2011-02-19T14:42:19-06:00 2010-03-31 RSM MCGLADREY INC ONE SOUTH WACKER DRIVE SUITE 800 CHICAGO IL 606063392 990 2009-04-01 361703630 ROSELAND COMMUNITY HOSPITAL ASSOCIATION ROSE 7739953000 45 WEST 111TH STREET CHICAGO IL 60628 EARMON IRONS JR 7739953000 2011-02-19 1 Zack Fortsch 3126343400 2009 2016-02-24 21:20:13Z earmon irons JR 45 WEST 111TH STREET CHICAGO IL 60628 76179350 0 X WWW.ROSELANDHOSPITAL.ORG X 1924 IL SHORT-TERM GENERAL ACUTE CARE HOSPITAL, ER, AND COMMUNITY CLINIC. 14 12 604 40 0 0 531965 577065 63573323 74202841 101702 18950 394633 1380494 64601623 76179350 0 0 22125114 25739546 0 0 36845337 44527517 58970451 70267063 5631172 5912287 31282022 35425765 24785097 22944398 6496925 12481367 PROVIDES GENERAL HEALTH CARE SERVICES TO RESIDENTS WITHIN THE PULLMAN, RIVERDALE, AND ROSELAND NEIGHBORHOODS, INCLUDING INPATIENT, OUTPATIENT, EMERGENCY ROOM PHYSICIAN AND OTHER SERVICES. 0 0 57259577 74202841 ROSELAND COMMUNITY HOSPITAL HAS PROVIDED THE COMMUNITY WITH QUALITY MEDICAL AND HEALTHCARE SERVICES FOR OVER 70 YEARS. THEY PROVIDE THE FOLLOWING CLINICS TO ACCOMODATE THE NEEDS OF THE SURROUNDING COMMUNITIES: URGENT CARE - HIV, PEDIATRIC CARDIOLOGY, PEDIATRIC ASTHMA/ALLERGY, STROKE STUDY, EAR, NOSE AND THROAT. 57259577 1 1 0 0 0 0 0 0 0 1 0 1 0 0 0 0 0 0 0 0 1 0 0 1 0 0 0 0 0 1 1 1 0 0 0 0 0 1 1 0 0 1 76 0 1 604 1 0 0 0 0 0 0 0 0 0 14 12 0 0 0 0 0 0 0 1 1 0 0 0 1 1 1 1 1 1 1 0 IL X ANWAR KINTE 7739953000 45 WEST 111TH STREET CHICAGO IL 60628 DIAN POWELL X X 0 0 0 EARMON IRONS JR X X 0 0 0 SHIRLEY PICKETT X X 0 0 0 SALIM AL NURRIDIN X 0 0 0 CRAIG WASHINGTON X 0 0 0 ALMEDA DUNN X 0 0 0 CATHERINE NICHOLS X 0 0 0 GENIVEE CHAPMAN X 0 0 0 LARRY MITCHELL X 0 0 0 ALAN JACKSON X 0 0 0 RONALD BLACKSTONE X 0 0 0 TUNJI LADIPO X 0 0 0 JAI DEV ARYA X 0 0 0 TERROLD BUTLER X 0 0 0 ANTHONY PUORRO 38.00 X 242876 0 9332 RON KROL 38.00 X 127801 0 9293 JOY WEST 49.00 X 434735 0 5600 OLGA ERESE 54.00 X 137549 0 9138 ADELE VANJACKSON 43.00 X 127038 0 6708 GLORIA GONZALES 49.00 X 116607 0 9626 JOSEPH AYOOLA 43.00 X 120351 0 0 1306957 0 49697 14 0 1 0 EMERGENCY MEDICAL SPECIALIST 1012 LAKE SHORE BLVD EVANSTON IL 60202 ER PHYSICIAN SERVICES 1380000 TOTAL SECURITY MANAGEMENT 17W220 W 22ND STREET SUITE 350 OAK BROOK IL 60181 SECURITY 661112 CRAWFORD AVENUE ANESTHESIA 19627 LA GRANGE ROAD MOKENA IL 60448 ANESTHESIA 473983 EXTEND HEALTHCARE LLC 500 WEST MAIN SUITE 14 HENDERSONVILLE TN 37075 COLLECTION AGENCY 380221 SPECIAL CARE HOSPITAL MANAGEMENT 514 EARTH CITY PLAZA EARTH CITY MO 63045 DETOX SERVICES 330080 5 575734 1331 577065 NET PATIENT REVENUE 621110 39274993 39274993 MEDICARE/MEDICAID 621110 34927848 34927848 74202841 17950 17950 89140 89140 89140 89140 1000 1000 1000 1000 settlement award 900099 925000 925000 MISCELLANEOUS 900099 207112 207112 CAFETERIA 722210 118376 118376 40866 40866 1291354 76179350 74202841 0 1399444 556833 556833 21550727 16111033 5439694 1974513 1429873 544640 1657473 1208298 449175 162658 162658 30000 30000 11199309 8231814 2967495 14380 14380 31345 24386 6959 135645 31186 104459 353693 257842 95851 1004844 732531 272313 1108853 808354 300499 BAD DEBT 19234003 19234003 SUPPLIES 5863295 4570068 1293227 MEDICAID ASSESSMENT TAX 3037666 3037666 OTHER MISC. EXPENSES 294544 82764 211780 2057282 1499759 557523 70267063 57259577 13007486 0 9333328 9148427 5227809 6985597 462355 495710 136926 840004 