Form990
Click to see attachment
Department of the Treasury
Internal Revenue Service
Return of Organization Exempt From Income Tax
Under section 501(c), 527, or 4947(a)(1) of the Internal Revenue Code (except black lung benefit trust or private foundation)

MediumBullet The organization may have to use a copy of this return to satisfy state reporting requirements.
OMB No. 1545-0047
2010
Open to Public Inspection
A For the calendar year, or tax year beginning 05-01-2010 and ending 04-30-2011
BCheck if applicable:
CName of organization
KISHWAUKEE COMMUNITY HOSPITAL
 
Doing Business As
 
 
Number and street (or P.O. box if mail is not delivered to street address)
ONE KISH HOSPITAL DRIVE
 
Room/suite
City or town, state or country, and ZIP + 4
DEKALB, IL60115
D Employer identification number

23-7087041
E Telephone number

G Gross receipts $ 193,633,562
F Name and address of principal officer:
KEVIN P POORTEN
ONE KISH HOSPITAL DRIVE
DEKALB,IL60115
I
Tax-exempt status: (   ) LeftBullet (insert no.) or
J
Website:MediumBullet
WWW.KISHHOSPITAL.ORG
H(a)
Is this a group return for
affiliates?
H(b)
Are all affiliates included?
If "No," attach a list. (see instructions)
H(c)
Group exemption number MediumBullet  
K Form of organization:
 
L Year of formation: 1970
M State of legal domicile: IL
Part I
Summary
Activities & Governance 1 Briefly describe the organization’s mission or most significant activities: TO PROVIDE COMPREHENSIVE HEALTH CARE SERVICES, INCLUDING INPATIENT ACUTE AND NONACUTE CARE, AND VARIOUS OUTPATIENT SERVICES IN THE AREA OF DEKALB COUNTY.
2 Check this box MediumBullet
3 Number of voting members of the governing body (Part VI, line 1a) .... 3 3
4 Number of independent voting members of the governing body (Part VI, line 1b) .... 4 2
5 Total number of individuals employed in calendar year 2010 (Part V, line 2a) ... 5 1,136
6 Total number of volunteers (estimate if necessary) .... 6 282
7a Total unrelated business revenue from Part VIII, column (C), line 12 .. 7a 141,780
b Net unrelated business taxable income from Form 990-T, line 34 .. 7b 43,953
Revenues; Prior Year Current Year
8 Contributions and grants (Part VIII, line 1h) ......... 439,308 1,113,923
9 Program service revenue (Part VIII, line 2g) ......... 154,699,731 163,834,645
10 Investment income (Part VIII, column (A), lines 3, 4, and 7d ) .... 2,817,426 2,966,348
11 Other revenue (Part VIII, column (A), lines 5, 6d, 8c, 9c, 10c, and 11e) 1,341,487 1,803,798
12 Total revenue—add lines 8 through 11 (must equal Part VIII, column (A), line 12)................... 159,297,952 169,718,714
Expenses; 13 Grants and similar amounts paid (Part IX, column (A), lines 1–3 )... 581,784 999,268
14 Benefits paid to or for members (Part IX, column (A), line 4) .... 0 0
15 Salaries, other compensation, employee benefits (Part IX, column (A), lines 5–10) 52,062,278 56,726,719
16a Professional fundraising fees (Part IX, column (A), line 11e).... 0 0
b Total fundraising expenses (Part IX, column (D), line 25) MediumBullet5,578    
17 Other expenses (Part IX, column (A), lines 11a–11d, 11f–24f).... 93,398,918 95,690,873
18 Total expenses. Add lines 13–17 (must equal Part IX, column (A), line 25) 146,042,980 153,416,860
19 Revenue less expenses. Subtract line 18 from line 12...... 13,254,972 16,301,854
Net Assets or Fund Balances; Beginning of Current Year End of Year
20 Total assets (Part X, line 16)............ 248,596,359 278,068,882
21 Total liabilities (Part X, line 26)............ 93,032,057 101,229,299
22 Net assets or fund balances. Subtract line 21 from line 20 ..... 155,564,302 176,839,583
Part II
Signature Block
Under penalties of perjury, I declare that I have examined this return, including accompanying schedules and statements, and to the best of my knowledge and belief, it is true, correct, and complete. Declaration of preparer (other than officer) is based on all information of which preparer has any knowledge.
Sign Here
JumboBullet
Signature of officer Date
JumboBullet
Type or print name and title.
Paid Preparer's Use Only Preparer's
signatureBig Right Arrow 		Date
right pointing bullet image Preparer’s taxpayer identification number
(see instructions)
Firm’s name (or yours
if self-employed),
address, and ZIP + 4Big Right Arrow




 		EIN right pointing bullet image
Phone no. right pointing bullet image
May the IRS discuss this return with the preparer shown above? (see instructions) .........
For Privacy Act and Paperwork Reduction Act Notice, see the separate instructions.
Cat. No. 11282Y
Form 990 (2010)
Form 990 (2010)
Page 2
Part III
Statement of Program Service Accomplishments
Check if Schedule O contains a response to any question in this Part III . . . . . . . . . .
1
Briefly describe the organization’s mission: TO PROVIDE COMPREHENSIVE HEALTH CARE SERVICES, INCLUDING INPATIENT ACUTE AND NONACUTE CARE, AND VARIOUS OUTPATIENT SERVICES IN THE AREA OF DEKALB COUNTY. KISHWAUKEE COMMUNITY HOSPITAL (KCH) SERVES ALL PEOPLE WITH SKILL AND COMPASSION WHILE RESPECTING THEIR DIGNITY, RIGHTS, AND CHOICES BY OFFERING ACCESS TO HIGH-QUALITY PREVENTIVE, CURATIVE, AND REHABILITATIVE CARE DELIVERED IN A COST EFFECTIVE MANNER. KISHWAUKEE COMMUNITY HOSPITAL RECOGNIZES THE NEED TO EFFECTIVELY MANAGE RESOURCES FOR PRESENT AND FUTURE GENERATIONS.
2
Did the organization undertake any significant program services during the year which were not listed on
the prior Form 990 or 990-EZ? ....................
If “Yes,” describe these new services on Schedule O.
3
Did the organization cease conducting, or make significant changes in how it conducts, any program services? ..........................
If “Yes,” describe these changes on Schedule O.
4
Describe the exempt purpose achievements for each of the organization’s three largest program services by expenses.
Section 501(c)(3) and 501(c)(4) organizations and section 4947(a)(1) trusts are required to report the amount of grants and allocations to others, the total expenses, and revenue, if any, for each program service reported.
4a (Code:   ) (Expenses $ 128,532,470 including grants of $ 999,268 ) (Revenue $ 165,465,868 )
KISHWAUKEE COMMUNITY HOSPITAL (KCH), LOCATED IN DEKALB, ILLINOIS, SERVES THE RESIDENTS OF DEKALB COUNTY AND THE SURROUNDING AREAS BY OFFERING A NUMBER OF PROGRAMS AND SERVICES FOR COMMUNITY BENEFIT, INCLUDING CHARITY CARE. KISHWAUKEE COMMUNITY HOSPITAL BELIEVES THAT IN ORDER TO BE A TRUE "COMMUNITY" HOSPITAL, WE MUST BE A RESOURCE FOR PREVENTATIVE AND CURATIVE HEALTH INFORMATION, EDUCATION AND SERVICES AND THAT WE MUST SUPPORT THE EFFORTS OF OTHERS WHO ALSO ARE DOING WORK FOR THE COMMUNITY GOOD. DOING SO HELPS BUILD TRUST, RESPECT AND LOYALTY FOR OUR HOSPITAL AND STRENGTHENS OUR ROLE AS A PARTNER IN IMPROVING THE HEALTH OF OUR CITIZENS AND THE QUALITY OF LIFE IN THE COMMUNITIES WE SERVE.THE COMMUNITY BENEFIT OBJECTIVES OF KCH INCLUDE PROGRAMS TO REDUCE GEOGRAPHIC, FINANCIAL, LANGUAGE AND CULTURAL BARRIERS; IMPROVE AND ENHANCE PUBLIC HEALTH; ADVANCE GENERALIZEABLE KNOWLEDGE, AND RELIEVE THE GOVERNMENT BURDEN OF PROVIDING HEALTH SERVICES FOR THE COMMUNITY, UNINSURED AND UNDERINSURED. THIS SECTION ELABORATES ON SEVERAL AREAS: COMMUNITY BENEFIT PATIENT SERVICES, EMERGENCY/DISASTER RESPONSE, CLINICAL EDUCATION, COMMUNITY WELLNESS ACTIVITIES, OTHER COMMUNITY EDUCATION AND OUTREACH, CASH CONTRIBUTIONS AND IN-KIND CONTRIBUTIONS.KISHWAUKEE COMMUNITY HOSPITAL SERVES ALL OF DEKALB COUNTY, IL, AND BORDER COMMUNITIES IN KANE AND OGLE COUNTIES. POPULATION OF THE HOSPITAL'S SERVICE AREA, BASED ON 2010 CENSUS, IS 131,782. THIS GEOGRAPHIC AREA INCLUDES A GROWING HISPANIC POPULATION. A UNIQUE POPULATION IN OUR SERVICE AREA IS NORTHERN ILLINOIS UNIVERSITY STUDENTS (23,850 FALL 2010 ENROLLMENT), INCLUDING FOREIGN STUDENTS AND VISITORS. THE HISPANIC POPULATION IS EXPECTED TO GROW BY 22.62% BY 2016. ACCORDING TO THE AMERICAN COMMUNITY SURVEY, 29.5% OF FAMILIES AND 42.7% OF INDIVIDUALS ARE BELOW THE POVERY LEVEL BASED ON POPULATION ADN HOUSING DATA FROM 2005-2009.COMMUNITY BENEFIT PATIENT SERVICESTHE HOSPITAL OPERATES A NUMBER OF HEALTH SERVICES AT A LOSS FOR THE GOOD OF THE HEALTH, SAFETY AND WELFARE OF OUR PATIENTS AND COMMUNITY. KCH FOCUSED ON THE FOLLOWING COMMUNITY HEALTH NEEDS FOR THE FISCAL YEAR ENDED APRIL 30, 2011:* THE PREVALENCE OF OBESITY IN CHILDREN AND ADULTS* ACCESS TO AFFORDABLE PRIMARY HELTH CARE IN THE DEKALB/SYCAMORE AREA AND OUTLYING RURAL AREA* OUTPATIENT BEHAVIORLA HEALTH SERVICES AT BOTH HOSPITALS* TYPE II DIABETES * CARDIOVASCULAR DISEASE AND ADEQUATE HOSPITAL-BASED AND COMMUNITY OUTREACH SERVICES * CANCER CARE SERVICES, EDUCATION AND PREVENTION * AFFORDABLE ACCESS TO CHILDBIRTH EDUCATION AND OB HOSPITAL SERVICES* OTHER COMMUNITY OUTREACH AND WELLNESS SERVICES.EACH OF THESE INITIATIVES IS SUMMARIZED BELOW:FY 2011 COMMUNITY WELLNESS OBESITY INITIATIVECOMMUNITY WELLNESS INITIATIVE IS TO DECREASE OBESITY AND THE CHRONIC DISEASES ASSOCIATED WITH IT BY OFFERING TARGETED WELLNESS PROGRAMS AND PREVENTATIVE SCREENINGS TO HELP OUR COMMUNITY GET WELL AND STAY WELL. CURRENT PROGRAMS INCLUDE:* KNOW YOUR NUMBERS EVENTS * ONGOING WELLNESS PROGRAMS: MANAGING YOUR CHOLESTEROL WITH TLC. FREE BLOOD PRESSURE CLINICS. TIME TO QUIT TOBACCO.* WELLNESS FOR KIDS PROGRAMS* "WE CAN" PROGRAM: DEVELOPED BY THE NATIONAL INSTITUTES OF HEALTH TO HELP PARENTS / FAMILIES ADDRESS THE ISSUE OF OVERWEIGHT CHILDREN (AGES 8 - 13) THROUGH NUTRITION, FITNESS AND REDUCED SCREEN TIME* CATCH (COORDINATED APPROACH TO CHILD HEALTH): TO CREATE BEHAVIORAL AND ENVIRONMENTAL CHANGE TO IMPROVE NUTRITION, PHYSICAL ACTIVITY AND REDUCE SCREEN TIME TO DECREASE OBESITY RATES; DEVELOPED BY THE CENTERS FOR DISEASE CONTROL.* WEIGHT NO MORE WITH THE YMCA: WELLNESS PRESENTATIONS AND FITNESS CLASSES OFFERED TWICE A YEARACCESS TO AFFORDABLE PRIMARY CARE. NEW PHYSICIANS WHO RECEIVE RECRUITMENT ASSISTANCE ARE REQUIRED TO ACCEPT MEDICAID PATIENTS. OUTPATIENT BEHAVIORAL HEALTHDURING FY 11, OUTPATIENT BEHAVIORAL HEALTH SERVICES WERE EXPANDED TO SISTER HOSPITAL, VALLEY WEST COMMUNITY HOSPITAL IN SANDWICH. FOR KISH HOSPITAL PRIMARY MARKET, A LARGER OFFICE SUITE OPENED IN SYCAMORE. THERE WERE MORE THAN 3,700 BEHAVIORAL HEALTH PATIENT VISITS, A 44% INCREASE OVER THE PREVIOUS YEAR. AT THE SYCAMORE LOCATION, ONE OF THE CENTER'S TWO PSYCHIATRISTS EXPANDED OFFICE HOURS, BILINGUAL EMPLOYEE ASSISTANCE PROGRAM SERVICES WERE ADDED, AND SPECIALIZED SERVICES FOR CHILDREN WERE EXPANDED. THE MOVE TO NEW OFFICE SPACE ALSO FACILITATED A COLLABORATIVE RELATIONSHIP WITH ANOTHER TENANT, ALEXIAN BROTHERS BEHAVIORAL HEALTH FROM HOFFMAN ESTATES, WHICH IS PROVIDING INTENSIVE OUTPATIENT TREATMENT FOR ADULTS IN THE AREA OF EATING DISORDERS AND OBSESSIVE COMPULSIVE DISORDER.TYPE II DIABETESTO ADDRESS THE PREVALENCE OF DIABETES IN THE ADULT POPULATION, THE HOSPITAL CONTINUED TO OPERATE A DIABETES EDUCATION CENTERS AND RURAL SATELLITE SERVICES AT KISHHEALTH FAMILY & SPECIALTY CARE IN GENOA AND WATERMAN. THE KISH DIABETES EDUCATION CENTER HAD 6,777 CONSULTATIONS, A 5.3% DECREASE FROM THE PREVIOUS YEAR.CARDIOVASCULAR DISEASE AND HOSPITAL-BASED AND COMMUNITY OUTREACH SERVICES ACCORDING TO THE SYSTEM'S 2009 COMMUNITY HEALTH STATUS TELEPHONE SURVEY, MORE THAN 80% OF THE ADULT POPULATION IN THE KCH MARKET AND HAVE ONE OR MORE CARDIOVASCULAR RISK FACTORS OR BEHAVIORS, SUCH AS HIGH BLOOD PRESSURE, HIGH CHOLESTEROL OR SMOKE. COMMUNITY BENEFIT ACTIVITIES IN FY 11 THAT PROMOTED CARDIOVASCULAR HEALTH WERE: * GO RED FOR WOMEN CAMPAIGN IN PARTNERSHIP WITH THE AMERICAN HEART ASSOCIATION: LUNCHEON IN MAY ATTENDED BY 150 PEOPLE. BUSINESS LEADER BREAKFAST IN APRIL, ATTENDED BY 50.* WOMEN'S HEALTH EVENT IN FEBRUARY ATTENDED BY 750* KNOW YOUR NUMBERS CAMPAIGN DURING THE SUMMER/FALL OF 2010* NUMEROUS COMMUNITY WELLNESS PROGRAMS AND CLASSESCANCER CARE SERVICES, EDUCATION AND PREVENTION * OPEN HOUSE FOR THE NEW CANCER CENTER AT KISHWAUKEE COMMUNITY HOSPITAL ATTENDED BY SEVERAL HUNDRED* SPACE PROVIDED FOR AMERICAN CANCER SOCIETY RESOURCE LIBRARY AT THE NEW CANCER CENTER OPEN TO THE PUBLIC* FINANCIAL SUPPORT OF AMERICAN CANCER SOCIETY RELAYS FOR LIFE FOR DEKALB COUNTY AND LOWER FOX VALLEY (KENDALL COUNTY)* FREE SUPPORT GROUPS INCLUDING GARDEN THERAPY, MEN AND WOMEN NETWORKING, CAREGIVER SUPPORT* PROVIDED FREE SKIN CANCER SCREENING AT WOMEN'S HEALTH EVENT* PROVIDED BREAST CANCER AWARENESS BOOTH AT SYCAMORE'S LADIES NIGHT OUTAFFORDABLE ACCESS TO CHILDBIRTH EDUCATION AND OB HOSPITAL SERVICES* 672 TUITION WAIVERS FOR INFANT AND CHILDBIRTH CLASSES FOR CLIENTS OF THE DEKALB COUNTY HEALTH DEPARTMENT IN THE WIC PROGRAM AND HEALTHY MOMS/HEALTHY KIDS PROGRAM.* FREE PREPARED CHILDBIRTH CLASSES FOR YOUNG MOMS* MONTHLY MOMS BREASTFEEDING SUPPORT GROUP LED BY A LACTATION COUNSELOR * FREE POST PARTUM VISITS FOR NEW MOMS* BEGAN PLANNING FOR LACTATION CENTEROTHER COMMUNITY OUTREACH AND WELLNESS EFFORTS* FREE SAFE SITTER PROGRAM FOR 24 STUDENTS IN THE SYCAMORE SPARTAN REACH, A PROGRAM FOR CHILDREN WHO RECEIVE EITHER REDUCED OR FREE LUNCHES.* COMMUNITY WELLNESS EDUCATORS TAUGHT HEALTH TOPICS IN AREA SCHOOLS: 477 CLASSROOMS TOUCHING 12,048 STUDENTS.* COMMUNITY WELLNESS EDUCATORS SERVED ON THE FOLLOWING COMMITTEES TO PROMOTE HEALTH AND WELLNESS: DEKALB LEADERSHIP ACADEMY, CO-COACH / PIONEERING HEALTHY COMMUNITIES, SYCAMORE SCHOOL DISTRICT WELLNESS COMMITTEE, DEKALB SCHOOL DISTRICT WELLNESS COMMITTEE AND SCHOOL LUNCH AND COMMUNITY OUTREACH SUB-COMMITTEES, LATINO ACTION GROUP, GO RED LUNCHEON COMMITTEE,CANCER COMMITTEE, * FREE AND LOW COST FITNESS AND INJURY PREVENTION CLASSES THROUGH UNLIMITED PERFORMANCE REHABILITATION AND SPORTS MEDICINE.* SPONSORED ANNUAL FITFEST, A WALKING EVENT WITH THE KISHWAUKEE FAMILY YMCA TO PROMOTE EMPLOYEE HEALTH AND FITNESS DAY TO AREA EMPLOYERS. ATTENDED BY 400.* PUBLISHED A COMMUNITY WELLNESS MAGAZINE THREE TIMES A YEAR PROVIDING INFORMATION ABOUT PROGRAMS, FREE SCREENINGS, AND GENERAL HEALTH TIPS.OPERATIONAL COMMUNITY BENEFITCHARITY CARE* AS PART OF ITS CHARITABLE MISSION, FREE AND DISCOUNTED CARE PROVIDED, INCLUDING ACCESS TO PHARMACEUTICAL ASSISTANCE FOR PATIENTS WHO MET THE ELIGIBILITY CRITERIA ESTABLISHED IN ITS FINANCIAL ASSISTANCE POLICY. THE POLICY IS REVIEWED BY THE BOARD OF DIRECTORS ANNUALLY. THE LAST REVIEW WAS APRIL 2011.* ADHERED TO THE REQUIREMENTS OF THE HOSPITAL UNINSURED PATIENT DISCOUNT ACT OF 2009, PROVIDING UNINSURED PATIENTS DISCOUNTS WHEN FAMILY INCOME IS AT OR BELOW 600% OF THE FEDERAL POVERTY LEVEL FOR KISHWAUKEE COMMUNITY HOSPITAL, 300% OF THE FEDERAL POVERTY LEVEL FOR VALLEY WEST COMMUNITY HOSPITAL.* COORDINATED WITH THE ILLINOIS BREAST AND CERVICAL CANCER PROGRAM FOR ASSISTANCE WITH BREAST AND CERVICAL CANCER SCREENINGS AND TREATMENT.SUBSIDIZED HEALTH SERVICESA NUMBER OF PROGRAMS AND SERVICES WERE OPERATED AT A LOSS, BUT WERE SUBSIDIZED BECAUSE THEY IMPROVE THE HEALTH AND SAFETY OF THE COMMUNITY. MANY ORGANIZATIONS ALSO RECEIVED CASH AND IN KIND DONATIONS.
4b (Code:   ) (Expenses $   including grants of $   ) (Revenue $   )
4c (Code:   ) (Expenses $   including grants of $   ) (Revenue $   )
4d Other program services. (Describe in Schedule O.)
(Expenses $   including grants of $   ) (Revenue $   )
4e Total program service expensesMediumBullet$ 128,532,470
Form 990 (2010)
Form 990 (2010)
Page 3
Part IV
Checklist of Required Schedules
Yes
No
1
Is the organization described in section 501(c)(3) or 4947(a)(1) (other than a private foundation)? If “Yes,” complete Schedule AClick to see attachment.....................
1
Yes
 
2
Is the organization required to complete Schedule B, Schedule of Contributors? Click to see attachment........
2
Yes
 
3
Did the organization engage in direct or indirect political campaign activities on behalf of or in opposition to candidates for public office? If “Yes,” complete Schedule C, Part IClick to see attachment..........
3
 
No
4
Section 501(c)(3) organizations. Did the organization engage in lobbying activities? If “Yes,” complete Schedule C,
Part IIClick to see attachment.........................
4
Yes
 
5
Is the organization a section 501(c)(4), 501(c)(5), or 501(c)(6) organization that receives membership dues, assessments, or similar amounts as defined in Revenue Procedure 98-19? If “Yes,” complete Schedule C, Part III........................
5
 
 
6
Did the organization maintain any donor advised funds or any similar funds or accounts where donors have the right to provide advice on the distribution or investment of amounts in such funds or accounts? If “Yes,” complete
Schedule D, Part IClick to see attachment.......................
6
 
No
7
Did the organization receive or hold a conservation easement, including easements to preserve open space,
the environment, historic land areas or historic structures? If “Yes,” complete Schedule D, Part IIClick to see attachment...
7
 
No
8
Did the organization maintain collections of works of art, historical treasures, or other similar assets? If “Yes,” complete Schedule D, Part III Click to see attachment....................
8
 
No
9
Did the organization report an amount in Part X, line 21; serve as a custodian for amounts not listed in Part X; or provide credit counseling, debt management, credit repair, or debt negotiation services? If “Yes,”
complete Schedule D, Part IVClick to see attachment...................
9
 
No
10
Did the organization, directly or through a related organization, hold assets in term, permanent,or quasi-endowments? If “Yes,” complete Schedule D, Part VClick to see attachment
10
 
