2011-07-15T16:25:36-05:00 2010-09-30 RSM McGladrey Inc 201 N Harrison Street Suite 300 Davenport IA 528011999 990 2009-10-01 362167767 KEWANEE HOSPITAL KEWA 3098527500 1051 WEST SOUTH STREET KEWANEE IL 61443 MARGARET GUSTAFSON 3098527500 2011-07-15 1 John J Romano 5638884000 2009 2016-02-24 21:20:13Z MARGARET GUSTAFSON 1051 WEST SOUTH STREET KEWANEE IL 61443 37995789 0 X WWW.KEWANEEHOSPITAL.COM X 1902 IL Operates a 25 bed critical access hospital plus related health care services. 11 9 357 90 643 0 99271 129521 32619839 29661283 -18887 745997 417264 140120 33117487 30676921 17935 14571 0 14935695 13520381 0 0 19099888 17906601 34053518 31441553 -936031 -764632 61705161 61234580 34503568 34353976 27201593 26880604 To improve the health and care of those we serve focusing on quality of care regardless of ability to pay. 0 1 18833750 14571 28468185 Kewanee Hospital is a 501(c)(3) not-for-profit corporation licensed as a 25-bed Critical Access Hospital (CAH) located in a rural community in Illinois. Kewanee Hospital strives to provide quality health care to all patients regardless of race, creed, sex, national origin, handicap, age, or ability to pay. Many of the community members would have no access to health care without Kewanee Hospital. The patients and their families ability to travel 50+ miles to a larger tertiary center is compromised by a lack of mobility, a lack of income, and a lack of transportation. Many of the services provided by Kewanee Hospital are reimbursed at or below the cost to provide care. Kewanee Hospital offers a wide variety of services including inpatient acute and critical care, skilled level care through swing beds, diagnostic capabilities including radiology, laboratory and cardiopulmonary, inpatient and outpatient rehabilitation and treatment, inpatient and outpatient surgical services, and primary care services through the Family Health Clinic (FHC). During FY 2010 Kewanee Hospital provided 3,440 days of inpatient care, 273 days of swing bed care, and 243 nursery days in 2010. Kewanee Hospital provided a wide scope of outpatient services which provided care to 35,521 outpatients. The emergency department (ED) is a safety net to the rural community of Kewanee and the surrounding area. The ED is staffed 24/7 by dedicated emergency department physicians; during FY 2010 the ED treated 9,373 patients, with over 50% of them paying less than the cost of the care received. The Hospital offers a variety of surgical services including general, orthopedic, urology, ophthalmologic, endoscopy and gastroenterology. In FY 2010 the Hospital provided a total of 1,026 surgical procedures. 2577198 1272823 Kewanee Hospital staffs a multi-disciplinary outpatient Family Health Clinic (FHC) with a compliment of both physician and mid-level providers employed by the Hospital. The FHC provides an array of services including primary care (adults and pediatrics) and surgical services. The FHC is a licensed Rural Health Clinic and provides many needed services to the community. The FHC is one of the only clinics in the area to accept the treatment and care of children with Attention Deficit Disorder. The providers in the FHC have participated in several outreach efforts including diabetic health, smoking cessation, medication management, and health and nutrition. In FY 2010 the FHC providers brought their services to the area high school to provide free sports physicals. Because of the high poverty level in the Kewanee district, many students have difficulty traveling to provider offices for their physicals and most cannot pay the cost. Kewanee Hospital made the decision to outreach to these students in order to ensure they can take part in sport activities and receive their needed physical exam. The FHC practices the medical home model through the Illinois Health Connect program. The nurse practitioners provide after-hours call in order to ensure patients have the ability to access a provider after-hours and on weekends when needed. The FHC Practitioners continually collaborate with the area schools and providers of other health services in order to provide the best care possible to the area community. 21410948 1 1 0 1 0 0 0 0 1 1 1 0 0 0 0 0 0 0 1 0 1 1 0 1 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 19 0 1 357 1 0 0 0 0 0 0 0 0 0 11 9 0 0 0 0 0 0 0 1 0 0 0 1 1 1 1 1 1 1 1 0 IL X PRESTON BECKER 3098527522 1051 W SOUTH STREET KEWANEE IL 61443 MICHAEL AHEARN MD 2.00 X 0 0 0 DAVID BOSWELL 2.00 X 0 0 0 DANIEL CONGREVE MD 40.00 X 198567 0 10655 MARGARET M GUSTAFSON 40.00 X X 211547 0 48595 RITA HUNGATE MD 2.00 X 0 0 0 HOLLY MAES MD 40.00 X 132982 0 36730 RUSSELL MEDLEY 2.00 X 0 0 0 MARY KAY NORTH 2.00 X X 0 0 0 WILLIAM OWENS 2.00 X 0 0 0 GARY PHEIFFER 2.00 X X 0 0 0 MARK REWERTS 2.00 X X 0 0 0 FRANK TOCHA 2.00 X 0 0 0 JENNIFER M COOMBES 40.00 X 105449 0 34108 LYNN A FULTON 40.00 X 115472 0 50324 JENNIFER JUNIS 40.00 X 99376 0 13070 CATHY HERRMANN