HENRY COUNTY HOSPITAL INC: Form 990, tax year 2020
View the entire original 990 at ProPublica ↗
- Organization
- HENRY COUNTY HOSPITAL INC (EIN 34-4477047)
- Tax period
- 2020-11-01 to 2021-10-31
- Filed
- 2022-09-14
- IRS object ID
- 202202579349301685
- Schema version
- 2020v4.2
- Source
- Download XML · Original 990 at ProPublica
Every field in the e-filed return. Faint text is the IRS element name, for citing.
- Return header
- Form 990
- Schedule A
- Schedule B
- Schedule C
- Schedule D
- Schedule H
- Schedule I
- Schedule J
- Schedule K
- Schedule O
- Schedule R
Return header ReturnHeader
| Field | Value | IRS element (for citing) |
|---|---|---|
| Return | 2022-09-14T15:04:51-05:00 | ReturnTs |
| Tax Period End | 2021-10-31 | TaxPeriodEndDt |
Preparer Firm PreparerFirmGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Preparer Firm EIN | 351178661 | PreparerFirmEIN |
Preparer Firm Name PreparerFirmName
| Field | Value | IRS element (for citing) |
|---|---|---|
| Business Name Line1 | BLUE & CO LLC | BusinessNameLine1Txt |
Preparer US Address PreparerUSAddress
| Field | Value | IRS element (for citing) |
|---|---|---|
| Address Line1 | 500 N MERIDIAN ST SUITE 200 | AddressLine1Txt |
| City | INDIANAPOLIS | CityNm |
| State Abbreviation | IN | StateAbbreviationCd |
| ZIP | 46204 | ZIPCd |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Return Type | 990 | ReturnTypeCd |
| Tax Period Begin | 2020-11-01 | TaxPeriodBeginDt |
Filer Filer
| Field | Value | IRS element (for citing) |
|---|---|---|
| EIN | 344477047 | EIN |
Business Name BusinessName
| Field | Value | IRS element (for citing) |
|---|---|---|
| Business Name Line1 | HENRY COUNTY HOSPITAL INC | BusinessNameLine1Txt |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Business Name Control | HENR | BusinessNameControlTxt |
| Phone | 4195924015 | PhoneNum |
US Address USAddress
| Field | Value | IRS element (for citing) |
|---|---|---|
| Address Line1 | 1600 EAST RIVERVIEW | AddressLine1Txt |
| City | NAPOLEON | CityNm |
| State Abbreviation | OH | StateAbbreviationCd |
| ZIP | 43545 | ZIPCd |
Business Officer BusinessOfficerGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Person | KRISTI BARND | PersonNm |
| Person Title | CEO | PersonTitleTxt |
| Phone | 4195924015 | PhoneNum |
| Signature | 2022-09-14 | SignatureDt |
| Discuss With Paid Preparer | Yes (1) | DiscussWithPaidPreparerInd |
Signing Officer SigningOfficerGrp
Person Full Name PersonFullName
| Field | Value | IRS element (for citing) |
|---|---|---|
| Person First | KRISTI | PersonFirstNm |
| Person Last | BARND | PersonLastNm |
| Field | Value | IRS element (for citing) |
|---|---|---|
| SSN | 999009999 | SSN |
Preparer Person PreparerPersonGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Preparer Person | NATHAN A RODGERS CPA | PreparerPersonNm |
| PTIN | P01568275 | PTIN |
| Phone | 3176334705 | PhoneNum |
| Preparation | 2022-09-14 | PreparationDt |
Additional Filer Information AdditionalFilerInformation
Trusted Customer TrustedCustomerGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Trusted Customer | 2 | TrustedCustomerCd |
| Authentication Assurance Level | AAL1 | AuthenticationAssuranceLevelCd |
| Identity Assurance Level | IAL1 | IdentityAssuranceLevelCd |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Tax | 2020 | TaxYr |
| Build TS | 2023-04-26 12:10:37Z | BuildTS |
Form 990 IRS990
| Field | Value | IRS element (for citing) |
|---|---|---|
| Principal Officer | KRISTI BARND | PrincipalOfficerNm |
US Address USAddress
| Field | Value | IRS element (for citing) |
|---|---|---|
| Address Line1 | 1600 EAST RIVERVIEW | AddressLine1Txt |
| City | NAPOLEON | CityNm |
| State Abbreviation | OH | StateAbbreviationCd |
| ZIP | 43545 | ZIPCd |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Gross Receipts | $37,622,894 | GrossReceiptsAmt |
| Group Return For Affiliates | 0 | GroupReturnForAffiliatesInd |
| Organization501c3 | Yes (X) | Organization501c3Ind |
| Website Address | WWW.HENRYCOUNTYHOSPITAL.ORG | WebsiteAddressTxt |
| Type Of Organization Corp | Yes (X) | TypeOfOrganizationCorpInd |
| Formation | 1982 | FormationYr |
| Legal Domicile State | OH | LegalDomicileStateCd |
| Activity Or Mission | PLEASE SEE SCHEDULE O FOR THE ORGANIZATION'S MISSION. | ActivityOrMissionDesc |
| Voting Members Governing Body | 10 | VotingMembersGoverningBodyCnt |
| Voting Members Independent | 8 | VotingMembersIndependentCnt |
| Total Employee | 352 | TotalEmployeeCnt |
| Total Volunteers | 44 | TotalVolunteersCnt |
| Total Gross UBI | $10,813 | TotalGrossUBIAmt |
| Net Unrelated Bus Txbl Incm | $0 | NetUnrelatedBusTxblIncmAmt |
| PY Contributions Grants | $4,471,082 | PYContributionsGrantsAmt |
| CY Contributions Grants | $3,546,406 | CYContributionsGrantsAmt |
| PY Program Service Revenue | $26,957,602 | PYProgramServiceRevenueAmt |
| CY Program Service Revenue | $32,876,630 | CYProgramServiceRevenueAmt |
| PY Investment Income | -$6,974 | PYInvestmentIncomeAmt |
| CY Investment Income | $0 | CYInvestmentIncomeAmt |
| PY Other Revenue | $789,862 | PYOtherRevenueAmt |
| CY Other Revenue | $1,199,858 | CYOtherRevenueAmt |
| PY Total Revenue | $32,211,572 | PYTotalRevenueAmt |
| CY Total Revenue | $37,622,894 | CYTotalRevenueAmt |
| PY Grants And Similar Paid | $92,790 | PYGrantsAndSimilarPaidAmt |
| CY Grants And Similar Paid | $97,481 | CYGrantsAndSimilarPaidAmt |
| PY Benefits Paid To Members | $0 | PYBenefitsPaidToMembersAmt |
| CY Benefits Paid To Members | $0 | CYBenefitsPaidToMembersAmt |
| PY Salaries Comp Emp Bnft Paid | $16,094,600 | PYSalariesCompEmpBnftPaidAmt |
| CY Salaries Comp Emp Bnft Paid | $16,248,326 | CYSalariesCompEmpBnftPaidAmt |
| PY Total Prof Fndrsng Expns | $0 | PYTotalProfFndrsngExpnsAmt |
| CY Total Prof Fndrsng Expns | $0 | CYTotalProfFndrsngExpnsAmt |
| CY Total Fundraising Expense | $0 | CYTotalFundraisingExpenseAmt |
| PY Other Expenses | $16,312,411 | PYOtherExpensesAmt |
| CY Other Expenses | $17,512,886 | CYOtherExpensesAmt |
| PY Total Expenses | $32,499,801 | PYTotalExpensesAmt |
| CY Total Expenses | $33,858,693 | CYTotalExpensesAmt |
| PY Revenues Less Expenses | -$288,229 | PYRevenuesLessExpensesAmt |
| CY Revenues Less Expenses | $3,764,201 | CYRevenuesLessExpensesAmt |
| Total Assets BOY | $28,288,928 | TotalAssetsBOYAmt |
| Total Assets EOY | $27,959,358 | TotalAssetsEOYAmt |
| Total Liabilities BOY | $17,267,538 | TotalLiabilitiesBOYAmt |
| Total Liabilities EOY | $12,808,085 | TotalLiabilitiesEOYAmt |
| Net Assets Or Fund Balances BOY | $11,021,390 | NetAssetsOrFundBalancesBOYAmt |
| Net Assets Or Fund Balances EOY | $15,151,273 | NetAssetsOrFundBalancesEOYAmt |
| Info In Schedule O Part III | Yes (X) | InfoInScheduleOPartIIIInd |
| Mission | PLEASE SEE SCHEDULE O FOR THE ORGANIZATION'S MISSION STATEMENT. | MissionDesc |
| Significant New Program Srvc | 0 | SignificantNewProgramSrvcInd |
| Significant Change | 0 | SignificantChangeInd |
| Expense | $2,459,680 | ExpenseAmt |
| Revenue | $5,033,169 | RevenueAmt |
| Desc | 1. LABORATORY--PROVIDING SERVICES FOR IP AND OP, EXTENDED CARE FACILITIES, PHYSICIAN OFFICES AND AREA BUSINESSES. THE LABORATORY PROVIDED OVER 114,401 BILLED TESTS IN 2021. | Desc |
Prog Srvc Accom Acty2 ProgSrvcAccomActy2Grp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Expense | $2,239,867 | ExpenseAmt |
| Revenue | $6,039,648 | RevenueAmt |
| Desc | 2: SURGERY: PROVIDING PRE-, INTRA-, AND POST PROCEDURE CARE FOR SURGICAL INPATIENTS AND OUTPATIENTS. INCLUDES GENERAL, ORTHOPEDIC, CATARACT, VEIN, UROLOGY, OBSTETRIC, GYNECOLOGICAL, PAIN, OPHTHALMIC AND ENDOSCOPIC PROCEDURES. SURGICAL CARE SERVICES PERFORMED OVER 1,562 PROCEDURES IN 2021. | Desc |
Prog Srvc Accom Acty3 ProgSrvcAccomActy3Grp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Expense | $2,046,796 | ExpenseAmt |
| Revenue | $2,479,708 | RevenueAmt |
| Desc | 3: EMERGENCY: CARE SERVICES ARE PROVIDED CONTINUALLY TO PATIENTS PRESENTING WITH INJURIES AND ILLNESSES. TOTAL PATIENTS TREATED IN THE EMERGENCY DEPARTMENT TOTALED OVER 6,685 FOR 2021. | Desc |
Prog Srvc Accom Acty Other ProgSrvcAccomActyOtherGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Expense | $20,043,441 | ExpenseAmt |
| Grant | $97,481 | GrantAmt |
| Revenue | $20,305,579 | RevenueAmt |
| Desc | 4: OTHER SERVICES PROVIDED BY HENRY COUNTY HOSPITAL ARE: MEDICAL IMAGING, INCLUDING X-RAY, CT SCANS, MRI, ULTRASOUND, AND STRESS TESTING; PHARMACY SERVICES; REHAB SERVICES, INCLUDING PHYSICAL THERAPY, OCCUPATIONAL THERAPY, AND SPEECH THERAPY; ONCOLOGY SERVICES; INPATIENT AND INTENSIVE CARE SERVICES; BIRTHING CARE SERVICES; CARDIAC REHAB,EKG, AND RESPIRATORY THERAPY; AND OUTPATIENT DRUG AND ALCOHOL TREATMENT. HENRY COUNTY HOSPITAL PROVIDED OVER 92,708 BILLED DOSES TO PATIENTS THROUGH PHARMACY SERVICES, OVER 602 INPATIENT ADMISSIONS WITH OVER 1,874 DAYS OF CARE, 67 SWING BED PATIENTS WITH OVER 552 DAYS OF CARE, 174 BIRTHS, AND OVER 51,350 OUTPATIENT VISITS IN 2021. | Desc |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Other Prog Srvc Expense | $20,043,441 | TotalOtherProgSrvcExpenseAmt |
| Total Other Prog Srvc Grant | $97,481 | TotalOtherProgSrvcGrantAmt |
| Total Other Prog Srvc Revenue | $20,305,579 | TotalOtherProgSrvcRevenueAmt |
| Total Program Service Expenses | $26,789,784 | TotalProgramServiceExpensesAmt |
| Described In Section501c3 | Yes (1) | DescribedInSection501c3Ind |
| Schedule B Required | Yes (1) | ScheduleBRequiredInd |
| Political Campaign Acty | 0 | PoliticalCampaignActyInd |
| Lobbying Activities | Yes (1) | LobbyingActivitiesInd |
| Subject To Proxy Tax | 0 | SubjectToProxyTaxInd |
| Donor Advised Fund | 0 | DonorAdvisedFundInd |
| Conservation Easements | 0 | ConservationEasementsInd |
| Collections Of Art | 0 | CollectionsOfArtInd |
| Credit Counseling | 0 | CreditCounselingInd |
