Form990
Click to see attachment
Department of the Treasury
Internal Revenue Service
Return of Organization Exempt From Income Tax
Under section 501(c), 527, or 4947(a)(1) of the Internal Revenue Code (except black lung benefit trust or private foundation)

MediumBullet The organization may have to use a copy of this return to satisfy state reporting requirements.
OMB No. 1545-0047
2010
Open to Public Inspection
A For the calendar year, or tax year beginning 05-01-2010 and ending 04-30-2011
BCheck if applicable:
CName of organization
Pekin Memorial Hospital
 
Doing Business As
 
 
Number and street (or P.O. box if mail is not delivered to street address)
600 South 13th Street
 
Room/suite
City or town, state or country, and ZIP + 4
Pekin, IL61554
D Employer identification number

37-0692351
E Telephone number

G Gross receipts $ 77,145,322
F Name and address of principal officer:
STEVEN HALL CFO
600 SOUTH 13TH STREET
PEKIN,IL61554
I
Tax-exempt status: (   ) LeftBullet (insert no.) or
J
Website:MediumBullet
WWW.PEKINHOSPITAL.ORG
H(a)
Is this a group return for
affiliates?
H(b)
Are all affiliates included?
If "No," attach a list. (see instructions)
H(c)
Group exemption number MediumBullet  
K Form of organization:
 
L Year of formation: 1913
M State of legal domicile: IL
Part I
Summary
Activities & Governance 1 Briefly describe the organization’s mission or most significant activities: TO BE THE HEALTHCARE PROVIDER OF CHOICE IN THE COMMUNITIES WE SERVE.
2 Check this box MediumBullet
3 Number of voting members of the governing body (Part VI, line 1a) .... 3 11
4 Number of independent voting members of the governing body (Part VI, line 1b) .... 4 7
5 Total number of individuals employed in calendar year 2010 (Part V, line 2a) ... 5 823
6 Total number of volunteers (estimate if necessary) .... 6 215
7a Total unrelated business revenue from Part VIII, column (C), line 12 .. 7a 1,103,941
b Net unrelated business taxable income from Form 990-T, line 34 .. 7b 0
Revenues; Prior Year Current Year
8 Contributions and grants (Part VIII, line 1h) ......... 205,325 260,885
9 Program service revenue (Part VIII, line 2g) ......... 77,150,680 75,334,988
10 Investment income (Part VIII, column (A), lines 3, 4, and 7d ) .... 685,254 841,992
11 Other revenue (Part VIII, column (A), lines 5, 6d, 8c, 9c, 10c, and 11e) 744,411 701,524
12 Total revenue—add lines 8 through 11 (must equal Part VIII, column (A), line 12)................... 78,785,670 77,139,389
Expenses; 13 Grants and similar amounts paid (Part IX, column (A), lines 1–3 )... 0 0
14 Benefits paid to or for members (Part IX, column (A), line 4) .... 0 0
15 Salaries, other compensation, employee benefits (Part IX, column (A), lines 5–10) 34,365,561 33,956,442
16a Professional fundraising fees (Part IX, column (A), line 11e).... 0 0
b Total fundraising expenses (Part IX, column (D), line 25) MediumBullet0    
17 Other expenses (Part IX, column (A), lines 11a–11d, 11f–24f).... 38,320,405 37,955,740
18 Total expenses. Add lines 13–17 (must equal Part IX, column (A), line 25) 72,685,966 71,912,182
19 Revenue less expenses. Subtract line 18 from line 12...... 6,099,704 5,227,207
Net Assets or Fund Balances; Beginning of Current Year End of Year
20 Total assets (Part X, line 16)............ 70,977,927 73,265,768
21 Total liabilities (Part X, line 26)............ 44,102,655 41,541,789
22 Net assets or fund balances. Subtract line 21 from line 20 ..... 26,875,272 31,723,979
Part II
Signature Block
Under penalties of perjury, I declare that I have examined this return, including accompanying schedules and statements, and to the best of my knowledge and belief, it is true, correct, and complete. Declaration of preparer (other than officer) is based on all information of which preparer has any knowledge.
Sign Here
JumboBullet
Signature of officer Date
JumboBullet
Type or print name and title.
Paid Preparer's Use Only Preparer's
signatureBig Right Arrow 		Date
right pointing bullet image Preparer’s taxpayer identification number
(see instructions)
Firm’s name (or yours
if self-employed),
address, and ZIP + 4Big Right Arrow




 		EIN right pointing bullet image
Phone no. right pointing bullet image
May the IRS discuss this return with the preparer shown above? (see instructions) .........
For Privacy Act and Paperwork Reduction Act Notice, see the separate instructions.
Cat. No. 11282Y
Form 990 (2010)
Form 990 (2010)
Page 2
Part III
Statement of Program Service Accomplishments
Check if Schedule O contains a response to any question in this Part III . . . . . . . . . .
1
Briefly describe the organization’s mission: TO BE THE HEALTHCARE PROVIDER OF CHOICE IN THE COMMUNITIES WE SERVE.
2
Did the organization undertake any significant program services during the year which were not listed on
the prior Form 990 or 990-EZ? ....................
If “Yes,” describe these new services on Schedule O.
3
Did the organization cease conducting, or make significant changes in how it conducts, any program services? ..........................
If “Yes,” describe these changes on Schedule O.
4
Describe the exempt purpose achievements for each of the organization’s three largest program services by expenses.
Section 501(c)(3) and 501(c)(4) organizations and section 4947(a)(1) trusts are required to report the amount of grants and allocations to others, the total expenses, and revenue, if any, for each program service reported.
4a (Code:   ) (Expenses $ 66,592,829 including grants of $   ) (Revenue $ 75,338,766 )
PEKIN MEMORIAL HOSPITAL PROVIDES INPATIENT, OUTPATIENT AND EMERGENCY SERVICES TO PATIENTS IN PEKIN, ILLINOIS AND SURROUNDING AREAS. THE HOSPITAL OPERATES A LICENSED 98 ACUTE CARE BED AND 27 SKILLED NURSING BED FACILITY. PATIENT DAYS WERE 17,491; ADJUSTED PATIENT DAYS WERE 44,256; CASE MIX INDEX WAS 1.3200. SEE SCHEDULE O.
4b (Code:   ) (Expenses $   including grants of $   ) (Revenue $   )
4c (Code:   ) (Expenses $   including grants of $   ) (Revenue $   )
4d Other program services. (Describe in Schedule O.)
(Expenses $   including grants of $   ) (Revenue $   )
4e Total program service expensesMediumBullet$ 66,592,829
Form 990 (2010)
Form 990 (2010)
Page 3
Part IV
Checklist of Required Schedules
Yes
No
1
Is the organization described in section 501(c)(3) or 4947(a)(1) (other than a private foundation)? If “Yes,” complete Schedule AClick to see attachment.....................
1
Yes
 
2
Is the organization required to complete Schedule B, Schedule of Contributors? Click to see attachment........
2
Yes
 
3
Did the organization engage in direct or indirect political campaign activities on behalf of or in opposition to candidates for public office? If “Yes,” complete Schedule C, Part IClick to see attachment..........
3
 
No
4
Section 501(c)(3) organizations. Did the organization engage in lobbying activities? If “Yes,” complete Schedule C,
Part IIClick to see attachment.........................
4
Yes
 
5
Is the organization a section 501(c)(4), 501(c)(5), or 501(c)(6) organization that receives membership dues, assessments, or similar amounts as defined in Revenue Procedure 98-19? If “Yes,” complete Schedule C, Part III........................
5
 
 
6
Did the organization maintain any donor advised funds or any similar funds or accounts where donors have the right to provide advice on the distribution or investment of amounts in such funds or accounts? If “Yes,” complete
Schedule D, Part IClick to see attachment.......................
6
 
No
7
Did the organization receive or hold a conservation easement, including easements to preserve open space,
the environment, historic land areas or historic structures? If “Yes,” complete Schedule D, Part IIClick to see attachment...
7
 
No
8
Did the organization maintain collections of works of art, historical treasures, or other similar assets? If “Yes,” complete Schedule D, Part III Click to see attachment....................
8
 
No
9
Did the organization report an amount in Part X, line 21; serve as a custodian for amounts not listed in Part X; or provide credit counseling, debt management, credit repair, or debt negotiation services? If “Yes,”
complete Schedule D, Part IVClick to see attachment...................
9
 
No
10
Did the organization, directly or through a related organization, hold assets in term, permanent,or quasi-endowments? If “Yes,” complete Schedule D, Part VClick to see attachment
10
 
No
11
If the organization’s answer to any of the following questions is ‘Yes,’ then complete Schedule D, Parts VI, VII, VIII, IX, or X as applicable:
a
Did the organization report an amount for land, buildings, and equipment in Part X, line10? If “Yes,” complete Schedule D, Part VI.Click to see attachment
11a
Yes
 
b
Did the organization report an amount for investments—other securities in Part X, line 12 that is 5% or more of its total assets reported in Part X, line 16? If “Yes,” complete Schedule D, Part VII.Click to see attachment
11b
 
No
c
Did the organization report an amount for investments—program related in Part X, line 13 that is 5% or more of its total assets reported in Part X, line 16? If “Yes,” complete Schedule D, Part VIII.Click to see attachment
11c
 
No
d
Did the organization report an amount for other assets in Part X, line 15 that is 5% or more of its total assets reported in Part X, line 16? If “Yes,” complete Schedule D, Part IX.Click to see attachment
11d
 
No
e
Did the organization report an amount for other liabilities in Part X, line 25? If “Yes,” complete Schedule D, Part X.Click to see attachment
11e
Yes
 
f
Did the organization’s separate or consolidated financial statements for the tax year include a footnote that addresses the organization’s liability for uncertain tax positions under FIN 48 (ASC 740)? If “Yes,” complete Schedule D, Part X.Click to see attachment
11f
 
No
12a
Did the organization obtain separate, independent audited financial statements for the tax year? If “Yes,” complete Schedule D, Parts XI, XII, and XIII Click to see attachment
12a
 
No
b
Was the organization included in consolidated, independent audited financial statements for the tax year? If “Yes,” and if the organization answered ‘No’ to line 12a, then completing Schedule D, Parts XI, XII, and XIII is optional Click to see attachment
12b
Yes
 
13
Is the organization a school described in section 170(b)(1)(A)(ii)? If “Yes,” complete Schedule E
13
 
No
14a
Did the organization maintain an office, employees, or agents outside of the United States?....
14a
 
No
b
Did the organization have aggregate revenues or expenses of more than $10,000 from grantmaking, fundraising, business, and program service activities outside the United States? If “Yes,” complete Schedule F, Part I.........
14b
 
No
15
Did the organization report on Part IX, column (A), line 3, more than $5,000 of grants or assistance to any organization or entity located outside the U.S.? If “Yes,” complete Schedule F, Part II..
15
 
No
16
Did the organization report on Part IX, column (A), line 3, more than $5,000 of aggregate grants or assistance to individuals located outside the U.S.? If “Yes,” complete Schedule F, Part III..
16
 
No
17
Did the organization report a total of more than $15,000, of expenses for professional fundraising services on Part IX, column (A), lines 6 and 11e? If “Yes,” complete Schedule G, Part I
17
 
No
18
Did the organization report more than $15,000 total of fundraising event gross income and contributions on Part VIII, lines 1c and 8a? If “Yes,” complete Schedule G, Part II..........
18
 
No
19
Did the organization report more than $15,000 of gross income from gaming activities on Part VIII, line 9a? If “Yes,” complete Schedule G, Part III...................
19
 
No
Form 990 (2010)
Form 990 (2010)
Page 4
Part IV
Checklist of Required Schedules (continued)
20a
Did the organization operate one or more hospitals? If “Yes,” complete Schedule H..... Click to see attachment
20a
Yes
 
b
Did the organization attach its audited financial statement to this return? Note: All Form 990 filers that operate one or more hospitals must attach audited financial statements. ..... Click to see attachment
20b
Yes
 
21
Did the organization report more than $5,000 of grants and other assistance to governments and organizations in the United States on Part IX, column (A), line 1? If “Yes,” complete Schedule I, Parts I and II..
21
 
No
22
Did the organization report more than $5,000 of grants and other assistance to individuals in the United States on Part IX, column (A), line 2? If “Yes,” complete Schedule I, Parts I and III.....
22
 
No
23
Did the organization answer “Yes” to Part VII, Section A, questions 3, 4, or 5, about compensation of the organization’s current and former officers, directors, trustees, key employees, and highest compensated employees? If “Yes,” complete Schedule J................ Click to see attachment
23
Yes
 
24a
Did the organization have a tax-exempt bond issue with an outstanding principal amount of more than $100,000 as of the last day of the year, that was issued after December 31, 2002? If “Yes,” answer questions 24b–24d and complete Schedule K. If “No,” go to line 25................ Click to see attachment
24a
Yes
 
b
Did the organization invest any proceeds of tax-exempt bonds beyond a temporary period exception?...
24b
 
No
c
Did the organization maintain an escrow account other than a refunding escrow at any time during the year
to defease any tax-exempt bonds?......................
24c
 
No
d
Did the organization act as an “on behalf of” issuer for bonds outstanding at any time during the year?...
24d
 
No
25a
Section 501(c)(3) and 501(c)(4) organizations. Did the organization engage in an excess benefit transaction with a disqualified person during the year? If “Yes,” complete Schedule L, Part I...... Click to see attachment
25a
 
No
b
Is the organization aware that it engaged in an excess benefit transaction with a disqualified person in a prior year, and that the transaction has not been reported on any of the organization’s prior Forms 990 or 990-EZ? If “Yes,” complete Schedule L, Part I................ Click to see attachment
25b
 
No
26
Was a loan to or by a current or former officer, director, trustee, key employee, highly compensated employee, or disqualified person outstanding as of the end of the organization’s tax year? If “Yes,” complete Schedule L,
Part II........................... Click to see attachment
26
 
No
27
Did the organization provide a grant or other assistance to an officer, director, trustee, key employee, substantial contributor, or a grant selection committee member, or to a person related to such an individual? If “Yes,” complete Schedule L, Part III............... Click to see attachment
27
 
No
28
Was the organization a party to a business transaction with one of the following parties? (see Schedule L, Part IV instructions for applicable filing thresholds, conditions, and exceptions):
a
A current or former officer, director, trustee, or key employee? If “Yes,” complete Schedule L, Part IV ......................... Click to see attachment
28a
 
No
b
A family member of a current or former officer, director, trustee, or key employee? If “Yes,”
complete Schedule L, Part IV................... Click to see attachment
28b
 
No
c
An entity of which a current or former officer, director, trustee, or key employee (or a family member thereof) was an officer, director, trustee, or owner? If “Yes,” complete Schedule L, Part IV.. Click to see attachment
28c
Yes
 
29
Did the organization receive more than $25,000 in non-cash contributions? If “Yes,” complete Schedule M
29
 
No
30
Did the organization receive contributions of art, historical treasures, or other similar assets, or qualified conservation contributions? If “Yes,” complete Schedule M............
30
 
No
31
Did the organization liquidate, terminate, or dissolve and cease operations? If “Yes,” complete Schedule N,
Part I...........................
31
 
No
32
Did the organization sell, exchange, dispose of, or transfer more than 25% of its net assets? If “Yes,” complete Schedule N, Part II.......................
32
 
No
33
Did the organization own 100% of an entity disregarded as separate from the organization under Regulations sections 301.7701-2 and 301.7701-3? If “Yes,” complete Schedule R, Part I........ Click to see attachment
33
 
No
34
Was the organization related to any tax-exempt or taxable entity? If “Yes,” complete Schedule R, Parts II, III, IV, and V, line 1..................... Click to see attachment
34
Yes
 
35
Is any related organization a controlled entity within the meaning of section 512(b)(13)? .....
35
 
No
a
Did the organization receive any payment from or engage in any transaction with a controlled entity within the meaning of section 512(b)(13)? If “Yes,” complete Schedule R, Part V, line 2... Click to see attachment
36
Section 501(c)(3) organizations. Did the organization make any transfers to an exempt non-charitable related organization? If “Yes,” complete Schedule R, Part V, line 2........... Click to see attachment
36
 
No
37
Did the organization conduct more than 5% of its activities through an entity that is not a related organization and that is treated as a partnership for federal income tax purposes? If “Yes,” complete Schedule R, Part VIClick to see attachment
37
 
No
38
Did the organization complete Schedule O and provide explanations in Schedule O for Part VI, lines 11 and 19? Note. All Form 990 filers are required to complete Schedule O. ............
38
Yes
 
Form 990 (2010)
Form 990 (2010)
Page 5
Part V
Statements Regarding Other IRS Filings and Tax Compliance
Check if Schedule O contains a response to any question in this Part V . . . . . . . . . .
Yes
No
1a
Enter the number reported in Box 3 of Form 1096. Enter -0- if not applicable. .......
1a
80
b
Enter the number of Forms W-2G included in line 1a. Enter -0- if not applicable.
1b
0
c
Did the organization comply with backup withholding rules for reportable payments to vendors and reportable gaming (gambling) winnings to prize winners? ..................
1c
Yes
 
2a
Enter the number of employees reported on Form W-3, Transmittal of Wage and Tax Statements filed for the calendar year ending with or within the year covered by this return .....................
2a
823
b
If at least one is reported on line 2a, did the organization file all required federal employment tax returns?

