2017-02-13T12:55:40-06:00 2016-06-30 BKD LLP 211 N BROADWAY SUITE 600 ST LOUIS MO 631022733 990 2015-07-01 370624255 Community Memorial Hospital Association % BRIAN ENGELKE COMM 6186354242 400 Caldwell Street Staunton IL 62088 BRIAN ENGELKE CFO 6186354242 2017-02-13 true Donna J Larson P00043751 3142315544 2017-01-31 2015 2021-01-29 14:40:06Z SUE E CAMPBELL 400 N CALDWELL STAUNTON IL 62088 18391592 false X WWW.STAUNTONHOSPITAL.ORG X 1946 IL COMMUNITY MEMORIAL HOSPITAL PROVIDES COMPASSIONATE PATIENT-CENTERED HEALTH CARE SERVICES, WHILE MAINTAINING CLINICAL EXCELLENCE AND FINANCIAL VIABILITY. 7 7 175 20 0 0 364501 1088290 15092235 16787469 33965 37367 110938 477496 15601639 18390622 2500 4075 0 0 6787104 6986687 0 0 0 8414495 10495065 15204099 17485827 397540 904795 23654827 26837290 10585594 13609928 13069233 13227362 COMMUNITY MEMORIAL HOSPITAL PROVIDES COMPASSIONATE PATIENT-CENTERED HEALTH CARE SERVICES, WHILE MAINTAINING CLINICAL EXCELLENCE AND FINANCIAL VIABILITY. false false 14468385 4075 17181932 THE ORGANIZATION OPERATES A FULL SERVICE CRITICAL ACCESS HOSPITAL IN STAUNTON, ILLINOIS WITH A TOTAL OF 25 BEDS. TOTAL PATIENT DAYS FOR THESE FISCAL YEAR ENDED JUNE 30, 2016 WAS 584 ACUTE DAYS AND 465 SWING BED DAYS. THE HOSPITAL ALSO PROVIDED SERVICES TO 23,455 OUTPATIENTS A 14468385 true true false false false false false false false false true false false false false false true false false false false false false false false false true true false false true true false false false false false false false false false false false false false false false false false false false true 20 0 true 175 true false false false false false false false false false false X 7 7 true false false false true true false true true false false true true true true true true true true false IL X BRIAN ENGELKE 6186354242 400 CALDWELL STAUNTON IL 62088 X DON KASUBKE PRESIDENT, BOARD OF TRUSTEES 5.0 0.0 X X 0 0 0 SYLVIA LUX BOARD MEMBER 2.0 0.0 X 0 0 0 BERNICE HENKE SECRETARY 2.0 0.0 X X 0 0 0 HULDA BLACK TREASURER 2.0 0.0 X X 0 0 0 EDDY SARACCO VICE PRESIDENT, BD OF TRUSTEES 2.0 0.0 X X 0 0 0 MIKE COX BOARD MEMBER 2.0 0.0 X 0 0 0 JEROME LESICKO BOARD MEMBER 2.0 0.0 X 0 0 0 LARRY ZIGLAR BOARD MEMBER 2.0 0.0 X 0 0 0 BRIAN URY BOARD MEMBER 2.0 0.0 X 0 0 0 SUE CAMPBELL CEO 40.0 0.0 X 171185 0 12919 BRIAN ENGELKE CFO 40.0 0.0 X 120026 0 12556 BHARATH POLA MD PHYSICIAN 40.0 0.0 X 206357 0 16943 JOSHUA POOS MD PHYSICIAN 40.0 0.0 X 183622 0 21629 SCOTT KATICH PHARMACIST 40.0 0.0 X 143764 0 