2011-11-11T08:34:42-07:00 2010-12-31 990 2010-01-01 314379443 ADENA HEALTH SYSTEM ADEN 7407794478 272 HOSPITAL ROAD CHILLICOTHE OH 456019031 Keith T Coleman 7407794273 2011-11-11 2010 2016-03-07 17:11:31Z Mark Shuter 272 Hospital Road Chillicothe OH 456019031 380151784 0 X WWW.ADENA.ORG X 1895 OH "To Heal, To Educate, To Care". The Organization is a regional healthcare system with 1 hospital and several ambulatory centers, in addition to multiple physician practices. AHS offers a wide scope of diagnostic and rehabilitative services both for inpatients and outpatients, including comprehensive cardiology and cancer care. 15 7 2682 349 46218 9049 3976944 13748492 308960773 360483761 705713 3840247 1751094 1862741 315394524 379935241 118723 126002 0 0 165434321 187026318 0 0 0 134030977 167743075 299584021 354895395 15810503 25039846 376144767 419282931 212818035 227217017 163326732 192065914 "To Heal, To Educate, To Care" is the mission of Adena Health System. Adena Health System is a regional healthcare system providing a wide scope of services to a 13 county area in south-central Ohio. 0 0 294741518 126002 321529984 Health Care Programs, General/Other: Routine hospital services - Room and board testing and monitoring by various ancillary specialties, physical therapy and surgical services. There were 15,150 inpatients and 872,390 outpatients treated in 2010. 4021994 0 32310981 Emergency Services - Treatment of emergency accident and illness as well as less urgent conditions in the absence of a family physician. The number of visits in 2010 was 48,471. 3100336 0 6642796 The Hospice and Home Health departments provide medical care, medications, home health needs, bereavement counseling, prescriptions, food and shelter to patients. There were 10,431 Hospice patient days in 2010. 0 0 0 301863848 1 1 0 1 0 0 0 0 0 1 1 0 0 0 1 0 0 1 0 0 0 0 0 0 1 0 1 0 1 1 1 1 1 1 0 0 0 1 0 0 1 1 0 0 0 0 1 1 1 1 0 0 1 100 0 1 2682 1 1 1 0 0 0 0 0 0 0 0 0 X 15 7 0 0 0 0 1 1 1 1 1 0 1 1 1 1 1 1 1 1 1 1 0 OH X Ken Dicken Controller 7407797500 272 HOSPITAL ROAD CHILLICOTHE OH 456019031 Deborah Barrington 2 X X 0 0 0 Jack Berno 40 X 305979 0 8932 Steve Burkhardt 2 X X 0 0 0 Doug Folzenlogen 40 X 325527 0 33886 James Grove 2 X 0 0 0 Chad Harris 2 X 0 0 0 Tom Kellenberger 2 X 0 0 0 Mike Lilly 2 X 0 0 0 Tim Nausbaum 2 X 0 0 0 Mathew Schmidt 2 X 0 0 0 Allen Shaw 40 X 247112 0 15142 Dave Strickland 2 X 0 0 0 Ginny Wettersten 2 X X 0 0 0 Tom White 2 X 0 0 0 Eric Wissler 2 X X 0 0 0 Keith Coleman 40 X 354835 0 45076 Mark Shuter 40 X 716522 0 45529 Karen Bolton 40 X 205951 0 28570 Marcus Bost 40 X 184393 0 29523 John Fortney 40 X 376426 0 23356 Jeff Graham 40 X 245724 0 35708 Denise Minor 40 X 171801 0 26706 Barbara Purdom 40 X 231339 0 33073 Patricia Roam 40 X 150184 0 14308 Faitha Shelton 40 X 152689 0 32279 Elisabeth Williams 40 X 215337 0 33061 Rob Bradley 40 X 1044317 0 33886 Brian Cohen 40 X 2450714 0 25506 Matt Cosenza 40 X 911608 0 15142 James Fleming 40 X 922745 0 35286 John Young 40 X 889153 0 11920 Rachel Rhude 0 X 156173 0 4663 10258529 0 531552 205 1 1 0 Kings Medical Company PO Box 72483 Cleveland OH 44192 MRI Services 2276325 Premier Health Care Services Inc 332 Congress Park Drive Dayton OH 45459 ER coverage, house coverage 1194233 