2013-10-28T10:35:21-05:00 2012-12-31 410746749 CLIFTONLARSONALLEN LLP 220 SOUTH SIXTH STREET SUITE 300 MINNEAPOLIS MN 55402 990 2012-01-01 411949230 GLENCOE REGIONAL HEALTH SERVICES GLEN 3208643121 1805 HENNEPIN AVENUE NORTH GLENCOE MN 553361416 JON BRABAND 3208643121 2013-10-23 1 ROBERT E SCHILE P00369682 6123764500 2012 2016-03-07 17:11:31Z JON BRABAND 1805 HENNEPIN AVENUE NORTH GLENCOE MN 553361416 59474067 0 X WWW.GRHSONLINE.ORG X 1999 MN TO PROVIDE HIGH QUALITY, CONVENIENT AND PERSONAL HEALTH CARE TO THOSE WE SERVE. 7 4 640 132 0 0 75532 270783 48316797 47977800 741680 1077985 215926 224294 49349935 49550862 30214 29215 0 0 29236745 29661362 0 0 0 17653594 17426763 46920553 47117340 2429382 2433522 75814953 79212619 28496553 28211821 47318400 51000798 X GLENCOE REGIONAL HEALTH SERVICES EXISTS TO PROVIDE HIGH QUALITY, CONVENIENT AND PERSONAL HEALTH CARE TO THOSE WE SERVE. WE DO SO BY PROVIDING COMPREHENSIVE, EVIDENCE-BASED, COST-EFFECTIVE HEALTH CARE SERVICES AND EDUCATION. WE COLLABORATE WITH OTHERS TO COORDINATE AND IMPROVE THE HEALTH OF OUR COMMUNITIES, AND COMMIT OUR SKILLS AND RESOURCES TO BENEFIT THE WHOLE PERSON THROUGH ALL STAGES OF LIFE. 0 0 34487785 29215 39612380 HOSPITAL - THE FACILITY IS LICENSED FOR 49 BEDS. MEDICAL/SURGICAL SERVICES ARE PROVIDED FOR ACUTE AND SWING BED PATIENTS. MAJOR SERVICES PROVIDED INCLUDE ER, MEDICAL IMAGING, SURGERY, LABORATORY, REHABILITATION THERAPY AND CLINIC SERVICES. 6835933 7899728 NURSING HOME - THE LONG-TERM CARE UNIT IS A 110-BED SKILLED NURSING FACILITY, WITH ALL BEDS MEDICARE AND MEDICAID CERTIFIED. 402981 465692 INDEPENDENT SENIOR LIVING - ORCHARD ESTATES IS A 40-UNIT SENIOR-HOUSING COMPLEX COMPRISED OF ONE AND TWO BEDROOM APARTMENTS. 41726699 1 1 0 1 0 0 0 0 1 0 1 0 0 0 1 1 1 0 0 0 0 0 0 0 0 0 1 1 0 1 1 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 28 0 640 1 0 0 0 0 0 0 0 0 0 0 X 7 4 0 1 0 0 0 0 0 1 1 0 0 1 1 1 1 1 1 1 1 0 MN X CHERYL TRIPPEL 3208647758 1805 HENNEPIN AVENUE NORTH GLENCOE MN 553361416 JEANNE CONKEL 0.50 X X 1300 0 0 JAN BRATSCH 0.50 X X 1300 0 0 JIM WATERS 0.50 X X 1200 0 0 CAROL HAUKOS 0.50 X 1400 0 0 DR KRISTINE KNUDTEN 40.50 X 240755 0 35099 DR BRYAN PETERSON 40.50 X 290809 0 40895 DR DOUGLAS WAGONER 40.50 X 247144 0 31645 JOHN BRABAND 40.00 X 212230 0 40900 JOHN DOIDGE 40.00 X 144462 0 30560 DR JOHN BERGSENG 40.00 X 469033 0 31645 DR JOHN MARK JOHNSON 40.00 