2017-11-13T14:48:39-06:00 2016-12-31 381357951 PLANTE & MORAN PLLC 250 S High St Suite 100 Columbus OH 43215 990 2016-01-01 341935236 LIMA MEMORIAL PROFESSIONAL CORPORATION LIMA 4192283335 1001 BELLEFONTAINE AVENUE LIMA OH 45804 JOHN T FISCHBACH VICE PRESIDENT/CFO 4192283335 2017-10-30 1 Bernie Ostrowski P00366367 6148493000 2017-09-27 74.113.40.52 2017-10-30 11:57:20 ED P DA39A3EE5E6B4B0D3255BFEF95601890AFD80709 CDA108602048A852A3C7A9C68094104E2D92ED46 2016 2017-02-10 21:41:12Z MICHAEL D SWICK 1001 BELLEFONTAINE AVENUE LIMA OH 45804 22208637 0 X WWW.DOCLMPC.ORG X 2000 OH WE ARE HERE TO IMPROVE THE QUALITY OF LIFE IN OUR COMMUNITIES THROUGH COMPREHENSIVE HEALTH SERVICES. 14 2 288 2 3150 0 0 0 19175335 22202811 477 388 23797 5438 19199609 22208637 10000 10000 0 0 22165814 26469186 0 0 0 6286613 8249905 28462427 34729091 -9262818 -12520454 4438576 6305101 90499683 104831132 -86061107 -98526031 WE ARE HERE TO IMPROVE THE QUALITY OF LIFE IN OUR COMMUNITIES THROUGH COMPREHENSIVE HEALTH SERVICES. 0 0 33024289 10000 22205099 PROVISION OF HEALTH CARE SERVICES TO THE COMMUNITY REGARDLESS OF ABILITY TO PAY. 33024289 1 0 0 0 0 0 0 0 0 0 1 0 0 0 1 1 0 1 0 0 0 0 0 0 0 0 0 1 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 1 1 1 0 0 1 54 0 1 288 1 1 1 0 0 0 0 0 0 0 0 0 X 14 2 0 0 0 0 0 0 0 1 1 0 0 1 1 1 1 1 1 0 0 0 X MERI FOSTER 4192265197 1001 BELLEFONTAINE AVENUE LIMA OH 45804 FRANK BALDAUF MD CHAIRMAN (SEE SCH J) 40.00 0.00 X X 160024 0 23028 KERMIT F STROH BOARD MEMBER (SEE SCH J) 1.00 1.00 X 0 0 0 KHA H TRAN MD VP/CMO/TREASURER (SEE SCH J) 20.00 20.00 X X 0 292811 108309 CHERYL WAYMAN PA-C SECRETARY (SEE SCH J) 40.00 0.00 X X 143421 0 20661 G ALLEN BRYANT BOARD MEMBER (SEE SCH J) 40.00 0.00 X 296897 0 24291 JEREMY HEFFNER MD BOARD MEMBER (SEE SCH J) 40.00 0.00 X 566908 0 48646 SUSAN KAUFMAN BOARD MEMBER (SEE SCH J) 40.00 0.00 X 300212 0 27167 JENNIFER MAAG BOARD MEMBER (SEE SCH J) 40.00 0.00 X 168021 0 34775 JOHN H JOHNSON BOARD MEMBER (SEE SCH J) 1.00 1.00 X 0 0 0 MASROOR ABRO MD BOARD MEMBER (SEE SCH J) 40.00 0.00 X 420876 0 48646 MICHAEL KERRIGAN CNP BOARD MEMBER 40.00 0.00 X 108080 0 25956 ERIC MILLER DPM BOARD MEMBER (SEE SCH J) 40.00 0.00 X 205259 0 28441 JOHN OEHLER DO BOARD MEMBER (SEE SCH J) 40.00 0.00 X 174250 0 5227 MELODY STEWART-CYRUS MD BOARD MEMBER (SEE SCH J) 40.00 0.00 X 156916 0 18157 DAVID ROSI THRU 616 BOARD MEMBER (SEE SCH J) 40.00 0.00 X 297373 0 20341 MICHAEL D SWICK PRESIDENT/CEO (SEE SCH J) 6.00 34.00 X 0 579615 246377 ROBERT E ARMSTRONG JR VICE PRESIDENT/COO (SEE