2014-05-15T15:17:47-05:00 2013-06-30 420714325 MCGLADREY LLP 201 N HARRISON STREET SUITE 300 DAVENPORT IA 528011999 990 2012-07-01 370673506 GRAHAM HOSPITAL ASSOCIATION GRAH 3096475240 210 WEST WALNUT CANTON IL 615202444 ROBERT G SENNEFF 3096475240 2014-05-13 1 JOHN J ROMANO P00227323 5638884000 2012 2015-11-30 17:44:51Z ROBERT G SENNEFF 210 WEST WALNUT CANTON IL 615202444 125419928 0 X WWW.GRAHAMHOSPITAL.ORG X 1905 IL TO PROVIDE COMPASSIONATE, QUALITY HEALTH SERVICES, IN A RESPONSIBLE AND CHARITABLE MANNER, TO THE PEOPLE AND COMMUNITIES WE SERVE. 14 13 879 102 102019 -107580 732354 683103 72812698 69768423 3707917 6657877 1026986 998110 78279955 78107513 4950 4950 0 0 36486753 36700431 0 0 0 38221551 33409038 74713254 70114419 3566701 7993094 129750620 136551074 46697379 45354081 83053241 91196993 X TO PROVIDE COMPASSIONATE, QUALITY HEALTH SERVICES, IN A RESPONSIBLE AND CHARITABLE MANNER, TO THE PEOPLE AND COMMUNITIES WE SERVE. 0 0 31815118 4950 36160620 GRAHAM HOSPITAL IS A PROVIDER OF HEALTHCARE SERVICES IN FULTON COUNTY AND SURROUNDING AREAS. DURING THIS REPORTING PERIOD, 2,213 ADULTS AND CHILDREN WERE ADMITTED AND 269 BABIES WERE BORN. THEY RECEIVED INPATIENT SERVICES IN THE ACUTE CARE FACILITY. 311 PATIENTS WERE ADMITTED FOR 11,110 DAYS OF SERVICE IN THE EXTENDED CARE FACILITY. 66,015 OUTPATIENT SERVICES WERE PROVIDED. 11844313 14257237 GRAHAM MEDICAL GROUP WHICH PROVIDES PHYSICIAN AND PROFESSIONAL HEALTH CARE SERVICES TO THE PATIENTS IN FULTON COUNTY, ILLINOIS. THIS INCLUDES CHARITY CARE TO QUALIFIED INDIVIDUALS AND 86,753 OFFICE VISITS AND 9,957 NURSING HOME AND HOSPITAL VISITS. 8873190 10680836 SURGICAL SERVICES - THE HOSPITAL PERFORMED 722 INPATIENT SURGERIES AND 2,639 OUTPATIENT SURGERIES IN FISCAL YEAR 2013. 7743119 9320548 THE HOSPITAL OPERATES A 24-HOUR EMERGENCY DEPARTMENT WHICH HAD 15,683 PATIENTS REGISTERED TO THE ED IN FISCAL YEAR 2013. 7743119 9320548 60275740 1 1 0 1 0 0 0 0 0 1 1 1 0 0 1 1 1 0 0 0 0 0 0 0 0 0 1 1 0 0 1 1 0 0 0 0 0 0 0 0 0 1 0 0 0 0 0 0 0 0 0 1 119 0 1 879 1 1 1 0 0 0 0 0 0 0 0 0 X 14 13 0 0 0 0 0 0 0 1 1 0 0 0 1 1 1 1 1 1 1 0 IL X ROBERT G SENNEFF 3096475240 210 WEST WALNUT CANTON IL 61520 JEFF JOCHUMS 2.00 X X 0 0 0 MIKE WALTERS 2.00 X X 0 0 0 WARREN WOLF 2.00 X 0 0 0 GORDON JAMES 2.00 X 0 0 0 PAULA GRIGSBY 2.00 X 0 0 0 KATHY TABER 2.00 X X 0 0 0 ALAN DILTS 2.00 X 0 0 0 MIKE RENNER 2.00 X 0 0 0 SUZANNE HOLTHAUS MD 2.00 X 0 0 0 BRAD ANDERSON 2.00 X 0 0 0 MARK PIRTLE 2.00 X X 0 0 0 ROBERT BOBELL OD 2.00 X 0 0 0 JULIE MELLERT 2.00 X 0 0 0 PATRICK RENICK MD 2.00 X 0 0 0 KENNETH KROCK MD 2.00 X 0 0 0 CAROLYN JACOBUS 40.00 X 122900 0 31710 JAMES T STRATTON 40.00 X 216959 0 55560 SARA KIMBLE 40.00 X 218376 0 31246 ROBERT G SENNEFF 40.00 X 457239 0 71142 JEDEDIAH CANTRELL 40.00 X 153213 0 37799 TERESA MCCONKEY 40.00 X 101699 0 25184 JOHN QUINONES DO 40.00 X 352831 0 36753 JEFFREY HEMP MD 44.00 X 345326 0 56387 DWAYNE BERNARD MD 50.00 X 460603 0 55160 JULIO ANTONIO RAMOS MD 45.00 X 363133 0 25230 ANGELA HOLTHAUS 65.00 X 234950 0 33088 GERRI DELOST 65.00 X 229688 0 0 3256917 0 459259 26 0 1 0 COLEMAN