2012-03-29T16:48:32-07:00 2011-02-28 990 2010-03-01 310949874 MONROE MEDICAL FOUNDATION INC MONR 2704879231 529 CAPP HARLAN ROAD TOMPKINSVILLE KY 42167 Rickie Brown 2704879231 2012-03-23 2010 2016-02-24 21:20:13Z Monroe County Medical Center Rickie F Brown 529 Capp Harlan Road Tompkinsville KY 42167 20699026 0 X www.mcmccares.com X 1979 KY ACUTE CARE HOSPITAL - Our mission is to be a rural healthcare organization who values compassion, respect and confidentiality, and provide quality, safe, primary and specialty services for the citizens of Monroe County and surrounding area through detection prevention and treatment of illness. We achieve this by operating a 49 bed acute care hospital, ambulance service, home health agency, HCB Waiver program, physician office and county 911 service. 9 7 276 0 0 0 468631 461942 20089033 20147129 82407 89178 24056 777 20664127 20699026 31249 24741 0 0 10442469 10627206 0 0 0 8725402 9125584 19199120 19777531 1465007 921495 23012332 23541254 1423907 1031334 21588425 22509920 ACUTE CARE HOSPITAL - The mission of the Monroe Medical Foundation, Inc. is to be a rural healthcare organization who values compassion, respect and confidentiality, and provides quality, safe, primary and specialty services for the citizens of Monroe County and surrounding area through detection prevention and treatmet of illness. We achieve this by operating a 49 bed acute care hospital, ambulance service, home health agency, HCB Waiver program, physician office and county 911 service. 0 0 16959166 24741 20147129 Inpatient Care - Monroe Medical Foundation, Inc. operates a 49 bed acute care hospital. The hospital admitted 2,117 patients, treated 8,200 patients in the emergency room, treated 21,976 patients as outpatient referrals and made 2,066 ambulance runs in FYE 02-28-11. The hospital also operates a Home Health agency which made 1,623 skilled visits, 4,713 home health aide visits, 1,168 physical therapy visits, 95 speech therapy visits, 43 social worker visits and 95 occupational therapy visits. The home health agency also operates a HCB Waiver Program which did 2,865 homemaker units, 435 case management units, 133 respite units, 10 assessments and 29 reassessments during the fiscal year. The patients admitted to the hospital consisted of approximately 58% Medicare patients and 23% Medicaid patients. Approximately 8% of patients admitted did not have Medicare or Medicaid, and did not have any type of insurance. (6 high school graduates scholarships and 5 others majoring in healthcare profession) 0 0 0 16959166 1 0 0 0 0 0 0 0 0 0 1 0 0 1 0 0 1 1 0 0 0 0 0 0 0 0 1 0 0 1 1 0 0 0 0 0 1 1 1 0 0 0 0 0 0 0 0 0 0 1 22 0 1 276 1 0 0 0 0 0 0 0 0 0 1 1 0 X 9 7 0 1 0 0 0 0 0 1 1 0 0 0 1 1 1 1 1 1 1 0 X Monroe County Medical Center 2704879231 529 CAPP HARLAN ROAD TOMPKINSVILLE KY 42167 Judy Rowland 