2011-08-09T16:20:38-05:00 2010-09-30 ECK SCHAFER & PUNKE LLP 600 East Adams Street Springfield IL 627011624 990 2009-10-01 370647938 Gibson Community Hospital Association GIBS 2177844251 1120 North Melvin Gibson City IL 60936 Rob Schmitt 2177844251 2011-07-12 1 Brent Leach 2175251111 2009 2016-02-24 21:20:13Z Rob Schmitt 1120 North Melvin Gibson City IL 60936 46529571 0 X http://www.gibsonhospital.org X 1952 IL Health care and related services 14 13 532 207 0 0 136282 50908 41267441 44564924 24567 67303 1476203 1846436 42904493 46529571 17000 0 23306288 27182663 0 0 20458840 21677518 43765128 48877181 -860635 -2347610 36555707 35525548 19252622 20338922 17303085 15186626 To provide personalized, professional services to the residents of the communities we serve. 0 0 40079288 17000 46411360 The organization provides for inpatient and outpatient health care along with long-term care for members of the community and surrounding areas. 40079288 1 1 0 0 0 0 0 0 0 1 0 1 0 0 0 0 0 0 0 0 1 1 0 1 1 0 0 0 0 0 1 0 1 0 0 0 0 0 0 0 1 0 0 0 1 48 0 1 532 1 0 0 0 0 0 0 0 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 Gary Abrams 40.00 X 101129 0 16272 Richard Foellner DO 40.00 X 524966 0 20377 John G Rowe 40.00 X 511382 0 20397 Douglas McDonald 40.00 X 197906 0 16905 Kathleen Antoline 40.00 X 186783 0 6877 Franki Crist 40.00 X 187082 0 15666 1709248 0 96494 16 0 1 0 All Inclusive Medical Services Orland Park Illinois Orland Park IL 60462 ER Hospitalist Physicians 1313714 Cardinal Health Pharmacy Management 1330 Enclave Parkway Houston TX 77077 Pharmacy Management 1305258 Quorum Health Resources 105 Continental Place Brentwood TN 37027 Hospital Management 495478 MCS Office Technologies 104 N Jordan Drive Gibson City IL 60936 Computer Services 268790 CPSI 6600 Wall St Mobile AL 36695 Computer Services 233793 6 50908 50908 Net Patient Service 621990 44564924 44564924 44564924 67303 67303 Miscellaneous 900099 1846436 1846436 1846436 46529571 46411360 0 67303 17000 17000 96585 79200 17385 21004306 17223531 3780775 6081772 4987053 1094719 2297608 1884039 413569 326210 267492 58718 569910 467326 102584 2323655 1905397 418258 813066 666714 146352 Purchased Services 4740563 3887262 853301 Supplies 4448368 3647662 800706 Other 1629110 1332810 296300 Rental Equipment 1574950 1291459 283491 Bad Debts 1460264 1197416 262848 1493814 1224927 268887 48877181 40079288 8797893 0 2733731 3865216 6591306 6790613 145707 521707 520794 314389 447468 42151871 21936587 21715921 20215284 3704500 3075545 403687 363318 424759 247310 36555707 35525548 4295835 6318225 4073 14952714 14020697 19252622 20338922 X 17185631 15067470 117454 119156 17303085 15186626 36555707 35525548 X 0 1 1 X 0 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 344036 344036 23632065 9949259 13682806 17172569 11320016 5852553 1003201 667312 335889 20215284 Investments 3075545 F 3075545 46529571 48877181 -2347610 230857 294 231151 -2116459 46760428 230857 230857 46529571 0 46529571 48877181 0 48877181 0 48877181 Part X: Description of Uncertain Tax Positions Under FIN 48: Effective October 1, 2009, the GAHHS adopted the new requirements related to the accounting for uncertainty in income taxes (as initially required by Financial Accounting Standards Board Financial Interpretation No. 48 and subsequently superseded by Accounting Standards Codification 740). This guidance 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 Septemeber 30, 2010 were reviewed, and it was determined that no provision for uncertain tax positions is required. Part XI, Line 8 - Other Adjustments: Transfer of Net Assets to Gibson Area Hospital Foundation #36-4311943 1 1 1 X 1 X 150.000000000000 1 1 0 1 1 1162856 627032 535824 0.01100 6811868 2817682 3994186 0.08170 7974724 3444714 4530010 0.09270 108925 108925 0.00220 14743114 9885879 4857235 0.09940 92401 92401 0.00190 14944440 9885879 5058561 0.10350 22919164 13330593 9588571 0.19620 1 791347 39657 9263960 11249628 -1985668 X 1 1 Gibson Community Hospital

1120 North Melvin Gibson City IL 60936

X X X Long-term care Paxton Clinic

227 N Market Paxton IL 60957

Physician clinic Onarga Clinic

109 N Chestnut Onarga IL 60955

Physician clinic Family Healthcare of Hoopeston

837 E Orange Hoopeston IL 60942

Physician clinic Family Health Care of Farmer City

1230 S George Rock Dr Farmer City IL 61842

Physician clinic Prairie Family Medicine and Obstetrics

122 E Wabash Forrest IL 60936

Physician clinic Gibson Area Hospital Orthopedics

10 Doctors Park Gibson City IL 60936

Physician clinic Gibson Area Ambulance Service

1120 North Melvin Gibson City IL 60936

Ambulance service Cristina Medrano MD

1 Doctors Park Gibson City IL 60936

Physician clinic 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. IL 1 Telecare 215 E 3rd St Gibson City IL 60936 237353001 501(c)3 10000 Community Benefit Community Economic Development Foundation 402 N Sangamon Ave Gibson City IL 60936 371336454 501(c)3 7000 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 388840 0 136126 0 0 0 18037 0 2340 0 545343 0 0 0 John G Rowe 425141 0 86241 0 0 0 19461 0 936 0 531779 0 0 0 Douglas McDonald 197906 0 0 0 0 0 16275 0 630 0 214811 0 0 0 Kathleen Antoline 186783 0 0 0 0 0 5447 0 1430 0 193660 0 0 0 Franki Crist 187082 0 0 0 0 0 15666 0 0 0 202748 0 0 0 The City of Gibson City 376000811 2005-08-01 12675000 Refinancing of prior bonds, costs associated with facility renovation 0 0 13797826 858595 7282727 39451 378150 5238903 1 0 1 0 0 0 0 0 0 0 Mark Spangler MD Start-up costs for his practice X 345000 116627 0 1 1 116627 Mark Spangler MD Current board member of the Organization 107554 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) is employed by a hospital management company. 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. Form 990, Part IV, Line 12 Explanation on audited financial statements 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 1 1 1 0 0 0 0