2014-03-28T15:12:52-05:00 2012-06-30 381357951 PLANTE & MORAN PLLC PO BOX 307 SOUTHFIELD MI 480370307 990 2011-07-01 381984289 MERCY MEMORIAL HOSPITAL CORPORATION MERC 7342404520 718 N MACOMB STREET MONROE MI 48162 THOMAS W SCHILLING 7342404520 2014-03-24 1 BETSY ARETZ P00996282 2483522500 2011 2016-03-07 17:11:31Z X THOMAS W SCHILLING 718 N MACOMB STREET MONROE MI 48162 208029042 0 X WWW.MERCYMEMORIAL.ORG X 1971 MI AS AN INDEPENDENT HEALTH CARE SYSTEM, WE PROVIDE HIGH QUALITY, COMPREHENSIVE SERVICES TO THE PEOPLE AND COMMUNITIES WE SERVE. 16 12 1882 789 5307144 -759971 1177458 1169957 169563395 171880471 3027515 3161149 -14714 -27991 173753654 176183586 4000 41300 0 0 82143925 86927030 0 0 133777 81430798 81826404 163578723 168794734 10174931 7388852 188002099 205039704 84143995 113555727 103858104 91483977 X AS AN INDEPENDENT HEALTH CARE SYSTEM, WE PROVIDE HIGH QUALITY, COMPREHENSIVE SERVICES TO THE PEOPLE AND COMMUNITIES WE SERVE. 0 0 142435639 2500 166557943 HOSPITAL BASED HEALTHCARE SERVICES -A MULTITUDE OF HEALTH CARE SERVICES WERE PROVIDED BY THE HOSPITAL TO THE PEOPLE OF MONROE COUNTY AND SURROUNDING AREAS. THESE PROGRAM SERVICES INCLUDED VARIOUS ASPECTS OF INPATIENT, OUTPATIENT, AND EMERGENCY CARE. THIS CARE WAS PROVIDED IN A MANNER THAT RESPECTED THE VALUE, PRIVACY, AND DIGNITY OF INDIVIDUAL PATIENTS AND THEIR FAMILIES. FURTHER, CONTINUOUS EFFORTS WERE MADE TO IDENTIFY AND IMPLEMENT NEW AND BETTER WAYS TO MEET THE PHYSICAL, SPIRITUAL, EMOTIONAL, AND SOCIAL NEEDS OF PATIENTS. DURING THE YEAR THE HOSPITAL PROVIDED:[A] 40,427 DAYS OF ACUTE CARE FOR ADULT AND PEDIATRIC INPATIENTS,[B] 1,471 DAYS OF ACUTE CARE FOR NEWBORNS,[C] EMERGENCY CARE FOR 48,658 OUTPATIENTS, AND[D] 1,365,170 OUTPATIENT SERVICE REGISTRATIONS. 10566 6000 109048 HOSPITAL GUILD - 129 MEMBERS RENDERED SERVICES TO THE HOSPITAL AND ITS PATIENTS BY OPERATING A GIFT SHOP, KNITTING CAPS FOR NEWBORNS, MAKING CRADLE PICTURES AVAILABLE, ASSISTING IN THE INTERNAL TRANSPORTATION OF PATIENTS AND ASSISTING IN OTHER PATIENT RELATED ACTIVITIES THROUGHOUT THE HOSPITAL. THE GIFT SHOP AND CRADLE PICTURES ARE PRIMARILY FOR THE CONVENIENCE OF EMPLOYEES, PATIENTS AND VISITORS. THE GUILD ALSO OFFERS SOME NURSING SCHOLARSHIPS. 42611 HOSPITAL MEDICAL STAFF - 332 MEMBERS [A] DIRECTED AND REVIEWED HOSPITAL BASED HEALTHCARE SERVICES AND [B] PARTICIPATED IN PERIODIC MEETINGS CONCERNING THE DELIVERY OF HEALTHCARE SERVICES, INCLUDING MEDICAL EDUCATION. 