2025-05-06T12:17:58+00:00 2024-06-30 350921680 CROWE LLP 225 West Wacker Drive Suite 2600 Chicago IL 606061224 990 2023-07-01 370663568 St Joseph's Hospital of the Hospital Sisters of the Third Order of St Franc is STJO 6186512525 12866 TROXLER AVENUE Highland IL 622491646 Chris Klay Market President & CEO 2025-05-06 true Mallory Fairless P01321579 3128997000 2025-05-06 2023 2025-03-06 01:10:19Z Chris Klay 12866 TROXLER AVENUE Highland IL 622491646 54183525 false 0928 X https://www.hshs.org/st-josephs-highland X 1878 IL To reveal and embody Christ's healing love for all people through our high quality Franciscan health care ministry. 11 10 268 56 0 0 139360 104006 50870335 53158372 63114 433581 618638 243321 51691447 53939280 0 0 14965474 15934272 0 0 29462036 26594165 44427510 42528437 7263937 11410843 64883287 65555450 48930620 44044518 15952667 21510932 X To reveal and embody Christ's healing love for all people through our high quality Franciscan health care ministry. false false 11520499 27859089 General patient care - St. Joseph's Hospital is a 25-bed critical access/swing bed hospital. The facility provides high quality, cost-effective emergency, medical and surgical care, and skilled nursing services. The hospital serves patients of all ages. The hospital is licensed by the State of Illinois to provide quality health care to local residents as well as consumers in surrounding areas. The hospital is accredited by the Joint Commission. St. Joseph's Hospital employs over 200 colleagues and contracts several services to provide a comprehensive panel of competent and mission-oriented colleagues. FY2024 had a inpatient average daily census was 18.8 with 1256 admissions, 61,428 outpatient visits, 9,587 Emergency Room visits, and 802 surgical cases. 9967469 16119154 EMERGENCY DEPARTMENT - The Emergency Department is a continuous operation department that must be staffed and able to receive patients at all hours of the day. The department is comprised of specially trained nurses and physicians who are supported by departments representative of the gamut of our Ministry. This team can rapidly identify, treat, and/or stabilize emergency medical conditions in patients ranging in age from newborns to centenarians and sees an average of 800 patients per month. As a critical access hospital, our Ministry has been able to provide lifesaving care to our community as well as serve as a local, and familiar, entry point into the juggernaut that is the healthcare system. Additionally, the department serves as a community resource for those struggling with substance use disorders, addiction related concerns, and acute mental health crisis through rapid identification of needs and provision of resources or transfer to specialty care facilities. 7414519 5993952 SURGERY CENTER - St. Joseph's Hospital Highland has a high functioning, high performing surgical team, using the latest technology and modern facilities to provide excellent care close to home. With 12 pre/post bays, 2 ORs and a stand-alone endoscopy room, we are able to provide a wide range of specialties for our community. We are the only hospital in the metro east to utilize the Mako Robot for orthopedics, which is the gold standard for joint replacement. In addition to our robust orthopedic program, we offer general surgery, gastrointestinal, gynecology, podiatry, ophthalmology and other procedures as needed. We provide exceptional patient care in our department and continue to strive for excellence in all of our quality measures. In FY24, we performed 1,910 surgeries which was almost 10% ahead of FY23. 3183044 3287174 INFECTIOUS DISEASE - St. Joseph's Hospital has seen 355 patient in the last fiscal year for infection diseases related diagnosis. The hospital was awarded High-Reliability zero harm award for no hospital acquired Catheter Associated Urinary Tract Infection (CAUTI) in the last 44 months, no hospital acquired Central Line- Associated Bloodstream Infection (CLABSI) for 133 months and no hospital acquired Methicillin Resistant Staphylococcus Aureus (MRSA) in the last 133 months. 3183044 3287174 32085531 true true false false false false false false false true false false true true true false true false false false false false false false false true true false false true false false false false false false false false false false false false false true false false false true X 1073 0 true 268 true false false false false false false false false false false false false X 11 10 false false false false true true true true true false false true true true true true true true true true true X Linda Dace 6182342120 3051 Hollis Drive Springfield IL 62704 CHRIS KLAY PRESIDENT/CEO 15.0 45.0 X X 247050 247050 65738 FRANK PADAK Vice Chair 2.0 0 X X 0 0 0 JAMES BURGETT Chair 2.0 0 X X 0 0 0 BILL SULLIVAN Board Member 1.0 0 X 0 0 0 Debra Feldott - Johnson Board Member 1.0 0 X 0 0 0 JEANNIE KORTE Board Member 1.0 0 X 0 0 0 LYNN BILLHARTZ Board Member 1.0 0 X 0 0 0 MARCUS ALVARADO MD Board Member 1.0 0 X 0 0 0 Marshall Rinderer Board Member 2.0 0 X 0 0 0 SR ANNA PHIRI OSF Board Member 2.0 1.0 X 0 0 0 TRICIA BUEHNE Board Member 1.0 0 X 0 0 0 Michael Scialdone Treasurer / HSHS SVP & CFO (began 01/08/24) 0.3 59.7 X 0 0 0 Paige Toth Secretary (began 11/1/23) 4.3 55.7 X 0 306108 66169 PATRICIA ALLEN CFO - CARE DELIVERY 3.0 57.0 X 0 649506 123627 TODD Smart Treasurer (UNTIL 5/3/24) 0.3 59.7 X 0 315606 66527 JOEL TUCKER Director of Pharmacy 40.0 0 X 188167 0 22207 MARK ENNEN Director of Finance 20.0 20.0 X 22213 128283 35171 Megan Espenschied Director of Surgical Services 40.0 0 X 141378 0 19133 Stephanie N Grant House Supervisor 40.0 0 X 144221 0 22742 TERESA CORNELIUS Chief Operating Officer 40.0 0 X 234052 0 17448 JOHN LUDWIG Former PRESIDENT/CEO 0.0 0.0 X 369342 0 41000 1346423 1646553 479762 16 true true false CEP America IL LLP 1601 Cummins Dr Suite D Modesto CA 953586411 Physician services/fees 1077444 CEP America Illinois Hospitalists 1601 Cummins Dr Suite D Modesto CA 953586411 Hospitalist services/fees 1021542 Compass One Healthcare PO BOX 102289 ATLANTA GA 30368 Food and Nutrition Services 499792 Diversified Clinical Services LLC 28525 Network Place Chicago IL 606731285 Wound Care management services 493573 North American Partners in Anesthesia 1305 Walt Whitman Rd Ste 300 Melville NY 11747 Anesthesia services/fees 414056 14 88002 16004 104006 PATIENT SERVICE REVENUE 622110 53109199 53109199 AFFILIATE RENTAL REVENUE 531120 49173 49173 0 0 0 0 53158372 199698 199698 233287 