39318289 22414000 14392855 16904289 54994 1673755 1051738 31282022 35425765 13824063 12698508 4833332 4666664 6127702 5579226 24785097 22944398 X 6436597 12409212 60328 72155 6496925 12481367 31282022 35425765 X 0 1 1 X 0 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 923853 923853 23528925 16375723 7153202 73398 73398 13707861 5624496 8083365 1084252 413781 670471 16904289 SELF-INSURANCE LIABILITIES 5412558 CAPITAL LEASE OBLIGATIONS 166668 5579226 Part X: Description of Uncertain Tax Positions Under FIN 48: On April 1, 2009, the Hospital adopted the accounting standard on accounting for uncertainty in income taxes, which addresses the determination of whether tax benefits claimed or expected to be claimed on a tax return should be recorded in the financial statements. Under this guidance, the Hospital may recognize the tax benefit from an uncertain tax position only if it is more likely than not that the tax position will be sustained on examination by taxing authorities, based on the technical merits of the position. Examples of tax positions include the tax-exempt status of the Hospital, and various positions related to the potential sources of unrelated business taxable income. The tax benefits recognized in the financial statements from such a position are measured based on the largest benefit that has a greater than 50 percent likelihood of being realized upon ultimate settlement. The guidance on accounting for uncertainty in income taxes also addresses de-recognition, classification, interest and penalties on income taxes, and accounting in interim periods. 1 1 1 X 1 X 600.000000000000 1 1 0 1 1 822666 822666 0.01170 19635828 21633853 -1998025 0.00000 20458494 21633853 -1175359 0.01170 20458494 21633853 -1175359 0.01170 1 5193180 1298295 14722293 13263995 1458298 X 1 1 roseland hospital

45 w 111th street chicago IL 60628

X X X Part I, Line 6a: ROSELAND FILES AN ANNUAL COMMUNITY BENEFIT REPORT WITH THE ILLINOIS ATTORNEY GENERAL'S OFFICE. Part I, Line 7: COST TO CHARGE RATIO WAS CALCULATED USING THE IRS'S SCHEDULE H WORKSHEET 2. Part I, Line 7f: BAD DEBT EXPENSE IS $19,234,003 Part III, Line 4: Per U.S. Census data, the communities serviced by Roseland Community Hospital have a significantly higher unemployment rate than the overall population:Chicago Community Area Unemployment Rates (2007)Community Unemployment RateROSELAND - 19.70%PULLMAN - 19.70%SOUTH DEERING - 13.20%WEST PULLMAN - 19.70%RIVERDALE - 19.70%CHICAGO TOTAL - 9.0%Furthermore, the average median household income for the communities served by the hospital is 18.4% lower than the City of Chicago (per the U.S. Census). Based on these demographic factors, the hospital estimates that at least 25% of the hospital's bad debt expense, or $1,298,295 could be reasonably attributable to patients who likely would qualify for financial assistance under the hospital's charity care policy, if sufficient information had been available to make a determination of their eligibility. Part III, Line 9b: 2. Needs Assessment: The hospital performs a community health care needs assessment on an annual basis utilizing data from the Cook County Health Department, Illinois Department of Public Health, Partnership for a Better Roseland (community focus group), and the hospital patient database. In October 2010 the Board of Trustees of Roseland