FORT MADISON COMMUNITY HOSPITAL: Form 990, tax year 2018
View the entire original 990 at ProPublica ↗
- Organization
- FORT MADISON COMMUNITY HOSPITAL (EIN 42-1081055)
- Tax period
- 2018-10-01 to 2019-09-30
- Filed
- 2020-08-14
- IRS object ID
- 202042279349300744
- Schema version
- 2018v3.2
- Source
- Download XML · Original 990 at ProPublica
Every field in the e-filed return. Faint text is the IRS element name, for citing.
- Return header
- Form 990
- Schedule A
- Schedule B
- Schedule C
- Schedule D
- Schedule H
- Schedule I
- Schedule J
- Schedule O
- Schedule R
Return header ReturnHeader
| Field | Value | IRS element (for citing) |
|---|---|---|
| Return | 2020-08-14T10:01:08-05:00 | ReturnTs |
| Tax Period End | 2019-09-30 | TaxPeriodEndDt |
Preparer Firm PreparerFirmGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Preparer Firm EIN | 420714325 | PreparerFirmEIN |
Preparer Firm Name PreparerFirmName
| Field | Value | IRS element (for citing) |
|---|---|---|
| Business Name Line1 | RSM US LLP | BusinessNameLine1Txt |
Preparer US Address PreparerUSAddress
| Field | Value | IRS element (for citing) |
|---|---|---|
| Address Line1 | 4650 E 53RD ST | AddressLine1Txt |
| City | DAVENPORT | CityNm |
| State Abbreviation | IA | StateAbbreviationCd |
| ZIP | 528073479 | ZIPCd |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Return Type | 990 | ReturnTypeCd |
| Tax Period Begin | 2018-10-01 | TaxPeriodBeginDt |
Filer Filer
| Field | Value | IRS element (for citing) |
|---|---|---|
| EIN | 421081055 | EIN |
Business Name BusinessName
| Field | Value | IRS element (for citing) |
|---|---|---|
| Business Name Line1 | FORT MADISON COMMUNITY HOSPITAL | BusinessNameLine1Txt |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Business Name Control | FORT | BusinessNameControlTxt |
| Phone | 3193726530 | PhoneNum |
US Address USAddress
| Field | Value | IRS element (for citing) |
|---|---|---|
| Address Line1 | 5445 AVENUE O PO BOX 174 | AddressLine1Txt |
| City | FORT MADISON | CityNm |
| State Abbreviation | IA | StateAbbreviationCd |
| ZIP | 52627 | ZIPCd |
Business Officer BusinessOfficerGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Person | DAN LINHART | PersonNm |
| Person Title | VICE PRESIDENT OF FINANCE | PersonTitleTxt |
| Phone | 3193726530 | PhoneNum |
| Signature | 2020-08-14 | SignatureDt |
| Discuss With Paid Preparer | Yes (1) | DiscussWithPaidPreparerInd |
Preparer Person PreparerPersonGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Preparer Person | JENIFER L CHASE | PreparerPersonNm |
| PTIN | P01306883 | PTIN |
| Phone | 5638884000 | PhoneNum |
Filing Security Information FilingSecurityInformation
IP Address IPAddress
| Field | Value | IRS element (for citing) |
|---|---|---|
| I Pv4 Address | 173.20.82.182 | IPv4AddressTxt |
| Field | Value | IRS element (for citing) |
|---|---|---|
| IP | 2020-08-14 | IPDt |
| IP Tm | 09:47:45 | IPTm |
| IP Timezone | CD | IPTimezoneCd |
| Filing License Type | P | FilingLicenseTypeCd |
| At Submission Creation Device Id | DA39A3EE5E6B4B0D3255BFEF95601890AFD80709 | AtSubmissionCreationDeviceId |
| At Submission Filing Device Id | 9D8C4631151EF1E1BB3DDB3444689A82E6B5C400 | AtSubmissionFilingDeviceId |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Tax | 2018 | TaxYr |
| Build TS | 2020-09-23 17:36:50Z | BuildTS |
Form 990 IRS990
| Field | Value | IRS element (for citing) |
|---|---|---|
| Principal Officer | JEREMY ALEXANDER | PrincipalOfficerNm |
US Address USAddress
| Field | Value | IRS element (for citing) |
|---|---|---|
| Address Line1 | 5445 AVENUE O PO BOX 174 | AddressLine1Txt |
| City | FORT MADISON | CityNm |
| State Abbreviation | IA | StateAbbreviationCd |
| ZIP | 52627 | ZIPCd |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Gross Receipts | $70,660,441 | GrossReceiptsAmt |
| Group Return For Affiliates | 0 | GroupReturnForAffiliatesInd |
| Organization501c3 | Yes (X) | Organization501c3Ind |
| Website Address | WWW.FMCHOSP.COM | WebsiteAddressTxt |
| Type Of Organization Corp | Yes (X) | TypeOfOrganizationCorpInd |
| Formation | 1977 | FormationYr |
| Legal Domicile State | IA | LegalDomicileStateCd |
| Activity Or Mission | TO ADVANCE THE HEALTH AND WELL BEING OF ALL PEOPLE THROUGH COMPASSIONATE QUALITY CARE, EDUCATION AND COMMUNITY SERVICE. | ActivityOrMissionDesc |
| Voting Members Governing Body | 7 | VotingMembersGoverningBodyCnt |
| Voting Members Independent | 7 | VotingMembersIndependentCnt |
| Total Employee | 542 | TotalEmployeeCnt |
| Total Volunteers | 20 | TotalVolunteersCnt |
| Total Gross UBI | $45,225 | TotalGrossUBIAmt |
| Net Unrelated Bus Txbl Incm | $0 | NetUnrelatedBusTxblIncmAmt |
| PY Contributions Grants | $200,000 | PYContributionsGrantsAmt |
| CY Contributions Grants | $12,810,999 | CYContributionsGrantsAmt |
| PY Program Service Revenue | $51,289,933 | PYProgramServiceRevenueAmt |
| CY Program Service Revenue | $53,508,433 | CYProgramServiceRevenueAmt |
| PY Investment Income | $521,408 | PYInvestmentIncomeAmt |
| CY Investment Income | $454,168 | CYInvestmentIncomeAmt |
| PY Other Revenue | $4,674,778 | PYOtherRevenueAmt |
| CY Other Revenue | $3,886,841 | CYOtherRevenueAmt |
| PY Total Revenue | $56,686,119 | PYTotalRevenueAmt |
| CY Total Revenue | $70,660,441 | CYTotalRevenueAmt |
| PY Grants And Similar Paid | $36,100 | PYGrantsAndSimilarPaidAmt |
| CY Grants And Similar Paid | $2,046,100 | CYGrantsAndSimilarPaidAmt |
| PY Benefits Paid To Members | $0 | PYBenefitsPaidToMembersAmt |
| CY Benefits Paid To Members | $0 | CYBenefitsPaidToMembersAmt |
| PY Salaries Comp Emp Bnft Paid | $36,651,193 | PYSalariesCompEmpBnftPaidAmt |
| CY Salaries Comp Emp Bnft Paid | $36,708,691 | CYSalariesCompEmpBnftPaidAmt |
| PY Total Prof Fndrsng Expns | $0 | PYTotalProfFndrsngExpnsAmt |
| CY Total Prof Fndrsng Expns | $0 | CYTotalProfFndrsngExpnsAmt |
| CY Total Fundraising Expense | $0 | CYTotalFundraisingExpenseAmt |
| PY Other Expenses | $24,905,635 | PYOtherExpensesAmt |
| CY Other Expenses | $23,181,761 | CYOtherExpensesAmt |
| PY Total Expenses | $61,592,928 | PYTotalExpensesAmt |
| CY Total Expenses | $61,936,552 | CYTotalExpensesAmt |
| PY Revenues Less Expenses | -$4,906,809 | PYRevenuesLessExpensesAmt |
| CY Revenues Less Expenses | $8,723,889 | CYRevenuesLessExpensesAmt |
| Total Assets BOY | $55,938,673 | TotalAssetsBOYAmt |
| Total Assets EOY | $61,295,317 | TotalAssetsEOYAmt |
| Total Liabilities BOY | $14,744,388 | TotalLiabilitiesBOYAmt |
| Total Liabilities EOY | $8,619,118 | TotalLiabilitiesEOYAmt |
| Net Assets Or Fund Balances BOY | $41,194,285 | NetAssetsOrFundBalancesBOYAmt |
| Net Assets Or Fund Balances EOY | $52,676,199 | NetAssetsOrFundBalancesEOYAmt |
| Info In Schedule O Part III | Yes (X) | InfoInScheduleOPartIIIInd |
| Mission | TO ADVANCE THE HEALTH AND WELL BEING OF ALL PEOPLE THROUGH COMPASSIONATE QUALITY CARE, EDUCATION AND COMMUNITY SERVICE. | MissionDesc |
| Significant New Program Srvc | 0 | SignificantNewProgramSrvcInd |
| Significant Change | 0 | SignificantChangeInd |
| Expense | $52,309,400 | ExpenseAmt |
| Grant | $2,046,100 | GrantAmt |
| Revenue | $57,177,097 | RevenueAmt |
| Desc | FORT MADISON COMMUNITY HOSPITAL IS A GENERAL MEDICAL AND SURGICAL HOSPITAL, LOCATED IN FORT MADISON, IOWA, TO MEET THE HEALTHCARE NEEDS OF ITS COMMUNITIES AS WELL AS PROVIDE PROGRAMS AND SERVICES AIMED AT HEALTH, SAFETY, EDUCATION, PREVENTION, AND OVERALL HEALTH AND WELLNESS. IN SO DOING, THEY STRENGTHEN THEIR ROLE AS A PARTNER IN THE COMMUNITY BY IMPROVING THE HEALTH OF AREA CITIZENS AND THE QUALITY OF LIFE IN THE COMMUNITIES THEY SERVE. FORT MADISON COMMUNITY HOSPITAL (FMCH) IS COMMITTED TO PROVIDING HEALTH CARE SERVICES TO AREA RESIDENTS. FMCH SERVES THE RESIDENTS OF SOUTHEAST IOWA AND WEST CENTRAL ILLINOIS. THE 50 BED HOSPITAL HAD 1,288 PATIENT ADMISSIONS AND 3,300 PATIENT DAYS OF MEDICAL CARE. THIS INCLUDED 431 PATIENT ACCOUNTS WHO RECEIVED UNCOMPENSATED CARE. HEALTH SERVICES AND CARE PROVIDED BY FMCH INCLUDE: PHYSICIANS AND SURGEONS PRACTICING IN THE FOLLOWING AREAS: FAMILY PRACTICE, INTERNAL MEDICINE, OBSTETRICS & GYNECOLOGY, ORTHOPEDICS & SPORTS MEDICINE, PEDIATRICS, PSYCHIATRY, SURGERY AND UROLOGY; BIRTHPLACE SERVICES; SPECIALTY CLINICS IN THE FOLLOWING AREAS: CARDIOLOGY, DERMATOLOGY, OTOLARYNGOLOGY, GASTROENTEROLOGY AND NEUROLOGY; EMERGENCY DEPARTMENT SERVICES; HOME HEALTH CARE; HOSPICE; REHABILITATION/THERAPY SERVICES; LABORATORY AND PATHOLOGY SERVICES; AND WOUND HEALING CARE. | Desc |
| Total Program Service Expenses | $52,309,400 | TotalProgramServiceExpensesAmt |
| Described In Section501c3 | Yes (1) | DescribedInSection501c3Ind |
| Schedule B Required | Yes (1) | ScheduleBRequiredInd |
| Political Campaign Acty | 0 | PoliticalCampaignActyInd |
| Lobbying Activities | Yes (1) | LobbyingActivitiesInd |
| Subject To Proxy Tax | 0 | SubjectToProxyTaxInd |
| Donor Advised Fund | 0 | DonorAdvisedFundInd |
| Conservation Easements | 0 | ConservationEasementsInd |
| Collections Of Art | 0 | CollectionsOfArtInd |
| Credit Counseling | 0 | CreditCounselingInd |
| Temp Or Permanent Endowments | 0 | TempOrPermanentEndowmentsInd |
| Report Land Building Equipment | Yes (1) | ReportLandBuildingEquipmentInd |
| Report Investments Other Sec | 0 | ReportInvestmentsOtherSecInd |
| Report Program Related Invst | Yes (1) | ReportProgramRelatedInvstInd |
| Report Other Assets | 0 | ReportOtherAssetsInd |
| Report Other Liabilities | 0 | ReportOtherLiabilitiesInd |
| Include FIN48 Footnote | 0 | IncludeFIN48FootnoteInd |
| Independent Audit Fincl Stmt | 0 | IndependentAuditFinclStmtInd |
| Consolidated Audit Fincl Stmt | 0 | ConsolidatedAuditFinclStmtInd |
| School Operating | 0 | SchoolOperatingInd |
| Foreign Office | 0 | ForeignOfficeInd |
| Foreign Activities | 0 | ForeignActivitiesInd |