X 369680 0 41645 DR CHAD ROBBINS 40.00 X 363522 0 36359 DR ROBERT ZAJAC 40.00 X 316388 0 40895 DR JAMES JESSEN 40.00 X 267074 0 26947 DR PETER SMYTH 40.00 X 206460 0 6484 3132757 0 363074 31 1 1 0 SCHATZ CONSTRUCTION INC 1011 ARMSTRONG AVENUE GLENCOE MN 55336 CONSTRUCTION 1025165 PARK NICOLLETMETHODIST HOSPITAL PO BOX 16300 ST LOUIS PARK MN 55416 MANAGEMENT FEES 333323 SHARED MEDICAL SERVICES PO BOX 330 COTTAGE GROVE WI 53527 MRI SERVICES 302025 ALLINA HOSPITALS & CLINICS PO BOX 9383 NW7710 MINNEAPOLIS MN 55440 ECHO FEES 226465 QUEST DIAGNOSTICS PO BOX 12989 CHICAGO IL 60693 REFERENCE LAB 213301 15 93558 177225 270783 HOSPITAL 623000 39854710 39854710 NURSING HOME 623000 7899728 7899728 SENIOR LIVING 623990 465692 465692 OTHER PROGRAM REVENUES 623000 41325 41325 EQUITY INVEST. INCOME 623000 -283655 -283655 47977800 519499 519499 8500 0 8500 8500 8500 10481691 9923205 558486 558486 558486 CAFETERIA REVENUE 722210 171043 171043 MISCELLANEOUS 900099 44751 44751 215794 49550862 47977800 0 1302279 29215 29215 1322000 878375 443625 22178142 20968428 1209714 806929 765663 41266 3842045 3631437 210608 1512246 1422686 89560 27588 27588 82936 82936 2941775 2187404 754371 190641 2874 187767 1304795 1075291 229504 201361 201361 1048764 1045239 3525 208071 155283 52788 11287 11287 1158134 1158134 3004276 3004276 746849 233450 513399 MEDICAL EXPENSES 2937232 2935813 1419 LICENSES & TAXES 1237847 86367 1151480 DRUGS 1193682 1189253 4429 BAD DEBT EXPENSE 514280 514280 617245 443231 174014 47117340 41726699 5390641 0 9992661 11260922 22338071 29562653 7131264 6906510 300216 297707 867956 748767 60073542 36988475 22658938 23085067 10799695 5790826 816117 532462 345383 325582 564652 702123 75814953 79212619 3664533 3974805 24239425 23505169 27943 29724 564652 702123 28496553 28211821 X 47318400 51000798 47318400 51000798 75814953 79212619 2433522 1248876 0 X 0 1 X 1 0 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 0 0 0 0 0 1 2322 0 0 0 2322 0 EXPLANATION OF LOBBYING ACTIVITIES: PART II-B, LINE 1: LOBBYING PORTION OF ASSOCIATION DUES PAID TO AHA AND MHA. 0 1 X 1221121 1221121 31233114 15990100 15243014 1436491 1058797 377694 24899415 19939578 4959837 1283401 1283401 23085067 DEFERRED COMPENSATION 702123 702123 X 48082373 1248876 -514280 734596 47347777 2203085 2203085 49550862 46603060 0 46603060 514280 514280 47117340 PART IV, LINE 2B: INDEPENDENT