2011-04-18T13:57:25-05:00 2010-06-30 EIDE BAILLY LLP 3999 PENNSYLVANIA AVE SUITE 100 DUBUQUE IA 52002 990 2009-07-01 370684691 Memorial Hospital Association MEMO 2173573131 PO Box 160 Carthage IL 62321 Teresa Smith 2173573131 2011-04-11 1 Carmen Krantz 5635561790 2009 2016-02-24 21:20:13Z Ada Bair PO Box 160 Carthage IL 62321 20411544 0 X www.mhtlc.org X 1947 IL Memorial Hospital provides clinical care, diagnostic, treatment, and wellness services 12 12 265 62 0 0 687153 737913 17190310 19429798 -101663 161942 66561 17775800 20396214 443219 0 10112868 10494603 0 3868 7796446 10038834 17909314 20976656 -133514 -580442 38693986 34939495 27032826 23781442 11661160 11158053 Memorial Hospital is committed to improving health by providing education and wellness programs and innovative services at all the stages of life. 0 0 14466361 443219 19427498 Memorial Hospital is dedicated to maintaining and improving the health of all people in the Hancock County area. Governed by a Board of Directors, we serve as a vital safety net, serving our communities with access to quality healthcare services. Memorial Hospital provides many types of community benefit care. Community benefit care includes charity care, community health fairs, lectures, and free health screenings, demonstrating our commitment to improving the overall health of the residents of the Hancock County area.We are always committed to providing compassionate care to every member of our community regardless of their ability to pay.We participate in community health-fairs county-wide. These events feature health information, screenings, and presentations. Memorial Hospital sponsors the bloodmobile and provides language assistance services.Memorial Hospital employees serve a vital role in local workforce development and youth mentoring in the health careers. In total, our employees provided over 6,000 hours of hands-on mentoring with area students, some interested in health careers, and some through our involvement with the school co-op program. Memorial Hospital also has partnerships with Kirksville School of Osteopathic Medicine and Carl Sandburg school of Nursing. In addition, we also host high school Leadership groups.Our employees volunteer many hours each year to many worthy community programs including serving on community coordinated coalition committees offering educational events to the community, participating in many local walks/events such as the Relay for Life and supporting disaster readiness planning, among hundreds of other activities.Memorial Hospital provides necessary meeting space for many area support groups and community programs, including HUGS, Hancock County Red Cross and many more.The Organization maintains records to identify and monitor the level of charity care it provides. These records include the amount of charges foregone for services and supplies furnished under its charity care policy. The amounts of charges foregone, based on established rates, were $345,040 for the year ended June 30, 2010. The estimated costs of the charges foregone, based upon an overall cost-to-charge ratio calculation, for the year end June 30, 2010, were $204,000. In addition, the Organization provides services to other medically indigent patients under certain government-reimbursed public aid programs. Such programs pay providers amounts which are less than established charges for the services provided to the recipients, and for some services the payments are less than the cost of rendering the services provided. The Organization also commits significant time and resources to endeavors and critical services which meet otherwise unfulfilled community needs. Many of these activities are sponsored with the knowledge that they will not be self-supporting or financially viable. 14466361 1 1 0 0 0 0 0 0 1 1 0 1 0 0 0 0 0 0 0 0 1 1 0 1 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 1 0 0 1 88 0 1 265 1 0 0 0 0 0 0 0 0 0 12 12 0 0 0 0 1 1 0 1 1 0 0 1 1 1 1 1 1 1 0 0 IL X Janet Fleming 2173573131 PO Box 160 Carthage IL 62321 Terry Pope 3.00 X X 0 0 0 Matt Dickinson 3.00 X X 0 0 0 Peggy Latherow 3.00 X X 0 0 0 Dan Asbury 3.00 X 0 0 0 Carol Gronewold 3.00 X 0 0 0 LuAnn Haas 3.00 X 0 0 0 Kathy Holst 3.00 X 0 0 0 Larry McClintock 3.00 X 0 0 0 Edward McKenney 3.00 X 0 4800 0 Sharon Morrison 3.00 X 0 0 0 Dennis Rankin 3.00 X 0 0 0 Angela Pollock 3.00 X 0 0 0 Ada Bair 40.00 X 174792 0 13839 Teresa Smith 37.00 X 106508 0 26151 Philip A Caropreso MD 40.00 X 268951 0 18280 Patrick D Lynch MD 40.00 X 253944 0 25617 Christopher M Jones MD 40.00 X 298371 0 18274 Michael R Hambrick MD 40.00 X 240030 0 22856 Rachel Rahman MD 40.00 X 172062 0 27545 1514658 4800 152562 11 0 1 0 Robins & Morton 5500 Maryland Way Suite 100 Brentwood TN 37027 General contractor 2867967 Emcare Inc 7032 Collection Center Drive Chicago IL 60693 ER Physician coverage 464093 McDonough District Hospital 525 E Grant Street Macomb IL 61455 Laboratory services 412934 