2016-04-18T14:35:25-05:00 2014-12-31 351178661 BLUE & CO LLC 8800 LYRA DRIVE SUITE 450 COLUMBUS OH 43240 990 2014-01-01 340714583 CITY HOSPITAL ASSOCIATION CITY 3303862000 425 WEST FIFTH STREET EAST LIVERPOOL OH 43920 KYLE JOHNSON CFO 3303862000 2016-02-29 1 MATTHEW DASTA P00544683 6148852583 2016-02-29 2014 2016-08-17 19:52:53Z EAST LIVERPOOL CITY HOSPITAL MIKE BRUNTON 425 WEST FIFTH STREET EAST LIVERPOOL OH 43920 65473599 0 X WWW.ELCH.ORG X 1905 OH THE ORGANIZATION IS ORGANIZED AND OPERATED TO PROVIDE THE PEOPLE OF THE TRI-STATE AREA HIGH QUALITY HEALTH CARE SERVICES, REGARDLESS OF THE PERSON'S ABILITY TO PAY. THESE SERVICES INCLUDE THE PREVENTION OF ILLNESS, RELIEF OF SUFFERING, HEALTH RESTORATION, AND HEALTH CARE EDUCATION. 17 16 0 17 0 0 24000 3490 64437682 60262469 2816337 1117908 1601954 4089732 68879973 65473599 150000 106067 0 0 33404712 28800867 0 0 0 36106043 43600914 69660755 72507848 -780782 -7034249 100749210 92365159 39331984 41678880 61417226 50686279 X WE WILL PROVIDE HIGH QUALITY, COMPASSIONATE HEALTH CARE SERVICES WITHIN THE AVAILABLE RESOURCES. HEALTHCARE SERVICES WILL BE PROVIDED TO PREVENT ILLNESS, RELIEVE SUFFERING, AID IN HEALTH RESTORATION AND TO PROMOTE WELLNESS. WE WILL PROVIDE SERVICES TO ANY PERSON, WITHOUT DISCRIMINATION. 0 0 51323780 106067 64104414 CITY HOSPITAL ASSOCIATION DBA EAST LIVERPOOL CITY HOSPITAL PROVIDES QUALITY MEDICAL HEALTHCARE REGARDLESS OF RACE, CREED, SEX, NATIONAL ORIGIN, HANDICAP, AGE, OR ABILITY TO PAY. ALTHOUGH REIMBURSEMENT FOR SERVICES RENDERED IS CRITICAL TO THE OPERATION AND STABILITY OF THE HOSPITAL, IT IS RECOGNIZED THAT NOT ALL INDIVIDUALS POSSESS THE ABILITY TO AFFORD ESSENTIAL MEDICAL SERVICES AND HEALTHCARE EDUCATION. THEREFORE, IN KEEPING WITH THE HOSPITAL'S COMMITMENT TO SERVE ALL MEMBERS OF OUR COMMUNITY WITH FREE CARE AND OR SUBSIDIZED CARE, CARE PROVIDED TO PERSONS COVERED BY GOVERNMENTAL PROGRAMS BELOW COSTS, AND HEALTH ACTIVITIES AND PROGRAMS TO SUPPORT THE COMMUNITY HAVE BEEN CONSIDERED WHERE THE NEED AND AN INDIVIDUAL'S INABILITY TO PAY EXIST. THESE ACTIVITIES INCLUDE WELLNESS PROGRAMS, COMMUNITY EDUCATION PROGRAMS, AND A VARIETY OF BROAD COMMUNITY SUPPORT ACTIVITIES. THE HOSPITAL PROVIDES CARE TO PERSONS COVERED BY GOVERNMENTAL PROGRAMS BELOW COST. RECOGNIZING ITS MISSION TO THE COMMUNITY, SERVICES ARE PROVIDED TO BOTH MEDICARE AND MEDICAID PATIENTS. TO THE EXTENT REIMBURSEMENT IS BELOW COST, THE HOSPITAL CONSIDERS THESE AMOUNTS AS UNCOMPENSATED CARE IN MEETING ITS MISSION TO THE ENTIRE COMMUNITY. THE HOSPITAL IS LOCATED IN EAST LIVERPOOL, OHIO AND SERVICES THE SURROUNDING COMMUNITIES; STAFFING 158 BEDS FOR ACUTE CARE, INTENSIVE CARE, NURSERY, AND SKILLED NURSING IN THIS MEDICALLY UNDERSERVED AREA.DURING 2014, THE HOSPITAL PROVIDED NUMEROUS BENEFITS TO THE SURROUNDING COMMUNITY, INCLUDING FINANCIAL SUPPORT