2025-11-17T09:00:23-06:00 2024-12-31 410746749 CLIFTONLARSONALLEN LLP 600 WASHINGTON AVENUE SUITE 1800 ST LOUIS MO 63101 990 2024-01-01 361000540 KATHERINE SHAW BETHEA HOSPITAL KATH 8152885531 403 EAST FIRST STREET DIXON IL 61021 KIRSTEN LARGENT CFO 8152885531 2025-11-13 1 1 STEPHANIE MCCARTHY P01805699 3149254300 2025-11-13 2024 2025-03-06 01:10:19Z KIRSTEN LARGENT 403 EAST FIRST STREET DIXON IL 61021 146640915 0 X WWW.OSFHEALTHCARE.ORG/HOSPITALS/SAINT-KATHARINE X 1893 IL RESTORE, MAINTAIN, AND ENHANCE HEALTH BY PROVIDING SUPERIOR CARE NOW AND IN THE FUTURE. 10 8 1093 23 64530 0 1546788 1215963 154006638 144435649 527912 354204 1076930 635099 157158268 146640915 70954 52130 0 0 88303930 92885234 0 0 0 73233422 80947811 161608306 173885175 -4450038 -27244260 103111013 84091211 68402871 76751114 34708142 7340097 TO RESTORE, MAINTAIN, AND ENHANCE HEALTH BY PROVIDING SUPERIOR CARE NOW AND IN THE FUTURE. 0 0 151627113 52130 144435649 IN 2024, KATHERINE SHAW BETHEA HOSPITAL (KSB) HAD 2,596 INPATIENT VISITS AND 238,050 OUTPATIENT VISITS. KSB IS COMMITTED TO PROVIDING THE HIGHEST QUALITY OF HEALTHCARE REGARDLESS OF ABILITY TO PAY. KSB SUBSIDIZES THE COST OF TREATING PATIENTS WHO ARE UNABLE TO PAY AND THOSE WHO RECEIVE GOVERNMENT ASSISTANCE WHERE REIMBURSEMENT IS LIMITED. THE COST OF CHARITY CARE, BASED ON THE HOSPITAL'S COST-TO-CHARGE RATIO, PROVIDED BY THE HOSPITAL, WAS APPROXIMATELY $255,000 IN 2024.KSB PROVIDES 24-HOUR EMERGENCY MEDICAL SERVICES STAFFED BY FULL-TIME PHYSICIANS. PATIENTS ARE TREATED REGARDLESS OF INSURANCE OR ABILITY TO PAY. ER VISITS IN 2024 WERE 18,090. 151627113 1 1 0 1 0 0 0 0 0 0 1 0 0 0 1 1 0 1 0 0 0 0 0 0 0 0 1 1 1 1 1 0 0 0 0 0 0 0 0 0 0 0 0 0 1 1 1 0 0 1 98 0 1 1093 1 1 1 0 0 0 0 0 0 0 0 0 0 0 X 10 8 0 0 0 0 0 1 1 1 1 0 0 1 1 1 1 1 1 1 1 0 IL X KIRSTEN LARGENT 8152855511 403 EAST FIRST STREET DIXON IL 61021 LYNETTE KNODLE BOARD MEMBER 2.10 1.00 X 0 0 0 COLLEEN T HENKEL PAST-CHAIRPERSON 1.40 0.00 X 0 0 0 CHRIS HAMMITT VICE-CHAIRPERSON 1.40 0.00 X X 0 0 0 RICK CURIA BOARD MEMBER 0.90 1.00 X 0 0 0 JOSEPH WELTY MD BOARD MEMBER / PHYSICIAN 9.00 0.00 X 126304 0 0 RAY NEISEWANDER III BOARD MEMBER 0.90 1.00 X 0 0 0 DAVID HELLMICH CHAIRPERSON 1.30 1.00 X X 0 0 0 RICHARD BOYSEN TREASURER 1.40 0.00 X X 0 0 0 PATRICK KING DDS SECRETARY 1.70 0.00 X X 0 0 0 DAVID SCHREINER CEO AND BOARD MEMBER 40.00 1.00 X X 623623 0 50162 LINDA CLEMEN VP-CHIEF NURSING OFFICER 40.00 0.00 X 298056 0 35813 RAY SHARP VP-CHIEF INFORMATION OFFIC 40.00 0.00 X 301154 0 59537 AUSTIN FRAZIER VP-CHIEF FINANCIAL OFFICER 40.00 2.00 X 387592 0 61218 DREW FENNER VP-CHIEF PEOPLE OFFICER 40.00 0.00 X 263513 0 27629 RYAN MILLER VP-CHIEF QUALITY OFFICER 40.00 2.00 X 261169 0 57359 MONTHER ELBZOUR MD PHYSICIAN 40.00 0.00 X 1600617 0 51802 SOHAIL HANIF MD PHYSICIAN 40.00 0.00 X 1425136 0 50970 KURT CROWE MD PHYSICIAN 40.00 0.00 X 797966 0 59916 FADI MOHAMAD MUSTAPHA PHYSICIAN 40.00 0.00 X 898384 0 54148 ABDULHAMID ALKHALAF PHYSICIAN 40.00 0.00 X 921247 0 54065 7904761 0 562619 112 0 1 0 ROCKFORD ANESTHESIOLOGISTS ASSOCIATED L 2202 HARLEM RD LOVES PARK IL 61111 ANESTHESIOLOGY 2251645 LAB CORPORATION PO BOX 12140 BURLINGTON NC 27216 LAB TESTING 827942 MIDWEST MEDICAL CARE LLC 1114 HICKORY DR WESTERN SPRINGS IL 60558 HOME HEALTH CARE SERVICES 525000 FAZLUR R ZAHURULLAH MD LLC 1802 ROTHCHILD LANE ROCKFORD IL 61107 OTOLARYNGOLOGIST 425000 TRU IMPACT HEALTHCARE SC 3 S WYNSTONE DRIVE NORTH BARRINGTON IL 60010 LONG-TERM CARE SERVICES 272943 9 951737 264226 1215963 NET PATIENT SERVICE REVENUE 621110 144171679 144171679 NET CLINIC SPACE RENTAL 621110 263970 263970 144435649 353861 353861 143 200 0 0 143 200 343 343 CAFETERIA SALES 900099 476212 64530 411682 REVENUE SHARE 900099 155595 155595 MEDICAL RECORD FEES 900099 3292 3292 635099 146640915 144435649 64530 924773 X 46130 46130 6000 6000 2553130 460174 2092956 68017751 67244617 773134 2418779 1841128 577651 15713513 11785404 3928109 4182061 3947704 234357 623331 333126 290205 179880 143610 36270 31787 31787 988 988 23154350 17963692 5190658 194389 145108 49281 18468390 17136841 1331549 5028470 3799954 1228516 2309343 1398017 911326 125099 114219 10880 156275 127678 28597 1097143 751830 345313 6527226 4754571 1772655 8511639 6403340 2108299 IPA/SALES & USE TAX 6676015 5845965 830050 BAD DEBT EXPENSE 5447356 5447356 REPAIRS AND MAINTENANCE 939949 746627 193322 FOOD SUPPLY 650818 486016 164802 825363 698006 127357 173885175 151627113 22258062 0 226456 749664 2890132 2849822 32752815 23282379 1680102 1608150 1373259 1210537 165863161 126644554 43718403 39218607 13510638 9386918 5116137 4140938 1843071 1644196 103111013 84091211 48795615 49454956 22019 0 17723609 0 1861628 27296158 68402871 76751114 X 34708142 6403294 936803 34708142 7340097 103111013 84091211 X -27244260 109932 -43682 -190035 X X 0 1 X 1 1 1 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 0 0 0 0 0 0 0 0 1 31787 31787 0 PART II-B, LINE 1: A PORTION OF THE HOSPITAL'S MEMBERSHIP DUES WITH THE ILLINOIS HOSPITAL ASSOCIATION AND THE AMERICAN HOSPITAL ASSOCIATION ARE USED BY THOSE ASSOCIATIONS TO CONDUCT LOBBYING ACTIVITIES ON BEHALF OF ALL MEMBER HOSPITALS. 