SCH J) 10.00 30.00 X 0 343323 115851 JOHN T FISCHBACH VP OF FINANCE/CFO (SEE SCH J) 1.00 39.50 X 0 249220 54109 PIERRE BAMDAD MD PHYSICIAN (SEE SCH J) 40.00 0.00 X 664582 0 39357 MEHRAN ARABPOUR MD PHYSICIAN (SEE SCH J) 40.00 0.00 X 707907 0 61896 PAUL N ANIKE MD PHYSICIAN (SEE SCH J) 40.00 0.00 X 705606 0 61896 VENKAT R BATTULA MD PHYSICIAN (SEE SCH J) 40.00 0.00 X 663569 0 57357 PAMELA R GARDNER PHYSICIAN (SEE SCH J) 40.00 0.00 X 610840 0 48280 6350741 1464969 1118768 58 0 1 0 LOCUMTENENSCOM PO BOX 405547 ATLANTA GA 30384 LOCUM TENENS 971839 WEATHERBY LOCUMS INC PO BOX 972633 DALLAS TX 75397 LOCUM TENENS 255171 VEIN CARE CONSULTANTS 229 S CHILLICOTHE STREET PLAIN CITY OH 43064 PHYSICIAN SERVICES 233938 ECLINICALWORKS LLC 110 TURNPIKE ROAD SUITE 308 WESTBORO MA 01581 EMR SOFTWARE 196382 PULMONARY & CRITICAL CARE SPECIALISTS 1661 HOLLAND ROAD 200 MAUMEE OH 43537 PHYSICIAN SERVICES 190100 7 PATIENT SERVICE REV 621110 22202811 22202811 22202811 388 388 BILLING SERVICES 561000 3150 3150 PURCHASE DISCOUNTS 621110 2288 2288 5438 22208637 22205099 3150 388 X 10000 10000 3026757 3026757 19036615 18155736 880879 509335 483420 25915 2731813 2553998 177815 1164666 1087386 77280 4333499 4104073 229426 160326 79739 80587 393896 288964 104932 239605 216365 23240 82673 67860 14813 62255 54170 8085 273952 273952 MEDICAL SUPPLIES 1174656 1174631 25 BAD DEBT EXPENSE 1008422 1008422 EDUCATION & REWARDS 145917 139949 5968 MANAGED CARE ORG 4604 4604 370100 294263 75837 34729091 33024289 1704802 0 632194 622515 906272 1297767 2024548 2426159 187263 1090275 346001 538432 1130478 800525 342298 329953 4438576 6305101 2049347 2964308 88450336 101866824 90499683 104831132 X -86061107 -98526031 -86061107 -98526031 4438576 6305101 X -12520454 55530 X X 0 1 X 1 0 X 30476 30476 1100002 800525 299477 329953 advances from lima memorial joint operating co. 99603340 PENSION FUND 457B & F 1297767 DEFERRED TAX LIABILITY 965717 101866824 X Part X, Line 2: THE HEALTH SYSTEM, LIMA MEMORIAL HOSPITAL, LIMA MEMORIAL PROFESSIONAL CORPORATION, LIMA MEMORIAL HOSPITAL FOUNDATION, AND LIMA MEMORIAL HOSPITAL AUXILIARY ARE NOT-FOR-PROFIT CORPORATIONS AS DESCRIBED IN SECTION 501(C)(3) OF THE INTERNAL REVENUE CODE (THE "CODE") AND ARE EXEMPT FROM FEDERAL INCOME TAXES PURSUANT TO SECTION 501(A) OF THE CODE. ELM TREE FOUNDATION, THE FOR-PROFIT SUBSIDIARY, IS A TAXABLE CORPORATION. ELM TREE FOUNDATION HAD NET OPERATING LOSS CARRYFORWARDS OF $763,936 AND $657,739 ON ITS FILED INCOME TAX RETURNS IN 2016 AND 2015, RESPECTIVELY. ACCOUNTING PRINCIPLES GENERALLY ACCEPTED IN THE UNITED STATES OF AMERICA REQUIRE MANAGEMENT TO EVALUATE TAX POSITIONS TAKEN BY THE HEALTH SYSTEM AND TO RECOGNIZE A TAX LIABILITY IF THE HEALTH SYSTEM HAS TAKEN AN UNCERTAIN POSITION THAT MORE LIKELY THAN NOT WOULD NOT BE SUSTAINED UPON EXAMINATION BY THE INTERNAL REVENUE SERVICE OR OTHER APPLICABLE TAXING AUTHORITIES. 