2011-12-14T14:42:06-06:00 2011-04-30 CLIFTON GUNDERSON LLP 114 E EVERETT DIXON IL 61021 990 2010-05-01 364244337 VALLEY WEST COMMUNITY HOSPITAL VALL 8157561521 ONE KISH HOSPITAL DRIVE DEKALB IL 60115 LOREN FOELSKE 8157561521 2011-12-13 1 KELLY JACKSON HARDY 8152842285 2010 2016-02-24 21:20:13Z KEVIN P POORTEN ONE KISH HOSPITAL DRIVE DEKALB IL 60115 51792767 0 X WWW.VWCH.ORG X 1998 IL TO PROVIDE COMPREHENSIVE HEALTH CARE SERVICES, INCLUDING INPATIENT ACUTE AND NONACUTE CARE, AND VARIOUS OUTPATIENT SERVICES IN THE AREAS OF DEKALB, KENDALL, AND LASALLE COUNTIES. 3 2 280 65 0 0 107846 85728 42087876 45655170 416483 396789 724963 928513 43337168 47066200 0 5000 0 0 13816719 14697950 0 0 0 27483072 28305660 41299791 43008610 2037377 4057590 52694037 59218227 9980452 10776741 42713585 48441486 X TO PROVIDE COMPREHENSIVE HEALTH CARE SERVICES, INCLUDING INPATIENT ACUTE AND NONACUTE CARE, AND VARIOUS OUTPATIENT SERVICES IN THE AREAS OF DEKALB, KENDALL, AND LASALLE COUNTIES. VALLEY WEST COMMUNITY HOSPITAL WILL STRIVE TO PROVIDE HIGH QUALITY PRIMARY CARE AND COMMUNITY HEALTH EDUCATION, WHILE PROMOTING COMMUNITY HEALTH SERVICES IN A FRIENDLY, CARING ENVIRONMENT. VALLEY WEST COMMUNITY HOSPITAL IS COMMITED TO PROVIDING HEALTH CARE IN ACCORDANCE WITH THE HIGHEST MEDICAL AND ETHICAL STANDARDS WITH CARE, COMPASSION, AND RESPECT FOR ALL, PROTECTING THE DIGNITY, AUTONOMY AND INTEGRITY OF ALL OUR PATIENTS, WHILE MANAGING THE MEDICAL RESOURCES AT OUR DISPOSAL WITH WISDOM AND FAIRNESS. 0 0 35976319 5000 46459997 VALLEY WEST COMMUNITY HOSPITAL (VALLEY WEST), LOCATED IN SANDWICH, ILLINOIS, SERVES THE RESIDENTS OF SOUTHERN DEKALB, NORTHERN LASALLE AND WESTERN KENDALL COUNTIES BY OFFERING A NUMBER OF PROGRAMS AND SERVICES THAT GO BEYOND BASIC HEALTH CARE. VALLEY WEST BELIEVES THAT IN ORDER TO BE A TRUE "COMMUNITY" HOSPITAL, WE MUST BE A RESOURCE FOR PREVENTATIVE AND CURATIVE HEALTH INFORMATION, EDUCATION AND SERVICES AND THAT WE MUST SUPPORT THE EFFORTS OF OTHERS WHO ALSO ARE DOING WORK FOR THE COMMUNITY GOOD. DOING SO HELPS BUILD TRUST, RESPECT AND LOYALTY FOR OUR HOSPITAL AND STRENGTHENS OUR ROLE AS A PARTNER IN IMPROVING THE HEALTH OF OUR CITIZENS AND THE QUALITY OF LIFE IN THE COMMUNITIES WE SERVE.THE COMMUNITY BENEFIT OBJECTIVES OF VALLEY WEST INCLUDE PROGRAMS TO REDUCE GEOGRAPHIC, FINANCIAL, LANGUAGE AND CULTURAL BARRIERS; IMPROVE AND ENHANCE PUBLIC HEALTH; ADVANCE GENERALIZEABLE KNOWLEDGE, AND RELIEVE THE GOVERNMENT BURDEN OF PROVIDING HEALTH SERVICES FOR THE COMMUNITY, UNINSURED AND UNDERINSURED. THIS SECTION ELABORATES ON SEVERAL AREAS: COMMUNITY BENEFIT PATIENT SERVICES, EMERGENCY/DISASTER RESPONSE, CLINICAL EDUCATION, COMMUNITY WELLNESS ACTIVITIES, OTHER COMMUNITY EDUCATION AND OUTREACH, CASH CONTRIBUTIONS AND IN-KIND CONTRIBUTIONS. VALLEY WEST COMMUNITY HOSPITAL SERVES ALL OF DEKALB COUNTY, IL, AND BORDER COMMUNITIES IN KENDALL AND LASALLE COUNTIES. POPULATION OF THE HOSPITAL'S SERVICE AREA, BASED ON 2010 CENSUS, IS 71,523. THE HISPANIC POPULATION IS EXPECTED TO GROW BY 44.69% BY 2016. ACCORDING TO THE AMERICAN COMMUNITY SURVEY, 18.2% OF FAMILIES AND 29.37% OF INDIVIDUALS ARE BELOW THE POVERTY LEVEL BASED ON POPULATION AND HOUSING DATA FROM 2005-2009.COMMUNITY BENEFIT PATIENT SERVICESTHE HOSPITAL OPERATES A NUMBER OF HEALTH SERVICES AT A LOSS FOR THE GOOD OF THE HEALTH, SAFETY AND WELFARE OF OUR PATIENTS AND COMMUNITY. VALLEY WEST FOCUSED ON THE FOLLOWING COMMUNITY HEALTH NEEDS FOR THE FISCAL YEAR ENDED APRIL 30, 2011:* THE PREVALENCE OF OBESITY IN CHILDREN AND ADULTS* OUTPATIENT BEHAVIORAL HEALTH SERVICES.* TYPE II DIABETES * PUBLIC EDUCATION ON CARDIOVASCULAR DISEASE * CANCER CARE SERVICES, EDUCATION AND PREVENTION * AFFORDABLE ACCESS TO CHILDBIRTH EDUCATION AND OB HOSPITAL SERVICES* OTHER COMMUNITY OUTREACH AND WELLNESS SERVICES.EACH OF THESE INITIATIVES IS SUMMARIZED BELOW:FY 2011 COMMUNITY WELLNESS OBESITY INITIATIVECOMMUNITY 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. CURRENT PROGRAMS INCLUDE:* MANAGING YOUR CHOLESTEROL WITH TLC. FREE BLOOD PRESSURE CLINICS. TIME TO QUIT TOBACCO.* WELLNESS FOR KIDS PROGRAMS: INCREASED CLASSES ON NUTRITION, PUBERTY, DECISION MAKING AND SELF ESTEEM IN COMMUNITY SCHOOLS* WE CAN! PROGRAM: DEVELOPED BY THE NATIONAL INSTITUTES OF HEALTH TO HELP PARENTS / FAMILIES ADDRESS THE ISSUE OF OVERWEIGHT CHILDREN (AGES 8 - 13) THROUGH NUTRITION, FITNESS AND REDUCED SCREEN TIME* LIVE FIT CHALLENGE WITH THE YMCA: WELLNESS PRESENTATIONS AND FITNESS.* DR. MICHELLE MAY PRESENTATION, A PHYSICIAN AND MOTIVATIONAL SPEAKER ON WEIGHT LOSS; AUTHOR OF EAT WHAT YOU LOVE, LOVE WHAT YOU EAT. ATTENDED BY 650.