THROUGH THE COMMUNITY BENEFIT INITIATIVE PROGRAM.COMMUNITY BENEFIT INITIATIVE - THE HOSPITAL PROVIDED FINANCIAL SUPPORT TOTALING $106,067 TO LOCAL PROGRAMS.COMMUNITY EDUCATION AND WELLNESS PROGRAMS - THE HOSPITAL OFFERED THE FOLLOWING TO THE COMMUNITY FREE OR AT A NOMINAL CHARGE:HEALTH FAIRSCPR CLASSESCHILDBIRTH CLASSESGARFIELD ELEMENTARY WELLNESS PROGRAMCOVER THE UNINSURED PROGRAMHEARTSAVER FIRST AID CLASSESADVANCE CARDIAC LIFE SUPPORTHEALTHCARE PROVIDE RECERTIFICATIONBREAST FEEDING SUPPORTPASTORAL OUTREACH PROGRAMSDIABETES EDUCATIONARTHRITIS AQUATICS CLASSESSMOKING CESSATION CLASSESBASICS IN BABYSITTING CLASSESAUTISM SUPPORT GROUPCONDUCTED HOSPITAL TOURS FOR AREA SCHOOLS AND COMMUNITY GROUPS. SERVED AS AN OBSERVATION SITE FOR THE HIGH SCHOOL FOR HEALTH PROFESSIONS DEVELOPED BY THE PUBLIC SCHOOLS. HOSTED SEVERAL SHADOW STUDENTS FROM AREA SCHOOLS. SERVED AS HOST SITE FOR OHIO HIGHER EDUCATION TELECOMMUNICATION SYSTEM.OPERATED A PHYSICIAN REFERRAL LINE FREE TO THE COMMUNITY.SPENT $45,972 TO RECRUIT PHYSICIANS TO THE UNDERSERVED COMMUNITY;HOSTED PROGRAMS FOR STUDENT NURSES AND RADIOLOGY TECHNICIANS IN TRAINING.SALVATION ARMY: PROVIDED FOOD TO NEEDY FAMILIES FOR THANKSGIVING, AND GIFTS TO NEEDY CHILDREN FOR CHRISTMAS.DAY OF CARING, DAY OF GIVING PROGRAM - MONEY AND FOOD DRIVE. 51323780 1 0 0 1 0 0 0 0 0 0 1 0 0 1 1 1 1 0 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 0 0 0 0 0 0 0 0 0 0 0 0 0 X 17 16 0 0 0 0 1 0 0 1 1 0 0 0 1 1 1 1 1 1 1 0 OH X ANTHONY PUORRO 3303862633 425 W FIFTH STREET EAST LIVERPOOL OH 43920 KENNETH COCHRAN CEO 40.00 X X 332717 0 0 STEVE LATULIPPE MD TRUSTEE 1.00 X 0 0 0 DR DONALD WILLIAMS TRUSTEE 1.00 X 0 0 0 JOSPEH LUDOVICI TRUSTEE 1.00 X 0 0 0 JERYL SCHREINER TRUSTEE 1.00 X 0 0 0 JD GAURON TRUSTEE 1.00 X 0 0 0 PETE WICKS SECRETARY/TREASURER 1.00 X X 0 0 0 ROB OHARA TRUSTEE 1.00 X 0 0 0 TAMMIE MCINTOSH TRUSTEE 1.00 X 0 0 0 WILLIAM MILLER VICE CHAIRMAN OF THE BOARD 1.00 X X 0 0 0 MICHAEL SIGLER TRUSTEE 1.00 X 0 0 0 MARY LOU VISNIC TRUSTEE 1.00 X 0 0 0 JOSEPH SHEMASEK TRUSTEE 1.00 X 0 0 0 DAVID HAMILTON TRUSTEE 1.00 X 0 0 0 JAY B VOTAW DVM TRUSTEE 1.00 X 0 0 0 GRETCHEN NICKELL DO TRUSTEE 1.00 X 0 0 0 FRANK MADER INFORMATION SERVICES DIRECTOR 40.00 X 109368 0 41655 CHARLES PARRY ADMINISTRATOR 40.00 X 105467 0 18723 TINA ROBINSON REGISTERED NURSE 40.00 X 100227 0 21869 KYLE JOHNSON FORMER CFO FORMER CFO 40.00 X 205058 0 20272 852837 0 102519 5 1 1 0 CARDINAL HEALTH 21377 NETWORK PL CHICAGO IL 60673 PHARMACY SERVICES 3161796 AVI FOODSYSTEMS INC 2590 ELM ROAD NE WARREN OH 44483 FOOD/SUPPLIES/PROFESSIONAL SERVICES 2562667 MEDLINE INDUSTRIES INC PO BOX 382075 PITTSBURGH PA 15251 HOSPITAL MED-SURG SUPPLY 1086828 INPATIENT MANAGEMENT INC 1 MCBRIDE SON CENTER DRIVE ST LOUIS MO 63005 PROFESSIONAL FEES 967852 PSYCHIATRIC RESOURCE PARTNERS 6100 TOWER CIRCLE DRIVE STE 1000 