| Donor Rstr Or Quasi Endowments | Yes (1) | DonorRstrOrQuasiEndowmentsInd |
| Report Land Building Equipment | Yes (1) | ReportLandBuildingEquipmentInd |
| Report Investments Other Sec | Yes (1) | ReportInvestmentsOtherSecInd |
| Report Program Related Invst | 0 | ReportProgramRelatedInvstInd |
| Report Other Assets | 0 | ReportOtherAssetsInd |
| Report Other Liabilities | Yes (1) | ReportOtherLiabilitiesInd |
| Include FIN48 Footnote | Yes (1) | IncludeFIN48FootnoteInd |
| Independent Audit Fincl Stmt | 0 | IndependentAuditFinclStmtInd |
| Consolidated Audit Fincl Stmt | Yes (1) | ConsolidatedAuditFinclStmtInd |
| School Operating | 0 | SchoolOperatingInd |
| Foreign Office | 0 | ForeignOfficeInd |
| Foreign Activities | 0 | ForeignActivitiesInd |
| More Than5000 K To Org | 0 | MoreThan5000KToOrgInd |
| More Than5000 K To Individuals | 0 | MoreThan5000KToIndividualsInd |
| Professional Fundraising | 0 | ProfessionalFundraisingInd |
| Fundraising Activities | 0 | FundraisingActivitiesInd |
| Gaming Activities | 0 | GamingActivitiesInd |
| Operate Hospital | Yes (1) | OperateHospitalInd |
| Audited Financial Stmt Att | Yes (1) | AuditedFinancialStmtAttInd |
| Grants To Organizations | Yes (1) | GrantsToOrganizationsInd |
| Grants To Individuals | 0 | GrantsToIndividualsInd |
| Schedule J Required | Yes (1) | ScheduleJRequiredInd |
| Tax Exempt Bonds | Yes (1) | TaxExemptBondsInd |
| Invest Tax Exempt Bonds | 0 | InvestTaxExemptBondsInd |
| Escrow Account | 0 | EscrowAccountInd |
| On Behalf Of Issuer | 0 | OnBehalfOfIssuerInd |
| Engaged In Excess Benefit Trans | 0 | EngagedInExcessBenefitTransInd |
| PY Excess Benefit Trans | 0 | PYExcessBenefitTransInd |
| Loan Outstanding | 0 | LoanOutstandingInd |
| Grant To Related Person | 0 | GrantToRelatedPersonInd |
| Business Rln With Org Mem | 0 | BusinessRlnWithOrgMemInd |
| Business Rln With Fam Mem | 0 | BusinessRlnWithFamMemInd |
| Business Rln With35 Ctrl Ent | 0 | BusinessRlnWith35CtrlEntInd |
| Deductible Non Cash Contri | 0 | DeductibleNonCashContriInd |
| Deductible Art Contribution | 0 | DeductibleArtContributionInd |
| Terminate Operations | 0 | TerminateOperationsInd |
| Partial Liquidation | 0 | PartialLiquidationInd |
| Disregarded Entity | 0 | DisregardedEntityInd |
| Related Entity | Yes (1) | RelatedEntityInd |
| Related Organization Ctrl Ent | 0 | RelatedOrganizationCtrlEntInd |
| Trnsfr Exmpt Non Chrtbl Rltd Org | 0 | TrnsfrExmptNonChrtblRltdOrgInd |
| Activities Conducted Prtshp | 0 | ActivitiesConductedPrtshpInd |
| Schedule O Required | Yes (1) | ScheduleORequiredInd |
| IRP Document | 53 | IRPDocumentCnt |
| IRP Document W2 G | 0 | IRPDocumentW2GCnt |
| Backup Wthld Compliance | Yes (1) | BackupWthldComplianceInd |
| Employee | 352 | EmployeeCnt |
| Employment Tax Returns Filed | Yes (1) | EmploymentTaxReturnsFiledInd |
| Unrelated Bus Incm Over Limit | 0 | UnrelatedBusIncmOverLimitInd |
| Foreign Financial Account | 0 | ForeignFinancialAccountInd |
| Prohibited Tax Shelter Trans | 0 | ProhibitedTaxShelterTransInd |
| Taxable Party Notification | 0 | TaxablePartyNotificationInd |
| Nondeductible Contributions | 0 | NondeductibleContributionsInd |
| Quid Pro Quo Contributions | 0 | QuidProQuoContributionsInd |
| Form8282 Property Disposed Of | 0 | Form8282PropertyDisposedOfInd |
| Rcv Fnds To Pay Prsnl Bnft Cntrct | 0 | RcvFndsToPayPrsnlBnftCntrctInd |
| Pay Premiums Prsnl Bnft Cntrct | 0 | PayPremiumsPrsnlBnftCntrctInd |
| Indoor Tanning Services | 0 | IndoorTanningServicesInd |
| Subj To Tax Rmnrtn Ex Prcht Pymt | 0 | SubjToTaxRmnrtnExPrchtPymtInd |
| Subject To Excs Tax Net Invst Inc | 0 | SubjectToExcsTaxNetInvstIncInd |
| Info In Schedule O Part VI | Yes (X) | InfoInScheduleOPartVIInd |
| Governing Body Voting Members | 10 | GoverningBodyVotingMembersCnt |
| Independent Voting Member | 8 | IndependentVotingMemberCnt |
| Family Or Business Rln | 0 | FamilyOrBusinessRlnInd |
| Delegation Of Mgmt Duties | 0 | DelegationOfMgmtDutiesInd |
| Change To Org Documents | 0 | ChangeToOrgDocumentsInd |
| Material Diversion Or Misuse | 0 | MaterialDiversionOrMisuseInd |
| Members Or Stockholders | 0 | MembersOrStockholdersInd |
| Election Of Board Members | 0 | ElectionOfBoardMembersInd |
| Decisions Subject To Approva | 0 | DecisionsSubjectToApprovaInd |
| Minutes Of Governing Body | Yes (1) | MinutesOfGoverningBodyInd |
| Minutes Of Committees | Yes (1) | MinutesOfCommitteesInd |
| Officer Mailing Address | 0 | OfficerMailingAddressInd |
| Local Chapters | 0 | LocalChaptersInd |
| Form990 Provided To Gvrn Body | Yes (1) | Form990ProvidedToGvrnBodyInd |
| Conflict Of Interest Policy | Yes (1) | ConflictOfInterestPolicyInd |
| Annual Disclosure Covered Prsn | Yes (1) | AnnualDisclosureCoveredPrsnInd |
| Regular Monitoring Enfrc | Yes (1) | RegularMonitoringEnfrcInd |
| Whistleblower Policy | Yes (1) | WhistleblowerPolicyInd |
| Document Retention Policy | Yes (1) | DocumentRetentionPolicyInd |
| Compensation Process CEO | Yes (1) | CompensationProcessCEOInd |
| Compensation Process Other | Yes (1) | CompensationProcessOtherInd |
| Investment In Joint Venture | Yes (1) | InvestmentInJointVentureInd |
| Written Policy Or Procedure | 0 | WrittenPolicyOrProcedureInd |
| States Where Copy Of Return Is Fld | OH | StatesWhereCopyOfReturnIsFldCd |
| Upon Request | Yes (X) | UponRequestInd |
Books In Care Of Detail BooksInCareOfDetail
Business Name BusinessName
| Field | Value | IRS element (for citing) |
|---|---|---|
| Business Name Line1 | DIANE WALTHER | BusinessNameLine1Txt |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Phone | 4195913826 | PhoneNum |
US Address USAddress
| Field | Value | IRS element (for citing) |
|---|---|---|
| Address Line1 | 1600 EAST RIVERVIEW | AddressLine1Txt |
| City | NAPOLEON | CityNm |
| State Abbreviation | OH | StateAbbreviationCd |
| ZIP | 43545 | ZIPCd |
Form990 Part VII Section A Form990PartVIISectionAGrp (18 entries)
| TitleTitleTxt | Average Hours Per WeekAverageHoursPerWeekRt | Average Hours Per Week Rltd OrgAverageHoursPerWeekRltdOrgRt | Individual Trustee Or DirectorIndividualTrusteeOrDirectorInd | OfficerOfficerInd | Reportable Comp From OrgReportableCompFromOrgAmt | Reportable Comp From Rltd OrgReportableCompFromRltdOrgAmt | Other CompensationOtherCompensationAmt | Highest Compensated EmployeeHighestCompensatedEmployeeInd | Former Ofcr Director TrusteeFormerOfcrDirectorTrusteeInd |
|---|---|---|---|---|---|---|---|---|---|
| MARVIN BARLOW | |||||||||
| CHAIRMAN | 4.00 | 0.00 | Yes (X) | Yes (X) | $0 | $0 | $0 | ||
| JOHN WILHELM | |||||||||
| VICE-CHAIR | 2.00 | 0.00 | Yes (X) | Yes (X) | $0 | $0 | $0 | ||
| THOMAS MACK | |||||||||
| SECRETARY | 2.00 | 0.00 | Yes (X) | Yes (X) | $0 | $0 | $0 | ||
| JIM BURKHART | |||||||||
| BOARD MEMBER | 2.00 | 0.00 | Yes (X) | $0 | $0 | $0 | |||
| DR MIKE CARPENTER | |||||||||
| BOARD MEMBER | 2.00 | 0.00 | Yes (X) | $0 | $0 | $0 | |||
| DR JOHN EWONUS | |||||||||
| BOARD MEMBER | 2.00 | 0.00 | Yes (X) | $0 | $0 | $0 | |||
| RICKY FRUTH | |||||||||
| BOARD MEMBER | 2.00 | 0.00 | Yes (X) | $0 | $0 | $0 | |||
| BRENT GERKEN | |||||||||
| BOARD MEMBER | 2.00 | 0.00 | Yes (X) | $0 | $0 | $0 | |||
| JOY ERMIE | |||||||||
| BOARD MEMBER | 2.00 | 0.00 | Yes (X) | $0 | $0 | $0 | |||
| KRISTI BARND | |||||||||
| CEO | 40.00 | 0.00 | Yes (X) | Yes (X) | $154,638 | $0 | $14,900 | ||
| WILLIAM GRIMM | |||||||||
| CIO-TERM ENDED NOV'20 | 40.00 | 0.00 | Yes (X) | $136,143 | $0 | $35,061 | |||
| TIFFANY KENNERK | |||||||||
| CNO | 40.00 | 0.00 | Yes (X) | $127,166 | $0 | $13,250 | |||
| DR ERAST HAFTKOWYCZ | |||||||||
| OBGYN | 40.00 | 0.00 | $278,133 | $0 | $18,664 | Yes (X) | |||
| DR MORRIS SEAL | |||||||||
| PHYSICIAN | 40.00 | 0.00 | $247,299 | $0 | $18,877 | Yes (X) | |||
| DR ANDREW GOMBASH | |||||||||
| PHYSICIAN | 40.00 | 0.00 | $243,907 | $0 | $15,252 | Yes (X) | |||
| DR JOSEPH KRUEGER | |||||||||
| PHYSICIAN | 40.00 | 0.00 | $270,926 | $0 | $17,524 | Yes (X) | |||
| MICHELE JAKUTOWICZ | |||||||||
| PHARMACIST | 40.00 | 0.00 | $147,372 | $0 | $25,862 | Yes (X) | |||
| KIMBERLY BORDENKIRCHER | |||||||||
| FORMER CEO | 40.00 | 0.00 | $173,089 | $0 | $12,471 | Yes (X) | |||
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Reportable Comp From Org | $1,778,673 | TotalReportableCompFromOrgAmt |
| Tot Reportable Comp Rltd Org | $0 | TotReportableCompRltdOrgAmt |
| Total Other Compensation | $171,861 | TotalOtherCompensationAmt |
| Indiv Rcvd Greater Than100 K | 16 | IndivRcvdGreaterThan100KCnt |
| Former Ofcr Employees Listed | Yes (1) | FormerOfcrEmployeesListedInd |
| Total Comp Greater Than150 K | Yes (1) | TotalCompGreaterThan150KInd |
| Compensation From Other Srcs | 0 | CompensationFromOtherSrcsInd |
Contractor Compensation ContractorCompensationGrp (5 entries)
| Address Line1ContractorAddress/USAddress/AddressLine1Txt | CityContractorAddress/USAddress/CityNm | State AbbreviationContractorAddress/USAddress/StateAbbreviationCd | ZIPContractorAddress/USAddress/ZIPCd | ServicesServicesDesc | CompensationCompensationAmt |
|---|---|---|---|---|---|
| ENVISION PHYSICIAN SERVICES | |||||
| 13737 NOEL ROAD SUITE 1600 | DALLAS | TX | 75240 | ANESTHESIOLOGIST | $1,291,322 |
| MERCY MEDICAL PARTNERS NORTHERN REGION | |||||
| 1400 EAST SECOND ST | DEFIANCE | OH | 43512 | REFERENCE LAB & PHYSICIAN COVERAGE | $1,132,057 |
| EMCARE PHYSICIAN SERVICES | |||||
| 7032 COLLECTION CENTER DRIVE | CHICAGO | IL | 60693 | EMERGENCY PHYSICIAN SERVICES | $1,024,792 |
| CREDIT SOLUTIONS LLC | |||||
| 2277 THUNDERSTICK DR STE 400 | LEXINGTON | KY | 40505 | COLLECTION AGENCY | $434,910 |
| HOSPITAL CARE GROUP PC | |||||
| 6435 W JEFFERSON BLVD | FORT WAYNE | IN | 46804 | INPATIENT PHYSICIAN SERVICES (HOSPITALIS | $294,553 |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Cntrct Rcvd Greater Than100 K | 12 | CntrctRcvdGreaterThan100KCnt |