MEDICAL ASSOCIATES 175 SOUTH MAIN STREET CANTON IL 61520 PHYSICIAN GROUP 6817096 PJ HOERR INC 107 W COMMERCE PEORIA IL 61604 BUILDING CONTRACTOR 1856347 PEORIA SURGICAL GROUP LTD 1001 MAIN ST SUITE 300 PEORIA IL 61606 SURGERY PHYSICIAN GROUP 666000 MEDICAL INFORMATION TECHNOLOGY INC PO BOX 74569 CHICAGO IL 60696 INFORMATION TECHNOLOGY SERVICES 524970 ENDURACARE ACUTE CARE SERVICES LLC 3765 A GOVERNMENT BLVD MOBILE AL 36693 PHYSICAL, OCCUPATIONAL, & SPEECH THERAPY 454633 19 222897 460206 683103 PATIENT SERVICES 621110 70936233 70936233 OTHER PROGRAM SERVICE 900099 2315913 2315913 SCHOOL OF NURSING 611600 794469 794469 LABORATORY SERVICES 621500 237228 170260 66968 LESS: PROVISION FOR UNCOLLECTIBLE 900099 -4515420 -4515420 69768423 1874926 1874926 270273 25000 245273 245273 245273 52070366 47262222 25193 4808144 -25193 4782951 4782951 CAFETERIA 722210 443714 443714 EMPLOYEE PHARMACY 446110 274072 274072 DURABLE EQUIPMENT 446199 35051 35051 752837 78107513 70419241 102019 6903150 X 4950 4950 1912610 711689 1200921 27244133 24264829 2979304 590792 520957 69835 4964201 4368257 595944 1988695 1696357 292338 18122 18122 108034 108034 22776 22776 8371000 8343685 27315 234039 1371 232668 9409132 8612936 796196 1035214 861887 173327 53952 41997 11955 1303647 1112011 191636 5030566 4291073 739493 1073857 894093 179764 PURCHASED SERVICES 4447124 3283307 1163817 MEDICAID ASSESSMENT 978695 978695 OTHER 570398 118383 452015 MISCELLANEOUS EXPENSES 464779 116102 348677 287703 53161 234542 70114419 60275740 9838679 0 587652 2605896 1624118 3371311 14289158 9508853 1424957 1429932 890900 687852 109292489 56039075 54355589 53253414 46410421 55131608 9769364 9772631 398461 789577 129750620 136551074 6140455 7358603 29085000 28345000 11471924 9650478 46697379 45354081 X 75135419 83008228 161473 202954 7756349 7985811 83053241 91196993 129750620 136551074 X 7993094 -2505956 2656614 X X 0 1 X 1 1 1 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 0 0 0 0 0 0 0 0 1 22776 22776 0 EXPLANATION OF LOBBYING ACTIVITIES: PART II-B, LINE 1: LOBBYING EXPENDITURES RELATED TO MEMBERSHIP DUES INCLUDED: 34% OF MEMBERSHIP DUES PAID TO THE ILLINOIS HOSPITAL ASSOCIATION, OR $20,785; 38.83% OF MEMBERSHIP DUES PAID TO THE ILLINOIS HEALTH CARE ASSOCIATION, OR $1,018; 50% OF MEMBERSHIP DUES PAID TO THE ILLINOIS HOME CARE & HOSPICE COUNCIL, OR $973. 54282312 32416479 4277745 4950 27923841 63047745 55402455 5002957 1395193 4950 7513343 54282312 54498646 2368195 8389005 4450 9848941 55402455 56079016 2547372 4063090 3885 8186947 54498646 43214801 23485459 -3422251 4005 7194988 56079016 0.87440 0.12560 0.00000 1 0 2213040 2213040 61347539 23804588 37542951 42762106 30931637 11830469 2969804 1302850 1666954 53253414 PERPETUAL TRUSTS 8145652 C DEFERRED FINANCING COSTS 197480 C LONG TERM NOTES RECEIVABLE 1429499 C 9772631 ESTIMATED SELF-INSURANCE COSTS 3811394 ASSET RETIREMENT OBLIGATION 266162 FAIR MARKET VALUE OF SWAP OPTION 3737156 DUE TO THIRD PARTY PAYORS 1835766 9650478 X 78283171 -2505956 2656614 150658 78132513 -25000 -25000 78107513 70139419 25000 25000 70114419 0 70114419 