Community Hospital commissioned an outside consulting firm, The Sibery Group, to conduct a strategic fit analysis of 12 potential clinical service lines. The healthcare needs of the Roseland community were identified as a component of this analysis, and community need was one of six metrics used to evaluate the strategic fit of each service line.3. Patient education of eligibility for assistance: The hospital contracts with DECO, an outsourced agency, to assists uninsured patients that receive services at Roseland Community Hospital. A daily census listing of all uninsured inpatients and any outpatients with charges of $1,500 or more is provided to DECO. The DECO representatives work closely with the Physicians, Social Workers, Nursing, Dialysis Center, Shelters and others in helping patients qualify. They have assisted approximately 20 patients per month to qualify for financial coverage. Roseland Community Hospital also offers those patients that are not eligible for Federal assistance the opportunity to qualify for charity care. The annually updated federal income/poverty guidelines are utilized as the criteria for the qualification of charity care. Under special circumstances, such as severe illnesses or severe financial burden, charity may be allowed outside of the formula-driven charity allowances. 4. Community information: For purposes of this plan, all statistical references to the "Community" refer to the population residing in the Community Areas (CA) defined by the city of Chicago as Roseland (49), Pullman (50), South Deering (51), West Pullman (53) and Riverdale (54).The five CA combined have a population of 125,091 and are overwhelmingly African American. However, Hispanics represent 30% of the population in the South Deering CA. South Deering is within 8 blocks of the Roseland community. The average median household income for the 5 CAs is $31,530 with Roseland being the highest at $38,237.00; and Riverdale lowest at $13,178.00 (2000 US Census). The average median household income for the City of Chicago is $38,625.Heart disease is the highest cause of death in each of the CAs. Roseland and West Pullman have significantly higher percentage of deaths from heart disease - 405.3% and 327.6% respectively. Cancer deaths are highest in Roseland, West Pullman and South Deering. According to findings from the Metropolitan Chicago Breast Cancer Task Force, African American women are twice as likely to die from breast cancer as their non-hispanic white counterparts even though White Women have a higher incidence of breast cancer.While in 1996, the mortality rates for African Americans and non-hispanic whites was equal; the disparity for African American women has steadily declined according to the MCBCTF study completed in Chicago 2007."Minority groups, particularly Blacks in the United States, are assumed to be genetically predisposed to virtually all common chronic diseases. The correlation between the use of unsupported genetic inferences and the social standing of a group is glaring evidence of bias and demonstrates how race is used both to categorize and to rank order subpopulations."