2022-02-09T14:33:29-06:00 2021-03-31 381357951 PLANTE & MORAN PLLC 750 TRADE CENTRE WAY STE 300 PORTAGE MI 49002 990 2020-04-01 381359265 MARY FREE BED REHABILITATION HOSPITAL MARY 8005288989 235 WEALTHY ST SE GRAND RAPIDS MI 495035247 RYAN PODVIN CHIEF FINANCIAL OFFICER 8005288989 2022-02-02 1 RYAN PODVIN 999009999 DAVID LOWENTHAL P00378651 2695674500 2022-02-02 2 AAL1 IAL1 2020 2022-09-23 18:48:47Z MARY FREE BED HOSPITAL AND REHABILITATION CENTER RYAN PODVIN 235 WEALTHY ST SE GRAND RAPIDS MI 495035247 157467005 0 X WWW.MARYFREEBED.COM X 1913 MI HELPING PEOPLE WITH DISABILITIES ACHIEVE INDEPENDENCE THROUGH REHABILITATION SERVICES. EDUCATING THE COMMUNITY ON DISABLING DISEASES AND INJURY PREVENTION. CARRYING OUT MEDICAL AND SCIENTIFIC RESEARCH TO IMPROVE THE CARE AND OUTCOMES FOR PEOPLE WITH DISABILITIES. 27 25 2199 142 0 0 2340437 5760256 143458907 147652103 488415 775022 182408 19280 146470167 154206661 165675 209101 0 0 97612159 105443232 0 0 0 36592424 37108523 134370258 142760856 12099909 11445805 169465731 203980049 45561220 64184144 123904511 139795905 X RESTORING HOPE AND FREEDOM THROUGH REHABILITATION. 0 0 19248140 0 52647946 PROVIDE NURSING SERVICES AND INFECTION CONTROL FOR 38,432 PATIENT DAYS. 16869938 0 17718474 PROVIDE OUTPATIENT REHABILITATION AND CLINIC SERVICES FOR APPROXIMATELY 99,142 PATIENT VISITS. 7602809 0 22188713 PROVIDE THERAPY AND OTHER MEDICAL SERVICES FOR 38,432 PATIENT DAYS. 71735754 209101 55096970 REHABILITATION STAFFING AND MANAGEMENT SERVICES; MEDICAL SERVICES REHABILITATION PROGRAM ADMINISTRATION; OFFICE EXPENSES FOR PROGRAM SERVICES; MEDICAL RECORDS; SUPPLIES; UTILITIES, MAINTENANCE, DEPRECIATION RELATED TO PROGRAM SERVICES AND ASSETS; PATIENT MEALS; INSURANCE; DRIVER REHABILITATION SERVICES; MOTION ANALYSIS/GAIT LAB SERVICES; BENEFIT COSTS AND PAYROLL TAXES ON PROGRAM SALARIES NOT SPECIFICALLY LISTED; OTHER PROGRAM SERVICES AND MEDICAL SERVICES NOT SPECIFICALLY LISTED; BAD DEBTS; TRAVEL/CONFERENCES. 71735754 209101 55096970 115456641 1 1 0 1 0 0 0 0 0 0 1 0 0 1 1 0 0 1 0 0 0 0 0 0 0 0 1 1 1 0 1 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 1 1 1 0 0 1 101 0 1 2199 1 0 0 0 0 0 0 0 0 0 0 0 0 X 27 25 0 0 0 0 1 1 1 1 1 0 0 1 1 1 1 1 1 1 1 1 1 X RYAN PODVIN 6168408676 235 WEALTHY ST SE GRAND RAPIDS MI 49503 KENT RIDDLE PRESIDENT 50.00 5.00 X X 840774 0 536660 INGRID CHESLEK CHIEF OPERATING OFFICER 45.00 0.00 X 441986 0 133810 BENJAMIN BRUINSMA PHYSICIAN, M.D. 40.00 0.00 X 506173 0 43807 DR MICHAEL JAKUBOWSKI MD DIRECTOR 50.00 4.00 X 502043 0 43807 WILLIAM VANDENBERG PHYSICIAN, M.D. 40.00 1.00 X 421165 0 34639 STUART YABLON PHYSICIAN, M.D. 40.00 0.00 X 378791 0 30394 JEFFREY GARBER CHIEF STRATEGY OFFICER 40.00 0.00 X 367107 0 27579 MARSHALL POOLE PHYSICIAN, D.O. 40.00 0.00 X 347337 0 39971 RANDALL DENEFF CFO 48.00 2.00 X 336568 0 39510 DAVID MUIR CHAIRMAN 1.00 1.00 X X 0 0 0 MOLLY KRAUSS VICE CHAIRMAN 1.00 1.00 X X 0 0 0 JENNIFER TAYLOR SECRETARY 1.00 4.00 X X 0 0 0 GREG CONWAY TREASURER 1.00 2.00 X X 0 0 0 JUDY PALMER ASST. TREASURER 1.00 3.00 X X 0 0 0 DR MIKE ANDARY MD DIRECTOR 1.00 1.00 X 0 0 0 DIANNE DEROSEAU DIRECTOR 1.00 1.00 X 0 0 0 JUDY DUNTEN DIRECTOR (THRU 1/21) 1.00 1.00 X 0 0 0 SCOTT LEWIS DIRECTOR 1.00 1.00 X 0 0 0 DR ANDREA KULDANEK MD DIRECTOR 1.00 1.00 X 0 0 0 TERRENCE O'ROURKE DIRECTOR (THRU 1/21) 1.00 1.00 X 0 0 0 HOLLY PETERSON DIRECTOR 1.00 1.00 X 0 0 0 LAURA PUFF DIRECTOR 1.00 3.00 X 0 0 0 JULIE RIDENOUR DIRECTOR (THRU 1/21) 1.00 