2012-05-15T09:46:42-05:00 2011-06-30 KPMG LLP 191 West Nationwide Blvd Ste 500 Columbus OH 432152568 990 2010-07-01 390808480 St Nicholas Hospital of the Hospital Sisters of the Third Order of St Francis STNI 9204598300 3100 Superior Avenue Sheboygan WI 530811948 ANDREW BAGNALL 9204598300 2012-05-11 true KPMG LLP 6142492300 2010 2016-02-24 21:20:13Z Andrew J Bagnall 3100 Superior Avenue Sheboygan WI 530811948 70531371 false 0928 X www.stnicholashospital.org X 1890 WI TO CARRY FORWARD THE HEALING MINISTRY OF THE HOSPITAL SISTERS OF ST. FRANCIS AS PART OF THE HEALTH MINISTRY OF THE ROMAN CATHOLIC CHURCH. 11 10 592 212 112888 -81455 134983 195887 65904071 65663911 1185719 2611371 287204 1100314 67511977 69571483 6000 0 0 0 29051834 27745134 0 0 0 40790199 46455254 69848033 74200388 -2336056 -4628905 108269768 107469074 36413096 32008096 71856672 75460978 X ST. NICHOLAS HOSPITAL IS DEDICATED TO SUFFERING HUMANITY FOR HIS SAKE, AND IS COMMITTED TO PROVIDING HIGH QUALITY, COMPASSIONATE CARE WITHOUT REGARD FOR RACE, CREED, OR ABILITY TO PAY. OUR CORE VALUES OF RESPECT, CARE, COMPETENCE AND JOY ARE LIVED BY ALL WHO WORK HERE, AND FELT BY ALL WHO USE OUR SERVICES. false false 5549281 0 8431945 surgical services - See Schedule O - Community Benefit Report 3524140 0 10308201 diagnostic imaging - See Schedule O - Community Benefit Report 1587818 0 6257118 emergency services - See Schedule O - Community Benefit Report 45930557 41686624 56591796 true true false true false false false false false false true false false false true true false true false false false false false false false false true true false false true false false false true false true false false false false false false true true false false false false true 33 0 592 true true true false false false false false false false false false X 11 10 false false false false true true true true true false false true true true true true true true true true true X GREG SIMIA 9204598300 3100 SUPERIOR AVENUE SHEBOYGAN WI 530811948 X Sr Marybeth Culnan OSF 1.0 X 0 0 0 Peter F Bemis 1.0 X 0 0 0 DAVID VAN DE WATER JD LLM 1.0 X X 0 0 0 William L Trager MD 1.0 X 0 0 0 andrew j bagnall 40.0 X X 0 226449 44748 sr bernadine gutowski OSF 1.0 X X 0 0 0 stuart w brotz 1.0 X 0 0 0 s mark betag MD 1.0 X 0 0 0 michael a lanser EDD 1.0 X X 0 0 0 christopher l larson MD 1.0 X 0 0 0 timothy kellner 1.0 X 0 0 0 ann carr 0.25 X 0 191336 109542 therese pandl 15.0 X 0 600501 157220 donna hutchinson 40.0 X 0 182261 76796 Greg Simia 15.0 X 0 0 0 barbara hocking 40.0 X 78777 0 2137 MICHELE OOSTDYK 40.0 X 150838 0 14674 JUDI JENSEN 40.0 X 90676 0 14056 ANDREA M ANGOTTI 40.0 X 110056 0 17982 SUSAN M WHEELER 40.0 X 128842 0 18612 mary brasseaux 0.0 X 0 277534 0 559189 1478081 455767 3 true true false prevea health services 2710 EXECUTIVE DRIVE GREEN BAY WI 54304 physician services 4775312 st vincent hospital 835 S VAN BUREN GREEN BAY WI 543013256 physician services 3152962 cd smith construction inc 899 E JOHNSON ST PO BOX 1006 FOND DU LAC WI 54936 construction 1065676 st mary's hospital medical center 1726 SHAWANO AVENUE GREEN BAY WI 54303 physician services 558253 infinity healthcare inc 111 E WISCONSIN AVENUE SUITE 2000 MILWAUKEE WI 53202 ER AND HYPERBARIC 522186 5 195887 195887 NET PATIENT SERVICE REVENUE 900099 64629034 64629034 LABORATORY OUTREACH REVENUE 621500 112888 112888 OTHER OPERATING REVENUES 900099 921989 921989 65663911 862550 862550 0 0 1902775 959888 942887 942887 942887 1741271 7550 1741271 7550 1748821 1748821 0 0 0 CAFETERIA SALES 722210 157427 157427 0 0 157427 69571483 66571000 112888 2691708 0 0 0 0 0 0 0 19994533 13343760 6650773 1566402 1045370 521032 4858073 3242134 1615939 1326126 885017 441109 4067450 2714496 1352954 406284 271142 135142 0 0 0 0 18675742 15598236 3077506 0 151089 151089 0 0 0 158083 130773 27310 0 99304 25110 74194 255975 170830 85145 0 3789421 2063907 1725514 29893 19950 9943 SUPPLIES 10223598 9853777 369821 0 EQUIPMENT RENTAL & MAINT. 2149904 1541093 608811 0 MEDICAID TAX 2126293 2126293 0 0 BAD DEBT 2030450 2030450 0 0 ALL OTHER EXPENSES 2291768 1529458 762310 0 74200388 56591796 17608592 0 2140703 2674232 9431117 10857930 250000 0 1766154 1629830 972391 303739 108878465 64513195 44465929 44365270 45987789 44211814 1128009 1252082 2127676 2174177 108269768 107469074 4850924 5332843 17167756 16755524 14394416 9919729 36413096 32008096 X 64792357 67628899 5434100 6201864 1630215 1630215 71856672 75460978 108269768 107469074 X -4628905 8233211 X false true true X true true X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED false false false false false false false false true 7264 7264 false Description of other lobbying activities Schedule C, part II B, QUestion 1I ST. nicholas HOSPITAL ("THE HOSPITAL") IS A MEMBER OF THE CATHOLIC HEALTH ASSOCIATION ("CHA"), THE wisconsin HEALTH ASSOCIATION ("WHA"), THE NATIONAL ASSOCIATION FOR HOME CARE AND HOSPICE, AND THE AMERICAN HEALTH ASSOCIATION ("AHA"). AS A MEMBER OF THESE ORGANIZATIONS, THE HOSPITAL PAYS DUES, WITH PART OF THESE DUES BEING ATTRIBUTABLE TO LOBBYING FEES PAID BY THE ORGANIZATIONS. THE AMOUNT LISTED ABOVE IS THE AMOUNT ATTRIBUTABLE TO THE HOSPITAL FROM ITS DUES PAID. 1392890 1392890 65185564 35753997 29431567 41892201 28759198 13133003 407810 407810 44365270 0 ACCRUED BENEFIT LIABILITIES 7991561 INTEREST RATE SWAP SETTLEMENT 882328 ESTIMATED SELF-INSURANCE LIABI 537160 OTHER LONG TERM LIABILITIES 508680 9919729 ASC SUBTOPIC 740-10 SCHEDULE D, PART X, LINE 2 On July 1, 2007, the Obligated Group adopted ASC Subtopic 740-10, Accounting for Uncertainty in Income Taxes - an Interpretation of FASB Statement No. 109. ASC Subtopic 740-10 addresses the determination of how tax benefits claimed or expected to be claimed on a tax return should be recorded in the consolidated financial statements. Under ASC Subtopic 740-10, the Obligated Group must recognize the tax benefit from an uncertain tax position only if it is more likely than not that the tax position will be sustained on examination by the taxing authorities, based on the technical merits of the position. The tax benefits recognized in the consolidated financial statements from such a position are measured based on the largest benefit that has a greater than 50% likelihood of being realized upon ultimate settlement. ASC Subtopic 740-10 also provides guidance on derecognition, classification, interest and penalties on income taxes, and accounting in interim periods, and requires increased disclosures. As of June 30, 2011 and 2010, the Obligated Group does not have a liability for unrecognized tax benefits. true true true X 225. true X true true false true true 1099449 1099449 0.01520 3466352 3466352 0.04800 4565801 4565801 0.06320 149737 149737 0.00210 5227 5227 0.00010 1669 1669 0.00000 156633 156633 0.00220 4722434 4722434 0.06540 200 230 230 0.00000 412 13180 13180 0.00020 612 13410 13410 0.00020 true 698475 0 21605464 30802457 -9196993 X true true orange cross ambulance services 0.50000 sheboygan surg cntr outpatient surgery center 0.50000 0.50000 1 1 St Nicholas Hospital X X X St Nicholas Hospital 1 PART I, LINE 3C NOT APPLICABLE, AS THE HOSPITAL DOES FOLLOW FPG TO DETERMINE ELIGIBILITY FOR CHARITY AND DISCOUNTED CARE TO LOW-INCOME UNINSURED AND UNDERINSURED INDIVIDUALS. PART I, LINE 6A YES. THE HOSPITAL'S COMMUNITY BENEFIT REPORT IS AVAILABLE UPON REQUEST FROM ST. NICHOLAS HOSPITAL, 3100 SUPERIOR AVENUE, SHEBOYGAN, WI 53081-1948, BY CONTACTING THE FUND DEVELOPMENT AND ADVOCACY DEPARTMENT AT 920.459.4714, OR BY VISITING THE HOSPITAL'S WEBSITE AT WWW.STNICHOLASHOSPITAL.ORG UNDER *GUIDE TO ST. NICHOLAS *ABOUT US *REPORT TO THE COMMUNITY *2011 HSHS DIVISION EASTERN WI ANNUAL REPORT. PART I, LINE 7G THE HOSPITAL DOES NOT HAVE SUFFICIENT INFORMATION AT THIS TIME TO DETERMINE IF SUBSIDIZED SERVICES EXIST BASED ON THE DEFINITION AND CALCULATIONS REQUIRED BY THE IRS AND IS WORKING TO PROVIDE SUCH INFORMATION IN NEXT YEAR'S RETURN. PART I, LINE 7, COLUMN (F) THE PERCENTAGE OF CHARITY CARE AND CERTAIN OTHER BENEFITS AT COST AS A PERCENT