17987 824954 0 82034 5 false true false HAROLD O'SHEA BUILDERS 3401 CONSTITUTION SPRINGFIELD IL 62711 CONTRACTOR 380191 SOUTH CENTRAL ANESTHESIA 7461 LESLIE DR EDWARDSVILLE IL 62025 CRNA 193100 CPP WOUND CARE 3445 N CAUSEWAY BOULEVARD METAIRIE LA 70002 WOUND CARE 222575 ALTON PHYSICAL THERAPY 1719 CLAWSON ALTON IL 62002 PHYSICAL THERAPY 600040 ILLINOIS EMERGENCY PHYSICIANS PO BOX 674519 DETROIT MI 68267 EMERGENCY PHYSICIANS 1452797 10 35215 1053075 1088290 NET PATIENT SERVICE REVENUE 621110 16787469 16787469 16787469 38337 38337 0 0 33724 33724 0 33724 33724 0 970 -970 -970 -970 0 0 0 CAFETERIA 721000 31923 31923 ANCILLARY SERVICES 900099 12256 12256 MEDICAL RECORDS 900099 382207 382207 17386 17386 443772 18390622 17181932 120400 X 2075 2075 2000 2000 0 0 324168 324168 0 5512086 4598733 913353 102132 85209 16923 641720 535387 106333 406581 339211 67370 120482 120482 330992 330992 72943 72943 0 0 0 3427693 2859724 567969 0 19104 15938 3166 1982878 1948040 34838 168633 140691 27942 0 330248 275526 54722 4325 3608 717 0 0 117052 117052 0 1117970 932722 185248 294201 245452 48749 PROVISION FOR BAD DEBTS 1429586 1429586 EQUIPMENT RENTAL 643486 536860 106626 HOSPITAL PROVIDER ASSESSMENT 224840 224840 DUES & SUBSCRIPTIONS 110388 92097 18291 100244 83634 16610 17485827 14468385 3017442 0 1301653 1316976 708517 510727 0 0 2272198 3659725 0 0 0 0 0 0 298347 309496 374674 410310 24209683 7946614 14415546 16263069 2940857 3770618 0 0 1343035 596369 0 0 0 0 23654827 26837290 2966029 2160781 0 0 0 0 478872 3083891 0 0 0 0 7140693 8365256 0 0 0 0 10585594 13609928 X 11726198 12630993 1343035 596369 0 0 13069233 13227362 23654827 26837290 X 904795 -746666 X false true X true true true X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 546486 546486 8492252 2400462 6091790 12863106 5213781 7649325 2307839 332371 1975468 16263069 16959036 16959036 1431586 1431586 18390622 16054241 16054241 1431586 1431586 17485827 SCHEDULE D, PART X, LINE 2 FIN 48 DISCLOSURE: MANAGEMENT HAS EVALUATED THEIR INCOME TAX POSITIONS UNDER THE GUIDANCE INCLUDED IN ASC 740. BASED ON THEIR REVIEW, MANAGEMENT HAS NOT IDENTIFIED ANY MATERIAL UNCERTAIN TAX POSITIONS TO BE RECORDED OR DISCLOSED IN THE FINANCIAL STATEMENTS. SCHEDULE D, PART XI, LINE 4B RECONCILIATION OF REVENUE PER FINANCIAL STATEMENTS TO REVENUE PER RETURN: SCHOLARSHIPS $ 2,000 BAD DEBT EXPENSE $1,429,586 ------------------------------------------------ TOTAL $1,431,586 THE ABOVE ACCOUNTS WERE CLASSIFIED WITH REVENUE ON THE AUDITED