2016-09-08T10:14:46-05:00 2015-10-31 351178661 BLUE & CO LLC 8800 LYRA DRIVE SUITE 450 COLUMBUS OH 43240 990 2014-11-01 344477047 HENRY COUNTY HOSPITAL INC HENR 4195924015 1600 EAST RIVERVIEW NAPOLEON OH 43545 KIMBERLY H BORDENKIRCHER CEO 4195924015 2016-09-07 1 MATTHEW DASTA P00544683 6148852583 2016-09-07 2014 2016-12-15 16:53:06Z KIMBERLY H BORDENKIRCHER 1600 EAST RIVERVIEW NAPOLEON OH 43545 29306223 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 7 336 80 0 -23005 118622 131450 28288804 28028257 14671 11202 823568 1135314 29245665 29306223 0 0 0 0 13607503 14499496 0 0 46550 14363120 14785061 27970623 29284557 1275042 21666 22246122 21499847 11940257 11155579 10305865 10344268 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 2123549 1343390 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 1820 PROCEDURES IN 2015. 2125882 8659582 2. LABORATORY: PROVIDING SERVICES FOR IP AND OP, EXTENDED CARE FACILITIES, PHYSICIAN OFFICES AND AREA BUSINESSES. THE LABORATORY PROVIDED OVER 138,000 BILLED TESTS IN 2015. 1587736 2961643 3. EMERGENCY CARE SERVICES ARE PROVIDED CONTINUALLY TO PATIENTS PRESENTING WITH INJURIES AND ILLNESSES. TOTAL PATIENTS TREATED IN THE EMERGENCY DEPARTMENT TOTALED OVER 9,300 FOR 2015. 18034896 15769801 4. 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 125,000 BILLED DOSES TO PATIENTS THROUGH PHARMACY SERVICES, OVER 700 INPATIENT ADMISSIONS WITH OVER 2,400 DAYS OF CARE, OVER 120 SWING BED PATIENTS WITH OVER 1,000 DAYS OF CARE, 106 BIRTHS, AND OVER 47,800 OUTPATIENT VISITS IN 2015. 18034896 15769801 23872063 1 1 0 1 0 0 0 0 0 0 1 0 0 1 0 1 0 1 0 0 0 0 0 0 0 0 1 1 0 0 1 1 0 0 0 0 0 0 0 1 0 0 0 0 0 0 0 1 0 0 0 1 59 0 1 336 1 1 1 0 0 0 0 0 0 0 0 0 X 9 7 0 0 0 0 0 0 0 1 1 0 0 1 1 1 1 1 1 1 1 0 OH X DIANE WALTHER 4195913826 1600 EAST RIVERVIEW NAPOLEON OH 43545 KIMBERLY BORDENKIRCHER TREASURER & CEO 40.00 X X 197764 0 23926 MARVIN BARLOW CHAIRMAN 4.00 X X 0 0 0 JOHN WILHELM VICE-CHAIR 2.00 X X 0 0 0 RICK FRUTH BOARD MEMBER 2.00 X 0 0 0 DR ROBERT LIMBIRD BOARD MEMBER 2.00 X 0 0 0 THOMAS MACK SECRETARY 2.00 X X 0 0 0 ANNE GOON BOARD MEMBER 2.00 X 0 0 0 JIM BURKHART BOARD MEMBER 2.00 X 0 0 0 DR JOSEPH KRUEGER - LEFT IN 2014 BOARD MEMBER 2.00 X 0 0 0 DR MORRIS SEAL PHYSICIAN 40.00 X 217174 0 17094 MICHELE JAKUTOWICZ PHARMACIST 40.00 X 114974 0 23414 DR ERAST HAFTKOWYCZ OB/GYN 40.00 X 241091 0 32179 SARAH HUBER MANAGER OF RADIOLOGY 40.00 X 112740 0 29790 CYNTHIA LATTA PHARMACIST 40.00 X 112060 0 10384 DR DOUGLAS LINDSEY PHYSICIAN 40.00 X 312402 0 36667 1308205 0 173454 8 0 1 0 SAFE ANESTHESIA LLC 356 MINER ROAD HIGHLAND HEIGHTS OH 44143 ANESTHESIA SERVICES 638822 EMCARE PHYSICIAN SERVICES 1717 MAIN ST STE 5200 DALLAS TX 75201 EMERGENCY PHYSICIAN SERVICES 586797 HOSPITAL CARE GROUP PC 6435 W JEFFERSON BLVD FORT WAYNE IN 46804 