2019-06-19T11:40:58-05:00 2018-12-31 410746749 CLIFTONLARSONALLEN LLP 600 WASHINGTON AVENUE SUITE 1800 ST LOUIS MO 63101 990 2018-01-01 361000540 KATHERINE SHAW BETHEA HOSPITAL KATH 8152885531 403 EAST FIRST STREET DIXON IL 61021 DAVID SCHREINER CEO 8152855521 2019-06-18 1 JEFF PARKER P00970069 3149254300 67.137.57.251 2019-06-18 12:25:46 CD P 4DC81AC5090E51A43603AD047BBA54151ACF830E 487AB1A67A5D20F4613B23BD8ED7DDEFEAED86AA 2018 2019-02-21 02:37:17Z DAVID SCHREINER 403 EAST FIRST STREET DIXON IL 61021 150545892 0 X WWW.KSBHOSPITAL.COM X 1893 IL RESTORE, MAINTAIN, AND ENHANCE HEALTH BY PROVIDING SUPERIOR CARE NOW AND IN THE FUTURE. 11 9 1159 71 5575 0 379488 596014 146958861 147949665 888689 683633 541479 597896 148768517 149827208 218441 234897 0 0 80073214 82565089 0 0 72481 63813192 63537246 144104847 146337232 4663670 3489976 123715545 135957530 51445799 60538193 72269746 75419337 THE MISSION OF KATHERINE SHAW BETHEA HOSPITAL (KSB) IS TO RESTORE, MAINTAIN, AND ENHANCE HEALTH BY PROVIDING SUPERIOR CARE NOW AND IN THE FUTURE. 0 0 120191487 234897 147949665 IN 2018, KATHERINE SHAW BETHEA HOSPITAL (KSB) HAD 9,915 INPATIENT VISITS AND 194,223 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 $252,340 IN 2018.KSB PROVIDES 24-HOUR EMERGENCY MEDICAL SERVICES STAFFED BY FULL-TIME PHYSICIANS. PATIENTS ARE TREATED REGARDLESS OF INSURANCE OR ABILITY PAY. ER VISITS IN 2018 WERE 19,608. 120191487 1 1 0 1 0 1 0 0 0 1 1 0 0 0 0 1 0 1 0 0 0 0 0 0 1 0 1 1 1 1 1 0 0 0 0 0 0 1 0 0 0 0 0 0 1 1 0 0 0 1 59 0 1159 1 1 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 X 11 9 0 0 0 0 0 1 0 1 1 0 0 1 1 1 1 1 1 1 1 0 IL X JERRY LILLIG 8152855523 403 EAST FIRST STREET DIXON IL 61021 DOUG LEE CHAIRPERSON 2.90 X X 0 0 0 LYNETTE KNODLE VICE CHAIRPERSON 1.70 X X 0 0 0 KATIE PRATT SECRETARY 0.90 X X 0 0 0 RAY NEISEWANDER III TREASURER 1.10 X X 0 0 0 COLLEEN T HENKEL PAST CHAIRPERSON 1.50 X 0 0 0 RICK CURIA BOARD MEMBER 1.10 X 0 0 0 JOSEPH WELTY MD BOARD MEMBER / PHYSICIAN 41.40 X 255179 0 44203 CHAD WEIGLE BOARD MEMBER 1.50 X 0 0 0 CHRIS HAMMITT BOARD MEMBER 1.60 X 0 0 0 DAVID HELLMICH BOARD MEMBER 1.40 X 0 0 0 DAVID SCHREINER CEO AND BOARD MEMBER 40.00 1.00 X X 551250 0 193284 LINDA CLEMEN VP-CHIEF NURSING OFFICER 40.00 X 259323 0 33050 ANTHONY EVERS VP-CHIEF FINANCIAL OFFICER 40.00 X 328214 0 45832 PRATIP NAG MD CHIEF MEDICAL OFFICER 40.00 X 355746 0 51853 JULIE MANN VP-ADMINISTRATIVE OFFICER 40.00 X 292951 0 27959 KEVIN T MARX VP-MEDICAL GROUP MANAGEMENT 40.00 X 226373 0 25178 SUZANNE RAVLIN VP-CHIEF LEGAL OFFICER 40.00 X 300499 0 34576 MONTHER ELBZOUR MD PHYSICIAN 40.00 X 1333696 0 51853 ROBB RYDZYNSKI MD PHYSICIAN 40.00 X 1074021 0 14961 SOHAIL HANIF MD PHYSICIAN 40.00 X 985025 0 46253 DAVID J POWERS MD PHYSICIAN 40.00 X 701543 0 32956 THOMAS HERNANDEZ MD PHYSICIAN 40.00 X 