2012-12-17T09:37:47-06:00 2012-04-30 410746749 CLIFTONLARSONALLEN LLP 114 E EVERETT DIXON IL 61021 990 2011-05-01 364244337 VALLEY WEST COMMUNITY HOSPITAL VALL 8157561521 ONE KISH HOSPITAL DRIVE DEKALB IL 60115 LOREN FOELSKE 8157561521 2012-12-12 1 KELLY JACKSON HARDY P00747242 8152842285 2011 2016-02-24 21:20:13Z KEVIN P POORTEN ONE KISH HOSPITAL DRIVE DEKALB IL 60115 56313483 0 X WWW.VWCH.ORG X 1998 IL TO PROVIDE COMPREHENSIVE HEALTH CARE SERVICES, INCLUDING INPATIENT ACUTE AND NONACUTE CARE, AND VARIOUS OUTPATIENT SERVICES IN THE AREAS OF DEKALB, KENDALL, AND LASALLE COUNTIES. 3 2 298 65 0 0 85728 380934 45655170 48706320 396789 729322 928513 857178 47066200 50673754 5000 19500 0 0 14697950 14703466 0 0 0 28305660 31329533 43008610 46052499 4057590 4621255 59218227 61625713 10776741 10500036 48441486 51125677 X TO PROVIDE COMPREHENSIVE HEALTH CARE SERVICES, INCLUDING INPATIENT ACUTE AND NONACUTE CARE, AND VARIOUS OUTPATIENT SERVICES IN THE AREAS OF DEKALB, KENDALL, AND LASALLE COUNTIES. VALLEY WEST COMMUNITY HOSPITAL WILL STRIVE TO PROVIDE HIGH QUALITY PRIMARY CARE AND COMMUNITY HEALTH EDUCATION, WHILE PROMOTING COMMUNITY HEALTH SERVICES IN A FRIENDLY, CARING ENVIRONMENT. VALLEY WEST COMMUNITY HOSPITAL IS COMMITED TO PROVIDING HEALTH CARE IN ACCORDANCE WITH THE HIGHEST MEDICAL AND ETHICAL STANDARDS WITH CARE, COMPASSION, AND RESPECT FOR ALL, PROTECTING THE DIGNITY, AUTONOMY AND INTEGRITY OF ALL OUR PATIENTS, WHILE MANAGING THE MEDICAL RESOURCES AT OUR DISPOSAL WITH WISDOM AND FAIRNESS. 0 0 38602769 19500 49443635 VALLEY WEST COMMUNITY HOSPITAL (VALLEY WEST), LOCATED IN SANDWICH, ILLINOIS, SERVES THE RESIDENTS OF SOUTHERN DEKALB, NORTHERN LASALLE AND WESTERN KENDALL COUNTIES BY OFFERING A NUMBER OF PROGRAMS AND SERVICES THAT GO BEYOND BASIC HEALTH CARE. VALLEY WEST BELIEVES THAT IN ORDER TO BE A TRUE "COMMUNITY" HOSPITAL, WE MUST BE A RESOURCE FOR PREVENTATIVE AND CURATIVE HEALTH INFORMATION, EDUCATION AND SERVICES AND THAT WE MUST SUPPORT THE EFFORTS OF OTHERS WHO ALSO ARE DOING WORK FOR THE COMMUNITY GOOD. DOING SO HELPS BUILD TRUST, RESPECT AND LOYALTY FOR OUR HOSPITAL AND STRENGTHENS OUR ROLE AS A PARTNER IN IMPROVING THE HEALTH OF OUR CITIZENS AND THE QUALITY OF LIFE IN THE COMMUNITIES WE SERVE.THE COMMUNITY BENEFIT OBJECTIVES OF VALLEY WEST INCLUDE PROGRAMS TO TO IMPROVE ACCESS TO HEALTH SERVICES BY REDUCING GEOGRAPHIC, FINANCIAL, LANGUAGE AND CULTURAL BARRIERS; IMPROVE AND ENHANCE PUBLIC HEALTH, ADVANCE GENERAL HEALTH KNOWLEDGE, AND RELIEVE THE GOVERNMENT BURDEN OF PROVIDING HEALTH SERVICES FOR THE COMMUNITY, AND FOR THE UNINSURED AND UNDERINSURED. COMMUNITY HEALTH NEEDS ARE IDENTIFIED AND ADDRESSED THROUGH COMMUNITY OUTREACH PROGRAMS, BY ADDING NEW SERVICES AND BY EXPANDING OTHERS. NEEDS ALSO ARE MET THROUGH OPERATIONAL PROGRAMS SUCH AS CHARITY CARE, SUBSIDIZED SERVICES AND PROVIDING CASH AND IN-KIND DONATIONS TO SUPPORT ORGANIZATIONS THAT ALSO STRIVE TO MEET COMMUNITY HEALTH AND QUALITY OF LIFE NEEDS. THE HOSPITAL IDENTIFIES COMMUNITY HEALTH NEEDS IN SEVERAL WAYS:* DEKALB COUNTY HEALTH DEPARTMENT I-PLAN* COMMUNITY HEALTH NEEDS SURVEY (LAST CONDUCTED FALL 2009)* U.S. HEALTHY PEOPLE 2010 AND 2020 OBJECTIVES* UNIVERSITY OF WISCONSIN POPULATION HEALTH INSTITUTE COUNTY HEALTH RANKINGS & ROADMAPS* INTERNAL REVIEW OF OUTPATIENT AND INPATIENT TRENDS, ESPECIALLY EMERGENCY DEPARTMENT USAGE * INPUT FROM OTHER COMMUNITY PROVIDERS. THIS INCLUDES PROVIDING HOSPITAL LEADERS TO SERVE ON BOARDS AND COMMITTEES THAT DIRECTLY OR INDIRECTLY IMPACT COMMUNITY HEALTH OR HELP THE HOSPITAL CONNECT TO UNDERSERVED OR VULNERABLE POPULATIONS.USING ALL THESE RESOURCES, THE HOSPITAL FOCUSED ON THE FOLLOWING COMMUNITY HEALTH NEEDS IN FY12: * THE PREVALENCE OF OBESITY IN CHILDREN AND ADULTS* CARDIOVASCULAR DISEASE AND ADEQUATE HOSPITAL-BASED AND COMMUNITY OUTREACH SERVICES * CANCER CARE SERVICES, EDUCATION AND PREVENTION * AFFORDABLE ACCESS TO CHILDBIRTH EDUCATION AND OB HOSPITAL SERVICES* OTHER COMMUNITY OUTREACH AND WELLNESS SERVICES.ACTIVITIES IN THESE AREAS ARE DETAILED IN SCHEDULE H OF THIS REPORT. ADDITIONAL ACTIVITIES ARE LISTED BELOW.* COMMUNITY WELLNESS RV TRAVELS THROUGHOUT THE HOSPITAL MARKET, PROVIDING BLOOD PRESSURE SCREENING, KNOW YOUR NUMBERS AND BONE DENSITY SCREENINGS AT DIFFERENT COMMUNITY SITES.* COMMUNITY WELLNESS EDUCATORS TAUGHT HEALTH TOPICS IN AREA SCHOOLS, VISITING 489 CLASSROOMS WORKING WITH 13,892 STUDENTS. COMMUNITY WELLNESS EDUCATORS SERVED ON THE FOLLOWING COMMITTEES TO PROMOTE HEALTH AND WELLNESS: PLANO CHAMBER OF COMMERCE BOARD OF DIRECTORS, KENDALL COUNTY HEALTH INITIATIVES COUNCIL, KENDALL COUNTY IPLAN STEERING COMMITTEE, SANDWICH PROJECT SUCCESS COMMITTEE, OB PRACTICE COMMITTEE CO-CHAIR.