2011-11-08T09:36:01-05:00 2011-06-30 BKD LLP 211 N BROADWAY SUITE 600 ST LOUIS MO 631022733 990 2010-07-01 370624255 Community Memorial Hospital Association COMM 6186352200 400 Caldwell Street Staunton IL 62088 SUE E CAMPBELL 2011-11-07 true Donna J Larson 3142315544 2010 2016-03-07 17:11:31Z SUE E CAMPBELL 400 CALDWELL STREET STAUNTON IL 62088 14460192 false X WWW.STAUNTONHOSPITAL.ORG X 1946 IL COMMUNITY MEMORIAL HOSPITAL PROVIDES COMPASSIONATE PATIENT-CENTERED HEALTH CARE SERVICES, WHILE MAINTAINING CLINICAL EXCELLENCE AND FINANCIAL VIABILITY. 9 8 164 25 0 0 52268 98377 14278971 14050104 94649 213846 72208 95794 14498096 14458121 1000 1000 0 0 6810902 6287741 0 0 0 7255790 7610558 14067692 13899299 430404 558822 13075369 13409508 2391042 2223544 10684327 11185964 X COMMUNITY MEMORIAL HOSPITAL PROVIDES COMPASSIONATE PATIENT-CENTERED HEALTH CARE SERVICES, WHILE MAINTAINING CLINICAL EXCELLENCE AND FINANCIAL VIABILITY. false true 11829418 1000 14065712 THE ORGANIZATION OPERATES A FULL SERVICE CRITICAL ACCESS HOSPITAL IN STAUNTON, ILLINOIS WITH A TOTAL OF 25 BEDS. TOTAL PATIENT DAYS WERE 1,491 OF WHICH APPROXIMATELY 90% WERE MEDICARE DAYS AND 3% WERE MEDICAID DAYS. THE HOSPITAL ALSO PROVIDED MEDICAL CARE TO ALMOST 28,000 OUTPATIENTS WITH OVER 45% BEING MEDICARE PATIENTS AND OVER 15% BEING MEDICAID PATIENTS. 11829418 true true false false false false false false false true false false false false false true false false false false false false false false false true true false false true true false false false false false false false false false false false false false false false false false false false false true 20 0 true 164 true false false false false false false false false false false X 9 8 false false false false true true false true true false false true true true true true true true true false IL X DONALD BRUNNWORTH 6186354242 400 CALDWELL STAUNTON IL 62088 DON KASUBKE 1.0 X X 0 0 0 LARRY LUX 1.0 X X 0 0 0 BERNICE HENKE 1.0 X X 0 0 0 HULDA BLACK 1.0 X X 0 0 0 EDDY SARACCO 1.0 X 0 0 0 MIKE COX 1.0 X 0 0 0 WAYNE BROOKE 1.0 X 0 0 0 LARRY ZIGLAR 1.0 X 0 0 0 NICOLAS PINEDA MD 40.0 X 132620 0 743 SUE CAMPBELL 40.0 X 131591 0 11071 DONALD BRUNNWORTH 40.0 X 112452 0 630 JOSHUA POOS 40.0 X 191981 0 13726 DARRELL PAPE 40.0 X 107646 0 13382 676290 0 39552 5 false true false EMERGENCY DEPARTMENT SERVICES PC 7032 COLLECTION CENTER DRIVE CHICAGO IL 60693 ER PHYSICIAN SERVICE 886042 ALTON PHYSICAL THERAPY SERVICES 1719 CLAWSON ALTON IL 62002 PHYSICAL THERAPY 405120 SOUTH CENTRAL ANESTHESIA LTD 7461 LESLIE DRIVE EDWARDSVILLE IL 62025 ANESTHESIA SERVICE 264327 QUEST DIAGNOSTICS PO BOX 14730 ST LOUIS MO 63150 LAB SERVICE 191921 SHARED MEDICAL SERVICES INC PO BOX 330 COTTAGE GROVE WI 53527 MOBILE MRI SERVICE 138125 6 38377 60000 98377 NET PATIENT SERVICE REVENUE 621110 14050104 14050104 14050104 64209 64209 0 0 43170 43170 43170 43170 151708 2071 149637 149637 149637 0 0 0 CAFETERIA 722210 25821 25821 OTHER INCOME 900099 26803 15608 0 11195 52624 14458121 14065712 0 294032 0 1000 1000 0 0 395945 133064 