2024-11-15T08:24:18-06:00 2023-12-31 410746749 CLIFTONLARSONALLEN LLP 600 WASHINGTON AVENUE SUITE 1800 ST LOUIS MO 63101 990 2023-01-01 361000540 KATHERINE SHAW BETHEA HOSPITAL KATH 8152885531 403 EAST FIRST STREET DIXON IL 61021 AUSTIN FRAZIER JR CFO 8152885531 2024-11-14 1 0 AMBER ROGNAN-HAMILTON P01251012 3149254300 2024-11-04 2023 2024-10-15 13:58:12Z DAVID SCHREINER 403 EAST FIRST STREET DIXON IL 61021 160543012 0 X WWW.KSBHOSPITAL.COM X 1893 IL RESTORE, MAINTAIN, AND ENHANCE HEALTH BY PROVIDING SUPERIOR CARE NOW AND IN THE FUTURE. 10 8 1304 23 64283 0 1348152 1546788 138172133 154006638 281288 527912 1067865 1076930 140869438 157158268 92282 70954 0 0 87355925 88303930 0 0 0 68526099 73233422 155974306 161608306 -15104868 -4450038 109247507 103111013 70096192 68402871 39151315 34708142 TO RESTORE, MAINTAIN, AND ENHANCE HEALTH BY PROVIDING SUPERIOR CARE NOW AND IN THE FUTURE. 0 0 142492098 70954 154006638 IN 2023, KATHERINE SHAW BETHEA HOSPITAL (KSB) HAD 2,718 INPATIENT VISITS AND 242,921 OUTPATIENT VISITS. KSB IS COMMITTED TO PROVIDING THE HIGHEST QUALITY OF HEALTHCARE REGARDLESS OF ABILITY TO PAY. KSB SUBSIDIZES THE COST OF TREATING PATIENTS WHO ARE UNABLE TO PAY AND THOSE WHO RECEIVE GOVERNMENT ASSISTANCE WHERE REIMBURSEMENT IS LIMITED. THE COST OF CHARITY CARE, BASED ON THE HOSPITAL'S COST-TO-CHARGE RATIO, PROVIDED BY THE HOSPITAL, WAS APPROXIMATELY $183,000 IN 2023.KSB PROVIDES 24-HOUR EMERGENCY MEDICAL SERVICES STAFFED BY FULL-TIME PHYSICIANS. PATIENTS ARE TREATED REGARDLESS OF INSURANCE OR ABILITY PAY. ER VISITS IN 2023 WERE 19,644. 142492098 1 1 0 1 0 0 0 0 0 1 1 0 0 0 1 1 0 1 0 0 0 0 0 0 0 0 1 1 1 0 1 0 0 0 0 0 0 1 0 0 0 0 0 0 1 1 1 0 0 1 97 0 1304 1 1 1 0 0 0 0 0 0 0 0 0 0 0 X 10 8 0 0 0 0 0 1 1 1 1 0 0 1 1 1 1 1 1 1 1 0 IL X AUSTIN FRAZIER JR 8152855511 403 EAST FIRST STREET DIXON IL 61021 X LYNETTE KNODLE BOARD MEMBER 2.10 0.00 X 0 0 0 COLLEEN T HENKEL PAST-CHAIRPERSON 1.40 0.00 X 0 0 0 CHRIS HAMMITT VICE-CHAIRPERSON 1.40 0.00 X X 0 0 0 RICK CURIA BOARD MEMBER 0.90 1.00 X 0 0 0 JOSEPH WELTY MD BOARD MEMBER / PHYSICIAN 9.00 0.00 X 147279 0 1620 RAY NEISEWANDER III BOARD MEMBER 0.90 1.00 X 0 0 0 DAVID HELLMICH CHAIRPERSON 1.30 1.00 X X 0 0 0 RICHARD BOYSEN TREASURER 1.40 0.00 X X 0 0 0 PATRICK KING DDS SECRETARY 1.70 0.00 X X 0 0 0 DAVID SCHREINER CEO AND BOARD MEMBER 40.00 1.00 X X 1049137 0 35884 LINDA CLEMEN VP-CHIEF NURSING OFFICER 40.00 0.00 X 268217 0 22486 SUZANNE RAVLIN VP-CHIEF LEGAL OFFICER (TERM ENDED) 40.00 1.00 X 68205 0 0 RAY SHARP VP-CHIEF INFORMATION OFFIC 40.00 0.00 X 266248 0 46090 AUSTIN FRAZIER VP-CHIEF FINANCIAL OFFICER 40.00 2.00 X 352455 0 45640 DREW FENNER VP-CHIEF QUALITY OFFICER 40.00 0.00 X 230386 0 45640 RYAN MILLER VP-CHIEF PEOPLE OFFICER 40.00 2.00 X 234820 0 25580 JOYCE JOHNSON MD MEDICAL STAFF PRESIDENT 40.00 0.00 X 525209 0 5666 MONTHER ELBZOUR MD PHYSICIAN 40.00 0.00 X 2008870 0 40888 SOHAIL HANIF MD PHYSICIAN 40.00 0.00 X 1548486 0 40828 KURT CROWE MD PHYSICIAN 40.00 0.00 X 841860 0 46090 STEPHEN GABRIEL PHYSICIAN 40.00 0.00 X 836174 0 34264 FADI MOHAMAD MUSTAPHA PHYSICIAN 40.00 0.00 X 984230 0 41458 9361576 0 432134 114 0 1 0 ROCKFORD ANESTHESIOLOGISTS ASSOCIATED L 2202 HARLEM RD LOVES PARK IL 61111 ANESTHESIOLOGY 1475327 BROWN CONSTRUCTION CO 200 N WASHINGTON ST MILLEDGEVILLE IL 61051 CONSTRUCTION SERVICES 901025 LAB CORPORATION PO BOX 12140 BURLINGTON NC 27216 LAB TESTING 759416 RSM US LLP 5155 PAYSPHERE CIRCLE CHICAGO IL 60674 CONSULTING SERVICES 509982 HORIZON HEALTH PO BOX 840839 DALLAS TX 75284 BEHAVIORAL HEALTH SERVICES 493204 18 82107 1464681 1546788 NET PATIENT SERVICE REVENUE 621110 153678599 153678599 NET CLINIC SPACE RENTAL 621110 328039 328039 154006638 267069 267069 3645587 3384744 260843 260843 260843 CAFETERIA SALES 900099 528784 64283 464501 INCENTIVE PAYMENT 900099 282133 282133 REVENUE SHARE 900099 166913 166913 99100 99100 1076930 157158268 154006638 64283 1540559 X 68954 68954 2000 2000 3302357 970477 2331880 66843224 66493557 349667 2027602 1503216 524386 11939761 9039185 2900576 4190986 3986084 204902 124331 124331 186160 147118 39042 32124 32124 1350 1350 19567458 15238628 4328830 224392 167353 57039 18884965 17313021 1571944 3810813 2826138 984675 1899735 1016798 882937 137041 121812 15229 205734 162192 43542 883759 590043 293716 6794744 4977166 1817578 3151356 2345591 805765 BAD DEBT EXPENSE 9663108 9663108 IPA/SALES & USE TAX 5789761 4285770 1503991 REPAIRS AND MAINTENANCE 727170 551917 175253 FOOD SUPPLY 714740 533647 181093 434681 363992 70689 161608306 142492098 19116208 0 263292 226456 7469772 2890132 25923697 32752815 1817881 1680102 1376613 1373259 164039236 120320833 47235272 43718403 15962413 13510638 5719400 5116137 3479167 0 1843071 109247507 103111013 50240812 48795615 22019 19855380 17723609 0 1861628 70096192 68402871 X 37871466 34708142 1279849 0 39151315 34708142 109247507 103111013 X -4450038 412628 -405763 X X 0 1 X 1 1 1 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 0 0 0 0 0 0 0 0 1 32124 32124 0 PART II-B, LINE 1: A PORTION OF THE HOSPITAL'S MEMBERSHIP DUES WITH THE ILLINOIS HOSPITAL ASSOCIATION AND THE AMERICAN HOSPITAL ASSOCIATION ARE USED BY THOSE ASSOCIATIONS TO CONDUCT LOBBYING ACTIVITIES ON BEHALF OF ALL MEMBER HOSPITALS. 