* THE HOSPITAL ALSO PROVIDES COMMUNITY BENEFIT THROUGH: CHARITY CARE, GOVERNMENT-SPONSORED INDIGENT HEALTH CARE, BAD DEBT, SUBSIDIZED HEALTH SERVICES, LANGUAGE ASSISTANCE, VOLUNTEER SERVICES, EDUCATION AND WORKFORCE DEVELOPMENT, AND CASH AND IN-KIND DONATIONS. - CHARITY CARE: AS PART OF ITS CHARITABLE MISSION, THE HOSPITAL PROVIDES FINANCIAL ASSISTANCE, INCLUDING ACCESS TO PHARMACEUTICAL ASSISTANCE FOR PATIENTS WHO MET THE ELIGIBILITY CRITERIA ESTABLISHED IN ITS FINANCIAL ASSISTANCE POLICY. THE POLICY IS REVIEWED BY THE BOARD OF DIRECTORS ANNUALLY. THE HOSPITAL ALSO COORDINATES WITH THE ILLINOIS BREAST AND CERVICAL CANCER PROGRAM FOR ASSISTANCE WITH BREAST AND CERVICAL CANCER SCREENINGS AND TREATMENT. MORE PATIENTS QUALIFIED FOR CHARITY CARE IN FY 2012 THAN IN PREVIOUS YEARS DUE TO THE POOR ECONOMY AND ALSO TO REDUCE THE HOSPITAL'S BAD DEBT. THE HOSPITAL ALSO UNDERWROTE UNREIMBURSED COSTS OF TREATING MEDICAID AND MEDICARE PATIENTS. - SUBSIDIZED HEALTH SERVICES: A NUMBER OF PROGRAMS AND SERVICES WERE OPERATED AT A LOSS, BUT WERE SUBSIDIZED BECAUSE THEY IMPROVE THE HEALTH AND SAFETY OF THE COMMUNITY. - LANGUAGE ASSISTANCE: THE HOSPITAL EMPLOYS SPANISH INTERPRETERS AVAILABLE OR ON CALL 24/7 AND USE VIDEOCONFERENCING EQUIPMENT VIA LAPTOP TO COMMUNICATE WITH THE HEARING IMPAIRED AND DUAL HANDSET PHONE SYSTEM THAT PROVIDES INSTANT INTERPRETATION FOR PATIENTS WHO DO NOT SPEAK ENGLISH- VOLUNTEER SERVICES: VOLUNTEER OPPORTUNITIES ARE PROVIDED TO EMPLOYEES TO SERVE IN THE COMMUNITY AND TO COMMUNITY MEMBERS TO SERVE THE HOSPITAL. EMPLOYEES ARE ENCOURAGED TO USE PAYROLL DEDUCTION FOR DONATIONS TO UNITED WAY, COMMUNITY FUND, KISHHEALTH FOUNDATION AND DEKALB COUNTY HOSPICE. A VOLUNTEER SERVICES DEPARTMENT SCHEDULES MEMBERS OF THE VALLEY WEST AUXILIARY TO VOLUNTEER IN THE HOSPITAL. - EDUCATION AND WORKFORCE DEVELOPMENT: HOSPITAL EMPLOYEES PROVIDE CLINICAL TRAINING, JOB SHADOWING AND MENTORING OF COLLEGE AND HIGH SCHOOL STUDENTS. THE AUXILIARY AND KISHHEALTH FOUNDATION AWARD ANNUAL SCHOLARSHIPS FOR HEALTH CAREERS. HOSPITAL TOURS ARE GIVEN TO LOCAL SCHOOLS AND YOUTH GROUPS TO MAKE YOUTH AWARE OF HEALTHCARE CAREERS. CASH CONTRIBUTIONS ARE GIVEN TO LOCAL LIBRARIES, PUBLIC AND POST-SECONDARY EDUCATION FOUNDATIONS TO UNDERWRITE SCHOLARSHIPS, AND PURCHASE OR PROVIDE HEALTH-RELATED MATERIALS, EQUIPMENT AND ACTIVITIESCASH AND IN-KIND DONATIONS: EACH YEAR AN ALLOCATION IS MADE IN THE OPERATING BUDGET FOR DONATIONS TO COMMUNITY EVENTS AND ORGANIZATIONS THAT IMPROVE THE HEALTH, WELFARE AND QUALITY OF LIFE IN THE COMMUNITIES SERVED BY THE HOSPITAL. THE HOSPITAL WANTS TO SUPPORT COMMUNITY ACTIVITIES THAT ENCOURAGE CHILD AND ADULT PHYSICAL ACTIVITY; EFFORTS THAT REACH UNDERSERVED AND VULNERABLE POPULATIONS; YOUTH MENTORING, EDUCATION AND THE ARTS; DISEASE PREVENTION, AWARENESS, RESEARCH; MENTAL HEALTH; ECONOMIC DEVELOPMENT AND OTHER COMMUNITY BUILDING ACTIVITIES. IN-KIND DONATIONS AND SERVICES SUCH AS PERSONNEL TIME, SURPLUS SUPPLIES, FOOD, AND BOTTLED WATER ALSO ARE TRACKED.- CASH CONTRIBUTION HIGHLIGHTS: IN FY 12, VALLEY WEST ENTERED INTO A THREE YEAR AGREEMENT WITH FOX VALLEY OLDER ADULT SERVICES TO PROVIDE COMPUTER TRAINING TO SENIORS, ENTERED INTO AN AGREEMENT WITH THE FOX VALLEY FAMILY YMCA TO UNDERWRITE THE COST OF COMMUNITY FITNESS PROGRAMS, AND WAS THE MAJOR SPONSOR OF THE AMERICAN CANCER SOCIETYS LOWER FOX VALLEY RELAY FOR LIFE. IN-KIND DONATIONS INCLUDED FIRST AID KITS FOR YOUTH SPORT GROUPS. ALSO HIGH SCHOOL SPORTS BOOSTERS, YOUTH SPORTS, SCHOOL EDUCATION FOUNDATIONS, AND LOCAL CHAMBERS OF COMMERCE IN SANDWICH, PLANO, SOMONAUK AND OTHER COMMUNITIES. 38602769 1 1 0 1 0 0 0 0 0 0 1 0 0 0 1 0 0 1 0 0 0 0 0 0 0 0 1 1 1 0 1 0 0 0 0 0 0 0 1 0 0 0 0 0 1 0 0 0 0 1 61 0 1 298 1 0 0 0 0 0 0 0 0 0 0 X 3 2 1 0 0 0 1 1 1 1 1 0 0 1 1 1 1 1 1 1 1 0 IL X LOREN FOELSKE VP FINANCE 8157561521 ONE KISH HOSPITAL DRIVE DEKALB IL 60115 X TERRENCE DUFFY 1.00 X X 0 0 0 KEVIN POORTEN 1.00 X X 0 698961 102663 ERIK ENGLEHART 1.00 X X 0 42797 4625 JAGDISH PATEL 1.00 X X 38592 0 0 LOREN FOELSKE 10.00 X 0 316761 41819 BRAD COPPLE 20.00 X 0 365900 42075 PAM DUFFY 20.00 X 0 241412 27266 JOE DANT 6.00 X 0 263727 41741 MIKE MUZZILLO 40.00 X 0 179349 27579 MIKE KOKOTT 10.00 X 0 198097 23734 ROGER HEATH BELL 15.00 X 0 253756 39782 DR MICHAEL KULISZ 20.00 X 0 391391 22661 MARK THATE 10.00 X 0 197280 29354 CHERYL FISHER 20.00 X 0 150191 32889 SUE HOHENBERGER 40.00 X 141274 0 25634 ALTHEA R RUSSELL 40.00 X 102836 0 30821 ALEX P LOMAHAN 40.00 X 121041 0 21879 403743 3299622 514522 3 0 1 0 KISH HEALTH SYSTEM ONE KISH HOSPITAL DRIVE DEKALB IL 60115 MANAGEMENT FEES 4298442 ANESTHESIA ASSOCIATES LLC 88 W COUNTRYSIDE PARKWAY YORKVILLE IL 60560 HEALTH SERVICES 1046734 COMPREHENSIVE THERAPEUTICS LTD 3703 WEST LAKE STREET GLENVIEW IL 60025 PHYSICAL THERAPY SERVICES 1025277 DOCTORS OF EMERGENCY MEDICINE 2807 BRITTANY COURT ST CHARLES IL 60175 HEALTH SERVICES 583163 DIAGNOSTIC HEALTH SERVICES INC 2445 GATEWAY DR STE 100 IRVING TX 75063 HEALTH SERVICES 502415 10 70545 310389 380934 NET PATIENT SERVICE RE 621110 48706320 48706320 48706320 951930 951930 121527 1664 119863 119863 119863 5339677 75780 5608136 29929 -268459 45851 -222608 -222608 OTHER INCOME 621110 626111 626111 DIETARY/CAFETERIA SALE 621110 76383 76383 DISCOUNTS AND REBATES 621110 34821 34821 737315 50673754 49443635 0 849185 19500 19500 38592 38592 10879051 10212596 666455 621421 583352 38069 2373973 2228542 145431 790429 742007 48422 3924864 3924864 42905 42905 3268 3268 100696 100696 8569565 8223631 345934 465054 22494 442560 5523073 5101005 422068 275025 1652 273373 1546399 1541132 5267 66664 66125 539 40362 40362 117347 117347 2749259 2749259 444332 259997 184335 BAD DEBT EXPENSE 5214395 5214395 PHYSICAN FEES AND RECRU 1430128 1092012 338116 FEDERAL AND STATE ASSES 456200 456200 COLLECTION FEES 251331 251331 108666 50278 58388 46052499 38602769 7449730 0 244359 219812 1280644 3745816 5492103 6321278 1381186 1428631 550210 1092870 36727914 18471314 19763617 18256600 26952150 28884626 1762108 238078 1791850 1438002 59218227 61625713 4017446 4758606 270100 228869 2261434 2009958 4227761 3502603 10776741 10500036 X 48372653 51076129 68833 49548 48441486 51125677 59218227 61625713 X 4621255 -1937064 X X 0 1 1 X 0 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 0 0 0 0 0 0 1 0 0 1 12106 12106 0 EXPLANATION OF LOBBYING ACTIVITIES: PART II-B, LINE 1: LOBBYING EXPENSES ARE ALLOCATED THROUGH MEMBERSHIP DUES WITH ILLINOIS HOSPITAL ASSOCIATION AND AMERICAN HOSPITAL ASSOCIATION. NO OTHER LOBBYING ACTIVITIES WERE CONDUCTED. 