Tatum LLC PO BOX 847872 Dallas TX 752847872 Staffing Services 968562 The Pendleton Group Inc 200 Chartwell Pt Road Seneca SC 29672 Consulting 857151 Design Group 515 E Main St Columbus OH 43215 Architectural 714791 6 0 91540 3475 13511245 37846 104386 0 13748492 Net Patient Service Revenue 622110 360483761 360483761 0 0 0 0 0 0 360483761 3904283 0 0 3904283 0 0 0 0 0 0 0 0 93442 0 0 0 93442 0 93442 0 0 93442 0 52752 0 116788 0 -64036 -64036 0 0 -64036 76307 3475 38388 37919 0 37919 153413 61367 92046 0 0 92046 Other revenue 622110 46218 0 46218 0 Food & Nutrition 622110 1151382 0 0 1151382 Consulting Fees 622110 150162 0 0 150162 291572 0 0 291572 1639334 379935241 360483761 46218 5656770 87610 87610 38392 38392 0 0 0 0 4148210 1816944 2331266 0 0 0 0 0 145020519 131392590 13627929 0 10921095 9453218 1467877 0 18953650 16404914 2548736 0 7982844 6907177 1075667 0 0 0 0 0 313248 0 313248 0 99996 0 99996 0 3192 0 3192 0 0 0 0 0 0 0 0 0 0 0 1449678 19395 1430283 0 524227 384145 140082 0 120774 11567 109207 0 0 0 0 0 4123799 2015163 2108636 0 1957671 1364766 592905 0 0 0 0 0 0 0 0 0 7056694 5701809 1354885 0 0 0 0 0 17721977 14319358 3402619 0 2949404 2721737 227667 0 Operating Supplies 55190052 54599654 590398 0 Purchased Services 33221401 22967191 10254210 0 Provision for Bad Debt 21840196 21840196 0 0 Repair, Maintenance & Rental 16756843 7630607 9126236 0 Professional Services 2090116 2090116 0 0 2323807 97299 2226508 0 354895395 301863848 53031547 0 11211 11632 70226184 77635482 4528253 4565558 40905671 47965899 0 0 0 0 0 0 5126945 6449362 3991008 2951771 313868389 170078555 141608590 143789834 105417405 127550069 0 0 0 0 4329500 8363324 376144767 419282931 42444283 30848157 0 0 0 0 151775981 179713947 0 0 0 0 0 0 0 0 18597771 16654913 212818035 227217017 X 162554983 191651223 771749 414691 0 0 163326732 192065914 376144767 419282931 X 25039846 3699336 X 0 1 1 X 0 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 0 0 0 0 0 0 0 0 1 3192 3192 0 SchC_P2B_S00_L01 Schedule C, Part II-B, Line 1 The Ohio Hospital Association does lobbying on behalf of hospital related causes. This activity is paid for through dues paid to the Ohio Hospital Association. 859540 50593 101333 32167 0 0 979299 762259 170668 85016 0 158403 0 859540 615256 263999 641 18520 99117 0 762259 1 0 0 0 1 1 0 2393357 2393357 0 146117647 44957301 101160346 0 10308569 8277763 2030806 0 145591477 112579943 33011534 0 9457339 4263548 5193791 143789834 Defined Benefit Plan Liability 11234135 Accrued Insurance Long-term 5420778 16654913 SchD_P05_S00_L04 Schedule D, Part V, Line 4 Adena Health Foundation Endowment Funds are used to provide scholarships and offset operating expenses of PACCAR Medical Education Center. Charity Ball 18802 3475 15327 0 0 1420 773 0 13134 Plant Sale 35256 0 35256 0 0 120 0 0 35136 0 54058 3475 50583 0 0 1540 773 0 48270 50583 0 1 1 X 1 X 1 X 0 1 1 0 1 1 18880607 5463774 13416833 0.0403 58371013 32842863 25528150 0.0766 0 0 0 0 0 0 77251620 38306637 38944983 0.1169 481448 0 481448 0.0014 0 0 0 0 0 0 0 0 0 0 0 0 54505 0 54505 0.0002 0 0 535953 0 535953 0.0016 0 0 77787573 38306637 39480936 0.1185 1 25000 25000 0.0001 1 0 25000 0 25000 0.0001 1 9565272 0 99139634 127405825 -28266191 X 1 1 1 1 Adena Regional Medical Center