No
11
If the organization’s answer to any of the following questions is ‘Yes,’ then complete Schedule D, Parts VI, VII, VIII, IX, or X as applicable:
a
Did the organization report an amount for land, buildings, and equipment in Part X, line10? If “Yes,” complete Schedule D, Part VI.Click to see attachment
11a
Yes
 
b
Did the organization report an amount for investments—other securities in Part X, line 12 that is 5% or more of its total assets reported in Part X, line 16? If “Yes,” complete Schedule D, Part VII.Click to see attachment
11b
Yes
 
c
Did the organization report an amount for investments—program related in Part X, line 13 that is 5% or more of its total assets reported in Part X, line 16? If “Yes,” complete Schedule D, Part VIII.Click to see attachment
11c
 
No
d
Did the organization report an amount for other assets in Part X, line 15 that is 5% or more of its total assets reported in Part X, line 16? If “Yes,” complete Schedule D, Part IX.Click to see attachment
11d
 
No
e
Did the organization report an amount for other liabilities in Part X, line 25? If “Yes,” complete Schedule D, Part X.Click to see attachment
11e
Yes
 
f
Did the organization’s separate or consolidated financial statements for the tax year include a footnote that addresses the organization’s liability for uncertain tax positions under FIN 48 (ASC 740)? If “Yes,” complete Schedule D, Part X.Click to see attachment
11f
 
No
12a
Did the organization obtain separate, independent audited financial statements for the tax year? If “Yes,” complete Schedule D, Parts XI, XII, and XIII Click to see attachment
12a
 
No
b
Was the organization included in consolidated, independent audited financial statements for the tax year? If “Yes,” and if the organization answered ‘No’ to line 12a, then completing Schedule D, Parts XI, XII, and XIII is optional Click to see attachment
12b
Yes
 
13
Is the organization a school described in section 170(b)(1)(A)(ii)? If “Yes,” complete Schedule E
13
 
No
14a
Did the organization maintain an office, employees, or agents outside of the United States?....
14a
 
No
b
Did the organization have aggregate revenues or expenses of more than $10,000 from grantmaking, fundraising, business, and program service activities outside the United States? If “Yes,” complete Schedule F, Part I.........
14b
 
No
15
Did the organization report on Part IX, column (A), line 3, more than $5,000 of grants or assistance to any organization or entity located outside the U.S.? If “Yes,” complete Schedule F, Part II..
15
 
No
16
Did the organization report on Part IX, column (A), line 3, more than $5,000 of aggregate grants or assistance to individuals located outside the U.S.? If “Yes,” complete Schedule F, Part III..
16
 
No
17
Did the organization report a total of more than $15,000, of expenses for professional fundraising services on Part IX, column (A), lines 6 and 11e? If “Yes,” complete Schedule G, Part I
17
 
No
18
Did the organization report more than $15,000 total of fundraising event gross income and contributions on Part VIII, lines 1c and 8a? If “Yes,” complete Schedule G, Part II..........
18
Yes
 
19
Did the organization report more than $15,000 of gross income from gaming activities on Part VIII, line 9a? If “Yes,” complete Schedule G, Part III...................
19
 
No
Form 990 (2010)
Form 990 (2010)
Page 4
Part IV
Checklist of Required Schedules (continued)
20a
Did the organization operate one or more hospitals? If “Yes,” complete Schedule H..... Click to see attachment
20a
Yes
 
b
Did the organization attach its audited financial statement to this return? Note: All Form 990 filers that operate one or more hospitals must attach audited financial statements. ..... Click to see attachment
20b
Yes
 
21
Did the organization report more than $5,000 of grants and other assistance to governments and organizations in the United States on Part IX, column (A), line 1? If “Yes,” complete Schedule I, Parts I and II.. Click to see attachment
21
Yes
 
22
Did the organization report more than $5,000 of grants and other assistance to individuals in the United States on Part IX, column (A), line 2? If “Yes,” complete Schedule I, Parts I and III..... Click to see attachment
22
Yes
 
23
Did the organization answer “Yes” to Part VII, Section A, questions 3, 4, or 5, about compensation of the organization’s current and former officers, directors, trustees, key employees, and highest compensated employees? If “Yes,” complete Schedule J................ Click to see attachment
23
Yes
 
24a
Did the organization have a tax-exempt bond issue with an outstanding principal amount of more than $100,000 as of the last day of the year, that was issued after December 31, 2002? If “Yes,” answer questions 24b–24d and complete Schedule K. If “No,” go to line 25................ Click to see attachment
24a
Yes
 
b
Did the organization invest any proceeds of tax-exempt bonds beyond a temporary period exception?...
24b
 
No
c
Did the organization maintain an escrow account other than a refunding escrow at any time during the year
to defease any tax-exempt bonds?......................
24c
 
No
d
Did the organization act as an “on behalf of” issuer for bonds outstanding at any time during the year?...
24d
 
No
25a
Section 501(c)(3) and 501(c)(4) organizations. Did the organization engage in an excess benefit transaction with a disqualified person during the year? If “Yes,” complete Schedule L, Part I...... Click to see attachment
25a
 
No
b
Is the organization aware that it engaged in an excess benefit transaction with a disqualified person in a prior year, and that the transaction has not been reported on any of the organization’s prior Forms 990 or 990-EZ? If “Yes,” complete Schedule L, Part I................ Click to see attachment
25b
 
No
26
Was a loan to or by a current or former officer, director, trustee, key employee, highly compensated employee, or disqualified person outstanding as of the end of the organization’s tax year? If “Yes,” complete Schedule L,
Part II........................... Click to see attachment
26
 
No
27
Did the organization provide a grant or other assistance to an officer, director, trustee, key employee, substantial contributor, or a grant selection committee member, or to a person related to such an individual? If “Yes,” complete Schedule L, Part III............... Click to see attachment
27
Yes
 
28
Was the organization a party to a business transaction with one of the following parties? (see Schedule L, Part IV instructions for applicable filing thresholds, conditions, and exceptions):
a
A current or former officer, director, trustee, or key employee? If “Yes,” complete Schedule L, Part IV ......................... Click to see attachment
28a
 
No
b
A family member of a current or former officer, director, trustee, or key employee? If “Yes,”
complete Schedule L, Part IV................... Click to see attachment
28b
 
No
c
An entity of which a current or former officer, director, trustee, or key employee (or a family member thereof) was an officer, director, trustee, or owner? If “Yes,” complete Schedule L, Part IV.. Click to see attachment
28c
Yes
 
29
Did the organization receive more than $25,000 in non-cash contributions? If “Yes,” complete Schedule M
29
 
No
30
Did the organization receive contributions of art, historical treasures, or other similar assets, or qualified conservation contributions? If “Yes,” complete Schedule M............
30
 
No
31
Did the organization liquidate, terminate, or dissolve and cease operations? If “Yes,” complete Schedule N,
Part I...........................
31
 
No
32
Did the organization sell, exchange, dispose of, or transfer more than 25% of its net assets? If “Yes,” complete Schedule N, Part II.......................
32
 
No
33
Did the organization own 100% of an entity disregarded as separate from the organization under Regulations sections 301.7701-2 and 301.7701-3? If “Yes,” complete Schedule R, Part I........ Click to see attachment
33
 
No
34
Was the organization related to any tax-exempt or taxable entity? If “Yes,” complete Schedule R, Parts II, III, IV, and V, line 1..................... Click to see attachment
34
Yes
 
35
Is any related organization a controlled entity within the meaning of section 512(b)(13)? .....
35
 
No
a
Did the organization receive any payment from or engage in any transaction with a controlled entity within the meaning of section 512(b)(13)? If “Yes,” complete Schedule R, Part V, line 2... Click to see attachment
36
Section 501(c)(3) organizations. Did the organization make any transfers to an exempt non-charitable related organization? If “Yes,” complete Schedule R, Part V, line 2........... Click to see attachment
36
 
No
37
Did the organization conduct more than 5% of its activities through an entity that is not a related organization and that is treated as a partnership for federal income tax purposes? If “Yes,” complete Schedule R, Part VIClick to see attachment
37
 
No
38
Did the organization complete Schedule O and provide explanations in Schedule O for Part VI, lines 11 and 19? Note. All Form 990 filers are required to complete Schedule O. ............
38
Yes
 
Form 990 (2010)
Form 990 (2010)
Page 5
Part V
Statements Regarding Other IRS Filings and Tax Compliance
Check if Schedule O contains a response to any question in this Part V . . . . . . . . . .
Yes
No
1a
Enter the number reported in Box 3 of Form 1096. Enter -0- if not applicable. .......
1a
136
b
Enter the number of Forms W-2G included in line 1a. Enter -0- if not applicable.
1b
0
c
Did the organization comply with backup withholding rules for reportable payments to vendors and reportable gaming (gambling) winnings to prize winners? ..................
1c
Yes
 
2a
Enter the number of employees reported on Form W-3, Transmittal of Wage and Tax Statements filed for the calendar year ending with or within the year covered by this return .....................
2a
1,136
b
If at least one is reported on line 2a, did the organization file all required federal employment tax returns?

Note. If the sum of lines 1a and 2a is greater than 250, you may be required to e-file. (see instructions)
2b
Yes
 
3a
Did the organization have unrelated business gross income of $1,000 or more during the year?.............................
3a
Yes
 
b
If “Yes,” has it filed a Form 990-T for this year? If “No,” provide an explanation in Schedule O.....
3b
Yes
 
4a
At any time during the calendar year, did the organization have an interest in, or a signature or other authority over, a financial account in a foreign country (such as a bank account or securities account)?.......................
4a
 
No
b
If "Yes," enter the name of the foreign country: MediumBullet
See instructions for filing requirements for Form TD F 90-22.1, Report of Foreign Bank and Financial Accounts.
5a
Was the organization a party to a prohibited tax shelter transaction at any time during the tax year?..
5a
 
No
b
Did any taxable party notify the organization that it was or is a party to a prohibited tax shelter transaction?
5b
 
No
c
If “Yes” to line 5a or 5b, did the organization file Form 8886-T? ........
5c
 
 
6a
Does the organization have annual gross receipts that are normally greater than $100,000, and did the organization solicit any contributions that were not tax deductible?..........
6a
 
No
b
If “Yes,” did the organization include with every solicitation an express statement that such contributions or gifts were not tax deductible?........................
6b
 
 
7
Organizations that may receive deductible contributions under section 170(c).
a
Did the organization receive a payment in excess of $75 made partly as a contribution and partly for goods and services provided to the payor?....................
7a
Yes
 
b
If “Yes,” did the organization notify the donor of the value of the goods or services provided?.....
7b
 
No
c
Did the organization sell, exchange, or otherwise dispose of tangible personal property for which it was required to file Form 8282?...........................
7c
 
No
d
If “Yes,” indicate the number of Forms 8282 filed during the year ....
7d
 
e
Did the organization receive any funds, directly or indirectly, to pay premiums on a personal benefit contract?..........................
7e
 
No
f
Did the organization, during the year, pay premiums, directly or indirectly, on a personal benefit contract?..
7f
 
No
g
If the organization received a contribution of qualified intellectual property, did the organization file Form 8899 as required?...................
7g
 
 
h
If the organization received a contribution of cars, boats, airplanes, or other vehicles, did the organization file a Form 1098-C?...............
7h
 
 
8
Sponsoring organizations maintaining donor advised funds and section 509(a)(3) supporting organizations. Did the supporting organization, or a donor advised fund maintained by a sponsoring organization, have excess business holdings at any time during the year?................
8
 
 
9
Sponsoring organizations maintaining donor advised funds.
a
Did the organization make any taxable distributions under section 4966?.........
9a
 
 
b
Did the organization make a distribution to a donor, donor advisor, or related person?......
9b
 
 
10
Section 501(c)(7) organizations. Enter:
a
Initiation fees and capital contributions included on Part VIII, line 12 ...
10a
 
b
Gross receipts, included on Form 990, Part VIII, line 12, for public use of club facilities
10b
 
11
Section 501(c)(12) organizations. Enter:
a
Gross income from members or shareholders .........
11a
 
b
Gross income from other sources (Do not net amounts due or paid to other sources against amounts due or received from them.) ........
11b
 
12a
Section 4947(a)(1) non-exempt charitable trusts. Is the organization filing Form 990 in lieu of Form 1041?
12a
 
 
b
If “Yes,” enter the amount of tax-exempt interest received or accrued during the year.
12b
 
13
Section 501(c)(29) qualified nonprofit health insurance issuers.
a
Is the organization licensed to issue qualified health plans in more than one state?
Note. All 501(c)(29) organizations must list in Schedule O each state in which they are licensed to issue qualified health plans, the amount of reserves required by each state, and the amount of reserves the organization allocated to each state.
13a
 
 
b
Enter the aggregate amount of reserves the organization is required to maintain by the states in which the organization is licensed to issue qualified health plans.
13b
 
c
Enter the aggregate amount of reserves on hand.
13c
 
14a
Did the organization receive any payments for indoor tanning services during the tax year?.....
14a
 
 
b
If "Yes," has it filed a Form 720 to report these payments? If “No,” provide an explanation in Schedule O..
14b
 
 
Form 990 (2010)
Form 990 (2010)
Page 6
Part VI
Governance, Management, and Disclosure For each “Yes” response to lines 2 through 7b below, and for a “No” response to lines 8a, 8b, or 10b below, describe the circumstances, processes, or changes in Schedule O. See instructions.
Check if Schedule O contains a response to any question in this Part VI . . . . . . . . . .
Section A. Governing Body and Management
Yes
No
1a
Enter the number of voting members of the governing body at the end of the tax year ..............
1a
3
b
Enter the number of voting members included in line 1a, above, who are independent .................
1b
2
2
Did any officer, director, trustee, or key employee have a family relationship or a business relationship with any other officer, director, trustee, or key employee? .................
2
Yes
 
3
Did the organization delegate control over management duties customarily performed by or under the direct supervision of officers, directors or trustees, or key employees to a management company or other person? ..
3
 
No
4
Did the organization make any significant changes to its governing documents since the prior Form 990 was filed?
4
 
No
5
Did the organization become aware during the year of a significant diversion of the organization’s assets? .
5
 
No
6
Does the organization have members or stockholders? ................
6
Yes
 
7a
Does the organization have members, stockholders, or other persons who may elect one or more members of the governing body? .........................
7a
Yes
 
b
Are any decisions of the governing body subject to approval by members, stockholders, or other persons? ..
7b
Yes
 
8
Did the organization contemporaneously document the meetings held or written actions undertaken during the year by the following:
a
The governing body? .........................
8a
Yes
 
b
Each committee with authority to act on behalf of the governing body? ............
8b
Yes
 
9
Is there any officer, director, trustee, or key employee listed in Part VII, Section A, who cannot be reached at the organization’s mailing address? If “Yes,” provide the names and addresses in Schedule O .....
9
 
No
Section B. Policies (This Section B requests information about policies not required by the Internal
Revenue Code.)
Yes
No
10a
Does the organization have local chapters, branches, or affiliates? ............
10a
 
No
b
If “Yes,” does the organization have written policies and procedures governing the activities of such chapters, affiliates, and branches to ensure their operations are consistent with those of the organization? ....
10b
 
 
11a
Has the organization provided a copy of this Form 990 to all members of its governing body before filing the form?
11a
Yes
 
b
Describe in Schedule O the process, if any, used by the organization to review the Form 990. .....
12a
Does the organization have a written conflict of interest policy? If “No,” go to line 13.......
12a
Yes
 
b
Are officers, directors or trustees, and key employees required to disclose annually interests that could give rise to conflicts? ...........................
12b
Yes
 
c
Does the organization regularly and consistently monitor and enforce compliance with the policy? If “Yes,” describe in Schedule O how this is done ....................
12c
Yes
 
13
Does the organization have a written whistleblower policy? ...............
13
Yes
 
14
Does the organization have a written document retention and destruction policy? .........
14
Yes
 
15
Did the process for determining compensation of the following persons include a review and approval by independent persons, comparability data, and contemporaneous substantiation of the deliberation and decision?
a
The organization’s CEO, Executive Director, or top management official ...........
15a
Yes
 
b
Other officers or key employees of the organization ................
15b
Yes
 
If "Yes" to line a or b, describe the process in Schedule O. (See instructions.)
16a
Did the organization invest in, contribute assets to, or participate in a joint venture or similar arrangement with a taxable entity during the year? ......................
16a
Yes
 
b
If “Yes,” has the organization adopted a written policy or procedure requiring the organization to evaluate its participation in joint venture arrangements under applicable federal tax law, and taken steps to safeguard the organization’s exempt status with respect to such arrangements? ............
16b
Yes
 
Section C. Disclosure
17
List the States with which a copy of this Form 990 is required to be filedMediumBullet
IL
18
Section 6104 requires an organization to make its Form 1023 (or 1024 if applicable), 990, and 990-T (501(c)(3)s only) available for public inspection. Indicate how you make these available. Check all that apply.
19
Describe in Schedule O whether (and if so, how), the organization makes its governing documents, conflict of interest policy, and financial statements available to the public.
20
State the name, physical address, and telephone number of the person who possesses the books and records of the organization: MediumBullet
PHILLIP JOHNSON DIR OF ACCTG
ONE KISH HOSPITAL DRIVE
DEKALB,IL60115
(815) 756-1521
Form 990 (2010)
Form 990 (2010)
Page 7
Part VII
Compensation of Officers, Directors,Trustees, Key Employees, Highest Compensated Employees, and Independent Contractors
Check if Schedule O contains a response to any question in this Part VII . . . . . . . . . .
Section A. Officers, Directors, Trustees, Key Employees, and Highest Compensated Employees
1a Complete this table for all persons required to be listed. Report compensation for the calendar year ending with or within the organization’s tax year.
RoundBullet List all of the organization’s current officers, directors, trustees (whether individuals or organizations), regardless of amount
of compensation, and current key employees. Enter -0- in columns (D), (E), and (F) if no compensation was paid.

RoundBullet List all of the organization’s current key employees, if any. See instructions for definition of "key employee."
RoundBullet List the organization’s five current highest compensated employees (other than an officer, director, trustee or key employee)
who received reportable compensation (Box 5 of Form W-2 and/or Box 7 of Form 1099-MISC) of more than $100,000 from the
organization and any related organizations.

RoundBullet List all of the organization’s former officers, key employees, or highest compensated employees who received more than $100,000
of reportable compensation from the organization and any related organizations.

RoundBullet List all of the organization’s former directors or trustees that received, in the capacity as a former director or trustee of the
organization, more than $10,000 of reportable compensation from the organization and any related organizations.

List persons in the following order: individual trustees or directors; institutional trustees; officers; key employees; highest
compensated employees; and former such persons.
Check this box if neither the organization nor any related organizations compensated any current or former officer, director, or trustee.
(A)
Name and Title 		(B)
Average hours per week (describe hours for related organizations in Schedule O) 		(C)
Position (check all that apply) 		(D)
Reportable compensation from the organization (W- 2/1099-MISC) 		(E)
Reportable compensation from related organizations (W- 2/1099-MISC) 		(F)
Estimated amount of other compensation from the organization and related organizations
Individual Trustee or Director; Institutional Trustee; Officer; Key Employee; Highest compensated employee; Former;
(1) MICHAEL MOONEY
CHAIR
 2.00 X   X       0 0 0
(2) MICHAEL CULLEN
VICE CHAIR
 2.00 X   X       0 0 0
(3) KEVIN POORTEN
PRESIDENT & CEO, KHS
 30.00 X   X       0 918,469 100,377
(4) LOREN FOELSKE
VP FINANCE
 10.00     X       0 303,588 39,563
(5) BRAD COPPLE
PRESIDENT - KCH & VWCH
 20.00       X     0 341,357 39,811
(6) PAM DUFFY
VP PATIENT CARE
 20.00       X     0 234,689 26,496
(7) JOE DANT
VP DEVELOPMENT
 20.00       X     0 258,586 39,499
(8) MIKE KOKOTT
ASST VP - MARKETING
 10.00       X     0 193,903 22,972
(9) ROGER HEATH BELL
VP - CHIEF INFORMATION OFF
 15.00       X     0 216,841 37,445
(10) DR MICHAEL KULISZ
CHIEF MEDICAL OFFICER
 20.00       X     0 204,758 20,414
(11) MARK THATE
VP - HUMAN RESOURCES
 20.00       X     0 179,403 27,847
(12) CHERYL FISHER
ASST VP - PATIENT CARE
 20.00       X     0 136,108 30,631
(13) THOMAS W TILTON DO
OPTHAMOLOGIST
 45.00         X   457,022 0 39,793
(14) RON C LUBCKE
DIRECTOR OF PHARMACY
 40.00         X   134,714 0 18,342
(15) KENYA M WILLIAMS MD
OPTHAMOLOGIST
 40.00         X   242,011 0 23,954
(16) JASMEET DHALIWAL
OPTHAMOLOGIST
 40.00         X   477,103 0 20,326
(17) ANJU VOHRA
LEAD CARDIAC SONOGRAPHER
 40.00         X   158,138 0 20,053
Form 990 (2010)
Form 990 (2010)
Page 8
Part VII
Section A. Officers, Directors, Trustees, Key Employees, and Highest Compensated Employees (continued)
(A)
Name and Title 		(B)
Average hours per week (describe hours for related organizations in Schedule O) 		(C)
Position (check all that apply) 		(D)
Reportable compensation from the organization (W- 2/1099-MISC) 		(E)
Reportable compensation from related organizations (W- 2/1099-MISC) 		(F)
Estimated amount of other compensation from the organization and related organizations
Individual Trustee or Director; Institutional Trustee; Officer; Key Employee; Highest compensated employee; Former;


























1b Sub-Total................MediumBullet
c Total from continuation sheets to Part VII, Section A....MediumBullet
d Total (add lines 1b and 1c)............MediumBullet 1,468,988 2,851,594 476,892
2
Total number of individuals (including but not limited to those listed above) who received more than $100,000 in reportable compensation from the organizationMediumBullet29
Yes
No
3
Did the organization list any former officer, director or trustee, key employee, or highest compensated employee on line 1a? If “Yes,” complete Schedule J for such individual .............
3
 
No
4
For any individual listed on line 1a, is the sum of reportable compensation and other compensation from the organization and related organizations greater than $150,000? If “Yes,” complete Schedule J for such individual...........................
4
Yes
 
5
Did any person listed on line 1a receive or accrue compensation from any unrelated organization or individual for services rendered to the organization? If “Yes,” complete Schedule J for such person .....
5
 