Note. If the sum of lines 1a and 2a is greater than 250, you may be required to e-file. (see instructions)
2b
Yes
 
3a
Did the organization have unrelated business gross income of $1,000 or more during the year?.............................
3a
Yes
 
b
If “Yes,” has it filed a Form 990-T for this year? If “No,” provide an explanation in Schedule O.....
3b
Yes
 
4a
At any time during the calendar year, did the organization have an interest in, or a signature or other authority over, a financial account in a foreign country (such as a bank account or securities account)?.......................
4a
 
No
b
If "Yes," enter the name of the foreign country: MediumBullet
See instructions for filing requirements for Form TD F 90-22.1, Report of Foreign Bank and Financial Accounts.
5a
Was the organization a party to a prohibited tax shelter transaction at any time during the tax year?..
5a
 
No
b
Did any taxable party notify the organization that it was or is a party to a prohibited tax shelter transaction?
5b
 
No
c
If “Yes” to line 5a or 5b, did the organization file Form 8886-T? ........
5c
 
 
6a
Does the organization have annual gross receipts that are normally greater than $100,000, and did the organization solicit any contributions that were not tax deductible?..........
6a
 
No
b
If “Yes,” did the organization include with every solicitation an express statement that such contributions or gifts were not tax deductible?........................
6b
 
 
7
Organizations that may receive deductible contributions under section 170(c).
a
Did the organization receive a payment in excess of $75 made partly as a contribution and partly for goods and services provided to the payor?....................
7a
 
No
b
If “Yes,” did the organization notify the donor of the value of the goods or services provided?.....
7b
 
 
c
Did the organization sell, exchange, or otherwise dispose of tangible personal property for which it was required to file Form 8282?...........................
7c
 
No
d
If “Yes,” indicate the number of Forms 8282 filed during the year ....
7d
 
e
Did the organization receive any funds, directly or indirectly, to pay premiums on a personal benefit contract?..........................
7e
 
No
f
Did the organization, during the year, pay premiums, directly or indirectly, on a personal benefit contract?..
7f
 
No
g
If the organization received a contribution of qualified intellectual property, did the organization file Form 8899 as required?...................
7g
 
 
h
If the organization received a contribution of cars, boats, airplanes, or other vehicles, did the organization file a Form 1098-C?...............
7h
 
 
8
Sponsoring organizations maintaining donor advised funds and section 509(a)(3) supporting organizations. Did the supporting organization, or a donor advised fund maintained by a sponsoring organization, have excess business holdings at any time during the year?................
8
 
 
9
Sponsoring organizations maintaining donor advised funds.
a
Did the organization make any taxable distributions under section 4966?.........
9a
 
 
b
Did the organization make a distribution to a donor, donor advisor, or related person?......
9b
 
 
10
Section 501(c)(7) organizations. Enter:
a
Initiation fees and capital contributions included on Part VIII, line 12 ...
10a
 
b
Gross receipts, included on Form 990, Part VIII, line 12, for public use of club facilities
10b
 
11
Section 501(c)(12) organizations. Enter:
a
Gross income from members or shareholders .........
11a
 
b
Gross income from other sources (Do not net amounts due or paid to other sources against amounts due or received from them.) ........
11b
 
12a
Section 4947(a)(1) non-exempt charitable trusts. Is the organization filing Form 990 in lieu of Form 1041?
12a
 
 
b
If “Yes,” enter the amount of tax-exempt interest received or accrued during the year.
12b
 
13
Section 501(c)(29) qualified nonprofit health insurance issuers.
a
Is the organization licensed to issue qualified health plans in more than one state?
Note. All 501(c)(29) organizations must list in Schedule O each state in which they are licensed to issue qualified health plans, the amount of reserves required by each state, and the amount of reserves the organization allocated to each state.
13a
 
 
b
Enter the aggregate amount of reserves the organization is required to maintain by the states in which the organization is licensed to issue qualified health plans.
13b
 
c
Enter the aggregate amount of reserves on hand.
13c
 
14a
Did the organization receive any payments for indoor tanning services during the tax year?.....
14a
 
 
b
If "Yes," has it filed a Form 720 to report these payments? If “No,” provide an explanation in Schedule O..
14b
 
 
Form 990 (2010)
Form 990 (2010)
Page 6
Part VI
Governance, Management, and Disclosure For each “Yes” response to lines 2 through 7b below, and for a “No” response to lines 8a, 8b, or 10b below, describe the circumstances, processes, or changes in Schedule O. See instructions.
Check if Schedule O contains a response to any question in this Part VI . . . . . . . . . .
Section A. Governing Body and Management
Yes
No
1a
Enter the number of voting members of the governing body at the end of the tax year ..............
1a
11
b
Enter the number of voting members included in line 1a, above, who are independent .................
1b
7
2
Did any officer, director, trustee, or key employee have a family relationship or a business relationship with any other officer, director, trustee, or key employee? .................
2
Yes
 
3
Did the organization delegate control over management duties customarily performed by or under the direct supervision of officers, directors or trustees, or key employees to a management company or other person? ..
3
Yes
 
4
Did the organization make any significant changes to its governing documents since the prior Form 990 was filed?
4
 
No
5
Did the organization become aware during the year of a significant diversion of the organization’s assets? .
5
 
No
6
Does the organization have members or stockholders? ................
6
Yes
 
7a
Does the organization have members, stockholders, or other persons who may elect one or more members of the governing body? .........................
7a
Yes
 
b
Are any decisions of the governing body subject to approval by members, stockholders, or other persons? ..
7b
Yes
 
8
Did the organization contemporaneously document the meetings held or written actions undertaken during the year by the following:
a
The governing body? .........................
8a
Yes
 
b
Each committee with authority to act on behalf of the governing body? ............
8b
Yes
 
9
Is there any officer, director, trustee, or key employee listed in Part VII, Section A, who cannot be reached at the organization’s mailing address? If “Yes,” provide the names and addresses in Schedule O .....
9
 
No
Section B. Policies (This Section B requests information about policies not required by the Internal
Revenue Code.)
Yes
No
10a
Does the organization have local chapters, branches, or affiliates? ............
10a
 
No
b
If “Yes,” does the organization have written policies and procedures governing the activities of such chapters, affiliates, and branches to ensure their operations are consistent with those of the organization? ....
10b
 
 
11a
Has the organization provided a copy of this Form 990 to all members of its governing body before filing the form?
11a
Yes
 
b
Describe in Schedule O the process, if any, used by the organization to review the Form 990. .....
12a
Does the organization have a written conflict of interest policy? If “No,” go to line 13.......
12a
Yes
 
b
Are officers, directors or trustees, and key employees required to disclose annually interests that could give rise to conflicts? ...........................
12b
Yes
 
c
Does the organization regularly and consistently monitor and enforce compliance with the policy? If “Yes,” describe in Schedule O how this is done ....................
12c
Yes
 
13
Does the organization have a written whistleblower policy? ...............
13
Yes
 
14
Does the organization have a written document retention and destruction policy? .........
14
Yes
 
15
Did the process for determining compensation of the following persons include a review and approval by independent persons, comparability data, and contemporaneous substantiation of the deliberation and decision?
a
The organization’s CEO, Executive Director, or top management official ...........
15a
 
No
b
Other officers or key employees of the organization ................
15b
Yes
 
If "Yes" to line a or b, describe the process in Schedule O. (See instructions.)
16a
Did the organization invest in, contribute assets to, or participate in a joint venture or similar arrangement with a taxable entity during the year? ......................
16a
 
No
b
If “Yes,” has the organization adopted a written policy or procedure requiring the organization to evaluate its participation in joint venture arrangements under applicable federal tax law, and taken steps to safeguard the organization’s exempt status with respect to such arrangements? ............
16b
 
 
Section C. Disclosure
17
List the States with which a copy of this Form 990 is required to be filedMediumBullet
IL
18
Section 6104 requires an organization to make its Form 1023 (or 1024 if applicable), 990, and 990-T (501(c)(3)s only) available for public inspection. Indicate how you make these available. Check all that apply.
19
Describe in Schedule O whether (and if so, how), the organization makes its governing documents, conflict of interest policy, and financial statements available to the public.
20
State the name, physical address, and telephone number of the person who possesses the books and records of the organization: MediumBullet
PAM ROGERS
600 SOUTH 13TH STREET
PEKIN,IL61554
(309) 353-0796
Form 990 (2010)
Form 990 (2010)
Page 7
Part VII
Compensation of Officers, Directors,Trustees, Key Employees, Highest Compensated Employees, and Independent Contractors
Check if Schedule O contains a response to any question in this Part VII . . . . . . . . . .
Section A. Officers, Directors, Trustees, Key Employees, and Highest Compensated Employees
1a Complete this table for all persons required to be listed. Report compensation for the calendar year ending with or within the organization’s tax year.
RoundBullet List all of the organization’s current officers, directors, trustees (whether individuals or organizations), regardless of amount
of compensation, and current key employees. Enter -0- in columns (D), (E), and (F) if no compensation was paid.

RoundBullet List all of the organization’s current key employees, if any. See instructions for definition of "key employee."
RoundBullet List the organization’s five current highest compensated employees (other than an officer, director, trustee or key employee)
who received reportable compensation (Box 5 of Form W-2 and/or Box 7 of Form 1099-MISC) of more than $100,000 from the
organization and any related organizations.

RoundBullet List all of the organization’s former officers, key employees, or highest compensated employees who received more than $100,000
of reportable compensation from the organization and any related organizations.

RoundBullet List all of the organization’s former directors or trustees that received, in the capacity as a former director or trustee of the
organization, more than $10,000 of reportable compensation from the organization and any related organizations.

List persons in the following order: individual trustees or directors; institutional trustees; officers; key employees; highest
compensated employees; and former such persons.
Check this box if neither the organization nor any related organizations compensated any current or former officer, director, or trustee.
(A)
Name and Title 		(B)
Average hours per week (describe hours for related organizations in Schedule O) 		(C)
Position (check all that apply) 		(D)
Reportable compensation from the organization (W- 2/1099-MISC) 		(E)
Reportable compensation from related organizations (W- 2/1099-MISC) 		(F)
Estimated amount of other compensation from the organization and related organizations
Individual Trustee or Director; Institutional Trustee; Officer; Key Employee; Highest compensated employee; Former;
(1) DR STEVEN CLARK
TRUSTEE
 1.0 X           0 372,007 26,134
(2) DR JOHN LOVELL
TRUSTEE
 1.0 X           0 0 0
(3) RONALD MILLER
CHAIRMAN
 1.0 X   X       0 0 0
(4) JANET LANGE
TRUSTEE
 1.0 X           0 0 0
(5) EDWARD SIROTAK
TRUSTEE
 1.0 X           0 0 0
(6) RICHARD KRIEGSMAN
VICE-CHAIRMAN
 1.0 X   X       0 0 0
(7) ANDREW SPARKS
SECRETARY/TREASURER
 1.0 X   X       0 0 0
(8) MICHAEL TIBBS
TRUSTEE
 1.0 X           0 0 0
(9) CURTIS EETEN
TRUSTEE
 1.0 X           0 0 0
(10) DR KATHRYN KRAMER
TRUSTEE
 1.0 X           0 0 0
(11) JASON PROHEL
TRUSTEE
 1.0 X           0 0 0
(12) KEVIN R ANDREWS
CEO
 40.0     X       427,344 0 0
(13) STEVEN C HALL
CFO
 40.0     X       211,999 0 37,411
(14) JO ELLEN PATTERSON
CNO
 40.0       X     166,028 0 12,513
(15) ANNE DIERKER
VP HOSPITAL SERVICES
 40.0       X     162,322 0 20,057
(16) MICHAEL ERICKSON
CRNA
 40.0         X   259,825 0 28,552
(17) PEGGE HALL
CRNA
 40.0         X   245,065 0 30,358
Form 990 (2010)
Form 990 (2010)
Page 8
Part VII
Section A. Officers, Directors, Trustees, Key Employees, and Highest Compensated Employees (continued)
(A)
Name and Title 		(B)
Average hours per week (describe hours for related organizations in Schedule O) 		(C)
Position (check all that apply) 		(D)
Reportable compensation from the organization (W- 2/1099-MISC) 		(E)
Reportable compensation from related organizations (W- 2/1099-MISC) 		(F)
Estimated amount of other compensation from the organization and related organizations
Individual Trustee or Director; Institutional Trustee; Officer; Key Employee; Highest compensated employee; Former;
(18) CAROLYN SUTTER
CRNA
 40.0         X   233,550 0 23,034
(19) MELISSA NGO
CRNA
 40.0         X   222,390 0 13,147
(20) STEVEN BOOKER
DIRECTOR OF ANESTHESIA/CRNA
 40.0         X   236,660 0 39,052




















1b Sub-Total................MediumBullet
c Total from continuation sheets to Part VII, Section A....MediumBullet
d Total (add lines 1b and 1c)............MediumBullet 2,165,183 372,007 230,258
2
Total number of individuals (including but not limited to those listed above) who received more than $100,000 in reportable compensation from the organizationMediumBullet22
Yes
No
3
Did the organization list any former officer, director or trustee, key employee, or highest compensated employee on line 1a? If “Yes,” complete Schedule J for such individual .............
3
 
No
4
For any individual listed on line 1a, is the sum of reportable compensation and other compensation from the organization and related organizations greater than $150,000? If “Yes,” complete Schedule J for such individual...........................
4
Yes
 
5
Did any person listed on line 1a receive or accrue compensation from any unrelated organization or individual for services rendered to the organization? If “Yes,” complete Schedule J for such person .....
5
Yes
 
Section B. Independent Contractors
1
Complete this table for your five highest compensated independent contractors that received more than $100,000 of compensation from the organization.
(A)
Name and business address 		(B)
Description of services 		(C)
Compensation
INSTITUTE OF PHYSICAL MEDICINE AND
6501 NORTH SHERIDAN RD
PEORIA,IL61614 		REHAB SERVICES 1,356,097
ARAMARK FOOD
PO BOX 651009
CHARLOTTE,NC28265 		DIETARY 704,223
ARAMARK FACILITY SVC
22506 NETWORK
CHICAGO,IL60673 		EQUIP SVC CONTRACTS 962,139
GHELARDINI INC
219 INDIAN CREEK DR
PEKIN,IL61554 		CONSTRUCTION 414,541
QHR
105 CONTINENTAL PLACE
BRENTWOOD,TN370271018 		CONSULTING 862,725
2
Total number of independent contractors (including but not limited to those listed above) who received more than $100,000 in compensation from the organization MediumBullet18
Form 990 (2010)
Form 990 (2010)
Page 9
Part VIII
Statement of Revenue
(A)
Total revenue 		(B)
Related or
exempt
function
revenue 		(C)
Unrelated
business
revenue 		(D)
Revenue
excluded from
tax under sections
512, 513, or 514
Contributions, gifts, grants and other similar amounts 1a Federated campaigns..1a  
b Membership dues....1b  
c Fundraising events....1c  
d Related organizations...1d 260,885
e Government grants (contributions)1e  
f All other contributions, gifts, grants, and
similar amounts not included above1f 		 
g Noncash contributions included in lines 1a-1f:$  
h Total. Add lines 1a-1f.......MediumBullet 260,885
Program Service Revenue Business Code
2a PATIENT REVENUE 621,110 74,204,152 74,204,152    
b MEDICAL RECORD REV 561,000 30,673 30,673    
c REFERENCE LAB REV. 621,500 1,100,163   1,100,163  
d
e
f All other program service revenue .        
g Total. Add lines 2a–2f........MediumBullet 75,334,988
Other Revenue 3 Investment income (including dividends, interest
and other similar amounts).....MediumBullet 743,109     743,109
4 Income from investment of tax-exempt bond proceeds..MediumBullet 0     0
5 Royalties............MediumBullet 0     0
(i) Real (ii) Personal
6a Gross Rents 73,296  
b Less: rental expenses    
c Rental income or (loss) 73,296  
d Net rental income or (loss).......MediumBullet 73,296     73,296
(i) Securities (ii) Other
7a Gross amount from sales of assets other than inventory 88,715 16,101
b Less: cost or other basis and sales expenses 0 5,933
c Gain or (loss) 88,715 10,168
d Net gain or (loss)..........MediumBullet 98,883     98,883
8a Gross income from fundraising events (not including
$  
of contributions reported on line 1c). See Part IV, line 18 ...
a  
b Less: direct expenses ...b  
c Net income or (loss) from fundraising events..MediumBullet 0   0
9a Gross income from gaming activities.
See Part IV, line 19 ...
a  
b Less: direct expenses ...b  
c Net income or (loss) from gaming activities...MediumBullet 0     0
10a Gross sales of inventory, less
returns and allowances .
a  
b Less: cost of goods sold ..b  
c Net income or (loss) from sales of inventory..MediumBullet 0     0
Miscellaneous Revenue Business Code
11a LAUNDRY SERVICE 812,300 3,778   3,778  
b CAFETERIA REVENUE 722,210 538,660     538,660
c MISC. OTHER REV. 900,099 85,790     85,790
d All other revenue ....        
e Total. Add lines 11a–11d ......MediumBullet 628,228
12 Total revenue. See Instructions....MediumBullet 77,139,389 74,234,825 1,103,941 1,539,738
Form 990 (2010)
Form 990 (2010)
Page 10
Part IX
Statement of Functional Expenses
Section 501(c)(3) and 501(c)(4) organizations must complete all columns. All other organizations must complete column (A) but are not required to complete columns (B), (C), and (D).
Do not include amounts reported on lines 6b,
7b, 8b, 9b, and 10b of Part VIII. 		(A)
Total expenses 		(B)
Program service expenses 		(C)
Management and general expenses 		(D)
Fundraising expenses
1 Grants and other assistance to governments and organizations in the U.S. See Part IV, line 21 0  
2 Grants and other assistance to individuals in the U.S. See Part IV, line 22 0  
3 Grants and other assistance to governments, organizations, and individuals outside the U.S. See Part IV, lines 15 and 16 0  
4 Benefits paid to or for members 0  
5 Compensation of current officers, directors, trustees, and key employees .... 603,750 359,847 243,903 0
6 Compensation not included above, to disqualified persons (as defined under section 4958(f)(1)) and persons described in section 4958(c)(3)(B) .... 0      
7 Other salaries and wages 26,747,342 24,266,603 2,480,739  
8 Pension plan contributions (include section 401(k) and section 403(b) employer contributions) .... 993,271 904,397 88,874  
9 Other employee benefits ....... 3,737,486 3,385,179 352,307  
10 Payroll taxes ........... 1,874,593 1,689,609 184,984  
11 Fees for services (non-employees):        
a Management ...... 879,382 16,657 862,725  
b Legal ......... 143,814   143,814  
c Accounting ........... 47,642   47,642  
d Lobbying ........... 0      
e Professional fundraising. See Part IV, line 17.. 0  
f Investment management fees ...... 0      
g Other .......... 7,003,159 7,003,159    
12 Advertising and promotion .... 679,102 93,600 585,502  
13 Office expenses ....... 10,658,124 10,631,659 26,465  
14 Information technology ...... 3,514 3,514    
15 Royalties .. 0      
16 Occupancy ........... 1,076,557 1,071,174 5,383  
17 Travel ............ 39,840 39,840    
18 Payments of travel or entertainment expenses for any federal, state, or local public officials ...... 0      
19 Conferences, conventions, and meetings .... 146,241 140,058 6,183  
20 Interest ........... 1,089,877 1,089,877    
21 Payments to affiliates ....... 0      
22 Depreciation, depletion, and amortization ..... 3,913,108 3,893,542 19,566  
23 Insurance .............. 1,050,969 901,115 149,854  
24 Other expenses. Itemize expenses not covered above. (Expenses grouped together and labeled miscellaneous may not exceed 5% of total expenses shown on line 25 below.)
a BAD DEBT EXPENSE 8,122,577 8,122,577    
b MEDICAID ASSESSMENT EXPENSE 1,567,049 1,567,049    
c FOOD EXPENSE 564,318 564,318    
d REFERENCE LAB 496,436 496,436    
e DUES & SUBSCRIPTIONS 227,481 227,481    
f All other expenses 246,550 125,138 121,412  
25 Total functional expenses. Add lines 1 through 24f 71,912,182 66,592,829 5,319,353 0
26 Joint costs. Check here MediumBullet if following
SOP 98-2 (ASC 958-720). Complete this line only if the organization reported in column (B) joint costs from a combined educational campaign and fundraising solicitation 		       
Form 990 (2010)
Form 990 (2010)
Page 11
Part X Balance Sheet
(A)
Beginning of year 		(B)
End of year
Assets 1 Cash—non-interest-bearing .......... 434,829 1 80,752
2 Savings and temporary cash investments ....... 8,497,944 2 6,917,460
3 Pledges and grants receivable, net .........   3  
4 Accounts receivable, net ......... 8,161,210 4 8,361,305
5 Receivables from current and former officers, directors, trustees, key employees, and highest compensated employees. Complete Part II of
Schedule L ..........   5  
6 Receivables from other disqualified persons (as defined under section 4958(f)(1)) and persons described in section 4958(c)(3)(B). Complete Part II of
Schedule L ..........   6  
7 Notes and loans receivable, net .............   7  
8 Inventories for sale or use .............. 1,040,230 8 1,054,081
9 Prepaid expenses and deferred charges ............ 945,604 9 1,209,448
10a Land, buildings, and equipment: cost or other basis. Complete Part VI of Schedule D 10a 72,002,279
b Less: accumulated depreciation. ..... 10b 50,015,437 20,925,183 10c 21,986,842
11 Investments—publicly traded securities .......... 24,738,506 11 30,277,722
12 Investments—other securities. See Part IV, line 11 ......   12  
13 Investments—program-related. See Part IV, line 11 ..   13  
14 Intangible assets .........   14  
15 Other assets. See Part IV, line 11 ........... 6,234,421 15 3,378,158
16 Total assets. Add lines 1 through 15 (must equal line 34)... 70,977,927 16 73,265,768
Liabilities 17 Accounts payable and accrued expenses . 6,307,225 17 5,850,532
18 Grants payable ..........   18  
19 Deferred revenue ..........   19  
20 Tax-exempt bond liabilities .......... 23,530,000 20 21,715,000
21 Escrow or custodial account liability. Complete Part IV of Schedule D..   21  
22 Payables to current and former officers, directors, trustees, key
employees, highest compensated employees, and disqualified
persons. Complete Part II of Schedule L..........   22  
23 Secured mortgages and notes payable to unrelated third parties .. 5,058,561 23 4,528,642
24 Unsecured notes and loans payable to unrelated third parties ....   24  
25 Other liabilities. Complete Part X of Schedule D..... 9,206,869 25 9,447,615
26 Total liabilities. Add lines 17 through 25..... 44,102,655 26 41,541,789
Net Assets or Fund Balance Organizations that follow SFAS 117, check here MediumBullet and complete lines 27 through 29, and lines 33 and 34.
27 Unrestricted net assets ..... 26,875,272 27 31,723,979
28 Temporarily restricted net assets .....   28  
29 Permanently restricted net assets .....   29  
Organizations that do not follow SFAS 117, check here MediumBullet and complete lines 30 through 34.
30 Capital stock or trust principal, or current funds .....   30  
31 Paid-in or capital surplus, or land, building or equipment fund .....   31  
32 Retained earnings, endowment, accumulated income, or other funds   32  
33 Total net assets or fund balances ..... 26,875,272 33 31,723,979
34 Total liabilities and net assets/fund balances ..... 70,977,927 34 73,265,768
Form 990 (2010)
Form 990 (2010)
Page 12
Part XI
Reconcilliation of Net Assets
Check if Schedule O contains a response to any question in this Part XI . . . . . . . . . .
1
Total revenue (must equal Part VIII, column (A), line 12) . . .
1
77,139,389
2
Total expenses (must equal Part IX, column (A), line 25) . . . . .
2
71,912,182
3
Revenue less expenses. Subtract line 2 from line 1 . . . .
3
5,227,207
4
Net assets or fund balances at beginning of year (must equal Part X, line 33, column (A)) . .
4
26,875,272
5
Other changes in net assets or fund balances (explain in Schedule O) . . . .
5
-378,500
6
Net assets or fund balances at end of year. Combine lines 3, 4, and 5 (must equal Part X, line 33, column (B)) . . . . . .
6
31,723,979
Part XII
Financial Statements and Reporting
Check if Schedule O contains a response to any question in this Part XII . . . . . . . . . .
Yes
No
1
Accounting method used to prepare the Form 990:  
If the organization changed its method of accounting from a prior year or checked "Other," explain in
Schedule O.
2a
Were the organization’s financial statements compiled or reviewed by an independent accountant?..
2a
 