2289039 2289039 61658114 40940348 20717766 5660750 4943590 717160 95320039 80760616 14559423 935219 935219 39218607 RIGHT OF USE LIABILITIES 1626804 DUE TO OSF HEALTHCARE 25669354 27296158 X PART X, LINE 2: THE HOSPITAL APPLIES THE INCOME TAX STANDARD FOR UNCERTAIN TAX POSITIONS. THIS STANDARD CLARIFIES THE ACCOUNTING FOR UNCERTAINTY IN INCOME TAXES RECOGNIZED IN AN ORGANIZATION'S FINANCIAL STATEMENTS IN ACCORDANCE WITH THE INCOME TAX STANDARD. THIS STANDARD PRESCRIBES RECOGNITION AND MEASUREMENT OF TAX POSITIONS TAKEN OR EXPECTED TO BE TAKEN ON A TAX RETURN THAT ARE NOT CERTAIN TO BE REALIZED. THE HOSPITAL DOES NOT CURRENTLY INCLUDE AN INCOME TAX PROVISION IN THE CONSOLIDATED FINANCIAL STATEMENTS. MANAGEMENT MONITORS THE REPORTING OF UNCERTAIN TAX POSITIONS, WHICH COULD RESULT IN RECORDING OF AN INCOME TAX PROVISION IN THE FUTURE. 1 1 X 1 X 1 X 1 1 0 0 255067 255067 0.00150 26687967 15503140 11184827 0.06430 159083 89132 69951 0.00040 27102117 15592272 11509845 0.06620 843041 843041 0.00480 1903557 1308027 595530 0.00340 7645968 5859299 1786669 0.01030 810795 810795 0.00470 11203361 7167326 4036035 0.02320 38305478 22759598 15545880 0.08940 1 14648512 14648512 16617394 25025798 -8408404 X 1 1 1 1 KATHERINE SHAW BETHEA HOSPITAL 403 E FIRST STREET DIXON IL 61021 WWW.KSBHOSPITAL.COM 2114484 X X X X KATHERINE SHAW BETHEA HOSPITAL 1 0 0 1 X X X X X X X X X 22 1 0 1 1 X SEE PART V, PAGE 8, LINE 7D X X 1 22 1 SEE PART V, PAGE 8, LINE 7D 0 1 X 200.000000000000 300.000000000000 X X X X 1 1 X X X X 1 X SEE PART V, LINE 16 X SEE PART V, LINE 16 X SEE PART V, LINE 16 X X X X X 1 X 0 X X X X 1 X 0 0 KATHERINE SHAW BETHEA HOSPITAL PART V, SECTION B, LINE 5: DATA FOR THIS CHNA WAS OBTAINED FROM A VARIETY OF SOURCES, BOTH IN PERSON AND ONLINE. DEMOGRAPHIC DATA AND HEALTH INDICATORS WERE OBTAINED ON FROM THE LEE COUNTY ILLINOIS YOUTH SURVEY 2020; CDC WONDER; ILLINOIS HEALTH AND HOSPITAL ASSOCIATION, COMP DATA; ILLINOIS BEHAVIORAL RISK SURVEY 2020; NATIONAL CENTER FOR HEALTH STATISTICS; AND ILLINOIS SECRETARY OF STATE. POPULATION DATA WAS OBTAINED FROM THE U.S. CENSUS BUREAU WEBSITE AND THEIR AMERICAN COMMUNITY SURVEY TOOL.KSB HOSPITAL PARTNERED WITH THE LEE COUNTY HEALTH DEPARTMENT TO COLLECT DATA FOR THE CHNA. LEE COUNTY HEALTH DEPARTMENT IS COMPLETING THEIR IPLAN FOR 2022. THIS WAS A GREAT COLLABORATION SINCE THE CHNA AND IPLAN ARE VERY SIMILAR ASSESSMENTS FOR LEE COUNTY AND OUR SERVICE AREA.A CHNA SURVEY WAS OPENED TO THE PUBLIC IN JUNE 2022 AND RESPONSES WERE SOLICITED THROUGH SOCIAL MEDIA ACCOUNTS. WE RECEIVED 396 RESPONSES. 5 FOCUS GROUPS WERE ALSO CONDUCTED BY LEE COUNTY HEALTH DEPARTMENT.DATA FROM THESE REPORTS, INTERVIEWS, AND SURVEYS WERE SHARED WITH THE KSB WELLNESS STEERING COMMITTEE TO SOLICIT INPUT AND STIMULATE DISCUSSION OF COMMUNITY HEALTH NEEDS AMONG A COMMITTEE THAT MEETS THROUGHOUT THE YEAR TO DISCUSS WELLNESS INITIATIVES. KATHERINE SHAW BETHEA HOSPITAL PART V, SECTION B, LINE 6B: THE HOSPITAL'S CHNA WAS CONDUCTED WITH THE LEE COUNTY HEALTH DEPARTMENT AND LEE-OGLE TRANSPORTATION SYSTEM KATHERINE SHAW BETHEA HOSPITAL PART V, SECTION B, LINE 7D: THE COMMUNITY HEALTH NEEDS ASSESSMENT REPORT AND IMPLEMENTATION STRATEGY ARE AVAILABLE ONILNE AT: HTTPS://WWW.OSFHEALTHCARE.ORG/PATIENTS-VISITORS/ABOUT/COMMUNITY-HEALTHTHE DIRECT LINK TO THE COMMUNITY HEALTH NEEDS ASSESSMENT REPORT AND IMPLEMENTATION PLAN IS: HTTPS://OSF-P-001.SITECORECONTENTHUB.CLOUD/API/PUBLIC/CONTENT/DD5FE1F1527441898B91048D2D31DB25?V=65E462B2KATHERINE SHAW BETHEA HOSPITAL IS A 80 BED RURAL ACUTE CARE HOSPITAL. ITS CHNA IS ALSO PROVIDED TO THE PUBLIC THROUGH SOCIAL MEDIA, INCLUDING BUT NOT LIMITED TO FACEBOOK AND TWITTER. KATHERINE SHAW BETHEA HOSPITAL PART V, SECTION B, LINE 11: TO IDENTIFY AND PRIORITIZE THE NEEDS, WE USED THE HANLON METHOD OF HEALTH PROBLEM PRIORITY SETTING, AND THE PEARL