2012-11-14T09:28:17-06:00 2012-03-31 BKD LLP 211 N BROADWAY SUITE 600 ST LOUIS MO 631022733 990 2011-04-01 362167785 MENDOTA COMMUNITY HOSPITAL % LARRY PEACH CFO MEND 8155397461 1401 E 12TH STREET MENDOTA IL 61342 LARRY PEACH 2012-11-13 true Donna J Larson 3142315544 2011 2016-02-24 21:20:13Z X LYNN KLEIN 1401 E 12TH STREET MENDOTA IL 61342 33216190 false X mendotahospital.org X 1944 IL MENDOTA COMMUNITY HOSPITAL'S MISSION IS TO WORK FOR THE HEALTH AND WELL-BEING OF THE CITIZENS OF OUR AREA THROUGH A BROAD RANGE OF HIGH-QUALITY, EFFICIENT HEALTH CARE SERVICES. 12 10 360 75 0 125952 366731 28235739 30524989 107331 166770 40766 128770 28509788 31187260 0 8675 0 0 16085901 17863060 0 0 176740 15760909 15165930 31846810 33037665 -3337022 -1850405 45640488 55624565 29514548 41294695 16125940 14329870 MENDOTA COMMUNITY HOSPITAL'S MISSION IS TO WORK FOR THE HEALTH AND WELL-BEING OF THE CITIZENS OF OUR AREA THROUGH A BROAD RANGE OF HIGH-QUALITY, EFFICIENT HEALTH CARE SERVICES. false false 27024038 8675 30524989 MENDOTA COMMUNITY HOSPITAL PROVIDED 25 BEDS FOR THE SERVICE OF 3,648 PATIENT DAYS IN FISCAL YEAR 2012. THIS HOSPITAL GAVE $1,238,237 IN CHARITY CARE, AND PROVIDED 8,661 MEALS ON WHEELS TO MEMBERS OF OUR COMMUNITY. MENDOTA COMMUNITY HOSPITAL OFFERS FLU & IMMUNIZATION CLINICS ALONG WITH MANY OTHER CLINICS IN MENDOTA AND OTHER OUTREACH COMMUNITIES. THE HOSPITAL HELD CPR CLASSES, DIABETIC SUPPORT GROUPS, PROVIDED FREE DIABETIC AND NUTRITION EDUCATION CLASSES, AND OFFERED SEVERAL OTHER PROGRAMS THROUGH OUT THE YEAR. 27024038 true true false true false false false false false true true false false false true false true false false false false false false false true false true true true false true false false false false false false true true false false false false false false false false false false true 44 0 true 360 true false false false false false false false false false false X 12 10 false false false false false false false true true false false true true true true true true true false false IL X LARRY PEACH CFO 8155397461 1401 E 12TH STREET MENDOTA IL 613421497 STEVEN F GAHAN 2.0 X 0 0 0 DAVID SCHOLL MD 40.0 X 188155 0 22237 MARGO GALLAGHER SCHMITZ RN 2.0 X X 0 0 0 CURTIS ZIMMERMAN 2.0 X 0 0 0 P DANIEL DOYLE OD 2.0 X X 0 0 0 ROBERT F STACHLEWITZ JR 2.0 X X 0 0 0 ERIC ANDERSON 2.0 X 0 0 0 JOSEPH BEETZ 2.0 X X 0 0 0 KERI SUNDBERG DDS 2.0 X X 0 0 0 WILLIAM GEHANT 2.0 X 0 0 0 SARA ESCATEL 2.0 X 0 0 0 KATHLEEN STEVENSON 2.0 X X 0 0 0 LYNN KLEIN 40.0 X 157741 0 22237 LARRY PEACH 40.0 X 128737 0 22009 KEITH P MINIHANE 40.0 X 750608 0 16664 KENNETH K POTTS 20.0 X 341909 0 17313 MARY M CHINN 40.0 X 196419 0 17313 AMY M MATHEIS-SOLIMAN 40.0 X 183830 0 20998 TIMOTHY O MINUS 40.0 X 320754 0 13113 JAMES F MEYER 20.0 X 201181 0 10603 2469334 0 162487 17 false true false ER DOCTORS LTD 7 WOOD DUCK LANE OTTAWA IL 61350 MEDICAL PHYSICIANS 1538909 MEDICAL STAFFING