No
b
Were the organization’s financial statements audited by an independent accountant?........
2b
Yes
 
c
If “Yes,” to 2a or 2b, does the organization have a committee that assumes responsibility for oversight of the audit, review, or compilation of its financial statements and selection of an independent accountant?
If the organization changed either its oversight process or selection process during the tax year, explain in Schedule O............................
2c
Yes
 
d
If “Yes” to line 2a or 2b, check a box below to indicate whether the financial statements for the year were issued on a separate basis, consolidated basis, or both:
3a
As a result of a federal award, was the organization required to undergo an audit or audits as set forth in the Single Audit Act and OMB Circular A-133? ................
3a
 
No
b
If “Yes,” did the organization undergo the required audit or audits? If the organization did not undergo the required audit or audits, explain why in Schedule O and describe any steps taken to undergo such audits. ..
3b
 
 
Form 990 (2010)
Additional Data


Software ID:  
Software Version:  
Form 990, Special Condition Description:
Special Condition Description
SCHEDULE A
(Form 990 or 990EZ)

Department of the Treasury
Internal Revenue Service
Public Charity Status and Public Support

Complete if the organization is a section 501(c)(3) organization or a section
4947(a)(1) nonexempt charitable trust.
right arrow Attach to Form 990 or Form 990-EZ. right arrow See separate instructions.
OMB No. 1545-0047
2010
Open to Public
Inspection
Name of the organization
Pekin Memorial Hospital
 
Employer identification number

37-0692351
Part I
Reason for Public Charity Status (All organizations must complete this part.) See instructions
The organization is not a private foundation because it is: (For lines 1 through 11, check only one box.)
1
2
3
4
5
section 170(b)(1)(A)(iv). (Complete Part II.)
6
7
8
9
receipts from activities related to its exempt functions—subject to certain exceptions, and (2) no more than 331/3% of
its support from gross investment income and unrelated business taxable income (less section 511 tax) from businesses
acquired by the organization after June 30, 1975. See section 509(a)(2). (Complete Part III.)
10
11
e
f
g
(i) a person who directly or indirectly controls, either alone or together with persons described in (ii)
Yes
No
and (iii) below, the governing body of the the supported organization? ................
11g(i)
 
 
(ii) a family member of a person described in (i) above? ......................
11g(ii)
 
 
(iii) a 35% controlled entity of a person described in (i) or (ii) above? ................
11g(iii)
 
 
h
(i)
Name of supported organization 		(ii)
EIN 		(iii)
Type of organization (described on lines 1- 9 above or IRC section (see instructions)) 		(iv)
Is the organization in col. (i) listed in your governing document? 		(v)
Did you notify the organization in col. (i) of your support? 		(vi)
Is the organization in col. (i) organized in the U.S.? 		(vii)
Amount of support?
Yes No Yes No Yes No
Total                  

For Paperwork Reduction Act Notice, see the Instructions for Form 990.
Cat. No. 11285F
Schedule A (Form 990 or 990-EZ) 2010
Schedule A (Form 990 or 990-EZ) 2010
Page 2
Part II
Support Schedule for Organizations Described in IRC 170(b)(1)(A)(iv) and 170(b)(1)(A)(vi)
(Complete only if you checked the box on line 5, 7, or 8 of Part I or if the organization failed to qualify under Part III. If the organization fails to qualify under the tests listed below, please complete Part III.)
Section A. Public Support
Calendar year(or fiscal year beginning in) (a) 2006 (b) 2007 (c) 2008 (d) 2009 (e) 2010 (f) Total
1 Gifts, grants, contributions, and membership fees received. (Do not include any "unusual grants.") ....            
2 Tax revenues levied for the organization's benefit and either paid to or expended on its behalf.......            
3 The value of services or facilities furnished by a governmental unit to the organization without charge..            
4 Total. Add lines 1 through 3..            
5 The portion of total contributions by each person (other than a governmental unit or publicly supported organization) included on line 1 that exceeds 2% of the amount shown on line 11, column (f)..            
6 Public Support. Subtract line 5 from line 4.            
Section B. Total Support
Calendar year(or fiscal year beginning in) (a) 2006 (b) 2007 (c) 2008 (d) 2009 (e) 2010 (f) Total
7 Amounts from line 4..            
8 Gross income from interest, dividends, payments received on securities loans, rents, royalties and income from similar sources..            
9 Net income from unrelated business activities, whether or not the business is regularly carried on..            
10 Other income. (Explain in Part IV.) Do not include gain or loss from the sale of capital assets..            
11 Total support (Add lines 7 through 10).            
12
12
 
13
Section C. Computation of Public Support Percentage
14
14
 
15
15
 
16a
b
17a
b
18
Schedule A (Form 990 or 990-EZ) 2010
Schedule A (Form 990 or 990-EZ) 2010
Page 3
Part III
Support Schedule for Organizations Described in IRC 509(a)(2)
(Complete only if you checked the box on line 9 of Part I or if the organization failed to qualify under Part II. If the organization fails to qualify under the tests listed below, please complete Part II.)
Section A. Public Support
Calendar year(or fiscal year beginning in) (a) 2006 (b) 2007 (c) 2008 (d) 2009 (e) 2010 (f) Total
1 Gifts, grants, contributions, and membership fees received. (Do not include any "unusual grants.") .            
2 Gross receipts from admissions, merchandise sold or services performed, or facilities furnished in any activity that is related to the organization's tax-exempt purpose......            
3 Gross receipts from activities that are not an unrelated trade or business under section 513..            
4 Tax revenues levied for the organization's benefit and either paid to or expended on its behalf...            
5 The value of services or facilities furnished by a governmental unit to the organization without charge..            
6 Total. Add lines 1 through 5.            
7a Amounts included on lines 1, 2, and 3 received from disqualified persons...            
b Amounts included on lines 2 and 3 received from other than disqualified persons that exceed the greater of $5,000 or 1% of the amount on line 13 for the year.            
c Add lines 7a and 7b..            
8 Public Support (Subtract line 7c from line 6.)            
Section B. Total Support
Calendar year (or fiscal year beginning in) (a) 2006 (b) 2007 (c) 2008 (d) 2009 (e) 2010 (f) Total
9 Amounts from line 6...            
10a Gross income from interest, dividends, payments received on securities loans, rents, royalties and income from similar sources..            
b Unrelated business taxable income (less section 511 taxes) from businesses acquired after June 30, 1975.            
c Add lines 10a and 10b.            
11 Net income from unrelated business activities not included in line 10b, whether or not the business is regularly carried on.            
12 Other income. Do not include gain or loss from the sale of capital assets (Explain in Part IV.)            
13 Total support (Add lines 9, 10c, 11 and 12.).            
14
Section C. Computation of Public Support Percentage
15
15
 
16
16
 
Section D. Computation of Investment Income Percentage
17
17
 
18
18
 
19a
b
20
Schedule A (Form 990 or 990-EZ) 2010
Schedule A (Form 990 or 990-EZ) 2010
Page 4
Part IV
Supplemental Information. Supplemental Information. Complete this part to provide the explanation required by Part II, line 10; Part II, line 17a or 17b; or Part III, line 12. Also complete this part for any additional information. (See instructions).
Facts And Circumstances Test
 
Explanation
 
 
 
 
Schedule A (Form 990 or 990-EZ) 2010

Additional Data


Software ID:  
Software Version:  
Schedule B
(Form 990, 990-EZ,
or 990-PF)
Department of the Treasury
Internal Revenue Service
Schedule of Contributors
Arrow Bullet Attach to Form 990, 990-EZ, or 990-PF.
OMB No. 1545-0047
2010
Name of organization
Pekin Memorial Hospital
 
Employer identification number

37-0692351
Organization type (check one):
Filers of:
Section:
Form 990 or 990-EZ





Form 990-PF




Check if your organization is covered by the General Rule or a Special Rule.  
Note. Only a section 501(c)(7), (8), or (10) organization can check boxes for both the General Rule and a Special Rule. See instructions.
General Rule—
Special Rules
......................... Arrow Bullet   $    
Caution. An Organization that is not covered by the General Rule and/or the Special Rules does not file Schedule B (Form 990,
990-EZ, or 990-PF), but it must answer “No” on Part IV, line 2 of its Form 990, or check the box in the heading of its
Form 990-EZ, or on line 2 of its Form 990-PF, to certify that it does not meet the filing requirements of Schedule B (Form 990,
990-EZ, or 990-PF).
For Paperwork Reduction Act Notice, see the Instructions
for Form 990, 990-EZ, or 990-PF.
Cat. No. 30613XSchedule B (Form 990, 990-EZ, or 990-PF) (2010)

Schedule B (Form 990, 990-EZ, or 990-PF) (2010)
Page 1 of 1 of Part I
Name of organization
Pekin Memorial Hospital
  		Employer identification number

37-0692351
Part I
Contributors (see Instructions)
     
(a)
No.		 (b)
Name, address, and ZIP + 4		 (c)
Aggregate contributions		 (d)
Type of contribution
RESTRICTED
RESTRICTED
 

     
RESTRICTED
RESTRICTED  
RESTRICTED, RESTRICTED   RESTRICTED

$RESTRICTED




(Complete Part II if there is
a noncash contribution.)
(a)
No.		 (b)
Name, address, and ZIP + 4		 (c)
Aggregate contributions		 (d)
Type of contribution
 
 
 

     
 
   

$  




(Complete Part II if there is
a noncash contribution.)
(a)
No.		 (b)
Name, address, and ZIP + 4		 (c)
Aggregate contributions		 (d)
Type of contribution
 
 
 

     
 
   

$  




(Complete Part II if there is
a noncash contribution.)
(a)
No.		 (b)
Name, address, and ZIP + 4		 (c)
Aggregate contributions		 (d)
Type of contribution
 
 
 

     
 
   

$  




(Complete Part II if there is
a noncash contribution.)
(a)
No.		 (b)
Name, address, and ZIP + 4		 (c)
Aggregate contributions		 (d)
Type of contribution
 
 
 

     
 
   

$  




(Complete Part II if there is
a noncash contribution.)
(a)
No.		 (b)
Name, address, and ZIP + 4		 (c)
Aggregate contributions		 (d)
Type of contribution
 
 
 

     
 
   

$  




(Complete Part II if there is
a noncash contribution.)
Schedule B (Form 990, 990-EZ, or 990-PF) (2010)

Schedule B (Form 990, 990-EZ, or 990-PF) (2010)
Page 1 of 1 of Part II
Name of organization
Pekin Memorial Hospital
  		Employer identification number

37-0692351
Part II
Noncash Property (see Instructions)
     
(a) No.
from
Part I		 (b)
Description of noncash property given		 (c)
FMV (or estimate)
(see instructions) 		(d)
Date received
 
$    
(a) No.
from
Part I		 (b)
Description of noncash property given		 (c)
FMV (or estimate)
(see instructions) 		(d)
Date received
 
$    
(a) No.
from
Part I		 (b)
Description of noncash property given		 (c)
FMV (or estimate)
(see instructions) 		(d)
Date received
 
$    
(a) No.
from
Part I		 (b)
Description of noncash property given		 (c)
FMV (or estimate)
(see instructions) 		(d)
Date received
 
$    
(a) No.
from
Part I		 (b)
Description of noncash property given		 (c)
FMV (or estimate)
(see instructions) 		(d)
Date received
 
$    
(a) No.
from
Part I		 (b)
Description of noncash property given		 (c)
FMV (or estimate)
(see instructions) 		(d)
Date received
 
$    
Schedule B (Form 990, 990-EZ, or 990-PF) (2010)

Schedule B (Form 990, 990-EZ, or 990-PF) (2010)
Page 1 of 1 of Part III
Name of organization
Pekin Memorial Hospital
  		Employer identification number

37-0692351
Part III
Exclusively religious, charitable, etc., individual contributions to section 501(c)(7), (8), or (10) organizations
aggregating more than $1,000 for the year. (Complete columns (a) through (e) and the following line entry.)
For organizations completing Part III, enter the total of exclusively religious, charitable, etc.,
contributions of $1,000 or less for the year. (Enter this information once. See instructions.) Arrow Bullet $  
(a) No.
from
Part I		 (b)
Purpose of gift		 (c)
Use of gift		 (d)
Description of how gift is held
 
(e)
Transfer of gift
Transferee's name, address, and ZIP 4 Relationship of transferor to transferee
 
 
       
 
(a) No.
from
Part I		 (b)
Purpose of gift		 (c)
Use of gift		 (d)
Description of how gift is held
 
(e)
Transfer of gift
Transferee's name, address, and ZIP 4 Relationship of transferor to transferee
 
 
       
 
(a) No.
from
Part I		 (b)
Purpose of gift		 (c)
Use of gift		 (d)
Description of how gift is held
 
(e)
Transfer of gift
Transferee's name, address, and ZIP 4 Relationship of transferor to transferee
 
 
       
 
(a) No.
from
Part I		 (b)
Purpose of gift		 (c)
Use of gift		 (d)
Description of how gift is held
 
(e)
Transfer of gift
Transferee's name, address, and ZIP 4 Relationship of transferor to transferee
 
 
       
 
Schedule B (Form 990, 990-EZ, or 990-PF) (2010)

Additional Data


Software ID:  
Software Version:  
SCHEDULE C
(Form 990 or 990-EZ)

Department of the Treasury
Internal Revenue Service
Political Campaign and Lobbying Activities

For Organizations Exempt From Income Tax Under section 501(c) and section 527
SchCMd Bullet Complete if the organization is described below.
SchCMd Bullet Attach to Form 990 or Form 990-EZ. SchCMd Bullet See separate instructions.
OMB No. 1545-0047
2010
Open to Public
Inspection
If the organization answered “Yes,” to Form 990, Part IV, Line 3, or Form 990-EZ, Part V, line 46 (Political Campaign Activities), then
Round Bullet Section 501(c)(3) organizations: Complete Parts I-A and B. Do not complete Part I-C.
Round Bullet Section 501(c) (other than section 501(c)(3)) organizations: Complete Parts I-A and C below. Do not complete Part I-B.
Round Bullet Section 527 organizations: Complete Part I-A only.
If the organization answered “Yes,” to Form 990, Part IV, Line 4, or Form 990-EZ, Part VI, line 47 (Lobbying Activities), then
Round Bullet Section 501(c)(3) organizations that have filed Form 5768 (election under section 501(h)) Complete Part II-A. Do not complete Part II-B.
Round Bullet Section 501(c)(3) organizations that have NOT filed Form 5768 (election under section 501(h)): Complete Part II-B. Do not complete Part II-A.
If the organization answered “Yes,” to Form 990, Part IV, Line 5 (Proxy Tax) or Form 990-EZ, Part V, line 35a (Proxy Tax), then
Round Bullet Section 501(c)(4), (5), or (6) organizations: Complete Part III.
Name of the organization
Pekin Memorial Hospital
 
Employer identification number

37-0692351
Part I-A
Complete if the organization is exempt under section 501(c) or is a section 527 organization.

1
Provide a description of the organization's direct and indirect political campaign activities on behalf of or in opposition to candidates for public office in Part IV.
2
Political expenditures ....................................SchCMd Bullet
$  
3
Volunteer hours ........................................
 

Part I-B
Complete if the organization is exempt under section 501(c)(3).
1
Enter the amount of any excise tax incurred by the organization under section 4955 .........SchCMd Bullet
$  
2
Enter the amount of any excise tax incurred by organization managers under section 4955 ......SchCMd Bullet
$  
3
If the organization incurred a section 4955 tax, did it file Form 4720 for this year? ..............
4a
Was a correction made? .........................................
b
If "Yes," describe in Part IV.
Part I-C
Complete if the organization is exempt under section 501(c) except section 501(c)(3).
1
Enter the amount directly expended by the filing organization for section 527 exempt function activities SchCMd Bullet
$  
2
Enter the amount of the filing organization's funds contributed to other organizations for section 527 exempt funtion activities ....................................SchCMd Bullet

$  
3
Total exempt function expenditures. Add lines 1 and 2. Enter here and on Form 1120-POL, line 17b..SchCMd Bullet

$  
4
Did the filing organization file Form 1120-POL for this year? ..........................
5
Enter the names, addresses and employer identification number (EIN) of all section 527 political organizations to which the filing
organization made payments. For each organization listed, enter the amount paid from the filing organization’s funds. Also enter the amount of political contributions received that were promptly and directly delivered to a separate political organization, such as a separate segregated fund or a political action committee (PAC). If additional space is needed, provide information in Part IV.
(a) Name (b) Address (c) EIN (d) Amount paid from filing organization's funds. If none, enter -0-. (e) Amount of political contributions received and promptly and directly delivered to a separate political organization. If none, enter -0-.










For Privacy Act and Paperwork Reduction Act Notice, see the instructions for Form 990.
Cat. No. 50084S
Schedule C (Form 990 or 990-EZ) 2010

Schedule C (Form 990 or 990-EZ) 2010
Page 2
Part II-A
Complete if the organization is exempt under section 501(c)(3) and filed Form 5768 (election under section 501(h)).
A Check
B Check
Limits on Lobbying Expenditures
(The term "expenditures" means amounts paid or incurred.) 		(a) Filing
Organization's
Totals 		(b) Affiliated Group
Totals
1a Total lobbying expenditures to influence public opinion (grass roots lobbying) ......    
b Total lobbying expenditures to influence a legislative body (direct lobbying) .......    
c Total lobbying expenditures (add lines 1a and 1b) ...................    
d Other exempt purpose expenditures ........................    
e Total exempt purpose expenditures (add lines 1c and 1d) ...............    
f Lobbying nontaxable amount. Enter the amount from the following table in both
columns.		    
  If the amount on line 1e, column (a) or (b) is:The lobbying nontaxable amount is:    
  Not over $500,00020% of the amount on line 1e.    
  Over $500,000 but not over $1,000,000$100,000 plus 15% of the excess over $500,000.    
  Over $1,000,000 but not over $1,500,000$175,000 plus 10% of the excess over $1,000,000.    
  Over $1,500,000 but not over $17,000,000$225,000 plus 5% of the excess over $1,500,000.    
  Over $17,000,000$1,000,000.    
       
g Grassroots nontaxable amount (enter 25% of line 1f) .................    
h Subtract line 1g from line 1a. If zero or less, enter -0-. ................    
i Subtract line 1f from line 1c. If zero or less, enter -0-. ................    
j If there is an amount other than zero on either line 1h or line 1i, did the organization file Form 4720 reporting
section 4911 tax for this year? ......................................

