2012-08-30T10:23:58-05:00 2011-12-31 621804252 WATKINS UIBERALL PLLC 1661 AARON BRENNER DR STE 300 MEMPHIS TN 38120 990 2011-01-01 436004544 PEMISCOT MEMORIAL HEALTH SYSTEMS PEMI 5733593415 PO BOX 489 HAYTI MO 63851 KERRY NOBLE 5733593415 2012-08-02 1 B COBENE WATKINS P00083192 9017612720 2011 2016-02-24 21:20:13Z KERRY NOBLE PO BOX 489 HAYTI MO 63851 46123964 0 X WWW.PEMISCOT.ORG X 1949 MO THE PRIMARY PURPOSE OF PEMISCOT MEMORIAL HEALTH SYSTEM IS TO PROVIDE QUALITY HEALTHCARE TO THE COMMUNITY REGARDLESS OF ABILITY TO PAY. 5 4 701 0 0 0 523370 1088152 44076922 42403894 27500 31653 432021 2600265 45059813 46123964 0 0 0 0 24573780 23137083 0 0 0 23524448 22124728 48098228 45261811 -3038415 862153 16452665 18220136 8730834 9636152 7721831 8583984 X PEMISCOT MEMORIAL HEALTH SYSTEMS IS COMMITTED TO PROVIDE AN ORGANIZED SYSTEM OF HEALTHCARE SERVICES TO ALL PERSONS WITHIN OUR SERVICE AREA WITHOUT REGARD TO AGE, SEX, RACE, COLOR, NATIONAL ORIGIN, CREED, FINANCIAL STATUS, PHYSICAL OR MENTAL CHALLENGE. DEMAND FOR EXPANSION OF EXISTING OR INITIATION OF NEW PROGRAMS AND SERVICES ARE EVALUATED ON AN ONGOING BASIS RESULTING IN INCREMENTAL IMPROVEMENTS IN THE DEGREE OF QUALITY OF SERVICES RENDERED IN DIRECT RESPONSE TO THE CHANGING HEALTHCARE NEEDS OF THE COMMUNITY(S). PEMISCOT MEMORIAL HEALTH SYSTEMS STRIVES TO WORK IN COLLABORATION WITH LOCAL, STATE AND FEDERAL ORGANIZATIONS TO ENSURE ACCESS TO PRIMARY CARE FOR ALL RESIDENTS WITH SPECIAL EMPHASIS ON PREVENTATIVE HEALTH AND WELLNESS. WE DILIGENTLY WORK TO MAINTAIN OUR FINANCIAL STRENGTH IN ORDER THAT WE REMAIN A PROMINENT PROVIDER OF MEDICAL SERVICES FOR THE REGION. 0 0 43178363 42374826 PROVIDING QUALITY HEALTH CARE TO THE COMMUNITY THROUGH THE OPERATION OF A HOSPITAL, TWO LONGTERM CARE FACILITIES, RURAL HEALTH CLINICS AND ADOLESCENT, ADULT, AND GERIATRIC PSYCHIATRIC UNITS. 43178363 1 0 0 0 0 0 0 0 0 0 1 0 0 1 1 0 1 0 0 0 0 0 0 0 0 0 1 1 0 0 1 1 0 0 0 0 0 0 0 1 0 1 0 0 0 0 0 0 0 0 0 0 1 67 0 1 701 1 0 0 0 0 0 0 0 0 X 5 4 0 0 0 0 0 0 0 1 1 0 0 0 0 0 1 0 0 0 MO X CARRIE BYERS 5733593415 946 EAST REED HAYTI MO 63851 GLENN HAYNES 2.00 X 0 0 0 LEE WIGGINTON 2.00 X 0 0 0 BOBBY KHOURIE 2.00 X 0 0 0 CAROL TILLMAN 2.00 X 0 0 0 JOHNNY HARMON 2.00 X 0 0 0 KERRY NOBLE 40.00 X 216481 0 11906 JACK PENNINGTON 40.00 X 3644 0 200 ABDULLAH ARSHAD 40.00 X 469781 0 25838 RALPH