2016-02-10T09:22:43-06:00 2015-03-31 BKD LLP 211 N BROADWAY SUITE 600 ST LOUIS MO 631022733 990 2014-04-01 362167785 MENDOTA COMMUNITY HOSPITAL % DAWN TROMPETER CFO MEND 8155397461 1401 E 12TH STREET MENDOTA IL 61342 DAWN TROMPETER CFO 8155397461 2016-02-09 true Donna J Larson P00043751 3142315544 2014 2016-04-25 22:37:26Z JENNIFER JUNIS 1401 E 12TH STREET MENDOTA IL 61342 34838201 false X mendotahospital.org X 1944 IL MENDOTA COMMUNITY HOSPITAL'S MISSION IS TO WORK FOR THE HEALTH AND WELL-BEING OF THE CITIZENS OF OUR AREA THROUGH A BROAD RANGE OF HIGH-QUALITY, EFFICIENT HEALTH SERVICES. 12 9 369 75 0 80429 57817 34366710 32595336 88563 542360 139233 133810 34674935 33329323 5000 5058 0 0 17745727 16846164 0 0 82543 18635816 19052156 36386543 35903378 -1711608 -2574055 46993908 44843640 37943530 38758876 9050378 6084764 MENDOTA COMMUNITY HOSPITAL'S MISSION IS TO WORK FOR THE HEALTH AND WELL-BEING OF THE CITIZENS OF OUR AREA THROUGH A BROAD RANGE OF HIGH-QUALITY, EFFICIENT HEALTH SERVICES. false false 28800099 5058 32595336 MENDOTA COMMUNITY HOSPITAL PROVIDED 25 BEDS IN FISCAL YEAR 2015. THIS HOSPITAL GAVE $610,272.55 IN CHARITY CARE, AND PROVIDED 6973 MEALS ON WHEELS TO MEMBERS OF OUR COMMUNITY. THE NET COMMUNITY BENEFIT EXPENSE WAS $44,753.14. MENDOTA COMMUNITY HOSPITAL OFFERS FLU & IMMUNIZATION CLINICS ALONG WITH MANY OTHER CLINICS IN MENDOTA AND OTHER OUTREACH COMMUNITIES. THE HOSPITAL HELD CPR CLASSES, DIABETIC SUPPORT GROUPS, PROVIDED FREE DIABETIC AND NUTRITION EDUCATION CLASSES, AND OFFERED SEVERAL OTHER PROGRAMS THROUGHOUT THE YEAR. THE NET COMMUNITY BENEFIT EXPENSE WAS $16,417.17. 28800099 true true false true false false false false false true true false false false true false true false false false false false false false true false true true false false true false false false false false false true false false false false false false false false false false true 40 0 true 369 true false false false false false false false false false false X 12 9 false false false false false false false true true true false false true true true true true true false false IL X DAWN TROMPETER CFO 8155397461 1401 E 12TH STREET MENDOTA IL 61342 X STEVEN F GAHAN DIRECTOR 2.0 0.0 X 0 0 0 DAVID SCHOLL MD DIRECTOR 42.0 0.0 X 198453 0 32016 MARGO GALLAGHER SCHMITZ RN PRESIDENT 2.0 0.0 X X 0 0 0 P DANIEL DOYLE OD TREASURER 2.0 0.0 X X 0 0 0 ROBERT F STACHLEWITZ JR SECRETARY 2.0 0.0 X X 0 0 0 ERIC ANDERSON DIRECTOR 2.0 0.0 X 0 0 0 JOSEPH BEETZ PAST PRESIDENT 2.0 0.0 X X 0 0 0 KERI SUNDBERG DDS DIRECTOR 2.0 0.0 X 0 0 0 MICHAEL PHALEN 1ST VICE PRESIDENT 2.0 0.0 X X 0 0 0 KATHLEEN STEVENSON DIRECTOR 2.0 0.0 X 0 0 0 JOSE DE J ARTEAGA DIRECTOR 2.0 0.0 X 0 0 0 CHRISTINE KLEIN DIRECTOR 2.0 0.0 X 0 0 0 GARY EICH CFO 40.0 0.0 X 175914 0 0 JUDY