COMMUNITY CARES CLINIC INC: Form 990, tax year 2012
View the entire original 990 at ProPublica ↗
- Organization
- COMMUNITY CARES CLINIC INC (EIN 80-0424001)
- Tax period
- 2012-05-01 to 2013-04-30
- Filed
- 2013-12-12
- IRS object ID
- 201313469349300031
- Schema version
- 2012v2.1
- Source
- Download XML · Original 990 at ProPublica
Every field in the e-filed return. Faint text is the IRS element name, for citing.
Return header ReturnHeader
| Field | Value | IRS element (for citing) |
|---|---|---|
| Timestamp | 2013-12-12T15:06:44-06:00 | Timestamp |
| Tax Period End Date | 2013-04-30 | TaxPeriodEndDate |
Preparer Firm PreparerFirm
| Field | Value | IRS element (for citing) |
|---|---|---|
| EIN | 410746749 | EIN |
Preparer Firm Business Name PreparerFirmBusinessName
| Field | Value | IRS element (for citing) |
|---|---|---|
| Business Name Line1 | CLIFTONLARSONALLEN LLP | BusinessNameLine1 |
Preparer Firm US Address PreparerFirmUSAddress
| Field | Value | IRS element (for citing) |
|---|---|---|
| Address Line1 | 114 E EVERETT | AddressLine1 |
| City | DIXON | City |
| State | IL | State |
| ZIP Code | 61021 | ZIPCode |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Return Type | 990 | ReturnType |
| Tax Period Begin Date | 2012-05-01 | TaxPeriodBeginDate |
Filer Filer
| Field | Value | IRS element (for citing) |
|---|---|---|
| EIN | 800424001 | EIN |
Name Name
| Field | Value | IRS element (for citing) |
|---|---|---|
| Business Name Line1 | COMMUNITY CARES CLINIC INC | BusinessNameLine1 |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Name Control | COMM | NameControl |
| Phone | 8157523253 | Phone |
US Address USAddress
| Field | Value | IRS element (for citing) |
|---|---|---|
| Address Line1 | ONE KISH HOSPITAL DRIVE | AddressLine1 |
| City | DEKALB | City |
| State | IL | State |
| ZIP Code | 60115 | ZIPCode |
Officer Officer
| Field | Value | IRS element (for citing) |
|---|---|---|
| Name | LOREN FOELSKE | Name |
| Title | VICE PRESIDENT - FINANCE, KHS | Title |
| Phone | 8157561521 | Phone |
| Date Signed | 2013-12-10 | DateSigned |
| Authorize Third Party | 1 | AuthorizeThirdParty |
Preparer Preparer
| Field | Value | IRS element (for citing) |
|---|---|---|
| Name | KELLY JACKSON HARDY | Name |
| PTIN | P00747242 | PTIN |
| Phone | 8152842285 | Phone |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Tax Year | 2012 | TaxYear |
| Build TS | 2015-11-30 17:44:51Z | BuildTS |
Form 990 IRS990
| Field | Value | IRS element (for citing) |
|---|---|---|
| Address Change | X | AddressChange |
| Name Of Principal Officer Person | KEVIN P POORTEN | NameOfPrincipalOfficerPerson |
Address Principal Officer US AddressPrincipalOfficerUS
| Field | Value | IRS element (for citing) |
|---|---|---|
| Address Line1 | ONE KISH HOSPITAL DRIVE | AddressLine1 |
| City | DEKALB | City |
| State | IL | State |
| ZIP Code | 60115 | ZIPCode |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Gross Receipts | 836570 | GrossReceipts |
| Group Return For Affiliates | 0 | GroupReturnForAffiliates |
| Organization501c3 | X | Organization501c3 |
| Web Site | WWW.KISHHEALTH.ORG | WebSite |
| Type Of Organization Corporation | X | TypeOfOrganizationCorporation |
| Year Formation | 2009 | YearFormation |
| State Legal Domicile | IL | StateLegalDomicile |
| Activity Or Mission Description | TO PROVIDE PRIMARY AND URGENT MEDICAL CARE TO INDIVIDUALS OF ANY AGE WITHOUT REGARD TO ABILITY TO PAY. | ActivityOrMissionDescription |
| Nbr Voting Members Governing Body | 8 | NbrVotingMembersGoverningBody |
| Nbr Independent Voting Members | 5 | NbrIndependentVotingMembers |
| Total Nbr Employees | 0 | TotalNbrEmployees |
| Total Nbr Volunteers | 5 | TotalNbrVolunteers |
| Total Gross UBI | 0 | TotalGrossUBI |
| Net Unrelated Business Txbl Income | 0 | NetUnrelatedBusinessTxblIncome |
| Contributions Grants Prior Year | 28714 | ContributionsGrantsPriorYear |
| Contributions Grants Current Year | 89971 | ContributionsGrantsCurrentYear |
| Program Service Revenue Prior Year | 594241 | ProgramServiceRevenuePriorYear |
| Program Service Revenue CY | 667772 | ProgramServiceRevenueCY |
| Investment Income Prior Year | 241 | InvestmentIncomePriorYear |
| Investment Income Current Year | 154 | InvestmentIncomeCurrentYear |
| Other Revenue Prior Year | 66993 | OtherRevenuePriorYear |
| Other Revenue Current Year | 78673 | OtherRevenueCurrentYear |
| Total Revenue Prior Year | 690189 | TotalRevenuePriorYear |
| Total Revenue Current Year | 836570 | TotalRevenueCurrentYear |
| Grants And Similar Amnts Prior Year | 0 | GrantsAndSimilarAmntsPriorYear |
| Grants And Similar Amnts CY | 0 | GrantsAndSimilarAmntsCY |
| Benefits Paid To Members Prior Year | 0 | BenefitsPaidToMembersPriorYear |
| Benefits Paid To Members CY | 0 | BenefitsPaidToMembersCY |
| Salaries Etc Prior Year | 0 | SalariesEtcPriorYear |