142488816 1 1 0 1 0 0 0 0 0 1 1 0 0 0 0 1 0 1 0 0 1 0 0 0 1 1 1 1 1 1 1 1 0 0 0 0 0 0 0 0 1 1 1 0 0 0 0 1 1 1 0 0 1 221 1 1 1882 1 1 1 1 CJ 0 0 0 1 1 0 0 0 0 X 16 12 1 0 0 0 0 0 0 1 1 0 0 1 1 1 1 1 1 1 1 0 X THOMAS W SCHILLING 7342404520 718 N MACOMB STREET MONROE MI 48162 X BELLINO KAREN M VUICH 1.00 X 0 0 0 BHURGRI MD AAMER 4.00 X 49278 0 45929 BRAUNLICH PAUL E 1.00 X 0 0 0 CALENDAR KAREN 1.00 X 0 0 0 CALENDAR KENYON S 1.00 X 0 0 0 CARTER KURT W 1.00 X 0 0 0 CHARBONEAU DO MICHAEL 40.00 X 363926 0 12543 DARROW KURT L 1.00 X 0 0 0 FRANZEN VICKI L 1.00 X X 0 0 0 KABIR MD ABDUL 4.00 X 35394 0 531 MCNAMEE MD KENNETH J 1.00 X 0 0 0 PETERS RUTH ANN 1.00 X 0 0 0 PHILLIPS ANNETTE S 40.00 X X 434409 0 29668 ROBBINS BASIL D 1.00 X X 0 0 0 RYAN SISTER JANET 1.00 X X 0 0 0 SABO CPA DEBORAH A 1.00 X X 0 0 0 SPENCER EDD DONALD A 1.00 X X 0 0 0 WALSH ARLENE R 1.00 X 0 0 0 WILBURN WALTER 1.00 X 0 0 0 WORRELL MARK 1.00 X 0 0 0 KUBISKE DAVID 1.00 X 0 0 0 KULISH BARTON 1.00 X 0 0 0 AMIN JATIN 1.00 X 0 0 0 JAVAID MUHAMMAD 1.00 X 0 0 0 SCHILLING THOMAS W 40.00 X 311655 0 30325 PROCHNOW TODD 40.00 X 493606 0 30829 OLENCHAK DANIEL 40.00 X 412292 0 8863 RAMASWAMI GANESH 40.00 X 273516 0 28551 MOHAMED ABDULLAHI 40.00 X 218863 0 22611 KIBBLE JOHN 40.00 X 218834 0 14579 2811773 0 224429 60 0 1 0 ECLIPSYS 3 RAVINA DRIVE ATLANTA GA 30346 SOFTWARE SERVICES 2976623 GE HEALTHCARE 101 CARNEGIE CENTER PRINCETON NJ 08540 EQUIPMENT SERVICES 1169064 MICHIGAN CO-TENANCY LABS DEPT CH 14271 PALATINE IL 60055 LABORATORY SERVICES 1028551 PHILIPS MEDICAL SYSTEM 5550 PRAIRIE STONE PKWY HOFFMAN ESTATES IL 60192 EQUIPMENT SERVICES 798287 AUCH GEORGE W CO 735 S PADDOCK PONTIAC MI 48341 CONSTRUCTION MGT. 627891 53 40402 156340 45012 928203 91261 1169957 HOSPITAL BASED HEALTHC 621990 166557943 166557943 NON-PATIENT PHARMACY 446110 3891646 3891646 NON-PATIENT REF. LAB 621500 993895 993895 DME 446110 421603 421603 HOSPITAL GUILD 621990 15384 15384 171880471 1483792 1483792 1109106 1207855 -98749 -98749 -98749 31916164 14935 30194762 58980 1721402 -44045 1677357 1677357 144367 156340 181482 -37115 -37115 52467 38258 14209 14209 257783 164119 93664 93664 176183586 166666991 5307144 3039494 32800 32800 8500 8500 1528159 631737 896422 68816807 58360506 10367606 88695 244348 217383 26638 327 11237872 9456581 1767073 14218 5099844 4279592 813818 6434 1311780 1311780 306296 306296 227461 227461 19811 19811 314444 314444 17310367 11229047 6071792 9528 353344 13251 340093 1900662 1138167 753603 8892 948030 948030 2750481 2536427 214054 568408 428292 140116 238052 50293 187759 2527082 2526592 490 9229545 8516397 713148 2294375 1923272 371103 HOSPITAL SUPPLIES 26859413 26859413 PROVISION FOR BAD DEBTS 8928499 8928499 QUALITY ASSURANCE ASSES 4568031 4568031 DIETARY SUPPLIES 779469 779469 390854 4567 381094 5193 168794734 142488816 26172141 133777 3036485 118553 17543562 16822030 21344529 35109790 2728503 2598929 1982485 2071720 191320805 109054355 79573260 82266450 58853299 62924175 226230 320601 2713746 2807456 188002099 205039704 36548154 63907268 44695841 43813402 2900000 5835057 84143995 113555727 X 100604017 88054229 3198335 3374057 55752 55691 103858104 91483977 188002099 205039704 X 7388852 -19762979 X X 0 1 1 X 0 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 0 0 0 0 0 0 0 0 1 19811 19811 0 EXPLANATION OF LOBBYING ACTIVITIES: PART II-B, LINE 1: THE ORGANIZATION PAID DUES TO ORGANIZATIONS WHICH PERFORMED LOBBYING ACTIVITIES. 