2013-02-04T11:18:40-06:00 2012-06-30 BKD LLP 211 N BROADWAY SUITE 600 ST LOUIS MO 631022733 990 2011-07-01 370624255 Community Memorial Hospital Association % BRIAN ENGELKE COMM 6186354242 400 Caldwell Street Staunton IL 62088 BRIAN ENGELKE 6186354242 2013-02-04 true Donna J Larson 3142315544 2011 2016-02-25 16:41:14Z SUE E CAMPBELL 400 CALDWELL STREET STAUNTON IL 62088 14765620 false X WWW.STAUNTONHOSPITAL.ORG X 1946 IL COMMUNITY MEMORIAL HOSPITAL PROVIDES COMPASSIONATE PATIENT-CENTERED HEALTH CARE SERVICES, WHILE MAINTAINING CLINICAL EXCELLENCE AND FINANCIAL VIABILITY. 9 8 155 8 0 0 98377 88502 14050104 14492371 213846 74482 95794 106323 14458121 14761678 1000 2830 0 0 6287741 6760828 0 0 0 7610558 7840878 13899299 14604536 558822 157142 13409508 13518878 2223544 2088193 11185964 11430685 COMMUNITY MEMORIAL HOSPITAL PROVIDES COMPASSIONATE PATIENT-CENTERED HEALTH CARE SERVICES, WHILE MAINTAINING CLINICAL EXCELLENCE AND FINANCIAL VIABILITY. false false 12328542 2830 14509203 THE ORGANIZATION OPERATES A FULL SERVICE CRITICAL ACCESS HOSPITAL IN STAUNTON, ILLINOIS WITH A TOTAL OF 25 BEDS. TOTAL PATIENT DAYS FOR THE FISCAL YEAR ENDED JUNE 30, 2012 WAS 1,231. THE HOSPITAL ALSO PROVIDED SERVICES TO 27,177 OUTPATIENTS AND 5,072 EMERGENCY DEPARTMENT PATIENTS. 12328542 true true false false false false false false false false true false false false false false true false false false false false false false false false true true false false true true false false false false false false false false false false false false false false false false false false false false true 29 0 true 155 true false false false false false false false false false false X 9 8 false false false false true true false true true false false true true true true true true true true false IL X BRIAN ENGELKE 6186354242 400 CALDWELL STAUNTON IL 62088 DON KASUBKE 4.0 X X 0 0 0 SYLVIA LUX 2.0 X 0 0 0 BERNICE HENKE 2.0 X X 0 0 0 HULDA BLACK 2.0 X X 0 0 0 EDDY SARACCO 2.0 X X 0 0 0 MIKE COX 2.0 X 0 0 0 JEROME LESICKO 2.0 X 0 0 0 LARRY ZIGLAR 2.0 X 0 0 0 NICOLAS PINEDA MD 40.0 X 136448 0 0 SUE CAMPBELL 40.0 X 141596 0 11409 DONALD BRUNNWORTH 40.0 X 117812 0 1143 BRIAN ENGELKE 40.0 X 0 0 0 JOSHUA POOS MD 40.0 X 196004 0 15386 DARRELL PAPE 40.0 X 115248 0 10483 707108 0 38421 5 false true false HAROLD O'SHEA BUILDERS 3401 CONSTITUTION SPRINGFIELD IL 62711 BUILDING 195347 SOUTH CENTRAL ANESTHESIA 7461 LESLIE DR EDWARDSVILLE IL 62025 ANESTHESIA SERVICE 276690 CPSI PO BOX 850309 MOBILE AL 36685 COMPUTER SERVICE 322960 ALTON PHYSICAL THERAPY 1719 