2014-02-04T09:59:08-06:00 2013-04-30 410746749 CLIFTONLARSONALLEN LLP 114 E EVERETT DIXON IL 61021 990 2012-05-01 237087041 KISHWAUKEE COMMUNITY HOSPITAL KISH 8157561521 ONE KISH HOSPITAL DRIVE DEKALB IL 60115 LOREN FOELSKE 8157561521 2014-01-27 1 KELLY JACKSON HARDY P00747242 8152842285 2012 2015-11-30 17:44:51Z KEVIN P POORTEN ONE KISH HOSPITAL DRIVE DEKALB IL 60115 256062578 0 X WWW.KISHHOSPITAL.ORG X 1970 IL TO PROVIDE COMPREHENSIVE HEALTH CARE SERVICES, INCLUDING INPATIENT ACUTE AND NONACUTE CARE, AND VARIOUS OUTPATIENT SERVICES IN THE AREA OF DEKALB COUNTY. 3 2 1241 300 102287 -44511 930478 498254 174560488 183790492 4533345 8160848 2395820 2013451 182420131 194463045 317643 326958 0 0 59347491 63821467 0 0 7373 103689576 109778090 163354710 173926515 19065421 20536530 294914074 319597870 104281500 107654934 190632574 211942936 X TO PROVIDE COMPREHENSIVE HEALTH CARE SERVICES, INCLUDING INPATIENT ACUTE AND NONACUTE CARE, AND VARIOUS OUTPATIENT SERVICES IN THE AREA OF DEKALB COUNTY. KISHWAUKEE COMMUNITY HOSPITAL (KCH) SERVES ALL PEOPLE WITH SKILL AND COMPASSION WHILE RESPECTING THEIR DIGNITY, RIGHTS, AND CHOICES BY OFFERING ACCESS TO HIGH-QUALITY PREVENTIVE, CURATIVE, AND REHABILITATIVE CARE DELIVERED IN A COST EFFECTIVE MANNER. KISHWAUKEE COMMUNITY HOSPITAL RECOGNIZES THE NEED TO EFFECTIVELY MANAGE RESOURCES FOR PRESENT AND FUTURE GENERATIONS. 0 0 145547580 326958 183709344 KISHWAUKEE COMMUNITY HOSPITAL (KCH), LOCATED IN DEKALB, ILLINOIS, SERVES THE RESIDENTS OF DEKALB COUNTY AND THE SURROUNDING AREAS BY OFFERING A NUMBER OF PROGRAMS AND SERVICES FOR COMMUNITY BENEFIT, INCLUDING CHARITY CARE. KISHWAUKEE COMMUNITY HOSPITAL BELIEVES THAT IN ORDER TO BE A TRUE "COMMUNITY" HOSPITAL, WE MUST BE A RESOURCE FOR PREVENTATIVE AND CURATIVE HEALTH INFORMATION, EDUCATION AND SERVICES AND THAT WE MUST SUPPORT THE EFFORTS OF OTHERS WHO ALSO ARE DOING WORK FOR THE COMMUNITY GOOD. DOING SO HELPS BUILD TRUST, RESPECT AND LOYALTY FOR OUR HOSPITAL AND STRENGTHENS OUR ROLE AS A PARTNER IN IMPROVING THE HEALTH OF OUR CITIZENS AND THE QUALITY OF LIFE IN THE COMMUNITIES WE SERVE.THE OBJECTIVES OF HOSPITAL'S COMMUNITY BENEFIT PROGRAM ARE TO IMPROVE ACCESS TO HEALTH SERVICES BY REDUCING GEOGRAPHIC, FINANCIAL, LANGUAGE AND CULTURAL BARRIERS; IMPROVE AND ENHANCE PUBLIC HEALTH, ADVANCE GENERAL HEALTH KNOWLEDGE, AND RELIEVE THE GOVERNMENT BURDEN OF PROVIDING HEALTH SERVICES FOR THE COMMUNITY, AND FOR THE UNINSURED AND UNDERINSURED. COMMUNITY HEALTH NEEDS ARE IDENTIFIED AND ADDRESSED THROUGH COMMUNITY OUTREACH PROGRAMS, BY ADDING NEW SERVICES AND BY EXPANDING OTHERS. NEEDS ALSO ARE MET THROUGH OPERATIONAL PROGRAMS SUCH AS CHARITY CARE, SUBSIDIZED SERVICES AND PROVIDING CASH AND IN-KIND DONATIONS TO SUPPORT ORGANIZATIONS THAT ALSO STRIVE TO MEET COMMUNITY HEALTH AND QUALITY OF LIFE NEEDS. THE HOSPITAL IDENTIFIES COMMUNITY HEALTH NEEDS IN SEVERAL WAYS:* DEKALB COUNTY HEALTH DEPARTMENT I-PLAN* KENDALL COUNTY HEALTH DEPARTMENT I-PLAN* KISHHEALTH SYSTEM, PRC COMMUNITY HEALTH NEEDS SURVEY 2009* U.S. DEPARTMENT OF HEALTH & HUMAN SERVICES, HEALTHY PEOPLE 2010 & 2020* UNIVERSITY OF WISCONSIN POPULATION HEALTH INSTITUTE COUNTY HEALTH RANKINGS & ROADMAPS* ILLINOIS DEPARTMENT OF PUBLIC HEALTH, HOSPITAL DATA* ILLINOIS HOSPITAL ASSOCIATION* INTERNAL REVIEW OF OUTPATIENT AND INPATIENT TRENDS, ESPECIALLY EMERGENCY DEPARTMENT USAGE * INPUT FROM OTHER COMMUNITY PROVIDERS. THIS INCLUDES PROVIDING HOSPITAL LEADERS TO SERVE ON BOARDS AND COMMITTEES THAT DIRECTLY OR INDIRECTLY IMPACT COMMUNITY HEALTH OR HELP THE HOSPITAL CONNECT TO UNDERSERVED OR VULNERABLE POPULATIONS,USING ALL THESE RESOURCES, KISHHEALTH SYSTEM FOCUSED ON THE FOLLOWING COMMUNITY HEALTH NEEDS IN FY2013:* THE PREVALENCE OF OBESITY IN CHILDREN AND ADULTS* ACCESS TO AFFORDABLE PRIMARY HEALTH CARE IN THE DEKALB/SYCAMORE AREA AND OUTLYING RURAL AREAS* TYPE II DIABETES* CARDIOVASCULAR DISEASE AND ADEQUATE HOSPITAL BASED AND COMMUNITY OUTREACH SERVICES* CANCER CARE SERVICES, EDUCATION AND PREVENTION* AFFORDABLE ACCESS TO CHILDBIRTH EDUCATION AND OB HOSPITAL SERVICES* OTHER COMMUNITY OUTREACH AND WELLNESS SERVICESCOMMUNITY COLLABORATION / OUTREACH / SCHOOL & WELLNESS PROGRAMS THE HOSPITAL'S COMMUNITY WELLNESS DEPARTMENT PROVIDES A VARIETY OF EDUCATIONAL ACTIVITIES AND PROGRAMS IN THE COMMUNITY. DEKALB COUNTY SCHOOLS ARE VISITED THROUGHOUT THE ACADEMIC YEAR, WITH HEALTH EDUCATORS PROVIDING EDUCATION ON NUTRITION, FITNESS ACTIVITIES, SCREEN TIME REDUCTION, HAND WASHING, DENTAL CARE, POISON PREVENTION, AND IN GENERAL LIVING A HEALTHY LIFESTYLE. ONE WAY THAT THIS IS ACCOMPLISHED IS IN COLLABORATION WITH NORTHERN ILLINOIS UNIVERSITY'S STUDENTS TRAINED TO SERVE AS CATCH INSTRUCTORS. CATCH (COORDINATED APPROACH TO CHILD HEALTH) IS AN EVIDENCE BASED CURRICULUM FOR CHILDREN PROMOTING HEALTHY LIFESTYLES THROUGH ITS MATERIALS. IN ADDITION, THE COMMUNITY HEALTH LIAISON SERVES ON THE DEKALB AND SYCAMORE SCHOOL DISTRICTS HEALTH & WELLNESS COMMITTEES. IN ADDITION, COMMUNITY WELLNESS PROVIDED SAFE SITTER INSTRUCTION TO 8 CHILDREN IN THE SYCAMORE SCHOOLS DISTRICT SPARTAN PROGRAM. COMMUNITY WELLNESS HEALTH EDUCATORS VISITED 225 CLASSROOMS WORKING WITH 5,944 STUDENTS.STAFF FROM COMMUNITY WELLNESS COLLABORATE WITH OR SERVE ON COMMITTEES AND PROMOTED HEALTH AND WELLNESS THOUGH THESE PARTNERSHIPS: DEKALB LEADERSHIP ACADEMY, LIVE HEALTHY DEKALB COUNTY (FORMERLY PIONEERING HEALTHIER COMMUNITIES), YMCA AND ITS DIABETES PREVENTION PROGRAM, SYCAMORE AND DEKALB SCHOOL DISTRICTS' HEALTH & WELLNESS COMMITTEES, LATINO ACTION GROUP, AMERICAN HEART ASSOCIATION, GO RED LUNCHEON, KISHWAUKEE COMMUNITY HOSPITAL'S CANCER CENTER, CANCER COMMITTEE.OPERATIONAL COMMUNITY BENEFITTHE HOSPITAL ALSO PROVIDED COMMUNITY BENEFIT THROUGH CHARITY CARE, GOVERNMENT-SPONSORED INDIGENT HEALTH CARE, BAD DEBT, SUBSIDIZED HEALTH SERVICES, LANGUAGE ASSISTANCE, VOLUNTEER SERVICES, EDUCATION AND WORKFORCE DEVELOPMENT, CASH AND IN-KIND DONATIONS, AND OTHER. CHARITY CARE AS PART OF ITS CHARITABLE MISSION, THE HOSPITAL PROVIDES FINANCIAL ASSISTANCE, INCLUDING ACCESS TO PHARMACEUTICAL ASSISTANCE FOR PATIENTS WHO MET THE ELIGIBILITY CRITERIA ESTABLISHED IN ITS FINANCIAL ASSISTANCE POLICY. THE POLICY IS REVIEWED BY THE BOARD OF DIRECTORS ANNUALLY. THE HOSPITAL ALSO COORDINATED WITH THE ILLINOIS BREAST AND CERVICAL CANCER PROGRAM FOR ASSISTANCE WITH BREAST AND CERVICAL CANCER SCREENINGS AND TREATMENT. MORE PATIENTS QUALIFIED FOR CHARITY CARE IN FY 2013 THAN IN PREVIOUS YEARS DUE TO THE POOR ECONOMY AND ALSO TO REDUCE THE HOSPITAL'S BAD DEBT. THE HOSPITAL ALSO UNDERWROTE UNREIMBURSED COSTS OF TREATING MEDICAID AND MEDICARE PATIENTS. SUBSIDIZED HEALTH SERVICES A NUMBER OF PROGRAMS AND SERVICES WERE OPERATED AT A LOSS, BUT WERE SUBSIDIZED BECAUSE THEY IMPROVE THE HEALTH AND SAFETY OF THE COMMUNITY. LANGUAGE ASSISTANCE THE HOSPITAL EMPLOYS SPANISH INTERPRETERS AVAILABLE OR ON CALL 24/7 AND USED VIDEOCONFERENCING EQUIPMENT, VIA LAPTOP, TO COMMUNICATE WITH THE HEARING IMPAIRED AND DUAL HANDSET PHONE SYSTEM THAT PROVIDED INSTANT INTERPRETATION FOR PATIENTS WHO DO NOT SPEAK ENGLISH.VOLUNTEER SERVICES VOLUNTEER OPPORTUNITIES ARE PROVIDED TO EMPLOYEES TO SERVE IN THE COMMUNITY AND FOR COMMUNITY MEMBERS TO SERVE THE HOSPITAL. THERE WERE ROUGHLY 863 OF VOLUNTEER HOURS RECORDED BY EMPLOYEES. A VOLUNTEER SERVICES DEPARTMENT SCHEDULED MEMBERS OF THE VOLUNTEERS IN THE HOSPITAL. EDUCATION & WORKFORCE DEVELOPMENT A MEDICAL LIBRARY WAS MAINTAINED FOR PHYSICIAN, STAFF AND PATIENT USE. HOSPITAL EMPLOYEES PROVIDED CLINICAL TRAINING, JOB SHADOWING AND MENTORING OF COLLEGE AND HIGH SCHOOL STUDENTS. THE AUXILIARY AND