262881 0 4657109 3964597 692512 107707 91691 16016 758525 645732 112793 368455 313666 54789 153683 153683 19331 19331 63024 63024 0 0 0 2614199 2225468 388731 14339 12207 2132 1506374 1483649 22725 107930 91881 16049 0 245443 208946 36497 16851 14345 2506 0 0 47145 47145 0 624480 531620 92860 248220 211310 36910 PROVISION FOR BAD DEBTS 1225845 1225845 EQUIPMENT RENTAL 453304 385898 67406 HOSPITAL PROVIDER ASSESSMENT 75124 75124 DUES & SUBSCRIPTIONS 62400 53121 9279 MISCELLANEOUS 132866 113109 19757 0 13899299 11829418 2069881 0 1708683 1862245 914218 920396 1970465 1897743 274090 254277 152203 193441 10975591 7441235 3614393 3534356 3945317 4308235 496000 438815 13075369 13409508 1270314 1095349 780000 715256 340728 412939 2391042 2223544 X 10188327 10747149 496000 438815 10684327 11185964 13075369 13409508 X 558822 -57185 X false true true X false X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 443004 443004 3424232 2301115 1123117 0 0 0 6519130 4970709 1548421 589225 169411 419814 3534356 14458121 13899299 558822 558822 14457121 14457121 1000 1000 14458121 13898299 13898299 1000 1000 13899299 FIN 48 DISCLOSURE 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. RECONCILIATION OF REVENUE PER FINANCIAL STATEMENTS TO REVENUE PER RETURN PART XII, LINE 4B SCHOLARSHIPS CLASSIFIED WITH REVENUE ON THE AUDITED FINANCIAL STATEMENTS AND CLASSIFIED AS EXPENSES ON FORM 990 - $1,000 RECONCILIATION OF EXPENSE PER FINANCIAL STATEMENTS TO EXPENSE PER RETURN PART XII, LINE 4B SCHOLARSHIPS CLASSIFIED WITH REVENUE ON THE AUDITED FINANCIAL STATEMENTS AND CLASSIFIED AS EXPENSES ON FORM 990 - $1,000 true true true X true X false true false false 18101 0 18101 0.00140 1563022 1139899 423123 0.03340 1581123 1139899 441224 0.03480 758 0 758 0.00010 6642 0 6642 0.00050 8957 0 8957 0.00070 16105 0 16105 0.00130 32462 0 32462 0.00260 1613585 1139899 473686 0.03740 true 631065 0 6626708 6360517 266191 X true true 1 1 COMMUNITY MEMORIAL HOSPITAL

400 CALDWELL STAUNTON IL 62088

X X X X COMMUNITY MEMORIAL HOSPITAL 1 1 COMMUNITY FAMILY PRACTICE

325 CLADWELL ST STAUNTON IL 62088

PHYSICIAN'S MEDICAL OFFICE PART I, LINE 7, COLUMN F: THE ORGANIZATION HAD BAD DEBT EXPENSE IN THE AMOUNT OF $1,225,845 REPORTED ON PART IX, LINE 25. HOWEVER, IT HAS BEEN SUBTRACTED FOR PURPOSES OF CALCULATING THE PERCENTAGE IN THIS COLUMN. 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. PART III, LINE 3: THE HOSPITAL BELIEVES THAT THE COMMUNITY BENEFIT OBTAINED FROM ITS CHARITY CARE IS UNDERSTATED DUE TO PATIENTS THAT COULD QUALIFY FOR CHARITY CARE BUT DO NOT APPLY OR PROVIDE INCOMPLETE INFORMATION. SOME CARE PROVIDED TO PATIENTS IS NOT CLASSIFIED AS CHARITY CARE DUE TO PATIENTS MISSING DOCUMENTATION THAT PROVES THEY QUALIFY FOR CHARITY CARE. THE HOSPITAL'S BAD DEBT DOES INCLUDE AMOUNTS THAT COULD BE CLASSIFIED AS CHARITY CARE IF THE PATIENTS WOULD APPLY OR PROVIDE THE APPROPRIATE INFORMATION TO COMPLETE THE CHARITY CARE APPLICATION. PART III, LINE 4: IN LINE WITH ITS MISSION, THE HOSPITAL PROVIDES A SAFETY NET FOR THE COMMUNITIES