912774 912774 912772 2 912774 912772 912772 1085170 172398 912772 1043624 41546 1085170 0.00000 0.00000 0.00000 1 0 2289039 2289039 61649114 39129977 22519137 5660750 4767118 893632 93798840 76423738 17375102 641493 641493 43718403 RIGHT OF USE LIABILITIES 1861628 1861628 X PART V, LINE 4: THE PURPOSE OF THE BULK OF THE ENDOWMENT FUND IS TO FUND COMMUNITY WELLNESS PROJECTS FOR THE KSB SERVICE AREA. THE REST OF THE ENDOWMENT, $25,000, WAS ESTABLISHED MANY YEARS AGO AND IS IN AN ACCOUNT WITH OTHER RESTRICTED FUNDS WHICH ALL EARN INTEREST. THE INTEREST ON THIS ENDOWMENT IS INTENDED TO BE USED TO PROVIDE FREE SERVICES TO THE NEEDY. AT THIS TIME, THE BANK GROUPS ALL INTEREST BEARING ACCOUNTS TOGETHER TO DETERMINE INTEREST EARNED AGAINST FEES INCURRED. ANY INTEREST EARNED IS THEN REPORTED IN TOTAL FOR ALL ACCOUNTS ON THE STATEMENT OF REVENUE. THOUGH KSB IS NOT ABLE TO SEPARATELY REPORT THE INTEREST EARNED ON THE ENDOWMENT, THE HOSPITAL HAS SHOWN ON SCHEDULE H THAT THEY PROVIDE MANY FREE SERVICES TO THOSE IN NEED WITH THE FUNDS THEY RECEIVE. DURING THE 2023 TAX YEAR, THE RESTRICTIONS ON THE ENDOWMENT FUNDS WERE RELEASED, AND AS SUCH, THE FUNDS NO LONGER QUALIFY AS AN ENDOWMENT UNDER ASC 958. THE FUNDS WERE UTILIZED FOR OPERATIONS DURING THE 2023 TAX YEAR AND ARE REPORTED AS OTHER EXPENDITURE FOR FACILITIES AND PROGRAMS ON SCHEDULE D. PART X, LINE 2: THE HOSPITAL APPLIES THE INCOME TAX STANDARD FOR UNCERTAIN TAX POSITIONS. THIS STANDARD CLARIFIES THE ACCOUNTING FOR UNCERTAINTY IN INCOME TAXES RECOGNIZED IN AN ORGANIZATION'S FINANCIAL STATEMENTS IN ACCORDANCE WITH THE INCOME TAX STANDARD. THIS STANDARD PRESCRIBES RECOGNITION AND MEASUREMENT OF TAX POSITIONS TAKEN OR EXPECTED TO BE TAKEN ON A TAX RETURN THAT ARE NOT CERTAIN TO BE REALIZED. THE HOSPITAL DOES NOT CURRENTLY INCLUDE AN INCOME TAX PROVISION IN THE CONSOLIDATED FINANCIAL STATEMENTS. MANAGEMENT MONITORS THE REPORTING OF UNCERTAIN TAX POSITIONS, WHICH COULD RESULT IN RECORDING OF AN INCOME TAX PROVISION IN THE FUTURE. 1 1 X 1 X 1 X 1 1 0 0 181928 181928 0.00110 29555928 10117340 19438588 0.12030 950046 950046 0.00590 30687902 10117340 20570562 0.12730 866220 8028 858192 0.00530 2883411 3111286 0 0.00000 11077 28816 0 0.00000 870308 870308 0.00540 87969 21320 66649 0.00040 4718985 3169450 1795149 0.01110 35406887 13286790 22365711 0.13840 1 9663108 2037280 19755034 23337153 -3582119 X 1 1 1 1 KATHERINE SHAW BETHEA HOSPITAL 403 E FIRST STREET DIXON IL 61021 WWW.KSBHOSPITAL.COM 2114484 X X X X KATHERINE SHAW BETHEA HOSPITAL 1 0 0 1 X X X X X X X X X 22 1 0 1 1 X WWW.KSBHOSPITAL.COM/CHNA X X 1 22 1 WWW.KSBHOSPITAL.COM/CHNA 0 1 X 200.000000000000 300.000000000000 X X X X 1 1 X X X X 1 X SEE PART V PAGE 8 X SEE PART V PAGE 8 X SEE PART V PAGE 8 X X X X X 1 X 0 X X X X 1 X 0 0 KATHERINE SHAW BETHEA HOSPITAL PART V, SECTION B, LINE 5: DATA FOR THIS CHNA WAS OBTAINED FROM A VARIETY OF SOURCES, BOTH IN PERSON AND ONLINE. DEMOGRAPHIC DATA AND HEALTH INDICATORS WERE OBTAINED ON FROM THE LEE COUNTY ILLINOIS YOUTH SURVEY 2020; CDC WONDER; ILLINOIS HEALTH AND HOSPITAL ASSOCIATION, COMP DATA; ILLINOIS BEHAVIORAL RISK SURVEY 2020; NATIONAL CENTER FOR HEALTH STATISTICS; AND ILLINOIS SECRETARY OF STATE. POPULATION DATA WAS OBTAINED FROM THE U.S. CENSUS BUREAU WEBSITE AND THEIR AMERICAN COMMUNITY SURVEY TOOL.KSB HOSPITAL PARTNERED WITH THE LEE COUNTY HEALTH DEPARTMENT TO COLLECT DATA FOR THE CHNA. LEE COUNTY HEALTH DEPARTMENT IS COMPLETING THEIR IPLAN FOR 2022. THIS WAS A GREAT COLLABORATION SINCE THE CHNA AND IPLAN ARE VERY SIMILAR ASSESSMENTS FOR LEE COUNTY AND OUR SERVICE AREA.A CHNA SURVEY WAS OPENED TO THE PUBLIC IN JUNE 2022 AND RESPONSES WERE SOLICITED THROUGH SOCIAL MEDIA ACCOUNTS. WE RECEIVED 396 RESPONSES. 