687436 0 51853 7351256 0 653811 87 0 1 0 CERNER HEALTH SERVICES PO BOX 412732 KANSAS CITY MO 64141 SOFTWARE SUPPORT 5499140 HEALTHCARE AND FAMILY SERVICES PO BOX 19493 SPRINGFIELD IL 62796 CONSULTING 3677026 AMERISOURCE BERGEN 1001 W TAYLOR ROAD ROMEOVILLE IL 60446 PHARMACEUTICAL SOLUTIONS 3000394 PHARMAVAIL BENEFIT MANAGEMENT 3380 TRICKLUM ROAD WOODSTOCK GA 30188 BENEFITS MANAGEMENT 2057550 PHILLIPS PO BOX 100355 ATLANTA GA 30384 HEALTHCARE SERVICES 1373688 108 14673 431229 150112 596014 NET PATIENT SERVICE REVENUE 621110 142557630 142557630 430B PROGRAM PAYMENTS 621110 5177898 5177898 NET CLINIC SPACE RENTAL 621110 214137 214137 147949665 664354 664354 723484 7052 709897 1360 13587 5692 19279 19279 9142 14673 7427 1715 1715 CAFETERIA SALES 900099 451461 5575 445886 ALL OTHER REVENUE 900099 67034 67034 COPY REVENUE 900099 48580 48580 29106 29106 596181 149827208 147949665 5575 1275954 X 225041 225041 9856 9856 2576088 699972 1876116 59905174 52736181 7146181 22812 2293519 2016783 275859 877 14232520 12284343 1942876 5301 3557788 3048793 507686 1309 85561 85561 113913 113913 29611 29611 17317 7439 9878 14765881 7412324 7353557 448157 25180 422977 18188688 17768795 379525 40368 3042296 381098 2661198 2298391 2051338 247053 227776 227776 312000 286689 25311 718152 718152 5498397 3530017 1967064 1316 2044702 1842438 202264 BAD DEBT EXPENSE 11437374 11437374 IPA/SALES & USE TAX 3725378 3725378 DUES & MEMBERSHIPS 431447 430949 498 MISCELLANEOUS 127091 18793 108298 25114 24930 184 146337232 120191487 26073264 72481 225477 209503 16108228 20029861 36843382 42434250 1515017 1374044 1000178 1313789 136663018 88757013 42339714 47906005 16800874 15116322 6135275 5353065 2747400 2220691 123715545 135957530 34534132 37196327 16911667 23341866 51445799 60538193 X 70989482 74190458 264248 185255 1016016 1043624 72269746 75419337 123715545 135957530 X 3489976 -498951 158566 X X 0 1 X 1 0 X 0 0 0 0 0 0 0 0 1 29611 29611 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. 1 31800 0 185255 1 1 1016016 27608 1043624 1892631 103244 979859 1016016 1602358 102102 193943 5772 1892631 1573393 28965 1602358 1266546 306847 1573393 0.00000 1.00000 0.00000 1 0 2343039 2343039 51011302 31205570 19805732 5529345 3562618 1966727 71669520 53988825 17680695 6109812 6109812 47906005 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. TICKLING THE IVORIES 23815 14673 9142 1000 3397 2500 530 23815 14673 9142 1000 3397 2500 530 7427 1715 1 1 X 1 X 1 X 1 1 0 0 815090 815090 0.00560 19953473 11558950 8394523 0.05740 20768563 11558950 9209613 0.06300 657463 657463 0.00450 2019256 3442758 0 0.00000 64381 152118 0 0.00000 1000 1000 0.00000 193105 193105 0.00130 2935205 3594876 851568 0.00580 23703768 15153826 10061181 0.06880 1 11437374 1143737 24639681 26474871 -1835190 