SENIOR LIVING TENANTS MAKE SECURITY DEPOSITS WHEN THEY MOVE IN TO THE FACILITY. DEPOSITS, WITH INTEREST, LESS ANY COSTS OF REPAIRS, ARE RETURNED TO TENANTS OR THEIR ESTATES WHEN THE TENANT LEAVES THE FACILITY. THE ORGANIZATION HOLDS SMALL AMOUNTS DEPOSITED BY RESIDENTS OF THE NURSING HOME ON THEIR BEHALF. RESIDENTS MAY MAKE DEPOSITS OR WITHDRAWALS AT ANY TIME. DESCRIPTION OF UNCERTAIN TAX POSITIONS UNDER FIN 48: PART X, LINE 2: THE FACILITY QUALIFIES AS A TAX-EXEMPT ORGANIZATION DESCRIBED IN SECTION 501(C)(3) OF THE INTERNAL REVENUE CODE. ACCORDINGLY, THE FACILITY IS EXEMPT FROM FEDERAL INCOME TAXES ON RELATED INCOME PURSUANT TO SECTION 501(C)(3) OF THE CODE. THE FACILITY HAS ELECTED TO ADOPT GUIDANCE IN THE INCOME TAX STANDARD REGARDING THE RECOGNITION AND MEASUREMENT OF UNCERTAIN TAX POSITIONS. THE FACILITY FOLLOWS THE ACCOUNTING STANDARD FOR CONTINGENCIES FOR EVALUATING UNCERTAIN TAX POSITIONS. THE ADOPTION OF THIS STANDARD HAS NO EFFECT ON THE FINANCIAL STATEMENTS. THE FACILITY'S TAX RETURNS ARE SUBJECT TO REVIEW AND EXAMINATION BY FEDERAL, STATE AND LOCAL AUTHORITIES. THE TAX RETURNS FOR THE YEARS 2009 TO 2012 ARE OPEN TO EXAMINATION BY FEDERAL, STATE AND LOCAL AUTHORITIES. PART XI, LINE 2D - OTHER ADJUSTMENTS: PROVISION FOR BAD DEBTS -514,280. PART XI, LINE 4B - OTHER ADJUSTMENTS: UNRESTRICTED CONTRIBUTIONS AND GRANT 60,556. INVESTMENT INCOME 2,326,861. EQUITY IN INCOME OF AFFILIATED ORGANIZATION -283,655. RENTAL PROPERTY 8,500. MISCELLANEOUS 44,751. CAPITAL GRANTS AND CONTRIBUTIONS 46,072. PART XII, LINE 4B - OTHER ADJUSTMENTS: PROVISION FOR BAD DEBTS 514,280. 1 1 X 1 X 1 X 0 1 0 1 1 972390 972390 0.02060 8060102 7224573 835529 0.01770 9032492 7224573 1807919 0.03830 283928 8699 275229 0.00580 80575 41557 39018 0.00080 50917 38015 12902 0.00030 64640 64640 0.00140 480060 88271 391789 0.00830 9512552 7312844 2199708 0.04660 4185 4185 0.00010 2078 2078 0.00000 6263 6263 0.00010 0 514280 0 11614273 11522654 91619 X 1 1 1 1 GLENCOE REGIONAL HEALTH SERVICES

1805 HENNEPIN AVENUE NORTH GLENCOE MN 55336

X X X X NURSING HOME/SNF GLENCOE REGIONAL HEALTH SERVICES 1 1 1 200.000000000000 1 400.000000000000 1 X X 1 1 X X X 1 0 1 X 0 0 4 GLENCOE REGIONAL HEALTH SERVICES

1024 CENTRAL AVENUE LESTER PRAIRIE MN 55354

CLINIC GLENCOE REGIONAL HEALTH SERVICES

300 BOWMAN STREET STEWART MN 55385

CLINIC GRHS LONG-TERM CARE

705 EAST 18TH STREET GLENCOE MN 55336

