2016-11-14T13:19:55-06:00 2015-12-31 410746749 CLIFTONLARSONALLEN LLP 114 E EVERETT DIXON IL 61021 990 2015-01-01 376062326 PANA COMMUNITY HOSPITAL ASSOCIATION PANA 2175622131 101 EAST NINTH STREET PANA IL 62557 KATRINA CASNER PRESIDENT & CEO 2175622131 2016-11-02 1 TODD M ETHERIDGE P00233050 8152859300 2015 2017-02-10 21:41:12Z KATRINA CASNER 101 EAST NINTH STREET PANA IL 62557 23785308 0 X WWW.PANAHOSPITAL.COM X 1966 IL OUR MISSION IS TO BE A LEADING PARTNER IN ASSURING COMMUNITY-BASED QUALITY HEALTH CARE. 12 11 233 86 7222 0 79015 118505 20998850 23438428 117464 112882 57695 83641 21253024 23753456 0 0 0 0 9955572 10609531 0 0 0 9995472 9895210 19951044 20504741 1301980 3248715 27148686 28182789 4415871 2325933 22732815 25856856 X OUR MISSION IS TO BE A LEADING PARTNER IN ASSURING COMMUNITY-BASED QUALITY HEALTH CARE. TO ACHIEVE THIS MISSION, WE PROMOTE A VISION STRIVING TO DEVELOP A COMPREHENSIVE SYSTEM OF HEALTHCARE SERVICES, IN PARTNERSHIP WITH THE OTHER COMMUNITY HEALTHCARE PROVIDERS, TO ASSIST OUR SERVICE AREA RESIDENTS IN REACHING THEIR PERSONAL MAXIMUM FOR HEALTH; TO PROVIDE PROGRAMS THAT PROMOTE HEALTH EDUCATION AND WELLNESS; TO ENHANCE OUR PERSONALIZED CARE CONCEPT IN THE PROVISION OF SERVICES TO OUR COMMUNITY; TO MAINTAIN AN ENVIRONMENT WHICH PROMOTES SATISFACTION AND OPPORTUNITY FOR THE PATIENT, THEIR FAMILY, THE EMPLOYEE, AND THE PHYSICIAN; TO MAINTAIN THE HOSPITAL'S ABILITY TO SUPPORT THE DELIVERY OF QUALITY HEALTH CARE AT A REASONABLE COST, IN ACCORDANCE WITH COMMUNITY NEEDS AND THE HEALTH CARE REGULATORY ENVIRONMENT; AND TO DEMONSTRATE BY ACTIONS AND RESULTS OUR COMMITMENT TO CONTINUOUS QUALITY IMPROVEMENT. 0 0 14251480 0 23438428 TO PROVIDE HEALTH CARE SERVICES TO THE CITIZENS OF PANA, ILLINOIS AND THE SURROUNDING AREA. THESE SERVICES INCLUDE NURSING, EMERGENCY AND ANCILLARY SERVICES FOR 787 INPATIENT DAYS, 21,473 OUTPATIENT ADMISSSIONS, 8,735 EMERGENCY VISITS AND 389 SURGICAL PATIENTS. 14251480 1 1 0 1 0 0 0 0 0 1 1 0 0 0 1 1 0 1 0 0 0 0 0 0 0 0 1 1 0 0 1 0 0 0 0 0 0 1 0 0 0 0 0 0 1 1 1 0 0 1 32 0 1 233 1 1 1 0 0 0 0 0 0 0 0 0 X 12 11 1 0 0 0 1 1 0 1 1 0 0 0 1 1 1 1 1 1 1 0 IL X JAMES MOON CFO 2175622131 101 EAST NINTH STREET PANA IL 62557 MARY ANN RHOADES CHAIRMAN 1.50 0.00 X X 0 0 0 MATT BEAVERS VICE CHAIRMAN 1.50 0.00 X X 0 0 0 CAROL SCHRAMM SECRETARY 1.50 0.00 X X 0 0 0 JOHN GARDNER TREASURER 1.50 0.00 X X 0 0 0 LARRY CEARLOCK DIRECTOR 1.50 0.00 X 0 0 0 DR TERRY CUNNINGTON DIRECTOR & PHYSICIAN 40.00 0.00 X 328051 0 29398 GREGORY HOLTHAUS DIRECTOR 1.50 0.00 X 0 0 0 DR DAVID LETT DIRECTOR 