2015-07-22T14:31:36-05:00 2014-09-30 381357951 PLANTE & MORAN PLLC 65 EAST STATE ST STE 600 COLUMBUS OH 43215 990 2013-10-01 341048666 COMMUNITY HOSPITALS & WELLNESS CENTERS COMM 4196361131 433 W HIGH STREET BRYAN OH 43506 CHAD D TINKEL CFO 4196361131 2015-07-16 1 BERNIE OSTROWSKI P00366367 6148493000 2013 2016-03-07 17:11:31Z PHILIP ENNEN 433 W HIGH STREET BRYAN OH 43506 77413484 0 X WWW.CHWCHOSPITAL.ORG X 1969 OH 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. 11 8 848 90 0 0 19968 17218 80091324 75752631 580013 763961 1284461 801689 81975766 77335499 306093 0 0 0 44167153 40434701 0 0 0 36538871 35289583 81012117 75724284 963649 1611215 151976982 149596635 81783767 76360106 70193215 73236529 X 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. 0 0 11610126 0 9751660 INPATIENT CARE: BRYAN HOSPITAL MEDICAL & SURGICAL UNIT HAS 54 BEDS AND PROVIDE CARE FOR 814 INPATIENTS AND 332 OBSERVATION PATIENTS; BRYAN HOSPITAL PEDIATRIC UNIT HAS 6 BEDS AND PROVIDE CARE FOR 22 INPATIENTS AND 53 OBSERVATION PATIENTS; BRYAN HOSPITAL INTENSIVE CARE UNIT AND TELEMETRY UNIT HAS 16 BEDS AND PROVIDE CARE FOR 689 INPATIENTS AND 478 OBSERVATION PATIENTS; BRYAN HOSPITAL OBSTETRICS HAS 9 BEDS AND PROVIDED CARE FOR 307 INPATIENTS. MONTPELIER HOSPITAL HAS 25 BEDS AND PROVIDED CARE TO 256 INPATIENTS. 11036197 0 12518248 SURGERY CARE: BRYAN SURGERY HAS 6 OPERATING ROOMS THAT DID 1,692 GENERAL SURGERY CASES, 2,209 PAIN MANAGEMENT CASES, 849 ORTHOPEDIC CASES, 646 OPHTHALMOLOGY CASES, 434 GYNECOLOGY CASES, 219 ENT CASES, AND 158 UROLOGY CASES. ARCHBOLD SURGERY HAS 4 OPERATING ROOMS THAT DID 426 ORTHOPEDIC CASES, 41 GENERAL SURGERY CASES, AND 195 UROLOGY CASES. 3853738 0 4299913 LABORATORY CARE: BRYAN LAB COMPLETED 11,341 COMPLETE BLOOD COUNT TESTS, 8,246 BASIC METABOLIC PANEL TESTS, 4,091 PROTHROMBIN TIME TESTS, 3,683 CREATINE PHOSPHOKINASE TESTS, AND 3,735 TROPONIN TESTS; MONTPELIER LAB COMPLETED 2,641 COMPLETE BLOOD COUNT TESTS, 1,784 BASIC METABOLIC PANEL TESTS, AND 1,353 PROTHROMBIN TESTS; ARCHBOLD LAB COMPLETED 789 PROTHROMBIN TIME TESTS, 898 COMPLETE BLOOD COUNT TESTS, AND 609 COMPREHENSIVE METABOLIC PANEL TESTS. 27065790 0 49444671 COMMUNITY HOSPITALS AND WELLNESS CENTERS PROVIDED SERVICES TO APPROXIMATELY 2,300 INPATIENTS, APPROXIMATELY 1,500 OBSERVATION PATIENTS, AND APPROXIMATELY 17,500 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 5,236 ACCOUNTS DURING THIS FISCAL YEAR. IN ADDITION, THE HOSPITAL PROVIDES THE FOLLOWING: COMMUNITY EDUCATION: THE PHARMACY DEPARTMENT HOLDS COMMINITY 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 30 POISON PREVENTION PROGRAMS TO APPROXIMATELY 425 CHILDREN. PHARMACY PRECEPTOR STUDENTS WERE MADE AVAILABLE TO VISIT AREA SENIOR CENTERS AND EDUCATE SENIORS ON MEDICATION USE.OFFERED SPEAKERS FOR SMOKING CESSATION PROGRAMS. 