2020-11-12T10:12:37-06:00 2019-12-31 351178661 BLUE & CO LLC 500 N MERIDIAN ST SUITE 200 INDIANAPOLIS IN 46204 990 2019-01-01 340719172 BARNESVILLE HOSPITAL ASSOCIATION INC DBA BARNESVILLE HOSPITAL BARN 7404253941 639 W MAIN STREEET BARNESVILLE OH 43713 WILLIE COOPER-LOHR CFO 7404253941 2020-11-12 1 NATHAN A RODGERS CPA P01568275 3176334705 2020-11-12 38.109.186.2 2020-11-12 09:27:08 ES P DA39A3EE5E6B4B0D3255BFEF95601890AFD80709 AF923E04E140C4DE71FD41AF2127CF5344A3E036 2019 2021-01-29 14:40:06Z WILLIE COOPER-LOHR 639 W MAIN STREEET BARNESVILLE OH 43713 18435548 0 X WWW.BARNESVILLEHOSPITAL.COM X 1940 OH WE SERVICE THE HEALTH NEEDS OF THE COMMUNITY AND SURROUNDING COUNTIES. OUR COUNTY TO THE SOUTH OF US DOES NOT HAVE A HOSPITAL. THE COMMUNITY IS SERVICED WITH A 24 HOUR EMERGENCY DEPARTMENT, ACUTE INPATIENT SERVICES ALONG WITH SWING BED TO HELP THEM REMAIN CLOSE TO THEIR FAMILIES. WE ALSO HAVE A FULL SERVICE OUTPATIENT SERVICE. 13 11 280 158 0 0 648955 840585 17671938 17173528 -199697 119791 227253 207480 18348449 18341384 1038095 1028741 0 0 11392566 11476127 0 0 0 7401064 8157972 19831725 20662840 -1483276 -2321456 12285426 11839224 7590962 9057705 4694464 2781519 X BARNESVILLE HOSPITAL ASSOCIATION, INC. OPERATES IN A MANNER CONSISTENT WITH THE REQUIREMENTS OF REV RUL 69-545, THROUGH IT'S PROVISION OF HEALTH CARE SERVICES TO THE COMMUNITY, REGARDLESS OF ABILITY TO PAY. OUR MISSION IS TO IMPROVE THE COMMUNITY'S HEALTH THROUGH THE EFFICIENT PROVISION, COORDINATION AND INTEGRATION OF QUALITY HEALTH SERVICES, HEALTH EDUCATION AND RESEARCH. WE ALSO PROVIDE COMPASSIONATE, QUALITY HEALTH SERVICES ACCORDING TO THE PHYSICAL, SPIRITUAL, PHYCHOLOGICAL, SOCIAL, RELIGIOUS, ENVIRONMENTAL AND ECONOMIC NEEDS OF OUR COMMUNITIES. 0 0 18394013 1028741 17173528 IN 2019 BARNESVILLE HOSPITAL PROVIDED CARE FOR 443 INPATIENT ADMISSIONS RESULTING IN 1,688 PATIENT DAYS. WE ALSO PROVIDED 24,393 OUTPATIENT VISITS PLUS 7,813 EMERGENCY ROOM VISITS. BARNESVILLE HOSPITAL IS A CRITICAL ACCESS HOSPITAL AND PROVIDES EXTENSIVE INPATIENT AND OUTPATIENT CARE FOR MEMBERS OF THE COMMUNITY REGARDLESS OF THEIR ABILITY TO PAY. 18394013 1 1 0 1 0 0 0 0 0 0 1 0 1 1 1 1 0 1 0 0 0 0 0 0 0 0 1 1 1 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 1 1 1 1 0 1 52 0 1 280 1 0 0 0 0 0 0 0 0 0 0 0 0 X 13 11 0 0 0 0 0 0 0 1 1 0 0 1 1 1 1 1 1 1 1 0 OH X WILLIE COOPER-LOHR 7404253941 639 W MAIN STREEET BARNESVILLE OH 43713 R MELVIN MILBURN PRESIDENT 1.00 0.00 X X 0 0 0 KENT GALLAGHER VICE PRESIDENT 1.00 0.00 X X 0 0 0 C J BRADFIELD TREASURER 1.00 0.00 X X 0 0 0 AARON BRUGGEMAN BOARD MEMBER 