INPATIENT PHYSICIAN SERVICES (HOSPITALIS 254206 MERCY MEDICAL PARTNERS NORTHERN REGION 1400 EAST SECOND ST DEFIANCE OH 43512 PHYSICIAN COVERAGE 252600 ALLIANCE HEALTHCARE SERVICES PO BOX 6600 NEWPORT BEACH CA 92658 MOBILE MRI UNIT 196261 6 106865 24585 131450 PATIENT REVENUE 900099 28028257 28028257 28028257 11202 11202 118154 0 118154 118154 118154 INVESTMENT IN LLCS 900099 342699 342699 MISCELLANEOUS 900099 330046 330046 EHR INCENTIVE PAYMENTS 900099 183272 183272 161143 33414 127729 1017160 29306223 28734416 0 440357 X 370383 370383 10984233 8787386 2196847 292650 234120 58530 1946159 1556927 389232 906071 724857 181214 75838 75838 67740 67740 5298907 4468951 829956 197626 53359 144267 2887172 2829429 57743 304725 60945 243780 883314 794983 88331 84478 38015 46463 52153 30770 21383 380466 380466 1325161 1325161 74212 24490 49722 BAD DEBT 1565919 1565919 DRUGS 1218883 1218883 MISCELLANEOUS 368467 157868 164049 46550 29284557 23872063 5365944 46550 300 300 8311223 6363270 3614732 3980382 648453 659024 214285 211756 28531855 20363017 8422812 8168838 860292 844003 174025 1272274 22246122 21499847 2235268 2020487 9335000 8935000 369989 200092 11940257 11155579 X 9522889 9561119 732976 733149 50000 50000 10305865 10344268 22246122 21499847 X 21666 16737 X 0 1 X 1 0 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 0 0 0 0 0 0 0 0 1 2990 2990 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. OHA - $697 AHA - $2,293 50000 50000 50000 50000 50000 50000 50000 50000 50000 50000 1.00000 0 0 153751 153751 8507193 5813101 2694092 762201 713972 48229 18899954 13835944 5064010 208756 208756 8168838 DEPOSITS 1000 BOARD DESIGNATED ASSETS 16966 DONOR RESTRICTED ASSETS 50000 UNAMORTIZED DEBT ISSUE COSTS 97027 ESTIMATED THIRD PARTY SETTLEMENTS 834003 RELATED PARTY RECEIVABLE 273278 1272274 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 THE ORGANIZATION AND HAS CONCLUDED THAT AS OF OCTOBER 31, 2015 AND 2014, 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 1 X 1 X 0 1 1 0 0 241 559501 973042 -413541 0.00000 2419 3989638 2427012 1562626 0.05340 2660 4549139 3400054 1149085 0.05340 217440 53282 2400 50882 0.00170 1 2594 2594 0.00010 1002 440359 356569 83790 0.00290 1050 9025 9025 0.00030 219493 505260 358969 146291 0.00500 222153 5054399 3759023 1295376 0.05840 11 3131 17013 17013 0.00060 4 1400 4988 4988 0.00020 15 4531 22001 22001 0.00080 1 592936 9365546 9234884 130662 X 1 0 1 HENRY COUNTY PAIN MANAGEMENT LLC MEDICAL PAIN MANAGEMENT 0.51000 0.00000 0.00000 2 VANTAGE HEALTHCARE OF OHIO LLC A COLLABORATIVE OF HOSPITALS WORKING TOGETHER TO IDENTIFY OPPORTUNITIES 0.11000 0.00000 0.00000 1 1 HENRY COUNTY HOSPITAL INC 1600 EAST RIVERVIEW AVE NAPOLEON OH 43545 X X HENRY COUNTY HOSPITAL INC 1 0 0 1 X X X X X X X X 13 1 0 0 1 X HTTPS://HENRYCOUNTYHOSPITAL.ORG 1 