1.00 X 0 0 0 CAROL SPRINGER DIRECTOR (THRU 1/21) 1.00 2.00 X 0 0 0 WENDY STOCK DIRECTOR 1.00 3.00 X 0 0 0 MICHELE SUCHOVSKY DIRECTOR 1.00 1.00 X 0 0 0 MICHAEL WILLIAMS DIRECTOR 1.00 1.00 X 0 0 0 MEG DERRER DIRECTOR 1.00 2.00 X 0 0 0 DEB KAY DIRECTOR 1.00 1.00 X 0 0 0 JAN LIPPERT DIRECTOR (THRU 1/21) 1.00 1.00 X 0 0 0 NANCY ALBERS DIRECTOR 1.00 1.00 X 0 0 0 ADRIANA ALMANZA DIRECTOR 1.00 1.00 X 0 0 0 PAUL DOYLE DIRECTOR 1.00 1.00 X 0 0 0 SANDRA GADDY DIRECTOR 1.00 1.00 X 0 0 0 DAN VAUGHAN DIRECTOR 1.00 1.00 X 0 0 0 MARYLN WALTON DIRECTOR 1.00 2.00 X 0 0 0 CAMERON YOUNG DIRECTOR 1.00 1.00 X 0 0 0 SUSAN BLOSS DIRECTOR 1.00 3.00 X 0 0 0 BECKY BECHLER DIRECTOR 1.00 1.00 X 0 0 0 4141944 0 930177 104 0 1 0 MILLER JOHNSON SNELL & CUMMISKY 45 OTTAWA AVE GRAND RAPIDS MI 49503 LEGAL SERVICES 652973 M SOHAIL JILANI MD PLLC 6725 FLEMING CREEK DRIVE YPSILANTI MI 48198 MEDICAL SERVICES 135063 SAXONY PARTNERS 13155 NOEL RD DALLAS TX 75240 BUSINESS CONSULTANTS 134235 PLANTE & MORAN PLLC 10060 COLLECTIONS CNT DR CHICAGO IL 60693 FINANCIAL SERVICES 133620 4 1723842 3969775 66639 5760256 PATIENT SERVICE REVENUE 621400 107537164 107537164 CONTRACT SERVICE REVENUE 621400 29022965 29022965 REHABILITATION JV INCOME 621400 10931483 10931483 RENT FROM AFFILIATES 621400 160491 160491 147652103 414389 414389 19280 0 19280 19280 19280 3620977 3260344 360633 360633 360633 154206661 147652103 0 794302 209101 209101 2319311 2319311 76047656 69554029 6493627 3436581 2428269 1008312 16280322 11517072 4763250 7359362 5077960 2281402 1935392 1296712 638680 761751 761751 90700 90700 15962 15962 1618418 1143149 475269 578036 30677 547359 302462 177382 125080 4207065 2476446 1730619 2495864 2086337 409527 114331 106285 8046 144380 124728 19652 445005 29189 415816 7166341 5084264 2082077 585060 409542 175518 MEDICAL SUPPLIES 11172548 11048363 124185 BAD DEBT EXPENSE 1080029 1080029 FOOD SERVICE 738877 738877 REPAIRS 528098 280440 247658 3128204 557790 2570414 142760856 115456641 27304215 0 11030 6465 19837366 34280243 13389752 14669232 226802 213293 1190555 998236 110455319 46102238 56136923 64353081 15489721 24335571 5445904 5445904 57737678 59678024 169465731 203980049 35197847 28655298 10209317 2492356 30535074 154056 2501416 45561220 64184144 X 123904511 139795905 0 0 123904511 139795905 169465731 203980049 X 11445805 5288501 -842912 X X 0 1 X 1 0 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 0 0 0 0 0 0 0 0 1 15962 15962 0 PART II-B, LINE 1: PORTION OF MEMBERSHIP FEES IDENTIFIED BY THE AMERICAN HOSPITAL ASSOCIATION, MICHIGAN HEALTH & HOSPITAL ASSOCIATION, COALITION PROTECTING AUTO NO FAULT, AMERICAN MEDICAL REHABILITATION PROVIDERS ASSOCIATION, AND PUBLIC AFFAIRS ASSOCIATES ARE ALLOCATED TO LOBBYING. CONTACTS WITH STATE AND FEDERAL LEGISLATORS THROUGH E-MAIL. 1102670 1102670 53926527 16447122 37479405 276220 276037 183 45434806 29379079 16055727 9715096 9715096 64353081 INVESTMENT IN JOINT VENTURE- REHABILITATION SERVICES 42716053 OTHER RECEIVABLES 3226526 DUE FROM MARY FREE BED FUND 39786 DUE FROM MARY FREE BED GUILD 15757 DUE FROM MARY FREE BED ORTHOTICS & PROSTHETICS 1747181 DUE FROM MARY FREE BED REHABILITATION HOSPITAL FOUNDATION 1519705 DUE FROM MARY FREE BED REHABILITATION, LLC 3951947 DUE FROM MARY FREE BED CONDO ASSOCIATION 6080 DUE FROM MARY FREE BED DRIVERS LLC 55572 DUE FROM ABVI 34674 CONTRACT ACCOUNTS RECEIVABLE 6364743 59678024 DUE TO MARY FREE BED GUILD 2500000 DUE TO MARY FREE BED REHABILITATION