CHRISTIANSEN CEO 40.0 0.0 X 208313 0 1670 MARY CHINN MD PHYSICIAN 40.0 0.0 X 201681 0 24286 AMY MATHEIS-SOLIMAN MD PHYSICIAN 40.0 0.0 X 192156 0 32016 ERIC KIVISTO MD GENERAL SURGEON 40.0 0.0 X 461366 0 27190 KENNETH K POTTS NURSE ANESTHETIST 40.0 0.0 X 235269 0 23258 ALLEN VAN MD ORTHOPEDIC SURGEON 40.0 0.0 X 857196 0 29979 2530348 0 170415 11 false true true ER DOCTORS LTD 7 WOOD DUCK LANE OTTAWA IL 61350 MEDICAL PHYSICIANS 1671457 MEDICAL OUTSOURCING SOLUTIONS INC 2060 ABERDEEN COURT SUITE D SYCAMORE IL 60178 RADIOLOGY SERVICE 533250 2 2720 9500 45597 57817 PROGRAM SERVICE REVENUE 621110 32085508 32085508 OTHER OPERATING REVENUE 621110 509828 509828 32595336 56282 56282 0 0 60285 7626 52659 0 52659 52659 1872829 87034 1402077 71708 470752 15326 486078 486078 17186 9500 13006 4180 4180 0 22154 14461 7693 7693 CAFETERIA 721110 67453 67453 AUXILIARY INCOME 900099 1825 1825 69278 33329323 32595336 676170 5058 5058 0 0 0 620492 230415 390077 120774 120774 12998779 11683877 1264568 50334 251341 219364 31032 945 1953729 1709343 237119 7267 901049 789085 108656 3308 0 106890 106890 116424 116424 0 0 0 2521767 2262181 259586 119440 12292 107148 5070858 3623958 1435430 11470 0 0 442993 400965 42028 38296 31064 7232 0 0 2024661 2024661 0 3668770 3668770 1261450 1215819 45631 BLOOD BANK 101323 101323 PROVISION FOR BAD DEBT 1379236 1379236 LINENS & OUTSIDE SERVICES 70795 70795 CONTRACTS/REPAIRS 1912930 1255792 657138 216323 19988 187116 9219 35903378 28800099 7020736 82543 3353 18303 3231463 4833624 0 0 3611590 4053595 0 0 0 0 0 0 753120 644448 443465 408242 52145690 18363729 37039141 33781961 1806629 930298 0 0 0 0 0 0 105147 173169 46993908 44843640 3275696 4506343 0 0 0 0 0 0 0 0 0 0 34642834 34227533 0 0 25000 25000 37943530 38758876 X 8389375 5423761 41868 41868 619135 619135 9050378 6084764 46993908 44843640 X -2574055 -403084 11525 X false true X true true true X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED false false false false false true 12970 false false false 12970 false SCHEDULE C, PART II-B, LINE 1F NATURE OF LOBBYING ACTIVITIES: THE ORGANIZATION'S LOBBYING ACTIVITIES INCLUDE PAYING MEMBERSHIP DUES TO THE ILLINOIS HOSPITAL ASSOCIATION WHICH PARTICIPATES IN LOBBYING ACTIVITIES. X 3908566 123950 810015 3222501 3797903 0 154423 0 43760 0 3908566 4638248 0 170921 0 1011266 0 3797903 6386687 0 190366 0 1938805 0 4638248 4915223 1311605 159859 0 0 0 6386687 0.79480 0.19260 0.01260 false false 40478 1269946 1310424 30684824 5915313 24769511 15173341 11211868 3961473 4977101 1236548 3740553 33781961 0 LEGAL CLAIMS RESERVE 25000 25000 X 31564382 -403084 29632 -373452 31937834 1391489 1391489 33329323 34544774 20632 20632 34524142 1379236 1379236 35903378 SCHEDULE D, PART V, LINE 4 INTENDED USES OF ENDOWMENT FUNDS: PROCEEDS OF