2022-08-29T10:56:08-05:00 2021-12-31 410746749 CLIFTONLARSONALLEN LLP 475 REGENCY PARK SUITE 175 OFALLON IL 62269 990 2021-01-01 376062326 PANA COMMUNITY HOSPITAL ASSOCIATION PANA 2175622131 101 EAST NINTH STREET PANA IL 62557 KATRINA CASNER PRESIDENT & CEO 2175622131 2022-08-25 1 KATRINA CASNER 999009999 JEFF PARKER P00970069 6182331200 2022-08-25 3 AAL1 IAL1 2021 2022-09-23 18:48:47Z KATRINA CASNER 101 EAST NINTH STREET PANA IL 62557 35287662 0 X WWW.PANAHOSPITAL.COM X 1966 IL TO BE A LEADING PARTNER IN ASSURING COMMUNITY-BASED QUALITY HEALTH CARE. 11 10 392 10 5688 0 4877919 2824896 26551416 32060873 158585 279932 94440 121961 31682360 35287662 0 0 0 0 15226971 16476635 0 0 57810 13834133 14426918 29061104 30903553 2621256 4384109 49959736 52819444 15947144 14033510 34012592 38785934 X TO BE A LEADING PARTNER IN ASSURING COMMUNITY-BASED QUALITY HEALTH CARE. 0 0 22685383 0 32199885 TO PROVIDE HEALTH CARE SERVICES TO THE CITIZENS OF PANA, ILLINOIS AND THE SURROUNDING AREA. THESE SERVICES INCLUDE NURSING, EMERGENCY AND ANCILLARY SERVICES FOR 743 INPATIENT DAYS, 22,446 OUTPATIENT ADMISSIONS, 5,079 EMERGENCY VISITS AND 479 OUTPATIENT SURGICAL PATIENTS.WE PROMOTE A VISION STRIVING TO DEVELOP A COMPREHENSIVE SYSTEM OF HEALTHCARE SERVICES, IN PARTNERSHIP WITH THE OTHER COMMUNITY HEALTHCARE PROVIDERS, TO ASSIST OUR SERVICE AREA RESIDENTS IN REACHING THEIR PERSONAL MAXIMUM FOR HEALTH; TO PROVIDE PROGRAMS THAT PROMOTE HEALTH EDUCATION AND WELLNESS; TO ENHANCE OUR PERSONALIZED CARE CONCEPT IN THE PROVISION OF SERVICES TO OUR COMMUNITY; TO MAINTAIN AN ENVIRONMENT WHICH PROMOTES SATISFACTION AND OPPORTUNITY FOR THE PATIENT, THEIR FAMILY, THE EMPLOYEE, AND THE PHYSICIAN; TO MAINTAIN THE HOSPITAL'S ABILITY TO SUPPORT THE DELIVERY OF QUALITY HEALTH CARE AT A REASONABLE COST, IN ACCORDANCE WITH COMMUNITY NEEDS AND THE HEALTH CARE REGULATORY ENVIRONMENT; AND TO DEMONSTRATE BY ACTIONS AND RESULTS OUR COMMITMENT TO CONTINUOUS QUALITY IMPROVEMENT. 0 0 -139012 THE HOSPITAL MAINTAINS RECORDS TO IDENTIFY AND MONITOR THE LEVEL OF CHARITY CARE IT PROVIDES. THE HOSPITAL PROVIDES 100% CHARITY CARE TO PATIENTS WHOSE INCOME LEVEL IS BELOW 200% OF THE FEDERAL POVERTY LEVEL. FOR PATIENTS WHOSE INCOME LEVEL IS BETWEEN 200% AND 300% OF THE FEDERAL POVERTY LEVEL, THE HOSPITAL PROVIDES 50% CHARITY CARE. THE HOSPITAL USES COST AS THE MEASUREMENT BASIS FOR CHARITY CARE DISCLOSURE PURPOSES WITH THE COST BEING IDENTIFIED AS THE DIRECT AND INDIRECT COSTS OF PROVIDING THE CHARITY CARE. CHARITY CARE INCLUDES THE AMOUNT OF COSTS FORGONE FOR SERVICES AND SUPPLIES FURNISHED UNDER ITS CHARITY CARE POLICY. CHARITY CARE COST WAS DETERMINED ON THE APPLICATION OF THE ASSOCIATED COST-TO-CHARGE RATIOS. 