2015-11-13T08:55:59-06:00 2014-12-31 410746749 CLIFTONLARSONALLEN LLP 114 E EVERETT DIXON IL 61021 990 2014-01-01 376062326 PANA COMMUNITY HOSPITAL ASSOCIATION PANA 2175622131 101 EAST NINTH STREET PANA IL 62557 TRINA CASNER CEO 2175622131 2015-11-11 1 TODD M ETHERIDGE P00233050 8152859300 2014 2016-02-25 16:41:14Z TRINA CASNER 101 EAST NINTH STREET PANA IL 62557 21254927 0 X WWW.PANAHOSPITAL.COM X 1966 IL OUR MISSION IS TO BE A LEADING PARTNER IN ASSURING COMMUNITY-BASED QUALITY HEALTH CARE. 12 12 227 90 8838 0 403163 79015 21736555 20998850 141110 117464 48997 57695 22329825 21253024 0 0 0 0 9590199 9955572 0 0 0 10574273 9995472 20164472 19951044 2165353 1301980 24647665 27148686 3192490 4415871 21455175 22732815 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 14037751 0 20998850 TO PROVIDE HEALTH CARE SERVICES TO THE CITIZENS OF PANA, ILLINOIS AND THE SURROUNDING AREA. THESE SERVICES INCLUDE NURSING, EMERGENCY AND ANCILLARY SERVICES FOR 889 INPATIENT DAYS, 22,039 OUTPATIENT ADMISSSIONS, 8,422 EMERGENCY VISITS AND 333 OUTPATIENT SURGICAL PATIENTS. 14037751 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 15 0 1 227 1 1 1 0 0 0 0 0 0 0 0 0 X 12 12 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 JOYCE MORGAN CHAIRMAN 1.50 0.10 X X 0 0 0 JIM RANDOLPH VICE CHAIRMAN 1.50 0.00 X X 0 0 0 JOYCE THRONEBURG SECRETARY & DIRECTOR 1.50 0.00 X X 0 0 0 MARY ANN RHOADES DIRECTOR & SECRETARY 1.50 0.00 X X 0 0 0 JOHN GARDNER TREASURER 1.50 0.00 X X 0 0 0 DJ ASUNCION MD DIRECTOR 1.50 0.00 X 0 0 0 MATTHEW BEAVERS DIRECTOR 1.50 0.00 X 0 0 0 CAROL SCHRAMM DIRECTOR 1.50 0.00 X 0 0 0 DR DAVID LETT DIRECTOR 1.50 0.00 X 0 0 0 CAROLYN MARLEY DIRECTOR 1.50 0.00 X 0 0 0 RICK MILES DIRECTOR 1.50 0.00 X 0 0 0 RICH SCHMITZ DIRECTOR 1.50 0.00 X 0 0 0 KATRINA J CASNER PRESIDENT & CEO 40.00 0.00 X 164284 0 23020 VICKI COEN CCO/CNE 40.00 0.00 X 113366 0 17636 JAMES MOON CFO 40.00 0.00 X 103058 0 12506 DIANNE BAILEY CIO 40.00 0.00 X 73933 0 12487 DR TERRY CUNNINGTON PHYSICIAN 40.00 0.00 X 316835 0 22660 DR MARLON MUNESES PHYSICIAN 40.00 1.50 X 207965 0 22660 CATHERINE TEODORA PHYSICIAN 40.00 0.00 X 199316 0 13960 MICHELLE FOREMAN PHARMACIST 40.00 0.00 X 115859 0 9993 DR STEVEN WEBER PT SURGEON 16.00 0.00 X 141437 0 0 1436053 0 134922 8 0 1 0 MIDWEST EMERGENCY SERVICE INC 320 E HIGHWAY 50 OFALLON IL 62269 EMERGENCY PHYSICIANS 1291704 MCKESSON TECHNOLOGIES INC PO BOX 98347 CHICAGO IL 60693 HARD/SOFT SUPPORT/MAINT 419439 CONSOCIATE-DANSIG 151 E DECATUR ST DECATUR IL 62525 THIRD PARTY ADMINISTRATION - HEALTH INSU 203713 GE HEALTHCARE PO BOX 96483 CHICAGO IL 60693 EQUIPMENT MAINTENANCE 149914 PRECISE SPECIALTIES CORP 514 S MAIN HILLSBORO IL 62049 ULTRASOUND TECH 109484 5 8402 59273 11340 79015 PATIENT CARE SERVICES 621110 20091775 20091775 ELECTRONIC HEALTH RECORDS