KISHHEALTH FOUNDATION AWARDED ANNUAL SCHOLARSHIPS FOR HEALTH CAREERS. HOSPITAL TOURS WERE GIVEN TO LOCAL SCHOOLS AND YOUTH GROUPS TO EDUCATE YOUTH ON HEALTHCARE CAREERS. CASH CONTRIBUTIONS WERE GIVEN TO LOCAL LIBRARIES, PUBLIC AND POST-SECONDARY EDUCATION FOUNDATIONS TO UNDERWRITE SCHOLARSHIPS, AND PURCHASE OR PROVIDE HEALTH-RELATED MATERIALS, EQUIPMENT AND ACTIVITIES.CASH AND IN-KIND DONATIONSAN ALLOCATION WAS MADE IN THE OPERATING BUDGET FOR DONATIONS TO COMMUNITY EVENTS AND ORGANIZATIONS THAT IMPROVE THE HEALTH, WELFARE AND QUALITY OF LIFE IN THE COMMUNITIES SERVED BY THE HOSPITAL. THE HOSPITAL SUPPORTED COMMUNITY ACTIVITIES THAT ENCOURAGE CHILD AND ADULT PHYSICAL ACTIVITY; EFFORTS THAT REACH UNDERSERVED AND VULNERABLE POPULATIONS; YOUTH MENTORING, EDUCATION; DISEASE PREVENTION, AWARENESS, RESEARCH; MENTAL HEALTH; ECONOMIC DEVELOPMENT AND OTHER COMMUNITY BUILDING ACTIVITIES. IN-KIND DONATIONS AND SERVICES SUCH AS PERSONNEL TIME, SURPLUS SUPPLIES, FOOD, AND BOTTLED WATER WERE ALSO TRACKED.DONATION HIGHLIGHTS THE HOSPITAL PROVIDED SUBSTANTIAL CASH CONTRIBUTIONS TO: BEN GORDON CENTER TO SUPPORT MENTAL HEALTH SERVICES FOR THE LOW INCOME, KISHWAUKEE FAMILY YMCA TO SUPPORT STRONG KIDS SCHOLARSHIP PROGRAM AND SPONSOR HEALTH AND WELLNESS ACTIVITIES FOR FAMILIES; FAMILY SERVICE AGENCY TO SUPPORT BIG BROTHERS/BIG SISTERS, COURT APPOINTED SPECIAL ADVOCATES; SENIOR SERVICES AND FAMILY COUNSELING; KISHWAUKEE COLLEGE FOUNDATION TO SUPPORT ITS NURSING AND RADIOLOGY TRAINING PROGRAMS; KISHWAUKEE UNITED WAY TO SUPPORT SOCIAL SERVICE AGENCIES THAT PROMOTE NUTRITION AND HEALTH ESPECIALLY AMONG THE LOW INCOME; VOLUNTARY ACTION CENTER TO SUPPORT MEALS ON WHEELS, TRANSPORTATION SERVICES AND DAY CARE LUNCH PROGRAMS; DEKALB COUNTY ECONOMIC DEVELOPMENT CORPORATION; DEKALB, SYCAMORE, AND GENOA CHAMBERS OF COMMERCE TO SUPPORT THE BUSINESS COMMUNITY AND ECONOMIC DEVELOPMENT FOR THE REGION; AREA HIGH SCHOOL SPORTS BOOSTERS TO SUPPORT SCHOLARSHIPS FOR STUDENTS TO PARTICIPATE IN SCHOOL ATHLETICS, DEKALB, SYCAMORE, GENOA EDUCATION FOUNDATION; AND DEKALB LIBRARIES TO SUPPORT THE PURCHASE OF HEALTH-RELATED BOOKS; NUMEROUS YOUTH SPORTS ORGANIZATIONS AND CLUBS TO SUPPORT SCHOLARSHIPS FOR THOSE WHO OTHERWISE COULD NOT AFFORD TO PARTICIPATE; DEKALB COUNTY YOUTH SERVICE BUREAU; DEKALB COUNTY RED CROSS; MIDWEST MUSEUM OF NATURAL HISTORY TO UNDERWRITE THE COST OF FREE ADMISSION DAYS PLUS SUPPLIES FOR YOUTH SPONSORED PROGRAMS; ILLINOIS POISON CONTROL CENTER; DISEASE RESEARCH, PREVENTION AND EDUCATION THROUGH THE AMERICAN CANCER SOCIETY, AMERICAN HEART ASSOCIATION, DIABETES EDUCATION ASSOCIATION, AND MARCH OF DIMES. 145547580 1 1 0 1 0 0 0 0 0 0 1 0 0 0 1 1 0 1 0 0 0 0 0 0 0 0 1 1 1 1 1 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 0 0 0 1 121 0 1 1241 1 1 1 0 0 0 0 0 0 0 0 0 X 3 2 1 0 0 0 1 1 1 1 1 0 0 1 1 1 1 1 1 1 1 0 IL X LOREN FOELSKE VP OF FINANCE 8157561521 ONE KISH HOSPITAL DRIVE DEKALB IL 60115 X MICHAEL CULLEN 2.00 9.00 X X 0 0 0 KEVIN POORTEN 10.00 45.00 X X 0 966472 220153 THOMAS MATYA 2.00 3.00 X X 0 0 0 LOREN FOELSKE 25.00 22.00 X 0 284734 117504 BRAD COPPLE 21.00 25.00 X 0 359637 72184 PAM DUFFY 10.00 35.00 X 0 249153 30870 JOE DANT 5.00 40.00 X 0 255673 45841 MIKE KOKOTT 15.00 30.00 X 0 194828 34842 ROGER HEATH BELL 10.00 37.00 X 0 273572 51107 DR MICHAEL KULISZ 15.00 37.00 X 0 402706 99258 MARK THATE 12.00 33.00 X 0 273139 26286 MICHAEL MUZZILLO THRU 62912 16.00 34.00 X 0 229519 12427 THOMAS W TILTON DO 40.00 X 414769 0 32116 THOMAS WARZECHA 40.00 X 143361 0 25199 KENYA M WILLIAMS MD 40.00 X 245831 0 7539 JASMEET DHALIWAL 40.00 X 745524 0 30951 LISA ACKLAND 40.00 X 140939 0 21882 1690424 3489433 828159 43 0 1 0 KISHHEALTH SYSTEM ONE KISH HOSPITAL DRIVE DEKALB IL 60115 MANAGEMENT SERVICES 13946136 DOCTORS OF EMERGENCY MEDICINE 2807 BRITTANY COURT ST CHARLES IL 60175 EMERGENCY MEDICINE SERVICES 7067990 POWER CONSTRUCTION COMPANY LLC 2360 NORTH PALMER DRIVE SCHAUMBURG IL 60173 CONSTRUCTION SERVICES 5536284 SIDDIQUI SABET MD PC 10 MORAINE TERRACE DEKALB IL 60115 MEDICAL SERVICES 1700000 SODEXO INC & AFFILIATES 4880 PAYSPHERE CIRCLE CHICAGO IL 60674 CONSULTING SERVICES 1498562 40 773 313028 35582 148871 3172 498254 NET PATIENT SERVICE REVENUE 621110 183790492 183709344 81148 183790492 5245670 5245670 307680 258938 48742 48742 48742 63976073 208240 61232950 36185 2743123 172055 2915178 2915178 113175 71460 41715 41715 OTHER SERVICES 621110 766945 21139 745806 CAFETERIA SALES 621110 721586 721586 INCOME PASSTHROUGH - MIDLAND SURG 621110 233354 233354 201109 201109 1922994 194463045 183709344 102287 10153160 X 306958 306958 20000 20000 45094522 43169903 1924619 2286535 2188946 97589 10430172 9985016 445156 6010238 5753723 256515 13362767 13362767 261414 261414 323 323 458803 458803 17450418 16279959 1170459 975957 55776 920181 31454302 30313107 1137089 4106 1999468 532846 1466622 3190744 3149791 40953 212874 203050 9824 18710 18710 3670612 3670612 11962633 11962633 3197446 960046 2237400 UNRELATED BUSINESS INCO 10437 10437 BAD DEBT EXPENSE 16881477 16881477 FEDERAL AND STATE ASSES 2019408 2019408 PHYSICIAN RECRUITMENT 1603973 1581889 22084 1046324 164342 878715 3267 173926515 145547580 28371562 7373 15302921 11234100 251766 80478 28815521 32318217 3725696 3873075 2901412 3292374 177032753 76823422 106921581 100209331 118483018 150226426 8089823 10222071 10422336 8141798 294914074 319597870 13536946 29692939 727790 743742 63685000 63685000 1226938 1204610 25088874 12344595 104281500 107654934 X 186447120 207748100 4185454 4194836 190632574 211942936 294914074 319597870 X 20536530 4296478 -3522646 X X 0 1 X 1 0 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 0 0 0 0 0 0 1 0 1 36605 36605 0 EXPLANATION OF LOBBYING ACTIVITIES: PART II-B, LINE 1: LOBBYING EXPENSES ARE ALLOCATED THROUGH MEMBERSHIP DUES WITH ILLINOIS HOSPITAL ASSOCIATION AND AMERICAN HOSPITAL ASSOCIATION. NO OTHER LOBBYING ACTIVITIES WERE CONDUCTED. 5255089 5255089 114748211 34101825 80646386 584334 190059 394275 54976029 42531538 12444491 1469090 1469090 100209331 THIRD PARTY PAYABLES 5860534 DUE TO AFFILIATES 1238490 ACCRUED INTEREST PAYABLE 304327 OTHER PAYABLES - LONG TERM 4941244 12344595 X 181980800 4296478 -16881477 -12584999 194565799 -102754 -102754 194463045 157375467 330429 330429 157045038 16881477 16881477 173926515 DESCRIPTION OF UNCERTAIN TAX POSITIONS UNDER FIN 48: PART X, LINE 2: THE SYSTEM, KCH, VWCH, KHF, KPG, DCH, CFHP, CFHM, AND KHC ARE TAX-EXEMPT ORGANIZATIONS UNDER SECTION 501(C)(3) OF THE INTERNAL REVENUE CODE. HPI IS A TAXABLE ORGANIZATION AND FILES A CORPORATE INCOME TAX RETURN, WHICH INCLUDES OPT, IRCC, AND HVL. THE SYSTEM FILES VARIOUS FORM 990'S (RETURN OF ORGANIZATION EXEMPT FROM INCOME TAX) ANNUALLY. WHEN THESE RETURNS ARE FILED, IT IS HIGHLY CERTAIN THAT SOME POSITIONS TAKEN WOULD BE SUSTAINED UPON EXAMINATION BY THE TAXING AUTHORITIES, WHILE OTHERS ARE SUBJECT TO UNCERTAINTY ABOUT THE MERITS OF THE POSITION TAKEN OR THE AMOUNT OF THE POSITION THAT WOULD ULTIMATELY BE SUSTAINED. EXAMPLES OF TAX POSITIONS INCLUDE SUCH MATTERS AS THE FOLLOWING: THE TAX EXEMPT STATUS OF THE ENTITY AND VARIOUS POSITIONS RELATIVE TO POTENTIAL SOURCES OF UNRELATED BUSINESS TAXABLE INCOME (UBIT). UBIT IS REPORTED ON FORM 990T, AS APPROPRIATE. THE BENEFIT OF A TAX POSITION IS RECOGNIZED IN THE FINANCIAL STATEMENTS IN THE PERIOD DURING WHICH, BASED ON ALL AVAILABLE EVIDENCE, MANAGEMENT BELIEVES THAT IT IS MORE LIKELY THAN NOT THAT THE POSITION WILL BE SUSTAINED UPON EXAMINATION, INCLUDING THE RESOLUTION OF APPEALS OR LITIGATION PROCESSES, IF ANY. TAX POSITIONS ARE NOT OFFSET OR AGGREGATED WITH OTHER