FINANCIAL STATEMENTS AND CLASSIFIED AS EXPENSES ON FORM 990. SCHEDULE D, PART XII, LINE 4B RECONCILIATION OF EXPENSE PER FINANCIAL STATEMENTS TO EXPENSE PER RETURN: SCHOLARSHIPS $ 2,000 BAD DEBT EXPENSE $1,429,586 ------------------------------------------------ TOTAL $1,431,586 THE ABOVE ACCOUNTS WERE CLASSIFIED WITH REVENUE ON THE AUDITED FINANCIAL STATEMENTS AND CLASSIFIED AS EXPENSES ON FORM 990. true true true X 125. true X true true false true true 16695 16695 0.00100 3576690 1870371 1706319 0.10630 3593385 1870371 1723014 0.10730 20278 20278 0.00130 2075 2075 0.00010 22353 22353 0.00140 3615738 1870371 1745367 0.10870 true 1429586 7284500 7427771 -143271 X true false 1 1 COMMUNITY MEMORIAL HOSPITAL 400 CALDWELL STAUNTON IL 62088 stauntonhospital.org 414 X X X X COMMUNITY MEMORIAL HOSPITAL 1 false false true X X X X X X X X X 15 true false false true X SEE PART V, SECTION C X true 15 true SEE PART V, SECTION C false true X 125. 300. true true X true X SEE PART V, SECTION C X SEE PART V, SECTION C X SEE PART V, SECTION C X X X X true X false X X X true X false false SCHEDULE H, PART V, SECTION B, LINE 5 INPUT FROM PERSONS WHO REPRESENT THE COMMUNITY: THE HOSPITAL HAD TWO FOCUS GROUPS. THE FIRST FOCUS GROUP WAS HEALTH CARE PROFESSIONALS WHICH INCLUDED REPRESENTATIVES OF MACOUPIN COUNTY HEALTH DEPARTMENT, VNA-TIP (HOME HEALTH), STAUNTON AREA AMBULANCE, GLENWOOD SUPPORTIVE LIVING, HERITAGE MANOR (NURSING HOME), A LOCAL PHARMACIST AND HOSPITAL DEPARTMENT MANAGERS. THE SECOND FOCUS GROUP INCLUDED COMMUNITY LEADERS AND REPRESENTATIVES FROM THE LOCAL SCHOOL, THE TOWNSHIP SUPERVISOR, A COMMUNITY BASED AMBULANCE SERVICE, LEWIS AND CLARK COMMUNITY COLLEGE NURSING PROGRAM AND A LOCAL PHYSICIAN. A TOWN HALL MEETING WAS ALSO HELD FOR MEMBERS OF THE COMMUNITY. SCHEDULE H, PART V, SECTION B, LINE 7 HOSPITAL FACILITY WEBSITE (URL): WWW.STAUNTONHOSPITAL.ORG/2016_COMMUNITY_MEMHOSP_CHNA_WEB.PDF SCHEDULE H, PART V, SECTION B, LINE 22D DETERMINING MAXIMUM AMOUNTS CHARGED TO FAP-ELIGIBLE INDIVIDUALS: THE HOSPITAL USED ITS AVERAGE RATE RECEIVED FROM COMMERCIAL AND MEDICARE. SCHEDULE H, PART V, SECTION B, LINE 11 SIGNIFICANT NEEDS: DURING THE LAST FISCAL YEAR COMMUNITY MEMORIAL HOSPITAL HAS CONTINUED TO PROVIDE SUPPORT EFFORTS TO IMPROVE THE HEALTH AND WELLNESS OF OUR COMMUNITY. SPECIFICALLY, WE HAVE SPONSORED THE STARTUP OF THE ALPHA DOG RUNNING CLUB. THIS CLUB HELP PROMOTES RUNNING AS A PART OF A HEALTHY LIFESTYLE. WE HAVE ALSO SUPPORTED THE KIDS CAFE A LOCAL ORGANIZATION THAT