2022-11-15T16:21:33-06:00 2021-12-31 410746749 CLIFTONLARSONALLEN LLP 600 WASHINGTON AVENUE SUITE 1800 ST LOUIS MO 63101 990 2021-01-01 361000540 KATHERINE SHAW BETHEA HOSPITAL KATH 8152885531 403 EAST FIRST STREET DIXON IL 61021 DAVID SCHREINER CEO 8152855521 2022-11-15 1 DAVID SCHREINER 361000540 AMBER ROGNAN-HAMILTON P01251012 3149254300 2022-11-15 3 AAL1 IAL1 2021 2022-09-23 18:48:47Z DAVID SCHREINER 403 EAST FIRST STREET DIXON IL 61021 160782073 0 X WWW.KSBHOSPITAL.COM X 1893 IL RESTORE, MAINTAIN, AND ENHANCE HEALTH BY PROVIDING SUPERIOR CARE NOW AND IN THE FUTURE. 11 9 1158 85 0 0 15551134 7654933 135437712 151479780 1215966 41570 904160 859460 153108972 160035743 102396 256991 0 0 80224804 86842852 0 0 131615 87838811 77699314 168166011 164799157 -15057039 -4763414 143545322 132187622 84645214 76989025 58900108 55198597 TO RESTORE, MAINTAIN, AND ENHANCE HEALTH BY PROVIDING SUPERIOR CARE NOW AND IN THE FUTURE. 0 0 141936619 256991 151479780 IN 2021, KATHERINE SHAW BETHEA HOSPITAL (KSB) HAD 3,224 INPATIENT VISITS AND 246,728 OUTPATIENT VISITS. KSB IS COMMITTED TO PROVIDING THE HIGHEST QUALITY OF HEALTHCARE REGARDLESS OF ABILITY TO PAY. KSB SUBSIDIZES THE COST OF TREATING PATIENTS WHO ARE UNABLE TO PAY AND THOSE WHO RECEIVE GOVERNMENT ASSISTANCE WHERE REIMBURSEMENT IS LIMITED. THE COST OF CHARITY CARE, BASED ON THE HOSPITAL'S COST-TO-CHARGE RATIO, PROVIDED BY THE HOSPITAL, WAS APPROXIMATELY $67,000 IN 2021.KSB PROVIDES 24-HOUR EMERGENCY MEDICAL SERVICES STAFFED BY FULL-TIME PHYSICIANS. PATIENTS ARE TREATED REGARDLESS OF INSURANCE OR ABILITY PAY. ER VISITS IN 2021 WERE 16,575. 141936619 1 1 0 1 0 0 0 0 0 1 1 0 0 0 0 1 0 1 0 0 0 0 0 0 0 0 1 1 1 1 1 0 0 0 0 0 0 1 0 0 0 0 0 0 1 1 1 0 0 1 87 0 1158 1 0 0 0 0 0 0 0 0 0 0 0 0 X 11 9 0 0 0 0 0 1 1 1 1 0 0 1 1 1 1 1 1 1 1 0 IL X AUSTIN FRAZIER JR 8152855511 403 EAST FIRST STREET DIXON IL 61021 LYNETTE KNODLE CHAIRPERSON 2.10 0.00 X X 0 0 0 COLLEEN T HENKEL VICE CHAIRPERSON 1.40 0.00 X X 0 0 0 KATIE PRATT SECRETARY 0.90 0.00 X X 0 0 0 CHRIS HAMMITT TREASURER 1.40 0.00 X X 0 0 0 RICK CURIA PAST CHAIRPERSON 0.90 1.00 X 0 0 0 JOSEPH WELTY MD BOARD MEMBER / PHYSICIAN 7.00 0.00 X 126830 0 6342 RAY NEISEWANDER III BOARD MEMBER 0.90 1.00 X 0 0 0 DAVID HELLMICH BOARD MEMBER 1.30 1.00 X 0 0 0 RICHARD BOYSEN BOARD MEMBER 1.40 0.00 X 0 0 0 PATRICK KING DDS BOARD MEMBER 1.70 0.00 X 0 0 0 DAVID SCHREINER CEO AND BOARD MEMBER 40.00 1.00 X X 562900 0 30778 LINDA CLEMEN VP-CHIEF NURSING OFFICER 40.00 0.00 X 263082 0 30231 SUZANNE RAVLIN VP-CHIEF LEGAL OFFICER 40.00 1.00 X 312601 0 25978 PRATIP NAG MD CHIEF MEDICAL OFFICER 40.00 0.00 X 294131 0 23437 MICHAEL KITTOE VP-CHIEF FINANCIAL OFFICER 40.00 0.00 X 339551 0 18648 RAY SHARP VP-CHIEF INFORMATION OFFICER 40.00 0.00 X 255751 0 25256 MONTHER ELBZOUR MD PHYSICIAN 40.00 0.00 X 1931934 0 37511 SOHAIL HANIF MD PHYSICIAN 40.00 0.00 X 1279598 0 37511 ROBB RYDZYNSKI MD PHYSICIAN 40.00 0.00 X 919548 0 46850 FADI MOHAMAD MUSTAPHA MD PHYSICIAN 40.00 0.00 X 887451 0 38711 KURT CROWE MD PHYSICIAN 40.00 0.00 X 829601 0 46850 8002978 0 368103 99 0 1 0 PAYCOM PAYROLL LLC 7501 W MEMORIAL ROAD OKLAHOMA CITY OK 73142 PAYROLL SERVICES 5112339 RSM US LLP 5155 PAYSPHERE CIRCLE CHICAGO IL 60674 CONSULTING SERVICES 1242114 LAB CORPORATION PO BOX 12140 BURLINGTON NC 27216 LAB TESTING 1138872 ROCKFORD ANESTHESIOLOGISTS ASSOCIATED L PO BOX 4569 ROCKFORD IL 61110 ANESTHESIOLOGY 602553 HORIZON HEALTH PO BOX 840839 DALLAS TX 75284 MENTAL HEALTH SERVICES 600919 17 12830 7613731 28372 7654933 NET PATIENT SERVICE REVENUE 621110 151033108 151033108 NET CLINIC SPACE RENTAL 621110 446672 446672 151479780 210131 210131 282102 295667 297461 448869 -15359 -153202 -168561 -168561 CAFETERIA SALES 900099 398327 398327 INCENTIVE PAYMENT 900099 192902 192902 REVENUE SHARE 900099 135061 135061 133170 133170 859460 160035743 151479780 0 901030 X 246991 246991 10000 10000 2315516 744053 1571463 64947882 62703712 2142380 101790 2026316 1515721 510595 13748056 10220240 3527816 3805082 3572693 224667 7722 100163 100163 66789 49424 17365 31106 31106 18387 18387 19131003 12933141 6197273 589 216253 160666 55587 19721939 18225340 1493621 2978 5579275 4152228 1426087 960 1633015 932098 700917 135508 120497 15011 174684 141854 32830 901827 640394 261433 7047221 5339890 1706017 1314 2610491 1900861 709630 BAD DEBT EXPENSE 11549521 11549521 IPA/SALES & USE TAX 4894779 3623591 1271188 REPAIRS AND MAINTENANCE 1669436 1386569 282867 LICENSE FEES 892434 668794 223640 1325483 998178 311043 16262 164799157 141936619 22730923 131615 303293 232511 24624463 20285472 38938505 31064802 1952691 1905297 1393908 1647567 157588078 107887523 51336570 49700555 19109357 21580012 5886535 5771406 143545322 132187622 53442198 50689260 4748667 6287141 20560941 20012624 5893408 84645214 76989025 X 57620259 53918748 1279849 1279849 58900108 55198597 143545322 132187622 X -4763414 777032 284871 X X 0 1 X 1 1 1 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 0 0 0 0 0 0 0 0 1 31106 31106 0 PART II-B, LINE 1: A PORTION OF THE HOSPITAL'S MEMBERSHIP DUES WITH THE ILLINOIS HOSPITAL ASSOCIATION AND THE AMERICAN HOSPITAL ASSOCIATION ARE USED BY THOSE ASSOCIATIONS TO CONDUCT LOBBYING ACTIVITIES ON BEHALF OF ALL MEMBER HOSPITALS. 