OF TOTAL EXPENSES LESS BAD DEBT IS 6.54%. THE AMOUNT OF BAD DEBT REMOVED WHEN CALCULATING PART I, LINE 7, COLUMN (F) WAS 2,030,450. PART I, LINE 7 THE CHARITY CARE REPORTED IS THE TOTAL FROM PATIENT BILLING THAT IS WRITTEN OFF TO CHARITY CARE CHARGE CODES. THIS AMOUNT MATCHES THE NUMBER THAT IS REPORTED ON THE HOSPITAL'S FISCAL YEAR ENDING 2011 AUDITED FINANCIAL STATEMENTS. THE TOTAL CHARITY CARE DOLLAR AMOUNT IS THEN REDUCED TO COST BY APPLYING THE HOSPITAL'S COST TO CHARGE RATIO AS CALCULATED ON IRS SCHEDULE H - WORKSHEET 2. Part II Our hospital has a long standing commitment to being environmentally sensitive, as part of our Franciscan heritage. There are many examples of how this is demonstrated, one of which is our participation in the Sheboygan County Sharps programs. The hospital serves as a drop-off site for sharps, such as needles used to inject insulin. Community members drop these items at the hospital, which then pays to have them disposed of properly. We actively contribute to the Hospital Sisters Mission Outreach program, whereby surplus or otherwise unused hospital supplies are collected and distributed to missions in the US and many other countries. In addition, we participate in the Wisconsin Hospital Emergency Preparedness Plan ("WHEPP"). The purpose of WHEPP is to develop processes to help participating institutions in Wisconsin meet community needs in a collaborative and organized manner during an incident emergency. The State of Wisconsin recognized that a mass casualty incident due to a biological, chemical, radiological, or natural disaster can easily overwhelm or damage the ability of local healthcare resources to meet community needs. Accordingly, WHEPP, a mutual aid plan, was developed to address this concern. We have actively participated in the organization and development of this group and led efforts in our region. As leaders in this group, we have helped to initiate the preparedness efforts by WHEPP that assist hospitals in our state to maintain the minimum levels of readiness that are expected by the federal and state governments. St. Nicholas' active participation with the local Hmong and Hispanic organizations has brought screenings and education to locations and venues which are easily accessible to members of those populations. The remainder of the support is for colleagues to participate in a variety of community organizations who requested our expertise at various meetings and events. Part III, Line 4 The hospital believes that its charity care, and the related community benefit, is understated because some patients that potentially qualify for charity care do not wish to apply for it, or do not provide all necessary documentation. Thus, the hospital's bad debt may include a portion that could be potentially classified as charity care. The hospital is continually assessing processes to more effectively capture charity care that are more patient-friendly. This will provide a more accurate reporting of charity care services provided by the hospital. The reported bad debt expense of $2,030,450 is the total from patient billing that is written off as bad debt, net of bad debt recoveries, and the net adjustment for the bad debt allowance. The bad debt allowance reflects the estimated future bad debt write-offs for the reported patient accounts receivable at year-end. The bad debt expense is then reduced to cost by applying the hospital's cost to charge ratio as calculated on the IRS schedule H - worksheet 2. Part III, Line 8 The hospital continually strives to provide exceptional, cost-effective patient care. The Medicare program does not provide payment that covers the full cost of the care provided. The fiscal year shortfall in Medicare payments of $12,837,424 is not classified as community benefit by the IRS. The hospital believes this is an important contribution to the health and well being of the community. The hospital's mission is to serve all patients with the highest possible quality and efficiency, regardless of ability to pay for services. Part III, Line 9b 1. Applications or requests for Community Care will be accepted from any patient without discrimination against race, ethnicity, sex, color, religion, origin or ancestry, age, marital status, disabilities or ability to pay. 2. Every effort will be made by the hospital to assist patients in utilizing Government & Third party insurance plans or financial aid programs prior to providing Community Care. Patients will be required to apply for plans or programs for which they may be eligible. 3. If the patient and or responsible party has collaborated with the hospital in seeking reimbursement from appropriate Government & Third party plans or charitable programs & agencies, relief from financial obligation is granted based on Community Care eligibility criteria. 4. Consideration is given to family/household size and income: including cash, savings and investments. Needs Assessment St. Nicholas has a community advisory committee. This committee is representative of the community that the hospital serves. The committee meets regularly to discuss hospital services and the ability of the hospital to meet community health care needs. Hospital colleagues represent the hospital on Hmong and Hispanic community groups to assess the unmet health needs of these groups. As a result, regular screening and education programs are offered from the hospital. The hospital is involved with the "Healthy Sheboygan County 2020" community-based program. This program assesses the health care needs of the community, identifies any potential health care gaps, and advises the hospital on the role it can have in addressing these needs. Patient Education of Eligibility for Assistance The hospital posts the charity care policy and application on its website. In addition, charity care applications are available and prominently displayed in the registration areas. The patient financial counselors meet with patients on site to assist in identifying whether they are eligible for government aid or financial assistance, and to assist in applying for programs for which they may be eligible. All patient access/registration colleagues are trained to provide guidance on financial assistance to patients. In addition, the hospital has contracted with an external organization to do active outreach with patients, who may need additional assistance in securing benefits. Community Information The hospital's service area includes Sheboygan County and parts of Ozaukee, Fond du Lac, Manitowoc and Calumet counties with a total population of approximately 140,000. Much of this area is rural and consists of small family farms. Immigrant communities have grown substantially in recent years, including Hispanic, Hmong, and Eastern Europeans populations. Promotion of Community Health Our hospital has an open medical staff and boards comprised of community members. because of the hospital's purpose and tradition, it is organized to promote the health of its primary service area and surrounding areas. the hospital is governed by a board of directors, the majority of which is comprised of persons who reside in the organization's primary service area and who are neither employees nor contractors of the hospital (nor family members thereof). Funds over and above what is needed for operations are reinvested in the facility and program services, using generally accepted accounting principles and market assessment to ensure that the funds are being used wisely. Our hospitals were founded over 100 years ago by a group of Catholic sisters whose purpose was to extend Christ's healing love throughout our area. Because of that, we comply with the Ethical and Religious Directives for Health Care issued by the US Council of Catholic Bishops. We also actively offer a variety of no-charge community and health education programs locally to assist community members in learning more about their health condition or possible health issues. in addition, the hospital operates an