2019-11-15T07:56:50-06:00 2018-12-31 420714325 RSM US LLP 1 S Wacker Drive Ste 800 Chicago IL 60606 990 2018-01-01 362169179 Palos Community Hospital PALO 7089234000 12251 S 80th Avenue Palos Heights IL 60463 Dr Terrence Moisan President & CEO 7089234000 2019-11-13 1 Rebekuh Eley P01247672 3126343400 66.98.98.134 2019-11-13 13:47:09 CS P DA39A3EE5E6B4B0D3255BFEF95601890AFD80709 2A28FA2E2A09A40AF4F0A751499BE74D16D20E85 2018 2020-03-31 21:24:44Z Dr Terrence Moisan 12251 S 80th Avenue Palos Heights IL 60463 413822244 0 X www.paloshealth.com X 1972 IL Palos Community Hospital (Palos) is a 501(c)(3) community hospital whose primary objective is the provision of inpatient and outpatient services that are responsive to the health care needs of the residents of southwestern Cook County and northeastern sections of Will County. X 11 7 3453 1022 39537 -35594 583649 319913 398082739 400506251 2271874 1255415 8132698 9672534 409070960 411754113 0 0 0 0 214602501 218350732 0 0 0 197488252 209916335 412090753 428267067 -3019793 -16512954 762361023 670245595 498196974 488044992 264164049 182200603 X The primary objective of Palos is to provide high quality patient care that is responsive to the health care needs of the residents of southwestern Cook County and northeastern sections of Will County. Palos is committed to a continued review and analysis of the changing needs of the community it serves and to respond with services based upon those needs. 0 0 339540000 407892910 Palos Hospital provides inpatient and outpatient health care services. The hospital has 425 licensed beds and is located 22 miles from downtown Chicago serving the southwest suburbs. During fiscal year 18, the hospital provided more than 87,431 patients days and more than 218,680 outpatient visits to the community. Please visit PalosHealth.com for additional information regarding our services. 339540000 1 1 0 1 0 0 0 0 0 0 1 0 0 0 1 1 0 1 0 0 1 0 0 0 0 0 1 1 0 0 1 1 0 0 0 0 0 0 0 0 1 0 0 0 0 1 1 1 1 1 0 0 1 365 0 1 3453 1 1 1 1 CJ 0 0 0 0 0 0 0 0 0 0 X 11 7 0 0 0 0 1 1 1 1 1 0 0 1 1 1 1 1 1 1 1 0 IL X Michael Rauwolf 7089234000 12251 S 80th Avenue Palos Heights IL 60463 Edward Mulcahy Chairman 2.00 1.00 X X 0 0 0 Dr Terrence Moisan President & CEO 40.00 1.00 X X 837795 0 44931 Lawrence Hunt Vice Chairman 2.00 1.00 X 0 0 0 Jason Ley Director 2.00 1.00 X 0 0 0 Lucie Boyadjian Director 2.00 X 0 0 0 Dr Mark Sinibaldi Director/Physician 42.00 1.00 X 388125 0 46810 Jack Vainauskas Director 2.00 1.00 X 0 0 0 Gary Collins Director 2.00 X 0 0 0 Timothy J McCarthy Director 2.00 X 0 0 0 Rosann S Demask Director 40.00 X 346557 0 48423 Vincent Muscarello Director 2.00 1.00 X 0 0 0 Don Dixon Secretary 40.00 1.00 X 399977 0 47023 Barbara J Medley Asst. Secretary (Thru 1/12/18) 40.00 1.00 X 7698 0 1349 Roger A Russell VP Finance/Treasurer 40.00 1.00 X 374882 0 58048 Mary C Denisienko VP Human Resources 40.00 X 185777 0 22558 Patricia Heerlein VP Clinical Services 40.00 X 261320 0 32852 William Earman Physician 40.00 X 551768 0 12114 Chaher Alhandalous Hospitalist 40.00 X 503078 0 41524 Michael Lynch Physician 40.00 X 440106 0 42568 Imad Qayyum Physician 40.00 X 427015 0 23614 Beatrice Correa-Rivera Hospitalist 40.00 X 399781 0 29378 Charles E Reiter III Former Officer 0.00 X 249323 0 1624 5373202 0 452816 169 1 1 0 Walsh Construction II LLC 929 W Adams Street Chicago IL 60607 Construction Services 36796662 Epic Systems Corporation 1979 Milky Way Verona WI 53593 Computer Software Services 5719044 ARAMARK 12483 Collection Center Drive Chicago IL 60693 Equipment Services 5016226 Dan King Therapy Services 7061 Willow Springs Road Countryside IL 60525 Physician Services 1149384 Radiology & Nuclear Consultants 270 W Loop road Wheaton IL 60189 Physical Therapy Services 1135303 69 5000 314913 319913 Net Patient Revenue 621110 387462143 387422606 39537 Provider Tax Revenue 900099 13643118 13643118 Surgi Center JV Revenu 900099 -599010 -599010 400506251 1885777 1885777 2249690 1437769 811921 811921 811921 630362 -630362 -630362 -630362 0 5000 0 0 Intercompany Revenue 900099 3997873 3997873 Gainsharing Revenue 900099 1729671 1729671 Cafeteria Revenue 900099 1473954 1473954 1659115 1659115 8860613 411754113 407853373 39537 3541290 2758134 2758134 249323 249323 174787348 142932528 31854820 8277089 6637732 1639357 20062159 15869198 4192961 12216679 9826317 2390362 4469627 4469627 632677 632677 97129 97129 165850 165850 16062059 8106834 7955225 500279 207 