912772 912772 1085170 172398 912772 1043624 41546 1085170 1016016 27608 1043624 1892631 103244 979859 1016016 0.00000 1.00000 0.00000 1 0 2289039 2289039 57286020 35652406 21633614 5639755 4342412 1297343 91286789 67892705 23394084 1086475 1086475 49700555 X PART V, LINE 4: THE PURPOSE OF THE BULK OF THE ENDOWMENT FUND IS TO FUND COMMUNITY WELLNESS PROJECTS FOR THE KSB SERVICE AREA. THE REST OF THE ENDOWMENT, $25,000, WAS ESTABLISHED MANY YEARS AGO AND IS IN AN ACCOUNT WITH OTHER RESTRICTED FUNDS WHICH ALL EARN INTEREST. THE INTEREST ON THIS ENDOWMENT IS INTENDED TO BE USED TO PROVIDE FREE SERVICES TO THE NEEDY. AT THIS TIME, THE BANK GROUPS ALL INTEREST BEARING ACCOUNTS TOGETHER TO DETERMINE INTEREST EARNED AGAINST FEES INCURRED. ANY INTEREST EARNED IS THEN REPORTED IN TOTAL FOR ALL ACCOUNTS ON THE STATEMENT OF REVENUE. THOUGH KSB IS NOT ABLE TO SEPARATELY REPORT THE INTEREST EARNED ON THE ENDOWMENT, THE HOSPITAL HAS SHOWN ON SCHEDULE H THAT THEY PROVIDE MANY FREE SERVICES TO THOSE IN NEED WITH THE FUNDS THEY RECEIVE. PART X, LINE 2: THE HOSPITAL APPLIES THE INCOME TAX STANDARD FOR UNCERTAIN TAX POSITIONS. THIS STANDARD CLARIFIES THE ACCOUNTING FOR UNCERTAINTY IN INCOME TAXES RECOGNIZED IN AN ORGANIZATION'S FINANCIAL STATEMENTS IN ACCORDANCE WITH THE INCOME TAX STANDARD. THIS STANDARD PRESCRIBES RECOGNITION AND MEASUREMENT OF TAX POSITIONS TAKEN OR EXPECTED TO BE TAKEN ON A TAX RETURN THAT ARE NOT CERTAIN TO BE REALIZED. THE HOSPITAL DOES NOT CURRENTLY INCLUDE AN INCOME TAX PROVISION IN THE CONSOLIDATED FINANCIAL STATEMENTS. MANAGEMENT MONITORS THE REPORTING OF UNCERTAIN TAX POSITIONS, WHICH COULD RESULT IN RECORDING OF AN INCOME TAX PROVISION IN THE FUTURE. 1 1 X 1 X 1 X 1 1 0 0 414118 414118 0.00250 24407548 7230264 17177284 0.10420 24821666 7230264 17591402 0.10670 697216 142 697074 0.00420 3656967 6072360 0 0.00000 44659 51207 0 0.00000 61567 61567 0.00040 4460409 6123709 758641 0.00460 29282075 13353973 18350043 0.11130 1 11549521 1462592 24840085 28785830 -3945745 X 1 1 1 1 KATHERINE SHAW BETHEA HOSPITAL 403 E FIRST STREET DIXON IL 61021 WWW.KSBHOSPITAL.COM 2114484 X X X X KATHERINE SHAW BETHEA HOSPITAL 1 0 0 1 X X X X X X X X X 19 1 0 1 1 X WWW.KSBHOSPITAL.COM/CHNA X X 1 19 1 WWW.KSBHOSPITAL.COM/CHNA 0 1 X 200.000000000000 300.000000000000 X X X X 1 1 X X X X 1 X WWW.KSBHOSPITAL.COM/FINANCIALASSISTANCE/ X WWW.KSBHOSPITAL.COM/FINANCIALASSISTANCE/ X SEE PART V PAGE 8 X X X X X 1 X 0 X X X X 1 X 0 0 KATHERINE SHAW BETHEA HOSPITAL PART V, SECTION B, LINE 5: DATA FOR THIS CHNA WAS OBTAINED FROM A VARIETY OF SOURCES, BOTH IN PERSON AND ONLINE. DEMOGRAPHIC DATA AND HEALTH INDICATORS WERE OBTAINED ON THE COMMUNITY COMMONS WEBSITE THROUGH THEIR CHNA REPORT TOOL. POPULATION DATA WAS OBTAINED FROM THE U.S. CENSUS BUREAU WEBSITE AND THEIR AMERICAN COMMUNITY SURVEY TOOL.AS PART OF A STRATEGIC PLANNING PROCESS IN EARLY 2019, KSB ADMINISTRATION AND MEMBERS OF THE BOARD OF DIRECTORS CONDUCTED MORE THAN 100 IN-PERSON INTERVIEWS WITH STAKEHOLDERS AND REPRESENTATIVES OF WIDELY VARIED PARTS OF THE COMMUNITY. THOSE INTERVIEWS WERE DOCUMENTED IN A STANDARDIZED WAY AND ALLOWED SEVERAL VALUABLE INSIGHTS INTO THE HEALTH NEEDS AND PERCEIVED LEVELS OF ACCESS TO VARIOUS SERVICES WITHIN OUR COMMUNITY.A CHNA SURVEY WAS OPENED TO THE GENERAL PUBLIC IN SEPTEMBER 2019 AND RESPONSES WERE SOLICITED THROUGH THE KSB HOSPITAL WEBSITE AND SOCIAL MEDIA ACCOUNTS. WE RECEIVED 122 RESPONSES, INCLUDING 14% FROM INDIVIDUALS WHO RECEIVED FINANCIAL ASSISTANCE IN PAST YEAR SUCH AS TANF, PUBLIC AID, MEDICAL CARD, FOOD STAMPS, TOWNSHIP ASSISTANCE, OR OTHER TYPES OF AID, NOT INCLUDING MEDICARE OR SOCIAL SECURITY.DATA FROM THESE REPORTS, INTERVIEWS, AND SURVEYS WERE SHARED WITH THE KSB WELLNESS STEERING COMMITTEE TO SOLICIT INPUT AND STIMULATE DISCUSSION OF COMMUNITY HEALTH NEEDS AMONG A COMMITTEE THAT MEETS THROUGHOUT THE YEAR TO DISCUSS WELLNESS INITIATIVES. KATHERINE SHAW BETHEA HOSPITAL PART V, SECTION B, LINE 6B: THE HOSPITAL'S CHNA WAS CONDUCTED WITH THE LEE COUNTY HEALTH DEPARTMENT AND LEE-OGLE TRANSPORTATION SYSTEM KATHERINE SHAW BETHEA HOSPITAL PART V, SECTION B, LINE 7D: KATHERINE SHAW BETHEA HOSPITAL IS A 80 BED RURAL ACUTE CARE HOSPITAL. ITS CHNA IS ALSO PROVIDED TO THE PUBLIC THROUGH SOCIAL MEDIA, INCLUDING BUT NOT LIMITED TO FACEBOOK AND TWITTER. KATHERINE SHAW BETHEA HOSPITAL PART