2011-11-10T11:47:41-06:00 2010-12-31 PLANTE & MORAN PLLC 65 EAST STATE ST STE 600 COLUMBUS OH 43215 990 2010-01-01 344428214 FULTON COUNTY HEALTH CENTER FULT 4193352015 725 SOUTH SHOOP AVENUE WAUSEON OH 435671701 DEAN BECK 4193352015 2011-11-01 1 6148493000 2010 2016-02-24 21:20:13Z DALE NAFZIGER 725 SOUTH SHOOP AVENUE WAUSEON OH 435671701 72606567 0 X WWW.FULTONCOUNTYHEALTHCENTER.ORG X 1973 OH PROMOTION OF HEALTH CARE TO THE GENERAL PUBLIC. 14 13 905 204 0 0 123879 72931 72900381 70539222 354888 1288418 145582 205011 73524730 72105582 0 0 0 0 37668651 37335294 0 0 0 34894066 34780298 72562717 72115592 962013 -10010 77256820 76504967 37354327 38332118 39902493 38172849 X THE FULTON COUNTY HEALTH CENTER CONTINUALLY STRIVES TO REACH A HIGH DEGREE OF EXCELLENCE IN MEETING THE NEEDS OF BOTH INTERNAL AND EXTERNAL CUSTOMERS 100% OF THE TIME. QUALITY OF PATIENT/RESIDENT CARE AND ALL OF THE INSTITUTIONAL PRACTICES IS THE PRIMARY CRITERION UTILIZED TO MONITOR THE HEALTH CENTER SERVICES AND TO EVALUATE PROPOSED CHANGES OF PROPOSED NEW SERVICES. 0 0 51727604 0 70605654 SEE SCHEDULE OLOCATION: THE FULTON COUNTY HEALTH CENTER IS LOCATED AT 725 SOUTH SHOOP AVENUE, WAUSEON, OH 43567. THE HEALTH CENTER IS EASILY ACCESSIBLE FROM INTERSTATE 80/90 (OHIO TURNPIKE) AND STATE ROUTE 2. IT IS CENTRALLY LOCATED WITHIN FULTON COUNTY WHERE WAUSEON IS THE COUNTY SEAT.PHILOSOPHY/AUSPICES: THE FULTON COUNTY HEALTH CENTER IS A PRIVATE, NON-PROFIT HOSPITAL, LONG-TERM CARE & INDEPENDENT LIVING FACILITY GOVERNED BY A BOARD OF DIRECTORS. THE HEALTH CENTER IS OPERATED ON THE PRINCIPLE THAT EVERY INDIVIDUAL HAS A BASIC RIGHT TO ATTAIN THE HIGHEST DEGREE OF WELLNESS POSSIBLE BASED ON HIS OR HER OWN NEEDS. THE SERVICES OF THE HOSPITAL SHALL BE AVAILABLE TO ALL INDIVIDUALS REGARDLESS OF RACE, COLOR, SEX, AGE, NATIONAL ORIGIN, RELIGIOUS CREED, ECONOMIC CONDITION OR DISABILITY.COMMITMENT TO QUALITY: THE FULTON COUNTY HEALTH CENTER CONTINUALLY STRIVES TO REACH A HIGH DEGREE OF EXCELLENCE IN MEETING THE NEEDS OF BOTH INTERNAL AND EXTERNAL CUSTOMERS 100% OF THE TIME. QUALITY OF PATIENT/RESIDENT CARE AND ALL OF THE INSTITUTIONAL PRACTICES IS THE PRIMARY CRITERION UTILIZED TO MONITOR THE HEALTH CENTER SERVICES AND TO EVALUATE PROPOSED CHANGES OF PROPOSED NEW SERVICES.LEVEL OF CARE: THE HEALTH CENTER IS A SHORT-TERM GENERAL HOSPITAL OFFERING A FULL RANGE OF SERVICES RELATED TO ACUTE CARE. INCLUDED IN THESE SERVICES AREA A WIDE RANGE OF OUTPATIENT SERVICES THAT INVOLVE DIAGNOSTIC AND