COMMUNITY HOSPITALS AND WELLNESS CENTERS: Form 990, tax year 2014
View the entire original 990 at ProPublica ↗
- Organization
- COMMUNITY HOSPITALS AND WELLNESS CENTERS (EIN 34-1048666)
- Tax period
- 2014-10-01 to 2015-09-30
- Filed
- 2016-08-01
- IRS object ID
- 201612149349301291
- Schema version
- 2014v6.0
- Source
- Download XML · Original 990 at ProPublica
Every field in the e-filed return. Faint text is the IRS element name, for citing.
- Return header
- Form 990
- Schedule A
- Schedule C
- Schedule D
- Schedule H
- Schedule J
- Schedule K
- Schedule L
- Schedule O
- Schedule R
Return header ReturnHeader
| Field | Value | IRS element (for citing) |
|---|---|---|
| Return | 2016-08-01T15:49:35-05:00 | ReturnTs |
| Tax Period End | 2015-09-30 | TaxPeriodEndDt |
Preparer Firm PreparerFirmGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Preparer Firm EIN | 381357951 | PreparerFirmEIN |
Preparer Firm Name PreparerFirmName
| Field | Value | IRS element (for citing) |
|---|---|---|
| Business Name Line1 | PLANTE & MORAN PLLC | BusinessNameLine1Txt |
Preparer US Address PreparerUSAddress
| Field | Value | IRS element (for citing) |
|---|---|---|
| Address Line1 | 250 HIGH ST STE 100 | AddressLine1Txt |
| City | COLUMBUS | CityNm |
| State Abbreviation | OH | StateAbbreviationCd |
| ZIP | 43215 | ZIPCd |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Return Type | 990 | ReturnTypeCd |
| Tax Period Begin | 2014-10-01 | TaxPeriodBeginDt |
Filer Filer
| Field | Value | IRS element (for citing) |
|---|---|---|
| EIN | 341048666 | EIN |
Business Name BusinessName
| Field | Value | IRS element (for citing) |
|---|---|---|
| Business Name Line1 | COMMUNITY HOSPITALS & WELLNESS CENTERS | BusinessNameLine1Txt |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Business Name Control | COMM | BusinessNameControlTxt |
| Phone | 4196361131 | PhoneNum |
US Address USAddress
| Field | Value | IRS element (for citing) |
|---|---|---|
| Address Line1 | 433 W HIGH STREET | AddressLine1Txt |
| City | BRYAN | CityNm |
| State Abbreviation | OH | StateAbbreviationCd |
| ZIP | 43506 | ZIPCd |
Business Officer BusinessOfficerGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Person | CHAD D TINKEL | PersonNm |
| Person Title | CFO | PersonTitleTxt |
| Phone | 4196361131 | PhoneNum |
| Signature | 2016-07-26 | SignatureDt |
| Discuss With Paid Preparer | Yes (1) | DiscussWithPaidPreparerInd |
Preparer Person PreparerPersonGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Preparer Person | BERNIE OSTROWSKI | PreparerPersonNm |
| PTIN | P00366367 | PTIN |
| Phone | 6148493000 | PhoneNum |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Tax | 2014 | TaxYr |
| Build TS | 2016-12-15 16:53:06Z | BuildTS |
Form 990 IRS990
| Field | Value | IRS element (for citing) |
|---|---|---|
| Principal Officer | PHILIP ENNEN | PrincipalOfficerNm |
US Address USAddress
| Field | Value | IRS element (for citing) |
|---|---|---|
| Address Line1 | 433 W HIGH STREET | AddressLine1Txt |
| City | BRYAN | CityNm |
| State Abbreviation | OH | StateAbbreviationCd |
| ZIP | 43506 | ZIPCd |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Gross Receipts | $77,722,937 | GrossReceiptsAmt |
| Group Return For Affiliates | 0 | GroupReturnForAffiliatesInd |
| Organization501c3 | Yes (X) | Organization501c3Ind |
| Website Address | WWW.CHWCHOSPITAL.ORG | WebsiteAddressTxt |
| Type Of Organization Corp | Yes (X) | TypeOfOrganizationCorpInd |
| Formation | 1969 | FormationYr |
| Legal Domicile State | OH | LegalDomicileStateCd |
| Activity Or Mission | TO PROVIDE QUALITY PATIENT CARE AT EVERY POINT OF SERVICE; TO RESPECT THE DIGNITY AND UNIQUENESS OF ALL PATIENTS; TO PROMOTE SAFE MEDICAL PRACTICES; TO ENCOURAGE MEDICAL RESEARCH; TO PERMIT ACCESS TO ALL SEEKING HEALTHCARE; AND TO MAINTAIN FISCAL SOUNDNESS. | ActivityOrMissionDesc |
| Voting Members Governing Body | 11 | VotingMembersGoverningBodyCnt |
| Voting Members Independent | 8 | VotingMembersIndependentCnt |
| Total Employee | 791 | TotalEmployeeCnt |
| Total Volunteers | 90 | TotalVolunteersCnt |
| Total Gross UBI | -$829 | TotalGrossUBIAmt |
| Net Unrelated Bus Txbl Incm | -$829 | NetUnrelatedBusTxblIncmAmt |
| PY Contributions Grants | $17,218 | PYContributionsGrantsAmt |
| CY Contributions Grants | $62,035 | CYContributionsGrantsAmt |
| PY Program Service Revenue | $75,752,631 | PYProgramServiceRevenueAmt |
| CY Program Service Revenue | $75,434,529 | CYProgramServiceRevenueAmt |
| PY Investment Income | $763,961 | PYInvestmentIncomeAmt |
| CY Investment Income | $1,035,677 | CYInvestmentIncomeAmt |
| PY Other Revenue | $801,689 | PYOtherRevenueAmt |
| CY Other Revenue | $688,886 | CYOtherRevenueAmt |
| PY Total Revenue | $77,335,499 | PYTotalRevenueAmt |
| CY Total Revenue | $77,221,127 | CYTotalRevenueAmt |
| PY Grants And Similar Paid | $0 | PYGrantsAndSimilarPaidAmt |
| CY Grants And Similar Paid | $0 | CYGrantsAndSimilarPaidAmt |
| PY Benefits Paid To Members | $0 | PYBenefitsPaidToMembersAmt |
| CY Benefits Paid To Members | $0 | CYBenefitsPaidToMembersAmt |
| PY Salaries Comp Emp Bnft Paid | $40,434,701 | PYSalariesCompEmpBnftPaidAmt |
| CY Salaries Comp Emp Bnft Paid | $39,195,086 | CYSalariesCompEmpBnftPaidAmt |
| PY Total Prof Fndrsng Expns | $0 | PYTotalProfFndrsngExpnsAmt |
| CY Total Prof Fndrsng Expns | $0 | CYTotalProfFndrsngExpnsAmt |
| CY Total Fundraising Expense | $0 | CYTotalFundraisingExpenseAmt |
| PY Other Expenses | $35,289,583 | PYOtherExpensesAmt |
| CY Other Expenses | $34,219,746 | CYOtherExpensesAmt |
| PY Total Expenses | $75,724,284 | PYTotalExpensesAmt |
| CY Total Expenses | $73,414,832 | CYTotalExpensesAmt |
| PY Revenues Less Expenses | $1,611,215 | PYRevenuesLessExpensesAmt |
| CY Revenues Less Expenses | $3,806,295 | CYRevenuesLessExpensesAmt |
| Total Assets BOY | $149,596,635 | TotalAssetsBOYAmt |
| Total Assets EOY | $154,186,711 | TotalAssetsEOYAmt |
| Total Liabilities BOY | $76,360,106 | TotalLiabilitiesBOYAmt |
| Total Liabilities EOY | $76,464,102 | TotalLiabilitiesEOYAmt |
| Net Assets Or Fund Balances BOY | $73,236,529 | NetAssetsOrFundBalancesBOYAmt |
| Net Assets Or Fund Balances EOY | $77,722,609 | NetAssetsOrFundBalancesEOYAmt |
| Info In Schedule O Part III | Yes (X) | InfoInScheduleOPartIIIInd |
| Mission | TO PROVIDE QUALITY PATIENT CARE AT EVERY POINT OF SERVICE; TO RESPECT THE DIGNITY AND UNIQUENESS OF ALL PATIENTS; TO PROMOTE SAFE MEDICAL PRACTICES; TO ENCOURAGE MEDICAL RESEARCH; TO PERMIT ACCESS TO ALL SEEKING HEALTHCARE; AND TO MAINTAIN FISCAL SOUNDNESS. | MissionDesc |
| Significant New Program Srvc | 0 | SignificantNewProgramSrvcInd |
| Significant Change | 0 | SignificantChangeInd |
| Expense | $11,171,011 | ExpenseAmt |
| Grant | $0 | GrantAmt |
| Revenue | $10,903,994 | RevenueAmt |
| Desc | INPATIENT CARE: BRYAN HOSPITAL MEDICAL & SURGICAL UNIT HAS 54 BEDS AND PROVIDE CARE FOR 812 INPATIENTS AND 321 OBSERVATION PATIENTS; BRYAN HOSPITAL PEDIATRIC UNIT HAS 6 BEDS AND PROVIDE CARE FOR 22 INPATIENTS AND 39 OBSERVATION PATIENTS; BRYAN HOSPITAL INTENSIVE CARE UNIT AND TELEMETRY UNIT HAS 16 BEDS AND PROVIDE CARE FOR 796 INPATIENTS AND 437 OBSERVATION PATIENTS; BRYAN HOSPITAL OBSTETRICS HAS 9 BEDS AND PROVIDED CARE FOR 310 INPATIENTS. MONTPELIER HOSPITAL HAS 25 BEDS AND PROVIDED CARE TO 343 INPATIENTS. | Desc |
Prog Srvc Accom Acty2 ProgSrvcAccomActy2Grp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Expense | $10,043,196 | ExpenseAmt |
| Grant | $0 | GrantAmt |
| Revenue | $11,496,062 | RevenueAmt |
| Desc | SURGERY CARE: BRYAN SURGERY HAS 6 OPERATING ROOMS THAT DID 1,806 GENERAL SURGERY CASES, 2,303 PAIN MANAGEMENT CASES, 698 ORTHOPEDIC CASES, 599 OPHTHALMOLOGY CASES, 466 GYNECOLOGY CASES, 90 ENT CASES, AND 234 UROLOGY CASES. ARCHBOLD SURGERY HAS 4 OPERATING ROOMS THAT DID 291 ORTHOPEDIC CASES, 115 GENERAL SURGERY CASES, AND 156 UROLOGY CASES. | Desc |
Prog Srvc Accom Acty3 ProgSrvcAccomActy3Grp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Expense | $4,284,968 | ExpenseAmt |
| Grant | $0 | GrantAmt |
| Revenue | $3,926,127 | RevenueAmt |
| Desc | EMERGENCY ROOM CARE: BRYAN ED CARED FOR 13,954 PATIENTS WITH 1090 BEING ADMITTED; MONTPELIER ED CARED FOR 4,486 PATIENTS WITH 10 BEING ADMITTED. | Desc |
Prog Srvc Accom Acty Other ProgSrvcAccomActyOtherGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Expense | $26,063,315 | ExpenseAmt |
| Grant | $0 | GrantAmt |
| Revenue | $49,108,346 | RevenueAmt |
| Desc | COMMUNITY HOSPITALS AND WELLNESS CENTERS PROVIDED SERVICES TO APPROXIMATELY 2,500 INPATIENTS, APPROXIMATELY 1,150 OBSERVATION PATIENTS, AND APPROXIMATELY 18,500 EMERGENCY DEPARTMENT PATIENTS DURING THIS FISCAL YEAR. THE HOSPITAL UTILIZES A BOARD APPROVED CHARITABLE CARE PROGRAM THAT MEASURES INDIVIDUAL AND FAMILY NEEDS BASED ON FEDERAL POVERTY GUIDELINES. THE PROGRAM IS APPLIED UNIFORMLY ACROSS ALL LEVELS OF HOSPITAL SERVICES. THE PROGRAM EXTENDS BEYOND THE FEDERAL POVERTY DEFINITIONS TO ALLOW THE HOSPITAL TO PROVIDE FREE AND/OR SUBSIDIZED CARE FOR PERSONS FALLING WITHIN AND BEYOND THE FEDERAL GUIDELINES. THIS PROGRAM PROVIDED ASSISTANCE TO APPROXIMATELY 5,050 ACCOUNTS DURING THIS FISCAL YEAR. | Desc |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Other Prog Srvc Expense | $26,063,315 | TotalOtherProgSrvcExpenseAmt |
| Total Other Prog Srvc Grant | $0 | TotalOtherProgSrvcGrantAmt |
| Total Other Prog Srvc Revenue | $49,108,346 | TotalOtherProgSrvcRevenueAmt |
| Total Program Service Expenses | $51,562,490 | TotalProgramServiceExpensesAmt |
| Described In Section501c3 | Yes (1) | DescribedInSection501c3Ind |
| Schedule B Required | 0 | ScheduleBRequiredInd |
| Political Campaign Acty | 0 | PoliticalCampaignActyInd |
| Lobbying Activities | Yes (1) | LobbyingActivitiesInd |
| Subject To Proxy Tax | 0 | SubjectToProxyTaxInd |
| Donor Advised Fund | 0 | DonorAdvisedFundInd |
| Conservation Easements | 0 | ConservationEasementsInd |
| Collections Of Art | 0 | CollectionsOfArtInd |
| Credit Counseling | 0 | CreditCounselingInd |
| Temp Or Permanent Endowments | 0 | TempOrPermanentEndowmentsInd |
| Report Land Building Equipment | Yes (1) | ReportLandBuildingEquipmentInd |
| Report Investments Other Sec | 0 | ReportInvestmentsOtherSecInd |
| Report Program Related Invst | 0 | ReportProgramRelatedInvstInd |
| Report Other Assets | 0 | ReportOtherAssetsInd |
| Report Other Liabilities | Yes (1) | ReportOtherLiabilitiesInd |
| Include FIN48 Footnote | Yes (1) | IncludeFIN48FootnoteInd |
| Independent Audit Fincl Stmt | 0 | IndependentAuditFinclStmtInd |
| Consolidated Audit Fincl Stmt | Yes (1) | ConsolidatedAuditFinclStmtInd |
| School Operating | 0 | SchoolOperatingInd |
| Foreign Office | 0 | ForeignOfficeInd |
| Foreign Activities | 0 | ForeignActivitiesInd |
| More Than5000 K To Org | 0 | MoreThan5000KToOrgInd |
| More Than5000 K To Individuals | 0 | MoreThan5000KToIndividualsInd |
| Professional Fundraising | 0 | ProfessionalFundraisingInd |
| Fundraising Activities | 0 | FundraisingActivitiesInd |
| Gaming Activities | 0 | GamingActivitiesInd |
| Operate Hospital | Yes (1) | OperateHospitalInd |
| Audited Financial Stmt Att | Yes (1) | AuditedFinancialStmtAttInd |
| Grants To Organizations | 0 | GrantsToOrganizationsInd |
| Grants To Individuals | 0 | GrantsToIndividualsInd |
| Schedule J Required | Yes (1) | ScheduleJRequiredInd |
| Tax Exempt Bonds | Yes (1) | TaxExemptBondsInd |
| Invest Tax Exempt Bonds | Yes (1) | InvestTaxExemptBondsInd |
| Escrow Account | 0 | EscrowAccountInd |
| On Behalf Of Issuer | 0 | OnBehalfOfIssuerInd |
| Engaged In Excess Benefit Trans | 0 | EngagedInExcessBenefitTransInd |
| PY Excess Benefit Trans | 0 | PYExcessBenefitTransInd |
| Loan Outstanding | 0 | LoanOutstandingInd |
| Grant To Related Person | 0 | GrantToRelatedPersonInd |
| Business Rln With Org Mem | 0 | BusinessRlnWithOrgMemInd |
| Business Rln With Fam Mem | 0 | BusinessRlnWithFamMemInd |
| Business Rln With Officer Ent | Yes (1) | BusinessRlnWithOfficerEntInd |
| Deductible Non Cash Contri | 0 | DeductibleNonCashContriInd |
| Deductible Art Contribution | 0 | DeductibleArtContributionInd |