TEST FOR FEASIBILITY. THE HANLON METHOD MEASURES THE SIZE OF THE HEALTH PROBLEM, THE IMPACT OF THE HEALTH PROBLEM, AND THE EFFECTIVENESS OF INTERVENTION. THE SCORING IDENTIFIED THE FOLLOWING THREE KEY PRIORITIES WHICH WILL BECOME THE FOCUS OF IMPLEMENTATION PLANS FROM KSB HOSPITAL DURING THE LIFE OF THIS COMMUNITY HEALTH NEEDS ASSESSMENT:BEHAVIORAL HEALTH (FOCUS ON ANXIETY AND DEPRESSION)HEART DISEASEOBESITY & PHYSICAL INACTIVITYBEHAVIORAL HEALTH:BEHAVIORAL HEALTH HAS BEEN PART OF COMMUNITY HEALTH NEEDS ASSESSMENTS SINCE OUR FIRST PROCESS IN 2013. AT KSB HOSPITAL, WE OFFER BOTH INPATIENT AND OUTPATIENT BEHAVIORAL HEALTH SERVICES. WE ALSO PARTNER WITH STRONG LOCAL PROVIDERS LIKE SINNISSIPPI CENTERS, A MULTI-COUNTY BEHAVIORAL HEALTH AND SUBSTANCE USE DISORDER SERVICE PROVIDER. TOGETHER WE OFFER BEHAVIORAL HEALTH SCREENINGS IN PRIMARY CARE OFFICES AND THE EMERGENCY DEPARTMENT. WE ALSO CREATED THE ROLE OF MENTAL HEALTH CRISIS PREVENTIONIST TO BE TRAINED AND READY TO RESPOND WITH DE-ESCALATION TECHNIQUES AND SUPPORT PATIENT AND STAFF SAFETY.WE HAVE INVESTED IN TELEHEALTH EQUIPMENT, IMPLEMENTING BEHAVIORAL HEALTH PRESCREENING TOOLS. REMOTE TELEHEALTH PROVIDERS HELP ENSURE CONTINUITY OF SERVICES IN OUR COMMUNITY. WE ALSO MADE SIGNIFICANT CAPITAL INVESTMENTS TO IMPROVE PATIENT SAFETY WITHIN THE INPATIENT UNIT.STILL TODAY, SURVEYS INDICATE WIDESPREAD NEED FOR BEHAVIORAL HEALTH SERVICES, ESPECIALLY WITH THE IMPACT OF THE OCVID 19 PANDEMIC. MORE THAN 70% OF SURVEY RESPONDENTS LISTED MENTAL HEALTH ISSUES AS THE NUMBER HEALTH ISSUE IN LEE COUNTY. 60% OF RESPONDENTS INDICATED THAT THEY OR SOMEONE IN THEIR HOUSEHOLD HAD EXPERIENCED ANXIETY IN THE PAST YEAR, AND 55% ANSWERED AFFIRMATIVELY FOR DEPRESSION. FURTHER, 21% LISTED BEING AFFECTED BY POST TRAUMATIC STRESS DISORDER WITH 19% THAT INDICATED THEY HAVE THOUGHT ABOUT OR ATTEMPTED SUICIDE.IMPLEMENTATION PLAN1. WE PARTNERED WITH SIU SCHOOL OF MEDICINE TO SHARE MARKETING MATERIALS IN OUR CLINICS ON THEIR FARM FAMILY RESOURCE INITIATIVE. THIS PROVIDES RESOURCES FOR ILLINOIS FARM FAMILIES FOR MENTAL AND PHYSICAL HEALTH NEEDS.2. PARTNERED WITH UNIVERSITY OF ILLINOIS EXTENSION TO PROVIDE MONTHLY BRAIN EXERCISE CLASSES. THE CLASS SIZE RANGED FROM 4-12 PARTICIPANTS EACH MONTH. WE PROVIDED CONFERENCE ROOM SPACE AND PROMOTED IN THE COMMUNITY.3. COPING SKILLS GROUP STARTED TO INCREASE ACCESS TO BEHAVIORAL HEALTH SERVICES FOR THE COMMUNITY. THE GROUP MEETS WEEKLY IN CONFERENCE ROOM AT THE HOSPITAL ON MONDAY AND AVERAGES 6-8 PARTICIPANTS.4. THE INTENSIVE OUTPATIENT PROGRAM (IOP) WAS STARTED AND IS NOW ON HOLD DUE TO GRADUATION OF PATIENTS AND TURNOVER IN STAFFING. IT WAS SUCCESSFUL AND WILL BE STARTED BACK.5. PARTICIPATED IN STOP THE STIGMA WALK. BEHAVIORAL HEALTH HAD A BOOTH WITH INFORMATION AND RESOURCES FOR PARTICIPANTS. TURNOUT WAS LOW THIS YEAR WITH AROUND 40 PARTICIPANTS.HEART DISEASE:BASED ON CDC WONDER DATA, HEART DISEASE IS A CONDITION THAT NEEDS ADDITIONAL ATTENTION. HEART DISEASE IS THE LEADING CAUSE OF DEATH IN LEE COUNTY, AVERAGE ONE HUNDRED DEATHS PER YEAR, WHICH ACCOUNTS FOR 24% OF ALL RESIDENT DEATHS.THE CRUDE DEATH RATE DUE TO HEART DISEASE IS 42% ABOVE THE NATIONAL RATE AND WHEN ADJUSTED FOR AGE IS 14% ABOVE THE NATIONAL RATE. ADDITIONALLY, THE DEATH RATE IS 7.7% HIGHER THAN A DECADE AGO. 19% OF THE COUNTY'S HEART DISEASE DEATHS OCCUR TO AGES UNDER 65 YEARS OF AGE, WITH 40% TO THOSE OVER 85.KSB OFFERS SERVICES FOR CARDIOLOGY, IN ADDITION TO PROVIDING CATH LAB PROCEDURES. CARDIAC REHAB, PHASES TWO & THREE ARE OFFERED AT KSB FOR PATIENTS RECOVERING FROM CARDIAC PROCEDURES. CARDIAC SCORING IS ALSO OFFERED TO THE COMMUNITY WITHOUT A PHYSICIAN REFERRAL.IMPLEMENTATION PLAN1. HOSTED A PERIPHERAL ARTERY DISEASE HEALTH FAIR IN SEPTEMBER. INFORMATION PROVIDED BY CARDIOLOGY, WOUND CENTER, MEDICAL GROUP AND DIETITIANS. FARI SAW ABOUT 100 PARTICIPANTS.2. PARTICIPATED IN SENIOR FAIRS IN STERLING AND OREGON. SHARED INFORMATION ON CARDIOLOGY DEPARTMENT AND PERIPHERAL ARTERY DISEASE. STERLING SENIOR FAIR HAD OVER 200 PARTICIPANTS AND OREGON SENIOR FAIR HAD AROUND 100 PARTICIPANTS.3. SKMC CARDIOLOGIST, DR. EL BZOUR PROVIDED A VIRTUAL PRESENTATION ON SOCIAL MEDIA ON PERIPHERAL ARTERY DISEASE. THE PRESENTATION HAD OVER 6,000 VIEWS ON SOCIAL MEDIA.4. PROVIDE FREE BLOOD PRESSURE CHECKS IN DIXON AND POLO. THE DIXON LOCATION SEES AND AVERAGE OF 5-6 PARTICIPANTS ON A WEEKLY BASIS. THE POLO LOCATION IS TWICE A MONTH AND SEES AN AVERAGE OF 6-8 PARTICIPANTS.OBESITY & PHYSICAL INACTIVITYAGAIN, IN THE 2022 COMMUNITY HEALTH NEEDS ASSESSMENT, BOTH SURVEY AND HEALTH INDICATOR DATA SHOW THAT RESIDENTS OF LEE COUNTY EXPERIENCE OBESITY OR BEING OVERWEIGHT AT RATES THAT EXCEED STATE AND NATIONAL AVERAGES. SURVEY RESPONSES INDICATE THAT THIS IS THE THIRD MOST UNHEALTHY BEHAVIOR THAT HAS THE GREATEST IMPACT ON THE OVERALL COMMUNITY HEALTH IN LEE COUNTY. 