244245 -10958 0 -10958 -10958 233883 233883 0 233883 233883 CAFETERIA 722310 131812 131812 Health Improvement Rebates 622110 52363 52363 Facility Cost reimbursement 811219 29100 29100 41004 19534 0 21470 254279 53939280 53259369 0 575905 X 312788 308911 3877 12017822 11870718 147104 600281 592936 7345 2115612 2089727 25885 887769 876907 10862 68248 68248 5768200 5759730 8470 0 5103 1150 3953 77194 67827 9367 52925 38777 14148 2388891 1219977 1168914 48855 47488 1367 32868 4969 27899 1436336 6 1436330 1787478 913541 873937 579795 464301 115494 Corporate Allocation 6560416 144152 6416264 Supplies 5822981 5818830 4151 Medicaid Assessment 1535035 1535035 Non-Medical Supplies 273034 196640 76394 156806 133909 22897 0 42528437 32085531 10442906 0 354333 -126173 7541424 7927363 0 0 0 0 742738 727306 332810 204789 59076496 27098080 32555952 31978416 14375466 18287338 0 0 8980564 6556411 64883287 65555450 3038577 2782797 0 28605284 26123947 0 0 7812500 6250000 9474259 8887774 48930620 44044518 X 15952667 21510932 15952667 21510932 64883287 65555450 X 11410843 233948 -6086526 X false true X true true true X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 2034874 2034874 41351489 13940226 27411263 139133 130332 8801 14066182 11592441 2473741 1484818 1435081 49737 31978416 Right of Use Assets 5771691 Accrued Pension Benefit Asset 784720 6556411 DUE TO THIRD PARTY 2747954 DERIVATIVE INSTRUMENTS 6565 OPERATING LEASE LIABILITY 6133255 8887774 X Schedule D, Part X, Line 2 FIN 48 (ASC 740) footnote HSHS and the Foundation are Illinois not-for-profit organizations as described in Section 501(c)(3) of the Internal Revenue Code (the Code) and are exempt from federal income taxes on related income pursuant to Section 501(a) of the Code. Kiara, Inc. is an Illinois for-profit corporation that recognizes income taxes under the asset-and-liability method. Deferred tax assets and liabilities are recognized for the future tax consequences attributable to differences between the consolidated financial statement carrying amounts of existing assets and liabilities and their respective tax basis and operating loss and tax credit carryforwards. Deferred tax assets and liabilities are measured using the enacted tax rates expected to apply to taxable income in the years in which those temporary differences are expected to be recovered or settled. The effect on deferred tax assets and liabilities of a change in tax rates is recognized in income in the period that includes the enactment date. In assessing the realizability of deferred tax assets, management considers whether it is more likely than not that some portion or all the deferred tax assets will not be realized. The ultimate realization of deferred tax assets is dependent upon the generation of future taxable income during the periods in which those temporary differences become deductible. Management considers projected future taxable income and tax planning strategies in making this assessment. Based upon the level of historical taxable losses and projections for future taxable losses over the periods for which the deferred tax assets are deductible, management believes it is more likely Kiara, Inc. will not realize most of the benefits of these deductible differences. Full valuation allowances have been applied against the deferred tax assets attributable to the net operating loss carryforwards not realized as of June 30, 2024 and 2023 in the accompanying consolidated financial statements due to the uncertainty of realization. HSHS recognizes the tax benefit from an uncertain tax position only if it is more likely than not the tax position will be sustained on examination by the taxing authorities, based on the technical merits of the position. As of June 30, 2024 and 2023, HSHS does not have any liabilities for unrecognized tax benefits. true true X true X true X 600 true true false true true 96434 0 96434 0.0023 4677678 4817893 0 0.0 0 0 0 0.0 0 0 4774112 4817893 96434 0.0023 102423 9050 93373 0.0022 311438 0 311438 0.0073 280856 0 280856 0.0066 0 0 0.0 45069 0 45069 0.0011 0 0 739786 9050 730736 0.0172 0 0 5513898 4826943 827170 0.0194 0 0.0 0 0.0 0 0.0 0 0.0 0 0.0 0 0.0 0 0.0 0 0.0 0 0.0 0 0 0 0 0 0.0 true 0 0 23457683 23465587 -7904 X true true 1 1 ST JOSEPH'S HOSPITAL 12866 TROXLER AVE HIGHLAND IL 62249 http://www.stjosephshighland.org 0005892 X X X X ST JOSEPH'S HOSPITAL 1 false false true X X X X X X X X X 23 true true true true X https://www.hshs.org/getmedia/f921f171-67b3-4d36-be66-ba8776e6e62d/CHNA_report_SJH_DY_2024_FINAL.pdf X true 24 true https://www.hshs.org/getmedia/1e02e9f3-649e-4000-832a-2780bdf2f2b2/Implementation-Plan_SJH_2025-2027 false true X 200.0 600.0 X X X X X X true true X X X true X https://www.hshs.org/about-us/patient-financial-services X https://www.hshs.org/about-us/patient-financial-services/illinois-financial-assistance X https://www.hshs.org/about-us/patient-financial-services/illinois-financial-assistance X X X X X X true X false X X X X true X false false Schedule H, Part V, Section B, Line 3E Yes, the significant health needs are a prioritized description of the significant health needs of the community and were identified through the CHNA process. Schedule H, Part V, Section B, Line 5 Facility , 1 Facility , 1 - HSHS St. Joseph's Hospital Highland. St. Joseph's Hospital undertook an eight-month planning and implementation effort to develop the CHNA, identify and prioritize community health needs for its service area and formulate an implementation plan to guide ongoing population health initiatives with like-missioned partners and collaborators. These planning and development activities included the following internal and external steps: 1. Identified the CHNA core group comprised of St. Joseph's Hospital and HSHS Illinois division leadership. 2. Convened a community advisory committee to solicit input and help narrow identified priorities. 3. Conducted a community survey to get input from community members around the priorities identified. 