No
Section B. Independent Contractors
1
Complete this table for your five highest compensated independent contractors that received more than $100,000 of compensation from the organization.
(A)
Name and business address 		(B)
Description of services 		(C)
Compensation
POWER CONSTRUCTION COMPANY LLC
2360 NORTH PALMER DRIVE
SCHAUMBURG,IL60173 		CONSTRUCTION SERVICES 11,652,165
KISHHEALTH SYSTEM
ONE KISH HOSPITAL DRIVE
DEKALB,IL60115 		MANAGEMENT SERVICES 11,135,722
DOCTORS OF EMERGENCY MEDICINE
2807 BRITTANY COURT
ST CHARLES,IL60175 		ER 6,557,328
SABET SIDDIQUI MDPC
6925 ERROL COURT
CHERRY VALLEY,IL61016 		PHYSICAN - CANCER CARE CENTER 1,700,000
SODEXO INC & AFFILIATES
4880 PAYSPHERE CIRCLE
CHICAGO,IL60674 		FOOD SERVICES 1,370,122
2
Total number of independent contractors (including but not limited to those listed above) who received more than $100,000 in compensation from the organization MediumBullet30
Form 990 (2010)
Form 990 (2010)
Page 9
Part VIII
Statement of Revenue
(A)
Total revenue 		(B)
Related or
exempt
function
revenue 		(C)
Unrelated
business
revenue 		(D)
Revenue
excluded from
tax under sections
512, 513, or 514
Contributions, gifts, grants and other similar amounts 1a Federated campaigns..1a  
b Membership dues....1b 950
c Fundraising events....1c 40,771
d Related organizations...1d 1,030,699
e Government grants (contributions)1e 34,267
f All other contributions, gifts, grants, and
similar amounts not included above1f 		7,236
g Noncash contributions included in lines 1a-1f:$ 15,758
h Total. Add lines 1a-1f.......MediumBullet 1,113,923
Program Service Revenue Business Code
2a NET PATIENT SERVICE RE 621,110 163,782,199 163,678,774 103,425  
b AFFILIATED RENTAL INCO 621,610 52,446 52,446    
c
d
e
f All other program service revenue .        
g Total. Add lines 2a–2f........MediumBullet 163,834,645
Other Revenue 3 Investment income (including dividends, interest
and other similar amounts).....MediumBullet 4,563,748     4,563,748
4 Income from investment of tax-exempt bond proceeds..MediumBullet        
5 Royalties............MediumBullet        
(i) Real (ii) Personal
6a Gross Rents 179,278  
b Less: rental expenses 207,570  
c Rental income or (loss) -28,292  
d Net rental income or (loss).......MediumBullet -28,292     -28,292
(i) Securities (ii) Other
7a Gross amount from sales of assets other than inventory 21,996,108 20,283
b Less: cost or other basis and sales expenses 23,596,108 17,683
c Gain or (loss) -1,600,000 2,600
d Net gain or (loss)..........MediumBullet -1,597,400     -1,597,400
8a Gross income from fundraising events (not including
$ 40,771
of contributions reported on line 1c). See Part IV, line 18 ...
a 40,727
b Less: direct expenses ...b 22,871
c Net income or (loss) from fundraising events..MediumBullet 17,856   17,856
9a Gross income from gaming activities.
See Part IV, line 19 ...
a  
b Less: direct expenses ...b  
c Net income or (loss) from gaming activities...MediumBullet        
10a Gross sales of inventory, less
returns and allowances .
a 111,847
b Less: cost of goods sold ..b 70,616
c Net income or (loss) from sales of inventory..MediumBullet 41,231     41,231
Miscellaneous Revenue Business Code
11a CAFETERIA SALES 621,110 671,700 657,365 14,335  
b INCOME PASSTHROUGH - K 621,110 618,461 618,461    
c DISCOUNTS AND REBATES 621,110 260,678 260,678    
d All other revenue .... 222,164 198,144 24,020  
e Total. Add lines 11a–11d ......MediumBullet 1,773,003
12 Total revenue. See Instructions....MediumBullet 169,718,714 165,465,868 141,780 2,997,143
Form 990 (2010)
Form 990 (2010)
Page 10
Part IX
Statement of Functional Expenses
Section 501(c)(3) and 501(c)(4) organizations must complete all columns. All other organizations must complete column (A) but are not required to complete columns (B), (C), and (D).
Do not include amounts reported on lines 6b,
7b, 8b, 9b, and 10b of Part VIII. 		(A)
Total expenses 		(B)
Program service expenses 		(C)
Management and general expenses 		(D)
Fundraising expenses
1 Grants and other assistance to governments and organizations in the U.S. See Part IV, line 21 975,868 975,868
2 Grants and other assistance to individuals in the U.S. See Part IV, line 22 23,400 23,400
3 Grants and other assistance to governments, organizations, and individuals outside the U.S. See Part IV, lines 15 and 16    
4 Benefits paid to or for members    
5 Compensation of current officers, directors, trustees, and key employees ....        
6 Compensation not included above, to disqualified persons (as defined under section 4958(f)(1)) and persons described in section 4958(c)(3)(B) ....        
7 Other salaries and wages 40,758,604 39,183,853 1,574,751  
8 Pension plan contributions (include section 401(k) and section 403(b) employer contributions) .... 2,324,647 2,234,832 89,815  
9 Other employee benefits ....... 10,668,658 10,256,757 411,901  
10 Payroll taxes ........... 2,974,810 2,859,875 114,935  
11 Fees for services (non-employees):        
a Management ...... 11,135,722   11,135,722  
b Legal ......... 202,275   202,275  
c Accounting ........... 4,512   4,512  
d Lobbying ...........        
e Professional fundraising. See Part IV, line 17..    
f Investment management fees ...... 431,158   431,158  
g Other .......... 17,727,299 16,211,821 1,515,478  
12 Advertising and promotion .... 902,557 82,150 820,407  
13 Office expenses ....... 22,672,615 21,891,120 777,338 4,157
14 Information technology ...... 1,747,972 481,037 1,266,935  
15 Royalties ..        
16 Occupancy ........... 3,356,192 3,316,678 39,514  
17 Travel ............ 171,777 152,827 18,950  
18 Payments of travel or entertainment expenses for any federal, state, or local public officials ......        
19 Conferences, conventions, and meetings .... 7,490 7,490    
20 Interest ........... 3,591,700   3,591,700  
21 Payments to affiliates .......        
22 Depreciation, depletion, and amortization ..... 9,934,236 9,934,236    
23 Insurance .............. 3,028,235 1,073,019 1,955,216  
24 Other expenses. Itemize expenses not covered above. (Expenses grouped together and labeled miscellaneous may not exceed 5% of total expenses shown on line 25 below.)
a UNRELATED BUSINESS INCO 7,045   7,045  
b BAD DEBT EXPENSE 11,210,035 11,210,035    
c PHYSICAN FEES 3,347,646 3,347,646    
d PHYSICIAN RECRUITMENT 3,127,261 3,127,261    
e FEDERAL AND STATE ASSES 2,063,616 2,063,616    
f All other expenses 1,021,530 98,949 921,160 1,421
25 Total functional expenses. Add lines 1 through 24f 153,416,860 128,532,470 24,878,812 5,578
26 Joint costs. Check here MediumBullet if following
SOP 98-2 (ASC 958-720). Complete this line only if the organization reported in column (B) joint costs from a combined educational campaign and fundraising solicitation 		       
Form 990 (2010)
Form 990 (2010)
Page 11
Part X Balance Sheet
(A)
Beginning of year 		(B)
End of year
Assets 1 Cash—non-interest-bearing .......... 7,816,993 1 6,499,149
2 Savings and temporary cash investments ....... 653,378 2 279,934
3 Pledges and grants receivable, net .........   3  
4 Accounts receivable, net ......... 22,393,791 4 25,341,679
5 Receivables from current and former officers, directors, trustees, key employees, and highest compensated employees. Complete Part II of
Schedule L ..........   5  
6 Receivables from other disqualified persons (as defined under section 4958(f)(1)) and persons described in section 4958(c)(3)(B). Complete Part II of
Schedule L ..........   6  
7 Notes and loans receivable, net .............   7  
8 Inventories for sale or use .............. 3,088,963 8 3,529,110
9 Prepaid expenses and deferred charges ............ 2,271,599 9 2,061,173
10a Land, buildings, and equipment: cost or other basis. Complete Part VI of Schedule D 10a 159,479,787
b Less: accumulated depreciation. ..... 10b 54,658,407 95,545,088 10c 104,821,380
11 Investments—publicly traded securities .......... 85,746,795 11 104,528,505
12 Investments—other securities. See Part IV, line 11 ...... 22,067,417 12 22,243,230
13 Investments—program-related. See Part IV, line 11 ..   13  
14 Intangible assets .........   14  
15 Other assets. See Part IV, line 11 ........... 9,012,335 15 8,764,722
16 Total assets. Add lines 1 through 15 (must equal line 34)... 248,596,359 16 278,068,882
Liabilities 17 Accounts payable and accrued expenses . 11,813,777 17 13,418,274
18 Grants payable ..........   18  
19 Deferred revenue .......... 156,389 19 945,417
20 Tax-exempt bond liabilities .......... 63,685,000 20 63,685,000
21 Escrow or custodial account liability. Complete Part IV of Schedule D..   21  
22 Payables to current and former officers, directors, trustees, key
employees, highest compensated employees, and disqualified
persons. Complete Part II of Schedule L..........   22  
23 Secured mortgages and notes payable to unrelated third parties .. 230,016 23 1,245,941
24 Unsecured notes and loans payable to unrelated third parties ....   24  
25 Other liabilities. Complete Part X of Schedule D..... 17,146,875 25 21,934,667
26 Total liabilities. Add lines 17 through 25..... 93,032,057 26 101,229,299
Net Assets or Fund Balance Organizations that follow SFAS 117, check here MediumBullet and complete lines 27 through 29, and lines 33 and 34.
27 Unrestricted net assets ..... 150,907,951 27 172,416,577
28 Temporarily restricted net assets ..... 4,656,351 28 4,423,006
29 Permanently restricted net assets .....   29  
Organizations that do not follow SFAS 117, check here MediumBullet and complete lines 30 through 34.
30 Capital stock or trust principal, or current funds .....   30  
31 Paid-in or capital surplus, or land, building or equipment fund .....   31  
32 Retained earnings, endowment, accumulated income, or other funds   32  
33 Total net assets or fund balances ..... 155,564,302 33 176,839,583
34 Total liabilities and net assets/fund balances ..... 248,596,359 34 278,068,882
Form 990 (2010)
Form 990 (2010)
Page 12
Part XI
Reconcilliation of Net Assets
Check if Schedule O contains a response to any question in this Part XI . . . . . . . . . .
1
Total revenue (must equal Part VIII, column (A), line 12) . . .
1
169,718,714
2
Total expenses (must equal Part IX, column (A), line 25) . . . . .
2
153,416,860
3
Revenue less expenses. Subtract line 2 from line 1 . . . .
3
16,301,854
4
Net assets or fund balances at beginning of year (must equal Part X, line 33, column (A)) . .
4
155,564,302
5
Other changes in net assets or fund balances (explain in Schedule O) . . . .
5
4,973,427
6
Net assets or fund balances at end of year. Combine lines 3, 4, and 5 (must equal Part X, line 33, column (B)) . . . . . .
6
176,839,583
Part XII
Financial Statements and Reporting
Check if Schedule O contains a response to any question in this Part XII . . . . . . . . . .
Yes
No
1
Accounting method used to prepare the Form 990:  
If the organization changed its method of accounting from a prior year or checked "Other," explain in
Schedule O.
2a
Were the organization’s financial statements compiled or reviewed by an independent accountant?..
2a
 
No
b
Were the organization’s financial statements audited by an independent accountant?........
2b
Yes
 
c
If “Yes,” to 2a or 2b, does the organization have a committee that assumes responsibility for oversight of the audit, review, or compilation of its financial statements and selection of an independent accountant?
If the organization changed either its oversight process or selection process during the tax year, explain in Schedule O............................
2c
Yes
 
d
If “Yes” to line 2a or 2b, check a box below to indicate whether the financial statements for the year were issued on a separate basis, consolidated basis, or both:
3a
As a result of a federal award, was the organization required to undergo an audit or audits as set forth in the Single Audit Act and OMB Circular A-133? ................
3a
 
No
b
If “Yes,” did the organization undergo the required audit or audits? If the organization did not undergo the required audit or audits, explain why in Schedule O and describe any steps taken to undergo such audits. ..
3b
 
 
Form 990 (2010)
Additional Data


Software ID:  
Software Version:  
Form 990, Special Condition Description:
Special Condition Description
SCHEDULE A
(Form 990 or 990EZ)

Department of the Treasury
Internal Revenue Service
Public Charity Status and Public Support

Complete if the organization is a section 501(c)(3) organization or a section
4947(a)(1) nonexempt charitable trust.
right arrow Attach to Form 990 or Form 990-EZ. right arrow See separate instructions.
OMB No. 1545-0047
2010
Open to Public
Inspection
Name of the organization
KISHWAUKEE COMMUNITY HOSPITAL
 
Employer identification number

23-7087041
Part I
Reason for Public Charity Status (All organizations must complete this part.) See instructions
The organization is not a private foundation because it is: (For lines 1 through 11, check only one box.)
1
2
3
4
5
section 170(b)(1)(A)(iv). (Complete Part II.)
6
7
8
9
receipts from activities related to its exempt functions—subject to certain exceptions, and (2) no more than 331/3% of
its support from gross investment income and unrelated business taxable income (less section 511 tax) from businesses
acquired by the organization after June 30, 1975. See section 509(a)(2). (Complete Part III.)
10
11
e
f
g
(i) a person who directly or indirectly controls, either alone or together with persons described in (ii)
Yes
No
and (iii) below, the governing body of the the supported organization? ................
11g(i)
 
 
(ii) a family member of a person described in (i) above? ......................
11g(ii)
 
 
(iii) a 35% controlled entity of a person described in (i) or (ii) above? ................
11g(iii)
 
 
h
(i)
Name of supported organization 		(ii)
EIN 		(iii)
Type of organization (described on lines 1- 9 above or IRC section (see instructions)) 		(iv)
Is the organization in col. (i) listed in your governing document? 		(v)
Did you notify the organization in col. (i) of your support? 		(vi)
Is the organization in col. (i) organized in the U.S.? 		(vii)
Amount of support?
Yes No Yes No Yes No
Total                  

For Paperwork Reduction Act Notice, see the Instructions for Form 990.
Cat. No. 11285F
Schedule A (Form 990 or 990-EZ) 2010
Schedule A (Form 990 or 990-EZ) 2010
Page 2
Part II
Support Schedule for Organizations Described in IRC 170(b)(1)(A)(iv) and 170(b)(1)(A)(vi)
(Complete only if you checked the box on line 5, 7, or 8 of Part I or if the organization failed to qualify under Part III. If the organization fails to qualify under the tests listed below, please complete Part III.)
Section A. Public Support
Calendar year(or fiscal year beginning in) (a) 2006 (b) 2007 (c) 2008 (d) 2009 (e) 2010 (f) Total
1 Gifts, grants, contributions, and membership fees received. (Do not include any "unusual grants.") ....            
2 Tax revenues levied for the organization's benefit and either paid to or expended on its behalf.......            
3 The value of services or facilities furnished by a governmental unit to the organization without charge..            
4 Total. Add lines 1 through 3..            
5 The portion of total contributions by each person (other than a governmental unit or publicly supported organization) included on line 1 that exceeds 2% of the amount shown on line 11, column (f)..            
6 Public Support. Subtract line 5 from line 4.            
Section B. Total Support
Calendar year(or fiscal year beginning in) (a) 2006 (b) 2007 (c) 2008 (d) 2009 (e) 2010 (f) Total
7 Amounts from line 4..            
8 Gross income from interest, dividends, payments received on securities loans, rents, royalties and income from similar sources..            
9 Net income from unrelated business activities, whether or not the business is regularly carried on..            
10 Other income. (Explain in Part IV.) Do not include gain or loss from the sale of capital assets..            
11 Total support (Add lines 7 through 10).            
12
12
 
13
Section C. Computation of Public Support Percentage
14
14
 
15
15
 
16a
b
17a
b
18
Schedule A (Form 990 or 990-EZ) 2010
Schedule A (Form 990 or 990-EZ) 2010
Page 3
Part III
Support Schedule for Organizations Described in IRC 509(a)(2)
(Complete only if you checked the box on line 9 of Part I or if the organization failed to qualify under Part II. If the organization fails to qualify under the tests listed below, please complete Part II.)
Section A. Public Support
Calendar year(or fiscal year beginning in) (a) 2006 (b) 2007 (c) 2008 (d) 2009 (e) 2010 (f) Total
1 Gifts, grants, contributions, and membership fees received. (Do not include any "unusual grants.") .            
2 Gross receipts from admissions, merchandise sold or services performed, or facilities furnished in any activity that is related to the organization's tax-exempt purpose......            
3 Gross receipts from activities that are not an unrelated trade or business under section 513..            
4 Tax revenues levied for the organization's benefit and either paid to or expended on its behalf...            
5 The value of services or facilities furnished by a governmental unit to the organization without charge..            
6 Total. Add lines 1 through 5.            
7a Amounts included on lines 1, 2, and 3 received from disqualified persons...            
b Amounts included on lines 2 and 3 received from other than disqualified persons that exceed the greater of $5,000 or 1% of the amount on line 13 for the year.            
c Add lines 7a and 7b..            
8 Public Support (Subtract line 7c from line 6.)            
Section B. Total Support
Calendar year (or fiscal year beginning in) (a) 2006 (b) 2007 (c) 2008 (d) 2009 (e) 2010 (f) Total
9 Amounts from line 6...            
10a Gross income from interest, dividends, payments received on securities loans, rents, royalties and income from similar sources..            
b Unrelated business taxable income (less section 511 taxes) from businesses acquired after June 30, 1975.            
c Add lines 10a and 10b.            
11 Net income from unrelated business activities not included in line 10b, whether or not the business is regularly carried on.            
12 Other income. Do not include gain or loss from the sale of capital assets (Explain in Part IV.)            
13 Total support (Add lines 9, 10c, 11 and 12.).            
14
Section C. Computation of Public Support Percentage
15
15
 
16
16
 
Section D. Computation of Investment Income Percentage
17
17
 
18
18
 
19a
b
20
Schedule A (Form 990 or 990-EZ) 2010
Schedule A (Form 990 or 990-EZ) 2010
Page 4
Part IV
Supplemental Information. Supplemental Information. Complete this part to provide the explanation required by Part II, line 10; Part II, line 17a or 17b; or Part III, line 12. Also complete this part for any additional information. (See instructions).
Facts And Circumstances Test
 
Explanation
 
 
 
 
Schedule A (Form 990 or 990-EZ) 2010

Additional Data


Software ID:  
Software Version:  
Schedule B
(Form 990, 990-EZ,
or 990-PF)
Department of the Treasury
Internal Revenue Service
Schedule of Contributors
Arrow Bullet Attach to Form 990, 990-EZ, or 990-PF.
OMB No. 1545-0047
2010
Name of organization
KISHWAUKEE COMMUNITY HOSPITAL
 
Employer identification number

23-7087041
Organization type (check one):
Filers of:
Section:
Form 990 or 990-EZ





Form 990-PF




Check if your organization is covered by the General Rule or a Special Rule.  
Note. Only a section 501(c)(7), (8), or (10) organization can check boxes for both the General Rule and a Special Rule. See instructions.
General Rule—
Special Rules
......................... Arrow Bullet   $    
Caution. An Organization that is not covered by the General Rule and/or the Special Rules does not file Schedule B (Form 990,
990-EZ, or 990-PF), but it must answer “No” on Part IV, line 2 of its Form 990, or check the box in the heading of its
Form 990-EZ, or on line 2 of its Form 990-PF, to certify that it does not meet the filing requirements of Schedule B (Form 990,
990-EZ, or 990-PF).
For Paperwork Reduction Act Notice, see the Instructions
for Form 990, 990-EZ, or 990-PF.
Cat. No. 30613XSchedule B (Form 990, 990-EZ, or 990-PF) (2010)

Schedule B (Form 990, 990-EZ, or 990-PF) (2010)
Page 1 of 1 of Part I
Name of organization
KISHWAUKEE COMMUNITY HOSPITAL
  		Employer identification number

23-7087041
Part I
Contributors (see Instructions)
     
(a)
No.		 (b)
Name, address, and ZIP + 4		 (c)
Aggregate contributions		 (d)
Type of contribution
RESTRICTED
RESTRICTED
 

     
RESTRICTED
RESTRICTED  
RESTRICTED, RESTRICTED   RESTRICTED

$RESTRICTED




(Complete Part II if there is
a noncash contribution.)
(a)
No.		 (b)
Name, address, and ZIP + 4		 (c)
Aggregate contributions		 (d)
Type of contribution
 
 
 

     
 
   

$  




(Complete Part II if there is
a noncash contribution.)
(a)
No.		 (b)
Name, address, and ZIP + 4		 (c)
Aggregate contributions		 (d)
Type of contribution
 
 
 

     
 
   

$  




(Complete Part II if there is
a noncash contribution.)
(a)
No.		 (b)
Name, address, and ZIP + 4		 (c)
Aggregate contributions		 (d)
Type of contribution
 
 
 

     
 
   

$  




(Complete Part II if there is
a noncash contribution.)
(a)
No.		 (b)
Name, address, and ZIP + 4		 (c)
Aggregate contributions		 (d)
Type of contribution
 
 
 

     
 
   

$  




(Complete Part II if there is
a noncash contribution.)
(a)
No.		 (b)
Name, address, and ZIP + 4		 (c)
Aggregate contributions		 (d)
Type of contribution
 
 
 

     
 
   

$  




(Complete Part II if there is
a noncash contribution.)
Schedule B (Form 990, 990-EZ, or 990-PF) (2010)

Schedule B (Form 990, 990-EZ, or 990-PF) (2010)
Page 1 of 1 of Part II
Name of organization
KISHWAUKEE COMMUNITY HOSPITAL
  		Employer identification number

23-7087041
Part II
Noncash Property (see Instructions)
     
(a) No.
from
Part I		 (b)
Description of noncash property given		 (c)
FMV (or estimate)
(see instructions) 		(d)
Date received
 
$    
(a) No.
from
Part I		 (b)
Description of noncash property given		 (c)
FMV (or estimate)
(see instructions) 		(d)
Date received
 
$    
(a) No.
from
Part I		 (b)
Description of noncash property given		 (c)
FMV (or estimate)
(see instructions) 		(d)
Date received
 
$    
(a) No.
from
Part I		 (b)
Description of noncash property given		 (c)
FMV (or estimate)
(see instructions) 		(d)
Date received
 
$    
(a) No.
from
Part I		 (b)
Description of noncash property given		 (c)
FMV (or estimate)
(see instructions) 		(d)
Date received
 
$    
(a) No.
from
Part I		 (b)
Description of noncash property given		 (c)
FMV (or estimate)
(see instructions) 		(d)
Date received
 
$    
Schedule B (Form 990, 990-EZ, or 990-PF) (2010)

Schedule B (Form 990, 990-EZ, or 990-PF) (2010)
Page 1 of 1 of Part III
Name of organization
KISHWAUKEE COMMUNITY HOSPITAL
  		Employer identification number

23-7087041
Part III
Exclusively religious, charitable, etc., individual contributions to section 501(c)(7), (8), or (10) organizations
aggregating more than $1,000 for the year. (Complete columns (a) through (e) and the following line entry.)
For organizations completing Part III, enter the total of exclusively religious, charitable, etc.,
contributions of $1,000 or less for the year. (Enter this information once. See instructions.) Arrow Bullet $  
(a) No.
from
Part I		 (b)
Purpose of gift		 (c)
Use of gift		 (d)
Description of how gift is held
 
(e)
Transfer of gift
Transferee's name, address, and ZIP 4 Relationship of transferor to transferee
 
 
       
 
(a) No.
from
Part I		 (b)
Purpose of gift		 (c)
Use of gift		 (d)
Description of how gift is held
 
(e)
Transfer of gift
Transferee's name, address, and ZIP 4 Relationship of transferor to transferee
 
 
       
 
(a) No.
from
Part I		 (b)
Purpose of gift		 (c)
Use of gift		 (d)
Description of how gift is held
 
(e)
Transfer of gift
Transferee's name, address, and ZIP 4 Relationship of transferor to transferee
 
 
       
 
(a) No.
from
Part I		 (b)
Purpose of gift		 (c)
Use of gift		 (d)
Description of how gift is held
 
(e)
Transfer of gift
Transferee's name, address, and ZIP 4 Relationship of transferor to transferee
 
 
       
 
Schedule B (Form 990, 990-EZ, or 990-PF) (2010)

Additional Data


Software ID:  
Software Version:  
SCHEDULE C
(Form 990 or 990-EZ)

Department of the Treasury
Internal Revenue Service
Political Campaign and Lobbying Activities

For Organizations Exempt From Income Tax Under section 501(c) and section 527
SchCMd Bullet Complete if the organization is described below.
SchCMd Bullet Attach to Form 990 or Form 990-EZ. SchCMd Bullet See separate instructions.
OMB No. 1545-0047
2010
Open to Public
Inspection
If the organization answered “Yes,” to Form 990, Part IV, Line 3, or Form 990-EZ, Part V, line 46 (Political Campaign Activities), then
Round Bullet Section 501(c)(3) organizations: Complete Parts I-A and B. Do not complete Part I-C.
Round Bullet Section 501(c) (other than section 501(c)(3)) organizations: Complete Parts I-A and C below. Do not complete Part I-B.
Round Bullet Section 527 organizations: Complete Part I-A only.
If the organization answered “Yes,” to Form 990, Part IV, Line 4, or Form 990-EZ, Part VI, line 47 (Lobbying Activities), then
Round Bullet Section 501(c)(3) organizations that have filed Form 5768 (election under section 501(h)) Complete Part II-A. Do not complete Part II-B.
Round Bullet Section 501(c)(3) organizations that have NOT filed Form 5768 (election under section 501(h)): Complete Part II-B. Do not complete Part II-A.
If the organization answered “Yes,” to Form 990, Part IV, Line 5 (Proxy Tax) or Form 990-EZ, Part V, line 35a (Proxy Tax), then
Round Bullet Section 501(c)(4), (5), or (6) organizations: Complete Part III.
Name of the organization
KISHWAUKEE COMMUNITY HOSPITAL
 
Employer identification number

23-7087041
Part I-A
Complete if the organization is exempt under section 501(c) or is a section 527 organization.

