2014-05-12T14:08:49-05:00 2013-06-30 KPMG LLP 191 West Nationwide Blvd Ste 500 Columbus OH 432152568 990 2012-07-01 390808480 St Nicholas Hospital of the Hospital Sisters of the Third Order of St Francis % GREG SIMIA STNI 9204598300 3100 Superior Avenue Suite Sheboygan WI 530811948 Andrew Bagnall 2174642966 2014-04-17 true 6142492300 2012 2015-11-30 17:44:51Z St Nicholas Hospital Andrew J Bagnall 3100 Superior Avenue Sheboygan WI 530811948 75806639 false 0928 X www.stnicholashospital.org X 1890 WI TO CARRY FORWARD THE HEALING MINISTRY OF THE HOSPITAL SISTERS OF ST. FRANCIS AS PART OF THE HEALTH MINISTRY OF THE ROMAN CATHOLIC CHURCH. 12 11 538 150 458995 321523 901063 60601783 69491523 2400003 1374588 1254926 1159622 64578235 72926796 0 0 0 0 26181320 27339375 0 0 0 39744596 40823984 65925916 68163359 -1347681 4763437 108806524 114585253 43413417 37693078 65393107 76892175 X ST. NICHOLAS HOSPITAL IS DEDICATED TO SUFFERING HUMANITY FOR HIS SAKE, AND IS COMMITTED TO PROVIDING HIGH QUALITY, COMPASSIONATE CARE WITHOUT REGARD FOR RACE, CREED OR ABILITY TO PAY. THE HOSPITAL'S CORE VALUES OF RESPECT, CARE, COMPETENCE AND JOY ARE LIVED BY ALL WHO SERVE HERE, AND FELT BY ALL WHO RECEIVE HEALTHCARE SERVICES AT ST. NICHOLAS HOSPITAL false false 5469838 9570088 Surgical Services - See Schedule O - Community Benefit Report 2622927 10584572 Diagnostic Imaging - See Schedule O - Community Benefit Report 1751854 7759082 Emergency Services - See Schedule O - Community Benefit Report 41116892 45013054 50961511 true true false true false false false false false false true false false false true true false true false false false false false false false false true true false false true false false false true false false false false false false false false true true false false false true 39 0 true 538 true true true false false false false false false false false false X 12 11 false false false false true true true true true false false true true true true true true true true true true X GREG SIMIA 9204598300 3100 SUPERIOR AVENUE SHEBOYGAN WI 530811948 ANDREW J BAGNALL 40.0 10.0 X X 0 259553 59296 STUART W BROTZ 1.0 X 0 0 0 TIMOTHY KELLNER 1.0 X 0 0 0 PETER F BEMIS 1.0 X 0 0 0 CARL CLAERBOUT 1.0 X 0 0 0 SR MARYBETH CULNAN OSF 1.0 59.0 X 0 0 0 SR BERNADINE GUTOWSKI OSF 1.0 X X 0 0 0 MICHAEL LANSER EdD 1.0 X X 0 0 0 CHRISTOPHER LARSON MD 1.0 X 0 0 0 WILLIAM TRAGER MD 1.0 X 0 0 0 DAVID VAN DE WATER JD 1.0 X X 0 0 0 S MARK BETTAG MD 1.0 X 0 0 0 ANN M CARR 0.25 59.75 X 0 272146 138031 THERESE PANDL 15.0 45.0 X 0 663886 124665 GREG SIMIA 10.0 30.0 X 0 339812 24098 DEBRA FRENN 40.0 X 93707 0 3714 ANDREA M ANGOTTI 40.0 X 133987 0 20564 SUSAN M WHEELER 40.0 X 132154 0 21098 MELISSA PALECEK 40.0 X 119022 0 20326 478870 1535397 411792 3 false true false St Vincent Hospital 835 S Van Buren GREEN BAY WI 543013256 physician services 6235487 Diversified Clinical Services 5220 Belfort Rd JACKSONVILLE FL 32256 wound center 561031 Sodexo Inc 4880 Payspheres Circle CHICAGO IL 60674 mgmt services 507297 Infinity Healthcare Inc 111 E Wisconsin Avenue MILWAUKEE WI 53202 er & hyperbaric 476736 Anesthesiology Assoc LTD Box 68-6160 MILWAUKEE WI 53268 physician services 418056 19 901063 901063 NET PATIENT SERVICE REVENUE 900099 66685752 66685752 OTHER OPERATING REVENUES 900099 2346776 2346776 LABORATORY OUTREACH REVENUE 621500 458995 458995 69491523 578794 578794 0 0 2000079 840456 1159623 0 1159622 1159622 2527561 307620 1545630 493757 981931 -186137 795794 795794 0 0 0 0 0 72926796 69032528 458995 2534210 0 0 0 0 0 0 0 0 0 20005410 13857079 6148331 1798425 1245709 552716 4243729 2939489 1304240 1291811 894794 397017 3939576 2728813 1210763 59692 41347 18345 0 0 0 0 14937658 10625817 4311841 0 110947 78801 32146 0 0 0 163517 142543 20974 0 69008 37435 31573 208544 144451 64093 0 3846975 1847587 1999388 253185 175373 77812 SUPPLIES 9552678 9276479 276199 BAD DEBT 2484277 2484277 MEDICAID TAX 2071180 2071180 EQUIPMENT RENTAL & MAINTENANCE 1500075 1067392 432683 1626672 1302945 323727 68163359 50961511 17201848 0 X 5662992 6211365 0 0 0 0 9269068 10220219 0 0 0 0 0 0 1560659 1610598 232193 139578 115913234 67228962 49137919 48684272 40116535 45321470 0 0 1237191 1258971 0 0 1589967 1138780 108806524 114585253 6108031 7543347 0 0 266636 283968 16333920 16172628 0 0 0 0 0 0 0 0 20704830 13693135 43413417 37693078 X 57687975 69448329 6064167 5792781 1640965 1651065 65393107 76892175 108806524 114585253 X 4763437 1535663 5199968 X false true X true false X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED false false false false false false false false true 4188 4188 false Description of other lobbying activities SCHEDULE C, PART II B, QUESTION 1I ST. NICHOLAS HOSPITAL ("THE HOSPITAL") IS A MEMBER OF THE CATHOLIC HEALTH ASSOCIATION ("CHA"), THE WISCONSIN HEALTH ASSOCIATION ("WHA"), THE NATIONAL ASSOCIATION FOR HOME CARE AND HOSPICE, AND THE AMERICAN HEALTH ASSOCIATION ("AHA"). AS A MEMBER OF THESE ORGANIZATIONS, THE HOSPITAL PAYS DUES, WITH PART OF THESE DUES BEING ATTRIBUTABLE TO LOBBYING FEES PAID BY THE ORGANIZATIONS. THE AMOUNT LISTED ABOVE IS THE AMOUNT ATTRIBUTABLE TO THE HOSPITAL FROM ITS DUES PAID. 0 1715010 1715010 0 72136409 38576997 33559412 0 283176 32337 250839 0 41551625 28619628 12931997 0 227014 227014 48684272 0 ACCRUED BENEFIT LIABILITIES 6979943 CAPITAL LEASE 5077669 INTEREST RATE SWAP SETTLEMENT 1049634 ESTIMATED SELF-INSURANCE LIAB 288072 OTHER LONG TERM LIABILITIES 297817 13693135 X ASC SUBTOPIC 740-10 SCHEDULE D, PART X, LINE 2 HSHS HAS ADOPTED ASC SUBTOPIC 740-10, ACCOUNTING FOR UNCERTAINTY IN INCOME TAXES - AN INTERPRETATION OF FASB STATEMENT NO. 109. ASC SUBTOPIC 740-10 ADDRESSES THE DETERMINATION OF HOW TAX BENEFITS CLAIMED OR EXPECTED TO BE CLAIMED ON A TAX RETURN SHOULD BE RECORDED IN THE CONSOLIDATED FINANCIAL STATEMENTS . UNDER ASC SUBTOPIC 740-10, HSHS MUST RECOGNIZE THE TAX BENEFIT FROM AN UNCERTAIN TAX POSITION ONLY IF IT IS MORE LIKELY THAN NOT THAT THE TAX POSITION WILL BE SUSTAINED ON EXAMINATION BY THE TAXING AUTHORITIES, BASED ON THE TECHNICAL MERITS OF THE POSITION. THE TAX BENEFITS RECOGNIZED IN THE CONSOLIDATED FINANCIAL STATEMENTS FROM SUCH A POSITION ARE MEASURED BASED ON THE LARGEST BENEFIT THAT HAS A GREATER THAN 50% LIKELIHOOD OF BEING REALIZED UPON ULTIMATE SETTLEMENT. ASC SUBTOPIC 740-10 ALSO PROVIDES GUIDANCE ON DERECOGNITION, CLASSIFICATION, INTEREST AND PENALTIES ON INCOME TAXES, AND ACCOUNTING IN INTERIM PERIODS AND REQUIRES INCREASED DISCLOSURES. AS OF JUNE 30, 2013 AND 2012, HSHS DOES NOT HAVE AN ASSET OR LIABILITY FOR UNRECOGNIZED TAX BENEFITS. true true true X 225. true X true true true false true true 1 1625 1439259 1439259 0.02190 10327620 5337362 4990258 0.07600 924856 658090 266766 0.00410 1 1625 12691735 5995452 6696283 0.10200 5701 220605 15790 204815 0.00310 12 25171 25171 0.00040 113 4725 1155 3570 0.00010 7410 72662 529 72133 0.00110 13236 323163 17474 305689 0.00470 1 14861 13014898 6012926 7001972 0.10670 89 906 906 0.00010 156 9217 414 8803 0.00010 245 10123 414 9709 0.00020 true 2484277 924374 24652986 38534615 -13881629 X true true orange cross ambulance services 0.50000 sheboygan surg cntr outpatient surgery center 0.50000 0.50000 1 1 St Nicholas Hospital

3100 Superior AVe Sheboygan WI 530811948

