2016-05-12T13:41:33-05:00 2015-06-30 450250958 EIDE BAILLY LLP 1545 ASSOCIATES DR STE 101 DUBUQUE IA 52002 990 2014-07-01 370684691 Memorial Hospital Association MEMO 2173573131 PO Box 160 Carthage IL 62321 Teresa Smith CFO 2173573131 2016-05-10 1 Carmen Krantz P00031958 5635561790 2016-05-09 2014 2016-08-17 19:52:53Z Ada Bair PO Box 160 Carthage IL 62321 26177501 0 X www.mhtlc.org X 1947 IL Memorial Hospital provides clinical care, diagnostic, treatment, and wellness services 13 8 245 100 0 0 395795 372373 22489896 23279164 356784 317766 25560 35246 23268035 24004549 0 0 0 0 10465034 11443292 0 0 0 11955393 11985751 22420427 23429043 847608 575506 35319847 40236205 21379153 25821980 13940694 14414225 X Memorial Hospital is committed to improving health by providing education and wellness programs and innovative services at all the stages of life. 0 0 17957890 23279164 Memorial Hospital is dedicated to maintaining and improving the health of all people in the Hancock County area. Governed by a Board of Directors, we serve as a vital safety net, serving our communities with access to quality healthcare services. Memorial Hospital provides many types of community benefit care. Community benefit care includes charity care, community health fairs, lectures, and free health screenings, demonstrating our commitment to improving the overall health of the residents of the Hancock County area.In FY 2015, the Hospital had 2,362 patient days with 739 admissions and 738 discharges. There were 4,493 emergency room visits, 17,156 provider based physician clinic visits, and 13,695 rural health physician clinic visits.We are always committed to providing compassionate care to every member of our community regardless of their ability to pay.To fulfill its mission of community service, the Organization provides care to patients and residents who meet certain criteria under its charity care policy without charge or at amounts less than its established rates. Revenue from services to these patients and residents is recorded in the accounting system at the established rates, but the Organization does not pursue collection of the amounts. The resulting adjustments are recorded as adjustments to patient and resident service revenue, depending on the timing of the charity determination.The Illinois legislature passed a bill titled the "Hospital Uninsured Patient Discount Act." Effective April 1, 2009, this Act requires hospitals to provide certain mandated discounts from charges to the uninsured in Illinois. Charges are to be discounted at 135% of cost. Furthermore, a hospital may not collect more than 25% of an uninsured family's gross income in any one year.The Organization provides care to patients and residents who meet certain criteria under its charity care policy without charge or at amounts less than established rates. Because the Organization does not pursue collection of amounts determined to qualify as charity care, they are not reported as revenue. The amounts of charges foregone, based on established rates was $333,236 for the year ended June 30, 2015. The estimated costs of the charges foregone, based upon an overall cost-to-charge ratio calculation, for the year end June 30, 2015 was $174,000.In addition, the Organization provides services to other medically indigent patients under certain government-reimbursed public aid programs. Such programs pay providers amounts which are less than established charges for the services provided to the recipients, and for some services the payments are less than the cost of rendering the services provided. The Organization also commits significant time and resources to endeavors and critical services which meet otherwise unfulfilled community needs. Many of these activities are sponsored with the knowledge that they will not be self-supporting or financially viable. 17957890 1 1 0 1 0 0 0 0 1 1 1 0 0 0 1 1 0 1 0 0 0 0 0 0 1 0 1 1 0 0 1 1 0 0 0 0 0 0 0 0 1 0 0 0 0 0 0 1 1 1 0 0 1 66 0 1 245 1 0 0 0 0 0 0 0 0 0 0 X 13 8 0 0 0 0 1 1 0 1 1 0 0 1 1 1 1 1 1 1 0 1 1 IL X Kim Byers 2173576571 PO Box 160 Carthage IL 62321 Dan Asbury President 3.00 1.00 X X 0 0 0 Matt Dickinson Vice President 3.00 1.00 X X 0 0 0 Dennis Rankin Secretary/Treasurer 3.00 1.00 X X 0 0 0 Terry Pope Director 3.00 1.00 X 0 0 0 Carol Gronewold Director 3.00 1.00 X 0 0 0 LuAnn Haas Director 4.00 1.00 X 0 0 0 Kathy Holst Director 3.00 1.00 X 0 0 0 Larry McClintock Director 5.00 1.00 X 0 0 0 Christopher Jones MD Director 3.00 1.00 X 342373 0 32546 Sharon Morrison Director 4.00 1.00 X 0 0 0 Peggy Latherow Director 3.00 1.00 X 0 0 0 Charles Gilbert Director 3.00 1.00 X 0 0 0 Edward McKenney DO Director 3.00 1.00 X 30800 0 0 Ada Bair CEO 40.00 3.00 X 194364 0 13276 Teresa Smith CFO 40.00 3.00 X 120780 0 19709 Aaron Wesp MD Family Practice Physician 40.00 0.00 X 221280 