2013-06-04T13:38:21-05:00 2011-03-31 MCGLADREY LLP 1 S WACKER DRIVE STE 800 CHICAGO IL 60606 990 2010-04-01 361703630 Roseland Community Hospital Association ROSE 7739953000 45 West 111th Street Chicago IL 60628 Dian Powell 7739953000 2013-06-04 1 Wayne Harder 3126343400 2010 2016-02-25 16:41:14Z Dian Powell 45 West 111th Street Chicago IL 60628 75213333 0 X www.roselandhospital.org X 1924 IL Short-term general acute care hospital, ER, and community clinic. 15 11 653 20 0 0 577065 482861 74202841 74152475 18950 3769 1380494 574228 76179350 75213333 0 0 0 0 25739546 26920808 0 0 0 44527517 53242217 70267063 80163025 5912287 -4949692 35425765 34463717 22944398 26932042 12481367 7531675 Provides general health care services to residents within the Pullman, Riverdale, and Roseland neighborhoods, including inpatient, outpatient, emergency room physician and other services. 0 0 63156311 74152475 Roseland Community Hospital has provided the community with quality medical and healthcare services for over 70 years. They provide the following clinics to accommodate the needs of the surrounding communities: urgent care - HIV, pediatric cardiology, pediatric asthma/allergy, stroke study, ear, nose and throat. 63156311 1 1 0 1 0 0 0 0 0 1 0 0 1 1 1 0 1 0 0 0 0 0 0 0 0 1 1 0 0 1 0 0 0 0 0 0 0 1 0 0 0 0 0 1 1 0 0 0 1 55 0 1 653 1 0 0 0 0 0 0 0 0 0 0 X 15 11 0 0 0 0 0 0 0 1 1 0 0 0 1 1 1 1 1 1 1 0 IL X Anwar Kinte 7739953000 45 West 111th Street Chicago IL 60628 Dian Powell 1.00 X X 0 0 0 Tunji Ladipo 1.00 X X 0 0 0 Earmon Irons Jr 38.00 X X 129197 0 0 Shirley Pickett 1.00 X X 0 0 0 Salim Al Nurridin 1.00 X 0 0 0 Larry Mitchell 1.00 X 0 0 0 Alan Jackson 1.00 X 0 0 0 Craig Washington 1.00 X 0 0 0 Almeda Dunn 1.00 X 0 0 0 Catherine Nichols 38.00 X X 122331 0 0 Genivee Chapman 1.00 X 0 0 0 Jai Dev Arya 1.00 X 0 0 0 Carl Vanco 1.00 X 0 0 0 Ronald Blackstone 1.00 X 0 0 0 Terrold Butler 1.00 X 0 0 0 Anthony Puorro 38.00 X 294173 0 27144 Ron Krol 38.00 X 58413 0 3261 Maribel Torres 54.00 X 177799 0 9726 Adele Vanjackson 43.00 X 130863 0 7418 Douglas Beck 38.00 X 130402 0 4698 Monica Cottrell 40.00 X 120627 0 0 Milagros Martinez 40.00 X 119482 0 1778 Joseph Ayoola 43.00 X 123148 0 951 1406435 0 54976 17 0 1 0 Emergency Medical Specialist 1012 Lake Shore Blvd Evanston IL 60202 ER Physician Services 1451500 Crawford Avenue Anesthesia 19627 La Grange Road Mokena IL 60448 Anesthesia 1209998 Tower Contracting 3062 W 167th Street Markham IL 60428 Construction 739402 Total Security Management 17W220 W 22nd Street Suite 350 Oak Brook IL 60181 Security 572450 John H Stroger Jr Hospital 1900 West Polk Suite 1337 Chicago IL 60612 Neonatal Services 453572 6 479910 2951 482861 Medicare/Medicaid 621110 42221097 42221097 Net Patient Revenue 621110 31931378 31931378 74152475 3769 3769 98628 98628 98628 98628 Miscellaneous Revenue 900099 324838 324838 Cafeteria 722210 107935 107935 Vending/Gift Shop 453220 42827 42827 475600 75213333 74152475 0 577997 739861 739861 22324420 18372639 3951781 202094 166320 35774 1911121 142638 1768483 1743312 1434718 308594 199752 159802 39950 206420 206420 30000 30000 6511228 3649240 2861988 3806467 3102197 704270 1020068 816054 204014 199875 199875 59351 24753 34598 390418 390418 1327682 1062146 265536 665221 532177 133044 Bad Debt 26803847 26803847 Physician Fees 3952638 3948739 3899 Medicaid Assessment Tax 3050323 3050323 5018927 2941041 2077886 80163025 63156311 17006714 0 789582 789582 6858845 6377241 6985597 2505756 495710 500439 840004 1133313 44870187 23741682 16904289 21128505 2551738 2028881 35425765 34463717 7653552 7817627 2521179 4666664 4666664 10624182 11926572 22944398 26932042 X 12409212 7459069 72155 72606 12481367 7531675 35425765 34463717 -4949692 0 X 0 1 1 X 0 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 0 0 0 0 0 0 1 30000 0 1 8590 38590 0 Explanation of Other Lobbying Activities: Part II-B, Line 1i: Metropolitan Chicago Healthcare Council lobbying dues - $8,590 923853 923853 26573412 17464551 9108861 73398 73398 15286982 5842909 9444073 2012542 434222 1578320 21128505 Due from Third-Party Payors 368335 Other Assets 160546 Self Insurance Fund 1500000 2028881 Self-Insurance Liabilities 5031299 Capital Lease Obligations 479435 Due to Third-Vendors 6415838 11926572 Description of Uncertain Tax Positions Under FIN 48: Part X: Roseland Community Hospital Association and the Foundation are non-for-profit corporations as described in Section 501(c)(3) of the Internal Revenue Code (IRC) and are exempt from Federal income taxes on related income pursuant to Section 501(a) of the Code. On April 1, 2009, the Hospital adopted the accounting standard on accounting for uncertainty in income taxes, which addresses the determination of whether tax benefits claimed or expected to be claimed on a tax return should be recorded in the financial statements. Under this guidance, the Hospital may recognize the tax benefit from an uncertain tax position only if it is more likely than not that the tax position will be sustained on examination by taxing authorities, based on the technical merits of the position. Examples of tax