500072 4363598 1334020 3029578 10105561 227149 9878412 6800566 5883291 917275 415686 389039 26647 119885 96947 22938 11589505 11589505 32906085 26345614 6560471 9662470 8775756 886714 Medical Supplies/Drugs 64424497 64424497 Bad Debt Expense 20092937 20092937 IL Bed Tax Assessment 14598168 14598168 Repairs and Maintenance 6693032 6693032 6216724 2410261 3806463 428267067 339540000 88727067 0 6155 6155 8832233 12909028 58273758 45224660 17502 10287 5504064 9143109 2879686 2983369 859852227 305375349 549082101 554476878 127659605 28239811 227073 138033 9878846 17114265 762361023 670245595 105968351 106358624 360195000 349830000 32033623 31856368 498196974 488044992 X 263810330 181817973 353719 382630 264164049 182200603 762361023 670245595 X -16512954 -197190 -65253302 X 0 1 X 1 0 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 0 0 0 0 0 0 0 0 1 36326 36326 0 Part II-B, Line 1: Palos Community Hospital paid $91,350 in dues to Illinois Health and Hospital Association, of which $35,627 was attributed to lobbying activity, as well as $14,500 in dues to National Hospice and Palliative Care Organization, of which $699 was attributed to lobbying activity. 33096527 33096527 598604699 171852063 426752636 165770 165770 223524460 133523286 90001174 4460771 4460771 554476878 Tax Exempt Bond Liability Premium 2088963 Supplemental Executive Retirement Plan Liability 644397 Professional Liability Insurance Reserve 26524130 Due To Affiliates 2598878 31856368 X Part X, Line 2: The Hospital has received determination letters from the Internal Revenue Service (IRS) stating that they are exempt from the payment of income taxes under Section 501(c)(3) of the Internal Revenue Code. Palos Medical Group is a disregarded entity and is considered part of the Hospital for income tax filing purposes. SGA is incorporated under the laws of the Cayman Islands, which imposes no tax on income or capital gains. However, SGA is subject to U.S. federal corporate taxation to the extent that it generates income that is effectively connected with a U.S. trade or business. SGA is not engaged in any such trade or business in the U.S. Accordingly, income taxes are not provided for in the accompanying consolidated financial statements. CHC, the Imaging Center and Sigma are also disregarded entities for income tax purposes. The Hospital follows the FASB-issued guidance for accounting for uncertainty in income taxes. The Hospital files a Form 990 (Return of Organization Exempt from Income Tax) annually. When this return is filed, it is highly certain that some positions taken would be sustained upon examination by the taxing authorities, while others are subject to uncertainty about the merits of the position taken or the amount of the position that would ultimately be sustained. Examples of tax positions common to health systems include such matters as the following: the tax exempt status of each entity, the continued tax exempt status of bonds issued by the obligated group, the nature, characterization and taxability of joint venture income and various positions relative to potential sources of unrelated business taxable income (UBTI). UBTI is reported on Form 990-T, as appropriate. The benefit of a tax position is recognized in the consolidated financial statements in the period during which, based on all available evidence, management believes that it is more likely than not that the position will be sustained upon examination, including the resolution of appeals or litigation processes, if any. Tax positions are not offset or aggregated with other positions. Tax positions that meet the "more-likely-than-not" recognition threshold are measured as the largest amount of tax benefit that is more than 50 percent likely to be realized on settlement with the applicable taxing authority. The portion of the benefits associated with tax positions taken that exceeds the amount measured as described above is reflected as a liability for unrecognized tax benefits in the accompanying consolidated balance sheets along with any associated interest and penalties that would be payable to the taxing authorities upon examination. Upon the adoption of the FASB-issued guidance at January 1, 2007, and since that date through December 31, 2018, there were no unrecognized tax benefits identified and recorded as a liability. Forms 990 and 990-T filed by The Hospital are subject to examination by the Internal Revenue Service (IRS) up to three