TY 2012 Form 990

(A) Name and Title	(B) Average hours per week (list any hours for related organizations below dotted line)	(C) Position (do not check more than one box, unless person is both an officer and a director/trustee)	(E) Reportable compensation from related organizations (W- 2/1099-MISC)
(1) STEVEN BROADUS........................................................................ CHAIR/B.O.D.	1.0 .......................	X	X		0	0	0
(2) SR MARYBETH CULNAN OSF........................................................................ MBR. B.O.D.	1.0 .......................59.0	X			0	0	0
(3) PATRICK GIBBONS........................................................................ MBR. BOARD OF DIRECTORS	1.0 .......................	X			0	0	0
(4) SHERYL KUZMA........................................................................ MBR. BOARD OF DIRECTORS	1.0 .......................	X			0	0	0
(5) JIMMIE LANSFORD........................................................................ SECRETARY B.O.D.	1.0 .......................	X	X		0	0	0
(6) EVERETT J SOLON........................................................................ VICE CHAIR/ B.O.D.	1.0 .......................	X	X		0	0	0
(7) WILLIAM FRANKLIN........................................................................ MBR. B.O.D.	1.0 .......................	X			0	0	0
(8) WILLIAM E EHLING MD........................................................................ MBR. BOARD OF DIRECTORS	1.0 .......................	X			0	0	0
(9) SR MAUREEN FAGAN OSF........................................................................ MBR. B.O.D.	1.0 .......................	X			0	0	0
(10) JOHN FLANDERS........................................................................ PRESIDENT/CEO	40.0 .......................	X	X		0	135,827	40,629
(11) TIMOTHY KENNEY........................................................................ MBR. B.O.D.	1.0 .......................	X			0	0	0
(12) MARK WARGO MD........................................................................ MBR. B.O.D.	1.0 .......................	X			0	242,414	22,167
(13) ANN CARR........................................................................ TREASURER	.25 .......................59.75		X		0	272,146	138,031
(14) KEVIN KAST........................................................................ DIVISION CEO	1.0 .......................		X		0	585,194	114,028
(15) KAREN CLARK........................................................................ CHIEF FINANCIAL OFFICER	40.0 .......................		X		172,700	0	8,812
(16) MARK DABBS........................................................................ COO/CNO	40.0 .......................		X		197,594	0	41,279
(17) DONALD DAMRON........................................................................ DIR. REHAB & ORTHO	40.0 .......................			X	105,746	0	23,665

(A) Name and business address	(B) Description of services	(C) Compensation
Emergency Medical Experts LTD, 1401 South Prairie AvenueCHICAGOIL60605	Emergency MD	1,643,333
Anesthesia Pain Services LLC, 1800 E Lake Shore DrDECATURIL62521	Anesthesia MD	1,221,630
Immediate Care Experts LLC, 1401 South Prairie AvenueCHICAGOIL60605	Immediate Care MD	1,109,861
Comphealth Medical Staffing, PO Box 972670DALLASTX753972670	Staffing	211,476
Executive Health Resources Inc, PO Box 822688PHILADELPHIAPA191822688	Compliance Services	210,324
2 Total number of independent contractors (including but not limited to those listed above) who received more than $100,000 of compensation from the organization 45

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 United States. See Part IV, line 21	0
2	Grants and other assistance to individuals in the United States. See Part IV, line 22	0
3	Grants and other assistance to governments, organizations, and individuals outside the United States. See Part IV, lines 15 and 16	0
4	Benefits paid to or for members	0
5	Compensation of current officers, directors, trustees, and key employees ....	438,025		438,025
6	Compensation not included above, to disqualified persons (as defined under section 4958(f)(1)) and persons described in section 4958(c)(3)(B) ....	0
7	Other salaries and wages	15,598,973	12,110,620	3,488,353
8	Pension plan accruals and contributions (include section 401(k) and 403(b) employer contributions) ....	1,929,923	1,406,678	523,245
9	Other employee benefits .......	3,447,799	2,513,024	934,775
10	Payroll taxes ...........	1,172,250	854,427	317,823
11	Fees for services (non-employees):
a	Management ......	0
b	Legal .........	29,207		29,207
c	Accounting ...........	0
d	Lobbying ...........	21,502		21,502
e	Professional fundraising services. See Part IV, line 17	0
f	Investment management fees ......	0
g	Other (If line 11g amount exceeds 10% of line 25, column (A) amount, list line 11g expenses on Schedule O) ........	9,479,321	6,531,448	2,947,873
12	Advertising and promotion ....	230,382	52,499	177,883
13	Office expenses .......	6,480,637	5,924,989	555,648
14	Information technology ......	1,048,660	230,696	817,964
15	Royalties ..	0
16	Occupancy ...........	1,174,147	1,075,577	98,570
17	Travel ............	57,784	48,377	9,407
18	Payments of travel or entertainment expenses for any federal, state, or local public officials ......	67,260	31,746	35,514
19	Conferences, conventions, and meetings ....	188		188
20	Interest ...........	154,536		154,536
21	Payments to affiliates .......	3,446,656		3,446,656
22	Depreciation, depletion, and amortization .....	3,739,397	3,189,529	549,868
23	Insurance ..............	372,367	9,694	362,673
24	Other expenses. Itemize expenses not covered above (List miscellaneous expenses in line 24e. If line 24e amount exceeds 10% of line 25, column (A) amount, list line 24e expenses on Schedule O.)
a	BAD DEBT EXPENSE	1,815,683	1,815,683	0
b	MISCELLANEOUS	1,030,114	183,130	846,984
c	REFERRAL LAB	526,787	526,787	0
d	DUES AND SUBSCRIPTIONS	102,854	6,965	95,889
e	All other expenses
25	Total functional expenses. Add lines 1 through 24e	52,364,452	36,511,869	15,852,583	0
26	Joint costs. Complete this line only if the organization reported in column (B) joint costs from a combined educational campaign and fundraising solicitation. Check here if following SOP 98-2 (ASC 958-720).

Part X Balance Sheet Check if Schedule O contains a response to any question in this Part X ...............
	1	Cashnon-interest-bearing .............	1,349	1	1,349
2	Savings and temporary cash investments .........	-421,339	2	-507,730
3	Pledges and grants receivable, net ...........	0	3	0
4	Accounts receivable, net .............	8,015,880	4	7,178,815
5	Loans and other receivables from current and former officers, directors, trustees, key employees, and highest compensated employees. Complete Part II of Schedule L ..................
		0	5	0
6	Loans and other receivables from other disqualified persons (as defined under section 4958(f)(1)), persons described in section 4958(c)(3)(B), and contributing employers and sponsoring organizations of section 501(c)(9) voluntary employees' beneficiary organizations (see instructions) Complete Part II of Schedule L
		0	6	0
7	Notes and loans receivable, net .............	0	7	0
8	Inventories for sale or use ..............	931,503	8	921,882
9	Prepaid expenses and deferred charges ..........	477,871	9	350,634
10a	Land, buildings, and equipment: cost or other basis. Complete Part VI of Schedule D	10a	80,414,173
b	Less: accumulated depreciation .....	10b	42,795,946	39,539,392	10c	37,618,227
11	Investments—publicly traded securities ..........	26,661,215	11	26,969,311
12	Investments—other securities. See Part IV, line 11 .....	0	12	0
13	Investments—program-related. See Part IV, line 11 .....	43,791	13	43,794
14	Intangible assets ...............	0	14	0
15	Other assets. See Part IV, line 11 ...........	7,021,048	15	8,321,641
16	Total assets. Add lines 1 through 15 (must equal line 34)......	82,270,710	16	80,897,923
	17	Accounts payable and accrued expenses .........	8,587,515	17	7,563,925
18	Grants payable .................	0	18	0
19	Deferred revenue ................	0	19	0
20	Tax-exempt bond liabilities .............	12,622,783	20	12,680,045
21	Escrow or custodial account liability. Complete Part IV of Schedule D..	0	21	0
22	Loans and other payables to current and former officers, directors, trustees, key employees, highest compensated employees, and disqualified
	persons. Complete Part II of Schedule L..........	0	22	0
23	Secured mortgages and notes payable to unrelated third parties ..	0	23	0
24	Unsecured notes and loans payable to unrelated third parties ....	0	24	0
25	Other liabilities (including federal income tax, payables to related third parties, and other liabilities not included on lines 17-24). Complete Part X of Schedule D....................	17,963,387	25	11,275,565
26	Total liabilities. Add lines 17 through 25.........	39,173,685	26	31,519,535
		Organizations that follow SFAS 117 (ASC 958), check here and complete lines 27 through 29, and lines 33 and 34.
27	Unrestricted net assets ..............	40,831,614	27	46,956,664
28	Temporarily restricted net assets ...........	2,184,308	28	2,339,264
29	Permanently restricted net assets ...........	81,103	29	82,460
	Organizations that do not follow SFAS 117 (ASC 958), check here 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 ...........	43,097,025	33	49,378,388
34	Total liabilities and net assets/fund balances ........	82,270,710	34	80,897,923

- TIN:

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.

Attach to Form 990 or Form 990-EZ. right arrow

See separate instructions.

OMB No. 1545-0047

2012

Open to Public
Inspection

Name of the organization

ST MARY'S HOSPITAL STREATOR HOSPITAL SISTERS
OF THE 3RD ORDER ST FRANCIS

Employer identification number

36-2169181

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.)

A church, convention of churches, or association of churches described in section 170(b)(1)(A)(i).

A school described in section 170(b)(1)(A)(ii). (Attach Schedule E.)

A hospital or a cooperative hospital service organization described in section 170(b)(1)(A)(iii).

A medical research organization operated in conjunction with a hospital described in section 170(b)(1)(A)(iii). Enter the hospital's name, city, and state:

An organization operated for the benefit of a college or university owned or operated by a governmental unit described in

section 170(b)(1)(A)(iv). (Complete Part II.)

A federal, state, or local government or governmental unit described in section 170(b)(1)(A)(v).

An organization that normally receives a substantial part of its support from a governmental unit or from the general public described in section 170(b)(1)(A)(vi). (Complete Part II.)

A community trust described in section 170(b)(1)(A)(vi). (Complete Part II.)

An organization that normally receives: (1) more than 331/3% of its support from contributions, membership fees, and gross

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.)

An organization organized and operated exclusively to test for public safety. See section 509(a)(4).

An organization organized and operated exclusively for the benefit of, to perform the functions of, or to carry out the purposes of one or more publicly supported organizations described in section 509(a)(1) or section 509(a)(2). See section 509(a)(3). Check the box that describes the type of supporting organization and complete lines 11e through 11h.

Type I

Type II

Type III - Functionally integrated

Type III - Non-functionally integrated

By checking this box, I certify that the organization is not controlled directly or indirectly by one or more disqualified persons other than foundation managers and other than one or more publicly supported organizations described in section 509(a)(1) or section 509(a)(2).

If the organization received a written determination from the IRS that it is a Type I, Type II, or Type III supporting organization, check this box ..................................................

Since August 17, 2006, has the organization accepted any gift or contribution from any of the
following persons?

(i) A person who directly or indirectly controls, either alone or together with persons described in (ii)

Yes

and (iii) below, the governing body of 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)

Provide the following information about the supported organization(s).

(i) Name of supported organization	(ii) EIN	(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 monetary support
(i) Name of supported organization	(ii) EIN	Yes	No	Yes	No	Yes	No	(vii) Amount of monetary support


Total

For Paperwork Reduction Act Notice, see the Instructions for Form 990 or 990EZ.

Cat. No. 11285F

Schedule A (Form 990 or 990-EZ) 2012

Page 2

Part II

Support Schedule for Organizations Described in Sections 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) 2008	(b) 2009	(c) 2010	(d) 2011	(e) 2012	(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) 2008	(b) 2009	(c) 2010	(d) 2011	(e) 2012	(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. Do not include gain or loss from the sale of capital assets (Explain in Part IV.)..
11	Total support (Add lines 7 through 10).

Gross receipts from related activities, etc. (see instructions) ..................

First five years. If the Form 990 is for the organization's first, second, third, fourth, or fifth tax year as a 501(c)(3) organization, check this box and stop here........................................ right arrow

Section C. Computation of Public Support Percentage

Public support percentage for 2012 (line 6, column (f) divided by line 11, column (f)) .........

Public support percentage for 2011 Schedule A, Part II, line 14 ...............

16a

33 1/3% support test—2012. If the organization did not check the box on line 13, and line 14 is 33 1/3% or more, check this box
and stop here. The organization qualifies as a publicly supported organization ....................... right arrow

33 1/3% support test—2011. If the organization did not check a box on line 13 or 16a, and line 15 is 33 1/3% or more, check this
box and stop here. The organization qualifies as a publicly supported organization ..................... right arrow

17a

10%-facts-and-circumstances test—2012. If the organization did not check a box on line 13, 16a, or 16b, and line 14
is 10% or more, and if the organization meets the "facts-and-circumstances" test, check this box and stop here. Explain
in Part IV how the organization meets the "facts-and-circumstances" test. The organization qualifies as a publicly supported
organization ..................................................... right arrow

10%-facts-and-circumstances test—2011. If the organization did not check a box on line 13, 16a, 16b, or 17a, and line
15 is 10% or more, and if the organization meets the "facts-and-circumstances" test, check this box and stop here.
Explain in Part IV how the organization meets the "facts-and-circumstances" test. The organization qualifies as a publicly
supported organization ................................................ right arrow

Private foundation. If the organization did not check a box on line 13, 16a, 16b, 17a, or 17b, check this box and see
instructions ..................................................... right arrow

Schedule A (Form 990 or 990-EZ) 2012

Page 3

Part III

Support Schedule for Organizations Described in Section 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) 2008	(b) 2009	(c) 2010	(d) 2011	(e) 2012	(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) 2008	(b) 2009	(c) 2010	(d) 2011	(e) 2012	(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.)..

First five years. If the Form 990 is for the organization's first, second, third, fourth, or fifth tax year as a 501(c)(3) organization,
check this box and stop here............................................. right arrow

Section C. Computation of Public Support Percentage

Public support percentage for 2012 (line 8, column (f) divided by line 13, column (f)) .........

Public support percentage from 2011 Schedule A, Part III, line 15 ...............

Section D. Computation of Investment Income Percentage

Investment income percentage for 2012 (line 10c, column (f) divided by line 13, column (f)) ......

Investment income percentage from 2011 Schedule A, Part III, line 17 .............

19a

33 1/3% support tests—2012. If the organization did not check the box on line 14, and line 15 is more than 33 1/3%, and line 17 is not more than 33 1/3%, check this box and stop here. The organization qualifies as a publicly supported organization ........ right arrow

33 1/3% support tests—2011. If the organization did not check a box on line 14 or line 19a, and line 16 is more than 33 1/3% and line 18 is not more than 33 1/3%, check this box and stop here. The organization qualifies as a publicly supported organization ..... right arrow

Private foundation. If the organization did not check a box on line 14, 19a, or 19b, check this box and see instructions ..... right arrow

Schedule A (Form 990 or 990-EZ) 2012

Page 4

Part IV

Supplemental Information. Complete this part to provide the explanations required by Part II, line 10; Part II, line 17a or 17b; and 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) 2012

Additional Data

Software ID:
Software Version:

- TIN:

Schedule B
(Form 990, 990-EZ,
or 990-PF)

Department of the Treasury
Internal Revenue Service

Schedule of Contributors

Attach to Form 990, 990-EZ, or 990-PF.

OMB No. 1545-0047

2012

Name of the organization

ST MARY'S HOSPITAL STREATOR HOSPITAL SISTERS
OF THE 3RD ORDER ST FRANCIS

Employer identification number

36-2169181

Organization type (check one):

Filers of:

Section:

Form 990 or 990-EZ

501(c)( ) (enter number) organization

4947(a)(1) nonexempt charitable trust not treated as a private foundation

527 political organization

Form 990-PF

501(c)(3) exempt private foundation

4947(a)(1) nonexempt charitable trust treated as a private foundation

501(c)(3) taxable private foundation

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

For an organization filing Form 990, 990-EZ, or 990-PF that received, during the year, $5,000 or more (in money or
property) from any one contributor. Complete Parts I and II.

Special Rules

For a section 501(c)(3) organization filing Form 990 or 990-EZ that met the 33¹/3% support test of the regulations
under sections 509(a)(1) and 170(b)(1)(A)(vi) and received from any one contributor, during the year, a contribution of the
greater of (1) $5,000 or (2) 2% of the amount on (i) Form 990, Part VIII, line 1h, or (ii) Form 990-EZ, line 1. Complete Parts I and II.

For a section 501(c)(7), (8), or (10) organization filing Form 990 or 990-EZ that received from any one contributor,
during the year, total contributions of more than $1,000 for use exclusively for religious, charitable,
scientific, literary, or educational purposes, or the prevention of cruelty to children or animals. Complete Parts I, II, and
III.

For a section 501(c)(7), (8), or (10) organization filing Form 990 or 990-EZ that received from any one contributor,
during the year, contributions for use exclusively for religious, charitable, etc., purposes, but these contributions did
not total to more than $1,000. If this box is checked, enter here the total contributions that were received during
the year for an exclusively religious, charitable, etc., purpose. Do not complete any of the parts unless the General Rule
applies to this organization because it received nonexclusively religious, charitable, etc., contributions of $5,000 or more
during the year ......................... 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 on line H of its
Form 990-EZ or on Part I, 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) (2012)

Schedule B (Form 990, 990-EZ, or 990-PF) (2012)

Page 2

Name of organization ST MARY'S HOSPITAL STREATOR HOSPITAL SISTERS OF THE 3RD ORDER ST FRANCIS

Part I	Contributors (see instructions). Use duplicate copies of Part I if additional space is needed.
(a) No.	(b) Name, address, and ZIP + 4	(c) Total contributions	(d) Type of contribution
RESTRICTED	RESTRICTED RESTRICTED RESTRICTED RESTRICTED, RESTRICTED RESTRICTED	$RESTRICTED	Person Payroll Noncash (Complete Part II if there is a noncash contribution.)
(a) No.	(b) Name, address, and ZIP + 4	(c) Total contributions	(d) Type of contribution
		$	Person Payroll Noncash (Complete Part II if there is a noncash contribution.)
(a) No.	(b) Name, address, and ZIP + 4	(c) Total contributions	(d) Type of contribution
		$	Person Payroll Noncash (Complete Part II if there is a noncash contribution.)
(a) No.	(b) Name, address, and ZIP + 4	(c) Total contributions	(d) Type of contribution
		$	Person Payroll Noncash (Complete Part II if there is a noncash contribution.)
(a) No.	(b) Name, address, and ZIP + 4	(c) Total contributions	(d) Type of contribution
		$	Person Payroll Noncash (Complete Part II if there is a noncash contribution.)
(a) No.	(b) Name, address, and ZIP + 4	(c) Total contributions	(d) Type of contribution
		$	Person Payroll Noncash (Complete Part II if there is a noncash contribution.)
Schedule B (Form 990, 990-EZ, or 990-PF) (2012)

Schedule B (Form 990, 990-EZ, or 990-PF) (2012)

Page 3

Name of organization ST MARY'S HOSPITAL STREATOR HOSPITAL SISTERS OF THE 3RD ORDER ST FRANCIS

Part II	Noncash Property (see instructions). Use duplicate copies of Part II if additional space is needed.
(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) (2012)

Schedule B (Form 990, 990-EZ, or 990-PF) (2012)

Page 4

Name of organization
ST MARY'S HOSPITAL STREATOR HOSPITAL SISTERS
OF THE 3RD ORDER ST FRANCIS

Employer identification number

36-2169181

Part III

Exclusively religious, charitable, etc., individual contributions to section 501(c)(7), (8), or (10) organizations
that total 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

$
Use duplicate copies of Part III if additional space is needed.