REHABILITATIVE TREATMENT. THE HEALTH CENTER ALSO HAS LONG-TERM CARE AND INDEPENDENT LIVING AVAILABLE TO OFFER THE CONTINUUM OF CARE. THE LEVEL OF CARE PROVIDED TO ALL PATIENTS AND RESIDENTS IS THE SAME WHETHER INPATIENT OR OUTPATIENT. THIS IS ACCOMPLISHED THROUGH PROGRESSIVE HEALTH AWARENESS.CENTERS OF EXCELLENCE: AMONG THE SPECIAL STRENGTHS OF THE HEALTH CENTER ARE AN OBSTETRICAL UNIT, A CRITICAL CARE/CARDIAC CARE UNIT, A SHORT TERM INPATIENT AND OUTPATIENT ADULT PSYCHIATRIC UNIT, AN EMERGENCY DEPARTMENT THAT IS STAFFED WITH LICENSED PHYSICIANS 24 HOURS PER DAY, EVERY DAY OF THE YEAR, AN INPATIENT AND OUTPATIENT SURGICAL UNIT AND OTHER DIAGNOSTIC AND THERAPEUTIC SERVICES. DAILY OUTPATIENT SPECIALTY CLINICS OFFER THE CONSULTATIVE AND DIAGNOSTIC SERVICES OF SEVERAL TYPES OF MEDICAL SPECIALISTS. LONG-TERM CARE AND INDEPENDENT LIVING FACILITY OFFERING THE CONTINUUM OF CARE FROM THE HOSPITAL AREA. A WIDE RANGE OF ORGANIZED EDUCATIONAL AND HEALTH PROMOTION OPPORTUNITIES ARE PROVIDED FOR PATIENTS, RESIDENTS, EMPLOYEES AND MEMBERS OF THE SURROUNDING COMMUNITIES.FOR 2011, FULTON COUNTY HEALTH CENTER HAS EARNED FROM HEALTHGRADES A FIVE STAR JOINT REPLACEMENT AND TOTAL KNEE REPLACEMENT AWARD. HEALTHGRADES IS A LEADING HEALTHCARE RANKING SERVICE THAT IS RECOGNIZED THROUGHOUT THE COUNTRY IN IDENTIFYING QUALITY HEALTH PROGRAMS. THIS AWARD ALSO MEANS THAT FCHC IS RANKED IN THE TOP 15% NATIONWIDE IN JOINT REPLACEMENTS INCLUDING TOTAL KNEE AND TOTAL HIP IN OVERALL CLINICAL PERFORMANCE. THIS AWARD AFFIRMS THE QUALITY OUTCOMES BY ALL WHO PROVIDE CARE FOR PATIENTS THAT RECEIVE JOINT REPLACEMENT SURGERY HERE AT FCHC.THE 2011 FIVE STAR JOINT REPLACEMENT AWARD IS DESIGNED TO IDENTIFY HOSPITALS WHO HAVE THE LOWEST COMPLICATION RATES IN JOINT REPLACEMENTS. HEALTHGRADES IS A LEADING INDEPENDENT HEALTHCARE RATING ORGANIZATION WHO RATES HOSPITALS THROUGH ANNUAL REVIEWS OF SEVERAL PUBLIC AND PRIVATE SOURCES, INCLUDING CENTER FOR MEDICARE AND MEDICAID SERVICES.LIMITATIONS: PATIENTS IN NEED OF TERTIARY CARE ARE REFERRED TO AREA SPECIALTY CENTERS.POPULATION SERVED: THE FULTON COUNTY HEALTH CENTER SERVES THE POPULATION IN FULTON COUNTY AND PATIENTS IN THE IMMEDIATE BORDER AREAS OF ADJACENT COUNTIES. TOTAL POPULATION OF OUR SERVICE AREA IS ESTIMATED BETWEEN 40,000 - 45,000. THE STRESS UNIT PRIMARILY SERVES A FOUR COUNTY AREA INCLUDING FULTON, DEFIANCE, HENRY AND WILLIAMS COUNTIES AS WELL AS FROM OUTSIDE OUR IMMEDIATE GEOGRAPHIC AREA.INSTITUTIONAL RELATIONSHIPS: THE HEALTH CENTER