years from the extended due date of each return. Forms 990 and 990-T filed by The Hospital are no longer subject to examination for the years 2014 and prior. Central America and the Caribbean 0 0 Investments 100000 0 0 0 0 0 0 100000 0 100000 0 0 1 0 0 0 1 1 X 1 X 1 X 600.000000000000 1 1 0 1 1 2561933 2561933 0.00630 45674528 24671709 21002819 0.05150 48236461 24671709 23564752 0.05780 778073 62760 715313 0.00180 237499 183027 54472 0.00010 26341369 19994699 6346670 0.01550 66181 66181 0.00020 27423122 20240486 7182636 0.01760 75659583 44912195 30747388 0.07540 1 20092937 135468255 139169449 -3701194 X 1 1 1 1 Palos Community Hospital 12251 S 80th Avenue Palos Heights IL 60463 State License #: 0003210 X X X Palos Community Hospital 1 0 0 1 X X X X X X X X X 18 1 1 0 1 X https://www.paloshealth.com/about-us/ X https://paloscommunity.healthforecast.net X 1 18 0 1 0 1 X 200.000000000000 600.000000000000 X X X X X 1 1 X X X 1 X paloshealth.com/app/files/public/2316/Financial-Assistance-Policy-2018.pdf X paloshealth.com/app/files/public/1996/Financial-Assistance-App-2016.pdf X www.paloshealth.com/patients-visitors/billing/financial-assistance/ X X X X X X 1 X 0 X X X X 1 X 0 0 Palos Community Hospital Part V, Section B, Line 5: The surveys asked respondents about health status of their communities and priority health needs. Survey collection efforts were concentrated in communities and populations that are typically underrepresented in assessment processes, such as veterans, individuals living with mental illness, communities of color, older adults, caregivers, teens and young adults, LGBTQ community members, adults and teens experiencing homelessness, families with children, faith communities, adults with disabilities, and children and adults living with chronic conditions such as diabetes and asthma. Palos Community Hospital Part V, Section B, Line 6a: The 2018 Community Health Needs Assessment was conducted through a membership collaborative called the Alliance for Health Equity. The member hospitals and health systems include: Advocate Aurora Children's Hospital, Advocate Aurora Christ Medical Center, Advocate Aurora Illinois Masonic Medical Center, Advocate Aurora Lutheran General Hospital, Advocate Aurora South Suburban Hospital, Advocate Aurora Trinity Hospital, AMITA Adventist Medical Center La Grange, AMITA Alexian Borthers Behavioral Health Hospital Hoffman Estates, AMITA Alexian Brothers Medical Center Elk Grove Village, AMITA Holy Family Medical Center, AMITA Resurrection Medical Center, AMITA Saint Francis Hospital, AMITA Saint Joseph Hospital, AMITA Saints Mary and Elizabeth Medical Center, AMITA St. Alexius Medical Center Hoffman Estates, Ann & Robert H. Lurie Children's Hospital, Gottlieb Memorial Hospital, Holy Cross Hospital, Ingalls Memorial Hospital, Loretto Hospital, Loyola University Medical Center, MacNeal Hospital, Mercy Hospital & Medical Center, Northwestern Memorial Hospital, Norwegian American Hospital, Palos Health, Roseland Community Hospital, Rush Oak Park, Rush University Medical Center, Schwab Rehab Hospital, Sinai Health System, South Shore Hospital, Swedish Covenant Hospital, University of Chicago Medicine and University of Illinois Hospital & Health Sciences System. Palos Community Hospital Part V, Section B, Line 11: Palos Hospital formed an internal, multi-disciplinary committee to review the results of the CHNA and to evaluate, discuss and prioritize health issues identified. The group used criteria focused on magnitude, scope/severity, Palos' ability to impact and the risk of inaction in determination of the areas of opportunity on which to focus. In consideration of the top health priorities identified through the CHNA process and taking into account hospital resources and overall alignment with the hospital's mission, goals and strategic priorities it was determined that Palos would focus on developing and/or supporting strategies and initiatives to improve: - Access to Health Care Services - Mental Health & Substance Abuse - Chronic Disease - Transportation and HousingIn acknowledging the wide range of priority health issues identified in the CHNA process, Palos Hospital determined that it could only effectively focus on those which it deemed most pressing, most under-addressed, and most within its ability to influence. As a consequence there were areas of opportunity identified in the CHNA which Palos had not prioritized to address due to the