2013-08-12T13:46:53-05:00 2012-09-30 390758449 WIPFLI LLP PO BOX 12237 GREEN BAY WI 543072237 990 2011-10-01 362167767 KEWANEE HOSPITAL KEWA 3098527500 1051 W SOUTH ST KEWANEE IL 61443 LYNN A FULTON 3098527525 2013-08-09 1 TERRI REXRODE CPA MST P00096513 9206620016 2013-08-09 2011 2016-02-24 21:20:13Z LYNN A FULTON 1051 W SOUTH ST KEWANEE IL 61443 29877529 0 X WWW.KEWANEEHOSPITAL.COM X 1902 IL OPERATES A 25 BED CRITICAL ACCESS HOSPITAL PLUS RELATED HEALTH CARE SERVICES. 10 8 275 86 194 0 121248 102928 27118267 27718747 565006 727361 174608 1264524 27979129 29813560 4300 11142 0 0 11163389 11333325 0 0 0 16852485 16473273 28020174 27817740 -41045 1995820 58950000 63224383 32626606 33412238 26323394 29812145 X TO IMPROVE THE HEALTH AND CARE OF THOSE WE SERVE FOCUSING ON QUALITY OF CARE REGARDLESS OF ABILITY TO PAY. 1 0 18232008 26804553 KEWANEE HOSPITAL IS A 501(C)(3) NOT-FOR-PROFIT CORPORATION LICENSED ASA 25-BED CRITICAL ACCESS HOSPITAL (CAH) LOCATED IN A RURAL COMMUNITY INILLINOIS. KEWANEE HOSPITAL STRIVES TO PROVIDE QUALITY HEALTH CARE TOALL PATIENTS REGARDLESS OF RACE, CREED, SEX, NATIONAL ORIGIN, HANDICAP,AGE, OR ABILITY TO PAY. MANY OF THE COMMUNITY MEMBERS WOULD HAVE NOACCESS TO HEALTH CARE WITHOUT KEWANEE HOSPITAL. THE PATIENTS AND THEIRFAMILIES ABILITY TO TRAVEL 50+ MILES TO A LARGER TERTIARY CENTER ISCOMPROMISED BY A LACK OF MOBILITY, A LACK OF INCOME, AND A LACK OFTRANSPORTATION. MANY OF THE SERVICES PROVIDED BY KEWANEE HOSPITAL ARE REIMBURSED AT OR BELOW THE COST TO PROVIDE CARE. KEWANEE HOSPITAL OFFERS A WIDE VARIETY OF SERVICES INCLUDING INPATIENT ACUTE AND CRITICAL CARE, SKILLED LEVEL CARE THROUGH SWING BEDS, DIAGNOSTIC CAPABILITIES INCLUDING RADIOLOGY,LABORATORY AND CARDIOPULMONARY, INPATIENT AND OUTPATIENT REHABILITATION AND TREATMENT, INPATIENT AND OUTPATIENT SURGICAL SERVICES, AND PRIMARY CARE SERVICES THROUGH THE FAMILY HEALTH CLINIC (FHC). DURING FY 2012 KEWANEE HOSPITAL PROVIDED 1,762 DAYS OF INPATIENT CARE AND 326 DAYS OF SWING BED CARE IN 2012. KEWANEE HOSPITAL PROVIDED A WIDE SCOPE OF OUTPATIENT SERVICES WHICH PROVIDED CARE TO 33,477 OUTPATIENTS. THE EMERGENCY DEPARTMENT (ED) IS A SAFETY NET TO THE RURAL COMMUNITY OF KEWANEE AND THE SURROUNDING AREA. THE ED IS STAFFED 24/7 BY DEDICATED EMERGENCY DEPARTMENT PHYSICIANS; DURING FY 2012 THE ED TREATED 9,739 PATIENTS, WITH OVER 50% OF THEM PAYING LESS THAN THE COST OF THE CARE RECEIVED. THE HOSPITAL OFFERS A VARIETY OF SURGICAL SERVICES INCLUDING GENERAL, ORTHOPEDIC, OPHTHALMOLOGIC, ENDOSCOPY AND GASTROENTEROLOGY. IN FY 2012 THE HOSPITAL PROVIDED A TOTAL OF 791 SURGICAL PROCEDURES. 1317897 2002806 KEWANEE HOSPITAL STAFFS A MULTI-DISCIPLINARY OUTPATIENT FAMILY HEALTHCLINIC (FHC) WITH A COMPLIMENT OF BOTH PHYSICIAN AND MID-LEVELPROVIDERS EMPLOYED BY THE HOSPITAL. THE FHC PROVIDES AN ARRAY OFSERVICES INCLUDING PRIMARY CARE (ADULTS AND PEDIATRICS) AND SURGICALSERVICES. THE FHC IS A LICENSED RURAL HEALTH CLINIC AND PROVIDES MANYNEEDED SERVICES TO THE COMMUNITY. THE FHC IS ONE OF THE ONLY CLINICSIN THE AREA TO ACCEPT THE TREATMENT AND CARE OF CHILDREN WITH ATTENTIONDEFICIT DISORDER. THE PROVIDERS IN THE FHC HAVE PARTICIPATED INSEVERAL OUTREACH EFFORTS INCLUDING DIABETIC HEALTH, SMOKING CESSATION,MEDICATION MANAGEMENT, AND HEALTH AND NUTRITION. IN FY 2012 THE FHCPROVIDERS BROUGHT THEIR SERVICES TO THE AREA HIGH SCHOOL TO PROVIDEFREE SPORTS PHYSICALS. BECAUSE OF THE