MAINTAINS RELATIONSHIPS WITH AREA NURSING HOMES, CITY AND COUNTY ORGANIZATIONS, AND REGIONAL TERTIARY CARE CENTERS. THE HEALTH CENTER IS A CLINIC-TRAINING SITE FOR A WIDE RANGE OF HEALTH CARE DISCIPLINES.EDUCATION: THE HEALTH CENTER MAINTAINS AN ACTIVE AND ONGOING IN-SERVICE AND CONTINUING EDUCATION PROGRAM FOR OUR STAFF TO KEEP THEM KNOWLEDGEABLE AND CURRENT ON DEVELOPMENTS IN HEALTH CARE DELIVERY. THE HEALTH CENTER ALSO ENCOURAGES EMPLOYEES TO PURSUE HIGHER EDUCATION. 51727604 1 1 0 1 0 0 0 0 1 1 0 0 0 1 0 0 1 0 0 0 0 0 0 0 0 1 0 0 0 1 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 0 1 0 0 0 1 75 0 1 905 1 0 0 0 0 0 0 0 0 0 0 X 14 13 0 0 0 0 0 0 0 1 1 1 0 1 1 1 1 1 1 1 1 0 OH X DARRELL TOPMILLER 4193352015 725 SOUTH SHOOP AVE WAUSEON OH 43567 DALE L NAFZIGER 0.80 X X 0 0 0 CARL HILL 0.80 X X 0 0 0 SANDY BARBER 0.80 X X 0 0 0 SHARON GILLESPIE 0.80 X X 0 0 0 MATTHEW J MCQUADE 0.80 X 0 0 0 BRETT KOLB 0.80 X 0 0 0 DAVID GRIESER 0.80 X 0 0 0 JENNIFER MCCULLOUGH 0.80 X 0 0 0 DR CHRIS SPIELES 40.00 X 650000 0 17344 MARK HAGANS 0.80 X 0 0 0 ALLEN LIECHTY 0.80 X 0 0 0 WILLIAM ANDERSON 0.80 X 0 0 0 STANLEY MULTHAUF 0.80 X 0 0 0 MERRILL NOFZIGER 0.80 X X 0 0 0 DR LEE DAVIS 0.80 X 0 0 0 ALAN SCHAFFNER 0.80 X 0 0 0 DEAN BECK 40.00 X 232877 0 19822 PATRICIA FINN 40.00 X 128107 0 23716 DARRELL TOPMILLER 40.00 X 109824 0 17155 JOANN SHORT 40.00 X 99570 0 12202 MARY JO SMALLMAN 40.00 X 85010 0 15748 EDWARD W CLAUSING 40.00 X 101847 0 17375 HARRY E MURTIFF 40.00 X 187816 0 11581 SEMEGHAGHA J FOFUNG 40.00 X 229094 0 6555 DANIEL J MCKERNAN 40.00 X 800010 0 17344 RONALD E MUSIC 40.00 X 165006 0 17344 2789161 0 176186 10 0 1 0 AMERISOURCE - BERGEN 27550 NETWORK PLACE CHICAGO IL 60673 DRUGS / SUPPLIES 4860924 ZIMMER US INC 14235 COLLECTIONS CENTER DRIVE CHICAGO IL 60693 ORTHOPEDIC SURGERY PRODUCTS 1716433 AMERICAN PHYSICAL REHABILITATION 6444 MONROE STREET SUITE 5 SYLVANIA OH 43560 OCCUPATIONAL/PHYSICAL/SPEECH THERAPY 1495984 SENECA MEDICAL INC PO BOX 636696 CINCINNATI OH 45263 MEDICAL SUPPLIES 1223202 GORDON FOODS PAYMENT PROCESSING CENTER DEPT CH PALATINE IL 600550490 FOOD 825919 52 72931 72931 PATIENT SERVICES 622110 70204797 70204797 REBATES AND REFUNDS 900099 135759 135759 OTHER INCOME 900099 113838 113838 EDUCATION SERVICES 611710 84828 84828 70539222 285280 285280 336812 487224 -150412 -150412 23785 -174197 981000 35899 13761 981000 22138 1003138 1003138 FOOD SALES 621110 312694 312694 FITNESS MEMBERSHIPS 621110 41681 41681 K-1 INCOME 621110 966 