71% OF PEOPLE HAVE PERSONAL OR FAMILY EXPERIENCE WITH BEING OBESE OR OVERWEIGHT. COUNTY HEALTH DATA SHOWS 34.9% OBESITY AND 36.3% OVERWEIGHT, COMPARED TO 31.64% OBESE AND 34.1% OVERWEIGHT AT THE STATE LEVEL.THE INCIDENCE OF OBESE, OVERWEIGHT, OR INACTIVE RESIDENTS PRESENTS SIGNIFICANT HEALTH CHALLENGES, INCLUDING HIGH BLOOD PRESSURE AND CHOLESTEROL, DIABETES, AND MANY OTHER ASSOCIATED CLINICAL ISSUES.KSB WILL CONTINUE TO OFFER AND SUPPORT LOCAL OPPORTUNITIES FOR PHYSICAL ACTIVITY AND EXERCISE. KSB IS A LEAD SPONSOR OF THE ANNUAL REAGAN 5K RUN DURING THE DIXON PETUNIA FESTIVAL, WHICH ALSO INCLUDES THE KSB CORPORATE CHALLENGE FOR EMPLOYER-BASED TEAM COMPETITION.KSB WILL ALSO SPONSOR A NEW TEAM-BASED WEIGHT LOSS COMPETITION CALLED THE HEALTHYWAGE JACKPOT CHALLENGE, WHICH INCLUDES ACCESS TO AN APP WITH SUPPORT, MOTIVATION, AND MINI-CHALLENGES TO ENGAGE TEAM MEMBERS IN HEALTHY WEIGHT LOSS GOALS. KSB IS THE PRESENTING SPONSOR OF THE KSB WELLNESS CENTER EXERCISE FACILITY IN THE DIXON FAMILY YMCA, WITH DONATIONS TO PURCHASE NEW EXERCISE AND WEIGHT EQUIPMENT. KSB CLINICIANS ALSO OFFER A 'PRESCRIPTION' FOR THE DIXON FAMILY YMCA, THE NASH RECREATION CENTER, AND ANYTIME FITNESS, WHICH PROVIDES A FREE TRIAL TO RESIDENTS LOOKING TO START NEW HEALTHY HABITS. A REGISTERED DIETITIAN HOST ONE-ON-ONE NUTRITION AND FITNESS CONSULTATIONS WITH LOCAL PATIENTS. KSB SPONSORED A DISC GOLF SET GIVEAWAY CONJUNCTION WITH THE DIXON CITY MARKET EVENTS.IMPLEMENTATION PLAN1. SPONSORED A WEIGHT LOSS CHALLENGE WITH HEALTHY WAGE WITH 5 TEAMS AND TOTAL OF 20 PEOPLE. THE TEAMS SUCCESSFULLY LOST 6% OF BODY WEIGHT DURING THE 12 WEEK CONTEST. THIS NUMBER OF TEAMS AND PARTICIPATION IS DOWN FROM PREVIOUS YEARS. THIS WAS THE 7TH YEAR HAVING THE CONTEST, SO THINK IT HAS RUN ITS COURSE AND LOOKING FOR A NEW PROGRAM IN 2026.2. PARTNERSHIP WITH DIXON FAMILY YMCA ON A PRESCRIPTION FOR EXERCISE PROGRAM. PROVIDERS HAVE PRESCRIPTION PADS FOR EXERCISE THAT THEY CAN WRITE FOR PATIENTS THAT WILL GIVE THEM A FREE 30 DAY MEMBERSHIP WITH THE DIXON FAMILY YMCA. THIS PROGRAM IS ALSO AROUND 8 YEARS OLD AND SEES AND AVERAGE OF 1-2 PATIENTS TAKE ADVANTAGE A MONTH.3. PARTNERED WITH DIXON PARK DISTRICT TO GIVE IN PERSON PRESENTATIONS ON PHYSICAL ACTIVITY. PROVIDERS FROM FAMILY HEALTH CENTER, PHYSICAL THERAPY AND PODIATRY HAVE GIVEN PRESENTATIONS. PARTICIPATION HAS BEEN LOW FOR THE IN-PERSON PRESENTATIONS FROM 2-10 PARTICIPANTS.4. PROVIDED EDUCATIONAL INFORMATION ON PHYSICAL ACTIVITY AT DIXON CITY MARKET TO PARTICIPANTS AT OUR BOOTH. CITY MARKET IS WEEKLY IN THE SUMMER JUNE-AUGUST. THE MARKET SEES OVER 1,000 PARTICIPANTS WEEKLY.5. SPONSORED THE REAGAN RUN 5K IN DIXON. RACE HAD OVER 1,000 WALKERS AND RUNNERS. PROVIDE 1ST AID TENT AT RACE STAFFED BY OUR PODIATRY DEPARTMENT. THEY PROVIDE ANY FIRST AID AND GIVE EDUCATION ON PREVENTION AND TREATMENT OF INJURIES RELATED TO EXERCISE. KATHERINE SHAW BETHEA HOSPITAL PART V, SECTION B, LINE 13B: STATE REGULATIONS ARE CONSIDERED IN DETERMINING ELIGIBILITY FOR FINANCIAL ASSISTANCE. PART V, LINE 16 C PLAIN LANGUAGE SUMMARY WEBSITE:HTTPS://WWW.OSFHEALTHCARE.ORG/PATIENTS-VISITORS/BILLING-INSURANCE/FINANCIAL-ASSISTANCEDIRECT LINK TO PLAIN LANGUAGE SUMMARY:HTTPS://OSF-P-001.SITECORECONTENTHUB.CLOUD/API/PUBLIC/CONTENT/55437BB7863748409B90FCEA2BE2852F?V=30303D27 PART V, LINE 16 A FINANCIAL ASSISTANCE POLICY WEBSITE:HTTPS://WWW.OSFHEALTHCARE.ORG/PATIENTS-VISITORS/BILLING-INSURANCE/FINANCIAL-ASSISTANCE/APPLY-FINANCIAL-ASSISTANCEDIRECT LINK TO THE FINANCIAL ASSISTANCE POLICY:HTTPS://OSF-LCMMC.POLICYSTAT.COM/POLICY/TOKEN_ACCESS/65A974F7-7575-405E-B730-45D6F6C16368/ PART V, LINE 16 B FINANCIAL ASSISTANCE APPLICATION WEBSITE:HTTPS://WWW.OSFHEALTHCARE.ORG/PATIENTS-VISITORS/BILLING-INSURANCE/FINANCIAL-ASSISTANCE/APPLY-FINANCIAL-ASSISTANCEDIRECT LINK TO THE FINANCIAL ASSISTANCE APPLICATION:HTTPS://OSF-P-001.SITECORECONTENTHUB.CLOUD/API/PUBLIC/CONTENT/57118E85E1F8428A976CBB73FE254B8E?V=D75F5AB3READERS USING THIS INFORMATION TO ACCESS THE FORMS ONLINE SHOULD FORMAT THE URL WITH LOWERCASE LETTERS WHEN COPYING AND PASTING THE DIRECT LINKS. PART V, LINE 22C THE ORGANIZATION UTILIZES THE "LOOK-BACK METHOD" DESCRIBED IN TREAS. REG. 1.501(R)-5(B)(3), USING THE PRIOR TWELVE-MONTH CALENDAR YEAR FOR ITS CALCULATIONS. THE ORGANIZATION CALCULATES ITS AMOUNTS GENERALLY BILLED AGB PERCENTAGES AS PRESCRIBED BY TREAS. REG. 1.501(R)-5(B)(3)(I). 