2015-05-13T10:24:58-05:00 2014-06-30 861065772 Deloitte Tax LLP 250 East Fifth Street Suite 1900 Cincinnati OH 45202 990 2013-07-01 311045101 Appalachian Community Visiting Nurse Association Hospice and Health Services APPA 7405948226 30 Herrold Avenue Athens OH 457012326 Craig Bjerke System VP and Corp Controller 7405948226 2015-05-13 1 Mary E Rauschenberg P00172604 5137847100 2013 2016-02-25 16:41:14Z LaMar Wyse 30 Herrold Avenue Athens OH 457012326 3543337 0 X www.acvna.org X 1982 OH Southeastern Ohio's premier source for the delivery of quality home care and hospice services. 22 12 99 54 0 0 85108 105000 3515715 3441135 1721 -2798 0 0 3602544 3543337 0 0 0 0 2632504 2751443 0 0 0 1214931 1189400 3847435 3940843 -244891 -397506 958141 1207303 649648 1230193 308493 -22890 X We are dedicated to providing cost effective, high quality home health services to the people in our Appalachian community. We provide services to Medicaid clients through Ohio Home Care Programs as well as for clients with workers' compensation, Veteran's Administration, Medicare and other payor sources. 0 0 2348911 0 3441135 The organization provides care to home-bound, indigent, and terminally ill patients in the community. The organization provides care to patients who meet certain criteria under its charity care policy without charge or at amounts less than its established rates. To accomplish its charitable purpose, the organization provided 8,707 days of hospice care, 12,743 home health visits, and 28,821 hours of health services. 2348911 1 1 0 0 0 0 0 0 0 1 1 0 0 1 1 1 0 1 0 0 0 0 0 0 0 0 0 0 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 1 1 1 0 0 1 10 0 1 99 1 0 0 0 0 0 0 0 0 0 0 X 22 12 1 1 0 0 1 1 1 1 1 0 0 1 1 1 1 1 1 0 0 0 X Todd Dougherty 7405929464 55 Hospital Drive Athens OH 45701 Rasmussen Steven Chairman - OhioHlth (start 1/14) 1.00 2.00 X X 0 0 0 McConnell John P Vice Chair - OhioHlth (start 1/14) 1.00 2.00 X X 0 0 0 Hondros Linda Secretary - OhioHlth (start 1/14) 1.00 2.00 X X 0 0 0 Anderson Kerrii B Treasurer - OhioHlth (start 1/14) 1.00 2.00 X X 0 0 0 Akins Nicholas Board Member - OhioHlth (start 1/14) 1.00 2.00 X 0 0 0 Abbott Lawrence C Ex-Officio - OhioHlth (start 1/14) 1.00 2.00 X 0 0 0 Anderson Thomas DO Board Member - OhioHlth (start 1/14) 1.00 2.00 X 0 0 0 Blosser T Laurence MD Ex-Officio - OhioHlth (start 1/14) 1.00 15.00 X 0 124805 0 Crane Tanny Board Member - OhioHlth (start 1/14) 1.00 2.00 X 0 0 0 Dewire Rev Dr Norman E Ex-Officio - OhioHlth (start 1/14) 1.00 2.00 X 0 0 0 Gabriel Paul MD Board Member - OhioHlth (start 1/14) 1.00 2.00 X 0 16690 0 James Donna Board Member - OhioHlth (start 1/14) 1.00 2.00 X 0 0 0 Jennings Matthew Ex-Officio - OhioHlth (start 1/14) 1.00 2.00 X 0 0 0 Johnston Tom Board Member - OhioHlth (start 1/14) 1.00 2.00 X 0 0 0 Levin Howard B DO Ex-Officio - OhioHlth (start 1/14) 1.00 2.00 X 0 0 0 Palmer Bishop Gregory Ex-Officio - OhioHlth (start 1/14) 1.00 2.00 X 0 0 0 Scott Bradley N Ex-Officio - OhioHlth (start 1/14) 1.00 2.00 X 0 0 0 Stevens Rev Dr Deborah Board Member - OhioHlth (start 1/14) 1.00 2.00 X 0 0 0 Walter Matt Board Member - OhioHlth (start 1/14) 1.00 2.00 X 0 0 0 Blom David P Pres/CEO/Ex-Off-OhioHlth(start 1/14) 1.00 40.00 X X 0 1593139 1195088 Stroh David Chair (end 1/14) 1.00 0.00 X X 0 0 0 Turner Michael Vice Chair (end 1/14) 1.00 0.00 X X 0 0 0 Althaus Ruth Ann Secretary (end 1/14) 1.00 0.00 X X 0 0 0 Stephens Ray Treasurer (end 1/14) 1.00 0.00 X X 0 0 0 Cyran Susan Trustee (end 1/14) 1.00 0.00 X 0 0 0 Hodson Jan Trustee (end 1/14) 1.00 0.00 X 0 0 0 Ireton Doreen Trustee (end 1/14) 1.00 0.00 X 0 0 0 Kemmerer Candy Trustee (end 1/14) 1.00 0.00 X 0 0 0 Shirey Sandra Trustee (end 1/14) 1.00 0.00 X 0 0 0 Strickmaker Ron Trustee (end 1/14) 1.00 0.00 X 0 0 0 Tarantelli Kathy Trustee (end 1/14) 1.00 0.00 X 0 0 0 Long Greg President/CEO 40.00 0.00 X X 0 334530 42436 McKinley Terri