22685383 1 1 0 1 0 0 0 0 0 0 1 0 0 0 0 1 0 1 0 0 0 0 0 0 0 0 1 1 0 0 1 1 0 0 0 0 0 0 0 0 1 0 0 0 0 0 0 1 1 1 0 0 1 15 0 392 1 1 1 0 0 0 0 0 0 0 0 0 0 0 X 11 10 0 0 0 0 1 1 0 1 1 0 0 0 1 1 1 1 1 1 1 0 IL X JAMES MOON CFO 2175622131 101 EAST NINTH STREET PANA IL 62557 MATT BEAVERS CHAIRMAN (TERM ENDED) 1.50 0.00 X X 0 0 0 RICK SCHMITZ CHAIRMAN 1.50 0.00 X X 0 0 0 SARAH MYER VICE CHAIRMAN 1.50 0.00 X X 0 0 0 CHARLES O'MALLEY TREASURER 1.50 0.00 X X 0 0 0 DR DAVID LETT DIRECTOR 1.50 0.00 X 0 0 0 DAVE DORN JR SECRETARY 1.50 0.00 X X 0 0 0 DAVE SLATER DIRECTOR 1.50 0.00 X 0 0 0 JIM BREWER DIRECTOR 1.50 0.00 X 0 0 0 GREGORY HOLTHAUS DIRECTOR 1.50 0.00 X 0 0 0 DR TERRY CUNNINGTON DIRECTOR, PHYSICIAN 40.00 0.00 X 358406 0 14061 KENNETH FLESCH DIRECTOR 1.50 0.00 X 0 0 0 PASTOR AMANDA RICHARDS DIRECTOR (TERM ENDED) 1.50 0.00 X 0 0 0 REV LEON GOFF DIRECTOR 1.50 0.00 X 0 0 0 KATRINA CASNER PRESIDENT & CEO 40.00 1.50 X 222849 0 15336 JAMES MOON CFO 40.00 1.50 X 136466 0 8805 VICKIE COEN CCO & CNE 40.00 0.00 X 145484 0 5214 DIANNE BAILEY CIO 40.00 0.00 X 106609 0 12847 ROBERT LUDWIG CRNA 40.00 0.00 X 192451 0 11808 DR MARLON MUNESES PHYSICIAN 40.00 1.50 X 296776 0 16468 DR CATHERINE TEODORO PHYSICIAN 40.00 0.00 X 190683 0 9165 DR DEMOSTHENES ASUNCION PHYSICIAN 40.00 0.00 X 242727 0 9134 MARC SCHOLES NURSE PRACTICIONER 40.00 0.00 X 192250 0 13427 2084701 0 116265 19 0 1 0 CROSSROADS EMERGENCY PHYSICIANS LLP PO BOX 674579 DALLAS TX 752677979 EMERGENCY PHYSICIANS 1853529 CERNER CORPORATION 2800 ROCKCREEK PARKWAY KANSAS CITY MO 64117 SUPPORT/MAINT 1015396 YAP FAMILY PRACTICE LTD 2979 LINDBERG BLVD SPRINGFIELD IL 62704 PHYSICIAN SERVICES 254534 HILLSBORO AREA HOSPITAL 1200 E TREMONT HILLSBORO IL 62049 PHYSICIAN SERVICES 209615 HSHS MEDICAL GROUP 3051 HOLLIS DR SPRINGFIELD IL 62704 PHYSICIAN SERVICES 137128 9 346 2791578 32972 2824896 PATIENT CARE SERVICES 621110 31778624 31778624 340B PHARMACY REVENUE 621110 200860 200860 OTHER OPERATING REVENUE 621110 81389 81389 32060873 279932 279932 68838 0 68838 68838 68838 CAFETERIA & VENDING 722514 47435 47435 CATERING 722320 5688 5688 53123 35287662 32060873 5688 396205 X 1026077 357568 668509 12022796 9939765 2037341 45690 284645 217520 66039 1086 2653010 1952772 690909 9329 490107 352929 135473 1705 88286 88286 75503 75503 12553 12553 4527367 4148123 379244 53369 53369 406119 347488 58631 938290 744304 193986 493130 16564 476566 158854 158854 36504 23504 13000 267007 267007 2189394 2189394 251042 42885 208157 MEDICAL SUPPLIES 2125884 2125884 BAD DEBT EXPENSE 1509831 1509831 MCAID PROVIDER ASSESSME 568295 568295 OTHER SUPPLIES 253845 253845 471645 179097 292548 30903553 22685383 8160360 57810 1425 1425 15479532 16440153 3076052 3562041 40739 107405 542235 605893 107333 178195 44695078 19029439 25378183 25665639 4102069 4673610 123870 302522 60921 43999 1047377 1238562 49959736 52819444 2723342 3667243 5470585 2995284 6738197 6539083 1015020 831900 15947144 14033510 X 34012592 38785934 34012592 38785934 49959736 52819444 X 4384109 335581 53652 X X 0 1 X 1 1 1 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 0 0 0 0 0 0 0 0 1 12553 12553 0 PART II-B, LINE 1: WE PARTICIPATE INDIRECTLY WITH LOBBYING ACTIVITIES THROUGH OUR MEMBERSHIPS IN THE ILLINOIS HOSPITAL ASSOCIATION AND THE AMERICAN HOSPITAL ASSOCIATION. 