| Salaries Etc Current Year | 0 | SalariesEtcCurrentYear |
| Total Prof Fundrsng Exp Prior Year | 0 | TotalProfFundrsngExpPriorYear |
| Total Prof Fundrsng Exp CY | 0 | TotalProfFundrsngExpCY |
| Total Fundrsng Exp Current Year | 0 | TotalFundrsngExpCurrentYear |
| Other Expense Prior Year | 1306824 | OtherExpensePriorYear |
| Other Expenses Current Year | 1433172 | OtherExpensesCurrentYear |
| Total Expenses Prior Year | 1306824 | TotalExpensesPriorYear |
| Total Expenses Current Year | 1433172 | TotalExpensesCurrentYear |
| Revenues Less Expenses Prior Year | -616635 | RevenuesLessExpensesPriorYear |
| Revenues Less Expenses CY | -596602 | RevenuesLessExpensesCY |
| Total Assets BOY | 865229 | TotalAssetsBOY |
| Total Assets EOY | 449456 | TotalAssetsEOY |
| Total Liabilities BOY | 873631 | TotalLiabilitiesBOY |
| Total Liabilities EOY | 201509 | TotalLiabilitiesEOY |
| Net Assets Or Fund Balances BOY | -8402 | NetAssetsOrFundBalancesBOY |
| Net Assets Or Fund Balances EOY | 247947 | NetAssetsOrFundBalancesEOY |
| Info In Schedule O Part III | X | InfoInScheduleOPartIII |
| Mission Description | TO PROVIDE COMPASSIONATE, INNOVATIVE, AND AFFORDABLE MEDICAL CARE AND TO COLLABORATE WITH PARTNERS TO SERVE THE HEALTH NEEDS OF OUR COMMUNITY. | MissionDescription |
| Significant New Program Services | 0 | SignificantNewProgramServices |
| Significant Change | 0 | SignificantChange |
| Expense | 1370520 | Expense |
| Grants | 0 | Grants |
| Revenue | 667772 | Revenue |
| Description | COMMUNITY CARES CLINIC (CCC) WAS ESTABLISHED TO PROVIDE THE UNINSURED AND UNDERINSURED ACCESS TO PRIMARY CARE (AND PREVENTATIVE SERVICES) AND AS A PARTNERSHIP WITH THE COMMUNITY INCLUDING NIU, LOCAL BOARD MEMBERS, AND KISHHEALTH SYSTEM. THE CONCEPT WAS TO GIVE THIS UNDERSERVED POPULATION A MEDICAL HOME AND NOT JUST PROVIDE URGENT CARE. COMMUNITY CARES CLINIC PROVIDED PRIMARY MEDICAL CARE FOR THE UNINSURED, UNDERINSURED, AND MEDICAID PATIENTS AMONGST A MEDICALLY UNDERSERVED POPULATION. IN FYE 4/30/13 THE COMMUNITY CARES CLINIC TREATED 7,421 PATIENTS WITH SELF PAY AND MEDICAID TOGETHER COMPRISING 83.5% OF THE TOTAL GROSS CHARGES. THE TOTAL NUMBER OF PATIENTS SEEN SINCE OPENING IS 26,559. 53% OF ALL WELL CHILD VISITS ARE FOR CHILDREN UNDER THE AGE OF 5. COMMUNITY CARES CLINIC HAS PROVIDED AFFORDABLE HEALTHCARE FOR 874 PATIENTS WITHOUT INSURANCE. CCC HAS SEEN 1,967 KIDS ON PUBLIC AID. IN FYE 4/30/13, $261,434 OF TOTAL CHARGES WERE CLASSIFIED AS CHARITY CARE.COMMUNITY CARES CLINIC RECEIVED AN IN-KIND DONATION OF $47,075 RELATED TO FACILITY RENTAL FROM NORTHERN ILLINOIS UNIVERSITY. IT ALSO RECEIVED AN IN-KIND DONATION OF SERVICES FROM KISHWAUKEE COMMUNITY HOSPITAL IN THE AMOUNT OF $146,262. THESE AMOUNTS HAVE NOT BEEN INCLUDED AS REVENUE ON FORM 990. | Description |
| Total Program Service Expense | 1370520 | TotalProgramServiceExpense |
| Described In501 C3 | 1 | DescribedIn501C3 |
| Schedule B Required | 1 | ScheduleBRequired |
| Political Activities | 0 | PoliticalActivities |
| Lobbying Activities | 0 | LobbyingActivities |
| Subject To Proxy Tax | 0 | SubjectToProxyTax |
| Donor Advised Funds | 0 | DonorAdvisedFunds |
| Conservation Easements | 0 | ConservationEasements |
| Collections Of Art | 0 | CollectionsOfArt |
| Credit Counseling | 0 | CreditCounseling |
| Term Or Permanent Endowments | 0 | TermOrPermanentEndowments |
| Report Land Bldg Equip | 1 | ReportLandBldgEquip |
| Report Invest Oth Securities | 0 | ReportInvestOthSecurities |
| Report Prog Rel Invest | 0 | ReportProgRelInvest |
| Report Other Assets | 0 | ReportOtherAssets |
| Report Other Liabilities | 1 | ReportOtherLiabilities |
| Report Fin48 Footnote | 1 | ReportFin48Footnote |
| Independent Audit Financial Stmt | 0 | IndependentAuditFinancialStmt |
| Consolidated Audit Financial Stmt | 1 | ConsolidatedAuditFinancialStmt |
| School | 0 | School |
| Foreign Office | 0 | ForeignOffice |
| Foreign Activities | 0 | ForeignActivities |
| More Than5000 K To Organizations | 0 | MoreThan5000KToOrganizations |
| More Than5000 K To Individuals | 0 | MoreThan5000KToIndividuals |
| Professional Fundraising | 0 | ProfessionalFundraising |
| Fundraising Activities | 0 | FundraisingActivities |
| Gaming | 0 | Gaming |
| Hospital | 0 | Hospital |
| Grants To Organizations | 0 | GrantsToOrganizations |
| Grants To Individuals | 0 | GrantsToIndividuals |
| Schedule J Required | 1 | ScheduleJRequired |
| Tax Exempt Bonds | 0 | TaxExemptBonds |
| Excess Benefit Transaction | 0 | ExcessBenefitTransaction |
| Prior Excess Benefit Transaction | 0 | PriorExcessBenefitTransaction |
| Loan To Officer Or DQP | 0 | LoanToOfficerOrDQP |
| Grant To Related Person | 0 | GrantToRelatedPerson |
| Bsnss Rltnshp With Organization | 0 | BsnssRltnshpWithOrganization |
| Bsnss Rltnshp Thru Family Member | 0 | BsnssRltnshpThruFamilyMember |
| Officer Entity With Bsnss Rltnshp | 1 | OfficerEntityWithBsnssRltnshp |