966 82 82 355423 72105582 70605654 0 1426997 1411376 1411376 27858027 20336360 7521667 1145052 835888 309164 4990541 3643095 1347446 1930298 1409118 521180 96914 96914 177478 177478 7630544 5570297 2060247 214716 214716 14566334 10633424 3932910 553976 404402 149574 2470397 1803390 667007 5743 4192 1551 712930 413499 299431 3943561 2287265 1656296 756314 756314 BAD DEBT EXPENSE 3573497 3573497 EDUCATION PROGRAMS 54207 39571 14636 INDEPENDENT LIVING 23687 17292 6395 72115592 51727604 20387988 0 1197020 452029 13122936 17018325 9984732 11560026 1514965 1545022 805189 857854 72472125 34277436 40497230 38194689 6729320 5843932 62141 37500 3343287 995590 77256820 76504967 5215191 5580904 38924 48441 28435000 28406250 3665212 4296523 37354327 38332118 X 39850493 38120849 52000 52000 39902493 38172849 77256820 76504967 X -10010 -1719634 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 5518 5518 0 EXPLANATION OF OTHER LOBBYING ACTIVITIES: PART II-B, LINE 1I: DUES PAYMENTS TO OHA AND AHA THAT WERE USED BY THAT ORGANIZATION FOR LOBBYING PURPOSES. 347069 6305 556 353930 463238 5300 923 121940 452 347069 458802 875 7133 3572 463238 0.85310 0.14690 0.00000 0 0 858990 858990 39770636 14270628 25500008 29873544 19328087 10545457 1968955 678721 1290234 38194689 FAIR VALUE OF INTEREST RATE SWAP 2722804 OBLIGATIONS UNDER CAPITAL LEASES 1573719 4296523 72105582 72115592 -10010 148635 -1868269 -1719634 -1729644 72740475 148635 486258 634893 72105582 0 72105582 70735513 -1380079 -1380079 72115592 0 72115592 DESCRIPTION OF INTENDED USE OF ENDOWMENT FUNDS: PART V, LINE 4: ENDOWMENT FUNDS WILL BE USED AS DIRECTED BY THE DONOR. BOARD DESIGNATED FUNDS ARE A MEMORIAL ACCOUNT AND FUNDS WILL BE SPEND AS DIRECTED BY THE BOARD OF DIRECTORS. PART XI, LINE 8 - OTHER ADJUSTMENTS: CHANGE IN FAIR VALUE OF INTEREST RATE SWAP -1,867,303. K-1 INCOME -966. PART XII, LINE 2D - OTHER ADJUSTMENTS: RECLASS OF RENTAL EXPENSES 487,224. CHANGE IN FAIR VALUE OF INTEREST SWAP AGREEMENTS K-1 INCOME -966. PART XIII, LINE 2D - OTHER ADJUSTMENTS: RECLASS OF RENTAL EXPENSES 487,224. CHANGE IN FAIR VALUE OF INTEREST SWAP AGREEMENTS -1,867,303. PART XI LINE 8 - CHANGE IN FAIR VALUE OF INTEREST RATE SWAP 1 1 X 1 X 1 X 1 1 1 0 1 1 1241434 71320 1170114 0.01710 5381498 2505802 2875696 0.04200 1107470 334740 772730 0.01130 7730402 2911862 4818540 0.07040 664949 84828 580121 0.00850 58112 3000 55112 0.00080 10618 4424 6194 0.00010 733679 92252 641427 0.00940 8464081 3004114 5459967 0.07980 0 1887926 56638 15317017 14966224 350793 X 1 1 1 1 FULTON COUNTY HEALTH CENTER

