2020-05-13T13:11:51-05:00 2019-06-30 381357951 PLANTE & MORAN PLLC 250 S HIGH ST SUITE 100 COLUMBUS OH 43215 990 2018-07-01 274385692 AVITA HEALTH SYSTEM AVIT 4194681244 269 PORTLAND WAY SOUTH GALION OH 44833 D ERIC DRAIME CFO 4194681244 2020-05-07 1 AMY CIMINELLO P00796388 6148493000 2020-05-07 65.60.155.87 2020-05-07 14:24:26 ED P DA39A3EE5E6B4B0D3255BFEF95601890AFD80709 F23B626FF7BA699FD824818B7D825A8FA45A01E7 2018 2020-09-23 17:36:50Z JERRY MORASKO 269 PORTLAND WAY SOUTH GALION OH 44833 63909260 0 X N/A X 2010 OH TO IMPROVE THE HEALTH AND WELL-BEING OF THOSE WE SERVE. 13 13 402 0 0 0 0 0 63178022 63733523 94017 141277 347075 34460 63619114 63909260 0 0 0 0 41861824 46114101 0 0 0 21757290 17795159 63619114 63909260 0 0 0 0 0 0 0 0 TO IMPROVE THE HEALTH AND WELL-BEING OF THOSE WE SERVE. 0 0 30547120 0 63767983 AVITA PROVIDES MANAGEMENT AND ADMINISTRATIVE SERVICES TO THE VARIOUS TAX EXEMPT ENTITIES WITHIN ITS HEALTH SYSTEM. AVITA PROVIDES SENIOR EXECUTIVE MANAGEMENT AND ADMINISTRATIVE STAFF TO ITS AFFILIATES AND THE FOLLOWING SERVICES: BILLING AND COLLECTION, INFORMATION TECHNOLOGY, HUMAN RESOURCES, ACCOUNTING AND FINANCE, FACILITIES MANAGEMENT (INCLUDING MAINTENANCE) AND OTHER SUPPORT SERVICES NECESSARY FOR THE ADMINISTRATIVE FUNCTIONS OF THE SYSTEM. 30547120 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 0 0 0 0 0 0 0 0 0 0 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 1 1 1 0 0 1 178 0 1 402 1 0 0 0 0 0 0 0 0 0 0 0 0 X 13 13 0 0 0 0 0 0 0 1 0 0 0 1 1 1 1 1 1 1 1 0 X D ERIC DRAIME 4194685501 269 PORTLAND WAY SOUTH GALION OH 44833 JOSEPH SHADEED CHAIR 0.10 0.30 X X 0 0 0 KYMBERLY FOX VICE CHAIR 0.10 0.10 X X 0 0 0 REX CRAMER TREASURER 0.10 0.10 X X 0 0 0 MARK SCHNEIDER DIRECTOR 0.10 0.10 X 0 0 0 DOUGLAS SCHILLING DIRECTOR 0.10 0.10 X 0 0 0 PHILLIP BROWN DIRECTOR 0.10 0.10 X 0 0 0 JASON MCMULLEN DIRECTOR 0.10 0.10 X 0 0 0 SHERRI CLEVENGER DIRECTOR 0.10 0.10 X 0 0 0 JEFFERY A UNDERWOOD DIRECTOR 0.10 0.10 X 0 0 0 KAY MCDONALD SECRETARY 0.10 0.10 X 0 0 0 BOYD EPPERSON DIRECTOR 0.10 0.30 X 0 0 0 LINDA H SMITH DIRECTOR 0.10 0.10 X 0 0 0 DONALD L PLOTTS DIRECTOR 0.10 0.10 X 0 0 0 JERRY MORASKO PRESIDENT 0.10 0.70 X X 722458 0 4740 D ERIC DRAIME CFO 0.10 0.70 X X 322212 0 0 KATHLEEN DURFLINGER VP CHIEF NURSING OFFICER 40.00 0.00 X 239212 0 3380 SHIRLEY FITZ VP OF ANCILLARY SERVICES 40.00 0.00 X 212097 0 1170 JAMES HEDDLESON PHYSICIAN 40.00 0.00 X 1228469 0 1950 TRACI OSWALD CHIEF HUMAN RESOURCES 40.00 0.00 X 233519 0 1170 MYLES CREED VP MEDICAL STAFF DEVELOPMENT 40.00 0.00 X 201432 0 3900 3159399 0 16310 22 0 1 0 GALION ANESTHESIA 1105 DEVONWOOD ROAD MANSFIELD OH 44907 ANESTHESIA 1880891 JASON JEFFREY COLLINS 2025 POMPEII CT WESTON FL 33327 EMERGENCY DEPT 513388 ALLIANCE HEALTHCARE SERVICES PO BOX 96485 CHICAGO IL 60693 IMAGING SERVICES 483851 BKD 312 WALNUT ST CINCINNATI OH 45201 ACCOUNTANTS 