1 LIMA MEMORIAL FOUNDATION 1001 BELLEFOUNTAINE AVENUE LIMA OH 45804 341707570 501(C)(3) 10000 CAPSTONE SPONSORSHIP 1 0 Part I, Line 2: GRANTS WERE PAID TO RELATED TAX-EXEMPT ENTITY TO SUPPORT ITS MISSION. THIS IS MONITORED INTERNALLY. THE LIMA MEMORIAL HOSPITAL SYSTEM MONITORS BOTH LIMA MEMORIAL PROFESSIONAL CORPORATION AND LIMA MEMORIAL FOUNDATION. 0 1 0 0 0 0 0 0 0 FRANK BALDAUF MD CHAIRMAN (SEE SCH J) 142978 0 17046 0 0 0 4871 0 18157 0 183052 0 0 0 KHA H TRAN MD VP/CMO/TREASURER (SEE SCH J) 0 202210 0 84376 0 6225 0 78738 0 29571 0 401120 0 0 CHERYL WAYMAN PA-C SECRETARY (SEE SCH J) 123893 0 19528 0 0 0 4320 0 16341 0 164082 0 0 0 G ALLEN BRYANT BOARD MEMBER (SEE SCH J) 296897 0 0 0 0 0 7950 0 16341 0 321188 0 0 0 JEREMY HEFFNER MD BOARD MEMBER (SEE SCH J) 411881 0 155027 0 0 0 25950 0 22696 0 615554 0 0 0 SUSAN KAUFMAN BOARD MEMBER (SEE SCH J) 216832 0 83380 0 0 0 9010 0 18157 0 327379 0 0 0 JENNIFER MAAG BOARD MEMBER (SEE SCH J) 131884 0 36137 0 0 0 5204 0 29571 0 202796 0 0 0 MASROOR ABRO MD BOARD MEMBER (SEE SCH J) 395876 0 25000 0 0 0 25950 0 22696 0 469522 0 0 0 ERIC MILLER DPM BOARD MEMBER (SEE SCH J) 198390 0 6869 0 0 0 5745 0 22696 0 233700 0 0 0 JOHN OEHLER DO BOARD MEMBER (SEE SCH J) 165571 0 8679 0 0 0 5227 0 0 0 179477 0 0 0 MELODY STEWART-CYRUS MD BOARD MEMBER (SEE SCH J) 156916 0 0 0 0 0 0 0 18157 0 175073 0 0 0 DAVID ROSI THRU 616 BOARD MEMBER (SEE SCH J) 283774 0 13599 0 0 0 8993 0 11348 0 317714 0 0 0 MICHAEL D SWICK PRESIDENT/CEO (SEE SCH J) 0 352679 0 213202 0 13734 0 223681 0 22696 0 825992 0 0 ROBERT E ARMSTRONG JR VICE PRESIDENT/COO (SEE SCH J) 0 233499 0 102708 0 7116 0 93155 0 22696 0 459174 0 0 JOHN T FISCHBACH VP OF FINANCE/CFO (SEE SCH J) 0 231105 0 12500 0 5615 0 54109 0 0 0 303329 0 0 PIERRE BAMDAD MD PHYSICIAN (SEE SCH J) 649582 0 15000 0 0 0 21200 0 18157 0 703939 0 0 0 MEHRAN ARABPOUR MD PHYSICIAN (SEE SCH J) 646883 0 61024 0 0 0 39200 0 22696 0 769803 0 0 0 PAUL N ANIKE MD PHYSICIAN (SEE SCH J) 649582 0 56024 0 0 0 39200 0 22696 0 767502 0 0 0 VENKAT R BATTULA MD PHYSICIAN (SEE SCH J) 597545 0 66024 0 0 0 39200 0 18157 0 720926 0 0 0 PAMELA R GARDNER PHYSICIAN (SEE SCH J) 549816 0 61024 0 0 0 