5 FOCUS GROUPS WERE ALSO CONDUCTED BY LEE COUNTY HEALTH DEPARTMENT.DATA FROM THESE REPORTS, INTERVIEWS, AND SURVEYS WERE SHARED WITH THE KSB WELLNESS STEERING COMMITTEE TO SOLICIT INPUT AND STIMULATE DISCUSSION OF COMMUNITY HEALTH NEEDS AMONG A COMMITTEE THAT MEETS THROUGHOUT THE YEAR TO DISCUSS WELLNESS INITIATIVES. KATHERINE SHAW BETHEA HOSPITAL PART V, SECTION B, LINE 6B: THE HOSPITAL'S CHNA WAS CONDUCTED WITH THE LEE COUNTY HEALTH DEPARTMENT AND LEE-OGLE TRANSPORTATION SYSTEM KATHERINE SHAW BETHEA HOSPITAL PART V, SECTION B, LINE 7D: KATHERINE SHAW BETHEA HOSPITAL IS A 80 BED RURAL ACUTE CARE HOSPITAL. ITS CHNA IS ALSO PROVIDED TO THE PUBLIC THROUGH SOCIAL MEDIA, INCLUDING BUT NOT LIMITED TO FACEBOOK AND TWITTER. KATHERINE SHAW BETHEA HOSPITAL PART V, SECTION B, LINE 11: TO IDENTIFY AND PRIORITIZE THE NEEDS, WE USED THE HANLON METHOD OF HEALTH PROBLEM PRIORITY SETTING, AND THE PEARL TEST FOR FEASIBILITY. THE HANLON METHOD MEASURES THE SIZE OF THE HEALTH PROBLEM, THE IMPACT OF THE HEALTH PROBLEM, AND THE EFFECTIVENESS OF INTERVENTION. THE SCORING IDENTIFIED THE FOLLOWING THREE KEY PRIORITIES WHICH WILL BECOME THE FOCUS OF IMPLEMENTATION PLANS FROM KSB HOSPITAL DURING THE LIFE OF THIS COMMUNITY HEALTH NEEDS ASSESSMENT:BEHAVIORAL HEALTH (FOCUS ON ANXIETY AND DEPRESSION)HEART DISEASEOBESITY & PHYSICAL INACTIVITYBEHAVIORAL HEALTH:BEHAVIORAL HEALTH HAS BEEN PART OF COMMUNITY HEALTH NEEDS ASSESSMENTS SINCE OUR FIRST PROCESS IN 2013. AT KSB HOSPITAL, WE OFFER BOTH INPATIENT AND OUTPATIENT BEHAVIORAL HEALTH SERVICES. WE ALSO PARTNER WITH STRONG LOCAL PROVIDERS LIKE SINNISSIPPI CENTERS, A MULTI-COUNTY BEHAVIORAL HEALTH AND SUBSTANCE USE DISORDER SERVICE PROVIDER. TOGETHER WE OFFER BEHAVIORAL HEALTH SCREENINGS IN PRIMARY CARE OFFICES AND THE EMERGENCY DEPARTMENT. WE ALSO CREATED THE ROLE OF MENTAL HEALTH CRISIS PREVENTIONIST TO BE TRAINED AND READY TO RESPOND WITH DE-ESCALATION TECHNIQUES AND SUPPORT PATIENT AND STAFF SAFETY.WE HAVE INVESTED IN TELEHEALTH EQUIPMENT, IMPLEMENTING BEHAVIORAL HEALTH PRESCREENING TOOLS. REMOTE TELEHEALTH PROVIDERS HELP ENSURE CONTINUITY OF SERVICES IN OUR COMMUNITY. WE ALSO MADE SIGNIFICANT CAPITAL INVESTMENTS TO IMPROVE PATIENT SAFETY WITHIN THE INPATIENT UNIT.STILL TODAY, SURVEYS INDICATE WIDESPREAD NEED FOR BEHAVIORAL HEALTH SERVICES, ESPECIALLY WITH THE IMPACT OF THE OCVID 19 PANDEMIC. MORE THAN 70% OF SURVEY RESPONDENTS LISTED MENTAL HEALTH ISSUES AS THE NUMBER HEALTH ISSUE IN LEE COUNTY. 60% OF RESPONDENTS INDICATED THAT THEY OR SOMEONE IN THEIR HOUSEHOLD HAD EXPERIENCED ANXIETY IN THE PAST YEAR, AND 55% ANSWERED AFFIRMATIVELY FOR DEPRESSION. FURTHER, 21% LISTED BEING AFFECTED BY POST TRAUMATIC STRESS DISORDER WITH 19% THAT INDICATED THEY HAVE THOUGHT ABOUT OR ATTEMPTED SUICIDE.IMPLEMENTATION PLAN1. HOSTING COMMUNITY EDUCATIONAL EVENT SERIES ON BRAIN HEALTH WITH PRESENTATIONS BY BEHAVIORAL HEALTH EXPERTS TO HELP REDUCE STIGMA AND PROVIDE TIPS ON SUPPORTING POSITIVE BRAIN HEALTH2. WORK WITH PARTNERS TO BRING INTERNATIONAL PRESENTATIONS FOR PROFESSIONALS AND THE COMMUNITY, INCLUDING CEU TRAINING FOR PROFESSIONALS.3. PARTNER WITH OTHER AGENCIES TO BRING MENTAL HEALTH RESOURCES TO SPECIAL INTEREST GROUPS, SUCH AS FARMERS.4. CONTINUE TO WORK WITH COMMUNITY NETWORK ESTABLISHED BY PROJECT OPEN, A COMMUNITY PROJECT OF MEDICAL, BEHAVIORAL HEALTH, PUBLIC HEALTH, EDUCATION, COURT, AND LAW ENFORCEMENT ORGANIZATIONS TO HELP BUILD A NETWORK TO ADDRESS TRAUMA AND PREVENT OPIOID ADDICTION THROUGH AWARENESS, EDUCATION, AND TRAINING5. ENGAGEMENT WITH THIRD-PARTY BEHAVIORAL HEALTH SERVICE LINE OPERATORS TO IMPROVE EFFICIENCY, ADOPT CLINICAL BEST PRACTICES, AND STRENGTHEN OPERATIONAL SUSTAINABILITY OF THE SPECTRUM OF MENTAL HEALTH SERVICES AT KSB6. MONTHLY BRAIN EXERCISE CLASSES TO HELP AGING RESIDENTS BETTER UNDERSTAND BRAIN HEALTH AND HOW THEY CAN PROMOTE PHYSICAL AND MENTAL WELLNESS7. WITHIN THE NEXT THREE YEARS WE WANT TO IMPLEMENT AN INTENSIVE OUTPATIENT PROGRAM (IOP) AT THE HOSPITAL THAT WOULD EXPAND OUR CONTINUUM OF SERVICES AND BE A STEP-DOWN FROM AN INPATIENT HOSPITALIZATION (AND A BRIDGE BETWEEN INPATIENT AND OUTPATIENT TREATMENT).8. WE JUST STARTED A COPING SKILLS GROUP FOR OUTPATIENTS TO INCREASE ACCESS TO SERVICES FOR THE COMMUNITY. WE WANT TO EXPAND AND HAVE OTHER 'STAND-ALONE' GROUPS LIKE THIS: GRIEF AND LOSS GROUP, PARENT TRAINING GROUP9. HAVE COMMUNITY LED GROUP HOSTED HERE: AA AND ALANON10. OUTREACH TO SCHOOLS AND TEACHERS TO PROVIDE SKILLS AND STRATEGIES FOR WORKING WITH BEHAVIORAL HEALTH NEEDS IN STUDENTSHEART DISEASE:BASED ON CDC WONDER DATA, HEART DISEASE IS A CONDITION THAT NEEDS ADDITIONAL ATTENTION. HEART DISEASE IS THE LEADING CAUSE OF DEATH IN LEE COUNTY, AVERAGE ONE HUNDRED DEATHS PER YEAR, WHICH ACCOUNTS