2012-11-15T10:18:46-06:00 2011-12-31 381357951 PLANTE & MORAN PLLC 65 EAST STATE ST STE 600 COLUMBUS OH 43215 990 2011-01-01 311072406 PIKE HEALTH SERVICES INC PIKE 7409476306 100 DAWN LANE WAVERLY OH 45690 CRAIG E SOLLE 7409476306 2012-11-14 1 BERNIE OSTROWSKI P00366367 6148493000 2011 2016-02-24 21:20:13Z SEE SCHEDULE O CRAIG E SOLLE 100 DAWN LANE WAVERLY OH 45690 22628146 0 X WWW.PIKECOMMUNITYHOSPITAL.ORG X 1983 OH PIKE HEALTH SERVICES IS A 25-BED CRITICAL ACCESS HOSPITAL AND CLINIC LOCATED IN THE STATE OF OHIO IN PIKE COUNTY. INCLUDED IN THE BED COUNT ARE 21 ACUTE BEDS AND 4 INTENSIVE CARE BEDS WITH AUTHORIZATION FOR SWING BEDS ON AN AS NEEDED BASIS. IN 2011, PIKE HEALTH SERVICES HAD 716 INPATIENT ADMISSIONS, 480 SURGERY CASES (INCLUDING AMBULATORY), AND 16,392 VISITS TO THE EMERGENCY DEPARTMENT. PIKE HEALTH SERVICES PROVIDED CHARITY CARE TO THE COMMUNITY IN THE AMOUNT OF $3,539,375 IN CHARGES FORGONE, BASED ON ESTABLISHED RATES, WITH 13.97% SELF PAY PATIENTS, WHO HAVE NO INSURANCE. 8 7 341 44 0 0 290543 73327 22084750 21456193 4041 1549 1049170 999065 23428504 22530134 161 3350 0 0 11541000 11869383 0 0 1284 11579102 11421614 23120263 23294347 308241 -764213 13573166 12322628 10456285 9950904 3116881 2371724 X PIKE HEALTH SERVICES IS HIGH QUALITY; COMPASSIONATE HEALTHCARE; ACCESSIBLE TO THE COMMUNITY; COMMITTED TO EXCELLENCE; RESPECTFUL OF EACH INDIVIDUAL; AND FOUNDED ON SERVICE TO OTHERS. 0 0 20191782 3350 21456193 SEE SCHEDULE OPIKE HEALTH SERVICES IS A 25-BED CRITICAL ACCESS HOSPITAL AND PHYSICIAN PRACTICE LOCATED IN THE STATE OF OHIO IN PIKE COUNTY. INCLUDED IN THE BED COUNT ARE 21 ACUTE BEDS AND 4 INTENSIVE CARE BEDS WITH AUTHORIZATION FOR SWING BEDS ON AN AS NEEDED BASIS. IN 2011, PIKE HEALTH SERVICES HAD 716 INPATIENT ADMISSIONS, 480 SURGERY CASES (INCLUDING AMBULATORY), AND 16,392 VISITS TO THE EMERGENCY DEPARTMENT. PIKE HEALTH SERVICES PROVIDED CHARITY CARE TO THE COMMUNITY IN THE AMOUNT OF $3,539,375, INCLUDING 13.97% SELF PAY PATIENTS, WHO HAVE NO INSURANCE.PIKE HEALTH SERVICE'S COMMUNITY OUTREACH ACTIVITY HAS SERVED 2,257 CITIZENS IN VARIOUS PROGRAMS THROUGHOUT PIKE COUNTY. DURING THE YEAR, THEY PARTICIPATED IN 50 HEALTH FAIRS AND 41 SCREENING AND EDUCATIONAL CLINICS FOR DIABETES, CHOLESTEROL AND ARTHRITIS. ADDITIONALLY THEY SUPPORT THE YOUNG RESIDENTS OF THE COUNTY IN VARIOUS PROGRAMS INCLUDING HEAD START AND CHILD SAFETY PRESENTATIONS. 