HIGH POVERTY LEVEL IN THE KEWANEE DISTRICT, MANY STUDENTS HAVE DIFFICULTY TRAVELING TO PROVIDEROFFICES FOR THEIR PHYSICALS AND MOST CANNOT PAY THE COST. KEWANEEHOSPITAL MADE THE DECISION TO OUTREACH TO THESE STUDENTS IN ORDER TOENSURE THEY CAN TAKE PART IN SPORT ACTIVITIES AND RECEIVE THEIR NEEDEDPHYSICAL EXAM.THE FHC PRACTICES THE MEDICAL HOME MODEL THROUGH THE ILLINOIS HEALTHCONNECT PROGRAM. THE NURSE PRACTITIONERS PROVIDE AFTER-HOURS CALL INORDER TO ENSURE PATIENTS HAVE THE ABILITY TO ACCESS A PROVIDERAFTER-HOURS AND ON WEEKENDS WHEN NEEDED. THE FHC PRACTITIONERSCONTINUALLY COLLABORATE WITH THE AREA SCHOOLS AND PROVIDERS OF OTHERHEALTH SERVICES IN ORDER TO PROVIDE THE BEST CARE POSSIBLE TO THE AREACOMMUNITY. 19549905 1 1 0 1 0 0 0 0 0 1 1 0 0 1 1 1 1 0 0 0 0 0 0 0 1 0 1 1 1 0 1 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 34 0 1 275 1 0 0 0 0 0 0 0 0 0 0 X 10 8 0 0 0 0 0 0 0 1 0 0 0 1 1 1 1 1 1 1 1 0 IL X PRESTON BECKER CFO 3098527525 1051 W SOUTH STREET KEWANEE IL 61443 LYNN A FULTON 40.00 X X 123601 0 37024 MARGARET M GUSTAFSON 40.00 X X 225037 0 36745 MARY KAY NORTH 2.00 X X 0 0 0 GARY PHEIFFER 2.00 X X 0 0 0 MARK REWERTS 2.00 X X 0 0 0 TOM BURHORN 2.00 X 0 0 0 DANIEL CONGREVE MD 40.00 X 337813 0 31832 RITA HUNGATE MD 2.00 X 0 0 0 RUSSELL MEDLEY 2.00 X 0 0 0 FRANK TOCHA 2.00 X 0 0 0 MIKE YAKLICH 2.00 X 0 0 0 PRESTON BECKER 40.00 X 98909 0 17682 JENNIFER JUNIS 40.00 X 105878 0 10330 MICHAEL STEWART CRNA 40.00 X 196958 0 21840 DEBRA EWING DO 40.00 X 186634 0 9691 AIMEE SHANE CRNA 40.00 X 165310 0 15789 1440140 0 180933 7 0 1 0 EPSS 12528 SR 78 HAVANA IL 62644 ED PHYSIAN STAFFING 1433849 HOSPITAL CARE CONSULTANTS 17304 PRESTON RD DALLAS TX 75252 HOSPITALIST STAFFING 523794 DRINKER BIDDLE & REATH LLP ONE LOGAN SQUARE SUITE 2000 PHILADELPHIA PA 19103 LEGAL 359834 OSF SAINT FRANCIS INC 1420 W PIONEER PARKWAY PEORIA IL 61615 MRI SERVICES 200050 CARLSON PARTNERS LTD 2500 S HIGHLAND AVE LOMBARD IL 60148 LEGAL 182229 7 26457 42711 33760 2715 102928 PATIENT SERVICE REVENU 621400 27606622 27606622 CAFETERIA MEALS 621400 93156 93156 MASSAGE THERAPY 621400 17408 17408 MEDICAL RECORDS 621400 1561 1561 27718747 730184 730184 79857 1691 78166 78166 78166 2823 -2823 -2823 -2823 9781 26457 9781 0 52509 49674 2835 2835 EHR REVENUE 900099 821313 821313 MISC OPERATING REVENUE 900099 340936 340936 MEDICAL STAFF 900099 16418 16418 4856 4662 194 1183523 29813560 28807359 194 903079 7842 7842 3300 3300 1440140 886715 553425 8148392 5875257 2273135 331850 234025 97825 655921 462565 193356 757022 533863 223159 3900 3900 302866 302866 2737639 1609333 1128306 164016 164016 326403 198408 127995 396727 25386 371341 107633 67878 39755 17183 7304 9879 1526474 1526474 2819397 1113921 1705476 387300 129531 257769 BAD DEBT EXPENSE 2638533 2638533 MEDICAL PROFESSIONAL FE 2470558 2470558 MEDICAL SUPPLIES 1227045 1226080 965 1347599 532932 814667 27817740 19549905 8267835 0 6383547 3237627 7277922 11510806 56959 18100 3322516 5169827 387588 384691 397391 426201 44018397 16649780 29280107 27368617 10508869 11730680 1335101 3377834 58950000 63224383 2689990 2821670 786616 644327 29100000 28225000 50000 1721241 32626606 33412238 X 25594118 29082522 55767 56114 673509 673509 26323394 29812145 58950000 63224383 X 1995820 1492931 X X 0 1 1 X 0 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 0 0 0 1 10 0 0 1 1000 0 1 21582 22592 0 EXPLANATION OF