PROVIDES NUTRITIOUS LUNCHES FOR LOW INCOME STUDENTS DURING THE SUMMER MONTHS WHEN SCHOOL IS NOT IN SESSION. WE HAVE ALSO CONTINUED TO OPERATE OUR SENIOR LIFE PROGRAM WHICH PROVIDES OUTPATIENT PSYCHIATRIC SERVICES TO THE ELDERLY IN OUR COMMUNITY. WE ALSO CONTINUE TO SUPPORT A WEEKLY ONCOLOGY CLINIC AND PROVIDE CHEMOTHERAPY SERVICES TO HELP THOSE IN OUR COMMUNITY WHO ARE BATTLING CANCER. MENTAL HEALTH - CONTINUE TO OPERATE AN OUTPATIENT GERIATRIC BEHAVIORAL HEALTH PROGRAM, HAVE GRIEF CONSOLING MEETINGS, CONTINUED TRAINING ON DRUG AWARENESS. SCHEDULE H, PART V, SECTION B, LINES 16A, 16B & 16C FAP, FAP APPLICATION, AND FAP PLAIN LANGUAGE SUMMARY AVAILABILITY: http://stauntonhospital.org/Financial_Assistance_Policy_-501r.pdf http://www.stauntonhospital.org/html/patient_accounts.html http://stauntonhospital.org/Financial_Assistance_Policy_-_Plain_Language_S ummary_.pdf SCHEDULE H, PART V, SECTION B, LINE 10A HOSPITAL FACILITY IMPLEMENTATION STRATEGY (URL): http://stauntonhospital.org/2016_Community_MemHosp_CHNA_Web.pdf 2 STAUNTON MEDICAL CLINIC 325 CALDWELL STAUNTON IL 62088 CLINIC BENLD CLINIC 311 EAST CENTRAL BENLD IL 62009 CLINIC SCHEDULE H, PART III, SECTION A, LINE 2 METHODOLOGY USED TO ESTIMATE BAD DEBT EXPENSE: THE BAD DEBT EXPENSE AS REPORTED ON THE FINANCIAL STATEMENT HAS BEEN REPORTED ON LINE 2, THEREFORE, THE COSTING METHODOLOGY FOR THIS LINE IS BASED ON THE PATIENT CHARGES THAT WERE WRITTEN OFF ON THE BOOKS. NO BAD DEBT AMOUNTS WERE INCLUDED IN COMMUNITY BENEFIT. SCHEDULE H, PART III, SECTION A, LINE 3 METHODOLOGY USED TO ESTIMATE BAD DEBT EXPENSE FOR FAP ELIGIBLE PATIENTS: THE HOSPITAL BELIEVES THAT THE COMMUNITY BENEFIT OBTAINED FROM ITS CHARITY CARE IS UNDERSTATED DUE TO PATIENTS THAT COULD QUALIFY FOR CHARITY CARE BUT DO NOT APPLY OR PROVIDE INCOMPLETE INFORMATION. SOME CARE PROVIDED TO PATIENTS IS NOT CLASSIFIED AS CHARITY CARE DUE TO PATIENTS MISSING DOCUMENTATION THAT PROVES THEY QUALIFY FOR CHARITY CARE. THE HOSPITAL'S BAD DEBT DOES INCLUDE AMOUNTS THAT COULD BE CLASSIFIED AS CHARITY CARE IF THE PATIENTS WOULD APPLY OR PROVIDE THE APPROPRIATE INFORMATION TO COMPLETE THE CHARITY CARE APPLICATION. IN LINE WITH ITS MISSION, THE HOSPITAL PROVIDES A SAFETY NET FOR THE COMMUNITIES SERVED TO ACCESS MUCH NEEDED CARE BY OFFERING SOME SERVICES TO PATIENTS WITHOUT REGARD TO THEIR ABILITY TO PAY FOR THOSE SERVICES. FOR SOME OF THEIR PATIENT SERVICES, THE HOSPITAL RECEIVES NO PAYMENT OR PAYMENT THAT IS LESS THAN THE FULL COST OF PROVIDING THE SERVICES. THE