DESCRIPTION OF INTENDED USE OF ENDOWMENT FUNDS: PART V, LINE 4: PROVIDE SCHOLARSHIPS BASED ON STUDENT NEEDS FROM THE INCOME OF THE DONOR-RESTRICTED ENDOWMENT FUNDS. THE PERMANENT ENDOWMENT IS USED FOR THE PURCHASE OF PROPERTY AND EQUIPMENT. DESCRIPTION OF UNCERTAIN TAX POSITIONS UNDER FIN 48: PART X, LINE 2: THE HOSPITAL IS EXEMPT FROM INCOME TAXES UNDER SECTION 501(C)(3) OF THE INTERNAL REVENUE CODE. THE HOSPITAL FILES A FORM 990 (RETURN OF ORGANIZATION EXEMPT FROM INCOME TAX) ANNUALLY. WHEN THE RETURNS ARE FILED, IT IS HIGHLY CERTAIN THAT SOME POSITIONS TAKEN WOULD BE SUSTAINED UPON EXAMINATION BY TAXING AUTHORITIES, WHILE OTHERS ARE SUBJECT TO UNCERTAINTY ABOUT THE MERITS OF THE TAX POSITION TAKEN OR THE AMOUNT OF THE POSITION THAT WOULD ULTIMATELY BE SUSTAINED. EXAMPLES OF TAX POSITIONS COMMON TO NONPROFIT ORGANIZATIONS INCLUDE SUCH MATTERS AS THE FOLLOWING: THE TAX EXEMPT STATUS OF EACH ENTITY AND VARIOUS POSITIONS RELATIVE TO POTENTIAL SOURCES OF UNRELATED BUSINESS INCOME (UBI). UBI IS REPORTED ON FORM 990-T, AS APPROPRIATE. THE BENEFIT OF A TAX POSITION IS RECOGNIZED IN THE FINANCIAL STATEMENTS IN THE PERIOD DURING WHICH, BASED ON ALL AVAILABLE EVIDENCE, MANAGEMENT BELIEVES THAT IT IS MORE LIKELY THAN NOT THAT THE POSITION WILL BE SUSTAINED UPON EXAMINATION, INCLUDING THE RESOLUTION OF APPEALS OR LITIGATION PROCESS, IF ANY. TAX POSITIONS ARE OFFSET OR AGGREGATED WITH OTHER POSITIONS. TAX POSITIONS THAT MEET THE "MORE LIKELY THAN NOT" RECOGNITION THRESHOLD ARE MEASURED AS THE LARGEST AMOUNT OF TAX BENEFIT THAT IS MORE THAN 50% LIKELY TO BE REALIZED ON SETTLEMENT WITH THE APPLICABLE TAXING AUTHORITY. THE PORTION OF THE BENEFITS ASSOCIATED WITH TAX POSITIONS TAKEN THAT EXCEEDS THE AMOUNT MEASURED AS DESCRIBED ABOVE IS REFLECTED AS A LIABILITY FOR UNCERTAIN TAX BENEFITS IN THE ACCOMPANYING BALANCE SHEETS ALONG WITH ANY ASSOCIATED INTEREST AND PENALTIES THAT WOULD BE PAYABLE TO THE TAXING AUTHORITIES UPON EXAMINATION. AS OF JUNE 30, 2013 AND 2012, THERE WERE NO UNRECOGNIZED TAX BENEFITS IDENTIFIED OR RECORDED AS A LIABILITY. FORMS 990 FILED BY THE HOSPITAL ARE SUBJECT TO EXAMINATION BY THE INTERNAL REVENUE SERVICE (IRS) UP TO THREE YEARS FROM THE EXTENDED DUE DATE OF EACH RETURN. FORMS 990 FILED BY THE HOSPITAL ARE GENERALLY NO LONGER SUBJECT TO EXAMINATION FOR THE YEARS ENDED JUNE 30, 2009 AND PRIOR. PART XI, LINE 2D - OTHER ADJUSTMENTS: CHANGE IN FAIR VALUE OF INTEREST RATE SWAP AGREEMENT 2,382,855. CHANGE IN INTEREST IN NET ASSETS OF THE FOUNDATION 44,297. CHANGE IN BENEFICIAL INTEREST IN PERPETUAL TRUSTS 229,462. PART XI, LINE 4B - OTHER ADJUSTMENTS: RENTAL EXP INCLUDED WITH REVENUE ON RETURN -25,000. PART XII, LINE 2D - OTHER ADJUSTMENTS: RENTAL EXPENSES NETTED WITH REVENUE 25,000. 1 1 1 X 180.000000000000 0 1 1 0 1 0 2678118 2678118 0.03820 13078382 9194157 3884225 0.05540 15756500 9194157 6562343 0.09360 191883 8034 183849 0.00260 21406 21406 0.00030 213289 8034 205255 0.00290 15969789 9202191 6767598 0.09650 5000 5000 0.00010 5000 5000 0.00010 1 4515420 0 18361000 18171764 189236 X 1 0 1 1 GRAHAM HOSPITAL ASSOCIATION