421367 MEADE & ASSOC 737 ENTERPRISE DR LEWIS CENTER OH 43035 COLLECTIONS 315411 15 MANAGEMENT FUNCTION 561000 63733523 63733523 63733523 141277 141277 EHR TECHNOLOGY INCOME 900099 34460 34460 34460 63909260 63767983 0 141277 796381 796381 13315681 1334099 11981582 2735081 2259451 475630 22761440 18803226 3958214 6505518 5374208 1131310 128032 128032 778126 778126 1782035 116461 1665574 376814 4870 371944 4696047 1074762 3621285 5496208 5496208 218570 8088 210482 84804 26780 58024 2927007 488031 2438976 1193429 1051411 142018 PHYSICIAN RECRUITING 106267 106267 MEDICAL SUPPLIES 7820 5733 2087 63909260 30547120 33362140 0 0 0 0 0 X 0 0 0 0 0 0 X X 0 1 X 1 0 X X 1 GALION COMMUNITY HOSPITAL 344451872 3 1 0 0 1 0 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 PART IV: AVITA PROVIDES MANAGEMENT AND ADMINISTRATIVE SERVICES TO THE VARIOUS TAX EXEMPT ENTITIES WITHIN ITS HEALTH SYSTEM. AVITA PROVIDES SENIOR EXECUTIVE MANAGEMENT AND ADMINISTRATIVE STAFF TO ITS AFFILIATES AND THE FOLLOWING SERVICES: BILLING AND COLLECTION, INFORMATION TECHNOLOGY, HUMAN RESOURCES, ACCOUNTING AND FINANCE, FACILITIES MANAGEMENT (INCLUDING MAINTENANCE) AND OTHER SUPPORT SERVICES NECESSARY FOR THE ADMINISTRATIVE FUNCTIONS OF THE SYSTEM. X 1 1 X X X 1 1 0 0 0 0 0 1 0 JERRY MORASKO PRESIDENT 663542 0 58916 0 0 0 0 0 4740 0 727198 0 0 0 D ERIC DRAIME CFO 279962 0 42250 0 0 0 0 0 0 0 322212 0 0 0 KATHLEEN DURFLINGER VP CHIEF NURSING OFFICER 207846 0 31366 0 0 0 0 0 3380 0 242592 0 0 0 SHIRLEY FITZ VP OF ANCILLARY SERVICES 184286 0 27811 0 0 0 0 0 1170 0 213267 0 0 0 JAMES HEDDLESON PHYSICIAN 404120 0 646849 0 177500 0 0 0 1950 0 1230419 0 0 0 TRACI OSWALD CHIEF HUMAN RESOURCES 202153 0 31366 0 0 0 0 0 1170 0 234689 0 0 0 MYLES CREED VP MEDICAL STAFF DEVELOPMENT 151432 0 50000 0 0 0 0 0 3900 0 205332 0 0 0 PART I, LINE 1A A MEMBERSHIP AT THE LOCAL COUNTRY CLUB IS PAID FOR THE CEO, JERRY MORASKO. THIS BENEFIT HAS NOT BEEN TREATED AS TAXABLE COMPENSATION. PART I, LINE 7 PHYSICIAN'S QUALIFY FOR BONUSES BASED ON THEIR TARGET RVU'S. THIS TARGET IS FIGURED BY TAKING THEIR YEARLY SALARY AND DIVIDING IT BY THE RVU RATE WHICH COMES FROM MGMA GUIDELINES. PHYSICIAN BONUSES VARY BASED ON THEIR CONTRACT. THESE BONUSES ARE ACCRUED ON A MONTHLY BASIS AND PAID ON A QUARTERLY BASIS BASED ON PHYSICIAN'S CONTRACT TERM UNLESS THE PHYSICIAN IS NOT LIKELY TO MEET THE YEARLY TARGET. THE OFFICERS' BONUSES ARE BASED ON EACH INDIVIDUAL'S GOALS ESTABLISHED AT THE START OF THE FISCAL YEAR. THE OFFICERS' CAN RECEIVE UP TO A CERTAIN PERCENTAGE OF THEIR WAGES. BONUSES ARE PAID OUT ONCE A YEAR AFTER THE FISCAL YEAR RESULTS HAVE BEEN DETERMINED. FORM 990, PART VI, SECTION A, LINE 8B THE ORGANIZATION DOES NOT HAVE SUB-COMMITTEES WITH THE AUTHORITY TO ACT ON BEHALF OF THE GOVERNING BODY. FORM 990, PART VI, SECTION B, LINE 11B THE FORM 990 IS PROVIDED TO THE BOARD OF