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 16 1 0 1 1 X WWW.KSBHOSPITAL.COM/CHNA X X 1 16 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: FOR THIS NEEDS ASSESSMENT, WE GATHERED INFORMATION FROM A VARIETY OF SOURCES IN ORDER TO GET A COMPREHENSIVE PICTURE OF THE HEALTH AND NEEDS OF OUR COMMUNITY. FIRST, WE REVIEWED A REPORT FROM COMMUNITY COMMONS THAT GAVE US TREMENDOUS INSIGHT INTO VARIOUS HEALTH RISK FACTORS FOR LEE COUNTY RESIDENTS. THE REPORT INCLUDED INFORMATION ON POPULATION, DEMOGRAPHICS, SOCIAL ECONOMIC FACTORS, PHYSICAL ENVIRONMENT, ACCESS TO CLINICAL CARE, HEALTH BEHAVIORS, AND HEALTH OUTCOMES. IN ALL, COMMUNITY COMMONS PROVIDED MORE THAN 100 DATA SETS TO ENABLE US TO LOOK FOR OUTLIER VALUES THAT SUGGEST LEE COUNTY'S AREAS FOR IMPROVEMENT.WE ALSO USED DATA GATHERED FROM LEE COUNTY 8TH GRADE, 10TH GRADE, AND 12TH GRADE STUDENTS ON TOPICS LIKE SUBSTANCE USE AND BULLYING. THE STUDENT DATA WAS MADE AVAILABLE THROUGH THE ILLINOIS YOUTH SURVEY, A SURVEY IN WHICH A MAJORITY OF LEE COUNTY STUDENTS PARTICIPATED. TO SUPPLEMENT OUR AVAILABLE DATA, WE ALSO CREATED AND DISSEMINATED A COMMUNITY SURVEY TO THE GENERAL POPULATION. THIS SURVEY ASKED RESPONDENTS TO RATE THE QUALITY AND AVAILABILITY OF SEVERAL HEALTH-RELATED SERVICES. IT ALSO ASKED FOR INCIDENCE OF VARIOUS HEALTH CONDITIONS AMONG THE RESPONDENTS AND THEIR HOUSEHOLDS. FINALLY, IT OFFERED RESPONDENTS A CHANCE FOR FREE-TEXT RESPONSES TO QUESTIONS ON HOW WE COULD IMPROVE. IN ALL, WE COLLECTED RESPONSES FROM 241 MEMBERS OF THE GENERAL PUBLIC, FROM SIX DIFFERENT COMMUNITIES WITHIN LEE COUNTY, AND WITH 7.5% OF THE RESPONSES COMING FROM HOUSEHOLDS WHICH RECEIVED FINANCIAL ASSISTANCE SUCH AS MEDICAID, FOOD STAMPS, TOWNSHIP ASSISTANCE, AND OTHERS DURING THE PAST YEAR.DATA FROM THE COMMUNITY COMMONS AND ILLINOIS YOUTH SURVEY HELPED DRIVE OUR CONVERSATIONS ON THE CHNA/IPLAN COMMITTEE THAT WAS COFOUNDED BY KSB HOSPITAL AND THE LEE COUNTY HEALTH DEPARTMENT FOR PURPOSES OF IDENTIFYING COMMUNITY HEALTH NEEDS. THE CHNA/IPLAN COMMITTEE WAS COMPRISED OF 23 MEMBERS REPRESENTING 17 DIFFERENT ORGANIZATIONS WHO SERVE LEE COUNTY. MEMBERS REPRESENTED LOCAL HEALTH CARE PROVIDERS, GOVERNMENT AGENCIES, SCHOOLS, LAW ENFORCEMENT, ADVOCACY GROUPS, AND NOT-FOR-PROFITS.FURTHER, THE DATA AND INITIAL FINDINGS WERE REVIEWED AND COMMENTED ON BY MEMBERS OF THE KSB HOSPITAL PATIENT & FAMILY ADVISORY COUNCIL, A PANEL OF MEMBERS OF THE COMMUNITY WHO PROVIDE FEEDBACK AND GUIDANCE FOR PATIENT-CENTERED DECISIONS, AND THE KSB HOSPITAL SENIOR EXECUTIVE TEAM. KATHERINE SHAW BETHEA HOSPITAL PART V, SECTION B, LINE 6B: THE HOSPITAL'S CHNA WAS CONDUCTED WITH THE LEE COUNTY HEALTH DEPARTMENT. 