725 S SHOOP AVE WAUSEON OH 43567

X X X X NA 1 2 FULTON MANOR

725 SOUTH SHOOP AVENUE WAUSEON OH 43567

SKILLED NURSING FACILITY FCHC MEDICAL CARE

725 SOUTH SHOOP AVENUE WAUSEON OH 43567

PHYSICIAN PRACTICES PART I, LINE 3C: FCHC USES THE FEDERAL POVERTY GUIDELINES FOR DETERMINING ELIGIBILITY FOR FREE OR DISCOUNTED CARE. PART I, LINE 6A: NOT APPLICABLE PART I, LINE 7: COST OF CHARITY CARE IS CALCULATED USING COST-TO-CHARGE RATIO FROM WORKSHEET 2. COST OF MEDICAID IS PER THE MEDICAID COST REPORT. THE REMAINING ITEMS ARE CALCULATED BASED ON ACTUAL COSTS OF SPECIFIC PROGRAMS WITHOUT THE USE OF A COST ACCOUNTING SYSTEM. PART I, L7 COL(F): THE AMOUNT OF BAD DEBT EXPENSE THAT WAS REMOVED FROM THE CALCULATION IN PART I LINE 7 COLUMN (F) TOTALED $3,573,497. PART II: N/A PART III, LINE 4: FINANCIAL STATEMENT FOOTNOTE REGARDING BAD DEBT: AN ALLOWANCE FOR UNCOLLECTIBLE ACCOUNTS IS ESTABLISHED ON AN AGGREGATE BASIS BY USING HISTORICAL LOSS-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. AN ALLOWANCE FOR CONTRACTUAL ADJUSTMENTS, INCLUDING INTERIM PAYMENT ADVANCES, IS BASED ON EXPECTED PAYMENT RATES FROM PAYORS BASED ON CURRENT REIMBURSEMENT METHODOLOGIES.FCHC USES THE COST TO CHARGE RATIO FROM WORKSHEET 2 TO DETERMINE THE COST OF THE BAD DEBT EXPENSE.THROUGHOUT ALL OF OUR COLLECTION PROCESSES, WE MAKE OUR BEST EFFORT TO GET ALL PATIENTS CLASSIFIED CORRECTLY. THIS IS ESPECIALLY TRUE FOR ANY OF OUR PATIENTS THAT ARE ELIGIBLE FOR FINANCIAL ASSISTANCE. WE PROVIDE INFORMATION TO OUR PATIENTS THROUGH POSTED SIGNS, PRINTED APPLICATIONS AND FOLLOW-UP PHONE CONVERSATIONS. WITH ALL OF THIS, WE REALIZE THAT SOME PATIENTS WILL EITHER NOT RESPOND TO OUR EFFORTS OR WILL FAIL TO PROVIDE ALL NECESSARY INFORMATION TO PROPERLY CLASSIFY THEM. BECAUSE OF THIS, WE KNOW THAT A PORTION OF OUR BAD DEBT EXPENSE WOULD QUALIFY FOR CHARITY CARE. WE ESTIMATE THIS PORTION TO BE 3% OF THE TOTAL BAD DEBT EXPENSE AT COST. PART III, LINE 8: MEDICARE ALLOWABLE COSTS WERE CALCULATED BY USING THE COST TO CHARGE RATIO FROM WORKSHEET 2. AS A CRITICAL ACCESS HOSPITAL, MEDICARE PAYS FCHC AT COST. THEREFORE, FCHC DOES NOT HAVE A MEDICARE SHORTFALL. PART III, LINE 9B: THE CRITERION FULTON COUNTY HEALTH CENTER UTILIZES TO COLLECT FROM PATIENTS INCLUDES: PATIENTS ARE SENT STATEMENTS FOR OUTSTANDING BALANCES FOR A PERIOD OF TIME NOT LESS THAN 105 DAYS, AFTER AN EFFORT HAS BEEN MADE TO COLLECT THE BALANCE OR PLAN A