FOR 24% OF ALL RESIDENT DEATHS.THE CRUDE DEATH RATE DUE TO HEART DISEASE IS 42% ABOVE THE NATIONAL RATE AND WHEN ADJUSTED FOR AGE IS 14% ABOVE THE NATIONAL RATE. ADDITIONALLY, THE DEATH RATE IS 7.7% HIGHER THAN A DECADE AGO. 19% OF THE COUNTY'S HEART DISEASE DEATHS OCCUR TO AGES UNDER 65 YEARS OF AGE, WITH 40% TO THOSE OVER 85.KSB OFFERS SERVICES FOR CARDIOLOGY, IN ADDITION TO PROVIDING CATH LAB PROCEDURES. CARDIAC REHAB, PHASES TWO & THREE ARE OFFERED AT KSB FOR PATIENTS RECOVERING FROM CARDIAC PROCEDURES. CARDIAC SCORING IS ALSO OFFERED TO THE COMMUNITY WITHOUT A PHYSICIAN REFERRAL.IMPLEMENTATION PLAN1. HOSTING COMMUNITY EDUCATIONAL EVENT SERIES ON HEART HEALTH WITH PRESENTATIONS BY HEALTH PROFESSIONALS TO FOCUS ON PREVENTION AND SCREENINGS.2. USE OF KSB HOSPITAL ADVERTISING SPENDING, SOCIAL MEDIA PRESENCE, AND WEBSITE TO SHARE AND DISSEMINATE INFORMATION ON HEALTH AND WELLNESS SERVICES THAT ARE AVAILABLE WITHIN OUR COMMUNITY3. CONTINUE TO OFFER FREE BLOOD PRESSURE SCREENINGS AT LOCAL PHARMACIES AND GROCERY STORES CONVENIENT TO THE PUBLIC.4. IMPLEMENTATION OF THE HEALTH E INTENT PLATFORM TO PROACTIVELY SCHEDULE PATIENTS FOR AGE-APPROPRIATE SCREENINGSOBESITY & PHYSICAL INACTIVITYAGAIN, IN THE 2022 COMMUNITY HEALTH NEEDS ASSESSMENT, BOTH SURVEY AND HEALTH INDICATOR DATA SHOW THAT RESIDENTS OF LEE COUNTY EXPERIENCE OBESITY OR BEING OVERWEIGHT AT RATES THAT EXCEED STATE AND NATIONAL AVERAGES. SURVEY RESPONSES INDICATE THAT THIS IS THE THIRD MOST UNHEALTHY BEHAVIOR THAT HAS THE GREATEST IMPACT ON THE OVERALL COMMUNITY HEALTH IN LEE COUNTY. 71% OF PEOPLE HAVE PERSONAL OR FAMILY EXPERIENCE WITH BEING OBESE OR OVERWEIGHT. COUNTY HEALTH DATA SHOWS 34.9% OBESITY AND 36.3% OVERWEIGHT, COMPARED TO 31.64% OBESE AND 34.1% OVERWEIGHT AT THE STATE LEVEL.THE INCIDENCE OF OBESE, OVERWEIGHT, OR INACTIVE RESIDENTS PRESENTS SIGNIFICANT HEALTH CHALLENGES, INCLUDING HIGH BLOOD PRESSURE AND CHOLESTEROL, DIABETES, AND MANY OTHER ASSOCIATED CLINICAL ISSUES.KSB WILL CONTINUE TO OFFER AND SUPPORT LOCAL OPPORTUNITIES FOR PHYSICAL ACTIVITY AND EXERCISE. KSB IS A LEAD SPONSOR OF THE ANNUAL REAGAN 5K RUN DURING THE DIXON PETUNIA FESTIVAL, WHICH ALSO INCLUDES THE KSB CORPORATE CHALLENGE FOR EMPLOYER-BASED TEAM COMPETITION.KSB WILL ALSO SPONSOR A NEW TEAM-BASED WEIGHT LOSS COMPETITION CALLED THE HEALTHYWAGE JACKPOT CHALLENGE, WHICH INCLUDES ACCESS TO AN APP WITH SUPPORT, MOTIVATION, AND MINI-CHALLENGES TO ENGAGE TEAM MEMBERS IN HEALTHY WEIGHT LOSS GOALS. KSB IS THE PRESENTING SPONSOR OF THE KSB WELLNESS CENTER EXERCISE FACILITY IN THE DIXON FAMILY YMCA, WITH DONATIONS TO PURCHASE NEW EXERCISE AND WEIGHT EQUIPMENT. KSB CLINICIANS ALSO OFFER A 'PRESCRIPTION' FOR THE DIXON FAMILY YMCA, THE NASH RECREATION CENTER, AND ANYTIME FITNESS, WHICH PROVIDES A FREE TRIAL TO RESIDENTS LOOKING TO START NEW HEALTHY HABITS. A REGISTERED DIETITIAN HOST ONE-ON-ONE NUTRITION AND FITNESS CONSULTATIONS WITH LOCAL PATIENTS. KSB SPONSORED A DISC GOLF SET GIVEAWAY CONJUNCTION WITH THE DIXON CITY MARKET EVENTS.IMPLEMENTATION PLAN1. OFFER RECURRING CLASSES ON EXERCISE TYPES AND NEW TRAINING METHODS TO HELP LOCAL RESIDENTS FIND AN INDIVIDUALIZED WAY TO INCORPORATE PHYSICAL ACTIVITY INTO THEIR LIFE2. SPONSOR THE HEALTHYWAGE JACKPOT CHALLENGE TO PROMOTE TEAM WEIGHT LOSS AND PROVIDE APP-BASED EDUCATION AND SUPPORT3. REACH PATIENTS THROUGH ONE-ON-ONE CONSULTATIONS WITH A REGISTERED DIETITIAN IN A CLINICAL OR COMMUNITY SETTING4. SPONSOR LEARNING FOR EDUCATIONAL SERIES WITH SPECIALIZED SESSIONS FOR NUTRITION, EXERCISE, GOAL-SETTING, AND SEASONAL FOCUS ON NEW YEAR'S RESOLUTIONS, HEALTH DURING THE HOLIDAYS, AND OTHER RELEVANT TOPICS5. ONGOING FINANCIAL COMMITMENT TO THE KSB WELLNESS CENTER AT THE DIXON FAMILY YMCA, AND ENGAGEMENT WITH DIXON PARK DISTRICT PLANS FOR THE CONSTRUCTION OF A NEW COMMUNITY CENTER WITH WELLNESS AND FITNESS SERVICES6. HOSTING WEEKLY FREE BLOOD PRESSURE CHECKS AT LOCAL GROCERY STORE, EXPANDING TO MT. MORRIS7. MONTHLY WELLNESS SCREENINGS FOR CHOLESTEROL AND GLUCOSE KATHERINE SHAW BETHEA HOSPITAL PART V, SECTION B, LINE 13B: STATE REGULATIONS ARE CONSIDERED IN DETERMINING ELIGIBILITY FOR FINANCIAL ASSISTANCE. PART V, LINE 16 C PLAIN LANGUAGE SUMMARY WEBSITE:HTTPS://WWW.KSBHOSPITAL.COM/WORDPRESS2017/WP-CONTENT/UPLOADS/2024/04/FINANCIAL-ASSISTANCE-PLAIN-LANGUAGE_4-2024.PDF PART V, LINE 16 A FINANCIAL ASSISTANCE POLICY WEBSITE:HTTPS://WWW.KSBHOSPITAL.COM/WORDPRESS2017/WP-CONTENT/UPLOADS/2024/04/FINANCIAL-ASSISTANCE-PROGRAM-POLICY_4-2024.PDF PART V, LINE 16 B FINANCIAL ASSISTANCE APPLICATION