2014-05-12T22:48:59-07:00 2013-09-30 990 2012-10-01 420710268 KEOKUK AREA HOSPITAL KEOK 3195247150 1600 Morgan Street Keokuk IA 52632 Joseph Whiting 3195247150 2014-05-12 2012 2015-11-30 17:44:51Z Joseph Whiting 1600 Morgan Street Keokuk IA 52632 22219243 0 X www.keokukhealthsystems.org X 1975 IA Improving Community Health and ensuring access to quality healthcare services regardless of ability to pay. 11 10 391 200 0 0 40056 64071 23853868 19759572 -43500 110599 1000324 2285001 24850748 22219243 0 0 0 0 14783615 12374704 0 0 0 10961151 10672584 25744766 23047288 -894018 -828045 15808372 14267387 12373410 12432783 3434962 1834604 Improving Community Health and ensuring access to quality healthcare services regardless of ability to pay. 0 0 22293086 0 22219243 Keokuk Area Hospital is a private 501 c 3 tax exempt acute care hospital with a mission of ensuring quality healthcare services are available to all residents of the community regardless of ability to pay. The hospital provides emergency care, inpatient and outpatient services to the Tri-State region. Approximately 65% of gross patient service revenue is derived under federal and state third-party reimbursement programs and another 7% is private pay. According to the FY 2013 Cost Report prepared by the hospital's external auditors, KAH is underfunded by Medicare and Medicaid by approximately $3,000,000. In order to close that deficit, the hospital is undergoing a turnaround journey to create a financially stable organization that meets the needs of the community. This journey includes expense reduction initiatives as well as revenue growth opportunities. Surgery has been identified as a center of excellence evident by the recruitment of a fulltime general surgeon and fulltime orthopedic surgeon. Primary care is also a main focus evident by the recruitment of three new mid-level providers who joined the hospital's primary care physician group, TSMG. 0 0 0 22293086 1 0 0 0 0 0 0 0 0 0 1 0 0 0 1 1 1 0 0 0 0 0 0 0 0 0 1 1 0 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 1 0 0 0 1 37 0 1 391 1 0 0 0 0 0 0 X 11 10 0 1 0 0 1 1 1 1 1 0 0 1 1 1 1 1 1 1 1 0 X X Keokuk Area Hospital ATTN Accounting 3195247150 1600 Morgan Street Keokuk IA 52632 Greg Miller 0 1 X 0 0 0 Walt Stephens 0 1 X X 0 0 0 Mike Klauser 0 1 X 0 0 0 Kiran Khanolkar MD 0 40 X 0 226062 15046 Kent Nixon 0 1 X X 0 0 0 Mike Maher 0 1 X 0 0 0 Wendy Swank 0 1 X X 0 0 0 Tom Marion 0 1 X 0 0 0 Ron Scott 0 1 X 0 0 0 David Waddell MD 0 1 X 0 0 0 Dick Logsdon 0 1 X 0 0 0 Wally Winkler 40 0 X 38250 0 2292 Susan Pankey 40 0 X 20940 0 1975 Elizabeth Gregory 40 0 X 122839 0 14727 Jagadamba Kantanmeni 40 0 X 300692 0 9452 482721 226062 43492 2 0 1 0 PT Services Rehabilitation Inc Box 833 Tiffin OH 44883 Physical Therapy 144265 Blessing Physician Services Box 5007 Quincy IL 61232 Emergency Room Physician Group 1634922 Fitch Healthcare 903 Commerce Drive Suite 160 Oak Brook IL 60523 Management Services 437634 Shared Medical Services 209 Limestone Cottage Grove WI 53527 MRI Services 303015 RPH On The Go PO Box 1024640 Atlanta GA 30368 Pharmacy Services 108508 5 0 0 0 0 40928 23143 0 64071 Hospital Services 622000 19759572 19759572 0 0 0 0 0 0 19759572 110599 110599 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 Cafeteria/laundry/rent/misc 622000 473191 473191 0 0 Weight Loss Program 622000 99474 99474 0 0 EHR Incentive Program 622000 1712336 1712336 0 0 0 0 0 0 2285001 22219243 22155172 0 0 X 59190 0 59190 9817148 9817148 0 8144 8095 49 1785539 1774838 10701 704683 700460 4223 568798 0 568798 24003 0 24003 55212 0 55212 2922206 2890180 32026 17951 17951 114941 114941 0 480270 480270 0 49207 49207 0 