2013-03-08T11:14:31-06:00 2012-09-30 371335003 ECK SCHAFER & PUNKE LLP 600 EAST ADAMS STREET SPRINGFIELD IL 627011624 990 2011-10-01 363637465 HOOPESTON COMMUNITY MEMORIAL HOSPITAL HOOP 2172835531 701 E ORANGE STREET HOOPESTON IL 60942 RUSS LEIGH 2172835531 2013-03-06 1 BRENT LEACH P00331592 2175251111 2011 2016-02-25 16:41:14Z RUSS LEIGH 701 E ORANGE STREET HOOPESTON IL 60942 25669561 0 X WWW.HOOPESTONHOSPITAL.ORG X 1962 IL PROVIDE ACUTE AND SKILLED NURSING CARE FOR RESIDENTS OF HOOPESTON AND THE SURROUNDING AREAS. 9 9 306 21 21344 -10480 104672 433358 24553662 25194607 84055 3203 63142 34316 24805531 25665484 0 0 0 0 11117034 11969713 0 0 0 12888426 14697938 24005460 26667651 800071 -1002167 20060737 31585792 13723855 26259893 6336882 5325899 PROVIDE ACUTE AND SKILLED NURSING CARE FOR RESIDENTS OF HOOPESTON AND THE SURROUNDING AREAS. 0 0 21004213 25194607 PROVIDE ACUTE INPATIENT AND OUTPATIENT HEALTHCARE SERVICES AND LONG TERM HEALTH CARE SERVICES 21004213 1 0 0 0 0 0 0 0 0 0 1 0 0 1 1 1 1 0 0 0 0 0 0 0 0 0 1 1 0 0 1 1 0 1 1 0 0 0 0 0 0 1 0 0 0 0 0 0 0 0 0 0 1 20 0 1 306 1 1 1 0 0 0 0 0 0 0 X 9 9 1 1 0 0 0 0 0 1 1 0 0 1 1 1 1 1 1 1 1 0 IL X KEN FOZDAR CONTROLLER 2172838487 701 E ORANGE HOOPESTON IL 60942 RUSS LEIGH 1.00 X X 0 0 0 RICHARD READ 1.00 X X 0 0 0 LYNN GALLOWAY 1.00 X X 0 0 0 KARLA COON 1.00 X 0 0 0 LONI GRESS 1.00 X 0 0 0 TODD HARRIS 1.00 X 0 0 0 GREG LANE 1.00 X 0 0 0 ED LAYDEN JR 1.00 X 0 0 0 HANK HORNBECK 1.00 X 0 0 0 ANGELA TOTHEROH 1.00 X 0 0 0 JAY COLBERT MD 40.00 X 258001 0 0 CHASE DANIEL 20.00 X 329508 0 0 DENNIS PRICE 40.00 X 151269 0 0 WILLIAM MCCARTHY 40.00 X 263053 0 0 DENNIS BIRKY 40.00 X 120100 0 0 1121931 0 0 5 0 1 0 HEALTH ALLIANCE MEDICAL PLANS 1677 RELIABLE PKWY CHICAGO IL 60686 HEALTH INSURANCE 1466632 CARLE HOSPITAL FOUNDATION 611 W PARK STREET URBANA IL 61801 PROFESSIONAL SERVICES 1213864 HOOPESTON ER MEDICAL SPECIALISTS 6948 WINDSOR AVE BERWYN IL 60402 ER & HOSPITALIST DOCTORS 1038000 QUORUM HEALTH RESOURCES 105 CONTINENTAL PLACE BRENTWOOD TN 37027 CONSULTING/MANAGEMENT 535264 SIGHTPATH MEDICAL 5775 W OLD SHAKOPEE ROAD SUITE 90 BLOOMINGTON MN 55437 CATARACT SERVICES 430060 30 17238 416120 433358 NET PATIENT SERVICES 621990 24562724 24562724 OTHER 900099 631883 631883 25194607 3203 3203 8444 0 8444 8444 8444 2160 17238 4077 -1917 -1917 CAFETERIA 722320 27789 21344 6445 27789 25665484 25194607 21344 16175 9806935 8325888 1481047 61966 49437 12529 