Interim Director (end 11/13) 40.00 0.00 X X 66042 0 16034 Sharp Cheryl Director (start 11/13) 40.00 0.00 X 89534 0 16312 Campbell Thomas Physical Therapist 40.00 0.00 X 162250 0 0 317826 2069164 1269870 2 0 1 0 0 105000 105000 Patient Services 621610 3441135 3441135 3441135 -2798 -2798 3543337 3441135 0 -2798 155576 138074 17502 2083265 1439250 644015 45017 45017 311000 22211 288789 156585 156585 35 35 15600 15600 165236 71938 93298 6630 6630 311201 239407 71794 49512 49512 91822 91822 201250 194306 6944 13093 13093 24814 24814 Hospice Room and Board 240685 240685 0 0 Minor Equipment 49943 0 49943 0 Development Expenses 7613 0 7613 0 Membership Dues 4169 0 4169 0 7797 3040 4757 3940843 2348911 1591932 0 141587 96649 561379 695485 11919 34406 10893 154996 8820 2557 146176 30830 246181 958141 1207303 414648 443878 48959 235000 737356 649648 1230193 X 122372 -325486 186121 302596 0 308493 -22890 958141 1207303 X -397506 6595 59528 X 0 1 X 1 0 X 230286 133112 99056 85108 105000 652562 3901744 3758424 3747453 3515715 3497550 18420886 4132030 3891536 3846509 3600823 3602550 19073448 0 231042 29813 260855 231042 29813 260855 18812593 2100 2286 2694 1721 -2798 6003 2100 2286 2694 1721 -2798 6003 4134130 3893822 3849203 3602544 3599752 19079451 0.98600 0.98740 0.00030 0.00060 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 189245 56936 246181 159228 30017 189245 2261 156967 159228 2259 2 2261 2257 2 2259 1.00000 1 0 154996 8820 146176 146176 Interest in Endowment Funds Held by Other Organizations 246181 246181 Intercompany Payable to OhioHealth Corporation 14032 Intercompany Payable to Sheltering Arms Hospital Foundation 723324 737356 X Part V, Line 4: The endowments are intended for the support of the organization's healthcare activities. Part X, Line 2: OhioHealth and substantially all of its subsidiaries are tax-exempt organizations as defined under various sections of the Internal Revenue Code. With respect to the taxable corporations, income taxes are insignificant in fiscal years 2014 and 2013. The corporation files all applicable federal, state, and local income tax returns. Fiscal years 2011 through 2014 are subject to audit by appropriate government authorities or their agents. Management has analyzed the tax positions taken by the Corporation and its subsidiaries and has concluded that as of June 30, 2014, there are no uncertain positions taken or expected to be taken that would require recognition of any benefits or liabilities, or disclosure in the financial statements. 0 1 0 0 0 0 0 0 0 Blom David P Pres/CEO/Ex-Off-OhioHlth(start 1/14) 0 1023172 0 539500 0 30467 0 1176190 0 18898 0 2788227 0 0 Long Greg President/CEO 0 238668 0 74261 0 21601 0 20285 0 22151 0 376966 0 0 Campbell Thomas Physical Therapist 162250 0 0 0 0 0 0 0 0 0 162250 0 0 0 Part I, Line 3 For the period 07/01/2013 - 01/07/2014, the CEO was compensated through an unrelated management company, OhioHealth Hospital Management Services, LLC. The contract with the management company is reviewed and approved by the board. The compensation for the CEO is reviewed and approved by the management company. Part I, Line 4b Eligible executives listed in the Form 990, Part VII participate in a supplemental non-qualified plan. These arrangements are an industry standard and are unfunded. Due to the substantial risk of forfeiture provision, there is no guarantee that these officers will ever receive these benefits. Amounts for these arrangements are included in the deferred compensation amount. Form 990, Part VI, Section A, line 2 Persons listed in Part VII may have a "business relationship" with each other by virtue of sitting on related OhioHealth entity boards or by virtue of their employment with related OhioHealth entities. OhioHealth Corporation has an ownership interest in limited liability companies (LLCs) that provide healthcare or related services. As