272 Hospital Rd Chillicothe OH 45601

X X X Adena Regional Medical Center 1 15 Adena Urgent Care

55 Centennial Blvd Chillicothe OH 45601

Ambulatory Care Center Adena Health Center - Waverly

12340 State Route 104 Waverly OH 45690

Ambulatory Care Center Adena Health Center - Jackson

1000 Veterans Drive Jackson OH 45640

Ambulatory Care Center Adena Health Pavilion

4437 State Route 159 Chillicothe OH 45601

General Medicine and Surgical Adena Medical Office Building

4439 State Route 159 Chillicothe OH 45601

Physician Offices Adena Rehabilitation and Wellness Center

445 Shawnee Lane Chillicothe OH 45601

Rehabilitation Center Adena Counseling Center

455 Shawnee Lane Chillicothe OH 45601

Counseling Center Adena Hospice and Home Health

111 W Water Street Chillicothe OH 45601

Hospice and Home Health Care Adena Family Medicine - Greenfield

Physician Offices Greenfield OH 45123

Physician Offices Adena Pickawy-Ross Family Physicians

100 N Walnut Street Chillicothe OH 45601

Physician Offices Adena Ross Urology

8 Medical Drive Chillicothe OH 45601

Physician Offices Adena Family Medicine of Chillicothe

626 Central Center Chillicothe OH 45601

Physician Offices Adena Family Medicine - Oak Hill

315 Washington Street Oak Hill OH 45656

Physician Offices Adena Family Medicine - Circleville

798 N Court Street Circleville OH 43113

Physicians Offices Adena Family Medicine - Washington Court House

1430 Columbus Ave Suite 102 Medical Arts Bldg 1 Washington Court House OH 43160

Physician Offices SchH_P01_S00_L03c Schedule H, Part I, Line 3c We have inserted the wording from our consolidated financial statements that deals with charity care. "The System provides care to patients who meet certain criteria under its charity care policy without charge or at amounts less than established rates. Because the System does not pursue collection of amounts determined to qualify as charity care, they are not reported as net patient revenue. Beginning in January 2008, the System began allocating charity write-offs based on an "ability to pay". This determination was derived from an analysis prepared by one of the System's collection vendors. From this analysis, management was able to determine that collections on patient accounts from guarantors with credit scores below a certain level was extremely doubtful and could be assumed to be a result of inability to pay rather than unwillingness to pay. The System began allocating those claims to the charity category." The credit scoring is only applicable to hospital charges and is not used for professional fee obligations. SchH_P01_S00_L04 Schedule H, Part I, Line 4 While there is no written policy to handle the resolution of claims for medical indigent cases, the business office will address the guarantor's needs on a case by case basis. SchH_P01_S00_L06a Schedule H, Part I, Line 6a Annually, Adena Health System provides a Community Benefit Report to the community of Chillicothe listing all system services and accomplishments including community benefit services. SchH_P01_S00_L07 Schedule H, Part I, Line 7 The cost-to-charge ratio derived from Worksheet 2 was used to convert charges to costs. SchH_P01_S00_L072f Schedule H, Part I, Line 7, Column f Bad debt expense was deducted from total operating expenses when calculating the percentages in this column. SchH_P02_S00_L00 Schedule H, Part II The hospital supported an economic development initiative which promotes additional business and job creation for the southern Ohio area. This would lead to additional opportunities for the hospital to promote its services to the community. SchH_P03_S0A_L03 Schedule H, Part III, Section A, Line 3 All self pay claims are turned over to a collection vendor who uses a credit scoring system. If the score is below a certain amount, the claim is considered charity after the patient supplies appropriate documentation. This is why the hospital believes the bad debt at cost reported in Part III Line 2 does not contain any amounts that would be attributable to patients under the hospital's financial assistance policy. SchH_P03_S0A_L04 Schedule H, Part III, Section A, Line 4 To derive our cost of bad debt, we followed the cost to charge formula outlined in Worksheet 2 and applied the calculated ratio to the bad debt provision. We do not have separate financial statements for Adena Health System. It