39200 0 9080 0 659120 0 0 0 Part I, Line 4b THE FOLLOWING INDIVIDUALS PARTICIPATED IN AN IRC 457(F) NON-QUALIFIED DEFERRED COMPENSATION PLAN. THIS PLAN IS FUNDED BY THE HOSPITAL AND VESTS WITH SERVICE THEREFORE IS SUBJECT TO RISK OF FORFEITURE. ROBERT E. ARMSTRONG: $51,305 MICHAEL D. SWICK: $181,831 KHA H. TRAN: $36,888 JOHN FISCHBACH: $18,532 PART I, LINE 3: RELATED ORGANIZATION, LIMA MEMORIAL JOINT OPERATING COMPANY, DETERMINES THE COMPENSATION OF THE ORGANIZATION'S CEO, OTHER OFFICERS AND KEY EMPLOYEES BY 1)REVIEW AND APPROVAL OF THE COMPENSATION COMMITTEE; 2)UTILIZATION OF AN INDEPENDENT COMPENSATION CONSULTANT; 3)COMPARABLE DATA; AND 4) CONTEMPORANEOUS DOCUMENTATION. ADDITIONAL INFORMATION: COMPENSATION PRESENTED ON FORM 990, PART VII AND SCHEDULE J RELATED TO THE BOARD MEMBERS ARE FOR SERVICES PERFORMED FOR THE ORGANIZATION OUTSIDE THOSE SERVICES PERFORMED ON THE BOARD. THERE IS NO COMPENSATION PAID FOR BOARD SERVICES. Form 990, Part VI, Section B, line 11b FORM 990 IS PROVIDED TO ALL BOARD MEMBERS PRIOR TO FILING WITH THE IRS. THE AUDIT COMMITTEE OF THE BOARD REVIEWS AND APPROVES FORM 990. Form 990, Part VI, Section B, line 12c EACH TRUSTEE, PRINCIPAL OFFICER, AND MEMBER OF A COMMITTEE WITH BOARD-DELEGATED POWERS SHALL ANNUALLY SIGN A STATEMENT WHICH AFFIRMS THAT SUCH PERSON: 1) HAS RECEIVED A COPY OF THE CONFLICTS OF INTEREST POLICY; 2) HAS READ AND UNDERSTANDS THE POLICY; 3) HAS AGREED TO COMPLY WITH THE POLICY; AND 4) UNDERSTANDS THAT THE CORPORATION IS A CHARITABLE ORGANIZATION AND THAT IN ORDER TO MAINTAIN ITS FEDERAL TAX EXEMPTION, IT MUST ENGAGE PRIMARILY IN ACTIVITIES WHICH ACCOMPLISH ONE OR MORE OF ITS TAX-EXEMPT PURPOSES. IF THE BOARD OR COMMITTEE HAS REASONABLE CAUSE TO BELIEVE THAT A MEMBER HAS FAILED TO DISCLOSE ACTUAL OR POSSIBLE CONFLICTS OF INTEREST, IT SHALL INFORM THE MEMBER OF THE BASIS FOR SUCH BELIEF AND AFFORD THE MEMBER AN OPPORTUNITY TO EXPLAIN THE ALLEGED FAILURE TO DISCLOSE. IF, AFTER HEARING THE RESPONSE OF THE MEMBER AND MAKING SUCH FURTHER INVESTIGATION AS MAY BE WARRANTED IN THE CIRCUMSTANCES, THE BOARD OR COMMITTEE DETERMINES THAT THE MEMBER HAS IN FACT FAILED TO DISCLOSE AN ACTUAL OR POSSIBLE CONFLICT OF INTEREST, IT SHALL TAKE APPROPRIATE DISCIPLINARY AND CORRECTIVE ACTION. Form 990, Part VI, Section C, line 19 THE GOVERNING DOCUMENTS, CONFLICT OF INTEREST POLICY AND FINANCIAL STATEMENTS ARE CURRENTLY NOT AVAILABLE TO THE PUBLIC. Form 990, Part IX, line 11g PURCHASED SERVICES: Program service expenses 223,898. Management and general expenses 