14 1 HTTP://HENRYCOHD.ORG/COMMUNITY-HEALTH-ASSESSMENTS-AND-IMPROVEMENT-PLANS/ 0 0 1 X 100.000000000000 250.000000000000 X X X X X 1 1 X X X X 1 X HTTPS://HENRYCOUNTYHOSPITAL.ORG X HTTPS://HENRYCOUNTYHOSPITAL.ORG X X X 1 X 0 X X 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 11: THE HENRY COUNTY HEALTH PARTNERS; INITIAL EFFORTS WILL FOCUS IN THREE AREAS:1. FIT-FRIENDLY INITIATIVE: INCREASE THE NUMBER OF HENRY COUNTY EMPLOYERS THAT HAVE WORKSITE POLICIES AND PROGRAMS TO INCREASE PHYSICAL ACTIVITY. HENRY COUNTY HOSPITAL HAS SCHEDULED FOCUS GROUPS IN ORDER TO SHARE TACTICS AND STRATEGIES IN ORDER TO COMPLETE AN APPLICATION FOR FIT FRIENDLY. HENRY COUNTY HOSPITAL HAS DEVELOPED A FITNESS MATTERS WELLNESS WORKS COMMITTEE IN ORDER TO REMAIN COMPLIANT WITH THE FIT FRIENDLY CRITERIA. HENRY COUNTY HOSPITAL HAS APPLIED AND RECEIVED THE WELLNESS AWARD FROM THE STATE OF OHIO.2. SUMMER NUTRITION PROGRAM: PARTNER WITH LOCAL AGENCIES, ORGANIZATIONS, AND INDIVIDUALS TO PROVIDE THE SUMMER NUTRITION PROGRAM (WITH PHYSICAL ACTIVITY) TO LOWER-INCOME CHILDREN AND FAMILIES. HENRY COUNTY HOSPITAL HAS PROVIDED THE NUTRITION (LUNCH) FOR THE SUMMER NUTRITION PROGRAM.3. BABY-FRIENDLY INITIATIVE: ADOPT AND USE MATERNITY CARE PRACTICES AT HENRY COUNTY HOSPITAL THAT EMPOWER NEW MOTHERS TO BREASTFEEDING, CONSISTENT WITH BABY-FRIENDLY HOSPITAL STANDARDS. HENRY COUNTY HOSPITAL IS ACTIVELY PURSUING THE BREAST FEEDING FRIENDLY DESIGNATION. SCHEDULE H, PT V, SEC B, LINE 5A THE HOSPITAL'S COMMUNITY HEALTH NEEDS ASSESSMENT CAN BE LOCATED AT THE FOLLOWING URL:HTTP://HENRYCOUNTYHOSPITAL.ORG PART V, SECTION B, LINE 16 FINANCIAL ASSISTANCE POLICY WEBSITE AVAILABILITY HENRY COUNTY HOSPITAL, INC. PART V, SECTION B, LINE 16A WEBSITE: HTTPS://HENRYCOUNTYHOSPITAL.ORG HENRY COUNTY HOSPITAL, INC. PART V, SECTION B, LINE 16B WEBSITE: HTTPS://HENRYCOUNTYHOSPITAL.ORG PART I, LN 7 COL(F): WE ESTIMATE THAT APPROXIMATELY 3% 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. THE HOSPITAL CHOSE TO USE A COST-TO-CHARGE RATIO FOR REPORTING COST THROUGHOUT THE FORM. 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 SUPPORT TO THE CHILDREN OF HENRY COUNTY AND THE NORTHWEST OHIO AREA 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 LOCAK 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 4: THE ORGANIZATION ESTIMATES AN ALLOWANCE FOR DOUBTFUL ACCOUNTS BASED ON AN EVALUATION OF HISTORICAL LOSSES, CURRENT ECONOMIC CONDITIONS AND OTHER FACTORS UNIQUE TO THE ORGANIZATION'S CLIENT BASE. 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 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 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, 2015 REPORT: HOSPITAL STATEMENT OF REIMBURSABLE COST. 