FRANLKIN TN 37067 BEHAVIORAL HEALTH PROFESSIONAL FEES 879504 5 3490 3490 NET PATIENT REVENUE 900099 60262469 60262469 60262469 1065538 1065538 89424 0 89424 89424 89424 52370 0 52370 52370 52370 HCAP 900099 2378746 2378746 MEDICAID SUBSIDY 900099 1357812 1357812 CAFETERIA INCOME 900099 158363 158363 105387 105387 4000308 65473599 64104414 0 1365695 X 106067 106067 332717 199630 133087 19601520 11760912 7840608 910548 910548 6237850 6237850 1718232 1254309 463923 563894 563894 62413 62413 12292939 7447277 4845662 271655 271655 122011 73207 48804 4177684 2506610 1671074 59254 35552 23702 69094 69094 2417547 2417547 4074632 4074632 561321 561321 BAD DEBTS 8967735 8967735 SUPPLIES 7887766 7098989 788777 MISCELLANEOUS 1979184 1583347 395837 RECRUITMENT 93785 93785 72507848 51323780 21184068 0 800 514685 12694318 11476879 80753 59940 995681 987191 95615000 68207965 29881382 27407035 51361210 42148838 5220381 10285276 100749210 92365159 4598968 7415460 29222102 26501239 1747538 5510914 6014643 39331984 41678880 X 61283754 50548456 75034 79385 58438 58438 61417226 50686279 100749210 92365159 X -7034249 679130 -4375828 X 0 1 X 1 0 X 0 0 0 0 0 0 0 0 1 6105 6105 0 PART II-B, LINE 1: A PERCENTAGE OF AHA AND OHA DUES ARE USED FOR LOBBYING PURPOSES. 1434347 1434347 44568504 27323581 17244923 49021814 40884384 8137430 590335 590335 27407035 DEFERRED BOND FINANCING COSTS 347106 DUE FROM AFFILIATES 166451 GUARANTEES 5494443 ESTIMATED THIRD PARTY SETTLEMENTS 4277276 10285276 INTEREST RATE SWAP 2984843 GUARANTEES 2930011 BANK OVERDRAFT 99789 6014643 X 55302296 0 55302296 10171303 10171303 65473599 62336545 0 62336545 10171303 10171303 72507848 PART X, LINE 2: ACCOUNTING PRINCIPLES GENERALLY ACCEPTED IN THE UNITED STATES OF AMERICA REQUIRE MANAGEMENT TO EVALUATE TAX POSITIONS TAKEN BY THE HOSPITAL AND RECOGNIZE A TAX LIABILITY IF THE HOSPITAL HAS TAKEN AN UNCERTAIN POSITION 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 HOSPITAL, AND HAS CONCLUDED THAT AS OF DECEMBER 31, 2014 AND 2013, 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 HOSPITAL IS SUBJECT TO ROUTINE AUDITS BY TAXING JURISDICTIONS; HOWEVER, THERE ARE CURRENTLY NO AUDITS FOR ANY TAX PERIODS IN PROGRESS. PART XI, LINE 4B - OTHER ADJUSTMENTS: BAD DEBT EXPENSE INCLUDED IN INCOME 8,967,735. CHANGE IN INTEREST RATE SWAP 1,203,568. PART XII, LINE 4B - OTHER ADJUSTMENTS: BAD DEBT EXPENSE INCLUDED IN INCOME 8,967,735. CHANGE IN INTEREST RATE SWAP 1,203,568. 