2012-03-20T14:48:33-04:00 2011-08-31 BKD LLP 211 N BROADWAY SUITE 600 ST LOUIS MO 631022733 990 2010-09-01 370512290 Shelby Memorial Hospital Association Inc SHEL 2177743961 200 South Cedar Street Shelbyville IL 62565 PHILIP MILLER 2177743961 2012-02-29 true Donna J Larson 3142315544 2010 2016-02-24 21:20:13Z MARILYN SEARS 200 SOUTH CEDAR SHELBYVILLE IL 62565 21652526 false X N/A X 1916 IL ORGANIZATION'S UNIFIED MISSION IS TO MAINTAIN AND IMPROVE THE QUALITY OF LIFE OF THE PEOPLE IN THIS SERVICE AREA THROUGH THE PROVISION OF QUALITY HEALTH CARE PROGRAMS, SERVICES, EQUIPMENT AND PERSONAL CARE. 12 12 213 0 -21339 -240629 69326 58636 14550846 17172953 322339 1146400 157813 200371 15100324 18578360 0 0 0 0 6680692 8191486 0 0 0 8086318 8715049 14767010 16906535 333314 1671825 32054721 36837824 9043418 11175834 23011303 25661990 THE ASSOCIATION'S PURPOSE IS TO ESTABLISH AND MAINTAIN A FACILITY FOR THE CARE OF PERSONS SUFFERING FROM ILLNESS OR DISABILITIES, REGARDLESS OF RACE, COLOR, CREED, SEX, NATIONAL ORIGIN OR ABILITY TO PAY; TO CARRY ON EDUCATIONAL ACTIVITIES RELATED TO RENDERING CARE TO THE SICK AND INJURED; AND TO PARTICIPATE IN ANY ACTIVITY DESIGNED AND CARRIED ON SO AS TO PROMOTE THE GENERAL HEALTH OF THE COMMUNITY. false false 14238621 17194292 OPERATION OF A 30 BED HOSPITAL FACILITY PROVIDING ALL ROUTINE AND ANCILLARY SERVICES. SERVICES INCLUDED 25,912 OUTPATIENT REGISTRATIONS, 7,697 RURAL HEALTH CLINIC VISITS, 3,569 INPATIENT DAYS & 5,234 EMERGENCY ROOM VISITS. 14238621 true true false false false false false false true true false false true true false false true false false false false false false false false true true false false true true false false false false false false false false false false false false false false false true true true false false true 21 0 true 213 true true true false false false false false false false false false X 12 12 false false false false false false false true true false false false true true true true true true true false IL X PHILIP MILLER 2177743961 200 SOUTH CEDAR SHELBYVILLE IL 62565 X ELAINE BERRY 1.0 X X 0 0 0 DR DAVID OLIGSCHLAEGER 1.0 X 0 0 0 SUSAN TYNAN 1.0 X 0 0 0 MARK LUCE 1.0 X 0 0 0 JACK YOCKEY 1.0 X 0 0 0 PAUL KARRAKER 1.0 X 0 0 0 TADD BRACHBILL 1.0 X 0 0 0 TAD MAYHALL 1.0 X X 0 0 0 LARRY DILLEY 1.0 X 0 0 0 JAMES KLEPZIG 1.0 X X 0 0 0 KEVIN ROSS 1.0 X 0 0 0 RANDY BIEHLER 1.0 X 0 0 0 MARILYN SEARS 40.0 X 135559 0 6442 REGINA CALVERT 40.0 X 108082 0 8527 PHILIP MILLER 40.0 X 91913 0 5802 DR ARNOLD AGAPITO 40.0 X 182005 0 7485 517559 0 28256 3 false true