| Related Organizations | $112,006 | RelatedOrganizationsAmt |
| Government Grants | $3,284,170 | GovernmentGrantsAmt |
| All Other Contributions | $150,230 | AllOtherContributionsAmt |
| Total Contributions | $3,546,406 | TotalContributionsAmt |
Program Service Revenue ProgramServiceRevenueGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Desc | PATIENT REVENUE | Desc |
| Business | 900099 | BusinessCd |
| Total Revenue Column | $32,876,630 | TotalRevenueColumnAmt |
| Related Or Exempt Func Income | $32,876,630 | RelatedOrExemptFuncIncomeAmt |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Program Service Revenue | $32,876,630 | TotalProgramServiceRevenueAmt |
Gross Rents GrossRentsGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Real | $81,622 | RealAmt |
Less Rental Expenses LessRentalExpensesGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Real | $0 | RealAmt |
Rental Income Or Loss RentalIncomeOrLossGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Real | $81,622 | RealAmt |
Net Rental Income Or Loss NetRentalIncomeOrLossGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Revenue Column | $81,622 | TotalRevenueColumnAmt |
| Exclusion | $81,622 | ExclusionAmt |
Other Revenue Misc OtherRevenueMiscGrp (3 entries)
| DescDesc | BusinessBusinessCd | Total Revenue ColumnTotalRevenueColumnAmt | Related Or Exempt Func IncomeRelatedOrExemptFuncIncomeAmt | ExclusionExclusionAmt |
|---|---|---|---|---|
| JOINT VENTURES | 900099 | $499,332 | $499,332 | |
| 340B REVENUE | 900099 | $243,984 | $243,984 | |
| NUTRITION/CAFETERIA | 900099 | $125,949 | $125,949 |
Miscellaneous Revenue MiscellaneousRevenueGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Revenue Column | $248,971 | TotalRevenueColumnAmt |
| Related Or Exempt Func Income | $238,158 | RelatedOrExemptFuncIncomeAmt |
| Unrelated Business Revenue | $10,813 | UnrelatedBusinessRevenueAmt |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Other Revenue Total | $1,118,236 | OtherRevenueTotalAmt |
Total Revenue TotalRevenueGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Revenue Column | $37,622,894 | TotalRevenueColumnAmt |
| Related Or Exempt Func Income | $33,858,104 | RelatedOrExemptFuncIncomeAmt |
| Unrelated Business Revenue | $10,813 | UnrelatedBusinessRevenueAmt |
| Exclusion | $207,571 | ExclusionAmt |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Info In Schedule O Part IX | Yes (X) | InfoInScheduleOPartIXInd |
Grants To Domestic Orgs GrantsToDomesticOrgsGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $97,481 | TotalAmt |
| Program Services | $97,481 | ProgramServicesAmt |
Comp Current Ofcr Directors CompCurrentOfcrDirectorsGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $349,408 | TotalAmt |
| Program Services | $275,286 | ProgramServicesAmt |
| Management And General | $74,122 | ManagementAndGeneralAmt |
Other Salaries And Wages OtherSalariesAndWagesGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $13,107,048 | TotalAmt |
| Program Services | $10,326,583 | ProgramServicesAmt |
| Management And General | $2,780,465 | ManagementAndGeneralAmt |
Pension Plan Contributions PensionPlanContributionsGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $362,009 | TotalAmt |
| Program Services | $285,214 | ProgramServicesAmt |
| Management And General | $76,795 | ManagementAndGeneralAmt |
Other Employee Benefits OtherEmployeeBenefitsGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $1,669,072 | TotalAmt |
| Program Services | $1,315,003 | ProgramServicesAmt |
| Management And General | $354,069 | ManagementAndGeneralAmt |
Payroll Taxes PayrollTaxesGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $760,789 | TotalAmt |
| Program Services | $599,399 | ProgramServicesAmt |
| Management And General | $161,390 | ManagementAndGeneralAmt |
Fees For Services Legal FeesForServicesLegalGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $173,596 | TotalAmt |
| Management And General | $173,596 | ManagementAndGeneralAmt |
Fees For Services Accounting FeesForServicesAccountingGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $56,250 | TotalAmt |
| Management And General | $56,250 | ManagementAndGeneralAmt |
Fees For Services Other FeesForServicesOtherGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $7,486,228 | TotalAmt |
| Program Services | $5,898,136 | ProgramServicesAmt |
| Management And General | $1,588,092 | ManagementAndGeneralAmt |
Advertising AdvertisingGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $246,103 | TotalAmt |
| Program Services | $193,896 | ProgramServicesAmt |
| Management And General | $52,207 | ManagementAndGeneralAmt |
Office Expenses OfficeExpensesGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $560,437 | TotalAmt |
| Program Services | $441,549 | ProgramServicesAmt |
| Management And General | $118,888 | ManagementAndGeneralAmt |
Occupancy OccupancyGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $1,960,190 | TotalAmt |
| Program Services | $1,544,365 | ProgramServicesAmt |
| Management And General | $415,825 | ManagementAndGeneralAmt |
Travel TravelGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $9,669 | TotalAmt |
| Program Services | $7,618 | ProgramServicesAmt |
| Management And General | $2,051 | ManagementAndGeneralAmt |
Conferences Meetings ConferencesMeetingsGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $24,921 | TotalAmt |
| Program Services | $19,634 | ProgramServicesAmt |
| Management And General | $5,287 | ManagementAndGeneralAmt |
Interest InterestGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $148,455 | TotalAmt |
| Management And General | $148,455 | ManagementAndGeneralAmt |
Depreciation Depletion DepreciationDepletionGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $1,231,438 | TotalAmt |
| Program Services | $970,207 | ProgramServicesAmt |
| Management And General | $261,231 | ManagementAndGeneralAmt |
Insurance InsuranceGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $246,958 | TotalAmt |
| Program Services | $194,570 | ProgramServicesAmt |
| Management And General | $52,388 | ManagementAndGeneralAmt |
Other Expenses OtherExpensesGrp (4 entries)
| DescDesc | TotalTotalAmt | Program ServicesProgramServicesAmt | Management And GeneralManagementAndGeneralAmt |
|---|---|---|---|
| DRUGS AND MEDICAL SUPPL | $4,342,623 | $4,342,623 | |
| FRANCHISE FEE | $672,888 | $672,888 | |
| NUTRITION/WELLNESS | $177,469 | $139,822 | $37,647 |
| DUES AND SUBSCRIPTIONS | $80,649 | $63,541 | $17,108 |
All Other Expenses AllOtherExpensesGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $95,012 | TotalAmt |
| Program Services | $74,857 | ProgramServicesAmt |
| Management And General | $20,155 | ManagementAndGeneralAmt |
Total Functional Expenses TotalFunctionalExpensesGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $33,858,693 | TotalAmt |
| Program Services | $26,789,784 | ProgramServicesAmt |
| Management And General | $7,068,909 | ManagementAndGeneralAmt |
| Fundraising | $0 | FundraisingAmt |
Cash Non Interest Bearing CashNonInterestBearingGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $1,830 | BOYAmt |
| EOY | $2,200 | EOYAmt |
Savings And Temp Cash Invst SavingsAndTempCashInvstGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $13,647,176 | BOYAmt |
| EOY | $10,574,953 | EOYAmt |
Accounts Receivable AccountsReceivableGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $5,372,866 | BOYAmt |
| EOY | $7,806,207 | EOYAmt |
Inventories For Sale Or Use InventoriesForSaleOrUseGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $685,242 | BOYAmt |
| EOY | $832,609 | EOYAmt |
Prepaid Expenses Defrd Charges PrepaidExpensesDefrdChargesGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $360,747 | BOYAmt |
| EOY | $411,784 | EOYAmt |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Land Bldg Equip Cost Or Other Bss | $26,535,894 | LandBldgEquipCostOrOtherBssAmt |
| Land Bldg Equip Accum Deprec | $20,011,794 | LandBldgEquipAccumDeprecAmt |
Land Bldg Equip Basis Net LandBldgEquipBasisNetGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $6,944,485 | BOYAmt |
| EOY | $6,524,100 | EOYAmt |
Investments Other Securities InvestmentsOtherSecuritiesGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $1,103,524 | BOYAmt |
| EOY | $1,533,069 | EOYAmt |
Other Assets Total OtherAssetsTotalGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $173,058 | BOYAmt |
| EOY | $274,436 | EOYAmt |
Total Assets TotalAssetsGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $28,288,928 | BOYAmt |
| EOY | $27,959,358 | EOYAmt |
Accounts Payable Accr Expnss AccountsPayableAccrExpnssGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $3,125,563 | BOYAmt |
| EOY | $2,727,556 | EOYAmt |
Tax Exempt Bond Liabilities TaxExemptBondLiabilitiesGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $6,216,870 | BOYAmt |
| EOY | $5,683,112 | EOYAmt |
Mortg Notes Pybl Scrd Invst Prop MortgNotesPyblScrdInvstPropGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $489,023 | BOYAmt |
| EOY | $626,500 | EOYAmt |
Unsecured Notes Loans Payable UnsecuredNotesLoansPayableGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $3,267,650 | BOYAmt |
| EOY | $0 | EOYAmt |
Other Liabilities OtherLiabilitiesGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $4,168,432 | BOYAmt |
| EOY | $3,770,917 | EOYAmt |
Total Liabilities TotalLiabilitiesGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $17,267,538 | BOYAmt |
| EOY | $12,808,085 | EOYAmt |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Organization Follows FASB117 | Yes (X) | OrganizationFollowsFASB117Ind |
No Donor Restriction Net Assets NoDonorRestrictionNetAssetsGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $9,938,974 | BOYAmt |
