD. WE HAVE EXPANDED DR. MANDHAN'S SUBSTANCE ABUSE CLINIC. WE HAVE PARTNERED WITH THE IMPACT COALITION TO PROVIDE INFORMATION TO THE COMMUNITY REGARDING HEROIN AND ADDICTION.TO ADDRESS CHRONIC DISEASE MANAGEMENT, WE HAVE HIRED AN RN TO WORK WITH PATIENTS TO MANAGE THEIR CHRONIC HEALTH NEEDS AND REMAIN COMPLIANT WITH THE CARE INSTRUCTIONS PRESCRIBED BY THEIR PRIMARY CARE PRACTITIONERS.WE WORK WITH OUR COMMUNITY PARTNERS ON THE PLAN TO ADDRESS THE OTHER NEEDS IDENTIFIED ON THE LATEST CHNA. KIRBY MEDICAL CENTER PART V, SECTION B, LINE 13H: KIRBY MEDICAL CENTER HAS A "PRESUMPTIVE ELIGIBILITY" POLICY THAT REDUCES ALL CHARGES TO ZERO, A FULL WRITE-OFF OF CHARGES, IF A PATIENT IS ELIGIBLE FOR A VARIETY OF STATE-FUNDED SUPPORT PROGRAMS. UNDER THE PRESUMPTIVE ELIGIBILITY POLICY, THERE IS NO NEED FOR A PATIENT TO APPLY FOR FINANCIAL ASSISTANCE BECAUSE THE PATIENT IS ASSUMED TO BE MEDICALLY FINANCIALLY INDIGENT. KIRBY MEDICAL CENTER PART V, SECTION B, LINE 16I: FINANCIAL ASSISTANCE INFORMATION IS PROVIDED BY THE PATIENT FINANCIAL SERVICES STAFF AND IS REFERENCED IN NEWSPAPER AND BILLBOARD ADVERTISING. KIRBY MEDICAL CENTER PART V, SECTION B, LINE 20E: BEFORE AN ACCOUNT IS SENT TO COLLECTIONS, KIRBY MEDICAL CENTER CHECKS THE INDIVIDUAL'S STATUS WITH VARIOUS STATE-FUNDED SUPPORT PROGRAMS, SUCH AS FOOD STAMPS, WIC, AND MEDICAID. IF AN INDIVIDUAL QUALIFIES TO PARTICIPATE IN ANY OF THESE PROGRAMS, THEY ARE PRESUMPTIVELY DETERMINED TO QUALIFY FOR A FULL WRITE-OFF OF CHARGES UNDER THE HOSPITAL'S FINANCIAL ASSISTANCE POLICY. KIRBY MEDICAL CENTER PART V, SECTION B, LINE 22D: WE USE THE AVERAGE OF ALL COMMERCIAL INSURANCE RATES WHEN CALCULATING THE MAXIMUM AMOUNT THAT CAN BE CHARGED AS AMOUNTS GENERALLY BILLED. WE ARE CURRENTLY IN THE PROCESS OF EVALUATING WHETHER INDIVIDUALS WHO QUALIFIED FOR FINANCIAL ASSISTANCE PAID MORE THAN AMOUNTS GENERALLY BILLED. IF ANY INDIVIDUALS PAID MORE THAN AMOUNTS GENERALLY BILLED, THE EXCESS AMOUNT IS BEING REFUNDED. 2 1 - KIRBY MEDICAL GROUP MONTICELLO 1000 MEDICAL CENTER DRIVE MONTICELLO IL 61856 RURAL HEALTH CLINIC 2 - KIRBY MEDICAL GROUP ATWOOD 108 N MAIN STREET ATWOOD IL 61913 RURAL HEALTH CLINIC PART I, LINE 3C: ELIGIBILITY FOR FINANCIAL ASSISTANCE IS BASED ON THE INDIVIDUAL'S INCOME AND ON CASH OR INVESTMENT ASSETS HELD BY THE INDIVIDUAL. EQUITY IN THE INDIVIDUAL'S HOME AND AUTOMOBILE ARE NOT CONSIDERED IN THE ELIGIBILITY CALCULATION. KIRBY MEDICAL CENTER MAY