2016-05-16T09:25:18-05:00 2015-06-30 340641962 BRUNER COX LLP 388 S MAIN STREET SUITE 403 AKRON OH 44311 990 2014-07-01 340714479 GRACE HOSPITAL GRAC 4402043500 17730 LORAIN AVE NO 2 CLEVELAND OH 44111 RAJIVE KHANNA PRESIDENT AND CEO 2164563880 2016-05-11 1 LISA M HILLING P01624111 3303760100 2014 2016-08-17 19:52:53Z RAJIVE KHANNA 17730 LORAIN AVE NO 2 CLEVELAND OH 44111 24382818 0 X WWW.GRACEHOSPITAL.ORG X 1910 OH TO SERVE AS A CENTER FOR EXCELLENCE IN THE PROVISION OF SPECIALIZED HEALTH CARE SERVICES AND COMFORT FOR PATIENTS AND FAMILIES COPING WITH CATASTROPHIC ILLNESS AND INJURY. 10 7 256 7 0 0 398910 419422 27791525 23683924 128130 242747 29266 36725 28347831 24382818 0 0 0 0 12085246 11635470 0 0 0 13776672 12409010 25861918 24044480 2485913 338338 19883631 19284122 5367590 5085633 14516041 14198489 X TO SERVE AS A CENTER FOR EXCELLENCE IN THE PROVISION OF SPECIALIZED HEALTH CARE SERVICES AND COMFORT FOR PATIENTS AND FAMILIES COPING WITH CATASTROPHIC ILLNESS AND INJURY. 0 0 20316644 23925614 GRACE HOSPITAL IS A NON-FOR-PROFIT, LONG-TERM ACUTE CARE HOSPITAL LOCATED IN CLEVELAND, OHIO DEDICATED TO PROVIDING PERSONALIZED CARE TO MEET THE NEEDS OF PATIENTS COPING WITH CATASTROPHIC OR CHRONIC INJURY OR ILLNESS REQUIRING EXTENDED HOSPITALIZATION. THE HOSPITAL WAS FOUNDED IN 1910 BY A GROUP OF PHYSICIANS WHO WERE COMMITTED TO MEETING THE HEALTHCARE NEEDS OF THE COMMUNITY. GRACE HOSPITAL HAS CONTINUOUSLY PROVIDED SERVICES FOR ITS PATIENTS. IN 1995, GRACE HOSPITAL EARNED APPROVAL TO BECOME THE FIRST CERTIFIED LONG-TERM ACUTE CARE HOSPITAL IN BOTH THE CITY OF CLEVELAND AND CUYAHOGA COUNTY. THE HOSPITAL PRESENTLY SPONSORS SEVERAL INPATIENT SERVICES INCLUDING COMPLEX MEDICAL, PULMONARY, REHABILITATION, VENTILATOR WEANING, LEFT VENTRICAL ASSIST DEVICE, TRANSPLANT SUPPORT, WOUND CARE, AND NEUROLOGICAL REHABILITATION PROGRAMS. THESE SERVICES ARE PROVIDED AT INPATIENT SATELLITES LOCATED WITHIN FAIRVIEW, LAKEWOOD, SOUTH POINTE AND BEDFORD HOSPITALS. GRACE HOSPITAL IS COMMITTED TO PROVIDING PERSONALIZED HEALTHCARE CHARACTERIZED BY QUALITY, ACCESSIBILITY, EFFICIENCY, AND COST EFFECTIVENESS. THE HOSPITAL IS SENSITIVE TO AGE, CULTURAL, AND ECONOMIC VARIATIONS, AND IS CONTINUOUSLY ASSESSED AND IMPROVED THROUGH A QUALITY MANAGEMENT PROGRAM. GRACE VOLUNTARILY MAINTAINS A CHARITY CARE POLICY THAT PROVIDES CARE TO INDIVIDUALS REGARDLESS OF ABILITY TO PAY. THE HOSPITAL IS ALSO COMMITTED TO EMPLOYING INDIVIDUALS TO MATCH CULTURAL DIVERSITY OF ITS PATIENT POPULATION. SEVERAL JOB POSTINGS IN THE HOSPITAL REQUIRE EMPLOYEES TO BE BILINGUAL IN EITHER SPANISH OR VIETNAMESE. GRACE HOSPITAL IS INVOLVED IN MANY COMMUNITY ACTIVITIES, INCLUDING HEALTH FAIRS, SPECIAL HEALTH-RELATED PRESENTATIONS, AND SPONSORSHIPS IN HEALTHCARE EDUCATION. IN ADDITION, THE HOSPITAL SPONSORS MEETINGS FOR MANY NON-PROFIT COMMUNITY ORGANIZATIONS. THE BOARD OF DIRECTORS, MEDICAL STAFF, AND MANAGEMENT OF GRACE HOSPITAL ARE COMMITTED TO THE PROVISION OF QUALITY SPECIALTY HEALTHCARE SERVICES, AS A LONG-TERM HOSPITAL, AND FULFILLING A LEADERSHIP ROLE IN THE COMMUNITY. DESPITE CHALLENGING ECONOMIC TIMES, GRACE HOSPITAL HAS SUCCESSFULLY CONTINUED ITS ROLE OF COMMUNITY SERVICE AS ORIGINALLY ENVISIONED BY ITS FOUNDERS. 