1.50 0.00 X 0 0 0 RIC MILES DIRECTOR 1.50 0.00 X 0 0 0 JOYCE MORGAN DIRECTOR 1.50 0.00 X 0 0 0 RICK SCHMITZ DIRECTOR 1.50 0.00 X 0 0 0 JOYCE THRONEBURG DIRECTOR 1.50 0.00 X 0 0 0 KATRINA CASNER PRESIDENT & CEO 40.00 0.00 X 177143 0 36266 JAMES MOON CFO 40.00 0.00 X 108444 0 18965 VICKIE COEN CCO & CNE 40.00 0.00 X 119550 0 28053 DIANE BAILEY CIO 40.00 0.00 X 77142 0 17478 DR MARLON MUNESES PHYSICIAN 40.00 1.50 X 293588 0 32188 DR CATHERINE TEODORO PHYSICIAN 40.00 0.00 X 198737 0 20447 MICHELLE FORMAN PHARMACIST 40.00 0.00 X 119370 0 18597 DR STEVEN WEBER PT SURGEON 16.00 0.00 X 193480 0 0 1615505 0 201392 8 0 1 0 MIDWEST EMERGENCY SERVICE INC 320 E HIGHWAY 50 OFALLON IL 62269 EMERGENCY PHYSICIANS 1370518 MCKESSON TECHNOLOGIES INC PO BOX 98347 CHICAGO IL 60693 HARD/SOFT SUPPORT/MAINT 380327 GE HEALTHCARE PO BOX 96483 CHICAGO IL 60693 EQUIPMENT MAINTENANCE 314015 CONSOCIATE-DANSIG 151 E DECATUR ST DECATUR IL 62525 THIRD PARTY ADMINISTRATION - HEALTH INSU 246801 RELAY HEALTH PO BOX 98347 CHICAGO IL 60693 BILLING SERVICES 123272 7 90480 12000 16025 118505 PATIENT CARE SERVICES 621110 22502666 22502666 ELECTRONIC HEALTH RECORDS REVENUE 621110 780061 780061 OTHER OPERATING REVENUE 621110 144420 144420 INVESTMENT INCOME FROM SUBSIDIARY 621110 11281 11281 23438428 141285 141285 36325 0 36325 36325 36325 3449 31852 -28403 -28403 -28403 CAFETERIA & VENDING 722514 40094 40094 CATERING 722320 7222 7222 47316 23753456 23438428 7222 189301 X 1485449 888109 597340 7146947 5682996 1463951 193220 158517 34703 1409042 1131751 277291 374873 287945 86928 18937 18937 58750 58750 2522882 2273239 249643 55319 55319 161498 161498 189226 189226 314987 314987 50706 50706 45284 45284 1327035 1327035 163331 163331 MEDICAL SUPPLIES 1954627 1954627 BAD DEBT EXPENSE 1482333 1482333 REPAIRS & MAINTENANCE 793640 793640 FEES & LICENSES 368945 271601 97344 387710 120362 267348 20504741 14251480 6253261 0 11471031 12992754 2827146 2815158 3773953 3147972 1850 1850 349762 361421 199619 180814 19391368 13060228 6927850 6331140 1317617 2061455 39779 98590 240079 191635 27148686 28182789 1646167 1683352 846465 384757 1923239 257824 4415871 2325933 X 22732815 25856856 22732815 25856856 27148686 28182789 3248715 -124674 0 X 0 1 X 1 0 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 0 0 0 0 0 0 0 0 1 8458 8458 0 PART II-B, LINE 1: WE PARTICIPATE INDIRECTLY WITH LOBBYING ACTIVITIES THROUGH OUR MEMBERSHIPS IN THE ILLINOIS HOSPITAL ASSOCIATION ("IHA") AND THE AMERICAN HOSPITAL ASSOCIATION ("AHA"). IT IS ESTIMATED THAT OUR LOBBYING EXPENDITURES FOR 2015 WERE 34% AND 22.12% OF OUR MEMBERSHIP DUES PAID TO AHA AND IHA, RESPECTIVELY. 