2012-12-17T09:39:05-06:00 2012-04-30 410746749 CLIFTONLARSONALLEN LLP 114 E EVERETT DIXON IL 61021 990 2011-05-01 237087041 KISHWAUKEE COMMUNITY HOSPITAL KISH 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 222419047 0 X WWW.KISHHOSPITAL.ORG X 1970 IL TO PROVIDE COMPREHENSIVE HEALTH CARE SERVICES, INCLUDING INPATIENT ACUTE AND NONACUTE CARE, AND VARIOUS OUTPATIENT SERVICES IN THE AREA OF DEKALB COUNTY. 3 2 1213 320 111772 19743 1113923 930478 163834645 174560488 2966348 4533345 1803798 2395820 169718714 182420131 999268 317643 0 0 56726719 59347491 0 0 6193 95690873 103689576 153416860 163354710 16301854 19065421 278068882 294914074 101229299 104281500 176839583 190632574 X TO PROVIDE COMPREHENSIVE HEALTH CARE SERVICES, INCLUDING INPATIENT ACUTE AND NONACUTE CARE, AND VARIOUS OUTPATIENT SERVICES IN THE AREA OF DEKALB COUNTY. KISHWAUKEE COMMUNITY HOSPITAL (KCH) SERVES ALL PEOPLE WITH SKILL AND COMPASSION WHILE RESPECTING THEIR DIGNITY, RIGHTS, AND CHOICES BY OFFERING ACCESS TO HIGH-QUALITY PREVENTIVE, CURATIVE, AND REHABILITATIVE CARE DELIVERED IN A COST EFFECTIVE MANNER. KISHWAUKEE COMMUNITY HOSPITAL RECOGNIZES THE NEED TO EFFECTIVELY MANAGE RESOURCES FOR PRESENT AND FUTURE GENERATIONS. 0 0 137216484 317643 176671127 KISHWAUKEE COMMUNITY HOSPITAL (KCH), LOCATED IN DEKALB, ILLINOIS, SERVES THE RESIDENTS OF DEKALB COUNTY AND THE SURROUNDING AREAS BY OFFERING A NUMBER OF PROGRAMS AND SERVICES FOR COMMUNITY BENEFIT, INCLUDING CHARITY CARE. KISHWAUKEE COMMUNITY HOSPITAL BELIEVES THAT IN ORDER TO BE A TRUE "COMMUNITY" HOSPITAL, WE MUST BE A RESOURCE FOR PREVENTATIVE AND CURATIVE HEALTH INFORMATION, EDUCATION AND SERVICES AND THAT WE MUST SUPPORT THE EFFORTS OF OTHERS WHO ALSO ARE DOING WORK FOR THE COMMUNITY GOOD. DOING SO HELPS BUILD TRUST, RESPECT AND LOYALTY FOR OUR HOSPITAL AND STRENGTHENS OUR ROLE AS A PARTNER IN IMPROVING THE HEALTH OF OUR CITIZENS AND THE QUALITY OF LIFE IN THE COMMUNITIES WE SERVE.THE OBJECTIVES OF HOSPITAL'S COMMUNITY BENEFIT PROGRAM ARE TO IMPROVE ACCESS TO HEALTH SERVICES BY REDUCING GEOGRAPHIC, FINANCIAL, LANGUAGE AND CULTURAL BARRIERS; IMPROVE AND ENHANCE PUBLIC HEALTH, ADVANCE GENERAL HEALTH KNOWLEDGE, AND RELIEVE THE GOVERNMENT BURDEN OF PROVIDING HEALTH SERVICES FOR THE COMMUNITY, AND FOR THE UNINSURED AND UNDERINSURED. COMMUNITY HEALTH NEEDS ARE IDENTIFIED AND ADDRESSED THROUGH COMMUNITY OUTREACH PROGRAMS, BY ADDING NEW SERVICES AND BY EXPANDING OTHERS. NEEDS ALSO ARE MET THROUGH OPERATIONAL PROGRAMS SUCH AS CHARITY CARE, SUBSIDIZED SERVICES AND PROVIDING CASH AND IN-KIND DONATIONS TO SUPPORT ORGANIZATIONS THAT ALSO STRIVE TO MEET COMMUNITY HEALTH AND QUALITY OF LIFE NEEDS. THE HOSPITAL IDENTIFIES COMMUNITY HEALTH NEEDS IN SEVERAL WAYS:* DEKALB COUNTY HEALTH DEPARTMENT I-PLAN* 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 POPULATIONSUSING ALL THESE RESOURCES, THE HEALTH SYSTEM FOCUSED ON THE FOLLOWING COMMUNITY HEALTH NEEDS IN FY12: * THE PREVALENCE OF OBESITY IN CHILDREN AND ADULTS* ACCESS TO AFFORDABLE PRIMARY HEALTH CARE IN THE DEKALB/SYCAMORE AREA AND OUTLYING RURAL AREA* OUTPATIENT MENTAL HEALTH SERVICES AT BOTH HOSPITALS* TYPE II DIABETES * CARDIOVASCULAR DISEASE AND ADEQUATE HOSPITAL-BASED AND COMMUNITY OUTREACH SERVICES * CANCER CARE SERVICES, EDUCATION AND PREVENTION * AFFORDABLE ACCESS TO CHILDBIRTH EDUCATION AND OB HOSPITAL SERVICES* OTHER COMMUNITY OUTREACH AND WELLNESS 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 COLLABORATION/SCHOOL & WELLNESS PROGRAMS. THE HOSPITAL'S COMMUNITY HEALTH LIAISON SERVES ON THE DEKALB WELLNESS SCHOOLS COMMITTEE. THE HOSPITAL SPONSORED "FOOD PLAY", A PROFESSIONAL PLAY/ASSEMBLY FOR DEKALB SCHOOL CHILDREN FOCUSED ON NUTRITION, FITNESS AND REDUCING SCREEN TIME WITH PRE- AND POST-TESTS GIVEN AS WELL AS PROGRAMS FOR THE TEACHERS TO IMPLEMENT. THE HOSPITAL'S COMMUNITY HEALTH LIAISON ALSO MET WITH SYCAMORE SCHOOL DISTRICT LEADERS TO DISCUSS IMPLEMENTATION OF HEALTHY MINDS AND BODIES IN THE SCHOOLS. * OTHER COMMUNITY OUTREACH AND WELLNESS EFFORTS. FREE SAFE SITTER PROGRAM FOR 24 STUDENTS IN THE SYCAMORE SPARTAN REACH, A PROGRAM FOR CHILDREN WHO RECEIVE EITHER REDUCED OR FREE LUNCHES. COMMUNITY WELLNESS EDUCATORS TAUGHT HEALTH TOPICS IN AREA SCHOOLS, VISITING 473 CLASSROOMS WORKING WITH 14,713 STUDENTS. COMMUNITY WELLNESS EDUCATORS SERVED ON THE FOLLOWING COMMITTEES TO PROMOTE HEALTH AND WELLNESS: DEKALB LEADERSHIP ACADEMY, CO-COACH/PIONEERING HEALTHY COMMUNITIES/YMCA, SYCAMORE SCHOOL DISTRICT WELLNESS COMMITTEE, DEKALB SCHOOL DISTRICT WELLNESS COMMITTEE (SCHOOL LUNCH POLICIES AND COMMUNITY OUTREACH SUBCOMMITTEES), LATINO ACTION GROUP, GO RED LUNCHEON COMMITTEE, HOSPITAL'S CANCER COMMITTEE. ALSO, FREE AND LOW COST FITNESS AND INJURY PREVENTION CLASSES THROUGH UNLIMITED PERFORMANCE REHABILITATION AND SPORTS MEDICINE. SPONSORED ANNUAL FITFEST, A WALKING EVENT WITH THE KISHWAUKEE FAMILY YMCA TO PROMOTE EMPLOYEE HEALTH AND FITNESS DAY TO AREA EMPLOYERS. ATTENDED BY 400. ENTERED INTO AGREEMENTS WITH THE KISHWAUKEE FAMILY YMCA (DEKALB) TO HELP UNDERWRITE THE COST OF FITNESS AND RECREATIONAL ACTIVITIES FOR COMMUNITY MEMBERS.