2015-09-14T09:10:05-05:00 2014-10-31 351178661 BLUE & CO LLC 8800 LYRA DRIVE SUITE 450 COLUMBUS OH 43240 990 2013-11-01 344477047 HENRY COUNTY HOSPITAL INC HENR 4195924015 1600 EAST RIVERVIEW NAPOLEON OH 43545 KIMBERLY H BORDENKIRCHER CEO 4195924015 2015-09-11 1 MATTHEW DASTA P00544683 6148852583 2015-09-10 2013 2016-04-25 22:37:26Z KIMBERLY H BORDENKIRCHER 1600 EAST RIVERVIEW NAPOLEON OH 43545 29273093 0 X WWW.HENRYCOUNTYHOSPITAL.ORG X 1982 OH HENRY COUNTY HOSPITAL PROVIDES QUALITY HEALTHCARE AND WELLNESS SERVICES WHILE EMPHASIZING PATIENT CENTERED CARE AND EXCELLENT CUSTOMER SERVICE. HENRY COUNTY HOSPITAL WILL IMPROVE THE HEALTH OF THE COMMUNITY BY BEING THE BEST PLACE FOR PATIENTS TO RECEIVE CARE, FOR EMPLOYEES TO WORK, AND FOR PHYSICIANS TO PRACTICE MEDICINE. WE ARE COMMITTED TO EACH OTHER AND THE COMMUNITY THROUGH STEWARDSHIP AND COOPERATION; CONTINUAL LEARNING AND INNOVATION; PERSONALIZED SERVICES AND A FAMILY FOCUS. 10 8 316 83 0 -15769 179353 118622 25626175 28288804 11489 14671 717991 823568 26535008 29245665 0 0 0 0 13694119 13607503 0 0 76638 13461828 14363120 27155947 27970623 -620939 1275042 21207673 22246122 12319063 11940257 8888610 10305865 X HENRY COUNTY HOSPITAL PROVIDES QUALITY HEALTHCARE AND WELLNESS SERVICES WHILE EMPHASIZING PATIENT CENTERED CARE AND EXCELLENT CUSTOMER SERVICE.HENRY COUNTY HOSPITAL WILL IMPROVE THE HEALTH OF THE COMMUNITY BY BEING THE BEST PLACE FOR PATIENTS TO RECEIVE CARE, FOR EMPLOYEES TO WORK, AND FOR PHYSICIANS TO PRACTICE MEDICINE. WE ARE COMMITTED TO EACH OTHER AND THE COMMUNITY THROUGH STEWARDSHIP AND COOPERATION; CONTINUAL LEARNING AND INNOVATION; PERSONALIZED SERVICES AND A FAMILY FOCUS. 0 0 1932221 11076879 1. SURGERY: PROVIDING PRE-, INTRA-, AND POST PROCEDURE CARE FOR SURGICAL INPATIENTS AND OUTPATIENTS. INCLUDES GENERAL, ORTHOPEDIC, CATARACT, AND ENDOSCOPIC PROCEDURES. SURGICAL CARE SERVICES PERFORMED OVER 1750 PROCEDURES IN FY 2014. 1935389 8661691 2. LABORATORY: PROVIDING SERVICES FOR IP AND OP, EXTENDED CARE FACILITIES, PHYSICIAN OFFICES AND AREA BUSINESSES. THE LABORATORY PROVIDED OVER 130,000 BILLED TESTS IN FY 2014. 1694114 2962610 3. EMERGENCY CARE SERVICES ARE PROVIDED CONTINUALLY TO PATIENTS PRESENTING WITH INJURIES AND ILLNESSES. TOTAL PATIENTS TREATED IN THE EMERGENCY DEPARTMENT TOTALED OVER 8,900 FOR FY 2014. 18056386 6271502 4. OTHER SERVICES PROVIDED BY HENRY COUNTY HOSPITAL ARE: MEDICAL IMAGING, INCLUDING X-RAY, CT SCANS, MRI, ULTRASOUND, AND STRESS TESTING; PHARMACY SERVICES; REHAB SERVICES, INCLUDING PHYSICAL THERAPY, OCCUPATIONAL THERAPY, AND SPEECH THERAPY; ONCOLOGY SERVICES; INPATIENT AND INTENSIVE CARE SERVICES; BIRTHING CARE SERVICES; CARDIAC REHAB, EKG, AND RESPIRATORY THERAPY; AND OUTPATIENT DRUG AND ALCOHOL TREATMENT. HENRY COUNTY HOSPITAL PROVIDED OVER 128,000 BILLED DOSES TO PATIENTS THROUGH PHARMACY SERVICES, OVER 710 INPATIENT ADMISSIONS WITH OVER 2,500 DAYS OF CARE, OVER 130 SWING BED PATIENTS WITH OVER 1,200 DAYS OF CARE, 106 BIRTHS, AND OVER 44,000 OUTPATIENT VISITS IN FY 2014. 