(a) No.
from
Part I

(b) Purpose 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

(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

(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

(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) (2012)

Additional Data

Software ID:
Software Version:

- TIN:

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

2012

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 35c (Proxy Tax), then
Round Bullet

Section 501(c)(4), (5), or (6) organizations: Complete Part III.

Name of the organization

ST MARY'S HOSPITAL STREATOR HOSPITAL SISTERS
OF THE 3RD ORDER ST FRANCIS

Employer identification number

36-2169181

Part I-A

Complete if the organization is exempt under section 501(c) or is a section 527 organization.

Provide a description of the organization’s direct and indirect political campaign activities in Part IV.

Political expenditures .................................... SchCMd Bullet

Volunteer hours ........................................

Part I-B

Complete if the organization is exempt under section 501(c)(3).

Enter the amount of any excise tax incurred by the organization under section 4955 ......... SchCMd Bullet

Enter the amount of any excise tax incurred by organization managers under section 4955 ...... SchCMd Bullet

If the organization incurred a section 4955 tax, did it file Form 4720 for this year? ..............

Yes No

Was a correction made? .........................................

Yes No

If "Yes," describe in Part IV.

Part I-C

Complete if the organization is exempt under section 501(c), except section 501(c)(3).

Enter the amount directly expended by the filing organization for section 527 exempt function activities SchCMd Bullet

Enter the amount of the filing organization's funds contributed to other organizations for section 527 exempt function activities ................................... SchCMd Bullet

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

Did the filing organization file Form 1120-POL for this year? ..........................

Yes No

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 Paperwork Reduction Act Notice, see the instructions for Form 990 or 990-EZ.

Cat. No. 50084S

Schedule C (Form 990 or 990-EZ) 2012

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 SchCMd Bullet

if the filing organization belongs to an affiliated group (and list in Part IV each affiliated group member's name, address, EIN, expenses, and share of excess lobbying expenditures).
B Check SchCMd Bullet

if the filing organization checked box A and "limited control" provisions apply.

Limits on Lobbying Expenditures (The term "expenditures" means amounts paid or incurred.)		(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? ......................................	Yes No

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) 2009	(b) 2010	(c) 2011	(d) 2012	(e) Total

2a	Lobbying nontaxable amount

b	Lobbying ceiling amount (150% of line 2a, column(e))

c	Total lobbying expenditures

d	Grassroots nontaxable amount

e	Grassroots ceiling amount (150% of line 2d, column (e))

f	Grassroots lobbying expenditures

Schedule C (Form 990 or 990-EZ) 2012

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)).

For each “Yes” response to lines 1a through 1i below, provide in Part IV a detailed description of the lobbying activity.

(a)

Yes

(b)

Amount

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:

Volunteers? .........................................

Paid staff or management (include compensation in expenses reported on lines 1c through 1i)? ....

Media advertisements? ....................................

Mailings to members, legislators, or the public? .........................

Publications, or published or broadcast statements? .......................

Grants to other organizations for lobbying purposes? .......................

Direct contact with legislators, their staffs, government officials, or a legislative body? ........

Rallies, demonstrations, seminars, conventions, speeches, lectures, or any similar means? ......

Other activities? ..........................

Yes

21,502

Total. Add lines 1c through 1i ...............................

21,502

Did the activities in line 1 cause the organization to be not described in section 501(c)(3)? .....

If "Yes," enter the amount of any tax incurred under section 4912 .................

If "Yes," enter the amount of any tax incurred by organization managers under section 4912 .....

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

Were substantially all (90% or more) dues received nondeductible by members? ................

Did the organization make only in-house lobbying expenditures of $2,000 or less? ................

Did the organization agree to carry over lobbying and political expenditures from the prior year? ..........

Part III-B

Complete if the organization is exempt under section 501(c)(4), section 501(c)(5), or section 501(c)(6) and if either (a) BOTH Part III-A, lines 1 and 2, are answered “No” OR (b) Part III-A, line 3, is answered “Yes."

Dues, assessments and similar amounts from members .....................

Section 162(e) nondeductible lobbying and political expenditures (do not include amounts of political
expenses for which the section 527(f) tax was paid).

Current year .........................................

Carryover from last year ....................................

Total ............................................

Aggregate amount reported in section 6033(e)(1)(A) notices of nondeductible section 162(e) dues .

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? ................................

Taxable amount of lobbying and political expenditures (see instructions) ..............

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; Part II-A (affiliated group list); Part II-A, line 2; and Part ll-B, line 1. Also, complete this part for any additional information.

Identifier	Return Reference	Explanation
DESCRIPTION OF OTHER LOBBYING ACTIVITIES	SCHEDULE C, PART II B, QUESTION 1I	ST. MARY'S HOSPITAL ("THE HOSPITAL") IS A MEMBER OF THE CATHOLIC HEALTH ASSOCIATION (CHA), THE ILLINOIS HOSPITAL ASSOCIATION (IHA), THE NATIONAL ASSOCIATION FOR HOME CARE AND HOSPICE, AND THE AMERICAN HOSPITAL ASSOCIATION (AHA). AS A MEMBER OF THESE ORGANIZATIONS, THE HOSPITAL PAYS DUES AND PART OF THESE DUES ARE ATTRIBUTABLE TO LOBBYING FEES PAID BY THE ORGANIZATIONS. THE AMOUNT LISTED ABOVE IS THE AMOUNT ATTRIBUTABLE TO THE HOSPITAL FOR ITS DUES PAID.

Schedule C (Form 990 or 990EZ) 2012

Additional Data

Software ID:
Software Version:

- TIN:

SCHEDULE D
(Form 990)

Department of the Treasury
Internal Revenue Service

Supplemental Financial Statements

Complete if the organization answered "Yes," to Form 990,
Part IV, line 6, 7, 8, 9, 10, 11a, 11b, 11c, 11d, 11e, 11f, 12a, or 12b
SchDMd Bullet

Attach to Form 990. SchDMd Bullet

See separate instructions.

OMB No. 1545-0047

2012

Open to Public Inspection

Name of the organization

ST MARY'S HOSPITAL STREATOR HOSPITAL SISTERS
OF THE 3RD ORDER ST FRANCIS

Employer identification number

36-2169181

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 ........

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? ............

Yes No

Did the organization inform all grantees, donors, and donor advisors in writing that grant funds can 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? ...................................

Yes No

Part II

Conservation Easements. Complete if the organization answered "Yes" to Form 990, Part IV, line 7.

Purpose(s) of conservation easements held by the organization (check all that apply).

Preservation of land for public use (e.g., recreation or education) Preservation of an historically important land area

Protection of natural habitat Preservation of a certified historic structure

Preservation of open space

Complete lines 2a through 2d if the organization held a qualified conservation contribution in the form of a conservation easement on the last day of the tax 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, and not on a historic structure listed in the National Register ....................	2d

Number of conservation easements modified, transferred, released, extinguished, or terminated by the organization during
the tax year SchDMd Bullet

Number of states where property subject to conservation easement is located SchDMd Bullet

Does the organization have a written policy regarding the periodic monitoring, inspection, handling of violations, and
enforcement of the conservation easements it holds? .............................

Yes No

Staff and volunteer hours devoted to monitoring, inspecting, and enforcing conservation easements during the year
SchDMd Bullet

Amount of expenses incurred in monitoring, inspecting, and enforcing conservation easements during the year
SchDMd Bullet

Does each conservation easement reported on line 2(d) above satisfy the requirements of section 170(h)(4)(B)(i) and section 170(h)(4)(B)(ii)? .......................................

Yes No

In Part XIII, 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.

If the organization elected, as permitted under SFAS 116 (ASC 958), 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 XIII, the text of the footnote to its financial statements that describes these items.

If the organization elected, as permitted under SFAS 116 (ASC 958), 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

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 (ASC 958) relating to these items:

Revenues included in Form 990, Part VIII, line 1 .......................... SchDMd Bullet

Assets included in Form 990, Part X ............................... SchDMd Bullet

For Paperwork Reduction Act Notice, see the Instructions for Form 990.

Cat. No. 52283D

Schedule D (Form 990) 2012

Page 2

Part III

Organizations Maintaining Collections of Art, Historical Treasures, or Other Similar Assets (continued)

Using the organization’s acquisition, accession, and other records, check any of the following that are a significant use of its collection items (check all that apply):

Public exhibition

Loan or exchange programs

Scholarly research

Other

Preservation for future generations

Provide a description of the organization’s collections and explain how they further the organization’s exempt purpose in
Part XIII.

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?........

Yes No

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.

Is the organization an agent, trustee, custodian or other intermediary for contributions or other assets not
included on Form 990, Part X? ....................................

Yes No

If "Yes," explain the arrangement in Part XIII and complete the following table:


c	Beginning balance .................................	1c
d	Additions during the year ..............................	1d
e	Distributions during the year .............................	1e
f	Ending balance ...................................	1f

Did the organization include an amount on Form 990, Part X, line 21? .....................

Yes No

If “Yes,” explain the arrangement in Part XIII. Check here if the explanation has been provided in Part XIII ........

Part V

Endowment Funds. Complete if the organization answered "Yes" to Form 990, Part IV, line 10.

		(a)Current year	(b)Prior year	b (c)Two years back	(d)Three years back	(e)Four years back
1a	Beginning of year balance ....
b	Contributions ........
c	Net investment earnings, gains, and losses
d	Grants or scholarships .....
e	Other expenditures for facilities and programs ........
f	Administrative expenses ....
g	End of year balance ......

Provide the estimated percentage of the current year end balance (line 1g, column (a)) held as:

Board designated or quasi-endowment SchDMd Bullet

Permanent endowment SchDMd Bullet

Temporarily restricted endowment SchDMd Bullet

The percentages in lines 2a, 2b, and 2c should equal 100%.

Are there endowment funds not in the possession of the organization that are held and administered for the
organization by:

Yes

(i) unrelated organizations ........................

3a(i)

(ii) related organizations ........................

3a(ii)

If "Yes" to 3a(ii), are the related organizations listed as required on Schedule R? .........

Describe in Part XIII the intended uses of the organization's endowment funds.

Part VI

Land, Buildings, and Equipment. See Form 990, Part X, line 10.

Description of property		(b)Cost or other basis (other)	(c) Accumulated depreciation	(d) Book value
1a	Land .................	1,259,924		1,259,924
b	Buildings ................	51,577,759	21,929,694	29,648,065
c	Leasehold improvements ............	976,810	752,786	224,024
d	Equipment ................	26,294,997	20,113,466	6,181,531
e	Other .................	304,683		304,683
Total. Add lines 1a through 1e. (Column (d) must equal Form 990, Part X, column (B), line 10(c).).......				37,618,227

Schedule D (Form 990) 2012

Page 3

Part VII

InvestmentsOther 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
Other








Total. (Column (b) must equal Form 990, Part X, col. (B) line 12.)

Part VIII

InvestmentsProgram 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) must equal Form 990, Part X, col.(B) line 13.)

Part IX

Other Assets. See Form 990, Part X, line 15.

(a) Description				(b) Book value
(1) VALUATION RESERVE				3,821,324
(2) ASSETS WHOSE USE IS LIMITED				2,421,726
(3) WORKERS COMP HS				1,277,715
(4) A/R NON-PATIENT				456,686
(5) A/R FOUNDATION				788
(6) PAY ADJUSTMENT				1,965
(7) OTHER ASSETS				341,437


Total. (Column (b) must equal Form 990, Part X, col.(B) line 15.)...........				8,321,641

Part X

Other Liabilities. See Form 990, Part X, line 25.

1.(a) Description of liability		(b) Book value
Federal income taxes		0
ACCRUED BENEFIT LIABILITY		9,418,262
RETIRE OBLIGATION - ASBESTOS		1,855,385
A/R SELF INSURANCE		1,918






Total. (Column (b) must equal Form 990, Part X, col.(B) line 25.)		11,275,565
2. Fin 48 (ASC 740) Footnote. In Part XIII, 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 (ASC 740). Check here if the text of the footnote has been provided in Part XIII .....................................................

Schedule D (Form 990) 2012

Page 4

Part XI Reconciliation of Revenue per Audited Financial Statements With Revenue per Return
1	Total revenue, gains, and other support per audited financial statements .......		1
2	Amounts included on line 1 but not on Form 990, Part VIII, line 12:
a	Net unrealized gains on investments ..........	2a
b	Donated services and use of facilities .........	2b
c	Recoveries of prior year grants ...........	2c
d	Other (Describe in Part XIII.) ............	2d
e	Add lines 2a through 2d .....................		2e
3	Subtract line 2e from line 1.....................		3
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 XIII.) ...........	4b
c	Add lines 4a and 4b.......................		4c
5	Total revenue. Add lines 3 and 4c. (This must equal Form 990, Part I, line 12.) ......		5

Part XII Reconciliation of Expenses per Audited Financial Statements With Expenses per Return
1	Total expenses and losses per audited financial statements ...........		1
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 XIII.) ............	2d
e	Add lines 2a through 2d......................		2e
3	Subtract line 2e from line 1.....................		3
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 XIII.) ............	4b
c	Add lines 4a and 4b.......................		4c
5	Total expenses. Add lines 3 and 4c. (This must equal Form 990, Part I, line 18.) ......		5

Part XIII

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, line 2; Part XI, lines 2d and 4b; and Part XII, lines 2d and 4b. Also complete this part to provide any additional information.

Identifier	Return Reference	Explanation
ASC SUBTOPIC 740-10		HSHS HAS ADOPTED ASC SUBTOPIC 740-10, ACCOUNTING FOR UNCERTAINTY IN INCOME TAXES - AN INTERPRETATION OF FASB STATEMENT NO. 109. ASC SUBTOPIC 740-10 ADDRESSES THE DETERMINATION OF HOW TAX BENEFITS CLAIMED OR EXPECTED TO BE CLAIMED ON A TAX RETURN SHOULD BE RECORDED IN THE CONSOLIDATED FINANCIAL STATEMENTS. UNDER ASC SUBTOPIC 740-10, HSHS MUST RECOGNIZE THE TAX BENEFIT FROM AN UNCERTAIN TAX POSITION ONLY IF IT IS MORE LIKELY THAN NOT THAT THE TAX POSITION WILL BE SUSTAINED ON EXAMINATION BY THE TAXING AUTHORITIES, BASED ON THE TECHNICAL MERITS OF THE POSITION. THE TAX BENEFITS RECOGNIZED IN THE CONSOLIDATED FINANCIAL STATEMENTS FROM SUCH A POSITION ARE MEASURED BASED ON THE LARGEST BENEFIT THAT HAS A GREATER THAN 50% LIKELIHOOD OF BEING REALIZED UPON ULTIMATE SETTLEMENT. ASC SUBTOPIC 740-10 ALSO PROVIDES GUIDANCE ON DERECOGNITION, CLASSIFICATION, INTEREST AND PENALTIES ON INCOME TAXES, AND ACCOUNTING IN INTERIM PERIODS AND REQUIRES INCREASED DISCLOSURES. AS OF JUNE 30, 2013 AND 2012, HSHS DOES NOT HAVE AN ASSET OR LIABILITY FOR UNRECOGNIZED TAX BENEFITS.

Schedule D (Form 990) 2012

Additional Data

Software ID:
Software Version:

- TIN:

SCHEDULE H (Form 990)

Department of the Treasury
Internal Revenue Service

Hospitals

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

2012

Open to Public Inspection

Name of the organization

ST MARY'S HOSPITAL STREATOR HOSPITAL SISTERS
OF THE 3RD ORDER ST FRANCIS

Employer identification number

36-2169181

Part I

Financial Assistance and Certain Other Community Benefits at Cost

Yes

Did the organization have a financial assistance policy during the tax year? If "No," skip to question 6a ...

Yes

If "Yes," was it a written policy? .......................

Yes

If the organization had multiple hospital facilities, indicate which of the following best describes application of the financial assistance policy to its various hospital facilities during the tax year.

Applied uniformly to all hospital facilities Applied uniformly to most hospital facilities Generally tailored to individual hospital facilities

Answer the following based on the financial assistance eligibility criteria that applied to the largest number of the organization's patients during the tax year.

Did the organization use Federal Poverty Guidelines (FPG) as a factor in determining eligibility for providing free care?

If "Yes," indicate which of the following was the FPG family income limit for eligibility for free care:

Yes

100% 150% 200% Other 135 %

Did the organization use FPG as a factor in determining eligibility for providing discounted care? If "Yes," indicate

which of the following was the family income limit for eligibility for discounted care: .........

Yes

200% 250% 300% 350% 400% Other 215 %

If the organization used factors other than FPG in determining eligibility, describe in Part VI the income based criteria for determining eligibility for free or discounted care. Include in the description whether the organization used an asset test or other threshold, regardless of income, as a factor in determining eligibility for free or discounted care.

Did the organization's financial assistance policy that applied to the largest number of its patients during the tax year provide for free or discounted care to the "medically indigent"? ..............

