2014-08-15T14:18:20-05:00 2013-09-30 273858252 DEAN DORTON ALLEN FORD PLLC 106 W VINE STREET SUITE 600 LEXINGTON KY 40507 990 2012-10-01 610420440 HARRISON MEMORIAL HOSPITAL INC HARR 8592353502 1210 KY HWY 36 E CYNTHIANA KY 410317498 JIM SPEARS CFO 8592353502 2014-08-12 1 LEIGH MCKEE P00169845 8592552341 2012 2015-11-30 17:44:51Z SHEILA CURRANS 1210 KY HWY 36 E CYNTHIANA KY 410317498 35364992 0 X WWW.HARRISONMEMHOSP.COM X 1906 KY TO PROVIDE HIGH QUALITY HEALTH AND MEDICAL CARE TO THE PEOPLE OF HARRISON AND SURROUNDING COUNTIES. 14 10 397 19 0 0 12860 8615 37073664 34564853 13489 13487 656973 656735 37756986 35243690 0 0 0 0 17243340 17913640 0 0 0 17383327 17979381 34626667 35893021 3130319 -649331 40306782 39723785 20767791 20776136 19538991 18947649 X HARRISON MEMORIAL HOSPITAL EXISTS FOR THE PURPOSE OF PROVIDING HIGH QUALITY HEALTH AND MEDICAL CARE SERVICES TO THE PEOPLE OF HARRISON AND SURROUNDING COUNTIES OF OUR REGION WITHIN THE CAPABILITIES OF OUR RESOURCES. IN FULFILLING THIS MISSION, WE STRIVE FOR EXCELLENCE IN: THE CARE WE DELIVER; IN PATIENT SAFETY; IN THE FACILITIES WE PROVIDE; IN THE RECRUITMENT, RETENTION, AND DEVELOPMENT OF DEDICATED PHYSICIANS AND PERSONNEL; IN FACILITATING, COORDINATING AND PROVIDING ACCESS TO GENERAL AND SPECIALIZED HEALTH SERVICES THROUGH OUR OWN RESOURCES AND IN COLLABORATION WITH THE RESOURCES OF OTHERS. 0 0 29834267 34564853 THE HOSPITAL PROVIDED HEALTH CARE TO 1,649 IN-PATIENTS, 264 NURSERY PATIENTS AND 53,216 OUT-PATIENTS. THE HOSPITAL HAS A HIGH VOLUME OF MEDICARE AND MEDICAID PATIENTS. THE HOSPITAL TREATS ALL PATIENTS REGARDLESS OF ABILITY TO PAY. HARRISON MEMORIAL HOSPITAL PROVIDED APPROXIMATELY $574,000 OF CHARITY CARE AT COST. 29834267 1 0 0 1 0 0 0 0 0 0 1 0 0 0 1 1 1 0 0 0 0 0 0 0 0 0 1 1 0 0 1 1 0 0 0 0 0 0 0 1 1 0 0 0 0 0 0 1 0 0 0 1 56 0 1 397 1 0 0 0 0 0 0 0 0 0 0 X 14 10 0 0 0 0 0 0 0 1 1 0 0 0 1 1 1 1 1 1 1 0 KY X THE ORGANIZATION 8592353502 1210 KY HWY 36 E CYNTHIANA KY 410317498 ALEX BARNETT 1.00 X 0 0 0 GERALD FIELDS 1.00 X 0 0 0 DOUG HAMPTON 1.00 X 0 0 0 JOHN LAIR 1.00 X 0 0 0 MS BRUCE FLORENCE 1.00 X 0 0 0 DR BRIAN MULBERRY 1.00 X 0 0 0 LARRY WILEY 1.00 X 0 0 0 JANE THOMAS 1.00 X 0 0 0 FRAZER LEBUS 1.00 X 0 0 0 STEVE JUDY 1.00 X 0 0 0 STEVE MOSES 1.00 X 0 0 0 PAUL TUCKER 1.00 X 0 0 0 DR STEPHEN BESSON 1.00 X 0 0 0 DR DEREK CLARK 1.00 X 0 0 0 SHEILA CURRANS 40.00 X 187806 0 13007 JIM SPEARS 40.00 X 155091 0 8436 GERALD HARPEL MD 40.00 X 400691 0 8503 JAMES PETTY 40.00 X 520358 