210 WEST WALNUT STREET CANTON IL 61520

WWW.GRAHAMHOSPITAL.ORG X X GRAHAM HOSPITAL ASSOCIATION 1 1 X X X X X X X X 12 1 0 1 X X X X X X X 1 0 1 1 180.000000000000 0 1 X X X X X X X 1 1 X X X X X 1 0 X X X X 1 X 0 0 9 GRAHAM HOSPITAL PHARMACY

210 WEST WALNUT STREET CANTON IL 61520

PHARMACY FOR PATIENTS & RETAIL FOR EMPLOYEES GRAHAM MEDICAL GROUP

180 SOUTH MAIN STREET CANTON IL 61520

MULTI-SPECIALTY OUTPATIENT PHYSICIAN CLINIC GRAHAM HOSPITAL EXTENDED CARE UNIT

210 WEST WALNUT STREET CANTON IL 61520

SKILLED NURSING & LONG TERM CARE UNITS GRAHAM HOSPITAL HOME HEALTHHOSPICE

225 WEST WALNUT CANTON IL 61520

HOME HEALTH AND HOSPICE PROVIDER GRAHAM HOME MEDICAL EQUIPMENT STORE

101 SOUTH MAIN STREET CANTON IL 61520

HOME MEDICAL EQUIPMENT RETAIL STORE GRAHAM MEDICAL GROUP - FARMINGTON

601 EAST FORT STREET FARMINGTON IL 61531

MULTI-SPECIALTY OUTPATIENT PHYSICIAN CLINIC GRAHAM HOSPITAL SCHOOL OF NURSING

210 WEST WALNUT STREET CANTON IL 61520

SCHOOL OF NURSING GRAHAM MEDICAL GROUP - LEWISTOWN

2001 NORTH MAIN STREET LEWISTOWN IL 61542

MULTI-SPECIALTY OUTPATIENT PHYSICIAN CLINIC GRAHAM MEDICAL GROUP - CUBA

114 SOUTH 4TH STREET CUBA IL 61427

OUTPATIENT PHYSICIAN CLINIC PART I, LINE 3C: ILLINOIS PATIENTS WITH LOW INCOME AND WITHOUT SIGNIFICANT ASSETS WHO ARE UNINSURED RECEIVING MEDICALLY NECESSARY SERVICES IN EXCESS OF $300 MAY QUALIFY FOR CHARITY CARE, AND THOSE WITH HIGHER INCOMES MAY BE CHARGED A MAXIMUM OF 25% OF THEIR ANNUAL FAMILY INCOME OVER A PERIOD OF ONE YEAR. ASSETS EXEMPT FROM CONSIDERATION ARE: A PRIMARY RESIDENCE AND CERTAIN PROTECTED PERSONAL PROPERTY, PENSION AND RETIREMENT PLANS, AND OTHER ASSETS WITH A VALUE OF UP TO 300% OF THE FEDERAL POVERTY LEVEL. PATIENTS WITH SIGNIFICANT ASSETS MAY BE EXCLUDED FROM THE UNINSURED DISCOUNT REGARDLESS OF THEIR INCOME LEVEL. PART I, LINE 6A: NOT APPLICABLE PART I, LINE 7: GRAHAM HOSPITAL ASSOCIATION UTILIZED WORKSHEET 2 TO CALCULATE ITS COST-TO-CHARGE RATIO. TOTAL EXPENSES REPORTED IN THE FINANCIAL REPORT FOR THE YEAR ENDED 06/30/13 LESS NONPATIENT CARE ACTIVITIES, THE MEDICAID ASSESSMENT PROVIDER TAX OF $978,695 AND THE COMMUNITY BENEFIT EXPENSES FOR VARIOUS PROGRAMS OF $205,255 ARE DIVIDED BY GROSS PATIENT CHARGES OF $166,140,953 TO REACH A COST TO CHARGE RATIO OF 40.1%.DURING EACH FISCAL YEAR VARIOUS COMMUNITY HEALTH IMPROVEMENT SERVICES ARE HELD AT A FACILITY OWNED BY GRAHAM HOSPITAL ASSOCIATION OR GRAHAM HOSPITAL ASSOCIATION EMPLOYEES ASSIST WITH SERVICES HELD AT VARIOUS LOCATIONS WITHIN THE CATCHMENT AREA. AN ACTUAL COUNT OF COMMUNITY MEMBERS SERVED IS RECORDED IF AVAILABLE OR ESTIMATED IF NOT AVAILABLE. COST FOR EACH ACTIVITY IS RECORDED AT THE ACTUAL COST OF SUPPLIES, AND STAFF TIME IS CALCULATED USING ACTUAL TIME SPENT MULTIPLIED BY AVERAGE WAGES FOR THE EMPLOYEES INVOLVED. ANY OFFSETTING REVENUE IS SUBTRACTED FROM THE COST OF THE ACTIVITY TO REACH A NET COST OF EACH EVENT. WHEN COMMUNITY GROUPS USE A ROOM IN ONE OF THE GRAHAM HOSPITAL ASSOCIATION FACILITIES, THERE IS NO CHARGE FOR THE COMMUNITY GROUP AND THE COST OF THE ROOM USE IS ESTIMATED AT A NOMINAL FLAT RATE FEE AND RECORDED HERE AS AN IN-KIND CONTRIBUTION. THESE ACTIVITES REPRESNT THE COMMUNITY