* 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, CASH AND IN-KIND DONATIONS, AND OTHER. - CHARITY CARE. AS PART OF ITS CHARITABLE MISSION, THE HOSPITAL PROVIDES FINANCIAL ASSISTANCE, INCLUDING ACCESS TO PHARMACEUTICAL ASSISTANCE FOR PATIENTS WHO MET THE ELIGIBILITY CRITERIA ESTABLISHED IN ITS FINANCIAL ASSISTANCE POLICY. THE POLICY IS REVIEWED BY THE BOARD OF DIRECTORS ANNUALLY. THE HOSPITAL ALSO 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 US 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 & WORKFORCE DEVELOPMENT. A MEDICAL LIBRARY IS MAINTAINED FOR PHYSICIAN, STAFF AND PATIENT USE. 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 ACTIVITIES- CASH AND IN-KIND DONATIONS. EACH YEAR AN ALLOCATION IS MADE IN THE OPERATING BUDGET FOR DONATIONS TO COMMUNITY EVENTS AND ORGANIZATIONS THAT IMPROVE THE HEALTH, WELFARE AND QUALITY OF LIFE IN THE COMMUNITIES SERVED BY 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.- DONATION HIGHLIGHTS. FY 12, THE HOSPITAL PROVIDED SUBSTANTIAL CASH CONTRIBUTIONS TO: BEN GORDON CENTER TO SUPPORT MENTAL HEALTH SERVICES FOR THE LOW INCOME, KISHWAUKEE FAMILY YMCA TO SUPPORT STRONG KIDS SCHOLARSHIP PROGRAM AND SPONSOR HEALTH AND WELLNESS ACTIVITIES FOR FAMILIES, FAMILY SERVICE AGENCY TO SUPPORT BIG BROTHERS BIG SISTERS, COURT APPOINTED SPECIAL ADVOCATES, SENIOR SERVICES AND FAMILY COUNSELING, KISHWAUKEE COLLEGE FOUNDATION TO SUPPORT ITS NURSING AND RADIOLOGY TRAINING PROGRAMS , KISHWAUKEE UNITED WAY TO SUPPORT SOCIAL SERVICE AGENCIES THAT PROMOTE NUTRITION AND HEALTH ESPECIALLY AMONG THE LOW INCOME, VOLUNTARY ACTION CENTER TO SUPPORT MEALS ON WHEELS, TRANSPORTATION SERVICES AND DAY CARE LUNCH PROGRAMS, DEKALB COUNTY ECONOMIC DEVELOPMENT CORPORATION, DEKALB, SYCAMORE, GENOA, SANDWICH AND PLANO CHAMBERS OF COMMERCE TO SUPPORT THE BUSINESS COMMUNITY AND ECONOMIC DEVELOPMENT FOR THE REGION, AND MANY OTHERS.- OTHER ACTIVITIES INCLUDE MEDICAL HELICOPTER SERVICES, UNLIMITED PERFORMANCE REHABILITATION AND SPORTS MEDICINE, FREE ACTIVITIES IN THE COMMUNITY RELATED TO EXERCISE AND FITNESS, PROPERTY TAXES, AND SALES TAXES PAID. 137216484 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 1 1 1 0 0 0 0 0 0 0 0 0 1 0 0 0 0 0 1 0 0 0 0 1 131 0 1 1213 1 1 1 0 0 0 0 0 0 0 0 0 X 3 2 1 0 0 0 1 1 1 1 1 0 0 1 1 1 1 1 1 1 1 1 1 IL X LOREN FOELSKE VP OF FINANCE 8157561521 ONE KISH HOSPITAL DRIVE DEKALB IL 60115 X MICHAEL MOONEY 2.00 X X 0 0 0 MICHAEL CULLEN 2.00 X X 0 0 0 KEVIN POORTEN 30.00 X X 0 698961 102663 THOMAS MATYA 2.00 X X 0 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 20.00 X 0 263727 41741 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 20.00 X 0 197280 29354 CHERYL FISHER 20.00 X 0 150191 32889 MICHAEL MUZZILLO 40.00 X 0 179349 27579 THOMAS W TILTON DO 40.00 X 464833 0 42105 THOMAS WARZECHA 40.00 X 145805 0 31872 KENYA M WILLIAMS MD 40.00 X 233584 0 20875 JASMEET DHALIWAL 40.00 X 574169 0 22746 KENNETH O'BRIEN 40.00 X 133538 0 30030 1551929 3256825 579191 38 0 1 0 KISHHEALTH SYSTEM ONE KISH HOSPITAL DRIVE DEKALB IL 60115 MANAGEMENT SERVICES 15272721 DOCTORS OF EMERGENCY MEDICINE 2807 BRITTANY COURT ST CHARLES IL 60175 EMERGENCY MEDICINE SERVICES 6697188 POWER CONSTRUCTION COMPANY LLC 2360 NORTH PALMER DRIVE SCHAUMBURG IL 60173 CONSTRUCTION SERVICES 4373874 SABET SIDDIQUI MDPC 6925 ERROL COURT CHERRY VALLEY IL 61016 PHYSICAN - CANCER CARE CENTER 1662237 SODEXO INC & AFFILIATES 4880 PAYSPHERE CIRCLE CHICAGO IL 60674 FOOD SERVICES 1416093 33 1016 194102 727932 7428 930478 NET PATIENT SERVICE RE 621110 174560488 174475466 85022 174560488 4827674 4827674 326421 213955 112466 112466 112466 39375564 46027 39715398 522 -339834 45505 -294329 -294329 14459 0 14459 14459 115525 69041 46484 46484 CAFETERIA SALES 621110 694127 689596 4531 OTHER SERVICES 621110 681183 658964 22219 INCOME PASSTHROUGH - K 621110 527223 527223 319878 319878 2222411 182420131 176671127 111772 4706754 292259 292259 25384 25384 44114548 42196844 1917704 2388137 2284322 103815 9654392 9234706 419686 3190414 3051723 138691 12642156 12642156 272308 272308 4327 4327 402633 402633 18328450 17245259 1083191 987722 77838 909884 24237983 23273485 960210 4288 1907496 480682 1426814 3684809 3621044 63765 207983 192534 15449 10044 10044 3712162 3712162 11689526 11689526 2168039 995852 1172187 UNRELATED BUSINESS INCO 11583 11583 BAD DEBT EXPENSE 13678918 13678918 PHYSICAN FEES 4395969 4395969 FEDERAL AND STATE ASSES 2348718 2348718 2998750 2121377 875468 1905 163354710 137216484 26132033 6193 6499149 15302921 279934 251766 25341679 28815521 3529110 3725696 2061173 2901412 173017997 66096416 104821380 106921581 104528505 118483018 22243230 8089823 8764722 10422336 278068882 294914074 13418274 13536946 945417 743742 63685000 63685000 1245941 1226938 21934667 25088874 101229299 104281500 X 172416577 186447120 4423006 4185454 176839583 190632574 278068882 294914074 X 19065421 -5272430 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 24583 24583 0 EXPLANATION OF LOBBYING ACTIVITIES: PART II-B, LINE 1: LOBBYING EXPENSES ARE ALLOCATED THROUGH MEMBERSHIP DUES WITH ILLINOIS HOSPITAL ASSOCIATION AND AMERICAN HOSPITAL ASSOCIATION. NO OTHER LOBBYING ACTIVITIES WERE CONDUCTED. 