2021-09-15T09:21:53-05:00 2020-10-31 351178661 BLUE & CO LLC 500 N MERIDIAN ST SUITE 200 INDIANAPOLIS IN 46204 990 2019-11-01 344477047 HENRY COUNTY HOSPITAL INC HENR 4195924015 1600 EAST RIVERVIEW NAPOLEON OH 43545 KRISTI BARND INTERIM CEO 4195924015 2021-09-15 1 NATHAN A RODGERS CPA P01568275 3176334705 2021-09-15 2019 2022-09-23 18:48:47Z KRISTI BARND 1600 EAST RIVERVIEW NAPOLEON OH 43545 32218546 0 X WWW.HENRYCOUNTYHOSPITAL.ORG X 1982 OH HENRY COUNTY HOSPITAL PROVIDES QUALITY HEALTHCARE AND WELLNESS SERVICES WHILE EMPHASIZING PATIENT CENTERED CARE AND EXCELLENT CUSTOMER SERVICE. HENRY COUNTY HOSPITAL WILL IMPROVE THE HEALTH OF THE COMMUNITY BY BEING THE BEST PLACE FOR PATIENTS TO RECEIVE CARE, FOR EMPLOYEES TO WORK, AND FOR PHYSICIANS TO PRACTICE MEDICINE. WE ARE COMMITTED TO EACH OTHER AND THE COMMUNITY THROUGH STEWARDSHIP AND COOPERATION; CONTINUAL LEARNING AND INNOVATION; PERSONALIZED SERVICES AND A FAMILY FOCUS. 9 8 359 52 5716 -13696 427876 4471082 30972870 26957602 -22852 -6974 1487574 789862 32865468 32211572 95397 92790 0 0 16509969 16094600 0 0 0 15750109 16312411 32355475 32499801 509993 -288229 21984151 28288928 10835766 17267538 11148385 11021390 X HENRY COUNTY HOSPITAL PROVIDES QUALITY HEALTHCARE AND WELLNESS SERVICES WHILE EMPHASIZING PATIENT CENTERED CARE AND EXCELLENT CUSTOMER SERVICE.HENRY COUNTY HOSPITAL WILL IMPROVE THE HEALTH OF THE COMMUNITY BY BEING THE BEST PLACE FOR PATIENTS TO RECEIVE CARE, FOR EMPLOYEES TO WORK, AND FOR PHYSICIANS TO PRACTICE MEDICINE. WE ARE COMMITTED TO EACH OTHER AND THE COMMUNITY THROUGH STEWARDSHIP AND COOPERATION; CONTINUAL LEARNING AND INNOVATION; PERSONALIZED SERVICES AND A FAMILY FOCUS. 0 0 2223167 3839481 1. LABORATORY--PROVIDING SERVICES FOR IP AND OP, EXTENDED CARE FACILITIES, PHYSICIAN OFFICES AND AREA BUSINESSES. THE LABORATORY PROVIDED OVER 96,536 BILLED TESTS IN 2020. 2162233 2761982 2. EMERGENCY CARE SERVICES ARE PROVIDED CONTINUALLY TO PATIENTS PRESENTING WITH INJURIES AND ILLNESSES. TOTAL PATIENTS TREATED IN THE EMERGENCY DEPARTMENT TOTALED OVER 6,800 FOR 2020. 2104828 5281038 3. 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 1,193 PROCEDURES IN 2020. 19709537 92790 15635761 #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 87,002 BILLED DOSES TO PATIENTS THROUGH PHARMACY SERVICES, OVER 499 INPATIENT ADMISSIONS WITH OVER 1,349 DAYS OF CARE, 77 SWING BED PATIENTS WITH OVER 780 DAYS OF CARE, 179 BIRTHS, AND OVER 41,800 OUTPATIENT VISITS IN 2020. 