18056386 6271502 23618110 1 1 0 1 0 0 0 0 0 0 1 0 0 0 0 1 0 1 0 0 0 0 0 0 0 0 1 1 0 0 1 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 0 0 0 1 52 0 1 316 1 1 1 0 0 0 0 0 0 0 0 0 X 10 8 0 0 0 0 0 0 0 1 1 0 0 1 1 1 1 1 1 1 1 0 OH X DIANE WALTHER 4195913826 1600 EAST RIVERVIEW NAPOLEON OH 43545 KIMBERLY BORDENKIRCHER TREASURER & CEO 40.00 X X 203263 0 21869 DR JOSEPH KRUEGER CHAIRMAN 4.00 X X 0 0 0 JOHN WILHELM SECRETARY 2.00 X X 0 0 0 RICK FRUTH BOARD MEMBER 2.00 X 0 0 0 DR ROBERT LIMBIRD BOARD MEMBER 2.00 X 0 0 0 DR MORRIS SEAL BOARD MEMBER-CHIEF OF STAFF- 1/1/14 40.00 X 217080 0 12571 THOMAS MACK BOARD MEMBER 2.00 X 0 0 0 ANNE GOON BOARD MEMBER 2.00 X 0 0 0 DR DOUGLAS LINDSEY CHIEF OF STAFF ENDING 12/31/13 40.00 X 298354 0 35008 JIM BURKHART BOARD MEMBER 2.00 X 0 0 0 MARVIN BARLOW VICE-CHAIR 2.00 X X 0 0 0 PATRICIA FRANK CHIEF NURSING OFFICER 40.00 X 103377 0 20932 MICHELE JAKUTOWICZ PHARMACIST 40.00 X 115664 0 22729 DR ERAST HAFTKOWYCZ OB/GYN 40.00 X 237674 0 31877 SARAH HUBER MANAGER OF RADIOLOGY 40.00 X 109770 0 29812 CYNTHIA LATTA PHARMACIST 40.00 X 141371 0 11531 JENNIFER FISHER-BAILEY HUMAN RESOURCES MANAGER 40.00 X 103687 0 29888 1530240 0 216217 9 0 1 0 EMCARE PHYSICIAN SERVICES 7032 COLLECTIONS CENTER DRIVE CHICAGO IL 60693 EMERGENCY PHYSICIAN SERVICES 738966 SAFE ANESTHESIA LLC 356 MINER ROAD HIGHLAND HEIGHTS OH 44143 ANESTHESIA SERVICES 680035 HOSPITAL CARE GROUP PC 6435 W JEFFERSON BLVD FORT WAYNE IN 46804 INPATIENT PHYSICIAN SERVICES (HOSPITALIS 294167 SOUTH BEND MEDICAL 530 NORTH LAFAYETTE BLVD SOUTH BEND IN 46601 LABORATORY SERVICES 278736 FULTON COUNTY HEALTH CENTER 725 SOUTH SHOOP AVE WAUSEON OH 43567 LABORATORY SERVICES 271606 7 118622 118622 PATIENT REVENUE 900099 28288804 28288804 28288804 11321 11321 108894 0 108894 108894 108894 3350 0 3350 3350 3350 58224 27428 30796 30796 MISCELLANEOUS 900099 494811 494811 CAFETERIA SALES 900099 126427 126427 EHR INCENTIVE PAYMENTS 900099 38113 38113 24527 24527 683878 29245665 28972682 0 154361 X 349440 349440 10445056 8738333 1706723 277704 232327 45377 1693898 1417115 276783 841405 703920 137485 45926 45926 65589 65589 5209486 4697349 512137 163220 41519 121701 2013823 1964579 49244 242131 39564 202567 747302 707485 39817 76962 31770 45192 84151 33968 50183 402832 402832 1307011 1307011 89305 21234 68071 BAD DEBT 1846529 1846529 DRUGS 1209076 1209076 MISCELLANEOUS 