KELLEY 40.00 X 230229 0 12663 J KULPEKSA 40.00 X 169562 0 9326 BABATUNDE OLADIRAN 40.00 X 250504 0 13778 GENEROSO GUZMAN 40.00 X 201364 0 11075 1541565 0 84786 15 0 1 0 AMERI SOURCE BERGEN 24663 NETWORK PLACE CHICAGO IL 60673 PHARMACY 1307289 HARDIN'S SYSCO FOOD SERVICES PO BOX 18872 MEMPHIS TN 38181 FOOD 854031 JIM PANG MD 8134 COUNTRY VILLAGE DR SUITE 102 CORDOVA TN 38016 PHYSICIAN 627567 CARDINAL HEALTH PO BOX 70539 CHICAGO IL 60673 MEDICAL SUPPLIES 598133 EXTENDED ENTERPRISES INC PO BOX 393 HAYTI MO 63851 BILLING SERVICES 572564 35 1087652 500 1088152 PATIENT SERVICES 621400 42403894 42374826 29068 42403894 31653 31653 MISCELLANEOUS 900099 2421114 2421114 CAFETERIA 722210 96619 96619 MEDICAL RECORDS 519100 65508 65508 17024 17024 2600265 46123964 42374826 0 2660986 232231 218294 13937 18514682 17403550 1111132 838118 785676 52442 2279012 2136410 142602 1273040 1193384 79656 62647 62647 44288 44288 536228 462005 74223 569916 512924 56992 45748 41024 4724 184963 166467 18496 1116402 1004762 111640 512591 501251 11340 BAD DEBT EXPENSE 7290684 7290684 OUTSIDE SERVICES 3882365 3730662 151703 MEDICAL SUPPLIES 2587786 2587786 FRA EXPENSE 2426303 2426303 2864807 2717181 147626 45261811 43178363 2083448 0 2405 2405 404832 1806772 7628290 6484446 278089 323599 106073 204503 26588304 19806280 6548097 6782024 1484879 2616387 16452665 18220136 3793801 3951334 1735000 1340000 277389 3202033 4067429 8730834 9636152 X 7721831 8583984 7721831 8583984 16452665 18220136 862153 0 X 0 1 1 X 1 1 X 135242 135242 10587573 6585421 4002152 409362 55136 354226 15288356 13165723 2122633 167771 167771 6782024 ACCRUED COUNTY TAX REVENUE 514906 ACCRUED DSH FUNDS 1152457 ASSETS WHOSE USE IS LIMITED 906600 BOND UNDERWRITER FEES, NET 26983 CASH HELD FOR RESIDENTS 15441 2616387 ACCRUED DSH RECOUPMENT 1444290 CAPITAL LEASE PAYABLE 2023905 ESTIMATED THIRD PARTY SETTLEMENT 547470 LEGAL SETTLEMENT PAYABLE 36323 RESIDENT TRUST FUND 15441 4067429 46123964 45261811 862153 862153 46123964 0 46123964 0 46123964 45261811 0 45261811 0 45261811 1 1 1 X 1 X 0 1 0 0 2842057 1763187 1078870 0.02380 7670179 7127380 542799 0.01200 10512236 8890567 1621669 0.03580 256430 256430 0.00570 4211 4211 0.00010 260641 260641 0.00580 10772877 8890567 1882310 0.04160 1 3468713 1214050 11625751 11422379 203372 X 1 0 1 1 PEMISCOT MEMORIAL HEALTH SYSTEMS