Diamond Healthcare Corp 701 East Byrd Street Richmond VA 23219 Gerophych contract service 200538 Quorum Health Resources 105 Continental Place Brentwood TN 37027 Hospital support services 176558 10 474737 263176 737913 Patient service revenu 622110 16728992 16728992 Clinic revenue 621111 2452440 2452440 Other supporting reven 900099 215768 215768 Equity in earnings of 900099 102742 102742 Equity in earnings of 900099 -70144 -70144 19429798 173635 173635 70198 3637 66561 66561 66561 11693 -11693 -11693 -11693 20396214 19429798 0 228503 443219 443219 324651 324651 7876840 7094461 782379 130469 107264 23205 1616397 1433485 182912 546246 475899 70347 60000 60000 6950 6950 83311 83311 3070601 2421334 649267 63104 17839 45265 1902869 1683302 215699 3868 475067 474917 150 53171 50348 2823 52647 48086 4561 1096287 1096287 1735960 1735960 383558 206250 177308 Bad debt expense 854938 854938 Provider tax 168153 168153 Miscellaneous expense 32218 9957 22261 20976656 14466361 6506427 3868 18519 176015 816015 354801 2626055 2708550 39282 50544 286829 253896 151755 150940 27465711 3899491 24685597 23566220 8480108 5609589 1120097 547705 469729 1521235 38693986 34939495 2150475 2204283 20385000 20020000 984952 950317 501842 3512399 105000 27032826 23781442 X 11606191 10639025 31603 495662 23366 23366 11661160 11158053 38693986 34939495 X 0 1 1 X 0 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 23366 23366 23366 23366 0.00000 1.00000 0.00000 0 0 189215 504757 693972 23033720 1155093 21878627 3517168 2718886 798282 220851 25512 195339 23566220 Estimated health claims payable 105000 105000 20396214 20976656 -580442 77335 77335 -503107 20153369 0 20153369 242845 242845 20396214 20537074 3637 3637 20533437 443219 443219 20976656 Part V, Line 4: Description of Intended Use of Endowment Funds: An endowment fund with the income to be used for the benefit of Memorial Hospital Association Part X: Description of Uncertain Tax Positions Under FIN 48: The Organization has adopted the provisions of FASB Accounting Standards Codification Topic 740-10 (previously Financial Interpretation No. 48, Accounting for Uncertainty in Income Taxes) on July 1, 2009. The implementation of this standard had no impact on the consolidated financial statements. As of both the date of adoption, and as of June 30, 2010, the unrecognized tax benefit accrual was zero. The Organization will recognize future accrued interest and penalties related to unrecognized tax benefits in income tax expense if incurred. The Organization is no longer subject to Federal or state tax examinations by tax authorities for years before 2006. Part XII, Line 4b - Other Adjustments: Capital contributions included in fund balance for financial statements: 137224. Rental expenses included in expenses for financial statements: -3637. Restricted contributions recorded in fund balance per financial statements: 109258. Part XIII, Line 2d - Other Adjustments: Rental expenses included in revenue on Form 990: 3637. Part XIII, Line 4b - Other Adjustments: Donations included in fund balance for financial statements: 443219. 1 1 X 1 X 1 X 1 1 1 0 1 1 204000 204000 0.01040 4777050 1218530 3558520 0.16400 4981050 1218530 3762520 0.17440 307 41680 41680 0.00210 4 17585 17585 0.00090 924249 642343 281906 0.01430 311 983514 642343 341171 0.01730 311 5964564 1860873 4103691 0.19170 0 501796 5369 7075329 7005276 70053 X 1 1 Memorial Hospital Association

1454 North County Road 2050 Carthage IL 62321

X X X X Part I, Line 7: Charity care expense was converted to cost on line 7a based on an overall cost to charge ratio addressing all patient segments. Unreimbursed Medicaid on line 7b was calculated using the costing methods to prepare the cost reports. Community health improvement services and health professions education, lines 7e and 7f, are reported based on actual expenses recorded in the organization's general ledger. The cost for subsidized health services reported on line 7g was determined using the Medicare Cost Report.Total community benefit expense as a percentage of total expenses is 26%. Part I, Line 7g: Costs of $1,580,853 were included in subsidized health services reported on line g. These are the costs to operate two rural health clinics. Part I, Line 7f: The amount of bad debt expense removed from total expenses to determine the percentage was $854,938. Part III, Line 4: The organization's bad debt expense was converted to cost using the cost-to-charge ratio derived from Worksheet 2.Accounts are not written off to bad debt until all payments on the account are applied including all third party payments, contractual allowances, and discounts. Any financial assistance or charity care is recorded as an adjustment to patient service revenue and is not written off to bad debt. We realize some patients may qualify for financial assistance but do not complete the required paperwork. We try to work with these patients to provide them with some form of financial