WEBSITE:HTTPS://WWW.KSBHOSPITAL.COM/WORDPRESS2017/WP-CONTENT/UPLOADS/2024/04/FINANCIAL-ASSISTANCE-APPLICATION_4-2024.PDF 9 1 - COMMERCE TOWERS 215 EAST FIRST STREET DIXON IL 61021 PHYSICIAN CLINIC 2 - TOWN SQUARE CENTER 102 S HENNEPIN AVENUE DIXON IL 61021 PHYSICIAN CLINIC 3 - KSB OREGON CLINIC 1307 WASHINGTON OREGON IL 61061 PHYSICIAN CLINIC 4 - EDWARDS CLINIC 144 NORTH COURT DIXON IL 61021 PHYSICIAN CLINIC 5 - AMBOY CLINIC 305 EAST JOE DRIVE AMBOY IL 61310 PHYSICIAN CLINIC 6 - KSB EYE & VISION CARE 511 PALMYRA STREET DIXON IL 61021 PHYSICIAN CLINIC 7 - POLO CLINIC 1107 SOUTH DIVISION AVENUE POLO IL 61064 PHYSICIAN CLINIC 8 - ASHTON CLINIC 707 S MAIN STREET ASHTON IL 61006 PHYSICIAN CLINIC 9 - PHYSICIANS IMMEDIATE CARE 1672 SOUTH GALENA AVENUE DIXON IL 61021 PHYSICIAN CLINIC PART I, LINE 3C: FINANCIAL ASSISTANCE IS DETERMINED BASED ON FAMILY INCOME, ASSETS AND LIABILITIES, INSURANCE STATUS, AND QUALIFICATION FOR OTHER AVAILABLE ASSISTANCE PROGRAMS. INDIVIDUALS MAY QUALIFY FOR A PRESUMPTIVE DETERMINATION BASED ON HOMELESSNESS, DECEASED WITH NO ESTATE, MENTAL INCAPACITATION WITH NO ONE TO ACT ON THE PATIENT'S BEHALF, MEDICAID ELIGIBILITY, AND INCARCERATION IN A PENAL INSTITUTION. PART I, LINE 7: IT IS KSB HOSPITAL'S POLICY NOT TO WITHHOLD OR DENY ANY REQUIRED MEDICAL CARE AS A RESULT OF A PATIENT'S LACK OF THE ABILITY TO PAY. THE COSTING METHODOLOGY USED TO CALCULATE THE AMOUNTS IN THE ABOVE TABLE WAS DERIVED FROM THE 2023 CALCULATED COST TO CHARGE RATIO USING THE IRS WORKSHEET 2. PART I, LINE 7G: FOR 2023, SUBSIDIZED HEALTH SERVICES INCLUDED A DIABETIC CLINIC AND EMERGENCY MEDICAL SERVICES. PART II, COMMUNITY BUILDING ACTIVITIES: KSB HOSPITAL STRIVES TO BRING THE BEST INTEGRATED, QUALITY, AND COST-EFFECTIVE CARE AND INNOVATIVE TECHNOLOGY TO OUR SERVICE AREA. KSB SUPPORTS OTHER LOCAL NON-PROFITS THROUGH CONTRIBUTIONS OF DOLLARS AND HOURS. WE SUPPORT THE LOCAL ECONOMIC DEVELOPMENT ORGANIZATIONS TO BRING EMPLOYERS AND JOBS TO OUR SERVICE AREA. KSB IS A SUPPORTER OF THE ADOPT-A-ROAD PROGRAM. OUR EMPLOYEES CLEAN UP A STRETCH OF ILLINOIS ROUTE 2 TWICE A YEAR TO HELP IMPROVE AND PRESERVE OUR ENVIRONMENT. KSB SUPPORTS WORKFORCE DEVELOPMENT THROUGH THE JUNIOR ACHIEVEMENT PROGRAM. HOURS AND DOLLARS ARE DONATED TO THIS PROGRAM. KSB ALSO SUPPORTS HABITAT FOR HUMANITY TO PROVIDE AFFORDABLE HOUSING IN OUR SERVICE AREA. MANY OF OUR EMPLOYEES DONATED THEIR OWN TIME TO THIS ORGANIZATION. KSB HAS SUPPORTED HABITAT FOR HUMANITY WITH CASH DONATIONS. PART III, LINE 2: A PATIENT'S ACCOUNT IS WRITTEN OFF TO BAD DEBT AFTER 180 DAYS. ANY PATIENT PAYMENTS AND DISCOUNTS ARE DEDUCTED FROM GROSS CHARGES PRIOR TO THE WRITE-OFF PART III, LINE 3: THIS PORTION OF BAD DEBT IS RELATED TO ACCOUNTS THAY MAY HAVE QUALIFIED FOR THE HOSPITAL'S FINANCIAL ASSISTANCE POLICY. THE METHODOLOGY USED IS BASED ON HISTORICAL INFORMATION. THIS PORTION OF BAD DEBT WOULD HAVE BEEN INCLUDED IN CHARITY CARE HAD THE PATIENT COMPLETED THE NECESSARY PAPERWORK. PART III, LINE 4: FOOTNOTE #2 IS LOCATED ON PAGE 16 OF THE ATTACHED AUDITED FINANCIAL STATEMENTS AND BRIEFLY DESCRIBES THE PROVISION FOR BAD DEBTS RELATED TO UNINSURED PATIENTS. BAD DEBT IS LISTED AS A DEDUCTION FROM REVENUE. THIS TREATEMENT IS CONSISTENT WITH THE HFMA PRINCIPLES AND PRACTICES BOARD STATEMENT NO. 15 AND WITH THE AICPA AUDIT AND ACCOUNTING GUIDE FOR HEALTHCARE ORGANIZATIONS. PART III, LINE 8: KSB HOSPITAL IS A SMALL 80 BED HOSPITAL LOCATED IN RURAL LEE COUNTY IN NORTHERN ILLINOIS. IT WAS ESTIMATED THAT THE POPULATION OF LEE COUNTY WAS 33,848 IN 2022. 21.2% OF THE POPULATION WAS AGE 65 AND OLDER. THE CENSUS BUREAU ESTIMATED THAT 12% OF LEE COUNTY WAS BELOW THE POVERTY LINE. IN 2022, 39.65% OF OUR PAYOR MIX WAS MEDICARE RECIPIENTS. AS A HEALTHCARE PROVIDER WE REALIZE THAT SUBSTANTIAL SHORTFALLS ARISE FROM PAYMENTS THAT ARE LESS THAN WHAT IT COSTS TO PROVIDE CARE OR SERVICE AND DO NOT INCLUDE ANY AMOUNTS THAT RESULT FROM INEFFICIENCIES OR POOR MANAGEMENT. KSB HOSPITAL ACCEPTS ALL MEDICARE PATIENTS KNOWING THAT THERE MAY BE SHORTFALLS, THEREFORE IT HAS TAKEN THE POSITION THAT THEY SHOULD BE COUNTED AS PART OF THE COMMUNITY BENEFIT. ADDITIONALLY, IT IS IMPLIED IN THE INTERNAL REVENUE SERVICE REVENUE RULING 69-545 THAT TREATING MEDICARE PATIENTS IS A COMMUNITY BENEFIT. REVENUE RULING 69-545, WHICH ESTABLISHED THE COMMUNITY BENEFIT STANDARD FOR NON-PROFIT HOSPITALS, STATES THAT IF A HOSPITAL SERVES PATIENTS WITH GOVERNMENTAL HEALTH BENEFITS, INCLUDING MEDICARE, THEN THIS IS AN INDICATION THAT THE HOSPITAL OPERATES TO PROMOTE THE HEALTH OF THE COMMUNITY.BASED ON KSB HOSPITAL'S FILED 2023 MEDICARE