51361 51361 30800472 10079571 20720901 3017777 948283 2069494 10684164 8001585 2682579 141304 141304 25665639 X PART X, LINE 2: AT DECEMBER 31, 2021 AND 2020, THERE WERE NO UNRECOGNIZED TAX BENEFITS IDENTIFIED OR RECORDED. PRESENTLY, THERE ARE NO ONGOING INCOME TAX AUDITS OR UNRESOLVED DISPUTES WITH THE TAX AUTHORITIES THAT THE ORGANIZATION CURRENTLY FILES OR HAS FILED WITH. 1 1 X 1 X 1 X 1 1 0 0 625014 625014 0.02020 5464481 4693825 770656 0.02490 6089495 4693825 1395670 0.04510 48501 3018 45483 0.00150 43929 43929 0.00140 5296586 3294648 2001938 0.06480 5389016 3297666 2091350 0.06770 11478511 7991491 3487020 0.11280 1 1509831 905898 8542792 8294548 248244 X 1 0 1 1 PANA COMMUNITY HOSPITAL 101 EAST 9TH STREET PANA IL 62557 WWW.PANAHOSPITAL.COM 0001776 X X X X PANA COMMUNITY HOSPITAL 1 0 0 1 X X X X X X X X X 19 1 0 0 1 X SEE PART V, PG.8 FOR URL X 1 19 1 SEE PART V, PG.8 FOR URL 0 1 X 200.000000000000 300.000000000000 X X 1 1 X X X X 1 X SEE NOTE ON THE FOLLOWING PAGES FOR FULL URL OF FAP X SEE NOTE ON FOLLOWING PAGES FOR FULL URL OF FAP APPLICATION X SEE NOTE ON FOLLOWING PAGES FOR FULL URL OF FAP PLAIN LANGUAGE SUMMARY X X X 1 X 0 X X X X 1 X 0 0 PANA COMMUNITY HOSPITAL PART V, SECTION B, LINE 5: PCH CONSULTED THE CHRISTIAN COUNTY HEALTH DEPT. AND CONDUCTED COMMUNITY MEETINGS WHICH A DIVERSE BACKGROUND OF INDIVIDUALS COULD ATTEND. ALL OF THIS WAS DONE UNDER THE DIRECTION OF A CONSULTANT FROM THE ILLINOIS CRITICAL ACCESS HOSPTIAL NETWORK.DATA WAS ALSO GATHERED REPRESENTING THE BROAD INTERESTS OF THE COMMUNITY. THE HOSPITAL TOOK INTO ACCOUNT INPUT FROM PERSONS WHO REPRESENT THE BROAD INTERESTS OF THE COMMUNITY SERVED BY THE HOSPITAL, INCLUDING THOSE WITH SPECIAL KNOWLEDGE OF, OR EXPERTISE IN PUBLIC HEALTH (LOCAL, REGIONAL, STATE AND/OR TRIBAL). MEMBERS OF MEDICALLY UNDERSERVED, LOW-INCOME, AND MINORITY POPULATIONS SERVED BY THE HOSPITAL OR INDIVIDUALS OR ORGANIZATIONS REPRESENTING THE INTERESTS OF SUCH POPULATIONS ALSO PROVIDED INPUT. PANA COMMUNITY HOSPITAL PART V, SECTION B, LINE 11: A) ACCESS TO LOCAL SERVICES FOR MENTAL HEALTH: ACCESS TO BEHAVIORAL HEALTH COUNSELING FOR ALL AGES, ACCESS TO PSYCHIATRISTS FOR ALL AGES, ACCESS TO LOCAL SERVICES FOR SUBSTANCE USE DISORDERS, ACCESS TO MEDICATION ASSISTED TREATMENT FOR PERSONS WITH OPIOID USE DISORDERSACTIONS THE HOSPITAL INTENDS TO TAKE TO ADDRESS THE MENTAL HEALTH NEED:1) EXPLORE OFFERING TELEPSYCHIATRY2) EXPLORE COLLABORATING WITH OTHER HOSPITALS TO PROVIDE MENTAL HEALTH SERVICES, INCLUDING HILLSBORO AREA HOSPITAL AND CARLINVILLE AREA HOSPITAL3) SUPPORT THE PROFESSIONAL DEVELOPMENT OF AN INTERNAL CANDIDATE FOR LICENSED CLINICAL SOCIAL WORKER CERTIFICATION4) EXPLORE SUPPORTING A LOCAL PHYSICIAN WITH OFFERING MEDICATION ASSISTED TREATMENTB) IMPROVING LIFE SKILLS: FOR YOUTH, YOUNG ADULTS, PERSONS AT-RISK FOR SUBSTANCE ABUSE, AND GRANDPARENTS RAISING GRANDCHILDRENACTIONS THE HOSPITAL INTENDS TO TAKE TO ADDRESS THE IMPROVING LIFE SKILLS NEED:1) EXPLORE COLLABORATION WITH SCHOOLS TO PROVIDE EDUCATION AND PROGRAMMING FOR YOUTH2) EXPLORE COLLABORATION WITH THE PUBLIC HEALTH DEPARTMENT TO PROVIDE COMMUNITY EDUCATION AND PROGRAMMING TO IMPROVE LIFE SKILLS