HOSPITAL FOUNDATION 1416 2501416 1 1 X 1 X 145.000000000000 1 X 1 1 0 0 343820 343820 0.00240 18097898 9777052 8320846 0.05870 117085 59427 57658 0.00040 18558803 9836479 8722324 0.06150 226 226 0.00000 3045283 1781216 1264067 0.00890 615578 448644 166934 0.00120 3661087 2229860 1431227 0.01010 22219890 12066339 10153551 0.07160 318821 228861 89960 0.00060 318821 228861 89960 0.00060 1 1080029 336479 32219315 34732465 -2513150 X 1 1 1 1 MARY FREE BED REHABILITATION HOSPITAL 235 WEALTHY ST SE GRAND RAPIDS MI 495035247 WWW.MARYFREEBED.COM 10600000134 X X X MARY FREE BED REHABILITATION HOSPITAL 1 0 0 1 X X X X X X X X X 18 1 1 1 1 X SEE PART V, PAGE 8 X 1 18 1 SEE PART V, PAGE 8 0 1 X 145.000000000000 250.000000000000 X X X X X 1 1 X X X X 1 X WWW.MARYFREEBED.COM/FINANCIAL-ASSISTANCE/ X WWW.MARYFREEBED.COM/FINANCIAL-ASSISTANCE/ X WWW.MARYFREEBED.COM/FINANCIAL-ASSISTANCE/ X X X X X X X 1 X 0 X X X X 0 X X 0 0 MARY FREE BED REHABILITATION HOSPITAL PART V, SECTION B, LINE 5: MARY FREE BED REHABILITATION HOSPITAL ENCOURAGES PATIENTS AND COMMUNITY MEMBERS TO PARTICIPATE IN VOICEKENT, A SURVEY ABOUT OUR COMMUNITY HEALTH OFFERINGS AND NEEDS, OFFERED BY THE JOHNSON CENTER FOR PHILANTHROPY AND KENT COUNTY HEALTH DEPARTMENT. THE GOAL IS TO PROVIDE OBJECTIVE DATA TO RESIDENTS, NONPROFIT ORGANIZATIONS AND OTHER DECISION MAKERS TO ASSIST IN IMPROVING THE OVERALL HEALTH OF OUR COMMUNITY. LEADERS FROM MARY FREE BED ANALYZED SECONDARY HEALTH ASSESSMENT RESEARCH CONDUCTED BY LOCAL, STATE, AND FEDERAL AGENCIES. MARY FREE BED UTILIZES- THOUGH AN APPROVED USER AGREEMENT- GEOGRAPHIC AND POPULATION DEMOGRAPHICS PROVIDED IN THE KENT COUNTY CHNA TO DESCRIBE OUR COMMUNITY AND POPULATIONS SERVED. THESE DEMOGRAPHICS ARE ACQUIRED BY KENT COUNTY THROUGH SURVEYING, TOWN HALL MEETINGS AND HEALTH DEPARTMENT WORKGROUPS. A VARIETY OF OTHER PRIMARY AND SECONDARY SOURCES ARE USED IN THE KENT COUNTY CHNA IN ORDER TO PROVIDE A BROAD OVERVIEW OF COMMUNITY NEEDS IN KENT COUNTY.SEE REFERENCES FOR WEB LINK TO KENT COUNTY CHNA FOR DATA SOURCE INFORMATIONALONG WITH THE ABOVE MENTIONED SOURCE OF DATA, MARY FREE BED ALSO UTILIZES FEDERAL AND STATE HEALTH DOCUMENTS TO PROVIDE A CLEAR UNDERSTANDING AND ALIGNMENT OF THE NEEDS OF OUR COMMUNITY.IT IS THE BROAD OBJECTIVE OF THE MARY FREE BED REHABILITATION HOSPITAL CHNA AND COMMUNITY BENEFITS PLAN TO SUPPORT COMMUNITY INITIATIVES THAT ARE ALIGNED WITH THE FEDERAL, STATE AND LOCAL HEALTH GOALS. MARY FREE BED REHABILITATION HOSPITAL PART V, SECTION B, LINE 6A: MERCY HEALTH, METRO HEALTH/UNIVERSITY OF MICHIGAN HEALTH, SPECTRUM HEALTH, AND PINE REST CHRISTIAN MENTAL HEALTH SERVICES MARY FREE BED REHABILITATION HOSPITAL PART V, SECTION B, LINE 6B: KENT COUNTY HEALTH DEPARTMENT MARY FREE BED REHABILITATION HOSPITAL PART V, SECTION B, LINE 7D: PART V, SECTION B, LINE 7B: HTTPS://WWW.MARYFREEBED.COM/COMMUNITY-HEALTH-NEEDS-ASSESSMENT/PART V, SECTION B, LINE 10: HTTPS://WWW.MARYFREEBED.COM/COMMUNITY-HEALTH-NEEDS-ASSESSMENT/ MARY FREE BED REHABILITATION HOSPITAL PART V, SECTION B, LINE 11: - IMPLEMENTATION STRATEGY: PROVIDE COMPREHENSIVE REHABILITATION FOCUSED ON THE SPECIALIZED NEEDS OF THE INCREASING NUMBER OF CANCER SURVIVORS BY INCREASING CANCER REHABILITATION AND SURVIVORSHIP PROGRAMS AND SERVICES ACROSS THE NETWORK-MEASUREABLE OUTCOME: INCREASE THE NUMBER OF ONCOLOGY PATIENTS WHO HAVE AN ENCOUNTER WITH A MARY FREE BED PROVIDER OR TEAM MEMBER ACROSS THE NETWORK- IMPLEMENTATION STRATEGY: MAINTAIN OR