1288135 -1288135 1284973 3162 1288135 1283522 1451 1284973 1282115 1407 1283522 1347734 -65619 1282115 0.00000 0.00000 0.00000 0 0 51361 51361 7264226 4423042 2841184 508954 234879 274075 11458258 8402307 3055951 108569 108569 6331140 THIRD PARTY PAYOR SETTLEMENTS 257824 257824 X PART V, LINE 4: PANA HOSPITAL USED THE FUNDS FOR CAPITAL IMPROVEMENTS PART X, LINE 2: PCH FILES 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 POSITION TAKEN OR THE AMOUNT OF THE POSITION THAT WOULD ULTIMATELY BE SUSTAINED. EXAMPLES OF TAX POSITIONS INCLUDE SUCH MATTERS AS THE FOLLOWING: THE TAX EXEMPT STATUS OF THE ENTITY AND VARIOUS POSITIONS RELATIVE TO POTENTIAL SOURCES OF UNRELATED BUSINESS TAXABLE INCOME (UBIT). UBIT IS REPORTED ON FORM 990T AND PCH HAS APPROPRIATELY FILED A FORM 990T. THE BENEFIT OF A TAX POSITION IS RECONGNIZED 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 IS REFLECTED AS A LIABILITY FOR UNRECOGNIZED TAX BENEFITS IN THE ACCOMPANYING STATEMENTS OF FINANCIAL POSITION ALONG WITH ANY ASSOCIATED INTEREST AND PENALTIES THAT WOULD BE PAYABLE TO THE TAXING AUTHORITIES UPON EXAMINATION. AT DECEMBER 31, 2015 AND 2014, THERE WERE NO UNRECOGNIZED TAX BENEFITS IDENTIFIED OR RECORDED. PRESENTLY, THERE ARE NO ONGOING INCOME TAX AUDITS OR UNRESOLVED DISPUTES WITH THE TAX AUTHORITIES THAT THE ORGANIZATION CURRENTLY FILES OR HAS FILED WITH. 1 1 X 1 X 1 X 1 1 0 0 431234 431234 0.02100 4356232 3606107 750125 0.03660 4787466 3606107 1181359 0.05760 43969 43969 0.00210 52384 52384 0.00260 96353 96353 0.00470 4883819 3606107 1277712 0.06230 1 1482333 889400 7275045 7518868 -243823 X 1 0 1 1 PANA COMMUNITY HOSPITAL 101 EAST 9TH STREET PANA IL 62557 WWW.PANAHOSPITAL.COM 0001776 X X X X PANA COMMUNITY HOSPITAL 1 0 0 1 X X X X X X X X X 13 1 0 0 1 X HTTP://WWW.PANAHOSPITAL.COM/ABOUTUS/ASSESSMENT.PHP X 1 13 1 HTTP://WWW.PANAHOSPITAL.COM/ABOUTUS/ASSESSMENT.PHP 0 0 1 X 200.000000000000 200.000000000000 X 1 1 X X X X 1 X HTTP://WWW.PANAHOSPITAL.COM/PATIENTSANDVISITORS/FINANCIALS.PHP X HTTP://WWW.PANAHOSPITAL.COM/PATIENTSANDVISITORS/FINANCIALS.PHP X HTTP://WWW.PANAHOSPITAL.COM/PATIENTSANDVISITORS/FINANCIALS.PHP X X X 1 X 0 X X X X 1 X 0 0 PANA COMMUNITY HOSPITAL PART V, SECTION B, LINE 5: PCH CONSULTED THE CHRISTIAN COUNTY HEALTH DEPT., UTILIZED SURVEYS MADE AVAILABLE TO THE PUBLIC, AND CONDUCTED COMMUNITY MEETINGS THAT ALL INTERESTED PARTIES COULD ATTEND. PANA COMMUNITY HOSPITAL PART V, SECTION B, LINE 11: PANA COMMUNITY HOSPITAL'S SIGNIFICANT