Form990
Department of the TreasuryInternal Revenue Service
Return of Organization Exempt From Income Tax
Under section 501(c), 527, or 4947(a)(1) of the Internal Revenue Code (except private foundations)
MediumBullet Do not enter social security numbers on this form as it may be made public.
MediumBullet Go to www.irs.gov/Form990 for instructions and the latest information.
OMB No. 1545-0047
2019
Open to Public Inspection
A For the 2019 calendar year, or tax year beginning 10-01-2019 , and ending 09-30-2020
BCheck if applicable:
CName of organization
Mendota Community Hospital
 
 
Doing business as
OSF Saint Paul Medical Center
 
Number and street (or P.O. box if mail is not delivered to street address)
1201 E 12TH STREET
 
Room/suite
City or town, state or province, country, and ZIP or foreign postal code
MENDOTA, IL61342
D Employer identification number

36-2167785
E Telephone number

G Gross receipts $ 37,142,891
F Name and address of principal officer:
Michael Allen
1201 E 12TH STREET
MENDOTA,IL61342
I
Tax-exempt status: (   ) LeftBullet (insert no.) or
J
Website:MediumBullet
www.osfhealthcare.org
H(a)
Is this a group return for
subordinates?
H(b)
Are all subordinates
included?
If "No," attach a list. (see instructions)
H(c)
Group exemption number MediumBullet  
K Form of organization:  
L Year of formation: 1944
M State of legal domicile: IL
Part I
Summary
Activities & Governance 1 Briefly describe the organization’s mission or most significant activities: IN THE SPIRIT OF CHRIST AND THE EXAMPLE OF FRANCIS OF ASSISI, THE MISSION OF OSF HEALTHCARE IS TO SERVE PERSONS WITH THE GREATEST CARE AND LOVE IN A COMMUNITY THAT CELEBRATES THE GIFT OF LIFE.
2 Check this box MediumBullet
3 Number of voting members of the governing body (Part VI, line 1a) ........ 3 9
4 Number of independent voting members of the governing body (Part VI, line 1b) ..... 4 6
5 Total number of individuals employed in calendar year 2019 (Part V, line 2a) ...... 5 180
6 Total number of volunteers (estimate if necessary) ............. 6 75
7a Total unrelated business revenue from Part VIII, column (C), line 12 ........ 7a 2,164
b Net unrelated business taxable income from Form 990-T, line 39 ......... 7b 0
Revenues Prior Year Current Year
8 Contributions and grants (Part VIII, line 1h) ......... 69,087 3,453,876
9 Program service revenue (Part VIII, line 2g) ......... 36,012,475 33,525,666
10 Investment income (Part VIII, column (A), lines 3, 4, and 7d ) .... -82,892 1,791
11 Other revenue (Part VIII, column (A), lines 5, 6d, 8c, 9c, 10c, and 11e) 152,771 123,140
12 Total revenue—add lines 8 through 11 (must equal Part VIII, column (A), line 12) 36,151,441 37,104,473
Expenses; 13 Grants and similar amounts paid (Part IX, column (A), lines 1–3 )...   0
14 Benefits paid to or for members (Part IX, column (A), line 4).....   0
15 Salaries, other compensation, employee benefits (Part IX, column (A), lines 5–10) 15,331,653 14,484,740
16a Professional fundraising fees (Part IX, column (A), line 11e) .....   0
b Total fundraising expenses (Part IX, column (D), line 25) MediumBullet0    
17 Other expenses (Part IX, column (A), lines 11a–11d, 11f–24e).... 17,697,994 17,318,559
18 Total expenses. Add lines 13–17 (must equal Part IX, column (A), line 25) 33,029,647 31,803,299
19 Revenue less expenses. Subtract line 18 from line 12....... 3,121,794 5,301,174
Net Assets or Fund Balances; Beginning of Current Year End of Year
20 Total assets (Part X, line 16)............. 33,074,155 33,605,582
21 Total liabilities (Part X, line 26)............. 29,275,455 25,357,726
22 Net assets or fund balances. Subtract line 21 from line 20..... 3,798,700 8,247,856
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 Use Only
Print/Type preparer's name
Preparer's signature
Date
PTIN
Firm's name MediumBullet

Firm's EIN MediumBullet
Firm's address MediumBullet



Phone no.
May the IRS discuss this return with the preparer shown above? (see instructions) ..........
For Paperwork Reduction Act Notice, see the separate instructions.
Cat. No. 11282Y Form 990 (2019)
Form 990 (2019)
Page 2
Part III
Statement of Program Service Accomplishments
Check if Schedule O contains a response or note to any line in this Part III..............
1
Briefly describe the organization’s mission: IN THE SPIRIT OF CHRIST AND THE EXAMPLE OF FRANCIS OF ASSISI, THE MISSION OF OSF HEALTHCARE IS TO SERVE PERSONS WITH THE GREATEST CARE AND LOVE IN A COMMUNITY THAT CELEBRATES THE GIFT OF LIFE.
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 organization’s program service accomplishments for each of its three largest program services, as measured by expenses. Section 501(c)(3) and 501(c)(4) organizations 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 $ 24,314,457 including grants of $   ) (Revenue $ 33,571,572 )
MENDOTA COMMUNITY HOSPITAL PROVIDED 25 BEDS IN FISCAL YEAR 2020. THE HOSPITAL GAVE $1,441,750 IN CHARITY CARE. THE HOSPITAL PROVIDED 2,185 PATIENT DAYS. THE HOSPITAL PROVIDED 31,951 OUTPATIENT VISITS AND THE EMERGENCY ROOM HAD 4,853 PATIENT VISITS.
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 expensesMediumBullet24,314,457
Form 990 (2019)
Form 990 (2019)
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 (see instructions)? 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 I.............
3
 
No
4
Section 501(c)(3) organizations. Did the organization engage in lobbying activities, or have a section 501(h) election in effect during the tax year? 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 for which 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 I.........................
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 II....
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..............
8
 
No
9
Did the organization report an amount in Part X, line 21 for escrow or custodial account liability; 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 IV..............
9
 
No
10
Did the organization, directly or through a related organization, hold assets in temporarily restricted endowments, permanent endowments, or quasi endowments? If "Yes," complete Schedule D, Part VClick to see attachment......
10
Yes
 
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, line 10? 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.......
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.......
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 IXClick to see attachment............
11d
Yes
 
e
Did the organization report an amount for other liabilities in Part X, line 25? If "Yes," complete Schedule D, Part XClick 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 XClick to see attachment
11f
Yes
 
12a
Did the organization obtain separate, independent audited financial statements for the tax year? If "Yes," complete
Schedule D, Parts XI and XII......................
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 and XII 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, investment, and program service activities outside the United States, or aggregate foreign investments valued at $100,000 or more? If "Yes," complete Schedule F, Parts I and IV.........
14b
 
No
15
Did the organization report on Part IX, column (A), line 3, more than $5,000 of grants or other assistance to or for any foreign organization? If “Yes,” complete Schedule F, Parts II and IV.....
15
 
No
16
Did the organization report on Part IX, column (A), line 3, more than $5,000 of aggregate grants or other assistance to or for foreign individuals? If “Yes,” complete Schedule F, Parts III and IV...
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(see instructions) ....
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
20a
Did the organization operate one or more hospital facilities? If "Yes," complete Schedule H....Click to see attachment
20a
Yes
 
b
If "Yes" to line 20a, did the organization attach a copy of its audited financial statements to this return? Click to see attachment
20b
Yes
 
21
Did the organization report more than $5,000 of grants or other assistance to any domestic organization or domestic government on Part IX, column (A), line 1? If “Yes,” complete Schedule I, Parts I and II.....
21
 
No
Form 990 (2019)
Form 990 (2019)
Page 4
Part IV
Checklist of Required Schedules (continued)
Yes
No
22
Did the organization report more than $5,000 of grants or other assistance to or for domestic individuals 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, line 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 lines 24b through 24d and complete Schedule K. If “No,” go to line 25a...............
24a
 
No
b
Did the organization invest any proceeds of tax-exempt bonds beyond a temporary period exception?...
24b
 
 
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
 
 
d
Did the organization act as an "on behalf of" issuer for bonds outstanding at any time during the year?...
24d
 
 
25a
Section 501(c)(3), 501(c)(4), and 501(c)(29) organizations. Did the organization engage in an excess benefit transaction with a disqualified person during the year? If "Yes," complete Schedule L, Part I ....
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.......................
25b
 
No
26
Did the organization report any amount on Part X, line 5 or 22 for receivables from or payables to any current or former officer, director, trustee, key employee, creator or founder, substantial contributor, or 35% controlled entity or family member of any of these persons? If "Yes," complete Schedule L, Part II...........
26
 
No
27
Did the organization provide a grant or other assistance to any current or former officer, director, trustee, key employee, creator or founder, substantial contributor, or employee thereof, a grant selection committee member, or to a 35% controlled entity (including an employee thereof) or family member of any of these persons?
If "Yes," complete
Schedule L, Part III.........................
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, key employee, creator or founder, or substantial contributor? If "Yes," complete Schedule L, Part IV......................
28a
 
No
b
A family member of any individual described in line 28a? If "Yes," complete Schedule L, Part IV.....
28b
 
No
c
A 35% controlled entity of one or more individuals and/or organizations described in lines 28a or 28b? If "Yes," complete Schedule L, Part IV.....................
28c
 
No
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............
33
 
No
34
Was the organization related to any tax-exempt or taxable entity? If "Yes," complete Schedule R, Part II, III, or IV, and Part V, line 1.........................Click to see attachment
34
Yes
 
35a
Did the organization have a controlled entity within the meaning of section 512(b)(13)?
35a
 
No
b
If ‘Yes’ to line 35a, 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 ...
35b
 
 
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.............
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 VI
37
 
No
38
Did the organization complete Schedule O and provide explanations in Schedule O for Part VI, lines 11b and 19? Note. All Form 990 filers are required to complete Schedule O. ............
38
Yes
 
Part V
Statements Regarding Other IRS Filings and Tax Compliance
Check if Schedule O contains a response or note to any line in this Part V...........
Yes
No
1a
Enter the number reported in Box 3 of Form 1096. Enter -0- if not applicable ..
1a
1
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
 
Form 990 (2019)
Form 990 (2019)
Page 5
Part V
Statements Regarding Other IRS Filings and Tax Compliance (continued)
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
180
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” to line 3b, 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, securities account, or other financial account)? ..
4a
 
No
b
If "Yes," enter the name of the foreign country: MediumBullet
See instructions for filing requirements for FinCEN Form 114, Report of Foreign Bank and Financial Accounts (FBAR).
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 as charitable contributions? ...
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. Did a donor advised fund maintained by the sponsoring organization have excess business holdings at any time during the year? ........
8
 
 
9
Sponsoring organizations maintaining donor advised funds.
a
Did the sponsoring organization make any taxable distributions under section 4966?........
9a
 
 
b
Did the sponsoring 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. See the instructions for additional information the organization must report on Schedule O.
13a
 
 
b
Enter the 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 amount of reserves on hand ............
13c
 
14a
Did the organization receive any payments for indoor tanning services during the tax year?.....
14a
 
No
b
If "Yes," has it filed a Form 720 to report these payments? If "No," provide an explanation in Schedule O..
14b
 
 
15
Is the organization subject to the section 4960 tax on payment(s) of more than $1,000,000 in remuneration or excess parachute payment(s) during the year? ....................
If "Yes," see instructions and file Form 4720, Schedule N.
15
 
No
16
Is the organization an educational institution subject to the section 4968 excise tax on net investment income? ..
If "Yes," complete Form 4720, Schedule O.
16
 
No
Form 990 (2019)
Form 990 (2019)
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 or note to any line 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
9
If there are material differences in voting rights among members of the governing body, or if the governing body delegated broad authority to an executive committee or similar committee, explain in Schedule O.
b
Enter the number of voting members included in line 1a, above, who are independent
1b
6
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
 
No
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
 
No
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
Did the organization have members or stockholders? ................
6
Yes
 
7a
Did the organization have members, stockholders, or other persons who had the power to elect or appoint one or more members of the governing body? ....................
7a
Yes
 
b
Are any governance decisions of the organization reserved to (or subject to approval by) members, stockholders, or persons other than the governing body? ...................
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
Yes
 
Section B. Policies (This Section B requests information about policies not required by the Internal Revenue Code.)
Yes
No
10a
Did the organization have local chapters, branches, or affiliates? ............
10a
 
No
b
If "Yes," did the organization have written policies and procedures governing the activities of such chapters, affiliates, and branches to ensure their operations are consistent with the organization's exempt purposes?
10b
 
 
11a
Has the organization provided a complete 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 this Form 990. .....
12a
Did the organization have a written conflict of interest policy? If "No," go to line 13.......
12a
Yes
 
b
Were officers, directors, or trustees, and key employees required to disclose annually interests that could give rise to conflicts? ..........................
12b
Yes
 
c
Did the organization regularly and consistently monitor and enforce compliance with the policy? If "Yes," describe in Schedule O how this was done...................
12c
Yes
 
13
Did the organization have a written whistleblower policy? ...............
13
Yes
 
14
Did 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
Yes
 
b
Other officers or key employees of the organization ................
15b
Yes
 
If "Yes" to line 15a or 15b, 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," did the organization follow a written policy or procedure requiring the organization to evaluate its participation in joint venture arrangements under applicable federal tax law, and take 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-A if applicable), 990, and 990-T (501(c)(3)s only) available for public inspection. Indicate how you made these available. Check all that apply.
19
Describe in Schedule O whether (and if so, how) the organization made its governing documents, conflict of interest policy, and financial statements available to the public during the tax year.
20
State the name, address, and telephone number of the person who possesses the organization's books and records:
MediumBulletMichael Allen800 NE GLEN OAK AVE   PEORIA,IL61603 (309) 655-7708
Form 990 (2019)
Form 990 (2019)
Page 7
Part VII
Compensation of Officers, Directors,Trustees, Key Employees, Highest Compensated Employees, and Independent Contractors
Check if Schedule O contains a response or note to any line 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. 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.

See instructions for the order in which to list the persons above.
Check this box if neither the organization nor any related organization compensated any current officer, director, or trustee.
(A)
Name and title 		(B)
Average hours per week (list any hours for related organizations below dotted line) 		(C)
Position (do not check more than one box, unless person is both an officer and a director/trustee) 		(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; OfficerInd; Key Employee; Highest compensated employee; FormerOfcrDirectorTrusteeInd;
(1) Robert C Sehring
 
Vice Chairperson CEO
 1.0
.................
43.0 		X   X       0 1,889,747 65,451
(2) Sister Agnes Joseph Williams OSF
 
Assistant Secretary
 1.0
.................
43.0 		X   X       0 5,440 0
(3) Sister Diane Marie McGrew OSF
 
President and Treasurer
 1.0
.................
43.0 		X   X       0 5,440 0
(4) Sister Judith Ann Duvall OSF
 
Chairperson
 1.0
.................
43.0 		X   X       0 5,440 0
(5) Sister Theresa Ann Brazeau OSF
 
Secretary
 1.0
.................
43.0 		X   X       0 5,440 0
(6) Brian Silverstein MD
 
Board Member
 1.0
.................
3.0 		X           0 45,000 0
(7) Gerald J McShane MD
 
Board Member
 1.0
.................
42.0 		X           0 387,328 65,492
(8) Sister M Mikela Meidl FSGM
 
Board Member
 1.0
.................
43.0 		X           0 0 0
(9) Sister Rose Therese Mann OSF
 
Board Member
 1.0
.................
43.0 		X           0 0 0
(10) Chad E Boore
 
Chief Executive Officer Eastern Region
 1.0
.................
41.0 		    X       0 547,917 44,458
(11) Divya-Devi Joshi
 
CEO Children SL (THROUGH FEB 2020)
 1.0
.................
41.0 		    X       0 696,742 25,647
(12) Dwight D Stapleton
 
Vice President Clinical Specialty Services (THROUGH FEB 2020)
 1.0
.................
41.0 		    X       0 511,009 27,402
(13) James J Mormann
 
Chief Information Officer
 1.0
.................
41.0 		    X       0 797,958 69,066
(14) Jeffry M Tillery
 
SVP Chief Transformation Officer
 1.0
.................
41.0 		    X       0 757,079 62,714
(15) John C Horne
 
SVP Chief Supply Chain Officer (THROUGHT NOV 2019)
 1.0
.................
41.0 		    X       0 453,426 57,341
(16) John R Evancho
 
SVP Chief Compliance Officer
 1.0
.................
41.0 		    X       0 358,395 44,145
(17) Leon A Yeh MD
 
VP CMO Emergency Serv
 1.0
.................
41.0 		    X       0 634,181 60,349
Form 990 (2019)
Form 990 (2019)
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 (list any hours for related organizations below dotted line) 		(C)
Position (do not check more than one box, unless person is both an officer and a director/trustee) 		(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; OfficerInd; Key Employee; Highest compensated employee; FormerOfcrDirectorTrusteeInd;
(18) Lori L Wiegand
 
Chief Nursing Officer
 1.0
.......................41.0 		    X       0 550,597 62,978
(19) Mark A Nafziger
 
Chief Ambulatory Care (THROUGH MAR 2020)
 1.0
.......................41.0 		    X       0 752,227 30,742
(20) Michael A Cruz MD
 
Chief Operating Officer
 1.0
.......................41.0 		    X       0 900,291 75,306
(21) Michael M Allen
 
CFO
 1.0
.......................42.0 		    X       0 879,093 65,710
(22) Michelle D Conger
 
Chief Strategy Officer
 1.0
.......................41.0 		    X       0 686,668 58,276
(23) Ralph R Velazquez MD
 
System Chief Medical Officer
 1.0
.......................42.0 		    X       0 669,097 67,500
(24) Robert L Brandfass
 
SVP Chief Legal Officer
 1.0
.......................41.0 		    X       0 724,825 64,002
(25) Roxanna Crosser
 
Chief Executive Officer Western Region
 1.0
.......................41.0 		    X       0 527,791 47,441
(26) Stephen E Hippler MD
 
Chief Clinical Officer
 1.0
.......................41.0 		    X       0 836,664 75,497
(27) Thomas G Hammerton
 
President OSF Healthcare Foundation Chief Development Officer
 1.0
.......................43.0 		    X       0 495,059 66,662
(28) Jane A Battles
 
ADVANCED PRACTICE NURSE
 40.0
.......................0 		        X   128,910 0 26,864
(29) Jodie L Borchelt
 
Director Surgical/Inpatient Services, Medical/Surgical Acute
 40.0
.......................0 		        X   103,823 0 33,274
(30) Katherine R Riva-Foster MD
 
Physician
 40.0
.......................0 		        X   240,296 0 15,804
(31) Kenneth K Potts MD
 
Physician
 40.0
.......................0 		        X   240,145 0 32,811
(32) Stacy A Piller
 
Advanced Practice Nurse
 40.0
.......................0 		        X   112,074 0 26,853
(33) David A Schertz
 
Former - CEO Northern Region
 0.0
.......................0.0 		          X 0 585,749 10,313
1b Sub-Total................MediumBullet
c Total from continuation sheets to Part VII, Section A....MediumBullet
d Total (add lines 1b and 1c)...........MediumBullet 825,248 14,708,601 1,282,101
2
Total number of individuals (including but not limited to those listed above) who received more than $100,000 of reportable compensation from the organization MediumBullet5
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
Yes
 
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
 
No
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. Report compensation for the calendar year ending with or within the organization’s tax year.
(A)
Name and business address 		(B)
Description of services 		(C)
Compensation
Emergency Physician Staffing Solutions