3257087 1265452 96131 2500 1183422 3432748 3106926 1263779 87576 1204194 3254087 4973922 1132367 168896 3168259 3106926 5308021 1121436 -178473 3000 1274062 4973922 0.98000 0.02000 0.00000 0 0 15227143 15227143 62416562 35301484 27115078 113150911 73752871 39398040 526189 526189 82266450 DESCRIPTION OF INTENDED USE OF ENDOWMENT FUNDS: PART V, LINE 4: TRUE ENDOWMENT FUNDS ARE INTENDED TO BE USED FOR NURSING SCHOLARSHIPS. QUASI-ENDOWMENT FUNDS HAVE BEEN DESIGNATED FOR VARIOUS USES TO FURTHER THE HOSPITAL'S MISSION TO PROVIDE QUALITY, COMPREHENSIVE HEALTH CARE SERVICES. SOME OF THESE DESIGNATIONS INCLUDE HOSPICE, CHAPLAINCY, CANCER TREATMENT ASSISTANCE, CAPITAL IMPROVEMENTS, AND PHARMACY ASSISTANCE. DESCRIPTION OF UNCERTAIN TAX POSITIONS UNDER FIN 48: PART X: ACCOUNTING PRINCIPLES GENERALLY ACCEPTED IN THE UNITED STATES OF AMERICA REQUIRE MANAGEMENT TO EVALUATE TAX POSITIONS TAKEN BY THE CORPORATION AND RECOGNIZE A TAX LIABILITY IF THE CORPORATION HAS TAKEN AN UNCERTAIN TAX POSITION THAT MORE LIKELY THAN NOT WOULD NOT BE SUSTAINED UPON EXAMINATION BY THE INTERNAL REVENUE SERVICE OR OTHER APPLICABLE TAXING AUTHORITIES. MANAGEMENT HAS ANALYZED THE TAX POSITIONS TAKEN BY THE CORPORATION AND HAS CONCLUDED THAT AS OF JUNE 30, 2012, THERE ARE NO UNCERTAIN TAX POSITIONS TAKEN OR EXPECTED TO BE TAKEN THAT WOULD REQUIRE RECOGNITION OF A LIABILITY OR DISCLOSURE IN THE CONSOLIDATED FINANCIAL STATEMENTS. CENTRAL AMERICA AND THE CARIBBEAN 0 0 PROGRAM SERVICE PAYMENTS TO FOREIGN INSURANCE COMPANY THAT PROVIDES INSURANCE TO THE HOSPITAL 2934618 CENTRAL AMERICA AND THE CARIBBEAN 0 0 INVESTMENT 3685407 0 0 0 0 0 0 6620025 0 6620025 1 0 1 0 0 0 FANTASY OF TREES 2011 141404 66473 74931 54561 4730 19745 1392 19874 BLACK TOP BASH 2012 43676 27292 16384 550 1000 2250 2646 12 115627 62575 53052 16610 36915 21209 300707 156340 144367 71721 5730 56660 3642 43729 181482 -37115 52467 8500 29155 603 1 1.00000 52467 8500 29155 603 38258 14209 MI 1 0 1 0 0.10000 0.90000 MOLLY MOORE 718 N MACOMB STREET MONROE MI 48162 0 MOLLY MOORE 725 OVERSEES GAMING ACTIVITIES AND RECORDKEEPING X 0 1 1 X 1 X 0 1 1 1 0 1 1 3352964 3352964 0.02100 27604836 19670928 7933908 0.04960 30957800 19670928 11286872 0.07060 743936 743936 0.00470 465577 465577 0.00290 236801 2000 234801 0.00150 55560 55560 0.00030 1501874 2000 1499874 0.00940 32459674 19672928 12786746 0.08000 10289 10289 0.00010 20889 20889 0.00010 18262 18262 0.00010 11818 11818 0.00010 859 859 0.00000 62117 62117 0.00040 1 8928499 892850 41915732 47476026 -5560294 X 1 1 1 1 MERCY MEMORIAL HOSPITAL CORPORATION