1 1 1 X 1 X 1 1 0 0 754126 754126 0.01190 17310696 11706538 5604158 0.08820 18064822 11706538 6358284 0.10010 1876342 721445 1154897 0.01820 1876342 721445 1154897 0.01820 19941164 12427983 7513181 0.11830 0 16535891 17081765 -545874 X 1 1 2 1 ELCH REHAB 15655 ST RTE 170 EAST LIVERPOOL OH 43920 PT, OT, SPEECH SERVICES 2 ELCH 5TH STREET EAST LIVERPOOL OH 43920 X X DSH EAST LIVERPOOL CITY HOSPITAL 1 0 0 1 X X X X X X X X X 13 1 1 0 1 X HTTP://WWW.ELCH.ORG/COMMUNITYHEALTH/ X 1 13 1 HTTP://WWW.ELCH.ORG/COMMUNITYHEALTH/ 0 0 1 X 100.000000000000 100.000000000000 X X 1 1 1 X HTTP://WWW.ELCH.ORG/PATIENT/BILLING/FINANCIAL-AID-FOR-PATIENTS/593/ X 1 X 1 X X X X X 1 0 1 EAST LIVERPOOL CITY HOSPITAL PART V, SECTION B, LINE 6A: SALEM COMMUNITY HOSPITAL EAST LIVERPOOL CITY HOSPITAL PART V, SECTION B, LINE 24: ALL PATIENTS ARE BILLED THE SAME GROSS CHARGE. DISCOUNTS ARE APPLIED AT THE TIME OF PAYMENT. PART V, SECTION B, LINE 16 FINANCIAL ASSISTANCE POLICY WEBSITE AVAILABILITY EAST LIVERPOOL CITY HOSPITAL PART V, SECTION B, LINE 16A WEBSITE: HTTP://WWW.ELCH.ORG/PATIENT/BILLING/FINANCIAL-AID-FOR-PATIENTS/593/ PART I, LINE 7, COLUMN (F): THE BAD DEBT EXPENSE INCLUDED ON FORM 990, PART IX, LINE 25, COLUMN (A), BUT SUBTRACTED FOR PURPOSES OF CALCULATING THE PERCENTAGE IN THIS COLUMN IS $ 8,967,735. PART II, COMMUNITY BUILDING ACTIVITIES: ONGOING EFFORTS AND EVALUATION OF MANAGEMENT, STAFF, PHYSICIANS WITH FEEDBACK FROM PATIENTS AND COMMUNITY. DEMOGRAPHIC RESEARCH AND STUDIES ALSO UTILIZED TO DETERMINE TYPE AND QUANTITY OF SERVICES NEEDED BY SPECIALTY TO BEST SERVE OUR COMMUNITY. PART III, LINE 4: ALTHOUGH NOT DESCRIBED IN THE FOOTNOTES TO THE HOSPITAL'S FINANCIAL STATEMENTS, THE PRACTICE OF THE HOSPITAL IS TO RECORD BAD DEBT EXPENSE AT THE UNPAID BALANCES AFTER CONTRACTUAL DISCOUNTS FOR PATIENT'S WITH INSURANCE AND AT THE FULL OR DISCOUNTED CHARGE LEVEL FOR THOSE WHO DO NOT HAVE INSURANCE. THE HOSPITAL NEGOTIATES WITH PAYERS TO COME UP WITH A FAIR DISCOUNTED RATE TO BE PAID FOR SERVICES RENDERED. THESE DISCOUNTS ARE NOT RECORDED AS BAD DEBT EXPENSES. SIMILARLY FOR PATIENTS WITHOUT ANY INSURANCE, THE HOSPITAL OFFERS SEVERAL DIFFERENT DISCOUNT PROGRAMS, BASED UPON FINANCIAL NEED, TO THESE PATIENTS AND ONCE AGAIN THESE DISCOUNTS ARE NOT RECORDED AS BAD DEBTS. FOR PATIENTS WHO DO NOT MEET OR DO NOT FOLLOW-THROUGH TO DEMONSTRATE FINANCIAL HARDSHIP, THE HOSPITAL DOES EXPECT TO BE REIMBURSED AT OUR FULL CHARGE LEVEL. ALL OF THE REMAINING BALANCES THAT ARE NOT PAID ARE RECORDED AS BAD DEBTS.THE HOSPITAL HAS COSTED THE BAD DEBT EXPENSE IN LINE 2 OF THIS SECTION AT THE FULL UNPAID CONTRACTED RATE FOR PATIENTS WITH INSURANCE AS THIS REPRESENTS THE "CONTRACTED COST" FOR THE SERVICE AND THUS NOT APPLICABLE TO AN OVERALL COST-TO-CHARGE RATION. FOR PATIENTS WITH NO INSURANCE, THE COSTS ON LINE 2 REPRESENT THE FULL CHARGE LEVELS MULTIPLIED BY THE OVERALL COST-TO-CHARGE RATIO FROM THE AUDITED FINANCIAL STATEMENTS.THE CRITERIA THE HOSPITAL USES FOR DISTINGUISHING BETWEEN CHARITY CARE AND BAD DEBT IS THAT IN ORDER FOR A PATIENT TO QUALIFY AS CHARITY CARE, THEY MUST SHARE THEIR FINANCIAL INFORMATION AND SHOW THAT THEY FALL WITHIN THE FEDERAL POVERTY GUIDELINES. THUS THE HOSPITAL BELIEVES THAT 