CLAWSON ALTON IL 62002 PHYSICAL THERAPY 524896 ILLINOIS EMERGENCY PO BOX 793 TRAVERSE CITY MI 49685 EMERGENCY SERVICES 1280853 21 88502 88502 NET PATIENT SERVICE REVENUE 621110 14492371 14492371 14492371 55522 55522 0 0 40965 40965 40965 40965 22902 3942 18960 18960 18960 0 0 0 CAFETERIA 722210 32802 32802 OTHER INCOME 900099 32556 16832 15724 65358 14761678 14509203 163973 830 830 2000 2000 0 0 472191 124512 347679 0 0 5072147 4335164 736983 0 99330 84897 14433 0 697124 595832 101292 0 420036 359005 61031 0 209898 209898 0 21951 21951 0 41938 41938 0 0 0 0 2984334 2550710 433624 0 23684 20243 3441 0 1323161 1295649 27512 0 102637 87724 14913 0 0 223312 190865 32447 0 15568 13306 2262 0 0 0 40116 40116 0 0 586890 501615 85275 0 266113 227447 38666 0 PROVISION FOR BAD DEBTS 1219692 1219692 EQUIPMENT RENTAL 524115 447961 76154 HOSPITAL PROVIDER ASSESSMENT 75123 75123 DUES & SUBSCRIPTIONS 61203 52310 8893 121143 103541 17602 14604536 12328542 2275994 0 1862245 919406 920396 925257 0 0 1897743 2673531 0 0 0 0 0 0 254277 271538 193441 216828 11433051 7780993 3534356 3652058 4308235 4333866 0 0 438815 526394 0 0 0 0 13409508 13518878 1095349 1063194 0 0 0 138601 715256 647875 0 0 0 0 412939 238523 0 0 0 0 2223544 2088193 X 10747149 10904291 438815 526394 0 0 11185964 11430685 13409508 13518878 X 157142 87579 X false true true X false X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 520386 520386 3432958 2417646 1015312 6459837 5157138 1302699 1019870 206209 813661 3652058 14761678 14604536 157142 157142 13539986 13539986 1221692 1221692 14761678 13382844 13382844 1221692 1221692 14604536 FIN 48 DISCLOSURE 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. RECONCILIATION OF REVENUE PER FINANCIAL STATEMENTS TO REVENUE PER RETURN PART XII, LINE 4B SCHOLARSHIPS $ 2,000 BAD DEBT EXPENSE $1,219,692 ------------------------------------------------ TOTAL $1,221,692 THE ABOVE ACCOUNTS WERE CLASSIFIED WITH REVENUE ON THE AUDITED FINANCIAL STATEMENTS AND CLASSIFIED AS EXPENSES ON FORM 990. RECONCILIATION OF EXPENSE PER FINANCIAL STATEMENTS TO EXPENSE PER RETURN PART XII, LINE 4B SCHOLARSHIPS $ 2,000 BAD DEBT EXPENSE $1,219,692 ------------------------------------------------ TOTAL $1,221,692 THE ABOVE ACCOUNTS WERE CLASSIFIED WITH REVENUE ON THE AUDITED FINANCIAL STATEMENTS AND CLASSIFIED AS EXPENSES ON FORM 990. true true true X true X true true false false 55209 0 55209 0.00410 1878698 1549811 328887 0.02460 1933907 1549811 384096 0.02870 26332 245 26087 0.00190 12389 0 12389 0.00090 38721 245 38476 0.00280 1972628 1550056 422572 0.03150 true 1219692 0 6718393 6653201 65192 X true true 1 1 COMMUNITY MEMORIAL HOSPITAL