20191782 1 1 0 1 0 0 0 0 0 0 1 0 0 1 1 1 1 0 0 0 0 0 0 0 1 0 1 1 0 0 1 0 0 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 85 0 1 341 1 0 0 0 0 0 0 0 0 0 0 X 8 7 0 0 0 0 0 0 0 1 1 0 0 1 1 1 1 1 1 1 0 0 OH X CRAIG SOLLE 7409476310 100 DAWN LANE WAVERLY OH 45690 CATHERINE FARINET 37.50 X 202627 0 14619 TONY FISH 0.10 X X 0 0 0 VAL FRANCIS 0.10 X X 0 0 0 LINDA B SHOEMAKER 0.10 X X 0 0 0 MELBY WILLIAMS 0.10 X X 0 0 0 TOD BURKETT 0.10 X 0 0 0 DENNIS MILLER 0.10 X 0 0 0 MARGARET FOILL 0.10 X 0 0 0 REV RONALD HINES 0.10 X 0 0 0 CRAIG E SOLLE 37.50 X 115586 0 19093 LINDA JAMES 37.50 X 76573 0 10797 SHARON NOVAK 37.50 X 78698 0 10905 TINA PERKO 37.50 X 69503 0 10595 CINDY INGRAM 37.50 X 219391 0 25934 DAVID KESSLER 37.50 X 208886 0 6487 ELLIS FRAZIER 37.50 X 168866 0 13657 JOHN CRAWFORD 37.50 X 154628 0 23994 CHERYL SMITH 37.50 X 109637 0 3430 1404395 0 139511 8 0 1 0 PREMIER HEALTH CARE SERVICES INC 221 CONGRESS PARK DRIVE DAYTON OH 45456 EMERGENCY DEPT PHYSICIANS 575600 M MODAL SERVICES LTD PO BOX 102467 ATLANTA GA 30368 TRANSCRIPTION 237548 QUEST DIAGNOSTICS 12436 COLLECTIONS CENTER DR CHICAGO IL 60693 LAB TESTING 212451 SIEMENS MEDICAL SOLUTIONS 51 VALLEY STREAM PARKWAY MALVERN PA 19355 SERVICE CONTRACT 155043 PHILLIPS HEALTHCARE 22100 BOTHELL EVERETT HIGHWAY BOGHELL WA 98021 SERVICE CONTRACT 137890 6 7400 65187 740 73327 PROGRAM SERVICES 621110 21456193 21456193 21456193 667 667 10668 46068 -35400 -35400 -35400 46374 45492 882 882 882 23965 7400 6452 17513 17513 COUNTY TAX LEVY 621110 962714 962714 CAFETERIA REVENUE 621110 54238 54238 1016952 22530134 21456193 0 1000614 3350 3350 409156 409156 8685348 7627713 1057386 249 1869452 1584838 284614 280314 268624 11690 625113 516587 108526 8167 8167 90216 90216 2862941 2340477 522248 216 16084 16084 2374013 2002156 371728 129 3324 3324 447213 402492 44721 20729 15039 5690 485039 436535 48504 1093310 983635 109675 440700 440700 BAD DEBT EXPENSE 3523309 3523309 BILLING EXPENSE 21569 21569 CONTINUING EDUCATION 14040 11292 2748 LAB EXPENSE 7591 7591 13369 5875 6804 690 23294347 20191782 3101281 1284 109731 167282 14378 93545 1756848 2094661 31710 18710 245475 255839 207346 151323 25104878 17811223 8278691 7293655 1255047 1258687 95975 166824 1577965 822102 13573166 12322628 3007420 3906272 5270000 4790000 2178865 1254632 10456285 9950904 X 3116881 2371724 3116881 2371724 13573166 12322628 X -764213 19056 X X 0 1 1 X 0 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 0 0 0 0 0 0 0 0 1 899 899 0 EXPLANATION OF LOBBYING ACTIVITIES: PART II-B, LINE 1: OHIO HOSPITAL ASSOCIATION STRATEGIC ISSUES AND ENERGY LITIGATION ASSESSMENT. 244450 244450 13169649 7608373 5561276 18000 7100 10900 11214758 9915814 1298944 458021 279936 178085 7293655 OTHER RECEIVABLES 533414 DEFERRED FINANCING COSTS 135175 COST REPORT SETTLEMENT RECEIVABLE 153513 822102 CAPITAL LEASE OBLIGATION 581867 ESTIMATED THIRD-PARTY PAYOR SETTLEMENTS 18634 LINE OF CREDIT 600125 OTHER NOTES PAYABLE 54006 1254632 22530134 23294347 -764213 19056 19056 -745157 22539894 19056 -61816 -42760 22582654 -52520 -52520 22530134 23285051 52520 