OF YOUNG ADULTS AND PERSONS AT-RISK FOR SUBSTANCE ABUSE3) EXPLORE COLLABORATION WITH THE PUBLIC HEALTH DEPARTMENT TO IMPROVE THE SKILLS AND ABILITIES OF GRANDPARENTS RAISING GRANDCHILDREN4) EXPLORE COLLABORATION WITH OTHER HOSPITALS IN THE COUNTY AND THE AREA TO DEVELOP LIFE SKILLS EDUCATION AND PROGRAMMING5) EXPLORE COLLABORATION WITH FAITH-BASED ORGANIZATIONS TO PROMOTE IMPROVEMENT OF LIFE SKILLS IN THE COMMUNITY6) EXPLORE COLLABORATION WITH THE PUBLIC HEALTH DEPARTMENT TO PROVIDE EDUCATION ABOUT TEEN PREGNANCY AND AWARENESS OF THE HIGH LOCAL TEEN PREGNANCY RATEC) ADDRESS THE NEEDS OF HOMELESS IN THE COMMUNITY: ADDRESS THE NEEDS OF YOUTH AND YOUNG ADULTS WITH NO FIXED PLACE OF RESIDENCE, ADDRESS THE NEEDS OF TRANSIENT HOMELESSACTIONS THE HOSPITAL INTENDS TO TAKE TO ADDRESS THE NEEDS OF HOMELESS:1) PANA COMMUNITY HOSPITAL RECOGNIZES HOMELESSNESS AS A COMPLEX COMMUNITY ISSUE THAT INCLUDES BOTH LOCAL RESIDENTS THAT HAVE BECOME HOMELESS, IN THE SENSE THAT THEY HAVE NO PERMANENT FIXED PLACE OF RESIDENCE FOR ANY OF A VARIETY OF REASONS AND THOSE WHO ARE TRANSIENT TO THE COMMUNITY AND HAVE NO SHELTER OR OTHER BASIC NEEDS2) PANA COMMUNITY HOSPITAL DOES PROVIDE A VARIETY OF SERVICES TO HOMELESS PERSONS THAT MAY PRESENT AT THE EMERGENCY ROOM AND WILL CONTINUE THOSE SERVICES AS ARE REASONABLE AND APPROPRIATE. IN ADDITION, PANA COMMUNITY HOSPITAL STANDS READY TO ASSIST THE PUBLIC HEALTH DEPARTMENT, COUNTY BOARD, CITY COUNCIL AND THE FAITH-BASED COMMUNITY OR OTHER APPROPRIATE AUTHORITIES OR PROVIDERS IN THEIR EFFORTS TO ADDRESS THIS ISSUED) MAINTAIN THE VITALITY AND VIABILITY OF THE COMMUNITY AS A SAFE AND HEALTHY PLACE FOR ALL AGES TO LIVE AND THRIVE.ACTIONS THE HOSPITAL INTENDS TO TAKE TO ADDRESS THE COMMUNITY VIABILITY NEED:1) INCREASE ITS PARTICIPATION IN PANA PRIDE2) SHARE RESOURCES ABOUT THE COMMUNITY DEVELOPMENT WITH CITY LEADERSHIP3) COLLABORATE WITH PANA PRIDE, CITY GOVERNMENT, BUSINESSES, SCHOOLS, THE FAITH-BASED COMMUNITY AND OTHERS TO MAINTAIN A SAFE, HEALTHY COMMUNITY WITH A QUALITY OF LIFE WHERE CURRENT AND FUTURE RESIDENTS WILL HAVE THE CHANCE TO THRIVE PANA COMMUNITY HOSPITAL PART V, SECTION B, LINE 13B: THE COST OF THE SERVICE MAY IMPACT AN INDIVIDUAL'S ELIGIBILITY FOR FINANCIAL ASSISTANCE. PRESUMPTIVE ELIGIBILITY FOR FREE CARE IS AVAILABLE FOR INDIVIDUALS WHO ARE HOMELESS, MENTALLY INCAPACITATED WITH NOBODY TO ACT ON THEIR BEHALF, MEDICAID ELIGIBLE (BUT NOT ON THE DATE OF SERVICE), FILING PERSONAL BANKRUPCTY, DECEASED WITH NO ESTATE, INCARCERATED IN A PENAL INSTITUTION, OR AFFILIATED WITH A RELIGIOUS ORDER AND TAKING A VOW OF POVERTY.BASED ON THE GUIDANCE FROM THE ILLINOIS ATTORNEY GENERAL'S OFFICE, PANA DETERMINES THE DISCOUNT PERCENT REQUIRED TO GIVE UNINSURED PATIENTS AT 300% OF FPG. THE SAME DISCOUNT IS GIVEN TO UNDERINSURED. PANA COMMUNITY HOSPITAL PART V, SECTION B, LINE 7A:URL FOR CHNA:HTTP://WWW.PANAHOSPITAL.COM/ABOUT/COMMUNITY-HEALTH-NEEDS-ASSESSMENT- PANA COMMUNITY HOSPITAL PART V, SECTION B, LINE 10A:URL FOR IMPLEMENTATION STRATEGY:HTTP://WWW.PANAHOSPITAL.COM/ABOUT/COMMUNITY-HEALTH-NEEDS-ASSESSMENT- PANA