4. Convened an internal advisory committee to force rank the final priorities and select the FY2022-FY2024 CHNA priorities. External St. Joseph's Hospital worked with core group partners to leverage existing relationships and provide diverse input for a comprehensive review and analysis of community health needs in Madison County. Representation on the community advisory council (CAC) was sought from health and social service organizations that: 1. Serve low-income populations 2. Serve at-risk populations 3. Serve minority members of the community 4. Represent the general community The following community stakeholders were invited to serve on the CAC: - HSHS St. Joseph's Hospital* - Madison County Health Department* - Highland Area Christian Service Ministry and Food Pantry* - Physician Groups - Highland Area Ministerial Alliance* - Highland Chamber of Commerce - Highland Community Unit School District #5* - Special Olympics* - Madison County Sheriff's Office - Madison County Regional Office of Education - Highland News Leader * Denotes groups representing the under resourced in our community including low-income seniors, children living in poverty and families who struggle with shelter and food. Schedule H, Part V, Section B, Line 6a Facility , 1 Facility , 1 - Holy Family Hospital and St. Joseph's Hospital in Clinton County. Schedule H, Part V, Section B, Line 6b Facility , 1 Facility , 1 - HSHS St. Joseph's Hospital Highland. Yes, the hospital conducted its FY2021 CHNA with: * Age Smart* * BCMW Community Services* * Birth to Five* * Bond County Community Unit School District 2 * Bond County Health Department* * Catholic Diocese of Belleville * Chestnut Health Systems* * City of Breese * City of Greenville * City of Highland * Greenville First Christian Church * HSHS Holy Family Hospital in Greenville* * HSHS St Joseph's Hospital Breese* * HSHS St Joseph's Hospital Highland* * Madison County Health Department* * MERS Goodwill* * Regional Office of Education #13 * Denotes groups representing medically underserved, low-income and minority populations " Schedule H, Part V, Section B, Line 11 Facility , 1 Facility , 1 - HSHS St. Joseph's Hospital Highland. Fiscal year ending June 30, 2024 was the final year of the Implementation Strategy adopted in tax year 2022 for the CHNA that was conducted in 2021. Information provided below relates to the activities that occurred during the third year of this CHNA cycle addressing the health needs identified in the 2021 CHNA. As part of the identification and prioritization of health needs, St Joseph's Hospital Senior Leadership Team considered the estimated feasibility and effectiveness of possible interventions by the hospital to impact health priorities Prioritization was based on scope, severity, and burden; health disparities associated with the need; the importance the community places on addressing the health need; the hospital and community assets and resources available to address the health need; and local expertise and input. Based on the CHNA planning and development process described, the following priority community health needs were identified: 1. Mental and behavioral health 2. Chronic conditions 3. Workforce development Implementation strategies established to address these needs through specific initiatives included: Mental and Behavioral Health Goal: Enhance access to comprehensive, high-quality mental and behavioral health services to improve community well-being and reduce health disparities. Strategy 1: Improve access to prevention and early intervention services. In FY2022, HSHS St Joseph's Hospital partnered with the Gateway Foundation to offer prevention and early intervention services for patients with substance use disorders Through this collaboration, an engagement specialist and a recovery coach screened patients, developed treatment plans, and assisted these patients in transitioning back to the community post-treatment By FY2023, over 60 patients had benefited from these screening and referral services. Strategy 2: Improve access to care. St Joseph's Hospital, along with three other hospitals in southern Illinois, engaged in an 18-month planning process to tackle crisis screening gaps in emergency departments They implemented a strategy that included comprehensive 365-day psychiatric coverage for mental health crises Furthermore, their ongoing commitment to providing transportation via the Friends Van ensured over 1,400 patients could access their essential medical appointments. Strategy 3: Unified planning and policy efforts. HSHS launched a Diversity, Equity, and Inclusion (DEI) committee in FY2022, with St Joseph's Hospital actively contributing to the Workforce subcommittee This initiative identified internal and external workforce gaps, such as those affecting readiness and obtainment, unifying planning and policy efforts to streamline health care provision Additionally, St Joseph's played a critical role in the Highland Area Meals on Wheels program, addressing broader health determinants by delivering over 17,000 meals to seniors in FY2022. Chronic Disease Goal: Reduce the incidence and impact of chronic disease by enhancing preventive care, education, and access to effective management resources. Strategy 1: Improve access to prevention and early intervention services. In FY2023, St Joseph's Hospital delivered over 14,000 meals to seniors through the Highland Area Meals on Wheels program By ensuring consistent delivery of these nutritious meals five days a week, the program plays a crucial role in preventing and managing chronic conditions, particularly for vulnerable elderly patients. Strategy 2: Improve access to care. The hospital made transportation a focal point in FY2023, providing more than 1,400 patients with essential transport services via the Friends Van This initiative improves access to necessary medical, dental and personal appointments, helping those with chronic conditions receive consistent care. Strategy 3: Unified planning and policy, and advocacy efforts. St Joseph's Hospital collaborated with neighboring hospitals to implement a unified plan addressing the needs of those with chronic conditions This plan includes 365-day psychiatric coverage in the emergency department, ensuring seamless care and immediate response for patients facing chronic health challenges By integrating comprehensive screening and treatment protocols, this initiative significantly enhances care coordination for patients with chronic diseases. Workforce Development and Barriers Strategy 1: Integrated programs, long-term goals with workers at the center. HSHS St Joseph's Hospital fulfilled this strategy with the launching of HSHS's Diversity, Equity, and Inclusion (DEI) committee in FY2022 By participating in the Workforce subcommittee, St Joseph's explored gaps in workforce readiness and success Their commitment to the long-term inclusion of workers was demonstrated through $612,491 worth of mentoring and job-shadowing experiences The hospital mentored 132 