emergency room that is open 24 hours to all persons regardless of ability to pay. St. Nicholas devotes significant resources to access for patients who cannot afford care, along with other community benefits. In fiscal year 2011, St. Nicholas provided over $4.5 million in community benefit services, including charity care at cost, unpaid costs of Medicaid and other public programs, and a range of diverse programs designed to enhance access and improve community health. Additionally, during this period, St. Nicolas provided nearly $10 million (at cost) in excess of Medicare payment for health care services. The Community Care Program is a St. Nicholas Hospital-funded program that pays a portion of the patient's hospital bill, based on the patient's income limitations. Another example of community benefit at St. Nicholas is the Hope After Loss Organization ("HALO"), which provides support to families that experience loss of life during pregnancy. This program serves the entire community, at no cost to participants, whether their loss occurred at St. Nicholas Hospital or another facility. Community benefits at St. Nicholas also include multiple programs aimed at health promotion. St. Nicholas Hospital actively participates in "Healthy Sheboygan County 2020". This collaborative group is made up of local health care organizations. The group's primary focus is to improve the lives of people in our county. Our hospital staff members helped the AODA Committee with the first County-wide Medication Drop Off as well as educational presentations. This was the springboard for permanent drop off locations within Sheboygan County. The Sheboygan County Activity & Nutrition ("SCAN") receives assistance through the hospital's participation in the employee Health & Fitness Day, Family Health & Fitness Day, and local health fair. Also, a hospital representative serves on the committee and assists with the coordination of these county-wide activities. St. Nicholas Hospital is a supporting co-sponsor of the Community Clinic being developed to address the need to increase access to health care for the un- and underinsured in Sheboygan County. In addition to the financial support, St. Nicholas Hospital has dedicated staff to assist with the important community benefit effort. Examples of other community benefit contributions include: * Free monthly screenings and health education for the Hmong Mutual Assistance; * Support groups free of charge for heart, renal, and stroke patients as well as grief counseling for adults and children; * Free monthly blood pressure screenings at dozens of locations throughout the county; * Free use of hospital conference and meeting rooms for area not-for-profit organizations; * Provide two houses with financial support and in-kind services for Sheboygan County Interfaith Organization and their Bridgeway House, which provides temporary housing for homeless women and children and families transitioning out of domestic abuse situations; * Child care seat safety checks by certified technicians open to the public free of charge; * Free bike helmet fittings and helmets at cost, open to the public; * Breast cancer screenings at cost for the underserved, including special services and translation for women from the local Hispanic community; * Financial support and in-kind services for Sheboygan County Interfaith Organization, Family Resource Center, Safe Harbor Domestic Abuse Shelter, Big Brothers/Big Sisters, and area churches and schools; * Food drives for area food pantries; school supply and clothing drives for area schools * HealthExpress visits in the community throughout the year to provide free screenings and health education. * Staff serves on the Mental Health Committee and the Board of Mental Health America-There is Hope-suicide prevention walk pro. Affiliated Health Care System St. nicholas Hospital is an affiliate of Hospital Sisters Health System. The mission of Hospital Sisters Health System ("HSHS") is to serve those in need through a health care ministry that values compassion, respect and reverence for life. The nearly 14,000 colleagues who make up HSHS are dedicated to this mission and to providing high quality health care to whoever seeks our services. By living our mission each day, HSHS colleagues constantly strive to provide the highest quality and most cost-effective and compassionate health care to those we are privileged to serve. Our health care ministry extends across 12 communities in Wisconsin and Illinois and includes 13 hospitals, dozens of community-based health centers and clinics, and more than 2,000 physician partners. As part of our mission to provide healing and hope to the three million people we serve, we have developed Community Benefit initiatives that 1) expand access to health care, 2) enhance overall health status and 3) promote medical education. In the Fiscal Year that ended June 30, 2011, HSHS hospitals provided $166.1 million in Community Benefits (or 8.7% of total expenses), an increase of $15.7 million from FY 2010. Of this amount, $37.1 million was provided for charity care and $99.8 million was the amount of unreimbursed care provided under the Medicaid program. In addition, HSHS hospitals committed significant resources in serving the Medicare population. The cost of providing services to primarily elderly beneficiaries of the Medicare program, in excess of governmental and managed care contract payments, was $183.8 million during Fiscal Year 2011. HSHS hospitals also recorded $103.9 million in uncollectible accounts. HSHS strengthens the health of our communities by continually reinvesting any surplus revenue from operations and investments into new medical technology, facility infrastructure and health care services. These investments ensure that our hospitals can continue to provide high quality, compassionate care to our patients. During Fiscal Year 2011, HSHS also continued to invest in our Care Integration strategy that places the patient at the center of our work while allowing us to deliver care in a more cost-effective and efficient manner. These investments are designed to better coordinate care, improve health outcomes, create new efficiencies, and help ensure that patients (especially those with chronic conditions) get well and stay well. Our Care Integration strategy is delivering promising results. An example is our three Medical Home pilot projects. Diabetic Patients enrolled in Medical Homes in rural Illinois experienced an average 42 percent decrease in their blood glucose levels while their unplanned readmissions to the hospital dropped to zero. HSHS is making significant progress implementing interoperable health information technologies and robust health information exchanges. In central Illinois, HSHS is joining with other health care providers to develop a statewide Health Information Exchange ("HIE") that will allow health care providers to exchange clinical information, such as medication histories and test results, access that information at the point of care and make better informed decisions with their patients. HSHS understands that our investments in information technology will have a positive impact on the quality, safety and efficiency of health care. 1. Expanding access to health care An integral component of our Community Benefit initiatives is to provide care to every patient who seeks our services without exception. To that end, HSHS hospitals have established Charity Care program guidelines that cover 100% of hospital charges for individuals and families who earn 125% to 250% of the federal poverty level. HSHS hospital's Charity Care guidelines have sliding scales, in some instances providing up to a 50% discount on charges for those earning up to 600% of the federal poverty level. HSHS hospitals have created simple forms for those wishing to apply for Charity Care and assign counselors to visit with inpatients who are uninsured to let them know about our charity care policies and provide assistance filling