positions include the tax-exempt status of the Hospital, and various positions related to the potential sources of unrelated business taxable income. The tax benefits recognized in the financial statements from such a position are measured based on the largest benefit that has a greater than 50 percent likelihood of being realized upon ultimate settlement. The guidance on accounting for uncertainty in income taxes also addresses de-recognition, classification, interest and penalties on income taxes, and accounting in interim periods. Roseland Community Hospital Association and the Foundation file forms 990 in the U.S. federal jurisdiction and the State of Illinois. With few exceptions, Roseland Community Hospital Association is no longer subject to examination by the Internal Revenue Service for fiscal years before 2007. The Foundation filed first return for the fiscal year ended March 31, 2010. 1 1 1 X 1 X 600.000000000000 1 1 0 1 1 4291208 4291208 0.05350 20210646 12446428 7764218 0.09690 33148534 71790758 -38642224 0.00000 57650388 84237186 -26586798 0.15040 57650388 84237186 -26586798 0.15040 1 7843480 1777979 56674710 49397174 7277536 X 1 0 1 1 Roseland Hospital

45 W 111th Street Chicago IL 60628

X X X na 1 Part I, Line 6a: Roseland files an annual community benefit report with the Illinois Attorney General's office. Part I, Line 7: Cost to charge ratio was calculated using the IRS's Schedule H Worksheet 2. Part I, L7 Col(f): Bad Debt Expense is $26,803,847. Part II: Roseland Community Hospital participated in the following community organizations through Board membership or event sponsorship:-US Census Bureau Complete Count Committee-Metropolitan Family Services of Chicago-Nehemiah Restoration Coalition-Roseland Cease Fire -University of Illinois Extension Program-Dunne Elementary SchoolRoseland Community Hospital donated community meeting space for the following groups or organizations:-Chicago Police Department -Rush University Women's Walking Program -Healthcare Consortium of Illinois-Community of African American Mental Health Professionals-US Census Complete Count Committee-Chicago State University - The Group Monetary donations were made to the following social programs in 2011:-Metropolitan Family Services-Monarch Awards Foundation -Youth 1st Counseling & Elite Community CounselingRoseland Community Hospital hosted community fundraisers to benefit the following causes in 2011:-Haiti Relief - raised more than $10,000-Blistery Night - Coats, Hats, gloves donated to more than 80 families-Annual Gift Drive for Families in Roseland Christian Ministries Shelter Part III, Line 4: The cost methodology used to calculate the amount reported as Bad Debt Expense, at cost, is the cost-to-charge ratio derived from the IRS's Schedule H, worksheet 2.Audited Financial Statements footnote regarding bad debt expense:The collection of receivables from third-party payors and patients is the Hospital's primary source of cash for operations and is critical to its operating performance. The primary collection risks relate to uninsured patient accounts and patient accounts for which the primary insurance payor has paid, but patient responsibility amounts (deductibles and co-payments) remain outstanding. Patient receivables, where a third-party payor is responsible for paying the amount, are carried at a net amount determined by the original charge for the service provided, less an estimate made for contractual adjustments or discounts provided to third-party payors. 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. Management estimates this allowance based on the aging of its accounts receivable and its historical collection experience for each payor type. Recoveries of receivables previously written off are recorded as a reduction of bad debt expense when received.The past-due status of receivables is determined on a case-by-case basis depending on the payor responsible. Interest is generally not charged on past-due accounts. Receivables or payables related to estimated settlements on various payor contracts, primarily Medicare and Blue Cross, are reported as amounts due from or to third-party payors. Significant changes in payor mix, business office operations, economic conditions or trends in federal and state governmental health care coverage could affect the Hospital's collection of accounts receivable, cash flows and results of operations. Part VI, Line 2: The hospital performs a community health care needs assessment on an annual basis utilizing data from the Cook County Health Department, Illinois Department of Public Health, Partnership for a Better Roseland (community focus group), and the hospital patient database. In October 2010 the Board of Trustees of Roseland Community Hospital commissioned an outside consulting firm, The Sibery Group, to conduct a strategic fit analysis of 12 potential clinical service lines. The healthcare needs of the Roseland community were identified as a component of this analysis, and community need was one of six metrics used to evaluate the strategic fit of each service line. Part VI, Line 3: Patient education of eligibility for assistance: The hospital contracts with DECO, an outsourced agency, to assists uninsured patients that receive services at Roseland Community Hospital. A daily census listing of all uninsured inpatients and any outpatients with charges of $1,500 or more is provided to DECO. The DECO representatives work closely with the Physicians, Social Workers, Nursing, Dialysis Center, Shelters and others in helping patients qualify. They have assisted approximately 20 patients per month to qualify for financial coverage. Roseland Community Hospital also offers those patients that are not eligible for Federal assistance the opportunity to qualify for charity care. The annually updated federal income/poverty guidelines are utilized as the criteria for the qualification of charity care. Under special circumstances, such as severe illnesses or severe financial burden, charity may be allowed outside of the formula-driven charity allowances. Part VI, Line 4: For purposes of this plan, all statistical references to the "Community" refer to the population residing in the Community Areas (CA) defined by the city of Chicago as Roseland (49), Pullman (50), South Deering (51), West Pullman (53) and Riverdale (54).The five CA combined have a population of 125,091 and are overwhelmingly African American. However, Hispanics represent 30% of the population in the South Deering CA. South Deering is within 8 blocks of the Roseland community. The average median household income for the 5 CAs is $31,530 with Roseland being the highest at $38,237; and Riverdale lowest at $13,178 (2000 US Census). The average median household income for the City of Chicago is $38,625.Heart disease is the highest cause of death in each of the CAs. Roseland and West Pullman have significantly higher percentage of deaths from heart disease - 405.3% and 327.6% respectively. Cancer deaths are highest in Roseland, West Pullman and South Deering. According to findings from the Metropolitan Chicago Breast Cancer Task Force, African American women are twice as likely to die from breast cancer as their non-hispanic white counterparts even though White Women have a higher incidence of breast cancer.While in 1996, the mortality rates for African Americans and non-hispanic whites was equal; the disparity for African American women has steadily declined according to the MCBCTF study completed in Chicago 2007."Minority groups, particularly blacks in the United States, are assumed to be genetically predisposed to virtually all common chronic diseases. The correlation between the use of unsupported genetic inferences and the social standing of a group is glaring evidence of bias and demonstrates how race is used both to categorize and to rank order subpopulations."* Cooper et al., NEJM, 348:12, 1166-70, 2003 Part VI, Line 6: Roseland Community Hospital hosted and funded the following community health workshops and events in 2011 - all were available to any community member at no charge:- "Who's Loving You" Caregivers Workshop"- "Fatherhood and Men's Health"- "Living with Diabetes"- "Breast Cancer Prevention and Awareness"- "How to Get a Job and Keep It"- "Aging Heart"- "Blood Donation Drive"Roseland Community Hospital also provided free health screenings to more than 600 community residents in 2011 at churches, schools, and other community organizations. Reports Filed With States Part VI, Line 7 IL X X X 1 0 0 0 0 0 0 0 0 Anthony Puorro 129865 0 0 0 164308 0 23883 0 3261 0 321317 0 0 0 Maribel Torres 177799 0 0 0 0 0 0 0 9726 0 187525 0 0 0 Part I, Line 4a Anthony Puorro received a severance payment in the amount of $164,308. Tunji Ladipo Owner of Emergency Medical Specialist and Director of The Governing Body 1380000 ER Physician Services 0 Alan Jackson Owner of Preventative Cardiovascular and Director of the Governing Body 126000 Physician Services 0 Form 990, Part VI, Section B, line 11 Financial staff gathered the information necessary to prepare the return. The tax advisors prepared and reviewed the tax return prior to the CFO's review and filing of the tax return. The final Form 990 will be provided to the Board of Directors after the filing date. Form 990, Part VI, Section B, line 12c Signed document submitted annually and kept on file. Any potential conflicts are examined and actions are taken to resolve or disclose such conflicts. Form 990, Part VI, Section B, line 15 Roseland secured the services of an independent compensation consultant to perform a salary survey for key executives, including the CEO. The Compensation Committee recommends a salary that is subsequently reviewed by the Board of Directors before approval by Board. Form 990, Part VI, Section C, line 19 The financial statements are available through the office of the Illinois Attorney General. Conflicts of interest and Roseland Communities Hospital's governing documents are not made available to the public. Roseland Community Hospital Foundation 45 W 111th Street Chicago IL 606284294 270428068 Supporting Organization IL 501(c)(3) Line 11b, II N/A 0 0 0 0 0 0 0 0 0 0 0 0 0 1 0 0 0 0 0