718 N MACOMB STREET MONROE MI 48162

X X X MERCY MEMORIAL HOSPITAL CORPORATION 1 1 1 200.000000000000 0 1 X X X X 1 0 1 0 1 X 0 0 30 DIAGNOSTIC CENTER

901 N MACOMB STREET MONROE MI 48162

DIAGNOSTIC, CARDIOPULMONARY, LAB MMH REHAB

650 STEWART ROAD MONROE MI 48162

REHAB SERVICES HOME CARE CONNECTION

721/725 N MONROE STREET MONROE MI 48162

HOME CARE SERVICES MMH OUTPATIENT SURGERY CENTER

750 STEWART ROAD MONROE MI 48162

AMBULATORY SURGERY CENTER MERCY MEMORIAL HOSPICE

721/725 N MONROE STREET MONROE MI 48162

HOSPICE SERVICES MMH POB

730 N MACOMB STREET MONROE MI 48162

OUTPATIENT CLINIC PHLEBOTOMY-DELISLE CENTER

1056 N MONROE STREET MONROE MI 48162

OUTREACH LAB PHLEBOTOMYXRAY-DRKABIR

219 W FRONT STREET MONROE MI 48162

OUTREACH LAB PHLEBOTOMY-DR MALOOD

3160 LEWIS ROAD IDA MI 48140

OUTREACH LAB WESTSIDE MEDICAL

100 POWELL DUNDEE MI 48131

DIAGNOSTIC THERAPY, LAB PHLEBOTOMY-DR STEWART

811 N MONROE STREET MONROE MI 48162

OUTREACH LAB DR AHADI OFFICE COMPLEX

55 COLE ROAD MONROE MI 48162

OUTREACH LAB SLEEP LAB MACOMB

717 N MACOMB STREET MONROE MI 48162

SLEEP LAB SERVICES PHLEBOTOMY-DR DONA

7505 GRAFTON ROAD SUITE 5 MONROE MI 48162

OUTREACH LAB NEWPORT MEDICAL

7825 NORTH DIXIE NEWPORT MI 48166

PATIENT ACCOUNTING, LAB KARPENKO

323 STEWART ROAD MONROE MI 48162

OUTREACH LAB DR DANIEL OLENCHAK

730 N MACOMB STREET SUITE 419 MONROE MI 48162

DOCTOR OFFICE DR TODD PROCHNOW

730 N MACOMB STREET SUITE 419 MONROE MI 48162

DOCTOR OFFICE PHLEBOTOMY-DR QURESHI

5290 W BROOKSHIRE ROAD MONROE MI 48161

OUTREACH LAB PHLEBOTOMY-DR ROECKER

14430 LAPLAISANCE ROAD MONROE MI 48162

OUTREACH LAB OUTPATIENT THERAPY

214 ELM STREET MONROE MI 48162

OCCUPATIONAL THERAPY SERVICES TEMPERANCE

1715 W DEAN ROAD TEMPERANCE MI 48182

SLEEP LAB, LAB SERVICES PHLEBOTOMY-CARLETON FAMILY MEDICAL

130 MEDICAL CENTER CARLETON MI 48117

OUTREACH LAB DR GANESH RAMASWAMI

730 N MACOMB STREET SUITE 300 MONROE MI 48162

DOCTOR OFFICE DR MICHAEL CHARBONEAU

730 N MACOMB STREET MONROE MI 48162

DOCTOR OFFICE DR JAMES DOYLE

920 N MACOMB STREET MONROE MI 48162

DOCTOR OFFICE DR BETTY RUMSCHLAG

7470 SECOR ROAD LAMBERTVILLE MI 48144

DOCTOR OFFICE DR LAURA GRIMA

110 MAIN STREET DUNDEE MI 48131

DOCTOR OFFICE DR MICHELLE CHARTIER

7825 N DIXIE HWY NEWPORT MI 48166

DOCTOR OFFICE DR KURT ROEKER

14930 LAPLAISANCE ROAD SUITE 419 MONROE MI 48161

DOCTOR OFFICE PART I, LINE 7: A COST TO CHARGE RATIO, DERIVED FROM WORKSHEET 2, IS USED FOR LINES 7A AND 7B. ACTUAL COSTS FROM THE COST ACCOUNTING SYSTEM AND ACCOUNTING RECORDS ARE USED FOR LINES 7E THROUGH 7I. PART I, LINE 7G: N/A - THE HOSPITAL DID NOT LIST ANY SUBSIDIZED HEALTH SERVICES. PART I, L7 COL(F): THE BAD DEBT EXPENSE INCLUDED ON FORM 990, PART IX, LINE 24B - BUT SUBTRACTED FOR PURPOSES OF CALCULATING THIS SCHEDULE H, PART I, COLUMN F PERCENTAGE EQUALS $8,928,499. PART II: PARTICIPATION IN TASK FORCES AND COMMITTEES ASSURES A MORE COORDINATED APPROACH TO SERVICES FOR AN AGING POPULATION. EMERGENCY PREPAREDNESS AND COORDINATION OF EFFORT AMONG AGENCIES PROVIDING HUMAN SERVICES. SPECIFIC AREAS OF IMPROVEMENT INCLUDE PRE-HOSPITAL AMBULANCE CARE, REFERRAL OF SENIORS TO SUPPORTIVE COMMUNITY SERVICES, SUICIDE PREVENTION, SUBSTANCE