1
Provide a description of the organization's direct and indirect political campaign activities on behalf of or in opposition to candidates for public office in Part IV.
2
Political expenditures ....................................SchCMd Bullet
$  
3
Volunteer hours ........................................
 

Part I-B
Complete if the organization is exempt under section 501(c)(3).
1
Enter the amount of any excise tax incurred by the organization under section 4955 .........SchCMd Bullet
$  
2
Enter the amount of any excise tax incurred by organization managers under section 4955 ......SchCMd Bullet
$  
3
If the organization incurred a section 4955 tax, did it file Form 4720 for this year? ..............
4a
Was a correction made? .........................................
b
If "Yes," describe in Part IV.
Part I-C
Complete if the organization is exempt under section 501(c) except section 501(c)(3).
1
Enter the amount directly expended by the filing organization for section 527 exempt function activities SchCMd Bullet
$  
2
Enter the amount of the filing organization's funds contributed to other organizations for section 527 exempt funtion activities ....................................SchCMd Bullet

$  
3
Total exempt function expenditures. Add lines 1 and 2. Enter here and on Form 1120-POL, line 17b..SchCMd Bullet

$  
4
Did the filing organization file Form 1120-POL for this year? ..........................
5
Enter the names, addresses and employer identification number (EIN) of all section 527 political organizations to which the filing
organization made payments. For each organization listed, enter the amount paid from the filing organization’s funds. Also enter the amount of political contributions received that were promptly and directly delivered to a separate political organization, such as a separate segregated fund or a political action committee (PAC). If additional space is needed, provide information in Part IV.
(a) Name (b) Address (c) EIN (d) Amount paid from filing organization's funds. If none, enter -0-. (e) Amount of political contributions received and promptly and directly delivered to a separate political organization. If none, enter -0-.










For Privacy Act and Paperwork Reduction Act Notice, see the instructions for Form 990.
Cat. No. 50084S
Schedule C (Form 990 or 990-EZ) 2010

Schedule C (Form 990 or 990-EZ) 2010
Page 2
Part II-A
Complete if the organization is exempt under section 501(c)(3) and filed Form 5768 (election under section 501(h)).
A Check
B Check
Limits on Lobbying Expenditures
(The term "expenditures" means amounts paid or incurred.) 		(a) Filing
Organization's
Totals 		(b) Affiliated Group
Totals
1a Total lobbying expenditures to influence public opinion (grass roots lobbying) ......    
b Total lobbying expenditures to influence a legislative body (direct lobbying) .......    
c Total lobbying expenditures (add lines 1a and 1b) ...................    
d Other exempt purpose expenditures ........................    
e Total exempt purpose expenditures (add lines 1c and 1d) ...............    
f Lobbying nontaxable amount. Enter the amount from the following table in both
columns.		    
  If the amount on line 1e, column (a) or (b) is:The lobbying nontaxable amount is:    
  Not over $500,00020% of the amount on line 1e.    
  Over $500,000 but not over $1,000,000$100,000 plus 15% of the excess over $500,000.    
  Over $1,000,000 but not over $1,500,000$175,000 plus 10% of the excess over $1,000,000.    
  Over $1,500,000 but not over $17,000,000$225,000 plus 5% of the excess over $1,500,000.    
  Over $17,000,000$1,000,000.    
       
g Grassroots nontaxable amount (enter 25% of line 1f) .................    
h Subtract line 1g from line 1a. If zero or less, enter -0-. ................    
i Subtract line 1f from line 1c. If zero or less, enter -0-. ................    
j If there is an amount other than zero on either line 1h or line 1i, did the organization file Form 4720 reporting
section 4911 tax for this year? ......................................

4-Year Averaging Period Under Section 501(h)
(Some organizations that made a section 501(h) election do not have to complete all of the five
columns below. See the instructions for lines 2a through 2f on page 4.)
Lobbying Expenditures During 4-Year Averaging Period
  Calendar year (or fiscal year
beginning in) 		(a) 2007 (b) 2008 (c) 2009 (d) 2010 (e) Total
             
2a Lobbying non-taxable amount          
             
b Lobbying ceiling amount
(150% of line 2a, column(e)) 		         
             
c Total lobbying expenditures          
             
d Grassroots non-taxable amount          
             
e Grassroots ceiling amount
(150% of line 2d, column (e))		          
             
f Grassroots lobbying expenditures          
Schedule C (Form 990 or 990-EZ) 2010


Schedule C (Form 990 or 990-EZ) 2010
Page 3
Part II-B
Complete if the organization is exempt under section 501(c)(3) and has NOT filed Form 5768 (election under section 501(h)).
(a)
Yes
No
(b)
Amount
1
During the year, did the filing organization attempt to influence foreign, national, state or local legislation, including any attempt to influence public opinion on a legislative matter or referendum, through the use of:
a
Volunteers? .........................................
 
No
b
Paid staff or management (include compensation in expenses reported on lines 1c through 1i)? ....
 
No
c
Media advertisements? ....................................
 
No
 
d
Mailings to members, legislators, or the public? .........................
 
No
 
e
Publications, or published or broadcast statements? .......................
 
No
 
f
Grants to other organizations for lobbying purposes? .......................
 
No
 
g
Direct contact with legislators, their staffs, government officials, or a legislative body? ........
Yes
 
0
h
Rallies, demonstrations, seminars, conventions, speeches, lectures, or any similar means? ......
 
No
 
i
Other activities? If "Yes," describe in Part IV ..........................
Yes
 
22,624
j
Total. lines 1c through 1i ...................................
22,624
2a
Did the activities in line 1 cause the organization to be not described in section 501(c)(3)? .....
 
No
b
If "Yes," enter the amount of any tax incurred under section 4912 .................
 
c
If "Yes," enter the amount of any tax incurred by organization managers under section 4912 .....
 
d
If the filing organization incurred a section 4912 tax, did it file Form 4720 for this year? .......
 
 
Part III-A
Complete if the organization is exempt under section 501(c)(4), section 501(c)(5), or section 501(c)(6).
Yes
No
1
Were substantially all (90% or more) dues received nondeductible by members? ................
1
 
 
2
Did the organization make only in-house lobbying expenditures of $2,000 or less? ................
2
 
 
3
Did the organization agree to carryover lobbying and political expenditures from the prior year? ..........
3
 
 
Part III-B
Complete if the organization is exempt under section 501(c)(4), section 501(c)(5), or section 501(c)(6) if BOTH Part III-A, lines 1 and 2 are answered “No” OR if Part III-A, line 3 is answered “Yes”.
1
Dues, assessments and similar amounts from members .....................
1
 
2
Section 162(e) non-deductible lobbying and political expenditures (do not include amounts of political
expenses for which the section 527(f) tax was paid).
a
Current year .........................................
2a
 
b
Carryover from last year ....................................
2b
 
c
Total ...........................................
2c
 
3
Aggregate amount reported in section 6033(e)(1)(A) notices of nondeductible section 162(e) dues .
3
 
4
If notices were sent and the amount on line 2c exceeds the amount on line 3, what portion of the excess does the organization agree to carryover to the reasonable estimate of nondeductible lobbying and political expenditure next year? ................................
4
 
5
Taxable amount of lobbying and political expenditures (see instructions) ..............
5
 
Part IV
Supplemental Information
Complete this part to provide the descriptions required for Part l-A, line 1; Part l-B, line 4; Part l-C, line 5; and Part ll-B, line 1i.
Also, complete this part for any additional information.
Identifier Return Reference Explanation
EXPLANATION OF OTHER LOBBYING ACTIVITIES: PART II-B, LINE 1I: LOBBYING EXPENSES ARE ALLOCATED THROUGH MEMBERSHIP DUES WITH ILLINOIS HOSPITAL ASSOCIATION AND AMERICAN HOSPITAL ASSOCIATION. NO OTHER LOBBYING ACTIVITIES WERE CONDUCTED.
Schedule C (Form 990 or 990EZ) 2010

Additional Data


Software ID:  
Software Version:  

SCHEDULE D
(Form 990)
Department of the Treasury
Internal Revenue Service
Supplemental Financial Statements
SchDMd Bullet Complete if the organization answered "Yes," to Form 990,
Part IV, line 6, 7, 8, 9, 10, 11, or 12.
SchDMd Bullet Attach to Form 990. SchDMd Bullet See separate instructions.
OMB No. 1545-0047
2010
Open to Public Inspection
Name of the organization
KISHWAUKEE COMMUNITY HOSPITAL
 
Employer identification number

23-7087041
Part I
Organizations Maintaining Donor Advised Funds or Other Similar Funds or Accounts. Complete if the organization answered "Yes" to Form 990, Part IV, line 6.
(a) Donor advised funds (b) Funds and other accounts
1 Total number at end of year .......    
2 Aggregate contributions to (during year) ...    
3 Aggregate grants from (during year) ...    
4 Aggregate value at end of year .......    
5
Did the organization inform all donors and donor advisors in writing that the assets held in donor advised
funds are the organization's property, subject to the organization's exclusive legal control? ............
6
Did the organization inform all grantees, donors, and donor advisors in writing that grant funds may be
used only for charitable purposes and not for the benefit of the donor or donor advisor, or for any other purpose conferring impermissible private benefit. ...................................
Part II
Conservation Easements. Complete if the organization answered "Yes" to Form 990, Part IV, line 7.
1
Purpose(s) of conservation easements held by the organization (check all that apply).
2
Complete lines 2a–2d if the organization held a qualified conservation contribution in the form of a conservation easement on the last day of the tax year.
Held at the End of the Year
a Total number of conservation easements ....................... 2a  
b Total acreage restricted by conservation easements .................. 2b  
c Number of conservation easements on a certified historic structure included in (a) ..... 2c  
d Number of conservation easements included in (c) acquired after 8/17/06 ........ 2d  
3
Number of conservation easements modified, transferred, released, extinguished, or terminated by the organization during
the taxable year SchDMd Bullet  
4
Number of states where property subject to conservation easement is located SchDMd Bullet  
5
Does the organization have a written policy regarding the periodic monitoring, inspection, handling of violations, and
enforcement of the conservation easements it holds? .............................
6
Staff and volunteer hours devoted to monitoring, inspecting and enforcing conservation easements during the year SchDMd Bullet  
7
Amount of expenses incurred in monitoring, inspecting, and enforcing conservation easements during the year SchDMd Bullet $  
8
Does each conservation easement reported on line 2(d) above satisfy the requirements of section
170(h)(4)(B)(i) and 170(h)(4)(B)(ii)? ....................................
9
In Part XIV, describe how the organization reports conservation easements in its revenue and expense statement, and
balance sheet, and include, if applicable, the text of the footnote to the organization’s financial statements that describes
the organization’s accounting for conservation easements.
Part III
Organizations Maintaining Collections of Art, Historical Treasures, or Other Similar Assets.
Complete if the organization answered "Yes" to Form 990, Part IV, line 8.
1a
If the organization elected, as permitted under SFAS 116, not to report in its revenue statement and balance sheet works of
art, historical treasures, or other similar assets held for public exhibition, education or research in furtherance of public service,
provide, in Part XIV, the text of the footnote to its financial statements that describes these items.
b
If the organization elected, as permitted under SFAS 116, to report in its revenue statement and balance sheet works of art,
historical treasures, or other similar assets held for public exhibition, education, or research in furtherance of public service,
provide the following amounts relating to these items:
(i)
Revenues included in Form 990, Part VIII, line 1 ........................SchDMd Bullet $  
(ii)
Assets included in Form 990, Part X ..............................SchDMd Bullet $  
2
If the organization received or held works of art, historical treasures, or other similar assets for financial gain, provide the
following amounts required to be reported under SFAS 116 relating to these items:
a
Revenues included in Form 990, Part VIII, line 1 ..........................SchDMd Bullet $  
b
Assets included in Form 990, Part X ...............................SchDMd Bullet $  
For Privacy Act and Paperwork Reduction Act Notice, see the Intructions for Form 990
Cat. No. 52283D
Schedule D (Form 990) 2010

Schedule D (Form 990) 2010
Page 2
Part III
Organizations Maintaining Collections of Art, Historical Treasures, or Other Similar Assets (continued)
3
Using the organization’s accession and other records, check any of the following that are a significant use of its collection
items (check all that apply):
a
d
b
e
 
c
4
Provide a description of the organization’s collections and explain how they further the organization’s exempt purpose in
Part XIV.
5
During the year, did the organization solicit or receive donations of art, historical treasures or other similar
assets to be sold to raise funds rather than to be maintained as part of the organization’s collection?........
Part IV
Escrow and Custodial Arrangements. Complete if the organization answered "Yes" to Form 990,
Part IV, line 9, or reported an amount on Form 990, Part X, line 21.
1a
Is the organization an agent, trustee, custodian or other intermediary for contributions or other assets not
included on Form 990, Part X? ....................................
b
If "Yes," explain the arrangement in Part XIV and complete the following table:
Amount
c Beginning balance ................................. 1c  
d Additions during the year .............................. 1d  
e Distributions during the year ............................. 1e  
f Ending balance ................................... 1f  
2a
Did the organization include an amount on Form 990, Part X, line 21? .....................
b
If “Yes,” explain the arrangement in Part XIV.
Part V
Endowment Funds. Complete if the organization answered "Yes" to Form 990, Part IV, line 10.
(a)Current Year (b)Prior Year (c)Two Years Back (d)Three Years Back (e)Four Years Back
1a Beginning of year balance ....      
b Contributions ........      
c Investment earnings or losses ...      
d Grants or scholarships .....      
e Other expenditures for facilities
and programs ........ 		     
f Administrative expenses ....      
g End of year balance ......      
2
Provide the estimated percentage of the year end balance held as:
a
Board designated or quasi-endowment: SchDMd Bullet  
b
Permanent endowment: SchDMd Bullet  
c
Term endowment: SchDMd Bullet  
3a
Are there endowment funds not in the possession of the organization that are held and administered for the
organization by:

Yes
No
(i) unrelated organizations ........................
3a(i)
 
 
(ii) related organizations ........................
3a(ii)
 
 
b
If "Yes" to 3a(ii), are the related organizations listed as required on Schedule R? .........
3b
 
 
4
Describe in Part XIV the intended uses of the organization's endowment funds.
Part VI
Investments—Land, Buildings, and Equipment. See Form 990, Part X, line 10.
Description of investment (a) Cost or other basis (investment) (b)Cost or other basis (other) (c) Accumulated depreciation (d) Book value
1a Land .................   4,110,685 4,110,685
b Buildings ................   93,721,369 18,945,921 74,775,448
c Leasehold improvements ............   554,682 85,302 469,380
d Equipment ................   46,120,556 33,167,524 12,953,032
e Other .................   14,972,495 2,459,660 12,512,835
Total. Add lines 1a-1e. (Column (d) should equal Form 990, Part X, column (B), line 10(c).)........SchDMdBullet 104,821,380
Schedule D (Form 990) 2010

Schedule D (Form 990) 2010
Page 3
Part VII
Investments—Other Securities. See Form 990, Part X, line 12.
(a) Description of security or category
(including name of security)		 (b)Book value (c) Method of valuation:
Cost or end-of-year market value
(1)Financial derivatives    
(2)Closely-held equity interests 2,107,306 C
(3)Other
(A) CASH EQUIVALENTS 		7,471,986 F

(B) ACCRUED INTEREST 		413,670 F

(C) CERTIFICATES OF DEPOSIT 		12,250,268 F






Total. (Column (b) should equal Form 990, Part X, col.(B) line 12.)Small Bullet 22,243,230
Part VIII
Investments—Program Related. See Form 990, Part X, line 13.
(a) Description of investment type (b) Book value (c) Method of valuation:
Cost or end-of-year market value








Total. (Column (b) should equal Form 990, Part X, col.(B) line 13.)Small Bullet  
Part IX
Other Assets. See Form 990, Part X, line 15.
(a) Description (b) Book value








Total. (Column (b) should equal Form 990, Part X, col.(B) line 15.)...........Small Bullet  
Part X
Other Liabilities. See Form 990, Part X, line 25.
1.(a) Description of Liability (b) Amount
Federal Income Taxes  
THIRD PARTY PAYABLES 14,538,082
DUE TO AFFILIATES 1,695,903
ACCRUED INTEREST PAYABLE 310,133
OTHER PAYABLES - LONG TERM 5,390,549





Total. (Column (b) should equal Form 990, Part X, col.(B) line 25.)Small Bullet 21,934,667
2. Fin 48 (ASC 740) Footnote. In Part XIV, provide the text of the footnote to the organization's financial statements that reports the organization's liability for uncertain tax positions under FIN 48 (ASC740).
Schedule D (Form 990) 2010

Schedule D (Form 990) 2010
Page 4
Part XI Reconciliation of Change in Net Assets from Form 990 to Financial Statements
1 Total revenue (Form 990, Part VIII, column (A), line 12) .................... 1 169,718,714
2 Total expenses (Form 990, Part IX, column (A), line 25) ..................... 2 153,416,860
3 Excess or (deficit) for the year. Subtract line 2 from line 1 ............. 3 16,301,854
4 Net unrealized gains (losses) on investments .......................... 4 7,085,798
5 Donated services and use of facilities ............................. 5  
6 Investment expenses ................................... 6  
7 Prior period adjustments .................................. 7  
8 Other (Describe in Part XIV) ................................. 8 -2,112,371
9 Total adjustments (net). Add lines 4 - 8 ............................. 9 4,973,427
10 Excess or (deficit) for the year per financial statements. Combine lines 3 and 9 ......... 10 21,275,281
Part XII Reconciliation of Revenue per Audited Financial Statements With Revenue per Return
1 Total revenue, gains, and other support per audited financial statements ....... 1 179,400,022
2 Amounts included on line 1 but not on Form 990, Part VIII, line 12:
a Net unrealized gains on investments .......... 2a 7,085,798
b Donated services and use of facilities ......... 2b  
c Recoveries of prior year grants ........... 2c  
d Other (Describe in Part XIV): ............ 2d 3,758,067
e Add lines 2a through 2d ..................... 2e 10,843,865
3 Subtract line 2e from line 1..................... 3 168,556,157
4 Amounts included on Form 990, Part VIII, line 12, but not on line 1:
a Investment expenses not included on Form 990, Part VIII, line 7b . 4a  
b Other (Describe in Part XIV): ........... 4b 1,162,557
c Add lines 4a and 4b....................... 4c 1,162,557
5 Total Revenue. Add lines 3 and 4c. (This should equal Form 990, Part I, line 12.) ...... 5 169,718,714
Part XIII Reconciliation of Expenses per Audited Financial Statements With Expenses per Return
1 Total expenses and losses per audited financial statements ............. 1 156,319,098
2 Amounts included on line 1 but not on Form 990, Part IX, line 25:
a Donated services and use of facilities .......... 2a  
b Prior year adjustments .............. 2b  
c Other losses ................ 2c  
d Other (Describe in Part XIV): ............ 2d 3,758,077
e Add lines 2a through 2d...................... 2e 3,758,077
3 Subtract line 2e from line 1..................... 3 152,561,021
4 Amounts included on Form 990, Part IX, line 25, but not on line 1:
a Investment expenses not included on Form 990, Part VIII, line 7b .. 4a  
b Other (Describe in Part XIV): ............ 4b 855,839
c Add lines 4a and 4b....................... 4c 855,839
5 Total expenses. Add lines 3 and 4c. (This should equal Form 990, Part I, line 18.) ...... 5 153,416,860
Part XIV
Supplemental Information
Complete this part to provide the descriptions required for Part II, lines 3, 5, and 9; Part III, lines 1a and 4; Part lV, lines 1b and 2b;
Part V, line 4; Part X; Part XI, line 8; Part XII, lines 2d and 4b; and Part XIII, lines 2d and 4b. Also complete this part to provide any additional information.
Identifier Return Reference Explanation
PART XI, LINE 8 - OTHER ADJUSTMENTS:   EQUITY DISTRIBUTION TO KISHHEALTH SYSTEM -1,880,000. CHANGE OF INTEREST IN NET ASSETS OF KISHHEALTH FOUNDATION -100,514. BOOK/TAX DIFFERENCES IN K-1 PASSTHROUGH ENTITIES -101,198. GRANT REVENUE INCLUDED IN FIXED ASSETS FOR FINANCIAL STATEMENT PURPOSES -30,659.
PART XII, LINE 2D - OTHER ADJUSTMENTS:   RECLASSIFICATION TO EXPENSES 3,758,067.
PART XII, LINE 4B - OTHER ADJUSTMENTS:   BOOK/TAX DIFFERENCE ON INCOME FROM PASSTHROUGH ENTITIES - KISH AREA PHO 67. CONTRIBUTION REVENUE FROM KISHHEALTH FOUNDATION 1,030,699. BOOK/TAX DIFFERENCE ON INCOME FROM PASSTHROUGH ENTITIES - MIDLAND SURGICAL 101,132. GRANT REVENUE INCLUDED IN FIXED ASSETS FOR FINANCIAL STATEMENT PURPOSES 30,659.
PART XIII, LINE 2D - OTHER ADJUSTMENTS:   RECLASSIFICATION FROM REVENUE 3,758,067. ROUNDING 10.
PART XIII, LINE 4B - OTHER ADJUSTMENTS:   CONTRIBUTION TO KISHHEALTH FOUNDATION 855,839.
    PART XI, LINE 10, EXCESS OR (DEFICIT) FOR THE YEAR PER FINANCIAL STATEMENTS: LINE 10 IDENTIFIES FINANCIAL STATEMENT INCOME AS EQUALING $21,275,281. FINANCIAL STATEMENT INCOME IS ACTUALLY $23,080,924. THE DIFFERENCE RELATES TO THE FOLLOWING ITEMS: 1. KISHWAUKEE COMMUNITY HOSPITAL MADE A CAPITAL DISTRIBUTION OF $1,880,000 TO ITS PARENT ORGANIZATION, KISHHEALTH SYSTEM. 2. KISHHEALTH FOUNDATION (KHF), AN AFFILIATED ENTITY, RECEIVES CONTRIBUTIONS DESIGNATED FOR USE BY KISHWAUKEE COMMUNITY HOSPITAL. THIS IS ALLOCATED TO KISHWAUKEE COMMUNITY HOSPITAL, VIA AN ENTRY TO INCREASE KISHWAUKEE COMMUNITY HOSPITAL'S INTEREST IN THE ASSETS OF KHF. A CORRESPONDING EQUITY ENTRY IS MADE ON KISHWAUKEE COMMUNITY HOSPITAL'S GENERAL LEDGER. THE CURRENT YEAR DECREASE WAS $96,459. 3. KCH RECEIVED CONTRIBUTIONS FROM AFFILIATES (KHF) IN THE AMOUNT OF $1,026,644 AND MADE CONTRIBUTIONS TO AFFILIATES IN THE AMOUNT OF $855,839. THESE ADJUSTMENTS WERE REFLECTED AS EQUITY TRANSACTIONS FOR FINANCIAL STATEMENT PURPOSES. 6. THERE IS A ROUNDING ADJUSTMENT OF $11
Schedule D (Form 990) 2010

