2019-09-06T13:53:54-05:00 2018-10-31 351178661 BLUE & CO LLC 500 N MERIDIAN ST SUITE 200 INDIANAPOLIS IN 46204 990 2017-11-01 344477047 HENRY COUNTY HOSPITAL INC HENR 4195924015 1600 EAST RIVERVIEW NAPOLEON OH 43545 KIMBERLY H BORDENKIRCHER CEO 4195924015 2019-09-06 1 MARGOT BURKE P01588992 3176334705 2019-09-05 38.109.186.2 2019-09-06 11:19:12 ED P DA39A3EE5E6B4B0D3255BFEF95601890AFD80709 B19D0506B86ED19F1A0FD2AFEEB91090E576B51F 2017 2019-02-21 02:37:17Z KIMBERLY H BORDENKIRCHER 1600 EAST RIVERVIEW NAPOLEON OH 43545 30880978 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 8 342 66 37730 -14218 112565 101643 29416638 29501903 5929 7500 1384741 1236703 30919873 30847749 96373 104239 0 0 14901230 16077488 0 0 0 15719119 15052902 30716722 31234629 203151 -386880 21976451 21647817 10931943 10949161 11044508 10698656 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 2461319 6021390 1. SURGERY--PROVIDING PRE-, INTRA-, AND POST PROCEDURE CARE FOR SURGICAL INPATIENTS AND OUTPATIENTS. INCLUDES GENERAL, ORTHOPEDIC, CATARACT, AND ENDOSCOPIC PROCEDURES. SURGICAL CARE SERVICES PERFORMED OVER 1,600 PROCEDURES IN 2018. 2388342 4386707 2. LABORATORY--PROVIDING SERVICES FOR IP AND OP, EXTENDED CARE FACILITIES, PHYSICIAN OFFICES AND AREA BUSINESSES. THE LABORATORY PROVIDED OVER 124,000 BILLED TESTS IN 2018. 1853086 2862761 3. EMERGENCY CARE SERVICES ARE PROVIDED CONTINUALLY TO PATIENTS PRESENTING WITH INJURIES AND ILLNESSES. TOTAL PATIENTS TREATED IN THE EMERGENCY DEPARTMENT TOTALED OVER 8,300 FOR 2018. 18837616 104239 17201023 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 103,000 BILLED DOSES TO PATIENTS THROUGH PHARMACY SERVICES, OVER 640 INPATIENT ADMISSIONS WITH OVER 1,800 DAYS OF CARE, 95 SWING BED PATIENTS WITH OVER 907 DAYS OF CARE, 202 BIRTHS, AND OVER 44,200 OUTPATIENT VISITS IN 2018. 18837616 104239 17201023 25540363 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 0 0 0 0 0 1 0 0 0 1 66 0 1 342 1 1 1 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 RICKY FRUTH BOARD MEMBER 2.00 0.00 X 0 0 0 JIM BURKHART BOARD MEMBER 2.00 0.00 X 0 0 0 BRENT GERKEN BOARD MEMBER 2.00 0.00 X 0 0 0 DR JOSEPH KRUEGER BOARD MEMBER-TERM BEGAN JAN'18 2.00 0.00 X 0 0 0 MARK ADAMS BOARD MEMBER-TERM BEGAN AUG'18 2.00 0.00 X 0 0 0 DR RACHEL BOSTELMAN BOARD MEMBER-TERM ENDED APR'18 2.00 0.00 X 0 0 0 DR EARNST HAFTKOWYCZ OB/GYN & BOD-TERM ENDED DEC'17 40.00 0.00 X 251469 0 18744 KIMBERLY BORDENKIRCHER CEO 40.00 0.00 X X 206573 0 29051 WILLIAM GRIMM CIO 40.00 0.00 X 130589 0 30887 PATRICIA FRANK CHIEF NURSING OFFICER 40.00 0.00 X 113565 0 31752 DR DOUGLAS LINDSEY PHYSICIAN 40.00 0.00 X 325578 0 38191 DR MORRIS SEAL PHYSICIAN 40.00 0.00 X 227377 0 20990 MICHELE JAKUTOWICZ PHARMACIST 40.00 0.00 X 128813 0 22932 SARAH HUBER MEDICAL IMAGING MANAGER 40.00 0.00 X 119847 0 31481 CHRISTIN MCMULLEN PHARMACIST 40.00 0.00 X 114594 0 11508 1618405 0 235536 10 0 1 0 EMCARE PHYSICIAN SERVICES 1717 MAIN ST STE 5200 DALLAS TX 75201 EMERGENCY PHYSICIAN SERVICES 964595 MERCY MEDICAL PARTNERS