52520 23232531 61816 61816 23294347 DESCRIPTION OF UNCERTAIN TAX POSITIONS UNDER FIN 48: PART X: THE INTERNAL REVENUE SERVICE HAS RULED THAT THE HOSPITAL IS EXEMPT FROM FEDERAL INCOME TAXES UNDER SECTION 501(C)(3) OF THE INTERNAL REVENUE CODE. THE HOSPITAL IS NO LONGER SUBJECT TO U.S. FEDERAL, STATE, AND LOCAL TAX EXAMINATIONS BY TAX AUTHORITIES FOR YEARS BEFORE 2007. PART XII, LINE 2D - OTHER ADJUSTMENTS: CHARITY CARE & BAD DEBT EXPENSES -61,816. PART XII, LINE 4B - OTHER ADJUSTMENTS: RECLASS RENTAL EXPENSES -46,068. RECLASS FUNDRAISING EXPENSES -6,452. PART XIII, LINE 2D - OTHER ADJUSTMENTS: RECLASS RENTAL EXPENSES 46,068. RECLASS FUNDRAISING EXPENSES 6,452. PART XIII, LINE 4B - OTHER ADJUSTMENTS: CHARITY CARE & BAD DEBT EXPENSES 61,816. FESTIVAL OF TREES 31365 7400 23965 6452 31365 7400 23965 6452 6452 17513 1 1 X 1 X 1 X 1 1 1 0 1 1 2193835 972045 1221790 0.06180 5913732 2843382 3070350 0.15530 8107567 3815427 4292140 0.21710 12226 1382 10844 0.00050 12226 1382 10844 0.00050 8119793 3816809 4302984 0.21760 9 707 2560 1787 773 0.00000 9 707 2560 1787 773 1 3523309 0 6965728 6896760 68968 X 1 1 1 1 PIKE COMMUNITY HOSPITAL

100 DAWN LANE WAVERLY OH 45690

X X X X PIKE HEALTH SERVICES INC 1 1 X X X X X X X X X X 10 1 1 1 X X X X 1 1 1 100.000000000000 1 200.000000000000 1 X X X X X X X 1 1 X X X X 1 0 1 X X 0 0 PART I, LINE 3C: N/A PART I, LINE 6A: N/A PART I, LINE 7: TOTAL COMMUNITY BENEFIT EXPENSE RELATED TO CHARITY CARE WAS CALCULATED USING A COST-TO-CHARGE RATIO AS CALCULATED USING SCHEDULE H WORKSHEET 2. TOTAL COMMUNITY BENEFIT RELATED TO MEDICAID WAS CALCULATED FROM THE MEDICAID COST REPORT. 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 $ 3523309. PART II: THE HEALTH OF THE COMMUNITY IS PROMOTED THROUGH NUMEROUS SCREENING AND EDUCATION ACTIVIES FOR DIABETES, CHOLESTEROL AND OTHER CIRCULATORY DISEASES. THE EDUCATION IS PROVIDED BY THE HOSPITAL AND OTHER HEALTH PROMOTING GROUPS IN THE COMMUNITY. ADDITIONALLY, THE HOSPITAL PARTICIPATES IN HEALTH FAIRS AND CLINICS FOR SENIOR GROUPS AND LOCAL BUSINESSES. ONGOING EDUCATION IN FIRST AID AND CPR IS GIVEN THROUGHOUT THE COMMUNITY. PART III, LINE 4: 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 HOSPITAL'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.BAD DEBT EXPENSE WAS CALCULATED USING ACTUAL UNCOLLECTIBLE AMOUNTS PER THE FINANCIAL STATEMENTS. WE DO NOT BELIEVE BAD DEBT SHOULD BE INCLUDED AS A COMMUNITY BENEFIT. NONE OF THE BAD DEBT EXPENSE COULD BE ATTRIBUTED TO PATIENTS ELIGIBLE UNDER THE FINANCIAL ASSISTANCE POLICY. ON A REGULAR BASIS, AMOUNTS INCLUDED IN BAD DEBT THAT COULD QUALIFY FOR FINANCIAL ASSISTANCE ARE RECLASSED OUT OF BAD DEBT TO HCAP OR CHARITY CARE. PART III, LINE 8: MEDICARE ALLOWABLE COSTS WERE CALCULATED