| Terminate Operations | 0 | TerminateOperationsInd |
| Partial Liquidation | 0 | PartialLiquidationInd |
| Disregarded Entity | 0 | DisregardedEntityInd |
| Related Entity | Yes (1) | RelatedEntityInd |
| Related Organization Ctrl Ent | Yes (1) | RelatedOrganizationCtrlEntInd |
| Transaction With Control Ent | Yes (1) | TransactionWithControlEntInd |
| Trnsfr Exmpt Non Chrtbl Rltd Org | 0 | TrnsfrExmptNonChrtblRltdOrgInd |
| Activities Conducted Prtshp | 0 | ActivitiesConductedPrtshpInd |
| Schedule O Required | Yes (1) | ScheduleORequiredInd |
| IRP Document | 42 | IRPDocumentCnt |
| IRP Document W2 G | 0 | IRPDocumentW2GCnt |
| Backup Wthld Compliance | Yes (1) | BackupWthldComplianceInd |
| Employee | 791 | EmployeeCnt |
| Employment Tax Returns Filed | Yes (1) | EmploymentTaxReturnsFiledInd |
| Unrelated Bus Incm Over Limit | 0 | UnrelatedBusIncmOverLimitInd |
| Foreign Financial Account | 0 | ForeignFinancialAccountInd |
| Prohibited Tax Shelter Trans | 0 | ProhibitedTaxShelterTransInd |
| Taxable Party Notification | 0 | TaxablePartyNotificationInd |
| Nondeductible Contributions | 0 | NondeductibleContributionsInd |
| Quid Pro Quo Contributions | 0 | QuidProQuoContributionsInd |
| Form8282 Property Disposed Of | 0 | Form8282PropertyDisposedOfInd |
| Rcv Fnds To Pay Prsnl Bnft Cntrct | 0 | RcvFndsToPayPrsnlBnftCntrctInd |
| Pay Premiums Prsnl Bnft Cntrct | 0 | PayPremiumsPrsnlBnftCntrctInd |
| Indoor Tanning Services | 0 | IndoorTanningServicesInd |
| Info In Schedule O Part VI | Yes (X) | InfoInScheduleOPartVIInd |
| Governing Body Voting Members | 11 | GoverningBodyVotingMembersCnt |
| Independent Voting Member | 8 | IndependentVotingMemberCnt |
| Family Or Business Rln | Yes (1) | FamilyOrBusinessRlnInd |
| Delegation Of Mgmt Duties | 0 | DelegationOfMgmtDutiesInd |
| Change To Org Documents | 0 | ChangeToOrgDocumentsInd |
| Material Diversion Or Misuse | 0 | MaterialDiversionOrMisuseInd |
| Members Or Stockholders | 0 | MembersOrStockholdersInd |
| Election Of Board Members | 0 | ElectionOfBoardMembersInd |
| Decisions Subject To Approva | 0 | DecisionsSubjectToApprovaInd |
| Minutes Of Governing Body | Yes (1) | MinutesOfGoverningBodyInd |
| Minutes Of Committees | Yes (1) | MinutesOfCommitteesInd |
| Officer Mailing Address | 0 | OfficerMailingAddressInd |
| Local Chapters | 0 | LocalChaptersInd |
| Form990 Provided To Gvrn Body | Yes (1) | Form990ProvidedToGvrnBodyInd |
| Conflict Of Interest Policy | Yes (1) | ConflictOfInterestPolicyInd |
| Annual Disclosure Covered Prsn | Yes (1) | AnnualDisclosureCoveredPrsnInd |
| Regular Monitoring Enfrc | Yes (1) | RegularMonitoringEnfrcInd |
| Whistleblower Policy | Yes (1) | WhistleblowerPolicyInd |
| Document Retention Policy | Yes (1) | DocumentRetentionPolicyInd |
| Compensation Process CEO | Yes (1) | CompensationProcessCEOInd |
| Compensation Process Other | Yes (1) | CompensationProcessOtherInd |
| Investment In Joint Venture | Yes (1) | InvestmentInJointVentureInd |
| Written Policy Or Procedure | Yes (1) | WrittenPolicyOrProcedureInd |
| States Where Copy Of Return Is Fld | OH | StatesWhereCopyOfReturnIsFldCd |
| Upon Request | Yes (X) | UponRequestInd |
Books In Care Of Detail BooksInCareOfDetail
Business Name BusinessName
| Field | Value | IRS element (for citing) |
|---|---|---|
| Business Name Line1 | CHAD TINKEL | BusinessNameLine1Txt |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Phone | 4196361131 | PhoneNum |
US Address USAddress
| Field | Value | IRS element (for citing) |
|---|---|---|
| Address Line1 | 433 W HIGH STREET | AddressLine1Txt |
| City | BRYAN | CityNm |
| State Abbreviation | OH | StateAbbreviationCd |
| ZIP | 43506 | ZIPCd |
Form990 Part VII Section A Form990PartVIISectionAGrp (20 entries)
| TitleTitleTxt | Average Hours Per WeekAverageHoursPerWeekRt | Average Hours Per Week Rltd OrgAverageHoursPerWeekRltdOrgRt | Individual Trustee Or DirectorIndividualTrusteeOrDirectorInd | OfficerOfficerInd | Reportable Comp From OrgReportableCompFromOrgAmt | Reportable Comp From Rltd OrgReportableCompFromRltdOrgAmt | Other CompensationOtherCompensationAmt | Key EmployeeKeyEmployeeInd | Highest Compensated EmployeeHighestCompensatedEmployeeInd |
|---|---|---|---|---|---|---|---|---|---|
| PHILIP L ENNEN | |||||||||
| PRESIDENT/SECRETARY, CEO | 40.00 | 0.50 | Yes (X) | Yes (X) | $403,047 | $0 | $34,900 | ||
| KATRINA P HESTER | |||||||||
| CHAIRMAN | 0.10 | 0.10 | Yes (X) | Yes (X) | $0 | $0 | $0 | ||
| CHRISTOPHER CULLIS | |||||||||
| VICE CHAIRMAN/TREASURER | 0.10 | 0.10 | Yes (X) | Yes (X) | $0 | $0 | $0 | ||
| JIM WYSE | |||||||||
| DIRECTOR | 0.10 | 0.10 | Yes (X) | $0 | $0 | $0 | |||
| JAMES RUPP | |||||||||
| DIRECTOR | 0.10 | 0.10 | Yes (X) | $0 | $0 | $0 | |||
| BRUCE SPANGLER | |||||||||
| DIRECTOR | 0.10 | 0.10 | Yes (X) | $0 | $0 | $0 | |||
| KEVIN KOLOVICH MD | |||||||||
| DIRECTOR | 0.10 | 0.10 | Yes (X) | $0 | $0 | $0 | |||
| GLEN SEAMAN MD | |||||||||
| DIRECTOR | 0.10 | 0.10 | Yes (X) | $0 | $0 | $0 | |||
| CHRISTOPHER KANNEL | |||||||||
| DIRECTOR | 0.10 | 0.10 | Yes (X) | $0 | $0 | $0 | |||
| LARRY DEWIRE | |||||||||
| DIRECTOR | 0.10 | 0.10 | Yes (X) | $0 | $0 | $0 | |||
| DAVID SWANSON | |||||||||
| DIRECTOR | 0.10 | 0.10 | Yes (X) | $0 | $0 | $0 | |||
| GREGORY E SLATTERY | |||||||||
| VP/CIO | 40.00 | 0.00 | Yes (X) | $268,135 | $0 | $34,900 | |||
| MICHAEL CULLER | |||||||||
| VP/COO | 40.00 | 0.00 | Yes (X) | $198,728 | $0 | $34,900 | |||
| CHAD D TINKEL | |||||||||
| VP/CFO | 40.00 | 0.50 | Yes (X) | $245,660 | $0 | $35,740 | |||
| JANICE DAVID | |||||||||
| VP PATIENT CARE | 40.00 | 0.00 | $241,633 | $0 | $17,800 | Yes (X) | |||
| SHANNON KEIL | |||||||||
| PATHOLOGY PHYISICAN | 40.00 | 0.00 | $274,997 | $0 | $24,900 | Yes (X) | |||
| LARRY SIMON | |||||||||
| CRNA | 40.00 | 0.00 | $202,212 | $0 | $24,900 | Yes (X) | |||
| CRAIG BUELL | |||||||||
| DIRECTOR OF PHARMACY | 40.00 | 0.00 | $133,994 | $0 | $25,740 | Yes (X) | |||
| MARILYN NUSSBAUMER | |||||||||
| DIRECTOR CATH LAB | 40.00 | 0.00 | $151,576 | $0 | $7,800 | Yes (X) | |||
| GARY D BROWN | |||||||||
| ASST DIRECTOR PHARMACY | 40.00 | 0.00 | $119,645 | $0 | $25,740 | Yes (X) | |||
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Reportable Comp From Org | $2,239,627 | TotalReportableCompFromOrgAmt |
| Tot Reportable Comp Rltd Org | $0 | TotReportableCompRltdOrgAmt |
| Total Other Compensation | $267,320 | TotalOtherCompensationAmt |
| Indiv Rcvd Greater Than100 K | 18 | IndivRcvdGreaterThan100KCnt |
| Former Ofcr Employees Listed | 0 | FormerOfcrEmployeesListedInd |
| Total Comp Greater Than150 K | Yes (1) | TotalCompGreaterThan150KInd |
| Compensation From Other Srcs | 0 | CompensationFromOtherSrcsInd |
Contractor Compensation ContractorCompensationGrp (5 entries)
| Address Line1ContractorAddress/USAddress/AddressLine1Txt | CityContractorAddress/USAddress/CityNm | State AbbreviationContractorAddress/USAddress/StateAbbreviationCd | ZIPContractorAddress/USAddress/ZIPCd | ServicesServicesDesc | CompensationCompensationAmt |
|---|---|---|---|---|---|
| EMCARE PHYSICIAN SERVICES | |||||
| 350 WEST CEDAR STREET FOURTH FLOOR | PENSACOLA | FL | 32502 | ER PHYSICIAN SERVICES | $1,950,499 |
| AMERISOURCE BERGEN | |||||
| 1300 MORRIS DRIVE | CHESTERBROOK | PA | 19087 | PHARMACEUTICAL SUPPLIES | $1,632,469 |
| SENECA MEDICAL | |||||
| 85 SHAFFER PARK DRIVE | TIFFIN | OH | 44883 | MEDICAL SUPPLIES | $1,314,542 |
| BIOMET | |||||
| 56 E BELL DR | WARSAW | IN | 46582 | MEDICAL DEVICES | $1,073,285 |
| BOSTON SCIENTIFIC | |||||
| ONE BOSTON SCIENTIFIC PLACE | NATICK | MA | 01760 | MEDICAL DEVICES | $991,007 |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Cntrct Rcvd Greater Than100 K | 44 | CntrctRcvdGreaterThan100KCnt |
| All Other Contributions | $62,035 | AllOtherContributionsAmt |
| Total Contributions | $62,035 | TotalContributionsAmt |
Program Service Revenue ProgramServiceRevenueGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Desc | NET PATIENT REVENUES | Desc |
| Business | 621400 | BusinessCd |
| Total Revenue Column | $75,434,529 | TotalRevenueColumnAmt |
| Related Or Exempt Func Income | $75,434,529 | RelatedOrExemptFuncIncomeAmt |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Program Service Revenue | $75,434,529 | TotalProgramServiceRevenueAmt |
Investment Income InvestmentIncomeGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Revenue Column | $1,086,861 | TotalRevenueColumnAmt |
| Exclusion | $1,086,861 | ExclusionAmt |
Gross Rents GrossRentsGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Real | $360,277 | RealAmt |
Less Rental Expenses LessRentalExpensesGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Real | $326,016 | RealAmt |
Rental Income Or Loss RentalIncomeOrLossGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Real | $34,261 | RealAmt |
Net Rental Income Or Loss NetRentalIncomeOrLossGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Revenue Column | $34,261 | TotalRevenueColumnAmt |
| Exclusion | $34,261 | ExclusionAmt |
Gross Amount Sales Assets GrossAmountSalesAssetsGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Other | $124,610 | OtherAmt |
Less Cost Oth Basis Sales Expnss LessCostOthBasisSalesExpnssGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Other | $175,794 | OtherAmt |
Gain Or Loss GainOrLossGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Other | -$51,184 | OtherAmt |
Net Gain Or Loss Investments NetGainOrLossInvestmentsGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Revenue Column | -$51,184 | TotalRevenueColumnAmt |
| Exclusion | -$51,184 | ExclusionAmt |
Other Revenue Misc OtherRevenueMiscGrp (2 entries)
| DescDesc | BusinessBusinessCd | Total Revenue ColumnTotalRevenueColumnAmt | ExclusionExclusionAmt | Unrelated Business RevenueUnrelatedBusinessRevenueAmt |
|---|---|---|---|---|
| CAFETERIA/VENDING | 621400 | $655,454 | $655,454 | |
| LOSS FROM VANTAGE HEALTHCARE | 621400 | -$829 | -$829 |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Other Revenue Total | $654,625 | OtherRevenueTotalAmt |
Total Revenue TotalRevenueGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Revenue Column | $77,221,127 | TotalRevenueColumnAmt |
| Related Or Exempt Func Income | $75,434,529 | RelatedOrExemptFuncIncomeAmt |
| Unrelated Business Revenue | -$829 | UnrelatedBusinessRevenueAmt |
| Exclusion | $1,725,392 | ExclusionAmt |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Info In Schedule O Part IX | Yes (X) | InfoInScheduleOPartIXInd |
Comp Current Ofcr Directors CompCurrentOfcrDirectorsGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $1,225,591 | TotalAmt |
| Management And General | $1,225,591 | ManagementAndGeneralAmt |
Other Salaries And Wages OtherSalariesAndWagesGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $29,126,896 | TotalAmt |
| Program Services | $21,764,178 | ProgramServicesAmt |
| Management And General | $7,362,718 | ManagementAndGeneralAmt |
Pension Plan Contributions PensionPlanContributionsGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $763,476 | TotalAmt |
| Program Services | $550,375 | ProgramServicesAmt |
| Management And General | $213,101 | ManagementAndGeneralAmt |
Other Employee Benefits OtherEmployeeBenefitsGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $5,908,319 | TotalAmt |
| Program Services | $4,163,963 | ProgramServicesAmt |
| Management And General | $1,744,356 | ManagementAndGeneralAmt |
Payroll Taxes PayrollTaxesGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $2,170,804 | TotalAmt |
| Program Services | $1,576,725 | ProgramServicesAmt |
| Management And General | $594,079 | ManagementAndGeneralAmt |
Fees For Services Management FeesForServicesManagementGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $6,345,195 | TotalAmt |
| Program Services | $5,396,538 | ProgramServicesAmt |
| Management And General | $948,657 | ManagementAndGeneralAmt |
Fees For Services Legal FeesForServicesLegalGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $444,233 | TotalAmt |
| Management And General | $444,233 | ManagementAndGeneralAmt |