BENEFIT EXPENSES NOTED ABOVE. PART I, LINE 7G: NOT APPLICABLE PART I, L7 COL(F): NO BAD DEBT EXPENSE WAS INCLUDED IN THE DENOMINATOR BECAUSE BAD DEBT WAS REPORTED IN LINE 2E OF PART VIII, STATEMENT OF REVENUE. THE ORGANIZATION'S TOTAL COMMUNITY BENEFIT EXPENSE AS A PERCENTAGE OF TOTAL EXPENSES IS 22.78%, AND THE PERCENTAGE INCREASES TO 48.69% IF MEDICARE ALLOWABLE COSTS ARE INCLUDED IN TOTAL COMMUNTY BENEFIT EXPENSE. PART II: NOT APPLICABLE PART III, LINE 2: PATIENT RECEIVABLES ARE WRITTEN OFF AS BAD DEBT EXPENSE BASED ON INDIVIDUAL CREDIT EVALUATION AND SPECIFIC CIRCUMSTANCES OF THE ACCOUNT. RECOVERIES OF RECEIVABLES PREVIOUSLY WRITTEN OFF ARE RECORDED AS A REDUCTION OF BAD DEBT EXPENSE WHEN RECEIVED. PART III, LINE 3: NOT APPLICABLE PART III, LINE 4: PATIENT RECEIVABLES DUE DIRECTLY FROM THE PATIENTS ARE CARRIED AT THE ORIGINAL CHARGE FOR THE SERVICE PROVIDED LESS AMOUNTS COVERED BY THIRD-PARTY PAYORS AND LESS AN ESTIMATED ALLOWANCE FOR DOUBTFUL RECEIVABLES BASED ON A REVIEW OF ALL OUTSTANDING AMOUNTS ON A MONTHLY BASIS. THE HOSPITAL DOES NOT CHARGE INTEREST ON RECEIVABLES. PATIENT ACCOUNTS RECEIVABLE ARE DUE IN FULL WHEN BILLED. ACCOUNTS ARE CONSIDERED PAST DUE WHEN AN AMOUNT IS PAST DUE ACCORDING TO THE PAYORS AGREED-UPON TERMS. PATIENT RECEIVABLES ARE WRITTEN OFF AS BAD DEBT EXPENSE BASED ON INDIVIDUAL CREDIT EVALUATION AND SPECIFIC CIRCUMSTANCES OF THE ACCOUNT. RECOVERIES OF RECEIVABLES PREVIOUSLY WRITTEN OFF ARE RECORDED AS A REDUCTION OF BAD DEBT EXPENSE WHEN RECEIVED. PART III, LINE 8: MEDICARE ALLOWABLE COSTS ARE TAKEN FROM WORKSHEET D-1 AS REPORTED IN THE FILED MEDICARE COST REPORT FOR THE YEAR ENDED 6/30/2013. THE ORGANIZATION DOES NOT HAVE A MEDICARE SHORTFALL. PART III, LINE 9B: THE COLLECTION POLICY DESCRIBES THE STEPS TAKEN TO COLLECT SELF PAY BALANCES OUTSTANDING INCLUDING NOTIFICATIONS TO THE PATIENT THROUGH STATEMENTS, FOLLOW-UP PHONE CALLS, VERIFICATION OF INSURANCE ELIGIBILITY AND ULTIMATELY AT WHAT POINT THE UNPAID BALANCE IS WRITTEN OFF AS UNCOLLECTIBLE. IN PRACTICE, WHEN A PATIENT IS IDENTIFIED AS QUALIFYING FOR FINANCIAL ASSISTANCE, A SEARCH OF ACCOUNTS WRITTEN OFF AS UNCOLLECTIBLE IS DONE AND THOSE ACCOUNTS ARE REPROCESSED. PART V, SECTION B, LINE 5A: WWW.GRAHAMHOSPITAL.ORG PART V, SECTION B, LINE 11: ILLINOIS PATIENTS WITH LOW INCOME AND WITHOUT SIGNIFICANT ASSETS WHO ARE UNINSURED AND RECEIVING MEDICALLY NECESSARY SERVICES IN EXCESS OF $300 MAY QUALIFY FOR CHARITY CARE AND THOSE WITH HIGER INCOMES MAY BE CHARGED A MAXIMUM OF 25% OF THEIR ANNUAL FAMILY INCOME OVER A PERIOD OF ONE YEAR. ASSETS EXEMPT FROM CONSIDERATION ARE A PRIMARY RESIDENCE AND CERTAIN PROTECTED PERSONAL PROPERTY, PENSION AND RETIREMENT PLANS, AND OTHER ASSETS WITH A VALUE OF UP TO 300% OF THE FEDERAL POVERTY LEVEL. PATIENTS WITH SIGNIFICANT ASSETS MAY BE EXCLUDED FROM THE UNINSURED DISCOUNT REGARDLESS OF THEIR INCOME LEVEL. GRAHAM HOSPITAL ASSOCIATION PART V, SECTION B, LINE 3: GRAHAM HOSPITAL ASSOCIATION CREATED THE FOLLOWING FOCUS GROUPS TO GATHER INPUT FOR THE COMMUNITY HEALTH NEEDS ASSESSMENT:FOCUS GROUP #1 INCLUDED THE FULTON COUNTY SHERIFF, THE CANTON FIRE CHIEF, A SCHOOL SUPERINTENDENT, A BANK EXECUTIVE, THE DIRECTOR OF