FORT MADISON COMMUNITY HOSPITAL: Form 990, tax year 2016
View the entire original 990 at ProPublica ↗
- Organization
- FORT MADISON COMMUNITY HOSPITAL (EIN 42-1081055)
- Tax period
- 2016-10-01 to 2017-09-30
- Filed
- 2018-08-15
- IRS object ID
- 201812279349302711
- Schema version
- 2016v3.0
- 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 D
- Schedule H
- Schedule I
- Schedule J
- Schedule K
- Schedule O
- Schedule R
Return header ReturnHeader
| Field | Value | IRS element (for citing) |
|---|---|---|
| Return | 2018-08-15T15:53:21-05:00 | ReturnTs |
| Tax Period End | 2017-09-30 | 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 | 201 N HARRISON STREET SUITE 300 | AddressLine1Txt |
| City | DAVENPORT | CityNm |
| State Abbreviation | IA | StateAbbreviationCd |
| ZIP | 528011999 | ZIPCd |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Return Type | 990 | ReturnTypeCd |
| Tax Period Begin | 2016-10-01 | 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 | JEREMY ALEXANDER | PersonNm |
| Person Title | CHIEF EXECUTIVE OFFICER | PersonTitleTxt |
| Phone | 3193726530 | PhoneNum |
| Signature | 2018-08-15 | SignatureDt |
| Discuss With Paid Preparer | Yes (1) | DiscussWithPaidPreparerInd |
Preparer Person PreparerPersonGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Preparer Person | JOHN J ROMANO | PreparerPersonNm |
| PTIN | P00227323 | PTIN |
| Phone | 5638884000 | PhoneNum |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Tax | 2016 | TaxYr |
| Build TS | 2022-09-23 18:48:47Z | 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 | $77,247,734 | 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 | 536 | TotalEmployeeCnt |
| Total Volunteers | 7 | TotalVolunteersCnt |
| Total Gross UBI | $15,145 | TotalGrossUBIAmt |
| Net Unrelated Bus Txbl Incm | -$24,587 | NetUnrelatedBusTxblIncmAmt |
| PY Contributions Grants | $300,000 | PYContributionsGrantsAmt |
| CY Contributions Grants | $250,000 | CYContributionsGrantsAmt |
| PY Program Service Revenue | $54,662,377 | PYProgramServiceRevenueAmt |
| CY Program Service Revenue | $54,286,510 | CYProgramServiceRevenueAmt |
| PY Investment Income | -$222,737 | PYInvestmentIncomeAmt |
| CY Investment Income | $497,505 | CYInvestmentIncomeAmt |
| PY Other Revenue | $1,737,465 | PYOtherRevenueAmt |
| CY Other Revenue | $2,088,775 | CYOtherRevenueAmt |
| PY Total Revenue | $56,477,105 | PYTotalRevenueAmt |
| CY Total Revenue | $57,122,790 | CYTotalRevenueAmt |
| PY Grants And Similar Paid | $41,710 | PYGrantsAndSimilarPaidAmt |
| CY Grants And Similar Paid | $44,445 | CYGrantsAndSimilarPaidAmt |
| PY Benefits Paid To Members | $0 | PYBenefitsPaidToMembersAmt |
| CY Benefits Paid To Members | $0 | CYBenefitsPaidToMembersAmt |
| PY Salaries Comp Emp Bnft Paid | $35,584,125 | PYSalariesCompEmpBnftPaidAmt |
| CY Salaries Comp Emp Bnft Paid | $35,460,093 | CYSalariesCompEmpBnftPaidAmt |
| PY Total Prof Fndrsng Expns | $0 | PYTotalProfFndrsngExpnsAmt |
| CY Total Prof Fndrsng Expns | $0 | CYTotalProfFndrsngExpnsAmt |
| CY Total Fundraising Expense | $0 | CYTotalFundraisingExpenseAmt |
| PY Other Expenses | $22,363,018 | PYOtherExpensesAmt |
| CY Other Expenses | $23,544,227 | CYOtherExpensesAmt |
| PY Total Expenses | $57,988,853 | PYTotalExpensesAmt |
| CY Total Expenses | $59,048,765 | CYTotalExpensesAmt |
| PY Revenues Less Expenses | -$1,511,748 | PYRevenuesLessExpensesAmt |
| CY Revenues Less Expenses | -$1,925,975 | CYRevenuesLessExpensesAmt |
| Total Assets BOY | $58,005,746 | TotalAssetsBOYAmt |
| Total Assets EOY | $57,315,704 | TotalAssetsEOYAmt |
| Total Liabilities BOY | $10,759,564 | TotalLiabilitiesBOYAmt |
| Total Liabilities EOY | $10,244,293 | TotalLiabilitiesEOYAmt |
| Net Assets Or Fund Balances BOY | $47,246,182 | NetAssetsOrFundBalancesBOYAmt |
| Net Assets Or Fund Balances EOY | $47,071,411 | 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 | $51,032,222 | ExpenseAmt |
| Grant | $44,445 | GrantAmt |
| Revenue | $56,275,931 | 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 1,606 PATIENT ADMISSIONS AND 5,010 PATIENT DAYS OF MEDICAL CARE. THIS INCLUDED 694 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; REHABILITATION/THERAPY SERVICES; LABORATORY AND PATHOLOGY SERVICES; AND WOUND HEALING CARE. | Desc |
| Total Program Service Expenses | $51,032,222 | TotalProgramServiceExpensesAmt |
| Described In Section501c3 | Yes (1) | DescribedInSection501c3Ind |
| Schedule B Required | Yes (1) | ScheduleBRequiredInd |
| Political Campaign Acty | 0 | PoliticalCampaignActyInd |
| Lobbying Activities | 0 | 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 | Yes (1) | IncludeFIN48FootnoteInd |
| Independent Audit Fincl Stmt | 0 | IndependentAuditFinclStmtInd |
| Consolidated Audit Fincl Stmt | Yes (1) | 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 | Yes (1) | TaxExemptBondsInd |
| Invest Tax Exempt Bonds | 0 | InvestTaxExemptBondsInd |
| Escrow Account | 0 | EscrowAccountInd |
| On Behalf Of Issuer | 0 | OnBehalfOfIssuerInd |
| 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 | 84 | IRPDocumentCnt |
| IRP Document W2 G | 0 | IRPDocumentW2GCnt |
| Backup Wthld Compliance | Yes (1) | BackupWthldComplianceInd |
| Employee | 536 | 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 |
| Info In Schedule O Part VI | Yes (X) | InfoInScheduleOPartVIInd |
| Governing Body Voting Members | 7 | GoverningBodyVotingMembersCnt |
| Independent Voting Member | 7 | IndependentVotingMemberCnt |
| Family Or Business Rln | Yes (1) | FamilyOrBusinessRlnInd |
| Delegation Of Mgmt Duties | Yes (1) | DelegationOfMgmtDutiesInd |
| Change To Org Documents | Yes (1) | ChangeToOrgDocumentsInd |
| Material Diversion Or Misuse | 0 | MaterialDiversionOrMisuseInd |
| Members Or Stockholders | 0 | MembersOrStockholdersInd |
| Election Of Board Members | 0 | ElectionOfBoardMembersInd |
| Decisions Subject To Approva | 0 | 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 | JEREMY ALEXANDER | BusinessNameLine1Txt |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Phone | 3193726530 | PhoneNum |