9 1 - COMMERCE TOWERS 215 EAST FIRST STREET DIXON IL 61021 PHYSICIAN CLINIC 2 - TOWN SQUARE CENTER 102 S HENNEPIN AVENUE DIXON IL 61021 PHYSICIAN CLINIC 3 - KSB OREGON CLINIC 1307 WASHINGTON OREGON IL 61061 PHYSICIAN CLINIC 4 - EDWARDS CLINIC 144 NORTH COURT DIXON IL 61021 PHYSICIAN CLINIC 5 - AMBOY CLINIC 305 EAST JOE DRIVE AMBOY IL 61310 PHYSICIAN CLINIC 6 - KSB EYE & VISION CARE 511 PALMYRA STREET DIXON IL 61021 PHYSICIAN CLINIC 7 - POLO CLINIC 1107 SOUTH DIVISION AVENUE POLO IL 61064 PHYSICIAN CLINIC 8 - ASHTON CLINIC 707 S MAIN STREET ASHTON IL 61006 PHYSICIAN CLINIC 9 - PHYSICIANS IMMEDIATE CARE 1672 SOUTH GALENA AVENUE DIXON IL 61021 PHYSICIAN CLINIC PART I, LINE 3C: FINANCIAL ASSISTANCE IS DETERMINED BASED ON FAMILY INCOME, ASSETS AND LIABILITIES, INSURANCE STATUS, AND QUALIFICATION FOR OTHER AVAILABLE ASSISTANCE PROGRAMS. INDIVIDUALS MAY QUALIFY FOR A PRESUMPTIVE DETERMINATION BASED ON HOMELESSNESS, DECEASED WITH NO ESTATE, MENTAL INCAPACITATION WITH NO ONE TO ACT ON THE PATIENT'S BEHALF, MEDICAID ELIGIBILITY, AND INCARCERATION IN A PENAL INSTITUTION. PART I, LINE 7: IT IS KSB HOSPITAL'S POLICY NOT TO WITHHOLD OR DENY ANY REQUIRED MEDICAL CARE AS A RESULT OF A PATIENT'S LACK OF THE ABILITY TO PAY. THE COSTING METHODOLOGY USED TO CALCULATE THE AMOUNTS IN THE ABOVE TABLE WAS DERIVED FROM THE 2024 CALCULATED COST TO CHARGE RATIO USING THE IRS WORKSHEET 2. PART I, LINE 7G: FOR 2024, SUBSIDIZED HEALTH SERVICES INCLUDED A DIABETIC CLINIC AND EMERGENCY MEDICAL SERVICES. PART II, COMMUNITY BUILDING ACTIVITIES: KSB HOSPITAL STRIVES TO BRING THE BEST INTEGRATED, QUALITY, AND COST-EFFECTIVE CARE AND INNOVATIVE TECHNOLOGY TO OUR SERVICE AREA. KSB SUPPORTS OTHER LOCAL NON-PROFITS THROUGH CONTRIBUTIONS OF DOLLARS AND HOURS. WE SUPPORT THE LOCAL ECONOMIC DEVELOPMENT ORGANIZATIONS TO BRING EMPLOYERS AND JOBS TO OUR SERVICE AREA. KSB IS A SUPPORTER OF THE ADOPT-A-ROAD PROGRAM. OUR EMPLOYEES CLEAN UP A STRETCH OF ILLINOIS ROUTE 2 TWICE A YEAR TO HELP IMPROVE AND PRESERVE OUR ENVIRONMENT. KSB SUPPORTS WORKFORCE DEVELOPMENT THROUGH THE JUNIOR ACHIEVEMENT PROGRAM. HOURS AND DOLLARS ARE DONATED TO THIS PROGRAM. KSB ALSO SUPPORTS HABITAT FOR HUMANITY TO PROVIDE AFFORDABLE HOUSING IN OUR SERVICE AREA. MANY OF OUR EMPLOYEES DONATED THEIR OWN TIME TO THIS ORGANIZATION. KSB HAS SUPPORTED HABITAT FOR HUMANITY WITH CASH DONATIONS. PART III, LINE 2: A PATIENT'S ACCOUNT IS WRITTEN OFF TO BAD DEBT AFTER 180 DAYS. ANY PATIENT PAYMENTS AND DISCOUNTS ARE DEDUCTED FROM GROSS CHARGES PRIOR TO THE WRITE-OFF PART III, LINE 3: THIS PORTION OF BAD DEBT IS RELATED TO ACCOUNTS THAY MAY HAVE QUALIFIED FOR THE HOSPITAL'S FINANCIAL ASSISTANCE POLICY. THE METHODOLOGY USED IS BASED ON HISTORICAL INFORMATION. THIS PORTION OF BAD DEBT WOULD HAVE BEEN INCLUDED IN CHARITY CARE HAD THE PATIENT COMPLETED THE NECESSARY PAPERWORK. PART III, LINE 4: FOOTNOTE #2 IS LOCATED ON PAGE 16 OF THE ATTACHED AUDITED FINANCIAL STATEMENTS AND BRIEFLY DESCRIBES THE PROVISION FOR BAD DEBTS RELATED TO UNINSURED PATIENTS. BAD DEBT IS LISTED AS A DEDUCTION FROM REVENUE. THIS TREATEMENT IS CONSISTENT WITH THE HFMA PRINCIPLES AND PRACTICES BOARD STATEMENT NO. 15 AND WITH THE AICPA AUDIT AND ACCOUNTING GUIDE FOR HEALTHCARE ORGANIZATIONS. PART III, LINE 8: KSB HOSPITAL IS A SMALL 80 BED HOSPITAL LOCATED IN RURAL LEE COUNTY IN NORTHERN ILLINOIS. IT WAS ESTIMATED THAT THE POPULATION OF LEE COUNTY WAS 33,654 IN 2023. 21.2% OF THE POPULATION WAS AGE 65 AND OLDER. THE CENSUS BUREAU ESTIMATED THAT 11.7% OF LEE COUNTY WAS BELOW THE POVERTY LINE. IN 2021, 42% OF OUR PAYOR MIX WAS MEDICARE RECIPIENTS. AS A HEALTHCARE PROVIDER WE REALIZE THAT SUBSTANTIAL SHORTFALLS ARISE FROM PAYMENTS THAT ARE LESS THAN WHAT IT COSTS TO PROVIDE CARE OR SERVICE AND DO NOT INCLUDED ANY AMOUNTS THAT RESULT FROM INEFFICIENCIES OR POOR MANAGEMENT. KSB HOSPITAL ACCEPTS ALL MEDICARE PATIENTS KNOWING THAT THERE MAY BE SHORTFALLS, THEREFORE IT HAS TAKEN THE POSITION THAT THEY SHOULD BE COUNTED AS PART OF THE COMMUNITY BENEFIT. ADDITIONALLY, IT IS IMPLIED IN THE INTERNAL REVENUE SERVICE REVENUE RULING 69-545 THAT TREATING MEDICARE PATIENTS IS A COMMUNITY BENEFIT. REVENUE RULING 69-545, WHICH ESTABLISHED THE COMMUNITY BENEFIT STANDARD FOR