A FOOD PANTRY, A LOCAL BUSINESS LEADER, THE DIRECTOR OF THE YMCA, A LIBRARIAN AND A COMMUNITY VOLUNTEER. THEY MET ON MAY 15, 2012.FOCUS GROUP #2 INCLUDED THE MAYOR OF CANTON, A VICE-PRESIDENT AT SPOON RIVER COLLEGE, A SCHOOL SUPERINTENDENT, A RETIRED PHYSICIAN, THE EXECUTIVE DIRECTOR OF THE YWCA AND THE PRESIDENT OF GRAHAM HOSPITAL SERVICE LEAGUE. THIS GROUP ALSO MET ON MAY 15, 2012.FOCUS GROUP #3 INCLUDED THE ADMINISTRATOR OF THE FULTON COUNTY HEALTH DEPARTMENT, THE DIRECTOR OF THE NURSING SCHOOL, THE ADMINISTRATOR OF A NURSING HOME, A PEDIATRIC PHYSICIAN, A PATHOLOGIST, A CHIROPRACTOR, A GENERAL SURGEON, NURSING HOME REPRESENTATIVES AND PHARMACISTS. THIS GROUP ALSO MET ON MAY 15, 2012. GRAHAM HOSPITAL ASSOCIATION PART V, SECTION B, LINE 20D: GRAHAM HOSPITAL FOLLOWS THE ILLINOIS HOSPITAL UNINSURED PATIENT DISCOUNT ACT THAT REQUIRES ILLINOIS HOSPITALS TO PROVIDE DISCOUNTS TO UNINSURED PATIENTS MEETING CERTAIN ELIGIBILITY CRITERIA. THE DISCOUNTS MUST RESULT IN BILLS OF NO MORE THAN 135% OF COST AND THE MAXIMUM COLLECTIBLE AMOUNT IS 25% OF THE ANNUAL FAMILY INCOME FOR THOSE WHO MEET THE ELIGIBILITY CRITERIA AND DO NOT HAVE SIGNIFICANT ASSETS. COST IS DETERMINED BY USING THE COST TO CHARGE RATIO FROM THE MOST RECENTLY FILED MEDICARE COST REPORT. PART VI, LINE 2: IN ADDITION TO THE COMMUNITY HEALTH NEEDS ASSESSMENT IMPLEMENTED DURING 2012, A PHYSICIAN NEEDS ASSESSMENT IS DONE TO IDENTIFY NEEDS FOR SPECIFIC SPECIALTY SERVICES BASED ON THE SIZE OF THE CATCHMENT AREA, DATA IS ANALYZED TO IDENTIFY SERVICES THAT ARE PROVIDED TO COUNTY RESIDENTS BY OTHER FACILITIES THAT WOULD BE MORE ACCESSIBLE TO PATIENTS IF PROVIDED AT GRAHAM HOSPITAL. INPUT IS GAINED FROM PHYSICIANS AND OTHER HEALTHCARE WORKERS PROVIDING SERVICE IN THE AREA ALONG WITH INPUT PROVIDED BY THE BOARD OF DIRECTORS WHO REPRESENT THE COMMUNITY AND PROVIDE A COMMUNICATION LINK BETWEEN GRAHAM HOSPITAL AND THE COMMUNITIES WE SERVE. PART VI, LINE 3: THE CHARITY CARE/FINANCIAL ASSISTANCE PROGRAM IS MADE AVAILABLE TO PATIENTS UPON REGISTRATION. FINANCIAL ASSISTANCE APPLICATIONS ARE AVAILABLE TO PATIENTS UPON REGISTRATION OR TO ANYONE REQUESTING THE APPLICATION AT ANYTIME FOR CLAIMS EXCEEDING $300. THE APPLICATIONS ARE AVAILABLE ON GRAHAM HEALTH SYSTEM'S WEBSITE AT HTTP://WWW.GRAHAMHOSPITAL.ORG/FINANCIALASSISTANCE. APPOINTMENTS MAY BE MADE WITH A FINANCIAL COUNSELOR IF ASSISTANCE IS NEEDED. MEDICAID SERVICES APPLICATION ASSISTANCE IS AVAILABLE. PART VI, LINE 4: THE GRAHAM HOSPITAL ASSOCIATION PRIMARY CATCHMENT AREA IS LOCATED PRIMARILY IN FULTON COUNTY AND INCLUDES ALL OR PORTIONS OF THE TOWNS OF CANTON, LEWISTOWN, CUBA, FARMINGTON, HAVANA, ST. DAVID, ASTORIA, DUNFERMLINE AND BRYANT. THE RACE AND ETHNICITY MAKEUP ARE TYPICAL OF RURAL ILLINOIS BASED ON US CENSUS BUREAU DATA AND INCLUDES 92.5% WHITE, 3.7% BLACK, 2.6% HISPANIC ORIGIN, AND 1.2% OTHER. ACCORDING TO THE US CENSUS BUREAU MEDIAN HOUSEHOLD INCOME 2012 WAS $41,899. FULTON COUNTY'S OCT 2013 UNEMPLOYMENT RATE WAS 9.4%. PART VI, LINE 5: DURING EACH FISCAL YEAR VARIOUS COMMUNITY HEALTH IMPROVEMENT SERVICES ARE HELD AT A FACILITY OWNED BY GRAHAM HOSPITAL ASSOCIATION OR GRAHAM HOSPITAL ASSOCIATION EMPLOYEES ASSIST WITH