COMMUNITY HEALTH NEEDS, AS IDENTIFIED IN ITS 2013 COMMUNITY HEALTH NEEDS ASSESSMENT, ARE CHRONIC DISEASES, WELLNESS AND HEALTHY LIFESTYLES, AND MENTAL HEALTH. DURING 2015, PANA COMMUNITY HOSPITAL TOOK THE FOLLOWING STEPS RELATED TO THESE HEALTH NEEDS:CHRONIC DISEASE MANAGEMENT - CANCER, HEART DISEASE, DIABETES AND STROKE:1. HOSTED MONTHLY "LUNCH, LEARN & LIVE WELL" MEETINGS THAT PROVIDED EDUCATION TO THE COMMUNITY RELATED TO THE MANAGEMENT OF THESE IDENTIFIED DISEASES.2. CONTINUED PARTICIPATING IN THE STAT HEART PROGRAM.3. PARTICIPATED IN STAT STROKE INITIATIVES AND BECAME A STROKE READY HOSPITAL.4. CONTINUED TO EXPAND BREAST CARE SERVICES TO FOCUS ON IMPROVING EARLY DETECTION AND TREATMENT OF BREAST CANCER.5. SPONSORED AN ANNUAL COMMUNITY HEALTH FAIR.6. PROVIDED DIETICIAN SERVICES THAT INCLUDED A FOCUS ON DIABETES MANAGEMENT.WELLNESS, FITNESS, HEALTHY LIFESTYLES AND ILLNESS PREVENTION:1. SPONSORED COMMUNITY WELLNESS INITIATIVES THROUGH THE REHAB WELLNESS CENTER, INCLUDING MULTIPLE 5K PROGRAMS AND WEEKLY COMMUNITY WELLNESS WORKSHOPS.2. PROVIDED FITNESS WELLNESS PROGRAMS TO THE COMMUNITY, INCLUDING INDIVIDUALIZED EXERCISE PROGRAM DEVELOPMENT AND GROUP EXERCISE CLASS OFFERINGS.3. SPONSORED QUARTERLY EMPLOYEE WELLNESS CHALLENGES WITH REWARDS FOR PARTICIPATION AND GOAL ACHIEVEMENT.MENTAL HEALTH:1. WORKED WITH CHRISTIAN COUNTY MENTAL HEALTH SERVICES TO STRENGTHEN EXISTING PROGRAMS.2. RESEARCHED ADDITIONAL OPPORTUNITIES TO OFFER MENTAL HEALTH SERVICES. PANA COMMUNITY HOSPITAL PART V, SECTION B, LINE 13B: THE COST OF THE SERVICE MAY IMPACT AN INDIVIDUAL'S ELIGIBILITY FOR FINANCIAL ASSISTANCE. PRESUMPTIVE ELIGIBILITY FOR FREE CARE IS AVAILABLE FOR INDIVIDUALS WHO ARE HOMELESS, MENTALLY INCAPACITATED WITH NOBODY TO ACT ON THEIR BEHALF, MEDICAID ELIGIBLE (BUT NOT ON THE DATE OF SERVICE), FILING PERSONAL BANKRUPCTY, DECEASED WITH NO ESTATE, INCARCERATED IN A PENAL INSTITUTION, OR AFFILIATED WITH A RELIGIOUS ORDER AND TAKING A VOW OF POVERTY. PANA COMMUNITY HOSPITAL PART V, SECTION B, LINE 22D: ALL INDIVIDUALS WHO QUALIFY FOR FINANCIAL ASSISTANCE RECEIVE A 100% DISCOUNT (FREE CARE), MAKING IT IMPOSSIBLE TO CHARGE A FINANCIAL ASSISTANCE-ELIGIBLE INDIVIDUAL MORE THAN THE AMOUNT GENERALLY BILLED TO INDIVIDUALS WHO HAVE INSURANCE. 