NON-PROFIT HOSPITALS, STATES THAT IF A HOSPITAL SERVES PATIENTS WITH GOVERNMENTAL HEALTH BENEFITS, INCLUDING MEDICARE, THEN THIS IS AN INDICATION THAT THE HOSPITAL OPERATES TO PROMOTE THE HEALTH OF THE COMMUNITY. BASED ON KSB HOSPITAL'S FILED 2024 MEDICARE COST REPORT THE MEDICARE ALLOWABLE COSTS FOR 2024 WERE $25,025,798 AND PAYMENTS RECEIVED FROM MEDICARE WERE $16,617,394. WE BELIEVE THAT THE SHORTFALL OF $8,408,404 SHOULD BE CONSIDERED COMMUNITY BENEFIT. PART III, LINE 9B: AFTER THREE STATEMENTS (90) DAYS WITH NO PAYMENT FROM PATIENT, THE ACCOUNT IS ELIGIBLE FOR COLLECTION ACCOUNTS UNDER $500 ARE TO BE PAID OFF IN 6 MONTHS AND OVER $500 PAID OFF WITHIN ONE YEAR. ACCOUNTS THAT HAVE BEEN APPROVED FOR FINANCIAL ASSISTANCE ARE NOT SENT TO COLLECTION. PART VI, LINE 2: IN THE 2019 CHNA, WE IDENTIFIED ACCESS TO CARE/TRANSPORTATION AS A KEY PRIORITY AND ENACTED AN IMPLEMENTATION PLAN TO MEET THE NEED. THIS PLAN INCLUDED KSB PARTNERING WITH THE LEE OGLE TRANSPORTATION SERVICE (LOTS) AND PROVIDING TELEHEALTH SERVICES TO ALLEVIATE THE NEED FOR IN OFFICE VISITS. THIS BECAME LESS OF AN ISSUE WITH THE IMPACT OF THE COVID 19 PANDEMIC. WE CONTINUE TO PARTICIPATE IN ACCESS TO CARE EFFORTS. WHILE THERE IS STILL ROOM FOR IMPROVEMENT, KSB WILL REMAIN ENGAGED IN FINDING SOLUTIONS. AS LOW NUMBERS IN THE DATA RESPONDED THAT THIS WAS AN ISSUE; IT WAS NOT SELECTED AMONG THE TOP THREE ITEMS IN THIS YEAR'S CHNA.ADDITIONALLY, WHILE KSB WILL ALSO BE ENGAGED FROM A CLINICAL AND EDUCATIONAL PERSPECTIVE IN TOBACCO USE AND E-CIGARETTE USE, WE DID NOT SCORE THIS IN THE TOP THREE BECAUSE OF THE NUMBER OF OTHER COMMUNITY ORGANIZATIONS WHO ARE SHARING RESPONSIBILITY FOR INTERVENTION IN THIS AREA. THE LEE COUNTY HEALTH DEPARTMENT, LOCAL SCHOOL DISTRICTS, LAW ENFORCEMENT, AND PARENT AND STUDENT ADVOCATES ARE WORKING TO EDUCATE AND PREVENT TOBACCO AND E-CIGARETTE USAGE. KSB WILL PARTICIPATE IN THESE EFFORTS EVEN THOUGH THIS IS NOT ONE OF THE TOP THREE PRIORITIES LISTED IN THIS CHNA.ALSO, WHILE KSB WILL BE ENGAGED FROM A CLINICAL AND EDUCATIONAL PERSPECTIVE IN SUBSTANCE USE DISORDER, WE DID NOT SCORE THIS IN THE TOP THREE BECAUSE OF THE NUMBER OF OTHER COMMUNITY ORGANIZATIONS WHO ARE SHARING RESPONSIBILITY FOR INTERVENTION IN THIS AREA. SINNISSIPPI CENTERS, RECOVERY FAMILY WORKPLACE ILLINOIS, LOCAL SCHOOL DISTRICTS, LAW ENFORCEMENT, LOCAL HEALTH DEPARTMENT AND PARENT AND STUDENT ADVOCATES ARE WORKING TO EDUCATE AND PREVENT SUBSTANCE USE DISORDER. KSB WILL PARTICIPATE IN THESE EFFORTS EVEN THOUGH THIS IS NOT ONE OF THE TOP THREE PRIORITIES LISTED IN THIS CHNA. PART VI, LINE 3: KSB HOSPITAL STRIVES TO EDUCATE OUR PATIENTS OF THEIR ELIGBILITY FOR ASSISTANCE UNDER FEDERAL, STATE, AND LOCAL PROGRAMS. PATIENTS ARE ALSO INFORMED OF OUR CHARITY CARE POLICY. EVERY SELF PAY PATIENT THAT COMES TO THE HSOPITAL IS GIVEN A CHARITY APPLICATION AND OFFERED ASSISTANCE IN HELPING THEM COMPLETE THE APPLICATION. NOTICES ABOUT ASSISTANCE PROGRAMS ARE POSTED IN THE REGISTRATION AREAS AND THE INFORMATION IS ALSO INCLUDED IN THE PATIENT'S STATEMENT AND ON THE KSB WEBSITE. A PATIENT ADVOCATE VISITS EACH INPATIENT WITH A NOTICE OF THEIR INSURANCE BENEFITS AND THEN COUNSELS EACH PATIENT OF ADDITIONAL OPTIONS FOR ASSISTANCE. PART VI, LINE 4: KSB HOSPITAL SERVES LEE COUNTY, A RURAL COUNTY IN NORTHWESTERN ILLINOIS ONE HUNDRED MILES WEST OF CHICAGO AND FORTY-FIVE MILES SOUTHWEST OF ROCKFORD. ACCORDING TO THE U.S. CENSUS BUREAU, THE 2022 POPULATION OF LEE COUNTY WAS ESTIMATED AT 33,848. THE COMMUNITIES OF LEE AND WESTERN OGLE COUNTY COMPRISE THE KSB HOSPITAL PRIMARY SERVICE AREA. THIS AREA SAW A POPULATION DECLINE OF 0.7% BETWEEN 2021 AND 2022, A PERIOD DURING WHICH THE STATE DECLINED BY 0.9%. DIXON IS THE COUNTY SEAT AND THE LARGEST COMMUNITY IN LEE COUNTY WITH AN ESTIMATED POPULATION OF 15,380. LEE COUNTY RACE AND ETHNICITY SHOWS 90.6% WHITE, NOT HISPANIC; 6.4% BLACK; 7.2% HISPANIC OR LATINO; WITH NO OTHER RACE ABOVE 1%. LEE COUNTY COVERS 725 SQUARE MILES. PUBLIC TRANSPORTATION IS AVAILABLE THROUGH THE LEE/OGLE TRANSPORTATION SYSTEM AND PRIVATE CAB COMPANIES. ACCORDING TO THE ILLINOIS DEPARTMENT OF EMPLOYMENT SECURITY, THE 2021 ANNUAL AVERAGE UNEMPLOYMENT RATE FOR LEE COUNTY WAS 4.0%, COMPARABLE TO NORTHWEST ILLINOIS OVERALL AND COMPARABLE TO THE STATE AVERAGE OF 4.6%. WITH A MEDIAN HOUSEHOLD IN INCOME OF $60,542, LEE COUNTY IS LOWER THAN THE STATE AVERAGE OF $78,020. LEE COUNTY PER CAPITA INCOME IS $30,461, BELOW THE STATE AVERAGE OF $39,571. THE PROPORTION OF LEE