2015-05-13T10:25:17-05:00 2014-06-30 861065772 Deloitte Tax LLP 250 East Fifth Suite 1900 Cincinnati OH 45202 990 2013-07-01 314446959 Sheltering Arms Hospital Foundation SHEL 55 Hospital Drive Athens OH 45701 Craig Bjerke System VP and Corp Controller 7405935551 2015-05-13 1 Mary E Rauschenberg P00172604 5137847100 2013 2016-02-25 16:41:14Z O'Bleness Memorial Hospital LaMar Wyse 55 Hospital Drive Athens OH 45701 88643217 0 X www.obleness.org X 1948 OH To improve the health of those we serve. 22 12 753 115 1099 0 209045 789999 88593096 82996401 1287890 131017 3660884 3984509 93750915 87901926 0 0 0 0 40557519 45054519 0 0 0 47903839 44015796 88461358 89070315 5289557 -1168389 80344106 82662814 43182827 38704925 37161279 43957889 To improve the health of those we serve. 0 0 74602524 85613965 Medical Services: Patient care provided included 8,043 inpatient days of care to 2,779 acute patients; 25,838 emergency room visits; 3,388 inpatient and outpatient surgeries; and 691 births. Procedures and tests perfomed included 893,368 lab tests; 25,522 X-rays; 3,316 mammographies; 2,638 ultrasounds; 810 nuclear medicine scans; 9,307 CT scans; 208 cardiovascular catheterizations; 15,309 physical therapy modalities; 25,746 cardiopulmonary procedures; 2,807 MRIs; and 10,476 EKGs. The hospital will offer and provide free or discounted care to any patient who meets the eligibility requirements for free or discounted care under the OCAP or HCAP financial assistance policies. Charges foregone for charity amounted to $13,054,064. 1026336 923787 Medical Education: The hospital is a teaching hospital that provides medical training to 22 interns and residents in the specialty areas of Family Medicine, Dermatology, and OB/GYN. 75628860 1 1 0 1 0 0 0 0 0 1 1 0 0 1 1 1 0 1 0 0 0 0 0 0 1 0 1 1 0 0 1 0 0 0 1 0 0 1 0 0 0 0 0 1 1 1 1 0 0 1 105 0 1 753 1 1 1 0 0 0 0 1 1 0 0 0 0 0 X 22 12 1 1 1 0 1 1 1 1 1 0 0 1 1 1 1 1 1 0 0 1 1 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 Abbott Lawrence C Ex-Officio - OhioHlth (start 1/14) 1.00 2.00 X 0 0 0 Akins Nicholas Board Member - 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 0 1593139 1195088 Bolon Douglas PhD Vice-Chair (end 1/14) 2.00 0.00 X X 0 0 0 Cooley Don Treasurer (end 1/14) 2.00 0.00 X X 0 0 0 Quinn Susan OD Chair (end 1/14) 2.00 0.00 X X 0 0 0 Legg Jacqueline Secretary (end 1/14) 2.00 0.00 X X 0 0 0 Bernstein Michael S Director (end 1/14) 2.00 0.00 X 0 0 0 Kemmerer Candy Director (end 1/14) 2.00 0.00 X 0 0 0 Mollica Gerald A Director (end 1/14) 2.00 0.00 X 0 0 0 Noftz Brenda Director (end 1/14) 2.00 0.00 X 0 0 0 Norris Bob Director (end 1/14) 2.00 0.00 X 0 0 0 Sammons Dawn Director (end 1/14) 2.00 0.00 X 0 0 0 Long Greg CEO/President 40.00 0.00 X X 0 334530 42436 Dicken Ken CFO (end 1/14) 40.00 0.00 X 0 233453 34125 Kless Adam VP Nursing 40.00 0.00 X 165160 0 0 Rothstein Mark Executive Director (end 7/13) 40.00 0.00 X 387752 0 44649 Adams Stenneth Physician 40.00 0.00 X 388892 0 30477 Bertuna Kathleen Physician 40.00 0.00 X 417692 0 7731 Nesbitt Neal Physician 40.00 0.00 X 429723 0 15507 Reedus Derrick Physician 40.00 0.00 X 552929 0 32284 Reed Jason Physician 40.00 0.00 X 1343742 0 30772 3685890 2302617 1433069 34 0 1 0 OhioHealth Corporation 180 East Broad Street Columbus OH 43215 Management Services 1276836 Bricker & Eckler LLP 100 South Third Street Columbus OH 432154291 Legal Services 328413 Access Health Athens LLC 7450 Huntington Park Drive Columbus OH 432355617 Healthcare Services 261500 Dawson Healthcare 3650 Olentangy River Road Columbus OH 43214 Healthcare Staffing Services 185713 Reliable Construction Services 1256 Stanley Avenue Dayton OH 45404 Construction and Design Services 155838 6 6355 500000 283644 789999 Patient Services 622110 82240126 82240126 Rent from Affiliate 631110 482457 482457 Joint Venture Income 621990 273818 273818 82996401 141336 141336 167517 251311 -83794 -83794 -83794 460328 451989 18658 8339 -18658 -10319 -10319 30053 6355 19333 10720 10720 Meaningful Use 900099 1771927 1771927 Cafeteria & Catering 722210 515133 515133 Vendor Rebates 900099 193938 193938 1576585 1575486 1099 4057583 87901926 86537752 1099 573076 X 584529 165160 419369 33073085 27853181 5219904 1221328 1016697 204631 8039752 6692706 1347046 2135825 1777971 357854 546995 546995 46195 46195 1270 1270 15962192 13287755 2674437 658474 548148 110326 3457487 2878191 579296 3830319 3188556 641763 1474837 1227731 247106 233814 194639 39175 100105 83333 16772 1378026 1147140 230886 2823214 2350190 473024 1064991 886554 178437 Medical Supplies 10856360 10856360 0 