0 30534 Randall Peters MD Surgeon 40.00 0.00 X 390270 0 24347 Kurtis Davis MD Family Practice Physician 40.00 0.00 X 256703 0 28839 Stephen Bergman CRNA 20.00 0.00 X 202877 0 23745 Douglas Heighton MD Family Practice Physician 40.00 0.00 X 194348 0 29034 1953795 0 202030 9 0 1 0 Gerald A Maas & Gerald S Maas 3615 St Anthony Rd Quincy IL 62305 Construction company 2130926 Aimes of Carthage LLC 12533 W Lakeview Dr Orland Park IL 604671071 ER physician service 1733152 Consociate Group PO Box 1068 Decatur IL 62525 Group health insurance TPA 259067 Diamond Healthcare Corp PO Box 85050 Richmond VA 23262 Gerophys & Cardio Rehab services 247762 Cell Dox PO Box 916 Hannibal MO 63401 Pathology services 216485 6 36518 84468 251387 372373 Patient & resident service revenu 622110 22948140 22948140 Meaningful use revenue 900099 237189 237189 Supporting revenue 900099 101582 101582 Equity in Advance Phys Therapy 900099 37137 37137 Equity in Sherrick Home Health 900099 -44884 -44884 23279164 130442 130442 51959 2200 10747 0 41212 2200 43412 43412 2337383 2145193 4866 192190 -4866 187324 187324 3980 36518 12146 -8166 -8166 24004549 23279164 0 353012 X 776871 418920 357951 91430 91430 8629984 7472453 1157531 90023 66770 23253 1241860 1162242 79618 613124 499065 114059 25434 25434 60627 60627 4756326 3228838 1527488 162441 162441 620489 425192 195297 505945 333846 172099 68277 53780 14497 72081 54788 17293 1102393 1102393 1674774 1674774 252295 178488 73807 Medical supplies 1495722 1495722 Bad debt expense 775281 775281 Provider tax 335378 335378 Dues, fees, subscriptio 78288 26301 51987 23429043 17957890 5471153 0 4388848 4462326 63369 78697 2905166 3266564 33398 284686 350323 111046 159875 34963195 12961327 17970742 22001868 8235305 8758261 637631 668659 38917 93854 359504 324633 362380 35319847 40236205 1535061 1488400 56107 18764 18430000 17995000 681867 4765894 278703 215606 397415 1338316 21379153 25821980 X 13872607 14309215 44721 81644 23366 23366 13940694 14414225 35319847 40236205 X 575506 -161215 -12502 71742 X 0 1 X 1 0 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 0 0 0 0 0 0 0 0 1 9622 9622 0 Part II-B, Line 1: Memorial Hospital Association paid dues to the Illinois Hospital Association of which a portion of the dues are used for lobbying. 1 2617 5165 3132 4650 0 4347365 10468 110116 1000 288764 20893 4157292 4122446 520010 274389 20702 4347365 3980678 386316 244548 4122446 4160911 106105 286338 3980678 3468333 936413 243835 4160911 0.99440 0.00560 0 0 139335 504757 644092 24661443 6983801 17677642 23098 9624 13474 8245124 5856109 2389015 1389438 111793 1277645 22001868 Estimated health claims 215000 Construction payable 534241 Estimated third-party payor settlements 589075 1338316 X 22835097 -161215 -762778 -923993 23759090 245459 245459 24004549 22673879 12502 10747 23249 22650630 778413 778413 23429043 Part IV, Line 1b: Memorial Hospital Auxiliary uses the Hospital's FEIN but has its own checking account. The Auxiliary account balances were not included in the financial statements. Part V, Line 4: An endowment fund with the income to be used for the benefit of Memorial Hospital Association. $23,366 is required to be retained permanently, either by explicit donor stipulation or by UPMIFA. Board designated funds are to be used for facility and equipment upgrades. Part X, Line 2: The Hospital is organized as an Illinois nonprofit corporation and has been recognized by the Internal Revenue Service (IRS) as exempt from federal income taxes under Internal Revenue Code Section 501(c)(3). The Hospital is annually required to file a Return of Organization Exempt from Income Tax (Form 990) with the IRS. In addition, the Hospital is subject to income tax on net income that is derived from business activities that are unrelated to their exempt purposes. The Hospital has determined they are not subject to unrelated business income tax and have not filed an Exempt Organization Business Income Tax Return (Form 990T) with the IRS. The Hospital believes they have appropriate support for any tax positions taken affecting their annual filing requirements, and as such, do not have any uncertain tax positions that are material to the consolidated financial statements. The Hospital would recognize future accrued interest and penalties related to unrecognized tax benefits and liabilities in income tax expense if such interest and penalties are incurred. Part XI, Line 2d - Other Adjustments: Net assets released from restrictions included in revenue for financial stmt 12,503. Provision for bad debts included in revenue for financial statements -775,281. Part XI, Line 4b - Other Adjustments: Rent expenses included in revenue for Form 990 -10,747. Contributions and grants for long-lived assets incl in fund balance for F/S 276,679. Auxiliary revenue included in revenue on Form 