CRNA 40.00 X 103425 0 11266 ELDON M SAMUEL MD 40.00 X 257737 0 40585 ELOISE SKELTON MD 40.00 X 308485 0 31823 JEREMY SMITH MD 40.00 X 107014 0 31873 ANGELA WALKER MD 40.00 X 298872 0 21674 1938926 0 330703 11 0 1 0 EPSS 12528 SR 78 HAVANA IL 62644 ED PHYSICIANS STAFFING 1340904 SYCAMORE ANESTHESIA SERVICES 942 WEST STATE STREET 500 SYCAMORE IL 60178 ANESTHESIA SERVICES 620971 CPS INC 6409 QUAIL HOLLOW ROAD MEMPHIS TN 38120 PHARMACY MANAGEMENT SERVICES 297424 SAINT FRANCIS INC 8001 N UNIVERSITY SUITE C PEORIA IL 61615 MRI SERVICES 288090 METHODIST REFERENCE LABORATORY 221 NE GLEN OAK PEORIA IL 61636 LAB TESTING 242429 13 30221 62118 37182 6225 129521 PATIENT SERVICE REVENU 900099 29562262 29562262 CAFETERIA MEALS 900099 87484 87484 MASSAGE THERAPY 900099 11075 11075 MEDICAL RECORDS 900099 462 462 29661283 575947 575947 63618 1011 62607 62607 62607 7333423 102164 7194828 70709 138595 31455 170050 170050 6542 30221 10753 -4211 -4211 42923 41567 1356 1356 MISC OPERATING REVENUE 900099 46967 46967 MEDICAL STAFF 900099 18375 18375 AUXILIARY REVENUE 900099 6571 6571 8455 7812 643 80368 30676921 29741008 643 805749 11471 11471 3100 3100 1056875 1056875 9887708 8122133 1765575 395781 293715 102066 1257022 932854 324168 922995 684968 238027 121371 121371 83458 83458 18078 18078 121917 121917 390978 215633 175345 438943 28199 410744 142000 64074 77926 35496 14208 21288 1602987 622921 980066 2749239 1068124 1681115 522041 279827 242214 PURCHASED SERVICES 2991203 1974254 1016949 BAD DEBT EXPENSE 2682569 2682569 MEDICAL PROFESSIONAL FE 2029870 2029870 MEDICAL SUPPLIES 1572406 1549164 23242 MISCELLANEOUS 1361906 179233 1182673 1042139 654631 387508 31441553 21410948 10030605 0 9193615 7814578 6488882 4741569 250381 113325 4346347 3132629 294442 291706 275287 263168 43611608 12035310 33552282 31576298 4592508 4089022 929196 7662142 1782218 1550143 61705161 61234580 3773568 2963701 851973 30730000 29935000 0 603302 34503568 34353976 X 26281089 26154137 249745 52958 670759 673509 27201593 26880604 61705161 61234580 X 0 1 1 X 0 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 0 0 0 1 10 0 0 1 500 0 1 17568 18078 0 Part II-B, Line 1i: Explanation of Other Lobbying Activities: The lobbying efforts by Kewanee Hospital for FY 2010 consisted of several letters and E-mails to area legislators regarding pending legislation. Annually, a portion of the American Hospital Association (AHA) and Illinois Hospital Association (IHA) dues are allocated to lobbying efforts both organizations exert on behalf of hospitals at the national and state level. According to the AHA and IHA, 25% and 31% respectively, of our annual dues went towards lobbying; this represents $17,568 for the year. Part IV, Supplemental Information: PART II-B, LINE 1(G), DIRECT CONTACT WITH LEGISLATORS, THEIR STAFFS, GOVERNMENTAL OFFICIALS, OR A LEGISLATIVE BODY: Margaret Gustafson, CEO; Jennifer Coombes, CFO; Jenny Pierce-Smith, Marketing and Gary Pheiffer, Board Chair attended the IHA's lobbying days in Springfield, IL in FY 2010. 5191411 2790 1420588 179243 6435546 5597772 20 -406381 5191411 0.89370 0.10470 0.00160 0 0 1248863 1248863 20513891 2747626 17766265 25127 25127 0 21820164 9262557 12557607 3563 3563 31576298 OTHER INVESTMENTS 7662142 F 7662142 OTHER LIABILITIES 603302 603302 30676921 31441553 -764632 443643 443643 -320989 31142440 443643 443643 30698797 -21876 -21876 30676921 31463429 21876 21876 31441553 0 31441553 Part V, Line 4: Description of Intended Use of Endowment Funds: THE INTENDED USe OF THE ORGANIZATION'S ENDOWMENT FUNDS IS TO PROVIDE FUNDING FOR HOSPITAL RELATED PROGRAMS AND SCHOLARSHIPS. BOARD DESIGNATED ENDOWMENT FUNDS ARE TO BE USED AT THE BOARD'S DISCRETION TO FURTHER THE EXEMPT PURPOSE OF THE ORGANIZATION. Part X: Description of Uncertain Tax Positions Under FIN 48: The Hospital is an Illinois not-for-profit corporation exempt from federal income taxes under Section 501(c)(3) of the Internal Revenue Code. Kewanee Hospital files a Form 990 (Return of Hospital Exempt from Income Tax) annually. When these returns are filed, it is highly certain that some positions taken would be sustained upon examination by the taxing authorities, while others are subject to uncertainty about the merits of the tax position taken or the amount of the position that would ultimately be sustained. Examples of tax positions common to hospitals include such matters as the following: the tax exempt status and various positions relative to potential sources of unrelated business income tax (UBIT). UBIT is reported on Form 990T, as appropriate. The benefit of a tax position is recognized in the financial statements in the period during which, based on all available evidence, management believes that it is more likely than not that the position will be sustained upon examination, including the resolution of appeals or litigation processes, if any. Tax positions are not offset or aggregated with other positions. Tax