SERVED TO ACCESS MUCH NEEDED CARE BY OFFERING SOME SERVICES TO PATIENTS WITHOUT REGARD TO THEIR ABILITY TO PAY FOR THOSE SERVICES. FOR SOME OF THEIR PATIENT SERVICES, THE HOSPITAL RECEIVES NO PAYMENT OR PAYMENT THAT IS LESS THAN THE FULL COST OF PROVIDING THE SERVICES. THE HOSPITAL VOLUNTARILY PROVIDES FREE CARE TO PATIENTS WHO ARE UNABLE TO PAY FOR ALL OR PART OF THEIR HEALTH CARE EXPENSES AS DETERMINED BY THE HOSPITAL'S CRITERIA FOR FINANCIAL ASSISTANCE. IN SOME CASES, THE HOSPITAL DOES NOT RECEIVE THE AMOUNT BILLED FOR PATIENT SERVICES EVEN THOUGH IT DID NOT RECEIVE INFORMATION NECESSARY TO DETERMINE IF THE PATIENTS MET THE CRITERIA FOR FINANCIAL ASSISTANCE. BAD DEBTS EXPENSE IS THE ESTIMATED AMOUNT OF PATIENT REVENUE THAT THE HOSPITAL WILL NOT COLLECT. THE COSTING METHODOLOGY USED WAS THE RATIO OF PATIENT CARE COST-TO-CHARGES. NO BAD DEBT AMOUNTS WERE INCLUDED IN COMMUNITY BENEFIT. FINANCIAL STATEMENT FOOTNOTE: THE HOSPITAL REPORTS PATIENT ACCOUNTS RECEIVABLE FOR SERVICES RENDERED AT NET REALIZABLE AMOUNTS FROM THIRD-PARTY PAYERS, PATIENTS AND OTHERS. THE HOSPITAL PROVIDES AN ALLOWANCE FOR DOUBTFUL ACCOUNTS BASED UPON A REVIEW OF OUTSTANDING RECEIVABLES, HISTORICAL COLLECTION INFORMATION AND EXISTING ECONOMIC CONDITIONS. AS A SERVICE TO THE PATIENT, THE HOSPITAL BILLS THIRD-PARTY PAYERS DIRECTLY AND BILLS THE PATIENT WHEN THE PATIENT'S LIABILITY IS DETERMINED. PATIENT ACCOUNTS RECEIVABLE ARE DUE IN FULL WHEN BILLED. ACCOUNTS ARE CONSIDERED DELINQUENT AND SUBSEQUENTLY WRITTEN OFF AS BAD DEBTS BASED ON INDIVIDUAL CREDIT EVALUATION AND SPECIFIC CIRCUMSTANCES OF THE ACCOUNT. PART III, LINE 8: THE COSTING METHODOLOGY USED TO DETERMINE MEDICARE ALLOWABLE COSTS WAS ALLOWABLE COST AS REPORTED IN OUR FISCAL YEAR 2011 MEDICARE COST REPORT. PART III, LINE 9B: THERE IS NO COLLECTION PRACTICE ON PATIENTS WHO QUALIFY FOR CHARITY. ANY PATIENT WHO SUBMITS AN APPLICATION FOR CHARITY AND MEETS THE GUIDELINES SET IN OUR CHARITY POLICY HAS THEIR ACCOUNT WRITTEN OFF WITH NO FURTHER COLLECTION EFFORT. NEEDS ASSESSMENT: THE HOSPITAL IS CONDUCTING A COMMUNITY NEEDS ASSESSMENT WHICH SHOULD BE COMPLETED SHORTLY. THE HOSPITAL HAS ALSO CONDUCTED A COMMUNITY PERCEPTION SURVEY TO HELP IDENTIFY AREAS TO IMPROVE PATIENT CARE OR THE NEED FOR ADDITIONAL SERVICES. PATIENT EDUCATION OF ELIGIBILITY FOR ASSISTANCE: INFORMATION REGARDING THE FINANCIAL ASSISTANCE PROGRAMS THAT THE HOSPITAL OFFERS IS LISTED ON THE HOSPITAL WEBSITE, AND IT IS PRINTED ON THE BOTTOM OF THE STATEMENTS THAT ARE MAILED TO THE PATIENTS. THE INFORMATION IS ALSO POSTED NEAR THE CASHIER'S WINDOW AND THE BUSINESS OFFICE STAFF ARE TRAINED TO PROVIDE THE INFORMATION TO PATIENTS THAT CALL INTO THE OFFICE AND DO NOT HAVE KNOWLEDGE OF THE PROGRAMS. COMMUNITY INFORMATION: THE COMMUNITY THAT THE ORGANIZATION SERVES CONSISTS OF ABOUT A TWELVE MILE RADIUS SURROUNDING STAUNTON AND THE COMMUNITIES WITHIN THAT RADIUS ARE: WORDEN, HAMEL, ALHAMBRA, LIVINGSTON, NEW DOUGLAS, MT. OLIVE, BENLD, GILLESPIE, BUNKER HILL, AND PRAIRIETOWN. THIS IS A RURAL AREA WITH A DEPRESSED