1279463 1279463 15159443 5646464 9512979 420249 110072 310177 19339880 12714778 6625102 528879 528879 18256600 IBNR RESERVE 162911 LEASE OBLIGATION PAYABLE 324065 DUE TO AFFILIATES 910735 ESTIMATED SETTLEMENTS DUE 2102653 OTHER LONG TERM LIABILITIES 2239 3502603 50673754 46052499 4621255 -157253 -1779811 -1937064 2684191 50145265 -157253 1664 -155589 50300854 372900 372900 50673754 45786813 1664 1664 45785149 267350 267350 46052499 PART XI, LINE 8 - OTHER ADJUSTMENTS: EQUITY DISTRIBUTION TO KISHHEALTH SYSTEM, INC. -1,710,000. GRANT INCOME RECORDED AS OFFSET TO FIXED ASSET ACCOUNTS -35,005. CHANGE IN NET ASSETS OF KISHHEALTH FOUNDATION -34,806. TOTAL TO SCHEDULE D, PART XI, LINE 8: -1,779,811. PART XII, LINE 2D - OTHER ADJUSTMENTS: RENTAL EXPENSES NETTED WITH REVENUE FOR FORM 990 PURPOSES 1,664. PART XII, LINE 4B - OTHER ADJUSTMENTS: CONTRIBUTION REVENUE FROM KISHHEALTH FOUNDATION 70,545. GRANTS NETTED WITH FIXED ASSETS FOR FINANCIAL STATEMENT PURPOSES 35,005. GRANT REVENUE NETTED WITH TELECOMMUNICATIONS COSTS FOR FINANCIAL STATEMENTS 267,350. PART XIII, LINE 2D - OTHER ADJUSTMENTS: RENTAL EXPENSES NETTED WITH REVENUE FOR 990 PURPOSES 1,664. PART XIII, LINE 4B - OTHER ADJUSTMENTS: GRANT REVENUE NETTED WITH TELECOMMUNICATIONS COSTS FOR FINANCIAL STATEMENTS 267,350. PART XI, LINE 10, EXCESS OR (DEFICIT) FOR THE YEAR PER FINANCIAL STATEMENTS: LINE 10 IDENTIFIES FINANCIAL STATEMENT INCOME AS EQUALING $2,684,191. FINANCIAL STATEMENT INCOME IS ACTUALLY $4,358,452. THE DIFFERENCE RELATES TO THE FOLLOWING ITEMS: 1. VALLEY WEST COMMUNITY HOSPITAL MADE A CAPITAL DISTRIBUTION OF $1,710,000 TO ITS PARENT CORPORATION, ANOTHER NON-PROFIT ENTITY (KISHHEALTH SYSTEM). 2. KISHHEALTH FOUNDATION (KHF), AN AFFILIATED ENTITY, RECEIVES CONTRIBUTIONS DESIGNATED FOR USE BY VALLEY WEST COMMUNITY HOSPITAL. THIS IS ALLOCATED TO VALLEY WEST, VIA AN ENTRY TO INCREASE VALLEY WEST'S INTEREST IN THE ASSETS OF KHF. A CORRESPONDING EQUITY ENTRY IS MADE ON VALLEY WEST'S GENERAL LEDGER. THE CURRENT YEAR INCREASE WAS $35,739, OF WHICH $(34,806) IS A DECREASE IN THE VWCH'S INTEREST IN THE ASSETS OF KHF AND $70,545 WERE ACTUAL CONTRIBUTIONS RECEIVED. 1 1 X 1 X 1 X 1 1 1 0 1 1 1201039 456200 744839 0.01620 7657997 2186526 5471471 0.11880 8859036 2642726 6216310 0.13500 2275748 35417 2240331 0.04860 89553 0 89553 0.00190 1109858 564146 545712 0.01180 135805 0 135805 0.00290 3610964 599563 3011401 0.06520 12470000 3242289 9227711 0.20020 1 5214395 1001165 11530577 11416413 114164 X 1 1 1 1 VALLEY WEST COMMUNITY HOSPITAL

11 EAST PLEASANT AVE SANDWICH IL 60548

X X X X VALLEY WEST COMMUNITY HOSPITAL 1 1 1 200.000000000000 1 300.000000000000 1 X X X X X 1 1 X X X 1 X X 0 1 X 0 0 PART II: NO COMMUNITY BUILDING ACTIVITIES ARE REPORTED IN PART II. PART III, LINE 4: NET PATIENT SERVICE REVENUETHE HOSPITAL HAS AGREEMENTS WITH THIRD-PARTY PAYORS WHICH PROVIDE FOR REIMBURSEMENT TO THE HOSPITAL AT AMOUNTS DIFFERENT FROM ITS ESTABLISHED RATES. CONTRACTUAL ADJUSTMENTS UNDER THIRD-PARTY REIMBURSEMENT PROGRAMS REPRESENT THE DIFFERENCE BETWEEN THE HOSPITAL'S BILLINGS AT LIST PRICE AND THE AMOUNTS REIMBURSED BY MEDICARE, MEDICAID, BLUE CROSS, AND CERTAIN OTHER THIRD-PARTY PAYORS;AND ANY DIFFERENCES BETWEEN ESTIMATED THIRD-PARTY REIMBURSEMENT SETTLEMENTS FOR PRIOR YEARS AND SUBSEQUENT FINAL SETTLEMENTS. CONTRACTUAL ADJUSTMENTS UNDER THIRD-PARTY REIMBURSEMENT PROGRAMS ARE ACCRUED ON AN ESTIMATED BASIS IN THE PERIOD THE RELATED SERVICES ARE RENDERED AND ARE ADJUSTED IN FUTURE PERIODS AS FINAL SETTLEMENTS ARE DETERMINED. A SUMMARY OF THE BASIS OF REIMBURSEMENT WITH MAJOR THIRD-PARTY PAYORS FOLLOWS:MEDICARE: VALLEY WEST COMMUNITY HOSPITAL (VWCH) WAS DESIGNATED AS A CRITICAL ACCESS HOSPITAL DURING FISCAL YEAR 2005. THIS DESIGNATION PROVIDES FOR INPATIENT AND OUTPATIENT SERVICES TO BE REIMBURSED ON A COST BASIS METHODOLOGY. THE HOSPITAL IS REIMBURSED AT A TENTATIVE RATE WITH FINAL SETTLEMENT DETERMINED AFTER SUBMISSION OF ANNUAL COST REPORTS BY THE HOSPITAL AND AUDITS THEREOF BY THE MEDICARE FISCAL INTERMEDIARY. THE HOSPITAL'S CLASSIFICATION OF PATIENTS UNDER THE MEDICARE PROGRAM AND THE APPROPRIATENESS OF THEIR ADMISSION ARE SUBJECT TO AN INDEPENDENT REVIEW BY A PEER REVIEW ORGANIZATION. CHANGES AS A RESULT OF THE CENTERS FOR MEDICARE AND MEDICAID SERVICES IMPLEMENTATION OF THE PROVISIONS OF THE FUTURE MEDICARE LEGISLATION MAY HAVE AN ADVERSE EFFECT ON THE HOSPITAL'S NET PATIENT SERVICE REVENUE. LAWS AND REGULATIONS GOVERNING THE MEDICARE PROGRAM ARE EXTREMELY COMPLEX AND SUBJECT TO INTERPRETATION. AS A RESULT, THERE IS AT LEAST A REASONABLE POSSIBILITY THAT RECORDED ESTIAMTES WILL CHANGE BY A MATERIAL AMOUNT IN THE NEAR-TERM.MEDICAID: THE HOSPITAL IS REIMBURSED AT PROSPECTIVELY DETERMINED RATES FOR EACH MEDICAID INPATIENT DISCHARGE. OUTPATIENT SERVICES ARE REIMBURSED BASED ON ESTABLISHED FEE SCREENS. FOR INPATIENT ACUTE CARE SERVICES, PAYMENT RATES VARY ACCORDING TO A PATIENT CLASSIFICATION SYSTEM THAT IS BASED ON CLINICAL, DIAGNOSTIC, AND OTHER FACTORS. THE PROSPECTIVELY DETERMINED RATES ARE NOT SUBJECT TO RETROACTIVE ADJUSTMENT. THE HOSPITAL ALSO RECEIVES INCREMENTAL MEDICAID REIMBURSEMENT FOR SPECIFIC PROGRAMS AND SERVICES AT THE DISCRETION OF THE STATE OF ILLINOIS MEDICAID PROGRAM. MEDICAID REIMBURSEMENT MAY BE