2012-11-15T15:38:10-06:00 2011-12-31 351178661 BLUE & CO LLC 8800 LYRA DRIVE SUITE 450 COLUMBUS OH 43240 990 2011-01-01 340714583 CITY HOSPITAL ASSOCIATION CITY 3303862000 425 WEST FIFTH STREET EAST LIVERPOOL OH 43920 KYLE JOHNSON 3303862000 2012-11-15 1 NANCY KIRCHNER P00386751 6148852583 2011 2016-02-24 21:20:13Z EAST LIVERPOOL CITY HOSPITAL KYLE JOHNSON 425 WEST FIFTH STREET EAST LIVERPOOL OH 43920 60982012 0 X WWW.ELCH.ORG X 1905 OH THE ORGANIZATION IS ORGANIZED AND OPERATED TO PROVIDE THE PEOPLE OF THE TRI-STATE AREA HIGH QUALITY HEALTH CARE SERVICES, REGARDLESS OF THE PERSON'S ABILITY TO PAY. THESE SERVICES INCLUDE THE PREVENTION OF ILLNESS, RELIEF OF SUFFERING, HEALTH RESTORATION, AND HEALTH CARE EDUCATION. 16 13 638 15 0 0 234439 29542 53516607 58319575 9496087 1840764 530565 473784 63777698 60663665 145756 1106978 0 0 32555747 33689807 0 0 0 29936983 34454395 62638486 69251180 1139212 -8587515 109896728 107284932 34420734 40519734 75475994 66765198 X THE ORGANIZATION IS ORGANIZED AND OPERATED TO PROVIDE THE PEOPLE OF THE TRI-STATE AREA HIGH QUALITY HEALTH CARE SERVICES, REGARDLESS OF THE PERSON'S ABILITY TO PAY. THESE SERVICES INCLUDE THE PREVENTION OF ILLNESS, RELIEF OF SUFFERING, HEALTH RESTORATION, AND HEALTH CARE EDUCATION. 0 0 59410355 58610616 CITY HOSPITAL ASSOCIATION DBA EAST LIVERPOOL CITY HOSPITAL PROVIDES QUALITY MEDICAL HEALTHCARE REGARDLESS OF RACE, CREED, SEX, NATIONAL ORIGIN, HANDICAP, AGE, OR ABILITY TO PAY. ALTHOUGH REIMBURSEMENT FOR SERVICES RENDERED IS CRITICAL TO THE OPERATION AND STABILITY OF THE HOSPITAL, IT IS RECOGNIZED THAT NOT ALL INDIVIDUALS POSSESS THE ABILITY TO AFFORD ESSENTIAL MEDICAL SERVICES AND HEALTHCARE EDUCATION. THEREFORE, IN KEEPING WITH THE HOSPITAL'S COMMITMENT TO SERVE ALL MEMBERS OF OUR COMMUNITY WITH FREE CARE AND OR SUBSIDIZED CARE, CARE PROVIDED TO PERSONS COVERED BY GOVERNMENTAL PROGRAMS BELOW COSTS, AND HEALTH ACTIVITIES AND PROGRAMS TO SUPPORT THE COMMUNITY HAVE BEEN CONSIDERED WHERE THE NEED AND AN INDIVIDUAL'S INABILITY TO PAY EXIST. THESE ACTIVITIES INCLUDE WELLNESS PROGRAMS, COMMUNITY EDUCATION PROGRAMS, AND A VARIETY OF BROAD COMMUNITY SUPPORT ACTIVITIES. THE HOSPITAL PROVIDES CARE TO PERSONS COVERED BY GOVERNMENTAL PROGRAMS BELOW COST. RECOGNIZING ITS MISSION TO THE COMMUNITY, SERVICES ARE PROVIDED TO BOTH MEDICARE AND MEDICAID PATIENTS. TO THE EXTENT REIMBURSEMENT IS BELOW COST, THE HOSPITAL CONSIDERS THESE AMOUNTS AS UNCOMPENSATED CARE IN MEETING ITS MISSION TO THE ENTIRE COMMUNITY. THE HOSPITAL IS LOCATED IN EAST LIVERPOOL, OHIO AND SERVICES THE SURROUNDING COMMUNITIES; STAFFING 158 BEDS FOR ACUTE CARE, INTENSIVE CARE, NURSERY, AND SKILLED NURSING IN THIS MEDICALLY UNDERSERVED AREA.DURING 2011, THE HOSPITAL PROVIDED NUMEROUS BENEFITS TO THE SURROUNDING COMMUNITY, INCLUDING FINANCIAL SUPPORT THROUGH THE COMMUNITY BENEFIT INITIATIVE PROGRAM.COMMUNITY BENEFIT INITIATIVE - THE HOSPITAL PROVIDED