| More Than5000 K To Org | 0 | MoreThan5000KToOrgInd |
| More Than5000 K To Individuals | 0 | MoreThan5000KToIndividualsInd |
| Professional Fundraising | 0 | ProfessionalFundraisingInd |
| Fundraising Activities | 0 | FundraisingActivitiesInd |
| Gaming Activities | 0 | GamingActivitiesInd |
| Operate Hospital | Yes (1) | OperateHospitalInd |
| Audited Financial Stmt Att | Yes (1) | AuditedFinancialStmtAttInd |
| Grants To Organizations | Yes (1) | GrantsToOrganizationsInd |
| Grants To Individuals | 0 | GrantsToIndividualsInd |
| Schedule J Required | Yes (1) | ScheduleJRequiredInd |
| Tax Exempt Bonds | 0 | TaxExemptBondsInd |
| Engaged In Excess Benefit Trans | 0 | EngagedInExcessBenefitTransInd |
| PY Excess Benefit Trans | 0 | PYExcessBenefitTransInd |
| Loan Outstanding | 0 | LoanOutstandingInd |
| Grant To Related Person | 0 | GrantToRelatedPersonInd |
| Business Rln With Org Mem | 0 | BusinessRlnWithOrgMemInd |
| Business Rln With Fam Mem | 0 | BusinessRlnWithFamMemInd |
| Business Rln With Officer Ent | 0 | BusinessRlnWithOfficerEntInd |
| Deductible Non Cash Contri | 0 | DeductibleNonCashContriInd |
| Deductible Art Contribution | 0 | DeductibleArtContributionInd |
| Terminate Operations | 0 | TerminateOperationsInd |
| Partial Liquidation | 0 | PartialLiquidationInd |
| Disregarded Entity | 0 | DisregardedEntityInd |
| Related Entity | Yes (1) | RelatedEntityInd |
| Related Organization Ctrl Ent | Yes (1) | RelatedOrganizationCtrlEntInd |
| Transaction With Control Ent | Yes (1) | TransactionWithControlEntInd |
| Trnsfr Exmpt Non Chrtbl Rltd Org | 0 | TrnsfrExmptNonChrtblRltdOrgInd |
| Activities Conducted Prtshp | 0 | ActivitiesConductedPrtshpInd |
| Schedule O Required | Yes (1) | ScheduleORequiredInd |
| IRP Document | 90 | IRPDocumentCnt |
| IRP Document W2 G | 0 | IRPDocumentW2GCnt |
| Backup Wthld Compliance | Yes (1) | BackupWthldComplianceInd |
| Employee | 542 | EmployeeCnt |
| Employment Tax Returns Filed | Yes (1) | EmploymentTaxReturnsFiledInd |
| Unrelated Bus Incm Over Limit | Yes (1) | UnrelatedBusIncmOverLimitInd |
| Form990 T Filed | Yes (1) | Form990TFiledInd |
| Foreign Financial Account | 0 | ForeignFinancialAccountInd |
| Prohibited Tax Shelter Trans | 0 | ProhibitedTaxShelterTransInd |
| Taxable Party Notification | 0 | TaxablePartyNotificationInd |
| Nondeductible Contributions | 0 | NondeductibleContributionsInd |
| Quid Pro Quo Contributions | 0 | QuidProQuoContributionsInd |
| Form8282 Property Disposed Of | 0 | Form8282PropertyDisposedOfInd |
| Rcv Fnds To Pay Prsnl Bnft Cntrct | 0 | RcvFndsToPayPrsnlBnftCntrctInd |
| Pay Premiums Prsnl Bnft Cntrct | 0 | PayPremiumsPrsnlBnftCntrctInd |
| Indoor Tanning Services | 0 | IndoorTanningServicesInd |
| Subj To Tax Rmnrtn Ex Prcht Pymt | 0 | SubjToTaxRmnrtnExPrchtPymtInd |
| Subject To Excs Tax Net Invst Inc | 0 | SubjectToExcsTaxNetInvstIncInd |
| Info In Schedule O Part VI | Yes (X) | InfoInScheduleOPartVIInd |
| Governing Body Voting Members | 7 | GoverningBodyVotingMembersCnt |
| Independent Voting Member | 7 | IndependentVotingMemberCnt |
| Family Or Business Rln | 0 | FamilyOrBusinessRlnInd |
| Delegation Of Mgmt Duties | Yes (1) | DelegationOfMgmtDutiesInd |
| Change To Org Documents | 0 | ChangeToOrgDocumentsInd |
| Material Diversion Or Misuse | 0 | MaterialDiversionOrMisuseInd |
| Members Or Stockholders | Yes (1) | MembersOrStockholdersInd |
| Election Of Board Members | Yes (1) | ElectionOfBoardMembersInd |
| Decisions Subject To Approva | Yes (1) | DecisionsSubjectToApprovaInd |
| Minutes Of Governing Body | Yes (1) | MinutesOfGoverningBodyInd |
| Minutes Of Committees | Yes (1) | MinutesOfCommitteesInd |
| Officer Mailing Address | 0 | OfficerMailingAddressInd |
| Local Chapters | 0 | LocalChaptersInd |
| Form990 Provided To Gvrn Body | 0 | Form990ProvidedToGvrnBodyInd |
| Conflict Of Interest Policy | Yes (1) | ConflictOfInterestPolicyInd |
| Annual Disclosure Covered Prsn | Yes (1) | AnnualDisclosureCoveredPrsnInd |
| Regular Monitoring Enfrc | Yes (1) | RegularMonitoringEnfrcInd |
| Whistleblower Policy | Yes (1) | WhistleblowerPolicyInd |
| Document Retention Policy | Yes (1) | DocumentRetentionPolicyInd |
| Compensation Process CEO | Yes (1) | CompensationProcessCEOInd |
| Compensation Process Other | Yes (1) | CompensationProcessOtherInd |
| Investment In Joint Venture | 0 | InvestmentInJointVentureInd |
| Upon Request | Yes (X) | UponRequestInd |
Books In Care Of Detail BooksInCareOfDetail
Business Name BusinessName
| Field | Value | IRS element (for citing) |
|---|---|---|
| Business Name Line1 | FORT MADISON COMMUNITY HOSPITAL | BusinessNameLine1Txt |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Phone | 3193726530 | PhoneNum |
US Address USAddress
| Field | Value | IRS element (for citing) |
|---|---|---|
| Address Line1 | 5445 AVENUE O PO BOX 174 | AddressLine1Txt |
| City | FORT MADISON | CityNm |
| State Abbreviation | IA | StateAbbreviationCd |
| ZIP | 526270174 | ZIPCd |
Form990 Part VII Section A Form990PartVIISectionAGrp (16 entries)
| TitleTitleTxt | Average Hours Per WeekAverageHoursPerWeekRt | Individual Trustee Or DirectorIndividualTrusteeOrDirectorInd | Reportable Comp From OrgReportableCompFromOrgAmt | Reportable Comp From Rltd OrgReportableCompFromRltdOrgAmt | Other CompensationOtherCompensationAmt | OfficerOfficerInd | Highest Compensated EmployeeHighestCompensatedEmployeeInd |
|---|---|---|---|---|---|---|---|
| DEANNA BARR | |||||||
| DIRECTOR | 2.00 | Yes (X) | $0 | $0 | $0 | ||
| NEAL DODD | |||||||
| DIRECTOR | 2.00 | Yes (X) | $0 | $0 | $0 | ||
| JOANN LAMPE | |||||||
| DIRECTOR | 2.00 | Yes (X) | $0 | $0 | $0 | ||
| JOHN MCKILLIP | |||||||
| DIRECTOR | 2.00 | Yes (X) | $0 | $0 | $0 | ||
| ANN MENKE | |||||||
| PRESIDENT | 2.00 | Yes (X) | $0 | $0 | $0 | Yes (X) | |
| DAVID POLAND | |||||||
| VICE PRESIDENT | 2.00 | Yes (X) | $0 | $0 | $0 | Yes (X) | |
| VICKI STEPHENSON | |||||||
| DIRECTOR | 2.00 | Yes (X) | $0 | $0 | $0 | ||
| DANIEL LINHART | |||||||
| VICE PRESIDENT OF FINANCE | 40.00 | $0 | $0 | $0 | Yes (X) | ||
| SHELBY BURCHETT | |||||||
| COO | 40.00 | $122,797 | $0 | $10,563 | Yes (X) | ||
| DAVID PIKE | |||||||
| FORMER INTERIM CFO | 40.00 | $151,250 | $0 | $36,638 | Yes (X) | ||
| JEREMY ALEXANDER | |||||||
| CEO/SECRETARY | 40.00 | $328,460 | $0 | $45,435 | Yes (X) | ||
| W RIGGS BAGAN MD | |||||||
| PHYSICIAN | 40.00 | $366,588 | $0 | $37,613 | Yes (X) | ||
| DEREK L BREDER MD | |||||||
| PHYSICIAN | 40.00 | $721,743 | $0 | $38,470 | Yes (X) | ||
| TIMOTHY S STAUDTE MD | |||||||
| PHYSICIAN | 40.00 | $484,051 | $0 | $31,213 | Yes (X) | ||
| KAICHUN WEI MD | |||||||
| PHYSICIAN | 40.00 | $362,386 | $0 | $36,079 | Yes (X) | ||
| BRENT G WOODBURY MD | |||||||
| PHYSICIAN | 40.00 | $703,669 | $0 | $35,663 | Yes (X) | ||
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Reportable Comp From Org | $3,240,944 | TotalReportableCompFromOrgAmt |
| Tot Reportable Comp Rltd Org | $0 | TotReportableCompRltdOrgAmt |
| Total Other Compensation | $271,674 | TotalOtherCompensationAmt |
| Indiv Rcvd Greater Than100 K | 49 | IndivRcvdGreaterThan100KCnt |
| Former Ofcr Employees Listed | 0 | FormerOfcrEmployeesListedInd |
| Total Comp Greater Than150 K | Yes (1) | TotalCompGreaterThan150KInd |
| Compensation From Other Srcs | 0 | CompensationFromOtherSrcsInd |
Contractor Compensation ContractorCompensationGrp (5 entries)
| Address Line1ContractorAddress/USAddress/AddressLine1Txt | CityContractorAddress/USAddress/CityNm | State AbbreviationContractorAddress/USAddress/StateAbbreviationCd | ZIPContractorAddress/USAddress/ZIPCd | ServicesServicesDesc | CompensationCompensationAmt |
|---|---|---|---|---|---|
| WAPITI MEDICAL STAFFING | |||||
| 6112 CHANCEOLLOR DRIVE | CEDAR FALLS | IA | 50613 | ER PHYSICIAN STAFFING | $2,833,011 |
| CARDINAL HEALTH | |||||
| 5303 COLLECTIONS CENTER DRIVER | CHICAGO | IL | 60693 | SUPPLIES | $2,343,437 |
| DEPUY MANUFACTURING | |||||
| 11156 AURORA AVENUE | DES MOINES | IA | 50322 | SUPPLIES | $1,104,235 |
| GE HEALTHCARE IITS USA CORP | |||||
| 3200 NORTH GRANDVIEW BLVD | WAUKESHA | WI | 53188 | TECHNICAL SUPPORT | $735,617 |
| SMITH & NEPHEW | |||||
| 5201 GEORGE MCVAY DR STE 1 | MCALLEN | TX | 78503 | SUPPLIES | $700,878 |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Cntrct Rcvd Greater Than100 K | 32 | CntrctRcvdGreaterThan100KCnt |
| Related Organizations | $12,810,999 | RelatedOrganizationsAmt |
| Total Contributions | $12,810,999 | TotalContributionsAmt |
Program Service Revenue ProgramServiceRevenueGrp (2 entries)
| DescDesc | BusinessBusinessCd | Total Revenue ColumnTotalRevenueColumnAmt | Related Or Exempt Func IncomeRelatedOrExemptFuncIncomeAmt |
|---|---|---|---|
| NET PATIENT SERVICE REVENUE | 621110 | $55,112,558 | $55,112,558 |
| LESS: PROVISION FOR BAD DEBTS | 900001 | -$1,604,125 | -$1,604,125 |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Program Service Revenue | $53,508,433 | TotalProgramServiceRevenueAmt |
Investment Income InvestmentIncomeGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Revenue Column | $453,766 | TotalRevenueColumnAmt |
| Exclusion | $453,766 | ExclusionAmt |
Gross Rents GrossRentsGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Real | $172,952 | RealAmt |
Less Rental Expenses LessRentalExpensesGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Real | $0 | RealAmt |
Rental Income Or Loss RentalIncomeOrLossGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Real | $172,952 | RealAmt |
Net Rental Income Or Loss NetRentalIncomeOrLossGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Revenue Column | $172,952 | TotalRevenueColumnAmt |
| Exclusion | $172,952 | ExclusionAmt |
Gross Amount Sales Assets GrossAmountSalesAssetsGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Securities | $402 | SecuritiesAmt |