0 Medicaid Tax 1070666 1070666 0 Membership Dues 139150 139150 0 0 Sponsorships 106969 106969 0 264732 264732 89070315 75628860 13441455 0 13030307 5055113 10087641 11839164 9069965 10289235 102819 26611 1700248 2673753 1892944 970468 44768610 1776990 35542229 42991620 -185650 -53472 9103603 8870322 80344106 82662814 4300976 3295152 26847083 0 985317 905802 11049451 34503971 43182827 38704925 X 36525620 43323234 25791 24787 609868 609868 37161279 43957889 80344106 82662814 X -1168389 1727682 6237317 X 0 1 X 1 0 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 0 0 0 0 0 0 0 0 0 0 1 1270 1270 0 Part II-B, Line 1: Lobbying expenses relate to the portion of dues paid to the Ohio Hospital Association which is used for lobbying. Sheltering Arms Hospital Foundation does not participate in or intervene in (including the publishing or distributing of statements) any politial campaign on behalf of (or in opposition to) any candidate for public office. 635659 -1005 634654 662294 -26635 635659 770777 -108483 662294 786504 -15727 770777 801779 -15275 786504 0.03910 0.96090 0 0 3151585 3151585 17978346 319069 17659277 22157331 1356638 20800693 1481348 101283 1380065 42991620 Long Term Assets Limited As to Use 5145357 Other Receivables 3724965 8870322 Accrued Wages 4293856 Other Liabilities 1945902 Leased Property Deposits 3647399 Note Payable to OhioHealth 24313000 Intercompany Payable to OhioHealth 303814 34503971 X Part V, Line 4: The endowments are intended for the support of the organization's healthcare activities. Part X, Line 2: 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. Golf Tournament 36408 6355 30053 1200 5332 5133 7668 36408 6355 30053 1200 5332 5133 7668 19333 10720 1 1 X 1 X 1 X 1 1 0 1 0 3580664 913731 2666933 0.02990 20798332 10520263 10278069 0.11540 0.00000 24378996 11433994 12945002 0.14530 7074 660 6414 0.00010 1026336 923787 102549 0.00120 0.00000 0.00000 99 99 0.00000 1033509 924447 109062 0.00130 25412505 12358441 13054064 0.14660 0.00000 0.00000 0.00000 0.00000 0.00000 0.00000 0.00000 0.00000 0.00000 1 6996249 209887 14843512 16750850 -1907338 X 1 1 1 Athens Surgery Center Ltd Outpatient Surgery 0.59790 0.04120 0.36090 2 O'Bleness Memorial Pain Management LLC Pain Management 0.51000 0.00000 0.49000 1 1 O'Bleness Memorial Hospital 55 Hospital Drive Athens OH 457010000 www.ohiohealth.com/obleness/ ODH1109 X X X X O'Bleness Memorial Hospital 1 1 X X X X X X X X X 12 1 0 1 X Included in Section C, Line 5d X X X X 1 0 1 1 150.000000000000 1 200.000000000000 1 X X X X 1 1 X X 1 0 X 1 X 0 0 O'Bleness Memorial Hospital Part V, Section B, Line 3: The hospital sought input from several strategic members of the community when conducting the CHNA. After input was obtained, these individuals, along with key members from the hospital, came together to develop the report and strategy. The community members included: Dr. Gaskell, Medical Director of the Health Department/Health Commissioner; Dr. Shubrook, Diabetes Research, Treatment, and Education; Kathy Trace, Director of Area Health Education Center and Community Health Services at the Ohio University Heritage College of Osteopathic Medicine; Dr. Clark, Vice President of Medical Affairs at O'Bleness Memorial Hospital; Adam Kless, Chief Nursing Officer at O'Bleness Memorial Hospital; and Dr. Basta, Associate Professor/Director of Social and Public Health College of Health Sciences and Professions. O'Bleness Memorial Hospital Part V, Section B, Line 5d: https://www.ohiohealth.com/aboutobleness/ O'Bleness Memorial Hospital Part V, Section B, Line 14g: Signs are posted at multiple O'Bleness Memorial Hospital entry points, patient registration locations, and the emergency room and waiting rooms stating Sheltering Arms Hospital Foundation's intent to comply with the State of Ohio's Hospital Care Assurance Program (HCAP). Additionally, the signage contains reference to the organization's charity care program. O'Bleness Memorial Hospital Part V, Section B, Line 18e: Signs are posted at multiple entry points and registration locations stating the intent to comply with the State of Ohio's Hospital Care Assurance Program (HCAP). Additionally, the signage contains reference to the organization's Charity Care Program. Information materials are available at registration locations and interpretive services can be arranged if the patient/guarantor does not speak English. OhioHealth facility billing statements also include information regarding HCAP and can be used to apply for financial assistance. Financial Counselors are located at each of the