FINANCIAL SUPPORT TOTALING $146,978 TO LOCAL PROGRAMS.COMMUNITY EDUCATION AND WELLNESS PROGRAMS - THE HOSPITAL OFFERED THE FOLLOWING TO THE COMMUNITY FREE OR AT A NOMINAL CHARGE:HEALTH FAIRSCPR CLASSESCHILDBIRTH CLASSESGARFIELD ELEMENTARY WELLNESS PROGRAMCOVER THE UNINSURED PROGRAMHEARTSAVER FIRST AID CLASSESADVANCE CARDIAC LIFE SUPPORTHEALTHCARE PROVIDE RECERTIFICATIONBREAST FEEDING SUPPORTPASTORAL OUTREACH PROGRAMSDIABETES EDUCATIONARTHRITIS AQUATICS CLASSESSMOKING CESSATION CLASSESBASICS IN BABYSITTING CLASSESAUTISM SUPPORT GROUPCONDUCTED HOSPITAL TOURS FOR AREA SCHOOLS AND COMMUNITY GROUPS. SERVED AS AN OBSERVATION SITE FOR THE HIGH SCHOOL FOR HEALTH PROFESSIONS DEVELOPED BY THE PUBLIC SCHOOLS. HOSTED SEVERAL SHADOW STUDENTS FROM AREA SCHOOLS. SERVED AS HOST SITE FOR OHIO HIGHER EDUCATION TELECOMMUNICATION SYSTEM.OPERATED A PHYSICIAN REFERRAL LINE FREE TO THE COMMUNITY.EXPENDED $271,070 TO RECRUIT PHYSICIANS TO THE UNDERSERVED COMMUNITY.PROVIDED SUBSIDIES TO VARIOUS PHYSICIANS TO ENSURE ACCESS TO ALL COMMUNITY BASED SERVICES, AS DEFINED BY THE COMMUNITY IN THE AMOUNT OF $765,000.ENCOURAGED EMPLOYEE PARTICIPATION IN COMMUNITY PROJECTS SUCH AS THE LACROFT SCHOOL READING PROGRAM, DAY OF CARING PROGRAM, STUDENT MENTORING PROGRAM, AND SERVICE ON NONPROFIT BOARDS.HOSTED PROGRAMS FOR STUDENT NURSES AND RADIOLOGY TECHNICIANS IN TRAINING.SALVATION ARMY: PROVIDED FOOD TO NEEDY FAMILIES FOR THANKSGIVING, AND GIFTS TO NEEDY CHILDREN FOR CHRISTMAS.DAY OF CARING, DAY OF GIVING PROGRAM - MONEY AND FOOD DRIVE. 59410355 1 1 0 1 0 0 0 0 0 0 1 0 0 1 1 1 1 1 0 0 0 0 0 0 0 0 1 1 1 0 1 1 0 0 0 0 0 0 0 0 0 1 0 0 0 0 0 1 0 0 0 0 1 107 0 1 638 1 0 0 0 0 0 0 0 0 0 0 X 16 13 0 0 0 0 1 0 0 1 1 0 0 0 1 1 1 1 1 1 1 0 OH X THE ORGANIZATION 3303862633 425 W FIFTH STREET EAST LIVERPOOL OH 43920 KENNETH COCHRAN 40.00 X X 274952 0 29302 CHARLES BEAVER II 40.00 X X 154386 0 32675 JAMES FOX 1.00 X 0 0 0 JD GAURON 1.00 X 0 0 0 TAMMIE MCINTOSH 1.00 X 0 0 0 MARK MANGANO 1.00 X X 0 0 0 MICHAEL PARKES 1.00 X 0 0 0 JAY B VOTAW DVM 1.00 X 0 0 0 MICHAEL SIGLER 1.00 X 0 0 0 DONNA TODD 1.00 X 0 0 0 JOSEPH SHEMASEK 1.00 X 0 0 0 PETE WICKS 1.00 X X 0 0 0 RICHARD WOLFE 1.00 X X 0 0 0 WILLIAM MILLER 1.00 X 0 0 0 JOSPEH LUDOVICI 1.00 X 0 0 0 HIRA ROHELA 1.00 X 0 0 0 PAMELA SMITH 40.00 X 129339 0 22058 KYLE JOHNSON 40.00 X 63634 0 8323 FRANK MADER III 40.00 X 100126 0 33757 CHARLES PARRY 40.00 X 100824 0 26396 MICHAEL WINIARSKI 40.00 X 116319 0 7932 ROBERT STEFFEN 40.00 X 114563 0 2089 1054143 0 162532 7 1 1 0 CARDINAL HEALTH 21377 NETWORK PL CHICAGO IL 60673 PHARMACY SERVICES 3407002 MANAGED CARE OF AMERICA 1910 COCHRAN RD PITTSBURGH PA 15220 HEALTH INSURANCE 3375371 THE BANK OF NEW YORK TRUST 525 WILLIAM PENN PL PITTSBURGH PA 15219 BOND SERVICE 1124700 RIVER VALLEY PHYSICIANS 425 WEST FIFTH STREET EAST LIVERPOOL OH 43290 PHYSICIAN SERVICES 960000 MEDLINE INDUSTRIES INC PO BOX 382075 PITTSBURGH PA 15251 