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: BASED ON THE DATA, INPUT FROM DIVERSE COMMUNITY MEMBERS, AND EXPERTISE FROM ORGANIZATIONAL LEADERS, THE FOLLOWING ARE THE PRIMARY HEALTH NEEDS OF OUR COMMUNITY IN WHICH KSB HOSPITAL CAN BEST MAKE AN IMPACT: DIABETES, FOOD INSECURITY, AND OBESITY & PHYSICAL INACTIVITY. DIABETES: PEOPLE IN LEE COUNTY STRUGGLE WITH DIABETES MORE AND MORE EACH YEAR. ACCORDING TO THE CENTERS FOR DISEASE CONTROL AND PREVENTION, THE RATE OF DIABETES AMONG LEE COUNTY ADULTS HAS INCREASED FROM 6.6% IN 2004 TO 9% IN 2012, THE MOST RECENT YEAR FOR WHICH WE HAVE DATA. THAT MEANS THAT MORE THAN 2,700 LOCAL ADULTS STRUGGLE WITH DIABETES.TO MEET THE COMMUNITY NEED FOR DIABETES CARE, KSB HOSPITAL WILL OFFER SPECIALLY TAILORED SERVICES IN THE KSB CENTER FOR DIABETES MANAGEMENT. THE CENTER OFFERS SERVICES FOR THOSE WITH PRE-DIABETES, GESTATIONAL DIABETES, AND BOTH TYPE 1 AND TYPE 2 DIABETES. PATIENTS WHO VISIT THE CENTER CAN COMPLETE A SCREENING, CONSULT WITH A CERTIFIED DIABETES EDUCATOR, GET HEALTHY RECIPES FROM A DIETITIAN, AND BE CONNECTED WITH DOCTORS, PHYSICAL THERAPISTS, AND PHARMACISTS ALL WITHIN KSB HOSPITAL.THE KSB CENTER FOR DIABETES MANAGEMENT OFFERS FREE BLOOD GLUCOSE SCREENINGS TO THE GENERAL PUBLIC ON THE FIRST TUESDAY OF EACH MONTH.ADDITIONALLY, TO MEET THE NEEDS OF THOSE WITH DIABETES, KSB COMMUNITY WELLNESS WILL HOST VARIOUS OUTREACH ACTIVITIES WHICH MAY INCLUDE A DIABETES PREVENTION PROGRAM IN ASSOCIATION WITH THE YMCA, A DIABETIC YOUTH CAMP, SCHOOL-BASED EDUCATION, AND THE LEARNING TO LIVE WELL COMMUNITY LECTURE SERIES.KSB HOSPITAL WILL EVALUATE THE SUCCESS OF OUR DIABETES CARE INITIATIVES BY THE NUMBER OF PEOPLE WHO PARTICIPATE IN COMMUNITY PROGRAMS, THE NUMBER OF PATIENTS WHO VISIT THE KSB CENTER FOR DIABETES MANAGEMENT, AND REVERSING OR SLOWING THE GROWTH OF DIABETES INCIDENCE IN LEE COUNTY.FOOD INSECURITY: SURVEY DATA FROM FEEDING AMERICA SHOWS THAT 12.9% OF LEE COUNTY RESIDENTS MEET THE CRITERIA FOR FOOD INSECURITY, THAT IS THEY HAVE LIMITED OR UNCERTAIN ACCESS TO ADEQUATE FOOD. FURTHER, MORE THAN 1 IN 5, OR 21.5%, OF LEE COUNTY CHILDREN ARE FOOD INSECURE. OF THOSE CHILDREN WHO ARE FOOD INSECURE, 30% ARE INELIGIBLE FOR ASSISTANCE PROGRAMS LIKE SNAP OR WIC.THESE FOOD INSECURITY FACTS DEMONSTRATE A COMMUNITY HEALTH NEED FOR STABLE, NUTRITIOUS FOOD. INADEQUATE NUTRITION CAN HAVE NEGATIVE EFFECTS ON MANY PREEXISTING HEALTH CONDITIONS, OR MAY MAKE INDIVIDUALS MORE LIKELY TO SUFFER ADVERSE HEALTH CONSEQUENCES. BECAUSE OF THIS, KSB HOSPITAL INTENDS TO INTERVENE TO HELP ALLEVIATE FOOD INSECURITY IN LEE COUNTY.KSB HOSPITAL IS THE COUNTY'S LARGEST EMPLOYER WITH NEARLY 1,000 EMPLOYEES. IN ADDITION, TENS OF THOUSANDS OF MEMBERS OF THE COMMUNITY VISIT KSB FACILITIES EACH YEAR FOR MEDICAL APPOINTMENTS, TO VISIT LOVED ONES, OR TO ATTEND ORGANIZATIONAL MEETINGS OR EVENTS. MAKING THE MOST OF THE HIGH TRAFFIC LOCATIONS, KSB HOSPITAL WILL CONDUCT FOOD DRIVES TO SOLICIT CHARITABLE CONTRIBUTIONS