POSITIONS. TAX POSITIONS THAT MEET THE "MORE LIKELY THAN NOT" RECOGNITION THRESHOLD ARE MEASURED AS THE LARGEST AMOUNT OF TAX BENEFIT THAT IS MORE THAN 50 PERCENT LIKELY TO BE REALIZED ON SETTLEMENT WITH THE APPLICABLE TAXING AUTHORITY. THE PORTION OF THE BENEFITS ASSOCIATED WITH TAX POSITIONS TAKEN THAT EXCEEDS THE AMOUNT MEASURED AS DESCRIBED ABOVE IS REFLECTED AS A LIABILITY FOR UNRECOGNIZED TAX BENEFITS IN THE ACCOMPANYING STATEMENTS OF FINANCIAL POSITION ALONG WITH ANY ASSOCIATED INTEREST AND PENALTIES THAT WOULD BE PAYABLE TO THE TAXING AUTHORITIES UPON EXAMINATION. AT APRIL 30, 2013 AND 2012, THERE WERE NO UNRECOGNIZED TAX BENEFITS IDENTIFIED OR RECORDED. PART XI, LINE 2D - OTHER ADJUSTMENTS: RECLASSIFICATION OF BAD DEBT EXPENSE (NETTED WITH REVENUE ON F/S) -16,881,477. PART XI, LINE 4B - OTHER ADJUSTMENTS: BOOK/TAX DIFFERENCE ON INCOME FROM PASSTHROUGH ENTITIES - KISH AREA PHO -32. CONTRIBUTION REVENUE FROM KISHHEALTH FOUNDATION 313,028. BOOK/TAX DIFFERENCE ON INCOME FROM PASSTHROUGH ENTITIES - MIDLAND SURGICAL -236,551. RECLASSIFICATION OF COST OF GOODS SOLD -71,460. RECLASSIFICATION OF RENTAL EXPENSES -258,939. RECLASSIFICATION OF GAIN ON SALE OF MIDLAND SURGICAL CENTER INTEREST 151,200. PART XII, LINE 2D - OTHER ADJUSTMENTS: RECLASSIFICATION OF COST OF GOODS SOLD 71,460. RECLASSIFICATION OF RENTAL EXPENSES 258,939. OTHER ADJUSTMENT 30. PART XII, LINE 4B - OTHER ADJUSTMENTS: RECLASSIFICATION OF BAD DEBT EXPENSE (NETTED WITH REVENUE ON F/S) 16,881,477. 1 1 X 1 X 1 X 600.000000000000 1 1 1 0 1 1 7033083 2041416 4991667 0.02870 17191031 9960140 7230891 0.04160 0 0 24224114 12001556 12222558 0.07030 5691204 843098 4848106 0.02790 953644 20620 933024 0.00540 1408513 444495 964018 0.00550 502680 0 502680 0.00290 8556041 1308213 7247828 0.04170 32780155 13309769 19470386 0.11200 1 16943873 1956561 32118634 51410682 -19292048 X 1 1 1 1 KISHWAUKEE COMMUNITY HOSPITAL

ONE KISH HOSPITAL DRIVE DEKALB IL 60115

WWW.KISHHEALTH.ORG X X X KISHWAUKEE COMMUNITY HOSPITAL 1 1 X X X X X X X X X 12 1 1 1 X X X X X X X X X 0 0 1 1 200.000000000000 1 600.000000000000 1 X X X X X 1 1 X X X 1 0 X X X X X 1 X 0 0 PART I, LINE 7: THE RESPECTIVE IRS WORKSHEET, AS PROVIDED IN THE INSTRUCTIONS FOR SCHEDULE H, WERE USED TO CALCULATE THE COSTS OF ITEMS WITHIN THE TABLE ABOVE. PART II: NO COMMUNITY BUILDING ACTIVITIES ARE REPORTED IN PART II. PART III, LINE 4: SEE FOOTNOTE 3 (PAGE 15) IN THE ATTACHED FINANCIAL STATEMENTS FOR A DESCRIPTION OF BAD DEBT EXPENSE.INTERNAL REVENUE SERVICE WORKSHEET 2 (PER SCHEDULE H INSTRUCTIONS) WAS UTILIZED TO DETERMINE THE COST OF BAD DEBTS ATTRIBUTABLE TO PATIENT ACCOUNTS. PART III, LINE 8: FOR THE 4/30/13 FISCAL YEAR, KCH PROVIDED BILLED CHARGES TO MEDICARE PATIENTS TOTALING $168,172,730. HOWEVER, DUE TO THE MEDICARE INPATIENT AND OUTPATIENT PAYMENT METHODOLOGIES, THE ACTUAL CASH PAYMENTS RECEIVED FROM PROVIDING CARE TO THOSE PATIENTS WAS JUST $32,118,634, OR 19% OF BILLED CHARGES. THE COST OF PROVIDING THIS CARE, PER THE MEDICARE COST REPORT, WAS $51,410,682. THUS, THE PAYMENTS RECEIVED FROM MEDICARE WERE $19,292,048 LESS THAN COST, OR 62% OF COST. TRULY THIS $19,292,048 SHORTFALL SHOULD BE INCLUDED AS A COMMUNITY BENEFIT. AS APPROXIMATELY 45% OF ALL KISHWAUKEE COMMUNITY HOSPITAL CHARGES GENERATED ARE FROM MEDICARE PATIENTS, THIS SHORTFALL PLACES A TREMENDOUS FINANCIAL BURDEN ON OUR HOSPITAL.KISHWAUKEE COMMUNITY HOSPITAL, LIKE OTHER NOT-FOR-PROFIT HOSPITALS, MUST ACCEPT MEDICARE PAYMENTS AS PAYMENT IN FULL FOR SERVICES PROVIDED, WITH THE EXCEPTION OF COLLECTING ON DEDUCTIBLES AND CO-INSURANCE AMOUNTS. HOSPITALS CANNOT BILL MEDICARE PATIENTS FOR THE DIFFERENCE BETWEEN THE BILLED CHARGES AND MEDICARE PAYMENTS.KISHWAUKEE COMMUNITY HOSPITAL PROVIDES SERVICES TO ALL PATIENTS WHO NEED CARE, ABIDING BY THE FEDERAL EMERGENCY MEDICAL TREATMENT AND LABOR ACT (EMTALA) REGULATION. IT REQUIRES HOSPITALS AND AMBULANCE SERVICES TO PROVIDE CARE TO ANYONE NEEDING EMERGENCY HEALTHCARE TREATMENT REGARDLESS OF CITIZENSHIP, LEGAL STATUS OR ABILITY TO PAY.KCH UTILIZED THE CALCULATION OF MEDICARE COST FROM THE ANNUAL MEDICARE COST REPORT. THIS APPROACH ALLOCATES COST FROM NON REVENUE PRODUCING DEPARTMENTS TO THE REVENUE GENERATING DEPARTMENTS, BASED ON STEP DOWN STATISTICAL COST FINDING. WHILE NOT AS COMPREHENSIVE AS A TRUE COST ACCOUNTING SYSTEM, THIS PROCESS RESULTS IN AN ACCEPTABLE BASIS OF THE DEPARTMENTAL COST FOR PROVIDING SERVICES. RECALL THAT PRIOR TO MEDICARE PROSPECTIVE PAYMENT SYSTEM (PPS), THIS METHODOLOGY WAS THE BASIS FOR THE REIMBURSEMENT TO HOSPITALS. PART III, LINE 9B: COLLECTION ACTIONS INVOLVING UNINSURED PATIENTS. KHS (KISHHEALTH SYSTEM, PARENT ORGANIZATION OF KISHWAUKEE COMMUNITY HOSPITAL) SHALL NOT PURSUE A COLLECTION ACTION AGAINST AN UNINSURED PATIENT, UNLESS THE PATIENT HAS BEEN GIVEN THE OPPORTUNITY TO ASSESS THE ACCURACY OF THE BILL; APPLY FOR FINANCIAL ASSISTANCE UNDER THE KHS FINANCIAL ASSISTANCE POLICY AND PROCEDURE; AND AVAIL HIMSELF OR HERSELF OF A REASONABLE PAYMENT PLAN. NOTWITHSTANDING THIS, KHS MAY NOT PURSUE THE COLLECTION ACTION UNDER THE FOLLOWING CIRCUMSTANCES: (A) IF THE PATIENT HAS INDICATED AN INABILITY TO PAY THE FULL AMOUNT OF THE DEBT IN ONE PAYMENT, UNTIL KHS HAS OFFERED THE PATIENT A PAYMENT PLAN. KHS MAY REQUIRE THE PATIENT TO PROVIDE REASONABLE VERIFICATION OF HIS OR HER INABILITY TO PAY THE FULL AMOUNT OF THE DEBT IN ONE PAYMENT.(B) IF KHS HAS REASON TO BELIEVE THE PATIENT MAY BE ELIGIBLE FOR FINANCIAL ASSISTANCE, UNTIL KHS HAS GIVEN THE PATIENT AT LEAST 60 DAYS FOLLOWING THE DATE OF DISCHARGE OR RECEIPT OF OUTPATIENT CARE TO SUBMIT AN APPLICATION FOR FINANCIAL ASSISTANCE. (C) IF THE PATIENT HAS AGREED TO A PAYMENT PLAN, UNTIL THE PATIENT HAS FAILED TO MAKE PAYMENTS IN ACCORDANCE WITH THAT PAYMENT PLAN. (D) IF THE PATIENT INFORMS KHS THAT HE OR SHE HAS APPLIED FOR HEALTH CARE COVERAGE UNDER MEDICAID, KIDCARE, OR OTHER GOVERNMENT-SPONSORED HEALTH CARE PROGRAM (AND THERE IS A REASONABLE BASIS TO BELIEVE THAT THE PATIENT WILL QUALIFY FOR SUCH PROGRAM), BUT THE PATIENT'S APPLICATION IS DENIED. KISHWAUKEE COMMUNITY HOSPITAL PART V, SECTION B, LINE 3: INDIVIDUALS REPRESENTING KISHWAUKEE COMMUNITY HOSPITAL, VALLEY WEST COMMUNITY HOSPITAL, DEKALB COUNTY HEALTH DEPARTMENT AND LIVE HEALTHY DEKALB COUNTY (FORMERLY KNOWN AS PIONEERING HEALTHIER COMMUNITIES), SERVED AS STEERING COMMITTEE MEMBERS. STEERING COMMITTEE MEMBERS MET MONTHLY FROM MAY 2012 TO NOVEMBER 2012 AND REVIEWED POPULATION DEMOGRAPHICS, BIRTH AND DEATH DATA AND SOCIAL AND HEALTH INDICATORS IN ORDER TO PRIORITIZE HEALTH PROBLEMS FOR THE DEKALB COUNTY COMMUNITY HEALTH PLAN AND KISHWAUKEE COMMUNITY HOSPITAL COMMUNITY HEALTH NEEDS ASSESSMENT. THE STEERING COMMITTEE WAS CHARGED WITH FURTHER PRIORITIZING THESE ISSUES BASED ON A MORE IN-DEPTH EXPLORATION AND A STANDARDIZED PROCESS. IN SEPTEMBER OF 2012, THE STEERING COMMITTEE PRESENTED HEALTH PRIORITIES TO THE EXTERNAL COMMITTEE MEMBERS, WHO INCLUDED A VARIETY OF INDIVIDUALS FROM LOCAL AND STATE GOVERNMENTAL AGENCIES, LEADERS FROM COMMUNITY BASED ORGANIZATIONS, FOUNDATIONS, SCHOOL DISTRICTS, COLLEGES, AND LOCAL NON-PROFIT ORGANIZATIONS. THESE PARTICIPANTS ARE EXPERTS IN HEALTH CARE, SOCIAL DETERMINANTS OF HEALTH AND HEALTH AND SOCIAL SERVICES. THE INPUT FROM THE EXTERNAL GROUP HELPED TO ENSURE THAT NEEDS WERE IDENTIFIED AND WILL BE RESPONDED TO. AFTER THOROUGH REVIEW OF THE DATA, KISHHEALTH SYSTEM COMMUNITY BENEFIT TEAM MEMBERS WERE GIVEN THE OPPORTUNITY TO DISCUSS THE INFORMATION AND FURTHER REVIEW HEALTH PROBLEMS FACING THE COUNTY. FOLLOWING A LENGTHY DISCUSSION, KISHHEALTH SYSTEM COMMUNITY BENEFIT TEAM