5 1 - COMMUNITY MEDICAL CLINIC OF PANA 101 EAST 9TH STREET PANA IL 62557 PHYSICIAN SATELLITE OFFICE 2 - QUAD COUNTY HOME HEALTH & HOSPICE 1 HUBER STREET PANA IL 62557 HOME HEALTH & HOSPICE AGENCY 3 - COMMUNITY MEDICAL CLINIC OF ASSUMPTION 118 N WALNUT STREET ASSUMPTION IL 62510 PHYSICIAN SATELLITE OFFICE 4 - COMMUNITY MEDICAL CLINIC OF RAMSEY 715 S SUPERIOR RAMSEY IL 62080 PHYSICIAN SATELLITE OFFICE 5 - COMMUNITY MEDICAL CLINIC OF NOKOMIS 120 CEDAR STREET NOKOMIS IL 62075 PHYSICIAN SATELLITE OFFICE PART I, LINE 3C: ELGIBILITY FOR FINANCIAL ASSISTANCE IS BASED ON FAMILY INCOME COMPARED TO FEDERAL POVERTY GUIDELINES AS WELL AS SUBMISSION OF A COMPLETE FINANCIAL ASSISTANCE APPLICATION. HOWEVER, IN THE FOLLOWING INSTANCES, AN INDIVIDUAL MAY PRESUMPTIVELY QUALIFY FOR 100% FINANCIAL ASSISTANCE WITHOUT SUBMITTING A FINANCIAL ASSISTANCE APPLICATION AND REGARDLESS OF THEIR INCOME: ENROLLMENT IN CERTAIN FEDERAL OR STATE PROGRAMS (E.G. WIC, SUPPLEMENTAL NUTRITION AND ASSISTANCE PROGRAM, ILLINOIS FREE BREAKFAST/LUNCH PROGRAM, TEMPORARY ASSISTANCE FOR NEEDY FAMILIES, ETC.), HOMELESSNESS, MENTAL INCAPACITATION WITH NO ONE TO ACT ON THE PATIENT'S BEHALF, MEDICAID ELIGIBILITY, RECENT PERSONAL BANKRUPTCY, DECEASED WITH NO ESTATE, INCARCERATION IN A PENAL INSTITUTION, AND AFFILIATION WITH A RELIGIOUS ORDER AND A VOW OF POVERTY. PART I, LINE 7: FINANCIAL ASSISTANCE AND CERTAIN OTHER COMMUNITY BENEFITS AT COST. THE COSTS REPORTED IN THE TABLE IN PART I, LINE 7 USED A RATIO OF PATIENT CARE COSTS TO CHARGES AS COMPUTED IN WORKSHEET 2 OF THE FORM INSTRUCTIONS. THIS METHODOLOGY WAS USED FOR ALL PATIENT SEGMENTS. PART I, LN 7 COL(F): FINANCIAL ASSISTANCE AND CERTAIN OTHER COMMUNITY BENEFITS AT COST. THE ORGANIZATION HAD BAD DEBT EXPENSE IN THE AMOUNT OF $1,482,333 REPORTED ON PART IX, LINE 25. HOWEVER, IT HAS BEEN SUBTRACTED FOR PURPOSED OF CALCULATING THE PERCENTAGE IN THIS COLUMN. PART III, LINE 2: ACCOUNTS RECEIVABLE ARE REDUCTED BY AN ALLOWANCE FOR DOUBTFUL ACCOUNTS. IN EVALUATING THE COLLECTIBILITY OF ACCOUNTS RECEIVABLE, THE HOSPITAL ANALYZES ITS PAST HISTORY AND IDENTIFIES TRENDS FOR EACH OF ITS MAJOR PAYER SOURCES OF REVENUE TO ESTIMATE THE APPROPRIATE ALLOWANCE FOR DOUBTFUL ACCOUNTS AND BAD DEBT EXPENSE. MANAGEMENT REGULARLY REVIEWS DATA ABOUT THESE MAJOR PAYER SOURCES OF REVENUE IN EVALUATING THE SUFFICIENCY OF THE ALLOWANCE FOR DOUBTFUL ACCOUNTS. PART III, LINE 3: THE BAD DEBT EXPENSE REPORTED ON LINE 2 REPRESENTS THE EXPENSE REPORTED ON THE ATTACHED FINANCIAL STATEMENTS BASED ON NET REALIZABLE AMOUNTS FROM THIRD PARTY PAYERS, PATIENTS AND OTHERS. BAD DEBT EXPENSE IS DETERMINED BASED ON THE CRITERIA DESCRIBED ABOVE. IT IS ESTIMATED THAT APPROXIMATELY 60% OF OUR BAD DEBT EXPENSE QUALIFIES UNDER THE ORGANIZATION'S CHARITY CARE POLICY. THIS PERCENTAGE WAS DETERMINED BASED UPON ANALYSIS OF DEMOGRAPHICS AND RECORD REVIEWS. PART