1504 Timber Trail
Washington,IL61571 		Emergency Services Physicians 2,075,758
2
Total number of independent contractors (including but not limited to those listed above) who received more than $100,000 of compensation from the organization MediumBullet1
Form 990 (2019)
Form 990 (2019)
Page 9
Part VIII
Statement of Revenue
Check if Schedule O contains a response or note to any line in this Part VIII.............
(A)
Total revenue 		(B)
Related or
exempt
function
revenue 		(C)
Unrelated
business
revenue 		(D)
Revenue
excluded from
tax under sections
512 - 514
Contributions, Gifts, GrantAmt and OtherAmt Similar Amounts 1a Federated campaigns..1a  
b Membership dues..1b  
c Fundraising events..1c  
d Related organizations1d 120,321
e Government grants (contributions)1e 3,238,599
f All other contributions, gifts, grants, and similar amounts not included above1f 94,956
g Noncash contributions included in lines 1a - 1f:$ 1g  
h Total. Add lines 1a-1f.......MediumBullet 3,453,876
Program Service RevenueAmt Business Code
2a PATIENT REVENUE 622110 31,773,298 31,773,298    
b CONTRACTED PHARMACY 622110 1,690,402 1,690,402    
c MEDICAL DIRECTORSHIPS 624200 61,966 61,966    
d
e
f All other program service revenue. 0 0 0 0
g Total. Add lines 2a–2f .....MediumBullet 33,525,666
OtherAmtRevenueAmt 3 Investment income (including dividends, interest, and othersimilar amounts) ......MediumBullet 1,791     1,791
4 Income from investment of tax-exempt bond proceedsMediumBullet        
5 Royalties...........MediumBullet        
(ii) Personal (i) Real
6a Gross rents   21,341 6a
b Less: rental expenses   0 6b
c Rental income or (loss) 0 21,341 6c
d Net rental income or (loss).......MediumBullet 21,341     21,341
(ii) Other (i) Securities
7a Gross amount from sales of assets other than inventory     7a
b Less: cost or other basis and sales expenses     7b
c Gain or (loss) 0 0 7c
d Net gain or (loss).........MediumBullet        
8a Gross income from fundraising events (not including $   of contributions reported on line 1c). See Part IV, line 18 ....
8a  
b Less: direct expenses ... 8b  
c Net income or (loss) from fundraising events..MediumBullet      
9a Gross income from gaming activities.
See Part IV, line 19 ...
9a  
b Less: direct expenses ... 9b  
c Net income or (loss) from gaming activities..MediumBullet        
10a Gross sales of inventory, less
returns and allowances ..
10a 44,549
b Less: cost of goods sold .. 10b 38,418
c Net income or (loss) from sales of inventory..MediumBullet 6,131     6,131
Business Code Miscellaneous Revenue
11a CAFETERIA 624200 47,598     47,598
b            
c            
d All other revenue .... 48,070 45,906 2,164 0
e Total. Add lines 11a–11d ...... MediumBullet 95,668
12 Total revenue. See instructions.....MediumBullet 37,104,473 33,571,572 2,164 76,861
Form 990 (2019)
Form 990 (2019)
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).Check if Schedule O contains a response or note to any line in this Part IX..............
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 domestic organizations and domestic governments. See Part IV, line 21 ....    
2 Grants and other assistance to domestic individuals. See Part IV, line 22 ...........    
3 Grants and other assistance to foreign organizations, foreign governments, and foreign individuals. See Part IV, lines 15 and 16. .............    
4 Benefits paid to or for members .......    
5 Compensation of current officers, directors, trustees, and key employees ...........        
6 Compensation not included above, to disqualified persons (as defined under section 4958(f)(1)) and persons described in section 4958(c)(3)(B) .........        
7 Other salaries and wages........ 11,412,042 9,254,331 2,157,711  
8 Pension plan accruals and contributions (include section 401(k) and 403(b) employer contributions) .... 420,079 261,188 158,891  
9 Other employee benefits ....... 2,041,009 1,381,384 659,625  
10 Payroll taxes ........... 611,610 378,110 233,500  
11 Fees for services (non-employees):        
a Management ......        
b Legal .........        
c Accounting ...........        
d Lobbying ........... 13,079   13,079  
e Professional fundraising services. See Part IV, line 17    
f Investment management fees ......        
g Other (If line 11g amount exceeds 10% of line 25, column (A) amount, list line 11g expenses on Schedule O) 2,208,833 2,155,757 53,076 0
12 Advertising and promotion ....        
13 Office expenses ....... 3,071,930 2,591,523 480,407  
14 Information technology ......        
15 Royalties ..        
16 Occupancy ........... 372,113 54,210 317,903  
17 Travel ............ 56,118 43,116 13,002  
18 Payments of travel or entertainment expenses for any federal, state, or local public officials .        
19 Conferences, conventions, and meetings .... 19,590 17,812 1,778  
20 Interest ........... 1,021,249 810,770 210,479  
21 Payments to affiliates ....... 5,153,373 3,410,336 1,743,037  
22 Depreciation, depletion, and amortization .. 711,621 256,867 454,754  
23 Insurance ... 41,633 11,607 30,026  
24 Other expenses. Itemize expenses not covered above (List miscellaneous expenses in line 24e. If line 24e amount exceeds 10% of line 25, column (A) amount, list line 24e expenses on Schedule O.)
a CONTRACTS AND REPAIRS 2,560,991 1,657,876 903,115  
b BAD DEBTS 1,186,015 1,186,015 0  
c PROVIDER TAX 843,555 843,555 0  
d COLLECTION AGENCIES 22,111 0 22,111  
e All other expenses 36,348 0 36,348 0
25 Total functional expenses. Add lines 1 through 24e 31,803,299 24,314,457 7,488,842 0
26 Joint costs. Complete this line only if the organization reported in column (B) joint costs from a combined educational campaign and fundraising solicitation. Check here MediumBullet if following SOP 98-2 (ASC 958-720).        
Form 990 (2019)
Form 990 (2019)
Page 11
Part X
Balance Sheet
Check if Schedule O contains a response or note to any line in this Part IX..............
(A)
Beginning of year 		(B)
End of year
Assets 1 Cash–non-interest-bearing ........ 1,262,564 1 1,256,119
2 Savings and temporary cash investments ......... 57,235 2 63,629
3 Pledges and grants receivable, net ...... 0 3 0
4 Accounts receivable, net ............. 4,066,617 4 4,652,378
5 Loans and other payables to any current or former officer, director, trustee, key employee, creator or founder, substantial contributor, or 35% controlled entity or family member of any of these persons .......
0 5 0
6 Loans and other receivables from other disqualified persons (as defined under section 4958(f)(1)), and persons described in section 4958(c)(3)(B) ...
0 6 0
7 Notes and loans receivable, net ........... 0 7 0
8 Inventories for sale or use ............ 670,364 8 718,557
9 Prepaid expenses and deferred charges ...... 106,028 9 0
10a Land, buildings, and equipment: cost or other basis. Complete Part VI of Schedule D 10a 50,663,994
b Less: accumulated depreciation 10b 36,599,967 14,155,148 10c 14,064,027
11 Investments—publicly traded securities . 137,723 11 194,574
12 Investments—other securities. See Part IV, line 11 ..... 0 12  
13 Investments—program-related. See Part IV, line 11 .. 0 13  
14 Intangible assets ...............   14  
15 Other assets. See Part IV, line 11 ........... 12,618,476 15 12,656,298
16 Total assets. Add lines 1 through 15 (must equal line 33)... 33,074,155 16 33,605,582
Liabilities 17 Accounts payable and accrued expenses ..... 2,636,171 17 1,725,085
18 Grants payable ... 0 18 0
19 Deferred revenue ......... 0 19 0
20 Tax-exempt bond liabilities ......... 0 20 0
21 Escrow or custodial account liability. Complete Part IV of Schedule D 0 21 0
22 Loans and other payables to any current or former officer, director, trustee, key employee, creator or founder, substantial contributor, or 35% controlled entity or family member of any of these persons .........
0 22 0
23 Secured mortgages and notes payable to unrelated third parties .. 0 23 0
24 Unsecured notes and loans payable to unrelated third parties .. 0 24 0
25 Other liabilities (including federal income tax, payables to related third parties, and other liabilities not included on lines 17 - 24). Complete Part X of Schedule D 26,639,284 25 23,632,641
26 Total liabilities. Add lines 17 through 25.. 29,275,455 26 25,357,726
Net Assets or Fund Balance Organizations that follow FASB ASC 958, check here MediumBullet and complete lines 27, 28, 32, and 33.
27 Net assets without donor restrictions .......... 1,998,095 27 6,409,428
28 Net assets with donor restrictions ........... 1,800,605 28 1,838,428
Organizations that do not follow FASB ASC 958, check here MediumBullet and complete lines 29 through 33.
29 Capital stock or trust principal, or current funds ..... 0 29 0
30 Paid-in or capital surplus, or land, building or equipment fund ... 0 30 0
31 Retained earnings, endowment, accumulated income, or other funds 0 31 0
32 Total net assets or fund balances ........... 3,798,700 32 8,247,856
33 Total liabilities and net assets/fund balances ........ 33,074,155 33 33,605,582
Form 990 (2019)
Form 990 (2019)
Page 12
Part XI
Reconcilliation of Net Assets
Check if Schedule O contains a response or note to any line in this Part XI..............
1
Total revenue (must equal Part VIII, column (A), line 12) ............
1
37,104,473
2
Total expenses (must equal Part IX, column (A), line 25) ............
2
31,803,299
3
Revenue less expenses. Subtract line 2 from line 1 ..............
3
5,301,174
4
Net assets or fund balances at beginning of year (must equal Part X, line 32, column (A)) ..
4
3,798,700
5
Net unrealized gains (losses) on investments ...............
5
3,004
6
Donated services and use of facilities .................
6
 
7
Investment expenses .....................
7
 
8
Prior period adjustments .....................
8
 
9
Other changes in net assets or fund balances (explain in Schedule O) ........
9
-855,022
10
Net assets or fund balances at end of year. Combine lines 3 through 9 (must equal Part X, line 32, column (B))
10
8,247,856
Part XII
Financial Statements and Reporting
Check if Schedule O contains a response or note to any line 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
If ‘Yes,’ check a box below to indicate whether the financial statements for the year were compiled or reviewed on a separate basis, consolidated basis, or both:
b
Were the organization’s financial statements audited by an independent accountant?
2b
Yes
 
If ‘Yes,’ check a box below to indicate whether the financial statements for the year were audited on a separate basis, consolidated basis, or both:
c
If "Yes," to line 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?
2c
Yes
 
If the organization changed either its oversight process or selection process during the tax year, explain in Schedule O.
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
Yes
 
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
Yes
 
Form 990 (2019)
Form 990 (2019)
Additional Data


Software ID: 19010655
Software Version: 2019v5.0
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 Go to www.irs.gov/Form990 for instructions and the latest information.
OMB No. 1545-0047
2019
Open to Public
Inspection
Name of the organization
Mendota Community Hospital
 
Employer identification number

36-2167785
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 12, check only one box.)
1
2
3
4
5
6
7
8
9
10
11
12
a
b
c
d
e
f
Enter the number of supported organizations ...............................  
g
Provide the following information about the supported organization(s).
(i) Name of supported organization (ii) EIN (iii) Type of organization (described on lines 1- 10 above (see instructions)) (iv) Is the organization listed in your governing document? (v) Amount of monetary support (see instructions) (vi) Amount of other support (see instructions)
Yes No
Total
 
   
For Paperwork Reduction Act Notice, see the Instructions for
Form 990 or 990-EZ.
Cat. No. 11285F
Schedule A (Form 990 or 990-EZ) 2019

Schedule A (Form 990 or 990-EZ) 2019
Page 2
Part II
Support Schedule for Organizations Described in Sections 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 failed to qualify under the tests listed below, please complete Part III.)
Section A. Public Support
Calendar year (or fiscal year beginning in) right arrow (a) 2015 (b) 2016 (c) 2017 (d) 2018 (e) 2019 (f) Total
1 Gifts, grants, contributions, and membership fees received. (Do not include any "unusual grant.") ..            
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) right arrow (a) 2015 (b) 2016 (c) 2017 (d) 2018 (e) 2019 (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. Do not include gain or loss from the sale of capital assets (Explain in Part VI.)..            
11 Total support. Add lines 7 through 10  
12
12
 
13
First five years. If the Form 990 is for the organization's first, second, third, fourth, or fifth tax year as a section 501(c)(3) organization, check this box and stop here........................................right arrow
Section C. Computation of Public Support Percentage
14
14
 
15
15
 
16a
b
17a
b
18
Private foundation. If the organization did not check a box on line 13, 16a, 16b, 17a, or 17b, check this box and see
instructions ..................................................... right arrow
Schedule A (Form 990 or 990-EZ) 2019

Schedule A (Form 990 or 990-EZ) 2019
Page 3
Part III
Support Schedule for Organizations Described in Section 509(a)(2)
(Complete only if you checked the box on line 10 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) right arrow (a) 2015 (b) 2016 (c) 2017 (d) 2018 (e) 2019 (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) right arrow (a) 2015 (b) 2016 (c) 2017 (d) 2018 (e) 2019 (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 VI.) ..            
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) 2019

Schedule A (Form 990 or 990-EZ) 2019
Page 4
Part IV
Supporting Organizations
(Complete only if you checked a box on line 12 of Part I. If you checked 12a of Part I, complete Sections A and B. If you checked 12b of Part I, complete Sections A and C. If you checked 12c of Part I, complete Sections A, D, and E. If you checked 12d of Part I, complete Sections A and D, and complete Part V.)
Section A. All Supporting Organizations
Yes
No
1
Are all of the organization’s supported organizations listed by name in the organization’s governing documents?
If "No," describe in Part VI how the supported organizations are designated. If designated by class or purpose,
describe the designation. If historic and continuing relationship, explain.
1
 
 
2
Did the organization have any supported organization that does not have an IRS determination of status under section 509(a)(1) or (2)? If "Yes," explain in Part VI how the organization determined that the supported organization was described in section 509(a)(1) or (2).
2
 
 
3a
Did the organization have a supported organization described in section 501(c)(4), (5), or (6)? If "Yes," answer (b) and (c) below.
3a
 
 
b
Did the organization confirm that each supported organization qualified under section 501(c)(4), (5), or (6) and satisfied the public support tests under section 509(a)(2)? If "Yes," describe in Part VI when and how the organization made the determination.
3b
 
 
c
Did the organization ensure that all support to such organizations was used exclusively for section 170(c)(2)(B) purposes? If "Yes," explain in Part VI what controls the organization put in place to ensure such use.
3c
 
 
4a
Was any supported organization not organized in the United States ("foreign supported organization")? If “Yes” and if you checked 12a or 12b in Part I, answer (b) and (c) below.
4a
 
 
b
Did the organization have ultimate control and discretion in deciding whether to make grants to the foreign supported organization? If “Yes,” describe in Part VI how the organization had such control and discretion despite being controlled or supervised by or in connection with its supported organizations.
4b
 
 
c
Did the organization support any foreign supported organization that does not have an IRS determination under sections 501(c)(3) and 509(a)(1) or (2)? If “Yes,” explain in Part VI what controls the organization used to ensure that all support to the foreign supported organization was used exclusively for section 170(c)(2)(B) purposes.
4c
 
 
5a
Did the organization add, substitute, or remove any supported organizations during the tax year? If “Yes,” answer (b) and (c) below (if applicable). Also, provide detail in Part VI, including (i) the names and EIN numbers of the supported organizations added, substituted, or removed; (ii) the reasons for each such action; (iii) the authority under the organization's organizing document authorizing such action; and (iv) how the action was accomplished (such as by amendment to the organizing document).
5a
 
 
b
Type I or Type II only. Was any added or substituted supported organization part of a class already designated in the organization's organizing document?
5b
 
 
c
Substitutions only. Was the substitution the result of an event beyond the organization's control?
5c
 
 
6
Did the organization provide support (whether in the form of grants or the provision of services or facilities) to anyone other than (i) its supported organizations, (ii) individuals that are part of the charitable class benefited by one or more of its supported organizations, or (iii) other supporting organizations that also support or benefit one or more of the filing organization’s supported organizations? If “Yes,” provide detail in Part VI.
6
 
 
7
Did the organization provide a grant, loan, compensation, or other similar payment to a substantial contributor (defined in section 4958(c)(3)(C)), a family member of a substantial contributor, or a 35% controlled entity with regard to a substantial contributor? If “Yes,” complete Part I of Schedule L (Form 990 or 990-EZ) .
7
 
 
8
Did the organization make a loan to a disqualified person (as defined in section 4958) not described in line 7? If “Yes,” complete Part I of Schedule L (Form 990 or 990-EZ).
8
 
 
9a
Was the organization controlled directly or indirectly at any time during the tax year by one or more disqualified persons as defined in section 4946 (other than foundation managers and organizations described in section 509(a)(1) or (2))? If “Yes,” provide detail in Part VI.
9a
 
 
b
Did one or more disqualified persons (as defined in line 9a) hold a controlling interest in any entity in which the supporting organization had an interest? If “Yes,” provide detail in Part VI.
9b
 
 
c
Did a disqualified person (as defined in line 9a) have an ownership interest in, or derive any personal benefit from, assets in which the supporting organization also had an interest? If “Yes,” provide detail in Part VI.
9c
 
 
10a
Was the organization subject to the excess business holdings rules of section 4943 because of section 4943(f) (regarding certain Type II supporting organizations, and all Type III non-functionally integrated supporting organizations)? If “Yes,” answer line 10b below.
10a
 
 
b
Did the organization have any excess business holdings in the tax year? (Use Schedule C, Form 4720, to determine whether the organization had excess business holdings).
10b
 
 
Schedule A (Form 990 or 990-EZ) 2019

Schedule A (Form 990 or 990-EZ) 2019
Page 5
Part IV
Supporting Organizations (continued)
Yes
No
11
Has the organization accepted a gift or contribution from any of the following persons?
a
A person who directly or indirectly controls, either alone or together with persons described in (b) and (c) below, the governing body of a supported organization?
11a
 
 
b
A family member of a person described in (a) above?
11b
 
 
c
A 35% controlled entity of a person described in (a) or (b) above? If “Yes” to a, b, or c, provide detail in Part VI.
11c
 
 
Section B. Type I Supporting Organizations
Yes
No
1
Did the directors, trustees, or membership of one or more supported organizations have the power to regularly appoint or elect at least a majority of the organization’s directors or trustees at all times during the tax year? If “No,” describe in Part VI how the supported organization(s) effectively operated, supervised, or controlled the organization’s activities. If the organization had more than one supported organization, describe how the powers to appoint and/or remove directors or trustees were allocated among the supported organizations and what conditions or restrictions, if any, applied to such powers during the tax year.
1
 
 
2
Did the organization operate for the benefit of any supported organization other than the supported organization(s) that operated, supervised, or controlled the supporting organization? If “Yes,” explain in Part VI how providing such benefit carried out the purposes of the supported organization(s) that operated, supervised or controlled the supporting organization.
2
 
 
Section C. Type II Supporting Organizations
Yes
No
1
Were a majority of the organization’s directors or trustees during the tax year also a majority of the directors or trustees of each of the organization’s supported organization(s)? If “No,” describe in Part VI how control or management of the supporting organization was vested in the same persons that controlled or managed the supported organization(s).
1
 
 
Section D. All Type III Supporting Organizations
Yes
No
1
Did the organization provide to each of its supported organizations, by the last day of the fifth month of the organization’s tax year, (i) a written notice describing the type and amount of support provided during the prior tax year, (ii) a copy of the Form 990 that was most recently filed as of the date of notification, and (iii) copies of the organization’s governing documents in effect on the date of notification, to the extent not previously provided?
1
 
 
2
Were any of the organization’s officers, directors, or trustees either (i) appointed or elected by the supported organization(s) or (ii) serving on the governing body of a supported organization? If "No," explain in Part VI how the organization maintained a close and continuous working relationship with the supported organization(s).
2
 
