2014-05-08T12:10:25-07:00 2013-09-30 Gray Hunter Stenn LLP 500 Maine Street Quincy IL 62301 990 2012-10-01 371396010 BLESSINGCARE CORPORATION dba ILLINI COMMUNITY HOSPITAL BLES 2172852113 640 WEST WASHINGTON PITTSFIELD IL 62363 PATRICK M GERVELER 2014-05-08 true STEPHEN C KOESTER CPA P00342386 2172220304 2012 2015-11-30 17:44:51Z 23754283 false false X www.illinihospital.org X 2000 IL TO PROVIDE THE BEST QUALITY HEALTHCARE AT THE BEST PRICE. 9 6 228 38 0 3957 287457 318053 22311917 22961559 7523 8886 1429798 459978 24036695 23748476 0 0 9992914 9746709 0 0 12301005 12067897 22293919 21814606 1742776 1933870 14529228 17222145 7366149 8125196 7163079 9096949 TO PROVIDE THE BEST QUALITY HEALTHCARE AT THE BEST PRICE. false false 15991052 22961559 THE HOSPITAL TREATED PATIENTS THROUGH THE FOLLOWING SERVICES DURING THE YEAR: 6,844 EMERGENCY ROOM VISITS, 22,584 OUTPATIENT VISITS, 444 SURGICAL OPERATIONS, 308 INPATIENT ADMISSIONS AND 118 OBSERVATION ADMISSIONS. 15991052 true true false false false false false false false false true false false true true false false true false false false false false false false false true true false false true false false false false false false false false false false false false false false false false true false false false false true 17 0 true 228 true true false false false false false false 0 false false false false false false false false false false X 9 6 false true false false true true true true true false false true true true true true true true true true true IL X KATHY HULL 2172852113 640 WEST WASHINGTON PITTSFIELD IL 62363 JOHN FRANK MCCARTNEY 1.00 0.00 X X 0 0 0 PAT SYRCLE 1.00 0.00 X 0 0 0 PATRICK M GERVELER 1.00 39.00 X X 0 389072 59743 JAMES C GAY 1.00 0.00 X 0 0 0 KATHLEEN E HULL 40.00 0.00 X X 0 213603 16304 KORHAN RAIF MD 1.00 0.00 X 0 0 0 CHRISTOPHER WAGONER MD 1.00 39.00 X 0 180694 21395 ROBERTA SIMPSON-DOLBEARE 1.00 0.00 X X 0 0 0 B BRADFORD BILLINGS 1.00 39.00 X X 0 821440 477102 JAN BLEICH 1.00 0.00 X 0 0 0 LAURA KENT-DONAHUE 1.00 0.00 X 0 0 0 ROBERT ROWLES 40.00 0.00 X 212568 0 7690 MARK TATUM 40.00 0.00 X 123773 0 18975 336341 1604809 601209 2 false true false SIEMENS MEDICAL SOLUTIONS INC 51 VALLEY STREAM PARKWAY MALVERN PA 19355 MAINTENANCE 203711 QUINCY MEDICAL GROUP 1025 MAINE ST QUINCY IL 62301 MEDICAL SERVICES 265480 BLESSING HOSPITAL BROADWAY AT 11TH QUINCY IL 62301 PHYSICIANS/SUPPORT 3989818 BLESSING CORPORATE SERVICES BROADWAY AT 11TH QUINCY IL 62301 MANAGEMENT SERVICES 399565 AIMS OF PITTSFIELD LLC 12533 W LAKE VIEW DR ORLAND PARK IL 60467 ER PHYSICIANS 1280045 7 225072 92981 318053 PATIENT REVENUE 45361006 45361006 CONTRACTUAL ALLOWANCE -22399447 -22399447 22961559 8886 8886 0 0 146609 5807 140802 140802 140802 0 0 0 46730 46730 46730 OTHER 198413 198413 EQUITY IN SUB'S INCOME 74033 74033 272446 23748476 22961559 468864 0 0 0 0 0 0 7277243 5430974 1846269 168227 125547 42680 1794216 1335657 458559 507023 378389 128634 0 -24391 -24391 0 0 0 0 0 74705 74705 0 0 0 323095 98018 225077 50059 22280 27779 0 0 95362 95362 0 1003674 306924 696750 178169 178169 BAD DEBTS 1828759 1828759 PATIENT SUPPLIES 1847973 1753149 94824 OUTSIDE FEES 2273737 867053 1406684 PHYSICIAN FEES 2607949 2607949 1808806 1236353 572453 21814606 15991052 5823554 0 1655645 2660426 1708550 1716059 0 4139661 5356069 0 0 0 495462 471094 169385 130175 15204091 9527296 5957319 5676795 0 0 0 0 403206 1211527 14529228 17222145 424904 468291 4285734 3900459 2655511 3756446 7366149 8125196 X 6968567 8749392 194512 347557 7163079 9096949 14529228 17222145 1933870 X false true X true false X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 138751 138751 7436571 3858485 3578086 303667 247443 56224 7180134 5421368 1758766 144968 144968 5676795 OTHER ACCOUNTS RECEIVABLE 1099632 DUE FROM BLESSING FOUNDATION 23872 1211527 PAYROLL TAXES & WITHHOLDING 12480 NONCURRENT ACCRUED MALPRACTICE 93431 ESTIMATED THIRD-PARTY SETTLEMENTS 2635055 DUE TO BLESSING HOSPITAL 220179 ACCRUED SALARIES 782089 ACCRUED INTEREST 6745 ACCRUED EMPLOYEE BENEFITS 6467 3756446 21683613 -1753127 -1753127 23436740 311736 311736 23748476 19991654 5807 5807 19985847 1828759 1828759 21814606 Part XII, Line 4b Part XII, Line 4b: Other revenue amounts included on 990 but not included in F/S BAD DEBT REDUCTION OF REVENUE ON