* COMMUNITY WELLNESS RV FOR BLOOD PRESSURE SCREENING, KNOW YOUR NUMBERS AND BONE DENSITY SCREENINGS S AT DIFFERENT COMMUNITY SITES* SCHOOL PROGRAMS: WELLNESS FOR KIDS PROGRAMS PROVIDED PROGRAMS IN 328 CLASSROOMS ON NUTRITION, PUBERTY, DECISION MAKING AND SELF ESTEEM IN COMMUNITY SCHOOLS. TOTAL CONTACTS: 7,742ACCESS TO AFFORDABLE PRIMARY CARE NEW PHYSICIANS WHO RECEIVE RECRUITMENT ASSISTANCE ARE REQUIRED TO ACCEPT MEDICAID PATIENTS. OUTPATIENT MENTAL HEALTHDURING FY 11, OUTPATIENT BEHAVIORAL HEALTH SERVICES WERE ADDED, PROVIDING COUNSELING SERVICES AND A PSYCHIATRIST.TYPE II DIABETESTO ADDRESS THE PREVALENCE OF DIABETES IN THE ADULT POPULATION, THE HOSPITAL CONTINUED TO OPERATE A DIABETES EDUCATION CENTER. THE VALLEY WEST DIABETES EDUCATION CENTER HAD 3,181 CONSULTATIONS, A 10.7% INCREASE FROM THE PREVIOUS YEARCARDIOVASCULAR DISEASE COMMUNITY OUTREACH ACCORDING TO THE SYSTEM'S 2009 COMMUNITY HEALTH STATUS TELEPHONE SURVEY, MORE THAN 86% OF THE ADULT POPULATION IN THE VALLEY WEST MARKET HAVE ONE OR MORE CARDIOVASCULAR RISK FACTORS OR BEHAVIORS, SUCH AS HIGH BLOOD PRESSURE, HIGH CHOLESTEROL OR SMOKE. COMMUNITY BENEFIT ACTIVITIES IN FY 11 THAT PROMOTED CARDIOVASCULAR HEALTH WERE: * WOMEN'S HEALTH EVENT IN MARCH ATTENDED BY 250* 3 KNOW YOUR NUMBERS EVENTS WITH 170 PARTICIPANTS* 31 HEARTWISE CARDIAC RISK EVALUATIONS* 1,653 FREE BLOOD PRESSURE CHECKS.* 278 FREE AND LOW COST CHOLESTEROL TESTS DURING SPECIAL PROMOTIONS IN FEBRUARY SEPTEMBER.* LOW COST CHOLESTEROL CLASSES* 3 FREE PRESENTATIONS BY CARDIOLOGISTSCANCER CARE SERVICES, EDUCATION AND PREVENTION * ESTABLISHED VALLEY WEST ONCOLOGY DEPARTMENT AND CANCER CENTER* FINANCIAL SUPPORT OF AMERICAN CANCER SOCIETY RELAYS FOR LIFE FOR LOWER FOX VALLEY (KENDALL COUNTY)* LOW COST PSA TESTSAFFORDABLE ACCESS TO CHILDBIRTH EDUCATION * 1,750 HOURS OF FREE LACTATION COUNSELING* 256 FREE POST PARTUM VISITS FOR NEW MOMS* 3 TUITION WAIVERS FOR CHILDBIRTH EDUCATIONOTHER COMMUNITY OUTREACH AND WELLNESS EFFORTS* 82 PRE-TEENS PARTICIPATED IN SAFE SITTER CLASSES* 45 PARTICIPANTS IN GIRLS ONLY CLASSES* MORE THAN 2,000 PARTICIPANTS AT THE ANNUAL WELLNESS FAIR WHICH INCLUDES GLUCOSE AND HEARING SCREENINGS * COMMUNITY WELLNESS EDUCATORS SERVED ON THE FOLLOWING COMMITTEES TO PROMOTE HEALTH AND WELLNESS: PLANO CHAMBER OF COMMERCE BOARD OF DIRECTORS, KENDALL COUNTY HEALTH INITIATIVES COUNCIL, KENDALL COUNTY IPLAN STEERING COMMITTEE, SANDWICH PROJECT SUCCESS COMMITTEE, OB PRACTICE COMMITTEE CO-CHAIR* MAINTAINED VALLEY WEST WEBSITE TO PROVIDE HEALTH INFORMATION TO CONSUMERS.* PUBLISHED A COMMUNITY WELLNESS MAGAZINE THREE TIMES A YEAR PROVIDING INFORMATION ABOUT PROGRAMS, FREE SCREENINGS, AND GENERAL HEALTH TIPS.* SPONSORED HEALTH EDUCATION SPOTS ON LOCAL RADIO STATIONS.* HELD MONTHLY LUNCHEONS FOR LOCAL ON-CALL CHAPLAIN GROUP THAT PROVIDES SPIRITUAL/PASTORAL CARE TO HOSPITAL PATIENTS AND FAMILIES. * PROVIDED SPACE FOR DEKALB COUNTY HEALTH DEPARTMENT IMMUNIZATION CLINICS* PROVIDED EMS PERSONNEL AND SUPPLIES FOR FIRST AID STATION DURING THE 5 DAYS OF THE SANDWICH FAIR.OPERATIONAL COMMUNITY BENEFITCHARITY CARE* AS PART OF ITS CHARITABLE MISSION, FREE AND DISCOUNTED CARE PROVIDED, 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 LAST REVIEW WAS APRIL 2011.* FOR FY 11, THE GUIDELINE FOR FINANCIAL ASSISTANCE ELIGIBILITY WAS FAMILY INCOME UP TO 350% OF THE FEDERAL POVERTY LEVEL. * ADHERED TO THE REQUIREMENTS OF THE HOSPITAL UNINSURED PATIENT DISCOUNT ACT OF 2009, PROVIDING UNINSURED PATIENTS DISCOUNTS WHEN FAMILY INCOME IS AT OR BELOW 300% OF THE FEDERAL POVERTY LEVEL.* COORDINATED WITH THE ILLINOIS BREAST AND CERVICAL CANCER PROGRAM FOR ASSISTANCE WITH BREAST AND CERVICAL CANCER SCREENINGS AND TREATMENT.SUBSIDIZED HEALTH SERVICESA NUMBER OF PROGRAMS AND SERVICES WERE OPERATED AT A LOSS, BUT WERE SUBSIDIZED BECAUSE THEY IMPROVE THE HEALTH AND SAFETY OF THE COMMUNITY. * SOCIAL SERVICES* PRE-HOSPITAL EMERGENCY MEDICAL SERVICES OVERSIGHT AND TRAINING* COMMUNITY WELLNESS * BEHAVIORAL HEALTH* DISCOUNT LAB WORK FOR SPECIAL EVENTS AND SERVICES* CONTINUITY OF CARE PATIENT TRANSPORTATION* OBSTETRICS MOM & BABY FOLLOW-UP VISITS* LACTATION CONSULTATIONS* RADIOLOGY NIGHT SERVICE* TEMPORARY PHYSICIAN COVERAGE* HOSPITALIST* ANESTHESIA COVERAGELANGUAGE ASSISTANCESPANISH INTERPRETERS AVAILABLE OR ON CALL 24/7 AND AS WELL AS 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 ENGLISHVOLUNTEER SERVICES* ENCOURAGED AND FACILITATED PAYROLL DEDUCTION FOR EMPLOYEE DONATIONS TO UNITED WAY, SANDWICH COMMUNITY FUND, KISHHEALTH FOUNDATION AND DEKALB COUNTY HOSPICE.* OPERATED A VOLUNTEER SERVICES DEPARTMENTS AND TRACKED THE NUMBER OF ADULT VOLUNTEER HOURS DONATED TO THE HOSPITALS* PROVIDED STAFF SUPPORT FOR VALLEY WEST AUXILIARY EVENTS THAT RAISE MONEY FOR HOSPITAL IMPROVEMENTS AND HEALTHCARE SCHOLARSHIPS.EDUCATION & WORKFORCE DEVELOPMENT * PROVIDED CLINICAL EXPERIENCE AND JOB SHADOWING FOR COLLEGE AND HIGH SCHOOL STUDENTS IN THE AREAS OF NURSING AND RADIOLOGY.* PROVIDE STAFF TO ATTEND AND PRESENT AT MIDDLE SCHOOL, HIGH SCHOOL AND COLLEGE CAREER FAIRS * PROVIDE TOURS OF THE HOSPITAL AND OTHER HEALTH SYSTEM FACILITIES TO PROMOTE HEALTHCARE CAREER OPPORTUNITIES.