2011-03-02T13:51:00-06:00 2010-06-30 Kerber Eck & Braeckel LLP One Memorial Drive Ste 950 St Louis MO 63102 990 2009-07-01 370624255 Community Memorial Hospital Association COMM 6186352200 400 Caldwell Street Staunton IL 62088 Susie Campbell 6186352200 2011-02-22 1 Brent McClure 3142316232 2011-02-21 2009 2016-02-24 21:20:13Z Susie Campbell 400 Caldwell Street Staunton IL 62088 14498096 0 X WWW.STAUNTONSHOSPITAL.ORG X 1946 IL HEALTH CARE 9 8 175 23 0 0 86306 52268 13977254 14278971 -72760 94649 99983 72208 14090783 14498096 1000 0 6787162 6810902 0 0 7046084 7255790 13833246 14067692 257537 430404 11373142 12579369 1615219 2391042 9757923 10188327 To provide healthcare services to the community of Staunton and surrounding areas. 0 0 11310074 14278971 THE ORGANIZATION OPERATES A FULL SERVICE HOSPITAL IN STAUNTON, ILLINOIS WITH 25 TOTAL BEDS. TOTAL PATIENT DAYS WERE 1,392 OF WHICH APPROXIMATELY 86% WERE MEDICARE DAYS AND 4% WERE MEDICAID DAYS. THE HOSPITAL ALSO PROVIDED 6,593 HOME HEALTH CARE VISITS OF WHICH 5,130 WERE PROVIDED TO MEDICARE PATIENTS AND 479 WERE PROVIDED TO MEDICAID PATIENTS. 11310074 1 1 0 0 0 0 0 0 0 1 1 0 0 0 0 0 0 0 0 0 1 0 0 1 1 0 0 0 0 0 0 0 0 0 1 0 0 0 0 0 1 0 0 0 1 19 0 1 175 1 0 0 0 0 0 0 0 0 0 9 8 0 0 0 0 1 1 0 1 1 0 0 1 1 1 1 1 1 1 1 0 IL X DONALD BRUNNWORTH 6186352200 400 CALDWELL ST STAUNTON IL 62088 DON KASUBKE 1.00 X 0 0 0 LARRY LUX 1.00 X 0 0 0 BERNICE HENKE 1.00 X 0 0 0 HULDA BLACK 1.00 X 0 0 0 EDDY SARACCO 1.00 X 0 0 0 MIKE COX 1.00 X 0 0 0 WAYNE BROOKe 1.00 X 0 0 0 LARRY ZIGLAR 1.00 X 0 0 0 NICOLAS PINEDA MD 40.00 X X 156643 0 877 SUSIE CAMPBELL 40.00 X 131877 0 16913 DONALD BRUNNWORTH 40.00 X 122710 0 11411 DARRELL PAPE 40.00 X 107880 0 11557 Joshua Poos 40.00 X 179455 0 7178 698565 0 47936 5 0 1 1 EMERGENCY DEPARTMENT SERVICES PC 7032 COLLECTION CENTER DRIVE CHICAGO IL 60693 ER PHYSICIANS 765560 Alton Physical Therapy Services 1719 Clawson Alton IL 62002 Physical Therapy Services 382080 South Central Anesthesia LTD 7461 leslie Drive edwardsville IL 62025 Anesthesia Services 254200 QHR LLC 105 Continental Place Brentwood TN 37027 Management Services 231059 Quest Diagnostics PO Box 14730 St Louis MO 63150 Lab Service 186694 7 19360 32908 52268 PROGRAM SERVICE REVENU 900099 14278971 14278971 14278971 94124 94124 35540 35540 35540 35540 525 525 525 525 CAFETERIA 900099 36668 36668 36668 14498096 14278971 0 166857 1000 1000 395635 146143 249492 5133353 4599872 533481 109274 93991 15283 780066 680648 99418 392574 337668 54906 138086 138086 39374 39374 44135 44135 2350765 2295780 54985 19600 9542 10058 276839 118436 158403 247594 220127 27467 58677 46018 12659 23768 23768 587789 522582 65207 261009 237002 24007 Medical Supplies 1464326 1464326 Provision for bad Debts 1074830 1074830 equipment Rental 402954 349263 53691 Miscellaneous 100678 63420 37258 Hospital Provider Asses 75123 75123 90243 25365 64878 14067692 11310074 2757618 0 1730191 1708683 2405646 2464218 1985926 1971971 277279 274090 199460 175864 10626127 7011734 2752231 3614393 2022409 2370150 11373142 12579369 1171287 1270314 443932 1120728 1615219 2391042 X 9757923 10188327 9757923 10188327 11373142 12579369 X 0 1 1 X 0 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 443004 443004 2659107 2200008 459099 269258 143674 125584 6050508 4668052 1382456 1204250 1204250 3614393 CASH 320150 F CERTIFICATES OF DEPOSIT 375000 F REPURCHASE AGREEMENTS 1675000 F 2370150 14498096 14067692 430404 0 430404 14497096 -1000 -1000 14498096 0 14498096 14066692 0 14066692 1000 1000 14067692 Part XII, Line 2d - Other Adjustments: Scholarship: -1000. Part XIII, Line 4b - Other Adjustments: Scholarship: 1000. Part X, Line 2: The Hospital is a not-for-profit organization under Section 501(c)(3) of the Internal Revenue Code and is exempt from income taxes on related income under Section 501(a) of the Code and similar provisions of state law. Effective July 1, 2009, the Hospital adopted the standards for accounting for uncertainty in income taxes. These standards prescribe a comprehensive model for financial statement recognition, measurement, classification and disclosure of uncertain tax positions. The implementation of the standards had no effect on net assets as of July 1, 2009. The Hospital continually evaluates the effects of all tax positions taken including expiring statutes of limitations, tax examinations, unrelated business income and new authoritative rulings. The Hospital files federal informational returns. The statutes of limitations for informational returns filed for the years ended June 30, 2007 through 2010 have not expired and therefore are subject to examination. 1 1 X 1 X 1 X 0 1 0 0 28664 28664 0.00220 1596905 807773 789132 0.06070 1625569 807773 817796 0.06290 27230 27230 0.00210 5236 5236 0.00040 32466 32466 0.00250 1658035 807773 850262 0.06540 1 556172 0 5069491 5007236 62255 X 1 1 Community Memorial Hospital