V, SECTION B, LINE 11: THE SURVEYS, INTERVIEWS, CENSUS INFORMATION, DEMOGRAPHICS, AND HEALTH INDICATOR DATA - COMBINED WITH THE INPUT FROM CLINICIANS AND ORGANIZATIONAL LEADERS - INDICATE THE FOLLOWING TO BE THE TOP HEALTH NEEDS OF THE COMMUNITY: BEHAVIORAL HEALTH, OBESITY AND PHYSICAL INACTIVITY, ACCESS TO CARE AND TRANSPORTATION, FOOD INSECURITY, AND TOBACCO AND E-CIGARETTE USE.BEHAVIORAL HEALTH: BEHAVIORAL HEALTH HAS BEEN PART OF COMMUNITY HEALTH NEEDS ASSESSMENTS SINCE OUR FIRST PROCESS IN 2013. AT KSB HOSPITAL, WE OFFER BOTH INPATIENT AND OUTPATIENT BEHAVIORAL HEALTH SERVICES. WE ALSO PARTNER WITH STRONG LOCAL PROVIDERS LIKE SINNISSIPPI CENTERS, A MULTI-COUNTY BEHAVIORAL HEALTH AND SUBSTANCE USE DISORDER SERVICE PROVIDER. TOGETHER WE OFFER BEHAVIORAL HEALTH SCREENINGS IN PRIMARY CARE OFFICES AND THE EMERGENCY DEPARTMENT. WE ALSO CREATED THE ROLE OF MENTAL HEALTH CRISIS PREVENTIONIST TO BE TRAINED AND READY TO RESPOND WITH DE-ESCALATION TECHNIQUES AND SUPPORT PATIENT AND STAFF SAFETY.WE'RE INVESTING IN TELEHEALTH EQUIPMENT AND TRAINING IN ORDER TO ADDRESS THE WORKFORCE RECRUITMENT CHALLENGES, ESPECIALLY WITH REGARD TO PSYCHIATRISTS AND THE NECESSITY OF PHYSICIAN SERVICES IN THE KSB INPATIENT BEHAVIORAL HEALTH UNIT. RECRUITMENT FOR AN ON-SITE PSYCHIATRIST CONTINUES, AND REMOTE TELEHEALTH PROVIDERS HELP ENSURE CONTINUITY OF SERVICES IN OUR COMMUNITY DURING THE SEARCH FOR DIFFICULT-TO-RECRUIT POSITIONS. WE ALSO MADE SIGNIFICANT CAPITAL INVESTMENTS TO IMPROVE PATIENT SAFETY WITHIN THE INPATIENT UNIT.STILL TODAY, SURVEYS INDICATE WIDESPREAD NEED FOR BEHAVIORAL HEALTH SERVICES. MORE THAN 50% OF SURVEY RESPONDENTS SAID THEY OR SOMEONE IN THEIR HOUSEHOLD HAD EXPERIENCED ANXIETY IN THE PAST YEAR, AND 45% ANSWERED AFFIRMATIVELY FOR DEPRESSION. FURTHER, 12% SAID YES FOR BIPOLAR DISORDER AND 9% YES FOR ADHD.IMPLEMENTATION PLAN FOR BEHAVIORAL HEALTH NEED:1)WORKING WITH THE BRAIN HEALTH NOW ORGANIZATION TO HELP END THE STIGMA AROUND MENTAL ILLNESS BY HOSTING STAFF MEETINGS, COMMUNITY SEMINARS, AND USING THE OUTREACH TOOLKIT2)FORMATION AND EXPANSION OF KSB MENTAL HEALTH COMMITTEE TO FOCUS ON STAFF TRAINING IN MENTAL HEALTH AWARENESS, CEU TRAINING FOR PROFESSIONALS, COMMUNITY AWARENESS SEMINARS, AND FUNDRAISING3)PROJECT OPEN, A COMMUNITY PROJECT OF MEDICAL, BEHAVIORAL HEALTH, PUBLIC HEALTH, EDUCATION, COURT, AND LAW ENFORCEMENT ORGANIZATIONS TO HELP BUILD A NETWORK TO PREVENT OPIOID ADDICTION THROUGH AWARENESS, EDUCATION, AND TRAINING4)ENGAGEMENT WITH THIRD-PARTY BEHAVIORAL HEALTH SERVICE LINE OPERATORS IN ORDER TO IMPROVE EFFICIENCY, ADOPT CLINICAL BEST PRACTICES, AND STRENGTHEN OPERATIONAL SUSTAINABILITY OF THE SPECTRUM OF MENTAL HEALTH SERVICES AT KSB5)HOSTING A TEN-PART COMMUNITY EDUCATIONAL EVENT SERIES ON BRAIN HEALTH WITH PRESENTATIONS BY BEHAVIORAL HEALTH EXPERTS TO HELP REDUCE STIGMA AND PROVIDE TIPS ON SUPPORTING POSITIVE BRAIN HEALTH6)MONTHLY BRAIN EXERCISE CLASSES TO HELP AGING LOCAL RESIDENTS BETTER UNDERSTAND BRAIN HEALTH AND HOW THEY CAN PROMOTE PHYSICAL AND MENTAL WELLNESS7)PATH 2 PURPOSE, A FREE, VOLUNTARY PROGRAM FOR TEENAGERS WHO WANT TO IMPROVE THEIR MOOD AND LEARN COPING SKILLS TO MANAGE DIFFICULT SITUATIONS, IN CONJUNCTION WITH A GRANT FROM THE NATIONAL CENTER FOR RURAL HEALTH PROFESSIONS8)IMPLEMENTATION OF A ZERO SUICIDE INITIATIVE THROUGH SCREENINGS AND ASSESSMENTS OF ALL PATIENTS ACROSS KSB SERVICE LINES AND FACILITIESOBESITY AND PHYSICAL INACTIVITY: AGAIN IN THE 2019 COMMUNITY HEALTH NEEDS ASSESSMENT, BOTH SURVEY AND HEALTH INDICATOR DATA SHOW THAT RESIDENTS OF LEE COUNTY EXPERIENCE OBESITY OR BEING OVERWEIGHT AT RATES THAT EXCEED STATE AND NATIONAL AVERAGES. SURVEY RESPONSES SHOW 63% OF PEOPLE HAVE PERSONAL OR FAMILY EXPERIENCE WITH BEING OBESE OR OVERWEIGHT. COUNTY HEALTH DATA SHOWS 37.6% OBESITY AND 53.4% OVERWEIGHT, COMPARED TO 29.4% OBESE AND 36.4% OVERWEIGHT AT THE STATE LEVEL.FURTHER SURVEY RESPONSES INDICATE 49% HAVE PERSONAL OR FAMILY EXPERIENCE WITH HIGH BLOOD PRESSURE AND 43% WITH HIGH CHOLESTEROL. AND 26.5% SAY THEY HAVE NO PHYSICAL ACTIVITY OUTSIDE OF WORK, COMPARED TO A STATE AVERAGE OF 21.8%.THE INCIDENCE OF OBESE, OVERWEIGHT, OR INACTIVE RESIDENTS PRESENTS SIGNIFICANT HEALTH CHALLENGES, INCLUDING HIGH BLOOD PRESSURE AND CHOLESTEROL, DIABETES, AND MANY OTHER ASSOCIATED CLINICAL ISSUES.KSB WILL CONTINUE TO OFFER AND SUPPORT LOCAL OPPORTUNITIES FOR PHYSICAL ACTIVITY AND EXERCISE. KSB IS A LEAD SPONSOR OF THE ANNUAL REAGAN 5K RUN DURING THE DIXON PETUNIA FESTIVAL, WHICH ALSO INCLUDES THE KSB CORPORATE CHALLENGE FOR EMPLOYER-BASED TEAM COMPETITION. KSB ALSO HOSTS EXERCISE CLASSES FOR ACTIVITIES LIKE A SIX-WEEK COURSE ON RESISTIVE BAND TRAINING, A SIX-WEEK COURSE ON INTERVAL TRAINING, AND YOGA.KSB WILL ALSO SPONSOR A NEW TEAM-BASED WEIGHT LOSS COMPETITION CALLED THE