2012-08-15T09:51:36-05:00 2011-09-30 ECK SCHAFER & PUNKE LLP 600 East Adams Street Springfield IL 627011624 990 2010-10-01 370647938 Gibson Community Hospital Association GIBS 2177844251 1120 North Melvin Gibson City IL 60936 Rob Schmitt 2177844251 2012-08-07 1 Brent Leach 2175251111 2010 2016-02-24 21:20:13Z Rob Schmitt 1120 North Melvin Gibson City IL 60936 55691727 0 X http://www.gibsonhospital.org X 1952 IL Health care and related services 14 13 565 200 0 0 50908 13304 44564924 53714155 67303 62935 1846436 1901333 46529571 55691727 17000 20000 0 0 27182663 31286379 0 0 0 21677518 23720257 48877181 55026636 -2347610 665091 35525548 32573458 20338922 16784389 15186626 15789069 To provide personalized, professional services to the residents of the communities we serve. 0 0 46222375 20000 55615488 The organization provides for inpatient and outpatient health care along with long-term care for members of the community and surrounding areas. 46222375 1 0 0 0 0 0 0 0 0 1 0 0 0 0 1 0 1 0 0 0 0 0 0 0 0 1 1 1 0 1 1 0 0 0 0 0 1 0 1 0 0 0 0 0 0 0 1 0 0 0 0 1 59 0 1 565 1 0 0 0 0 0 0 0 0 X 14 13 1 1 0 0 1 1 1 1 1 0 0 1 1 1 1 1 1 1 1 0 IL X Rob Schmitt 2177844251 1120 North Melvin Gibson City IL 60936 Jim Hood 1.00 X X 0 0 0 Margo Martin 1.00 X X 0 0 0 Tracy Epps 1.00 X X 0 0 0 Ellen Lee 1.00 X X 0 0 0 Carl Hudson Jr 1.00 X 0 0 0 Steve Kelly 1.00 X 0 0 0 David J Hagan MD 1.00 X 0 0 0 Marty Nuss 1.00 X 0 0 0 Mark Spangler MD 1.00 X 0 0 0 Nancy Krumwiede 1.00 X 0 0 0 John Leonard 1.00 X 0 0 0 Michael Young 1.00 X 0 0 0 Kathy Bennett 1.00 X 0 0 0 Ted Swanson 1.00 X 0 0 0 Rob Schmitt 40.00 X 0 0 0 John Jacobson 40.00 X 67231 0 4665 Richard Foellner DO 40.00 X 552102 0 24626 John G Rowe MD 40.00 X 505820 0 23040 Benjamin Brewer MD 40.00 X 382037 0 13141 Katherine Austman MD 40.00 X 253463 0 11890 Ishwar Jagasia 20.00 X 261923 0 930 2022576 0 78292 21 0 1 0 All Inclusive Medical Services Orland Park Illinois Orland Park IL 60462 ER Hospitalist Physicians 1414899 Cardinal Health Pharmacy Management 1330 Enclave Parkway Houston TX 77077 Pharmacy Management 1383694 Quorum Health Resources 105 Continental Place Brentwood TN 37027 Hospital Management 486077 MCS Office Technologies 104 N Jordan Drive Gibson City IL 60936 Computer Services 201545 CPSI 6600 Wall St Mobile AL 36695 Computer Services 192101 6 13304 13304 Net Patient Service 621990 53714155 53714155 53714155 62935 62935 Miscellaneous 900099 1901333 1901333 1901333 55691727 55615488 0 62935 20000 20000 125366 105307 20059 24304566 20415836 3888730 6856447 5759415 1097032 2218664 1863678 354986 329633 276892 52741 569039 477993 91046 2224412 1868506 355906 865585 727091 138494 Supplies 5566916 4676209 890707 Purchased Services 5143575 4320603 822972 Bad Debts 1842389 1547607 294782 Rental Equipment 1603721 1347126 256595 Other 1581117 1324938 256179 1775206 1491174 284032 55026636 46222375 8804261 0 3865216 325507 6790613 9629945 520794 655914 447468 637336 43003123 24087193 20215284 18915930 3075545 1459437 363318 322950 247310 626439 35525548 32573458 6318225 5289976 14020697 11494413 20338922 16784389 X 15067470 15695416 119156 93653 15186626 15789069 35525548 32573458 X 665091 -62648 X 0 1 1 X 0 X 344036 344036 23806775 11275934 12530841 17849111 12098161 5750950 1003201 713098 290103 18915930 55691727 55026636 665091 -62648 -62648 602443 55691727 0 55691727 0 55691727 55026636 0 55026636 0 55026636 Description of Uncertain Tax Positions Under FIN 48: Part X: GAHHS follows accounting principles generally accepted in the United States of America related to the accounting for uncertainty in income taxes 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, 2011 were reviewed, and it was determined that no provision for uncertain tax positions is required. GAHHSs information and income tax returns for years subsequent to fiscal year 2008 are open, by statute, for review by authorities. Part XI, Line 8 - Other Adjustments: Loss on Extinguishment of Debt Transfer of Net Assets from Gibson Area Hospital Foundation #36-4311943 1 1 1 X 1 X 150.000000000000 1 1 0 1 1 1191764 420272 771492 0.01400 6416694 3399863 3016831 0.05480 7608458 3820135 3788323 0.06880 119310 119310 0.00220 15405267 11338189 4067078 0.07390 112479 112479 0.00200 15637056 11338189 4298867 0.07810 23245514 15158324 8087190 0.14690 1 911365 45568 13968761 19628563 -5659802 X 1 1 9 1 Gibson Community Hospital