400 CALDWELL STAUNTON IL 62088

X X X X COMMUNITY MEMORIAL HOSPITAL 1 false true true 100 true 200. true X X X true true X X true false X true X false false 2 COMMUNITY MEMORIAL MEDICAL CLINIC

325 CLADWELL STAUNTON IL 62088

PHYSICIAN OFFICE COMMUNITY MEMORIAL MEDICAL CLINIC

311 EAST CENTRAL BENLD IL 62009

PHYSICIAN OFFICE PART I, LINE 7, COLUMN F: THE ORGANIZATION HAD BAD DEBT EXPENSE IN THE AMOUNT OF $1,219,692 REPORTED ON PART IX, LINE 25. HOWEVER, IT HAS BEEN SUBTRACTED FOR PURPOSES OF CALCULATING THE PERCENTAGE IN THIS COLUMN. PART I, LINE 7: 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. PART III, LINE 3: THE HOSPITAL BELIEVES THAT THE COMMUNITY BENEFIT OBTAINED FROM ITS CHARITY CARE IS UNDERSTATED DUE TO PATIENTS THAT COULD QUALIFY FOR CHARITY CARE BUT DO NOT APPLY OR PROVIDE INCOMPLETE INFORMATION. SOME CARE PROVIDED TO PATIENTS IS NOT CLASSIFIED AS CHARITY CARE DUE TO PATIENTS MISSING DOCUMENTATION THAT PROVES THEY QUALIFY FOR CHARITY CARE. THE HOSPITAL'S BAD DEBT DOES INCLUDE AMOUNTS THAT COULD BE CLASSIFIED AS CHARITY CARE IF THE PATIENTS WOULD APPLY OR PROVIDE THE APPROPRIATE INFORMATION TO COMPLETE THE CHARITY CARE APPLICATION. PART III, LINE 4: IN LINE WITH ITS MISSION, THE HOSPITAL PROVIDES A SAFETY NET FOR THE COMMUNITIES SERVED TO ACCESS MUCH NEEDED CARE BY OFFERING SOME SERVICES TO PATIENTS WITHOUT REGARD TO THEIR ABILITY TO PAY FOR THOSE SERVICES. FOR SOME OF THEIR PATIENT SERVICES, THE HOSPITAL RECEIVES NO PAYMENT OR PAYMENT THAT IS LESS THAN THE FULL COST OF PROVIDING THE SERVICES. THE HOSPITAL VOLUNTARILY PROVIDES FREE CARE TO PATIENTS WHO ARE UNABLE TO PAY FOR ALL OR PART OF THEIR HEALTH CARE EXPENSES AS DETERMINED BY THE HOSPITAL'S CRITERIA FOR FINANCIAL ASSISTANCE. IN SOME CASES, THE HOSPITAL DOES NOT RECEIVE THE AMOUNT BILLED FOR PATIENT SERVICES EVEN THOUGH IT DID NOT RECEIVE INFORMATION NECESSARY TO DETERMINE IF THE PATIENTS MET THE CRITERIA FOR FINANCIAL ASSISTANCE. BAD DEBTS EXPENSE IS THE ESTIMATED AMOUNT OF PATIENT REVENUE THAT THE HOSPITAL WILL NOT COLLECT. THE BAD DEBT EXPENSE AS REPORTED ON THE FINANCIAL STATEMENT HAS BEEN REPORTED ON LINE 2, THEREFORE, THE COSTING METHODOLOGY FOR THIS LINE IS BASED ON THE PATIENT CHARGES THAT WERE WRITTEN OFF ON THE BOOKS. NO BAD DEBT AMOUNTS WERE INCLUDED IN COMMUNITY BENEFIT. FINANCIAL STATEMENT FOOTNOTE: 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. PART III, LINE 8: THE COSTING METHODOLOGY