20316644 1 1 0 0 0 0 0 0 0 0 1 0 0 1 1 1 0 1 0 0 0 0 0 0 0 0 1 1 0 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 1 0 0 0 1 55 0 256 1 0 0 0 0 0 0 0 0 0 0 X 10 7 0 0 0 0 0 0 0 1 1 0 0 1 1 1 0 1 1 1 1 0 OH X X MICHELLE HENNIS 2164563880 17730 LORAIN AVENUE CLEVELAND OH 44111 WILLARD E BARTEL CHAIRPERSON 1.00 1.00 X X 0 0 0 ROBERT A GREVEY VICE CHAIRPERSON 1.00 1.00 X X 0 0 0 DONALD L LONG CPA TREASURER (RESIGNED JUNE 2015) 1.00 1.00 X X 0 0 0 RICHARD J RYMOND TREASURER 1.00 1.00 X X 0 0 0 REV JOSEPH D MCNULTY SECRETARY 1.00 1.00 X X 0 0 0 MP PATEL MD DIRECTOR 1.00 1.00 X 0 0 0 GERALD L JEPPE DIRECTOR 1.00 1.00 X 0 0 0 JOHN H NICKELS DIRECTOR OF MEDICAL STAFF 10.00 1.00 X 79417 0 0 JUDITH Z PETERS DIRECTOR 1.00 1.00 X 0 0 0 DEEPAK RAHEJA DIRECTOR OF NEUROLOGY 5.00 1.00 X 46800 0 0 PAUL C VENIZELOS MEDICAL DIRECTOR (LAKEWOOD UNIT) 5.00 1.00 X 19175 0 0 RAJIVE KHANNA PRESIDENT & CEO - GRACE HOSPITAL 40.00 1.00 X 196006 0 3453 ROBERT P RANGE PRESIDENT & CEO - GRACE FOUNDATION 20.00 20.00 X 161102 0 0 MICHELLE HENNIS DIRECTOR OF FINANCE 40.00 1.00 X 112410 0 27765 BARBARA J MORAN CNO/COO 40.00 0.00 X 138891 0 2229 MARY CHENTNIK DIRECTOR OF HUMAN RESOURCES 40.00 0.00 X 100120 0 20798 853921 0 54245 5 0 1 0 MAXIM HEALTHCARE SERVICES INC 13841 COLLECTIONS DR CHICAGO IL 60693 EMPLOYMENT AGENCY 459663 FRESENIUS KABI USA LLC THREE CORPORATE DRIVE LAKE ZURICH IL 60047 MEDICAL DEVICES 267316 ALLIANCE HEALTHCARE SOLUTIONS LLC 4500 ROCKSIDE ROAD SUITE 210 INDEPENDENCE OH 44131 EMPLOYMENT AGENCY 181011 REVENUE ASSISTANCE CORPORATION 4780 HINCKLEY PARKWAY SUITE 200 CLEVELAND OH 44109 BILLING SERVICES 173121 WESTLAKE REED LESKOSKY LTD 1422 EUCLID AVENUE CLEVELAND OH 44115 ARCHITECTURE 119618 6 419422 419422 PATIENT SERVICE REVENUE 624100 22838786 22838786 SPECIALTY HOSPITAL OF LORAIN SERV 624100 647013 647013 OTHER PROGRAM SERVICE REVENUE 624100 198125 198125 23683924 242747 241690 1057 30725 0 30725 30725 30725 PARKING FEES 812930 6000 6000 6000 24382818 23925614 0 37782 646128 145392 500736 8917925 8079883 838042 1193018 1025995 167023 878399 755423 122976 125746 125746 26806 26806 1037001 1037001 2950 2950 19148 19148 1583008 1255931 327077 55562 45208 10354 27406 27406 297279 289477 7802 449584 237153 212431 PURCHASED SERVICES-PROF 5177844 5177844 SUPPLIES - MEDICAL 2729052 2729052 EQUIPMENT RENTAL AND MA 497561 455167 42394 SUPPLIES - GENERAL 142863 91026 51837 237200 1687 235513 24044480 20316644 3727836 0 601763 1275773 2602499 2103952 4984071 4299252 301833 321534 36844 159964 10710956 9201050 1528572 1509906 301166 552915 594605 9275134 8717970 19883631 19284122 3310472 3471185 485396 300914 1571722 1313534 5367590 5085633 X 5240907 5480519 9275134 8717970 14516041 14198489 19883631 19284122 X 338338 -555997 -99893 X X 0 1 X 1 0 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 32151 32151 4363409 4213498 149911 145197 136306 8891 5738068 4851246 886822 432131 432131 1509906 ASSETS HELD IN PERPETUAL TRUST 8717970 8717970 CAPITAL LEASE OBLIGATIONS 350137 EST SETTLEMENTS TO THIRD-PARTIES 963397 1313534 X PART X, LINE 2: THE FOUNDATION AND HOSPITAL ARE NOT-FOR-PROFIT CORPORATIONS AND ARE RECOGNIZED AS TAX-EXEMPT PURSUANT TO SECTION 501(C)(3) OF THE INTERNAL REVENUE CODE. THE HOLDING AND GRACE CENTER ARE INCORPORATED AS A LIMITED LIABILITY COMPANIES IN ACCORDANCE WITH CHAPTER 1705 OF THE OHIO REVISED CODE. THE HOLDING HAS FILED A 168(H) ELECTION. UNDER THESE PROVISIONS, THE TAXABLE INCOME FOR GRACE CENTER IS TAXED DIRECTLY TO THE HOLDING MEMBERS; THEREFORE, NO PROVISION HAS BEEN MADE FOR FEDERAL OR STATE INCOME TAXES ON THE ACCOMPANYING CONSOLIDATED FINANCIAL STATEMENTS. WHEN TAX RETURNS ARE FILED, IT IS HIGHLY CERTAIN THAT SOME POSITIONS TAKEN WOULD BE SUSTAINED UPON EXAMINATION BY THE TAXING AUTHORITIES, WHILE OTHERS ARE SUBJECT TO UNCERTAINTY ABOUT THE MERITS OF THE POSITION TAKEN OR THE AMOUNT OF THE POSITION THAT WOULD BE ULTIMATELY SUSTAINED. IN ACCORDANCE WITH THE INCOME TAXES TOPIC OF THE FINANCIAL ACCOUNTING STANDARDS BOARD (FASB) ACCOUNTING STANDARDS CODIFICATION, THE BENEFIT OF A TAX POSITION IS RECOGNIZED IN THE FINANCIAL STATEMENTS IN THE PERIOD DURING WHICH, BASED ON ALL AVAILABLE