HOSPITAL MED-SURG SUPPLY 909308 5 29542 29542 NET PATIENT REVENUE 900099 58319575 58319575 58319575 2054862 2054862 68600 68600 11754 0 11754 11754 11754 17445 300143 0 -300143 17445 -282698 -282698 27915 18204 9711 9711 H.C.A.P. REVENUE 900099 182332 182332 CAFETERIA INCOME 900099 161278 161278 OTHER REVENUE 900099 108709 108709 452319 60663665 58610616 0 2023507 1106978 1106978 23623260 20079771 3543489 1332273 1332273 6876959 6876959 1857315 1578718 278597 76368 76368 71154 71154 55000 55000 5641550 5246641 394909 216447 216447 355783 92504 263279 1099217 1099217 43982 43982 3060518 3060518 4290457 4290457 474681 474681 SUPPLIES 7887663 7808786 78877 BAD DEBTS 7366590 7366590 REPAIRS AND MAINTENANCE 2179337 1852436 326901 MISCELLANEOUS 1635648 1390301 245347 69251180 59410355 9840825 0 800 800 2371093 1755915 7812332 9656040 621174 544386 70171 63230 805370 841039 82655711 55459826 26946934 27195885 70338344 61098385 0 930510 6129252 109896728 107284932 5680281 7212269 26941367 26251471 1799086 7055994 34420734 40519734 X 75356588 66654495 60968 52265 58438 58438 75475994 66765198 109896728 107284932 X -8587515 -123281 X 0 1 1 X 0 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 0 0 0 0 0 0 0 0 1 3364 3364 0 EXPLANATION OF LOBBYING ACTIVITIES: PART II-B, LINE 1: A PERCENTAGE OF OHA DUES IS USED FOR LOBBYING PURPOSES. 1420191 1420191 39173897 21376332 17797565 41471261 33675660 7795601 590362 407834 182528 27195885 DEFERRED BOND FINANCING COSTS 453878 DUE FROM AFFILIATES 402606 PHYSICIAN GUARANTEES 5272768 6129252 INTEREST RATE SWAP 3397046 GUARANTEES 3658948 7055994 60663665 69251180 -8587515 -114578 -8703 -123281 -8710796 60663665 0 60663665 0 60663665 69374461 123281 123281 69251180 0 69251180 PART XI, LINE 8 - OTHER ADJUSTMENTS: CHANGE IN TEMPORARILY RESTRICTED NET ASSETS -8,703. 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 POSITION TAKEN BY THE HOSPITAL AND HAS CONCLUDED THAT AS OF DECEMBER 31, 2011 AND 2010, 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 HOSPITAL IS SUBJECT TO ROUTINE AUDITS BY TAXING JURISDICTIONS; HOWEVER, THERE ARE CURRENTLY NO AUDITS FOR ANY TAX PERIODS IN PROGRESS. ELCH CARDIAC CLASSIC 27915 27915 18204 27915 27915 18204 18204 9711 1 1 1 X 1 X 1 1 0 0 787295 182333 604962 0.00980 3091127 3091127 0.04990 3878422 182333 3696089 0.05970 3878422 182333 3696089 0.05970 0 3929987 X 1 1 2 1 ELCH REHAB

15655 ST RTE 170 EAST LIVERPOOL OH 43920

PT, OT, SPEECH SERVICES 2 ELCH

5TH STREET EAST LIVERPOOL OH 43920