FROM THE MEDICARE COST REPORT. WE DO NOT BELIEVE THE COST OF MEDICARE SHOULD BE INCLUDED AS A COMMUNITY BENEFIT. MEDICARE ALLOWABLE COSTS REPORTED ON THE COST REPORT WERE DETERMINED USING A COST-TO-CHARGE RATIO IN ACCORDANCE WITH MEDICARE REQUIREMENTS. PART III, LINE 9B: ALL TYPES OF PATIENTS MUST COMPLETE APPLICATIONS FOR FINANCIAL ASSISTANCE. IF THE PATIENT DOES NOT, ALL PATIENTS WILL BE TREATED EQUALLY PER THE COLLECTION POLICY. IF THE PATIENT DOES COMPLETE THE APPLICATION AND QUALIFIES, THEIR ACCOUNT WILL BE ADJUSTED PER THE POLICY. PIKE HEALTH SERVICES, INC. PART V, SECTION B, LINE 1J: THE COMMUNITY NEEDS ASSESSMENT ALSO DESCRIBES THE ECONOMIC IMPACT ON THE COMMUNITY IN THE NUMBER OF EMPLOYEES AND WAGES ALONG WITH THE STATE AND LOCAL TAX AS WELL AS THE GOALS OF THE REGION. PIKE HEALTH SERVICES, INC. PART V, SECTION B, LINE 3: THE HOSPITAL TOOK INTO ACCOUNT INPUT FROM PERSONS WHO REPRESENT THE COMMUNITY THROUGH SURVEYS OF PATIENTS OF THE HOSPITAL AND THROUGH REPRESENTATIVES AT THE OHIO DEPARTMENT OF HEALTH RURAL FLEX PROGRAM. PIKE HEALTH SERVICES, INC. PART V, SECTION B, LINE 4: THE HOSPITAL FACILITY NEEDS ASSESSMENT WAS CONDUCTED WITH THE FOLLOWING HOSPITAL FACILITIES: ADAMS COUNTY REGIONAL MEDICAL CENTER, DOCTORS HOSPITAL NELSONVILLE, FAYETTE COUNTY MEMORIAL HOSPITAL, ADENA GREENFIELD MEDICAL CENTER, HIGHLAND HOSPITAL, AND HOLZER MEDICAL CENTER DISTRICT JACKSON PIKE HEALTH SERVICES, INC. PART V, SECTION B, LINE 19D: THE HOSPITAL FACILITY TAILORS THE PAYMENT PLANS FOR FAP-ELIGIBLE INDIVIDUALS TO EACH PATIENT. THE HOSPITAL FACILITY WORKS WITH PATIENTS TO NEGOIATE AMOUNTS THAT ARE REASONABLE AND PAYMENTS ARE ALWAYS DISCOUNTED. THE HOSPITAL FACILITY'S MAXIMUM AMOUNTS CHARGED TO FAP-ELIGIBLE INDIVIDUALS GENERALLY FALLS IN LINE WITH THE AVERAGE OF ITS THREE LOWEST NEGOTIATED COMMERCIAL INSURANCE RATES. PART VI, LINE 2: PIKE PROVIDES SCREENING ACTIVITIES THROUGHOUT THE COMMUNITY. THERE IS A LARGE POPULATION OF SENIORS AND MEDICARE RECIPIENTS WHO BENEFIT. PIKE ALSO PARTNERS WITH THE YMCA TO PROVIDE DIABETES SCREENINGS. THERE IS NO FORMAL NEEDS ASSESSMENT HOWEVER FOR THE FUTURE THE HOSPITAL IS IN THE PROCESS OF DEVELOPING A MORE COMPREHENSIVE ASSESSMENT BASED ON SURVEYS TO MEMBERS OF THE COMMUNITY. PART VI, LINE 3: ELIGIBILITY FOR ASSISTANCE SIGNAGE IS POSTED THROUGHOUT THE HOSPITAL (AT ALL PARTIENT ENTRANCES) AND BROCHURES ARE AVAILABLE THROUGHOUT THE HOSPITAL AND PHYSICIAN OFFICES. AWARENESS OF THE ASSISTANCE PROGRAMS ARE PROMOTED THROUGH MANY HEALTH FAIRS AND SCREENINGS. ALL PATIENTS WITHOUT THIRD PARTY COVERAGE ARE GIVEN CHARITY APPLICATIONS AT THE TIME OF REGISTRATION. PART VI, LINE 4: PIKE COMMUNITY HOSPITAL SERVES A POPULATION OF 28,700 PEOPLE IN PIKE COUNTY, OHIO. THE PIKE COUNTY PER CAPITA INCOME IS $31,649. 