990 5,165. Book/tax adjustment for Advance Physical Therapy -25,638. Part XII, Line 2d - Other Adjustments: Rent expenses included in revenue for Form 990 10,747. Part XII, Line 4b - Other Adjustments: Provision for bad debts included in revenue for financial statements 775,281. Auxiliary expenses included in expenses for Form 990 3,132. Gala 28258 24278 3980 3980 3300 1135 Barn Dance 12240 12240 1700 2031 40498 36518 3980 5680 3300 3166 12146 -8166 1 1 X 1 X 1 X 0 1 1 0 1 1 174000 174000 0.00770 7541519 3103695 4437824 0.19590 7715519 3103695 4611824 0.20360 4685264 4617271 67993 0.00300 4685264 4617271 67993 0.00300 12400783 7720966 4679817 0.20660 0 775281 77528 5434522 5489724 -55202 X 1 1 1 1 Memorial Hospital Association 1454 North County Road 2050 Carthage IL 62321 www.mhtlc.org 0005611 X X X X 4 RHCs - Memorial Medical Clinic Bowen, Memorial Medical Clinic LaHarpe, Mem Memorial Hospital Association 1 0 0 1 X X X X X X 12 1 0 0 1 X www.mhtlc.org/pages/reports X 1 12 1 www.mhtlc.org/pages/reports 0 0 1 X 150.000000000000 300.000000000000 X X X 1 1 X X X 1 X www.mhtlc.com/pages/financialassistance X www.mhtlc.com/pages/financialassistance X www.mhtlc.com/pages/financialassistance X X X X 1 X 0 X X X X 1 X 0 1 Memorial Hospital Association Part V, Section B, Line 5: Local residents were asked to note what they perceived the problems and needs to be in the community. An online survey was developed within the local population for any resident to complete. 160 area residents provided community input. Local experts were interviewed throughout the data collection phase and asked to agree or disagree with the summary conclusions. The local experts answered questionnaires and participated in interviews, resulting in a supportive collection of needs and guided the hospital in developing its implementation response. Memorial Hospital Association Part V, Section B, Line 11: 1. Monitor clinic physician availability, wait times for appointments and in office wait times. a. Increased physician availability, lower wait times, increased doctors who take calls and increased the supply of primary care physicians. b. Still investigating eMD capability for reports versus manual process. c. Took over the provider records when the urology provider in a nearby town retired and increased the clinic frequency from every-other week to every week.2. Develop outreach initiatives focused on areas of the county with the lowest market share. a. Still evaluating possible site locations for Hamilton and Sutter. b. We promoted clinics and hospital services through health fairs and community events. c. We conduct sports physicals in Hamilton and Carthage. Co-sponsor the family fair with the Health Department for kids, and held a health screening day in conjunction with the Farm Bureau for members. d. We are including the schedule for the specialty clinics in the paper monthly. Households receive a mailing for walk in hours and availability.3. Develop a business plan to see if other clinic sites within Hancock County are viable. a. OB and surgery - evaluating having a clinic in Hamilton. b. Opened clinic in Augusta.4. Strategic opportunities to align with joint physician recruiting a. Recruited new surgeon for our facility to replace retiring provider who was previously shared with another local hospital.5. Explore telemedicine opportunities to increase inpatient clinical consult availability a. Acuity levels of patient mix and telemedicine ICU is not something we are ready to take on.6. Recruit for General Surgeon, Family Practice and Internal Medicine or General Practitioner a. Recruited general surgeon and added full time Physician Assistant in Nauvoo. Recruited a full time midlevel provider in place of part-time physician at Nauvoo clinic location.7. Adverse Habits a. Started partnership with local schools for daily health tips and quarterly newsletter for distribution on health habits for students.8. Prevention a. Increased prevention service use through community wellness and prevention seminars. b. Continued to do more in the community focusing on offering events on site to meet health needs. c. The specialty calendar is posted on the health department website. d. Currently looking at possibilities through the Illinois Critical Access Hospital Network to collaborate with other CAH hospitals for collaborative care. e. Increased use of cancer detection services and support educational services. Sent annual reminders to patients for required screenings.9. Improve access to Urgent Care. a. Increased urgent care resources. b. Started after hour program at Rural Health Clinic for walk-in appointments in evenings and Saturday mornings.10. Diabetes a. Increased diabetic education services availability from part time to full time. b. Developed Diabetic Spotlight annual program held