393422 393422 0 1265340 1265340 0 116208 116208 0 Supplies (Medical & Office) 3173506 3173506 0 0 Repairs and Minor Equipment 646679 646679 0 0 Recruitment & Physician Support 322540 322540 0 0 Miscellaneous 522301 522301 0 0 23047288 22293086 754202 0 553965 1115769 1468715 1512593 4957833 3878350 307973 173368 991376 990032 152478 92057 29363449 23280595 6499605 6082854 876427 422364 15808372 14267387 6517545 7735484 3305608 2910968 2550257 1786331 12373410 12432783 X 3409735 1801321 25227 33283 0 0 3434962 1834604 15808372 14267387 X -828045 0 0 0 0 -772313 X 0 1 1 0 X 0 438675 438675 0 505333 457268 48065 0 17041957 13537069 3504888 0 7239570 6358337 881233 0 4137914 2927921 1209993 6082854 0 Capital Lease Obligations 1155628 Notes Payable 608510 Line of Credit 22193 1786331 X 22044573 0 0 0 0 0 22044573 0 174670 174670 22219243 23047288 0 0 0 0 0 23047288 0 0 0 23047288 SchD_P10_S00_L02 Schedule D, Part X, Line 2 Footnote for uncertain tax positions under fin 48: 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 uncertain tax benefits in the accompanying balance sheets along with any associated interest and penalties that would be payable to the taxing authorities upon examination. As of September 30, 2013 and 2012, there were no uncertain tax benefits related to uncertain tax positions identified and recorded as a liability. SchD_P11_S00_L04b Schedule D, Part XI, Line 4b Total contains $64,071 of unrestricted donations and grant income and $110,599 of a gain in sale of investments, change in unrealized gains on trading investments and income on investments limited as to use. 1 1 1 X 1 X 1 1 1 0 1 0 411505 411505 770250 770250 87946 87946 0 0 1269701 0 1269701 0 43455 43455 382954 382954 755964 755964 0 0 0 0 0 0 1182373 0 1182373 0 0 0 2452074 0 2452074 0 600 600 2620 2620 3410 3410 0 0 2761 2761 13693 13693 800 800 8509 8509 0 0 0 0 32393 0 32393 0 1 2369233 1097757 9245585 11478880 -2233295 X 1 1 1 1 Keokuk Area Hospital

1600 Morgan Street Keokuk IA 52632

www.keokukhealthsystems.org X X X Keokuk Area Hospital 1 1 X X X X X X X X 13 1 1 1 X X X X X X X 0 0 1 1 100 1 400 1 X X X X 1 1 X 1 X 0 X X X 1 X 0 0 SchH_P01_S00_L07 Schedule H, Part I, Line 7 Ratio of cost to charges is applied to gross charges. SchH_P01_S00_L072f Schedule H, Part I, Line 7, Column f 0 (zero) SchH_P01_S00_L07g Schedule H, Part I, Line 7g All of the $755,964 is attributable to the hospital providing subsidized services to patients of Tri-State Medical Group, a related organization which is affiliated with the Community Health Centers of Southeastern Iowa (CHC), and Keokuk Area Hospital provides the subsidy to ensure CHC patients have access to primary care services. SchH_P02_S00_L00 Schedule H, Part II Involving hospital staff in outside organizations and working with them to provide health education and assessment provides a forum to keep the hospital aware of the community needs while building coalitions to address those needs. SchH_P03_S0A_L04 Schedule H, Part III, Section A, Line 4 Patient receivables are written off as bad debt when deemed uncollectable. Recoveries of receivables previously written off are recorded as a reduction of bad debt expense when received (page 10). SchH_P03_S0B_L08 Schedule H, Part III, Section B, Line 8 Medicare pays Keokuk Area Hospital substantially less than reasonable cost which represents uncompensated care just like provided to the indigent patients who cannot pay for their services. The cost of this care is calculated per the Medicare Cost Report methodology. SchH_P03_S0C_L09b Schedule H, Part III, Section C, Line 9b If information is available to confirm eligibility for charity