HOSPITAL VOLUNTARILY PROVIDES FREE CARE TO PATIENTS WHO ARE UNABLE TO PAY FOR ALL OR PART OF THEIR HEALTH CARE EXPENSES AS DETERMINED BY THE HOSPITAL'S CRITERIA FOR FINANCIAL ASSISTANCE. IN SOME CASES, THE HOSPITAL DOES NOT RECEIVE THE AMOUNT BILLED FOR PATIENT SERVICES EVEN THOUGH IT DID NOT RECEIVE INFORMATION NECESSARY TO DETERMINE IF THE PATIENTS MET THE CRITERIA FOR FINANCIAL ASSISTANCE. BAD DEBTS EXPENSE IS THE ESTIMATED AMOUNT OF PATIENT REVENUE THAT THE HOSPITAL WILL NOT COLLECT. SCHEDULE H, PART III, SECTION A, LINE 4 FINANCIAL STATEMENT BAD DEBT EXPENSE: FINANCIAL STATEMENT FOOTNOTE: ACCOUNTS RECEIVABLE ARE REDUCED BY AN ALLOWANCE FOR DOUBTFUL ACCOUNTS. IN EVALUATING THE COLLECTABILITY OF ACCOUNTS RECEIVABLE, THE HOSPITAL ANALYZES ITS PAST HISTORY AND IDENTIFIES TRENDS FOR EACH OF ITS MAJOR PAYER SOURCES OF REVENUE TO ESTIMATE THE APPROPRIATE ALLOWANCE FOR DOUBTFUL ACCOUNTS AND PROVISION FOR UNCOLLECTIBLE ACCOUNTS. MANAGEMENT REGULARLY REVIEWS DATA ABOUT THESE MAJOR PAYER SOURCES OF REVENUE IN EVALUATING THE SUFFICIENCY OF THE ALLOWANCE FOR DOUBTFUL ACCOUNTS. FOR RECEIVABLES ASSOCIATED WITH SERVICES PROVIDED TO PATIENTS WHO HAVE THIRD-PARTY COVERAGE, THE HOSPITAL ANALYZES CONTRACTUALLY DUE AMOUNTS AND PROVIDES AN ALLOWANCE FOR DOUBTFUL ACCOUNTS AND A PROVISION FOR UNCOLLECTIBLE ACCOUNTS, IF NECESSARY (FOR EXAMPLE, FOR EXPECTED UNCOLLECTIBLE DEDUCTIBLES AND COPAYMENTS ON ACCOUNTS FOR WHICH THE THIRD-PARTY PAYER HAS NOT YET PAID, OR FOR PAYERS WHO ARE KNOWN TO BE HAVING FINANCIAL DIFFICULTIES THAT MAKE THE REALIZATION OF AMOUNTS DUE UNLIKELY). FOR RECEIVABLES ASSOCIATED WITH SELF-PAY PATIENTS (WHICH INCLUDES BOTH PATIENTS WITHOUT INSURANCE AND PATIENTS WITH DEDUCTIBLE AND COPAYMENT BALANCES DUE FOR WHICH THIRD-PARTY COVERAGE EXISTS FOR PART OF THE BILL), THE HOSPITAL RECORDS A SIGNIFICANT PROVISION FOR UNCOLLECTIBLE ACCOUNTS IN THE PERIOD OF SERVICE ON THE BASIS OF ITS PAST EXPERIENCE, WHICH INDICATES THAT MANY PATIENTS ARE UNABLE OR UNWILLING TO PAY THE PORTION OF THEIR BILL FOR WHICH THEY ARE FINANCIALLY RESPONSIBLE. THE DIFFERENCE BETWEEN THE STANDARD RATES (OR THE DISCOUNTED RATES IF NEGOTIATED OR PROVIDED BY POLICY) AND THE AMOUNTS ACTUALLY COLLECTED AFTER ALL REASONABLE COLLECTION EFFORTS HAVE BEEN EXHAUSTED IS CHARGED OFF AGAINST THE ALLOWANCE FOR DOUBTFUL ACCOUNTS. SCHEDULE H, PART III, SECTION B, LINE 8 SHORTFALL TREATED AS A COMMUNITY BENEFIT: THE COSTING METHODOLOGY USED TO DETERMINE MEDICARE ALLOWABLE COSTS WAS ALLOWABLE COST AS REPORTED IN