X X X ST NICHOLAS HOSPITAL 1 true X X X X X X X X X 12 true true true X X X X X X X false false true true 225. true 300. true X X X X X true true X X X X true false true X false false PART I, LINE 3C Not applicable, as the organization does follow FPG to determine eligibility for providing charity and discounted care to low-income uninsured and underinsured individuals. PART I, LINE 6A The Hospital's community benefit report can be accessed at www.stnicholashospital.org. PART I, LINE 7, COLUMN (F) THE PERCENTAGE OF CHARITY CARE AND CERTAIN OTHER BENEFITS AT COST AS A PERCENT OF TOTAL EXPENSES LESS BAD DEBT IS 10.67%. THE AMOUNT OF BAD DEBT REMOVED WHEN CALCULATING PART I, LINE 7, COLUMN (F) WAS 2,484,277. PART I, LINE 7 Charity care is calculated by determining the total amount from patient billing that is written off to charity care charge codes or allowances. This amount matches the number that is reported on our fiscal year ending 2013 audited financial statements. The total charity care dollar amount is then reduced to cost by applying the hospital's cost to charge ratio as calculated on IRS Schedule H-Worksheet J. Part II The community building activities that we have tracked and reported in our community benefit report are a minor potion of our total community benefit efforts. They consist primarily of actively participating in and supporting the work of community groups to advance community awareness about health issues such as Healthy Sheboygan County 2020 Steering Committee, Hispanic/Latino Task Force and the Mental Health America Board. Part III, Line 4 Bad debt expense of HSHS is described on pages 18 and 19 of the audited financial statements, a copy of which is attached to the return. Part III, Line 8 The hospital continually strives to provide excellent patient care in the most cost effective fashion. Nonetheless, the Medicare program, in many cases, does not provide payment that covers the full cost of the care provided. Since it is the mission of the hospital to respond to community need, hospital management continually advocates for improved Medicare payment so that the cost of quality care to those patients that are not able to afford it is not compromised and is fairly subsidized by all payers. While this shortfall in Medicare payments is not classified as community benefit by the IRS, we nonetheless believe it is an important contribution made by the hospital to the health and well being of the community. Our mission calls us to serve all patients with the highest possible quality and efficiency, even if we are not paid fully for doing so. The hospital computes the unpaid costs of providing care to Medicare patients by comparing the cost of the services to the reimbursement received from Medicare during the year. The cost of Medicare services is calculated by applying the ratio of patient care cost to charges to the annual Medicare charges. The patient care cost is determined by reducing the total annual operating expense by bad debt expenses, Medicaid provider taxes and community benefit expense. The difference between the reimbursement received and the calculated cost of the services is reported as the Medicare shortfall. The hospital Medicare shortfall for fiscal year 2013 was $13,881,629. Part III, Line 9b Every effort is made prior to, during, and after provision of medical services to determine whether a patient is eligible for charity/community care and to assist the patient in completing the application and providing adequate documentation. If the patient qualifies for charity/community care for the full balance of their account, the entire amount is written off to charity/community care and hence no dept collection is pursued. If the patient qualifies for charity/community care for a portion of their account balance, that portion is written off to charity/community care, with the patient being responsible for the remainder of the balance. Additionally, reasonable effort will be made to obtain third-party or government payer reimbursement on behalf of the patient. If those efforts are not fruitful, an offer will be extended to the patient to make installment payments on their balance. Only at such point that the patient defaults on installment payments or refuses to cooperate with the hospital's efforts to be reimbursed will the account be sent to collections. Part V-B, Line 3 Yes. The hospital's CHNA involved people broadly representative of the community. How the Community Needs Assessment Was Conducted The community needs assessment was a collaborative, multistage process that included St. Nicholas Hospital, the Sheboygan County Health Division of Public Health, and community partners. Two complementary community engagement sessions occurred: A Community Health Needs Forum sponsored by St. Nicholas Hospital. As described in the companion brochure also posted on our website, this Forum included presentations and engagement by a group broadly representative of the community. The Community Health Improvement Call to Action event sponsored by the Sheboygan County Division of Public Health and Healthy Sheboygan County 2020 (HSC 2020). HSC 2020 is a coalition of community and health-related organizations. This event also entailed broad community participation, including representation from St. Nicholas Hospital. In both of the above sessions, participants developed priorities for community-wide action based on the 2009 Community Health Needs Assessment conducted by the Sheboygan County Division of Public Health - including updated data from the 2010 census and more current publicly reported public health statistics. This Health Assessment utilized the health focus framework of Healthiest Wisconsin 2020 to gather Sheboygan County data and key findings. Major Needs and How Priorities Were Established At the May 2011 St. Nicholas Hospital Community Health Needs Forum, approximately 70 community leaders participated in the event with representation from business, non-profit agencies, healthcare, education, public health and safety and elected officials. The objective of the forum was to obtain community input to identify and prioritize health issues that the hospital is best positioned to address in partnership with other organizations in the community. This event included a presentation by Jean Beinemann, RN, Program Supervisor from the Sheboygan County Division of Public Health on the 2009 Sheboygan County Community Health Needs Assessment. Her presentation also included updated data from the 2010 census and more current publicly reported public health statistics. The larger group was broken down into nine subgroups to rate and rank the health needs using two documents developed for this process to assess the needs against three criteria: (a) magnitude of problem; (b) seriousness of the consequences; and (c) feasibility of correcting. These documents included a Problem Importance Worksheet for each of the identified 12 key focus areas identified in the Sheboygan County Health Needs Assessment and a Problem Prioritization Worksheet to rank the problems identified in the Problem Importance Worksheet. A similar process was used at the June 2011 Call to Action event sponsored by the Health Department and HSC 2020. This event included about 60 representatives from government, not-for-profit, healthcare, education, public safety and business. The group reviewed health data in relation to the Healthy People 2020 and Healthiest Wisconsin 2020 framework. They discussed health needs in small groups, and then established priorities using the dot method whereby each participant can attribute an allocated number of votes to the needs that they deem most important. The two priority-setting forums had slightly different but complementary purposes. Results from the Call to Action event fed into the Sheboygan County Community Health Improvement Plan. This plan includes extensive involvement from St. Nicholas Hospital staff who serve on several implementing committees. The St. Nicholas forum also sought community input to set priorities, but with a focus on needs that the hospital is best positioned to help address and to support development of this Implementation Strategy. The St. Nicholas Hospital forum identified five priority issues: 1. Oral health 2. Physical activity 3. Adequate, appropriate and safe food and nutrition (tie) 4. Unhealthy drug and alcohol use (tie) 5. Tobacco use and exposure. In addition (though not formally identified as a separate priority) each issue includes health literacy as a component. The Sheboygan County/HSC 2020 event also identified five top priorities: 1. Oral/dental health issues 2. Mental health issues 3. Improvement of health literacy 4. AODA and tobacco use issues 5. Obesity The next step for St. Nicholas Hospital was to identify commonality between the identified issues which emerged as a result of the community engagement sessions. The priorities identified at both of the community engagement sessions shared many commonalities. Oral Health emerged as the top issue at both sessions. Another set of the priorities could be grouped together: physical activity, adequate, appropriate and safe food and nutrition, and obesity. AODA, including