offsite location for attendees to learn diabetic nutrition and managing care. c. Promoted diabetic education services. Memorial Hospital Association Part V, Section B, Line 13h: PRESUMPTIVE ELIGIBILITY: A patient may appear eligible for charity care discounts but there is no financial assistance form and a lack of supporting documentation. Often there is adequate information provided by the patient through other sources which could provide sufficient evidence to provide the patient with charity care assistance.In the event there is no evidence to support a patient's eligibility for charity care, Memorial Hospital and Memorial Medical Clinics could use outside agencies in determining estimate income amounts for the basis of determining charity care eligibility and potential discount amounts.Presumptive eligibility may be determined on the basis of individual life circumstance. In these situations, a patient is deemed to be eligible for 100% write off. A patient in this situation is presumed to be eligible and therefore does not need to complete a financial assistance applicationif they can provide proof that they meet one of the following criteria:a. Patient states that he/she is homeless. The due diligence efforts must be documented.b. Patient is deceased with no known estate.c. Patient is mentally incapacitated with no one to act on their behalf.d. Patient is currently eligible for Medicaid, but was not eligible on a prior date of service or for non-covered services. Instead of making the patient duplicate the required paperwork Memorial Hospital will rely on the financial assistance determination process from Medicaid.e. Accounts deemed uncollectible by a contracted collection agency.f. In the event of "special" circumstances where the income exceeds the poverty guidelines but medical bills are high, the Patient Account Director and/or Chief Financial Officer may determine partial or full eligibility provided proper documentation is available.PROPENSITY TO PAY: Propensity to pay may be determined by obtaining a healthcare score from an outside vendor. Memorial Hospital Association Part V, Section B, Line 22d: The Hospital calculates the amounts generally billed using the Look-Back Method. This method takes into account all commercial insurance and Medicare. All individuals without insurance receive the Illinois Uninsured Discount Act discount. Also, prompt pay discounts are offered to all patients. Memorial Hospital Association Part V, Section B, Line 24: All individuals eligible under the hospital financial assistance policy are provided a discount for emergency and other medically necessary care. The financial assistance policy does not apply to elective procedures. Therefore, FAP-eligible patients without insurance may be charged gross charges on elective procedures. Part V, Section B, Line 16 Financial Assistance Policy Website Availability Memorial Hospital Association Part V, Section B, line 16a website: www.mhtlc.com/pages/financialassistance Memorial Hospital Association Part V, Section B, line 16b website: www.mhtlc.com/pages/financialassistance Memorial Hospital Association Part V, Section B, line 16c website: www.mhtlc.com/pages/financialassistance 3 Advance Physical Therapy 620 Wabash Street Carthage IL 62321 Physical therapy rehabilitation Memorial Medical Clinic Augusta 204 Center Street Augusta IL 62311 Physician clinic Sherrick Home Health 1204 Buchanan Street 2 Carthage IL 62321 Home health care services Part I, Line 6a: The community benefit report information is shared in Memorial Hospital's annual report and available on their website www.mhtlc.org. Part I, Line 7: Charity care expense was converted to cost on line 7a based on an overall cost to charge ratio addressing all patient segments. Unreimbursed Medicaid on line 7b was calculated using the costing methods to prepare the cost reports. The cost for subsidized health services reported on line 7g was determined using the Medicare Cost Report. Part I, Line 7g: Memorial Medical Augusta Clinic is a physician clinic included as a subsidized service on the 990. Direct and indirect costs were $187,258. Part I, Ln 7 Col(f): The amount of bad debt expense removed from total expenses to determine the percentage was $775,281. Part III, Line 2: Accounts are not written off to bad debt until all payments on the account are applied including all third party payments, contractual allowances, and discounts. Any financial assistance or charity care is recorded as an adjustment to patient service revenue and is not written off to bad debt. We realize some patients may qualify for financial assistance but do not complete the required paperwork. We try to work with these patients to provide them with some form of financial assistance or other payment arrangements, but when patients are able to pay and