SERVIES HELD AT VARIOUS LOCATIONS WITHIN THE CATCHMENT AREA. EXAMPLES OF THESE ACTIVITIES INCLUDE SPONSORSHIP OF AN ANNUAL WOMEN'S HEALTH FAIR HELD IN THE HOSPITAL LOBBY THAT IS OPEN TO THE PUBLIC WHERE EDUCATIONAL BOOTHS, FREE HEALTH SCREENINGS, HEALTHY LUNCHES, PRESENTATIONS BY LOCAL PHYSICIANS ARE AVAILABLE TO ATTENDEES DURING THE DAY; ANNUAL SPONSORSHIP OF A COMMUNITY TALK AND DINNER THAT IS FREE TO THE PUBLIC COVERING HEART HEALTH; FREE BLOOD PRESSURE CLINICS OFFERED THROUGHOUT THE COUNTY ON A REGULAR BASIS. GRAHAM HOSPITAL PROVIDES THE SPACE FOR OPERATION OF AN OUTPATIENT CLINIC THAT PROVIDES FREE HEALTHCARE SERVICES TO FULTON COUNTY RESIDENTS. CLINIC SERVICES ARE PROVIDED BY COMMUNITY VOLUNTEERS. PART VI, LINE 6: NOT APPLICABLE X X X X X 1 1 0 0 0 0 0 1 0 CAROLYN JACOBUS 113970 0 7919 0 1011 0 15105 0 16605 0 154610 0 0 0 JAMES T STRATTON 195585 0 20266 0 1108 0 26790 0 28770 0 272519 0 0 0 SARA KIMBLE 161717 0 14249 0 42410 0 15595 0 15651 0 249622 0 29090 0 ROBERT G SENNEFF 408572 0 47776 0 891 0 62418 0 8724 0 528381 0 0 0 JEDEDIAH CANTRELL 137699 0 14866 0 648 0 19460 0 18339 0 191012 0 0 0 JOHN QUINONES DO 305157 0 43750 0 3924 0 7500 0 29253 0 389584 0 0 0 JEFFREY HEMP MD 289860 0 53015 0 2451 0 7500 0 48887 0 401713 0 0 0 DWAYNE BERNARD MD 388239 0 71398 0 966 0 7500 0 47660 0 515763 0 0 0 JULIO ANTONIO RAMOS MD 307748 0 54143 0 1242 0 7500 0 17730 0 388363 0 0 0 ANGELA HOLTHAUS 215948 0 50 0 18952 0 7160 0 25928 0 268038 0 0 0 GERRI DELOST 229638 0 50 0 0 0 0 0 0 0 229688 0 0 0 PART I, LINES 4A-B THE FOLLOWING INDIVIDUAL RECEVIED A SEVERANCE PAYMENT FROM THE ORGANIZATION IN 2012: SARA KIMBLE - $47,272. THIS AMOUNT IS INCLUDED IN REPORTABLE COMPENSATION ON THE FORM 990, PART VII AND SCHEDULE J, PART II. THE FOLLOWING INDIVIDUALS PARTICIPATED IN A 457(F) PLAN IN 2012 SPONSORED BY GRAHAM HOSPITAL ASSOCIATION: ROBERT G. SENNEFF - $54,918, JAMES T. STRATTON - $20,100, SARA KIMBLE - $11,025, JEDEDIAH CANTRELL - $14,743, AND CAROLYN JACOBUS - $11,346. THE DOLLAR AMOUNT REPRESENTS THE CURRENT YEAR CONTRIBUTION MADE BY GRAHAM HOSPITAL ASSOCIATION ON BEHALF OF THE INDIVIDUALS TO THE PLAN IN 2012. THIS INFORMATION IS INCLUDED IN DEFERRED COMPENSATION ON THE FORM 990, PART VII AND SCHEDULE J, PART II. PART I, LINE 7 INCENTIVE AWARDS ARE BASED ON THE ATTAINMENT OF HOSPITAL AND INDIVIDUAL TARGETS AND ARE CALCULATED AS A PERCENTAGE OF WAGES. PAYMENT OF INCENTIVE AWARDS IS DEPENDENT ON THE ACHIEVEMENT OF ORGANIZATIONAL KEY INDICATORS. SUPPLEMENTAL INFORMATION PART III PART II, COLUMN F: THE FOLLOWING INDIVIDUAL ALSO PARTICIPATED IN A SUPPLEMENTAL EXECUTIVE RETIREMENT PLAN IN 2009, 2010, 2011 AND 2012 SPONSORED BY GRAHAM HOSPITAL ASSOCIATION: SARA KIMBLE - $29,090. THE DOLLAR AMOUNT REPRESENTS PRIOR YEAR CONTRIBUTIONS MADE BY GRAHAM HOSPITAL ASSOCIATION ON BEHALF OF THE INDIVIDUALS TO THE PLAN IN 2009, 2010 AND 2011. THIS INFORMATION WAS INCLUDED IN DEFERRED COMPENSATION ON THE PRIOR YEARS' FORM 990, PART VII AND SCHEDULE J, PART II. THIS INDIVIDUAL REACHED A SPECIFIED LEVEL OF VESTING IN 2012, SO THE DOLLAR AMOUNT IS NOW INCLUDED IN REPORTABLE COMPENSATION ON THE CURRENT YEAR FORM 990, PART VII AND SCHEDULE J, PART II. THE