US Address USAddress
| Field | Value | IRS element (for citing) |
|---|---|---|
| Address Line1 | 5445 AVENUE O | 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 | Former Ofcr Director TrusteeFormerOfcrDirectorTrusteeInd |
|---|---|---|---|---|---|---|---|---|
| DEANNA BARR | ||||||||
| DIRECTOR | 2.00 | Yes (X) | $1,804 | $0 | $0 | |||
| ROBERT BONTA | ||||||||
| PRESIDENT | 2.00 | Yes (X) | $0 | $0 | $0 | Yes (X) | ||
| JAMES GERDES | ||||||||
| DIRECTOR | 2.00 | Yes (X) | $0 | $0 | $0 | |||
| JOHN MCKILLIP | ||||||||
| DIRECTOR | 2.00 | Yes (X) | $1,654 | $0 | $0 | |||
| ANN MENKE | ||||||||
| VICE PRESIDENT | 2.00 | Yes (X) | $0 | $0 | $0 | Yes (X) | ||
| DAVID POLAND | ||||||||
| DIRECTOR | 2.00 | Yes (X) | $1,086 | $0 | $0 | |||
| VICKI STEPHENSON | ||||||||
| DIRECTOR | 2.00 | Yes (X) | $0 | $0 | $0 | |||
| JEREMY ALEXANDER | ||||||||
| CEO/SECRETARY | 40.00 | $28,571 | $0 | $7,371 | Yes (X) | |||
| PAT BIRA | ||||||||
| FORMER CEO/SECRETARY | 40.00 | $206,903 | $0 | $53,381 | Yes (X) | |||
| BRADLEY J KOKJOHN | ||||||||
| FORMER CFO/TREASURER | 40.00 | $234,086 | $0 | $43,707 | Yes (X) | |||
| KATHY J ANDERSON MD | ||||||||
| PHYSICIAN | 40.00 | $395,837 | $0 | $34,744 | Yes (X) | |||
| MEENAKSHI PALANI MD | ||||||||
| PHYSICIAN | 40.00 | $453,078 | $0 | $32,545 | Yes (X) | |||
| TIMOTHY S STAUDTE MD | ||||||||
| PHYSICIAN | 40.00 | $501,810 | $0 | $34,855 | Yes (X) | |||
| DAVID C WENGER-KELLER MD | ||||||||
| PHYSICIAN | 40.00 | $341,238 | $0 | $22,404 | Yes (X) | |||
| BRENT G WOODBURY MD | ||||||||
| PHYSICIAN | 40.00 | $721,711 | $0 | $37,694 | Yes (X) | |||
| C JAMES PLATT | ||||||||
| FORMER CEO/SECRETARY | 40.00 | $246,176 | $0 | $0 | Yes (X) | |||
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Reportable Comp From Org | $3,133,954 | TotalReportableCompFromOrgAmt |
| Tot Reportable Comp Rltd Org | $0 | TotReportableCompRltdOrgAmt |
| Total Other Compensation | $266,701 | TotalOtherCompensationAmt |
| Indiv Rcvd Greater Than100 K | 35 | IndivRcvdGreaterThan100KCnt |
| Former Ofcr Employees Listed | Yes (1) | 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 | |||||
| 3480 - 9TH STREET | WATERLOO | IA | 50702 | ER PHYSICIAN STAFFING | $2,726,800 |
| QUORUM HEALTH RESOURCES | |||||
| 105 CONTINENTAL PLACE | BRENTWOOD | TN | 37027 | PROFESSIONAL HOSPITAL MANAGEMENT | $1,054,051 |
| SMITH AND NEPHEW INC | |||||
| 5201 GEORGE MCVAY DRIVE SUITE 1 | MCALLEN | TX | 78503 | MECHANICAL SUPPORT | $362,624 |
| GE HEALTHCARE IITS USA CORP | |||||
| 3200 NORTH GRANDVIEW BLVD | WAUKESHA | WI | 53188 | TECHNICAL SUPPORT | $357,825 |
| COMPHEALTH | |||||
| 6440 SOUTH MILLROCK DRIVE SUITE 17 | SALT LAKE CITY | UT | 84121 | CONTRACT LABOR | $347,141 |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Cntrct Rcvd Greater Than100 K | 49 | CntrctRcvdGreaterThan100KCnt |
| Related Organizations | $250,000 | RelatedOrganizationsAmt |
| Total Contributions | $250,000 | TotalContributionsAmt |
Program Service Revenue ProgramServiceRevenueGrp (2 entries)
| DescDesc | BusinessBusinessCd | Total Revenue ColumnTotalRevenueColumnAmt | Related Or Exempt Func IncomeRelatedOrExemptFuncIncomeAmt |
|---|---|---|---|
| NET PATIENT SERVICE REVENUE | 621110 | $56,547,399 | $56,547,399 |
| LESS: PROVISION FOR BAD DEBTS | 900001 | -$2,260,889 | -$2,260,889 |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Program Service Revenue | $54,286,510 | TotalProgramServiceRevenueAmt |
Investment Income InvestmentIncomeGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Revenue Column | $384,212 | TotalRevenueColumnAmt |
| Exclusion | $384,212 | ExclusionAmt |
Gross Rents GrossRentsGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Real | $84,209 | 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 | $84,209 | RealAmt |
Net Rental Income Or Loss NetRentalIncomeOrLossGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Revenue Column | $84,209 | TotalRevenueColumnAmt |
| Exclusion | $84,209 | ExclusionAmt |
Gross Amount Sales Assets GrossAmountSalesAssetsGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Securities | $20,202,237 | SecuritiesAmt |
| Other | $36,000 | OtherAmt |
Less Cost Oth Basis Sales Expnss LessCostOthBasisSalesExpnssGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Securities | $20,039,429 | SecuritiesAmt |
| Other | $85,515 | OtherAmt |
Gain Or Loss GainOrLossGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Securities | $162,808 | SecuritiesAmt |
| Other | -$49,515 | OtherAmt |
Net Gain Or Loss Investments NetGainOrLossInvestmentsGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Revenue Column | $113,293 | TotalRevenueColumnAmt |
| Exclusion | $113,293 | ExclusionAmt |
Other Revenue Misc OtherRevenueMiscGrp (3 entries)
| DescDesc | BusinessBusinessCd | Total Revenue ColumnTotalRevenueColumnAmt | Related Or Exempt Func IncomeRelatedOrExemptFuncIncomeAmt |
|---|---|---|---|
| MISCELLANEOUS | 900099 | $1,091,951 | $1,091,951 |
| PHARMACY | 446110 | $331,659 | $331,659 |
| MEANINGFULL USE REVENUE | 900099 | $323,232 | $323,232 |
Miscellaneous Revenue MiscellaneousRevenueGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Revenue Column | $257,724 | TotalRevenueColumnAmt |
| Related Or Exempt Func Income | $242,579 | RelatedOrExemptFuncIncomeAmt |
| Unrelated Business Revenue | $15,145 | UnrelatedBusinessRevenueAmt |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Other Revenue Total | $2,004,566 | OtherRevenueTotalAmt |
Total Revenue TotalRevenueGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Revenue Column | $57,122,790 | TotalRevenueColumnAmt |
| Related Or Exempt Func Income | $56,275,931 | RelatedOrExemptFuncIncomeAmt |
| Unrelated Business Revenue | $15,145 | UnrelatedBusinessRevenueAmt |
| Exclusion | $581,714 | ExclusionAmt |
Grants To Domestic Orgs GrantsToDomesticOrgsGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $44,445 | TotalAmt |
| Program Services | $44,445 | ProgramServicesAmt |
Comp Current Ofcr Directors CompCurrentOfcrDirectorsGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $594,590 | TotalAmt |