Fees For Services Accounting FeesForServicesAccountingGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $134,260 | TotalAmt |
| Management And General | $134,260 | ManagementAndGeneralAmt |
Advertising AdvertisingGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $328,133 | TotalAmt |
| Program Services | $328,133 | ProgramServicesAmt |
Office Expenses OfficeExpensesGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $2,819,493 | TotalAmt |
| Program Services | $764,509 | ProgramServicesAmt |
| Management And General | $2,054,984 | ManagementAndGeneralAmt |
Information Technology InformationTechnologyGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $341,615 | TotalAmt |
| Management And General | $341,615 | ManagementAndGeneralAmt |
Occupancy OccupancyGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $1,420,835 | TotalAmt |
| Program Services | $688,237 | ProgramServicesAmt |
| Management And General | $732,598 | ManagementAndGeneralAmt |
Travel TravelGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $116,000 | TotalAmt |
| Program Services | $65,064 | ProgramServicesAmt |
| Management And General | $50,936 | ManagementAndGeneralAmt |
Conferences Meetings ConferencesMeetingsGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $167,617 | TotalAmt |
| Program Services | $46,478 | ProgramServicesAmt |
| Management And General | $121,139 | ManagementAndGeneralAmt |
Interest InterestGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $1,712,351 | TotalAmt |
| Program Services | $852,830 | ProgramServicesAmt |
| Management And General | $859,521 | ManagementAndGeneralAmt |
Depreciation Depletion DepreciationDepletionGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $5,879,013 | TotalAmt |
| Program Services | $2,261,346 | ProgramServicesAmt |
| Management And General | $3,617,667 | ManagementAndGeneralAmt |
Insurance InsuranceGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $490,043 | TotalAmt |
| Program Services | $374,960 | ProgramServicesAmt |
| Management And General | $115,083 | ManagementAndGeneralAmt |
Other Expenses OtherExpensesGrp (4 entries)
| DescDesc | TotalTotalAmt | Program ServicesProgramServicesAmt | Management And GeneralManagementAndGeneralAmt |
|---|---|---|---|
| BILLABLE/NONBILLABLE SU | $8,076,455 | $8,076,455 | |
| REPAIRS AND MAINTENANCE | $3,396,109 | $2,171,352 | $1,224,757 |
| BAD DEBT EXPENSE | $1,889,419 | $1,889,419 | |
| TAXES | $1,359,052 | $1,276,510 | $82,542 |
All Other Expenses AllOtherExpensesGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | -$700,077 | TotalAmt |
| Program Services | -$684,582 | ProgramServicesAmt |
| Management And General | -$15,495 | ManagementAndGeneralAmt |
Total Functional Expenses TotalFunctionalExpensesGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $73,414,832 | TotalAmt |
| Program Services | $51,562,490 | ProgramServicesAmt |
| Management And General | $21,852,342 | ManagementAndGeneralAmt |
| Fundraising | $0 | FundraisingAmt |
Cash Non Interest Bearing CashNonInterestBearingGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $4,707,765 | BOYAmt |
| EOY | $3,496,119 | EOYAmt |
Savings And Temp Cash Invst SavingsAndTempCashInvstGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $24,717,913 | BOYAmt |
| EOY | $31,713,588 | EOYAmt |
Accounts Receivable AccountsReceivableGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $7,845,324 | BOYAmt |
| EOY | $8,469,949 | EOYAmt |
Inventories For Sale Or Use InventoriesForSaleOrUseGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $1,084,198 | BOYAmt |
| EOY | $1,244,414 | EOYAmt |
Prepaid Expenses Defrd Charges PrepaidExpensesDefrdChargesGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $1,826,531 | BOYAmt |
| EOY | $1,815,870 | EOYAmt |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Land Bldg Equip Cost Or Other Bss | $160,375,875 | LandBldgEquipCostOrOtherBssAmt |
| Land Bldg Equip Accum Deprec | $80,144,075 | LandBldgEquipAccumDeprecAmt |
Land Bldg Equip Basis Net LandBldgEquipBasisNetGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $84,560,995 | BOYAmt |
| EOY | $80,231,800 | EOYAmt |
Investments Pub Traded Sec InvestmentsPubTradedSecGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $22,499,036 | BOYAmt |
| EOY | $23,942,752 | EOYAmt |
Investments Other Securities InvestmentsOtherSecuritiesGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $735,853 | BOYAmt |
| EOY | $671,738 | EOYAmt |
Other Assets Total OtherAssetsTotalGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $1,619,020 | BOYAmt |
| EOY | $2,600,481 | EOYAmt |
Total Assets TotalAssetsGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $149,596,635 | BOYAmt |
| EOY | $154,186,711 | EOYAmt |
Accounts Payable Accr Expnss AccountsPayableAccrExpnssGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $6,963,075 | BOYAmt |
| EOY | $6,811,151 | EOYAmt |
Tax Exempt Bond Liabilities TaxExemptBondLiabilitiesGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $42,025,000 | BOYAmt |
| EOY | $41,195,000 | EOYAmt |
Mortg Notes Pybl Scrd Invst Prop MortgNotesPyblScrdInvstPropGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $23,099,758 | BOYAmt |
| EOY | $21,213,600 | EOYAmt |
Other Liabilities OtherLiabilitiesGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $4,272,273 | BOYAmt |
| EOY | $7,244,351 | EOYAmt |
Total Liabilities TotalLiabilitiesGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $76,360,106 | BOYAmt |
| EOY | $76,464,102 | EOYAmt |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Organization Follows SFAS117 | Yes (X) | OrganizationFollowsSFAS117Ind |
Unrestricted Net Assets UnrestrictedNetAssetsGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $73,236,529 | BOYAmt |
| EOY | $77,722,609 | EOYAmt |
Total Net Assets Fund Balance TotalNetAssetsFundBalanceGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $73,236,529 | BOYAmt |
| EOY | $77,722,609 | EOYAmt |
Tot Liab Net Assets Fund Balance TotLiabNetAssetsFundBalanceGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $149,596,635 | BOYAmt |
| EOY | $154,186,711 | EOYAmt |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Info In Schedule O Part XI | Yes (X) | InfoInScheduleOPartXIInd |
| Reconcilation Revenue Expnss | $3,806,295 | ReconcilationRevenueExpnssAmt |
| Net Unrlzd Gains Losses Invst | $345,044 | NetUnrlzdGainsLossesInvstAmt |
| Other Changes In Net Assets | $334,741 | OtherChangesInNetAssetsAmt |
| Info In Schedule O Part XII | Yes (X) | InfoInScheduleOPartXIIInd |
| Method Of Accounting Accrual | Yes (X) | MethodOfAccountingAccrualInd |
| Accountant Compile Or Review | 0 | AccountantCompileOrReviewInd |
| FS Audited | Yes (1) | FSAuditedInd |
FS Audited Basis FSAuditedBasisGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Consolidated Basis Fincl Stmt | Yes (X) | ConsolidatedBasisFinclStmtInd |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Audit Committee | Yes (1) | AuditCommitteeInd |
| Federal Grant Audit Required | 0 | FederalGrantAuditRequiredInd |
Schedule A IRS990ScheduleA
| Field | Value | IRS element (for citing) |
|---|---|---|
| Hospital | Yes (X) | HospitalInd |
Schedule C IRS990ScheduleC
| Field | Value | IRS element (for citing) |
|---|---|---|
| Volunteers | 0 | VolunteersInd |
| Paid Staff Or Management | 0 | PaidStaffOrManagementInd |
| Media Advertisements | 0 | MediaAdvertisementsInd |
| Mailings Members | 0 | MailingsMembersInd |
| Publications Or Broadcast | 0 | PublicationsOrBroadcastInd |
| Grants Other Organizations | 0 | GrantsOtherOrganizationsInd |
| Direct Contact Legislators | 0 | DirectContactLegislatorsInd |
| Rallies Demonstrations | 0 | RalliesDemonstrationsInd |
| Other Activities | Yes (1) | OtherActivitiesInd |
| Other Activities | $1,496 | OtherActivitiesAmt |
| Total Lobbying Expenditures | $1,496 | TotalLobbyingExpendituresAmt |
| Not Described Section501c3 | 0 | NotDescribedSection501c3Ind |
Supplemental Information Detail SupplementalInformationDetail
| Field | Value | IRS element (for citing) |
|---|---|---|
| Form And Line Reference | PART II-B, LINE 1: | FormAndLineReferenceDesc |
| Explanation | PART OF OHA DUES ARE ATTRIBUTED TO LOBBYING, TOTAL DUES WERE $41,565 OF WHICH 3.6% WERE CONTRIBUTED TO LOBBYING. | ExplanationTxt |
Schedule D IRS990ScheduleD
Land LandGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Investment Cost Or Other Basis | $830,800 | InvestmentCostOrOtherBasisAmt |
| Other Cost Or Other Basis | $2,124,658 | OtherCostOrOtherBasisAmt |
| Book Value | $2,955,458 | BookValueAmt |
Buildings BuildingsGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Other Cost Or Other Basis | $96,155,148 | OtherCostOrOtherBasisAmt |
| Depreciation | $25,967,146 | DepreciationAmt |
| Book Value | $70,188,002 | BookValueAmt |
Leasehold Improvements LeaseholdImprovementsGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Investment Cost Or Other Basis | $6,320,727 | InvestmentCostOrOtherBasisAmt |
| Depreciation | $3,771,513 | DepreciationAmt |
| Book Value | $2,549,214 | BookValueAmt |
Equipment EquipmentGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Other Cost Or Other Basis | $54,641,366 | OtherCostOrOtherBasisAmt |
| Depreciation | $50,188,661 | DepreciationAmt |
| Book Value | $4,452,705 | BookValueAmt |
Other Land Buildings OtherLandBuildingsGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Other Cost Or Other Basis | $303,176 | OtherCostOrOtherBasisAmt |
| Depreciation | $216,755 | DepreciationAmt |
| Book Value | $86,421 | BookValueAmt |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Book Value Land Buildings | $80,231,800 | TotalBookValueLandBuildingsAmt |
Other Liabilities Org OtherLiabilitiesOrgGrp (3 entries)
| DescDesc | AmtAmt |
|---|---|
| DEFERRED COMPENSATION | $406,218 |
| SETTLEMENTS PAYABLE UNDER THIRD PARTY REIMBURSEMENT CONTRACTS | $5,394,197 |
| INTEREST RATE SWAP | $1,443,936 |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Liability | $7,244,351 | TotalLiabilityAmt |
| Footnote Text | Yes (X) | FootnoteTextInd |
Supplemental Information Detail SupplementalInformationDetail
| Field | Value | IRS element (for citing) |
|---|---|---|
| Form And Line Reference | PART X, LINE 2: | FormAndLineReferenceDesc |
| Explanation | ACCOUNTING PRINCIPLES GENERALLY ACCEPTED IN THE UNITED STATES OF AMERICA REQUIRE MANAGEMENT TO EVALUATE TAX POSITIONS TAKEN BY THE HOSPITAL AND TO RECOGNIZE A TAX LIABILITY IF THE HOSPITAL 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. MANAGEMENT HAS ANALYZED THE TAX POSITIONS TAKEN BY THE HOSPITAL AND HAS CONCLUDED THAT AS OF SEPTEMBER 30, 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 CONSOLIDATED FINANCIAL STATEMENTS. THE HOSPITAL IS SUBJECT TO ROUTINE AUDITS BY TAXING JURISDICTIONS; HOWEVER, THERE ARE CURRENTLY NO AUDITS FOR ANY TAX PERIODS IN PROGRESS. MANAGEMENT BELIEVES THAT IT IS NO LONGER SUBJECT TO INCOME TAX EXAMINATIONS FOR YEARS PRIOR TO FISCAL YEAR 2012. | ExplanationTxt |
Schedule H IRS990ScheduleH
| Field | Value | IRS element (for citing) |
|---|---|---|
| Financial Assistance Policy | Yes (1) | FinancialAssistancePolicyInd |
| Written Policy | Yes (1) | WrittenPolicyInd |
| All Hospitals Policy | Yes (X) | AllHospitalsPolicyInd |
| FPG Reference Free Care | Yes (1) | FPGReferenceFreeCareInd |
| Percent200 | Yes (X) | Percent200Ind |
| FPG Reference Discounted Care | Yes (1) | FPGReferenceDiscountedCareInd |
| Percent300 | Yes (X) | Percent300Ind |
| Free Care Medically Indigent | Yes (1) | FreeCareMedicallyIndigentInd |
| Financial Assistance Budget | Yes (1) | FinancialAssistanceBudgetInd |
| Expenses Exceed Budget | 0 | ExpensesExceedBudgetInd |
| Annual Community Bnft Report | 0 | AnnualCommunityBnftReportInd |
Financial Assistance At Cost Typ FinancialAssistanceAtCostTyp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Community Benefit Expns | $3,152,838 | TotalCommunityBenefitExpnsAmt |
| Direct Offsetting Revenue | $3,220,843 | DirectOffsettingRevenueAmt |
| Net Community Benefit Expns | -$68,005 | NetCommunityBenefitExpnsAmt |