COMMUNITY HOSPITAL PART V, SECTION B, LINE 16A:URL FOR FAP:HTTPS://PANAHOSPITAL.COM/PATIENTS-AND-VISITORS/PATIENTS-AND-VISITORS/PROFILE/FINANCIAL-ASSISTANCE PANA COMMUNITY HOSPITAL PART V, SECTION B, LINE 16B:URL FOR FAP APPLICATION:HTTPS://PANAHOSPITAL.COM/PATIENTS-AND-VISITORS/PATIENTS-AND-VISITORS/PROFILE/FINANCIAL-ASSISTANCE PANA COMMUNITY HOSPITAL PART V, SECTION B, LINE 16C:URL FOR FAP PLAIN LANGUAGE SUMMARY:HTTPS://PANAHOSPITAL.COM/PATIENTS-AND-VISITORS/PATIENTS-AND-VISITORS/PROFILE/FINANCIAL-ASSISTANCE 7 1 - COMMUNITY MEDICAL CLINIC OF PANA 101 EAST 9TH STREET PANA IL 62557 PHYSICIAN SATELLITE OFFICE 2 - QUAD COUNTY HOME HEALTH & HOSPICE 8 HUBER STREET PANA IL 62557 HOME HEALTH & HOSPICE AGENCY 3 - COMMUNITY MEDICAL CLINIC OF ASSUMPTION 118 N WALNUT STREET ASSUMPTION IL 62510 PHYSICIAN SATELLITE OFFICE 4 - COMMUNITY MEDICAL CLINIC OF RAMSEY 715 S SUPERIOR RAMSEY IL 62080 PHYSICIAN SATELLITE OFFICE 5 - COMMUNITY MEDICAL CLINIC OF NOKOMIS 120 CEDAR STREET NOKOMIS IL 62075 PHYSICIAN SATELLITE OFFICE 6 - PANA MEDICAL GROUP 217 SOUTH LOCUST STREET PANA IL 62557 PHYSICIAN SATELLITE OFFICE 7 - NOKOMIS MEDICAL GROUP 107 WEST STATE STREET NOKOMIS IL 62075 PHYSICIAN SATELLITE OFFICE PART I, LINE 3C: ELGIBILITY FOR FINANCIAL ASSISTANCE IS BASED ON FAMILY INCOME COMPARED TO FEDERAL POVERTY GUIDELINES AS WELL AS SUBMISSION OF A COMPLETE FINANCIAL ASSISTANCE APPLICATION. HOWEVER, IN THE FOLLOWING INSTANCES, AN INDIVIDUAL MAY PRESUMPTIVELY QUALIFY FOR 100% FINANCIAL ASSISTANCE WITHOUT SUBMITTING A FINANCIAL ASSISTANCE APPLICATION AND REGARDLESS OF THEIR INCOME: ENROLLMENT IN CERTAIN FEDERAL OR STATE PROGRAMS (E.G. WIC, SUPPLEMENTAL NUTRITION AND ASSISTANCE PROGRAM, ILLINOIS FREE BREAKFAST/LUNCH PROGRAM, TEMPORARY ASSISTANCE FOR NEEDY FAMILIES, ETC.), HOMELESSNESS, MENTAL INCAPACITATION WITH NO ONE TO ACT ON THE PATIENT'S BEHALF, MEDICAID ELIGIBILITY, RECENT PERSONAL BANKRUPTCY, DECEASED WITH NO ESTATE, INCARCERATION IN A PENAL INSTITUTION, AND AFFILIATION WITH A RELIGIOUS ORDER AND A VOW OF POVERTY. PART I, LINE 7: FINANCIAL ASSISTANCE AND CERTAIN OTHER COMMUNITY BENEFITS AT COST. 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 I, LN 7 COL(F): FINANCIAL ASSISTANCE AND CERTAIN OTHER COMMUNITY BENEFITS AT COST. THE ORGANIZATION HAD BAD DEBT EXPENSE IN THE AMOUNT OF $1,509,831 REPORTED ON PART IX, LINE 24. HOWEVER, IT HAS BEEN SUBTRACTED FOR PURPOSED OF CALCULATING THE PERCENTAGE IN THIS COLUMN. PART III, LINE 2: ACCOUNTS RECEIVABLE ARE REDUCTED BY AN ALLOWANCE FOR DOUBTFUL ACCOUNTS. IN EVALUATING THE COLLECTIBILITY OF ACCOUNTS RECEIVABLE, THE HOSPITAL ANALYZES ITS PAST HISTORY AND IDENTIFIES TRENDS FOR EACH OF ITS MAJOR PAYER SOURCES OF REVENUE TO ESTIMATE THE APPROPRIATE ALLOWANCE FOR DOUBTFUL ACCOUNTS AND BAD DEBT EXPENSE. MANAGEMENT REGULARLY REVIEWS DATA ABOUT THESE MAJOR PAYER SOURCES OF REVENUE IN EVALUATING THE SUFFICIENCY OF THE ALLOWANCE FOR DOUBTFUL ACCOUNTS. PART III, LINE 3: THE BAD DEBT EXPENSE REPORTED ON LINE 2 REPRESENTS THE EXPENSE REPORTED ON THE ATTACHED