PATIENT-PAY ACCOUNT PAYMENT PLAN THROUGH A SERIES OF 4 LETTERS AND 2 TELEPHONE CONTACTS DURING THE AFOREMENTIONED 105 DAY PERIOD, THE ACCOUNT IS TURNED OVER TO A COLLECTION AGENCY FOR FURTHER COLLECTION EFFORTS OR LEGAL ACTION.COLLECTION EFFORTS ARE NOT ENFORCED FOR BALANCES KNOWN TO QUALIFY UNDER CHARITY CARE OR OTHER FINANCIAL ASSISTANCE CRITERIA. PART VI, LINE 2: EVERY FIVE YEARS, THE ORGANIZATION PERFORMS A COMMUNITY HEALTH NEEDS ASSESSMENT TO DETERMINE THE CURRENT HEALTH NEEDS WITHIN THE COMMUNITY. IN ADDITION, THE MEDICAL STAFF PROVIDES THE HOSPITAL WITH HEALTH CARE NEEDS WITHIN THE COMMUNITY BASED ON THEIR OWN PATIENTS HEALTH CARE NEEDS. PART VI, LINE 3: FCHC HAS SIGNS POSTED AT EACH PLACE THAT REGISTERS PATIENTS TO INFORM THEM OF FINANCIAL ASSISTANCE AVAILABLE. ALSO, EACH BILLING STATEMENT SENT TO THE PATIENTS PROVIDES INFORMATION ON WHO THE PATIENT MAY CONTACT FOR INFORMATION REGARDING FINANCIAL ASSISTANCE. FINALLY, FINANCIAL COUNSELORS VISIT CERTAIN PATIENTS IN THE EMERGENCY DEPARTMENT AND ON THE INPATIENT FLOORS TO DISCUSS THE FINANCIAL ASSISTANCE AVAILABLE TO THEM. PART VI, LINE 4: FCHC SERVES FULTON COUNTY, OHIO AS THE PRIMARY SERVICE AREA, AS WELL AS PORTIONS OF HENRY & WILLIAMS COUNTIES IN OHIO AND MORENCI, MICHIGAN AS THE SECONDARY SERVICE AREA. THE ORGANIZATION IS A RURAL COMMUNITY. THE HOSPITAL SERVES ALL RESIDENTS WITH VARIOUS DEMOGRAPHIC CHARACTERISTICS. THE POPULATION THAT THE HOSPITAL SERVICES RANGES FROM 40,000 TO 45,000. THERE ARE NO OTHER HOSPITALS IN FULTON COUNTY. THE PERCENTAGE OF PERSONS BELOW THE POVERTY LEVEL IS APPROXIMATELY 9-10%. THE AVERAGE MEDIAN HOUSEHOLD INCOME IS APPROXIMATELY $53,000. PART VI, LINE 6: ALL OF THE ORGANIZATION'S BOARD MEMBERS RESIDE IN THE SERVICE AREA OF THE HOSPITAL. BOARD MEMBERS REPRESENT AND LIVE IN THE CITIES AND VILLAGES OF FULTON COUNTY. WITH THE EXCEPTION OF DR. CHRIS SPIELES WHO IS A BOARD MEMBER AS CHIEF OF STAFF, THE BOARD MEMBERS ARE NEITHER EMPLOYEES NOR INDEPENDENT CONTRACTORS OF THE ORGANIZATION. THE ORGANIZATION EXTENDS MEDICAL STAFF PRIVILEGES TO ALL QUALIFIES PHYSICIANS IN ITS COMMUNITY THAT MEET THE MEDICAL STAFF BYLAW REQUIREMENTS. THE ORGANIZATION REINVESTS SURPLUS FUNDS INTO THE ORGANIZATION IN THE FORM OF NEW EQUIPMENT, RENOVATIONS, AND ADDITIONAL SERVICES. THE ORGANIZATION HAD 13% OF ITS REVENUE SOURCED FROM MEDICAID AND UNINSURED PATIENTS.FCHC INCURRED $252,528 EXPENSES RELATED TO RECRUITING AND MAINTAINING QUALIFIED PHYSICIANS AND SPECIALISTS TO THE HOSPITAL. THESE