1.00 0.00 X 0 0 0 WILLIAM E FRANK JR BOARD MEMBER 1.00 0.00 X 0 0 0 ANGELA HANNAHS BOARD MEMBER 1.00 0.00 X 0 0 0 DAVID HILLIARD DO BOARD MEMBER 40.00 0.00 X 160684 0 26459 MINDY JOHNSON BOARD MEMBER 1.00 0.00 X 0 0 0 TOM JOHNSON BOARD MEMBER 1.00 0.00 X 0 0 0 KENNETH PHILLIPS BOARD MEMBER 1.00 0.00 X 0 0 0 DR SHAUN ROE BOARD MEMBER 1.00 39.00 X 0 313032 36887 P K SOURI MD BOARD MEMBER 1.00 0.00 X 0 0 0 DELORES WELLS BOARD MEMBER 1.00 0.00 X 0 0 0 MELISSA HARTSHORN SECRETARY 40.00 0.00 X 47538 0 35200 DAVID PHILLIPS CEO 38.00 2.00 X 115184 0 16601 WILLIE COOPER - LOHR CFO 38.00 2.00 X 109290 0 27594 CYNTHIA TOUVELLE CNO 40.00 0.00 X 115507 0 27497 JOSEPH A JEFFRIES PHARMACIST 40.00 0.00 X 114293 0 35468 AMY PERRY PHARMACIST 40.00 0.00 X 117025 0 21575 JANET LALLATHIN PHARMACIST 40.00 0.00 X 115124 0 13282 894645 313032 240563 7 0 1 0 MEDSTAFF SERVICES LLC PO BOX 1895 POWELL OH 43065 HOSPITALIST SERVICES 419660 ALLSCRIPTS HEALTHCARE LLC 24630 NETWORK PLACE CHICAGO IL 60673 COMPUTER SYSTEM SERVICES 371532 NES OHIO INC PO BOX 936451 ATLANTA GA 31193 ER PHYSICIANS 267301 LAB CORP PO BOX 12140 BURLINGTON NC 27216 LAB SERVICES 231272 ACUTE CARE INC 1609 N ANKENY BLVD SUITE 200 ANKENY IA 43718 ER PHYSICIANS 192580 7 385223 421362 34000 840585 NET PATIENT REVENUE 900099 17173528 17173528 17173528 119794 119794 86731 94161 -7430 -7430 -7430 3 -3 -3 -3 CAFETERIA 722210 90083 90083 AUXILIARY INCOME 900099 40425 40425 84402 84402 214910 18341384 17173528 0 327271 X 1028741 1028741 681555 603799 77756 7133050 6319271 813779 316501 271909 44592 2792449 2399022 393427 552572 474720 77852 30507 25830 4677 3349629 2836069 513560 12525 10163 2362 335696 331170 4526 1897562 1719741 177821 35466 28777 6689 7412 6014 1398 88190 78424 9766 438991 391194 47797 146719 129857 16862 DRUGS AND MEDICAL SUPPL 1635676 1635676 DUES & SUB. 89251 72419 16832 AUXILIARY EXPENSES 51876 51876 38472 31217 7255 20662840 18394013 2268827 0 571 571 292441 229475 2058029 1891993 447614 403879 264095 223815 20104034 15834699 4249058 4269335 2345600 2816339 103274 808319 835069 1716425 1168748 12285426 11839224 2617216 3700269 1899739 1832296 3074007 3525140 7590962 9057705 X 4694464 2781519 4694464 2781519 12285426 11839224 X -2321456 416918 -8407 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 4157 4157 0 PART II-B, LINE 1: A PORTION OF ANNUAL MEMBERSHIP DUES PAID TO TRADE ASSOCIATIONS IS ALLOCATED TO LOBBYING EXPENDITURES. 