availability of other community-based programs and services to better address these opportunities and the low volume of respondents within the Palos Hospital service area requiring services. The areas of opportunity not addressed include: - Age-related illness - Cancers - Lung disease/Tobacco use - Motor vehicle crash injuries - Oral health Part V, Section B, Line 3 Primary data was collected through community input surveys and community resident focus groups. More than 250 community input surveys were collected from individuals 18 or older living in the Palos Community Hospital service area. Secondary data for numerous health indicators was collected and collated by Cook County Department of Public Health. The Illinois Public Health Institute (IPHI) conducted all administration of the surveys and focus groups, data collection and data analysis. Part V, Section B, Line 16i To be in compliance with section 501(r)(4)(v), Palos Community Hospital translated its FAP, FAP application form, and plain language summary of the FAP in the languages spoken by each LEP language group as described in Treas. Reg. 1.501(r)-4. The languages determined include Spanish, Polish, and Arabic and Palos posted translations to the Hospital's website before filing the Form 990.Please visit the following URL: www.paloshealth.com/patients-visitors/billing/financial-assistance/. Part V, Section B, line 22 It is the policy of Palos Community Hospital to provide quality medical health care to all persons regardless of race, creed, gender, national origin, handicap, age, ability to pay or other protected status. PCH recognizes that not all individuals possess the ability or means to purchase essential medical services, and further, that our mission is to serve our community with respect to providing health care services and health care education. Therefore, in keeping with PCH's commitment to serve all members of the community, free and/or discounted care ("Financial Assistance") will be considered where the need and/or inability to pay are identified as set forth in the Financial Assistance Policy. This policy was also extended to all clinically-necessary procedures and was not limited to emergency care only. Palos has created a set of discounts for patients without insurance that ranged from free care for those who earned less than 200% of the FPG to a 80% discount off of regularly billed charges for any uninsured patient who earned less than 600% of the FPG. Palos also created a policy to help those who are underinsured. Similar to its uninsured policy, the underinsured policy creates a set of discounts that can be applied to co-payments and deductibles owed for those patients that earn less than 400% of the FPG. 3 1 - Palos Primary Care Center 15300 West Avenue Suite 122 Orland Park IL 60462 Primary Care Center, Physician Group and Imaging Center 2 - Palos Home Health Care 15295 E 127th St Lemont IL 60439 Home Health Care 3 - Palos Diagnostic & Women's Center 17333 S LaGrange Rd Tinley Park IL 60477 Diagnostic Testing and Women's Health Part I, Line 3c: Palos has created a set of discounts for patients without insurance that ranged from free care for those who earned less than 200% of the FPG to a 80% discount off of regularly billed charges for any uninsured patient who earned less than 600% of the FPG. Palos also created a policy to help those who are underinsured. Similar to its uninsured policy, the underinsured policy creates a set of discounts that can be applied to co-payments and deductibles owed for those patients that earn less than 400% of the FPG.All self-pay patients are provided information regarding our charity care program at the time of registration and are asked to complete a one-page application. This enables the Hospital to expedite the charity care approval process. For balances after insurance, patients are made aware of our charity care program via the statement they receive. Additional information is available on the Hospital's website.The Financial Counselors see approximately 20 patients daily for assistance with screening for Medicaid applications, financial assistance, payment plans, estimated pricing for services, account review/inquiries/complaints, Medicare liability, etc. The Financial Counselors assist patients with current, past and future visits. The Financial Counselors and Self Pay Collectors processed 3,229 financial assistance applications in 2018. There were 2,550 charity