NETWORK PO BOX 202996 DALLAS TX 753202996 NURSING AGENCY 243168 FICEK ELECTRIC AND COMMUNICATION PO BOX 1456 LASALLE IL 61301 IT TECHNICIANS 152516 THOMPSON ELECTRONICS CO 905 S BOSCH ROAD PEORIA IL 616071199 IT TECHNICIANS 149589 BKD 211 N BROADWAY SUITE 600 ST LOUIS MO 631022733 AUDITORS 101857 5 13771 352960 366731 PROGRAM SERVICE REVENUE 621110 30050216 30050216 OTHER OPERATING REVENUE 621110 474773 474773 30524989 109519 109519 0 0 55015 4488 50527 50527 50527 2038741 32470 2012220 1740 26521 30730 57251 57251 14290 13771 10482 3808 3808 0 0 OTHER NON OPERATING REVENUE 900099 220 220 CAFETERIA 722210 74215 74215 74435 31187260 30524989 295540 8675 8675 0 0 0 1326437 989586 336851 0 13171204 11607520 1517796 45888 270179 246759 22493 927 2146134 1939314 199600 7220 949106 844302 101728 3076 0 19013 19013 95325 95325 0 0 0 2456708 2368395 88313 221592 91073 130519 5745462 3794764 1856733 93965 0 0 589679 531657 58022 92036 70059 21977 0 0 698482 698482 0 1477732 1477732 595315 541815 53500 BLOOD BANK 148757 148757 PROVISION FOR BAD DEBT 1214427 1214427 LINENS & OUTSIDE SERVICES 82792 82792 CONTRACTS/REPAIRS 1539616 1043359 496257 188994 23052 140278 25664 33037665 27024038 5836887 176740 4200 3603 6406663 3387737 0 0 4484980 6197564 0 0 0 0 0 0 685957 735837 619953 570828 50751863 7977768 31424241 42774095 2001975 1943141 0 0 0 0 0 0 12519 11760 45640488 55624565 3313002 3234286 0 0 0 0 0 0 0 0 0 0 26028689 37705409 0 0 172857 355000 29514548 41294695 X 15453650 13657538 41738 41780 630552 630552 16125940 14329870 45640488 55624565 X -1850405 54335 X false true true X true true X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED false false false false false true 12259 false false 12259 false 6386687 0 190366 0 1938805 0 4638248 4915223 1311605 159859 0 0 0 6386687 6628180 0 452043 0 2165000 0 4915223 7871246 0 -53066 0 1190000 0 6628180 0.85510 0.13620 0.00870 false false 40478 1282124 1322602 0 30549469 1593485 28955984 0 0 0 0 0 14095483 6224552 7870931 0 4784309 159731 4624578 42774095 0 LEGAL CLAIMS RESERVE 25000 ASBESTOS REMEDIATION LIABILITY 330000 355000 31187260 33037665 -1850405 54326 54326 -1796079 30042129 54326 14970 69296 29972833 1214427 1214427 31187260 31838208 14970 14970 31823238 1214427 1214427 33037665 INTENDED USES OF ENDOWMENT FUNDS PART V, LINE 4 PROCEEDS OF ENDOWMENT, AS DICTATED BY THE DONORS, ARE USED AS BEST DETERMINED BY ADMINISTRATION OF THE HOSPITAL. BOARD DESIGNATED FUNDS ARE TO BE USED FOR CAPITAL ACQUISITIONS. OTHER REVENUE INCLUDED ON BOOKS BUT NOT ON RETURN PART XII, LINE 2D SPECIAL EVENTS DIRECT EXPENSE $10,482 RENTAL EXPENSE $ 4,488 --------------------------------------- TOTAL $14,970 OTHER EXPENSES ON BOOKS BUT NOT ON RETURN PART XIII, LINE 2D SPECIAL EVENTS DIRECT EXPENSE $10,482 RENTAL EXPENSE $ 4,488 --------------------------------------- TOTAL $14,970 UNCERTAIN TAX POSITIONS 