FROM EMPLOYEES, VISITORS, AND GUESTS. THESE FOOD DRIVES WILL BENEFIT LOCAL FOOD PANTRIES AND BE AVAILABLE FOR THOSE WHO ARE FOOD INSECURE.KSB WILL PARTICIPATE IN THE PARTNERSHIP FOR A HEALTHY LEE COUNTY (PHLC) ALONG WITH THE LEE COUNTY HEALTH DEPARTMENT, THE UNIVERSITY OF ILLINOIS EXTENSION, MASTER GARDNER PROGRAM, AND LOCAL CHURCHES TO OFFER A HEALTHY HARVEST COMMUNITY GARDEN PROGRAM IN WHICH CHILDREN LEARN ABOUT GROWING AND EATING HEALTHY FOODS. IN ADDITION TO THE GARDENING, CHILDREN PARTICIPATE IN EDUCATIONAL SESSIONS ON TOPICS INCLUDE PLOTTING, CANNING, PESTS, AND HEALTHY EATING.FURTHER, KSB HOSPITAL WILL WORK IN PARTNERSHIP WITH THE UNITED WAY, LEE COUNTY HEALTH DEPARTMENT, DIXON FAMILY YMCA, AND OTHERS TO OFFER A SUMMER FOOD PROGRAM FOR LOCAL CHILDREN. KSB IS WELL POSITIONED TO BE A KEY CONTRIBUTOR TO THE SUMMER FOOD PROGRAM WITH A LARGE, PRODUCTIVE COMMERCIAL KITCHEN, SKILLED STAFF, AND A WIDE AREA OF COVERAGE THROUGH LOCAL CLINIC LOCATIONS.KSB HOSPITAL WILL EVALUATE THE SUCCESS OF MEETING THE COMMUNITY NEED FOR FOOD SECURITY BY THE NUMBER OF CHILDREN SERVED BY SUMMER FOOD PROGRAMS, THE NUMBER OF PARTICIPANTS WITH A COMMUNITY GARDEN PLOT, AND THE POUNDS OF FOOD THAT ARE COLLECTED DURING FOOD DRIVES.OBESITY & PHYSICAL INACTIVITY: INFORMATION FROM THE CENTERS FOR DISEASE CONTROL AND PREVENTION SHOW US THAT LEE COUNTY RESIDENTS STRUGGLE WITH HEALTHY BODY WEIGHTS AND ARE LESS PHYSICALLY ACTIVE THAN AVERAGE. THE DATA SHOWS THAT 53.4% OF LEE COUNTY ADULTS ARE CLASSIFIED AS OVERWEIGHT, THAT IS THEY HAVE A BMI BETWEEN 25 AND 30. AN ADDITIONAL 31.9% OF LEE COUNTY ADULTS ARE OBESE, THAT IS THEY HAVE A BMI IN EXCESS OF 30. TAKEN TOGETHER, WE SEE THAT 85.3% OF LEE COUNTY ADULTS ARE OVERWEIGHT OR OBESE. THAT COMPARES TO A COMBINED RATE OF 63.4% OF ILLINOIS ADULTS AND 63.3% OF AMERICAN ADULTS. FURTHER, 27.9% OF LEE COUNTY ADULTS REPORT NO PHYSICAL ACTIVITY AT ALL OUTSIDE WORK, WHICH IS A HIGHER RATE OF INACTIVITY THAN EITHER STATE OR NATIONAL AVERAGES.KSB PLANS TO MEET THE COMMUNITY HEALTH NEED OF IMPROVED PHYSICAL ACTIVITY AND DECREASED INCIDENCE OF OVERWEIGHT OR OBESITY BY ENGAGING THE COMMUNITY IN INTERESTING AND ENJOYABLE WAYS. KSB COMMUNITY WELLNESS AMBASSADORS WILL PROVIDE HEALTHY RECIPES AND FOOD SAMPLES AT THE DIXON MAIN STREET SUMMER CITY MARKET EVENTS. TO FURTHER EDUCATION ON HEALTHY EATING CHOICES THAT AFFECT WEIGHT, KSB WILL BE THE LEAD SPONSOR AND ORGANIZER OF THE LEARNING TO LIVE WELL COMMUNITY LECTURE SERIES WITH SPECIAL PRESENTATIONS BY MULTIDISCIPLINARY PROVIDERS.PHYSICAL ACTIVITY IS AN IMPORTANT CONTRIBUTOR TO BODY WEIGHT, AND KSB WILL PLAY AN ACTIVE ROLE IN PROMOTING PHYSICAL ACTIVITY AND FITNESS. KSB WILL SPONSOR THE REAGAN RUN 5K AND COORDINATE THE KSB CORPORATE CHALLENGE DURING THE RACE TO ENCOURAGE LOCAL EMPLOYERS TO FORM TEAMS TO ENTER THE