positions that meet the "more likely than not" recognition threshold are measured as the largest amount of tax benefit that is more than 50% likely to be realized on settlement with the applicable taxing authority. The difference between the benefit of a tax position recorded for financial statement purposes in accordance with the guidance and the amount reflected on a tax return is recorded as a liability for uncertain tax benefits in the accompanying balance sheets along with any associated interest and penalties that would be payable to the taxing authorities upon examination. As of September 30, 2010 and 2009, there were no uncertain tax benefits related to uncertain tax positions identified and recorded as a liability. Forms 990 filed by Kewanee Hospital are subject to examination by the Internal Revenue Service (IRS) up to three years from the extended due date of each return. Forms 990 filed by Kewanee Hospital are no longer subject to examination for the years ended September 30, 2006 and prior. Part XII, Line 4b - Other Adjustments: GAIN/LOSS ON SALE OF FIXED ASSETS: 31455. COST OF GOODS SOLD: -41567. SPECIAL EVENTS EXPENSES INCLUDED WITH REVENUE ON RETURN: -10753. RENTAL EXPENSES INCLUDED WITH REVENUE ON RETURN: -1011. Part XIII, Line 2d - Other Adjustments: COST OF GOODS SOLD: 41567. GAIN/LOSS ON SALE OF FIXED ASSETS: -31455. SPECIAL EVENT EXPENSES INCLUDED WITH REVENUE ON RETURN: 10753. RENTAL EXPENSES INCLUDED WITH REVENUE ON RETURN: 1011. LININGER GOLF OUTING 36763 30221 6542 5675 1250 3828 36763 30221 6542 5675 1250 3828 10753 -4211 1 1 1 X 1 X 1 1 1 0 1 1 603564 603564 0.02100 6416613 3477595 2939018 0.10220 7020177 3477595 3542582 0.12320 202106 202106 0.00700 3100 3100 0.00010 57733 57733 0.00200 262939 262939 0.00910 7283116 3477595 3805521 0.13230 1 1269472 166324 12831466 12106641 724825 X 1 1 KEWANEE HOSPITAL

1051 WEST SOUTH STREET PO BOX 747 KEWANEE IL 61443

X X X X HOMECARE, HOSPICE, DME, RURAL HEALTH CLINIC Part I, Line 3c: Part I, Line 6a: Part I, Line 7: Kewanee Hospital utilized Worksheet 2 to calculate its cost-to-charge ratio. This ratio was used to calculate the amounts reported in Part I, Line 7. Part I, Line 7g: Part I, Line 7f: $2,682,569 OF BAD DEBT EXPENSE IS SUBTRACTED FOR PURPOSES OF COMPUTING THE PERCENTAGE IN PART I, LINE 7K, COLUMN F. THE ORGANIZATION'S TOTAL COMMUNITY BENEFIT EXPENSE AS A PERCENTAGE OF TOTAL EXPENSES, LESS BAD DEBT, IS 25.33%, AND THE PERCENTAGE INCREASES TO 67.43% IF MEDICARE ALLOWABLE COSTS ARE INCLUDED IN TOTAL COMMUNTY BENEFIT EXPENSE. Part III, Line 4: Patient accounts receivable, due directly from the patients, are carried at the original charge for the service provided, less amounts covered by third-party payors and less an estimated allowance for doubtful receivables based on a review of all outstanding amounts on a monthly basis. Management determines the allowance for doubtful accounts by identifying troubled accounts, by historical experience applied to an aging of accounts and by considering the patient's financial history, credit history and current economic conditions. The Hospital does not charge interest on patient receivables. Patient receivables are written off as bad debt expense when deemed uncollectible. Recoveries of receivables previously written off are recorded as a reduction of bad debt expense when received. Part III, Line 8: The hospital followed Medicare's prescribed methods of determining costs payable under title XVIII (Medicare) in completing its annual Medicare cost report (cost report) using data available from the institution's basic accounts, as usually maintained, to arrive at equitable and proper payment for services. The cost report was completed using the hospital's trial balance of expenses, as well as other statistical and financial records maintained by the hospital. As required by Medicare regulations, certain reclassifications and adjustments to costs were included in the cost report to determine Medicare allowable costs.After Medicare allowable costs are determined, the cost report provides for the step down method of cost finding. This method provides for allocating the cost of services rendered by each general service cost center to other cost centers, which utilize the services. Once the costs of a general service cost center have been allocated, that cost center is considered closed. Once closed, it does not receive any of the costs subsequently allocated from the remaining general service cost centers. After all costs of the general service cost centers have been allocated to the remaining cost centers, the total costs of these remaining cost centers are further distributed to the departmental classification to which they pertain, e.g., hospital general inpatient routine, subprovider, ancillary, etc.After the step-down process, the cost report provides for the apportionment of costs to the Medicare program based on a number of different