F/S $1828759 Part XII, Line 2d Part XII, Line 2d: Other expenses and losses per audited F/S RENTAL EXPENSES $5807 Part XI, Line 4b Part XI, Line 4b: Other revenue amounts included on 990 but not included in F/S RESTRICTED CONTRIBUTIONS $317543 RENTAL EXPENSES $-5807 true true X true X true X true true true false true true 629164 629164 0.03080 3485299 3145490 339809 0.01660 4114463 3145490 968973 0.04740 42337 42337 0.00210 42337 42337 0.00210 4156800 3145490 1011310 0.04950 true 1828759 85403 8841675 9059950 -218275 X true true ADVANCE PTILLINI COMM HOSP PHYSICAL THERAPY SERVICES 0.47000 ILLINI HEALTH SERVICES LLC PHARMACY/MEDICAL EQUIPMENT 0.05000 1 1 ILLINI COMMUNITY HOSPITAL

640 WEST WASHINGTON PITTSFIELD IL 62363

X X X X ILLINI COMMUNITY HOSPITAL 1 true X X X X X X X X X 12 true false true X X X X X X X false false false true true 150.0000 true 400.0000 true X X X X X X X true true X X X X X X true X X true X X X X X X true X false false 1 ILLINI COMMUNITY HOSPITAL RURAL HEALTH CLINIC

321 WEST WASHINGTON PITTSFIELD IL 62363

RURAL HEALTH CLINIC Part VI - Additional Information Part I, line 3C - Illini Hospital uses Federal Poverty Guidelines to determine eligibility for providing free or discounted care.Part I, line 6A - Illini Hospital's Community Benefit Report is prepared by Illini Hospital, not by a related organization.Part I, line 6B - Illini Hospital's community benefit report is published in the local newspaper as an insert and is available on the hospital's website. Part V - Explanation of Number of Facility Type Illini Hospital operated no facilities other than the locations listed in Part V. Part VI - States Where Community Benefit Report Filed IL Part VI - Affilated Health Care System Roles and Promotion Blessing Corporate Services, Inc. is the parent organization of a group of related organizations and provides overall direction to all entities within the structure. During the year ended September 30, 2005, Blessing Corporate Services, Inc. began operating a division comprised of practicing physicians. The Group is related through Board control. The following is a brief description of each member of the Group.Organization - Blessing Hospital (Hospital), located in Quincy, Illinois, is a not-for-profit acute care hospital. The Hospital provides inpatient, outpatient and emergency care services for residents of Western Illinois and Northeastern Missouri. The Hospital was incorporated in Illinois in 1875.Organization - The Blessing Foundation, Inc. serves Blessing Corporate Services and its affiliated entities by providing financial support for services and programs promoting the improvement and availability of healthcare services within the general community.Organization - Denman Services, Inc. (a taxable corporation) engages primarily in the business of selling and renting medical equipment and operating a commercial laundry. Denman Services, Inc. is a wholly owned subsidiary of Blessing Corporate Services, Inc.Organization - BlessingCare Corporation dba Illini Community Hospital and Subsidiary, located in Pittsfield, Illinois, is a not-for-profit acute care hospital. The Hospital provides inpatient, outpatient and emergency care services for residents of Western Illinois. The Hospital was incorporated on January 20, 2000. For financial reporting purposes, the Hospital's financial information is consolidated with West Central Illinois Therapy & Sports Medicine, LLC. The Hospital has a 51% partnership interest in West Central Illinois Therapy & Sports Medicine, LLC, and the outside investor's 49% interest in the partnership is included as a minority interest. This partnership was dissolved in FY2013.Organization - Illini Health Services, LLC conducts a pharmacy business in Pittsfield, Illinois. The Pharmacy is owned ninety-five percent (95%) by Denman Services, Inc. and five percent (5%) by BlessingCare Corporation dba Illini Community Hospital. Part VI - Explanation Of How Organization Furthers Its Exempt Purpose Illini Hospital offers a wide range of services important to promoting the health and well-being of Pike County and the surrounding area. Illini Hospital operates an emergency room available to all regardless of the ability to pay. The financial assistance policy of Illini Hospital