NORTHERN REGION 1400 EAST SECOND ST DEFIANCE OH 43512 ANESTHESIOLOGIST & PHYSICAL COVERAGE 789573 CREDIT SOLUTIONS LLC 2277 THUNDERSTICK DR STE 400 LEXINGTON KY 40505 COLLECTION AGENCY 313381 HOSPITAL CARE GROUP PC 6435 W JEFFERSON BLVD FORT WAYNE IN 46804 INPATIENT PHYSICIAN SERVICES (HOSPITALIS 291161 PHARMACY SYSTEMS INC 5050 BRADENTON AVE DUBLIN OH 43017 MANAGE PHARMACY DIRECTOR 239948 10 76105 25538 101643 PATIENT REVENUE 900099 29501903 29501903 29501903 106040 1632 104408 104408 104408 7500 0 7500 7500 7500 17079 31597 -14518 -14518 JOINT VENTURES 900099 549139 549139 NUTRITION/CAFETERIA 900099 139105 139105 340B REVENUE 900099 114436 114436 344133 306403 37730 1146813 30847749 30471881 37730 236495 X 104239 104239 667313 542611 124702 11884716 9663805 2220911 321969 261802 60167 2384115 1938593 445522 819375 666257 153118 58432 58432 53908 53908 5844444 4752286 1092158 208597 169616 38981 70199 57081 13118 1861557 1513686 347871 69681 56660 13021 43407 35295 8112 321264 321264 1170329 951628 218701 197114 160279 36835 DRUGS AND MEDICAL SUPPL 4371275 4371275 FRANCHISE FEE 419590 419590 NUTRITION/WELLNESS 230643 187542 43101 DUES AND SUBSCRIPTIONS 70004 56922 13082 62458 50786 11672 31234629 25540363 5694266 0 1342 1492 8229752 6844709 3849403 4029458 653211 657834 278268 244649 27163974 19705720 7774300 7458254 1114803 1215693 75372 1195728 21976451 21647817 2484538 3095423 8025532 7674064 273298 114883 148575 64791 10931943 10949161 X 10146615 9668589 847893 980067 50000 50000 11044508 10698656 21976451 21647817 X -386880 -44209 85237 X X 0 1 X 1 0 X 0 0 0 0 0 0 0 0 1 3417 3417 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 153751 153751 18656286 13006469 5649817 7981638 6699251 1282387 372299 372299 7458254 INVESTMENT IN JOINT VENTURE 1215693 C 1215693 BOARD DESIGNATED ASSETS 24076 DONOR RESTRICTED ASSETS 50000 DEPOSITS 1000 CLINIC RENT RECEIVABLE 1100 THIRD PARTY RECEIVABLE 1119552 1195728 DUE TO/FROM RELATED PARTIES 64791 64791 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, 2018 AND 2017, 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 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 0 320 709432 1054552 0 0.00000 2128 4651784 2505643 2146141 0.06870 2448 5361216 3560195 2146141 0.06870 112630 58498 180 58318 0.00190 1 2848 2848 0.00010 1590 526128 411022 115106 0.00370 6632 13405 13405 0.00040 120853 600879 411202 189677 0.00610 123301 5962095 3971397 2335818 0.07480 20 23497 22473 22473 0.00070 1 300 966 966 0.00000 21 23797 23439 23439 0.00070 1 2239044 7364592 10847408 -3482816 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 X 16 1 0 1 1 X SEE PART V SUPPLEMENTAL FACILITY INFO X 1 16 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 THREE AREAS:1. RISK FACTORS FOR OBESITY - INCREASE ACCESS TO AFFORDABLE HEALTHY FOOD, INCREASE NUTRITION EDUCATION, EXPAND THE AVAILABILITY OF AND PARTICIPATION IN PHYSICAL ACTIVITY & PHYSCIAL EDUCATION AND ENGAGE COMMUNITY STAKEHOLDERS AS PARTNERS IN THE CREATION & SUSTAINABILITY OF A HEALTHY COMMUNITY. IN 2018, THE COMMUNITY WELCOMED AN ADDITIONAL GYM LOCATION WITHIN THE COMMUNITY, ANYTIME FITNESS. NUTRITION EDUCATION CONTINUED WITHIN THE FOUR COUNTY SCHOOLS FROM KINDERGARTEN-4TH GRADE. 