LOBBYING ACTIVITIES: PART II-B, LINE 1: THE LOBBYING EFFORTS BY KEWANEE HOSPITAL FOR 2012 CONSISTED OF SEVERAL LETTERS AND E-MAILS TO AREA LEGISLATORS REGARDING PENDING LEGISLATION. ANNUALLY, A PORTION OF THE AMERICAN HOSPITAL ASSOCIATION (AHA) AND ILLINOIS HOSPITAL ASSOCIATION (IHA) DUES ARE ALLOCATED TO LOBBYING EFFORTS BOTH ORGANIZATIONS EXERT ON BEHALF OF HOSPITALS AT THE NATIONAL AND STATE LEVEL. ACCORDING TO THE AHA AND IHA, 24% AND 39% RESPECTIVELY, OF OUR DUES WENT TOWARDS LOBBYING; THIS REPRESENTS $21,582 FOR THE YEAR. PART II-B 1 (G), DIRECT CONTACT WITH LEGISLATORS, THEIR STAFFS, GOVERNMENTAL OFFICIALS, OR A LEGISLATIVE BODY: LEADERSHIP TIME SPENT WITH LEGISLATORS CONCERNING ISSUES RELATING TO PROPERTY TAX LEGISLATION. 8148017 1280567 56174 9372410 9131640 -552439 431184 8148017 7210168 892005 1241101 211634 9131640 7970742 118559 -664217 214916 7210168 0.92210 0.07190 0.00600 1 0 1040521 1040521 20581269 4713531 15867738 25127 25127 0 22022189 11911122 10111067 349291 349291 27368617 OTHER RECEIVABLES 1162973 LIFE INSURANCE 20298 UNAMORTIZED BOND COSTS 728923 EHR RECEIVABLE 1465640 3377834 DUE TO THIRD PARTY PAYORS 1721241 1721241 29813560 27817740 1995820 1492584 347 1492931 3488751 29874706 0 29874706 -61146 -61146 29813560 27878886 61146 61146 27817740 0 27817740 DESCRIPTION OF INTENDED USE OF ENDOWMENT FUNDS: PART V, LINE 4: ENDOWMENTS INCLUDED ON FORM 990 INCLUDE ASSETS SET ASIDE BY THE BOARD OF TRUSTEES FOR FUTURE CAPITAL IMPROVEMENTS, OVER WHICH THE BOARD RETAINS CONTROL AND MAY AT ITS DISCRETION SUBSEQUENTLY USE FOR OTHER PURPOSES. ENDOWMENTS ALSO INCLUDE DONOR-RESTRICTED FUNDS WHICH WILL BE USED FOR PROPERTY AND EQUIPMENT ADDITIONS, REIMBURSEMENT OF OPERATING EXPENSES, AND TO SUPPORT HEALTH CARE SERVICES. DESCRIPTION OF UNCERTAIN TAX POSITIONS UNDER FIN 48: PART X: IN ORDER TO ACCOUNT FOR UNCERTAIN TAX POSITIONS, THE HOSPITAL DETERMINES WHETHER IT IS MORE LIKELY THAN NOT A TAX POSITION WILL BE SUSTAINED UPON EXAMINATION OF THE TECHNICAL MERITS OF THE POSITION, ASSUMING THE TAXING AUTHORITY HAS FULL KNOWLEDGE OF ALL INFORMATION. IF THE TAX POSITION DOES NOT MEET THE MORE-LIKELY-THAN-NOT RECOGNITION THRESHOLD, THE BENEFIT OF THAT POSITION IS NOT RECOGNIZED IN THE FINANCIAL STATEMENTS. THE HOSPITAL RECORDED NO ASSETS OR LIABILITIES FOR UNCERTAIN TAX POSITIONS IN 2012 OR 2011. FEDERAL AND STATE INCOME TAX RETURNS FOR THE YEARS ENDED SEPTEMBER 30, 2009, AND BEYOND REMAIN SUBJECT TO EXAMINATION BY MAJOR TAX JURISDICTIONS. PART XI, LINE 8 - OTHER ADJUSTMENTS: CONTRIBUTIONS AND UNREALIZED GAIN LOSS 347. PART XII, LINE 4B - OTHER ADJUSTMENTS: COGS ON INVENTORY SALES -49,674. RENTAL EXPENSES -1,691. FUNDRAISING EXPENSES -9,781. PART XIII, LINE 2D - OTHER ADJUSTMENTS: COGS ON INVENTORY SALES 49,674. RENTAL EXPENSE 1,691. FUNDRAISING EXPENSES 9,781. WILLIAM LININGER GOLF CLASSIC 36238 26457 9781 5946 1573 2262 36238 26457 9781 5946 1573 2262 9781 0 1 1 1 X 125.000000000000 1 X 1 1 1 0 1 1 1002577 1002577 0.03980 6130772 3041249 3089523 0.12270 7133349 3041249 4092100 0.16250 250705 250705 0.01000 18606 18606 0.00070 20187 20187 0.00080 289498 289498 0.01150 7422847 3041249 4381598 0.17400 1 1411875 6773207 9380554 -2607347 X 1 1 1 1 KEWANEE HOSPITAL

1051 WEST SOUTH STREET KEWANEE IL 61443

X X X X RURAL HEALTH KEWANEE HOSPITAL 1 0 1 1 125.000000000000 1 300.000000000000 1 X X X X X X X 1 1 X X X X 1 0 1 X X 0 0 1 KEWANEE HOSPITAL FAMILY HEALTH CLINIC

