2016-02-29T10:03:48-06:00 2015-06-30 410746749 CLIFTONLARSONALLEN LLP 114 E EVERETT DIXON IL 61021 990 2014-07-01 370661215 KIRBY MEDICAL CENTER KIRB 2177622115 1000 MEDICAL CENTER DRIVE MONTICELLO IL 61856 MR STEVEN TENHOUSE CHIEF EXECUTIVE OFFICER 2177622115 2016-02-24 1 TODD M ETHERIDGE P00233050 8152859300 2014 2016-08-17 19:52:53Z MR STEVEN TENHOUSE 1000 MEDICAL CENTER DRIVE MONTICELLO IL 61856 35330435 0 X WWW.KIRBYHEALTH.ORG X 1939 IL KIRBY MEDICAL CENTER IS COMMITTED TO PROVIDING QUALITY AND COMPASSIONATE CARE TO ALL. 9 6 301 239 0 0 62324 175130 28606182 30742045 158599 495813 1067632 813509 29894737 32226497 72811 61145 0 0 12278239 12908541 0 0 0 14695884 14821828 27046934 27791514 2847803 4434983 74255072 76436390 34910578 32913324 39344494 43523066 KIRBY MEDICAL CENTER IS COMMITTED TO PROVIDING QUALITY AND COMPASSIONATE CARE TO ALL. 0 0 18914409 61145 30742045 THE HOSPITAL PROVIDES QUALITY INPATIENT AND OUTPATIENT SERVICES TO ITS COMMUNITY. FREE, SUBSIDIZED, AND GOVERNMENT ASSISTED CARE ARE PROVIDED AT A REDUCED RATE WHEN NEEDED. SERVICES PROVIDED DURING THE YEAR INCLUDE APPROXIMATELY 20,359 PATIENT VISITS THROUGH THE KIRBY MEDICAL CLINIC, 2,295 NURSING CARE INPATIENT DAYS, AND 79,004 LABORATORY PROCEDURES. 18914409 1 1 0 1 0 0 0 0 0 1 1 1 0 0 1 1 0 1 0 0 0 0 0 0 0 0 1 1 1 1 1 0 0 0 0 0 0 0 0 0 0 0 0 0 1 1 1 0 0 1 42 0 1 301 1 0 0 0 0 0 0 0 0 0 0 X 9 6 0 0 0 0 0 0 0 1 1 0 0 0 1 1 1 1 1 1 0 0 IL X MR STEVEN TENHOUSE 2177622115 1000 MEDICAL CENTER DRIVE MONTICELLO IL 61856 CRAIG WEBB CHAIRMAN OF THE BOARD 1.00 0.00 X X 16950 0 0 GARY HUISINGA VICE CHAIRMAN OF THE BOARD 1.00 0.00 X X 12600 0 0 JAMES BALLSRUD TREASURER 1.00 0.00 X X 12900 0 0 STEVE TENHOUSE SECRETARY OF THE BOARD, CEO 40.00 0.50 X X 209016 0 35235 STEPHEN AYERS BOARD MEMBER 1.00 0.00 X 4350 0 0 EDWARD EWALD BOARD MEMBER 1.00 0.50 X 6000 0 0 DONN PIATT III BOARD MEMBER 1.00 0.50 X 7500 0 0 WILLIAM TRACY BOARD MEMBER 1.00 0.00 X 6750 0 0 KARLA BRADLEY BOARD MEMBER 1.00 0.00 X 5700 0 0 STEVEN MILLS BOARD MEMBER 1.00 0.00 X 6750 0 0 NARAIN MANDHAN CHIEF MEDICAL OFFICER 40.00 0.00 X 283656 0 38343 ALEXANDER NAZARIAN CHIEF FINANCIAL OFFICER 40.00 0.00 X 109301 0 8244 JENNIFER MOSS CHIEF CLINICAL OFFICER 40.00 0.00 X 112290 0 20412 MARK FRED CHIEF OPERATING OFFICER 40.00 0.00 X 45449 0 5764 JOSEPH LAMB PHYSICIAN'S ASSISTANT 40.00 0.00 X 100437 0 29981 LAURIE LEE PHYSICIAN'S ASSISTANT 40.00 0.00 X 109437 0 16923 JAMES MANINT PHYSICIAN 40.00 0.00 X 180748 0 12654 JOSHUA SAWLAW PHYSICIAN 40.00 0.00 X 198993 0 34444 1428827 0 202000 8 0 1 0 CARLE PHYSICIAN GROUP 611 W PARK STREET URBANA IL 61801 PHYSICIAN SERVICES 2169494 CARLE FOUNDATION HOSPITAL 611 W PARK STREET URBANA IL 61801 PHYSICIAN SERVICES 568706 DECATUR MEMORIAL HOSPITAL 2300 N EDWARDS STREET DECATUR IL 62526 LAB CONTRACTED SERVICES 203439 MEDICAL INFORMATION TECHNOLOGY PO BOX 74569 CHICAGO IL 60696 OPERATING SYSTEM SUPPORT 173689 OSF ST FRANCIS INC 7314 N WILLOW LAKE CT SUITE C PEORIA IL 61614 MRI/PET