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, PROVIDED DE-ESCALATION TRAINING FOR AREA COMMUNITY MENTAL HEALTH AGENCIES, AND OFFERED CRISIS STABILIZATION TO AREA SCHOOLS AFTER SUICIDE. OFFERED A DIABETIC SUPPORT GROUP THAT PROVIDES FREE MONTHLY MEETINGS TO APPROXIMATELY 20 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 75 AREA HIGH SCHOOL ATHLETES. PROVIDED FREE BLOOD PRESSURE CHECKS THROUGH OUR EMERGENCY AND CARDIOPULMONARY DEPARTMENTS. PROVIDED 9,021 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 32 UT STUDENTS WAS $5,150. 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 HEALTH INFORMATION 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 32 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. 27065790 0 49444671 53565851 1 1 0 1 0 0 0 0 0 0 1 0 0 0 1 1 0 1 0 0 0 0 0 0 0 0 1 1 0 0 1 1 1 0 0 0 0 0 0 0 0 1 0 0 0 0 0 1 1 1 0 0 1 40 0 1 848 1 0 0 0 0 0 0 0 0 0 0 X 11 8 1 0 0 0 0 0 0 1 1 0 0 1 1 1 1 1 1 1 1 1 1 OH X CHAD TINKEL 4196361131 433 W HIGH STREET BRYAN OH 43506 PHILIP L ENNEN PRESIDENT/SECRETARY, CEO 40.00 0.50 X X 361032 0 36240 KATRINA P HESTER CHAIRMAN 0.10 0.10 X X 0 0 0 CHRISTOPHER CULLIS VICE CHAIRMAN/TREASURER 0.10 0.10 X X 0 0 0 JIM WYSE DIRECTOR 0.10 0.10 X 0 0 0 JAMES RUPP DIRECTOR 0.10 0.10 X 0 0 0 BRUCE SPANGLER DIRECTOR 0.10 0.10 X 0 0 0 KEVIN KOLOVICH MD DIRECTOR 0.10 0.10 X 0 0 0 GLEN SEAMAN MD DIRECTOR 0.10 0.10 X 0 0 0 CHRISTOPHER KANNEL DIRECTOR 0.10 0.10 X 0 0 0 LARRY DEWIRE DIRECTOR 0.10 0.10 X 0 0 0 DAVID SWANSON DIRECTOR 0.10 0.10 X 0 0 0 C NICHOLAS WALZ UNTIL 112014 VP/CMO 40.00 0.00 X 254987 0 21240 GREGORY E SLATTERY VP/CIO 40.00 0.00 X 236623 0 36240 MICHAEL CULLER VP/COO 40.00 0.00 X 252670 0 21240 CHAD D TINKEL VP/CFO 40.00 0.50 X 222414 0 36240 JANICE DAVID VP PATIENT CARE 40.00 0.00 X 189593 0 21480 SHANNON KEIL PATHOLOGY PHYISICAN 40.00 0.00 X 331825 0 21240 SCOTT FREDERICK INTERNAL MEDICINE PHYSICIAN 40.00 0.00 X 340814 0 15000 LARRY SIMON CRNA 40.00 0.00 X 205557 0 21240 CRAIG BUELL DIRECTOR OF PHARMACY 40.00 0.00 X 132550 0 21240 MARILYN NUSSBAUMER DIRECTOR CATH LAB 40.00 0.00 X 150728 0 6480 2678793 0 257880 20 0 1 0 AMERISOURCE BERGEN 1300 MORRIS DRIVE CHESTERBROOK PA 19087 PHARMACEUTICAL SUPPLIES 1840357 SENECA MEDICAL 85 SHAFFER PARK DRIVE TIFFIN OH 44883 MEDICAL SUPPLIES 1603223 BIOMET 56 E BELL DR WARSAW IN 46582 MEDICAL DEVICES 1361922 BOSTON SCIENTIFIC ONE BOSTON SCIENTIFIC PLACE NATICK MA 01760 MEDICAL DEVICES 1258447 MIDWEST COMMUNITY HEALTH 442 W HIGH ST BRYAN OH 435061685 PHYSICIAN SERVICES 1078033 54 17218 17218 NET PATIENT REVENUES 621400 75752631 75752631 75752631 805046 805046 297861 36000 261861 261861 261861 900 41985 -41085 -41085 -41085 CAFETERIA/VENDING 621400 539828 539828 539828 77335499 76014492 0 1303789 1208375 1208375 28348022 21120961 7227061 604859 579564 25295 8156406 5631958 2524448 2117039 1526735 590304 6250025 5469436 780589 215535 215535 