NURSING HOME ORCHARD ESTATES

1900 FORD AVENUE NORTH GLENCOE MN 55336

SENIOR APARTMENTS PART I, LINE 7: THE AMOUNTS IN PART I, LINE 7 WERE CALCULATED USING A COST-TO-CHARGE RATIO DERIVED FROM WORKSHEET 2 IN THE IRS INSTRUCTIONS TO FORM 990, SCHEDULE H. PART I, LINE 7G: THE ORGANIZATION DID NOT INCLUDE ANY COSTS ATTRIBUTABLE TO A PHYSICIAN CLINIC IN ITS SUBSIDIZED HEALTH SERVICES IN SCHEDULE H, PART I, LINE 7G. PART I, L7 COL(F): BAD DEBT EXPENSE REPORTED IN FORM 990, PART IX, LINE 24D WERE $514,280. THIS AMOUNT WAS SUBTRACTED IN CALCULATING THE PERCENTAGES IN SCHEDULE H, PART I, LINE 7, COLUMN F. PART II: OUR COMMUNITY BUILDING ACTIVITIES PROMOTE THE HEALTH OF OUR COMMUNITIES THROUGH DISASTER PREPAREDNESS EFFORTS, CASE MANAGEMENT OF UNDERINSURED AND UNINSURED PATIENTS, FINANCIAL AND IN-KIND SUPPORT, AND EDUCATION. FIRST, THROUGH DISASTER PREPAREDNESS TRAINING, WE SUPPORT AND PROTECT THE HEALTH OF OUR COMMUNITIES BY WORKING TO INSURE THAT THOSE NEEDING MEDICAL ATTENTION CAN ACCESS QUALITY CARE IN A SAFE AND TIMELY MANNER. DISASTER PREPAREDNESS EFFORTS ARE A YEAR-ROUND ACTIVITY, AS DISASTERS CAN INCLUDE PANDEMICS, NATURAL DISASTERS AND MASS CASUALTY SITUATIONS. SECOND, BY PROVIDING CASE MANAGEMENT OF UNDERINSURED AND UNINSURED PATIENTS, WE WORK TO HELP PATIENTS RETURN HOME AND REGAIN THEIR INDEPENDENCE AFTER AN ILLNESS, INJURY OR SURGERY. IN CASES WHERE IT IS NOT POSSIBLE FOR SOMEONE TO RETURN HOME, WE WORK TO MAKE SURE THEY HAVE ACCESS TO THE CARE AND RESOURCES THEY NEED TO CONTINUE THEIR RECOVERY OR LIVE WITH DIGNITY. THROUGH HELPING OUR PATIENTS OBTAIN FINANCIAL SUPPORT, AS WELL AS OBTAIN ACCESS TO COMMUNITY SUPPORT SYSTEMS, WE WORK TO ENSURE THAT THEY GET ADDITIONAL SERVICES THAT MAY BE NEEDED TO ASSIST IN THEIR RECOVERY. THIS PROMOTES THE HEALTH OF THE COMMUNITY BY INSURING THAT PATIENTS HAVE THE SUPPORT AND RESOURCES THEY NEED TO RETURN TO THE COMMUNITY AS PRODUCTIVE CITIZENS, AS WELL HELPING TO CREATE A COMMUNITY IN WHICH PEOPLE ARE VALUED AND TREATED WITH RESPECT. THIRD, BY PROVIDING FINANCIAL AND IN-KIND SUPPORT TO THE GLENCOE AREA CHAMBER OF COMMERCE, WE SUPPORT THE ECONOMIC HEALTH OF OUR REGION. A STRONG LOCAL ECONOMY CONTRIBUTES TO THE OVERALL HEALTH AND WELL-BEING OF ALL ITS RESIDENTS. BY PROVIDING FINANCIAL AND IN-KIND SUPPORT FOR COMMUNITY ACTIVITIES, SUCH AS THE MCLEOD COUNTY FOOD DRIVE CHALLENGE, WE ENHANCE