859777 626331 156808 76638 27970623 23618110 4275875 76638 300 300 7765209 8311223 2770039 3614732 585834 648453 164686 214285 27479447 19056635 8974731 8422812 636687 860292 310187 174025 21207673 22246122 2075710 2235268 9710000 9335000 533353 369989 12319063 11940257 X 8206770 9522889 631840 732976 50000 50000 8888610 10305865 21207673 22246122 X 1275042 142213 X 0 1 X 1 0 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 0 0 0 0 0 0 0 0 1 2956 2956 0 PART II-B, LINE 1: REPRESENTS PORTION OF ANNUAL DUES PAID TO AMERICAN HOSPITAL ASSOCIATION AND OHIO HOSPITAL ASSOCIATION ESTIMATED TO PERTAIN TO LOBBYING ACTIVITIES. OHA - $628 AHA - $2328 50000 50000 50000 50000 50000 50000 50000 50000 50000 50000 1.00000 0 0 915952 915952 8498568 6245682 2252886 17829076 12810953 5018123 235851 235851 8422812 X PART X, LINE 2: ACCOUNTING PRINCIPLES GENERALLY ACCEPTED IN THE UNITED STATES OF AMERICA REQUIRE MANAGEMENT TO EVALUATE TAX POSITIONS TAKEN AND RECOGNIZE A TAX LIABILITY IF AN UNCERTAIN POSITION HAS BEEN TAKEN THAT MORE LIKELY THAN NOT WOULD NOT BE SUSTAINED UPON EXAMINATION BY VARIOUS FEDERAL AND STATE TAXING AUTHORITIES. MANAGEMENT HAS ANALYZED THE TAX POSITIONS TAKEN BY THE ORGANIZATION AND HAS CONCLUDED THAT AS OF OCTOBER 31, 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 ACCOMPANYING FINANCIAL STATEMENTS. THE ORGANIZATION IS SUBJECT TO ROUTINE AUDITS BY TAXING JURISDICTIONS; HOWEVER, THERE ARE CURRENTLY NO AUDITS FOR ANY TAX PERIODS IN PROGRESS. 1 1 1 X 1 X 0 1 1 0 0 335 255273 692028 -436755 0.00000 2185 4112034 2267509 1844525 0.07060 2520 4367307 2959537 1407770 0.07060 45856 42855 0 42855 0.00160 2 2543 0 2543 0.00010 741 427308 288667 138641 0.00530 4050 7343 7343 0.00030 50649 480049 288667 191382 0.00730 53169 4847356 3248204 1599152 0.07790 4 3022 7267 7267 0.00030 5 602 4046 4046 0.00020 9 3624 11313 11313 0.00050 1 771080 8844672 8468319 376353 X 1 0 1 HENRY COUNTY PAIN MANAGEMENT LLC MEDICAL PAIN MANAGEMENT 0.51000 0.00000 0.00000 2 VANTAGE HEALTHCARE OF OHIO LLC A COLLABORATIVE OF HOSPITALS WORKING TOGETHER TO IDENTIFY OPPORTUNITIES 0.11000 0.00000 0.00000 1 1 HENRY COUNTY HOSPITAL INC 1600 EAST RIVERVIEW AVE NAPOLEON OH 43545 X X HENRY COUNTY HOSPITAL INC 1 1 X X X X X X X X 13 1 0 1 X WWW.HENRYCOUNTYHOSPITAL.ORG X X X X X 1 0 1 1 100.000000000000 1 250.000000000000 1 X X X 1 1 X 1 X 0 X X X X 1 X 0 0 HENRY COUNTY HOSPITAL, INC. PART V, SECTION B, LINE 3: 95% CONFIDENCE RATE THAT RESPONSES REPRESENT ENTIRE COUNTY. SEE EXPLANATION PARAGRAPH FOR PART VI LINE 2 FOR ADDITIONAL INFORMATION REGARDING THE CHNA SCHEDULE H, PT V, SEC B, LINE 5A THE HOSPITAL'S COMMUNITY HEALTH NEEDS ASSESSMENT CAN BE LOCATED AT THE FOLLOWING