1 X X 0 0 0 Fowler Ross JR OD 1 X 0 0 0 Jimmy Goodman 1 X 0 0 0 Johnny Travis 1 X 0 0 0 Timothy Hume MD 1 X 0 0 0 Polly Baker 1 X 0 0 0 Gene Hagan 1 X 0 0 0 Greg Crabtree DMD 1 X X 0 0 0 Kimberly Eakle-Hume M D 7 X 26210 0 0 Anthony Carter MD 2 X 2450 0 0 Vicky McFall 40 X 0 0 0 Rickie Brown 40 X 0 0 0 Deborah Bentley 40 X 129093 0 0 Andrea McAlpin 40 X 124710 0 0 Clella Hays MD 40 X 164039 0 0 Lisa Davis 40 X 101130 0 0 547632 0 0 4 0 1 0 Quorum Health Resources LLC 105 Continental Place Brentwood TN 37027 Management Contract & Provides CEO and CFO 623574 Inspire Medical Inc 2323 Lime Kiln Lane Louisville KY 40222 Emergency Room Physicians 1111905 CPSI 6600 Wall St Mobile AL 36695 Computer Software and Maintenance 210779 Philips Medical Systems P O Box 100355 Atlanta GA 30384 Maintenance services on radiology equipment 274415 4 0 0 0 0 461942 0 0 461942 Hospital Services Net of Contractual Adjustments and Charity 622000 20147129 20147129 0 0 0 0 0 0 20147129 89178 0 0 89178 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 777 777 0 0 777 20699026 20147906 0 89178 0 0 24741 24741 0 0 0 0 0 0 0 0 0 0 0 0 8894559 8049783 844776 0 133984 121259 12725 0 940816 851460 89356 0 657847 595367 62480 0 618743 0 618743 0 27899 0 27899 0 29552 0 29552 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 14589 14589 0 0 2586709 2372739 213970 0 146447 0 146447 0 0 0 0 0 439814 0 439814 0 80238 67112 13126 0 0 0 0 0 11719 10081 1638 0 0 0 0 0 0 0 0 0 1358780 1322195 36585 0 153735 152054 1681 0 Provision for Bad Debts 1097258 1097258 0 0 Physician Fees 1191412 1191412 0 0 Other Expenses 518872 253649 265223 0 Equipment Repairs and Maintenance 531372 517022 14350 0 Kentucky Provider Tax 318445 318445 0 0 19777531 16959166 2818365 0 7397 1149 880848 1293899 0 0 4008073 2808830 0 0 0 0 0 0 334368 307078 222372 230658 29162981 15960523 14133917 13202458 0 0 0 0 0 0 0 0 3425357 5697182 23012332 23541254 1029786 1031334 0 0 0 0 0 0 0 0 0 0 0 0 0 0 394121 0 1423907 1031334 X 21407713 22370071 180712 139849 0 0 21588425 22509920 23012332 23541254 921495 0 X 0 1 1 X 0 X 0 378922 378922 0 12210014 3691955 8518059 0 0 0 0 0 16574045 12268568 4305477 0 0 0 0 13202458 Fubded Depreciation Restricted 5059058 Cash Restricted for Adult Daycare 16815 Other Receivables 613934 Other Assets 7375 5697182 20699026 19777531 921495 0 0 0 0 0 0 921495 20699026 0 0 0 0 0 20699026 0 0 0 20699026 19777531 0 0 0 0 0 19777531 0 0 0 19777531 1 1 1 X 1 X 1 1 0 1 1 1038224 300642 737582 0.0373 3050515 2544556 505959 0.0256 0 0 0 0.00 0 0 4088739 2845198 1243541 0.0629 7802 0 7802 0.0004 24741 0 24741 0.0013 1242393 1054973 187420 0.0095 0 0 1274936 1054973 219963 0.0112 0 0 5363675 3900171 1463504 0.0741 1 449332 80880 10717068 8996033 1721035 X 1 1 Quorum Health Resources LLC Management Company 0 0 0 1 1 Monroe County Medical Center