Yes

Did the organization budget amounts for free or discounted care provided under its financial assistance policy during the tax year? ............................

Yes

If "Yes," did the organization's financial assistance expenses exceed the budgeted amount? ......

Yes

If "Yes" to line 5b, as a result of budget considerations, was the organization unable to provide free or discountedcare to a patient who was eligibile for free or discounted care? ..............

Did the organization prepare a community benefit report during the tax year? ..........

Yes

If "Yes," did the organization make it available to the public? ..............

Yes

Complete the following table using the worksheets provided in the Schedule H instructions. Do not submit these worksheets with the Schedule H.

Financial Assistance and Certain Other Community Benefits at Cost

Financial Assistance 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	Financial Assistance at cost (from Worksheet 1) ..		2,000	2,766,650		2,766,650	5.470 %
b	Medicaid (from Worksheet 3, column a) ....		8,857	7,479,607	3,728,873	3,750,734	7.420 %
c	Costs of other means-tested government programs (from Worksheet 3, column b) .
d	Total Financial Assistance and Means-Tested Government Programs .		10,857	10,246,257	3,728,873	6,517,384	12.890 %
Other Benefits		16	22,892	306,026	2,296	303,730	0.600 %
e	Community health improvement services and community benefit operations (from Worksheet 4) ..	16	22,892	306,026	2,296	303,730	0.600 %
f	Health professions education (from Worksheet 5) ..
g	Subsidized health services (from Worksheet 6) ..
h	Research (from Worksheet 7)
i	Cash and in-kind contributions for community benefit (from Worksheet 8)	25	1,079	53,508		53,508	0.110 %
j	Total. Other Benefits ..	41	23,971	359,534	2,296	357,238	0.710 %
k	Total. Add lines 7d and 7j .	41	34,828	10,605,791	3,731,169	6,874,622	13.600 %

For Paperwork Reduction Act Notice, see the Instructions for Form 990. Cat. No. 50192T Schedule H (Form 990) 2012

Schedule H (Form 990) 2012

Page

Part II

Community Building Activities Complete this table if the organization conducted any community building activities during the tax year, and describe in Part VI how its community building activities promoted the health of the communities it serves.

		(a) Number of activities or programs (optional)	(c) Total community building expense	(e) Net community building 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	1	289	289
8	Workforce development
9	Other
10	Total	1	289	289

Part III

Bad Debt, Medicare, & Collection Practices

Section A. Bad Debt Expense

Yes

Did the organization report bad debt expense in accordance with Heathcare Financial Management Association Statement No. 15? ..........................

Yes

Enter the amount of the organization's bad debt expense. Explain in Part VI the methodology used by the organization to estimate this amount. ......

620,934

Enter the estimated amount of the organization's bad debt expense attributable to patients eligible under the organization's financial assistance policy. Explain in Part VI the methodology used by the organization to estimate this amount and the rationale, if any, for including this portion of bad debt as community benefit. ......

Provide in Part VI the text of the footnote to the organization’s financial statements that describes bad debt expense or the page number on which this footnote is contained in the attached financial statements.

Section B. Medicare

Enter total revenue received from Medicare (including DSH and IME).....

17,100,814

Enter Medicare allowable costs of care relating to payments on line 5.....

24,086,943

Subtract line 6 from line 5. This is the surplus (or shortfall)........

-6,986,129

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:

Cost accounting system Cost to charge ratio Other

Section C. Collection Practices

Did the organization have a written debt collection policy during the tax year? ..........

Yes

If "Yes," did the organization’s collection policy that applied to the largest number of its patients during the tax year contain provisions on the collection practices to be followed for patients who are known to qualify for financial assistance? Describe in Part VI.......................

Yes

Part IV

Management Companies and Joint Ventures(owned 10% or more by officers, directors, trustees, key employees, and physicians—see instructions)

(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 %
1
2
3
4
5
6
7
8
9
10
11
12
13

Schedule H (Form 990) 2012

Page

Part VFacility Information

Section A. Hospital Facilities (list in order of size from largest to smallest—see instructions) How many hospital facilities did the organization operate during the tax year?1 Name, address, and primary website address
1	St Mary's Hospital 111 Spring Street Streator,IL61364	X	X	X

Schedule H (Form 990) 2012

Page

Part VFacility Information (continued)

Section B. Facility Policies and Practices

(Complete a separate Section B for each of the hospital facilities or facility reporting groups listed in Part V, Section A)

	St Mary's Hospital
Name of hospital facility or facility reporting group

For single facility filers only: line Number of Hospital Facility (from Schedule H, Part V, Section A)

Yes

Community Health Needs Assessment (Lines 1 through 8c are optional for tax years begining on or before March 23, 2012)

During the tax year or either of the two immediately preceding tax years, did the hospital facility conduct a community health needs assessment (CHNA)? If "No," skip to line 9....................

Yes

If “Yes,” indicate what the CHNA report describes (check all that apply):

A definition of the community served by the hospital facility

Demographics of the community

Existing health care facilities and resources within the community that are available to respond to the health needs of the community

How data was obtained

The health needs of the community

Primary and chronic disease needs and other health issues of uninsured persons, low-income persons, and minority groups

The process for identifying and prioritizing community health needs and services to meet the community health needs

The process for consulting with persons representing the community’s interests

Information gaps that limit the hospital facility’s ability to assess the community’s health needs

Other (describe in Part VI)

Indicate the tax year the hospital facility last conducted a CHNA: 20 11

In conducting its most recent CHNA, did the hospital facility take into account input from representatives of the community served by the hospital facility, including those with special knowledge of or expertise in public health? 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 ....................

Yes

Was the hospital facility’s CHNA conducted with one or more other hospital facilities? If “Yes,” list the other hospital facilities in Part VI................................

Did the hospital facility make its CHNA report widely available to the public? .............

Yes

If “Yes,” indicate how the CHNA report was made widely available (check all that apply):

Hospital facility’s website

Available upon request from the hospital facility

Other (describe in Part VI)

If the hospital facility addressed needs identified in its most recently conducted CHNA, indicate how (check all that apply to date):

Adoption of an implementation strategy that addresses each of the community health needs identified through the CHNA

Execution of the implementation strategy

Participation in the development of a community-wide plan

Participation in the execution of a community-wide plan

Inclusion of a community benefit section in operational plans

Adoption of a budget for provision of services that address the needs identified in the CHNA

Prioritization of health needs in its community

Prioritization of services that the hospital facility will undertake to meet health needs in its community

Other (describe in Part VI)

Did the hospital facility address all of the needs identified in its most recently conducted CHNA? If “No,” explain in Part VI which needs it has not addressed and the reasons why it has not addressed such needs ........

Did the organization incur an excise tax under section 4959 for the hospital facility's failure to conduct a CHNA as required by section 501(r)(3)? ...........................

If "Yes" to line 8a, did the organization file Form 4720 to report the section 4959 excise tax? ......

If "Yes" to line 8b, what is the total amount of section 4959 excise tax the organization reported on Form 4720 for all of its hospital facilities? $

Schedule H (Form 990) 2012

Page

Part VFacility Information (continued)

Financial Assistance Policy			Yes	No
9	Did the hospital facility have in place during the tax year a written financial assistance policy that:
	Explained eligibility criteria for financial assistance, and whether such assistance includes free or discounted care?	9	Yes
10	Used federal poverty guidelines (FPG) to determine eligibility for providing free care?...........	10	Yes
	If "Yes," indicate the FPG family income limit for eligibility for free care: 135.% If "No," explain in Part VI the criteria the hospital facility used.
11	Used FPG to determine eligibility for providing discounted care?.................	11	Yes
	If “Yes,” indicate the FPG family income limit for eligibility for discounted care: 215.% If "No," explain in Part VI the criteria the hospital facility used.
12	Explained the basis for calculating amounts charged to patients?.................	12	Yes
	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)
13	Explained the method for applying for financial assistance?...................	13	Yes
14	Included measures to publicize the policy within the community served by the hospital facility?.......	14	Yes
	If “Yes,” indicate how the hospital facility publicized the policy (check all that apply):
a	The policy was posted on the hospital facility’s website
b	The policy was attached to 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 on admission to the hospital facility
f	The policy was available upon request
g	Other (describe in Part VI)
Billing and Collections
15	Did the hospital facility have in place during the tax year a separate billing and collections policy, or a written financial assistance policy (FAP) that explained actions the hospital facility may take upon non-payment?.......	15	Yes
16	Check all of the following actions against an individual that were permitted under the hospital facility's policies during the tax year before making reasonable efforts to determine the patient’s eligibility under the facility’s FAP:
a	Reporting to credit agency
b	Lawsuits
c	Liens on residences
d	Body attachments
e	Other similar actions (describe in Part VI)
17	Did the hospital facility or an authorized third party perform any of the following actions during the tax year before making reasonable efforts to determine the patient’s eligibility under the facility’s FAP?..........	17		No
	If “Yes,” check all actions in which the hospital facility or a third party engaged:
a	Reporting to credit agency
b	Lawsuits
c	Liens on residences
d	Body attachments
e	Other similar actions (describe in Part VI)

Schedule H (Form 990) 2012

Page

Part VFacility Information (continued)

Indicate which efforts the hospital facility made before initiating any of the actions listed in line 17 (check all that apply):

Notified individuals of the financial assistance policy on admission

Notified individuals of the financial assistance policy prior to discharge

Notified individuals of the financial assistance policy in communications with the patients regarding the patients’ bills

Documented its determination of whether patients were eligible for financial assistance under the hospital facility’s financial assistance policy

Other (describe in Part VI)

Policy Relating to Emergency Medical Care

Yes

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?..........

Yes

If “No,” indicate why:

The hospital facility did not provide care for any emergency medical conditions

The hospital facility’s policy was not in writing

The hospital facility limited who was eligible to receive care for emergency medical conditions (describe in Part VI)

Other (describe in Part VI)

Charges to Individuals Eligible for Assistance under the FAP (FAP-Eligible Individuals)

Indicate how the hospital facility determined, during the tax year, the maximum amounts that can be charged to FAP-eligible individuals for emergency or other medically necessary care.

The hospital facility used its lowest negotiated commercial insurance rate when calculating the maximum amounts that can be charged

The hospital facility used the average of its three lowest negotiated commercial insurance rates when calculating the maximum amounts that can be charged

The hospital facility used the Medicare rates when calculating the maximum amounts that can be charged

Other (describe in Part VI)

During the tax year, did the hospital facility charge any FAP-eligible individuals 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? ............................

If “Yes,” explain in Part VI.

During the tax year, did the hospital facility charge any FAP-eligible individuals an amount equal to the gross charge for any service provided to that individual? .........................

If “Yes,” explain in Part VI.

Schedule H (Form 990) 2012

Page

Part VFacility Information (continued)

Section C. Other Health Care Facilities That Are Not Licensed, Registered, or Similarly Recognized as a Hospital Facility (list in order of size, from largest to smallest) How many non-hospital health care 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) 2012

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Part VI

Supplemental Information

Complete this part to provide the following information.

1	Required descriptions. Provide the descriptions required for Part I, lines 3c, 6a, and 7; Part II; Part III, lines 4, 8, and 9b; Part V, Section A; and Part V, Section B, lines 1j, 3, 4, 5c, 6i, 7, 10, 11, 12h, 14g, 16e, 17e, 18e, 19c, 19d, 20d, 21, and 22.
2	Needs assessment. Describe how the organization assesses the health care needs of the communities it serves, in addition to any 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.
8	Facility reporting group(s). If applicable, for each hospital facility in a facility reporting group provide the descriptions required for Part V, Section B, lines 1j, 3, 4, 5c, 6i, 7, 10, 11, 12h, 14g, 16e, 17e, 18e, 19c, 19d, 20d, 21, and 22.