0 2963 RACHEL KATHRYNE HARNEY 40.00 X 127437 0 13438 1391383 0 46347 5 0 1 0 MARSHALL PHYSICIAN SERVICES LLC 1792 ALYSHEBA WAY LEXINGTON KY 40509 ER PHYSICIANS 614210 COMMUNITY ANESTHESIA OF THE BLUEGRASS 1210 KY HWY 36E CYNTHIANA KY 41031 ANESTHESIA SERVICES 502828 MESSER CONSTRUCTION 854 W MAIN STREET LEXINGTON KY 40504 CONSTRUCTION CONTRACTOR 291518 NEW LEXINGTON CLINIC PSC 1221 SOUTH BROADWAY LEXINGTON KY 40508 UROLOGY PHYSICIANS 205749 KENTUCKY MEDICAL SERVICES FOUNDATION INC 138 LEADER AVENUE LEXINGTON KY 40508 ONCOLOGY & SURGERY PHYSICIANS 198948 7 8615 8615 PATIENT SERVICE REVENUE 623990 34564853 34564853 34564853 18514 18514 136753 116275 20478 20478 20478 5027 -5027 -5027 -5027 CAFETERIA/VENDING 722210 165488 165488 DAY CARE 624410 161799 161799 OTHER REVENUE 900099 106130 106130 202840 202840 636257 35243690 34564853 0 670222 352020 278096 73924 14278424 11279955 2998469 341082 269455 71627 1937546 1530661 406885 1004568 793609 210959 14343 14343 30603 30603 2914846 2302728 612118 192239 151869 40370 186695 147489 39206 34193 27012 7181 610022 481917 128105 34905 27575 7330 771018 771018 2701986 2701986 465858 368028 97830 DRUGS & SUPPLIES 4630788 3895798 734990 BAD DEBT EXPENSE 2182335 2182335 OUTSOURCING 1528243 1207312 320931 KY PROVIDER TAX 549805 549805 1131502 867619 263883 35893021 29834267 6058754 0 6272463 2959353 3723284 4830798 139987 256471 810665 834025 655436 684002 52822594 30034138 23331374 22788456 4212753 6209184 379169 347909 781651 813587 40306782 39723785 2316800 2555276 94139 8893 16721694 16258142 1460575 1221003 174583 732822 20767791 20776136 X 18855406 18227687 683585 719962 19538991 18947649 40306782 39723785 -649331 57989 0 X X 0 1 X 1 0 X 0 0 0 0 0 0 0 0 1 4971 4971 0 EXPLANATION OF LOBBYING ACTIVITIES: PART II-B, LINE 1: THE HOSPITAL IS A MEMBER OF THE AMERICAN HOSPITAL ASSOCIATION AND THE KENTUCKY HOSPITAL ASSOCIATION AND PAID DUES OF $27,116 OF WHICH $4,971 IS ATTRIBUTABLE TO LOBBYING. 293371 293371 25129792 10547746 14582046 98630 34520 64110 25724749 18507457 7217292 1576052 944415 631637 22788456 DUE TO THIRD PARTY PAYORS 591624 PHYSICIAN COMMITMENTS 141198 732822 X 33235619 57989 116275 174264 33061355 2182335 2182335 35243690 33826961 116275 116275 33710686 2182335 2182335 35893021 DESCRIPTION OF UNCERTAIN TAX POSITIONS UNDER FIN 48: PART X, LINE 2: THE HOSPITAL HAS ADOPTED THE PROVISIONS OF GAAP RELATING TO UNCERTAINTY IN INCOME TAXES. THE ASSESSMENT INCLUDES EVALUATING THE TAX