X X DSH EAST LIVERPOOL CITY HOSPITAL 1 1 1 100.000000000000 1 100.000000000000 1 X X X 1 1 X X X X X X 1 X 1 X X X X X 1 0 1 PART I, LINE 7, COLUMN (F): THE BAD DEBT EXPENSE INCLUDED ON FORM 990, PART IX, LINE 25, COLUMN (A), BUT SUBTRACTED FOR PURPOSES OF CALCULATING THE PERCENTAGE IN THIS COLUMN IS $ 7366590. PART II: ONGOING EFFORTS AND EVALUATION OF MANAGEMENT, STAFF, PHYSICIANS WITH FEEDBACK FROM PATIENTS AND COMMUNITY. DEMOGRAPHIC RESEARCH AND STUDIES ALSO UTILIZED TO DETERMINE TYPE AND QUANTITY OF SERVICES NEEDED BY SPECIALTY TO BEST SERVE OUR COMMUNITY. PART III, LINE 4: ALTHOUGH NOT DESCRIBED IN THE FOOTNOTES TO THE HOSPITAL'S FINANCIAL STATEMENTS, THE PRACTICE OF THE HOSPITAL IS TO RECORD BAD DEBT EXPENSE AT THE UNPAID BALANCES AFTER CONTRACTUAL DISCOUNTS FOR PATIENT'S WITH INSURANCE AND AT THE FULL OR DISCOUNTED CHARGE LEVEL FOR THOSE WHO DO NOT HAVE INSURANCE. THE HOSPITAL NEGOTIATES WITH PAYERS TO COME UP WITH A FAIR DISCOUNTED RATE TO BE PAID FOR SERVICES RENDERED. THESE DISCOUNTS ARE NOT RECORDED AS BAD DEBT EXPENSES. SIMILARLY FOR PATIENTS WITHOUT ANY INSURANCE, THE HOSPITAL OFFERS SEVERAL DIFFERENT DISCOUNT PROGRAMS, BASED UPON FINANCIAL NEED, TO THESE PATIENTS AND ONCE AGAIN THESE DISCOUNTS ARE NOT RECORDED AS BAD DEBTS. FOR PATIENTS WHO DO NOT MEET OR DO NOT FOLLOW-THROUGH TO DEMONSTRATE FINANCIAL HARDSHIP, THE HOSPITAL DOES EXPECT TO BE REIMBURSED AT OUR FULL CHARGE LEVEL. ALL OF THE REMAINING BALANCES THAT ARE NOT PAID ARE RECORDED AS BAD DEBTS.THE HOSPITAL HAS COSTED THE BAD DEBT EXPENSE IN LINE 2 OF THIS SECTION AT THE FULL UNPAID CONTRACTED RATE FOR PATIENTS WITH INSURANCE AS THIS REPRESENTS THE "CONTRACTED COST" FOR THE SERVICE AND THUS NOT APPLICABLE TO AN OVERALL COST-TO-CHARGE RATION. FOR PATIENTS WITH NO INSURANCE, THE COSTS ON LINE 2 REPRESENT THE FULL CHARGE LEVELS MULTIPLIED BY THE OVERALL COST-TO-CHARGE RATIO FROM THE AUDITED FINANCIAL STATEMENTS.THE CRITERIA THE HOSPITAL USES FOR DISTINGUISHING BETWEEN CHARITY CARE AND BAD DEBT IS THAT IN ORDER FOR A PATIENT TO QUALIFY AS CHARITY CARE, THEY MUST SHARE THEIR FINANCIAL INFORMATION AND SHOW THAT THEY FALL WITHIN THE FEDERAL POVERTY GUIDELINES. THUS THE HOSPITAL BELIEVES THAT 23% OF THE FIGURE RECORDED AS BAD DEBT EXPENSE ON LINE 2 WOULD QUALIFY FOR CHARITY CARE IF THE PATIENTS HAD SHARED THEIR FINANCIAL INFORMATION. THIS PERCENTAGE WAS DERIVED FROM DEMOGRAPHIC STUDIES OF THE COMMUNITY FOR FAMILIES FALLING BELOW THE FEDERAL POVERTY GUIDELINES IN OUR MARKET AREA. THUS THIS AMOUNT SHOULD BE INCLUDED IN THE TOTAL COMMUNITY BENEFIT PROVIDED BY THE HOSPITAL. PART III, LINE 8: THE HOSPITAL CONTENDS THAT THE ENTIRE AMOUNT OF THE MEDICARE SHORTFALL SHOULD ALSO BE CONSIDERED AS A COMMUNITY BENEFIT. THE REASON FOR THIS IS THAT THE MEDICARE RATES ARE SET UNILATERALLY BY THE FEDERAL GOVERNMENT AND THE HOSPITAL AGREES TO SERVICE THESE PATIENTS AT THESE RATES AS PART OF OUR MISSION AND SERVICE TO THE COMMUNITY.THE COST INCLUDED ON LINE 6 COMES FROM THE MEDICARE COST REPORT WHICH THE FEDERAL GOVERNMENT HAS SET UP AS THEIR WAY TO CAPTURE AND SEGREGATE THE COSTS OF SERVICES PROVIDED TO MEDICARE PATIENTS. PART III, LINE 9B: THE HOSPITAL PRACTICE IS THAT UPON VERIFICATION THAT A PATIENT QUALIFIES FOR CHARITY OR FINANCIAL ASSISTANCE, THE HOSPITAL DISCONTINUES COLLECTION EFFORTS AND MAKES THE