interns across health care fields such as nursing, pharmacy and radiology, emphasizing a worker-centric approach. Strategy 2: Develop workforce plan and training programs. St Joseph's Hospital collaborated with local schools and colleges to train interns, providing hands-on experience in their respective fields Their partnership with these institutions fostered a training program that prepared individuals for health care careers, contributing to the community's workforce development This comprehensive training ensured that future health care workers gained practical skills, enhancing their employability. Strategy 3: Unified planning and policy, and advocacy efforts. Unified planning and policy efforts were achieved through the 18-month planning process that identified gaps in emergency department crisis screening The hospital, alongside others in southern Illinois, devised a plan for 365-day psychiatric coverage Additionally, they engaged with the Illinois Human Trafficking Task Force to raise awareness and respond to trafficking issues affecting workforce safety. Schedule H, Part V, Section B, Line 13 Facility , 1 Facility , 1 - . Presumptive eligibility is presumed under certain circumstances for uninsured patients based on their enrollment in other means-tested programs or other sources of information, not provided directly by the patient. Once determined, presumptive eligibility provides individuals participating in one of the following categories with a 100% write off. These programs are granted by outside organizations based on screening criteria of less than 200% of the FPG. 1. Homelessness 2. Deceased with no estate 3. Mental incapacitation with no one to act on patient's behalf 4. Medicaid eligibility, but not on date of service or for non-covered services 5. Incarceration in a penal institution 6. Enrollment in the following assistance programs for low-income individuals: 6a. Temporary Assistance for Needy Families (TANF) 6b. Illinois Housing Development Authority's Rental Housing Support Program 6c. Wisconsin Department of Health Services Housing Assistance Program 7. Participation in Women, Infants and Children programs (WIC); 8. Supplemental Nutrition Assistance Program (SNAP) eligibility; 9. Low Income Home Energy Assistance Program (LIHEAP); 10. Wisconsin Home Energy Assistance Program (WHEAP); 11. Enrollment in an organized community-based program providing access to medical care that assesses and documents limited low-income financial status as criteria; 12. Receipt of grant assistance for medical services 0 Schedule H, Part I, Line 7g Subsidized Health Services No costs attributable to a physician clinic are included on Line 7G. Schedule H, Part I, Line 7 Costing Methodology used to calculate financial assistance THE COSTING METHODOLOGY USED TO CALCULATE THE AMOUNTS REPORTED VARY ACCORDING TO INFORMATION REQUESTED AND THE MOST ACCURATE MEANS OF GATHERING THE REQUIRED INFORMATION. THE IRS PROVIDED WORKSHEET 2 WAS USED TO CALCULATE A COST TO CHARGE RATIO USING INFORMATION FROM THE ORGANIZATION'S GENERAL LEDGER AND COST REPORTS. THAT RATIO WAS THEN USED IN CONJUNCTION WITH IRS WORKSHEET 1 TO CALCULATE THE COST OF FINANCIAL ASSISTANCE PROVIDED AND WORKSHEET 3 TO CALCULATE UNREIMBURSED MEDICAID AMOUNTS. THE COMMUNITY HEALTH IMPROVEMENT AND COMMUNITY BENEFIT PROGRAMS, HEALTH PROFESSIONS EDUCATION, SUBSIDIZED HEALTH SERVICES, RESEARCH PROGRAM, AND DONATIONS ARE STATED AT ACTUAL COST (WHEN APPLICABLE). THE COST OF THESE ITEMS ARE TRACKED THROUGH THE GENERAL LEDGER PROCESS AND THROUGH OTHER ACCOUNTING SOFTWARE. Schedule H, Part III, Line 2 Bad debt expense - methodology used to estimate amount FOR FINANCIAL STATEMENT PURPOSES, HOSPITAL SISTERS HEALTH SYSTEM HAS ADOPTED ACCOUNTING STANDARDS UPDATE NO. 2014-09 (TOPIC 606). IMPLICIT PRICE CONCESSIONS INCLUDES BAD DEBTS. THEREFORE, BAD DEBTS ARE INCLUDED IN NET PATIENT REVENUE IN ACCORDANCE WITH HEALTHCARE FINANCIAL MANAGEMENT ASSOCIATION STATEMENT NO. 15 AND BAD DEBT EXPENSE IS NOT SEPARATELY REPORTED AS AN EXPENSE. Schedule H, Part III, Line 4 Bad debt expense - financial statement footnote The text of the footnote to the organization's financial statements that describes bad debt expense can be found on pages 16-19 in the HSHS Consolidated Audit Report. Schedule H, Part III, Line 8 Community benefit & methodology for determining medicare costs 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 leadership continually advocates for improved Medicare payment so that the cost of quality care to those patients who are not able to afford it is not compromised and is fairly subsidized by all payers. The IRS does not classify this shortfall in Medicare payments as Community Benefit. However, we believe it is an important contribution made by the hospital to the health and well-being of the community. If the Medicare program did not exist, many Medicare patients would be eligible for financial assistance or other means-tested government programs. Further, by absorbing this shortfall and providing care below cost to these individuals, the hospital is relieving the burden of the government. Accordingly, this shortfall restricts the hospital's ability to make funds available to provide for financial assistance and other Community Benefit. The hospital's Medicare shortfall at cost for fiscal year 2024 was $7,904. Schedule H, Part III, Line 9b Collection practices for patients eligible for financial assistance 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 provide adequate documentation. If the patient qualified for charity/community care for the full balance of their account, the entire amount is written off to charity/community care and hence no debt collection is pursued. If the patient qualified 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. The hospital will make reasonable efforts to determine whether a patient is eligible under the financial assistance policy before it engages in an ECA. To the extent a patient is determined to be eligible for financial assistance under the FAP, the hospital will take all reasonably available measures to reverse any ECA taken against the patient to obtain payment for the care. Schedule H, Part V, Section B, Line 16a FAP website - ST. JOSEPH'S HOSPITAL: Line 16a URL: https://www.hshs.org/about-us/patient-financial-services; Schedule H, Part V, Section B, Line 16b FAP Application website - ST. JOSEPH'S HOSPITAL: Line 16b URL: https://www.hshs.org/about-us/patient-financial-services/illinois-financial-assistance; Schedule