19709537 92790 15635761 26199765 1 1 0 1 0 0 0 0 0 1 1 0 0 0 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 0 0 0 0 0 1 0 0 0 1 58 0 1 359 1 1 1 0 0 0 0 0 0 0 0 0 0 0 X 9 8 0 0 0 0 0 0 0 1 1 0 0 1 1 1 1 1 1 1 1 1 0 OH X DIANE WALTHER 4195913826 1600 EAST RIVERVIEW NAPOLEON OH 43545 MARVIN BARLOW CHAIRMAN 4.00 0.00 X X 0 0 0 JOHN WILHELM VICE-CHAIR 2.00 0.00 X X 0 0 0 THOMAS MACK SECRETARY 2.00 0.00 X X 0 0 0 JIM BURKHART BOARD MEMBER 2.00 0.00 X 0 0 0 DR MIKE CARPENTER BOARD MEMBER 2.00 0.00 X 0 0 0 DR JOHN EWONUS BOARD MEMBER-TERM BEGAN JAN'20 2.00 0.00 X 0 0 0 RICKY FRUTH BOARD MEMBER 2.00 0.00 X 0 0 0 BRENT GERKEN BOARD MEMBER 2.00 0.00 X 0 0 0 MARK ADAMS BOARD MEMBER-TERM ENDED OCT'20 2.00 0.00 X 0 0 0 DR JOSEPH KRUEGER BOARD MEMBER-TERM ENDED DEC'19 40.00 0.00 X 242405 0 13083 KRISTI BARND COO/INTERIM CEO 40.00 0.00 X X 122878 0 13787 KIMBERLY BORDENKIRCHER CEO-TERM ENDED AUG'20 40.00 0.00 X X 215406 0 17773 WILLIAM GRIMM CIO-TERM ENDED NOV'20 40.00 0.00 X 135873 0 37117 TIFFANY KENNERK CNO 40.00 0.00 X 69861 0 5788 SARAH HUBER MEDICAL IMAGING MANAGER 40.00 0.00 X 121048 0 28608 MICHELE JAKUTOWICZ PHARMACIST 40.00 0.00 X 133061 0 27749 DR ANDREW GOMBASH PHYSICIAN 40.00 0.00 X 151166 0 7390 DR MORRIS SEAL PHYSICIAN 40.00 0.00 X 251591 0 18647 DR ERAST HAFTKOWYCZ OBGYN 40.00 0.00 X 266152 0 18209 1709441 0 188151 12 0 1 0 MERCY MEDICAL PARTNERS NORTHERN REGION 1400 EAST SECOND ST DEFIANCE OH 43512 ANESTHESIOLOGIST & PHYSICIAN COVERAGE 1854375 EMCARE PHYSICIAN SERVICES 1717 MAIN ST STE 5200 DALLAS TX 75201 EMERGENCY PHYSICIAN SERVICES 1074260 CREDIT SOLUTIONS LLC 2277 THUNDERSTICK DR STE 400 LEXINGTON KY 40505 COLLECTION AGENCY 330138 RADAR HEALTHCARE PROVIDERS 1741 HOG MOUNTAIN RD BLDG 200 WATKINSVILLE GA 30677 ANESTHESIOLOGIST 305932 HOSPITAL CARE GROUP PC 6435 W JEFFERSON BLVD FORT WAYNE IN 46804 INPATIENT PHYSICIAN SERVICES (HOSPITALIS 261849 11 48569 4392208 30305 4471082 PATIENT REVENUE 900099 26957602 26957602 26957602 100777 0 100777 100777 100777 6974 -6974 -6974 -6974 340B REVENUE 900099 202497 202497 JOINT VENTURES 900099 131728 131728 NUTRITION/CAFETERIA 900099 122709 122709 232151 226435 5716 689085 32211572 27518262 5716 216512 X 92790 92790 873971 705884 168087 12327140 9956312 2370828 313889 253520 60369 1281711 1035205 246506 1297889 1048271 249618 80264 80264 52289 52289 7267716 5869947 1397769 168219 135866 32353 551757 445640 106117 2016901 1628999 387902 22001 17770 4231 21096 17039 4057 281589 281589 1215238 981516 233722 246419 199026 47393 DRUGS AND MEDICAL SUPPL 3557528 3557528 FRANCHISE FEE 516348 516348 NUTRITION/WELLNESS 178107 143852 34255 DUES AND SUBSCRIPTIONS 65910 53234 12676 71029 57366 13663 32499801 26199765 6300036 0 1755 1830 7907573 13647176 4266793 5372866 635269 685242 392095 360747 26200764 19256279 7411211 6944485 1074107 1103524 295348 173058 21984151 28288928 2958196 3125563 7218952 6216870 34023 489023 3267650 624595 4168432 10835766 17267538 X 10218551 9938974 929834 1082416 11148385 11021390 21984151 28288928 X -288229 15362 145872 X X 0 1 X 1 0 