66199 66199 13575705 10369646 3206059 400235 247005 153230 6034207 5218048 816159 27688 27688 4269335 EQUITY IN BELMONT COUNTY HEALTH SERVICES 835069 F 835069 RELATED PARTY RECEIVABLES 1168748 1168748 ACCRUED PENSION COSTS 3270315 ESTIMATED THIRD PARTY SETTLEMENTS 254825 3525140 X 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 THESE ENTITIES, AND HAS CONCLUDED THAT AS OF DECEMBER 31, 2019 AND 2018, THERE ARE NO UNCERTAIN POSITIONS TAKEN OR EXPECTED TO BE TAKEN THAT WOULD REQUIRE RECOGNITION OF A LIABILITY OR DISCLOSURE IN THE ACCOMPANYING FINANCIAL STATEMENTS. THE ENTITIES ARE SUBJECT TO ROUTINE AUDITS BY TAXING JURISDICTIONS; HOWEVER, THERE ARE CURRENTLY NO AUDITS FOR ANY TAX PERIODS IN PROGRESS. SCHEDULE D, PART X, LINE 1 THE HOSPITAL HAS A NON-CONTRIBUTORY DEFINED BENEFIT PENSION PLAN FOR EMPLOYEES WHO MEET CERTAIN REQUIREMENTS AS TO AGE AND LENGTH OF SERVICE. THE PLAN PROVIDES PENSION BENEFITS THAT ARE BASED ON THE EMPLOYEE'S COMPENSATION DURING THEIR PERIOD OF CREDITED SERVICE. 1 1 X 1 X 1 X 1 1 0 1 1 354291 118050 236241 0.01140 2792240 909313 1882927 0.09110 3146531 1027363 2119168 0.10250 72905 72905 0.00350 1028741 1028741 0.04980 1101646 1101646 0.05330 4248177 1027363 3220814 0.15580 1 1647820 5761365 5880925 -119560 X 1 1 1 1 BARNESVILLE HOSPITAL ASSOCIATION INC 639 W MAIN ST BARNESVILLE OH 43713 WWW.BARNESVILLEHOSPITAL.COM X BARNESVILLE HOSPITAL ASSOCIATION 1 0 0 1 X X X X X X X X X 19 1 0 0 1 X SEE PART V, PAGE 8 X 1 19 1 SEE PART V, PAGE 8 0 1 X 100.000000000000 250.000000000000 X X X X 1 1 X X X X X 1 X HTTP://WWW.BARNESVILLEHOSPITAL.COM/SERVICES/PATIENT-FINANCIAL-SERVICES/ X HTTP://WWW.BARNESVILLEHOSPITAL.COM/SERVICES/PATIENT-FINANCIAL-SERVICES/ X HTTP://WWW.BARNESVILLEHOSPITAL.COM/SERVICES/PATIENT-FINANCIAL-SERVICES/ X X X X X X X 1 X 0 X X X X 1 X 0 0 BARNESVILLE HOSPITAL ASSOCIATION PART V, SECTION B, LINE 5: MET WITH FOCUS GROUPS FROM DIFFERENT COMMUNITIES (BARNESVILLE, BETHESDA, AND WOODSFIELD). IN ADDITION TO THE COMMUNITY FOCUS GROUPS, AN ADDITIONAL MEETING WAS HELD WITH INDIVIDUALS HAVING A SPECIAL KNOWLEDGE IN PUBLIC HEALTH, COMMUNITY ORGANIZATIONS, AND RESOURCES TO UTILIZE THEIR EXPERTISE AND TO SOLICIT THEIR FEEDBACK. COLLABORATING PARTNERS WITHIN THE COMMUNITY INCLUDED:- ADDICTION SERVICES OF EASTERN OHIO- ASTORIA PLACE NURSING FACILITY- BARNESVILLE CHIEF OF POLICE- BARNESVILLE EMS/FIRE DEPARTMENT- BARNESVILLE EXEMPTED VILLAGE SCHOOLS- BARNESVILLE HOSPITAL CHIEF OF STAFF- BARNESVILLE HOSPITAL MARKETING SPECIALIST- BARNESVILLE HOSPITAL PRESIDENT & CEO- BARNESVILLE HOSPITAL SOCIAL WORKER- BELMONT COUNTY 911- BELMONT COUNTY COMMISSIONER- BELMONT COUNTY EMERGENCY MANAGEMENT AGENCY- BELMONT COUNTY HEALTH DEPARTMENT- BELMONT COUNTY JOB AND FAMILY