H, Part V, Section B, Line 16c FAP plain language summary website - ST. JOSEPH'S HOSPITAL: Line 16c URL: https://www.hshs.org/about-us/patient-financial-services/illinois-financial-assistance; Schedule H, Part VI, Line 2 Needs assessment As indicated in Part V, Section C, HSHS St. Joseph Hospital conducted a Community Health Needs Assessment in FY2024 (July 1, 2023 through June 30, 2024). Throughout the three-year CHNA cycle, the hospital continuously reviews updated local and state data, Illinois Comp Data, patient surveys and feedback, and local needs assessments conducted by community groups. Additionally, the hospital receives input from public health officials, community groups and community boards on an ongoing basis. The information received and reviewed is used to inform ongoing strategic initiatives developed to meet CHNA health priorities; as well as new areas of need that are going unmet. Schedule H, Part VI, Line 3 Patient education of eligibility for assistance Patients may learn of FAP resources online. Materials are presented in English and Spanish with translation services available in more than 25-languages. At the time of registration, patients are provided with information on financial assistance. Then again during discharge, the care management team works with patients to confirm eligibility for financial assistance and provide resources accordingly. Financial Counselors are also available to assist self-pay patients with Medicaid eligibility. Schedule H, Part VI, Line 4 Community information St. Joseph's Hospital Highland is a critical access, tertiary hospital located in Madison County, Illinois. For more than 140 years, the hospital has been the leader in health and wellness in Madison County. St. Joseph's Hospital provides a wide range of specialties, including inpatient, surgical services, rehab services, emergency care, and outpatient services such as medical imaging and laboratory. HSHS St. Joseph's Hospital's service area is defined as Madison County for the purposes of this assessment. The total population in 2022 was 263,864. HSHS St. Joseph's Hospital does not exclude Medically Underserved Areas (MUAs), low income or minority populations from its service area. The average income for the hospital's service area is $71,759 with 12.3% of service area community residents below the federal poverty guideline. Up to 3.9% of the hospital's and community's patients are uninsured and 17.5% are Medicaid recipients. There are three (3) other hospitals (Anderson Hospital, Maryville; HSHS Holy Family Greenville, Greenville; HSHS St. Joseph's Hospital, Breese) serving the community or communities that HSHS St. Joseph's Hospital also serves. St. Joseph's Hospital partners with other area organizations to address the health needs of the community, living its mission to reveal and embody Christ's healing love for all people through our high-quality Franciscan health care ministry, with a preference for the poor and vulnerable. The hospital is part of Hospital Sisters Health System (HSHS), a highly-integrated health care delivery system serving rural and midsized communities in Illinois and Wisconsin. With 13 hospitals along with community-based health centers and clinics, the HSHS mission is carried out by 14,000 colleagues and 2,100 physicians who care for patients and their families in both states. Schedule H, Part VI, Line 5 Promotion of community health As a healing ministry of the Catholic Church and an affiliate of Hospital Sisters Health System (HSHS), St. Joseph's Hospital Highland is committed to delivering high quality, compassionate, and cost-effective health care services to all. Founded in 1878, the hospital brings a healing presence and improves the health of our community, especially those persons who are sick, poor, and disadvantaged. Because of the hospital's mission and heritage, the hospital is dedicated to promoting the health of Highland and surrounding areas. The hospital is governed by a Board of Directors, most of whom reside in the hospital's primary service area and are neither employees nor independent contractors of the hospital (nor family members thereof). The Board ensures that St. Joseph's Hospital is responding to community need. In addition, annual reports are developed and reviewed with members. In addition, St. Joseph's Hospital receives community support and guidance through the Patient Family Advisory Council, Community Engagement Council, and HSHS St. Joseph's Foundation Leadership Council. The Family Advisory Council and Community Engagement Council meet quarterly, while the Foundation Leadership Council meets every other month. These groups provide feedback from the community on additional services or improvements needed, as well as help the hospital understand the community's perception of those services and identify potential opportunities for improvement. St. Joseph's Hospital is blessed with a strong volunteer program. Volunteers are active in many hospital departments and donate many more hours throughout the year to hospital-sponsored community programs. Consistent with its exempt purpose, St. Joseph's Hospital has an open medical staff with privileges available to all qualified physicians in the area. The hospital also 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. Joseph's Hospital reinvests surplus funds to support the mission of the organization and promote the health of the community rather than distributing surplus funds 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. St. Joseph's Hospital also devotes significant resources to access for patients who cannot afford care, along with other Community Benefits. In FY2024, St. Joseph's provided more than $827,170 in Community Benefit, including financial assistance at cost, unpaid costs of Medicaid and other public programs, and a range of diverse programs designed to enhance access and improve community health. St. Joseph's Hospital provides a range of Community Benefit initiatives and programs that further our mission and long-standing commitment to our community. In many cases, these Community Benefits would not exist without the leadership role played by St. Joseph's Hospital and they often relieve a burden that would otherwise be carried by government. Schedule H, Part VI, Line 6 Affiliated health care system Headquartered in Springfield, Illinois, Hospital Sisters Health System (HSHS) is a highly integrated, multi-institutional health care system comprised of 15 hospitals and more than 