methodologies including per patient day, per visit, and percentage of charges, as most prevalent. Medicare costs as determined by the cost report methodologies described previously were utilized to complete the applicable Medicare allowable costs of care for Schedule H (Form 990) Part III Section B Line 6. Part III, Line 9b: It is the policy of Kewanee Hospital to extend a full or partial discount from charges to qualifying patients whose care is not covered by other financial aid or government healthcare programs. Kewanee Hospital utilizes a number of methods for communicating financial assistance, including Charity Care, to patients and the community including:a.Signs stating the availability of financial assistance are posted in the Emergency Department, Registration and Admitting Areas and the Cashiers Office. Brochures with information regarding charity care are also available. b.Notice of the availability of charity care is included on the hospitals web site.c.Patient Financial Services staff is knowledgeable about the policy and process.d.The staffs of the outsourced self pay billing service and bad debt collection agency are also knowledgeable about the policy and process.e.Notice of the availability of financial assistance is included on or with hospital billing statements to guarantors.Kewanee Hospital attempts to identify uninsured patients eligible for charity care prior to or at time of service. Financial Assistance information and applications may be obtained from the Financial Counselors. Completed applications and documentation will be reviewed and processed. Applicants will then receive a written determination of eligibility. Part V: All health care facilities were reported in Part V. Part VI, Line 2: Kewanee Hospital continually strives to meet the health care needs of the community served and performs ongoing assessments in order to best allocate the Hospitals scarce resources. The Hospital evaluates the needs of the Kewanee community through internal evaluation of market data, community demographics, CDC and other health related data, analysis of patients served through the Hospitals Family Health Clinic, review of emergency department visits, and collaborative meetings with the area school districts and the county health department. Kewanee Hospital works with a number of community volunteers through the Hospitals Development Council. The Community Relations Committee is charged with needed education for the community and utilizes the information gained as topics for education. Through the ongoing assessment process the Hospital has identified and provided outreach for diabetic education, suicide prevention educational series for teachers and parents, health and nutrition for at-risk populations, importance of preventative screening, skin-cancer prevention, and a positive parenting series.Through collaboration with Kewanee Hospitals regional partners, including the Henry County Health Department, the Hospital identified Disaster Preparedness as a community need. As a rural community, Kewanee has few city resources. Citizens view the Hospital as the mainstay or community cornerstone and thus would look to Kewanee Hospital in an emergency. The Hospital leadership team, staff and providers have gone through education and training on Incident Command and in June of 2010 led a city-wide disaster exercise. Part VI, Line 3: Kewanee Hospital provided over $600,000 in Charity Care to needy community members in FY 2010. Kewanee Hospital communicates to patients about their financial obligations throughout the health care experience. It is the Hospitals goal to assess financial need as soon as possible in the care process. Patients setting up diagnostic testing through centralized scheduling discuss the payment obligations prior to visiting the Hospital, allowing for patients needing assistance to start the process right then. The Family Health Clinic (FHC) patients benefit from having FHC staff talk with them about obligations related to procedures, diagnostics, etc. and are often able to access financial assistance prior to the procedure. Kewanee Hospital staff is trained to recognize potential need and to proactively discuss payment arrangements. The Hospital promotes financial assistance throughout the organization and through various publications. Information about the Hospitals Charity Care and Financial Assistance programs is posted through: - Signage (admissions/registration at main entrance, emergency department admissions, admission booths). - Kewanee Hospitals website, www.kewaneehospital.com- Direct mail pieces including quarterly newsletters and community benefit report- Henry County Tourism Video/Web-Site Link - Radio program, Monday morning Tuned-In, WKEI- Patient education throughout the care process- Financial Assistance brochures at cashiers window- Patient bill for service. - Identification of need and education through centralized scheduling, admissions staff, FHC staff, cashiers office, financial counselors, providers of services, and other staff as they become aware of the patients need.