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. OTHER REVENUE INCLUDED ON RETURN BUT NOT ON BOOKS PART XII, LINE 4B PROVISION FOR BAD DEBT $1,214,427 OTHER EXPENSES ON RETURN BUT NOT ON BOOKS PART XIII, LINE 4B PROVISION FOR BAD DEBT $1,214,427 FORE THE HOSPIT 17546 9296 8250 1878 2169 100 1209 CORNAPALOOZA 10515 4475 6040 669 100 4356 0 28061 13771 14290 2547 2169 200 5565 10481 3809 true true true X true X true true true false false 630522 630522 0.01980 3964527 2031035 1933492 0.06080 14593 14593 0.00050 4609642 2031035 2578607 0.08110 49531 17108 32423 0.00100 29691 29691 0.00090 9827 9827 0.00030 89049 17108 71941 0.00220 4698691 2048143 2650548 0.08330 true 1214427 0 13186945 13295884 -108939 X true true 1 1 MENDOTA COMMUNITY HOSPITAL

1401 E 12TH STREET MENDOTA IL 61342

X X X X MENDOTA COMMUNITY HOSPITAL 1 false true true 200. true 200. true X X X true true X X X X X X true X false X X X X true X false false PERCENT OF TOTAL EXPENSE PART I, LINE 7, COLUMN F THE ORGANIZATION HAD BAD DEBT EXPENSE IN THE AMOUNT OF $1,214,427 REPORTED ON PART IX, LINE 25, HOWEVER, IT HAS BEEN SUBTRACTED FOR PURPOSES OF CALCULATING THE PERCENTAGE IN THIS COLUMN. FINANCIAL ASSISTANCE AND CERTAIN OTHER COMMUNITY BENEFITS AT COST 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. FINANCIAL STATEMENTS BAD DEBT EXPENSE PART III, LINE 4 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 BAD DEBTS. 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 BAD DEBTS, 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 BAD DEBTS 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 REPONSIBLE. 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. FOR LINE 2, WE PROVIDED OUR FISCAL YEAR EXPENSE AMOUNT FOR BAD DEBT. FOR LINE 3, THE HOSPITAL ACKNOWLEDGES THE FACT THAT SOME PATIENTS DO NOT TURN IN ALL OF THE NECESSARY PAPERWORK TO DETERMINE IF THEY ARE ELIGIBLE FOR CHARITY CARE, BUT WE CANNOT MAKE ANY ASSUMPTIONS AS TO WHAT THEIR INCOME IS, OR IF THEY WOULD HAVE QUALIFIED FOR CHARITY CARE. THEREFORE, WE HAVE NO CHOICE BUT TO PUT ZERO IN LINE 3. SHORTFALL TREATED AS A COMMUNITY BENEFIT PART III, LINE 8 THIS SHORTFALL IS DUE TO HOME HEALTH THAT IS A NECESSARY OUTREACH SERVICE PROVIDED TO THE COMMUNITY FOR THOSE PATIENTS RESTRICTED TO THEIR HOMES. DEBT COLLECTION POLICY PART III, LINE 9B THE HOSPITAL'S DEBT COLLECTION POLICY STATES PATIENT FINANCIAL SERVICES COLLECTION DEPARTMENT WILL ASSIST PATIENTS IN FINDING OTHER SOURCES FOR PAYING BILLS SUCH AS FINANCIAL ASSISTANCE. WE ALSO HAVE A SEPARATE POLICY FOR CHARITY CARE THAT THE COLLECTORS FOLLOW. THIS POLICY LISTS THE ITEMS NEEDED TO VERIFY ELIGIBILITY AND DESCRIBES THE PROCESS OF HOW THE COLLECTORS DETERMINE IF THE PATIENT IS ELIGIBLE TO RECEIVE CHARITY CARE. NEEDS ASSESSMENT PART VI, LINE 2 WE LOOK AT OUR TOP DIAGNOSES AND DETERMINE WHAT TYPE OF PROGRAMS WE SHOULD BE OFFERING TO OUR PATIENTS. WE HAVE ROUTINE BLOOD PRESSURE