200 physician practice sites in Illinois and Wisconsin. HSHS is sponsored by Hospital Sisters Ministries (HSM), which is a public juridic person of the Roman Catholic Church. HSHS continues the health care ministries begun by its founders, the Hospital Sisters of St. Francis, more than 140 years ago, in rural and midsized communities throughout Illinois and Wisconsin. HSHS provides compassionate, holistic, high quality, and cost-effective health care through its acute care hospitals, physician practices, home health programs, palliative and hospice programs, and community outreach services. In addition, HSHS affiliated hospitals include critical access facilities that offer essential health services that otherwise would not be available in many communities. Our mission calls us to reveal and embody Christ's healing love for all people, and we extend our high quality Franciscan health care ministry beyond the walls of our hospitals by providing community health improvement services with special emphasis on the poor and vulnerable. In addition to providing community health improvement services to the broader community, HSHS cares for everyone who comes to its facilities, regardless of their ability to pay. In tandem with a variety of cross sector community partners, HSHS's Community Benefit initiatives are strategically planned and professionally implemented to improve access to health care services; enhance the health of the community; advance medical or general health care knowledge; and relieve or reduce the burden of government to improve health. In FY2024, HSHS collectively provided $259.6 million in Community Benefit (8.1% of total hospital expenses). Of the total Community Benefit provided, HSHS provided $2.8 million for Financial Assistance (aka Charity Care) and $191.3 million for unreimbursed care provided as part of the Medicaid program. In addition, HSHS hospitals committed significant resources to treat 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 $379.4 million. HSHS hospitals also recorded $72.8 million in uncollectible accounts. While HSHS does not count the latter two amounts as Community Benefit, they nonetheless reflect our commitment to serving all persons in need of care. In addition to the dollars invested in our Community Benefit programs, HSHS 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 so, we ensure our ability to meet the ongoing demand for high quality, efficient and easily accessible health care. Schedule H, Part VI, Line 7 State filing of community benefit report IL X X X X X false true false false false false false false false JOHN LUDWIG Former PRESIDENT/CEO 172555 0 78739 0 118048 0 26689 0 14311 0 410342 0 99920 0 CHRIS KLAY PRESIDENT/CEO 189660 189660 12348 12348 45042 45042 18118 18118 14751 14751 279919 279919 15326 15326 PATRICIA ALLEN CFO - CARE DELIVERY 0 498772 0 53821 0 96913 0 99475 0 24152 0 773133 0 34179 TODD Smart Treasurer (UNTIL 5/3/24) 0 275819 0 37512 0 2275 0 46882 0 19645 0 382133 0 0 Paige Toth Secretary (began 11/1/23) 0 283016 0 23092 0 0 0 33609 0 32560 0 372277 0 0 TERESA CORNELIUS Chief Operating Officer 207298 0 26629 0 125 0 889 0 16559 0 251500 0 0 0 MARK ENNEN Director of Finance 22213 128283 0 0 0 0 22975 0 1878 10318 47066 138601 0 0 Megan Espenschied Director of Surgical Services 141378 0 0 0 0 0 18377 0 756 0 160511 0 0 0 Stephanie N Grant House Supervisor 140816 0 3360 0 45 0 8860 0 13882 0 166963 0 0 0 JOEL TUCKER Director of Pharmacy 188117 0 0 0 50 0 -12687 0 34894 0 210374 0 0 0 Schedule J, Part I, Line 3 Arrangement used to establish the top management official's compensation PLEASE SEE RESPONSE TO FORM 990, PART VI, LINE 15A IN SCHEDULE O. Schedule J, Part I, Line 4b Supplemental nonqualified retirement plan HSHS EXECUTIVES ELIGIBLE TO PARTICIPATE IN SUPPLEMENTAL EXECUTIVE RETIREMENT PLAN (SERP) ARE DEFINED IN THE SERP PLAN DOCUMENTS. THE SERP WAS ESTABLISHED TO PROVIDE ADDITIONAL RETIREMENT BENEFITS TO ENSURE REASONABLE MARKET COMPETITIVE BENEFITS IN ACCORDANCE WITH THE HSHS EXECUTIVE COMPENSATION PHILOSOPHY ESTABLISHED BY THE HSHS COMPENSATION COMMITTEE. THE PLAN PROVIDES A DEFINED RETIREMENT CONTRIBUTION TO PARTICIPANTS COMMENCING ON JANUARY 1, 2008, EQUAL TO A PERCENTAGE OF COMPENSATION AS DEFINED IN THE SERP PLAN DOCUENTS FOR THE PLAN YEAR. PARTICIPANTS CONSTRUCTIVELY RECEIVE A DISTRIBUTION FROM THE PLAN NO LATER THAN MARCH 15TH OF THE CALENDAR YEAR FOLLOWING THE CALENDAR YEAR IN WHICH AN AMOUNT IS VESTED AND TAXABLE PURSUANT TO A VESTING SCHEDULE AS SPECIFIED IN THE PLAN DOCUMENT. THE ACTUAL DISTRIBUTION OF THE VESTED BENEFIT UNDER THE PLAN IS PAID IN A SINGLE LUMP SUM TO THE PARTICIPANT OR THE PARTICIPANT'S BENEFICIARY UPON THE EARLIER OF THE PARTICIPANT'S TERMINATION OF EMPLOYMENT, DEATH, OR TOTAL AND PERMANENT DISABILITY. THE FOLLOWING INTERESTED PERSONS CONSTRUCTIVELY RECEIVED DEFERRALS TO THE SUPPLEMENTAL EXECUTIVE RETIREMENT PLAN (SERP) IN 2023; THESE DEFERRALS ARE INCLUDED IN SCHEDULE J, PART II, COLUMN (C). CHRIS KLAY-- $40,910 TODD SMART -- $25,441 PATRICIA ALLEN -- $44,695 PAIGE TOTH -- $14,542 THE FOLLOWING INTERESTED PERSONS RECEIVED DISTRIBUTIONS FROM THE SUPPLEMENTAL EXECUTIVE RETIREMENT PLAN (SERP) IN 2023; THESE PAYMENTS ARE INCLUDED IN SCHEDULE J, PART II, COLUMN (B)(III) AND SCHEDULE J, PART II, COLUMN (F), AS APPLICABLE. PATRICIA ALLEN -- $34,179 CHRIS KLAY-- $30,652 JOHN LUDWIG -- $99,920 Form 990, Part III, Line 4d Description of other program services (Expenses $ 3,183,044 including grants of $)(Revenue $ 3,287,174) INFECTIOUS DISEASE - St. Joseph's Hospital has seen 355 patient in the last fiscal year for infection diseases related diagnosis. The hospital was awarded High-Reliability zero harm award for no hospital acquired Catheter Associated Urinary Tract Infection (CAUTI) in the last 44 months, no hospital acquired Central Line- Associated Bloodstream Infection (CLABSI) for 133 months and no hospital acquired Methicillin Resistant Staphylococcus Aureus (MRSA) in the last 133 months. Form 990, Part IV, Line 24a TAX EXEMPT BONDS ST JOSEPH'S HOSPITAL HOLDS A LIABILITY ON ITS BOOKS FOR TAX-EXEMPT BONDS, WHICH IS AN ALLOCATION FROM ITS SOLE COROPORATE MEMBER, HOSPITAL SISTERS SERVICES, INC. AS A RESULT, THIS QUESTION WAS ANSWERED NO, AND SCHEDULE K WILL BE COMPLETED ON THE HOSPITAL SISTERS SERVICES, INC. FORM 990. Form 990, Part IV, Line 10 Endowment Funds The organization maintains net assets with donor restrictions and without donor restrictions on its balance sheet. Such funds are held by Hospital