1051 WEST SOUTH STREET KEWANEE IL 61443

RURAL HEALTH CLINIC PART I, L7 COL(F): THE BAD DEBT EXPENSE INCLUDED ON FORM 990, PART IX, LINE 25, COLUMN (A), BUT SUBTRACTED FOR PURPOSES OF CALCULATING THE PERCENTAGE IN THIS COLUMN IS $2,638,533. PART II: KEWANEE HOSPITAL HAS AN OPEN MEDICAL STAFF AND WELCOMES PHYSICIANS AND MID-LEVEL PROVIDERS TO PRACTICE AND PROVIDE CARE IN THE KEWANEE COMMUNITY. THE BOARD OF TRUSTEES IS MADE UP OF COMMUNITY MEMBERS FROM THE LOCAL SERVICE AREA WHO ARE COMMITTED TO THEIR ROLE IN KEEPING QUALITY HEALTH CARE LOCAL. THE HOSPITAL PROVIDES MANY SERVICES THAT WOULD OTHERWISE BE UNAVAILABLE, PARTICULARLY TO THOSE COMMUNITY MEMBERS UNABLE TO TRAVEL FOR SERVICES OR UNABLE TO PAY. THE HOSPITAL CONTINUALLY WORKS WITH AREA STUDENTS PURSUING MEDICAL RELATED CAREERS AND PARTNERS WITH THE AREA COMMUNITY COLLEGE AND REGIONAL COLLEGES AND UNIVERSITIES TO OFFER CLINICAL AND ADMINISTRATIVE EXPERIENCES. THIS INCLUDES PRE-MED, NURSING, LAB, RADIOLOGY, CARDIOPULMONARY, FINANCE, AND ADMINISTRATION.IN ORDER TO RECRUIT AND RETAIN PHYSICIANS AND MID-LEVEL PROVIDERS TO THE RURAL COMMUNITY, KEWANEE HOSPITAL MUST OFFER COMPETITIVE EMPLOYMENT OPPORTUNITIES. EMPLOYING PHYSICIANS IS AN EXPENSIVE UNDERTAKING WHICH INCLUDES TAKING THE RISK OF PRACTICE DEVELOPMENT AND ASSUMING THE EXPENSE AND RISK FOR LIABILITY INSURANCE. CURRENTLY THE FHC PROVIDERS STRUGGLE TO ACCESS SPECIALISTS FOR THEIR PATIENTS WHEN NEEDED. THERE IS A RELUCTANCE OF OUT-OF-TOWN SPECIALISTS TO ACCEPT PATIENTS RELIANT ON MEDICAID. ILLINOIS' CURRENT MEDICAID CRISISHAS CAUSED THOSE SPECIALISTS ONCE WILLING TO TAKE NEW MEDICAID PATIENTS TO CEASE BECAUSE THEY CANNOT DETERMINE WHEN THEY WILL RECEIVE PAYMENT. THE CHILDREN UNDER THE CARE OF THE FHC ARE TURNED DOWN BY ENT'S, PSYCHIATRIST, AND OTHER NEEDED SPECIALIST BECAUSE OF THEIR RELIANCE ON MEDICAID. BECAUSE OF THE SIZE OF THE COMMUNITY, THE DEMOGRAPHICS AND THE CURRENT PHYSICIAN SHORTAGE, KEWANEE HOSPITAL IS UNABLE TO RECRUIT SPECIALISTS SUCH AS ENT, PSYCHIATRISTS, UROLOGISTS, CARDIOLOGISTS,ETC. TO THE AREA. THE FHC PROVIDERS THEREFORE HAVE TO RELY ON OUT-OF-TOWN SPECIALISTS FOR REFERRAL. THE FHC HAS STARTED A PATIENT ASSISTANCE PROGRAM THAT REACHES OUT TO ORGANIZATIONS, PROGRAMS, FOUNDATIONS, ETC. TO MATCH PATIENTS SO THEY CAN ACCESS SPECIALTY CARE, TREATMENT, OR MEDICATIONS THAT ARE NEEDED.KEWANEE HOSPITAL CONTINUES THE COMMITMENT TO THEIR MISSION OF IMPROVING THE HEALTH AND CARE OF THOSE THEY SERVE WITHIN THEIR COMMUNITIES. FY 2012 CONTINUES A FOCUS ON HEALTH EDUCATION, DISEASE MANAGEMENT, PREVENTION, AND WELLNESS. DESPITE GROWING ECONOMIC HARDSHIPS DUE TO CONTINUED DECREASE IN THE NUMBER OF COMMERCIALLY INSURED INDIVIDUALS, THE GROWTH IN PATIENTS RELIANT ON MEDICAID, AND THE INCREASE IN UNINSURED PATIENTS, THE HOSPITAL WILL CONTINUE TO PROVIDE COMMUNITY OUTREACH TO ASSIST THOSE IN NEED. THE HOSPITAL'S VALUE TO THE COMMUNITY WELL EXCEEDS $4 MILLION CONTRIBUTED IN FY 2012. THE HOSPITAL IS THERE 24 HOURS A DAY, 7 DAYS A WEEK, FOR COMMUNITY MEMBERS IN THEIR TIME OF NEED-WHETHER FOR A CHILD WHO IS SICK THROUGHOUT THE NIGHT, A PARENT EXPERIENCING CHEST PAINS, A GRANDMOTHER WITH THE WARNING SIGNS OF A STROKE, OR THE VICTIMS OF A TRAUMATIC CAR ACCIDENT. KEWANEE HOSPITAL STANDS READY TO TAKE CARE OF THOSE COMMUNITY MEMBERS IN NEED AND CONTINUES TO WORK TOWARDS THEIR VISION OF SETTING THE