is included in the consolidated statements. The billing for Adena Health System is centralized and billing and collection procedures are uniform throughout the system. The footnote in our financial statements includes the following about our bad debt expense and allowance for uncollectibles."An allowance for uncollectible accounts is established on an aggregate basis by using historical write-off 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 System's ability to collect outstanding amounts. Uncollectible accounts are written off against the allowance for doubtful accounts in the period they are determined to be uncollectible." SchH_P03_S0B_L08 Schedule H, Part III, Section B, Line 8 In addition to the hospital's regular Medicare shortfall that would be included on our Medicare Cost Report, we have also included the Medicare Advantage plan results and our professional fees billed to Medicare and Medicare Advantage plans. Our service area is a very rural 13 county area in southern Ohio. The population is an aging population which results in Medicare as our largest payer group.In addition, the economic conditions that result from Appalachian designation create a recruiting issue. To combat this issue, we are forced to not only employ physicians but must pay a premium to get them to agree to serve the area's residents. Based on these issues, we believe serving our Medicare population is a community benefit. Also, the hospital used the methodology required for completing the Medicare Cost Report when determining the amount on Part III - Line 6. SchH_P03_S0C_L09b Schedule H, Part III, Section C, Line 9b The System's collection based debt policy clearly states "if agencies identify accounts that qualify for charity care or financial assistance, they are to cease further collection activities and return accounts to Adena Health System for disposition SchH_P05_S0A_L00 Schedule H, Part V, Section A Adena Health System is a licensed general medical and surgical hospital with a 24 hour Emergency Department. In addition it offers a wide range of ancillary services for both inpatients and outpatients. SchH_P05_S0B_L00 Schedule H, Part V, Section B We chose not to complete this section because it is optional for 2010. SchH_P06_S00_L02 Schedule H, Part VI, Line 2 Adena Medical Center (AMC) in Chillicothe, OH, is one of two hospitals operated by the Adena Health System and served by the Adena Health Foundation. AMC is a 261-bed inpatient facility featuring an emergency department, inpatient rehabilitation unit and medical/surgical, diagnostic and treatment services, as well as family practice and specialty physicians. Adena Health System recently commissioned the Ohio University's Voinovich School of Leadership and Public Affairs to develop a snapshot assessment of the communities served by the health system. Adena also bases need on applications it receives from locally based nonprofit organizations, including schools. A recent ranking of Ohio counties placed eight of the counties in the Adena service area in the bottom quartile for health outcomes, based on mortality and morbidity measures. The same study, prepared by Ohio University's Voinovich School of Leadership and Public Affairs, ranked six of the counties in the bottom quartile for health factors, including health behaviors, clinical care, socioeconomic factors and physical environment. All of the counties in the area fall below the state average of 25.4 physicians per 10,000 people. And in the majority of counties served by Adena, more than 10 percent of families live below the poverty level. SchH_P06_S00_L03 Schedule H, Part VI, Line 3 Part VI - Line 3 - The availability of financial assistance is communicated in the following manner: * Statements from Adena as well as collection vendors explain and list the 100% guidelines on the backside of the statement. * There is signage explaining the program at all the registration areas. * A contracted vendor supplies staff at the Cashier area to explain options available to the patient. * We send an application with the self-pay discount letters in case the patient/guarantor can't set up a payment plan. * The Customer Service staff is educated on all the options and can explain the programs when patients call. * Our physician offices, as well as collection vendors have financial aid applications available. We utilize