PRESUMPTIVELY DETERMINE AN INDIVIDUAL TO BE ELIGIBLE FOR A FULL WRITE-OFF, 100% FINANCIAL ASSISTANCE, IF THEY MEET ONE OR MORE OF THE FOLLOWING CRITERIA:1. PARTICIPATION IN STATE FUNDED PRESCRIPTION PROGRAMS;2. PARTICIPATION IN THE WOMEN, INFANTS, AND CHILDREN (WIC) PROGRAM;3. FOOD STAMP ELIGIBILITY;4. SUBSIDIZED SCHOOL LUNCH PROGRAM ELIGIBILITY;5. LOW-INCOME / SUBSIDIZED HOUSING IS PROVIDED AS A VALID ADDRESS;6. PATIENT IS DECEASED WITH NO KNOWN ESTATE;7. PATIENT STATES THAT THEY ARE HOMELESS, ALTHOUGH DUE DILIGENCE EFFORTS WILL BE TAKEN TO CONFIRM;8. PATIENT IS ELIGIBLE FOR MEDICAID, BUT WAS NOT ELIGIBLE ON A PRIOR DATE OF SERVICE;9. PATIENT DOES NOT COMPLETE AN APPLICATION, BUT THERE IS ADEQUATE INFORMATION TO SUPPORT THE PATIENT'S INABILITY TO PAY; OR10. PATIENT IS MENTALLY INCAPACITATED WITH NO ONE TO REPRESENT THEM. PART I, LINE 7: THE COSTS REPORTED IN SCHEDULE H, PART I, LINE 7 USED A RATIO OF PATIENT CARE COSTS TO CHARGES AS COMPUTED IN WORKSHEET 2 OF THE INSTRUCTIONS TO SCHEDULE H. THIS METHODOLOGY WAS USED FOR ALL PATIENT SEGMENTS. PART I, LINE 7, COLUMN (F): THE BAD DEBT EXPENSE INCLUDED ON FORM 990, PART IX, LINE 25, COLUMN (A), BUT SUBTRACTED FOR PURPOSES OF CALCULATING THE PERCENTAGE IN THIS COLUMN IS $ 1,047,105. PART II, COMMUNITY BUILDING ACTIVITIES: ECONOMIC DEVELOPMENT INCLUDES CHAMBER OF COMMERCE. COMMUNITY SUPPORT IS DISASTER READINESS OVER AND ABOVE REQUIREMENTS. LEADERSHIP DEVELOPMENT IS SUPPORT FOR ILLINOIS PROMISE PROGRAM. COALITION BUILDING INCLUDES 911 AND CRISIS TEAM MEETINGS. PART III, LINE 2: THE BAD DEBT AMOUNT INCLUDED ON LINE 2 IS THE BAD DEBT EXPENSE THAT WAS REPORTED IN THE HOSPITAL'S AUDITED FINANCIAL STATEMENTS. SEE THE "ACCOUNTS RECEIVABLE AND CREDIT POLICIES" SECTION OF NOTE 1, ON PAGE 11, IN THE ATTACHED AUDITED FINANCIAL STATEMENTS FOR AN EXPLANATION OF HOW BAD DEBT EXPENSE WAS ESTIMATED. PART III, LINE 3: THE ORGANIZATION HAS NOT IDENTIFIED A REASONABLE METHOD OF ESTIMATING THE AMOUNT OF BAD DEBT EXPENSE ATTRIBUTABLE TO PATIENTS WHO WOULD HAVE QUALIFIED FOR FINANCIAL ASSISTANCE HAD THEY COMPLETED AN APPLICATION. PART III, LINE 4: SEE THE "ACCOUNTS RECEIVABLE AND CREDIT POLICIES" SECTION OF NOTE 1, ON PAGE 11, IN THE ATTACHED AUDITED FINANCIAL STATEMENTS FOR AN EXPLANATION OF HOW BAD DEBT EXPENSE WAS ESTIMATED. PART III, LINE 8: UNDER THE CURRENT MEDICARE RULES, CRITICAL ACCESS HOSPITALS RECEIVE A REIMBURSEMENT OF 101 PERCENT OF