STANDARD FOR LOCAL HEALTH CARE WITH A TEAM OF COMPASSIONATE PROFESSIONALS WHO ARE FOCUSED ON CLINICAL EXCELLENCE AND CUSTOMER SERVICE. PART III, LINE 4: BAD DEBTS WERE REPORTED ON THE FINANCIAL STATEMENTS AT GROSS CHARGES. THEN THE COST TO CHARGE RATIO WAS USED TO CONVERT THE BAD DEBT AMOUNT FROM A CHARGE BASED NUMBER TO A COST BASED NUMBER. PART III, LINE 8: THE MEDICARE PROGRAM DOES NOT COVER ALL SERVICES PROVIDED TO THEIR PARTICIPANTS AND THE HOSPITAL IS NOT ALLOWED TO COLLECT FROM THE PARTICIPANTS FOR SOME SERVICES BASED ON THE HOSPITAL'S AGREEMENT WITH THE PROGRAM. THEREFORE, NOT ALL REVENUES ARE COVERED BY MEDICARE. IN ADDITION, MEDICARE DOES NOT ALLOW ALL BUSINESS COSTS OF THE HOSPITAL TO BE INCLUDED IN THE COST REPORT, SO THERE ARE ADDITIONAL UNCOVERED COSTS. THE SHORTFALL BY THE MEDICARE PROGRAM COULD BE AVOIDED BY NOT PROVIDING CARE TO MEDICARE PATIENTS; THEREFORE, THIS SHORTFALL SHOULD BE INCLUDED AS A BENEFIT PROVIDED BY THE HOSPITAL.PART I, LINE 7: THE COSTING METHODOLOGY USED TO DETERMINE THE MEDICARE ALLOWABLE COST REPORT IS BASED ON THE AUDITED FINANCIAL STATEMENTS OF KEWANEE HOSPITAL AND THE HOSPITAL'S EXPENSING OF COSTS TO THE APPROPRIATE COST CENTER THROUGH THE HOSPITAL'S INTERNAL COMPUTER SYSTEM. PART III, LINE 9B: IT IS THE POLICY OF KEWANEE HOSPITAL TO EXTEND A FULL OR PARTIAL DISCOUNT FROM CHARGES TO QUALIFYING PATIENTS WHOSE CARE IS NOT COVERED BY OTHER FINANCIAL AID OR GOVERNMENT HEALTHCARE PROGRAMS. KEWANEE HOSPITAL UTILIZES A NUMBER OF METHODS FOR COMMUNICATING FINANCIAL ASSISTANCE, INCLUDING CHARITY CARE, TO PATIENTS AND THE COMMUNITY INCLUDING:A. SIGNS STATING THE AVAILABILITY OF FINANCIAL ASSISTANCE ARE POSTED INTHE EMERGENCY DEPARTMENT, REGISTRATION AND ADMITTING AREAS AND THECASHIERS OFFICE. BROCHURES WITH INFORMATION REGARDING CHARITY CARE ARE ALSO AVAILABLE.B. NOTICE OF THE AVAILABILITY OF CHARITY CARE IS INCLUDED ON THEHOSPITALS WEB SITE.C. PATIENT FINANCIAL SERVICES STAFF IS KNOWLEDGEABLE ABOUT THE POLICY AND PROCESS.D. THE STAFFS OF THE OUTSOURCED SELF PAY BILLING SERVICE AND BAD DEBTCOLLECTION AGENCY ARE ALSO KNOWLEDGEABLE ABOUT THE POLICY AND PROCESS.E. NOTICE OF THE AVAILABILITY OF FINANCIAL ASSISTANCE IS INCLUDED ON ORWITH HOSPITAL BILLING STATEMENTS TO GUARANTORS.KEWANEE HOSPITAL ATTEMPTS TO IDENTIFY UNINSURED PATIENTS ELIGIBLE FORCHARITY CARE PRIOR TO OR AT TIME OF SERVICE. FINANCIAL ASSISTANCEINFORMATION AND APPLICATIONS MAY BE OBTAINED FROM THE FINANCIALCOUNSELORS. COMPLETED APPLICATIONS AND DOCUMENTATION WILL BE REVIEWED AND PROCESSED. APPLICANTS WILL THEN RECEIVE A WRITTEN DETERMINATION OF ELIGIBILITY. KEWANEE HOSPITAL PART V, SECTION B, LINE 9: KEWANEE HOSPITAL REVIEWS THE FOLLOWING CRITERIA TO DETERMINE FREE AND/OR DISCOUNTED CARE: INCOME LEVEL, ASSET LEVEL, MEDICAL INDIGENCY, INSURANCE STATUS, UNINSURED DISCOUNT, MEDICARE/MEDICAID AND STATE REGULATION. KEWANEE HOSPITAL PART V, SECTION B, LINE 10: KEWANEE HOSPITAL REVIEWS THE FOLLOWING CRITERIA TO DETERMINE FREE AND/OR DISCOUNTED CARE: INCOME LEVEL, ASSET LEVEL, MEDICAL INDIGENCY, INSURANCE STATUS, UNINSURED DISCOUNT, MEDICARE/MEDICAID AND STATE REGULATION. KEWANEE HOSPITAL PART V, SECTION B, LINE 19D: FOR UNINSURED, THE MAXIMUM CHARGED AMOUNT CANNOT EXCEED 25% OF ANNUAL INCOME. PART VI, LINE 2: KEWANEE HOSPITAL CONTINUALLY STRIVES TO MEET THE HEALTH CARE NEEDS OF THE COMMUNITY SERVED AND PERFORMS ONGOING ASSESSMENTS IN ORDER TO