tobacco, was also highlighted as a top concern. While mental health was not identified as one of the top five priorities at the St. Nicholas Hospital forum, it was identified as the sixth priority. Health Care Facilities and Resources within the Community There are two acute care hospitals in Sheboygan County-St. Nicholas Hospital and Aurora Sheboygan Medical Center; both provide inpatient, outpatient and emergency care. Other facilities and resources include Aurora Sheboygan Memorial mental health and AODA treatment programs. In 2012, a community health clinic and a community dental clinic were started to serve the health care needs of low income people. Sheboygan County Community Health Needs Forum Sponsored by St. Nicholas Hospital May 6, 2011 Attendee List - Ann Wondergem, Sheboygan & Plymouth Area United Way# - Dr. Clifford Martin, Prevea Sheboygan Womens Care - Beverly Randall, Mental Health America# - Marty Folan, St. Nicholas Hospital - Katy Pruitt, Safe Harbor# - Dr. Al Hardersen, UW-Sheboygan - Tanya Smith, St. Nicholas Hospital - Steve Stauber, Friends of St. Nicholas Hospital - Heidi Selberg, HSHS Division-Eastern Wisconsin - Jean Beinemann, Sheboygan County Division of Public Health* - Sue Wheeler, St. Nicholas Hospital - Aly Flaskrud, Willowdale Nursing and Rehabilitation Center - Brian Charlier, Prevea Health - Andy Bagnall, St. Nicholas Hospital - Dr. Donald Gore, Sheboygan Orthopaedic Associates - Sherri Samuels-Fuerst, Sargento Foods, Inc. - Chris Jensema, HSHS Division-Eastern Wisconsin - Judy Halverson, Partners of St. Nicholas Hospital - Mary Schueller, HSHS Division-Eastern Wisconsin - Annette Selk, Public Health Nurse, Sheboygan County Division of Public Health* - Joseph Leibham, Wisconsin State Senate - Jeanette Miller, Partners of St. Nicholas Hospital - Nancy Jusky, Sheboygan & Plymouth Area United Way# - Eve Kovacs, Partners of St. Nicholas Hospital - Mary Jo Tittl, Family Resource Center# - Beth Millin, St. Nicholas Hospital - Jill Niemczyk, Northeastern Wisconsin Area Health Education Center - Mark Radtke, Wind Mill Slatwall Products - Jody Moesch Ebeling, Public Health Nurse, Sheboygan County Division of Public Health * - Dale Hippensteel, Health Officer, Sheboygan County Division of Public Health* - Kristin Blanchard, Sheboygan County Interfaith Organization# - Susie Runaas, St. Nicholas Hospital - Amy Betke, Public Health Nurse, Sheboygan County Division of Public Health* - Carrie Bender, Rockline Industries - Steve Neisius, Rockline Industries - Jean McMurray, Aurora Health Care - Wendy Elgin, BridgePoint Health# - Jan Mulhern, St. Nicholas Hospital - Michelle Niemi-Prange, Sheboygan Progressive Care Center - Dawn Kind, Prairie States Enterprises - Mary Paluchniak, St. Nicholas Hospital - Cynthia Bertsch, St. Nicholas Hospital - Xue Yang, St. Nicholas Hospital - Kaitlin Swanson, HSHS Division-Eastern Wisconsin - Virginia Thomas, Sheboygan Area Community Clinics, Inc.# - Alejandra Klemme, Catholic Charities# - Phil Duket, Family Resource Center# - Chasong Yang, Hmong Mutual Assistance Association# - Dr. David Wyatt Seal, Medical College of Wisconsin - Ryan Perkins, St. Nicholas Hospital - Jenny Pernat, St. Nicholas Hospital - Marlene Mielke, Regional Representative for U.S. Senator Herbert Kohl - Terri Boxrucker, Public Health Nurse,Sheboygan County Division of Public Health* - Connie Bitter, Friends of St. Nicholas Hospital and Bemis Manufacturing - Mike Klein, Bemis Manufacturing - Robert Weber, D.D.S. - Dr. Gregory Grose, Prevea Sheboygan Urology - Jessica Muchowski, Willowdale Nursing and Rehabilitation Center - Cindy Musial, The Gathering Place# - Nichol Fidlin, Prevea Health - Mel Blanke, Sheboygan Area Community Clinics, Inc.# - John Koehler, Sheboygan Area School District - Joann Wieland, Sheboygan & Plymouth Area United Way# - John Wenig, Friends of St. Nicholas Hospital - Lorraine Pashley, St. Nicholas Hospital - Thomas Eggebrecht, Sheboygan County Health and Human Services Department# - Check Butler, Sheboygan City Fire Department *Public health representative #Representative of minority, underserved or low in Needs Assessment As indicated in Part V, Section B, St. Nicholas Hospital conducted a Community Health Needs Assessment in our FY2012. In prior years, we employed a number of methods to assess health care needs. For example, we have a community advisory committee that is representative of the community that the hospital serves. The committee meets regularly to discuss hospital services and the ability of the hospital to meet community health care needs. Agendas are purposely organized to include time for feedback from members on what they are hearing in the community. In addition, hospital colleagues represent the hospital on a variety of community groups. Through this representation, the hospital becomes aware of emerging needs and as a result is able to offer or support screening and education programs that address these needs. Patient Education of Eligibility for Assistance Our hospital posts our charity care policy and application on our website. In addition, charity care applications are available and prominently displayed in our waiting and registration areas. Our financial counselors are available to meet with patients on site before or at the time of service to assist them in identifying whether they are eligible for government aid or financial assistance, and to assist them in applying for programs for which they may be eligible. After patients receive service, our customer service representatives are also trained to assist them to apply for various government programs or for our charity care program. Our collectors are trained to provide this assistance as well. Last but not least, we have contracted with an outside firm to do active outreach with patients who may need additional assistance or advocacy to apply for benefits, appeal denials, or who need transportation to government agencies to apply for benefits. Community Information Sheboygan County is primarily an urban county, one of 72 counties, and is located in eastern Wisconsin. The population of approximately 115,000 is primarily Caucasian (88%). However, 5% of the population is Hispanic, and another 5% is Asian. The percent of people age 65 and over exceeds state and national levels. According to the WI Department of Health Services, 9% of residents are below the federal poverty level, Over 18,000 residents are covered by Medicaid/BadgerCare Plus. According to the Wisconsin Department of Health Services Division of Public Health, 5% of Sheboygan County's population is uninsured. Sheboygan County contains a primary care and a mental health HPSA (health professional shortage area). There are two not for profit, general medical and surgical hospitals serving Sheboygan county. Promotion of Community Health St. Nicholas Hospital offers hope to our community in the tradition of the Hospital Sisters of St. Francis. As a healing ministry of the Catholic Church and an affiliate of the Hospital Sisters Health System (HSHS), St. Nicholas is committed to delivering high quality, compassionate, and cost-effective health care services to all. The hospital was founded over 120 years ago to bring a healing presence and improve the health of our community, especially for people who are sick, poor, and disadvantaged. Because of the hospital's purpose and tradition, it is organized to promote the health of Sheboygan County, Wisconsin, and surrounding areas. The hospital is governed by a Board of Directors, the majority of which is comprised of persons who reside in the organization's primary service area and who are neither employees nor contractors of the hospital (nor family members thereof). The Board ensures that St. Nicholas is responding to community need. During the last year, for example, the Board reviewed the Community Health Needs Assessment and approved an implementation strategy for addressing selected needs. In addition our hospital Advisory Council, Friends of St. Nicholas Foundation and the Partners of St. Nicholas Hospital, whose volunteer members assist in many areas of the hospital, provide the hospital with additional connections to and insights into the larger community and its health