INCREASE INITIATIVES AND SERVICES OFFERED THROUGH THE BETTY BLOOMER FORD CANCER REHABILITATION PROGRAM- MEASUREABLE OUTCOME: NUMBER OF PROGRAMS OFFERED, [MAINTAIN OR INCREASE] COMMUNITY PARTNERSHIPS OFFERED THROUGH THE BETTY BLOOMER FORD CANCER REHABILITATION PROGRAM- IMPLEMENTATION STRATEGY: INCREASE PATIENT SELF-MANAGEMENT AND AWARENESS OF BODY WEIGHT, NUTRITION, AND CHRONIC DISEASE RISK- MEASUREABLE OUTCOME: INCREASE THE NUMBER OF PATIENTS ENROLLED IN THE MARY FREE BED WEIGHT MANAGEMENT PROGRAM- MEASUREABLE OUTCOME: INCREASE THE NUMBER OF PATIENT ENCOUNTERS WITH THE OUTPATIENT NUTRITION PROGRAM DIETITIAN- IMPLEMENTATION STRATEGY: IMPLEMENT USE OF THE KENT COUNTY HEALTH DEPARTMENT COMMUNITY NUTRITION SURVEY ON ACCESS TO HEALTHY FOOD CHOICES ACROSS THE CONTINUUM (KCCNA 2015)- MEASUREABLE OUTCOME: OBTAIN AND REPORT TO KENT COUNTY RESULTS OF ACCESS TO HEALTHY FOOD CHOICES SURVEY AS REPORTED BY PATIENTS- IMPLEMENTATION STRATEGY: IMPROVE PHYSICAL, EMOTIONAL AND MENTAL HEALTH OF PERSONS WITH DISABILITIES BY RECEIVING RECREATIONAL THERAPY SERVICES- MEASUREABLE OUTCOME: FIM SCORES OR OTHER HRQOL PRE-POST ASSESSMENTS, MAINTAIN OR IMPROVE THE FUNCTIONALITY AND QUALITY OF LIFE FOR PERSONS WITH DISABILITIES OR IMPAIRMENTS WHO RECEIVE INPATIENT RECREATIONAL THERAPY SERVICESSPECIFIC NEEDS IDENTIFIED IN CHNA: CHRONIC DISEASESPECIFIC NEEDS IDENTIFIED IN CHNA: NUTRITION & OBESITYSPECIFIC NEEDS IDENTIFIED IN CHNA: MENTAL HEALTH & QUALITY OF LIFE- IMPLEMENTATION STRATEGY: MAINTAIN TARGETED EFFORTS TOWARD UTILIZERS OF MARY FREE BED REHABILITATION HOSPITAL'S WHEELCHAIR AND ADAPTIVE SPORTS PROGRAMS AND SERVICES- MEASURABLE OUTCOME: NUMBER OF PARTICIPANTS, MAINTAIN OR INCREASE THE CLINICS AND TEAMS OFFERED BY WHEELCHAIR AND ADAPTIVE SPORTS FOR PERSONS WITH DISABILITIES OR IMPAIRMENTS- IMPLEMENTATION STRATEGY: PROMOTE THE HEALTH AND WELL-BEING OF PERSONS WITH DISABILITIES WHO HAVE THE OPPORTUNITY TO TAKE PART IN THE DRIVER REHABILITATION PROGRAM- MEASUREABLE OUTCOME: MAINTAIN OR INCREASE THE NUMBER OF PERSONS ENGAGING IN THE DRIVER REHABILITATION PROGRAM- IMPLEMENTATION STRATEGY: USING HEALTH INFORMATION TECHNOLOGY, IMPROVE COORDINATION OF CARE AND SERVICES ACROSS THE CONTINUUM OF CARE AND SERVICES- MEASUREABLE OUTCOME: USING HEALTH INFORMATION TECHNOLOGY, INCREASE THE NUMBER OF PERSONS WITH COMPLEX CARE NEEDS WHO ARE BEING MEDICALLY MANAGED WITH A NURSE CASE MANAGER OR NURSE NAVIGATOR- MEASUREABLE OUTCOME: REDUCE DELAYS IN ACCESS TO CARE THROUGH TRACKING TIME OF INBOUND CALLS TO CONVERSION TO AN APPOINTMENT OR SPEAKING WITH A TEAM MEMBER FOR INFORMATION (ACCESS CENTER)- IMPLEMENTATION STRATEGY: EXPAND CAPACITY FOR NEXT STEPS DAY REHAB PROGRAM FOR PATIENTS WHO REQUIRE INTENSIVE REHABILITATION SERVICES IN AN OUTPATIENT SETTING- MEASUREABLE OUTCOME: INCREASE ACCESS TO NEXT STEPS DAY REHAB PROGRAM AS MEASURED BY PATIENT ENCOUNTERS WITH PROGRAM STAFF- IMPLEMENTATION STRATEGY: MAINTAIN UNIVERSAL ACCESS PRACTICES TO ASSURE ACCESS TO QUALITY HEALTH CARE IN THE POST-ACUTE CARE SETTING (2013 MFB CHNA)- MEASUREABLE OUTCOME: ACCEPT FOR TREATMENT, ALL PATIENTS WHOM ARE CLINICALLY APPROPRIATE REGARDLESS OF THEIR ABILITY TO PAY (SEE MFB 2016-2018 CHNA FOR UNIVERSAL ACCESS DEFINITION)- IMPLEMENTATION STRATEGY: MAINTAIN OR IMPROVE THE PROPORTION OF COMMUNITY MEMBERS, INCLUDING THE UNINSURED AND WORKING POOR, THAT ACCESS HEALTHCARE SERVICES AT MFB (2013 MFB CHNA)- MEASUREABLE OUTCOME: MAINTAIN OR INCREASE THE NUMBER OF CHARITY AND