* AWARDED ANNUAL HEALTH CAREER SCHOLARSHIPS THROUGH THE AUXILIARYMANY ORGANIZATIONS ALSO RECEIVED CASH AND IN KIND DONATIONS. 35976319 1 1 0 1 0 0 0 0 0 0 1 0 0 0 1 0 0 1 0 0 0 0 0 0 0 0 1 1 1 0 1 0 0 0 0 0 0 0 1 0 0 0 0 0 1 0 0 0 0 1 66 0 1 280 1 0 0 0 0 0 0 0 0 0 0 X 3 2 1 0 0 0 1 1 1 1 1 0 0 1 1 1 1 1 1 1 1 0 IL X PHILLIP JOHNSON DIR OF ACCTG 8157561521 ONE KISH HOSPITAL DRIVE DEKALB IL 60115 X TERRENCE DUFFY 1.00 X X 0 0 0 KEVIN POORTEN 1.00 X X 0 918469 100377 ERIK ENGLEHART 1.00 X X 0 0 0 LOREN FOELSKE 10.00 X 0 303588 39563 BRAD COPPLE 20.00 X 0 341357 39811 PAM DUFFY 20.00 X 0 234689 26496 JOE DANT 6.00 X 0 258586 39499 MIKE MUZZILLO 40.00 X 0 161261 26134 MIKE KOKOTT 10.00 X 0 193903 22972 ROGER HEATH BELL 15.00 X 0 216841 37445 DR MICHAEL KULISZ 20.00 X 0 204758 20414 MARK THATE 10.00 X 0 179403 27847 CHERYL FISHER 20.00 X 0 136108 30631 SUE HOHENBERGER 40.00 X 135783 0 23870 ALTHEA R RUSSELL 40.00 X 114300 0 22196 ALEX P LOMAHAN 40.00 X 118023 0 19457 BARBARA DOBSON 40.00 X 101073 0 27625 KATHRYN VALENZUELA 40.00 X 96037 0 2447 469179 3012855 473706 4 0 1 0 KISH HEALTH SYSTEM ONE KISH HOSPITAL DRIVE DEKALB IL 60115 MANAGEMENT FEES 3905562 COMPREHENSIVE THERAPEUTICS LTD 3703 WEST LAKE STREET GLENVIEW IL 60025 PHYSICAL THERAPY SERVICES 1031509 ANESTHESIA ASSOCIATES LLC 88 W COUNTRYSIDE PARKWAY YORKVILLE IL 60560 HEALTH SERVICES 964460 DIAGNOSTIC HEALTH SERVICES INC 2445 GATEWAY DR STE 100 IRVING TX 75063 HEALTH SERVICES 507298 DEKALB MRI CENTER 2475 W BETHANY ROAD SYCAMORE IL 60178 HEALTH SERVICES 367600 8 42162 43566 902 85728 NET PATIENT SERVICE RE 621110 45655170 45655170 45655170 876132 876132 125165 1479 123686 123686 123686 3621118 624627 4112538 612550 -491420 12077 -479343 -479343 OTHER INCOME 621110 693551 693551 DIETARY/CAFETERIA SALE 621110 71955 71955 DISCOUNTS AND REBATES 621110 39321 39321 804827 47066200 46459997 0 520475 5000 5000 10455129 9808724 646405 565206 530261 34945 2913564 2733428 180136 764051 716812 47239 3501975 3501975 40603 40603 3191 3191 81872 81872 6659403 6510301 149102 406248 3885 402363 4701629 4386282 315347 242898 2898 240000 1623921 1620362 3559 61267 60754 513 33730 33730 129082 129082 2553675 2553675 769815 262397 507418 BAD DEBT EXPENSE 4308328 4308328 PHYSICAN FEES AND RECRU 2295040 1974134 320906 FEDERAL AND STATE ASSES 456196 456196 COLLECTION FEES 308005 308005 DUES, SUBSCRIPTIONS, AN 98499 39133 59366 30283 3749 26534 43008610 35976319 7032291 0 12550 244359 5215363 1280644 4893730 5492103 1152382 1381186 504833 550210 35968701 16205084 19679141 19763617 17492911 26952150 269548 1762108 3473579 1791850 52694037 59218227 4397492 4017446 270100 2502686 2261434 3080274 4227761 9980452 10776741 X 42635654 48372653 77931 68833 42713585 48441486 52694037 59218227 X 4057590 1670311 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 10738 10738 0 EXPLANATION OF OTHER LOBBYING ACTIVITIES: PART II-B, LINE 1I: LOBBYING EXPENSES ARE ALLOCATED THROUGH MEMBERSHIP DUES WITH ILLINOIS HOSPITAL ASSOCIATION AND AMERICAN HOSPITAL ASSOCIATION. NO OTHER LOBBYING ACTIVITIES WERE CONDUCTED. 1279463 1279463 13618375 4199501 9418874 394840 82332 312508 18058407 11066018 6992389 2617616 857233 1760383 19763617 IBNR RESERVE 179970 LEASE OBLIGATION PAYABLE 358792 DUE TO AFFILIATES 1592276 ESTIMATED SETTLEMENTS DUE 2095752 OTHER LONG TERM LIABILITIES 971 4227761 47066200 43008610 4057590 2170056 -499745 1670311 5727901 49164617 2170056 1479 2171535 46993082 73118 73118 47066200 43009644 1479 1479 43008165 445 445 43008610 PART XI, LINE 8 - OTHER ADJUSTMENTS: EQUITY DISTRIBUTION TO KISHHEALTH SYSTEM, INC. -470,000. GRANT INCOME RECORDED AS OFFSET TO FIXED ASSET ACCOUNTS -30,511. EQUITY CONTRIBUTION FROM KISHHEALTH SYSTEM, INC. 56. CHANGE IN NET ASSETS OF KISHHEALTH FOUNDATION 710. PART XII, LINE 2D - OTHER ADJUSTMENTS: RENTAL EXPENSES NETTED WITH REVENUE FOR FORM 990 PURPOSES 1,479. PART XII, LINE 4B - OTHER ADJUSTMENTS: CONTRIBUTION REVENUE FROM KISHHEALTH FOUNDATION 42,162. GAIN ON SALE OF FIXED ASSETS NETTED WITH EXPENSE ON FINANCIAL STATEMENTS 445. GRANTS NETTED WITH FIXED ASSETS FOR FINANCIAL STATEMENT PURPOSES 30,511. PART XIII, LINE 2D - OTHER ADJUSTMENTS: RENTAL EXPENSES NETTED WITH REVENUE FOR 990 PURPOSES 1,479. PART XIII, LINE 4B - OTHER ADJUSTMENTS: GAIN ON SALE OF FIXED ASSETS NETTED WITH EXPENSES ON FINANCIAL STATEMENTS 445. PART XI, LINE 10, EXCESS OR (DEFICIT) FOR THE YEAR PER FINANCIAL STATEMENTS: LINE 10 IDENTIFIES FINANCIAL STATEMENT INCOME AS EQUALING $5,727,901. FINANCIAL STATEMENT INCOME IS ACTUALLY $6,154,973. THE DIFFERENCE RELATES TO THE FOLLOWING ITEMS: 1. VALLEY WEST COMMUNITY HOSPITAL MADE A CAPITAL DISTRIBUTION OF $470,000 TO ITS PARENT CORPORATION, ANOTHER NON-PROFIT ENTITY (KISHHEALTH SYSTEM). 