SERVICES- BELMONT PROFESSIONAL ASSOCIATES- COMMUNITY ACTION COMMISSION OF BELMONT COUNTY- EMERALD POINTE NURSING FACILITY- MENTAL HEALTH AND RECOVERY BOARD- MONROE COUNTY HEALTH DEPARTMENT- OHIO HILLS HEALTH SERVICES- PUBLIC RELATIONS & CORPORATE COMMUNICATIONS, WVUHS DIRECTOR- UNION LOCAL SCHOOLSA COMMUNITY MEETING WAS HELD IN BARNESVILLE TO GET MORE INPUT FROM THE PUBLIC, ESPECIALLY FROM ORGANIZATIONS WHO PROVIDE SOCIAL SERVICES TO INDIVIDUALS WITHIN THE SERVICE AREA OF THE HOSPITAL. REPRESENTATIVES FROM FIFTEEN DIFFERENT ORGANIZATIONS HELD DISCUSSIONS IN SMALL GROUPS TO COMPILE A WORKING LIST OF EXISTING RESOURCES, PROGRAMS, POLICIES, AND IDEAS TO ADDRESS EACH AREA OF CONCERN, IN ADDITION TO RAISING QUESTIONS AND PROVIDING INFORMATION AND PERSPECTIVE DURING OVERALL DISCUSSION OF THE SURVEY DATA RESULTS. THEY ALSO WORKED IN THEIR SMALL GROUPS AND AS PART OF A LARGER DISCUSSION TO FORMULATE SOME NEW SUGGESTIONS TO ADDRESS EACH HEALTH CONCERN. BARNESVILLE HOSPITAL ASSOCIATION PART V, SECTION B, LINE 11: THE HOSPITAL FACILITY IDENTIFIED THREE SIGNIFICANT NEEDS IN ITS MOST RECENTLY CONDUCTED CHNA. THE NEEDS & THE ACTION TAKEN BY THE HOSPITAL FACILITY TO ADDRESS THE NEEDS DURING 2019 ARE AS FOLLOWS:SUBSTANCE USE AND ABUSE: -BARNESVILLE HOSPITAL PARTNERS WITH CROSSROADS COUNSELING TO OPERATE AN ADDICTION CLINIC. -PROVIDED A DROP BOX IN THE HOSPITAL LOBBY TO ALLOW COMMUNITY MEMBERS A VEHICLE TO DISPOSE OF UNWANTED MEDICATIONS AND SYRINGES ON AN AS NEEDED BASIS. -PROVIDED SPACE FOR ALCOHOLIC ANONYMOUS TO MEET AT THE HOSPITAL. -SUPPORTED SEVERAL DRUG PROGRAMS AT THE LOCAL HIGH SCHOOL.-COLLABORATED THROUGH COMMUNITY AND EMS MEETINGS TO PROVIDE EDUCATION REGARDING NARCAN FOR COMMUNITY MEMBERS AND HEALTH CARE PROFESSIONALS AND TO PROVIDE NARCAN FREE OF CHARGE THROUGH THE PROJECT DAWN PROGRAM.OBESITY AND DIABETES: -CONDUCTED FITNESS SCREENINGS IN THE COMMUNITY (BODY COMPOSITION ANALYSIS, FLEXIBILITY TESTING, GRIP STRENGTH AND BLOOD PRESSURE). -FACILITATED A WEIGHT LOSS PROGRAM FOR EMPLOYEES TO PROMOTE WELLNESS; THIS INCLUDED INCENTIVES FOR YEARLY PHYSICALS, VOLUNTARY STAFF MONTHLY WEIGH-INS, PROMOTED HEALTHY EATING AND 5K RUN/WALKS.-HOSPITAL DIETICIAN OFFERED A HEALTH PROGRAM EMPHASIZING PROPER NUTRITION, THE IMPORTANCE OF EXERCISE AND THE BENEFITS OF SMOKING CESSATION. -OFFERED COMMUNITY WELLNESS PROGRAM ON TOPICS PERTINENT TO COMMUNITY MEMBERS.-FREE PICKLEBALL IN ST. CLAIRSVILLE AND BELMONT.MENTAL HEALTH: -DEVELOPED REFERRAL BROCHURE INCLUDING MENTAL HEALTH RESOURCES IN SERVICE AREA WHICH CAN BE PROVIDED TO PATIENTS AND FAMILY MEMBERS. ADDITIONALLY, REFERRED TO CROSSROADS COUNSELING WHEN A DRUG OR MENTAL HEALTH ISSUE AROSE IN ER.