| Deductible Non Cash Contributions | 0 | DeductibleNonCashContributions |
| Deductible Contributions Of Art | 0 | DeductibleContributionsOfArt |
| Terminated | 0 | Terminated |
| Partial Liquidation | 0 | PartialLiquidation |
| Disregarded Entity | 0 | DisregardedEntity |
| Related Entity | 1 | RelatedEntity |
| Related Org Controlled Entity | 0 | RelatedOrgControlledEntity |
| Transfers To Exempt Non Chrtbl Org | 0 | TransfersToExemptNonChrtblOrg |
| Activities Conducted Partnership | 0 | ActivitiesConductedPartnership |
| Schedule O Required | 1 | ScheduleORequired |
| Number Forms Transmitted With1096 | 0 | NumberFormsTransmittedWith1096 |
| Number W2 G Included | 0 | NumberW2GIncluded |
| Number Of Employees | 0 | NumberOfEmployees |
| Unrelated Business Income | 0 | UnrelatedBusinessIncome |
| Foreign Financial Account | 0 | ForeignFinancialAccount |
| Prohibited Tax Shelter Trans | 0 | ProhibitedTaxShelterTrans |
| Taxable Party Notification | 0 | TaxablePartyNotification |
| Non Deductible Contributions | 0 | NonDeductibleContributions |
| Quid Pro Quo Contributions | 0 | QuidProQuoContributions |
| Form8282 Property Disposed Of | 0 | Form8282PropertyDisposedOf |
| Funds To Pay Premiums | 0 | FundsToPayPremiums |
| Premiums Paid | 0 | PremiumsPaid |
| Indoor Tanning Services | 0 | IndoorTanningServices |
| Info In Schedule O Part VI | X | InfoInScheduleOPartVI |
| Nbr Voting Governing Body Members | 8 | NbrVotingGoverningBodyMembers |
| Number Independent Voting Members | 5 | NumberIndependentVotingMembers |
| Family Or Business Relationship | 1 | FamilyOrBusinessRelationship |
| Delegation Of Management Duties | 0 | DelegationOfManagementDuties |
| Changes To Organizing Docs | 0 | ChangesToOrganizingDocs |
| Material Diversion Or Misuse | 0 | MaterialDiversionOrMisuse |
| Members Or Stockholders | 1 | MembersOrStockholders |
| Election Of Board Members | 1 | ElectionOfBoardMembers |
| Decisions Subject To Approval | 1 | DecisionsSubjectToApproval |
| Minutes Of Governing Body | 1 | MinutesOfGoverningBody |
| Minutes Of Committees | 1 | MinutesOfCommittees |
| Officer Mailing Address | 0 | OfficerMailingAddress |
| Local Chapters | 0 | LocalChapters |
| Form990 Provided To Governing Body | 1 | Form990ProvidedToGoverningBody |
| Conflict Of Interest Policy | 1 | ConflictOfInterestPolicy |
| Annual Disclosure Covered Persons | 1 | AnnualDisclosureCoveredPersons |
| Regular Monitoring Enforcement | 1 | RegularMonitoringEnforcement |
| Whistleblower Policy | 1 | WhistleblowerPolicy |
| Document Retention Policy | 1 | DocumentRetentionPolicy |
| Compensation Process CEO | 0 | CompensationProcessCEO |
| Compensation Process Other | 0 | CompensationProcessOther |
| Investment In Joint Venture | 0 | InvestmentInJointVenture |
| States Where Copy Of Return Is Filed | IL | StatesWhereCopyOfReturnIsFiled |
| Upon Request | X | UponRequest |
The Books Are In Care Of TheBooksAreInCareOf
Name Business NameBusiness
| Field | Value | IRS element (for citing) |
|---|---|---|
| Business Name Line1 | LOREN FOELSKE VP FINANCE | BusinessNameLine1 |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Telephone Number | 8157561521 | TelephoneNumber |
Address US AddressUS
| Field | Value | IRS element (for citing) |
|---|---|---|
| Address Line1 | ONE KISH HOSPITAL DRIVE | AddressLine1 |
| City | DEKALB | City |
| State | IL | State |
| ZIP Code | 60115 | ZIPCode |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Info In Schedule O Part VII | X | InfoInScheduleOPartVII |
Form990 Part VII Section A Form990PartVIISectionA (11 entries)
| TitleTitle | Average Hours Per WeekAverageHoursPerWeek | Average Hours Per Week RelatedAverageHoursPerWeekRelated | Individual Trustee Or DirectorIndividualTrusteeOrDirector | Reportable Comp From OrganizationReportableCompFromOrganization | Reportable Comp From Related OrgsReportableCompFromRelatedOrgs | Other CompensationOtherCompensation | OfficerOfficer |
|---|---|---|---|---|---|---|---|
| RAY ALDEN | |||||||
| DIRECTOR | 1.00 | 1.00 | X | 0 | 0 | 0 | |
| MIKE CULLEN | |||||||
| DIRECTOR | 1.00 | 10.00 | X | 0 | 0 | 0 | |
| JOE DANT | |||||||
| DIRECTOR, VP-BUS DEV KISHHEALTH SYSTEM | 1.00 | 44.00 | X | 0 | 255673 | 45841 | |
| GEORGE GONNELLA | |||||||
| DIRECTOR (THRU AUG 2012) | 1.00 | X | 0 | 0 | 0 | ||
| DAVE JUDAY | |||||||
| VICE CHAIR & SECRETARY | 1.00 | 1.00 | X | 0 | 0 | 0 | X |
| DOUG ROBERTS | |||||||
| DIRECTOR | 1.00 | 1.00 | X | 0 | 0 | 0 | |
| KEVIN POORTEN | |||||||
| CHAIR & PRES KISHHEALTH SYS | 1.00 | 54.00 | X | 0 | 966472 | 220153 | X |
| SHELLY JOHNSON | |||||||
| EXECUTIVE DIRECTOR | 18.00 | 22.00 | X | 0 | 100621 | 28073 | |
| MARY PRITCHARD | |||||||
| DIRECTOR (THRU AUG 2012) | 1.00 | X | 0 | 0 | 0 | ||
| DERRLY BLOCK | |||||||
| DIRECTOR | 1.00 | 1.00 | X | 0 | 0 | 0 | |
| LOREN FOELSKE | |||||||