assistance or other payment arrangements, but when patients are able to pay and do not, their balances are written off to bad debt. Payments received on an account previously written off to bad debt reduces bad debt expense.The estimated amount of the organization's bad debt expense attributable to patients eligible under the organization's charity care policy is calculated based on the ratio of charity care to gross charges. Financial Statement Footnote: The carrying amount of patient and resident receivables is reduced by a valuation allowance that reflects management's estimate of amounts that will not be collected from patients, residents, and third-party payors. Management reviews patient and resident receivables by payor class and applies percentages to determine estimated amounts that will not be collected from third parties under contractual agreements and amounts that will not be collected from patients and residents due to bad debts. Management considers historical write off and recovery information in determining the estimated bad debt provision. Management also reviews accounts to determine if classification as charity care is appropriate. Part III, Line 8: Memorial Hospital Association did not have a Medicare shortfall for fiscal year 2010. If the organization were to have a Medicare shortfall this would be considered a community benefit. Memorial Hospital provides services to patients under the Medicare program knowing they will not recover all the costs associated with providing these services. Providing these services is essential to these patients and the community and increases their access to healthcare services.Total revenue received from Medicare is the gross reimbursement plus settlement. Both total revenue received from Medicare and the Medicare allowable costs are reported from the Medicare Cost Report. These amounts do not include fee schedule amounts. Part III, Line 9b: Memorial Hospital does not pursue collection activities for patients that qualify for charity care or patients that have set up payment arrangements for their accounts. Also, collection activities are not pursued for patients that are in the process of applying for charity care and patients waiting for approval or denial from public aid. Any personal portion due after financial assistance is established would follow normal collection procedures.After all third-party payments have been made on an account, a statement generates through the CPSI system. The patient has 30 days to pay the account in full. If the account is not paid in full within 30 days, another statement is sent to the patient. If the account is not paid in full within the next 10 days, the account is referred to Healthcare Billing Service (HCBS), the contracted professional medical billing company used by Memorial Hospital. HCBS assists patients with payment options for their account balances. Memorial Hospital does not charge patients interest. HCBS works all accounts for a minimum of 90 days. As accounts fall outside of the guidelines, HCBS prepares a listing of accounts that have gone through the standard collection activity and submit the listing to the Director of Patient Financial Services to be reviewed for approval to forward to the collection agency. The CFO and CEO approve all accounts to be forwarded to the collection agency and written off to bad debt. Memorial Hospital does not refuse services to patients that generate bad debt. Part V: The organization also has the following types of facilities other than those required to be licensed separately as healthcare facilities in the state of Illinois:2 rural health clinics2 family medical clinics1 Behavioral health center Part VI, Line 2: Memorial Hospital, based on its mission, wants to ensure that the health care needs of the communities we serve are met. The hospital has medical clinics located throughout Hancock County to improve access to health care services to our patients. The Board also has four committees; finance, planning, quality and community health, and marketing committees that have community representation to ensure that input is obtained from the community when considering the health care needs of those we serve. Community input on desired services is obtained through patient satisfaction surveys that are initiated by the inpatient unit, emergency department, and medical clinics that provide a line of communication to identify additional health care services that community desires. Part VI, Line 3: Memorial Hospital strives to provide a rewarding and healing process to our patients, plus an affordable, comfortable process to meet their financial obligations. Memorial Hospital informs their patients individually upon admission about the eligibility for assistance under federal, state or local government programs, and provides the patient with information regarding the organization's charity care policy.When our organization contacts a patient to