COMPETITION. KSB WILL AGAIN SPONSOR A COMMUNITY-WIDE HEALTHY WEIGHT CONTEST NAMED MOVE FOR A CHANGE, BUILDING ON A SUCCESSFUL PROGRAM WITH HUNDREDS OF LOCAL PARTICIPANTS AND TEAMS COMPETING TO LOSE WEIGHT IN A HEALTHY AND SUSTAINABLE WAY.KSB WILL ALSO SPONSOR THE KSB WELLNESS CENTER AT THE DIXON FAMILY YMCA AND UNDERWRITE NEW EXERCISE EQUIPMENT PURCHASES TO INCREASE OPPORTUNITIES FOR THOSE LOOKING FOR PHYSICAL ACTIVITIES. KSB ALSO WORKS WITH THE YMCA ON A YOUTH RUNNING PROGRAM THAT TEACHES KIDS HOW TO TRAIN FOR AND PRACTICE RUNNING FOR EXERCISE. KSB WILL PROVIDE PHYSICAL THERAPISTS AND PHYSICIANS TO COMMUNITY RACES AND SPORTING EVENTS TO ENSURE PARTICIPANTS HAVE ACCESS TO PROFESSIONAL ADVICE ON HEALTHY FITNESS PRACTICES.TO SUPPORT THOSE WHO WANT TO BEGIN EXERCISING FOR THE FIRST TIME, KSB PHYSICIANS WILL WRITE PRESCRIPTIONS FOR A FREE 30-DAY MEMBERSHIP TO THE DIXON FAMILY YMCA, WHERE NEW MEMBERS RECEIVE AN EDUCATIONAL ORIENTATION ON HOW TO GET STARTED WORKING OUT INDIVIDUALLY OR IN A GROUP OR CLASS SETTING.FURTHER POTENTIAL ACTIVITIES TO PROMOTE HEALTHY LIFESTYLES INCLUDE AN AMAZING RACE-STYLE CONTEST, WALKING CLUBS, EDUCATIONAL EVENTS WITH THE YMCA OR OTHER COMMUNITY PARTNERS, A BICYCLING INITIATIVE, AND TARGETED OUTREACH THROUGH LARGE LOCAL EMPLOYERS.KSB HOSPITAL DID NOT CHOOSE TO FOCUS ON BEHAVIORAL HEALTH BECAUSE IT IS A PRIMARY FOCUS OF SINNISSIPPI CENTERS, A COMMUNITY LEADER IN MENTAL HEALTH AND SUBSTANCE ABUSE COUNSELING. KSB HOSPITAL WILL CONTINUE TO PARTNER WITH SINNISSIPPI ON THESE EFFORTS. ADDITIONALLY, KSB HOSPITAL DID NOT CHOOSE BULLYING AS AN AREA OF FOCUS BECAUSE IT IS AN ISSUE THAT IS BEST DEALT WITH BY SCHOOLS AND YOUTH-CENTERED ORGANIZATIONS. AS A MEDICAL CENTER, KSB HOSPITAL DID NOT FEEL IT IS BEST POSITIONED TO LEAD EFFORTS AGAINST BULLYING. 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 11 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 6 - MT MORRIS CLINIC 405 CHARLES AVENUE MT MORRIS IL 61054 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 2018 CALCULATED COST TO CHARGE RATIO USING THE IRS WORKSHEET 2. PART I, LINE 7G: FOR 2018, 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 17 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 34,223 IN 2018. 19.1% OF THE POPULATION WAS AGE 65 AND OLDER. THE CENSUS BUREAU ESTIMATED THAT 11.4% OF LEE COUNTY WAS BELOW THE POVERTY LINE. IN 2018, 46.2% 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, INCLUDINGMEDICARE, THEN THIS IS AN INDICATION THAT THE HOSPITAL OPERATES TO PROMOTE THE HEALTH OF THE COMMUNITY.BASED ON KSB HOSPITAL'S FILED 2018 MEDICARE COST REPORT THE MEDICARE ALLOWABLE COSTS FOR 2018 WERE $26,474,871 AND PAYMENTS RECEIVED FROM MEDICARE WERE $24,639,681. WE BELIEVE THAT THE SHORTFALL OF $1,835,190 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 