USED TO DETERMINE MEDICARE ALLOWABLE COSTS WAS ALLOWABLE COST AS REPORTED IN OUR FISCAL YEAR 2012 MEDICARE COST REPORT. PART III, LINE 9B: THERE IS NO COLLECTION PRACTICE ON PATIENTS WHO QUALIFY FOR CHARITY. ANY PATIENT WHO SUBMITS AN APPLICATION FOR CHARITY AND MEETS THE GUIDELINES SET IN OUR CHARITY POLICY HAS THEIR ACCOUNT WRITTEN OFF WITH NO FURTHER COLLECTION EFFORT. NEEDS ASSESSMENT: THE HOSPITAL'S BOARD IS MADE UP OF INDIVIDUALS WHO LIVE WITHIN THE HOSPITAL'S SERVICE AREA. THESE INDIVIDUALS ALONG WITH SUPPORT FROM THE HOSPITAL'S MANAGEMENT AND MEDICAL STAFF ARE CONTINUALLY REVIEWING HOW THE HOSPITAL CAN BE AN ASSET WITHIN OUR SERVICE AREA. THE HOSPITAL HAS ALSO CONDUCTED A COMMUNITY PERCEPTION SURVEY TO HELP IDENTIFY AREAS TO IMPROVE PATIENT CARE OR THE NEED FOR ADDITIONAL SERVICES. PATIENT EDUCATION OF ELIGIBILITY FOR ASSISTANCE: INFORMATION REGARDING THE FINANCIAL ASSISTANCE PROGRAMS THAT THE HOSPITAL OFFERS IS LISTED ON THE HOSPITAL WEBSITE, AND IT IS PRINTED ON THE BOTTOM OF THE STATEMENTS THAT ARE MAILED TO THE PATIENTS. THE INFORMATION IS ALSO POSTED NEAR THE CASHIER'S WINDOW AND THE BUSINESS OFFICE STAFF ARE TRAINED TO PROVIDE THE INFORMATION TO PATIENTS THAT CALL INTO THE OFFICE AND DO NOT HAVE KNOWLEDGE OF THE PROGRAMS. COMMUNITY INFORMATION: THE COMMUNITY THAT THE ORGANIZATION SERVES CONSISTS OF ABOUT A TWELVE MILE RADIUS SURROUNDING STAUNTON AND THE COMMUNITIES WITHIN THAT RADIUS ARE: WORDEN, HAMEL, ALHAMBRA, LIVINGSTON, NEW DOUGLAS, MT. OLIVE, BENLD, GILLESPIE, BUNKER HILL, AND PRAIRIETOWN. THIS IS A RURAL AREA WITH A DEPRESSED ECONOMIC CLIMATE. MANY OF THE INDIVIDUALS ARE ELDERLY, POOR, AND INDIGENT WHICH RESULTS IN HIGHER NUMBERS OF MEDICARE AND MEDICAID RECIPIENTS. PROMOTION OF COMMUNITY HEALTH: THE HOSPITAL RESTOCKS THE AMBULANCES OF ANY SUPPLIES USED DURING THE TRANSPORT OF PATIENTS AT NO COST TO THE AMBULANCE SERVICE. THE HOSPITAL ALSO COMMITS SIGNIFICANT TIME AND RESOURCES TO ACTIVITIES AND SERVICES THAT MEET UNMET COMMUNITY NEEDS. MANY OF THESE ACTIVITIES ARE SPONSORED WITH THE KNOWLEDGE THAT THEY WILL NOT BE SELF-SUPPORTING OR FINANCIALLY VIABLE. SUCH PROGRAMS INCLUDE HEALTH SCREENINGS AND ASSESSMENTS, PARENTAL EDUCATION AND CARE, CPR TRAINING, BABY SITTER TRAINING, FIRST AID TRAINING, SUPPORT FOR VITAL COMMUNITY SERVICES, TRAUMA CARE, COMMUNITY EDUCATIONAL SERVICES, AND VARIOUS SUPPORT GROUPS. THE HOSPITAL PARTICIPATES IN EVENTS AND HEALTH FAIRS IN EACH OF THE COMMUNITIES WITHIN THE SERVICE AREA, AND IT DONATES STAFF LABOR, SUPPLIES, AND OTHER GOODS. AFFILIATED HEALTH CARE