POSITIONS TAKEN ON ALL INCOME TAX RETURNS THAT REMAIN OPEN TO EXAMINATION BY THE RESPECTIVE TAXING AUTHORITIES (RETURNS FILED AFTER 2009). THE HOSPITAL DOES NOT BELIEVE THAT THERE ARE ANY UNCERTAIN TAX POSITIONS ON THOSE RETURNS THAT SHOULD BE REFLECTED IN THE FINANCIAL STATEMENTS. PART XI, LINE 2D - OTHER ADJUSTMENTS: RENTAL EXPENSES NETTED AGAINST RENTAL INCOME ON PAGE 1 116,275. PART XI, LINE 4B - OTHER ADJUSTMENTS: BAD DEBT EXPENSE NETTED ON FINANCIALS 2,182,335. PART XII, LINE 2D - OTHER ADJUSTMENTS: RENTAL EXPENSES NETTED AGAINST RENTAL INCOME ON PAGE 1 116,275. PART XII, LINE 4B - OTHER ADJUSTMENTS: BAD DEBT EXPENSE NETTED ON FINANCIALS 2,182,335. 1 1 1 X 1 X 150.000000000000 1 1 1 0 1 1 777484 1011434 -233950 0.00000 5692543 4774140 918403 0.02560 6470027 5785574 684453 0.02560 457145 457145 0.01270 4000 4000 0.00010 461145 461145 0.01280 6931172 5785574 1145598 0.03840 1 2182335 8106934 9934987 -1828053 X 1 1 1 1 HARRISON MEMORIAL HOSPITAL

1210 KY HWY 36 EAST CYNTHIANA KY 41031

X X X HARRISON MEMORIAL HOSPITAL INC 1 1 X X X X X X X X X 11 1 0 1 X X X X X X X X X 1 0 1 1 150.000000000000 1 150.000000000000 1 X X X X X X X 1 1 X X 1 X X 1 X X X X 1 X 0 0 PART I, LINE 7: AMOUNTS WERE DETERMINED USING A COST-TO-CHARGE RATIO DERIVED FROM THE WORKSHEETS IN THE INSTRUCTIONS TO SCHEDULE H. PART I, L7 COL(F): $2,182,335 OF BAD DEBT EXPENSE INCLUDED IN FORM 990, PART IX, LINE 25, COLUMN (A) WAS REMOVED FROM THE DENOMINATOR OF THIS CALCULATION PER THE INSTRUCTIONS. PART II: HARRISON MEMORIAL HOSPITAL IS VERY ACTIVE IN THE COMMUNITY WITH PROMOTING HEALTH EDUCATION. HMH PARTNERS WITH SEVERAL COMMUNITY ORGANIZATIONS TO REACH THE LARGEST AUDIENCE. IN MOST RECENT YEARS, HMH HAS PROVIDED HEALTH FAIRS AND SEMINARS IN SEVERAL COUNTIES LIKE PENDLETON, BRACKEN AND ROBERTSON. BY PROVIDING THESE EVENTS, HMH IS ABLE TO PROVIDE EDUCATION AND SCREENINGS MORE LOCALLY FOR THE RESIDENTS. IN ADDITION, THE EVENTS AID IN BUILDING RELATIONSHIPS WITH COMMUNITY LEADERS AND RESIDENTS. THE EVENTS LIKE HEALTH FAIRS PROVIDE FREE TESTS AND SCREENINGS, WHICH WOULD NORMALLY COST $1200 PER PERSON. THE HEALTH FAIRS PROVIDE AN OPPORTUNITY FOR THE UNDERINSURED AND UNINSURED TO RECEIVE MEDICAL CARE. THE EVENTS ALSO HAVE SEVERAL OPPORTUNITIES TO MEET WITH HEALTH CARE PROFESSIONALS TO DISCUSS HEALTH ISSUES. THE HMH SPONSORED EDUCATIONAL SEMINARS PROVIDE AN OPPORTUNITY FOR INDIVIDUALS TO MEET HEALTH CARE PROFESSIONALS AND DISCUSS MAJOR HEALTH TOPICS. PART III, LINE 4: BAD