2024-09-10T07:49:24-05:00 2023-10-31 351178661 BLUE & CO LLC 500 N MERIDIAN ST SUITE 200 INDIANAPOLIS IN 46204 990 2022-11-01 344477047 HENRY COUNTY HOSPITAL INC HENR 4195924015 1600 EAST RIVERVIEW NAPOLEON OH 43545 KRISTI BARND CEO 4195924015 2024-09-10 1 0 TYLER K GREENE CPA P00057872 3176334705 2024-09-10 2022 2024-08-08 14:25:15Z KRISTI BARND 1600 EAST RIVERVIEW NAPOLEON OH 43545 36649675 0 X WWW.HENRYCOUNTYHOSPITAL.ORG X 1982 OH PLEASE SEE SCHEDULE O FOR THE ORGANIZATION'S MISSION. 10 8 355 37 14240 0 1410324 277040 33299492 34297610 -8216 -4040 1052853 2075025 35754453 36645635 100885 106975 0 0 18041805 17797762 0 0 0 18675175 17278878 36817865 35183615 -1063412 1462020 22828724 23991931 8659278 7976306 14169446 16015625 X PLEASE SEE SCHEDULE O FOR THE ORGANIZATION'S MISSION STATEMENT. 0 0 2915724 4950137 1. LABORATORY--PROVIDING SERVICES FOR IP AND OP, EXTENDED CARE FACILITIES, PHYSICIAN OFFICES AND AREA BUSINESSES. THE LABORATORY PROVIDED OVER 119,222 BILLED TESTS IN 2023. 2194274 5476687 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 1,717 PROCEDURES IN 2023. 2328482 2352469 3. EMERGENCY: CARE SERVICES ARE PROVIDED CONTINUALLY TO PATIENTS PRESENTING WITH INJURIES AND ILLNESSES. TOTAL PATIENTS TREATED IN THE EMERGENCY DEPARTMENT TOTALED OVER 6,764 FOR 2023. 20612310 106975 23291085 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 87,438 BILLED DOSES TO PATIENTS THROUGH PHARMACY SERVICES, OVER 399 INPATIENT ADMISSIONS WITH OVER 1,302 DAYS OF CARE, 76 SWING BED PATIENTS WITH OVER 732 DAYS OF CARE, 96 BIRTHS, AND OVER 63,901 OUTPATIENT VISITS IN 2023. 20612310 106975 23291085 28050790 1 1 0 1 0 0 0 0 0 1 1 1 0 1 1 1 0 1 0 0 0 0 0 0 0 0 1 1 1 0 1 1 0 0 0 0 0 0 0 0 0 0 1 0 0 0 0 1 0 0 0 1 68 0 1 355 1 0 0 0 0 0 0 0 0 0 0 0 0 X 10 8 0 0 0 0 0 0 0 1 1 0 0 1 1 1 1 1 1 1 1 1 1 OH X DIANE WALTHER 4195913826 1600 EAST RIVERVIEW NAPOLEON OH 43545 MARVIN BARLOW CHAIRMAN 4.00 0.00 X X 0 0 0 BRENT GERKEN VICE-CHAIR 2.00 0.00 X X 0 0 0 JIM BURKHART SECRETARY 2.00 0.00 X X 0 0 0 DR MIKE CARPENTER TREASURER 2.00 0.00 X X 0 0 0 DR ERAST HAFTKOWYCZ BOARD MEMBER & OBGYN 40.00 0.00 X 281870 0 18986 THOMAS MACK BOARD MEMBER 2.00 0.00 X 0 0 0 MELISSA PEPER FIRESTONE BOARD MEMBER 2.00 0.00 X 0 0 0 RICKY FRUTH BOARD MEMBER 2.00 0.00 X 0 0 0 JOY ERMIE BOARD MEMBER 2.00 0.00 X 0 0 0 JOHN WILHELM VICE-CHAIR PARTIAL TERM 2.00 0.00 X X 0 0 0 DR JOHN EWONUS BOARD MEMBER PARTIAL TERM 2.00 0.00 X 0 0 0 KRISTI BARND CEO 40.00 0.00 X X 211102 0 16780 TIFFANY KENNERK CNO 40.00 0.00 X 135601 0 14875 BENJAMIN FISER CIO 40.00 0.00 X 75943 0 5362 JAMES NOWACZYK CNO 40.00 0.00 X 156361 0 16160 DR MORRIS SEAL PHYSICIAN 20.00 0.00 X 167354 0 17610 DR ANDREW GOMBASH PHYSICIAN 40.00 0.00 X 230666 0 17455 DR JOSEPH KRUEGER PHYSICIAN 40.00 0.00 X 263493 0 17914 MICHELE JAKUTOWICZ PHARMACIST 40.00 0.00 X 142311 0 25943 1664701 0 151085 16 0 1 0 SIMPLE VMS 7793 FIVE MILE RD CINCINNATI OH 45230 NURSE STAFFING 906360 EMCARE PHYSICIAN