false CARDINAL HEALTH 21377 NETWORK PLACE CHICAGO IL 60673 PHARMACY MANAGEMENT 768288 EMERGENCY STAFFING SOLUTIONS 17304 PRESTON ROAD SUITE 555 DALLAS TX 75252 ER PHYSICIANS 609720 MURRAY COMPANY 1807 PARK 270 DRIVE SUITE 460 ST LOUIS MO 63146 CONSTRUCTION 1702085 CPSI PO BOX 850309 MOBILE AL 36685 COMPUTER SYSTEMS 334642 IMPACT COMMUNICATIONS 303 N 2ND STREET SUITE 28 ST CHARLES IL 60174 MARKETING 216938 18 21276 37360 58636 CHARGE FOR MEDICAL SRVC, ROOM, CARE & OTHER 621110 15540815 15540815 SHE ANCILLARY 446199 -21339 -21339 MISCELLANEOUS INCOME 900099 60477 60477 EHR INCENTIVE PAYMENT 900099 1593000 1593000 17172953 550942 550942 0 0 0 0 175178 13940 161238 161238 161238 3652784 2900 3060226 0 592558 2900 595458 595458 0 0 0 0 0 0 CATERING INCOME 722320 1570 1570 CAFETERIA SALES 722100 37563 37563 39133 18578360 17194292 -21339 1346771 0 0 0 0 516866 516866 0 5975096 5430315 544781 0 192455 162057 30398 1059973 928806 131167 447096 376478 70618 0 10470 10470 92064 92064 0 0 0 2067635 2067635 265261 265261 1900424 1513509 386915 0 0 313129 313129 69533 43891 25642 0 0 198564 198564 0 918278 826450 91828 348934 348934 BAD DEBT EXPENSE 1767469 1767469 IPA ASSESSMENT FEE 250484 250484 PHARMACY 124546 124546 COLLECTION & ADMINISTRATION 127841 127841 DUES & FEES 108248 49124 59124 152169 119467 32702 16906535 14238621 2667914 0 2454034 1993911 845773 851577 2323384 2744377 73212 0 185064 186157 435863 282916 27370024 17960601 7433158 9409423 16944038 18949721 4356 4356 18333 20208 1337506 2395178 32054721 36837824 1068418 1625410 7315000 9000000 660000 550424 9043418 11175834 X 22911303 25561990 60000 60000 40000 40000 23011303 25661990 32054721 36837824 X 1671825 978862 X false true false X false X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 1358320 56 958779 399597 1348180 9900 240 1358320 1324418 22970 792 1348180 0.74970 0.10010 0.15020 false false 473600 473600 10859529 6842980 4016549 245904 84709 161195 3863954 3321967 541987 11927037 7710945 4216092 9409423 DEFERRED FINANCING COSTS 80471 ASSETS LIMITED TO USE 2314707 2395178 0 EST. THIRD PARTY SETTLEMENTS 550424 550424 USE OF ENDOWMENT FUNDS PART V, LINE 4 THE FUNDS ARE TO BE USED FOR BOND RESERVE FUND, A LETTER OF CREDIT AGREEMENT, OPERATIONS, AND MAINTENANCE OF ASSOCIATION. FIN 48 DISCLOSURE PART X, LINE 2 MANAGEMENT HAS EVALUATED THEIR INCOME TAX POSITIONS UNDER THE GUIDANCE INCLUDED IN ASC 740. BASED ON THEIR REVIEW, MANAGEMENT HAS NOT IDENTIFIED ANY MATERIAL UNCERTAIN TAX POSITIONS TO BE RECORDED OR DISCLOSED IN THE FINANCIAL STATEMENTS. true true X true X true X true true false false 525755 525755 0.03470 1937421 1301805 635616 0.04200 2463176 1301805 1161371 0.07670 38777 38777 0.00260 38777 38777 0.00260 2501953 1301805 1200148 0.07930 true 393000 7748187 6403139 1345048 X false 1 1 SHELBY MEMORIAL HOSPITAL ASSOCIATIONINC

