| FORM 990, PART VI, SECTION A, LINE 3 |
GREAT RIVER HEALTH SYSTEM BEGAN PROVIDING MANAGEMENT SERVICES TO THE FORT MADISON COMMUNITY HOSPITAL AS OF AUGUST 1, 2018. GREAT RIVER HEALTH SYSTEM BEGAN COMPENSATING JEREMY ALEXANDER DURING THE CALENDAR YEAR ENDED DECEMBER 31, 2018. COMPENSATION FROM GREAT RIVER HEALTH SYSTEM IS INCLUDED IN REPORTABLE COMPENSATION IN PART VII, LINE 1 AND SCHEDULE J, AS APPLICABLE. |
| FORM 990, PART VI, SECTION A, LINE 6 |
GREAT RIVER HEALTH SYSTEM, INC., A RELATED ORGANIZATION AND IOWA NONPROFIT CORPORATION, IS THE SOLE CORPORATE MEMBER OF FORT MADISON COMMUNITY HOSPITAL. |
| FORM 990, PART VI, SECTION A, LINE 7A |
AS THE SOLE MEMBER OF FORT MADISON COMMUNITY HOSPITAL, GREAT RIVER HEALTH SYSTEM, INC. HAS THE EXCLUSIVE POWER TO APPOINT, AFTER NOMINATION OF DIRECTORS FOR ELECTION BY THE CORPORATION'S BOARD, ANY DIRECTOR TO THE CORPORATION'S BOARD. |
| FORM 990, PART VI, SECTION A, LINE 7B |
AS THE SOLE MEMBER OF FORT MADISON COMMUNITY HOSPITAL (FMCH), GREAT RIVER HEALTH SYSTEM, INC. (GRHS) HAS THE EXCLUSIVE POWER TO APPOINT, AFTER NOMINATION OF DIRECTORS FOR ELECTION BY THE CORPORATION'S BOARD, ANY DIRECTOR TO THE CORPORATION'S BOARD. THE BOARD OF DIRECTORS MAY ONLY REMOVE DIRECTORS THAT WERE NOT SELECTED AND APPOINTED BY GRHS. FMCH MUST ALSO RECEIVE CONSENT FROM GRHS' BOARD OF DIRECTORS FOR CERTAIN ACTIONS TO BE TAKEN, SUCH AS ADOPTION OF STRATEGIC PLANS FOR FMCH OR FMCH AFFILIATES; ADOPTION OF OPERATING AND CAPITAL BUDGETS FOR FMCH OR FMCH AFFILIATES; APPROVAL OF INDEBTEDNESS INCURRED BY FMCH OR FMCH AFFILIATES; THE TRANSFER, SALE OR CLOSURE OF ANY FACILITY, DEPARTMENT OR FUNCTION OF FMCH OR FMCH AFFILIATES; ANY AMENDMENT TO THE ARTICLES OR BYLAWS OF FMCH OR FMCH AFFILIATES, ETC. |
| FORM 990, PART VI, SECTION B, LINE 11B |
A COPY OF THE FORM 990 IS REVIEWED BY THE ORGANIZATION'S CONTROLLER AND VICE PRESIDENT OF FINANCE WITH THE EXTERNAL ACCOUNTANTS FOR COMPLETENESS AND ACCURACY PRIOR TO FILING THE FORM 990 WITH THE INTERNAL REVENUE SERVICE. |
| FORM 990, PART VI, SECTION B, LINE 12C |
EACH DIRECTOR, PRINCIPAL OFFICER AND MEMBER OF A COMMITTEE WITH BOARD DELEGATED POWERS ANNUALLY SIGNS A STATEMENT WHICH AFFIRMS THAT SUCH PERSON: 1) HAS RECEIVED A COPY OF THE CONFLICT OF INTEREST POLICY, 2) HAS READ AND UNDERSTANDS THE POLICY, 3) HAS AGREED TO COMPLY WITH THE POLICY, AND 4) UNDERSTANDS THAT THE HOSPITAL IS A CHARITABLE ORGANIZATION AND THAT IN ORDER TO MAINTAIN ITS FEDERAL TAX EXEMPTION IT MUST ENGAGE PRIMARILY IN ACTIVITIES WHICH ACCOMPLISH ONE OR MORE OF ITS TAX-EXEMPT PURPOSES. IN CONNECTION WITH ANY ACTUAL OR POSSIBLE CONFLICTS OF INTEREST, ANY INTERESTED PERSON MUST DISCLOSE THE EXISTENCE AND NATURE OF HIS OR HER FINANCIAL INTEREST TO THE DIRECTORS AND MEMBERS OF COMMITTEES WITH BOARD DELEGATED POWERS CONSIDERING THE PROPOSED TRANSACTION OR ARRANGEMENT. UPON ANY DISCLOSURE OF THE FINANCIAL INTEREST, THE INTERESTED PERSON LEAVES THE BOARD OR COMMITTEE WHILE THE FINANCIAL INTEREST IS DISCUSSED AND VOTED UPON. THE REMAINING BOARD OR COMMITTEE MEMBERS DECIDE IF A CONFLICT OF INTEREST EXISTS. ALL SUCH ACTIONS ARE RECORDED IN THE MINUTES OF THE BOARD OR COMMITTEE MEETING. |