do not, their balances are written off to bad debt. Payments received on an account previously written off to bad debt reduces bad debt expense.Bad debt expense on line 2 is reported at charges as presented on the financial statements. Part III, Line 3: The estimated amount of the Organization's bad debt expense attributable to patients eligible under the Organization's charity care policy is calculated based on a percentage of applications denied for failure to complete required information. Part III, Line 4: The footnote to the Organization's financial statements can be found on page 9 of the attached audited financial statements. Part III, Line 8: Memorial Hospital Association is a critical access hospital and in prior years has not shown a Medicare shortfall. There was a shortfall for fiscal year 2014 due to sequestration. Even though Medicare was at a loss, the Hospital provides services to these patients because access to healthcare and individual's health is important to the Hospital. Therefore, the Medicare shortfall is considered a community benefit.Total revenue received from Medicare is the gross reimbursement plus settlement. Both total revenue received from Medicare and the Medicare allowable costs are reported from the Medicare Cost Report. The Medicare Cost Report is completed based on the rules and regulations set forth by Centers for Medicare and Medicaid Services. These amounts do not include fee schedule amounts. Part III, Line 9b: Memorial Hospital does not pursue collection activities for patients that qualify for charity care or patients that have set up payment arrangements for their accounts. Memorial Hospital does not charge interest on patients with payment arrangements. Also, collection activities are not pursued for patients that are in the process of applying for charity care and patients waiting for approval or denial from public aid. Any personal portion due after financial assistance is established would follow normal collection procedures. Part VI, Line 2: Memorial Hospital, based on its mission, wants to ensure that the health care needs of the community it serves are met. The Hospital has medical clinics located throughout Hancock County to improve access to health care services to our patients. The Board also has four committees; Finance, Planning, Quality and Community Health, and Marketing Committees that have community representation to ensure that input is obtained from the community when considering the health care needs of those we serve. Community input on desired services is obtained through patient satisfaction surveys that are initiated by the inpatient unit, emergency department, and medical clinics that provide a line of communication to identify additional health care services that community desires. The Community Health Needs Assessment is completed and posted to our website at www.mhtlc.com. Part VI, Line 3: Memorial Hospital strives to provide a rewarding and healing process to our patients, plus an affordable, comfortable process to meet their financial obligations. Memorial Hospital informs their patients individually upon admission about the eligibility for assistance under federal, state or local government programs, and provides the patient with information regarding the Organization's charity care policy.Our Collection and Financial Assistance Policies and applications are on our website. We also provide financial counseling to any patient. We post our Charity Care Policy and information regarding federal, state, and local programs at all our registration areas. Brochures are distributed regarding financial assistance with all admission packages.Billing statements have financial assistance support telephone numbers at the bottom of each statement. Our third party billing service provides counseling to our patients regarding available financial assistance if there is a need. Part VI, Line 4: Memorial Hospital Association is an 18-bed critical access hospital located in Carthage, IL. Carthage is a city in Hancock County, Illinois. It is located in western Illinois along the Mississippi River. The nearest city with a population > 50,000 is Peoria, IL. Its primary service area from its most recently completed community health needs assessment is defined as Hancock County, with Colchester, Lomax, Keokuk, Tennessee and Blandinsville as the secondary service area. The 2011 population for this area is estimated at 35,758 and is expected to decrease approximately 5.2%, to achieve a 2015 population of 33,863 contrary to the state growth average of 1.6% and national growth rate of 4.0%. The 2015 median age for the population is projected to be 43 years of age, slightly older than both the Illinois and national median ages. The 2011 median household income is approximately $41,000, significantly lower than the