-EDUCATED CLINICAL STAFF AS TO THE ROLE A HOSPITAL'S MEDICAL SOCIAL WORKER CAN PLAY IN ASSISTING WITH APPROPRIATE REFERRALS FOR COUNSELING AND IN ASSISTING IN PSYCHIATRIC PLACEMENTS WHEN WARRANTED. -EDUCATED COMMUNITY ON SERVICES AVAILABLE AT BARNESVILLE HOSPITAL VIA NEW BROCHURES AND ACTIVE PROMOTION FROM OUR CLINICAL LEADERSHIP. BARNESVILLE HOSPITAL ASSOCIATION PART V, SECTION B, LINE 13B: EVERY SELF PAY PATIENT RECEIVES 20% OFF THEIR INVOICE WHETHER THEY ARE ELIGIBLE FOR THE FINANCIAL ASSISTANCE OR NOT. BARNESVILLE HOSPITAL ASSOCIATION PART V, SECTION B, LINE 15E: PATIENTS CAN FILL OUT THE FORM PROVIDED IN THE REGISTRATION PACKET, ONLINE, OR CALL THE FINANCIAL COUNSELOR FOR ASSISTANCE. BARNESVILLE HOSPITAL ASSOCIATION PART V, SECTION B, LINE 16J: FINANCIAL COUNSELOR PERSONALLY CALLS SELF PAY PATIENTS AND OFFERS THEM AN APPLICATION TO APPLY FOR FAP. BARNESVILLE HOSPITAL ASSOCIATION PART V, SECTION B, LINE 24: THE GROSS CHARGES FOR ANY INDIVIDUAL SERVICE ARE ALL THE SAME. SELF PAY PATIENTS RECEIVE A 20% DISCOUNT AND PATIENTS WITH ANY TYPE OF INSURANCE ARE GIVEN THE DISCOUNT NEGOTIATED IN THE CONTRACT. MEDICARE AND MEDICAID RECEIVE THE MEDICARE AND MEDICAID CONTRACTUALS. BARNESVILLE HOSPITAL ASSOCIATION, INC.: SCHEDULE H, PART V, LINE 7A:HTTP://WWW.BARNESVILLEHOSPITAL.COM/WP-CONTENT/UPLOADS/2020/03/CHNA-2020.PDF BARNESVILLE HOSPITAL ASSOCIATION, INC.: SCHEDULE H, PART V, LINE 10A:HTTP://WWW.BARNESVILLEHOSPITAL.COM/WP-CONTENT/UPLOADS/2020/03/CHNA-2020.PDF PART I, LINE 3C: IN ADDITION TO FPG, THE ORGANIZATION USES THE FOLLOWING CRITERIA TO DETERMINE ELIGIBILITY: MEDICAL INDIGENCY, INSURANCE STATUS, UNDERINSURANCE STATUS, AND RESIDENCY. ADDITIONALLY, EVERY SELF PAY PATIENT RECEIVES 20% OFF THEIR INVOICE WHETHER THEY ARE ELIGIBLE FOR THE FINANCIAL ASSISTANCE OR NOT. PART I, LINE 7: BARNESVILLE HOSPITAL ASSOCIATION CALCULATED THE COST OF FINANCIAL ASSISTANCE AND MEANS-TESTED GOVERNMENT PROGRAMS USING THE COST-TO-CHARGE RATIO DERIVED FROM SCHEDULE H, WORKSHEET 2, RATIO OF PATIENT CARE COST-TO CHARGES. PART I, LINE 7G: BARNESVILLE HOSPITAL ASSOCIATION INCLUDED COSTS ATTRIBUTABLE TO A PHYSICIAN CLINIC (BELMONT PROFESSIONAL ASSOCIATES) AS SUBSIDIZED HEALTH SERVICES ON LINE 7G. FOR 2019, THE AMOUNT WAS $1,028,741. PART I, LN 7 COL(F): 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 THAT 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 2: THE ORGANIZATION PROVIDES CARE WITHOUT CHARGE OR AT AMOUNTS LESS THAN ITS ESTABLISHED RATES TO PATIENTS WHO MEET