CONTRACTED SERVICE 169335 9 2526 75513 97091 175130 NET PATIENT SERVICE REVENUE 621110 29873843 29873843 EMR INCENTIVE REIMBURSEMENT 900099 455460 455460 PHARMACY INCOME 900099 324120 324120 PHYSICAL THERAPY INCOME 621110 88622 88622 30742045 274294 274294 688746 98193 590553 590553 590553 3227264 3005745 221519 221519 221519 MISCELLANEOUS INC 900099 222956 222956 222956 32226497 30742045 0 1309322 X 28425 28425 32720 32720 1092725 1092725 9232865 6823907 2408958 426568 321208 105360 1442743 906757 535986 713640 479868 233772 21962 21962 33291 33291 3856558 3318948 537610 116688 116688 320426 226136 94290 63098 63098 380133 363403 16730 88126 46000 42126 90664 30401 60263 1653975 1653975 3337672 3337672 608417 608417 MEDICAL SUPPLIES 1273175 1273002 173 REPAIRS AND MAINTENANCE 676945 458182 218763 EQUIPMENT LEASE 360167 338170 21997 BAD DEBT 292999 292999 1647532 636611 1010921 27791514 18914409 8877105 0 875310 24396 6672821 6731627 5029683 4786155 230497 207812 849620 1129888 43978868 12809636 33131905 31169232 5757246 10733856 20850926 20863317 857064 790107 74255072 76436390 3519163 3574570 29327943 28434403 2063472 904351 34910578 32913324 X 17994624 22659749 498944 0 20850926 20863317 39344494 43523066 74255072 76436390 X 4434983 -319858 63447 X 0 1 X 1 1 1 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 0 0 0 0 0 0 0 0 0 0 0 0 1 8099 8099 0 PART II-B, LINE 1: LOBBYING EXPENSES ARE ALLOCATED THROUGH MEMBERSHIP DUES WITH THE ILLINOIS AND AMERICAN HOSPITAL ASSOCIATION. NO OTHER LOBBY ACTIVITIES WERE CONDUCTED. 31680492 1345559 741871 404540 48695 33314687 22438948 2993464 6752754 444082 60592 31680492 15594288 7189877 683374 988050 40541 22438948 15987486 1234605 525859 2112809 40853 15594288 11769155 201691 4513189 465369 31180 15987486 0.37380 0.62620 0.00000 1 0 2455305 349650 2804955 818591 15981398 3448633 13351356 19363514 8307409 11056105 5010410 1053594 3956816 31169232 BENEFICIAL INTEREST IN TRUSTS 20863317 C 20863317 DUE TO MEDICARE 904351 904351 X PART V, LINE 4: THE PERMANENT ENDOWMENT AND THE BOARD DESIGNATED QUASI-ENDOWMENT FUNDS PROVIDE INCOME TO SUPPORT CURRENT HOSPITAL OPERATIONS. ANY TERM ENDOWMENT FUND ALSO SUPPORTS CURRENT OPERATIONS THROUGH ITS SPECIFIED PURPOSE. PART X, LINE 2: KMC IS A NOT-FOR-PROFIT CORPORATIONS AND HAVE BEEN RECOGNIZED AS TAX-EXEMPT PURSUANT TO SEC. 501(C)(3) OF THE INTERNAL REVENUE CODE AND HAVE BEEN CLASSIFIED AS OTHER THAN A PRIVATE FOUNDATION. KMC FILES 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, 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 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. PRESENTLY, THERE ARE NO ONGOING INCOME TAX AUDITS OR UNRESOLVED DISPUTES WITH TAX AUTHORITIES THAT THE MEDICAL CENTER CURRENTLY FILES OR HAS FILED WITH. 1 1 X 1 X 1 X 280.000000000000 1 1 0 1 0 1479 974141 974141 0.03540 3653147 3210354 442793 0.01610 1479 4627288 3210354 1416934 0.05150 13566 201 13365 0.00050 1034413 876849 157564 0.00570 30854 30854 