HEALTHYWAGE JACKPOT CHALLENGE, WHICH INCLUDES ACCESS TO AN APP WITH SUPPORT, MOTIVATION, AND MINI- CHALLENGES TO ENGAGE TEAM MEMBERS IN HEALTHY WEIGHT LOSS GOALS. KSB IS THE PRESENTING SPONSOR OF THE KSB WELLNESS CENTER EXERCISE FACILITY IN THE DIXON FAMILY YMCA, WITH DONATIONS TO PURCHASE NEW EXERCISE AND WEIGHT EQUIPMENT. KSB CLINICIANS ALSO OFFER A 'PRESCRIPTION' FOR THE DIXON FAMILY YMCA, THE NASH RECREATION CENTER, AND ANYTIME FITNESS, WHICH PROVIDES A FREE TRIAL TO RESIDENTS LOOKING TO START NEW HEALTHY HABITS. A REGISTERED DIETITIAN HOST ONE-ON-ONE NUTRITION AND FITNESS CONSULTATIONS WITH LOCAL PATIENTS. KSB WILL ALSO SPONSOR A BIKE GIVEAWAY AND AN ADOLESCENT BIKE RIDING GROUP IN CONJUNCTION WITH THE DIXON CITY MARKET EVENTS.IMPLEMENTATION PLAN FOR OBESITY AND PHYSICAL INACTIVITY NEED:1) OFFER RECURRING CLASSES ON EXERCISE TYPES AND NEW TRAINING METHODS TO HELP LOCAL RESIDENTS FIND AN INDIVIDUALIZED WAY TO INCORPORATE PHYSICAL ACTIVITY IN TO THEIR LIFE2) SPONSOR THE HEALTHYWAGE JACKPOT CHALLENGE TO PROMOTE TEAM WEIGHT LOSS AND PROVIDE APP-BASED EDUCATION AND SUPPORT3) REACH PATIENTS THROUGH ONE-ON-ONE CONSULTATIONS WITH A REGISTERED DIETITIAN IN A CLINICAL OR COMMUNITY SETTING4) SPONSOR LEARNING TO LIVE WELL EDUCATIONAL SERIES WITH SPECIALIZED SESSIONS FOR NUTRITION, EXERCISE, GOAL-SETTING, AND SEASONAL FOCUS ON NEW YEAR'S RESOLUTIONS, HEALTH DURING THE HOLIDAYS, AND OTHER RELEVANT TOPICS5) ONGOING FINANCIAL COMMITMENT TO THE KSB WELLNESS CENTER AT THE DIXON FAMILY YMCA, AND ENGAGEMENT WITH DIXON PARK DISTRICT PLANS FOR THE CONSTRUCTION OF A NEW COMMUNITY CENTER WITH WELLNESS AND FITNESS SERVICES6) HOSTING WEEKLY FREE BLOOD PRESSURE CHECKS AT LOCAL GROCERY STORE, AND EXPANDING TO OREGON CLINIC7) MONTHLY WELLNESS SCREENINGS FOR CHOLESTEROL AND ONE-ON-ONE CONSULTATIONS WITH A REGISTERED DIETITIANACCESS AND TRANSPORTATION: HEALTH SERVICES MAY BE AVAILABLE WITHIN A COMMUNITY BUT LOCAL RESIDENTS ARE UNABLE TO ACCESS THOSE SERVICES BECAUSE THEY DON'T KNOW ABOUT THEM, THEY CAN'T FIND TRANSPORTATION TO THEM, THEY CAN'T GET A CONVENIENT SCHEDULED APPOINTMENT TIME, OR THEY HAVE FINANCIAL LIMITATIONS TO ACCESS.CHNA SURVEY RESPONDENTS RATED "PUBLIC TRANSPORTATION FOR ALL RESIDENTS" WITH THE LOWEST SCORE OUT OF 11 CATEGORIES ON THE SURVEY. ADDITIONALLY, "EASY TO FIND INFORMATION ABOUT LOCAL SERVICES" WAS THE THIRD-LOWEST SCORE. SCORING SLIGHTLY BETTER WERE PUBLIC TRANSPORTATION FOR SENIORS OR THOSE WITH DISABILITIES. THE LEE-OGLE TRANSPORTATION SYSTEM OFFERS REGIONAL PUBLIC TRANSPORTATION, BUT HAS MORE RIDERS FROM THE SENIOR OR DISABLED POPULATIONS THAN FROM THE POPULATION AT-LARGE.KSB WILL SEEK TO OFFER MEDICAL SERVICES WHEN POSSIBLE VIA VIRTUAL VISITS, THUS ALLEVIATING THE NEED FOR TRANSPORTATION FOR SOME TYPES OF MEDICAL VISITS. A WIDER IMPLEMENTATION OF TELEMEDICINE WILL PROVIDE LOCAL RESIDENTS WITH A COST-EFFECTIVE WAY TO RECEIVE MEDICAL CARE WITHOUT THE RESULTING TRANSPORTATION HURDLES THAT MAY APPLY FOR PATIENTS WITH LIMITED OPTIONS.ADDITIONALLY, KSB IS PARTICIPATING IN A GRANT-SPONSORED MOBILITY PROJECT WITH THE LEE-OGLE TRANSPORTATION SYSTEM TO IDENTIFY SOLUTIONS TO MOBILITY PROBLEMS FOR LOW-INCOME INDIVIDUALS AND CHILDREN. THE MOBILITY PROJECT MEMBERS INTERVIEWED LOW-INCOME INDIVIDUALS AND USERS OF PUBLIC TRANSPORTATION TO ABOUT THE CHALLENGES THEY FACE, AND WHAT OPTIONS THEY HAVE FOR TRANSPORTATION TODAY.IMPLEMENTATION PLAN FOR ACCESS AND TRANSPORTATION NEED:1) LAUNCH AND SCALE UP KSB CARE ANYWHERE VIRTUAL VISITS THROUGH THE ZIPNOSIS TELEMEDICINE PLATFORM TO OFFER MEDICAL CARE FROM THE CONVENIENCE OF THE PATIENT'S HOME OR WORKPLACE TO ALLEVIATE THE NEED FOR TRANSPORTATION AND REDUCE WORK- AND SCHOOL-RELATED SCHEDULING CONFLICTS2) USE OF KSB HOSPITAL ADVERTISING SPENDING, SOCIAL MEDIA PRESENCE, FACILITY SIGNAGE, AND WEBSITE TO SHARE AND DISSEMINATE INFORMATION ON HEALTH AND WELLNESS SERVICES THAT ARE AVAILABLE WITHIN OUR COMMUNITY3) PARTICIPATE ON STEERING COMMITTEE OF LEE-OGLE TRANSPORTATION SYSTEM MOBILITY PROJECT AND SHARE INFORMATION ON APPOINTMENT CANCELLATIONS AND NO-SHOWS RELATED TO PATIENT TRANSPORTATION PROBLEMS4) SEE SCHEDULE O FOR REST OF EXPLANATION KATHERINE SHAW BETHEA HOSPITAL PART V, SECTION B, LINE 13B: STATE REGULATIONS ARE CONSIDERED IN DETERMINING ELIGIBILITY FOR FINANCIAL ASSISTANCE. PART V, LINE 16 C PLAIN LANGUAGE SUMMARY WEBSITE:WWW.KSBHOSPITAL.COM/WORDPRESS2017/WP-CONTENT/UPLOADS/2019/06/FINANCIAL-ASSISTANCE-PLAIN-LANGUAGE-SUMMARY.PDF 10 1 - COMMERCE TOWERS 215 EAST FIRST STREET DIXON IL 61021 PHYSICIAN CLINIC 2 - TOWN SQUARE CENTER 102 S HENNEPIN AVENUE DIXON IL 61021 PHYSICIAN CLINIC 3 - KSB OREGON CLINIC 1307 WASHINGTON OREGON IL 61061 PHYSICIAN CLINIC 4 - EDWARDS CLINIC 144 NORTH COURT DIXON IL 61021 PHYSICIAN CLINIC 5 - AMBOY CLINIC 305 EAST JOE DRIVE AMBOY IL 