CERTAIN CRITERIA UNDER ITS CHARITY CARE POLICY. BECAUSE THE ORGANIZATION DOES NOT COLLECT AMOUNTS DEEMED TO BE CHARITY CARE, THEY ARE NOT REPORTED AS REVENUE.OF THE ORGANIZATION'S TOTAL REPORTED EXPENSES (APPROXIMATELY $24,177,000 AND $24,200,000 DURING 2019 AND 2018 RESPECTIVELY), AN ESTIMATED $142,000 AND $133,000 AROSE FROM PROVIDING SERVICES TO CHARITY PATIENTS. THE ESTIMATED COSTS OF PROVIDING CHARITY SERVICES ARE BASED ON A CALCULATION WHICH APPLIES A RATIO OF COSTS TO CHARGES TO THE GROSS UNCOMPENSATED CHARGES ASSOCIATED WITH PROVIDING CARE TO CHARITY PATIENTS. THE RATIO OF COST TO CHARGES IS CALCULATED BASED ON THE ORGANIZATION'S TOTAL EXPENSES DIVIDED BY GROSS PATIENT SERVICE REVENUE. THE ORGANIZATION PARTICIPATES IN THE HOSPITAL CARE ASSURANCE PROGRAM (HCAP) WHICH PROVIDES FOR ADDITIONAL PAYMENTS TO HOSPITALS THAT PROVIDE A DISPROPORTIONATE SHARE OF UNCOMPENSATED SERVICES TO THE INDIGENT AND UNINSURED. HCAP REVENUE IS RECORDED IN NET PATIENT SERVICE REVENUE ON THE CONSOLIDATED STATEMENTS OF OPERATIONS AND CHANGES IN NET ASSETS. NET AMOUNTS RECEIVED THROUGH THIS PROGRAM TOTALED APPROXIMATELY $727,000 AND $764,000 FOR 2019 AND 2018, RESPECTIVELY.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 WILL LIMITED ABILITY TO PAY REGARDING FINANCIAL ASSISTANCE. FOR THIS REASON THE ORGANIZATION BELIEVES THAT 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 3: BARNESVILLE HOSPITAL ASSOCIATION DOES NOT ATTRIBUTE ANY BAD DEBT EXPENSE TO PATIENTS ELIGIBLE UNDER THE ORGANIZATION'S FINANCIAL ASSISTANCE POLICY (FAP), THEREFORE NO PORTION OF BAD DEBT ATTRIBUTABLE TO FAP-ELIGIBLE INDIVIDUALS IS CONSIDERED A COMMUNITY BENEFIT. PART III, LINE 4: THE FOOTNOTE TO THE ORGANIZATION'S FINANCIAL STATEMENTS DESCRIBING BAD DEBT EXPENSE IS LOCATED ON PAGE 9 OF THE ATTACHED FINANCIAL STATEMENTS UNDER NOTE "ACCOUNT RECEIVABLES AND CONTINUES ON PAGE 10 UNDER NOTE "PATIENT CARE SERVICE REVENUE." PART III, LINE 8: SURPLUS/ (SHORTFALL): THE COST WAS DETERMINED BY COST TO CHARGE RATIO ON THE COST REPORT. THIS IS AN AGING COMMUNITY AND THEY DESERVE THE BEST CARE AVAILABLE EVEN THOUGH WE HAVE TO SUPPLEMENT THE COST.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 DECEMBER 31, 2019 HOSPITAL STATEMENT OF REIMBURSABLE COST. PART III, LINE 9B: EVERY SELF PAY PATIENT RECEIVES A FINANCIAL AID PACKET WITH PAYMENT OPTIONS AND AN APPLICATION FOR FINANCIAL ASSISTANCE. AS A FOLLOW-UP THE FINANCIAL COUNSELOR PERSONALLY CONTACTS ANY SELF-PAY PATIENT PRESENTING DURING THE WEEK DAYS. PATIENTS ARE BILLED MONTHLY FOR BALANCES NOT COVERED BY INSURANCE, ELIGIBLE FOR FREE