BEST ALLOCATE THE HOSPITAL'S SCARCE RESOURCES, THE HOSPITAL EVALUATES THE NEEDS OF THE KEWANEE COMMUNITY THROUGH INTERNAL EVALUATION OF MARKET DATA, COMMUNITY DEMOGRAPHICS, CDC AND OTHER HEALTH RELATED DATA, ANALYSIS OF PATIENTS SERVED THROUGH THE HOSPITALS FAMILY HEALTH CLINIC, REVIEW OF EMERGENCY DEPARTMENT VISITS, AND COLLABORATIVE MEETINGS WITH THE AREA SCHOOL DISTRICTS AND THE COUNTY HEALTH DEPARTMENT.KEWANEE HOSPITAL WORKS WITH A NUMBER OF COMMUNITY VOLUNTEERS THROUGH THE HOSPITALS DEVELOPMENT COUNCIL. THE COMMUNITY RELATIONS COMMITTEE IS CHARGED WITH NEEDED EDUCATION FOR THE COMMUNITY AND UTILIZES THE INFORMATION GAINED AS TOPICS FOR EDUCATION. THROUGH THE ONGOING ASSESSMENT PROCESS THE HOSPITAL HAS IDENTIFIED AND PROVIDED OUTREACH INCLUDING A SUICIDE PREVENTION EDUCATIONAL SERIES FOR TEACHERS AND PARENTS, FINANCIAL WELLNESS FOR WOMEN, AND SKIN-CANCER PREVENTION.THROUGH COLLABORATION WITH KEWANEE HOSPITAL'S REGIONAL PARTNERS, INCLUDING THE HENRY COUNTY HEALTH DEPARTMENT, THE HOSPITAL IDENTIFIED DISASTER PREPAREDNESS AS A COMMUNITY NEED. AS A RURAL COMMUNITY, KEWANEE HAS FEW CITY RESOURCES. CITIZENS VIEW THE HOSPITAL AS THE MAINSTAY OR COMMUNITY CORNERSTONE AND THUS WOULD LOOK TO KEWANEE HOSPITAL IN AN EMERGENCY. THE HOSPITAL LEADERSHIP TEAM, STAFF AND PROVIDERS HAVE GONE THROUGH EDUCATION AND TRAINING ON INCIDENT COMMAND. PART VI, LINE 3: KEWANEE HOSPITAL PROVIDED NEARLY $1,900,000 IN CHARITY CARE TO NEEDY COMMUNITY MEMBERS IN FY 2012. KEWANEE HOSPITAL COMMUNICATES TO PATIENTS ABOUT THEIR FINANCIAL OBLIGATIONS THROUGHOUT THE HEALTH CARE EXPERIENCE. IT IS THE HOSPITAL'S GOAL TO ASSESS FINANCIAL NEED AS SOON AS POSSIBLE IN THE CARE PROCESS. PATIENTS SETTING UP DIAGNOSTIC TESTING THROUGH CENTRALIZED SCHEDULING DISCUSS THE PAYMENT OBLIGATIONS PRIOR TO VISITING THE HOSPITAL, ALLOWING FOR PATIENTS NEEDING ASSISTANCE TO START THE PROCESS RIGHT THEN. THE FAMILY HEALTH CLINIC (FHC) PATIENTS BENEFIT FROM HAVING FHC STAFF TALK WITH THEM ABOUT OBLIGATIONS RELATED TO PROCEDURES, DIAGNOSTICS, ETC. AND ARE OFTEN ABLE TO ACCESS FINANCIAL ASSISTANCE PRIOR TO THE PROCEDURE. KEWANEE HOSPITAL STAFF IS TRAINED TO RECOGNIZE POTENTIAL NEED AND TO PROACTIVELY DISCUSS PAYMENT ARRANGEMENTS. THE HOSPITAL PROMOTES FINANCIAL ASSISTANCE THROUGHOUT THE ORGANIZATION AND THROUGH VARIOUS PUBLICATIONS. INFORMATION ABOUT THE HOSPITAL'S CHARITY CARE AND FINANCIAL ASSISTANCE PROGRAMS IS POSTED THROUGH:-SIGNAGE (ADMISSIONS/REGISTRATION AT MAIN ENTRANCE, EMERGENCY DEPARTMENT ADMISSIONS, ADMISSION BOOTHS).-KEWANEE HOSPITAL'S WEBSITE, WWW.KEWANEEHOSPITAL.COM DIRECT MAIL PIECES INCLUDING BIANNUAL NEWSLETTERS AND COMMUNITY BENEFIT REPORT-HENRY COUNTY TOURISM VIDEO/WEB-SITE LINK-RADIO PROGRAM, MONDAY MORNING TUNED-IN, WKEI-PATIENT EDUCATION THROUGHOUT THE CARE PROCESS-FINANCIAL ASSISTANCE BROCHURES AT CASHIERS WINDOW-PATIENT BILL FOR SERVICE.-IDENTIFICATION OF NEED AND EDUCATION THROUGH CENTRALIZED SCHEDULING, ADMISSIONS STAFF, FHC STAFF, CASHIERS OFFICE, FINANCIAL COUNSELORS, PROVIDERS OF SERVICES, AND OTHER STAFF AS THEY BECOME AWARE OF THE PATIENTS NEED.