5TH GRADERS AT THE AREA SCHOOLS LEARN ABOUT THE BENEFITS OF PHYSICAL ACTIVITY BY PARTICIPATING IN A COMMUNITY-WIDE EXERCISE CHALLENGE HOSTED BY THE UNITED WAY OF HENRY COUNTY, COMING ALIVE. IN ADDITION, ALL AREA ELEMENTARY STUDENTS HAVE CONTINUAL ACCESS TO GONOODLE, A PROGRAM THAT COMBINES LEARNING WITH PHYSICAL ACTIVITY.2. HEALTHCARE ACCESS & COST - HELP MORE HENRY COUNTY RESIDENTS OBTAIN HEALTH INSURANCE COVERAGE, INCREASE THE NUMBER OF PRIMARY CARE PROVIDERS AVAILABLE IN HENRY COUNTY, INCREASE LINKAGES AMONG PRIMARY CARE PROVIDER & COMMUNITY AGENCIES & ORGANIZATIONS, CONNECT HENRY COUNTY RESIDENTS WITH PRIMARY CARE PROVIDERS & HELP RESIDENTS USE HEALTH INSURANCE & HEALTH CARE SERVICES MORE EFFECTIVELY. IN 2018, HENRY COUNTY HOSPITAL BEGAN TO RECRUIT FOR AN ADDITIONAL FAMILY PRACTICE PHYSICIAN. THE HENRY COUNTY HEALTH DEPARTMENT CONTINUED PROMOTING THE SERVICES OF A COMMUNITY HEALTH WORKER THROUGH THE PATHWAY PROGRAM, WHOSE PRIMARY JOB RESPONSIBILITY IS TO HELP RESIDENTS LIVE A HEALTHIER LIFE. THEY CAN CONNECT YOU TO COMMUNITY RESOURCES, PROVIDE SUPPORT AND BASIC HEALTH EDUCATION, MAKE SURE YOU GET TO THE DOCTOR, AND PROVIDE INFORMATION BASED ON YOUR UNIQUE NEEDS.3. BEHAVIORAL HEALTH ISSUES - INCREASE THE NUMBER OF HENRY COUNTY SUICIDE SURVIVORS WHO GET INTO TREATMENT TO 51% BY 2018, PRIMARY CARE PROVIDERS IN HENRY COUNTY WILL PERFORM A DEPRESSION SCREENING ON 51% OF THEIR PATIENTS BY 2018, & DECREASE YOUTH WHO "FELT SAD OR HOPELESS" ALMOST EVERY DAY FOR 2 WEEKS OR MORE IN A ROW TO LESS THAN 15% BY 2018. HENRY COUNTY HOSPITAL SENDS A STAFF REPRESENTATIVE TO THE SUICIDE PREVENTION MEETING HOSTED BY NAMI. IN ADDITION, THE NORTHWEST OHIO L.O.S.S. TEAM CONTINUED TO WORK WITH LOCAL LAW ENFORCEMENT AND WAS PRESENT AT THE SCENE OF EVERY SUICIDE OR ATTEMPTED SUICIDE TO SUPPORT THE VICTIMS' FAMILIES. 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: IN ORDER TO HELP COMBAT RISK FACTORS OF OBESITY HENRY COUNTY HOSPITAL SPONSORS AND PARTICIPATES IN A VARIETY OF COMMUNITY EVENTS AT WHICH TIME HEALTHY ACTIVITY AND GOOD NUTRITION IS PROMOTED. THE BELOW EVENTS ARE EXAMPLES: KIDZ FEST: PRESENTING SPONORS. OFFERED HEALTHY EATING INFORMATION, BUILD YOUR OWN GRANOLA ACTIVITY AND OBSTACLE COURSES. HENRY COUNTY RELAY FOR LIFE - CORPORATE SPONSOR. OFFERED INFORMATION ON CANCER PREVENTION AND DISPLAYED A LARGE INFLATABLE COLON THAT ALLOWED FOR ATTENDEES TO WALK THROUGH AND SEE WHAT COLON CANCER LOOKS LIKE INTERNALLY. SYMPHONY OF TREES - PARTICIPATE BY HAVING TWO MEMBERS OF THE STAFF SIT ON THE SYMPHONY OF TREES BOARD. THE SYMPHONY OF TREES IS A NON-PROFIT ORGANIZATION THAT PROVIDES FUNDS TO PROTECT AND SUPPORT THE CHILDREN OF NORTHWEST OHIO THROUGH THREE BENEFITTING AGENCIES; HENRY COUNTY CASA, THE CENTER FOR CHILD AND FAMILY ADVOCACY AND HENRY COUNTY HOSPITAL. NAPOLEON