| EOY | $13,876,514 | EOYAmt |
Donor Restriction Net Assets DonorRestrictionNetAssetsGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $1,082,416 | BOYAmt |
| EOY | $1,274,759 | EOYAmt |
Total Net Assets Fund Balance TotalNetAssetsFundBalanceGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $11,021,390 | BOYAmt |
| EOY | $15,151,273 | EOYAmt |
Tot Liab Net Assets Fund Balance TotLiabNetAssetsFundBalanceGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $28,288,928 | BOYAmt |
| EOY | $27,959,358 | EOYAmt |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Info In Schedule O Part XI | Yes (X) | InfoInScheduleOPartXIInd |
| Reconcilation Revenue Expnss | $3,764,201 | ReconcilationRevenueExpnssAmt |
| Net Unrlzd Gains Losses Invst | $29,813 | NetUnrlzdGainsLossesInvstAmt |
| Other Changes In Net Assets | $335,869 | OtherChangesInNetAssetsAmt |
| Info In Schedule O Part XII | Yes (X) | InfoInScheduleOPartXIIInd |
| Method Of Accounting Accrual | Yes (X) | MethodOfAccountingAccrualInd |
| Accountant Compile Or Review | 0 | AccountantCompileOrReviewInd |
| FS Audited | Yes (1) | FSAuditedInd |
FS Audited Basis FSAuditedBasisGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Consolidated Basis Fincl Stmt | Yes (X) | ConsolidatedBasisFinclStmtInd |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Audit Committee | Yes (1) | AuditCommitteeInd |
| Federal Grant Audit Required | Yes (1) | FederalGrantAuditRequiredInd |
| Federal Grant Audit Performed | Yes (1) | FederalGrantAuditPerformedInd |
Schedule A IRS990ScheduleA
| Field | Value | IRS element (for citing) |
|---|---|---|
| Hospital | Yes (X) | HospitalInd |
Schedule B IRS990ScheduleB
Contributor Information ContributorInformationGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Contributor | RESTRICTED | ContributorNum |
Contributor Business Name ContributorBusinessName
| Field | Value | IRS element (for citing) |
|---|---|---|
| Business Name Line1 | RESTRICTED | BusinessNameLine1 |
Contributor US Address ContributorUSAddress
| Field | Value | IRS element (for citing) |
|---|---|---|
| Address Line1 | RESTRICTED | AddressLine1 |
| Address Line2 | RESTRICTED | AddressLine2 |
| City | RESTRICTED | City |
| State | RESTRICTED | State |
| ZIP Code | RESTRICTED | ZIPCode |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Contributions | RESTRICTED | TotalContributionsAmt |
Schedule C IRS990ScheduleC
| Field | Value | IRS element (for citing) |
|---|---|---|
| Volunteers | 0 | VolunteersInd |
| Paid Staff Or Management | 0 | PaidStaffOrManagementInd |
| Media Advertisements | 0 | MediaAdvertisementsInd |
| Mailings Members | 0 | MailingsMembersInd |
| Publications Or Broadcast | 0 | PublicationsOrBroadcastInd |
| Grants Other Organizations | 0 | GrantsOtherOrganizationsInd |
| Direct Contact Legislators | 0 | DirectContactLegislatorsInd |
| Rallies Demonstrations | 0 | RalliesDemonstrationsInd |
| Other Activities | Yes (1) | OtherActivitiesInd |
| Other Activities | $4,326 | OtherActivitiesAmt |
| Total Lobbying Expenditures | $4,326 | TotalLobbyingExpendituresAmt |
| Not Described Section501c3 | 0 | NotDescribedSection501c3Ind |
Supplemental Information Detail SupplementalInformationDetail
| Field | Value | IRS element (for citing) |
|---|---|---|
| Form And Line Reference | PART II-B, LINE 1: | FormAndLineReferenceDesc |
| Explanation | REPRESENTS PORTION OF ANNUAL DUES PAID TO AMERICAN HOSPITAL ASSOCIATION AND OHIO HOSPITAL ASSOCIATION ESTIMATED TO PERTAIN TO LOBBYING ACTIVITIES. | ExplanationTxt |
Schedule D IRS990ScheduleD
CY Endwmt Fund CYEndwmtFundGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Beginning Year Balance | $50,000 | BeginningYearBalanceAmt |
| End Year Balance | $50,000 | EndYearBalanceAmt |
CY Minus1 Yr Endwmt Fund CYMinus1YrEndwmtFundGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Beginning Year Balance | $50,000 | BeginningYearBalanceAmt |
| End Year Balance | $50,000 | EndYearBalanceAmt |
CY Minus2 Yr Endwmt Fund CYMinus2YrEndwmtFundGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Beginning Year Balance | $50,000 | BeginningYearBalanceAmt |
| End Year Balance | $50,000 | EndYearBalanceAmt |
CY Minus3 Yr Endwmt Fund CYMinus3YrEndwmtFundGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Beginning Year Balance | $50,000 | BeginningYearBalanceAmt |
| End Year Balance | $50,000 | EndYearBalanceAmt |
CY Minus4 Yr Endwmt Fund CYMinus4YrEndwmtFundGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Beginning Year Balance | $50,000 | BeginningYearBalanceAmt |
| End Year Balance | $50,000 | EndYearBalanceAmt |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Board Designated Balance EOY | 0.00000 | BoardDesignatedBalanceEOYPct |
| Prmnnt Endowment Balance EOY | 1.00000 | PrmnntEndowmentBalanceEOYPct |
| Term Endowment Balance EOY | 0.00000 | TermEndowmentBalanceEOYPct |
| Endowments Held Unrelated Org | 0 | EndowmentsHeldUnrelatedOrgInd |
| Endowments Held Related Org | 0 | EndowmentsHeldRelatedOrgInd |
Land LandGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Other Cost Or Other Basis | $141,813 | OtherCostOrOtherBasisAmt |
| Book Value | $141,813 | BookValueAmt |
Buildings BuildingsGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Other Cost Or Other Basis | $19,118,649 | OtherCostOrOtherBasisAmt |
| Depreciation | $14,304,962 | DepreciationAmt |
| Book Value | $4,813,687 | BookValueAmt |
Equipment EquipmentGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Other Cost Or Other Basis | $6,811,924 | OtherCostOrOtherBasisAmt |
| Depreciation | $5,706,832 | DepreciationAmt |
| Book Value | $1,105,092 | BookValueAmt |
Other Land Buildings OtherLandBuildingsGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Other Cost Or Other Basis | $463,508 | OtherCostOrOtherBasisAmt |
| Book Value | $463,508 | BookValueAmt |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Book Value Land Buildings | $6,524,100 | TotalBookValueLandBuildingsAmt |
Other Securities OtherSecuritiesGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Desc | INVESTMENT IN JOINT VENTURE | Desc |
| Book Value | $1,533,069 | BookValueAmt |
| Method Valuation | C | MethodValuationCd |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Book Value Securities | $1,533,069 | TotalBookValueSecuritiesAmt |
Other Liabilities Org OtherLiabilitiesOrgGrp (3 entries)
| DescDesc | AmtAmt |
|---|---|
| DUE TO/FROM RELATED PARTIES | $31,413 |
| THIRD PARTY PAYABLE | $967,782 |
| REFUNDABLE ADVANCE | $2,771,722 |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Liability | $3,770,917 | TotalLiabilityAmt |
| Footnote Text | Yes (X) | FootnoteTextInd |
Supplemental Information Detail SupplementalInformationDetail (2 entries)
| Form And Line ReferenceFormAndLineReferenceDesc | ExplanationExplanationTxt |
|---|---|
| PART V, LINE 4: | THE INTENDED USE OF THE ENDOWMENT FUNDS IS TO SUPPORT OPERATIONS OF THE HOSPITAL AS DIRECTED BY THE HOSPITAL BOARD. |
| PART X, LINE 2: | ACCOUNTING PRINCIPLES GENERALLY ACCEPTED IN THE UNITED STATES OF AMERICA REQUIRE MANAGEMENT TO EVALUATE TAX POSITIONS TAKEN AND RECOGNIZE A TAX LIABILITY IF AN UNCERTAIN POSITION HAS BEEN TAKEN THAT MORE LIKELY THAN NOT WOULD NOT BE SUSTAINED UPON EXAMINATION BY VARIOUS FEDERAL AND STATE TAXING AUTHORITIES. MANAGEMENT HAS ANALYZED THE TAX POSITIONS TAKEN BY THE ORGANIZATION AND HAS CONCLUDED THAT AS OF OCTOBER 31, 2021 AND 2020, THERE ARE NO UNCERTAIN POSITIONS TAKEN OR EXPECTED TO BE TAKEN THAT WOULD REQUIRE RECOGNITION OF A LIABILITY OR DISCLOSURE IN THE ACCOMPANYING CONSOLIDATED FINANCIAL STATEMENTS. THE ORGANIZATION IS SUBJECT TO ROUTINE AUDITS BY TAXING JURISDICTIONS; HOWEVER, THERE ARE CURRENTLY NO AUDITS FOR ANY TAX PERIODS IN PROGRESS. |
Schedule H IRS990ScheduleH
| Field | Value | IRS element (for citing) |
|---|---|---|
| Financial Assistance Policy | Yes (1) | FinancialAssistancePolicyInd |
| Written Policy | Yes (1) | WrittenPolicyInd |
| All Hospitals Policy | Yes (X) | AllHospitalsPolicyInd |
| FPG Reference Free Care | Yes (1) | FPGReferenceFreeCareInd |
| Percent100 | Yes (X) | Percent100Ind |
| FPG Reference Discounted Care | Yes (1) | FPGReferenceDiscountedCareInd |
| Percent400 | Yes (X) | Percent400Ind |
| Free Care Medically Indigent | Yes (1) | FreeCareMedicallyIndigentInd |
| Financial Assistance Budget | Yes (1) | FinancialAssistanceBudgetInd |
| Expenses Exceed Budget | 0 | ExpensesExceedBudgetInd |
| Annual Community Bnft Report | Yes (1) | AnnualCommunityBnftReportInd |
| Report Publically Available | Yes (1) | ReportPublicallyAvailableInd |
Financial Assistance At Cost Typ FinancialAssistanceAtCostTyp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Persons Served | 382 | PersonsServedCnt |
| Total Community Benefit Expns | $944,092 | TotalCommunityBenefitExpnsAmt |
| Direct Offsetting Revenue | $1,030,005 | DirectOffsettingRevenueAmt |
| Net Community Benefit Expns | $0 | NetCommunityBenefitExpnsAmt |
| Total Expense | 0.00000 | TotalExpensePct |
Unreimbursed Medicaid UnreimbursedMedicaidGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Persons Served | 2025 | PersonsServedCnt |
| Total Community Benefit Expns | $4,660,685 | TotalCommunityBenefitExpnsAmt |
| Direct Offsetting Revenue | $3,443,830 | DirectOffsettingRevenueAmt |
| Net Community Benefit Expns | $1,216,855 | NetCommunityBenefitExpnsAmt |
| Total Expense | 0.03590 | TotalExpensePct |
Total Financial Assistance Typ TotalFinancialAssistanceTyp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Persons Served | 2407 | PersonsServedCnt |
| Total Community Benefit Expns | $5,604,777 | TotalCommunityBenefitExpnsAmt |
| Direct Offsetting Revenue | $4,473,835 | DirectOffsettingRevenueAmt |
| Net Community Benefit Expns | $1,216,855 | NetCommunityBenefitExpnsAmt |
| Total Expense | 0.03590 | TotalExpensePct |
