2012-05-11T13:51:05-05:00 2011-06-30 PLANTE & MORAN PLLC PO BOX 307 SOUTHFIELD MI 480370307 990 2010-07-01 381984289 MERCY MEMORIAL HOSPITAL CORPORATION MERC 7342404520 718 N MACOMB STREET MONROE MI 48162 THOMAS W SCHILLING 7342404520 2012-05-10 1 2483522500 2010 2016-02-24 21:20:13Z THOMAS W SCHILLING 718 N MACOMB STREET MONROE MI 48162 203313026 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. 19 13 1720 894 4234019 -483940 1084161 1177458 162794123 169563395 18995966 3027515 36243 -14714 182910493 173753654 3000 4000 0 0 77604281 82143925 0 0 116329 83519962 81430798 161127243 163578723 21783250 10174931 166919072 188002099 87032573 84143995 79886499 103858104 X AS AN INDEPENDENT HEALTH CARE SYSTEM, WE PROVIDE HIGH QUALITY, COMPREHENSIVE SERVICES TO THE PEOPLE AND COMMUNITIES WE SERVE. 0 0 137521235 0 165314102 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] 39,571 DAYS OF ACUTE CARE FOR ADULT AND PEDIATRIC INPATIENTS,[B] 1,358 DAYS OF ACUTE CARE FOR NEWBORNS,[C] EMERGENCY CARE FOR 46,123 OUTPATIENTS, AND[D] 1,336,938 OUTPATIENT SERVICE REGISTRATIONS. 40409 4000 97492 HOSPITAL GUILD - 134 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 PATIENTS AND VISITORS. THE GUILD ALSO OFFERS SOME NURSING SCHOLARSHIPS. 34871 0 0 HOSPITAL MEDICAL STAFF - 310 MEMBERS [A] DIRECTED AND REVIEWED HOSPITAL BASED HEALTHCARE SERVICES AND [B] PARTICIPATED IN PERIODIC MEETINGS CONCERNING THE DELIVERY OF HEALTHCARE SERVICES, INCLUDING MEDICAL EDUCATION. 137596515 1 1 0 1 0 0 0 0 1 1 0 0 0 0 0 0 1 0 0 1 0 0 0 1 1 1 1 0 0 1 1 0 0 0 0 0 0 0 1 1 1 1 0 0 0 0 1 1 1 0 0 1 196 1 1 1720 1 1 1 0 0 0 0 1 1 0 0 0 0 X 19 13 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 BELLINO KAREN M VUICH 1.00 X 0 0 0 BHURGRI MD AAMER 4.00 X 47407 0 0 BRAUNLICH PAUL E 1.00 X 0 0 0 CALENDER KENYON S 1.00 X 0 0 0 CARTER KURT W 1.00 X 0 0 0 CHARBONEAU DO MICHAEL 1.00 X 0 0 0 DARROW KURT L 1.00 X 0 0 0 FRANZEN VICKI L 1.00 X 0 0 0 KABIR MD ABDUL 4.00 X 22596 0 0 MCNAMEE MD KENNETH J 1.00 X 2052 0 0 PETERS RUTH ANN 1.00 X 0 0 0 PHILLIPS ANNETTE S 40.00 X X 448314 0 14126 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 G 1.00 X 0 0 0 HECK GERALD 1.00 X 0 0 0 MILLER JAMES 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 347872 0 23946 LENKEVICH ELLEN 40.00 X 224718 0 17051 PROCHNOW TODD 40.00 X 497246 0 15628 SOROSIAK MICHAEL 40.00 X 287874 0 21057 SEAL WILLIAM 40.00 X 220515 0 11497 KIBBLE JOHN 40.00 X 229473 0 5112 BURGOS GILBERT 40.00 X 382271 0 7350 2710338 0 115767 47 0 1 0 AUCH GEORGE W CO 735 S PADDOCK PONTIAC MI 48341 CONSTRUCTION MGT. 1202186 GE HEALTHCARE 101 CARNEGIE CENTER PRINCETON NJ 08540 EQUIPMENT SERVICES 1087545 MICHIGAN CO-TENANCY LABS DEPT CH 14271 PALATINE IL 60055 LABORATORY SERVICES 989430 CONTRACTING RESOURCES 403 E GRAND RIVER SUITE C BRIGHTON MI 48116 CONSTRUCTION MGT. 913704 ECLIPSYS 3 RAVINA DRIVE ATLANTA GA 30346 SOFTWARE SERVICES 857458 48 23720 173235 34058 946445 55554 1177458 HOSPITAL BASED HEALTHC 621990 165314102 165314102 NON-PATIENT PHARMACY 446110 3892513 3892513 NON-PATIENT REF. LAB 621500 341506 341506 HOSPITAL GUILD 621990 15274 15274 169563395 1340630 1340630 921301 951474 -30173 -30173 -30173 29872781 22257 28201170 6983 1671611 15274 1686885 