a "hindsight" vendor that screens all bad debt accounts, after the year-end, against the state Medicaid eligibility and Federal Poverty Guidelines to attempt one last effort to obtain financial assistance for individuals SchH_P06_S00_L04 Schedule H, Part VI, Line 4 The Adena Medical Center is a 261-bed inpatient facility in Chillicothe, OH featuring an emergency department, diagnostic and treatment services, advanced surgical suites, intensive/cardiac care, medical office building and the Adena Health Pavilion, which includes outpatient surgery, physician offices and the Adena Sleep Center. Currently under construction on the campus of the medical center is the $21 million, 35,000-square-foot freestanding Adena Cancer Center, which is scheduled to open in late 2011. In October 2010, Adena Medical Center achieved 5-Star ratings from HealthGrades for Chronic Obstructive Pulmonary Disease survival six months after hospitalization, Respiratory failure survival while in the hospital, Respiratory failure survival one month after hospitalization, Respiratory failure survival six months after hospitalization, heart failure survival while in the hospital and heart failure survival six months after hospitalization. A ranking of Ohio counties, which was conducted last year and released this year, placed eight of the counties in the Adena service area in the bottom quartile for health outcomes, based on mortality and morbidity measures. The same study ranked six of the counties in the bottom quartile for health factors, including health behaviors, clinical care, socioeconomic factors and physical environment. All of the counties in the area fall below the state average of 25.4 physicians per 10,000 people. And in the majority of counties served by Adena, more than 10 percent of families live below the poverty level. Adena employs more than 2,400 people and uses a physician-led, patient-centered model of care while working collaboratively with local hospitals and health care organizations. In 2010, nearly 1 million services were provided to patients and the health system is planning for increased patient volumes of up to 30 percent during the next five years. SchH_P06_S00_L05 Schedule H, Part VI, Line 5 Our mission is to be a catalyst for advancing the health of people in the counties we serve, while our vision is to be regionally recognized as beneficial, respected and needs-driven. To do so we provide a number of benefits to our communities. Among those benefits are charity care provided to qualifying patients. In 2010, AMC charity care, based on gross charges, amounted to $29.3 million. Here are other benefits offered to patients in the 13-county region served by Adena, followed by snapshots of some of those offerings: * Free or low-cost health screenings * Staff time and materials for community education effort * Community outreach through illness prevention and health information * Grants to other non-profit and public service organizations * Scholarships for students and teachers * Financial assistance to schools to promote student health * Community Benefit program expenses Additionally, Adena Health System sponsored eight school districts at the 2010 Coordinated School Health Conference, including Greenfield Village Exempt Schools in the market area served by GAMC. School districts that participated in the conference completed an action plan and developed a goal that would impact a significant health issue within the school district. The plans included action steps, timelines, needed resource needs and evaluation process, with implementation during the 2010-2011 school year. SchH_P06_S00_L06 Schedule H, Part VI, Line 6 The Adena Medical Center is a 261-bed inpatient facility in Chillicothe, OH featuring an emergency department, diagnostic and treatment services, advanced surgical suites, intensive/cardiac care, medical office building and the Adena Health Pavilion, which includes outpatient surgery, physician offices and the Adena Sleep Center. Currently under construction is the $21 million, 35,000-square-foot freestanding Adena Cancer Center, which is scheduled to open in late 2011. In October 2010, Adena Medical Center achieved 5-Star ratings from Health Grades for Chronic Obstructive Pulmonary Disease survival six months after hospitalization, Respiratory failure survival while in the hospital, Respiratory