2014-11-06T11:11:06-06:00 2014-03-31 BKD LLP 211 N BROADWAY SUITE 600 ST LOUIS MO 631022733 990 2013-04-01 362167785 MENDOTA COMMUNITY HOSPITAL % GARY EICH CFO MEND 8155397461 1401 E 12TH STREET Suite MENDOTA IL 61342 GARY EICH CFO 8155397461 2014-11-05 true Donna J Larson P00043751 8155397461 2013 2015-11-30 17:44:51Z JUDY CHRISTIANSEN 1401 E 12TH STREET MENDOTA IL 61342 35602036 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. 13 9 390 75 0 135251 80429 32596729 34366710 1127184 88563 130789 139233 33989953 34674935 13000 5000 0 0 18095047 17745727 0 0 73717 18558396 18635816 36666443 36386543 -2676490 -1711608 50809287 46993908 40112290 37943530 10696997 9050378 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 29142801 5000 34366710 MENDOTA COMMUNITY HOSPITAL PROVIDED 25 BEDS IN FISCAL YEAR 2014. THIS HOSPITAL GAVE $1,222,192.21 IN CHARITY CARE, AND PROVIDED 7514 MEALS ON WHEELS TO MEMBERS OF OUR COMMUNITY. THE NET COMMUNITY BENEFIT EXPENSE WAS $47,940.51. 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 $19,946.04. 29142801 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 49 0 true 390 true false false false false false false false false false false X 13 9 false false false false false false false true true true false true true true true true true true false false IL X GARY EICH CFO 8155397461 1401 E 12TH STREET MENDOTA IL 61342 X STEVEN F GAHAN DIRECTOR 2.0 X 0 0 0 DAVID SCHOLL MD PHYSICIAN 40.0 X 198473 0 27605 MARGO GALLAGHER SCHMITZ RN PRESIDENT 2.0 X X 0 0 0 P DANIEL DOYLE OD TREASURER 2.0 X X 0 0 0 ROBERT F STACHLEWITZ JR SECRETARY 2.0 X X 0 0 0 ERIC ANDERSON DIRECTOR 2.0 X 0 0 0 JOSEPH BEETZ PAST PRESIDENT 2.0 X X 0 0 0 KERI SUNDBERG DDS DIRECTOR 2.0 X 0 0 0 MICHAEL PHALEN 1ST VICE PRESIDENT 2.0 X X 0 0 0 MARY CHINN MD PHYSICIAN 40.0 X 199199 0 20635 KATHLEEN STEVENSON DIRECTOR 2.0 X 0 0 0 JOSE DE J ARTEAGA DIRECTOR 2.0 X 0 0 0 CHRISTINE KLEIN DIRECTOR 2.0 X 0 0 0 LYNN E KLEIN CEO 40.0 X 184244 0 24555 JUDY CHRISTIANSEN CEO 40.0 X 684 0 0 HOWARD SCHOU CFO 40.0 X 65389 0 4065 GARY EICH CFO 40.0 X 4300 0 0 KENNETH K POTTS NURSE ANESTHETIST 20.0 X 304076 0 21675 AMY MATHEIS-SOLIMAN MD PHYSICIAN 40.0 X 198186 0 27605 KEITH MINIHANE MD ORTHOPEDIC SURGEON 40.0 X 600603 0 17407 RICHARD BAKER NURSE ANESTHETIST 20.0 X 198491 0 21604 ERIC KIVISTO MD GENERAL SURGEON 40.0 X 243868 0 14403 2197513 0 179554 16 false true true ER DOCTORS LTD 7 WOOD DUCK LANE OTTAWA IL 61350 MEDICAL PHYSICIANS 1686566 MEDICAL STAFFING NETWORK 4525 WEAVER PARKWAY SUITE 310 WARRENVILLE IL 605554031 NURSING AGENCY 126095 MEDICAL OUTSOURCING SOLUTIONS INC 2060 ABERDEEN COURT SUITE D SYCAMORE IL 60178 RADIOLOGY SERVICE 519700 READY LINK HEALTHCARE 72030 METROPLEX DR PO BOX 1047 THOUSAND PALMS CA 92276 NURSING AGENCY 127114 4 11800 68629 80429 PROGRAM SERVICE REVENUE 621110 33559872 33559872 OTHER OPERATING REVENUE 621110 806838 806838 34366710 63285 63285 0 0 69511 7521 61990 0 61990 61990 933050 0 906901 871 26149 -871 25278 25278 14771 11800 11808 2963 2963 0 0 CAFETERIA 722210 74280 74280 74280 34674935 34366710 227796 5000 5000 0 0 0 789164 447470 341694 0 13795398 12240841 1519846 34711 210047 186157 23346 544 1976641 1731105 240680 4856 974477 848642 123504 2331 0 25708 25708 114297 114297 0 0 0 2613692 2501240 112452 175888 20055 155833 5107706 3607200 1491836 8670 0 0 386244 348491 37753 69364 54205 15159 0 0 2165158 2165158 0 3641724 3641724 818252 753302 64950 BLOOD BANK 99625 99625 PROVISION FOR BAD DEBT 1249811 1249811 COLLECTION 82632 82632 CONTRACTS/REPAIRS 1875576 1300193 575383 210139 107740 79794 22605 36386543 29142801 7170025 