PHYSICIANS AND SPECIALISTS ARE CRITICAL TO ENHANCING THE HEALTH AND LEVEL OF CARE PROVIDED TO THE COMMUNITY. WITHOUT FCHC RECRUITING AND MAINTAINING THESE PHYSICIANS, THE COMMUNITY WOULD NOT HAVE ACCESS TO THESE DOCTORS. AS SUCH, FCHC CONSIDERS THESE PHYSICIAN RECRUITMENT COSTS TO BE A COMMUNITY BENEFIT SERVICE. PART VI, LINE 7: N/A X X 0 0 0 0 0 0 0 0 0 DR CHRIS SPIELES 650000 0 0 0 0 0 0 0 17344 0 667344 0 0 0 DEAN BECK 232877 0 0 0 0 0 11644 0 8178 0 252699 0 0 0 PATRICIA FINN 128107 0 0 0 0 0 6405 0 17311 0 151823 0 0 0 HARRY E MURTIFF 187816 0 0 0 0 0 0 0 11581 0 199397 0 0 0 SEMEGHAGHA J FOFUNG 225014 0 0 0 4080 0 0 0 6555 0 235649 0 0 0 DANIEL J MCKERNAN 800010 0 0 0 0 0 0 0 17344 0 817354 0 0 0 RONALD E MUSIC 165006 0 0 0 0 0 0 0 17344 0 182350 0 0 0 COUNTY OF FULTON OHIO 346400540 360241AA1 2005-12-01 28500000 FUNDS FOR EXPANSION AND RENOVATION AND CURRENT BOND REFUNDING 0 0 0 29238057 310443 231601 17546274 2009 1 0 1 1 0 0 1 1 1 0.00000 0.00000 0.00000 1 0 1 1 MORGAN STANLEY 30.000000000000 0 0 0 1 0 FORM 990, SCHEDULE K, PART III, LINE 3A: FOOTNOTE: MANAGEMENT CONTRACTS DO NOT RESULT IN PRIVATE BUSINESS USE UNDER THE SAFE-HARBOR PROVISIONS OF REVENUE PROCEDURE 97-13. FORM 990, SCHEDULE K, PART III, LINE 3B: FOOTNOTE: FULTON COUNTY HEALTH CENTER'S ONCOLOGY DEPARTMENT PARTICIPATES IN THE TOLEDO ONCOLOGY PROGRAM. THIS AGREEMENT DOES NOT RESULT IN PRIVATE BUSINESS USE FOR FULTON COUNTY HEALTH CENTER. FORM 990, PART VI, SECTION B, LINE 11 THE FORM 990 IS PROVIDED TO AND REVIEWED BY THE ORGANIZATION'S GOVERNING BODY INCLUDING DARRELL TOPMILLER, DIRECTOR OF FINANCE, THE BOARD OF DIRECTORS, AND DEAN BECK, THE ORGANIZATION'S ADMINISTRATOR, BEFORE THE FORM IS FILED. FORM 990, PART VI, SECTION B, LINE 12C CONFLICT OF INTEREST QUESTIONNAIRES ARE DISTRIBUTED ANNUALLY TO THE BOARD OF DIRECTORS AND DEPARTMENT HEADS. VENDORS ARE REVIEWED REGULARLY BY DEPARTMENT HEADS TO DETERMINE IF ANY RELATIONSHIPS EXIST PER THE CONFLICT OF INTEREST QUESTIONNAIRES. AN OFFICER, DIRECTOR, OR KEY EMPLOYEE WHO HAS A CONFLICT OF INTEREST SHALL DISCLOSE THE CONFLICT OF INTEREST WHEN IT ARISES, AND BEFORE ACTION ON THE TRANSACTION OR CLAIM IN QUESTION. DISCLOSURE IS REQUIRED EVEN IF A DECISION CONCERNING THE TRANSACTION OR CLAIM IS NOT SUBJECT TO APPROVAL BY THE OFFICER, DIRECTOR, OR KEY EMPLOYEE OR THE BOARD OR COMMITTEE ON WHICH THE OFFICER, DIRECTOR, OR KEY EMPLOYEE SERVES. THE POLICY PROVIDES A PROCEDURE FOR REPORTING POTENTIAL CONFLICTS WHEN THEY ARISE AND