ABUSE, AND BREASTFEEDING FOR IMPROVED CHILD HEALTH. PART III, LINE 4: ACCOUNT RECEIVABLE FINANCIAL STATEMENT FOOTNOTE:THE PROVISION FOR BAD DEBTS IS BASED UP ON MANAGEMENT'S ASSESSMENT OF THE HISTORICAL AND EXPECTED NET COLLECTIONS CONSIDERING BUSINESS AND ECONOMIC CONDITIONS, TRENDS IN HEALTHCARE COVERAGE, AND OTHER COLLECTION INDICATORS. PERIODICALLY THROUGHOUT THE YEAR, MANAGEMENT ASSESSES THE ADEQUACY OF THE ALLOWANCE FOR DOUBTFUL ACCOUNTS BASED UPON HISTORICAL WRITE-OFF EXPERIENCE BY PAYOR CATEGORY. THE RESULTS OF THIS REVIEW ARE THEN USED TO MAKE ANY MODIFICATIONS TO THE PROVISION FOR BAD DEBTS TO ESTABLISH AN APPROPRIATE ALLOWANCE FOR UNCOLLECTABLE RECEIVABLES. AFTER SATISFACTION OF AMOUNTS DUE FROM INSURANCE, THE CORPORATION FOLLOWS ESTABLISHED GUIDELINES FOR PLACING CERTAIN PAST DUE PATIENT BALANCES WITH COLLECTION AGENCIES.THE AMOUNT OF BAD DEBT ESTIMATED TO BE ATTRIBUTABLE TO PATIENTS ELIGIBLE UNDER THE HOSPITAL'S FINANCIAL ASSISTANCE POLICY IS ESTIMATED AT 10 PERCENT OF BAD DEBT EXPENSE. PART III, LINE 8: THE SHORTFALL SHOULD BE CONSIDERED AND INCLUDED IN THE COMMUNITY BENEFIT AS THE REIMBURSEMENT DID NOT MEET THE "COST" OF THE EXPENSE BASED ON REASONABLE COSTING METHODOLOGIES. THIS IS BASED ON THE METHODOLOGY REQUIRED FOR COMPLETING THE MEDICARE COST REPORT. MERCY MEMORIAL HOSPITAL CORPORATION PART V, SECTION B, LINE 10: THE FINANCIAL ASSISTANCE POLICY IS FOR FREE CARE AND THE ONLY OTHER DISCOUNTED CARE AVAILABLE IS FOR ANY PATIENT PAYING WITHIN 30 DAYS RECEIVES A 20% DISCOUNT. MERCY MEMORIAL HOSPITAL CORPORATION PART V, SECTION B, LINE 13G: ANY INDIVIDUAL WHO SELF PAYS IS ROUTED TO THE FINANCIAL COUNSELING DEPARTMENT. MERCY MEMORIAL HOSPITAL CORPORATION PART V, SECTION B, LINE 19D: FAP-ELIGIBLE INDIVIDUALS ARE NOT CHARGED AND DO NOT RECEIVE A BILL IF THEY QUALIFY UNDER THE HOSPITAL'S FAP. PART VI, LINE 2: TO IDENTIFY COMMUNITY NEEDS TO BE ADDRESSED IN THE ORGANIZATION'S 2010-2013 STRATEGIC PLAN: INTERVIEWS WITH ELECTED COMMUNITY LEADERS, EMPLOYERS, PHYSICIANS AND THE PUBLIC; SUPPLEMENTED ANALYSIS OF DATA FROM SOURCES SUCH AS THE MICHIGAN DEPARTMENT OF COMMUNITY HEALTH BEHAVIORAL RISK FACTOR SURVEY, ROBERT WOOD JOHNSON FOUNDATION COUNTY HEALTH RANKINGS, AND THE HHS COMMUNITY HEALTH STATUS REPORT FOR MONROE COUNTY. PART VI, LINE 3: WHEN IT IS DETERMINED THAT A PATIENT IS UNABLE TO PAY FOR SERVICES (EITHER BEFORE OR AFTER SERVICES ARE RENDERED) A FINANCIAL COUNSELOR WILL SPEAK TO THE PATIENT TO EXPLAIN FINANCIAL ASSISTANCE. THE FIRST OPTION OFFERED IS STATE MEDICAID. THE PATIENT IS ASSESSED FOR MEDICAID QUALIFICATION AND IF IT IS DETERMINED THE PATIENT DOES NOT QUALIFY, THEY ARE OFFERED CHARITY CARE ASSISTANCE. THE PATIENT IS GIVEN A CHARITY CARE APPLICATION AND REQUESTED TO COMPLETE AND RETURN TO THE FINANCIAL COUNSELOR WITH THE APPROPRIATE DOCUMENTATION. ONCE THE APPLICATION IS RETURNED TO THE FINANCIAL COUNSELOR, IT IS ASSEMBLED AND SENT TO THE PATIENT ACCOUNTING OFFICE FOR APPROVAL. DEPENDING ON THE AMOUNT, VARYING LEVELS OF APPROVAL ARE REQUIRED. PART VI, LINE 4: CONSISTENT WITH THE US CENTERS FOR MEDICARE AND MEDICAID SERVICES, THE PRIMARY SERVICE AREA INCLUDES CONTIGUOUS ZIP CODES FOR THE CITY OF MONROE AND NEWPORT THAT PROVIDE 75 % OF MERCY MEMORIAL HOSPITAL'S DISCHARGES. THE SECONDARY SERVICE AREA IS THE REMAINDER OF MONROE COUNTY. IN 2011 THE TOTAL COUNTY POPULATION WAS ESTIMATED AT 151,560 WITH A HISTORIC APPROXIMATION OF 45% RESIDING IN THE PRIMARY SERVICE AREA. UNEMPLOYMENT WITH OUTMIGRATION HAS RESULTED IN A SLIGHT DECLINE OVER THIS LAST DECADE. INDIVIDUALS OVER AGE 65 IS THE MOST RAPIDLY GROWING COHORT IN A POPULATION THAT'S APPROXIMATELY 95% WHITE AND 2.5% EACH BLACK AND HISPANIC. SOME NORTHERN AND SOUTHERN PORTIONS OF MONROE COUNTY ARE FEDERALLY DESIGNATED MEDICALLY UNDERSERVED AREAS. PART VI, LINE 5: OPEN MEDICAL STAFF WITH ACTIVE RECRUITMENT OF PHYSICIANS IN SPECIALTY AREAS OF IDENTIFIED COMMUNITY NEED AND PLACEMENT OF PHYSICIANS IN THE COUNTY TO ENHANCE PATIENT ACCESS, PURSUIT OF GRANTS TO SUPPORT MAMMOGRAPHY SCREENING FOR INDIGENT WOMEN, SUPPORT OF EMPLOYEE VOLUNTARY EFFORTS TO SUPPLY FOOD BANKS FOR IMPROVED NUTRITION AND HEALTH PRODUCTS TO ENHANCE HYGIENE, PRO-ACTIVELY EDUCATING AND ENROLLING ELIGIBLE PEOPLE IN MEDICAID, AND SOLICITING DONATIONS TO SUBSIDIZE PRESCRIPTIONS AND TRANSPORTATION FOR PEOPLE IN NEED. THE ORGANIZATION'S EMPLOYEES SERVE ON VARIOUS HUMAN SERVICE AGENCY BOARDS THAT IMPACT SOCIAL OR MEDICAL ASPECTS OF HEALTH. PART VI, LINE 6: N/A - NOT AFFILIATED. REPORTS FILED WITH STATES PART VI, LINE 7 MI 1 FAMILY MEDICAL CENTER 28 S MACOMB ST MONROE MI 48162 382236628 501(C)(3) 19800 RENT FOR FEDERALLY QUALIFIED CLINIC COMMUNITY FOUNDATION 905 N MACOMB ST MONROE MI 48162 382308659 501(C)(3) 13000 SPONSORSHIP OF VARIOUS FOUNDATION EVENTS AND PROJECTS 2 NURSING SCHOLARSHIPS TO MONROE COUNTY COMMUNITY COLLEGE 3 8500 PROCEDURE FOR MONITORING GRANTS IN THE U.S.: PART I, LINE 2: SCHEDULE I, PART I, LINE 2: NURSING SCHOLARSHIPS ARE AWARDED BASED ON AN APPLICATION PROCESS. THE FUNDS ARE DISBURSED DIRECTLY TO THE EDUCATIONAL INSTITUTION. X 1 1 X X X X X 0 1 0 0 0 0 0 0 0 CHARBONEAU DO MICHAEL 276533 0 75 0 87318 0 4000 0 8543 0 376469 0 0 0 PHILLIPS ANNETTE S 340138 0 89471 0 4800 0 10378 0 19290 0 464077 0 0 0 SCHILLING THOMAS W 254155 0 51500 0 6000 0 10559 0 19766 0 341980 0 0 0 PROCHNOW TODD 493231 0 375 0 0 0 7350 0 23479 0 524435 0 0 0 OLENCHAK DANIEL 412067 0 225 0 0 0 8750 0 113 0 421155 0 0 0 RAMASWAMI GANESH 273141 0 375 0 0 0 7350 0 21201 0 302067 0 0 0 MOHAMED ABDULLAHI 218675 0 188 0 0 0 4727 0 17884 0 241474 0 0 0 KIBBLE JOHN 184434 0 29600 0 4800 0 7081 0 7498 0 233413 0 0 0 PART I, LINE 1A THE HOSPITAL MAINTAINS A MEMBERSHIP WITH A COMMUNITY GOLF / COUNTRY CLUB. THE MEMBERSHIP IS INTENDED FOR THE GENERAL USE OF THE HOSPITAL, AND IS MAINTAINED UNDER THE NAME OF THE CHIEF EXECUTIVE OFFICER (AS A REPRESENTATIVE MUST BE NAMED IN THIS INSTANCE). USE OF THE MEMBERSHIP IS MADE AVAILABLE FOR BUSINESS PURPOSES ONLY, AND PERSONAL USE IS PROHIBITED. FACILITIES AT THE COUNTRY CLUB ARE USED FOR HOSPITAL FUNCTIONS, BUSINESS MEETINGS, VOLUNTEER RECOGNITION, AND FUNDRAISING. THIS BENEFIT IS NOT TREATED AS TAXABLE COMPENSATION. PART I, LINE 4B THE ORGANIZATION OFFERS SELECT MANAGEMENT OR HIGHLY COMPENSATED EMPLOYEES ANNUAL EMPLOYER-FUNDED CONTRIBUTIONS EQUAL TO A FIXED PERCENT OF BASE SALARY: 15% FOR CEO, 10% FOR SENIOR VICE PRESIDENTS AND 5% FOR VICE PRESIDENTS. BENEFITS