2011-10-06T10:25:42-05:00 2010-12-31 LARSONALLEN LLP 220 SOUTH SIXTH STREET SUITE 300 MINNEAPOLIS MN 55402 990 2010-01-01 411949230 GLENCOE REGIONAL HEALTH SERVICES GLEN 3208643121 1805 HENNEPIN AVENUE NORTH GLENCOE MN 553361416 JEFF GRANT 3208643121 2011-10-06 1 ROBERT E SCHILE 6123764500 2011-10-06 2010 2016-03-07 17:11:31Z JON BRABAND 1805 HENNEPIN AVENUE NORTH GLENCOE MN 553361416 59948777 0 X WWW.GRHSONLINE.ORG X 1999 MN TO PROVIDE HIGH QUALITY, CONVENIENT AND PERSONAL HEALTH CARE TO THOSE WE SERVE. 7 4 653 235 0 0 263748 375430 49105674 48763734 -59032 518905 241409 227889 49551799 49885958 130213 15103 0 0 28435957 29311037 0 0 0 18399451 17585658 46965621 46911798 2586178 2974160 70856509 74499893 29610879 29087110 41245630 45412783 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 STATES OF LIFE. 0 0 39214732 15103 41406079 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. 2633980 6905670 NURSING HOME - THE LONG-TERM CARE UNIT IS A 110-BED SKILLED NURSING FACILITY, WITH ALL BEDS MEDICARE AND MEDICAID CERTIFIED. 169294 451985 INDEPENDENT SENIOR LIVING - ORCHARD ESTATES IS A 40-UNIT SENIOR-HOUSING COMPLEX COMPRISED OF ONE AND TWO BEDROOM APARTMENTS. 42018006 1 1 0 1 0 0 0 1 0 1 0 0 0 1 1 1 0 0 0 0 0 0 0 0 0 1 0 0 1 1 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 27 0 653 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 JEFF GRANT 0.50 X X 1200 0 0 DR DOUG WAGONER 40.50 X X 252807 0 27546 JIM WATERS 0.50 X X 1100 0 0 DR JOHN BERGSENG 40.50 X 431052 0 27772 MIKE LONG 0.50 X 700 0 0 CAROL HAUKOS 0.50 X 300 0 0 DR BRYAN PETERSEN 40.50 X 291512 0 32881 JEANNE CONKEL 0.50 X 1000 0 0 JAN BRATSCH 0.50 X 1000 0 0 JON BRABAND 40.00 X 208071 0 40436 JOHN DOIDGE 40.00 X 147992 0 25382 DR JOHN MARK JOHNSON 40.00 X 374567 0 33002 DR ROBERT ZAJAC 40.00 X 336364 0 32663 DR CHAD ROBBINS 40.00 X 306489 0 32086 DR PREMAN SINGH 40.00 X 274692 0 9486 ROBERT LARTER 40.00 X 252491 0 16255 DR PETER SMYTH 40.00 X 233738 0 19933 DR KRISTINE KNUDTEN 40.00 X 251704 0 28157 3366779 0 325599 30 1 1 0 SHARED MEDICAL SERVICES PO BOX 330 COTTAGE GROVE WI 53527 MRI SERVICES 308200 QUEST DIAGNOSTICS PO BOX 12989 CHICAGO IL 60693 REFERENCE LAB 302226 PARK NICOLLETMETHODIST HOSPITAL PO BOX 16300 ST LOUIS PARK MN 55416 MANAGEMENT FEES 255545 CONSULTING RADIOLOGISTS 1221 NICOLLET MALL STE 600 MINNEAPOLIS MN 55403 NUCLEAR MED TECH 193680 ALLINA HOSPITALS & CLINICS PO BOX 9383 NW7710 MINNEAPOLIS MN 55440 ECHO FEES 180087 11 196902 178528 375430 HOSPITAL 623000 41317306 41317306 NURSING HOME 623000 