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200 SOUTH CEDAR SHELBYVILLE IL 62565

LONG TERM CARE CHARITY CARE & COMMUNITY BENEFITS AT COST PART I, LINE 7 THE COSTS REPORTED IN THE TABLE IN PART I, LINE 7 USED A RATIO OF PATIENT CARE COSTS TO CHARGES AS COMPUTED IN WORKSHEET 2 OF THE FORM INSTRUCTIONS. THIS METHODOLOGY WAS USED FOR ALL PATIENT SEGMENTS. CHARITY CARE & COMMUNITY BENEFITS AT COST PERCENT OF TOTAL EXPENSE PART I, LINE 7, COLUMN F THE ORGANIZATION HAD BAD DEBT EXPENSE IN THE AMOUNT OF $1,767,469 REPORTED ON PART IX, LINE 25, HOWEVER, IT HAS BEEN SUBTRACTED FOR PURPOSES OF CALCULATING THE PERCENTAGE IN THIS COLUMN. BAD DEBT EXPENSE PART III, LINE 4 THE ASSOCIATION REPORTS PATIENT ACCOUNTS RECEIVABLE FOR SERVICES RENDERED AT NET REALIZABLE AMOUNTS FROM THIRD-PARTY PAYERS, PATIENTS AND OTHERS. THE ASSOCIATION PROVIDES AN ALLOWANCE FOR DOUBTFUL ACCOUNTS BASED UPON A REVIEW OF OUTSTANDING RECEIVABLES, HISTORICAL COLLECTION INFORMATION AND EXISTING ECONOMIC CONDITIONS. AS A SERVICE TO THE PATIENT, THE ASSOCIATION BILLS THIRD-PARTY PAYERS DIRECTLY AND BILLS THE PATIENT WHEN THE PATIENT'S LIABILITY IS DETERMINED. PATIENT ACCOUNTS RECEIVABLE ARE DUE IN FULL WHEN BILLED. ACCOUNTS ARE CONSIDERED DELINQUENT AND SUBSEQUENTLY WRITTEN OFF AS BAD DEBTS BASED ON INDIVIDUAL CREDIT EVALUATION AND SPECIFIC CIRCUMSTANCES OF THE ACCOUNT. THE AMOUNT REPORTED ON LINE 2 WAS DETERMINED USING THE COST TO CHARGE RATIO. MEDICARE COSTS PART III, LINE 8 THE AMOUNT REPORTED ON LINE 6 WAS OBTAINED FROM THE ORGANIZATION'S MEDICARE COST REPORT. NEEDS ASSESSMENT PART VI, LINE 2 SHELBY MEMORIAL HOSPITAL HAS CONDUCTED JOINT COMMUNITY HEALTH ASSESSMENTS THROUGH A LOCAL COMMUNITY HEALTH COMMITTEE. THE COMMITTEE CONSISTS OF EXECUTIVES OF SHELBY MEMORIAL HOSPITAL, PHYSICIAN REPRESENTATION FROM THE SHELBY COUNTY BOARD OF HEALTH, A REPRESENTATIVE FROM THE SHELBY COUNTY COMMUNITY SERVICES, A REPRESENTATIVE OF THE LOCAL COMMUNITY, AND LOCAL HEALTH DEPARTMENT OFFICIALS. DATA FROM DIFFERENT GROUPINGS WAS COLLECTED AND ANALYZED TO HELP ESTABLISH PRIORITIES. GROUPINGS INCLUDED DEMOGRAPHIC AND SOCIOECONOMIC CHARACTERISTICS, GENERAL HEALTH AND ACCESS TO CARE, MATERNAL AND CHILD HEALTH CARE, CHRONIC DISEASE, INFECTIOUS DISEASE, AND ENVIRONMENTAL/OCCUPATIONAL