 
3
By reason of the relationship described in (2), did the organization’s supported organizations have a significant voice in the organization’s investment policies and in directing the use of the organization’s income or assets at all times during the tax year? If "Yes," describe in Part VI the role the organization’s supported organizations played in this regard.
3
 
 
Section E. Type III Functionally-Integrated Supporting Organizations
1
Check the box next to the method that the organization used to satisfy the Integral Part Test during the year (see instructions):
a
b
c
2
Activities Test. Answer (a) and (b) below.
Yes
No
a
Did substantially all of the organization’s activities during the tax year directly further the exempt purposes of the supported organization(s) to which the organization was responsive? If "Yes," then in Part VI identify those supported organizations and explain how these activities directly furthered their exempt purposes, how the organization was responsive to those supported organizations, and how the organization determined that these activities constituted substantially all of its activities.
2a
 
 
b
Did the activities described in (a) constitute activities that, but for the organization’s involvement, one or more of the organization’s supported organization(s) would have been engaged in? If "Yes," explain in Part VI the reasons for the organization’s position that its supported organization(s) would have engaged in these activities but for the organization’s involvement.
2b
 
 
3
Parent of Supported Organizations. Answer (a) and (b) below.
a
Did the organization have the power to regularly appoint or elect a majority of the officers, directors, or trustees of each of the supported organizations? Provide details in Part VI.
3a
 
 
b
Did the organization exercise a substantial degree of direction over the policies, programs and activities of each of its supported organizations? If "Yes," describe in Part VI. the role played by the organization in this regard.
3b
 
 
Schedule A (Form 990 or 990-EZ) 2019

Schedule A (Form 990 or 990-EZ) 2019
Page 6
Part V
Type III Non-Functionally Integrated 509(a)(3) Supporting Organizations
1
Section A - Adjusted Net Income (A) Prior Year (B) Current Year
(optional)
1 Net short-term capital gain 1    
2 Recoveries of prior-year distributions 2    
3 Other gross income (see instructions) 3    
4 Add lines 1 through 3 4    
5 Depreciation and depletion 5    
6 Portion of operating expenses paid or incurred for production or collection of gross income or for management, conservation, or maintenance of property held for production of income (see instructions) 6    
7 Other expenses (see instructions) 7    
8 Adjusted Net Income (subtract lines 5, 6 and 7 from line 4) 8    
Section B - Minimum Asset Amount (A) Prior Year (B) Current Year
(optional)
1 Aggregate fair market value of all non-exempt-use assets (see instructions for short tax year or assets held for part of year): 1
a Average monthly value of securities 1a    
b Average monthly cash balances 1b    
c Fair market value of other non-exempt-use assets 1c    
d Total (add lines 1a, 1b, and 1c) 1d    
e Discount claimed for blockage or other factors
(explain in detail in Part VI):  
2 Acquisition indebtedness applicable to non-exempt use assets 2    
3 Subtract line 2 from line 1d 3    
4 Cash deemed held for exempt use. Enter 1-1/2% of line 3 (for greater amount, see instructions). 4    
5 Net value of non-exempt-use assets (subtract line 4 from line 3) 5    
6 Multiply line 5 by .035 6    
7 Recoveries of prior-year distributions 7    
8 Minimum Asset Amount (add line 7 to line 6) 8    
Section C - Distributable Amount Current Year
1 Adjusted net income for prior year (from Section A, line 8, Column A) 1  
2 Enter 85% of line 1 2  
3 Minimum asset amount for prior year (from Section B, line 8, Column A) 3  
4 Enter greater of line 2 or line 3 4  
5 Income tax imposed in prior year 5  
6 Distributable Amount. Subtract line 5 from line 4, unless subject to emergency temporary reduction (see instructions) 6  
7
Schedule A (Form 990 or 990-EZ) 2019

Schedule A (Form 990 or 990-EZ) 2019
Page 7
Part V
Type III Non-Functionally Integrated 509(a)(3) Supporting Organizations(continued)
Section D - Distributions Current Year
1 Amounts paid to supported organizations to accomplish exempt purposes  
2 Amounts paid to perform activity that directly furthers exempt purposes of supported organizations, in
excess of income from activity		  
3 Administrative expenses paid to accomplish exempt purposes of supported organizations  
4 Amounts paid to acquire exempt-use assets  
5 Qualified set-aside amounts (prior IRS approval required)  
6 Other distributions (describe in Part VI). See instructions  
7Total annual distributions. Add lines 1 through 6.  
8 Distributions to attentive supported organizations to which the organization is responsive (provide
details in Part VI). See instructions		  
9 Distributable amount for 2019 from Section C, line 6  
10 Line 8 amount divided by Line 9 amount  
Section E - Distribution Allocations (see instructions) (i)
Excess Distributions 		(ii)
Underdistributions
Pre-2019 		(iii)
Distributable
Amount for 2019
1 Distributable amount for 2019 from Section C, line 6  
2 Underdistributions, if any, for years prior to 2019 (reasonable cause required-- explain in Part VI).
See instructions.		  
3 Excess distributions carryover, if any, to 2019:
a From 2014.......  
b From 2015.......  
c From 2016.......  
d From 2017.......  
e From 2018.......  
fTotal of lines 3a through e  
g Applied to underdistributions of prior years  
h Applied to 2019 distributable amount  
i Carryover from 2014 not applied (see
instructions) 		 
j Remainder. Subtract lines 3g, 3h, and 3i from 3f.  
4Distributions for 2019 from Section D, line 7:
$  
a Applied to underdistributions of prior years  
b Applied to 2019 distributable amount  
c Remainder. Subtract lines 4a and 4b from 4.  
5 Remaining underdistributions for years prior to
2019, if any. Subtract lines 3g and 4a from line 2.
If the amount is greater than zero, explain in Part VI.
See instructions.		  
6 Remaining underdistributions for 2019. Subtract
lines 3h and 4b from line 1. If the amount is greater
than zero, explain in Part VI. See instructions.		  
7 Excess distributions carryover to 2020. Add lines
3j and 4c.		  
8 Breakdown of line 7:
a Excess from 2015.....  
b Excess from 2016.....  
c Excess from 2017.....  
d Excess from 2018.....  
e Excess from 2019.....  
Schedule A (Form 990 or 990-EZ) (2019)

Schedule A (Form 990 or 990-EZ) 2019
Page 8
Part VI
Supplemental Information. Provide the explanations required by Part II, line 10; Part II, line 17a or 17b; Part III, line 12; Part IV, Section A, lines 1, 2, 3b, 3c, 4b, 4c, 5a, 6, 9a, 9b, 9c, 11a, 11b, and 11c; Part IV, Section B, lines 1 and 2; Part IV, Section C, line 1; Part IV, Section D, lines 2 and 3; Part IV, Section E, lines 1c, 2a, 2b, 3a and 3b; Part V, line 1; Part V, Section B, line 1e; Part V Section D, lines 5, 6, and 8; and Part V, Section E, lines 2, 5, and 6. Also complete this part for any additional information. (See instructions).
Facts And Circumstances Test
 
Return Reference Explanation
Schedule A (Form 990 or 990-EZ) 2019


Additional Data


Software ID: 19010655
Software Version: 2019v5.0
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.
Arrow Bullet Go to www.irs.gov/Form990 for the latest information.
OMB No. 1545-0047
2019
Name of the organization
Mendota Community Hospital
 
Employer identification number

36-2167785
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 isn't covered by the General Rule and/or the Special Rules doesn't 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 on line H of its Form 990-EZ
or on its Form 990PF, Part I, line 2, to certify that it doesn't 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) (2019)
Schedule B (Form 990, 990-EZ, or 990-PF) (2019) Page 2
Name of organization
Mendota Community Hospital
  		Employer identification number
36-2167785
Part I
Contributors
Contributors (see instructions). Use duplicate copies of Part I if additional space is needed.
(a)
No.		 (b)
Name, address, and ZIP + 4		 (c)
Total contributions		 (d)
Type of contribution
RESTRICTED
 
 
 
 
  ,    

$ RESTRICTED


(Complete Part II for noncash contributions.)
(a)
No.		 (b)
Name, address, and ZIP + 4		 (c)
Total contributions		 (d)
Type of contribution
 
 
 
 

$  


(Complete Part II for noncash contributions.)
(a)
No.		 (b)
Name, address, and ZIP + 4		 (c)
Total contributions		 (d)
Type of contribution
 
 
 
 

$  


(Complete Part II for noncash contributions.)
(a)
No.		 (b)
Name, address, and ZIP + 4		 (c)
Total contributions		 (d)
Type of contribution
 
 
 
 

$  


(Complete Part II for noncash contributions.)
(a)
No.		 (b)
Name, address, and ZIP + 4		 (c)
Total contributions		 (d)
Type of contribution
 
 
 
 

$  


(Complete Part II for noncash contributions.)
(a)
No.		 (b)
Name, address, and ZIP + 4		 (c)
Total contributions		 (d)
Type of contribution
 
 
 
 

$  


(Complete Part II for noncash contributions.)
Schedule B (Form 990, 990-EZ, or 990-PF) (2019)
Schedule B (Form 990, 990-EZ, or 990-PF) (2019)
Page 3
Name of organization
Mendota Community Hospital
  		Employer identification number

36-2167785
Part II
Noncash Property (see instructions). Use duplicate copies of Part II if additional space is needed.
(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) (2019)
Schedule B (Form 990, 990-EZ, or 990-PF) (2019)
Page 4
Name of organization
Mendota Community Hospital
  		Employer identification number

36-2167785
Part III
Exclusively religious, charitable, etc., contributions to organizations described in section 501(c)(7), (8), or (10) that total more than $1,000 for the year from any one contributor. 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 $1,000 or less for the year. (Enter this information once. See instructions.) Arrow Bullet$  
Use duplicate copies of Part III if additional space is needed.
(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) (2019)

Additional Data


Software ID: 19010655
Software Version: 2019v5.0
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 BulletGo to www.irs.gov/Form990 for instructions and the latest information.
OMB No. 1545-0047
2019
Open to Public
Inspection
If the organization answered "Yes" on 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" on 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" on Form 990, Part IV, Line 5 (Proxy Tax) (see separate instructions) or Form 990-EZ, Part V, line 35c (Proxy Tax) (see separate instructions), then
Round Bullet Section 501(c)(4), (5), or (6) organizations: Complete Part III.
Name of the organization
Mendota Community Hospital
 
Employer identification number

36-2167785
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 in Part IV (see instructions for definition of “political campaign activities")

2
Political campaign activity expenditures (see instructions) ....................................................................SchCMd Bullet
$  
3
Volunteer hours for political campaign activities (see instructions) ..................................................................
 

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 function 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-.
1
2
3
4
5
6
For Paperwork Reduction Act Notice, see the instructions for Form 990 or 990-EZ.
Cat. No. 50084S
Schedule C (Form 990 or 990-EZ) 2019

Schedule C (Form 990 or 990-EZ) 2019
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 SchCMd Bulletexpenses, and share of excess lobbying expenditures).
B Check SchCMd Bullet
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 separate instructions for lines 2a through 2f.)
Lobbying Expenditures During 4-Year Averaging Period
Calendar year (or fiscal year
beginning in) 		(a) 2016 (b) 2017 (c) 2018 (d) 2019 (e) Total
2a Lobbying nontaxable amount          
b Lobbying ceiling amount
(150% of line 2a, column(e)) 		 
c Total lobbying expenditures          
d Grassroots nontaxable amount          
e Grassroots ceiling amount
(150% of line 2d, column (e))		  
f Grassroots lobbying expenditures          
Schedule C (Form 990 or 990-EZ) 2019


Schedule C (Form 990 or 990-EZ) 2019
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)).
For each "Yes" response on lines 1a through 1i below, provide in Part IV a detailed description of the lobbying activity.
(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? ..........................................................
 
No
 
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? ...................................................................................................................
Yes
 
13,079
j
Total. Add lines 1c through 1i ....................................................................................................
13,079
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 carry over 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) and if either (a) BOTH Part III-A, lines 1 and 2, are answered "No" OR (b) Part III-A, line 3, is answered “Yes."
1
Dues, assessments and similar amounts from members ......................................................................
1
 
2
Section 162(e) nondeductible 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
Provide the descriptions required for Part l-A, line 1; Part l-B, line 4; Part l-C, line 5; Part II-A (affiliated group list); Part II-A, lines 1 and 2 (see instructions), and Part ll-B, line 1. Also, complete this part for any additional information.
Return Reference Explanation
Schedule C, Part II-B, Line 1 DETAILED DESCRIPTION OF THE LOBBYING ACTIVITY THE ORGANIZATION'S LOBBYING ACTIVITIES INCLUDE PAYING MEMBERSHIP DUES TO THE ILLINOIS HOSPITAL ASSOCIATION AND AMERICAN HOSPITAL ASSOCIATION, WHO PARTICIPATE IN LOBBYING ACTIVITIES ON BEHALF OF HEALTHCARE ORGANIZATIONS.
Schedule C (Form 990 or 990EZ) 2019


Additional Data


Software ID: 19010655
Software Version: 2019v5.0

SCHEDULE D
(Form 990)
Department of the Treasury
Internal Revenue Service
Supplemental Financial Statements
SchDMd Bullet Complete if the organization answered "Yes," on Form 990,
Part IV, line 6, 7, 8, 9, 10, 11a, 11b, 11c, 11d, 11e, 11f, 12a, or 12b.
SchDMd Bullet Attach to Form 990.
SchDMd Bullet Go to www.irs.gov/Form990 for instructions and the latest information.
OMB No. 1545-0047
2019
Open to Public Inspection
Name of the organization
Mendota Community Hospital
 
Employer identification number

36-2167785
Part I
Organizations Maintaining Donor Advised Funds or Other Similar Funds or Accounts. Complete if the organization answered "Yes" on Form 990, Part IV, line 6.
(a) Donor advised funds (b) Funds and other accounts
1 Total number at end of year .........    
2 Aggregate value of contributions to (during year)    
3 Aggregate value of 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 can 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" on Form 990, Part IV, line 7.
1
Purpose(s) of conservation easements held by the organization (check all that apply).
2
Complete lines 2a through 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 7/25/06, and not on a historic structure listed in the National Register ... 2d  
3
Number of conservation easements modified, transferred, released, extinguished, or terminated by the organization during the
tax 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, handling of violations, and enforcing conservation easements during the year
SchDMd Bullet  
7
Amount of expenses incurred in monitoring, inspecting, handling of violations, 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 section 170(h)(4)(B)(ii)? .............................
9
In Part XIII, 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" on Form 990, Part IV, line 8.
1a
If the organization elected, as permitted under FASB ASC 958, 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 XIII, the text of the footnote to its financial statements that describes these items.
b
If the organization elected, as permitted under FASB ASC 958, 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)
Revenue included on 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 FASB ASC 958 relating to these items:
a
Revenue included on Form 990, Part VIII, line 1 ..........................SchDMd Bullet $  
b
Assets included in Form 990, Part X ...............................SchDMd Bullet $  
For Paperwork Reduction Act Notice, see the Instructions for Form 990.
Cat. No. 52283D
Schedule D (Form 990) 2019

Schedule D (Form 990) 2019
Page 2
Part III
Organizations Maintaining Collections of Art, Historical Treasures, or Other Similar Assets (continued)
3
Using the organization’s acquisition, 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 XIII.
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" on 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 XIII 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, for escrow or custodial account liability? ...
b
If "Yes," explain the arrangement in Part XIII. Check here if the explanation has been provided in Part XIII ....
Part V
Endowment Funds.
Complete if the organization answered "Yes" on 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 .... 805,217 801,256 731,914 644,870 591,555
b Contributions ...          
c Net investment earnings, gains, and losses 49,600 3,961 69,342 87,044 53,315
d Grants or scholarships ...          
e Other expenditures for facilities
and programs ... 		         
f Administrative expenses ....          
g End of year balance ...... 854,817 805,217 801,256 731,914 644,870
2
Provide the estimated percentage of the current year end balance (line 1g, column (a)) held as:
a
Board designated or quasi-endowment SchDMd Bullet0 %
b
Permanent endowment SchDMd Bullet72.59 %
c
Term endowment SchDMd Bullet27.41 %
The percentages on lines 2a, 2b, and 2c should equal 100%.
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)
 
No
(ii) Related organizations .................
3a(ii)
Yes
 
b
If "Yes" on 3a(ii), are the related organizations listed as required on Schedule R? .........
3b
Yes
 
4
Describe in Part XIII the intended uses of the organization's endowment funds.
Part VI
Land, Buildings, and Equipment.
Complete if the organization answered "Yes" on Form 990, Part IV, line 11a. See Form 990, Part X, line 10.
Description of property (a) Cost or other basis
(investment) 		(b) Cost or other basis (other) (c) Accumulated depreciation (d) Book value
1a Land .....   1,927,000 1,927,000
b Buildings ....   4,937,398 4,476,128 461,270
c Leasehold improvements   29,590,471 20,774,499 8,815,972
d Equipment ....   14,209,125 11,349,340 2,859,785
e Other .....        
Total. Add lines 1a through 1e. (Column (d) must equal Form 990, Part X, column (B), line 10(c).)..SchDMdBullet 14,064,027
Schedule D (Form 990) 2019

Schedule D (Form 990) 2019
Page 3
Part VII
Investments—Other Securities.
Complete if the organization answered "Yes" on Form 990, Part IV, line 11b. 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........    
(3)Other
(B)
(C)
(D)
(E)
(F)
(G)
(H)
(I)
Total. (Column (b) must equal Form 990, Part X, col. (B) line 12.)Small Bullet  
Part VIII
Investments—Program Related. Complete if the organization answered 'Yes' on Form 990, Part IV, line 11c. See Form 990, Part X, line 13.
(a) Description of investment (b) Book value (c) Method of valuation:
Cost or end-of-year market value
(2)
(3)
(4)
(5)
(6)
(7)
(8)
(9)
(10)
Total. (Column (b) must equal Form 990, Part X, col.(B) line 13.)Small Bullet  
Part IX
Other Assets.
Complete if the organization answered 'Yes' on Form 990, Part IV, line 11d. See Form 990, Part X, line 15.
(a) Description (b) Book value
(1)GOODWILL 10,817,871
(2)RESTRICTED FOUNDATION ASSETS 1,838,427
(3)
(4)
(5)
(6)
(7)
(8)
(9)
(10)
Total. (Column (b) must equal Form 990, Part X, col.(B) line 15.)...........Small Bullet 12,656,298
Part X
Other Liabilities.
Complete if the organization answered 'Yes' on Form 990, Part IV, line 11e or 11f. See Form 990, Part X, line 25.
1.(a) Description of liability (b) Book value
(1) Federal income taxes  
(7)
(8)
(9)
Total. (Column (b) must equal Form 990, Part X, col.(B) line 25.)Small Bullet 23,632,641
2. Liability for uncertain tax positions. In Part XIII, 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 (ASC 740). Check here if the text of the footnote has been provided in Part XIII
Schedule D (Form 990) 2019