Less Cost Oth Basis Sales Expnss LessCostOthBasisSalesExpnssGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Securities | $0 | SecuritiesAmt |
Gain Or Loss GainOrLossGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Securities | $402 | SecuritiesAmt |
Net Gain Or Loss Investments NetGainOrLossInvestmentsGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Revenue Column | $402 | TotalRevenueColumnAmt |
| Exclusion | $402 | ExclusionAmt |
Other Revenue Misc OtherRevenueMiscGrp (3 entries)
| DescDesc | BusinessBusinessCd | Total Revenue ColumnTotalRevenueColumnAmt | Related Or Exempt Func IncomeRelatedOrExemptFuncIncomeAmt |
|---|---|---|---|
| PHARMACY | 446110 | $2,959,129 | $2,959,129 |
| PARTNERSHIP INCOME (LOSS) | 900099 | $312,673 | $312,673 |
| MISCELLANEOUS | 900099 | $230,739 | $230,739 |
Miscellaneous Revenue MiscellaneousRevenueGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Revenue Column | $211,348 | TotalRevenueColumnAmt |
| Related Or Exempt Func Income | $166,123 | RelatedOrExemptFuncIncomeAmt |
| Unrelated Business Revenue | $45,225 | UnrelatedBusinessRevenueAmt |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Other Revenue Total | $3,713,889 | OtherRevenueTotalAmt |
Total Revenue TotalRevenueGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Revenue Column | $70,660,441 | TotalRevenueColumnAmt |
| Related Or Exempt Func Income | $57,177,097 | RelatedOrExemptFuncIncomeAmt |
| Unrelated Business Revenue | $45,225 | UnrelatedBusinessRevenueAmt |
| Exclusion | $627,120 | ExclusionAmt |
Grants To Domestic Orgs GrantsToDomesticOrgsGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $2,046,100 | TotalAmt |
| Program Services | $2,046,100 | ProgramServicesAmt |
Comp Current Ofcr Directors CompCurrentOfcrDirectorsGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $576,659 | TotalAmt |
| Management And General | $576,659 | ManagementAndGeneralAmt |
Other Salaries And Wages OtherSalariesAndWagesGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $28,468,556 | TotalAmt |
| Program Services | $25,546,598 | ProgramServicesAmt |
| Management And General | $2,921,958 | ManagementAndGeneralAmt |
Pension Plan Contributions PensionPlanContributionsGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $1,024,690 | TotalAmt |
| Program Services | $729,361 | ProgramServicesAmt |
| Management And General | $295,329 | ManagementAndGeneralAmt |
Other Employee Benefits OtherEmployeeBenefitsGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $4,826,449 | TotalAmt |
| Program Services | $3,435,403 | ProgramServicesAmt |
| Management And General | $1,391,046 | ManagementAndGeneralAmt |
Payroll Taxes PayrollTaxesGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $1,812,337 | TotalAmt |
| Program Services | $1,289,998 | ProgramServicesAmt |
| Management And General | $522,339 | ManagementAndGeneralAmt |
Fees For Services Legal FeesForServicesLegalGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $56,953 | TotalAmt |
| Management And General | $56,953 | ManagementAndGeneralAmt |
Fees For Services Accounting FeesForServicesAccountingGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $100,454 | TotalAmt |
| Management And General | $100,454 | ManagementAndGeneralAmt |
Fees For Services Lobbying FeesForServicesLobbyingGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $5,106 | TotalAmt |
| Management And General | $5,106 | ManagementAndGeneralAmt |
Fees For Services Other FeesForServicesOtherGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $4,143,787 | TotalAmt |
| Program Services | $2,761,835 | ProgramServicesAmt |
| Management And General | $1,381,952 | ManagementAndGeneralAmt |
Advertising AdvertisingGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $200,948 | TotalAmt |
| Management And General | $200,948 | ManagementAndGeneralAmt |
Office Expenses OfficeExpensesGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $8,801,337 | TotalAmt |
| Program Services | $8,389,926 | ProgramServicesAmt |
| Management And General | $411,411 | ManagementAndGeneralAmt |
Occupancy OccupancyGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $710,523 | TotalAmt |
| Program Services | $689,474 | ProgramServicesAmt |
| Management And General | $21,049 | ManagementAndGeneralAmt |
Travel TravelGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $165,023 | TotalAmt |
| Program Services | $139,188 | ProgramServicesAmt |
| Management And General | $25,835 | ManagementAndGeneralAmt |
Interest InterestGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $96,678 | TotalAmt |
| Program Services | $68,814 | ProgramServicesAmt |
| Management And General | $27,864 | ManagementAndGeneralAmt |
Depreciation Depletion DepreciationDepletionGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $3,538,426 | TotalAmt |
| Program Services | $2,518,605 | ProgramServicesAmt |
| Management And General | $1,019,821 | ManagementAndGeneralAmt |
Insurance InsuranceGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $707,576 | TotalAmt |
| Program Services | $411,024 | ProgramServicesAmt |
| Management And General | $296,552 | ManagementAndGeneralAmt |
Other Expenses OtherExpensesGrp (4 entries)
| DescDesc | TotalTotalAmt | Program ServicesProgramServicesAmt | Management And GeneralManagementAndGeneralAmt |
|---|---|---|---|
| PHYSICIAN FEES | $2,796,229 | $2,796,229 | |
| RECRUITMENT | $531,124 | $531,124 | |
| REPAIRS AND MAINTENANCE | $454,669 | $453,910 | $759 |
| MEDICAID ASSESSMENT | $394,422 | $394,422 |
All Other Expenses AllOtherExpensesGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $478,506 | TotalAmt |
| Program Services | $107,389 | ProgramServicesAmt |
| Management And General | $371,117 | ManagementAndGeneralAmt |
Total Functional Expenses TotalFunctionalExpensesGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $61,936,552 | TotalAmt |
| Program Services | $52,309,400 | ProgramServicesAmt |
| Management And General | $9,627,152 | ManagementAndGeneralAmt |
| Fundraising | $0 | FundraisingAmt |
Cash Non Interest Bearing CashNonInterestBearingGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $410,311 | BOYAmt |
| EOY | $12,887,122 | EOYAmt |
Savings And Temp Cash Invst SavingsAndTempCashInvstGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $370,000 | BOYAmt |
| EOY | $370,000 | EOYAmt |
Accounts Receivable AccountsReceivableGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $9,191,933 | BOYAmt |
| EOY | $8,295,869 | EOYAmt |
Inventories For Sale Or Use InventoriesForSaleOrUseGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $575,041 | BOYAmt |
| EOY | $636,318 | EOYAmt |
Prepaid Expenses Defrd Charges PrepaidExpensesDefrdChargesGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $1,321,430 | BOYAmt |
| EOY | $688,133 | EOYAmt |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Land Bldg Equip Cost Or Other Bss | $24,237,540 | LandBldgEquipCostOrOtherBssAmt |
| Land Bldg Equip Accum Deprec | $4,113,697 | LandBldgEquipAccumDeprecAmt |
Land Bldg Equip Basis Net LandBldgEquipBasisNetGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $23,065,664 | BOYAmt |
| EOY | $20,123,843 | EOYAmt |
Investments Pub Traded Sec InvestmentsPubTradedSecGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $16,171,029 | BOYAmt |
| EOY | $13,438,161 | EOYAmt |
Investments Program Related InvestmentsProgramRelatedGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $4,792,246 | BOYAmt |
| EOY | $4,855,871 | EOYAmt |
Other Assets Total OtherAssetsTotalGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $41,019 | BOYAmt |
| EOY | $0 | EOYAmt |
Total Assets TotalAssetsGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $55,938,673 | BOYAmt |
| EOY | $61,295,317 | EOYAmt |
Accounts Payable Accr Expnss AccountsPayableAccrExpnssGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $11,252,236 | BOYAmt |
| EOY | $6,101,130 | EOYAmt |
Tax Exempt Bond Liabilities TaxExemptBondLiabilitiesGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $3,492,152 | BOYAmt |
| EOY | $2,517,988 | EOYAmt |
Total Liabilities TotalLiabilitiesGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $14,744,388 | BOYAmt |
| EOY | $8,619,118 | EOYAmt |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Organization Follows SFAS117 | Yes (X) | OrganizationFollowsSFAS117Ind |
Unrestricted Net Assets UnrestrictedNetAssetsGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $40,905,826 | BOYAmt |
| EOY | $52,388,937 | EOYAmt |
Temporarily Rstr Net Assets TemporarilyRstrNetAssetsGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $83,766 | BOYAmt |
| EOY | $82,569 | EOYAmt |
Permanently Rstr Net Assets PermanentlyRstrNetAssetsGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $204,693 | BOYAmt |
| EOY | $204,693 | EOYAmt |
Total Net Assets Fund Balance TotalNetAssetsFundBalanceGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $41,194,285 | BOYAmt |
| EOY | $52,676,199 | EOYAmt |
Tot Liab Net Assets Fund Balance TotLiabNetAssetsFundBalanceGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $55,938,673 | BOYAmt |
| EOY | $61,295,317 | EOYAmt |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Info In Schedule O Part XI | Yes (X) | InfoInScheduleOPartXIInd |
| Reconcilation Revenue Expnss | $8,723,889 | ReconcilationRevenueExpnssAmt |
| Net Unrlzd Gains Losses Invst | $62,975 | NetUnrlzdGainsLossesInvstAmt |
| Other Changes In Net Assets | $2,695,050 | OtherChangesInNetAssetsAmt |
| Info In Schedule O Part XII | Yes (X) | InfoInScheduleOPartXIIInd |
| Method Of Accounting Accrual | Yes (X) | MethodOfAccountingAccrualInd |
| Accountant Compile Or Review | 0 | AccountantCompileOrReviewInd |
| FS Audited | 0 | FSAuditedInd |
| Federal Grant Audit Required | 0 | FederalGrantAuditRequiredInd |
Schedule A IRS990ScheduleA
| Field | Value | IRS element (for citing) |
|---|---|---|