III, LINE 4: SEE NOTE 2: NET PATIENT SERVICE REVENUE ON PAGE 14 OF THE AUDITED FINANCIAL STATEMENTS. ALSO, SEE NOTE 1: PATIENT ACCOUNTS RECEIVABLE ON PAGE 8 OF THE AUDITED FINANCIAL STATEMENTS. PART III, LINE 8: MEDICARE. LINE 6 COSTS WERE TAKEN DIRECTLY FROM THE ORGANIZATION'S 12/31/15 MEDICARE COST REPORT. PART III, LINE 9B: COLLECTION PRACTICES. THE COLLECTION PRACTICES FOLLOWED BY THE ORGANIZATION FOR PATIENTS WHO QUALIFY FOR CHARITY CARE OR FINANCIAL ASSISTANCE ARE ADDRESSED IN ITS HEALTHCARE ASSISTANCE POLICY. PART VI, LINE 2: NEEDS ASSESSMENT. THE ORGANIZATION ASSESSES THE HEALTH CARE NEEDS OF THE COMMUNITIES IT SERVES THROUGH STRATEGIC PLANNING ACTIVITIES THAT INCORPORATE ANALYSIS OF SERVICE AREA DEMOGRAPHICS AND STRUCTURED AND CONSISTENT PATIENT SURVEY PROCESSES. THE ORGANIZATION ALSO ASSESSES COMMUNITY HEALTH NEEDS THROUGH INPUT FROM ITS ACTIVE AND CONSULTING MEDICAL STAFF, COMMUNITY LEADERS, ORGANIZATION BOARD MEMBERS AND COUNTY HEALTH DEPARTMENTS. PART VI, LINE 3: PATIENT EDUCATION OF ELIGIBILITY FOR ASSISTANCE. THE ORGANIZATION INFORMS AND EDUCATES ITS PATIENTS REGARDING ASSISTANCE FROM FEDERAL, STATE, OR LOCAL GOVERNMENT PROGRAMS THROUGH ITS SOCIAL SERVICES DIRECTOR. THE ORGANIZATION INFORMS AND EDUCATES PATIENTS REGARDING ASSISTANCE FROM ITS CHARITY CARE POLICY THROUGH DISCUSSION AT REGISTRATION OR DISCHARGE, AN INFORMATIONAL DOCUMENT SENT WITH BILLING STATEMENTS AND A DESCRIPTION OF THE PROGRAM PLUS AN APPLICATION POSTED ON ITS WEBSITE. PART VI, LINE 4: COMMUNITY INFORMATION. THE ORGANIZATION SERVES A RURAL AREA THAT INCLUDES 13 SMALL COMMUNITIES. THE POPULATION OF THE SERVICE AREA TOTALS APPROXIMATELY 13,000 RESIDENTS. THE SIZE OF THE COMMUNITIES WE SERVE IN OUR SERVICE AREA RANGE FROM LESS THAN 150 TO APPROXIMATELY 5,800 RESIDENTS. OF THE 13,000 RESIDENTS, 16.7% ARE BELOW THE FEDERAL POVERTY LEVEL AND THE AVERAGE HOUSEHOLD INCOME IS APPROXIMATELY $30,900. OUR SERVICE ARE POPULATION CONSISTS OF 22.9% MEDICAID AND 3.1% UNINSURED. OUR ORGANIZATION PROVIDES SERVICES TO FEDERALLY-DESIGNATED MEDICALLY UNDERSERVED AREAS. PART VI, LINE 5: PROMOTION OF COMMUNITY HEALTH. ONE OF THE VERY IMPORTANT ASSETS OF A COMMUNITY IS IT'S HOSPITAL. THE HOSPITAL, AS AN ORGANIZATION, FILLS THE ROLE AS THE FOCAL POINT OF THE COMMUNITY'S HEALTHCARE ACTIVITIES AND THE CATALYST WHICH BRINGS TOGETHER THE PRACTICING PHYICIANS, OTHER HEALTHCARE PROVIDERS, COMMUNITY HEALTHCARE AGENCIES, AND OTHER HEALTHCARE FOCUSED RESOURCES TO MAINTAIN AND PRESERVE THE COMMUNITY'S HEALTH STATUS. THE ORGANIZATION IS GOVERNED BY A