| Management And General | $594,590 | ManagementAndGeneralAmt |
Other Salaries And Wages OtherSalariesAndWagesGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $27,506,906 | TotalAmt |
| Program Services | $24,721,941 | ProgramServicesAmt |
| Management And General | $2,784,965 | ManagementAndGeneralAmt |
Pension Plan Contributions PensionPlanContributionsGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $988,531 | TotalAmt |
| Program Services | $888,446 | ProgramServicesAmt |
| Management And General | $100,085 | ManagementAndGeneralAmt |
Other Employee Benefits OtherEmployeeBenefitsGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $4,645,944 | TotalAmt |
| Program Services | $4,175,561 | ProgramServicesAmt |
| Management And General | $470,383 | ManagementAndGeneralAmt |
Payroll Taxes PayrollTaxesGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $1,724,122 | TotalAmt |
| Program Services | $1,549,561 | ProgramServicesAmt |
| Management And General | $174,561 | ManagementAndGeneralAmt |
Fees For Services Management FeesForServicesManagementGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $323,785 | TotalAmt |
| Management And General | $323,785 | ManagementAndGeneralAmt |
Fees For Services Legal FeesForServicesLegalGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $152,803 | TotalAmt |
| Management And General | $152,803 | ManagementAndGeneralAmt |
Fees For Services Accounting FeesForServicesAccountingGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $106,272 | TotalAmt |
| Management And General | $106,272 | ManagementAndGeneralAmt |
Fees For Services Other FeesForServicesOtherGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $5,101,642 | TotalAmt |
| Program Services | $3,881,864 | ProgramServicesAmt |
| Management And General | $1,219,778 | ManagementAndGeneralAmt |
Advertising AdvertisingGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $199,847 | TotalAmt |
| Management And General | $199,847 | ManagementAndGeneralAmt |
Office Expenses OfficeExpensesGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $7,114,092 | TotalAmt |
| Program Services | $6,993,526 | ProgramServicesAmt |
| Management And General | $120,566 | ManagementAndGeneralAmt |
Occupancy OccupancyGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $885,779 | TotalAmt |
| Program Services | $866,979 | ProgramServicesAmt |
| Management And General | $18,800 | ManagementAndGeneralAmt |
Travel TravelGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $157,126 | TotalAmt |
| Program Services | $121,158 | ProgramServicesAmt |
| Management And General | $35,968 | ManagementAndGeneralAmt |
Interest InterestGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $196,987 | TotalAmt |
| Program Services | $140,719 | ProgramServicesAmt |
| Management And General | $56,268 | ManagementAndGeneralAmt |
Depreciation Depletion DepreciationDepletionGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $3,748,333 | TotalAmt |
| Program Services | $2,677,646 | ProgramServicesAmt |
| Management And General | $1,070,687 | ManagementAndGeneralAmt |
Insurance InsuranceGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $529,184 | TotalAmt |
| Program Services | $275,945 | ProgramServicesAmt |
| Management And General | $253,239 | ManagementAndGeneralAmt |
Other Expenses OtherExpensesGrp (4 entries)
| DescDesc | TotalTotalAmt | Program ServicesProgramServicesAmt | Management And GeneralManagementAndGeneralAmt |
|---|---|---|---|
| PHYSICIAN FEES | $3,097,400 | $3,097,400 | |
| RECRUITMENT | $653,638 | $653,638 | |
| REPAIRS AND MAINTENANCE | $413,908 | $413,308 | $600 |
| MEDICAID ASSESSMENT | $394,422 | $394,422 |
All Other Expenses AllOtherExpensesGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $469,009 | TotalAmt |
| Program Services | $135,663 | ProgramServicesAmt |
| Management And General | $333,346 | ManagementAndGeneralAmt |
Total Functional Expenses TotalFunctionalExpensesGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $59,048,765 | TotalAmt |
| Program Services | $51,032,222 | ProgramServicesAmt |
| Management And General | $8,016,543 | ManagementAndGeneralAmt |
| Fundraising | $0 | FundraisingAmt |
Cash Non Interest Bearing CashNonInterestBearingGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $1,023,715 | BOYAmt |
| EOY | $178,652 | EOYAmt |
Savings And Temp Cash Invst SavingsAndTempCashInvstGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $1,603,597 | BOYAmt |
| EOY | $670,000 | EOYAmt |
Accounts Receivable AccountsReceivableGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $8,368,268 | BOYAmt |
| EOY | $9,553,177 | EOYAmt |
Inventories For Sale Or Use InventoriesForSaleOrUseGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $591,831 | BOYAmt |
| EOY | $598,655 | EOYAmt |
Prepaid Expenses Defrd Charges PrepaidExpensesDefrdChargesGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $1,473,882 | BOYAmt |
| EOY | $1,328,563 | EOYAmt |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Land Bldg Equip Cost Or Other Bss | $74,278,150 | LandBldgEquipCostOrOtherBssAmt |
| Land Bldg Equip Accum Deprec | $49,690,440 | LandBldgEquipAccumDeprecAmt |
Land Bldg Equip Basis Net LandBldgEquipBasisNetGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $25,342,602 | BOYAmt |
| EOY | $24,587,710 | EOYAmt |
Investments Pub Traded Sec InvestmentsPubTradedSecGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $14,492,100 | BOYAmt |
| EOY | $16,135,480 | EOYAmt |
Investments Program Related InvestmentsProgramRelatedGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $5,041,396 | BOYAmt |
| EOY | $4,208,780 | EOYAmt |
Other Assets Total OtherAssetsTotalGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $68,355 | BOYAmt |
| EOY | $54,687 | EOYAmt |
Total Assets TotalAssetsGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $58,005,746 | BOYAmt |
| EOY | $57,315,704 | EOYAmt |
Accounts Payable Accr Expnss AccountsPayableAccrExpnssGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $5,284,247 | BOYAmt |
| EOY | $5,741,556 | EOYAmt |