main hospital campuses to provide information about the financial assistance programs to the patients as well as assist with completing the financial assistance application. All self pay registrations are referred to the financial counselors or on-site vendors and an attempt is made for direct contact to discuss and complete the financial assistance application. There may be times, such as very late in the evening or very early morning, when all self pay patients are not seen face-to-face before they are discharged. However, there are phone attempts and letters mailed to these patients to explain financial assistance and attempt completion of the financial assistance application. The front of every patient billing statement references assistance for amounts not covered by insurance to those individuals whose income is below the established poverty level. There are telephone numbers for customer service, with service hours, and an email address provided on the front of every patient billing statement. On the back of every patient billing statement is the financial assistance application with the federal poverty guidelines. Included are directions to complete the application, sign, and where to send the application. The Customer Call Center will discuss financial assistance with any patient that expresses need or concern in paying the balance on their account. The representative will forward the caller to the verbal financial assistance queue or have a financial assistance application mailed to the patient. The financial assistance application is available in five different languages based on the needs of the communities.The internet (ohiohealth.com) has information pertaining to the charity programs as well as the financial assistance application, in five different languages, as well as directions on how to complete the financial assistance application. O'Bleness Memorial Hospital Part V, Section B, Line 20d: The maximum amounts charged to financial assistance policy eligible individuals for emergency or other medically necessary is $0 for patients who fall within 150% of the FPG and 50% of chargemaster rates for patients who fall within 200% of the FPG. 1 Athens Medical Associates LLC 55 Hospital Drive Athens OH 45701 Physician Services Part I, Line 3c: The hospital has more than one policy concerning free or discounted care. O'Bleness Memorial Hospital will offer and provide free care to any patient who meets the eligibility requirement for free care under the OCAP or HCAP financial assistance policies. The following steps will be used to determine eligibility for free care under OCAP (O'Bleness Care Assurance Program):1. A recipient of the Ohio Medicaid Program is not eligible. (OAC Rule 5 10 1:3-2-07.17)2. If the patient is covered under a third-party insurer or a governmental program, the third party will be billed and any payment received will be applied to the account first. Any balance on the account will be considered for the OCAP write-off.3. OCAP assistance will be approved only when services are provided by O'Bleness Memorial Hospital. These services also include physician interpretation fees for cardiopulmonary services and service provided in the O'Bleness Family Practice Clinic.4. Family income is between 100 to 150% of the federal poverty guidelines. Family: Family shall be defined as the patient, the patient's spouse, and all of the patient's children, natural and adoptive under the age of eighteen who live at home. If the patient is under the age of eighteen the family shall include the patient, the patient's natural or adoptive parent(s) and the parent(s) children, natural or adoptive under the age of eighteen who live in the home. If the patient is a child of a minor parent who still resides in the home of the patient's grandparents, the family shall include only the parent(s) of any of the parent(s) natural or adoptive children who reside in the home. Income: Income shall be defined as the total salaries, wages and cash receipts before taxes: Receipts that reflect reasonable deduction for business expenses shall be counted for both farm and non-farm self-employment.The following steps will be used to determine eligibility for free care under HCAP (Hospital Care Assurance Program):1. A completed application will be obtained from all patients seeking free care under HCAP.2. A patient must be a resident of the state of Ohio to be eligible for HCAP.3. O'Bleness Memorial Hospital will define income requirements using the federal poverty guidelines as indicated yearly.4. O'Bleness