169529 169529 276049 276049 2762862 593085 2169777 288836 288836 1475697 744973 730724 93549 50398 43151 227551 103631 123920 1858674 921718 936956 6790186 3034689 3755497 BILLABLE/NONBILLABLE SU 8493081 8493081 REPAIRS AND MAINTENANCE 3320281 2145074 1175207 BAD DEBT EXPENSE 2406313 2406313 TAXES 1252414 1169472 82942 -590999 -701286 110287 75724284 53565851 22158433 0 5665707 4707765 26148967 24717913 8069414 7845324 1242778 1084198 1681382 1826531 158968174 74407179 88986664 84560995 19242972 22499036 530181 735853 408917 1619020 151976982 149596635 7108965 6963075 42820000 42025000 27445242 23099758 4409560 4272273 81783767 76360106 X 70193215 73236529 70193215 73236529 151976982 149596635 X 1611215 871544 560555 X X 0 1 X 1 0 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 0 0 0 0 0 0 0 0 1 1385 1385 0 PART II-B, LINE 1: PART OF OHA DUES ARE ATTRIBUTED TO LOBBYING, TOTAL DUES WERE $40,721 OF WHICH 3.4% WERE CONTRIBUTED TO LOBBYING. 830800 2220658 3051458 96299148 23718352 72580796 5388947 3438150 1950797 53353675 47048237 6305438 874946 202440 672506 84560995 DEFFERRED COMPENSATION 509097 SETTLEMENTS PAYABLE UNDER THIRD PARTY REIMBURSEMENT CONTRACTS 1985328 INTEREST RATE SWAP 1777848 4272273 X PART X, LINE 2: ACCOUNTING PRINCIPLES GENERALLY ACCEPTED IN THE UNITED STATES OF AMERICA REQUIRE MANAGEMENT TO EVALUATE TAX POSITIONS TAKEN BY THE HOSPITAL AND 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, 2014 AND 2013, THERE ARE NO UNCERTAIN POSITIONS TAKEN OR EXPECTED TO BE TAKEN THAT WOULD REQUIRE RECOGNITION OF A LIABILITY OR DISCLOSURE IN THE 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 2011. 1 1 X 1 X 1 X 1 1 0 0 4066466 2235892 1830574 0.02500 8954545 4403082 4551463 0.06210 13021011 6638974 6382037 0.08710 13021011 6638974 6382037 0.08710 1 2406313 240631 20371725 24946489 -4574764 X 1 1 2 1 BRYAN HOSPITAL 433 WEST HIGH STREET BRYAN OH 43506 X X X 2 MONTPELIER HOSPITAL 909 EAST SNYDER AVENUE MONTPELIER OH 43543 X X X BRYAN HOSPITAL 1 1 X X X X X X X X X X 12 1 1 1 X HTTP://WWW.CHWCHOSPITAL.ORG/COMMUNITYBENE X SEE STATEMENT FOR 5D X X X X X X X X X X 0 0 1 1 200.000000000000 1 300.000000000000 1 X X X 1 1 X X X X X 1 0 X X X X 1 X 0 0 MONTPELIER HOSPITAL 2 1 X X X X X X X X X X 12 1 1 1 X HTTP://WWW.CHWCHOSPITAL.ORG/COMMUNITYBENE X SEE STATEMENT FOR 5D X X X X X X X X X X 0 0 1 1 200.000000000000 1 300.000000000000 1 X X X 1 1 X X X X X 1 0 X X X X 1 X 0 0 BRYAN HOSPITAL PART V, SECTION B, LINE 1J: 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 1J: 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 3: LOCAL COMMUNITY AGENCIES WERE INVITED TO PARTICIPATE IN THE HEALTH ASSESSMENT PROCESS, INCLUDING CHOOSING QUESTIONS FOR THE SURVEYS, PROVIDING LOCAL DATA, REVIEWING DRAFT REPORTS AND PLANNING THE COMMUNITY EVENT, RELEASE OF THE DATA AND SETTING PRIORITIES. THE NEEDS