Tax Exempt Bond Liabilities TaxExemptBondLiabilitiesGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $5,475,317 | BOYAmt |
| EOY | $4,502,737 | EOYAmt |
Total Liabilities TotalLiabilitiesGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $10,759,564 | BOYAmt |
| EOY | $10,244,293 | EOYAmt |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Organization Follows SFAS117 | Yes (X) | OrganizationFollowsSFAS117Ind |
Unrestricted Net Assets UnrestrictedNetAssetsGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $46,986,518 | BOYAmt |
| EOY | $46,784,201 | EOYAmt |
Temporarily Rstr Net Assets TemporarilyRstrNetAssetsGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $54,971 | BOYAmt |
| EOY | $82,517 | 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 | $47,246,182 | BOYAmt |
| EOY | $47,071,411 | EOYAmt |
Tot Liab Net Assets Fund Balance TotLiabNetAssetsFundBalanceGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $58,005,746 | BOYAmt |
| EOY | $57,315,704 | EOYAmt |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Info In Schedule O Part XI | Yes (X) | InfoInScheduleOPartXIInd |
| Reconcilation Revenue Expnss | -$1,925,975 | ReconcilationRevenueExpnssAmt |
| Net Unrlzd Gains Losses Invst | $1,281,683 | NetUnrlzdGainsLossesInvstAmt |
| Other Changes In Net Assets | $469,521 | 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 | Yes (1) | FSAuditedInd |
FS Audited Basis FSAuditedBasisGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Consolidated Basis Fincl Stmt | Yes (X) | ConsolidatedBasisFinclStmtInd |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Audit Committee | Yes (1) | AuditCommitteeInd |
| 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 D IRS990ScheduleD
Land LandGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Other Cost Or Other Basis | $1,164,258 | OtherCostOrOtherBasisAmt |
| Book Value | $1,164,258 | BookValueAmt |
Buildings BuildingsGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Other Cost Or Other Basis | $40,014,642 | OtherCostOrOtherBasisAmt |
| Depreciation | $24,815,028 | DepreciationAmt |
| Book Value | $15,199,614 | BookValueAmt |
Leasehold Improvements LeaseholdImprovementsGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Other Cost Or Other Basis | $556,068 | OtherCostOrOtherBasisAmt |
| Depreciation | $433,052 | DepreciationAmt |
| Book Value | $123,016 | BookValueAmt |
Equipment EquipmentGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Other Cost Or Other Basis | $32,148,751 | OtherCostOrOtherBasisAmt |
| Depreciation | $24,442,360 | DepreciationAmt |
| Book Value | $7,706,391 | BookValueAmt |
Other Land Buildings OtherLandBuildingsGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Other Cost Or Other Basis | $394,431 | OtherCostOrOtherBasisAmt |
| Book Value | $394,431 | BookValueAmt |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Book Value Land Buildings | $24,587,710 | TotalBookValueLandBuildingsAmt |
Invst Program Related Org InvstProgramRelatedOrgGrp (5 entries)
| DescDesc | Book ValueBookValueAmt | Method ValuationMethodValuationCd |
|---|---|---|
| SE RENAL DIALYSIS, LC | $1,028,717 | C |
| BFM KEOKUK CLINIC, LLC | $116,954 | C |
| INVESTMENT IN FORT MADISON COMMUNITY HOSPITAL FOUNDATION | $2,951,310 | C |
| INVESTMENT IN ADVANCE PHYSICAL THERAPY | $98,878 | C |
| INVESTMENT IN RENAISSANCE HEALTH SERVICES | $12,921 | C |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Book Value Program Rltd | $4,208,780 | TotalBookValueProgramRltdAmt |
| Footnote Text | Yes (X) | FootnoteTextInd |
Supplemental Information Detail SupplementalInformationDetail
| Field | Value | IRS element (for citing) |
|---|---|---|
| Form And Line Reference | PART X, LINE 2: | FormAndLineReferenceDesc |
| Explanation | THE FORT MADISON COMMUNITY HOSPITAL (HOSPITAL) AND AFFILIATES (FORT MADISON PROFESSIONAL BUILDING ASSOCIATION, FORT MADISON COMMUNITY HOSPITAL FOUNDATION, AND RENAISSANCE HEALTH SERVICES, INC.), EXCEPT FOR RENAISSANCE HEALTH SERVICES, INC., ARE NOT-FOR-PROFIT CORPORATIONS AS DESCRIBED IN SECTION 501(C)(3) OF THE INTERNAL REVENUE CODE AND ARE EXEMPT FROM FEDERAL INCOME TAXES ON RELATED INCOME PURSUANT TO SECTION 501(A) OF THE CODE. RENAISSANCE HEALTH SERVICES, INC. IS A FOR PROFIT CORPORATION SUBJECT TO FEDERAL AND STATE INCOME TAXES, HOWEVER THERE WERE NO MATERIAL INCOME TAX PROVISIONS FOR THE YEARS ENDED SEPTEMBER 30, 2017 AND 2016. THE HOSPITAL, FORT MADISON COMMUNITY HOSPITAL FOUNDATION (FOUNDATION) AND FORT MADISON PROFESSIONAL BUILDING ASSOCIATION FILE A FORM 990 (RETURN OF ORGANIZATION EXEMPT FROM INCOME TAX) ANNUALLY. WHEN THESE RETURNS ARE 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 TAX POSITION TAKEN OR THE AMOUNT OF THE POSITION THAT WOULD ULTIMATELY BE SUSTAINED. EXAMPLES OF TAX POSITIONS COMMON TO ORGANIZATIONS SUCH AS THIS INCLUDE SUCH MATTERS AS THE FOLLOWING: THE TAX EXEMPT STATUS OF THE ENTITY, THE CONTINUED TAX EXEMPT STATUS OF BONDS ISSUED BY THE HOSPITAL, THE NATURE, THE CHARACTERIZATION AND TAXABILITY OF JOINT VENTURE INCOME AND VARIOUS POSITIONS RELATIVE TO POTENTIAL SOURCES OF UNRELATED BUSINESS INCOME (UBI). UBI IS REPORTED ON FORM 990T, AS APPROPRIATE. THE BENEFIT OF A TAX POSITION IS RECOGNIZED IN THE 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% 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 WOULD BE REFLECTED AS A LIABILITY FOR UNRECOGNIZED TAX BENEFITS IN THE ACCOMPANYING BALANCE SHEET ALONG WITH ANY ASSOCIATED INTEREST AND PENALTIES THAT WOULD BE PAYABLE TO THE TAXING AUTHORITIES UPON EXAMINATION. HOWEVER, AS OF SEPTEMBER 30, 2017 AND 2016, THERE WERE NO UNRECOGNIZED TAX BENEFITS IDENTIFIED AND RECORDED AS A LIABILITY AS MANAGEMENT DOES NOT BELIEVE THE ORGANIZATION HAS TAKEN ANY TAX POSITIONS THAT WOULD NOT BE SUSTAINED UPON EXAMINATION BY THE TAXING AUTHORITIES. FORMS 990 AND 990T FILED BY THE HOSPITAL, FOUNDATION AND FORT MADISON PROFESSIONAL BUILDING ASSOCIATION ARE GENERALLY SUBJECT TO EXAMINATION BY THE INTERNAL REVENUE SERVICE (IRS) UP TO THREE YEARS FROM THE EXTENDED DUE DATE OF EACH RETURN. THE HOSPITAL'S IRS FORMS 990 AND 990T ARE NO LONGER SUBJECT TO EXAMINATION FOR THE YEARS ENDED SEPTEMBER 30, 2013 AND PRIOR. RENAISSANCE HEALTH SERVICES, INC. IS A TAXABLE ORGANIZATION AND CURRENTLY FILES INCOME TAX RETURNS IN THE U.S. FEDERAL JURISDICTION AND THE APPLICABLE STATE JURISDICTIONS. THIS ENTITY IS NO LONGER SUBJECT TO INCOME TAX EXAMINATIONS FOR YEARS ENDED SEPTEMBER 30, 2013 AND PRIOR. | ExplanationTxt |