MEDICAID PATIENTS TREATED OVER THE CYCLE- IMPLEMENTATION STRATEGY: EXPAND OUT-PATIENT SERVICES STATEWIDE BY 2018 (MFB SO1.8)- MEASUREABLE OUTCOME: MAINTAIN OR INCREASE IN PATIENT VISITS SEEN BY OUTPATIENT ENCOUNTERSSPECIFIC NEEDS IDENTIFIED IN CHNA: ACCESS- IMPLEMENTATION STRATEGY: EXPAND THE CAPACITY FOR POST-ACUTE CARE BY INCREASING THE NUMBER OF REFERRAL SOURCES- MEASUREABLE OUTCOME: INCREASE NUMBER OF INPATIENT VISITS FROM REFERRAL SOURCES SEEN BY MFB PROVIDERS- IMPLEMENTATION STRATEGY: EXPAND CAPACITY FOR POST-ACUTE CARE THROUGH THE DEVELOPMENT OF TWO NEW SUBSPECIALTY INPATIENT PROGRAMS IN OUR NETWORK (LANSING & MUSKEGON)(MFB SO1.3)- MEASUREABLE OUTCOME: INCREASE IN INPATIENT SUBSPECIALTY VISITS SEEN IN LANSING & MUSKEGON BY AN MFB PROVIDER- IMPLEMENTATION STRATEGY: MAINTAIN OR EXPAND MFB REHABILITATION HOME & COMMUNITY SERVICES PROGRAM OF RECEIVING THERAPY AT HOME FOR BRAIN OR SPINAL CORD INJURY PATIENTS (NEW)- MEASUREABLE OUTCOME: MAINTAIN OR INCREASE THE NUMBER OF PATIENTS SEEN BY HOME & COMMUNITY SERVICES PROVIDERS- IMPLEMENTATION STRATEGY: MAINTAIN OR INCREASE INITIATIVES AND SERVICES OFFERED THROUGH MFB WHEELCHAIR AND ADAPTIVE SPORTS- MEASUREABLE OUTCOME: NUMBER OF PROGRAMS OFFERED BY WHEELCHAIR AND ADAPTIVE SPORTS- IMPLEMENTATION STRATEGY: MAINTAIN OR INCREASE INITIATIVES, SERVICES, AND COMMUNITY PARTNERSHIPS OFFERED THROUGH THE MFB YMCA- MEASUREABLE OUTCOME: NUMBER OF VISITS OF GUESTS HAVING A DISABILITY OR IMPAIRMENT WHO ACCESS THE MFB YMCACOMPETENT WORKFORCE- IMPLEMENTATION STRATEGY: MAINTAIN OR INCREASE INITIATIVES AND SERVICES OFFERED THROUGH MEDICAL & HEALTH EDUCATION THAT ARE FOCUSED ON POST-ACUTE CARE AND REHABILITATION- MEASUREABLE OUTCOME: NUMBER OF ATTENDEES- MEASUREABLE OUTCOME: NUMBER OF MEDICAL EDUCATION EVENTS AND CERTIFICATIONS OFFERED AT MFB OPEN TO MFB AND WEST MICHIGAN COMMUNITY MEMBERS THAT ARE FOCUSED ON POST-ACUTE CARE AND REHABILITATION- IMPLEMENTATION STRATEGY: REDUCE RISK OF CHRONIC DISEASE, IMPROVE CARDIOVASCULAR HEALTH, AND PROMOTE QUALITY OF LIFE IN THE MFB WORKFORCESPECIFIC NEEDS IDENTIFIED IN CHNA: DISABILITYSPECIFIC NEEDS IDENTIFIED IN CHNA: CHRONIC DISEASE, NUTRITION & OBESITYTHROUGH THE IMPLEMENTATION OF A COMPREHENSIVE EMPLOYEE WELLNESS PROGRAM (MFB SO4.3) AND USE OF POPULATION HEALTH MANAGEMENT REPORTS (NEW)- MEASUREABLE OUTCOME: USE POPULATION HEALTH MANAGEMENT VALUES TO DRIVE EMPLOYEE WELLNESS INITIATIVES AND CHALLENGES- MEASUREABLE OUTCOME: IMPROVE NUTRITIONAL HABITS BY INCREASING NUMBER OF EMPLOYEES ACCESSING THE OUTPATIENT REGISTERED DIETICIAN VIA HEALTH CARE CLAIMS DATA OR ENCOUNTERS- MEASUREABLE OUTCOME: IMPROVE BMI AND WEIGHT STATUS AWARENESS BY INCREASING THE NUMBER OF EMPLOYEES WHO REGULARLY PARTICIPATE IN THE MFB HEALTHY! YOU WELLNESS PROGRAM OR OTHER WEIGHT MANAGEMENT PROGRAM- MEASUREABLE OUTCOME: IMPROVE PHYSICAL ACTIVITY LEVELS AMONG MFB EMPLOYEES THROUGH PEER EXERCISE/PHYSICAL ACTIVITY CHALLENGES- MEASUREABLE OUTCOME: IMPROVE EMPLOYEE LIFE SATISFACTION PER SELF-REPORTED LIFE SATISFACTION ON POPULATION HEALTH MANAGEMENT REPORTSOTHER NEEDS IDENTIFIED IN CHNA NOT ADDRESSED IN THIS STRATEGY- MARY FREE BED REHABILITATION HOSPITAL'S COMMUNITY HEALTH NEEDS ASSESSMENT AND IMPLEMENTATION PLAN WILL ADDRESS THE THREE AFOREMENTIONED COMMUNITY IDENTIFIED HEALTH NEEDS. WHILE THE CHNA AND IP CHOSE TO FOCUS ON HOSPITAL RESOURCES THAT STRENGTHEN THESE THREE COMMUNITY NEEDS AREAS, IT IS IMPORTANT TO RECOGNIZE THAT THESE ARE NOT THE ONLY NEEDS BEING ADDRESSED BY THE HOSPITAL. THE MARY FREE BED IP WILL NOT ADDRESS CERTAIN COMMUNITY NEEDS IDENTIFIED BY THE KENT COUNTY CHNA- SUCH AS SUBSTANCE ABUSE OR VIOLENCE AND SAFETY. WHILE THESE NEEDS WERE IDENTIFIED IN OUR COMMUNITY, AND MARY FREE BED HAS AN OBLIGATION TO ASSESS PATIENTS FOR THESE CONDITIONS, HOWEVER, OTHER AREA ORGANIZATION ARE BETTER ABLE TO ALLOCATE RESOURCES TO THESE NEEDS AS THEY RELATE TO PERSONS IN THE COMMUNITY.