61310 PHYSICIAN CLINIC 7 - KSB EYE & VISION CARE 511 PALMYRA STREET DIXON IL 61021 PHYSICIAN CLINIC 8 - POLO CLINIC 1107 SOUTH DIVISION AVENUE POLO IL 61064 PHYSICIAN CLINIC 9 - ASHTON CLINIC 707 S MAIN STREET ASHTON IL 61006 PHYSICIAN CLINIC 10 - PHYSICIANS IMMEDIATE CARE 1672 SOUTH GALENA AVENUE DIXON IL 61021 PHYSICIAN CLINIC 11 - LOVETT CENTER 101 W FIRST ST DIXON IL 61021 ADMIN, TRAINING PART I, LINE 3C: FINANCIAL ASSISTANCE IS DETERMINED BASED ON FAMILY INCOME, ASSETS AND LIABILITIES, INSURANCE STATUS, AND QUALIFICATION FOR OTHER AVAILABLE ASSISTANCE PROGRAMS. INDIVIDUALS MAY QUALIFY FOR A PRESUMPTIVE DETERMINATION BASED ON HOMELESSNESS, DECEASED WITH NO ESTATE, MENTAL INCAPACITATION WITH NO ONE TO ACT ON THE PATIENT'S BEHALF, MEDICAID ELIGIBILITY, AND INCARCERATION IN A PENAL INSTITUTION. PART I, LINE 7: IT IS KSB HOSPITAL'S POLICY NOT TO WITHHOLD OR DENY ANY REQUIRED MEDICAL CARE AS A RESULT OF A PATIENT'S LACK OF THE ABILITY TO PAY. THE COSTING METHODOLOGY USED TO CALCULATE THE AMOUNTS IN THE ABOVE TABLE WAS DERIVED FROM THE 2021 CALCULATED COST TO CHARGE RATIO USING THE IRS WORKSHEET 2. PART I, LINE 7G: FOR 2021, SUBSIDIZED HEALTH SERVICES INCLUDED A DIABETIC CLINIC AND EMERGENCY MEDICAL SERVICES. PART II, COMMUNITY BUILDING ACTIVITIES: KSB HOSPITAL STRIVES TO BRING THE BEST INTEGRATED, QUALITY AND COST EFFECTIVE CARE AND INNOVATIVE TECHNOLOGY TO OUR SERVICE AREA. KSB SUPPORTS OTHER LOCAL NON-PROFITS THROUGHT CONTRIBUTIONS OF DOLLARS AND HOURS. WE SUPPORT THE LOCAL ECONOMIC DEVELOPMENT ORGANIZATIONS IN AN EFFORT TO BRING EMPLOYERS AND JOBS TO OUR SERVICE AREA. KSB IS A SUPPORTER OF THE ADOPT-A-ROAD PROGRAM. OUR EMPLOYEES CLEAN UP A STRETCH OF ILLINOIS ROUTE 2 TWICE A YEAR TO HELP IMPROVE AND PRESERVE OUR ENVIRONMENT. KSB SUPPORTS WORKFORCE DEVELOPMENT THROUGHT THE JUNIOR ACHIEVEMENT PROGRAM. HOURS AND DOLLARS ARE DONATED TO THIS PROGRAM. KSB ALSO SUPPORTS HABITAT FOR HUMANITY IN AN EFFORT TO PROVIDE AFFORDABLE HOUSING IN OUR SERVICE AREA. MANY OF OUR EMPLOYEES DONATED THEIR OWN TIME TO THIS ORGANIZATION. KSB HAS SUPPORTED HABITAT FOR HUMANITY WITH CASH DONATIONS. PART III, LINE 2: A PATIENT'S ACCOUNT IS WRITTEN OFF TO BAD DEBT AFTER 180 DAYS. ANY PATIENT PAYMENTS AND DISCOUNTS ARE DEDUCTED FROM GROSS CHARGES PRIOR TO THE WRITE-OFF PART III, LINE 3: THIS PORTION OF BAD DEBT IS RELATED TO ACCOUNTS THAY MAY HAVE QUALIFIED FOR THE HOSPITAL'S FINANCIAL ASSISTANCE POLICY. THE METHODOLOGY USED IS BASED ON HISTORICAL INFORMATION. THIS PORTION OF BAD DEBT WOULD HAVE BEEN INCLUDED IN CHARITY CARE HAD THE PATIENT COMPLETED THE NECESSARY PAPERWORK. PART III, LINE 4: FOOTNOTE #2 IS LOCATED ON PAGE 16 OF THE ATTACHED AUDITED FINANCIAL STATEMENTS AND BRIEFLY DESCRIBES THE PROVISION FOR BAD DEBTS RELATED TO UNINSURED PATIENTS. BAD DEBT IS LISTED AS A DEDUCTION FROM REVENUE. THIS TREATEMENT IS CONSISTENT WITH THE HFMA PRINCIPLES AND PRACTICES BOARD STATEMENT NO. 15 AND WITH THE AICPA AUDIT AND ACCOUNTING GUIDE FOR HEALTHCARE ORGANIZATIONS. PART III, LINE 8: KSB HOSPITAL IS A SMALL 80 BED HOSPITAL LOCATED IN RURAL LEE COUNTY IN NORTHERN ILLINOIS. IT WAS ESTIMATED THAT THE POPULATION OF LEE COUNTY WAS 34,049 IN 2021. 20.5% OF THE POPULATION WAS AGE 65 AND OLDER. THE CENSUS BUREAU ESTIMATED THAT 10.6% OF LEE COUNTY WAS BELOW THE POVERTY LINE. IN 2021, 70.1% OF OUR PAYOR MIX WAS MEDICARE RECIPIENTS. AS A HEALTHCARE PROVIDER WE REALIZE THAT SUBSTANTIAL SHORTFALLS ARISE FROM PAYMENTS THAT ARE LESS THAN WHAT IT COSTS TO PROVIDE CARE OR SERVICE AND DO NOT INCLUDED ANY AMOUNTS THAT RESULT FROM INEFFICIENCIES OR POOR MANAGEMENT. KSB HOSPITAL ACCEPTS ALL MEDICARE PATIENTS KNOWING THAT THERE MAY BE SHORTFALLS, THEREFORE IT HAS TAKEN THE POSITION THAT THEY SHOULD BE COUNTED AS PART OF THE COMMUNITY BENEFIT. ADDITIONALLY, IT IS IMPLIED IN THE INTERNAL REVENUE SERVICE REVENUE RULING 69-545 THAT TREATING MEDICARE PATIENTS IS A COMMUNITY BENEFIT. REVENUE RULING 69-545, WHICH ESTABLISHED THE COMMUNITY BENEFIT STANDARD FOR NON-PROFIT HOSPITALS, STATES THAT IF A HOSPITAL SERVES PATIENTS WITH GOVERNMENTAL HEALTH BENEFITS, INCLUDING MEDICARE, THEN THIS IS AN INDICATION THAT THE HOSPITAL OPERATES TO PROMOTE THE HEALTH OF THE COMMUNITY. BASED ON KSB HOSPITAL'S FILED 2021 MEDICARE COST REPORT THE MEDICARE ALLOWABLE COSTS FOR 2021 WERE $28,785,830 AND PAYMENTS RECEIVED FROM MEDICARE WERE $24,840,085. WE BELIEVE THAT THE SHORTFALL OF $3,945,745 SHOULD BE CONSIDERED COMMUNITY BENEFIT. PART III, LINE 9B: AFTER THREE STATEMENTS (90) DAYS WITH NO PAYMENT FROM PATIENT, THE ACCOUNT IS ELIGIBLE FOR COLLECTION ACCOUNTS UNDER $500 ARE TO BE PAID OFF IN 6 MONTHS AND OVER $500 PAID OFF WITHIN ONE YEAR. ACCOUNTS THAT HAVE BEEN APPROVED FOR FINANCIAL ASSISTANCE ARE NOT SENT TO COLLECTION. PART VI, LINE 2: KSB HAS A LONGSTANDING HISTORY, IN