23% OF THE FIGURE RECORDED AS BAD DEBT EXPENSE ON LINE 2 WOULD QUALIFY FOR CHARITY CARE IF THE PATIENTS HAD SHARED THEIR FINANCIAL INFORMATION. THIS PERCENTAGE WAS DERIVED FROM DEMOGRAPHIC STUDIES OF THE COMMUNITY FOR FAMILIES FALLING BELOW THE FEDERAL POVERTY GUIDELINES IN OUR MARKET AREA. THUS THIS AMOUNT SHOULD BE INCLUDED IN THE TOTAL COMMUNITY BENEFIT PROVIDED BY THE HOSPITAL. PART III, LINE 8: THE HOSPITAL CONTENDS THAT THE ENTIRE AMOUNT OF THE MEDICARE SHORTFALL SHOULD ALSO BE CONSIDERED AS A COMMUNITY BENEFIT. THE REASON FOR THIS IS THAT THE MEDICARE RATES ARE SET UNILATERALLY BY THE FEDERAL GOVERNMENT AND THE HOSPITAL AGREES TO SERVICE THESE PATIENTS AT THESE RATES AS PART OF OUR MISSION AND SERVICE TO THE COMMUNITY.THE COST INCLUDED ON LINE 6 COMES FROM THE MEDICARE COST REPORT WHICH THE FEDERAL GOVERNMENT HAS SET UP AS THEIR WAY TO CAPTURE AND SEGREGATE THE COSTS OF SERVICES PROVIDED TO MEDICARE PATIENTS. PART III, LINE 9B: THE HOSPITAL PRACTICE IS THAT UPON VERIFICATION THAT A PATIENT QUALIFIES FOR CHARITY OR FINANCIAL ASSISTANCE, THE HOSPITAL DISCONTINUES COLLECTION EFFORTS AND MAKES THE APPROPRIATE ADJUSTMENT TO THE PATIENT'S ACCOUNT BASED UPON THE PATIENT'S INDIVIDUAL CIRCUMSTANCES. PART VI, LINE 2: ONGOING EFFORTS AND EVALUATION OF MANAGEMENT, STAFF, PHYSICIANS WITH FEEDBACK FROM PATIENTS AND COMMUNITY. DEMOGRAPHIC RESEARCH AND STUDIES ALSO UTILIZED TO DETERMINE TYPE AND QUANTITY OF SERVICES NEEDED BY SPECIALTY TO BEST SERVE OUR COMMUNITY. PART VI, LINE 3: INFORMATION REGARDING FINANCIAL ASSISTANCE AND CHARITY CARE IS MADE AVAILABLE AT TIME OF REGISTRATION, ON THE HOSPITAL'S WEBSITE, AND ON PATIENT STATEMENTS. APPLICATIONS ARE ALSO MADE AVAILABLE TO PATIENTS AT TIME OF REGISTRATION IF APPROPRIATE. PART VI, LINE 4: EAST LIVERPOOL CITY HOSPITAL IS THE ONLY HOSPITAL WITHIN 20 MILES OF THE CITY. THE HOSPITAL SERVES PATIENTS WITHIN A 10-15 MILE RADIUS INCLUDING PATIENTS FROM NEIGHBORING PENNSYLVANIA AND WEST VIRGINIA. MOST RESIDENTS HAVE LIVED HERE ALL THEIR LIVES AND THE COMMUNITY SERVED IS COMPRISED OF A SIGNIFICANT BIAS OF SENIOR CITIZENS. PART VI, LINE 5: EAST LIVERPOOL CITY HOSPITAL HAS AN OPEN MEDICAL STAFF, A COMMUNITY BOARD OF TRUSTEES AND IS EXTREMELY GENEROUS WITH FUNDING COMMUNITY CHARITIES AND DONATING EMPLOYEE TIME TO SERVE THE GENERAL POPULATION OF THE AREA SERVED. PART VI, LINE 6: NOT APPLICABLE 1 COMMUNITY RESOURCE CENTER 940 PENNSYLVANIA AVE EAST LIVERPOOL OH 43920 501C3 7000 MEALS OR FOOD TO COMMUNITY ELHS JOB TRAINING PROGRAM 500 MARYLAND AVENUE EAST LIVERPOOL OH 43920 501C3 5500 FUNDING TO ASSIST WITH PLACEMENT OF HIGH SCHOOL KIDS WITH DISABILITIES RSVP (RX PROGRAM) 966 1/2 NORTH MARKET STREET LISBON OH 44432 501C3 9994 FUNDING OF MEDICATION SERVICES CERAMIC CITY SENIOR CENTER 600 E 4TH STREET EAST LIVERPOOL OH 43920 501C3 5000 COMMUNITY SUPPORT TEAM MOJO