adjustments including 1,511 presumptive eligibility charity adjustments. Part I, Line 7: Cost amounts reported in Item 7 were calculated using available data including the overall hospital cost to charge ratio as well as direct and indirect costs for certain specific departments of the hospital. Part I, Line 7, Column (f): The Bad Debt expense included on Form 990, Part IX, Line 25, Column (A), but subtracted for purposes of calculating the percentage in this column is $ 20,092,937. Part III, Line 2: Estimated bad debt expense is calculated by totaling the amounts from patient accounts written off as uncollectible plus an estimate of the uncollectible portion of accounts receivable, aged by financial class, all multiplied by the appropriate cost to charge ratio. Part III, Line 3: Information to determine this amount is not available. Part III, Line 4: 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, in 2017, estimated allowances for doubtful accounts. During 2017, management estimated the allowance for doubtful accounts based on the aging of its accounts receivable and its historical collection experience for each payor type. Recoveries of accounts receivable previously written off as uncollectible were recorded as an increase of net patient services revenue when received. For receivables associated with services provided to patients who have third-party coverage, the Hospital analyzed contractually due amounts and provided an allowance for doubtful accounts (for example, for unexpected uncollectible deductibles and copayments on accounts for which the third-party payor has not yet paid, or for payors who are known to be having financial difficulties that make the realization of amounts due unlikely). Patients who meet certain criteria under the Hospital's charity care policy are eligible for discounts from the Hospital's established rates. The difference betweenthe standard rates (or the discounted rates if applicable) and the amounts actually collected after all reasonable collection efforts have been exhausted were charged off against the allowance for doubtful accounts.The past due status of receivables is determined on a case-by-case basis depending on the payor responsible. Interest is generally not charged on past due accounts.The Hospital's allowance for doubtful accounts for self-pay patients was $12,155, or approximately 18 percent of patient accounts receivable, at December 31, 2017. The Hospital's self-pay write-offs were $24,848 in 2017. At December 31, 2017, the Hospital did not maintain a material allowance for doubtful accounts from third-party payors, nor did it have significant write-offs from third-party payors. Part III, Line 8: Medicare costs are calculated using the hospital wide cost to charge ratio. Palos does include the Medicare shortfall in its Illinois state community benefit report as Palos continues to treat its Medicare community despite the fact that its costs for these patients exceed reimbursement. Part III, Line 9b: It is the policy of Palos not to pursue collection practices against patient balances known to qualify under the financial assistance policy. Part VI, Line 2: In addition to the CHNA, Palos Hospital monitors trends in diseases, medical conditions, utilization of medical services and demographics that may affect the patients served and community at large. Palos uses this information as it designs and modifies programs and services to meet the needs to if patients and community either on its own or in collaboration with other entities. This information has demonstrated the need to focus on the management of an aging patient population, chronic health conditions, the incidence of readmission, and coordination of care from pre-hospitalization to post-acute. Part VI, Line 3: At the time of registration, each patient is referred to a copy of Palos' financial assistance policy and asked to fill out a simple registration form that may help them qualify for charity care. This policy lays out the eligibility requirements and what the patient must do to qualify. Also at registration, any patient without insurance is advised as to what other programs they may qualify for and are given assistance in applying as necessary. Palos employs a company that helps patients apply for Medicaid coverage and SSI disability. Upon discharge, each patient receives a summary bill that includes information related to eligibility for financial assistance. All