FINANCIAL STATEMENTS BASED ON NET REALIZABLE AMOUNTS FROM THIRD PARTY PAYERS, PATIENTS AND OTHERS. BAD DEBT EXPENSE IS DETERMINED BASED ON THE CRITERIA DESCRIBED ABOVE. IT IS ESTIMATED THAT APPROXIMATELY 60% OF OUR BAD DEBT EXPENSE QUALIFIES UNDER THE ORGANIZATION'S CHARITY CARE POLICY. THIS PERCENTAGE WAS DETERMINED BASED UPON ANALYSIS OF DEMOGRAPHICS AND RECORD REVIEWS. PART III, LINE 4: SEE NOTE 9: NET PATIENT SERVICE REVENUE ON PAGES 19-23 OF THE AUDITED FINANCIAL STATEMENTS. ALSO, SEE NOTE 1: PATIENT ACCOUNTS RECEIVABLE ON PAGE 9 OF THE AUDITED FINANCIAL STATEMENTS. PART III, LINE 8: MEDICARE. LINE 6 COSTS WERE TAKEN DIRECTLY FROM THE ORGANIZATION'S 12/31/21 MEDICARE COST REPORT.THE ORGANIZATION PARTICIPATES IN MEDICARE AND INCURS COSTS TO PROVIDE HEALTHCARE SERVICES TO MEDICARE BENEFICIARIES, WHO ARE A SIGNIFICANT PORTION OF OUR COMMUNITY. AS A DESIGNATED CRITICAL ACCESS HOSPITAL, THESE COSTS ARE REIMBURSED AT 101%, RESULTING IN THE SURPLUS REPORTED IN PART III, LINE 7. PART III, LINE 9B: THE COLLECTION PRACTICES FOLLOWED BY THE ORGANIZATION FOR PATIENTS WHO QUALIFY FOR CHARITY CARE OR FINANCIAL ASSISTANCE ARE ADDRESSED IN ITS HEALTHCARE ASSISTANCE POLICY. PART VI, LINE 2: NEEDS ASSESSMENT. THE ORGANIZATION ASSESSES THE HEALTH CARE NEEDS OF THE COMMUNITIES IT SERVES THROUGH STRATEGIC PLANNING ACTIVITIES THAT INCORPORATE ANALYSIS OF SERVICE AREA DEMOGRAPHICS AND STRUCTURED AND CONSISTENT PATIENT SURVEY PROCESSES. THE ORGANIZATION ALSO ASSESSES COMMUNITY HEALTH NEEDS THROUGH INPUT FROM ITS ACTIVE AND CONSULTING MEDICAL STAFF, COMMUNITY LEADERS, ORGANIZATION BOARD MEMBERS AND COUNTY HEALTH DEPARTMENTS. PART VI, LINE 3: PATIENT EDUCATION OF ELIGIBILITY FOR ASSISTANCE. THE ORGANIZATION INFORMS AND EDUCATES ITS PATIENTS REGARDING ASSISTANCE FROM FEDERAL, STATE, OR LOCAL GOVERNMENT PROGRAMS THROUGH ITS SOCIAL SERVICES DIRECTOR. THE ORGANIZATION INFORMS AND EDUCATES PATIENTS REGARDING ASSISTANCE FROM ITS CHARITY CARE POLICY THROUGH DISCUSSION AT REGISTRATION OR DISCHARGE, AN INFORMATIONAL DOCUMENT SENT WITH BILLING STATEMENTS AND A DESCRIPTION OF THE PROGRAM PLUS AN APPLICATION POSTED ON ITS WEBSITE. PART VI, LINE 4: COMMUNITY INFORMATION. THE ORGANIZATION SERVES A RURAL AREA THAT INCLUDES 13 SMALL COMMUNITIES. THE POPULATION OF THE SERVICE AREA TOTALS APPROXIMATELY 21,000 RESIDENTS. THE SIZE OF THE COMMUNITIES WE SERVE IN OUR SERVICE AREA RANGE FROM LESS THAN 150 TO APPROXIMATELY 5,800 RESIDENTS. OF THE 21,000 RESIDENTS, APPROXIMATELY 17% ARE BELOW THE FEDERAL POVERTY LEVEL AND THE PER CAPITA INCOME IS APPROXIMATELY $20,100. OUR SERVICE AREA POPULATION CONSISTS OF 17.01% MEDICAID AND APPROXIMATELY 2.44% UNINSURED. OUR ORGANIZATION PROVIDES SERVICES TO FEDERALLY-DESIGNATED MEDICALLY UNDERSERVED AREAS. PART VI, LINE 5: PROMOTION OF COMMUNITY HEALTH IS ONE OF THE VERY IMPORTANT RESPONSIBILITIES OF A COMMUNITY HOSPITAL. THE HOSPITAL, AS AN ORGANIZATION, FILLS THE ROLE AS THE FOCAL POINT OF THE COMMUNITY'S HEALTHCARE ACTIVITIES AND THE CATALYST WHICH BRINGS TOGETHER THE PRACTICING PHYSICIANS, OTHER