* Cooper et al., NEJM, 348:12, 1166-70, 20035. Community Building Activities: Roseland Community Hospital participated in the following community organizations through Board membership or event sponsorship:-US Census Bureau Complete Count Committee-Metropolitan Family Services of Chicago-Nehemiah Restoration Coalition-Roseland Cease Fire -University of Illinois Extension Program-Dunne Elementary SchoolRoseland Community Hospital donated community meeting space for the following groups or organizations:-Chicago Police Department -Rush University Women's Walking Program -Healthcare Consortium of Illinois-Community of African American Mental Health Professionals-US Census Complete Count Committee-Chicago State University - The Group Monetary donations were made to the following social programs in 2010:-Metropolitan Family Services-Monarch Awards Foundation -Youth 1st Counseling & Elite Community CounselingRoseland Community Hospital hosted community fundraisers to benefit the following causes in 2010:-Haiti Relief - raised more than $10,000.00-Blistery Night - Coats, Hats, gloves donated to more than 80 families-Annual Gift Drive for Families in Roseland Christian Ministries Shelter6. Promoting the Health of the Community: Roseland Community Hospital hosted and funded the following community health workshops and events in 2010 - all were available to any community member at no charge:- "Who's Loving You" Caregivers Workshop"- "Fatherhood and Men's Health"- "Living with Diabetes"- "Breast Cancer Prevention and Awareness"- "How to Get a Job and Keep It"- "Aging Heart"- "Blood Donation Drive"Roseland Community Hospital also provided free health screenings to more than 600 community residents in 2010 at churches, schools, and other community organizations. IL X X X 0 1 0 0 0 0 0 0 0 ANTHONY PUORRO 242876 0 0 0 0 0 22000 0 18792 0 283668 0 0 0 JOY WEST 434735 0 0 0 0 0 0 0 15015 0 449750 0 0 0 Part I, Line 4a ROSELAND HAS A SUPPLEMENTAL EMPLOYEE RETIREMENT PLAN (SERP) IN 2009. THE FOLLOWING AMOUNTS WERE CONTRIBUTED: ANTHONY PUORRO - $22,000 ALAN JACKSON OWNER OF PREVENTATIVE CARDIOVASCULAR AND DIRECTOR OF THE GOVERNING BODY 126000 PHYSICIAN SERVICES 0 TUNJI LADIPO OWNER OF EMERGENCY MEDICAL SPECIALIST AND DIRECTOR OF THE GOVERNING BODY 1380000 ER PHYSICIAN SERVICES 0 Form 990, Part VI, Section B, line 11 Financial staff gathered the information necessary to prepare the return. The tax advisors prepared and reviewed the tax return prior to the CFO's review and filing of the tax return. The final Form 990 will be provided to the board of directors after the filing date. Form 990, Part VI, Section B, line 12c SIGNED DOCUMENT SUBMITTED ANNUALLY AND KEPT ON FILE. ANY POTENTIAL CONFLICTS ARE EXAMINED AND ACTIONS ARE TAKEN TO RESOLVE OR DISCLOSE SUCH CONFLICTS. Form 990, Part VI, Section B, line 15 ROSELAND SECURED THE SERVICES OF AN OUTSIDE COMPENSATION CONSULTANT TO PERFORM A SALARY SURVEY FOR KEY EXECUTIVES, INCLUDING THE CEO. THE COMPENSATION COMMITTEE RECOMMENDS A SALARY THAT IS SUBSEQUENTLY REVIEWED BY THE BOARD OF DIRECTORS BEFORE APPROVAL BY BOARD. Form 990, Part VI, Section C, line 19 THE FINANCIAL STATEMENTS ARE AVAILABLE THROUGH THE OFFICE OF THE ILLINOIS ATTORNEY GENERAL. CONFLICTS OF INTEREST AND ROSELAND COMMUNITIES HOSPITAL'S GOVERNING DOCUMENTS ARE NOT MADE AVAILABLE TO THE PUBLIC. ROSELAND COMMUNITY HOSPITAL FOUNDATION 45 W 111TH STREET CHICAGO IL 606284294 270428068 SUPPORTING ORGANIZATION IL 501(c)(3) Line 11b, II N/A 0 0 0 0 0 0 0 0 0 0 0 0 1 0 0 0 0 0 ROSELAND COMMUNITY HOSPITAL FOUNDATION M 0