care needs. Also consistent with its exempt purpose, St. Nicholas has an open medical staff with privileges available to all qualified physicians in the area. In addition, the hospital operates an emergency department that is open 24 hours to all persons regardless of their ability to pay. As a not-for-profit hospital, St. Nicholas reinvests surplus funds into the mission of the organization and health of the community rather than distributing them as profits to shareholders or individuals. Funds not committed to ongoing operations are generally used to upgrade facilities, secure new technologies, improve patient care, and support initiatives designed to promote health and ensure access for all. For example, St. Nicholas is currently working with its parent organization, Hospital Sisters Health System, to continuously enhance quality and improve coordination of care both inside the hospital and with a growing number of physician partners. Supported by investments in information technology, this "care integration" strategy is designed to better coordinate care, improve health outcomes, create new efficiencies, and help ensure that patients (especially those with chronic conditions) get well and stay well. For example, the Epic electronic medical record system enables providers to connect with their patients' medical record from wherever they are as well as allows emergency physicians access to patient medical records from any facility that has Epic. This reduces duplicate testing, puts critical health information at providers' fingertips, helps better manage chronic conditions, and improves patient safety. A Heart Failure Clinic has been established to assist heart failure patients with maintaining good health and staying out of the hospital incorporating diet, exercise and other wellness information into the long-term care plan. This growing program has shown success in reducing readmissions, something that is also especially helpful for those with limited financial resources. St. Nicholas Hospital provides significant resources to access for patients who cannot afford care, along with other community benefits. In fiscal year 2013, St. Nicholas provided over $7 million in community benefit services, including charity care at cost, unpaid costs of Medicaid and other public programs, and a range of diverse programs designed to enhance access and improve community health. During this period, St. Nicholas provided $13.8 million (at cost) in excess of Medicare payment for health care services. Responding to Community Need The range of benefits provided by St. Nicholas flows from our mission and long-standing commitment to our community. In many cases, these programs would be unlikely to exist without the leadership role played by St. Nicholas, and they often relieve a burden that would otherwise be carried by government. St. Nicholas' active participation with the Hmong community continues with the addition of a partnership with a local Catholic Church to provide screenings and education in a location which is nonthreatening to members of this population. In doing so, the hospital has reached out to this community and been able to identify critical health conditions and encourage and promote ongoing proactive health care rather than reactive care. Another example of community benefit at St. Nicholas is the Hope After Loss Organization (HALOTM), which provides support to families that experience loss of life during pregnancy. This program serves the entire community, at no cost to participants, whether their loss occurred at St. Nicholas Hospital or another facility. Over 80 individuals attended HALO support programs. Community benefits at St. Nicholas also include multiple programs aimed at health promotion. * St. Nicholas Hospital actively participates in "Healthy Sheboygan County 2020". This collaborative group is made up of local community organizations. The group's primary focus is to improve the lives of people in our county Hospital staff co-chair the Health Literacy Committee. * The Sheboygan County Activity & Nutrition (SCAN) receives assistance through the hospital's participation in the employee Health & Fitness Day, Family Health & Fitness Day and local health fairs. * St. Nicholas Hospital is a supporting co-sponsor of the Community Clinic being developed to address the need to increase access to health care for the un- and underinsured in Sheboygan County. In addition to the financial support, St. Nicholas Hospital has dedicated staff to assist with the important community benefit effort. * Free screenings and health education for the Hmong Mutual Assistance Association. * Support groups free of charge for heart, renal, and stroke patients for adults and teens. * Free use of hospital conference and meeting rooms for area not-for-profit organizations. * Professionals at the hospital assisted in excess of 1,000 people to apply for the appropriate assistance, such as Social Security or Medical Assistance when they came to the hospital in a time of medical need. * Provide a house with financial support and in-kind services for Sheboygan County Interfaith Organization and their Bridgeway House, which provides temporary housing for homeless women and children and families transitioning out of domestic abuse situations. * More than 40 families took advantage of child care seat safety checks by certified technicians open to the public free of charge; the checks include education so that parents understand the need for regular use of safety seats and the importance of proper installation and child restraint. * Free bike helmet fittings and helmets at cost, open to the public; * More than 1,200 individuals attended foot clinics for the elderly and individuals with diabetes. The clinics assist with care that can be difficult due to degenerative health conditions as well as provide regular specialized care for diabetics. * Diagnostic imaging services for Salvation Army Free Clinic patients. * Financial support and in-kind services for Sheboygan County Interfaith Organization, Family Resource Center, Safe Harbor Domestic Abuse Shelter, Big Brothers/Big Sisters, and area churches and schools reaches thousands in need within the greater Sheboygan County area; * Food drives for area food pantries; candy collection for troops overseas, school supply and clothing drives for area schools. * Offer community blood drives with the Red Cross twice yearly. The annual Good Friday Blood Drive has been ongoing for more than 30 years, drawing members from the Catholic Community to donate blood after Good Friday Mass. We collect an average of 25 pints a drive. * Collected one truckload of home medical supplies for the annual Community Medical Collection supporting our system missions throughout the world. Collection included wheelchairs, walker, canes, bandages, body bags, ace wraps, and other home medical supplies. * In response to one of the community needs identified through our CHNA (adequate food and nutrition), donated supplies to the Free Summer Lunch program which feeds over 650 children a day. * Also in response to the community need for "adequate and appropriate nutrition", participated in the Farmers' Market with nutritional information and "ask a dietitian". Affiliated Health Care System St. Nicholas Hospital in Sheboygan, Wisconsin is an affiliate of Hospital Sisters Health System (HSHS), a health care ministry that includes 13 hospitals, scores of community-based health centers and clinics, and hundreds of physician partners across Illinois and Wisconsin. The Mission of HSHS is to reveal and embody Christs healing love for all people through our high quality Franciscan health care ministry. We live our Mission by providing holistic healing to all who seek our care, as well as through Community Benefit. Working collaboratively with others in the communities we serve, our Community Benefit initiatives are strategically and successfully expanding access to care, improving the health status of residents, and furthering medical education and knowledge. In FY2013, our 13 hospitals responded to needs identified in each of their Community Health Needs Assessments (CHNAs) completed in FY2012. The information gathered