HEALTHCARE PROVIDERS, COMMUNITY HEALTHCARE AGENCIES, AND OTHER HEALTHCARE FOCUSED RESOURCES TO MAINTAIN AND PRESERVE THE COMMUNITY'S HEALTH STATUS. THE ORGANIZATION IS GOVERNED BY A VOLUNTEER BOARD OF DIRECTORS THAT CONSIST OF INDIVIDUALS WHO RESIDE IN THE HOSPITAL'S SERVICE AREA. MEDICAL STAFF PRIVILEGES ARE EXTENDED TO ALL PHYSICIANS IN OUR SERVICE AREA. SURPLUS FUNDS GENERATED THROUGH THE PROVISION OF SERVICES ARE INVESTED IN IMPROVED PATIENT CARE TECHNOLOGIES AND ENHANCED TREATMENT AREAS SO THAT THE ORGANIZATION CAN CONTINUE TO PROVIDE QUALITY PATIENT CARE. PART VI, LINE 6: NOT APPLICABLE X X X X X X 0 0 0 0 0 0 0 1 0 DR TERRY CUNNINGTON DIRECTOR, PHYSICIAN 204815 0 153591 0 0 0 7542 0 6519 0 372467 0 0 0 DR MARLON MUNESES PHYSICIAN 295676 0 1100 0 0 0 9949 0 6519 0 313244 0 0 0 DR DEMOSTHENES ASUNCION PHYSICIAN 242727 0 0 0 0 0 0 0 9134 0 251861 0 0 0 KATRINA CASNER PRESIDENT & CEO 202148 0 20701 0 0 0 7932 0 7404 0 238185 0 0 0 MARC SCHOLES NURSE PRACTICIONER 108096 0 84154 0 0 0 4408 0 9019 0 205677 0 0 0 ROBERT LUDWIG CRNA 184951 0 7500 0 0 0 7089 0 4719 0 204259 0 0 0 DR CATHERINE TEODORO PHYSICIAN 189640 0 1043 0 0 0 7116 0 2049 0 199848 0 0 0 VICKIE COEN CCO & CNE 136848 0 8636 0 0 0 3114 0 2100 0 150698 0 0 0 PART I, LINE 7 MARLON MUNESES, TERRY CUNNINGTON AND CATHERINE TEODORO ARE COMPENSATED USING A BASE SALARY PLUS PRODUCTIVITY COMPENSATION. THE PRODUCTIVITY COMPENSATION IS CALCULATED BASED UPON MINIMUM LEVELS OF RECEIPTS GENERATED BY EACH PHYSICIAN. BONUSES ARE BASED ON COLLECTIONS. A CERTAIN PORTION OF COLLECTIONS ARE SHARED WITH THE PHYSICIANS AFTER REACHING A MINIMUM THRESHOLD. AFTER REACHING THE THRESHOLD, AN INCREASING % IS SHARED AS COLLECTIONS INCREASE. A THE COUNTY OF CHRISTIAN ILLINOIS 376000560 2018-02-22 7000000 EXPANSION AND RENOVATION PROJECT 0 0 0 A 363508 7000000 7000000 2019 0 0 1 1 A 0 1 1 1 0 0.00000 0.00000 0.00000 0 0 1 A 0 1 0 0 1 0 0 0 1 A 1 DR LAURIE CUNNINGTON WIFE OF DR. TERRY CUNNINGTON, A BOARD MEMBER 26000 EMPLOYED BY HOSPITAL 0 ANDREW CASNER SON OF KATRINA CASNER, PRESIDENT & CEO 49655 EMPLOYED BY HOSPITAL 0 FORM 990, PART VI, SECTION A, LINE 1A THE BOARD OF DIRECTORS HAS AN EXECUTIVE COMMITTEE CONSISTING OF THE OFFICERS AND ONE OTHER MEMBER OF THE BOARD OF DIRECTORS. THE EXECUTIVE COMMITTEE HAS THE POWER TO TRANSACT ALL REGULAR BUSINESS OF THE HOSPITAL DURING THE INTERIM BETWEEN THE REGULAR MEETINGS OF THE BOARD OF DIRECTORS, PROVIDED ANY ACTION TAKEN SHALL NOT CONFLICT WITH THE POLICIES AND EXPRESS WISHES OF THE BOARD OF DIRECTORS AND THAT IT SHALL REFER ALL MATTERS OF MAJOR IMPORTANCE TO THE BOARD OF DIRECTORS. FORM 990, PART VI, SECTION A, LINE 6 PANA COMMUNITY HOSPITAL HAS TWO CLASSES OF MEMBERS, KNOWN AS REGULAR MEMBERS AND LIFE MEMBERS. REGULAR MEMBERS CONSIST OF INDIVIDUALS WHO PAY THE APPROPRIATE MEMBERSHIP DUES TO PANA COMMUNITY HOSPITAL. LIFE MEMBERS CONSIST OF INDIVIDUALS WHO CONTRIBUTE $5000.00 OR MORE TO PANA COMMUNITY HOSPITAL OR PANA COMMUNITY HOSPITAL FOUNDATION, FOR THE PURPOSE OF SUPPORTING THE FINANCING OF BUILDING, EQUIPMENT, LIFE