0.00110 1078833 877050 201783 0.00730 1479 5706121 4087404 1618717 0.05880 1581 1581 0.00010 435 435 0.00000 290 290 0.00000 45 45 0.00000 2351 2351 0.00010 1 292999 0 6712473 6726434 -13961 X 1 1 1 1 KIRBY MEDICAL CENTER 1000 MEDICAL CENTER DRIVE MONTICELLO IL 61856 WWW.KIRBYHOSPITAL.ORG 5785 X X X X KIRBY MEDICAL CENTER 1 0 0 1 X X X X X X X X X 12 1 0 1 1 X WWW.KIRBYHOSPITAL.ORG X 1 12 0 0 0 1 X 150.000000000000 280.000000000000 X X X 1 1 X X X 1 X WWW.KIRBYHOSPITAL.ORG X WWW.KIRBYHOSPITAL.ORG X X X X X X 1 0 X X X X 1 X 0 0 KIRBY MEDICAL CENTER PART V, SECTION B, LINE 5: A FOCUS GROUP COMPRISED OF COMMUNITY LEADERS AND GROUP REPRESENTATIVES MET ON JANUARY 14, 2013. THE GROUP INCLUDED A MEMBER OF THE PIATT COUNTY BOARD, THE PIATT COUNTY SHERIFF, A CHAMBER OF COMMERCE EXECUTIVE, AND OTHERS. ANOTHER FOCUS GROUP COMPRISED OF COMMUNITY LEADERS AND ELECTED OFFICIALS MET ON JANUARY 15, 2013. THE GROUP INCLUDED THE ADMINISTRATOR OF THE DEWITT/PIATT BI-COUNTY HEALTH DEPARTMENT, A SCHOOL NURSE, A PHYSICIAN, NURSING HOME ADMINISTRATORS, AND OTHERS. A THIRD FOCUS GROUP COMPRISED OF COMMUNITY LEADERS AND REPRESENTATIVES OF COMMUNITY ORGANIZATIONS MET ON JANUARY 15, 2013. THE GROUP INCLUDED THE CHAIRPERSON OF A DOMESTIC VIOLENCE CENTER, A SCHOOL SUPERINTENDENT, THE MAYOR OF MONTICELLO, A CHAMBER OF COMMERCE REPRESENTATIVE FROM BEMENT, AND OTHERS. KIRBY MEDICAL CENTER PART V, SECTION B, LINE 6B: THE COMMUNITY HEALTH NEEDS ASSESSMENT WAS CONDUCTED IN COLLABORATION WITH THE MONTICELLO CHAMBER OF COMMERCE, THE DOMESTIC VIOLENCE CENTER AND THE PIATT COUNTY NURSING HOME. KIRBY MEDICAL CENTER PART V, SECTION B, LINE 11: BECAUSE OF LIMITED RESOURCES, WE CANNOT RESPOND EFFECTIVELY TO EVERY IDENTIFIED COMMUNITY HEALTH NEED. WE HAVE CHOSEN OUR RESPONSES BASED ON ANALYSIS OF OUR RESOURCES, OUR MISSION, OUR EXISTING SPECIALTIES, COMMUNITY PRIORITIES, AND EXISTING COMMUNITY RESOURCES. WE HAVE CHOSEN TO FOCUS OUR RESOURCES ON ADDRESSING THE FOLLOWING HEALTH NEEDS:1. WELLNESS EDUCATION AND BASIC WELLNESS SERVICES FOR ALL AGES2. MENTAL HEALTH SERVICES3. SUPPORTING UNREIMBURSED CARE FOR UNDERINSURED AND UNINSURED PATIENTSWELLNESS EDUCATION: WE BUILT A WELLNESS TRAIL LOOPING AROUND THE HOSPITAL OPEN TO THE PUBLIC. MENTAL HEALTH SERVICES: WE HAVE STRONG COLLABORATIVE RELATIONSHIPS WITH MENTAL HEALTH PROVIDERS AND ACTIVELY PROVIDE RESOURCES TO THEM AND IDENTIFY AND REFER PATIENTS WHO WOULD BENEFIT FROM SUCH SERVICES. SUPPORTING UNREIMBURSED CARE: WE HAVE ENHANCED CHARITY GUIDELINES TO BENEFIT THE LESS FORTUNATE IN OUR COMMUNITY.WE ARE NOT ACTIVELY PLANNING TO RESPOND TO ANY OTHER IDENTIFIED HEALTH NEEDS. KIRBY MEDICAL CENTER PART V, SECTION B, LINE 13H: KIRBY MEDICAL CENTER HAS A "PRESUMPTIVE ELIGIBILITY" POLICY THAT REDUCES ALL CHARGES TO ZERO, A FULL WRITE-OFF OF CHARGES, IF A PATIENT IS ELIGIBLE FOR A VARIETY OF STATE-FUNDED SUPPORT PROGRAMS. UNDER THE PRESUMPTIVE ELIGIBILITY POLICY, THERE IS NO NEED FOR A PATIENT TO APPLY FOR FINANCIAL ASSISTANCE BECAUSE