failure survival one month after hospitalization, Respiratory failure survival six months after hospitalization, heart failure survival while in the hospital and heart failure survival six months after hospitalization. Here's snapshot of the other facilities: Greenfield Area Medical Center (GAMC): Located in Greenfield, OH, is one of two hospitals operated by the Adena Health System and served by the Adena Health Foundation. GAMC is a 25-bed inpatient facility featuring an emergency department, inpatient rehabilitation unit and medical/surgical, diagnostic and treatment services, as well as family practice and specialty physicians. GAMC is located in Highland County and also serves parts of Fayette and Ross counties. Adena Health Centers: Located in Chillicothe and at regional sites in Circleville, Jackson, Oak Hill, Washington Court House and Waverly, OH, featuring physician offices, diagnostic and treatment services, physical, occupation and speech therapies. Urgent care services are offered in Chillicothe and Waverly. Adena Home Care and Hospice: Provides highly personalized, quality care to patients of four service lines -- home health, hospice, home respiratory and home infusion. Adena Rehabilitation and Wellness Center: Provides physical, occupational, massage and industrial rehabilitation, as well as orthopaedics, sports medicine, women's health, vestibular, fibromyalgia and chronic pain programs, as well as industrial and specialized hand programs. Adena Counseling Center: Provides a wide range of outpatient counseling services, including group, individual and family counseling. A variety of support groups also meet at the center. Off-Campus Physician Offices: A number of physician offices are located throughout the region served by Adena. They include offices for family physicians, endocrinologists, gerontologists and urologists. SchH_P06_S00_L07 Schedule H, Part VI, Line 7 Adena Health System complied with the Ohio Hospital Association's request for data, but we did not file our Community Benefit Report with anyone. 1 Economic DevelopmentAlliance of Southern Ohio 45 East Main Street Chillicothe OH 45601 203786756 501(c)(3) 25000 Book To help the developement of jobs for Southern Ohio. Adena Mansion & Gardens Society 848 Adena Road Chillicothe OH 45601 271330314 10100 0 Sponsorship to help manage the Adena historical mansion. Vinton County Local School District 307 West High Street McArthur OH 45651 310714641 501(c)(3) 10000 Book To help support programs for the benefit of students. Chillicothe Education Foundation 45 East Main Street Chillicothe OH 45601 311480939 501(c)(3) 9000 Book To help students develop into future highly effective workers and managers. Vinton County Health Department 31927 St Rt 93 McArthur OH 45651 316400088 501(3)(c) 6231 Book Educate Children to understand proportions and serving sizes and to make healthier food choices. 45 0 The Franklin Fund is money left to Adena Health System for the purpose of paying the healthcare bills of patients who meet certain qualifications. 19 38392 0 Gross Charges SchI_P01_S00_L02 Schedule I, Part I, Line 2 Each grantee is required to submit 2 progress reports and a final report with an accounting for the use of funds. In addition to progress reports, Community Health staff visit each grantee at least twice during the project period. Summary reports are prepared for the for the Health System's Board of Trustees. X X 1 1 X X 1 0 0 0 0 1 0 0 0 Jack Berno 288589 0 8173 0 9217 0 9989 0 0 0 315968 0 0 0 Doug Folzenlogen 308065 0 9176 0 8286 0 35093 0 0 0 360620 0 0 Allen Shaw 239252 0 0 0 7860 0 16018 0 0 0 263130 0 0 0 Mark Shuter 532750 0 72002 0 111770 0 23953 0 22827 0 763302 0 0 0 Keith Coleman 309798 0 42337 0 2700 0 25363 0 20964 0 401162 0 0 0 Karen Bolton 178904 0 24767 0 2280 0 16419 0 13135 0 235505 0 0 0 Marcus Bost 146988 0 21889 0 15516 0 23691 0 6711 0 214795 0 0 John Fortney 319013 0 49008 0 8405 0 24607 0 0 0 401033 0 0 Jeff Graham 214375 0 29009 0 2340 0 19704 0 17251 0 282679 0 0 0 Denise Minor 160686 0 10801 0 314 0 23731 0 3895 0 199427 0 0 0 Barbara Purdom 201588 0 27648 0 2103 0 25568 0 8612 0 265519 0 0 0 Patricia Roam 129664 0 7680 0 12840 0 11351 0 3688 0 165223 0 0 0 Faitha Shelton 136680 0 15856 0 153 0 24071 0 9028 0 185788 0 0 0 Elisabeth Williams 191944 0 21060 0 2333 0 25188 0 8950 0 249475 0 0 0 Brian Cohen 2442254 0 0 