Schedule H IRS990ScheduleH
| Field | Value | IRS element (for citing) |
|---|---|---|
| Financial Assistance Policy | Yes (1) | FinancialAssistancePolicyInd |
| Written Policy | Yes (1) | WrittenPolicyInd |
| 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 | Yes (1) | ExpensesExceedBudgetInd |
| Unable To Provide Care | 0 | UnableToProvideCareInd |
| 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 | $662,443 | TotalCommunityBenefitExpnsAmt |
| Net Community Benefit Expns | $662,443 | NetCommunityBenefitExpnsAmt |
| Total Expense | 0.01120 | TotalExpensePct |
Unreimbursed Medicaid UnreimbursedMedicaidGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Community Benefit Expns | $5,741,484 | TotalCommunityBenefitExpnsAmt |
| Direct Offsetting Revenue | $5,341,592 | DirectOffsettingRevenueAmt |
| Net Community Benefit Expns | $399,892 | NetCommunityBenefitExpnsAmt |
| Total Expense | 0.00680 | TotalExpensePct |
Total Financial Assistance Typ TotalFinancialAssistanceTyp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Community Benefit Expns | $6,403,927 | TotalCommunityBenefitExpnsAmt |
| Direct Offsetting Revenue | $5,341,592 | DirectOffsettingRevenueAmt |
| Net Community Benefit Expns | $1,062,335 | NetCommunityBenefitExpnsAmt |
| Total Expense | 0.01800 | TotalExpensePct |
Community Health Services CommunityHealthServicesGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Community Benefit Expns | $923,805 | TotalCommunityBenefitExpnsAmt |
| Net Community Benefit Expns | $923,805 | NetCommunityBenefitExpnsAmt |
| Total Expense | 0.01560 | TotalExpensePct |
Health Professions Education HealthProfessionsEducationGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Community Benefit Expns | $231,364 | TotalCommunityBenefitExpnsAmt |
| Net Community Benefit Expns | $231,364 | NetCommunityBenefitExpnsAmt |
| Total Expense | 0.00390 | TotalExpensePct |
Subsidized Health Services SubsidizedHealthServicesGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Community Benefit Expns | $12,238,446 | TotalCommunityBenefitExpnsAmt |
| Direct Offsetting Revenue | $11,083,628 | DirectOffsettingRevenueAmt |
| Net Community Benefit Expns | $1,154,818 | NetCommunityBenefitExpnsAmt |
| Total Expense | 0.01960 | TotalExpensePct |
Cash And In Kind Contributions CashAndInKindContributionsGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Community Benefit Expns | $44,445 | TotalCommunityBenefitExpnsAmt |
| Net Community Benefit Expns | $44,445 | NetCommunityBenefitExpnsAmt |
| Total Expense | 0.00080 | TotalExpensePct |
Total Other Benefits TotalOtherBenefitsGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Community Benefit Expns | $13,438,060 | TotalCommunityBenefitExpnsAmt |
| Direct Offsetting Revenue | $11,083,628 | DirectOffsettingRevenueAmt |
| Net Community Benefit Expns | $2,354,432 | NetCommunityBenefitExpnsAmt |
| Total Expense | 0.03990 | TotalExpensePct |
Total Community Benefits TotalCommunityBenefitsGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Community Benefit Expns | $19,841,987 | TotalCommunityBenefitExpnsAmt |
| Direct Offsetting Revenue | $16,425,220 | DirectOffsettingRevenueAmt |
| Net Community Benefit Expns | $3,416,767 | NetCommunityBenefitExpnsAmt |
| Total Expense | 0.05790 | TotalExpensePct |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Bad Debt Expense Reported | Yes (1) | BadDebtExpenseReportedInd |
| Bad Debt Expense | $2,260,889 | BadDebtExpenseAmt |
| Reimbursed By Medicare | $11,732,030 | ReimbursedByMedicareAmt |
| Cost Of Care Reimbursed By Medcr | $12,602,483 | CostOfCareReimbursedByMedcrAmt |
| Medicare Surplus Or Shortfall | -$870,453 | 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 | 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 Definition | Yes (X) | CommunityDefinitionInd |
| Community Demographics | Yes (X) | CommunityDemographicsInd |
| Existing Resources | Yes (X) | ExistingResourcesInd |
| How Data Obtained | Yes (X) | HowDataObtainedInd |
| Community Health Needs | Yes (X) | CommunityHealthNeedsInd |
| Other Health Issues | Yes (X) | OtherHealthIssuesInd |
| Community Hlth Needs Id Process | Yes (X) | CommunityHlthNeedsIdProcessInd |
| Consulting Process | Yes (X) | ConsultingProcessInd |
| CHNA Conducted | 15 | 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 | WWW.FMCHOSP.COM | OwnWebsiteURLTxt |
| Implementation Strategy Adopt | Yes (1) | ImplementationStrategyAdoptInd |
| Implementation Strategy Adpt | 15 | 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 | WWW.FMCHOSP.COM/PATIENTS-VISITORS/FMCH-CHARITY-POLICY/ | FAPAvailableOnWebsiteURLTxt |
| FAP App Available On Website | Yes (X) | FAPAppAvailableOnWebsiteInd |
| FAP App Available On Website URL | WWW.FMCHOSP.COM/PATIENTS-VISITORS/FMCH-CHARITY-POLICY/ | FAPAppAvailableOnWebsiteURLTxt |
| FAP Summary On Website | Yes (X) | FAPSummaryOnWebsiteInd |
| FAP Summary On Website URL | 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 |
| 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 (6 entries)
| Form And Line ReferenceFormAndLineReferenceDesc | ExplanationExplanationTxt |
|---|---|
| FORT MADISON COMMUNITY HOSPITAL | PART V, SECTION B, LINE 5: FORT MADISON COMMUNITY HOSPITAL, KEOKUK AREA HOSPITAL, AND LEE COUNTY HEALTH DEPARTMENT ARE THE REPRESENTATIVES FOR THE CHNA. A COMMUNITY WIDE SURVEY WAS DISTRIBUTED TO THE GENERAL POPULATION AS WELL AS SOME TARGETED FOCUS GROUPS (ELDERLY, YOUTH, AND VULNERABLE POPULATIONS) BEGINNING IN JULY 2015. IN ADDITIONAL A TOWN HALL MEETING WAS CONDUCTED AND ALL LEE COUNTY RESIDENTS WERE INVITED TO ATTEND. COMMUNITY MEMBERS ATTENDED THE MEETING AND PARTICIPATED IN THE ASSESSMENT. IN SEPTEMBER 2015, SEVERAL COMMUNITY PARTNERS AND STAKEHOLDERS BEGAN TO ORGANIZE, GATHER AND ASSESS COUNTY AND STATE LEVEL DATA, SURVEY RESULTS, AS WELL AS ANALYZE OUR COUNTY STRENGTHS AND ASSETS. THE REPORT OF ALL THE DATA COLLECTED THAT PROVIDED A VERY DESCRIPTIVE ASSESSMENT OF THE HEALTH OF LEE COUNTY WAS REVIEWED BY ALL PARTNERS INVOLVED IN THE PROCESS ON SEPTEMBER 22, 2015. |