1686885 143524 173235 212954 -69430 -69430 23723 21052 2671 2671 247957 165739 82218 82218 173753654 165411594 4234019 2930583 4000 4000 1097525 201755 895770 64998016 55545035 9380442 72539 1352644 1161555 189554 1535 9929921 8392308 1526681 10932 4765819 4021953 738630 5236 206389 206389 240062 240062 323496 323496 17519 17519 235465 235465 16173226 11306966 4862604 3656 175607 32392 143215 1690095 1094856 592651 2588 999378 999378 2887863 2664724 223139 385697 233388 151138 1171 218273 16043 202230 2453612 2453612 8447473 7794754 652719 2294709 2096829 197880 HOSPITAL SUPPLIES 27035421 27035421 PROVISION FOR BAD DEBTS 12678186 12678186 QUALITY ASSURANCE ASSES 3979380 3979380 DIETARY SUPPLIES 826329 826329 FUNDRAISING / RESTRICTE 18672 18672 143946 36409 107537 163578723 137596515 25865879 116329 7634118 3036485 17355431 17543562 21968851 21344529 2489759 2728503 1752094 1982485 186520408 106947148 74614933 79573260 39020475 58853299 157643 226230 1925768 2713746 166919072 188002099 41489181 36548154 45543392 44695841 2900000 87032573 84143995 X 76779573 100604017 3051924 3198335 55002 55752 79886499 103858104 166919072 188002099 X 10174931 13796674 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 17519 17519 0 EXPLANATION OF OTHER LOBBYING ACTIVITIES: PART II-B, LINE 1I: THE ORGANIZATION PAID DUES TO ORGANIZATIONS WHICH PERFORMED LOBBYING ACTIVITIES. 3106926 1263779 87576 1204194 3254087 4973922 1132367 168896 3168259 3106926 5308021 1121436 -178473 3000 1274062 4973922 0.98000 0.02000 0.00000 0 0 14807903 14807903 56717925 29314023 27403902 111256840 77633125 33623715 3737740 3737740 79573260 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, CAPITAL IMPROVEMENTS, AND PHARMACY ASSISTANCE. CENTRAL AMERICA AND THE CARIBBEAN 0 0 PROGRAM SERVICE OWNERSHIP IN FOREIGN INSURANCE COMPANIES THAT PROVIDE INSURANCE TO HOSPITAL. 1036542 0 0 0 0 0 0 1036542 0 1036542 1 0 1 0 0 0 METHOD USED TO ACCCOUNT FOR EXPENDITURES: SCHEDULE F, PART I, LINE 3: CASH - ACTUAL AMOUNTS PAID. FANTASY OF TREES 2010 163527 97940 65587 0 54277 2120 16900 975 28108 CANCER CENTER GALA 46237 33336 12901 0 4431 11509 25251 1100 10761 6 106995 41959 65036 0 10997 645 18737 0 27143 316759 173235 143524 69705 14274 60888 2075 66012 212954 -69430 23723 500 18301 0 2251 1 1.00000 23723 500 18301 2251 21052 2671 MI 1 0 1 0 0.10000 0.90000 MOLLY MOORE 718 N MACOMB STREET MONROE MI 48162 0 0 1 1 X 1 X 0 1 1 1 0 1 1 1810294 0 1810294 0.01200 26744065 20156770 6587295 0.04370 28554359 20156770 8397589 0.05570 573 12028 356911 0 356911 0.00240 28 428 140049 140049 0.00090 101 138966 9181 129785 0.00090 39153 0 39153 0.00030 601 12557 675079 9181 665898 0.00450 601 12557 29229438 20165951 9063487 0.06020 4440 4440 0.00000 3021 3021 0.00000 1411 1411 0.00000 29747 29747 0.00020 6857 6857 0.00000 1209 1209 0.00000 46685 46685 0.00020 1 4902563 538823 43737382 44620348 -882966 X 1 1 1 1 MERCY MEMORIAL HOSPITAL CORPORATION

718 N MACOMB STREET MONROE MI 48162