SUBJECT TO PERIODIC ADJUSTMENT, AS WELL AS TO CHANGES IN EXISTING PAYMENT LEVELS AND RATES, BASED ON THE AMOUNT OF FUNDING AVAILABLE TO THE MEDICAID PROGRAM. LAWS AND REGULATIONS GOVERNING THE MEDICAID PROGRAM ARE EXTREMELY COMPLEX AND SUBJECT TO INTERPRETATION. AS A RESULT, THERE IS AT LEAST A REASONABLE POSSIBILITY THAT RECORDED ESTIMATES WILL CHANGE BY A MATERIAL AMOUNT IN THE NEAR-TERM.IN DECEMBER 2004, THE FEDERAL CENTERS FOR MEDICARE & MEDICAID SERVICES (CMS) APPROVED STATE OF ILLINOIS (STATE) LEGISLATION FOR A MEDICAID HOSPITAL ASSESSMENT PROGRAM (PROGRAM). UNDER THE PROGRAM, THE HOSPITAL RECEIVES ADDITIONAL MEDICAID REIMBURSEMENT FROM THE STATE AND PAYS A RELATED ASSESSMENT TAX. THE PROGRAM HAS BEEN EXTENDED THROUGH DECEMBER 31, 2014. BLUE CROSS: THE SYSTEM ALSO PARTICIPATES AS A PROVIDER OF HEALTH CARE SERVICES UNDER A REIMBURSEMENT AGREEMENT WITH BLUE CROSS. THE PROVISIONS OF THIS AGREEMENT STIPULATE THAT INPATIENT SERVICES WILL BE REIMBURSED AT A TENTATIVE REIMBURSEMENT RATE AND THAT FINAL REIMBURSEMENT FOR THESE SERVICES IS DETERMINED AFTER THE SUBMISSION OF AN ANNUAL COST REPORT BY THE SYSTEM AND A REVIEW BY BLUE CROSS. MANAGED CARE ORGANIZATIONS: THE HOSPITAL HAS ALSO ENTERED INTO REIMBURSEMENT AGREEMENTS WITH CERTAIN COMMERCIAL INSURANCE CARRIERS, HEALTH MAINTENANCE ORGANIZATIONS, AND PREFERRED PROVIDER ORGANIZATIONS. THE BASIS FOR PAYMENT UNDER THESE AGREEMENTS INCLUDES DISCOUNTS FROM ESTABLISHED CHARGES AND PROSPECTIVELY DETERMINED PER DIEM RATES.INTERNAL REVENUE SERVICE WORKSHEET 2 (PER SCHEDULE H INSTRUCTIONS) WAS UTILIZED TO DETERMINE THE COST OF BAD DEBTS ATTRIBUTABLE TO PATIENT ACCOUNTS. PART III, LINE 8: NONE PART III, LINE 9B: COLLECTION ACTIONS INVOLVING UNINSURED PATIENTS. KHS (KISHHEALTH SYSTEM, PARENT ORGANIZATION OF VALLEY WEST COMMUNITY HOSPITAL) SHALL NOT PURSUE A COLLECTION ACTION AGAINST AN UNINSURED PATIENT, UNLESS THE PATIENT HAS BEEN GIVEN THE OPPORTUNITY TO ASSESS THE ACCURACY OF THE BILL; APPLY FOR FINANCIAL ASSISTANCE UNDER THE KHS FINANCIAL ASSISTANCE POLICY AND PROCEDURE; AND AVAIL HIMSELF OR HERSELF OF A REASONABLE PAYMENT PLAN. NOTWITHSTANDING THIS, KHS MAY NOT PURSUE THE COLLECTION ACTION UNDER THE FOLLOWING CIRCUMSTANCES: (A) IF THE PATIENT HAS INDICATED AN INABILITY TO PAY THE FULL AMOUNT OF THE DEBT IN ONE PAYMENT, UNTIL KHS HAS OFFERED THE PATIENT A PAYMENT PLAN. KHS MAY REQUIRE THE PATIENT TO PROVIDE REASONABLE VERIFICATION OF HIS OR HER INABILITY TO PAY THE FULL AMOUNT OF THE DEBT IN ONE PAYMENT.(B) IF KHS HAS REASON TO BELIEVE THE PATIENT MAY BE ELIGIBLE FOR FINANCIAL ASSISTANCE, UNTIL KHS HAS GIVEN THE PATIENT AT LEAST 60 DAYS FOLLOWING THE DATE OF DISCHARGE OR RECEIPT OF OUTPATIENT CARE TO SUBMIT AN APPLICATION FOR FINANCIAL ASSISTANCE. (C) IF THE PATIENT HAS AGREED TO A PAYMENT PLAN, UNTIL THE PATIENT HAS FAILED TO MAKE PAYMENTS IN ACCORDANCE WITH THAT PAYMENT PLAN. (D) IF THE PATIENT INFORMS KHS THAT HE OR SHE HAS APPLIED FOR HEALTH CARE COVERAGE UNDER MEDICAID, KIDCARE, OR OTHER GOVERNMENT-SPONSORED HEALTH CARE PROGRAM (AND THERE IS A REASONABLE BASIS TO BELIEVE THAT THE PATIENT WILL QUALIFY FOR SUCH PROGRAM), BUT THE PATIENT'S APPLICATION IS DENIED. VALLEY WEST COMMUNITY HOSPITAL PART V, SECTION B, LINE 19D: BASED ON COMPLIANCE WITH LAWS OF STATE OF ILLINOIS, SPECIFICALLY THE UNINSURED PATIENT DISCOUNT ACT. PART VI, LINE 2: VALLEY WEST COMMUNITY HOSPITAL, A CRITICAL ACCESS HOSPITAL, IDENTIFIES COMMUNITY HEALTH NEEDS IN SEVERAL WAYS:* DEKALB AND KENDALL COUNTY HEALTH DEPARTMENT I-PLANS* COMMUNITY HEALTH NEEDS SURVEY* U.S. GOVERNMENT HEALTHY PEOPLE 2010 AND 2010 GUIDELINES* UNIVERSITY OF WISCONSIN POPULATION HEALTH INSTITUTE COUNTY HEALTH RANKINGS & ROADMAPS* INTERNAL REVIEW OF OUTPATIENT AND INPATIENT TRENDS, ESPECIALLY EMERGENCY DEPARTMENT USAGE * INPUT FROM OTHER COMMUNITY PROVIDERS. THIS INCLUDES PROVIDING HOSPITAL LEADERS SERVING ON BOARDS AND COMMITTEES THAT DIRECTLY OR INDIRECTLY IMPACT COMMUNITY HEALTH OR HELP THE HOSPITAL CONNECT TO UNDERSERVED OR VULNERABLE POPULATIONS. PART VI, LINE 3: INFORMATION IS PROVIDED AT REGISTRATION, VIA THE HOSPITAL WEBSITE, THROUGH CONSULTATIONS WITH FINANCIAL COUNSELORS, DURING THE BILLING PROCESS ON STATEMENTS, AND VIA PHONE CONVERSATIONS. PART VI, LINE 4: VALLEY WEST COMMUNITY HOSPITAL SERVES ALL OF DEKALB COUNTY, IL, AND BORDER COMMUNITIES IN KENDALL AND LASALLE COUNTIES. THE POPULATION OF THE VALLEY WEST SERVICE AREA, BASED ON THE 2010 CENSUS, WAS 73,630. THIS GEOGRAPHIC AREA INCLUDES A GROWING HISPANIC POPULATION. THE HISPANIC POPULATION IS EXPECTED TO GROW BY 37% BY 2017. POVERTY LEVELS FOR VALLEY WEST'S PRIMARY MARKET AT SANDWICH, 5.5%; SOMONAUK, 10.6%; LELAND, 10.4%; AND PLANO, 6.9%. PART VI, LINE 5: VALLEY WEST COMMUNITY HOSPITAL, A CRITICAL ACCESS HOSPITAL IN SANDWICH, IL, IS PART OF KISHHEALTH SYSTEM. THE HEALTH SYSTEM IS GOVERNED BY AN APPOINTED VOLUNTEER BOARD OF DIRECTORS, INDEPENDENT COMMUNITY LEADERS WHO RESIDE IN THE PRIMARY MARKETS SERVED BY THE HEALTH SYSTEM'S TWO HOSPITALS. THESE INDIVIDUALS ARE SELECTED FOR THE BOARD BECAUSE OF THEIR INTEREST AND EXPERTISE IN VARIOUS AREAS THAT CAN HELP MANAGEMENT CARRY OUT THE HEALTHY SYSTEM'S MISSION. MEMBERS OF THE BOARD ARE NOT COMPENSATED FOR THEIR TIME. THE MEDICAL STAFF IS OPEN TO PHYSICIANS WHO MEET CRITERIA ESTABLISHED BY THE MEDICAL STAFF BYLAWS. PHYSICIANS ARE GIVEN AND TAKE THE OPPORTUNITY TO VOLUNTEER TO DO FREE COMMUNITY WELLNESS PROGRAMS ON HEALTH TOPICS. SURPLUS FUNDS GO BACK INTO THE ORGANIZATION TO SUPPORT OPERATIONS, CAPITAL