4-Year Averaging Period Under Section 501(h)
(Some organizations that made a section 501(h) election do not have to complete all of the five
columns below. See the instructions for lines 2a through 2f on page 4.)
Lobbying Expenditures During 4-Year Averaging Period
  Calendar year (or fiscal year
beginning in) 		(a) 2007 (b) 2008 (c) 2009 (d) 2010 (e) Total
             
2a Lobbying non-taxable amount          
             
b Lobbying ceiling amount
(150% of line 2a, column(e)) 		         
             
c Total lobbying expenditures          
             
d Grassroots non-taxable amount          
             
e Grassroots ceiling amount
(150% of line 2d, column (e))		          
             
f Grassroots lobbying expenditures          
Schedule C (Form 990 or 990-EZ) 2010


Schedule C (Form 990 or 990-EZ) 2010
Page 3
Part II-B
Complete if the organization is exempt under section 501(c)(3) and has NOT filed Form 5768 (election under section 501(h)).
(a)
Yes
No
(b)
Amount
1
During the year, did the filing organization attempt to influence foreign, national, state or local legislation, including any attempt to influence public opinion on a legislative matter or referendum, through the use of:
a
Volunteers? .........................................
 
No
b
Paid staff or management (include compensation in expenses reported on lines 1c through 1i)? ....
 
No
c
Media advertisements? ....................................
 
No
 
d
Mailings to members, legislators, or the public? .........................
 
No
 
e
Publications, or published or broadcast statements? .......................
 
No
 
f
Grants to other organizations for lobbying purposes? .......................
Yes
 
25,200
g
Direct contact with legislators, their staffs, government officials, or a legislative body? ........
 
No
 
h
Rallies, demonstrations, seminars, conventions, speeches, lectures, or any similar means? ......
 
No
 
i
Other activities? If "Yes," describe in Part IV ..........................
 
No
 
j
Total. lines 1c through 1i ...................................
25,200
2a
Did the activities in line 1 cause the organization to be not described in section 501(c)(3)? .....
 
No
b
If "Yes," enter the amount of any tax incurred under section 4912 .................
 
c
If "Yes," enter the amount of any tax incurred by organization managers under section 4912 .....
 
d
If the filing organization incurred a section 4912 tax, did it file Form 4720 for this year? .......
 
 
Part III-A
Complete if the organization is exempt under section 501(c)(4), section 501(c)(5), or section 501(c)(6).
Yes
No
1
Were substantially all (90% or more) dues received nondeductible by members? ................
1
 
 
2
Did the organization make only in-house lobbying expenditures of $2,000 or less? ................
2
 
 
3
Did the organization agree to carryover lobbying and political expenditures from the prior year? ..........
3
 
 
Part III-B
Complete if the organization is exempt under section 501(c)(4), section 501(c)(5), or section 501(c)(6) if BOTH Part III-A, lines 1 and 2 are answered “No” OR if Part III-A, line 3 is answered “Yes”.
1
Dues, assessments and similar amounts from members .....................
1
 
2
Section 162(e) non-deductible lobbying and political expenditures (do not include amounts of political
expenses for which the section 527(f) tax was paid).
a
Current year .........................................
2a
 
b
Carryover from last year ....................................
2b
 
c
Total ...........................................
2c
 
3
Aggregate amount reported in section 6033(e)(1)(A) notices of nondeductible section 162(e) dues .
3
 
4
If notices were sent and the amount on line 2c exceeds the amount on line 3, what portion of the excess does the organization agree to carryover to the reasonable estimate of nondeductible lobbying and political expenditure next year? ................................
4
 
5
Taxable amount of lobbying and political expenditures (see instructions) ..............
5
 
Part IV
Supplemental Information
Complete this part to provide the descriptions required for Part l-A, line 1; Part l-B, line 4; Part l-C, line 5; and Part ll-B, line 1i.
Also, complete this part for any additional information.
Identifier Return Reference Explanation
LOBBYING ACTIVITIES SCHEDULE C, PART II-B, QUESTION 1 LOBBYING EXPENSES ARE ONLY INCURRED THROUGH ASSOCIATIONS WITH NATIONAL ORGANIZATIONS OF WHICH THE ORGANIZATION IS A MEMBER.
Schedule C (Form 990 or 990EZ) 2010

Additional Data


Software ID:  
Software Version:  

SCHEDULE D
(Form 990)
Department of the Treasury
Internal Revenue Service
Supplemental Financial Statements
SchDMd Bullet Complete if the organization answered "Yes," to Form 990,
Part IV, line 6, 7, 8, 9, 10, 11, or 12.
SchDMd Bullet Attach to Form 990. SchDMd Bullet See separate instructions.
OMB No. 1545-0047
2010
Open to Public Inspection
Name of the organization
Pekin Memorial Hospital
 
Employer identification number

37-0692351
Part I
Organizations Maintaining Donor Advised Funds or Other Similar Funds or Accounts. Complete if the organization answered "Yes" to Form 990, Part IV, line 6.
(a) Donor advised funds (b) Funds and other accounts
1 Total number at end of year .......    
2 Aggregate contributions to (during year) ...    
3 Aggregate grants from (during year) ...    
4 Aggregate value at end of year .......    
5
Did the organization inform all donors and donor advisors in writing that the assets held in donor advised
funds are the organization's property, subject to the organization's exclusive legal control? ............
6
Did the organization inform all grantees, donors, and donor advisors in writing that grant funds may be
used only for charitable purposes and not for the benefit of the donor or donor advisor, or for any other purpose conferring impermissible private benefit. ...................................
Part II
Conservation Easements. Complete if the organization answered "Yes" to Form 990, Part IV, line 7.
1
Purpose(s) of conservation easements held by the organization (check all that apply).
2
Complete lines 2a–2d if the organization held a qualified conservation contribution in the form of a conservation easement on the last day of the tax year.
Held at the End of the Year
a Total number of conservation easements ....................... 2a  
b Total acreage restricted by conservation easements .................. 2b  
c Number of conservation easements on a certified historic structure included in (a) ..... 2c  
d Number of conservation easements included in (c) acquired after 8/17/06 ........ 2d  
3
Number of conservation easements modified, transferred, released, extinguished, or terminated by the organization during
the taxable year SchDMd Bullet  
4
Number of states where property subject to conservation easement is located SchDMd Bullet  
5
Does the organization have a written policy regarding the periodic monitoring, inspection, handling of violations, and
enforcement of the conservation easements it holds? .............................
6
Staff and volunteer hours devoted to monitoring, inspecting and enforcing conservation easements during the year SchDMd Bullet  
7
Amount of expenses incurred in monitoring, inspecting, and enforcing conservation easements during the year SchDMd Bullet $  
8
Does each conservation easement reported on line 2(d) above satisfy the requirements of section
170(h)(4)(B)(i) and 170(h)(4)(B)(ii)? ....................................
9
In Part XIV, describe how the organization reports conservation easements in its revenue and expense statement, and
balance sheet, and include, if applicable, the text of the footnote to the organization’s financial statements that describes
the organization’s accounting for conservation easements.
Part III
Organizations Maintaining Collections of Art, Historical Treasures, or Other Similar Assets.
Complete if the organization answered "Yes" to Form 990, Part IV, line 8.
1a
If the organization elected, as permitted under SFAS 116, not to report in its revenue statement and balance sheet works of
art, historical treasures, or other similar assets held for public exhibition, education or research in furtherance of public service,
provide, in Part XIV, the text of the footnote to its financial statements that describes these items.
b
If the organization elected, as permitted under SFAS 116, to report in its revenue statement and balance sheet works of art,
historical treasures, or other similar assets held for public exhibition, education, or research in furtherance of public service,
provide the following amounts relating to these items:
(i)
Revenues included in Form 990, Part VIII, line 1 ........................SchDMd Bullet $  
(ii)
Assets included in Form 990, Part X ..............................SchDMd Bullet $  
2
If the organization received or held works of art, historical treasures, or other similar assets for financial gain, provide the
following amounts required to be reported under SFAS 116 relating to these items:
a
Revenues included in Form 990, Part VIII, line 1 ..........................SchDMd Bullet $  
b
Assets included in Form 990, Part X ...............................SchDMd Bullet $  
For Privacy Act and Paperwork Reduction Act Notice, see the Intructions for Form 990
Cat. No. 52283D
Schedule D (Form 990) 2010

Schedule D (Form 990) 2010
Page 2
Part III
Organizations Maintaining Collections of Art, Historical Treasures, or Other Similar Assets (continued)
3
Using the organization’s accession and other records, check any of the following that are a significant use of its collection
items (check all that apply):
a
d
b
e
 
c
4
Provide a description of the organization’s collections and explain how they further the organization’s exempt purpose in
Part XIV.
5
During the year, did the organization solicit or receive donations of art, historical treasures or other similar
assets to be sold to raise funds rather than to be maintained as part of the organization’s collection?........
Part IV
Escrow and Custodial Arrangements. Complete if the organization answered "Yes" to Form 990,
Part IV, line 9, or reported an amount on Form 990, Part X, line 21.
1a
Is the organization an agent, trustee, custodian or other intermediary for contributions or other assets not
included on Form 990, Part X? ....................................
b
If "Yes," explain the arrangement in Part XIV and complete the following table:
Amount
c Beginning balance ................................. 1c  
d Additions during the year .............................. 1d  
e Distributions during the year ............................. 1e  
f Ending balance ................................... 1f  
2a
Did the organization include an amount on Form 990, Part X, line 21? .....................
b
If “Yes,” explain the arrangement in Part XIV.
Part V
Endowment Funds. Complete if the organization answered "Yes" to Form 990, Part IV, line 10.
(a)Current Year (b)Prior Year (c)Two Years Back (d)Three Years Back (e)Four Years Back
1a Beginning of year balance ....      
b Contributions ........      
c Investment earnings or losses ...      
d Grants or scholarships .....      
e Other expenditures for facilities
and programs ........ 		     
f Administrative expenses ....      
g End of year balance ......      
2
Provide the estimated percentage of the year end balance held as:
a
Board designated or quasi-endowment: SchDMd Bullet  
b
Permanent endowment: SchDMd Bullet  
c
Term endowment: SchDMd Bullet  
3a
Are there endowment funds not in the possession of the organization that are held and administered for the
organization by:

Yes
No
(i) unrelated organizations ........................
3a(i)
 
 
(ii) related organizations ........................
3a(ii)
 
 
b
If "Yes" to 3a(ii), are the related organizations listed as required on Schedule R? .........
3b
 
 
4
Describe in Part XIV the intended uses of the organization's endowment funds.
Part VI
Investments—Land, Buildings, and Equipment. See Form 990, Part X, line 10.
Description of investment (a) Cost or other basis (investment) (b)Cost or other basis (other) (c) Accumulated depreciation (d) Book value
1a Land .................   1,449,581 1,449,581
b Buildings ................   11,554,361 7,976,140 3,578,221
c Leasehold improvements ............   16,676,915 13,010,358 3,666,557
d Equipment ................   38,385,431 27,650,116 10,735,315
e Other .................   3,935,991 1,378,823 2,557,168
Total. Add lines 1a-1e. (Column (d) should equal Form 990, Part X, column (B), line 10(c).)........SchDMdBullet 21,986,842
Schedule D (Form 990) 2010

Schedule D (Form 990) 2010
Page 3
Part VII
Investments—Other Securities. See Form 990, Part X, line 12.
(a) Description of security or category
(including name of security)		 (b)Book value (c) Method of valuation:
Cost or end-of-year market value
(1)Financial derivatives    
(2)Closely-held equity interests    
Other








Total. (Column (b) should equal Form 990, Part X, col.(B) line 12.)Small Bullet  
Part VIII
Investments—Program Related. See Form 990, Part X, line 13.
(a) Description of investment type (b) Book value (c) Method of valuation:
Cost or end-of-year market value








Total. (Column (b) should equal Form 990, Part X, col.(B) line 13.)Small Bullet  
Part IX
Other Assets. See Form 990, Part X, line 15.
(a) Description (b) Book value








Total. (Column (b) should equal Form 990, Part X, col.(B) line 15.)...........Small Bullet  
Part X
Other Liabilities. See Form 990, Part X, line 25.
1.(a) Description of Liability (b) Amount
Federal Income Taxes 0
DUE TO THIRD PARTIES 4,799,151
MINIMUM PENSION LIABILITY 4,648,464







Total. (Column (b) should equal Form 990, Part X, col.(B) line 25.)Small Bullet 9,447,615
2. Fin 48 (ASC 740) Footnote. In Part XIV, provide the text of the footnote to the organization's financial statements that reports the organization's liability for uncertain tax positions under FIN 48 (ASC740).
Schedule D (Form 990) 2010

Schedule D (Form 990) 2010
Page 4
Part XI Reconciliation of Change in Net Assets from Form 990 to Financial Statements
1 Total revenue (Form 990, Part VIII, column (A), line 12) .................... 1  
2 Total expenses (Form 990, Part IX, column (A), line 25) ..................... 2  
3 Excess or (deficit) for the year. Subtract line 2 from line 1 ............. 3  
4 Net unrealized gains (losses) on investments .......................... 4  
5 Donated services and use of facilities ............................. 5  
6 Investment expenses ................................... 6  
7 Prior period adjustments .................................. 7  
8 Other (Describe in Part XIV) ................................. 8  
9 Total adjustments (net). Add lines 4 - 8 ............................. 9  
10 Excess or (deficit) for the year per financial statements. Combine lines 3 and 9 ......... 10  
Part XII Reconciliation of Revenue per Audited Financial Statements With Revenue per Return
1 Total revenue, gains, and other support per audited financial statements ....... 1  
2 Amounts included on line 1 but not on Form 990, Part VIII, line 12:
a Net unrealized gains on investments .......... 2a  
b Donated services and use of facilities ......... 2b  
c Recoveries of prior year grants ........... 2c  
d Other (Describe in Part XIV): ............ 2d  
e Add lines 2a through 2d ..................... 2e  
3 Subtract line 2e from line 1..................... 3  
4 Amounts included on Form 990, Part VIII, line 12, but not on line 1:
a Investment expenses not included on Form 990, Part VIII, line 7b . 4a  
b Other (Describe in Part XIV): ........... 4b  
c Add lines 4a and 4b....................... 4c  
5 Total Revenue. Add lines 3 and 4c. (This should equal Form 990, Part I, line 12.) ...... 5  
Part XIII Reconciliation of Expenses per Audited Financial Statements With Expenses per Return
1 Total expenses and losses per audited financial statements ............. 1  
2 Amounts included on line 1 but not on Form 990, Part IX, line 25:
a Donated services and use of facilities .......... 2a  
b Prior year adjustments .............. 2b  
c Other losses ................ 2c  
d Other (Describe in Part XIV): ............ 2d  
e Add lines 2a through 2d...................... 2e  
3 Subtract line 2e from line 1..................... 3  
4 Amounts included on Form 990, Part IX, line 25, but not on line 1:
a Investment expenses not included on Form 990, Part VIII, line 7b .. 4a  
b Other (Describe in Part XIV): ............ 4b  
c Add lines 4a and 4b....................... 4c  
5 Total expenses. Add lines 3 and 4c. (This should equal Form 990, Part I, line 18.) ...... 5  
Part XIV
Supplemental Information
Complete this part to provide the descriptions required for Part II, lines 3, 5, and 9; Part III, lines 1a and 4; Part lV, lines 1b and 2b;
Part V, line 4; Part X; Part XI, line 8; Part XII, lines 2d and 4b; and Part XIII, lines 2d and 4b. Also complete this part to provide any additional information.
Identifier Return Reference Explanation
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.
Schedule D (Form 990) 2010

Additional Data


Software ID:  
Software Version:  




SCHEDULE H
(Form 990)
Department of the Treasury
Internal Revenue Service
Hospitals
MediumBullet Complete if the organization answered "Yes" to Form 990, Part IV, question 20.
MediumBullet Attach to Form 990. MediumBullet See separate instructions.
OMB No. 1545-0047
2010
Open to Public Inspection
Name of the organization
Pekin Memorial Hospital
 
Employer identification number

37-0692351
Part I
Charity Care and Certain Other Community Benefits at Cost
Yes
No
1a
Does the organization have a charity care policy? If "No," skip to question 6a...........
1a
Yes
 
b
If "Yes," is it a written policy? .......................
1b
Yes
 
2
If the organization has multiple hospitals, indicate which of the following best describes application of the charity care policy to the various hospitals.
3
Answer the following based on the charity care eligibility criteria that applies to the largest number of the organization's patients.
a
Does the organization use Federal Poverty Guidelines (FPG) to determine eligibility for providing free care to low
income individuals? If "Yes," indicate which of the following is the FPG family income limit for eligibility for free care:
3a
Yes
 
b
Does the organization use FPG to determine eligibility for providing discounted care to low income individuals? If
"Yes," indicate which of the following is the family income limit for eligibility for discounted care: .....
3b
Yes
 
c
If the organization does not use FPG to determine eligibility, describe in Part VI the income based criteria for determining eligibility for free or discounted care. Include in the description whether the organization uses an asset test or other threshold, regardless of income, to determine eligibility for free or discounted care.
4
Does the organization's policy provide free or discounted care to the "medically indigent"? ......
4
 
No
5a
Does the organization budget amounts for free or discounted care provided under its charity care policy? ...
5a
Yes
 
b
If "Yes," did the organization's charity care expenses exceed the budgeted amount?.........
5b
Yes
 
c
If "Yes" to line 5b, as a result of budget considerations, was the organization unable to provide free or discounted
care to a patient who was eligibile for free or discounted care?...............
5c
 
No
6a
Does the organization prepare an annual community benefit report?.............
6a
Yes
 
6b
If "Yes," does the organization make it available to the public? ..............
6b
Yes
 
Complete the following table using the worksheets provided in the Schedule H instructions. Do not submit these worksheets with the Schedule H.
7
Charity Care and Certain Other Community Benefits at Cost
Charity Care and
Means-Tested Government Programs		 (a) Number of activities or programs (optional) (b) Persons served (optional) (c) Total community benefit expense (d) Direct offsetting revenue (e) Net community benefit expense (f) Percent of total expense
a Charity care at cost (from
Worksheets 1 and 2) .. 		    1,638,611   1,638,611 2.570 %
b Unreimbursed Medicaid (from
Worksheet 3, column a) . 		    10,700,982 6,894,062 3,806,920 5.970 %
c Unreimbursed costs—other means-tested government programs (from Worksheet 3, column b) ....            
dTotal Charity Care and
Means-Tested Government Programs ..... 		    12,339,593 6,894,062 5,445,531 8.540 %
Other Benefits
e Community health improvement
services and community
benefit operations (from
(Worksheet 4) .... 		    42,957 2,760 40,197 0.060 %
f Health professions education
(from Worksheet 5) .. 		           
g Subsidized health services
(from Worksheet 6) .. 		           
h Research (from Worksheet 7)            
i Cash and in-kind contributions
to community groups
(from Worksheet 8) .. 		    1,254   1,254  
jTotal Other Benefits ...     44,211 2,760 41,451 0.060 %
kTotal. Add lines 7d and 7j. ..     12,383,804 6,896,822 5,486,982 8.600 %
For Privacy Act and Paperwork Reduction Act Notice, see the Instructions for Form 990. Cat. No. 50192T Schedule H (Form 990) 2010
Schedule H (Form 990) 2010
Page 2
Part II
Community Building Activities Complete this table if the organization conducted any community building activities.
(a) Number of activities or programs (optional) (b) Persons served (optional) (c) Total community building expense (d) Direct offsetting
revenue 		(e) Net community building expense (f) Percent of total expense
1 Physical improvements and housing            
2 Economic development            
3 Community support            
4 Environmental improvements            
5 Leadership development and training for community members            
6 Coalition building            
7 Community health improvement advocacy            
8 Workforce development            
9 Other            
10 Total            
Part III
Bad Debt, Medicare, & Collection Practices
Section A. Bad Debt Expense
Yes
No
1
Does the organization report bad debt expense in accordance with Heathcare Financial Management Association Statement No. 15? ..........................
1
Yes
 
2
Enter the amount of the organization's bad debt expense (at cost).....
2
2,140,000
3
Enter the estimated amount of the organization's bad debt expense (at cost) attributable to patients eligible under the organization's charity care policy ..
3
321,000
4
Provide in Part VI the text of the footnote to the organization's financial statements that describes bad debt expense. In addition, describe the costing methodology used in determining the amounts reported on lines 2 and 3, and rationale for including a portion of bad debt amounts as community benefit.
Section B. Medicare
5
Enter total revenue received from Medicare (including DSH and IME).....
5
16,257,628
6
Enter Medicare allowable costs of care relating to payments on line 5.....
6
26,822,803
7
Subtract line 6 from line 5. This is the surplus or (shortfall)........
7
-10,565,175
8
Describe in Part VI the extent to which any shortfall reported in line 7 should be treated as community benefit.
Also describe in Part VI the costing methodology or source used to determine the amount reported on line 6.
Check the box that describes the method used:
Section C. Collection Practices
9a
Does the organization have a written debt collection policy? ...............
9a
Yes
 
b
If "Yes," does the organization's collection policy contain provisions on the collection practices to be followed for patients who are known to qualify for charity care or financial assistance? Describe in Part VI......
9b
Yes
 
Part IV
Management Companies and Joint Ventures
(a) Name of entity (b) Description of primary
activity of entity 		(c) Organization's
profit % or stock
ownership % 		(d) Officers, directors,
trustees, or key
employees' profit %
or stock ownership% 		(e) Physicians'
profit % or stock
ownership %
1
2
3
4
5
6
7
8
9
10
11
12
13
Schedule H (Form 990) 2010
Schedule H (Form 990) 2010
Page 3
Part VFacility Information
Section A. Hospital Facilities
(list in order of size, measured by total revenue per facility, from largest to smallest)
How many hospital facilities did the organization operate during the tax year?1
Name and address 		Licensed Hospital General-Medical-Surgical Children's Hospital Teaching Hospital Critical Hospital Research Facility ER-24Hours ER-Other Other (Describe)
1 PEKIN MEMORIAL HOSPITAL
600 SOUTH 13TH STREET
PEKIN,IL61554 		X X         X    
Schedule H (Form 990) 2010
Schedule H (Form 990) 2010
Page 4
Part VFacility Information (continued)

Section B. Facility Policies and Practices.