2. KISHHEALTH FOUNDATION (KHF), AN AFFILIATED ENTITY, RECEIVES CONTRIBUTIONS DESIGNATED FOR USE BY VALLEY WEST COMMUNITY HOSPITAL. THIS IS ALLOCATED TO VALLEY WEST, VIA AN ENTRY TO INCREASE VALLEY WEST'S INTEREST IN THE ASSETS OF KHF. A CORRESPONDING EQUITY ENTRY IS MADE ON VALLEY WEST'S GENERAL LEDGER. THE CURRENT YEAR INCREASE WAS $42,026, OF WHICH $710 IS AN INCREASE IN THE VWCH'S INTEREST IN THE ASSETS OF KHF AND $41,316 WERE ACTUAL CONTRIBUTIONS RECEIVED. 3. IN-KIND/NON-CASH DONATIONS OF $902 WERE RECORDED ONLY AS AN EQUITY TRANSACTION FOR FINANCIAL STATEMENT PURPOSES. THEY WERE NOT INCLUDED IN FINANCIAL STATEMENT INCOME, BUT ARE INCLUDED IN INCOME PER THE TAX RETURN. 1 1 X 1 X 1 X 1 1 1 0 1 1 1357827 456196 901631 0.02330 7362028 3351046 4010982 0.10360 8719855 3807242 4912613 0.12690 3081129 28477 3052652 0.07890 88798 0 88798 0.00230 882345 602044 280301 0.00720 0 0 81565 0 81565 0.00210 4133837 630521 3503316 0.09050 12853692 4437763 8415929 0.21740 1 1682580 504774 10352851 10250348 102503 X 1 1 1 1 VALLEY WEST COMMUNITY HOSPITAL

11 EAST PLEASANT AVE SANDWICH IL 60548

X X X X NOT REQUIRED 1 PART I, LINE 7, COLUMN (F): THE BAD DEBT EXPENSE INCLUDED ON FORM 990, PART IX, LINE 25, COLUMN (A), BUT SUBTRACTED FOR PURPOSES OF CALCULATING THE PERCENTAGE IN THIS COLUMN IS $ 4308328. PART II: NO COMMUNITY BUILDING ACTIVITIES ARE REPORTED IN PART II. PART III, LINE 4: NET PATIENT SERVICE REVENUETHE HOSPITAL HAS AGREEMENTS WITH THIRD-PARTY PAYORS WHICH PROVIDE FOR REIMBURSEMENT TO THE HOSPITAL AT AMOUNTS DIFFERENT FROM ITS ESTABLISHED RATES. CONTRACTUAL ADJUSTMENTS UNDER THIRD-PARTY REIMBURSEMENT PROGRAMS REPRESENT THE DIFFERENCE BETWEEN THE HOSPITAL'S BILLINGS AT LIST PRICE AND THE AMOUNTS REIMBURSED BY MEDICARE, MEDICAID, BLUE CROSS, AND CERTAIN OTHER THIRD-PARTY PAYORS;AND ANY DIFFERENCES BETWEEN ESTIMATED THIRD-PARTY REIMBURSEMENT SETTLEMENTS FOR PRIOR YEARS AND SUBSEQUENT FINAL SETTLEMENTS. CONTRACTUAL ADJUSTMENTS UNDER THIRD-PARTY REIMBURSEMENT PROGRAMS ARE ACCRUED ON AN ESTIMATED BASIS IN THE PERIOD THE RELATED SERVICES ARE RENDERED AND ARE ADJUSTED IN FUTURE PERIODS AS FINAL SETTLEMENTS ARE DETERMINED. A SUMMARY OF THE BASIS OF REIMBURSEMENT WITH MAJOR THIRD-PARTY PAYORS FOLLOWS:MEDICARE: VALLEY WEST COMMUNITY HOSPITAL (VWCH) WAS DESIGNATED AS A CRITICAL ACCESS HOSPITAL DURING FISCAL YEAR 2005. THIS DESIGNATION PROVIDES FOR INPATIENT AND OUTPATIENT SERVICES TO BE REIMBURSED ON A COST BASIS METHODOLOGY. THE HOSPITAL IS REIMBURSED AT A TENTATIVE RATE WITH FINAL SETTLEMENT DETERMINED AFTER SUBMISSION OF ANNUAL COST REPORTS BY THE HOSPITAL AND AUDITS THEREOF BY THE MEDICARE FISCAL INTERMEDIARY. THE HOSPITAL'S CLASSIFICATION OF PATIENTS UNDER THE MEDICARE PROGRAM AND THE APPROPRIATENESS OF THEIR ADMISSION ARE SUBJECT TO AN INDEPENDENT REVIEW BY A PEER REVIEW ORGANIZATION. CHANGES AS A RESULT OF THE CENTERS FOR MEDICARE AND MEDICAID SERVICES IMPLEMENTATION OF THE PROVISIONS OF THE FUTURE MEDICARE LEGISLATION MAY HAVE AN ADVERSE EFFECT ON THE HOSPITAL'S NET PATIENT SERVICE REVENUE.LAWS AND REGULATIONS GOVERNING THE MEDICARE PROGRAM ARE EXTREMELY COMPLEX AND SUBJECT TO INTERPRETATION. AS A RESULT,THERE IS AT LEAST A REASONABLE POSSIBILITY THAT RECORDED ESTIMATES WILL CHANGE BY A MATERIAL AMOUNT IN THE NEAR-TERM.MEDICAID: THE HOSPITAL IS REIMBURSED AT PROSPECTIVELY DETERMINED RATES FOR EACH MEDICAID INPATIENT DISCHARGE. OUTPATIENT SERVICES ARE REIMBURSED BASED ON ESTABLISHED FEE SCREENS. FOR INPATIENT ACUTE CARE SERVICES, PAYMENT RATES VARY ACCORDING TO A PATIENT CLASSIFICATION SYSTEM THAT IS BASED ON CLINICAL, DIAGNOSTIC, AND OTHER FACTORS. THE PROSPECTIVELY DETERMINED RATES ARE NOT SUBJECT TO RETROACTIVE ADJUSTMENT. THE HOSPITAL ALSO RECEIVES INCREMENTAL MEDICAID REIMBURSEMENT FOR SPECIFIC PROGRAMS AND SERVICES AT THE DISCRETION OF THE STATE OF ILLINOIS MEDICAID PROGRAM. MEDICAID REIMBURSEMENT MAY BE SUBJECT TO PERIODIC ADJUSTMENT, AS WELL AS TO CHANGES IN EXISTING PAYMENT LEVELS AND RATES, BASED ON THE AMOUNT OF FUNDING AVAILABLE TO THE MEDICAID PROGRAM. LAWS AND REGULATIONS GOVERNING THE MEDICAID PROGRAM ARE EXTREMELY COMPLEX AND SUBJECT TO INTERPRETATION. AS A RESULT, THERE IS AT LEAST A REASONABLE POSSIBILITY THAT RECORDED ESTIMATES WILL CHANGE BY A MATERIAL AMOUNT IN THE NEAR-TERM.IN DECEMBER 2004, THE FEDERAL CENTERS FOR MEDICARE & MEDICAID SERVICES (CMS) APPROVED STATE OF ILLINOIS (STATE) LEGISLATION FOR A MEDICAID HOSPITAL ASSESSMENT PROGRAM (PROGRAM). UNDER THE PROGRAM, THE HOSPITAL RECEIVES ADDITIONAL MEDICAID REIMBURSEMENT FROM THE STATE AND PAYS A RELATED ASSESSMENT TAX. THE PROGRAM HAS BEEN EXTENDED THROUGH JUNE 30, 2013. BLUE CROSS: THE SYSTEM ALSO PARTICIPATES AS A PROVIDER OF HEALTH CARE SERVICES UNDER A REIMBURSEMENT AGREEMENT WITH BLUE CROSS. THE PROVISIONS OF THIS AGREEMENT STIPULATE THAT INPATIENT SERVICES WILL BE REIMBURSED AT A TENTATIVE REIMBURSEMENT RATE AND THAT FINAL REIMBURSEMENT FOR THESE SERVICES IS DETERMINED AFTER THE SUBMISSION OF AN ANNUAL COST REPORT BY THE SYSTEM AND A REVIEW BY BLUE CROSS. MANAGED CARE ORGANIZATIONS: THE HOSPITAL HAS ALSO ENTERED