2018 POPULATION OF LEE COUNTY WAS ESTIMATED AT 34,223. THE COMMUNITIES OF LEE AND WESTERN OGLE COUNTY COMPRISE THE KSB HOSPITAL PRIMARY SERVICE AREA. THIS AREA SAW A POPULATION DECLINE OF 5.0% BETWEEN 2010 AND 2018, A PERIOD DURING WHICH THE STATE DECLINED BY 0.7%. DIXON IS THE COUNTY SEAT AND THE LARGEST COMMUNITY IN LEE COUNTY WITH AN ESTIMATED POPULATION OF 15,165. LEE COUNTY RACE AND ETHNICITY SHOWS 86.4% WHITE, NOT HISPANIC; 5.5% BLACK; 6.2% HISPANIC; WITH THE REMAINING 2.6% AMERICAN INDIAN AND ALASKA NATIVE, ASIAN, OR PERSONS REPORTING TWO OR MORE RACES. 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 2018 ANNUAL AVERAGE UNEMPLOYMENT RATE FOR LEE COUNTY WAS 4.4%, COMPARABLE TO NORTHWEST ILLINOIS OVERALL AND COMPARABLE TO THE STATE AVERAGE OF 4.3%. WITH A MEDIAN HOUSEHOLD IN INCOME OF $58,319, LEE COUNTY IS LOWER THAN THE STATE AVERAGE OF $61,229. LEE COUNTY PER CAPITA INCOME IS $28,179, BELOW THE STATE AVERAGE OF $32,924. THE PROPORTION OF LEE COUNTY RESIDENTS, 11.4%, LIVING BELOW THE FEDERAL POVERTY LEVEL IS HIGHER THAN THE STATE AVERAGE OF 12.6%. UNINSURED (2.5%) AND MEDICAID (19.4%) PATIENTS COMPRISE A TOTAL OF 22.0% OF OUR PAYER MIX FOR 2018. 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 2016 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 AMBOY COMMUNITY SCHOOL DISTRICT 272 11 E HAWLEY STREET AMBOY IL 61310 366005054 GOVERNMENT 6206 GENERAL OPERATING SUPPORT DIXON FAMILY YMCA 110 N GALENA AVENUE DIXON IL 61021 362487927 501(C)(3) 20280 GENERAL OPERATING SUPPORT DIXON PUBLIC SCHOOL DISTRICT 170 1335 FRANKLIN GROVE ROAD DIXON IL 61021 366007311 GOVERNMENT 8000 GENERAL OPERATING SUPPORT HOME OF HOPE CANCER WELLNESS CENTERS 1637 PLOCK ROAD DIXON IL 61021 010743626 501(C)(3) 15000 GENERAL OPERATING SUPPORT NEWMAN CENTRAL CATHOLIC HIGH SCHOOL 1101 W 23RD STREET STERLING IL 61081 237055337 501(C)(3) 8100 GENERAL OPERATING SUPPORT UNIVERSITY OF ILLINOIS FOUNDATION 1305 WEST GREEN STREET URBANA IL 61801 376006007 501(C)(3) 10000 GENERAL OPERATING SUPPORT DIXON CHAMBER OF COMMERCE & MAIN STREET 87 S HENNEPIN AVE DIXON IL 61021 362031370 501(C)(6) 8679 GENERAL OPERATING SUPPORT LEE COUNTY COUNCIL ON AGING (LCCOA) 100 WEST SECOND ST DIXON IL 61021 362861690 501(C)(3) 5016 GENERAL OPERATING SUPPORT METROPOLITAN CHICAGO HEALTHCARE COUNCIL (MCHC) 1151 E WARRENVILLE RD PO BOX 3015 NAPERVILLE IL 60563 362167008 501(C)(3) 7610 GENERAL OPERATING SUPPORT 7 2 STUDENT SCHOLARSHIPS 12 9856 PART I, LINE 2: GRANTS TO OTHER ORGANIZATIONS ARE NOT MONITORED. SCHOLARSHIPS ARE GRANTED BASED ON SET CRITERIA. APPLICATIONS ARE REVIEWED AND RECIPIENTS ARE CHOSEN BY A SCHOLARSHIP COMMITTEE. USE OF SCHOLARSHIPS ARE NOT RESTRICTIVE. X X X X X 0 1 0 0 0 0 0 1 0 JOSEPH WELTY MD BOARD MEMBER / PHYSICIAN 254783 0 0 0 396 0 12798 0 31405 0 299382 0 0 0 DAVID SCHREINER