| Hospital | Yes (X) | HospitalInd |
Schedule B IRS990ScheduleB
Contributor Information ContributorInformationGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Contributor | RESTRICTED | ContributorNum |
Contributor Business Name ContributorBusinessName
| Field | Value | IRS element (for citing) |
|---|---|---|
| Business Name Line1 | RESTRICTED | BusinessNameLine1 |
Contributor US Address ContributorUSAddress
| Field | Value | IRS element (for citing) |
|---|---|---|
| Address Line1 | RESTRICTED | AddressLine1 |
| Address Line2 | RESTRICTED | AddressLine2 |
| City | RESTRICTED | City |
| State | RESTRICTED | State |
| ZIP Code | RESTRICTED | ZIPCode |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Contributions | RESTRICTED | TotalContributionsAmt |
Schedule C IRS990ScheduleC
| Field | Value | IRS element (for citing) |
|---|---|---|
| Volunteers | 0 | VolunteersInd |
| Paid Staff Or Management | 0 | PaidStaffOrManagementInd |
| Media Advertisements | 0 | MediaAdvertisementsInd |
| Mailings Members | 0 | MailingsMembersInd |
| Publications Or Broadcast | 0 | PublicationsOrBroadcastInd |
| Grants Other Organizations | 0 | GrantsOtherOrganizationsInd |
| Direct Contact Legislators | 0 | DirectContactLegislatorsInd |
| Rallies Demonstrations | 0 | RalliesDemonstrationsInd |
| Other Activities | Yes (1) | OtherActivitiesInd |
| Other Activities | $5,106 | OtherActivitiesAmt |
| Total Lobbying Expenditures | $5,106 | TotalLobbyingExpendituresAmt |
| Not Described Section501c3 | 0 | NotDescribedSection501c3Ind |
Supplemental Information Detail SupplementalInformationDetail
| Field | Value | IRS element (for citing) |
|---|---|---|
| Form And Line Reference | PART II-B, LINE 1: | FormAndLineReferenceDesc |
| Explanation | LOBBYING EXPENDITURES RELATED TO MEMBERSHIP DUES INCLUDED: 22.73% OF MEMBERSHIP DUES PAID TO THE AMERICAN HOSPITAL ASSOCIATION, OR $5,106. | ExplanationTxt |
Schedule D IRS990ScheduleD
Land LandGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Other Cost Or Other Basis | $1,300,000 | OtherCostOrOtherBasisAmt |
| Book Value | $1,300,000 | BookValueAmt |
Buildings BuildingsGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Other Cost Or Other Basis | $12,006,107 | OtherCostOrOtherBasisAmt |
| Depreciation | $1,328,762 | DepreciationAmt |
| Book Value | $10,677,345 | BookValueAmt |
Leasehold Improvements LeaseholdImprovementsGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Other Cost Or Other Basis | $680,100 | OtherCostOrOtherBasisAmt |
| Depreciation | $58,311 | DepreciationAmt |
| Book Value | $621,789 | BookValueAmt |
Equipment EquipmentGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Other Cost Or Other Basis | $9,858,972 | OtherCostOrOtherBasisAmt |
| Depreciation | $2,726,624 | DepreciationAmt |
| Book Value | $7,132,348 | BookValueAmt |
Other Land Buildings OtherLandBuildingsGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Other Cost Or Other Basis | $392,361 | OtherCostOrOtherBasisAmt |
| Book Value | $392,361 | BookValueAmt |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Book Value Land Buildings | $20,123,843 | TotalBookValueLandBuildingsAmt |
Invst Program Related Org InvstProgramRelatedOrgGrp (3 entries)
| DescDesc | Book ValueBookValueAmt | Method ValuationMethodValuationCd |
|---|---|---|
| SE RENAL DIALYSIS, LC | $1,114,610 | C |
| INVESTMENT IN FORT MADISON COMMUNITY HOSPITAL FOUNDATION | $3,628,259 | C |
| INVESTMENT IN ADVANCE PHYSICAL THERAPY | $113,002 | C |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Book Value Program Rltd | $4,855,871 | TotalBookValueProgramRltdAmt |
Schedule H IRS990ScheduleH
| Field | Value | IRS element (for citing) |
|---|---|---|
| Financial Assistance Policy | Yes (1) | FinancialAssistancePolicyInd |
| Written Policy | Yes (1) | WrittenPolicyInd |
| All Hospitals Policy | Yes (X) | AllHospitalsPolicyInd |
| FPG Reference Free Care | Yes (1) | FPGReferenceFreeCareInd |
| Percent150 | Yes (X) | Percent150Ind |
| FPG Reference Discounted Care | Yes (1) | FPGReferenceDiscountedCareInd |
| Percent350 | Yes (X) | Percent350Ind |
| Free Care Medically Indigent | Yes (1) | FreeCareMedicallyIndigentInd |
| Financial Assistance Budget | Yes (1) | FinancialAssistanceBudgetInd |
| Expenses Exceed Budget | 0 | ExpensesExceedBudgetInd |
| Annual Community Bnft Report | Yes (1) | AnnualCommunityBnftReportInd |
| Report Publically Available | Yes (1) | ReportPublicallyAvailableInd |
Financial Assistance At Cost Typ FinancialAssistanceAtCostTyp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Community Benefit Expns | $678,113 | TotalCommunityBenefitExpnsAmt |
| Net Community Benefit Expns | $678,113 | NetCommunityBenefitExpnsAmt |
| Total Expense | 0.01090 | TotalExpensePct |
Unreimbursed Medicaid UnreimbursedMedicaidGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Community Benefit Expns | $6,204,505 | TotalCommunityBenefitExpnsAmt |
| Direct Offsetting Revenue | $4,760,484 | DirectOffsettingRevenueAmt |
| Net Community Benefit Expns | $1,444,021 | NetCommunityBenefitExpnsAmt |
| Total Expense | 0.02330 | TotalExpensePct |
Total Financial Assistance Typ TotalFinancialAssistanceTyp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Community Benefit Expns | $6,882,618 | TotalCommunityBenefitExpnsAmt |
| Direct Offsetting Revenue | $4,760,484 | DirectOffsettingRevenueAmt |
| Net Community Benefit Expns | $2,122,134 | NetCommunityBenefitExpnsAmt |
| Total Expense | 0.03420 | TotalExpensePct |
Community Health Services CommunityHealthServicesGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Community Benefit Expns | $997,301 | TotalCommunityBenefitExpnsAmt |
| Net Community Benefit Expns | $997,301 | NetCommunityBenefitExpnsAmt |
| Total Expense | 0.01610 | TotalExpensePct |
Health Professions Education HealthProfessionsEducationGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Community Benefit Expns | $388,352 | TotalCommunityBenefitExpnsAmt |
| Net Community Benefit Expns | $388,352 | NetCommunityBenefitExpnsAmt |
| Total Expense | 0.00630 | TotalExpensePct |
Subsidized Health Services SubsidizedHealthServicesGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Community Benefit Expns | $11,884,464 | TotalCommunityBenefitExpnsAmt |
| Direct Offsetting Revenue | $8,299,844 | DirectOffsettingRevenueAmt |
| Net Community Benefit Expns | $3,584,620 | NetCommunityBenefitExpnsAmt |
| Total Expense | 0.05790 | TotalExpensePct |
Cash And In Kind Contributions CashAndInKindContributionsGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Community Benefit Expns | $46,100 | TotalCommunityBenefitExpnsAmt |
| Net Community Benefit Expns | $46,100 | NetCommunityBenefitExpnsAmt |
| Total Expense | 0.00070 | TotalExpensePct |
Total Other Benefits TotalOtherBenefitsGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Community Benefit Expns | $13,316,217 | TotalCommunityBenefitExpnsAmt |
| Direct Offsetting Revenue | $8,299,844 | DirectOffsettingRevenueAmt |
| Net Community Benefit Expns | $5,016,373 | NetCommunityBenefitExpnsAmt |
| Total Expense | 0.08100 | TotalExpensePct |
Total Community Benefits TotalCommunityBenefitsGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Community Benefit Expns | $20,198,835 | TotalCommunityBenefitExpnsAmt |
| Direct Offsetting Revenue | $13,060,328 | DirectOffsettingRevenueAmt |
| Net Community Benefit Expns | $7,138,507 | NetCommunityBenefitExpnsAmt |
| Total Expense | 0.11520 | TotalExpensePct |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Bad Debt Expense Reported | Yes (1) | BadDebtExpenseReportedInd |
| Bad Debt Expense | $1,604,125 | BadDebtExpenseAmt |
| Reimbursed By Medicare | $12,682,616 | ReimbursedByMedicareAmt |
| Cost Of Care Reimbursed By Medcr | $14,450,251 | CostOfCareReimbursedByMedcrAmt |
| Medicare Surplus Or Shortfall | -$1,767,635 | MedicareSurplusOrShortfallAmt |
Costing Methodology Used CostingMethodologyUsedGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Other | Yes (X) | OtherInd |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Written Debt Collection Policy | Yes (1) | WrittenDebtCollectionPolicyInd |
| Financial Assistance Prvsn | Yes (1) | FinancialAssistancePrvsnInd |
| Hospital Facilities | 1 | HospitalFacilitiesCnt |
Hospital Facilities HospitalFacilitiesGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Facility | 1 | FacilityNum |
Business Name BusinessName
| Field | Value | IRS element (for citing) |
|---|---|---|
| Business Name Line1 | FORT MADISON COMMUNITY HOSPITAL | BusinessNameLine1Txt |
US Address USAddress
| Field | Value | IRS element (for citing) |
|---|---|---|
| Address Line1 | 5445 AVENUE O PO BOX 174 | AddressLine1Txt |
| City | FORT MADISON | CityNm |
| State Abbreviation | IA | StateAbbreviationCd |
| ZIP | 52627 | ZIPCd |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Website Address | WWW.FMCHOSP.COM | WebsiteAddressTxt |
| State License | 560087H | StateLicenseNum |
| Licensed Hospital | Yes (X) | LicensedHospitalInd |
| General Medical And Surgical | Yes (X) | GeneralMedicalAndSurgicalInd |
| Emergency Room24 Hrs | Yes (X) | EmergencyRoom24HrsInd |
| Emergency Room Other | Yes (X) | EmergencyRoomOtherInd |
| Other | TRAUMA CENTER | OtherDesc |
Hospital Fclty Policies Prctc HospitalFcltyPoliciesPrctcGrp
Hospital Facility Name HospitalFacilityName
| Field | Value | IRS element (for citing) |
|---|---|---|
| Business Name Line1 | FORT MADISON COMMUNITY HOSPITAL | BusinessNameLine1Txt |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Facility | 1 | FacilityNum |
| First Licensed CY Or PY | 0 | FirstLicensedCYOrPYInd |
| Tax Exempt Hospital CY Or PY | 0 | TaxExemptHospitalCYOrPYInd |
| CHNA Conducted | Yes (1) | CHNAConductedInd |
| Community Demographics | Yes (X) | CommunityDemographicsInd |
| Community Health Needs | Yes (X) | CommunityHealthNeedsInd |