1120 North Melvin Gibson City IL 60936

X X X Long-term care 2 Paxton Clinic

227 N Market Paxton IL 60957

Physician clinic 3 Onarga Clinic

109 N Chestnut Onarga IL 60955

Physician clinic 4 Family Healthcare of Hoopeston

837 E Orange Hoopeston IL 60942

Physician clinic 5 Family Health Care of Farmer City

1230 S George Rock Dr Farmer City IL 61842

Physician clinic 6 Prairie Family Medicine and Obstetrics

122 E Wabash Forrest IL 60936

Physician clinic 7 Gibson Area Hospital Orthopedics

10 Doctors Park Gibson City IL 60936

Physician clinic 8 Gibson Area Ambulance Service

1120 North Melvin Gibson City IL 60936

Ambulance service 9 Cristina Medrano MD

1 Doctors Park Gibson City IL 60936

Physician clinic Not Required 1 Part I, Line 7: Cost to charge ratio was obtained using Cost Accounting System. This system does address all patient segments. It is an overall cost to charge ratio for the hospital. Part III, Line 4: Cost methodology for numbers in 2, and 3: 2 - actual bad debt expenses recorded in FY 2010 times 53.7% cost to charge ratio. 3 - 5% of total bad debt expense. Patient Financial Services works towards getting charity eligible patients qualified several times during the collection process. Ultimately, unpaid patient accounts are turned over to agencies that try to collect the patient balance due, but patients accounts are never turned over to a credit reporting agency. Part III, Line 8: Part of the shortfall will be settled on the Cost Report. Also filed Cost Report will be reviwed by intermediary, and will be settled according to Medicare Guidelines. Part III, Line 9b: To the extent patients qualify for charity and financial assistance, no further collection efforts are taken on those balances qualified. No patient balances are credit reportable. Part VI, Line 2: The hospital is currently working on a community needs assessment outlined by CMS guidelines. Part VI, Line 3: Charity care/financial assistance is posted on the hospital website. It is also discussed during the pre-registration process for all self pay and patients with a high deductible. Informational packets are distributed from each registration area [including ED] for self pay & high deductible. The informational packets have a application, cover letter about the program, and contact info on who/where to call for more info or assistance. Each self pay patient is contacted by Financial Healthcare Resources to discuss the government programs they may be eligible for and/or charity care. Charity care is also offered on the first statement that the patient receives. Part VI, Line 4: The hospital is located Ford County, IL. The hospital also has clinics in Livingston, DeWitt, and Iroquois counties, as well as serving Vermillion County. The hospital and clinics serve areas that are all considered rural; small towns and farmland. Of the counties listed above, as of 2008, percentage of persons below poverty level: Ford, 9.8%; Livingston 11.4%; DeWitt 10.2%; Iroquois 10.8%; Vermillion 14.6%; State level is 12.2% . Median Income, 2008: Ford, $51,313; Livingston, $50,972, DeWitt, $47,645; Iroquois, $46,529; Vermillion $41,292; State level is $56,230. Percent of population enrolled with HFS for benefits as of 2009: Ford, 18.8%; Livingston, 17.2%; DeWitt 18.7%; Iroquois 19.6%; Vermillion 27.1%. Closest hospital facilities are 30 miles to the southeast in Champaign/Urbana (Carle, Provena), and 35 miles to the west in Bloomington/Normal (OSF, Advocate/BroMenn). Part VI, Line 6: The entire Board of Directors is comprised of persons who reside in our primary service area, as do the Administrative Staff of the hospital. All of the physicians in the community have privileges at the hospital. The organization has also recruited and placed physicians in other rural communities, that also have privileges at the hospital. The hospital runs and maintains EMS services to several rural