DEBT COST REPRESENTS THE EXPENSE THE HOSPITAL INCURRED DUE TO NONPAYMENT OF HOSPITAL CHARGES INCLUDING, BUT NOT LIMITED TO, NONPAYMENT OF MEDICARE COINSURANCE AND DEDUCTIBLE AMOUNTS. THIS EXPENSE IS LISTED AS AN OPERATING EXPENSE ON THE FINANCIAL STATEMENTS.BAD DEBT COST IS CALCULATED BY MULTIPLYING THE BAD DEBT EXPENSE LISTED ON THE FINANCIAL STATEMENTS BY THE COST TO CHARGE RATIO COMPUTED ON WORKSHEET 2. PART III, LINE 8: ALL THE SHORTFALL REPORTED IN LINE 7 SHOULD BE TREATED AS COMMUNITY BENEFIT. LINE 6 WAS COMPUTED USING REVENUE AMOUNTS LISTED ON THE SETTLEMENT WORKSHEETS ON THE AS-FILED MEDICARE COST REPORT. PART III, LINE 9B: THE HOSPITAL PROVIDES FINANCIAL ASSISTANCE BASED ON FEDERAL POVERTY GUIDELINES TO DETERMINE ELIGIBILITY FOR PROVIDING FREE CARE AND DISCOUNTED CARE. FOR PATIENTS QUALIFYING FOR FINANCIAL ASSISTANCE WITH DISCOUNTED CARE, COLLECTION PURSUITS FOR THE DISCOUNTED CHARGES ARE FOLLOWED AS STATED IN OUR PROMPT PAYMENT ON SELF-PAY ACCOUNTS POLICY. HARRISON MEMORIAL HOSPITAL, INC. PART V, SECTION B, LINE 3: INDIVIDUALS THAT REPRESENT THE BROAD INTERESTS OF THE COMMUNITY, INCLUDING THOSE WITH SPECIAL KNOWLEDGE OF OR EXPERTISE IN PUBLIC HEALTH WERE INTERVIEWED DURING THE COURSE OF PREPARING THE COMMUNITY NEEDS ASSESSMENT. THESE INDIVIDUALS INCLUDED BOTH FAMILY SPECIALTY PHYSICIANS AND DIRECTORS OF LOCAL HEALTH DEPARTMENTS OF HARRISON COUNTY AND THE SURROUNDING COUNTIES AND THE MAYOR OF CYNTHIANA. HARRISON MEMORIAL HOSPITAL, INC. PART V, SECTION B, LINE 14G: THE POLICY IS NOT CURRENTLY POSTED ON THE WEBSITE, BUT WILL BE POSTED ALONG WITH THE WEB PAYMENT INFORMATION. A SUMMARY IS CURRENTLY AVAILABLE THAT IS INCLUDED IN THE PATIENT INFORMATION BOOKS IN EVERY PATIENT ROOM OR TREATMENT AREA. IT STATES THERE IS A POLICY, THAT HELP CAN BE OBTAINED, AND TO CALL THE FINANCIAL COUNSELOR TO OBTAIN INFORMATION. PART VI, LINE 2: THE HOSPITAL COMPLETED A COMPREHENSIVE COMMUNITY HEALTH NEEDS ASSESSMENT AS REQUIRED BY THE PATIENT PROTECTION AND AFFORDABLE CARE ACT. IN ADDITION, HARRISON MEMORIAL HOSPITAL ASSESSES THE COMMUNITY THROUGH SEVERAL METHODS. THE HMH COMMUNITY CONSISTS OF A SEVEN-COUNTY AREA. HMH HAS TWO BOARD LEVEL COMMITTEES WHO PROVIDE RECOMMENDATIONS TO THE HMH BOARD OF DIRECTORS. PLANNING: MARKET SHARE ENHANCEMENT COMMITTEE IS COMPRISED OF HMH BOARD MEMBERS AND HMH PHYSICIAN STAFF MEMBERS. THE COMMITTEE IS PRESENTED WITH MARKET SHARE DATA OF THE INPATIENT ACTIVITY OF THE HOSPITAL AND OF MAJOR SERVICE LINES LIKE