| FORT MADISON COMMUNITY HOSPITAL | PART V, SECTION B, LINE 6A: KEOKUK AREA HOSPITAL |
| 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 HAS REPRESENTATION ON COUNTY-WIDE TASK FORCES, AS WELL AS HAS MULTIPLE INTERNAL STRATEGIES CURRENTLY IN PLACE TO ADDRESS THE FOUR AREAS IDENTIFIED. 1) PROMOTE HEALTHY LIFESTYLES AND BEHAVIORS FOR ALL: INTERNAL AND EXTERNAL HEALTH MESSAGING; COMMUNITY OUTREACH EVENTS; AND LEAD ROLES IN COMMUNITY ORGANIZATIONS FOCUSED ON HEALTHY LIFESTYLES. 2) IMPROVE MENTAL HEALTH, BEHAVIORAL HEALTH ISSUES, AND ACCESS TO CARE: IMPLEMENTATION OF ASSESSMENT TOOLS; DISTRIBUTION OF COMMUNITY RESOURCE GUIDES; AND SUPPORT OF THE PSYCHIATRY CLINIC. 3) REDUCE TRANSPORTATION BARRIERS OF OUR WORKFORCE AND THOSE WITH ACCESS TO CARE ISSUES: ACTIVE MEMBER OF PORT COMMITTEE TO CONNECT THE CITY WITH TRAILS; SUPPORT COURTESY VAN SERVICE; AND PROVIDE PUBLIC TRANSPORTATION INFORMATION TO OUR PATIENTS. 4) IMPROVE COMMUNICATION, PROVIDE EDUCATION, AND MOTIVATE OUR POPULATION FOR CHANGE: PARTICIPATE IN AN ACO WITH TWO NURSE CARE COORDINATORS; PARTICIPATE IN HEALTH FAIRS AND EDUCATIONAL SESSIONS; EDUCATION IN THE SCHOOLS; EMPLOYEE EDUCATION; AND HEALTH PROMOTION. |
| 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 INDVIDUALS 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 INDVIDUALS 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. |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Facility | 3 | FacilityNum |
Oth Hlth Care Fclts Not Hospital OthHlthCareFcltsNotHospitalGrp
Oth Hlth Care Fclts OthHlthCareFcltsGrp (3 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 |
| 2 - BFM KEOKUK CLINIC LLC | ||||
| 5445 AVENUE O | FORT MADISON | IA | 52627 | MEDICAL CLINIC |
| 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: | NOT APPLICABLE |
| 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 2F OF PART VIII, STATEMENT OF REVENUE. THE ORGANIZATION'S TOTAL COMMUNITY BENEFIT EXPENSE AS A PERCENTAGE OF TOTAL EXPENSES IS 33.60%, AND THE PERCENTAGE INCREASES TO 54.95% 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 FORT MADISON COMMUNITY HOSPITAL AND AFFILIATES CONSOLIDATED FINANCIAL STATEMENTS. THE FOOTNOTE FROM THE CONSOLIDATED FINANCIAL STATEMENT IS AS FOLLOWS: PATIENT RECEIVABLES DUE DIRECTLY FROM THE 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 PATIENT'S FINANCIAL HISTORY AND CURRENT ECONOMIC CONDITIONS. THE HOSPITAL DOES NOT CHARGE INTEREST ON PATIENT RECEIVABLES. PATIENT RECEIVABLES ARE WRITTEN OFF AS BAD DEBT WHEN DEEMED UNCOLLECTIBLE. RECOVERIES OF RECEIVABLES PREVIOUSLY WRITTEN OFF ARE RECORDED AS A REDUCTION OF BAD DEBT WHEN RECEIVED. THE CHARITY CARE FOOTNOTE DISCLOSURE AS REPORTED IN THE CONSOLIDATED FINANCIAL STATEMENT IS AS FOLLOWS: THE ORGANIZATION PROVIDES CARE TO PATIENTS WHO MEET CERTAIN CRITERIA UNDER ITS CHARITY CARE POLICY WITHOUT CHARGE OR AT AMOUNTS LESS THAN ITS ESTABLISHED RATES. BECAUSE THE ORGANIZATION DOES NOT PURSUE COLLECTION OF AMOUNTS DETERMINED TO QUALIFY AS CHARITY CARE, THEY ARE NOT REPORTED AS REVENUE. THE AMOUNT OF CHARGES FOREGONE FOR SERVICES AND SUPPLIES FURNISHED UNDER THE ORGANIZATION'S CHARITY CARE POLICY AGGREGATED TO APPROXIMATELY $740,000 FOR THE YEAR ENDED SEPTEMBER 30, 2017. |
| 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. THE MEDICARE SHORTFALL ON FEE SCHEDULE REIMBURSED SERVICES TOTALED $486,901 FOR THE REPORTABLE YEAR. THIS SHORTFALL IS NOT INCLUDED ON SCH H, PART III, LINE 7.THE REASONS MEDICARE SHORTFALL SHOULD BE TREATED AS A COMMUNITY BENEFIT ARE: ABSENT THE MEDICARE PROGRAM, IT IS LIKELY MANY OF THE INDIVIDUALS WHOULD QUALIFY FOR FINANCIAL ASSISTANCE OR OTHER NEEDS-BASED GOVERNMENT PROGRAMS; BY ACCEPTING PAYMENT BELOW COST TO TREAT THESE INDIVIDUALS, THE BURDENS OF GOVERNMENT ARE RELIEVED WITH RESPECT TO THESE INDIVIDUALS; THERE IS A SIGNIFICANT POSSIBILITY THAT CONTINUED REDUCTION IN REIMBURSEMENT MAY ACTUALLY CREATE DIFFICULTIES IN ACCESS FOR THESE INDIVIDUALS; AND THE AMOUNT SPENT TO COVER MEDICARE SHORTFALL IS MONEY NOT AVAILABLE TO COVER FINANCIAL ASSISTANCE AND OTHER COMMUNITY BENEFIT NEEDS. |
| 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. THE FINANCIAL ASSISTANCE CONTACT INFORMATION IS AVAILABLE AT ALL OF THE REGISTRATION POINTS IN WHICH ELIGIBLE PATIENTS ARE LIKELY TO BE PRESENT. IN ADDITION, FINANCIAL ASSISTANCE CONTACT INFORMATION IS INCLUDED IN THE PATIENT BILLS, INCLUDED IN A PATIENT'S HANDBOOK GIVEN UPON ADMISSION, ADDRESSED IN LETTER FORM TO PATIENTS THAT APPEAR TO BE HAVING DIFFICULTY PAYING THEIR BILL AND/OR A DISCUSSION IS HAD WITH THE PATIENT ON THE AVAILABILITY OF VARIOUS GOVERNMENT BENEFITS, SUCH AS MEDICAID OR STATE PROGRAMS. WHERE APPLICABLE, THE PATIENT IS ASSISTED WITH QUALIFICATION FOR SUCH PROGRAMS.ADDITIONALLY, A CONCERTED EFFORT IS MADE TO INFORM NON-ENGLISH SPEAKING PATIENTS ABOUT FINANCIAL ASSISTANCE POLICIES. MULTILINGUAL SIGNS ARE POSTED IN THE REGISTRATION AND WAITING AREAS SO THAT THE POLICIES ARE CLEARLY COMMUNICATED TO PATIENTS AND PROSPECTIVE PATIENTS. THE ROLE AND RESPONSIBILITIES OF THE FINANCIAL ASSISTANCE COUNSELOR INCLUDE HOW TO QUALIFY PATIENTS FOR MEDICAID, SCHIP AND OTHER GOVERNMENT PROGRAMS. |
| PART VI, LINE 4: | FORT MADISON COMMUNITY HOSPITAL SERVES A COMMUNITY OF APPROXIMATELY 13,105 AND A COMBINED SERVICE AREA OF APPROXIMATELY 41,920. 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 24,035 AND A MEDIAN AGE OF 43.4. 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: | NOT APPLICABLE |
| 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 (3 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) | $15,600 | PROMOTE COMMUNITY ACTIVE LIFESTYLE |
| LEE COUNTY ECONOMIC DEVELOPMENT GROUP | |||||||