0 8460 0 26757 0 0 0 2477471 0 0 Matt Cosenza 899964 0 2500 0 9144 0 16393 0 0 0 928001 0 0 Rob Bradley 1035759 0 0 0 8558 0 35137 0 0 0 1079454 0 0 James Fleming 903294 0 12788 0 6663 0 35137 0 0 0 957882 0 0 John Young 842543 0 13333 0 33277 0 13171 0 0 0 902324 0 0 0 Rachel Rhude 0 0 0 0 156173 0 0 0 4663 0 160836 0 0 0 SchJ_P01_S00_L01a Schedule J, Part I, Line 1a Adena Health System provides for a membership to the local Country Club for all Officers and Key Employees. This benefit is taxed. SchJ_P01_S00_L04 Schedule J, Part I, Line 4 Rachel Rhude the former Chief Nursing Officer received severence pay.The severance agreement included 12 months of compensation with an additional guarantee of 6 months if not employed at the end of 12 months. SchJ_P01_S00_L06 Schedule J, Part I, Line 6 Schedule J, Part I, Line 6 - The Adena Health System Management Incentive Plan was established to communicate strategic performance priorities to the management team and to encourage the highest level of performance in the delivery of health care services. The Incentive Award is funded by an Incentive Pool based upon Margin Percentage recommended by Management and approved by the Executive Compensation Committee. The Incentive Pool shall be based upon the percentage of "salary at risk" and number of participants for each eligibility level. Prior to the beginning of each Plan Year, organizational goals shall be developed to support and further the accomplishments of the System's mission, strategic plan, financial goals and business outcomes. At the end of each Plan Year, Management, with the support of the CFO and CHRO shall submit a report summarizing the performance level of the System and the recommended funding level for the Incentive Pool. This proposal is approved by the Executive Compensation Committee. County of Ross Ohio 316400085 778260EX3 2008-09-17 141346983 Restructuring 2001 and 2006 Issues 0 0 0 County of Ross Ohio 316400085 2010-09-15 29985000 Cancer Care Building and additional Cath Lab 0 0 0 200000 0 196848510 10920538 0 0 1366439 487668 0 55557232 0 0 2010 1 0 1 1 0 0 30012389 0 0 0 411604 0 0 1803746 0 27797040 2012 0 0 0 1 0 1 0 0 1 0 0 0 1 0 0 0 0 1 0 0 0 1 0 0 0 1 Bayerische Landesbank 3 1 0 0 0 1 0 0 0 0 SchK_P02_S00_L03 Schedule K, Part II, Line 3 This represents the original issue, plus the unused proceeds from issue 2006, plus investment earnings through December 31, 2010. SchK_P02_S00_L06 Schedule K, Part II, Line 6 The 2001 and 2006 issues were refunded on October 29, 2008. This was $116,560,000 of principal and $149,427 of interest. SchK_P02_S00_L11 Schedule K, Part II, Line 11 $11,750,000 of issue was used to pay off qualified hedges in the 2001 and 2006 Bonds. SchK_P03_S00_L02 Schedule K, Part III, Line 2 The System leases approximately 300 square feet to a for profit company that operates a coffee kiosk. This is considered deminimis space and so 0% is in line 4 of part III. SchK_P04_S00_L04a Schedule K, Part IV, Line 4a The proceeds invested in a GIC were from the 2006 issue. The unused portion was transferred to the 2010 issue. The GIC matured in July 2009, 36 months after the 2006 issue. Matt Cosenza Sign-on bonus X 7500 1827 0 1 1 Doug Folzenlogen Sign-on bonus X 25000 9286 0 1 1 John Young Sign-on bonus X 40000 23590 0 1 1 34703 Steve Burkhardt Officer of Horizon Chillicothe Telephone Company 954009 Business Vendor 0 Jennifer White Daughter in-law of Board member Tom White 100873 Employee compensation 0 Robin Berno Spouse of Director Jack Berno 90630 Employee compensation 0 Dean Kuchta Spouse of Key Employee Karen Bolton 73758 Employee compensation 0 Kristen Davis Daughter of COO Jeff Graham 40395 Employee compensation 0 Jennifer Strickland Spouse of Board member David Strickland 26628 Employee compensation 0 Roger Nusbaum Son of Board member Tim Nusbaum 25904 Employee compensation 0 F990_P06_S0A_L06 Form 990, Part VI, Section A, Line 6 The organization is composed of 9 member churches. All of the churches are in the Chillicothe, Ohio area. F990_P06_S0A_L07a Form 990, Part VI, Section A, Line 7a The corporate member churches may only elect one person per church to act as their Trustee. The Trustee at Large get appointed as follows. Section 3.03 of the code of Regulations of AHS - "The Board shall elect six (6) at-large Trustee positions. Two of these positions shall be filled with physicians