VOLUNTEER BOARD OF DIRECTORS THAT CONSIST OF INDIVIDUALS WHO RESIDE IN THE HOSPITAL'S SERVICE AREA. MEDICAL STAFF PRIVILEGES ARE EXTENDED TO ALL PHYSICIANS IN OUR SERVICE AREA. SURPLUS FUNDS GENERATED THROUGH THE PROVISION OF SERVICES ARE INVESTED IN IMPROVED PATIENT CARE TECHNOLOGIES AND ENHANCED TREATMENT AREA SO THAT THE ORGANIZATIONS CAN CONTINUE TO PROVIDE QUALITY PATIENT CARE. PART VI, LINE 6: NOT APPLICABLE X X X X X 0 0 0 1 0 0 0 0 0 DR TERRY CUNNINGTON DIRECTOR & PHYSICIAN 148560 0 167218 0 12273 0 5808 0 23590 0 357449 0 0 0 KATRINA CASNER PRESIDENT & CEO 163953 0 12500 0 690 0 6526 0 29740 0 213409 0 0 0 DR MARLON MUNESES PHYSICIAN 150149 0 142137 0 1302 0 6598 0 25590 0 325776 0 0 0 DR CATHERINE TEODORO PHYSICIAN 149949 0 48519 0 269 0 6214 0 14233 0 219184 0 0 0 DR STEVEN WEBER PT SURGEON 97538 0 95942 0 0 0 0 0 0 0 193480 0 0 0 PART I, LINE 5 MARLON MUNESES, TERRY CUNNINGTON AND CATHERINE TEODORO ARE COMPENSATED USING A BASE SALARY PLUS PRODUCTIVITY COMPENSATION. THE PRODUCTIVITY COMPENSATION IS CALCULATED BASED UPON MINIMUM LEVELS OF RECEIPTS GENERATED BY EACH PHYSICIAN. DR LAURIE CUNNINGTON WIFE OF DR. TERRY CUNNINGTON, A BOARD MEMBER 20300 EMPLOYED BY HOSPITAL 0 ANDREW CASNER SON OF KATRINA CASNER, PRESIDENT & CEO 17533 EMPLOYED BY HOSPITAL 0 FORM 990, PART VI, SECTION A, LINE 1 THE BOARD OF DIRECTORS HAS AN EXECUTIVE COMMITTEE CONSISTING OF THE OFFICERS AND ONE OTHER MEMBER OF THE BOARD OF DIRECTORS. THE EXECUTIVE COMMITTEE HAS THE POWER TO TRANSACT ALL REGULAR BUSINESS OF THE HOSPITAL DURING THE INTERIM BETWEEN THE REGULAR MEETINGS OF THE BOARD OF DIRECTORS, PROVIDED ANY ACTION TAKEN SHALL NOT CONFLICT WITH THE POLICIES AND EXPRESS WISHES OF THE BOARD OF DIRECTORS AND THAT IT SHALL REFER ALL MATTERS OF MAJOR IMPORTANCE TO THE BOARD OF DIRECTORS. FORM 990, PART VI, SECTION A, LINE 2 JOYCE MORGAN, JOHN GARDNER, MARY ANN RHOADES, MATT BEAVERS, AND CAROL SCHRAMM HAVE A BUSINESS RELATIONSHIP DUE TO THE FACT THAT THEY ARE ALL BOARD MEMBERS OF QUAD COUNTY HOME MEDICAL SUPPLIES & EQUIPMENT, A TAXABLE SUBSIDIARY OF PANA COMMUNITY HOSPITAL ASSOCIATION. FORM 990, PART VI, SECTION A, LINE 6 PANA COMMUNITY HOSPITAL HAS TWO CLASSES OF MEMBERS, KNOWN AS REGULAR MEMBERS AND LIFE MEMBERS. REGULAR MEMBERS CONSIST OF INDIVIDUALS WHO PAY THE APPROPRIATE MEMBERSHIP DUES TO PANA COMMUNITY HOSPITAL. LIFE MEMBERS CONSIST OF INDIVIDUALS WHO CONTRIBUTE $100.00 OR MORE TO PANA COMMUNITY HOSPITAL OR PANA COMMUNITY HOSPITAL FOUNDATION. FOR THE PURPOSE OF SUPPORTING THE FINANCING OF BUILDING, EQUIPMENT, LIFE MEMBERSHIP, ENDOWMENT, OR