5255089 5255089 109056324 27854971 81201353 565362 137173 428189 52696409 38104272 14592137 5444813 5444813 106921581 THIRD PARTY PAYABLES 17173388 DUE TO AFFILIATES 1430949 ACCRUED INTEREST PAYABLE 307958 OTHER PAYABLES - LONG TERM 6176579 25088874 182420131 163354710 19065421 -1139781 -4132649 -5272430 13792991 181671811 -1139781 -1139781 182811592 -391461 -391461 182420131 163628496 282996 282996 163345500 9210 9210 163354710 PART XI, LINE 8 - OTHER ADJUSTMENTS: EQUITY DISTRIBUTION TO KISHHEALTH SYSTEM -4,440,000. CHANGE OF INTEREST IN NET ASSETS OF KISHHEALTH FOUNDATION -65,942. BOOK/TAX DIFFERENCES IN K-1 PASSTHROUGH ENTITIES 333,417. GRANT REVENUE INCLUDED IN FIXED ASSETS FOR FINANCIAL STATEMENT PURPOSES -30,850. OTHER EQUITY ADJUSTMENT 70,726. TOTAL TO SCHEDULE D, PART XI, LINE 8: -4,132,649. PART XII, LINE 4B - OTHER ADJUSTMENTS: BOOK/TAX DIFFERENCE ON INCOME FROM PASSTHROUGH ENTITIES - KISH AREA PHO 3,600. CONTRIBUTION REVENUE FROM KISHHEALTH FOUNDATION 194,102. BOOK/TAX DIFFERENCE ON INCOME FROM PASSTHROUGH ENTITIES - MIDLAND SURGICAL -337,017. GRANT REVENUE INCLUDED IN FIXED ASSETS FOR FINANCIAL STATEMENT PURPOSES 30,850. RECLASSIFICATION OF COST OF GOODS SOLD -69,041. RECLASSIFICATION OF RENTAL EXPENSES -213,955. PART XIII, LINE 2D - OTHER ADJUSTMENTS: RECLASSIFICATION OF COST OF GOODS SOLD 69,041. RECLASSIFICATION OF RENTAL EXPENSES 213,955. PART XIII, LINE 4B - OTHER ADJUSTMENTS: CONTRIBUTION TO KISHHEALTH FOUNDATION 9,210. PART XI, LINE 10, EXCESS OR (DEFICIT) FOR THE YEAR PER FINANCIAL STATEMENTS: LINE 10 IDENTIFIES FINANCIAL STATEMENT INCOME AS EQUALING $13,792,991. FINANCIAL STATEMENT INCOME IS ACTUALLY $18,043,313. THE DIFFERENCE RELATES TO THE FOLLOWING ITEMS: 1. KISHWAUKEE COMMUNITY HOSPITAL MADE A NET CAPITAL DISTRIBUTION OF $4,440,000 TO ITS PARENT ORGANIZATION, KISHHEALTH SYSTEM. 2. KISHHEALTH FOUNDATION (KHF), AN AFFILIATED ENTITY, RECEIVES CONTRIBUTIONS DESIGNATED FOR USE BY KISHWAUKEE COMMUNITY HOSPITAL. THIS IS ALLOCATED TO KISHWAUKEE COMMUNITY HOSPITAL, VIA AN ENTRY TO INCREASE KISHWAUKEE COMMUNITY HOSPITAL'S INTEREST IN THE ASSETS OF KHF. A CORRESPONDING EQUITY ENTRY IS MADE ON KISHWAUKEE COMMUNITY HOSPITAL'S GENERAL LEDGER. THE CURRENT YEAR DECREASE WAS $65,942. 3. KCH RECEIVED CONTRIBUTIONS FROM AFFILIATES (KHF) IN THE AMOUNT OF $194,102 AND MADE CONTRIBUTIONS TO AFFILIATES IN THE AMOUNT OF $9,210. THESE CONTRIBUTIONS WERE REFLECTED AS EQUITY TRANSACTIONS FOR FINANCIAL STATEMENT PURPOSES. 4. THERE WERE OTHER ADJUSTMENTS OF $70,726. 1 1 X 1 X 1 X 600.000000000000 1 1 1 0 1 1 5469441 2041416 3428025 0.02100 17846231 9835333 8010898 0.04900 23315672 11876749 11438923 0.07000 6111897 775500 5336397 0.03270 1522784 17627 1505157 0.00920 930410 305212 625198 0.00380 0 0 483955 0 483955 0.00300 9049046 1098339 7950707 0.04870 32364718 12975088 19389630 0.11870 1 13678918 2325416 33911481 52259678 -18348197 X 1 1 1 MIDLAND SURGICAL CENTER (MSC) AMBULATORY SURGERY 0.77500 0.00000 0.00000 1 1 KISHWAUKEE COMMUNITY HOSPITAL

ONE KISH HOSPITAL DRIVE DEKALB IL 60115

X X X KISHWAUKEE COMMUNITY HOSPITAL 1 1 1 200.000000000000 1 600.000000000000 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: 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: FOR THE 4/30/12 FISCAL YEAR, KCH PROVIDED BILLED CHARGES TO MEDICARE PATIENTS TOTALING $161,000,000. HOWEVER, DUE TO THE MEDICARE INPATIENT AND OUTPATIENT PAYMENT METHODOLOGIES, THE ACTUAL CASH PAYMENTS RECEIVED FROM PROVIDING CARE TO THOSE PATIENTS WAS JUST $34,000,000, OR 21% OF BILLED CHARGES. THE COST OF PROVIDING THIS CARE, PER THE MEDICARE COST REPORT, WAS $52,500,000. THUS, THE PAYMENTS RECEIVED FROM MEDICARE WERE $18,500,000 LESS THAN COST, OR 65% OF COST. TRULY THIS $18,500,000 SHORTFALL SHOULD BE INCLUDED AS A COMMUNITY BENEFIT. AS APPROXIMATELY 46% OF ALL KISHWAUKEE COMMUNITY HOSPITAL CHARGES GENERATED ARE FROM MEDICARE PATIENTS, THIS SHORTFALL PLACES A TREMENDOUS FINANCIAL BURDEN ON OUR HOSPITAL.KISHWAUKEE COMMUNITY HOSPITAL, LIKE OTHER NOT-FOR-PROFIT HOSPITALS, MUST ACCEPT MEDICARE PAYMENTS AS PAYMENT IN FULL FOR SERVICES PROVIDED, WITH THE EXCEPTION OF COLLECTING ON DEDUCTIBLES AND CO-INSURANCE AMOUNTS. HOSPITALS CANNOT BILL MEDICARE PATIENTS FOR THE DIFFERENCE BETWEEN THE BILLED CHARGES AND MEDICARE PAYMENTS.KISHWAUKEE COMMUNITY HOSPITAL PROVIDES SERVICES TO ALL PATIENTS WHO NEED CARE, ABIDING BY THE FEDERAL EMERGENCY MEDICAL TREATMENT AND LABOR ACT (EMTALA) REGULATION. IT REQUIRES HOSPITALS AND AMBULANCE SERVICES TO PROVIDE CARE TO ANYONE NEEDING EMERGENCY HEALTHCARE TREATMENT REGARDLESS OF CITIZENSHIP, LEGAL STATUS OR ABILITY TO PAY.KCH UTILIZED THE CALCULATION OF MEDICARE COST FROM THE ANNUAL MEDICARE COST REPORT. THIS APPROACH ALLOCATES COST FROM NON REVENUE PRODUCING DEPARTMENTS TO THE REVENUE GENERATING DEPARTMENTS, BASED ON STEP DOWN STATISTICAL COST FINDING. WHILE NOT AS COMPREHENSIVE AS A TRUE COST ACCOUNTING SYSTEM, THIS PROCESS RESULTS IN AN ACCEPTABLE BASIS OF THE DEPARTMENTAL COST FOR PROVIDING SERVICES. RECALL THAT PRIOR TO MEDICARE PROSPECTIVE PAYMENT SYSTEM (PPS), THIS METHODOLOGY WAS THE BASIS FOR THE REIMBURSEMENT TO HOSPITALS. PART III, LINE 9B: COLLECTION ACTIONS INVOLVING UNINSURED PATIENTS. KHS (KISHHEALTH SYSTEM, PARENT ORGANIZATION OF KISHWAUKEE COMMUNITY HOSPITAL) SHALL NOT PURSUE A COLLECTION ACTION AGAINST AN UNINSURED PATIENT, UNLESS THE PATIENT HAS BEEN GIVEN THE OPPORTUNITY TO ASSESS THE ACCURACY OF THE BILL; APPLY FOR FINANCIAL ASSISTANCE UNDER THE KHS FINANCIAL ASSISTANCE POLICY AND PROCEDURE; AND AVAIL HIMSELF OR HERSELF OF A REASONABLE PAYMENT PLAN. NOTWITHSTANDING THIS, KHS MAY NOT PURSUE THE COLLECTION ACTION UNDER THE FOLLOWING CIRCUMSTANCES: (A) IF THE PATIENT HAS INDICATED AN INABILITY TO PAY THE FULL AMOUNT OF THE DEBT IN ONE PAYMENT, UNTIL KHS HAS OFFERED THE PATIENT A PAYMENT PLAN. KHS MAY REQUIRE THE PATIENT TO PROVIDE REASONABLE VERIFICATION OF HIS OR HER INABILITY TO PAY THE FULL AMOUNT OF THE DEBT IN ONE PAYMENT.(B) IF KHS HAS REASON TO BELIEVE THE PATIENT MAY BE ELIGIBLE FOR FINANCIAL ASSISTANCE, UNTIL KHS HAS GIVEN THE PATIENT AT LEAST 60 DAYS FOLLOWING THE DATE OF DISCHARGE OR RECEIPT OF OUTPATIENT CARE TO SUBMIT AN APPLICATION FOR FINANCIAL ASSISTANCE. (C) IF THE PATIENT HAS AGREED TO A PAYMENT PLAN, UNTIL THE PATIENT HAS FAILED TO MAKE PAYMENTS IN ACCORDANCE WITH THAT PAYMENT PLAN. (D) IF THE PATIENT INFORMS KHS THAT HE OR SHE HAS APPLIED FOR HEALTH CARE COVERAGE UNDER MEDICAID, KIDCARE, OR OTHER GOVERNMENT-SPONSORED HEALTH CARE PROGRAM (AND THERE IS A REASONABLE BASIS TO BELIEVE THAT THE PATIENT WILL QUALIFY FOR SUCH PROGRAM), BUT THE PATIENT'S APPLICATION IS DENIED. KISHWAUKEE COMMUNITY HOSPITAL PART V, SECTION B, LINE 19D: BASED ON COMPLIANCE WITH LAWS OF STATE OF ILLINOIS, SPECIFICALLY THE UNINSURED PATIENT DISCOUNT ACT. PART VI, LINE 2: KISHWAUKEE COMMUNITY HOSPITAL IDENTIFIES COMMUNITY HEALTH NEEDS IN SEVERAL WAYS:* DEKALB COUNTY HEALTH DEPARTMENT I-PLAN* COMMUNITY HEALTH NEEDS SURVEY* U.S. GOVERNMENT HEALTHY PEOPLE 2010 AND 2010 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. PART VI, LINE 3: INFORMATION IS PROVIDED AT REGISTRATION, VIA THE HOSPITAL WEBSITE, THROUGH CONSULTATIONS WITH FINANCIAL COUNSELORS FOR SOME OUTPATIENTS AS WELL AS INPATIENTS, DURING THE BILLING PROCESS ON STATEMENTS AND VIA PHONE CONVERSATIONS. PART VI, LINE 4: KISHWAUKEE COMMUNITY HOSPITAL SERVES ALL OF DEKALB COUNTY, IL, AND BORDER COMMUNITIES IN KANE AND OGLE COUNTIES. POPULATION OF THE HOSPITAL'S SERVICE AREA, BASED ON 2010 CENSUS, IS 130,000. THIS GEOGRAPHIC AREA INCLUDES A GROWING HISPANIC POPULATION. A UNIQUE POPULATION IN OUR SERVICE AREA IS NORTHERN ILLINOIS UNIVERSITY STUDENTS (22,900 ENROLLED IN 2012), INCLUDING FOREIGN STUDENTS AND VISITORS. THE HISPANIC POPULATION IS EXPECTED TO GROW BY 23.5% BY 2017. THE POVERTY LEVELS IN THE HOSPITAL'S PRIMARY MARKET ARE DEKALB, 26.3%; SYCAMORE, 6.7%; AND CORTLAND, 10.4%. PART VI, LINE 5: KISHWAUKEE COMMUNITY HOSPITAL IN DEKALB, IL, IS PART OF KISHHEALTH SYSTEM. THE HEALTH SYSTEM IS GOVERNED BY AN APPOINTED VOLUNTEER BOARD OF DIRECTORS, INDEPENDENT COMMUNITY LEADERS WHO RESIDE IN THE PRIMARY MARKETS SERVED BY THE HEALTH SYSTEM'S TWO HOSPITALS. THESE INDIVIDUALS ARE SELECTED FOR THE BOARD BECAUSE OF THEIR INTEREST AND EXPERTISE IN VARIOUS AREAS THAT CAN HELP MANAGEMENT CARRY OUT THE HEALTH SYSTEM'S MISSION. MEMBERS OF THE BOARD ARE NOT COMPENSATED FOR THEIR TIME. THE MEDICAL STAFF IS OPEN TO PHYSICIANS WHO MEET CRITERIA ESTABLISHED BY MEDICAL STAFF BYLAWS. PHYSICIANS ARE GIVEN THE OPPORTUNITY TO VOLUNTEER TO DO FREE COMMUNITY WELLNESS PROGRAMS ON HEALTH TOPICS. SURPLUS FUNDS GO BACK INTO THE ORGANIZATION TO SUPPORT OPERATIONS, CAPITAL IMPROVEMENTS, THE HEALTH SYSTEM'S COMMITMENT TO EXCELLENCE, EDUCATION AND INNOVATION, AND TO PROVIDE MEDICAL CARE TO ALL REGARDLESS OF ABILITY TO PAY. A COMMUNITY HEALTH ASSESSMENT WAS CONDUCTED IN THE FALL OF 2009, VIA A RANDOM TELEPHONE SURVEY. RESULTS ARE ONE COMPONENT USED FOR FY 12 ACTION PLANNING FOR. 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. COMMUNITY HEALTH NEEDS ASSESSMENT: IN COLLABORATION WITH DEKALB COUNTY HEALTH DEPARTMENT, KISHWAUKEE COMMUNITY 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 ORGANIZATIONS, 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, COORDINATED APPROACH TO CHILD HEALTH (CATCH) IN THE SCHOOLS AND THE YMCA SUMMER CAMP; AND SERVING ON THE SYCAMORE WELLNESS SCHOOLS COMMITTEE. SCHOOL PROGRAMS TOUCHED 14,713 STUDENTS.KISH / YMCA "PHC PIONEERING HEALTHIER COMMUNITIES": PHC IS A GRANT SPONSORED BY THE NATIONAL YMCA AND AWARDED TO KISHWAUKEE FAMILY YMCA IN DEKALB. THE INITIATIVE FOCUSES ON COLLABORATIVE ENGAGEMENT WITH COMMUNITY LEADERS AND ENVIRONMENTAL CHANGE EFFORTS THAT SUPPORT AND PROMOTE HEALTHY LIFESTYLES. THE INITIATIVE EMPOWERS LOCAL COMMUNITIES WITH PROVEN STRATEGIES AND MODELS TO CREATE AND SUSTAIN POSITIVE, LASTING CHANGE FOR HEALTHY LIVING. THE KISH HOSPITAL COMMUNITY HEALTH LIAISON CO- FACILITATES THE PHC WITH A YMCA REPRESENTATIVE.FARMERS MARKET VOUCHERS: KISH HOSPITAL TRIALED A VOUCHER PROGRAM FOR THE DEKALB FARMERS MARKET. WORKING WITH THE DEKALB COUNTY HEALTH DEPARTMENT'S WIC PROGRAM AND THE FAMILY SERVICE AGENCY'S SENIOR CENTERS. MORE THAN $6,000 IN FRUITS AND VEGETABLES WERE PURCHASED.OTHER ACCESS INITIATIVES: 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: MADE $50,000 CONTRIBUTION TO BEN GORDON (MENTAL HEALTH) CENTER TO SUPPORT THE COST OF MENTAL HEALTH SERVICES FOR DEKALB COUNTY'S UNINSURED. 