X X X NOT REQUIRED 1 28 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 PART I, LINE 6A: N/A - NO IDENTIFIED RELATED PARTIES. 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 $12,678,186. 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 RATIO OF PATIENT CARE COST TO CHARGES IS APPLIED TO BAD DEBT EXPENSE, NET OF RECOVERIES, TO ARRIVE AT THE ESTIMATED COST OF BAD DEBT $4,902,563.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 AT COST, WHICH WAS COMPUTED USING THE COST TO CHARGE RATIO FROM THE 2010 FINALIZED COST REPORT. 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. 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 2010 THE TOTAL COUNTY POPULATION WAS ESTIMATED AT 152,021 WITH APPROXIMATELY 45% RESIDING IN THE PRIMARY SERVICE AREA. UNEMPLOYMENT WITH OUTMIGRATION HAVE RESULTED IN A SLIGHT DECLINE OVER THIS LAST DECADE. 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 6: 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 7: N/A - NOT AFFILIATED. REPORTS FILED WITH STATES PART VI, LINE 7 MI X 1 1 X X X X X 0 0 0 0 0 0 0 0 0 PHILLIPS ANNETTE S 301074 0 139979 0 7261 0 7350 0 6776 0 462440 0 0 0 SCHILLING THOMAS W 247094 0 92500 0 8278 0 7350 0 16596 0 371818 0 0 0 LENKEVICH ELLEN 156550 0 56000 0 12168 0 4754 0 12297 0 241769 0 0 0 PROCHNOW TODD 476946 0 20300 0 0 0 0 0 15628 0 512874 0 0 0 SOROSIAK MICHAEL 284499 0 3375 0 0 0 4381 0 16676 0 308931 0 0 0 SEAL WILLIAM 220140 0 375 0 0 0 4584 0 6913 0 232012 0 0 0 KIBBLE JOHN 175644 0 49029 0 4800 0 5112 0 0 0 234585 0 0 0 BURGOS GILBERT 275119 0 99750 0 7402 0 7350 0 0 0 389621 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. 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 52639779 3812411 709013 36382719 2009 1 0 1 1 0 0 1 0 0 0.00000 0.00000 0.00000 1 0 0 0 0 0 0 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: 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. SCHEDULE K, PART IV, LINE 1: A FORM 8038-T, ARBITRAGE REBATE, YIELD REDUCTION AND PENALTY IN LIEU OF ARBITRAGE REBATE, WAS FILED IN AUGUST 2011 - AFTER THE HOSPITAL'S FISCAL YEAR END. ACCORDINGLY, WE HAVE ANSWERED THIS QUESTION AS 'NO'. MARY CARTER FAMILY MEMBER OF BOARD MEMBER KURT CARTER. 21013 EMPLOYMENT 0 LARRY CSOKASY FAMILY MEMBER OF BOARD MEMBER KURT CARTER. 73297 EMPLOYMENT 0 MONROE HEALTH CENTER >35% OWNED BY BOARD MEMBER AAMER BHURGRI. 161418 LEASE OF PROPERTY 0 MONROE EQUIPMENT LEASING BOARD MEMBER ABDUL KABIR IS AN OFFICER OF MONROE EQUIPMENT LEASING 857750 MRI LEASE 0 X 49977 COMPARABLE SALES X 24 5577 COMPARABLE SALES 0 0 0 FORM 990, PART VI, SECTION A, LINE 2 BOARD MEMBER DR. KENNETH MCNAMEE AND BOARD MEMBER DR. JAMES MILLER HAVE A BUSINESS 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 2011. FORM 990, PART VI, SECTION C, LINE 19 DOCUMENTS ARE MADE AVAILABLE UPON REQUEST. CHANGES IN NET ASSETS OR FUND BALANCES: FORM 990, PART XI, LINE 5: NET UNREALIZED GAINS ON INVESTMENTS: 3,820,292. SURGERY CENTER EQUITY TRANSFER 3,843,704. PENSION LIABILITY ADJUSTMENT 5,986,191. INCOME FROM PROCEEDS OF BOND ISSUE NOT UNDER THE CONTROL OF THE HOSPITAL 146,487. TOTAL TO FORM 990, PART XI, LINE 5: 13,796,674. 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 122733 ACTUAL ALLOCATED COST MONROE COMMUNITY HEALTH SERVICES L 150021 ACTUAL ALLOCATED COST MONROE COMMUNITY HEALTH SERVICES P 4163923 ACTUAL ALLOCATED COST MONROE COMMUNITY HEALTH SERVICES Q 3628899 ACTUAL ALLOCATED COST MONROE COMMUNITY HEALTH SERVICES R 3843704 COST ON BOOKS