IMPROVEMENTS, THE HEALTH SYSTEM'S COMMITMENT TO EXCELLENCE, EDUCATION AND INNOVATION, AND TO PROVIDE MEDICAL CARE TO ALL REGARDLESS OF ABILITY TO PAY. A COMMUNITY HEALTH ASSESSMENT WAS CONDUCTED IN THE FALL OF 2009, VIA A RANDOM TELEPHONE SURVEY. RESULTS ARE ONE COMPONENT USED FOR FY 12 ACTION PLANNING. A COMMUNITY NEEDS ASSESSMENT ALSO WAS DONE DURING THIS CURRENT FISCAL YEAR, THE RESULTS OF WHICH WILL BE REPORTED IN THE 990 REPORT FOR FY 13. BELOW ARE SPECIFIC EXAMPLES OF THE HOSPITAL'S EFFORTS TO PROMOTE HEALTH WITHIN THE COMMUNITY.COMMUNITY HEALTH NEEDS ASSESSMENT: IN COLLABORATION WITH DEKALB COUNTY HEALTH DEPARTMENT, VALLEY WEST COMMUNITY HOSPITAL UNDEWROTE THE COST OF THE DATA COLLECTION PROCESS FOR THE COMMUNITY HEALTH NEEDS ASSESSMENT. THE PREVALENCE OF OBESITY IN CHILDREN AND ADULTS: COMMUNITY WELLNESS INITIATIVE IS TO DECREASE OBESITY AND THE CHRONIC DISEASES ASSOCIATED WITH IT BY OFFERING TARGETED WELLNESS PROGRAMS AND PREVENTATIVE SCREENINGS TO HELP OUR COMMUNITY GET WELL AND STAY WELL. THREE HEALTH PROMOTION SPECIALISTS AND A HEALTHY CULINARY INSTRUCTOR WERE HIRED TO COLLABORATE WITH COMMUNITY ORGANIZATION, SCHOOLS AND TO WORK WITH THE COMMUNITY TO PROMOTE HEALTHY FOOD CHOICES, INCREASE FITNESS, AND DECREASE CHRONIC DISEASE. PROGRAMS INCLUDE FREE KNOW YOUR NUMBERS EVENTS, MANAGING YOUR CHOLESTEROL WITH TLC, FREE BLOOD PRESSURE CLINICS, TIME TO QUIT TOBACCO CLASSES, WELLNESS FOR KIDS PROGRAM IN THE SCHOOLS, WE CAN PROGRAM IN THE SCHOOLS TO HELP PARENTS ADDRESS THE ISSUE OF OVERWEIGHT CHILDREN, KIDS IN THE KITCHEN, LIVE FIT CHALLENGE WITH THE FOX VALLEY FAMILY YMCA, AM I HUNGRY MINDFUL EATING WORKSHOPS. SCHOOL PROGRAMS TOUCHED 13,892 STUDENTS.ACCESS TO AFFORDABLE PRIMARY CARE: NEW PHYSICIANS WHO RECEIVE RECRUITMENT ASSISTANCE FROM KISHHEALTH SYSTEM OR WHO ARE EMPLOYED BY KISHHEALTH SYSTEM ARE REQUIRED TO ACCEPT MEDICAID AND UNINSURED PATIENTS. DURING FY 12, THE HEALTH SYSTEM ESTABLISHED THE NON-PROFIT KISHHEALTH PHYSICIAN GROUP, EMPLOYING SEVEN PHYSICIANS WITH PRACTICES IN SANDWICH, DEKALB AND GENOA . A PEDIATRICIAN AND AN INTERNIST ARE UNDER CONTRACT WITH THE HEALTH SYSTEM TO PROVIDE PART-TIME OFFICE HOURS AT KISHHEALTH FAMILY & SPECIALTY CARE IN WATERMAN, PROVIDING THE RURAL AREAS OF WATERMAN, SHABBONA AND HINCKLEY ACCESS TO CONVENIENT PRIMARY CARE. THE WATERMAN OFFICE ALSO PROVIDES SERVICES FOR THE RURAL MEDICAID POPULATION.MENTAL HEALTH- OUTPATIENT SERVICES: SISTER HOPSITAL, KISHWAUKEE COMMUNITY HOSPITAL, MADE A $50,000 CONTRIBUTION TO BEN GORDON (MENTAL HEALTH) CENTER TO SUPPORT THE COST OF MENTAL HEALTH SERVICES FOR DEKALB COUNTY'S UNINSURED, INCLUDING SERVICES IN SANDWICH. DURING FY 12, CHILD DEVELOPMENT SERVICES OF KISHHEALTH SYSTEM'S BEHAVIORAL HEALTH DEPARTMENT WERE EXPANDED BY ADDING A CHILD PSYCHOLOGIST TO THE STAFF OF THE CHILD DEVELOPMENT CLINIC. THE CHILD DEVELOPMENT CLINIC NOW PROVIDES ASSESSMENT AND INTERVENTION OF CHILDHOOD DISORDERS INCLUDING AUTISM SPECTRUM DISORDERS, DEVELOPMENTAL DELAYS, SLEEP PROBLEMS, ANXIETY, DEPRESSION, AND OTHER MOOD DISORDERS, AS WELL AS COMMON SCHOOL, FAMILY, AND SOCIAL STRESSORS TYPICAL IN CHILDHOOD. IN ADDITION, THE CLINIC IS COLLABORATES WITH KISH HOSPITAL'S UNLIMITED PERFORMANCE REHABILITATION & SPORTS MEDICINE TO PROVIDE A MULTIDISCIPLINARY APPROACH TO THE EVALUATION AND TREATMENT OF CHILDREN WITH COMPLEX DEVELOPMENTAL CONCERNS. THIS UNIQUE AFFILIATION TAKES ADVANTAGE OF UP'S EXPERTISE IN SPEECH-LANGUAGE, GROSS MOTOR, AND FINE MOTOR DEVELOPMENT. THERE WERE 995 VISITS TO THE CHILD DEVELOPMENT CLINIC IN FY 12, A 20.3% INCREASE FROM THE PREVIOUS YEAR. IN ADDITION, PSYCHIATRY, COUNSELING AND EMPLOYEE ASSISTANCE PROGRAM SERVICES AT THE BEHAVIORAL HEALTH CENTER IN SYCAMORE AND AT THE VALLEY WEST COMMUNITY HOSPITAL MEDICAL OFFICE BUILDING HAD A 45% INCREASE OVER THE PREVIOUS YEAR. MENTAL HEALTH - OUTPATIENT SERVICES: DURING FY 12, TALKS WITH ALEXIAN BROTHERS BEHAVIORAL HEALTH HOSPITAL, HOFFMAN ESTATES, TO ADDRESS THE NEED FOR INPATIENT MENTAL HEALTH SERVICES FOR KISH AND VALLEY HOSPITAL ER AND INPATIENTS. AN AGREEMENT WAS REACHED, TO BE IMPLEMENTED IN FY 13 THAT WILL FACILITATE TRANSFER OF KISH AND VALLEY WEST PATIENTS TO ALEXIAN BROTHERS BEHAVIORAL HEALTH HOSPITAL. THE COST OF THAT CARE FOR UNINSURED PATIENTS WILL BE BORNE BY THE TWO HOSPITALS. TYPE II DIABETES: TO ADDRESS THE PREVALENCE OF DIABETES IN THE ADULT POPULATION, THE SYSTEM CONTINUED TO OPERATE DIABETES EDUCATION CENTERS AT KISH HOSPITAL AND VALLEY WEST WITH SATELLITE SERVICES AT KISHHEALTH FAMILY & SPECIALTY CARE IN GENOA. THE KISH HOSPITAL DIABETES EDUCATION CENTER HAD 8,879 CONSULTATIONS IN FY 12, A 31% INCREASE FROM THE PREVIOUS YEAR. IN FY12, KISH HOSPITAL HELD "THE ABCS OF DIABETES" IN CONJUNCTION WITH DEKALB CLINIC PROVIDING RESOURCES FOR PEOPLE WITH DIABETES. ABOUT 100 PEOPLE ATTENDED. CARDIOVASCULAR DISEASE AND HOSPITAL-BASED AND COMMUNITY OUTREACH SERVICES: COMMUNITY BENEFIT ACTIVITIES IN FY 12 THAT PROMOTED CARDIOVASCULAR HEALTH INCLUDED A WOMEN'S HEALTH EVENT AT VALLEY WEST IN FEBRUARY GREW FROM 250 ATTENDEES IN FY 11 TO 500 IN FY 12. KNOW YOUR NUMBERS EVENTS RESULTED IN 444 FREE SCREENINGS; NUMEROUS COMMUNITY WELLNESS PROGRAMS AND CLASSES'HEALTHY U SUMMER CAMPAIGN: THE SUMMER CAMPAIGN FOR VALLEY WEST AND KISHWAUKEE COMMUNITY HOSPITAL TOOK WELLNESS EDUCATION AND PREVENTION ON THE ROAD TO 69 EVENTS THROUGHOUT THE COMMUNITY AND FOR EMPLOYEES. BLOOD PRESSURE CLINICS: TOTAL FREE BLOOD PRESSURE CHECKS FOR VALLEY WEST WAS 1,396.CANCER CARE SERVICES: MARROW REGISTRY