INTO REIMBURSEMENT AGREEMENTS WITH CERTAIN COMMERCIAL INSURANCE CARRIERS, HEALTH MAINTENANCE ORGANIZATIONS, AND PREFERRED PROVIDER ORGANIZATIONS. THE BASIS FOR PAYMENT UNDER THESE AGREEMENTS INCLUDES DISCOUNTS FROM ESTABLISHED CHARGES AND PROSPECTIVELY DETERMINED PER DIEM RATES.INTERNAL REVENUE SERVICE WORKSHEET 2 (PER SCHEDULE H INSTRUCTIONS) WAS UTILIZED TO DETERMINE THE COST OF BAD DEBTS ATTRIBUTABLE TO PATIENT ACCOUNTS. PART III, LINE 8: NONE PART III, LINE 9B: COLLECTION ACTIONS INVOLVING UNINSURED PATIENTS. KHS (KISHHEALTH SYSTEM, PARENT ORGANIZATION OF VALLEY WEST COMMUNITY HOSPITAL) SHALL NOT PURSUE A COLLECTION ACTION AGAINST AN UNINSURED PATIENT, UNLESS THE PATIENT HAS BEEN GIVEN THE OPPORTUNITY TO ASSESS THE ACCURACY OF THE BILL; APPLY FOR FINANCIAL ASSISTANCE UNDER THE KHS FINANCIAL ASSISTANCE POLICY AND PROCEDURE; AND AVAIL HIMSELF OR HERSELF OF A REASONABLE PAYMENT PLAN. NOTWITHSTANDING THIS, KHS MAY NOT PURSUE THE COLLECTION ACTION UNDER THE FOLLOWING CIRCUMSTANCES: (A) IF THE PATIENT HAS INDICATED AN INABILITY TO PAY THE FULL AMOUNT OF THE DEBT IN ONE PAYMENT, UNTIL KHS HAS OFFERED THE PATIENT A PAYMENT PLAN. KHS MAY REQUIRE THE PATIENT TO PROVIDE REASONABLE VERIFICATION OF HIS OR HER INABILITY TO PAY THE FULL AMOUNT OF THE DEBT IN ONE PAYMENT.(B) IF KHS HAS REASON TO BELIEVE THE PATIENT MAY BE ELIGIBLE FOR FINANCIAL ASSISTANCE, UNTIL KHS HAS GIVEN THE PATIENT AT LEAST 60 DAYS FOLLOWING THE DATE OF DISCHARGE OR RECEIPT OF OUTPATIENT CARE TO SUBMIT AN APPLICATION FOR FINANCIAL ASSISTANCE. (C) IF THE PATIENT HAS AGREED TO A PAYMENT PLAN, UNTIL THE PATIENT HAS FAILED TO MAKE PAYMENTS IN ACCORDANCE WITH THAT PAYMENT PLAN. (D) IF THE PATIENT INFORMS KHS THAT HE OR SHE HAS APPLIED FOR HEALTH CARE COVERAGE UNDER MEDICAID, KIDCARE, OR OTHER GOVERNMENT-SPONSORED HEALTH CARE PROGRAM (AND THERE IS A REASONABLE BASIS TO BELIEVE THAT THE PATIENT WILL QUALIFY FOR SUCH PROGRAM), BUT THE PATIENT'S APPLICATION IS DENIED. PART VI, LINE 2: VALLEY WEST COMMUNITY HOSPITAL, A CRITICAL ACCESS HOSPITAL, IDENTIFIES COMMUNITY HEALTH NEEDS IN SEVERAL WAYS:* DEKALB AND KENDALL COUNTY HEALTH DEPARTMENT I-PLANS* COMMUNITY HEALTH NEEDS SURVEY* U.S. GOVERNMENT HEALTHY PEOPLE 2010 AND 2010 GUIDELINES* GUIDELINES FOR RURAL HOSPITALS WITH CRITICAL ACCESS DESIGNATION* INTERNAL REVIEW OF OUTPATIENT AND INPATIENT TRENDS, ESPECIALLY EMERGENCY DEPARTMENT USAGE * INPUT FROM OTHER COMMUNITY PROVIDERS. THIS INCLUDES PROVIDING HOSPITAL LEADERS SERVING ON BOARDS AND COMMITTEES THAT DIRECTLY OR INDIRECTLY IMPACT COMMUNITY HEALTH OR HELP THE HOSPITAL CONNECT TO UNDERSERVED OR VULNERABLE POPULATIONS. PART VI, LINE 3: INFORMATION IS PROVIDED AT REGISTRATION, VIA THE HOSPITAL WEBSITE, THROUGH CONSULTATIONS WITH FINANCIAL COUNSELORS, DURING THE BILLING PROCESS ON STATEMENTS, AND VIA PHONE CONVERSATIONS. PART VI, LINE 4: VALLEY WEST COMMUNITY HOSPITAL SERVES ALL OF DEKALB COUNTY, IL, AND BORDER COMMUNITIES IN KENDALL AND LASALLE COUNTIES. THE POPULATION OF THE VALLEY WEST SERVICE AREA, BASED ON THE 2010 CENSUS, WAS 71,523. THIS GEOGRAPHIC AREA INCLUDES A GROWING HISPANIC POPULATION. THE HISPANIC POPULATION IS EXPECTED TO GROW BY 44.69% BY 2016. ACCORDING TO THE AMERICAN COMMUNITY SURVEY, 18.2 % OF FAMILIES AND 29.3% OF INDIVIDUALS ARE BELOW THE POVERTY LEVEL BASED ON POPULATION AND HOUSING DATA FROM 2005-2009. PART VI, LINE 6: VALLEY WEST COMMUNITY, A CRITICAL ACCESS HOSPITAL IN SANDWICH, IL, IS PART OF KISHHEALTH SYSTEM. THE HEALTH SYSTEM IS GOVERNED BY AN APPOINTED VOLUNTEER BOARD OF DIRECTORS, INDEPENDENT COMMUNITY LEADERS WHO RESIDE IN THE PRIMARY MARKETS SERVED BY THE HEALTH SYSTEM'S TWO HOSPITALS. THESE INDIVIDUALS ARE SELECTED FOR THE BOARD BECAUSE OF THEIR INTEREST AND EXPERTISE IN VARIOUS AREAS THAT CAN HELP MANAGEMENT CARRY OUT THE HEALTHY SYSTEM'S MISSION. MEMBERS OF THE BOARD ARE NOT COMPENSATED FOR THEIR TIME. THE MEDICAL STAFF IS OPEN TO PHYSICIANS WHO MEET CRITERIA ESTABLISHED BY THE MEDICAL STAFF BYLAWS. PHYSICIANS ARE GIVEN AND TAKE THE OPPORTUNITY TO VOLUNTEER TO DO FREE COMMUNITY WELLNESS PROGRAMS ON HEALTH TOPICS. SURPLUS FUNDS GO BACK INTO THE ORGANIZATION TO SUPPORT OPERATIONS, CAPITAL IMPROVEMENTS, THE HEALTH SYSTEM'S COMMITMENT TO EXCELLENCE, EDUCATION AND INNOVATION, AND TO PROVIDE MEDICAL CARE TO ALL REGARDLESS OF ABILITY TO PAY. A COMMUNITY HEALTH ASSESSMENT WAS CONDUCTED IN THE FALL OF 2009, VIA A RANDOM TELEPHONE SURVEY. RESULTS ARE ONE COMPONENT USED FOR FY 11 ACTION PLANNING FOR. (SEE SCHEDULE O OF THIS REPORT FOR DETAILS ABOUT COMMUNITY WELLNESS ACTIVITIES FOR FY 10.) PART VI, LINE 7: KISHHEALTH SYSTEM MADE $120,000 IN CONTRIBUTIONS TO SEVERAL ORGANIZATIONS IN FY11, 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. OTHER GRANTS WERE MADE TO THE KISHWAUKEE (COMMUNITY COLLEGE) COLLEGE FOUNDATION TO SUPPORT AN ENDOWMENT FOR SCHOLARSHIPS IN HEALTH-RELATED FIELDS. OTHER MONETARY GIFTS SUPPORTED THE ECONOMIC