preregister we explain the charity care and financial assistance. Our collection and financial assistance policies and applications are on our website. We also provide financial counseling to any patient.We post our charity care policy and information regarding federal, state, and local programs at all our registration areas. Brochures are distributed regarding financial assistance with all admission packages.Billing statements have financial assistance support telephone numbers at the bottom of each statement.Our third party billing service provides counseling to our patients regarding available financial assistance if there is a need. Part VI, Line 4: Carthage is a city in Hancock County, Illinois. It is located in western Illinois along the Mississippi River. The nearest city with a population > 50,000 is Peoria, IL. The population of Carthage was 2,725 at the 2000 census. Memorial Hospital serves the county of Hancock in the State of Illinois. Hancock County is a rural community with the median income of $42,732 compared to $53,966 in the state of Illinois. In the years 2005-2009 13% of the population was in poverty. The unemployment rate is 11.3%, compared to 10.2% for the U.S. average. The most common industries are agriculture, transportation, and health care. The nearest hospital is Keokuk Area Hospital about 15 miles away. Part VI, Line 6: Memorial Hospital is dedicated to improving health by providing education and wellness programs and innovative services at all the stages of life for residents of Hancock County. The hospital is governed by a 12-member, volunteer Board of Directors that represent key areas within Hancock County as well as the medical staff. Our employees volunteer each year to many worthy community programs including serving on community coordinated coalition committees offering educational events to the community, participating in many local walks/events such as the Relay for Life, and supporting disaster readiness planning, among hundreds of other activities. As a critical access hospital, Memorial Hospital is an 18-bed facility that provides general medical, surgical services along with obstetrics and an array of outpatient services for the community. Specialty clinics are also provided locally in the areas of cardiology, oncology, neurology, ophthalmology, podiatry, orthopedic, pulmonology, and sleep apnea so that our patients don't have to travel far to receive needed health care services. These specialty physicians are members of the hospital's medical staff along with other providers that desire to serve members of our service area. With the support of the community, Memorial Hospital built a new 18-bed hospital that was occupied in August, 2009. The facility provides up-to-date, diagnostic equipment and services with a capital budget also presented and approved on an annual basis to ensure that needed equipment is obtained to meet the expectations of our patients. The hospital also participates in several health care events throughout the year providing free services as well as a listing of services that are offered through the hospital, clinics, and specialty clinics. This includes, but is not limited to, health fairs, blood pressure screenings, and diabetic education. 1 Hancock County Nursing Home Association PO Box 160 Carthage IL 62321 370902248 501(c)(3) 413765 Book value Land improvements and building Additional medical space for improved health and wellness Hickory Grove Apartments (Hancock County Supportive Living Facility LLP) 403 S Adams Carthage IL 62321 204445121 29454 Book value Equipment Medical equipment for seniors 1 1 Procedure for Monitoring Grants in the U.S.: Part I, Line 2: Schedule I, Part I, Line 2: Memorial Hospital was located in a building that was attached to Hancock County Nursing Home. The Hospital built a new facility and donated the old building, equipment, and land improvements to Hancock County Nursing Home and Hickory Grove Apartments (Hancock Co. Supportive Living Facility, LLP.) X X X X 0 0 0 0 0 0 0 0 0 Ada Bair 174792 0 0 0 0 0 5345 0 8520 0 188657 0 0 0 Philip A Caropreso MD 268951 0 0 0 0 0 3739 0 14583 0 287273 0 0 0 Patrick D Lynch MD 253944 0 0 0 0 0 3154 0 22501 0 279599 0 0 0 Christopher M Jones MD 298371 0 0 0 0 0 8250 0 10069 0 316690 0 0 0 Michael R Hambrick MD 240030 0 0 0 0 0 856 0 22037 0 262923 0 0 0 Rachel Rahman MD 172062 0 0 0 0 0 4995 0 22577 0 199634 0 0 0 Western Illinois Development Authority 352256539 958362AT2 2008-08-22 9972195 New facility and equipment upgrades 0 0 Western Illinois Development Authority 352256539 958362AU9 2008-09-16 10385000 New facility and equipment upgrades 0 0 9972195 9778750 193445 2009 1 0 1 1 10385000 207014 10177986 2009 0 0 1 1 0 0 0 0 0 0.00000 0.00000 0.00000 1 0 0 0 0 0 0.00000 0.00000 0.00000 1 0 1 0 0 0 0 0 0 0 0 0 0 Form 990, Part VI, Section A, line 1 The President only votes when there is a tie. Form 990, Part VI, Section A, line 6 The corporation