| Total Expense | 0.00000 | TotalExpensePct |
Unreimbursed Medicaid UnreimbursedMedicaidGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Community Benefit Expns | $10,173,725 | TotalCommunityBenefitExpnsAmt |
| Direct Offsetting Revenue | $4,725,614 | DirectOffsettingRevenueAmt |
| Net Community Benefit Expns | $5,448,111 | NetCommunityBenefitExpnsAmt |
| Total Expense | 0.07580 | TotalExpensePct |
Unreimbursed Costs UnreimbursedCostsGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Community Benefit Expns | $0 | TotalCommunityBenefitExpnsAmt |
| Direct Offsetting Revenue | $0 | DirectOffsettingRevenueAmt |
Total Financial Assistance Typ TotalFinancialAssistanceTyp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Community Benefit Expns | $13,326,563 | TotalCommunityBenefitExpnsAmt |
| Direct Offsetting Revenue | $7,946,457 | DirectOffsettingRevenueAmt |
| Net Community Benefit Expns | $5,380,106 | NetCommunityBenefitExpnsAmt |
| Total Expense | 0.07580 | TotalExpensePct |
Community Health Services CommunityHealthServicesGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Community Benefit Expns | $221,931 | TotalCommunityBenefitExpnsAmt |
| Direct Offsetting Revenue | $5,700 | DirectOffsettingRevenueAmt |
| Net Community Benefit Expns | $216,231 | NetCommunityBenefitExpnsAmt |
| Total Expense | 0.00300 | TotalExpensePct |
Total Other Benefits TotalOtherBenefitsGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Community Benefit Expns | $221,931 | TotalCommunityBenefitExpnsAmt |
| Direct Offsetting Revenue | $5,700 | DirectOffsettingRevenueAmt |
| Net Community Benefit Expns | $216,231 | NetCommunityBenefitExpnsAmt |
| Total Expense | 0.00300 | TotalExpensePct |
Total Community Benefits TotalCommunityBenefitsGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Community Benefit Expns | $13,548,494 | TotalCommunityBenefitExpnsAmt |
| Direct Offsetting Revenue | $7,952,157 | DirectOffsettingRevenueAmt |
| Net Community Benefit Expns | $5,596,337 | NetCommunityBenefitExpnsAmt |
| Total Expense | 0.07880 | TotalExpensePct |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Bad Debt Expense Reported | Yes (1) | BadDebtExpenseReportedInd |
| Bad Debt Expense | $1,889,419 | BadDebtExpenseAmt |
| Bad Debt Expense Attributable | $188,942 | BadDebtExpenseAttributableAmt |
| Reimbursed By Medicare | $21,080,214 | ReimbursedByMedicareAmt |
| Cost Of Care Reimbursed By Medcr | $25,405,056 | CostOfCareReimbursedByMedcrAmt |
| Medicare Surplus Or Shortfall | -$4,324,842 | MedicareSurplusOrShortfallAmt |
Costing Methodology Used CostingMethodologyUsedGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Cost To Charge Ratio | Yes (X) | CostToChargeRatioInd |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Written Debt Collection Policy | Yes (1) | WrittenDebtCollectionPolicyInd |
| Financial Assistance Prvsn | Yes (1) | FinancialAssistancePrvsnInd |
| Hospital Facilities | 2 | HospitalFacilitiesCnt |
Hospital Facilities HospitalFacilitiesGrp (2 entries)
| FacilityFacilityNum | Address Line1USAddress/AddressLine1Txt | CityUSAddress/CityNm | State AbbreviationUSAddress/StateAbbreviationCd | ZIPUSAddress/ZIPCd | Licensed HospitalLicensedHospitalInd | General Medical And SurgicalGeneralMedicalAndSurgicalInd | Emergency Room24 HrsEmergencyRoom24HrsInd | Critical Access HospitalCriticalAccessHospitalInd |
|---|---|---|---|---|---|---|---|---|
| BRYAN HOSPITAL | ||||||||
| 1 | 433 WEST HIGH STREET | BRYAN | OH | 43506 | Yes (X) | Yes (X) | Yes (X) | |
| MONTPELIER HOSPITAL | ||||||||
| 2 | 909 EAST SNYDER AVENUE | MONTPELIER | OH | 43543 | Yes (X) | Yes (X) | Yes (X) | |
Hospital Fclty Policies Prctc HospitalFcltyPoliciesPrctcGrp (2 entries)
| FacilityFacilityNum | First Licensed CY Or PYFirstLicensedCYOrPYInd | Tax Exempt Hospital CY Or PYTaxExemptHospitalCYOrPYInd | CHNA ConductedCHNAConductedInd | Community DefinitionCommunityDefinitionInd | Community DemographicsCommunityDemographicsInd | Existing ResourcesExistingResourcesInd | How Data ObtainedHowDataObtainedInd | Community Health NeedsCommunityHealthNeedsInd | Other Health IssuesOtherHealthIssuesInd | Community Hlth Needs Id ProcessCommunityHlthNeedsIdProcessInd | Consulting ProcessConsultingProcessInd | Information GapsInformationGapsInd | OtherOtherInd | CHNA ConductedCHNAConductedYr | Take Into Account Others InputTakeIntoAccountOthersInputInd | CHNA Conducted With Other FcltsCHNAConductedWithOtherFcltsInd | CHNA Conducted With Non FcltsCHNAConductedWithNonFcltsInd | CHNA Report Widely AvailableCHNAReportWidelyAvailableInd | Rpt Available On Own WebsiteRptAvailableOnOwnWebsiteInd | Own Website URLOwnWebsiteURLTxt | Other WebsiteOtherWebsiteInd | Other Website URLOtherWebsiteURLTxt | Paper Copy Public InspectionPaperCopyPublicInspectionInd | Rpt Available Thru Other MethodRptAvailableThruOtherMethodInd | Implementation Strategy AdoptImplementationStrategyAdoptInd | Implementation Strategy AdptImplementationStrategyAdptYr | Strategy Posted WebsiteStrategyPostedWebsiteInd | Strategy Website URLStrategyWebsiteURLTxt | Strategy AttachedStrategyAttachedInd | Organization Incur Excise TaxOrganizationIncurExciseTaxInd | Elig Criteria ExplainedEligCriteriaExplainedInd | FPG Family Incm Lmt Free DscntFPGFamilyIncmLmtFreeDscntInd | FPG Family Incm Lmt Free CareFPGFamilyIncmLmtFreeCarePct | FPG Family Incm Lmt Dscnt CareFPGFamilyIncmLmtDscntCarePct | Income Level CriteriaIncomeLevelCriteriaInd | Asset Level CriteriaAssetLevelCriteriaInd | Medical Indigency CriteriaMedicalIndigencyCriteriaInd | Explained BasisExplainedBasisInd | App Financial Asst ExplnAppFinancialAsstExplnInd | Described InfoDescribedInfoInd | Described Suprt DocDescribedSuprtDocInd | Provided Hospital ContactProvidedHospitalContactInd | Includes Publicity MeasuresIncludesPublicityMeasuresInd | FAP App Available On WebsiteFAPAppAvailableOnWebsiteInd | FAP App Available On Website URLFAPAppAvailableOnWebsiteURLTxt | FAP Avlbl On Request No ChargeFAPAvlblOnRequestNoChargeInd | FAP Actions On NonpaymentFAPActionsOnNonpaymentInd | Permit No ActionsPermitNoActionsInd | Collection ActivitiesCollectionActivitiesInd | FAP Notified Before DischargeFAPNotifiedBeforeDischargeInd | FAP Notified All PatientsFAPNotifiedAllPatientsInd | Documented Elig DeterminationDocumentedEligDeterminationInd | Other Actions TakenOtherActionsTakenInd | Nondis Emergency Care PolicyNondisEmergencyCarePolicyInd | Other Method UsedOtherMethodUsedInd | Amounts Generally BilledAmountsGenerallyBilledInd | Gross ChargesGrossChargesInd |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| BRYAN HOSPITAL | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| 1 | 0 | 0 | Yes (1) | Yes (X) | Yes (X) | Yes (X) | Yes (X) | Yes (X) | Yes (X) | Yes (X) | Yes (X) | Yes (X) | Yes (X) | 12 | Yes (1) | Yes (1) | Yes (1) | Yes (1) | Yes (X) | HTTP://WWW.CHWCHOSPITAL.ORG/COMMUNITYBENEFITS.ASP. | Yes (X) | HTTP://WWW.CHWCHOSPITAL.ORG/WP-CONTENT/UPLOADS/2014/08/BRYAN-HOSPITAL-CHA- | Yes (X) | Yes (X) | Yes (1) | 12 | Yes (1) | HTTP://WWW.CHWCHOSPITAL.ORG/COMMUNITYBENEFITS.ASP. | 0 | 0 | Yes (1) | Yes (X) | 200.000000000000 | 300.000000000000 | Yes (X) | Yes (X) | Yes (X) | Yes (1) | Yes (1) | Yes (X) | Yes (X) | Yes (X) | Yes (1) | Yes (X) | HTTPS://WWW.CHWCHOSPITAL.ORG/PATIENT-SERVICES/CHWC-FINANCIAL-ASSISTANCE/ | Yes (X) | Yes (1) | Yes (X) | 0 | Yes (X) | Yes (X) | Yes (X) | Yes (X) | Yes (1) | Yes (X) | 0 | 0 |
| MONTPELIER HOSPITAL | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| 2 | 0 | 0 | Yes (1) | Yes (X) | Yes (X) | Yes (X) | Yes (X) | Yes (X) | Yes (X) | Yes (X) | Yes (X) | Yes (X) | Yes (X) | 12 | Yes (1) | Yes (1) | Yes (1) | Yes (1) | Yes (X) | HTTP://WWW.CHWCHOSPITAL.ORG/COMMUNITYBENEFITS.ASP. | Yes (X) | HTTP://WWW.CHWCHOSPITAL.ORG/WP-CONTENT/UPLOADS/2014/08/MONTPELIER-HOSPITAL | Yes (X) | Yes (X) | Yes (1) | 12 | Yes (1) | HTTP://WWW.CHWCHOSPITAL.ORG/COMMUNITYBENEFITS.ASP. | 0 | 0 | Yes (1) | Yes (X) | 200.000000000000 | 300.000000000000 | Yes (X) | Yes (X) | Yes (X) | Yes (1) | Yes (1) | Yes (X) | Yes (X) | Yes (X) | Yes (1) | Yes (X) | HTTPS://WWW.CHWCHOSPITAL.ORG/PATIENT-SERVICES/CHWC-FINANCIAL-ASSISTANCE/ | Yes (X) | Yes (1) | Yes (X) | 0 | Yes (X) | Yes (X) | Yes (X) | Yes (X) | Yes (1) | Yes (X) | 0 | 0 |
Supplemental Information SupplementalInformationGrp (19 entries)
| Form And Line ReferenceFormAndLineReferenceDesc | ExplanationExplanationTxt |
|---|---|
| BRYAN HOSPITAL | PART V, SECTION B, LINE 3J: THE OVERALL GOAL OF THE NEEDS ASSESSMENT WAS TO PERFORM A COMMUNITY HEALTH ASSESSMENT THAT WILL LEAD TO IMPROVED QUALITY OF PUBLIC AND PRIVATE HEALTH SERVICES. IN ADDITION, THE HEALTH ASSESSMENT CAN BE USED FOR A VARIETY OF PURPOSES SUCH AS THE FOLLOWING:- TO ASSESS THE DISTRIBUTION OF DISEASE AND BEHAVIORAL RISK FACTORS.- TO ASSESS BROAD COMMUNITY HEALTH ISSUES AND TO SHAPE A BROADER DEFINITION OF COMMUNITY HEALTH.- TO MONITOR THE IMPACT OF COMMUNITY HEALTH ACTION PLANS AND TRENDS IN BEHAVIORAL RISK MODIFICATIONS. - TO PROVIDE A VEHICLE TO DISCUSS WAYS TO IMPROVE COMMUNITY HEALTH. THE STUDY CAN ASSIST STAKEHOLDERS WORKING COLLABORATIVELY IN THE COMMUNITY TO ADDRESS ISSUES THAT AFFECT HEALTH.THE COMMUNITY HEALTH ASSESSMENT WILL CONTINUE TO BE REPEATED EVERY THREE YEARS TO DETERMINE IF ACTIONS TAKEN BY COMMUNITIES ARE IMPACTING THE BEHAVIORS THAT LEAD TO POOR HEALTH. |
| MONTPELIER HOSPITAL | PART V, SECTION B, LINE 3J: THE OVERALL GOAL OF THE NEEDS ASSESSMENT WAS TO PERFORM A COMMUNITY HEALTH ASSESSMENT THAT WILL LEAD TO IMPROVED QUALITY OF PUBLIC AND PRIVATE HEALTH SERVICES. IN ADDITION, THE HEALTH ASSESSMENT CAN BE USED FOR A VARIETY OF PURPOSES SUCH AS THE FOLLOWING:- TO ASSESS THE DISTRIBUTION OF DISEASE AND BEHAVIORAL RISK FACTORS.- TO ASSESS BROAD COMMUNITY HEALTH ISSUES AND TO SHAPE A BROADER DEFINITION OF COMMUNITY HEALTH.- TO MONITOR THE IMPACT OF COMMUNITY HEALTH ACTION PLANS AND TRENDS IN BEHAVIORAL RISK MODIFICATIONS. - TO PROVIDE A VEHICLE TO DISCUSS WAYS TO IMPROVE COMMUNITY HEALTH. THE STUDY CAN ASSIST STAKEHOLDERS WORKING COLLABORATIVELY IN THE COMMUNITY TO ADDRESS ISSUES THAT AFFECT HEALTH.THE COMMUNITY HEALTH ASSESSMENT WILL CONTINUE TO BE REPEATED EVERY THREE YEARS TO DETERMINE IF ACTIONS TAKEN BY COMMUNITIES ARE IMPACTING THE BEHAVIORS THAT LEAD TO POOR HEALTH. |
| BRYAN HOSPITAL | PART V, SECTION B, LINE 5: THE COMMUNITY HEALTH NEEDS ASSESSMENT STRATEGIC PLANNING PROCESS WAS FACILITATED BY BRITNEY WARD, MPH, DIRECTOR OF COMMUNITY HEALTH IMPROVEMENT, FROM THE HOSPITAL COUNCIL OF NORTHWEST OHIO. THE COMMITTEE MET ON A QUARTERLY BASIS SINCE THE ORIGINAL CHNA WAS COMPLETED IN 2013.COMMITTEE MEMBERS:- AMERICAN CANCER SOCIETY - AMY BOEHM, JESSICA WEST- BOARD OF DEVELOPMENTAL DISABILITIES - DEBRA GUILFORD, DENNIS MYERS- BRYAN CITY SCHOOLS - DIANA SAVAGE- CLERGY - DAVID TILLY- COMMUNITY HEALTH & WELLNESS CENTERS - JAN DAVID, TAMMY DEGRYSE, PHIL ENNEN, MIKE FREEMAN, JESSICA REITZEL, JEANETTE ROBERTS, LINDA TRAUSCH- FOUR COUNTY ADAMHS BOARD - LES MCCASLIN- JOB & FAMILY SERVICES - PAMELA JOHNSON- NORTH CENTRAL SCHOOLS - KEN BOYER- PARKVIEW PHYSICIANS GROUP - KRYSTAL MILLER, SALLY TAYLOR- SAFE SCHOOLS HEALTHY STUDENTS - RON RITTICHIER- WILLIAMS COUNTY HEALTH DEPARTMENT - EMILY GOLIAS, MEGAN RILEY, BETH SCHWEITZER, BECKI SNYDER, JIM WATKINS- WILLIAMS COUNTY SHERIFF - STEVE TOWNS- UNITED WAY - BILL PEPPLE- YMCA - ROB IMBER |
| MONTPELIER HOSPITAL | PART V, SECTION B, LINE 5: THE COMMUNITY HEALTH NEEDS ASSESSMENT STRATEGIC PLANNING PROCESS WAS FACILITATED BY BRITNEY WARD, MPH, DIRECTOR OF COMMUNITY HEALTH IMPROVEMENT, FROM THE HOSPITAL COUNCIL OF NORTHWEST OHIO. THE COMMITTEE MET ON A QUARTERLY BASIS SINCE THE ORIGINAL CHNA WAS COMPLETED IN 2013.COMMITTEE MEMBERS:- AMERICAN CANCER SOCIETY - AMY BOEHM, JESSICA WEST- BOARD OF DEVELOPMENTAL DISABILITIES - DEBRA GUILFORD, DENNIS MYERS- BRYAN CITY SCHOOLS - DIANA SAVAGE- CLERGY - DAVID TILLY- COMMUNITY HEALTH & WELLNESS CENTERS - JAN DAVID, TAMMY DEGRYSE, PHIL ENNEN, MIKE FREEMAN, JESSICA REITZEL, JEANETTE ROBERTS, LINDA TRAUSCH- FOUR COUNTY ADAMHS BOARD - LES MCCASLIN- JOB & FAMILY SERVICES - PAMELA JOHNSON- NORTH CENTRAL SCHOOLS - KEN BOYER- PARKVIEW PHYSICIANS GROUP - KRYSTAL MILLER, SALLY TAYLOR- SAFE SCHOOLS HEALTHY STUDENTS - RON RITTICHIER- WILLIAMS COUNTY HEALTH DEPARTMENT - EMILY GOLIAS, MEGAN RILEY, BETH SCHWEITZER, BECKI SNYDER, JIM WATKINS- WILLIAMS COUNTY SHERIFF - STEVE TOWNS- UNITED WAY - BILL PEPPLE- YMCA - ROB IMBER |