from these assessments was used to develop new and enhance existing Community Benefit programs and services that best addressed community needs. Included among the many priority needs identified in our CHNAs were chronic disease prevention and management, obesity, adequate food and nutrition, mental health, and access to health care services. HSHS hospitals are proactively addressing these and other needs through patient, provider and community education, preventative screenings, self-management classes, and new or enhanced clinical services. Across HSHS, we collectively provided $185.6 million in Community Benefit (or 10.2% of total hospital expenses) in FY2013. Included in this amount was $45.9 million provided for Financial Assistance (i.e. Charity Care) and $104.2 million for unreimbursed care provided under the Medicaid program. In addition, HSHS hospitals committed significant resources to care for Medicare patients. The cost of providing services to primarily elderly beneficiaries of the Medicare program - in excess of governmental and managed care contract payments - was $152.3 million. HSHS hospitals also recorded $107.1 million in uncollectible accounts. In addition to the dollars invested in our Community Benefit programs, HSHS also continues to reinvest any surplus revenue from operations and investments into new medical technology, facility infrastructure and health care services in our communities. By doing do, we ensure we are able to meet the ongoing demand for high quality, efficient and easily accessible health care. Recognizing that the health care delivery model in the United States is evolving, HSHS remains focused on implementing our Care Integration strategy. Care Integration coordinates the delivery of care around the needs of each patient. During FY2013, we made significant progress with this strategy as we further implemented interoperable health information technologies, expanded the number of Medical Homes, and strengthened our alignment with physicians. Greater access to care As a Franciscan health care ministry, HSHS is deeply committed to serving those who are most in need. We not only provide care to every patient who walks through our doors, but also reach out beyond the walls of our hospitals and clinics to care for those in our communities. Our efforts to ensure residents in the communities we serve receive the right care at the right time in the right setting often involve partnering with others to achieve this goal. Across our two-state System, there are numerous examples of HSHS collaborating with other organizations to enhance access to care for those in need. From 2006 to 2009, the United States saw a 16% increase in individuals seeking dental care at hospital emergency rooms. With the support of St. Marys Hospital Medical Center and St. Vincent Hospital in Green Bay, Wisconsin, the NEW Dental Clinic on the campus of Northeast Wisconsin Technical College expanded in FY2013 and was able to accommodate up to 6,000 visits. The clinic provides dental services to low-income and uninsured persons including the homeless in Brown County. St. Francis Hospital in Litchfield, Illinois partnered with Lewis & Clark Community College to bring their mobile health unit to the Litchfield area; the unit provides dental exams and screenings, x-rays and dental hygiene to those in need. In western Wisconsin, St. Josephs Hospital in Chippewa Falls works closely with the Chippewa Health Improvement Partnership (CHIP) to support the Open Door Clinic. The free medical clinic provides health care for those without insurance coverage. This past year, the clinic received a total of 2,672 patient visits, an 11% increase from the prior year. With more than 166 individuals volunteering, the clinic provided more than 6,751 hours (including 753 provider hours and 675 nursing hours) of service to individuals. The Open Door Clinic is an example of HSHS providing leadership and support to a community-based program designed to meet the needs of those less fortunate. In southeast Illinois, area residents can get help filling a prescription through the long-term collaboration between St. Anthonys Memorial Hospital in Effingham and Catholic Charities. Last year, St. Anthonys helped underwrite the cost of prescription medications for more than 280 residents. In southwest Illinois, St. Joseph's Hospital in Highland enhanced their offerings to their senior population based on their CHNA. Senior Renewal is an outpatient counseling program for senior adults who may be facing emotional and physical problems unique to the aging process such as feelings of loneliness, isolation and anxiety. Clients receive an intensive level of treatment without inpatient hospitalization through counseling strategies and education. In addition, in collaboration with the Illinois Department of Insurance, St. Josephs Hospital participates in the Senior Health Insurance Program (SHIP), a free health insurance counseling service for Medicare beneficiaries and their caregivers. In addition to programs such as these, HSHS makes sure that those who need financial assistance for care receive it. Our Financial Assistance (i.e. Charity Care) program covers 100% of hospital charges for individuals and families who earn less than 200% of the federal poverty level. HSHS Financial Assistance programs have a sliding scale, in some instances providing up to a 60% discount on charges for those earning up to 600% of the federal poverty level. Counselors are available in our hospitals to explain our financial assistance policies to patients, provide them with assistance in filling out a simple application form, or help them enroll in publicly funded health care programs. Better community health As part of our Mission to embody Christs healing love, we understand that we have a responsibility to improve the overall quality of life in our communities by supporting initiatives that promote health and wellness. We recognize we are most successful when we work together with a wide array of public and private organizations that share our commitment to improving lives. By doing so, we maximize our efforts and reduce the duplication of services. HSHS hospitals also understand we need to listen closely to the residents of the communities we serve to ensure the health care needs of all are being met. To that end, each of our 13 hospitals completed Community Health Needs Assessments (CHNA) during FY2012. The information gathered from these assessments is being used to help us develop new, and enhance existing, programs and services that best address the needs of the community. Among the many priority needs identified from the CHNAs include metabolic and cardiovascular disease management, adequate food and nutrition, and mental health. HSHS hospitals are addressing these and other needs by proactively offering educational opportunities, preventative screenings, and new or enhanced clinical services. In partnership with the Sangamon County Health Department (SCDH) and local farmers, St. Johns Hospital in Springfield, Illinois took a lead role in bringing a Farmers Market to the east side of Springfield. The East Side Farmers Market addresses three community needs: childhood obesity, childhood poverty (26% of children in Sangamon County live in poverty vs. 18% in the state) and providing fresh produce to persons living in a known food desert. WIC Cooking Classes are also offered in tandem with the East Side Farmers Market to teach participants how to prepare fresh produce. The Farmers Market and cooking classes are hosted at the SCDH. St. Marys Hospital in Streator, Illinois teamed up with the Streator YMCA to offer a 12 week weight loss program Healthy You to motivate 282 participants (nearly double the participants from last year) to lose weight and maintain a healthy lifestyle. The program included aerobics classes, cooking classes, and a maintenance program to encourage participants to weigh in monthly. A total of 191 participants completed the program, losin X X true true X X X X X X false true false false false false false false false ANDREW J BAGNALL 0 219727 0 22244 0 17582 0 35898 0 24291 0 319742 0 0 ANN M CARR 0 193454 0 29440 0 49252 0 121170 