BEFORE ACTION TO APPROVE OR AUTHORIZE THE TRANSACTION IS TAKEN. THE POLICY COVERS DIRECTORS, OFFICERS, EMPLOYEES OR AGENTS OF FULTON COUNTY HEALTH CENTER AND MEMBERS OF COMMITTEES AUTHORIZED TO APPROVE TRANSACTIONS OR ASSERT CLAIMS ON BEHALF OF THE FULTON COUNTY HEALTH CENTER. THE BOARD OF DIRECTORS, OTHER THAN ANY BOARD MEMBER DIRECTLY INVOLVED WITH THE CONFLICT, DETERMINES WHETHER A CONFLICT OF INTEREST INVOLVING AN INDIVIDUAL COVERED BY THE POLICY EXISTS AND REVIEWS ACTUAL CONFLICTS. INDIVIDUALS WITH CONFLICTS ARE NOT PERMITTED TO PARTICIPATE IN DELIBERATIONS OR VOTE TO AUTHORIZE A TRANSACTION OR ASSERTION OF A CLAIM. FORM 990, PART VI, SECTION B, LINE 15 THE COMPENSATION OF THE ORGANIZATION'S ADMINISTRATOR, DEAN BECK, IS APPROVED BY THE BOARD OF DIRECTORS. THE ORGANIZATION PARTICIPATES WITH THE OHA AND USES THEIR WAGE SURVEYS TO HELP DETERMINE THE ADIMISTRATOR'S COMPENSATION. THE ADMINISTRATOR'S COMPENSATION IS REVIEWED ANNUALLY AND DECISIONS ARE DOCUMENTED IN THE BOARD OF DIRECTOR MEETING MINUTES. THE COMPENSATION OF OFFICERS AND KEY EMPLOYEES ARE REVIEWED BY THE BOARD OF DIRECTORS. THE ORGANIZATION PARTICIPATES WITH THE OHA AND USES THEIR WAGE SURVEYS TO HELP DETERMINE OFFICER COMPENSATION. THE BOARD APPROVES THE COMPENSATION OF EMPLOYEES IN THE AGGREGATE. OFFICER COMPENSATION IS REVIEWED ANNUALLY AND DECISIONS ARE DOCUMENTED IN THE BOARD OF DIRECTOR MEETING MINUTES. THE COMPENSATION REVIEW PROCESS FOR THE ADMINISTRATOR, OFFICERS, AND KEY EMPLOYEES WAS LAST PERFORMED IN OCTOBER 2010. FORM 990, PART VI, SECTION C, LINE 19 THE ORGANIZATION MAKES ITS FORM 990 AVAILABLE FOR PUBLIC INSPECTION UPON REQUEST. GOVERNING DOCUMENTS, CONFLICT OF INTEREST POLICY, AND THE FINANCIAL STATEMENTS ARE NOT AVAILABLE TO THE PUBLIC. PART VI, LINE 9: MERRILL NOFZIGER 720 SIEGEL DRIVE ARCHBOLD, OH 43502 DR. LEE DAVIS 629 MEADOW LANE WAUSEON, OH 43567 CHANGES IN NET ASSETS OR FUND BALANCES: FORM 990, PART XI, LINE 5: NET UNREALIZED GAINS ON INVESTMENTS: 148,635. CHANGE IN FAIR VALUE OF INTEREST RATE SWAP -1,867,303. K-1 INCOME -966. TOTAL TO FORM 990, PART XI, LINE 5: -1,719,634. COMMITTEE OVERVIEW OF FINANCIAL STATEMENTS FORM 990, PART XII, LINE 2C: THE OVERSIGHT OF THE AUDIT OF THE FINANCIAL STATEMENTS HAS NOT CHANGED SINCE THE PRIOR YEAR. FCHC MEDICAL CARE LLC 725 S SHOOP AVE WAUSEON OH 435671702 010877201 PHYSICIAN BILLING AND PHYSICIAN PRACTICES OH -1466310 2352028 N/A FCHC MEDICAL SERVICES LLC 725 S SHOOP AVE WAUSEON OH 435671702 HOLD LAND OH 0 452433 N/A