EVIDENCE, MANAGEMENT BELIEVES IT IS MORE LIKELY THAN NOT THAT THE POSITION WILL BE SUSTAINED UPON EXAMINATION, INCLUDING THE RESOLUTION OF APPEALS OR LITIGATION PROCESSES, IF ANY. TAX POSITIONS TAKEN ARE NOT OFFSET OR AGGREGATED WITH OTHER POSITIONS. TAX POSITIONS THAT MEET THE MORE-LIKELY-THAN-NOT RECOGNITION THRESHOLD ARE MEASURED AS THE LARGEST AMOUNT OF TAX BENEFIT THAT IS MORE THAN 50% LIKELY OF BEING REALIZED UPON SETTLEMENT WITH THE APPLICABLE TAXING AUTHORITY. THE PORTION OF THE BENEFITS ASSOCIATED WITH TAX POSITIONS TAKEN THAT EXCEEDS THE AMOUNT MEASURED AS DESCRIBED ABOVE IS RECORDED AS A LIABILITY FOR UNRECOGNIZED TAX BENEFITS ALONG WITH ANY ASSOCIATED INTEREST AND PENALTIES THAT WOULD BE PAYABLE TO THE TAXING AUTHORITIES UPON EXAMINATION. 1 1 X 1 X 1 X 1 0 0 5816927 3260278 2556649 0.10630 24796 24796 0.00100 5841723 3260278 2581445 0.10730 5841723 3260278 2581445 0.10730 1 972338 232450 13139271 13077214 62057 X 1 1 1 SPECIALTY HOSPITAL OF LORAIN NOT-FOR-PROFIT LONG-TERM ACUTE CARE HOSPITAL IN LORAIN, OHIO 0.33330 0.00000 0.00000 5 1 GRACE FAIRVIEW 18101 LORAIN AVE CLEVELAND OH 44111 WWW.GRACEHOSPITAL.ORG X LONG TERM ACUTE CARE A 2 GRACE SOUTH POINTE 20000 HARVARD AVE CLEVELAND OH 44122 WWW.GRACEHOSPITAL.ORG X LONG TERM ACUTE CARE A 3 GRACE BEDFORD 44 BLAINE AVENUE BEDFORD OH 44146 WWW.GRACEHOSPITAL.ORG X LONG TERM ACUTE CARE A 4 GRACE LAKEWOOD 14519 DETROIT AVE LAKEWOOD OH 44107 WWW.GRACEHOSPITAL.ORG X LONG TERM ACUTE CARE A 5 SPECIALTY HOSPITAL OF LORAIN 254 CLEVELAND AVE AMHERST OH 44001 WWW.SPECIALTYHOSPITALOFLORAIN.ORG X LONG TERM ACUTE CARE SPECIALTY HOSPITAL OF LORAIN 5 0 0 0 0 1 X 100.000000000000 200.000000000000 X X X X X 1 1 X X X 1 X 1 X 0 X X X X 0 X X X 0 0 FACILITY REPORTING GROUP - A 0 0 0 0 1 X 100.000000000000 200.000000000000 X X X X X 1 1 X X X 1 X 1 X 0 X X X X 0 X X X 0 0 SPECIALTY HOSPITAL OF LORAIN PART V, SECTION B, LINE 13H: THE FOLLOWING STRUCTURE WILL BE UTILIZED TO DETERMINE THE AMOUNT OF FREE CARE TO BE PROVIDED. HOUSEHOLD INCOME AND THE NUMBER OF PEOPLE LIVING IN HOUSEHOLD WILL BE THE TWO MAJOR CRITERIA USED TO DETERMINE IF A PATIENT IS ELIGIBLE FOR FREE CARE. EXTENUATING CIRCUMSTANCES SHOULD BE NOTED AND MAY INCLUDE INFORMATION SUPPLIED TO SUPPORT EXCEPTIONAL SCENARIOS INCLUDING A TERMINAL ILLNESS, DEATH OF A SPOUSE, OR CATASTROPHIC PROBLEMS. SPECIALTY HOSPITAL OF LORAIN PART V, SECTION B, LINE 16I: THE POLICY IS ATTACHED TO BILLING INVOICES. SPECIALTY HOSPITAL OF LORAIN PART V, SECTION B, LINE 21D: SPECIALTY HOSPITAL OF LORAIN IS A LONG TERM ACUTE CARE (LTAC) FACILITY LOCATED ON A FLOOR OF AMHERST HOSPITAL. DUE TO THE TYPE OF SERVICES PROVIDED, SHL DOES NOT PROVIDE CARE FOR EMERGENCY MEDICAL CONDITIONS. IF FULL-SERVICE EMERGENCY ROOM CARE IS NEEDED, THE FACILITIES OF AMHERST HOSPITAL ARE AVAILABLE. SPECIALTY HOSPITAL OF LORAIN PART V, SECTION B, LINE 22D: A SLIDING SCALE FEE SCHEDULE IS USED TO DETERMINE THE MAXIMUM AMOUNTS THAT CAN BE CHARGED TO FAP-ELIGIBLE INDIVIDUALS. PART V, SECTION B FACILITY REPORTING GROUP A FACILITY REPORTING GROUP A CONSISTS OF: - FACILITY 1: GRACE FAIRVIEW, - FACILITY 3: GRACE BEDFORD, - FACILITY 4: GRACE LAKEWOOD, - FACILITY 2: GRACE SOUTH POINTE GROUP A-FACILITY 1 -- GRACE FAIRVIEW PART V, SECTION B, LINE 13H: THE FOLLOWING STRUCTURE WILL BE UTILIZED TO DETERMINE THE AMOUNT OF FREE CARE TO BE PROVIDED. HOUSEHOLD INCOME AND THE NUMBER OF PEOPLE LIVING IN HOUSEHOLD WILL BE THE TWO MAJOR CRITERIA USED TO DETERMINE IF A PATIENT IS ELIGIBLE FOR FREE CARE. EXTENUATING CIRCUMSTANCES SHOULD BE NOTED AND MAY INCLUDE INFORMATION SUPPLIED TO SUPPORT EXCEPTIONAL SCENARIOS INCLUDING A TERMINAL ILLNESS, DEATH OF A SPOUSE, OR CATASTROPHIC PROBLEMS. GROUP