| VP - FINANCE KISHHEALTH SYSTEM | 1.00 | 46.00 | 0 | 284734 | 117504 | X | |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Reportable Comp From Org | 0 | TotalReportableCompFromOrg |
| Total Reportable Comp Frm Rltd Orgs | 1607500 | TotalReportableCompFrmRltdOrgs |
| Total Other Compensation | 411571 | TotalOtherCompensation |
| Number Individuals GT100 K | 0 | NumberIndividualsGT100K |
| Formers Listed | 0 | FormersListed |
| Total Comp GT150 K | 1 | TotalCompGT150K |
| Compensation From Other Sources | 0 | CompensationFromOtherSources |
Contractor Compensation ContractorCompensation (4 entries)
| Address Line1AddressOfContractor/AddressUS/AddressLine1 | CityAddressOfContractor/AddressUS/City | StateAddressOfContractor/AddressUS/State | ZIP CodeAddressOfContractor/AddressUS/ZIPCode | Description Of ServicesDescriptionOfServices | CompensationCompensation |
|---|---|---|---|---|---|
| KISHWAUKEE COMMUNITY HOSPITAL | |||||
| ONE KISH HOPSITAL DRIVE | DEKALB | IL | 60115 | HEALTHCARE - MEDICAL SERVICES/PURCHASED | 743718 |
| KISHWAUKEE PHYSICIAN GROUP | |||||
| ONE KISH HOPSITAL DRIVE | DEKALB | IL | 60115 | HEALTHCARE - PHYSICIAN SERVICES | 361062 |
| SYCAMORE MEDICAL ASSOCIATES | |||||
| 2560 HAUSER ROSS DR 450 | SYCAMORE | IL | 60178 | HEALTHCARE - PHYSICIAN SERVICES & BILLIN | 228444 |
| POWER CONSTRUCTION COMPANY LLC | |||||
| 2360 NORTH PALMER DRIVE | SCHAUMBURG | IL | 60173 | CONSTRUCTION SERVICES | 106479 |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Number Of Contractors GT100 K | 4 | NumberOfContractorsGT100K |
| Related Organizations | 84828 | RelatedOrganizations |
| All Other Contributions | 5143 | AllOtherContributions |
| Noncash Contributions | 5572 | NoncashContributions |
| Total Contributions | 89971 | TotalContributions |
Program Service Revenue ProgramServiceRevenue
| Field | Value | IRS element (for citing) |
|---|---|---|
| Description | MEDICAL SERVICES | Description |
| Business Code | 621110 | BusinessCode |
| Total Revenue Column | 667772 | TotalRevenueColumn |
| Related Or Exempt Function Income | 667772 | RelatedOrExemptFunctionIncome |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Program Service Revenue | 667772 | TotalProgramServiceRevenue |
Investment Income InvestmentIncome
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Revenue Column | 154 | TotalRevenueColumn |
| Exclusion | $154 | ExclusionAmount |
Other Revenue Misc OtherRevenueMisc
| Field | Value | IRS element (for citing) |
|---|---|---|
| Description | MISCELLANEOUS | Description |
| Business Code | 621110 | BusinessCode |
| Total Revenue Column | 78673 | TotalRevenueColumn |
| Exclusion | $78,673 | ExclusionAmount |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Other Revenue | 78673 | TotalOtherRevenue |
Total Revenue TotalRevenue
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Revenue Column | 836570 | TotalRevenueColumn |
| Related Or Exempt Function Income | 667772 | RelatedOrExemptFunctionIncome |
| Unrelated Business Revenue | 0 | UnrelatedBusinessRevenue |
| Exclusion | $78,827 | ExclusionAmount |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Info In Schedule O Part IX | X | InfoInScheduleOPartIX |
Fees For Services Legal FeesForServicesLegal
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | 2109 | Total |
| Management And General | 2109 | ManagementAndGeneral |
Fees For Services Accounting FeesForServicesAccounting
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | 1900 | Total |
| Management And General | 1900 | ManagementAndGeneral |
Fees For Services Other FeesForServicesOther
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | 1185588 | Total |
| Program Services | 1132112 | ProgramServices |
| Management And General | 53476 | ManagementAndGeneral |
Advertising Advertising
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | 15802 | Total |
| Program Services | 11443 | ProgramServices |
| Management And General | 4359 | ManagementAndGeneral |
Office Expenses OfficeExpenses
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | 159162 | Total |
| Program Services | 159162 | ProgramServices |
Information Technology InformationTechnology
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | 23261 | Total |
| Program Services | 23261 | ProgramServices |
Occupancy Occupancy
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | 15516 | Total |
| Program Services | 15516 | ProgramServices |
Travel Travel
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | 4081 | Total |
| Program Services | 4081 | ProgramServices |
Interest Interest
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | 5143 | Total |
| Program Services | 5143 | ProgramServices |
Depreciation Depletion DepreciationDepletion
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | 3754 | Total |
| Program Services | 3754 | ProgramServices |
Insurance Insurance