THE PATIENT IS ASSUMED TO BE MEDICALLY FINANCIALLY INDIGENT. KIRBY MEDICAL CENTER PART V, SECTION B, LINE 16I: FINANCIAL ASSISTANCE INFORMATION IS PROVIDED BY THE PATIENT FINANCIAL SERVICES STAFF AND IS REFERENCED IN NEWSPAPER AND BILLBOARD ADVERTISING. KIRBY MEDICAL CENTER PART V, SECTION B, LINE 20E: BEFORE AN ACCOUNT IS SENT TO COLLECTIONS, KIRBY MEDICAL CENTER CHECKS THE INDIVIDUAL'S STATUS WITH VARIOUS STATE-FUNDED SUPPORT PROGRAMS, SUCH AS FOOD STAMPS, WIC, AND MEDICAID. IF AN INDIVIDUAL QUALIFIES TO PARTICIPATE IN ANY OF THESE PROGRAMS, THEY ARE PRESUMPTIVELY DETERMINED TO QUALIFY FOR A FULL WRITE-OFF OF CHARGES UNDER THE HOSPITAL'S FINANCIAL ASSISTANCE POLICY. KIRBY MEDICAL CENTER PART V, SECTION B, LINE 22D: WE USE THE AVERAGE OF ALL COMMERCIAL INSURANCE RATES WHEN CALCULATING THE MAXIMUM AMOUNT THAT CAN BE CHARGED AS AMOUNTS GENERALLY BILLED. WE ARE CURRENTLY IN THE PROCESS OF EVALUATING WHETHER INDIVIDUALS WHO QUALIFIED FOR FINANCIAL ASSISTANCE PAID MORE THAN AMOUNTS GENERALLY BILLED. IF ANY INDIVIDUALS PAID MORE THAN AMOUNTS GENERALLY BILLED, THE EXCESS AMOUNT IS BEING REFUNDED. PART V, SECTION B, LINE 16 FINANCIAL ASSISTANCE POLICY WEBSITE AVAILABILITY KIRBY MEDICAL CENTER PART V, SECTION B, LINE 16B WEBSITE: WWW.KIRBYHOSPITAL.ORG KIRBY MEDICAL CENTER PART V, SECTION B, LINE 16C WEBSITE: WWW.KIRBYHOSPITAL.ORG 2 KIRBY MEDICAL GROUP MONTICELLO 1000 MEDICAL CENTER DRIVE MONTICELLO IL 61856 RURAL HEALTH CLINIC KIRBY MEDICAL GROUP ATWOOD 108 N MAIN STREET ATWOOD IL 61913 RURAL HEALTH CLINIC PART I, LINE 3C: ELIGIBILITY FOR FINANCIAL ASSISTANCE IS BASED ON THE INDIVIDUAL'S INCOME AND ON CASH OR INVESTMENT ASSETS HELD BY THE INDIVIDUAL. EQUITY IN THE INDIVIDUAL'S HOME AND AUTOMOBILE ARE NOT CONSIDERED IN THE ELIGIBILITY CALCULATION. KIRBY MEDICAL CENTER MAY PRESUMPTIVELY DETERMINE AN INDIVIDUAL TO BE ELIGIBLE FOR A FULL WRITE-OFF, 100% FINANCIAL ASSISTANCE, IF THEY MEET ONE OR MORE OF THE FOLLOWING CRITERIA:1. PARTICIPATION IN STATE FUNDED PRESCRIPTION PROGRAMS;2. PARTICIPATION IN THE WOMEN, INFANTS, AND CHILDREN (WIC) PROGRAM;3. FOOD STAMP ELIGIBILITY;4. SUBSIDIZED SCHOOL LUNCH PROGRAM ELIGIBILITY;5. LOW-INCOME / SUBSIDIZED HOUSING IS PROVIDED AS A VALID ADDRESS;6. PATIENT IS DECEASED WITH NO KNOWN ESTATE;7. PATIENT STATES THAT THEY ARE HOMELESS, ALTHOUGH DUE DILIGENCE EFFORTS WILL BE TAKEN TO CONFIRM;8. PATIENT IS ELIGIBLE FOR MEDICAID, BUT WAS NOT ELIGIBLE ON A PRIOR DATE OF SERVICE;9. PATIENT DOES NOT COMPLETE AN APPLICATION, BUT THERE IS ADEQUATE INFORMATION TO SUPPORT THE PATIENT'S INABILITY TO PAY; OR10. PATIENT IS MENTALLY INCAPACITATED WITH NO ONE TO REPRESENT THEM. PART I, LINE 7: THE COSTS REPORTED IN SCHEDULE H, PART I, LINE 7 USED A RATIO OF PATIENT CARE COSTS TO CHARGES AS COMPUTED IN WORKSHEET 2 OF THE INSTRUCTIONS TO SCHEDULE H. THIS METHODOLOGY WAS USED FOR ALL PATIENT SEGMENTS. PART I, LINE 7, COLUMN (F): THE BAD DEBT EXPENSE INCLUDED ON FORM 990, PART IX, LINE 25, COLUMN (A), BUT SUBTRACTED FOR PURPOSES