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 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 WERE; GO RED FOR WOMEN CAMPAIGN IN PARTNERSHIP WITH THE AMERICAN HEART ASSOCIATION LUNCHEON ATTENDED IN MAY ATTENDED BY 150 PEOPLE. WOMEN'S HEALTH EVENT AT KISH HOSPITAL IN FEBRUARY GREW FROM 750 ATTENDEES IN FY 11 TO 1,300 IN FY 12. KNOW YOUR NUMBERS EVENTS 2012 RESULTED IN 527 FREE SCREENINGS; NUMEROUS COMMUNITY WELLNESS PROGRAMS AND CLASSESHEALTHY U SUMMER CAMPAIGN: THE SUMMER CAMPAIGN FOR KISH HOSPITAL TOOK WELLNESS EDUCATION AND PREVENTION ON THE ROAD TO 69 EVENTS THROUGHOUT THE COMMUNITY AND FOR EMPLOYEES. BLOOD PRESSURE CLINICS: THE CAMPAIGN PROMOTION OF THE FREE BLOOD PRESSURE CLINICS SHOWED HUGE SUCCESS. THE AVERAGE MONTHLY PARTICIPANT COUNT FOR BLOOD PRESSURE CHECKS AT KISH WAS AN AVERAGE OF 184 PER MONTH, WITH INCREASES IN GENOA ON AVERAGE 7 MORE PER MONTH AND IN WATERMAN ON AVERAGE 12 PER MONTH. TOTAL BLOOD PRESSURE CHECKS WERE 3,158.CANCER CARE SERVICES, EDUCATION AND PREVENTION: A "WOMEN MATTER" EVENT AT KISH HOSPITAL PROVIDED FREE MAMMOGRAMS TO 26 UNINSURED WOMEN. MARROW REGISTRY DRIVE ADDED 125 PEOPLE TO THE NATIONAL REGISTRY. A COMMUNITY PROGRAM SPONSORED BY THE HOSPITAL, TITLED "THOSE WHO LAUGH, WILL LAST," FEATURED A NATIONALLY-RECOGNIZED SPEAKER ON THE IMPORTANCE OF LAUGHTER AND EXERCISE WHEN COPING WITH SERIOUS ILLNESS. WORKED WITH THE KISHWAUKEE FAMILY YMCA TO ESTABLISH THE LIVESTRONG FITNESS PROGRAM FOR CANCER PATIENTS. CO-SPONSORED 5K RUN IN PLANO/SANDWICH, OUR SOUTHERN MARKET, TO RAISE MONEY FOR A CANCER PATIENT RETREAT. STARTED THE FREE PROGRAM CLIMB-CHILDREN'S LIVES INCLUDE MOMENTS OF BRAVERY FOR AGES 6-12 WHO HAVE BEEN TOUCHED BY A LOVED ONES CANCER. CONTINUED THE FOLLOWING PROGRAMS AND SUPPORTS GROUPS: LOOK GOOD...FEEL BETTER, CARING THE CAREGIVER, CREATIVE CONNECTIONS, GREEN THUMB HEALING, WOMEN WITH CANCER SUPPORT GROUP, MEN WITH CANCER SUPPORT. HELD QUARTERLY EDUCATIONAL AND SOCIAL ACTIVITIES AT THE KISH CANCER CENTER FOR PATIENTS AND THE PUBLIC. PROVIDED SPACE TO AMERICAN CANCER SOCIETY FOR A RESOURCE LIBRARY AT THE CANCER CENTER, OPEN TO THE PUBLIC. PROVIDED FINANCIAL SUPPORT OF AMERICAN CANCER SOCIETY RELAYS FOR LIFE FOR DEKALB COUNTY, NORTHERN ILLINOIS UNIVERSITY AND LOWER FOX VALLEY (KENDALL COUNTY). PROVIDED FREE SKIN CANCER SCREENING AT KISH HOSPITAL WOMEN'S HEALTH EVENT. PROVIDED BREAST CANCER AWARENESS BOOTH AT SYCAMORE'S LADIES NIGHT OUT.AFFORDABLE ACCESS TO CHILDBIRTH EDUCATION AND OB HOSPITAL SERVICES: A BREASTFEEDING CENTER WAS OPENED AT KISHWAUKEE COMMUNITY HOSPITAL PROVIDING FREE LACTATION COUNSELING, SUPPORT GROUPS, IN PERSON, ONLINE AND OVER THE PHONE. 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, EMPLOYEES OF THE HEALTH SYSTEM AND BOTH HOSPITALS 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. HOW KISHWAUKEE COMMUNITY HOSPITAL SERVES THE HEALTH OF OUR COMMUNITES IS WELL DOCUMENTED IN THIS SECTION. OF NOTE ARE A $50,000 GRANT TO BEN GORDON CENTER FOR MENTAL HEALTH SERVICES FOR THE UNINSURED; $25,000 GRANT FOR A CONSTRUCTION PROJECT FOR THE HOPE HAVEN HOMELESS SHELTER; $25,000 TO HELP THE Y PROVIDE FITNESS AND HEALTH ACTIVITIES FOR 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 PROVIDE HEALTH RELATED EDUCATION. REPORTS FILED WITH STATES PART VI, LINE 7 IL 1 AMERICAN CANCER SOCIETY 143 FIRST STREET BATAVIA IL 60510 131788491 501(C)(3) 16000 TO PROVIDE FINANCIAL ASSISTANCE FOR ACTIVITIES RELATED TO CANCER RESEARCH AND EDUCATION AMERICAN HEART ASSOCIATION PO BOX 4002902 DES MOINES IA 50340 135613797 501(C)(3) 19000 TO PROVIDE FINANCIAL ASSISTANCE FOR ACTIVITIES RELATED TO HEART HEALTH RESEARCH AND EDUCATION BEN GORDON CENTER 12 HEALTH SERVICES DRIVE DEKALB IL 60115 362771343 501(C)(3) 50000 TO PROVIDE FINANCIAL ASSISTANCE FOR MENTAL HEALTH SERVICES FOR UNDER OR UNINSURED KISHHEALTH FOUNDATION ONE KISH HOSPITAL DRIVE DEKALB IL 60115 363649077 501(C)(3) 9210 FMV SUPPLIES TO PROVIDE FINANCIAL SUPPORT OF HEALTH FOUNDATION ACTIVITIES COMMUNITY FOUNDATION FOR THE LAND OF LINCOLN 205 SOUTH FIFTH STREET SUITE 930 SPRINGFIELD IL 62701 204191391 501(C)(3) 5000 TO PROVIDE FINANCIAL SUPPORT FOR PARTNERS IN NURSING INITIATIVE DEKALB CHAMBER OF COMMERCE 164 E LINCOLN HWY DEKALB IL 60115 360981630 501(C)(6) 8275 TO PROVIDE FINANCIAL SUPPORT FOR COMMUNITY ECONOMIC VITALITY AND DEVELOPMENT AS WELL AS LEADERSHIP ACADEMY FOR ADULTS AND HIGH SCHOOL STUDENTS DEKALB COUNTY EDC 421 NORTH CROSS STREET SYCAMORE IL 60178 363524353 501(C)(6) 11500 TO PROVIDE FINANCIAL ASSISTANCE FOR SUPPOR OF LOCAL ECONOMIC DEVELOPMENT DEKALB COUNTY AMERICAN RED CROSS 2727 SYCAMORE ROAD SUITE 2A DEKALB IL 60115 530196605 501(C)(3) 5718 TO PROVIDE FINANCIAL ASSISTANCE FOR LOCAL DISASTER RELIEF DEKALB COUNTY YOUR SERVICES BUREAU 330 GROVE STREET DEKALB IL 60115 363034427 501(C)(3) 5000 TO PROVIDE FINANCIAL ASSISTANCE FOR ACTIVITIES RELATED TO YOUTH SERVICES DEKALB CORN FEST 1586 BARBER GREENE RD DEKALB IL 60115 364028426 501(C)(3) 7700 TO