15.10% OF THE POPULATION FALLS BELOW THE FEDERAL POVERTY LEVEL. OVER 10% OF THE POPULATION IS OVER 65 YEARS OF AGE. PART VI, LINE 5: PIKE HEALTH SERVICES, INC. STRIVES TO MEET THE HEALTHCARE NEEDS OF ITS COMMUNITY. PIKE HEALTH SERVICE'S COMMUNITY OUTREACH ACTIVITY INCLUDES PARTICIPATION IN HEALTH FAIRS, SCREENINGS, AND EDUCATIONAL CLINICS FOR DIABETES, CHOLESTEROL AND ARTHRITIS. ADDITIONALLY, THEY SUPPORT THE YOUNG RESIDENTS OF THE COUNTY IN VARIOUS PROGRAMS INCLUDING HEAD START AND CHILD SAFETY PRESENTATIONS. MEDICAL AND HOSPITAL STAFF ARE ACTIVE PARTICIPATANTS ON NUMEROUS BOARDS THROUGHOUT THE AREA IN AN EFFORT TO PROMOTE COMMUNITY HEALTH AND HEALTHIER LIFESTYLES. PART VI, LINE 6: N/A REPORTS FILED WITH STATES PART VI, LINE 7 OH X X X X 0 0 0 0 0 0 0 0 0 CATHERINE FARINET 202627 0 0 0 0 0 6075 0 8544 0 217246 0 0 0 CINDY INGRAM 219391 0 0 0 0 0 6719 0 19215 0 245325 0 0 0 DAVID KESSLER 208886 0 0 0 0 0 6262 0 225 0 215373 0 0 0 ELLIS FRAZIER 168866 0 0 0 0 0 5125 0 8532 0 182523 0 0 0 JOHN CRAWFORD 154628 0 0 0 0 0 4809 0 19185 0 178622 0 0 0 CINDY INGRAM TUITION ASSISTANCE, TO BE FORGIVEN WITH HOURS WORKED OVER 7 YEARS. X 127960 18710 0 1 1 18710 FORM 990, PART VI, SECTION B, LINE 11 THE CEO OR VICE PRESIDENT OF FINANCE REVIEWS THE FORM 990 AND THE BOARD WILL BE PRESENTED WITH A COPY OF THE FORM 990 PRIOR TO FILING. FORM 990, PART VI, SECTION B, LINE 12C OFFICERS, BOARD MEMBERS, AND KEY EMPLOYEES ARE REQUIRED TO REVIEW AND DISCLOSE CONFLICTS OF INTEREST BY AN ANNUAL FORM SIGN-OFF. THROUGHOUT THE YEAR, BOARD MEMBERS ARE REQUIRED TO DISCLOSE ANY CONFLICT OF INTERESTS THAT ARISE AND MUST REFRAIN FROM VOTING ON ANY ISSUES IN WHICH A CONFLICT OF INTEREST IS PRESENT. FORM 990, PART VI, SECTION B, LINE 15A INDIVIDUAL BOARD MEMBERS EVALUATE THE CEO ANNUALLY, AND THEN DETERMINE RECOMMENDATIONS AS TO THE CEO'S COMPENSATION. ANY CEO COMPENSATION DECISIONS ARE DOCUMENTED. OTHER OFFICERS' COMPENSATION IS REVIEWED ANNUALLY BY THE CEO AND THE COMPENSATION DECISIONS ARE DOCUMENTED. THE ORGANIZATION USES A WRITTEN EMPLOYEE CONTRACT AND UTILIZES THE OHIO HOSPITAL ASSOCIATION'S COMPENSATION STUDIES TO DETERMINE COMPENSATION LEVELS FOR BOTH THE CEO AND OTHER OFFICERS. FORM 990, PART VI, SECTION C, LINE 19 THE GOVERNING DOCUMENTS, CONFLICT OF INTEREST POLICY, AND FINANCIAL STATEMENTS ARE AVAILABLE UPON REQUEST. CHANGES IN NET ASSETS OR FUND BALANCES: FORM 990, PART XI, LINE 5: NET UNREALIZED GAINS ON INVESTMENTS: 19,056. FORM 990, PART XII, LINE 2C: THE BOARD OF DIRECTORS OVERSEES THE AUDIT PROCESS AND APPROVES THE INDEPENDENT AUDIT FIRM. THIS PROCESS HAS NOT CHANGED FROM PRIOR YEARS. DOING BUSINESS AS: FORM 990, PAGE 1, LINE C PIKE COMMUNITY HOSPITAL; PIKE MEDICAL & SURGICAL ASSOCIATES