(Complete a separate Section B for each of the hospital facilities listed in Part V, Section A)
Name of Hospital Facility:PEKIN MEMORIAL HOSPITAL
Line Number of Hospital Facility (from Schedule H, Part V, Section A):1

Yes No
Community Health Needs Assessment (Lines 1 through 7 are optional for 2010)
1 During the tax year or any prior tax year, did the hospital facility conduct a community health needs assessment (“Needs Assessment”)? If “No,” skip to question 8. ..................... 1    
If “Yes,” indicate what the Needs Assessment describes (check all that apply):
a A definition of the community served by the hospital facility
b Demographics of the community
c Existing health care facilities and resources within the community that are available to respond to the health needs of the community
d How data was obtained
e The health needs of the community
f Primary and chronic disease needs and other health issues of uninsured persons, low-income persons, and minority groups
g The process for identifying and prioritizing community health needs and services to meet those needs
h The process for consulting with persons representing the community’s interests
i Information gaps that limit the hospital facility’s ability to assess all of the community’s health needs
j Other (describe in Part VI)
2 Indicate the tax year the hospital facility last conducted a Needs Assessment: 20  
3 In conducting its most recent Needs Assessment, did the hospital facility take into account input from persons who represent the community served by the hospital facility? If “Yes,” describe in Part VI how the hospital facility took into account input from persons who represent the community, and identify the persons the hospital facility consulted. 3    
4 Was the hospital facility’s Needs Assessment conducted with one or more other hospital facilities? If “Yes,” list the other hospital facilities in Part VI............................ 4    
5 Did the hospital facility make its Needs Assessment widely available to the public? ........... 5    
If “Yes,” indicate how the Needs Assessment was made widely available (check all that apply):
a Hospital facility’s website
b Available upon request from the hospital facility
c Other (describe in Part VI)
6 If the hospital facility addressed needs identified in its most recently conducted Needs Assessment, indicate how (check all that apply):
a Adoption of an implementation strategy to address the health needs of the hospital facility’s community
b Execution of the implementation strategy
c Development of a community benefit plan for the facility
d Participation in community-wide community benefit plan
e Inclusion of a community benefit section in operational plans
f Adoption of a budget for provision of services that address the needs identified in the CHNA
g Prioritization of health needs in the community
h Prioritization of services that the hospital facility will undertake to meet health needs in its community
i Other (describe in Part VI)
7 Did the hospital facility address all of the needs identified in its most recently conducted Needs Assessment? If “No,” explain in Part VI which needs it has not addressed together with the reasons why it has not addressed such needs. 7    
Financial Assistance Policy
Did the hospital facility have in place during the tax year a written financial assistance policy that:
8 Explains eligibility criteria for financial assistance, and whether such assistance includes free or discounted care? 8    
9 Used federal poverty guidelines (FPG) to determine eligibility for providing free care to low incomeindividuals?.. 9    
If “Yes,” indicate the FPG family income limit for eligibility for free care:   %
Schedule H (Form 990) 2010
Schedule H (Form 990) 2010
Page 5
Part VFacility Information (continued)

Yes No
10 Used FPG to determine eligibility for providing discounted care to low income individuals?......... 10    
If “Yes,” indicate the FPG family income limit for eligibility for discounted care:   %
11 Explained the basis for calculating amounts charged to patients?................. 11    
If “Yes,” indicate the factors used in determining such amounts (check all that apply):
a Income level
b Asset level
c Medical indigency
d Insurance status
e Uninsured discount
f Medicaid/Medicare
g State regulation
h Other (describe in Part VI)
12 Explained the method for applying for financial assistance?................... 12    
13 Included measures to publicize the policy within the community served by the hospital facility?....... 13    
If “Yes,” indicate how the hospital facility publicized the policy (check all that apply):
a The policy was posted at all times on the hospital facility’s web site
b The policy was attached to all billing invoices
c The policy was posted in the hospital facility’s emergency rooms or waiting rooms
d The policy was posted in the hospital facility’s admissions offices
e The policy was provided, in writing, to patients upon admission to the hospital facility
f The policy was available upon request
g Other (describe in Part VI)
Billing and Collections
14 Did the hospital facility have in place during the tax year a separate billing and collections policy, or a written financial assistance policy that explained actions the hospital facility may take upon non-payment?........ 14    
15 Check all of the following collection actions against a patient that were permitted under the hospital facility's policies at any time during the tax year:
a Reporting to credit agency
b Lawsuits
c Liens on residences
d Body attachments or arrests
e Other (describe in Part VI)
16 Did the hospital facility engage in or authorize a third party to engage in any of the following collection actions during the tax year?................................... 16    
If “Yes,” check all collection actions in which the hospital facility or a third party engaged (check all that apply):
a Reporting to credit agency
b Lawsuits
c Liens on residences
d Body attachments
e Other (describe in Part VI)
17 Indicate which actions the hospital facility took before initiating any of the collection actions checked in question 16 (check all that apply):
a Notified patients of the financial assistance policy upon admission
b Notified patients of the financial assistance policy prior to discharge
c Notified patients of the financial assistance policy in communications with the patients regarding the patients’ bills
d Documented its determination of whether a patient who applied for financial assistance under the financial assistance policy qualified for financial assistance
e Other (describe in Part VI)
Schedule H (Form 990) 2010
Schedule H (Form 990) 2010
Page 6
Part VFacility Information (continued)

Policy Relating to Emergency Medical Care
Yes No
18 Did the hospital facility have in place during the tax year a written policy relating to emergency medical care that requires the hospital facility to provide, without discrimination, care for emergency medical conditions to individuals regardless of their eligibility under the hospital facility’s financial assistance policy?.......... 18    
If “No,” indicate the reasons why (check all that apply):
a The hospital facility did not provide care for any emergency medical conditions
b The hospital facility did not have a policy relating to emergency medical care
c The hospital facility limited who was eligible to receive care for emergency medical conditions (describe in Part VI)
d Other (describe in Part VI)
Charges for Medical Care
19 Indicate how the hospital facility determined the amounts generally billed to individuals who had insurance covering emergency or other medically necessary care (check all that apply):
a The hospital facility used the lowest negotiated commercial insurance rate for those services at the hospital facility
b The hospital facility used the average of the three lowest negotiated commercial insurance rates for those services at the hospital facility
c The hospital facility used the Medicare rate for those services
d Other (describe in Part VI)
20 Did the hospital facility charge any of its patients who were eligible for assistance under the hospital facility’s financial assistance policy, and to whom the hospital facility provided emergency or other medically necessary services, more than the amounts generally billed to individuals who had insurance covering such care?......... 20    
If “Yes,” explain in Part VI.
21 Did the hospital facility charge any of its patients an amount equal to the gross charge for services provided to that patient?................................... 21    
If “Yes,” explain in Part VI.
Schedule H (Form 990) 2010
Schedule H (Form 990) 2010
Page 7
Part VFacility Information (continued)

Section C. Other Facilities That Are Not Licensed, Registered, or Similarly Recognized as a Hospital Facility
(list in order of size, measured by total revenue per facility, from largest to smallest)
How many non-hospital facilities did the organization operate during the tax year?1
Name and address Type of Facility (Describe)
1 PEKIN HOSPITAL MRI BUILDING
1300 PARK AVENUE
PEKIN,IL61554 		DIAGNOSTIC CENTER
2
3
4
5
6
7
8
9
10
Schedule H (Form 990) 2010
Schedule H (Form 990) 2010
Page 8
Part VI
Supplemental Information
Complete this part to provide the following information.
1 Required descriptions. Provide the description required for Part I, lines 3c, 6a, and 7; Part II; Part III, lines 4, 8, and 9b; and Part V, Section B, lines 1j, 2, 4c, 6i, 7, 11i, 13i, 17l, 18l, 19e, 21d, 25, and 26.
2 Community health needs assessment. Describe how the organization assesses the health care needs of the communities it serves, in addition to any community health needs assessments reported in Part V, Section B.
3 Patient education of eligibility for assistance. Describe how the organization informs and educates patients and persons who may be billed for patient care about their eligibility for assistance under federal, state, or local government programs or under the organization’s financial assistance policy.
4 Community information. Describe the community the organization serves, taking into account the geographic area and demographic constituents it serves.
5 Promotion of community health. Provide any other information important to describing how the organization’s hospital facilities or other health care facilities further its exempt purpose by promoting the health of the community (e.g., open medical staff, community board, use of surplus funds, etc.).
6 Affiliated health care system. If the organization is part of an affiliated health care system, describe the respective roles of the organization and its affiliates in promoting the health of the communities served.
7 State filing of community benefit report. If applicable, identify all states with which the organization, or a related organization, files a community benefit report.
Identifier ReturnReference Explanation
COST METHODOLOGY 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.
BAD DEBT PART I, LINE 7, COLUMN (F) THE ORGANIZATION HAD BAD DEBT EXPENSE IN THE AMOUNT OF $8,122,577 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 4A PEKIN REPORTS PATIENT ACCOUNTS RECEIVABLE FOR SERVICES RENDERED AT NET REALIZABLE AMOUNTS FROM THIRD-PARTY PAYERS, PATIENTS AND OTHERS. PROGRESSIVE 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, PEKIN 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.
BAD DEBT COST METHODOLOGY PART III, LINE 4B THE HOSPITAL COMMITS TO SIGNIFICANT TIME AND RESOURCES TO ENDEAVORS AND CRITICAL SERVICES WHICH MEET OTHERWISE UNFILLED COMMUNITY NEEDS. MANY OF THESE ACTIVITIES ARE SPONSORED WITH THE KNOWLEDGE THAT THEY WILL NOT BE SELF-SUPPORTING OR FINANCIALLY VIABLE. ADDITIONALLY, AMOUNTS IN LINE 3 EXIST DUE TO THE NUMBER OF PATIENTS WHO DID NOT TAKE THE TIME TO APPLY FOR CHARITY CARE, BUT OTHERWISE QUALIFIED.
SHORTFALL PART III, LINE 8 LINE 6 IS TAKEN FROM MCR COST REPORT - COST TO CHARGE RATIO. THE MEDICARE COST REPORT IS FILED FOLLOWING THE COST REPORT GUIDELINES. MEDICARE PAYMENT SHORTFALLS SHOULD BE REFLECTED AS COMMUNITY BENEFIT AS THE FEDERAL GOVERNMENT PROSPECTIVELY SETS THE HOSPITAL PAYMENT RATES; THE RATES ARE NOT NEGOTIABLE AND CONSEQUENTLY, NO LONGER COVER THE HOSPITAL'S COST TO PROVIDE SERVICES TO MEDICARE BENEFICIARIES.
DEBT COLLECTION POLICY PART III, LINE 9B PEKIN FOLLOWS THE CHARITY POLICY, REGARDLESS OF THEIR INSURANCE SITUATION. FOR EXAMPLE, IF THE PERSON HAS A FORM OF INSURANCE, THE INSURANCE COMPANY PAYS, AND PEKIN APPLIES CHARITY CARE BENEFITS TO THE SELF-PAY PORTION REMAINING AFTER THE INSURANCE PAYMENT.
NEEDS ASSESSMENT PART VI, LINE 2 PEKIN HOSPITAL CONTRACTED WITH QHR, ITS MANAGEMENT CONSULTANT, TO ASSIST WITH THE CREATION OF ITS STRATEGIC PLAN. THE COMMUNITY ASSESSMENT WAS PERFORMED THROUGH A SERIES OF FOCUS GROUPS, COMMUNITY SURVEYS, PHYSICIAN PANEL DISCUSSIONS, INTERNAL STATISTICAL DATA, AND COUNTY AND SERVICE AREA DEMOGRAPHICS.
PATIENT EDUCATION OF ELIGIBILITY FOR ASSISTANCE PART VI, LINE 3 PEKIN'S CHARITY CARE POLICY IS ON ITS WEB-SITE. IT IS ALSO POSTED IN MOST OF THE COMMON AREAS THOUGHOUT THE FACILITY, AND IS VISIBLY POSTED IN THE REGISTRATION AND PATIENT ACCOUNTS AREAS.
COMMUNITY INFORMATION PART VI, LINE 4 PEKIN HOSPITAL PRIMARILY SERVES TAZEWELL, MASON AND PEORIA COUNTIES IN THE STATE OF ILLINOIS. IT IS ONE OF THE LARGEST EMPLOYERS IN THE CITY OF PEKIN AND IN TAZEWELL COUNTY. THE SERVICE AREA SITS TO THE SOUTH AND EAST OF THE GREATER PEORIA AREA, WHERE CATERPILLAR IS A MAJOR INDUSTRIAL EMPLOYER. ITS PRIMARY SERVICE AREA HAS A POPULATION OF JUST OVER 60,000 WITH A SECONDARY SERVICE AREA OF APPROXIMATELY 13,500. THE MEDIAN AGE OF ITS SERVICE AREA IS 40 YEARS, WHILE THE MEDIAN HOUSEHOLD INCOME IS $54,000.
PROMOTION OF COMMUNITY HEALTH PART VI, LINE 5 IT IS REPORTED THAT 85%-90% OF WOMEN MAKE THE HEALTHCARE DECISIONS IN THEIR HOUSEHOLDS. THAT'S WHY PEKIN HOSPITAL HAS PARTNERED WITH THE NATIONAL SPIRIT OF WOMEN HEALTH NETWORK TO REACH OUT TO THE WOMEN OF THE COMMUNITY TO EDUCATE AND INFORM THEM OF VARIOUS HEALTH CONCERNS AND TO PROMOTE HEALTHY LIFESTYLES. PEKIN HOSPITAL ALSO PROVIDES MANY FREE HEALTH SCREENINGS THROUGHOUT THE YEAR TO PROMOTE EARLY DETECTION AND PREVENTION. THIS INCLUDES BUT IS NOT LIMITED TO MAMMOGRAPHY, BONE DENSITY, BLOOD PRESSURE, COLON, OBESITY, AND SPIROMETRY. PEKIN HOSPITAL HAS ENGAGED ITS PHYSICIANS TO SPEAK AT DIFFERENT COMMUNITY ORGANIZATIONS, TO SHARE INFORMATION ON HEALTH AND WELL-BEING. IT HAS ALSO SENT REPRESENTATIVES OUT TO DISCUSS HEALTHCARE REFORM. THIS INCLUDES LUNCH-AND-LEARNS WITH GROUPS SUCH AS ROTARY, KIWANIS, SPIRIT OF WOMEN EVENTS, SENIOR BREAKFASTS, THE PEKIN CHAMBER OF COMMERCE, AND OTHER COMMUNITY GROUPS. IN FY 2010, PEKIN HOSPITAL HAD CONSOLIDATED BAD DEBT AND CHARITY CARE TOTALING $13.4M. IN FY 2011 THAT NUMBER JUMPED TO $14.8M. THIS MEANS THAT IN FY 2011, PEKIN HOSPITAL DELIVERED $14.8M OF FREE CARE TO THE COMMUNITY.
AFFILIATED HEALTH CARE SYSTEM PART VI, LINE 6 PROGRESSIVE HEALTH SYSTEM IS THE SOLE MEMBER OF PEKIN HOSPITAL, PEKIN HOSPITAL FOUNDATION, PARK COURT LIMITED, AND PRO HEALTH INC. PEKIN HOSPITAL IS A NOT-FOR-PROFIT ENTITY AND IS THE ONLY HOSPITAL UNDER THE PROGRESSIVE HEALTH SYSTEM UMBRELLA. THE FOUNDATION IS A NOT-FOR-PROFIT ENTITY THAT RAISES FUNDS ON BEHALF OF PEKIN HOSPITAL TO ASSIST WITH PURCHASES OF CAPITAL EQUIPMENT AND OTHER LARGE EXPENSES FOR MEDICAL CARE. PARK COURT LIMITED IS A NOT-FOR-PROFIT ENTITY THAT FUNCTIONS AS A PROPERTY HOLDING COMPANY WHICH LEASES MEDICAL OFFICE SPACE TO MEDICAL CARE PROVIDERS. PRO HEALTH INC. IS A FOR-PROFIT PHYSICIAN CLINIC THAT EMPLOYS PHYSICIANS TO CARE FOR ITS PATIENTS AND WHO ALSO HAVE ADMITTING RIGHTS TO PEKIN HOSPITAL.
STATE FILING OF COMMUNITY BENEFIT REPORT PART VI, LINE 7 ILLINOIS ONLY
Schedule H (Form 990) 2010
Additional Data


Software ID:  
Software Version:  
Schedule J
(Form 990)
Department of the Treasury
Internal Revenue Service
Compensation Information
For certain Officers, Directors, Trustees, Key Employees, and Highest
Compensated Employees
SchJMediumBullet Complete if the organization answered "Yes" to Form 990,
Part IV, question 23.
SchJMediumBullet Attach to Form 990. SchJMediumBullet See separate instructions.
OMB No. 1545-0047
2010
Open to Public Inspection
Name of the organization
Pekin Memorial Hospital
 
Employer identification number

37-0692351
Part I
Questions Regarding Compensation
Yes
No
1a
Check the appropiate box(es) if the organization provided any of the following to or for a person listed in Form
990, Part VII, Section A, line 1a. Complete Part III to provide any relevant information regarding these items.
b
If any of the boxes in line 1a are checked, did the organization follow a written policy regarding payment or reimbursement orprovision of all the expenses described above? If "No," complete Part III to explain....
1b
 
No
2
Did the organization require substantiation prior to reimbursing or allowing expenses incurred by all
officers, directors, trustees, and the CEO/Executive Director, regarding the items checked in line 1a? ....
2
 
No
3
Indicate which, if any, of the following the organization uses to establish the compensation of the
organization's CEO/Executive Director. Check all that apply.
4
During the year, did any person listed in Form 990, Part VII, Section A, line 1a with respect to the filing organization or a related organization:
a
Receive a severance payment or change-of-control payment? ...............
4a
 
No
b
Participate in, or receive payment from, a supplemental nonqualified retirement plan? ........
4b
 
No
c
Participate in, or receive payment from, an equity-based compensation arrangement? ........
4c
 
No
If "Yes" to any of lines 4a-c, list the persons and provide the applicable amounts for each item in Part III.
Only 501(c)(3) and 501(c)(4) organizations only must complete lines 5-9.
5
For persons listed in form 990, Part VII, Section A, line 1a, did the organization pay or accrue any
compensation contingent on the revenues of:
a
The organization? ...........................
5a
 
No
b
Any related organization? .........................
5b
 
No
If "Yes," to line 5a or 5b, describe in Part III.
6
For persons listed in form 990, Part VII, Section A, line 1a, did the organization pay or accrue any
compensation contingent on the net earnings of:
a
The organization? ...........................
6a
 
No
b
Any related organization? .........................
6b
 
No
If "Yes," to line 6a or 6b, describe in Part III.
7
For persons listed in Form 990, Part VII, Section A, line 1a, did the organization provide any non-fixed
payments not described in lines 5 and 6? If "Yes," describe in Part III ............
7
 
No
8
Were any amounts reported in Form 990, Part VII, paid or accured pursuant to a contract that was
subject to the initial contract exception described in Regs. section 53.4958-4(a)(3)? If "Yes," describe
in Part III .............................
8
 
No
9
If "Yes" to line 8, did the organization also follow the rebuttable presumption procedure described in Regulations section 53.4958-6(c)? .........................
9
 
 
For Privacy Act and Paperwork Reduction Act Notice, see the Intructions for Form 990
Cat. No. 50053T
Schedule J (Form 990) 2010

Schedule J (Form 990) 2010
Page 2
Part II
Officers, Directors, Trustees, Key Employees, and Highest Compensated Employees. Use Schedule J-1 if additional space needed.
For each individual whose compensation must be reported in Schedule J, report compensation from the organization on row (i) and from related organizations, described in the
instructions on row (ii). Do not list any individuals that are not listed on Form 990, Part VII.