-ANNOUNCEMENTS AND POSTINGS AT BOOTHS AT FREE COMMUNITY EDUCATION AND OUTREACH CONDUCTED BY KEWANEE HOSPITAL. PART VI, LINE 4: KEWANEE HOSPITAL IS LOCATED IN A RURAL AREA OF NORTHERN WEST-CENTRAL ILLINOIS, ABOUT 10 MILES SOUTH OF INTERSTATE 80 AND BETWEEN THE LARGER URBAN AREAS OF PEORIA, ILLINOIS AND THE QUAD CITIES (LOCATED ABOUT 50-55 MILES FROM EACH). THE HOSPITAL SERVES THE PRIMARY MARKET AREA (POPULATION APPROXIMATELY 19,700) OF KEWANEE AND THE SURROUNDING RURAL COMMUNITIES INCLUDING GALVA AND TOULON. THE OVERALL MARKET (POPULATION APPROXIMATELY 29,000) INCLUDES THE THREE COUNTY PORTIONS OF HENRY, BUREAU, AND STARK IN RURAL ILLINOIS. THE LARGEST PERCENTAGES OF KEWANEE HOSPITALS PATIENTS ARE DERIVED FROM THE KEWANEE ZIP CODE OF 61443. THE POPULATION OF KEWANEE IS AGING AND POOR WITH THE GREATEST NUMBERS IN THE OVER 65 AND UNDER 18. IN 2000, 12.8% OF THE POPULATION WAS BELOW THE POVERTY LEVEL. THE KEWANEE SCHOOL DISTRICT REPORTED OVER 85% OF CHILDREN ATTENDING SCHOOL ON THE FREE AND REDUCED LUNCH PROGRAM. SUBSEQUENTLY THAT LEAVES FEW CITIZENS IN THE MIDDLE WHERE A COMMUNITY TYPICALLY SEES THE WORKING CLASS. AS A RESULT OF THE DEMOGRAPHICS, KEWANEE HOSPITAL SEES A HIGH PROPORTION OF PATIENTS RELIANT ON MEDICAID AND UNINSURED. FOLLOWING THE NATIONAL TREND, THE HIGHEST CONCENTRATION IS IN THE EMERGENCY DEPARTMENT AND THE HOSPITAL'S FAMILY HEALTH CLINIC (FHC). FY 2012 REPORTED 30% OF PATIENTS IN THE EMERGENCY DEPARTMENT WERE RELIANT ON MEDICAID WHILE 15% WERE UNINSURED. THE FAMILY HEALTH CLINIC REPORTED 42% OF PATIENTS WERE RELIANT ON MEDICAID AND 11% WERE UNINSURED. THE OVERALL HOSPITAL REPORTED 22% RELIANT ON MEDICAID AND 10% UNINSURED. 1 IL HOSPITAL RESEARCH & EDUCATION FOUNDATION 1151 E WARRENVILLE NAPERVILLE IL 60566 237421930 501(C)(3) 7842 TO ADDRESS THE DISPARATE AND NEGATIVE EFFECTS OF THE ILLINOIS MEDICAID PROGRAM. 1 0 PROCEDURE FOR MONITORING GRANTS IN THE U.S.: PART I, LINE 2: SCHEDULE I, PART I, LINE 2: FOR GRANTS GIVEN TO ORGANIZATIONS, SUBSTANTIATION IS REQUIRED PRIOR TO DISBURSEMENT OF ALL FUNDS FOR SCHOLARSHIPS, ALL INDIVIDUALS MUST SIGN A SUPPORT AGREEMENT VERIFYING THEIR OBLIGATIONS AS AWARD RECIPIENTS AND THE RAMIFICATIONS IF THE AGREEMENT IS NOT MET. X X X X X 0 0 0 0 0 0 0 0 0 LYNN A FULTON 123601 0 0 0 0 0 6870 0 30154 0 160625 0 0 0 MARGARET M GUSTAFSON 225037 0 0 0 0 0 10689 0 26056 0 261782 0 0 0 DANIEL CONGREVE MD 337813 0 0 0 0 0 11076 0 20756 0 369645 0 0 0 MICHAEL STEWART CRNA 196958 0 0 0 0 0 4804 0 17036 0 218798 0 0 0 DEBRA EWING DO 186634 0 0 0 0 0 0 0 9691 0 196325 0 0 0 AIMEE SHANE CRNA 165310 0 0 0 0 0 4227 0 11562 0 181099 0 0 0 ILLINOIS FINANCE AUTHORITY 861091967 45200BH27 2006-08-31 32114451 SEE PART VI 0 0 0 3980000 33978645 2352650 642289 33336356 2008 0 0 1 1 0 0 1 1 0 0.00000 0.00650 0.00650 1 1 0 0 1 SEE PART VI 1 0 0 FORM 990, SCHEDULE K, PART I, LINES A(F) DESCRIPTION OF PURPOSE THE PURPOSE OF THE $32,205,000 ILLINOIS FINANCE AUTHORITY REVENUE BONDS, SERIES 2006 (KEWANEE HOSPITAL PROJECT) (THE "BONDS") WAS, TOGETHER WITH CERTAIN OTHER AMOUNTS AVAILABLE TO KEWANEE HOSPITAL, TO (A) PAY OR REIMBURSE KEWANEE HOSPITAL FOR THE PAYMENT OF THE COST OF ACQUIRING, CONSTRUCTING, RENOVATING, REMODELING AND EQUIPPING CERTAIN OF ITS HEALTH FACILITIES, (B) PROVIDE FUNDED INTEREST FOR THE BONDS, AND (C) PAY CERTAIN EXPENSES INCURRED IN CONNECTION WITH THE ISSUANCE OF THE BONDS. FORM 990, SCHEDULE K, PART IV, LINES 4B & 4C NAME OF GIC PROVIDER AND TERM OF GIC TRANSAMERICA OCCIDENTAL LIFE INSURANCE COMPANY- GIC PROVIDER FOR PROCEEDS DEPOSITED IN A PROJECT FUND - 1.61 YEARS. CITIGROUP FINANCIAL PRODUCTS, INC. - GIC PROVIDER FOR GROSS PROCEEDS DEPOSITED IN A DEBT SERVICE FUND - 4.90 YEARS - TERMINATED ON