- MONITORING OF IMPLEMENTATION STRATEGY AND REPORTING OF OUTCOMES- MARY FREE BED HAS IDENTIFIED INDIVIDUALS WITHIN THE ORGANIZATION WHO WILL BE ACCOUNTABLE FOR EACH STRATEGY. IN ADDITION, A WORKGROUP HAS BEEN ESTABLISHED TO IDENTIFY METRICS OF MEASUREMENT FOR EACH OUTCOME. SYSTEMS AND PROCESSES ARE BEING PUT INTO PLACE TO OBTAIN SPECIFIC MEASURES AND TRACK EACH HEALTH NEED. THESE MEASURES WILL BE COLLECTED ANNUALLY AND RESULTS SUBMITTED TO THE BOARD AND MARY FREE BED COMMUNITY. UPON REVIEW, ADJUSTMENTS OR CHANGES WILL BE MADE TO THE STRATEGIES AND MEASURABLE OUTCOMES AS DEEMED APPROPRIATE OR NECESSARY. MARY FREE BED REHABILITATION HOSPITAL PART V, SECTION B, LINE 16J: THE ADMISSIONS/ACCESS DEPARTMENTS REVIEW THE AVAILABILITY OF INSURANCE COVERAGES, AND AVAILABILITY OF FINANCIAL ASSISTANCE IF UNINSURED OR UNDER-INSURED WITH EACH PATIENT/GUARANTOR AT THE TIME OF ADMISSION. 25 1 - MARY FREE BED OUTPATIENT SERVICES 235 WEALTHY ST SE GRAND RAPIDS MI 49503 OUTPATIENT THERAPY, PSYCHOLOGY, AND NUTRITION 2 - MARY FREE BED PHYSICIAN CLINIC 235 WEALTHY ST SE GRAND RAPIDS MI 49503 OUTPATIENT PHYSICIAN CLINIC 3 - MARY FREE BED PAIN REHABILITATION 235 WEALTHY ST SE GRAND RAPIDS MI 49503 OUTPATIENT PAIN REHABILITATION 4 - MARY FREE BED KALAMAZOO SOUTHWEST 7125 STADIUM DRIVE KALAMAZOO MI 49009 OUTPATIENT THERAPY, OUTPATIENT PAIN REHABILITATION 5 - MARY FREE BED AT MUNSON MEDICAL CENTER 5191 ROSEWOOD DR TRAVERSE CITY MI 49685 OUTPATIENT THERAPY, OUTPATIENT PAIN REHABILITATION 6 - MARY FREE BED SPARTANNASH YMCA 5722 METRO WAY SW SUITE B WYOMING MI 49519 OUTPATIENT THERAPY 7 - MARY FREE BED HOLLAND 3290 N WELLNESS DR SUITE 170 HOLLAND MI 49424 OUTPATIENT THERAPY, OUTPATIENT PAIN REHABILITATION 8 - MARY FREE BED ABA PROGRAM 1550 3 MILE RD NW SUITE A GRAND RAPIDS MI 49544 OUTPATIENT ABA THERAPY 9 - MARY FREE BED AT MUNSON MEDICAL CENTER 128 AMES ST ELK RAPIDS MI 49629 OUTPATIENT THERAPY 10 - MARY FREE BED AT CANCER & HEMATOLOGY 6425 S HARVEY ST NORTON SHORES MI 49444 OUTPATIENT THERAPY, OUTPATIENT PAIN REHABILITATION 11 - MARY FREE BED HOME & COMMUNITY THERAPY 350 LAFAYETTE AVENUE SE GRAND RAPIDS MI 49503 HOME THERAPY SERVICES 12 - MFB HAND CENTER 1000 EAST PARIS AVE SUITE 115A GRAND RAPIDS MI 49546 OUTPATIENT THERAPY 13 - MARY FREE BED AT CANCER & HEMATOLOGY - E 5800 FOREMOST DR SE GRAND RAPIDS MI 49546 OUTPATIENT THERAPY 14 - MARY FREE BED AT MUNSON MEDICAL CENTER 3988 WEST ROYAL DRIVE TRAVERSE CITY MI 49684 OUTPATIENT THERAPY 15 - THE MARY FREE BED YMCA 5500 BURTON ST SE GRAND RAPIDS MI 49546 OUTPATIENT THERAPY 16 - MARY FREE BED AT MUNSON MEDICAL CENTER 4025 CHUMS VILLAGE DR SUITE E TRAVERSE CITY MI 49685 OUTPATIENT THERAPY 17 - MARY FREE BED HOLLAND PEDIATRICS 3290 N WELLNESS DR SUITE 170 HOLLAND MI 49424 OUTPATIENT THERAPY 18 - MARY FREE BED AT MUNSON MEDICAL CENTER 550 MUNSON AVENUE TRAVERSE CITY MI 49686 OUTPATIENT PHYSICIAN CLINIC 19 - MARY FREE BED PSYCHOLOGY - TRAVERSE CITY 550 MUNSON AVENUE TRAVERSE CITY MI 49686 OUTPATIENT PSYCHOLOGY, OUTPATIENT ABA THERAPY 20 - MARY FREE