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 0 0 0 0 0 0 0 0 1 4171 4171 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 1.00000 0 0 141813 141813 18856673 13615939 5240734 7135690 5640340 1495350 66588 66588 6944485 DUE TO/FROM RELATED PARTIES 39036 THIRD PARTY PAYABLE 351439 REFUNDABLE ADVANCE 3777957 4168432 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, 2020 AND 2019, 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. 1 1 X 1 X 1 X 1 1 0 1 1 339 1032785 909839 122946 0.00380 1834 3811080 2033731 1777349 0.05470 2173 4843865 2943570 1900295 0.05850 11 508375 37634 37634 0.00120 1 4 9607 9607 0.00030 3 3968 535203 293458 241745 0.00740 2 2884 4338 4338 0.00010 17 515231 586782 293458 293324 0.00900 17 517404 5430647 3237028 2193619 0.06750 25 21761 18230 18230 0.00060 25 21761 18230 18230 0.00060 1 1851719 6985831 9791679 -2805848 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 18 1 0 1 1 X SEE PART V SUPPLEMENTAL FACILITY INFO X 1 18 1 SEE PART V SUPPLEMENTAL FACILITY INFO 0 1 X 100.000000000000 250.000000000000 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 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 250% 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 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 OVER THE 250% 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, HOWEVER LIKE MANY ORGANIZATIONS, COVID PRESENTED SOME CHALLENGES TO OUR USUAL PROGRAMING. DUE TO COVID, WE PROVIDED ON-GOING COMMUNITY EDUCATION AND TRAINING THROUGH THIS TIME PERIOD, WHICH INCLUDED INFORMATION AND EDUCATION PROVIDED THROUGH LOCAL MEDIA, RADIO, AND SOCIAL MEDIA. WE ALSO CONTINUED TO PARTICIPATE VIRTUALLY IN THE FOLLOWING: SYMPHONY OF TREES PARTICIPATE BY HAVING 1 MEMBER 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. IN ADDITION, WE PROVIDED SPONSORSHIPS INCLUDING FIRE FIGHTER PHIL PROGRAM WITH THE LOCAL FIRE DEPARTMENT AS WELL AS NATIONAL CHILD SAFETY COUNCIL THROUGH THE HENRY COUNTY SHERIFF'S OFFICE. PROVIDED HEALTH TOPICS THROUGH THE LOCAL RADIO STATION. IMAGINATION LIBRARY PROVIDED ALL NEWBORNS, DELIVERED AT HOSPITAL, A BOOK A MONTH SUBSCRIPTION FOR THEIR FIRST YEAR.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 BLOOD PRESSURE SCREENINGS AT HENRY COUNTY SENIOR CENTER AND LOCAL HEALTH FAIRS PRIOR TO FEBRUARY 2020. 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. PROVIDING FREE VIRTUAL PRENATAL AND BREASTFEEDING CLASSES AND IN-PERSON LACTATION CONSULTATIONS. POISON PREVENTION WEEK PROVIDED IN SCHOOL EDUCATIONAL PRESENTATION INCLUDING HANDOUTS AND GAMES.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 9 OF THE AUDITED FINANCIAL STATEMENTS UNDER THE HEADING "ALLOWANCE FOR DOUBTFUL ACCOUNTS." 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 PRITORITIES. 