enables patients to have access to area resources to assist them with payment of medical expenses. Illini Hospital is the largest employer in the area with 182 employees. Of significant importance is the volunteers that serve the Hospital. In Fiscal Year 2013, Illini Community Hospital had 38 active volunteers. In addition to the volunteers actively working in the hospital, Illini's Board of Trustees is comprised of volunteers that includes business leaders, physicians, and other community leaders. Part VI - Community Building Activities Illini Hospital conducts no activities considered Community Building Activities as defined by the Schedule H instructions. Part VI - Community Information Illini opened its doors on January 26, 1942 to serve the people residing within a 25 mile radius of Pittsfield, Illinois, which is primarily Pike County but includes parts of Scott, Green, Calhoun, Brown, and Adams County. Pike County has 831 square miles of land area and a population of around 16,300 and the total service area is around 25,000. Pike County age demographics include 6.0% under 5 years old, 22.5% under 18 years old, AND 18.9% over 65 years old. 50.0% of the population is female, 96.9% are white, and 1.8% are black. 84.9% of the population have graduated from high school and 12.1% have a bachelors degree OR higher. The median household income is $40,668 and 16.2% of the population is below the poverty level. Pike County is designated as a health professional shortage area and medically underserved area. The unemployment rate in Pike County WAS 7.4% AT 12/31/2012. The region's economy is heavily agriculture with retail and tourism associated with deer hunting. Illini is one of the largest employers with 182 employees. Part VI - Patient Education of Eligibility for Assistance All Illini Hospital self-pay inpatients are contacted by a Financial Counselor within 24 hours of admission ON WEEKDAYS. The patient is screened for government programs or eligibility for participation in available community programs. Outpatients are contacted once the patient's condition has been stabilized and are screened in the same manner as inpatients. If the financial counselor is not available to meet with a patient at an appropriate time OR IT IS THE WEEKEND, the patient is given contact information and asked to call if assistance is needed. Part VI - Needs Assessment Illini has contracted with the Illinois Critical Access Hospital Network to assist with the completion of the community health needs assessment. Illini will partner with the Pike County Community Health Partnership to assure the broad interests of the community served by the hospital are assessed and individuals with special knowledge or expertise in public health are included. Number of Hospital Faciltiy - 1 Part V, Line 7 - Explanation of Needs Not Addressed and Reasons Why Illini Community Hospital did not address Prevention and Tax of Substance abuse. There are other resources in the county who address these issues: ATOD (Alcohol, Tobacco & Other Drugs) task force and Mental Health Services of Western Illinois. Number of Hospital Faciltiy - 1 Part V, Line 3 - Account Input from Person Who Represent the Community The community health needs assessment was conducted with Illini Community Hospital through a consulting arrangement with the Illinois Critical Access Hospital Network. Avenues for gathering primary data were reviewed and it was determined to proceed with three focus groups. Focus Group #1, comprised of Health Care Professionals/Partners included a doctor, a representative of the local health department, a pharmacist, and a representative of an ambulance service. Focus Group #2, comprised of Community Leaders and Groups included representatives of local service organizations, a food bank, a chamber of commerce, and a nutrition program at University of Illinois Extension and a rural electric cooperative. Focus Group #3, comprised of Community Officials and Program Administrators, included school board members, school officials, mayors, and representatives of the mental health center and nursing homes. Part III, Line 9b - Provisions On Collection Practices For Qualified Patients Collection practices are not pursued if a completed financial assistance