| BRYAN HOSPITAL | PART V, SECTION B, LINE 6A: MONTPELIER HOSPITAL |
| MONTPELIER HOSPITAL | PART V, SECTION B, LINE 6A: BRYAN HOSPITAL |
| BRYAN HOSPITAL | PART V, SECTION B, LINE 6B: WILLIAMS COUNTY HEALTH DEPARTMENT |
| MONTPELIER HOSPITAL | PART V, SECTION B, LINE 6B: WILLIAMS COUNTY HEALTH DEPARTMENT |
| BRYAN HOSPITAL | PART V, SECTION B, LINE 7D: THE ASSESSMENT IS AVAILABLE ON THE FOLLOWING ADDITIONAL WEBSITES: WILLIAMS COUNTY GENERAL HEALTH DISTRICTHTTP://WWW.WILLIAMSCOUNTYHEALTH.ORG/WILLIAMSCOUNTYFINALHEALTHASSESSMENT.PDFHOSPITAL COUNCIL OF NORTHWEST OHIOHTTP://WWW.HCNO.ORG/PDF/COUNTIES/WILLIAMSCOUNTY2013HEALTHASSESSMENT.PDFALSO, CDS WITH A DIGITAL COPY OF THE FULL REPORT WERE GIVEN TO ALL KEY LEADERS AT COMMUNITY EVENT AND THESE ARE NOW MADE AVAILABLE TO ANYONE WHO MAY REQUEST THEM. |
| MONTPELIER HOSPITAL | PART V, SECTION B, LINE 7D: THE ASSESSMENT IS AVAILABLE ON THE FOLLOWING ADDITIONAL WEBSITES: WILLIAMS COUNTY GENERAL HEALTH DISTRICTHTTP://WWW.WILLIAMSCOUNTYHEALTH.ORG/WILLIAMSCOUNTYFINALHEALTHASSESSMENT.PDFHOSPITAL COUNCIL OF NORTHWEST OHIOHTTP://WWW.HCNO.ORG/PDF/COUNTIES/WILLIAMSCOUNTY2013HEALTHASSESSMENT.PDFALSO, CDS WITH A DIGITAL COPY OF THE FULL REPORT WERE GIVEN TO ALL KEY LEADERS AT COMMUNITY EVENT AND THESE ARE NOW MADE AVAILABLE TO ANYONE WHO MAY REQUEST THEM. |
| BRYAN HOSPITAL | PART V, SECTION B, LINE 11: RESOURCE RESTRICTIONS DO NOT ALLOW THE HOSPITAL TO ADDRESS ALL OF THE NEEDS IDENTIFIED THROUGH THE HEALTH ASSESSMENT. OF THE PRIORITY NEEDS IDENTIFIED BY THE COMMUNITY PLANNING PROCESS, THE HOSPITAL IS NOT DIRECTLY ADDRESSING THE ISSUES OF YOUTH AND ADULT OBESITY RELATED BEHAVIORS AND PREVENTIVE HEALTH. THIS IS BECAUSE MANY COMMUNITY AGENCIES ACROSS WILLIAMS COUNTY ARE ADDRESSING THESE ISSUES THROUGH THE FOLLOWING ACTION STEPS: BRYAN CITY SCHOOLS ARE GOING TO ORGANIZE A MEETING WITH ALL WILLIAMS COUNTY SCHOOL DISTRICT SUPERINTENDENTS TO OFFER SUPPORT, SERVICES, AND COORDINATE EFFORTS TO INCREASE SCHOOL NUTRITION. WILLIAMS COUNTY HEALTH DEPARTMENT IS GOING TO RESEARCH THE AWARENESS CAMPAIGN WE CAN! PROGRAM AND CREATE A COMMUNITY CALENDAR/GUIDE AND WELLNESS BLOG WITH THE MOST UP-TO-DATE INFORMATION REGARDING NUTRITION AND EXERCISE PROGRAMS AND OPPORTUNITIES IN WILLIAMS COUNTY. THE WILLIAMS COUNTY CITY HEALTH DEPARTMENT WILL ALSO INCORPORATE VARIOUS SECTORS OF THE COMMUNITY INTO THE COMMUNITY-WIDE PLAN (SUCH AS COMMUNITY ORGANIZATIONS, CHURCHES, POLITICAL OFFICIALS, LAW ENFORCEMENT, SCHOOLS, MEDIA, ETC.) THE PARKVIEW PHYSICIANS GROUP WILL WORK WITH PRIMARY CARE PHYSICIAN OFFICES TO ASSESS WHAT INFORMATION AND/OR MATERIALS THEY ARE LACKING TO PROVIDE BETTER CARE FOR OVERWEIGHT AND OBESE PATIENTS. THEY WILL ALSO COLLECT BASELINE DATA ON BUSINESSES AND ORGANIZATIONS OFFERING WELLNESS AND INSURANCE INCENTIVE PROGRAMS TO EMPLOYEES. THEY ARE GOING TO PROVIDE SECTORS WITH WAYS TO SUPPORT THE CAMPAIGN: POSTING OR HANDING OUT FLYERS, OFFERING THEIR FACILITY AS A FLU CLINIC SITE, OFFER FREE VACCINES TO EMPLOYEES, ETC.) PARKVIEW PHYSICIANS GROUP IS GOING TO COMPLETE A BASELINE SURVEY WITH PHYSICIAN'S OFFICES TO DETERMINE WHICH SCREENINGS THEY ARE RECOMMENDING.COMMUNITY MEMBER, SISTER RITA WILL OBTAIN BASELINE DATA REGARDING WHICH CITIES/TOWNS, SCHOOL DISTRICTS, CHURCHES, AND ORGANIZATIONS CURRENTLY HAVE COMMUNITY GARDENS AND/OR FARMER'S MARKETS. PARKVIEW PHYSICIAN GROUP WILL ENLIST PRIMARY CARE AND OB/GYN AND FAMILY PHYSICIAN OFFICES TO EDUCATE WOMEN OF CHILDBEARING AGE ON USING PRENATAL VITAMINS AND FOLIC ACID BEFORE GETTING PREGNANT, AND SEND EDUCATION ON PREGNANCY DO'S AND DON'TS WHEN PATIENT CALLS IN TO CONFIRM A PREGNANCY. THE IMPLEMENTATION STRATEGY IS POSTED ON THE HOSPITAL'S WEBSITE AT HTTP://WWW.CHWCHOSPITAL.ORG/COMMUNITYBENEFITS.ASP. |
| MONTPELIER HOSPITAL | PART V, SECTION B, LINE 11: RESOURCE RESTRICTIONS DO NOT ALLOW THE HOSPITAL TO ADDRESS ALL OF THE NEEDS IDENTIFIED THROUGH THE HEALTH ASSESSMENT. OF THE PRIORITY NEEDS IDENTIFIED BY THE COMMUNITY PLANNING PROCESS, THE HOSPITAL IS NOT DIRECTLY ADDRESSING THE ISSUES OF YOUTH AND ADULT OBESITY RELATED BEHAVIORS AND PREVENTIVE HEALTH. THIS IS BECAUSE MANY COMMUNITY AGENCIES ACROSS WILLIAMS COUNTY ARE ADDRESSING THESE ISSUES THROUGH THE FOLLOWING ACTION STEPS: BRYAN CITY SCHOOLS ARE GOING TO ORGANIZE A MEETING WITH ALL WILLIAMS COUNTY SCHOOL DISTRICT SUPERINTENDENTS TO OFFER SUPPORT, SERVICES, AND COORDINATE EFFORTS TO INCREASE SCHOOL NUTRITION. WILLIAMS COUNTY HEALTH DEPARTMENT IS GOING TO RESEARCH THE AWARENESS CAMPAIGN WE CAN! PROGRAM AND CREATE A COMMUNITY CALENDAR/GUIDE AND WELLNESS BLOG WITH THE MOST UP-TO-DATE INFORMATION REGARDING NUTRITION AND EXERCISE PROGRAMS AND OPPORTUNITIES IN WILLIAMS COUNTY. THE WILLIAMS COUNTY CITY HEALTH DEPARTMENT WILL ALSO INCORPORATE VARIOUS SECTORS OF THE COMMUNITY INTO THE COMMUNITY-WIDE PLAN (SUCH AS COMMUNITY ORGANIZATIONS, CHURCHES, POLITICAL OFFICIALS, LAW ENFORCEMENT, SCHOOLS, MEDIA, ETC.) THE PARKVIEW PHYSICIANS GROUP WILL WORK WITH PRIMARY CARE PHYSICIAN OFFICES TO ASSESS WHAT INFORMATION AND/OR MATERIALS THEY ARE LACKING TO PROVIDE BETTER CARE FOR OVERWEIGHT AND OBESE PATIENTS. THEY WILL ALSO COLLECT BASELINE DATA ON BUSINESSES AND ORGANIZATIONS OFFERING WELLNESS AND INSURANCE INCENTIVE PROGRAMS TO EMPLOYEES. THEY ARE GOING TO PROVIDE SECTORS WITH WAYS TO SUPPORT THE CAMPAIGN: POSTING OR HANDING OUT FLYERS, OFFERING THEIR FACILITY AS A FLU CLINIC SITE, OFFER FREE VACCINES TO EMPLOYEES, ETC.) PARKVIEW PHYSICIANS GROUP IS GOING TO COMPLETE A BASELINE SURVEY WITH PHYSICIAN'S OFFICES TO DETERMINE WHICH SCREENINGS THEY ARE RECOMMENDING.COMMUNITY MEMBER, SISTER RITA WILL OBTAIN BASELINE DATA REGARDING WHICH CITIES/TOWNS, SCHOOL DISTRICTS, CHURCHES, AND ORGANIZATIONS CURRENTLY HAVE COMMUNITY GARDENS AND/OR FARMER'S MARKETS. PARKVIEW PHYSICIAN GROUP WILL ENLIST PRIMARY CARE AND OB/GYN AND FAMILY PHYSICIAN OFFICES TO EDUCATE WOMEN OF CHILDBEARING AGE ON USING PRENATAL VITAMINS AND FOLIC ACID BEFORE GETTING PREGNANT, AND SEND EDUCATION ON PREGNANCY DO'S AND DON'TS WHEN PATIENT CALLS IN TO CONFIRM A PREGNANCY. THE IMPLEMENTATION STRATEGY IS POSTED ON THE HOSPITAL'S WEBSITE AT HTTP://WWW.CHWCHOSPITAL.ORG/COMMUNITYBENEFITS.ASP. |
| BRYAN HOSPITAL | PART V, SECTION B, LINE 20E: PAID UNITED COLLECTION AGENCY $1,000 PER MONTH TO IDENTIFY UNRESPONSIVE ACCOUNTS AS POSSIBLE CHARITABLE CARE RECIPIENTS BEFORE SENDING THE ACCOUNT TO A COLLECTION AGENCY. |
| MONTPELIER HOSPITAL | PART V, SECTION B, LINE 20E: PAID UNITED COLLECTION AGENCY $1,000 PER MONTH TO IDENTIFY UNRESPONSIVE ACCOUNTS AS POSSIBLE CHARITABLE CARE RECIPIENTS BEFORE SENDING THE ACCOUNT TO A COLLECTION AGENCY. |
| BRYAN HOSPITAL | PART V, SECTION B, LINE 22D: FINANCIAL APPLICATIONS NOT MEETING ELIGIBILITY FOR HCAP WILL BE REVIEWED BY THE PATIENT ACCOUNTS DIRECTOR, ALONG WITH ASSISTANCE FROM SOCIAL WORKERS, HOSPITAL PATIENT REPRESENTATIVES, AND THE PATIENT ACCOUNTS CLERK, TO DETERMINE THE APPROPRIATE LEVEL OF CHARITABLE DISCOUNT THAT CAN BE APPLIED TO THE VISITS. THE FOLLOWING CRITERIA ARE USED TO DETERMINE ELIGIBILITY FOR THE HOSPITAL CHARITABLE ASSISTANCE PROGRAM. 1. THE INCOME AND SLIDING DISCOUNT LEVELS ARE BASED ON THE MOST RECENT FEDERAL POVERTY INCOME GUIDELINES. 2. CURRENT GROSS INCOME IS USED TO DETERMINE THE LEVEL OF DISCOUNT, AND INCOME FOR THE MONTHS PRIOR TO SERVICE CAN BE USED TO SUPPORT ANY ADDITIONAL DISCOUNTS THAT MAY BE APPROPRIATE THROUGH THE EXCEPTIONS PROCESS. THE PT ACCTS DIRECTOR MAY ALSO USE BANK BALANCES AND OTHER WRITTEN DOCUMENTATION ABOUT THE FAMILY'S FINANCIAL SITUATION TO REQUEST A HIGHER DISCOUNT THROUGH THE EXCEPTIONS PROCESS.3. ANY PROOF OF INCOME PROVIDED WITH THE APPLICATION IS REVIEWED TO VERIFY ACCURACY WITH THE WRITTEN INFORMATION ON THE APPLICATION. PROOF OF INCOME IS NOT REQUIRED FOR THE HOSPITAL CHARITABLE ASSISTANCE PROGRAM BUT IS USUALLY PROVIDED TO DETERMINE IF THE PATIENT IS ELIGIBLE FOR HCAP.4. THE FAMILY SIZE DETERMINATION VARIES FOR THE HCAP PROGRAM. STEP-CHILDREN AND STEP-PARENTS, IN RELATIONSHIP TO THE PATIENT ARE INCLUDED IF THEY RESIDE IN THE SAME HOME. ALSO, CHILDREN OVER 18 ARE INCLUDED IN FAMILY SIZE, IF THE CHILD IS STILL SUPPORTED BY THE PARENT (CHILD IS STILL A STUDENT)5. CHILD SUPPORT PAID IS SUBTRACTED FROM GROSS INCOME TO DETERMINE THE APPROPRIATE INCOME LEVEL, WHEN THE CHILD IS NOT INCLUDED WITH THE FAMILY SIZE. CHILD SUPPORT RECEIVED IS ADDED TO THE GROSS INCOME WHEN THE CHILD IS INCLUDED WITH THE FAMILY SIZE. IF A CHILD IS THE PATIENT AND IS IN A FAMILY WITH SPLIT CUSTODY, WITH NO CHILD SUPPORT PAID BY EITHER PARENT, AND THE PARENT RESPONSIBLE FOR PAYING THE MEDICAL BILLS APPLIES FOR FINANCIAL ASSISTANCE, THE CHILD IS COUNTED AS HALF WHEN DETERMINING THE FAMILY SIZE. A DISCOUNT LEVEL HALF WAY BETWEEN THE INCOME LEVEL FOR THE FAMILY SIZE INCLUDING THE CHILD, AND THE INCOME LEVEL FOR THE FAMILY SIZE EXCLUDING THE CHILD, IS FIGURED AND USED TO DETERMINE THE CHARITY LEVEL. ADD THE 2 DISCOUNT LEVELS TOGETHER AND DIVIDE BY 2 TO DETERMINE THE AMOUNT THAT IS HALF WAY BETWEEN THE 2 FIGURES. IF THERE IS AN EVEN NUMBER OF CHILDREN IN THE FAMILY, COUNT HALF OF THE CHILDREN TO FIGURE FAMILY SIZE, WHEN THERE IS SPLIT CUSTODY, AND ONE PARENT IS RESPONSIBLE FOR PAYING THE MEDICAL BILLS. WHEN A CHILD IS THE PATIENT AND IS IN A FAMILY WITH SPLIT CUSTODY WITH NO CHILD SUPPORT PAID, AND BOTH PARENTS ARE RESPONSIBLE FOR PAYING THE MEDICAL BILL, BOTH BIOLOGICAL PARENTS INCOME SHOULD BE OBTAINED AND THE FAMILY SIZE WILL INCLUDE THE CHILD, BOTH BIOLOGICAL PARENTS AND ANY OTHER BIOLOGICAL OR ADOPTED SIBLINGS TO THE PATIENT. 6. THE PATIENT'S CHECKING AND SAVINGS ACCOUNT BALANCES (OR PARENTS IF THE PATIENT IS A MINOR) ARE REVIEWED TO DETERMINE IF RESOURCES ARE AVAILABLE TO PAY ON THE OUTSTANDING BALANCES. A GENERAL GUIDELINE IS FOLLOWED TO DETERMINE A REDUCTION IN THE DISCOUNT LEVEL BASED ON THE PATIENT'S CHECKING AND SAVINGS ACCOUNT BALANCES. IF 50% OF THE SAVINGS AND CHECKING ACCOUNT BALANCE IS EQUAL TO OR GREATER THAN THE OUTSTANDING ACCOUNT BALANCE, THE PERCENT OF DISCOUNT DETERMINED BY THE INCOME MAY BE REDUCED BY ONE LEVEL, UNLESS THE PATIENT ACCOUNTS DIRECTOR, CEO OR CFO DETERMINE OTHER CIRCUMSTANCES ALLOW THE FULL DISCOUNT WITH NO REDUCTION.LETTERS ARE SENT TO ALL GUARANTORS THAT APPLY FOR THE CHARITABLE ASSISTANCE PROGRAM, INCLUDING THOSE WHO DO NOT QUALIFY FOR A DISCOUNT. THE DISCOUNT WILL BE APPLIED TO ALL OPEN VISITS AT THE TIME THE APPLICATION IS RECEIVED, EXCLUDING BAD DEBT VISITS, UNLESS AUTHORIZED BY ADMINISTRATION. THE APPLICATION MAY ALSO BE USED FOR ADDITIONAL NEW ACCOUNTS FOR UP TO 90 DAYS FROM THE PREVIOUS APPLICATION DATE. THE TOTAL AMOUNT AND TOTAL NUMBER OF VISITS RECEIVING A CHARITY ADJUSTMENT FOR THE MONTH ARE PROVIDED ON A MONTHLY SUMMARY REPORT FOR THE BOARD OF DIRECTORS, ALONG WITH ANY VISITS FOR WHICH THE DIRECTOR IS REQUESTING APPROVAL FOR ADDITIONAL DISCOUNTS THROUGH THE EXCEPTIONS PROCESS. ON THE EXCEPTIONS REPORT, THE PATIENT ACCOUNTS DIRECTOR PROVIDES A BRIEF SUMMARY OF THE REASONS WHY THE GUARANTOR HAS EXTENUATING CIRCUMSTANCES TO QUALIFY FOR A HIGHER DISCOUNT THAN DETERMINED THROUGH THE NORMAL REVIEW PROCESS. THE DISCOUNT IS APPLIED AND THE LETTER IS SENT TO THE GUARANTOR AFTER THE CEO OR CFO SENDS A WRITTEN APPROVAL FOLLOWING THE BOARD MEETING.THE HOSPITAL PRESIDENT/CEO OR VP OF FINANCE MAY ALSO DETERMINE A VISIT TO BE ELIGIBLE FOR FINANCIAL ASSISTANCE, BASED ON INFORMATION THEY HAVE RECEIVED FROM THE PATIENT. THE PRESIDENT/CEO OR VP OF FINANCE WILL PROVIDE WRITTEN NOTICE TO THE PATIENT ACCOUNTS DIRECTOR TO APPLY THE DISCOUNT.BEGINNING IN JUNE 2008, VISITS DETERMINED TO BE CHARITY ELIGIBLE THROUGH THE I-SOLUTIONS PROGRAM, WILL RECEIVE CHARITY DISCOUNTS ACCORDING TO THE "SELF-PAY/COLLECTION POLICY." FOR THOSE WHO ARE NOT FAP-ELIGIBLE, THERE IS A PROMPT PAY DISCOUNT THAT IS EQUAL TO THE LOWEST NEGOTIATED COMMERCIAL INSURANCE RATE. |