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | 15820 | Total |
| Program Services | 15012 | ProgramServices |
| Management And General | 808 | ManagementAndGeneral |
Other Expenses OtherExpenses (4 entries)
| DescriptionDescription | TotalTotal | Program ServicesProgramServices |
|---|---|---|
| MISCELLANEOUS EXPENSE | 639 | 639 |
| DUES AND LICENSES | 525 | 525 |
| EMPLOYEE RECOGNITION | 384 | 384 |
| PLEDGE PRESENT VALUE AD | -512 | -512 |
Total Functional Expenses TotalFunctionalExpenses
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | 1433172 | Total |
| Program Services | 1370520 | ProgramServices |
| Management And General | 62652 | ManagementAndGeneral |
| Fundraising | 0 | Fundraising |
Cash Non Interest Bearing CashNonInterestBearing
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | 60796 | BOY |
| EOY | 336337 | EOY |
Savings And Temp Cash Investments SavingsAndTempCashInvestments
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | 639328 | BOY |
| EOY | 0 | EOY |
Pledges And Grants Receivable PledgesAndGrantsReceivable
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | 48394 | BOY |
| EOY | 0 | EOY |
Accounts Receivable AccountsReceivable
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | 84618 | BOY |
| EOY | 99559 | EOY |
Prepaid Expenses Deferred Charges PrepaidExpensesDeferredCharges
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | 3202 | BOY |
| EOY | 3149 | EOY |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Land Buildings Equipment Basis | 33790 | LandBuildingsEquipmentBasis |
| Land Bldg Equipment Accum Deprec | 33790 | LandBldgEquipmentAccumDeprec |
Land Buildings Equipment Basis Net LandBuildingsEquipmentBasisNet
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | 3754 | BOY |
| EOY | 0 | EOY |
Other Assets Total OtherAssetsTotal
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | 25137 | BOY |
| EOY | 10411 | EOY |
Total Assets TotalAssets
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | 865229 | BOY |
| EOY | 449456 | EOY |
Accounts Payable Accrued Expenses AccountsPayableAccruedExpenses
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | 56218 | BOY |
| EOY | 42599 | EOY |
Mort Notes Pybl Secured Invest Prop MortNotesPyblSecuredInvestProp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | 400000 | BOY |
| EOY | 0 | EOY |
Other Liabilities OtherLiabilities
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | 417413 | BOY |
| EOY | 158910 | EOY |
Total Liabilities TotalLiabilities
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | 873631 | BOY |
| EOY | 201509 | EOY |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Follow SFAS117 | X | FollowSFAS117 |
Unrestricted Net Assets UnrestrictedNetAssets
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | -16411 | BOY |
| EOY | 247866 | EOY |
Temporarily Restricted Net Assets TemporarilyRestrictedNetAssets
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | 8009 | BOY |
| EOY | 81 | EOY |
Total Net Assets Fund Balances TotalNetAssetsFundBalances
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | -8402 | BOY |
| EOY | 247947 | EOY |
Total Liab Net Assets Fund Balances TotalLiabNetAssetsFundBalances
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | 865229 | BOY |
| EOY | 449456 | EOY |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Info In Schedule O Part XI | X | InfoInScheduleOPartXI |
| Reconcilation Revenue Expenses | -596602 | ReconcilationRevenueExpenses |
| Reconcilation Other Changes | 852951 | ReconcilationOtherChanges |
| Info In Schedule O Part XII | X | InfoInScheduleOPartXII |
| Method Of Accounting Accrual | X | MethodOfAccountingAccrual |
| Accountant Compile Or Review | 0 | AccountantCompileOrReview |
| FS Audited | 1 | FSAudited |
FS Audited Basis FSAuditedBasis
| Field | Value | IRS element (for citing) |
|---|---|---|
| Financial Statement Consolidated | X | FinancialStatementConsolidated |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Audit Committee | 1 | AuditCommittee |
| Federal Grant Audit Required | 0 | FederalGrantAuditRequired |
Schedule A IRS990ScheduleA
| Field | Value | IRS element (for citing) |
|---|---|---|
| Hospital170b1 Aiii | X | Hospital170b1Aiii |
Schedule B IRS990ScheduleB
Contributor Info ContributorInfo
| Field | Value | IRS element (for citing) |
|---|---|---|
| Contributor Number | RESTRICTED | ContributorNumber |
Contributor Name Business ContributorNameBusiness
| Field | Value | IRS element (for citing) |
|---|---|---|
| Business Name Line1 | RESTRICTED | BusinessNameLine1 |
Contributor Address US ContributorAddressUS
| Field | Value | IRS element (for citing) |
|---|---|---|
| Address Line1 | RESTRICTED | AddressLine1 |
| Address Line2 | RESTRICTED | AddressLine2 |
| City | RESTRICTED | City |
| State | RESTRICTED | State |
| ZIP Code | RESTRICTED | ZIPCode |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Aggregate Contributions | RESTRICTED | AggregateContributions |