Memorial Hospital will define a family as indicated in Baldwin's Ohio Administrative Code Chapter 5101:3-2-0717.5. The income provided by the applicant will be verified via sworn signature.6. A recipient of the Ohio Medicaid Program is not eligible (OAC Rule: 5101:3-2-0717) if a patient has insurance coverage, O'Bleness Memorial Hospital will first bill the insurance and receive a payment of a denial before the HCAP application is processed. Part I, Line 7: The cost of charity care, unreimbursed Medicaid and other means-tested government programs was estimated using a cost to charge ratio derived from Worksheet 2 of the Schedule H instructions.Costing methodology used to determine the cost of community health improvement services and community benefit operations: The hospital uses the computer software CBISA to track our programs that happen in the community or at the hospital for the community. The computer tracks direct expenses associated with the programs as well as any offsetting revenue that will decrease the community benefit. The system accounts for utilities used if the activity occurs at the facility (hospital). The system also accounts for any supplies used and wages of any employee that is present at the activity. A hospital wide wage average is used in determining the amount of salary to use in the direct expenses. Part III, Line 3: The bad debt was determined based on Form 990, Part IX. The estimated amount of the organization's bad debt expense attributable to patients eligible under the organization's financial assistance policy is estimated at 3% of bad debt. Part III, Line 4: Accounts receivable for patients, insurance companies, and governmental agencies are based on gross charges. An allowance for contractual adjustments is based on expected payment rates from payors based on current reimbursement methodologies. This amount also includes amounts received as interim payments against unpaid claims by certain payors. An allowance for uncollectible accounts is established on an aggregate basis by using historical write-off rate factors applied to unpaid accounts based on aging. Loss rate factors are based on historical loss experience and adjusted for economic conditions and other trends affecting the Corporation's ability to collect outstanding amounts. Uncollectible amounts are written off against the allowance for doubtful accounts in the period they are determined to be uncollectible.For receivables associated with self-pay patients (which includes both patients without insurance and patients with deductible and copayment balances due for which third-party coverage exists for part of the bill), the Corporation records a 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 (including uninsured discount) and the amounts actually collected after all reasonable collection efforts have been exhausted is charged off against the allowance for doubtful accounts in the period they are determined to be uncollectable. Part III, Line 8: In accordance with the Catholic Health Association guidelines per "A Guide for Planning and Reporting Community Benefits," Sheltering Arms Hospital Foundation does not report Medicare shortfall as community benefit. Part III, Line 9b: Patients known to qualify for charity care or financial assistance are asked to fill out the paperwork associated with the programs we have available to patients with low income. We do not have a collections process for charity care patients and the full amount is written off to the associated program. This does not apply to patients that do not qualify for either of the programs. If it is determined that the patient is capable of paying for their medical care, then at that point they are billed at a discounted rate for the services provided. If they fail to pay at the discounted rate then collections practices ensue. Part VI, Line 2: The hospital conducted a community health needs assessment to best serve the needs of the patients and be in compliance with future healthcare legislation. Part VI, Line 3: The hospital informs patients of their eligibility for assistance in different ways. There is a sign in the admitting area that directs their attention to the fact that there is available care at a reduced fee or free of charge. On each data mailer that is sent out to patients, there is a section that informs them of the availability of this care. Any patient that comes in without insurance or proof of insurance is supplied a self-pay packet. In this packet is an outline on how to obtain free or discounted care; the packet