| 2700 KINDUSTRY PARK ROAD | KEOKUK | IA | 52632 | 043605260 | 501(C)(3) | $5,000 | GENERAL SUPPORT |
| SOUTHEASTERN COMMUNITY COLLEGE FOUNDATION | |||||||
| 1500 W AGENCY ROAD PO BOX 180 | WEST BURLINGTON | IA | 52655 | 421212111 | 501(C)(3) | $20,000 | GENERAL SUPPORT |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total501c3 Org | 2 | 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 | Yes (1) | 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 (8 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 |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| PAT BIRA | ||||||||||||||
| FORMER CEO/SECRETARY | $206,903 | $0 | $0 | $0 | $0 | $0 | $0 | $0 | $53,381 | $0 | $260,284 | $0 | $0 | $0 |
| BRADLEY J KOKJOHN | ||||||||||||||
| FORMER CFO/TREASURER | $201,710 | $0 | $32,376 | $0 | $0 | $0 | $0 | $0 | $43,707 | $0 | $277,793 | $0 | $0 | $0 |
| KATHY J ANDERSON MD | ||||||||||||||
| PHYSICIAN | $250,649 | $0 | $145,188 | $0 | $0 | $0 | $13,250 | $0 | $21,494 | $0 | $430,581 | $0 | $0 | $0 |
| MEENAKSHI PALANI MD | ||||||||||||||
| PHYSICIAN | $367,964 | $0 | $85,114 | $0 | $0 | $0 | $13,250 | $0 | $19,295 | $0 | $485,623 | $0 | $0 | $0 |
| TIMOTHY S STAUDTE MD | ||||||||||||||
| PHYSICIAN | $218,648 | $0 | $283,162 | $0 | $0 | $0 | $13,250 | $0 | $21,605 | $0 | $536,665 | $0 | $0 | $0 |
| DAVID C WENGER-KELLER MD | ||||||||||||||
| PHYSICIAN | $243,321 | $0 | $97,917 | $0 | $0 | $0 | $5,300 | $0 | $17,104 | $0 | $363,642 | $0 | $0 | $0 |
| BRENT G WOODBURY MD | ||||||||||||||
| PHYSICIAN | $585,961 | $0 | $135,750 | $0 | $0 | $0 | $13,250 | $0 | $24,444 | $0 | $759,405 | $0 | $0 | $0 |
| C JAMES PLATT | ||||||||||||||
| FORMER CEO/SECRETARY | $246,176 | $0 | $0 | $0 | $0 | $0 | $0 | $0 | $0 | $0 | $246,176 | $0 | $0 | $0 |
Supplemental Information Detail SupplementalInformationDetail (2 entries)
| Form And Line ReferenceFormAndLineReferenceDesc | ExplanationExplanationTxt |
|---|---|
| PART I, LINE 4A | THE FOLLOWING INDIVIDUAL RECEIVED SEVERANCE PAY FROM FORT MADISON COMMUNITY HOSPITAL DURING THE CALENDAR YEAR 2016: C. JAMES PLATT - $246,176. THIS INFORMATION IS INCLUDED IN REPORTABLE COMPENSATION ON FORM 990, PART VII AND SCHEDULE J, PART II, IF APPLICABLE. |
| FORM 990, SCHEDULE J, PART II | AMOUNTS REPORTED IN PART II FOR JEREMY ALEXANDER, BRADLEY KOKJOHN, AND C. JAMES PLATT WERE PAID BY QUORUM HEALTH RESOURCES, A HEALTHCARE MANAGEMENT SERVICES COMPANY. |
Schedule K IRS990ScheduleK
Tax Exempt Bonds Issues TaxExemptBondsIssuesGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Bond Reference | A | BondReferenceCd |
Issuer Name IssuerName
| Field | Value | IRS element (for citing) |
|---|---|---|
| Business Name Line1 | CITY OF FORT MADISON IOWA | BusinessNameLine1Txt |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Bond Issuer EIN | 426004688 | BondIssuerEIN |
| CUSIP | NONEAVAIL | CUSIPNum |
| Bond Issued | 2011-10-01 | BondIssuedDt |
| Issue Price | $8,500,000 | IssuePriceAmt |
| Purpose | FINANCE A PORTION OF COSTS OF REMODELING, CONSTRUCTING, EQUIPPING AND FURNIS | PurposeDesc |
| Defeased | 0 | DefeasedInd |
| On Behalf Of Issuer | Yes (1) | OnBehalfOfIssuerInd |
| Pool Financing | 0 | PoolFinancingInd |
Tax Exempt Bonds Proceeds TaxExemptBondsProceedsGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Bond Reference | A | BondReferenceCd |
| Total Proceeds | $8,500,000 | TotalProceedsAmt |
| Capital Expenditures | $8,500,000 | CapitalExpendituresAmt |
| Substantial Completion | 2013 | SubstantialCompletionYr |
| Current Refunding | 0 | CurrentRefundingInd |
| Advance Refunding | 0 | AdvanceRefundingInd |
| Final Allocation Made | 0 | FinalAllocationMadeInd |
| Adequate Books And Rec Maint | Yes (1) | AdequateBooksAndRecMaintInd |
Tax Exempt Bonds Private Bus Use TaxExemptBondsPrivateBusUseGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Bond Reference | A | BondReferenceCd |
| Owning Bond Financed Property | 0 | OwningBondFinancedPropertyInd |
| Any Lease Arrangements | 0 | AnyLeaseArrangementsInd |
| Mgmt Contract Bond Fincd Prop | 0 | MgmtContractBondFincdPropInd |
| Any Research Agreements | 0 | AnyResearchAgreementsInd |
| Private Bus Use By Others | 0.00000 | PrivateBusUseByOthersPct |
| Private Bus Concerning UBI | 0.00000 | PrivateBusConcerningUBIPct |
| Total Private Business Use | 0.00000 | TotalPrivateBusinessUsePct |
| Bond Iss Meet Prvt Sec Pymt Test | 0 | BondIssMeetPrvtSecPymtTestInd |
| Change In Use Bond Financed Prop | 0 | ChangeInUseBondFinancedPropInd |
| Procs Nonqualified Bond Remdtd | 0 | ProcsNonqualifiedBondRemdtdInd |
Tax Exempt Bonds Arbitrage TaxExemptBondsArbitrageGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Bond Reference | A | BondReferenceCd |
| Form8038 T Filed | Yes (1) | Form8038TFiledInd |
| Variable Rate Issue | Yes (1) | VariableRateIssueInd |
| Hedge Identified In Bks And Rec | 0 | HedgeIdentifiedInBksAndRecInd |
| Gross Proceeds Invested In GIC | 0 | GrossProceedsInvestedInGICInd |
| Gross Proceeds Invested | 0 | GrossProceedsInvestedInd |
| Written Proc To Monitor Reqs | 0 | WrittenProcToMonitorReqsInd |
Procedures Corrective Action ProceduresCorrectiveActionGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Bond Reference | A | BondReferenceCd |
| Procedures Corrective Action | 0 | ProceduresCorrectiveActionInd |
Schedule O IRS990ScheduleO
Supplemental Information Detail SupplementalInformationDetail (10 entries)
| Form And Line ReferenceFormAndLineReferenceDesc | ExplanationExplanationTxt |
|---|---|
| FORM 990, PART VI, SECTION A, LINE 2 | JEREMY ALEXANDER, PAT BIRA, AND BRADLEY J. KOKJOHN HAVE A BUSINESS RELATIONSHIP AS THEY ALL WERE BOARD MEMBERS OF RENAISSANCE HEALTH SERVICES, INC., A RELATED ORGANIZATION, AT SOME POINT DURING THE TAX YEAR. |
| FORM 990, PART VI, SECTION A, LINE 3 | JEREMY ALEXANDER, PAT BIRA, BRADLEY J. KOKJOHN, AND C. JAMES PLATT HAVE A BUSINESS RELATIONSHIP AS THEY ARE ALL EMPLOYED BY QUORUM HEALTH RESOURCES, A HEALTHCARE MANAGEMENT SERVICES COMPANY, WHICH PROVIDES MANAGEMENT SERVICES TO THE ORGANIZATION. |