has one class of members. Any individual or organization that contributes One Hundred Dollars ($100.00) or more, upon application is entitled to receive life membership in the corporation. Such memberships are not transferable. The membership of this corporation is unlimited. Form 990, Part VI, Section A, line 7a Memorial Hospital Association has association members who are presented with a slate of officers and board members at the annual meeting. The association votes by proxy to elect these officers and board members. Each member is entitled to one vote on each matter submitted to a vote of the members. No person whose name does not appear on the list of members kept by the Secretary-Treasurer is entitled to vote and there is no cumulative voting. Form 990, Part VI, Section B, line 11 The Form 990 is reviewed by the Board of Directors' Finance Committee and recommended for approval by the Board of Directors. The final return is reviewed and signed by the CFO. Form 990, Part VI, Section B, line 12c Officers, board members, and key employees are required to sign a conflict of interest statement upon hiring or becoming a board member. The disclosure is updated at the annual association meeting. Any possible conflict of interest is disclosed to the other board members and made a matter of record through an annual procedure and also when the interest becomes a matter of board action. Disclosures are reviewed by the Board of Directors and any member for whom conflicts have been identified leave the room and abstain from voting. Appropriate documentation of the handling of the conflict is kept to protect the interested party and Hancock County Nursing Home. Additionally, the Compliance Officer meets with the Compliance Committee of the board. Any issues identified are logged and followed up by the Compliance Officer. Form 990, Part VI, Section B, line 15a Salary surveys are reviewed annually to ensure all positions individually are within the market rate. Surveys are used from the local area (Blessing survey) and LSN & QHR (comparable organization surveys). The Executive Committee determines the salary for the CEO. Each board member does an independent performance review of the CEO, which is compiled and used by the Executive Committee. The Executive Committee uses the Illinois Hospital Association salary survey as a guide for compensation using the high, middle, and low ranges for similar size organizations. Measures such as revenue, performance of the CEO, and budgetary constraints are all factors that are considered when reviewing the CEO's salary. The most recent review of salary occurred in December 2009 and January 2010. The salary for the CFO is determined by the CEO using the Blessing Survey and the Illinois Hospital Association survey as a guide for similar organizations based on the local area. Form 990, Part VI, Section C, line 19 The organization's governing documents, conflict of interest policy, and financial statements are available to the public upon request. Form 990, Schedule R, Part V, line 2: The method used to determine the amount on line 2(1) was fund equity transfer noted in the financial statements. This was the value of the land and building given to Hancock County Nursing Home. The method used to determine the amount on line 2(2) and 2(3) was the amount of the services provided from the general ledger. Form 990, Page 7, Part VII: The following individuals devoted time providing services to these related organizations: Hancock County Nursing Home Association Dan Asbury 1 hour per week LuAnn Haas 1 hour per week Peggy Latherow 1 hour per week Matt Dickinson 1 hour per week Carol Gronewold 1 hour per week Kathy Holst 1 hour per week Larry McClintock 1 hour per week Edward McKenney 1 hour per week Sharon Morrison 1 hour per week Terry Pope 1 hour per week Dennis Rankin 1 hour per week Angela Pollock 1 hour per week Ada Bair 3 hours per week Teresa Smith 3 hours per week Advance Physical Therapy Larry McClintock 1 hour per week Sherrick Home Health Larry McClintock 1 hour per week Hickory Grove Apartments (Hancock County Supportive Living Facility, LLP) Dan Asbury 1 hour per week Peggy Latherow 1 hour per week LuAnn Haas 1 hour per week Hancock County Nursing Home PO Box 160 Carthage IL 62321 370902248 Provide nursing home care in a 57 bed home IL 501(c)(3) 3 N/A Advance Physical Therapy 620 Wabash Street Carthage IL 62321 113655886 Physical therapy rehabilitation IL N/A Related 131512 26813 0 1 Hickory Grove Apartments (Hancock County Supportive Living Facility LLP) 403 S Adams Carthage IL 62321 204445121 Assisted living facility IL N/A Sherrick Home Health 525 Main St Carthage IL 62321 371180373 Home health IL N/A C 7707 424411 1.00000 0 1 0 0 0 0 0 0 0 1 1 1 1 1 0 0 0 0 Hancock County Nursing Home Association B 413765 Hancock County Nursing Home Association J 89026 Hancock County Nursing Home Association K 163027 Advance Physical Therapy Sherrick Home Health