TRIATHALON AND OTHER RACE SPONSORSHIPS - PREMIER SPONSOR OF THE NAPOLEON TRIATHALON, CORPORATE SPONSOR FOR OTHER LOCAL RACES. UNITED WAY COMING ALIVE - COMING ALIVE IS A COMMUNITY WIDE EXERCISE PROGRAM AND HENRY COUNTY HOSPITAL IS A PROUD SPONSOR AND PARTICIPANT. HENRY COUNTY HOSPITAL'S FITNESS INSTRUCTOR ATTENDS AREA SCHOOLS AND PROVIDES EDUCATION TO THE STUDENTS REGARDING THE IMPORTANCE OF PHYSICAL ACTIVITY. AFTER SCHOOL PROGRAMMING - FITNESS INSTRUCTORS AND REGISTERED DIETITIANS EMPLOYED BY HENRY COUNTY HOSPITAL PARTICIPATED IN AN AFTER SCHOOL PROGRAM WHERE THEY DISCUSSED THE IMPORTANCE OF EXERCISE AS WELL AS PROVIDED COOKING DEMONSTRATIONS AND SAMPLES. AMERICAN HEART ASSOCIATION HEART WALK SPONSOR. SPONSORED AND PROVIDED STAFF TO LEAD THE WARM UP. BLESSINGS IN A BACKPACK - PURCHASED BACKPACKS TO BE USED BY A LOCAL SCHOOL DISTRICT THAT SENDS HOME FOOD ON FRIDAY FOR CHILDREN IN NEED. SPONSORSHIP OF LOCAL GOLF OUTINGS. IN ORDER TO IMPROVE HEALTHCARE ACCESS HENRY COUNTY HOSPITAL PARTICIPATED IN THE FOLLOWING: FREE COMMUNITY HEALTH SCREENINGS - OFFERED 100 FREE BLOOD DRAWS THAT INCLUDED LIPID PROFILES AND METABOLIC PANELS. FREE MONTHLY BLOOD PRESSURE SCREENINGS AT HENRY COUNTY SENIOR CENTER AND RIVERVIEW TERRACE APARTMENTS (SENIOR LIVING FACILITY). FREE USE OF LANGUAGE LINE SERVICES. FREE BLOOD PRESSURE SCREENINGS AT LOCAL HEALTH FAIRS AND THE HENRY COUNTY FAIR. HENRY COUNTY TRANSPORTATION NETWORK - WORK WITH THE HENRY COUNTY TRANSPORTATION NETWORK TO PROVIDE FREE TRANSPORTATION FOR PATIENTS TO AND FROM THE HENRY COUNTY HOSPITAL. SPORTS PHYSICALS - PROVIDE PHYSICALS AT LOCAL SCHOOLS AND DONATE THE MONEY BACK TO THE SCHOOLS. PRENATAL CLASSES - PROVIDE FREE PRENATAL CLASSES, BREASTFEEDING CLASSES AND LACTATION CONSULTATIONS. POISON PREVENTION WEEK - HOST AREA PRESCHOOLS AT THE HOSPITAL WHERE AN EDUCATIONAL PRESENTATION IS GIVEN, HANDOUTS AND GAMES. THEN THE CHILDREN ARE TAKEN ON TOURS TO FAMILIARIZE THEM WITH THE HOSPITAL SO IF THEY EVER HAVE TO COME THEY FEEL COMFORTABLE. 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, 2018 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 GOALS WERE DETERMINED: RISK FACTORS FOR OBESITY GOAL: PROMOTE HEALTHY LIFESTYLES TO REDUCE OBESITY AND ITS RISK FACTORS AMONG HENRY COUNTY RESIDENTS. BEHAVIORAL HEALTH ISSUES GOAL: TO PROTECT THE HEALTH, SAFETY AND QUALITY OF LIFE OF HENRY COUNTY RESIDENTS BY ENSURING ACCESS TO BEHAVIORAL HEALTH SERVICES. HEALTHCARE ACCESS AND COST GOAL: TO IMPROVE HENRY COUNTY RESIDENTS' ACCESS TO COMPREHENSIVE, QUALITY AND AFFORDABLE HEALTH CARE SERVICES. INDIVIDUAL WORK GROUPS HAVE BEEN ASSIGNED TO WORK ON EACH OF THE ABOVE GOALS. THESE WORK GROUPS DEVELOP AND CARRY OUT TACTICS THAT HELP IMPACT THE SPECIFIC GOAL THEY HAVE BEEN ASSIGNED. THE OBJECTIVES/PROGRAMS THAT WE ARE UTILIZING TO MEET THESE GOALS ARE CURRENTLY:- SUPPORT AND IMPROVE THE SUMMER NUTRITION (AND PHYSICAL ACTIVITY) PROGRAM SUPPORT HENRY COUNTY HOSPITAL IN ITS JOURNEY TO BECOME A BABY - FRIENDLY HOSPITAL (WHICH FOCUSES ON BREASTFEEDING).