COST REPORT THE MEDICARE ALLOWABLE COSTS FOR 2023 WERE $19,930,790 AND PAYMENTS RECEIVED FROM MEDICARE WERE $23,337,153. WE BELIEVE THAT THE SHORTFALL OF $3,406,363 SHOULD BE CONSIDERED COMMUNITY BENEFIT. PART III, LINE 9B: AFTER THREE STATEMENTS (90) DAYS WITH NO PAYMENT FROM PATIENT, THE ACCOUNT IS ELIGIBLE FOR COLLECTION ACCOUNTS UNDER $500 ARE TO BE PAID OFF IN 6 MONTHS AND OVER $500 PAID OFF WITHIN ONE YEAR. ACCOUNTS THAT HAVE BEEN APPROVED FOR FINANCIAL ASSISTANCE ARE NOT SENT TO COLLECTION. PART VI, LINE 2: IN THE 2019 CHNA, WE IDENTIFIED ACCESS TO CARE/TRANSPORTATION AS A KEY PRIORITY AND ENACTED AN IMPLEMENTATION PLAN TO MEET THE NEED. THIS PLAN INCLUDED KSB PARTNERING WITH THE LEE OGLE TRANSPORTATION SERVICE (LOTS) AND PROVIDING TELEHEALTH SERVICES TO ALLEVIATE THE NEED FOR IN OFFICE VISITS. THIS BECAME LESS OF AN ISSUE WITH THE IMPACT OF THE COVID 19 PANDEMIC. WE CONTINUE TO PARTICIPATE IN ACCESS TO CARE EFFORTS. WHILE THERE IS STILL ROOM FOR IMPROVEMENT, KSB WILL REMAIN ENGAGED IN FINDING SOLUTIONS. AS LOW NUMBERS IN THE DATA RESPONDED THAT THIS WAS AN ISSUE; IT WAS NOT SELECTED AMONG THE TOP THREE ITEMS IN THIS YEAR'S CHNA.ADDITIONALLY, WHILE KSB WILL ALSO BE ENGAGED FROM A CLINICAL AND EDUCATIONAL PERSPECTIVE IN TOBACCO USE AND E-CIGARETTE USE, WE DID NOT SCORE THIS IN THE TOP THREE BECAUSE OF THE NUMBER OF OTHER COMMUNITY ORGANIZATIONS WHO ARE SHARING RESPONSIBILITY FOR INTERVENTION IN THIS AREA. THE LEE COUNTY HEALTH DEPARTMENT, LOCAL SCHOOL DISTRICTS, LAW ENFORCEMENT, AND PARENT AND STUDENT ADVOCATES ARE WORKING TO EDUCATE AND PREVENT TOBACCO AND E-CIGARETTE USAGE. KSB WILL PARTICIPATE IN THESE EFFORTS EVEN THOUGH THIS IS NOT ONE OF THE TOP THREE PRIORITIES LISTED IN THIS CHNA.ALSO, WHILE KSB WILL BE ENGAGED FROM A CLINICAL AND EDUCATIONAL PERSPECTIVE IN SUBSTANCE USE DISORDER, WE DID NOT SCORE THIS IN THE TOP THREE BECAUSE OF THE NUMBER OF OTHER COMMUNITY ORGANIZATIONS WHO ARE SHARING RESPONSIBILITY FOR INTERVENTION IN THIS AREA. SINNISSIPPI CENTERS, RECOVERY FAMILY WORKPLACE ILLINOIS, LOCAL SCHOOL DISTRICTS, LAW ENFORCEMENT, LOCAL HEALTH DEPARTMENT AND PARENT AND STUDENT ADVOCATES ARE WORKING TO EDUCATE AND PREVENT SUBSTANCE USE DISORDER. KSB WILL PARTICIPATE IN THESE EFFORTS EVEN THOUGH THIS IS NOT ONE OF THE TOP THREE PRIORITIES LISTED IN THIS CHNA. PART VI, LINE 3: KSB HOSPITAL STRIVES TO EDUCATE OUR PATIENTS OF THEIR ELIGBILITY FOR ASSISTANCE UNDER FEDERAL, STATE, AND LOCAL PROGRAMS. PATIENTS ARE ALSO INFORMED OF OUR CHARITY CARE POLICY. EVERY SELF PAY PATIENT THAT COMES TO THE HSOPITAL IS GIVEN A CHARITY APPLICATION AND OFFERED ASSISTANCE IN HELPING THEM COMPLETE THE APPLICATION. NOTICES ABOUT ASSISTANCE PROGRAMS ARE POSTED IN THE REGISTRATION AREAS AND THE INFORMATION IS ALSO INCLUDED IN THE PATIENT'S STATEMENT AND ON THE KSB WEBSITE. A PATIENT ADVOCATE VISITS EACH INPATIENT WITH A NOTICE OF THEIR INSURANCE BENEFITS AND THEN COUNSELS EACH PATIENT OF ADDITIONAL OPTIONS FOR ASSISTANCE. PART VI, LINE 4: KSB HOSPITAL SERVES LEE COUNTY, A RURAL COUNTY IN NORTHWESTERN ILLINOIS ONE HUNDRED MILES WEST OF CHICAGO AND FORTY-FIVE MILES SOUTHWEST OF ROCKFORD. ACCORDING TO THE U.S. CENSUS BUREAU, THE 2022 POPULATION OF LEE COUNTY WAS ESTIMATED AT 33,848. THE COMMUNITIES OF LEE AND WESTERN OGLE COUNTY COMPRISE THE KSB HOSPITAL PRIMARY SERVICE AREA. THIS AREA SAW A POPULATION DECLINE OF 0.7% BETWEEN 2021 AND 2022, A PERIOD DURING WHICH THE STATE DECLINED BY 0.9%. DIXON IS THE COUNTY SEAT AND THE LARGEST COMMUNITY IN LEE COUNTY WITH AN ESTIMATED POPULATION OF 15,380. LEE COUNTY RACE AND ETHNICITY SHOWS 90.6% WHITE, NOT HISPANIC; 6.4% BLACK; 7.2% HISPANIC OR LATINO; WITH NO OTHER RACE ABOVE 1%. LEE COUNTY COVERS 725 SQUARE MILES. PUBLIC TRANSPORTATION IS AVAILABLE THROUGH THE LEE/OGLE TRANSPORTATION SYSTEM AND PRIVATE CAB COMPANIES. ACCORDING TO THE ILLINOIS DEPARTMENT OF EMPLOYMENT SECURITY, THE 2021 ANNUAL AVERAGE UNEMPLOYMENT RATE FOR LEE COUNTY WAS 4.0%, COMPARABLE TO NORTHWEST ILLINOIS OVERALL AND COMPARABLE TO THE STATE AVERAGE OF 4.6%. WITH A MEDIAN HOUSEHOLD IN INCOME OF $60,542, LEE COUNTY IS LOWER THAN THE STATE AVERAGE OF $78,020. LEE COUNTY PER CAPITA INCOME IS $30,461, BELOW THE STATE AVERAGE OF $39,571. THE PROPORTION OF LEE COUNTY RESIDENTS, 10.7%, LIVING BELOW THE FEDERAL POVERTY LEVEL IS LOWER THAN THE STATE AVERAGE OF 12.1%. UNINSURED (1.5%) AND MEDICAID (20.68%) PATIENTS COMPRISE A TOTAL OF 22.2% OF OUR PAYER MIX FOR 2022. KATHERINE SHAW BETHEA HOSPITAL IS THE SOLE HOSPITAL IN THE COMMUNITY OF DIXON. THE AREA OF DIXON DOES NOT CONTAIN ANY FEDERALLY