inpatients without insurance are visited by a financial counselor who helps direct the patient and their families to the appropriate level of assistance. Brochures explaining the charity care policy are displayed and available at registration areas and in the Emergency Department. Palos also displays the plain language summary of the financial assistance policy on the website along with the financial assistance application. Part VI, Line 4: Zip codes within the Palos Hospital service area include: 60462, 60467, 60463, 60464, 60465, 60482, 60445, 60452, 60477, 60487, 60453, 60455, 60457, 60458, 60459, 60415, 60805, 60655, 60803, 60439, 60441, 60491, 60423, 60448, 60451Of those living within the service area of Palos Hospital:Household poverty rates range from 3% to 23% of households in the communities served.Three of the cities served by Palos Hospital have over 25% of children living in poverty (Bridgeview, Chicago Ridge, and d Hickory Hills). Over 10% of older adults are living in poverty in Justice, Crestwood, and Bridgeview.There more than 20,000 limited English speaking households, accounting for 4.1% of households in thearea.One-third of households (33.2%) in the communities served by Palos Community Hospital are "Housing Cost-Burdened", meaning they spend over 30% of household income on housing costs. Part VI, Line 5: Palos Hospital is an acute care facility with 425 licensed beds, 14 operating rooms, nearly 600 physicians on the medical staff and approximately 3,000 employees. Within the service area, Palos serves as a valuable resource for health education and wellness initiatives for residents. Palos continues to monitor the health care needs of its service area to insure the need for the services it offers and evaluate the opportunity to develop new programs and services as necessary. Palos works with and in support of other not-for-profit, educational, governmental, civic or community organizations, as appropriate, to promote health and wellness through awareness, education, research, access or support. During 2018, Palos Hospital offered more than 100 disease prevention and/or wellness focused programs with more than 2,500 participants. Programs range from how to eat a more plant based diet to better understanding the latest in the management/treatment of atrial fibrillation. Palos Hospital supports the local farmer's market, which accepts the LINK card, which is a debit card distributed to those qualified for food stamps). Through participation in many community events throughout the surrounding communities, Palos Hospital serves as a resource for health information. Additionally, the organization uses direct mail to publish articles intended to inform area residents about certain health conditions, community education opportunities offered through the hospital by subject matter experts as well related services available. To support local non-profit organizations, Palos provided more than 20 speaking presentations throughout 2018. Topics covered during these presentations include anxiety, heart health and nutrition. Palos has a very active community volunteer program. In 2018, we managed more than 600 volunteers, ranging in age from 15 to 94 years of age. Volunteers drive for our Home Delivered Meals Program as well as assist patients and visitors navigate our facilities. Palos Hospital sponsors several events throughout the southwest surburbs with purposes that align with the organization's mission, such as the Southwest Half Marathon and American Cancer Society's Making Strides Against Breast Cancer.Each year, a few community cancer screening programs, as well as the direction of the Cancer Program at Palos, are designed in response to our community's needs based on guidance provided by the Palos Oncology Committee. This group, consisting of hospital leaders, caregivers and physicians, provides direction on how to better meet the needs of cancer patients in our community. Palos Hospital is governed by the Board of Directors, comprised of community leaders from the hospital's service area. Employees of Palos Hospital are encouraged to volunteer in our community through various events throughout the year in the service area. Palos serves as a Senior Health Insurance Program (SHIP) site. This is a free statewide health insurance counseling service for Medicare beneficiaries and their caregivers. The hospital provides office space and other resources to support volunteers