A-FACILITY 1 -- GRACE FAIRVIEW PART V, SECTION B, LINE 16I: THE POLICY IS ATTACHED TO BILLING INVOICES. GROUP A-FACILITY 1 -- GRACE FAIRVIEW PART V, SECTION B, LINE 21D: GRACE HOSPITAL IS A LONG TERM ACUTE CARE (LTAC) FACILITY LOCATED ON A FLOOR OF FAIRVIEW HOSPITAL, A CLEVELAND CLINIC HOSPITAL. DUE TO THE TYPE OF SERVICES PROVIDED, GRACE DOES NOT PROVIDE CARE FOR EMERGENCY MEDICAL CONDITIONS. IF FULL-SERVICE EMERGENCY ROOM CARE IS NEEDED, THE FACILITIES OF FAIRVIEW HOSPITAL ARE AVAILABLE. GROUP A-FACILITY 1 -- GRACE FAIRVIEW PART V, SECTION B, LINE 22D: A SLIDING SCALE FEE SCHEDULE IS USED TO DETERMINE THE MAXIMUM AMOUNTS THAT CAN BE CHARGED TO FAP-ELIGIBLE INDIVIDUALS. GROUP A-FACILITY 3 -- GRACE LAKEWOOD PART V, SECTION B, LINE 13H: THE FOLLOWING STRUCTURE WILL BE UTILIZED TO DETERMINE THE AMOUNT OF FREE CARE TO BE PROVIDED. HOUSEHOLD INCOME AND THE NUMBER OF PEOPLE LIVING IN HOUSEHOLD WILL BE THE TWO MAJOR CRITERIA USED TO DETERMINE IF A PATIENT IS ELIGIBLE FOR FREE CARE. EXTENUATING CIRCUMSTANCES SHOULD BE NOTED AND MAY INCLUDE INFORMATION SUPPLIED TO SUPPORT EXCEPTIONAL SCENARIOS INCLUDING A TERMINAL ILLNESS, DEATH OF A SPOUSE, OR CATASTROPHIC PROBLEMS. GROUP A-FACILITY 3 -- GRACE LAKEWOOD PART V, SECTION B, LINE 16I: THE POLICY IS ATTACHED TO BILLING INVOICES. GROUP A-FACILITY 3 -- GRACE LAKEWOOD PART V, SECTION B, LINE 21D: GRACE HOSPITAL IS A LONG TERM ACUTE CARE (LTAC) FACILITY LOCATED ON A FLOOR OF LAKEWOOD HOSPITAL, A CLEVELAND CLINIC HOSPITAL. DUE TO THE TYPE OF SERVICES PROVIDED, GRACE DOES NOT PROVIDE CARE FOR EMERGENCY MEDICAL CONDITIONS. IF FULL-SERVICE EMERGENCY ROOM CARE IS NEEDED, THE FACILITIES OF LAKEWOOD HOSPITAL ARE AVAILABLE. GROUP A-FACILITY 3 -- GRACE LAKEWOOD PART V, SECTION B, LINE 22D: A SLIDING SCALE FEE SCHEDULE IS USED TO DETERMINE THE MAXIMUM AMOUNTS THAT CAN BE CHARGED TO FAP-ELIGIBLE INDIVIDUALS. GROUP A-FACILITY 4 -- GRACE SOUTH POINTE PART V, SECTION B, LINE 13H: THE FOLLOWING STRUCTURE WILL BE UTILIZED TO DETERMINE THE AMOUNT OF FREE CARE TO BE PROVIDED. HOUSEHOLD INCOME AND THE NUMBER OF PEOPLE LIVING IN HOUSEHOLD WILL BE THE TWO MAJOR CRITERIA USED TO DETERMINE IF A PATIENT IS ELIGIBLE FOR FREE CARE. EXTENUATING CIRCUMSTANCES SHOULD BE NOTED AND MAY INCLUDE INFORMATION SUPPLIED TO SUPPORT EXCEPTIONAL SCENARIOS INCLUDING A TERMINAL ILLNESS, DEATH OF A SPOUSE, OR CATASTROPHIC PROBLEMS. GROUP A-FACILITY 4 -- GRACE SOUTH POINTE PART V, SECTION B, LINE 16I: THE POLICY IS ATTACHED TO BILLING INVOICES. GROUP A-FACILITY 4 -- GRACE SOUTH POINTE PART V, SECTION B, LINE 21D: GRACE HOSPITAL IS A LONG TERM ACUTE CARE (LTAC) FACILITY LOCATED ON A FLOOR OF SOUTH POINTE HOSPITAL, A CLEVELAND CLINIC HOSPITAL. DUE TO THE TYPE OF SERVICES PROVIDED, GRACE DOES NOT PROVIDE CARE FOR EMERGENCY MEDICAL CONDITIONS. IF FULL-SERVICE EMERGENCY ROOM CARE IS NEEDED, THE FACILITIES OF SOUTH POINTE HOSPITAL ARE AVAILABLE. GROUP A-FACILITY 4 -- GRACE SOUTH POINTE PART V, SECTION B, LINE 22D: A SLIDING SCALE FEE SCHEDULE IS USED TO DETERMINE THE MAXIMUM AMOUNTS THAT CAN BE CHARGED TO FAP-ELIGIBLE INDIVIDUALS. GROUP A-FACILITY 2 -- GRACE BEDFORD PART V, SECTION B, LINE 13H: THE FOLLOWING STRUCTURE WILL BE UTILIZED TO DETERMINE THE AMOUNT OF FREE CARE TO BE PROVIDED. HOUSEHOLD INCOME AND THE NUMBER OF PEOPLE LIVING IN HOUSEHOLD WILL BE THE TWO MAJOR CRITERIA USED TO DETERMINE IF A PATIENT IS ELIGIBLE FOR FREE CARE. EXTENUATING CIRCUMSTANCES SHOULD BE NOTED AND MAY INCLUDE INFORMATION SUPPLIED TO SUPPORT EXCEPTIONAL SCENARIOS INCLUDING A TERMINAL ILLNESS, DEATH OF A SPOUSE, OR CATASTROPHIC PROBLEMS. GROUP A-FACILITY 2 -- GRACE BEDFORD PART V, SECTION B, LINE 16I: THE POLICY IS ATTACHED TO BILLING INVOICES. GROUP A-FACILITY 