Community Health Services CommunityHealthServicesGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Activities Or Programs | 14 | ActivitiesOrProgramsCnt |
| Persons Served | 800123 | PersonsServedCnt |
| Total Community Benefit Expns | $58,852 | TotalCommunityBenefitExpnsAmt |
| Net Community Benefit Expns | $58,852 | NetCommunityBenefitExpnsAmt |
| Total Expense | 0.00170 | TotalExpensePct |
Health Professions Education HealthProfessionsEducationGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Activities Or Programs | 1 | ActivitiesOrProgramsCnt |
| Persons Served | 4 | PersonsServedCnt |
| Total Community Benefit Expns | $10,084 | TotalCommunityBenefitExpnsAmt |
| Net Community Benefit Expns | $10,084 | NetCommunityBenefitExpnsAmt |
| Total Expense | 0.00030 | TotalExpensePct |
Subsidized Health Services SubsidizedHealthServicesGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Activities Or Programs | 2 | ActivitiesOrProgramsCnt |
| Persons Served | 4872 | PersonsServedCnt |
| Total Community Benefit Expns | $592,074 | TotalCommunityBenefitExpnsAmt |
| Direct Offsetting Revenue | $406,650 | DirectOffsettingRevenueAmt |
| Net Community Benefit Expns | $185,424 | NetCommunityBenefitExpnsAmt |
| Total Expense | 0.00550 | TotalExpensePct |
Cash And In Kind Contributions CashAndInKindContributionsGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Activities Or Programs | 2 | ActivitiesOrProgramsCnt |
| Persons Served | 5200 | PersonsServedCnt |
| Total Community Benefit Expns | $14,305 | TotalCommunityBenefitExpnsAmt |
| Net Community Benefit Expns | $14,305 | NetCommunityBenefitExpnsAmt |
| Total Expense | 0.00040 | TotalExpensePct |
Total Other Benefits TotalOtherBenefitsGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Activities Or Programs | 19 | ActivitiesOrProgramsCnt |
| Persons Served | 810199 | PersonsServedCnt |
| Total Community Benefit Expns | $675,315 | TotalCommunityBenefitExpnsAmt |
| Direct Offsetting Revenue | $406,650 | DirectOffsettingRevenueAmt |
| Net Community Benefit Expns | $268,665 | NetCommunityBenefitExpnsAmt |
| Total Expense | 0.00790 | TotalExpensePct |
Total Community Benefits TotalCommunityBenefitsGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Activities Or Programs | 19 | ActivitiesOrProgramsCnt |
| Persons Served | 812606 | PersonsServedCnt |
| Total Community Benefit Expns | $6,280,092 | TotalCommunityBenefitExpnsAmt |
| Direct Offsetting Revenue | $4,880,485 | DirectOffsettingRevenueAmt |
| Net Community Benefit Expns | $1,485,520 | NetCommunityBenefitExpnsAmt |
| Total Expense | 0.04380 | TotalExpensePct |
Community Support CommunitySupportGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Activities Or Programs | 34 | ActivitiesOrProgramsCnt |
| Persons Served | 1605 | PersonsServedCnt |
| Total Community Benefit Expns | $6,945 | TotalCommunityBenefitExpnsAmt |
| Net Community Benefit Expns | $6,945 | NetCommunityBenefitExpnsAmt |
| Total Expense | 0.00020 | TotalExpensePct |
Health Improvement Advocacy HealthImprovementAdvocacyGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Activities Or Programs | 47 | ActivitiesOrProgramsCnt |
| Persons Served | 4949 | PersonsServedCnt |
| Total Community Benefit Expns | $63,237 | TotalCommunityBenefitExpnsAmt |
| Net Community Benefit Expns | $63,237 | NetCommunityBenefitExpnsAmt |
| Total Expense | 0.00190 | TotalExpensePct |
Total Communtity Building Acty TotalCommuntityBuildingActyGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Activities Or Programs | 81 | ActivitiesOrProgramsCnt |
| Persons Served | 6554 | PersonsServedCnt |
| Total Community Benefit Expns | $70,182 | TotalCommunityBenefitExpnsAmt |
| Net Community Benefit Expns | $70,182 | NetCommunityBenefitExpnsAmt |
| Total Expense | 0.00210 | TotalExpensePct |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Bad Debt Expense Reported | Yes (1) | BadDebtExpenseReportedInd |
| Bad Debt Expense | $1,255,320 | BadDebtExpenseAmt |
| Reimbursed By Medicare | $6,114,651 | ReimbursedByMedicareAmt |
| Cost Of Care Reimbursed By Medcr | $9,433,821 | CostOfCareReimbursedByMedcrAmt |
| Medicare Surplus Or Shortfall | -$3,319,170 | MedicareSurplusOrShortfallAmt |
Costing Methodology Used CostingMethodologyUsedGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Cost To Charge Ratio | Yes (X) | CostToChargeRatioInd |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Written Debt Collection Policy | Yes (1) | WrittenDebtCollectionPolicyInd |
| Financial Assistance Prvsn | Yes (1) | FinancialAssistancePrvsnInd |
| Hospital Facilities | 1 | HospitalFacilitiesCnt |
Hospital Facilities HospitalFacilitiesGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Facility | 1 | FacilityNum |
Business Name BusinessName
| Field | Value | IRS element (for citing) |
|---|---|---|
| Business Name Line1 | HENRY COUNTY HOSPITAL INC | BusinessNameLine1Txt |
US Address USAddress
| Field | Value | IRS element (for citing) |
|---|---|---|
| Address Line1 | 1600 EAST RIVERVIEW AVE | AddressLine1Txt |
| City | NAPOLEON | CityNm |
| State Abbreviation | OH | StateAbbreviationCd |
| ZIP | 43545 | ZIPCd |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Website Address | WWW.HENRYCOUNTYHOSPITAL.ORG | WebsiteAddressTxt |
| State License | 1198 | StateLicenseNum |
| Critical Access Hospital | Yes (X) | CriticalAccessHospitalInd |
| Emergency Room24 Hrs | Yes (X) | EmergencyRoom24HrsInd |
Hospital Fclty Policies Prctc HospitalFcltyPoliciesPrctcGrp
Hospital Facility Name HospitalFacilityName
| Field | Value | IRS element (for citing) |
|---|---|---|
| Business Name Line1 | HENRY COUNTY HOSPITAL INC | BusinessNameLine1Txt |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Facility | 1 | FacilityNum |
| First Licensed CY Or PY | 0 | FirstLicensedCYOrPYInd |
| Tax Exempt Hospital CY Or PY | 0 | TaxExemptHospitalCYOrPYInd |
| CHNA Conducted | Yes (1) | CHNAConductedInd |
| Community Definition | Yes (X) | CommunityDefinitionInd |
| Community Demographics | Yes (X) | CommunityDemographicsInd |
| Existing Resources | Yes (X) | ExistingResourcesInd |
| How Data Obtained | Yes (X) | HowDataObtainedInd |
| Community Health Needs | Yes (X) | CommunityHealthNeedsInd |
| Other Health Issues | Yes (X) | OtherHealthIssuesInd |
| Community Hlth Needs Id Process | Yes (X) | CommunityHlthNeedsIdProcessInd |
| Consulting Process | Yes (X) | ConsultingProcessInd |
| CHNA Conducted | 18 | CHNAConductedYr |
| Take Into Account Others Input | Yes (1) | TakeIntoAccountOthersInputInd |
| CHNA Conducted With Other Fclts | 0 | CHNAConductedWithOtherFcltsInd |
| CHNA Conducted With Non Fclts | Yes (1) | CHNAConductedWithNonFcltsInd |
| CHNA Report Widely Available | Yes (1) | CHNAReportWidelyAvailableInd |
| Rpt Available On Own Website | Yes (X) | RptAvailableOnOwnWebsiteInd |
| Own Website URL | SEE PART V SUPPLEMENTAL FACILITY INFO | OwnWebsiteURLTxt |
| Paper Copy Public Inspection | Yes (X) | PaperCopyPublicInspectionInd |
| Implementation Strategy Adopt | Yes (1) | ImplementationStrategyAdoptInd |
| Implementation Strategy Adpt | 18 | ImplementationStrategyAdptYr |
| Strategy Posted Website | Yes (1) | StrategyPostedWebsiteInd |
| Strategy Website URL | SEE PART V SUPPLEMENTAL FACILITY INFO | StrategyWebsiteURLTxt |
| Organization Incur Excise Tax | 0 | OrganizationIncurExciseTaxInd |
| Elig Criteria Explained | Yes (1) | EligCriteriaExplainedInd |
| FPG Family Incm Lmt Free Dscnt | Yes (X) | FPGFamilyIncmLmtFreeDscntInd |
| FPG Family Incm Lmt Free Care | 100.000000000000 | FPGFamilyIncmLmtFreeCarePct |
| FPG Family Incm Lmt Dscnt Care | 400.000000000000 | FPGFamilyIncmLmtDscntCarePct |
| Income Level Criteria | Yes (X) | IncomeLevelCriteriaInd |
| Medical Indigency Criteria | Yes (X) | MedicalIndigencyCriteriaInd |
| Insurance Status Criteria | Yes (X) | InsuranceStatusCriteriaInd |
| Underinsurance Stat Criteria | Yes (X) | UnderinsuranceStatCriteriaInd |
| Residency Criteria | Yes (X) | ResidencyCriteriaInd |
| Explained Basis | Yes (1) | ExplainedBasisInd |
| App Financial Asst Expln | Yes (1) | AppFinancialAsstExplnInd |
| Described Info | Yes (X) | DescribedInfoInd |
| Described Suprt Doc | Yes (X) | DescribedSuprtDocInd |
| Provided Hospital Contact | Yes (X) | ProvidedHospitalContactInd |
| Provided Nonprofit Contact | Yes (X) | ProvidedNonprofitContactInd |
| Includes Publicity Measures | Yes (1) | IncludesPublicityMeasuresInd |
| FAP Available On Website | Yes (X) | FAPAvailableOnWebsiteInd |
| FAP Available On Website URL | SEE PART V PAGE 8 | FAPAvailableOnWebsiteURLTxt |
| FAP App Available On Website | Yes (X) | FAPAppAvailableOnWebsiteInd |
| FAP App Available On Website URL | SEE PART V PAGE 8 | FAPAppAvailableOnWebsiteURLTxt |
| FAP Summary On Website | Yes (X) | FAPSummaryOnWebsiteInd |
| FAP Summary On Website URL | SEE PART V PAGE 8 | FAPSummaryOnWebsiteURLTxt |
| FAP Avlbl On Request No Charge | Yes (X) | FAPAvlblOnRequestNoChargeInd |
| FAP App Avlbl On Request No Chrg | Yes (X) | FAPAppAvlblOnRequestNoChrgInd |
| FAP Sum Avlbl On Request No Chrg | Yes (X) | FAPSumAvlblOnRequestNoChrgInd |
| Notified FAP Copy Bill Display | Yes (X) | NotifiedFAPCopyBillDisplayInd |
| Communtity Notified FAP | Yes (X) | CommuntityNotifiedFAPInd |
| FAP Translated | Yes (X) | FAPTranslatedInd |
| Other Publicity | Yes (X) | OtherPublicityInd |
| FAP Actions On Nonpayment | Yes (1) | FAPActionsOnNonpaymentInd |
| Permit No Actions | Yes (X) | PermitNoActionsInd |
| Collection Activities | 0 | CollectionActivitiesInd |
| Made Effort Orally Notify | Yes (X) | MadeEffortOrallyNotifyInd |
| Nondis Emergency Care Policy | Yes (1) | NondisEmergencyCarePolicyInd |
| Look Back Medicare Private | Yes (X) | LookBackMedicarePrivateInd |
| Amounts Generally Billed | 0 | AmountsGenerallyBilledInd |