- Announcements and booths at free community education and outreach conducted by Kewanee Hospital. Part VI, Line 4: Kewanee Hospital is located in a rural area of northern west-central Illinois, about 10 miles south of Interstate 80 and between the larger urban areas of Peoria, Illinois and the Quad Cities (located about 50-55 miles from each). The Hospital serves the primary market area (population approximately 19,700) of Kewanee and the surrounding rural communities including Galva and Toulon. The overall market (population approximately 29,000) includes the three county portions of Henry, Bureau, and Stark in rural Illinois. The largest percentages of Kewanee Hospitals patients are derived from the Kewanee zip code of 61443. The population of Kewanee is aging and poor with the greatest numbers in the over 65 and under 18. In 2000, 12.8% of the population was below the poverty level. The Kewanee School District reported over 85% of children attending school on the free and reduced lunch program. Subsequently that leaves few citizens in the middle where a community typically sees the working class. As a result of the demographics, Kewanee Hospital sees a high proportion of patients reliant on Medicaid and uninsured. Following the national trend, the highest concentration is in the emergency department and the Hospitals Family Health Clinic (FHC). FY 2010 reported 33% of patients in the emergency department were reliant on Medicaid while 14% were uninsured. The Family Health Clinic reported 53% of patients were reliant on Medicaid and 9% were uninsured. The overall hospital reported 21% reliant on Medicaid and 8% uninsured. Part VI, Line 5: Community Services/Community Outreach:Kewanee Hospital provides a great deal of free community services and community outreach. The Hospital recognizes the difficulty in reaching the at-risk population and has made a practice to use a variety of notification mechanisms to make the community aware of outreach and educational opportunities. Depending on the target audience, the Hospital utilizes local media (newspaper and radio), community bulletin boards (grocery store, Churches, senior citizens center, community center at the local housing authority, etc.), web-site, e-mail notifications, postings at the Hospital and in the Family Health Clinic (FHC), and direct mail. The Hospital provides free sports physicals for the area athletes at the school to assist them in meeting the Illinois High School Association requirements. Many of the Kewanee athletes would not be able to make it to the Hospital or area physician offices. Kewanee Hospital Rehabilitation Services provides free athletic training services to the Kewanee sports programs. The athletic trainer works collaboratively with the coaches to ensure a safe environment for the athletes. The Rehabilitation Department has also started a Competitive Edge, sports strengthening program. Understanding that many of the athletes in the Kewanee area do not have the financial means to participate in the program, the Hospital has offered scholarships to assist athletes into the program. The program not only helps the athletes' physical abilities, but also gives some of these kids added confidence. The Hospital has provided a variety of free screening opportunities including cholesterol, blood pressure, blood glucose, etc. so that community members can take an active role in their health without feeling the fiscal constraints. Recently Kewanee Hospital hosted a Ladies' Night Out and offered discounted mammograms, free food, and free mini manicures and massages to promote early detection and prevention. The Hospital has also provided a variety of free educational dinner programs to area citizens on topics such as healthy eating, diabetes, and cancer awareness (colorectal, skin, and breast), as well as a series on positive parenting and suicide prevention, targeting parents of school-age children. The event was coordinated with the Kewanee Schools and invites were distributed through the area schools to the parents. At the beginning of December the Hospital offered a free smoking cessation program along with discounted smoking cessation aids. The program is ongoing and several participants are still smoke-free four months later. Support of Local Service Agencies:Kewanee Hospital supports several area service agencies and other not-for-profits both through volunteer hours and monetary support. Many hospital staff members actively participate in local Kiwanis, Rotary, and Lion's service clubs. The Hospital provides space free of charge to Freedom House, a service agency supporting battered woman and children. Kewanee Hospital has supported the Good Fellows baskets through Hospital sponsored labor hours. In 2010 the Good