HEALTH OF COMMUNITIES SERVED, SUCH AS DOWNTOWN DEKALB RENEWAL AND OTHER DEKALB COUNTY ECONOMIC DEVELOPMENT EFFORTS. HEALTH SYSTEM LEADERS SERVED ON NUMEROUS COMMUNITY BOARDS AND COMMITTEES, MOST NOTABLY THE COMMUNITY CARES CLINIC, VOLUNTARY ACTION CENTER, FAMILY SERVICE AGENCY, FOX VALLEY OLDER ADULT SERVICES, KISHWAUKEE UNITED WAY, AND KISHWAUKEE FAMILY YMCA, DEKALB COUNTY ECONOMIC DEVELOPMENT CORPORATION, PLANO ECONOMIC DEVELOPMENT COMMISSION AND SANDWICH CHAMBER OF COMMERCE.IN ADDITION, HEALTH SYSTEM EMPLOYEES CONTRIBUTED MORE THAN 1,300 HOURS OF IN-KIND SERVICE TO COMMUNITY ORGANIZATIONS, EDUCATIONAL INSTITUTIONS AND OTHER ACTIVITIES THAT PROMOTE HEALTH, EDUCATION AND QUALITY OF LIFE. OTHER NON-PROFIT HEALTH SYSTEM ENTITIES THAT PROMOTE THE HEALTH OF THE COMMUNITY ARE VALLEY WEST COMMUNITY HOSPITAL, A CRITICAL ACCESS HOSPITAL IN SANDWICH, IL; COMMUNITY CARES CLINIC, DEKALB, IL, A PRIMARY CARE CLINIC FOR MEDICAID AND UNINSURED; DEKALB COUNTY HOSPICE, DEKALB, IL, WHICH PROVIDES FREE CARE AND SUPPORT FOR THE TERMINALLY ILL AS WELL AS GRIEF SUPPORT TO THE PUBLIC; AND KISHHEALTH FOUNDATION IN DEKALB, IL, WHICH RAISES MONEY FOR KISHWAUKEE COMMUNITY HOSPITAL, VALLEY WEST COMMUNITY HOSPITAL, DEKALB COUNTY HOSPICE AND THE COMMUNITY CARES CLINIC. REPORTS FILED WITH STATES PART VI, LINE 7 IL 1 AMERICAN HEART ASSOCIATION 7272 GREENVILLE AVE DALLAS TX 75231 135613797 501(C)(3) 5000 SUPPORT INITIATIVE TO REDUCE HEART DISEASE IN WOMEN 1 PROCEDURE FOR MONITORING GRANTS IN THE U.S.: PART I, LINE 2: SCHEDULE I, PART I, LINE 2: THE ORGANIZATION MAINTAINS SPECIFIC POLICIES AND QUALIFICATIONS FOR ALL GRANTS AVAILABLE. APPLICANTS MUST APPLY FOR THE RESPECTIVE GRANT AND BE APPROVED BY THE FUNDS GOVERNING BOARD. THE USE OF THE FUNDS IS MONITORED BY THE GOVERNING BOARD OF VALLEY WEST COMMUNITY HOSPITAL. REQUESTS FOR FINANCIAL ASSISTANCE FROM OTHER CHARITABLE ORGANIZATIONS ARE REVIEWED AND APPROVED BY THE VP - FINANCE OF KISHHEALTH SYSTEM. IF NECESSARY DUE TO THE DOLLAR AMOUNT OF THE REQUEST, THESE ITEMS MAY ALSO BE PRESENTED TO THE BOARD OF DIRECTORS. A BUDGET IS SET ANNUALLY FOR CHARITABLE ASSISTANCE TO OTHER ORGANIZATIONS X 1 1 X X X X 0 1 0 0 0 0 0 0 0 KEVIN POORTEN 0 493308 0 175161 0 250000 0 79288 0 21089 0 1018846 0 250000 LOREN FOELSKE 0 248671 0 54917 0 0 0 19288 0 20275 0 343151 0 0 BRAD COPPLE 0 267332 0 74025 0 0 0 19288 0 20523 0 381168 0 0 PAM DUFFY 0 190811 0 43878 0 0 0 18566 0 7930 0 261185 0 0 JOE DANT 0 210725 0 47861 0 0 0 19288 0 20211 0 298085 0 0 MIKE MUZZILLO 0 141062 0 20199 0 0 0 12707 0 13427 0 187395 0 0 MIKE KOKOTT 0 165989 0 27914 0 0 0 15303 0 7669 0 216875 0 0 ROGER HEATH BELL 0 168475 0 48366 0 0 0 17393 0 20052 0 254286 0 0 DR MICHAEL KULISZ 0 204758 0 0 0 0 0 0 0 20414 0 225172 0 0 MARK THATE 0 145067 0 34336 0 0 0 14318 0 13529 0 207250 0 0 SUE HOHENBERGER 128470 0 7313 0 0 0 10749 0 13121 0 159653 0 0 0 PART I, LINE 1A HEALTH AND SOCIAL CLUB DUES PAID BY THE ORGANIZATION ARE REPORTED ON THE INDIVIDUALS FORM W-2 AS COMPENSATION. PART I, LINE 4B THE ORGANIZATION'S CEO PARTICIPATES IN A NONQUALIFIED DEFERRED COMPENSATION PLAN. CONTRIBUTIONS FOR CALENDAR YEAR 2010 WERE $60,000. DURING 2010, THE CEO TOOK A DISTRIBUTION FROM THE DEFERRED COMPENSATION PLAN IN THE AMOUNT OF $250,000. THIS DISTRIBUTION IS INCLUDED AS W-2 WAGES, HOWEVER THE ACCRUAL OF THE DEFERRED COMPENSATION PAYMENTS HAS ALSO BEEN INCLUDED AS "OTHER COMPENSATION" ON PRIOR YEAR FORM 990S. KISHHEALTH SYSTEM COMMON DIRECTORS/OFFICERS/KEY EMPLOYEES, KHS IS PARENT ORGANIZATION OF VWCH 3501975 KISHHEALTH SYSTEM (KHS) IS THE PARENT ORGANIZATION OF VALLEY WEST COMMUNITY HOSPITAL. THE PURPOSE OF KHS IS TO PROVIDE MANAGEMENT AND SUPPORT SERVICES TO ITS RELATED ORGANIZATIONS, ALL OF WHICH PROVIDE HEALTHCARE SERVICES. FEES PAID TO KHS ARE IN EXCHANGE FOR THESE SERVICES, INCLUDING THE ORGANIZATIONS SHARE OF COMPENSATION OF DIRECTORS, OFFICERS, AND KEY EMPLOYEES. DURING THE CURRENT YEAR, VALLEY WEST COMMUNITY HOSPITAL ALSO MADE AN EQUITY DISTRIBUTION BACK TO ITS PARENT COMPANY IN THE AMOUNT OF $470,000. 0 HEALTH PROGRESS INC COMMON DIRECTORS/OFFICERS/KEY EMPLOYEES, BROTHER/SISTER AFFILIATE 67491 HEALTH PROGRESS, INC. IS AN AFFILIATE OF VALLEY WEST COMMUNITY HOSPITAL. HEALTH PROGRESS SUBLEASES OFFICE SPACE FROM VALLEY WEST COMMUNITY HOSPITAL. 0 KISHHEALTH FOUNDATION COMMON DIRECTORS/OFFICERS/KEY EMPLOYEES, BROTHER/SISTER AFFILIATE 42928 KISHHEALTH FOUNDATION WAS ORGANIZED TO SUPPORT CHARITABLE HEALTHCARE ORGANIZATIONS. THE FOUNDATION ANNUALLY MAKES CONTRIBUTIONS TO VALLEY WEST COMMUNITY HOSPITAL. 0 KISHHEALTH SYSTEM COMMON DIRECTORS/OFFICERS/KEY EMPLOYEES, KHS IS PARENT ORGANIZATION OF VWCH 470000 DURING THE CURRENT YEAR, VALLEY WEST COMMUNITY HOSPITAL ALSO MADE AN EQUITY DISTRIBUTION BACK TO ITS PARENT ORGANIZATION. 