DRIVE AT VALLEY WEST ADDED 25 PEOPLE TO THE NATIONAL REGISTRY. PROVIDED FINANCIAL SUPPORT OF AMERICAN CANCER SOCIETY RELAYS FOR LIFE LOWER FOX VALLEY (KENDALL COUNTY). OTHER: ENTERED INTO AGREEMENTS WITH THE), FOX VALLEY YMCA (PLANO) AND THE SANDWICH PARK DISTRICT TO HELP UNDERWRITE THE COST OF FITNESS AND RECREATIONAL ACTIVITIES FOR COMMUNITY MEMBERS. PART VI, LINE 6: KISHHEALTH SYSTEM AND ITS NON-PROFIT AFFILIATES, KISHWAUKEE COMMUNITY HOSPITAL, VALLEY WEST COMMUNITY HOSPITAL, DEKALB COUNTY HOSPICE, COMMUNITY CARES CLINIC, KISHHEALTH PHYSICIAN GROUP AND THE KISHHEALTH FOUNDATION, ALL PROMOTE THE HEALTH OF COMMUNITIES IN OUR REGION THROUGH DIRECT SERVICES, DONATIONS OF LEADERSHIP TIME ON VARIOUS COMMITTEES AND BOARDS, AND THROUGH CASH CONTRIBUTIONS.KISHHEALTH SYSTEM UNDERWROTE $500,000 IN OPERATIONAL LOSSES IN FY 12 FOR THE COMMUNITY CARES CLINIC, AND $690,000 FOR DEKALB COUNTY HOSPICE, BOTH VITAL SERVICES FOR THE HEALTH OF THE COMMUNITY. IT ALSO MADE $167,500 IN CONTRIBUTIONS TO SEVERAL ORGANIZATIONS IN FY12, NOTABLY A $50,000 GRANT TO DEKALB COUNTY GOVERNMENT FOR A FIBER OPTIC PROJECT THAT IS ESTABLISHING BROADBAND CONNECTIVITY THROUGHOUT DEKALB COUNTY. THIS PROJECT IS ENABLING HIGH SPEED ELECTRONIC COMMUNICATION TO RURAL AREAS AND TO COMMUNITY INSTITUTIONS SUCH AS SCHOOLS, LOCAL GOVERNMENT, LIBRARIES AND THE TWO KISHHEALTH SYSTEM HOSPITALS IN THE COUNTY. ALSO, $75,000 WAS GIVEN TO DEKALB COUNTY COMMUNITY FOUNDATION TO REMODEL A HISTORIC LANDMARK FOR OFFICES ; AND $25,000 WAS GIVEN TO THE NORTHERN ILLINOIS UNIVERSITY FOUNDATION TO SUPPORT CONSTRUCTION OF AN INDOOR ATHLETIC FACILITY. KISHHEALTH SYSTEM LEADERS SERVE ON THE BOARDS OF PIONEERING HEALTHY COMMUNITIES, KISHWAUKEE YMCA, KISHWAUKEE COLLEGE FOUNDATION, VOLUNTARY ACTION CENTER, DEKALB COUNTY YOUTH SERVICES BUREAU, DEKALB COUNTY EDC;DEKALB, SYCAMORE , GENOA, SANDWICH AND PLANO CHAMBERS OF COMMERCE AND EDCS; THE COMMUNITY CARES CLINIC, VOLUNTARY ACTION CENTER, FAMILY SERVICE AGENCY, FOX VALLEY OLDER ADULT SERVICES, KISHWAUKEE UNITED WAY, IN ADDITION, HEALTH SYSTEM EMPLOYEES CONTRIBUTED MORE THAN 2,400 HOURS OF IN-KIND SERVICE TO COMMUNITY ORGANIZATIONS, EDUCATIONAL INSTITUTIONS AND OTHER ACTIVITIES THAT PROMOTE HEALTH, EDUCATION AND QUALITY OF LIFE. VALLEY WEST COMMUNITY HOSPITAL IS A CRITICAL ACCESS HOSPITAL IN SANDWICH. DEKALB COUNTY HOSPICE, DEKALB, IL, PROVIDES FREE CARE AND SUPPORT FOR THE TERMINALLY ILL AS WELL AS GRIEF SUPPORT TO THE PUBLIC. COMMUNITY CARES CLINIC, DEKALB, IL IS A PRIMARY CARE CLINIC FOR MEDICAID AND UNINSURED; KISHHEALTH PHYSICIAN GROUP PROVIDES ACCESS TO MEDICAL SERVICES, ESPECIALLY THE RURAL AREAS AND ACCEPTS MEDICAID AND UNINSURED PATIENTS, AND KISHHEALTH FOUNDATION IN DEKALB, IL RAISES MONEY FOR KISHWAUKEE COMMUNITY HOSPITAL, VALLEY WEST COMMUNITY HOSPITAL, DEKALB COUNTY HOSPICE AND THE COMMUNITY CARES CLINIC AND FUNDS EQUIPMENT PURCHASES AND PATIENT SERVICES PARTICULARLY IN THE AREA OF CANCER CARE FOR THOSE WHO CANNOT AFFORD IT. KISHWAUKEE COMMUNITY HOSPITAL GAVE $50,000 TO BEN GORDON CENTER FOR MENTAL HEALTH SERVICES FOR THE UNINSURED; $25,000 GRANT TO A CONSTRUCTION PROJECT FOR THE HOPE HAVEN HOMELESS SHELTER; $25,000 TO HELP THE Y PROVIDE FITNESS AND HEALTH ACTIVITIES FOR THE LOW INCOME FAMILIES, $25,000 TO FAMILY SERVICE AGENCY TO SUPPORT BIG BROTHERS BIG SISTERS AND THE COURT APPOINTED SPECIAL ADVOCATE SERVICES FOR ABUSED AND NEGLECTED CHILDREN, AND $17,500 TO HELP KISHWAUKEE COLLEGE EDUCATE HEALTH PROFESSIONALS FOR THE FUTURE. REPORTS FILED WITH STATES PART VI, LINE 7 IL 1 FOX VALLEY FAMILY YMCA 3875 ELDAMAIN ROAD PLANO IL 60545 363028169 501(C)(3) 10500 UNDERWRITE COST OF HEALTH AND FITNESS PROGRAMS, INCLUDING DISCOUNT FOR EMPLOYEE MEMBERSHIPS AMERICAN CANCER SOCIETY 143 FIRST STREET BATAVIA IL 60510 131788491 501(C)(3) 5000 SUPPORT FOR RELAY FOR LIFE PROGRAM WHICH RAISES FUNDS FOR CANCER RESEARCH AND EDUCATION FOX VALLEY OLDER ADULT SERVICES 1406 SUYDAM ROAD SANDWICH IL 60548 362738669 501(C)(3) 4000 FIRST OF THREE YEAR $10,000 PLEDGE TO SUPPORT COMUPTER TRAINING FOR LOCAL SENIOR CITIZENS 3 PROCEDURE FOR MONITORING GRANTS IN THE U.S.: PART I, LINE 2: SCHEDULE I, PART I, LINE 2: THE ORGANIZATION MAINTAINS SPECIFIC POLICIES AND QUALIFICATIONS FOR ALL GRANTS AVAILABLE. APPLICANTS MUST APPLY FOR THE RESPECTIVE GRANT AND BE APPROVED BY THE FUNDS GOVERNING BOARD. THE USE OF THE FUNDS IS MONITORED BY THE GOVERNING BOARD OF VALLEY WEST COMMUNITY HOSPITAL. REQUESTS FOR FINANCIAL ASSISTANCE FROM OTHER CHARITABLE ORGANIZATIONS ARE REVIEWED AND APPROVED BY THE VP - FINANCE OF KISHHEALTH SYSTEM. IF NECESSARY DUE TO THE DOLLAR AMOUNT OF THE REQUEST, THESE ITEMS MAY ALSO BE PRESENTED TO THE BOARD OF DIRECTORS. A BUDGET IS SET ANNUALLY FOR CHARITABLE ASSISTANCE TO OTHER ORGANIZATIONS X X X X 0 1 0 0 0 0 0 0 0 KEVIN POORTEN 0 515921 0 183040 0 0 0 79288 0 23375 0 801624 0 0 LOREN FOELSKE 0 249213 0 67548 0 0 0 19288 0 22531 0 358580 0 0 BRAD COPPLE 0 287064 0 78836 0 0 0 19288 0 22787 0 407975 0 0 PAM DUFFY 0 196437 0 44975 0 0 0 18566 0 8700 0 268678 0 0 JOE DANT 0 204572 0 59155 0 0 0 19288 0 22453 0 305468 0 0 MIKE MUZZILLO 0 145011 0 34338 0 0 0 12707 0 14872 0 206928 0 0 MIKE KOKOTT 0 161458 0 36639 0 0 0 15303 0 8431 0 221831 0 0 ROGER HEATH BELL 0 191687 0 62069 0 0 0 17393 0 22389 0 293538 0 0 DR MICHAEL KULISZ 0 301391 0 90000 0 0 0 0 0 22661 0 414052 0 0 MARK THATE 0 159512 0 37768 0 0 0 14318 0 15036 0 226634 0 0 CHERYL FISHER 0 125884 0 24307 0 0 0 11004 0 21885 0 183080 0 0 SUE HOHENBERGER 133741 0 7533 0 0 0 10749 0 14885 0 166908 0 0 0 PART I, LINE 4B THE ORGANIZATION'S CEO PARTICIPATES IN A NONQUALIFIED DEFERRED COMPENSATION PLAN. CONTRIBUTIONS FOR CALENDAR YEAR 2011 WERE $60,000. KISHHEALTH SYSTEM COMMON DIRECTORS/OFFICERS/KEY EMPLOYEES, KHS IS PARENT ORGANIZATION OF VWCH 3924864 KISHHEALTH SYSTEM (KHS) IS THE PARENT ORGANIZATION OF VALLEY WEST COMMUNITY HOSPITAL. THE PURPOSE OF KHS IS TO PROVIDE MANAGEMENT AND SUPPORT SERVICES TO ITS RELATED ORGANIZATIONS, ALL OF WHICH PROVIDE HEALTHCARE SERVICES. FEES PAID TO KHS ARE IN EXCHANGE FOR THESE SERVICES, INCLUDING THE ORGANIZATIONS SHARE OF COMPENSATION OF DIRECTORS, OFFICERS, AND KEY EMPLOYEES. 