THE QUALITY OF LIFE IN OUR COMMUNITY. FINALLY, BY PROVIDING EDUCATIONAL PRESENTATIONS AND TOURS TO OUR AREA SCHOOLS, WE ARE INVESTING IN A FUTURE GENERATION OF HEALTH CARE WORKERS WHO MAY SOMEDAY PROVIDE DIRECT CARE TO OUR PATIENTS AND OTHERS IN THE COMMUNITIES WE SERVE. WE ARE ALSO EDUCATING INDIVIDUALS ABOUT THE WORK WE DO, WHY WE DO IT, AND HOW OUR EFFORTS AFFECT THEIR LIVES AND THE LIVES OF OTHERS. PART III, LINE 4: SEE THE "PATIENT ACCOUNT RECEIVABLES, NET" PARAGRAPH IN NOTE 1 (PAGES 7-8) TO THE ATTACHED FINANCIAL STATEMENTS. PART III, LINE 8: THE ORGANIZATION USES A COST-TO-CHARGE RATIO TO CALCULATE THE MEDICARE ALLOWABLE COSTS REPORTED IN ITS MEDICARE COST REPORT. THE ORGANIZATION USES THE MEDICARE REIMBURSEMENT PROVIDER MANUAL 15-2 TO DETERMINE ACCEPTABLE METHODOLOGIES. PART III, LINE 9B: OUR GENERAL DEBT COLLECTION POLICY FOR ALL PATIENTS IS AS FOLLOWS: TWO BILLING STATEMENTS ARE SENT OUT TO THE PATIENT. ACCOUNTS WITH NO SELF-PAY ACTIVITY WITHIN TWO MONTHS RECEIVE A FIRST REMINDER LETTER. IF NO PAYMENT IS RECEIVED WITHIN ONE MONTH OF THE FIRST REMINDER LETTER, A SECOND REMINDER IS SENT. IF NO PAYMENT IS MADE WITHIN THREE WEEKS OF THE SECOND LETTER BEING SENT, A PHONE CALL IS PLACED TO THE PATIENT IN ORDER TO SET UP PAYMENT ARRANGEMENTS. IF AN AGREEMENT IS NOT MET THE ACCOUNT IS SENT TO COLLECTIONS. IN ALL, PATIENTS RECEIVE FOUR NOTICES BEFORE AN ACCOUNT IS SENT TO COLLECTIONS. PAYMENT PLANS ARE AVAILABLE TO ALL PATIENTS REGARDLESS OF INSURANCE COVERAGE OR FINANCIAL SITUATION. WE DO NOT CHARGE INTEREST OR FEES ON PAYMENT PLANS. FOR 2012, THERE WAS A MINIMUM $50.00 PAYMENT REQUIRED ON PAYMENT PLANS.IF PATIENTS CONTACT US ABOUT THEIR BILL, WE WILL REFER THEM TO FINANCIAL ASSISTANCE PROGRAMS THAT ARE AVAILABLE OR DETERMINE IF THEY ARE ELIGIBLE FOR CHARITY CARE PROGRAMS OR UNINSURED DISCOUNT PROGRAMS. INFORMATION ABOUT THE DISCOUNTS AND PROGRAMS THAT ARE AVAILABLE TO PATIENTS CAN ALSO BE FOUND ON THE BACK OF EACH MONTHLY STATEMENT AND ON EACH PAYMENT REMINDER LETTER THAT IS SENT. WHEN INSURANCE COMPANIES NEED MORE INFORMATION FROM THE PATIENT TO PROCESS THE CLAIM, WE WILL CALL THE PATIENT AND SEND THE PATIENT A REMINDER LETTER ASKING THE PATIENT TO CONTACT THEIR INSURANCE COMPANY. GLENCOE REGIONAL HEALTH SERVICES PART V, SECTION B, LINE 20D: MAXIMUM AMOUNT CHARGED IS THE NEGOTIATED RATE FROM THE HOSPITAL'S LARGEST COMMERCIAL INSURANCE