DESIGNATED MEDICALLY UNDERSERVED AREAS OR POPULATIONS. PART VI, LINE 5: IN ADDITION TO MEDICAL CARE, SOUND LEADERSHIP AND MANAGEMENT ARE CRITICAL PARTS OF ANY GOOD HOSPITAL. AT KSB HOSPITAL, OUR MISSION AND VISION ARE PUT INTO ACTION EVERY DAY BY AN ADMINISTRATIVE TEAM, A BOARD OF DIRECTORS AND THE MEDICAL STAFF. THESE LEADERS OVERSEE THE HOSPITAL'S OPERATIONS AND MAKE VALUES-BASED DECISIONS THAT ARE CONSISTENT WITH OUR MISSION. MOST OF THE BOARD OF DIRECTORS IS COMPRISED OF PERSONS WHO RESIDE IN OUR SERVICE AREA, WHO ARE NEITHER EMPLOYEES NOR INDEPENDENT CONTRACTORS OF THE ORGANIZATION. KSB HAS CLINICS IN 10 LOCATIONS AND THOSE COMMUNITIES ARE WELL REPRESENTED ON THE KSB BOARD. FOR EXAMPLE, COLLEEN HENKLE IS FROM THE AMBOY AREA AND LYNETTE KNODLE WORKS IN OREGON-THESE ARE TWO LOCALES WHERE KSB HAS CLINICS THAT SERVE THOSE COMMUNITIES. OFFERING MORE THAN 60 PHYSICIANS IN A VARIETY OF DISCIPLINES, KSB MEDICAL GROUP ENHANCES HEALTHCARE OPTIONS FOR SAUK VALLEY RESIDENTS. THIS MULTI-SPECIALTY PRACTICE HAS BROUGHT TOGETHER PHYSICIANS WHO ARE NEW TO THE AREA AND THOSE WHO HAVE SPENT AN ENTIRE CAREER IN OUR HOMETOWNS. KSB ALSO EXTENDS AN OPPORTUNITY TO ALL QUALIFIED PHYSICIANS SEEKING PRIVILEGES IN THE SAUK VALLEY SERVICE AREA. KSB UTILIZES ALL SURPLUS FUNDS FOR IMPROVEMENTS IN PATIENT CARE, INNOVATIVE TECHNOLOGY, AND OUR PHYSICAL PROPERTIES. THE LAST YEAR HAS SEEN SIGNIFICANT GROWTH WITHIN AND OUTSIDE THE WALLS OF KSB. IN 2023, WE CONTINUED UPDATING PATIENT ROOMS TO INCLUDE THE LATEST IN TECHNOLOGY AND EQUIPMENT. OUR EDUCATION DEPARTMENT OFFERS A VARIETY OF CLASSES TO EMPLOYEES AND THE PUBLIC. OUR COMMUNITY WELLNESS DEPARTMENT COLLABORATES WITH OTHER COMMUNITY ORGANIZATIONS TO BRING A VARIETY OF HEALTH-RELATED AND WELLNESS PROGRAMS TO THE COMMUNITY. THESE OPPORTUNITIES ARE AN OUTREACH TO THE COMMUNITY THAT ARE FUN AND EDUCATIONAL. A LOOK AROUND AT THE VARIOUS DEPARTMENTS THAT MAKE UP KSB HOSPITAL REVEALS A CONTEMPORARY MEDICAL FACILITY THAT IS PROUD TO OFFER PATIENTS THE FINEST SERVICE POSSIBLE YET IS NEVER CONTENT TO REST ON ITS PAST ACCOMPLISHMENTS. 1 DIXON FAMILY YMCA 110 N GALENA AVENUE DIXON IL 61021 362487927 501(C)(3) 20250 0 GENERAL OPERATING SUPPORT HOME OF HOPE CANCER WELLNESS CENTERS 1637 PLOCK ROAD DIXON IL 61021 010743626 501(C)(3) 15000 0 GENERAL OPERATING SUPPORT SAUK VALLEY COMMUNITY COLLEGE 173 IL-2 DIXON IL 61021 362588599 GOVERNMENT 8313 0 GENERAL OPERATING SUPPORT THE HISTORIC DIXON THEATRE GROUP 93 S HENNEPIN AVE DIXON IL 61021 833904556 501(C)(3) 7500 0 GENERAL OPERATING SUPPORT 4 PART I, LINE 2: GRANTS TO OTHER ORGANIZATIONS ARE NOT MONITORED. X X X X X 0 1 0 0 0 0 0 0 0 MONTHER ELBZOUR MD PHYSICIAN 1895930 0 112940 0 0 0 1230 0 39658 0 2049758 0 0 0 SOHAIL HANIF MD PHYSICIAN 1539059 0 9427 0 0 0 1170 0 39658 0 1589314 0 0 0 DAVID SCHREINER CEO AND BOARD MEMBER 785283 0 475 0 263379 0 1620 0 34264 0 1085021 0 0 0 FADI MOHAMAD MUSTAPHA PHYSICIAN 941667 0 42563 0 0 0 1800 0 39658 0 1025688 0 0 0 KURT CROWE MD PHYSICIAN 781385 0 60475 0 0 0 1800 0 44290 0 887950 0 0 0 STEPHEN GABRIEL PHYSICIAN 741694 0 94480 0 0 0 0 0 34264 0 870438 0 0 0 JOYCE JOHNSON MD MEDICAL STAFF PRESIDENT 240587 0 189622 0 95000 0 5666 0 0 0 530875 0 0 0 AUSTIN FRAZIER VP-CHIEF FINANCIAL OFFICER 336980 0 15475 0 0 0 1350 0 44290 0 398095 0 0 0 RAY SHARP VP-CHIEF INFORMATION OFFIC 265773 0 475 0 0 0 1800 0 44290 0 312338 0 0 0 LINDA CLEMEN VP-CHIEF NURSING OFFICER 267742 0 475 0 0 0 1800 0 20686 0 290703 0 0 0 DREW FENNER VP-CHIEF QUALITY OFFICER 229911 0 475 0 0 0 1350 0 44290 0 276026 0 0 0 RYAN MILLER VP-CHIEF PEOPLE OFFICER 234345 0 475 0 0 0 843 0 24737 0 260400 0 0 0 PART I, LINE 4B DAVID SCHREINER RECEIVED CONTRIBUTIONS TO A SERP PLAN IN THE AMOUNT OF $263,379. KAILE VALDEZ FAMILY MEMBER OF DAVID SCHREINER, CURRENT OFFICER/TRUSTEE 15954 EMPLOYEE COMPENSATION 0 SCHEDULE L, PART IV KSB IS ONE OF THE LARGEST EMPLOYERS IN LEE COUNTY, ILLINOIS AND IT IS VERY COMMON IN LESSER POPULATED RURAL AREAS FOR FAMILY MEMBERS TO WORK AT SUCH A SIGNIFICANT EMPLOYER. FORM 990, PART VI, SECTION A, LINE 1A THE EXECUTIVE COMMITTEE SHALL CONSIST OF THE BOARD CHAIRPERSON AS CHAIRPERSON OF THE COMMITTEE, THE VICE CHAIRPERSON, THE SECRETARY, THE TREASURER AND THE CHIEF EXECUTIVE OFFICER. THE EXECUTIVE COMMITTEE SHALL HAVE THE POWER TO TRANSACT ALL REGULAR BUSINESS OF THE HOSPITAL DURING THE INTERIM BETWEEN BOARD MEETINGS PROVIDED ANY ACTION TAKEN SHALL NOT CONFLICT WITH THE POLICIES AND EXPRESSED WISHES OF THE BOARD. FORM 990, PART VI, SECTION A, LINE 7A BOARD MEMBERS ARE ELECTED BY A MAJORITY VOTE OF THE