Fellows delivered over 300 baskets of food to needy area families. The Hospital regularly supports the Salvation Army, Food Pantry, Big Brothers/Big Sisters, American Cancer Society and Relay for Life, Senior Citizens Center and Junior Achievement. Kewanee Hospital has provided free meeting space to area support groups including Alzheimer's, Grief Support, Cancer Survivors, and Multiple Sclerosis. The local Food Pantry is always in need of donations as more and more local families are reliant on their services. The Hospital had a contest with other regional hospitals for their respective food pantry organizations on who could donate the most food and Kewanee Hospital won with over 1,500 pounds of food donated to the Kewanee Food Pantry. The Hospital supports local economic development and is an active participant in the community wide planning effort; committing meeting space, A/V equipment, food, and leadership hours to the effort in order to support positive growth in the community. Disaster Preparedness:A comprehensive disaster preparedness program was started by the Hospital a few years ago with ongoing efforts to work collaboratively with the county health department, local city agencies, and the region to build on that program. The leadership team has been through the Incident Command System (ICS) education and has used the ICS structure for several area emergencies including a chemical spill, H1N1 Pandemic. The team has practiced the structure, participating in drills at the local and regional level. Last June the Hospital participated in a comprehensive city-wide disaster exercise. During the planning of the new hospital, it was identified that a fixed indoor decontamination unit would be beneficial. Kewanee is surrounded by agriculture with the ongoing risk of chemical exposure as well as experiencing an increase in the number of local meth labs. The Hospital has identified and trained a "Decon Team" that has used the unit several times in the three years the new hospital has been open. Kewanee Hospital knows that the community will rely on them in the face of a disaster or local emergency and wants to have plans in place to ensure continued operations to the best of their ability. Environmental Awareness:Kewanee Hospital believes in being a good steward to the community and setting the standard for environmental awareness in their area. In FY 2010 a goal was set to eliminate Styrofoam usage in the Cafe and to replace those products with biodegradable options. Overall paper usage in the Cafe was decreased through a "green" tax on to-go orders. The environmental services department furthered a recycling initiative and saved over 230 trees and 97,000 gallons of water. Overall energy use was decreased by scaling back heating/cooling in non-patient areas after hours. Many light bulbs have been changed to greener options utilizing less energy. The Hospital continues to transition chemicals to greener alternatives as they become available. Bike racks were installed so employees and visitors can bike to the hospital and save fuel. Tiling was installed on the adjoining farm ground to prevent runoff of precious topsoil. The Hospital has challenged other organizations in Kewanee to join them in lowering their carbon footprint. Health and Wellness:As one of the largest employers, Kewanee Hospital believes that in order to better care for patients and the community, the Hospital needs to be a leader in health and wellness. The Hospital has focused on health and wellness for their employees with plans to roll out a program to the community. In FY 2010 the wellness endeavor was started with a "Know Your Numbers" campaign. Employees were offered free screenings for cholesterol, blood glucose, blood pressure, BMI and waist measurement. Employees in warning categories were provided free follow-up visits in the Hospital's Family Health Clinic. Employees retested six months later and showed marked improvement in all areas. A weight loss competition was started patterned off the popular show, "Biggest Loser". There were 84 participants who lost a combined total of 750 pounds and improved their overall health status. The wellness team has rolled out a number of free services to employees to assist them in their wellness endeavor including: personal training sessions, off-hours access to the fitness center, consultations with the FHC providers, ongoing testing, smoking cessation, EAP program, and a program on budgeting and finance. The Hospital has started linking this information to other community education to inform the community of the wellness initiative and to entice community members to take an active role in their own health. Part VI, Line 6: Kewanee Hospital has an open medical staff and welcomes physicians and mid-level providers to practice and provide care in the Kewanee community. The Board of Trustees is made up of community members from the local service