JANUARY 9, 2009. NEW PROGRAM SERVICES FORM 990, PART III, LINE 2 IN JULY 2012, KEWANEE HOSPITAL ENTERED INTO A RELATIONSHIP WITH GREAT PLAINS ORTHOPAEDICS TO PROVIDE ROUTINE ORTHOPAEDIC CARE AT KEWANEE HOSPITAL INCLUDING CONSULTATION AND SURGICAL SERVICES. FORM 990, PART VI, SECTION A, LINE 8B THE ORGANIZATION DOES NOT HAVE ANY COMMITTEES WITH AUTHORITY TO ACT ON BEHALF OF THE GOVERNING BODY. FORM 990, PART VI, SECTION B, LINE 11 THE STRATEGIC PLANNING AND FINANCE COMMITTEE (SPF) IS THE BOARD OF TRUSTEE LEVEL COMMITTEE CHARGED WITH REVIEWING THE FINAL FORM 990 PRIOR TO ITS FILING. EACH BOARD MEMBER IS PROVIDED A COPY OF THE 990 FOR THEIR REVIEW AND GIVEN THE OPPORTUNITY TO ASK QUESTIONS AND MAKE COMMENTS. A FORMAL PRESENTATION OF THE 990 TO THE BOARD OF TRUSTEES WILL OCCUR AFTER FILING. FORM 990, PART VI, SECTION B, LINE 12C ANY INTERESTED PERSON WHO HAS A PERSONAL OR PRIVATE INTEREST IN A MEASURE, CONTRACT, RESOLUTION, OR OTHER TRANSACTION PRESENTED TO THE BOARD OR A COMMITTEE THEREOF FOR DELIBERATION, AUTHORIZATION, APPROVAL, OR RATIFICATION, OR ANY INTERESTED PERSON WHO REASONABLY BELIEVES SUCH AN INTEREST EXISTS IN ANOTHER PERSON, SHALL MAKE A PROMPT, FULL, AND FRANK DISCLOSURE IN WRITING OF THE PERSONAL OR PRIVATE INTEREST TO THE BOARD OR COMMITTEE PRIOR TO ITS ACTING ON SUCH CONTRACT OR TRANSACTION. THE INTERESTED PERSON SHALL DISCLOSE THE EXISTENCE OF HIS OR HER PERSONAL OR PRIVATE INTEREST AND ALL MATERIAL FACTS, KNOWN TO HIM OR HER ABOUT THE PERSONAL OR PRIVATE INTEREST AND POTENTIAL CONFLICT OF INTEREST. FORM 990, PART VI, SECTION B, LINE 15 THE EXECUTIVE COMMITTEE OF THE HOSPITAL BOARD OF TRUSTEES ACTS AS THE COMPENSATION COMMITTEE FOR KEWANEE HOSPITAL. ANNUALLY THE EXECUTIVE COMMITTEE OF THE BOARD MEETS TO REVIEW AND APPROVE COMPENSATION FOR THE EXECUTIVE TEAM WHICH INCLUDES THE CHIEF EXECUTIVE OFFICER, CHIEF FINANCIAL OFFICER AND CHIEF NURSING OFFICER. RESOURCE DATA FOR THIS REVIEW COMES FROM SALARY SURVEYS FROM A NUMBER OF SOURCES INCLUDING SULLIVAN COTTER, CENTRAL ILLINOIS SOCIETY FOR HEALTHCARE HUMAN RESOURCE ADMINISTRATION (CISHRA), IHA EXECUTIVE AND MANAGEMENT SALARY SURVEY, AND A 990 REVIEW THROUGH GUIDESTAR.ORG OF LOCAL AND REGIONAL ORGANIZATIONS. THE SURVEYS ARE ANALYZED BY REVIEWING APPLICABLE CUTS OF THE SURVEY INCLUDING CRITICAL ACCESS HOSPITALS, HOSPITALS WITH LIKE REVENUE, AND SIMILARLY STAFFED ORGANIZATIONS. SURVEYS ARE ALSO REVIEWED AT REGIONAL AND NATIONAL LEVELS. COMPENSATION IS PROPOSED TO THE COMMITTEE TAKING INTO CONSIDERATION THE MEDIAN RANGE OF ALL SALARY SOURCES, EDUCATION/DEGREE, TRAINING, CERTIFICATION, AND EXPERIENCE. THE COMMITTEE REVIEWS THE SALARY PROPOSAL FOR REASONABLENESS BASED ON THE DATA SOURCES. THE CHIEF EXECUTIVE OFFICER MAKES RECOMMENDATIONS FOR THE SALARIES OF THE OTHER EXECUTIVES (CFO AND CNO). FORM 990, PART VI, SECTION C, LINE 19 THE ORGANIZATION'S GOVERNING DOCUMENTS, CONFLICT OF INTEREST POLICY, AND FINANCIAL STATEMENTS ARE NOT MADE AVAILABLE TO THE PUBLIC. CHANGES IN NET ASSETS OR FUND BALANCES: FORM 990, PART XI, LINE 5: NET UNREALIZED GAINS ON INVESTMENTS: 1,492,584. CONTRIBUTIONS AND UNREALIZED GAIN LOSS 347. TOTAL TO FORM 990, PART XI, LINE 5: 1,492,931. AUDITED FINANCIAL STATEMENTS FORM 990, PART XII, LINE 2C THE ORGANIZATION'S BOARD OF TRUSTEES ENGAGES THE INDEPENDENT ACCOUNTANTS TO PERFORM THE AUDIT. THE BOARD MEETS WITH THE AUDITORS TO GO OVER THE AUDIT REPORT.