MEMBERSHIP, ENDOWMENT, OR ANY OTHER LAWFUL PURPOSE. FORM 990, PART VI, SECTION A, LINE 7A MEMBERS OF THE HOSPITAL VOTE FOR THE MEMBERS OF THE GOVERNING BODY DURING THE HOSPITAL'S ANNUAL MEETING. FORM 990, PART VI, SECTION B, LINE 11B THE ORGANIZATION CONTRACTS WITH A PUBLIC ACCOUNTING FIRM FOR THE PREPARATION OF THE FORM 990. THE RETURN IS PREPARED BASED ON INFORMATION PROVIDED BY FINANCIAL MANAGEMENT AND OTHERS WITHIN THE FOUNDATION. THE FORM 990 IS REVIEWED BY THE CFO PRIOR TO FILING WITH THE IRS. CFO PRESENTS A COPY OF FORM 990 TO THE GOVERNING BOARD FOR REVIEW. FORM 990, PART VI, SECTION B, LINE 12C ALL BOARD MEMBERS, MEMBERS OF THE MEDICAL STAFF, ADMINISTRATION AND DEPARTMENT MANAGERS ARE ASKED TO COMPLETE A CONFLICT OF INTEREST QUESTIONNIARE ANNUALLY. THE HUMAN RESOURCES MANAGER REVIEWS QUESTIONNAIRES AND PRESENTS ANY CONFLICTS NOTED TO THE PRESIDENT & CEO TO REVIEW AND RESOLVE. IF ANY CONFLICTS ARE NOTED, THE PRESIDENT & CEO, WITH BOARD APPROVAL, IMPOSES APPROPRIATE RESTRICTIONS ON THE INDIVIDUAL(S) WITH A CONFLICT OF INTEREST. FORM 990, PART VI, SECTION B, LINE 15 EACH YEAR THE BOARD OF DIRECTORS DETERMINES COMPENSATION FOR THE CEO, CCO/CNE AND THE CFO. THE BOARD USES COMPARATIVE COMPENSATION INFORMATION FROM THE ILLINOIS HOSPITAL ASSOCIATION TO DETERMINE THE ABOVE INDIVIDUALS' COMPENSATION. THIS PROCESS LAST TOOK PLACE IN 2021. FORM 990, PART VI, SECTION C, LINE 19 REQUESTS FOR THE ORGANIZATION'S GOVERNING DOCUMENTS AND CONFLICT OF INTEREST POLICY WILL BE EVALUATED ON A CASE-BY-CASE BASIS. IF DEEMED APPROPRIATE, THE DOCUMENT(S) WILL BE PROVIDED TO THE PUBLIC. THE ORGANIZATION'S AUDITED FINANCIAL STATEMENTS ARE AVAILABLE FOR THE PUBLIC TO REVIEW DURING THE ORGANIZATION'S ANNUAL MEETING. FORM 990, PART IX, LINE 11G IMAGING: PROGRAM SERVICE EXPENSES 535,108. MANAGEMENT AND GENERAL EXPENSES 0. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 535,108. EMERGENCY DEPARTMENT: PROGRAM SERVICE EXPENSES 1,858,216. MANAGEMENT AND GENERAL EXPENSES 0. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 1,858,216. LAB: PROGRAM SERVICE EXPENSES 132,210. MANAGEMENT AND GENERAL EXPENSES 0. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 132,210. OTHER: PROGRAM SERVICE EXPENSES 1,415,015. MANAGEMENT AND GENERAL EXPENSES 240,198. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 1,655,213. CONTRACT LABOR: PROGRAM SERVICE EXPENSES 207,574. MANAGEMENT AND GENERAL EXPENSES 139,046. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 346,620. FORM 990, PART XI, LINE 9: CHANGE IN VALUE OF AFFILIATE - QUAD COUNTY 53,652. FORM 990, PART XII, LINE 2C NO CHANGE IN PROCESS FROM PRIOR YEARS PANA COMMUNITY HOSPITAL FOUNDATION 101 EAST 9TH STREET PANA IL 62557 371293506 FUNDRAISING IL 501(C)(3) LINE 12A, I PANA COMMUNITY HOSPITAL ASSOCIATION 1 QUAD COUNTY HOME MEDICAL SUPPLIES & EQUIPMENT 1 HUBER STREET PANA IL 62557 371198049 EQUIPMENT RETAILER IL PANA COMMUNITY HOSPITAL C 126064 339420 1.00000 1 0 0 1 1 0 0 0 0 0 0 0 0 0 1 1 0 1 0 1 QUAD COUNTY HOME MEDICAL SUPPLIES & EQUIPMENT D 161899 GENERAL LEDGER