also details the parameters of each program. If any of our employees are asked in admissions or during their care if there are any options available for payment of their care, the employees will describe to the patients the programs available or provide them with materials on how to apply and be accepted into the free or discounted care programs. Part VI, Line 4: O'Bleness Memorial Hospital is a community hospital in a rural area of Appalachia. Our primary service area includes the communities within Athens County, Ohio, which has been identified by the Appalachian Regional Commission as an ARC-designated distressed county. According to the United States Census Bureau, the population of Athens County in 2013 was 64,681. The median income of $33,836 is not truly representative of the population, as the community includes a major university. Athens County has the highest poverty level of any county in Ohio, as 32.2% of the community residents have incomes at or below the federal poverty guideline. Uninsured individuals in Athens County represent 21% of the population. The hospital's patient population includes 8.8% who are uninsured and 23.18% who are Medicaid recipients. Located within O'Bleness's primary service area of Athens County is one additional hospital, Doctors Hospital of Nelsonville affiliated with OhioHealth based in Columbus, Ohio Portions of the patient population are also served by eight other hospitals in Washington, Gallia, Jackson, Hocking, Fairfield and Ross Counties in Ohio and Wood County in West Virginia, as well as three major health systems with multiple facilities in Franklin County, Ohio. Two townships in Athens County have been designated as medically underserved areas/populations by the U.S. Department of Health and Human Services: Lodi and Trimble. Part VI, Line 5: At O'Bleness Memorial Hospital it is our goal to give access to any person in our community to modern day healthcare at a cost effective price. As the only hospital in Athens, we strive to give help where help is needed. To further our commitment to the community and our exempt purpose we engage in many activities. Our board is compiled of people who reside in our community without a conflict of interest with the hospital. We believe the more diverse the board the better they will be able to identify the needs of the community. The majority of the board has no connection to the organization nor is contracted with the hospital. They provide their consult and guidance out of the pure desire to see their community be afforded the same quality of care as bigger markets. We extend medical privileges to qualified physicians that have a desire to practice within our facilities. We continue to search for programs and activities that will be new to the community in order to give the population variety and health oriented alternatives. Funds are used to purchase capital equipment that is vital in keeping up with an ever evolving medical world. It is also used to fund activities inside and outside of the hospital that involves the community on various levels whether it be a health fair or an interactive exercise program. We have many volunteers from the community that are instrumental in carrying out various activities. Part VI, Line 6: The O'Bleness Health System is designed to offer the most comprehensive medical attention to a mainly centralized location to the community in which we live. The affiliates of the system work together in a collaborative effort to increase the efficiency and cost of healthcare to the patient. The O'Bleness Memorial Hospital is the main component of the health system. At the hospital we offer a variety of inpatient and outpatient services. The emergency department is operational 24 hours a day 7 days a week. We offer care to anyone regardless of ability to pay. We are the only fully functional hospital in the community. It is our goal not to exclude anyone from our community that is in need of care. The Athens Medical Lab (AML) is an affiliate of the system that is a medical reference lab that offers convenience and cost efficiency for the patient. This allows us to keep patients close to home and speed up result time. The Athens Medical Associates (AMA) is a multi-physician practice that offers a variety of services to patients. AMA is comprised of a multifaceted OB/GYN practice, an orthopedic surgeon, and a Family Practice Clinic that service numerous members of the community. There is also Appalachian Community Visiting Nurses Association, Hospice and Health Services (ACVNAHHS). This affiliate provides hospice services to not only Athens County but surrounding counties. They are also providers of visiting nurses that serve our clients out of the comfort of their own home.OhioHealth Corporation became the owner of Sheltering Arms Hospital Foundation through member substitution in January, 2014. 