ALLOWABLE HOSPITAL COSTS AND 100 PERCENT OF CLINIC ALLOWABLE COSTS. DESPITE THE REIMBURSEMENT RATES, KIRBY MEDICAL CENTER STILL HAD A SHORTFALL IN THE CURRENT YEAR, NONE OF WHICH WAS TREATED AS COMMUNITY BENEFIT. THE REIMBURSEMENTS WERE SLIGHTLY LOWER DUE TO THE FEDERAL GOVERNMENT'S SEQUESTRATION IN THE SUMMER OF 2014. THE MEDICARE ALLOWABLE COSTS REPORTED IN LINE 6 WERE CALCULATED USING THE 2016 FILED MEDICARE COST REPORT. PART III, LINE 9B: ALL PATIENTS WHO FAIL TO MAKE PAYMENTS RECEIVE THREE BILLING STATEMENTS THAT INCLUDE INFORMATION ABOUT FINANCIAL ASSISTANCE. WHEN THE FOURTH BILLING STATEMENT IS SENT TO THE INDIVIDUAL, THE ACCOUNT IS SENT TO ACOLLECTION AGENT. BEFORE A PATIENT IS SENT TO A COLLECTION AGENT, WE CHECK WHETHER THEY PRESUMPTIVELY QUALIFY FOR OUR FINANCIAL ASSISTANCE PROGRAM. IF A PATIENT CONTACTS KIRBY MEDICAL CENTER, WE CHECK THEIR PRESUMPTIVEELIGIBILITY FOR OUR FINANCIAL ASSISTANCE PROGRAM AND THEIR ELIGIBILITY FOR MEDICAID. PART VI, LINE 2: KIRBY MEDICAL CENTER WORKS IN CONCERT WITH LOCAL COMMUNITY HEALTH AGENCIES TO ASSESS THE HEALTH NEEDS OF THE LOCAL COMMUNITY AND THE IMMEDIATELY SURROUNDING COUNTY. IN THE YEAR ENDED JUNE 30, 2016, A COMMUNITY HEALTH NEEDS ASSESSMENT WAS CONDUCTED THROUGH A CONSULTING ARRANGEMENT WITH THE ILLINOIS CRITICAL ACCESS HOSPITAL NETWORK. TERRY MADSEN, AN ICAHN CONSULTANT, ATTORNEY AND FORMER EDUCATOR, AND COMMUNITY DEVELOPMENT SPECIALIST, MET WITH HOSPITAL EXECUTIVE STAFF TO DEFINE THE COMMUNITY, THE SCOPE OF THE PROJECT, AND SPECIAL NEEDS AND CONCERNS. AN INTERNAL WORKING GROUP, POSSIBLE LOCAL SOURCES FOR SECONDARY DATA, AND KEY EXTERNAL CONTACTS WERE IDENTIFIED, AND A TIMELINE WAS ESTABLISHED.THE COMMUNITY HEALTH NEEDS ASSESSMENT INVOLVED THE REVIEW OF SEVERAL HUNDRED PAGES OF DEMOGRAPHIC AND HEALTH DATA SPECIFIC TO THE KIRBY MEDICAL CENTER SERVICE AREA. INPUT INCLUDED FOCUS GROUPS COMPRISED OF AREA HEALTH CARE PROVIDERS, PARTNERS, AND PERSONS WHO REPRESENT THE BROAD INTERESTS OF THE COMMUNITY SERVED BY THE HOSPITAL, INCLUDING THOSE WITH SPECIAL KNOWLEDGE OF, OR EXPERTISE IN PUBLIC HEALTH. THE ASSESSMENT EXPLORED THE INSULAR NEEDS OF RESIDENTS LIVING IN POVERTY BY SPECIFICALLY SEEKING INPUT FROM PERSONS WITH KNOWLEDGE OF THE SPECIFIC HEALTH CONCERNS OF YOUTH AND ADULTS LIVING IN POVERTY IN THE COMMUNITY. INPUT WAS ALSO SOUGHT FROM PROFESSIONALS WITHIN THE COMMUNITY AND ALL ITS MEMBERS. PART VI, LINE 3: INFORMATION REGARDING