communities, which the organization runs at a loss every year. Any surplus funds are used to improve medical equipment, purchase needed supplies and pharmaceuticals, recruit providers for needed services, pay for staff to attend educational workshops, and other needed items and services for the betterment of the community. No excess of revenue over expenses are used to pay any shareholders or investors. This organization does not have either of the latter. Part VI, Line 7: Gibson Hospital is not part of an affiliated healthcare system. Reports Filed With States Part VI, Line 7 IL 1 Telecare 215 E 3rd St Gibson City IL 60936 237353001 501(c)3 15000 Community Benefit Community Economic Development Foundation 402 N Sangamon Ave Gibson City IL 60936 371336454 501(c)3 5000 Community Benefit 2 Procedure for Monitoring Grants in the U.S.: Part I, Line 2: Schedule I, Part I, Line 2: Grants are made to 501 (c)(3) organizations to provide community benefit. 0 0 0 0 0 0 0 0 0 Richard Foellner DO 420814 0 131288 0 0 0 22000 0 2626 0 576728 0 0 0 John G Rowe MD 497920 0 7900 0 0 0 22000 0 1040 0 528860 0 0 0 Benjamin Brewer MD 299172 0 82865 0 0 0 10515 0 2626 0 395178 0 0 0 Katherine Austman MD 174362 0 79101 0 0 0 9264 0 2626 0 265353 0 0 0 Ishwar Jagasia 261923 0 0 0 0 0 0 0 930 0 262853 0 0 0 The City of Gibson City 376000811 2010-12-01 11720000 Refinancing of prior bonds, costs associated with facility renovation 0 0 0 9085000 13306062 858896 77708 11398979 281280 689199 1 0 1 0 0 0 0 0 0 0 0 0 0 0 0 Mark Spangler MD Start-up costs for his practice X 345000 101534 0 1 1 101534 Mark Spangler MD Current board member of the Organization 135594 Pays the Organization a monthly fee for management services for his office. 0 Form 990, Part VI, Section A, line 2 Mark Spangler has a outstanding loan with the Hospital. Form 990, Part VI, Section A, line 3 The Chief Executive Officer (CEO) was employed by a hospital management company until May of 2011. The hospital, as of June 2011, is in a contract with a new managment company but the CEO remains employed by the hospital. Form 990, Part VI, Section A, line 6 The Hospital has association members. These members are any individual who contributed $100 or more to the Hospital during the fiscal year and Life Members - Being those who have contributed a sum of One Thousand ($1,000) dollars or more to further the objectives of the Hospital. Form 990, Part VI, Section A, line 7a The Association's members are allowed to vote annually at the member meeting. Form 990, Part VI, Section A, line 7b At the annual meeting, the members are asked to vote on the approval of the Board of Directors acting on the member's behalf. 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 is reviewed in detail by the Controller and CFO. Form 990, Part VI, Section B, line 12c Yearly conflict of interest agreements are signed by board members. There is also a quarterly compliance review of these agreeements. Form 990, Part VI, Section B, line 15 Top management and key employees' compensation is determined based on a review of current market comparables, experience level, and competitive compensation packages. The CEO is responsible for all compensation negotiations. Form 990, Part VI, Section C, line 19 All documents are available to the public upon request. Changes in Net Assets or Fund Balances: Form 990, Part XI, line 5: Loss on Extinguishment of Debt -219,951. Transfer of Net Assets from Gibson Area Hospital Foundation #36-4311943 157,303. Total to Form 990, Part XI, Line 5: -62,648. Explanation on audited financial statements Form 990, Part IV, Line 12 The Hospital received an unqualified GAAP opinion on financial statements that were combined with the Gibson Area Hospital Foundation. Gibson Area Hospital Foundation 1120 N Melvin Gibson City IL 60936 364311943 Support of the Hospital IL 501(c)3 509(a)2 N/A 0 0 0 0 0 0 0 0 0 0 0 0 1 1 1 0 0 0 0