ADVANCE OF THE COMMUNITY BENEFITS STATUTE, OF WORKING COLLABORATIVELY WITH OTHER ORGANIZATIONS TO ASSESS AND ADDRESS COMMUNITY NEEDS. THERE ARE SEVERAL AREA AGENCIES THAT WE GARNER INFORMATION FROM IN GAUGING THE PULSE OF THE NEEDS OF THE SAUK VALLEY AREA. KSB EXAMINES THE NEEDS OF OUR SERVICE AREA AND RESPONDS THROUGH AVAILABLE PHYSICIANS, OPEN DISCLOSURE FROM OUR PATIENTS, AND INFORMATION FROM COLLABORATIVE AGENCIES. PATIENT OUTREACH SERVICES ARE CONDUCTED WITH COMMUNITY PARTNERS SUCH AS THE LEE COUNTY HEALTH DEPARTMENT, DIXON FAMILY YMCA, YWCA OF THE SAUK VALLEY, SINNISSIPPI CENTERS AND AN ABUNDANCE OF PARTNERS PROVIDING SERVICES TO INDIVIDUALS IN NEED. THESE PROJECTS BRING TOGETHER REPRESENTATIVES OF MANY HEALTH AND HUMAN SERVICE PROVIDER AGENCIES TO UNDERTAKE A COLLABORATIVE APROACH TO UNDERSTAND THE CRUCIAL HEALTH ISSUES IN THE COMMUNITY AND TO PRIORITIZE THOSE PROBLEMS. PART VI, LINE 3: KSB HOSPITAL STRIVES TO EDUCATE OUR PATIENTS OF THEIR ELIGBILITY FOR ASSISTANCE UNDER FEDERAL, STATE, AND LOCAL PROGRAMS. PATIENTS ARE ALSO INFORMED OF OUR CHARITY CARE POLICY. EVERY SELF PAY PATIENT THAT COMES TO THE HSOPITAL IS GIVEN A CHARITY APPLICATION AND OFFERED ASSISTANCE IN HELPING THEM COMPLETE THE APPLICATION. NOTICES ABOUT ASSISTANCE PROGRAMS ARE POSTED IN THE REGISTRATION AREAS AND THE INFORMATION IS ALSO INCLUDED IN THE PATIENT'S STATEMENT AND ON THE KSB WEBSITE. A PATIENT ADVOCATE VISITS EACH INPATIENT WITH A NOTICE OF THEIR INSURANCE BENEFITS AND THEN COUNSELS EACH PATIENT OF ADDITIONAL OPTIONS FOR ASSISTANCE. PART VI, LINE 4: KSB HOSPITAL SERVES LEE COUNTY, A RURAL COUNTY IN NORTHWESTERN ILLINOIS ONE HUNDRED MILES WEST OF CHICAGO AND FORTY-FIVE MILES SOUTHWEST OF ROCKFORD. ACCORDING TO THE U.S. CENSUS BUREAU, THE 2021 POPULATION OF LEE COUNTY WAS ESTIMATED AT 34,049. THE COMMUNITIES OF LEE AND WESTERN OGLE COUNTY COMPRISE THE KSB HOSPITAL PRIMARY SERVICE AREA. THIS AREA SAW A POPULATION DECLINE OF 0.3% BETWEEN 2020 AND 2021, A PERIOD DURING WHICH THE STATE DECLINED BY 1.1%. DIXON IS THE COUNTY SEAT AND THE LARGEST COMMUNITY IN LEE COUNTY WITH AN ESTIMATED POPULATION OF 15,380. LEE COUNTY RACE AND ETHNICITY SHOWS 84.3% WHITE, NOT HISPANIC; 6.4% BLACK; 7.2% HISPANIC OR LATINO; WITH NO OTHER RACE ABOVE 1%. LEE COUNTY COVERS 725 SQUARE MILES. PUBLIC TRANSPORTATION IS AVAILABLE THROUGH THE LEE/OGLE TRANSPORTATION SYSTEM AND PRIVATE CAB COMPANIES. ACCORDING TO THE ILLINOIS DEPARTMENT OF EMPLOYMENT SECURITY, THE 2021 ANNUAL AVERAGE UNEMPLOYMENT RATE FOR LEE COUNTY WAS 4.5%, COMPARABLE TO NORTHWEST ILLINOIS OVERALL AND COMPARABLE TO THE STATE AVERAGE OF 6.1%. WITH A MEDIAN HOUSEHOLD IN INCOME OF $59,986, LEE COUNTY IS LOWER THAN THE STATE AVERAGE OF $68,428. LEE COUNTY PER CAPITA INCOME IS $29,343, BELOW THE STATE AVERAGE OF $37,306. THE PROPORTION OF LEE COUNTY RESIDENTS, 10.6%, LIVING BELOW THE FEDERAL POVERTY LEVEL IS LOWER THAN THE STATE AVERAGE OF 12.1%. UNINSURED (1.2%) AND MEDICAID (28.7%) PATIENTS COMPRISE A TOTAL OF 29.9% OF OUR PAYER MIX FOR 2021. KATHERINE SHAW BETHEA HOSPITAL IS THE SOLE HOSPITAL IN THE COMMUNITY OF DIXON. THE AREA OF DIXON DOES NOT CONTAIN ANY FEDERALLY DESIGNATED MEDICALLY UNDERSERVED AREAS OR POPULATIONS. PART VI, LINE 5: IN ADDITION TO MEDICAL CARE, SOUND LEADERSHIP AND MANAGEMENT ARE CRITICAL PARTS OF ANY GOOD HOSPITAL. AT KSB HOSPITAL, OUR MISSION AND VISION ARE PUT INTO ACTION EVERY DAY BY AN ADMINISTRATIVE TEAM, A BOARD OF DIRECTORS AND THE MEDICAL STAFF. THESE LEADERS OVERSEE THE HOSPITAL'S OPERATIONS AND MAKE VALUES-BASED DECISIONS THAT ARE CONSISTENT WITH OUR MISSION. THE MAJORITY OF THE BOARD OF DIRECTORS IS COMPRISED OF PERSONS WHO RESIDE IN OUR SERVICE AREA, WHO ARE NEITHER EMPLOYEES NOR INDEPENDENT CONTRACTORS OF THE ORGANIZATION. KSB HAS CLINICS IN 10 LOCATIONS AND THOSE COMMUNITIES ARE WELL REPRESENTED ON THE KSB BOARD. FOR EXAMPLE, COLLEEN HENKLE IS FROM THE AMBOY AREA AND LYNETTE KNODLE WORKS IN OREGON-THESE ARE TWO LOCALES WHERE KSB HAS CLINICS THAT SERVE THOSE COMMUNITIES. OFFERING MORE THAN 60 PHYSICIANS IN A VARIETY OF DISCIPLINES, KSB MEDICAL GROUP ENHANCES HEALTHCARE OPTIONS FOR SAUK VALLEY RESIDENTS. THIS MULTI-SPECIALTY PRACTICE HAS BROUGHT TOGETHER PHYSICIANS WHO ARE NEW TO THE AREA AND THOSE WHO HAVE SPENT AN ENTIRE CAREER IN OUR HOMETOWNS. KSB ALSO EXTENDS AN OPPORTUNITY TO ALL QUALIFIED PHYSICIANS SEEKING PRIVILEGES IN THE SAUK VALLEY SERVICE AREA. KSB UTILIZES ALL SURPLUS FUNDS FOR IMPROVEMENTS IN PATIENT CARE, NEW TECHNOLOGY AND OUR PHYSICAL PROPERTIES. THE LAST YEAR HAS SEEN SIGNIFICANT GROWTH WITHIN AND OUTSIDE THE WALLS OF KSB. IN 2021 WE CONTINUED UPDATING PATIENT ROOMS TO INCLUDE THE LATEST IN TECHNOLOGY AND EQUIPMENT. OUR EDUCATION DEPARTMENT OFFERS A VARIETY OF CLASSES TO EMPLOYEES AND THE PUBLIC. OUR COMMUNITY WELLNESS DEPARTMENT WORKS WITH OTHER COMMUNITY ORGANIZATIONS TO BRING A VARIETY OF HEALTH-RELATED AND WELLNESS PROGRAMS TO THE COMMUNITY. THESE OPPORTUNITIES ARE AN OUTREACH TO THE COMMUNITY THAT ARE FUN AND EDUCATIONAL. A LOOK AROUND AT THE VARIOUS DEPARTMENTS THAT MAKE UP KSB HOSPITAL REVEALS A CONTEMPORARY MEDICAL FACILITY THAT IS PROUD TO OFFER PATIENTS THE FINEST SERVICE POSSIBLE, YET IS NEVER CONTENT TO REST ON ITS PAST ACCOMPLISHMENTS. 