COUNTY RESIDENTS, 10.7%, LIVING BELOW THE FEDERAL POVERTY LEVEL IS LOWER THAN THE STATE AVERAGE OF 12.1%. UNINSURED (1.5%) AND MEDICAID (20.68%) PATIENTS COMPRISE A TOTAL OF 22.2% OF OUR PAYER MIX FOR 2022. KATHERINE SHAW BETHEA HOSPITAL IS THE SOLE HOSPITAL IN THE COMMUNITY OF DIXON. THE AREA OF DIXON DOES NOT CONTAIN ANY FEDERALLY DESIGNATED MEDICALLY UNDERSERVED AREAS OR POPULATIONS. PART VI, LINE 5: IN ADDITION TO MEDICAL CARE, SOUND LEADERSHIP AND MANAGEMENT ARE CRITICAL PARTS OF ANY GOOD HOSPITAL. AT KSB HOSPITAL, OUR MISSION AND VISION ARE PUT INTO ACTION EVERY DAY BY AN ADMINISTRATIVE TEAM, A BOARD OF DIRECTORS AND THE MEDICAL STAFF. THESE LEADERS OVERSEE THE HOSPITAL'S OPERATIONS AND MAKE VALUES-BASED DECISIONS THAT ARE CONSISTENT WITH OUR MISSION. MOST OF THE BOARD OF DIRECTORS IS COMPRISED OF PERSONS WHO RESIDE IN OUR SERVICE AREA, WHO ARE NEITHER EMPLOYEES NOR INDEPENDENT CONTRACTORS OF THE ORGANIZATION. KSB HAS CLINICS IN 10 LOCATIONS AND THOSE COMMUNITIES ARE WELL REPRESENTED ON THE KSB BOARD. FOR EXAMPLE, COLLEEN HENKLE IS FROM THE AMBOY AREA AND LYNETTE KNODLE WORKS IN OREGON-THESE ARE TWO LOCALES WHERE KSB HAS CLINICS THAT SERVE THOSE COMMUNITIES. OFFERING MORE THAN 60 PHYSICIANS IN A VARIETY OF DISCIPLINES, KSB MEDICAL GROUP ENHANCES HEALTHCARE OPTIONS FOR SAUK VALLEY RESIDENTS. THIS MULTI-SPECIALTY PRACTICE HAS BROUGHT TOGETHER PHYSICIANS WHO ARE NEW TO THE AREA AND THOSE WHO HAVE SPENT AN ENTIRE CAREER IN OUR HOMETOWNS. KSB ALSO EXTENDS AN OPPORTUNITY TO ALL QUALIFIED PHYSICIANS SEEKING PRIVILEGES IN THE SAUK VALLEY SERVICE AREA. KSB UTILIZES ALL SURPLUS FUNDS FOR IMPROVEMENTS IN PATIENT CARE, INNOVATIVE TECHNOLOGY, AND OUR PHYSICAL PROPERTIES. THE LAST YEAR HAS SEEN SIGNIFICANT GROWTH WITHIN AND OUTSIDE THE WALLS OF KSB. IN 2023, WE CONTINUED UPDATING PATIENT ROOMS TO INCLUDE THE LATEST IN TECHNOLOGY AND EQUIPMENT. OUR EDUCATION DEPARTMENT OFFERS A VARIETY OF CLASSES TO EMPLOYEES AND THE PUBLIC. OUR COMMUNITY WELLNESS DEPARTMENT COLLABORATES WITH OTHER COMMUNITY ORGANIZATIONS TO BRING A VARIETY OF HEALTH-RELATED AND WELLNESS PROGRAMS TO THE COMMUNITY. THESE OPPORTUNITIES ARE AN OUTREACH TO THE COMMUNITY THAT ARE FUN AND EDUCATIONAL. A LOOK AROUND AT THE VARIOUS DEPARTMENTS THAT MAKE UP KSB HOSPITAL REVEALS A CONTEMPORARY MEDICAL FACILITY THAT IS PROUD TO OFFER PATIENTS THE FINEST SERVICE POSSIBLE YET IS NEVER CONTENT TO REST ON ITS PAST ACCOMPLISHMENTS. 1 DIXON FAMILY YMCA 110 N GALENA AVENUE DIXON IL 61021 362487927 501(C)(3) 20000 0 GENERAL OPERATING SUPPORT HOME OF HOPE CANCER WELLNESS CENTERS 1637 PLOCK ROAD DIXON IL 61021 010743626 501(C)(3) 15000 0 GENERAL OPERATING SUPPORT 2 2 SCHOLARSHIP 6 6000 FMV SCHOLARSHIPS TO INDIVIDUALS TO ASSIST IN REACHING PROFESSIONAL GOALS IN MEDICAL FIELDS PART I, LINE 2: GRANTS TO OTHER ORGANIZATIONS ARE NOT MONITORED. X X X X X 0 0 0 0 0 0 0 0 0 MONTHER ELBZOUR MD PHYSICIAN 1299155 0 301324 0 138 0 12144 0 39658 0 1652419 0 0 0 SOHAIL HANIF MD PHYSICIAN 1415728 0 9012 0 396 0 11312 0 39658 0 1476106 0 0 0 ABDULHAMID ALKHALAF PHYSICIAN 527045 0 394202 0 0 0 14407 0 39658 0 975312 0 0 0 FADI MOHAMAD MUSTAPHA PHYSICIAN 669707 0 228539 0 138 0 14490 0 39658 0 952532 0 0 0 KURT CROWE MD PHYSICIAN 621032 0 176676 0 258 0 15626 0 44290 0 857882 0 0 0 DAVID SCHREINER CEO AND BOARD MEMBER 612106 0 8000 0 3517 0 15898 0 34264 0 673785 0 0 0 AUSTIN FRAZIER VP-CHIEF FINANCIAL OFFICER 361052 0 26000 0 540 0 16928 0 44290 0 448810 0 0 0 RAY SHARP VP-CHIEF INFORMATION OFFIC 286590 0 11000 0 3564 0 15247 0 44290 0 360691 0 0 0 LINDA CLEMEN VP-CHIEF NURSING OFFICER 283492 0 11000 0 3564 0 15127 0 20686 0 333869 0 0 0 RYAN MILLER VP-CHIEF QUALITY OFFICER 249359 0 11000 0 810 0 13185 0 44174 0 318528 0 0 0 DREW FENNER VP-CHIEF PEOPLE OFFICER 251973 0 11000 0 540 0 13289 0 14340 0 291142 0 0 0 FORM 990, PART VI, SECTION A, LINE 1A THE EXECUTIVE COMMITTEE SHALL CONSIST OF THE BOARD CHAIRPERSON AS CHAIRPERSON OF THE COMMITTEE, THE VICE CHAIRPERSON, THE SECRETARY, THE TREASURER AND THE CHIEF EXECUTIVE OFFICER. THE EXECUTIVE COMMITTEE SHALL HAVE THE POWER TO TRANSACT ALL REGULAR BUSINESS OF THE HOSPITAL DURING THE INTERIM BETWEEN BOARD MEETINGS PROVIDED ANY ACTION TAKEN SHALL NOT CONFLICT WITH THE POLICIES AND EXPRESSED WISHES OF THE BOARD. FORM 990, PART VI, SECTION A, LINE 7A BOARD MEMBERS ARE ELECTED BY A MAJORITY VOTE OF THE CITY COUNCIL OF THE CITY OF DIXON, ILLINOIS. IF TWO-THIRDS OR MORE OF THE BOARD POSITIONS ARE VACATED IN ANY ONE YEAR, THE MAYOR OF