0 1 0 0 0 0 0 1 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 CEO/President 0 238668 0 74261 0 21601 0 20285 0 22151 0 376966 0 0 Dicken Ken CFO (end 1/14) 0 176132 0 54557 0 2764 0 11983 0 22142 0 267578 0 0 Kless Adam VP Nursing 159799 0 0 0 5361 0 0 0 0 0 165160 0 0 0 Rothstein Mark Executive Director (end 7/13) 334810 0 0 0 52942 0 11494 0 33155 0 432401 0 0 0 Adams Stenneth Physician 332293 0 0 0 56599 0 7650 0 22827 0 419369 0 0 0 Bertuna Kathleen Physician 280500 0 136292 0 900 0 7650 0 81 0 425423 0 0 0 Nesbitt Neal Physician 389273 0 0 0 40450 0 7650 0 7857 0 445230 0 0 0 Reedus Derrick Physician 422542 0 0 0 130387 0 7650 0 24634 0 585213 0 0 0 Reed Jason Physician 646322 0 684414 0 13006 0 7650 0 23122 0 1374514 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. Part I, Line 7 Incentive bonuses are calculated using an objective formula that includes clinical quality, patient, physician and employee satisfaction, and financial items. Minor modifications to increase or decrease incentive payments, within the maximum amount established for each position, may be made based on individual performance and accountabilities. In addition, one time bonuses may be awarded to recognize exemplary performance. All payments are examined for reasonableness and are reviewed and approved by either the Executive Compensation Committee (for disqualified persons) or through management and the company's human resources function (for non-disqualified persons). Dawn Sammons Director/Physician Physician Education Loan X 250000 6000 0 1 1 Derrick Reedus Physician Physician Education Loan X 178624 20611 0 1 1 26611 Stephen Noftz Director of Org - Husband of Director (Brenda Noftz) 62728 Comp/Ben - Husband is employed at Sheltering Arms Hospital Foundation and receives compensation. 0 Pam Born Director - Sister-in-Law of Director (Brenda Noftz) 58796 Comp/Ben - Sister-in-law is employed at Sheltering Arms Hospital Foundation and receives compensation. 0 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 OhioHealth Hospital Management Services, LLC, an Ohio nonprofit limited liability company, effective August 1, 2010 for a five-year term. OhioHealth Hospital Management Services, LLC is a wholly-owned subsidiary of OhioHealth Corporation, an Ohio nonprofit corporation that is exempt from federal income tax under IRS Code Section 501(c)(3). This contract terminated as of the acquistion date, 1/7/2014, when OhioHealth Corporation became the owner through member substitution. Form 990, Part VI, Section A, line 4 Effective January 7, 2014, Sheltering Arms Hospital Foundation was acquired by Member Substitution. OhioHealth Corporation (headquartered in Columbus, Ohio) is now the sole member. Form 990, Part VI, Section A, line 6 OhioHealth Corporation is the sole member of Sheltering Arms Hospital Foundation, and this membership is permissible under Ohio Revised Code Section 1702.13. Form 990, Part VI, Section A, line 7a The West Ohio Conference of The United Methodist Church is the sole voting member of OhioHealth Corporation which in turn is the sole voting member of all subsidiary organizations which includes Sheltering Arms Hospital Foundation. This membership is permissible under Ohio Revised Code Section 1702.13. Form 990, Part VI, Section A, line 7b Revisions of the Code of Regulations that affect the rights of the Member must be approved by the Member, OhioHealth Corporation. 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 parent company of the organization. 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 Compensation of the Executive Director is determined based on comparability data, contemporaneous substantiation of the deliberation and decision and by a compensation committee. The executive's compensation is reviewed and approved by OhioHealth Hospital Management Services, LLC. The executive is paid through this management company. The management agreement with them is reviewed and approved by the board. The last compensation review was completed in 2013. Form 990, Part VI, Section C, line 19 Information is made available as required. Form 990, Part IX, line 11g Physician Contracted Services: Program service expenses 3,184,799. Management and general expenses 641,007. Fundraising