2 -- GRACE BEDFORD PART V, SECTION B, LINE 21D: GRACE HOSPITAL IS A LONG TERM ACUTE CARE (LTAC) FACILITY LOCATED ON A FLOOR OF BEDFORD MEDICAL CENTER, A CAMPUS OF UNIVERSITY HOSPITALS REGIONAL HOSPITALS. DUE TO THE TYPE OF SERVICES PROVIDED, GRACE DOES NOT PROVIDE CARE FOR EMERGENCY MEDICAL CONDITIONS. IF FULL-SERVICE EMERGENCY ROOM CARE IS NEEDED, THE FACILITIES OF BEDFORD HOSPITAL ARE AVAILABLE. GROUP A-FACILITY 2 -- GRACE BEDFORD PART V, SECTION B, LINE 22D: A SLIDING SCALE FEE SCHEDULE IS USED TO DETERMINE THE MAXIMUM AMOUNTS THAT CAN BE CHARGED TO FAP-ELIGIBLE INDIVIDUALS. PART V, SECTION B, QUESTION #3 FAILURE TO CONDUCT CHNA - SHL PURSUANT TO INTERNAL REVENUE BULLETIN 2015-5, IRS NOTICE 2014-3, AND REV. PROC. 2015-21, SPECIALTY HOSPITAL OF LORAIN (SHL) IS DISCLOSING FAILURE TO COMPLY WITH IRC SECTION 501(R)(3) WHICH REQUIRES A HOSPITAL ORGANIZATION TO CONDUCT A COMMUNITY HEALTH NEEDS ASSESSMENT (CHNA). UNDER REG. 1.501(R)-2(C), "A HOSPITAL FACILITY'S FAILURE TO MEET ONE OR MORE OF THE REQUIREMENTS DESCRIBED IN 1.501(R)-3 THROUGH 1.501(R)-6 THAT IS NEITHER WILLFUL NOR EGREGIOUS SHALL BE EXCUSED FOR PURPOSES OF THIS SECTION IF THE HOSPITAL FACILITY CORRECTS AND MAKES DISCLOSURE IN ACCORDANCE WITH THE RULES SET FORTH IN THE GUIDANCE." SHL'S FAILURE TO COMPLY WITH THE REQUIREMENT TO CONDUCT A CHNA WAS NEITHER WILLFUL NOR EGREGIOUS. SHL IS A LONG-TERM ACUTE CARE HOSPITAL (LTAC) THAT OPERATES ON A FLOOR AT AMHERST HOSPITAL. DUE TO LIMITED RESOURCES, STAFF LIMITATIONS AND BASED ON THE SERVICES THAT SHL PROVIDES, SHL WAS NOT AWARE OF THE REQUIREMENT TO CONDUCT A CHNA AND DID NOT CONDUCT A CHNA FOR TAX YEAR 2014. UPON CONSULTATION FROM OUTSIDE CONSULTANTS, SHL WAS MADE AWARE OF THE REQUIREMENT. ONCE ADVISED ON REQUIREMENT TO CONDUCT A CHNA, SHL BEGAN THE PROCESS OF PREPARING AND ADOPTING A CHNA REPORT CONTAINING ALL OF THE REQUIRED ELEMENTS AND WILL MAKE THE CHNA REPORT WIDELY AVAILABLE ON A WEB SITE WITHIN THE MEANING OF 1.501(R)-1(C)(4) OF THE REGULATIONS.SUBSEQUENT TO TAX YEAR 2014 AND DURING TAX YEAR 2015, SHL COMPLETED THE CHNA AND PUBLISHED TO THE SHL WEBSITE. PART V, SECTION B, QUESTION #3 FAILURE TO CONDUCT CHNA - GRACE PURSUANT TO INTERNAL REVENUE BULLETIN 2015-5, IRS NOTICE 2014-3, AND REV. PROC. 2015-21, GRACE HOSPITAL (GRACE) IS DISCLOSING FAILURE TO COMPLY WITH IRC SECTION 501(R)(3) WHICH REQUIRES A HOSPITAL ORGANIZATION TO CONDUCT A COMMUNITY HEALTH NEEDS ASSESSMENT (CHNA). UNDER REG 1.501(R)-2(C), "A HOSPITAL FACILITY'S FAILURE TO MEET ONE OR MORE OF THE REQUIREMENTS DESCRIBED IN 1.501(R)-3 THROUGH 1.501(R)-6 THAT IS NEITHER WILLFUL NOR EGREGIOUS SHALL BE EXCUSED FOR PURPOSES OF THIS SECTION IF THE HOSPITAL FACILITY CORRECTS AND MAKES DISCLOSURE IN ACCORDANCE WITH THE RULES SET FORTH IN THE GUIDANCE." GRACE'S FAILURE TO COMPLY WITH THE REQUIREMENT TO CONDUCT A CHNA WAS NEITHER WILLFUL NOR EGREGIOUS. GRACE IS A LONG-TERM ACUTE CARE HOSPITAL (LTAC) THAT OPERATES ON FLOORS WITHIN THREE CLEVELAND CLINIC HOSPITALS AND ONE UNIVERSITY HOSPITAL FACILITY. FOR EACH HOSPITAL FACILITY THAT GRACE OPERATES WITHIN, A CHNA WAS CONDUCTED BY THAT HOSPITAL SYSTEM. DUE TO LIMITED RESOURCES, STAFF LIMITATIONS AND BASED ON THE SERVICES THAT GRACE PROVIDES, GRACE DID NOT CONDUCT A CHNA FOR FISCAL YEAR 2015 (7/1/2014 - 6/30/2015). UPON CONSULTATION FROM OUTSIDE CONSULTANTS, GRACE WAS MADE AWARE OF THE REQUIREMENT. ONCE ADVISED ON REQUIREMENT TO CONDUCT A CHNA, GRACE HAS BEGUN THE PROCESS OF IMPLEMENTING A PLAN TO CONDUCT A CHNA AND WILL PREPARE AND ADOPT A CHNA REPORT CONTAINING ALL OF THE REQUIRED ELEMENTS AND WILL MAKE THE CHNA REPORT WIDELY AVAILABLE ON A WEB SITE WITHIN THE MEANING OF 1.501(R)-1(C)(4) OF THE REGULATIONS. GRACE