OUR FISCAL YEAR 2016 MEDICARE COST REPORT. THE SHORTFALL SHOULD BE CONSIDERED A COMMUNITY BENEFIT SINCE IT REPRESENTS THE UNREIMBURSED COSTS OF CARING FOR THE ELDERLY IN OUR COMMUNITY. SCHEDULE H, PART III, SECTION B, LINE 9B DEBT COLLECTION POLICY: THERE IS NO COLLECTION PRACTICE ON PATIENTS WHO QUALIFY FOR CHARITY. ANY PATIENT WHO SUBMITS AN APPLICATION FOR CHARITY AND MEETS THE GUIDELINES SET IN OUR CHARITY POLICY HAS THEIR ACCOUNT WRITTEN OFF WITH NO FURTHER COLLECTION EFFORT. SCHEDULE H, PART VI, LINE 2 NEEDS ASSESSMENT: THE HOSPITAL'S BOARD IS MADE UP OF INDIVIDUALS WHO LIVE WITHIN THE HOSPITAL'S SERVICE AREA. THESE INDIVIDUALS ALONG WITH SUPPORT FROM THE HOSPITAL'S MANAGEMENT AND MEDICAL STAFF ARE CONTINUALLY REVIEWING HOW THE HOSPITAL CAN BE AN ASSET WITHIN OUR SERVICE AREA. THE HOSPITAL HAS ALSO CONDUCTED A COMMUNITY PERCEPTION SURVEY TO HELP IDENTIFY AREAS TO IMPROVE PATIENT CARE OR THE NEED FOR ADDITIONAL SERVICES. SCHEDULE H, PART VI, LINE 3 PATIENT EDUCATION OF ELIGIBILITY FOR ASSISTANCE: INFORMATION REGARDING THE FINANCIAL ASSISTANCE PROGRAMS THAT THE HOSPITAL OFFERS IS LISTED ON THE HOSPITAL WEBSITE, AND IT IS PRINTED ON THE BOTTOM OF THE STATEMENTS THAT ARE MAILED TO THE PATIENTS. THE INFORMATION IS ALSO POSTED NEAR THE CASHIER'S WINDOW AND THE BUSINESS OFFICE STAFF ARE TRAINED TO PROVIDE THE INFORMATION TO PATIENTS THAT CALL INTO THE OFFICE AND DO NOT HAVE KNOWLEDGE OF THE PROGRAMS. SCHEDULE H, PART VI, LINE 4 COMMUNITY INFORMATION: THE COMMUNITY THAT THE ORGANIZATION SERVES CONSISTS OF ABOUT A TWELVE MILE RADIUS SURROUNDING STAUNTON AND THE COMMUNITIES WITHIN THAT RADIUS ARE: WORDEN, HAMEL, ALHAMBRA, LIVINGSTON, NEW DOUGLAS, MT. OLIVE, BENLD, GILLESPIE, BUNKER HILL, AND PRAIRIETOWN. THIS IS A RURAL AREA WITH A DEPRESSED ECONOMIC CLIMATE. MANY OF THE INDIVIDUALS ARE ELDERLY, POOR, AND INDIGENT WHICH RESULTS IN HIGHER NUMBERS OF MEDICARE AND MEDICAID RECIPIENTS. SCHEDULE H, PART VI, LINE 5 PROMOTION OF COMMUNITY HEALTH: THE HOSPITAL RESTOCKS THE AMBULANCES OF ANY SUPPLIES USED DURING THE TRANSPORT OF PATIENTS AT NO COST TO THE AMBULANCE SERVICE. THE HOSPITAL ALSO COMMITS SIGNIFICANT TIME AND RESOURCES TO ACTIVITIES AND SERVICES THAT MEET UNMET COMMUNITY NEEDS. MANY OF THESE ACTIVITIES ARE SPONSORED WITH THE KNOWLEDGE THAT THEY WILL NOT BE SELF-SUPPORTING OR FINANCIALLY VIABLE. SUCH PROGRAMS INCLUDE HEALTH SCREENINGS AND ASSESSMENTS, PARENTAL EDUCATION AND CARE, CPR TRAINING, BABY SITTER TRAINING, FIRST AID TRAINING, SUPPORT FOR VITAL COMMUNITY