FUNDED DEPRECIATION ENDOWMENT, AS DICTATED BY THE DONORS, ARE USED AS BEST DETERMINED BY ADMINISTRATION OF THE HOSPITAL. SCHEDULE D, PART XI, LINE 2D OTHER REVENUE INCLUDED ON BOOKS BUT NOT ON RETURN: SPECIAL EVENTS DIRECT EXPENSE $13,006 RENTAL EXPENSE $ 7,626 INTERCOMPANY DONATION FROM AUXILIARY ACTIVITY $ 9,000 -------------------------------------------------------- TOTAL $29,632 SCHEDULE D, PART XII, LINE 2D OTHER EXPENSES ON BOOKS BUT NOT ON RETURN: SPECIAL EVENTS DIRECT EXPENSE $13,006 RENTAL EXPENSE $ 7,626 --------------------------------------------------------- TOTAL $20,632 SCHEDULE D, PART X, LINE 2 UNCERTAIN TAX POSITIONS: 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 OTHER REVENUE INCLUDED ON RETURN BUT NOT ON BOOKS: PROVISION FOR BAD DEBT $1,379,236 AUXILIARY ACTIVITY ON RETURN, NOT ON BOOKS 4,560 GIFT SHOP ACTIVITY ON RETURN, NOT ON BOOKS 7,693 ------------------------------------------------------- TOTAL $1,391,489 SCHEDULE D, PART XII, LINE 4B OTHER EXPENSES ON RETURN BUT NOT ON BOOKS: PROVISION FOR BAD DEBT $1,379,236 FORE THE HOSPIT 13418 5900 7518 2229 2379 1682 CORNAPALOOZA 13268 3600 9668 834 88 5794 0 26686 9500 17186 3063 2467 7476 13006 4180 true true true X true X true true false false 308554 308554 0.00890 5658628 2162080 3496548 0.10130 3468 3468 0.00010 5970650 2162080 3808570 0.11030 90837 29352 61485 0.00180 47812 47812 0.00140 5058 5058 0.00010 143707 29352 114355 0.00330 6114357 2191432 3922925 0.11360 true 1379236 13246585 14353204 -1106619 X true true 1 1 MENDOTA COMMUNITY HOSPITAL 1401 E 12TH STREET MENDOTA IL 61342 WWW.MENDOTAHOSPITAL.ORG 5819 X X X X MENDOTA COMMUNITY HOSPITAL 1 false false true X X X X X X X X X 12 true false false true X SEE SCHEDULE H, PART V, SECTION C X true 12 false true false true X 100 200. X X X X X true true X X X X true X SEE SCHEDULE H, PART V, SECTION C X SEE SCHEDULE H, PART V, SECTION C X SEE SCH H, PART V, SECTION C X X X X X X true X false X X X X true X false false SCHEDULE H, PART V, SECTION B, LINE 5 INPUT FROM PERSONS WHO REPRESENT THE COMMUNITY: THE FOCUS GROUP AND INTERVIEW PARTICIPANTS THAT HELPED US WITH OUR CHNA CAME FROM A VARIETY OF BACKGROUNDS IN THE COMMUNITY. WE HAD PARTICIPANTS SUCH AS THE SCHOOL NURSE, THE DIRECTORS AND NURSES FROM THE COMMUNITIES' FREE CLINICS, NURSE PRACTITIONER OF A READY CARE CLINIC, DIRECTORS OF SENIOR SERVICES AND LIVING FACILITIES, COUNSELORS, ATTORNEYS, PASTORS OF AREA CHURCHES, PRESIDENTS OF AREA BANKS, ACCOUNTANTS/CPA'S, CHIEFS OF AREA FIRE DEPARTMENTS, MAYORS AND CLERKS FROM AREA COMMUNITIES, AND MANAGERS FROM AREA BUSINESSES. THE HOSPITAL SOUGHT INPUT FROM THESE PERSONS WHEN GATHERING PRIMARY DATA FOR THE CHNA. SCHEDULE H, PART V, SECTION B, LINE 7A HOSPITAL FACILITY WEBBSITE (URL): HTTPS://WWW.OSFHEALTHCARE.ORG/SAINT-PAUL/ABOUT/COMMUNITY-HEALTH SCHEDULE H, PART V, SECTION B, LINE 11 NEEDS NOT ADDRESSED: THE ONLY ISSUE THAT WAS NOT IDENTIFIED AS A PRIORITIZED NEED WAS THAT MENDOTA COMMUNITY HOSPITAL DOES NOT HAVE A MATERNITY DEPARTMENT. THE COSTS OF PROVIDING THIS SERVICE AND LACK OF LOCAL PROVIDERS PERFORMING DELIVERIES MAKE THIS NEED IMPRACTICAL IN THE NEAR FUTURE SINCE MATERNITY DEPARTMENTS ARE LOCATED IN OTHER FACILITIES IN CLOSE GEOGRAPHIC PROXIMITY. THE MOST RECENT CHNA IDENTIFIED THREE SIGNIFICANT NEEDS. AT LEAST TWO LONG-TERM OBJECTIVES AND OUTCOMES WERE IDENTIFIED TO ADDRESS EACH NEED. A TWO-YEAR PLAN OF ACTIVITIES WAS CREATED TO ACHIEVE EACH OBJECTIVE. MORE DETAILS OF THIS PROGRAM ARE FOUND IN THE IMPLEMENTATION STRATEGY ATTACHED TO THIS RETURN. SCHEDULE H, PART V, SECTION B, LINES 16A-16C DURING THE TAX YEAR, THE ORGANIZATION POSTED THE FAP & PLAIN LANGUAGE SUMMARY OF THE FAP ON ITS WEBSITE. ON APRIL 1, 2015, THE ORGANIZATION MERGED WITH OSF HEALTHCARE SYSTEM AND THE WEBSITE IS NOW INACTIVE. FAP APPLICATION FORM: HTTPS://WWW.OSFHEALTHCARE.ORG/MEDIA/FILER_PUBLIC/45/A7/45A7FC7D-444E-422C- AC70-D918DCF00D2B/C0390-10000-11-0076_ENABLED.PDF SCHEDULE H, PART V, SECTION B, LINE 16I PUBLISHING OF FINANCIAL ASSISTANCE POLICY: THERE IS A FULL PARAGRAPH ON THE BACKSIDE OF THE PATIENT STATEMENTS AND ITEMIZED BILLS EXPLAINING OUR FINANCIAL ASSISTANCE PROGRAM AND PHONE NUMBERS TO CALL FOR FURTHER INFORMATION. SCHEDULE H, PART V, SECTION B, LINE 18D COLLECTIONS POLICIES AGAINST PATIENTS: LIENS (NOT ON RESIDENCES) ARE SENT OUT FOR ONLY GENERAL AUTOMOBILE AND GENERAL LIABILITY CLAIMS. THESE ARE SENT TO THE PATIENT, THE INSURANCE COMPANY, AND THE ATTORNEY (IF THERE IS ONE) TO LET THE INSURANCE COMPANY KNOW TO PAY THE HOSPITAL AND NOT THE PATIENT. SCHEDULE H, PART V, SECTION B, LINE 22D DETERMINING MAXIMUM AMOUNTS CHARGED TO FAP-ELIGIBLE INDIVIDUALS: WE USE THE AVERAGE OF NEGOTIATED COMMERCIAL INSURANCE RATES FOR THOSE SERVICES AT THE FACILITY. SCHEDULE H, PART I, LINE 7, COLUMN F FINANCIAL ASISTANCE 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 $1,379,236 REPORTED ON PART IX, LINE 25, HOWEVER, IT HAS BEEN SUBTRACTED FOR PURPOSES OF CALCULATING THE PERCENTAGE IN THIS COLUMN. SCHEDULE H, PART III, SECTION A, LINE 2 METHODOLOGY USED TO ESTIMATE BAD DEBT EXPENSE: FOR LINE 2, WE PROVIDED OUR FISCAL YEAR EXPENSE AMOUNT FOR BAD DEBT. SCHEDULE H, PART III, SECTION A, LINE 3 METHODOLOGY USED TO ESTIMATE BAD DEBT EXPENSE FOR FAP ELIGIBLE PATIENTS: FOR LINE 3, THE HOSPITAL ACKNOWLEDGES THE FACT THAT SOME PATIENTS DO NOT TURN IN ALL THE NECESSARY PAPERWORK TO DETERMINE IF THEY ARE ELIGIBLE FOR CHARITY CARE, BUT WE CANNOT MAKE ANY ASSUMPTIONS AS TO WHAT THEIR INCOME IS, OR IF THEY WOULD HAVE QUALIFIED FOR CHARITY CARE. THEREFORE, WE HAVE