BED ABA PROGRAM 550 MUNSON AVENUE TRAVERSE CITY MI 49686 OUTPATIENT PSYCHOLOGY, OUTPATIENT ABA THERAPY 21 - MFB AT PLASTIC SURGERY ASSOCIATES 220 LYONS ST NW SUITE 700 GRAND RAPIDS MI 49503 OUTPATIENT THERAPY 22 - MARY FREE BED TROY 1845 LIVERNOIS RD TROY MI 48083 OUTPATIENT PAIN REHABILITATION 23 - MARY FREE BED NOVI 39475 LEWIS DR NOVI MI 48377 OUTPATIENT PAIN REHABILITATION 24 - MARY FREE BED MOTION ANALYSIS CENTER 301 MICHIGAN ST NE GRAND RAPIDS MI 49503 OUTPATIENT THERAPY 25 - MARY FREE BED AT MUNSON MEDICAL CENTER 2291 M-113 E KINGLSEY MI 49649 OUTPATIENT THERAPY PART I, LINE 7: THE COST TO CHARGE RATIO IS USED TO CALCULATE COMMUNITY BENEFITS. PART I, LN 7 COL(F): THE BAD DEBT EXPENSE INCLUDED ON FORM 990, PART IX, LINE 25(A),BUT SUBTRACTED FOR PURPOSES OF CALCULATING THE PERCENTAGE INTHIS COLUMN IS $ 1,080,029 PART II, COMMUNITY BUILDING ACTIVITIES: COMMUNITY BUILDING ACTIVITIES INCLUDED WORKING WITH "WEST MICHIGAN WORKS!" TO HELP YOUNG PEOPLE IDENTIFY THEIR INTERESTS, GAIN KNOWLEDGE OF HEALTH CARE CAREERS, AND OBTAIN TRAINING FOR THOSE CAREERS. IN ADDITION, COMMUNITY BUILDING ACTIVITIES INCLUDED THE MARY FREE BED REHABILITATION HOSPITAL'S CFO SERVING ON THE BOARD OF ANOTHER NON-PROFIT COMMUNITY SERVICE ORGANIZATION. PART III, LINE 2: FOR RECEIVABLES ASSOCIATED WITH SERVICES PROVIDED TO PATIENTS WHO HAVE THIRD-PARTY COVERAGE, THE HOSPITAL ANALYZES CONTRACTUALLY DUE AMOUNTS AND PROVIDES FOR AN ALLOWANCE FOR DOUBTFUL ACCOUNTS AND A PROVISION FOR BAD DEBTS, IF NECESSARY. FOR RECEIVABLES ASSOCIATED WITH SELF-PAY PATIENTS (WHICH INCLUDES BOTH PATIENTS WITHOUT INSURANCE AND PATIENTS WITH DEDUCTIBLE AND COPAYMENT BALANCES DUE FOR WHICH THIRD-PARTY COVERAGE EXISTS FOR PART OF THE BILL), THE HOSPITAL RECORDS A PROVISION FOR BAD DEBTS IN THE PERIOD OF SERVICE ON THE BASIS OF ITS PAST EXPERIENCE, WHICH INDICATES THAT MANY PATIENTS ARE UNABLE OR UNWILLING TO PAY THE PORTION OF THEIR BILL FOR WHICH THEY ARE FINANCIALLY RESPONSIBLE. THE DIFFERENCE BETWEEN THE STANDARD RATES (OR THE DISCOUNTED RATES, IF NEGOTIATED) AND THE AMOUNTS ACTUALLY COLLECTED AFTER ALL REASONABLE COLLECTION EFFORTS HAVE BEEN EXHAUSTED IS CHARGED OFF AGAINST THE ALLOWANCE FOR DOUBTFUL ACCOUNTS IN THE PERIOD THEY ARE DETERMINED TO BE UNCOLLECTIBLE. PART III, LINE 3: REVIEWED THE LISTING OF BAD DEBT WRITE-OFFS POSTED DURING THE YEAR, AND FILTERED TO ACCOUNTS WITH CHARITY, MEDICAID, OR SELF-PAY AS SECONDARY PLANS. HIGHER AMOUNTS WERE CHECKED FOR PATIENT FINANCIAL SERVICE NOTES INDICATING THE PATIENT WAS LIKELY ELIGIBLE FOR CFA, BUT THE PATIENT/GUARANTOR DID NOT PROVIDE THE NECESSARY INFORMATION TO MEDICAID, MFB, OR TO ANY OTHER ACUTE HOSPITAL INVOLVED IN THEIR CARE DESPITE REPEATED ATTEMPT TO OBTAIN THIS INFORMATION. PART III, LINE 4: ACCOUNTS RECEIVABLE FOR PATIENTS, INSURANCE COMPANIES, AND GOVERNMENTAL AGENCIES ARE BASED ON GROSS CHARGES, REDUCED BY EXPLICIT PRICE CONCESSIONS PROVIDED TO THIRD-PARTY PAYORS, DISCOUNTS PROVIDED TO QUALIFYING INDIVIDUALS AS PART OF OUR FINANCIAL ASSISTANCE POLICY, AND IMPLICIT PRICE CONCESSIONS PROVIDED PRIMARILY TO SELF-PAY PATIENTS. ESTIMATES FOR EXPLICIT PRICE CONCESSIONS ARE BASED ON PROVIDER CONTRACTS, PAYMENT TERMS FOR RELEVANT PROSPECTIVE PAYMENT SYSTEMS, AND HISTORICAL EXPERIENCE ADJUSTED FOR ECONOMIC CONDITIONS AND OTHER TRENDS AFFECTING THE ORGANIZATION'S ABILITY TO COLLECT OUTSTANDING AMOUNTS. FOR RECEIVABLES ASSOCIATED WITH SELF-PAY PATIENTS (WHICH INCLUDE BOTH PATIENTS WITHOUT