CARDIOLOGY, ORTHOPEDICS. THE DATA INFORMS THE COMMITTEE WHERE PATIENTS IN THE HMH SERVICE AREA CHOOSE TO RECEIVE HEALTHCARE. THE DATA IS EXTRACTED FROM KENTUCKY INFOSUITE EACH QUARTER. THE REPORTS AID THE COMMITTEE IN MAKING DECISIONS IN REGARDS TO THE NEEDS OF THE COMMUNITY. EACH YEAR THE PMSE COMMITTEE HOSTS A STRATEGIC RETREAT INVITING HMH BOARD MEMBERS, PHYSICIAN STAFF MEMBERS AND SENIOR MANAGEMENT TO DISCUSS COMMUNITY NEEDS AND PLANS FOR THE FUTURE. ANOTHER BOARD LEVEL COMMITTEE IS CALLED MEDICAL STAFF DEVELOPMENT. THE COMMITTEE IS COMPRISED OF HMH BOARD MEMBERS, HMH PHYSICIAN STAFF MEMBERS AND COMMUNITY VOLUNTEERS. EACH YEAR THE MEDICAL STAFF DEVELOPMENT COMMITTEE COMPLETES A PHYSICIAN NEEDS ASSESSMENT. THE ASSESSMENT DEMONSTRATES THE PHYSICIAN NEED IN THE AREA BASED ON POPULATION. THE ASSESSMENT IS USED TO FORM A PHYSICIAN RECRUITING PLAN FOR THE FUTURE AND IS RECOMMENDED TO THE BOARD FOR APPROVAL. FINALLY, THE HMH MEDICAL STAFF MEETINGS ARE HELD ONCE A MONTH WHERE MEMBERS OF THE HMH SENIOR MANAGEMENT ALSO ATTEND. WITHIN THESE MEETINGS, THE STAFF MEMBERS DISCUSS PATIENT NEEDS. THE INFORMATION GATHERED AT THESE MEETINGS AID IN THE DECISIONS OF SERVICE LINE ENHANCEMENT. PART VI, LINE 3: NOTIFICATION ABOUT CHARITY AVAILABLE FROM HARRISON MEMORIAL HOSPITAL , WHICH SHALL INCLUDE A CONTACT NUMBER, SHALL BE DISSEMINATED BY HARRISON MEMORIAL HOSPITAL BY VARIOUS MEANS, WHICH MAY INCLUDE, BUT ARE NOT LIMITED TO, THE PUBLICATION OF NOTICES IN PATIENT BILLS AND BY POSTING NOTICES IN EMERGENCY ROOMS, SPECIALTY PHYSICIAN CLINICS, ADMITTING AND REGISTRATION DEPARTMENTS, HOSPITAL BUSINESS OFFICES, AND PATIENT FINANCIAL SERVICES OFFICES THAT ARE LOCATED ON FACILITY CAMPUSES, AND AT OTHER PUBLIC PLACES AS HARRISON MEMORIAL HOSPITAL MAY ELECT. SUCH INFORMATION SHALL BE PROVIDED IN THE PRIMARY LANGUAGES SPOKEN BY THE POPULATION SERVICED BY HARRISON MEMORIAL HOSPITAL. REFERRAL OF PATIENTS FOR CHARITY MAY BE MADE BY ANY MEMBER OF THE HARRISON MEMORIAL HOSPITAL STAFF OR MEDICAL STAFF, INCLUDING PHYSICIANS, NURSES, FINANCIAL COUNSELORS, SOCIAL WORKERS, CASE MANAGERS, CHAPLAINS, AND RELIGIOUS SPONSORS. A REQUEST FOR CHARITY MAY BE MADE BY THE PATIENT OR A FAMILY MEMBER, CLOSE FRIEND, OR ASSOCIATE OF THE PATIENT, SUBJECT TO APPLICABLE PRIVACY LAWS. PART VI, LINE 4: HARRISON MEMORIAL HOSPITAL SERVES SEVEN COUNTIES IN THE CENTRAL KENTUCKY AREA MAKING IT A REGIONAL FACILITY. THOSE COUNTIES ARE HARRISON, PENDLETON, ROBERTSON, BRACKEN, NICHOLAS, BOURBON AND SCOTT. HMH