out applications for financial assistance or enrollment in publicly funded health care programs. HSHS hospitals also work collaboratively with others to enhance access to health care services for those in need. St. John's Hospital in Springfield, IL has partnered with Memorial Medical Center, Southern Illinois University School and Medicine and other community partners to support the Coordinated Access to Community Health ("CATCH") initiative. The free program is being made available to uninsured adults in Sangamon County to help them access routine medical care, specialty doctors and affordable medicine. Launched in May 2011, CATCH enrolls patients as they visit social service agencies or when they leave hospital emergency rooms. Enrollees are then referred to Springfield's federally funded primary care clinic, Capitol Community Health Center, or participating doctors' private offices. Grants from St. John's Hospital, Memorial Medical Center, United Way of Central Illinois and the Dominican Sisters offset CATCH's first year of expenses. Patient advocates at St. John's Hospital and Memorial Medical Center help uninsured patients find primary or specialty doctors and make appointments, and arrange for financial assistance from participating social service agencies for prescription drugs. In the first three months since the program was launched, CATCH signed up more than 250 physicians in the community who agreed to see patients at no charge. The program endeavors to enroll up to 6,000 uninsured patients within the next few years. By making it easier for uninsured residents to get preventive health care services, CATCH organizers believe uninsured patients' medical problems will be addressed early, helping improve their quality of life. St. Mary's Hospital Medical Center in Green Bay, WI supports the NEW Community Clinic, a 38-year-old free health center for the uninsured and underinsured. St. Mary's provides free and discounted laboratory and radiology services to the clinic. More than 70 percent of patients say the clinic's care allowed them to avoid having to seek care in a local Emergency Room. For the past decade, St. Anthony's Memorial Hospital in Effingham, IL has teamed up with Effingham Catholic Charities to co-sponsor the Prescription Assistance Program. Catholic Charities' staff members work with clients who need prescription medication but may not be able to afford them because they are uninsured or underinsured. Due to the financial support of St. Anthony's, the program is able to provide needed prescriptions to dozens of residents each month. St. Francis Hospital in Litchfield, IL collaborated with local dental care providers to coordinate and provide a free day of dental care to uninsured individuals. The collaboration was the result of a community needs assessment that determined access to dental care was a priority in the community. The "Community Day of Dental Care" provided free dental cleanings, X-Rays, and extractions to 90 uninsured individuals. Among those 90 people served included a military veteran who has been unable to obtain dental care after a St. Louis facility closed. He was able to have five teeth extracted. Another person served was a young woman who needed some minor restorative care which greatly improved her appearance. She was very grateful because she had a job interview coming up and would be able to attend the interview feeling better about her appearance. 2. Enhancing the health status of the community Another component of our Community Benefit initiatives is to improve the quality of life in our communities. Our hospitals work closely with a wide array of public and private organizations that share our commitment to enhancing health and wellness. We know that by working together, we can maximize our efforts by sharing resources, reduce duplication of services, and make it easier for residents to get the services and knowledge they need to live healthier lives. HSHS hospitals also understand they need to listen closely to the residents of the communities they serve to ensure the health care needs of all are being met. Sacred Heart Hospital in Eau Claire, WI invited more than 1,400 area residents to share their vision for health care during a series of focus groups. Participants included constituents that are often overlooked: low-income, vulnerable populations and minority groups. The visioning sessions captured the voices of special populations, Among Mutual Assistance Association members, Amish farmers, seniors, young children and other diverse groups. The feedback provided led to more than 100 actionable items that were assessed and/or implemented over the first six months since the sessions concluded. One action taken by Sacred Heart Hospital and St. Joseph's Hospital in Chippewa STATE FILING OF COMMUNITY BENEFIT REPORT 990 SCHEDULE H, PART VI WI, X true true X X X X X X true false false false false false false false false MICHELE OOSTDYK 91138 0 0 0 59700 0 0 0 15066 0 165904 0 0 0 andrew j bagnall 0 152992 0 31800 0 41657 0 26322 0 18994 0 271765 0 0 ann carr 0 152228 0 11100 0 28008 0 92165 0 18090 0 301591 0 0 therese pandl 0 544799 0 35400 0 20302 0 132192 0 29068 0 761761 0 0 donna hutchinson 0 154369 0 5300 0 22592 0 72762 0 4778 0 259801 0 0 mary brasseaux 0 83 0 0 0 277451 0 0 0 0 0 277534 0 0 Greg Simia Greg Simia, Division CFO, began his employment during calendar year 2011. Accordingly, he would have no calendar year 2010 compensation for purposes of reporting on Form 990, Part VII, Or Schedule J, Part II. Social Club Dues Schedule J, Part I, Line 1a St. Nicholas paid social club dues on Andrew Bagnall's behalf during the year. The fair market value was included in his reportable compensation for the year. Severance Pay Schedule J, Part I, Line 4a Mary Brasseaux received severance payments during the year for her services as President and CEO. THERESE PANDL mortgage extension X 250000 250000 false true true 250000 Barbara Hocking Temporary Placement 362781 Director of Surgery placement false Loans to/from interested persons Schedule L, Part II All loans involving interested persons are compliant with the organization's conflict of interest policy. any transactions requiring board approval are reviewed by an independent board prior to being approved. business transactions involving interested persons schedule l, part iv All business transactions involving interested persons are compliant with the organization's conflict of interest policy. any transactions requiring board approval are reviewed by an independent board prior to being approved. Organization's Mission FORM 990 PART III, LINE 1 ST. NICHOLAS HOSPITAL IS DEDICATED TO SUFFERING HUMANITY FOR HIS SAKE, AND IS COMMITTED TO PROVIDING HIGH QUALITY, COMPASSIONATE CARE WITHOUT REGARD FOR RACE, CREED, OR ABILITY TO PAY. OUR CORE VALUES OF RESPECT, CARE, COMPETENCE AND JOY ARE LIVED BY ALL WHO WORK HERE, AND FELT BY ALL WHO USE OUR SERVICES. STATEMENT OF PROGRAM SERVICE ACCOMPLISHMENTS FORM 990 PART III, LINE 4A THE COMMUNITY BENEFIT CONTRIBUTION OF ST. NICHOLAS HOSPITAL OF THE HOSPITAL SISTERS OF THE THIRD ORDER OF ST. FRANCIS INCLUDES PROGRAMS AND ACTIVITIES THAT IMPROVE ACCESS TO HEALTH CARE AND IMPROVE HEALTH IN OUR COMMUNITIES. IN ORDER TO PORTRAY THE FULL BREADTH OF OUR CONTRIBUTION, OUR COMMUNITY BENEFIT INFORMATION IS DESCRIBED BELOW: SECTION 1: QUALITATIVE DESCRIPTION OF COMMUNITY BENEFIT - DESCRIBES THE HOSPITAL'S COMMUNITY BENEFIT MISSION, HOW THE MISSION IS TRANSLATED INTO A PROACTIVE APPROACH DESIGNED TO MEET COMMUNITY HEALTH NEEDS, HOW THE HOSPITAL MEETS TAX-EXEMPT REQUIREMENTS, AND A DESCRIPTION OF COMMUNITY BENEFIT PROGRAMS AND SERVICES THAT HIGHLIGHT THE HOSPITAL'S IMPACT ON COMMUNITY HEALTH. SECTION 2: QUANTITATIVE DESCRIPTION OF COMMUNITY BENEFIT - DESCRIBES THE HOSPITAL'S COMMUNITY BENEFIT CONTRIBUTION IN FINANCIAL TERMS PRESENTING THE AMOUNT OF CHARITY CARE, THE UNPAID SHORTFALL FROM GOVERNMENT HEALTH CARE FOR THE INDIGENT, AND THE NET EXPENSE OF COMMUNITY BENEFIT SERVICES. SECTION 