Note. The sum of columns (B)(i)-(iii) must equal the applicable column (D) or column (E) amounts on Form 990, Part VII, line 1a.
(A) Name (B) Breakdown of W-2 and/or 1099-MISC compensation (C) Retirement and other deferred compensation (D) Nontaxable
benefits		 (E) Total of columns
(B)(i)-(D) 		(F) Compensation
reported in prior
Form 990 or
Form 990-EZ
(i) Base compensation (ii) Bonus & incentive compensation (iii) Other reportable compensation
(1) DR STEVEN CLARK (i)
(ii)		 0
370,322 		0
0 		0
1,685 		0
3,675 		0
22,459 		0
398,141 		0
0
(2) KEVIN R ANDREWS (i)
(ii)		 427,344
0 		0
0 		0
0 		0
0 		0
0 		427,344
0 		0
0
(3) STEVEN C HALL (i)
(ii)		 179,466
0 		32,533
0 		0
0 		12,352
0 		25,059
0 		249,410
0 		0
0
(4) JO ELLEN PATTERSON (i)
(ii)		 140,397
0 		25,631
0 		0
0 		11,013
0 		1,500
0 		178,541
0 		0
0
(5) ANNE DIERKER (i)
(ii)		 135,064
0 		25,586
0 		1,672
0 		9,170
0 		10,887
0 		182,379
0 		0
0
(6) MICHAEL ERICKSON (i)
(ii)		 259,825
0 		0
0 		0
0 		15,925
0 		12,627
0 		288,377
0 		0
0
(7) PEGGE HALL (i)
(ii)		 245,065
0 		0
0 		0
0 		13,475
0 		16,883
0 		275,423
0 		0
0
(8) CAROLYN SUTTER (i)
(ii)		 233,550
0 		0
0 		0
0 		10,907
0 		12,127
0 		256,584
0 		0
0
(9) MELISSA NGO (i)
(ii)		 222,390
0 		0
0 		0
0 		10,157
0 		2,990
0 		235,537
0 		0
0
(10) STEVEN BOOKER (i)
(ii)		 223,802
0 		11,960
0 		898
0 		13,093
0 		25,959
0 		275,712
0 		0
0






Schedule J (Form 990) 2010

Schedule J (Form 990) 2010
Page 3
Part III
Supplemental Information
Complete this part to provide the information, explanation, or descriptions required for Part I, lines 1a, 1b, 4c, 5a, 5b, 6a, 6b, 7, and 8. Also complete this part for any additional information.
Identifier Return Reference Explanation
HEALTH OR SOCIAL CLUB DUES OR INITIATION FEES PART I, LINE 1(A) KEVIN ANDREWS, CEO, IS THE ONLY INDIVIDUAL THAT RECEIVED PAYMENT FOR HEALTH/SOCIAL CLUB MEMBERSHIP DUES. THE ORGANIZATION ONLY PAYS FOR EXPENSES RELATED TO THE BUSINESS USE OF THE MEMBERSHIP.
WRITTEN POLICY REGARDING PAYMENT OR REIMBURSEMENT PART I, LINE 1(B) THE COUNTRY CLUB DOES NOT ALLOW MEMBERSHIPS TO BE IN THE NAME OF ANY BUSINESS, THEREFORE, THE ORGANIZATION IS USING THE NAME OF ITS CEO. THE ORGANIZATION ONLY PAYS FOR EXPENSES RELATED TO THE BUSINESS USE OF THE MEMBERSHIP.
COMPENSATION PAID BY AN UNRELATED MANAGEMENT COMPANY   THE CEO, KEVIN ANDREWS, IS PAID BY AN UNRELATED MANAGEMENT COMPANY, QUORUM HEALTH RESOURCES. QUORUM PROVIDED KEVIN ANDREWS WITH COMPENSATION IN THE AMOUNT OF $427,344. ALL FEES ARE PAID TO QUORUM BY PEKIN MEMORIAL HOSPITAL.
Schedule J (Form 990) 2010

Additional Data


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Schedule K
(Form 990)
Department of the Treasury
Internal Revenue Service
Supplemental Information on Tax Exempt Bonds
SchKMediumBullet Complete if the organization answered "Yes" to Form 990, Part IV, line 24a. Provide descriptions,
explanations, and any additional information in Schedule O (Form 990).
SchKMediumBullet Attach to Form 990. SchKMediumBullet See separate instructions.
OMB No. 1545-0047
2010
Open to Public
Inspection
Name of the organization
Pekin Memorial Hospital
 
Employer identification number
37-0692351
Part I
Bond Issues
(a) Issuer Name (b) Issuer EIN (c) CUSIP # (d) Date Issued (e) Issue Price (f) Description of Purpose (g) Defeased (h) On
Behalf of
Issuer 		(i) Pool
financing
Yes No Yes No Yes No
A CITY OF PEKIN TAZEWELL COUNTY ILLINOIS
  		37-6002169   03-30-2010 23,530,000 REV REFUNDING BONDS SER 1993B+C &   X   X   X
Part II
Proceeds
A B C D
1 Amount of bonds retired. . . . . 1,815,000      
2 Amount of bonds defeased . . . . 0      
3 Total proceeds of issue . . . . 23,530,000      
4 Gross proceeds in reserve funds . . 2,430,000      
5 Capitalized interest from proceeds. 0      
6 Proceeds in refunding escrow. . . . . 21,715,000      
7 Issuance costs from proceeds . . . 325,773      
8 Credit enhancement from proceeds. 0      
9 Working capital expenditures from proceeds . . 0      
10 Capital expenditures from proceeds . . 0      
11 Other spent proceeds . . 0      
12 Other unspent proceeds. . . 0      
13 Year of substantial completion . . . 2017
Yes No Yes No Yes No Yes No
14 Were the bonds issued as part of a current refunding issue? X              
15 Were the bonds issued as part of an advance refunding issue?   X            
16 Has the final allocation of proceeds been made? . .   X            
17 Does the organization maintain adequate books and records to support the final allocation of proceeds? . X              
Part III
Private Business Use
A B C D
Yes No Yes No Yes No Yes No
1 Was the organization a partner in a partnership, or a member of an LLC, which owned property financed by tax-exempt bonds? . . .   X            
2 Are there any lease arrangements that may result in private business use of bond-financed property? . . . . . X              
For Privacy Act and Paperwork Reduction Act Notice, see the Instructions for Form 990.
Cat. No. 50193E
Schedule K (Form 990) 2010
Schedule K (Form 990) 2010
Page 2
Part III
Private Business Use (Continued)
A B C D
Yes No Yes No Yes No Yes No
3a Are there any management or service contracts that may result in private business use?   X            
b Are there any research agreements that may result in private business use of bond-financed property? . .   X            
c Does the organization routinely engage bond counsel or other outside counsel to review any management or service contracts or research agreements relating to the financed property? .   X            
4 Enter the percentage of financed property used in a private business use by entities other than a section 501(c)(3) organization or a state or local government . . . . . . . . . . . . . SchKMediumBullet 2.400 %      
5 Enter the percentage of financed property used in a private business use as a result of unrelated trade or business activity carried on by your organization, another section 501(c)(3) organization, or a state or local government . SchKMediumBullet 0 %      
6 Total of lines 4 and 5 . . .. . . . . . 2.400 %      
7 Has the organization adopted management practices and procedures to ensure the post-issuance compliance of its tax-exempt bond liabilities?   X            
Part IV
Arbitrage
A B C D
Yes No Yes No Yes No Yes No
1 Has a Form 8038-T, Arbitrage Rebate, Yield Reduction and Penalty in Lieu of Arbitrage Rebate, been filed with respect to the bond issue? . . . X              
2 Is the bond issue a variable rate issue?   X            
3a Has the organization or the governmental issuer entered into a hedge with respect to the bond issue?   X            
b Name of provider .  
  		 
  		 
  		 
 
c Term of hedge . .        
d Was the hedge superintegrated? .   X            
e Was a hedge terminated? .   X            
4a Were gross proceeds invested in a GIC? .   X            
b Name of provider .  
  		 
  		 
  		 
 
c Term of GIC . .        
d Was the regulatory safe harbor for establishing the fair market value of the GIC satisfied? .                
5 Were any gross proceeds invested beyond an available temporary period? .   X            
6 Did the bond issue qualify for an exception to rebate? . . .   X            
Schedule K (Form 990) 2010

Schedule K (Form 990) 2010
Page 3
Part V
Supplemental Information
Complete this part to provide additional information for responses to questions on Schedule K (see instructions).
Identifier Return Reference Explanation
Schedule K (Form 990) 2010

Additional Data


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Schedule L
(Form 990 or 990-EZ)
Department of the Treasury
Internal Revenue Service
Transactions with Interested Persons
MediumBullet Complete if the organization answered
"Yes" on Form 990, Part IV, lines 25a, 25b, 26, 27, 28a, 28b, or 28c,
or Form 990-EZ, Part V lines 38a or 40b.
MediumBullet Attach to Form 990 or Form 990-EZ. MediumBulletSee separate instructions.
OMB No. 1545-0047
2010
Open to Public Inspection
Name of the organization
Pekin Memorial Hospital
 
Employer identification number

37-0692351
Part I
Excess Benefit Transactions (section 501(c)(3) and section 501 (c)(4) organizations only).
Complete if the organization answered "Yes" on Form 990, Part IV, line 25a or 25b, or Form 990-EZ, Part V, line 40b.
1(a) Name of disqualified person (b) Description of transaction (c) Corrected?
Yes No





2
Enter the amount of tax imposed on the organization managers or disqualified persons during the year under section 4958. ......................... Bullet Image$
 
3
Enter the amount of tax, if any, on line 2, above, reimbursed by the organization ....... Bullet Image$
 

Part II
Loans to and/or From Interested Persons.
Complete if the organization answered "Yes" on Form 990, Part IV, line 26, or Form 990-EZ, Part V, line 38a.
(a) Name of interested person and purpose (b) Loan to or from the organization? (c)Original principal amount (d)Balance due (e) In default? (f) Approved by board or committee? (g)Written agreement?
To From Yes No Yes No Yes No
Total ...............Small Bullet $  
Part III
Grants or Assistance Benefitting Interested Persons.
Complete if the organization answered "Yes" on Form 990, Part IV, line 27.
(a) Name of interested person (b)Relationship between interested person and the organization (c)Amount of grant or type of assistance
For Privacy Act and Paperwork Reduction Act Notice, see the
Instructions for Form 990 or 990-EZ.
Cat. No. 50056A
Schedule L (Form 990 or 990-EZ) 2010
Schedule L (Form 990 or 990-EZ) 2010
Page 2
Part IV
Business Transactions Involving Interested Persons.
Complete if the organization answered "Yes" on Form 990, Part IV, line 28a, 28b, or 28c.
(a) Name of interested person (b) Relationship between interested person and the organization (c) Amount of transaction (d) Description of transaction (e) Sharing of organization's revenues?
Yes No
(1) HERGET BANK R MILLER & R KRIEGSMAN 121,307 INTEREST INCOME FROM THE BANK   No
(2) TRUSTEES FOR THE BANK ARE TRUSTEES OF THE ORG        
(3) HERGET BANK R MILLER & R KRIEGSMAN 21,061 FEES PAID TO THE BANK   No
(4) TRUSTEES FOR THE BANK ARE TRUSTEES OF THE ORG        
(5) PEKIN INSURANCE R KRIEGSMAN & C EETEN 1,591,932 PAYMENTS RECEIVED FOR HEALTH   No
(6) TRUSTEES FOR THE INSURANCE CO ARE TRUSTEES OF THE ORG   INSURANCE CLAIMS    
Part V
Supplemental Information
Complete this part to provide additional information for responses to questions on Schedule L (see instructions).
Identifier Return Reference Explanation
Schedule L (Form 990 or 990-EZ) 2010

Additional Data


Software ID:  
Software Version:  




SCHEDULE O
(Form 990 or 990-EZ)

Department of the Treasury
Internal Revenue Service
Supplemental Information to Form 990 or 990-EZ

Complete to provide information for responses to specific questions on
Form 990 or to provide any additional information.
MediumBullet Attach to Form 990 or 990-EZ.
OMB No. 1545-0047
2010
Open to Public
Inspection
Name of the organization
Pekin Memorial Hospital
 