ELIGIBILITY FOR FEDERAL, STATE AND LOCAL GOVERNMENT PROGRAMS, AS WELL AS THE HOSPITAL'S FINANCIAL ASSISTANCE PROGRAM, IS PUBLISHED ON THE HOSPITAL'S WEBSITE AND IS AVAILABLE VIA LITERATURE AT THE VARIOUS ADMISSIONS AREAS IN THE HOSPITAL. INFORMATION IS ALSO PROVIDED BY THE PATIENT FINANCIAL SERVICES STAFF AND IS REFERENCED IN NEWSPAPER AND BILLBOARD ADVERTISING. PART VI, LINE 4: KIRBY MEDICAL CENTER'S COMMUNITY IS A GEOGRAPHIC AREA THAT INCLUDES ALL OR PORTIONS OF THE ZIP CODE SERVICE AREAS SURROUNDING MONTICELLO, BEMENT, ATWOOD, HAMMOND, WHITE HEATH, DELAND AND MANSFIELD IN IL. THIS GEOGRAPHIC AREA DEFINITION OF COMMUNITY IS WELL-SUITED TO KIRBY MEDICAL CENTER, A DESIGNATED CRITICAL ACCESS HOSPITAL PROVIDING BASIC, PRIMARY CARE THROUGH INPATIENT CARE, ANCILLARY SERVICES, CLINICS, AND SPECIALTY CLINICS TO RESIDENTS OF THIS UNDERSERVED RURAL AREA. THE KIRBY MEDICAL CENTER SERVICE COMMUNITY IS NEARLY CONTIGUOUS TO PIATT COUNTY. MAJOR MEDICAL CENTERS IN CHAMPAIGN-URBANA, BLOOMINGTON, AND DECATUR RECEIVE PATIENTS FROM THE SERVICE AREA. THE PRIMARY SERVICE AREA AND POPULATIONS ARE THE ZIP CODES WITHIN A GEOGRAPHIC AREA SLIGHTLY SMALLER THAN THE GEOGRAPHIC AREAS OF PIATT COUNTY. THE PRIMARY SERVICE AREA IS COMPRISED OF APPROXIMATELY 390.08 SQUARE MILES WITH A POPULATION OF APPROXIMATELY 15,547 AND A POPULATION DENSITY OF 39.86 PER SQUARE MILE. THE NUMBER OF CHILDREN ELIGIBLE FOR FREE OR REDUCED LUNCH IS BELOW THE STATEWIDE AVERAGE. THE UNEMPLOYMENT RATE IN OUR COMMUNITY IS BELOW THE STATEWIDE AVERAGE. TEEN BIRTH RATE PER 1,000 POPULATION IS BELOW THE STATE AVERAGE. OVER 7% OF THE ADULTS IN OUR COMMUNITY DO NOT HAVE A HIGH SCHOOL DIPLOMA. PART VI, LINE 5: EVERY YEAR, KIRBY MEDICAL CENTER OFFERS NUMEROUS COMMUNITY-BASED SERVICES TO THOSE IN THE LOCAL AREA. COMMUNITY-BASED SERVICES PROVIDED BY KIRBY MEDICAL CENTER INCLUDE: SPORTS PHYSICAL CLINIC FOR STUDENT ATHLETES, SCHOOL-BASED HEALTH EDUCATION PROGRAMS, CPR TRAINING, SENIOR CITIZEN OUTREACH, DIABETES EDUCATION, WEEKLY FREE BLOOD PRESSURE SCREENINGS. ANNUALLY WE PROVIDE THE THOMAS DIXON MEMORIAL SCHOLARSHIPS TO AREA STUDENTS THAT HAVE AN INTEREST IN PURSUING A CAREER IN A MEDICAL FIELD. PART VI, LINE 7, REPORTS FILED WITH STATES IL 1 DEWITT-PIATT BI-COUNTY HEALTH DEPARTMENT 1020 SOUTH MARKET STREET MONTICELLO IL 61856 320196168 501(C)(3) 9000 N/A N/A GENERAL OPERATING SUPPORT 1 0 PART I, LINE 2: KIRBY MEDICAL CENTER PROVIDES GRANT FUNDS