Identifier	ReturnReference	Explanation
Part I, line 3c		Not applicable. The organization follows federal poverty guidelines to determine eligibility for providing charity and discounted care to low-income uninsured and underinsured individuals.
Part I, line 6a		St. Mary's Hospital prepares an annual community benefit report as a part of our annual report in booklet form distributed to the public via mail and available at St. Mary's Hospital, 111 Spring Street, Streator, IL. The annual report can also be accessed on St. Mary's website at www.stmaryshospital.org/publications. Part I, Line 7 St. Mary's Hospital uses the Lyons Software (CBISA) which follows the Catholic Health Association (CHA) guidelines on reporting charity care and certain other community benefits at cost. Lyons Software uses the hospitals audited financials for total expenses, bad debt and gross patient charges to calculate the appropriate cost to charge ratio in determining charity care and other community benefits at cost.
Part I, line 7g		The hospital uses Lyons Software (CBISA) to determine subsidized services. Physician clinics were not included in the subsidized health services.
Part I, line 7, column (f)		The percent of charity care and certain other benefits at cost as a percent of total expenses less bad debt is 13.60%. Total amount of bad debt removed when calculating the percentages in Part I, Line 7, column (F) was $1,815,683.
Part II		Community Building through community support, health improvement advocacy, and workforce development is an important part of St. Mary's Hospital's commitment to enhancing community-wide health and well-being. St. Mary's is engaged in community building by developing support groups and through coalition building with community outreach events. As part of our commitment to provide our community with the highest quality of care, St. Mary's Hospital participated in a number of health fairs providing free health screenings and educational information. In FY2013, St. Mary's colleagues donated their time to travel to several health fairs throughout the Illinois Valley, offering health education and free screenings such as bone density tests, ankle brachial index screenings, blood pressure checks and pulse ox screenings. Health fairs are just one way that our hospital educates the community and promotes early detection and disease prevention, as well as encourages a healthy lifestyle. Throughout the course of the year, St. Mary's Hospital lent our support by sponsoring a variety of events in our community. In February, St. Mary's Hospital was a corporate sponsor of Streator's Taste of the Town, a culinary auction event that raises funds for several local organizations in the community. In addition to our sponsorship, the hospital provided event volunteers. St. Mary's Hospital partners with the March of Dimes, an organization that supports research aimed at preventing birth defects, premature birth and infant mortality, to help create awareness about premature birth; the hospital also sponsored the market place tent at the March for Babies. In conjunction with Earth Day, St. Mary's Hospital hosted an electronics recycling event with multiple drop-off locations. St. Mary's collected a total of 14,269 pounds of electronic recyclables. The hospital also collected 22 pounds of unused pharmaceuticals for proper disposal and sent 471 pounds of various waste products to a local recycler for proper disposal in an effort to further protect our environment. St. Mary's also takes pride in our partnership with the Streator Area Chamber of Commerce. St. Mary's Hospital colleagues attended several Chamber events to raise money to build a better community as well as sponsored the Chamber's corporate bowling challenge, dessert auction and golf outing. St. Mary's Hospital is also a proud supporter of the American Cancer Society's Relay for Life. This year the hospital was a Gold Sponsor of Relay for Life. This event represents the hope that those lost to cancer will never be forgotten, that those who face cancer will be supported, and that one-day cancer will be eliminated. In addition to being a Gold Sponsor, the hospital supported Relay for Life by printing the event programs in-house free of charge and supplying bottled water for the night of the event. In addition to sponsorship and in kind donations, a group of St. Mary's colleagues volunteered at the event and distributed health care information and water to the walkers. St. Mary's Hospital is proud to be a sponsor of this great event - one that educates the public about the importance of cancer research and celebrates those whose lives have been affected by cancer. In January, St. Mary's coordinated and provided the venue for a cardiologist who gave a community presentation at St. Mary's Health Care-Ottawa on the importance of knowing your cholesterol numbers, how to interpret the results and how to lower the risk of cardiovascular disease. One lucky winner received a free copy of the American Heart Association's "Low-Fat, Low Cholesterol" cookbook. St. Mary's Hospital strives to promote and improve the health of the communities it serves by providing a teaching environment for nursing and technical clinical expertise for the regional workforce, recruiting and retaining the professional medical staff to meet the area need, and by providing care through a collaborative approach. Consistent with its exempt purpose, St. Mary's serves as a clinical site for students in the fields of nursing, laboratory, diagnostic imaging, physical therapy, speech and pharmacy. St. Mary's hospital is a community partner with Illinois Valley Community College to provide a clinical training site, professional oversight, and supportive entrance to the nursing field. By providing this medical education, the hospital is contributing to the regional and national workforce in a way that will continue to ensure access and high quality care for the families St. Mary's serves. St. Mary's Hospital supported fundraising efforts to provide scholarships for students who wish to go into the field of health care. Friends of St. Mary's Hospital awarded three $800 scholarships for the 2013 Chad Scoles Memorial Scholarship. The scholarship was established in memory of Chad Scoles, son of Dick Scoles, a long-term St. Mary's Hospital employee, and his wife Sally. Chad passed away in 2004 at the age of 21. The scholarship fund was created by two emergency room physicians.
Part III, Line 4		Bad debt expense of HSHS is discussed at pages 18 and 19 of the audited financial statements, a copy of which is attached to this return.
Part III, Line 8		Our total Medicare shortfall was estimated at $6,986,129. Of that amount, the hospital is considering Community Benefit reportable portion of Medicare Shortfall to be $2,959,213. Medicare Cost is calculated total to be $24,086,943, and Medicare reimbursements to be $17,100,814. The hospital removed $12,002,986 in charges that are not considered reportable on the Medicare Cost Report (Medicare Managed Care, Physician Fees, and charges reimbursed by a fee schedule), which resulted in removing $1,854,312 in Medicare reimbursements and $2,125,275 in costs related to those charges. Finally, St. Mary's also had an additional $3,755,953 in cost that is not considered reportable on the Cost Report (difference between the Medicare Cost report and the Overall Hospital cost to charge ratio). The Medicare Cost was calculated using the Cost to Charge ratio from the Medicare Cost report, while the Overall Hospital cost was calculated using all hospital charges and costs. The difference in the removal of costs and reimbursements resulted in a net difference of Community Benefit reportable Medicare Shortfall to calculated Medicare Shortfall of $4,026,916.
Part III, line 9b		Prior to an account being sent to collection, the patient predictability for a 'no response' patient will be checked through Search America. "No response" for this purpose is described as no response for at least sixty (60) days, during which at least three (3) contact attempts have been made. Attempts include mailing an application, sending patient statements, and/or making telephone calls. If the result of the payment predictability comes back as low or undetermined, the Search America result is stored and retrievable through the system and the account written off to charity. If an indication of the inability to pay is apparent, the patient will be given the option to complete Illinois Public Aid - Form 450, if appropriate. The final option would then be to ask the patient to cooperate with the Christian Care determination process to determine the patient's ability to pay. Part V, Section B, line 1 St. Mary's Hospital in cooperation with Leede Research, a research firm specializing in health care information programs and tools, completed the 2012 Community Health Needs Assessment. The goal of the study was to identify population perceptions of community issues and needs that could be combined with other information for a Community Health Needs Assessment. The needs assessment report was used as a basis for the implementation strategy that outlined a plan to address selected needs which would benefit the community and general populations. The next scheduled date for a formal Community Heath Needs Assessment is the hospital's fiscal year 2015 (July 1, 2014 - June 30, 2015).
Part V, Section B, Line 3		Yes. A Community Needs Steering Committee was established in our prior fiscal year 2012 to review the results. This was a diverse group of twenty-one community leaders from LaSalle, Livingston and Marshall Counties, consisting of health care and physician leaders, political leaders, individuals with expertise in public health, and representatives of underserved, low-income and minority populations. Part V, line 5c The Community Health Needs Assessment and associated Implementation Strategy guided the hospital's efforts in FY2013. Both documents are available to the public at http://www.stmaryshospital.org on the "Check Up 2012" and "Implementation Strategy" link.
Part V, SECTION B, Line 7		St. Mary's Hospital's Board of Directors approved an implementation strategy based on the CHNA during the prior fiscal year, and the identified needs were addressed in our fiscal year FY2013. Using the data from the CHNA, the steering committee identified four priority needs for the community including: obesity, family violence, substance/alcohol abuse, and education. St. Mary's Hospital will focus on two of the four major needs - obesity and family violence - because they best match our core competencies and would offer St. Mary's Hospital the best opportunity to affect the most change. One identified need in the community not specifically addressed by St. Mary's was substance/alcohol abuse. Since St. Mary's Hospital does not have a specific substance/alcohol abuse program and is not an educational institution, the hospital collaborated with other organizations to support their efforts in these areas. Physicians and hospital colleagues refer patients as appropriate to local resources that can better support healing in this area. Substance/alcohol abuse is also served by the Streator Substance Abuse Prevention Coalition, in which a hospital chaplain actively participates. The current implementation strategy consists of an expansion of St. Mary's "Healthy You" program and the development of a community garden, both focused on reducing obesity and encouraging the community to embrace a healthier lifestyle. In addition, St. Mary's is also engaged in a process with other community organizations to assess how the hospital could support local resources already in place for domestic violence. In particular, St. Mary's is collaborating with ADV/SAS (A Domestic Violence & Sexual Assault Service) to help strengthen their medical advocate program through our hospital.
Part V, section b, Line 14g		The Registration Department provides brochures to patients upon request regarding the Payment Assistance Program available to them at St. Mary's Hospital. The Christian Care brochures are also supplied in waiting and ancillary areas, as well as on the hospital's website at www.stmaryshospital.org. Information outlining the program is also available on Patient Statements and upon request.
Part V, section b, Line 18e		Patient Financial Representatives conduct telephone interviews and in-person counseling sessions with patients as to program availability and potential qualification based on discussion results. Once a patient completes the self-pay questionnaire, a determination is made based on policy guidelines through an internet-based tool. If a patient fails to comply with the questions, prior to an account being sent to collection, the patient payment predictability from an outside vendor is reviewed and based on the information an account may be written off to charity. As directed by Illinois State Law, the hospital internet site lists the information regarding income guidelines for financial assistance as well as the process to apply. These guidelines are updated annually based on changes in the federal poverty guidelines. All billing statements list various payment options including a statement that reads, "Financial Assistance is available to eligible persons who meet requirements." Self-pay patient statements also include the following statement "Please contact our office to see if you qualify for the level of Uninsured Discounts or Financial Assistance." Part V, Line 20d, 21, 22 Every patient is charged the same amount. All uninsured received the uninsured discount. All other patients were discounted per their insurance plan.
Needs assessment		As indicated in Part V, Section B, St. Mary's conducted a Community Health Needs Assessment in our FY2012. In prior years, St. Mary's used other methods to identify community need. For example, historic encounters are reviewed for trends and demographic information is reviewed annually during our strategic planning process. Indigent levels, educational levels, housing costs, unemployment and uninsured children are all considered in the planning process. While physician demand analysis is always an ongoing process, in the last 12 months St. Mary's also engaged an independent, third party, to assist with completing a comprehensive 'Community Physician Needs Analysis.' This information is used in conjunction with our community health needs assessment and other internal planning documents to guide the broader hospital strategic planning process. St. Mary's Hospital engages in conversations with the community to ascertain those services that are in demand and which ones are out-migrating. Those conversations are held informally and sometimes formally. As areas are identified a business plan and proforma are done to validate the need.
Patient education of eligibility for assistance		The Registration Department provides brochures to patients upon request regarding the Payment Assistance Program available to them at St. Mary's Hospital. The Christian Care brochures are also supplied in waiting and ancillary areas, as well as on the hospital's website at www.stmaryshospital.org. Information outlining the program is also available on Patient Statements and upon request. St. Mary's Hospital contracts with an organization that assists patients who may be eligible for Medicaid assistance through the Illinois Department of Public Assistance. This organization works with patients to determine if they are potentially eligible, assisting in compiling the documentation necessary for application submission. One-on-one conversations to educate patients about financial assistance often stem from patients receiving a statement or a pre-collection letter. The customer service representative, cashier, or other qualified staff member, will inform/educate the patient about financial assistance options. The Search America system is utilized after attempts made by the hospital to work out payment arrangements have failed. The Search America system accesses credit and other information allowing the hospital to see the probability of a patient being able to pay their bill. After assessing that information, the hospital makes a determination whether to grant charity care or continue collection efforts.
Community Information		St. Mary's primary service area population, with 44.6% of the residents currently 45 years of age or older, is older than both the U.S. average at 39.3% and the state of Illinois average at 37.9%. According to the 2010 Census, the demographic make-up of the city of Streator is 85.2% Caucasian, 10.4% Latino, 2.5% African American, and 1.9% from other races. The number of persons living below the poverty level in the city of Streator is 14.8%, which is above the LaSalle County level of 10.8% and the Illinois state level of 12.6%. Obesity has reached epidemic proportions in Illinois - 62 percent of Illinois adults are overweight or obese. One in five children are obese, the fourth worst rate in the nation. LaSalle County exceeds the Illinois benchmark with 28% of the population obese, according to the Illinois Behavioral Risk Factor Surveillance System (IBRFSS, 2009). In addition, St. Mary's has provided charity benefits for 2,000 uninsured persons and transportation trips totaling 5,925 to underserved persons.
Promotion of Community Health		St. Mary's Hospital offers hope to our community in the tradition of the Hospital Sisters of St. Francis. As a healing ministry of the Catholic Church and an affiliate of the Hospital Sisters Health System (HSHS), St. Mary's is committed to delivering high quality, compassionate, and cost-effective health care services to all. The hospital was founded over 125 years ago to bring a healing presence and improve the health of our community, especially for people who are sick, poor, and disadvantaged. Because of the hospital's purpose and tradition, it is organized to promote the health of Streator, Illinois and surrounding areas. The hospital is governed by a Board of Directors, the majority of whom reside in the organization's primary service area and who are neither employees nor contractors of the hospital. The Board ensures that St. Mary's is responding to community need. During our prior fiscal year 2012, the Board reviewed the Community Health Needs Assessment and approved an implementation strategy for addressing selected needs. Also consistent with its exempt purpose, St. Mary's has an open medical staff with privileges available to all qualified physicians in the area. In addition, the hospital operates an emergency department that is open 24 hours to all persons regardless of their ability to pay. As a not-for-profit hospital, St. Mary's reinvests surplus funds into the mission of the organization and health of the community rather than distributing them as profits to shareholders or individuals. Funds not committed to ongoing operations are generally used to upgrade facilities, secure new technologies, improve patient care, and support initiatives designed to promote health and ensure access for all. For example, St. Mary's is currently working with its parent organization, Hospital Sisters Health System, to continuously enhance quality and improve coordination of care both inside the hospital and with a growing number of physician partners. Supported by investments in information technology, this "care integration" strategy is designed to better coordinate care, improve health outcomes, create new efficiencies, and help ensure that patients (especially those with chronic conditions) get well and stay well. St. Mary's Hospital has taken an active role in leading the Central Illinois Health Information Exchange (HIE). The primary goal of the exchange is to provide an integrated long-term aggregated health care record. The HIE is the first to become operational in Illinois. St. Mary's Hospital has been contributing information to the exchange since 2012 and membership has grown to 32 members, 16 of which are hospitals located in the region. Because of St. Mary's Hospital participation in the electronic sharing of information, there will be a positive impact on the quality of care, care coordination, improved efficiency, and reduction of health care costs. St. Mary's continues to enhance quality of care by implementing Computerized Provider Order Entry (CPOE) beginning in November 2012. Benefits of this technological advancement include advancing ability to meet quality and care integration goals, improving clinical and operational efficiencies, promoting evidence based care to provide predictable clinical outcomes, and enhancing the ability to provide clinical decision support. St. Mary's Hospital devotes significant resources to provide access for patients who cannot afford care, along with other community benefits. In fiscal year 2012, St. Mary's provided over $9.8 million in community benefit services, including charity care at cost, unpaid costs of Medicaid and other public programs, and a range of diverse programs designed to enhance access and improve community health. During this period, St. Mary's provided $6.5 million (at cost) in uncompensated care to patients that qualified for charity care or public assistance and over $2.9 million (at cost) in excess of Medicare payment for health care services (please see note below). St. Mary's Hospital participates in multiple government-sponsored health care programs, including Medicaid, Medicare, Champus and Tricare. NOTE: Our total Medicare shortfall was estimated at $6.86 million, and of that St. Mary's is considering Community Benefit reportable portion of Medicare Shortfall to be $2.9 million. St. Mary's calculated total Medicare Costs to be $24,086,943 and Medicare reimbursements to be $17.1 million. St. Mary's removed $12 million in charges that are not considered reportable on the Medicare Cost Report (Medicare Managed Care, Physician Fees, and charges reimbursed by a fee schedule), which resulted in removing $1.85 million in Medicare reimbursements and $2.13 million in costs related to those charges. Lastly, St. Mary's also had an additional $3.76 million in cost that is not considered reportable on the Cost Report (difference between the Medicare Cost report and Overall Hospital cost to charge ratio). The Medicare Cost was calculated using the Cost to Charge ratio from the Medicare Cost report, while the Overall Hospital cost was calculated using all hospital charges and costs. The difference in the removal of costs and reimbursements resulted in a net difference of Community Benefit reportable Medicare Shortfall to calculated Medicare Shortfall of $4.03 million. St. Mary's Hospital provides a range of community benefits which flows from its mission and long-standing commitment to the community. In many cases, these programs would be unlikely to exist without the leadership role played by St. Mary's Hospital, and they often relieve a burden that would otherwise be carried by government. Based on the assessment of community needs, St. Mary's has focused on the following priorities: obesity and family violence. These major needs in our community best match the hospital's core competencies and would offer the best opportunity to affect the most change in the communities St. Mary's serves. These programs and activities were designed in response to our FY2012 Community Health Needs Assessment, which surfaced the following priority needs for attention from the hospital in collaboration with other community organizations: 1) Obesity a. Expand/enhance Lean To Green Program b. Develop community garden on hospital property 2) Domestic violence a. Develop a new Medical Advocate Program Expand Lean to Green Program (Identified need - Obesity) To address obesity in the communities served, St. Mary's Hospital focused on exercise, nutrition and healthy lifestyles. In FY2013, St. Mary's Hospital reintroduced a 12-week weight-loss competition previously called "Lean to Green", and a new partnership was announced with the Streator YMCA to evolve "Lean to Green" into a bigger and better community program. As part of this partnership, the program was renamed "Healthy You" - emphasizing that this is not just a weight loss program, but a more holistic program aimed at helping individuals live an all-around healthier lifestyle. Added program benefits included a pedometer to help motivate weight loss, a maintenance program to maintain weight loss year-round, and cooking classes provided by the hospital for participants to learn methods of cooking with fresh, healthy foods and new low-fat recipes. The hospital's program partner, the Streator YMCA, also provided five free aerobics classes for participants. The 2013 "Healthy You" program attracted 282 participants (66 teams), nearly double the number of participants from the previous year. The teams began with a combined weight of 59,145 pounds. A total of 191 participants completed the program losing a total of 2,491 pounds or 4.21% overall. To help individuals stay motivated and stay on track with a healthy lifestyle journey, "Healthy You" offers a maintenance component that encourages participants to weigh in on a monthly basis; approximately 50 individuals are participating in the maintenance program. Create Community Garden (Identified need - Obesity) In FY2013, many of the above activities were continued or strengthened as St. Mary's continues to focus on the priority needs identified in the FY2012 Community Health Needs Assessment process. To further support Streator's underserved population and promote healthy eating choices, a community garden was established and planted on hospital property; the garden is maintained by hospital and community volunteers. All harvest proceeds are donated to the local food pantry to provide fresh, healthy produce to those in need to further promote improved health in the community and reduction of obesity. Enhance Medical Advocate Program (Identified need - Domestic Violence) St. Mary's Hospital has engaged in a process with other community organizations to assess how the hospital could support local resources already in place for domestic violence. In particular, the hospital is collaborating with ADV/SAS (A Domestic Violence & Sexual Assault Service) to help strengthen their medical advocate progr
STATE FILING OF COMMUNITY BENEFIT REPORT	990 SCHEDULE H, PART VI	IL,

Schedule H (Form 990) 2012

Additional Data

Software ID:
Software Version:

- TIN:

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

2012

Open to Public Inspection

Name of the organization

ST MARY'S HOSPITAL STREATOR HOSPITAL SISTERS
OF THE 3RD ORDER ST FRANCIS

Employer identification number

36-2169181

Part I

Questions Regarding Compensation

Yes

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.

First-class or charter travel Housing allowance or residence for personal use

Travel for companions Payments for business use of personal residence

Tax idemnification and gross-up payments Health or social club dues or initiation fees

Discretionary spending account Personal services (e.g., maid, chauffeur, chef)

If any of the boxes in line 1a are checked, did the organization follow a written policy regarding payment or reimbursement or provision of all of the expenses described above? If "No," complete Part III to explain....

Yes

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? .......

Yes

Indicate which, if any, of the following the filing organization used to establish the compensation of the
organization's CEO/Executive Director. Check all that apply. Do not check any boxes for methods
used by a related organization to establish compensation of the CEO/Executive Director, but explain in Part III.

Compensation committee Written employment contract

Independent compensation consultant Compensation survey or study

Form 990 of other organizations Approval by the board or compensation committee

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:

Receive a severance payment or change-of-control payment? ................

Participate in, or receive payment from, a supplemental nonqualified retirement plan? .........

Yes

Participate in, or receive payment from, an equity-based compensation arrangement? .........

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.

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:

The organization? ...........................

Any related organization? .........................

If "Yes," to line 5a or 5b, describe in Part III.

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:

The organization? ...........................

Any related organization? .........................

If "Yes," to line 6a or 6b, describe in Part III.

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 ............

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 Regulations section 53.4958-4(a)(3)? If "Yes," describe
in Part III .............................

If "Yes" to line 8, did the organization also follow the rebuttable presumption procedure described in Regulations section 53.4958-6(c)? .........................

For Paperwork Reduction Act Notice, see the Instructions for Form 990.

Cat. No. 50053T

Schedule J (Form 990) 2012

Page 2

Part II

Officers, Directors, Trustees, Key Employees, and Highest Compensated Employees. Use duplicate copies if additional space is 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) for each listed individual must equal the total amount of Form 990, Part VII, Section A, line 1a, applicable column (D) and (E) amounts for that individual.

(A) Name and Title		(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 as deferred in prior Form 990
(A) Name and Title		(i) Base compensation	(ii) Bonus & incentive compensation	(iii) Other reportable compensation	(C) Retirement and other deferred compensation	(D) Nontaxable benefits	(E) Total of columns (B)(i)-(D)	(F) Compensation reported as deferred in prior Form 990
(1)ANN CARRTREASURER	(i) (ii)	0 193,454	0 29,440	0 49,252	0 121,170	0 17,686	0 411,002	0 18,215
(2)KEVIN KASTDIVISION CEO	(i) (ii)	0 378,897	0 55,273	0 151,024	0 90,300	0 24,621	0 700,115	0 112,204
(3)KAREN CLARKCHIEF FINANCIAL OFFICER	(i) (ii)	159,413 0	13,262 0	25 0	652 0	8,892 0	182,244 0	0 0
(4)MARK DABBSCOO/CNO	(i) (ii)	175,504 0	21,757 0	333 0	29,416 0	12,688 0	239,698 0	0 0
(5)JOHN FLANDERSPRESIDENT/CEO	(i) (ii)	0 76,610	0 0	0 59,217	0 10,692	0 30,222	0 176,741	0 0
(6)MARK WARGO MDMBR. B.O.D.	(i) (ii)	0 241,597	0 0	0 817	0 0	0 23,031	0 265,445	0 0

Schedule J (Form 990) 2012

Page 3

Part III

Supplemental Information

Complete this part to provide the information, explanation, or descriptions required for Part I, lines 1a, 1b, 3, 4a, 4b, 4c, 5a, 5b, 6a, 6b, 7, and 8, and for Part II.
Also complete this part for any additional information.

Identifier	Return Reference	Explanation
Part I, Line 1A		Country club dues are paid for John Flanders in his capacity as President of the Hospital and are only used for hospital-associated events. As such, this benefit is not treated as taxable compensation to John Flanders. Kevin Kast Schedule J, Part I, Line 4b kevin kast participated in a serp plan during the year in the amount of $157,883.
ann m. carr	schedule j, part i, line 4b	ann m. carr participated in a serp plan during the year in the amount of $42,817.

Schedule J (Form 990) 2012

Additional Data

Software ID:
Software Version:

- TIN:

Schedule L
(Form 990 or 990-EZ)

Department of the Treasury
Internal Revenue Service

Transactions with Interested Persons

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, line 38a or 40b.
MediumBullet

Attach to Form 990 or Form 990-EZ. MediumBullet

See separate instructions.