| MONTPELIER HOSPITAL | PART V, SECTION B, LINE 22D: FINANCIAL APPLICATIONS NOT MEETING ELIGIBILITY FOR HCAP WILL BE REVIEWED BY THE PATIENT ACCOUNTS DIRECTOR, ALONG WITH ASSISTANCE FROM SOCIAL WORKERS, HOSPITAL PATIENT REPRESENTATIVES, AND THE PATIENT ACCOUNTS CLERK, TO DETERMINE THE APPROPRIATE LEVEL OF CHARITABLE DISCOUNT THAT CAN BE APPLIED TO THE VISITS. THE FOLLOWING CRITERIA ARE USED TO DETERMINE ELIGIBILITY FOR THE HOSPITAL CHARITABLE ASSISTANCE PROGRAM. 1. THE INCOME AND SLIDING DISCOUNT LEVELS ARE BASED ON THE MOST RECENT FEDERAL POVERTY INCOME GUIDELINES. 2. CURRENT GROSS INCOME IS USED TO DETERMINE THE LEVEL OF DISCOUNT, AND INCOME FOR THE MONTHS PRIOR TO SERVICE CAN BE USED TO SUPPORT ANY ADDITIONAL DISCOUNTS THAT MAY BE APPROPRIATE THROUGH THE EXCEPTIONS PROCESS. THE PT ACCTS DIRECTOR MAY ALSO USE BANK BALANCES AND OTHER WRITTEN DOCUMENTATION ABOUT THE FAMILY'S FINANCIAL SITUATION TO REQUEST A HIGHER DISCOUNT THROUGH THE EXCEPTIONS PROCESS.3. ANY PROOF OF INCOME PROVIDED WITH THE APPLICATION IS REVIEWED TO VERIFY ACCURACY WITH THE WRITTEN INFORMATION ON THE APPLICATION. PROOF OF INCOME IS NOT REQUIRED FOR THE HOSPITAL CHARITABLE ASSISTANCE PROGRAM BUT IS USUALLY PROVIDED TO DETERMINE IF THE PATIENT IS ELIGIBLE FOR HCAP.4. THE FAMILY SIZE DETERMINATION VARIES FOR THE HCAP PROGRAM. STEP-CHILDREN AND STEP-PARENTS, IN RELATIONSHIP TO THE PATIENT ARE INCLUDED IF THEY RESIDE IN THE SAME HOME. ALSO, CHILDREN OVER 18 ARE INCLUDED IN FAMILY SIZE, IF THE CHILD IS STILL SUPPORTED BY THE PARENT (CHILD IS STILL A STUDENT)5. CHILD SUPPORT PAID IS SUBTRACTED FROM GROSS INCOME TO DETERMINE THE APPROPRIATE INCOME LEVEL, WHEN THE CHILD IS NOT INCLUDED WITH THE FAMILY SIZE. CHILD SUPPORT RECEIVED IS ADDED TO THE GROSS INCOME WHEN THE CHILD IS INCLUDED WITH THE FAMILY SIZE. IF A CHILD IS THE PATIENT AND IS IN A FAMILY WITH SPLIT CUSTODY, WITH NO CHILD SUPPORT PAID BY EITHER PARENT, AND THE PARENT RESPONSIBLE FOR PAYING THE MEDICAL BILLS APPLIES FOR FINANCIAL ASSISTANCE, THE CHILD IS COUNTED AS HALF WHEN DETERMINING THE FAMILY SIZE. A DISCOUNT LEVEL HALF WAY BETWEEN THE INCOME LEVEL FOR THE FAMILY SIZE INCLUDING THE CHILD, AND THE INCOME LEVEL FOR THE FAMILY SIZE EXCLUDING THE CHILD, IS FIGURED AND USED TO DETERMINE THE CHARITY LEVEL. ADD THE 2 DISCOUNT LEVELS TOGETHER AND DIVIDE BY 2 TO DETERMINE THE AMOUNT THAT IS HALF WAY BETWEEN THE 2 FIGURES. IF THERE IS AN EVEN NUMBER OF CHILDREN IN THE FAMILY, COUNT HALF OF THE CHILDREN TO FIGURE FAMILY SIZE, WHEN THERE IS SPLIT CUSTODY, AND ONE PARENT IS RESPONSIBLE FOR PAYING THE MEDICAL BILLS. WHEN A CHILD IS THE PATIENT AND IS IN A FAMILY WITH SPLIT CUSTODY WITH NO CHILD SUPPORT PAID, AND BOTH PARENTS ARE RESPONSIBLE FOR PAYING THE MEDICAL BILL, BOTH BIOLOGICAL PARENTS INCOME SHOULD BE OBTAINED AND THE FAMILY SIZE WILL INCLUDE THE CHILD, BOTH BIOLOGICAL PARENTS AND ANY OTHER BIOLOGICAL OR ADOPTED SIBLINGS TO THE PATIENT. 6. THE PATIENT'S CHECKING AND SAVINGS ACCOUNT BALANCES (OR PARENTS IF THE PATIENT IS A MINOR) ARE REVIEWED TO DETERMINE IF RESOURCES ARE AVAILABLE TO PAY ON THE OUTSTANDING BALANCES. A GENERAL GUIDELINE IS FOLLOWED TO DETERMINE A REDUCTION IN THE DISCOUNT LEVEL BASED ON THE PATIENT'S CHECKING AND SAVINGS ACCOUNT BALANCES. IF 50% OF THE SAVINGS AND CHECKING ACCOUNT BALANCE IS EQUAL TO OR GREATER THAN THE OUTSTANDING ACCOUNT BALANCE, THE PERCENT OF DISCOUNT DETERMINED BY THE INCOME MAY BE REDUCED BY ONE LEVEL, UNLESS THE PATIENT ACCOUNTS DIRECTOR, CEO OR CFO DETERMINE OTHER CIRCUMSTANCES ALLOW THE FULL DISCOUNT WITH NO REDUCTION.LETTERS ARE SENT TO ALL GUARANTORS THAT APPLY FOR THE CHARITABLE ASSISTANCE PROGRAM, INCLUDING THOSE WHO DO NOT QUALIFY FOR A DISCOUNT. THE DISCOUNT WILL BE APPLIED TO ALL OPEN VISITS AT THE TIME THE APPLICATION IS RECEIVED, EXCLUDING BAD DEBT VISITS, UNLESS AUTHORIZED BY ADMINISTRATION. THE APPLICATION MAY ALSO BE USED FOR ADDITIONAL NEW ACCOUNTS FOR UP TO 90 DAYS FROM THE PREVIOUS APPLICATION DATE. THE TOTAL AMOUNT AND TOTAL NUMBER OF VISITS RECEIVING A CHARITY ADJUSTMENT FOR THE MONTH ARE PROVIDED ON A MONTHLY SUMMARY REPORT FOR THE BOARD OF DIRECTORS, ALONG WITH ANY VISITS FOR WHICH THE DIRECTOR IS REQUESTING APPROVAL FOR ADDITIONAL DISCOUNTS THROUGH THE EXCEPTIONS PROCESS. ON THE EXCEPTIONS REPORT, THE PATIENT ACCOUNTS DIRECTOR PROVIDES A BRIEF SUMMARY OF THE REASONS WHY THE GUARANTOR HAS EXTENUATING CIRCUMSTANCES TO QUALIFY FOR A HIGHER DISCOUNT THAN DETERMINED THROUGH THE NORMAL REVIEW PROCESS. THE DISCOUNT IS APPLIED AND THE LETTER IS SENT TO THE GUARANTOR AFTER THE CEO OR CFO SENDS A WRITTEN APPROVAL FOLLOWING THE BOARD MEETING.THE HOSPITAL PRESIDENT/CEO OR VP OF FINANCE MAY ALSO DETERMINE A VISIT TO BE ELIGIBLE FOR FINANCIAL ASSISTANCE, BASED ON INFORMATION THEY HAVE RECEIVED FROM THE PATIENT. THE PRESIDENT/CEO OR VP OF FINANCE WILL PROVIDE WRITTEN NOTICE TO THE PATIENT ACCOUNTS DIRECTOR TO APPLY THE DISCOUNT.BEGINNING IN JUNE 2008, VISITS DETERMINED TO BE CHARITY ELIGIBLE THROUGH THE I-SOLUTIONS PROGRAM, WILL RECEIVE CHARITY DISCOUNTS ACCORDING TO THE "SELF-PAY/COLLECTION POLICY." FOR THOSE WHO ARE NOT FAP-ELIGIBLE, THERE IS A PROMPT PAY DISCOUNT THAT IS EQUAL TO THE LOWEST NEGOTIATED COMMERCIAL INSURANCE RATE. |
| PART V, SECTION B, LINE 16 | FINANCIAL ASSISTANCE POLICY WEBSITE AVAILABILITY |
| BRYAN HOSPITAL PART V, SECTION B, LINE 16B WEBSITE: | HTTPS://WWW.CHWCHOSPITAL.ORG/PATIENT-SERVICES/CHWC-FINANCIAL-ASSISTANCE/ |
| MONTPELIER HOSPITAL PART V, SECTION B, LINE 16B WEBSITE: | HTTPS://WWW.CHWCHOSPITAL.ORG/PATIENT-SERVICES/CHWC-FINANCIAL-ASSISTANCE/ |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Facility | 3 | FacilityNum |
Oth Hlth Care Fclts Not Hospital OthHlthCareFcltsNotHospitalGrp
Oth Hlth Care Fclts OthHlthCareFcltsGrp (3 entries)
| Address Line1USAddress/AddressLine1Txt | CityUSAddress/CityNm | State AbbreviationUSAddress/StateAbbreviationCd | ZIPUSAddress/ZIPCd | FacilityFacilityTxt |
|---|---|---|---|---|
| ARCHBOLD MEDICAL CENTER | ||||
| 121 WESTFIELD DR | ARCHBOLD | OH | 43502 | OP SURGERY CENTER, OP RADIOLOGY, OP LAB, OP THERAPIES, AND MOB |
| RADIATION ONCOLOGY CENTER | ||||
| 524 WEST HIGH ST | BRYAN | OH | 43506 | RADIATION ONCOLOGY |
| WAUSEON INTERNAL MEDICINE CLINIC | ||||
| 447 NORTH SHOOP AVE | WAUSEON | OH | 43567 | PHYSICIAN OFFICE |
Supplemental Information Detail SupplementalInformationDetail (17 entries)
| Form And Line ReferenceFormAndLineReferenceDesc | ExplanationExplanationTxt |
|---|---|
| PART I, LINE 3C: | NOT APPLICABLE |
| PART I, LINE 6A: | NOT APPLICABLE |
| PART I, LINE 7: | CHARITY CARE AND MEDICAID COSTS WERE CALCULATED USING A COST TO CHARGE RATIO (51%) WHICH WAS DERIVED FROM WORKSHEET 2. |
| PART I, LINE 7G: | NOT APPLICABLE |
| PART I, LN 7 COL(F): | THE PERCENTAGE CALCULATED ON LINE 7F IS BASED ON TOTAL EXPENSES FROM FORM 990, PART IX, LESS BAD DEBTS IN THE AMOUNT OF $1,889,419. |
| PART I, LINE 7E: | THE PHARMACY DEPARTMENT HOLDS COMMUNITY MEDICATION RECONCILIATION DAYS. COLLECTED AND DISSEMINATED INFORMATION REGARDING AVAILABLE MEDICARE ADVANTAGE PLANS FOR WILLIAMS COUNTY RESIDENCE AT THE BRYAN SENIOR CENTER AND THE WILLIAMS COUNTY FAIR. BRYAN HOSPITAL HOSTED AND PRESENTED A PROGRAM TO RAISE AWARENESS AND PROVIDE EDUCATION REGARDING THE IMPORTANT CAUSE OF ORGAN, EYE AND TISSUE DONATIONS. ADVANCED CARDIAC LIFE SUPPORT (ACLS) AND PEDIATRIC ADVANCED LIFE SUPPORT (PALS) COURSES FOR PHYSICIANS, FOR OUR COUNTY EMS PROVIDERS, AND FOR EMPLOYEES OF OTHER HOSPITALS AT NO CHARGE. CPR COURSES TO AREA LIFEGUARDS AND COACHES AT NO CHARGE. PROVIDE CPR EQUIPMENT TO AREA SCHOOLS TO ALLOW THEM TO PROVIDE TRAINING. CHILDBIRTH EDUCATION CLASSES (INCLUDING PREPARED CHILDBIRTH, BABY CARE, SIBLING READINESS, AND BREAST FEEDING) AT NO CHARGE. HOSPITAL REPRESENTATIVES GAVE OVER 50 COMMUNITY PRESENTATIONS ON A VARIETY OF HEALTH CARE TOPICS. PHARMACY REPRESENTATIVES VISITED AREA PRESCHOOLS AND KINDERGARTENS AND PROVIDED 32 POISON PREVENTION PROGRAMS TO APPROXIMATELY 456 CHILDREN. PHARMACY PRECEPTOR STUDENTS WERE MADE AVAILABLE TO VISIT AREA SENIOR CENTERS AND EDUCATE SENIORS ON MEDICATION USE. OFFERED SPEAKERS FOR SMOKING CESSATION PROGRAMS. NURSING PROVIDE HAND HYGIENE PROGRAMS TO 50 KIDS. HOST CAREER DAY FOR LOCAL SCHOOLS EDUCATING STUDENTS ON OPPORTUNITIES IN HEALTH CARE PROFESSIONS. PROVIDE A FIELD PLACEMENT SETTING FOR SOCIAL WORK STUDENTS FROM AREA UNIVERSITIES. LACTATION CONSULTANT PROVIDED FOLLOW UP AND HOME VISITS WHEN NEEDED AT NO CHARGE. COUNSELING SERVICES AT NO CHARGE PROVIDED STRESS MANAGEMENT PRESENTATIONS FOR AREA BUSINESSES, AND PROVIDED DE-ESCALATION TRAINING FOR AREA COMMUNITY MENTAL HEALTH AGENCIES. OFFERED A DIABETIC SUPPORT GROUP THAT PROVIDES FREE MONTHLY MEETINGS TO APPROXIMATELY 10 PEOPLE. OFFERED NUTRITION PRESENTATIONS TO VARIOUS COMMUNITY GROUPS.COMMUNITY SUPPORT: CONTINUED OUR SOCIAL SERVICES PROGRAM THAT ASSISTS INDIVIDUALS IN OBTAINING MEDICATIONS WHEN PERSONAL FUNDS ARE NOT AVAILABLE. PROVIDED HEALTH INFORMATION AND HOSPITAL STAFF TO SUPPORT AREA INDUSTRIES EMPLOYEE HEALTH FAIRS. CONTINUED OUR SOCIAL SERVICES PROGRAM THAT ASSISTED INDIVIDUALS IN COMPLETING THEIR OWN ADVANCED DIRECTIVES (E.G. LIVING WILL AND DURABLE POWER OF ATTORNEY FOR HEALTH CARE). CONTINUED OUR SOCIAL SERVICES PROGRAM FOR A GRIEF SUPPORT GROUP FOR THE COMMUNITY. OFFER STROKE SUPPORT GROUP THAT MEETS ON A MONTHLY BASIS. OFFER A LOW VISION SUPPORT GROUP THAT MEETS ON A MONTHLY BASIS. OFFERED A SATURDAY SPORTS INJURY ASSESSMENT CLINIC AND PROVIDE THE CLINIC ASSESSMENT FREE OF CHARGE TO AT LEAST 60 AREA HIGH SCHOOL ATHLETES. PROVIDED FREE BLOODPRESSURE CHECKS THROUGH OUR EMERGENCY AND CARDIOPULMONARY DEPARTMENTS. PROVIDED 9,561 MEALS ON WHEELS FOR HOMEBOUND PEOPLE AT A FREE WILL DONATION. IN OUR WILLIAMS COUNTY AREA PROGRAM THIS INCLUDES PROVIDING STAFF AND VEHICLES TO DELIVER THE MEALS TO HOMES. PROVIDED RENT-FREE LIVING SPACE IN BRYAN, OHIO TO UT STUDENTS ASSOCIATED WITH BAHEC, TOTAL ANNUAL RELIEF TO 27 UT STUDENTS WAS $18,600. THE HOSPITAL COORDINATES OUTPATIENT SERVICES FOR CLIENTS OF THE LOCAL COMPASSION MEDICAL CLINIC, WHICH IS A NON-PROFIT CLINIC SERVING UNDER INSURED AND UNINSURED RESIDENTS OF WILLIAMS COUNTY. PAID UNITED COLLECTION AGENCY $35 PER UNRESPONSIVE ACCOUNT THAT THEY WERE ABLE TO REGISTER WITH HCAP OR MEDICAID. PAID UNITED COLLECTION AGENCY $1,000 PER MONTH TO IDENTIFY UNRESPONSIVE ACCOUNTS AS POSSIBLE CHARITABLE CARE RECIPIENTS BEFORE SENDING THE ACCOUNT TO A COLLECTION AGENCY. PROVIDED HEALTHINFORMATION AND HOSPITAL STAFF TO PROVIDE BLOOD PRESSURE AND BMI CHECKS FOR THE COUNTY HEALTH DEPARTMENT'S HEART HEALTH WALK/RUN AND FOR THE COUNTY FAIR. THE CARDIOPULMONARY REHABILITATION DEPARTMENT CONDUCTED 22 FITNESS ASSESSMENTS ON MEMBERS OF THE BRYAN FIRE DEPARTMENT AT NO CHARGE. PROVIDED FREE LUNCHES TO AREA TEACHERS AND STUDENTS TO RECOGNIZE STUDENTS OF THE MONTH TOTAL COSTS $800. PROVIDED BASIC SUPPLIES AND MEDICATIONS FOR VARIOUS MISSION TRIPS CONDUCTED BY EMPLOYEES AND MEDICAL STAFF. MAINTAIN AND SUSTAIN A DIABETIC SUPPORT GROUP THAT MEETS ON A MONTHLY BASIS AT THE HOSPITAL. PROVIDE FREE PATIENT NAVIGATOR PROGRAM, WHICH PROVIDES ASSISTANCE AND SUPPORT TO WOMEN IN TWO DISTINCT AREAS: WOMEN WHO ARE DIAGNOSED WITH BREAST CANCER AND WOMEN WHO ARE PREGNANT. PAID $5,000 TO HELP FUND THE CENTRAL OHIO POISON CENTER, WHICH 46 CALLS WERE PLACED FROM OUR COMMUNITY. HELPED FUND THE PURCHASE OF BOVIE MEDICAL CORPORATION AARON 1250-G AND SUPPORT MATERIALS FOR OUR SISTER HOSPITAL IN ADAMA, ETHIOPIA OUR COSTS WERE $8,000. |
| PART II, COMMUNITY BUILDING ACTIVITIES: | NOT APPLICABLE |
| PART III, LINE 2: | BAD DEBT WAS CALCULATED USING AUDITED FINANCIALS. |
| PART III, LINE 3: | ESTIMATE OF 10% OF TOTAL BAD DEBT EXPENSE IN ORDER TO CALCULATE THE AMOUNT RECORDED AS BAD DEBT THAT WOULD BE ATTRIBUTABLE TO PATIENTS WHO WOULD QUALIFY UNDER THE HOSPITAL'S CHARITY CARE POLICY. NONE OF THE BAD DEBT EXPENSE IS TREATED AS A COMMUNITY BENEFIT. |