Sisters of St. Francis Foundation, Inc., a related tax-exempt organization. While these funds are held to further one or more exempt purposes of the filing organization, they are not maintained exclusively for the filing organization. The board of directors of Hospital Sisters of St. Francis Foundation, Inc. maintains ownership and ultimately authority and discretion over the use of these funds. Based on the above, the related amounts have not been reported as endowment funds on Part V of Schedule D. Form 990, Part V, Line 1a number reported in Box 3 of Form 1096. The Form 1096, Annual Summary and Transmittal of U.S. Information Return is filed by the organization's parent, Hospital Sisters Health System (HSHS) on the organization's behalf to transmit to the IRS Forms 1099, 1098, 5498, and W-2G. The organization is unable to determine the number of Forms 1099, 1098, 5498 and W-2G filed by HSHS, on their behalf. However, as the parent organization, HSHS ensures that the filing organization complies with all information return reporting requirements and backup withholding rules for reportable payments to vendors and reportable gaming winnings to prize winners, as applicable. Form 990, Part VI, Line 13 WHISTLEBLOWER POLICY PROVISIONS WITHIN THE CORPORATE COMPLIANCE PROGRAM AND CONFLICT OF INTEREST POLICY PROVIDE PROTECTIONS FOR WHISTLEBLOWER TYPE ACTIVITIES. Form 990, Part VI, Line 16b JOINT VENTURES HOSPITAL SISTERS HEALTH SYSTEM ADOPTED A JOINT VENTURE COMPLIANCE PROGRAM POLICY EFFECTIVE ON JANUARY 1, 2012 FOR ALL SYSTEM HOSPITALS, INCLUDING ST. JOSEPH'S 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. JOSEPH'S HOSPITAL, AND ALL HSHS HOSPITALS, TO EVALUATE THEIR PARTICIPATION IN JOINT VENTURE ARRANGEMENTS, INCLUDING UNDER APPLICABLE FEDERAL TAX LAWS, AND TO SAFEGUARD ST. JOSEPH'S HOSPITAL'S TAX EXEMPT STATUS WITH RESPECT TO ANY JOINT VENTURE ARRANGEMENTS. Form 990, Part VI, Line 1a Delegate broad authority to a committee PER ARTICLE 5.5 OF THE ORGANIZATION'S BY-LAWS, THE GOVERNING BODY DELEGATES BROAD AUTHORITY TO AN EXECUTIVE COMMITTEE. THE EXECUTIVE COMMITTEE SHALL BE VESTED WITH AND MAY IN ITS DISCRETION EXERCISE THE FULL POWERS, DUTIES, RESPONSIBILITIES, AND AUTHORITY OF THE BOARD EXCEPT WHERE PROHIBITED BY LAW AND SUBJECT TO ANY LIMITATIONS IMPOSED BY THE BYLAWS OR THE BOARD OF DIRECTORS. AS PROVIDED IN THE BY-LAWS, THE EXECUTIVE COMMITTEE SHALL CONSIST OF FOUR TO SIX MEMBERS, INCLUDING THE CHAIRPERSON OF THE BOARD, THE VICE CHAIRPERSON, THE PRESIDENT AND OTHER MEMBERS SELECTED FROM AMONG THE DIRECTORS BY THE BOARD. Form 990, Part VI, Line 6 Classes of members or stockholders THE SOLE CORPORATE MEMBER OF ST. JOSEPH'S HOSPITAL HIGHLAND (THE CORPORATION) 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. Form 990, Part VI, Line 7a Members or stockholders electing members of governing body PURSUANT TO SECTION 2.3 OF THE CORPORATION'S BYLAWS, THE ORGANIZATION'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, HAS THE RIGHT TO APPOINT AND REMOVE THE CORPORATION'S BOARD OF DIRECTORS. Form 990, Part VI, Line 7b Decisions requiring approval by members or stockholders RESPONSIBILITY FOR THE POLICY AND OPERATIONS OF ST. JOSEPH'S HOSPITAL HIGHLAND (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 governance and operations of the Corporation shall be subject in all respects to the Member's right to exercise the reserved powers set forth in this section (the "Reserved Powers") with respect to the Corporation and organizations of which the Corporation is either, directly or indirectly, a controlling member or controlling shareholder (the "Affiliates"). The Member shall have the exclusive right to exercise the Reserved Powers, and the Board of Directors of the Corporation shall have no power or authority over the Corporation which would in any way conflict with the Member's exclusive right to exercise the Reserved Powers. The Reserved Powers shall include all rights granted to the Member of a not-for-profit corporation 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 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, and the 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 the Member; (g) Approve debt incurred by the Corporation or any Affiliate in an amount in excess of limits set from time to time by the Member; (h) Approve the operating and capital budgets of the Corporation or of any Affiliate, and any deviations by the Corporation or any Affiliate from such budgets in an amount or percentage specified by the Member from time to time; (i) Approve the strategic plan and annual goals of the Corporation or of any Affiliate; (j) Approve the sale of substantially all of the assets of the Corporation or of any Affiliate; (k) Approve the merger or dissolution of the Corporation or of any Affiliate; (l) Adopt or amend the plan for ministry education and governance for the Corporation and its Affiliates; (m) Approve the Corporation's Mission Accountability Reports and those of any Affiliate; (n) 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; (o) Approve material actions with respect to employee retirement plans sponsored by the Corporation or any Affiliate; and (p) Adopt policies to implement the Reserved Powers of the Member. Form 990, Part VI, Line 11b Review of form 990 by governing body THE HOSPITAL EMPLOYS CROWE LLP TO ASSIST IN THE OVERALL REVIEW AND ELECTRONIC SUBMISSION OF ITS FORM 990. CROWE LLP 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. Form 990, Part VI, Line 12c Conflict of interest policy 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. A REVISED CORPORATE COMPLIANCE PROGRAM AND CONFLICT OF INTEREST POLICY HAVE BEEN IMPLEMENTED SINCE 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 PROMPTLY TO DISCLOSE THE 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 THAT 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 AND, IN THE ABSENCE OF ALTERNATIVES THAT ARE IN THE BEST INTERESTS OF HSHS, 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. Form 990, Part VI, Line 15a Process to establish compensation of top management official 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 HSHS EXECUTIVES. SULLIVAN COTTER, 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 HSHS EXECUTIVES. SULLIVAN COTTER 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. 