1423685 1161290 262395 677127 570240 106887 412654 412654 287960 287960 104169 104169 2635780 2635780 186347 162741 23606 2519632 1226778 1292854 650159 501476 148683 163372 114180 49192 50503 24471 26032 621789 519882 101907 858914 675192 183722 504060 497986 6074 DRUGS AND OTHER SUPPLIE 2425236 2200223 225013 BAD DEBTS 1839611 1839611 PURCHASED SERVICES/PROF 1437752 499038 938714 26667651 21004213 5663438 0 817551 128541 2631148 4148360 245659 255780 153488 333676 30582801 8371309 11706082 22211492 539925 563832 90000 3966884 3854111 20060737 31585792 3383515 5679500 9851548 20437825 488792 142568 13723855 26259893 X 2771484 1762142 3565398 3563757 6336882 5325899 20060737 31585792 X -1002167 -8816 X 0 1 1 X 0 X 297500 297500 13503787 4539722 8964065 831030 199653 631377 8339001 3631934 4707067 7611483 7611483 22211492 BENEFICIAL INTEREST IN PERPETUAL TRUST 3563757 DEFERRED FINANCING COSTS 290354 3854111 ASSET RETIREMENT OBLIGATION 142568 142568 25665484 26667651 -1002167 -7175 -1641 -8816 -1010983 25662386 -7175 4077 -3098 25665484 0 25665484 26671728 4077 4077 26667651 0 26667651 DESCRIPTION OF UNCERTAIN TAX POSITIONS UNDER FIN 48: PART X: THE CENTER FOLLOWS ACCOUNTING PRINCIPLES GENERALLY ACCEPTED IN THE UNITED STATES OF AMERICA WHICH SETS A MINIMUM THRESHOLD FOR FINANCIAL STATEMENT RECOGNITION OF THE BENEFIT OF A TAX POSITION TAKEN OR EXPECTED TO BE TAKEN IN A TAX RETURN. TAX POSITIONS FOR THE OPEN TAX YEARS AS OF SEPTEMBER 30, 2012 WERE REVIEWED, AND IT WAS DETERMINED THAT NO PROVISION FOR UNCERTAIN TAX POSITIONS IS REQUIRED. THE CENTERS INFORMATION INCOME TAX RETURNS FOR YEARS SUBSEQUENT TO FISCAL YEAR 2009 ARE OPEN, BY STATUTE, FOR REVIEW BY AUTHORITIES. PART XI, LINE 8 - OTHER ADJUSTMENTS: CHANGE IN VALUATION OF PERMANENTLY RESTRICTED NET ASSET -1,641. PART XII, LINE 2D - OTHER ADJUSTMENTS: DIRECT FUNDRAISING EXPENSES NETTED WITH FUNDRAISING REVENUE 4,077. PART XIII, LINE 2D - OTHER ADJUSTMENTS: DIRECT FUNDRAISING EXPENSES NETTED WITH FUNDRAISING REVENUE 4,077. GOLF OUTING 19398 17238 2160 2226 1851 19398 17238 2160 2226 1851 4077 -1917 1 1 1 X 125.000000000000 1 X 1 1 1 0 0 846 958017 958017 0.03680 846 958017 958017 0.03680 250 9220 7044 2176 0.00010 250 9220 7044 2176 0.00010 1096 967237 7044 960193 0.03690 1 661022 650564 5264295 5457199 -192904 X 1 1 1 QUORUM HEALTH RESOURCES MANAGEMENT AND CONSULTING 0.00000 0.00000 0.00000 1 1 HOOPESTON COMMUNITY MEMORIAL HOSPITAL