| PART III, LINE 4: | ACCOUNTS RECEIVABLE ARE REDUCED BY AN ALLOWANCE FOR DOUBTFUL ACCOUNTS. IN EVALUATING THE COLLECTIBILITY OF ACCOUNTS RECEIVABLE, THE HOSPITAL ANALYZES ITS PAST HISTORY AND IDENTIFIES THRENDS FOR EACH OF ITS MAJOR PAYOR SOURCES OF REVENUE IN EVALUATING THE SUFFICIENCY OF THE ALLOWANCE FOR DOUBTFUL ACCOUNTS. FOR RECEIVABLES ASSOCIATED WITH SERVICES PROVIDED TO PATIENTS WHO HAVE THIRD-PARTY COVERAGE, THE HOSPITAL ANALYZES CONTRACTUAL DUE AMOUNTS AND PROVIDES AN ALLOWANCE FOR DOUBTFUL ACCOUNTS AND PROVISIONS FOR BAD DEBTS, IF NECESSARY. FOR RECEIVABLES ASSOCIATED WITH SELF-PAY PATIENTS (WHICH INCLUDE BOTH PATIENTS WITHOUT INSURANCE AND PATIENTS WITH DEDUCTIBLE AND COPAYMENT BALANCES DUE FOR WHICH THIRD-PARTY COVERAGE EXISTS FOR PART OF THE BILL), THE HOSPITAL RECORDS A SIGNIFICANT PROVISION FOR BAD DEBTS IN THE PERIOD OF SERVICE ON THE BASIS OF ITS PAST EXPERIENCE, WHICH INDICATES THAT MANY PATIENTS ARE UNABLE OR UNWILLING TO PAY THE PORTION OF THEIR BILL FOR WHICH THEY ARE FINANCIALLY RESPONSIBLE. THE DIFFERENCE BETWEEN THE STANDARD RATES (OR THE DISCOUNTED RATES IF NEGOTIATED) AND THE AMOUNTS ACTUALLY COLLECTED AFTER ALL REASONABLE COLLECTION EFFORTS HAVE BEEN EXHAUSTED IS CHARGED OFF AGAINST THE ALLOWANCE FOR DOUBTFUL ACCOUNTS. |
| PART III, LINE 8: | MEDICARE COSTS WERE CALCULATED USING A COST TO CHARGE RATIO BASED ON METHODOLOGY REQUIRED FOR COMPLETING THE MEDICARE COST REPORT. THE SHORTFALL IS CONSIDERED COMMUNITY BENEFIT DUE TO THE ELDERLY POPULATION IN THE HOSPITAL'S SERVICE AREA. |
| PART III, LINE 9B: | ALL SELF-PAY BALANCES ARE BILLED ON STATEMENTS AT THIRTY DAY INTERVALS. THE PATIENT REP WILL SET UP MONTHLY PAYMENTS ACCORDING TO THE FOLLOWING GUIDELINES:THE GUARANTOR IS ASKED TO PAY IN FULL. IF PAYMENT IN FULL IS NOT POSSIBLE, THE GUARANTOR IS ASKED TO MAKE MONTHLY PAYMENTS TO PAY THE ACCOUNT IN FULL WITHIN 18 MONTHS, WITH A MINIMUM PAYMENT OF $50 PER MONTH. IF THE GUARANTOR IS NOT ABLE TO AGREE TO THESE ARRANGEMENTS, HE/SHE IS ASKED TO COMPLETE A FINANCIAL APPLICATION TO DETERMINE ELIGIBILITY FOR FINANCIAL ASSISTANCE. IF NO PAYMENT IS RECEIVED OR ARRANGEMENT ESTABLISHED WITHIN 60 DAYS OF THE INITIAL STATEMENT, A "PAST DUE LETTER" IS SENT TO THE GUARANTOR WITH A REQUEST TO PAY IN FULL OR CONTACT PATIENT ACCOUNTS WITHIN 30 DAYS. IF THE GUARANTOR DOES NOT RESPOND BY THE DUE DATE ON THIS LETTER OR ACCEPTABLE PAYMENTS HAVE NOT BEEN ESTABLISHED, THE VISIT IS REVIEWED BY THE PATIENT ACCOUNTS DIRECTOR TO DETERMINE ELIGIBILITY FOR BAD DEBT AND COLLECTION AGENCY PROCESSING. PRIOR TO SENDING THE ACCOUNT TO COLLECTION, THE PATIENT ACCOUNTS DIRECTOR SENDS THE ACCOUNTS TO "I-SOLUTIONS" TO REVIEW ACCOUNTS FOR COLLECTABILITY. IF ANY ACCOUNT IS DETERMINED THROUGH THIS PROCESS TO BE ELIGIBLE FOR CHARITY, THE ACCOUNT WILL RECEIVE A 100% CHARITY WRITE OFF. ANY ACCOUNT ON THE REPORT THAT LISTS A MAXIMUM PAYMENT AMOUNT THAT IS LESS THAN THE ACCOUNT BALANCE AND THAT FALLS IN THE "BD OR "LOW" PROPENSITY TO PAY CATEGORY WILL RECEIVE A CHARITY ADJUSTMENT THAT REDUCES THE BALANCE ON THE ACCOUNT TO THE I-SOLUTIONS CALCULATED MAXIMUM PAYMENT AMOUNT. BEGINNING OCTOBER 1, 2008, ACCOUNTS WITH NO LISTED PROPENSITY TO PAY AND A MAXIMUM PAYMENT LESS THAN THE CHARGES WILL ALSO RECEIVE THE SAME CHARITY DISCOUNT. THE BALANCE EQUAL TO THE MAXIMUM PAYMENT AMOUNT IS THEN ADJUSTED TO BAD DEBT AND SENT TO COLLECTION ALONG WITH ALL OTHER ACCOUNTS ELIGIBLE FOR BAD DEBT WRITE OFF. THE HOSPITAL HAS ADDED A STATEMENT TO THE ADMISSION FORM AUTHORIZING THE HOSPITAL TO REVIEW THE GUARANTOR'S CREDIT INFORMATION. IF THIS IS NOT SIGNED BY THE PATIENT, THE ACCOUNT WILL NOT BE SENT TO I-SOLUTIONS FOR COLLECTABILITY REVIEW. IT WILL BE FORWARDED DIRECTLY TO THE COLLECTION AGENCY. ACCOUNTS LISTED IN BAD DEBT ARE NOT CONSIDERED TO BE ACTIVE ACCOUNTS ON THE HOSPITAL SYSTEM. THE COLLECTION AGENCY MAKES ARRANGEMENTS FOR PAYMENTS AND MONITORS THE PAYMENTS. THE HOSPITAL CAN ACCEPT DIRECT PAYMENTS ON THE ACCOUNTS, BUT THE GUARANTOR SHOULD BE ENCOURAGED TO MAKE PAYMENT DIRECT TO THE COLLECTION AGENCY. A REPORT OF PAYMENTS MADE DIRECT TO THE HOSPITAL IS FAXED TO THE COLLECTION AGENCY EVERY MONDAY THRU FRIDAY. THE PATIENT ACCOUNTS DIRECTOR AUTHORIZES THE COLLECTION AGENCY TO FILE A LEGAL SUIT IN ORDER TO OBTAIN PAYMENT WHEN THE GUARANTOR IS UNCOOPERATIVE. IF AN ACCOUNT SENT TO COLLECTION IS LATER DETERMINED TO QUALIFY FOR CHARITY CARE, COLLECTION EFFORTS STOP ON THE APPROVED AMOUNT. |
| PART VI, LINE 2: | THE NEEDS ASSESSMENT WAS A COMBINED ASSESSMENT WITH THE WILLIAMS COUNTY OHIO PUBLIC HEALTH DEPARTMENT AND MIDWEST COMMUNITY HEALTH ASSOCIATES MEDICAL GROUP. ALL THREE ENTITIES MADE THE REPORT WIDELY AVAILABLE IN THEIR ORGANIZATIONS. THE PUBLIC HEALTH DEPARTMENT MADE PRESENTATIONS TO COMMUNITY GROUPS AND ORGANIZATIONS. |
| PART VI, LINE 3: | AT THE TIME OF REGISTRATION, FORMS ARE GIVEN TO ALL PATIENTS WITH NO INSURANCE, EXPLAINING OUR FINANCIAL ASSISTANCE PROGRAM. ALSO, SOCIAL WORKERS HAVE THESE FORMS TO GIVE TO PATIENTS THEY ARE WORKING WITH. THEY ARE ALSO GIVEN TO PATIENTS WITH INSURANCE WHEN REQUESTED.FOR ALL PATIENTS WITH NO THIRD PARTY COVERAGE, OR MEDICARE PATIENTS WITH NO SUPPLEMENT INSURANCE, A LETTER WILL BE SENT AT THE TIME THE ACCOUNT IS FINAL BILLED IF PRIOR ARRANGEMENTS HAVE NOT BEEN MADE. THE LETTER EXPLAINS THE HOSPITAL CARE ASSURANCE PROGRAM THROUGH THE STATE OF OHIO AND THE HOSPITAL CHARITABLE CARE PROGRAM. ENCLOSED WITH THE LETTER IS A COPY OF THE FINANCIAL APPLICATION, A COPY OF THE PATIENT'S SUMMARIZED BILL AND A BUSINESS CARD WITH THE NAME AND PHONE NUMBER OF THE PATIENT REPRESENTATIVE RESPONSIBLE FOR THE PATIENT'S ACCOUNT. THIS PACKET MAY ALSO BE SENT TO ANY GUARANTOR WITH A BALANCE AFTER INSURANCE THAT HE/SHE IS NOT ABLE TO PAY ACCORDING TO THE HOSPITAL GUIDELINES.DEPENDING ON THE PATIENT TYPE, SOCIAL SERVICES PATIENTS ARE MADE AWARE OF FINANCIAL ASSISTANCE POLICY AND FINANCIAL ASSISTANCE CONTACT INFORMATION IN THEIR DISCHARGE MATERIALS AS PART OF THE PACKET OF INFORMATION THEY RECEIVE. GOVERNMENT OR COMMERCIAL PATIENTS ARE NOT MADE AWARE IN THEIR DISCHARGE MATERIALS AS IT IS NOT INCLUDED IN THEIR DISCHARGE PACKET. HOWEVER, THE PATIENT ACCOUNT WOULD BE BROUGHT UP AGAIN IF THERE WAS A PATIENT RESPONSIBILITY PORTION AFTER THE PRIMARY CARE PROVIDER WAS BILLED. |
| PART VI, LINE 4: | HOSPITALS ARE LOCATED IN BRYAN AND MONTPELIER, OHIO, IN ADDITION TO A MEDICAL CENTER LOCATED IN ARCHBOLD. APPROXIMATELY 16.8% OF THE POPULATION IS 65 YEARS OR OLDER, 18.3% IS BELOW POVERTY LEVEL, AND 11.6% ARE WITHOUT HEALTH INSURANCE UNDER AGE 65. |
| PART VI, LINE 5: | TEN OUT OF 11 OF THE ORGANIZATION'S BOARD RESIDES IN THE ORGANIZATION'S PRIMARY SERVICE AREA, WITH NONE BEING EMPLOYEES, INDEPENDENT CONTRACTORS OR RELATED TO THE MANAGEMENT TEAM AND ONLY TWO BEING ON THE MEDICAL STAFF. TEN OF THE ELEVEN BOARD MEMBERS ARE VOLUNTEER POSITIONS WITH NO PAY. |
| PART VI, LINE 6: | NOT APPLICABLE |
Schedule J IRS990ScheduleJ
| Field | Value | IRS element (for citing) |
|---|---|---|
| Compensation Committee | Yes (X) | CompensationCommitteeInd |
| Form990 Of Other Organizations | Yes (X) | Form990OfOtherOrganizationsInd |
| Written Employment Contract | Yes (X) | WrittenEmploymentContractInd |
| Compensation Survey | Yes (X) | CompensationSurveyInd |
| Board Or Committee Approval | Yes (X) | BoardOrCommitteeApprovalInd |
| Severance Payment | 0 | SeverancePaymentInd |
| Supplemental Nonqual Rtr Plan | Yes (1) | SupplementalNonqualRtrPlanInd |
| Equity Based Comp Arrngm | 0 | EquityBasedCompArrngmInd |
| Comp Based On Revenue Of Flng Org | 0 | CompBasedOnRevenueOfFlngOrgInd |
| Comp Bsd On Rev Related Orgs | 0 | CompBsdOnRevRelatedOrgsInd |
| Comp Bsd Net Earns Flng Org | 0 | CompBsdNetEarnsFlngOrgInd |
| Comp Bsd Net Earns Rltd Orgs | 0 | CompBsdNetEarnsRltdOrgsInd |
| Any Non Fixed Payments | 0 | AnyNonFixedPaymentsInd |
| Initial Contract Exception | 0 | InitialContractExceptionInd |
Rltd Org Officer Trst Key Empl RltdOrgOfficerTrstKeyEmplGrp (9 entries)
| TitleTitleTxt | Base Compensation Filing OrgBaseCompensationFilingOrgAmt | Compensation Based On Rltd OrgsCompensationBasedOnRltdOrgsAmt | Bonus Filing OrganizationBonusFilingOrganizationAmount | Bonus Related OrganizationsBonusRelatedOrganizationsAmt | Other Compensation Filing OrgOtherCompensationFilingOrgAmt | Other Compensation Rltd OrgsOtherCompensationRltdOrgsAmt | Deferred Compensation Flng OrgDeferredCompensationFlngOrgAmt | Deferred Comp Rltd OrgsDeferredCompRltdOrgsAmt | Nontaxable Benefits Filing OrgNontaxableBenefitsFilingOrgAmt | Nontaxable Benefits Rltd OrgsNontaxableBenefitsRltdOrgsAmt | Total Compensation Filing OrgTotalCompensationFilingOrgAmt | Total Compensation Rltd OrgsTotalCompensationRltdOrgsAmt | Comp Report Prior990 Filing OrgCompReportPrior990FilingOrgAmt | Comp Report Prior990 Rltd OrgsCompReportPrior990RltdOrgsAmt |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| PHILIP L ENNEN | ||||||||||||||
| PRESIDENT/SECRETARY, CEO | $345,643 | $0 | $10,000 | $0 | $47,404 | $0 | $10,000 | $0 | $24,900 | $0 | $437,947 | $0 | $0 | $0 |
| GREGORY E SLATTERY | ||||||||||||||
| VP/CIO | $221,573 | $0 | $0 | $0 | $46,562 | $0 | $10,000 | $0 | $24,900 | $0 | $303,035 | $0 | $0 | $0 |
| MICHAEL CULLER | ||||||||||||||
| VP/COO | $192,088 | $0 | $0 | $0 | $6,640 | $0 | $10,000 | $0 | $24,900 | $0 | $233,628 | $0 | $0 | $0 |
| CHAD D TINKEL | ||||||||||||||
| VP/CFO | $211,300 | $0 | $0 | $0 | $34,360 | $0 | $10,000 | $0 | $25,740 | $0 | $281,400 | $0 | $0 | $0 |
| JANICE DAVID | ||||||||||||||
| VP PATIENT CARE | $174,960 | $0 | $0 | $0 | $66,673 | $0 | $10,000 | $0 | $7,800 | $0 | $259,433 | $0 | $0 | $0 |
| SHANNON KEIL | ||||||||||||||
| PATHOLOGY PHYISICAN | $274,997 | $0 | $0 | $0 | $0 | $0 | $0 | $0 | $24,900 | $0 | $299,897 | $0 | $0 | $0 |
| LARRY SIMON | ||||||||||||||
| CRNA | $202,212 | $0 | $0 | $0 | $0 | $0 | $0 | $0 | $24,900 | $0 | $227,112 | $0 | $0 | $0 |
| CRAIG BUELL | ||||||||||||||
| DIRECTOR OF PHARMACY | $133,994 | $0 | $0 | $0 | $0 | $0 | $0 | $0 | $25,740 | $0 | $159,734 | $0 | $0 | $0 |
| MARILYN NUSSBAUMER | ||||||||||||||
| DIRECTOR CATH LAB | $151,576 | $0 | $0 | $0 | $0 | $0 | $0 | $0 | $7,800 | $0 | $159,376 | $0 | $0 | $0 |
Supplemental Information Detail SupplementalInformationDetail
| Field | Value | IRS element (for citing) |
|---|---|---|
| Form And Line Reference | PART I, LINE 4B | FormAndLineReferenceDesc |
| Explanation | THE FOLLOWING INDVIDUALS PARTICIPATED IN A 457(B) RETIREMENT PLAN: PHILIP ENNEN, JANICE DAVID, GREGORY SLATTERY, CHAD TINKEL, AND MIKE CULLER. A $10,000 CONTRIBUTION WAS MADE TO 457(B) PLAN. THESE AMOUNTS HAVE BEEN PROPERLY INCLUDED IN OFFICERS' COMPENSATION ON SCHEDULE J, PART II, COLUMN B(III). THE HOSPITAL HAS A SUPPLEMENTAL EXECUTIVE RETENTION PLAN FOR THESE EXECUTIVES UNDER IRC SECTION 457(B). THE AMOUNTS DEFERRED UNDER THIS PLAN WILL BE TAXABLE TO THE EXECUTIVE WHEN VESTED AND THERE IS NO LONGER A SUBSTANTIAL RISK OF FORFEITURE. IN ORDER TO HAVE THE RIGHT TO FUTURE PAYMENT OF ANY EMPLOYER DEFERRAL, THE EXECUTIVE WILL HAVE TO REMAIN IN SERVICE UNTIL THE ACCOUNT BECOMES VESTED AS PROVIDED IN THE PLAN DOCUMENT. | ExplanationTxt |
Schedule K IRS990ScheduleK
Tax Exempt Bonds Issues TaxExemptBondsIssuesGrp (4 entries)
| Bond ReferenceBondReferenceCd | Bond Issuer EINBondIssuerEIN | Bond IssuedBondIssuedDt | Issue PriceIssuePriceAmt | PurposePurposeDesc | DefeasedDefeasedInd | On Behalf Of IssuerOnBehalfOfIssuerInd | Pool FinancingPoolFinancingInd | CUSIPCUSIPNum |
|---|---|---|---|---|---|---|---|---|
| CITY OF BRYAN OH | ||||||||
| A | 346400228 | 2008-07-01 | $10,000,000 | SEE PART VI | 0 | 0 | 0 | |
| COUNTY OF WILLIAMS OH | ||||||||
| B | 346401595 | 2008-07-17 | $45,000,000 | SEE PART VI | 0 | 0 | 0 | 96948QAA3 |
| VILLAGE OF ARCHBOLD OH | ||||||||
| C | 346400063 | 2008-08-20 | $10,000,000 | SEE PART VI | 0 | 0 | 0 | |
| COUNTY OF WILLIAMS OH | ||||||||
| D | 346401595 | 2012-09-26 | $2,905,428 | SEE PART VI | 0 | 0 | 0 | |
Tax Exempt Bonds Proceeds TaxExemptBondsProceedsGrp (4 entries)
| Bond ReferenceBondReferenceCd | RetiredRetiredAmt | Total ProceedsTotalProceedsAmt | Capital ExpendituresCapitalExpendituresAmt | Substantial CompletionSubstantialCompletionYr | Current RefundingCurrentRefundingInd | Advance RefundingAdvanceRefundingInd | Final Allocation MadeFinalAllocationMadeInd | Adequate Books And Rec MaintAdequateBooksAndRecMaintInd | Issuance Costs From ProceedsIssuanceCostsFromProceedsAmt | Credit EnhancementCreditEnhancementAmt |