expenses 0. Total expenses 3,825,806. Diagnotic/Testing Outsourced Services: Program service expenses 2,267,247. Management and general expenses 456,331. Fundraising expenses 0. Total expenses 2,723,578. Anesthesia/Pharmacy Outsourced Services: Program service expenses 1,931,211. Management and general expenses 388,696. Fundraising expenses 0. Total expenses 2,319,907. Repairs and Maintenance Contracts: Program service expenses 1,360,427. Management and general expenses 273,814. Fundraising expenses 0. Total expenses 1,634,241. Physical Therapy Outsourced Services: Program service expenses 952,593. Management and general expenses 191,729. Fundraising expenses 0. Total expenses 1,144,322. Other Outsourced Services: Program service expenses 3,591,478. Management and general expenses 722,860. Fundraising expenses 0. Total expenses 4,314,338. Form 990, Part XI, line 9: Other -397. Inherent Contributions from Acquisition of Hospitals 6,237,714. Athens Medical Associates LLC 75 Hospital Drive Athens OH 457010000 020734615 Physician Services OH 11135488 2113732 Sheltering Arms Hospital Foundation 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 Appalachian Community Visiting Nurse Association 30 Herrold Avenue Athens OH 45701 311045101 Hospice and Health Services OH 501(c)(3) Schedule A, Line 3 Sheltering Arms Hospital Foundation 1 Marion General Hospital 1000 McKinley Park Drive Marion OH 43302 311070877 Health Care OH 501(c)(3) Schedule A, Line 3 OhioHealth Corporation 1 Grady Memorial Hospital 561 West Central Avenue Delaware OH 43015 314379436 Health Care OH 501(c)(3) Schedule A, Line 3 OhioHealth Corporation 1 Hardin Memorial Hospital 921 East Franklin Street Kenton OH 43326 344440479 Health Care OH 501(c)(3) Schedule A, Line 3 OhioHealth Corporation 1 Hardin Physician Foundation Inc 921 East Franklin Street Kenton OH 43326 311414276 Foundation OH 501(c)(3) Schedule A, Line 3 Hardin Memorial Hospital 1 Hardin Memorial Hospital Foundation 921 East Franklin Street Kenton OH 43326 341521537 Foundation OH 501(c)(3) Schedule A, Line 3 Hardin Memorial Hospital 1 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 1 GrantRiverside Medical Care Foundation (dba OPG) 180 East Broad Street 33rd Floor Columbus OH 432153707 311351965 Health Care OH 501(c)(3) Schedule A, Line 3 OhioHealth Corporation 1 OhioHealth Foundation 180 East Broad Street 33rd Floor Columbus OH 432153707 237446919 Foundation OH 501(c)(3) Schedule A, Line 3 OhioHealth Corporation 1 HomeReach 180 East Broad Street 33rd Floor Columbus OH 432153707 311372702 Health Care OH 501(c)(3) Schedule A, Line 3 OhioHealth Corporation 1 HomeReach HomeCare 180 East Broad Street 33rd Floor Columbus OH 432153707 311417595 Health Care OH 501(c)(3) Schedule A, Line 3 HomeReach 1 OhioHealth Research Institute 180 East Broad Street 33rd Floor Columbus OH 432153707 316059784 Research OH 501(c)(3) Schedule A, Line 3 OhioHealth Corporation 1 Hospital Properties Inc 180 East Broad Street 33rd Floor Columbus OH 432153707 311206071 Property Management OH 501(c)(2) N/A OhioHealth Corporation 1 MedCentral Health System 335 Glessner Avenue Mansfield OH 44906 340714456 Health Care OH 501(c)(3) Schedule A, Line 3 OhioHealth Corporation 1 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 OHRH LLC 4714 Gettysburg Road Mechanicsburg PA 17055 462458436 Medical Services PA N/A Westerville Endoscopy Center LLC 700 E Broad Street 1st Floor Columbus OH 43214 462755661 Endoscopy Services OH N/A Knightsbridge Surgery Center LTD 4845 Knightsbridge Blvd Suite 110 Columbus OH 43214 870650797 Medical Services OH N/A O'Bleness Memorial Pain Management LLC 55 Hospital Drive Athens OH 45701 454587317 Medical Services OH Sheltering Arms Hospital Foundation Related 33815 212643 0 1 0.51000 Athens Surgery Center 75 Hospital Drive Athens OH 45701 550840856 Medical Services OH Sheltering Arms Hospital Foundation Related 246412 478936 0 1 0.59790 Athens Medical Laboratory Associates Inc 265 West Union Street Athens OH 45701 311381808 Medical Laboratory OH Sheltering Arms Hospital Foundation S 1099 645713 1.00000 1 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 0 0 1 1 1 0 0 0 0 0 1 0 0 0 1 1 0 0 0 Appalachian Community Visiting Nurse Association K 73333 Lease Agreement Appalachian Community Visiting Nurse Association D 315000 Loan Agreement Increase Doctor's Hospital at Nelsonville O 1550114 Actual Amount Paid OhioHealth Corporation P 3113142 Actual Amount Paid OhioHealth Corporation E 24313000 Loan Balance OhioHealth Corporation C 500000 Actual Amount Transferred