PROVIDE FINANCIAL ASSISTANCE FOR CORN FEST RACE FAMILY SERVICE AGENCY 14 HEALTH SERVICES DRIVE DEKALB IL 60115 362360012 501(C)(3) 25000 TO PROVIDE FINANCIAL ASSISTANCE FOR ACTIVITIES RELATED TO CASA AND BIG BROTHERS/BIG SISTERS PROGRAMS GENOA CHAMBER OF COMMERCE 327 W MAIN STREET GENOA IL 60135 362355846 501(C)(6) 5950 TO PROVIDE FINANCIAL ASSISTANCE FOR ACTIVITIES RELATED TO PROMOTION OF GENOA AREA ECONOMIC VITALITY HOPE HAVEN 1145 RUSHMOORE DRIVE DEKALB IL 60115 363537762 501(C)(3) 25000 TO PROVIDE FINANCIAL ASSISTANCE FOR LOCAL HOMELESS SHELTER ILLINOIS POISON CONTROL CENTER 222 SOUTH RIVERSIDE PLAZA SUITE 1900 CHICAGO IL 60606 362167008 501(C)(3) 7480 TO PROVIDE FINANCIAL ASSISTANCE FOR POISON CONTROL HOTLINE KISHWAUKEE COLLEGE FOUNDATION 21193 MALTA ROAD MALTA IL 60150 237433949 501(C)(3) 17500 TO PROVIDE FINANCIAL ASSISTANCE FOR PROMOTION OF HEALTHCARE EDUCATION KISHWAUKEE FAMILY YMCA 2500 BETHANY ROAD SYCAMORE IL 60178 362379643 501(C)(3) 21500 TO PROVIDE FINANCIAL ASSISTANCE RELATED TO HEALTH AND FITNESS ACTIVITES FOR LOW INCOME CHILDREN AND FAMILIES KISHWAUKEE UNITED WAY PO BOX 311 115 N FIRST STREET DEKALB IL 60115 366158489 501(C)(3) 14321 TO PROVIDE FINANCIAL ASSISTANCE IN SUPPORT OF COMMUNITY SOCIAL SERVICES MARCH OF DIMES 5411 E STATE STREET STE 8 ROCKFORD IL 61108 131846366 501(C)(3) 9677 TO PROVIDE FINANCIAL ASSISTANCE IN SUPPORT OF PRE-NATAL EDUCATION AND RESEARCH NORTHERN PUBLIC RADIO 801 N FIRST STREET DEKALB IL 60115 366086819 501(C)(3) 13795 TO PROVIDE FINANCIAL ASSISTANCE TO UNDERWRITE LOCAL PUBLIC RADIO SYCAMORE CHAMBER OF COMMERCE 407 W STATE STREET STE 10 SYCAMORE IL 60178 361848940 501(C)(6) 6725 TO PROVIDE FINANCIAL ASSISTANCE TO PROMOTE SYCAMORE ECONOMIC VITALITY AND DEVELOPMENT VOLUNTARY ACTION CENTER 1606 BETHANY ROAD SYCAMORE IL 60178 362798257 501(C)(3) 5000 TO PROVIDE FINANCIAL ASSISTANCE IN SUPPORT OF MEALS ON WHEELS AND TRANSPORTATION SERVICES FOR LOW INCOME AND ELDERLY 17 21 KISHWAUKEE COMMUNITY HOSPITAL AUXILIARY SCHOLARSHIP PROGRAM 13 23000 KISHWAUKEE COMMUNITY HOSPITAL BNA SCHOLARSHIP PROGRAM 2 2384 PROCEDURE FOR MONITORING GRANTS IN THE U.S.: PART I, LINE 2: SCHEDULE I, PART I, LINE 2: THE ORGANIZATION MAINTAINS SPECIFIC POLICIES AND QUALIFICATIONS FOR ALL GRANTS AVAILABLE. APPLICANTS MUST APPLY FOR THE RESPECTIVE GRANT AND BE APPROVED BY THE FUNDS GOVERNING BOARD. THE USE OF THE FUNDS IS MONITORED BY THE GOVERNING BOARD OF KISHWAUKEE COMMUNITY HOSPITAL. REQUESTS FOR FINANCIAL ASSISTANCE FROM OTHER CHARITABLE ORGANIZATIONS ARE REVIEWED AND APPROVED BY THE VP - FINANCE OF KISHHEALTH SYSTEM. IF NECESSARY DUE TO THE DOLLAR AMOUNT OF THE REQUEST, THESE ITEMS MAY ALSO BE PRESENTED TO THE BOARD OF DIRECTORS. A BUDGET IS SET ANNUALLY FOR CHARITABLE ASSISTANCE TO OTHER ORGANIZATIONS 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 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 MICHAEL MUZZILLO 0 145011 0 34338 0 0 0 12707 0 14872 0 206928 0 0 THOMAS W TILTON DO 355841 0 108992 0 0 0 19288 0 22817 0 506938 0 0 0 THOMAS WARZECHA 137854 0 7951 0 0 0 9769 0 22103 0 177677 0 0 0 KENYA M WILLIAMS MD 221233 0 12351 0 0 0 19288 0 1587 0 254459 0 0 0 JASMEET DHALIWAL 268795 0 305374 0 0 0 0 0 22746 0 596915 0 0 0 KENNETH O'BRIEN 133538 0 0 0 0 0 8102 0 21928 0 163568 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. CITY OF SYCAMORE DEKALB COUNTY ILLINOIS HEALTH FACILITIES REVENUE BOND 861091967 452032AJ4 2008-08-01 63685000 CONSTRUCTION OF NEW FACILITY FOR KISHWAUKEE COMMUNITY HOSPITAL 1 1 0 63371994 328434 2007 0 1 1 1 0 0 0 0 0 0 0 0 0 0 0 KISHHEALTH SYSTEM COMMON DIRECTORS/OFFICERS/KEY EMPLOYEES, KHS IS PARENT ORGANIZATION OF KCH 12642156 KISHHEALTH SYSTEM (KHS) IS THE PARENT ORGANIZATION OF KISHWAUKEE 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 KISHHEALTH SYSTEM COMMON DIRECTORS/OFFICERS/KEY EMPLOYEES, KHS IS PARENT ORGANIZATION OF KCH 4440000 DURING THE CURRENT YEAR, KISHWAUKEE COMMUNITY HOSPITAL ALSO MADE A NET EQUITY DISTRIBUTION BACK TO ITS PARENT ORGANIZATION. 0 DEKALB COUNTY HOSPICE COMMON DIRECTORS/OFFICERS/KEY EMPLOYEES, BROTHER/SISTER AFFILIATE 117323 DEKALB COUNTY HOSPICE (DCH) IS AN AFFILIATE OF KISHWAUKEE COMMUNITY HOSPITAL (SAME PARENT CORPORATION). KCH IS UTILIZED BY DEKALB COUNTY HOSPICE FOR MEDICAL TREATMENTS AND SUPPLIES. 0 DEKALB COUNTY HOSPICE COMMON DIRECTORS/OFFICERS/KEY EMPLOYEES, BROTHER/SISTER AFFILIATE 53976 KISHWAUKEE COMMUNITY HOSPITAL (KCH) IS AN AFFILIATE OF DEKALB COUNTY HOSPICE (SAME PARENT CORPORATION). DEKALB COUNTY HOSPICE RENTS SPACE IN THE BUILDING OWNED BY KCH. 0 KISHHEALTH FOUNDATION COMMON DIRECTORS/OFFICERS/KEY EMPLOYEES, BROTHER/SISTER AFFILIATE 191062 KISHWHEALTH FOUNDATION UTILIZES EMPLOYEES OF KISHWAUKEE COMMUNITY HOSPITAL. EMPLOYEES ARE LEASED FROM KISHWAUKEE COMMUNITY HOSPTIAL. 0 HEALTH PROGRESS INC COMMON DIRECTORS/OFFICERS/KEY EMPLOYEES, BROTHER/SISTER AFFILIATE 9493 KISHWAUKEE COMMUNITY HOSPITAL PROVIDES FOR HOUSEKEEPING SERVICES UTILIZED BY HEALTH PROGRESS, INC. 0 VALLEY WEST COMMUNITY HOSPITAL COMMON DIRECTORS/OFFICERS/KEY EMPLOYEES, BROTHER/SISTER AFFILIATE 5031688 KISHWAUKEE COMMUNITY HOSPITAL ROUTINELY SELLS SUPPLIES AND SERVICES TO VALLEY WEST COMMUNITY HOSPITAL AS PART OF ITS DAY-TO-DAY BUSINESS. 