DOLLAR AMOUNT IS ALSO LISTED AS COMPENSATION REPORTED IN A PRIOR FORM 990 ON THE CURRENT YEAR FORM 990, SCHEDULE J, PART II. A CITY OF CANTON IL 376000876 138206AA5 2009-06-30 31085000 PHYSICIAN CLINIC & FARMINGTON CLINIC CONSTRUCTION, OB RENOVATION 0 0 0 A 31085000 476622 30608378 2011 1 0 1 1 A 0 0 0 0 0 0 0 A 0 0 0 1 1 1 MORGAN STANLEY & HARRIS NA 25.000000000000 0 0 0 0 0 A 0 SCHEDULE K PART IV, ARBITRAGE, LINE 2C DATE REBATE COMPUTATION PERFORMED ISSUER NAME: CITY OF CANTON, IL DATE THE REBATE COMPUTATION WAS PERFORMED: 05/08/2014 MIDAMERICA NATIONAL BANK SEE BELOW FOR DESCRIPTION OF RELATIONSHIP 485660 INTEREST, DIVIDENDS, AND REALIZED GAINS EARNED ON THE ORGANIZATION'S INVESTMENTS WITH MIDAMERICA NATIONAL BANK. 0 MIDAMERICA NATIONAL BANK SEE BELOW FOR DESCRIPTION OF RELATIONSHIP 71159 BANK FEES PAID BY THE ORGANIZATION TO MIDAMERICA NATIONAL BANK 0 FORM 990, SCHEDULE L, PART IV: RELATIONSHIP BETWEEN INTEREST PERSON AND THE ORGANIZATION WARREN WOLF, A TRUSTEE OF GRAHAM HOSPITAL ASSOCIATION, IS A DIRECTOR ON THE BOARD OF MIDAMERICA NATIONAL BANK. FORM 990, PART I, LINE 6: THE GRAHAM HOPSITAL SERVICE LEAGUE VOLUNTEERS OPERATE AND MANAGE THEIR OWN GIFT SHOP WHICH IS LOCATED WITHIN GRAHAM HOSPITAL. A PORTION OF THE PROCEEDS FROM THE GIFT SHOP AND ALL OTHER FUND-RAISING EVENTS IS GIVEN TO THE HOSPITAL ANNUALLY TO PROVIDE FOR MUCH NEEDED EQUIPMENT. VOLUNTEERS ALSO PERFORM VARIOUS OTHER SERVICES WITHIN THE HOSPITAL; PATIENT ESCORT, SURGERY HOSTESS, PHARMACY, AND THE RED CROSS INFORMATION DESK. FORM 990, PART VI, SECTION B, LINE 11 THE PREPARED FORM 990 IS REVIEWED BY THE CFO, DIRECTOR OF ACCOUNTING AND SENIOR ACCOUNTANT BEFORE FILING WITH THE IRS. FORM 990, PART VI, SECTION B, LINE 12C GRAHAM HOSPITAL REQUIRES THAT ALL TRUSTEES AND ADMINISTRATIVE OFFICERS KEEP THE BOARD OF TRUSTEES INFORMED OF POTENTIAL CONFLICTS OF INTEREST, AND THAT EACH PERSON MAKE AN ANNUAL DECLARATION OF SUCH INTEREST. A CONFLICT OF INTEREST MIGHT EXIST WHEN ORGANIZATIONS IN WHICH TRUSTEES OR OFFICERS HAVE A MATERIAL FINANCIAL INTEREST ARE EITHER DOING BUSINESS WITH, COMPETING WITH, OR HAVE A FINANCIAL INTEREST IN GRAHAM HOSPITAL. FORM 990, PART VI, SECTION B, LINE 15 THE COMPENSATION OF THE ADMINISTRATIVE OFFICERS ARE REVIEWED ANNUALLY BY THE EXECUTIVE COMPENSATION COMMITTEE OF THE BOARD OF TRUSTEES. THE ORGANIZATION UTILIZES AN OUTSIDE FIRM, SULLIVAN, COTTER AND ASSOCIATES, INC. TO PROVIDE OUTSIDE EXECUTIVE COMPENSATION INFORMATION. THE LAST REVIEW WAS COMPLETED IN JUNE, 2013. FORM 990, PART VI, SECTION C, LINE 19 THE GOVERNING DOCUMENTS, CONFLICT OF INTEREST POLICY AND FINANCIAL STATEMENTS ARE NOT MADE AVAILABLE TO THE PUBLIC. OTHER FEES FORM 990, PART IX, LINE 11G OTHER FEES: PROGRAM SERVICE EXPENSES 8,343,685. MANAGEMENT AND GENERAL EXPENSES 27,315. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 8,371,000. CHANGES IN NET ASSETS OR FUND BALANCES: FORM 990, PART XI, LINE 9: CHANGE IN FAIR VALUE OF SWAP OPTION 2,382,855. CHANGE IN NET ASSETS OF GRAHAM HOSPITAL FOUNDATION 44,297. CHANGE IN BENEFICIAL INTEREST IN PERPETUAL TRUSTS 229,462. FORM 990, PART XII, LINE 2C: THE OVERSIGHT AND SELECTION PROCESS HAS NOT CHANGED FROM THE PRIOR TAX YEAR.