6905670 6905670 SENIOR LIVING 623990 451985 451985 EQUITY INVEST. INCOME 623000 46707 46707 OTHER PROGRAM REVENUES 623000 42066 42066 48763734 598671 598671 6028 6028 6028 6028 9981853 1200 10059884 2935 -78031 -1735 -79766 -79766 CAFETERIA REVENUE 722210 177101 177101 MISCELLANEOUS 900099 44760 44760 221861 49885958 48763734 0 746794 15103 15103 1290719 862970 427749 21891933 20934231 957702 788016 740412 47604 3859248 3626111 233137 1481121 1391647 89474 7038 7038 60828 60828 2624364 2051450 572914 217257 4294 212963 1186836 969054 217782 199979 199979 1091197 1091197 218843 170230 48613 8135 8135 1234476 1234476 3223566 3223566 698850 227207 471643 MEDICAL EXPENSES 2997790 2997726 64 LICENSES & TAXES 1247630 73470 1174160 DRUGS 1144211 1139253 4958 BAD DEBT EXPENSE 752467 752467 REPAIRS & MAINTENANCE 267377 247650 19727 404814 189491 215323 46911798 42018006 4893792 0 7618180 8434552 18207141 23661926 6638322 6543268 245453 287019 792851 569518 56171486 32194821 25575683 23976665 10102043 9235291 864891 911598 396753 371068 415192 508988 70856509 74499893 3561676 3607651 25602937 24938681 31074 31790 415192 508988 29610879 29087110 X 41245630 45412783 41245630 45412783 70856509 74499893 X 2974160 1192993 X 0 1 1 X 0 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 0 0 0 0 0 1 2348 0 0 0 2348 0 EXPLANATION OF OTHER LOBBYING ACTIVITIES: PART II-B, LINE 1I: LOBBYING PORTION OF ASSOCIATION DUES PAID TO AHA AND MHA. 0 1 1221121 1221121 29712277 18914454 10797823 1410463 1040145 370318 23607331 12240222 11367109 220294 220294 23976665 DEFERRED COMPENSATION 508988 508988 49885958 46911798 2974160 1192993 1192993 4167153 48975438 1192993 1192993 47782445 2103513 2103513 49885958 46911798 0 46911798 0 46911798 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: 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. PART XII, LINE 4B - OTHER ADJUSTMENTS: UNRESTRICTED CONTRIBUTIONS AND GRANT 176,059. INVESTMENT INCOME 1,705,807. EQUITY IN INCOME OF AFFILIATED ORGANIZATION 46,707. RENTAL PROPERTY 6,028. MISCELLANEOUS 64,954. LOSS ON DISPOSAL OF ASSETS -1,735. CAPITAL GRANTS AND CONTRIBUTIONS 105,693. 1 1 X 1 X 1 X 0 1 1 0 1 1 1026037 1026037 0.02190 8796748 7587773 1208975 0.02580 9822785 7587773 2235012 0.04770 278668 38660 240008 0.00510 73969 73484 485 0.00000 54708 47879 6829 0.00010 0.00000 96157 96157 0.00200 503502 160023 343479 0.00720 10326287 7747796 2578491 0.05490 10232 10232 0.00020 10232 10232 0.00020 0 435449 9655031 10058446 -403415 X 1 1 1 1 GLENCOE REGIONAL HEALTH SERVICES