area who are committed to their role in keeping quality health care local. The Hospital provides many services that would otherwise be unavailable, particularly to those community members unable to travel for services or unable to pay. The Hospital continually works with area students pursuing medical related careers and partners with the area community college and regional colleges and universities to offer clinical and administrative experiences. This includes pre-med, nursing, lab, radiology, cardiopulmonary, finance, and administration.In order to recruit and retain physicians and mid-level providers to the rural community, Kewanee Hospital must offer competitive employment opportunities. Employing physicians is an expensive undertaking which includes taking the risk of practice development and assuming the expense and risk for liability insurance.Currently the FHC providers struggle to access specialists for their patients when needed. There is a reluctance of out-of-town specialists to accept patients reliant on Medicaid. Illinois' current Medicaid crisis has caused those specialists once willing to take new Medicaid patients to cease because they cannot determine when they will receive payment. The children under the care of the FHC are turned down by ENT's, Psychiatrist, and other needed specialist because of their reliance on Medicaid. Because of the size of the community, the demographics and the current physician shortage, Kewanee Hospital is unable to recruit specialists such as ENT, Psychiatrists, Orthopedics, etc. to the area. The FHC providers therefor have to rely on out-of-town specialists for referral. The FHC has started a Patient Assistance program that reaches out to organizations, programs, foundations, etc. to match patients so they can access specialty care, treatment, or medications that are needed. Kewanee Hospital continues the commitment to their mission of improving the health and care of those they serve within their communities. FY 2011 continues a focus on health education, disease management, prevention, and wellness. Despite growing economic hardships due to continued decrease in the number of commercially insured individuals, the growth in patients reliant on Medicaid, and the increase in uninsured patients, the Hospital will continue to provide community outreach to assist those in need. The Hospital's value to the community well exceeds the nearly $4 million contributed in FY 2010. The Hospital is there 24 hours a day, 7 days a week, for community members in their time of need-whether for a child who is sick throughout the night, a parent experiencing chest pains, a grandmother with the warning signs of a stroke, or the victims of a traumatic car accident. Kewanee Hospital stands ready to take care of those community members in need and continues to work towards their vision of setting the standard for local health care with a team of compassionate professionals who are focused on clinical excellence and customer service. 1 IL HOSPITAL RESEARCH & EDUCATION FOUNDATION 1151 E WARRENVILLE NAPERVILLE IL 60566 237421930 501(c)(3) 11471 TO ADDRESS THE DISPARATE AND NEGATIVE EFFECTS OF THE ILLINOIS MEDICAID PROGRAM 1 0 Procedure for Monitoring Grants in the U.S.: Part I, Line 2: Schedule I, Part I, Line 2: FOR GRANTS GIVEN TO ORGANIZATIONS, SUBSTANTIATION IS REQUIRED PRIOR TO DISBURSEMENT OF ALL FUNDS. FOR SCHOLARSHIPS, ALL INDIVIDUALS MUST SIGN A SUPPORT AGREEMENT VERIFYING THEIR OBLIGATIONS AS AWARD RECIPIENTS AND THE RAMIFICATIONS IF THE AGREEMENT IS NOT MET. X X X X X 0 0 0 0 0 0 0 0 0 DANIEL CONGREVE MD 198567 0 0 0 0 0 0 0 10655 0 209222 0 0 0 MARGARET M GUSTAFSON 211547 0 0 0 0 0 26500 0 22095 0 260142 0 0 0 HOLLY MAES MD 132982 0 0 0 0 0 19575 0 17155 0 169712 0 0 0 LYNN A FULTON 115472 0 0 0 0 0 22893 0 27431 0 165796 0 0 0 ELDON M SAMUEL MD 257737 0 0 0 0 0 19747 0 20838 0 298322 0 0 0 ELOISE SKELTON MD 308485 0 0 0 0 0 16500 0 15323 0 340308 0 0 0 ANGELA WALKER MD 298872 0 0 0 0 0 13085 0 8589 0 320546 0 0 0 ILLINOIS FINANCE AUTHORITY 861091967 45200BH27 2006-08-31 32114451 SEE SCHEDULE O 0 0 33978645 2352650 642289 33336356 2008 0 0 1 1 0 0 1 0 1 0.00000 0.00600 0.00600 1 0 0 0 1 SEE SCHEDULE O 1 0 0 Form 990, Part III, line 3 Changes in Program Services Kewanee Hospital made the difficult decision in FY 2010 to close the obstetric service line due to excessive financial losses resulting from inadequate reimbursement. In three years, the Hospital had lost close to two-million dollars providing obstetric services. The Hospital staff and leadership believe deeply in living the mission of improving the health and care of those served, but realized that continuing the service was jeopardizing the existence of the overall organization. Upon review of the community members served, obstetrics was less than 3% of the overall patients treated-but used a disproportionate share of the resources. The Hospital worked proactively