1 - QUALITATIVE DESCRIPTION OF COMMUNITY BENEFIT 1. ORGANIZATIONAL COMMITMENT TO PROVIDING COMMUNITY BENEFIT A. DESCRIBE HOSPITAL'S MISSION AND PRIMARY EXEMPT PURPOSE. (IF APPLICABLE, IDENTIFY HOSPITAL'S STATUS AS A CRITICAL ACCESS HOSPITAL, SOLE COMMUNITY HOSPITAL, DISPROPORTIONATE SHARE HOSPITAL, OR RELATED STATUS.) THE MISSION OF ST. NICHOLAS HOSPITAL IS TO CARRY FORWARD THE HEALING MINISTRY OF THE HOSPITAL SISTERS OF THE THIRD ORDER OF ST. FRANCIS AS PART OF THE HEALTH MINISTRY OF THE ROMAN CATHOLIC CHURCH. ST. NICHOLAS HOSPITAL IS DEDICATED TO SUFFERING HUMANITY FOR HIS SAKE AND IS COMMITTED TO PROVIDING HIGH QUALITY, COMPASSIONATE CARE WITHOUT REGARD FOR RACE, CREED, OR ABILITY TO PAY. OUR CORE VALUES OF RESPECT, CARE, COMPETENCE, AND JOY ARE LIVED BY ALL WHO WORK HERE, AND FELT BY ALL WHO USE OUR SERVICES. B. SUMMARIZE HOSPITAL'S APPROACH TO PROVIDING COMMUNITY BENEFIT. THIS SUMMARY COULD INCLUDE THE FOLLOWING INFORMATION: GEOGRAPHIC AREA AND TARGET POPULATIONS. ST. NICHOLAS HOSPITAL'S SERVICE AREA INCLUDES SHEBOYGAN COUNTY AND PARTS OF OZAUKEE, FOND DU LAC, MANITOWOC, AND CALUMET COUNTIES WITH A TOTAL POPULATION OF APPROXIMATELY 140,000. MUCH OF THIS AREA IS RURAL AND CONSISTS OF SMALL FAMILY FARMS. IMMIGRANT COMMUNITIES HAVE GROWN SUBSTANTIALLY IN RECENT YEARS, PARTICULARLY HISPANIC GROUPS FROM MEXICO AND LATIN AMERICA, HMONG FAMILIES FROM SOUTHEAST ASIA, AND EASTERN EUROPEANS. IT IS ESTIMATED THAT OVER 10% OF THE US POPULATION IS UNINSURED. IN ADDITION TO MEDICAID, WISCONSIN HAS BADGERCARE, A PROGRAM THAT WAS INTRODUCED IN 1999. THE NEW BADGERCARE PLUS PROGRAM REACHED MAXIMUM ENROLLMENT LEVELS JUST THREE MONTHS AFTER ITS LAUNCH. WISCONSIN'S BADGERCARE PLUS IS RECEIVING INCREASED ATTENTION FROM HEALTH REFORMERS AROUND THE COUNTRY. THE STATE WAS RECENTLY FORCED TO CAP ENROLLMENT FOR CHILDLESS ADULTS IN ITS BADGERCARE PLUS CORE PROGRAM AFTER 33,000 ADULTS HAD ENROLLED IN THE FIRST FEW MONTHS OF THE PROGRAM. MAJOR TRENDS, NEEDS, AND PROBLEMS IN THE COMMUNITY; AS NOTED ABOVE, JOB LOSSES WITH THE LOSS OF INSURANCE AS WELL AS HAVING OUR IMMIGRANT COMMUNITIES CONTINUE TO GROW SUBSTANTIALLY IN RECENT YEARS. LANGUAGE AND CULTURAL BARRIERS THAT CONTINUE TO INCREASE CAN HAMPER COMMUNICATIONS. NUTRITION AND LIFESTYLE CHOICES HAVE LED TO RISING RATES OF DIABETES, CARDIOVASCULAR DISEASE, AND OBESITY AMONG ALL POPULATIONS. MAJOR STRATEGIES TO ADDRESS IDENTIFIED NEEDS AND PROBLEMS; UTILIZING DATA COLLECTED BY THE STATE OF WISCONSIN, THE COUNTY DEPARTMENT OF PUBLIC HEALTH, THE NORTHEASTERN WISCONSIN AREA HEALTH EDUCATION CENTER, AND OTHER AREA HEALTHCARE PROVIDERS, ST. NICHOLAS HOSPITAL MONITORS CHANGES IN POPULATION, DISEASE INDICATORS, ETC. AND DEVELOPS A BROAD RANGE OF PROGRAMS TO ADDRESS UNMET HEALTHCARE NEEDS. THE MAJORITY OF THESE PROGRAMS ARE PROVIDED FREE OF CHARGE OR AT/BELOW COST. COMMUNITY ORGANIZATIONS COLLABORATING WITH THE HOSPITAL TO IMPROVE COMMUNITY HEALTH, EXPAND ACCESS TO HEALTH CARE, OR IN OTHER WAYS BENEFIT THE COMMUNITY; ST. NICHOLAS HOSPITAL WAS A FOUNDING MEMBER OF "HEALTHY SHEBOYGAN COUNTY 2020", A COLLABORATIVE EFFORT TO IMPROVE THE LIVES OF PEOPLE IN OUR COUNTY; PARTNERS IN THIS EFFORT INCLUDE THE PUBLIC HEALTH DEPARTMENT, AURORA HEALTH CARE, THE MENTAL HEALTH ASSOCIATION, FAMILY RESOURCE CENTER, SALVATION ARMY, AND PRAIRIE STATES ENTERPRISES. OUTREACH PROGRAMS ARE CURRENTLY FOCUSED ON OBESITY/INACTIVITY, ALCOHOL AND OTHER DRUG ABUSE PREVENTION, AND MENTAL HEALTH ISSUES, PARTICULARLY SUICIDE PREVENTION. HSC 2020 IS CURRENTLY IN A LONG-RANGE PLANNING PROCESS (FUNDED BY A GRANT FROM THE LOCAL UNITED WAY) THAT IS ADDRESSING THE NEED TO INCREASE ACCESS TO HEALTHCARE FOR THE UN- AND UNDERINSURED IN THE COUNTY. OUR HOSPITAL HAS DEDICATED STAFF TO ASSIST THE COMMUNITY BENEFIT EFFORT. THE HOSPITAL'S COMMUNITY EDUCATION AND OUTREACH DEPARTMENTS ARE STAFFED BY NURSES, SCREENERS, AND EDUCATORS WHO ARE TRAINED AND DEDICATED TO BRINGING HEALTH EDUCATION AND SERVICES TO THE COMMUNITY, PARTICULARLY FOR THE POOR AND ETHNIC MINORITIES. AN INTERPRETER SERVICE IS AVAILABLE TO ASSIST WITH LANGUAGE BARRIERS FOR ANY POPULATION. C. DESCRIBE THE HOSPITAL'S FINANCIAL ASSISTANCE POLICIES OR PROGRAMS (E.G. CHARITY CARE, DISCOUNTING) FOR LOW-INCOME PERSONS AND HOW THEY ARE COMMUNICATED TO THE PUBLIC. AS A CATHOLIC ORGANIZATION, ST. NICHOLAS HOSPITAL IS RESPECTFUL OF THE DIGNITY OF EVERY PERSON, AND PROVIDES SERVICES IN A COURTEOUS MANNER REGARDLESS OF FINANCIAL STATUS. WE OFFER FINANCIAL ASSISTANCE TO THOSE PATIENTS IN NEED. GUIDELINES, HOWEVER, HAVE BEEN ESTABLISHED TO ENSURE THAT THE HOSPITAL'S LIMITED RESOURCES ARE USED TO TREAT PATIENTS WHO ARE TRULY UNABLE TO PAY AND ARE NOT CONSUMED BY THOSE UNWILLING TO PAY OR WHO HAVE ALTERNATE PAY SOURCES. PATIENT ACCOUNT SPECIALISTS HELP PEOPLE EXPLORE OPTIONS FOR FINANCIAL ASSISTANCE AND THEN OFFER OUR CHARITY CARE PROGRAM. UPON APPLICATION, AND IF THE GUIDELINES ARE MET, THE HOSPITAL WILL PROVIDE COVERAGE OF 25 - 100%, BASED ON THE MINIMUM ANNUAL INCOME GUIDELINES ESTABLISHED BY THE US DEPARTMENT OF HEALTH AND SOCIAL SERVICES. DISCOUNTS ARE ALSO AVAILABLE FOR PATIENTS WHO MAY BE UN- OR UNDERINSURED BUT WHO FALL OUTSIDE THE CHARITY CARE PROGRAM GUIDELINES. FINANCIAL ASSISTANCE INFORMATION IS AVAILABLE AT ADMITTING/REGISTRATION, THE CASHIER OFFICE, AND EMERGENCY DEPARTMENT. STATEMENT OF PROGRAM SERVICE ACCOMPLISHMENTS CONTINUED FORM 990 PART III, LINE 4A 2. ORGANIZATIONAL DESCRIPTION FOR TAX EXEMPTION INDICATE WHETHER THE HOSPITAL: OPERATES AN EMERGENCY ROOM THAT IS OPEN TO ALL PERSONS REGARDLESS OF ABILITY TO PAY; ST. NICHOLAS HOSPITAL OPERATES A LEVEL III TRAUMA CENTER/EMERGENCY DEPARTMENT THAT IS OPEN 24/7 AND STAFFED BY THE AREA'S FIRST BOARD-CERTIFIED EMERGENCY MEDICINE PHYSICIAN SPECIALISTS. STAFF MEMBERS ARE CERTIFIED IN ADVANCED CARDIAC LIFE SUPPORT, PEDIATRIC ADVANCED LIFE SUPPORT, AND TRAUMA. LIKE ALL HOSPITAL SERVICES, EMERGENCY CARE IS PROVIDED REGARDLESS OF RACE, CREED, OR ABILITY TO PAY, AND FINANCIAL ASSISTANCE IS AVAILABLE AFTER CARE IS PROVIDED FOR THOSE IN NEED. HAS AN OPEN MEDICAL STAFF WITH PRIVILEGES AVAILABLE TO ALL QUALIFIED PHYSICIANS IN THE AREA; OUR MEDICAL STAFF IS OPEN TO ALL AREA PHYSICIANS WHO APPLY AND ARE PROPERLY CREDENTIALED. HAS A GOVERNING BODY IN WHICH INDEPENDENT PERSONS REPRESENTATIVE OF THE COMMUNITY COMPRISE A MAJORITY; ST. NICHOLAS HOSPITAL'S BOARD OF DIRECTORS IS COMPRISED OF HOSPITAL SISTERS HEALTH SYSTEM EXECUTIVES AS WELL AS REPRESENTATIVES FROM OUR GEOGRAPHIC AREA. OUR ADVISORY COUNCIL IS COMPRISED OF 19 MEN AND WOMEN REPRESENTING A BROAD RANGE OF AREA BUSINESS AND PHYSICIAN INTERESTS AS WELL AS LOCAL FAITH COMMUNITIES AND SOCIAL SERVICE AGENCIES. ENGAGES IN MEDICAL OR SCIENTIFIC RESEARCH PROGRAMS; THE HOSPITAL HAS CONDUCTED SOME LIMITED MEDICAL/SCIENTIFIC RESEARCH PROGRAMS, I.E. DRUG TRIALS, ONLY UNDER CAREFUL MEDICAL STAFF/ INSTITUTIONAL REVIEW BOARD SUPERVISION. ENGAGES IN THE TRAINING AND EDUCATION OF HEALTH CARE PROFESSIONALS; ST. NICHOLAS HOSPITAL PROVIDES EDUCATIONAL TRAINING AND SUPERVISED HANDS-ON EXPERIENCE FOR INTERNS AND EXTERNS FROM AREA COLLEGES AND LAKESHORE TECHNICAL COLLEGE. PARTICIPATES IN MEDICAID, MEDICARE, CHAMPUS, TRICARE, AND/OR OTHER GOVERNMENT-SPONSORED HEALTH CARE PROGRAMS; ST. NICHOLAS HOSPITAL PARTICIPATES IN MEDICAID, MEDICARE, CHAMPUS, AND OTHER GOVERNMENT-SPONSORED HEALTHCARE PROGRAMS. 