SERVICES 7032 COLLECTION CENTER DRIVE CHICAGO IL 60693 EMERGENCY PHYSICIAN SERVICES 641382 ENVISION PHYSICIAN SERVICES 13737 NOEL ROAD SUITE 1600 DALLAS TX 75240 ANESTHESIOLOGIST 623696 ASHLAND EMERGENCY GROUP LLC PO BOX 677979 DALLAS TX 75267 EMERGENCY PHYSICIAN SERVICES 607382 CLINICAL COLLEAGUES INC PO BOX 824246 PHILADELPHIA PA 19182 ANESTHESIOLOGIST 494456 18 244085 32955 250185 277040 NET PATIENT REVENUE 623990 34297610 34297610 34297610 100096 0 100096 100096 100096 4040 -4040 -4040 -4040 JOINT VENTURES 623990 437934 437934 340B REVENUE 623990 326007 326007 CAFETERIA 722514 144766 144766 1066222 1051982 14240 1974929 36645635 36113533 14240 240822 X 106975 106975 823075 660699 162376 13699710 10997038 2702672 363063 291438 71625 1803633 1447813 355820 1108281 889640 218641 46481 46481 76552 76552 7488566 6011226 1477340 227257 182424 44833 477741 383492 94249 1913823 1536265 377558 14580 11704 2876 20045 16091 3954 142219 142219 939232 753941 185291 375400 301341 74059 DRUGS AND MEDICAL SUPPL 4315712 3464311 851401 FRANCHISE FEE 842069 675946 166123 NUTRITION/WELLNESS 209123 167867 41256 DUES AND SUBSCRIPTIONS 65713 52749 12964 124365 99830 24535 35183615 28050790 7132825 0 2050 1850 6055583 7769444 5771571 5904028 841387 747085 427227 446415 26881522 21159768 6047251 5721754 1376946 1740016 2306709 1661339 22828724 23991931 2976166 2394269 5042612 4400261 640500 655000 0 526776 8659278 7976306 X 12925703 14694123 1243743 1321502 14169446 16015625 22828724 23991931 X 1462020 66652 317507 X X 0 1 X 1 1 1 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 0 0 0 0 0 0 0 0 1 5070 5070 0 PART II-B, LINE 1: REPRESENTS PORTION OF ANNUAL DUES PAID TO AMERICAN HOSPITAL ASSOCIATION AND OHIO HOSPITAL ASSOCIATION ESTIMATED TO PERTAIN TO LOBBYING ACTIVITIES. 50000 50000 50000 50000 50000 50000 50000 50000 50000 50000 0.00000 1.00000 0.00000 0 0 141813 141813 9671966 7501463 2170503 16820092 13658305 3161787 247651 247651 5721754 INVESTMENT IN JOINT VENTURE 1740016 C 1740016 DONOR RESTRICTED ASSETS 64474 DEPOSITS 1000 OTHER RECEIVABLES 74268 ASSETS WHOSE USE IS LIMITED 151876 THIRD PARTY RECEIVABLE 954595 OPERATING LEASE ROU ASSETS 415126 1661339 OPERATING LEASE LIABILITY 418271 DUE TO/FROM RELATED PARTIES 108505 526776 X 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, 2023 AND 2022, 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. PART XI, LINE 2D - OTHER ADJUSTMENTS: CHANGE IN INTEREST IN FOUNDATION NET ASSETS 1 1 X 1 X 1 X 1 1 0 1 1 408 1084461 1388810 0 0.00000 2494 4793573 2978199 1815374 0.05160 2902 5878034 4367009 1815374 0.05160 14 830003 79955 8060 71895 0.00200 1 22 7032 0 7032 0.00020 2 2631 375706 305179 70527 0.00200 2 30690 29556 29556 0.00080 19 863346 492249 313239 179010 0.00500 19 866248 6370283 4680248 1994384 0.05660 65 71669 17536 17536 0.00050 2 370 1245 1245 0.00000 67 72039 18781 18781 0.00050 1 863915 5645448 9675704 -4030256 X 1 1 1 1 HENRY COUNTY HOSPITAL INC 1600 EAST