Schedule D (Form 990) 2019
Page 4
Part XI Reconciliation of Revenue per Audited Financial Statements With Revenue per Return. Complete if the organization answered 'Yes' on Form 990, Part IV, line 12a.
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 (losses) on investments .... 2a  
b Donated services and use of facilities ......... 2b  
c Recoveries of prior year grants ........... 2c  
d Other (Describe in Part XIII.) ............ 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 XIII.) ........... 4b  
c Add lines 4a and 4b.................... 4c  
5 Total revenue. Add lines 3 and 4c. (This must equal Form 990, Part I, line 12.) ...... 5  
Part XII Reconciliation of Expenses per Audited Financial Statements With Expenses per Return. Complete if the organization answered 'Yes' on Form 990, Part IV, line 12a.
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 XIII.) ............ 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 XIII.) ............ 4b  
c Add lines 4a and 4b..................... 4c  
5 Total expenses. Add lines 3 and 4c. (This must equal Form 990, Part I, line 18.) ...... 5  
Part XIII
Supplemental Information
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, line 2; Part XI, lines 2d and 4b; and Part XII, lines 2d and 4b. Also complete this part to provide any additional information.
Return Reference Explanation
Schedule D, Part V, Line 4 Intended uses of endowment funds THE ENDOWMENT IS HELD BY OSF HEALTHCARE FOUNDATION, A RELATED 501(c)(3) ENTITY. PROCEEDS OF THE ENDOWMENT, AS DICTATED BY THE DONORS, ARE USED AS BEST DETERMINED BY THE FOUNDATION COUNCIL.
Schedule D, Part X, Line 2 FIN 48 (ASC 740) footnote OSF is a not-for-profit corporation as described by Section 501(c)(3) of the Internal Revenue Code (the Code) and is exempt from federal income taxes on related income pursuant to Section 501(c)(3) of the Code. Under ASC Subtopic 740-10, Accounting for Uncertainty in Income Taxes - An Interpretation of FASB Statement No. 109, OSF and PCI must recognize the tax benefit from an uncertain tax position only if it is more likely than not that the tax position will be sustained on examination by the taxing authorities, based on the technical merits of the position. The tax benefits recognized in the consolidated financial statements from such a position are measured based on the largest benefit that has a greater than 50% likelihood of being realized upon ultimate settlement. As of September 30, 2020 or 2019, OSF and PCI do not have any uncertain tax positions.
Schedule D (Form 990) 2019


Additional Data


Software ID: 19010655
Software Version: 2019v5.0




SCHEDULE H
(Form 990)
Department of the Treasury
Internal Revenue Service
Hospitals
MediumBullet Complete if the organization answered "Yes" on Form 990, Part IV, question 20.
MediumBullet Attach to Form 990.
MediumBullet Go to www.irs.gov/Form990EZ for instructions and the latest information.
OMB No. 1545-0047
2019
Open to Public Inspection
Name of the organization
Mendota Community Hospital
 
Employer identification number

36-2167785
Part I
Financial Assistance and Certain Other Community Benefits at Cost
Yes
No
1a
Did the organization have a financial assistance policy during the tax year? If "No," skip to question 6a . . . .
1a
Yes
 
b
If "Yes," was it a written policy? ......................
1b
Yes
 
2
If the organization had multiple hospital facilities, indicate which of the following best describes application of the financial assistance policy to its various hospital facilities during the tax year.
3
Answer the following based on the financial assistance eligibility criteria that applied to the largest number of the organization's patients during the tax year.
a
Did the organization use Federal Poverty Guidelines (FPG) as a factor in determining eligibility for providing free care?
If "Yes," indicate which of the following was the FPG family income limit for eligibility for free care:
3a
Yes
 
b
Did the organization use FPG as a factor in determining eligibility for providing discounted care? If "Yes," indicate
which of the following was the family income limit for eligibility for discounted care: . . . . . . . .
3b
Yes
 
%
c
If the organization used factors other than FPG in determining eligibility, describe in Part VI the criteria used for determining eligibility for free or discounted care. Include in the description whether the organization used an asset test or other threshold, regardless of income, as a factor in determining eligibility for free or discounted care.
4
Did the organization's financial assistance policy that applied to the largest number of its patients during the tax year provide for free or discounted care to the "medically indigent"? . . . . . . . . . . . . .

4

Yes

 
5a
Did the organization budget amounts for free or discounted care provided under its financial assistance policy during
the tax year? . . . . . . . . . . . . . . . . . . . . . . .

5a

Yes

 
b
If "Yes," did the organization's financial assistance 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 discountedcare to a patient who was eligibile for free or discounted care? . . . . . . . . . . . . .
5c
 
No
6a
Did the organization prepare a community benefit report during the tax year? . . . . . . . . .
6a
Yes
 
b
If "Yes," did 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
Financial Assistance and Certain Other Community Benefits at Cost
Financial Assistance 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 Financial Assistance at cost
(from Worksheet 1) . . . 		    546,934   546,934 1.72 %
b Medicaid (from Worksheet 3, column a) . . . . .     4,422,564 3,924,045 498,519 1.57 %
c Costs of other means-tested government programs (from Worksheet 3, column b) . .         0 0 %
d Total Financial Assistance and Means-Tested Government Programs . . . . . 0 0 4,969,498 3,924,045 1,045,453 3.29 %
Other Benefits
e Community health improvement services and community benefit operations (from Worksheet 4).     238,700 22,883 215,817 0.68 %
f Health professions education (from Worksheet 5) . . .     95,696   95,696 0.30 %
g Subsidized health services (from Worksheet 6) . . . .     803,906 640,519 163,387 0.51 %
h Research (from Worksheet 7) .         0 0 %
i Cash and in-kind contributions for community benefit (from Worksheet 8) . . . .     9,000   9,000 0.03 %
j Total. Other Benefits . . 0 0 1,147,302 663,402 483,900 1.52 %
k Total. Add lines 7d and 7j . 0 0 6,116,800 4,587,447 1,529,353 4.81 %
For Paperwork Reduction Act Notice, see the Instructions for Form 990. Cat. No. 50192T Schedule H (Form 990) 2019
Schedule H (Form 990) 2019
Page
Part II
Community Building Activities Complete this table if the organization conducted any community building activities during the tax year, and describe in Part VI how its community building activities promoted the health of the communities it serves.
(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         0 0 %
2 Economic development         0 0 %
3 Community support         0 0 %
4 Environmental improvements         0 0 %
5 Leadership development and
training for community members		         0 0 %
6 Coalition building         0 0 %
7 Community health improvement advocacy         0 0 %
8 Workforce development         0 0 %
9 Other         0 0 %
10 Total 0 0 0 0 0 0 %
Part III
Bad Debt, Medicare, & Collection Practices
Section A. Bad Debt Expense
Yes
No
1
Did the organization report bad debt expense in accordance with Healthcare Financial Management Association Statement No. 15? ..........................
1
Yes
 
2
Enter the amount of the organization's bad debt expense. Explain in Part VI the methodology used by the organization to estimate this amount. ......
2
499,998
3
Enter the estimated amount of the organization's bad debt expense attributable to patients eligible under the organization's financial assistance policy. Explain in Part VI the methodology used by the organization to estimate this amount and the rationale, if any, for including this portion of bad debt as community benefit. ......
3
0
4
Provide in Part VI the text of the footnote to the organization’s financial statements that describes bad debt expense or the page number on which this footnote is contained in the attached financial statements.
Section B. Medicare
5
Enter total revenue received from Medicare (including DSH and IME).....
5
12,309,704
6
Enter Medicare allowable costs of care relating to payments on line 5.....
6
11,628,460
7
Subtract line 6 from line 5. This is the surplus (or shortfall)........
7
681,244
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
Did the organization have a written debt collection policy during the tax year? ..........
9a
Yes
 
b
If "Yes," did the organization’s collection policy that applied to the largest number of its patients during the tax year
contain provisions on the collection practices to be followed for patients who are known to qualify for financial assistance? Describe in Part VI .........................

9b

Yes

 
Part IV
Management Companies and Joint Ventures(owned 10% or more by officers, directors, trustees, key employees, and physicians—see instructions)
(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) 2019
Schedule H (Form 990) 2019
Page
Part VFacility Information
Section A. Hospital Facilities
(list in order of size from largest to smallest—see instructions)How many hospital facilities did the organization operate during the tax year?1Name, address, primary website address, and state license number (and if a group return, the name and EIN of the subordinate hospital organization that operates the hospital facility) 		Licensed Hospital General-Medical-Surgical Children's Hospital Teaching Hospital Critical Hospital ResearchGrp Facility ER-24Hours ER-Other Other (describe) Facility reporting group
1 MENDOTA COMMUNITY HOSPITAL
1401 E 12TH STREET
MENDOTA,IL61342
HTTPS://WWW.OSFHEALTHCARE.ORG/SAINT-PAUL/
IL0005819 		X X     X   X      
Schedule H (Form 990) 2019
Schedule H (Form 990) 2019
Page 4
Part VFacility Information (continued)

Section B. Facility Policies and Practices

(Complete a separate Section B for each of the hospital facilities or facility reporting groups listed in Part V, Section A)
MENDOTA COMMUNITY HOSPITAL
Name of hospital facility or letter of facility reporting group  
Line number of hospital facility, or line numbers of hospital facilities in a facility
reporting group (from Part V, Section A): 		1
Yes No
Community Health Needs Assessment
1 Was the hospital facility first licensed, registered, or similarly recognized by a state as a hospital facility in the current tax year or the immediately preceding tax year?........................ 1   No
2 Was the hospital facility acquired or placed into service as a tax-exempt hospital in the current tax year or the immediately preceding tax year? If “Yes,” provide details of the acquisition in Section C............... 2   No
3 During the tax year or either of the two immediately preceding tax years, did the hospital facility conduct a community health needs assessment (CHNA)? If "No," skip to line 12...................... 3 Yes  
If "Yes," indicate what the CHNA report describes (check all that apply):
a
b
c
d
e
f
g
h
i
j
4 Indicate the tax year the hospital facility last conducted a CHNA: 20 19
5 In conducting its most recent CHNA, did the hospital facility take into account input from persons who represent the broad interests of the community served by the hospital facility, including those with special knowledge of or expertise in public health? If "Yes," describe in Section C how the hospital facility took into account input from persons who represent the community, and identify the persons the hospital facility consulted ................. 5 Yes  
6 a Was the hospital facility’s CHNA conducted with one or more other hospital facilities? If "Yes," list the other hospital facilities in Section C.................................. 6a Yes  
b Was the hospital facility’s CHNA conducted with one or more organizations other than hospital facilities?” If “Yes,” list the other organizations in Section C. ............................ 6b   No
7 Did the hospital facility make its CHNA report widely available to the public?.............. 7 Yes  
If "Yes," indicate how the CHNA report was made widely available (check all that apply):
a
b
c
d
8 Did the hospital facility adopt an implementation strategy to meet the significant community health needs
identified through its most recently conducted CHNA? If "No," skip to line 11. .............. 		8 Yes  
9 Indicate the tax year the hospital facility last adopted an implementation strategy: 20 19
10 Is the hospital facility's most recently adopted implementation strategy posted on a website?......... 10   No
a If "Yes" (list url):  
b If "No," is the hospital facility’s most recently adopted implementation strategy attached to this return? ...... 10b Yes  
11 Describe in Section C how the hospital facility is addressing the significant needs identified in its most recently conducted CHNA and any such needs that are not being addressed together with the reasons why such needs are not being addressed.
12a Did the organization incur an excise tax under section 4959 for the hospital facility's failure to conduct a CHNA as required by section 501(r)(3)?............................... 12a   No
b If "Yes" on line 12a, did the organization file Form 4720 to report the section 4959 excise tax?........ 12b    
c If "Yes" on line 12b, what is the total amount of section 4959 excise tax the organization reported on Form 4720 for all of its hospital facilities? $  

Schedule H (Form 990) 2019
Schedule H (Form 990) 2019
Page 5
Part VFacility Information (continued)

Financial Assistance Policy (FAP)
MENDOTA COMMUNITY HOSPITAL
Name of hospital facility or letter of facility reporting group  
Yes No
Did the hospital facility have in place during the tax year a written financial assistance policy that:
13 Explained eligibility criteria for financial assistance, and whether such assistance included free or discounted care? 13 Yes  
If “Yes,” indicate the eligibility criteria explained in the FAP:
a
b
c
d
e
f
g
h
14 Explained the basis for calculating amounts charged to patients?................. 14 Yes  
15 Explained the method for applying for financial assistance?................... 15 Yes  
If “Yes,” indicate how the hospital facility’s FAP or FAP application form (including accompanying instructions) explained the method for applying for financial assistance (check all that apply):
a
b
c
d
e
16 Was widely publicized within the community served by the hospital facility?........ 16 Yes  
If "Yes," indicate how the hospital facility publicized the policy (check all that apply):
a
https://www.osfhealthcare.org/billing/financial-assistance/
b
https://www.osfhealthcare.org/billing/financial-assistance/
c
d
e
f
g
h
i
j
Schedule H (Form 990) 2019
Schedule H (Form 990) 2019
Page 6
Part VFacility Information (continued)

Billing and Collections
MENDOTA COMMUNITY HOSPITAL
Name of hospital facility or letter of facility reporting group  
Yes No
17 Did the hospital facility have in place during the tax year a separate billing and collections policy, or a written financial assistance policy (FAP) that explained all of the actions the hospital facility or other authorized party may take upon nonpayment?.................................. 17 Yes  
18 Check all of the following actions against an individual that were permitted under the hospital facility's policies during the tax year before making reasonable efforts to determine the individual’s eligibility under the facility’s FAP:
a
b
c
d
e
f
19 Did the hospital facility or other authorized party perform any of the following actions during the tax year before making reasonable efforts to determine the individual’s eligibility under the facility’s FAP?............ 19   No
If "Yes," check all actions in which the hospital facility or a third party engaged:
a
b
c
d
e
20 Indicate which efforts the hospital facility or other authorized party made before initiating any of the actions listed (whether or not checked) in line 19. (check all that apply):
a
b
c
d
e
f
Policy Relating to Emergency Medical Care
21 Did the hospital facility have in place during the tax year a written policy relating to emergency medical care that required 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?.................. 21 Yes  
If "No," indicate why:
a
b
c
d
Schedule H (Form 990) 2019
Schedule H (Form 990) 2019
Page 7
Part VFacility Information (continued)