OMB No. 1545-0047

2012

Open to Public Inspection

Name of the organization

ST MARY'S HOSPITAL STREATOR HOSPITAL SISTERS
OF THE 3RD ORDER ST FRANCIS

Employer identification number

36-2169181

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	(c) Description of transaction	(d) Corrected?
1(a) Name of disqualified person	(c) Description of transaction	Yes	No

Enter the amount of tax incurred by organization managers or disqualified persons during the year under section 4958. ........................... Bullet Image

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-EZ, Part V, line 38a, or Form 990, Part IV, line 26; or if the organization reported an amount on Form 990, Part X, line 5, 6, or 22

(a) Name of interested person	(b) Relationship with organization	(c) Purpose of loan	(d) Loan to or from the organization?		(e)Original principal amount	(f)Balance due	(g) In default?		(h) Approved by board or committee?		(i)Written agreement?
(a) Name of interested person	(b) Relationship with organization	(c) Purpose of loan	To	From	(e)Original principal amount	(f)Balance due	Yes	No	Yes	No	Yes	No






Total ...... $

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 assistance	(d) Type of assistance	(e) Purpose of assistance

For Paperwork Reduction Act Notice, see the Instructions for Form 990 or 990-EZ.

Cat. No. 50056A

Schedule L (Form 990 or 990-EZ) 2012

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?
(a) Name of interested person		(c) Amount of transaction	(d) Description of transaction	Yes	No
(1) Georgene Lansford	Spouse of Director	65,131	Employment		No
(2) Jeannine Solon	Spouse of Director	59,470	Employment		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
BUSINESS TRANSACTIONS INVOLVING INTERESTED PERSONS	FORM 990 SCHEDULE L, PART IV	THERE ARE TWO ST. MARY'S HOSPITAL COLLEAGUES WHO ARE SPOUSES OF DIRECTORS. ALL PERSONS LISTED ON SCHEDULE L, PART IV WERE HIRED IN ACCORDANCE WITH THE HOSPITAL HIRING POLICY AT COMPARATIVE INDUSTRY MARKET COMPENSATION. GEORGENE LANSFORD AND JEANNINE SOLON WERE HIRED PRIOR TO THEIR RESPECTIVE SPOUSES' APPOINTMENT AS BOARD MEMBERS.

Schedule L (Form 990 or 990-EZ) 2012

Additional Data

Software ID:
Software Version:

- TIN:

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

2012

Open to Public
Inspection

Name of the organization

ST MARY'S HOSPITAL STREATOR HOSPITAL SISTERS
OF THE 3RD ORDER ST FRANCIS

Employer identification number

36-2169181

Identifier	Return Reference	Explanation
Organization's mission	FORM 990 PART III, Line 1	TO CONTINUE CHRIST'S HEALING MINISTRY THROUGH SERVICE TO THE SICK, THE AGED, THE POOR AND THE TERMINALLY ILL, REGARDLESS OF RACE, CREED, SEX, HANDICAPS, RELIGION, AGE, SEXUAL ORIENTATION, MARITAL, MILITARY DISCHARGE, OR FINANCIAL STATUS. THE VALUES OF COMPASSION, JUSTICE, REVERENCE FOR LIFE, AND INDIVIDUAL DIGNITY ARE FOSTERED. HEALTH SERVICES THAT IMPROVE OR MAINTAIN THE QUALITY OF LIFE ARE SUPPORTED. THE SISTERS, ADMINISTRATION, MEDICAL STAFF AND EMPLOYEES PRACTICE THIS MISSION BY IDENTIFYING WITH THE CORE VALUES OF THE HOSPITAL SISTERS HEALTH SYSTEM - RESPECT, CARE, COMPETENCE AND JOY. FORM 990, PART 111, LINE 4 THREE LARGEST PROGRAMS INPATIENT AND OUTPATIENT CARE SERVICES WITH DIRECT EXPENSES OF $2,911,047 INCLUDES MEDICAL SURGICAL, WOMEN'S HEALTH, AND INTENSIVE CARE ACUTE INPATIENT AND OBSERVATION PATIENT SERVICES AS WELL AS NURSERY INPATIENT CARE. THESE SERVICES PROVIDED 6,647 ACUTE PATIENT DAYS, PROVIDED SERVICES FOR 1,221 OBSERVATION PATIENTS AND 435 NURSERY DAYS. IMAGING SERVICES WITH DIRECT EXPENSES OF $3,408,690 INCLUDE ROUTING DIAGNOSTIC, ANGIOGRAPHY, ULTRASOUND, MRI, CT, AND NUCLEAR MEDICINE SERVICES. DIAGNOSTIC IMAGING CONDUCTED 19,171 IP/OP PROCEDURES; ANGIOGRAPHY CONDUCTED 450 IP/OP PROCEDURES; ULTRASOUND CONDUCTED 6,436 IP/OP PROCEDURES; MRI CONDUCTED 1,092 IP/OP PROCEDURES; CT 4,223 IP/OP PROCEDURES AND NUCLEAR MEDICINE CONDUCTED 1,354 IP/OP PROCEDURES. THE IMAGING DEPARTMENTS PROVIDE NECESSARY INPATIENT AND OUTPATIENT SERVICES TO THE COMMUNITY WE SERVE. SURGICAL SERVICES WITH DIRECT EXPENSES OF $3,303,625 INCLUDED BOTH INPATIENT AND OUTPATIENT SERVICES. SURGERY PERFORMED A TOTAL OF 2,753 SURGICAL PROCEDURES. 490 OF THOSE SERVICES WERE PROVIDED FOR INPATIENTS AND 2,263 FOR OUTPATIENTS. THE SURGERY DEPARTMENT MEETS THE NEEDS OF THE COMMUNITY BY PROVIDING BOTH EMERGENT AND ELECTIVE SURGERY ON AN INPATIENT AND OUTPATIENT BASIS. PROGRAM SERVICE ACCOMPLISHMENTS - FORM 990 PART III, LINE 4A THE COMMUNITY BENEFIT CONTRIBUTION OF ST. MARY'S HOSPITAL INCLUDES PROGRAMS AND ACTIVITIES THAT IMPROVE ACCESS TO HEALTH CARE AND IMPROVE HEALTH IN OUR COMMUNITIES. IN ORDER TO PORTRAY THE FULL BREADTH OF OUR CONTRIBUTION, OUR COMMUNITY BENEFIT INFORMATION IS DESCRIBED BELOW: SECTION 1: QUALITATIVE DESCRIPTION OF COMMUNITY BENEFIT - DESCRIBES THE HOSPITAL'S COMMUNITY BENEFIT MISSION, HOW THE MISSION IS TRANSLATED INTO A PROACTIVE APPROACH DESIGNED TO MEET COMMUNITY HEALTH NEEDS, HOW THE HOSPITAL MEETS TAX-EXEMPT REQUIREMENTS, AND A DESCRIPTION OF COMMUNITY BENEFIT PROGRAMS AND SERVICES THAT HIGHLIGHT THE HOSPITAL'S IMPACT ON COMMUNITY HEALTH. SECTION 2: QUANTITATIVE DESCRIPTION OF COMMUNITY BENEFIT - DESCRIBES THE HOSPITAL'S COMMUNITY BENEFIT CONTRIBUTION IN FINANCIAL TERMS PRESENTING THE AMOUNT OF CHARITY CARE, THE UNPAID SHORTFALL FROM GOVERNMENT HEALTH CARE FOR THE INDIGENT, AND THE NET EXPENSE OF COMMUNITY BENEFIT SERVICES. SECTION 1 - QUALITATIVE DESCRIPTION OF COMMUNITY BENEFIT 1. ORGANIZATIONAL COMMITMENT TO PROVIDING COMMUNITY BENEFIT- ST. MARY'S HOSPITAL MISSION IS TO CONTINUE CHRIST'S HEALING MINISTRY THROUGH SERVICE TO THE SICK, THE AGED, THE POOR AND THE TERMINALLY ILL REGARDLESS OF RACE, CREED, SEX, HANDICAPS, AGE, RELIGION, SEXUAL ORIENTATION, MARITAL, MILITARY-DISCHARGE OR FINANCIAL STATUS. ALTHOUGH REIMBURSEMENT FOR SERVICES RENDERED IS CRITICAL TO THE OPERATION AND STABILITY OF ST. MARY'S HOSPITAL, IT IS RECOGNIZED THAT NOT ALL INDIVIDUALS POSSESS THE ABILITY TO PURCHASE ESSENTIAL MEDICAL SERVICES AND FURTHER THAT OUR MISSION IS TO SERVE THE COMMUNITY WITH RESPECT TO PROVIDING HEALTHCARE SERVICES AND HEALTHCARE EDUCATION. A. ST. MARY'S HOSPITAL IS LOCATED IN STREATOR, ILLINOIS AND SERVES A PRIMARY SERVICE AREA OF APPROXIMATELY 113,921 RESIDENTS; WITH A SECONDARY SERVICE AREA OF APPROXIMATELY 90,254 RESIDENTS. ST. MARY'S HOSPITAL HAS BEEN DESIGNATED AS A MEDICARE DEPENDENT HOSPITAL MEETING THE CRITERIA OF AT LEAST 60 PERCENT OF INPATIENT DAYS OR DISCHARGES COVERED BY MEDICARE. THIS GREATER DEPENDENCE ON MEDICARE MAKES THE HOSPITAL MORE FINANCIALLY VULNERABLE TO PROSPECTIVE PAYMENT. ST. MARY'S HOSPITAL HAS IDENTIFIED TRANSPORTATION AS A NEED OF OUR SERVICE AREA. THE INCREASE IN THE ELDERLY POPULATION WHO ARE STILL IN THEIR HOMES AND DO NOT HAVE TRANSPORTATION TO OBTAIN MEDICAL NEEDS HAS INCREASED IN THIS SERVICE AREA. THE HOSPITAL HAS PROVIDED TRANSPORTATION BENEFITS TO 5,925 UNDERSERVED PERSONS AND IS WORKING IN CONJUNCTION WITH THE INTERAGENCY COORDINATING COMMITTEE ON TRANSPORTATION FOR LASALLE COUNTY TO ADDRESS THIS GROWING NEED. ST. MARY'S HOSPITAL'S BOARD OF DIRECTORS APPROVED AN IMPLEMENTATION STRATEGY BASED ON THE CHNA DURING THE PRIOR FISCAL YEAR, AND THE IDENTIFIED NEEDS WERE ADDRESSED IN OUR FISCAL YEAR FY2013. USING THE DATA FROM THE CHNA, THE STEERING COMMITTEE IDENTIFIED FOUR PRIORITY NEEDS FOR THE COMMUNITY INCLUDING: OBESITY, FAMILY VIOLENCE, SUBSTANCE/ALCOHOL ABUSE, AND EDUCATION. ST. MARY'S HOSPITAL WILL FOCUS ON TWO OF THE FOUR MAJOR NEEDS - OBESITY AND FAMILY VIOLENCE - BECAUSE THEY BEST MATCH OUR CORE COMPETENCIES AND WOULD OFFER ST. MARY'S HOSPITAL THE BEST OPPORTUNITY TO AFFECT THE MOST CHANGE. ONE IDENTIFIED NEED IN THE COMMUNITY NOT SPECIFICALLY ADDRESSED BY ST. MARY'S WAS SUBSTANCE/ALCOHOL ABUSE. SINCE ST. MARY'S HOSPITAL DOES NOT HAVE A SPECIFIC SUBSTANCE/ALCOHOL ABUSE PROGRAM AND IS NOT AN EDUCATIONAL INSTITUTION, THE HOSPITAL COLLABORATED WITH OTHER ORGANIZATIONS TO SUPPORT THEIR EFFORTS IN THESE AREAS. PHYSICIANS AND HOSPITAL COLLEAGUES REFER PATIENTS AS APPROPRIATE TO LOCAL RESOURCES THAT CAN BETTER SUPPORT HEALING IN THIS AREA. SUBSTANCE/ALCOHOL ABUSE IS ALSO SERVED BY THE STREATOR SUBSTANCE ABUSE PREVENTION COALITION, IN WHICH A HOSPITAL CHAPLAIN ACTIVELY PARTICIPATES. THE CURRENT IMPLEMENTATION STRATEGY CONSISTS OF AN EXPANSION OF ST. MARY'S "HEALTHY YOU" PROGRAM AND THE DEVELOPMENT OF A COMMUNITY GARDEN, BOTH FOCUSED ON REDUCING OBESITY AND ENCOURAGING THE COMMUNITY TO EMBRACE A HEALTHIER LIFESTYLE. IN ADDITION, ST. MARY'S IS ALSO ENGAGED IN A PROCESS WITH OTHER COMMUNITY ORGANIZATIONS TO ASSESS HOW THE HOSPITAL COULD SUPPORT LOCAL RESOURCES ALREADY IN PLACE FOR DOMESTIC VIOLENCE. IN PARTICULAR, ST. MARY'S IS COLLABORATING WITH ADV/SAS (A DOMESTIC VIOLENCE & SEXUAL ASSAULT SERVICE) TO HELP STRENGTHEN THEIR MEDICAL ADVOCATE PROGRAM THROUGH OUR HOSPITAL. TO ADDRESS OBESITY IN THE COMMUNITIES SERVED, ST. MARY'S HOSPITAL FOCUSED ON EXERCISE, NUTRITION AND HEALTHY LIFESTYLES. IN FY2013, ST. MARY'S HOSPITAL REINTRODUCED A 12-WEEK WEIGHT-LOSS COMPETITION PREVIOUSLY CALLED "LEAN TO GREEN", AND A NEW PARTNERSHIP WAS ANNOUNCED WITH THE STREATOR YMCA TO EVOLVE "LEAN TO GREEN" INTO A BIGGER AND BETTER COMMUNITY PROGRAM. AS PART OF THIS PARTNERSHIP, THE PROGRAM WAS RENAMED "HEALTHY YOU" - EMPHASIZING THAT THIS IS NOT JUST A WEIGHT LOSS PROGRAM, BUT A MORE HOLISTIC PROGRAM AIMED AT HELPING INDIVIDUALS LIVE AN ALL-AROUND HEALTHIER LIFESTYLE. ADDED PROGRAM BENEFITS INCLUDED A PEDOMETER TO HELP MOTIVATE WEIGHT LOSS, A MAINTENANCE PROGRAM TO MAINTAIN WEIGHT LOSS YEAR-ROUND, AND COOKING CLASSES PROVIDED BY THE HOSPITAL FOR PARTICIPANTS TO LEARN METHODS OF COOKING WITH FRESH, HEALTHY FOODS AND NEW LOW-FAT RECIPES. THE HOSPITAL'S PROGRAM PARTNER, THE STREATOR YMCA, ALSO PROVIDED FIVE FREE AEROBICS CLASSES FOR PARTICIPANTS. THE 2013 "HEALTHY YOU" PROGRAM ATTRACTED 282 PARTICIPANTS (66 TEAMS), NEARLY DOUBLE THE NUMBER OF PARTICIPANTS FROM THE PREVIOUS YEAR. THE TEAMS BEGAN WITH A COMBINED WEIGHT OF 59,145 POUNDS. A TOTAL OF 191 PARTICIPANTS COMPLETED THE PROGRAM LOSING A TOTAL OF 2,491 POUNDS OR 4.21% OVERALL. TO HELP INDIVIDUALS STAY MOTIVATED AND STAY ON TRACK WITH A HEALTHY LIFESTYLE JOURNEY, "HEALTHY YOU" OFFERS A MAINTENANCE COMPONENT THAT ENCOURAGES PARTICIPANTS TO WEIGH IN ON A MONTHLY BASIS; APPROXIMATELY 50 INDIVIDUALS ARE PARTICIPATING IN THE MAINTENANCE PROGRAM. ST. MARY'S HOSTED AN ELECTRONIC RECYCLING AND USED MEDICAL EQUIPMENT DRIVE OPEN TO ALL COLLEAGUES AND THE COMMUNITY IN HONOR OF EARTH DAY. VINTAGE TECH RECYCLERS, INC. AS ON SITE WITH A TRUCK COLLECTING VARIOUS ELECTRONIC ITEMS TO BE RECYCLED AND THE USED MEDICAL EQUIPMENT WAS DONATED TO HSHS MISSION OUTREACH IN SPRINGFIELD, ILLINOIS. BECAUSE OF OUR EVENT, WE WERE ABLE TO RECYCLE 14,269 POUNDS OF ELECTRONICS THAT OTHERWISE WOULD END UP IN OUR LANDFILLS. IN ADDITION TO THE ELECTRONICS RECYCLING DRIVE, ST. MARY'S PHARMACY SET UP A MEDICATION DISPOSAL DRIVE TO HELP PRESERVE OUR WATER SUPPLY. THE PHARMACY COLLECTED 22 POUNDS OF EXPIRED OR UNWANTED MEDICATIONS THAT INDIVIDUALS WISHED TO SAFELY DISCARD.
B. THE REGISTRATION DEPARTMENT PROVIDES BROCHURES TO PATIENTS UPON REQUEST		B. THE REGISTRATION DEPARTMENT PROVIDES BROCHURES TO PATIENTS UPON REQUEST REGARDING THE PAYMENT ASSISTANCE PROGRAM AVAILABLE TO THEM AT ST. MARY'S HOSPITAL. THE CHRISTIAN CARE BROCHURES ARE ALSO SUPPLIED IN WAITING AND ANCILLARY AREAS, AS WELL AS ON THE HOSPITAL'S WEBSITE AT WWW.STMARYSHOSPITAL.ORG. INFORMATION OUTLINING THE PROGRAM IS ALSO AVAILABLE ON PATIENT STATEMENTS AND UPON REQUEST. 2. ORGANIZATIONAL DESCRIPTION FOR TAX EXEMPTION- ST. MARY'S HOSPITAL OPERATES AN EMERGENCY DEPARTMENT THAT IS OPEN 24 HOURS TO ALL PERSONS REGARDLESS OF THEIR ABILITY TO PAY. THE HOSPITAL HAS AN OPEN MEDICAL STAFF WITH PRIVILEGES AVAILABLE TO ALL QUALIFIED PHYSICIANS IN THE AREA. ST. MARY'S HOSPITAL SERVES AS A CLINICAL SITE FOR STUDENTS IN THE FIELDS OF NURSING, LABORATORY, DIAGNOSTIC IMAGING, PHYSICAL THERAPY, SPEECH AND PHARMACY. ST. MARY'S HOSPITAL PARTICIPATES IN THE GOVERNMENT-SPONSORED HEALTH CARE PROGRAMS FOR MEDICAID, MEDICARE, CHAMPUS AND TRICARE. 3. IN FY2013, MANY OF THE ABOVE ACTIVITIES WERE CONTINUED OR STRENGTHENED AS ST. MARY'S CONTINUES TO FOCUS ON THE PRIORITY NEEDS IDENTIFIED IN THE FY2012 COMMUNITY HEALTH NEEDS ASSESSMENT PROCESS. TO FURTHER SUPPORT STREATOR'S UNDERSERVED POPULATION AND PROMOTE HEALTHY EATING CHOICES, A COMMUNITY GARDEN WAS ESTABLISHED AND PLANTED ON HOSPITAL PROPERTY; THE GARDEN IS MAINTAINED BY HOSPITAL AND COMMUNITY VOLUNTEERS. ALL HARVEST PROCEEDS ARE DONATED TO THE LOCAL FOOD PANTRY TO PROVIDE FRESH, HEALTHY PRODUCE TO THOSE IN NEED TO FURTHER PROMOTE IMPROVED HEALTH IN THE COMMUNITY AND REDUCTION OF OBESITY. ST. MARY'S HOSPITAL IS AWARE OF THE NEED IN THE COMMUNITY FOR TRANSPORTATION TO AND FROM MEDICAL SERVICES. IN AN EFFORT TO ALLEVIATE THIS NEED, THE HOSPITAL PROVIDES A MEDICAL TRANSPORTATION PROGRAM WHICH INCLUDES FREE VAN SERVICE TO MEDICAL APPOINTMENTS FOR PATIENTS WITH SPECIAL NEEDS AND NO MEANS OF TRANSPORTATION. THIS SERVICE INCLUDES TRANSPORTATION TO PHYSICIAN OFFICE AND ALL OUTPATIENT SERVICES AFFILIATED WITH ST. MARY'S HOSPITAL. TRANSPORTATION IS MADE WITH THE PARTICIPANTS SAFETY IN MIND WITH A QUALIFIED STAFF TO ASSIST INDIVIDUALS WITH BOARDING AND DISEMBARKING IN VANS MAINTAINED TO ILLINOIS DEPARTMENT OF TRANSPORTATION STANDARDS. ST. MARY'S HOSPITAL HAS ENGAGED IN A PROCESS WITH OTHER COMMUNITY ORGANIZATIONS TO ASSESS HOW THE HOSPITAL COULD SUPPORT LOCAL RESOURCES ALREADY IN PLACE FOR DOMESTIC VIOLENCE. IN PARTICULAR, THE HOSPITAL IS COLLABORATING WITH ADV/SAS (A DOMESTIC VIOLENCE & SEXUAL ASSAULT SERVICE) TO HELP STRENGTHEN THEIR MEDICAL ADVOCATE PROGRAM THROUGHOUT LASALLE AND LIVINGSTON COUNTIES. MEDICAL ADVOCATES PROVIDE SUPPORT AND INFORMATION TO SURVIVORS OF DOMESTIC OR SEXUAL VIOLENCE, ADVOCATE FOR THE VICTIM WITH THE MEDICAL STAFF AND LAW ENFORCEMENT PERSONNEL, EXPLAIN THE MEDICAL EVIDENCE COLLECTION AND CRIMINAL JUSTICE PROCEDURES, AND ARRANGE TRANSPORTATION AND SHELTER IF THE VICTIM WISHES. IN FY2013, ALL HOSPITAL EMERGENCY DEPARTMENT COLLEAGUES RECEIVED ADDITIONAL TRAINING ON DOMESTIC VIOLENCE RESOURCES WITHIN THE COMMUNITY AND THE TOOLS TO MAKE REFERRALS FOR THESE PATIENTS AS APPROPRIATE. IN ADDITION, ST. MARY'S HOSPITAL COLLEAGUES PROUDLY SERVE ON THE ILLINOIS HEALTHCARES COALITION (IHC), A LOCAL SITE OF A STATEWIDE HEALTH INITIATIVE ADDRESSING DOMESTIC VIOLENCE, INTIMATE PARTNER VIOLENCE, SEXUAL ASSAULT/VIOLENCE AND ELDER ABUSE, AS A PUBLIC HEALTH CONCERN. ADV/SAS IS A PARTNER IN THIS COALITION.. 4. LINKS TO ADDITIONAL COMMUNITY BENEFIT INFORMATION- ST. MARY'S HOSPITAL CHRISTIAN CARE POLICY, REQUEST FOR FINANCIAL ASSISTANCE, FINANCIAL ELIGIBILITY CRITERIA TABLE AND COMMUNITY BENEFITS REPORT IS ATTACHED. SECTION 2 - QUANTIFIABLE COMMUNITY BENEFIT THE FINANCIAL INFORMATION IN THIS REPORT WAS PREPARED IN ACCORDANCE WITH THE CATHOLIC HEALTH ASSOCIATION'S (CHA) COMMUNITY BENEFIT REPORTING GUIDELINES. THESE GUIDELINES RECOMMEND THE FOLLOWING: "REPORT CHARITY CARE AT COST, NOT CHARGES. "DO NOT INCLUDE BAD DEBT, CONTRACTUAL ALLOWANCES, AND QUICK PAY DISCOUNTS AS PART OF CHARITY CARE EXPENSE. "DO NOT COUNT MEDICARE SHORTFALL AS A COMMUNITY BENEFIT. "REPORT THE NET EXPENSE FOR COMMUNITY BENEFIT SERVICES, I.E., THE TOTAL COMMUNITY BENEFIT EXPENSE MINUS ANY ASSOCIATED REVENUE FROM PATIENTS, PAYERS, AND OTHER EXTERNAL SOURCES. THE CHA REPORTING GUIDELINES REFLECT A CONSERVATIVE APPROACH TO REPORTING QUANTIFIABLE COMMUNITY BENEFIT. THE GOAL OF THE REPORTING GUIDELINES IS TO PRODUCE COMMUNITY BENEFIT FINANCIAL REPORTS THAT REFLECT TRUE COSTS AND THAT DESCRIBE COMMUNITY BENEFIT ACTIVITIES THAT INCREASE ACCESS TO HEALTH CARE AND IMPROVE COMMUNITY HEALTH. CATEGORY A, COMMUNTIY HEALTH IMPROVEMENT SERVICES- EDUCATION, CLINICAL, AND SUPPORT SERVICES WERE PROVIDED TO 22,892 PEOPLE, AT A COST OF $301,522, FOR A TOTAL BENEFIT AMOUNT OF $299,226. A1 - COMMUNITY HEALTH EDUCATION: COMMUNITY HEALTH EDUCATION BENEFIT PROGRAMS, SERVED 22,554 PERSONS AT A COST OF $90,890, WITH OFFSETTING REVENUES OF $275 FOR A TOTAL BENEFIT AMOUNT OF $90,615. A2 - COMMUNITY BASED CLINICAL SERVICES: COMMUNITY HEALTH EDUCATION BENEFIT PROGRAMS SERVED 55 PERSONS AT A COST OF $54,928, WITH NO OFFSETTING REVENUES FOR A TOTAL BENEFIT AMOUNT OF $54,928. A3 - HEALTH CARE SUPPORT SERVICES: COMMUNITY HEALTH EDUCATION BENEFIT PROGRAMS SERVED 283 PERSONS AT A COST OF $152,152 WITH OFFSETTING REVENUES OF $2,021 FOR A TOTAL BENEFIT AMOUNT OF $150,131. CATEGORY B- NO ACTIVITY CATEGORY C- NO ACTIVITY CATEGORY E, FINANCIAL AND IN-KIND CONTRIBUTIONS TOTALED $53,508 SERVING 1,079 PEOPLE. E1 - CASH DONATIONS TOTALED $7,718. E3 - IN-KIND DONANTIONS: IN-KIND DONATIONS SERVED 1,079 PERSONS AT A COST OF $45,790 WITH NO OFFSETTING REVENUES FOR A TOTAL BENEFIT AMOUNT OF $45,790. CATEGORY F - COMMUNITY BUILDING ACTIVITIES, INCLUDED SUPPORT SYSTEM ENHANCEMENTS AT A COST OF $289. CATEGORY G- COMMUNITY BENEFIT OPERATIONS INCLUDES EXPENSES RELATED TO TRACKING, RECORDING, AND REPORTING COMMUNITY BENEFIT FOR A TOTAL BENEFIT OF $4,504. A TOTAL OF 42 COMMUNITY BENEFIT ACTIVITIES WERE COMPLETED, AT A COST OF $359,823 WITH OFFSETTING REVENUES OF $2,296 FOR A TOTAL BENEFIT AMOUNT OF $357,527. TOTAL NUMBER OF PERSONS SERVED WAS 23,971. CHARITY CARE SERVED 2,000 PERSONS AT A COST OF $2,766,650. THIS IS IN ADDITION TO THE 42 ACTIVITIES MENTIONED ABOVE AT A BENEFIT OF $357,527. BOTH PROVIDED A TOTAL COMBINED BENEFIT AMOUNT OF $3,124,177. TAX EXEMPT BONDS FORM 990, PART IV, QUESTION 4 ST. MARY'S - STREATOR HOLDS A LIABILITY ON ITS BOOKS FOR TAX-EXEMPT BONDS, WHICH IS AN ALLOCATION FROM ITS SOLE CORPORATE MEMBER, HOSPITAL SISTERS SERVICES, INC. AS A RESULT, THIS QUESTION WAS ANSWERED NO, AND SCHEDULE K WILL BE COMPLETED ON THE HOSPITAL SISTERS SERVICES, INC. FORM 990. Changes to By-Laws Form 990, Part VI, Line 4 Section 2.3(g) - This is a new section giving the Members authority over the incurrence of debt above a limit set by the Members. This section makes explicit what was implied in Section 2.3(f) and clarifies that the authority extends also to debt secured by other than real estate. Section 3.2 - The added language to this section clarifies the position of the President as Board member. Section 4.8 - This revision gives the board the ability to use electronic voting technology. The Board members are not likely to use this ability frequently. Section 4.9 - This revision broadens the use of Telecommunications to any Board Committees. Section 5.5 - This revision clarifies the role of the Executive Committee in financial transactions with physicians (as per HSHS policy). Section 5.7 - The underlined is an addition to the Quality Care Committee. Most Local Systems will not be using a combined Quality Care Committee, but it is available to them should they desire to do so. Article 7 Medical Staff - Revisions are made to address recent Joint Commission changes to Medical Staff accreditation standards. RIGHTS OF MEMBERS TO ELECT GOVERNING BODY FORM 990 PART VI, LINES 6 & 7A THE SENIOR GOVERNING BODY OF ST. MARY'S HOSPITAL STREATOR (THE "CORPORATION") IS THE MEMBER OF THE CORPORATION, WHICH IS HOSPITAL SISTERS HEALTH SERVICES, INC. ("HSSI"), AN ILLINOIS NOT FOR PROFIT CORPORATION EXEMPT FROM FEDERAL TAXATION UNDER SECTION 501(C)(3) OF THE INTERNAL REVENUE CODE. PURSUANT TO SECTION 2.3 OF THE CORPORATION'S BYLAWS, HSSI HAS THE RIGHT TO APPOINT AND REMOVE THE CORPORATION'S BOARD OF DIRECTORS, CHAIRPERSON OF THE BOARD AND PRESIDENT. OF DIRECTORS, CHAIRPERSON OF THE BOARD AND PRESIDENT.