Additional Data


Software ID:  
Software Version:  




SCHEDULE G
(Form 990 or 990-EZ)
Department of the Treasury
Internal Revenue Service
Supplemental Information Regarding
Fundraising or Gaming Activities
Complete if the organization answered "Yes" to Form 990, Part IV, lines 17, 18, or 19,
or if the organization entered more than $15,000 on Form 990-EZ, line 6a.
right arrow Attach to Form 990 or Form 990-EZ. right arrow See separate instructions.
OMB No. 1545-0047
2010
Open to Public Inspection
Name of the organization
KISHWAUKEE COMMUNITY HOSPITAL
 
Employer identification number

23-7087041
Part I
Fundraising Activities. Complete if the organization answered "Yes" to Form 990, Part IV, line 17.
1
Indicate whether the organization raised funds through any of the following activities. Check all that apply.
a e
b f
c g
d
2a
Did the organization have a written or oral agreement with any individual (including officers, directors, trustees
or key employees listed in Form 990, Part VII) or entity in connection with professional fundraising services?
b
If “Yes,” list the ten highest paid individuals or entities (fundraisers) pursuant to agreements under which the fundraiser is
to be compensated at least $5,000 by the organization. Form 990-EZ filers are not required to complete this table.
(i) Name and address of individual
or entity (fundraiser) 		(ii) Activity (iii) Did fundraiser have custody or control of contributions? (iv) Gross receipts
from activity 		(v) Amount paid to
(or retained by)
fundraiser listed in
col. (i) 		(vi) Amount paid to
(or retained by)
organization
Yes No
Total .................right arrow      
3
List all states in which the organization is registered or licensed to solicit funds or has been notified it is exempt from registration or licensing.
For Privacy Act and Paperwork Reduction Act Notice, see the Instructions for Form 990.
Cat. No. 50083H
Schedule G (Form 990 or 990-EZ) 2010
Schedule G (Form 990 or 990-EZ) 2010
Page 2
Part II
Fundraising Events. Complete if the organization answered "Yes" to Form 990, Part IV, line 18, or reported more than $15,000 on Form 990-EZ, line 6a. List events with gross receipts greater than $5,000.
(a) Event #1

ANNUAL SCHOLARSHIP BALL
(event type) 		(b) Event #2

 
(event type) 		(c) Other Events

  
(total number) 		(d) Total Events
(Add col. (a) through col. (c))
VerticalRevenue 1 Gross receipts . . . 81,498     81,498
2 Less: Charitable
contributions . . . 		40,771     40,771
3 Gross income (line 1
minus line 2) . . . 		40,727     40,727
VerticalDirectExpenses 4 Cash prizes . . .        
5 Non-cash prizes . .        
6 Rent/facility costs . .        
7 Food and beverages . . 15,963     15,963
8 Entertainment . . . 2,500     2,500
9 Other direct expenses . 4,408     4,408
10 Direct expense summary. Add lines 4 through 9 in column (d) ........... right arrow 22,871
11 Net income summary. Combine lines 3 and 10 in column (d)............ right arrow 17,856
Part III
Gaming. Complete if the organization answered "Yes" to Form 990, Part IV, line 19, or reported more than $15,000 on Form 990-EZ, line 6a.
VerticalRevenue (a) Bingo (b) Pull tabs/Instant
bingo/progressive bingo 		(c) Other gaming (d) Total gaming (Add col. (a) through col. (c))
1 Gross revenue . . . .        
VerticalDirectExpenses 2 Cash prizes . . . .        
3 Non-cash prizes . . .        
4 Rent/facility costs . . .        
5 Other direct expenses . .        
6 Volunteer labor . . .
 
 
 
7 Direct expense summary. Add lines 2 through 5 in column (d) ........... right arrow  
8 Net gaming income summary. Combine lines 1 and 7 in column (d) .......... right arrow  
9
Enter the state(s) in which the organization operates gaming activities:
a
Is the organization licensed to operate gaming activities in each of these states? ............
b
If "No," Explain:
 
10a
Were any of the organization's gaming licenses revoked, suspended or terminated during the tax year? .....
b
If "Yes," Explain:
 
11
Does the organization operate gaming activities with nonmembers? .................
12
Is the organization a grantor, beneficiary or trustee of a trust or a member of a partnership or other entity
formed to administer charitable gaming? ...........................
Schedule G (Form 990 or 990-EZ) 2010
Schedule G (Form 990 or 990-EZ) 2010
Page 3
13
Indicate the percentage of gaming activity operated in:
a
The organization's facility ......................
13a
 
b
An outside facility ........................
13b
 
14
Provide the name and address of the person who prepares the organization's gaming/special events books and records:
Name right arrow
Address right arrow
15a
Does the organization have a contract with a third party from whom the organization receives gaming
revenue? ......................................
b
If "Yes," enter the amount of gaming revenue received by the organization right arrow $   and the
amount of gaming revenue retained by the third party right arrow $   .
c
If "Yes," enter name and address:
Name right arrow
Address right arrow
 
 
16
Gaming manager information:
Name right arrow
Gaming manager compensation right arrow $  
Description of services provided right arrow
 
17
Mandatory distributions:
a
Is the organization required under state law to make charitable distributions from the gaming proceeds to
retain the state gaming license? ............................
b
Enter the amount of distributions required under state law distributed to other exempt organizations or spent
in the organization's own exempt activities during the tax year right arrow$  
Part IV
Complete this part to provide additional information for responses to quuestion on Schedule G (see instructions.)
Identifier ReturnReference Explanation
Schedule G (Form 990 or 990-EZ) 2010
Additional Data


Software ID:  
Software Version:  
SCHEDULE H
(Form 990)
Department of the Treasury
Internal Revenue Service
Hospitals
MediumBullet Complete if the organization answered "Yes" to Form 990, Part IV, question 20.
MediumBullet Attach to Form 990. MediumBullet See separate instructions.
OMB No. 1545-0047
2010
Open to Public Inspection
Name of the organization
KISHWAUKEE COMMUNITY HOSPITAL
 
Employer identification number

23-7087041
Part I
Charity Care and Certain Other Community Benefits at Cost
Yes
No
1a
Does the organization have a charity care policy? If "No," skip to question 6a...........
1a
Yes
 
b
If "Yes," is it a written policy? .......................
1b
Yes
 
2
If the organization has multiple hospitals, indicate which of the following best describes application of the charity care policy to the various hospitals.
3
Answer the following based on the charity care eligibility criteria that applies to the largest number of the organization's patients.
a
Does the organization use Federal Poverty Guidelines (FPG) to determine eligibility for providing free care to low
income individuals? If "Yes," indicate which of the following is the FPG family income limit for eligibility for free care:
3a
Yes
 
b
Does the organization use FPG to determine eligibility for providing discounted care to low income individuals? If
"Yes," indicate which of the following is the family income limit for eligibility for discounted care: .....
3b
Yes
 
c
If the organization does not use FPG to determine eligibility, describe in Part VI the income based criteria for determining eligibility for free or discounted care. Include in the description whether the organization uses an asset test or other threshold, regardless of income, to determine eligibility for free or discounted care.
4
Does the organization's policy provide free or discounted care to the "medically indigent"? ......
4
Yes
 
5a
Does the organization budget amounts for free or discounted care provided under its charity care policy? ...
5a
Yes
 
b
If "Yes," did the organization's charity care expenses exceed the budgeted amount?.........
5b
Yes
 
c
If "Yes" to line 5b, as a result of budget considerations, was the organization unable to provide free or discounted
care to a patient who was eligibile for free or discounted care?...............
5c
 
No
6a
Does the organization prepare an annual community benefit report?.............
6a
Yes
 
6b
If "Yes," does the organization make it available to the public? ..............
6b
Yes
 
Complete the following table using the worksheets provided in the Schedule H instructions. Do not submit these worksheets with the Schedule H.
7
Charity Care and Certain Other Community Benefits at Cost
Charity Care and
Means-Tested Government Programs		 (a) Number of activities or programs (optional) (b) Persons served (optional) (c) Total community benefit expense (d) Direct offsetting revenue (e) Net community benefit expense (f) Percent of total expense
a Charity care at cost (from
Worksheets 1 and 2) .. 		    4,930,972 2,041,416 2,889,556 2.030 %
b Unreimbursed Medicaid (from
Worksheet 3, column a) . 		    15,454,005 9,931,068 5,522,937 3.880 %
c Unreimbursed costs—other means-tested government programs (from Worksheet 3, column b) ....            
dTotal Charity Care and
Means-Tested Government Programs ..... 		    20,384,977 11,972,484 8,412,493 5.910 %
Other Benefits
e Community health improvement
services and community
benefit operations (from
(Worksheet 4) .... 		    6,665,130 540,568 6,124,562 4.310 %
f Health professions education
(from Worksheet 5) .. 		    1,376,232 20,348 1,355,884 0.950 %
g Subsidized health services
(from Worksheet 6) .. 		    875,853 218,863 656,990 0.460 %
h Research (from Worksheet 7)            
i Cash and in-kind contributions
to community groups
(from Worksheet 8) .. 		    376,091   376,091 0.260 %
jTotal Other Benefits ...     9,293,306 779,779 8,513,527 5.980 %
kTotal. Add lines 7d and 7j. ..     29,678,283 12,752,263 16,926,020 11.890 %
For Privacy Act and Paperwork Reduction Act Notice, see the Instructions for Form 990. Cat. No. 50192T Schedule H (Form 990) 2010
Schedule H (Form 990) 2010
Page 2
Part II
Community Building Activities Complete this table if the organization conducted any community building activities.
(a) Number of activities or programs (optional) (b) Persons served (optional) (c) Total community building expense (d) Direct offsetting
revenue 		(e) Net community building expense (f) Percent of total expense
1 Physical improvements and housing            
2 Economic development            
3 Community support            
4 Environmental improvements            
5 Leadership development and training for community members            
6 Coalition building            
7 Community health improvement advocacy            
8 Workforce development            
9 Other            
10 Total            
Part III
Bad Debt, Medicare, & Collection Practices
Section A. Bad Debt Expense
Yes
No
1
Does the organization report bad debt expense in accordance with Heathcare Financial Management Association Statement No. 15? ..........................
1
Yes
 
2
Enter the amount of the organization's bad debt expense (at cost).....
2
4,016,221
3
Enter the estimated amount of the organization's bad debt expense (at cost) attributable to patients eligible under the organization's charity care policy ..
3
682,758
4
Provide in Part VI the text of the footnote to the organization's financial statements that describes bad debt expense. In addition, describe the costing methodology used in determining the amounts reported on lines 2 and 3, and rationale for including a portion of bad debt amounts as community benefit.
Section B. Medicare
5
Enter total revenue received from Medicare (including DSH and IME).....
5
33,036,390
6
Enter Medicare allowable costs of care relating to payments on line 5.....
6
51,759,695
7
Subtract line 6 from line 5. This is the surplus or (shortfall)........
7
-18,723,305
8
Describe in Part VI the extent to which any shortfall reported in line 7 should be treated as community benefit.
Also describe in Part VI the costing methodology or source used to determine the amount reported on line 6.
Check the box that describes the method used:
Section C. Collection Practices
9a
Does the organization have a written debt collection policy? ...............
9a
Yes
 
b
If "Yes," does the organization's collection policy contain provisions on the collection practices to be followed for patients who are known to qualify for charity care or financial assistance? Describe in Part VI......
9b
Yes
 
Part IV
Management Companies and Joint Ventures
(a) Name of entity (b) Description of primary
activity of entity 		(c) Organization's
profit % or stock
ownership % 		(d) Officers, directors,
trustees, or key
employees' profit %
or stock ownership% 		(e) Physicians'
profit % or stock
ownership %
11 MIDLAND SURGICAL CENTER (MSC)
  		AMBULATORY SURGERY 77.500 % 0 % 0 %
2
3
4
5
6
7
8
9
10
11
12
13
Schedule H (Form 990) 2010
Schedule H (Form 990) 2010
Page 3
Part VFacility Information
Section A. Hospital Facilities
(list in order of size, measured by total revenue per facility, from largest to smallest)
How many hospital facilities did the organization operate during the tax year?1
Name and address 		Licensed Hospital General-Medical-Surgical Children's Hospital Teaching Hospital Critical Hospital Research Facility ER-24Hours ER-Other Other (Describe)
1 KISHWAUKEE COMMUNITY HOSPITAL
ONE KISH HOSPITAL DRIVE
DEKALB,IL60115 		X X         X    
Schedule H (Form 990) 2010
Schedule H (Form 990) 2010
Page 4
Part VFacility Information (continued)

Section B. Facility Policies and Practices.

(Complete a separate Section B for each of the hospital facilities listed in Part V, Section A)
Name of Hospital Facility:NOT REQUIRED
Line Number of Hospital Facility (from Schedule H, Part V, Section A):1

Yes No
Community Health Needs Assessment (Lines 1 through 7 are optional for 2010)
1 During the tax year or any prior tax year, did the hospital facility conduct a community health needs assessment (“Needs Assessment”)? If “No,” skip to question 8. ..................... 1    
If “Yes,” indicate what the Needs Assessment describes (check all that apply):
a A definition of the community served by the hospital facility
b Demographics of the community
c Existing health care facilities and resources within the community that are available to respond to the health needs of the community
d How data was obtained
e The health needs of the community
f Primary and chronic disease needs and other health issues of uninsured persons, low-income persons, and minority groups
g The process for identifying and prioritizing community health needs and services to meet those needs
h The process for consulting with persons representing the community’s interests
i Information gaps that limit the hospital facility’s ability to assess all of the community’s health needs
j Other (describe in Part VI)
2 Indicate the tax year the hospital facility last conducted a Needs Assessment: 20  
3 In conducting its most recent Needs Assessment, did the hospital facility take into account input from persons who represent the community served by the hospital facility? If “Yes,” describe in Part VI how the hospital facility took into account input from persons who represent the community, and identify the persons the hospital facility consulted. 3    
4 Was the hospital facility’s Needs Assessment conducted with one or more other hospital facilities? If “Yes,” list the other hospital facilities in Part VI............................ 4    
5 Did the hospital facility make its Needs Assessment widely available to the public? ........... 5    
If “Yes,” indicate how the Needs Assessment was made widely available (check all that apply):
a Hospital facility’s website
b Available upon request from the hospital facility
c Other (describe in Part VI)
6 If the hospital facility addressed needs identified in its most recently conducted Needs Assessment, indicate how (check all that apply):
a Adoption of an implementation strategy to address the health needs of the hospital facility’s community
b Execution of the implementation strategy
c Development of a community benefit plan for the facility
d Participation in community-wide community benefit plan
e Inclusion of a community benefit section in operational plans
f Adoption of a budget for provision of services that address the needs identified in the CHNA
g Prioritization of health needs in the community
h Prioritization of services that the hospital facility will undertake to meet health needs in its community
i Other (describe in Part VI)
7 Did the hospital facility address all of the needs identified in its most recently conducted Needs Assessment? If “No,” explain in Part VI which needs it has not addressed together with the reasons why it has not addressed such needs. 7    
Financial Assistance Policy
Did the hospital facility have in place during the tax year a written financial assistance policy that:
8 Explains eligibility criteria for financial assistance, and whether such assistance includes free or discounted care? 8    
9 Used federal poverty guidelines (FPG) to determine eligibility for providing free care to low incomeindividuals?.. 9    
If “Yes,” indicate the FPG family income limit for eligibility for free care:   %
Schedule H (Form 990) 2010
Schedule H (Form 990) 2010
Page 5
Part VFacility Information (continued)

Yes No
10 Used FPG to determine eligibility for providing discounted care to low income individuals?......... 10    
If “Yes,” indicate the FPG family income limit for eligibility for discounted care:   %
11 Explained the basis for calculating amounts charged to patients?................. 11    
If “Yes,” indicate the factors used in determining such amounts (check all that apply):
a Income level
b Asset level
c Medical indigency
d Insurance status
e Uninsured discount
f Medicaid/Medicare
g State regulation
h Other (describe in Part VI)
12 Explained the method for applying for financial assistance?................... 12    
13 Included measures to publicize the policy within the community served by the hospital facility?....... 13    
If “Yes,” indicate how the hospital facility publicized the policy (check all that apply):
a The policy was posted at all times on the hospital facility’s web site
b The policy was attached to all billing invoices
c The policy was posted in the hospital facility’s emergency rooms or waiting rooms
d The policy was posted in the hospital facility’s admissions offices
e The policy was provided, in writing, to patients upon admission to the hospital facility
f The policy was available upon request
g Other (describe in Part VI)
Billing and Collections
14 Did the hospital facility have in place during the tax year a separate billing and collections policy, or a written financial assistance policy that explained actions the hospital facility may take upon non-payment?........ 14    
15 Check all of the following collection actions against a patient that were permitted under the hospital facility's policies at any time during the tax year:
a Reporting to credit agency
b Lawsuits
c Liens on residences
d Body attachments or arrests
e Other (describe in Part VI)
16 Did the hospital facility engage in or authorize a third party to engage in any of the following collection actions during the tax year?................................... 16    
If “Yes,” check all collection actions in which the hospital facility or a third party engaged (check all that apply):
a Reporting to credit agency
b Lawsuits
c Liens on residences
d Body attachments
e Other (describe in Part VI)
17 Indicate which actions the hospital facility took before initiating any of the collection actions checked in question 16 (check all that apply):
a Notified patients of the financial assistance policy upon admission
b Notified patients of the financial assistance policy prior to discharge
c Notified patients of the financial assistance policy in communications with the patients regarding the patients’ bills
d Documented its determination of whether a patient who applied for financial assistance under the financial assistance policy qualified for financial assistance
e Other (describe in Part VI)
Schedule H (Form 990) 2010
Schedule H (Form 990) 2010
Page 6
Part VFacility Information (continued)

Policy Relating to Emergency Medical Care
Yes No
18 Did the hospital facility have in place during the tax year a written policy relating to emergency medical care that requires the hospital facility to provide, without discrimination, care for emergency medical conditions to individuals regardless of their eligibility under the hospital facility’s financial assistance policy?.......... 18    
If “No,” indicate the reasons why (check all that apply):
a The hospital facility did not provide care for any emergency medical conditions
b The hospital facility did not have a policy relating to emergency medical care
c The hospital facility limited who was eligible to receive care for emergency medical conditions (describe in Part VI)
d Other (describe in Part VI)
Charges for Medical Care
19 Indicate how the hospital facility determined the amounts generally billed to individuals who had insurance covering emergency or other medically necessary care (check all that apply):
a The hospital facility used the lowest negotiated commercial insurance rate for those services at the hospital facility
b The hospital facility used the average of the three lowest negotiated commercial insurance rates for those services at the hospital facility
c The hospital facility used the Medicare rate for those services
d Other (describe in Part VI)
20 Did the hospital facility charge any of its patients who were eligible for assistance under the hospital facility’s financial assistance policy, and to whom the hospital facility provided emergency or other medically necessary services, more than the amounts generally billed to individuals who had insurance covering such care?......... 20    
If “Yes,” explain in Part VI.
21 Did the hospital facility charge any of its patients an amount equal to the gross charge for services provided to that patient?................................... 21    
If “Yes,” explain in Part VI.
Schedule H (Form 990) 2010
Schedule H (Form 990) 2010
Page 7
Part VFacility Information (continued)