| FORM 990, PART VI, SECTION A, LINE 4 | FORT MADISON COMMUNITY HOSPITAL'S BOARD OF DIRECTORS VOTED ON THE FOLLOWING CHANGES TO THE ORGANIZATION'S BY-LAWS: 1. A WRITTEN CONSENT DESCRIBING THE ACTION TO BE TAKEN MAY BE SUBMITTED BY A MEMBER OF THE BOARD OR COMMITTEE FOR ANY ACTION REQUIRING A VOTE. 2. EACH BOARD COMMITTEE WILL CONSISTENT OF TWO OR MORE DIRECTORS. 3. THE CHIEF EXECUTIVE OFFICER EXPLANATION WAS CONDENSED TO STATE THAT THE BOARD WILL ENGAGE A CEO THROUGH DIRECT EMPLOYMENT, A MANAGEMENT CONTRACT, OR OTHER CONTRACTUAL ARRANGEMENT. THE CEO WILL BE THE EXECUTIVE REPRESENTATIVE IN THE MANAGEMENT OF THE HOSPITAL. THE CEO WILL BE GIVEN THE NECESSARY AUTHORITY AND BE HELD RESPONSIBLE FOR ALL HOSPITAL ACTIVITIES. THE BOARD WILL CONDUCT AN ANNUAL APPRAISAL AND ALL DIRECTORS WILL BE GIVEN THE OPPORTUNITY TO PARTICIPATE IN THE APPRAISAL. 4. THE MEDICAL STAFF EXPLANATION WAS CONDENSED TO STATE THE BOARD WILL APPOINT A MEDICAL STAFF THAT ARE ACCEPTED BY THE BOARD OF MEDICAL STAFF MEMBERSHIP AND APPROPRIATE CLINICAL PRIVILEGES. THE MEDICAL STAFF WILL BE DELEGATED THE TASK OF DRAFTING MEDICAL STAFF BY-LAWS, RULES, REGULATIONS, POLICIES, AND PROTOCOLS FOR THE BOARD TO APPROVE. THE BOARD HAS A RIGHT TO DEPRIVE MEDICAL STAFF MEMBERSHIP OR CLINICAL PRIVILEGES TO ANY APPLICANT. |
| FORM 990, PART VI, SECTION B, LINE 11B | A COPY OF THE FORM 990 IS REVIEWED BY THE ORGANIZATION'S CONTROLLER WITH THE EXTERNAL ACCOUNTANTS FOR COMPLETENESS AND ACCURACY PRIOR TO FILING THE FORM 990. A COPY OF THE FINAL VERSION IS PROVIDED TO EACH BOARD MEMBER AFTER THE RETURN IS FILED 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. QUORUM HEALTH RESOURCES, AN INDEPENDENT MANAGEMENT CONSULTANT, PRESENTS TO THE FULL BOARD OF DIRECTORS COMPENSATION INFORMATION WHICH INCLUDES COMPARABLES AND INDUSTRY GUIDELINES ALONG WITH RECOMMENDATIONS FOR THE BOARD'S APPROVAL FOR COMPENSATION OF THE CEO AND CFO. 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. COMPENSATION OF PHYSICIANS EMPLOYED OR CONTRACTED BY FMCH OR AN AFFILIATE ARE REVIEWED ANNUALLY USING 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. THIS PROCESS OCCURS ANNUALLY. |
| 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 719,521. CONTRIBUTION FROM SUBSIDIARY REPORTED AS NET ASSET TRANSFER ON REPORT -250,000. |
| FORM 990, PART XII, LINE 2C: | THE FORT MADISON COMMUNITY HOSPITAL GOVERNING BOARD MEETS WITH THE AUDITORS TO REVIEW THE AUDIT REPORT AND MANAGEMENT LETTER. THE OVERSIGHT AND SELECTION PROCESS HAS NOT CHANGED FROM THE PRIOR TAX YEAR. |
| FORM 990, PART VII, LINE 1A | FORT MADISON COMMUNITY HOSPITAL, FORT MADISON COMMUNITY HOSPITAL FOUNDATION, AND FORT MADISON PROFESSIONAL BUILDING ASSOCIATION 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 (2 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 |
|---|---|---|---|---|---|---|---|---|---|---|
| FORT MADISON PROFESSIONAL BUILDING ASSOCIATION | ||||||||||
| 5445 AVENUE O PO BOX 174 | FORT MADISON | IA | 52627 | 421298064 | SUPPORT FORT MADISON COMMUNITY HOSPITAL | IA | 501(C)(3) | LINE 12A, I | FORT MADISON COMMUNITY HOSPITAL | Yes (1) |
| 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) |
Id Related Org Txbl Partnership IdRelatedOrgTxblPartnershipGrp
Related Organization Name RelatedOrganizationName
| Field | Value | IRS element (for citing) |
|---|---|---|
| Business Name Line1 | BFM KEOKUK CLINIC LLC | 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) |
|---|---|---|
| EIN | 472472717 | EIN |
| Primary Activities | HEALTHCARE SERVICES | PrimaryActivitiesTxt |
| Legal Domicile State | IA | LegalDomicileStateCd |
Direct Controlling Entity Name DirectControllingEntityName
| Field | Value | IRS element (for citing) |
|---|---|---|
| Business Name Line1 | FORT MADISON COMMUNITY HOSPITAL | BusinessNameLine1Txt |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Predominant Income Type | RELATED | PredominantIncomeTypeTxt |
| Share Of Total Income | -$338,932 | ShareOfTotalIncomeAmt |
| Share Of EOY Assets | $265,676 | ShareOfEOYAssetsAmt |
| Disproportionate Allocations | 0 | DisproportionateAllocationsInd |
| General Or Managing Partner | 0 | GeneralOrManagingPartnerInd |
| Ownership | 0.50000 | OwnershipPct |
Id Related Org Txbl Corp Tr IdRelatedOrgTxblCorpTrGrp
Related Organization Name RelatedOrganizationName
| Field | Value | IRS element (for citing) |
|---|---|---|
| Business Name Line1 | RENAISSANCE HEALTH SERVICES INC | 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) |
|---|---|---|
| EIN | 421298222 | EIN |
| Primary Activities | MEDICAL SERVICE | PrimaryActivitiesTxt |
| Legal Domicile State | IA | LegalDomicileStateCd |
Direct Controlling Entity Name DirectControllingEntityName
| Field | Value | IRS element (for citing) |
|---|---|---|
| Business Name Line1 | FORT MADISON COMMUNITY HOSPITAL | BusinessNameLine1Txt |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Entity Type | C | EntityTypeTxt |
| Share Of Total Income | $5 | ShareOfTotalIncomeAmt |
| Share Of EOY Assets | $12,891 | ShareOfEOYAssetsAmt |
| Ownership | 1.00000 | OwnershipPct |
| Controlled Organization | 0 | ControlledOrganizationInd |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Receipt Of Int Annts Rnts Rylts | 0 | 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 | 0 | 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 | Yes (1) | 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 | 0 | PaidEmployeesSharingInd |
| Reimbursement Paid To Other Org | 0 | ReimbursementPaidToOtherOrgInd |
| Reimbursement Paid By Other Org | 0 | ReimbursementPaidByOtherOrgInd |
| Transfer To Other Org | 0 | TransferToOtherOrgInd |
| Transfer From Other Org | 0 | TransferFromOtherOrgInd |
Transactions Related Org TransactionsRelatedOrgGrp (3 entries)
| Transaction TypeTransactionTypeTxt | InvolvedInvolvedAmt | Method Of Amount DeterminationMethodOfAmountDeterminationTxt |
|---|---|---|
| FORT MADISON PROFESSIONAL BUILDING ASSOCIATION | ||
| C | $250,000 | FAIR MARKET VALUE |
| FORT MADISON PROFESSIONAL BUILDING ASSOCIATION | ||
| K | $362,691 | FAIR MARKET VALUE |
| BFM KEOKUK CLINIC LLC | ||
| B | $200,000 | FAIR MARKET VALUE |