RIVERVIEW AVE NAPOLEON OH 43545 WWW.HENRYCOUNTYHOSPITAL.ORG 1198 X X HENRY COUNTY HOSPITAL INC 1 0 0 1 X X X X X X X X 22 1 0 1 1 X SEE PART V SUPPLEMENTAL FACILITY INFO X 1 22 1 SEE PART V SUPPLEMENTAL FACILITY INFO 0 1 X 200.000000000000 400.000000000000 X X X X X 1 1 X X X X 1 X SEE PART V PAGE 8 X SEE PART V PAGE 8 X SEE PART V PAGE 8 X X X X X X X 1 X 0 X X 1 X 0 0 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 2022, THE DATA FROM THE SURVEY WAS PUBLISHED IN JANUARY 2023. WORK GROUPS HAVE BEEN FORMED AND ARE CURRENTLY DETERMINING THE PRIORITIES BASED ON THE CHNA RESULTS. THE PRIORITIES FROM THE CHNA IN 2023 ARE AS FOLLOWS:1. HOUSING2. SUBSTANCE MISUSE - THIS PRIORITY IS A CONTINUATION FROM THE LAST SURVEY AND GOALS ARE SIMILAR TO THE PREVIOUS EFFORTS.3. HEALTHCARE 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 EFFORTS. HENRY COUNTY HOSPITAL, INC. PART V, SECTION B, LINE 13B: 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 201% TO 400% FEDERAL POVERTY GUIDELINES, MEDICAL INDIGENCY, INSURANCE STATUS, UNDERINSURANCE STATUS, AND RESIDENCY. 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 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 201% 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, AND WE CONTINUE TO SUPPORT OUR LOCAL COMMUNITY WITH ONGOING EDUCATION AND RESOURCES. WE PARTICIPATED IN THE SYMPHONY OF TREES PARTICIPATE BY HAVING A MEMBER OF 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. WE ARE ACTIVE IN THE FOLLOWING: NAPOLEON ROTARY CLUB PARTICIPATE BY HAVING ONE 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 TWO TIMES PER YEAR; HENRY COUNTY CHAMBER OF COMMERCE- MEMBER OF THE LEADERSHIP TEAM HOLDS A BOARD SEAT AND PARTICIPATES IN VARIOUS CHAMBER EVENTS; NAPOLEON TRIATHLON AND OTHER RACE SPONSORSHIPS - PREMIER SPONSOR; HENRY COUNTY SENIOR CENTER ADVISORY COMMITTEE- MEMBER OF THE LEADERSHIP TEAM HOLDS A COMMITTEE SEAT AND PARTICIPATES IN ANNUAL SENIOR CENTER HEALTH FAIR. TO IMPROVE HEALTHCARE ACCESS, HENRY COUNTY HOSPITAL COLLABORATES WITH THE HENRY COUNTY TRANSPORTATION NETWORK TO PROVIDE FREE TRANSPORTATION FOR PATIENTS TO AND FROM HENRY COUNTY HOSPITAL. THE HOSPITAL ALSO SUPPORTS THE LOCAL SCHOOL DISTRICTS BY OFFERING YEARLY SPORTS PHYSICALS TO STUDENTS AND VARIOUS HEALTHCARE EDUCATION. DURING POISON PREVENTION WEEK, A PHARMACY LEADER PRESENTED AT THE LOCAL KINDERGARTEN CLASSES WHICH INCLUDED FREE EDUCATIONAL ACTIVITY BOOKS, STICKERS, AND MAGNETS. THE FOLLOWING WELLNESS OPPORTUNITIES WERE OFFERED: KEEPING OUR GIRLS SAFE (KOGS) SELF-DEFENSE COURSES, QUARTERLY CPR CLASSES, SAFE SITTER, MENTAL HEALTH FIRST AID TRAINING, AMERICAN RED CROSS BLOOD DRIVES, AND TEDDY BEAR CLINIC. THE HOSPITAL CONTINUES TO PROVIDE EDUCATION ON HEALTH TOPICS THROUGH THE LOCAL RADIO STATION, SOCIAL MEDIA, AND FREE PUBLICATION MAILED TO EVERY HOME IN THE COUNTY. THE HOSPITAL CONTINUES TO BE ACTIVE AT THE HENRY COUNTY FAIR, HENRY COUNTY RELAY FOR LIFE, FULTON COUNTY FAIR, AND UNITED WAY OF HENRY COUNTY. 