CARRIER. PART VI, LINE 2: GRHS ASSESSES OUR COMMUNITIES' HEALTH NEEDS THROUGH VARIOUS METHODS. WE HAVE CONDUCTED COMMUNITY-BASED RESEARCH ON SEVERAL OCCASIONS, INCLUDING USE OF FOCUS GROUPS AND STATISTICALLY VALID TELEPHONIC SURVEYS. DURING OUR ANNUAL STRATEGIC PLANNING PROCESS, WE REVIEW UTILIZATION TRENDS, ALONG WITH THE RESULTS OF ANY COMMUNITY-BASED RESEARCH CONDUCTED THAT YEAR. WE SOLICIT FEEDBACK FROM OUR MEDICAL STAFF REGARDING ISSUES AND TRENDS THEY SEE. WE VERIFY THOSE TRENDS, AS WELL AS IDENTIFY OTHER ISSUES AND NEEDS BY CONDUCTING INTERNAL RESEARCH AND REVIEWS OF PATIENT DATA AND STATISTICS. WE ALSO MONITOR FEEDBACK RECEIVED THROUGH PATIENT SATISFACTION SURVEYS. IN ADDITION, WE SURVEY OUR PATIENTS AT ALL OF OUR COMMUNITY HEALTH EVENTS TO FIND OUT WHAT TOPICS THEY WOULD LIKE TO KNOW MORE ABOUT. WE ALSO COLLABORATE WITH LOCAL PUBLIC HEALTH AND OTHER AGENCIES AS APPROPRIATE TO LEARN ABOUT OUR COMMUNITIES' NEEDS. PART VI, LINE 3: GRHS EDUCATES AND INFORMS PATIENTS ABOUT FINANCIAL ASSISTANCE, CHARITY CARE AND UNINSURED DISCOUNT PROGRAMS IN ALL BILLING INVOICES SENT. THE INFORMATION IS LISTED ON THE BACK OF THE BILLING STATEMENT. WE ALSO POST THE INFORMATION IN OUR FACILITY AND INCLUDE IT ON OUR WEB SITE, WWW.GRHSONLINE.ORG. IN ADDITION, WE PROVIDE A REPORT BACK TO THE COMMUNITY ANNUALLY ABOUT OUR FINANCES AND CHARITY CARE AMOUNTS. THIS REPORT IS SENT TO ALL OF OUR PATIENTS, AS WELL AS THE RESIDENTS IN THE COMMUNITIES WE SERVE. PART VI, LINE 4: PATIENTS CARED FOR BY GRHS RESIDE, PRIMARILY, IN AN AREA WITHIN A RADIUS OF TWENTY MILES OF THE CITY OF GLENCOE, WHICH IS APPROXIMATELY 55 MILES WEST OF MINNEAPOLIS. IN THE 12-MONTH PERIOD JANUARY - DECEMBER 2012, 43.5% OF THE INPATIENTS ADMITTED TO GRHS RESIDED IN GLENCOE, AND ANOTHER 44.6% OF THE INPATIENTS ADMITTED RESIDED WITHIN TWENTY MILES OF GLENCOE (FOR A TOTAL OF 88.1%). THE POPULATION OF GRHS'S PRIMARY SERVICE AREA WAS PROJECTED TO BE 29,148 IN 2000, AN INCREASE OF 4.8% SINCE 1990. THE REPORTED POPULATION OF THE CITY OF GLENCOE FOR THE YEAR 2000 AND 2010 WAS 5,453 AND 5,631 RESPECTIVELY. AN INCREASE OF 3.3%. PART VI, LINE 6: THE ORGANIZATION IS NOT PART OF AN AFFILIATED HEALTH CARE SYSTEM. 