0 17686 0 411002 0 18215 THERESE PANDL 0 565288 0 77968 0 20630 0 100815 0 28586 0 793287 0 0 GREG SIMIA 0 339812 0 0 0 0 0 0 0 25043 0 364855 0 0 ANDREA M ANGOTTI 133207 0 0 0 780 0 6630 0 14542 0 155159 0 0 0 SUSAN M WHEELER 130534 0 0 0 1620 0 3654 0 18093 0 153901 0 0 0 Social Club Dues SCHEDULE J, PART I, Line 1A St. Nicholas paid social club dues on Andrew Bagnall's behalf during the year. The fair market value was included in his reportable compensation for the year. Tax Indemnification and Gross-up Payments Schedule J, Part I, Line 1A Tax gross-ups were paid by HSHS to Ann Carr for $11 during the year. The fair value of this was included in her annual reported income. THERESE PANDL SCHEDULE J, PART I, LINE 4B Therese pandl participated in a SERP plan during the year in the amount of $64,900. ANN M. CARR SCHEDULE J, PART I, LINE 4B Ann M. Carr participated in a SERP plan during the year in the amount of $42,817. ANDREW BAGNALL SCHEDULE J, PART I, LINE 4B Andrew Bagnall participated in a SERP plan during the year in the amount of $24,726. THERESE PANDL OFFICER mort ext X 250000 251973 false true true THERESE PANDL OFFICER stock purch X 4125 4125 false true true 256098 Barbara Hocking Temporary Placement Director of Surgery placement Loans to/from interested persons SCHEDULE L, PART II ALL LOANS INVOLVING INTERESTED PERSONS ARE COMPLIANT WITH THE ORGANIZATION organization's conflict of interest policy. any transactions requiring board approval are reviewed by an independent board prior to being approved. Organization's Mission FORM 990 PART III, LINE 1 ST. NICHOLAS HOSPITAL IS DEDICATED TO SUFFERING HUMANITY FOR HIS SAKE, AND IS COMMITTED TO PROVIDING HIGH QUALITY, COMPASSIONATE CARE WITHOUT REGARD FOR RACE, CREED, OR ABILITY TO PAY. The hospital's CORE VALUES OF RESPECT, CARE, COMPETENCE AND JOY ARE LIVED BY ALL WHO serve HERE, AND FELT BY ALL WHO receive healthcare services at St. nicholas Hospital. Program Service Revenue - Surgery FORM 990 PART III, LINE 4A SURGICAL SERVICES ST. NICHOLAS HOSPITAL SURGICAL SERVICES ARE COMPRISED OF CENTRAL PROCESSING, ANESTHESIA, SURGERY AND RECOVERY. THIS INCLUDES SEVEN OR SUITES. SERVICES ARE AVAILABLE 24/7 AND INCLUDE BOTH INPATIENT AND OUTPATIENT PROCEDURES. IN FISCAL YEAR 2012-2013, 2,478 SURGICAL PROCEDURES WERE PERFORMED. SURGICAL PROCEDURES INCLUDE GENERAL, ORTHOPEDIC, UROLOGY, TRAUMA AND GYNECOLOGY. ANESTHESIA AND CENTRAL PROCESSING ALSO PROVIDE HOSPITAL-WIDE SERVICES TO INPATIENT NURSING, LABOR AND DELIVERY AND THE EMERGENCY DEPARTMENT. FORM 990, PART III, LINE 4B RADIOLOGY SERVICES ST. NICHOLAS HOSPITAL IMAGING SERVICES PROVIDES INPATIENT, OUTPATIENT, AND EMERGENCY CARE. OVERALL, THE DEPARTMENT PERFORMS MORE THAN 34,000 INPATIENT AND OUTPATIENT EXAMS AND PROCEDURES ANNUALLY. PATIENTS HAVE ACCESS TO THE LATEST TECHNOLOGY IN RADIOLOGY, COMPUTED TOMOGRAPHY, MAGNETIC RESONANCE IMAGING (MRI), NUCLEAR MEDICINE, POSITRON EMISSION TOMOGRAPHY (PET), AND ULTRASOUND. THE STAFF CONSISTS OF BOARD CERTIFIED RADIOLOGISTS AS WELL AS LICENSED AND CERTIFIED TECHNOLOGISTS, NURSES, AND SONOGRAPHERS. THE MODALITIES ARE ACCREDITED AND UTILIZE STATE-OF-THE-ART EQUIPMENT TO AFFORD THE RADIOLOGISTS OPTIMAL IMAGES FOR INTERPRETATION. THE DEPARTMENT AND HOSPITAL ARE ACCREDITED BY THE JOINT COMMISSION. FORM 990 PART III, LINE 4C EMERGENCY SERVICES ST. NICHOLAS HOSPITAL OPERATES A LEVEL III TRAUMA CENTER/EMERGENCY DEPARTMENT THAT IS OPEN 24/7 AND STAFFED BY BOARD-CERTIFIED EMERGENCY MEDICINE PHYSICIAN SPECIALISTS. STAFF MEMBERS ARE CERTIFIED IN ADVANCED CARDIAC LIFE SUPPORT, PEDIATRIC ADVANCED LIFE SUPPORT, AND TRAUMA. IN FISCAL 2012 - 2013 THERE WERE 14,159 VISITS TO THE EMERGENCY CENTER. LIKE ALL HOSPITAL SERVICES, EMERGENCY CARE IS PROVIDED REGARDLESS OF RACE, CREED, OR ABILITY TO PAY, AND FINANCIAL ASSISTANCE IS AVAILABLE AFTER CARE IS PROVIDED FOR THOSE IN NEED. FORM 990, PART III, LINE 4D OTHER PROGRAM SERVICES ST. NICHOLAS HOSPITAL PROVIDES COMPREHENSIVE INPATIENT AND OUTPATIENT MEDICAL SERVICES TO THE COMMUNITY. BESIDES THE THREE LARGEST PROGRAM SERVICES IDENTIFIED IN PART III, ST NICHOLAS HOSPITAL PROVIDES ADDITIONAL SERVICES INCLUDING A MEDICAL/SURGICAL FLOOR, INTENSIVE CARE UNIT, WOMENS' AND INFANT SERVICES, HOME HEALTH AND HOSPICE CARE, CARDIAC SERVICES, WOUND CARE, RADIATION THERAPY, ORTHOPEDIC SERVICES, RENAL DIALYSIS, SLEEP CENTER SERVICES, AND A VARIETY OF ADDITIONAL MEDICAL SERVICES. ST. NICHOLAS HOSPITAL PROVIDES AN ARRAY OF COMMUNITY HEALTH SERVICES INCLUDING, BUT NOT EXCLUSIVE TO THE FOLLOWING, DIABETIC SCREENINGS, FLU SHOTS, FOOT CLINICS, AND A VARIETY OF COMMUNITY EDUCATION CLASSES. IN ADDITION, ST. NICHOLAS HOSPITAL PARTNERS WITH SEVERAL PHYSICIAN GROUPS AND OTHER JOINT VENTURES THAT PROVIDE NEEDED MEDICAL SERVICES TO THE COMMUNITY. Tax Exempt Bonds Form 990 Part IV, Question 24 ST. NICHOLAS HOSPITAL HOLDS A LIABILITY ON ITS BOOKS FOR TAX-EXEMPT BONDS, WHICH IS AN ALLOCATION FROM ITS SOLE CORPORATE MEMBER, HOSPITAL SISTERS SERVICES, INC. ("HSSI"). AS A RESULT, THIS QUESTION WAS ANSWERED NO, AND SCHEDULE K WILL BE COMPLETED ON THE HSSI FORM 990. RIGHTS OF MEMBERS TO ELECT GOVERNING BODY FORM 990 PART VI, LINES 6 & 7A THE SENIOR GOVERNING BODY OF ST. NICHOLAS HOSPITAL (THE CORPORATION) IS THE MEMBER OF THE CORPORATION, WHICH IS HOSPITAL SISTERS SERVICES, INC. ("HSSI"), AN ILLINOIS NOT FOR PROFIT CORPORATION EXEMPT FROM FEDERAL TAXATION UNDER SECTION 501(C)(3) OF THE INTERNAL REVENUE CODE. PURSUANT TO SECTION 2.3 OF THE CORPORATION'S BYLAWS, HSSI HAS THE RIGHT TO APPOINT AND REMOVE THE CORPORATION'S BOARD OF DIRECTORS, CHAIRPERSON OF THE BOARD, AND PRESIDENT. MEMBER RESERVED POWERS FORM 990 PART VI, LINE 7B Responsibility for the policy and operations of St. Nicholas Hospital (the "Corporation") is vested in its Board of Directors, except with respect to specific powers reserved in the Corporation's Bylaws to the Corporation's Member, Hospital Sisters Services, Inc. ("HSSI"), an Illinois not for profit corporation exempt from federal taxation under Section 501(c)(3) of the Internal Revenue Code. The member of HSSI is Hospital Sisters Health System ("HSHS"), an Illinois not for profit corporation exempt from federal taxation under Section 501(c)(3) of the Internal Revenue Code. The members of HSHS are the individual sisters who, from time to time, are the duly elected Provincial Superior and Provincial Councilors, respectively of the American Province of the Hospital Sisters of St. Francis ("American Province"). The American Province is the United States organization of the Congregation of the Hospital Sisters of the Third Order Regular of St. Francis, a religious institute of the Roman Catholic Church. The governance and operations of the Corporation are subject to HSSI's right to exercise these reserved powers with respect to the Corporation and organizations of which the Corporation is either, directly or indirectly, a controlling member or a controlling shareholder ("Affiliates"). HSSI's right to exercise certain of these reserved powers is, in turn, subject to the approval of HSHS and HSHS' members. The reserved powers include all rights granted to HSSI by law and the right to: (a) Adopt, approve amendments to, or amend any statement of philosophy, mission, mission integration or values, or any name, logo, or mark of the Corporation or of any Affiliate; (b) Adopt, approve amendments to, or amend the Articles of Incorporation of the Corporation or of any Affiliate; (c) Adopt, approve amendments to, or amend the Bylaws of the Corporation or of any Affiliate; (d) Appoint and remove the Board of Directors, any one or more of the Directors of the Corporation or of any Affiliate, and the Chairperson and President of the Corporation or of any Affiliate; (e) Approve the recommendation of the Board of Directors to appoint or remove the Board of Directors, any one or more Directors of the Corporation or of any Affiliate, or the Chairperson and President of the Corporation or of any Affiliate. (f) With respect to the Corporation or any Affiliate, approve the purchase, sale, alienation, exchange, lease, or encumbrance of any real property of the Corporation or of any Affiliate, which property has a value in excess of limits set from time to time by HSSI; (g) Approve