DIRECTORS AND SENT TO THE EXECUTIVE COMMITTEE FOR THEIR REVIEW PRIOR TO FILING. THE BOARD EXECUTIVE COMMITTEE APPROVES THE FORM 990 FOLLOWING REVIEW, AS AUTHORIZED BY THE FULL GOVERNING BODY. FORM 990, PART VI, SECTION B, LINE 12C THE CONFLICT OF INTEREST POLICY COVERS ALL BOARD OF DIRECTORS AND OFFICERS OF THE CORPORATION. CONFLICT OF INTEREST SURVEYS ARE REVIEWED BY BOARD CHAIRMAN AND THE CEO TO ENSURE COMPLIANCE. VARIOUS RESTRICTIONS ARE IMPOSED ON INDIVIDUALS WITH POTENTIAL CONFLICTS OF INTEREST (I.E. INABILITY TO VOTE) UNTIL DECISION HAS BEEN MADE ON POTENTIAL CONFLICT. AVITA HEALTH SYSTEM HAS ADOPTED THIS POLICY. FORM 990, PART VI, SECTION B, LINE 15 THE PROCESS FOR DETERMINING COMPENSATION CONSISTED OF BOARD EXECUTIVE COMMITTEE REVIEW OF OHIO HOSPITAL ASSOCIATION COMPENSATION SURVEYS, AND THE COMMITTEE DETERMINES EXECUTIVE COMPENSATION BASED ON THIS COMPARABILITY DATA. CONTEMPORANEOUS MINUTES ARE KEPT OF MEETINGS HELD BY THE EXECUTIVE COMMITTEE REGARDING DECISIONS AND DELIBERATIONS OF THIS PROCESS. THIS PROCESS WAS LAST COMPLETED IN 2018. FORM 990, PART VI, SECTION C, LINE 19 NO DOCUMENTS ARE AVAILABLE TO THE PUBLIC, OTHER THAN THE FINANCIAL STATEMENTS WHICH ARE ATTACHED TO GALION COMMUNITY HOSPITAL'S FORM 990. FORM 990, PART XI, LINE 2C THE ORGANIZATION HAS A FINANCE COMMITTEE WHICH OVERSEES THE AUDIT OF THE FINANCIAL STATEMENTS. THIS PROCESS HAS NOT CHANGED FROM THE PRIOR YEAR. FORM 990, PART IX AVITA HEALTH SYSTEM REPORTS EMPLOYEE BENEFIT AND RETIREMENT EXPENSES FOR COMMUNITY HEALTH ASSOCIATES, INC. AND GALION COMMUNITY HOSPITAL IN PART IX. GALION COMMUNITY HOSPITAL 269 PORTLAND WAY SOUTH GALION OH 44833 344451872 HOSPITAL SERVICES OH 501 (C)(3) LINE 3 AVITA HEALTH SYSTEM 1 COMMUNITY HEALTH ASSOCIATES INC 955 BUCYRUS ROAD GALION OH 44833 341784017 PHYSICIAN OFFICE OH 501 (C)(3) LINE 12A, I GALION COMMUNITY HOSPITAL 1 NORTH CENTRAL OHIO FAMILY CARE CENTER INC 269 PORTLAND WAY SOUTH GALION OH 44833 341807906 PHYSICIAN OFFICE OH 501 (C)(3) LINE 12A, I GALION COMMUNITY HOSPITAL 1 AVITA HEALTH FOUNDATION 269 PORTLAND WAY SOUTH GALION OH 44833 200934451 FOUNDATION OH 501 (C)(3) LINE 7 GALION COMMUNITY HOSPITAL 1 CRAWFORD COUNTY SHARED HEALTH SERVICES INC 1220 NORTH MARKET STREET GALION OH 44833 341484014 HOME HEALTH & HOSPICE OH 501 (C)(3) LINE 10 GALION COMMUNITY HOSPITAL 1 GALION COMMUNITY PAIN MANAGEMENT LLC 269 PORTLAND WAY SOUTH GALION OH 44833 300602607 HOSPITAL SUPPORT OH N/A GALION COMMUNITY VASCULAR SERVICES LLC 269 PORTLAND WAY SOUTH GALION OH 44833 611613817 HOSPITAL SUPPORT OH N/A AMERICAN SURGICAL SPINE SERVICES 629 N SANDUSKY AVE BUCYRUS OH 44820 371786727 HOSPITAL SUPPORT OH N/A 0 0 0 0 0 0 0 0 0 0 0 1 0 0 1 0 0 1 1 GALION COMMUNITY HOSPITAL S 83705904 FORGIVENESS OF PAYABLE GALION COMMUNITY HOSPITAL R 14102111 FORGIVENESS OF PAYABLE GALION COMMUNITY HOSPITAL L 61211901 MANAGEMENT FEE