MEMBERS IDENTIFIED PRIORITIES FOR CONSIDERATION FOR THE COMMUNITY BENEFIT IMPLEMENTATION PLAN. THE FULL LIST OF PARTICIPANTS IN TEH ASSESSMENT PROCESS INCLUDES:STEERING COMMITTEE MEMBERS (PARTICIPANTS LISTED ALPHABETICALLY)* BETH BUSCHING, MANAGER, COMMUNITY WELLNESS, KISHWAUKEE COMMUNITY HOSPITAL* BETTE CHILTON, DEAN OF HEALTH AND EDUCATION, KISHWAUKEE COMMUNITY COLLEGE* DAWN ROZNOWSKI, COMMUNITY ENGAGEMENT ADVISOR, KISHHEALTH SYSTEM* JANE LUX, DIRECTOR, DEKALB COUNTY HEALTH DEPARTMENT* KIM JASS-RAMIREZ, SENIOR DIRECTOR OF HEALTHY LIVING, KISHWAUKEE YMCA* LISA CUMINGS, COMMUNITY HEALTH LIAISON, KISHWAUKEE COMMUNITY HOSPITAL* MARCY ZANELLATO, HEALTH EDUCATION DIVISION, DEKALB COUNTY HEALTH DEPARTMENT* SHELLY JOHNSON, DIRECTOR, COMMUNITY CARES CLINIC AND CENTER FOR FAMILY HEALTH, EMPLOYEE HEALTH, COMMUNITY WELLNESS, KISHHEALTH SYSTEMEXTERNAL COMMITTEE MEMBERS* ERICA BARNES, LCPC, COUNSELOR/OUTREACH COORDINATOR, NORTHERN ILLINOIS UNIVERSITY COUNSELING AND STUDENT DEVELOPMENT* JAMES BRISCOE, SUPERINTENDENT, DEKALB SCHOOL DISTRICT #428* CINDY CAPEK, EXECUTIVE DIRECTOR, DEKALB PARK DISTRICT* BETTE CHILTON, DEAN OF HEALTH & EDUCATION, KISHWAUKEE COMMUNITY COLLEGE* BRENDA COURTNEY, DIRECTOR OF ADMINISTRATIVE SERVICES, DEKALB COUNTY HEALTH DEPARTMENT* KATHY COUNTRYMAN, SUPERINTENDENT, SYCAMORE SCHOOL DISTRICT #427* MICHAEL KOKOTT, ASSISTANT VICE PRESIDENT, MARKETING & PLANNING, KISHHEALTH SYSTEM* DAWN LITLEFIELD, EXECUTIVE DIRECTOR, KISHWAUKEE YMCA* CRISTY MEYER, PRINCIPAL, JEFFERSON ELEMENTARY SCHOOL* DONNA MOULTON, EXECUTIVE DIRECTOR, COMMUNITY MENTAL HEALTH BOARD & COMMUNITY SERVICES, DEKALB COUNTY* GABRIELA ORTIZ, PUBLIC HEALTH NURSE, DEKALB COUNTY HEALTH DEPARTMENT* MARY PRITCHARD, PHD., ASSOCIATE DEAN, NORTHERN ILLINOIS UNIVERSITY, COLLEGE OF HEALTH & HUMAN SCIENCES* TED STRACK, PRESIDENT, SYCAMORE PARK DISTRICT* DAN TEMPLIN, EXECUTIVE DIRECTOR, DEKALB COUNTY COMMUNITY FOUNDATION * ROB WILKINSON, CEO, KISHWAUKEE YMCAKISHHEALTH SYSTEM COMMITTEE MEMBERS* KEVIN POORTEN, PRESIDENT & CEO, KISHHEALTH SYSTEM* ALLISON BRYAN, COMMUNITY RELATIONS, VALLEY WEST COMMUNITY HOSPITAL* BECKIE FRIEDERS, EMPLOYEE WELLNESS COORDINATOR, KISHHEALTH SYSTEM* BETH BUSCHING, MANAGER, COMMUNITY WELLNESS, KISHWAUKEE COMMUNITY HOSPITAL* BETH GALE, DIRECTOR, CONTINUITY OF CARE* CINDY JOHNSTON, DIRECTOR, COMMUNITY WELLNESS, VALLEY WEST COMMUNITY HOSPITAL* DAVID WESTER, PHYSICIAN ASSISTANT, CENTER FOR FAMILY HEALTH* DAWN ROZNOWSKI, COMMUNITY ENGAGEMENT ADVISOR, KISHHEALTH SYSTEM* DR. MICHAEL KULISZ, PHYSICIAN, CHIEF MEDICAL OFFICER, KISHHEALTH SYSTEM* JENNIFER RENFER, READMISSION NURSE* KAREN ROUSE, DIRECTOR, OUTPATIENT CLINICS* MICHAEL KOKOTT, ASSISTANT VICE PRESIDENT OF MARKETING AND PLANNING, KISHHEALTH SYSTEM* PAMELA DUFFY, VICE PRESIDENT, PATIENT CARE SERVICES AND CHIEF NURSING OFFICER* SHELLY JOHNSON, DIRECTOR, COMMUNITY CARES CLINIC AND CENTER FOR FAMILY HEALTH, EMPLOYEE HEALTH, COMMUNITY WELLNESS, KISHHEALTH SYSTEM* THERESA KOMITAS, COMMUNITY RELATIONS, KISHWAUKEE COMMUNITY HOSPITAL KISHWAUKEE COMMUNITY HOSPITAL PART V, SECTION B, LINE 4: OTHER HOSPITAL FACILITIES INCLUDE VALLEY WEST COMMUNITY HOSPITAL KISHWAUKEE COMMUNITY HOSPITAL PART V, SECTION B, LINE 7: NINE OTHER TOPIC AREAS (ACCIDENTS, ALCOHOL/DRUG USE, ALLERGIES, CRIME, JOB AVAILABILITY, ORAL HEALTH, SUICIDE AND UNEMPLOYMENT) WERE IDENTIFIED FOR DATA COLLECTION, REVIEW AND PRIORITY SETTING. BELOW ARE THE AREAS IDENTIFIED AND A BRIEF DESCRIPTION WHY THE HOSPITAL DID NOT SELECT TO ADDRESS.PRIORITY IDENTIFIED: ACCIDENTSSUPPORTING DATA: 2007-2009 CENTERS FOR DISEASE CONTROL AND PREVENTION, LISTS ACCIDENTS (MOTOR VEHICLE, FALLS AND POISONING) AS THE THIRD LEADING CAUSE OF DEATH FOR DEKALB COUNTY RESIDENTS. EXPLANATION FOR NOT ADDRESSING: KISHWAUKEE COMMUNITY HOSPITAL DOES NOT HAVE THE EXPERTISE OR INFRASTRUCTURE TO SERVE AS A LEAD AROUND THIS AREA OF NEED.PRIORITY IDENTIFIED: ALCOHOL/DRUG USE SUPPORTING DATA: *ILLINOIS DEPARTMENT OF PUBLIC HEALTH BEHAVIORAL RISK FACTOR SURVEILLANCE SURVEY INDICATED 22.4% OF THE POPULATION REPORT RISK FOR ACUTE/BINGE DRINKING.* PER ILLINOIS SECRETARY OF STATE, THERE WERE 585 ARRESTS FOR DRIVING UNDER THE INFLUENCE IN 2010.* IN 2009, ILLINOIS STATE POLICE REPORTS INDICATE THERE WERE 571 ARRESTS FOR DRUG OFFENSES.* BASED ON ILLINOIS DEPARTMENT OF HUMAN SERVICES, DIVISION OF ALCOHOLISM AND SUBSTANCE ABUSE REPORT, AS ESTIMATED 13,155 (15.6%) OF DEKALB COUNTY RESIDENTS AGED 16 AND OLDER WERE IN NEED OF ALCOHOL TREATMENT, AS WELL AS 2,024 PERSONS IN NEED OF DRUG ABUSE TREATMENT. EXPLANATION FOR NOT ADDRESSING: KISHWAUKEE COMMUNITY HOSPITAL DOES NOT HAVE THE EXPERTISE OR INFRASTRUCTURE TO SERVE AS A LEAD AROUND THIS AREA OF NEED. KISHWAUKEE COMMUNITY HOSPITAL WILL SUPPORT COMMUNITY AGENCIES SUCH AS BEN GORDON CENTER YOUTH SERVICES BUREAU, DCPSAFE AND OTHER COMMUNITY PROGRAMS TO ADDRESS ISSUES NOT DIRECTLY ADDRESSED BY THE HEALTH SYSTEM.PRIORITY IDENTIFIED: ALLERGIES SUPPORTING DATA: 62% OF RESPONDENTS TO THE COMMUNITY HEALTH NEEDS ASSESSMENT ONLINE SURVEY INDICATED ALLERGIES AS A MODERATE TO SEVERE PROBLEM IN DEKALB COUNTY. EXPLANATION FOR NOT ADDRESSING: KISHWAUKEE COMMUNITY HOSPITAL DID NOT CHOOSE THIS AS A PRIORITY TO ADDRESS, HOWEVER, IT MAY BE INDIRECTLY ADDRESSED AS A RESULT OF WORK ON OTHER IDENTIFIED HEALTH PRIORITIES LIKE ACCESS TO CARE, CARDIOVASCULAR DISEASE, RESPIRATORY DISEASE AND OVERWEIGHT/OBESITY IN ADULTS/CHILDREN.PRIORITY IDENTIFIED: CRIMESUPPORTING DATA: 71% OF RESPONDENTS TO THE COMMUNITY HEALTH NEEDS ASSESSMENT ONLINE SURVEY INDICATED THAT CRIME IS A MODERATE TO SERIOUS CONCERN IN DEKALB COUNTY. ALSO, ILLINOIS STATE POLICE REPORT THAT FOR 2009, CITY OF DEKALB WAS HIGHEST AT 3,573.8 PER 100,000 POPULATION, FOLLOWED BY SOMONAUK (2093.9) AND SYCAMORE (1763.5).EXPLANATION FOR NOT ADDRESSING: KISHWAUKEE COMMUNITY HOSPITAL DOES NOT HAVE THE EXPERTISE OR INFRASTRUCTURE TO SERVE AS A LEAD AROUND THIS AREA OF NEED.PRIORITY IDENTIFIED: JOB AVAILABILITYSUPPORTING DATA: 75% OF RESPONDENTS TO THE COMMUNITY HEALTH NEEDS ASSESSMENT ONLINE SURVEY INDICATED THAT JOB AVAILABILITY IS A MODERATE TO SERIOUS CONCERN IN DEKALB COUNTY.EXPLANATION FOR NOT ADDRESSING: KISHWAUKEE COMMUNITY HOSPITAL DOES NOT HAVE THE EXPERTISE OR INFRASTRUCTURE TO SERVE AS A LEAD AROUND THIS AREA OF NEED. KISHWAUKEE COMMUNITY HOSPITAL WILL SUPPORT COMMUNITY AGENCIES SUCH AS ILLINOIS EMPLOYMENT TRAINING CENTER, DEKALB COUNTY ECONOMIC DEVELOPMENT CORPORATION AND OTHER COMMUNITY PROGRAMS TO ADDRESS ISSUES NOT DIRECTLY ADDRESSED BY THE HEALTH SYSTEM.PRIORITY IDENTIFIED: ORAL HEALTHSUPPORTING DATA: 71.6% OF DEKALB COUNTY RESIDENTS HAVE DENTAL INSURANCE, HIGHER THAN THE STATE AVERAGE AT 61.9%. HOWEVER, 25.3% OF DEKALB COUNTY RESIDENTS CANNOT AFFORD DENTAL CARE WITHIN THE PAST YEAR.EXPLANATION FOR NOT ADDRESSING: KISHWAUKEE COMMUNITY HOSPITAL DOES NOT HAVE THE EXPERTISE OR INFRASTRUCTURE TO SERVE AS A LEAD AROUND THIS AREA OF NEED. PRIORITY IDENTIFIED: SUICIDESUPPORTING DATA: FOR THE PERIOD OF 2007-2009, SUICIDE RANKED AS THE 10TH LEADING CAUSE OF DEATH FOR DEKALB COUNTY RESIDENTS, AND THE SECOND LEADING CAUSE OF DEATH AMONG RESIDENTS AGED 15-44 YEARS OF AGE, PER THE CENTERS FOR DISEASE CONTROL AND PREVENTION. EXPLANATION FOR NOT ADDRESSING: KISHWAUKEE COMMUNITY HOSPITAL DOES NOT HAVE THE EXPERTISE OR INFRASTRUCTURE TO SERVE AS A LEAD AROUND THIS AREA OF NEED. KISHWAUKEE COMMUNITY HOSPITAL WILL SUPPORT COMMUNITY AGENCIES SUCH AS BEN GORDON CENTER YOUTH SERVICES BUREAU, DCPSAFE AND OTHER COMMUNITY PROGRAMS TO ADDRESS ISSUES NOT DIRECTLY ADDRESSED BY THE HEALTH SYSTEM.PRIORITY IDENTIFIED: UNEMPLOYMENTSUPPORTING DATA: 74% OF