Charges to Individuals Eligible for Assistance Under the FAP (FAP-Eligible Individuals)
MENDOTA COMMUNITY HOSPITAL
Name of hospital facility or letter of facility reporting group  
Yes No
22 Indicate how the hospital facility determined, during the tax year, the maximum amounts that can be charged to FAP-eligible individuals for emergency or other medically necessary care.
a
b
c
d
23 During the tax year, did the hospital facility charge any FAP-eligible individual 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? ............................... 23   No
If "Yes," explain in Section C.
24 During the tax year, did the hospital facility charge any FAP-eligible individual an amount equal to the gross charge for any service provided to that individual? ........................... 24   No
If "Yes," explain in Section C.
Schedule H (Form 990) 2019
Schedule H (Form 990) 2019
Page 8
Part V
Facility Information (continued)
Section C. Supplemental Information for Part V, Section B. Provide descriptions required for Part V, Section B, lines 2, 3j, 5, 6a, 6b, 7d, 11, 13b, 13h, 15e, 16j, 18e, 19e, 20a, 20b, 20c, 20d, 20e, 21c, 21d, 23, and 24. If applicable, provide separate descriptions for each hospital facility in a facility reporting group, designated by facility reporting group letter and hospital facility line number from Part V, Section A (“A, 1,” “A, 4,” “B, 2,” “B, 3,” etc.) and name of hospital facility.
Form and Line Reference Explanation
Schedule H, Part V, Section B, Line 3E The significant health needs were prioritized as significant health needs of the community and identified through the CHNA. See CHNA for further information.
Schedule H, Part V, Section B, Line 5 Facility , 1 Facility , 1 - MENDOTA COMMUNITY HOSPITAL. FOR THE 2019 CHNA, MENDOTA COMMUNITY HOSPITAL d/b/a SAINT PAUL MEDICAL CENTER SOLICITED AND TOOK INTO ACCOUNT INPUT FROM THE FOLLOWING SOURCES: 1) CURRENT PUBLIC HEALTH ADMINISTRATOR AT THE LASALLE COUNTY HEALTH DEPT. and CURRENT HEALTH EDUCATOR AND PUBLIC INFORMATION FROM THE LASALLE COUNTY HEALTH DEPT. 2) PRIMARY DATA WAS COLLECTED FROM THE AT-RISK AND ECONOMICALLY DISADVANTAGED POPULATION BY COLLECTING A STRATIFIED SAMPLE OF SURVEYS DISTRIBUTED IN ENGLISH AND SPANISH AT ALL HOMELESS SHELTERS, FOOD PANTRIES AND SOUP KITCHENS. 3) THE 2013 & 2016 CHNA ARE MADE WIDELY AVAILABLE TO THE COMMUNITY AND FEEDBACK RECEIVED FROM COMMUNITY SERVICE ORGANIZATIONS WAS TAKEN INTO ACCOUNT. 4) ADDITIONAL SOURCES OF INPUT WAS RECEIVED FROM A COLLABORATIVE TEAM CREATED TO CONDUCT THE 2019 CHNA, WHICH INCLUDED CONSUMER ADVOCATES, REPRESENTATIVES FROM NONPROFIT AND COMMUNITY-BASED ORGANIZATIONS, ACADEMIC EXPERTS AND HEALTH EDUCATORS, LOCAL GOVERNMENT OFFICIALS, ADMINISTRATORS FROM LOCAL SCHOOL DISTRICTS, HEALTH CARE PROVIDERS AND COMMUNITY HEALTH CENTERS, EXECUTIVE DIRECTOR OF IL VALLEY PADS HOMELESS SHELTER PROGRAM, PROGRAM COORDINATOR FOR THE YOUTH SERVICE BUREAU OF IL VALLEY SERVING THE LATINO POPULATION ENROLLED IN PUBLIC BENEFITS, EXECUTIVE DIRECTOR OF UNITED WAY, AND EXECUTIVE DIRECTOR OF MENDOTA AREA SENIOR SERVICES. MEMBERS OF THE COLLABORATIVE TEAM BY NAME, AFFILIATIONS, TITLE AND EXPERTISE ARE LISTED IN APPENDIX 1 OF THE 2019 CHNA.
Schedule H, Part V, Section B, Line 6a Facility , 1 Facility , 1 - MENDOTA COMMUNITY HOSPITAL DBA OSF SAINT PAUL MEDICAL CENTER - MENDOTA, IL. THE COMMUNITY HEALTH NEEDS ASSESSMENT FOR 2019 FOR LASALLE COUNTY WAS A COLLABORATIVE UNDERTAKING BY OTTAWA REGIONAL HOSPITAL AND HEALTHCARE CENTER DBA OSF SAINT ELIZABETH MEDICAL CENTER AND MENDOTA COMMUNITY HOSPITAL DBA OSF SAINT PAUL MEDICAL CENTER. THE CHNA HIGHLIGHTS THE HEALTH NEEDS AND WELL-BEING OF RESIDENTS IN LASALLE COUNTY.
Schedule H, Part V, Section B, Line 11 Facility , 1 Facility , 1 - MENDOTA COMMUNITY HOSPITAL. MENDOTA COMMUNITY HOSPITAL DBA OSF SAINT PAUL MEDICAL CENTER COMPLETED A COMMUNITY HEALTH NEEDS ASSESSMENT ("CHNA") DURING FISCAL YEAR 2019 AS REQUIRED BY INTERNAL REVENUE CODE SECTION 501(R)(3). THE FINAL CHNA FOR THE HOSPITAL WAS APPROVED AND ADOPTED BY THE SYSTEM'S BOARD OF DIRECTORS ON JULY 29, 2019. THIS CHNA IS EFFECTIVE FOR FISCAL YEARS 2020, 2021 AND 2022. THE LASALLE COUNTY CHNA WAS DONE AS A COLLABORATIVE UNDERTAKING BY OSF SAINT ELIZABETH AND OSF SAINT PAUL MEDICAL CENTERS TO HIGHLIGHT THE HEALTH NEEDS AND WELL BEING OF RESIDENTS IN LASALLE COUNTY. THE COLLABORATIVE TEAM IDENTIFIED THE FOLLOWING SIGNIFICANT COMMUNITY HEALTH NEEDS AS A PRIORITY: HEALTHY BEHAVIORS AND BEHAVIORAL HEALTH. IN RESPONSE TO THESE PRIORITY HEALTH NEEDS, THE HOSPITALS DEVELOPED AN IMPLEMENTATION STRATEGY DESCRIBING THE ACTIONS THE HOSPITALS INTEND TO TAKE TO ADDRESS BOTH PRIORITY HEALTH NEEDS, THE RESOURCES THE HOSPITALS PLAN TO COMMIT TO ADDRESS THE HEALTH NEEDS, AND ANY PLANNED COLLABORATIONS WITH OTHER ORGANIZATIONS TO ADDRESS THE HEALTH NEEDS. THE HOSPITALS REVIEW THEIR IMPLEMENTATION STRATEGY AT LEAST ANNUALLY AND MAKE REVISIONS AS NEEDED TO MAXIMIZE THE IMPACT ON IDENTIFIED PRIORITY HEALTH NEEDS. A SUMMARY OF HOW THE HOSPITALS HAVE ADDRESSED THE PRIORITY HEALTH NEEDS IS PROVIDED BELOW. HEALTHY BEHAVIORS DEFINED AS - ACTIVE LIVING, HEALTHY EATING AND OBESITY GOALS ACTIVE LIVING - A HEALTHY LIFESTYLE, COMPRISED OF REGULAR PHYSICAL ACTIVITY, HAS BEEN SHOWN TO INCREASE PHYSICAL, MENTAL, AND EMOTIONAL WELL-BEING. GOAL 1: INCREASE ACTIVE LIVING IN LASALLE COUNTY OVER THE NEXT THREE YEARS AS EVIDENCED BY THE COMMUNITY HEALTH NEEDS ASSESSMENT SURVEY. OUTCOME METRIC: INCREASE ACTIVE LIVING IN LASALLE COUNTY BY INCREASING THE NUMBER OF RESPONDENTS EXERCISING (HEALTHY ACTIVITY) 1 - 5 TIMES PER WEEK FROM 60% TO 62% AND DECREASING THOSE REPORTING THEY DO NOT EXERCISE AT ALL FROM 28% TO 25%. BASELINE: NOTED FROM THE MOST CURRENT CHNA SURVEY THAT 28% OF RESPONDENTS INDICATED THAT THEY DO NOT EXERCISE AT ALL AND 60% OF RESPONDENTS INDICATED THAT THEY EXERCISE BETWEEN 1 - 5 TIMES PER WEEK. TACTICS AND PROGRESS FOR FY 2020 (1) PROMOTE THE USE OF BIKE ROUTES/WALKING PATHS IN MENDOTA, OTTAWA AND STREATOR PROGRESS FY 2020 - THE LIVE WELL STREATOR ACTIVITY MAPS POSTED ON OUR WEBSITE. IT HAS BEEN PROMOTED ON THE LIVE WELL STREATOR FACEBOOK PAGE AND WAS HANDED OUT AT OUR 3/11/20 MOVE YOUR WAY KICKOFF EVENT AT THE STREATOR BUSINESS INCUBATOR. MENDOTA - BIKE PATH PROMOTED ON MARQUEE. OTTAWA - NO PROGRESS DUE TO COVID. (2) INCREASE OFFERING OF THE HEALTHY KIDS U PROGRAM PROGRESS FY 2020 - DUE TO COVID THIS PROGRAM WAS CANCELLED. (3) IMPLEMENT JOURNEY TO HEALTH - REDESIGNED PROGRAM. PROGRESS FY 2020 - DUE TO COVID THIS PROGRAM WAS CANCELLED. HEALTHY EATING - A HEALTHY LIFESTYLE, COMPRISED OF A PROPER DIET, HAS BEEN SHOWN TO INCREASE PHYSICAL, MENTAL, AND EMOTIONAL WELL-BEING. OBESITY - A HEALTH OUTCOME, WHICH IS DIRECTLY RELATED TO HEALTHY BEHAVIORS. GOAL 2: INCREASE COMMUNITY CONSUMPTION OF FRUITS/VEGETABLES TO MORE THAN 2 SERVINGS PER DAY. OUTCOME METRIC 2: INCREASE THE RATE FROM 44% TO 48% OF THE COMMUNITY THAT REPORTED THAT THEY CONSUME MORE THAN 2 SERVINGS OF FRUITS/VEGETABLES PER DAY ON THE 2022 CHNA SURVEY. BASELINE: PER THE 2019 CHNA, 44% OF THE COMMUNITY REPORTED THAT THEY CONSUME MORE THAN 2 SERVICES OF FRUITS/VEGETABLES PER DAY. TACTICS AND PROGRESS FOR FY 2020 (1) PROMOTE AWARENESS OF COMMUNITY GARDENS AT OSF HEALTHCARE, OTTAWA COMMUNITY GARDENS, SHS EDIBLE GARDEN, NORTHLAWN JR. HIGH SCHOOL GARDEN AND THE DISTRIBUTION LOCATIONS TO ADDRESS LOCAL FOOD DISPARITIES AND ACCESS TO HEALTHY FOODS. PROGRESS FY2020 - STREATOR - 1030.5LBS WENT TO STREATOR LAND FOOD PANTRY, NEW BEGINNINGS FOOD PANTRY AND GRACE CHURCH FOOD PANTRY. STREATOR LAND COMMUNITY FOOD GARDEN 562 POUNDS DONATED BY STREATOR FFA. OTTAWA - 180LBS AND GAVE THEM TO A SERVANT'S HEART. MENDOTA - 736.07LBS. (2) INCREASE OFFERINGS OF THE HEALTHY KIDS U PROGRAM. HOST A HEALTHY KIDS U SESSION QUARTERLY PROGRESS FY2020 - DUE TO COVID THIS PROGRAM WAS CANCELLED. (3) DEVELOP AND PROMOTE LIVE WELL STREATOR HEALTH EATING RESTAURANT MENU GUIDE THE LIVE WELL STREATOR RESTAURANT GUIDE HAS BEEN DEVELOPED. THE LIVE WELL STREATOR HEALTHY EATING ACTION TEAM HAD A VIRTUAL MEETING ON 9/16/20 AND IDENTIFIED 7 STREATOR RESTAURANTS THAT ARE WILLING TO WORK WITH US TO DEVELOP HEALTHY MENU OPTIONS. (4) CONDUCT THE ILLINOIS JR. CHEF'S COOKING SCHOOL IN THREE COMMUNITIES PROGRESS FY2020 - DUE TO THE COVID-19 PANDEMIC, THE UNIVERSITY OF ILLINOIS EXTENSION JUNIOR CHEF PROGRAM WAS CANCELLED IN STREATOR. (5) PROMOTE HEALTHIER SCHOOL LUNCHROOM ENVIRONMENTS PROGRESS FY2020 - DUE TO THE COVID-19 PANDEMIC, OUR APRIL 2020 FRUIT AND VEGGIE TASTE TESTINGS AT KIMES & CENTENNIAL SCHOOLS IN STREATOR WERE CANCELLED. ON 7/30/20, ELLEN VOGEL SPOKE ABOUT LIVE WELL STREATOR TO A GROUP OF TEACHERS AND SCHOOL FOODSERVICE EMPLOYEES ON THE UNIVERSITY OF ILLINOIS EXTENSIONS'S SERVE IT SAFELY VIRTUAL TRAINING CALL. (6) KING CAREAVAN CLIENT NUTRITION EDUCATION AND FOOD DEMONSTRATIONS WITHIN OSF SERVICE AREA THROUGH MOBILE KING CARE A VAN SERVICE. PROGRESS FY2020 - COOKING DEMOS AT FOOD PANTRY. NOV 2019 AT STREATOR SALVATION ARMY. MARCH 2020 AT GRACE COMMUNITY CHURCH FOOD PANTRY IN STREATOR. MARCH 2020 AT BUREAU COUNTY FOOD PANTRY IN PRINCETON. BEHAVIORAL HEALTH MENTAL HEALTH - THE CHNA SURVEY ASKED RESPONDENTS TO INDICATE PREVALENCE OF SPECIFIC MENTAL-HEALTH ISSUES, NAMELY DEPARESSION AND STRESS/ANXIETY. OF RESPONDENTS, 41% INDICATED THEY FELT DEPRESSED IN THE LAST 30 DAYS AND 39% INDICATED THEY FELT ANXIOUS OR STRESSED. GOAL1: INCREASE THE OVERALL COMMUNITY UNDERSTANDING OF MENTAL HEALTH NEEDS AND ACCESS TO MENTAL HEALTH SERVICES. OUTCOME METRIC 1: DECREASE SELF-REPORTS OF DEPRESSION AND ANXIETY TO SEE A REDUCTION OF INDIVIDUALS REPORTING DEPRESSION AND ANXIETY WITHIN THE LAST 30 DAYS FROM 35% TO 32% BY 2022. (PER CHNA SURVEY, 2019) TACTICS FOR PROGRESS IN 2020 (1) CONDUCT MENTAL HEALTH FIRST AID TRAINING, GROUPS/PROGRAMS FOR BEHAVIORAL/MENTAL HEALTH FOR SPECIFIC AGES FROM YOUTH, 18-35 AND SENIOR. PROGRESS FY2020 - DUE TO COVID THIS TRAINING WAS CANCELLED. (2) EMBED BILINGUAL BEHAVIORAL HEALTH PROVIDER AT OSF MULTI-SPECIALTY GROUP MENDOTA, BILINGUAL PROGRAMMING'S AND COMMUNICATIONS. PROGRESS FY2020 - DELAYED DUE TO COVID. (3) ENGAGE FAITH COMMUNITY NURSE TO WORK WITH SCHOOL NURSES REGARDING STUDENTS NOT HAVING MEDICATIONS NEEDED PROGRESS FY2020 - DELAYED DUE TO STAFF TURNOVER. (4) PROVIDE FREE ACCESS TO DIGITAL BEHAVIORAL HEALTH SOLUTION - SILVERCLOUD PROGRESS FY2020 - 104 UTILIZING APP. (5) PROVIDE FREE BEHAVIORAL HEALTH NAVIGATION SERVICE PROGRESS FY2020 - 9 USING SERVICE. GOAL 2: USE SOCIAL DETERMINATES OF HEALTH (SDOH) TO IDENTIFY PATIENTS AT INCREASED RISK OF POOR MENTAL HEALTH AND CONNECT THEM TO COMMUNITY ORGANIZATIONS IN ORDER TO IMPROVE MENTAL HEALTH OUTCOMES. OUTCOME MEASURE 2: DECREASE THE PERCENTAGE OF RESPONDENTS STATING THEY HAVE POOR OVERALL MENTAL HEALTH BY 1%. BASELINE: PER THE 2019 CHNA SURVEY, 8% OF RESPONDENTS STATED THEY HAVE POOR OVERALL MENTAL HEALTH. NOT HAVING BASIC HUMAN NEEDS IS LIKELY LINKED TO POOR MENTAL HEALTH. IF A SURVEY RESPONDENT DOES NOT HAVE HOUSING, FOOD, TRANSPORTATION (ETC.), THEIR OVERALL STATE OF MENTAL HEALTH WOULD LIKELY BE RATED LOWER. TACTICS FOR PROGRESS IN 2020 (1) IMPLEMENT SCREENING OF PATIENTS FOR SDOH. SCREEN AND CONNECT. NUMBER OF PATIENTS SCREENED. PROGRESS FY2020 - DUE TO COVID PROGRAM WAS DELAYED IN ROLLOUT. (2) TRACK NUMBER OF PATIENTS REFERRED TO COMMUNITY BASED ORGANIZATIONS (CBO) PROGRESS FY2020 - DUE TO COVID PROGRAM WAS DELAYED IN ROLLOUT. (3) TRACK NUMBER OF MISSION PARTNERS EDUCATED FOR CONTINUED ROLL-OUT PROGRESS FY2020 - DUE TO COVID PROGRAM WAS DELAYED IN ROLLOUT. (4) TRACK NUMBER OF PATIENT REFERRALS TO OSF CARE MANAGEMENT AND SOCIAL WORKERS PROGRESS FY2020 - DUE TO COVID PROGRAM WAS DELAYED IN ROLLOUT. SUBSTANCE ABUSE - DATA FROM THE 2018 ILLINOIS YOUTH SURVEY MEASURES ILLEGAL SUBSTANCE USE (ALCOHOL, TOBACCO, AND OTHER DRUGS - MAINLY MARIHUANA) AMONG ADOLESCENTS. GOAL: IMPROVE COMMUNITY COMPLIANCE WITH PROPER DRUG DISPOSAL PROCESSES TO DECREASE AVAILABILITY OF PRESCRIPTION AND NON-PRESCRIPTION DRUGS UTILIZED FOR SUBSTANCE ABUSE. OUTCOME MEASURE: INCREASE THE POUNDS OF DRUGS COLLECTED THROUGH THE RX DISPOSAL PROGRAM BY 10%. BASELINE - 96 POUNDS OF DRUGS REMOVED FROM HFMC DRUG DISPOSAL RECEPTACLE (2019 ACTUAL REPORTED AMOUNT) TACTICS FOR PROGRESS IN 2020 (1) PROVIDE TESTIMONIALS ON HOW SUBSTANCE USE AFFECTS LIVES IN TARGET SCHOOLS THROUGHOUT COMMUNITIES. PROGRESS FY2020 - DUE TO COVID THIS WAS CANCELLED. (2) PROVIDE EDUCATION ON SUBSTANCE USE IN TARGET SCHOOLS THROUGHOUT COMMUNITIES. PROGRESS FY2020 -PROGRAM WORKED WITH YOUTH ON VAPING, INTRO TO MENTAL HEALTH, TEAMWORK AND HANDLING ANXIETY. THE PROGRAM HAD 199 7TH GRADE AND 211 8TH GRADE STUDENTS.
Schedule H, Part V, Section B, Line 13 Facility , 1 Facility , 1 - MENDOTA COMMUNITY HOSPITAL. CATASTROPHIC FINANCIAL ASSISTANCE IS AVAILABLE WHEN CHARGES EXCEED 25% OF ANNUAL FAMILY INCOME. THE AMOUNT BILLED IS ADJUSTED TO 25% OF FAMILY INCOME WHEN OSF DETERMINES THIS ADJUSTMENT IS THE MOST GENERAL ASSISTANCE.
Schedule H, Part V, Section B, Line 13 Facility , 1 Facility , 1 - MENDOTA COMMUNITY HOSPITAL. PRESUMPTIVE FINANCIAL ASSISTANCE IS AVAILABLE AND PROVIDES FOR A DISCOUNT OF 100% OF BILLED CHARGES FOR MEDICALLY NECESSARY SERVICES PROVIDED TO A PATIENT WITH NO INSURANCE BENEFITS, WHEN THE PATIENT ESTABLISHES FINANCIAL NEED AT TIME OF REGISTRATION BY SATISFYING ONE OF THE FOLLOWING CATEGORIES OF PRESUMPTIVE ELIGIBILITY CRITERIA: HOMELESSNESS; DECEASED WITH NO ESTATE; MENTAL INCAPACITATION WITH NO ONE TO ACT ON THE PATIENT'S BEHALF; AND CURRENT MEDICAID ELIGIBILITY, BUT NOT ON DATE OF SERVICE OR FOR NON-COVERED SERVICE. IN ADDITION, ENROLLMENT IN ANY ONE OF THE FOLLOWING PROGRAMS WITH CRITERIA AT OR BELOW 200% OF THE FEDERAL POVERTY INCOME GUIDELINES ESTABLISHES ELIGIBILITY FOR PRESUMPTIVE CHARITY: WIC; SNAP; LIHEAP, IL FREE LUNCH AND BREAKFAST PROGRAM; RECEIPT OF GRANT ASSISTANCE FOR MEDICAL SERVICES; OR ENROLLMENT IN AN ORGANIZED COMMUNITY BASED PROGRAM PROVIDING ACCESS TO MEDICAL CARE THAT ASSESSES AND DOCUMENTS LIMITED LOW INCOME FINANCIAL STATUS AS CRITERION FOR MEMBERSHIP.
Schedule H, Part V, Section B, Line 15 Facility , 1 Facility , 1 - MENDOTA COMMUNITY HOSPITAL. THE FINANCIAL ASSISTANCE POLICY DIRECTS PATIENTS TO STAFF IN THE PATIENT FINANCIAL SERVICES AND ADMITTING AREAS AT OSF HOSPITALS FOR ASSISTANCE IN OBTAINING ANSWERS TO QUESTIONS REGARDING THE POLICY. A NEW FINANCIAL ASSISTANCE POLICY CAME OUT NOVEMBER 2020 AFTER FISCAL YEAR END. USE THE LINKS ASSOCIATED WITH THIS RETURN TO FIND FINANCIAL ASSISTANCE POLICY EFFECTIVE FOR FY2020.
Schedule H, Part V, Section B, Line 16 Facility , 1 Facility , 1 - MENDOTA COMMUNITY HOSPITAL. A PLAIN LANGUAGE SUMMARY OF THE FAP IS OFFERED TO PATIENTS AS PART OF THE INTAKE OR DISCHARGE PROCESS, INFORMATION ABOUT FINANCIAL ASSISTANCE AND THE APPLICATION PROCESS IS INCLUDED ON OR WITH THE OSF PATIENT BILLING STATEMENT, AND OSF PROVIDES COPIES OF THE PLAIN LANGUAGE SUMMARY AND THE FAP APPLICATION FORM TO REFERRING STAFF PHYSICIANS.
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
Schedule H (Form 990) 2019
Schedule H (Form 990) 2019
Page 9
Part VFacility Information (continued)