IS CURRENTLY WORKING ON THE CHNA AND ANTICIPATES COMPLETING THE CHNA AND IMPLEMENTATION PLAN PRIOR TO THE END OF THE NEXT FISCAL YEAR (6/30/2016) FOR TAX YEAR 2015. PART I, LINE 3C: N/A PART I, LINE 6A: N/A PART I, LINE 7: THE AMOUNTS REPORTED ON LINE B WERE GENERATED FROM THE MEDICAID COST REPORT FILED FOR FY2015 AND THE HOSPITAL'S ACCOUNTING SYSTEM. THE AMOUNTS REPORTED INCLUDE GRACE HOSPITAL'S PROPORTIONATE SHARE FROM SPECIALTY HOSPITAL OF LORAIN. ACUTE CARE HOSPITAL SERVICES RENDERED TO MEDICAID PROGRAM BENEFICIARIES ARE PAID AT PROSPECTIVELY DETERMINED RATES. THESE RATES VARY ACCORDING TO A PATIENT CLASSIFICATION SYSTEM THAT IS BASED ON CLINICAL, DIAGNOSTIC AND OTHER FACTORS. CAPITAL COSTS FOR MEDICAID INPATIENT SERVICES ARE REIMBURSED BASED ON A COST REIMBURSEMENT METHODOLOGY. THE HOSPITAL IS REIMBURSED FOR COST REIMBURSABLE ITEMS AT A TENTATIVE RATE WITH FINAL SETTLEMENT DETERMINED AFTER SUBMISSION OF ANNUAL COST REPORTS AND AUDITS THEREOF BY THE FISCAL INTERMEDIARY. PART I, LINE 7G: N/A PART II, COMMUNITY BUILDING ACTIVITIES: N/A PART III, LINE 2: THE AMOUNT REPORTED ON LINE 2 REPRESENTS THE PROVISION FOR DOUBTFUL ACCOUNTS REPORTED ON THE 2015 AUDITED FINANCIAL STATEMENTS. THE AMOUNTS REPORTED ALSO INCLUDE GRACE HOSPITAL'S PROPORTIONATE SHARE FROM SPECIALTY HOSPITAL OF LORAIN. PART III, LINE 3: THE AMOUNT REPORTED ON LINE 3 REPRESENTS CHARGES WRITTEN OFF FOR SELF-PAY INDIVIDUALS WHO LIKELY WOULD QUALIFY FOR FINANCIAL ASSISTANCE UNDER THE HOSPITAL'S FINANCIAL ASSISTANCE POLICY BUT FOR WHOM INSUFFICIENT INFORMATION WAS OBTAINED TO DETERMINE THEIR ELIGIBILITY. THIS AMOUNT WAS DETERMINED BASED ON REVIEW OF BAD DEBT WRITE-OFFS DURING THE YEAR. THE AMOUNTS REPORTED ALSO INCLUDE GRACE HOSPITAL'S PROPORTIONATE SHARE FROM SPECIALTY HOSPITAL OF LORAIN. PART III, LINE 4: IN EVALUATING THE COLLECTABILITY OF ACCOUNTS RECEIVABLE, THE HOSPITAL ANALYZES ITS PAST HISTORY AND IDENTIFIES TRENDS FOR EACH OF ITS MAJOR PAYOR SOURCES OF REVENUE TO ESTIMATE THE APPROPRIATE ALLOWANCE FOR DOUBTFUL ACCOUNTS AND PROVISION FOR DOUBTFUL ACCOUNTS. IN ADDITION, MANAGEMENT REGULARLY REVIEWS DATA ABOUT THESE MAJOR PAYOR SOURCES OF REVENUE IN EVALUATING THE SUFFICIENCY OF THE CONTRACTUAL ALLOWANCE. FOR RECEIVABLES ASSOCIATED WITH SERVICES PROVIDED TO PATIENTS WHO HAVE THIRD-PARTY COVERAGE, THE HOSPITAL ANALYZES CONTRACTUALLY DUE AMOUNTS AND PROVIDES AN ALLOWANCE, IF NECESSARY (FOR EXAMPLE, FOR EXPECTED UNCOLLECTIBLE DEDUCTIBLES AND CO-PAYMENTS ON ACCOUNTS FOR WHICH THE THIRD-PARTY PAYOR HAS NOT YET PAID, OR FOR PAYORS WHO ARE KNOWN TO BE HAVING FINANCIAL DIFFICULTIES THAT MAKE THE REALIZATION OF AMOUNTS DUE UNLIKELY). FOR RECEIVABLES ASSOCIATED WITH SELF-PAY PATIENTS (WHICH INCLUDES BOTH PATIENTS WITHOUT INSURANCE AND PATIENTS WITH DEDUCTIBLE AND CO-PAYMENT BALANCES DUE FOR WHICH THIRD-PARTY COVERAGE EXISTS FOR PART OF THE BILL), THE HOSPITAL IMMEDIATELY RESERVES THEIR BALANCES IN THE ALLOWANCE DOUBTFUL ACCOUNTS AND WRITES-OFF TO COLLECTION AFTER THE PATIENT IS BILLED FOUR TIMES, 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. PART III, LINE 8: MEDICARE SHORTHALL IS NOT TREATED AS COMMUNITY BENEFIT. THE AMOUNTS REPORTED WERE GENERATED FROM THE MEDICARE COST REPORT FILED FOR FY2015. INPATIENT ACUTE CARE SERVICES AND OUTPATIENT SERVICES RENDERED TO MEDICARE PROGRAM BENEFICIARIES ARE PAID AT PROSPECTIVELY DETERMINED RATES PER DISCHARGE. THESE RATES VARY ACCORDING TO A PATIENT CLASSIFICATION SYSTEM THAT IS BASED ON CLINICAL, DIAGNOSTIC, AND OTHER FACTORS. INPATIENT NONACUTE CARE SERVICES RELATED TO MEDICARE BENEFICIARIES ARE PAID BASED ON A COST REIMBURSEMENT METHODOLOGY. THE HOSPITAL IS REIMBURSED FOR COST REIMBURSABLE ITEMS AT TENTATIVE RATES