CARE OR ELIGIBLE FOR CHARITY DISCOUNTS. AFTER THREE MONTHLY STATEMENTS, IF NO PAYMENTS ARE RECEIVED OR THE PATIENT HAS NOT CONTACTED THE FINANCIAL COUNSELOR, A FINAL NOTICE IS SENT SAYING THEY ARE BEING SENT TO A SECONDARY BILLING COMPANY. THEY WILL TRY TO COLLECT FOR ANOTHER 90 DAYS. PART VI, LINE 2: WE GO INTO THE COMMUNITY AND PERFORM SURVEYS FOR NEEDS ASSESSMENT. WE ALSO GET INPUT FROM AREA PHYSICIANS, PATIENTS, STAFF AND OTHER BUSINESS FACILITIES. PART VI, LINE 3: THE PATIENT FINANCIAL COUNSELOR MEETS WITH ANYONE THAT PRESENTS IF THEY DO NOT HAVE INSURANCE. WE ALSO HAVE IT ON OUR WEBSITE AND POSTED IN THE HOSPITAL. OUR STAFF GOES INTO THE COMMUNITY AND SPEAKS TO DIFFERENT ORGANIZATIONS ABOUT OUR CHARITY AND FREE CARE POLICIES; TELLING THEM WHAT IS AVAILABLE. A FINANCIAL FORM IS GIVEN TO EACH SELF PAY PATIENT THAT REGISTERS AND THE FINANCIAL COUNSELOR'S TELEPHONE NUMBER IS ON ALL INVOICES TO THE PATIENTS. PART VI, LINE 4: BARNESVILLE HOSPITAL IS LOCATED IN AN ECONOMICALLY DEPRESSED APPALACHIAN AREA IN SOUTHEASTERN OHIO. WE SERVE SEVERAL COUNTIES AND THE COUNTY TO THE SOUTH OF US HAS NO HOSPITAL. IT IS AN AGING COMMUNITY WITH A LOT OF RESIDENTS UNDER THE FEDERAL POVERTY LEVEL. WE HAVE LITTLE INDUSTRY WITH THE HOSPITAL BEING THE LARGEST EMPLOYER IN THE COMMUNITY AND THE SCHOOLS ARE SECOND LARGEST. PART VI, LINE 5: OUR BOARD CONSISTS OF COMMUNITY MEMBERS AND THE MAJORITY OF OUR MEDICAL STAFF ARE FROM THE COMMUNITY. IT IS VERY IMPORTANT TO BARNESVILLE HOSPITAL TO PROMOTE THE HEALTH OF THE COMMUNITY BY ORGANIZING COMMUNITY HEALTH SCREENINGS AND EDUCATION FOR OUR COMMUNITY. WE HAVE AN AGING COMMUNITY AND EVERY EFFORT IS MADE TO ASSIST THEM WITH THEIR HEALTHCARE NEEDS. 0 BELMONT PROFESSIONAL ASSOCIATES 639 WEST MAIN STREET BARNESVILLE OH 43713 311352493 501C3 1028741 DEBT FORGIVENESS 1 X X X 0 0 0 0 0 0 0 0 0 DAVID HILLIARD DO BOARD MEMBER 160684 0 0 0 0 0 4312 0 22147 0 187143 0 0 0 DR SHAUN ROE BOARD MEMBER 0 313032 0 0 0 0 0 3220 0 33667 0 349919 0 0 FORM 990, PART VI, SECTION B, LINE 11B AFTER THE INITIAL REVIEW IT IS REVIEWED BY THE FINANCE COMMITTEE OF THE BARNESVILLE HOSPITAL BOARD OF TRUSTEES FOR REVIEW AND COMMENT. THEN IT IS APPROVED BY THE HOSPITAL BOARD. FORM 990, PART VI, SECTION B, LINE 12C THE WRITTEN CONFLICT OF INTEREST POLICY IS REGULARLY AND CONSISTENTLY MONITORED AND COMPLIANCE ENFORCED BY THE CORPORATE COMPLIANCE OFFICER WHO REPORTS TO THE BOARD. THE SCOPE OF THIS POLICY INCLUDES ALL EMPLOYEES PLUS CONTRACTED EMPLOYEES AND BOARD MEMBERS. THE POLICY IS IN PLACE TO DEFINE SITUATIONS THAT MIGHT OCCUR AND COULD RESULT