Illinois and national median. The unemployment rate as of August 2011 was 9.3%, lower than the Michigan rate and in line with the national rate of unemployment.The most common industries are agriculture, transportation, and health care. The nearest hospital is Keokuk Area Hospital about 15 miles away on the Iowa side of the Mississippi River. Part VI, Line 5: Memorial Hospital is dedicated to improving health by providing education and wellness programs and innovative services at all the stages of life for residents of Hancock County. The Hospital is governed by a 13-member, volunteer Board of Directors that represent key areas within Hancock County as well as the medical staff. As a critical access hospital, Memorial Hospital is an 18-bed facility that provides general medical, surgical services along with obstetrics and an array of outpatient services for the community. Specialty clinics are also provided locally in the areas of cardiology, oncology, neurology, ophthalmology, podiatry, orthopedic, pulmonology, and sleep apnea so that our patients don't have to travel far to receive needed health care services. These specialty physicians are members of the Hospital's medical staff along with other providers that desire to serve members of our service area. The Hospital extends medical staff privileges to all qualified physicians in the community. With the support of the community, Memorial Hospital built a new 18-bed hospital that was occupied in August 2009. The facility provides up-to-date, diagnostic equipment and services with a capital budget also presented and approved on an annual basis to ensure that needed equipment is obtained to meet the expectations of our patients. Memorial Hospital operates an emergency room available to all regardless of ability to pay.The Hospital also participates in several health care events throughout the year providing free services as well as a listing of services that are offered through the Hospital, clinics, and specialty clinics. This includes, but is not limited to, health fairs, blood pressure screenings, and diabetic education. Memorial Hospital sponsors the bloodmobile and provides language assistance services. X X X X 0 0 0 0 0 0 0 0 0 Christopher Jones MD Director 342103 0 0 0 270 0 3513 0 29124 0 375010 0 0 0 Ada Bair CEO 192078 0 0 0 2286 0 1990 0 11376 0 207730 0 0 0 Aaron Wesp MD Family Practice Physician 220866 0 0 0 414 0 0 0 30624 0 251904 0 0 0 Randall Peters MD Surgeon 379496 0 10000 0 774 0 3731 0 20706 0 414707 0 0 0 Kurtis Davis MD Family Practice Physician 256559 0 0 0 144 0 0 0 28929 0 285632 0 0 0 Stephen Bergman CRNA 200591 0 0 0 2286 0 2175 0 21660 0 226712 0 0 0 Douglas Heighton MD Family Practice Physician 193574 0 0 0 774 0 0 0 29124 0 223472 0 0 0 A Western Illinois Economic Development Authority 352256539 958362AT2 2008-08-22 9972195 Facility/equip upgrades & refund Revenue Bonds Series 2007 issued 12/27/07 0 0 0 B Western Illinois Economic Development Authority 352256539 958362AU9 2008-09-16 10385000 New facility and equipment upgrades 0 0 0 A 2362195 9972195 193445 9778750 2009 1 0 1 1 B 10385000 392128 207014 10177986 2009 0 0 1 1 A 0 0 0 0 0.00000 0.00000 0.00000 0 0 1 B 0 0 0 0 0.00000 0.00000 0.00000 0 0 1 A 0 0 0 1 1 0 0 0 1 B 0 0 0 1 0 0 0 0 0 A 1 B 1 Date Rebate Computation Performed Issuer Name: Western Illinois Economic Development Authority Date the Rebate Computation was Performed: 07/15/2013 Issuer Name: Western Illinois Economic Development Authority Date the Rebate Computation was Performed: 07/15/2013 Schedule K, Part II, Line 11: The other spent proceeds were used to currently refund bonds on August 22, 2008. Mallory Holst Family member to Kathy Holst, Director of board 26184 Employee compensation and benefits 0 Roxanne Rankin Family member to Dennis Rankin, Secretary/Treasure of board 35745 Employee compensation and benefits 0 Danielle Gronewold Family member to Carol Gronewold, Director of board 29501 Employee compensation and benefits 0 Form 990, Part VI, Section A, line 1 The Executive Committee consists of the President, Vice President, Secretary-Treasurer, additional members as the Board appoints, the Chief Executive Officer and any other leadership team members deemed appropriate by the officers of the Board. The Chief Executive Officer and any Leadership Team members do not have the right to vote upon any action being taken. The Executive Committee meets only in the event that the Board is unable to take necessary action, has an agenda for each meeting, keeps minutes of its meetings, and mails a copy of the minutes of each meeting to each member of the Board of Directors within twenty-four (24) hours of the adjournment of the meeting. The primary purpose of the Executive Committee is to carry out critical tasks for effective Board functioning, including, but