2012-07-30T14:13:10-05:00 2011-09-30 ECK SCHAFER & PUNKE LLP 600 East Adams Street Springfield IL 627011624 990 2010-10-01 363637465 HOOPESTON COMMUNITY MEMORIAL HOSPITAL HOOP 2172835531 701 E ORANGE STREET HOOPESTON IL 60942 RUSS LEIGH 2172835531 2012-07-20 1 Brent Leach 2175251111 2010 2016-02-24 21:20:13Z RUSS LEIGH 701 E ORANGE STREET HOOPESTON IL 60942 24805531 0 X www.hoopestonhospital.org X 1962 IL PROVIDE ACUTE AND SKILLED NURSING CARE FOR RESIDENTS OF HOOPESTON AND THE SURROUNDING AREAS. 10 10 306 15 25673 2993 1005 104672 21077296 24553662 110256 84055 86386 63142 21274943 24805531 0 0 0 0 9918245 11117034 0 0 0 11304574 12888426 21222819 24005460 52124 800071 17546086 20060737 11684286 13723855 5861800 6336882 PROVIDE ACUTE AND SKILLED NURSING CARE FOR RESIDENTS OF HOOPESTON AND THE SURROUNDING AREAS. 0 0 19265948 24553662 PROVIDE ACUTE INPATIENT AND OUTPATIENT HEALTHCARE SERVICES AND LONG TERM HEALTH CARE SERVICES 19265948 1 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 10 10 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 X 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 DAVE MCFADDEN 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 274237 0 0 CHASE DANIEL 20.00 X 162098 0 0 DENNIS PRICE 40.00 X 143206 0 0 WILLIAM MCCARTHY 40.00 X 163885 0 0 DENNIS BIRKY 40.00 X 148040 0 0 891466 0 0 5 0 1 0 CARLE FOUNDATION HOSPITAL 610 W PARK STREET URBANA IL 61801 PROFESSIONAL SERVICES 1586548 HEALTH ALLIANCE MEDICAL PLANS 301 S VINE URBANA IL 61801 HEALTH INSURANCE 1329113 HOOPESTON ER MEDICAL SPECIALISTS 6948 Windsor Ave BERWYN IL 60402 ER & HOSPITALIST DOCTORS 1038000 WRIGHT MEDICAL TECHNOLOGY PO BOX 503842 ST LOUIS MO 63150 MEDICAL/SURGICAL SUPPLIES 699573 SIGHTPATH MEDICAL 5775 W OLD SHAKOPEE ROAD SUITE 90 BLOOMINGTON MN 55437 MEDICAL/SURGICAL SUPPLIES 523077 26 104672 104672 NET PATIENT SERVICES 621990 23918176 23918176 OTHER 900099 635486 635486 24553662 84055 84055 10564 10564 10564 10564 CAFETERIA 722320 52578 25673 26905 52578 24805531 24553662 25673 121524 9158883 7488745 1670138 60471 45467 15004 1262354 985039 277315 635326 515960 119366 373056 373056 144080 144080 68056 68056 2381721 2364670 17051 164421 138719 25702 1867932 1026120 841812 239426 239426 123230 86568 36662 56507 49578 6929 566015 459426 106589 792870 636155 156715 452502 447589 4913 DRUGS AND OTHER SUPPLIE 2761476 2608024 153452 BAD DEBTS 1931978 1931978 PURCHASED SERVICES/PROF 965156 481910 483246 24005460 19265948 4739512 0 817551 2190787 2631148 232022 245659 53597 153488 19227843 7521761 9161303 11706082 1678639 539925 4229738 3966884 17546086 20060737 2880764 3383515 8551776 9851548 251746 488792 11684286 13723855 X 2314936 2771484 3546864 3565398 5861800 6336882 17546086 20060737 X 800071 -324989 X 0 1 1 X 0 X 295000 295000 10431604 4090622 6340982 264490 168835 95655 4569031 3262304 1306727 3667718 3667718 11706082 BENEFICIAL INTEREST IN PERPETUAL TRUST 3565398 DEFERRED FINANCING COSTS 291486 ESTIMATED AMOUNTS DUE FROM THIRD-PARTY PAYERS 110000 3966884 ASSET RETIREMENT OBLIGATION 135779 ESTIMATED AMOUNTS DUE TO THIRD-PARTY PAYERS 353013 488792 24805531 24005460 800071 3353 -328342 -324989 475082 24808884 3353 3353 24805531 0 24805531 24352336 346876 346876 24005460 0 24005460 Description of Uncertain Tax Positions Under FIN 48: Part X: The Center 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. The Centers information and income tax returns for years subsequent to fiscal year 2007 are open, by statute, for review by authorities. Part XI, Line 8 - Other Adjustments: CHANGE IN VALUATION OF PERMANENTLY RESTRICTED NET ASSET BOND REFINANCING Part XIII, Line 2d - Other Adjustments: Bond Refinancing 346,876. 1 1 1 X 125.000000000000 1 X 1 1 1 0 0 753 689742 689742 0.02980 753 689742 689742 0.02980 1500 31891 3626 28265 0.00120 1500 31891 3626 28265 0.00120 2253 721633 3626 718007 0.03100 1 837791 524444 5612436 5769009 -156573 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 HOOPESTON COMMUNITY MEMORIAL HOSPITAL 1 1 09 1 0 1 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 $ 837791. 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 Emergency Room to be complete in 20122. New Surgery Suite to be complete in 20123. New Clinic in Rossville, IL was opened in November 20114. Replacement Nursing Home facility to be complete in 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 2 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, a physician and 2 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.9. Recruitment of a dentist to start in summer 2013.We perform a formal 3rd party assessment once every three years and will be completed again 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. Once a bill reaches 45 days past due, our internal financial staff calls and discusses needs with the individual. 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 5,300 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 2010 was $38,167. In 2010, 18.3% of the population had an income below the poverty line. Part VI, Line 6: 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 274237 0 0 0 0 0 0 0 0 0 274237 0 0 0 CHASE DANIEL 162098 0 0 0 0 0 0 0 0 0 162098 0 0 0 WILLIAM MCCARTHY 163885 0 0 0 0 0 0 0 0 0 163885 0 0 0 Farm Credit Services of Illinois 371270645 2011-08-02 7450000 Refinancing of prior bonds 0 0 0 7265000 7450000 500000 6930095 19905 1 0 1 0 0 0 0 0 0 0 0 0 0 0 0 DICK READ BOARD MEMBER 28113 VAN, AMBULANCE AND AUTO REPAIRS 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 gains on investments: 3,353. CHANGE IN VALUATION OF PERMANENTLY RESTRICTED NET ASSET 18,534. BOND REFINANCING -346,876. Total to Form 990, Part XI, Line 5: -324,989.