REVENUE 621110 680538 680538 OTHER OPERATING REVENUE 621110 204140 204140 INVESTMENT INCOME FROM SUBSIDIARY 621110 22397 22397 20998850 115561 115561 7800 0 7800 7800 7800 3806 1903 1903 1903 1903 CAFETERIA & VENDING 722514 41057 41057 CATERING 722320 8838 8838 49895 21253024 20998850 8838 166321 1313859 1005757 308102 6825903 5225219 1600684 78647 60204 18443 1352893 1035637 317256 384270 294158 90112 147 147 64389 64389 1904604 1904604 58709 58709 136718 136718 20259 20259 130082 130082 41995 41995 68677 68677 1299700 1299700 103147 103147 BAD DEBT EXPENSE 2179007 2179007 MEDICAL SUPPLIES 1888323 1888323 REPAIRS & MAINTENANCE 686420 686420 MISCELLANEOUS 528249 528249 885046 444842 440204 19951044 14037751 5913293 0 9762589 11471031 3091042 2827146 2783225 3773953 1850 1850 295614 349762 147801 199619 18867230 11939380 7358329 6927850 886693 1317617 15632 39779 304890 240079 24647665 27148686 1466853 1646167 1308173 846465 417464 1923239 3192490 4415871 X 21455175 22732815 21455175 22732815 24647665 27148686 1301980 -24340 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 9241 9241 0 PART II-B, LINE 1F GRANTS TO OTHER ORGANIZATIONS FOR LOBBYING PURPOSES WE PARTICIPATE INDIRECTLY WITH LOBBYING ACTIVITIES THROUGH OUR MEMBERSHIPS IN THE ILLINOIS HOSPITAL ASSOCIATION AND THE AMERICAN HOSPITAL ASSOCIATION. IT IS ESTIMATED THAT OUR LOBBYING EXPENDITURES ARE 38% AND 22.80%, RESPECTIVELY, OF OUR MEMBERSHIP DUES AS PROVIDED BY THE IHA. 1284973 3162 1288135 1283522 1451 1284973 1282115 1407 1283522 1347734 -65619 1282115 1470956 -123222 1347734 1.00000 0.00000 0.00000 0 0 11496 11496 7118938 4305081 2813857 500149 206225 293924 11014482 7428074 3586408 222165 222165 6927850 THIRD PARTY PAYOR SETTLEMENTS 1923239 1923239 X PART V, LINE 4: PANA HOSPITAL INTENDS TO USE 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, 2014 THERE WAS NO UNRECOGNIZED TAX BENEFITS IDENTIFIED OR RECORDED. AT DECEMBER 31, 2014, THE 2014, 2013, 2012, AND 2011 TAX RETURN YEARS ARE OPEN FOR EXAMINATION BY TAXING AUTHORITIES. 1 1 X 1 X 1 X 1 1 1 0 0 686741 0 686741 0.03440 3795338 3195484 599854 0.03010 0 0 4482079 3195484 1286595 0.06450 32078 100 31978 0.00160 75658 0 75658 0.00380 0 0 0 0 0 0 107736 100 107636 0.00540 4589815 3195584 1394231 0.06990 1 2179007 1024361 7508641 8143535 -634894 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 150.000000000000 250.000000000000 X 1 1 X X X X 1 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 INTERESTEDPARTIES 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 2014, 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. PREPARED TO PARTICIPATE IN STAT STROKE INITIATIVES AND BECAME A STROKE READY HOSPITAL.4. IMPLEMENTED EXPANDED 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 A COUCH TO 5K PROGRAM 