SERVICES, TRAUMA CARE, COMMUNITY EDUCATIONAL SERVICES, AND VARIOUS SUPPORT GROUPS. THE HOSPITAL PARTICIPATES IN EVENTS AND HEALTH FAIRS IN EACH OF THE COMMUNITIES WITHIN THE SERVICE AREA, AND IT DONATES STAFF LABOR, SUPPLIES, AND OTHER GOODS. SCHEDULE H, PART VI, LINE 6 AFFILIATED HEALTH CARE SYSTEM: NOT APPLICABLE SCHEDULE H, PART VI, LINE 7 STATE FILING OF COMMUNITY BENEFIT REPORT: NOT APPLICABLE SCHEDULE H, PART I, LINE 7 FINANCIAL ASSISTANCE AND CERTAIN OTHER COMMUNITY BENEFITS AT COST: THE COSTS REPORTED IN THE TABLE IN PART I, LINE 7 USED A RATIO OF PATIENT CARE COSTS TO CHARGES AS COMPUTED IN WORKSHEET 2 OF THE FORM INSTRUCTIONS. THIS METHODOLOGY WAS USED FOR ALL PATIENT SEGMENTS. SCHEDULE H, PART I, LINE 7, COLUMN F PERCENT OF TOTAL EXPENSE: THE ORGANIZATION HAD BAD DEBT EXPENSE IN THE AMOUNT OF $1,429,586 REPORTED ON PART IX, LINE 24A. HOWEVER, IT HAS BEEN SUBTRACTED FOR PURPOSES OF CALCULATING THE PERCENTAGE IN THIS COLUMN. X X X false false false false false false false false false SUE CAMPBELL CEO 171185 0 0 0 0 0 5167 0 7752 0 184104 0 BHARATH POLA MD PHYSICIAN 206357 0 0 0 0 0 4244 0 12699 0 223300 0 JOSHUA POOS MD PHYSICIAN 183622 0 0 0 0 0 5735 0 15894 0 205251 0 SCOTT KATICH PHARMACIST 143764 0 0 0 0 0 2293 0 15694 0 161751 0 A ILLINOIS FINANCE AUTHORITY 861091967 2010-06-25 780000 5500 SQ. FT. MEDICAL OFFICE BUILDI false false false B CITY OF STAUNTON 376001380 2014-07-10 3000000 HOSPITAL RENOVATION false false false A 0 0 780000 0 0 0 0 0 0 780000 0 0 2010 false false true true B 0 0 3000000 0 0 0 60000 0 0 2892066 0 47934 2016 false false true true A false false false false 0 false false false true B false false false false 0 false false false true A false false true false false false 0 false 0 false false B false false true false false false 0 false 0 false true A false B true FORM 990, PART VI, SECTION A, LINE 2 BUSINESS RELATIONSHIPS: BRIAN URY AND EDDY SARACCO HAVE A BUSINESS RELATIONSHIP FORM 990, PART VI, SECTION A, LINE 6 GOVERNING BODY AND MANAGEMENT: COMMUNITY MEMORIAL HOSPITAL HAS ONE CLASS OF MEMBERS WHICH SHALL BE ENTITLED TO ONE REPRESENTATION AND ONE VOTE IN ALL MEETINGS OF COMMUNITY MEMORIAL HOSPITAL. THE ANNUAL MEETING OF THE MEMBERS IS HELD FOR THE PURPOSE OF ELECTING TRUSTEES AND TRANSACTING SUCH OTHER BUSINESS AS MAY COME BEFORE THE MEETING. EACH MEMBER IS ENTITLED TO ONE VOTE. FORM 990, PART VI, SECTION A, LINE 7A GOVERNING BODY AND MANAGEMENT: COMMUNITY MEMORIAL HOSPITAL HAS ONE CLASS OF MEMBERS WHICH SHALL BE ENTITLED