who are members of the active Medical Staff recommended by the Medical Staff in accordance with the Medical Staff bylaws.When a vacancy occurs among the four (4) at large Trustees, with the exception of members eligible for reappointment, the Trustee Committee shall nominate to the board a candidate for the vacant position." F990_P06_S0A_L07b Form 990, Part VI, Section A, Line 7b Section 2.04 Rights of the Corporate Members: (a). The right to elect nine trustees of the Corporation as specified in these Bylaws. (b) The right to approve any lease, sale exchange, transfer,or other disposition of all or substantially all of the assets of the Corporation. (c). The right to approve any proposed merger or consolidation of the Corporation. (d). The right to approve any proposed dissolution of the Corporation. (e).The right to approve any proposed change to the fundemental purpose of the corporation as stated in Section 1.01. (f).The right to approve any proposed amendments to the Code of Regulations. F990_P06_S0B_L11a Form 990, Part VI, Section B, Line 11a The 990 was reviewed with the trustees at a board meeting prior to filing. Each board member was provided with a copy of the 990. F990_P06_S0B_L12c Form 990, Part VI, Section B, Line 12c The Corporate Compliance Office of Adena Health System annually coordinates the distribution and return of the conflict of interest statements. The Corporate Compliance Officer is responsible for reviewing the responses and communicating any extra steps that need to take place regarding any of the responses. At every Board meeting and committee of the Board, the agenda item of conflict of interest is included and called out. Conflict Board members abstain from voting on the particular items. All Adena Health System employees are subject to the Conflict of Interest policy. F990_P06_S0B_L15 Form 990, Part VI, Section B, Line 15 Compensation is determined through market surveys on all executives(including CEO). The market surveys are conducted by a 3rd party- Mercer. Mercer makes recommendations to the Executive Compensation Committee which is a subcommittee of the board. The CEO is not present for the CEO recommendation for integrity purposes. The Executive Compensation Committee approves the salary and all aspects of compensation. The Chief Human Resources Officer works with the Human Resources department to implement any changes. The CEO contract is a 8 year contract. The Committee reviews and approves all aspects of the contract which must be approved and signed by all parties prior to processing the changes.The process was last undertaken in April 2010. F990_P06_S0C_L19 Form 990, Part VI, Section C, Line 19 The organization prepares an annual report to the public which includes its statement of revenues and expenses. Additionally, its governing documents and conflict of interest policy is available upon request. The financial statements are not available. F990_P11_S00_L05 Form 990, Part XI, Line 5 1. Pension-related Changes Other than Net Periodic Cost (565,139). 2. Change in unrealized investment 5,334,582. 3. The Women's Board /VAC financial information is included in this 990. The excess of revenue over expenses was (109,643). 4.Restricted Funds financial information is included in the 990.The excess of revenue over expenses was (357,058). 5.Contributions from Adena Health Foundation (603,406). Adena Medical Group LLC Dept L637 Columbus OH 43260 271370967 Healthcare providers OH -22804100 7929097 Adena Health System Greenfield Area Medical Center 550 Mirabeau St Greenfield OH 45123 310993422 Hospital OH 501(c((3) 3 N/A 1 Adena Health Foundation 272 Hospital Road Chillicothe OH 45601 753008742 Foundation OH 501(c)(3) 11a N/A 1 Southern Ohio Healthcare Network 272 Hospital Road Chillicothe OH 45601 261566590 Fiberoptic network grants OH N/A C 0 1 1 0 0 0 0 0 0 0 0 1 1 0 0 1 0 0 Adena Health Foundation c 603406 Cash Greenfield Area Medical Center l 3005147 Medicare cost report allocation method, estimate of fmv. Greenfield Area Medical Center m 24000 Medicare cost report allocation method. Adena Health Foundation p 252843 Actual operating cost funded by. Greenfield Area Medical Center c 12907839 Book Value of liability forgiven. Greenfield Area Medical Center q 11412770 Book Value of liability forgiven. Greenfield Area Medical Center r 14851536 Book Value of liability forgiven.