RESPONDENTS TO THE COMMUNITY HEALTH NEEDS ASSESSMENT ONLINE SURVEY INDICATED THAT UNEMPLOYMENT IS A MODERATE TO SERIOUS CONCERN IN DEKALB COUNTY. ILLINOIS DEPARTMENT OF EMPLOYMENT SECURITY REPORTS 9.2% OF DEKALB COUNTY RESIDENTS AS BEING UNEMPLOYED, LOWER THAN BOTH THE STATE AND U.S. RATES. EXPLANATION FOR NOT ADDRESSING: KISHWAUKEE COMMUNITY HOSPITAL DOES NOT HAVE THE EXPERTISE OR INFRASTRUCTURE TO SERVE AS A LEAD AROUND THIS AREA OF NEED. KISHWAUKEE COMMUNITY HOSPITAL WILL SUPPORT COMMUNITY AGENCIES SUCH AS ILLINOIS EMPLOYMENT TRAINING CENTER, DEKALB COUNTY ECONOMIC DEVELOPMENT CORPORATION AND OTHER COMMUNITY PROGRAMS TO ADDRESS ISSUES NOT DIRECTLY ADDRESSED BY THE HEALTH SYSTEM. KISHWAUKEE COMMUNITY HOSPITAL PART V, SECTION B, LINE 18E: POSTING OF FINANCIAL ASSISTANCE POLICY TO SYSTEM'S WEBSITE. KISHWAUKEE COMMUNITY HOSPITAL PART V, SECTION B, LINE 20D: BASED ON COMPLIANCE WITH LAWS OF STATE OF ILLINOIS, SPECIFICALLY THE UNINSURED PATIENT DISCOUNT ACT. PART VI, LINE 2: KISHWAUKEE COMMUNITY HOSPITAL IDENTIFIES COMMUNITY HEALTH NEEDS IN SEVERAL WAYS:* DEKALB AND KENDALL COUNTY HEALTH DEPARTMENT I-PLANS* KISHHEALTH SYSTEM, PRC COMMUNITY HEALTH NEEDS SURVEY 2009* U.S. GOVERNMENT HEALTHY PEOPLE 2010 AND 2020 GUIDELINES* UNIVERSITY OF WISCONSIN POPULATION HEALTH INSTITUTE COUNTY HEALTH RANKINGS & ROADMAPS* ILLINOIS DEPARTMENT OF PUBLIC HEALTH, HOSPITAL DATA* ILLINOIS HOSPITAL ASSOCIATION* INTERNAL REVIEW OF OUTPATIENT AND INPATIENT TRENDS, ESPECIALLY EMERGENCY DEPARTMENT USAGE * INPUT FROM OTHER COMMUNITY PROVIDERS. THIS INCLUDES PROVIDING HOSPITAL LEADERS SERVING ON BOARDS AND COMMITTEES THAT DIRECTLY OR INDIRECTLY IMPACT COMMUNITY HEALTH OR HELP THE HOSPITAL CONNECT TO UNDERSERVED OR VULNERABLE POPULATIONS. PART VI, LINE 3: INFORMATION IS PROVIDED AT REGISTRATION, VIA THE HOSPITAL WEBSITE, THROUGH CONSULTATIONS WITH FINANCIAL COUNSELORS FOR SOME OUTPATIENTS AS WELL AS INPATIENTS, DURING THE BILLING PROCESS ON STATEMENTS AND VIA PHONE CONVERSATIONS. PART VI, LINE 4: KISHWAUKEE COMMUNITY HOSPITAL SERVES ALL OF DEKALB COUNTY, IL, AND BORDER COMMUNITIES IN KANE AND OGLE COUNTIES. POPULATION OF THE HOSPITAL'S SERVICE AREA, BASED ON 2010 CENSUS, IS 127,307. THIS GEOGRAPHIC AREA INCLUDES A GROWING HISPANIC POPULATION. A UNIQUE POPULATION IN OUR SERVICE AREA IS NORTHERN ILLINOIS UNIVERSITY STUDENTS (22,900 ENROLLED IN 2012), INCLUDING FOREIGN STUDENTS AND VISITORS. THE HISPANIC POPULATION IS EXPECTED TO DECREASE BY 16% BY 2017. THE POVERTY LEVELS IN THE HOSPITAL'S PRIMARY MARKET ARE DEKALB, 15.9%; SYCAMORE, 7.0%; AND CORTLAND, 13.4%. PART VI, LINE 5: KISHWAUKEE COMMUNITY HOSPITAL IN DEKALB, IL, IS PART OF KISHHEALTH SYSTEM. THE HEALTH SYSTEM IS GOVERNED BY AN APPOINTED VOLUNTEER BOARD OF DIRECTORS, INDEPENDENT COMMUNITY LEADERS WHO RESIDE IN THE PRIMARY MARKETS SERVED BY THE HEALTH SYSTEM'S TWO HOSPITALS. THESE INDIVIDUALS ARE SELECTED FOR THE BOARD BECAUSE OF THEIR INTEREST AND EXPERTISE IN VARIOUS AREAS THAT CAN HELP MANAGEMENT CARRY OUT THE HEALTH SYSTEM'S MISSION. MEMBERS OF THE BOARD ARE NOT COMPENSATED FOR THEIR TIME. THE MEDICAL STAFF IS OPEN TO PHYSICIANS WHO MEET CRITERIA ESTABLISHED BY MEDICAL STAFF BYLAWS. PHYSICIANS ARE GIVEN THE OPPORTUNITY TO VOLUNTEER TO DO FREE COMMUNITY WELLNESS PROGRAMS ON HEALTH TOPICS. SURPLUS FUNDS GO BACK INTO THE ORGANIZATION TO SUPPORT OPERATIONS, CAPITAL IMPROVEMENTS, THE HEALTH SYSTEM'S COMMITMENT TO EXCELLENCE, EDUCATION AND INNOVATION, AND TO PROVIDE MEDICAL CARE TO ALL REGARDLESS OF ABILITY TO PAY. A COMMUNITY HEALTH ASSESSMENT WAS CONDUCTED IN THE FALL OF 2009, VIA A RANDOM TELEPHONE SURVEY. RESULTS ARE ONE COMPONENT USED FOR FY 13 ACTION PLANNING FOR. A COMMUNITY NEEDS ASSESSMENT ALSO WAS DONE DURING THIS CURRENT FISCAL YEAR, THE RESULTS OF WHICH WILL ARE REPORTED IN THE CURRENT YEAR FORM 990. BELOW ARE SPECIFIC EXAMPLES OF THE HOSPITAL'S EFFORTS TO PROMOTE HEALTH WITHIN THE COMMUNITY.COMMUNITY HEALTH NEEDS ASSESSMENT: IN COLLABORATION WITH DEKALB COUNTY HEALTH DEPARTMENT, KISHWAUKEE COMMUNITY HOSPITAL UNDEWROTE THE COST OF THE DATA COLLECTION PROCESS FOR THE COMMUNITY HEALTH NEEDS ASSESSMENT.THE PREVALENCE OF OBESITY IN CHILDREN AND ADULTS: COMMUNITY WELLNESS INITIATIVE IS TO DECREASE OBESITY AND THE CHRONIC DISEASES ASSOCIATED WITH IT BY OFFERING TARGETED WELLNESS PROGRAMS AND PREVENTATIVE SCREENINGS TO HELP OUR COMMUNITY GET WELL AND STAY WELL. THREE HEALTH PROMOTION SPECIALISTS AND A HEALTHY CULINARY INSTRUCTOR ARE EMPLOYED TO COLLABORATE WITH COMMUNITY ORGANIZATION, SCHOOLS AND TO WORK WITH THE COMMUNITY TO PROMOTE HEALTHY FOOD CHOICES, INCREASE FITNESS, AND DECREASE CHRONIC DISEASE. PROGRAMS INCLUDE FREE KNOW YOUR NUMBERS EVENTS, FREE BLOOD PRESSURE CLINICS, TIME TO QUIT TOBACCO CLASSES, WELLNESS FOR KIDS PROGRAM IN THE SCHOOLS, COORDINATED APPROACH TO CHILD HEALTH (CATCH) PROGRAM IN THE SCHOOLS TO PROMOTE PHYSICAL ACTIVITY, HEALTHIER EATING AND TO DECREASE SCREEN TIME, LIVEHEALTHY TEAM CHALLENGE WITH THE YMCA, AND INGREDIENTS FOR HEALTH LIVING SERIES. THE CATCH PROGRAM WAS NEW IN FY13 AND IS A PLANNED, SYSTEMATIC APPROACH TO CREATE BEHAVIORAL AND ENVIRONMENTAL CHANGE TO IMPROVE NUTRITION, PHYSICAL ACTIVITY, AND REDUCE SCREEN TIME TO DECREASE OBESITY RATES. THE CATCH PROGRAM IS EVIDENCE BASED AND DEVELOPED BY THE CENTERS FOR DISEASE CONTROL. DURING THE YEAR, 131 INDIVIDUALS WERE TRAINED TO TEACH CATCH. OF THE SCHOOL PROGRAMS MENTIONED ABOVE, IN EXCESS OF 21,468 STUDENTS WERE INSTRUCTED. ACCESS TO AFFORDABLE PRIMARY CARE: NEW PHYSICIANS WHO RECEIVE RECRUITMENT ASSISTANCE FROM KISHHEALTH SYSTEM OR WHO ARE EMPLOYED BY KISHHEALTH SYSTEM ARE REQUIRED TO ACCEPT MEDICAID AND UNINSURED PATIENTS. DURING FY 13, KISHHEALTH PHYSICIAN GROUP EMPLOYED SEVEN PHYSICIANS WITH PRACTICES IN SANDWICH, DEKALB AND GENOA . MENTAL HEALTH- DURING FY 13, THE CHILD DEVELOPMENT CLINIC NOW PROVIDES ASSESSMENT AND INTERVENTION OF CHILDHOOD DISORDERS INCLUDING AUTISM SPECTRUM DISORDERS, DEVELOPMENTAL DELAYS, SLEEP PROBLEMS, ANXIETY, DEPRESSION, AND OTHER MOOD DISORDERS, AS WELL AS COMMON SCHOOL, FAMILY, AND SOCIAL STRESSORS TYPICAL IN CHILDHOOD. THERE WERE 1525 VISITS TO THE CHILD DEVELOPMENT CLINIC IN FY 12. IN ADDITION, PSYCHIATRY, COUNSELING AND EMPLOYEE ASSISTANCE PROGRAM SERVICES ARE PROVIDED AT THE BEHAVIORAL HEALTH CENTER IN SYCAMORE AND AT THE VALLEY WEST COMMUNITY HOSPITAL MEDICAL OFFICE BUILDING. THERE WERE OVER 6,200 BEHAVIORAL HEALTH PATIENT VISITS IN FY13. TYPE II DIABETES: TO ADDRESS THE PREVALENCE OF DIABETES IN THE ADULT POPULATION, THE SYSTEM CONTINUED TO OPERATE DIABETES EDUCATION CENTERS AT KISH HOSPITAL AND VALLEY WEST WITH SATELLITE SERVICES AT KISHHEALTH FAMILY & SPECIALTY CARE IN GENOA. THE KISHWAUKEE COMMUNITY HOSPITAL DIABETES EDUCATION CENTER HAD 7,915 CONSULTATIONS IN FY13. ON AVERAGE, 36 INPATIENTS A MONTH AT KCH WERE DIAGNOSED WITH DIABETES. IN FY13, KISH HOSPITAL HELD "THE ABCS OF DIABETES" IN CONJUNCTION WITH DEKALB CLINIC PROVIDING RESOURCES FOR PEOPLE WITH DIABETES. ABOUT 150 PEOPLE ATTENDED. RESULTS OF THE KISHHEALTH SYSTEM PRC COMMUNITY HEALTH NEEDS SURVEY 2009 INDICATED THAT AMONG SURVEYED ADULTS IN THE VWCH SERVICE AREA, 8.2% REPORT HAVING BEEN DIAGNOSED WITH DIABETES, EQUAL TO STATE BUT LOWER THAN NATIONAL PROPORTIONS. CARDIOVASCULAR DISEASE AND HOSPITAL-BASED AND COMMUNITY OUTREACH SERVICES: COMMUNITY BENEFIT ACTIVITIES IN FY 13 THAT PROMOTED CARDIOVASCULAR HEALTH INCLUDED A WOMEN'S HEALTH EVENT AT KCH IN FEBRUARY WHICH HAD 1,300 ATTENDEES AND KNOW YOUR NUMBERS EVENTS RESULTED IN 234 FREE SCREENINGS. BLOOD PRESSURE CLINICS: TOTAL FREE BLOOD PRESSURE CHECKS FOR KCH WAS 2,430.CANCER CARE SERVICES: PROVIDED FREE SKIN CANCER SCREENINGS AT WOMEN'S HEALTH EVENT RESULTING IN 75 SKIN CANCER SCREENINGS AT KCH. MORE THAN 30 MAMMOGRAMS WERE ALSO PROVIDED TO UNINSURED WOMEN AT A "WOMEN MATTER" EVENT AT THE HOSPITAL. PROVIDED FINANCIAL SUPPORT OF AMERICAN CANCER SOCIETY RELAYS FOR LIFE DEKALB COUNTY AND NORTHERN ILLINOIS UNIVERSITY. OTHER: ENTERED INTO AGREEMENTS WITH THE KISHWAUKEE FAMILY YMCA TO HELP UNDERWRITE THE COST OF FITNESS AND RECREATIONAL ACTIVITIES FOR COMMUNITY MEMBERS. IN ADDITION, COMMUNITY WELLNESS EDUCATORS VISITED 225 CLASSROOMS AND WORKED WITH 5,944 STUDENTS.AFFORDABLE ACCESS TO CHILDBIRTH EDUCATION AND OBSTETRIC HOSPITAL SERVICES: THE BREASTFEEDING CENTER OPERATED ITS FIRST FULL YEAR AT KISHWAUKEE COMMUNITY HOSPITAL, WHICH PROVIDED FREE IN-PERSON LACTATION COUNSELING, ONLINE, AND OVER THE PHONE, AS WELL AS, SUPPORT GROUPS. THE TOTAL NUMBER OF TELEPHONE CALLS RECEIVED AT THE BREASTFEEDING CENTER WAS 754. THERE WERE 270 INITIAL LACTATION VISITS TO THE BREASTFEEDING CENTER AND 319 FOLLOW-UP VISITS. KCH OFFERED 72 TUITION WAIVERS FOR INFANT AND CHILDBIRTH CLASSES FOR CLIENTS OF THE DEKALB COUNTY HEALTH DEPARTMENT IN THE WIC PROGRAM AND HEALTHY MOMS/HEALTHY KIDS PROGRAM AND PROVIDED FREE PREPARED CHILDBIRTH CLASSES FOR YOUNG MOMS. MONTHLY MOMS BREASTFEEDING SUPPORT GROUP WAS HELD FOR 134 PARTICIPANTS AND WAS LED BY A LACTATION CONSULTANT.FARMERS MARKET VOUCHERS: DURING THE SUMMER OF FY13, KISHWAUKEE COMMUNITY HOSPITAL WORKING WITH THE DEKALB COUNTY HEALTH DEPARTMENT'S WIC PROGRAM AND THE FAMILY SERVICE AGENCY'S SENIOR SERVICES, VOUCHERS WERE PROVIDED TO LOW INCOME INDIVIDUALS. THE VOUCHERS WERE USED TO PURCHASE FRUITS, VEGETABLES, AND HERBS FROM PARTICIPATING VENDORS. THE VENDORS TURNED THE VOUCHERS IN TO THE HOSPITAL, WHICH ISSUED PAYMENT. MORE THAN $6,000 IN FRUITS AND VEGETABLES WERE PURCHASED. CASH AND IN-KIND DONATIONS: EACH YEAR AN ALLOCATION IS MADE IN THE OPERATING BUDGET FOR DONATIONS TO COMMUNITY EVENTS AND ORGANIZATIONS THAT IMPROVE THE HEALTH, WELFARE, AND QUALITY OF LIFE IN THE COMMUNITIES SERVED BY KISHHEALTH SYSTEM. THE SYSTEM ESPECIALLY WANTS TO SUPPORT COMMUNITY ACTIVITIES THAT ENCOURAGE CHILD AND ADULT PHYSICAL ACTIVITY; EFFORTS THAT REACH UNDERSERVED AND VULNERABLE POPULATIONS; YOUTH MENTORING, EDUCATION, AND THE ARTS; DISEASE PREVENTION, AWARENESS, AND RESEARCH; MENTAL HEALTH; ECONOMIC DEVELOPMENT, AND OTHER COMMUNITY BUILDING ACTIVITIES. IN-KIND DONATIONS AND SERVICES SUCH AS PERSONNEL TIME, SURPLUS SUPPLIES, FOOD, AND BOTTLED WATER ALSO ARE TRACKED. PART VI, LINE 6: KISHHEALTH SYSTEM AND ITS NON-PROFIT AFFILIATES, KISHWAUKEE COMMUNITY HOSPITAL, VALLEY WEST COMMUNITY HOSPITAL, DEKALB COUNTY HOSPICE, CENTER FOR FAMILY HEALTH, CENTER FOR FAMILY HEALTH-MALTA, KISHHEALTH HOME CARE, KISHHEALTH PHYSICIAN GROUP AND THE KISHHEALTH FOUNDATION, ALL PROMOTE THE HEALTH OF COMMUNITIES IN OUR REGION THROUGH DIRECT SERVICES, DONATIONS OF LEADERSHIP TIME ON VARIOUS COMMITTEES AND BOARDS, AND THROUGH CASH CONTRIBUTIONS.KISHHEALTH SYSTEM UNDERWROTE $1,190,000 IN OPERATIONAL LOSSES IN FY 13 FOR THE TWO CENTERS FOR FAMILY HEALTH, AND $3,000,000 FOR KISHWAUKEE PHYSICIANS GROUP, BOTH VITAL SERVICES FOR THE HEALTH OF THE COMMUNITY. KCH ALSO MADE $462,240 IN CONTRIBUTIONS TO SEVERAL ORGANIZATIONS IN FY13, NOTABLY $135,000 TO KISHWAUKEE COLLEGE FOUNDATION, $25,000 TO KISHWAUKEE FAMILY YMCA, $22,240 TO THE ILLINOIS HOSPITAL RESEARCH AND EDUCATION FOUNDATION, AND $8,180 TO THE KISHWAUKEE UNITED WAY. IN ADDITION, HEALTH SYSTEM EMPLOYEES CONTRIBUTED MORE THAN 2,032 HOURS OF IN-KIND SERVICE TO COMMUNITY ORGANIZATIONS, EDUCATIONAL INSTITUTIONS AND OTHER ACTIVITIES THAT PROMOTE HEALTH, EDUCATION AND QUALITY OF LIFE. VALLEY WEST COMMUNITY HOSPITAL IS A CRITICAL ACCESS HOSPITAL IN SANDWICH. DEKALB COUNTY HOSPICE, DEKALB, IL, PROVIDES FREE CARE AND SUPPORT FOR THE TERMINALLY ILL AS WELL AS GRIEF SUPPORT TO THE PUBLIC. COMMUNITY CARES CLINIC, DEKALB, IL IS A PRIMARY CARE CLINIC FOR MEDICAID AND UNINSURED; KISHHEALTH PHYSICIAN GROUP PROVIDES ACCESS TO MEDICAL SERVICES, ESPECIALLY THE RURAL AREAS AND ACCEPTS MEDICAID AND UNINSURED PATIENTS, AND KISHHEALTH FOUNDATION IN DEKALB, IL RAISES MONEY FOR KISHWAUKEE COMMUNITY HOSPITAL, VALLEY WEST COMMUNITY HOSPITAL, DEKALB COUNTY HOSPICE AND THE CENTERS FOR FAMILY HEALTH AND FUNDS EQUIPMENT PURCHASES AND PATIENT SERVICES. REPORTS FILED WITH STATES PART VI, LINE 7 IL 1 AMERICAN CANCER SOCIETY 143 FIRST STREET BATAVIA IL 60510 131788491 501(C)(3) 19659 TO PROVIDE FINANCIAL ASSISTANCE FOR ACTIVITIES RELATED TO CANCER RESEARCH AND EDUCATION AMERICAN HEART ASSOCIATION PO BOX 4002902 DES MOINES IA 50340 135613797 501(C)(3) 15000 TO PROVIDE FINANCIAL ASSISTANCE FOR ACTIVITIES RELATED TO HEART HEALTH RESEARCH AND EDUCATION BEN GORDON CENTER 12 HEALTH SERVICES DRIVE DEKALB IL 60115 362771343 501(C)(3) 25000 TO PROVIDE FINANCIAL ASSISTANCE FOR MENTAL HEALTH SERVICES FOR UNDER OR UNINSURED DEKALB COUNTY AMERICAN RED CROSS 2727 SYCAMORE ROAD SUITE 2A DEKALB IL 60115 530196605 501(C)(3) 5000 TO PROVIDE FINANCIAL ASSISTANCE FOR LOCAL DISASTER RELIEF DEKALB COUNTY YOUTH SERVICES BUREAU 330 GROVE STREET DEKALB IL 60115 363034427 501(C)(3) 7500 TO PROVIDE FINANCIAL ASSISTANCE FOR ACTIVITIES RELATED TO YOUTH SERVICES GENOA CHAMBER OF COMMERCE 327 W MAIN STREET GENOA IL 60135 362355846 501(C)(6) 5700 TO PROVIDE FINANCIAL ASSISTANCE FOR ACTIVITIES RELATED TO PROMOTION OF GENOA AREA ECONOMIC DEVELOPMENTTO PROVIDE FINANCIAL ASSISTANCE FOR ACTIVITIES RELATED TO PROMOTION OF GENOA AREA ECONOMIC VITALITYTO PROVIDE FINANCIAL ASSISTANCE FOR ACTIVITIES RELATED TO PROMOTION OF GENOA AREA ECONOMIC VITALITY IHREF 24676 NETWORK PLACE CHICAGO IL 60673 237421930 501(C)(3) 22240 TO PROVIDE RELIEF FOR HOPSITALS NEGATIVELY AFFECTED BY ASSESSMENTS KISHWAUKEE COLLEGE FOUNDATION 21193 MALTA ROAD MALTA IL 60150 237433949 501(C)(3) 135000 TO PROVIDE FINANCIAL ASSISTANCE FOR PROMOTION OF HEALTHCARE EDUCATION KISHWAUKEE FAMILY YMCA 2500 BETHANY ROAD SYCAMORE IL 60178 362379643 501(C)(3) 25000 TO PROVIDE FINANCIAL ASSISTANCE RELATED TO HEALTH AND FITNESS ACTIVITES FOR LOW INCOME CHILDREN AND FAMILIES KISHWAUKEE UNITED WAY PO BOX 311 115 N FIRST STREET DEKALB IL 60115 366158489 501(C)(3) 8179 TO PROVIDE FINANCIAL ASSISTANCE IN SUPPORT OF COMMUNITY SOCIAL SERVICES MARCH OF DIMES 5411 E STATE STREET STE 10 SYCAMORE IL 60178 131846366 501(C)(3) 7405 TO PROVIDE FINANCIAL ASSISTANCE IN SUPPORT OF PRE-NATAL EDUCATION AND RESEARCH MIDWEST MUSEUM OF NATURAL HISTORY 425 WEST STATE STREET SYCAMORE IL 60178 611402985 501(C)(3) 6000 TO PROVIDE FINANCIAL ASSISTANCE IN SUPPORT OF PRODUCING EDUCATION MATERIALS FOR THE MUSEUM NORTHERN ILLINOIS FOOD BANK 273 DEARBORN COURT GENEVA IL 60134 363203648 501(C)(3) 5000 TO PROVIDE FINANCIAL ASSISTANCE IN SUPPORT OF A FOOD PANTRY FOR THE COMMUNITY VOLUNTARY ACTION CENTER 1606 BETHANY ROAD SYCAMORE IL 60178 362798257 501(C)(3) 8000 TO PROVIDE FINANCIAL ASSISTANCE IN SUPPORT OF MEALS ON WHEELS AND TRANSPORTATION SERVICES FOR LOW INCOME AND ELDERLY OPPORTUNITY HOUSE 202 LUCAS STREET PO BOX 9 SYCAMORE IL 60178 362476231 501(C)(3) 5000 TO PROVIDE ASSISTANCE IN SUPPORT OF SPECIAL OLYMPICS SYCAMORE CHAMBER OF COMMERCE 407 W STATE STREET STE 10 SYCAMORE IL 60178 361848940 501(C)(6) 7275 TO PROVIDE FINANCIAL ASSISTANCE TO PROMOTE SYCAMORE ECONOMIC VITALITY AND DEVELOPMENT 14 2 KISHWAUKEE COMMUNITY HOSPITAL AUXILIARY SCHOLARSHIP PROGRAM 23 20000 PROCEDURE FOR MONITORING GRANTS IN THE U.S.: PART I, LINE 2: SCHEDULE I, PART I, LINE 2: THE ORGANIZATION MAINTAINS SPECIFIC POLICIES AND QUALIFICATIONS FOR ALL GRANTS AVAILABLE. APPLICANTS MUST