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 29,000. THE RACIAL MAKEUP OF THE COUNTY WAS 95.33% WHITE, 0.58% BLACK OR AFRICAN AMERICAN, 0.26% NATIVE AMERICAN, 0.42% ASIAN, 2.56% FROM OTHER RACES, AND 0.85% FROM TWO OR MORE RACES. 5.40% OF THE POPULATION WERE HISPANIC OR LATINO OF ANY RACE. 94.3% SPOKE ENGLISH, 3.7% SPANISH AND 1.7% GERMAN AS THEIR FIRST LANGUAGE. THE MEDIAN INCOME FOR A HOUSEHOLD IN THE COUNTY WAS $42,657, AND THE MEDIAN INCOME FOR A FAMILY WAS $49,881. MALES HAD A MEDIAN INCOME OF $35,901 VERSUS $24,076 FOR FEMALES. THE PER CAPITA INCOME FOR THE COUNTY WAS $18,667. ABOUT 5.30% OF FAMILIES AND 7.00% OF THE POPULATION WERE BELOW THE POVERTY LINE, INCLUDING 9.90% 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.THE 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 MEMBER. THE HOSPITAL WORKS COLLABORATIVELY WITH THE HENRY COUNTY HEALTH DEPARTMENT, THE UNITED WAY AND OTHERS IN PROMOTING HEALTHY LIVING. 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. X X 1 1 X X X X 0 0 0 0 0 0 0 0 0 KIMBERLY BORDENKIRCHER TREASURER & CEO 197764 0 0 0 0 0 5711 0 18215 0 221690 0 0 0 DR MORRIS SEAL PHYSICIAN 217174 0 0 0 0 0 6867 0 10227 0 234268 0 0 0 DR ERAST HAFTKOWYCZ OB/GYN 241091 0 0 0 0 0 7112 0 25067 0 273270 0 0 0 DR DOUGLAS LINDSEY PHYSICIAN 312402 0 0 0 0 0 7850 0 28817 0 349069 0 0 0 PART I, LINE 1A THE HOSPITAL GROSSES UP THE PERSONAL USE OF A BUSINESS OWNED VEHICLE FOR THE CEO. THIS IS BASED ON PAST PRACTICE. THE HOSPITAL PAYS DUES FOR THE ROTARY CLUB FOR KIM BORDENKIRCHER, CEO, AND MICHELLE RYCHENER, DIRECTOR OF DEVELOPMENT. PART I, LINE 1B THE HOSPITAL GROSSES UP THE PERSONAL USE OF A BUSINESS OWNED VEHICLE FOR THE CEO. THIS IS BASED ON PAST PRACTICE. THE HOSPITAL PAYS DUES FOR THE ROTARY CLUB FOR KIM BORDENKIRCHER, CEO, AND MICHELLE RYCHENER, DIRECTOR OF DEVELOPMENT. 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 10680000 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 RICKY FRUTH BOARD MEMBER INDIRECT BUSINESS RELATIONSHIP 0 FORM 990, PART VI, SECTION B, LINE 11 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 PROFESSIONAL FEES: PROGRAM SERVICE EXPENSES 3,799,322. MANAGEMENT AND GENERAL EXPENSES 618,494. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 4,417,816. PURCHASED SERVICES: PROGRAM SERVICE EXPENSES 669,629. MANAGEMENT AND GENERAL EXPENSES 211,462. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 881,091. FORM 990, PART XI, LINE 9: INTEREST IN FOUNDATION NET ASSETS 173. NET ASSETS RELEASED FROM TEMPORARY RESTRICTION 16,564. HENRY COUNTY HOSPITAL FOUNDATION 1600 EAST RIVERVIEW NAPOLEON OH 43545 341919852 TO RAISE FUNDS AND PROVIDE FINANCIAL ASSISTANCE TO HENRY COUNTY HOSPITAL. OH 501(C)(3) LINE 11A, I HENRY COUNTY HOSPITAL 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 0 0 0 1 HENRY COUNTY HOSPITAL FOUNDATION INC O 80918 CASH HENRY COUNTY HOSPITAL FOUNDATION INC S 106865 CASH