the operating and capital budgets of the Corporation or of any Affiliate, and any deviations by the Corporation or of any Affiliate from such budgets in an amount or percentage specified by HSSI from time to time; (h) Approve the strategic plan and goals of the Corporation or of any Affiliate; (i) Approve the sale of substantially all of the assets of the Corporation or of any Affiliate; (j) Approve the merger or dissolution of the Corporation or of any Affiliate; (k) Adopt or amend the plan for ministry education and governance for the Corporation and its Affiliates; (l) Approve the Corporation's Mission Accountability Reports and those of any Affiliate; (m) Approve the financial policies and procedures of the Corporation or of any Affiliate, and approve any deviations from such policies and procedures by the Corporation or any Affiliate; and (n) Adopt policies to implement the Reserved Powers of HSSI. FORM 990 REVIEW PROCESS FORM 990 PART VI, LINE 11B The hospital employs KPMG to assist in the overall review and electronic submission of its Form 990. KPMG provides guidance in identifying critical errors in the return submission, and feedback on quantitative and qualitative responses. Additionally, the hospital CFO performs a thorough review of the return and reviews it with the hospital CEO and/or senior leaders before presenting it in its entirety to the hospital Board for questioning and review prior to the return's signing and submission to the IRS. CONFLICT OF INTEREST POLICY FORM 990 PART VI, LINE 12C The organization is subject to the corporate compliance program and conflict of interest policy ("policy") of Hospital Sisters Health System, an Illinois not for profit corporation exempt from federal taxation under section 501(c)(3) of the internal revenue code. the current CORPORATE COMPLIANCE PROGRAM AND CONFLICT OF INTEREST POLICY was effective JANUARY 2009 TO MANAGE CONFLICTS OF INTEREST USING A SYSTEM-WIDE PROTOCOL FOR DISCLOSURE STATEMENTS. IN ACCORDANCE WITH the organizaton's CONFLICT OF INTEREST POLICY, ALL COVERED PERSONS HAVE A DUTY TO COMPLY WITH THE CONFLICT OF INTEREST POLICY FOR ANY CONTRACT, TRANSACTION, RELATIONSHIP, OR ACTIVITY CONTEMPLATED, ENTERED INTO, OR CONDUCTED AT HSHS OR ITS AFFILIATES. THE POLICY DEFINES COVERED PERSONS AS BOARD MEMBERS, BOARD COMMITTEE MEMBERS, OFFICERS, BOARD DESIGNEES, SENIOR MANAGEMENT, MEMBERS OF ANY COMMITTEE THAT OVERSEES THE APPROVAL OF PHARMACEUTICALS AND MEDICAL DEVICES, and ANY OTHER INDIVIDUAL WHO HOLDS A POSITION OF TRUST. ON AN ANNUAL BASIS, HSHS DISCLOSES A COPY OF THE CONFLICT OF INTEREST POLICY (AND ALL CORRESPONDING PROCEDURES, GUIDELINES, FORMS, AND TOOLS) TO ALL COVERED PERSONS, AND ADVISES ALL COVERED PERSONS IN WRITING OF ANY SUBSTANTIVE CHANGES TO THIS POLICY AND SUCH RELATED MATERIALS. COVERED PERSONS ARE REQUIRED TO REVIEW AND COMPLETE THE CORRESPONDING CONFLICT OF INTEREST STATEMENT. THE SYSTEM OFFICE VICE PRESIDENT - SYSTEM RESPONSIBILITY, VICE PRESIDENT - RISK & COMPLIANCE, OR MEMBERS OF THE AUDIT AND INTEGRITY COMMITTEE ("COMMITTEE") ARE AVAILABLE TO ANSWER ANY QUESTIONS A COVERED PERSON MAY HAVE. IN ADDITION, IF AT ANY TIME AFTER SUBMITTING AN ANNUAL CONFLICT OF INTEREST STATEMENT, A COVERED PERSON BECOMES AWARE OF AN INTEREST THAT HE OR SHE WOULD HAVE HAD TO DISCLOSE AT THE ANNUAL INTERVAL, THE COVERED PERSON IS REQUIRED to PROMPTLY DISCLOSE such INTEREST TO THE COMMITTEE USING THE HSHS CONFLICT OF INTEREST DISCLOSURE STATEMENT. COMPLETED CONFLICT OF INTEREST STATEMENTS ARE SUBMITTED TO THE COMMITTEE, WHICH IS RESPONSIBLE FOR IDENTIFYING, ASSESSING, AND MANAGING CONFLICTS OF INTEREST, which ARISE IN THE COURSE OF CONDUCTING THE AFFAIRS OF HSHS AND ITS AFFILIATES. IF THE COMMITTEE DETERMINES THAT A CONFLICT OF INTEREST EXISTS, THE CONFLICT OF INTEREST POLICY REQUIRES HSHS NOT TO ENGAGE IN, OR ENTER INTO, A PROPOSED CONTRACT, TRANSACTION, RELATIONSHIP, ARRANGEMENT, OR ACTIVITY UNLESS THE COMMITTEE OR, WHERE NECESSARY, THE BOARD OF DIRECTORS (ACTING THROUGH ITS DISINTERESTED MEMBERS), HAS INVESTIGATED ALTERNATIVES TO THE PROPOSED CONTRACT, TRANSACTION, RELATIONSHIP, ARRANGEMENT, OR ACTIVITY IN THE ABSENCE OF ALTERNATIVES THAT ARE IN THE BEST INTERESTS OF HSHS, the committee HAS DETERMINED: 1. THAT, REGARDLESS OF WHETHER THE COVERED PERSON PARTICIPATES IN THE IMPLEMENTATION OF THE PROPOSED CONTRACT, TRANSACTION, RELATIONSHIP, ARRANGEMENT, OR ACTIVITY; 2. THE CONTRACT, TRANSACTION, ARRANGEMENT, OR ACTIVITY IS IN THE BEST INTERESTS OF HSHS; 3. THE CONTRACT, TRANSACTION, ARRANGEMENT, OR ACTIVITY IS FAIR AND REASONABLE FROM THE PERSPECTIVE OF HSHS; AND 4. HSHS CANNOT OBTAIN A MORE ADVANTAGEOUS CONTRACT, TRANSACTION, ARRANGEMENT, OR ACTIVITY WITH REASONABLE EFFORTS UNDER THE CIRCUMSTANCES. IN DETERMINING WHETHER A CONTRACT, TRANSACTION, OR ARRANGEMENT IS FAIR AND REASONABLE TO HSHS, THE COMMITTEE SHALL CONSIDER, WHERE APPLICABLE: 1. APPRAISALS OR OTHER INDEPENDENT VALUATIONS OF THE FAIR MARKET VALUE OF THE CONTRACT, TRANSACTION, OR ARRANGEMENT; 2. INFORMATION REGARDING COMPARABLE CONTRACTS, TRANSACTIONS, OR ARRANGEMENTS BETWEEN UNRELATED PARTIES; 3. OFFERS FROM COMPARABLE COMPETING ENTITIES; AND/OR 4. STUDIES OF COMPARABLE COMPENSATION ARRANGEMENTS. IN ANY CASE IN WHICH THE COMMITTEE FINDS, AFTER TAKING THE STEPS DESCRIBED ABOVE, THAT HSHS SHOULD PARTICIPATE IN A PROPOSED TRANSACTION OR ARRANGEMENT DESPITE THE EXISTENCE OF A CONFLICT OF INTEREST, THE COMMITTEE SHALL DEVELOP, IMPLEMENT, MONITOR, AND ENFORCE COMPLIANCE WITH, A CONFLICT MANAGEMENT PLAN FOR MANAGING THE CONFLICT OF INTEREST AS IT CONSIDERS NECESSARY FOR SUCH FINDINGS TO REMAIN VALID THROUGHOUT THE LIFE OF THE CONTRACT, TRANSACTION, RELATIONSHIP, ARRANGEMENT, OR ACTIVITY. ALL CONFLICT MANAGEMENT PLANS SHALL: 1. STATE THAT THE COMMITTEE WILL OVERSEE, MONITOR, AND ENFORCE COMPLIANCE WITH THE PLAN THROUGHOUT THE COURSE OF THE STUDY, AND SPECIFY MEANS FOR DOING SO, INCLUDING, WITHOUT LIMITATION, THAT THE APPROPRIATE INDIVIDUALS MUST PROVIDE THE COMMITTEE WITH WRITTEN REPORTS PERTAINING TO COMPLIANCE WITH THE CONFLICT MANAGEMENT PLAN, THAT THE COMMITTEE SHALL HAVE THE RIGHT TO AUDIT THE STUDY FOR SUCH COMPLIANCE, AND THE RIGHT TO IMPOSE SANCTIONS FOR NON-COMPLIANCE; 2. STATE THAT THE PLAN MUST BE SHARED WITH COVERED PERSON WHOSE INTERESTS IT WAS DEVELOPED TO MANAGE; 3. STATE THAT THE PLAN MUST BE SHARED WITH, AND PERIODIC REPORTS ON COMPLIANCE WITH THE PLAN MUST BE PROVIDED TO, THE BOARD, SENIOR MANAGEMENT, AND/OR GOVERNMENT AGENCIES; AND 4. PROVIDE FOR SUCH OTHER MANAGEMENT STEPS AND MECHANISMS THE COMMITTEE CONSIDERS NECESSARY AND APPROPRIATE. IN ADDITION TO THE COMMITTEE, THE SYSTEM OFFICE VICE PRESIDENTS OF SYSTEM RESPONSIBILITY AND RISK & COMPLIANCE MAY RETAIN SUCH INDEPENDENT ADVISORS OR EXPERTS AS DEEMED NECESSARY TO ASSIST IN MAKING ITS DETERMINATIONS AND DECISIONS. IF THE COMMITTEE DETERMINES THAT THE CONTEMPLATED TRANSACTION, RELATIONSHIP, ARRANGEMENT, OR ACTIVITY CANNOT PROCEED DUE TO A CONFLICT OF INTEREST, THE COMMITTEE SHALL INFORM THE APPLICABLE COVERED PERSON OR DECISION-MAKING BODY OF SUCH DETERMINATION WITHIN ONE WEEK OF THE COMMITTEE MEETING AT WHICH THE CONTEMPLATED TRANSACTION WAS DISCUSSED. THE COMMITTEE SHALL DOCUMENT ITS REJECTION OF THE CONTEMPLATED TRANSACTION IN THE COMMITTEE'S MEETING MINUTES. WHISTLEBLOWER POLICY FORM 990 PART VI, LINE 13 Provisions within the Corporate Compliance Program and Conflict of Interest Policy provide protections for whistleblower type activities. COMPENSATION PROCESS FORM 990 PART VI, LINE 15 The Compensation Committee (Committee) is comprised of independent members of the Board of Directors. The Committee develops a compensation philosophy for the System and all affiliates. The Committee selects and hires the independent compensation consultant to develop comparability data and advise the Committee during its deliberations regarding all elements of total compensation for all disqualified individuals. Integrated Healthcare Strategies ("IHS"), the consultants utilized by the Committee, use data from multiple tax-exempt peer group sources to determine salary ranges, incentive opportunity ranges, and benefits for the disqualified individuals. IHS then assists the Committee in preparing contemporaneous documentation of