APPROPRIATE ADJUSTMENT TO THE PATIENT'S ACCOUNT BASED UPON THE PATIENT'S INDIVIDUAL CIRCUMSTANCES. EAST LIVERPOOL CITY HOSPITAL PART V, SECTION B, LINE 21: ALL PATIENTS ARE BILLED THE SAME GROSS CHARGE. DISCOUNTS ARE APPLIED AT THE TIME OF PAYMENT. PART VI, LINE 2: ONGOING EFFORTS AND EVALUATION OF MANAGEMENT, STAFF, PHYSICIANS WITH FEEDBACK FROM PATIENTS AND COMMUNITY. DEMOGRAPHIC RESEARCH AND STUDIES ALSO UTILIZED TO DETERMINE TYPE AND QUANTITY OF SERVICES NEEDED BY SPECIALTY TO BEST SERVE OUR COMMUNITY. PART VI, LINE 3: INFORMATION REGARDING FINANCIAL ASSISTANCE AND CHARITY CARE IS MADE AVAILABLE AT TIME OF REGISTRATION, ON THE HOSPITAL'S WEBSITE, AND ON PATIENT STATEMENTS. APPLICATIONS ARE ALSO MADE AVAILABLE TO PATIENTS AT TIME OF REGISTRATION IF APPROPRIATE. PART VI, LINE 4: EAST LIVERPOOL CITY HOSPITAL IS THE ONLY HOSPITAL WITHIN 20 MILES OF THE CITY. THE HOSPITAL SERVES PATIENTS WITHIN A 10-15 MILE RADIUS INCLUDING PATIENTS FROM NEIGHBORING PENNSYLVANIA AND WEST VIRGINIA. MOST RESIDENTS HAVE LIVED HERE ALL THEIR LIVES AND THE COMMUNITY SERVED IS COMPRISED OF A SIGNIFICANT BIAS OF SENIOR CITIZENS. PART VI, LINE 5: EAST LIVERPOOL CITY HOSPITAL HAS AN OPEN MEDICAL STAFF, A COMMUNITY BOARD OF TRUSTEES AND IS EXTREMELY GENEROUS WITH FUNDING COMMUNITY CHARITIES AND DONATING EMPLOYEE TIME TO SERVE THE GENERAL POPULATION OF THE AREA SERVED. PART VI, LINE 6: NOT APPLICABLE 1 COMMUNITY RESOURCE CENTER 940 PENNSYLVANIA AVENUE EAST LIVERPOOL OH 43920 501(C)(3) 10000 TO PROVIDE NUTRITIOUS MEALS FOR CHILDREN PARTICIPATING IN AFTER SCHOOL PROGRAMS. CERAMIC CITY SENIOR CITIZENS CENTER 2401 BELMONT AVENUE YOUNGSTOWN OH 44505 501(C)(3) 11000 TO PROVIDE COMPUTER EDUCATION CLASSES TO AREA SENIOR CITIZENS AMERICAN RED CROSS - POTTERY AREA CHAPTER 401 COLLEGE STREET EAST LIVERPOOL OH 43920 501(C)(3) 10000 TO PROVIDE EMERGENCY AND DISASTER FUNDS TO RESIDNETS OF HANCOCK COUNTY WV RETIRED SENIOR VOLUNTEER PROGRAM 966 1/2 NORTH MARKET STREET LISBON OH 44432 501(C)(3) 12500 TO PROVIDE FUNDS TO SUPPORT A COUNTY WIDE COORDINATOR OF A RETURED SENIOR VOLUNTEER PROGRAM. CHRISTINA HOUSE PO BOX 262 LISBON OH 44432 501(C)(3) 10000 TO COVER OPERATIONAL EXPENSES FOR A WOMEN'S VICTIM'S RELIEF SHELTER. WAYSTATION 614 ST CLAIR AVENUE EAST LIVERPOOL OH 43920 501(C)(3) 7000 TO SUPPORT AN AREA AGENCY IN PROVIDING BASIC NEEDS TO UNDERSERVED RESIDENTS OF THE TRI STATE AREA. FAMILY CENTER 940 PENNSYLVANIA AVENUE EAST LIVERPOOL OH 43920 501(C)(3) 9000 TO PROVIDE SUPPORT TO A LOCAL CHARITY ELHS JOBS TRAINING PROGRAM 500 MARYLAND AVE EAST LIVERPOOL OH 43920 501(C)(3) 12500 TO PROVIDE SUPPORT TO A LOCAL CHARITY YOUTH WITH A PURPOSE 36128 HAZELRUN ROAD SALINEVILLE OH 43945 501(C)(3) 6000 TO PROVIDE SUPPORT TO A LOCAL CHARITY THE FISH INC PO BOX 2646 EAST LIVERPOOL OH 43920 501(C)(3) 12000 TO PROVIDE FUNDS TO SUPPORT THE DELIVERY OF FOOD TO AN ESTIMATED 5,000 HOUSEHOLDS IN THE TRI STATE AREA. MEALS ON