OF CALCULATING THE PERCENTAGE IN THIS COLUMN IS $ 292,999. PART II, COMMUNITY BUILDING ACTIVITIES: ECONOMIC DEVELOPMENT INCLUDES CHAMBER OF COMMERCE. COMMUNITY SUPPORT IS DISASTER READINESS OVER AND ABOVE REQUIREMENTS. LEADERSHIP DEVELOPMENT IS SUPPORT FOR ILLINOIS PROMISE PROGRAM. COALITION BUILDING INCLUDES 911 AND CRISIS TEAM MEETINGS. PART III, LINE 2: THE BAD DEBT AMOUNT INCLUDED ON LINE 2 IS THE BAD DEBT EXPENSE THAT WAS REPORTED IN THE HOSPITAL'S AUDITED FINANCIAL STATEMENTS. SEE THE "ACCOUNTS RECEIVABLE AND CREDIT POLICIES" SECTION OF NOTE 1, ON PAGE 11, IN THE ATTACHED AUDITED FINANCIAL STATEMENTS FOR AN EXLANATION OF HOW BAD DEBT EXPENSE WAS ESTIMATED. PART III, LINE 3: THE ORGANIZATION HAS NOT IDENTIFIED A REASONABLE METHOD OF ESTIMATING THE AMOUNT OF BAD DEBT EXPENSE ATTRIBUTABLE TO PATIENTS WHO WOULD HAVE QUALIFIED FOR FINANCIAL ASSISTANCE HAD THEY COMPLETED AN APPLICATION. PART III, LINE 4: SEE THE "ACCOUNTS RECEIVABLE AND CREDIT POLICIES" SECTION OF NOTE 1, ON PAGE 11, IN THE ATTACHED AUDITED FINANCIAL STATEMENTS FOR AN EXLANATION OF HOW BAD DEBT EXPENSE WAS ESTIMATED. PART III, LINE 8: UNDER THE CURRENT MEDICARE RULES, CRITICAL ACCESS HOSPITALS RECEIVE A REIMBURSEMENT OF 101 PERCENT OF ALLOWABLE HOSPITAL COSTS AND 100 PERCENT OF CLINIC ALLOWABLE COSTS. BECAUSE OF THESE REIMBURSEMENT RATES, KIRBY MEDICAL CENTER DOES NOT HAVE A MEDICARE SHORTFALL. IN THE CURRENT YEAR, THE REIMURSEMENTS WERE SLIGHTLY LOWER DUE TO THE FEDERAL GOVERNMENT'S SEQUESTRATION IN THE SUMMER OF 2014. THE MEDICARE ALLOWABLE COSTS REPORTED IN LINE 6 WERE CALCULATED USING THE 2015 FILED MEDICARE COST REPORT. PART III, LINE 9B: ALL PATIENTS WHO FAIL TO MAKE PAYMENTS RECEIVE THREE BILLING STATEMENTS THAT INCLUDE INFORMATION ABOUT FINANCIAL ASSISTANCE. WHEN THE FOURTH BILLING STATEMENT IS SENT TO THE INDIVIDUAL, THE ACCOUNT IS SENT TO ACOLLECTION AGENT. BEFORE A PATIENT IS SENT TO A COLLECTION AGENT, WE CHECK WHETHER THEY PRESUMPTIVELY QUALIFY FOR OUR FINANCIAL ASSISTANCE PROGRAM. IF A PATIENT CONTACTS KIRBY MEDICAL CENTER, WE CHECK THEIR PRESUMPTIVEELIGIBILITY FOR OUR FINANCIAL ASSISTANCE PROGRAM AND THEIR ELIGIBILITY FOR MEDICAID. PART VI, LINE 2: KIRBY MEDICAL CENTER WORKS IN CONCERT WITH LOCAL COMMUNITY HEALTH AGENCIES TO ASSESS THE HEALTH NEEDS OF THE LOCAL COMMUNITY AND THE IMMEDIATELY SURROUNDING COUNTY. IN THE YEAR ENDED JUNE 30, 2013, A COMMUNITY HEALTH NEEDS ASSESSMENT WAS CONDUCTED THROUGH A CONSULTING ARRANGEMENT WITH THE ILLINOIS CRITICAL ACCESS HOSPITAL NETWORK. TERRY MADSEN, A COMMUNITY DEVELOPMENT SPECIALIST AND UNIVERSITY OF ILLINOIS EXTENSION EDUCATOR, MET WITH HOSPITAL EXECUTIVE STAFF TO DEFINE THE COMMUNITY, THE SCOPE OF THE PROJECT, AND SPECIAL NEEDS AND CONCERNS. AN INTERNAL WORKING GROUP, POSSIBLE LOCAL SOURCES FOR SECONDARY DATA, AND KEY EXTERNAL CONTACTS WERE IDENTIFIED, AND A TIMELINE WAS ESTABLISHED.THE COMMUNITY HEALTH NEEDS ASSESSMENT INCLUDED DISCUSSIONS WITH AREA HEALTH CARE PARTNERS, COMMUNITY LEADERS, AND