Employer identification number

37-0692351
Identifier Return Reference Explanation
STATEMENT OF PROGRAM SERVICE ACCOMPLISHMENT FORM 990, SUPPLEMENT TO PART III, LINE 4A PROGRESSIVE HEALTH SYSTEMS PEKIN HOSPITAL COMPREHENSIVE COMMUNITY BENEFIT REPORT FOR THE YEAR-ENDED APRIL 30, 2011 MISSION STATEMENT: TO BE THE HEALTHCARE PROVIDER OF CHOICE IN THE COMMUNITIES THAT WE SERVE. ADOPTED JULY 24, 2004 OUR VISION: PEKIN HOSPITAL WILL BE THE PLACE WHERE PATIENTS RECEIVE THE HIGHEST QUALITY HEALTHCARE AND WHERE EVERY PHYSICIAN AND EMPLOYEE CAN MAKE A DIFFERENCE. PEKIN HOSPITAL IS: ACCREDITED BY: JOINT COMMISSION ON ACCREDITATION OF HEALTHCARE ORGANIZATIONS LICENSED BY: THE STATE OF ILLINOIS DEPARTMENT OF PUBLIC HEALTH AFFILIATED WITH: OSF HEALTHCARE SYSTEM UNIVERSITY OF ILLINOIS COLLEGE OF MEDICINE AT PEORIA INSTITUTE OF PHYSICAL MEDICINE AND REHABILITATION ILLINOIS CENTRAL COLLEGE BRADLEY UNIVERSITY QUORUM HEALTH RESOURCES MEMBER OF: AMERICAN HOSPITAL ASSOCIATION AMERICAN RED CROSS PEORIA REGIONAL BLOOD PROGRAM CONSORTIUM FOR TOTAL HEALTH CARE ILLINOIS ASSOCIATION OF HOME CARE (IAHC) ILLINOIS MATERNAL CHILD HEALTH COUNCIL PEKIN CHAMBER OF COMMERCE REGION IB TRAUMA AND PERINATAL NETWORKS ILLINOIS HOSPITAL ASSOCIATION CERTIFIED BY ILLINOIS DEPARTMENT OF PUBLIC HEALTH DESIGNATED AFFILIATE TRAUMA HOSPITAL EMERGENCY DEPARTMENT APPROVED FOR PEDIATRICS (EDAP) COMMUNITY BENEFIT PLAN - GOALS AND OBJECTIVES A. MEDICATION RECONCILIATION TO FURTHER PROMOTE PATIENT SAFETY, PEKIN HOSPITAL'S MEDICATION RECONCILIATION TEAM WILL HEIGHTEN COMMUNITY AWARENESS OF THE IMPORTANCE OF HAVING AN ACCURATE LISTING OF THEIR MEDICATIONS, AS WELL AS ANY HERBALS, SUPPLEMENTS, OVER-THE-COUNTERS, ETC. B. COMMUNITY EDUCATION TO IMPROVE THE HEALTH OF THE COMMUNITIES WE SERVE, PEKIN HOSPITAL WILL OFFER A VARIETY OF EDUCATIONAL OPPORTUNITIES FOR AREA RESIDENTS INCLUDING LECTURES AND CLASSROOM SESSIONS. C. COMMUNITY SUPPORT UNITED WAY - PEKIN HOSPITAL'S CALENDAR YEAR 2010 GOAL WAS TO RAISE $20,000 TO CONTRIBUTE TO THE ANNUAL CAMPAIGN. D. COMMUNITY EMERGENCY RESPONSE E. PROVIDING CARE BASED ON NEED 1. CHARITY CARE 2. MEDICAID 3. MEDICARE F. COMMUNITY INVOLVEMENT 1. SERVICE GROUPS PEKIN HOSPITAL WILL ENCOURAGE EMPLOYEE MEMBERSHIP OF THE MANY COMMUNITY ORGANIZATIONS, INCLUDING THE FOLLOWING: KIWANIS CLUB OF PEKIN, PEKIN AREA CHAMBER OF COMMERCE, KNIGHTS OF COLUMBUS, PEKIN REGISTERED NURSES GROUP, ROTARY CLUB, AMONG OTHERS. 2. PEKIN AREA CHAMBER OF COMMERCE PEKIN HOSPITAL WILL CONTINUE ITS ACTIVE ROLE WITH THE CHAMBER OF COMMERCE, AND WILL ENCOURAGE EMPLOYEE PARTICIPATION IN THEIR MANY EVENTS AND/OR VOLUNTEER ROLES. 3. COMMUNITY LEADERSHIP ACADEMY PEKIN HOSPITAL IS DEDICATED TO IDENTIFYING AND PROMOTING FUTURE COMMUNITY LEADERS AND WILL CONTINUE TO ENROLL EMPLOYEES IN THE PEKIN AREA CHAMBER OF COMMERCE ANNUAL COMMUNITY LEADERSHIP ACADEMY. THE ACADEMY AIMS TO INFORM AND EDUCATE EXISTING AND EMERGING LEADERS OF THE LOCAL COMMUNITY, AND TO MOTIVATE THEM TOWARD LEADERSHIP RESPONSIBILITIES BY EXPOSING THEM TO THE REALITIES, OPPORTUNITIES AND CHALLENGES OF THE LOCAL COMMUNITY. G. COMMUNITY SCREENINGS TO FURTHER PROMOTE THE HEALTH OF THE COMMUNITIES WE SERVE, PEKIN HOSPITAL IS COMMITTED TO OFFERING FREE COMMUNITY SCREENINGS EACH MONTH. POPULATIONS AND COMMUNITIES SERVED BY THE HOSPITAL PEKIN HOSPITAL'S PRIMARY SERVICE AREA IS COMPRISED OF THE THREE PEKIN ZIP CODES (INCLUDES SOUTH PEKIN) AND SEVEN ADDITIONAL ZIP CODES LOCATED WEST, SOUTH AND EAST OF PEKIN. PEKIN HOSPITAL'S SECONDARY SERVICE AREA IS COMPRISED OF FIVE ZIP CODES LOCATED NORTHWEST, NORTHEAST AND EAST OF PEKIN. MEDIAN AGE PRIMARY SERVICE AREA: 39.8 YEARS MEDIAN AGE SECONDARY SERVICE AREA: 44.0 YEARS MEDIAN AGE ILLINOIS: 35.7 YEARS COMPARED TO THE STATE OF ILLINOIS OVERALL, PRIMARY SERVICE AREA RESIDENTS HAVE MORE HOUSEHOLD INCOME AND SECONDARY SERVICE AREA RESIDENTS HAVE LESS. MEDIAN HOUSEHOLD INCOME PRIMARY SERVICE AREA: $53,904 MEDIAN HOUSEHOLD INCOME SECONDARY SERVICE AREA: $47,330 MEDIAN HOUSEHOLD INCOME ILLINOIS: $53,974 CHARITY CARE MEDICAL CARE IS AVAILABLE TO PATIENTS, BASED ON MEDICAL NECESSITY, REGARDLESS OF THEIR ABILITY TO PAY. PATIENTS MAY REQUEST CHARITY ASSISTANCE APPLICATIONS BY TELEPHONE OR IN PERSON. PEKIN HOSPITAL WAIVES CHARGES BASED ON REVIEW OF THE PATIENT'S FINANCIAL STATUS COMPARED TO FEDERAL POVERTY GUIDELINES. INFORMATION REGARDING CHARITY CARE MAY BE FOUND THROUGHOUT THE HOSPITAL INCLUDING IN PATIENT REGISTRATION, OUTPATIENT DEPARTMENTS, EMERGENCY DEPARTMENT, AND THE PATIENT SERVICE DEPARTMENTS. INFORMATION REGARDING FINANCIAL PROGRAMS, INCLUDING CHARITY CARE, CAN ALSO BE FOUND ON THE HOSPITAL'S WEBSITE AT WWW.PEKINHOSPITAL.ORG. CHARITY CARE DOES NOT INCLUDE BAD DEBT OR UNREIMBURSED COSTS OF MEDICARE, MEDICAID OR OTHER GOVERNMENT PROGRAMS. THE COST OF PROVIDING CHARITY CARE FOR THE FISCAL YEAR ENDING APRIL 30, 2011 WAS $1,690,000 COMMUNITY BENEFITS A. LANGUAGE ASSISTANT SERVICES BASED ON THE NEEDS OF OUR NON-ENGLISH SPEAKING GUESTS, PEKIN HOSPITAL PROVIDES INTERPRETER PHONE SERVICES FOR A VARIETY OF LANGUAGES. PEKIN ALSO HAS INTERNAL INTERPRETERS. B. GOVERNMENT SPONSORED INDIGENT HEALTH CARE UNREIMBURSED CARE PROVIDED TO PATIENTS UNDER MEDICARE AND PUBLIC AID PROGRAMS, ELIGIBILITY WHICH IS BASED ON FINANCIAL NEED. INPATIENT AND OUTPATIENTS COSTS ARE INCLUDED. UNREIMBURSED CARE FROM MEDICARE WAS $5,631,103 AND PUBLIC AID WAS $5,239,000 FOR FISCAL YEAR ENDING APRIL 30, 2011 FOR A TOTAL OF $10,870,103. C. DIRECT SUPPORT OF OTHER COMMUNITY ORGANIZATIONS 1. CONFERENCE SPACE: OVER 1,000 HOURS WERE DONATED FOR CONFERENCE ROOMS - LOCAL CHURCH GROUPS, ALZHEIMER'S SUPPORT GROUP, LOSS AND GRIEF SUPPORT GROUP, BOY SCOUTS, AWAKE (SLEEP APNEA SUPPORT GROUP), COMPASSIONATE FRIENDS GROUP, CULTURAL CLUB, KIWANIS CLUB, AND OTHERS. 2. UNITED WAY OF PEKIN: $17,111 WAS DONATED IN SUPPORT OF THE 2010 UNITED WAY CAMPAIGN. OUR GOAL FOR THE 2011 CAMPAIGN IS $18,000. D. VOLUNTEERS 1. VOLUNTEER HOURS - 41,727.5 2. VOLUNTEER HOURS FROM SCREENINGS - 149 E. SCREENINGS/HEALTH FAIRS 1. COMMUNITY SCREENINGS: FROM MAY 1, 2010 THROUGH APRIL 30, 2011, PEKIN HOSPITAL PROVIDED A VARIETY OF FREE COMMUNITY SCREENINGS TO 2,363 INDIVIDUALS IN THE PEKIN AREA. OF THE 2,363 INDIVIDUALS SCREENED, 594 HAD ABNORMAL RESULTS. THE FOLLOWING SCREENINGS WERE PROVIDED: SKIN SCREENING, BONE DENSITY, BLOOD PRESSURE CHECKS, BODY COMPOSITION, CHOLESTEROL CHECKS, HEMOGLOBIN, PULMONARY FUNCTION TESTING, PHYSICAL THERAPY, DISTANT ACUITY, AND COGNITION ASSESSMENT. AS PART OF NATIONAL MAMMOGRAPHY DAY 2010, PEKIN HOSPITAL PARTNERED WITH TAZEWELL COUNTY HEALTH DEPARTMENT TO OFFER FREE MAMMOGRAMS TO TAZEWELL COUNTY WOMEN AGES 40 AND OVER WHO ARE UNDERINSURED OR UNINSURED. 55 FREE MAMMOGRAMS WERE PROVIDED. THIS WAS THE NINTH YEAR FOR THE ANNUAL EVENT. 2. HEALTH FAIRS: PEKIN HOSPITAL PARTICIPATED BY PROVIDING SCREENINGS AT A NUMBER OF LOCAL HEALTH FAIRS. A. PEKIN HOSPITAL EMPLOYEE HEALTH FAIR: OVER A TWO-DAY PERIOD, 295 EMPLOYEES RECEIVED BLOOD PRESSURES, BONE DENSITY, SPIROMETRY, AND BLOODWORK. B. DELAVAN METHODIST CHURCH: 25 RECEIVED CHOLESTEROL SCREENINGS, BODY COMPOSITION, AND BLOOD PRESSURES. C. MIDWEST GENERATION HEALTH FAIR: 35 RECEIVED BLOOD PRESSURE SCREENINGS AND 4 RECEIVED BODY COMPOSITION SCREENINGS. D. AVENTINE SAFETY FAIR: 25 WERE SCREENED FOR BLOOD PRESSURES, 3 FOR BODY COMPOSITION, AND 2 FOR BONE DENSITY. E. DIXON FISHERIES HEALTH FAIR: 7 WERE SCREENED FOR CHOLESTEROL AND TRIGLYCERIDES, GLUCOSE, BLOOD PRESSURES, AND HEMOGLOBIN. F. FOUNDATIONS FOR HEALTH (DONOR HEALTH FAIR): OVER A TWO-DAY PERIOD, 174 PARTICIPANTS RECEIVED BONE DENSITY TESTING, BODY COMPOSITION, PULMONARY FUNCTION TESTING, AND BLOOD PRESSURES. G. GLASFORD COMMUNITY HEALTH FAIR: 117 RESIDENTS WERE SCREENED FOR BONE DENSITY, BODY COMPOSITION, SPIROMETRY, AND BLOOD PRESSURES. H. TN&W IRRIGATION HEALTH FAIR: CHOLESTEROL SCREENINGS WERE PROVIDED TO 8 INDIVIDUALS. I. MANITO COMMUNITY BANK SENIOR BREAKFAST: 18 RECEIVED CHOLESTEROL SCREENINGS. J. ST. JOHN'S LUTHERAN CHURCH GREEN VALLEY - 12 RECEIVED SPIROMETRY SCREENINGS. K. DEPARTMENT OF HUMAN SERVICES & REHABILITATION HEALTH FAIR: 11 RECEIVED BODY COMPOSITION SCREENINGS, 12 RECEIVED SPIROMETRY, AND 12 RECEIVED BLOOD PRESSURE SCREENINGS. L. BETHEL LUTHERAN CHURCH MORTON HEALTH FAIR: 19 RECEIVED BODY COMPOSITION SCREENINGS, 13 RECEIVED SPIROMETRY, AND 14 BONE DENSITY. M. FALL PREVENTION CLINIC: 19 RESIDENTS OF THE UAW HIGHRISE WERE INCLUDED IN BLOOD PRESSURE SCREENINGS, PHYSICAL THERAPY SCREENINGS, OCCUPATIONAL THERAPY SCREENINGS, AND SPEECH THERAPY SCREENINGS. N. TREMONT UNITED METHODIST CHURCH HEALTH FAIR: 117 WERE SCREENED FOR SPIROMETRY, BONE DENSITY, BODY COMPOSITION, AND BLOOD PRESSURES. O. TREMONT LIBRARY: 12 RECEIVED GLUCOSE SCREENINGS. P. MANITO FOODS: 6 RECEIVED BLOOD PRESSURE SCREENINGS. Q. DELAVAN FAMILY PHARMACY: 2 RECEIVED BLOOD PRESSURE SCREENINGS. R. GROVELAND LIBRARY: 10 RECEIVED BLOOD PRESSURE SCREENINGS. S. HEARTLAND BANK & TRUST DELAVAN: 13 RECEIVED BLOOD PRESSURE SCREENINGS. T. PEKIN MANOR SENIOR HEALTH FAIR: 18 RECEIVED BLOOD PRESSURE SCREENINGS.
STATEMENT OF PROGRAM SERVICE ACCOMPLISHMENT FORM 990, SUPPLEMENT TO PART III, LINE 1 (CONT') F. COMMUNITY EDUCATION 1. DIABETES EDUCATION: THREE COMMUNITY DIABETES CLASSES ARE OFFERED 6 TIMES TO INCLUDE A TOTAL OF 37 PARTICIPANTS. FOUR ADDITIONAL DIABETES PROGRAMS FOR THE COMMUNITY WERE OFFERED PROVIDING AN UPDATE ON DIABETES CARE IN THE COMMUNITY. THESE PROGRAMS WERE ATTENDED BY A TOTAL OF 62 PERSONS. 2. CPR CLASSES: MONTHLY COMMUNITY CLASSES ARE OFFERED TO OUR COMMUNITY MEMBERS. IN ADDITION, PEKIN HOSPITAL STAFF MEMBERS ALSO PROVIDE CPR TRAINING TO PEKIN COMMUNITY HIGH SCHOOL STUDENTS. 3. MEDICATION RECONCILIATION: TO RAISE COMMUNITY AWARENESS ON THIS TOPIC, WALLET CARDS THAT ASSIST PATIENTS IN KEEPING ACCURATE LISTS OF MEDICATIONS WERE PLACED IN ALL INPATIENT FOLDERS. THE WALLET CARDS WERE ALSO PROVIDED AT OUR RETAIL PHARMACY, SENIOR EXPO EVENTS, AND OTHER COMMUNITY EVENTS. 4. PUBLIC LECTURES: A. SPIRIT OF WOMEN REINVENTION FACTOR PROGRAM: IN JUNE 2010, A RESPIRATORY HEALTH LECTURE WAS PROVIDED AT THE PEKIN YWCA. A SPIROMETRY SCREENING WAS ALSO OFFERED. B. SPIRIT GIRLS' NIGHT OUT: IN OCTOBER 2010, AT PEKIN MOOSE LODGE, PUBLIC LECTURES WERE OFFERED ON THE FOLLOWING TOPICS: BREAST HEALTH, DVT, AND SLEEP DISORDERS. C. DAY OF DANCE: IN FEBRUARY 2011, AT FIRST BAPTIST CHURCH OF PEKIN, COMMUNITY LECTURES WERE PROVIDED ON THE FOLLOWING TOPICS: WOMEN'S HEART HEALTH AND BONE AND JOINT HEALTH. D. WEIGHT LOSS PROGRAM: PEKIN HOSPITAL PARTNERED WITH THE PEKIN TIMES NEWSPAPER TO OFFER PERSONAL DOWN SIZING, A COMMUNITY WEIGHT LOSS PROGRAM TO RESIDENTS. 220 COMMUNITY MEMBERS PARTICIPATED IN THE PROGRAM. AWARDS WERE GIVEN TO THE TEAM WITH THE HIGHEST PERCENTAGE OF WEIGHT LOST, AS WELL AS INDIVIDUAL AWARDS FOR THE MOST WEIGHT LOST AND THE HIGHEST PERCENTAGE OF WEIGHT LOST. G. TRAUMA AND EMERGENCY SERVICES 1. EMS/AMBULANCE EDUCATION: A. CONTINUED AGREEMENT WITH THE PEORIA AREA EMS SYSTEM TO ALLOW STUDENTS TO COME TO PEKIN HOSPITAL FOR CLINICAL EXPERIENCE AND EDUCATION. B. STUDENTS ARE GIVEN 24HOUR AVAILABILITY TO ALLOW MORE OPPORTUNITIES FOR EDUCATION. C. BOTH BASIC AND PARAMEDIC STUDENTS WORK DIRECTLY WITH THE NURSING STAFF TO OBTAIN TRAINING IN THE CARE OF PATIENTS. WE ARE AVAILABLE TO PRECEPT ON ALL SHIFTS. 2. DISASTER TRAINING AND PREPAREDNESS: A. JUNE 1, 2010: MASS CASUALTY INCIDENT SCHOOL SHOOTING. TABLE TOP EXERCISE WITH OSF AND MEDCOM. B. JULY 14, 2010: MASS CASUALTY INCIDENT; CODE YELLOW WITH INFLUX OF MULTIPLE PEDIATRIC PATIENTS. TABLE TOP EXERCISE WITH THE EMERGENCY MANAGEMENT COMMITTEE. C. AUGUST 25, 2010: TRAINING FOR ER STAFF AND NURSING ADMINISTRATION ON THE PORTABLE DECON TENT. D. SEPTEMBER 2, 2010: CODE GREY/CODE YELLOW/CODE BLACK WINDOWS. TABLETOP DRILL HOSTED BY TAZEWELL COUNTY EMERGENCY MANAGEMENT AGENCY WITH PARTICIPATION OF MULTIPLE COMMUNITY PARTNERS. E. SEPTEMBER 22-SEPTEMBER 23, 2010: 16 HOURS OF DECONTAMINATION TRAINING. 22 STAFF MEMBERS TRAINED. F. OCTOBER 13, 2010: CODE WHITE CALL TREE DRILL. TABLETOP DRILL WITH MEMBERS OF EMERGENCY MANAGEMENT COMMITTEE, HOSPITAL OPERATORS, AND MEMBERS OF SENIOR LEADERSHIP G. OCTOBER 25, 2010: PEKIN HOSPITAL HOSTED THE QUARTERLY TAZEWELL COUNTY LOCAL EMERGENCY PLANNING COMMITTEE MEETING. PARTICIPANTS INCLUDED TCHD, AMT, PEKIN POLICE, PEKIN FIRE, AND MANY MORE COMMUNITY PARTNERS. H. DECEMBER 8, 2010: TRAINING ON THE USE OF OUR REDUNDANT COMMUNICATIONS OPTIONS. ALL MEMBERS OF EMERGENCY MANAGEMENT COMMITTEE WERE INCLUDED. I. JANUARY - MAY 2011: ALL NURSING SERVICE EMPLOYEES RECEIVE TRAINING ON THE PAPRS DURING YEARLY MANDATORY TRAINING. J. JANUARY 8, 2011: CODE UTILITY. THIS WAS AN ACTUAL EVENT WITH THE LOSS OF OUR COMPUTER SYSTEM WHICH LED TO THE INABILITY TO READ CAT SCANS. K. JANUARY 31-FEBRUARY 4, 2011: CODE WHITE. THIS WAS AN ACTUAL EVENT. WE WERE IN CONSTANT COMMUNICATION WITH OUR COMMUNITY PARTNERS. L. MARCH 4, 2011: STATE OF ILLINOIS HELPS DRILL. TABLETOP DRILL WITH IDPH AND PARTICIPATING HOSPITALS IN REGION 2. M. MARCH 11, 2011: STATE BYPASS SYSTEM WEB PORTAL: WEB BASED TABLETOP DRILL WITH IDPH AND PARTICIPATING HOSPITALS IN REGION 2. N. MARCH 18, 2011: CONTINUITY OF OPERATIONS DRILL. WEB BASED TABLETOP DRILL WITH IDPH AND PARTICIPATING HOSPITALS IN REGION 2. O. APRIL 9, 2011: MASS CASUALTY EVENT WITH SPECIAL NEEDS POPULATIONS. FULL SCALE EXERCISE HOSTED BY PEORIA AIRPORT AUTHORITY. PEKIN HOSPITAL PROVIDED 16 PEDIATRIC VICTIMS TO THE SITE OF THE "CRASH". PATIENTS WERE THEN BROUGHT TO PEKIN HOSPITAL FOR FULL SCALE CODE YELLOW/CODE ORANGE. P. APRIL 20, 2011: MANAGEMENT OF THE SPECIAL NEEDS POPULATION DURING A DISASTER. WEB BASED DISASTER DRILL HOSTED BY IDPH AND PARTICIPATING HOSPITALS IN REGION 2. Q. ONGOING: ALL NEW EMPLOYEES ARE ASSIGNED TO A HEALTH STREAM LEARNING MODULE THAT INCLUDED A 45 MINUTE PRESENTATION OF OUR EMERGENCY OPERATION PLAN. H. SUPPORT GROUPS EDUCATION, SUPPORT AND FELLOWSHIP ARE KEY TO A THRIVING, HEALTHY COMMUNITY. THAT'S WHY PEKIN HOSPITAL OFFERS SEVERAL OPPORTUNITIES FOR INDIVIDUALS WITHIN THE COMMUNITY TO LEARN TOGETHER, SHARE JOYS AND SORROWS, AND SIMPLY ENJOY GOOD TIMES. PEKIN HOSPITAL OFFERS THE FOLLOWING SUPPORT GROUPS: 1. ALZHEIMER'S SUPPORT GROUP 2. THE COMPASSIONATE FRIENDS GROUP 3. LOSS AND GRIEF SUPPORT GROUP 4. STROKE SUPPORT GROUP 5. MOTHERLINK IS AN UMBRELLA ORGANIZATION AIMED AT BRINGING FAMILIES TOGETHER TO CELEBRATE THE EXPERIENCES OF PARENTHOOD; MOTHERLINK CONTINUES TO PROVIDE SUPPORT AND COMPREHENSIVE EDUCATION LONG AFTER THE BABY'S BIRTH. MOTHERLINK SERVES AS A VALUABLE RESOURCE FOR DEVELOPING FRIENDSHIPS, FINDING SUPPORT IN SPECIAL CIRCUMSTANCES, AND FOSTERING EDUCATION. UNDER THE MOTHERLINK UMBRELLA ARE THE FOLLOWING: BREASTFEEDING SUPPORT: THIS GROUP ENABLES NEW MOTHERS THE OPPORTUNITY TO SHARE THEIR EXPERIENCES OF BREASTFEEDING AND BEING A NEW MOTHER. A PROFESSIONAL LACTATION CONSULTANT IS ALSO AVAILABLE DURING CERTAIN MEETINGS. THE GROUP MEETS WEDNESDAYS FROM 10 A.M. TO NOON AND EVERY FIRST AND THIRD MONDAY FROM 7 TO 9 P.M. IN THE PARK COURT CONFERENCE CENTER. CHILDBIRTH EDUCATION CLASS: LEARN ABOUT SIGNS OF LABOR, COMFORT MEASURES, PAIN RELIEF OPTIONS, WHAT TO EXPECT DURING AND AFTER CHILDBIRTH AND BASIC BABY CARE. SIBLING CLASS: HELPS CHILDREN PREPARE FOR A NEW ADDITION TO THE FAMILY. CHILDREN LEARN ABOUT BECOMING A BIG BROTHER OR SISTER. BAD DEBT UNCOLLECTIBLE AMOUNTS, EXCLUSIVE OF CHARITY CARE, WRITTEN OFF DURING THE FISCAL YEAR ENDING APRIL 30, 2011 WERE $8,319,890. INTRODUCTION IN 1986, PEKIN HOSPITAL RESTRUCTURED, AND PROGRESSIVE HEALTH SYSTEMS WAS FORMED. PROGRESSIVE HEALTH SYSTEMS HAS ALLOWED US TO OFFER PREVENTIVE CARE, ADVANCED MEDICAL TREATMENT, HEALTH EDUCATION AND MUCH MORE TO MEET THE COMMUNITY'S HEALTH NEEDS WELL BEYOND THE PEKIN HOSPITAL CAMPUS. MEMBERS OF PROGRESSIVE HEALTH SYSTEMS INCLUDE... PEKIN HOSPITAL - WE CONTINUE GROWING AND INCREASING OUR PROGRAMS AND SERVICES - FROM CANCER TREATMENT TO URGENT CARE - TO MEET OUR COMMUNITY'S NEEDS. WE DO SO WHILE MAINTAINING AN AVERAGE COST OF INPATIENT STAY THAT IS WELL BELOW THOSE OF OTHER HOSPITALS IN OUR AREA. (37-0692351) PROHEALTH INC. - PROHEALTH OPERATES PRIMARY-CARE PHYSICIANS' OFFICES IN PEKIN; PARK COURT PHARMACY IN PEKIN HOSPITAL; AND PHYSICIAN MANAGEMENT SERVICES. PROHEALTH ALSO OPERATES PROCARE HOME HEALTH SERVICES, A MEDICAL EQUIPMENT COMPANY AT THREE LOCATIONS OFFERING A COMPLETE LINE OF PRODUCTS, FREE DELIVERY, PROFESSIONAL SET-UP AND HOME FOLLOW-UP, 24-HOUR AVAILABILITY AND QUALIFIED SERVICE TECHNICIANS AND RESPIRATORY THERAPISTS ON STAFF. (37-1117052) HOME HEALTH - STAFFED BY REGISTERED NURSES AND CERTIFIED NURSING ASSISTANTS, PEKIN HOSPITAL HOME HEALTH PROVIDES EXPERT NURSING CARE FOR PATIENTS IN THE COMFORT OF THEIR OWN HOME. (PEKIN HOSPITAL) PEKIN HOSPITAL FOUNDATION - THE FOUNDATION OFFERS SUPPORT BY RAISING VITAL FUNDS FOR SPECIAL PROJECTS, FACILITY MODERNIZATION AND IMPROVEMENTS, MEDICAL EQUIPMENT AND PROGRAMMING NEEDS. IN ADDITION, THE FOUNDATION COLLABORATES WITH COMMUNITY LEADERS, AGENCIES, BUSINESSES AND OTHER ORGANIZATIONS TO PROMOTE PEKIN HOSPITAL AND THE PEKIN COMMUNITY. (37-1200267) PARK COURT LTD. - PARK COURT LTD. OWNS REAL-ESTATE HOLDINGS, INCLUDING PARK COURT MEDICAL CENTER FOR PROGRESSIVE HEALTH SYSTEMS. (37-1178386)
FAMILY AND BUSINESS RELATIONSHIPS FORM 990, PART VI, SECTION A, LINE 2 JANET LANGE AND RICHARD KRIEGSMAN HAVE A FAMILY RELATIONSHIP; RON MILLER HAS A BUSINESS RELATIONSHIP WITH RICHARD KRIEGSMAN. ALL BOARD MEMBERS AND OFFICERS HAVE A BUSINESS RELATIONSHIP WITH EACH OTHER AS A RESULT OF ALL SERVING AS BOARD MEMBERS OR OFFICERS OF PEKIN PROHEALTH, INC., A FOR-PROFIT AFFILIATE OF THE ORGANIZATION.
DELEGATING AUTHORITY FORM 990, PART VI, SECTION A, LINE 3 THE BOARD OF DIRECTORS HAS CONTRACTED WITH QUORUM HEALTH RESOURCES (QHR) TO SERVE AS A MANAGEMENT CORPORATION TO ASSIST IN THE LEADERSHIP OF THE HOSPITAL. QHR PROVIDES PEKIN HOSPITAL WITH LEADERSHIP VIA THE CEO ALONG WITH OTHER CONSULTING SERVICES ON FINANCIAL AND STAFFING NEEDS.
ORGANIZATION MEMBER FORM 990, PART VI, SECTION A, LINE 6 PROGRESSIVE HEALTH SYSTEMS IS THE SOLE MEMBER OF THE ORGANIZATION
ELECTION OF GOVERNING BODY FORM 990, PART VI, SECTION A, LINE 7A THE SOLE MEMBER, PROGRESSIVE HEALTH SYSTEMS, HAS THE POWER TO ELECT AND REMOVE THE MEMBERS OF THE BOARD OF TRUSTEES OF THE ORGANIZATION.
APPROVAL BY MEMBERS FORM 990, PART VI, SECTION A, LINE 7B THE SOLE MEMBER, PROGRESSIVE HEALTH SYSTEMS, HAS THE RIGHT TO APPROVE THE FOLLOWING DECISIONS BY THE GOVERNING BODY: A) ESTABLISHMENT OR MODIFICATION OF COMPENSATION AND BENEFIT POLICIES; B) DEVELOPMENT OR MODIFICATION OF CORPORATE COMPLIANCE PROGRAMS, INCLUDING PROGRAMS DESIGNED TO DETECT OR PREVENT HEALTH CARE FRAUD OR IMPROPER THIRD PARTY BILLING, ACTIVITIES REGARDING LEGAL AND REGULATORY COMPLIANCE RELATING TO THE CODE, ENVIRONMENTAL ISSUES, OCCUPATIONAL SAFETY AND HEALTH, ANTITRUST, FEDERAL ELECTION LAWS, AND ALL OTHER LAWS APPLICABLE TO THE CORPORATION. VARIOUS OTHER POWERS ARE RESERVED EXCLUSIVELY TO THE SOLE MEMBER, AS OUTLINED IN THE BYLAWS OF THE ORGANIZATION.
PROCESS TO REVIEW 990 FORM 990, PART VI, SECTION A, LINE 11B FORM 990 WAS REVIEWED BY THE CEO, CFO, AND CONTROLLER. PRIOR TO FILING, THE 990 WAS PROVIDED TO THE BOARD OF DIRECTORS ELECTRONICALLY, AND REVIEWED INDEPENDENTLY BY EACH MEMBER. QUESTIONS BY BOARD MEMBERS WERE HANDLED ON AN INDIVIDUAL BASIS WITH MANAGEMENT.
ORGANIZATION'S POLICY FOR MONITORING COMPLIANCE FORM 990, PART VI, SECTION B, LINE 12C PERIODIC SURVEYS ARE PERFORMED REQUESTING DISCLOSURES OF CONFLICTS OF INTEREST. IF IT IS DETERMINED THAT A CONFLICT EXISTS, THE EMPLOYEE WILL BE REQUIRED TO RELINQUISH EITHER THE OUTSIDE BUSINESS INTEREST/ARRANGEMENT OR HIS/HER PHS EMPLOYMENT. THE CONFLICT OF INTEREST POLICIES APPLY TO INDIVIDUALS WHO SERVE AS TRUSTEES, MANAGERS (DEPARTMENT HEADS AND ABOVE), CHIEFS OF CLINICAL DEPARTMENTS, AND ANY OTHER EMPLOYEE, MEDICAL STAFF MEMBER OR NON-EMPLOYED CONTRACTOR ACTING IN A MANAGERIAL OR CLINICAL LEADERSHIP CAPACITY DEEMED BY AN ADMINISTRATIVE OFFICER OR CHIEF OF SERVICE TO BE IN A POSITION TO INFLUENCE DECISION-MAKING FOR THE ORGANIZATION. DISCLOSURE WILL OCCUR THROUGH AN ANNUAL CONFLICT OF INTEREST DISCLOSURE STATEMENT AND THE DISCLOSURE OF OTHER ACTUAL OR POTENTIAL CONFLICTS AS THEY ARISE. POTENTIAL CONFLICTS OF INTEREST SHOULD BE REPORTED TO AN IMMEDIATE SUPERVISOR, WHO, IN TURN, IS OBLIGATED TO REPORT THE MATTER TO THE CORPORATE COMPLIANCE OFFICER. THE CORPORATE COMPLIANCE OFFICER IS EXPECTED TO INVESTIGATE REPORTED CONFLICTS AND MAKE A REPORT TO THE COMPLIANCE COMMITTEE ON A QUARTERLY BASIS. ALL BOARD MEMBERS ARE REQUIRED TO REPORT ANY POTENTIAL CONFLICTS OF INTEREST TO THE BOARD OR AN APPLICABLE COMMITTEE OF THE BOARD. AFTER EXCUSING THE MEMBER WITH A POTENTIAL CONFLICT, THE REMAINING MEMBERS OF THE BOARD OR COMMITTEE WILL DISCUSS AND DECIDE IF A CONFLICT EXISTS, BOARD MEMBERS FOUND TO HAVE A CONFLICT ARE REQUIRED TO EXCUSE THEMSELVES FROM ANY DISCUSSIONS REGARDING A TRANSACTION RELATED TO A POTENTIAL CONFLICT AND ARE PROHIBITED FROM VOTING ON ANY SUCH MATTER.
COMPENSATION REVIEW FORM 990, PART VI, SECTION B, LINE 15A THE CEO IS EMPLOYED BY AN OUTSIDE MANAGEMENT COMPANY.
COMPENSATION REVIEW FORM 990, PART VI, SECTION B, LINE 15B HUMAN RESOURCES AND THE CEO REVIEW THE COMPENSATION OF OTHER OFFICERS AND KEY EMPLOYEES OF THE ORGANIZATION ON AN ANNUAL BASIS.
DISCLOSURE FORM 990, PART VI, LINE 19 THE GOVERNING DOCUMENTS, CONFLICT OF INTEREST POLICY, AND FINANCIAL STATEMENTS ARE NOT MADE AVAILABLE TO THE PUBLIC.
OTHER CHANGES IN NET ASSETS FORM 990, PART XI, LINE 5 CHANGE IN UNREALIZED GAIN $ 2,251,295 CHANGE IN MINIMUM PENSION LIABILITY $ 512,463 TRANSFERS TO AFFILIATES $ <3,142,258> __________ TOTAL OTHER CHANGE IN NET ASSETS $ <378,500>
HOURS DEVOTED FOR RELATED ORGANIZATION FORM 990 PART VII NAME:DR. STEVEN CLARK TITLE:TRUSTEE HOURS:43
HOURS DEVOTED FOR RELATED ORGANIZATION FORM 990 PART VII NAME:DR. JOHN LOVELL TITLE:TRUSTEE HOURS:4
HOURS DEVOTED FOR RELATED ORGANIZATION FORM 990 PART VII NAME:RONALD MILLER TITLE:CHAIRMAN HOURS:4
HOURS DEVOTED FOR RELATED ORGANIZATION FORM 990 PART VII NAME:JANET LANGE TITLE:TRUSTEE HOURS:4
HOURS DEVOTED FOR RELATED ORGANIZATION FORM 990 PART VII NAME:EDWARD SIROTAK TITLE:TRUSTEE HOURS:4
HOURS DEVOTED FOR RELATED ORGANIZATION FORM 990 PART VII NAME:RICHARD KRIEGSMAN TITLE:VICE-CHAIRMAN HOURS:4
HOURS DEVOTED FOR RELATED ORGANIZATION FORM 990 PART VII NAME:ANDREW SPARKS TITLE:SECRETARY/TREASURER HOURS:4
HOURS DEVOTED FOR RELATED ORGANIZATION FORM 990 PART VII NAME:MICHAEL TIBBS TITLE:TRUSTEE HOURS:4
HOURS DEVOTED FOR RELATED ORGANIZATION FORM 990 PART VII NAME:CURTIS EETEN TITLE:TRUSTEE HOURS:4
HOURS DEVOTED FOR RELATED ORGANIZATION FORM 990 PART VII NAME:DR. KATHRYN KRAMER TITLE:TRUSTEE HOURS:4
HOURS DEVOTED FOR RELATED ORGANIZATION FORM 990 PART VII NAME:JASON PROHEL TITLE:TRUSTEE HOURS:4
HOURS DEVOTED FOR RELATED ORGANIZATION FORM 990 PART VII NAME:KEVIN R. ANDREWS TITLE:CEO HOURS:4
HOURS DEVOTED FOR RELATED ORGANIZATION FORM 990 PART VII NAME:STEVEN C. HALL TITLE:CFO HOURS:4
HOURS DEVOTED FOR RELATED ORGANIZATION FORM 990 PART VII NAME:JO ELLEN PATTERSON TITLE:CNO HOURS:
HOURS DEVOTED FOR RELATED ORGANIZATION FORM 990 PART VII NAME:ANNE DIERKER TITLE:VP HOSPITAL SERVICES HOURS:
HOURS DEVOTED FOR RELATED ORGANIZATION FORM 990 PART VII NAME:MICHAEL ERICKSON TITLE:CRNA HOURS:
HOURS DEVOTED FOR RELATED ORGANIZATION FORM 990 PART VII NAME:PEGGE HALL TITLE:CRNA HOURS:
HOURS DEVOTED FOR RELATED ORGANIZATION FORM 990 PART VII NAME:CAROLYN SUTTER TITLE:CRNA HOURS:
HOURS DEVOTED FOR RELATED ORGANIZATION FORM 990 PART VII NAME:MELISSA NGO TITLE:CRNA HOURS:
HOURS DEVOTED FOR RELATED ORGANIZATION FORM 990 PART VII NAME:STEVEN BOOKER TITLE:DIRECTOR OF ANESTHESIA/CRNA HOURS:
For Paperwork Reduction Act Notice, see the Instructions for Form 990 or 990-EZ.
Cat. No. 51056K
Schedule O (Form 990 or 990-EZ) 2010