offering community members information and resources regarding applying for Medicare and Medicare coverage.Palos provides financial assistance to people with limited means. Uninsured or underinsured individuals may be eligible for discounts on the cost of care. Financial counselors are available to help patients determine terms befitting of the financial situation, as well as provide patients with information regarding local, state and federal assistance programs.For the purpose of disease prevention, Palos provides the influenza vaccination to all employees, medical staff members, volunteers and patients during flu season. To help heart failure and COPD inpatients transition from the hospital to home, Palos Community Hospital offers the Heart Failure/COPD Wellness Clinic. As a non-profit, Palos Hospital returns surplus funds to the organization for the enhancement of care and quality services delivered to our community. Part VI, Line 6: Palos Community Hospital is not part of an affiliated health care system. Part VI, Line 7, Reports Filed With States IL X X X X 1 1 0 0 0 0 0 1 0 Dr Terrence Moisan President & CEO 717817 0 18375 0 101603 0 20625 0 24306 0 882726 0 0 0 Dr Mark Sinibaldi Director/Physician 361227 0 7875 0 19023 0 20625 0 26185 0 434935 0 7750 0 Rosann S Demask Director 306356 0 8500 0 31701 0 20291 0 28132 0 394980 0 12518 0 Don Dixon Secretary 328829 0 8750 0 62398 0 35000 0 12023 0 447000 0 40881 0 Roger A Russell VP Finance/Treasurer 289905 0 7875 0 77102 0 31502 0 26546 0 432930 0 57551 0 Mary C Denisienko VP Human Resources 157323 0 6545 0 21909 0 13348 0 9210 0 208335 0 0 0 Patricia Heerlein VP Clinical Services 237520 0 6250 0 17550 0 13414 0 19438 0 294172 0 0 0 William Earman Physician 549018 0 1250 0 1500 0 0 0 12114 0 563882 0 0 0 Chaher Alhandalous Hospitalist 474703 0 28375 0 0 0 14699 0 26825 0 544602 0 0 0 Michael Lynch Physician 383536 0 38500 0 18070 0 20625 0 21943 0 482674 0 0 0 Imad Qayyum Physician 401945 0 6594 0 18476 0 0 0 23614 0 450629 0 0 0 Beatrice Correa-Rivera Hospitalist 353466 0 28375 0 17940 0 20625 0 8753 0 429159 0 0 0 Charles E Reiter III Former Officer 0 0 0 0 249323 0 0 0 1624 0 250947 0 0 0 Part I, Lines 4a-b Charles E. Reiter, III received a severance payment of $249,323 during 2018. The following individuals participate in a 457(f) plan and the amounts are the contributions to each plan during 2018: Dr. Terrence Moisan - $67,576 Roger Russell - $10,877 Rosann S. Demask - $12,518 Mary C. Denisienko - $2,360 Dr. Mark Sinibaldi - $10,877 Don Dixon - $14,375 The following individuals report amounts vested under a 457(f) plan on Part II, column B(iii). Dr. Terrence Moisan - $84,103 Roger Russell - $59,102 Rosann S. Demask - $13,698 Dr. Mark Sinibaldi - $19,023 Mary C. Denisienko - $3,409 Don Dixon - $43,898 Part I, Line 7 Discretionary bonuses paid to executives were directed/approved by the Board of Directors. A Ill Fin AuthorityPalos Comm Hospital 861091967 45200F2Z1 2010-05-06 151146301 Fund construction of new bed tower and modernization of existing bed tower 0 1 0 B Ill Fin AuthorityPalos Comm Hospital 861091967 NoneAvail 2015-10-01 232015000 Refinanced Series 2015A bonds and advance refund Series 2007A bonds 0 1 0 A 24060000 151146301 1950637 149195664 2012 0 0 1 1 B 5650000 232015000 230865171 1149829 2015 1 1 1 1 A 0 0 0 0 0 0 1 B 0 0 0 0 0 0 1 A 0 0 0 1 0 0 0 0 1 B 0 1 0 0 1 0 0 0 1 A 1 B 1 Date Rebate Computation Performed Issuer Name: Ill Fin Authority/Palos Comm Hospital Date the Rebate Computation was Performed: 02/25/2015 Child of Patricia Heerlein See Part V 46706 Employee compensation 0 Child of Edward Mulcahy See Part V 79094 Employee compensation 0 Child of Mark Sinibaldi See Part V 46995 Employee compensation 0 Sch. L, Part IV, Business Transactions Involving Interested Persons: Patricia Heerlein's daughter is employed by PCH.Edward Mulcahy's daughter is employed by PCH.Mark Sinibaldi's son is employed by PCH. Short-term Investments 2018-09-30 60345302 Bank Statement 364383840 St George Corporation 12251 S 80th Avenue Palos Heights IL 60463 501(c)(3) Cash 2018-04-12 8400000 Cash 364383840 St George Corporation 12251 S 80th Avenue Palos Heights IL 60463 501(c)(3) 1 0 0 0 Part II, Line 2e: Person(s) Involved: St. George Corporation is the sole corporate member of Palos Community Hospital. The following officers and directors listed on Form 990, Part VII are directors on St. George Corporation:Edward MulcahyLawrence