| Gross Charges | 0 | GrossChargesInd |
Supplemental Information SupplementalInformationGrp (8 entries)
| Form And Line ReferenceFormAndLineReferenceDesc | ExplanationExplanationTxt |
|---|---|
| HENRY COUNTY HOSPITAL, INC. | PART V, SECTION B, LINE 5: 95% CONFIDENCE RATE THAT RESPONSES REPRESENT ENTIRE COUNTY. SEE EXPLANATION PARAGRAPH FOR PART VI LINE 2 FOR ADDITIONAL INFORMATION REGARDING THE CHNA. |
| HENRY COUNTY HOSPITAL, INC. | PART V, SECTION B, LINE 6B: HENRY COUNTY HOSPITAL'S CHNA WAS CONDUCTED WITH THE HENRY COUNTY HEALTH DEPARTMENT, FOUR COUNTY ADAMHS BOARD, UNITED WAY OF HENRY COUNTY, AND COMMUNITY HEALTH SERVICES. |
| HENRY COUNTY HOSPITAL, INC. | PART V, SECTION B, LINE 11: THE HENRY COUNTY HEALTH PARTNERS: INITIAL EFFORTS WILL FOCUS IN FOUR AREAS:A COMMUNITY HEATH ASSESSMENT WAS COMPLETED FOR 2019, THE DATA FROM THE SURVEY HAS BEEN OBTAINED, AND PRIORITIES HAVE BEEN SET. WORK GROUPS WERE FORMED, AND SOME WORKGROUPS HAVE MET VIRTUALLY. HOWEVER, WITH THE TIMING OF COVID, WE HAVE BEEN UNABLE TO WORK THROUGH ALL OF THE SURVEY DATA OR ACT ON THE PRIORITIES SET FOR 2020 AT THIS TIME. THE PRIORITIES FROM THE CHNA ARE AS FOLLOWS:1. ECONOMIC STABILITY2. SUBSTANCE MISUSE3. HEALTH CARE ACCESS - THIS PRIORITY IS A CONTINUATION FROM THE LAST SURVEY AND GOALS ARE SIMILAR TO THE PREVIOUS EFFORTS. 4. MENTAL HEALTH - THIS PRIORITY IS A CONTINUATION FROM THE LAST SURVEY AND THE GOALS ARE SIMILAR TO THE PREVIOUS SURVEY. |
| HENRY COUNTY HOSPITAL, INC. | PART V, SECTION B, LINE 13B: FOR ELIGIBILITY GUIDELINES, A SLIDING SCALE IS USED FOR DISCOUNTED CARE IF THE PATIENT IS OVER OUR 400% FEDERAL POVERTY GUIDELINES. |
| HENRY COUNTY HOSPITAL, INC. | PART V, SECTION B, LINE 16J: PAPER COPIES OF THE FAP ARE AVAILABLE AT ACCESS POINTS THROUGHOUT THE HOSPITAL, AS WELL AS AT THE SENIOR CENTER, HEALTH DEPARTMENT, JOBS & FAMILY SERVICES, CHURCHES, AND FISH PROGRAM (FOOD BANK). |
| HENRY COUNTY HOSPITAL, INC.: | FORM 990, SCHEDULE H, PART V, LINE 7A, CHNA URL: HTTPS://WWW.HENRYCOUNTYHOSPITAL.ORG/PATIENTS-VISITORS/COMMUNITY-HEALTH-ASSESSMENT.ASPX |
| HENRY COUNTY HOSPITAL, INC.: | FORM 990, SCHEDULE H, LINE 16A, FAP URL:HTTPS://WWW.HENRYCOUNTYHOSPITAL.ORG/PATIENTS-VISITORS/PATIENT-FINANCIAL-SERVICES.ASPXFORM 990, SCHEDULE H, LINE 16B, FAP APPLICATION URL:HTTPS://WWW.HENRYCOUNTYHOSPITAL.ORG/PATIENTS-VISITORS/PATIENT-FINANCIAL-SERVICES.ASPXFORM 990, SCHEDULE H, LINE 16C, PLAIN LANGUAGE SUMMARY OF FAP URL:HTTPS://WWW.HENRYCOUNTYHOSPITAL.ORG/PATIENTS-VISITORS/PATIENT-FINANCIAL-SERVICES.ASPX |
| HENRY COUNTY HOSPITAL, INC.: | FORM 990, SCHEDULE H, PART V, LINE 10A, IMPLEMENTATION STRATEGY URL:HTTPS://WWW.HENRYCOUNTYHOSPITAL.ORG/PATIENTS-VISITORS/COMMUNITY-HEALTH-ASSESSMENT.ASPX |
Supplemental Information Detail SupplementalInformationDetail (13 entries)
| Form And Line ReferenceFormAndLineReferenceDesc | ExplanationExplanationTxt |
|---|---|
| PART I, LINE 3C: | IN ADDITION TO THE FPG, THE ORGANIZATION USES THE FOLLOWING CRITERIA TO DETERMINE ELIGIBILITY FOR FINANCIAL ASSISTANCE: A SLIDING SCALE FOR DISCOUNTED CARE IF THE PATIENT IS 101% TO 400% FEDERAL POVERTY GUIDELINES, MEDICAL INDIGENCY, INSURANCE STATUS, UNDERINSURANCE STATUS, AND RESIDENCY. |
| PART I, LINE 7: | THE COST TO CHARGE RATIO METHOD WAS USED TO CALCULATE THE CHARITY CARE AND CERTAIN OTHER COMMUNITY BENEFITS AT COST. |
| PART I, LN 7 COL(F): | WE ESTIMATE THAT APPROXIMATELY 0% OF THE ACCOUNTS SENT TO BAD DEBT MAY QUALIFY FOR FINANCIAL ASSISTANCE IF THE PATIENT WOULD APPLY OR FULLY COMPLETE THE APPLICATION. WE ASSIST OUR PATIENTS EARLY IN THE PROCESS TO QUALIFY THEM FOR MEDICAID OR FINANCIAL ASSISTANCE, SO WE DEEM OUR PERCENTAGE TO BE LOW. |
| PART II, COMMUNITY BUILDING ACTIVITIES: | HENRY COUNTY HOSPITAL IS A GREAT COMMUNITY PARTNER, DESPITE CONTINUED CHALLENGES DUE TO COVID, WE CONTINUE TO SUPPORT OUR LOCAL COMMUNITY WITH ONGOING EDUCATION AND RESOURCES. WE HELD OVER 2 DOZEN COVID VACCINE CLINICS TO HELP REDUCE THE SPREAD OF COVID 19. THESE FREE CLINICS WERE HELD AT VARIOUS TIMES AND DATES FOR EASY ACCESS AND TO BE CONVENIENT FOR OUR COMMUNITY. WE PARTICIPATED IN THE SYMPHONY OF TREES PARTICIPATE BY HAVING 2 MEMBERS OF THE STAFF ON THE SYMPHONY OF TREE BOARD. THE SYMPHONY OF TREES IS A NON-PROFIT ORGANIZATION THAT PROVIDES SUPPORT TO THE CHILDREN OF HENRY COUNTY AND NORTHWEST OHIO THROUGH THREE BENEFITTING AGENCIES: CASA OF NORTHWEST OHIO, THE CENTER FOR CHILD AND FAMILY ADVOCACY AND HENRY COUNTY HOSPITAL. NAPOLEON ROTARY CLUB PARTICIPATE BY HAVING 1 STAFF MEMBER ON THE ROTARY EXECUTIVE BOARD. THIS ALLOWS THE HOSPITAL TO HAVE A PRESENCE AT WEEKLY MEETINGS AND MONTHLY BOARD MEETINGS AS WELL AS PROVIDE SPEAKERS REGARDING HEALTHCARE TOPICS AT LEAST 2 TIMES PER YEAR. PROVIDED EDUCATION ON HEALTH TOPICS THROUGH THE LOCAL RADIO STATION, SOCIAL MEDIA AND FREE PUBLICATION MAILED TO EVERY HOME IN THE COUNTY. IMAGINATION LIBRARY PROVIDED ALL NEWBORNS, DELIVERED AT HOSPITAL, A BOOK A MONTH SUBSCRIPTION FOR THEIR FIRST YEAR. NAPOLEON TRIATHLON AND OTHER RACE SPONSORSHIPS - PREMIER SPONSOR OF THE NAPOLEON TRIATHLON, CORPORATE SPONSOR FOR OTHER LOCAL RACES. FALL PREVENTION SCREENINGS. IN ORDER TO IMPROVE HEALTHCARE ACCESS, HENRY COUNTY HOSPITAL COLLABORATES WITH THE FOLLOWING: HENRY COUNTY TRANSPORTATION NETWORK TO PROVIDE FREE TRANSPORTATION FOR PATIENTS TO AND FROM HENRY COUNTY HOSPITAL. PROVIDED MONTHLY EDUCATION PRESENTATIONS AT HENRY COUNTY SENIOR CENTER. LOCAL SCHOOL DISTRICTS BY PROVIDING YEARLY SPORTS PHYSICALS TO STUDENTS IN THE DISTRICT, THE MONEY RAISED FROM THESE EVENTS IS THEN DONATED BACK TO THE RESPECTIVE SCHOOL DISTRICT. POISON PREVENTION WEEK PROVIDED LOCAL PRESCHOOLS WITH EDUCATIONAL, FREE ACTIVITY BOOKS, STICKERS, MAGNETS AND DONATED POISON PREVENTION STORYBOOKS TO AREA LIBRARIES. OUR TEAM COLLABORATED WITH NOCAC TO DISTRIBUTE MEALS TO YOUTH OVER THE SUMMER MONTHS. THE FOLLOWING ACTIVITIES HELP ENSURE ACCESS TO BEHAVIORAL HEALTH SERVICES: WORK WITH A NON-PROFIT AGENCY, SUFFICIENT GRACE MINISTRIES TO OFFER STAFF EDUCATION REGARDING PROVIDING SUPPORT TO MOTHERS/FAMILIES WHO HAVE HAD A MISCARRIAGE OR STILLBIRTH. THIS ORGANIZATION ALSO PROVIDES MOTHERS/FAMILIES KEEPSAKE ITEMS AND EXTRA SUPPORT IF THEY WOULD LIKE. |
| PART III, LINE 2: | MANAGEMENT ESTIMATES AN ALLOWANCE FOR UNCOLLECTIBLE ACCOUNTS RECEIVABLE BASED ON AN EVALUATION OF HISTORICAL LOSSES, CURRENT ECONCOMIC CONDITIONS, AND OTHER FACTORS UNIQUE TO THE HOSPITAL'S CUSTOMER BASE. |
| PART III, LINE 3: | NO OTHER BAD DEBT AMOUNTS HAVE BEEN INCLUDED AS COMMUNITY BENEFIT. THE HOSPITAL HAS A DETAILED FINANCIAL ASSISTANCE POLICY WHICH STATES THAT TO PARTICIPATE IN CHARITY CARE, CANDIDATES MUST COOPERATE FULLY. IN ADDITION, THE HOSPITAL EDUCATES PATIENTS WITH LIMITED ABILITY TO PAY REGARDING FINANCIAL ASSISTANCE. FOR THIS REASON, THE ORGANIZATION BELIEVES IT ACCURATELY CAPTURES ALL CHARITY CARE DEDUCTIONS PROVIDED ACCORDING TO THE FINANCIAL ASSISTANCE POLICY AND THE AMOUNT OF BAD DEBT EXPENSE ATTRIBUTABLE TO PATIENTS ELIGIBLE UNDER THE ORGANIZATION'S CHARITY CARE POLICY IS NEGLIGIBLE. |
| PART III, LINE 4: | THE FOOTNOTE EXPLAINING THE METHODOLOGY USED TO ESTIMATE THE AMOUNT OF THE ORGANIZATION'S BAD DEBT CAN BE FOUND ON PAGE 10 OF THE AUDITED FINANCIAL STATEMENTS UNDER THE HEADING "ACCOUNTS RECEIVEABLE." |
| PART III, LINE 8: | HENRY COUNTY HOSPITAL PROVIDES CARE TO THE MEDICARE POPULATION OF HENRY COUNTY, OHIO AND THE SURROUNDING AREA. IF THE HOSPITAL DID NOT PARTICIPATE IN MEDICARE, THOSE PATIENTS WOULD NEED TO SEEK CARE OUTSIDE OF HENRY COUNTY. THE MEDICARE SHORTFALL IS A BENEFIT THAT HENRY COUNTY HOSPITAL PROVIDES TO THE MEDICARE BENEFICIARIES IN THE COMMUNITY HENRY COUNTY HOSPITAL SERVES. THE SOURCE USED TO DETERMINE THE AMOUNT OF MEDICARE ALLOWABLE COSTS REPORTED FOR PART III, SECTION B, MEDICARE HAS BEEN PROVIDED FROM THE YEAR ENDED OCTOBER 31, 2020 REPORT: HOSPITAL STATEMENT OF REIMBURSABLE COST. |
| PART III, LINE 9B: | PER THE FINANCIAL ASSISSTANCE POLICY: NO PATIENT SEEKING MEDICAL SERVICE THAT CAN BE PROVIDED BY THE HOSPTIAL WILL BE DENIED ACCESS TO THOSE SERVICES SOLELY BECAUSE OF THE INABILTIY TO PAY FOR THOSE SERVICES. IF THE PATIENT IS KNOWN TO QUALIFY FOR FINANCIAL ASSISTANCE THE HOSPITAL DOES NOT SEND THEM TO COLLECTIONS BUT WORKS WITH THE PATIENT TO COMPLETE THE REQUIRED FINANCIAL ASSISTANCE APPLICATION. |
| PART VI, LINE 2: | EVERY THREE YEARS HENRY COUNTY HOSPITAL WORKS IN CONJUNCTION WITH THE HENRY COUNTY HEALTH DEPARTMENT AND OTHER COMMUNITY PARTNERS TO COMPLETE A COMPREHENSIVE COMMUNITY HEALTH ASSESSMENT. THIS COMMUNITY HEALTH ASSESSMENT PROVIDES VITAL INFORMATION TO THE HOSPITAL AND ENABLES HEALTH PROFESSIONALS TO DETERMINE THE NEEDS OF THE COMMUNITY. FROM THE COMMUNITY HEALTH ASSESSMENT, THE FOLLOWING PRIORITIES WERE DETERMINED:ECONOMIC STABILITY SUBSTANCE MISUSEHEALTHCARE ACCESS AND COSTMENTAL HEALTH INDIVIDUAL WORK GROUPS HAVE BEEN ASSIGNED TO WORK ON EACH OF THE ABOVE PRIORITIES. THESE WORK GROUPS DEVELOP A GOAL FOR EACH PRIORITY AND CARRY OUT TACTICS THAT HELP IMPACT THE SPECIFIC GOAL THEY HAVE BEEN ASSIGNED. SPECIFIC OBJECTIVES/PROGRAMS WILL BE IDENTIFIED TO HELP MEET THE DETERMINED GOALS. |
| PART VI, LINE 3: | AT THE TIME OF SERVICE, EACH SELF PAY PATIENT IS GIVEN A PACKET UPON DISCHARGE. THE PACKET INCLUDES AN HCAP APPLICATION (<100% FEDERAL POVERTY GUIDELINES) WITH DIRECTIONS, FINANCIAL ASSISTANCE PROGRAM INFORMATION, INCOME GUIDELINES FOR PROGRAMS, AND THE CONTACT INFORMATION FOR THE FINANCIAL COUNSELOR. EACH BILLING STATEMENT THAT IS SENT OUT TO PATIENTS CONTAINS THE HOSPITAL HCAP APPLICATION AND FINANCIAL COUNSELOR CONTACT INFORMATION. SIGNAGE IS ALSO POSTED IN THE HOSPITAL PER STATE OF OHIO REQUIREMENTS REGARDING FREE CARE. |