0 KISHWAUKEE COMMUNITY HOSPITAL COMMON DIRECTORS/OFFICERS/KEY EMPLOYEES, BROTHER/SISTER AFFILIATE 3917755 VALLEY WEST COMMUNITY HOSPITAL ROUTINELY PURCHASES SUPPLIES AND SERVICES FROM A KISHWAUKEE COMMUNITY HOSPITAL AS PART OF ITS DAY-TO-DAY BUSINESS. 0 FORM 990, PART VI, SECTION A, LINE 2 KEVIN POORTEN AND LOREN FOELSKE ARE BOTH EMPLOYEES OF KISHHEALTH SYSTEM, THE PARENT ORGANIZATION OF VALLEY WEST COMMUNITY HOSPITAL. MR. POORTEN IS PRESIDENT AND CEO OF KISHHEALTH SYSTEM AND SERVES AS AN EX-OFFICIO DIRECTOR FOR ALL ORGANIZATIONS RELATED TO KISHHEALTH SYSTEM. MR. FOELSKE SERVES AS THE VICE-PRESIDENT - FINANCE OF KISHHEALTH SYSTEM, WHICH IS THE PARENT ORGANIZATION FOR ALL RELATED ENTITIES. BRAD COPPLE, AS THE PRESIDENT OF VWCH, IS CONSIDERED AN OFFICER. HE IS ALSO PRESIDENT OF KISHWAUKEE COMMUNITY HOSPITAL, A RELATED ENTITY, AND IS COMPENSATED BY KISHHEALTH SYSTEM. MR. POORTEN AND MR. FOELSKE ARE ALSO CONSIDERED OFFICERS OF KISHWAUKEE COMMUNITY HOSPITAL AND KISHHEALTH SYSTEM, AS DESCRIBED ABOVE. ERIK ENGLEHART AND TERRENCE DUFFY ARE MEMBERS OF THE VALLEY WEST COMMUNITY HOSPITAL BOARD OF DIRECTORS. THEY ALSO SERVE ON THE BOARD OF DIRECTORS OF KISHHEALTH SYSTEM, THE PARENT ORGANIZATION OF VALLEY WEST COMMUNITY HOSPITAL. THE FOLLOWING INDIVIDUALS ARE OFFICERS OR KEY EMPLOYEES OF KISHHEALTH SYSTEM AND ARE ALSO CONSIDERED OFFICERS OR KEY EMPLOYEES OF VALLEY WEST COMMUNITY HOSPITAL. THEY ARE ALL COMPENSATED BY KISHHEALTH SYSTEM: BRAD COPPLE, PRESIDENT KCH & VWCH PAM DUFFY, VP PATIENT CARE JOE DANT, VP DEVELOPMENT MIKE KOKOTT, ASST. VP MARKETING ROGER HEATH BELL, VP AND CHIEF INFORMATION OFFICER MARK THATE, VP HUMAN RESOURCES DR. MICHAEL KULISZ, CHIEF MEDICAL OFFICER MIKE MUZZILLO, VP OPERATIONS - VWCH FORM 990, PART VI, SECTION A, LINE 6 KISHHEALTH SYSTEM IS THE SOLE MEMBER OF VALLEY WEST COMMUNITY HOSPITAL. FORM 990, PART VI, SECTION A, LINE 7A AS THE SOLE MEMBER AND PARENT ORGANIZATION OF VALLEY WEST COMMUNITY HOSPITAL, KISHHEALTH SYSTEM HAS THE RIGHT TO APPROVE THE ELECTION OF MEMBERS OF THE HOSPITAL'S GOVERNING BOARD, PER THE HOSPITAL'S BYLAWS. FORM 990, PART VI, SECTION A, LINE 7B KISHHEALTH SYSTEM (KHS) SERVES AS THE SOLE MEMBER AND PARENT ORGANIZATION OF VALLEY WEST COMMUNITY HOSPITAL (VWCH). PER THE BYLAWS, WITH RESPECT TO THE GOVERNANCE OF VWCH, THE FOLLOWING POWERS SHALL BE RESERVED TO THE SOLE CORPORATE MEMBER: A. ELECTING THE MEMBERS OF THE VWCH BOARD; B. APPROVING, EVALUATING AND/OR REMOVING THE PRESIDENT AND CEO AND REVIEWING AND APPROVING THE EMPLOYMENT CONTRACT OF THE PRESIDENT AND CEO AND ESTABLISHING COMPENSATION FOR SUCH OFFICE; C. APPROVING THE STRATEGIC PLAN FOR VWCH; D. APPROVING THE DISPOSITION OF ANY ASSETS OTHER THAN IN THE ORDINARY COURSE OF BUSINESS FOR VWCH; E. APPROVING ANY CHANGE IN MEMBERSHIP OF VWCH; F. APPROVING THE ADOPTION OF AND AMENDMENTS TO THE ORGANIZATIONAL DOCUMENTS, INCLUDING THE ARTICLES OF INCORPORATION AND BYLAWS OF VWCH; G. APPROVING A PLAN OF MERGER OR A PLAN OF CONSOLIDATION OF VWCH OR ESTABLISHING A NEW SUBSIDIARY OR SISTER ENTITY; H. APPROVING A PLAN FOR THE DISTRIBUTION OF THE ASSETS OF VWCH; I. INITIATING, TAKING ANY AND ALL ACTIONS, AND EXERCISING ALL APPROVAL RIGHTS OF THE DIRECTORS PURSUANT TO THE APPLICABLE MEDICAL STAFF BYLAWS; J. IMPLEMENTING AND MONITORING VWCH OPERATIONAL QUALITY IMPROVEMENT POLICIES AND PROGRAMS; K. ACCEPTING GIFTS, GRANTS, BEQUESTS AND DONATIONS ON BEHALF OF VWCH; L. APPROVAL OF THE ANNUAL OPERATING AND CAPITAL BUDGETS FOR VWCH; M. EXERCISING ANY RIGHTS THAT VWCH HAS AS A SHAREHOLDER OR MEMBER OF ANY SUBSIDIARY ENTITY; N. APPROVING ANY AFFILIATIONS OF VWCH; O. APPROVING AND/OR DETERMINING (I) THE CREATION OF NEW HEALTH SERVICES TO BE PROVIDED AND THE LOCATION OF SUCH HEALTH SERVICES AND (II) THE DISCONTINUANCE OF ANY HEALTH SERVICE; P. AUTHORIZING THE SALE, LEASE, EXCHANGE OR MORTGAGE OF ALL OR SUBSTANTIALLY ALL OF THE PROPERTY OR ASSETS OF VWCH; Q. AUTHORIZING THE VOLUNTARY DISSOLUTION OF VWCH, OR REVOKING THE PROCEEDINGS THEREOF; R. REQUIRING MINUTES OF MEETINGS, FINANCIAL RECORDS, AND SUCH OTHER INFORMATION AS MAY BE NECESSARY TO PROPERLY EVALUATE THE PERFORMANCE OF VWCH; S. INITIATING ACTION TO REMOVE OR REINSTATE A DIRECTOR WHEN, IN THE OPINION OF THE KHS BOARD, IT IS IN THE BEST INTERESTS OF KHS OR VWCH. ANY ACTION TO REMOVE OR REINSTATE SHALL REQUIRE A MAJORITY VOTE OF THOSE KHS DIRECTORS THEN IN OFFICE PRESENT AND VOTING AT A MEETING OF THE KHS BOARD AT WHICH A QUORUM IS PRESENT. IN ANY ACTION(S) TO REMOVE TAKEN BY THE KHS BOARD, THE DIRECTOR IN QUESTION SHALL BE ADVISED AT LEAST TWENTY (20) DAYS PRIOR TO THE MEETING THAT THE ACTION WILL BE CONSIDERED AND SHALL BE GIVEN THE OPPORTUNITY TO MAKE A STATEMENT, PRESENT WITNESSES ON HIS/HER BEHALF AND QUESTION THOSE PRESENTING REASONS FOR HIS/HER REMOVAL. ALL ACTIONS TO REMOVE SHALL BE TAKEN IN CLOSED SESSIONS OF THE KHS BOARD; AND T. TRANSFERRING MONEY OR PROPERTY AMONG VWCH, KHS AND/OR ONE OR MORE SUBSIDIARY CORPORATIONS AND TRANSFERRING MONEY OR PROPERTY FROM A SUBSIDIARY CORPORATION, INCLUDING