OF THE POPULATION, ESPECIALLY THOSE WHO ARE MEDICALLY UNDERSERVED, LOW-INCOME, MINORITY POPULATIONS AND POPULATIONS WITH CHRONIC DISEASE NEEDS, WERE TAKEN INTO ACCOUNT THROUGH THE SAMPLE METHODOLOGY THAT SURVEYED THESE POPULATIONS AND OVER-SAMPLED MINORITY POPULATIONS. IN ADDITION, THE ORGANIZATIONS THAT SERVE THESE POPULATIONS PARTICIPATED IN THE HEALTH ASSESSMENT AND COMMUNITY PLANNING PROCESS, SUCH AS BOARD OF DEVELOPMENTAL DISABILITIES, VILLAGE OF WEST UNITY, WILLIAMS COUNTY JOB AND FAMILY SERVICES, ETC. THE PARTICIPANTS INCLUDED:- COMMUNITY HOSPITALS AND WELLNESS CENTERS: JAN DAVID, TAMMY DEGRYSE, PHIL ENNEN, MIKE FREEMAN, JESSICA REITZEL, JEANETTE ROBERTS, LINDA TRAUSCH- FOUR COUNTY ADAMHS BOARD: LES MCCASLIN- WILLIAMS COUNTY HEALTH DEPARTMENT: JIM WATKINS, MEGAN RILEY, BETH SCHWEITZER, BECKI SNYDER - BRYAN CITY SCHOOLS: DIANA SAVAGE, SUPERINTENDENT & KARYN COX- BOARD OF DEVELOPMENTAL DISABILITIES: DEBRA GUILFORD & DENNIS MYERS - WILLIAMS COUNTY JOB AND FAMILY SERVICES: PAMELA JOHNSON - UNITED WAY: BILL PEPPLE- WILLIAMS COUNTY SHERIFF: STEVE TOWNS- PARKVIEW PHYSICIAN GROUP: KRYSTAL MILLER- WILLIAMS COUNTY YMCA: ROB IMBER- CLERGY: DAVE TILLY MONTPELIER HOSPITAL PART V, SECTION B, LINE 3: LOCAL COMMUNITY AGENCIES WERE INVITED TO PARTICIPATE IN THE HEALTH ASSESSMENT PROCESS, INCLUDING CHOOSING QUESTIONS FOR THE SURVEYS, PROVIDING LOCAL DATA, REVIEWING DRAFT REPORTS AND PLANNING THE COMMUNITY EVENT, RELEASE OF THE DATA AND SETTING PRIORITIES. THE NEEDS OF THE POPULATION, ESPECIALLY THOSE WHO ARE MEDICALLY UNDERSERVED, LOW-INCOME, MINORITY POPULATIONS AND POPULATIONS WITH CHRONIC DISEASE NEEDS, WERE TAKEN INTO ACCOUNT THROUGH THE SAMPLE METHODOLOGY THAT SURVEYED THESE POPULATIONS AND OVER-SAMPLED MINORITY POPULATIONS. IN ADDITION, THE ORGANIZATIONS THAT SERVE THESE POPULATIONS PARTICIPATED IN THE HEALTH ASSESSMENT AND COMMUNITY PLANNING PROCESS, SUCH AS BOARD OF DEVELOPMENTAL DISABILITIES, VILLAGE OF WEST UNITY, WILLIAMS COUNTY JOB AND FAMILY SERVICES, ETC. THE PARTICIPANTS INCLUDED:- COMMUNITY HOSPITALS AND WELLNESS CENTERS: JAN DAVID, TAMMY DEGRYSE, PHIL ENNEN, MIKE FREEMAN, JESSICA REITZEL, JEANETTE ROBERTS, LINDA TRAUSCH- FOUR COUNTY ADAMHS BOARD: LES MCCASLIN- WILLIAMS COUNTY HEALTH DEPARTMENT: JIM WATKINS, MEGAN RILEY, BETH SCHWEITZER, BECKI SNYDER - BRYAN CITY SCHOOLS: DIANA SAVAGE, SUPERINTENDENT & KARYN COX- BOARD OF DEVELOPMENTAL DISABILITIES: DEBRA GUILFORD & DENNIS MYERS - WILLIAMS COUNTY JOB AND FAMILY SERVICES: PAMELA JOHNSON - UNITED WAY: BILL PEPPLE- WILLIAMS COUNTY SHERIFF: STEVE TOWNS- PARKVIEW PHYSICIAN GROUP: KRYSTAL MILLER- WILLIAMS COUNTY YMCA: ROB IMBER- CLERGY: DAVE TILLY BRYAN HOSPITAL PART V, SECTION B, LINE 4: MONTPELIER HOSPITAL MONTPELIER HOSPITAL PART V, SECTION B, LINE 4: BRYAN HOSPITAL BRYAN HOSPITAL PART V, SECTION B, LINE 5D: 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 5D: 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 7: 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 7: 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 18E: 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 18E: 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 20D: 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 20D: 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. 