529 Capp Harlan Road Tompkinsville KY 42167

X X X Monroe County Medical Center 1 0 1 1 100 1 200 1 X X 1 1 X X X X 1 X X 1 X X X X X X 1 X 0 1 2 Monroe County Medical Center Home Health Agency

417 Capp Harlan Road Tompkinsville KY 42167

Home Health Services and HCB Waiver Program. Monroe County Medical Center Adult Daycare

417 Capp Harlan Road Tompkinsville KY 42167

Provides adult daycare services Monroe County Ambulance Service

415 Capp Harlan Road Tompkinsville KY 42167

Ambulance Service operated for the county. Monroe County 911 Service

415 Capp Harlan Road Tompkinsville KY 42167

911 service operated for the county. SchH_P01_S00_L07 Schedule H, Part I, Line 7 Ratio of Patient Care Cost to Charges was used as the costing methodology. SchH_P01_S00_L072f Schedule H, Part I, Line 7, Column f Bad debt expense at cost of $33,531 was removed and Charity Care expense at cost of $46,511 was removed from this figure for purposes of calculating the percentage in Schedule H, Part I, Line 7, Column (f). SchH_P01_S00_L07g Schedule H, Part I, Line 7g There were no costs attributable to a physician clinic included as subsidized health services in the line 7(g). SchH_P03_S0A_L04 Schedule H, Part III, Section A, Line 4 The costing methodology used to determine the amounts reported is based on the Ratio of Patient Care Cost to Charges applied to the gross amounts written off as bad debts. SchH_P03_S0B_L08 Schedule H, Part III, Section B, Line 8 There is no shortfall on Medicare. The costing methodology used is the Ratio of Patient Care Cost to Charges applied to the gross charges. SchH_P03_S0C_L09b Schedule H, Part III, Section C, Line 9b Upon registration, financial information is gathered, when possible, to determine if they qualify for charity or financial assistance. If they are not able to provide the information at that time they are given a financial information form to complete later. If they are admitted to the hospital, the patient financial counseler goes to the patient room and discusses the charity and financial assistance information with the patient. If we are unable to obtain the necessary information from the patient at that time, we send the information to a contracted company to obtain the necessary information, and assist them in obtaining the information and financial assistance they qualify for. SchH_P05_S0B_L21 Schedule H, Part V, Section B, Line 21 The hospital has the same charges for all patients. If the patients meet the indigent policy criteria, a portion of their bill is adjusted according to the indigent care policy. Patients who meet the KHCP program criteria are totally written off, and the patients are not responsible for the bill. Other patients have the opportunity to receive a discount on their bill equivalent to the negotiated commercial insurance rate. SchH_P06_S00_L02 Schedule H, Part VI, Line 2 In the past the Community Needs Assessment has been developed in connection with the Monroe County Health Department. It has been a while since one was completed. We are in the process of doing a joint community needs assessment with the Monroe County Health Department and the Barren River Area Development District (BRADD). The hospital also has suggestion boxes for patients, visitors and employees to obtain suggestions for new or better health services. In addition, the hospital obtains input from the physicians, Board members and employees at the annual hospital, Board/Medical Staff planning retreat. SchH_P06_S00_L03 Schedule H, Part VI, Line 3 The Indigent Care Policy is posted on the wall in the registration offices. There are also copies in the registration areas with a sign instructing the patients to take one if they feel they may qualify for the financial assistance. If the patients do not have Medicare, Medicaid or any other type of insurance, the patient information is provided to a contracted company to follow up with the patients to help them obtain medical cards and assist them in getting the necessary information to qualify for financial assistance. If the patient is admitted, the Patient Financial Counselor visits the patient in their patient room and discusses their financial options. The hospital's Indigent Care Policy is posted on the hospital's web site. SchH_P06_S00_L04 Schedule H, Part VI, Line 4 The Monroe County Medical Center is located in Monroe County, Kentucky which is a rural area of Kentucky. The hospital primarily serves the citizens of Monroe County and parts of the joining counties. The population of Monroe County is approximately 10,900. Approximately 11.6% of persons age 25 and above have a bachelor's degree or higher compared to 30.44% for the national average. The median household income is approximately $28,439 compared to the national median household income of $46,326. Approximately 27.1% of the persons in Monroe County live below the poverty level compared to 15.1% for the national average. The unemployment rate for Monroe County is 12.0% compared to the national average of 8.9%. the primary industries in Monroe County are a concrete plant manufacturer, lumber and