0 HEALTH PROGRESS INC COMMON DIRECTORS/OFFICERS/KEY EMPLOYEES, BROTHER/SISTER AFFILIATE 70307 HEALTH PROGRESS, INC. IS AN AFFILIATE OF VALLEY WEST COMMUNITY HOSPITAL. HEALTH PROGRESS SUBLEASES OFFICE SPACE FROM VALLEY WEST COMMUNITY HOSPITAL. 0 KISHHEALTH FOUNDATION COMMON DIRECTORS/OFFICERS/KEY EMPLOYEES, BROTHER/SISTER AFFILIATE 70545 KISHHEALTH FOUNDATION WAS ORGANIZED TO SUPPORT CHARITABLE HEALTHCARE ORGANIZATIONS. THE FOUNDATION ANNUALLY MAKES CONTRIBUTIONS TO VALLEY WEST COMMUNITY HOSPITAL. 0 KISHHEALTH SYSTEM COMMON DIRECTORS/OFFICERS/KEY EMPLOYEES, KHS IS PARENT ORGANIZATION OF VWCH 1710000 DURING THE CURRENT YEAR, VALLEY WEST COMMUNITY HOSPITAL ALSO MADE AN EQUITY DISTRIBUTION BACK TO ITS PARENT ORGANIZATION. 0 KISHWAUKEE COMMUNITY HOSPITAL COMMON DIRECTORS/OFFICERS/KEY EMPLOYEES, BROTHER/SISTER AFFILIATE 5031688 VALLEY WEST COMMUNITY HOSPITAL ROUTINELY PURCHASES SUPPLIES AND SERVICES FROM A KISHWAUKEE COMMUNITY HOSPITAL AS PART OF ITS DAY-TO-DAY BUSINESS. 0 FORM 990, PART VI, SECTION A, LINE 2 KEVIN POORTEN AND LOREN FOELSKE ARE BOTH EMPLOYEES OF KISHHEALTH SYSTEM, THE PARENT ORGANIZATION OF VALLEY WEST COMMUNITY HOSPITAL. MR. POORTEN IS PRESIDENT AND CEO OF KISHHEALTH SYSTEM AND SERVES AS AN EX-OFFICIO DIRECTOR FOR ALL ORGANIZATIONS RELATED TO KISHHEALTH SYSTEM. MR. FOELSKE SERVES AS THE VICE-PRESIDENT - FINANCE OF KISHHEALTH SYSTEM, WHICH IS THE PARENT ORGANIZATION FOR ALL RELATED ENTITIES. BRAD COPPLE, AS THE PRESIDENT OF VWCH, IS CONSIDERED AN OFFICER. HE IS ALSO PRESIDENT OF KISHWAUKEE COMMUNITY HOSPITAL, A RELATED ENTITY, AND IS COMPENSATED BY KISHHEALTH SYSTEM. MR. POORTEN AND MR. FOELSKE ARE ALSO CONSIDERED OFFICERS OF KISHWAUKEE COMMUNITY HOSPITAL AND KISHHEALTH SYSTEM, AS DESCRIBED ABOVE. ERIK ENGLEHART AND TERRENCE DUFFY ARE MEMBERS OF THE VALLEY WEST COMMUNITY HOSPITAL BOARD OF DIRECTORS. THEY ALSO SERVE ON THE BOARD OF DIRECTORS OF KISHHEALTH SYSTEM, THE PARENT ORGANIZATION OF VALLEY WEST COMMUNITY HOSPITAL. THE FOLLOWING INDIVIDUALS ARE OFFICERS OR KEY EMPLOYEES OF KISHHEALTH SYSTEM AND ARE ALSO CONSIDERED OFFICERS OR KEY EMPLOYEES OF VALLEY WEST COMMUNITY HOSPITAL. THEY ARE ALL COMPENSATED BY KISHHEALTH SYSTEM: BRAD COPPLE, PRESIDENT KCH & VWCH PAM DUFFY, VP PATIENT CARE JOE DANT, VP DEVELOPMENT MIKE KOKOTT, ASST. VP MARKETING ROGER HEATH BELL, VP AND CHIEF INFORMATION OFFICER MARK THATE, VP HUMAN RESOURCES DR. MICHAEL KULISZ, CHIEF MEDICAL OFFICER MIKE MUZZILLO, VP OPERATIONS - VWCH FORM 990, PART VI, SECTION A, LINE 6 KISHHEALTH SYSTEM IS THE SOLE MEMBER OF VALLEY WEST COMMUNITY HOSPITAL. FORM 990, PART VI, SECTION A, LINE 7A AS THE SOLE MEMBER AND PARENT ORGANIZATION OF VALLEY WEST COMMUNITY HOSPITAL, KISHHEALTH SYSTEM HAS THE RIGHT TO APPROVE THE ELECTION OF MEMBERS OF THE HOSPITAL'S GOVERNING BOARD, PER THE HOSPITAL'S BYLAWS. FORM 990, PART VI, SECTION A, LINE 7B KISHHEALTH SYSTEM (KHS) SERVES AS THE SOLE MEMBER AND PARENT ORGANIZATION OF VALLEY WEST COMMUNITY HOSPITAL (VWCH). PER THE BYLAWS, WITH RESPECT TO THE GOVERNANCE OF VWCH, THE FOLLOWING POWERS SHALL BE RESERVED TO THE SOLE CORPORATE MEMBER: A. ELECTING THE MEMBERS OF THE VWCH BOARD; B. APPROVING, EVALUATING AND/OR REMOVING THE PRESIDENT AND CEO AND REVIEWING AND APPROVING THE EMPLOYMENT CONTRACT OF THE PRESIDENT AND CEO AND ESTABLISHING COMPENSATION FOR SUCH OFFICE; C. APPROVING THE STRATEGIC PLAN FOR VWCH; D. APPROVING THE DISPOSITION OF ANY ASSETS OTHER THAN IN THE ORDINARY COURSE OF BUSINESS FOR VWCH; E. APPROVING ANY CHANGE IN MEMBERSHIP OF VWCH; F. APPROVING THE ADOPTION OF AND AMENDMENTS TO THE ORGANIZATIONAL DOCUMENTS, INCLUDING THE ARTICLES OF INCORPORATION AND BYLAWS OF VWCH; G. APPROVING A PLAN OF MERGER OR A PLAN OF CONSOLIDATION OF VWCH OR ESTABLISHING A NEW SUBSIDIARY OR SISTER ENTITY; H. APPROVING A PLAN FOR THE DISTRIBUTION OF THE ASSETS OF VWCH; I. INITIATING, TAKING ANY AND ALL ACTIONS, AND EXERCISING ALL APPROVAL RIGHTS OF THE DIRECTORS PURSUANT TO THE APPLICABLE MEDICAL STAFF BYLAWS; J. IMPLEMENTING AND MONITORING VWCH OPERATIONAL QUALITY IMPROVEMENT POLICIES AND PROGRAMS; K. ACCEPTING GIFTS, GRANTS, BEQUESTS AND DONATIONS ON BEHALF OF VWCH; L. APPROVAL OF THE ANNUAL OPERATING AND CAPITAL BUDGETS FOR VWCH; M. EXERCISING ANY RIGHTS THAT VWCH HAS AS A SHAREHOLDER OR MEMBER OF ANY SUBSIDIARY ENTITY; N. APPROVING ANY AFFILIATIONS OF VWCH; O. APPROVING AND/OR DETERMINING (I) THE CREATION OF NEW HEALTH SERVICES TO BE PROVIDED AND THE LOCATION OF SUCH HEALTH SERVICES AND (II) THE DISCONTINUANCE OF ANY HEALTH SERVICE; P. AUTHORIZING THE SALE, LEASE, EXCHANGE OR MORTGAGE OF ALL OR SUBSTANTIALLY ALL OF THE PROPERTY OR ASSETS OF VWCH; Q. AUTHORIZING THE VOLUNTARY DISSOLUTION OF VWCH, OR REVOKING THE PROCEEDINGS THEREOF; R. REQUIRING MINUTES OF MEETINGS, FINANCIAL RECORDS, AND SUCH OTHER INFORMATION AS MAY BE NECESSARY TO PROPERLY EVALUATE THE