WITH FINAL SETTLEMENT AFTER SUBMISSION OF ANNUAL COST REPORTS AND AUDITS THEREOF BY THE MEDICARE FISCAL INTERMEDIARY.THE AMOUNTS REPORTED ALSO INCLUDE GRACE HOSPITAL'S PROPORTIONATE SHARE FROM SPECIALTY HOSPITAL OF LORAIN. PART III, LINE 9B: FREE CARE WILL BE EXTENDED TO THOSE WHO QUALIFY FOR THESE REASONS: THE PATIENT IS UNINSURED, THE PATIENT IS NOT ELIGIBLE FOR MEDICAID OR PENDING MEDICAID APPROVAL,THE PATIENT IS DETERMINED TO BE UNABLE TO PAY FOR SERVICES PROVIDED, THE PATIENT IS UNABLE TO ACCEPT AN INSTALLMENT PAYMENT ARRANGEMENT, THE PATIENT IS BELOW 200% OF THE FEDERAL POVERTY GUIDELINES, AND THE PATIENT IS A HARDSHIP CASE AS DESIGNATED BY THE PHYSICIAN AND GRACE HOSPITAL. THE PATIENT WILL NEED TO COMPLETE A CHARITY CARE FORM AND RETURN TO GRACE HOSPITAL FOR DETERMINATION OF FREE CARE. GRACE HOSPITAL STAFF OR ITS BILLING REPRESENTATIVES WILL HELP THE PATIENT COMPLETE THE FORM ON REQUEST. ULTIMATELY, IT IS THE PATIENT'S RESPONSIBILITY TO COMPLETE THE FORM. HE/SHE WILL CONTINUE TO BE FULLY RESPONSIBLE FOR THE BILL UNTIL A DETERMINATION IS MADE. DOCUMENTED PROOF OF INCOME IS REQUIRED. PART IV, JOINT VENTURES IN FISCAL YEAR 2008, GRACE HOSPITAL ENTERED INTO A JOINT VENTURE WITH TWO OTHER HEALTHCARE PROVIDERS TO OPERATE SPECIALTY HOSPITAL OF LORAIN (SPECIALTY), A NOT-FOR-PROFIT LONG-TERM ACUTE CARE HOSPITAL IN LORAIN, OHIO. THE PARTIES TO THE JOINT VENTURE OPERATE AS MEMBER ORGANIZATIONS OF SPECIALTY, EACH WITH A 33-1/3% INTEREST. EACH MEMBER ORGANIZATION HAS ALSO AGREED TO SERVE AS CO-GUARANTORS WITH SEVERAL LIABILITIES ON A LINE OF CREDIT NOT TO EXCEED $1,000,000, WHICH IS SECURED BY SPECIALTY'S ASSETS. THE LINE OF CREDIT AGREEMENT EXPIRED ON FEBRUARY 28, 2013 AND THE OBLIGATION WAS PAID IN FULL.IN FISCAL YEAR 2008, GRACE HOSPITAL ENTERED INTO A MANAGERIAL, AS WELL AS, VARIOUS CLINICAL SERVICE AGREEMENTS WITH SPECIALTY. THE AGREEMENTS SPECIFY GRACE HOSPITAL IS TO PROVIDE MANAGERIAL AND CLINICAL SERVICES AT COST AND COST PLUS 3%, RESPECTIVELY. FOR THE YEARS ENDED JUNE 30, 2015 AND 2014, REVENUE RECOGNIZED AS A RESULT OF THESE AGREEMENTS IS REPORTED ON GRACE HOSPITAL'S STATEMENTS OF OPERATIONS TOTALING $647,013 AND $647,784, RESPECTIVELY. RECEIVABLES FOR THESE SERVICES, IN ADDITION TO OTHER REIMBURSEMENTS, ARE REPORTED ON GRACE HOSPITAL'S STATEMENTS OF FINANCIAL POSITION TOTALING $281,353 AND $422,151 AT JUNE 30, 2015 AND 2014, RESPECTIVELY.GRACE HOSPITAL'S INVESTMENT IN SPECIALTY IS CARRIED ON THE STATEMENT OF FINANCIAL POSITION AT JUNE 30, 2015 AND 2014. THESE ASSETS REPRESENT GRACE HOSPITAL'S PROPORTIONATE SHARE OF SPECIALTY'S NET ASSET BALANCES, WHICH ARE RECORDED ON THE EQUITY METHOD.ON JULY 1, 2015, THE MANAGERIAL AGREEMENT WAS AMENDED TO SPECIFY THE GRACE FOUNDATION FOR HEALTH, WELLNESS & EDUCATION AS THE ENTITY TO PROVIDE MANAGERIAL AND CLINICAL SERVICES AT COST PLUS 3% TO SPECIALTY AND THE FOUNDATION AS THE MEMBER OF SPECIALTY.GRACE HOSPITAL'S PROPORTIONATE SHARE OF SPECIALTY'S FINANCIAL ASSISTANCE AND CERTAIN OTHER COMMUNITY BENEFITS AT COST AND BAD DEBTS HAVE BEEN INCLUDED IN SCHEDULE H. PART VI, LINE 2: THE HOSPITAL PRESENTLY SPONSORS SEVERAL INPATIENT SERVICES INCLUDING COMPLEX MEDICAL, PULMONARY, REHABILITATION, VENTILATOR WEANING, LEFT VENTRICAL ASSIST DEVICE, TRANSPLANT SUPPORT, WOUND CARE, AND NEUROLOGICAL REHABILITATION PROGRAMS. THESE SERVICES ARE PROVIDED AT INPATIENT SATELLITES LOCATED WITHIN AMHERST, FAIRVIEW, BEDFORD, LAKEWOOD, AND SOUTH POINTE HOSPITALS. GRACE HOSPITAL IS COMMITTED TO PROVIDING PERSONALIZED HEALTHCARE CHARACTERIZED BY QUALITY, ACCESSIBILITY, EFFICIENCY, AND COST EFFECTIVENESS. THE HOSPITAL IS SENSITIVE TO AGE, CULTURAL, AND ECONOMIC VARIATIONS, AND IS CONTINUOUSLY ASSESSED AND IMPROVED