1 DIXON FAMILY YMCA 110 N GALENA AVENUE DIXON IL 61021 362487927 501(C)(3) 20300 0 GENERAL OPERATING SUPPORT HOME OF HOPE CANCER WELLNESS CENTERS 1637 PLOCK ROAD DIXON IL 61021 010743626 501(C)(3) 15000 0 GENERAL OPERATING SUPPORT KSB HOSPITAL FOUNDATION 403 EAST FIRST STREET DIXON IL 61021 841787288 501(C)(3) 200000 0 GENERAL OPERATING SUPPORT 3 0 SCHOLARSHIPS 12 10000 PART I, LINE 2: GRANTS TO OTHER ORGANIZATIONS ARE NOT MONITORED. X X X X X 1 1 0 0 0 0 0 1 0 MONTHER ELBZOUR MD PHYSICIAN 1087209 0 844725 0 0 0 7250 0 30261 0 1969445 0 0 0 SOHAIL HANIF MD PHYSICIAN 798961 0 480637 0 0 0 7250 0 30261 0 1317109 0 0 0 ROBB RYDZYNSKI MD PHYSICIAN 741964 0 162584 0 15000 0 7250 0 39600 0 966398 0 0 0 FADI MOHAMAD MUSTAPHA MD PHYSICIAN 582419 0 290032 0 15000 0 7250 0 31461 0 926162 0 0 0 KURT CROWE MD PHYSICIAN 617076 0 212525 0 0 0 7250 0 39600 0 876451 0 0 0 DAVID SCHREINER CEO AND BOARD MEMBER 560925 0 0 0 1975 0 7250 0 23528 0 593678 0 0 0 MICHAEL KITTOE VP-CHIEF FINANCIAL OFFICER 339551 0 0 0 0 0 7250 0 11398 0 358199 0 0 0 SUZANNE RAVLIN VP-CHIEF LEGAL OFFICER 312601 0 0 0 0 0 7250 0 18728 0 338579 0 0 0 PRATIP NAG MD CHIEF MEDICAL OFFICER 294131 0 0 0 0 0 7250 0 16187 0 317568 0 0 0 LINDA CLEMEN VP-CHIEF NURSING OFFICER 263082 0 0 0 0 0 6459 0 23772 0 293313 0 0 0 RAY SHARP VP-CHIEF INFORMATION OFFICER 255751 0 0 0 0 0 7250 0 18006 0 281007 0 0 0 PART I, LINE 7 CERTAIN PHYSICIANS THAT ARE CONSIDERED "PERSONS OF INTEREST" RECEIVE BONUSES BASED ON NET CASH COLLECTIONS OF THEIR INDIVIDUAL PRACTICE. KAILE VALDEZ FAMILY MEMBER OF DAVID SCHREINER, CURRENT OFFICER/TRUSTEE 30579 EMPLOYEE COMPENSATION 0 LINDA HELLMICH FAMILY MEMBER OF DAVID HELLMICH, CURRENT BOARD MEMBER 63593 EMPLOYEE COMPENSATION 0 SUSAN NAG FAMILY MEMBER OF PRATIP NAG, CURRENT OFFICER 56761 EMPLOYEE COMPENSATION 0 SCHEDULE L, PART IV KSB IS ONE OF THE LARGEST EMPLOYERS IN LEE COUNTY, ILLINOIS AND IT IS VERY COMMON IN LESSER POPULATED RURAL AREAS FOR FAMILY MEMBERS TO WORK AT SUCH A SIGNIFICANT EMPLOYER. FORM 990, PART VI, SECTION A, LINE 1A THE EXECUTIVE COMMITTEE SHALL CONSIST OF THE BOARD CHAIRPERSON AS CHAIRPERSON OF THE COMMITTEE, THE VICE CHAIRPERSON, THE SECRETARY, THE TREASURER AND THE IMMEDIATE PAST CHAIRPERSON IF STILL A BOARD MEMBER. IF THE IMMEDIATE PAST CHAIRPERSON IS NO LONGER ON THE BOARD, THEN THE BOARD SHALL BY MAJORITY VOTE ELECT A MEMBER AT-LARGE TO SERVE AS THE FIFTH PERSON ON THE EXECUTIVE COMMITTEE. THIS MEMBER AT-LARGE SHALL SERVE AS PER ARTICLE III IN THE BYLAWS IN REGARDS TO TENURE OF OFFICE. THE EXECUTIVE COMMITTEE SHALL HAVE THE POWER TO TRANSACT ALL REGULAR BUSINESS OF THE HOSPITAL DURING THE INTERIM BETWEEN BOARD MEETINGS PROVIDED ANY ACTION TAKEN SHALL NOT CONFLICT WITH THE POLICIES AND EXPRESSED WISHES OF THE BOARD. FORM 990, PART VI, SECTION A, LINE 7A BOARD MEMBERS ARE ELECTED BY A MAJORITY VOTE OF THE CITY COUNCIL OF THE CITY OF DIXON, ILLINOIS. IF TWO-THIRDS OR MORE OF THE BOARD POSITIONS ARE VACATED IN ANY ONE YEAR, THE MAYOR OF THE CITY OF DIXON, ILLINOIS, WOULD HAVE THE POWER TO APPOINT ALL BOARD MEMBERS TO FILL SUCH VACANCIES. FORM 990, PART VI, SECTION A, LINE 7B THE MAYOR MAY, BY AND WITH THE CONSENT OF THE CITY COUNCIL, REMOVE ANY DIRECTOR FOR MISCONDUCT OR NEGLECT OF DUTY. FORM 990, PART VI, SECTION B, LINE 11B FULL COMPLETE COPIES OF THE FORM 990 ARE PROVIDED TO THE ENTIRE GOVERNING BODY AND MANAGEMENT PRIOR TO FILING, WITH A REVIEW AT THE BOARD MEETING TO ADDRESS ANY QUESTIONS THAT MAY ARISE. FORM 990, PART VI, SECTION B, LINE 12C ON AN ANNUAL BASIS, A CONFLICT OF INTEREST QUESTIONNAIRE IS DISTRIBUTED TO ALL MEMBERS OF THE GOVERNING BODY AND MANAGEMENT TO IDENTIFY ANY CONFLICTS OF INTEREST. IN ADDITION, ON AN ONGOING BASIS, PRIOR TO EACH BOARD ACTION, EACH VOTING OFFICER IS RESPONSIBLE TO SELF-EVALUATE TO DETERMINE WHETHER A CONFLICT OF INTEREST IS PRESENT. AN INDIVIDUAL WITH A POTENTIAL CONFLICT DISCLOSES THE MATTER TO THE BOARD OR COMMITTEE. AFTER DISCLOSURE OF THE RELEVANT FACTS, THAT INDIVIDUAL LEAVES THE ROOM WHILE THE REMAINING BOARD OR COMMITTEE MEMBERS VOTE ON WHETHER A CONFLICT OF INTEREST EXISTS. IN THE INSTANCE THAT CONFLICT EXISTS, THE NECESSARY PARTIES ARE EXCUSED FROM THE ROOM WHILE THE REMAINING BOARD OR COMMITTEE MEMBERS DISCUSS THE TRANSACTION AND VOTE ON THE MATTER. IF AN INDIVIDUAL FAILS TO DISCLOSE A CONFLICT, THE BOARD WILL TAKE APPROPRIATE