WHEELS 110 MAIN BLVD EAST LIVERPOOL OH 43920 501(C)(3) 8500 TO PROVIDE SUPPORT TO A LOCAL CHARITY RIVER VALLEY HEALTH PARTNERS 425 W 5TH STREET EAST LIVERPOOL OH 43920 341552205 501(C)(3) 960000 TO HELP FINANCE BOTH CAPITAL AND OPERATING NEEDS 11 0 PROCEDURE FOR MONITORING GRANTS IN THE U.S.: PART I, LINE 2: SCHEDULE I, PART I, LINE 2: THE ORGANIZATION MAINTAINS RECORDS TO SUBSTANTIATE THE AMOUNT OF GRANTS OR ASSISTANCE, AND THE SELECTION CRITERIA USED TO AWARD THE GRANTS OR ASSISTANCE. SCHEDULE I COMMUNITY BENEFIT APPLICATION DEAR COMMUNITY BENEFIT FUND APPLICANT: THE COMMUNITY BENEFIT INITIATIVE PROGRAM (CBI), WHICH IS ADMINISTERED BY EAST LIVERPOOL CITY HOSPITAL, INVITES YOUR APPLICATION TO RECEIVE FUNDING FOR YOUR PROGRAM, PROJECT, OR ACTIVITY. EACH YEAR, CBI SUPPORTS PROJECTS AND ACTIVITIES THAT IMPROVE LOCAL HEALTH STATUS, IMPROVE THE QUALITY OF LIFE, AND PROVIDE A BENEFIT TO OUR COMMUNITY AND RESIDENTS. WE ARE CONTINUALLY LOOKING FOR NEW AND INNOVATIVE PROJECTS THAT TARGET AN UNMET NEED OR UNDERSERVED SEGMENT OF OUR POPULATION. ELCH MAKES INVESTMENTS IN COMMUNITY ASSETS AND THOSE GRANTED FUNDING ARE NOT MERELY RECIPIENTS, BUT HAVE SHARED ACCOUNTABILITY FOR IMPROVING HEALTH AND QUALITY OF LIFE IN OUR COMMUNITY. OVER THE PAST SEVERAL YEARS, THE NUMBER OF REQUESTS FOR PROJECT FUNDING HAS INCREASED DRAMATICALLY. IN AN EFFORT TO REDUCE DUPLICATION OF SERVICES, EFFICIENTLY USE EXISTING RESOURCES, AND INSURE THE INTEGRITY OF THE PROGRAMS OFFERED, WE ARE REQUESTING THAT YOUR AGENCY OR ORGANIZATION PROVIDE THE FOLLOWING INFORMATION: A. GENERAL INFORMATION 1. LOCAL ORGANIZATION APPLYING _______________________________________________________________ (NAME OF ORGANIZATION OR AGENCY) _______________________________________________________________ (LOCAL STREET ADDRESS) _______________________________________________________________ (CITY) (STATE) (ZIP) (COUNTY) 2. LOCAL DIRECTOR / LOCAL CONTACT PERSON OF ORGANIZATION OR AGENCY APPLYING _______________________________________________________________ (NAME/TITLE) (PHONE) _______________________________________________________________ (FAX) (EMAIL) 3. IF PROJECT IS APPROVED, LIST CONTACT NAME, TITLE, AND ADDRESS WHERE FUNDING SHOULD BE SENT: ____________________________________________________________ ____________________________________________________________ B. PROJECT INFORMATION FOR CALENDAR YEAR 2009 1. WHAT IS THE TOTAL BUDGET FOR THE PROJECT OR ACTIVITY?$___________ 2. AMOUNT OF FUNDING BEING REQUESTED FROM ELCH? $_________________ 3. WILL THERE BE ADDITIONAL FUNDING SOURCES? _____YES _____NO PLEASE LIST SOURCES: SOURCE __________________________AMOUNT $ __________________ SOURCE __________________________AMOUNT $ __________________ SOURCE __________________________AMOUNT $ __________________ 4. WHAT IS THE PROJECT / ACTIVITY TIME PERIOD? FROM: _______________________ TO: _______________________ 5. WHAT IS THE OVERALL MISSION OF YOUR AGENCY OR PROGRAM? 