Section D. Other Health Care Facilities That Are Not Licensed, Registered, or Similarly Recognized as a Hospital Facility
(list in order of size, from largest to smallest)
How many non-hospital health care facilities did the organization operate during the tax year?0
Name and address Type of Facility (describe)
1
2
3
4
5
6
7
8
9
10
Schedule H (Form 990) 2019
Schedule H (Form 990) 2019
Page 10
Part VI
Supplemental Information
Provide the following information.
1 Required descriptions. Provide the descriptions required for Part I, lines 3c, 6a, and 7; Part II and Part III, lines 2, 3, 4, 8 and 9b.
2 Needs assessment. Describe how the organization assesses the health care needs of the communities it serves, in addition to any CHNAs 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.
Form and Line Reference Explanation
Schedule H, Part I, Line 3c Criteria for Free or Discounted Care CATASTROPHIC CHARITY ASSISTANCE REGARDLESS OF INCOME OR ASSET LEVELS FOR MEDICALLY NECESSARY SERVICES WHICH EXCEED 25% OF ANNUAL FAMILY INCOME. THE AMOUNT DUE IS ADJUSTED TO 25% OF FAMILY INCOME WHEN OSF DETERMINES CATASTROPHIC CHARITY IS MORE GENEROUS. PRESUMPTIVE CHARITY: CHARGES MAY BE ADJUSTED TO PROVIDE FOR A CHARITY DISCOUNT OF 100% OF BILLED CHARGES FOR MEDICALLY NECESSARY SERVICES PROVIDED TO AN UNINSURED PATIENT WHO ESTABLISHES FINANCIAL NEED AT TIME OF REGISTRATION BY SATISFYING ONE OF THE FOLLOWING CATEGORIES OF PRESUMPTIVE ELIGIBILITY CRITERIA. PRESUMPTIVE CHARITY CATEGORIES FOR ALL OSF HOSPITALS: -HOMELESSNESS; - DECEASED WITH NO ESTATE; - MENTAL INCAPACITATION WITH NO ONE TO ACT ON PATIENT'S BEHALF; OR - CURRENT MEDICAID ELIGIBILITY, BUT NOT ON DATE OF SERVICE OR FOR NON-COVERED SERVICE. ALL PATIENTS RECEIVE THE GREATEST REQUESTED DISCOUNT AVAILABLE UNDER ANY OF THE OSF PROGRAMS. NO ASSET TESTS ARE USED. EXCEPT AS OTHERWISE NOTED, THESE POLICIES APPLY BOTH TO UNINSURED PATIENTS AND TO INSURED PATIENTS WITH RESPECT TO THE PATIENT RESPONSIBILITY AMOUNT.
Schedule H, Part I Coronavirus Pandemic On March 11, 2020, the World Health Organization designated COVID-19 as a global pandemic. Patient volumes and the related revenues for most our services were significantly impacted in the last two weeks of the second quarter of the fiscal year 2020 and continued to be impacted in the third and forth quarters of 2020. Various policies were implemented by federal, state, and local governments in response to the COVID-19 pandemic that have caused many people to remain at home and forced the closure of or limitations on certain businesses, as well as suspended elective surgical procedures by healthcare facilities. While some of these restrictions have been eased across the U.S. and most states have lifted moratoriums on non-emergent procedures, some restrictions remain in place, and some state and local governments are re-imposing certain restrictions due to increasing rates of COVID-19 cases. Patient volumes and revenues experienced gradual improvement beginning in May and continuing through the end of the fiscal year.
Schedule H, Part I, Line 7g Subsidized Health Services Costs reported on Line 7G do not include Physician Clinic costs. These costs Reflect a hospital department that is eligible to be claimed but had not been claimed in past returns.
Schedule H, Part I, Line 7 Costing Methodology used to calculate financial assistance Medicare Cost to Charge Ratio
Schedule H, Part III, Line 2 Bad debt expense - methodology used to estimate amount IN GENERAL, AND IN ACCORDANCE WITH MEDICARE REGULATIONS, PATIENT ACCOUNT BALANCES ARE WRITTEN OFF TO BAD DEBT EXPENSE AFTER REASONABLE COLLECTION EFFORTS HAVE BEEN EXHAUSTED AND THE ACCOUNT HAS BEEN SENT TO A COLLECTION AGENCY OR LAW FIRM. PATIENTS' ACCOUNTS RECEIVABLE ARE REDUCED BY AN ALLOWANCE FOR UNCOLLECTIBLE ACCOUNTS. IN EVALUATING THE COLLECTABILITY OF PATIENTS' ACCOUNTS RECEIVABLE, OSF ANALYZES PAST HISTORY AND IDENTIFIES TRENDS FOR EACH OF ITS MAJOR PAYER SOURCES OF REVENUE TO ESTIMATE THE APPROPRIATE ALLOWANCE FOR UNCOLLECTIBLE ACCOUNTS AND PROVISION FOR BAD DEBTS. MANAGEMENT REGULARLY REVIEWS DATA ABOUT THESE MAJOR PAYER SOURCES OF REVENUE IN EVALUATING THE SUFFICIENCY OF THE ALLOWANCE FOR DOUBTFUL ACCOUNTS. FOR RECEIVABLES ASSOCIATED WITH SERVICES PROVIDED TO PATIENTS WHO HAVE THIRD-PARTY COVERAGE, OSF ANALYZES CONTRACTUALLY DUE AMOUNTS AND PROVIDES AN ALLOWANCE FOR DOUBTFUL ACCOUNTS AND A PROVISION FOR BAD DEBTS, IF NECESSARY. FOR RECEIVABLES ASSOCIATED WITH PATIENT RESPONSIBILITY (WHICH INCLUDES BOTH PATIENTS WITHOUT INSURANCE AND PATIENTS WITH DEDUCTIBLE AND CO-PAYMENT BALANCES DUE FOR WHICH THIRD-PARTY COVERAGE EXISTS FOR PART OF THE BILL), THE PATIENTS ARE SCREENED AGAINST THE OSF FINANCIAL ASSISTANCE POLICY AND UNINSURED DISCOUNT POLICY. FOR ANY REMAINING PATIENT RESPONSIBILITY BALANCE, OSF RECORDS A PROVISION FOR BAD DEBTS IN THE PERIOD OF SERVICE ON THE BASIS OF ITS PAST EXPERIENCE, WHICH INDICATES THAT MANY PATIENTS ARE UNABLE OR UNWILLING TO PAY THE PORTION OF THEIR BILL FOR WHICH THEY ARE FINANCIALLY RESPONSIBLE. THE DIFFERENCE BETWEEN THE STANDARD RATES (OR THE DISCOUNTED RATES IF NEGOTIATED) AND THE AMOUNTS ACTUALLY COLLECTED AFTER ALL REASONABLE COLLECTION EFFORTS HAVE BEEN EXHAUSTED IS CHARGED OFF AGAINST THE ALLOWANCE FOR DOUBTFUL ACCOUNTS. BAD DEBT EXPENSE OF 1,186,015 ON FORM 990, PART IX, LINE 24B IS BASED UPON ACCRUAL ACCOUNTING REQUIRED BY GENERALLY ACCEPTED ACCOUNTING PRINCIPLES. THIS AMOUNT CONSEQUENTLY DIFFERS FROM THE BAD DEBT EXPENSE OF 499,998 ON SCHEDULE H, PART III, LINE 2 WHICH REQUIRES THE ORGANIZATION TO REPORT AGGREGATE BAD DEBT AT COST. BAD DEBT EXPENSE REPORTED ON PART III, LINE 2 IS THEREFORE CALCULATED BY MULTIPLYING GROSS CHARGES WRITTEN OFF TO BAD DEBT EXPENSE TIMES THE MEDICARE COST-TO-CHARGE RATIO DERIVED FROM THE MEDICARE COST REPORT. DISCOUNTS, INCLUDING ANY APPLICABLE THIRD PARTY PAYER CONTRACTUAL ALLOWANCES AND ANY CHARITY CARE DISCOUNTS (VALUED AT GROSS CHARGES), ARE APPLIED TO PATIENT ACCOUNT GROSS CHARGES TO DETERMINE THE ACCOUNT BALANCE BEFORE PATIENT PAYMENTS. THE AGGREGATE AMOUNT OF ALL PATIENT PAYMENTS IS THEN APPLIED TO THE ACCOUNT BALANCE. WHEN DETERMINATION IS MADE THAT NO FURTHER AMOUNTS CAN BE COLLECTED IN ACCORDANCE WITH THE CORPORATION'S BAD DEBT POLICY, THE REMAINING BALANCE IS WRITTEN OFF TO BAD DEBT EXPENSE. PRESUMPTIVE CHARITY: CHARGES MAY BE ADJUSTED TO PROVIDE FOR A CHARITY DISCOUNT OF 100% OF BILLED CHARGES FOR MEDICALLY NECESSARY SERVICES PROVIDED TO AN UNINSURED PATIENT WHO ESTABLISHES FINANCIAL NEED AT TIME OF REGISTRATION BY SATISFYING ONE OF THE FOLLOWING CATEGORIES OF PRESUMPTIVE ELIGIBILITY CRITERIA. PRESUMPTIVE CHARITY CATEGORIES FOR ALL OSF HOSPITALS: -HOMELESSNESS; -DECEASED WITH NO ESTATE; -MENTAL INCAPACITATION WITH NO ONE TO ACT ON PATIENT'S BEHALF; OR -CURRENT MEDICAID ELIGIBILITY, BUT NOT ON DATE OF SERVICE OR FOR NON-COVERED SERVICE. THEREFORE, THE CORPORATION DOES NOT BELIEVE THAT BAD DEBT EXPENSE REPORTED ON PART III, LINE 2 INCLUDES ANY AMOUNTS THAT REASONABLY COULD BE ATTRIBUTABLE TO PATIENTS WHO WOULD LIKELY QUALIFY UNDER THE CORPORATION'S FINANCIAL ASSISTANCE POLICY.
Schedule H, Part III, Line 4 Bad debt expense - financial statement footnote PLEASE SEE PAGE 19 OF NOTES TO CONSOLIDATED FINANCIAL STATEMENTS
Schedule H, Part III, Line 8 Community benefit & methodology for determining medicare costs OSF IS COMMITTED TO SERVING PATIENTS, REGARDLESS OF ABILITY TO PAY OR IF THE PAYMENTS TO BE RECEIVED WILL BE LESS THAN THE COST TO PROVIDE THE SERVICE, WHICH IS THE CASE FOR MEDICARE AND MEDICAID PATIENTS. THE MEDICARE ALLOWABLE COSTS ON LINE 6 PART III HAVE BEEN CALCULATED BY USING THE MEDICARE COST TO CHARGE RATIO. THE AMOUNT IS COMPARED TO TOTAL MEDICARE PAYMENTS RECEIVED INCLUDING DSH AND IME PAYMENTS. SHOULD THERE BE A SHORTFALL, IT WOULD BE TREATED AS A COMMUNITY BENEFIT SINCE IT REFLECTS UN-REIMBURSED COSTS FOR PROVIDING MEDICAL SERVICES TO THE MEDICARE RESIDENTS OF THE COMMUNITY.
Schedule H, Part III, Line 9b Collection practices for patients eligible for financial assistance THE CORPORATION HAS A FAIR BILLING/COLLECTION POLICY WHICH APPLIES FOR ALL PATIENTS. THE POLICY INCLUDES: -REQUIRED INFORMATION PROVIDED IN BILLS TO PATIENTS (INCLUDING A REQUIREMENT THAT INFORMATION BE PROVIDED ON HOW THE PATIENT MAY APPLY FOR FINANCIAL ASSISTANCE). -PROCESS FOR PATIENTS TO INQUIRE ABOUT OR DISPUTE A BILL, INCLUDING TOLL-FREE TELEPHONE NUMBER, ADDRESS, CONTACT NAME AND E-MAIL ADDRESS. -REQUIREMENTS FOR TIMELY RESPONSE TO PATIENT INQUIRIES. -CONDITIONS WHICH MUST BE SATISFIED BEFORE PATIENT MAY BE SENT TO A COLLECTION AGENCY OR ATTORNEY. -LEGAL ACTION FOR NON-PAYMENT OF A PATIENT BILL MAY NOT BE INITIATED UNTIL AN AUTHORIZED HOSPITAL OFFICIAL HAS DETERMINED THAT ALL CONDITIONS IN THE CORPORATION'S POLICY (INCLUDING ALL THE FOREGOING POLICY PROVISIONS) HAVE BEEN SATISFIED FOR INITIATING LEGAL ACTION. -LEGAL ACTION MAY NOT BE PURSUED AGAINST UNINSURED PATIENTS WHO HAVE CLEARLY DEMONSTRATED THAT THEY HAVE NEITHER SUFFICIENT INCOME NOR ASSETS TO MEET THEIR FINANCIAL OBLIGATIONS - EVEN IF SUCH PATIENTS DO NOT APPLY FOR FINANCIAL ASSISTANCE. -THE CORPORATION SHALL NOT ENGAGE IN ANY EXTRAORDINARY COLLECTION ACTIONS, SUCH AS SUBMITTING REPORTS TO CREDIT AGENCIES BEFORE REASONABLE ATTEMPTS TO DETERMINE ELIGIBILITY FOR FINANCIAL ASSISTANCE HAVE BEEN COMPLETED. -IF A PATIENT RECEIVES AN APPLICATION FOR FINANCIAL ASSISTANCE BUT FAILS TO RETURN IT, OSF WILL TRY TO USE SECONDARY SOURCES TO DETERMINE THE PATIENT'S ELIGIBILITY FOR NON COMPLIANT CHARITY BEFORE PURSUING LEGAL ACTION FOR NONPAYMENT. IF A COMPLETE APPLICATION IS RECEIVED DURING THE APPLICATION PERIOD, OSF WILL SUSPEND EXTRAORDINARY COLLECTION ACTIONS AND MAKE A DETERMINATION OF ELIGIBILITY FOR ASSISTANCE. IF THE PATIENT IS ELIGIBLE FOR FINANCIAL ASSISTANCE, OSF WILL ISSUE APPROPRIATE REFUNDS AND REVERSE ANY EXTRAORDINARY COLLECTION ACTIONS TAKEN, AS MORE FULLY DESCRIBED IN THE OSF FAIR BILLING - COLLECTION POLICY.
Schedule H, Part V, Section B, Line 16a FAP website - MENDOTA COMMUNITY HOSPITAL: Line 16a URL: https://www.osfhealthcare.org/billing/financial-assistance/;
Schedule H, Part V, Section B, Line 16b FAP Application website - MENDOTA COMMUNITY HOSPITAL: Line 16b URL: https://www.osfhealthcare.org/billing/financial-assistance/;
Schedule H, Part V, Section B, Line 16c FAP plain language summary website - MENDOTA COMMUNITY HOSPITAL: Line 16c URL: https://www.osfhealthcare.org/billing/financial-assistance/;
Schedule H, Part VI, Line 2 Needs assessment MENDOTA COMMUNITY HOSPITAL DBA OSF SAINT PAUL MEDICAL CENTER COMPLETED A COMMUNITY HEALTH NEEDS ASSESSMENT ("CHNA") DURING FISCAL YEAR 2019 AS PREVIOUSLY STATED. THE CHNA IS UPDATED EVERY 3 YEARS AND CORRESPONDING IMPLEMENTATION STRATEGY IS REFRESHED YEARLY. NOT ONLY DOES THE PLAN GET REFRESHED YEARLY, BUT EACH ACTION ITEM HAS A RESPONSIBLE PARTY INVOLVED TO GET THE WORK ASSOCIATED WITH THE NEED ACCOMPLISHED. THE NEW CHNA WAS APPROVED AND ADOPTED BY THE OSF BOARD OF DIRECTORS ON JULY 29, 2019 AND THE CORRESPONDING IMPLEMENTATION STRATEGY WAS APPROVED JANUARY 27, 2020. THE ASSOCIATED PLAN GOALS AND ACCOMPLISHMENTS ARE LISTED IN THIS YEARS FILING. LEADERSHIP WITHIN OSF SIT ON VARIOUS COMMUNITY ADVISORY BOARDS TO STAY CONNECTED TO THE OTHER AGENCIES WITHIN THE COMMUNITY. THIS WORK ALIGNS WITH OUR MISSION STATEMENT TO SERVE PERSONS WITH THE GREATEST CARE AND LOVE IN A COMMUNITY THAT CELEBRATES THE GIFT OF LIFE.
Schedule H, Part VI, Line 3 Patient education of eligibility for assistance THE CORPORATION INFORMS AND EDUCATES PATIENTS AND PERSONS WHO ARE BILLED FOR PATIENT CARE ABOUT THEIR ELIGIBILITY FOR ASSISTANCE UNDER GOVERNMENT PROGRAMS AND THE CORPORATION'S FINANCIAL ASSISTANCE POLICY, IN ENGLISH AND IN ANY OTHER LANGUAGE SPOKEN BY POPULATIONS WITH LIMITED ENGLISH PROFICIENCY THAT CONSTITUTE THE LESSER OF 1,000 INDIVIDUALS OR 5% OF THE COMMUNITY OF THE HOSPITAL, IN THE FOLLOWING WAYS: -SIGNS ARE POSTED IN PATIENT REGISTRATION AREAS (INCLUDING EMERGENCY DEPARTMENT REGISTRATION) INFORMING PATIENTS OF THE AVAILABILITY OF FINANCIAL ASSISTANCE, THE AVAILABILITY OF FINANCIAL ASSISTANCE COUNSELORS, AND HOW TO OBTAIN A COPY OF THE OSF FINANCIAL ASSISTANCE POLICY AND APPLICATION. -A PLAIN LANGUAGE SUMMARY OF THE OSF FINANCIAL ASSISTANCE POLICY IS OFFERED TO PATIENTS AS PART OF THE INTAKE OR DISCHARGE PROCESS AND INCLUDED IN THE BILLING STATEMENT MAILED PRIOR TO INITIATING EXTRAORDINARY COLLECTION ACTIONS. IN ADDITION, THE PLAIN LANGUAGE SUMMARY AND APPLICATION ARE PROVIDED TO REFERRING STAFF PHYSICIANS. -OSF MAKES REASONABLE EFFORTS TO ORALLY NOTIFY PATIENTS ABOUT THE FINANCIAL ASSISTANCE POLICY AND HOW TO OBTAIN ASSISTANCE IN APPLYING. -A NOTICE OF AVAILABILITY OF THE CORPORATION'S FINANCIAL ASSISTANCE AND UNINSURED PATIENT DISCOUNT POLICIES IS PROMINENTLY AVAILABLE ON THE CORPORATION'S WEBSITE. THE APPLICATION FORM WITH INSTRUCTIONS AND THE PLAIN LANGUAGE SUMMARY IS AVAILABLE FOR DOWNLOAD. -A NOTE REGARDING THE AVAILABILITY OF FINANCIAL ASSISTANCE (TOGETHER WITH CONTACT PHONE NUMBERS) APPEARS ON EVERY PATIENT BILLING STATEMENT AS WELL AS THE WEBSITE WHERE COPIES OF THE POLICY, APPLICATION AND PLAIN LANGUAGE SUMMARY MAY BE OBTAINED. -FINANCIAL ASSISTANCE COUNSELORS ARE AVAILABLE IN PERSON AND BY PHONE TO ASSIST PATIENTS IN COMPLETING THE FINANCIAL ASSISTANCE APPLICATION AND IN DETERMINING ELIGIBILITY AND APPLYING FOR GOVERNMENT PROGRAM BENEFITS, INCLUDING MEDICAID. -THE CORPORATION'S FINANCIAL ASSISTANCE POLICY IS FILED WITH THE ILLINOIS ATTORNEY GENERAL AND IS AVAILABLE TO THE PUBLIC.
Schedule H, Part VI, Line 4 Community information MENDOTA COMMUNITY HOSPITAL DBA OSF SAINT PAUL MEDICAL CENTER IS LOCATED IN LASALLE COUNTY. THE OSF SAINT PAUL MEDICAL CENTER SERVICE COMMUNITY IS LOCATED PRIMARILY IN LASALLE COUNTY BUT EXTENDS INTO PORTIONS OF LEE, BUREAU, AND DEKALB COUNTIES. THE RACE AND ETHNICITY MAKEUP OF THE SERVICE AREA INDICATES THAT MORE THAN 12.6% OF THE POPULATION IS OF HISPANIC ORIGIN. OTHER RACE AND ETHNICITY NUMBERS ARE TYPICAL OF RURAL ILLINOIS. THERE ARE NO LARGE CHANGES IN THE PROFILE OVER THE PAST FIVE YEARS. THE POVERTY RATE FOR LASALLE COUNTY WAS 13.6 PERCENT IN 2017. THE POPULATION USED FOR THE CALCULATION WAS 110,067 YIELDING 14,969 RESIDENTS LIVING IN POVERTY IN THE LASALLE COUNTY AREA. DATA FROM THE LAST CENSUS INDICATE THE POPULATION OF LASALLE COUNTY HAS SLIGHTLY DECREASED (2.1%) BETWEEN 2013 AND 2017. THE POPULATION IN LASALLE COUNTY HAS DECREASED FROM 112,424 IN 2013 TO 110,067 IN 2017.
Schedule H, Part VI, Line 5 Promotion of community health MENDOTA COMMUNITY HOSPITAL DBA OSF SAINT PAUL MEDICAL CENTER SPONSORING ORGANIZATION IS A RELIGIOUS CONGREGATION OF THE ROMAN CATHOLIC CHURCH KNOWN AS THE SISTERS OF THE THIRD ORDER OF ST. FRANCIS. IN ACCORDANCE WITH CANON LAW OF THE ROMAN CATHOLIC CHURCH AND FEDERAL TAX LAW APPLICABLE TO SUPPORTING ORGANIZATIONS, A MAJORITY OF THE MEMBERS OF THE BOARD OF DIRECTORS OF THE CORPORATION ARE PROFESSED MEMBERS OF THE SPONSORING RELIGIOUS CONGREGATION. THEY HAVE A COMMUNITY ADVISORY BOARD CONSISTING OF MEMBERS OF THE COMMUNITY WHO ARE NOT DIRECTORS, OFFICERS, OR CONTRACTORS OF ORHHC. EXCEPT FOR HOSPITAL DEPARTMENTS WHICH HAVE BEEN CLOSED, OR IN WHICH CLINICAL PRIVILEGES HAVE BEEN RESTRICTED, FOR CLINICAL OR QUALITY OF CARE REASONS BY ACTIONS OF THE HOSPITAL'S MEDICAL STAFF AND THE BOARD OF DIRECTORS, ORHHC EXTENDS MEDICAL STAFF PRIVILEGES TO ALL QUALIFIED PHYSICIANS IN ITS COMMUNITIES. THE ORHHC'S SURPLUS FUNDS WERE USED DURING ITS FISCAL YEAR ENDED SEPTEMBER 30, 2019 FOR IMPROVEMENTS IN PATIENT CARE, MEDICAL EDUCATION, AND RESEARCH. THEY MEET THE REQUIREMENTS OF REVENUE RULING 69-545 BY: -OPERATING AN EMERGENCY DEPARTMENT WHICH IS STAFFED 24 HOURS PER DAY BY QUALIFIED PHYSICIANS AND OTHER MEDICAL PERSONNEL AND WHICH IS OPEN TO ALL PERSONS WITHOUT REGARD TO ABILITY TO PAY. -HAVING MEDICAL STAFFS WHICH ARE OPEN TO ALL QUALIFIED PHYSICIANS, MID-LEVEL PROVIDERS, PODIATRISTS, AND DENTISTS IN THE COMMUNITY (EXCEPT WHERE RESTRICTED IN RARE CASES FOR CLINICAL QUALITY REASONS BY ACTION OF THE MEDICAL STAFF AND THE BOARD OF DIRECTORS). -ACCEPTING MEDICARE, MEDICAID AND OTHER GOVERNMENT PROGRAM PATIENTS. -ACCEPTING ALL PATIENTS, INCLUDING UNINSURED PATIENTS, WITHOUT REGARD TO THEIR ABILITY TO PAY. -USING SURPLUS FUNDS TO IMPROVE THEIR FACILITIES, EQUIPMENT, PATIENT CARE, MEDICAL TRAINING, EDUCATION, AND RESEARCH AS DESCRIBED ABOVE.
Schedule H, Part VI, Line 6 Affiliated health care system The Corporation is part of an affiliated health care system (the "OSF System"), which is an integrated health system that operates acute care hospitals, home health care services, two colleges of nursing, a medical training simulation center, emergency medical transportation, and other health care facilities in Illinois and Michigan. The OSF System includes many other entities which are controlled, directly or indirectly by the Sisters of the Third Order of St. Francis (the "Congregation"). All affiliated entities apply and follow the charity care policies of the Corporation and are operated in furtherance of the mission to provide comprehensive, integrated quality care to the communities served by the Corporation. The OSF System's corporate office in Peoria, Illinois (the "Corporate Office"), provides corporate management services as well as direction, consultation and assistance to the administration of the OSF System's health care facilities and subsidiary corporations. The primary affiliated corporations of the OSF System are the following: The Congregation, which works exclusively in the health care apostolate, holds the assets of the religious congregation and directs all other corporations in the affiliated health care system through board representation and the exercise of reserved powers. OSF Multi-Specialty Group was incorporated in 2011. Virtually all physicians and advance practice providers providing professional services through the OSF System's acute care hospital facilities and ambulatory practice settings (with a few limited exceptions) provide services pursuant to employment agreements or professional service agreements with the Multi-Specialty Group. OSF Medical Group is a d/b/a of Multi-Specialty Group. Pointcore, Inc., formerly known as OSF Saint Francis, Inc., was originally incorporated in 1986 and is engaged in the following lines of business: retail pharmacies, retail shops, a mobile medical system, durable medical equipment, home therapeutics, real estate, equipment technology services, telecommunications, electronic health records, telehealth services, and consulting services. Pointcore, Inc. also participates in various health related joint ventures. OSF Healthcare Foundation was incorporated in 1989 to conduct fundraising and other activities for the benefit of OSF Healthcare System and in support of the mission of the Congregation. Ottawa Regional Hospital & Healthcare Center, formerly known as Community Hospital of Ottawa was incorporated in 1964. OSF Healthcare System became the sole member of Ottawa Regional Hospital & Healthcare Center in 2012, and the hospital was renamed as d/b/a/ OSF Saint Elizabeth Medical Center. Mendota Community Hospital, formerly known as Mendota Hospital Foundation, was incorporated in 1944. OSF Healthcare System became the sole member of Mendota Community Hospital in 2015, and the hospital was renamed as d/b/a/ OSF Saint Paul Medical Center.
Schedule H, Part VI, Line 7 State filing of community benefit report IL
Schedule H (Form 990) 2019
Additional Data