| Other Health Issues | Yes (X) | OtherHealthIssuesInd |
| CHNA Conducted | 18 | CHNAConductedYr |
| Take Into Account Others Input | Yes (1) | TakeIntoAccountOthersInputInd |
| CHNA Conducted With Other Fclts | Yes (1) | CHNAConductedWithOtherFcltsInd |
| CHNA Conducted With Non Fclts | Yes (1) | CHNAConductedWithNonFcltsInd |
| CHNA Report Widely Available | Yes (1) | CHNAReportWidelyAvailableInd |
| Rpt Available On Own Website | Yes (X) | RptAvailableOnOwnWebsiteInd |
| Own Website URL | SEE PART V | OwnWebsiteURLTxt |
| Paper Copy Public Inspection | Yes (X) | PaperCopyPublicInspectionInd |
| Implementation Strategy Adopt | Yes (1) | ImplementationStrategyAdoptInd |
| Implementation Strategy Adpt | 18 | ImplementationStrategyAdptYr |
| Strategy Posted Website | 0 | StrategyPostedWebsiteInd |
| Strategy Attached | Yes (1) | StrategyAttachedInd |
| Organization Incur Excise Tax | 0 | OrganizationIncurExciseTaxInd |
| Elig Criteria Explained | Yes (1) | EligCriteriaExplainedInd |
| FPG Family Incm Lmt Free Dscnt | Yes (X) | FPGFamilyIncmLmtFreeDscntInd |
| FPG Family Incm Lmt Free Care | 150.000000000000 | FPGFamilyIncmLmtFreeCarePct |
| FPG Family Incm Lmt Dscnt Care | 350.000000000000 | FPGFamilyIncmLmtDscntCarePct |
| Asset Level Criteria | Yes (X) | AssetLevelCriteriaInd |
| Medical Indigency Criteria | Yes (X) | MedicalIndigencyCriteriaInd |
| Underinsurance Stat Criteria | Yes (X) | UnderinsuranceStatCriteriaInd |
| Residency Criteria | Yes (X) | ResidencyCriteriaInd |
| Explained Basis | Yes (1) | ExplainedBasisInd |
| App Financial Asst Expln | Yes (1) | AppFinancialAsstExplnInd |
| Described Info | Yes (X) | DescribedInfoInd |
| Described Suprt Doc | Yes (X) | DescribedSuprtDocInd |
| Provided Hospital Contact | Yes (X) | ProvidedHospitalContactInd |
| Provided Nonprofit Contact | Yes (X) | ProvidedNonprofitContactInd |
| Includes Publicity Measures | Yes (1) | IncludesPublicityMeasuresInd |
| FAP Available On Website | Yes (X) | FAPAvailableOnWebsiteInd |
| FAP Available On Website URL | HTTPS://WWW.FMCHOSP.COM/PATIENTS-VISITORS/FMCH-CHARITY-POLICY/ | FAPAvailableOnWebsiteURLTxt |
| FAP App Available On Website | Yes (X) | FAPAppAvailableOnWebsiteInd |
| FAP App Available On Website URL | HTTPS://WWW.FMCHOSP.COM/PATIENTS-VISITORS/FMCH-CHARITY-POLICY/ | FAPAppAvailableOnWebsiteURLTxt |
| FAP Summary On Website | Yes (X) | FAPSummaryOnWebsiteInd |
| FAP Summary On Website URL | HTTPS://WWW.FMCHOSP.COM/PATIENTS-VISITORS/FMCH-CHARITY-POLICY/ | FAPSummaryOnWebsiteURLTxt |
| FAP Avlbl On Request No Charge | Yes (X) | FAPAvlblOnRequestNoChargeInd |
| FAP App Avlbl On Request No Chrg | Yes (X) | FAPAppAvlblOnRequestNoChrgInd |
| FAP Sum Avlbl On Request No Chrg | Yes (X) | FAPSumAvlblOnRequestNoChrgInd |
| Notified FAP Copy Bill Display | Yes (X) | NotifiedFAPCopyBillDisplayInd |
| Communtity Notified FAP | Yes (X) | CommuntityNotifiedFAPInd |
| FAP Translated | Yes (X) | FAPTranslatedInd |
| Other Publicity | Yes (X) | OtherPublicityInd |
| FAP Actions On Nonpayment | Yes (1) | FAPActionsOnNonpaymentInd |
| Permit No Actions | Yes (X) | PermitNoActionsInd |
| Collection Activities | 0 | CollectionActivitiesInd |
| Provided Written Notice | Yes (X) | ProvidedWrittenNoticeInd |
| Made Effort Orally Notify | Yes (X) | MadeEffortOrallyNotifyInd |
| Other Actions Taken | Yes (X) | OtherActionsTakenInd |
| Nondis Emergency Care Policy | Yes (1) | NondisEmergencyCarePolicyInd |
| Look Back Medicare Private | Yes (X) | LookBackMedicarePrivateInd |
| Amounts Generally Billed | 0 | AmountsGenerallyBilledInd |
| Gross Charges | 0 | GrossChargesInd |
Supplemental Information SupplementalInformationGrp (7 entries)
| Form And Line ReferenceFormAndLineReferenceDesc | ExplanationExplanationTxt |
|---|---|
| FORT MADISON COMMUNITY HOSPITAL | PART V, SECTION B, LINE 5: THE FIRST STEP OF THE PROCESS WAS A COUNTY-WIDE SURVEY MADE AVAILABLE THROUGH SURVEYMONKEY AND PAPER COPIES. THE PURPOSE OF THE SURVEY WAS TO GET COMMUNITY MEMBERS VIEWPOINT ON THE HEALTH NEEDS OF THE COUNTY. WE WORKED WITH COUNTY LIBRARIES, HEALTH DEPARTMENT AGENCIES, LARGE EMPLOYERS AND PUBLIC INVITATION THROUGH MASS MEDIA TO ENCOURAGE PARTICIPATION. THE SURVEYS WERE MADE AVAILABLE FROM MAY THROUGH SEPTEMBER 2018. THE RESULTS OF THE SURVEY WERE COMPILED. A TOWN HALL MEETING WAS HELD ON OCTOBER 4, 2018. THIS WAS AN OPEN MEETING HELD IN THE COUNTY-COUNTY LEADERS, HEALTH CARE PROFESSIONALS AND GENERAL PUBLIC WERE INVITED TO ATTEND. THE PARTICIPANTS WERE GIVEN COUNTY DATA ALONG WITH THE SURVEY RESULTS. THEY WERE THEN LED THROUGH THE PROCESS OF DRILLING DOWN TO THE MOST PREVALENT AND IMMEDIATE COMMUNITY HEALTH NEEDS FOR THE COUNTY. THE RESULTING GOALS WERE DRAFTED BY LEE COUNTY HEALTH DEPARTMENT AND FMCH FORMULATED THEIR GOALS AND HAD THEM APPROVED BY THE LEE COUNTY BOARD OF HEALTH. |
| FORT MADISON COMMUNITY HOSPITAL | PART V, SECTION B, LINE 6A: UNITY POINT KEOKUK |
| FORT MADISON COMMUNITY HOSPITAL | PART V, SECTION B, LINE 6B: LEE COUNTY HEALTH DEPARTMENT |
| FORT MADISON COMMUNITY HOSPITAL | PART V, SECTION B, LINE 11: FORT MADISON COMMUNITY HOSPITAL PARTNERED WITH THE LEE COUNTY HEALTH DEPARTMENT AND UNITY POINT KEOKUK TO CONDUCT A COMMUNITY HEALTH NEEDS ASSESSMENT. THIS CONSISTED OF A COMMUNITY-WIDE SURVEY AND TOWN HALL MEETING. THE FOLLOWING OUTLINE THE HEALTH NEEDS IDENTIFIED AS 2020-2023 COMMUNITY HEALTH NEEDS GOALS AND THE STRATEGIES FORT MADISON COMMUNITY HOSPITAL WILL EMPLOY TO ADDRESS THESE NEEDS:1. FORT MADISON COMMUNITY HOSPITAL IS DEDICATED TO PROMOTING HEALTHY BEHAVIORS AND IMPROVING HEALTH OUTCOMES TO ACHIEVE THIS GOAL WE HAVE ADOPTED STRATEGIES TO REDUCE OBESITY RATES AND PREVENTABLE HOSPITAL STAYS DUE TO CHRONIC DISEASE; PREVENT OR REDUCE TEEN BIRTHS AND STD'S; PREVENT AND REDUCE ALCOHOL, TOBACCO AND OTHER DRUG ABUSE AMONG OUR YOUTH AND YOUNG ADULTS; AND IMPROVE THE MENTAL HEALTH AND WELL-BEING OF OUR POPULATION.2. FOCUS ON PROMOTING ELDERLY WELLNESS BY IMPLEMENTING STRATEGIES TO IMPROVE THE HEALTH, FUNCTION AND QUALITY OF LIFE OF OLDER ADULTS.FORT MADISON COMMUNITY HOSPITAL IS DEDICATED TO MAKING A STRONGER, HEALTHIER COMMUNITY. |
| FORT MADISON COMMUNITY HOSPITAL | PART V, SECTION B, LINE 16J: IN ADDITION TO THE METHODS IDENTIFIED IN PART V, SECTION B, QUESTIONS 16A-16H, FORT MADISON COMMUNITY HOSPITAL WILL ALSO ADVISE INDIVIDUALS AND FAMILIES OF THE FINANCIAL ASSISTANCE POLICY THROUGH THE FOLLOWING METHODS:- DIRECT PATIENT CONTACT, IN PERSON OR ON THE PHONE.- NOTICE OF AVAILABILITY OF FINANCIAL ASSISTANCE WILL BE POSTED IN REGISTRATION AREAS, EMERGENCY DEPARTMENT AND OTHER WAITING AREAS.- NOTICE OF AVAILABILITY OF FINANCIAL ASSISTANCE IS PRINTED ON PATIENT STATEMENTS.- NOTICE OF AVAILABILITY OF FINANCIAL ASSISTANCE IS POSTED ON THE HOSPITAL'S WEBSITE ALONG WITH THE FINANCIAL ASSISTANCE POLICY.- OUTREACH TO PUBLIC AGENCIES AND OTHER NON-FOR-PROFIT AGENCIES SERVING THE COMMUNITY MOST LIKELY TO UTILIZE FINANCIAL ASSISTANCE. |
| FORT MADISON COMMUNITY HOSPITAL | PART V, SECTION B, LINE 20E: IN ADDITION TO THE METHODS IDENTIFIED IN PART V, SECTION B, QUESTIONS 20A-20D, FORT MADISON COMMUNITY HOSPITAL WILL ALSO ADVISE INDIVIDUALS AND FAMILIES OF THE FINANCIAL ASSISTANCE POLICY THROUGH THE FOLLOWING METHODS:- DIRECT PATIENT CONTACT, IN PERSON OR ON THE PHONE.- NOTICE OF AVAILABILITY OF FINANCIAL ASSISTANCE WILL BE POSTED IN REGISTRATION AREAS, EMERGENCY DEPARTMENT AND OTHER WAITING AREAS.- NOTICE OF AVAILABILITY OF FINANCIAL ASSISTANCE IS PRINTED ON PATIENT STATEMENTS.- NOTICE OF AVAILABILITY OF FINANCIAL ASSISTANCE IS POSTED ON THE HOSPITAL'S WEBSITE ALONG WITH THE FINANCIAL ASSISTANCE POLICY.- OUTREACH TO PUBLIC AGENCIES AND OTHER NON-FOR-PROFIT AGENCIES SERVING THE COMMUNITY MOST LIKELY TO UTILIZE FINANCIAL ASSISTANCE. |
| PART V, SECTION B, LINE 7A: | HTTPS://WWW.FMCHOSP.COM/COMMUNITY-WELLNESS/COMMUNITY-HEALTH-NEEDS-ASSESSMENT/ |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Facility | 2 | FacilityNum |
Oth Hlth Care Fclts Not Hospital OthHlthCareFcltsNotHospitalGrp
Oth Hlth Care Fclts OthHlthCareFcltsGrp (2 entries)
| Address Line1USAddress/AddressLine1Txt | CityUSAddress/CityNm | State AbbreviationUSAddress/StateAbbreviationCd | ZIPUSAddress/ZIPCd | FacilityFacilityTxt |
|---|---|---|---|---|
| 1 - SOUTHEASTERN RENAL DIALYSIS LC | ||||
| 407 SOUTH WHITE STREET | MT PLEASANT | IA | 52641 | DIALYSIS SERVICES |
| 3 - ADVANCE PHYSICAL THERAPY LLC | ||||
| 3032 BROADWAY | QUINCY | IL | 62301 | PHYSICAL THERAPY |
Supplemental Information Detail SupplementalInformationDetail (17 entries)
| Form And Line ReferenceFormAndLineReferenceDesc | ExplanationExplanationTxt |
|---|---|
| PART I, LINE 3C: | NOT APPLICABLE |
| PART I, LINE 6A: | THE COMMUNITY BENEFIT REPORT IS PREPARED BY FORT MADISON COMMUNITY HOSPITAL AND IS NOT INCLUDED IN A REPORT PREPARED BY ITS RELATED ORGANIZATIONS. |
| PART I, LINE 7: | THE ORGANIZATION CALCULATED THE COST AMOUNTS NOTED IN PART 1, LINE 7 BY UTILIZING ITS CURRENT COST ACCOUNTING SYSTEM. THE COST ACCOUNTING SYSTEM ADDRESSES ALL PATIENT SEGMENTS REPORTED ON, INCLUDING, BUT NOT LIMITED TO INPATIENT, OUTPATIENT, MEDICAID, UNINSURED, AND MEDICARE. WORKSHEET 2, RATIO OF PATIENT CARE COST TO CHARGES, AS PROVIDED IN THE IRS INSTRUCTIONS, WAS USED TO DETERMINE THE APPROPRIATE RATIO. |
| PART I, LINE 7G: | THE AMOUNTS REPORTED ON LINE 7G ARE ASSOCIATED WITH PHYSICIAN CLINICS. |
| PART I, LN 7 COL(F): | NO BAD DEBT EXPENSE WAS INCLUDED IN THE DENOMINATOR BECAUSE BAD DEBT WAS REPORTED IN LINE 2B OF PART VIII, STATEMENT OF REVENUE. THE ORGANIZATION'S TOTAL COMMUNITY BENEFIT EXPENSE AS A PERCENTAGE OF TOTAL EXPENSES IS 32.61%, AND THE PERCENTAGE INCREASES TO 55.94% IF MEDICARE ALLOWABLE COSTS ARE INCLUDED IN TOTAL COMMUNITY BENEFIT EXPENSE. |
| PART II, COMMUNITY BUILDING ACTIVITIES: | NOT APPLICABLE |