URL:HTTP://HENRYCOUNTYHOSPITAL.ORG PART I, LN 7 COL(F): WE ESTIMATE THAT APPROXIMATELY 3% OF THE ACCOUNTS SENT TO BAD DEBT MAY QUALIFY FOR FINANCIAL ASSISTANCE IF THE PATIENT WOULD APPLY OR FULLY COMPLETE THE APPLICATION. WE ASSIST OUR PATIENTS EARLY IN THE PROCESS TO QUALIFY THEM FOR MEDICAID OR FINANCIAL ASSISTANCE, SO WE DEEM OUR PERCENTAGE TO BE LOW. THE HOSPITAL CHOSE TO USE A COST-TO-CHARGE RATIO FOR REPORTING COST THROUGHOUT THE FORM. PART I LINE 7A - FINANCIAL ASSISTANCE AT COST: THE NUMBERS ARE SKEWED DUE TO THE FACT THAT THE LEVEL OF HCAP REIMBURSEMENT RECEIVED IS BASED ON 2012 NUMBERS. PART II, COMMUNITY BUILDING ACTIVITIES: HENRY COUNTY HOSPITAL SPONSORS AN ANNUAL KIDZ FEST. THIS ACTIVITY SUPPORTS OUR LOCAL COMMUNITY BY PROVIDING EDUCATION ON NUTRITION AND FITNESS, TARGETING THE CHILDREN OF HENRY COUNTY. IN ADDITION, THE HOSPITAL IS A SPONSOR FOR THE UNITED WAY COMING ALIVE PROGRAM. THE WELLNESS DEPARTMENT VISITS THE 5TH GRADERS OF HENRY COUNTY TO PROMOTE EXERCISE AND ENCOURAGE THE CHILDREN TO PARTICIPATE IN A FRIENDLY CHALLENGE BETWEEN THE LOCAL SCHOOLS. IN ADDITION, VARIOUS HOSPITAL EXECUTIVES SERVE ON HEALTH RELATED COMMUNITY BOARDS SUCH AS THE AMERICAN CANCER SOCIETY, THE AMERICAN HEART ASSOCIATION, THE BREAST AND COLON HEALTH PARTNERSHIP, AND THE COMMUNITY HEALTH PARTNERS. HENRY COUNTY HOSPITAL SPONSORS LOCAL GOLF OUTINGS THROUGH THE LOCAL HENRY COUNTY COMMUNITY FOUNDATION AND CHAMBER OF COMMERCE, AS WELL AS SUPPORTING THE LOCAL HOSPICE BAZAAR WITH DONATIONS. PART III, LINE 3: EXPLANATION FOR LINE 2 AND 3 OR RATIONAL FOR INCLUDING OTHER BAD DEBT AMOUNT IN COMMUNITY BENEFIT: [THE HOSPITAL HAS A DETAILED FINANCIAL ASSISTANCE POLICY WHICH STATES THAT TO PARTICIPATE IN CHARITY CARE CANDIDATES MUST COOPERATE FULLY. IN ADDITION THE HOSPITAL EDUCATES PATIENTS WILL LIMITED ABILITY TO PAY REGARDING FINANCIAL ASSISTANCE. FOR THIS REASON THE ORGANIZATION BELIEVES THAT IT ACCURATELY CAPTURES ALL CHARITY CARE DEDUCTIONS PROVIDED ACCORDING TO THE FINANCIAL ASSISTANCE POLICY AND THE AMOUNT OF BAD DEBT EXPENSE ATTRIBUTABLE TO PATIENTS ELIGIBLE UNDER THE ORGANIZATION'S CHARITY CARE POLICY IS NEGLIGIBLE.] PART III, LINE 4: THE ORGANIZATION ESTIMATES AN ALLOWANCE FOR DOUBTFUL ACCOUNTS BASED ON AN EVALUATION OF HISTORICAL LOSSES, CURRENT ECONOMIC CONDITIONS AND OTHER FACTORS UNIQUE TO THE ORGANIZATION'S CLIENT BASE. THE HOSPITAL HAS A DETAILED FINANCIAL ASSISTANCE POLICY WHICH STATES THAT TO PARTICIPATE IN CHARITY CARE CANDIDATES MUST COOPERATE FULLY. IN ADDITION THE HOSPITAL EDUCATES PATIENTS WITH LIMITED ABILITY TO PAY REGARDING FINANCIAL ASSISTANCE. FOR THIS REASON THE ORGANIZATION BELIEVES THAT IT ACCURATELY CAPTURES ALL CHARITY CARE DEDUCTIONS PROVIDED