Software ID: 19010655
Software Version: 2019v5.0
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" on Form 990, Part IV, line 23.
SchJMediumBullet Attach to Form 990.
SchJMediumBullet Go to www.irs.gov/Form990 for instructions and the latest information.
OMB No. 1545-0047
2019
Open to Public Inspection
Name of the organization
Mendota Community Hospital
 
Employer identification number

36-2167785
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 on 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 on Line 1a are checked, did the organization follow a written policy regarding payment or reimbursement or provision of all of the expenses described above? If "No," complete Part III to explain .........
1b
Yes
 
2
Did the organization require substantiation prior to reimbursing or allowing expenses incurred by all
directors, trustees, officers, including the CEO/Executive Director, regarding the items checked on Line 1a? ..
2
Yes
 
3
Indicate which, if any, of the following the filing organization used to establish the compensation of the
organization's CEO/Executive Director. Check all that apply. Do not check any boxes for methods
used by a related organization to establish compensation of the CEO/Executive Director, but explain in Part III.
4
During the year, did any person listed on 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
Yes
 
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), 501(c)(4), and 501(c)(29) organizations must complete lines 5-9.
5
For persons listed on 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," on line 5a or 5b, describe in Part III.
6
For persons listed on 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," on line 6a or 6b, describe in Part III.
7
For persons listed on Form 990, Part VII, Section A, line 1a, did the organization provide any nonfixed
payments not described in lines 5 and 6? If "Yes," describe in Part III ............
7
 
No
8
Were any amounts reported on Form 990, Part VII, paid or accured pursuant to a contract that was
subject to the initial contract exception described in Regulations section 53.4958-4(a)(3)? If "Yes," describe
in Part III ..........................
8
 
No
9
If "Yes" on line 8, did the organization also follow the rebuttable presumption procedure described in Regulations section 53.4958-6(c)? .........................
9
 
 
For Paperwork Reduction Act Notice, see the Instructions for Form 990.
Cat. No. 50053T
Schedule J (Form 990) 2019

Schedule J (Form 990) 2019
Page 2
Part II
Officers, Directors, Trustees, Key Employees, and Highest Compensated Employees. Use duplicate copies if additional space is needed.
For each individual whose compensation must be reported on 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) for each listed individual must equal the total amount of Form 990, Part VII, Section A, line 1a, applicable column (D) and (E) amounts for that individual.
(A) Name and Title (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 in column (B) reported as deferred on prior Form 990
(i) Base
compensation 		(ii) Bonus & incentive
compensation 		(iii) Other reportable compensation
1Robert C Sehring
 
Vice Chairperson CEO 		(i)

(ii)		 0
-------------
1,323,003 		0
-------------
523,061 		0
-------------
43,683 		0
-------------
38,950 		0
-------------
26,502 		0
-------------
1,955,198 		0
-------------
0
2Gerald J McShane MD
 
Board Member 		(i)

(ii)		 0
-------------
347,761 		0
-------------
30,100 		0
-------------
9,467 		0
-------------
43,313 		0
-------------
22,180 		0
-------------
452,820 		0
-------------
0
3David A Schertz
 
Former - CEO Northern Region 		(i)

(ii)		 0
-------------
0 		0
-------------
0 		0
-------------
585,749 		0
-------------
10,313 		0
-------------
0 		0
-------------
596,062 		0
-------------
34,000
4Mark A Nafziger
 
Chief Ambulatory Care (THROUGH MAR 2020) 		(i)

(ii)		 0
-------------
532,379 		0
-------------
208,420 		0
-------------
11,428 		0
-------------
17,916 		0
-------------
12,826 		0
-------------
782,969 		0
-------------
0
5Michael A Cruz MD
 
Chief Operating Officer 		(i)

(ii)		 0
-------------
686,698 		0
-------------
207,333 		0
-------------
6,259 		0
-------------
43,313 		0
-------------
31,994 		0
-------------
975,597 		0
-------------
0
6Michael M Allen
 
CFO 		(i)

(ii)		 0
-------------
647,679 		0
-------------
228,024 		0
-------------
3,389 		0
-------------
33,741 		0
-------------
31,969 		0
-------------
944,803 		0
-------------
0
7Stephen E Hippler MD
 
Chief Clinical Officer 		(i)

(ii)		 0
-------------
643,962 		0
-------------
187,525 		0
-------------
5,177 		0
-------------
43,530 		0
-------------
31,967 		0
-------------
912,161 		0
-------------
0
8James J Mormann
 
Chief Information Officer 		(i)

(ii)		 0
-------------
605,563 		0
-------------
183,500 		0
-------------
8,895 		0
-------------
37,125 		0
-------------
31,941 		0
-------------
867,024 		0
-------------
0
9Jeffry M Tillery
 
SVP Chief Transformation Officer 		(i)

(ii)		 0
-------------
577,696 		0
-------------
174,750 		0
-------------
4,633 		0
-------------
42,940 		0
-------------
19,774 		0
-------------
819,793 		0
-------------
0
10Robert L Brandfass
 
SVP Chief Legal Officer 		(i)

(ii)		 0
-------------
547,893 		0
-------------
166,852 		0
-------------
10,080 		0
-------------
37,125 		0
-------------
26,877 		0
-------------
788,827 		0
-------------
0
11Michelle D Conger
 
Chief Strategy Officer 		(i)

(ii)		 0
-------------
522,331 		0
-------------
153,514 		0
-------------
10,823 		0
-------------
32,683 		0
-------------
25,593 		0
-------------
744,943 		0
-------------
0
12Ralph R Velazquez MD
 
System Chief Medical Officer 		(i)

(ii)		 0
-------------
508,617 		0
-------------
149,193 		0
-------------
11,287 		0
-------------
43,313 		0
-------------
24,188 		0
-------------
736,597 		0
-------------
0
13Divya-Devi Joshi
 
CEO Children SL (THROUGH FEB 2020) 		(i)

(ii)		 0
-------------
532,817 		0
-------------
162,448 		0
-------------
1,476 		0
-------------
16,063 		0
-------------
9,585 		0
-------------
722,389 		0
-------------
0
14Leon A Yeh MD
 
VP CMO Emergency Serv 		(i)

(ii)		 0
-------------
515,867 		0
-------------
118,302 		0
-------------
12 		0
-------------
35,063 		0
-------------
25,287 		0
-------------
694,530 		0
-------------
0
15Lori L Wiegand
 
Chief Nursing Officer 		(i)

(ii)		 0
-------------
410,214 		0
-------------
121,779 		0
-------------
18,604 		0
-------------
43,313 		0
-------------
19,666 		0
-------------
613,575 		0
-------------
0
16Chad E Boore
 
Chief Executive Officer Eastern Region 		(i)

(ii)		 0
-------------
418,600 		0
-------------
120,927 		0
-------------
8,390 		0
-------------
16,281 		0
-------------
28,178 		0
-------------
592,375 		0
-------------
0
17Roxanna Crosser
 
Chief Executive Officer Western Region 		(i)

(ii)		 0
-------------
394,408 		0
-------------
112,088 		0
-------------
21,295 		0
-------------
32,910 		0
-------------
14,530 		0
-------------
575,232 		0
-------------
0
18Thomas G Hammerton
 
President OSF Healthcare Foundation Chief Development Officer 		(i)

(ii)		 0
-------------
351,548 		0
-------------
106,534 		0
-------------
36,977 		0
-------------
36,886 		0
-------------
29,776 		0
-------------
561,721 		0
-------------
0
19Dwight D Stapleton
 
Vice President Clinical Specialty Services (THROUGH FEB 2020) 		(i)

(ii)		 0
-------------
403,822 		0
-------------
107,108 		0
-------------
79 		0
-------------
18,125 		0
-------------
9,277 		0
-------------
538,411 		0
-------------
0
20John C Horne
 
SVP Chief Supply Chain Officer (THROUGHT NOV 2019) 		(i)

(ii)		 0
-------------
336,114 		0
-------------
109,169 		0
-------------
8,144 		0
-------------
35,151 		0
-------------
22,190 		0
-------------
510,768 		0
-------------
0
21John R Evancho
 
SVP Chief Compliance Officer 		(i)

(ii)		 0
-------------
266,583 		0
-------------
83,176 		0
-------------
8,635 		0
-------------
16,067 		0
-------------
28,078 		0
-------------
402,540 		0
-------------
0
22Kenneth K Potts MD
 
Physician 		(i)

(ii)		 239,898
-------------
0 		0
-------------
0 		247
-------------
0 		10,978
-------------
0 		21,834
-------------
0 		272,957
-------------
0 		0
-------------
0
23Katherine R Riva-Foster MD
 
Physician 		(i)

(ii)		 240,286
-------------
0 		0
-------------
0 		11
-------------
0 		7,304
-------------
0 		8,500
-------------
0 		256,101
-------------
0 		0
-------------
0
24Jane A Battles
 
ADVANCED PRACTICE NURSE 		(i)

(ii)		 126,243
-------------
0 		0
-------------
0 		2,667
-------------
0 		8,492
-------------
0 		18,372
-------------
0 		155,774
-------------
0 		0
-------------
0
Schedule J (Form 990) 2019

Schedule J (Form 990) 2019
Page 3
Part III
Supplemental Information
Provide the information, explanation, or descriptions required for Part I, lines 1a, 1b, 3, 4a, 4b, 4c, 5a, 5b, 6a, 6b, 7, and 8, and for Part II. Also complete this part for any additional information.
Return Reference Explanation
Schedule J, Part I, Line 3 SCH J, PART I, LINE 3 THE BOARD OF DIRECTORS HAS ESTABLISHED A BOARD COMMITTEE KNOWN AS THE HUMAN RESOURCES COMMITTEE WHOSE MEMBERS ARE ALL PROFESSED MEMBERS OF A RELIGIOUS CONGREGATION THAT OWNS OR IS ASSOCIATED WITH THE HEALTHCARE SYSTEM WHO HAVE TAKEN A VOW OF POVERTY. HENCE, THEY DO NOT PERSONALLY BENEFIT FROM DECISIONS OF THE COMMITTEE. THE COMMITTEE DETERMINES WHICH OFFICERS, KEY EMPLOYEES AND OTHER EMPLOYEES ARE ELIGIBLE TO PARTICIPATE IN THE EXECUTIVE COMPENSATION PLAN. BASED ON PERFORMANCE REVIEWS BY THE SUPERVISORS OF SUCH PERSONS, COMPENSATION SURVEY DATA AND RECOMMENDATIONS FROM A NATIONALLY KNOWN INDEPENDENT COMPENSATION CONSULTANT, THE COMMITTEE APPROVES ANY EXECUTIVE COMPENSATION PLAN APPLICABLE TO KEY EMPLOYEES AND ESTABLISHES THE BASE SALARY AND BENEFITS FOR PLAN PARTICIPANTS. PRIOR TO PAYMENT OF ANY BONUS OR INCENTIVE COMPENSATION, THE TOTAL COMPENSATION FOR EACH KEY EMPLOYEE, INCLUDING BASE SALARY, BENEFITS, AND PROPOSED BONUS OR INCENTIVE COMPENSATION, IS AGAIN REVIEWED BY A NATIONALLY RECOGNIZED COMPENSATION CONSULTANT TO ENSURE THAT NO EXCESS BENEFIT AMOUNT IS PAID OR FURNISHED.
Schedule J, Part I, Line 1a Health or social club dues or initiation fees THE CORPORATION REIMBURSES CERTAIN EXECUTIVES FOR SOCIAL CLUB DUES PAID BY SUCH EXECUTIVES. ELIGIBILITY FOR CLUB DUES REIMBURSEMENT IS DETERMINED BY THE HUMAN RESOURCES COMMITTEE OF THE BOARD OF DIRECTORS AND IS TAKEN INTO CONSIDERATION BY THE COMMITTEE IN DETERMINING FAIR MARKET COMPENSATION. SEE FORM 990 - SCHEDULE O - PART VI - LINES 15A AND 15B FOR AN EXPLANATION OF THE ROLE OF THE HUMAN RESOURCES COMMITTEE AND THE MANNER IN WHICH FAIR MARKET COMPENSATION IS DETERMINED. CLUB DUES ARE NOT ELIGIBLE FOR REIMBURSEMENT IF THE CLUB IN QUESTION DISCRIMINATES ON THE BASIS OF RACE, RELIGION, SEX, NATIONAL ORIGIN, OR OTHER PROHIBITED FACTORS. DUES REIMBURSEMENT IS TREATED AND REPORTED AS TAXABLE COMPENSATION.
Schedule J, Part I, Line 4a Severance or change-of-control payment During calendar year 2019, David Schertz received a severance payment in the amount of $585,749.
Schedule J (Form 990) 2019

Additional Data


Software ID: 19010655
Software Version: 2019v5.0
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 990-EZ or to provide any additional information.
MediumBullet Attach to Form 990 or 990-EZ.
MediumBullet Go to www.irs.gov/Form990 for the latest information.
OMB No. 1545-0047
2019
Open to Public
Inspection
Name of the organization
Mendota Community Hospital
 