NO CHOICE BUT TO PUT ZERO IN LINE 3. SCHEDULE H, PART III, SECTION A, LINE 4 FINANCIAL STATEMENTS BAD DEBT EXPENSE: 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: THIS SHORTFALL IS DUE TO HOME HEALTH THAT IS A NECESSARY OUTREACH SERVICE PROVIDED TO THE COMMUNITY FOR THOSE PATIENTS RESTRICTED TO THEIR HOMES. SCHEDULE H, PART III, SECTION B, LINE 9B DEBT COLLECTION POLICY THE HOSPITAL'S DEBT COLLECTION POLICY STATES PATIENT FINANCIAL SERVICES WILL ASSIST PATIENTS IN FINDING OTHER SOURCES FOR PAYING BILLS SUCH AS FINANCIAL ASSISTANCE. WE ALSO HAVE A SEPARATE POLICY FOR CHARITY CARE THAT THE FINANCIAL COUNSELORS FOLLOW. THIS POLICY LISTS THE ITEMS NEEDED TO VERIFY ELIGIBILITY AND DESCRIBES THE PROCESS OF HOW THE FINANCIAL COUNSELORS DETERMINE IF THE PATIENT IS ELIGIBLE TO RECEIVE CHARITY CARE. SCHEDULE H, PART VI, LINE 2 NEEDS ASSESSMENT: WE LOOK AT OUR TOP DIAGNOSES TO DETERMINE WHAT TYPE OF PROGRAMS WE SHOULD BE OFFERING TO OUR PATIENTS. WE HAVE ROUTINE BLOOD PRESSURE PROGRAMS, A DIABETIC SUPPORT GROUP AS WELL AS OTHER SCREENINGS THAT ARE OFFERED BASED ON STAFF EXPERTISE AND PATIENT NEEDS. WE WORK CLOSELY WITH AREA BUSINESSES ON LOSS PREVENTION AND INSTITUTE PROGRAMS TO MEET THEIR PARTICULAR NEEDS. WE ALSO HAVE DRUG AND ALCOHOL TEST PROGRAMS AVAILABLE FOR OUR BUSINESS COMMUNITY. WE HAVE SPECIALTY CLINICS FOR CARDIOLOGY, ONCOLOGY, PODIATRY, ORTHOPEDICS, RHEUMATOLOGY, PULMONOLOGY, ETC. SO THAT OUR PATIENTS WHO NEED THESE SPECIALTIES CAN BE SEEN LOCALLY VERSUS DRIVING TO A METROPOLITAN AREA FOR THESE SERVICES. SCHEDULE H, PART VI, LINE 3 PATIENT EDUCATION OF ELIGIBILITY FOR ASSISTANCE: AT THE TIME OF REGISTRATION, PATIENTS RECEIVE HANDOUTS REGARDING SELF-PAY UNINSURED DISCOUNTS. ALSO, WHEN A PATIENT RECEIVES A BILL, THERE IS INFORMATION ON THE BACK REGARDING WHERE THEY CAN GET MORE INFORMATION ABOUT FINANCIAL ASSISTANCE, SUCH AS CHARITY CARE, BY GOING ON THE HOSPITAL WEBSITE OR CALLING THE FINANCIAL COUNSELORS, WHOSE NUMBERS ARE LISTED. SCHEDULE H, PART VI, LINE 4 COMMUNITY INFORMATION: MCH IS LOCATED IN NORTH-CENTRAL ILLINOIS. WE SERVE A POPULATION OF APPROXIMATELY 25,000 RESIDENTS. WE ARE A FARMING COMMUNITY WITH SOME MANUFACTURING PLANTS. MANY OF OUR RESIDENTS ARE SELF-EMPLOYED. WE ALSO SERVE A LARGE HISPANIC POPULATION. OUR MEDICARE POPULATION REPRESENTS OVER 50% OF THE PATIENTS WE SERVE. WE ARE DESIGNATED AS A CRITICAL ACCESS HOSPITAL. SCHEDULE H, PART VI, LINE 5 PROMOTION OF COMMUNITY HEALTH: MCH HAS A BOARD OF DIRECTORS THAT IS REPRESENTATIVE OF THE COMMUNITIES WE SERVE. THEY SERVE ON A VOLUNTEER BASIS AND REPRESENT ALL AREAS OF OUR SERVICE AREA. MCH HAS IMPLEMENTED A CHARITY CARE PROGRAM WITH GUIDELINES THAT ARE CONSISTENT WITH THOSE OF OTHER HOSPITALS IN THE STATE OF IL. WE SUPPORT OUR LOCAL FREE CARE CLINIC -- TRINITY HEALTH CARE -- BY PROVIDING ESTABLISHED LAB TESTS AT NO CHARGE. MCH IS INVOLVED WITH COMMUNITY PROGRAMS BY PROVIDING HEALTH SCREENING BOOTHS, SPEAKER'S BUREAU AND INVOLVEMENT AT THE COMMITTEE LEVEL IN MANY ORGANIZATIONS. 