all actions. Each Committee meeting is conducted with the intent to create a rebuttable presumption of reasonableness for all elements of executive total compensation for the disqualified individuals. The Chairman makes this declaration and also inquires if there are any conflicts of interest by any attendees. Any conflicts are disclosed and the Committee then acts in a manner to avoid any conflicted individual participating in any manner where a conflict might exist. At the end of the meeting, the Committee prepares contemporaneous minutes that record all actions taken during the meeting. Joint Ventures FORM 990 PART VI, LINE 16B Hospital Sisters Health System adopted a Joint Venture Compliance Program policy effective on January 1, 2012 for all system hospitals, including St. Nicholas Hospital. The overall purpose of the policy is to provide practical guidelines for ethical business conduct, to achieve compliance, and to detect and prevent violations of applicable laws. The policy requires St. Nicholas Hospital, and all HSHS hospitals, to evaluate their participation in joint venture arrangements, including under applicable federal tax laws, and to safeguard St. Nicholas hospitals tax exempt status with respect to any joint venture arrangements. DOCUMENTS AVAILABLE TO THE PUBLIC FORM 990 PART VI, LINE 19 Board-approved financial statements are made available to the public upon request. The governing documents and conflict of interest policy are not made available to the general public at this time. POOLED INVESTMENT ACCOUNT FORM 990 PART X, LINE 11 St. Nicholas Hospital's cash reserves are invested in a pooled investment account. Participation in the pooled fund is limited to the 501(C)(3) Hospitals and related health services organizations sponsored by the Hospital Sisters Health System. The pooled account consists of cash, and equity and debt securities that are publicly traded. In accordance with the provisions of SFAS No. 124 "Accounting for certain investments held by Not-For-Profit Organizations," investments in equity securities with readily determinable values, and all investments in debt securities, are reported at fair value on the Balance Sheet. Income, realized and unrealized gains and losses are pooled and allocated to the participants. Individual components of assets and revenue are not identified to the participants. OTHER CHANGES IN NET ASSETS FORM 990, PART XI, LINE 5 transfer to/from affiliates (623,418) change in temporarily restricted net assets (833,718) change in permanently restricted net assets 10,100 pension changes other than net periodic cost 6,119,438 swap payments (221,156) loss on early extinguishment of debt (188,660) change in fair value of interest rate swaps 937,382 ----------- 5,199,968 =========== KIARA CLINICAL INTEGRATION NETWORK LLC 4936 LAVERNA ROAD SPRINGFIELD IL 62707 261417684 HEALTHCARE IL 0 0 HSSI PHYSICIAN CLINICAL INTEGRATION NETWORK L 4936 LAVERNA ROAD SPRINGFIELD IL 62707 371668647 HEALTHCARE IL 0 0 KCIN SPRINGFIELD HEALTH PARTNERS LLC 4936 LAVERNA ROAD SPRINGFIELD IL 62707 371364419 HEALTHCARE IL 0 0 HSHS MG HOSPITAL SISTERS OF ST FRANCIS FDTN 4936 LAVERNA ROAD SPRINGFIELD IL 62707 371186514 HEALTHCARE IL 501(C)(3) 11A HSHS false HOSPITAL SISTERS HEALTH SYSTEM 4936 LAVERNA ROAD SPRINGFIELD IL 62707 371058692 HEALTHCARE IL 501(C)(3) 11A NA false HOSPITAL SISTERS SERVICES INC 4936 LAVERNA ROAD SPRINGFIELD IL 62707 371163402 HEALTHCARE IL 501(C)(3) 11A HSHS false HSHS HEALTH CARE PLAN TRUST FUND 4936 LAVERNA ROAD SPRINGFIELD IL 62707 371137724 HEALTHCARE IL 501(C)(9) N/A HSHS false HOSPITAL SISTERS HEALTHCARE - WEST INC 2661 COUNTY HIGHWAY I CHIPPEWA FALLS WI 54729 510157933 HEALTHCARE WI 501(C)(3) 11A HSSI false SACRED HEART HOSPITAL 900 WEST CLAIREMONT AVENUE EAU CLAIRE WI 54701 390807060 HEALTHCARE WI 501(C)(3) 3 HSSI false ST NICHOLAS HOSPITAL 3100 SUPERIOR AVENUE SHEBOYGAN WI 53081 390808480 HEALTHCARE WI 501(C)(3) 3 HSSI false ST ELIZABETH'S HOSPITAL 211 SOUTH THIRD STREET BELLEVILLE IL 62220 370663567 HEALTHCARE IL 501(C)(3) 3 HSSI false ST JOHN'S HOSPITAL 800 EAST CARPENTER STREET SPRINGFIELD IL 62769 370661238 HEALTHCARE IL 501(C)(3) 3 HSSI false ST FRANCIS HOSPITAL 1215 FRANCISCAN DRIVE LITCHFIELD IL 62056 370661236 HEALTHCARE IL 501(C)(3) 3 HSSI false ST JOSEPH'S HOSPITAL 9515 HOLY CROSS LANE BREESE IL 62230 371208459 HEALTHCARE IL 501(C)(3) 3 HSSI false ST JOSEPH'S HOSPITAL 1515 MAIN STREET HIGHLAND IL 62249 370663568 HEALTHCARE IL 501(C)(3) 3 HSSI false ST JOSEPH'S HOSPITAL 2661 COUNTY HIGHWAY 1 CHIPPEWA FALLS WI 54729 390810545 HEALTHCARE WI 501(C)(3) 3 HSSI false ST MARY'S HOSPITAL 1800 E LAKE SHORE DRIVE DECATUR IL 62521 362169181 HEALTHCARE IL 501(C)(3) 3 HSSI false ST MARY'S HOSPITAL 111 SPRING STREET STREATOR IL 61364 362169181 HEALTHCARE IL 501(C)(3) 3 HSSI false ST VINCENT HOSPITAL 835 S VAN BUREN GREEN BAY WI 54301 390817529 HEALTHCARE WI 501(C)(3) 3 HSSI false ST MARY'S HOSPITAL MEDICAL CENTER 1726 SHAWANO AVENUE GREEN BAY WI 54303 390818682 HEALTHCARE WI 501(C)(3) 3 HSSI false HSHS MEDICAL GROUP INC 3215 Executive Park Drive SPRINGFIELD IL 62703 263956318 HEALTHCARE IL 501(C)(3) 11A HSSI false HSHS WISCONSIN MEDICAL GROUP INC 3215 Executive Park Drive Springfield IL 62703 264515959 HEALTHCARE WI 501(C)(3) 11A HSSI false HSHS SELF INSURANCE TRUST FUND 4936 LAVERNA ROAD SPRINGFIELD IL 62707 371120626 INSURANCE IL 501(C)(3) 11A HSHS false ORANGE CROSS AMBULANCE INC 919 ASHLAND AVE SHEBOYGAN WI 53081 391860942 HEALTHCARE WI 501(C)(3) 9 ST NICHOLAS true WISCONSIN UPPER PEN ONC MNGMT SERVICES 835 S VAN BUREN GREEN BAY WI 54301 391677100 HEALTHCARE WI 501(C)(3) 3 ST VINCENT false UNITY LIMITED PARTNERSHIP 2366 OAK RIDGE CIRCLE DE PERE WI 54115 391750729 HEALTHCARE WI 501(C)(3) 9 HSSI false MEMORIAL AND ST ELIZABETH'S HEALTHCARE 4000 NORTH ILLINOIS STREET SWANSEA IL 62226 371312961 HEALTHCARE IL ST ELIZABETH'S related 0 0 false 0 false 0.00000 PRAIRIE HEART INSUTUTE - CARBONDALE LLC 800 EAST CARPENTER STREET SPRINGFIELD IL 62769 371321197 HEALTHCARE IL ST JOHN'S related 0 0 false 0 false 0.00000 NORTHEAST WISCONSIN RADIATION THERAPY SE 1821 S WEBSTER AVENUE STE 300 GREEN BAY WI 543079047 263749065 HEALTHCARE WI HSSI related 0 0 false 0 false 0.00000 PAIN CENTER OF WISCONSIN 4131 W LOOMIS ROAD STE 300 GREENFIELD WI 53221 263155343 HEALTHCARE WI ST VINCENT related 0 0 false 0 false 0.00000 SURGERY CENTER OF SHEBOYGAN LLC 3141 SAEMANN AVE SHEBOYGAN WI 53081 260822209 HEALTHCARE WI ST NICHOLAS related 200415 505268 false 0 false 0.50000 PREVEA VENTURES LLC 2710 EXECUTIVE DR GREEN BAY WI 54304 203775127 HEALTHCARE WI HSSI related 0 0 false 0 false 0.00000 CARPENTER STREET HOTEL LLC 525 NORTH SIXTH STREET SPRINGFIELD IL 62702 364128127 HOTEL IL LASANTE INC related 0 0 false 0 false 0.00000 SPRINGFIELD URGENT CARE REAL ESTATE LLC PO BOX 19456 SPRINGFIELD IL 627949456 030413258 RENT. REAL ES IL LASANTE INC related 0 0 false 0 false 0.00000 Prairie Heart Institute Management LLC 4936 Laverna Road Springfield IL 62707 261417684 Medical IL HSHS Related 0 0 false 0 false KIARA INC 4936 LAVERNA RD SPRINGFIELD IL 62707 371163401 HEALTHCARE IL HSHS C CORP false LASANTE WISCONSIN INC 4936 LAVERNA RD SPRINGFIELD IL 62707 391572196 HEALTHCARE IL KIARA INC C CORP false LASANTE INC 4936 LAVERNA RD SPRINGFIELD IL 62707 371163400 HEALTHCARE IL KIARA INC C CORP false PRAIRIE CARDIOVASCULAR 619 EAST MASON STE 4P57 SPRINGFIELD IL 62701 371071858 HEALTHCARE IL KIARA INC C CORP false PREVEA HEALTH SERVICES 2710 EXECUTIVE DR GREEN BAY WI 54304 391839351 HEALTHCARE WI HSSI C CORP false PREVEA CLINIC INC 2710 EXECUTIVE DR GREEN BAY WI 54304 391839349 HEALTHCARE WI HSSI C CORP false PREVEA HEALTH NETWORK 2710 EXECUTIVE DR GREEN BAY WI 54304 392000537 HEALTHCARE WI HSSI C CORP false RENAISSANCE QUALITY INSURANCE PO BOX 1159 grand caymans CJ KY1-1102 980669953 INSURANCE CJ hssi c corp false OJV INC 4936 LAVERNA RD SPRINGFIELD IL 62707 460873384 Healthcare IL Lasante Inc C Corp false false false true false false true true false true false false false true true true true false false TRANSACTIONS WITH RELATED ENTITIES FORM 990 SCHEDULE R, PART V LINE 2 The Transactions reported in Question 1 are between related 501(c)(3) public charities and are not reported in this section.