application has been returned and approved. Part III, Line 8 - Explanation Of Shortfall As Community Benefit The hospital uses a cost-to-charge ratio to calculate cost amounts. This ratio is computed using Illini Hospital's as-filed Medicare cost report. These costs and charges are adjusted to account for items not reimbursed through the cost report such as provider-based physician services. IRS Revenue Ruling 69-545, which established the community benefit standard for nonprofit hospital's states that if a hospital serves patients with government health benefits, including Medicare, then this is an indication that the hospital operates to promote the health of the community. Part III, Line 4 - Bad Debt Expense See Note (3) on page 13 of the attached financial statements for Blessing Corporate Services, Inc. and Affiliates, in which Illini Community Hospital is included. Part III, Line 3 - Methodology of Estimated Amount & Rationale for Including in Community Benefit Methodology of estimated amount & rationale for including in Community Benefit - A number of patients are truly unable to pay for their medical expenditures but do not complete the process required to apply for financial assistance. The Hospital uses financial and other information of such patients otherwise available to the Hospital to identify those patients that would qualify for charity care if they completed the paperwork. The bad debt expense associated with such patient's accounts are treated as community benefit. Part III, Line 2 - Methodology Used To Estimate Bad Debt Expense Methodology used to Determine Bad Debt Expense - Bad Debt Expense is calculated on the Net Patient Account balance after the balance has been reduced for any payments received or discounts/adjustments that are known. Patients qualifying for financial assistance are recognized as charity care accounts when sufficient information is received to determine their eligibility. Prior to this point, an Allowance for Doubtful Accounts is calculated on uninsured accounts. This allowance is reversed if the account is determined to qualify for financial assistance. Part I, Line 7g - Costs Associated With Physicans Clinics Illini Hospital does not include as subsidized health services any costs attributable to a physician clinic. Part I, Line 7, Column F - Explanation of Bad Debt Expense Bad Debt Expense of $1,828,759 is subtracted from total expenses of $21,814,606 reported on line 25, column a of Form 990, part IX. Part I, Line 7 - Explanation of Costing Methodology When possible, calculations of direct and indirect costs associated with the services provided are reported. If not available, a cost-to-charge ratio is used to calculate the cost amounts. This ratio is computed using Illini Hospital's as-filed Medicare cost report. These costs and charges are adjusted to account for items not reimbursed through the cost report such as provider-based physician services. false true false false false false false false false false ROBERT ROWLES 210287 248 2033 7690 220258 PATRICK M GERVELER 268164 81817 39091 44614 15129 448815 KATHLEEN E HULL 155922 49341 8340 1690 14614 229907 CHRISTOPHER WAGONER MD 179871 823 1851 19544 202089 B BRADFORD BILLINGS 435328 345933 40179 462674 14428 1298542 193647 Form 990, Part VI, Line 19 Form 990, Part VI, Line 19: Other Organization Documents Publicly Available THESE DOCUMENTS ARE LOCATED IN THE HOSPITAL'S ADMINISTRATIVE OFFICES AND ARE AVAILABLE UPON REQUEST FOR PUBLIC INSPECTION. Form 990, Part VI, Line 15b Form 990, Part VI, Line 15b: Compensation Review and Approval Process for Officers and Key Employees Brad Billings uses Sullivan and Cotter to identify appropriate compensation. He takes his recommendations to the BCS board compensation committee. He leaves and the committee decides. Form 990, Part VI, Line 15a Form 990, Part VI, Line 15a: Compensation Review & Approval Process - CEO, Top Management Brad Billings uses Sullivan and Cotter to identify appropriate compensation. He takes his recommendations to the BCS board compensation committee. He leaves and the committee decides. Form 990, Part VI, Line 12c Form 990, Part VI, Line 12c: Explanation of Monitoring and Enforcement of Conflicts A COPY OF THE CONFLICT OF INTEREST POLICY IS DISTRIBUTED