Additional Data


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SCHEDULE R
(Form 990)
Department of the Treasury
Internal Revenue Service
Related Organizations and Unrelated Partnerships
MediumBulletComplete if the organization answered "Yes" to Form 990, Part IV, line 33, 34, 35, 36, or 37.
MediumBulletAttach to Form 990. MediumBullet See separate instructions.

OMB No. 1545-0047
2010
Open to Public Inspection
Name of the organization
Pekin Memorial Hospital
 
Employer identification number

37-0692351
Part I
Identification of Disregarded Entities (Complete if the organization answered "Yes" on Form 990, Part IV, line 33.)
(a)
Name, address, and EIN of disregarded entity


(b)
Primary activity


 		(c)
Legal domicile (state
or foreign country)

 		(d)
Total income
(e)
End-of-year assets


 		(f)
Direct controlling
entity

















Part II
Identification of Related Tax-Exempt Organizations (Complete if the organization answered "Yes" on Form 990, Part IV, line 34 because it had one or more related tax-exempt organizations during the tax year.)
(a)
Name, address, and EIN of related organization


(b)
Primary activity


 		(c)
Legal domicile (state
or foreign country)

 		(d)
Exempt Code section
(e)
Public charity status
(if section 501(c)(3))

 		(f)
Direct controlling
entity

 		(g)
Section 512(b)(13) controlled organization
Yes No
(1) PROGRESSIVE HEALTH SYSTEMS

600 SOUTH 13TH STREET

PEKIN,IL61554
37-1200263 		SUPPORT ORG IL 501(C)3 11 - I NA
 
 
 
(2) PARK COURT LIMITED

600 SOUTH 13TH STREET

PEKIN,IL61554
37-1178386 		SUPPORT ORG IL 501(C)3 11 - II PROG HEALTH
 
 
 
(3) PEKIN MEMORIAL HOSPITAL FOUNDATION

600 SOUTH 13TH STREET

PEKIN,IL61554
37-1200267 		SUPPORT ORG IL 501(C)3 11 - II PROG HEALTH
 
 
 








For Privacy Act and Paperwork Reduction Act Notice, see the Instructions for Form 990.
Cat. No. 50135Y
Schedule R (Form 990) 2010
Schedule R (Form 990) 2010
Page 2
Part III
Identification of Related Organizations Taxable as a Partnership (Complete if the organization answered "Yes" on Form 990, Part IV, line 34 because it had one or more related organizations treated as a partnership during the tax year.)
(a)
Name, address, and EIN of
related organization



 		(b)
Primary activity




 		(c)
Legal
domicile
(state or foreign
country)


 		(d)
Direct controlling
entity



 		(e)
Predominant income(related, unrelated, excluded from tax under sections 512-514)

(f)
Share of total income




 		(g)
Share of end-of-year
assets



 		(h)
Disproprtionate allocations?




 		(i)
Code V—UBI
amount in box 20 of
Schedule K-1
(Form 1065)
 		(j)
General or
managing
partner?



 		(k)
Percentage
ownership
Yes No Yes No












Part IV
Identification of Related Organizations Taxable as a Corporation or Trust (Complete if the organization answered "Yes" on Form 990, Part IV, line 34 because it had one or more related organizations treated as a corporation or trust during the tax year.)
(a)
Name, address, and EIN of related organization



 		(b)
Primary activity



 		(c)
Legal domicile
(state or
foreign
country)
 		(d)
Direct controlling
entity


 		(e)
Type of entity
(C corp, S corp,
or trust)

 		(f)
Share of total income



 		(g)
Share of
end-of-year
assets

 		(h)
Percentage
ownership
(1) PRO HEALTH INC (PHI)
600 SOUTH 13TH STREET
PEKIN,IL61554
37-1117052 		CLINIC IL NA
  		C CORP 0 0 0 %












Schedule R (Form 990) 2010
Schedule R (Form 990) 2010
Page 3
Part V
Transactions With Related Organizations (Complete if the organization answered "Yes" on Form 990, Part IV, line 34, 35, 35A, or 36.)
Note. Complete line 1 if any entity is listed in Parts II, III or IV.
Yes
No
1 During the tax year, did the orgranization engage in any of the following transactions with one or more related organizations listed in Parts II-IV?
a Receipt of (i) interest (ii) annuities (iii) royalties (iv) rent from a controlled entity . . . . . . . . . . . . . . . . . . . . . . .
1a
 
No
b Gift, grant, or capital contribution to other organization(s) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1b
Yes
 
c Gift, grant, or capital contribution from other organization(s) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1c
Yes
 
d Loans or loan guarantees to or for other organization(s) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1d
 
No
e Loans or loan guarantees by other organization(s) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1e
 
No
f Sale of assets to other organization(s) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1f
 
No
g Purchase of assets from other organization(s) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1g
 
No
h Exchange of assets . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1h
 
No
i Lease of facilities, equipment, or other assets to other organization(s) . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1i
 
No
j Lease of facilities, equipment, or other assets from other organization(s) . . . . . . . . . . . . . . . . . . . . . . . . . . .
1j
 
No
k Performance of services or membership or fundraising solicitations for other organization(s) . . . . . . . . . . . . . . . . . . . . . .
1k
Yes
 
l Performance of services or membership or fundraising solicitations by other organization(s) . . . . . . . . . . . . . . . . . . . . . .
1l
 
No
m Sharing of facilities, equipment, mailing lists, or other assets . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1m
Yes
 
n Sharing of paid employees . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1n
Yes
 
o Reimbursement paid to other organization for expenses . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1o
 
No
p Reimbursement paid by other organization for expenses . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1p
 
No
q Other transfer of cash or property to other organization(s) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1q
 
No
r Other transfer of cash or property from other organization(s) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1r
 
No
2
If the answer to any of the above is "Yes," see the instructions for information on who must complete this line, including covered relationships and transaction thresholds.
(a)
Name of other organization 		(b)
Transaction
type(a-r) 		(c)
Amount involved 		(d)
Method of determining amount involved
(1)
(2)
(3)
(4)
(5)
(6)
Schedule R (Form 990) 2010
Schedule R (Form 990) 2010
Page 4
Part VI
Unrelated Organizations Taxable as a Partnership (Complete if the organization answered "Yes" on Form 990, Part IV, line 37.)
Provide the following information for each entity taxed as a partnership through which the organization conducted more than five percent of its activities (measured by total assets or gross revenue) that was not a related organization. See instructions regarding exclusion for certain investment partnerships.
(a)
Name, address, and EIN of entity 		(b)
Primary activity 		(c)
Legal domicile
(state or foreign
country) 		(d)
Are all
partners
section
501(c)(3)
organizations? 		(e)
Share of
end-of-year
assets 		(f)
Disproprtionate allocations? 		(g)
Code V—UBI
amount in box
20 of Schedule K-1
(Form 1065) 		(h)
General or
managing
partner?
Yes No Yes No Yes No






























Schedule R (Form 990) 2010
Schedule R (Form 990) 2010
Page 5
Part VII
Supplemental Information
Complete this part to provide additional information for responses to questions on Schedule R (see instructions).
Identifier Return Reference Explanation
Additional Data


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