MEMBER RESERVED POWERS	FORM 990 PART VI, LINE 7B	RESPONSIBILITY FOR THE POLICY AND OPERATIONS OF ST. MARY'S HOSPITAL STREATOR (THE "CORPORATION") IS VESTED IN ITS BOARD OF DIRECTORS, EXCEPT WITH RESPECT TO SPECIFIC POWERS RESERVED IN THE CORPORATION'S BYLAWS TO THE CORPORATION'S MEMBER, HOSPITAL SISTERS HEALTH SERVICES, INC. ("HSSI"), AN ILLINOIS NOT FOR PROFIT CORPORATION EXEMPT FROM FEDERAL TAXATION UNDER SECTION 501(C)(3) OF THE INTERNAL REVENUE CODE. THE MEMBER OF HSSI IS HOSPITAL SISTERS HEALTH SYSTEM ("HSHS"), AN ILLINOIS NOT FOR PROFIT CORPORATION EXEMPT FROM FEDERAL TAXATION UNDER SECTION 501(C)(3) OF THE INTERNAL REVENUE CODE. THE MEMBERS OF HSHS ARE THE INDIVIDUAL SISTERS WHO FROM TIME TO TIME ARE THE DULY ELECTED PROVINCIAL SUPERIOR AND PROVINCIAL COUNCILORS, RESPECTIVELY OF THE AMERICAN PROVINCE OF THE HOSPITAL SISTERS OF ST. FRANCIS ("AMERICAN PROVINCE"). THE AMERICAN PROVINCE IS THE UNITED STATES ORGANIZATION OF THE CONGREGATION OF THE HOSPITAL SISTERS OF THE THIRD ORDER REGULAR OF ST. FRANCIS, A RELIGIOUS INSTITUTE OF THE ROMAN CATHOLIC CHURCH. THE GOVERNANCE AND OPERATIONS OF THE CORPORATION ARE SUBJECT TO HSSI'S RIGHT TO EXERCISE THESE RESERVED POWERS WITH RESPECT TO THE CORPORATION AND ORGANIZATIONS OF WHICH THE CORPORATION IS EITHER, DIRECTLY OR INDIRECTLY, A CONTROLLING MEMBER OR A CONTROLLING SHAREHOLDER ("AFFILIATES"). HSSI'S RIGHT TO EXERCISE CERTAIN OF THESE RESERVED POWERS IS, IN TURN, SUBJECT TO THE APPROVAL OF HSHS AND HSHS' MEMBERS. THE RESERVED POWERS INCLUDE ALL RIGHTS GRANTED TO HSSI BY LAW AND THE RIGHT TO: (A) ADOPT, APPROVE AMENDMENTS TO, OR AMEND ANY STATEMENT OF PHILOSOPHY, MISSION, MISSION INTEGRATION OR VALUES OR ANY NAME, LOGO, OR MARK OF THE CORPORATION OR OF ANY AFFILIATE; (B) ADOPT, APPROVE AMENDMENTS TO, OR AMEND THE ARTICLES OF INCORPORATION OF THE CORPORATION OR OF ANY AFFILIATE; (C) ADOPT, APPROVE AMENDMENTS TO, OR AMEND THE BYLAWS OF THE CORPORATION OR OF ANY AFFILIATE; (D) APPOINT AND REMOVE THE BOARD OF DIRECTORS, ANY ONE OR MORE OF THE DIRECTORS OF THE CORPORATION OR OF ANY AFFILIATE, AND THE CHAIRPERSON AND PRESIDENT OF THE CORPORATION OR OF ANY AFFILIATE; (E) APPROVE THE RECOMMENDATION OF THE BOARD OF DIRECTORS TO APPOINT OR REMOVE THE BOARD OF DIRECTORS, ANY ONE OR MORE DIRECTORS OF THE CORPORATION OR OF ANY AFFILIATE, OR THE CHAIRPERSON AND PRESIDENT OF THE CORPORATION OR OF ANY AFFILIATE. (F) WITH RESPECT TO THE CORPORATION OR ANY AFFILIATE, APPROVE THE PURCHASE, SALE, ALIENATION, EXCHANGE, LEASE OR ENCUMBRANCE OF ANY REAL PROPERTY OF THE CORPORATION OR OF ANY AFFILIATE, WHICH PROPERTY HAS A VALUE IN EXCESS OF LIMITS SET FROM TIME TO TIME BY HSSI; (G) APPROVE THE OPERATING AND CAPITAL BUDGETS OF THE CORPORATION OR OF ANY AFFILIATE, AND ANY DEVIATIONS BY THE CORPORATION OR OF ANY AFFILIATE FROM SUCH BUDGETS IN AN AMOUNT OR PERCENTAGE SPECIFIED BY HSSI FROM TIME TO TIME; (H) APPROVE THE STRATEGIC PLAN AND GOALS OF THE CORPORATION OR OF ANY AFFILIATE; (I) APPROVE THE SALE OF SUBSTANTIALLY ALL OF THE ASSETS OF THE CORPORATION OR OF ANY AFFILIATE; (J) APPROVE THE MERGER OR DISSOLUTION OF THE CORPORATION OR OF ANY AFFILIATE; (K) ADOPT OR AMEND THE PLAN FOR MINISTRY EDUCATION AND GOVERNANCE FOR THE CORPORATION AND ITS AFFILIATES; (L) APPROVE THE CORPORATION'S MISSION ACCOUNTABILITY REPORTS AND THOSE OF ANY AFFILIATE; (M) APPROVE THE FINANCIAL POLICIES AND PROCEDURES OF THE CORPORATION OR OF ANY AFFILIATE AND APPROVE ANY DEVIATIONS FROM SUCH POLICIES AND PROCEDURES BY THE CORPORATION OR ANY AFFILIATE; AND (N) ADOPT POLICIES TO IMPLEMENT THE RESERVED POWERS OF HSSI.
FORM 990 REVIEW PROCESS	FORM 990 PART VI, LINE 11b	THE HOSPITAL EMPLOYS KPMG TO ASSIST IN THE OVERALL REVIEW AND ELECTRONIC SUBMISSION OF ITS FORM 990. KPMG PROVIDES GUIDANCE IN IDENTIFYING CRITICAL ERRORS IN THE RETURN SUBMISSION AND FEEDBACK ON QUANTITATIVE AND QUALITATIVE RESPONSES. ADDITIONALLY, THE HOSPITAL CFO PERFORMS A THOROUGH REVIEW OF THE RETURN AND REVIEWS IT WITH THE HOSPITAL CEO AND/OR SENIOR LEADERS BEFORE PRESENTING IT IN ITS ENTIRETY TO THE HOSPITAL BOARD FOR QUESTIONING AND REVIEW PRIOR TO THE RETURN'S SIGNING AND SUBMISSION TO THE IRS.
CONFLICT OF INTEREST POLICY	FORM 990 PART VI, LINE 12C	THE ORGANIZATION IS SUBJECT TO THE CORPORATE COMPLIANCE PROGRAM AND CONFLICT OF INTEREST POLICY ("POLICY") OF HOSPITAL SISTERS HEALTH SYSTEM, AN ILLINOIS NOT FOR PROFIT CORPORATION EXEMPT FROM FEDERAL TAXATION UNDER SECTION 501(C)(3) OF THE INTERNAL REVENUE CODE. A REVISED CORPORATE COMPLIANCE PROGRAM AND CONFLICT OF INTEREST POLICY HAVE BEEN IMPLEMENTED SINCE JANUARY 2009 TO MANAGE CONFLICTS OF INTEREST USING A SYSTEM-WIDE PROTOCOL FOR DISCLOSURE STATEMENTS. IN ACCORDANCE WITH THE ORGANIZATON'S CONFLICT OF INTEREST POLICY, ALL COVERED PERSONS HAVE A DUTY TO COMPLY WITH THE CONFLICT OF INTEREST POLICY FOR ANY CONTRACT, TRANSACTION, RELATIONSHIP OR ACTIVITY CONTEMPLATED, ENTERED INTO OR CONDUCTED AT HSHS OR ITS AFFILIATES. THE POLICY DEFINES COVERED PERSONS AS BOARD MEMBERS, BOARD COMMITTEE MEMBERS, OFFICERS, BOARD DESIGNEES, SENIOR MANAGEMENT, MEMBERS OF ANY COMMITTEE THAT OVERSEES THE APPROVAL OF PHARMACEUTICALS AND MEDICAL DEVICES, ANY OTHER INDIVIDUAL WHO HOLDS A POSITION OF TRUST. ON AN ANNUAL BASIS, HSHS DISCLOSES A COPY OF THE CONFLICT OF INTEREST POLICY (AND ALL CORRESPONDING PROCEDURES, GUIDELINES, FORMS AND TOOLS) TO ALL COVERED PERSONS AND ADVISES ALL COVERED PERSONS IN WRITING OF ANY SUBSTANTIVE CHANGES TO THIS POLICY AND SUCH RELATED MATERIALS. COVERED PERSONS ARE REQUIRED TO REVIEW AND COMPLETE THE CORRESPONDING CONFLICT OF INTEREST STATEMENT. THE SYSTEM OFFICE VICE PRESIDENT - SYSTEM RESPONSIBILITY- SYSTEM OR MEMBERS OF THE AUDIT AND INTEGRITY COMMITTEE ("COMMITTEE") ARE AVAILABLE TO ANSWER ANY QUESTIONS A COVERED PERSON MAY HAVE. IN ADDITION, IF, AT ANY TIME AFTER SUBMITTING AN ANNUAL CONFLICT OF INTEREST STATEMENT, A COVERED PERSON BECOMES AWARE OF AN INTEREST THAT HE OR SHE WOULD HAVE HAD TO DISCLOSE AT THE ANNUAL INTERVAL, THE COVERED PERSON IS REQUIRED PROMPTLY TO DISCLOSE THE INTEREST TO THE COMMITTEE USING THE HSHS CONFLICT OF INTEREST DISCLOSURE STATEMENT. COMPLETED CONFLICT OF INTEREST STATEMENTS ARE SUBMITTED TO THE COMMITTEE, WHICH IS RESPONSIBLE FOR IDENTIFYING, ASSESSING, AND MANAGING CONFLICTS OF INTEREST THAT ARISE IN THE COURSE OF CONDUCTING THE AFFAIRS OF HSHS AND ITS AFFILIATES. IF THE COMMITTEE DETERMINES THAT A CONFLICT OF INTEREST EXISTS, THE CONFLICT OF INTEREST POLICY REQUIRES HSHS NOT TO ENGAGE IN OR ENTER INTO A PROPOSED CONTRACT, TRANSACTION, RELATIONSHIP, ARRANGEMENT OR ACTIVITY UNLESS THE COMMITTEE OR, WHERE NECESSARY, THE BOARD OF DIRECTORS (ACTING THROUGH ITS DISINTERESTED MEMBERS), HAS INVESTIGATED ALTERNATIVES TO THE PROPOSED CONTRACT, TRANSACTION, RELATIONSHIP, ARRANGEMENT OR ACTIVITY AND, IN THE ABSENCE OF ALTERNATIVES THAT ARE IN THE BEST INTERESTS OF HSHS, HAS DETERMINED: 1. THAT, REGARDLESS OF WHETHER THE COVERED PERSON PARTICIPATES IN THE IMPLEMENTATION OF THE PROPOSED CONTRACT, TRANSACTION, RELATIONSHIP, ARRANGEMENT, OR ACTIVITY; 2. THE CONTRACT, TRANSACTION, ARRANGEMENT OR ACTIVITY IS IN THE BEST INTERESTS OF HSHS; 3. THE CONTRACT, TRANSACTION, ARRANGEMENT OR ACTIVITY IS FAIR AND REASONABLE FROM THE PERSPECTIVE OF HSHS; AND 4. HSHS CANNOT OBTAIN A MORE ADVANTAGEOUS CONTRACT, TRANSACTION, ARRANGEMENT OR ACTIVITY WITH REASONABLE EFFORTS UNDER THE CIRCUMSTANCES. IN DETERMINING WHETHER A CONTRACT, TRANSACTION OR ARRANGEMENT IS FAIR AND REASONABLE TO HSHS, THE COMMITTEE SHALL CONSIDER, WHERE APPLICABLE: 1. APPRAISALS OR OTHER INDEPENDENT VALUATIONS OF THE FAIR MARKET VALUE OF THE CONTRACT, TRANSACTION OR ARRANGEMENT; 2. INFORMATION REGARDING COMPARABLE CONTRACTS, TRANSACTIONS OR ARRANGEMENTS BETWEEN UNRELATED PARTIES; 3. OFFERS FROM COMPARABLE COMPETING ENTITIES; AND/OR 4. STUDIES OF COMPARABLE COMPENSATION ARRANGEMENTS. IN ANY CASE IN WHICH THE COMMITTEE FINDS, AFTER TAKING THE STEPS DESCRIBED ABOVE, THAT HSHS SHOULD PARTICIPATE IN A PROPOSED TRANSACTION OR ARRANGEMENT DESPITE THE EXISTENCE OF A CONFLICT OF INTEREST, THE COMMITTEE SHALL DEVELOP, IMPLEMENT, MONITOR, AND ENFORCE COMPLIANCE WITH, A CONFLICT MANAGEMENT PLAN FOR MANAGING THE CONFLICT OF INTEREST AS IT CONSIDERS NECESSARY FOR SUCH FINDINGS TO REMAIN VALID THROUGHOUT THE LIFE OF THE CONTRACT, TRANSACTION, RELATIONSHIP, ARRANGEMENT OR ACTIVITY. ALL CONFLICT MANAGEMENT PLANS SHALL: 1. STATE THAT THE COMMITTEE WILL OVERSEE, MONITOR AND ENFORCE COMPLIANCE WITH THE PLAN THROUGHOUT THE COURSE OF THE STUDY AND SPECIFY MEANS FOR DOING SO, INCLUDING, WITHOUT LIMITATION, THAT THE APPROPRIATE INDIVIDUALS MUST PROVIDE THE COMMITTEE WITH WRITTEN REPORTS PERTAINING TO COMPLIANCE WITH THE CONFLICT MANAGEMENT PLAN, THAT THE COMMITTEE SHALL HAVE THE RIGHT TO AUDIT THE STUDY FOR SUCH COMPLIANCE AND THE RIGHT TO IMPOSE SANCTIONS FOR NON-COMPLIANCE; 2. STATE THAT THE PLAN MUST BE SHARED WITH COVERED PERSON WHOSE INTERESTS IT WAS DEVELOPED TO MANAGE; 3. STATE THAT THE PLAN MUST BE SHARED WITH, AND PERIODIC REPORTS ON COMPLIANCE WITH THE PLAN MUST BE PROVIDED TO, THE BOARD, SENIOR MANAGEMENT AND/OR GOVERNMENT AGENCIES; AND 4. PROVIDE FOR SUCH OTHER MANAGEMENT STEPS AND MECHANISMS THE COMMITTEE CONSIDERS NECESSARY AND APPROPRIATE. IN ADDITION TO THE COMMITTEE, THE SYSTEM OFFICE VICE PRESIDENTS OF SYSTEM RESPONSIBILITY AND RISK & COMPLIANCE MAY RETAIN SUCH INDEPENDENT ADVISORS OR EXPERTS AS DEEMED NECESSARY TO ASSIST IN MAKING ITS DETERMINATIONS AND DECISIONS. IF THE COMMITTEE DETERMINES THAT THE CONTEMPLATED TRANSACTION, RELATIONSHIP ARRANGEMENT OR ACTIVITY CANNOT PROCEED DUE TO A CONFLICT OF INTEREST, THE COMMITTEE SHALL INFORM THE APPLICABLE COVERED PERSON OR DECISION-MAKING BODY OF SUCH DETERMINATION WITHIN ONE WEEK OF THE COMMITTEE MEETING AT WHICH THE CONTEMPLATED TRANSACTION WAS DISCUSSED. THE COMMITTEE SHALL DOCUMENT ITS REJECTION OF THE CONTEMPLATED TRANSACTION IN THE COMMITTEE'S MEETING MINUTES.
WHISTLEBLOWER POLICY	FORM 990 PART VI, LINE 13	PROVISIONS WITHIN THE CORPORATE COMPLIANCE PROGRAM AND CONFLICT OF INTEREST POLICY PROVIDE PROTECTIONS FOR WHISTLEBLOWER TYPE ACTIVITIES.
COMPENSATION PROCESS	FORM 990 PART VI, LINE 15	THE COMPENSATION COMMITTEE (COMMITTEE) IS COMPRISED OF INDEPENDENT MEMBERS OF THE BOARD OF DIRECTORS. THE COMMITTEE DEVELOPS A COMPENSATION PHILOSOPHY FOR THE SYSTEM AND ALL AFFILIATES. THE COMMITTEE SELECTS AND HIRES THE INDEPENDENT COMPENSATION CONSULTANT TO DEVELOP COMPARABILITY DATA AND ADVISE THE COMMITTEE DURING ITS DELIBERATIONS REGARDING ALL ELEMENTS OF TOTAL COMPENSATION FOR ALL DISQUALIFIED INDIVIDUALS. INTEGRATED HEALTHCARE STRATEGIES (IHS), THE CONSULTANTS UTILIZED BY THE COMMITTEE, USE DATA FROM MULTIPLE TAX-EXEMPT PEER GROUP SOURCES TO DETERMINE SALARY RANGES, INCENTIVE OPPORTUNITY RANGES AND BENEFITS FOR THE DISQUALIFIED INDIVIDUALS. IHS THEN ASSISTS THE COMMITTEE IN PREPARING CONTEMPORANEOUS DOCUMENTATION OF ALL ACTIONS. EACH COMMITTEE MEETING IS CONDUCTED WITH THE INTENT TO CREATE A REBUTTABLE PRESUMPTION OF REASONABLENESS FOR ALL ELEMENTS OF EXECUTIVE TOTAL COMPENSATION FOR THE DISQUALIFIED INDIVIDUALS. THE CHAIRMAN MAKES THIS DECLARATION AND ALSO INQUIRES IF THERE ARE ANY CONFLICTS OF INTEREST BY ANY ATTENDEES. ANY CONFLICTS ARE DISCLOSED AND THE COMMITTEE THEN ACTS IN A MANNER TO AVOID ANY CONFLICTED INDIVIDUAL PARTICIPATING IN ANY MANNER WHERE A CONFLICT MIGHT EXIST. AT THE END OF THE MEETING, THE COMMITTEE PREPARES CONTEMPORANEOUS MINUTES THAT RECORD ALL ACTIONS TAKEN DURING THE MEETING. JOINT VENTURES FORM 990, PART VI, LINE 16B HOSPITAL SISTERS HEALTH SYSTEM ADOPTED A JOINT VENTURE COMPLIANCE PROGRAM POLICY EFFECTIVE ON JANUARY 1, 2012 FOR ALL SYSTEM HOSPITALS, INCLUDING ST. MARY'S HOSPITAL. THE OVERALL PURPOSE OF THE POLICY IS TO PROVIDE PRACTICAL GUIDELINES FOR ETHICAL BUSINESS CONDUCT, TO ACHIEVE COMPLIANCE, AND TO DETECT AND PREVENT VIOLATIONS OF APPLICABLE LAWS. THE POLICY REQUIRES ST. MARY'S HOSPITAL, AND ALL HSHS HOSPITALS, TO EVALUATE THEIR PARTICIPATION IN JOINT VENTURE ARRANGEMENTS, INCLUDING UNDER APPLICABLE FEDERAL TAX LAWS, AND TO SAFEGUARD ST. MARY'S HOSPITAL'S TAX EXEMPT STATUS WITH RESPECT TO ANY JOINT VENTURE ARRANGEMENTS.
DOCUMENTS AVAILABLE TO THE PUBLIC	FORM 990 PART VI, LINE 19	BOARD-APPROVED FINANCIAL STATEMENTS ARE MADE AVAILABLE TO THE PUBLIC UPON REQUEST. THE GOVERNING DOCUMENTS AND CONFLICT OF INTEREST POLICY ARE NOT MADE AVAILABLE TO THE GENERAL PUBLIC AT THIS TIME.
POOLED INVESTMENT ACCOUNT	FORM 990 PART X, LINE 11	THE HOSPITALS CASH RESERVES ARE INVESTED IN A POOLED INVESTMENT ACCOUNT MAINTAINED BY HOSPITAL SISTERS HEALTH SYSTEM (HSHS). PARTICIPATION IN THE POOLED INVESTMENT FUND IS LIMITED TO THE 501(C)(3) HOSPITALS AND HEALTH SERVICES ORGANIZATIONS SPONSORED BY HSHS. THE POOLED ACCOUNT CONSISTS OF CASH, EQUITY AND DEBT SECURITIES THAT ARE PUBLICLY TRADED. IN ACCORDANCE WITH THE PROVISIONS OF STATEMENT OF FINANCIAL ACCOUNTING STANDARDS (SFAS) NO. 124, "ACCOUNTING FOR CERTAIN INVESTMENTS HELD BY NOT-FOR-PROFIT ORGANIZATIONS", INVESTMENTS IN EQUITY SECURITIES WITH READILY DETERMINABLE FAIR VALUES AND ALL INVESTMENTS IN DEBT SECURITIES ARE REPORTED AT FAIR VALUE ON THE BALANCE SHEET. INCOME, REALIZED AND UNREALIZED GAINS AND LOSSES ARE POOLED AND ALLOCATED TO THE PARTICIPANTS. INDIVIDUAL COMPONENTS OF ASSETS AND REVENUE ARE NOT IDENTIFIED TO THE INDIVIDUAL HOSPITAL PARTICIPANTS.
Other changes in net assets	Form 990, Part XI, Line 9	CHANGE IN FAIR VALUE OF INTEREST RATE SWAPS 691,621 TEMPORARILY RESTRICTED NET INCOME (9,000) PERMANENTLY RESTRICED NET INCOME 1,357 RECOGNITION OF CHANGES IN PENSION FUNDED STATUS 6,714,215 TRANSFER TO/FROM AFFILIATES (1,796,721) LOSS ON EARLY EXTINGUISHMENT OF DEBT (141,042) SWAP PAYMENTS (170,905) ROUNDING (250) ----------- 5,289,275 ===========