APPLY FOR THE RESPECTIVE GRANT AND BE APPROVED BY THE FUNDS GOVERNING BOARD. THE USE OF THE FUNDS IS MONITORED BY THE GOVERNING BOARD OF KISHWAUKEE COMMUNITY HOSPITAL. REQUESTS FOR FINANCIAL ASSISTANCE FROM OTHER CHARITABLE ORGANIZATIONS ARE REVIEWED AND APPROVED BY THE VP - FINANCE OF KISHHEALTH SYSTEM. IF NECESSARY DUE TO THE DOLLAR AMOUNT OF THE REQUEST, THESE ITEMS MAY ALSO BE PRESENTED TO THE BOARD OF DIRECTORS. A BUDGET IS SET ANNUALLY FOR CHARITABLE ASSISTANCE TO OTHER ORGANIZATIONS 0 1 0 0 0 0 0 0 0 KEVIN POORTEN 0 548333 0 168139 0 250000 0 196100 0 24053 0 1186625 0 0 LOREN FOELSKE 0 256230 0 28504 0 0 0 94286 0 23218 0 402238 0 0 BRAD COPPLE 0 290654 0 68983 0 0 0 48700 0 23484 0 431821 0 0 PAM DUFFY 0 205275 0 43878 0 0 0 21863 0 9007 0 280023 0 0 JOE DANT 0 215055 0 40618 0 0 0 22696 0 23145 0 301514 0 0 MIKE KOKOTT 0 164639 0 30189 0 0 0 19424 0 15418 0 229670 0 0 ROGER HEATH BELL 0 216114 0 57458 0 0 0 22712 0 28395 0 324679 0 0 DR MICHAEL KULISZ 0 310004 0 92702 0 0 0 75900 0 23358 0 501964 0 0 MARK THATE 0 175149 0 40790 0 57200 0 10707 0 15579 0 299425 0 0 MICHAEL MUZZILLO THRU 62912 0 107905 0 31214 0 90400 0 11876 0 551 0 241946 0 0 THOMAS W TILTON DO 347770 0 66999 0 0 0 10146 0 21970 0 446885 0 0 0 THOMAS WARZECHA 137901 0 5460 0 0 0 3309 0 21890 0 168560 0 0 0 KENYA M WILLIAMS MD 216756 0 29075 0 0 0 7184 0 355 0 253370 0 0 0 JASMEET DHALIWAL 294054 0 451470 0 0 0 8995 0 21956 0 776475 0 0 0 LISA ACKLAND 130787 0 10152 0 0 0 0 0 21882 0 162821 0 0 0 PART I, LINE 4B THE ORGANIZATION'S EXECUTIVES PARTICIPATE IN A NONQUALIFIED DEFERRED COMPENSATION PLAN. CONTRIBUTIONS FOR CALENDAR YEAR 2012 RELATED TO OFFICERS, DIRECTORS, AND KEY EMPLOYEES OF KISHHEALTH FOUNDATION WERE $334,200. THIS CONTRIBUTION REFLECTS AMOUNTS DUE FOR BOTH THE FISCAL YEARS ENDING APRIL 30, 2011 AND APRIL 30, 2012, WITH 50% OF THE CONTRIBUTION BEING ALLOCATED TO EACH YEAR. THE ORGANIZATION'S CEO PARTICIPATES IN AN ADDITIONAL NONQUALIFIED DEFERRED COMPENSATION PLAN. CONTRIBUTIONS FOR CALENDAR YEAR 2012 WERE $60,000. DURING FY13, THE CEO TOOK A DISTRIBUTION FROM THE DEFERRED COMPENSATION PLAN IN THE AMOUNT OF $250,000. THIS DISTRIBUTION IS INCLUDED AS W-2 WAGES, HOWEVER THE ACCRUAL OF THE DEFERRED COMPENSATION PAYMENTS HAS ALSO BEEN INCLUDED AS "OTHER COMPENSATION" ON PRIOR YEAR FORM 990S. A CITY OF SYCAMORE DEKALB COUNTY ILLINOIS HEALTH FACILITIES REVENUE BOND 861091967 452032AJ4 2008-08-01 63685000 CONSTRUCTION OF NEW FACILITY FOR KISHWAUKEE COMMUNITY HOSPITAL 1 1 0 A 63371994 328434 2007 0 1 1 1 A 0 0 0 0 0 0 0 A 0 1 0 1 0 0 0 0 0 A 0 SCHEDULE K PART IV, ARBITRAGE, LINE 2C DATE REBATE COMPUTATION PERFORMED ISSUER NAME: CITY OF SYCAMORE, DEKALB COUNTY, ILLINOIS HEALTH FACILITIES RE DATE THE REBATE COMPUTATION WAS PERFORMED: 07/31/2013 FORM 990, PART VI, SECTION A, LINE 2 KEVIN POORTEN AND LOREN FOELSKE ARE BOTH EMPLOYEES OF KISHHEALTH SYSTEM, THE PARENT ORGANIZATION OF KISHWAUKEE COMMUNITY HOSPITAL. MR. POORTEN IS PRESIDENT AND CEO OF KISHWHEALTH SYSTEM AND SERVES AS AN EX-OFFICIO DIRECTOR FOR ALL ORGANIZATIONS RELATED TO KISHHEALTH SYSTEM. MR. FOELSKE SERVES AS THE VICE-PRESIDENT - FINANCE OF KISHHEALTH SYSTEM, WHICH IS THE PARENT ORGANIZATION FOR ALL RELATED ENTITIES. BRAD COPPLE, AS THE PRESIDENT OF KISHWAUKEE COMMUNITY HOSPITAL, IS CONSIDERED AN OFFICER. HE IS ALSO PRESIDENT OF VALLEY WEST COMMUNITY HOSPITAL, A RELATED ENTITY, AND IS COMPENSATED BY KISHHEALTH SYSTEM. MR. POORTEN AND MR. FOELSKE ARE ALSO CONSIDERED OFFICERS OF KISHWAUKEE COMMUNITY HOSPITAL AND KISHHEALTH SYSTEM, AS DESCRIBED ABOVE. TOM MATYA AND MICHAEL CULLEN ARE MEMBERS OF THE KISHWAUKEE COMMUNITY HOSPITAL BOARD OF DIRECTORS. THEY ALSO SERVE ON THE BOARD OF DIRECTORS OF KISHHEALTH SYSTEM, THE PARENT ORGANIZATION OF KISHWAUKEE COMMUNITY HOSPITAL. THE FOLLOWING INDIVIDUALS ARE OFFICERS OR KEY EMPLOYEES OF KISHHEALTH SYSTEM AND ARE ALSO CONSIDERED OFFICERS OR KEY EMPLOYEES OF KISHWAUKEE COMMUNITY HOSPITAL. THEY ARE ALL COMPENSATED BY KISHHEALTH SYSTEM: BRAD COPPLE, PRESIDENT KCH & VWCH PAM DUFFY, VP PATIENT CARE JOE DANT, VP DEVELOPMENT MIKE KOKOTT, ASST. VP MARKETING HEATH BELL, VP AND CHIEF INFORMATION OFFICER MARK THATE, VP HUMAN RESOURCES DR. MICHAEL KULISZ, CHIEF MEDICAL OFFICER DAVE PROULX, VP OPERATIONS VWCH MICHAEL MUZZILLO, VP OPERATIONS VWCH (TERMINATED EMPLOYMENT IN 2012) FORM 990, PART VI, SECTION A, LINE 6 KISHHEALTH SYSTEM IS THE SOLE MEMBER OF KISHWAUKEE COMMUNITY HOSPITAL. FORM 990, PART VI, SECTION A, LINE 7A AS THE SOLE MEMBER AND PARENT ORGANIZATION OF KISHWAUKEE COMMUNITY HOSPITAL, KISHHEALTH SYSTEM HAS THE RIGHT TO APPROVE THE ELECTION OF MEMBERS OF THE HOSPITAL'S GOVERNING BOARD, PER THE HOSPITAL'S BYLAWS. FORM 990, PART VI, SECTION A, LINE 7B KISHHEALTH SYSTEM (KHS) SERVES AS THE SOLE MEMBER AND PARENT ORGANIZATION OF VALLEY WEST COMMUNITY HOSPITAL (VWCH). PER THE BYLAWS, WITH RESPECT TO THE GOVERNANCE OF VWCH, THE FOLLOWING POWERS SHALL BE RESERVED TO THE SOLE CORPORATE MEMBER. PER THE BYLAWS, WITH RESPECT TO THE GOVERNANCE OF KCH, THE FOLLOWING POWERS SHALL BE RESERVED TO THE SOLE CORPORATE MEMBER: A. ELECTING THE MEMBERS OF THE KCH BOARD; B. APPROVING, EVALUATING AND/OR REMOVING THE PRESIDENT AND CEO AND REVIEWING AND APPROVING THE EMPLOYMENT CONTRACT OF THE PRESIDENT AND CEO AND ESTABLISHING COMPENSATION FOR SUCH OFFICE; C. APPROVING THE STRATEGIC PLAN FOR KCH; D. APPROVING THE DISPOSITION OF ANY ASSETS OTHER THAN IN THE ORDINARY COURSE OF BUSINESS FOR KCH; E. APPROVING ANY CHANGE IN MEMBERSHIP OF KCH; F. APPROVING THE ADOPTION OF AND AMENDMENTS TO THE ORGANIZATIONAL DOCUMENTS, INCLUDING THE ARTICLES OF INCORPORATION AND BYLAWS OF KCH; G. APPROVING A PLAN OF MERGER OR A PLAN OF CONSOLIDATION OF KCH OR ESTABLISHING A NEW SUBSIDIARY OR SISTER ENTITY; H. APPROVING A PLAN FOR THE DISTRIBUTION OF THE ASSETS OF KCH; I. INITIATING, TAKING ANY AND ALL ACTIONS, AND EXERCISING ALL APPROVAL RIGHTS OF THE DIRECTORS PURSUANT TO THE APPLICABLE MEDICAL STAFF BYLAWS; J. IMPLEMENTING AND MONITORING KCH OPERATIONAL QUALITY IMPROVEMENT POLICIES AND PROGRAMS; K. ACCEPTING GIFTS, GRANTS, BEQUESTS AND DONATIONS ON BEHALF OF KCH; L. APPROVAL OF THE ANNUAL OPERATING AND CAPITAL BUDGETS FOR KCH; M. EXERCISING ANY RIGHTS THAT KCH HAS AS A SHAREHOLDER OR MEMBER OF ANY SUBSIDIARY ENTITY; N. APPROVING ANY AFFILIATIONS OF KCH; O. APPROVING AND/OR DETERMINING (I) THE CREATION OF NEW HEALTH SERVICES TO BE PROVIDED AND THE LOCATION OF SUCH HEALTH SERVICES AND (II) THE DISCONTINUANCE OF ANY HEALTH SERVICE; P. AUTHORIZING THE SALE, LEASE, EXCHANGE OR MORTGAGE OF ALL OR SUBSTANTIALLY ALL OF THE PROPERTY OR ASSETS OF KCH; Q. AUTHORIZING THE VOLUNTARY DISSOLUTION OF KCH, OR REVOKING THE PROCEEDINGS THEREOF; R. REQUIRING MINUTES OF MEETINGS, FINANCIAL RECORDS, AND SUCH OTHER INFORMATION AS MAY BE NECESSARY TO PROPERLY EVALUATE THE PERFORMANCE OF KCH; S. INITIATING ACTION TO REMOVE OR REINSTATE A DIRECTOR WHEN, IN THE OPINION OF THE KHS BOARD, IT IS IN THE BEST INTERESTS OF KHS OR KCH. ANY ACTION TO REMOVE OR REINSTATE SHALL REQUIRE A MAJORITY VOTE OF THOSE KHS DIRECTORS THEN IN OFFICE PRESENT AND VOTING AT A MEETING OF THE KHS BOARD AT WHICH A QUORUM IS PRESENT. IN ANY ACTION(S) TO REMOVE TAKEN BY THE KHS BOARD, THE DIRECTOR IN QUESTION SHALL BE ADVISED AT LEAST TWENTY (20) DAYS PRIOR TO THE MEETING THAT THE ACTION WILL BE CONSIDERED AND SHALL BE GIVEN THE OPPORTUNITY TO MAKE A STATEMENT, PRESENT WITNESSES ON HIS/HER BEHALF AND QUESTION THOSE PRESENTING REASONS FOR HIS/HER REMOVAL. ALL ACTIONS TO REMOVE SHALL BE TAKEN IN CLOSED SESSIONS OF THE KHS BOARD; AND T. TRANSFERRING MONEY OR PROPERTY AMONG