care, collection activity is not pursued. SchH_P05_S0B_L04 Schedule H, Part V, Section B, Line 4 Keokuk Area Hospital participated in the Community Wide Needs Assessment with Fort Madison Community Hospital. SchH_P05_S0B_L07 Schedule H, Part V, Section B, Line 7 SOME OF THE HEALTH ISSUES IDENTIFIED THROUGH THE ASSESSMENT WERE ALREADY BEING ADDRESSED IN THE SERVICE AREA BY THE LEE COUNTY HEALTH DEPARTMENT AND FORT MADISON COMMUNITY HOSPITAL. ADDITIONALLY, SOME COMMUNITY NEEDS SUCH AS INCREASED NUTRITION & FITNESS, IMPROVED BICYCLE/WALKING TRAILS AND IMPROVED HEALTH DEPARTMENT FACILITIES WERE BEYOND THE SCOPE, EXPERTISE AND RESOURCES AVAILABE AT KEOKUK AREA HOSPTIAL. SchH_P05_S0B_L16 Schedule H, Part V, Section B, Line 16 PATIENTS FOLLOW THE HOSPTIAL BILLING AND COLLECTIONS POLICY UNLESS THEY APPLY AND QUALIFY FOR FINANCIAL ASSISTANCE. THE FINANCIAL ASSISTANCE POLICY REQUIRES PATIENTS TO AGREE AND ADHERE TO A PAYMENT SCHEUDULE TO OBTAIN THE COMPLETE DISCOUNT THEY QUALIFY FOR. SchH_P05_S0B_L20 Schedule H, Part V, Section B, Line 20 THE HOSPTIAL USES ITS CHARGE MASTER RATES LESS A 40% DISCOUNT. SchH_P06_S00_L02 Schedule H, Part VI, Line 2 KEOKUK AREA HOSPTIAL PARTICIPATES WITH MANY HEALTH RELATED ORGANZIATIONS TO ASSESS HEALTHCARE NEEDS IN LEE COUNTY, IOWA AND SHARES THE RESULTS IN A WRITTEN COMMUNITY ASSESSMENT REPORT. SchH_P06_S00_L03 Schedule H, Part VI, Line 3 Bills and statements include a written notice to patients that financial assistance is available and encourages patients to either call or visit the Business Office is they are interested. SchH_P06_S00_L04 Schedule H, Part VI, Line 4 KEOKUK AREA HOSPITAL SERVES THE POPULATIONS OF SOUTHERN LEE COUNTY IN IOWA, WESTERN HANCOCK COUNTY IN ILLINOIS, AND NORTHERN CLARK COUNTY IN MISSOURI. MORE THAN 23% OF THE KEOKUK POPULATION IS BELOW THE FEDERAL POVERTY LEVEL. 75% OF ALL PATIENTS ARE MEDICARE, MEDICAID OR INDIGENT ALL OF WHICH REIMBURSE THE HOSPITAL LESS THAN COST AND 25% OF THE REMAINING INSURED POPULATION DOES NOT MAKE UP FO THESE COST SHORTFALLS. SchH_P06_S00_L05 Schedule H, Part VI, Line 5 KEOKUK AREA HOSPITAL HAS AN ALL VOLUNTEER BOARD OF DIRECTORS MADE UP OF LOCAL COMMUNITY MEMBERS WHO SERVE WITHOUT COMPENSATION. THE MEDCIAL STAFF IS OPEN TO ALL INTERESTED MEDICAL PRACTITIONERS WHO ARE APPROPRAITELY CREDENTIALED. ALL FUNDS GENERATED BY THE HOSPTIAL ARE UTILIZED FOR PATIENT RELATED SERVICES AND TO ENSURE THAT ALL PATIENTS IN OUR MARKET HAVE ACCESS TO QUALITY HEALTHCARE SERVICES REGARDLESS OF THEIR ABILITY TO PAY. SchH_P06_S00_L06 Schedule H, Part VI, Line 6 KEOKUK AREA HOSPITAL PROVIDES INPATIENT AND OUTPATIENT HEALTHCARE SERVICES. TRI-STATE MEDICAL GROUP PROVIDES MEDICAL OFFICES AND ACCESS TO PRIMARY CARE FOR COMMUNITY HEALTH CENTER PATIENTS. KEOKUK AREA MEDICAL EQUIPMENT AND SUPPLY PROVIDES DME AND PHARMACY SERVICES IN CLOSE PROXIMITY TO BOTH KAH AND TSMG. ALL SERVICES ARE COORDINATED TO HELP REDUCE LENGTH OF STAY IN THE HOSPTIAL AND ENSURE CONTINUITY OF CARE FROM ONE LEVEL TO ANOTHER. SchH_P06_S00_L07 Schedule H, Part VI, Line 7 IOWA X X X X 0 0 0 0 0 0 0 0 0 Kiran Khanolkar MD 0 140256 0 85806 0 0 0 0 0 24452 0 250514 0 0 SchJ_P01_S00_L03 Schedule J, Part I, Line 3 All highly compensated employees are reviewed with the Board of Directors using benchmark data from numerous sources including the Iowa Hospital Association salary surveys, MGMA physician compensation and similar hospital 990s. F990_P06_S0A_L03 Form 990, Part VI, Section A, Line 3 The organization delegated control over management duties to Fitch Healthcare. F990_P06_S0A_L06 Form 990, Part VI, Section A, Line 6 The Chief of Staff and KAH Foundation President are automatically on the Board based