DISCIPLINARY AND CORRECTIVE ACTION. FORM 990, PART VI, SECTION B, LINE 15 THE ORGANZATION ENGAGES AN OUTSIDE CONSULTANT TO PROVIDE COMPARABILITY COMPENSATION DATA FOR THE CEO POSITION. THE OUTSIDE CONSULTANT PROVIDES THE BOARD WITH A SUGGESTED RANGE FOR COMPENSATION. THE BOARD AND COMPENSATION COMMITTEE THEN REVIEWS THE INFORMATION RECEIVED AND DETERMINES THE COMPENSATION OF THE CEO WITH LEGAL COUNSEL. THE BOARD APPROVES IN ADVANCE AND DOCUMENTS THE COMPENSATION DETERMINATIONS IN THE BOARD MINUTES ON A TIMELY BASIS. A FIVE YEAR CONTRACT WAS NEGOTATED. THIS CONTRACT IS IN EFFECT FOR 2021. THE VICE PRESIDENTS' (CFO, CNO, CPO(CHIEF PRACTICE OFFICER), CMO AND CAO) COMPENSATION ARE DETERMINED BY PROVIDING THE CEO WITH COMPARABILITY DATA. THE COMPARABILITY DATA IS GATHERED BY THE HUMAN RESOURCES DEPARTMENT. THE CEO DETERMINES THE APPROPRIATE COMPENSATION FOR THE VICE PRESIDENTS AND PRESENTS A REPORT TO THE COMPENSATION COMMITTEE. PHYSCICIAN COMPENSATION IS NEGOTIATED AT THE TIME OF CONTRACT RENEWAL. THE ORGANZATION ENGAGES AN OUTSIDE CONSULTANT TO PROVIDE COMPARABILITY DATA FOR THE PHYSICIANS. FORM 990, PART VI, SECTION C, LINE 19 FINANCIAL STATEMENTS, GOVERNING DOCUMENTS AND CONFLICTS OF INTEREST POLICIES ARE NOT REQUIRED DISCLOSURES PURSUANT TO IRC SECTION 6104. PORTIONS OF THE FINANCIAL STATEMENTS ARE PUBLISHED IN THE ANNUAL REPORT THAT IS MAILED TO THE LOCAL COMMUNITY. THE GOVERNING DOCUMENTS AND CONFLICT OF INTEREST POLICY ARE NOT AVAILABLE TO THE PUBLIC AT THIS TIME. FORM 990, PART IX, LINE 11G REPAIRS AND MAINTENANCE CONTRACTS: PROGRAM SERVICE EXPENSES 1,934,344. MANAGEMENT AND GENERAL EXPENSES 284,819. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 2,219,163. PROFESSIONAL: PROGRAM SERVICE EXPENSES 0. MANAGEMENT AND GENERAL EXPENSES 178,947. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 178,947. PURCHASED: PROGRAM SERVICE EXPENSES 10,920,760. MANAGEMENT AND GENERAL EXPENSES 5,523,901. FUNDRAISING EXPENSES 589. TOTAL EXPENSES 16,445,250. RECOGNITION: PROGRAM SERVICE EXPENSES 20,065. MANAGEMENT AND GENERAL EXPENSES 2,722. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 22,787. OTHER: PROGRAM SERVICE EXPENSES 57,972. MANAGEMENT AND GENERAL EXPENSES 206,884. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 264,856. FORM 990, PART XI, LINE 9: CHANGES IN VALUE OF SUBSIDIARIES 284,871. FORM 990, PAGE 12, PART XII, LINE 2C THE PROCESS HAS NOT CHANGED FROM THE PRIOR YEAR. FORM 990, SCHEDULE H, PART V, LINE 11 CONTINUED EXPLANATION FOR LINE 11: 4) IDENTIFY POSSIBLE SOLUTIONS INCLUDING LAUNCH OF LYFT OR UBER RIDE-SHARING PLATFORMS IN THE LOCAL AREA, AND PROVIDE FINANCIAL SUPPORT TO DEFRAY THE COST OF USING PUBLIC TRANSPORTATION, TAXIS, OR RIDE-SHARING TO GET TO CLINICAL APPOINTMENTS, PHARMACIES, OR HEALTH AND WELLNESS ACTIVITIES PRIORTIES NOT SELECTED: IN THE 2016 CHNA, WE IDENTIFIED FOOD INSECURITY AS A KEY PRIORITY AND ENACTED AN IMPLEMENTATION PLAN TO MEET THE NEED. THIS PLAN INCLUDED KSB PARTICIPATION IN SEVERAL COMMUNITY EFFORTS TO PROVIDE FOOD TO BOTH CHILDREN AND ADULTS WHO WERE FOOD INSECURE. WE ARE CONTINUING TO PARTICIPATE IN THESE EFFORTS AND HAVE BEEN PLEASED WITH THE PROGRESS THEY'VE MADE TOWARD REDUCING FOOD INSECURITY. AT THE TIME OF THE 2016 CHNA, THE FOOD INSECURITY RATE WAS 12.9%, WHICH WAS ABOVE THE STATE AND NATIONAL AVERAGES. THE LATEST DATA SHOWS THAT NUMBER HAS DROPPED TO 9.9%, WHICH IS BELOW THE STATE AND NATIONAL AVERAGES. THE FOOD INSECURITY RATE FOR CHILDREN HAS DROPPED FROM 21.5% TO 14.9%. WHILE THERE IS STILL ROOM FOR IMPROVEMENT, AND KSB WILL REMAIN ENGAGED WITH "FIGHTING HUNGER, FEEDING WELLNESS AND HOSTING FOOD DRIVES TO REDUCE FOOD INSECURITY, THE GAINS MADE IN THE LAST THREE YEARS HAVE LED THIS TO BECOME A PRIORITY WHICH WAS NOT SELECTED AMONG THE TOP THREE ITEMS IN THIS YEAR'S CHNA. ADDITIONALLY, WHILE KSB WILL ALSO BE ENGAGED FROM A CLINICAL AND EDUCATIONAL PERSPECTIVE IN TOBACCO USE AND E-CIGARETTE USE, WE DID NOT SCORE THIS IN THE TOP THREE BECAUSE OF THE NUMBER OF OTHER COMMUNITY ORGANIZATIONS WHO ARE SHARING RESPONSIBILITY FOR INTERVENTION IN THIS AREA. THE LEE COUNTY HEALTH DEPARTMENT, LOCAL SCHOOL DISTRICTS, LAW ENFORCEMENT, AND PARENT AND STUDENT ADVOCATES ARE WORKING TO EDUCATE AND PREVENT TOBACCO AND E-CIGARETTE USAGE. KSB WILL PARTICIPATE IN THESE EFFORTS EVEN THOUGH THIS IS NOT ONE OF THE TOP THREE PRIORITIES LISTED IN THIS CHNA. KSB HOSPITAL FOUNDATION 403 EAST FIRST STREET DIXON IL 61021 841787288 TO RAISE FUNDS TO SUPPORT KSB'S MISSION IL 501(C)(3) LINE 12A, I KATHERINE SHAW BETHEA HOSPITAL 1 KSB VENTURES INC 403 EAST 1ST STREET DIXON IL 61021 465278274 HOLD PARTNERSHIP INVESTMENT IL KATHERINE SHAW BETHEA HOSPITAL C 162845 1402897 1.00000 1 0 1 1 0 0 0 0 0 0 0 0 0 1 1 1 0 0 0 0 KSB HOSPITAL FOUNDATION B 200000 GENERAL LEDGER