PO BOX 44 EAST LIVERPOOL OH 43920 501C3 7000 COMMUNITY SUPPORT 5 PART I, LINE 2: THE ORGANIZATION MAINTAINS RECORDS TO SUBSTANTIATE THE AMOUNT OF GRANTS OR ASSISTANCE, AND THE SELECTION CRITERIA USED TO AWARD THE GRANTS OR ASSISTANCE. SCHEDULE I DEAR COMMUNITY BENEFIT FUND APPLICANT: THE COMMUNITY BENEFIT INITIATIVE PROGRAM (CBI), WHICH IS ADMINISTERED BY EAST LIVERPOOL CITY HOSPITAL, INVITES YOUR APPLICATION TO RECEIVE FUNDING FOR YOUR PROGRAM, PROJECT, OR ACTIVITY. EACH YEAR, CBI SUPPORTS PROJECTS AND ACTIVITIES THAT IMPROVE LOCAL HEALTH STATUS, IMPROVE THE QUALITY OF LIFE, AND PROVIDE A BENEFIT TO OUR COMMUNITY AND RESIDENTS. WE ARE CONTINUALLY LOOKING FOR NEW AND INNOVATIVE PROJECTS THAT TARGET AN UNMET NEED OR UNDERSERVED SEGMENT OF OUR POPULATION. ELCH MAKES INVESTMENTS IN COMMUNITY ASSETS AND THOSE GRANTED FUNDING ARE NOT MERELY RECIPIENTS, BUT HAVE SHARED ACCOUNTABILITY FOR IMPROVING HEALTH AND QUALITY OF LIFE IN OUR COMMUNITY. OVER THE PAST SEVERAL YEARS, THE NUMBER OF REQUESTS FOR PROJECT FUNDING HAS INCREASED DRAMATICALLY. IN AN EFFORT TO REDUCE DUPLICATION OF SERVICES, EFFICIENTLY USE EXISTING RESOURCES, AND INSURE THE INTEGRITY OF THE PROGRAMS OFFERED, WE ARE REQUESTING THAT YOUR AGENCY OR ORGANIZATION PROVIDE THE FOLLOWING INFORMATION: A. GENERAL INFORMATION 1. LOCAL ORGANIZATION APPLYING _______________________________________________________________ (NAME OF ORGANIZATION OR AGENCY) _______________________________________________________________ (LOCAL STREET ADDRESS) _______________________________________________________________ (CITY) (STATE) (ZIP) (COUNTY) 2. LOCAL DIRECTOR / LOCAL CONTACT PERSON OF ORGANIZATION OR AGENCY APPLYING _______________________________________________________________ (NAME/TITLE) (PHONE) _______________________________________________________________ (FAX) (EMAIL) 3. IF PROJECT IS APPROVED, LIST CONTACT NAME, TITLE, AND ADDRESS WHERE FUNDING SHOULD BE SENT: ____________________________________________________________ ____________________________________________________________ B. PROJECT INFORMATION FOR CALENDAR YEAR 2014 1. WHAT IS THE TOTAL BUDGET FOR THE PROJECT OR ACTIVITY? $___________ 2. AMOUNT OF FUNDING BEING REQUESTED FROM ELCH? $_________________ 3. WILL THERE BE ADDITIONAL FUNDING SOURCES? _____YES _____NO PLEASE LIST SOURCES: SOURCE __________________________AMOUNT $ __________________ SOURCE __________________________AMOUNT $ __________________ SOURCE __________________________AMOUNT $ __________________ 4. WHAT IS THE PROJECT / ACTIVITY TIME PERIOD? FROM: _______________________ TO: _______________________ 5. WHAT IS THE OVERALL MISSION OF YOUR AGENCY OR PROGRAM? 