- ENCOURAGE/ENGAGE WORKPLACE WELLNESS THROUGHOUT THE COMMUNITY BY ASSISTING LOCAL ORGANIZATIONS IN BECOMING FIT-FRIENDLY (AMERICAN HEART ASSOCIATION'S WORKPLACE WELLNESS PROGRAM). IN ADDITION, FEEDBACK IS GATHERED FROM PATIENTS USING PROFESSIONAL RESOURCE CONSULTANTS SURVEYING SERVICES. THIS FEEDBACK GIVES HENRY COUNTY EMPLOYEES AN OPPORTUNITY TO BEST MEET THE PATIENTS' NEEDS. THE USE OF FOCUS GROUPS IS ALSO UTILIZED TO GATHER INFORMATION FROM SPECIFIC COMMUNITY GROUPS AND PATIENTS OF SPECIFIC SERVICE LINES. 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 OFHENRY COUNTY IS NEARLY 27,000. THE RACIAL MAKEUP OF THE COUNTY WAS 97% WHITE, 0.8% BLACK OR AFRICAN AMERICAN, 0.5% NATIVE AMERICAN, 0.5% ASIAN, 1.2% FROM OTHER RACES, AND 1.1% FROM TWO OR MORE RACES. 7.8% OF THE POPULATION WERE HISPANIC OR LATINO OF ANY RACE. 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 $68,966. MALES HAD A MEDIAN INCOME OF $45,809 VERSUS $32,502 FOR FEMALES. THE PER CAPITA INCOME FOR THE COUNTY WAS $27,325. ABOUT 5.30% OF FAMILIES AND 9.00% OF THE POPULATION WERE BELOW THE POVERTY LINE, INCLUDING 10.1% OF THOSE UNDER AGE 18 AND 4.20% 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 TWO OF THE FOUR 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, LUTHERAN HOME STRATEGIC VISIONING COMMITTEE, LUTHERAN HOME AT NAPOLEON - MEETING OF THE MINISTRY BOARD OF DIRECTORS, 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 104239 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 EARNST HAFTKOWYCZ OB/GYN & BOD-TERM ENDED DEC'17 251469 0 0 0 0 0 7432 0 11312 0 270213 0 0 0 KIMBERLY BORDENKIRCHER CEO 206097 0 0 0 476 0 5972 0 23079 0 235624 0 0 0 WILLIAM GRIMM CIO 130589 0 0 0 0 0 2639 0 28248 0 161476 0 0 0 DR DOUGLAS LINDSEY PHYSICIAN 325578 0 0 0 0 0 8000 0 30191 0 363769 0 0 0 DR MORRIS SEAL PHYSICIAN 227377 0 0 0 0 0 6774 0 14216 0 248367 0 0 0 MICHELE JAKUTOWICZ PHARMACIST 128813 0 0 0 0 0 3793 0 19139 0 151745 0 0 0 SARAH HUBER MEDICAL IMAGING MANAGER 119847 0 0 0 0 0 3565 0 27916 0 151328 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 2420000 10680000 9952500 135325 592175 2011 1 0 1 1 A 0 0 0 0 0 0 0 A 0 1 0 0 0 0 0 0 0 A 1 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 CEO. THE SCOPE OF THIS POLICY INCLUDES BOARD MEMBERS AND THE LEADERSHIP TEAM. 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 2,283,997. MANAGEMENT AND GENERAL EXPENSES 524,903. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 2,808,900. PHYSICIAN SERVICES: PROGRAM SERVICE EXPENSES 2,468,289. MANAGEMENT AND GENERAL EXPENSES 567,255. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 3,035,544. FORM 990, PART XI, LINE 9: INTEREST IN FOUNDATION NET ASSETS 132,174. TRANSFER OF AUXILIARY NET ASSETS TO FOUNDATION -46,937. FORM 990, PART XII, LINE 2C: THE PROCESS HAS NOT CHANGED FROM THE PREVIOUS 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 349323 209117 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 104239 CASH HENRY COUNTY HOSPITAL FOUNDATION INC C 76105 CASH