with expectant mothers and area providers for a delivery plan. Tertiary providers in Peoria and Galesburg stated that they were willing to accept all of the patients from Kewanee and could handle the increased volume. Kewanee Hospital has referred patients to them when needed and facilitated any transfer needs. The service closed as of July 31, 2010. The Hospital's Family Health Clinic continues to care for young mothers and their children after delivery. Form 990, Part VI, Section A, line 8b THE ORGANIZATION DOES NOT HAVE ANY COMMITTEES WITH AUTHORITY TO ACT ON BEHALF OF THE GOVERNING BODY. Form 990, Part VI, Section B, line 11 The Strategic Planning and Finance Committee (SPF) is the Board of Trustee level committee charged with reviewing the final form 990 prior to its filing. The entire Board is invited to the SPF committee meeting where the 990 will be presented to participate in the review. The tax return preparer conducts the overview of the Form 990, projecting the 990 on the screen and explaining the pertinent schedules. Each Board member is provided a copy of the 990 for their review. The Board members are given the opportunity to ask questions and make comments. The 990 is not filed until after the Board of Trustees meeting where the 990 will be approved and accepted. Form 990, Part VI, Section B, line 12c ANY INTERESTED PERSON WHO HAS A PERSONAL OR PRIVATE INTEREST IN A MEASURE, CONTRACT, RESOLUTION, OR OTHER TRANSACTION PRESENTED TO THE BOARD OR A COMMITTEE THEREOF FOR DELIBERATION, AUTHORIZATION, APPROVAL, OR RATIFICATION, OR ANY INTERESTED PERSON WHO REASONABLY BELIEVES SUCH AN INTEREST EXISTS IN ANOTHER PERSON, SHALL MAKE A PROMPT, FULL, AND FRANK DISCLOSURE IN WRITING OF THE PERSONAL OR PRIVATE INTEREST TO THE BOARD OR COMMITTEE PRIOR TO ITS ACTING ON SUCH CONTRACT OR TRANSACTION. THE INTERESTED PERSON SHALL DISCLOSE THE EXISTENCE OF HIS OR HER PERSONAL OR PRIVATE INTEREST AND ALL MATERIAL FACTS, KNOWN TO HIM OR HER ABOUT THE PERSONAL OR PRIVATE INTEREST AND POTENTIAL CONFLICT OF INTEREST. Form 990, Part VI, Section B, line 15 The Executive Committee of the Hospital Board of Trustees acts as the Compensation Committee for Kewanee Hospital. Annually the Executive Committee of the Board meets to review and approve compensation for the Executive Team which includes the Chief Executive Officer, Chief Operating Officer, Chief Financial Officer and Chief Nursing Officer. Resource data for this review comes from salary surveys from a number of sources including Sullivan Cotter, Central Illinois Society for Healthcare Human Resource Administration (CISHRA), IHA Executive and Management Salary Survey, and a 990 review through Guidestar.org of local and regional organizations. The surveys are analyzed by reviewing applicable cuts of the survey including Critical Access Hospitals, Hospitals with like revenue, and similarly staffed organizations. Surveys are also reviewed at regional and national levels. Compensation is proposed to the committee taking into consideration the median range of all salary sources, education/degree, training, certification, and experience. The committee reviews the salary proposal for reasonableness based on the data sources. The Chief Executive Officer makes recommendations for the salaries of the other executives (COO, CFO and CNO). THIS PROCESS WAS LAST COMPLETED IN 2010. Form 990, Part VI, Section C, line 19 THE ORGANIZATION'S GOVERNING DOCUMENTS, CONFLICT OF INTEREST POLICY, AND FINANCIAL STATEMENTS ARE NOT MADE AVAILABLE TO THE PUBLIC. FORM 990, PART XI, LINE 2C THE ORGANIZATION'S BOARD OF TRUSTEES ENGAGES THE INDEPENDENT ACCOUNTANTS TO PERFORM THE AUDIT. THE BOARD MEETS WITH THE AUDITORS TO GO OVER THE AUDIT REPORT. FORM 990, SCHEDULE K, PART I, LINE A DESCRIPTION OF PURPOSE In response to Part I, line A (f), the purpose of the $32,205,000 Illinois Finance Authority Revenue Bonds, Series 2006 (Kewanee Hospital Project) (the "Bonds") was, together with certain other amounts available to Kewanee Hospital, to (a) pay or reimburse Kewanee Hospital for the payment of the cost of acquiring, constructing, renovating, remodeling and equipping certain of its health facilities, (b) provide funded interest for the Bonds, and (c) pay certain expenses incurred in connection with the issuance of the Bonds. FORM 990, SCHEDULE K, PART IV, LINE 1 FORM 8038-T FILING In response to Part IV, line 1, the filing of the Form 8038-T, Arbitrage Rebate, Yield Reduction and Penalty in Lieu of Arbitrage Rebate is in process as it is not due until five years and 60 days after the bond issue date. FORM 990, SCHEDULE K, PART IV, LINES 4B & 4C NAME OF GIC PROVIDER AND TERM OF GIC TRANSAMERICA OCCIDENTAL LIFE INSURANCE COMPANY - GIC PROVIDER FOR PROCEEDS DEPOSITED IN A PROJECT FUND - 1.61 YEARS CITIGROUP FINANCIAL PRODUCTS, INC. - GIC PROVIDER FOR GROSS PROCEEDS DEPOSITED IN A DEBT SERVICE RESERVE FUND - 4.90 YEARS - TERMINATED ON JANUARY 9, 2009