Employer identification number

36-2167785
Return Reference Explanation
Form 990, Part I, Line 1 PART I THE TAX LAW REQUIRES THAT EACH LEGAL ENTITY WITHIN THE OSF HEALTHCARE SYSTEM COMPLETE A SEPARATE TAX RETURN WHICH APPROPRIATELY REFLECTS THE ACTIVITIES AND FINANCIAL POSITION OF THE PARTICULAR ORGANIZATION. THIS REPORTING, HOWEVER, IS NOT REFLECTIVE OF THE OSF HEALTHCARE SYSTEM AS A WHOLE. PLEASE SEE THE ATTACHED AUDITED FINANCIAL STATEMENTS OF OSF HEALTHCARE SYSTEM AND SUBSIDIARIES FOR A COMPLETE OVERVIEW OF THE SYSTEM.
Form 990, Part VI, Line 6 Classes of members or stockholders OSF HEALTHCARE SYSTEM IS THE SOLE CORPORATE MEMBER OF MENDOTA COMMUNITY HOSPITAL.
Form 990, Part VI, Line 7a Members or stockholders electing members of governing body OSF HEALTHCARE SYSTEM AS A SOLE CORPORATE MEMBER OF MENDOTA COMMUNITY HOSPITAL HAS THE POWER TO ELECT MEMBERS OF THE BOARD.
Form 990, Part VI, Line 7b Decisions requiring approval by members or stockholders RESERVED POWERS: THE FOLLOWING POWERS ARE RESERVED FOR THE MEMBER: A) TO ESTABLISH, APPROVE, OR MODIFY THE PHILOSOPHY, VISION, VALUES, AND MISSION ACCORDING TO WHICH THE CORPORATION OPERATES. (B) TO AMEND THE CORPORATION'S ARTICLES OF INCORPORATION AND BYLAWS. (C) TO APPOINT AND REMOVE, WITH OR WITHOUT CAUSE, THE DIRECTORS OF THE CORPORATION. (D) TO MERGE OR CONSOLIDATE THE CORPORATION WITH OTHER ENTITIES OR TO DISSOLVE THE CORPORATION. (E) TO ACQUIRE AN INTEREST IN AN EXISTING ENTITY OR TO ESTABLISH A NEW ENTITY. (F) TO LEASE, SELL, ENCUMBER OR OTHERWISE ALIENATE ANY REAL PROPERTY OR INTEREST IN REAL PROPERTY OF THE CORPORATION. (G) TO APPROVE ANY TRANSFER, LEASE, SALE OR ENCUMBRANCE OF PERSONAL PROPERTY OF THE CORPORATION EXCEPT IN THE ORDINARY COURSE OF BUSINESS. (H) TO APPROVE ANY BORROWING OR DEBT FINANCING ON BEHALF OF THE CORPORATION. (I) TO APPOINT, DISCIPLINE, TERMINATE AND REMOVE THE CORPORATION'S OPERATING DIVISION PRESIDENT. (J) TO APPOINT AND REMOVE THE CORPORATION'S CHAIRPERSON, VICE CHAIRPERSON(S), CHIEF EXECUTIVE OFFICER, PRESIDENT, SECRETARY, AND TREASURER, AND THE ASSISTANT SECRETARY AND ASSISTANT TREASURER, IF ANY. (K) TO APPROVE OR AMEND STRATEGIC PLANS, MANAGEMENT OBJECTIVES, AND CAPITAL AND OPERATING BUDGETS OF THE CORPORATION. (L) TO APPROVE ANY PURCHASE OR OTHER AQUISITION BY THE CORPORATION THAT IS NOT INCLUDED IN ITS CAPITAL BUDGET AND EXCEEDS ONE MILLION DOLLARS ($1,000,000) PER ITEM. (M) TO NAME OR RENAME ANY HOSPITAL OR MEDICAL CENTER OWNED AND OPERATED BY THE CORPORATION. (N) TO REQUIRE A CERTIFIED AUDIT OF FINANCES OF THE CORPORATION AND TO APPOINT THE CERTIFIED PUBLIC ACCOUNTANT TO PERFORM THE AUDIT. (O) TO APPROVE THE ENGAGEMENT OF AND TO DISMISS ANY OUTSIDE LEGAL COUNSEL TO REPRESENT THE CORPORATION ON A REGULAR BASIS OR IN CONNECTION WITH ANY MATTER DEEMED BY THE MEMBER, IN GOOD FAITH, TO HAVE SIGNIFICANCE FOR THE CORPORATION AS A WHOLE. (P) TO GIVE PRELIMINARY APPROVAL PRIOR TO THE DEVELOPMENT OF, AND TO GIVE FINAL APPROVAL PRIOR TO THE EXECUTION OF, ALL DOCUMENTS TO WHICH THE CORPORATION IS OR WILL BE A PARTY AND WHICH RELATE TO THE CREATION, FORMATION, ORGANIZATION, OR TERMINATION OF ANY OTHER LEGAL ENTITY (WHETHER A CORPORATION, LIMITED LIABILITY COMPANY, PARTNERSHIP, OR ANY OTHER ENTITY) IN WHICH THE CORPORATION WILL HAVE ANY OWNERSHIP INTEREST, MEMBERSHIP INTEREST, POWER TO ELECT OR APPOINT BOARD MEMBERS OR OFFICERS, OR ANY OTHER FORMAL PARTICIPATION ARRANGEMENT, WHETHER ACTING ALONE OR IN CONJUNCTION WITH ANY OTHER PERSON OR ENTITY. (Q) TO TAKE ANY AND ALL ACTIONS DEEMED NECESSARY, IN THE SOLE JUDGEMENT OF THE MEMBER BOARD TO PROTECT AND PRESERVE THE TAX-EXEMPT STATUS AND PUBLIC CHARITY STATUS OF THE CORPORATION OR THE MEMBER AND ANY TAX-EXEMPT AFFILIATE OF THE CORPORATION OR THE MEMBER (INCLUDING FEDERAL AND STATE INCOME TAX EXEMPTIONS, PROPERTY TAX EXEMPTIONS, AND SALES TAX EXEMPTIONS); PROVIDED THE MEMBER BOARD HAS GIVEN A WRITTEN REQUEST TO THE BOARD TO TAKE ACTION OR REFRAIN FROM TAKING ACTION, WHICH WOULD HAVE SUFFICIENTLY PROTECTED AND PRESERVED SUCH TAX-EXEMPT AND PUBLIC CHARITY STATUS, AND THE BOARD HAS FAILED TO PROMPTLY TAKE SUCH ACTION OR REFRAIN FROM TAKING SUCH ACTION.
Form 990, Part VI, Line 9 Interested person not at organization's address BRIAN SILVERSTEIN, M.D. 711 APPLE TREE LANE GLENCOE, IL 60022
Form 990, Part VI, Line 11b Review of form 990 by governing body THE PROPOSED FINAL VERSION OF THE 990 IS SENT VIA E-MAIL TO ALL OFFICERS AND MEMBER OF THE BOARD OF DIRECTORS FOR THEIR REVIEW PRIOR TO FILING. ANY APPROPRIATE CHANGES REQUESTED BY THE OFFICERS AND DIRECTORS ARE THEN INCORPORATED INTO THE FINAL FORM 990 AND ALL SCHEDULES FOR FILING.
Form 990, Part VI, Line 12c Conflict of interest policy DISCLOSURES BY OFFICERS, DIRECTORS AND TRUSTEES, AS WELL AS KEY EMPLOYEES AND EMPLOYEES CHARGED WITH PURCHASING, PROCUREMENT AND CONTRACTION DECISION-MAKING ARE MADE THROUGH AN ELECTRONIC REPORTING SYSTEM ON AN ANNUAL BASIS. DISCLOSURES ARE RECEIVED AND REVIEWED BY THE CORPORATE COMPLIANCE DIVISION ON AN ANNUAL BASIS. IF A POTENTIAL CONFLICT OF INTEREST IS IDENTIFIED, THEN THE DISCLOSING EMPLOYEE IS NOTIFIED OF THE POTENTIAL CONFLICT AND MAY BE ASKED FOR ADDITIONAL INFORMATION. THE CORPORATE COMPLIANCE DIVISION DETERMINES WHETHER A PLAN TO MANAGE A POSSIBLE OR ACTUAL CONFLICT OF INTEREST IS NEEDED, DISCUSSES THE MANGEMENT PLAN WITH THE EMPLOYEE AND MONITORS THE EMPLOYEE'S COMPLIANCE WITH THE PLAN. PLANS TO MANAGE CONFLICTS ARE TRACKED THROUGH THE ELECTRONIC DISCLOSURE SYSTEM.
Form 990, Part VI, Line 15a Process to establish compensation of top management official THE BOARD OF DIRECTORS HAS ESTABLISHED A BOARD COMMITTEE KNOWN AS THE HUMAN RESOURCES COMMITTEE WHOSE MEMBERS ARE ALL PROFESSED MEMBERS OF THE RELIGIOUS CONGREGATION KNOWN AS THE SISTERS OF THE THIRD ORDER OF SAINT FRANCIS WHO HAVE TAKEN A VOW OF POVERTY. HENCE, THEY DO NOT PERSONALLY BENEFIT FROM DECISION OF THE COMMITTEE. THE PERFORMANCE OF THE CEO AND HIS ACHIEVEMENT OF ANNUAL GOALS IS EVALUATED EACH YEAR BY THE FULL BOARD OF DIRECTORS, AND THIS PERFORMANCE REVIEW IS PROVIDED TO THE COMMITEE. THE COMMITEE ALSO OBTAINS COMPENSATION SURVEY DATA AND RECOMMENDATION FROM A NATIONALLY RECOGNIZED INDEPENDENT COMPENSATION CONSULTANT. BASED ON ALL OF THESE FACTORS, THE COMMITTEE SETS BASE SALARY AND BENEFITS OF THE CEO AND APPROVES THE EXECUTIVE COMPENSATION PLAN APPLICABLE TO THE CEO. PRIOR TO PAYMENT OF ANY BONUS OR INCENTIVE COMPENSATION, THE TOTAL COMPENSATION FOR THE CEO, INCLUDING BASE SALARY, BENEFITS, AND PROPOSED BONUS OR INCENTIVE COMPENSATION, IS AGAIN REVEIWED BY A NATIONALLY RECOGNIZED COMPENSATION CONSULTANT TO ENSURE THAT NO EXESS BENEFIT AMOUNT IS PAID OR FURNISHED. THE COMPENSATION REVIEW IS DONE ANNUALLY IN NOVEMBER.
Form 990, Part VI, Line 15b Process to establish compensation of other employees THE BOARD OF DIRECTORS HAS ESTABLISHED A BOARD COMMITTEE KNOWN AS THE HUMAN RESOURCES COMMITTEE WHOSE MEMBERS ARE ALL PROFESSED MEMBER OF THE RELIGIOUS CONGREGATION KNOWN AS THE SISTERS OF THE THIRD ORDER OF SAINT FRANCIS WHO HAVE TAKEN A VOW OF POVERTY. HENCE, THEY DO NOT PERSONALLY BENEFIT FROM DECISIONS OF THE COMMITTEE. THE COMMITTEE DETERMINES WHICH OFFICERS, KEY EMPLOYEES AND OTHER EMPLOYEES ARE ELIGIBLE TO PARTICIPATE IN THE EXECUTIVE COMPENSATION PLAN. BASED ON PERFORMANCE REVIEWS BY THE SUPERVISORS OF SUCH PERSONS AND COMPENSATION SURVEY DATA AND RECOMMENDATIONS FROM A NATIONALLY KNOWN INDEPENDENT COMPENSATION CONSULTANT, THE COMMITTEE APPROVES ANY EXECUTIVE COMPENSATION PLAN APPLICABLE TO KEY EMPLOYEES AND ESTABLISHED THE BASE SALARY AND BENEFITS FOR PLAN PARTICIPANTS. PRIOR TO PAYMENT OF ANY BONUS OR INCENTIVE COMPENSATION, THE TOTAL COMPENSATION FOR EACH KEY EMPLOYEE, INCLUDING BASE SALARY, BENEFITS, AND PROPOSED BONUS OR INCENTIVE COMPENSATION, IS AGAIN REVIEWED BY A NATIONALLY RECOGNIZED COMPENSATION CONSULTANT TO ENSURE THAT NO EXCESS BENEFIT AMOUNT IS PAID OR FURNISHED. THE COMPENSATION REVIEW IS DONE ANNUALLY IN NOVEMBER.
Form 990, Part VI, Line 19 Required documents available to the public THE ORGANIZATION'S GOVERNING DOCUMENTS, CONFLICT OF INTEREST POLICY, AND FINANCIAL STATEMENTS ARE AVAILABLE TO THE PUBLIC UPON REQUEST.
Form 990, Part VIII, Line 11d Other Miscellaneous Revenue Other Revenue - Total Revenue: 48070, Related or Exempt Function Revenue: 45906, Unrelated Business Revenue: 2164, Revenue Excluded from Tax Under Sections 512, 513, or 514: ;
Form 990, Part XI, Line 9 Other changes in net assets or fund balances Inter-company Transfers - -364936; Net assets Released from Restrictions - 37823; Equity Transfers - -527909;
Form 990 Coronavirus Pandemic On March 11, 2020, the World Health Organization designated COVID-19 as a global pandemic. Patient volumes and the related revenues for most our services were significantly impacted in the last two weeks of the second quarter of the fiscal year 2020 and continued to be impacted in the third and forth quarters of 2020. Various policies were implemented by federal, state, and local governments in response to the COVID-19 pandemic that have caused many people to remain at home and forced the closure of or limitations on certain businesses, as well as suspended elective surgical procedures by healthcare facilities. While some of these restrictions have been eased across the U.S. and most states have lifted moratoriums on non-emergent procedures, some restrictions remain in place, and some state and local governments are re-imposing certain restrictions due to increasing rates of COVID-19 cases. Patient volumes and revenues experienced gradual improvement beginning in May and continuing through the end of the fiscal year.
For Paperwork Reduction Act Notice, see the Instructions for Form 990 or 990-EZ.
Cat. No. 51056K
Schedule O (Form 990 or 990-EZ) 2019


Additional Data


Software ID: 19010655
Software Version: 2019v5.0
SCHEDULE R
(Form 990)
Department of the Treasury
Internal Revenue Service
Related Organizations and Unrelated Partnerships
MediumBulletComplete if the organization answered "Yes" on Form 990, Part IV, line 33, 34, 35b, 36, or 37.
MediumBulletAttach to Form 990.
MediumBullet Go to www.irs.gov/Form990 for instructions and the latest information.

OMB No. 1545-0047
2019
Open to Public Inspection
Name of the organization
Mendota Community Hospital
 
Employer identification number

36-2167785
Part I
Identification of Disregarded Entities. Complete if the organization answered "Yes" on Form 990, Part IV, line 33.
(a)
Name, address, and EIN (if applicable) 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 entity?
Yes No
(1)SISTERS OF THE THIRD ORDER OF ST FRANCIS
800 NE GLEN OAK AVE

PEORIA,IL61603
37-1259286 		PARENT/SU ORG IL 501(c)(3) Type II NA
 
 
No
(2)OSF HEALTHCARE FOUNDATION
800 NE GLEN OAK AVE

PEORIA,IL61603
37-1259284 		SUPPORT ORG IL 501(c)(3) Type II SIS 3RD OSF
 
 
No
(3)OTTAWA REGIONAL HOSP & HEALTHCARE CTR
1100 EAST NORRIS DRIVE

OTTAWA,IL61350
36-2604009 		HOSPITAL IL 501(c)(3) 3 OSF
 
 
No
(4)OTTAWA REGIONAL HOSPITAL FOUNDATION
1100 EAST NORRIS DRIVE

OTTAWA,IL61350
36-4007569 		SUPPORT ORG IL 501(c)(3) Type I ORHHC
 
 
No
(5)OSF MULTI-SPECIALTY GROUP
800 NE GLEN OAK AVE

PEORIA,IL61603
38-3852646 		HLTHCARE SVCS IL 501(c)(3) Type I OSF
 
 
No
(6)OSF HEALTHCARE SYSTEM
800 NE GLEN OAK AVE

PEORIA,IL61603
37-0813229 		HOSPITAL IL 501(c)(3) 3 SIS 3RD OSF
 
 
No
(7)OTTAWA REGIONAL HOSPITAL AUXILIARY
1100 EAST NORRIS DRIVE

OTTAWA,IL61350
36-3854788 		SUPPORT ORG IL 501(c)(3) Type I OSF
 
 
No
(8)OSF College of Health Sciences
800 NE Glen Oak Avenue

Peoria,IL61603
36-4868939 		COLLEGE OF NURSING IL 501(c)(3) 2 OSF
 
 
No
For Paperwork Reduction Act Notice, see the Instructions for Form 990.
Cat. No. 50135Y
Schedule R (Form 990) 2019
Schedule R (Form 990) 2019
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
(1) CENTER FOR HEALTH AMBULATORY

8800 RTE 91 N
PEORIA,IL61615
20-5557171 		SURGICAL CENTER IL OSF
  		Related       No   Yes   0 %
(2) EASTLAND MEDICAL PLAZA

1505 EASTLAND DRIVE
Bloomington,IL61701
37-1400643 		SURGICAL CENTER IL OSF
  		Related       No   Yes   0 %
(3) FORT JESSE IMAGING CENTER LLC

2200 FT JESSE ROAD
NORMAL,IL61761
46-0515604 		MEDICAL IMAGING IL OSF
  		Related       No   Yes   0 %
(4) SAINT CLARE'S VILLA

915 EAST 5TH STREET
ALTON,IL62002
37-1397289 		LOW INC HOUSING IL OSF
  		Related       No   Yes   0 %
(5) FOX RIVER CANCER CENTER

1211 STARFISH DRIVE
OTTAWA,IL61350
87-0805865 		ONCOLOGY IL ORHHC
  		Related       No   Yes   0 %




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
 		(i)
Section 512(b)(13) controlled entity?
Yes No
(1) POINTCORE INC

800 NE GLEN OAK AVE
PEORIA,IL61603
36-3484677 		HLTHCARE SVCS IL OSF
  		C Corporation         No
(2) ILLINOIS PATHOLOGST SERVICES LLC

5666 EAST STATE STREET
ROCKFORD,IL61108
80-0439081 		PATHOLOGY SVCS IL OSF
  		C Corporation         No
(3) Lakeview Medical Office Building

812 N Logan Ave
Danville,IL61832
37-1100761 		Condominium Association IL OSF
  		C Corporation         No
(4) SOUTHWEST HEALTH SYSTEMS INC

2800 WEST 95TH STREET
EVERGREEN PARK,IL60805
36-3425830 		HEALTHCARE SERVICES IL OSF
  		C Corporation         No
(5) MARY CAP INSURANCE INC

75 ST PAUL STREET
SUITE 500
BURLINGTON,VT05401
03-0304812 		INSURANCE COMPANY VT OSF
  		C Corporation         No
(6) OSF Aviation LLC

800 Glen Oak Ave
Peoria,IL61603
30-0032408 		Medical transportation IL Pointcore LLC
  		C Corporation         No
(7) OSF Assurance Company

76 St Paul Street
Suite 500
Burlington,VT05401
20-2015375 		Insurance Company VT Pointcore LLC
  		C Corporation         No
Schedule R (Form 990) 2019
Schedule R (Form 990) 2019
Page 3
Part V
Transactions With Related Organizations. Complete if the organization answered "Yes" on Form 990, Part IV, line 34, 35b, or 36.
Note. Complete line 1 if any entity is listed in Parts II, III, or IV of this schedule.
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, or (iv) rent from a controlled entity .....................
1a
 
No
b Gift, grant, or capital contribution to related organization(s) ............................
1b
 
No
c Gift, grant, or capital contribution from related organization(s) ............................
1c
Yes
 
d Loans or loan guarantees to or for related organization(s) ............................
1d
 
No
e Loans or loan guarantees by related organization(s) ............................
1e
 
No
f Dividends from related organization(s) ............................
1f
 
No
g Sale of assets to related organization(s) ............................
1g
 
No
h Purchase of assets from related organization(s) ............................
1h
 
No
i Exchange of assets with related organization(s) ............................
1i
 
No
j Lease of facilities, equipment, or other assets to related organization(s) .......................
1j
Yes
 
k Lease of facilities, equipment, or other assets from related organization(s) ......................
1k
Yes
 
l Performance of services or membership or fundraising solicitations for related organization(s) .....................
1l
Yes
 
m Performance of services or membership or fundraising solicitations by related organization(s) .................
1m
Yes
 
n Sharing of facilities, equipment, mailing lists, or other assets with related organization(s) ...................
1n
Yes
 
o Sharing of paid employees with related organization(s) ............................
1o
Yes
 
p Reimbursement paid to related organization(s) for expenses ............................
1p
Yes
 
q Reimbursement paid by related organization(s) for expenses ............................
1q
 
No
r Other transfer of cash or property to related organization(s) ............................
1r
 
No
s Other transfer of cash or property from related organization(s) ............................
1s
 
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 related organization 		(b)
Transaction
type (a-s) 		(c)
Amount involved 		(d)
Method of determining amount involved





Schedule R (Form 990) 2019
Schedule R (Form 990) 2019
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)
Predominant income (related, unrelated, excluded from tax under sections 512-514)

(e)
Are all partners
section
501(c)(3)
organizations? 		(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 Yes No






























Schedule R (Form 990) 2019
Schedule R (Form 990) 2019
Page 5
Part VII
Supplemental Information
Provide additional information for responses to questions on Schedule R. (see instructions).
Return Reference Explanation
Schedule R (Form 990) 2019

Additional Data


Software ID: 19010655
Software Version: 2019v5.0