THROUGH A QUALITY MANAGEMENT PROGRAM. GRACE VOLUNTARILY MAINTAINS A CHARITY CARE POLICY THAT PROVIDES CARE TO INDIVIDUALS REGARDLESS OF ABILITY TO PAY. THE HOSPITAL IS ALSO COMMITTED TO EMPLOYING INDIVIDUALS TO MATCH CULTURAL DIVERSITY OF ITS PATIENT POPULATION. SEVERAL JOB POSTINGS IN THE HOSPITAL REQUIRE EMPLOYEES TO BE BILINGUAL IN EITHER SPANISH OR VIETNAMESE. GRACE HOSPITAL IS INVOLVED IN MANY COMMUNITY ACTIVITIES, INCLUDING HEALTH FAIRS, SPECIAL HEALTH-RELATED PRESENTATIONS, AND SPONSORSHIPS IN HEALTHCARE EDUCATION. IN ADDITION, THE HOSPITAL SPONSORS MEETINGS FOR MANY NON-PROFIT COMMUNITY ORGANIZATIONS. THE BOARD OF DIRECTORS, MEDICAL STAFF, AND MANAGEMENT OF GRACE HOSPITAL ARE COMMITTED TO THE PROVISION OF QUALITY SPECIALTY HEALTHCARE SERVICES, AS A LONG-TERM HOSPITAL, AND FULFILLING A LEADERSHIP ROLE IN THE COMMUNITY. DESPITE CHALLENGING ECONOMIC TIMES, GRACE HOSPITAL HAS SUCCESSFULLY CONTINUED ITS ROLE OF COMMUNITY SERVICE AS ORIGINALLY ENVISIONED BY ITS FOUNDERS. PART VI, LINE 3: INFORMATION ABOUT ELIGIBILITY FOR ASSISTANCE UNDER FEDERAL, STATE OR LOCAL GOVERNMENT PROGRAMS IS DESCRIBED ON THE PATIENT'S BILL. THE PATIENT WILL NEED TO COMPLETE A CHARITY CARE FORM AND RETURN TO GRACE FOR DETERMINATION OF FREE CARE. GRACE STAFF OR ITS BILLING REPRESENTATIVES WILL HELP THE PATIENT COMPLETE THE FORM ON REQUEST. PART VI, LINE 4: GRACE HOSPITAL IS A LONG-TERM ACUTE CARE HOSPITAL (LTACH) DEDICATED TO PROVIDING HIGH QUALITY PRIMARY AND SECONDARY HEALTH CARE SERVICES TO MEET THE NEEDS OF LOCAL COMMUNITIES IN NORTHEAST OHIO. PART VI, LINE 5: GRACE HOSPITAL AND THE GRACE FOUNDATION FOR HEALTH, WELLNESS & EDUCATION PROMOTES HEALTH, WELLNESS AND ECONOMIC DEVELOPMENT IN THE TREMONT, OHIO AREA. THIS IS THE GEOGRAPHIC AREA THE HOSPITAL HAS HISTORICALLY SERVED. THE FACILITY ON WEST 14TH STREET INCLUDES OUTPATIENT, INPATIENT, AND DIAGNOSTIC AND REHABILITATIVE CARE PROGRAMS DIRECTED TOWARD THE HEALTH AND WELLNESS NEEDS OF THE ADULT POPULATION. THE FACILITY ALSO INCLUDES AN EDUCATION CENTER, FITNESS CENTER, THERAPEUTIC SPA AND COMPOUNDING PHARMACY. PART VI, LINE 6: N/A PART VI, LINE 7 N/A X 0 0 0 0 0 0 0 0 0 RAJIVE KHANNA PRESIDENT & CEO - GRACE HOSPITAL 196006 0 0 0 0 0 3260 0 193 0 199459 0 0 0 ROBERT P RANGE PRESIDENT & CEO - GRACE FOUNDATION 161102 0 0 0 0 0 0 0 0 0 161102 0 0 0 FORM 990, PART VI, SECTION B, LINE 11 THE HOSPITAL CONTRACTS WITH AN OUTSIDE ACCOUNTING FIRM FOR THE PREPARATION OF THE FORM 990. THE HOSPITAL PROVIDES MATERIAL BASED ON REQUESTS FROM THE ACCOUNTING FIRM. MOST OF THE INFORMATION IS PROVIDED BY THE DIRECTOR OF FINANCE. THE FINAL FORM IS REVIEWED BY THE DIRECTOR OF FINANCE AND THE CEO. A COPY OF THE FORM 990 IS PROVIDED TO THE BOARD OF TRUSTEES. FORM 990, PART VI, SECTION B, LINE 15 THE COMPENSATION OF THE ORGANIZATION'S CEO IS DETERMINED BY THE BOARD OF DIRECTORS. 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 XI, LINE 9: TRANSFER OF EQUITY FROM RESTRUCTURE -500,000. BOOK GAIN ON TRANSFER OF PROPERTY TO RELATED ENTITY 400,107. FORM 990, PART XII, LINE 2C THE ORGANIZATION HAS NOT CHANGED ITS OVERSIGHT OR THE SELECTION PROCESS DURING THE TAX YEAR. THE GRACE FOUNDATION FOR HEALTH WELLNESS & EDUCATION 2307 WEST 14TH STREET CLEVELAND OH 44114 273418360 SUPPORTING ORGANIZATION OH 501(C)(3) LINE 11A, I N/A 0 THE GRACE CENTER PROPERTY LLC 2307 WEST 14TH STREET CLEVELAND OH 44113 473431477 REAL ESTATE OH N/A GRACE CENTER PROPERTY HOLDING LLC 2307 WEST 14TH STREET CLEVELAND OH 44113 473494723 HOLDING COMPANY OH N/A C 0 0 0 0 1 0 0 0 0 0 0 0 0 0 1 1 0 0 1 0 THE GRACE FOUNDATION FOR HEALTH WELLNESS & EDUCATION R 500000 FMV PROPERTY TRANSFERRED THE GRACE CENTER PROPERTY LLC D 2500000 BALANCE ON LOAN GUARANTEE