a member of such LLCs, OhioHealth Corporation has the right to appoint two individuals to the managing board of such LLCs. As a result, these individuals may be deemed to have a "business relationship" with each other for purposes of Part VI, Section A, Line 2. Kerrii B. Anderson, Treasurer of OhioHealth Corporation, and John P. McConnell, Vice Chair of OhioHealth Corporation, have a business relationship. Form 990, Part VI, Section A, line 3 The organization entered into a management agreement with HomeReach, an Ohio not-for-profit corporation, effective from November 6, 2012. This agreement was in effect until Appalachian Community Visiting Nurse Association ("ACVNA") became part of OhioHealth in January of 2014. HomeReach is a wholly-owned subsidiary of OhioHealth Corporation, an Ohio nonprofit corporation that is exempt from federal income tax under Section 501(c)(3). The management agreement required the management company to perform management services and oversight of daily operations, IT and support services, billing and collection services, and compliance with laws and regulations. Form 990, Part VI, Section A, line 6 Sheltering Arms Hospital Foundation, Inc. d/b/a O'Bleness Memorial Hospital is the sole member of the organization. Form 990, Part VI, Section A, line 7a The sole member has the right to elect or appoint members of the governing body. Form 990, Part VI, Section A, line 7b Governance decisions of the organization, such as approval of the election or removal of members of the governing body and decisions to dissolve, are reserved for the sole member. Form 990, Part VI, Section B, line 11 Corporate Finance, using a public accounting tax firm, prepares the Form 990. Multiple levels of internal review occur, as well as a presentation to the Board Finance and Audit Committee, prior to copies being provided to the Board before filing. Form 990, Part VI, Section B, line 12c The conflict of interest policy has been reviewed by independent tax counsel to assure its compliance with the requirements of the Internal Revenue Service. The policy requires all officers, directors and key employees to complete an annual questionnaire pertaining to conflicts of interest. The questionnaire is administered by the General Counsel of OhioHealth. The responses are recorded and reported to the Board in the format approved by the Chair of the Board (a community member). In the interim between questionnaires, conflicts are to be reported to the General Counsel, who will advise the conflicted officer, director or key employee on the steps required to manage or clear the conflict. Failure to report a conflict, or failure to follow the steps advised to clear the conflict, constitutes grounds for disciplinary action. Members of the governing board with a transactional conflict are required to recuse themselves from any discussion and/or vote pertaining to the conflicted transaction, and this is reflected in the minutes of the organization. Legal counsel attends Board meetings and Board committee meetings with the instruction to assure the conflict of interest policy is followed. Form 990, Part VI, Section B, line 15 For the period 07/01/2013 - 01/07/2014, the CEO was compensated through an unrelated management company, OhioHealth Hospital Management Services, LLC. The contract with the management company is reviewed and approved by the board. The compensation for the CEO is reviewed and approved by the management company. Form 990, Part VI, Section C, line 19 Information is made available as required. Form 990, Part XI, line 9: Net Assets Released from Restriction -103,617. Inherent Contributions from Acquisition of Hospitals 113,766. Temp Restriction Reclass from Operating Cash -7,036. Restricted Contributions 56,415. OhioHealth Corporation 180 East Broad Street 33rd Floor Columbus OH 432153707 314394942 Health Care OH 