CEO AND BOARD MEMBER 528375 0 0 0 22875 0 163625 0 29659 0 744534 0 0 0 LINDA CLEMEN VP-CHIEF NURSING OFFICER 258081 0 0 0 1242 0 11388 0 21662 0 292373 0 0 0 ANTHONY EVERS VP-CHIEF FINANCIAL OFFICER 313400 0 0 0 14814 0 12996 0 32836 0 374046 0 0 0 PRATIP NAG MD CHIEF MEDICAL OFFICER 354936 0 0 0 810 0 13625 0 38228 0 407599 0 0 0 JULIE MANN VP-ADMINISTRATIVE OFFICER 272129 0 0 0 20822 0 13508 0 14451 0 320910 0 0 0 KEVIN T MARX VP-MEDICAL GROUP MANAGEMENT 222809 0 0 0 3564 0 10798 0 14380 0 251551 0 0 0 SUZANNE RAVLIN VP-CHIEF LEGAL OFFICER 300013 0 0 0 486 0 13214 0 21362 0 335075 0 0 0 MONTHER ELBZOUR MD PHYSICIAN 874432 0 440674 0 18590 0 13625 0 38228 0 1385549 0 0 0 ROBB RYDZYNSKI MD PHYSICIAN 619408 0 435975 0 18638 0 13625 0 1336 0 1088982 0 0 0 SOHAIL HANIF MD PHYSICIAN 783139 0 183128 0 18758 0 13625 0 32628 0 1031278 0 0 0 DAVID J POWERS MD PHYSICIAN 682785 0 0 0 18758 0 13625 0 19331 0 734499 0 0 0 THOMAS HERNANDEZ MD PHYSICIAN 687376 0 0 0 60 0 13625 0 38228 0 739289 0 0 0 PART I, LINE 4B DAVID SCHREINER - $150,000 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 24063 EMPLOYEE COMPENSATION 0 LESLIE MANN FAMILY MEMBER OF JULIE MANN, OFFICER 68463 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 1 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 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 2018. 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 1,311,436. MANAGEMENT AND GENERAL EXPENSES 190,315. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 1,501,751. PROFESSIONAL: PROGRAM SERVICE EXPENSES 310,660. MANAGEMENT AND GENERAL EXPENSES 335,830. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 646,490. PURCHASED: PROGRAM SERVICE EXPENSES 3,621,764. MANAGEMENT AND GENERAL EXPENSES 5,946,557. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 9,568,321. COMMUNICATIONS: PROGRAM SERVICE EXPENSES 180,951. MANAGEMENT AND GENERAL EXPENSES 297,354. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 478,305. RECOGNITION: PROGRAM SERVICE EXPENSES 21,392. MANAGEMENT AND GENERAL EXPENSES 1,720. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 23,112. OTHER: PROGRAM SERVICE EXPENSES 1,966,121. MANAGEMENT AND GENERAL EXPENSES 581,781. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 2,547,902. FORM 990, PART XI, LINE 9: CHANGES IN VALUE OF SUBSIDIARIES 158,566. FORM 990, PAGE 12, PART XII, LINE 2C THE PROCESS HAS NOT CHANGED FROM THE PRIOR YEAR. KSB - RMHSC PARTNERSHIP 2400 N ROCKTON AVE ROCKFORD IL 61103 364143516 HEALTHCARE OFFICES IL -16612 809953 KATHERINE SHAW BETHEA HOSPITAL KSB HOSPITAL AUXILIARY 403 E FIRST STREET DIXON IL 61021 366192116 FUNDRAISING FOR RELATED HOSPITAL IL 501(C)(3) LINE 12D, III-O 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 407555 1.00000 1 0 0 0 0 0 0 0 0 0 0 0 0 0 1 1 0 0 0 0