701 E ORANGE HOOPESTON IL 60942

X X X X 2 HOOPESTON COM MEMORIAL NURSING HOM

701 E ORANGE HOOPESTON IL 60942

LONG TERM CARE/NURSING HOME 3 COUNTRY TERRACE INDEPENDENT LIVING APART

705 E ORANGE HOOPESTON IL 60942

SENIOR INDEPENDENT LIVING APTS 4 BRIDGEWAY CLINIC

843 E ORANGE HOOPESTON IL 60942

MEDICAL CLINIC 5 HOOPESTON BUSINESS OFFICE

847 E ORANGE HOOPESTON IL 60942

ACCTING, BO, HR, IT 6 ROSSVILLE MEDICAL CENTER

619 N CHICAGO HOOPESTON IL 60942

MEDICAL CLINIC 7 CISSNA PARK MEDICAL CLINIC

141 W GARFIELD HOOPESTON IL 60942

MEDICAL CLINIC 8 HOOPESTON AMBULANCE SERVICES

413 E MAIN HOOPESTON IL 60942

AMBULANCE SERVICES 9 CHARLOTTE ANN RUSSELL MEDICAL CENTER

801 E ORANGE HOOPESTON IL 60942

MEDICAL CLINIC 10 ROBERTS CLINIC

845 SOUTH 4TH STREET WATSEKA IL 60970

MEDICAL CLINIC HOOPESTON COMMUNITY MEMORIAL HOSPITAL 1 1 11 1 0 1 X X X X X X X 1 1 1 125.000000000000 1 300.000000000000 1 X X X X X X 1 1 X X 1 X X 1 X X X X X X 0 X X 0 0 PART I, LINE 7, COLUMN (F): THE BAD DEBT EXPENSE INCLUDED ON FORM 990, PART IX, LINE 25, COLUMN (A), BUT SUBTRACTED FOR PURPOSES OF CALCULATING THE PERCENTAGE IN THIS COLUMN IS $ 661022. PART II: THE HOSPITAL'S BUILDING PROGRAM WILL ENHANCE THE HEALTHCARE OF THE COMMUNITY BY PROVIDING EASIER ACCESS TO SERVICES AND A GREATER NUMBER OF SERVICES TO BE PROVIDED LOCALLY:1. NEW CLINIC IN ROSSVILLE, IL WAS OPENED IN NOVEMBER 2011 2. NEW EMERGENCY ROOM WAS OPENED IN SEPTEMBER 20123. NEW SURGERY SUITE WAS OPENED IN SEPTEMBER 20124. NEW CLINIC IN WATSEKA, IL WAS OPENED IN JUNE 20125. REPLACEMENT NURSING HOME FACILITY TO BE COMPLETE IN OCTOBER 20126. NEW CLINIC IN MILFORD, IL TO BE COMPLETE IN DECEMBER 2012 HOOPESTON COMMUNITY MEMORIAL HOSPITAL PART V, SECTION B, LINE 13G: CHARITY CARE APPLICATIONS ARE OFFERED TO PATIENTS AT THE TIME OF REGISTRATION. A COMMUNICATION SHEET INCLUDING A BRIEF DESCRIPTION AND CONTACT INFORMATION IS AVAILABLE AT REGISTRATION AND ALSO SENT WITH THE FIRST STATEMENT. FINANCIAL ASSISTANCE CONTACT INFORMATION IS PRINTED ON THE STATEMENTS. CHARITY CARE IS ON OUR WEBSITE WITH CONTACT INFORMATION. CHARITY CARE IS OFFERED TO PATIENTS WHO EXPRESS FINANCIAL HARDSHIP AND TO THOSE THAT WE ASSUME ARE GOING THROUGH A FINANCIAL HARDSHIP. HOOPESTON COMMUNITY MEMORIAL HOSPITAL PART V, SECTION B, LINE 18D: HOOPESTON COMMUNITY MEMORIAL HOSPITAL FOLLOWS EMTALA LAWS. HOOPESTON COMMUNITY MEMORIAL HOSPITAL PART V, SECTION B, LINE 19D: THE HOSPITAL USES A DISCOUNT EQUAL TO THE HIGHEST NEGOTIATED COMMERCIAL OUT-PATIENT INSURANCE RATE. PART VI, LINE 2: HOOPESTON REGIONAL HEALTH CENTER ASSESSES COMMUNITY NEEDS ON AN ANNUAL BASIS THROUGH A PUBLICLY ADVERTISED STATE OF THE HOSPITAL MEETING, WHERE COMMUNITY RESIDENTS ARE SURVEYED UPON ENTRY CONCERNING THE MOST SIGNIFICANT HEALTH CONCERNS THEY MAY HAVE IN OUR COMMUNITY TODAY. THROUGH THESE ASSESSMENTS THE HOSPITAL HAS INITIATED THE FOLLOWING PROGRAMS OVER THE PAST 3 YEARS:1. NURSE DOING HEAD CHECKS IN THE LOCAL SCHOOL SYSTEM. WE PROVIDE THIS SERVICE FOR FREE.2. VISION AND HEARING TESTING FOR ALL SCHOOLS IN THE REGION. WE PROVIDE THIS SERVICE FOR FREE.3. ATHLETIC TRAINER TO CARE FOR STUDENT ATHLETES, SPECIALIZING IN CONCUSSION CARE. WE PROVIDE THIS SERVICE FOR FREE.4. AFTER HOURS CARE PROGRAM. WE HAVE EXPANDED OUR