| FORM 990, PART VI, SECTION B, LINE 15 |
THE COMPENSATION COMMITTEE, ACTING ON BEHALF OF THE BOARD OF DIRECTORS, MEETS AT LEAST ANNUALLY TO ASSIST THE BOARD OF DIRECTORS IN FULFILLING ITS OVERSIGHT RESPONSIBILITIES FOR EXECUTIVE COMPENSATION. THE COMPENSATION COMMITTEE REVIEWS COMPENSATION DATA AND RELATED POLICIES AND DETERMINES WHETHER SUCH COMPENSATION IS REASONABLE AND CONSISTENT WITH FAIR MARKET VALUE IN ORDER TO RECOMMEND TO THE FULL BOARD OF DIRECTORS COMPENSATION AMOUNTS FOR APPROVAL. THE COMPENSATION COMMITTEE MAINTAINS DOCUMENTATION, CONSISTENT WITH THE RECORD RETENTION POLICY, OF ITS ACTIVITIES AND THE BASIS FOR ITS DECISIONS. THE COMPENSATION COMMITTEE, ACTING ON BEHALF OF THE BOARD OF DIRECTORS, REVIEWS AND APPROVES COMPENSATION OF PHYSICIANS EMPLOYED OR CONTRACTED BY FMCH OR AN AFFILIATE ANNUALLY. THE COMPENSATION COMMITTEE USES THE MGMA DATA FOR COMPARISON. THE COMPENSATION COMMITTEE MAINTAINS DOCUMENTATION, CONSISTENT WITH THE RECORD RETENTION POLICY, OF ITS ACTIVITIES AND THE BASIS FOR ITS DECISIONS. |
| FORM 990, PART VI, SECTION C, LINE 19 |
THE ORGANIZATION'S GOVERNING DOCUMENTS, CONFLICT OF INTEREST POLICY, AND FINANCIAL STATEMENTS ARE NOT MADE AVAILABLE TO THE PUBLIC. |
| FORM 990, PART XI, LINE 9: |
EQUITY IN SUBSIDIARY EARNINGS 248,772. ADJUSTMENT OF BAD DEBT EXPENSE RECOGNIZED IN FY18 BUT WRITTEN OFF IN FY19 340,000. FAIR MARKET VALUE ADJUSTMENT RELATED TO PROPERTY AND EQUIPMENT ACQUIRED 106,278. CONTRIBUTION PLEDGE EXECUTED TO GRHS-FMCH COMMUNITY HEALTH FOUNDATION 2,000,000. |
| FORM 990, PART IV, LINE 12B & PART XII, LINE 2B & 2C: |
THE ORGANIZATION'S FINANCIAL STATEMENTS ARE AUDITED ON A CONSOLIDATED BASIS BY AN INDEPENDENT ACCOUNTANT. HOWEVER, THE STATEMENTS ARE AUDITED ON A FISCAL YEAR-END OF JUNE 30, 2019, WHILE THE ORGANIZATION'S TAX YEAR-END IS SEPTEMBER 30, 2019. FORT MADISON COMMUNITY HOSPITAL WILL TRANSITION TO A JUNE 30 YEAR-END IN THE NEXT REPORTING PERIOD TO ALIGN WITH ITS NEW AFFILIATES' YEAR-END AND THE CONSOLIDATED AUDITED FINANCIALS REPORTING PERIOD. |
| FORM 990, PART VII, LINE 1A: |
FORT MADISON COMMUNITY HOSPITAL AND FORT MADISON COMMUNITY HOSPITAL FOUNDATION ARE RELATED ENTITIES. AS A RESULT, BOARD OVERLAP EXISTS AMONG THESE ENTITIES AND IT WOULD BE ADMINISTRATIVELY IMPRACTICAL FOR MEMBERS OF THE GOVERNING BOARD AND THE EXECUTIVE TEAM TO BREAKOUT THEIR HOURS DEVOTED AMONG EACH ORGANIZATION. |
Attach to Form 990 or 990-EZ.