946 EAST REED HAYTI MO 63851

X PEMISCOT MEMORIAL HEALTH SYSTEMS 1 1 1 100.000000000000 1 200.000000000000 1 X 1 1 X 1 X X X 0 1 X 0 1 10 PEMISCOT MEMORIAL NURSING HOME

946 EAST REED HAYTI MO 63851

LONG-TERM CARE FACILITY CARUTHERSVILLE NURSING CENTER

500 TRUMAN BLVD CARUTHERSVILLE MO 63830

SKILLED NURSING FACILITY PEMISCOT PRIMARY CARE CENTER

907 EAST REED HAYTI MO 63851

OUTPATIENT PHYSICIAN CLINIC DOCTOR'S CLINIC

106 WEST 12 CARUTHERSVILLE MO 63830

OUTPATIENT PHYSICIAN CLINIC WOMEN'S PRIMARY CARE CENTER

701 EAST LINCOLN HAYTI MO 63851

OUTPATIENT PHYSICIAN CLINIC PEMISCOT CONVENIENT CARE CLINIC

946 EAST REED HAYTI MO 63851

OUTPATIENT PHYSICIAN CLINIC PORTAGEVILLE PRIMARY CARE CENTER

712 NORTH HIGHWAY 61 PORTAGEVILLE MO 63873

OUTPATIENT PHYSICIAN CLINIC BOOTHEEL PRIMARY CARE - CARUTHERSVILLE

1502 WARD AVENUE CARUTHERSVILLE MO 63830

OUTPATIENT PHYSICIAN CLINIC BOOTHEEL PRIMARY CARE - HAYTI

223 SOUTH 3RD HAYTI MO 63851

OUTPATIENT PHYSICIAN CLINIC BOOTHEEL PRIMARY CARE - STEELE

213 S WALNUT STEELE MO 63877

OUTPATIENT PHYSICIAN CLINIC PART III, LINE 4: A FOOTNOTE TO THE FINANCIAL STATEMENTS READS:NET PATIENT SERVICE REVENUE IS REPORTED AT THE ESTIMATED NET REALIZABLE AMOUNTS FROM PATIENTS, THIRD PARTY PAYORS AND OTHERS FOR SERVICES RENDERED . . . RETROACTIVE ADJUSTMENTS ARE ACCRUED ON AN ESTIMATED BASIS IN THE PERIOD THE RELATED SERVICES ARE RENDERED AND ADJUSTED IN FUTURE PERIODS AS FINAL SETTLEMENTS ARE DETERMINED . . . LAWS AND REGULATIONS GOVERNING THE MEDICARE AND MEDICAID PROGRAMS ARE EXTREMELY COMPLEX AND SUBJECT TO INTERPRETATION. AS A RESULT THERE IS AT LEAST A REASONABLE POSSIBILITY THAT RECORDED ESTIMATES WILL CHANGE BY A MATERIAL AMOUNT IN THE NEAR TERM. THE HOSPITAL PROVIDES CARE TO PATIENTS WHO MEET CERTAIN CRITERIA UNDER ITS CHARITY CARE POLICY WITHOUT CHARGE OR AT AMOUNTS LESS THAN ITS ESTABLISHED RATES. BECAUSE THE HOSPITAL DOES NOT PURSUE COLLECTION OF AMOUNTS DETERMINED TO QUALIFY AS CHARITY CARE, THEY ARE NOT REPORTED AS REVENUE.COST TO CHARGE RATIO IS USED TO DETERMINE THE REPORTED AMOUNTS. PART III, LINE 8: MEDICARE ALLOWABLE COSTS ARE TAKEN FROM THE HOSPITAL'S COST REPORT. PEMISCOT MEMORIAL HEALTH SYSTEMS PART V, SECTION B, LINE 19D: THE HOSPITAL FACILITY USES 130% OF THE MEDICARE RATE. PEMISCOT MEMORIAL HEALTH SYSTEMS PART V, SECTION B, LINE 21: PRIVATE PAY PATIENTS ARE CHARGED AT