3. DESCRIPTION OF COMMUNITY BENEFIT PROGRAMS A. DESCRIBE AND HIGHLIGHT ONE OR MORE PROGRAMS THAT HAVE CLEARLY MET AN IDENTIFIED COMMUNITY HEALTH NEED. FREE MONTHLY SCREENINGS AND HEALTH EDUCATION FOR THE HMONG MUTUAL ASSISTANCE ASSOCIATION AND THE HISPANIC CONGREGATION AT ST. CLEMENT PARISH, INCLUDING CULTURALLY APPROPRIATE NUTRITION EDUCATION PROVIDING TWO HOUSES, INCLUDING UTILITIES, FREE OF CHARGE TO THE SHEBOYGAN SAFE HARBOR AGENCY FOR USE AS DOMESTIC ABUSE SHELTERS; PROVIDING ATHLETIC TRAINERS TO THE SHEBOYGAN AREA SCHOOL DISTRICT FOR LOCAL HIGH SCHOOL SPORTING EVENTS; PROVIDING SUPPORT GROUPS FREE OF CHARGE FOR HEART, RENAL, AND STROKE PATIENTS AS WELL AS GRIEF COUNSELING FOR ADULTS AND CHILDREN; FREE MONTHLY BLOOD PRESSURE SCREENINGS AT DOZENS OF LOCATIONS THROUGHOUT THE COUNTY; FREE USE OF HOSPITAL CONFERENCE AND MEETING ROOMS FOR AREA NOT-FOR-PROFIT ORGANIZATIONS; PROVIDING THREE HOMES WITH FINANCIAL SUPPORT AND IN-KIND SERVICES FOR SHEBOYGAN COUNTY INTERFAITH ORGANIZATION AND BRIDGEWAY AND BEYOND, WHICH PROVIDES TEMPORARY HOUSING FOR HOMELESS WOMEN AND CHILDREN AND FAMILIES TRANSITIONING OUT OF DOMESTIC ABUSE SITUATIONS; CHILD CAR SEAT SAFETY CHECKS BY CERTIFIED TECHNICIANS OPEN TO THE PUBLIC FREE OF CHARGE; FREE PRENATAL CARE PROGRAM FOR THE POOR; FREE BIKE HELMET FITTINGS AND HELMETS AT COST, OPEN TO THE PUBLIC BREAST CANCER SCREENINGS AT COST FOR THE UNDERSERVED, INCLUDING SPECIAL SERVICES AND TRANSLATION FOR WOMEN OF THE LOCAL HISPANIC COMMUNITY; FREE ADVANCE DIRECTIVE EDUCATION IN LOCAL CHURCHES AND OTHER VENUES TO ASSIST THE PUBLIC WITH END-OF-LIFE PLANNING; PARTNER WITH THE PUBLIC HEALTH DEPARTMENT TO OFFER FREE CHILDBIRTH EDUCATION IN SPANISH; PROVIDING FINANCIAL SUPPORT AND IN-KIND SERVICES FOR SHEBOYGAN COUNTY INTERFAITH ORGANIZATION, FAMILY RESOURCE CENTER, SAFE HARBOR DOMESTIC ABUSE SHELTER, BIG BROTHERS/BIG SISTERS, AND AREA CHURCHES AND SCHOOLS; PROVIDE SAFE SHARPS DISPOSAL FREE OF CHARGE TO THE PUBLIC; ANNUAL ASSESSMENT BY THE STATE OF WISCONSIN TO FUND WISCONSINCARE THAT SERVES THE UNINSURED; FOOD DRIVES FOR AREA FOOD PANTRIES; SCHOOL SUPPLY AND CLOTHING DRIVES FOR AREA SCHOOLS; SENDING THE HEALTHEXPRESS INTO THE COMMUNITY THROUGHOUT THE YEAR TO PROVIDE FREE SCREENINGS AND HEALTH EDUCATION; 4. LINKS TO ADDITIONAL COMMUNITY BENEFIT INFORMATION A. PLEASE VISIT OUR WEBSITE FOR ADDITIONAL INFORMATION ABOUT OUR HOSPITAL PROVIDED SERVICES AND OUR 2010 COMMUNITY BENEFIT REPORT: YOU CAN FIND US AT WWW.STNICHOLASHOSPITAL.ORG. SECTION 2 - QUANTIFIABLE COMMUNITY BENEFIT THIS SECTION INCLUDES A LIST OF THE TYPES OF PROGRAMS AND SERVICES THAT COULD BE INCLUDED AS COMMUNITY BENEFIT ACTIVITIES. SEE WWW.CHAUSA.ORG/COMMUNITYBENEFIT/COUNTING FOR MORE DETAILS ABOUT THESE PROGRAMS AND SERVICES. THE FINANCIAL INFORMATION IN THIS REPORT WAS PREPARED IN ACCORDANCE WITH THE CATHOLIC HEALTH ASSOCIATION'S ("CHA") COMMUNITY BENEFIT REPORTING GUIDELINES. OUR REPORT FOLLOWS THESE ("CHA") RECOMMENDATIONS: - REPORT CHARITY CARE AT COST, NOT CHARGES. - DO NOT INCLUDE BAD DEBT, CONTRACTUAL ALLOWANCES, AND QUICK PAY DISCOUNTS AS PART OF CHARITY CARE EXPENSE. - DO NOT COUNT MEDICARE SHORTFALL AS A COMMUNITY BENEFIT. - REPORT THE NET EXPENSE FOR COMMUNITY BENEFIT SERVICES, I.E., THE TOTAL COMMUNITY BENEFIT EXPENSE MINUS ANY ASSOCIATED REVENUE FROM PATIENTS, PAYERS, AND OTHER EXTERNAL SOURCES. THE CHA REPORTING GUIDELINES REFLECT A CONSERVATIVE APPROACH TO REPORTING QUANTIFIABLE COMMUNITY BENEFIT. THE GOAL OF THE REPORTING GUIDELINES IS TO PRODUCE COMMUNITY BENEFIT FINANCIAL REPORTS THAT REFLECT TRUE COSTS AND THAT DESCRIBE COMMUNITY BENEFIT ACTIVITIES THAT INCREASE ACCESS TO HEALTH CARE AND IMPROVE COMMUNITY HEALTH. FOR FISCAL YEAR ENDED JUNE 30, 2011, 1) CHARITY CARE - AT COST DO NOT INCLUDE BAD DEBT. $ 1,099,449 2) GOVERNMENT SPONSORED HEALTH CARE - NET EXPENSE $ 3,466,352 UNPAID COST OF PUBLIC INDIGENT CARE PROGRAMS (INCLUDES MEDICAID, SCHIP, OTHER SAFETY NET PROGRAMS; DOES NOT INCLUDE MEDICARE SHORTFALL) 3) COMMUNITY BENEFIT PROGRAMS - NET EXPENSE $ 303,731 SPECIFIC EXPENSES MAY BE ITEMIZED AS APPROPRIATE. TOTAL QUANTIFIABLE COMMUNITY BENEFIT $ 4,869,532 OTHER EXAMPLES OF COMMUNITY BENEFIT PROGRAM NET EXPENSES OTHER PROGRAM SERVICES Form 990, Part IV, Line 4D St. Nicholas Hospital provides comprehensive inpatient and outpatient medical services to the community. Besides the three largest program services identified in Part III, St Nicholas Hospital provides additional services including womens' and infant services, wound care, radiation therapy, orthopedic services, renal dialysis, sleep center services, and a variety of additional medical services. We provide an array of community health services including, but not exclusive to the following, diabetic screenings, flu shots, and a variety of community education classes. In addition, St. Nicholas Hospital partners with several physician groups and other joint ventures that provide needed medical services to the community. Tax Exempt Bonds Form 990 Part IV, Question 4 St. Nicholas Hospital HOLDS A LIABILITY ON ITS BOOKS FOR TAX-EXEMPT BONDS, WHICH IS AN ALLOCATION FROM ITS SOLE CORPORATE MEMBER, HOSPITAL SISTERS SERVICES, INC. AS A RESULT, THIS QUESTION WAS ANSWERED NO, AND SCHEDULE K WILL BE COMPLETED ON THE HOSPITAL SISTERS SERVICES, INC. FORM 990. RIGHTS OF MEMBERS TO ELECT GOVERNING BODY FORM 990 PART VI, LINES 6 & 7A THE SENIOR GOVERNING BODY OF ST. NICHOLAS HOSPITAL (THE "CORPORATION") IS THE MEMBER OF THE CORPORATION, WHICH IS HOSPITAL SISTERS SERVICES, INC. ("HSSI"), AN ILLINOIS NOT FOR PROFIT CORPORATION EXEMPT FROM FEDERAL TAXATION UNDER SECTION 501(C)(3) OF THE INTERNAL REVENUE CODE. PURSUANT TO SECTION 2.3 OF THE CORPORATION'S BYLAWS, HSSI HAS THE RIGHT TO APPOINT AND REMOVE THE CORPORATION'S BOARD OF DIRECTORS, CHAIRPERSON OF THE BOARD, AND PRESIDENT. MEMBER RESERVED POWERS FORM 990 PART VI, LINE 7B Responsibility for the policy and operations of St. Nicholas Hospital (the "Corporation") is vested in its Board of Directors, except with respect to specific powers reserved in the Corporation's Bylaws to the Corporation's Member, Hospital Sisters Services, Inc. ("HSSI"), an Illinois not for profit corporation exempt from federal taxation under Section 501(c)(3) of the Internal Revenue Code. The member of HSSI is Hospital Sisters Health System ("HSHS"), an Illinois not for profit corporation exempt from federal taxation under Section 501(c)(3) of the Internal Revenue Code. The members of HSHS are the individual sisters who, from time to time, are the duly elected Provincial Superior and Provincial Councilors, respectively of the American Province of the Hospital Sisters of St. Francis ("American Province"). The American Province is the United States organization of the Congregation of the Hospital Sisters of the Third Order Regular of St. Francis, a religious institute of the Roman Catholic Church. The governance and operations of the Corporation are subject to HSSI's right to exercise these reserved powers with respect to the Corporation and organizations of which the Corporation is either, directly or indirectly, a controlling member or a controlling shareholder ("Affiliates"). HSSI's right to exercise certain of these reserved powers is, in turn, subject to the approval of HSHS and HSHS' members. The reserved powers include all rights granted to HSSI by law and the right to: (a) Adopt, approve amendments to, or amend any statement of philosophy, mission, mission integration or values, or any name, logo, or mark of the Corporation or of any Affiliate; (b) Adopt, approve amendments to, or amend the Articles of Incorporation of the Corporation or of any Affiliate; (c) Adopt, approve amendments to, or amend the Bylaws of the Corporation or of any Affiliate; (d) Appoint and remove the Board of Directors, any one or more of the Directors of the Corporation or of any Affiliate, and the Chairperson and President of the Corporation or of any Affiliate; (e) Approve the recommendation of the Board of Directors to appoint or remove the Board of Directors, any one or more Directors of the Corporation or of any Affiliate, or the Chairperson and President of the Corporation or of any Affiliate. (f) With respect to the Corporation or any Affiliate, approve the purchase, sale, alienation, exchange, lease, or encumbrance of any real property of the Corporation or of any Affiliate, which property has a value in excess of limits set from time to time by HSSI; (g) Approve the operating and capital budgets of the Corporation or of any Affiliate, and any deviations by the Corporation or of any Affiliate from such budgets in an amount or percentage specified by HSSI from time to time; (h) Approve the strategic plan and goals of the Corporation or of any