1805 HENNEPIN AVENUE NORTH GLENCOE MN 55336

X X X X NURSING HOME/SNF NA 1 2 GLENCOE REGIONAL HEALTH SERVICES

1024 CENTRAL AVENUE LESTER PRAIRIE MN 55354

CLINIC GLENCOE REGIONAL HEALTH SERVICES

300 BOWMAN STREET STEWART MN 55385

CLINIC 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 $752,467. 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: THE FACILITY PROVIDES AN ALLOWANCE FOR UNCOLLECTIBLE ACCOUNTS BASED ON MANAGEMENT'S JUDGMENT. PATIENTS AND RESIDENTS ARE NOT REQUIRED TO PROVIDE COLLATERAL FOR SERVICES PROVIDED. PAYMENT FOR SERVICES IS REQUIRED WITHIN 30 DAYS OF RECEIPT OF INVOICE. PAST DUE ACCOUNTS ARE INDIVIDUALLY ANALYZED FOR COLLECTIBILITY, AND THEN TURNED OVER TO COLLECTION AGENTS. ACCOUNTS FOR WHICH NO PAYMENTS HAVE BEEN RECEIVED ARE ANALYZED AND AFTER APPROVAL ARE WRITTEN OFF. IN ADDITION, AN ALLOWANCE IS ESTIMATED FOR OTHER ACCOUNTS BASED ON HISTORICAL EXPERIENCE OF THE FACILITY.BAD DEBT EXPENSE (AT COST) IS CALCULATED BY APPLYING THE COST-TO-CHARGE RATIO TO THE TOTAL BAD DEBT ATTRIBUTABLE TO PATIENT ACCOUNTS. 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 2010, 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. 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'D 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 2010, 44.5% 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 89.1%). 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 WAS 5,306. PART VI, LINE 7: THE ORGANIZATION IS NOT PART OF AN AFFILIATED HEALTH CARE SYSTEM. 1 EMPLOYEE SCHOLARSHIPS 14 14953 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. ONCE EMPLOYEES HAVE SUCCESSFULLY PASSED/COMPLETED THEIR COURSE(S) THEY ARE TO SUBMIT THEIR GRADES-WE REQUIRE C OR BETTER, AND THEN ARE 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 DOUG WAGONER 241913 0 9694 0 1200 0 0 0 27546 0 280353 0 0 0 DR JOHN BERGSENG 410070 0 20082 0 900 0 0 0 27772 0 458824 0 0 0 DR BRYAN PETERSEN 278644 0 10814 0 2054 0 0 0 32881 0 324393 0 0 0 JON BRABAND 180327 0 27744 0 0 0 0 0 40436 0 248507 0 0 0 JOHN DOIDGE 141457 0 6535 0 0 0 6797 0 18585 0 173374 0 0 0 DR JOHN MARK JOHNSON 358130 0 16437 0 0 0 0 0 33002 0 407569 0 0 0 DR ROBERT ZAJAC 320661 0 15703 0 0 0 0 0 32663 0 369027 0 0 0 DR CHAD ROBBINS 286461 0 14028 0 6000 0 0 0 32086 0 338575 0 0 0 DR PREMAN SINGH 271367 0 3325 0 0 0 0 0 9486 0 284178 0 0 0 ROBERT LARTER 252491 0 0 0 0 0 0 0 16255 0 268746 0 0 0 DR PETER SMYTH 222292 0 5446 0 6000 0 0 0 19933 0 253671 0 0 0 DR KRISTINE KNUDTEN 240199 0 11505 0 0 0 0 0 28157 0 279861 0 0 0 PART I, LINE 4B JOHN DOIDGE - 457(B) PLAN - $16,500 ROBERT LARTER - 457(B) PLAN - $16,500 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. CITY OF GLENCOE 416005185 378160BF1 2005-08-18 25440900 DEFEASE PART OF 2001 REV. BONDS & FUND EXPANSATION OF MEDICAL/SURGICAL UNIT. 0 0 0 1550900 25499173 353688 19021387 466682 5709899 0 1 1 1 0 0 0 0 0.00000 0.00000 0.00000 1 0 0 0 0 0 0 SCHEDULE K, PART II, LINE 3 DIFFERENCE FROM ISSUE PRICE THE GROSS PROCEEDS REPORTED ON PART II, LINE 3 ARE GREATER THAN THE ISSUE PRICE REPORTED ON PART I, COLUMN (E) BY $58,273. THE DIFFERENCE IS PROCEEDS USED FOR ACCRUED INTEREST. 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 2010. 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. CHANGES IN NET ASSETS OR FUND BALANCES: FORM 990, PART XI, LINE 5: NET UNREALIZED GAINS ON INVESTMENTS: 1,192,993.