REPRESENTATIVES OF THE MANY GROUPS SERVED BY THE HOSPITAL. INPUT INCLUDED THREE FOCUS GROUPS COMPRISED OF AREA HEALTH CARE PROFESSIONALS/ PARTNERS, COMMUNITY OFFICIALS, AND COMMUNITY LEADERS AND GROUPS. THE ASSESSMENT EXPLORED THE INSULAR NEEDS OF RESIDENTS LIVING IN POVERTY BY SPECIFICALLY SEEKING INPUT FROM PERSONS WITH KNOWLEDGE OF THE SPECIFIC HEALTH CONCERNS OF YOUTH AND ADULTS LIVING IN POVERTY IN THE COMMUNITY. INPUT WAS ALSO SOUGHT FROM PROFESSIONALS WITHIN THE COMMUNITY AND ALL ITS MEMBERS, INCLUDING SCHOOL OFFICIALS DEALING WITH YOUTH AND FAMILIES ON A DAILY BASIS. PART VI, LINE 3: INFORMATION REGARDING ELIGIBILITY FOR FEDERAL, STATE AND LOCAL GOVERNMENT PROGRAMS, AS WELL AS THE HOSPITAL'S FINANCIAL ASSISTANCE PROGRAM, IS PUBLISHED ON THE HOSPITAL'S WEBSITE AND IS AVAILABLE VIA LITERATURE AT THE VARIOUS ADMISSIONS AREAS IN THE HOSPITAL. INFORMATION IS ALSO PROVIDED BY THE PATIENT FINANCIAL SERVICES STAFF AND IS REFERENCED IN NEWSPAPER AND BILLBOARD ADVERTISING. PART VI, LINE 4: KIRBY MEDICAL CENTER'S COMMUNITY IS A GEOGRAPHIC AREA THAT INCLUDES ALL OR PORTIONS OF THE ZIP CODE SERVICE AREAS SURROUNDING MONTICELLO, BEMENT, ATWOOD, HAMMOND, WHITE HEATH, DELAND AND MANSFIELD IN IL. THIS GEOGRAPHIC AREA DEFINITION OF COMMUNITY IS WELL-SUITED TO KIRBY MEDICAL CENTER, A DESIGNATED CRITICAL ACCESS HOSPITAL PROVIDING BASIC, PRIMARY CARE THROUGH INPATIENT CARE, ANCILLARY SERVICES, CLINICS, AND SPECIALTY CLINICS TO RESIDENTS OF THIS UNDERSERVED RURAL AREA. THE KIRBY MEDICAL CENTER SERVICE COMMUNITY IS NEARLY CONTIGUOUS TO PIATT COUNTY. MAJOR MEDICAL CENTERS IN CHAMPAIGN-URBANA, BLOOMINGTON, AND DECATUR RECEIVE PATIENTS FROM THE SERVICE AREA. THE COMMUNITY IS MARKED BY SMALL COMMUNITIES RELYING PRIMARILY ON SMALL BUSINESSES AND INDUSTRIES, AGRICULTURE, AND SERVICE PROVIDERS FOR ITS LOCAL EMPLOYEMNT. THE COMMUNITY IS EXPERIENCING RECOVERING EMPLOYMENT NUMBERS. THE NUMBER OF CHILDREN ELIGIBLE FOR FREE OR REDUCED LUNCH IS INCREASING, BUT IS STILL BELOW THE STATEWIDE AVERAGE. WHILE MOST OF OUR COMMUNITY IS IN A SIMILAR ECONOMIC POSITION TO MANY RURAL COMMUNITIES IN ILLINOIS, THE CITY OF MONTICELLO IS GENERALLY IN A BETTER ECONOMIC POSITION. THE UNEMPLOYMENT RATE IN OUR COMMUNITY IS BELOW THE STATEWIDE AVERAGE. OVER 30% OF THE ADULTS IN OUR COMMUNITY DO NOT HAVE A HIGH SCHOOL DIPLOMA. PART VI, LINE 5: EVERY YEAR, KIRBY MEDICAL CENTER OFFERS NUMEROUS COMMUNITY-BASED SERVICES TO THOSE IN THE LOCAL AREA. COMMUNITY-BASED SERVICES PROVIDED BY KIRBY MEDICAL CENTER INCLUDE: SPORTS PHYSICAL CLINIC FOR STUDENT ATHLETES, SCHOOL-BASED HEALTH EDUCATION PROGRAMS, CPR TRAINING, SENIOR CITIZEN OUTREACH, DIABETES EDUCATION, WEEKLY FREE BLOOD PRESSURE SCREENINGS. ANNUALLY WE PROVIDE THE THOMAS DIXON MEMORIAL SCHOLARSHIPS TO AREA STUDENTS THAT HAVE AN INTEREST IN PURSUING A CAREER IN A MEDICAL FIELD. PART VI, LINE 7, REPORTS FILED WITH STATES IL 0 DEWITT-PIATT BI-COUNTY HEALTH DEPARTMENT 1020 SOUTH MARKET STREET MONTICELLO IL 61856 320196168 501(C)(3) 