PROGRAMS, A DIABETIC SUPPORT GROUP AS WELL AS OTHER SCREENINGS THAT ARE OFFERRED BASED ON STAFF EXPERTISE AND PATIENT NEEDS. WE OFFER A "BROWN BAG" DRUG REVIEW WHERE THE PUBLIC CAN BRING IN THEIR MEDICATIONS WHICH ARE REVIEWED BY OUR REGISTERED PHARMACIST FOR POTENTIAL INTERACTIONS AND INAPPROPRIATE TAKING OF THESE MEDICATIONS BY THE PATIENT. WE WORK CLOSELY WITH AREA BUSINESSES ON LOSS PREVENTION AND INSTITUTE PROGRAMS TO MEET THEIR PARTICULAR NEEDS. WE ALSO HAVE DRUG AND ALCOHOL TEST PROGRAMS AVAILABLE FOR OUR BUSINESS COMMUNITY. WE HAVE SPECIALTY CLINICS FOR CARDIOLOGY, ONCOLOGY, PODIATRY, ORTHOPEDICS, RHEUMATOLOGY, PULMONOLOGY, ETC. SO THAT OUR PATIENTS WHO NEED THESE SPECIALTIES CAN BE SEEN LOCALLY VERSUS DRIVING TO METROPOLITAN AREAS FOR THESE SERVICES. PATIENT EDUCATION OF ELIGIBILITY FOR ASSISTANCE PART VI, LINE 3 AT THE TIME OF REGISTRATION PATIENTS RECEIVE HANDOUTS REGARDING SELF PAY UNINSURED DISCOUNTS. ALSO, WHEN A PATIENT RECEIVES A BILL, THERE IS INFORMATION ON THE BACK REGARDING WHERE THEY CAN GET MORE INFORMATION ABOUT FINANCIAL ASSISTANCE SUCH AS CHARITY CARE, BY GOING ON THE HOSPITAL WEBSITE OR CALLING THE COLLECTORS WHOSE NUMBERS ARE LISTED. COMMUNITY INFORMATION PART VI, LINE 4 MCH IS LOCATED IN NORTH-CENTAL ILLINOIS. WE SERVE A POPULATION OF APPROXIMATELY 25,000 RESIDENTS. WE ARE A FARMING COMMUNITY WITH SOME MANUFACTURING PLANTS. MANY OF OUR RESIDENTS ARE SELF-EMPLOYED. WE ALSO SERVE A LARGE HISPANIC POPULATION. OUR MEDICARE POPULATION REPRESENTS OVER 50% OF THE PATIENTS WE SERVE. WE ARE DESIGNATED AS A CRITICAL ACCESS HOSPITAL. PROMOTION OF COMMUNITY HEALTH PART VI, LINE 5 MCH HAS A BOARD OF DIRECTORS THAT IS REPRESENTATIVE OF THE COMMUNITIES WE SERVE. THEY SERVE ON A VOLUNTEER BASIS AND REPRESENT ALL AREAS OF OUR SERVICE AREA. MCH HAS IMPLEMENTED A CHARITY CARE PROGRAM WITH GUIDELINES THAT ARE CONSISTENT WITH THOSE OF OTHER HOSPITALS IN THE STATE OF IL. WE WORK CLOSELY WITH OUR AREA EMS PROVIDERS AND REGULARLY REPLACE THEIR STOCK AT NO CHARGE TO THEM. WE SUPPORT OUR LOCAL FREE CARE CLINIC - TRINITY HEALTH CARE - BY PROVIDING ESTABLISHED LAB TESTS AT NO CHARGE. MCH IS INVOLVED WITH COMMUNITY PROGRAMS BY PROVIDING HEALTH SCREENING BOOTHS, SPEAKERS BUREAU AND INVOLVEMENT AT THE COMMITTEE LEVEL IN MANY ORGANIZATIONS. FACTORS USED TO DETERMINE DISCOUNTED OR FREE CARE PART V, SECTION B, LINE 11 THE COLLECTORS REQUEST EXPENSES AND FAMILY SIZE FROM OUR PATIENTS THAT ARE APPLYING FOR FINANCIAL ASSISTANCE. PUBLISHING OF FINANCIAL ASSISTANCE POLICY PART V, SECTION B, LINE 13 THE POLICY IS NOT ATTACHED TO BILLING INVOICES, BUT THE BACK OF THE BILL LISTS THE PHONE NUMBERS OF OUR COLLECTORS WHO WILL HELP WITH FINANCIAL ASSISTANCE. COLLECTIONS POLICIES AGAINST PATIENTS PART V, SECTION B, LINE 15 MCH ALSO UTILIZES NON-RESIDENTIAL LIENS TO COLLECT FROM PATIENTS. LIENS ARE SENT OUT ONLY FOR GENERAL AUTOMOBILE AND GENERAL LIABILITY CLAIMS. THEY