1 EMPLOYEE SCHOLARSHIPS 19 28314 COST PROCEDURE FOR MONITORING GRANTS IN THE U.S.: PART I, LINE 2: SCHEDULE I, PART I, LINE 2: GLENCOE REGIONAL HEALTH SERVICES PROVIDES TUITION REIMBURSEMENT ASSISTANCE TO EMPLOYEES. EMPLOYEES ARE REQUIRED TO COMPLETE THE REIMBURSEMENT REQUEST FORM, WHICH IS TO BE SIGNED BY THEIR SUPERVISOR, PRIOR TO BEGINNING THEIR COURSE(S) TO RESERVE FUNDS. THEY ARE TO INCLUDE A DESCRIPTION OF THE COURSE(S) THEY PLAN TO TAKE, AND RECEIPTS FOR TUITION AND BOOKS, (FEES ARE NOT ELIGIBLE FOR REIMBURSEMENT), WITH THEIR REQUEST. EMPLOYEES ARE REQUIRED TO COMPLETE THEIR COURSE WITH A GRADE OF C OR BETTER TO BE ELIGIBLE FOR REIMBURSEMENT. EMPLOYEES ARE RESPONSIBLE FOR ALL UP-FRONT COSTS. X X X X 0 1 0 0 0 0 0 0 0 DR KRISTINE KNUDTEN 229318 0 11437 0 0 0 0 0 35099 0 275854 0 0 0 DR BRYAN PETERSON 276194 0 14615 0 0 0 0 0 40895 0 331704 0 0 0 DR DOUGLAS WAGONER 234001 0 13143 0 0 0 0 0 31645 0 278789 0 0 0 JOHN BRABAND 184792 0 27438 0 0 0 0 0 40900 0 253130 0 0 0 JOHN DOIDGE 134968 0 6797 0 2697 0 6933 0 23627 0 175022 0 0 0 DR JOHN BERGSENG 446680 0 22353 0 0 0 0 0 31645 0 500678 0 0 0 DR JOHN MARK JOHNSON 352652 0 17028 0 0 0 0 0 41645 0 411325 0 0 0 DR CHAD ROBBINS 346924 0 16598 0 0 0 0 0 36359 0 399881 0 0 0 DR ROBERT ZAJAC 300799 0 15589 0 0 0 0 0 40895 0 357283 0 0 0 DR JAMES JESSEN 256743 0 10331 0 0 0 0 0 26947 0 294021 0 0 0 DR PETER SMYTH 206460 0 0 0 0 0 0 0 6484 0 212944 0 0 0 PART I, LINE 4B JOHN DOIDGE - 457(B) PLAN - $17,000 SUPPLEMENTAL INFORMATION PART III JON BRABAND (CEO) IS EMPLOYED BY PARK NICOLLET, AN UNRELATED THIRD PARTY. HE OPERATES AS CEO OF GLENCOE REGIONAL HEALTH SERVICES UNDER A MANAGEMENT CONTRACT WITH PARK NICOLLET. AS SUCH, HIS COMPENSATION IS REPORTED ON FORM 990, PART VII AND ON SCHEDULE J, PART II. A CITY OF GLENCOE 416005185 378160BF1 2005-08-18 25440900 DEFEASE PART OF 2001 REV. BONDS & FUND EXPANSION OF MEDICAL/SURGICAL UNIT. 0 0 0 A 1865900 25499173 353688 19021387 466682 5709899 0 1 1 1 A 0 0 0 0 0.00000 0.00000 0.00000 0 0 0 A 0 0 0 0 0 0 0 0 0 A 0 FORM 990, PART VI, SECTION A, LINE 1 THERE SHALL BE AN EXECUTIVE COMMITTEE OF THE BOARD OF DIRECTORS WHICH SHALL CONSIST OF THE CHAIRPERSON OF THE BOARD OF DIRECTORS, THE VICE CHAIRPERSON OF THE BOARD, THE PRESIDENT AND THE SECRETARY OF THE BOARD OF DIRECTORS. THE CHAIRPERSON OF THE BOARD OF DIRECTORS SHALL BE THE CHAIRPERSON OF THE EXECUTIVE COMMITTEE AND THE SECRETARY SHALL ACT AS THE SECRETARY THEREOF. THE EXECUTIVE COMMITTEE SHALL ADVISE WITH AND AID THE OFFICERS OF THE CORPORATION IN ALL MATTERS CONCERNING THE MANAGEMENT OF ITS