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. Form 990, Part VI, Line 15b Process to establish compensation of other employees PLEASE SEE RESPONSE TO FORM 990, PART VI, LINE 15A. Form 990, Part VI, Line 19 Required documents available to the public 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. Form 990, Part VIII, Line 11d Other Miscellaneous Revenue GIFT SHOP - Total Revenue: 21470, Related or Exempt Function Revenue: , Unrelated Business Revenue: , Revenue Excluded from Tax Under Sections 512, 513, or 514: 21470; Other Revenue - Total Revenue: 19534, Related or Exempt Function Revenue: 19534, Unrelated Business Revenue: , Revenue Excluded from Tax Under Sections 512, 513, or 514: ; Form 990, Part IX, Line 11g Other Fees PURCHASED SERVICES - Total Expense: 2980888, Program Service Expense: 2977810, Management and General Expenses: 3078, Fundraising Expenses: ; PROFESSIONAL FEES - Total Expense: 2728848, Program Service Expense: 2723456, Management and General Expenses: 5392, Fundraising Expenses: ; OTHER FEES - CONTRACT LABOR - Total Expense: 58464, Program Service Expense: 58464, Management and General Expenses: 0, Fundraising Expenses: ; Form 990, Part X, Line 11 POOLED INVESTMENT ACCOUNT ST. JOSEPH'S 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. Form 990, Part XI, Line 9 Other changes in net assets or fund balances TRANSFER TO/FROM AFFILIATE - -4788723; CHANGE IN NET PERIODIC PENSION COSTS-NET OF SERVICE COSTS - -1444063; CHANGE IN FAIR VALUE OF INTEREST RATE SWAPS - 146260; HOSPITAL SISTERS HEALTH SYSTEM 4936 LAVERNA ROAD SPRINGFIELD IL 62707 371058692 HEALTHCARE IL 501(c)(3) Type III-FI NA false HOSPITAL SISTERS OF ST FRANCIS FOUNDATION INC 4936 LAVERNA ROAD SPRINGFIELD IL 62707 371186514 HEALTHCARE IL 501(c)(3) 7 HSHS true HOSPITAL SISTERS HEALTHCARE-WEST INC 2661 COUNTY HIGHWAY 1 CHIPPEWA FALLS WI 54729 510157933 HEALTHCARE WI 501(c)(3) Type I HSSI true SACRED HEART HOSPITAL OF HOSPITAL SISTERS OF THIRD ORDER OF ST FRANCIS 990 WEST CLAIREMONT AVENUE EAU CLAIRE WI 54701 390807060 HEALTHCARE WI 501(c)(3) 3 HSSI true ST ANTHONY'S MEMORIAL HOSPITAL OF THE HOSPITAL SISTERS OF THE THIRD ORDER O F ST FRANCIS 503 N MAPLE STREET EFFINGHAM IL 62401 370661233 HEALTHCARE IL 501(c)(3) 3 HSSI true ST ELIZABETH'S HOSPITAL OF THE HOSPITAL SISTERS OF THE THIRD ORDER OF ST FR ANCIS ONE ST ELIZABETHS BLVD OFALLON IL 62269 370663567 HEALTHCARE IL 501(c)(3) 3 HSSI true ST NICHOLAS HOSPITAL OF THE HOSPITAL SISTERS OF THE THIRD ORDER OF ST FRANC IS 3100 SUPERIOR AVENUE SHEBOYGAN WI 53081 390808480 HEALTHCARE WI 501(c)(3) 3 HSSI true ST JOHN'S HOSPITAL OF THE HOSPITAL SISTERS OF THE THIRD ORDER OF ST FRANCIS 800 EAST CARPENTER STREET SPRINGFIELD IL 62769 370661238 HEALTHCARE IL 501(c)(3) 3 HSSI true ST JOSEPH'S HOSPITAL OF THE HOSPITAL SISTERS OF THE THIRD ORDER OF ST FRANC IS 9515 HOLY CROSS LANE BREESE IL 62230 371208459 HEALTHCARE IL 501(c)(3) 3 HSSI true ST JOSEPH'S HOSPITAL OF THE HOSPITAL SISTERS OF THE THIRD ORDER OF ST FRANC IS 2661 COUNTY HIGHWAY 1 CHIPPEWA FALLS WI 54729 390810545 HEALTHCARE WI 501(c)(3) 3 HSSI true ST MARY'S HOSPITAL DECATUR OF THE HOSPITAL SISTERS OF THE THIRD ORDER OF ST FRANCIS 1800 E LAKE SHORE DRIVE DECATUR IL 62521 370661244 HEALTHCARE IL 501(c)(3) 3 HSSI true ST MARY'S HOSPITAL MEDICAL CENTER OF GREEN BAY INC - HOSPITAL SISTERS 1762 SHAWANO AVENUE GREEN BAY WI 54303 390818682 HEALTHCARE WI 501(c)(3) 3 HSSI true ST VINCENT HOSPITAL OF THE HOSPITAL SISTERS OF THE THIRD ORDER OF ST FRANCI S 835 S VAN BUREN GREEN BAY WI 51301 390817529 HEALTHCARE WI 501(c)(3) 3 HSSI true ST FRANCIS HOSPITAL SISTERS OF THE THIRD ORDER OF ST FRANCIS 1215 FRANCISCAN DRIVE LITCHFIELD IL 62056 370661236 HEALTHCARE IL 501(c)(3) 3 HSSI true HOSPITAL SISTERS SERVICES INC 4936 LAVERNA ROAD SPRINGFIELD IL 62707 371163402 HEALTHCARE IL 501(c)(3) Type III-FI HSHS true HSHS MEDICAL GROUP INC 3051 HOLLIS DRIVE SPRINGFIELD IL 62704 263956318 HEALTHCARE IL 501(c)(3) Type III-FI HSSI true HSHS WISCONSIN MEDICAL GROUP INC 3051 HOLLIS DRIVE SPRINGFIELD IL 62704 264515959 HEALTHCARE WI 501(c)(3) Type III-FI HSSI true ORANGE CROSS AMBULANCE INC 919 ASHLAND AVENUE SHEBOYGAN WI 53081 391860942 HEALTHCARE WI 501(c)(3) 10 ST NICHOLAS true UNITY LIMITED PARTNERSHIP 2366 OAK RIDGE CIRCLE DE PERE WI 54115 391750729 HEALTHCARE WI 501(c)(3) 10 HSSI true PRAIRIE EDUCATION & RESEARCH COOPERATIVE 800 EAST CARPENTER STREET 62 SPRINGFIELD IL 62769 371157915 HEALTHCARE IL 501(c)(3) 4 HSSI true ST CLARE MEMORIAL HOSPITAL INC 855 S MAIN STREET OCONTO FALLS WI 54154 390848401 HEALTHCARE WI 501(c)(3) 3 HSSI true HSHS HOLY FAMILY HOSPITAL 200 HEALTHCARE DRIVE GREENVILLE IL 62246 370792770 HEALTHCARE IL 501(c)(3) 3 HSSI true UTLAUT MEMORIAL FOUNDATION 200 HEALTHCARE DRIVE GREENVILLE IL 62246 371140166 FUNDRAISING IL 501(c)(3) Type II HSSI true HSHS GOOD SHEPHERD HOSPITAL INC 200 SOUTH CEDAR STREET SHELBYVILLE IL 62565 370512290 HEALTHCARE IL 501(c)(3) 3 HSSI true HOSPITAL SISTERS MISSION OUTREACH CORPORATION 4849 LAVERNA ROAD SPRINGFIELD IL 62707 352271729 RECYCLING MEDICAL SUPPLIES IL 501(c)(3) HSHS true PRAIRIE CARDIOVASCULAR CONSULTANTS LTD 3051 HOLLIS DRIVE SPRINGFIELD IL 62704 371071858 HEALTHCARE IL 501(c)(3) 10 HSSI true PRAIRIE HEART INSTITUTE MANAGEMENT COMPANY LLC 4936 LAVERNA ROAD SPRINGFIELD IL 62707 261479945 MEDICAL IL HSHS Related 0 0 false true 1 KIARA INC 4936 LAVERNA ROAD SPRINGFIELD IL 62707 371163401 HEALTHCARE IL HSHS C Corporation 953484 19065022 1 true LASANTE WISCONSIN INC 4936 LAVERNA ROAD SPRINGFIELD IL 62707 391572196 HEALTHCARE IL KIARA INC C Corporation true LASANTE INC 4936 LAVERNA ROAD SPRINGFIELD IL 62707 371163400 HEALTHCARE IL KIARA INC C Corporation true PREVEA HEALTH SERVICES INC 2710 EXECUTIVE DRIVE GREEN BAY WI 54304 391839351 HEALTHCARE WI HSSI C Corporation -678213 23739679 0.5 true PREVEA CLINIC INC 2710 EXECUTVE DRIVE GREEN BAY WI 54304 391839349 HEALTHCARE WI PHSI C Corporation true RENAISSANCE QUALITY INSURANCE LTD PO BOX 1159 GRAND CAYMAN CJ KY11102 980669953 INSURANCE CJ HSSI C Corporation 0 204854765 1 true false false true false true false false false false false false false true true true true true true true Schedule R, Part V, Line 2 TRANSACTIONS WITH RELATED ENTTIES Due to the increasingly complex organization structure of Hospital Sisters Health System and Affiliates, the filing organization has elected to report all tax-exempt organizations, partnerships, and corporations within Hospital Sisters Health System as related, regardless of ownership interest or "control" as defined by the instructions to Schedule R. The intent of this reporting is to promote transparency and increase consistency across the numerous Form 990 submissions by Hospital Sisters Health System and Affiliates.