| PART VI, LINE 4: | HENRY COUNTY IS LOCATED IN NORTHWEST OHIO, COMPOSED OF THIRTEEN TOWNSHIPS AND NINE MUNICIPALITIES. HENRY COUNTY IS RICH IN AGRICULTURE, BUSINESS, CHURCHES, SCHOOLS, AND COMMUNITY ORGANIZATIONS. THE POPULATION OF HENRY COUNTY IS NEARLY 27,500. THE RACIAL MAKEUP OF THE COUNTY WAS 90% WHITE, 1% BLACK OR AFRICAN AMERICAN, 7% HISPANIC, AND 2% FROM TWO OR MORE RACES. IN HENRY COUNTY, 95.9% SPOKE ENGLISH, 2.7% SPANISH AND 0.8% GERMAN AS THEIR FIRST LANGUAGE. THE MEDIAN INCOME FOR A HOUSEHOLD IN THE COUNTY WAS $58,070, AND THE MEDIAN INCOME FOR A FAMILY WAS $66,771. MALES HAD A MEDIAN INCOME OF $61,819 VERSUS $45,809 FOR FEMALES. THE PER CAPITA INCOME FOR THE COUNTY WAS $27,235. ABOUT 5.30% OF FAMILIES AND 10.8% OF THE POPULATION WERE BELOW THE POVERTY LINE, INCLUDING 11% OF THOSE UNDER AGE 18 AND 5% OF THOSE AGE 65 OR OVER. |
| PART VI, LINE 5: | HENRY COUNTY HOSPITAL IS ACTIVE IN THE COMMUNITY BY PARTICIPATING IN HEALTH FAIRS, PROVIDING EDUCATION TO THE COMMUNITY, PROVIDING SCHOOL NURSES IN ALL FOUR SCHOOL SYSTEMS IN THE COUNTY, SUPPORTING OUR PATIENTS WITH TRANSPORTATION NEEDS, AND PROMOTING FITNESS AND WELLNESS CLASSES. THE HOSPITAL SUPPORTS THE EMPLOYEES BY PROMOTING WELLNESS ACTIVITIES, SUCH AS BREAK FOR HEALTH, RACE REIMBURSEMENT, HEALTHY RECIPES, FREE HEALTH SCREENINGS AND MENTAL HEALTH RESOURCES. OUR BOARD OF TRUSTEES IS MADE UP OF COMMUNITY MEMBERS WHO ACT IN THE BEST INTEREST OF OUR PATIENT POPULATION. EACH MEMBER BRINGS A UNIQUE PERSPECTIVE FROM THEIR POSITIONS IN THE COMMUNITY THAT ENABLES THEM TO BE ACTIVELY ENGAGED IN ADMINISTERING THEIR DUTIES AS A BOARD. THE HOSPITAL WORKS COLLABORATIVELY WITH THE HENRY COUNTY HEALTH DEPARTMENT, THE UNITED WAY, AND OTHERS IN PROMOTING HEALTHY LIVING. AS AN EXAMPLE, THE HOSPITAL IS WORKING TO INCREASE THE NUMBER OF BREASTFED BABIES WITH THE ASSISTANCE OF WIC (WOMEN, INFANTS AND CHILDREN) STAFF, BIRTHING CARE SERVICES NURSES, AND PATIENTS. HENRY COUNTY HOSPITAL HAS OFFERED 97 BREASTFEEDING CONSULTATIONS LAST YEAR.SENIOR LEADERS IN THE ORGANIZATION PARTICIPATE ON THE FOLLOWING BOARDS AND COMMITTEES THAT CONTINUE TO MEET THE NEEDS OF THE RESIDENTS OF HENRY COUNTY AND SURROUNDING AREAS: AMERICAN CANCER SOCIETY VOLUNTEER LEADERSHIP COUNCIL, HENRY COUNTY HEALTH PARTNERS, BREAST & COLON COALITION, SYMPHONY OF TREES BOARD OF DIRECTORS, SUICIDE PREVENTION, LION'S CLUB MEMBER, SENIOR CENTER HEALTH FAIR COMMITTEE, NAPOLEON SAFETY SERVICES STRATEGIC PLANNING COMMITTEE, UNITED WAY ANNUAL CAMPAIGN CABINET MEMBER, FAMILY AND CHILDREN'S FIRST COUNCIL, ECONOMIC STABILITY WORK GROUP, ACCESS TO HEALTHCARE WORK GROUP, CANCER CARE ALLIANCE BOARD MEMBER, CANCER CARE ALLIANCE FOUNDATION BOARD MEMBER |
Schedule I IRS990ScheduleI
| Field | Value | IRS element (for citing) |
|---|---|---|
| Grant Records Maintained | 0 | GrantRecordsMaintainedInd |
Recipient Table RecipientTable
Recipient Business Name RecipientBusinessName
| Field | Value | IRS element (for citing) |
|---|---|---|
| Business Name Line1 | HENRY COUNTY HOSPITAL FOUNDATION INC | BusinessNameLine1Txt |
US Address USAddress
| Field | Value | IRS element (for citing) |
|---|---|---|
| Address Line1 | 1600 EAST RIVERVIEW | AddressLine1Txt |
| City | NAPOLEON | CityNm |
| State Abbreviation | OH | StateAbbreviationCd |
| ZIP | 43545 | ZIPCd |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Recipient EIN | 341919852 | RecipientEIN |
| IRC Section | 501C3 | IRCSectionDesc |
| Cash Grant | $97,480 | CashGrantAmt |
| Purpose Of Grant | SUPPORT THE WORK OF THE FOUNDATION | PurposeOfGrantTxt |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total501c3 Org | 1 | Total501c3OrgCnt |
Schedule J IRS990ScheduleJ
| Field | Value | IRS element (for citing) |
|---|---|---|
| Idemnification Gross Up Pmts | Yes (X) | IdemnificationGrossUpPmtsInd |
| Club Dues Or Fees | Yes (X) | ClubDuesOrFeesInd |
| Written Policy Ref T And E Expnss | Yes (1) | WrittenPolicyRefTAndEExpnssInd |
| Substantiation Required | Yes (1) | SubstantiationRequiredInd |
| Compensation Committee | Yes (X) | CompensationCommitteeInd |
| Form990 Of Other Organizations | Yes (X) | Form990OfOtherOrganizationsInd |
| Compensation Survey | Yes (X) | CompensationSurveyInd |
| Board Or Committee Approval | Yes (X) | BoardOrCommitteeApprovalInd |
| Severance Payment | Yes (1) | SeverancePaymentInd |
| Supplemental Nonqual Rtr Plan | 0 | SupplementalNonqualRtrPlanInd |
| Equity Based Comp Arrngm | 0 | EquityBasedCompArrngmInd |
| Comp Based On Revenue Of Flng Org | 0 | CompBasedOnRevenueOfFlngOrgInd |
| Comp Bsd On Rev Related Orgs | 0 | CompBsdOnRevRelatedOrgsInd |
| Comp Bsd Net Earns Flng Org | 0 | CompBsdNetEarnsFlngOrgInd |
| Comp Bsd Net Earns Rltd Orgs | 0 | CompBsdNetEarnsRltdOrgsInd |
| Any Non Fixed Payments | 0 | AnyNonFixedPaymentsInd |
| Initial Contract Exception | 0 | InitialContractExceptionInd |
Rltd Org Officer Trst Key Empl RltdOrgOfficerTrstKeyEmplGrp (8 entries)
| TitleTitleTxt | Base Compensation Filing OrgBaseCompensationFilingOrgAmt | Compensation Based On Rltd OrgsCompensationBasedOnRltdOrgsAmt | Bonus Filing OrganizationBonusFilingOrganizationAmount | Bonus Related OrganizationsBonusRelatedOrganizationsAmt | Other Compensation Filing OrgOtherCompensationFilingOrgAmt | Other Compensation Rltd OrgsOtherCompensationRltdOrgsAmt | Deferred Compensation Flng OrgDeferredCompensationFlngOrgAmt | Deferred Comp Rltd OrgsDeferredCompRltdOrgsAmt | Nontaxable Benefits Filing OrgNontaxableBenefitsFilingOrgAmt | Nontaxable Benefits Rltd OrgsNontaxableBenefitsRltdOrgsAmt | Total Compensation Filing OrgTotalCompensationFilingOrgAmt | Total Compensation Rltd OrgsTotalCompensationRltdOrgsAmt | Comp Report Prior990 Filing OrgCompReportPrior990FilingOrgAmt | Comp Report Prior990 Rltd OrgsCompReportPrior990RltdOrgsAmt |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| KRISTI BARND | ||||||||||||||
| CEO | $154,638 | $0 | $0 | $0 | $0 | $0 | $4,004 | $0 | $10,896 | $0 | $169,538 | $0 | $0 | $0 |
| WILLIAM GRIMM | ||||||||||||||
| CIO-TERM ENDED NOV'20 | $136,143 | $0 | $0 | $0 | $0 | $0 | $4,068 | $0 | $30,993 | $0 | $171,204 | $0 | $0 | $0 |
| DR ERAST HAFTKOWYCZ | ||||||||||||||
| OBGYN | $278,133 | $0 | $0 | $0 | $0 | $0 | $8,104 | $0 | $10,560 | $0 | $296,797 | $0 | $0 | $0 |
| DR MORRIS SEAL | ||||||||||||||
| PHYSICIAN | $247,299 | $0 | $0 | $0 | $0 | $0 | $7,505 | $0 | $11,372 | $0 | $266,176 | $0 | $0 | $0 |
| DR ANDREW GOMBASH | ||||||||||||||
| PHYSICIAN | $243,907 | $0 | $0 | $0 | $0 | $0 | $4,785 | $0 | $10,467 | $0 | $259,159 | $0 | $0 | $0 |
| DR JOSEPH KRUEGER | ||||||||||||||
| PHYSICIAN | $270,926 | $0 | $0 | $0 | $0 | $0 | $7,057 | $0 | $10,467 | $0 | $288,450 | $0 | $0 | $0 |
| MICHELE JAKUTOWICZ | ||||||||||||||
| PHARMACIST | $147,372 | $0 | $0 | $0 | $0 | $0 | $4,306 | $0 | $21,556 | $0 | $173,234 | $0 | $0 | $0 |
| KIMBERLY BORDENKIRCHER | ||||||||||||||
| FORMER CEO | $154,125 | $0 | $0 | $0 | $18,964 | $0 | $5,642 | $0 | $6,829 | $0 | $185,560 | $0 | $0 | $0 |
Supplemental Information Detail SupplementalInformationDetail (2 entries)
| Form And Line ReferenceFormAndLineReferenceDesc | ExplanationExplanationTxt |
|---|---|
| PART I, LINE 1A | THE HOSPITAL GROSSES UP THE PERSONAL USE OF A BUSINESS OWNED VEHICLE FOR KIM BORDENKIRCHER, CEO. THIS BENEFIT IS INCLUDED IN TAXABLE COMPENSATION. THE HOSPITAL PAID DUES FOR THE ROTARY CLUB FOR KIM BORDENKIRCHER, CEO. THIS BENEFIT IS NOT INCLUDED IN TAXABLE COMPENSATION. |
| PART I, LINE 4A | FORMER CEO KIMBERLY BORDENKIRCHER RECEIVED SEVERENCE PAY WHICH IS INCLUDED IN THE AMOUNT ON PART II, COLUMN B (III). |
Schedule K IRS990ScheduleK
Tax Exempt Bonds Issues TaxExemptBondsIssuesGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Bond Reference | A | BondReferenceCd |
Issuer Name IssuerName
| Field | Value | IRS element (for citing) |
|---|---|---|
| Business Name Line1 | HENRY COUNTY OHIO | BusinessNameLine1Txt |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Bond Issuer EIN | 346400633 | BondIssuerEIN |
| Bond Issued | 2020-11-20 | BondIssuedDt |
| Issue Price | $6,875,000 | IssuePriceAmt |
| Purpose | $6,875,000 COUNTY OF HENRY, OHIO, HOSPITAL REFUNDING REVENUE BONDS | PurposeDesc |
| Defeased | 0 | DefeasedInd |
| On Behalf Of Issuer | 0 | OnBehalfOfIssuerInd |
| Pool Financing | 0 | PoolFinancingInd |
Tax Exempt Bonds Proceeds TaxExemptBondsProceedsGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Bond Reference | A | BondReferenceCd |
| Retired | $455,000 | RetiredAmt |
| Total Proceeds | $6,875,000 | TotalProceedsAmt |
| Issuance Costs From Proceeds | $137,500 | IssuanceCostsFromProceedsAmt |
| Substantial Completion | 2020 | SubstantialCompletionYr |
| Refunding Tax Exempt Bonds | Yes (1) | RefundingTaxExemptBondsInd |
| Refunding Taxable Bonds | 0 | RefundingTaxableBondsInd |
| Final Allocation Made | Yes (1) | FinalAllocationMadeInd |
| Adequate Books And Rec Maint | Yes (1) | AdequateBooksAndRecMaintInd |
Tax Exempt Bonds Private Bus Use TaxExemptBondsPrivateBusUseGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Bond Reference | A | BondReferenceCd |
| Owning Bond Financed Property | 0 | OwningBondFinancedPropertyInd |
| Any Lease Arrangements | 0 | AnyLeaseArrangementsInd |
| Mgmt Contract Bond Fincd Prop | 0 | MgmtContractBondFincdPropInd |
| Any Research Agreements | 0 | AnyResearchAgreementsInd |
| Bond Iss Meet Prvt Sec Pymt Test | 0 | BondIssMeetPrvtSecPymtTestInd |
| Change In Use Bond Financed Prop | 0 | ChangeInUseBondFinancedPropInd |
| Procs Nonqualified Bond Remdtd | Yes (1) | ProcsNonqualifiedBondRemdtdInd |
Tax Exempt Bonds Arbitrage TaxExemptBondsArbitrageGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Bond Reference | A | BondReferenceCd |
| Form8038 T Filed | 0 | Form8038TFiledInd |
| Rebate Not Due Yet | 0 | RebateNotDueYetInd |
| Exception To Rebate | Yes (1) | ExceptionToRebateInd |
| No Rebate Due | 0 | NoRebateDueInd |
| Variable Rate Issue | 0 | VariableRateIssueInd |