| PART III, LINE 2: | THE ORGANIZATION USED ITS AUDITED FINANCIAL STATEMENTS TO DETERMINE THE AMOUNT OF BAD DEBT EXPENSE TO REPORT ON LINE 2. |
| PART III, LINE 3 | NOT APPLICABLE |
| PART III, LINE 4: | THE ORGANIZATION DOES NOT ISSUE A STANDALONE FINANCIAL STATEMENT; HOWEVER, IT IS INCLUDED AS A PART OF THE GREAT RIVER HEALTH SYSTEM, INC AND SUBSIDIARIES CONSOLIDATED FINANCIAL STATEMENTS. THE FOOTNOTE FROM THE CONSOLIDATED FINANCIAL STATEMENT IS AS FOLLOWS: ACCOUNTS RECEIVABLE CONSISTS MAINLY OF PATIENT RECEIVABLES. PATIENT RECEIVABLES WHERE A THIRD-PARTY PAYOR IS RESPONSIBLE FOR PAYING THE AMOUNT ARE CARRIED AT A NET AMOUNT DETERMINED BY THE ORIGINAL CHARGE FOR THE SERVICE PROVIDED, LESS AN ESTIMATE MADE FOR CONTRACTUAL ADJUSTMENTS OR DISCOUNTS PROVIDED TO THIRD-PARTY PAYORS.PATIENT RECEIVABLES DUE DIRECTLY FROM PATIENTS ARE CARRIED AT THE ORIGINAL CHARGE FOR THE SERVICE PROVIDED LESS AMOUNTS COVERED BY THIRD-PARTY PAYORS AND LESS AN ESTIMATED ALLOWANCE FOR DOUBTFUL RECEIVABLES BASED ON A REVIEW OF ALL OUTSTANDING AMOUNTS ON A MONTHLY BASIS. MANAGEMENT DETERMINES THE ALLOWANCE FOR DOUBTFUL ACCOUNTS BY IDENTIFYING TROUBLED ACCOUNTS, BY HISTORICAL EXPERIENCE APPLIED TO AN AGING OF ACCOUNTS AND BY CONSIDERING THE PATIENTS' FINANCIAL HISTORY, CREDIT HISTORY, AND CURRENT ECONOMIC CONDITIONS. GREAT RIVER MEDICAL CENTER, RIVERVIEW SYSTEM, LTD., AND FORT MADISON COMMUNITY HOSPITAL DO NOT CHARGE INTEREST ON PATIENT RECEIVABLES.PATIENT RECEIVABLES ARE WRITTEN OFF WHEN DEEMED UNCOLLECTIBLE. RECOVERIES OF RECEIVABLES PREVIOUSLY WRITTEN OFF ARE RECORDED AS A RECOVERY OF BAD DEBT WHEN RECEIVED.THE CHARITY CARE FOOTNOTE DISCLOSURE AS REPORTED IN THE CONSOLIDATED FINANCIAL STATEMENT IS AS FOLLOWS: GREAT RIVER MEDICAL CENTER AND FORT MADISON COMMUNITY HOSPITAL PROVIDE CARE TO PATIENTS WHO MEET CERTAIN CRITERIA UNDER ITS CHARITY CARE POLICY WITHOUT CHARGE OR AT AMOUNTS LESS THAN ITS ESTABLISHED RATES. BECAUSE THE MEDICAL CENTER DOES NOT PURSUE COLLECTION OF AMOUNTS DETERMINED TO QUALIFY AS CHARITY CARE, THEY ARE NOT INCLUDED IN NET PATIENT SERVICE REVENUE. |
| PART III, LINE 8: | THE ORGANIZATION DERIVED ITS COSTING METHODOLOGY USED TO DETERMINE THE MEDICARE ALLOWABLE COSTS REPORTED IN THE ORGANIZATION'S MEDICARE COST REPORT BY USING COST REPORT WORKSHEETS. MEDICARE COSTS ARE DETERMINED THROUGH THE MEDICARE COST FINDING PROCESS WHICH ALLOCATES GENERAL SERVICE CENTER COSTS TO REVENUE DEPARTMENTS. ROUTINE AND ICU COSTS ARE DETERMINED BASED ON AN AVERAGE COST PER DAY MULTIPLIED BY THE NUMBER OF MEDICARE ALLOWABLE DAYS. MEDICARE ANCILLARY COSTS ARE DETERMINED BY THE RATIO OF DEPARTMENT COSTS TO DEPARTMENT CHARGES, THEN THE RESULTING PERCENT IS APPLIED TO MEDICARE ALLOWABLE CHARGES. THE METHODOLOGY DESCRIBED IN THE INSTRUCTIONS TO SCHEDULE H, PART III, SECTION B, LINE 6 DOES NOT TAKE INTO ACCOUNT ALL COSTS INCURRED BY THE HOSPITAL AND DOES NOT REPRESENT THE TOTAL COMMUNITY BENEFIT CONFERRED IN THIS AREA. |
| PART III, LINE 9B: | THE FORT MADISON COMMUNITY HOSPITAL (FMCH) CHARITY PROGRAM IS DESIGNED TO IDENTIFY THOSE ACCOUNTS WHERE THE GUARANTOR IS NOT ABLE TO MAKE PAYMENT, OR ONLY LIMITED PAYMENTS THAT WOULD WORK A DEFINITE HARDSHIP ON THE HOUSEHOLD, AND "ADJUST" THOSE ACCOUNTS AS EARLY AS POSSIBLE.FINANCIAL EVALUATION OF PATIENT - IF THE PRIMARY PAYOR IS OTHER THAN AN INSURANCE COMPANY, FMCH EVALUATES THE ABILITY OF THE GUARANTOR TO: 1) HANDLE THE PROJECTED FINANCIAL OBLIGATION PERSONALLY; 2) QUALIFY FOR COUNTY, STATE OR FEDERAL ASSISTANCE. ASSISTANCE MAY BE AVAILABLE IF: A) THERE ARE DEPENDENT CHILDREN IN THE HOME (MEDICAID); B) POSSIBLE DETERMINATION OF DISABILITY BY THE SOCIAL SECURITY ADMINISTRATION; AND C) PATIENT IS PREGNANT (MEDICAID); 3) IF PATIENT APPEARS TO QUALIFY FOR ASSISTANCE IN ONE OF THE ABOVE CATEGORIES, FMCH EVALUATES HOW LIKELY IT IS THAT THE PATIENT WILL FOLLOW THROUGH WITH THE APPLICATION PROCESS. IF THE PATIENT IS NOT LIKELY TO FOLLOW THROUGH, ASSISTANCE IS OBTAINED FROM AN OUTSIDE AGENCY TO HELP THE PATIENT THROUGH THE APPLICATION PROCESS; 4) IF THE INITIAL REVIEW INDICATES THERE IS NO OTHER PAYOR THAN THE INDIVIDUAL GUARANTOR, AND AN ASSESSMENT OF THE GUARANTOR'S MEANS (INCOME, ASSETS AND LIABILITIES) LEAVES CONSIDERABLE QUESTIONS AS TO HOW HE/SHE WILL RESOLVE THE IMPENDING DEBT, FMCH THEN DETERMINES IF FULL OR PARTIAL CHARITY IS APPROPRIATE; 5) RESIDENCY TEST - TO BE ELIGIBLE FOR CHARITY CARE, THE PATIENT'S HOME MUST BE WITHIN THE PRIMARY OR SECONDARY SERVICE AREA OF FMCH. THESE AREAS ARE DEFINED BY ZIP CODES; 6) USING THE COMPLETED PERSONAL FINANCIAL STATEMENT, A COPY OF THE MOST RECENT TAX RETURN, A COPY OF THE MOST RECENT PAYROLL STUBS AND ANY OTHER INFORMATION THAT MAY BE APPROPRIATE, THE GUARANTOR'S INCOME MUST BE EVALUATED ON A SLIDING SCALE BASED ON POVERTY GUIDELINES; 7) ADDITIONAL CIRCUMSTANCES SUCH AS, BUT NOT LIMITED TO, IF THE GUARANTOR HAS LIMITED CASH INCOME BUT HAS SIGNIFICIANT PROPERTY HOLDINGS (PERSONAL OR BUSINESS), THOSE ASSETS MUST BE TAKEN INTO ACCOUNT AND MAY SUPERSEDE THE APPLICATION OF THE ABOVE DISCOUNT GUIDELINES;NEGOTIATIONS - DEPENDENT UPON THE GUARANTOR'S MEANS, FMCH MAY NEGOTIATE A SETTLEMENT. IF A RESONABLE MONTHLY PAYMENT FOR THE BALANCE OWED CAN NOT BE AGREED UPON, IT IS IN EVERYONE'S BEST INTEREST TO RESOLVE THE DEBT EARLIER BY AGREEING TO A NEGOTIATED AMOUNT. RECOMMENDATIONS FROM STAFF SUCH AS THE CEO, CFO, DON, RU, DOCTORS AND DEPARTMENT HEADS TO ASSIST WITH PATIENTS THAT ARE HAVING FINANCIAL DIFFICULTY IS ALWAYS CONSIDERED. FOLLOWING DISCHARGE OR BILLING, A DETERMINATION OF CHARITY MAY BE MADE BY USING THE ABOVE PROCESS AS SOON AS THE QUESTION OF POSSIBLE CHARITY IS RAISED. THIS DETERMINATION SHOULD ALWAYS BE MADE AT THE EARLIEST POSSIBLE TIME IN THE LIFE OF THE ACCOUNT. |
| PART VI, LINE 2: | FORT MADISON COMMUNITY HOSPITAL UTILIZES A COMMUNITY HEALTH NEEDS ASSESSMENT PERFORMED BY THE LOCAL UNITED WAY. IN ADDITION TO THIS NEEDS ASSESSMENT, THE HOSPITAL BOARD OF DIRECTORS HOLD AN ANNUAL PLANNING MEETING WITH REPRESENTATIVES FROM THE MEDICAL STAFF IN ATTENDANCE. THIS PHYSICIAN REPRESENTATION ALLOWS FOR GOOD INPUT OF THE COMMUNITY MEDICAL NEEDS BY THOSE THAT ARE CLOSEST TO THE ISSUES. |
| PART VI, LINE 3: | THE HOSPITAL HAS A WRITTEN CHARITY CARE POLICY IN PLACE TO ENSURE THAT NECESSARY HEALTH CARE SERVICES ARE NOT DENIED BASED ON ABILITY TO PAY AND THAT ALL PATIENTS ARE TREATED FAIRLY AND EQUITABLY, AND WITH RESPECT AND COMPASSION. THE HOSPITAL ASSISTS PERSONS WITHOUT INSURANCE COVERAGE BY WAIVING ALL OR PART OF THE CHARGES FOR SERVICES IT PROVIDES. CHARGES FOR SERVICES ARE DISCOUNTED ON A SLIDING FEE SCALE BASED ON FEDERAL POVERTY GUIDELINES. INDIVIDUALS WHOSE INCOME IS WITHIN 0% TO 350% OF THE FEDERAL POVERTY GUIDELINES ARE ELIGIBLE FOR FREE OR DISCOUNTED SERVICES. |
| PART VI, LINE 4: | FORT MADISON COMMUNITY HOSPITAL SERVES A COMMUNITY OF APPROXIMATELY 11,051 AND A COMBINED SERVICE AREA OF APPROXIMATELY 43,862. THE HOSPITAL'S PRIMARY SERVICE AREA INCLUDES MOST OF LEE COUNTY, IA AS WELL AS PORTIONS OF HANCOCK COUNTY, IL. THE PRIMARY SERVICE AREA HAS A POPULATION OF APPROXIMATELY 35,862 AND A MEDIAN AGE OF 40. FORT MADISON COMMUNITY HOSPITAL RECEIVES 50.8% OF THE PRIMARY SERVICE AREA INPATIENT MARKET SHARE. THE HOSPITAL'S SECONDARY SERVICE AREA INCLUDES PORTIONS OF LEE COUNTY, IA, VAN BUREN COUNTY, IA AND HANCOCK COUNTY, IL. THE SECONDARY SERVICE AREA HAS A POPULATION OF APPROXIMATELY 17,885 AND A MEDIAN AGE OF 42. FORT MADISON COMMUNITY HOSPITAL RECEIVES 10.2% OF THE SECONDARY SERVICE AREA INPATIENT MARKET SHARE. |
| PART VI, LINE 5: | FORT MADISON COMMUNITY HOSPITAL IS AN INTIMATE PART OF PROMOTING HEALTH LIFESTYLES IN OUR COMMUNITY. WE ARE ACTIVE PARTICIPANTS ON THE LIVE HEALTHY LEE COUNTY COALITION; COMMUNITY TASK FORCES FORMED AS A RESULT OF THE COMMUNITY HEALTH NEEDS ASSESSMENT AND THE NATIONAL ALLIANCE ON MENTAL HEALTH (NAMI). WE PARTNER WITH THE LEE COUNTY HEALTH DEPARTMENT ON MANY PROJECTS THAT EDUCATE AND MOTIVATE COMMUNITY MEMBERS TO ADOPT HEALTHY HABITS, I.E. VETERAN'S HEALTH FAIR; PRODUCE BOXES, ETC. THE HOSPITAL SPONSORED OR PARTICIPATED IN COMMUNITY HEALTH FAIRS AND THE COMMUNITY HEALTH AND FITNESS FAIR IS HELD ANNUALLY BY THE HOSPITAL FOR THE COMMUNITY CONSISTING OF VARIOUS EXHIBITS ON HEALTH RELATED TOPICS. IT IS OPEN TO ALL AGES. ANOTHER ANNUAL EVENT IS THE WOMEN'S HEALTH CONFERENCE FOR AREA WOMEN OF ALL AGES. THE CONFERENCE INCLUDES SPEAKERS ON WOMEN RELATED HEALTH ISSUES. THE HOSPITAL ALSO SPONSORS A KID'S DAY AT THE LEE COUNTY FAIR, THE LEE COUNTY FAIR SENIOR DAY, AND THE LOCAL RELAY FOR LIFE. FORT MADISON COMMUNITY HOSPITAL IS A STAUNCH SUPPORTER, BOTH FINANCIALLY AND WITH STAFFING, FOR COMMUNITY PROJECTS THAT PROMOTE AN ACTIVE LIFESTYLE; THIS INCLUDES THE PORT RECREATIONAL TRAIL DEVELOPMENT, THE LOCAL YMCA AND THE BUILDING OF THE BAXTER SPORTS COMPLEX. FORT MADISON COMMUNITY HOSPITAL PROVIDES FULL TIME ATHLETIC TRAINERS TO THE TWO AREA HIGH SCHOOLS IN OUR PRIMARY SERVICE AREA. THESE HEAVILY SUBSIDIZED POSITIONS PROVIDE FOR THE HEALTH AND SAFETY OF OUR STUDENT ATHLETES. AS PART OF THIS PROGRAM, WE ALSO OFFER ATHLETIC SCREENINGS AT A DISCOUNTED RATE WITH HALF OF THE PROCEEDS DONATED BACK TO THE SCHOOLS.FORT MADISON COMMUNITY HOSPITAL FURTHERS ITS EFFORTS TO PROMOTE THE HEALTH OF THE COMMUNITY BY ENSURING THE MAJORITY OF THE ORGANIZATION'S GOVERNING BODY IS COMPRISED OF PERSONS WHO RESIDE IN THE ORGANIZATION'S PRIMARY SERVICE AREA WHO ARE NEITHER EMPLOYEES NOR CONTRACTORS OF THE ORGANIZATION, NOR FAMILY MEMBERS OF SUCH. THE ORGANIZATION ALSO EXTENDS MEDICAL PRIVILEGES TO ALL QUALIFIED PHYSICIANS IN ITS COMMUNITY FOR SOME OR ALL OF ITS DEPARTMENTS. FORT MADISON COMMUNITY HOSPITAL IS COMMITTED TO SERVING THE RESIDENTS OF AREA COMMUNITIES. THE HOSPITAL CONTINUES THESE EFFORTS BY USING EXCESS FUNDS TO EXPAND ITS FACILITIES AND SERVICES TO BETTER SERVE THE COMMUNITY. WE CONTRACT WITH AREA SPECIALISTS TO HOLD ONSITE