73717 3711 3353 1790227 3231463 0 0 4873178 3611590 0 0 0 0 0 0 705529 753120 504584 443465 51873578 14834437 40424566 37039141 2506873 1806629 0 0 0 0 0 0 619 105147 50809287 46993908 3247940 3275696 0 0 0 0 0 0 0 0 0 0 36839350 34642834 0 0 25000 25000 40112290 37943530 X 10036038 8389375 41824 41868 619135 619135 10696997 9050378 50809287 46993908 -1711608 64989 X false true X true true true X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED false false false false false true 11633 false false false 11633 false PART II-B, LINE 1F THE ORGANIZATION'S LOBBYING ACTIVITIES INCLUDE PAYING MEMBERSHIP DUES TO THE ILLINOIS HOSPITAL ASSOCIATION AND NATIONAL RURAL HEALTH ASSOCIATION, BOTH OF WHICH PARTICIPATE IN LOBBYING ACTIVITIES. 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 6628180 0 452043 0 2165000 0 4915223 0.83080 0.15880 0.01040 false false 40478 1272124 1312602 0 30822579 4518053 26304526 0 0 0 0 0 14761296 9434742 5326554 0 4977101 881642 4095459 37039141 0 LEGAL CLAIMS RESERVE 25000 25000 33509442 64989 19329 84318 33425124 1249811 1249811 34674935 35156061 19329 19329 35136732 1249811 1249811 36386543 INTENDED USES OF ENDOWMENT FUNDS PART V, LINE 4 PROCEEDS OF FUNDED DEPRECIATION ENDOWMENT, AS DICTATED BY THE DONORS, ARE USED AS BEST DETERMINED BY ADMINISTRATION OF THE HOSPITAL. OTHER REVENUE INCLUDED ON BOOKS BUT NOT ON RETURN PART XI, LINE 2D SPECIAL EVENTS DIRECT EXPENSE $11,808 RENTAL EXPENSE $ 7,521 ------------------------------------------ TOTAL $19,329 OTHER EXPENSES ON BOOKS BUT NOT ON RETURN PART XII, LINE 2D SPECIAL EVENTS DIRECT EXPENSE $11,808 RENTAL EXPENSE $ 7,521 ------------------------------------------ TOTAL $19,329 UNCERTAIN TAX POSITIONS PART X, LINE 2 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. OTHER REVENUE INCLUDED ON RETURN BUT NOT ON BOOKS PART XI, LINE 4B PROVISION FOR BAD DEBT $1,249,811 OTHER EXPENSES ON RETURN BUT NOT ON BOOKS PART XII, LINE 4B PROVISION FOR BAD DEBT $1,249,811 FORE THE HOSPIT 15005 7450 7555 2192 2302 100 1521 CORNAPALOOZA 11566 4350 7216 857 117 100 4619 0 26571 11800 14771 3049 2419 200 6140 11808 2963 true true true X true X true true false false 613497 613497 0.01750 4160169 3377550 782619 0.02230 13616 13616 0.00040 4787282 3377550 1409732 0.04020 117607 35005 82602 0.00240 47000 47000 0.00130 6049 6049 0.00020 170656 35005 135651 0.00390 4957938 3412555 1545383 0.04410 true 1249811 0 14556055 14882549 -326494 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 true X X X X X X X X X 12 true false true X SEE PART V, SECTION C X X X X X X X X false false true true 100 true 200. true X X X X X X X X true true X X X X true X false X X X X true X false false INPUT FROM PERSONS WHO REPRESENT THE COMMUNITY PART V, SECTION B, LINE 3 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. HOSPITAL FACILITY WEBBSITE (URL) PART V, SECTION B, LINE 5A HTTP://WWW.MENDOTAHOSPITAL.ORG/IMAGES/PDFS/MCHNEEDSASSESMENT.PDF NEEDS NOT ADDRESSED PART V, SECTION B, LINE 7 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. PUBLISHING OF FINANCIAL ASSISTANCE POLICY PART V, SECTION B, LINE 14G 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. COLLECTIONS POLICIES AGAINST PATIENTS PART V, SECTION B, LINE 16E 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. DETERMINING MAXIMUM AMOUNTS CHARGED TO FAP-ELIGIBLE INDIVIDUALS PART V, SECTION B, LINE 20D WE USE THE AVERAGE OF NEGOTIATED COMMERCIAL INSURANCE RATES FOR THOSE SERVICES AT THE FACILITY. FINANCIAL ASISTANCE AND CERTAIN OTHER COMMUNITY BENEFITS AT COST PART I, LINE 7, COLUMN F 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. PERCENT