| Hedge Identified In Bks And Rec | 0 | HedgeIdentifiedInBksAndRecInd |
| Gross Proceeds Invested In GIC | 0 | GrossProceedsInvestedInGICInd |
| Gross Proceeds Invested | 0 | GrossProceedsInvestedInd |
| Written Proc To Monitor Reqs | 0 | WrittenProcToMonitorReqsInd |
Procedures Corrective Action ProceduresCorrectiveActionGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Bond Reference | A | BondReferenceCd |
| Procedures Corrective Action | Yes (1) | ProceduresCorrectiveActionInd |
Schedule O IRS990ScheduleO
Supplemental Information Detail SupplementalInformationDetail (9 entries)
| Form And Line ReferenceFormAndLineReferenceDesc | ExplanationExplanationTxt |
|---|---|
| FORM 990, PART I, LINE 1: | HENRY COUNTY HOSPITAL PROVIDES QUALITY HEALTHCARE AND WELLNESS SERVICES WHILE EXMPHASIZING PATIENT CARE AND EXCELLENT CUSTOMER SERVICE. HENRY COUNTY HOSPITAL WILL BE THE HEALTHCARE PROVIDER OF CHOICE BY BEING THE BEST PLACE TO RECEIVE PATIENT-CENTERED CARE, WORK AND PRACTICE MEDICINE. |
| FORM 990, PART III, LINE 1: | PEOPLE CENTERED. WE ARE FAMILY AND FRIENDS TAKING CARE OF FAMILY AND FRIENDS. WE OFFER PERSONALIZED SERVICES THAT INCLUDE FAMILY MEMBERS IN THE PATIENT'S CARE. DECISIONS AT ALL LEVELS OF THE ORGANIZATION ARE BASED ON WHAT IS BEST FOR THE PATIENT. WE CREATE A FAMILY-FRIENDLY, FLEXIBLE ENVIRONMENT FOR STAFF TO WORK. TRANSPARENCY AND OPEN FEEDBACK CREATE A POSITIVE CULTURE FOR STAFF TO PROVIDE SERVICES AND CELEBRATE ACHIEVEMENTS. EXCELLENCE DRIVEN. WE STRIVE FOR EXCELLENCE IN EVERYTHING THAT WE DO. OUR FOCUS IS ON "GETTING IT RIGHT" EVERY TIME AT ALL LEVELS OF THE ORGANIZATION. WE CREATE A NON-PUNITIVE CULTURE THAT IS COMMITTED TO ELIMINATING DEFECTS QUICKLY IN ORDER TO PROVIDE SAFE, QUALITY CARE TO ALL PATIENTS. COMMUNITY FOCUSED. WE EXIST TO SUPPORT THE COMMUNITY'S HEALTHCARE NEEDS. OUR GOAL IS TO PROVIDE AFFORDABLE HEALTHCARE AND WELLNESS SERVICES LOCALLY, SO PATIENTS CAN REMAIN WITHIN HENRY COUNTY FOR CARE REGARDLESS OF THEIR ABILITY TO PAY. WE COLLABORATE WITH LOCAL ORGANIZATIONS TO IMPROVE THE HEALTH AND WELL-BEING OF THE COMMUNITY. ALWAYS. THESE VALUES ARE INGRAINED IN OUR CULTURE AND ARE THE FOUNDATION OF HENRY COUNTY HOSPITAL. |
| FORM 990, PART VI, SECTION B, LINE 11B | THE FINANCE COMMITTEE OF THE BOARD REVIEWS THE FORM 990 BEFORE FILING AT A REGULARLY SCHEDULED MEETING, TYPICALLY THE FOURTH MONDAY OF THE MONTH. THE FORM 990 THEN GOES TO THE FULL BOARD AT THE FOLLOWING BOARD MEETING FOR REVIEW, TYPICALLY THE FIRST MONDAY OF THE MONTH. |
| FORM 990, PART VI, SECTION B, LINE 12C | THE WRITTEN CONFLICT OF INTEREST POLICY IS REGULARLY AND CONSISTENTLY MONITORED AND COMPLIANCE ENFORCED BY THE COMPLIANCE OFFICER. THE SCOPE OF THIS POLICY INCLUDES BOARD MEMBERS, THE LEADERSHIP TEAM, MEDICAL STAFF, AND EMPLOYEES. THE POLICY IS IN PLACE TO IDENTIFY POTENTIAL CONFLICTS OF INTEREST AND PROVIDE A MECHANISM TO MANAGE POTENTIAL CONFLICTS OF INTERESTS. THE COVERED PERSONS ARE TO IDENTIFY POTENTIAL CONFLICTS AND NOT PARTICIPATE IN DISCUSSIONS AND DECISIONS RELATED TO THE IDENTIFIED CONFLICTS. A SELF DISCLOSURE FROM COVERED PERSONS TO THE COMPLIANCE OFFICER AND THE BOARD IS REQUIRED ON ANY POTENTIAL CONFLICTS OF INTEREST. THE COVERED PERSONS ARE TO RECUSE FROM PARTICIPATING IN ANY DELIBERATION OR DECISIONS ON SUCH TRANSACTIONS. |
| FORM 990, PART VI, SECTION B, LINE 15 | THE CEO'S COMPENSATION IS DETERMINED BY BOARD OF DIRECTORS REVIEW. THE BOARD OF DIRECTORS USES THE OHIO HOSPITAL ASSOCIATION COMPENSATION DATA, COMPARABLE DATA OF OUR SURROUNDING HOSPITALS, AND INTERNAL EQUITY TO DETERMINE THE COMPENSATION OF THE CEO. THE FINAL DETERMINATION OF THE COMPENSATION IS APPROVED BY BOARD VOTE. THE COMPENSATION OF OTHER OFFICERS OR KEY EMPLOYEES OF THE ORGANIZATION IS DONE BY SIMILAR REVIEW OF COMPARABLE WAGE DATA FROM THE OHIO HOSPITAL ASSOCIATION AND THE HOSPITAL COUNCIL OF NORTHWEST OHIO. THE MANAGER OF HUMAN RESOURCES MAKES A COMPENSATION RECOMMENDATION BASED ON THE DATA AND INTERNAL EQUITY TO THE CEO. THE CEO AUTHORIZES THE COMPENSATION BASED ON THE DATA AND THE RECOMMENDATION. |
| FORM 990, PART VI, SECTION C, LINE 19 | THE ORGANIZATION DOES NOT MAKE GOVERNING DOCUMENTS, CONFLICT OF INTEREST POLICY OR FINANCIAL STATEMENTS AVAILABLE TO THE PUBLIC. |
| FORM 990, PART IX, LINE 11G | OTHER PURCHASED SERVICES: PROGRAM SERVICE EXPENSES 2,139,355. MANAGEMENT AND GENERAL EXPENSES 576,028. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 2,715,383. PHYSICIAN SERVICES: PROGRAM SERVICE EXPENSES 3,758,781. MANAGEMENT AND GENERAL EXPENSES 1,012,064. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 4,770,845. |
| FORM 990, PART XI, LINE 9: | INTEREST IN FOUNDATION NET ASSETS INTEREST IN FOUNDATION 223,863. AUXILIARY NET ASSET - TRANSFER 112,006. |
| FORM 990, PART XII, LINE 2C: | OVERSIGHT OF AUDIT: THE FINANCE COMMITTEE OF THE BOARD OF DIRECTORS ASSUMES RESPONSIBILITY FOR THE OVERSIGHT OF THE AUDIT OF THE FINANCIAL STATEMENTS AND NO PROCESSES HAVE CHANGED FROM THE PRIOR YEAR. |
Schedule R IRS990ScheduleR
Id Related Tax Exempt Org IdRelatedTaxExemptOrgGrp
Disregarded Entity Name DisregardedEntityName
| Field | Value | IRS element (for citing) |
|---|---|---|
| Business Name Line1 | HENRY COUNTY HOSPITAL FOUNDATION INC | BusinessNameLine1Txt |
US Address USAddress
| Field | Value | IRS element (for citing) |
|---|---|---|
| Address Line1 | 1600 EAST RIVERVIEW | AddressLine1Txt |
| City | NAPOLEON | CityNm |
| State Abbreviation | OH | StateAbbreviationCd |
| ZIP | 43545 | ZIPCd |
| Field | Value | IRS element (for citing) |
|---|---|---|
| EIN | 341919852 | EIN |
| Primary Activities | TO RAISE FUNDS AND PROVIDE FINANCIAL ASSISTANCE TO HENRY COUNTY HOSPITAL. | PrimaryActivitiesTxt |
| Legal Domicile State | OH | LegalDomicileStateCd |
| Exempt Code Section | 501(C)(3) | ExemptCodeSectionTxt |
| Public Charity Status | LINE 12A, I | PublicCharityStatusTxt |
| Direct Controlling NA | N/A | DirectControllingNACd |
| Controlled Organization | 0 | ControlledOrganizationInd |
Id Related Org Txbl Partnership IdRelatedOrgTxblPartnershipGrp
Related Organization Name RelatedOrganizationName
| Field | Value | IRS element (for citing) |
|---|---|---|
| Business Name Line1 | HENRY COUNTY PAIN MANAGEMENT LLC | BusinessNameLine1Txt |
US Address USAddress
| Field | Value | IRS element (for citing) |
|---|---|---|
| Address Line1 | 1600 E RIVERVIEW AVE | AddressLine1Txt |
| City | NAPOLEON | CityNm |
| State Abbreviation | OH | StateAbbreviationCd |
| ZIP | 43545 | ZIPCd |
| Field | Value | IRS element (for citing) |
|---|---|---|
| EIN | 462262320 | EIN |
| Primary Activities | MEDICAL PAIN MANAGEMENT | PrimaryActivitiesTxt |
| Legal Domicile State | OH | LegalDomicileStateCd |
Direct Controlling Entity Name DirectControllingEntityName
| Field | Value | IRS element (for citing) |
|---|---|---|
| Business Name Line1 | HENRY COUNTY HOSPITAL | BusinessNameLine1Txt |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Predominant Income Type | RELATED | PredominantIncomeTypeTxt |
| Share Of Total Income | $20,975 | ShareOfTotalIncomeAmt |
| Share Of EOY Assets | $90,074 | ShareOfEOYAssetsAmt |
| Disproportionate Allocations | 0 | DisproportionateAllocationsInd |
| General Or Managing Partner | Yes (1) | GeneralOrManagingPartnerInd |
| Ownership | 0.51000 | OwnershipPct |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Receipt Of Int Annts Rnts Rylts | 0 | ReceiptOfIntAnntsRntsRyltsInd |
| Gift Grnt Or Cap Contri To Oth Org | Yes (1) | GiftGrntOrCapContriToOthOrgInd |
| Gift Grnt Cap Contri From Oth Org | Yes (1) | GiftGrntCapContriFromOthOrgInd |
| Loans Or Guarantees To Other Org | 0 | LoansOrGuaranteesToOtherOrgInd |
| Loans Or Guarantees From Oth Org | 0 | LoansOrGuaranteesFromOthOrgInd |
| Div Related Organization | 0 | DivRelatedOrganizationInd |
| Asset Sale To Other Org | 0 | AssetSaleToOtherOrgInd |
| Asset Purchase From Other Org | 0 | AssetPurchaseFromOtherOrgInd |
| Asset Exchange | 0 | AssetExchangeInd |
| Rental Of Facilities To Oth Org | 0 | RentalOfFacilitiesToOthOrgInd |
| Rental Of Fclts From Oth Org | 0 | RentalOfFcltsFromOthOrgInd |
| Perform Of Services For Oth Org | 0 | PerformOfServicesForOthOrgInd |
| Perform Of Services By Other Org | 0 | PerformOfServicesByOtherOrgInd |
| Sharing Of Facilities | 0 | SharingOfFacilitiesInd |
| Paid Employees Sharing | 0 | PaidEmployeesSharingInd |
| Reimbursement Paid To Other Org | 0 | ReimbursementPaidToOtherOrgInd |
| Reimbursement Paid By Other Org | 0 | ReimbursementPaidByOtherOrgInd |
| Transfer To Other Org | 0 | TransferToOtherOrgInd |
| Transfer From Other Org | 0 | TransferFromOtherOrgInd |
Transactions Related Org TransactionsRelatedOrgGrp (2 entries)
| Transaction TypeTransactionTypeTxt | InvolvedInvolvedAmt | Method Of Amount DeterminationMethodOfAmountDeterminationTxt |
|---|---|---|
| HENRY COUNTY HOSPITAL FOUNDATION INC | ||
| B | $97,480 | CASH |
| HENRY COUNTY HOSPITAL FOUNDATION INC | ||
| C | $112,006 | CASH |
Unrelated Org Txbl Partnership UnrelatedOrgTxblPartnershipGrp (2 entries)
| Address Line1USAddress/AddressLine1Txt | CityUSAddress/CityNm | State AbbreviationUSAddress/StateAbbreviationCd | ZIPUSAddress/ZIPCd | EINEIN | Primary ActivitiesPrimaryActivitiesTxt | Legal Domicile StateLegalDomicileStateCd | All Partners C3 SAllPartnersC3SInd | Disproportionate AllocationsDisproportionateAllocationsInd | General Or Managing PartnerGeneralOrManagingPartnerInd | OwnershipOwnershipPct |
|---|---|---|---|---|---|---|---|---|---|---|
| VANTAGE HEALTHCARE OF OHIO LLC | ||||||||||
| 950 W WOOSTER ST | BOWLING GREEN | OH | 43402 | 472124397 | HOSPITALS WORKING TOGETHER FOR COST SAVINGS / REVENUE ENHANCEMENT | OH | 0 | 0 | Yes (1) | 0.14000 |
| HENRY COUNTY PAIN MANAGEMENT LLC | ||||||||||
| 1600 E RIVERVIEW AVE | NAPOLEAN | OH | 43545 | 462262320 | MEDICAL PAIN MANAGEMENT | OH | 0 | 0 | Yes (1) | 0.51000 |