PERFORMANCE OF VWCH; S. INITIATING ACTION TO REMOVE OR REINSTATE A DIRECTOR WHEN, IN THE OPINION OF THE KHS BOARD, IT IS IN THE BEST INTERESTS OF KHS OR VWCH. ANY ACTION TO REMOVE OR REINSTATE SHALL REQUIRE A MAJORITY VOTE OF THOSE KHS DIRECTORS THEN IN OFFICE PRESENT AND VOTING AT A MEETING OF THE KHS BOARD AT WHICH A QUORUM IS PRESENT. IN ANY ACTION(S) TO REMOVE TAKEN BY THE KHS BOARD, THE DIRECTOR IN QUESTION SHALL BE ADVISED AT LEAST TWENTY (20) DAYS PRIOR TO THE MEETING THAT THE ACTION WILL BE CONSIDERED AND SHALL BE GIVEN THE OPPORTUNITY TO MAKE A STATEMENT, PRESENT WITNESSES ON HIS/HER BEHALF AND QUESTION THOSE PRESENTING REASONS FOR HIS/HER REMOVAL. ALL ACTIONS TO REMOVE SHALL BE TAKEN IN CLOSED SESSIONS OF THE KHS BOARD; AND T. TRANSFERRING MONEY OR PROPERTY AMONG VWCH, KHS AND/OR ONE OR MORE SUBSIDIARY CORPORATIONS AND TRANSFERRING MONEY OR PROPERTY FROM A SUBSIDIARY CORPORATION, INCLUDING REQUIRING THE DIRECTORS, OFFICERS, OR TRUSTEES OF ANY SUBSIDIARY CORPORATION TO TRANSFER MONEY OR OTHER PROPERTY TO KHS. SUBJECT TO THE POWERS OF THE BOARD OF DIRECTORS OF EACH SUBSIDIARY CORPORATION, THE KHS BOARD MAY INITIATE AND TAKE THE FOREGOING ACTIONS ON BEHALF OF KHS AND THE SUBSIDIARY CORPORATIONS. FORM 990, PART VI, SECTION B, LINE 11 A DRAFT COPY OF FORM 990 IS PROVIDED TO THE GOVERNING BODY (BOARD OF DIRECTORS) AND THE GOVERANCE COMMITTEE FOR REVIEW BY THE RETURN PREPARER PRIOR TO FILING. THE ORGANIZATION'S CEO, CFO, AND OTHER MEMBERS OF THE ACCOUNTING DEPARTMENT ARE ALSO PROVIDED A COPY OF THE RETURN FOR THEIR REVIEW. THE CHAIR OF THE AUDIT COMMITTEE AND THE AUDIT COMMITTEE MEMBERS ARE ALSO PROVIDED DRAFT COPIES AND REVIEW. IF CHANGES ARE NECESSARY, THEY ARE REPORTED TO THE RETURN PREPARER AND INCORPORATED INTO THE FINAL RETURN. FORM 990, PART VI, SECTION B, LINE 12C CONFLICTS OF INTEREST ARE INVESTIGATED BY APPOINTED MEMBERS OF THE GOVERANCE COMMITTEE ON AN ONGOING BASIS. IF IT IS DETERMINED THAT AN INDIVIDUAL FAILED TO DISCLOSE AN ACTUAL OR POSSIBLE CONFLICT OF INTEREST, IT SHALL INFORM THE INDIVIDUAL OF SUCH A BELIEF AND AFFORD HIM AN OPPORTUNITY TO EXPLAIN. AFTER SAID EXPLANATION, THE BOARD SHALL TAKE APPROPRIATE DISCIPLINARY AND CORRECTIVE ACTION AS DEEMED NECESSARY. THE CONFLICT OF INTEREST POLICY IS REVIEWED BY THE BOARD ANNUALLY AND UPDATED AS NEEDED. FORM 990, PART VI, SECTION B, LINE 15 THROUGH THE OVERSIGHT OF THE BOARD OF DIRECTORS EXECUTIVE COMPENSATION COMMITTEE, THE KISHHEALTH SYSTEM EXECUTIVE TOTAL COMPENSATION PROGRAM WILL BE COMPETITIVELY POSITIONED IN THE MARKET PLACE OF RELEVANT ORGANIZATIONS AND FALL WITHIN THE SAFE HARBOR GUIDELINES ESTABLISHED BY THE INTERMEDIATE SANCTIONS RULES. THE EXECUTIVE COMPENSATION COMMITTEE IS MADE UP OF THREE MEMBERS OF THE BOARD OF DIRECTORS WHO MEET THE BOARD APPROVED DEFINITION OF "INDEPENDENT DIRECTORS". ANNUALLY THE EXECUTIVE COMPENSATION COMMITTEE CONTRACTS WITH SULLIVAN, COTTER AND ASSOCIATES, AN INDEPENDENT HUMAN RESOURCES CONSULTING FIRM TO PROVIDE THE COMMITTEE ANALYSIS AND COMPARABILITY DATA. USING THE SUPPLIED DATA THE COMPENSATION COMMITTEE APPROVES EACH EXECUTIVE'S TOTAL CASH COMPENSATION AND PROVIDES CONTEMPORANEOUS SUBSTANTIATION OF THE DELIBERATION AND DECISION. TOTAL CASH COMPENSATION IS DEFINED AS THE SUM OF BASE SALARIES PLUS INCENTIVE AWARDS. BASED ON THE COMPARABILITY DATA AND THE PERFORMANCE OF EACH EXECUTIVE IN MEETING GOALS AND STRATEGIC OBJECTIVES, THE EXECUTIVE COMPENSATION COMMITTEE APPROVES INCREASES AND INCENTIVE AWARDS FOR EACH EXECUTIVE WITHIN THE GUIDELINES ESTABLISHED. THE EXECUTIVE COMPENSATION COMMITTEE REPORTS ON ALL COMPENSATION MATTERS TO THE FULL BOARD OF DIRECTORS. FORM 990, PART VI, SECTION C, LINE 19 THE ORGANIZATION'S GOVERNING DOCUMENTS ARE AVAILABLE TO THE PUBLIC UPON REQUEST IN WRITING TO ADMINISTRATION. DESCRIPTION OF HOURS FOR RELATED ORGANIZATIONS FORM 990, PART VII, COLUMN (B) AVERAGE HOURS PER WEEK FOR THE INDIVIDUALS IDENTIFIED AS OFFICER'S ARE ESTIMATES OF THE INDIVIDUALS TOTAL TIME PER WEEK UTILIZED FOR WORK RELATED TO VALLEY WEST COMMUNITY HOSPITAL. CHANGES IN NET ASSETS OR FUND BALANCES: FORM 990, PART XI, LINE 5: NET UNREALIZED LOSSES ON INVESTMENTS: -157,253. EQUITY DISTRIBUTION TO KISHHEALTH SYSTEM, INC. -1,710,000. GRANT INCOME RECORDED AS OFFSET TO FIXED ASSET ACCOUNTS -35,005. CHANGE IN NET ASSETS OF KISHHEALTH FOUNDATION -34,806. TOTAL TO FORM 990, PART XI, LINE 5: -1,937,064. REPONSIBILITY FOR OVERSIGHT OF FINANCIAL STATEMENTS FORM 990, PART XI, LINE 2C 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 VALLEY WEST COMMUNITY HOSPITAL. KISHHEALTH SYSTEM ONE KISH HOSPITAL DRIVE DEKALB IL 60115 363649080 PARENT CORPORATION OF 501(C)(3) HEALTH SYSTEM IL 501(C)(3) 11B N/A 0 KISHHEALTH FOUNDATION ONE KISH HOSPITAL DRIVE DEKALB IL 60115 363649077 SUPPORT OF CHARITABLE HEALTH ORGANIZATIONS IL 501(C)(3) 7 N/A 0 KISHWAUKEE COMMUNITY HOSPITAL ONE KISH HOSPITAL DRIVE DEKALB IL 60115 237087041 HEALTHCARE SERVICES, PRIMARILY ACUTE CARE IL 501(C)(3) 3 N/A 0 DEKALB COUNTY HOSPICE 2727 SYCAMORE ROAD DEKALB IL 60115 363164329 HOSPICE SERVICES IL 501(C)(3) 7 N/A 0 COMMUNITY CARES CLINIC 3100 SYCAMORE ROAD DEKALB IL 60115 800424001 HEALTHCARE SERVICES, PRIMARY CARE IL 501(C)(3) 3 N/A 0 KISHWAUKEE PHYSICIANS GROUP INC 2240 GATEWAY DRIVE SYCAMORE IL 60178 651293967 HEALTHCARE SERVICES, PRIMARILY FAMILY PRACTICE IL 501(C)(3) 3 N/A 0 HEALTH PROGRESS INC ONE KISH HOSPITAL DRIVE DEKALB IL 60115 363824138 INVESTMENT IN HEALTHCARE RELATED SMALL BUSINESSES IL N/A C 0 0 1 0 0 0 0 0 0 0 0 0 1 1 1 1 1 1