Schedule D IRS990ScheduleD
Leasehold Improvements LeaseholdImprovements
| Field | Value | IRS element (for citing) |
|---|---|---|
| Other Cost Or Other Basis | 33790 | OtherCostOrOtherBasis |
| Depreciation | 33790 | Depreciation |
| Book Value | 0 | BookValue |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Of Book Value Land Buildings | 0 | TotalOfBookValueLandBuildings |
Other Liabilities OtherLiabilities (2 entries)
| DescriptionDescription | AmountAmount |
|---|---|
| DUE TO AFFILIATES | $155,580 |
| ACCRUED MALPRACTICE CLAIMS | $3,330 |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Of Amounts | 158910 | TotalOfAmounts |
| Footnote In Part XIII | X | FootnoteInPartXIII |
| Tot Revenue Etc Audited Fincl Stmt | 898004 | TotRevenueEtcAuditedFinclStmt |
| Donated Srvc And Use Of Facilities | 146262 | DonatedSrvcAndUseOfFacilities |
| Revenue Not Rptd F990 | 146262 | RevenueNotRptdF990 |
| Revenue Subtotal | 751742 | RevenueSubtotal |
| Other Revenues Not Included | 84828 | OtherRevenuesNotIncluded |
| Revenue Not Rptd On Fin Stmt | 84828 | RevenueNotRptdOnFinStmt |
| Total Revenue Per Form990 | 836570 | TotalRevenuePerForm990 |
| Tot Expenses Etc Audited Fincl Stmt | 1626509 | TotExpensesEtcAuditedFinclStmt |
| Donated Services Use Of Facilities | 193337 | DonatedServicesUseOfFacilities |
| Expenses Not Rptd F990 | 193337 | ExpensesNotRptdF990 |
| Expenses Subtotal | 1433172 | ExpensesSubtotal |
| Expenses Not Rptd On Fin Stmt | 0 | ExpensesNotRptdOnFinStmt |
| Total Expenses Per Form990 | 1433172 | TotalExpensesPerForm990 |
Form990 Schedule D Part XIII Form990ScheduleDPartXIII (2 entries)
| IdentifierIdentifier | Return ReferenceReturnReference | ExplanationExplanation |
|---|---|---|
| DESCRIPTION OF UNCERTAIN TAX POSITIONS UNDER FIN 48: | PART X, LINE 2: | THE SYSTEM, KCH, VWCH, KHF, KPG, DCH, CFHP (CCC), 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 4B - OTHER ADJUSTMENTS: | CONTRIBUTION FROM KISHHEALTH FOUNDATION INCLUDED IN EQUITY 84,828. |
Schedule J IRS990ScheduleJ
| Field | Value | IRS element (for citing) |
|---|---|---|
| Severance Payment | 0 | SeverancePayment |
| Supplemental Nonqual Retire Plan | 1 | SupplementalNonqualRetirePlan |
| Equity Based Comp Arrangement | 0 | EquityBasedCompArrangement |
| Comp Based On Revenue Of Filing Org | 0 | CompBasedOnRevenueOfFilingOrg |
| Comp Based On Revenue Related Orgs | 0 | CompBasedOnRevenueRelatedOrgs |
| Comp Based Net Earnings Filing Org | 0 | CompBasedNetEarningsFilingOrg |
| Comp Based Net Earnings Relate Orgs | 0 | CompBasedNetEarningsRelateOrgs |
| Any Non Fixed Payments | 0 | AnyNonFixedPayments |
| Initial Contract Exception | 0 | InitialContractException |
Form990 Schedule J Part II Form990ScheduleJPartII (3 entries)
| TitleTitle | Base Compensation Filing OrgBaseCompensationFilingOrg | Comp Based On Related OrgsCompBasedOnRelatedOrgs | Bonus Filing OrgBonusFilingOrg | Bonus Related OrgsBonusRelatedOrgs | Other Compensation Filing OrgOtherCompensationFilingOrg | Other Compensation Related OrgsOtherCompensationRelatedOrgs | Deferred Comp Filing OrgDeferredCompFilingOrg | Deferred Comp Related OrgsDeferredCompRelatedOrgs | Nontaxable Benefits Filing OrgNontaxableBenefitsFilingOrg | Nontaxable Benefits Related OrgsNontaxableBenefitsRelatedOrgs | Total Compensation Filing OrgTotalCompensationFilingOrg | Total Compensation Related OrgsTotalCompensationRelatedOrgs | Comp Report Prior990 Filing OrgCompReportPrior990FilingOrg | Comp Report Prior990 Related OrgsCompReportPrior990RelatedOrgs |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| JOE DANT | ||||||||||||||
| DIRECTOR, VP-BUS DEV KISHHEALTH SYST | 0 | 215055 | 0 | 40618 | 0 | 0 | 0 | 22696 | 0 | 23145 | 0 | 301514 | 0 | 0 |
| KEVIN POORTEN | ||||||||||||||
| CHAIR & PRES KISHHEALTH SYS | 0 | 548333 | 0 | 168139 | 0 | 250000 | 0 | 196100 | 0 | 24053 | 0 | 1186625 | 0 | 0 |
| LOREN FOELSKE | ||||||||||||||
| VP - FINANCE KISHHEALTH SYSTEM | 0 | 256230 | 0 | 28504 | 0 | 0 | 0 | 94286 | 0 | 23218 | 0 | 402238 | 0 | 0 |
Form990 Schedule J Part III Form990ScheduleJPartIII (2 entries)
| Return ReferenceReturnReference | ExplanationExplanation | IdentifierIdentifier |
|---|---|---|
| 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 COMMUNITY CARES CLINIC WERE $200,200. 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. | |
| PART III | PART I, LINE 3: THE ORGANIZATION RELIED ON A RELATED ORGANIZATION THAT USED ONE OR MORE METHODS DESCRIBED TO ESTABLISH THE TOP MANAGEMENT OFFICIAL'S COMPENSATION. | SUPPLEMENTAL INFORMATION |
Schedule L IRS990ScheduleL
Form990 Schedule L Part IV Form990ScheduleLPartIV
Name Of Interested Person NameOfInterestedPerson
Name Business NameBusiness
| Field | Value | IRS element (for citing) |
|---|---|---|