ARE VESTED AFTER THREE YEARS OF SERVICE AND ARE PAID OUT IN A LUMP SUM BY MARCH 15 OF THE YEAR FOLLOWING THE YEAR IN WHICH THEY BECOME VESTED. THE FOLLOWING INDIVIDUALS REPORTED ON FORM 990, PART VII ARE PARTICIPANTS: ANNETTE PHILLIPS, THOMAS SCHILLING AND JOHN KIBBLE. COUNTY OF MONROE HOSPITAL FINANCE AUTHORITY 386004873 610648AR8 2006-06-15 50405076 CONSTRUCTION PROJECT ADDING 58,995 SQ FT; RENOVATING 66,910 SQ FT 0 0 0 COUNTY OF MONROE HOSPITAL FINANCE AUTHORITY 386004873 2012-03-30 3170830 CATH LAB RENOVATION AND EQUIPMENT 0 0 0 52639779 3812411 709013 36382719 2009 1 0 1 1 3170830 30000 3140830 2012 0 0 0 1 0 0 1 1 0 0.00000 0.00000 0.00000 1 0 0 1 1 0 0.00000 0.00000 0.00000 1 1 0 0 0 0 0 0 0 0 0 0 1 X SCHEDULE K, PART I, BOND ISSUES: MONROE COMMUNITY HEALTH SERVICES IS A MEMBER OF THE MERCY MEMORIAL HOSPITAL CORPORATION OBLIGATED GROUP OF WHICH MONROE COMMUNITY HEALTH SERVICES HAS BEEN ALLOCATED FUNDS FROM THIS 2006 BOND ISSUANCE. SCHEDULE K, PART I, BOND ISSUES: A- THE BOND ISSUE PRICE WAS $50,405,076.58 WITH A REDEMPTION PRICE OF $49,550,000 AT MATURITY. PROCEEDS OF THE ISSUE WERE USED FOR BOND ISSUANCE COSTS, REQUIRED RESERVE FUND, REFUND PRIOR ISSUE BONDS AND INDEBTEDNESS (02/01/1994 BONDS) AND BUILDING EXPANSION AND EQUIPMENT. B - SIEMENS PUBLIC INC. PROGRAM REVENUE NOTE ISSUE PRICE WAS $3,170,830. PROCEEDS OF THE ISSUE WERE USED FOR NOTE ISSUANCE COSTS AND CATH LAB RENOVATION EQUIPMENT. MARY CARTER FAMILY MEMBER OF BOARD MEMBER KURT CARTER. 28113 EMPLOYMENT 0 LARRY CSOKASY FAMILY MEMBER OF BOARD MEMBER KURT CARTER. 95208 EMPLOYMENT 0 MONROE HEALTH CENTER >35% OWNED BY BOARD MEMBER AAMER BHURGRI. 180372 LEASE OF PROPERTY 0 MONROE EQUIPMENT LEASING BOARD MEMBERS KABIR, AMIN & BHURGRI ARE OFFICERS OF MONROE EQUIP. LEASING 851875 MRI LEASE 0 X 28705 COMPARABLE SALES X 2 42272 COMPARABLE SALES X 12 2000 COMPARABLE SALES X 17 3056 COMPARABLE SALES X AUCTION ITEMS 150 15227 COMPARABLE SALES 0 0 0 EXPLANATION OF AMENDED RETURN: FORM 990, ITEM B: THE FEDERAL FORM 990 HAS BEEN AMENDED TO CORRECT SCHEDULE H, PART III LINES 6 AND 7 BECAUSE AN EXPENSE WAS INADVERTENTLY OMITTED FROM THE MEDICARE ALLOWABLE COSTS OF CARE REPORTED ON LINE 6 ON THE ORIGINAL FORM 990. FORM 990, PART VI, SECTION A, LINE 2 BOARD MEMBERS DR. KENNETH MCNAMEE, DR. AAMER BHURGRI, DR. MICHAEL CHARBONEAU, JATIN AMIN AND DR. ABDUL KABIR HAVE A BUSINESS RELATIONSHIP. BOARD MEMBERS KAREN CALENDAR AND KENYON CALENDAR HAVE A FAMILY RELATIONSHIP. FORM 990, PART VI, SECTION B, LINE 11 FORM 990 INPUT DATA IS REVIEWED AND ANALYZED BY THE CONTROLLER AND THEN SUBMITTED TO THE CERTIFIED PUBLIC ACCOUNTING FIRM FOR PREPARATION. THE COMPLETED FORM 990 IS THEN RETURNED TO THE CFO AND THE CEO FOR FINAL REVIEW AND APPROVAL BEFORE THE BOARD MEETING. BEFORE THE RETURN IS FILED, THE FORM 990 IS REVIEW BY THE BOARD. ALL MEMBERS RECEIVE A COPY OF THE FORM 990, EVEN THOSE THAT ARE UNABLE TO ATTEND THE SCHEDULED MEETING. THE REVIEW IS PERFORMED DURING ONE OF THE MONTHLY BOARD MEETINGS, WHERE EACH MEMBER HAS A CHANGE TO ASK QUESTIONS. THIS REVIEW IS DOCUMENTED VIA MINUTES TO THE MEETING. FORM 990, PART VI, SECTION B, LINE 12C THE CONFLICT OF INTEREST POLICY COVERS BOARD MEMBERS, OFFICERS AND EMPLOYEES