HEALTH AND INJURY CONTROL. PATIENT EDUCATION OF ELIGIBILITY FOR ASSISTANCE PART VI, LINE 3 MULTIPLE AVENUES OF EDUCATION ARE UTILIZED TO INSURE ELIGIBLE INDIVIDUALS ARE AWARE OF AVAILABILITY OF ASSISTANCE THROUGH GOVERNMENTAL AND HOSPITAL BASED PROGRAMS. PATIENTS ARE PROVIDED WITH A PACKET OF INFORMATION THAT DETAILS THE AVAILABILITY OF UNINSURED DISCOUNTS AND CHARITY CARE PROGRAMS. ALL STATEMENTS WITH PATIENT DUE BALANCES HAVE WORDING INCLUDED TO SHOW THE AVAILABILITY OF SUCH ASSISTANCE. PRINTED MATERIALS CLEARLY IDENTIFY THE AVAILABILITY OF PROGRAMS. THE HOSPITAL WEB SITE ALSO HAS PROMINENT LANGUAGE ON ALL PAGES CONCERNING AVAILABILITY OF ASSISTANCE. COMMUNITY INFORMATION PART VI, LINE 4 SHELBY MEMORIAL HOSPITAL PRIMARILY SERVES THE RESIDENTS OF SHELBY COUNTY, ILLINOIS. TOTAL POPULATION IS 21,874 ACCORDING TO THE 2008 CENSUS ESTIMATES AVAILABLE ON FACTFINDER.CENSUS.GOV. 22% OF RESIDENTS ARE UNDER THE AGE OF 18; 18.6% ARE 65 AND OLDER. 10.4% OF ALL PEOPLE ARE IDENTIFIED AS BEING AT OR BELOW POVERTY LEVEL. PROMOTION OF COMMUNITY HEALTH PART VI, LINE 5 SINCE 1918, SHELBY MEMORIAL HOSPITAL HAS PROVIDED FOR THE HEALTH CARE NEEDS OF SHELBY COUNTY AND OTHER SURROUNDING COMMUNITIES. SMH IS LOCATED IN CENTRAL ILLINOIS, IT IS THE ONLY HOSPITAL IN SHELBY COUNTY. SMH IS COMMITTED TO THE HEALTH AND WELFARE OF THE PEOPLE IT SERVES. OVER THE LAST 90+ YEARS, SMH HAS PROVIDED EMERGENT AND NON-EMERGENT CARE REGARDLESS OF A PERSON'S ABILITY TO PAY. SMH WORKS CLOSELY WITH OTHER AGENCIES IN THE AREA TO PROVIDE FOR THOSE NEEDS BEYOND THE SCOPE OF THE HOSPITAL, SUCH AS TRANSPORTATION, PRESCRIPTION ASSISTANCE, SOCIAL WELFARE AND DAILY LIVING NEEDS. SMH PROVIDES THE RESOURCES TO RECRUIT HEALTHCARE WORKERS, PHYSICIAN ASSISTANTS, AND PHYSICIANS TO THE AREA. SMH HAS ESTABLISHED A RURAL HEALTH CARE CENTER TO HELP COMBAT THE PHYSICIAN SHORTAGE IN RURAL AMERICA AND PROVIDE FOR THOSE UNABLE TO PAY FOR SUCH CARE. MEMBERS OF THE SMH TEAM ARE ACTIVE MEMBERS IN THE ECONOMIC DEVELOPMENT COMMITTEE OF SHELBY COUNTY, THE CHAMBER OF COMMERCE, THE MID-ILLINOIS CHAPTER OF THE AMERICAN RED CROSS AND OTHER CIVIC AND NOT FOR PROFIT ORGANIZATIONS DEDICATED TO THE BETTERMENT OF LIVING STANDARDS FOR THE RESIDENTS OF THE AREA. THE BOARD OF DIRECTORS AND MANAGEMENT OF SMH ARE COMMITTED TO PROVIDING THE BEST IN CARE AND EQUIPMENT TO THE COMMUNITY AS IS DEMONSTRATED IN OUR MOST RECENT PURCHASE OF DIGITAL MAMMOGRAPHY EQUIPMENT, LAPAROSCOPIC SURGERY EQUIPMENT AND NEW CARDIAC MONITORING SYSTEMS IN THE PAST TWO YEARS. ADDITIONALLY, SMH HAS SPENT MONIES