0 COMMUNITY CARES CLINIC INC COMMON DIRECTORS/OFFICERS/KEY EMPLOYEES, BROTHER/SISTER AFFILIATE 347910 KISHWAUKEE COMMUNITY HOSPITAL PROVIDES MEDICAL SERVICES AND STAFF TO THE CLINIC. FEES PAID TO KCH ARE IN EXCHANGE FOR THESE SERVICES. 0 HEALTH PROGRESS INC COMMON DIRECTORS/OFFICERS/KEY EMPLOYEES, BROTHER/SISTER AFFILIATE 1011 KISHHEALTH SYSTEM (KHS) IS THE PARENT ORGANIZATION OF HEALTH PROGRESS, INC. KHS LEASES LAND TO HEALTH PROGRESS, INC. THIS LAND IS THEN SUBLEASED TO A RELATED ENTITY WHICH PROVIDES CANCER TREATMENT SERVICES. 0 FORM 990, PART VI, SECTION A, LINE 2 KEVIN POORTEN AND LOREN FOELSKE ARE BOTH EMPLOYEES OF KISHHEALTH SYSTEM, THE PARENT ORGANIZATION OF KISHWAUKEE COMMUNITY HOSPITAL. MR. POORTEN IS PRESIDENT AND CEO OF KISHWHEALTH SYSTEM AND SERVES AS AN EX-OFFICIO DIRECTOR FOR ALL ORGANIZATIONS RELATED TO KISHHEALTH SYSTEM. MR. FOELSKE SERVES AS THE VICE-PRESIDENT - FINANCE OF KISHHEALTH SYSTEM, WHICH IS THE PARENT ORGANIZATION FOR ALL RELATED ENTITIES. MICHAEL MOONEY AND MICHAEL CULLEN ARE MEMBERS OF THE KISHWAUKEE COMMUNITY HOSPITAL BOARD OF DIRECTORS. THEY ALSO SERVE ON THE BOARD OF DIRECTORS OF KISHHEALTH SYSTEM, THE PARENT ORGANIZATION OF KISHWAUKEE COMMUNITY HOSPITAL. THE FOLLOWING INDIVIDUALS ARE OFFICERS OR KEY EMPLOYEES OF KISHHEALTH SYSTEM AND ARE ALSO CONSIDERED OFFICERS OR KEY EMPLOYEES OF KISHWAUKEE COMMUNITY HOSPITAL. THEY ARE ALL COMPENSATED BY KISHHEALTH SYSTEM: BRAD COPPLE, PRESIDENT KCH & VWCH PAM DUFFY, VP PATIENT CARE JOE DANT, VP DEVELOPMENT MIKE KOKOTT, ASST. VP MARKETING HEATH BELL, VP AND CHIEF INFORMATION OFFICER MARK THATE, VP HUMAN RESOURCES DR. MICHAEL KULISZ, CHIEF MEDICAL OFFICER FORM 990, PART VI, SECTION A, LINE 6 KISHHEALTH SYSTEM IS THE SOLE MEMBER OF KISHWAUKEE COMMUNITY HOSPITAL. FORM 990, PART VI, SECTION A, LINE 7A AS THE SOLE MEMBER AND PARENT ORGANIZATION OF KISHWAUKEE COMMUNITY HOSPITAL, KISHHEALTH SYSTEM HAS THE RIGHT TO APPROVE THE ELECTION OF MEMBERS OF THE HOSPITAL'S GOVERNING BOARD, PER THE HOSPITAL'S BYLAWS. FORM 990, PART VI, SECTION A, LINE 7B KISHHEALTH SYSTEM (KHS) SERVES AS THE SOLE MEMBER AND PARENT ORGANIZATION OF VALLEY WEST COMMUNITY HOSPITAL (VWCH). PER THE BYLAWS, WITH RESPECT TO THE GOVERNANCE OF VWCH, THE FOLLOWING POWERS SHALL BE RESERVED TO THE SOLE CORPORATE MEMBER. PER THE BYLAWS, WITH RESPECT TO THE GOVERNANCE OF KCH, THE FOLLOWING POWERS SHALL BE RESERVED TO THE SOLE CORPORATE MEMBER: A. ELECTING THE MEMBERS OF THE KCH BOARD; B. APPROVING, EVALUATING AND/OR REMOVING THE PRESIDENT AND CEO AND REVIEWING AND APPROVING THE EMPLOYMENT CONTRACT OF THE PRESIDENT AND CEO AND ESTABLISHING COMPENSATION FOR SUCH OFFICE; C. APPROVING THE STRATEGIC PLAN FOR KCH; D. APPROVING THE DISPOSITION OF ANY ASSETS OTHER THAN IN THE ORDINARY COURSE OF BUSINESS FOR KCH; E. APPROVING ANY CHANGE IN MEMBERSHIP OF KCH; F. APPROVING THE ADOPTION OF AND AMENDMENTS TO THE ORGANIZATIONAL DOCUMENTS, INCLUDING THE ARTICLES OF INCORPORATION AND BYLAWS OF KCH; G. APPROVING A PLAN OF MERGER OR A PLAN OF CONSOLIDATION OF KCH OR ESTABLISHING A NEW SUBSIDIARY OR SISTER ENTITY; H. APPROVING A PLAN FOR THE DISTRIBUTION OF THE ASSETS OF KCH; I. INITIATING, TAKING ANY AND ALL ACTIONS, AND EXERCISING ALL APPROVAL RIGHTS OF THE DIRECTORS PURSUANT TO THE APPLICABLE MEDICAL STAFF BYLAWS; J. IMPLEMENTING AND MONITORING KCH OPERATIONAL QUALITY IMPROVEMENT POLICIES AND PROGRAMS; K. ACCEPTING GIFTS, GRANTS, BEQUESTS AND DONATIONS ON BEHALF OF KCH; L. APPROVAL OF THE ANNUAL OPERATING AND CAPITAL BUDGETS FOR KCH; M. EXERCISING ANY RIGHTS THAT KCH HAS AS A SHAREHOLDER OR MEMBER OF ANY SUBSIDIARY ENTITY; N. APPROVING ANY AFFILIATIONS OF KCH; O. APPROVING AND/OR DETERMINING (I) THE CREATION OF NEW HEALTH SERVICES TO BE PROVIDED AND THE LOCATION OF SUCH HEALTH SERVICES AND (II) THE DISCONTINUANCE OF ANY HEALTH SERVICE; P. AUTHORIZING THE SALE, LEASE, EXCHANGE OR MORTGAGE OF ALL OR SUBSTANTIALLY ALL OF THE PROPERTY OR ASSETS OF KCH; Q. AUTHORIZING THE VOLUNTARY DISSOLUTION OF KCH, OR REVOKING THE PROCEEDINGS THEREOF; R. REQUIRING MINUTES OF MEETINGS, FINANCIAL RECORDS, AND SUCH OTHER INFORMATION AS MAY BE NECESSARY TO PROPERLY EVALUATE THE PERFORMANCE OF KCH; S. INITIATING ACTION TO REMOVE OR REINSTATE A DIRECTOR WHEN, IN THE OPINION OF THE KHS BOARD, IT IS IN THE BEST INTERESTS OF KHS OR KCH. ANY ACTION TO REMOVE OR REINSTATE SHALL REQUIRE A MAJORITY VOTE OF THOSE KHS DIRECTORS THEN IN OFFICE PRESENT AND VOTING AT A MEETING OF THE KHS BOARD AT WHICH A QUORUM IS PRESENT. IN ANY ACTION(S) TO REMOVE TAKEN BY THE KHS BOARD, THE DIRECTOR IN QUESTION SHALL BE ADVISED AT LEAST TWENTY (20) DAYS PRIOR TO THE MEETING THAT THE ACTION WILL BE CONSIDERED AND SHALL BE GIVEN THE OPPORTUNITY TO MAKE A STATEMENT, PRESENT WITNESSES ON HIS/HER BEHALF AND QUESTION THOSE PRESENTING REASONS FOR HIS/HER REMOVAL. ALL ACTIONS TO REMOVE SHALL BE TAKEN IN CLOSED SESSIONS OF THE KHS BOARD; AND T. TRANSFERRING MONEY OR PROPERTY AMONG KCH, KHS AND/OR ONE OR MORE SUBSIDIARY CORPORATIONS AND TRANSFERRING MONEY OR PROPERTY FROM A SUBSIDIARY CORPORATION, INCLUDING REQUIRING THE DIRECTORS, OFFICERS, OR