9000 N/A N/A GENERAL OPERATING SUPPORT 1 0 SCHOLARSHIPS 15 32720 N/A N/A PART I, LINE 2: KIRBY MEDICAL CENTER TRACKS THE USE OF SCHOLARSHIP FUNDS. SCHOLARSHIP RECIPIENTS ARE REQUIRED TO SHOW THAT THEIR FIELD OF STUDY IS HEALTH CARE AND THAT THEY MEET MINIMUM GRADE/GRADE POINT AVERAGE THRESHOLDS. X 1 1 X X X 0 0 0 0 0 0 0 1 0 STEVE TENHOUSE SECRETARY OF THE BOARD, CEO 175826 0 28116 0 5074 0 13282 0 21953 0 244251 0 0 0 NARAIN MANDHAN CHIEF MEDICAL OFFICER 251426 0 27308 0 4922 0 15600 0 22743 0 321999 0 0 0 JAMES MANINT PHYSICIAN 120472 0 58828 0 1448 0 10763 0 1891 0 193402 0 0 0 JOSHUA SAWLAW PHYSICIAN 164976 0 33750 0 267 0 12139 0 22305 0 233437 0 0 0 PART I, LINE 1A KIRBY MEDICAL CENTER PAYS PROFESSIONAL AND OTHER DUES FOR THE CEO, STEVEN TENHOUSE, INCLUDING A GOLF CLUB MEMBERSHIP. ANY DUES MUST BE APPROVED BY THE CHAIRMAN OF THE BOARD BEFORE THEY ARE PAID AS BEING IN THE BEST INTEREST OF THE MEDICAL CENTER. ANY PERSONAL USE ASSOCIATED WITH GOLF CLUB DUES IS INCLUDED IN THE TAXABLE COMPENSATION OF THE CEO. PART I, LINE 7 THE CEO, STEVEN TENHOUSE, RECEIVES A BONUS OF UP TO 15% OF BASED COMPENSATION BASED ON SUCCESSFUL FINANCIAL, OPERATIONAL, AND QUALITY INDICATORS OF THE KIRBY ORGANIZATION. THE FOLLOWING INDIVIDUALS RECEIVED A BONUS BASED ON THEIR CLINIC PATIENT PRODUCTION AND QUALITY INDICATORS SUCH AS CHART REVIEW, CHART AUDITS, AND PATIENT SATISFACTION: NARAIN DAS MANDHAN JAMES MANINT JOSHUA SAWLAW LAURIE LEE THE BONUS AMOUNTS ARE DETERMINED BASED ON A FUNCTION OF BASE SALARY AND NATIONAL SURVEYS ON PHYSICIAN COMPENSATION AND PRODUCTION FORM 990, PART VI, SECTION A, LINE 1 MEMBERS OF ALL COMMITTEES ARE APPOINTED BY THE CHAIRMAN OF THE BOARD; PROVIDED, HOWEVER, THAT A MAJORITY OF EACH COMMITTEE MEMBERSHIP SHALL BE BOARD MEMBERS. SPECIAL COMMITTEES MAY BE APPOINTED BY THE CHAIRMAN WITH CONCURRENCE OF THE BOARD FOR SUCH SPECIAL TASKS AS CIRCUMSTANCES WARRANT. A SPECIAL COMMITTEE SHALL LIMIT ITS ACTIVITIES TO THE ACCOMPLISHMENT OF THE TASK FOR WHICH IT IS APPOINTED AND SHALL HAVE NO POWER TO ACT EXCEPT SUCH AS IS SPECIFICALLY CONFERRED BY ACTION OF THE BOARD. UPON COMPLETION OF THE TASK FOR WHICH APPOINTED, SUCH SPECIAL COMMITTEE SHALL STAND DISCHARGED. BOARD COMMITTEES SHALL HOLD MEETINGS WHEN NECESSARY AND SHALL KEEP A FULL RECORD OF THEIR PROCEEDINGS, WHICH SHALL BE ENTERED IN A BOOK OF MINUTES. EACH COMMITTEE SHALL HAVE A CHARTER, APPROVED BY THE BOARD, DELINEATING ITS ORGANIZATION/MEMBERSHIP, RESPONSIBILITIES, AND MEETING FREQUENCY. FORM 990, PART VI, SECTION B, LINE 11 THE FORM 990 FINANCIAL INFORMATION IS REVIEWED BY THE INTERNAL ACCOUNTING STAFF FOR ACCURACY TO THE HOSPITAL'S AUDITED FINANCIAL STATEMENTS. OTHER FORM 990 INFORMATION IS REVIEWED BY THE CFO AND CEO. THE FINAL VERSION OF THE FORM 990 IS REVIEWED BY THE GOVERNING BOARD'S AUDIT AND COMPLIANCE COMMITTEE BEFORE THE FORM IS FILED WITH THE IRS. FORM 990, PART VI, SECTION B, LINE 12C GENERALLY THE BOARD ASSESSES THE CONFLICTS THAT EXIST WITH ITS MEMBERS AND