Affiliate; (i) Approve the sale of substantially all of the assets of the Corporation or of any Affiliate; (j) Approve the merger or dissolution of the Corporation or of any Affiliate; (k) Adopt or amend the plan for ministry education and governance for the Corporation and its Affiliates; (l) Approve the Corporation's Mission Accountability Reports and those of any Affiliate; (m) Approve the financial policies and procedures of the Corporation or of any Affiliate, and approve any deviations from such policies and procedures by the Corporation or any Affiliate; and (n) Adopt policies to implement the Reserved Powers of HSSI. FORM 990 REVIEW PROCESS FORM 990 PART VI, LINE 11B The hospital employs KPMG to assist in the overall review and electronic submission of its Form 990. KPMG provides guidance in identifying critical errors in the return submission, and feedback on quantitative and qualitative responses. Additionally, the hospital CFO performs a thorough review of the return and reviews it with the hospital CEO and/or senior leaders before presenting it in its entirety to the hospital Board for questioning and review prior to the return's signing and submission to the IRS. CONFLICT OF INTEREST POLICY FORM 990 PART VI, LINE 12C The organization is subject to the corporate compliance program and conflict of interest policy ("policy") of Hospital Sisters Health System, an Illinois not for profit corporation exempt from federal taxation under section 501(c)(3) of the internal revenue code. A REVISED CORPORATE COMPLIANCE PROGRAM AND CONFLICT OF INTEREST POLICY HAVE BEEN IMPLEMENTED SINCE JANUARY, 2009 TO MANAGE CONFLICTS OF INTEREST USING A SYSTEM-WIDE PROTOCOL FOR DISCLOSURE STATEMENTS. IN ACCORDANCE WITH the organizaton's CONFLICT OF INTEREST POLICY, ALL COVERED PERSONS HAVE A DUTY TO COMPLY WITH THE CONFLICT OF INTEREST POLICY FOR ANY CONTRACT, TRANSACTION, RELATIONSHIP, OR ACTIVITY CONTEMPLATED, ENTERED INTO, OR CONDUCTED AT HSHS OR ITS AFFILIATES. THE POLICY DEFINES COVERED PERSONS AS BOARD MEMBERS, BOARD COMMITTEE MEMBERS, OFFICERS, BOARD DESIGNEES, SENIOR MANAGEMENT, MEMBERS OF ANY COMMITTEE THAT OVERSEES THE APPROVAL OF PHARMACEUTICALS AND MEDICAL DEVICES, and ANY OTHER INDIVIDUAL WHO HOLDS A POSITION OF TRUST. ON AN ANNUAL BASIS, HSHS DISCLOSES A COPY OF THE CONFLICT OF INTEREST POLICY (AND ALL CORRESPONDING PROCEDURES, GUIDELINES, FORMS, AND TOOLS) TO ALL COVERED PERSONS, AND ADVISES ALL COVERED PERSONS IN WRITING OF ANY SUBSTANTIVE CHANGES TO THIS POLICY AND SUCH RELATED MATERIALS. COVERED PERSONS ARE REQUIRED TO REVIEW AND COMPLETE THE CORRESPONDING CONFLICT OF INTEREST STATEMENT. THE SYSTEM OFFICE VICE PRESIDENT - SYSTEM RESPONSIBILITY, VICE PRESIDENT - RISK & COMPLIANCE, OR MEMBERS OF THE AUDIT AND INTEGRITY COMMITTEE ("COMMITTEE") ARE AVAILABLE TO ANSWER ANY QUESTIONS A COVERED PERSON MAY HAVE. IN ADDITION, IF AT ANY TIME AFTER SUBMITTING AN ANNUAL CONFLICT OF INTEREST STATEMENT, A COVERED PERSON BECOMES AWARE OF AN INTEREST THAT HE OR SHE WOULD HAVE HAD TO DISCLOSE AT THE ANNUAL INTERVAL, THE COVERED PERSON IS REQUIRED PROMPTLY TO DISCLOSE THE INTEREST TO THE COMMITTEE USING THE HSHS CONFLICT OF INTEREST DISCLOSURE STATEMENT. COMPLETED CONFLICT OF INTEREST STATEMENTS ARE SUBMITTED TO THE COMMITTEE, WHICH IS RESPONSIBLE FOR IDENTIFYING, ASSESSING, AND MANAGING CONFLICTS OF INTEREST THAT ARISE IN THE COURSE OF CONDUCTING THE AFFAIRS OF HSHS AND ITS AFFILIATES. IF THE COMMITTEE DETERMINES THAT A CONFLICT OF INTEREST EXISTS, THE CONFLICT OF INTEREST POLICY REQUIRES HSHS NOT TO ENGAGE IN, OR ENTER INTO, A PROPOSED CONTRACT, TRANSACTION, RELATIONSHIP, ARRANGEMENT, OR ACTIVITY UNLESS THE COMMITTEE OR, WHERE NECESSARY, THE BOARD OF DIRECTORS (ACTING THROUGH ITS DISINTERESTED MEMBERS), HAS INVESTIGATED ALTERNATIVES TO THE PROPOSED CONTRACT, TRANSACTION, RELATIONSHIP, ARRANGEMENT, OR ACTIVITY AND, IN THE ABSENCE OF ALTERNATIVES THAT ARE IN THE BEST INTERESTS OF HSHS, HAS DETERMINED: 1. THAT, REGARDLESS OF WHETHER THE COVERED PERSON PARTICIPATES IN THE IMPLEMENTATION OF THE PROPOSED CONTRACT, TRANSACTION, RELATIONSHIP, ARRANGEMENT, OR ACTIVITY; 2. THE CONTRACT, TRANSACTION, ARRANGEMENT, OR ACTIVITY IS IN THE BEST INTERESTS OF HSHS; 3. THE CONTRACT, TRANSACTION, ARRANGEMENT, OR ACTIVITY IS FAIR AND REASONABLE FROM THE PERSPECTIVE OF HSHS; AND 4. HSHS CANNOT OBTAIN A MORE ADVANTAGEOUS CONTRACT, TRANSACTION, ARRANGEMENT, OR ACTIVITY WITH REASONABLE EFFORTS UNDER THE CIRCUMSTANCES. IN DETERMINING WHETHER A CONTRACT, TRANSACTION, OR ARRANGEMENT IS FAIR AND REASONABLE TO HSHS, THE COMMITTEE SHALL CONSIDER, WHERE APPLICABLE: 1. APPRAISALS OR OTHER INDEPENDENT VALUATIONS OF THE FAIR MARKET VALUE OF THE CONTRACT, TRANSACTION, OR ARRANGEMENT; 2. INFORMATION REGARDING COMPARABLE CONTRACTS, TRANSACTIONS, OR ARRANGEMENTS BETWEEN UNRELATED PARTIES; 3. OFFERS FROM COMPARABLE COMPETING ENTITIES; AND/OR 4. STUDIES OF COMPARABLE COMPENSATION ARRANGEMENTS. IN ANY CASE IN WHICH THE COMMITTEE FINDS, AFTER TAKING THE STEPS DESCRIBED ABOVE, THAT HSHS SHOULD PARTICIPATE IN A PROPOSED TRANSACTION OR ARRANGEMENT DESPITE THE EXISTENCE OF A CONFLICT OF INTEREST, THE COMMITTEE SHALL DEVELOP, IMPLEMENT, MONITOR, AND ENFORCE COMPLIANCE WITH, A CONFLICT MANAGEMENT PLAN FOR MANAGING THE CONFLICT OF INTEREST AS IT CONSIDERS NECESSARY FOR SUCH FINDINGS TO REMAIN VALID THROUGHOUT THE LIFE OF THE CONTRACT, TRANSACTION, RELATIONSHIP, ARRANGEMENT, OR ACTIVITY. ALL CONFLICT MANAGEMENT PLANS SHALL: 1. STATE THAT THE COMMITTEE WILL OVERSEE, MONITOR, AND ENFORCE COMPLIANCE WITH THE PLAN THROUGHOUT THE COURSE OF THE STUDY, AND SPECIFY MEANS FOR DOING SO, INCLUDING, WITHOUT LIMITATION, THAT THE APPROPRIATE INDIVIDUALS MUST PROVIDE THE COMMITTEE WITH WRITTEN REPORTS PERTAINING TO COMPLIANCE WITH THE CONFLICT MANAGEMENT PLAN, THAT THE COMMITTEE SHALL HAVE THE RIGHT TO AUDIT THE STUDY FOR SUCH COMPLIANCE, AND THE RIGHT TO IMPOSE SANCTIONS FOR NON-COMPLIANCE; 2. STATE THAT THE PLAN MUST BE SHARED WITH COVERED PERSON WHOSE INTERESTS IT WAS DEVELOPED TO MANAGE; 3. STATE THAT THE PLAN MUST BE SHARED WITH, AND PERIODIC REPORTS ON COMPLIANCE WITH THE PLAN MUST BE PROVIDED TO, THE BOARD, SENIOR MANAGEMENT, AND/OR GOVERNMENT AGENCIES; AND 4. PROVIDE FOR SUCH OTHER MANAGEMENT STEPS AND MECHANISMS THE COMMITTEE CONSIDERS NECESSARY AND APPROPRIATE. IN ADDITION TO THE COMMITTEE, THE SYSTEM OFFICE VICE PRESIDENTS OF SYSTEM RESPONSIBILITY AND RISK & COMPLIANCE MAY RETAIN SUCH INDEPENDENT ADVISORS OR EXPERTS AS DEEMED NECESSARY TO ASSIST IN MAKING ITS DETERMINATIONS AND DECISIONS. IF THE COMMITTEE DETERMINES THAT THE CONTEMPLATED TRANSACTION, RELATIONSHIP, ARRANGEMENT, OR ACTIVITY CANNOT PROCEED DUE TO A CONFLICT OF INTEREST, THE COMMITTEE SHALL INFORM THE APPLICABLE COVERED PERSON OR DECISION-MAKING BODY OF SUCH DETERMINATION WITHIN ONE WEEK OF THE COMMITTEE MEETING AT WHICH THE CONTEMPLATED TRANSACTION WAS DISCUSSED. THE COMMITTEE SHALL DOCUMENT ITS REJECTION OF THE CONTEMPLATED TRANSACTION IN THE COMMITTEE'S MEETING MINUTES. WHISTLEBLOWER POLICY FORM 990 PART VI, LINE 13 Provisions within the Corporate Compliance Program and Conflict of Interest Policy provide protections for whistleblower type activities. COMPENSATION PROCESS FORM 990 PART VI, LINE 15 The Compensation Committee ("Committee") is comprised of independent members of the Board of Directors. The Committee develops a compensation philosophy for the System and all affiliates. The Committee selects and hires the independent compensation consultant to develop comparability data and advise the Committee during its deliberations regarding all elements of total compensation for all disqualified individuals. Integrated Healthcare Strategies ("IHS"), the consultants utilized by the Committee, use data from multiple tax-exempt peer group sources to determine salary ranges, incentive opportunity ranges, and benefits for the disqualified individuals. IHS then assists the Committee in preparing contemporaneous documentation of all actions. Each Committee meeting is conducted with the intent to create a