TRUSTEES OF ANY SUBSIDIARY CORPORATION TO TRANSFER MONEY OR OTHER PROPERTY TO KHS. SUBJECT TO THE POWERS OF THE BOARD OF DIRECTORS OF EACH SUBSIDIARY CORPORATION, THE KHS BOARD MAY INITIATE AND TAKE THE FOREGOING ACTIONS ON BEHALF OF KHS AND THE SUBSIDIARY CORPORATIONS. FORM 990, PART VI, SECTION B, LINE 11 A DRAFT COPY OF FORM 990 IS PROVIDED TO THE GOVERNING BODY (BOARD OF DIRECTORS) AND THE GOVERANCE COMMITTEE FOR REVIEW BY THE RETURN PREPARER PRIOR TO FILING. THE ORGANIZATION'S CEO, CFO, AND OTHER MEMBERS OF THE ACCOUNTING DEPARTMENT ARE ALSO PROVIDED A COPY OF THE RETURN FOR THEIR REVIEW. THE CHAIR OF THE AUDIT COMMITTEE AND THE AUDIT COMMITTEE MEMBERS ARE ALSO PROVIDED DRAFT COPIES AND REVIEW. IF CHANGES ARE NECESSARY, THEY ARE REPORTED TO THE RETURN PREPARER AND INCORPORATED INTO THE FINAL RETURN. FORM 990, PART VI, SECTION B, LINE 12C CONFLICTS OF INTEREST ARE INVESTIGATED BY APPOINTED MEMBERS OF THE GOVERANCE COMMITTEE ON AN ONGOING BASIS. IF IT IS DETERMINED THAT AN INDIVIDUAL FAILED TO DISCLOSE AN ACTUAL OR POSSIBLE CONFLICT OF INTEREST, IT SHALL INFORM THE INDIVIDUAL OF SUCH A BELIEF AND AFFORD HIM AN OPPORTUNITY TO EXPLAIN. AFTER SAID EXPLANATION, THE BOARD SHALL TAKE APPROPRIATE DISCIPLINARY AND CORRECTIVE ACTION AS DEEMED NECESSARY. THE CONFLICT OF INTEREST POLICY IS REVIEWED BY THE BOARD ANNUALLY AND UPDATED AS NEEDED. FORM 990, PART VI, SECTION B, LINE 15 THROUGH THE OVERSIGHT OF THE BOARD OF DIRECTORS EXECUTIVE COMPENSATION COMMITTEE, THE KISHHEALTH SYSTEM EXECUTIVE TOTAL COMPENSATION PROGRAM WILL BE COMPETITIVELY POSITIONED IN THE MARKET PLACE OF RELEVANT ORGANIZATIONS AND FALL WITHIN THE SAFE HARBOR GUIDELINES ESTABLISHED BY THE INTERMEDIATE SANCTIONS RULES. THE EXECUTIVE COMPENSATION COMMITTEE IS MADE UP OF THREE MEMBERS OF THE BOARD OF DIRECTORS WHO MEET THE BOARD APPROVED DEFINITION OF "INDEPENDENT DIRECTORS". ANNUALLY THE EXECUTIVE COMPENSATION COMMITTEE CONTRACTS WITH SULLIVAN, COTTER AND ASSOCIATES, AN INDEPENDENT HUMAN RESOURCES CONSULTING FIRM TO PROVIDE THE COMMITTEE ANALYSIS AND COMPARABILITY DATA. USING THE SUPPLIED DATA THE COMPENSATION COMMITTEE APPROVES EACH EXECUTIVE'S TOTAL CASH COMPENSATION AND PROVIDES CONTEMPORANEOUS SUBSTANTIATION OF THE DELIBERATION AND DECISION. TOTAL CASH COMPENSATION IS DEFINED AS THE SUM OF BASE SALARIES PLUS INCENTIVE AWARDS. BASED ON THE COMPARABILITY DATA AND THE PERFORMANCE OF EACH EXECUTIVE IN MEETING GOALS AND STRATEGIC OBJECTIVES, THE EXECUTIVE COMPENSATION COMMITTEE APPROVES INCREASES AND INCENTIVE AWARDS FOR EACH EXECUTIVE WITHIN THE GUIDELINES ESTABLISHED. THE EXECUTIVE COMPENSATION COMMITTEE REPORTS ON ALL COMPENSATION MATTERS TO THE FULL BOARD OF DIRECTORS. FORM 990, PART VI, SECTION C, LINE 19 THE ORGANIZATION'S GOVERNING DOCUMENTS ARE AVAILABLE TO THE PUBLIC UPON REQUEST IN WRITING TO ADMINISTRATION. DESCRIPTION OF HOURS FOR RELATED ORGANIZATIONS FORM 990, PART VII, COLUMN (B) AVERAGE HOURS PER WEEK FOR THE INDIVIDUALS IDENTIFIED AS OFFICER'S ARE ESTIMATES OF THE INDIVIDUALS TOTAL TIME PER WEEK UTILIZED FOR WORK RELATED TO KISHWAUKEE COMMUNITY HOSPITAL. CHANGES IN NET ASSETS OR FUND BALANCES: FORM 990, PART XI, LINE 5: NET UNREALIZED LOSSES ON INVESTMENTS: -1,139,781. EQUITY DISTRIBUTION TO KISHHEALTH SYSTEM -4,440,000. CHANGE OF INTEREST IN NET ASSETS OF KISHHEALTH FOUNDATION -65,942. BOOK/TAX DIFFERENCES IN K-1 PASSTHROUGH ENTITIES 333,417. GRANT REVENUE INCLUDED IN FIXED ASSETS FOR FINANCIAL STATEMENT PURPOSES -30,850. OTHER EQUITY ADJUSTMENT 70,726. TOTAL TO FORM 990, PART XI, LINE 5: -5,272,430. RESPONSIBILITY FOR OVERSIGHT OF FINANCIAL STATEMENTS FORM 990, PART XI, LINE 2C NO CHANGES IN THIS PROCESS WERE MADE DURING THE TAX YEAR. THE ORGANIZATION MAINTAINS AN INDEPENDENT AUDIT COMMITTEE WHICH IS RESPONSIBLE FOR OVERSIGHT OF THE AUDITED FINANCIAL STATEMENTS. THIS COMMITTEE IS ALSO RESPONSIBLE FOR THE SELECTION OF THE INDEPENDENT AUDITOR. MEMBERS OF THE AUDIT COMMITTEE ARE ALSO MEMBERS OF THE KISHHEALTH SYSTEM BOARD OF DIRECTORS. KISHHEALTH SYSTEM ONE KISH HOSPITAL DRIVE DEKALB IL 60115 363649080 PARENT ORGANIZATION OF 501(C)(3) HEALTH SYSTEM IL 501(C)(3) 11B N/A 0 VALLEY WEST COMMUNITY HOSPITAL ONE KISH HOSPITAL DRIVE DEKALB IL 60115 364244337 HEALTHCARE SERVICES, PRIMARILY ACUTE CARE IL 501(C)(3) 3 N/A 0 DEKALB COUNTY HOSPICE 2727 SYCAMORE ROAD 1B DEKALB IL 60115 363164329 HEALTHCARE SERVICES, HOSPICE SERVICES IL 501(C)(3) 7 N/A 0 KISHHEALTH FOUNDATION ONE KISH HOSPITAL DRIVE DEKALB IL 60115 363649077 SUPPORT OF KISHWAUKEE HEALTH SYSTEM NOT FOR PROFIT ENTITIES IL 501(C)(3) 7 N/A 0 COMMUNITY CARES CLINIC 3100 SYCAMORE ROAD DEKALB IL 60115 800424001 HEALTHCARE SERVICES, PRIMARY CARE IL 501(C)(3) 3 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 KISHWAUKEE AREA PHO ONE KISH HOSPITAL DRIVE DEKALB IL 60115 364205273 MEDICARE SERVICES IL RELATED -27776 3022 0 0 0.50000 THE MIDLAND SURGICAL CENTER LLC 3085 WOLF COURT DEKALB IL 60115 352194610 SURGICAL SERVICES IL RELATED 527237 655734 0 0 0.77500 HEALTH PROGRESS INC ONE KISH HOSPITAL DRIVE DEKALB IL 60115 363824138 INVESTMENT IN HEALTHCARE RELATED SMALL BUSINESS IL N/A C 0 1 1 0 0 0 0 0 1 0 0 0 0 1 1 1 1 1