COMMUNITY IS CONSIDERED IN MOST PARTS RURAL WITH CYNTHIANA BEING ITS LARGEST TOWN IT SERVES WITH A POPULATION AROUND 7,000. THE AREA IS ALSO DESCRIBED AS A BEDROOM COMMUNITY OF LEXINGTON. THE AREA IS A FARMING COMMUNITY WITH SEVERAL STRONG INDUSTRIES BASED IN THE AREA. HMH CONSIDERS ITS SERVICE AREA POPULATION TO BE 35,000. THE DEMOGRAPHIC OF THE COMMUNITIES IS PREDOMINANTLY CAUCASIAN WITH AN AGING POPULATION. X X X 0 0 0 0 0 0 0 0 0 SHEILA CURRANS 187806 0 0 0 0 0 6115 0 6892 0 200813 0 0 0 JIM SPEARS 155091 0 0 0 0 0 0 0 8436 0 163527 0 0 0 GERALD HARPEL MD 400691 0 0 0 0 0 0 0 8503 0 409194 0 0 0 JAMES PETTY 520358 0 0 0 0 0 2377 0 586 0 523321 0 0 0 A COUNTY OF HARRISON KY 616000746 2009-11-13 17475000 REFINANCE SERIES 2005 AND RETIRE THE INTEREST RATE SWAP AGREEMENT 1 1 0 A 17475000 95217 79432 17300351 2009 1 0 1 1 A 0 0 0 0 0 0 0 A 1 1 0 0 0 0 PEGGY LAIR PEGGY LAIR IS MARRIED TO A BOARD MEMBER 78304 PEGGY LAIR IS EMPLOYED AS THE CONTROLLER FOR THE HOSPITAL 0 MARY BETH SLADE MARY BETH SLADE IS SISTER TO AN OFFICER 71820 MARY BETH SLADE IS AN EMPLOYEE OF THE HOSPITAL 0 JULIE FAIN JULIE FAIN IS SISTER TO AN OFFICER 15335 JULIE FAIN IS AN EMPLOYEE OF THE HOSPITAL 0 CRISTIN CURRANS CRISTIN CURRANS IS DAUGHTER OF AN OFFICER 37081 CRISTIN CURRANS IS AN EMPLOYEE OF THE HOSPITAL 0 FORM 990, PART VI, SECTION B, LINE 11 THE 990 AFTER FILING IS REVIEWED IN DETAIL AT THE FINANCE COMMITTEE MEETING WITH BOARD MEMBERS PRESENT. THEY ARE ASKED IF THEY WANT A COPY AND ARE ENCOURAGED TO PERSONALLY VISIT WITH THE CFO TO COVER ANY TOPICS NECESSARY. FORM 990, PART VI, SECTION B, LINE 12C ANNUALLY, ALL APPLICABLE PERSONNEL SIGN A CONFLICT OF INTEREST STATMENT AND, WHEN NEEDED, IT IS INCORPORATED INTO POLICIES. FORM 990, PART VI, SECTION B, LINE 15 THE BOARD CHAIR AND EXECUTIVE COMMITTEE REVIEW THE COMPENSATION ANNUALLY AFTER RECEIPT OF THE AHA ANNUAL SALARY SURVEY. FORM 990, PART VI, SECTION C, LINE 19 THESE DOCUMENTS ARE AVAILABLE UPON REQUEST. A NEW PATIENT HANDBOOK HAS BEEN DEVELOPED FOR ALL PATIENTS AND WILL BE HANDED OUT AT OUTPATIENT ADMISSIONS OR AVAILABLE FOR USE IN PATIENT ROOMS. FORM 990, PART XII, LINE 2C THE ORGANIZATION HAS NOT CHANGED EITHER ITS OVERSIGHT PROCESS OF THE AUDIT OR THE SELECTION PROCESS OF THE INDEPENDENT ACCOUNTANT FROM THE PRIOR YEAR. COMMUNITY HEALTH PARTNERSHIP LLC 1210 KY HWY 36E CYNTHIANA KY 41031 611348611 HEALTH CARE PROMOTION KY N/A C 41379 4230 0.50000 0 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0