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 X false false false false false false false false false GARY EICH CFO 175914 0 0 0 0 0 0 0 0 0 175914 0 0 0 JUDY CHRISTIANSEN CEO 208313 0 0 0 0 0 0 0 1670 0 209983 0 0 0 DAVID SCHOLL MD DIRECTOR 180137 0 0 0 18316 0 6000 0 26016 0 230469 0 0 0 MARY CHINN MD PHYSICIAN 183365 0 0 0 18316 0 6000 0 18286 0 225967 0 0 0 AMY MATHEIS-SOLIMAN MD PHYSICIAN 191778 0 0 0 378 0 6000 0 26016 0 224172 0 0 0 ERIC KIVISTO MD GENERAL SURGEON 461366 0 0 0 0 0 0 0 27190 0 488556 0 0 0 KENNETH K POTTS NURSE ANESTHETIST 229206 0 0 0 6063 0 6953 0 16305 0 258527 0 0 0 ALLEN VAN MD ORTHOPEDIC SURGEON 839696 0 0 0 17500 0 0 0 29979 0 887175 0 0 0 FORM 990, PART VII, SECTION A, LINE 5 COMPENSATION PAID BY AN UNRELATED MANAGEMENT COMPANY: THE CFO, GARY EICH, IS PAID BY AN UNRELATED MANAGEMENT COMPANY, OSF. OSF PROVIDED GARY EICH WITH COMPENSATION IN THE AMOUNT OF $175,914. ALL FEES ARE PAID TO OSF BY MENDOTA COMMUNITY HOSPITAL. JOELLYN GAHAN SPOUSE OF BOARD MEMBER 45188 EMPLOYEE false JARED WISE SON-IN-LAW OF BOARD MEMBE 75586 EMPLOYEE false FORM 990, PART VI, SECTION A, LINE 9 OFFICERS WHO CANNOT BE REACHED AT THE ORGANIZATION'S ADDRESS: JUDY CHRISTIANSEN 912 DEERFIELD LANE OTTAWA, IL 61350 GARY EICH 2330 E US ROUTE 52 SERENA, IL 60549 FORM 990, PART VI, SECTION B, LINE 11B REVIEW OF 990: THE ORGANIZATION'S GOVERNING BODY WILL MEET WITH THE ORGANIZATION'S SENIOR FINANCIAL ANALYST AT A BOARD MEETING TO REVIEW THE FINAL FORM 990 AFTER ITS FILING. FORM 990, PART VI, SECTION B, LINE 12C COMPLIANCE WITH WRITTEN CONFLICT OF INTEREST POLICY: THE CONFLICT OF INTEREST POLICY COVERS THE GOVERNING BODY. ADMINISTRATION REQUIRES THE GOVERNING BODY TO FILL OUT AN ANNUAL CONFLICT OF INTEREST POLICY. ADMINISTRATION REVIEWS THE FORMS. IF A PROBLEM ARISES, THE CEO WILL CONTACT THE PRESIDENT OF THE GOVERNING BODY TO DISCUSS HOW TO HANDLE THE ISSUE. THE PERSON INVOLVED IN THE CONFLICT OF INTEREST WOULD NOT BE INVOLVED IN THE DELIBERATIONS HELD ON THE ISSUE IN QUESTION. FORM 990, PART VI, SECTION B, LINE 15A COMPENSATION DETERMINATION: THE EXECUTIVE BOARD CONDUCTED A REVIEW OF THE COMPENSATION FOR THE CEO ON APRIL 1, 2014. FORM 990, PART VI, SECTION C, LINE 19 AVAILABLE TO THE PUBLIC: THE ORGANIZATION DOES NOT MAKE THESE DOCUMENTS AVAILABLE TO THE PUBLIC. HOWEVER, THE AUDITED FINANCIAL STATEMENTS ARE INCLUDED IN THE COPY OF FORM 990 THAT IS MADE AVAILABLE TO THE PUBLIC. FORM 990, PART XI, LINE 10 OTHER CHANGES IN NET ASSETS: RECORD BEGINNING OF YEAR AUXILIARY AND GIFT SHOP CASH BALANCES $11,525