ACCORDING TO THE FINANCIAL ASSISTANCE POLICY AND THE AMOUNT OF BAD DEBT EXPENSE ATTRIBUTABLE TO PATIENTS ELIGIBLE UNDER THE ORGANIZATION'S CHARITY CARE POLICY IS NEGLIGIBLE. PART III, LINE 8: HENRY COUNTY HOSPITAL PROVIDES CARE TO THE MEDICARE POPULATION OF HENRY COUNTY, OHIO AND THE SURROUNDING AREA. IF THE HOSPITAL DID NOT PARTICIPATE IN MEDICARE, THOSE PATIENTS WOULD NEED TO SEEK CARE OUTSIDE OF HENRY COUNTY. THE SOURCE USED TO DETERMINE THE AMOUNT OF MEDICARE ALLOWABLE COSTS REPORTED FOR PART III, SECTION B, MEDICARE HAS BEEN PROVIDED FROM THE YEAR ENDED OCTOBER 31, 2014 REPORT: HOSPITAL STATEMENT OF REIMBURSABLE COST. PART VI, LINE 2: EVERY THREE YEARS HENRY COUNTY HOSPITAL WORKS IN CONJUNCTION WITH THE HENRY COUNTY HEALTH DEPARTMENT AND OTHER COMMUNITY PARTNERS TO COMPLETE A COMPREHENSIVE COMMUNITY HEALTH ASSESSMENT. THIS COMMUNITY HEALTH ASSESSMENT PROVIDES VITAL INFORMATION TO THE HOSPITAL AND ENABLES HEALTH PROFESSIONALS TO DETERMINE THE NEEDS OF THE COMMUNITY. FROM THE COMMUNITY HEALTH ASSESSMENT THERE ARE THREE DIFFERENT OBJECTIVES TO ASSIST IN MEETING THE FOLLOWING TWO GOALS:1. LOWER CHILDHOOD OVERWEIGHT/OBESITY IN HENRY COUNTY2. LOWER ADULT OVERWEIGHT/OBESITY IN HENRY COUNTYTHE THREE OBJECTIVES/PROGRAMS THAT WE ARE UTILIZING TO MEET THESE GOALS ARE CURRENTLY:1. SUPPORT AND IMPROVE THE SUMMER NUTRITION (AND PHYSICAL ACTIVITY) PROGRAM2. SUPPORT HENRY COUNTY HOSPITAL IN ITS JOURNEY TO BECOME A BABY - FRIENDLY HOSPITAL (WHICH FOCUSES ON BREASTFEEDING)3. ENCOURAGE/ENGAGE WORKPLACE WELLNESS THROUGHOUT THE COMMUNITY BY ASSISTING LOCAL ORGANIZATIONS IN BECOMING FIT - FRIENDLY (AMERICAN HEART ASSOCIATION'S WORKPLACE WELLNESS PROGRAM)IN ADDITION, FEEDBACK IS GATHERED FROM PATIENTS USING PROFESSIONAL RESOURCE CONSULTANTS SURVEYING SERVICES. THIS FEEDBACK GIVES HENRY COUNTY EMPLOYEES AN OPPORTUNITY TO BEST MEET THE PATIENTS' NEEDS. THE USE OF FOCUS GROUPS IS ALSO UTILIZED TO GATHER INFORMATION FROM SPECIFIC COMMUNITY GROUPS AND PATIENTS OF SPECIFIC SERVICE LINES. PART VI, LINE 3: AT THE TIME OF SERVICE, EACH SELF PAY PATIENT IS GIVEN A PACKET UPON DISCHARGE. THE PACKET INCLUDES AN HCAP APPLICATION (<100% FEDERAL POVERTY GUIDELINES) WITH DIRECTIONS, FINANCIAL ASSISTANCE PROGRAM INFORMATION, INCOME GUIDELINES FOR PROGRAMS, AND THE CONTACT INFORMATION FOR THE FINANCIAL COUNSELOR. EACH BILLING STATEMENT THAT IS SENT OUT TO PATIENTS CONTAINS THE HOSPITAL HCAP APPLICATION AND FINANCIAL COUNSELOR CONTACT INFORMATION. SIGNAGE IS ALSO POSTED IN THE HOSPITAL PER STATE OF OHIO REQUIREMENTS REGARDING FREE CARE. PART VI, LINE 4: HENRY COUNTY IS LOCATED IN NORTHWEST OHIO, COMPOSED OF THIRTEEN TOWNSHIPS AND NINE MUNICIPALITIES. HENRY COUNTY IS RICH IN