TO A COUNTY AGENCY TO SUPPORT HAVING A NURSE IN THE LOCAL SCHOOL DISTRICT. X 1 1 X X X X X 0 1 0 0 0 0 0 1 0 STEVEN TENHOUSE SECRETARY & CEO 164463 0 29483 0 4537 0 13192 0 29196 0 240871 0 0 0 DR NARAIN MANDHAN CHIEF MEDICAL OFFICER 232085 0 32621 0 4765 0 15890 0 23238 0 308599 0 0 0 MARK FRED CHIEF OPERATING OFFICER 106349 0 13793 0 462 0 8056 0 22470 0 151130 0 0 0 DR JAMES MANINT PHYSICIAN 132947 0 24924 0 1719 0 9477 0 1959 0 171026 0 0 0 PART I, LINE 1A KIRBY MEDICAL CENTER PAYS PROFESSIONAL AND OTHER DUES FOR THE CEO, STEVEN TENHOUSE, INCLUDING A CLUB MEMBERSHIP. ANY DUES MUST BE APPROVED BY THE CHAIRMAN OF THE BOARD BEFORE THEY ARE PAID AS BEING IN THE BEST INTEREST OF THE MEDICAL CENTER. ANY PERSONAL USE ASSOCIATED WITH CLUB DUES IS INCLUDED IN THE TAXABLE COMPENSATION OF THE CEO. PART I, LINE 4B IN 2016, THE MEDICAL CENTER ENTERED INTO A SUPPLEMENTAL COMPENSATION AGREEMENT COVERING THE CEO WHICH PROVIDES FOR THE OFFICER TO RECEIVE, UPON TERMINATION OF EMPLOYMENT, PAYMENTS IN MONTHLY INSTALLMENTS OVER A TWO YEAR PERIOD FOLLOWING TERMINATION. THE BENEFIT TO WHICH THE OFFICER IS ENTITLED TO RECEIVE IS IN ACCORDANCE WITH A VESTING SCHEDULE PROVIDED FOR IN THE AGREEMENT WITH VESTING SET TO BEGIN IN 2021 PROGRESSING TO 100% VESTING IN 2026. IF DEATH OR DISABILITY OCCURS DURING THE PERIOD COVERED BY THE AGREEMENT, THE BALANCE OF ACCOUNT BECOMES 100% VESTED WITH THE BENEFIT PAYMENTS MADE TO THE BENEFICIARY. THE MEDICAL CENTER'S FUNDING OF THIS BENEFIT IS BEING RECOGNIZED AS COMPENSATION COST ON AN ANNUAL BASIS. THE MEDICAL CENTER INTENDS TO USE CASH FROM OPERATIONS TO FUND THIS OBLIGATION. THE PLAN BEGAN ON JANUARY 1, 2016 BUT NO AMOUNTS WERE CONTRIBUTED AS OF FISCAL YEAR END. PART I, LINE 7 THE CEO, STEVEN TENHOUSE, RECEIVES A BONUS OF UP TO 15% OF BASED COMPENSATION BASED ON SUCCESSFUL FINANCIAL, OPERATIONAL, AND QUALITY INDICATORS OF THE KIRBY ORGANIZATION. THE FOLLOWING INDIVIDUALS RECEIVED A BONUS BASED ON THEIR CLINIC PATIENT PRODUCTION AND QUALITY INDICATORS SUCH AS CHART REVIEW, CHART AUDITS, AND PATIENT SATISFACTION: NARAIN DAS MANDHAN JAMES MANINT JAY LAMB THE BONUS AMOUNTS ARE DETERMINED BASED ON A FUNCTION OF BASE SALARY AND NATIONAL SURVEYS ON PHYSICIAN COMPENSATION AND PRODUCTION. THE FOLLOWING INDIVIDUALS RECEIVE A BONUS OF APPROXIMATELY 12% OF BASE COMPENSATION BASED ON SUCCESSFUL ACHIEVEMENT OF PRE-DETERMINED STRATEGIC AND OPERATIONAL GOALS ALIGNED WITH