ANY OTHER LAWFUL PURPOSE. FORM 990, PART VI, SECTION A, LINE 7A MEMBERS OF THE HOSPITAL VOTE FOR THE MEMBERS OF THE GOVERNING BODY DURING THE HOSPITAL'S ANNUAL MEETING. FORM 990, PART VI, SECTION B, LINE 11 THE FORM 990 IS REVIEWED BY THE CFO PRIOR TO THE FILING WITH THE IRS. FORM 990, PART VI, SECTION B, LINE 12C ALL BOARD MEMBERS, MEMBERS OF THE MEDICAL STAFF, ADMINISTRATION AND DEPARTMENT MANAGERS ARE ASKED TO COMPLETE A CONFLICT OF INTEREST QUESTIONNIARE ANNUALLY. THE HUMAN RESOURCES MANAGER REVIEWS QUESTIONNAIRES AND PRESENTS ANY CONFLICTS NOTED TO THE PRESIDENT & CEO TO REVIEW AND RESOLVE. IF ANY CONFLICTS ARE NOTED, THE PRESIDENT & CEO, WITH BOARD APPROVAL, IMPOSES APPROPRIATE RESTRICTIONS ON THE INDIVIDUAL(S) WITH A CONFLICT OF INTEREST. FORM 990, PART VI, SECTION B, LINE 15 EACH YEAR THE BOARD OF DIRECTORS DETERMINES COMPENSATION FOR THE CEO, CCO/CNE AND THE CFO. THE BOARD USES COMPARATIVE COMPENSATION INFORMATION FROM THE ILLINOIS HOSPITAL ASSOCIATION TO DETERMINE THE ABOVE INDIVIDUALS' COMPENSATION. FORM 990, PART VI, SECTION C, LINE 19 REQUESTS FOR THE ORGANIZATION'S GOVERNING DOCUMENTS AND CONFLICT OF INTEREST POLICY WILL BE EVALUATED ON A CASE-BY-CASE BASIS. IF DEEMED APPROPRIATE, THE DOCUMENT(S) WILL BE PROVIDED TO THE PUBLIC. THE ORGANIZATION'S AUDITED FINANCIAL STATEMENTS ARE AVAILABLE FOR THE PUBLIC TO REVIEW DURING THE ORGANIZATION'S ANNUAL MEETING. FORM 990, PART IX, LINE 11G IMAGING: PROGRAM SERVICE EXPENSES 481,128. MANAGEMENT AND GENERAL EXPENSES 0. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 481,128. EMERGENCY DEPARTMENT: PROGRAM SERVICE EXPENSES 1,375,232. MANAGEMENT AND GENERAL EXPENSES 0. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 1,375,232. LAB: PROGRAM SERVICE EXPENSES 107,338. MANAGEMENT AND GENERAL EXPENSES 0. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 107,338. OTHER: PROGRAM SERVICE EXPENSES 61,595. MANAGEMENT AND GENERAL EXPENSES 0. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 61,595. CONTRACT LABOR: PROGRAM SERVICE EXPENSES 247,946. MANAGEMENT AND GENERAL EXPENSES 249,643. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 497,589. PANA COMMUNITY HOSPITAL FOUNDATION 101 EAST 9TH STREET PANA IL 62557 371293506 FUNDRAISING IL 501(C)(3) LINE 11A, I PANA COMMUNITY HOSPITAL ASSOCIATION 1 QUAD COUNTY HOME MEDICAL SUPPLIES & EQUIPMENT 1 HUBER STREET PANA IL 62557 371198049 EQUIPMENT RETAILER IL PANA COMMUNITY HOSPITAL C 28795 172932 1.00000 1 0 0 1 0 0 0 0 0 0 0 0 0 0 1 1 0 1 0 0 PANA COMMUNITY HOSPITAL FOUNDATION C 90480 CASH TRANSFER