SYSTEM NOT APPLICABLE STATE FILING OF COMMUNITY BENEFIT REPORT NOT APPLICABLE PART V, SECTION B, LINE 11H: THE BASIS FOR CALCULATING AMOUNTS CHARGED TO PATIENTS INCLUDES FAMILY SIZE. PART V, SECTION B, LINE 19D: THE HOSPITAL HAS BOTH A CHARITY AND AN UNINSURED DISCOUNT POLICY. THE HOSPITAL'S STANDARD CHARGES ARE DISCOUNTED BASED UPON THE PATIENT'S ELIGIBILITY UNDER THESE PROGRAMS. X X X false false false false false false false false false SUE CAMPBELL 141596 0 0 0 0 0 4236 0 7173 0 153005 0 0 0 JOSHUA POOS MD 196004 0 0 0 0 0 618 0 14768 0 211390 0 0 0 ILLINOIS FINANCE AUTHORITY 861091967 2010-06-25 780000 5500 SQ. FT. MEDICAL OFFICE BUILDI false false false 132125 0 780000 0 0 0 0 0 0 780000 0 0 2010 false false true true false false false false 0.00000 0.00000 0.00000 true false false false 0 false 0 false true GOVERNING BODY AND MANAGEMENT PART VI, SECTION A, LINES 6 & 7A COMMUNITY MEMORIAL HOSPITAL HAS ONE CLASS OF MEMBERS WHICH SHALL BE ENTITLED TO ONE REPRESENTATION AND ONE VOTE IN ALL MEETINGS OF COMMUNITY MEMORIAL HOSPITAL. THE ANNUAL MEETING OF THE MEMBERS IS HELD FOR THE PURPOSE OF ELECTING TRUSTEES AND TRANSACTING SUCH OTHER BUSINESS AS MAY COME BEFORE THE MEETING. EACH MEMBER IS ENTITLED TO ONE VOTE. FORM 990 REVIEW PROCESS PART VI, SECTION B, LINE 11 THE CFO REVIEWS THE FORM 990, WHICH IS THEN REVIEWED BY THE CEO, FOLLOWED BY THE BOARD. COMPLIANCE WITH CONFLICT OF INTEREST POLICY PART VI, SECTION B, LINE 12C THE CONFLICT OF INTEREST POLICY AND A DISCLOSURE STATEMENT ARE PRESENTED TO OFFICERS, DIRECTORS OR TRUSTEES AND KEY EMPLOYEES ANNUALLY. THE DISCLOSURE STATEMENT MUST BE RETURNED AND IS REVIEWED BY FINANCIAL AUDITORS AND HOSPITAL ADMINISTRATION. PROCESS FOR DETERMINING COMPENSATION PART VI, SECTION B, LINE 15A & 15B THE BOARD OF TRUSTEES CONDUCTS AN ANNUAL EVALUATION OF OFFICERS AND KEY EMPLOYEES. THEY USE COMPARABILITY DATA RECEIVED FROM AN INDEPENDENT CONSULTANT AND SET SALARY BASED UPON COMPARABILITY DATA AND THEIR JOB PERFORMANCE. DECISIONS ARE DOCUMENTED IN THE BOARD MINUTES. THE CFO COMPENSATION IS DETERMINED BY THE CEO AND APPROVED BY THE BOARD OF DIRECTORS. ALL OTHER EMPLOYEES RECEIVE AN ANNUAL PRECENTAGE INCREASE BASED UPON THE HOSPITAL'S PREFORMANCE. PROCESS FOR MAKING GOVERNING DOCUMENTS AVAILABLE TO THE PUBLIC PART VI, SECTION C, LINE 19 COMMUNITY MEMORIAL HOSPITAL MAKES ITS GOVERNING DOCUMENTS, CONFLICT OF INTEREST POLICY AND FINANCIAL STATEMENTS AVAILABLE TO THE PUBLIC UPON REQUEST. OTHER CHANGES IN FUND BALANCES PART XI, LINE 5 CHANGE IN INTEREST IN FOUNDATION 87,579