ECONOMIC CLIMATE. MANY OF THE INDIVIDUALS ARE ELDERLY, POOR, AND INDIGENT WHICH RESULTS IN HIGHER NUMBERS OF MEDICARE AND MEDICAID RECIPIENTS. PROMOTION OF COMMUNITY HEALTH: THE HOSPITAL RESTOCKS THE AMBULANCES OF ANY SUPPLIES USED DURING THE TRANSPORT OF PATIENTS AT NO COST TO THE AMBULANCE SERVICE. THE HOSPITAL ALSO COMMITS SIGNIFICANT TIME AND RESOURCES TO ACTIVITIES AND SERVICES THAT MEET UNMET COMMUNITY NEEDS. MANY OF THESE ACTIVITIES ARE SPONSORED WITH THE KNOWLEDGE THAT THEY WILL NOT BE SELF-SUPPORTING OR FINANCIALLY VIABLE. SUCH PROGRAMS INCLUDE HEALTH SCREENINGS AND ASSESSMENTS, PARENTAL EDUCATION AND CARE, SUPPORT FOR VITAL COMMUNITY SERVICES, TRAUMA CARE, COMMUNITY EDUCATIONAL SERVICES, AND VARIOUS SUPPORT GROUPS. THE HOSPITAL PARTICIPATES IN EVENTS AND HEALTH FAIRS IN EACH OF THE COMMUNITIES WITHIN THE SERVICE AREA, AND IT DONATES STAFF LABOR, SUPPLIES, AND OTHER GOODS. X X X false false false false false false false false false JOSHUA POOS 191981 0 0 0 0 0 0 0 13726 0 205707 0 0 0 ILLINOIS FINANCE AUTHORITY 861091967 NONEAVAIL 2010-06-25 780000 5500 SQ. FT. MEDICAL OFFICE BUILDI false false false 64744 780000 780000 2010 false false true true false false false false false 0.00000 0.00000 0.00000 true false false false false false true SIGNIFICANT CHANGES TO PROGRAM SERVICES FORM 990, PART III, LINE 3 COMMUNITY MEMORIAL HOSPITAL SOLD ITS HOME HEALTH DEPARTMENT AND NO LONGER PROVIDES HOME HEALTH SERVICES. HOME HEALTH SERVICES ARE PROVIDED BY VNA TIP, TO WHOM THE HOSPITAL SOLD THE DEPARTMENT. GOVERNING BODY AND MANAGEMENT PART VI, SECTION A, LINES 6 & 7A COMMUNITY MEMORIAL HOSPITAL HAS ONE CLASS OF MEMBERS WHICH SHALL BE ENTITLED TO ONE REPRESENTATION AND ONE VOTE IN ALL MEETINGS OF COMMUNITY MEMORIAL HOSPITAL. THE ANNUAL MEETING OF THE MEMBERS IS HELD FOR THE PURPOSE OF ELECTING TRUSTEES AND TRANSACTING SUCH OTHER BUSINESS AS MAY COME BEFORE THE MEETING. EACH MEMBER IS ENTITLED TO ONE VOTE. FORM 990 REVIEW PROCESS PART VI, SECTION B, LINE 11 THE CEO AND CFO OF THE ORGANIZATION REVIEW THE FORM 990 PRIOR TO FILING. COMPLIANCE WITH CONFLICT OF INTEREST POLICY PART VI, SECTION B, LINE 12C THE CONFLICT OF INTEREST POLICY AND A DISCLOSURE STATEMENT ARE PRESENTED TO OFFICERS, DIRECTORS OR TRUSTEES AND KEY EMPLOYEES ANNUALLY. THE DISCLOSURE STATEMENT MUST BE RETURNED AND IS REVIEWED BY FINANCIAL AUDITORS AND HOSPITAL ADMINISTRATION. PROCESS FOR DETERMINING COMPENSATION PART VI, SECTION B, LINE 15A & 15B THE BOARD OF TRUSTEES CONDUCTS AN ANNUAL EVALUATION OF OFFICERS AND KEY EMPLOYEES. THEY USE COMPARABILITY DATA RECEIVED FROM AN INDEPENDENT CONSULTANT AND SET SALARY BASED UPON COMPARABILITY DATA AND THEIR JOB PERFORMANCE. DECISIONS ARE DOCUMENTED IN THE BOARD MINUTES. PROCESS FOR MAKING GOVERNING DOCUMENTS AVAILABLE TO THE PUBLIC PART VI, SECTION C, LINE 19 COMMUNITY MEMORIAL HOSPITAL MAKES ITS GOVERNING DOCUMENTS, CONFLICT OF INTEREST POLICY AND FINANCIAL STATEMENTS AVAILABLE TO THE PUBLIC UPON REQUEST. OTHER CHANGES IN FUND BALANCES PART XI, LINE 5 CHANGE IN INTEREST IN FOUNDATION -57,185