on their elected positions. F990_P06_S0A_L07a Form 990, Part VI, Section A, Line 7a Keokuk Health Systems Inc 42-1237361 F990_P06_S0A_L07b Form 990, Part VI, Section A, Line 7b Keokuk Health Systems Inc 42-1237361 is the parent company of Keokuk Area Hospital and sole member. F990_P06_S0B_L11b Form 990, Part VI, Section B, Line 11b A draft of the 990 is distributed to the Board of Directors prior to filing. F990_P06_S0B_L12c Form 990, Part VI, Section B, Line 12c All employees, officers, and directors are required to disclose any conflicts of interest at the point they arise and sign a conflict of interest statement annually attesting that they have disclosed any conflicts of interest. F990_P06_S0B_L15 Form 990, Part VI, Section B, Line 15 The Board of Directors Executive Committee review and establishes all compensation arrangements with highly paid employees utilizing benchmark data from various sources including the Iowa Hospital Association wage and salary surveys and physician compensation surveys. F990_P06_S0C_L19 Form 990, Part VI, Section C, Line 19 Organizational documents are available upon request and the 990 is published on www.guidestar.com. F990_P09_S00_L11g Form 990, Part IX, Line 11g Amount represents contracted services in the ancillary departments as well as the emergency room. F990_P11_S00_L09 Form 990, Part XI, Line 9 Transfer of equity to TSMG to subsidize medical care (-$410,000); allowance recorded against affiliate advances (-$1,025,000); net asset transfer from Keokuk Health Systems for dissolution of ODS ($554,597); contributions for property and equipment and minor equipment ($108,090). Keokuk Health Systems Inc 1600 Morgan Street Keokuk IA 52632 421237361 Parent Company of Keokuk Area Hospital IA 501 c 3 exempt non profit N/A Tri State Medical Group 1600 Morgan Street Keokuk IA 52632 421435525 Medical Offices IA 501 c 3 exempt non profit Keokuk Health Systems Inc Keokuk Area Hospital Foundation 1600 Morgan Street Keokuk IA 52632 411202608 Fundraising IA 501 c 3 exempt non profit Keokuk Health Systems Inc Keokuk Area Hospital Organized Delivery System 1600 Morgan Street Keokuk IA 52632 421474799 Non Profit Indemnity Health Insurance IA Keokuk Health Systems Inc C 1 Keokuk Area Medical Equipment Inc 1600 Morgan Street Keokuk IA 52632 421237312 Durable Medical Equipment and Pharmacy Sales IA Keokuk Health Systems Inc C 1 0 1 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 Tri State Medical Group b 755964 Keokuk Area Hospital subsidizes care of patients seen at TSMG through an affiliation agreement with the Community Health Centers of Southeastern Iowa. This subsidy basically represents the cost of expenditures utilized by TSMG to care for these patients that were not reimbursed by third party programs or individuals. Keokuk Health Systems Inc c 554597 Keokuk Area Hospital provided equity to the Keokuk Area Hospital Organized Delivery System through Keokuk Health Systems. The KAH ODS has been non operational for the past three years and this amount involved is a return of equity to KAH through KHS. The longtime CFO and Controller left in 2013 and no one remaining in the organization had participated in the completion of the 990s in prior years. An extension was filed for Keokuk Health Systems by February 15, 2014 under the assumption that the Health Systems return would cover all entities. However, in April of 2014 it was discovered that each entity files a separate 990 and therefore an extension until May 15, 2014 was immediately filed. Please allow the three month extension without a fine as the organization does not have the financial resources available to pay the penalties.