Section C. Other Facilities That Are Not Licensed, Registered, or Similarly Recognized as a Hospital Facility
(list in order of size, measured by total revenue per facility, from largest to smallest)
How many non-hospital facilities did the organization operate during the tax year?  
Name and address Type of Facility (Describe)
1
2
3
4
5
6
7
8
9
10
Schedule H (Form 990) 2010
Schedule H (Form 990) 2010
Page 8
Part VI
Supplemental Information
Complete this part to provide the following information.
1 Required descriptions. Provide the description required for Part I, lines 3c, 6a, and 7; Part II; Part III, lines 4, 8, and 9b; and Part V, Section B, lines 1j, 2, 4c, 6i, 7, 11i, 13i, 17l, 18l, 19e, 21d, 25, and 26.
2 Community health needs assessment. Describe how the organization assesses the health care needs of the communities it serves, in addition to any community health needs assessments reported in Part V, Section B.
3 Patient education of eligibility for assistance. Describe how the organization informs and educates patients and persons who may be billed for patient care about their eligibility for assistance under federal, state, or local government programs or under the organization’s financial assistance policy.
4 Community information. Describe the community the organization serves, taking into account the geographic area and demographic constituents it serves.
5 Promotion of community health. Provide any other information important to describing how the organization’s hospital facilities or other health care facilities further its exempt purpose by promoting the health of the community (e.g., open medical staff, community board, use of surplus funds, etc.).
6 Affiliated health care system. If the organization is part of an affiliated health care system, describe the respective roles of the organization and its affiliates in promoting the health of the communities served.
7 State filing of community benefit report. If applicable, identify all states with which the organization, or a related organization, files a community benefit report.
Identifier ReturnReference Explanation
    PART I, LINE 7, COLUMN (F): THE BAD DEBT EXPENSE INCLUDED ON FORM 990, PART IX, LINE 25, COLUMN (A), BUT SUBTRACTED FOR PURPOSES OF CALCULATING THE PERCENTAGE IN THIS COLUMN IS $ 11210035.
    PART II: NO COMMUNITY BUILDING ACTIVITIES ARE REPORTED IN PART II.
    PART III, LINE 4: NET PATIENT SERVICE REVENUETHE HOSPITAL HAS AGREEMENTS WITH THIRD-PARTY PAYORS WHICH PROVIDE FOR REIMBURSEMENT TO THE HOSPITAL AT AMOUNTS DIFFERENT FROM ITS ESTABLISHED RATES. CONTRACTUAL ADJUSTMENTS UNDER THIRD-PARTY REIMBURSEMENT PROGRAMS REPRESENT THE DIFFERENCE BETWEEN THE HOSPITAL'S BILLINGS AT LIST PRICE AND THE AMOUNTS REIMBURSED BY MEDICARE, MEDICAID, BLUE CROSS, AND CERTAIN OTHER THIRD-PARTY PAYORS; AND ANY DIFFERENCES BETWEEN ESTIMATED THIRD-PARTY REIMBURSEMENT SETTLEMENTS FOR PRIOR YEARS AND SUBSEQUENT FINAL SETTLEMENTS. CONTRACTUAL ADJUSTMENTS UNDER THIRD-PARTY REIMBURSEMENT PROGRAMS ARE ACCRUED ON AN ESTIMATED BASIS IN THE PERIOD THE RELATED SERVICES ARE RENDERED AND ARE ADJUSTED IN FUTURE PERIODS AS FINAL SETTLEMENTS ARE DETERMINED. A SUMMARY OF THE BASIS OF REIMBURSEMENT WITH MAJOR THIRD-PARTY PAYORS FOLLOWS:MEDICARE: KISHWAUKEE COMMUNITY HOSPITAL (KCH) IS PAID FOR INPATIENT ACUTE CARE AND OUTPATIENT CARE SERVICES RENDERED TO MEDICARE PROGRAM BENEFICIARY UNDER PROSPECTIVELY DETERMINED RATES PER DISCHARGE (PROSPECTIVE PAYMENT SYSTEMS). THESE RATES VARY ACCORDING TO A PATIENT CLASSIFICATION SYSTEM THAT IS BASED ON CLINICAL, DIAGNOSTIC, AND OTHER FACTORS. THE HOSPITAL'S CLASSIFICATION OF PATIENTS UNDER PROSPECTIVE PAYMENT SYSTEMS AND THE APPROPRIATENESS OF THE PATIENT'S ADMISSIONS ARE SUBJECT TO VALIDATION REVIEWS. THE HOSPITAL IS REIMBURSED FOR COST REIMBURSABLE ITEMS AT TENTATIVE RATES WITH FINAL SETTLEMENT DETERMINED AFTER SUBMISSION OF ANNUAL REIMBURSEMENT REPORTS BY THE HOSPITAL AND AUDITS BY THE MEDICARE FISCAL INTERMEDIARY. THE HOSPITAL'S CLASSIFICATION OF PATIENTS UNDER THE MEDICARE PROGRAM AND THE APPROPRIATENESS OF THEIR ADMISSION ARE SUBJECT TO AN INDEPENDENT REVIEW BY A PEER REVIEW ORGANIZATION. CHANGES AS A RESULT OF THE CENTERS FOR MEDICARE AND MEDICAID SERVICES IMPLEMENTATION OF THE PROVISIONS OF THE FUTURE MEDICARE LEGISLATION MAY HAVE AN ADVERSE EFFECT ON THE HOSPITAL'S NET PATIENT SERVICE REVENUE.LAWS AND REGULATIONS GOVERNING THE MEDICARE PROGRAM ARE EXTREMELY COMPLEX AND SUBJECT TO INTERPRETATION. AS A RESULT,THERE IS AT LEAST A REASONABLE POSSIBILITY THAT RECORDED ESTIMATES WILL CHANGE BY A MATERIAL AMOUNT IN THE NEAR-TERM.MEDICAID: THE HOSPITAL IS REIMBURSED AT PROSPECTIVELY DETERMINED RATES FOR EACH MEDICAID INPATIENT DISCHARGE. OUTPATIENT SERVICES ARE REIMBURSED BASED ON ESTABLISHED FEE SCREENS. FOR INPATIENT ACUTE CARE SERVICES, PAYMENT RATES VARY ACCORDING TO A PATIENT CLASSIFICATION SYSTEM THAT IS BASED ON CLINICAL, DIAGNOSTIC, AND OTHER FACTORS. THE PROSPECTIVELY DETERMINED RATES ARE NOT SUBJECT TO RETROACTIVE ADJUSTMENT. THE HOSPITAL ALSO RECEIVES INCREMENTAL MEDICAID REIMBURSEMENT FOR SPECIFIC PROGRAMS AND SERVICES AT THE DISCRETION OF THE STATE OF ILLINOIS MEDICAID PROGRAM. MEDICAID REIMBURSEMENT MAY BE SUBJECT TO PERIODIC ADJUSTMENT, AS WELL AS TO CHANGES IN EXISTING PAYMENT LEVELS AND RATES, BASED ON THE AMOUNT OF FUNDING AVAILABLE TO THE MEDICAID PROGRAM.LAWS AND REGULATIONS GOVERNING THE MEDICAID PROGRAM ARE EXTREMELY COMPLEX AND SUBJECT TO INTERPRETATION. AS A RESULT, THERE IS AT LEAST A REASONABLE POSSIBILITY THAT RECORDED ESTIMATES WILL CHANGE BY A MATERIAL AMOUNT IN THE NEAR-TERM.IN DECEMBER 2004, THE FEDERAL CENTERS FOR MEDICARE & MEDICAID SERVICES (CMS) APPROVED STATEOF ILLINOIS (STATE) LEGISLATION FOR A MEDICAID HOSPITAL ASSESSMENT PROGRAM (PROGRAM). UNDER THE PROGRAM, THE HOSPITAL RECEIVES ADDITIONAL MEDICAID REIMBURSEMENT FROM THE STATE AND PAYS ARELATED ASSESSMENT TAX. THE PROGRAM HAS BEEN EXTENDED THROUGH JUNE 30, 2013. BLUE CROSS: THE HOSPITAL ALSO PARTICIPATES AS A PROVIDER OF HEALTH CARE SERVICES UNDER A REIMBURSEMENT AGREEMENT WITH BLUE CROSS. THE PROVISIONS OF THIS AGREEMENT STIPULATE THAT INPATIENT SERVICES WILL BE REIMBURSED AT A TENTATIVE REIMBURSEMENT RATE AND THAT FINAL REIMBURSEMENT FOR THESE SERVICES IS DETERMINED AFTER THE SUBMISSION OF AN ANNUAL COST REPORT BY THE HOSPITAL AND A REVIEW BY BLUE CROSS. MANAGED CARE ORGANIZATIONS: THE HOSPITAL HAS ALSO ENTERED INTO REIMBURSEMENT AGREEMENTS WITH CERTAIN COMMERCIAL INSURANCE CARRIERS, HEALTH MAINTENANCE ORGANIZATIONS, AND PREFERRED PROVIDER ORGANIZATIONS. THE BASIS FOR PAYMENT UNDER THESE AGREEMENTS INCLUDES DISCOUNTS FROMESTABLISHED CHARGES AND PROSPECTIVELY DETERMINED PER DIEM RATES.INTERNAL REVENUE SERVICE WORKSHEET 2 (PER SCHEDULE H INSTRUCTIONS) WAS UTILIZED TO DETERMINE THE COST OF BAD DEBTS ATTRIBUTABLE TO PATIENT ACCOUNTS. 20% OF THE ORGANIZATION'S BAD DEBT EXPENSE WAS ATTRIBUTABLE TO PATIENTS ELIGIBLE UNDER THE ORGANIZATION'S CHARITY CARE POLICY.
    PART III, LINE 8: FOR THE 4/30/11 FISCAL YEAR, KCH PROVIDED BILLED CHARGES TO MEDICARE PATIENTS TOTALING $150,000,000. HOWEVER, DUE TO THE MEDICARE INPATIENT AND OUTPATIENT PAYMENT METHODOLOGIES, THE ACTUAL CASH PAYMENTS RECEIVED FROM PROVIDING CARE TO THOSE PATIENTS WAS JUST $33,036,390, OR 22% OF BILLED CHARGES. THE COST OF PROVIDING THIS CARE, PER THE MEDICARE COST REPORT, WAS $51,759,695. THUS, THE PAYMENTS RECEIVED FROM MEDICARE WERE $18,723,305 LESS THAN COST, OR 64% OF COST. TRULY THIS $18,723,305 SHORTFALL SHOULD BE INCLUDED AS A COMMUNITY BENEFIT. AS APPROXIMATELY 46% OF ALL KISHWAUKEE COMMUNITY HOSPITAL CHARGES GENERATED ARE FROM MEDICARE PATIENTS, THIS SHORTFALL PLACES A TREMENDOUS FINANCIAL BURDEN ON OUR HOSPITAL.KISHWAUKEE COMMUNITY HOSPITAL, LIKE OTHER NOT-FOR-PROFIT HOSPITALS, MUST ACCEPT MEDICARE PAYMENTS AS PAYMENT IN FULL FOR SERVICES PROVIDED, WITH THE EXCEPTION OF COLLECTING ON DEDUCTIBLES AND CO-INSURANCE AMOUNTS. HOSPITALS CANNOT BILL MEDICARE PATIENTS FOR THE DIFFERENCE BETWEEN THE BILLED CHARGES AND MEDICARE PAYMENTS.KISHWAUKEE COMMUNITY HOSPITAL PROVIDES SERVICES TO ALL PATIENTS WHO NEED CARE, ABIDING BY THE FEDERAL EMERGENCY MEDICAL TREATMENT AND LABOR ACT (EMTALA) REGULATION. IT REQUIRES HOSPITALS AND AMBULANCE SERVICES TO PROVIDE CARE TO ANYONE NEEDING EMERGENCY HEALTHCARE TREATMENT REGARDLESS OF CITIZENSHIP, LEGAL STATUS OR ABILITY TO PAY.KCH UTILIZED THE CALCULATION OF MEDICARE COST FROM THE ANNUAL MEDICARE COST REPORT. THIS APPROACH ALLOCATES COST FROM NON REVENUE PRODUCING DEPARTMENTS TO THE REVENUE GENERATING DEPARTMENTS, BASED ON STEP DOWN STATISTICAL COST FINDING. WHILE NOT AS COMPREHENSIVE AS A TRUE COST ACCOUNTING SYSTEM, THIS PROCESS RESULTS IN AN ACCEPTABLE BASIS OF THE DEPARTMENTAL COST FOR PROVIDING SERVICES. RECALL THAT PRIOR TO MEDICARE PROSPECTIVE PAYMENT SYSTEM (PPS), THIS METHODOLOGY WAS THE BASIS FOR THE REIMBURSEMENT TO HOSPITALS.
    PART III, LINE 9B: COLLECTION ACTIONS INVOLVING UNINSURED PATIENTS. KHS (KISHHEALTH SYSTEM, PARENT ORGANIZATION OF KISHWAUKEE COMMUNITY HOSPITAL) SHALL NOT PURSUE A COLLECTION ACTION AGAINST AN UNINSURED PATIENT, UNLESS THE PATIENT HAS BEEN GIVEN THE OPPORTUNITY TO ASSESS THE ACCURACY OF THE BILL; APPLY FOR FINANCIAL ASSISTANCE UNDER THE KHS FINANCIAL ASSISTANCE POLICY AND PROCEDURE; AND AVAIL HIMSELF OR HERSELF OF A REASONABLE PAYMENT PLAN. NOTWITHSTANDING THIS, KHS MAY NOT PURSUE THE COLLECTION ACTION UNDER THE FOLLOWING CIRCUMSTANCES: (A) IF THE PATIENT HAS INDICATED AN INABILITY TO PAY THE FULL AMOUNT OF THE DEBT IN ONE PAYMENT, UNTIL KHS HAS OFFERED THE PATIENT A PAYMENT PLAN. KHS MAY REQUIRE THE PATIENT TO PROVIDE REASONABLE VERIFICATION OF HIS OR HER INABILITY TO PAY THE FULL AMOUNT OF THE DEBT IN ONE PAYMENT.(B) IF KHS HAS REASON TO BELIEVE THE PATIENT MAY BE ELIGIBLE FOR FINANCIAL ASSISTANCE, UNTIL KHS HAS GIVEN THE PATIENT AT LEAST 60 DAYS FOLLOWING THE DATE OF DISCHARGE OR RECEIPT OF OUTPATIENT CARE TO SUBMIT AN APPLICATION FOR FINANCIAL ASSISTANCE. (C) IF THE PATIENT HAS AGREED TO A PAYMENT PLAN, UNTIL THE PATIENT HAS FAILED TO MAKE PAYMENTS IN ACCORDANCE WITH THAT PAYMENT PLAN. (D) IF THE PATIENT INFORMS KHS THAT HE OR SHE HAS APPLIED FOR HEALTH CARE COVERAGE UNDER MEDICAID, KIDCARE, OR OTHER GOVERNMENT-SPONSORED HEALTH CARE PROGRAM (AND THERE IS A REASONABLE BASIS TO BELIEVE THAT THE PATIENT WILL QUALIFY FOR SUCH PROGRAM), BUT THE PATIENT'S APPLICATION IS DENIED.
    PART VI, LINE 2: KISHWAUKEE COMMUNITY HOSPITAL IDENTIFIES COMMUNITY HEALTH NEEDS IN SEVERAL WAYS:* DEKALB COUNTY HEALTH DEPARTMENT I-PLAN* COMMUNITY HEALTH NEEDS SURVEY* U.S. GOVERNMENT HEALTHY PEOPLE 2010 AND 2010 GUIDELINES* INTERNAL REVIEW OF OUTPATIENT AND INPATIENT TRENDS, ESPECIALLY EMERGENCY DEPARTMENT USAGE * INPUT FROM OTHER COMMUNITY PROVIDERS. THIS INCLUDES PROVIDING HOSPITAL LEADERS TO SERVE ON BOARDS AND COMMITTEES THAT DIRECTLY OR INDIRECTLY IMPACT COMMUNITY HEALTH OR HELP THE HOSPITAL CONNECT TO UNDERSERVED OR VULNERABLE POPULATIONS.
    PART VI, LINE 3: INFORMATION IS PROVIDED AT REGISTRATION, VIA THE HOSPITAL WEBSITE, THROUGH CONSULTATIONS WITH FINANCIAL COUNSELORS FOR SOME ED AND OUTPATIENTS AS WELL AS INPATIENTS, DURING THE BILLING PROCESS ON STATEMENTS AND VIA PHONE CONVERSATIONS.
    PART VI, LINE 4: KISHWAUKEE COMMUNITY HOSPITAL SERVES ALL OF DEKALB COUNTY, IL, AND BORDER COMMUNITIES IN KANE AND OGLE COUNTIES. POPULATION OF THE HOSPITAL'S SERVICE AREA, BASED ON 2010 CENSUS, IS 131,782. THIS GEOGRAPHIC AREA INCLUDES A GROWING HISPANIC POPULATION. A UNIQUE POPULATION IN OUR SERVICE AREA IS NORTHERN ILLINOIS UNIVERSITY STUDENTS (23,850 FALL 2010 ENROLLMENT), INCLUDING FOREIGN STUDENTS AND VISITORS. THE HISPANIC POPULATION IS EXPECTED TO GROW BY 22.62% BY 2016. ACCORDING TO THE AMERICAN COMMUNITY SURVEY, 29.5% OF FAMILIES AND 42.7% OF INDIVIDUALS ARE BELOW THE POVERTY LEVEL BASED ON POPULATION AND HOUSING DATA FROM 2005-2009.
    PART VI, LINE 6: KISHWAUKEE COMMUNITY HOSPITAL IN DEKALB, IL, IS PART OF KISHHEALTH SYSTEM. THE HEALTH SYSTEM IS GOVERNED BY AN APPOINTED VOLUNTEER BOARD OF DIRECTORS, INDEPENDENT COMMUNITY LEADERS WHO RESIDE IN THE PRIMARY MARKETS SERVED BY THE HEALTH SYSTEM'S TWO HOSPITALS. THESE INDIVIDUALS ARE SELECTED FOR THE BOARD BECAUSE OF THEIR INTEREST AND EXPERTISE IN VARIOUS AREAS THAT CAN HELP MANAGEMENT CARRY OUT THE HEALTH SYSTEM'S MISSION. MEMBERS OF THE BOARD ARE NOT COMPENSATED FOR THEIR TIME. THE MEDICAL STAFF IS OPEN TO PHYSICIANS WHO MEET CRITERIA ESTABLISHED BY THE MEDICAL STAFF BYLAWS. PHYSICIANS ARE GIVEN AND TAKE THE OPPORTUNITY TO VOLUNTEER TO DO FREE COMMUNITY WELLNESS PROGRAMS ON HEALTH TOPICS. SURPLUS FUNDS GO BACK INTO THE ORGANIZATION TO SUPPORT OPERATIONS, CAPITAL IMPROVEMENTS, THE HEALTH SYSTEM'S COMMITMENT TO EXCELLENCE, EDUCATION AND INNOVATION, AND TO PROVIDE MEDICAL CARE TO ALL REGARDLESS OF ABILITY TO PAY. A COMMUNITY HEALTH ASSESSMENT WAS CONDUCTED IN THE FALL OF 2009, VIA A RANDOM TELEPHONE SURVEY. OUR COMMUNITY WELLNESS DEPARTMENT USED THE FINDINGS AS ONE COMPONENT OF ITS DECISION TO EMBARK ON A MULTI-YEAR INITIATIVE TO ADDRESS THE PREVALENCE OF OBESITY AMONG CHILDREN AND ADULTS IN OUR COMMUNITIES. (SEE SCHEDULE O OF THIS REPORT FOR DETAILS ABOUT COMMUNITY WELLNESS ACTIVITIES FOR FY 11). DURING FY 11, KISHHEALTH SYSTEM'S OUTPATIENT BEHAVIORAL HEALTH SERVICES WERE EXPANDED BY ADDING SERVICES AT VALLEY WEST COMMUNITY HOSPITAL IN SANDWICH AND MOVING TO A LARGER OFFICE SUITE IN SYCAMORE. THERE WERE MORE THAN 3,700 BEHAVIORAL HEALTH PATIENT VISITS, A 44% INCREASE OVER THE PREVIOUS YEAR. AT THE SYCAMORE LOCATION, ONE OF THE CENTERS TWO PSYCHIATRISTS EXPANDED OFFICE HOURS, BILINGUAL EMPLOYEE ASSISTANCE PROGRAM SERVICES WERE ADDED, AND SPECIALIZED SERVICES FOR CHILDREN WERE EXPANDED.FOR THE SECOND YEAR, THE HOSPITAL ALSO MADE A $25,000 GRANT TO THE COMMUNITY MENTAL HEALTH CENTER (BEN GORDON CENTER) TO HELP THE AGENCY BETTER MEET THE NEEDS OF THE MEDICAID AND UNINSURED POPULATION.THE HEALTH SYSTEM PLAYS A CRITICAL ROLE IN FINANCING AND MANAGING THE COMMUNITY CARES CLINIC, WHICH PROVIDES PRIMARY CARE TO THE UNINSURED AND UNDERINSURED, BOTH CHILDREN AND ADULTS. IN 2009, THE HEALTH SYSTEM PLEDGED $650,000 OVER THREE YEARS FOR THE OPERATION AND MANAGEMENT OF THE CLINIC. THE CLINIC IS A PARTNERSHIP AMONG KISHHEALTH SYSTEM, NORTHERN ILLINOIS UNIVERSITY AND PRIVATE DONORS, OVER THE PAST TWO YEARS, THE CLINIC HAS SEEN 4,136 PATIENTS AND HAD 11,658 VISITS. IT HAS PROVIDED HEALTHCARE FOR 804 PATIENTS WITHOUT INSURANCE AND FOR 1,866 CHILDREN ON PUBLIC AID FOR WHOM ACCESS TO CARE WAS PREVIOUSLY VERY LIMITED. DUE TO STATE FUNDING CUTS, THE CLINIC TOOK OVER THE RESPONSIBILITY OF PUBLIC AID WELL-CHILD VISITS PREVIOUSLY HANDLED BY THE DEKALB COUNTY HEALTH DEPARTMENT.
    PART VI, LINE 7: KISHHEALTH SYSTEM MADE $120,000 IN CONTRIBUTIONS TO SEVERAL ORGANIZATIONS IN FY11, NOTABLY A $50,000 GRANT TO DEKALB COUNTY GOVERNMENT FOR A FIBER OPTIC PROJECT THAT IS ESTABLISHING BROADBAND CONNECTIVITY THROUGHOUT DEKALB COUNTY. THIS PROJECT IS ENABLING HIGH SPEED ELECTRONIC COMMUNICATION TO RURAL AREAS AND TO COMMUNITY INSTITUTIONS SUCH AS SCHOOLS, LOCAL GOVERNMENT, LIBRARIES AND THE TWO KISHHEALTH SYSTEM HOSPITALS IN THE COUNTY. OTHER GRANTS WERE MADE TO THE KISHWAUKEE (COMMUNITY COLLEGE) COLLEGE FOUNDATION TO SUPPORT AN ENDOWMENT FOR SCHOLARSHIPS IN HEALTH-RELATED FIELDS. OTHER MONETARY GIFTS SUPPORTED THE ECONOMIC HEALTH OF COMMUNITIES SERVED, SUCH AS DOWNTOWN DEKALB RENEWAL AND OTHER DEKALB COUNTY ECONOMIC DEVELOPMENT EFFORTS. HEALTH SYSTEM LEADERS SERVED ON NUMEROUS COMMUNITY BOARDS AND COMMITTEES, MOST NOTABLY THE COMMUNITY CARES CLINIC, VOLUNTARY ACTION CENTER, FAMILY SERVICE AGENCY, FOX VALLEY OLDER ADULT SERVICES, KISHWAUKEE UNITED WAY, AND KISHWAUKEE FAMILY YMCA, DEKALB COUNTY ECONOMIC DEVELOPMENT CORPORATION AND THE PLANO ECONOMIC DEVELOPMENT. IN ADDITION, HEALTH SYSTEM EMPLOYEES CONTRIBUTED MORE THAN 1,300 HOURS OF IN-KIND SERVICE TO COMMUNITY ORGANIZATIONS, EDUCATIONAL INSTITUTIONS AND OTHER ACTIVITIES THAT PROMOTE HEALTH, EDUCATION AND QUALITY OF LIFE. OTHER NON-PROFIT HEALTH SYSTEM ENTITIES THAT PROMOTE THE HEALTH OF THE COMMUNITY ARE VALLEY WEST COMMUNITY HOSPITAL, A CRITICAL ACCESS HOSPITAL IN SANDWICH, IL; COMMUNITY CARES CLINIC, DEKALB, IL, A PRIMARY CARE CLINIC FOR MEDICAID AND UNINSURED; DEKALB COUNTY HOSPICE, DEKALB, IL, WHICH PROVIDES FREE CARE AND SUPPORT FOR THE TERMINALLY ILL AS WELL AS GRIEF SUPPORT TO THE PUBLIC; AND KISHHEALTH FOUNDATION IN DEKALB, IL, WHICH RAISES MONEY FOR KISHWAUKEE COMMUNITY HOSPITAL, VALLEY WEST COMMUNITY HOSPITAL, DEKALB COUNTY HOSPICE AND THE COMMUNITY CARES CLINIC.
REPORTS FILED WITH STATES PART VI, LINE 7 IL
Schedule H (Form 990) 2010
Additional Data


Software ID:  
Software Version:  
Schedule I
(Form 990)
Department of the Treasury
Internal Revenue Service
Grants and Other Assistance to Organizations,
Governments and Individuals in the United States
Complete if the organization answered "Yes," to Form 990, Part IV, line 21 or 22.
lBullet Attach to Form 990
OMB No. 1545-0047
2010
Open to Public
Inspection
Name of the organization
KISHWAUKEE COMMUNITY HOSPITAL
 