| Business Name Line1 | SYCAMORE MEDICAL ASSOCIATES LLC | BusinessNameLine1 |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Relationship | COMMON DIRECTOR/MEMBER | Relationship |
| Amount Of Transaction | 126703 | AmountOfTransaction |
| Description Of Transaction | SYCAMORE MEDICAL ASSOCIATES, LLC PROVIDES MEDICAL SERVICES TO COMMUNITY CARES CLINIC. DR. GEORGE GONNELLA IS A MEMBER OF THIS ENTITY AND ALSO SERVED ON THE COMMUNITY CARES CLINIC BOARD OF DIRECTORS FOR A PORTION OF THE FISCAL YEAR. | DescriptionOfTransaction |
| Sharing Of Revenues | 0 | SharingOfRevenues |
Schedule O IRS990ScheduleO
General Explanation GeneralExplanation (12 entries)
| Return ReferenceReturnReference | ExplanationExplanation | IdentifierIdentifier |
|---|---|---|
| FORM 990, PART VI, SECTION A, LINE 2 | KEVIN POORTEN AND LOREN FOELSKE ARE BOTH EMPLOYEES OF KISHHEALTH SYSTEM (KHS). KHS IS THE PARENT OF KISHWAUKEE COMMUNITY HOSPITAL, WHICH IS THE SOLE MEMBER OF COMMUNITY CARES CLINIC. MR. POORTEN IS PRESIDENT AND CEO OF KISHHEALTH SYSTEM AND SERVES AS CHAIR OF THE BOARD OF DIRECTOR FOR COMMUNITY CARES CLINIC. MR. FOELSKE SERVES AS THE VICE-PRESIDENT - FINANCE FOR ALL KISHHEALTH SYSTEM RELATED ENTITIES. JOE DANT ALSO SERVES ON THE BOARD OF OTHER KISHHEALTH SYSTEM ENTITIES, AS WELL AS THE BOARD OF THE CLINIC. SHELLEY JOHNSON IS EMPLOYED BY KISHHEALTH SYSTEM AND SERVES AS THE DIRECTOR OF COMMUNITY CARES CLINIC. MIKE CULLEN AND DOUG ROBERTS ARE BOARD MEMBERS EMPLOYED BY NATIONAL BANK AND TRUST. KISHHEALTH SYSTEM HAS A BANKING RELATIONSHIP WITH THIS BANK, THUS LEADING TO A BUSINESS RELATIONSHIP BETWEEN BOARD MEMBERS. COMMUNITY CARES CLINIC HAS ALSO BORROWED FUNDS FOR OPERATION FROM NATIONAL BANK AND TRUST. MR. CULLEN ALSO SERVES ON THE BOARD OF KISHHEALTH SYSTEM, THE PARENT ORGANIZATION OF COMMUNITY CARES CLINIC. RAY ALDEN AND DERRLY BLOCK AND MARY PRITCHARD ARE EMPLOYED BY NORTHERN ILLINOIS UNIVERSITY SERVE ON THE BOARD OF COMMUNITY CARES CLINIC. NORTHERN ILLINOIS UNIVERSITY DONATES SPACE TO THE CLINIC FOR ITS OPERATIONS. | |
| FORM 990, PART VI, SECTION A, LINE 6 | KISHWAUKEE COMMUNITY HOSPITAL (KCH) IS THE SOLE MEMBER OF COMMUNITY CARES CLINIC PER THE ORGANIZATIONS BYLAWS. HOWEVER, COMMUNITY CARES CLINIC IS OPERATIONALLY AFFILIATED WITH KISH HEALTH SYSTEM. KISHHEALTH SYSTEM IS DEEMED TO BE THE OWNER OF THE ORGANIZATION VIA CONTROL WITHIN THE CONSOLIDATED ENTITY STRUCTURE, GOVERNING DOCUMENTS AND FUNDING. | |
| FORM 990, PART VI, SECTION A, LINE 7A | PER THE CLINIC'S BYLAWS, AT LEAST TWO OF THE DIRECTORS ARE DESIGNATED BY KISHHEALTH SYSTEM AND AT LEAST TWO DIRECTORS ARE DESIGNATED BY THE PRESIDENT OF NORTHERN ILLINOIS UNIVERSITY. THE BALANCE OF THE DIRECTORS ARE MUTUALLY ELECTED BY THE DESIGNEES OF KISHHEALTH SYSTEM AND NORTHERN ILLINOIS UNIVERSITY. | |
| FORM 990, PART VI, SECTION A, LINE 7B | GOVERNANCE DECISIONS ARE RESERVED TO THE SOLE MEMBER OF THE ORGANIZATION AS RELATED TO THE ELECTION OF THE BOARD OF DIRECTORS. PER THE BYLAWS, SO LONG AS KISHWAUKEE COMMUNITY HOSPITAL REMAINS THE SOLE MEMBER OF THE CLINIC, IT SHALL VOTE AND APPROVE BY RESOLUTION TO HAVE A BOARD OF EIGHT DIRECTORS CONSISTING OF AT LEAST TWO DIRECTORS DESIGNATED BY KISHHEALTH SYSTEM AND AT LEAST TWO DIRECTORS DESIGNATED BY THE PRESIDENT OF NORTHERN ILLINOIS UNIVERSITY. SUBJECT IN ALL CASES TO ANY CONTRACTUAL OBLIGATION OF THE CLINIC TO ELECT A DIRECTOR DESIGNATED BY THE PHYSICIAN GROUP PROVIDING PROFESSIONAL SERVICES TO THE CLINIC, THE BALANCE OF THE DIRECTORS SHALL BE (I) MUTUALLY ELECTED BY THE KHS DESIGNESS AND THE NIU DESIGNEES AND (II) COMPRISED OF INDIVIDUALS WHO ARE NOT EMPLOYED BY NIU, KHS OR ANY OF THEIR RESPECTIVE AFFILIATES. | |
| 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. | |
| COMMUNITY CARES CLINIC 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. | |
| 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 COMMUNITY CARES CLINIC. | DESCRIPTION OF HOURS FOR RELATED ORGANIZATIONS |
| FORM 990, PART IX, LINE 11G | PHYSICIAN FEES: PROGRAM SERVICE EXPENSES 371,023. MANAGEMENT AND GENERAL EXPENSES 0. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 371,023. PURCHASED PERSONNEL: PROGRAM SERVICE EXPENSES 694,973. MANAGEMENT AND GENERAL EXPENSES 0. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 694,973. OTHER FEES: PROGRAM SERVICE EXPENSES 42,016. MANAGEMENT AND GENERAL EXPENSES 0. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 42,016. MEDICAL DIRECTOR FEES: PROGRAM SERVICE EXPENSES 24,100. MANAGEMENT AND GENERAL EXPENSES 0. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 24,100. COLLECTION FEES: PROGRAM SERVICE EXPENSES 0. MANAGEMENT AND GENERAL EXPENSES 53,476. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 53,476. | OTHER FEES |
| FORM 990, PART XI, LINE 9: | CAPITAL CONTRIBUTION FROM KISHHEALTH SYSTEM 900,000. EXPENSES RECORDED TO REFLECT COSTS OF IN-KIND SERVICES AND FACILITIES -193,337. REVENUE RECORDED TO REFLECT DONATION OF IN-KIND SERVICES 146,262. CHANGE IN INTEREST IN ASSETS OF KISHHEALTH FOUNDATION 26. | CHANGES IN NET ASSETS OR FUND BALANCES: |