CLINICS SO OUR PATIENTS CAN GET THE CARE THEY NEED WITHOUT HAVING TO TRAVEL OUTSIDE THE AREA. WE FINANCIALLY SUPPORT A REGIONAL DIALYSIS CENTER IN FORT MADISON, WHICH IS A COLLABORATIVE EFFORT OF ALL SOUTHEAST IOWA HEALTH CARE ORGANIZATIONS. FORT MADISON COMMUNITY HOSPITAL ACTS AS A TEACHING RESOURCE AT ALL LEVELS OF HEALTH CARE EDUCATION INCLUDING HIGH SCHOOL STUDENTS; COLLEGE STUDENTS IN A VARIETY OF HEALTH CARE CAREERS; AND MEDICAL STUDENTS DOING CLINICAL ROTATIONS. FORT MADISON COMMUNITY HOSPITAL IS A DISPROPORTIONATE SHARE (FOR MEDICAID) HOSPITAL WHICH PARTICIPATES IN MEDICARE, MEDICAID, CHAMPUS, TRICARE AND OTHER GOVERNMENT SPONSORED HEALTH CARE PROGRAMS. PAYMENTS FOR SERVICES PROVIDED TO BENEFICIARIES OF THESE PROGRAMS ARE BASED ON PRE-ESTABLISHED AND UNILATERALLY SET FEE SCHEDULES IN ACCORDANCE WITH THE PATIENT'S DIAGNOSIS OR TEST OR PROCEDURE PERFORMED. THE DIFFERENCE BETWEEN THE SERVICE PRICE AND THE CONTRACTED PRICE IS WRITTEN-OFF BY THE HOSPITAL. THE CONTRACTED AMOUNT RECEIVED FROM THESE PROGRAMS IS OFTEN LESS THAN THE ACTUAL COST OF THE SERVICE, THE DIFFERENCE OF WHICH REPRESENTS A BENEFIT TO THE PATIENT AND THE COMMUNITY.FORT MADISON COMMUNITY HOSPITAL OPERATES AN EMERGENCY ROOM THAT IS OPEN 24 HOURS PER DAY, 365 DAYS PER YEAR. THE EMERGENCY ROOM HAS A TRAUMA CENTER WITH A CERTIFICATION LEVEL OF IV. THE HOSPITAL'S EMERGENCY ROOM PROVIDES SERVICES TO ALL INDIVIDUALS, REGARDLESS OF THEIR ABILITY TO PAY AND DENIES SERVICES TO NO ONE.FORT MADISON COMMUNITY HOSPITAL PARTICIPATES IN COMMUNITY BUILDING ACTIVITIES IN A VARIETY OF WAYS. FMCH EMPLOYEES ROUTINELY PARTICIPATE IN COMMUNITY ACTIVITIES SUCH AS PARADES, FIRST AID TENTS AT COMMUNITY EVENTS AND A VARIETY OF LOCAL CHARITY ACTIVITIES. MEMBERS OF OUR LEADERSHIP TEAM SIT ON THE FORT MADISON CHAMBER OF COMMERCE, FORT MADISON ECONOMIC DEVELOPMENT AND LOCAL CIVIC ORGANIZATIONS.THE OUTPATIENT REHABILITATION CENTER INCLUDES AN INDOOR WALKING TRACK FOR USE BY THE PUBLIC. THE WALKING TRACK IS USED TO PROMOTE WELLNESS WITH ALL OF OUR CLIENT GROUPS: BUSINESS, PATIENTS, EMPLOYEES. IN ADDITION, THE HOSPITAL MAINTAINS AN OUTDOOR WALKING TRACK OPEN FOR PUBLIC USE. THE HOSPITAL PROVIDES VARIOUS PROGRAMS AND SERVICES TO INFORM AND TRAIN MEMBERS OF THE COMMUNITY ON SAFETY, HEALTH AND LIFESTYLE TOPICS, AS WELL AS PROVIDE OPPORTUNITIES FOR LEARNING IN A SAFE ENVIRONMENT. THE PROGRAMS ARE FREE OR A NOMINAL FEE IS CHARGED TO DEFRAY A PORTION OF THE COST. EXAMPLES OF THE PROGRAMS ARE EDUCATION PROGRAMS FOR CPR/FIRST AID, PRENATAL, FAMILY/PARENTING AND SIBLING RELATIONSHIPS, AS WELL AS TRAINING TO STUDENTS OF A VARIETY OF AGES. THE HOSPITAL PROVIDES A COURTESY TRANSPORTATION SERVICE TO RESIDENTS OF SEVERAL AREA COMMUNITIES. VARIOUS PICK-UP TIMES AND LOCATIONS ARE PROVIDED.FORT MADISON COMMUNITY HOSPITAL MAINTAINS A WEBSITE TO PROVIDE THE COMMUNITY WITH ACCESS TO PROVIDER INFORMATION, COMMUNITY PROGRAMS, HEALTH SERVICES, EMPLOYMENT OPPORTUNITIES AND THE PATIENT PORTAL.THE HOSPITAL PROVIDES VARIOUS SERVICES TO AREA BUSINESSES ON A CONTRACT BASIS INCLUDING EDUCATION PROGRAMS ON WELLNESS AND WORKPLACE INJURY PREVENTION, ON-SITE ERGONOMIC EVALUATIONS, DRUG/ALCOHOL TESTING/SCREENING, EVALUATION OF WORK RELATED INJURIES AND VACCINES. THE HOSPITAL UNDERWRITES A PORTION OF THE COST OF THESE SERVICES. |
| PART VI, LINE 6: | UPON THE AFFILIATION OF GREAT RIVER HEALTH AND FORT MADISON COMMUNITY HOSPITAL, A GRHS-FMCH COMMUNITY HEALTH FOUNDATION WAS FORMED TO PROVIDE FINANCIAL SUPPORT FOR COMMUNITY PROJECTS THAT WILL POSITIVELY AFFECT THE HEALTH OF OUR COMMUNITY. THE FIRST PROJECT FUNDED IS AN EXPANSION OF RECREATIONAL TRAILS IN FORT MADISON THROUGH PORT OF FORT MADISON. RECREATIONAL TRAILS PROVIDE A TOOL TO ENCOURAGE HEALTHY LIVING. THIS IS ALSO ONE OF OUR CHNA GOALS. WE WILL CONTINUE TO LOOK FOR WAYS TO WORK TOGETHER TO IMPACT THE HEALTH OF OUR COMMUNITIES WE SERVE. |
| PART VI, LINE 7, REPORTS FILED WITH STATES | IA |
Schedule I IRS990ScheduleI
| Field | Value | IRS element (for citing) |
|---|---|---|
| Grant Records Maintained | Yes (1) | GrantRecordsMaintainedInd |
Recipient Table RecipientTable (4 entries)
| Address Line1USAddress/AddressLine1Txt | CityUSAddress/CityNm | State AbbreviationUSAddress/StateAbbreviationCd | ZIPUSAddress/ZIPCd | Recipient EINRecipientEIN | IRC SectionIRCSectionDesc | Cash GrantCashGrantAmt | Purpose Of GrantPurposeOfGrantTxt |
|---|---|---|---|---|---|---|---|
| FORT MADISON RODEO CORP | |||||||
| PO BOX 80 | FORT MADISON | IA | 52627 | 420658297 | 501(C)(4) | $16,100 | PROMOTE COMMUNITY ACTIVE LIFESTYLE |
| SOUTHEASTERN COMMUNITY COLLEGE FOUNDATION | |||||||
| 1500 W AGENCY ROAD PO BOX 180 | WEST BURLINGTON | IA | 52655 | 421212111 | 501(C)(3) | $20,000 | GENERAL SUPPORT |
| LEE COUNTY ECONOMIC DEVELOPMENT GROUP | |||||||
| 2700 KINDUSTRY PARK ROAD | KEOKUK | IA | 52632 | 043605260 | 501(C)(3) | $10,000 | GENERAL SUPPORT |
| GRHS-FMCH COMMUNITY HEALTH FOUNDATION | |||||||
| 5445 AVENUE O | FORT MADISON | IA | 52627 | 832357759 | 501(C)(3) | $2,000,000 | GENERAL SUPPORT |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total501c3 Org | 3 | Total501c3OrgCnt |
| Total Other Org | 1 | TotalOtherOrgCnt |
Supplemental Information Detail SupplementalInformationDetail
| Field | Value | IRS element (for citing) |
|---|---|---|
| Form And Line Reference | PART I, LINE 2: | FormAndLineReferenceDesc |
| Explanation | AS DONATION REQUESTS ARE RECEIVED BY THE HOSPITAL, AN INDEPENDENT SENIOR LEADERSHIP TEAM EVALUATES AND APPROVES THE RECIPIENTS FOR THE CHARITABLE/COMMUNITY BENEFIT DONATIONS. | ExplanationTxt |
Schedule J IRS990ScheduleJ
| Field | Value | IRS element (for citing) |
|---|---|---|
| Compensation Committee | Yes (X) | CompensationCommitteeInd |
| Compensation Survey | Yes (X) | CompensationSurveyInd |
| Board Or Committee Approval | Yes (X) | BoardOrCommitteeApprovalInd |
| Severance Payment | 0 | SeverancePaymentInd |
| Supplemental Nonqual Rtr Plan | 0 | SupplementalNonqualRtrPlanInd |
| Equity Based Comp Arrngm | 0 | EquityBasedCompArrngmInd |
| Comp Based On Revenue Of Flng Org | 0 | CompBasedOnRevenueOfFlngOrgInd |
| Comp Bsd On Rev Related Orgs | 0 | CompBsdOnRevRelatedOrgsInd |
| Comp Bsd Net Earns Flng Org | 0 | CompBsdNetEarnsFlngOrgInd |
| Comp Bsd Net Earns Rltd Orgs | 0 | CompBsdNetEarnsRltdOrgsInd |
| Any Non Fixed Payments | 0 | AnyNonFixedPaymentsInd |
| Initial Contract Exception | 0 | InitialContractExceptionInd |
Rltd Org Officer Trst Key Empl RltdOrgOfficerTrstKeyEmplGrp (7 entries)
| TitleTitleTxt | Base Compensation Filing OrgBaseCompensationFilingOrgAmt | Compensation Based On Rltd OrgsCompensationBasedOnRltdOrgsAmt | Bonus Filing OrganizationBonusFilingOrganizationAmount | Bonus Related OrganizationsBonusRelatedOrganizationsAmt | Other Compensation Filing OrgOtherCompensationFilingOrgAmt | Other Compensation Rltd OrgsOtherCompensationRltdOrgsAmt | Deferred Compensation Flng OrgDeferredCompensationFlngOrgAmt | Deferred Comp Rltd OrgsDeferredCompRltdOrgsAmt | Nontaxable Benefits Filing OrgNontaxableBenefitsFilingOrgAmt | Nontaxable Benefits Rltd OrgsNontaxableBenefitsRltdOrgsAmt | Total Compensation Filing OrgTotalCompensationFilingOrgAmt | Total Compensation Rltd OrgsTotalCompensationRltdOrgsAmt | Comp Report Prior990 Filing OrgCompReportPrior990FilingOrgAmt | Comp Report Prior990 Rltd OrgsCompReportPrior990RltdOrgsAmt |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| DAVID PIKE | ||||||||||||||
| FORMER INTERIM CFO | $151,250 | $0 | $0 | $0 | $0 | $0 | $0 | $0 | $36,638 | $0 | $187,888 | $0 | $0 | $0 |
| JEREMY ALEXANDER | ||||||||||||||
| CEO/SECRETARY | $328,460 | $0 | $0 | $0 | $0 | $0 | $0 | $0 | $45,435 | $0 | $373,895 | $0 | $0 | $0 |
| W RIGGS BAGAN MD | ||||||||||||||
| PHYSICIAN | $228,795 | $0 | $137,793 | $0 | $0 | $0 | $13,750 | $0 | $23,863 | $0 | $404,201 | $0 | $0 | $0 |
| DEREK L BREDER MD | ||||||||||||||
| PHYSICIAN | $642,818 | $0 | $78,925 | $0 | $0 | $0 | $13,750 | $0 | $24,720 | $0 | $760,213 | $0 | $0 | $0 |
| TIMOTHY S STAUDTE MD | ||||||||||||||
| PHYSICIAN | $239,575 | $0 | $244,476 | $0 | $0 | $0 | $13,750 | $0 | $17,463 | $0 | $515,264 | $0 | $0 | $0 |
| KAICHUN WEI MD | ||||||||||||||
| PHYSICIAN | $331,613 | $0 | $30,773 | $0 | $0 | $0 | $13,750 | $0 | $22,329 | $0 | $398,465 | $0 | $0 | $0 |
| BRENT G WOODBURY MD | ||||||||||||||
| PHYSICIAN | $578,781 | $0 | $124,888 | $0 | $0 | $0 | $13,750 | $0 | $21,913 | $0 | $739,332 | $0 | $0 | $0 |
Schedule O IRS990ScheduleO
Supplemental Information Detail SupplementalInformationDetail (11 entries)
| Form And Line ReferenceFormAndLineReferenceDesc | ExplanationExplanationTxt |
|---|---|
| FORM 990, PART VI, SECTION A, LINE 3 | GREAT RIVER HEALTH SYSTEM BEGAN PROVIDING MANAGEMENT SERVICES TO THE FORT MADISON COMMUNITY HOSPITAL AS OF AUGUST 1, 2018. GREAT RIVER HEALTH SYSTEM BEGAN COMPENSATING JEREMY ALEXANDER DURING THE CALENDAR YEAR ENDED DECEMBER 31, 2018. COMPENSATION FROM GREAT RIVER HEALTH SYSTEM IS INCLUDED IN REPORTABLE COMPENSATION IN PART VII, LINE 1 AND SCHEDULE J, AS APPLICABLE. |
| FORM 990, PART VI, SECTION A, LINE 6 | GREAT RIVER HEALTH SYSTEM, INC., A RELATED ORGANIZATION AND IOWA NONPROFIT CORPORATION, IS THE SOLE CORPORATE MEMBER OF FORT MADISON COMMUNITY HOSPITAL. |
| FORM 990, PART VI, SECTION A, LINE 7A | AS THE SOLE MEMBER OF FORT MADISON COMMUNITY HOSPITAL, GREAT RIVER HEALTH SYSTEM, INC. HAS THE EXCLUSIVE POWER TO APPOINT, AFTER NOMINATION OF DIRECTORS FOR ELECTION BY THE CORPORATION'S BOARD, ANY DIRECTOR TO THE CORPORATION'S BOARD. |