BUSINESS; AND BETWEEN MEETINGS OF DIRECTORS THE EXECUTIVE COMMITTEE SHALL POSSESS AND MAY EXERCISE ALL OF THE POWERS OF THE BOARD OF DIRECTORS EXCEPT WITH REFERENCE TO MAKING OR AMENDING THE BYLAWS FOR THE BOARD OF DIRECTORS, REMOVING ANY MEMBER OF THE BOARD OF DIRECTORS OR FILLING VACANCIES IN THEIR OWN MEMBERSHIP. FORM 990, PART VI, SECTION A, LINE 3 THE ORGANIZATION HAS A CONTRACTUAL ARRANGEMENT WITH PARK NICOLLET HEALTH SERVICES, UNDER WHICH PARK NICOLLET HEALTH SERVICES PROVIDES A CHIEF EXECUTIVE OFFICER, MANAGEMENT CONSULTATION, AND OTHER SERVICES TO THE FACILITY. THE ARRANGEMENT DOES NOT ALTER THE AUTHORITY OR RESPONSIBILITY OF THE BOARD OF DIRECTORS OF GLENCOE REGIONAL HEALTH SERVICES. FORM 990, PART VI, SECTION B, LINE 11 THE 990 REPORT WAS REVIEWED WITH THE BOARD MEMBERS AT A REGULARY SCHEDULED BOARD MEETING. THE BOARD WAS ASKED TO APPROVE THE DOCUMENT PRIOR TO SUBMISSION TO THE IRS. FORM 990, PART VI, SECTION B, LINE 12C GLENCOE REGIONAL HEALTH SERVICES HAS A CONFLICT OF INTEREST POLICY THAT APPLIES TO ALL MEMBERS OF THE BOARD OF DIRECTORS, MEMBERS OF A COMMITTEE OF THE BOARD OF DIRECTORS, AND SENIOR MANAGEMENT. ANNUALLY, THE BOARD MEMBERS AND SENIOR MANAGMENT ARE ASKED TO COMPLETE THE CONFLICT OF INTEREST DECLARATION. ANY INDIVIDUAL HAVING A CONFLICT OF INTEREST IS REQUIRED TO INFORM THE BOARD OR COMMITTEE. THE INDIVIDUAL ABSTAINS FROM VOTING ON THE MATTER, BUT IS PERMITTED TO BRIEFLY STATE THEIR POSITION AND ANSWER PERTINENT QUESTIONS. THE MINUTES OF THE MEETING REFLECT THAT THE DISCLOSURE WAS MADE AND THAT THE PERSON ABSTAINED FROM VOTING. THE PRESIDENT AND CEO IS RESPONSIBLE FOR MONITORING CONFLICTS OF INTEREST. FORM 990, PART VI, SECTION B, LINE 15 THE CEO REVIEW PROCESS IS PERFORMED UNDER THE DIRECTION OF PARK NICOLLET AND INDEPENDENT COMPARISON DATA IS USED TO ESTABLISH COMPENSATION. THE BOARD OF DIRECTORS FINALIZES THE REVIEW AND COMPENSATION. THE VICE PRESIDENT OF FINANCE REVIEW IS CONDUCTED BY THE CEO AND COMPENSATION IS DETERMINED USING INDEPENDENT COMPARISON DATA. BOTH POSITIONS WERE REVIEWED IN 2012. FORM 990, PART VI, SECTION C, LINE 19 THE GOVERNING DOCUMENTS AND CONFLICT OF INTEREST POLICY ARE AVAILABLE TO THE PUBLIC UPON REQUEST. ANNUAL FINANCIAL STATEMENTS ARE PUBLISHED ONCE PER YEAR IN THE FACILITY PUBLICATION TOUCHING LIVES. THE TOUCHING LIVES PUBLICATION IS MAILED TO ALL RESIDENTS IN THE FACILITY'S SERVICE AREA.