Employer identification number
23-7087041
Part I
General Information on Grants and Assistance
1
Does the organization maintain records to substantiate the amount of the grants or assistance, the grantees' eligibility for the grants or assistance, and
the selection criteria used to award the grants or assistance? ....................................
2
Describe in Part IV the organization's procedures for monitoring the use of grant funds in the United States.
Part II
Grants and Other Assistance to Governments and Organizations in the United States. Complete if the organization answered "Yes" to
Form 990, Part IV, line 21 for any recipient that received more than $5,000. Check this box if no one recipient received more than $5,000. Use
Part IV and Schedule I-1 (Form 990) if additional space is needed ......................... lBullet
(a) Name and address of organization
or government		 (b) EIN (c) IRC Code section
if applicable		 (d) Amount of cash grant (e) Amount of non-cash
assistance		 (f) Method of valuation
(book, FMV, appraisal,
other)		 (g) Description of
non-cash assistance		 (h) Purpose of grant
or assistance
(1) AMERICAN CANCER SOCIETY - FOX VALLEY REGION143 FIRST STREET
BATAVIA,IL60510 		13-1788491 501(C)(3) 10,000       TO PROVIDE FINANCIAL ASSISTANCE FOR ACTIVITIES RELATED TO CANCER RESEARCH AND TREATMENT
(2) AMERICAN HEART ASSOCIATION MIDWEST AFFILIATEPO BOX 4002902
DES MOINES,IA50340 		13-5613797 501(C)(3) 20,000       TO PROVIDE FINANCIAL ASSISTANCE FOR ACTIVITIES RELATED TO HEART HEALTH RESEARCH AND TREATMENT
(3) KISHWAUKEE COLLEGE FOUNDATION21193 MALTA ROAD
MALTA,IL60150 		23-7433949 501(C)(3) 18,200       TO PROVIDE FINANCIAL ASSISTANCE FOR ACTIVITIES RELATED TO HEALTH EDUCATION
(4) NORTHERN PUBLIC RADIO801 N FIRST STREET
DEKALB,IL60115 		36-6086819 501(C)(3) 8,517       TO PROVIDE CORPORATE SUPPORT OF PUBLIC RADIO
(5) FAMILY SERVICE AGENCY14 HEALTH SERVICES DRIVE
DEKALB,IL60115 		36-2360012 501(C)(3) 24,000       TO PROVIDE FINANCIAL ASSISTANCE FOR ACTIVITIES RELATED TO FAMILY HEALTH SERVICES
(6) DEKALB CHAMBER OF COMMERCE164 E LINCOLN HWY
DEKALB,IL60115 		36-0981630 501(C)(3) 7,000       TO PROVIDE FINANCIAL ASSISTANCE FOR ACTIVITIES RELATED TO COMMUNITY SERVICES
(7) DEKALB COUNTY YOUTH SERVICE BUREAU330 GROVE STREET
DEKALB,IL60115 		36-3034427 501(C)(3) 5,000       TO PROVIDE FINANCIAL ASSISTANCE FOR ACTIVITIES RELATED TO YOUTH SERVICES
(8) KISHWAUKEE UNITED WAYPO BOX 311 115 N FIRST ST
DEKALB,IL60115 		36-6158489 501(C)(3) 11,976       TO PROVIDE FINANCIAL ASSISTANCE FOR ACTIVITIES RELATED TO COMMUNITY SERVICES
(9) KISHHEALTH FOUNDATIONONE KISH HOSPITAL DRIVE
DEKALB,IL60115 		36-3649077 501(C)(3) 855,839       TO PROVIDE FOR HEALTH SYSTEM ENDOWMENT






2
Enter total number of section 501(c)(3) and government organizations ......................... Bullet Image
 
3
Enter total number of other organizations ................................ . Bullet Image
 
For Privacy Act and Paperwork Reduction Act Notice, see the Instructions for Form 990.
Cat. No. 50055P
Schedule I (Form 990) 2010

Schedule I (Form 990) 2010
Page 2
Part III
Grants and Other Assistance to Individuals in the United States. Complete if the organization answered "Yes" to Form 990, Part IV, line 22.
Use Schedule I-1 (Form 990) if additional space is needed.
(a)Type of grant or assistance (b)Number of
recipients		 (c)Amount of
cash grant		 (d)Amount of
non-cash assistance		 (e)Method of valuation (book,
FMV, appraisal, other)		 (f)Description of non-cash assistance
(1) KISHWAUKEE COMMUNITY HOSPITAL AUXILIARY SCHOLARSHIP PROGRAM 11 23,400      













Part IV
Supplemental Information. Complete this part to provide the information required in Part I, line 2, and any other additional information.
Identifier Return Reference Explanation
PROCEDURE FOR MONITORING GRANTS IN THE U.S.: PART I, LINE 2: SCHEDULE I, PART I, LINE 2: THE ORGANIZATION MAINTAINS SPECIFIC POLICIES AND QUALIFICATIONS FOR ALL GRANTS AVAILABLE. APPLICANTS MUST APPLY FOR THE RESPECTIVE GRANT AND BE APPROVED BY THE FUNDS GOVERNING BOARD. THE USE OF THE FUNDS IS MONITORED BY THE GOVERNING BOARD OF KISHWAUKEE COMMUNITY HOSPITAL. REQUESTS FOR FINANCIAL ASSISTANCE FROM OTHER CHARITABLE ORGANIZATIONS ARE REVIEWED AND APPROVED BY THE VP - FINANCE OF KISHHEALTH SYSTEM. IF NECESSARY DUE TO THE DOLLAR AMOUNT OF THE REQUEST, THESE ITEMS MAY ALSO BE PRESENTED TO THE BOARD OF DIRECTORS. A BUDGET IS SET ANNUALLY FOR CHARITABLE ASSISTANCE TO OTHER ORGANIZATIONS
Schedule I (Form 990) 2010


Additional Data


Software ID:  
Software Version:  


Schedule J
(Form 990)
Department of the Treasury
Internal Revenue Service
Compensation Information
For certain Officers, Directors, Trustees, Key Employees, and Highest
Compensated Employees
SchJMediumBullet Complete if the organization answered "Yes" to Form 990,
Part IV, question 23.
SchJMediumBullet Attach to Form 990. SchJMediumBullet See separate instructions.
OMB No. 1545-0047
2010
Open to Public Inspection
Name of the organization
KISHWAUKEE COMMUNITY HOSPITAL
 
Employer identification number

23-7087041
Part I
Questions Regarding Compensation
Yes
No
1a
Check the appropiate box(es) if the organization provided any of the following to or for a person listed in Form
990, Part VII, Section A, line 1a. Complete Part III to provide any relevant information regarding these items.
b
If any of the boxes in line 1a are checked, did the organization follow a written policy regarding payment or reimbursement orprovision of all the expenses described above? If "No," complete Part III to explain....
1b
 
 
2
Did the organization require substantiation prior to reimbursing or allowing expenses incurred by all
officers, directors, trustees, and the CEO/Executive Director, regarding the items checked in line 1a? ....
2
Yes
 
3
Indicate which, if any, of the following the organization uses to establish the compensation of the
organization's CEO/Executive Director. Check all that apply.
4
During the year, did any person listed in Form 990, Part VII, Section A, line 1a with respect to the filing organization or a related organization:
a
Receive a severance payment or change-of-control payment? ...............
4a
 
No
b
Participate in, or receive payment from, a supplemental nonqualified retirement plan? ........
4b
Yes
 
c
Participate in, or receive payment from, an equity-based compensation arrangement? ........
4c
 
No
If "Yes" to any of lines 4a-c, list the persons and provide the applicable amounts for each item in Part III.
Only 501(c)(3) and 501(c)(4) organizations only must complete lines 5-9.
5
For persons listed in form 990, Part VII, Section A, line 1a, did the organization pay or accrue any
compensation contingent on the revenues of:
a
The organization? ...........................
5a
 
No
b
Any related organization? .........................
5b
 
No
If "Yes," to line 5a or 5b, describe in Part III.
6
For persons listed in form 990, Part VII, Section A, line 1a, did the organization pay or accrue any
compensation contingent on the net earnings of:
a
The organization? ...........................
6a
 
No
b
Any related organization? .........................
6b
 
No
If "Yes," to line 6a or 6b, describe in Part III.
7
For persons listed in Form 990, Part VII, Section A, line 1a, did the organization provide any non-fixed
payments not described in lines 5 and 6? If "Yes," describe in Part III ............
7
 
No
8
Were any amounts reported in Form 990, Part VII, paid or accured pursuant to a contract that was
subject to the initial contract exception described in Regs. section 53.4958-4(a)(3)? If "Yes," describe
in Part III .............................
8
 
No
9
If "Yes" to line 8, did the organization also follow the rebuttable presumption procedure described in Regulations section 53.4958-6(c)? .........................
9
 
 
For Privacy Act and Paperwork Reduction Act Notice, see the Intructions for Form 990
Cat. No. 50053T
Schedule J (Form 990) 2010

Schedule J (Form 990) 2010
Page 2
Part II
Officers, Directors, Trustees, Key Employees, and Highest Compensated Employees. Use Schedule J-1 if additional space needed.
For each individual whose compensation must be reported in Schedule J, report compensation from the organization on row (i) and from related organizations, described in the
instructions on row (ii). Do not list any individuals that are not listed on Form 990, Part VII.

Note. The sum of columns (B)(i)-(iii) must equal the applicable column (D) or column (E) amounts on Form 990, Part VII, line 1a.
(A) Name (B) Breakdown of W-2 and/or 1099-MISC compensation (C) Retirement and other deferred compensation (D) Nontaxable
benefits		 (E) Total of columns
(B)(i)-(D) 		(F) Compensation
reported in prior
Form 990 or
Form 990-EZ
(i) Base compensation (ii) Bonus & incentive compensation (iii) Other reportable compensation
(1) KEVIN POORTEN (i)
(ii)		 0
493,308 		0
175,161 		0
250,000 		0
79,288 		0
21,089 		0
1,018,846 		0
250,000
(2) LOREN FOELSKE (i)
(ii)		 0
248,671 		0
54,917 		0
0 		0
19,288 		0
20,275 		0
343,151 		0
0
(3) BRAD COPPLE (i)
(ii)		 0
267,332 		0
74,025 		0
0 		0
19,288 		0
20,523 		0
381,168 		0
0
(4) PAM DUFFY (i)
(ii)		 0
190,811 		0
43,878 		0
0 		0
18,566 		0
7,930 		0
261,185 		0
0
(5) JOE DANT (i)
(ii)		 0
210,725 		0
47,861 		0
0 		0
19,288 		0
20,211 		0
298,085 		0
0
(6) MIKE KOKOTT (i)
(ii)		 0
165,989 		0
27,914 		0
0 		0
15,303 		0
7,669 		0
216,875 		0
0
(7) ROGER HEATH BELL (i)
(ii)		 0
168,475 		0
48,366 		0
0 		0
17,393 		0
20,052 		0
254,286 		0
0
(8) DR MICHAEL KULISZ (i)
(ii)		 0
204,758 		0
0 		0
0 		0
0 		0
20,414 		0
225,172 		0
0
(9) MARK THATE (i)
(ii)		 0
145,067 		0
34,336 		0
0 		0
14,318 		0
13,529 		0
207,250 		0
0
(10) THOMAS W TILTON DO (i)
(ii)		 366,224
0 		90,798
0 		0
0 		19,288
0 		20,505
0 		496,815
0 		0
0
(11) RON C LUBCKE (i)
(ii)		 124,569
0 		10,145
0 		0
0 		10,790
0 		7,552
0 		153,056
0 		0
0
(12) KENYA M WILLIAMS MD (i)
(ii)		 214,490
0 		27,521
0 		0
0 		19,288
0 		4,666
0 		265,965
0 		0
0
(13) JASMEET DHALIWAL (i)
(ii)		 253,957
0 		223,146
0 		0
0 		0
0 		20,326
0 		497,429
0 		0
0
(14) ANJU VOHRA (i)
(ii)		 158,138
0 		0
0 		0
0 		12,452
0 		7,601
0 		178,191
0 		0
0


Schedule J (Form 990) 2010

Schedule J (Form 990) 2010
Page 3
Part III
Supplemental Information
Complete this part to provide the information, explanation, or descriptions required for Part I, lines 1a, 1b, 4c, 5a, 5b, 6a, 6b, 7, and 8. Also complete this part for any additional information.
Identifier Return Reference Explanation
  PART I, LINE 4B THE ORGANIZATION'S CEO PARTICIPATES IN A NONQUALIFIED DEFERRED COMPENSATION PLAN. CONTRIBUTIONS FOR CALENDAR YEAR 2010 WERE $60,000. DURING 2010, THE CEO TOOK A DISTRIBUTION FROM THE DEFERRED COMPENSATION PLAN IN THE AMOUNT OF $250,000. THIS DISTRIBUTION IS INCLUDED IN W-2 WAGES, HOWEVER THE ACCRUAL OF THE DEFERRED COMPENSATION PAYMENTS HAS ALSO BEEN INCLUDED AS "OTHER COMPENSATION" ON PRIOR YEAR FORM 990S.
Schedule J (Form 990) 2010

Additional Data


Software ID:  
Software Version:  
Schedule K
(Form 990)
Department of the Treasury
Internal Revenue Service
Supplemental Information on Tax Exempt Bonds
SchKMediumBullet Complete if the organization answered "Yes" to Form 990, Part IV, line 24a. Provide descriptions,
explanations, and any additional information in Schedule O (Form 990).
SchKMediumBullet Attach to Form 990. SchKMediumBullet See separate instructions.
OMB No. 1545-0047
2010
Open to Public
Inspection
Name of the organization
KISHWAUKEE COMMUNITY HOSPITAL
 
Employer identification number
23-7087041
Part I
Bond Issues
(a) Issuer Name (b) Issuer EIN (c) CUSIP # (d) Date Issued (e) Issue Price (f) Description of Purpose (g) Defeased (h) On
Behalf of
Issuer 		(i) Pool
financing
Yes No Yes No Yes No
A CITY OF SYCAMORE DEKALB COUNTY ILLINOIS HEALTH FACILITIES REVENUE BOND
  		86-1091967 452032AJ4 08-01-2008 63,685,000 CONSTRUCTION OF NEW FACILITY FOR KISHWAUKEE COMMUNITY HOSPITAL X   X     X
Part II
Proceeds
A B C D
1 Amount of bonds retired. . . . .        
2 Amount of bonds defeased . . . .        
3 Total proceeds of issue . . . . 63,371,994      
4 Gross proceeds in reserve funds . .        
5 Capitalized interest from proceeds.        
6 Proceeds in refunding escrow. . . . .        
7 Issuance costs from proceeds . . . 328,434      
8 Credit enhancement from proceeds.        
9 Working capital expenditures from proceeds . .        
10 Capital expenditures from proceeds . .        
11 Other spent proceeds . .        
12 Other unspent proceeds. . .        
13 Year of substantial completion . . . 2007
Yes No Yes No Yes No Yes No
14 Were the bonds issued as part of a current refunding issue?   X            
15 Were the bonds issued as part of an advance refunding issue? X              
16 Has the final allocation of proceeds been made? . . X              
17 Does the organization maintain adequate books and records to support the final allocation of proceeds? . X              
Part III
Private Business Use
A B C D
Yes No Yes No Yes No Yes No
1 Was the organization a partner in a partnership, or a member of an LLC, which owned property financed by tax-exempt bonds? . . .   X            
2 Are there any lease arrangements that may result in private business use of bond-financed property? . . . . .   X            
For Privacy Act and Paperwork Reduction Act Notice, see the Instructions for Form 990.
Cat. No. 50193E
Schedule K (Form 990) 2010
Schedule K (Form 990) 2010
Page 2
Part III
Private Business Use (Continued)
A B C D
Yes No Yes No Yes No Yes No
3a Are there any management or service contracts that may result in private business use?   X            
b Are there any research agreements that may result in private business use of bond-financed property? . .   X            
c Does the organization routinely engage bond counsel or other outside counsel to review any management or service contracts or research agreements relating to the financed property? .                
4 Enter the percentage of financed property used in a private business use by entities other than a section 501(c)(3) organization or a state or local government . . . . . . . . . . . . . SchKMediumBullet        
5 Enter the percentage of financed property used in a private business use as a result of unrelated trade or business activity carried on by your organization, another section 501(c)(3) organization, or a state or local government . SchKMediumBullet        
6 Total of lines 4 and 5 . . .. . . . . .        
7 Has the organization adopted management practices and procedures to ensure the post-issuance compliance of its tax-exempt bond liabilities?   X            
Part IV
Arbitrage
A B C D
Yes No Yes No Yes No Yes No
1 Has a Form 8038-T, Arbitrage Rebate, Yield Reduction and Penalty in Lieu of Arbitrage Rebate, been filed with respect to the bond issue? . . .   X            
2 Is the bond issue a variable rate issue?   X            
3a Has the organization or the governmental issuer entered into a hedge with respect to the bond issue?   X            
b Name of provider .  
  		 
  		 
  		 
 
c Term of hedge . .        
d Was the hedge superintegrated? .                
e Was a hedge terminated? .                
4a Were gross proceeds invested in a GIC? .   X            
b Name of provider .  
  		 
  		 
  		 
 
c Term of GIC . .        
d Was the regulatory safe harbor for establishing the fair market value of the GIC satisfied? .                
5 Were any gross proceeds invested beyond an available temporary period? .   X            
6 Did the bond issue qualify for an exception to rebate? . . .   X            
Schedule K (Form 990) 2010

Schedule K (Form 990) 2010
Page 3
Part V
Supplemental Information
Complete this part to provide additional information for responses to questions on Schedule K (see instructions).
Identifier Return Reference Explanation
Schedule K (Form 990) 2010

Additional Data


Software ID:  
Software Version:  

Schedule L
(Form 990 or 990-EZ)
Department of the Treasury
Internal Revenue Service
Transactions with Interested Persons
MediumBullet Complete if the organization answered
"Yes" on Form 990, Part IV, lines 25a, 25b, 26, 27, 28a, 28b, or 28c,
or Form 990-EZ, Part V lines 38a or 40b.
MediumBullet Attach to Form 990 or Form 990-EZ. MediumBulletSee separate instructions.
OMB No. 1545-0047
2010
Open to Public Inspection
Name of the organization
KISHWAUKEE COMMUNITY HOSPITAL
 
Employer identification number

23-7087041
Part I
Excess Benefit Transactions (section 501(c)(3) and section 501 (c)(4) organizations only).
Complete if the organization answered "Yes" on Form 990, Part IV, line 25a or 25b, or Form 990-EZ, Part V, line 40b.
1(a) Name of disqualified person (b) Description of transaction (c) Corrected?
Yes No





2
Enter the amount of tax imposed on the organization managers or disqualified persons during the year under section 4958. ......................... Bullet Image$
 
3
Enter the amount of tax, if any, on line 2, above, reimbursed by the organization ....... Bullet Image$
 

Part II
Loans to and/or From Interested Persons.
Complete if the organization answered "Yes" on Form 990, Part IV, line 26, or Form 990-EZ, Part V, line 38a.
(a) Name of interested person and purpose (b) Loan to or from the organization? (c)Original principal amount (d)Balance due (e) In default? (f) Approved by board or committee? (g)Written agreement?
To From Yes No Yes No Yes No
Total ...............Small Bullet $  
Part III
Grants or Assistance Benefitting Interested Persons.
Complete if the organization answered "Yes" on Form 990, Part IV, line 27.
(a) Name of interested person (b)Relationship between interested person and the organization (c)Amount of grant or type of assistance
(1) KISHHEALTH FOUNDATION
  		BROTHER/SISTER ORGANIZATIONS 855,839
For Privacy Act and Paperwork Reduction Act Notice, see the
Instructions for Form 990 or 990-EZ.
Cat. No. 50056A
Schedule L (Form 990 or 990-EZ) 2010
Schedule L (Form 990 or 990-EZ) 2010
Page 2
Part IV
Business Transactions Involving Interested Persons.
Complete if the organization answered "Yes" on Form 990, Part IV, line 28a, 28b, or 28c.
(a) Name of interested person (b) Relationship between interested person and the organization (c) Amount of transaction (d) Description of transaction (e) Sharing of organization's revenues?
Yes No
(1) KISHHEALTH SYSTEM
  		COMMON DIRECTORS/OFFICERS/KEY EMPLOYEES, KHS IS PARENT ORGANIZATION OF KCH 11,135,722 KISHHEALTH SYSTEM (KHS) IS THE PARENT ORGANIZATION OF KISHWAUKEE COMMUNITY HOSPITAL. THE PURPOSE OF KHS IS TO PROVIDE MANAGEMENT AND SUPPORT SERVICES TO ITS RELATED ORGANIZATIONS, ALL OF WHICH PROVIDE HEALTHCARE SERVICES. FEES PAID TO KHS ARE IN EXCHANGE FOR THESE SERVICES, INCLUDING THE ORGANIZATIONS SHARE OF COMPENSATION OF DIRECTORS, OFFICERS, AND KEY EMPLOYEES.   No
(2) KISHHEALTH SYSTEM
  		COMMON DIRECTORS/OFFICERS/KEY EMPLOYEES, KHS IS PARENT ORGANIZATION OF KCH 1,880,000 DURING THE CURRENT YEAR, KISHWAUKEE COMMUNITY HOSPITAL ALSO MADE A AN EQUITY DISTRIBUTION BACK TO ITS PARENT ORGANIZATION.   No
(3) KISHHEALTH FOUNDATION
  		COMMON DIRECTORS/OFFICERS/KEY EMPLOYEES, BROTHER/SISTER AFFILIATE 1,026,644 KISHHEALTH FOUNDATION WAS ORGANIZED TO SUPPORT CHARITABLE HEALTHCARE ORGANIZATIONS. THE FOUNDATION ANNUALLY MAKES CONTRIBUTIONS TO KISHWAUKEE COMMUNITY HOSPITAL.   No
(4) DEKALB COUNTY HOSPICE
  		COMMON DIRECTORS/OFFICERS/KEY EMPLOYEES, BROTHER/SISTER AFFILIATE 302,107 DEKALB COUNTY HOSPICE (DCH) IS AN AFFILIATE OF KISHWAUKEE COMMUNITY HOSPITAL (SAME PARENT CORPORATION). KCH IS UTILIZED BY DEKALB COUNTY HOSPICE FOR MEDICAL TREATMENTS AND SUPPLIES.   No
(5) DEKALB COUNTY HOSPICE
  		COMMON DIRECTORS/OFFICERS/KEY EMPLOYEES, BROTHER/SISTER AFFILIATE 47,736 KISHWAUKEE COMMUNITY HOSPITAL (KCH) IS AN AFFILIATE OF DEKALB COUNTY HOSPICE (SAME PARENT CORPORATION). DEKALB COUNTY HOSPICE RENTS SPACE IN THE BUILDING OWNED BY KCH.   No
(6) KISHHEALTH FOUNDATION
  		COMMON DIRECTORS/OFFICERS/KEY EMPLOYEES, BROTHER/SISTER AFFILIATE 262,472 KISHWHEALTH FOUNDATION UTILIZES EMPLOYEES OF KISHWAUKEE COMMUNITY HOSPITAL. EMPLOYEES ARE LEASED FROM KISHWAUKEE COMMUNITY HOSPTIAL.   No
(7) HEALTH PROGRESS INC
  		COMMON DIRECTORS/OFFICERS/KEY EMPLOYEES, BROTHER/SISTER AFFILIATE 8,576 KISHWAUKEE COMMUNITY HOSPITAL PROVIDES FOR HOUSEKEEPING SERVICES UTILIZED BY HEALTH PROGRESS, INC.   No
(8) VALLEY WEST COMMUNITY HOSPITAL
  		COMMON DIRECTORS/OFFICERS/KEY EMPLOYEES, BROTHER/SISTER AFFILIATE 3,917,755 KISHWAUKEE COMMUNITY HOSPITAL ROUTINELY SELLS SUPPLIES AND SERVICES TO VALLEY WEST COMMUNITY HOSPITAL AS PART OF ITS DAY-TO-DAY BUSINESS.   No
(9) COMMUNITY CARES CLINIC INC
  		COMMON DIRECTORS/OFFICERS/KEY EMPLOYEES, BROTHER/SISTER AFFILIATE 276,491 KISHWAUKEE COMMUNITY HOSPITAL PROVIDES MEDICAL SERVICES AND STAFF TO THE CLINIC. FEES PAID TO KCH ARE IN EXCHANGE FOR THESE SERVICES.   No
Part V
Supplemental Information
Complete this part to provide additional information for responses to questions on Schedule L (see instructions).
Identifier Return Reference Explanation
Schedule L (Form 990 or 990-EZ) 2010