OF TOTAL EXPENSE PART I, LINE 7, COLUMN F THE ORGANIZATION HAD BAD DEBT EXPENSE IN THE AMOUNT OF $1,249,811 REPORTED ON PART IX, LINE 25, HOWEVER, IT HAS BEEN SUBTRACTED FOR PURPOSES OF CALCULATING THE PERCENTAGE IN THIS COLUMN. METHODOLOGY USED TO ESTIMATE BAD DEBT EXPENSE PART III, LINE 2 FOR LINE 2, WE PROVIDED OUR FISCAL YEAR EXPENSE AMOUNT FOR BAD DEBT. METHODOLOGY USED TO ESTIMATE BAD DEBT EXPENSE FOR FAP ELIGIBLE PATIENTS PART III, LINE 3 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. FINANCIAL STATEMENTS BAD DEBT EXPENSE PART III, LINE 4: 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. SHORTFALL TREATED AS A COMMUNITY BENEFIT PART III, LINE 8 THIS SHORTFALL IS DUE TO HOME HEALTH THAT IS A NECESSARY OUTREACH SERVICE PROVIDED TO THE COMMUNITY FOR THOSE PATIENTS RESTRICTED TO THEIR HOMES. DEBT COLLECTION POLICY PART III, LINE 9B: 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. NEEDS ASSESSMENT PART VI, LINE 2 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. THIS YEAR WE ALSO CONDUCTED A COMMUNITY HEALTH NEEDS ASSESSMENT WHICH LEADS US TO WHAT OUR COMMUNITY NEEDS US TO OFFER TO THEM. PATIENT EDUCATION OF ELIGIBILITY FOR ASSISTANCE PART VI, LINE 3 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. COMMUNITY INFORMATION: PART VI, LINE 4 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. PROMOTION OF COMMUNITY HEALTH PART VI, LINE 5 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. AFFILIATED HEALTH CARE SYSTEM PART VI, LINE 6 NOT APPLICABLE STATE FILING OF COMMUNITY BENEFIT REPORT PART VI, LINE 7 NOT APPLICABLE X false false false false false false false false false LYNN E KLEIN CEO 136678 0 0 0 47566 0 6551 0 18004 0 208799 0 0 0 DAVID SCHOLL MD PHYSICIAN 177876 0 0 0 20597 0 6000 0 21605 0 226078 0 0 0 KENNETH K POTTS NURSE ANESTHETIST 298505 0 0 0 5571 0 7650 0 14025 0 325751 0 0 0 MARY CHINN MD PHYSICIAN 176646 0 0 0 22553 0 6000 0 14635 0 219834 0 0 0 AMY MATHEIS-SOLIMAN MD PHYSICIAN 195572 0 0 0 2614 0 6000 0 21605 0 225791 0 0 0 KEITH MINIHANE MD ORTHOPEDIC SURGEON 554149 0 0 0 46454 0 7650 0 9757 0 618010 0 0 0 RICHARD BAKER NURSE ANESTHETIST 197031 0 0 0 1460 0 0 0 21604 0 220095 0 0 0 ERIC KIVISTO MD GENERAL SURGEON 241841 0 0 0 2027 0 0 0 14403 0 258271 0 0 0 GARY EICH CFO 4300 0 0 0 0 0 0 0 0 0 4300 0 0 0 COMPENSATION PAID BY AN UNRELATED MANAGEMENT COMPANY FORM 990, PART VII, LINE 5 THE CFO, GARY EICH, IS PAID BY AN UNRELATED MANAGEMENT COMPANY, OSF. OSF PROVIDED GARY EICH WITH COMPENSATION IN THE AMOUNT OF $4,300. ALL FEES ARE PAID TO OSF BY MENDOTA COMMUNITY HOSPITAL. JOELLYN GAHAN SPOUSE OF BOARD MEMBER 43083 EMPLOYEE false JARED WISE SON-IN-LAW OF BOARD MEMBE 73444 EMPLOYEE false BRIGITTE KLEIN DAUGHTER OF CEO 15695 EMPLOYEE false OFFICERS WHO CANNOT BE REACHED AT THE ORGANIZATION'S ADDRESS FORM 990, PART VI, SECTION A, LINE 9 LYNNE KLEIN PO BOX 246 CHERRY, IL 61317 HOWARD SCHOU 1420 DEERFIELD ROAD PRINCETON, IL 61356 COPY OF 990 PROVIDED TO GOVERNING BODY FORM 990, PART VI, LINE 11 MENDOTA COMMUNITY HOSPITAL EMAILS THE GOVERNING BODY A COPY OF THE FORM 990 BEFORE IT IS FILED SO THEY CAN REVIEW IT. IN ADDITION, THE CEO AND CFO REVIEW THE FORM 990 BEFORE IT IS FILED WITH THE GOVERNMENT. COMPLIANCE WITH WRITTEN CONFLICT OF INTEREST POLICY FORM 990, PART VI, LINE 12C 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. COMPENSATION DETERMINATION FORM 990, PART VI, LINE 15A THE EXECUTIVE BOARD CONDUCTED A REVIEW OF THE COMPENSATION FOR THE CEO ON APRIL 1, 2013. AVAILABLE TO THE PUBLIC FORM 990, PART VI, LINE 19 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.