| FORM 990, PART VI, SECTION A, LINE 7B | AS THE SOLE MEMBER OF FORT MADISON COMMUNITY HOSPITAL (FMCH), GREAT RIVER HEALTH SYSTEM, INC. (GRHS) HAS THE EXCLUSIVE POWER TO APPOINT, AFTER NOMINATION OF DIRECTORS FOR ELECTION BY THE CORPORATION'S BOARD, ANY DIRECTOR TO THE CORPORATION'S BOARD. THE BOARD OF DIRECTORS MAY ONLY REMOVE DIRECTORS THAT WERE NOT SELECTED AND APPOINTED BY GRHS. FMCH MUST ALSO RECEIVE CONSENT FROM GRHS' BOARD OF DIRECTORS FOR CERTAIN ACTIONS TO BE TAKEN, SUCH AS ADOPTION OF STRATEGIC PLANS FOR FMCH OR FMCH AFFILIATES; ADOPTION OF OPERATING AND CAPITAL BUDGETS FOR FMCH OR FMCH AFFILIATES; APPROVAL OF INDEBTEDNESS INCURRED BY FMCH OR FMCH AFFILIATES; THE TRANSFER, SALE OR CLOSURE OF ANY FACILITY, DEPARTMENT OR FUNCTION OF FMCH OR FMCH AFFILIATES; ANY AMENDMENT TO THE ARTICLES OR BYLAWS OF FMCH OR FMCH AFFILIATES, ETC. |
| FORM 990, PART VI, SECTION B, LINE 11B | A COPY OF THE FORM 990 IS REVIEWED BY THE ORGANIZATION'S CONTROLLER AND VICE PRESIDENT OF FINANCE WITH THE EXTERNAL ACCOUNTANTS FOR COMPLETENESS AND ACCURACY PRIOR TO FILING THE FORM 990 WITH THE INTERNAL REVENUE SERVICE. |
| FORM 990, PART VI, SECTION B, LINE 12C | EACH DIRECTOR, PRINCIPAL OFFICER AND MEMBER OF A COMMITTEE WITH BOARD DELEGATED POWERS ANNUALLY SIGNS A STATEMENT WHICH AFFIRMS THAT SUCH PERSON: 1) HAS RECEIVED A COPY OF THE CONFLICT OF INTEREST POLICY, 2) HAS READ AND UNDERSTANDS THE POLICY, 3) HAS AGREED TO COMPLY WITH THE POLICY, AND 4) UNDERSTANDS THAT THE HOSPITAL IS A CHARITABLE ORGANIZATION AND THAT IN ORDER TO MAINTAIN ITS FEDERAL TAX EXEMPTION IT MUST ENGAGE PRIMARILY IN ACTIVITIES WHICH ACCOMPLISH ONE OR MORE OF ITS TAX-EXEMPT PURPOSES. IN CONNECTION WITH ANY ACTUAL OR POSSIBLE CONFLICTS OF INTEREST, ANY INTERESTED PERSON MUST DISCLOSE THE EXISTENCE AND NATURE OF HIS OR HER FINANCIAL INTEREST TO THE DIRECTORS AND MEMBERS OF COMMITTEES WITH BOARD DELEGATED POWERS CONSIDERING THE PROPOSED TRANSACTION OR ARRANGEMENT. UPON ANY DISCLOSURE OF THE FINANCIAL INTEREST, THE INTERESTED PERSON LEAVES THE BOARD OR COMMITTEE WHILE THE FINANCIAL INTEREST IS DISCUSSED AND VOTED UPON. THE REMAINING BOARD OR COMMITTEE MEMBERS DECIDE IF A CONFLICT OF INTEREST EXISTS. ALL SUCH ACTIONS ARE RECORDED IN THE MINUTES OF THE BOARD OR COMMITTEE MEETING. |
| FORM 990, PART VI, SECTION B, LINE 15 | THE COMPENSATION COMMITTEE, ACTING ON BEHALF OF THE BOARD OF DIRECTORS, MEETS AT LEAST ANNUALLY TO ASSIST THE BOARD OF DIRECTORS IN FULFILLING ITS OVERSIGHT RESPONSIBILITIES FOR EXECUTIVE COMPENSATION. THE COMPENSATION COMMITTEE REVIEWS COMPENSATION DATA AND RELATED POLICIES AND DETERMINES WHETHER SUCH COMPENSATION IS REASONABLE AND CONSISTENT WITH FAIR MARKET VALUE IN ORDER TO RECOMMEND TO THE FULL BOARD OF DIRECTORS COMPENSATION AMOUNTS FOR APPROVAL. THE COMPENSATION COMMITTEE MAINTAINS DOCUMENTATION, CONSISTENT WITH THE RECORD RETENTION POLICY, OF ITS ACTIVITIES AND THE BASIS FOR ITS DECISIONS. THE COMPENSATION COMMITTEE, ACTING ON BEHALF OF THE BOARD OF DIRECTORS, REVIEWS AND APPROVES COMPENSATION OF PHYSICIANS EMPLOYED OR CONTRACTED BY FMCH OR AN AFFILIATE ANNUALLY. THE COMPENSATION COMMITTEE USES THE MGMA DATA FOR COMPARISON. THE COMPENSATION COMMITTEE MAINTAINS DOCUMENTATION, CONSISTENT WITH THE RECORD RETENTION POLICY, OF ITS ACTIVITIES AND THE BASIS FOR ITS DECISIONS. |
| FORM 990, PART VI, SECTION C, LINE 19 | THE ORGANIZATION'S GOVERNING DOCUMENTS, CONFLICT OF INTEREST POLICY, AND FINANCIAL STATEMENTS ARE NOT MADE AVAILABLE TO THE PUBLIC. |
| FORM 990, PART XI, LINE 9: | EQUITY IN SUBSIDIARY EARNINGS 248,772. ADJUSTMENT OF BAD DEBT EXPENSE RECOGNIZED IN FY18 BUT WRITTEN OFF IN FY19 340,000. FAIR MARKET VALUE ADJUSTMENT RELATED TO PROPERTY AND EQUIPMENT ACQUIRED 106,278. CONTRIBUTION PLEDGE EXECUTED TO GRHS-FMCH COMMUNITY HEALTH FOUNDATION 2,000,000. |
| FORM 990, PART IV, LINE 12B & PART XII, LINE 2B & 2C: | THE ORGANIZATION'S FINANCIAL STATEMENTS ARE AUDITED ON A CONSOLIDATED BASIS BY AN INDEPENDENT ACCOUNTANT. HOWEVER, THE STATEMENTS ARE AUDITED ON A FISCAL YEAR-END OF JUNE 30, 2019, WHILE THE ORGANIZATION'S TAX YEAR-END IS SEPTEMBER 30, 2019. FORT MADISON COMMUNITY HOSPITAL WILL TRANSITION TO A JUNE 30 YEAR-END IN THE NEXT REPORTING PERIOD TO ALIGN WITH ITS NEW AFFILIATES' YEAR-END AND THE CONSOLIDATED AUDITED FINANCIALS REPORTING PERIOD. |
| FORM 990, PART VII, LINE 1A: | FORT MADISON COMMUNITY HOSPITAL AND FORT MADISON COMMUNITY HOSPITAL FOUNDATION ARE RELATED ENTITIES. AS A RESULT, BOARD OVERLAP EXISTS AMONG THESE ENTITIES AND IT WOULD BE ADMINISTRATIVELY IMPRACTICAL FOR MEMBERS OF THE GOVERNING BOARD AND THE EXECUTIVE TEAM TO BREAKOUT THEIR HOURS DEVOTED AMONG EACH ORGANIZATION. |
Schedule R IRS990ScheduleR
Id Related Tax Exempt Org IdRelatedTaxExemptOrgGrp (6 entries)
| Address Line1USAddress/AddressLine1Txt | CityUSAddress/CityNm | State AbbreviationUSAddress/StateAbbreviationCd | ZIPUSAddress/ZIPCd | EINEIN | Primary ActivitiesPrimaryActivitiesTxt | Legal Domicile StateLegalDomicileStateCd | Exempt Code SectionExemptCodeSectionTxt | Public Charity StatusPublicCharityStatusTxt | Business Name Line1DirectControllingEntityName/BusinessNameLine1Txt | Controlled OrganizationControlledOrganizationInd | Direct Controlling NADirectControllingNACd |
|---|---|---|---|---|---|---|---|---|---|---|---|
| FORT MADISON COMMUNITY HOSPITAL FOUNDATION | |||||||||||
| 5445 AVENUE O PO BOX 174 | FORT MADISON | IA | 52627 | 421446727 | SUPPORT FORT MADISON COMMUNITY HOSPITAL | IA | 501(C)(3) | LINE 12A, I | FORT MADISON COMMUNITY HOSPITAL | Yes (1) | |
| GREAT RIVER HEALTH SYSTEM INC | |||||||||||
| 1221 SOUTH GEAR AVENUE | WEST BURLINGTON | IA | 52655 | 421193185 | HOLDING COMPANY | IA | 501(C)(3) | LINE 12B, II | 0 | N/A | |
| GREAT RIVER MEDICAL CENTER | |||||||||||
| 1221 SOUTH GEAR AVENUE | WEST BURLINGTON | IA | 52655 | 420680407 | HOSPITAL | IA | 501(C)(3) | LINE 3 | GREAT RIVER HEALTH SYSTEM INC | Yes (1) | |
| GRMC FOUNDATION CORP | |||||||||||
| 1221 SOUTH GEAR AVENUE | WEST BURLINGTON | IA | 52655 | 421193186 | SUPPORT RELATED ORGANIZATIONS | IA | 501(C)(3) | LINE 12B, II | GREAT RIVER HEALTH SYSTEM INC | Yes (1) | |
| GREAT RIVER FOUNDATION INC | |||||||||||
| 1221 SOUTH GEAR AVENUE | WEST BURLINGTON | IA | 52655 | 421469162 | SUPPORT FORT MADISON COMMUNITY HOSPITAL | IA | 501(C)(3) | LINE 12B, II | GREAT RIVER HEALTH SYSTEM INC | Yes (1) | |
| GRHS-FMCH COMMUNITY HEALTH FOUNDATION | |||||||||||
| 5445 AVENUE O | FORT MADISON | IA | 52627 | 832357759 | SPONSORS HEALTH INITIATIVES IN LEE COUNTY, IA | IA | 501(C)(3) | LINE 12B, II | GREAT RIVER HEALTH SYSTEM INC | Yes (1) | |
Id Related Org Txbl Corp Tr IdRelatedOrgTxblCorpTrGrp (7 entries)
| Address Line1USAddress/AddressLine1Txt | CityUSAddress/CityNm | State AbbreviationUSAddress/StateAbbreviationCd | ZIPUSAddress/ZIPCd | EINEIN | Primary ActivitiesPrimaryActivitiesTxt | Legal Domicile StateLegalDomicileStateCd | Direct Controlling NADirectControllingNACd | Entity TypeEntityTypeTxt | Controlled OrganizationControlledOrganizationInd |
|---|---|---|---|---|---|---|---|---|---|
| RIVERVIEW SYSTEMS LTD | |||||||||
| 1221 SOUTH GEAR AVENUE | WEST BURLINGTON | IA | 52655 | 421191960 | MEDICAL SERVICES | IA | N/A | C | Yes (1) |
| GREAT RIVER MEDICAL SERVICES INC | |||||||||
| 1221 SOUTH GEAR AVENUE | WEST BURLINGTON | IA | 52655 | 421493449 | MEDICAL SERVICE | IA | N/A | C | Yes (1) |
| MUTUAL CONSULTING AND MANAGEMENT SERVICES | |||||||||
| 1221 SOUTH GEAR AVENUE | WEST BURLINGTON | IA | 52655 | 421349668 | MANAGEMENT SERVICES | IA | N/A | C | Yes (1) |
| HEALTH CARE REALTY | |||||||||
| 1221 SOUTH GEAR AVENUE | WEST BURLINGTON | IA | 52655 | 421193532 | REAL ESTATE | IA | N/A | C | Yes (1) |
| HERITAGE PARK PHARMACY | |||||||||
| 1221 SOUTH GEAR AVENUE | WEST BURLINGTON | IA | 52655 | 421191957 | PHARMACY | IA | N/A | C | Yes (1) |
| HERITAGE MEDICAL EQUIPMENT AND SUPPLY | |||||||||
| 1221 SOUTH GEAR AVENUE | WEST BURLINGTON | IA | 52655 | 421191958 | MEDICAL SUPPLY | IA | N/A | C | Yes (1) |
| SOUTHEASTERN IOWA MEDICAL SERVICES | |||||||||
| 1221 SOUTH GEAR AVENUE | WEST BURLINGTON | IA | 52655 | 421307141 | PHYSICIAN CLINICS | IA | N/A | C | Yes (1) |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Receipt Of Int Annts Rnts Rylts | Yes (1) | ReceiptOfIntAnntsRntsRyltsInd |
| Gift Grnt Or Cap Contri To Oth Org | Yes (1) | GiftGrntOrCapContriToOthOrgInd |
| Gift Grnt Cap Contri From Oth Org | Yes (1) | GiftGrntCapContriFromOthOrgInd |
| Loans Or Guarantees To Other Org | 0 | LoansOrGuaranteesToOtherOrgInd |
| Loans Or Guarantees From Oth Org | Yes (1) | LoansOrGuaranteesFromOthOrgInd |
| Div Related Organization | 0 | DivRelatedOrganizationInd |
| Asset Sale To Other Org | 0 | AssetSaleToOtherOrgInd |
| Asset Purchase From Other Org | 0 | AssetPurchaseFromOtherOrgInd |
| Asset Exchange | 0 | AssetExchangeInd |
| Rental Of Facilities To Oth Org | 0 | RentalOfFacilitiesToOthOrgInd |
| Rental Of Fclts From Oth Org | 0 | RentalOfFcltsFromOthOrgInd |
| Perform Of Services For Oth Org | 0 | PerformOfServicesForOthOrgInd |
| Perform Of Services By Other Org | 0 | PerformOfServicesByOtherOrgInd |
| Sharing Of Facilities | 0 | SharingOfFacilitiesInd |
| Paid Employees Sharing | Yes (1) | PaidEmployeesSharingInd |
| Reimbursement Paid To Other Org | Yes (1) | ReimbursementPaidToOtherOrgInd |
| Reimbursement Paid By Other Org | 0 | ReimbursementPaidByOtherOrgInd |
| Transfer To Other Org | 0 | TransferToOtherOrgInd |
| Transfer From Other Org | 0 | TransferFromOtherOrgInd |
Transactions Related Org TransactionsRelatedOrgGrp (6 entries)
| Transaction TypeTransactionTypeTxt | InvolvedInvolvedAmt | Method Of Amount DeterminationMethodOfAmountDeterminationTxt |
|---|---|---|
| GREAT RIVER MEDICAL CENTER | ||
| A | $47,903 | FAIR MARKET VALUE |
| GRHS-FMCH COMMUNITY HEALTH FOUNDATION | ||
| B | $2,000,000 | FAIR MARKET VALUE |
| GREAT RIVER HEALTH SYSTEM INC | ||
| C | $12,800,000 | FAIR MARKET VALUE |
| GREAT RIVER MEDICAL CENTER | ||
| E | $3,100,000 | FAIR MARKET VALUE |
| MUTUAL CONSULTING AND MANAGEMENT SERVICES INC | ||
| O | $186,510 | FAIR MARKET VALUE |
| MUTUAL CONSULTING AND MANAGEMENT SERVICES INC | ||
| P | $417,358 | FAIR MARKET VALUE |