THEIR JOB DUTIES AND THE DEPARTMENTS THEY MANAGE: ALEX NAZARIAN JENNIFER MOSS MARK FRED ANDREW BUFFENBARGER FORM 990, PART III, LINE 2 CROSSFIT KMC IS A LICENSED CROSSFIT AFFILIATE LOCATED ON THE CAMPUS OF KIRBY MEDICAL CENTER IN MONTICELLO, IL. OUR PASSION IS EDUCATING PEOPLE ABOUT MOVEMENT, FITNESS, NUTRITION, AND COMMUNITY. ALL OF THESE THINGS WORK TOGETHER AND REQUIRE A RESPONSIBLE, COMMON SENSE APPROACH. OUR PROMISE IS TO INCORPORATE THAT WHICH IS BENEFICIAL TO OUR BODY, MIND, AND OVERALL HEALTH. OUR GOAL IS TO PROVIDE OUR COMMUNITY WITH A HIGH QUALITY, FUN TRAINING ENVIRONMENT AND THE NECESSARY ATTENTION THEY NEED EACH TIME THEY TRAIN WITH US. FORM 990, PART VI, SECTION A, LINE 1 MEMBERS OF ALL COMMITTEES ARE APPOINTED BY THE CHAIRMAN OF THE BOARD; PROVIDED, HOWEVER, THAT A MAJORITY OF EACH COMMITTEE MEMBERSHIP SHALL BE BOARD MEMBERS. SPECIAL COMMITTEES MAY BE APPOINTED BY THE CHAIRMAN WITH CONCURRENCE OF THE BOARD FOR SUCH SPECIAL TASKS AS CIRCUMSTANCES WARRANT. A SPECIAL COMMITTEE SHALL LIMIT ITS ACTIVITIES TO THE ACCOMPLISHMENT OF THE TASK FOR WHICH IT IS APPOINTED AND SHALL HAVE NO POWER TO ACT EXCEPT SUCH AS IS SPECIFICALLY CONFERRED BY ACTION OF THE BOARD. UPON COMPLETION OF THE TASK FOR WHICH APPOINTED, SUCH SPECIAL COMMITTEE SHALL STAND DISCHARGED. BOARD COMMITTEES SHALL HOLD MEETINGS WHEN NECESSARY AND SHALL KEEP A FULL RECORD OF THEIR PROCEEDINGS, WHICH SHALL BE ENTERED IN A BOOK OF MINUTES. EACH COMMITTEE SHALL HAVE A CHARTER, APPROVED BY THE BOARD, DELINEATING ITS ORGANIZATION/MEMBERSHIP, RESPONSIBILITIES, AND MEETING FREQUENCY. FORM 990, PART VI, SECTION B, LINE 11 THE FORM 990 FINANCIAL INFORMATION IS REVIEWED BY THE INTERNAL ACCOUNTING STAFF FOR ACCURACY TO THE HOSPITAL'S AUDITED FINANCIAL STATEMENTS. OTHER FORM 990 INFORMATION IS REVIEWED BY THE CFO AND CEO. THE FINAL VERSION OF THE FORM 990 IS REVIEWED BY THE GOVERNING BOARD'S AUDIT AND COMPLIANCE COMMITTEE BEFORE THE FORM IS FILED WITH THE IRS. FORM 990, PART VI, SECTION B, LINE 12C GENERALLY THE BOARD ASSESSES THE CONFLICTS THAT EXIST WITH ITS MEMBERS AND REQUESTS THAT MEMBERS WITH THESE CONFLICTS BE EXCUSED FROM ANY DISCUSSION RELATED TO THEM. BECAUSE OF THE FAMILIARITY OF BOARD MEMBERS WITH ONE ANOTHER AND THE SIZE OF THE COMMUNITY, THE BOARD'S SELF ASSESSMENT OF CONFLICTS CAN BE MADE WITH RELATIVE EASE. AN INTERESTED PERSON INCLUDES ANY PERSON ASSOCIATED WITH KMC WHO HAS A DIRECT OR INDIRECT FINANCIAL