6. A. LIST TWO SPECIFIC COMMUNITY NEEDS, QUALITY OF LIFE, OR HEALTH CONCERNS AFFECTING OUR RESIDENTS: 1. ________________________________________________________ 2. ________________________________________________________ B. BRIEFLY SUMMARIZE YOUR PROJECT / ACTIVITY, 2014 GOALS, AND THE PURPOSE FOR THE REQUESTED FUNDING: C. EXPLAIN HOW THIS PROGRAM SPECIFICALLY ADDRESSES THE NEEDS LISTED IN QUESTION 6A: D. WHAT ARE THE GEOGRAPHIC LIMITS OF THIS PROGRAM OR AGENCY (EX: INDIVIDUALS RESIDE IN EAST LIVERPOOL, CHESTER, MIDLAND, ETC) AND DESCRIBE THE POPULATION SERVED: 7. HOW DO YOU TRACK THE EFFECTIVENESS OF YOUR PROJECT OR PROGRAM? (EX: DO YOU HAVE A DESIGNATED PERSON OR COMMITTEE THAT COMPILES DATA QUARTERLY, ANNUALLY, ETC? WHAT SYSTEM IS IN PLACE TO AVOID DUPLICATION OF EFFORTS?) 8. LIST COLLABORATING AGENCIES: (PRIORITY CONSIDERATION WILL BE GIVEN TO THOSE WHO SHOW COLLABORATIVE EFFORT WITH OTHER AGENCIES TO BUILD PARTNERSHIPS AND DECREASE DUPLICATION OF SERVICES) B. CERTIFICATION AS A CONDITION OF RECEIVING A GRANT, THE APPLICANT AGREES TO PROVIDE TO EAST LIVERPOOL CITY HOSPITAL: TWO EVALUATION REPORTS, ONE TO BE SUBMITTED BY APRIL 30, 2014 AND THE SECOND TO BE SUBMITTED BY AUGUST 31, 2014, DESCRIBING HOW FUNDS HAVE BEEN USED, MEASURABLE RESULTS (WHO WAS SERVED BY THE PROGRAM ACTIVITIES AND ACCOMPLISHMENTS), AND PLANS FOR CONTINUING THE PROGRAM AFTER THIS YEAR. THE APPLICANT ALSO AGREES TO CONTACT THE PLANNING DEPARTMENT AND OBTAIN PERMISSION TO CREDIT EAST LIVERPOOL CITY HOSPITAL IN PUBLIC RELEASES AND REFERENCES TO PROJECTS, EQUIPMENT/MATERIALS PURCHASED, AND ACTIVITIES MADE POSSIBLE THROUGH THIS GRANT. I CERTIFY THAT THE FOREGOING INFORMATION IS TRUE TO THE BEST OF MY KNOWLEDGE AND THE TERMS OF THE GRANT HAVE BEEN MET. NAME _______________________________________________________ TITLE _________________________________DATE ________________ ALL APPLICATIONS AND SUBSEQUENT REPORTS SHOULD BE SENT TO: ROBERT STEFFEN PLANNING DEPARTMENT - EAST LIVERPOOL CITY HOSPITAL 425 WEST FIFTH STREET EAST LIVERPOOL, OH 43920 IF YOU HAVE ANY QUESTIONS PERTAINING TO THIS APPLICATION, I CAN BE REACHED AT (330) 386-2086. APPLICATIONS MUST BE RETURNED BY AUGUST 31, 2014. NOTE: THE RECEIPT OF THESE MONIES CARRIES NO OBLIGATION TO REFER OR OTHERWISE DIRECT PATIENTS TO SERVICES PROVIDED BY EAST LIVERPOOL CITY HOSPITAL. X X 1 1 X X X 0 0 0 0 0 0 0 0 0 KENNETH COCHRAN CEO 280678 0 48539 0 3500 0 0 0 0 0 332717 0 0 0 FRANK MADER INFORMATION SERVICES DIRECTOR 109368 0 0 0 0 0 23000 0 18655 0 151023 0 0 0 KYLE JOHNSON FORMER CFO FORMER CFO 191794 0 13264 0 0 0 0 0 20272 0 225330 0 0 0 PART I, LINE 1A CITY HOSPITAL ASSOCIATION ALLOWS COMPANION TRAVEL BY EXECUTIVES ONLY WHEN IT SERVES A JUSTIFIED BUSINESS PURPOSE. IF IT IS LATER DETERMINED THAT THERE WAS NOT A JUSTIFIED BUSINESS PURPOSE, THIS WILL RESULT IN TAXABLE COMPENSATION TO THE EXECUTIVE IN QUESTION. CITY HOSPITAL PROVIDES A MEMBERSHIP TO AN AREA SOCIAL CLUB IN ORDER FOR EXECUTIVES TO CONDUCT HOSPITAL BUSINESS. ANY