KCH, KHS AND/OR ONE OR MORE SUBSIDIARY CORPORATIONS AND TRANSFERRING MONEY OR PROPERTY FROM A SUBSIDIARY CORPORATION, INCLUDING REQUIRING THE DIRECTORS, OFFICERS, OR TRUSTEES OF ANY SUBSIDIARY CORPORATION TO TRANSFER MONEY OR OTHER PROPERTY TO KHS. SUBJECT TO THE POWERS OF THE BOARD OF DIRECTORS OF EACH SUBSIDIARY CORPORATION, THE KHS BOARD MAY INITIATE AND TAKE THE FOREGOING ACTIONS ON BEHALF OF KHS AND THE SUBSIDIARY CORPORATIONS. FORM 990, PART VI, SECTION B, LINE 11 A DRAFT COPY OF FORM 990 IS PROVIDED TO THE GOVERNING BODY (BOARD OF DIRECTORS) AND THE GOVERANCE COMMITTEE FOR REVIEW BY THE RETURN PREPARER PRIOR TO FILING. THE ORGANIZATION'S CEO, CFO, AND OTHER MEMBERS OF THE ACCOUNTING DEPARTMENT ARE ALSO PROVIDED A COPY OF THE RETURN FOR THEIR REVIEW. THE CHAIR OF THE AUDIT COMMITTEE AND THE AUDIT COMMITTEE MEMBERS ARE ALSO PROVIDED DRAFT COPIES AND REVIEW. IF CHANGES ARE NECESSARY, THEY ARE REPORTED TO THE RETURN PREPARER AND INCORPORATED INTO THE FINAL RETURN. FORM 990, PART VI, SECTION B, LINE 12C CONFLICTS OF INTEREST ARE INVESTIGATED BY APPOINTED MEMBERS OF THE GOVERANCE COMMITTEE ON AN ONGOING BASIS. IF IT IS DETERMINED THAT AN INDIVIDUAL FAILED TO DISCLOSE AN ACTUAL OR POSSIBLE CONFLICT OF INTEREST, IT SHALL INFORM THE INDIVIDUAL OF SUCH A BELIEF AND AFFORD HIM AN OPPORTUNITY TO EXPLAIN. AFTER SAID EXPLANATION, THE BOARD SHALL TAKE APPROPRIATE DISCIPLINARY AND CORRECTIVE ACTION AS DEEMED NECESSARY. THE CONFLICT OF INTEREST POLICY IS REVIEWED BY THE BOARD ANNUALLY AND UPDATED AS NEEDED. FORM 990, PART VI, SECTION B, LINE 15 KISHWAUKEE COMMUNITY HOSPITAL IS NOT DIRECTLY INVOLVED IN DETERMINING THE COMPENSATION OF THE CEO, EXECUTIVE DIRECTOR, OR TOP MANAGEMENT, AS THE INDIVIDUALS ARE EMPLOYED THROUGH KISHHEALTH SYSTEM. KISHHEALTH SYSTEM DOES COMPLY WITH THE REQUIREMENTS NOTED ABOVE. THROUGH THE OVERSIGHT OF THE BOARD OF DIRECTORS EXECUTIVE COMPENSATION COMMITTEE, THE KISHHEALTH SYSTEM EXECUTIVE TOTAL COMPENSATION PROGRAM WILL BE COMPETITIVELY POSITIONED IN THE MARKET PLACE OF RELEVANT ORGANIZATIONS AND FALL WITHIN THE SAFE HARBOR GUIDELINES ESTABLISHED BY THE INTERMEDIATE SANCTIONS RULES. THE EXECUTIVE COMPENSATION COMMITTEE IS MADE UP OF THREE MEMBERS OF THE BOARD OF DIRECTORS WHO MEET THE BOARD APPROVED DEFINITION OF "INDEPENDENT DIRECTORS". ANNUALLY THE EXECUTIVE COMPENSATION COMMITTEE CONTRACTS WITH SULLIVAN, COTTER AND ASSOCIATES, AN INDEPENDENT HUMAN RESOURCES CONSULTING FIRM TO PROVIDE THE COMMITTEE ANALYSIS AND COMPARABILITY DATA. USING THE SUPPLIED DATA THE COMPENSATION COMMITTEE APPROVES EACH EXECUTIVE'S TOTAL CASH COMPENSATION AND PROVIDES CONTEMPORANEOUS SUBSTANTIATION OF THE DELIBERATION AND DECISION. TOTAL CASH COMPENSATION IS DEFINED AS THE SUM OF BASE SALARIES PLUS INCENTIVE AWARDS. BASED ON THE COMPARABILITY DATA AND THE PERFORMANCE OF EACH EXECUTIVE IN MEETING GOALS AND STRATEGIC OBJECTIVES, THE EXECUTIVE COMPENSATION COMMITTEE APPROVES INCREASES AND INCENTIVE AWARDS FOR EACH EXECUTIVE WITHIN THE GUIDELINES ESTABLISHED. THE EXECUTIVE COMPENSATION COMMITTEE REPORTS ON ALL COMPENSATION MATTERS TO THE FULL BOARD OF DIRECTORS. FORM 990, PART VI, SECTION C, LINE 19 THE ORGANIZATION'S GOVERNING DOCUMENTS ARE AVAILABLE TO THE PUBLIC UPON REQUEST IN WRITING TO ADMINISTRATION. DESCRIPTION OF HOURS FOR RELATED ORGANIZATIONS FORM 990, PART VII, COLUMN (B) AVERAGE HOURS PER WEEK FOR THE INDIVIDUALS IDENTIFIED AS OFFICER'S ARE ESTIMATES OF THE INDIVIDUALS TOTAL TIME PER WEEK UTILIZED FOR WORK RELATED TO KISHWAUKEE COMMUNITY HOPSITAL. OTHER FEES FORM 990, PART IX, LINE 11G PURCHASED PERSONNEL : PROGRAM SERVICE EXPENSES 900,374. MANAGEMENT AND GENERAL EXPENSES 6,822. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 907,196. OTHER CONTRACTED SERVICES : PROGRAM SERVICE EXPENSES 3,034,628. MANAGEMENT AND GENERAL EXPENSES 659,715. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 3,694,343. OTHER CONSULTING : PROGRAM SERVICE EXPENSES 40,741. MANAGEMENT AND GENERAL EXPENSES 250,522. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 291,263. MEDICAL DIRECTOR FEES : PROGRAM SERVICE EXPENSES 383,873. MANAGEMENT AND GENERAL EXPENSES 75,000. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 458,873. BROKER FEES : PROGRAM SERVICE EXPENSES 7,368. MANAGEMENT AND GENERAL EXPENSES 0. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 7,368. SERVICE CONTRACTS : PROGRAM SERVICE EXPENSES 654,028. MANAGEMENT AND GENERAL EXPENSES 0. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 654,028. LAB FEES : PROGRAM SERVICE EXPENSES 904,053. MANAGEMENT AND GENERAL EXPENSES 0. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 904,053. PHYSICIAN FEES : PROGRAM SERVICE EXPENSES 10,354,894. MANAGEMENT AND GENERAL EXPENSES 178,400. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 10,533,294. CHANGES IN NET ASSETS OR FUND BALANCES: FORM 990, PART XI, LINE 9: EQUITY DISTRIBUTION TO KISHHEALTH SYSTEM -3,573,000. CHANGE OF INTEREST IN NET ASSETS OF KISHHEALTH FOUNDATION 4,979. BOOK/TAX DIFFERENCES IN K-1 PASSTHROUGH ENTITIES 236,584. OTHER EQUITY ADJUSTMENT -8,246. CUMULATIVE EQUITY ADJUSTMENT -182,933. ROUNDING -30. RESPONSIBILITY FOR OVERSIGHT OF FINANCIAL STATEMENTS FORM 990, PART XI, LINE 3C NO CHANGES IN THIS PROCESS WERE MADE DURING THE TAX YEAR. THE ORGANIZATION MAINTAINS AN INDEPENDENT AUDIT COMMITTEE WHICH IS RESPONSIBLE FOR OVERSIGHT OF THE AUDITED FINANCIAL STATEMENTS. THIS COMMITTEE IS ALSO RESPONSIBLE FOR THE SELECTION OF THE INDEPENDENT AUDITOR. MEMBERS OF THE AUDIT COMMITTEE ARE ALSO MEMBERS OF THE KISHHEALTH SYSTEM BOARD OF DIRECTORS. KISHEALTH SYSTEM IS THE PARENT CORPORATION OF KISHWAUKEE COMMUNITY HOSPITAL. KISHHEALTH SYSTEM ONE KISH HOSPITAL DRIVE DEKALB IL 60115 363649080 PARENT ORGANIZATION OF 501(C)(3) HEALTH SYSTEM IL 501(C)(3) 11B N/A 0 VALLEY WEST COMMUNITY HOSPITAL ONE KISH HOSPITAL DRIVE DEKALB IL 60115 364244337 HEALTHCARE SERVICES, PRIMARILY ACUTE CARE IL 501(C)(3) 3 KISHHEALTH SYSTEM 0 DEKALB COUNTY HOSPICE ONE KISH HOSPITAL DRIVE DEKALB IL 60115 363164329 HEALTHCARE SERVICES, HOSPICE SERVICES IL 501(C)(3) 7 KISHHEALTH SYSTEM 0 KISHHEALTH FOUNDATION ONE KISH HOSPITAL DRIVE DEKALB IL 60115 363649077 SUPPORT OF KISHWAUKEE HEALTH SYSTEM NOT FOR PROFIT ENTITIES IL 501(C)(3) 7 KISHHEALTH SYSTEM 0 COMMUNITY CARES CLINIC ONE KISH HOSPITAL DRIVE DEKALB IL 60115 800424001 HEALTHCARE SERVICES, PRIMARY CARE IL 501(C)(3) 3 KISHHEALTH SYSTEM 0 KISHWAUKEE PHYSICIANS GROUP INC 2240 GATEWAY DRIVE SYCAMORE IL 60178 651293967 HEALTHCARE SERVICES, PRIMARILY FAMILY PRACTICE IL 501(C)(3) 3 KISHHEALTH SYSTEM 0 CENTER FOR FAMILY HEALTH - MALTA ONE KISH HOSPITAL DRIVE DEKALB IL 60115 800869393 HEALTHCARE SERVICES, PRIMARILY ACUTE CARE IL 501(C)(3) 3 KISHHEALTH SYSTEM 0 KISHHEALTH SYSTEM HOME CARE ONE KISH HOSPITAL DRIVE DEKALB IL 60115 371703513 HEALTHCARE SERVICES, HOME CARE IL 501(C)(3) 3 KISHHEALTH SYSTEM 0 KISHWAUKEE AREA PHO ONE KISH HOSPITAL DRIVE DEKALB IL 60115 364205273 MEDICARE SERVICES IL KISHWAUKEE COMMUNITY HOSPITAL INVESTMENT -20496 5326 0 0 0.50000 THE MIDLAND SURGICAL CENTER LLC 3085 WOLF COURT DEKALB IL 60115 352194610 SURGICAL SERVICES IL KISHWAUKEE COMMUNITY HOSPITAL INVESTMENT 233354 291962 0 0 0.74500 HEALTH VENTURES LLC ONE KISH HOSPITAL DRIVE DEKALB IL 60115 753255958 RENTAL REAL ESTATE PROVIDED TO HEALTHCARE RELATED BUSINESSES IL N/A ILLINOIS REGIONAL CANCER CENTER 10 HEALTH SERVICES DRIVE DEKALB IL 60115 363847273 CANCER TREATMENT SERVICES IL N/A HEALTH PROGRESS INC ONE KISH HOSPITAL DRIVE DEKALB IL 60115 363824138 INVESTMENT IN HEALTHCARE RELATED SMALL BUSINESS IL N/A C 0 0 1 1 0 0 0 0 0 0 1 1 0 0 0 1 1 1 1 1