AGRICULTURE, BUSINESS, CHURCHES, SCHOOLS, AND COMMUNITY ORGANIZATIONS. THE POPULATION OF HENRY COUNTY IS NEARLY 29,000. THE DEMOGRAPHICS OF THOSE NEARLY 29,000 RESIDENTS ARE AS FOLLOWS; 91.2% WHITE PERSONS NOT HISPANIC, 6.9% PERSONS OF HISPANIC OR LATINO ORIGIN, 0.6% BLACK PERSONS, 0.4% ASIAN PERSONS, AND 0.4% AMERICAN INDIAN AND ALASKA NATIVE PERSONS. THE MEDIAN HOUSEHOLD INCOME AS OF 2010 IS $48,932 AND 11.7% OF PERSONS RANK BELOW THE POVERTY LEVEL. PART VI, LINE 5: HENRY COUNTY HOSPITAL IS ACTIVE IN THE COMMUNITY BY PARTICIPATING IN HEALTH FAIRS, PROVIDING EDUCATION TO THE COMMUNITY, PROVIDING SCHOOL NURSES IN TWO OF THE FOUR SYSTEMS IN THE COUNTY, SUPPORTING OUR PATIENTS WITH TRANSPORTATION NEEDS, AND PROMOTING FITNESS AND WELLNESS CLASSES. THE HOSPITAL SUPPORTS THE EMPLOYEES BY PROMOTING WELLNESS ACTIVITIES, SUCH AS BREAK FOR HEALTH, HEALTHY EATING, AND "DRINK MORE WATER" CHALLENGES. OUR BOARD OF TRUSTEES IS MADE UP OF COMMUNITY MEMBERS WHO ACT IN THE BEST INTEREST OF OUR PATIENT POPULATION. EACH MEMBER BRINGS A UNIQUE PERSPECTIVE FROM THEIR OWN POSITIONS IN THE COMMUNITY THAT ENABLES THEM TO BE ACTIVELY ENGAGED IN ADMINISTERING THEIR DUTIES AS A BOARD. THE HOSPITAL WORKS COLLABORATIVELY WITH THE HENRY COUNTY HEALTH DEPARTMENT, THE UNITED WAY, AND OTHERS IN PROMOTING HEALTHY LIVING. AS AN EXAMPLE, THE HOSPITAL IS WORKING TO INCREASE THE NUMBER OF BREAST-FED BABIES WITH THE ASSISTANCE OF WIC (WOMEN, INFANTS AND CHILDREN) STAFF, BIRTHING CARE SERVICES NURSES, AND PATIENTS. X X 1 1 X X X X 0 0 0 0 0 0 0 0 0 KIMBERLY BORDENKIRCHER TREASURER & CEO 197168 0 0 0 6095 0 1887 0 19982 0 225132 0 0 0 DR MORRIS SEAL BOARD MEMBER-CHIEF OF STAFF- 1/1/14 203288 0 9982 0 3810 0 2049 0 10522 0 229651 0 0 0 DR DOUGLAS LINDSEY CHIEF OF STAFF ENDING 12/31/13 297064 0 0 0 1290 0 2982 0 32026 0 333362 0 0 0 DR ERAST HAFTKOWYCZ OB/GYN 236384 0 0 0 1290 0 2351 0 29526 0 269551 0 0 0 CYNTHIA LATTA PHARMACIST 139918 0 0 0 1453 0 1384 0 10147 0 152902 0 0 0 PART I, LINE 1A THE HOSPITAL GROSSES UP THE PERSONAL USE OF A BUSINESS OWNED VEHICLE FOR THE CEO. THIS IS BASED ON PAST PRACTICE. THE HOSPITAL PAYS DUES FOR THE ROTARY CLUB FOR KIM BORDENKIRCHER, CEO, AND MICHELLE RYCHENER, DIRECTOR OF DEVELOPMENT. PART I, LINE 1B THE HOSPITAL GROSSES UP THE PERSONAL USE OF A BUSINESS OWNED VEHICLE FOR THE CEO. THIS IS BASED ON PAST PRACTICE. THE HOSPITAL PAYS DUES FOR THE ROTARY CLUB FOR KIM BORDENKIRCHER, CEO, AND MICHELLE RYCHENER, DIRECTOR OF DEVELOPMENT. A HENRY COUNTY OHIO 346400633 2010-12-16 10680000 BQ PRIVATE PLACEMENT WITH SWAP PAYOFF AND REFINANCING OF 2006 BOND ISSUE 0 0 0 A 10680000 135325 592175 2011 1 0 1 1 A 0 0 0 0 0 0 0 A 0 1 0 0 0 0 0 0 0 A 1 FORM 990, PART VI, SECTION