PERSONAL USE BY THE EXECUTIVES IN INCLUDED IN THAT EXECUTIVE'S TAXABLE WAGES. A CITY OF EAST LIVERPOOL 346000900 2734505DU 2006-04-24 17165000 FINANCE THE ACQUISITION, CONSTRUCTION, INSTALLATION, & EQUIPPING FACILITIES 0 0 0 A 17165000 131212 33788 0 0 0 0 A 0 0 0 0 0 0 0 A 0 0 0 0 1 0 0 0 0 A 0 FORM 990, PART VI, SECTION A, LINE 6 TRI-COUNTY CARE SYSTEMS, INC. IS THE SOLE MEMBER FORM 990, PART VI, SECTION B, LINE 11 INFORMATION WAS COMPILED BY THE FINANCE DEPARTMENT AND REVIEWED BY A THIRD PARTY CPA FIRM. A FORMAL BOARD REVIEW DID NOT OCCUR THIS YEAR DUE TO TIME CONSTRAINTS. FORM 990, PART VI, SECTION B, LINE 12C ALL DUALITY OF INTEREST OR POSSIBLE CONFLICT OF INTEREST, ON THE PART OF ANY MEMBERS OF THE BOARD OF TRUSTEES, ON ANY ISSUE, SHOULD BE DISCLOSED TO THE OTHER MEMBERS OF THE BOARD OF TRUSTEES AND MADE A MATTER OF RECORD. ANY MEMBER OF THE BOARD OF TRUSTEES HAVING A DUALITY OF INTEREST OR POSSIBLE CONFLICT OF INTEREST, ON ANY MATTER SHOULD NOT VOTE OR USE HIS/HER PERSONAL INFLUENCE ON THE MATTER. THE MINUTES OF THE MEETING SHOULD REFLECT THAT A DISCLOSURE WAS MADE AND THE ABSTENTION FROM VOTING. FORM 990, PART VI, SECTION B, LINE 15 FOR THE CEO, EXECUTIVE DIRECTOR OR TOP MANAGEMENT: ESTABLISHED BY BOARD PERSONNEL COMPENSATION COMMITTEE AND REVIEWED AND APPROVED BY THE ENTIRE BOARD IN EXECUTIVE SESSION. FOR OTHER OFFICERS OR KEY EMPLOYEES: SUBMITTED AND REVIEWED BY BOARD CHAIRMAN AND THEN PRESENTED BY BOARD EXECUTIVE COMMITTEE FOR REVIEW AND APPROVAL. THE LAST REVIEW WAS COMPLETED IN NOVEMBER, 2012. FORM 990, PART VI, SECTION C, LINE 19 THE DOCUMENTS ARE AVAILABLE UPON REQUEST FORM 990, PART IX, LINE 11G COLLECTIONS: PROGRAM SERVICE EXPENSES 178,783. MANAGEMENT AND GENERAL EXPENSES 0. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 178,783. PURCHASED SERVICES: PROGRAM SERVICE EXPENSES 7,268,494. MANAGEMENT AND GENERAL EXPENSES 4,845,662. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 12,114,156. FORM 990, PART XI, LINE 9: CHANGE IN RESTRICTED NET ASSETS 4,351. TRANSFER TO AFFILIATES -4,380,179. EAST LIVERPOOL PROFESSIONALS 425 W 5TH STREET EAST LIVERPOOL OH 43290 PROFESSIONAL MEDICAL SERVICES OH TRI-COUNTY CARE TRI-COUNTY CARE SYSTEMS 425 W FIFTH EAST LIVERPOOL OH 43920 341552205 PARENT HOLDING COMPANY OH 501(C)(3) LINE 3 NONE 0 OHIO VALLEY HOME HEALTH SERVICES 15679 ST RTE 170 EAST LIVERPOOL OH 43920 341014198 HOME HEALTH SERVICES OH 501(C)(3) LINE 9 TRI-COUNTY CARE SYSTEMS 0 AMERICAN COMMUNITY SERVICES 422 W 6TH ST EAST LIVERPOOL OH 43290 341522019 MANAGEMENT SERVICES OH OHIO VALLEY HOME HEALTH SERVICES C 0 MONROE HEALTH 422 W 6TH ST EAST LIVERPOOL OH 43290 341562035 PHYSICIAN SERVICES OH AMERICAN COMMUNITY SERVICES C 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 0 OHIO VALLEY HOME HEALTH SERVICE R 3246000 CASH RIVER VALLEY PHYSICIANS R 1017015 CASH