THE CITY OF DIXON, ILLINOIS, WOULD HAVE THE POWER TO APPOINT ALL BOARD MEMBERS TO FILL SUCH VACANCIES. FORM 990, PART VI, SECTION A, LINE 7B THE MAYOR MAY, BY AND WITH THE CONSENT OF THE CITY COUNCIL, REMOVE ANY DIRECTOR FOR MISCONDUCT OR NEGLECT OF DUTY. FORM 990, PART VI, SECTION B, LINE 11B FULL COMPLETE COPIES OF THE FORM 990 ARE PROVIDED TO THE ENTIRE GOVERNING BODY AND MANAGEMENT PRIOR TO FILING, WITH A REVIEW AT THE BOARD MEETING TO ADDRESS ANY QUESTIONS THAT MAY ARISE. FORM 990, PART VI, SECTION B, LINE 12C ON AN ANNUAL BASIS, A CONFLICT OF INTEREST QUESTIONNAIRE IS DISTRIBUTED TO ALL MEMBERS OF THE GOVERNING BODY AND MANAGEMENT TO IDENTIFY ANY CONFLICTS OF INTEREST. IN ADDITION, ON AN ONGOING BASIS, PRIOR TO EACH BOARD ACTION, EACH VOTING OFFICER IS RESPONSIBLE TO SELF-EVALUATE TO DETERMINE WHETHER A CONFLICT OF INTEREST IS PRESENT. AN INDIVIDUAL WITH A POTENTIAL CONFLICT DISCLOSES THE MATTER TO THE BOARD OR COMMITTEE. AFTER DISCLOSURE OF THE RELEVANT FACTS, THAT INDIVIDUAL LEAVES THE ROOM WHILE THE REMAINING BOARD OR COMMITTEE MEMBERS VOTE ON WHETHER A CONFLICT OF INTEREST EXISTS. IN THE INSTANCE THAT CONFLICT EXISTS, THE NECESSARY PARTIES ARE EXCUSED FROM THE ROOM WHILE THE REMAINING BOARD OR COMMITTEE MEMBERS DISCUSS THE TRANSACTION AND VOTE ON THE MATTER. IF AN INDIVIDUAL FAILS TO DISCLOSE A CONFLICT, THE BOARD WILL TAKE APPROPRIATE DISCIPLINARY AND CORRECTIVE ACTION. FORM 990, PART VI, SECTION B, LINE 15 THE ORGANZATION ENGAGES AN OUTSIDE CONSULTANT TO PROVIDE COMPARABILITY COMPENSATION DATA FOR THE CEO POSITION. THE OUTSIDE CONSULTANT PROVIDES THE BOARD WITH A SUGGESTED RANGE FOR COMPENSATION. THE BOARD AND COMPENSATION COMMITTEE THEN REVIEWS THE INFORMATION RECEIVED AND DETERMINES THE COMPENSATION OF THE CEO WITH LEGAL COUNSEL. THE BOARD APPROVES IN ADVANCE AND DOCUMENTS THE COMPENSATION DETERMINATIONS IN THE BOARD MINUTES ON A TIMELY BASIS. A FIVE YEAR CONTRACT WAS NEGOTATED. THIS CONTRACT IS IN EFFECT FOR 2024. THE VICE PRESIDENTS' (CFO, CNO, CPO(CHIEF PRACTICE OFFICER), CMO AND CAO) COMPENSATION ARE DETERMINED BY PROVIDING THE CEO WITH COMPARABILITY DATA. THE COMPARABILITY DATA IS GATHERED BY THE HUMAN RESOURCES DEPARTMENT. THE CEO DETERMINES THE APPROPRIATE COMPENSATION FOR THE VICE PRESIDENTS AND PRESENTS A REPORT TO THE COMPENSATION COMMITTEE. PHYSCICIAN COMPENSATION IS NEGOTIATED AT THE TIME OF CONTRACT RENEWAL. THE ORGANZATION ENGAGES AN OUTSIDE CONSULTANT TO PROVIDE COMPARABILITY DATA FOR THE PHYSICIANS. FORM 990, PART VI, SECTION C, LINE 19 FINANCIAL STATEMENTS, GOVERNING DOCUMENTS AND CONFLICTS OF INTEREST POLICIES ARE NOT REQUIRED DISCLOSURES PURSUANT TO IRC SECTION 6104. PORTIONS OF THE FINANCIAL STATEMENTS ARE PUBLISHED IN THE ANNUAL REPORT THAT IS MAILED TO THE LOCAL COMMUNITY. THE GOVERNING DOCUMENTS AND CONFLICT OF INTEREST POLICY ARE NOT AVAILABLE TO THE PUBLIC AT THIS TIME. FORM 990, PART IX, LINE 11G REPAIRS AND MAINTENANCE CONTRACTS: PROGRAM SERVICE EXPENSES 2,351,331. MANAGEMENT AND GENERAL EXPENSES 333,036. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 2,684,367. PROFESSIONAL: PROGRAM SERVICE EXPENSES 0. MANAGEMENT AND GENERAL EXPENSES 160. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 160. PURCHASED: PROGRAM SERVICE EXPENSES 15,536,987. MANAGEMENT AND GENERAL EXPENSES 4,796,212. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 20,333,199. RECOGNITION: PROGRAM SERVICE EXPENSES 27,400. MANAGEMENT AND GENERAL EXPENSES 6,584. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 33,984. OTHER: PROGRAM SERVICE EXPENSES 47,974. MANAGEMENT AND GENERAL EXPENSES 54,666. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 102,640. FORM 990, PART XI, LINE 9: CHANGES IN VALUE OF SUBSIDIARIES -190,035. FORM 990, PAGE 12, PART XII, LINE 2C THE PROCESS HAS NOT CHANGED FROM THE PRIOR YEAR. FORM 990, SCHEDULE D, PART V DURING THE 2023 TAX YEAR, THE RESTRICTIONS ON THE ENDOWMENT FUNDS WERE RELEASED, AND AS SUCH, THE FUNDS NO LONGER QUALIFY AS AN ENDOWMENT UNDER ASC 958. THE FUNDS WERE UTILIZED FOR OPERATIONS DURING THE 2023 TAX YEAR. NO FUNDS WERE UTILIZED IN 2024 SO PART V IS BLANK. KSB HOSPITAL FOUNDATION 403 EAST FIRST STREET DIXON IL 61021 841787288 TO RAISE FUNDS TO SUPPORT KSB'S MISSION IL 501(C)(3) LINE 12A, I KATHERINE SHAW BETHEA HOSPITAL 1 KSB VENTURES INC 403 EAST 1ST STREET DIXON IL 61021 465278274 HOLD PARTNERSHIP INVESTMENT IL KATHERINE SHAW BETHEA HOSPITAL C 1.00000 1 0 0 1 0 0 0 0 0 0 0 0 0 1 1 1 0 0 0 0 KSB HOSPITAL FOUNDATION C 951737 FMV