Additional Data


Software ID:  
Software Version:  




SCHEDULE O
(Form 990 or 990-EZ)

Department of the Treasury
Internal Revenue Service
Supplemental Information to Form 990 or 990-EZ

Complete to provide information for responses to specific questions on
Form 990 or to provide any additional information.
MediumBullet Attach to Form 990 or 990-EZ.
OMB No. 1545-0047
2010
Open to Public
Inspection
Name of the organization
KISHWAUKEE COMMUNITY HOSPITAL
 
Employer identification number

23-7087041
Identifier Return Reference Explanation
FORM 990, PART VI, SECTION A, LINE 2   KEVIN POORTEN AND LOREN FOELSKE ARE BOTH EMPLOYEES OF KISHHEALTH SYSTEM, THE PARENT ORGANIZATION OF KISHWAUKEE COMMUNITY HOSPITAL. MR. POORTEN IS PRESIDENT AND CEO OF KISHWHEALTH SYSTEM AND SERVES AS AN EX-OFFICIO DIRECTOR FOR ALL ORGANIZATIONS RELATED TO KISHHEALTH SYSTEM. MR. FOELSKE SERVES AS THE VICE-PRESIDENT - FINANCE OF KISHHEALTH SYSTEM, WHICH IS THE PARENT ORGANIZATION FOR ALL RELATED ENTITIES. MICHAEL MOONEY AND MICHAEL CULLEN ARE MEMBERS OF THE KISHWAUKEE COMMUNITY HOSPITAL BOARD OF DIRECTORS. THEY ALSO SERVE ON THE BOARD OF DIRECTORS OF KISHHEALTH SYSTEM, THE PARENT ORGANIZATION OF KISHWAUKEE COMMUNITY HOSPITAL. THE FOLLOWING INDIVIDUALS ARE OFFICERS OR KEY EMPLOYEES OF KISHHEALTH SYSTEM AND ARE ALSO CONSIDERED OFFICERS OR KEY EMPLOYEES OF KISHWAUKEE COMMUNITY HOSPITAL. THEY ARE ALL COMPENSATED BY KISHHEALTH SYSTEM: BRAD COPPLE, PRESIDENT KCH & VWCH PAM DUFFY, VP PATIENT CARE JOE DANT, VP DEVELOPMENT MIKE KOKOTT, ASST. VP MARKETING HEATH BELL, VP AND CHIEF INFORMATION OFFICER MARK THATE, VP HUMAN RESOURCES DR. MICHAEL KULISZ, CHIEF MEDICAL OFFICER
FORM 990, PART VI, SECTION A, LINE 6   KISHHEALTH SYSTEM IS THE SOLE MEMBER OF KISHWAUKEE COMMUNITY HOSPITAL.
FORM 990, PART VI, SECTION A, LINE 7A   AS THE SOLE MEMBER AND PARENT ORGANIZATION OF KISHWAUKEE COMMUNITY HOSPITAL, KISHHEALTH SYSTEM HAS THE RIGHT TO APPROVE THE ELECTION OF MEMBERS OF THE HOSPITAL'S GOVERNING BOARD, PER THE HOSPITAL'S BYLAWS.
FORM 990, PART VI, SECTION A, LINE 7B   KISHHEALTH SYSTEM (KHS) SERVES AS THE SOLE MEMBER AND PARENT ORGANIZATION OF VALLEY WEST COMMUNITY HOSPITAL (VWCH). PER THE BYLAWS, WITH RESPECT TO THE GOVERNANCE OF VWCH, THE FOLLOWING POWERS SHALL BE RESERVED TO THE SOLE CORPORATE MEMBER. PER THE BYLAWS, WITH RESPECT TO THE GOVERNANCE OF KCH, THE FOLLOWING POWERS SHALL BE RESERVED TO THE SOLE CORPORATE MEMBER: A. ELECTING THE MEMBERS OF THE KCH BOARD; B. APPROVING, EVALUATING AND/OR REMOVING THE PRESIDENT AND CEO AND REVIEWING AND APPROVING THE EMPLOYMENT CONTRACT OF THE PRESIDENT AND CEO AND ESTABLISHING COMPENSATION FOR SUCH OFFICE; C. APPROVING THE STRATEGIC PLAN FOR KCH; D. APPROVING THE DISPOSITION OF ANY ASSETS OTHER THAN IN THE ORDINARY COURSE OF BUSINESS FOR KCH; E. APPROVING ANY CHANGE IN MEMBERSHIP OF KCH; F. APPROVING THE ADOPTION OF AND AMENDMENTS TO THE ORGANIZATIONAL DOCUMENTS, INCLUDING THE ARTICLES OF INCORPORATION AND BYLAWS OF KCH; G. APPROVING A PLAN OF MERGER OR A PLAN OF CONSOLIDATION OF KCH OR ESTABLISHING A NEW SUBSIDIARY OR SISTER ENTITY; H. APPROVING A PLAN FOR THE DISTRIBUTION OF THE ASSETS OF KCH; I. INITIATING, TAKING ANY AND ALL ACTIONS, AND EXERCISING ALL APPROVAL RIGHTS OF THE DIRECTORS PURSUANT TO THE APPLICABLE MEDICAL STAFF BYLAWS; J. IMPLEMENTING AND MONITORING KCH OPERATIONAL QUALITY IMPROVEMENT POLICIES AND PROGRAMS; K. ACCEPTING GIFTS, GRANTS, BEQUESTS AND DONATIONS ON BEHALF OF KCH; L. APPROVAL OF THE ANNUAL OPERATING AND CAPITAL BUDGETS FOR KCH; M. EXERCISING ANY RIGHTS THAT KCH HAS AS A SHAREHOLDER OR MEMBER OF ANY SUBSIDIARY ENTITY; N. APPROVING ANY AFFILIATIONS OF KCH; O. APPROVING AND/OR DETERMINING (I) THE CREATION OF NEW HEALTH SERVICES TO BE PROVIDED AND THE LOCATION OF SUCH HEALTH SERVICES AND (II) THE DISCONTINUANCE OF ANY HEALTH SERVICE; P. AUTHORIZING THE SALE, LEASE, EXCHANGE OR MORTGAGE OF ALL OR SUBSTANTIALLY ALL OF THE PROPERTY OR ASSETS OF KCH; Q. AUTHORIZING THE VOLUNTARY DISSOLUTION OF KCH, OR REVOKING THE PROCEEDINGS THEREOF; R. REQUIRING MINUTES OF MEETINGS, FINANCIAL RECORDS, AND SUCH OTHER INFORMATION AS MAY BE NECESSARY TO PROPERLY EVALUATE THE PERFORMANCE OF KCH; S. INITIATING ACTION TO REMOVE OR REINSTATE A DIRECTOR WHEN, IN THE OPINION OF THE KHS BOARD, IT IS IN THE BEST INTERESTS OF KHS OR KCH. ANY ACTION TO REMOVE OR REINSTATE SHALL REQUIRE A MAJORITY VOTE OF THOSE KHS DIRECTORS THEN IN OFFICE PRESENT AND VOTING AT A MEETING OF THE KHS BOARD AT WHICH A QUORUM IS PRESENT. IN ANY ACTION(S) TO REMOVE TAKEN BY THE KHS BOARD, THE DIRECTOR IN QUESTION SHALL BE ADVISED AT LEAST TWENTY (20) DAYS PRIOR TO THE MEETING THAT THE ACTION WILL BE CONSIDERED AND SHALL BE GIVEN THE OPPORTUNITY TO MAKE A STATEMENT, PRESENT WITNESSES ON HIS/HER BEHALF AND QUESTION THOSE PRESENTING REASONS FOR HIS/HER REMOVAL. ALL ACTIONS TO REMOVE SHALL BE TAKEN IN CLOSED SESSIONS OF THE KHS BOARD; AND T. TRANSFERRING MONEY OR PROPERTY AMONG KCH, KHS AND/OR ONE OR MORE SUBSIDIARY CORPORATIONS AND TRANSFERRING MONEY OR PROPERTY FROM A SUBSIDIARY CORPORATION, INCLUDING REQUIRING THE DIRECTORS, OFFICERS, OR TRUSTEES OF ANY SUBSIDIARY CORPORATION TO TRANSFER MONEY OR OTHER PROPERTY TO KHS. SUBJECT TO THE POWERS OF THE BOARD OF DIRECTORS OF EACH SUBSIDIARY CORPORATION, THE KHS BOARD MAY INITIATE AND TAKE THE FOREGOING ACTIONS ON BEHALF OF KHS AND THE SUBSIDIARY CORPORATIONS.
FORM 990, PART VI, SECTION B, LINE 11   A DRAFT COPY OF FORM 990 IS PROVIDED TO THE GOVERNING BODY (BOARD OF DIRECTORS) AND THE GOVERANCE COMMITTEE FOR REVIEW BY THE RETURN PREPARER PRIOR TO FILING. THE ORGANIZATION'S CEO, CFO, AND OTHER MEMBERS OF THE ACCOUNTING DEPARTMENT ARE ALSO PROVIDED A COPY OF THE RETURN FOR THEIR REVIEW. THE CHAIR OF THE AUDIT COMMITTEE AND THE AUDIT COMMITTEE MEMBERS ARE ALSO PROVIDED DRAFT COPIES AND REVIEW. IF CHANGES ARE NECESSARY, THEY ARE REPORTED TO THE RETURN PREPARER AND INCORPORATED INTO THE FINAL RETURN.
  FORM 990, PART VI, SECTION B, LINE 12C CONFLICTS OF INTEREST ARE INVESTIGATED BY APPOINTED MEMBERS OF THE GOVERANCE COMMITTEE ON AN ONGOING BASIS. IF IT IS DETERMINED THAT AN INDIVIDUAL FAILED TO DISCLOSE AN ACTUAL OR POSSIBLE CONFLICT OF INTEREST, IT SHALL INFORM THE INDIVIDUAL OF SUCH A BELIEF AND AFFORD HIM AN OPPORTUNITY TO EXPLAIN. AFTER SAID EXPLANATION, THE BOARD SHALL TAKE APPROPRIATE DISCIPLINARY AND CORRECTIVE ACTION AS DEEMED NECESSARY. THE CONFLICT OF INTEREST POLICY IS REVIEWED BY THE BOARD ANNUALLY AND UPDATED AS NEEDED.
  FORM 990, PART VI, SECTION B, LINE 15 THROUGH THE OVERSIGHT OF THE BOARD OF DIRECTORS EXECUTIVE COMPENSATION COMMITTEE, THE KISHHEALTH SYSTEM EXECUTIVE TOTAL COMPENSATION PROGRAM WILL BE COMPETITIVELY POSITIONED IN THE MARKET PLACE OF RELEVANT ORGANIZATIONS AND FALL WITHIN THE SAFE HARBOR GUIDELINES ESTABLISHED BY THE INTERMEDIATE SANCTIONS RULES. THE EXECUTIVE COMPENSATION COMMITTEE IS MADE UP OF THREE MEMBERS OF THE BOARD OF DIRECTORS WHO MEET THE BOARD APPROVED DEFINITION OF "INDEPENDENT DIRECTORS". ANNUALLY THE EXECUTIVE COMPENSATION COMMITTEE CONTRACTS WITH SULLIVAN, COTTER AND ASSOCIATES, AN INDEPENDENT HUMAN RESOURCES CONSULTING FIRM TO PROVIDE THE COMMITTEE ANALYSIS AND COMPARABILITY DATA. USING THE SUPPLIED DATA THE COMPENSATION COMMITTEE APPROVES EACH EXECUTIVE'S TOTAL CASH COMPENSATION AND PROVIDES CONTEMPORANEOUS SUBSTANTIATION OF THE DELIBERATION AND DECISION. TOTAL CASH COMPENSATION IS DEFINED AS THE SUM OF BASE SALARIES PLUS INCENTIVE AWARDS. BASED ON THE COMPARABILITY DATA AND THE PERFORMANCE OF EACH EXECUTIVE IN MEETING GOALS AND STRATEGIC OBJECTIVES, THE EXECUTIVE COMPENSATION COMMITTEE APPROVES INCREASES AND INCENTIVE AWARDS FOR EACH EXECUTIVE WITHIN THE GUIDELINES ESTABLISHED. THE EXECUTIVE COMPENSATION COMMITTEE REPORTS ON ALL COMPENSATION MATTERS TO THE FULL BOARD OF DIRECTORS.
  FORM 990, PART VI, SECTION C, LINE 19 THE ORGANIZATION'S GOVERNING DOCUMENTS ARE AVAILABLE TO THE PUBLIC UPON REQUEST IN WRITING TO ADMINISTRATION.
DESCRIPTION OF HOURS FOR RELATED ORGANIZATIONS FORM 990, PART VII, COLUMN (B) AVERAGE HOURS PER WEEK FOR THE INDIVIDUALS IDENTIFIED AS OFFICER'S ARE ESTIMATES OF THE INDIVIDUALS TOTAL TIME PER WEEK UTILIZED FOR WORK RELATED TO KISHWAUKEE COMMUNITY HOSPITAL.
CHANGES IN NET ASSETS OR FUND BALANCES: FORM 990, PART XI, LINE 5: NET UNREALIZED GAINS ON INVESTMENTS: 7,085,798. EQUITY DISTRIBUTION TO KISHHEALTH SYSTEM -1,880,000. CHANGE OF INTEREST IN NET ASSETS OF KISHHEALTH FOUNDATION -100,514. BOOK/TAX DIFFERENCES IN K-1 PASSTHROUGH ENTITIES -101,198. GRANT REVENUE INCLUDED IN FIXED ASSETS FOR FINANCIAL STATEMENT PURPOSES -30,659. TOTAL TO FORM 990, PART XI, LINE 5: 4,973,427.
RESPONSIBILITY FOR OVERSIGHT OF FINANCIAL STATEMENTS FORM 990, PART XI, LINE 2C NO CHANGES IN THIS PROCESS WERE MADE DURING THE TAX YEAR. THE ORGANIZATION MAINTAINS AN INDEPENDENT AUDIT COMMITTEE WHICH IS RESPONSIBLE FOR OVERSIGHT OF THE AUDITED FINANCIAL STATEMENTS. THIS COMMITTEE IS ALSO RESPONSIBLE FOR THE SELECTION OF THE INDEPENDENT AUDITOR. MEMBERS OF THE AUDIT COMMITTEE ARE ALSO MEMBERS OF THE KISHHEALTH SYSTEM BOARD OF DIRECTORS.
For Paperwork Reduction Act Notice, see the Instructions for Form 990 or 990-EZ.
Cat. No. 51056K
Schedule O (Form 990 or 990-EZ) 2010

Additional Data


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SCHEDULE R
(Form 990)
Department of the Treasury
Internal Revenue Service
Related Organizations and Unrelated Partnerships
MediumBulletComplete if the organization answered "Yes" to Form 990, Part IV, line 33, 34, 35, 36, or 37.
MediumBulletAttach to Form 990. MediumBullet See separate instructions.

OMB No. 1545-0047
2010
Open to Public Inspection
Name of the organization
KISHWAUKEE COMMUNITY HOSPITAL
 
Employer identification number

23-7087041
Part I
Identification of Disregarded Entities (Complete if the organization answered "Yes" on Form 990, Part IV, line 33.)
(a)
Name, address, and EIN of disregarded entity


(b)
Primary activity


 		(c)
Legal domicile (state
or foreign country)

 		(d)
Total income
(e)
End-of-year assets


 		(f)
Direct controlling
entity

















Part II
Identification of Related Tax-Exempt Organizations (Complete if the organization answered "Yes" on Form 990, Part IV, line 34 because it had one or more related tax-exempt organizations during the tax year.)
(a)
Name, address, and EIN of related organization


(b)
Primary activity


 		(c)
Legal domicile (state
or foreign country)

 		(d)
Exempt Code section
(e)
Public charity status
(if section 501(c)(3))

 		(f)
Direct controlling
entity

 		(g)
Section 512(b)(13) controlled organization
Yes No
(1) KISHHEALTH SYSTEM

ONE KISH HOSPITAL DRIVE

DEKALB,IL60115
36-3649080 		PARENT ORGANIZATION OF 501(C)(3) HEALTH SYSTEM IL 501(C)(3) 11B N/A
 
No
(2) VALLEY WEST COMMUNITY HOSPITAL

ONE KISH HOSPITAL DRIVE

DEKALB,IL60115
36-4244337 		HEALTHCARE SERVICES, PRIMARILY ACUTE CARE IL 501(C)(3) 3 N/A
 
No
(3) DEKALB COUNTY HOSPICE

2727 SYCAMORE ROAD 1B

DEKALB,IL60115
36-3164329 		HEALTHCARE SERVICES, HOSPICE SERVICES IL 501(C)(3) 7 N/A
 
No
(4) KISHHEALTH FOUNDATION

ONE KISH HOSPITAL DRIVE

DEKALB,IL60115
36-3649077 		SUPPORT OF KISHWAUKEE HEALTH SYSTEM NOT FOR PROFIT ENTITIES IL 501(C)(3) 7 N/A
 
No
(5) COMMUNITY CARES CLINIC

3100 SYCAMORE ROAD

DEKALB,IL60115
80-0424001 		HEALTHCARE SERVICES, PRIMARY CARE IL 501(C)(3) 3  
 
No
(6) H-R EYE INSTITUTE

2240 GATEWAY DRIVE

SYCAMORE,IL60178
 HEALTHCARE SERVICES IL 501(C)(3) 3 N/A
 
No


For Privacy Act and Paperwork Reduction Act Notice, see the Instructions for Form 990.
Cat. No. 50135Y
Schedule R (Form 990) 2010
Schedule R (Form 990) 2010
Page 2
Part III
Identification of Related Organizations Taxable as a Partnership (Complete if the organization answered "Yes" on Form 990, Part IV, line 34 because it had one or more related organizations treated as a partnership during the tax year.)
(a)
Name, address, and EIN of
related organization



 		(b)
Primary activity




 		(c)
Legal
domicile
(state or foreign
country)


 		(d)
Direct controlling
entity



 		(e)
Predominant income(related, unrelated, excluded from tax under sections 512-514)

(f)
Share of total income




 		(g)
Share of end-of-year
assets



 		(h)
Disproprtionate allocations?




 		(i)
Code V—UBI
amount in box 20 of
Schedule K-1
(Form 1065)
 		(j)
General or
managing
partner?



 		(k)
Percentage
ownership
Yes No Yes No
(1) KISHWAUKEE AREA PHO

ONE KISH HOSPITAL DRIVE
DEKALB,IL60115
36-4205273 		MEDICARE SERVICES IL  
RELATED -24,246 15,399   No     No 50.000 %
(2) THE MIDLAND SURGICAL CENTER LLC

3085 WOLF COURT
DEKALB,IL60115
35-2194610 		SURGICAL SERVICES IL  
RELATED 618,461 1,242,703   No     No 77.500 %










Part IV
Identification of Related Organizations Taxable as a Corporation or Trust (Complete if the organization answered "Yes" on Form 990, Part IV, line 34 because it had one or more related organizations treated as a corporation or trust during the tax year.)
(a)
Name, address, and EIN of related organization



 		(b)
Primary activity



 		(c)
Legal domicile
(state or
foreign
country)
 		(d)
Direct controlling
entity


 		(e)
Type of entity
(C corp, S corp,
or trust)

 		(f)
Share of total income



 		(g)
Share of
end-of-year
assets

 		(h)
Percentage
ownership
(1) HEALTH PROGRESS INC
ONE KISH HOSPITAL DRIVE
DEKALB,IL60115
36-3824138 		INVESTMENT IN HEALTHCARE RELATED SMALL BUSINESS IL N/A
 C      












Schedule R (Form 990) 2010
Schedule R (Form 990) 2010
Page 3
Part V
Transactions With Related Organizations (Complete if the organization answered "Yes" on Form 990, Part IV, line 34, 35, 35A, or 36.)
Note. Complete line 1 if any entity is listed in Parts II, III or IV.
Yes
No
1 During the tax year, did the orgranization engage in any of the following transactions with one or more related organizations listed in Parts II-IV?
a Receipt of (i) interest (ii) annuities (iii) royalties (iv) rent from a controlled entity . . . . . . . . . . . . . . . . . . . . . . .
1a
 
No
b Gift, grant, or capital contribution to other organization(s) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1b
Yes
 
c Gift, grant, or capital contribution from other organization(s) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1c
Yes
 
d Loans or loan guarantees to or for other organization(s) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1d
 
No
e Loans or loan guarantees by other organization(s) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1e
 
No
f Sale of assets to other organization(s) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1f
 
No
g Purchase of assets from other organization(s) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1g
 
No
h Exchange of assets . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1h
 
No
i Lease of facilities, equipment, or other assets to other organization(s) . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1i
Yes
 
j Lease of facilities, equipment, or other assets from other organization(s) . . . . . . . . . . . . . . . . . . . . . . . . . . .
1j
 
No
k Performance of services or membership or fundraising solicitations for other organization(s) . . . . . . . . . . . . . . . . . . . . . .
1k
 
No
l Performance of services or membership or fundraising solicitations by other organization(s) . . . . . . . . . . . . . . . . . . . . . .
1l
 
No
m Sharing of facilities, equipment, mailing lists, or other assets . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1m
 
No
n Sharing of paid employees . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1n
Yes
 
o Reimbursement paid to other organization for expenses . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1o
Yes
 
p Reimbursement paid by other organization for expenses . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1p
Yes
 
q Other transfer of cash or property to other organization(s) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1q
Yes
 
r Other transfer of cash or property from other organization(s) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1r
Yes
 
2
If the answer to any of the above is "Yes," see the instructions for information on who must complete this line, including covered relationships and transaction thresholds.
(a)
Name of other organization 		(b)
Transaction
type(a-r) 		(c)
Amount involved 		(d)
Method of determining amount involved
(1)
(2)
(3)
(4)
(5)
(6)
Schedule R (Form 990) 2010
Schedule R (Form 990) 2010
Page 4
Part VI
Unrelated Organizations Taxable as a Partnership (Complete if the organization answered "Yes" on Form 990, Part IV, line 37.)
Provide the following information for each entity taxed as a partnership through which the organization conducted more than five percent of its activities (measured by total assets or gross revenue) that was not a related organization. See instructions regarding exclusion for certain investment partnerships.
(a)
Name, address, and EIN of entity 		(b)
Primary activity 		(c)
Legal domicile
(state or foreign
country) 		(d)
Are all
partners
section
501(c)(3)
organizations? 		(e)
Share of
end-of-year
assets 		(f)
Disproprtionate allocations? 		(g)
Code V—UBI
amount in box
20 of Schedule K-1
(Form 1065) 		(h)
General or
managing
partner?
Yes No Yes No Yes No






























Schedule R (Form 990) 2010
Schedule R (Form 990) 2010
Page 5
Part VII
Supplemental Information
Complete this part to provide additional information for responses to questions on Schedule R (see instructions).
Identifier Return Reference Explanation
Additional Data


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