|---|---|---|---|---|---|---|---|---|---|---|
| A | $1,281,982 | $10,208,153 | $10,208,153 | 2011 | 0 | 0 | Yes (1) | Yes (1) | ||
| B | $3,805,000 | $47,692,402 | $47,072,458 | 2011 | 0 | 0 | Yes (1) | Yes (1) | $303,337 | $316,607 |
| C | $1,295,810 | $10,208,153 | $10,208,153 | 2011 | 0 | 0 | Yes (1) | Yes (1) | ||
| D | $1,321,827 | $2,905,428 | $2,905,428 | 2005 | Yes (1) | 0 | Yes (1) | Yes (1) |
Tax Exempt Bonds Private Bus Use TaxExemptBondsPrivateBusUseGrp (4 entries)
| Bond ReferenceBondReferenceCd | Owning Bond Financed PropertyOwningBondFinancedPropertyInd | Any Lease ArrangementsAnyLeaseArrangementsInd | Mgmt Contract Bond Fincd PropMgmtContractBondFincdPropInd | Engage Bond Counsel ContractsEngageBondCounselContractsInd | Any Research AgreementsAnyResearchAgreementsInd | Bond Iss Meet Prvt Sec Pymt TestBondIssMeetPrvtSecPymtTestInd | Change In Use Bond Financed PropChangeInUseBondFinancedPropInd | Procs Nonqualified Bond RemdtdProcsNonqualifiedBondRemdtdInd | Private Bus Use By OthersPrivateBusUseByOthersPct | Total Private Business UseTotalPrivateBusinessUsePct |
|---|---|---|---|---|---|---|---|---|---|---|
| A | 0 | 0 | Yes (1) | Yes (1) | 0 | 0 | 0 | Yes (1) | ||
| B | 0 | Yes (1) | Yes (1) | Yes (1) | 0 | 0 | 0 | Yes (1) | 0.01240 | 0.01240 |
| C | 0 | 0 | Yes (1) | Yes (1) | 0 | 0 | 0 | Yes (1) | ||
| D | 0 | 0 | Yes (1) | Yes (1) | 0 | 0 | 0 | Yes (1) |
Tax Exempt Bonds Arbitrage TaxExemptBondsArbitrageGrp (4 entries)
| Bond ReferenceBondReferenceCd | Form8038 T FiledForm8038TFiledInd | Rebate Not Due YetRebateNotDueYetInd | Exception To RebateExceptionToRebateInd | No Rebate DueNoRebateDueInd | Variable Rate IssueVariableRateIssueInd | Hedge Identified In Bks And RecHedgeIdentifiedInBksAndRecInd | Gross Proceeds Invested In GICGrossProceedsInvestedInGICInd | Gross Proceeds InvestedGrossProceedsInvestedInd | Written Proc To Monitor ReqsWrittenProcToMonitorReqsInd | Term Of HedgeTermOfHedgePct | Superintegrated HedgeSuperintegratedHedgeInd | Hedge TerminatedHedgeTerminatedInd |
|---|---|---|---|---|---|---|---|---|---|---|---|---|
| (no name) | ||||||||||||
| A | 0 | 0 | Yes (1) | Yes (1) | 0 | 0 | 0 | 0 | Yes (1) | |||
| FIFTH THIRD BANK | ||||||||||||
| B | 0 | 0 | 0 | Yes (1) | Yes (1) | Yes (1) | 0 | Yes (1) | Yes (1) | 9.500000000000 | 0 | 0 |
| (no name) | ||||||||||||
| C | 0 | 0 | Yes (1) | Yes (1) | Yes (1) | 0 | 0 | 0 | Yes (1) | |||
| (no name) | ||||||||||||
| D | 0 | Yes (1) | Yes (1) | 0 | 0 | 0 | 0 | 0 | Yes (1) | |||
Procedures Corrective Action ProceduresCorrectiveActionGrp (4 entries)
| Bond ReferenceBondReferenceCd | Procedures Corrective ActionProceduresCorrectiveActionInd |
|---|---|
| A | Yes (1) |
| B | Yes (1) |
| C | Yes (1) |
| D | Yes (1) |
Supplemental Information Detail SupplementalInformationDetail (2 entries)
| Form And Line ReferenceFormAndLineReferenceDesc | ExplanationExplanationTxt |
|---|---|
| SCHEDULE K SUPPLENTAL INFORMATION | PART I, ISSUE A, COLUMN F: CONSTRUCTION, EQUIPPING, EXPANSION, IMPROVEMENT, INSTALLATION, AND SUBSTANTIAL RENOVATION OF THE ORGANIZATION'S CAMPUS. PART I, ISSUE B, COLUMN F: ACQUISITION, CONSTRUCTION, FURNISHING, AND EQUIPPING OF NEW FACILITIES AND ADDITIONS AND IMPROVEMENTS TO THE ORGANIZATION'S CAMPUS. PART I, ISSUE C, COLUMN F: CONSTRUCTION, EQUIPPING, EXPANSION, IMPROVEMENT, INSTALLATION, AND SUBSTANTIAL RENOVATION OF THE ORGANIZATION'S CAMPUS. PART I, ISSUE D, COLUMN F: CURRENTLY REFUND SERIES 2005 BONDS WHICH PROCEEDS CURRENTLY REFUNDED TAXABLE LOANS USED FOR CONSTRUCTING OR EQUIPPING SEVERAL HOSPITALS. |
| FORM 990, SCHEDULE K, PART II | PART II, ISSUE A, LINE 3: TOTAL PROCEEDS OF ISSUE ARE $10,208,153, WHICH ARE SALE PROCEEDS OF $10,000,000 PLUS INVESTMENT EARNINGS OF $208,153. PART II, ISSUE B, LINE 3: TOTAL PROCEEDS OF ISSUE ARE $47,692,402, WHICH ARE SALE PROCEEDS OF $45,000,000 PLUS INVESTMENT EARNINGS OF $2,692,402. PART II, ISSUE C, LINE 3: TOTAL PROCEEDS OF ISSUE ARE $10,208,153, WHICH ARE SALE PROCEEDS OF $10,000,000 PLUS INVESTMENT EARNINGS OF $208,153. PART II, ISSUE D, LINE 6: THE ESCROW WAS SPENT ON THE DAY OF CLOSING OF THE 2012 ISSUE. |
Schedule L IRS990ScheduleL
Bus Tr Involve Interested Prsn BusTrInvolveInterestedPrsnGrp
Name Of Interested NameOfInterested
Business Name BusinessName
| Field | Value | IRS element (for citing) |
|---|---|---|
| Business Name Line1 | PPG OHIOMIDWEST COMMUNITY HEALTH ASSOCIATES | BusinessNameLine1Txt |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Relationship Description | SEE SCH L, PART V | RelationshipDescriptionTxt |
| Transaction | $1,354,370 | TransactionAmt |
| Transaction | PPG OHIO/MCHA PROVIDES MEDICAL SERVICES TO COMMUNITY HOSPITALS & WELLNESS CENTERS. | TransactionDesc |
| Sharing Of Revenues | 0 | SharingOfRevenuesInd |
Supplemental Information Detail SupplementalInformationDetail
| Field | Value | IRS element (for citing) |
|---|---|---|
| Form And Line Reference | FORM 990, SCHEDULE L, PART IV, COLUMN B: | FormAndLineReferenceDesc |
| Explanation | DR. KOLOVICH AND DR. SEAMAN ARE BOTH VOTING MEMBERS OF CHWC AND VOTING MEMBERS OF PPG OHIO/MCHA. | ExplanationTxt |
Schedule O IRS990ScheduleO
Supplemental Information Detail SupplementalInformationDetail (8 entries)
| Form And Line ReferenceFormAndLineReferenceDesc | ExplanationExplanationTxt |
|---|---|
| FORM 990, PART VI, SECTION A, LINE 2 | DRS. KOLOVICH AND SEAMAN HAVE A BUSINESS RELATIONSHIP WITH THE PHYSICIAN GROUP MCHA/PPG-OH. CHRISTOPHER CULLIS IS THE OWNER/EDITOR OF THE LOCAL NEWSPAPER AND THUS HAS BUSINESS RELATIONSHIPS WITH THE ORGANIZATION AND OTHER TRUSTEES. |
| FORM 990, PART VI, SECTION B, LINE 11 | PRIOR TO FILING, FORM 990 IS PROVIDED TO THE BOARD, AND A SUMMARY OF THE DISCLOSURES ARE PRESENTED BY THE PLANTE MORAN AT A MONTHLY BOARD MEETING. IF A BOARD MEMBER IS NOT IN ATTENDANCE FOR THIS PRESENTATION, THAT INDIVIDUAL WILL RECEIVE A COPY OF FORM 990 AT A LATER DATE, PRIOR TO FILING. |
| FORM 990, PART VI, SECTION B, LINE 12C | OFFICERS AND VOTING MEMBERS OF THE BOARD ARE COVERED BY THE CONFLICT OF INTEREST POLICY. CONFLICTS OF INTEREST ARE REVIEWED ON A CASE BY CASE BASIS. IF A TRANSACTION ARISES THAT WOULD RESULT IN A CONFLICT, THE INTERESTED INDIVIDUAL SIGNS A CONFLICT OF INTEREST STATEMENT NOTING THAT THEY ARE NOT INDEPENDENT WITH RESPECT TO THE TRANSACTION, AND THEY ABSTAIN FROM VOTING ON THAT MATTER. THE POLICY IS MONITORED BY ALL BOARD MEMBERS AND OFFICERS. THE POLICY IS REVIEWED WITH ANY NEW BOARD MEMBERS OR OFFICERS. |
| FORM 990, PART VI, SECTION B, LINE 15 | THE CEO'S AND VICE PRESIDENT'S COMPENSATION ARE REVIEWED ANNUALLY AND APPROVED BY THE COMPENSATION COMMITTEE. THE DECISIONS REGARDING COMPENSATION ARE DOCUMENTED IN THE MINUTES FROM THE COMPENSATION COMMITTEE MEETINGS. OHA SURVEY DATA IS USED FOR COMPARABILITY PURPOSES. SIMILAR HOSPITALS' 990'S ARE REVIEWED FOR COMPARABILITY PURPOSES. THE PROCESS WAS LAST UNDERTAKEN OCTOBER 2015 FOR THE VICE PRESIDENTS AND DECEMBER 2015 FOR THE PRESIDENT. |
| FORM 990, PART VI, SECTION C, LINE 19 | THE ORGANIZATION MAKES ITS GOVERNING DOCUMENTS, CONFLICT OF INTEREST POLICY, AND FINANCIAL STATEMENTS AVAILABLE TO THE PUBLIC UPON REQUEST. |
| FORM 990, PART IX, LINE 24E: | AMOUNT REPORTED INCLUDES REIMBURSEMENT OF EXPENSES FROM CHWC PAIN MANAGEMENT, LLC. |
| FORM 990, PART XI, LINE 9: | CHANGE IN FAIR VALUE OF INTEREST SWAP AGREEMENTS 333,912. FLOW THROUGH LOSS FROM VANTAGE HEALTHCARE OF OHIO LLC 829. |
| FORM 990, PART XII, LINE 2C: | THE ORGANIZATION HAS AN AUDIT COMMITTEE THAT OVERSEES THE AUDIT AND SELECTION OF AN INDEPENDENT ACCOUNTANT. THIS PROCESS HAS NOT CHANGED FROM THE PRIOR YEAR. |
Schedule R IRS990ScheduleR
Id Related Tax Exempt Org IdRelatedTaxExemptOrgGrp
Disregarded Entity Name DisregardedEntityName
| Field | Value | IRS element (for citing) |
|---|---|---|
| Business Name Line1 | SHARE FOUNDATION | BusinessNameLine1Txt |
US Address USAddress
| Field | Value | IRS element (for citing) |
|---|---|---|
| Address Line1 | 433 WEST HIGH STREET | AddressLine1Txt |
| City | BRYAN | CityNm |
| State Abbreviation | OH | StateAbbreviationCd |
| ZIP | 43506 | ZIPCd |
| Field | Value | IRS element (for citing) |
|---|---|---|
| EIN | 341596175 | EIN |
| Primary Activities | ASSIST COMMUNITY HOSPITALS AND WELLNESS CENTERS WITH FUNDRAISING | PrimaryActivitiesTxt |
| Legal Domicile State | OH | LegalDomicileStateCd |
| Exempt Code Section | 501(C)(3) | ExemptCodeSectionTxt |
| Public Charity Status | 11A | PublicCharityStatusTxt |
Direct Controlling Entity Name DirectControllingEntityName
| Field | Value | IRS element (for citing) |
|---|---|---|
| Business Name Line1 | COMMUNITY HOSPITALS AND WELLNESS CENTERS | BusinessNameLine1Txt |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Controlled Organization | Yes (1) | ControlledOrganizationInd |
Id Related Org Txbl Partnership IdRelatedOrgTxblPartnershipGrp
Related Organization Name RelatedOrganizationName
| Field | Value | IRS element (for citing) |
|---|---|---|
| Business Name Line1 | COMMUNITY HOSPITALS & WELLNESS CENTERS PAIN MANAGEMENT LLC | BusinessNameLine1Txt |
US Address USAddress
| Field | Value | IRS element (for citing) |
|---|---|---|
| Address Line1 | 433 WEST HIGH STREET | AddressLine1Txt |
| City | BRYAN | CityNm |
| State Abbreviation | OH | StateAbbreviationCd |
| ZIP | 43506 | ZIPCd |
| Field | Value | IRS element (for citing) |
|---|---|---|
| EIN | 461084537 | EIN |
| Primary Activities | MEDICAL SERVICES | PrimaryActivitiesTxt |
| Legal Domicile State | OH | LegalDomicileStateCd |
Direct Controlling Entity Name DirectControllingEntityName
| Field | Value | IRS element (for citing) |
|---|---|---|
| Business Name Line1 | COMMUNITY HOSPITALS & WELLNESS CENTERS | BusinessNameLine1Txt |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Predominant Income Type | RELATED | PredominantIncomeTypeTxt |
| Share Of Total Income | $984,849 | ShareOfTotalIncomeAmt |
| Share Of EOY Assets | $454,438 | ShareOfEOYAssetsAmt |
| Disproportionate Allocations | 0 | DisproportionateAllocationsInd |
| General Or Managing Partner | Yes (1) | GeneralOrManagingPartnerInd |
| Ownership | 0.51000 | OwnershipPct |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Receipt Of Int Annts Rnts Rylts | 0 | ReceiptOfIntAnntsRntsRyltsInd |
| Gift Grnt Or Cap Contri To Oth Org | 0 | GiftGrntOrCapContriToOthOrgInd |
| Gift Grnt Cap Contri From Oth Org | 0 | GiftGrntCapContriFromOthOrgInd |
| Loans Or Guarantees To Other Org | 0 | LoansOrGuaranteesToOtherOrgInd |
| Loans Or Guarantees From Oth Org | 0 | LoansOrGuaranteesFromOthOrgInd |
| Div Related Organization | 0 | DivRelatedOrganizationInd |
| Asset Sale To Other Org | 0 | AssetSaleToOtherOrgInd |
| Asset Purchase From Other Org | 0 | AssetPurchaseFromOtherOrgInd |
| Asset Exchange | 0 | AssetExchangeInd |
| Rental Of Facilities To Oth Org | 0 | RentalOfFacilitiesToOthOrgInd |
| Rental Of Fclts From Oth Org | 0 | RentalOfFcltsFromOthOrgInd |
| Perform Of Services For Oth Org | 0 | PerformOfServicesForOthOrgInd |
| Perform Of Services By Other Org | 0 | PerformOfServicesByOtherOrgInd |
| Sharing Of Facilities | Yes (1) | SharingOfFacilitiesInd |
| Paid Employees Sharing | Yes (1) | PaidEmployeesSharingInd |
| Reimbursement Paid To Other Org | 0 | ReimbursementPaidToOtherOrgInd |
| Reimbursement Paid By Other Org | Yes (1) | ReimbursementPaidByOtherOrgInd |
| Transfer To Other Org | 0 | TransferToOtherOrgInd |
| Transfer From Other Org | 0 | TransferFromOtherOrgInd |
Transactions Related Org TransactionsRelatedOrgGrp
Other Organization Name OtherOrganizationName
| Field | Value | IRS element (for citing) |
|---|---|---|
| Business Name Line1 | CHWC PAIN MANAGEMENT LLC | BusinessNameLine1Txt |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Transaction Type | Q | TransactionTypeTxt |
| Involved | $680,041 | InvolvedAmt |
| Method Of Amount Determination | ACCRUAL TRANSACTION | MethodOfAmountDeterminationTxt |