2018-05-14T15:57:33-05:00 2017-06-30 381357951 PLANTE & MORAN PLLC 250 S High St Suite 100 Columbus OH 43215 990 2016-07-01 274385692 AVITA HEALTH SYSTEM AVIT 4194681244 269 PORTLAND WAY SOUTH GALION OH 44833 D ERIC DRAIME CFO 4194681244 2018-05-14 1 Bernie Ostrowski P00366367 6148493000 2018-05-04 2016 2022-09-23 18:48:47Z JERRY MORASKO 269 PORTLAND WAY SOUTH GALION OH 44833 55305328 0 X N/A X 2010 OH TO IMPROVE THE HEALTH AND WELL-BEING OF THOSE WE SERVE. 17 17 304 17 0 0 0 0 44442818 53983917 0 4400 1317011 1317011 45759829 55305328 0 0 0 0 30005107 36589837 0 0 0 15754722 18715491 45759829 55305328 0 0 0 0 0 0 0 0 TO IMPROVE THE HEALTH AND WELL-BEING OF THOSE WE SERVE. 0 0 55305328 0 55300928 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. 55305328 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 1 184 0 1 304 1 0 0 0 0 0 0 0 0 0 0 X 17 17 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 DOUGLAS SCHILLING CHAIR 0.10 0.10 X X 0 0 0 KYMBERLY FOX CO-VICE CHAIR 0.10 0.10 X X 0 0 0 JOSEPH SHADEED CO-VICE CHAIR 0.10 0.10 X X 0 0 0 REX CRAMER TREASURER 0.10 0.10 X X 0 0 0 LINDA CHAMBERS SECRETARY 0.10 0.10 X X 0 0 0 JEFFERY A UNDERWOOD DIRECTOR 0.10 0.10 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 CHARLES WALKER DIRECTOR 0.10 0.10 X 0 0 0 PHILLIP BROWN DIRECTOR 0.10 0.10 X 0 0 0 KAY MCDONALD DIRECTOR 0.10 0.10 X 0 0 0 JASON MCMULLEN DIRECTOR 0.10 0.10 X 0 0 0 ERIC GEYER DIRECTOR 0.10 0.30 X 0 0 0 DONALD BARR DIRECTOR 0.10 0.10 X 0 0 0 SHERRI CLEVENGER DIRECTOR 0.10 0.10 X 0 0 0 BOYD EPPERSON DIRECTOR 0.10 0.30 X 0 0 0 MARK SCHNEIDER DIRECTOR 0.10 0.10 X 0 0 0 JERRY MORASKO CEO/EX-OFFICIO PRESIDENT 0.10 0.70 X X 498470 0 47050 D ERIC DRAIME CFO 0.10 0.70 X X 259664 0 0 MYLES CREED DIRECTOR OF PHYSICIAN 40.00 0.00 X 165788 0 4482 SHIRLEY FITZ VP PATIENT CARE 40.00 0.00 X 164579 0 1898 TRACI OSWALD VP HUMAN RESOURCES 40.00 0.00 X 166191 0 1898 SHELLIE BURGIN VP PHYSICIAN SERVICES 40.00 0.00 X 178425 0 1898 DR JAMES HEDDLESON PHYSICIAN 40.00 0.00 X 917088 0 1980 ANDREW DANIELS COO 40.00 0.00 X 174956 0 3546 2525161 0 62752 17 1 1 0 MID-AMERICAN THERAPY 7652 EAGLE DRIVE FINDLAY OH 45840 PHYSICAL THERAPY 1769564 GALION ANESTHESIA 1105 DEVONWOOD ROAD MANSFIELD OH 44907 ANESTHESIA 1724150 ALLIANCE HEALTHCARE SERVICES PO BOX 96485 CHICAGO IL 60693 IMAGING SERVICES 258846 STEVEN CLAUS 800 FORT PICKENS ROAD 904 PENSACOLA BEACH FL 32561 HOSPITALIST 188639 CDW GOVERNMENT INC 75 REMITTANCE DRIVE SUITE 1515 CHICAGO IL 60675 COMPUTER SERVICES 172912 12 MANAGEMENT FUNCTION 561000 53983917 53983917 53983917 4400 4400 EHR TECHNOLOGY INCOME 900099 1317011 1317011 1317011 55305328 55300928 0 4400 841610 841610 13914564 13914564 2853542 2853542 13380898 13380898 5599223 5599223 321588 321588 748820 748820 3009259 3009259 525364 525364 6181324 6181324 3955784 3955784 2510282 2510282 102540 102540 1030560 1030560 7140 7140 PHYSICIAN RECRUITING 185017 185017 MEDICAL SUPPLIES 138371 138371 BAD DEBT EXPENSE -558 -558 55305328 55305328 0 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 CEO/EX-OFFICIO PRESIDENT 453470 0 45000 0 0 0 45000 0 2050 0 545520 0 0 0 D ERIC DRAIME CFO 226004 0 33660 0 0 0 0 0 0 0 259664 0 0 0 MYLES CREED DIRECTOR OF PHYSICIAN 120148 0 45640 0 0 0 0 0 4482 0 170270 0 0 0 SHIRLEY FITZ VP PATIENT CARE 145538 0 19041 0 0 0 0 0 1898 0 166477 0 0 0 TRACI OSWALD VP HUMAN RESOURCES 145012 0 21179 0 0 0 0 0 1898 0 168089 0 0 0 SHELLIE BURGIN VP PHYSICIAN SERVICES 155473 0 22952 0 0 0 0 0 1898 0 180323 0 0 0 DR JAMES HEDDLESON PHYSICIAN 403082 0 514006 0 0 0 0 0 1980 0 919068 0 0 0 ANDREW DANIELS COO 0 0 0 0 174956 0 0 0 3546 0 178502 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, Lines 4a-b 457(F)- SUBJECT TO SUBSTANTIAL RISK OF FORFEITURE JERRY MORASKO- $45,000 ANDREW DANIELS RECEIVED SEVERANCE PAYMENTS IN THE AMOUNT OF $174,956. 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 2016. 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 5913525 FORGIVENESS OF PAYABLE GALION COMMUNITY HOSPITAL L 52454792 MANAGEMENT FEE GALION COMMUNITY HOSPITAL R 15860927 FORGIVENESS OF PAYABLE GALION COMMUNITY HOSPITAL S 85333 FORGIVENESS OF PAYABLE