3 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 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 (54%) 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 $2,406,313. PART II, COMMUNITY BUILDING ACTIVITIES: NOT APPLICABLE PART III, LINE 4: BAD DEBT WAS CALCULATED USING THE AUDITED FINANCIAL STATEMENTS. CHWC USES AN 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. THE BAD DEBT EXPENSE ESTIMATE IS TREATED AS A COMMUNITY BENEFIT SINCE THOSE DEBTS SHOULD HAVE BEEN CAPTURED UNDER THE FINANCIAL ASSISTANCE POLICY.FOOTNOTE TO FINANCIAL STATEMENTS: 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 TRENDS 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 CONTRACTUALLY DUE AMOUNTS AND PROVIDES AN ALLOWANCE FOR DOUBTFUL ACCOUNTS AND A PROVISION FOR BAD DEBTS, IF NECESSARY (FOR EXAMPLE, FOR EXPECTED UNCOLLECTIBLE DEDUCTIBLES AND COPAYMENTS 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 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. ALSO, THERE ARE PHYSICIANS OFFICES LOCATED IN WAUSEON, OHIO. APPROXIMATELY 16.0% OF THE POPULATION IS 65 YEARS OR OLDER AND 11.8% IS BELOW POVERTY LEVEL. PART VI, LINE 5: COMMUNITY HOSPITALS AND WELLNESS CENTERS PROVIDED SERVICES TO APPROXIMATELY 2,300 INPATIENTS, APPROXIMATELY 1,500 OBSERVATION PATIENTS, AND APPROXIMATELY 17,500 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 5,236 ACCOUNTS DURING THIS FISCAL YEAR. IN ADDITION, THE HOSPITAL PROVIDES THE FOLLOWING: COMMUNITY EDUCATION: THE PHARMACY DEPARTMENT HOLDS COMMINITY 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 30 POISON PREVENTION PROGRAMS TO APPROXIMATELY 425 CHILDREN. PHARMACY PRECEPTOR STUDENTS WERE MADE AVAILABLE TO VISIT AREA SENIOR CENTERS AND EDUCATE SENIORS ON MEDICATION USE.OFFERED SPEAKERS FOR SMOKING CESSATION PROGRAMS. 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, PROVIDED DE-ESCALATION TRAINING FOR AREA COMMUNITY MENTAL HEALTH AGENCIES, AND OFFERED CRISIS STABILIZATION TO AREA SCHOOLS AFTER SUICIDE. OFFERED A DIABETIC SUPPORT GROUP THAT PROVIDES FREE MONTHLY MEETINGS TO APPROXIMATELY 20 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 75 AREA HIGH SCHOOL ATHLETES. PROVIDED FREE BLOOD PRESSURE CHECKS THROUGH OUR EMERGENCY AND CARDIOPULMONARY DEPARTMENTS. PROVIDED 9,021 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 32 UT STUDENTS WAS $5,150. 