not limited to, Chief Executive Officer Management performance, management company performance, if applicable, and providing assistance to the Board in situations requiring action when it is impossible or impractical to convene a full Board meeting. Form 990, Part VI, Section A, line 6 The Corporation has one class of members. Any individual or organization that contributes one hundred dollars ($100) or more, upon application is entitled to receive life membership in the Corporation. Such memberships are not transferable. The membership of this Corporation is unlimited. Form 990, Part VI, Section A, line 7a Memorial Hospital Association has Association Members who are presented with a slate of officers and Board members at the annual meeting. The Association votes by proxy to elect these officers and Board members. Each Member is entitled to one vote on each matter submitted to a vote of the Members. No person whose name does not appear on the list of Members kept by the Secretary-Treasurer is entitled to vote and there is no cumulative voting. Form 990, Part VI, Section B, line 11 The Form 990 is reviewed by the Finance Committee and then by the Board of Directors before it is filed. The final return is reviewed and signed by the CFO. Form 990, Part VI, Section B, line 12c Officers, Board members, and key employees are required to sign a conflict of interest statement upon hiring or becoming a Board member. The disclosure is updated at the annual Association meeting. Any possible conflict of interest is disclosed to the other Board members and made a matter of record through an annual procedure and also when the interest becomes a matter of Board action. Disclosures are reviewed by the Board of Directors and any Member for whom conflicts have been identified leaves and abstains from voting. Appropriate documentation of the handling of the conflict is kept to protect the interested party and Memorial Hospital Association. Additionally, the Compliance Officer meets with the Compliance Committee of the board. Any issues identified are logged and followed up by the Compliance Officer. Form 990, Part VI, Section B, line 15a Salary surveys are reviewed annually to ensure all positions individually are within the market rate. Surveys are used from the local area (Blessing survey) and LSN & QHR (comparable organization surveys). The Executive Committee determines the salary for the CEO. Each Board member does an independent performance review of the CEO, which is compiled and used by the Executive Committee. The Executive Committee uses the Illinois Hospital Association salary survey as a guide for compensation using the high, middle, and low ranges for similar size organizations. Measures such as revenue, performance of the CEO, and budgetary constraints are all factors that are considered when reviewing the CEO's salary. The most recent review of salary occurred in January 2015. The salary for the CFO is determined by the CEO using the Blessing Survey and the Illinois Hospital Association survey as a guide for similar organizations based on the local area. The most recent review of salary occurred in January 2015. Form 990, Part VI, Section C, line 19 The Organization's governing documents, conflict of interest policy, and financial statements are available to the public upon request. The financial statements are also required to be attached to the Form 990. Form 990, Part IX, line 11g Repairs and maintenance: Program service expenses 207,862. Management and general expenses 120,938. Fundraising expenses 0. Total expenses 328,800. Purchased services: Program service expenses 2,983,227. Management and general expenses 999,551. Fundraising expenses 0. Total expenses 3,982,778. Professional fees: Program service expenses 37,749. Management and general expenses 406,999. Fundraising expenses 0. Total expenses 444,748. Form 990, Part XI, line 9: Change in Memorial Hospital Auxiliary's assets -2,033. Book/tax difference for Advance Physical Therapy 25,638. Change in interest in net assets of Memorial Hospital Foundation 48,137. Hancock County Nursing Home Association PO Box 160 Carthage IL 62321 370902248 Provide education and wellness programs and innovative services IL 501(c)(3) Line 3 Memorial Hospital Association 1 Advance Physical Therapy of Hancock County 620 Wabash Street Carthage IL 62321 113655886 Physical therapy rehabilitation IL Memorial Hospital Association Related 37137 31181 0 1 0.50000 Hancock County SLF LLP 403 S Adams Carthage IL 62321 204445121 Assisted living facility IL N/A Hancock Area Medical Supply dba Sherrick Home Health 1204 Buchanan St Ste 2 Carthage IL 62321 371180373 Home health IL Memorial Hospital Association C 542605 511054 1.00000 1 0 0 0 0 0 0 0 0 0 1 1 1 0 1 1 0 0 0 1 Hancock County Nursing Home Association K 102264 General ledger