REQUIRING THE DIRECTORS, OFFICERS, OR TRUSTEES OF ANY SUBSIDIARY CORPORATION TO TRANSFER MONEY OR OTHER PROPERTY TO KHS. SUBJECT TO THE POWERS OF THE BOARD OF DIRECTORS OF EACH SUBSIDIARY CORPORATION, THE KHS BOARD MAY INITIATE AND TAKE THE FOREGOING ACTIONS ON BEHALF OF KHS AND THE SUBSIDIARY CORPORATIONS. FORM 990, PART VI, SECTION B, LINE 11 A DRAFT COPY OF FORM 990 IS PROVIDED TO THE GOVERNING BODY (BOARD OF DIRECTORS) AND THE GOVERANCE COMMITTEE FOR REVIEW BY THE RETURN PREPARER PRIOR TO FILING. THE ORGANIZATION'S CEO, CFO, AND OTHER MEMBERS OF THE ACCOUNTING DEPARTMENT ARE ALSO PROVIDED A COPY OF THE RETURN FOR THEIR REVIEW. THE CHAIR OF THE AUDIT COMMITTEE AND THE AUDIT COMMITTEE MEMBERS ARE ALSO PROVIDED DRAFT COPIES AND REVIEW. IF CHANGES ARE NECESSARY, THEY ARE REPORTED TO THE RETURN PREPARER AND INCORPORATED INTO THE FINAL RETURN. FORM 990, PART VI, SECTION B, LINE 12C CONFLICTS OF INTEREST ARE INVESTIGATED BY APPOINTED MEMBERS OF THE GOVERANCE COMMITTEE ON AN ONGOING BASIS. IF IT IS DETERMINED THAT AN INDIVIDUAL FAILED TO DISCLOSE AN ACTUAL OR POSSIBLE CONFLICT OF INTEREST, IT SHALL INFORM THE INDIVIDUAL OF SUCH A BELIEF AND AFFORD HIM AN OPPORTUNITY TO EXPLAIN. AFTER SAID EXPLANATION, THE BOARD SHALL TAKE APPROPRIATE DISCIPLINARY AND CORRECTIVE ACTION AS DEEMED NECESSARY. THE CONFLICT OF INTEREST POLICY IS REVIEWED BY THE BOARD ANNUALLY AND UPDATED AS NEEDED. FORM 990, PART VI, SECTION B, LINE 15 THROUGH THE OVERSIGHT OF THE BOARD OF DIRECTORS EXECUTIVE COMPENSATION COMMITTEE, THE KISHHEALTH SYSTEM EXECUTIVE TOTAL COMPENSATION PROGRAM WILL BE COMPETITIVELY POSITIONED IN THE MARKET PLACE OF RELEVANT ORGANIZATIONS AND FALL WITHIN THE SAFE HARBOR GUIDELINES ESTABLISHED BY THE INTERMEDIATE SANCTIONS RULES. THE EXECUTIVE COMPENSATION COMMITTEE IS MADE UP OF THREE MEMBERS OF THE BOARD OF DIRECTORS WHO MEET THE BOARD APPROVED DEFINITION OF "INDEPENDENT DIRECTORS". ANNUALLY THE EXECUTIVE COMPENSATION COMMITTEE CONTRACTS WITH SULLIVAN, COTTER AND ASSOCIATES, AN INDEPENDENT HUMAN RESOURCES CONSULTING FIRM TO PROVIDE THE COMMITTEE ANALYSIS AND COMPARABILITY DATA. USING THE SUPPLIED DATA THE COMPENSATION COMMITTEE APPROVES EACH EXECUTIVE'S TOTAL CASH COMPENSATION AND PROVIDES CONTEMPORANEOUS SUBSTANTIATION OF THE DELIBERATION AND DECISION. TOTAL CASH COMPENSATION IS DEFINED AS THE SUM OF BASE SALARIES PLUS INCENTIVE AWARDS. BASED ON THE COMPARABILITY DATA AND THE PERFORMANCE OF EACH EXECUTIVE IN MEETING GOALS AND STRATEGIC OBJECTIVES, THE EXECUTIVE COMPENSATION COMMITTEE APPROVES INCREASES AND INCENTIVE AWARDS FOR EACH EXECUTIVE WITHIN THE GUIDELINES ESTABLISHED. THE EXECUTIVE COMPENSATION COMMITTEE REPORTS ON ALL COMPENSATION MATTERS TO THE FULL BOARD OF DIRECTORS. FORM 990, PART VI, SECTION C, LINE 19 THE ORGANIZATION'S GOVERNING DOCUMENTS ARE AVAILABLE TO THE PUBLIC UPON REQUEST IN WRITING TO ADMINISTRATION. DESCRIPTION OF HOURS FOR RELATED ORGANIZATIONS FORM 990, PART VII, COLUMN (B) AVERAGE HOURS PER WEEK FOR THE INDIVIDUALS IDENTIFIED AS OFFICER'S ARE ESTIMATES OF THE INDIVIDUALS TOTAL TIME PER WEEK UTILIZED FOR WORK RELATED TO VALLEY WEST COMMUNITY HOSPITAL. CHANGES IN NET ASSETS OR FUND BALANCES: FORM 990, PART XI, LINE 5: NET UNREALIZED GAINS ON INVESTMENTS: 2,170,056. EQUITY DISTRIBUTION TO KISHHEALTH SYSTEM, INC. -470,000. GRANT INCOME RECORDED AS OFFSET TO FIXED ASSET ACCOUNTS -30,511. EQUITY CONTRIBUTION FROM KISHHEALTH SYSTEM, INC. 56. CHANGE IN NET ASSETS OF KISHHEALTH FOUNDATION 710. TOTAL TO FORM 990, PART XI, LINE 5: 1,670,311. REPONSIBILITY FOR OVERSIGHT OF FINANCIAL STATEMENTS FORM 990, PART XI, LINE 2C THE ORGANIZATION MAINTAINS AN INDEPENDENT AUDIT COMMITTEE WHICH IS RESPONSIBLE FOR OVERSIGHT OF THE AUDITED FINANCIAL STATEMENTS. THIS COMMITTEE IS ALSO RESPONSIBLE FOR THE SELECTION OF THE INDEPENDENT AUDITOR. MEMBERS OF THE AUDIT COMMITTEE ARE ALSO MEMBERS OF THE KISHHEALTH SYSTEM BOARD OF DIRECTORS. KISHHEALTH SYSTEM IS THE PARENT CORPORATION OF VALLEY WEST COMMUNITY HOSPITAL. KISHHEALTH SYSTEM ONE KISH HOSPITAL DRIVE DEKALB IL 60115 363649080 PARENT CORPORATION OF 501(C)(3) HEALTH SYSTEM IL 501(C)(3) 11B N/A 0 KISHHEALTH FOUNDATION ONE KISH HOSPITAL DRIVE DEKALB IL 60115 363649077 SUPPORT OF CHARITABLE HEALTH ORGANIZATIONS IL 501(C)(3) 7 N/A 0 KISHWAUKEE COMMUNITY HOSPITAL ONE KISH HOSPITAL DRIVE DEKALB IL 60115 237087041 HEALTHCARE SERVICES, PRIMARILY ACUTE CARE IL 501(C)(3) 3 N/A 0 DEKALB COUNTY HOSPICE 2727 SYCAMORE ROAD DEKALB IL 60115 363164329 HOSPICE SERVICES IL 501(C)(3) 7 N/A 0 COMMUNITY CARES CLINIC 3100 SYCAMORE ROAD DEKALB IL 60115 800424001 HEALTHCARE SERVICES, PRIMARY CARE IL 501(C)(3) 3 N/A 0 H-R EYE INSTITUTE 2240 GATEWAY DRIVE SYCAMORE IL 60178 651293967 HEALTHCARE SERVICES IL 501(C)(3) 3 N/A 0 HEALTH PROGRESS INC ONE KISH HOSPITAL DRIVE DEKALB IL 60115 363824138 INVESTMENT IN HEALTHCARE RELATED SMALL BUSINESSES IL N/A C 0 0 1 0 0 0 0 0 0 0 0 0 1 1 1 1 1 1