For Paperwork Reduction Act Notice, see the Instructions for Form 990 or 990-EZ.

Cat. No. 51056K

Schedule O (Form 990 or 990-EZ) 2012

Additional Data

Software ID:
Software Version:

- TIN:

SCHEDULE R
(Form 990)

Department of the Treasury
Internal Revenue Service

Related Organizations and Unrelated Partnerships

Complete if the organization answered "Yes" to Form 990, Part IV, line 33, 34, 35, 36, or 37.
MediumBullet

Attach to Form 990. MediumBullet

See separate instructions.

OMB No. 1545-0047

2012

Open to Public Inspection

Name of the organization

ST MARY'S HOSPITAL STREATOR HOSPITAL SISTERS
OF THE 3RD ORDER ST FRANCIS

Employer identification number

36-2169181

Part I

Identification of Disregarded Entities (Complete if the organization answered "Yes" to Form 990, Part IV, line 33.)

(a) Name, address, and EIN (if applicable) 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
(1) Kiara Clinical Integration Network LLC 4936 Laverna Road Springfield,IL62707 26-1417684	Healthcare	IL	0	0	HSSI
(2) PHYSICIANS CLINICAL INTEGRATION NETWORK 4936 Laverna Road Springfield,IL62707 31-1668647	Healthcare	IL	0	0	KCIN
(3) Springfield Health Partners LLC 4936 Laverna Road Springfield,IL62707 37-1364419	Healthcare	IL			HSHS MG

Part II

Identification of Related Tax-Exempt Organizations (Complete if the organization answered "Yes" to 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 entity?
(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	Yes	No
(1) HOSPITAL SISTERS HEALTH SYSTEM 4936 LAVERNA ROAD SPRINGFIELD,IL62707 37-1058692	HEALTHCARE	IL	501(C)(3)	11A	NA		No
(2) HOSPITAL SISTERS SERVICES INC 4936 LAVERNA ROAD SPRINGFIELD,IL62707 37-1163402	HEALTHCARE	IL	501(C)(3)	11A	HSHS		No
(3) HOSPITAL SISTERS OF ST FRANCIS FDTN 4936 LAVERNA ROAD SPRINGFIELD,IL62707 37-1186514	HEALTHCARE	IL	501(C)(3)	11A	HSHS		No
(4) HSHS HEALTH CARE PLAN TRUST FUND 4936 LAVERNA ROAD SPRINGFIELD,IL62707 37-1137724	HEALTHCARE	IL	501(C)(9)	N/A	HSHS		No
(5) ST ANTHONY'S HOSPITAL 503 N MAPLE STREET EFFINGHAM,IL62401 37-0661233	HEALTHCARE	IL	501(C)(3)	3	HSSI		No
(6) ST ELIZABTH'S HOSPITAL 211 SOUTH THIRD STREET BELLEVILLE,IL62220 37-0663567	HEALTHCARE	IL	501(C)(3)	3	HSSI		No
(7) ST FRANCIS HOSPITAL 1215 FRANCISCAN DRIVE LITCHFIELD,IL62056 37-0661236	HEALTHCARE	IL	501(C)(3)	3	HSSI		No
(8) ST JOHN'S HOSPITAL 800 EAST CARPENTER STREET SPRINGFIELD,IL62769 37-0661238	HEALTHCARE	IL	501(C)(3)	3	HSSI		No
(9) ST JOSEPH'S HOSPITAL 9515 HOLY CROSS LANE BREESE,IL62230 37-1208459	HEALTHCARE	IL	501(C)(3)	3	HSSI		No
(10) ST JOSEPH'S HOSPITAL 1515 MAIN STREET HIGHLAND,IL62249 37-0663568	HEALTHCARE	IL	501(C)(3)	3	HSSI		No
(11) ST JOSEPH'S HOSPITAL 2661 COUNTY HIGHWAY 1 CHIPPEWA FALLS,WI54729 39-0810545	HEALTHCARE	WI	501(C)(3)	3	HSSI		No
(12) ST MARY'S HOSPITAL 1800 E LAKE SHORE DRIVE DECATUR,IL62521 37-0661244	HEALTHCARE	IL	501(C)(3)	3	HSSI		No
(13) SACRED HEART HOSPITAL 900 WEST CLAIREMONT AVE EAU CLAIRE,WI54701 39-0807060	HEALTHCARE	WI	501(C)(3)	3	HSSI		No
(14) ST MARY'S MEDICAL CENTER 1726 SHAWANO AVENUE GREEN BAY,WI54303 39-0818682	HEALTHCARE	WI	501(C)(3)	3	HSSI		No
(15) ST NICHOLAS HOSPITAL 3100 SUPERIOR AVENUE SHEBOYGAN,WI53081 39-0808480	HEALTHCARE	WI	501(C)(3)	3	HSSI		No
(16) ST VINCENT HOSPITAL 835 S VAN BUREN GREEN BAY,WI54301 39-0817529	HEALTHCARE	WI	501(C)(3)	3	HSSI		No
(17) Hospital Sisters Healthcare West Inc 2661 COUNTY HIGHWAY I CHIPPEWA FALLS,WI54729 51-0157933	HEALTHCARE	WI	501(C)(3)	11A	HSSI		No
(18) HSHS SELF INSURANCE TRUST FUND 4936 LAVERNA ROAD SPRINGFIELD,IL62707 37-1120626	INSURANCE	IL	501(C)(3)	11A	HSHS		No
(19) HSHS Medical Group Inc 3215 Executive Park Drive SPRINGFIELD,IL62703 26-3956318	HEALTHCARE	IL	501(C)(3)	11A	HSSI		No
(20) HSHS Wisconsin Medical Group Inc 3215 Executive Park Drive springfield,IL62703 26-4515959	HEALTHCARE	WI	501(C)(3)	11A	HSSI		No
(21) Orange Cross Ambulance Inc 919 ASHLAND AVENUE SHEBOYGAN,WI53081 39-1860942	HEALTHCARE	WI	501(C)(3)	9	ST NICHOLAS		No
(22) WISCONSIN UPPER PENINSULA ONCOLOGY MGMT 835 S VAN BUREN GREEN BAY,WI54301 39-1677100	HEALTHCARE	WI	501(C)(3)	3	ST VINCENT		No
(23) UNITY LIMITED PARTNERSHIP 2366 OAK RIDGE CIRCLE DE PERE,WI54115 39-1750729	HEALTHCARE	WI	501(C)(3)	9	HSSI		No

For Paperwork Reduction Act Notice, see the Instructions for Form 990.

Cat. No. 50135Y

Schedule R (Form 990) 2012

Page 2

Part III

Identification of Related Organizations Taxable as a Partnership (Complete if the organization answered "Yes" to 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 VUBI amount in box 20 of Schedule K-1 (Form 1065)	(j) General or managing partner?		(k) Percentage ownership
(a) Name, address, and EIN of related organization	(b) Primary activity	(c) Legal domicile (state or foreign country)	(d) Direct controlling entity		(f) Share of total income	(g) Share of end-of-year assets	Yes	No	(i) Code VUBI amount in box 20 of Schedule K-1 (Form 1065)	Yes	No
(1) Memorial and St Elizabeth's Healthcare 4000 North Illinois Street Swansea,IL62226 37-1312961	HealthCare	IL	St Elizabeth's	related	0	0		No	0		No	0 %
(2) Prairie Heart Institute - Carbondale 800 East Carpenter Street Springfield,IL62769 37-1321197	HealthCare	IL	St John's	related	0	0		No	0		No	0 %
(3) Northeast Wisconsin Radiation Therapy Se 1821 S Webster Avenue STE 300 Green Bay,WI543079047 26-3749065	HealthCare	WI	HSSI	related	0	0		No	0		No	0 %
(4) Pain Center of Wisconsin 4131 W Loomis Road STE 300 Greenfield,WI53221 26-3155343	HealthCare	WI	St Vincent	related	0	0		No	0		No	0 %
(5) Prevea Ventures LLC 2710 EXECUTIVE DRIVE Green Bay,WI54304 20-3775127	HealthCare	WI	HSSI	related	0	0		No	0		No	0 %
(6) Surgery Center of Sheboygan LLC 3141 Saemann Avenue Sheboygan,WI53081 26-0822209	Healthcare	WI	St Nicholas	related	0	0		No	0		No	0 %
(7) Carpenter Street Hotel LLC 525 North Sixth Street Springfield,IL62702 36-4128127	Hotel	IL	LaSante Inc	related	0	0		No	0		No	0 %
(8) Springfield Urgent Care Real Estate LLC PO Box 19456 Springfield,IL627949456 03-0413258	Rent. Real Es	IL	LaSante Inc	related	0	0		No	0		No	0 %

Part IV

Identification of Related Organizations Taxable as a Corporation or Trust (Complete if the organization answered "Yes" to 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	(i) Section 512(b)(13) controlled entity?
(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		Yes	No
(1) Kiara Inc 4936 Laverna ROAd Springfield,IL62707 37-1163401	HealthCare	IL	HSHS	C Corp	0	0	0 %		No
(2) LaSante Wisconsin Inc 4936 Laverna ROAd Springfield,IL62707 39-1572196	HealthCare	IL	Kiara Inc	C Corp	0	0	0 %		No
(3) LaSante Inc 4936 Laverna ROAd Springfield,IL62707 37-1163400	HealthCare	IL	Kiara Inc	C Corp	0	0	0 %		No
(4) Prairie Cardiovascular 619 East Mason STE 4P57 Springfield,IL62701 37-1071858	HealthCare	IL	Kiara Inc	C Corp	0	0	0 %		No
(5) Prevea Health Services 2710 EXECUTIVE DRIVE Green Bay,WI54304 39-1839351	HealthCare	WI	HSSI	C Corp	0	0	0 %		No
(6) Prevea Clinic Inc 2710 EXECUTIVE DRIVE Green Bay,WI54304 39-1839349	HealthCare	WI	HSSI	C Corp	0	0	0 %		No
(7) Prevea Health Network 2710 EXECUTIVE DRIVE Green Bay,WI54304 39-2000537	HealthCare	WI	HSSI	C Corp	0	0	0 %		No
(8) RENAISSANCE QUALITY INSURANCE PO Box 1159 Grand Caymans KY1-1102 CJ 98-0669953	Insurance	CJ	HSSI	C Corp	0	0	0 %		No
(9) OJV INC 4936 Laverna Rd Springfield,IL62707 46-0873384	Healthcare	IL	LaSante	C Corp	0	0			No

Schedule R (Form 990) 2012

Page 3

Part V

Transactions With Related Organizations (Complete if the organization answered "Yes" to Form 990, Part IV, line 34, 35b, or 36.)

Note. Complete line 1 if any entity is listed in Parts II, III, or IV of this schedule.

Yes

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 or (iv) rent from a controlled entity . . . . . . . . . . . . . . . . . . . . . . .

b Gift, grant, or capital contribution to related organization(s) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

c Gift, grant, or capital contribution from related organization(s) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Yes

d Loans or loan guarantees to or for related organization(s) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

e Loans or loan guarantees by related organization(s) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

f Dividends from related organization(s) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

g Sale of assets to related organization(s) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Yes

h Purchase of assets from related organization(s) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

i Exchange of assets with related organization(s) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

j Lease of facilities, equipment, or other assets to related organization(s) . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Yes

k Lease of facilities, equipment, or other assets from related organization(s) . . . . . . . . . . . . . . . . . . . . . . . . . . .

l Performance of services or membership or fundraising solicitations for related organization(s) . . . . . . . . . . . . . . . . . . . .

m Performance of services or membership or fundraising solicitations by related organization(s) . . . . . . . . . . . . . . . . . . . .

Yes

n Sharing of facilities, equipment, mailing lists, or other assets with related organization(s) . . . . . . . . . . . . . . . . . . . . .

o Sharing of paid employees with related organization(s) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Yes

p Reimbursement paid to related organization(s) for expenses . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Yes

q Reimbursement paid by related organization(s) for expenses . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Yes

r Other transfer of cash or property to related organization(s) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Yes

s Other transfer of cash or property from related organization(s) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Yes

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-s)	(c) Amount involved	(d) Method of determining amount involved

Schedule R (Form 990) 2012

Page 4

Part VI

Unrelated Organizations Taxable as a Partnership (Complete if the organization answered "Yes" to 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)	(e) Are all partners section 501(c)(3) organizations?		(f) Share of total income	(g) Share of end-of-year assets	(h) Disproprtionate allocations?		(i) Code VUBI amount in box 20 of Schedule K-1 (Form 1065)	(j) General or managing partner?
(a) Name, address, and EIN of entity	(b) Primary activity	(c) Legal domicile (state or foreign country)	Yes	No	(f) Share of total income	(g) Share of end-of-year assets	Yes	No	(i) Code VUBI amount in box 20 of Schedule K-1 (Form 1065)	Yes	No

Schedule R (Form 990) 2012

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
transactions with related organizations	schedule r, part v, line 2	The transactions reported on line 1 and not specifically identified on line 2 are between related 501(c)(3) public charities. accordingly they are not reported in this section.

Additional Data

Software ID:
Software Version:

1	Briefly describe the organization’s mission or most significant activities: TO CONTINUE CHRIST'S HEALING MINISTRY THROUGH SERVICE TO THE SICK, THE AGED, THE POOR, AND THE TERMINALLY ILL.
2	Check this box
3	Number of voting members of the governing body (Part VI, line 1a) ........	3	12
4	Number of independent voting members of the governing body (Part VI, line 1b) .....	4	8
5	Total number of individuals employed in calendar year 2011 (Part V, line 2a) ......	5	543
6	Total number of volunteers (estimate if necessary) .............	6	117
7a	Total unrelated business revenue from Part VIII, column (C), line 12 ........	7a	173
b	Net unrelated business taxable income from Form 990-T, line 34 .........	7b	-102

		Prior Year	Current Year
8	Contributions and grants (Part VIII, line 1h) .........	65,053	2,179,983
9	Program service revenue (Part VIII, line 2g) .........	53,476,524	48,050,023
10	Investment income (Part VIII, column (A), lines 3, 4, and 7d ) ....	1,897,769	1,294,440
11	Other revenue (Part VIII, column (A), lines 5, 6d, 8c, 9c, 10c, and 11e)	551,911	401,490
12	Total revenue—add lines 8 through 11 (must equal Part VIII, column (A), line 12)...................	55,991,257	51,925,936
13	Grants and similar amounts paid (Part IX, column (A), lines 1–3 )...	0	0
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)	23,488,886	22,586,970
16a	Professional fundraising fees (Part IX, column (A), line 11e).....	0	0
b	Total fundraising expenses (Part IX, column (D), line 25) 0
17	Other expenses (Part IX, column (A), lines 11a–11d, 11f–24e)....	31,962,242	29,777,482
18	Total expenses. Add lines 13–17 (must equal Part IX, column (A), line 25)	55,451,128	52,364,452
19	Revenue less expenses. Subtract line 18 from line 12.......	540,129	-438,516
		Beginning of Current Year	End of Year
20	Total assets (Part X, line 16).............	82,270,710	80,897,923
21	Total liabilities (Part X, line 26).............	39,173,685	31,519,535
22	Net assets or fund balances. Subtract line 21 from line 20.....	43,097,025	49,378,388

Sign Here

	Signature of officer	Date

	Type or print name and title


4a	(Code: ) (Expenses $ 36,511,869 including grants of $ 0 ) (Revenue $ 48,049,850 )
	See Schedule O - Community Benefit Report

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 expenses36,511,869

(A) Name and Title	(B) Average hours per week (list any hours for related organizations below dotted line)		(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
(A) Name and Title
(18) CATHERINE CHAPMAN........................................................................ DIRECTOR PHARMACY	40.0 .......................	X	126,270	0	19,124
(19) JEANNE A WASHKO........................................................................ PHARMACIST	40.0 .......................	X	113,986	0	32,092
(20) RENA A MATHESIUS........................................................................ PHARMACIST	40.0 .......................	X	117,485	0	16,121
(21) SHERRI L SNYDER........................................................................ PHARMACIST	40.0 .......................	X	98,222		7,390

1b	Sub-Total................
c	Total from continuation sheets to Part VII, Section A....
d	Total (add lines 1b and 1c)............	932,003	1,235,581	463,338

				(A) Total revenue	(B) Related or exempt function revenue	(C) Unrelated business revenue	(D) Revenue excluded from tax under sections 512, 513, or 514
1a	Federated campaigns..1a
b	Membership dues....1b
c	Fundraising events....1c
d	Related organizations...1d		66,409
e	Government grants (contributions)1e		2,113,574

f	All other contributions, gifts, grants, and similar amounts not included above1f

g	Noncash contributions included in lines 1a-1f:$
h	Total. Add lines 1a-1f.......			2,179,983
			Business Code
2a	NET PATIENT SERVICE REVENUE		900000	48,050,023	48,049,850	173
b
c
d
e
f	All other program service revenue .
g	Total. Add lines 2a–2f........			48,050,023
3	Investment income (including dividends, interest, and other similar amounts).......			469,552	0		469,552
4	Income from investment of tax-exempt bond proceeds..			0
5	Royalties...........			0
		(i) Real	(ii) Personal
6a	Gross rents
b	Less: rental expenses
c	Rental income or (loss)	0	0
d	Net rental income or (loss).......			0
		(i) Securities	(ii) Other
7a	Gross amount from sales of assets other than inventory	807,852	19,000
b	Less: cost or other basis and sales expenses		1,964
c	Gain or (loss)	807,852	17,036
d	Net gain or (loss)..........			824,888			824,888
8a	Gross income from fundraising events (not including $ of contributions reported on line 1c). See Part IV, line 18 ..
	a
b	Less: direct expenses ...b
c	Net income or (loss) from fundraising events..			0
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...			0
10a	Gross sales of inventory, less returns and allowances .
	a
b	Less: cost of goods sold ..b
c	Net income or (loss) from sales of inventory..			0
Miscellaneous Revenue			Business Code
11a	Misc Healthcare Revenue		532000	345,651			345,651
b	Gift Shop		453220	55,839			55,839
c
d	All other revenue ....
e	Total. Add lines 11a–11d ......			401,490
12	Total revenue. See Instructions......			51,925,936	48,049,850	173	1,695,930


				(A) Beginning of year		(B) End of year
1	Cashnon-interest-bearing .............			1,349	1	1,349
2	Savings and temporary cash investments .........			-421,339	2	-507,730
3	Pledges and grants receivable, net ...........			0	3	0
4	Accounts receivable, net .............			8,015,880	4	7,178,815
5	Loans and other receivables from current and former officers, directors, trustees, key employees, and highest compensated employees. Complete Part II of Schedule L ..................
				0	5	0
6	Loans and other receivables from other disqualified persons (as defined under section 4958(f)(1)), persons described in section 4958(c)(3)(B), and contributing employers and sponsoring organizations of section 501(c)(9) voluntary employees' beneficiary organizations (see instructions) Complete Part II of Schedule L
				0	6	0
7	Notes and loans receivable, net .............			0	7	0
8	Inventories for sale or use ..............			931,503	8	921,882
9	Prepaid expenses and deferred charges ..........			477,871	9	350,634
10a	Land, buildings, and equipment: cost or other basis. Complete Part VI of Schedule D	10a	80,414,173
b	Less: accumulated depreciation .....	10b	42,795,946	39,539,392	10c	37,618,227
11	Investments—publicly traded securities ..........			26,661,215	11	26,969,311
12	Investments—other securities. See Part IV, line 11 .....			0	12	0
13	Investments—program-related. See Part IV, line 11 .....			43,791	13	43,794
14	Intangible assets ...............			0	14	0
15	Other assets. See Part IV, line 11 ...........			7,021,048	15	8,321,641
16	Total assets. Add lines 1 through 15 (must equal line 34)......			82,270,710	16	80,897,923
17	Accounts payable and accrued expenses .........			8,587,515	17	7,563,925
18	Grants payable .................			0	18	0
19	Deferred revenue ................			0	19	0
20	Tax-exempt bond liabilities .............			12,622,783	20	12,680,045
21	Escrow or custodial account liability. Complete Part IV of Schedule D..			0	21	0
22	Loans and other payables to current and former officers, directors, trustees, key employees, highest compensated employees, and disqualified
	persons. Complete Part II of Schedule L..........			0	22	0
23	Secured mortgages and notes payable to unrelated third parties ..			0	23	0
24	Unsecured notes and loans payable to unrelated third parties ....			0	24	0
25	Other liabilities (including federal income tax, payables to related third parties, and other liabilities not included on lines 17-24). Complete Part X of Schedule D....................			17,963,387	25	11,275,565
26	Total liabilities. Add lines 17 through 25.........			39,173,685	26	31,519,535
	Organizations that follow SFAS 117 (ASC 958), check here and complete lines 27 through 29, and lines 33 and 34.
27	Unrestricted net assets ..............			40,831,614	27	46,956,664
28	Temporarily restricted net assets ...........			2,184,308	28	2,339,264
29	Permanently restricted net assets ...........			81,103	29	82,460
	Organizations that do not follow SFAS 117 (ASC 958), check here 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 ...........			43,097,025	33	49,378,388
34	Total liabilities and net assets/fund balances ........			82,270,710	34	80,897,923