501(c)(3) Schedule A, Line 3 N/A 0 Marion General Hospital 1000 McKinley Park Drive Marion OH 43302 311070877 Health Care OH 501(c)(3) Schedule A, Line 3 OhioHealth Corporation 0 Grady Memorial Hospital 561 West Central Avenue Delaware OH 43015 314379436 Health Care OH 501(c)(3) Schedule A, Line 3 OhioHealth Corporation 0 Hardin Memorial Hospital 921 East Franklin Street Kenton OH 43326 344440479 Health Care OH 501(c)(3) Schedule A, Line 3 OhioHealth Corporation 0 Hardin Physician Foundation Inc 921 East Franklin Street Kenton OH 43326 311414276 Foundation OH 501(c)(3) Schedule A, Line 3 Hardin Memorial Hospital 0 Hardin Memorial Hospital Foundation 921 East Franklin Street Kenton OH 43326 341521537 Foundation OH 501(c)(3) Schedule A, Line 3 Hardin Memorial Hospital 0 Doctors Health Corporation of Nelsonville 1950 Mount St Mary Drive Nelsonville OH 45764 311620551 Health Care OH 501(c)(3) Schedule A, Line 3 OhioHealth Corporation 0 GrantRiverside Medical Care Foundation (dba OHPMS & dba OHMSF) 180 East Broad Street 33rd Floor Columbus OH 432153707 311351965 Health Care OH 501(c)(3) Schedule A, Line 3 OhioHealth Corporation 0 OhioHealth Foundation 180 East Broad Street 33rd Floor Columbus OH 432153707 237446919 Foundation OH 501(c)(3) Schedule A, Line 3 OhioHealth Corporation 0 HomeReach 180 East Broad Street 33rd Floor Columbus OH 432153707 311372702 Health Care OH 501(c)(3) Schedule A, Line 3 OhioHealth Corporation 0 HomeReach HomeCare 180 East Broad Street 33rd Floor Columbus OH 432153707 311417595 Health Care OH 501(c)(3) Schedule A, Line 3 HomeReach 0 OhioHealth Research Institute 180 East Broad Street 33rd Floor Columbus OH 432153707 316059784 Research OH 501(c)(3) Schedule A, Line 3 OhioHealth Corporation 0 Hospital Properties Inc 180 East Broad Street 33rd Floor Columbus OH 432153707 311206071 Property Management OH 501(c)(2) N/A OhioHealth Corporation 0 Sheltering Arms Hospital Foundation 55 Hospital Drive Athens OH 45701 314446959 Patient Care OH 501(c)(3) Schedule A, Line 3 OhioHealth Corporation 0 MedCentral Health System 335 Glessner Avenue Mansfield OH 44906 340714456 Health Care OH 501(c)(3) Schedule A, Line 3 OhioHealth Corporation 0 OhioHealth Sleep Services LLC 6186 Huntley Road STE B Columbus OH 43229 201547399 Physician Practice OH N/A Polaris Surgery Center LLC 6200 Cleveland Avenue Columbus OH 43231 208074623 Medical Services OH N/A Upper Arlington Medical Limited Partnership 180 East Broad Street 33rd Floor Columbus OH 43215 311472667 Medical Services OH N/A ESWL Real Estate & Equipment Limited Partnership 100 West Third Avenue Suite 350 Columbus OH 43201 311138732 Equipment Rental OH N/A Grant Scope Center LLC 180 East Broad Street 33rd Floor Columbus OH 43215 260765486 Endoscopy Services OH N/A O'Bleness Memorial Pain Management LLC 55 Hospital Drive Athens OH 45701 454587317 Medical Services OH N/A Athens Surgery Center 75 Hospital Drive Athens OH 45701 550840856 Medical Services OH N/A OHRH LLC 4714 Gettysburg Road Mechanicsburg OH 17055 462458436 Medical Services OH N/A Westerville Endoscopy Center LLC 262 Neil Avenue Columbus OH 43215 462755661 Endoscopy Services OH N/A Knightsbridge Surgery Center LLC 4845 Knightsbridge Columbus OH 43214 870650797 Medical Services OH N/A OhioHealth Star Corporation 180 East Broad Street 33rd Floor Columbus OH 432153707 311119936 Administrative Services OH N/A C 0 HardinCare Inc 921 East Franklin Street Kenton OH 43326 341492617 Property Management OH N/A C 0 Intel Health Services PO Box 1051 Governors Square Bu Grand Cayman KY1-1102, Cayman Islan CJ 314394942 Insurance/Reinsurance CJ N/A C 0 Athens Medical Laboratory Associates Inc 265 W Union Street Suite B Athens OH 45701 311381808 Medical Lab Services OH N/A S 0 0 0 0 0 1 0 0 0 0 1 0 0 0 0 0 0 0 0 0 Sheltering Arms Hospital Foundation J 73333 Lease Agreement Sheltering Arms Hospital Foundation E 315000 Loan Agreement