TO ONE REPRESENTATION AND ONE VOTE IN ALL MEETINGS OF COMMUNITY MEMORIAL HOSPITAL. THE ANNUAL MEETING OF THE MEMBERS IS HELD FOR THE PURPOSE OF ELECTING TRUSTEES AND TRANSACTING SUCH OTHER BUSINESS AS MAY COME BEFORE THE MEETING. EACH MEMBER IS ENTITLED TO ONE VOTE. FORM 990, PART VI, SECTION B, LINE 11B FORM 990 REVIEW PROCESS: THE CFO REVIEWS THE FORM 990, WHICH IS THEN REVIEWED BY THE CEO, FOLLOWED BY THE BOARD. FORM 990, PART VI, SECTION B, LINE 12C COMPLIANCE WITH CONFLICT OF INTEREST POLICY: THE CONFLICT OF INTEREST POLICY AND A DISCLOSURE STATEMENT ARE PRESENTED TO OFFICERS, DIRECTORS OR TRUSTEES AND KEY EMPLOYEES ANNUALLY. THE DISCLOSURE STATEMENT MUST BE RETURNED AND IS REVIEWED BY FINANCIAL AUDITORS AND HOSPITAL ADMINISTRATION. FORM 990, PART VI, SECTION B, LINE 15A PROCESS FOR DETERMINING COMPENSATION: THE BOARD OF TRUSTEES CONDUCTS AN ANNUAL EVALUATION OF OFFICERS AND KEY EMPLOYEES. THEY USE COMPARABILITY DATA RECEIVED FROM AN INDEPENDENT CONSULTANT AND SET SALARY BASED UPON COMPARABILITY DATA AND THEIR JOB PERFORMANCE. DECISIONS ARE DOCUMENTED IN THE BOARD MINUTES. THE CFO COMPENSATION IS DETERMINED BY THE CEO AND APPROVED BY THE BOARD OF DIRECTORS. ALL OTHER EMPLOYEES RECEIVE AN ANNUAL PRECENTAGE INCREASE BASED UPON THE HOSPITAL'S PREFORMANCE. FORM 990, PART VI, SECTION B, LINE 15B PROCESS FOR DETERMINING COMPENSATION: THE BOARD OF TRUSTEES CONDUCTS AN ANNUAL EVALUATION OF OFFICERS AND KEY EMPLOYEES. THEY USE COMPARABILITY DATA RECEIVED FROM AN INDEPENDENT CONSULTANT AND SET SALARY BASED UPON COMPARABILITY DATA AND THEIR JOB PERFORMANCE. DECISIONS ARE DOCUMENTED IN THE BOARD MINUTES. THE CFO COMPENSATION IS DETERMINED BY THE CEO AND APPROVED BY THE BOARD OF DIRECTORS. ALL OTHER EMPLOYEES RECEIVE AN ANNUAL PRECENTAGE INCREASE BASED UPON THE HOSPITAL'S PREFORMANCE. FORM 990, PART VI, SECTION C, LINE 19 PROCESS FOR MAKING GOVERNING DOCUMENTS AVAILABLE TO THE PUBLIC: COMMUNITY MEMORIAL HOSPITAL MAKES ITS GOVERNING DOCUMENTS, CONFLICT OF INTEREST POLICY AND FINANCIAL STATEMENTS AVAILABLE TO THE PUBLIC UPON REQUEST. FORM 990, PART XI, LINE 9 OTHER CHANGES IN FUND BALANCES: CHANGE IN INTEREST IN FOUNDATION (746,666) FORM 990 PART IX LINE 11G DESCRIPTION:PHYSICIAN PROFESSIONAL FEES TOTAL FEES:1579696 FORM 990 PART IX LINE 11G DESCRIPTION:NONPHYSICIAN PROFESSIONAL FEES TOTAL FEES:1005040 FORM 990 PART IX LINE 11G DESCRIPTION:OTHER PURCHASED SERVICES TOTAL FEES:726175 FORM 990 PART IX LINE 11G DESCRIPTION:OTHER PROFESSIONAL SERVICES TOTAL FEES:116782