400 Caldwell Street Staunton IL 62088

X X X X Part I, Line 7: The cost to charges ratio was used as derived from Worksheet 2, Ratio of patient care cost-to-charges. 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: Text of footnote from the financial statementsIn line with its mission, the Hospital provides a safety net for the communities served to access much needed health 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. Part III, Line 8: The costing methodology used to determine Medicare allowable cost was the cost to charge ratio from our Fiscal Year 2010 Medicare Cost Report as shown at the bottom of the Schedule H worksheet, Worksheet 2. 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. Part VI, Line 2: The hospital has conducted two focus groups to gather information. One group consisted of health care providers and consisted of the Macoupin County Public Health Director, administrators of nursing homes and the assisted living center, pharmacists, ambulance provider and physicians. The second focus group consisted of community leaders who help provide resources to people in need and this group consisted of schoolsuperintendents, township supervisors, representative of the community college and others. A Town Hall was also hosted; however, therewas very low turnout. A survey will also be sent to approximately 10-20 patients that live in the communities that we serve asking for additionalinput in community health needs. This information is then summarized and prioritized and will be presented to the Board of Trustees for review. Part VI, Line 3: 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. Part VI, Line 4: The community that the organization serves consists of about a twelve (12) 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 individules are elderly, poor and indigent which results in higher numbers of Medicare and Medicaid recipients. Part VI, Line 6: 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 0 0 0 0 0 0 0 0 0 NICOLAS PINEDA MD 156643 0 0 0 0 0 0 0 877 0 157520 0 0 0 Joshua Poos 179455 0 0 0 0 0 0 0 7178 0 186633 0 0 0 Supplemental Information Part III The CEO, Susie Campbell, and CFO, Donald Brunnworth, of Community Memorial Hospital were employed by a management company, Quorum Health Resources, until March 19, 2009. The following amounts are amounts that were paid by Quorum Health Resources. Wages received by the CEO and CFO from 1/1/09 to 3/19/09 were $35,085 and $39,054, respectively. Benefits received by the CEO and CFO from 1/1/09 to 3/19/09 were $9,831 and $10,943, respectively. Illinois Finance Authority 861091967 NONEaVAIL 2010-06-25 780000 5500 sq. ft medical office building 0 0 780000 780000 2010 0 0 1 1 0 0 0 0 0 0.00000 0.00000 0.00000 1 0 0 0 0 0 1 Larry Ziglar Larry Ziglar is president at first National Bank and a director of CMH 780000 First National Bank purchased the bonds that were issued to Community Memorial Hospital on June 25, 2010. 0 Form 990, Part VI, Section A, line 6 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. Form 990, Part VI, Section A, line 7a 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, Part VI, Section B, line 11 The CEO and CFO of the organization review the form 990 prior to filing. Form 990, Part VI, Section B, line 12c The conflict of interest policy and a disclosure statement is 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. Form 990, Part VI, Section B, line 15 the Board of trustees does 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 perfomance. Decisions are documented in the board minutes. Form 990, 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 written request. Friends of Community Memorial Hospital Foundation 400 Caldwell Staunton IL 62088 363913722 Donations To CMH IL Section 501(C)(3) Line 9 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0