ARE SENT TO THE PATIENT, THE INSURANCE COMPANY, AND THE ATTORNEY (IF THERE IS ONE) TO LET THE INSURANCE KNOW TO PAY THE HOSPITAL BILL AND NOT THE PATIENT. DETERMINING MAXIMUM AMOUNTS CHARGED TO FAP-ELIGIBLE INDIVIDUALS PART V, SECTION B, LINE 19 WE USE THE AVERAGE OF NEGOTIATED COMMERCIAL INSURANCE RATES FOR THOSE SERVICES AT THE FACILITY. true X PROCEDURES FOR MONITORING THE USE OF GRANT FUNDS IN THE UNITED STATES PART I, LINE 2 THE ORGANIZATION ONLY MAKES GRANTS TO PRE-SELECTED ORGANIZATIONS IN SUPPORT OF HEALTH CARE SERVICES. X false false false false false false false false false LYNN KLEIN 154828 0 0 0 2913 0 4200 0 18037 0 179978 0 0 0 LARRY PEACH 125773 0 0 0 2964 0 3972 0 18037 0 150746 0 0 0 DAVID SCHOLL MD 167736 0 0 0 20419 0 4200 0 18037 0 210392 0 0 0 KENNETH K POTTS 335729 0 0 0 6180 0 4200 0 13113 0 359222 0 0 0 MARY M CHINN 175346 0 0 0 21073 0 4200 0 13113 0 213732 0 0 0 AMY M MATHEIS-SOLIMAN 181010 0 0 0 2820 0 2961 0 18037 0 204828 0 0 0 KEITH P MINIHANE 724009 0 0 0 26599 0 3551 0 13113 0 767272 0 0 0 TIMOTHY O MINUS 318622 0 0 0 2132 0 0 0 13113 0 333867 0 0 0 JAMES F MEYER 193123 0 0 0 8058 0 4200 0 6403 0 211784 0 0 0 0 JOELLYN GAHAN SPOUSE OF BOARD MEMBER 43795 EMPLOYEE false WILLIAM GEHANT DIRECTOR SEE BELOW false BUSINESS RELATIONSHIPS BETWEEN INTERESTED PARTIES SCHEDULE L, PART IV, LINE 2 WILLIAM GEHANT, A DIRECTOR OF MENDOTA COMMUNITY HOSPITAL, IS AN OFFICER OF A BANK WITH WHICH MENDOTA HAS ACCOUNTS. INTEREST RECEIVED FROM ACCOUNTS WAS BELOW THE REPORTING THRESHOLD. COPY OF 990 PROVIDED TO GOVERNING BODY FORM 990, PART VI, LINE 11 MENDOTA COMMUNITY HOSPITAL EMAILS THE GOVERNING BODY A COPY OF THE FORM 990 BEFORE IT IS FILED SO THEY CAN REVIEW IT. IN ADDITION, THE CEO AND CFO REVIEW THE FORM 990 BEFORE IT IS FILED WITH THE GOVERNMENT. COMPLIANCE WITH WRITTEN CONFLICT OF INTEREST POLICY FORM 990, PART VI, LINE 12C THE CONFLICT OF INTEREST POLICY COVERS THE GOVERNING BODY. ADMINISTRATION REQUIRES THE GOVERNING BODY TO FILL OUT AN ANNUAL CONFLICT OF INTEREST POLICY. ADMINISTRATION REVIEWS THE FORMS. IF A PROBLEM ARISES, THE CEO WILL CONTACT THE PRESIDENT OF THE GOVERNING BODY TO DISCUSS HOW TO HANDLE THE ISSUE. THE PERSON INVOLVED IN THE CONFLICT OF INTEREST WOULD NOT BE INVOLVED IN THE DELIBERATIONS HELD ABOUT THE ISSUE IN QUESTION. COMPENSATION DETERMINATION FORM 990, PART VI, LINE 15A THE EXECUTIVE BOARD CONDUCTED A REVIEW OF THE COMPENSATION FOR THE CEO IN APRIL 2011. AVAILABLE TO THE PUBLIC FORM 990, PART VI, LINE 19 THE ORGANIZATION DOES NOT MAKE THESE DOCUMENTS AVAILABLE TO THE PUBLIC. HOWEVER, THE AUDITED FINANCIAL STATEMENTS ARE INCLUDED IN THE COPY OF FORM 990 THAT IS MADE AVAILABLE TO THE PUBLIC. OTHER CHANGES IN NET ASSETS FORM 990, PART XI, LINE 5 UNREALIZED GAINS ON INVESTMENTS $54,326 CORRECTION OF PRIOR YEAR BOOK/TAX DIFFERENCE 9 ------------------------------------------------------------------ TOTAL $54,335