B, LINE 11 THE FINANCE COMMITTEE OF THE BOARD REVIEWS THE FORM 990 BEFORE FILING AT A REGULARLY SCHEDULED MEETING, TYPICALLY THE FOURTH MONDAY OF THE MONTH. THE FORM 990 THEN GOES TO THE FULL BOARD AT THE FOLLOWING BOARD MEETING FOR REVIEW, TYPICALLY THE FIRST MONDAY OF THE MONTH. FORM 990, PART VI, SECTION B, LINE 12C THE WRITTEN CONFLICT OF INTEREST POLICY IS REGULARLY AND CONSISTENTLY MONITORED AND COMPLIANCE ENFORCED BY THE CEO. THE SCOPE OF THIS POLICY INCLUDES BOARD MEMBERS AND THE LEADERSHIP TEAM. THE POLICY IS IN PLACE TO IDENTIFY POTENTIAL CONFLICTS OF INTEREST AND PROVIDE A MECHANISM TO MANAGE POTENTIAL CONFLICTS OF INTERESTS. THE COVERED PERSONS ARE TO IDENTIFY POTENTIAL CONFLICTS AND NOT PARTICIPATE IN DISCUSSIONS AND DECISIONS RELATED TO THE IDENTIFIED CONFLICTS. A SELF DISCLOSURE FROM COVERED PERSONS TO THE CEO AND THE BOARD IS REQUIRED ON ANY POTENTIAL CONFLICTS OF INTEREST. THE COVERED PERSONS ARE TO RECUES FROM PARTICIPATING IN ANY DELIBERATION OR DECISIONS ON SUCH TRANSACTIONS. FORM 990, PART VI, SECTION B, LINE 15 THE CEO'S COMPENSATION IS DETERMINED BY BOARD OF DIRECTORS REVIEW. THE BOARD OF DIRECTORS USES THE OHIO HOSPITAL ASSOCIATION COMPENSATION DATA, COMPARABLE DATA OF OUR SURROUNDING HOSPITALS, AND INTERNAL EQUITY TO DETERMINE THE COMPENSATION OF THE CEO. THE FINAL DETERMINATION OF THE COMPENSATION IS APPROVED BY BOARD VOTE. THE COMPENSATION OF OTHER OFFICERS OR KEY EMPLOYEES OF THE ORGANIZATION IS DONE BY SIMILAR REVIEW OF COMPARABLE WAGE DATA FROM THE OHIO HOSPITAL ASSOCIATION AND THE HOSPITAL COUNCIL OF NORTHWEST OHIO. THE MANAGER OF HUMAN RESOURCES MAKES A COMPENSATION RECOMMENDATION BASED ON THE DATA AND INTERNAL EQUITY TO THE CEO. THE CEO AUTHORIZES THE COMPENSATION BASED ON THE DATA AND THE RECOMMENDATION. FORM 990, PART VI, SECTION C, LINE 19 THE ORGANIZATION DOES NOT MAKE GOVERNING DOCUMENTS, CONFLICT OF INTEREST POLICY OR FINANCIAL STATEMENTS AVAILABLE TO THE PUBLIC. FORM 990, PART IX, LINE 11G PROFESSIONAL FEES: PROGRAM SERVICE EXPENSES 3,940,325. MANAGEMENT AND GENERAL EXPENSES 383,308. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 4,323,633. PURCHASED SERVICES: PROGRAM SERVICE EXPENSES 757,024. MANAGEMENT AND GENERAL EXPENSES 128,829. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 885,853. FORM 990, PART XI, LINE 9: NET ASSET TRANSFERS 41,077. INTEREST IN FOUNDATION NET ASSETS 101,136. HENRY COUNTY HOSPITAL FOUNDATION 1600 EAST RIVERVIEW NAPOLEON OH 43545 341919852 TO RAISE FUNDS AND PROVIDE FINANCIAL ASSISTANCE TO HENRY COUNTY HOSPITAL. OH 501(C)(3) LINE 11A, I HENRY COUNTY HOSPITAL 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 0 0 0 1 HENRY COUNTY HOSPITAL FOUNDATION INC P 91010 CASH