REQUESTS THAT MEMBERS WITH THESE CONFLICTS BE EXCUSED FROM ANY DISCUSSION RELATED TO THEM. BECAUSE OF THE FAMILIARITY OF BOARD MEMBERS WITH ONE ANOTHER AND THE SIZE OF THE COMMUNITY, THE BOARD'S SELF ASSESSMENT OF CONFLICTS CAN BE MADE WITH RELATIVE EASE. AN INTERESTED PERSON INCLUDES ANY PERSON ASSOCIATED WITH KMC WHO HAS A DIRECT OR INDIRECT FINANCIAL INTEREST IN THE MATTER AT HAND. IF THE INTERESTED PERSON IS IN A SENIOR LEADERSHIP POSITION, IS A BOARD OR COMMITTEE MEMBER, THE APPLICABLE BOARD OR COMMITTEE SHALL DETERMINE WHETHER A CONFLICT OF INTEREST EXISTS. IF THE INTERESTED PERSON IS NOT A BOARD OR COMMITTEE MEMBER, THE CEO, IN CONSULTATION WITH BOARD MEMBERS AND/OR OTHER MANAGEMENT PERSONNEL, SHALL DETERMINE WHETHER A CONFLICT OF INTEREST EXISTS. IF IT IS DETERMINED THAT AN INTERESTED PERSON HAS A CONFLICT, THE INTERESTED PERSON MAY BE EXCLUDED FROM ALL DISCUSSIONS REGARDING THAT AGREEMENT, TRANSACTION, OR ARRANGEMENT. PROCEEDINGS RESULTING FROM CONFLICTS OF INTEREST ARE DOCUMENTED IN THE BOARD MINUTES. FORM 990, PART VI, SECTION B, LINE 15A THE KIRBY BOARD UTILIZES THE BI-ANNUAL IHA COMPENSATION SURVEY RESULTS TO SET AND COMPARE THE CEO'S COMPENSATION. THE LATEST REVIEW WAS DONE IN THE SPRING OF 2015. THIS PROCESS IS PRESENTED TO THE FULL BOARD FOR APPROVAL AND IS DOCUMENTED IN THE BOARD MINUTES. OTHER OFFICER'S COMPENSATION IS DETERMINED INTERNALLY BY UTILIZING BENCHMARK DATA. IT IS THEN REVIEWED BY THE CEO. FORM 990, PART VI, SECTION C, LINE 19 THE ORGANIZATION'S GOVERNING DOCUMENTS ARE AVAILABLE TO THE PUBLIC UPON REQUEST IN WRITING TO ADMINISTRATION. FORM 990, PART IX, LINE 11G ER PROFESSIONAL FEES: PROGRAM SERVICE EXPENSES 1,813,293. MANAGEMENT AND GENERAL EXPENSES 0. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 1,813,293. ADMIN PROFESSIONAL FEES: PROGRAM SERVICE EXPENSES 0. MANAGEMENT AND GENERAL EXPENSES 279,484. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 279,484. CONTRACTED SERVICES: PROGRAM SERVICE EXPENSES 3,150. MANAGEMENT AND GENERAL EXPENSES 0. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 3,150. PHYSICIAN SERVICES: PROGRAM SERVICE EXPENSES 569,589. MANAGEMENT AND GENERAL EXPENSES 258,126. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 827,715. OTHER PROFESSIONAL FEES: PROGRAM SERVICE EXPENSES 932,916. MANAGEMENT AND GENERAL EXPENSES 0. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 932,916. FORM 990, PART XI, LINE 9: INCREASE IN VALUE OF LIFE INSURANCE 30,000. CHANGE IN INTEREST IN PERPETUAL TRUST 12,391. CHANGE IN VALUE OF LIFE INTEREST 21,056. THE KIRBY FOUNDATION 1000 MEDICAL CENTER DR MONTICELLO IL 61856 061836473 SUPPORT OF KIRBY MEDICAL CENTER IL 501(C)(3) LINE 7 KIRBY MEDICAL CENTER 1 PERPETUAL TRUSTS (4) KIRBY MEDICAL CENTER IS AN INCOME BENEFICIARY OF THE TRUSTS IL N/A T 0 CHARITABLE REMAINDER TRUSTS (1) CONTRIBUTION TO KIRBY MEDICAL CENTER UPON DEATH OF THE DONOR IL N/A T 0 0 0 1 0 0 0 0 0 0 0 0 0 0 1 1 0 0 0 0 THE KIRBY FOUNDATION C 65402 CASH TRANSFERRED