INTEREST IN THE MATTER AT HAND. IF THE INTERESTED PERSON IS IN A SENIOR LEADERSHIP POSITION, IS A BOARD OR COMMITTEE MEMBER, THE APPLICABLE BOARD OR COMMITTEE SHALL DETERMINE WHETHER A CONFLICT OF INTEREST EXISTS. IF THE INTERESTED PERSON IS NOT A BOARD OR COMMITTEE MEMBER, THE CEO, IN CONSULTATION WITH BOARD MEMBERS AND/OR OTHER MANAGEMENT PERSONNEL, SHALL DETERMINE WHETHER A CONFLICT OF INTEREST EXISTS. IF IT IS DETERMINED THAT AN INTERESTED PERSON HAS A CONFLICT, THE INTERESTED PERSON MAY BE EXCLUDED FROM ALL DISCUSSIONS REGARDING THAT AGREEMENT, TRANSACTION, OR ARRANGEMENT. PROCEEDINGS RESULTING FROM CONFLICTS OF INTEREST ARE DOCUMENTED IN THE BOARD MINUTES. FORM 990, PART VI, SECTION B, LINE 15A THE KIRBY BOARD UTILIZES THE BI-ANNUAL IHA COMPENSATION SURVEY RESULTS TO SET AND COMPARE THE CEO'S COMPENSATION. THE LATEST REVIEW WAS DONE IN THE SPRING OF 2016. THIS PROCESS IS PRESENTED TO THE FULL BOARD FOR APPROVAL AND IS DOCUMENTED IN THE BOARD MINUTES. OTHER OFFICER'S COMPENSATION IS DETERMINED USING SALARY SURVEY DATA PROMULGATED ANNUALLY BY ASHHRA. IT IS THEN REVIEWED BY THE CHIEF COMPLIANCE OFFICER AND CEO. FORM 990, PART VI, SECTION C, LINE 19 THE ORGANIZATION'S GOVERNING DOCUMENTS ARE AVAILABLE TO THE PUBLIC UPON REQUEST IN WRITING TO ADMINISTRATION. FORM 990, PART IX, LINE 11G ER PROFESSIONAL FEES: PROGRAM SERVICE EXPENSES 1,814,314. MANAGEMENT AND GENERAL EXPENSES 0. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 1,814,314. ADMIN PROFESSIONAL FEES: PROGRAM SERVICE EXPENSES 0. MANAGEMENT AND GENERAL EXPENSES 237,943. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 237,943. PHYSICIAN SERVICES: PROGRAM SERVICE EXPENSES 567,266. MANAGEMENT AND GENERAL EXPENSES 247,321. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 814,587. OTHER PROFESSIONAL FEES: PROGRAM SERVICE EXPENSES 992,582. MANAGEMENT AND GENERAL EXPENSES 0. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 992,582. FORM 990, PART XI, LINE 9: INCREASE IN VALUE OF LIFE INSURANCE 30,000. CHANGE IN INTEREST IN PERPETUAL TRUST -55,729. FORM 990, PART XII, LINE 2C: THIS PROCESS HAS NOT CHANGED FROM THE PRIOR YEAR. THE KIRBY FOUNDATION 1000 MEDICAL CENTER DR MONTICELLO IL 61856 061836473 SUPPORT OF KIRBY MEDICAL CENTER IL 501(C)(3) LINE 7 KIRBY MEDICAL CENTER 1 PERPETUAL TRUSTS (4) INCOME BENEFICIARY IL N/A T 0 0 0 1 0 0 0 0 0 0 0 0 0 0 1 1 0 0 0 0 THE KIRBY FOUNDATION C 114443 CASH TRANSFERRED