ANNUALLY TO OFFICERS, DIRECTORS, TRUSTEES, AND KEY EMPLOYEES TO BE READ, SIGNED, AND RETURNED TO THE ORGANIZATION. THE SIGNED POLICIES ARE RETAINED IN THE CORPORATE ADMINISTRATIVE FILES. IN ADDITION, EACH OFFICER, DIRECTOR, OR TRUSTEE IS REQUIRED TO DECLARE NO CONFLICT OF INTEREST IN REGARDS TO AGENDA ITEMS BEING PRESENTED AT THE START OF EACH MONTHLY BOARD MEETING. Form 990, Part VI, Line 11b Form 990, Part VI, Line 11b: Form 990 Review Process FOLLOWING MANAGEMENT AND LEGAL REVIEW, THE FORM 990 WAS PROVIDED TO THE BOARD OF TRUSTEES FOR REVIEW AND COMMENT PRIOR TO FILING. Form 990, Part VI, Line 7b Form 990, Part VI, Line 7b: Describe Decisions of Governing Body Approval by Members or Shareholders BLESSING CORPORATE SERVICES SHALL POSSESS THE RIGHTS AND RESPONSIBILITIES TO (b)appoint the corporation's president and nominate all candidates to serveas directors of Quincy Health Care Management, Inc., (c) approveexpressly all amendments to the corporation's articles of incorporationand bylaws before they may become effective, (d) approve long-term debt,long-range plans and capital and operating budgets, (e) approve thepurchase and sale of real and personal property and contracts enteredinto by the corporation, not expressly made part of an approved budget,the reasonable value of which exceeds an amount set forth in the bylawsof the member, (f) approval of material investment decisions,including without limitation establishment and modification ofinvestment policies, engagement and removal of investment managers andadvisors, and changes in investment allocations not permitted by anexisting investment policy, (g) approval of the parameters for terms of employment of physicians, including physician compensation plans, and any material variances from such parameters for individual physicians, (h) approval of the selection of auditors and legal counsel, (i) approval of charity care and community benefits-related policies, (j) approval of the formation of subsidiary entities and/or joint ventures, (k) approval of the filing of a petition in bankruptcy, making and assignment for the benefit of creditors, or applying for protection under any insolvency laws, (l) approval of the participation in any merger, combination, consolidation, liquidation, dissolution or other corporate or business entity restructuring, and (m) the power to compel the corporation to enforce and/or perform any contractual obligation. Form 990, Part VI, Line 7a Form 990, Part VI, Line 7a: How Members or Shareholders Elect Governing Body BLESSING CORPORATE SERVICES SHALL POSSESS THE RIGHTS AND RESPONSIBILITIES TO (A) Appoint AND/OR REMOVE ALL THE TRUSTEES OF THE CORPORATION. Form 990, Part VI, Line 6 Form 990, Part VI, Line 6: Explanation of Classes of Members or Shareholder BLESSING CORPORATE SERVICES, INC. IS THE SOLE VOTING MEMBER OF BLESSINGCARE CORPORATION. Form 990, Part VI, Line 3 Form 990, Part VI, Line 3: Description of Delegated Duties to Management Company 1) BLESSING CORPORATE SERVICES PROVIDES GENERAL MANAGEMENT SERVICES.2) QUINCY MEDICAL GROUP PROVIDES MANAGEMENT OF THERAPY.3) NATIONAL HEALING PROVIDES MANAGEMENT OF THE WOUND CLINIC. THE BLESSING FOUNDATION INC PO BOX 7005 QUINCY IL 62301 371128705 FUNDRAISING TO BENEFIT THE RELATED HOSPITALS IL 501(C)(3) 11b BLESSING CORPORATE SERVICES INC false BLESSING AFFILIATES INC BROADWAY AT 11TH PO BOX 7005 QUINCY IL 623057005 371128708 COMMUNITY OUTREACH CLINIC, EDUCATIONAL PROGRAMS IL 501(C)(3) 9 BLESSING CORPORATE SERVICES INC false BLESSING HOSPITAL 1005 BROADWAY QUINCY IL 62301 370661183 NOT-FOR-PROFIT HOSPITAL IL 501(C)(3) 3 BLESSING CORPORATE SERVICES INC false BLESSING CORPORATE SERVICES INC BROADWAY AT 11TH PO BOX 7005 QUINCY IL 623057005 371128706 PROVIDES DIRECTION AND CONTROL TO ENTITIES IL 501(C)(3) 9 N/A false W CEN IL THERAPY & SPORTS MED CTR LLC 128 WEST WASHINGTON ST PITTSFIELD IL 62363 208207543 PHYS THERAP IL BCC RELATED -11752 false true ILLINI HEALTH SERVICES LLC PO BOX 40 QUINCY IL 623060040 470901851 PHARMACY IL BCS INC RELATED 29759 80269 false false DENMAN SERVICES INC BROADWAY AT 11TH PO BOX 40 QUINCY IL 62306 371132117 MED EQUIP IL BCS INC C CORP false false false false false true false false false false true true false true false true true false false false