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, 2023 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:HOUSING SUBSTANCE MISUSEHEALTHCARE ACCESS MENTAL 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 APPROXIMATELY 27,500. THE RACIAL MAKEUP OF THE COUNTY WAS 89% NON-HISPANIC WHITE, 1% BLACK OR AFRICAN AMERICAN, 8% 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 $71,616. ABOUT 9% OF THE POPULATION WERE BELOW THE POVERTY LINE. 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. 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, LION'S CLUB, SENIOR CENTER ADVISORY COMMITTEE, NAPOLEON SAFETY SERVICES, STRATEGIC PLANNING COMMITTEE, UNITED WAY COMMITTEE, ACCESS TO HEALTHCARE WORK GROUP, HENRY COUNTY CHAMBER OF COMMERCE, CANCER CARE ALLIANCE. 0 HENRY COUNTY HOSPITAL FOUNDATION INC 1600 EAST RIVERVIEW NAPOLEON OH 43545 341919852 501C3 106975 0 SUPPORT THE WORK OF THE FOUNDATION 1 0 1 X X X X 0 0 0 0 0 0 0 0 0 DR ERAST HAFTKOWYCZ BOARD MEMBER & OBGYN 281870 0 0 0 0 0 8294 0 10692 0 300856 0 0 0 DR JOSEPH KRUEGER PHYSICIAN 263493 0 0 0 0 0 7489 0 10425 0 281407 0 0 0 DR ANDREW GOMBASH PHYSICIAN 230666 0 0 0 0 0 7030 0 10425 0 248121 0 0 0 KRISTI BARND CEO 211102 0 0 0 0 0 5672 0 11108 0 227882 0 0 0 DR MORRIS SEAL PHYSICIAN 167354 0 0 0 0 0 6481 0 11129 0 184964 0 0 0 JAMES NOWACZYK CNO 156361 0 0 0 0 0 1397 0 14763 0 172521 0 0 0 MICHELE JAKUTOWICZ PHARMACIST 142311 0 0 0 0 0 4435 0 21508 0 168254 0 0 0 TIFFANY KENNERK CNO 135601 0 0 0 0 0 3858 0 11017 0 150476 0 0 0 A HENRY COUNTY OHIO 346400633 2020-11-20 6875000 $6,875,000 COUNTY OF HENRY, OHIO, HOSPITAL REFUNDING REVENUE BONDS 0 0 0 A 1722000 6875000 137500 2020 1 0 1 1 A 0 0 0 0 0 0 1 A 0 1 0 0 0 0 0 0 0 A 1 X MEDICAL EQUIPMENT AND DEVICES 2 250185 0 0 0 FORM 990, PART I, LINE 1: HENRY COUNTY HOSPITAL PROVIDES QUALITY HEALTHCARE AND WELLNESS SERVICES WHILE EMPHASIZING 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 2,032,429. MANAGEMENT AND GENERAL EXPENSES 499,497. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 2,531,926. PHYSICIAN SERVICES: PROGRAM SERVICE EXPENSES 3,978,797. MANAGEMENT AND GENERAL EXPENSES 977,843. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 4,956,640. FORM 990, PART XI, LINE 9: INTEREST IN FOUNDATION 73,672. AUXILIARY NET ASSET - TRANSFER 243,835. 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. HENRY COUNTY HOSPITAL FOUNDATION INC 1600 EAST RIVERVIEW NAPOLEON OH 43545 341919852 TO RAISE FUNDS AND PROVIDE FINANCIAL ASSISTANCE TO HENRY COUNTY HOSPITAL. OH 501(C)(3) LINE 12A, I N/A 0 HENRY COUNTY PAIN MANAGEMENT LLC 1600 E RIVERVIEW AVE NAPOLEON OH 43545 462262320 MEDICAL PAIN MANAGEMENT OH HENRY COUNTY HOSPITAL RELATED 218948 187688 0 1 0.51000 0 1 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 HENRY COUNTY HOSPITAL FOUNDATION INC B 106975 CASH HENRY COUNTY HOSPITAL FOUNDATION INC C 244085 CASH 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 1 0.14000