21,730. Fundraising expenses 0. Total expenses 245,628. LOCUM TENENS FEE: Program service expenses 1,563,135. Management and general expenses 1,021. Fundraising expenses 0. Total expenses 1,564,156. COLLECTION FEES: Program service expenses 439,074. Management and general expenses 44,875. Fundraising expenses 0. Total expenses 483,949. EQUIPMENT RENTAL FEES: Program service expenses 1,518,238. Management and general expenses 131,893. Fundraising expenses 0. Total expenses 1,650,131. WASTE REMOVAL FEES: Program service expenses 16,811. Management and general expenses 0. Fundraising expenses 0. Total expenses 16,811. GROUNDS FEES: Program service expenses 666. Management and general expenses 0. Fundraising expenses 0. Total expenses 666. LAUNDRY FEES: Program service expenses 13,804. Management and general expenses 1,296. Fundraising expenses 0. Total expenses 15,100. CLEANING FEES: Program service expenses 66,455. Management and general expenses 0. Fundraising expenses 0. Total expenses 66,455. SERVICE CONTRACTS: Program service expenses 261,992. Management and general expenses 28,611. Fundraising expenses 0. Total expenses 290,603. Form 990, Part XI, line 9: ADJUSTMENT FROM NCOPS ACQUISITION 55,530. FORM 990, PART XI, LINE 2C EXPLANATION: THE AUDIT COMMITTEE ASSUMES RESPONSIBILITY FOR THE OVERSIGHT OF THE AUDIT AND THE SELECTION OF THE INDEPENDENT ACCOUNTANT. THIS PROCESS HAS NOT CHANGED FROM THE PRIOR YEAR. LIMA MEMORIAL HOSPITAL 1001 BELLEFONTAINE AVENUE LIMA OH 45804 344434676 HEALTHCARE OH 501(C)(3) Line 3 LIMA MEMORIAL JOINT OPERATING COMPANY 1 LIMA MEMORIAL HOSPITAL FOUNDATION 1001 BELLEFONTAINE AVENUE LIMA OH 45804 341707570 SUPPORTING ORGANIZATION FOR LIMA MEMORIAL HOSPITAL OH 501(C)(3) Line 12a, I LIMA MEMORIAL JOINT OPERATING COMPANY 1 LIMA MEMORIAL HOSPITAL AUXILIARY 1001 BELLEFONTAINE AVENUE LIMA OH 45804 341694632 SUPPORTING ORGANIZATION FOR LIMA MEMORIAL HOSPITAL OH 501(C)(3) Line 12a, I LIMA MEMORIAL JOINT OPERATING COMPANY 1 LIMA MEMORIAL JOINT OPERATING COMPANY 1001 BELLEFONTAINE AVENUE LIMA OH 45804 341883284 HEALTHCARE OH 501(C)(3) Line 3 N/A 0 LMHS WOMEN'S HEALTH CO-MANAGEMENT COMPANY LLC 1001 BELLEFONTAINE AVE LIMA OH 45804 271023520 WOMEN'S HEALTH CO-MANAGEMENT OH N/A ELM TREE FOUNDATION 1220 EAST ELM STREET LIMA OH 45804 341417720 RENTAL REAL ESTATE OH N/A C 1 0 0 0 0 0 0 0 0 0 0 1 0 0 1 1 0 1 0 1 LIMA MEMORIAL JOINT OPERATING COMPANY S 12059275 EQUITY TRANSFER LIMA MEMORIAL JOINT OPERATING COMPANY K 988162 LEASE CONTRACT ELM TREE FOUNDATION K 318633 LEASE CONTRACT