AND TIME IN MEETING MEANINGFUL USE FOR THE COMPUTERIZED MEDICAL RECORD. SMH'S COMMITMENT TO ELECTRONIC MEDICAL RECORDS MAKES US ONE OF THE FEW SMALL RURAL HOSPITALS IN THE NATION APPLYING TO THE FEDERAL GOVERNMENT FOR THE FUNDS AS OF JANUARY 2011 UNDER THE AMERICAN RECOVERY ACT OF 2009. ALL FUNDS ARE RETAINED BY THE CORPORATION AND REINVESTED IN THE HEALTHCARE NEEDS OF THE COMMUNITY PRESENT OR FUTURE. X X X X false false false false false false false false false DR ARNOLD AGAPITO 143405 0 38600 0 0 0 7280 0 205 0 189490 0 0 0 CITY OF SHELBYVILLE 421741646 2010-12-30 9000000 CONSTRUCTION/RETIREMENT OF BONDS false false false 0 0 9000000 0 0 7165000 0 0 0 0 1835000 2015 true false false true false false false false false 0.00000 0.00000 0.00000 true false false false false false false false false REVIEW PROCESS FORM 990, PART IV, SECTION A, LINE 11 THE 990 IS REVIEWED BY THE CFO FOR ACCURACY. NO REVIEW WAS OR WILL BE CONDUCTED BY THE ORGANIZATION'S GOVERNING BODY. COMPLIANCE WITH CONFLICT OF INTEREST POLICY FORM 990, PART IV, SECTION B, LINE 12C OFFICERS, DIRECTORS OR TRUSTEES, AND KEY EMPLOYEES ARE REQUIRED TO DISCLOSE ANNUALLY INTERESTS THAT COULD GIVE RISE TO CONFLICTS. THE ORGANIZATION ALSO HOLDS QUARTERLY MEETINGS WITH EMPLOYEES. THE HOSPITAL'S CEO, CFO, AND CNE ARE RESPONSIBLE FOR DETERMINING AND REVIEWING ANY CONFLICTS OF INTEREST. PROCESS FOR DETERMINING COMPENSATION FORM 990, PART VI, SECTION B, LINE 15A/B WAGE SCALE IS PREPARED USING COMPARISON INFO FROM OTHER HOSPITALS. IT IS PREPARED BY THE HUMAN RESOURCE DIRECTOR AND ENFORCED BY THE HUMAN RESOURCE DIRECTOR AND THE CFO. PROCESS FOR MAKING DOCUMENTS AVAILABLE TO PUBLIC FORM 990, PART VI, SECTION C, LINE 19 THE ORGANIZATION MAKES ITS GOVERNING DOCUMENTS, CONFLICT OF INTEREST POLICY, AND FINANCIAL STATEMENTS AVAILABLE TO THE PUBLIC UPON REQUEST. OTHER CHANGES IN NET ASSETS FORM 990, PART XI, LINE 5 UNREALIZED GAIN $ 979,056 MISC. DIFFERENCE $ <194> _________ TOTAL OTHER CHANGES $ 978,862 HOURS DEVOTED FOR RELATED ORGANIZATION FORM 990 PART VII NAME:ELAINE BERRY TITLE:CHAIRMAN HOURS:1 HOURS DEVOTED FOR RELATED ORGANIZATION FORM 990 PART VII NAME:MARILYN SEARS TITLE:PRESIDENT/CEO HOURS:1 HOURS DEVOTED FOR RELATED ORGANIZATION FORM 990 PART VII NAME:PHILIP MILLER TITLE:CFO HOURS:1 SHELBY MEMORIAL HOSPITAL FOUNDATIONINC 200 SOUTH CEDAR STREET SHELBYVILLE IL 62565 371294401 FUNDRAISING IL 501(C)3 11 - I SMHA false false true false false false false false false false false false true true false false false true SHELBY MEMORIAL HOSPITAL FOUNDATION INC R 73212