6. A. LIST TWO SPECIFIC COMMUNITY NEEDS, QUALITY OF LIFE, OR HEALTH CONCERNS AFFECTING OUR RESIDENTS: 1. ________________________________________________________ 2. ________________________________________________________ B. BRIEFLY SUMMARIZE YOUR PROJECT / ACTIVITY, 2009 GOALS, AND THE PURPOSE FOR THE REQUESTED FUNDING: C. EXPLAIN HOW THIS PROGRAM SPECIFICALLY ADDRESSES THE NEEDS LISTED IN QUESTION 6A: D. WHAT ARE THE GEOGRAPHIC LIMITS OF THIS PROGRAM OR AGENCY (EX: INDIVIDUALS RESIDE IN EAST LIVERPOOL, CHESTER, MIDLAND, ETC) AND DESCRIBE THE POPULATION SERVED: 7. HOW DO YOU TRACK THE EFFECTIVENESS OF YOUR PROJECT OR PROGRAM? (EX: DO YOU HAVE A DESIGNATED PERSON OR COMMITTEE THAT COMPILES DATA QUARTERLY, ANNUALLY, ETC? WHAT SYSTEM IS IN PLACE TO AVOID DUPLICATION OF EFFORTS?) 8. LIST COLLABORATING AGENCIES: (PRIORITY CONSIDERATION WILL BE GIVEN TO THOSE WHO SHOW COLLABORATIVE EFFORT WITH OTHER AGENCIES TO BUILD PARTNERSHIPS AND DECREASE DUPLICATION OF SERVICES) B. CERTIFICATION AS A CONDITION OF RECEIVING A GRANT, THE APPLICANT AGREES TO PROVIDE TO EAST LIVERPOOL CITY HOSPITAL: TWO EVALUATION REPORTS, ONE TO BE SUBMITTED BY APRIL 30, 2009 AND THE SECOND TO BE SUBMITTED BY AUGUST 31, 2009, DESCRIBING HOW FUNDS HAVE BEEN USED, MEASURABLE RESULTS (WHO WAS SERVED BY THE PROGRAM ACTIVITIES AND ACCOMPLISHMENTS), AND PLANS FOR CONTINUING THE PROGRAM AFTER THIS YEAR. THE APPLICANT ALSO AGREES TO CONTACT THE PLANNING DEPARTMENT AND OBTAIN PERMISSION TO CREDIT EAST LIVERPOOL CITY HOSPITAL IN PUBLIC RELEASES AND REFERENCES TO PROJECTS, EQUIPMENT/MATERIALS PURCHASED, AND ACTIVITIES MADE POSSIBLE THROUGH THIS GRANT. I CERTIFY THAT THE FOREGOING INFORMATION IS TRUE TO THE BEST OF MY KNOWLEDGE AND THE TERMS OF THE GRANT HAVE BEEN MET. NAME _______________________________________________________ TITLE _________________________________DATE ________________ ALL APPLICATIONS AND SUBSEQUENT REPORTS SHOULD BE SENT TO: ROBERT STEFFEN PLANNING DEPARTMENT - EAST LIVERPOOL CITY HOSPITAL 425 WEST FIFTH STREET EAST LIVERPOOL, OH 43920 IF YOU HAVE ANY QUESTIONS PERTAINING TO THIS APPLICATION, I CAN BE REACHED AT (330) 386-2086. APPLICATIONS MUST BE RETURNED BY AUGUST 31, 2009. NOTE: THE RECEIPT OF THESE MONIES CARRIES NO OBLIGATION TO REFER OR OTHERWISE DIRECT PATIENTS TO SERVICES PROVIDED BY EAST LIVERPOOL CITY HOSPITAL. X X 1 1 X X X 0 0 0 0 0 0 0 0 0 KENNETH COCHRAN 274952 0 0 0 0 0 9458 0 19844 0 304254 0 0 0 CHARLES BEAVER II 154386 0 0 0 0 0 16926 0 15749 0 187061 0 0 0 PAMELA SMITH 129339 0 0 0 0 0 16910 0 5148 0 151397 0 0 0 MICHAEL WINIARSKI 116319 0 0 0 0 0 6620 0 1312 0 124251 0 0 0 ROBERT STEFFEN 114563 0 0 0 0 0 777 0 1312 0 116652 0 0 0 PART I, LINE 1A CITY HOSPITAL ASSOCIATION ALLOWS COMPANION TRAVEL BY EXECUTIVES ONLY WHEN IT SERVES A JUSTIFIED BUSINESS PURPOSE. IF IT IS LATER DETERMINED THAT THERE WAS NOT A JUSTIFIED BUSINESS