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 DETERMINTED 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, HEALTHY EATING, AND "DRINK MORE WATER" CHALLENGES. 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 OWN 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 BREAST-FED BABIES WITH THE ASSISTANCE OF WIC (WOMEN, INFANTS AND CHILDREN) STAFF, BIRTHING CARE SERVICES NURSES, AND PATIENTS.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, AMERICAN HEART ASSOCIATION HEART WALK/EXECUTIVE LEADERSHIP COMMITTEE, SUICIDE PREVENTION, COMMUNITY HEALTH SERVICES, FAMILY & CHILDREN FIRST COUNCIL AND TOGETHER WE CAN MAKE A DIFFERENCE - MENTORING PROGRAM. 0 HENRY COUNTY HOSPITAL FOUNDATION INC 1600 EAST RIVERVIEW NAPOLEON OH 43545 341919852 501C3 92790 SUPPORT THE WORK OF THE FOUNDATION 1 X X 1 1 X X X X 0 0 0 0 0 0 0 0 0 DR JOSEPH KRUEGER BOARD MEMBER-TERM ENDED DEC'19 242405 0 0 0 0 0 2424 0 10659 0 255488 0 0 0 KIMBERLY BORDENKIRCHER CEO-TERM ENDED AUG'20 210696 0 0 0 4710 0 6342 0 11431 0 233179 0 0 0 WILLIAM GRIMM CIO-TERM ENDED NOV'20 135873 0 0 0 0 0 4101 0 33016 0 172990 0 0 0 MICHELE JAKUTOWICZ PHARMACIST 133061 0 0 0 0 0 4084 0 23665 0 160810 0 0 0 DR ANDREW GOMBASH PHYSICIAN 151166 0 0 0 0 0 1173 0 6217 0 158556 0 0 0 DR MORRIS SEAL PHYSICIAN 251591 0 0 0 0 0 7378 0 11269 0 270238 0 0 0 DR ERAST HAFTKOWYCZ OBGYN 266152 0 0 0 0 0 8034 0 10175 0 284361 0 0 0 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 PAYS DUES FOR THE ROTARY CLUB FOR KIM BORDENKIRCHER, CEO. THIS BENEFIT IS NOT INCLUDED IN TAXABLE COMPENSATION. A HENRY COUNTY OHIO 346400633 2010-12-16 10680000 BQ PRIVATE PLACEMENT WITH SWAP PAYOFF AND REFINANCING OF 2006 BOND ISSUE 0 0 0 A 3405000 10680000 135325 592175 9952500 2011 1 0 1 1 A 0 0 0 0 0 0 1 A 0 0 1 0 0 0 0 0 0 A 1 SCHEDULE K, PART I, BOND ISSUE: (A) ISSUER NAME: HENRY COUNTY, OHIO (F) DESCRIPTION OF PURPOSE: BQ PRIVATE PLACEMENT WITH SWAP PAYOFF AND REFINANCING OF 2006 BOND ISSUE 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 CEO AND THE BOARD IS REQUIRED ON ANY POTENTIAL CONFLICTS OF INTEREST. THE COVERED PERSONS ARE TO RECUES 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 2,044,957. MANAGEMENT AND GENERAL EXPENSES 486,951. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 2,531,908. PHYSICIAN SERVICES: PROGRAM SERVICE EXPENSES 3,824,990. MANAGEMENT AND GENERAL EXPENSES 910,818. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 4,735,808. FORM 990, PART XI, LINE 9: INTEREST IN FOUNDATION NET ASSETS INTEREST IN FOUNDATION 121,062. AUXILIARY NET ASSET - TRANSFER 24,810. 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 163452 116568 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 92790 CASH HENRY COUNTY HOSPITAL FOUNDATION INC C 48569 CASH