CITY COUNCIL OF THE CITY OF DIXON, ILLINOIS. IF TWO-THIRDS OR MORE OF THE BOARD POSITIONS ARE VACATED IN ANY ONE YEAR, THE MAYOR OF THE CITY OF DIXON, ILLINOIS, WOULD HAVE THE POWER TO APPOINT ALL BOARD MEMBERS TO FILL SUCH VACANCIES. FORM 990, PART VI, SECTION A, LINE 7B THE MAYOR MAY, BY AND WITH THE CONSENT OF THE CITY COUNCIL, REMOVE ANY DIRECTOR FOR MISCONDUCT OR NEGLECT OF DUTY. FORM 990, PART VI, SECTION B, LINE 11B FULL COMPLETE COPIES OF THE FORM 990 ARE PROVIDED TO THE ENTIRE GOVERNING BODY AND MANAGEMENT PRIOR TO FILING, WITH A REVIEW AT THE BOARD MEETING TO ADDRESS ANY QUESTIONS THAT MAY ARISE. FORM 990, PART VI, SECTION B, LINE 12C ON AN ANNUAL BASIS, A CONFLICT OF INTEREST QUESTIONNAIRE IS DISTRIBUTED TO ALL MEMBERS OF THE GOVERNING BODY AND MANAGEMENT TO IDENTIFY ANY CONFLICTS OF INTEREST. IN ADDITION, ON AN ONGOING BASIS, PRIOR TO EACH BOARD ACTION, EACH VOTING OFFICER IS RESPONSIBLE TO SELF-EVALUATE TO DETERMINE WHETHER A CONFLICT OF INTEREST IS PRESENT. AN INDIVIDUAL WITH A POTENTIAL CONFLICT DISCLOSES THE MATTER TO THE BOARD OR COMMITTEE. AFTER DISCLOSURE OF THE RELEVANT FACTS, THAT INDIVIDUAL LEAVES THE ROOM WHILE THE REMAINING BOARD OR COMMITTEE MEMBERS VOTE ON WHETHER A CONFLICT OF INTEREST EXISTS. IN THE INSTANCE THAT CONFLICT EXISTS, THE NECESSARY PARTIES ARE EXCUSED FROM THE ROOM WHILE THE REMAINING BOARD OR COMMITTEE MEMBERS DISCUSS THE TRANSACTION AND VOTE ON THE MATTER. IF AN INDIVIDUAL FAILS TO DISCLOSE A CONFLICT, THE BOARD WILL TAKE APPROPRIATE DISCIPLINARY AND CORRECTIVE ACTION. FORM 990, PART VI, SECTION B, LINE 15 THE ORGANZATION ENGAGES AN OUTSIDE CONSULTANT TO PROVIDE COMPARABILITY COMPENSATION DATA FOR THE CEO POSITION. THE OUTSIDE CONSULTANT PROVIDES THE BOARD WITH A SUGGESTED RANGE FOR COMPENSATION. THE BOARD AND COMPENSATION COMMITTEE THEN REVIEWS THE INFORMATION RECEIVED AND DETERMINES THE COMPENSATION OF THE CEO WITH LEGAL COUNSEL. THE BOARD APPROVES IN ADVANCE AND DOCUMENTS THE COMPENSATION DETERMINATIONS IN THE BOARD MINUTES ON A TIMELY BASIS. A FIVE YEAR CONTRACT WAS NEGOTATED. THIS CONTRACT IS IN EFFECT FOR 2023. THE VICE PRESIDENTS' (CFO, CNO, CPO(CHIEF PRACTICE OFFICER), CMO AND CAO) COMPENSATION ARE DETERMINED BY PROVIDING THE CEO WITH COMPARABILITY DATA. THE COMPARABILITY DATA IS GATHERED BY THE HUMAN RESOURCES DEPARTMENT. THE CEO DETERMINES THE APPROPRIATE COMPENSATION FOR THE VICE PRESIDENTS AND PRESENTS A REPORT TO THE COMPENSATION COMMITTEE. PHYSCICIAN COMPENSATION IS NEGOTIATED AT THE TIME OF CONTRACT RENEWAL. THE ORGANZATION ENGAGES AN OUTSIDE CONSULTANT TO PROVIDE COMPARABILITY DATA FOR THE PHYSICIANS. FORM 990, PART VI, SECTION C, LINE 19 FINANCIAL STATEMENTS, GOVERNING DOCUMENTS AND CONFLICTS OF INTEREST POLICIES ARE NOT REQUIRED DISCLOSURES PURSUANT TO IRC SECTION 6104. PORTIONS OF THE FINANCIAL STATEMENTS ARE PUBLISHED IN THE ANNUAL REPORT THAT IS MAILED TO THE LOCAL COMMUNITY. THE GOVERNING DOCUMENTS AND CONFLICT OF INTEREST POLICY ARE NOT AVAILABLE TO THE PUBLIC AT THIS TIME. FORM 990, PART VII, SECTION B, LINE 1 IT IS POSSIBLE THAT A PORTION OF THE AMOUNT REPORTED FOR BROWN CONSTRUCTION CO. WAS RELATED TO MATERIALS IN ADDITION TO AMOUNTS PAID FOR SERVICES, HOWEVER, THE AMOUNTS ARE NOT DISTINGUISHABLE. FORM 990, PART IX, LINE 11G REPAIRS AND MAINTENANCE CONTRACTS: PROGRAM SERVICE EXPENSES 2,182,629. MANAGEMENT AND GENERAL EXPENSES 242,284. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 2,424,913. PROFESSIONAL: PROGRAM SERVICE EXPENSES 0. MANAGEMENT AND GENERAL EXPENSES 68,211. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 68,211. PURCHASED: PROGRAM SERVICE EXPENSES 12,914,556. MANAGEMENT AND GENERAL EXPENSES 3,767,785. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 16,682,341. RECOGNITION: PROGRAM SERVICE EXPENSES 42,663. MANAGEMENT AND GENERAL EXPENSES 12,117. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 54,780. OTHER: PROGRAM SERVICE EXPENSES 98,780. MANAGEMENT AND GENERAL EXPENSES 238,433. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 337,213. FORM 990, PART XI, LINE 9: CHANGES IN VALUE OF SUBSIDIARIES -405,763. FORM 990, PAGE 12, PART XII, LINE 2C THE PROCESS HAS NOT CHANGED FROM THE PRIOR YEAR. KSB HOSPITAL FOUNDATION 403 EAST FIRST STREET DIXON IL 61021 841787288 TO RAISE FUNDS TO SUPPORT KSB'S MISSION IL 501(C)(3) LINE 12A, I KATHERINE SHAW BETHEA HOSPITAL 1 KSB VENTURES INC 403 EAST 1ST STREET DIXON IL 61021 465278274 HOLD PARTNERSHIP INVESTMENT IL KATHERINE SHAW BETHEA HOSPITAL C 294652 1.00000 1 0 0 1 0 0 0 0 0 0 0 0 0 1 1 1 0 0 0 0 KSH HOSPITAL FOUNDATION C 82107 FMV