rebuttable presumption of reasonableness for all elements of executive total compensation for the disqualified individuals. The Chairman makes this declaration and also inquires if there are any conflicts of interest by any attendees. Any conflicts are disclosed and the Committee then acts in a manner to avoid any conflicted individual participating in any manner where a conflict might exist. At the end of the meeting, the Committee prepares contemporaneous minutes that record all actions taken during the meeting. Joint Ventures FORM 990 PART VI, LINE 16B Hospital Sisters Health System adopted a Joint Venture Compliance Program policy effective on January 1, 2012 for all system hospitals, including St. Nicholas Hospital. The overall purpose of the policy is to provide practical guidelines for ethical business conduct, to achieve compliance, and to detect and prevent violations of applicable laws. The policy requires St. Nicholas Hospital, and all HSHS hospitals, to evaluate their participation in joint venture arrangements, including under applicable federal tax laws, and to safeguard St. Nicholass tax exempt status with respect to any joint venture arrangements. DOCUMENTS AVAILABLE TO THE PUBLIC FORM 990 PART VI, LINE 19 Board-approved financial statements are made available to the public upon request. The governing documents and conflict of interest policy are not made available to the general public at this time. POOLED INVESTMENT ACCOUNT FORM 990 PART X, LINE 11 St. Nicholas Hospital's cash reserves are invested in a pooled investment account. Participation in the pooled fund is limited to the 501(C)(3) Hospitals and related health services organizations sponsored by the Hospital Sisters Health System. The pooled account consists of cash, and equity and debt securities that are publicly traded. In accordance with the provisions of SFAS No. 124 "Accounting for certain investments held by Not-For-Profit Organizations," investments in equity securities with readily determinable values, and all investments in debt securities, are reported at fair value on the Balance Sheet. Income, realized and unrealized gains and losses are pooled and allocated to the participants. Individual components of assets and revenue are not identified to the participants. OTHER CHANGES IN NET ASSETS FORM 990, PART XI, LINE 5 unrealized gains from investments 2,949,629 increase in temporarily restricted net assets 768,000 net assets released from restrictions 456,000 Transfer to affiliates (502,000) recognition of changes in pension funded status 4,561,582 --------- total 8,233,211 ========= HOURS DEVOTED FOR RELATED ORGANIZATION FORM 990 PART VII NAME:Sr. Marybeth Culnan, OSF TITLE:BOARD MEMBER HOURS:74 HOURS DEVOTED FOR RELATED ORGANIZATION FORM 990 PART VII NAME:ann carr TITLE:treasurer HOURS:75 HOURS DEVOTED FOR RELATED ORGANIZATION FORM 990 PART VII NAME:therese pandl TITLE:divisional ceo HOURS:45 HOURS DEVOTED FOR RELATED ORGANIZATION FORM 990 PART VII NAME:Greg Simia TITLE:DIVISION CFO HOURS:45 SPRINGFIELD HEALTH PARTNERS LLC 4936 LAVERNA ROAD SPRINGFIELD IL 62707 371364419 HEALTHCARE IL 0 0 HSHS MG Kiara Clinical Integration Network LLC 4936 Laverna ROAd springfield IL 62707 261417684 healthcare IL 0 0 kiara inc HSHS SELF INSURANCE TRUST FUND 4936 LAVERNA ROAD SPRINGFIELD IL 62707 371120626 INSURANCE IL 501(c)(3) 11A NA HOSPITAL SISTERS HEALTH SYSTEM 4936 LAVERNA ROAD SPRINGFIELD IL 62707 371058692 HEALTHCARE IL 501(c)(3) 11A NA HOSPITAL SISTERS SERVICES INC 4936 LAVERNA ROAD SPRINGFIELD IL 62707 371163402 HEALTHCARE IL 501(c)(3) 11A NA HOSPITAL SISTERS OF ST FRANCIS FDTN 4936 LAVERNA ROAD SPRINGFIELD IL 62707 371186514 HEALTHCARE IL 501(c)(3) 11A NA HSHS HEALTH CARE PLAN TRUST FUND 4936 LAVERNA ROAD SPRINGFIELD IL 62707 371137724 HEALTHCARE IL 501(c)(9) N/A NA Hospital Sisters Healthcare West Inc 2661 COUNTY HIGHWAY I CHIPPEWA FALLS WI 54729 510157933 HEALTHCARE WI 501(c)(3) 11A NA SACRED HEART HOSPITAL 900 WEST CLAIREMONT AVENUE EAU CLAIRE WI 54701 390807060 HEALTHCARE WI 501(c)(3) 3 NA ST ANTHONY'S HOSPITAL 503 N MAPLE STREET EFFINGHAM IL 624012099 370661233 HEALTHCARE IL 501(c)(3) 3 NA ST ELIZABETH'S HOSPITAL 211 SOUTH THIRD STREET BELLEVILLE IL 622201998 370663567 HEALTHCARE IL 501(c)(3) 3 NA ST JOHN'S HOSPITAL 800 EAST CARPENTER STREET SPRINGFIELD IL 62769 370661238 HEALTHCARE IL 501(c)(3) 3 NA ST FRANCIS HOSPITAL 1215 FRANCISCAN DRIVE LITCHFIELD IL 62056 370661236 HEALTHCARE IL 501(c)(3) 3 NA ST JOSEPH'S HOSPITAL 9515 HOLY CROSS LANE BREESE IL 622300099 371208459 HEALTHCARE IL 501(c)(3) 3 NA ST JOSEPH'S HOSPITAL 1515 MAIN STREET HIGHLAND IL 62249 370663568 HEALTHCARE IL 501(c)(3) 3 NA ST JOSEPH'S HOSPITAL 2661 COUNTY HIGHWAY 1 CHIPPEWA FALLS WI 54729 390810545 HEALTHCARE WI 501(c)(3) 3 NA ST MARY'S HOSPITAL 1800 E LAKE SHORE DRIVE DECATUR IL 62521 370661244 HEALTHCARE IL 501(c)(3) 3 NA ST MARY'S HOSPITAL 111 SPRING STREET STREATOR IL 613643332 362169181 HEALTHCARE IL 501(c)(3) 3 NA ST VINCENT HOSPITAL 835 S VAN BUREN GREEN BAY WI 543013256 390817529 HEALTHCARE WI 501(c)(3) 3 NA ST MARY'S HOSPITAL MEDICAL CENTER 1726 SHAWANO AVENUE GREEN BAY WI 54303 390818682 HEALTHCARE WI 501(c)(3) 3 NA HSHS MEDICAL GROUP INC 4936 LAVERNA ROAD SPRINGFIELD IL 62707 263956318 HEALTHCARE IL 501(c)(3) 11A NA HSHS WISCONSIN MEDICAL GROUP INC 8040 EXCELSIOR DRIVE STE 200 MADISON WI 53717 264515959 HEALTHCARE WI 501(c)(3) 11A NA Orange Cross Ambulance Inc 919 ASHLAND AVENUE SHEBOYGAN WI 53081 391860942 HEALTHCARE WI 501(c)(3) 11A NA WISCONSIN UPPER PENINSULA ONCOLOGY MGMT 835 S VAN BUREN GREEN BAY WI 54301 391677100 HEALTHCARE WI 501(c)(3) 3 ST VINCENT UNITY LIMITED PARTNERSHIP 2366 OAK RIDGE CIRCLE DE PERE WI 54115 391750729 HEALTHCARE WI 501(c)(3) 9 HSSI MEMORIAL AND ST ELIZABETH'S HEALTHCARE 4000 NORTH ILLINOIS STREET SWANSEA IL 62226 371312961 HealthCare IL St Elizabeth's Related 0 0 false 0 false 0.00000 Prairie Heart Insutute - Carbondale LLC 800 East Carpenter Street Springfield IL 62769 371321197 HealthCare IL St John's Related 0 0 false 0 false 0.00000 NORTHEAST WISCONSIN RADIATION THERAPY SE 1821 S WEBSTER AVE STE 300 GREEN BAY WI 543079047 263749065 HealthCare WI HSSI Related 0 0 false 0 false 0.00000 PAIN CENTER OF WISCONSIN 4131 W LOOMIS ROAD STE 300 GREENFIELD WI 53221 263155343 HealthCare WI ST VINCENT Related 0 0 false 0 false 0.00000 Surgery Center of Sheboygan LLC 3141 Saemann AveNUE Sheboygan WI 53081 260822209 HealthCare WI NA Related 0 0 false 0 false 0.00000 PREVEA VENTURES LLC 2710 EXECUTIVE DRIVE GREEN BAY WI 54304 203775127 HealthCare WI HSSI Related 0 0 false 0 false 0.00000 CARPENTER STREET HOTEL LLC 525 NORTH SIXTH STREET Springfield IL 62702 364128127 HOTEL IL LASANTE INC RELATED 0 0 false 0 false 0.00000 SPRINGFIELD URGENT CARE REAL ESTATE PO BOX 19456 Springfield IL 627949456 030413258 RENT. REAL ESTATE IL LASANTE INC RELATED 0 0 false 0 false 0.00000 KIARA INC 4936 LAVERNA ROAD SPRINGFIELD IL 62707 371163401 HEALTHCARE IL HSHS C Corp 0 0 0.00000 PRAIRIE CARDIOVASCULAR 619 EAST MASON SUITE 4P57 SPRINGFIELD IL 62701 371071858 HEALTHCARE IL Kiara Inc C Corp 0 0 0.00000 LaSante Inc 4936 Laverna ROAd Springfield IL 62707 371163400 HealthCare IL Kiara Inc C Corp 0 0 0.00000 LASANTE WISCONSIN INC 4936 LAVERNA ROAD SPRINGFIELD IL 62707 391572196 HEALTHCARE IL KIARA INC C Corp 0 0 0.00000 PREVEA HEALTH SERVICES 2710 EXECUTIVE DRIVE GREEN BAY WI 54304 391839351 HealthCare WI HSSI C Corp 0 0 0.00000 Prevea Clinic Inc 2710 EXECUTIVE DRIVE Green Bay WI 54304 391839349 HealthCare WI HSSI C Corp 0 0 0.00000 PREVEA HEALTH NETWORK 2710 EXECUTIVE DRIVE GREEN BAY WI 54304 392000537 HealthCare WI HSSI C Corp 0 0 0.00000 RENAISSANCE QUALITY INSURANCE PO Box 1159 Grand Cayman CJ KY1-1102 980669953 Insurance CJ HSSI C Corp 0 0 0.00000 false false true false false true true false true false false false true true true true false false TRANSACTIONS WITH RELATED ENTITIES FORM 990 SCHEDULE R, PART V LINE 2 The Transactions reported in Question 1 are between related 501(c)(3) public charities and are not reported in this section.