IN A CONFLICT OF INTEREST BETWEEN AN EMPLOYEE OR BOARD MEMBER AND THE HOSPITAL. THE COVERED PERSONS ARE TO REFRAIN FROM SOLICITING HOSPITAL PATIENTS, PHYSICIANS, STAFF, ETC.; OR ANYTHING THAT COULD RESULT IN A PERSONAL GAIN FOR THE EMPLOYEE OR BOARD MEMBER OR THEIR IMMEDIATE FAMILIES. A SELF DISCLOSURE FROM COVERED PERSONS TO THE CORPORATE COMPLIANCE OFFICER IS REQUIRED ON ANY POTENTIAL CONFLICTS OF INTEREST. THE COVERED PERSONS ARE TO RECUSE THEMSELVES FROM PARTICIPATING IN ANY DELIBERATION OR DECISIONS ON SUCH TRANSACTIONS. THE CORPORATE COMPLIANCE OFFICER WILL REVIEW/RESEARCH THE CONFLICTS DISCLOSED. FORM 990, PART VI, SECTION B, LINE 15 BARNESVILLE HOSPITAL BOARD OF DIRECTORS HAS A COMPENSATION COMMITTEE THAT SETS THE COMPENSATION FOR THE CEO AND REVIEWS ALL PAY CHANGES FOR ANY OTHER EMPLOYEES WHETHER IT IS A SEPARATE INCREASE OR AN ALL EMPLOYEE INCREASE. THE BOARD USES A MANUAL PUBLISHED BY AN INDEPENDENT THIRD-PARTY AS A SOURCE TO DETERMINE REASONABLE COMPENSATION AMOUNTS FOR THE EXECUTIVE COMMITTEE AND ALL OTHER EMPLOYEES. PAY CHANGES ARE APPROVED OR REJECTED BY THE FULL BOARD AND IS DOCUMENTED IN THE BOARD OF DIRECTOR MINUTES. FORM 990, PART VI, SECTION C, LINE 19 THE 990 IS THE ONLY DOCUMENT MADE AVAILABLE TO THE PUBLIC. IF ANYONE WANTS TO REVIEW THE 990 THEY MAY CONTACT THE ADMINISTRATIVE OFFICE IN PERSON, BY TELEPHONE OR MAIL. WE WILL MAKE THE DOCUMENTS AVAILABLE AT THAT TIME. IF THE PERSON PRESENTS IN PERSON WE WILL TRY TO ACCOMODATE THEM THAT DAY. FORM 990, PART IX, LINE 11G OTHER PURCHASED SERVICES: PROGRAM SERVICE EXPENSES 1,850,794. MANAGEMENT AND GENERAL EXPENSES 335,145. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 2,185,939. SERVICE CONTRACTS: PROGRAM SERVICE EXPENSES 985,275. MANAGEMENT AND GENERAL EXPENSES 178,415. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 1,163,690. FORM 990, PART XI, LINE 9: PENSION RELATED CHANGES -8,407. FORM 990 PART XII, LINE 2C THE PROCESS HAS NOT CHANGED FROM THE PRIOR YEAR. BELMONT PROFESSIONAL ASSOCIATES INC 639 W MAIN ST BARNESVILLE OH 43713 311352493 PHYSICIAN PRACTICE OH 501(C)(3) LINE 3 BARNESVILLE HOSPITAL 1 BARNESVILLE HOSPITAL FOUNDATION 639 W MAIN ST BARNESVILLE OH 43713 113804786 SUPPORT FOR HOSPITAL OH 501(C)(3) LINE 12A, I N/A 0 BELMONT CO HEALTH SERVICES INC 639 W MAIN ST BARNESVILLE OH 43713 341566526 RETAIL PHARMACY OH BARNESVILLE HOSPITAL C 2650437 1434313 1.00000 1 0 1 1 0 0 0 0 0 0 0 0 0 0 0 0 0 1 0 0 BARNESVILLE HOSPITAL FOUNDATION C 385223 CASH VALUE BARNESVILLE HOSPITAL FOUNDATION Q 77000 CASH VALUE BELMONT PROFESSIONAL ASSOCIATES B 1028741 CASH VALUE