CLINIC HOURS UNTIL 8PM DURING THE WEEK AND 9AM TO 5PM ON SATURDAY AND SUNDAY.5. HIRED A GENERAL SURGEON, 3 PHYSICIANS AND 4 PHYSICIAN ASSISTANTS FOR OUR COMMUNITY.6. FREE DIABETES EDUCATION FROM OUR REGISTERED DIETICIAN. CLASSROOM AND INDIVIDUAL COUNSELING ARE OFFERED.7. FUTURE PROGRAM DEVELOPMENTS WILL INCLUDE AGING AND OBESITY.8. CONTRACTED 2 ADDITIONAL CARDIOLOGISTS FOR OUR COMMUNITY.WE PERFORM A FORMAL 3RD PARTY ASSESSMENT ONCE EVERY THREE YEARS. CHNA WAS COMPLETED IN 2012. ALL SURVEYS AND ASSESSMENTS ARE DISCUSSED AT OUR ANNUAL STRATEGIC PLANNING SESSIONS WITH THE COMMUNITY BOARD OF DIRECTORS EACH SEPTEMBER. PART VI, LINE 3: PATIENTS ARE EDUCATED ON THE FINANCIAL ASSISTANCE POLICIES AND AVAILABILITY IN THE FOLLOWING WAYS;1. SIGNS ARE POSTED AT ALL AREAS OF PATIENT REGISTRATION FOR SERVICES.2. DISCUSS WITH PATIENTS EXPRESSING DIFFICULTY OR NEED. WE THEN HELP DETERMINE IF THEY ARE AVAILABLE FOR STATE MEDICAID OR IF THEY QUALIFY FOR CHARITY CARE UNDER OUR POLICY. IF SO, WE ASSIST THEM WITH THE APPLICATION PROCESS. PART VI, LINE 4: HOOPESTON REGIONAL HEALTH CENTER SERVES A ZIP CODE WITH 5,400 PEOPLE IN A RURAL ENVIRONMENT. A VAST MAJORITY OF THE PEOPLE LIVING IN THIS AREA ARE OF A WHITE RACE. THE ESTIMATED MEDIAN HOUSEHOLD INCOME IN 2011 WAS $37,276. IN 2011, 24.3% OF THE POPULATION HAD AN INCOME BELOW THE POVERTY LINE. PART VI, LINE 5: THE HOSPITAL FURTHERS HEALTH IN THE COMMUNITY BY:1. PROVIDING CHILDREN'S ACTIVITIES THROUGHOUT THE YEAR FREE OF CHARGE, IE; MOVIES, PONY RIDES, AND FIREWORKS,2. MAINTAINING AN OPEN MEDICAL STAFF TO ENCOURAGE PHYSICIAN MEMBERSHIP IN OUR ORGANIZATION AND PROVIDE CHOICE FOR LOCAL PATIENTS,3. 10 MEMBER COMMUNITY BOARD SERVES ON A VOLUNTEER BASIS. 0 0 0 0 0 0 0 0 0 JAY COLBERT MD 258001 0 0 0 0 0 0 0 0 0 258001 0 0 0 CHASE DANIEL 329508 0 0 0 0 0 0 0 0 0 329508 0 0 0 DENNIS PRICE 151269 0 0 0 0 0 0 0 0 0 151269 0 0 0 WILLIAM MCCARTHY 263053 0 0 0 0 0 0 0 0 0 263053 0 0 0 FARM CREDIT SERVICES OF ILLINOIS 371270645 2011-08-02 7450000 REFINANCING OF PRIOR BONDS 0 0 0 203158 7450000 500000 6930095 19905 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 DICK READ BOARD MEMBER 31752 MAINTENANCE AND VEHICLE PURCHASE 0 FORM 990, PART VI, SECTION A, LINE 2 TWO BOARD MEMBERS, KARLA COON AND ANGELA TOTHEROH, ARE STEP-MOTHER AND STEP-DAUGHTER. FORM 990, PART VI, SECTION A, LINE 3 THE CEO OF THE ORGANIZATION IS EMPLOYED BY QUORUM HEALTH RESOURCES. THE ORGANIZATION NEGOTIATED A MANAGEMENT CONTRACT WITH THAT FIRM. FORM 990, PART VI, SECTION B, LINE 11 FORM 990 IS PREPARED BY OUR INDEPENDENT ACCOUNTANTS AND PROVIDED TO THE GOVERNING BODY PRIOR TO FILING. FORM 990, PART VI, SECTION B, LINE 12C CONFLICT OF INTEREST DISCLOSURE FORMS ARE ANNUALLY COMPLETED BY EMPLOYEES AND BOARD MEMBERS. FORM 990, PART VI, SECTION B, LINE 15 THE CEO OF THE ORGANIZATION IS EMPLOYED BY QUORUM HEALTH RESOURCES. THE ORGANIZATION NEGOTIATED A MANAGEMENT CONTRACT WITH THAT FIRM. THERE IS CURRENTLY NO CFO. FORM 990, PART VI, SECTION C, LINE 19 ALL DOCUMENTS AVAILABLE UPON REQUEST. CHANGES IN NET ASSETS OR FUND BALANCES: FORM 990, PART XI, LINE 5: NET UNREALIZED LOSSES ON INVESTMENTS: -7,175. CHANGE IN VALUATION OF PERMANENTLY RESTRICTED NET ASSET -1,641. TOTAL TO FORM 990, PART XI, LINE 5: -8,816.