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 HEALTH INFORMATION 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 32 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. PART VI, LINE 6: NOT APPLICABLE X X X X X 0 1 0 0 0 0 0 0 0 PHILIP L ENNEN PRESIDENT/SECRETARY, CEO 346032 0 0 0 15000 0 15000 0 21240 0 397272 0 0 0 C NICHOLAS WALZ UNTIL 112014 VP/CMO 254987 0 0 0 0 0 0 0 21240 0 276227 0 0 0 GREGORY E SLATTERY VP/CIO 221623 0 0 0 15000 0 15000 0 21240 0 272863 0 0 0 MICHAEL CULLER VP/COO 192288 0 0 0 60382 0 0 0 21240 0 273910 0 0 0 CHAD D TINKEL VP/CFO 207414 0 0 0 15000 0 15000 0 21240 0 258654 0 0 0 JANICE DAVID VP PATIENT CARE 174593 0 0 0 15000 0 15000 0 6480 0 211073 0 0 0 SHANNON KEIL PATHOLOGY PHYISICAN 331825 0 0 0 0 0 0 0 21240 0 353065 0 0 0 SCOTT FREDERICK INTERNAL MEDICINE PHYSICIAN 325814 0 0 0 15000 0 15000 0 0 0 355814 0 0 0 LARRY SIMON CRNA 205557 0 0 0 0 0 0 0 21240 0 226797 0 0 0 CRAIG BUELL DIRECTOR OF PHARMACY 132550 0 0 0 0 0 0 0 21240 0 153790 0 0 0 MARILYN NUSSBAUMER DIRECTOR CATH LAB 150728 0 0 0 0 0 0 0 6480 0 157208 0 0 0 PART I, LINE 4B THE FOLLOWING INDVIDUALS PARTICIPATED IN A 457(B) RETIREMENT PLAN: PHILIP ENNEN, JANICE DAVID, GREGORY SLATTERY, CHAD TINKEL, AND SCOTT FREDERICK. A $75,000 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. A CITY OF BRYAN OH 346400228 2008-07-01 10000000 SEE PART VI 0 0 0 B COUNTY OF WILLIAMS OH 346401595 96948QAA3 2008-07-17 45000000 SEE PART VI 0 0 0 C VILLAGE OF ARCHBOLD OH 346400063 2008-08-20 10000000 SEE PART VI 0 0 0 D COUNTY OF WILLIAMS OH 346401595 2012-09-26 2905428 SEE PART VI 0 0 0 A 974299 10208153 10208153 2011 0 0 1 1 B 2975000 47692402 303337 316607 47072458 2011 0 0 1 1 C 985238 10208153 10208153 2011 0 0 1 1 D 871594 2905428 2905428 2005 1 0 1 1 A 0 0 1 1 0 0.00000 0.00000 0.00000 0 0 1 B 0 1 1 1 0 0.01240 0.00000 0.01240 0 0 1 C 0 0 1 1 0 0.00000 0.00000 0.00000 0 0 1 D 0 0 1 1 0 0.00000 0.00000 0.00000 0 0 1 A 0 0 1 1 0 0 0 0 1 B 0 0 0 1 1 1 FIFTH THIRD BANK 9.500000000000 0 0 0 1 1 C 0 0 1 1 1 0 0 0 1 D 0 1 1 0 0 0 0 0 1 A 1 B 1 C 1 D 1 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. PPG OHIOMIDWEST COMMUNITY HEALTH ASSOCIATES SEE SCH L, PART V 1078033 PPG OHIO/MCHA PROVIDES MEDICAL SERVICES TO COMMUNITY HOSPITALS & WELLNESS CENTERS. 0 FORM 990, SCHEDULE L, PART IV, COLUMN B: DR. KOLOVICH AND DR. SEAMAN ARE BOTH VOTING MEMBERS OF CHWC AND VOTING MEMBERS OF PPG OHIO/MCHA. FORM 990, PART VI SECTION B, LINE 16B THE HOSPITAL'S EXTERNAL COUNSEL DRAFTED THE JOINT VENTURE DOCUMENTS. 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 AND CHANGES TO THE FORM IS PRESENTED BY THE CFO 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 IN JANUARY 2015. 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: CHANGE IN FAIR VALUE OF INTEREST SWAP AGREEMENTS 560,555. 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. 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