HuntJason LeyDr. Terrence MoisanDr. Vincent MuscarelloDr. Mark SinibaldiJack Vainauskas Form 990, Part VI, Section A, line 6 St. George Corporation is the sole Corporate Member. Form 990, Part VI, Section A, line 7a St. George Corporation holds the power to appoint members of the governing body. Form 990, Part VI, Section A, line 7b St. George Corporation can exercise action on the following matters: (a) removal of directors, with or without cause; (b) all amendments to the bylaws or the Corporation's Articles of Incorporation; (c) the sale or transfer of substantially all of the property of the corporation, except for leases in excess of one year; (d) all long term borrowing in excess of one year; (e) merger or consolidation by the Corporation with any other institution, hospital, corporation or legal entity; (f) formal affiliation with a medical school or research facility; (g) acceptance of any gift, bequest or legacy that imposes a permanent or continuing obligation on the Corporation for a period of more than one year; (h) decisions to authorize voluntary dissolution of the Corporation or to revoke proceedings therefor; (i) adoption of a plan for the distribution of the assets of the Corporation; and (j) any other matters required by law to be submitted to the Corporate Member or which the Board determines by resolution to submit. Form 990, Part VI, Section B, line 11b Senior management reviewed the Form 990 that was prepared by our tax advisors with the information we provided to them. Once reviewed by senior management it was made available to our Board prior to filing. Form 990, Part VI, Section B, line 12c On an annual basis directors, key personnel (VP, department heads (budget administrators)), and all purchasing staff must complete a Conflict of Interest Form disclosing any conflict of interest that may exist or be perceived to exist between themselves and/or family members and vendors, contractors and others with whom Palos has a contract/transaction agreement. Annual disclosure statements of key personnel are reviewed by the VP of Human Resources. Any issue identified as part of this annual disclosure is referred to the Compliance Officer, in consultation with General Counsel, for disposition. The full Board reviewed the disclosure statement of each Director that identified an interest. Form 990, Part VI, Section B, line 15 Palos engaged an independent consultant to complete a market analysis of executive positions. The market analysis included base rates, bonuses and benefits resulting in a total remuneration benchmark. They compared Palos executives to executives in organizations of similar size and with similar characteristics. The consultants presented their report and findings to the Compensation Committee of the Board. The independent members of the Compensation Committee approved compensation and this approval was documented in the minutes at the time of approval. Form 990, Part VI, Section C, line 19 All policies, governing documents and financial statements required to be available to the public are available upon request. Requests can be made from the Finance Department of Palos Community Hospital. Documents are available for the same period of disclosure as set forth in IRC Section 6104(d). Form 990, Part XI, line 9: Net Asset Transfer to St. George Corporation -68,753,302. Net Asset Transfer from St. George Corporation 3,500,000. Palos Medical Group LLC 12251 S 80th Avenue Palos Heights IL 60463 271472342 Health Care IL 21530598 12161620 Palos Community Hospital Chicago Health Colleagues LLC 12251 S 80th Avenue Palos Heights IL 60463 362169179 Health Care IL 1729671 1170070 Palos Community Hospital Palos Imaging LLC 12251 S 80th Avenue Palos Heights IL 60463 364836347 Health Care IL 5839732 3644947 Palos Community Hospital St George Corporation 12251 S 80th Avenue Palos Heights IL 60463 364383840 Holding Company IL 501(c)(3) Line 12b, II N/A 0 South Campus Partners Inc 15300 West Avenue Orland Park IL 60462 320517854 Health Care IL 501(c)(3) Line 3 Palos Community Hospital 1 Palos Health Surgery Center LLC 15300 West Avenue Orland Park IL 60462 352634975 Health Care IL Palos Community Hospital Related 856800 0 0 0.50500 St George Assurance LTD PO Box 1159 878 W Bay Road Grand Cayman CJ KY1-1102 981313176 Captive Insurance CJ Palos Community Hospital C 11255 28657805 1.00000 1 0 0 0 0 0 0 0 0 0 1 0 1 0 1 1 0 1 1 1 St George Assurance LTD S 8400000 Cash