agriculture. SchH_P06_S00_L05 Schedule H, Part VI, Line 5 The Monroe County Medical Center has an open medical staff to promote patient care for the citizens of our community. The Board of Directors of the Monroe Medical Foundation, Inc. is made up of nine individuals. They all reside in Monroe County, and serve on the Board with no pay for providing those services. They serve because they are interested in the Community and want to give something back to the Community by helping assure that good medical services are provided to the citizens of Monroe and surrounding counties. The current Board is made up of two local business men, a banker, a retired banker and farmer, a retired school teacher, a dentist, an optomitrist, the chief of the medical staff and the vice chief of the medical staff. Any surplus funds of the Monroe Medical Foundation, Inc. are used to upgrade the building, purchase updated equipment and provide other wellness services and quality healthcare for our community. SchH_P06_S00_L06 Schedule H, Part VI, Line 6 The hospital is managed by Quorum Health Resources, LLC to provide the day-to-day management of the hospital. The Board of Directors has the ultimate decision making authority for the hospital. 1 See Schedule I, Part IV, Statement 1 11 24741 0 SchI_P01_S00_L02 Schedule I, Part I, Line 2 The grant funds or assistance is monitored by CEO, CFO and the Board of Directors. The Board of Directors approves teh grants or other assistance for education, etc. the individuals are required to provide proof of enrollment, etc. and appropriate grades to receive the grants or assistance. X 0 0 0 0 0 0 0 0 0 Clella Hays MD 165000 0 0 0 0 0 2570 0 4142 0 171712 0 SchJ_P01_S00_L03 Schedule J, Part I, Line 3 Vicky McFall - Compensation paid to Vicky McFall, CEO and Rickie Brown, CFO was paid by Quorum Health Resources, LLC which is the management Company. Gene Hagan Board Member 656 Purchase of Supplies 0 Johnny Travis Board Member 2762 Purchase of Supplies 0 Terry L Carter Daughter of Board Member 57485 Employee Wages for RN 0 Jo Ann Brown Spouse of CFO 60856 Employee Wages for RN 0 Emily J Shaw Daughter of CFO 43341 Employee Wages for RN 0 F990_P06_S0A_L03 Form 990, Part VI, Section A, Line 3 The Monroe Medical foundation, Inc. has contracted with a management company, Quorum Health Resources, LLC, to provide management servcies to the hospital. The CEO and CFO are employees of the management company, but they are still under the control of the Board of Directors. The CEO and CFO reports to the Board of Directors each month at the Board meetings and other times as necessary. F990_P06_S0B_L11a Form 990, Part VI, Section B, Line 11a The Form 990 is prepared by the CFO and is reviewed with the CEO before it is filed. F990_P06_S0B_L12c Form 990, Part VI, Section B, Line 12c Each member of the Board of Directors and the CEO and CFO completes a conflict of interest questionaire annually. Any time there is a conflict of interest with any Board Member on any issue being discussed by the Board of Directors, the Board member who has the conflict abstains from any vote on the issue. F990_P06_S0B_L15 Form 990, Part VI, Section B, Line 15 The process for determining compensation of the CEO and CFO includes a review and approval by Quorum Health Resources, LLC., the management company, and the Board of Directors. Each member of the Board of Directors completes an evaluation of the CEO, and submits it to the Quorum regional Vice President. The Regional Vice President presents the evaluations and his recommendations to the Board of Directors based on the evaluations and the salary scale of the management company. The Board of Directors approves or disapproves the recommendation of the Quorum Regional Vice President. The CEO completes the evaluation of the CFO and submits it to the Quorum regional Vice President. The Regional Vice President presents his recommendations to the Board of Directors based on the evaluation and the salary scale of the management company. The Board of Directors approves or disapproves the recommendation of the Quorum Regional Vice President. F990_P06_S0C_L19 Form 990, Part VI, Section C, Line 19 The governing documents, conflict of interest policy, and financial statements are available to the public upon request in the Administrative office of the Monroe County Medical Center, 529 Capp Harlan Road, Tomplinsville, Kentucky 42167. The Monroe Medical Foundation, Inc. filed and received approval for an extension to file the Form 990 until January 15, 2012. I was trying to file the return the first of January and discovered that the IRS had suspended their electronic filing systems for the Form 990 through February 29, 2012. According to the IRS Notice 2012-4, an organization with a second extended due date that falls during the suspension period, the organization will have reasonable cause for late filing and will not be subject to the late filing penalties if it files by March 30, 2012. I respectfully request that you do not generate a penalty notice for late filing based on the Notice 2012-4. Thank you very much.