| FORM 990, PART XI, LINE 2C | 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. KISHHEALTH SYSTEM IS THE PARENT CORPORATION OF COMMUNITY CARES CLINIC. | RESPONSIBILITY FOR OVERSIGHT OF FINANCIAL STATEMENTS |
Schedule R IRS990ScheduleR
Form990 Schedule R Part II Form990ScheduleRPartII (8 entries)
| Address Line1AddressUS/AddressLine1 | CityAddressUS/City | StateAddressUS/State | ZIP CodeAddressUS/ZIPCode | EINEIN | Primary ActivitiesPrimaryActivities | Legal Domicile StateLegalDomicileState | Exempt Code SectionExemptCodeSection | Public Charity StatusPublicCharityStatus | Business Name Line1DirectControllingEntityName/BusinessNameLine1 | Controlled OrgControlledOrg | Direct Controlling Entity NADirectControllingEntityNA |
|---|---|---|---|---|---|---|---|---|---|---|---|
| KISHWAUKEE COMMUNITY HOSPITAL | |||||||||||
| ONE KISH HOSPITAL DRIVE | DEKALB | IL | 60115 | 237087041 | HEALTHCARE SERVICES, PRIMARILY ACUTE CARE | IL | 501(C)(3) | 3 | KISHHEALTH SYSTEM | 0 | |
| KISHHEALTH SYSTEM | |||||||||||
| ONE KISH HOSPITAL DRIVE | DEKALB | IL | 60115 | 363649080 | PARENT CORPORATION OF 501(C)(3) HEALTH SYSTEM | IL | 501(C)(3) | 11B | 0 | N/A | |
| KISHHEALTH FOUNDATION | |||||||||||
| ONE KISH HOSPITAL DRIVE | DEKALB | IL | 60115 | 363649077 | SUPPORT OF CHARITABLE HEALTH ORGANIZATIONS | IL | 501(C)(3) | 7 | KISHHEALTH SYSTEM | 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 | |
| KISHWAUKEE PHYSICIAN GROUP INC | |||||||||||
| ONE KISH HOSPITAL DRIVE | DEKALB | IL | 60115 | 651293967 | HEALTHCARE SERVICES, PRIMARILY FAMILY PRACTICE | 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 | |
| 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 | |
Form990 Schedule R Part III Form990ScheduleRPartIII (4 entries)
| Address Line1AddressUS/AddressLine1 | CityAddressUS/City | StateAddressUS/State | ZIP CodeAddressUS/ZIPCode | EINEIN | Primary ActivityPrimaryActivity | Legal Domicile StateLegalDomicileState | Direct Controlling Entity NADirectControllingEntityNA |
|---|---|---|---|---|---|---|---|
| HEALTH VENTURES LLC | |||||||
| ONE KISH HOSPITAL DRIVE | DEKALB | IL | 60115 | 753255958 | RENTAL REAL ESTATE PROVIDED TO HEALTHCARE RELATED BUSINESSES | IL | N/A |
| KISHWAUKEE AREA PHO | |||||||
| ONE KISH HOSPITAL DRIVE | DEKALB | IL | 60115 | 364205273 | MEDICARE SERVICES | IL | N/A |
| ILLINOIS REGIONAL CANCER CENTER | |||||||
| 10 HEALTH SERVICES DRIVE | DEKALB | IL | 60115 | 363847273 | ILLINOIS REGIONAL CANCER CENTER | IL | N/A |
| MIDLAND SURGICAL CENTER LLC | |||||||
| 3085 WOLF COURT | DEKALB | IL | 60115 | 352194610 | SURGICAL SERVICES | IL | N/A |
Form990 Schedule R Part IV Form990ScheduleRPartIV
Name Of Related Org NameOfRelatedOrg
| Field | Value | IRS element (for citing) |
|---|---|---|
| Business Name Line1 | HEALTH PROGRESS INC | BusinessNameLine1 |
Address US AddressUS
| Field | Value | IRS element (for citing) |
|---|---|---|
| Address Line1 | ONE KISH HOSPITAL DRIVE | AddressLine1 |
| City | DEKALB | City |
| State | IL | State |
| ZIP Code | 60115 | ZIPCode |
| Field | Value | IRS element (for citing) |
|---|---|---|
| EIN | 363824138 | EIN |
| Primary Activity | INVESTMENT IN HEALTHCARE RELATED SMALL BUSINESSES | PrimaryActivity |
| Legal Domicile State | IL | LegalDomicileState |
| Direct Controlling Entity NA | N/A | DirectControllingEntityNA |
| Type Of Entity | C | TypeOfEntity |
| Controlled Org | 0 | ControlledOrg |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Receipt Of Int Ann Rents Royalties | 0 | ReceiptOfIntAnnRentsRoyalties |
| Gift Grant Or Cap Contr To Other Org | 0 | GiftGrantOrCapContrToOtherOrg |
| Gift Grant Or Cap Contr Fr Other Org | 1 | GiftGrantOrCapContrFrOtherOrg |
| Loans Or Guarantees To Other Org | 0 | LoansOrGuaranteesToOtherOrg |
| Loans Or Guarantees From Other Org | 0 | LoansOrGuaranteesFromOtherOrg |
| Dividends Related Organization | 0 | DividendsRelatedOrganization |
| Sale Of Assets To Other Org | 0 | SaleOfAssetsToOtherOrg |
| Purchase Of Assets From Other Org | 0 | PurchaseOfAssetsFromOtherOrg |
| Exchange Of Assets | 0 | ExchangeOfAssets |
| Rental Of Facilities To Other Orgs | 1 | RentalOfFacilitiesToOtherOrgs |
| Rental Of Facilities Fr Other Orgs | 0 | RentalOfFacilitiesFrOtherOrgs |
| Perform Of Services For Other Orgs | 0 | PerformOfServicesForOtherOrgs |
| Perform Of Services By Other Orgs | 0 | PerformOfServicesByOtherOrgs |
| Sharing Of Facilities | 0 | SharingOfFacilities |
| Sharing Of Paid Employees | 1 | SharingOfPaidEmployees |
| Reimbursement Paid To Other Org | 1 | ReimbursementPaidToOtherOrg |
| Reimbursement Paid By Other Org | 0 | ReimbursementPaidByOtherOrg |
| Other Transfer To Other Org | 0 | OtherTransferToOtherOrg |
| Other Transfer From Other Org | 1 | OtherTransferFromOtherOrg |
Comments