OF THE HOSPITAL. ON AN ANNUAL BASIS, THE CONFLICT OF INTEREST POLICY AND QUESTIONNAIRE IS DISTRIBUTED TO OFFICERS, EMPLOYEES, AND TRUSTEES OF MERCY MEMORIAL HOSPITAL CORPORATION. POTENTIAL CONFLICTS OF INTEREST ARE ANALYZED BY THE HOSPITAL'S LEGAL DEPARTMENT AND ARE GIVEN RANKINGS OF LOW, MODERATE, AND SEVERE RISK. THIS ANALYSIS IS GIVEN TO THE BOARD CHAIR AND THE HOSPITAL'S CHIEF EXECUTIVE OFFICER. ANY MEMBER WITH AN IDENTIFIED CONFLICT OF INTEREST IS EXCUSED FROM THE MEETING DURING DISCUSSIONS PERTAINING TO THE ISSUE OF CONFLICT, AND THE MEMBER IS NOT PERMITTED TO VOTE ON ANY ISSUE OF CONFLICT. FORM 990, PART VI, SECTION B, LINE 15 THE EXECUTIVE COMPENSATION COMMITTEE OF THE BOARD OF TRUSTEES DETERMINES AND APPROVES ALL COMPENSATION FOR THOSE DESIGNATED IN SENIOR LEADERSHIP POSITIONS SUCH AS THE CHIEF EXECUTIVE OFFICER & PRESIDENT, THE CHIEF MEDICAL OFFICER & VICE PRESIDENT OF MEDICAL AFFAIRS, THE CHIEF FINANCIAL OFFICER & SENIOR VICE PRESIDENT OF FINANCE, THE CHIEF NURSING OFFICER & SENIOR VICE PRESIDENT OF CLINICAL OPERATIONS, AND OTHER VICE PRESIDENTS. THE INDEPENDENT BOARD COMMITTEE RETAINS AN OUTSIDE CONSULTANT TO ANALYZE AND ASSIST IN MAKING THESE DETERMINATIONS THROUGH A VARIETY OF MARKET SURVEYS/STUDIES. THIS PROCESS IS UNDERTAKEN ANNUALLY AND WAS LAST PERFORMED IN 2012. FORM 990, PART VI, SECTION C, LINE 19 DOCUMENTS ARE MADE AVAILABLE UPON REQUEST. FORM 990, PART VII: THESE INDIVIDUALS DEVOTE THE FOLLOWING HOURS PER WEEK TO, RELATED ORGANIZATION, MONROE COMMUNITY HEALTH SERVICES: JATIN AMIN 1 HOUR KAREN M. VUICH BELLINO 1 HOUR AAMER BHURGRI, M.D. 4 HOURS PAUL E. BRAUNLICH 1 HOUR KAREN CALENDAR 1 HOUR KENYON S. CALENDAR 1 HOUR KURT W. CARTER 1 HOUR MICHAEL CHARBONEAU, D.O. 1 HOUR KURT L. DARROW 1 HOUR VICKI L. FRANZEN 1 HOUR MUHAMMAD JAVAID 1 HOUR ABDUL KABIR, M.D. 1 HOUR DAVID KUBISKE 1 HOUR BARTON KULISH 1 HOUR KENNETH J. MCNAMEE, M.D. 1 HOUR RUTH ANN PETERS 1 HOUR ANNETTE S. PHILLIPS 4 HOURS BASIL D. ROBBINS 1 HOUR SISTER JANET RYAN 1 HOUR DEBORAH A. SABO, C.P.A. 1 HOUR DONALD A. SPENCER, ED.D. 1 HOUR ARLENE R. WALSH 1 HOUR WALTER WILBURN 1 HOUR MARK WORRELL 1 HOUR THOMAS W. SCHILLING 4 HOURS CHANGES IN NET ASSETS OR FUND BALANCES: FORM 990, PART XI, LINE 5: NET UNREALIZED LOSSES ON INVESTMENTS: -1,350,787. PENSION LIABILITY ADJUSTMENT -18,532,339. INCOME FROM PROCEEDS OF BOND ISSUE NOT UNDER THE CONTROL OF THE HOSPITAL 120,147. TOTAL TO FORM 990, PART XI, LINE 5: -19,762,979. FORM 990, PART XII, LINE 2C: THE ORGANIZATION HAS NOT CHANGED ITS OVERSIGHT OR SELECTION PROCESS FROM THE PRIOR YEAR. MONROE COMMUNITY HEALTH SERVICES 718 N MACOMB STREET MONROE MI 48164 382934134 SKILLED NURSING AND OUTPATIENT SURGERY MI 501(C)(3) LINE 9 MERCY MEMORIAL HOSPITAL CORPORATION 1 MONROE HEALTH VENTURES 718 N MACOMB STREET MONROE MI 48164 382704426 PHARMACY MI MERCY MEMORIAL HOSPITAL CORPORATION C 1.00000 0 0 0 0 0 0 0 0 0 0 1 1 0 0 1 1 1 1 MONROE COMMUNITY HEALTH SERVICES K 133397 ACTUAL ALLOCATED COST MONROE COMMUNITY HEALTH SERVICES L 134415 ACTUAL ALLOCATED COST MONROE COMMUNITY HEALTH SERVICES P 1263606 ACTUAL ALLOCATED COST MONROE COMMUNITY HEALTH SERVICES O 81828 ACTUAL ALLOCATED COST MONROE COMMUNITY HEALTH SERVICES R 1028460 ACTUAL ALLOCATED COST