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 FOUR 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: INDIVIDUALS ELIGIBILITY FOR FINANCIAL ASSISTANCEALL PATIENTS QUALIFYING FOR THE FACILITY'S FINANCIAL ASSISTANCE POLICY ARE BILLED A MAXIMUM OF 50% OF GROSS CHARGES. THIS RATE IS SIGNIFICANTLY BELOW OUR LOWEST NEGOTIATED COMMERCIAL INSURANCE RATE. PART V, SECTION B, LINE 5 THE IMPLEMENTATION STRATEGY IS INCLUDED IN THE CHNA POSTED ON THE WEBSITE. PART V, SECTION B, LINE 16 FINANCIAL ASSISTANCE POLICY WEBSITE AVAILABILITY PANA COMMUNITY HOSPITAL PART V, SECTION B, LINE 16B WEBSITE: HTTP://WWW.PANAHOSPITAL.COM/PATIENTSANDVISITORS/FINANCIALAPPLICATION_REVISE 5 COMMUNITY MEDICAL CLINIC OF PANA 101 EAST 9TH STREET PANA IL 62557 PHYSICIAN SATELLITE OFFICE QUAD COUNTY HOME HEALTH & HOSPICE 1 HUBER STREET PANA IL 62557 HOME HEALTH & HOSPICE AGENCY COMMUNITY MEDICAL CLINIC OF ASSUMPTION 118 N WALNUT STREET ASSUMPTION IL 62510 PHYSICIAN SATELLITE OFFICE COMMUNITY MEDICAL CLINIC OF RAMSEY 715 S SUPERIOR RAMSEY IL 62080 PHYSICIAN SATELLITE OFFICE COMMUNITY MEDICAL CLINIC OF NOKOMIS 120 CEDAR STREET NOKOMIS IL 62075 PHYSICIAN SATELLITE OFFICE 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 $2,179,007 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 REDUCED 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 47% 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 13 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 12/31/14 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 19.5% MEDICAID AND 7.4% UNINSURED. OUR ORGANIZATION PROVIDES SERVICES TO FEDERALLY-DESIGNATED MEDICALLY UNDERSERVED AREAS. PART VI, LINE 5: 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 PART VI, LINE 7 STATE FILING OF COMMUNITY BENEFIT REPORT. NOT APPLICABLE X X X X X 0 0 0 1 0 0 0 0 0 KATRINA J CASNER PRESIDENT & CEO 153821 0 10000 0 463 0 17500 0 5520 0 187304 0 0 0 DR TERRY CUNNINGTON PHYSICIAN 152020 0 164516 0 299 0 17500 0 5160 0 339495 0 0 0 DR MARLON MUNESES PHYSICIAN 143091 0 63397 0 1477 0 17500 0 5160 0 230625 0 0 0 CATHERINE TEODORA PHYSICIAN 151009 0 48050 0 257 0 12220 0 1740 0 213276 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. CUNNINGTON 26898 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 JOHN GARDNER AND JIM RANDOLPH HAVE A BUSINESS RELATIONSHIP. JOYCE MORGAN, JIM RANDOLPH, JOYCE THRONEBURG, MARY ANN RHOADES, AND JOHN GARDNER 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. PANA COMMUNITY HOSPITAL FOUNDATION 101 EAST 9TH STREET PANA IL 62557 371293506 FUNDRAISING IL 501(C)(3) 11-I PANA COMMUNITY HOSPITAL 1 QUAD COUNTY HOME MEDICAL SUPPLIES & EQUIPMENT 1 HUBER STREET PANA IL 62557 371198049 EQUIPMENT RETAILER IL PANA COMMUNITY HOSPITAL C 152167 214664 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 8402 CASH TRANSFER