PURPOSE, THIS WILL RESULT IN TAXABLE COMPENSATION TO THE EXECUTIVE IN QUESTION. CITY HOSPITAL PROVIDES A MEMBERSHIP TO AN AREA SOCIAL CLUB IN ORDER FOR EXECUTIVES TO CONDUCT HOSPTIAL BUSINESS. ANY PERSONAL USE BY THE EXECUTIVES IN INCLUDED IN THAT EXECUTIVE'S TAXABLE WAGES. CITY OF EAST LIVERPOOL 346000900 2734505DU 2006-04-20 17165000 FINANCE THE ACQUISITION, CONSTRUCTION, INSTALLATION, & EQUIPPING FACILITIES 0 0 0 17165000 0 0 0 1 0 0 0 0 1 0 1 0 0 0 0 JD GAURON FOR MEGA INSURANCE COMPANY BOARD TRUSTEE INSURANCE AGENT OF THE HOSPITAL 0 FORM 990, PART VI, SECTION A, LINE 6 TRI-COUNTY CARE SYSTEMS, INC. IS THE SOLE MEMBER FORM 990, PART VI, SECTION B, LINE 11 INFORMATION WAS COMPILED BY THE FINANCE DEPARTMENT AND REVIEWED BY A THIRD PARTY CPA FIRM. A FORMAL BOARD REVIEW DID NOT OCCUR THIS YEAR DUE TO TIME CONSTRAINTS. FORM 990, PART VI, SECTION B, LINE 12C ALL DUALITY OF INTEREST OR POSSIBLE CONFLICT OF INTEREST, ON THE PART OF ANY MEMBERS OF THE BOARD OF TRUSTEES, ON ANY ISSUE, SHOULD BE DISCLOSED TO THE OTHER MEMBERS OF THE BOARD OF TRUSTEES AND MADE A MATTER OF RECORD. ANY MEMBER OF THE BOARD OF TRUSTEES HAVING A DUALITY OF INTEREST OR POSSIBLE CONFLICT OF INTEREST, ON ANY MATTER SHOULD NOT VOTE OR USE HIS/HER PERSONAL INFLUENCE ON THE MATTER. THE MINUTES OF THE MEETING SHOULD REFLECT THAT A DISCLOSURE WAS MADE AND THE ABSTENTION FROM VOTING. FORM 990, PART VI, SECTION B, LINE 15 FOR THE CEO, EXECUTIVE DIRECTOR OR TOP MANAGEMENT: ESTABLISHED BY BOARD PERSONNEL COMPENSATION COMMITTEE AND REVIEWED AND APPROVED BY THE ENTIRE BOARD IN EXECUTIVE SESSION. FOR OTHER OFFICERS OR KEY EMPLOYEES: SUBMITTED AND REVIEWED BY BOARD CHAIRMAN AND THEN PRESENTED BY BOARD EXECUTIVE COMMITTEE FOR REVIEW AND APPROVAL. FORM 990, PART VI, SECTION C, LINE 19 THE DOCUMENTS ARE AVAILABLE UPON REQUEST CHANGES IN NET ASSETS OR FUND BALANCES: FORM 990, PART XI, LINE 5: NET UNREALIZED LOSSES ON INVESTMENTS: -114,578. CHANGE IN TEMPORARILY RESTRICTED NET ASSETS -8,703. TOTAL TO FORM 990, PART XI, LINE 5: -123,281. EAST LIVERPOOL PROFESSIONALS 425 W 5TH STREET EAST LIVERPOOL OH 43290 PROFESSIONAL MEDICAL SERVICES OH TRI-COUNTY CARE TRI-COUNTY CARE SYSTEMS 425 W FIFTH EAST LIVERPOOL OH 43920 341552205 PARENT HOLDING COMPANY OH 501(C)(3) LINE 3 NONE 0 OHIO VALLEY HOME HEALTH SERVICES 15679 ST RTE 170 EAST LIVERPOOL OH 43920 341014198 HOME HEALTH SERVICES OH 501(C)(3) LINE 9 TRI-COUNTY CARE SYSTEMS 0 OHIO VALLEY HOME CARE 108 E FIFTH EAST LIVERPOOL OH 43290 341847153 HOME CARE SERVICES OH 501(C)(3) LINE 9 OHIO VALLEY HOME HEALTH SERVICES 0 AMERICAN COMMUNITY SERVICES 422 W 6TH ST EAST LIVERPOOL OH 43290 341522019 MANAGEMENT SERVICES OH OHIO VALLEY HOME HEALTH SERVICES C MONROE HEALTH 422 W 6TH ST EAST LIVERPOOL OH 43290 341562035 PHYSICIAN SERVICES OH AMERICAN COMMUNITY SERVICES C 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 0 RIVER VALLEY PHYSICIANS Q 960000 PHYSICAL CHECKS