GROSS CHARGES. IF THE PATIENT QUALIFIES FOR THE SLIDING FEE SCALES, THE CHARGES ARE DISCOUNTED ACCORDINGLY. ALSO, DISCOUNTS APPLY FOR PAYING WITHIN 30/60/90 DAYS AND FOR PAYING WITHIN THE TERMS OF A FINANCING AGREEMENT WITH THE HOSPITAL. THE AMOUNT CHARGED IS EQUAL TO GROSS CHARGES ONLY IF THE PATIENT IS MORE THAN 60 DAYS DELINQUENT ON A PAYMENT PLAN. PART VI, LINE 2: GENERAL NEEDS ASSESSMENT IS PERFORMED BY THE BOARD OF DIRECTORS AND MANAGEMENT. APPROPRIATE PROGRAMS ARE IMPLEMENTED AS A RESULT. PART VI, LINE 3: PATIENTS ARE ASKED UPON ADMISSION IF THEY WOULD LIKE TO APPLY FOR ASSISTANCE. A CASEWORKER MAKES IN-ROOM VISITS TO THOSE WHO APPLY AND ASSISTS IN ENROLLMENT IN ANY PROGRAMS FOR WHICH THE PATIENT QUALIFIES. PART VI, LINE 4: THE HOSPITAL SERVES PEMISCOT, EASTERN DUNKLIN, AND SOUTHERN NEW MADRID COUNTIES OF SOUTHEAST MISSOURI. PEMISCOT COUNTY'S MEDIAN HOUSEHOLD INCOME WAS $27,188 WHEN LAST MEASURED IN 2008, WITH 31.7% OF PERSONS BELOW THE FEDERAL POVERTY LEVEL. PART VI, LINE 5: THE HOSPITAL SENDS EMPLOYEES TO WORK AT LOCAL HEALTH FAIRS, INCLUDING CHECKING BLOOD PRESSURE AND BASIC LAB WORK. ONE DOCTOR HAS STARTED A NEW PROGRAM TO ADDRESS TEEN PREGNANCY. THE HOSPITAL ALSO PROVIDES EMPLOYEES TO ADMINISTER FLU SHOTS. X 0 0 X X X 0 0 0 0 0 0 0 0 0 KERRY NOBLE 216481 0 0 0 0 0 11906 0 0 0 228387 0 0 0 ABDULLAH ARSHAD 469781 0 0 0 0 0 25838 0 0 0 495619 0 0 0 RALPH KELLEY 230229 0 0 0 0 0 12663 0 0 0 242892 0 0 0 J KULPEKSA 169562 0 0 0 0 0 9326 0 0 0 178888 0 0 0 BABATUNDE OLADIRAN 250504 0 0 0 0 0 13778 0 0 0 264282 0 0 0 GENEROSO GUZMAN 201364 0 0 0 0 0 11075 0 0 0 212439 0 0 0 PART I, LINE 1A HAYTI ROTARY CLUB DUES WERE PAID ON BEHALF OF THE OFFICERS AT $200.00 PER QUARTER. PEMISCOT COUNTY MISSOURI 2004-06-01 4265000 REFUND OUTSTANDING BOND ISSUES 0 0 0 4265000 426500 4776317 101185 1 0 1 1 0 0 0 0 0 0 0 0 0 0 0 GLENN HAYNES PRESIDENT 33792 CAPITAL LEASE 0 EXTENDED HEALTH SERVICES ENTITY MORE THAN 35% OWNED BY BOARD PRESIDENT 576163 INDEPENDENT CONTRACTOR 0 FORM 990, PART VI, SECTION B, LINE 11 FORM 990 WILL BE PROVIDED TO THE BOARD OF DIRECTORS AT A REGULARLY SCHEDULED BOARD MEETING FOLLOWING THE FILING OF THE RETURN. COMPENSATION FOR EXISTING OFFICERS AND KEY EMPLOYEES IS COMPARED WITH MO HOSPITAL ASSOCIATION SALARY SURVEY DATA. FORM 990, PART VI, SECTION C, LINE 19 FINANCIAL STATEMENTS ARE AVAILABLE UPON WRITTEN REQUEST.