INSURANCE AND PATIENTS WITH DEDUCTIBLE AND COPAYMENT BALANCES DUE FOR WHICH THIRD-PARTY COVERAGE EXISTS FOR PART OF THE BILL), THE ORGANIZATION RECORDS SIGNIFICANT IMPLICIT PRICE CONCESSIONS IN THE PERIOD OF SERVICE ON THE BASIS OF ITS PAST EXPERIENCE, WHICH INDICATES THAT MANY PATIENTS ARE UNABLE OR UNWILLING TO PAY THE PORTION OF THEIR BILL FOR WHICH THEY ARE FINANCIALLY RESPONSIBLE. PART III, LINE 8: (1) MEDICARE GROSS REIMBURSMENTS AMOUNTS WERE TAKEN FROM THE CMS PROVIDER STATISTICAL AND REIMBURSEMENT SYSTEM REPORT (PS&R REPORTS) LESS SEQUESTRATION DEDUCTIONS. (2) ALL OF THE MEDICARE SHORTFALL SHOULD BE CONSIDERED A COMMUNITY BENEFIT BECAUSE SERVICES ARE PROVIDED WITH THE FULL RECOGNITION THAT MEDICARE REIMBURSEMENT WILL BE INSUFFICIENT TO COVER THE COSTS OF PROVIDING THOSE SERVICES. (3) THE COST TO CHARGE RATIO WAS CALCULATED BASED ON THE FY2021 MEDICARE COST REPORT. PART III, LINE 9B: PATIENTS RECEIVING 100% CHARITY CARE HAVE A UNIQUE FINANCIAL CLASS ASSIGNED TO THEM. UNDERINSURED AND LOW INCOME INSUREDS WILL HAVE A SECONDARY FINANCIAL CLASS OF CFA. ALL CHARITY CARE ACCOUNTS ARE EXCLUDED FROM ACCOUNTS BEING SENT TO THE COLLECTION AGENCY. FOR THOSE PATIENTS/GUARANTORS WHOM WE HAVE REASON TO BELIEVE WOULD QUALIFY FOR FAP, COPIES OF THE POLICIES AND APPLICATIONS ARE PROVIDED, AND ASSISTANCE OFFERED TO COMPLETE THE FORMS. PART VI, LINE 2: THE HEALTHCARE NEEDS OF THE COMMUNITIES SERVED ARE DETERMINED THROUGH THE HOSPITAL'S ANNUAL STRATEGIC PLANNING PROCESS AND A COMMUNITY-WIDE SURVEY BY THE KENT COUNTY HEALTH DEPARTMENT. INPUT FROM PATIENTS, FAMILIES OF PATIENTS, REFERRING PHYSICIANS, HOSPITAL DISCHARGE PLANNERS, AS WELL AS INFORMATION FROM OTHER COMMUNITY HEALTHCARE PROVIDERS ARE USED TO DETERMINE THE REHAB HEALTHCARE NEEDS OF THE COMMUNITIES SERVED. PART VI, LINE 3: EACH PATIENT RECEIVES AN INFORMATION PACKET WHICH INCLUDES A COPY OF OUR CHARITY CARE POLICY AND APPLICATION. FURTHER, IF ANY SERVICES ARE NOT COVERED OR ONLY PARTIALLY COVERED BY THEIR INSURANCE, PATIENTS ARE CONTACTED AND CHARITY CARE IS AGAIN OFFERED, IF APPROPRIATE. MANY OF OUR PATIENTS COME FROM AN ACUTE CARE HOSPITAL WITH SIMILAR CHARITY POLICIES; WE ARE OFTEN ABLE TO CONTACT THE REFERRING HOSPITAL TO DISCUSS A PATIENT'S ELIGIBILITY. PART VI, LINE 4: THE HOSPITAL PRIMARILY SERVES KENT COUNTY IN WESTERN MICHIGAN AND 12 OR SO SURROUNDING COUNTIES. KENT COUNTY HAD 657,974 PEOPLE ACCORDING TO THE 2020 CENSUS. APPROXIMATELY 82% OF THE RESIDENTS WERE WHITE, AND 10% WERE BLACK/AFRICAN AMERICAN. IN 2019, 9.3% HAD NO HIGH SCHOOL DIPLOMA, AND 80.7% HAD A HIGH SCHOOL DIPLOMA/GED OR HIGHER. IN 2019, 11.2% OF ITS RESIDENTS LIVED BELOW THE POVERTY LEVEL. PART VI, LINE 5: MARY FREE BED REHABILITATION HOSPITAL HAS AN OPEN MEDICAL STAFF AND A COMMUNITY BOARD. THE HOSPITAL AND A SISTER CORPORATION, THE MARY FREE BED FUND, USE SURPLUS AND DONATED FUNDS FOR A VARIETY OF ACTIVITIES TO SUPPORT THE HEALTH OF OUR GENERAL COMMUNITY, AND MORE SPECIFICALLY, THE HEALTH AND WELL-BEING OF PERSONS WITH DISABILITIES. PART VI, LINE 7, REPORTS FILED WITH STATES MI 0 HEART OF WEST MICHIGAN UNITED WAY 118 COMMERCE AVE SW GRAND RAPIDS MI 49503 680480736 501(C)(3) 27500 N/A N/A HEALTH AND HUMAN SERVICES GRAND VALLEY STATE UNIVERSITY 301 FULTON ST SW GRAND RAPIDS MI 49501 381684280 501(C)(3) 133000 N/A N/A CONSTRUCTION AND EDUCATION THE SPARROW FOUNDATION 1322 E MICHIGAN AVE LANSING MI 48912 386100687 501(C)(3) 12900 N/A N/A PROGRAM SUPPORT AMERICAN HEART ASSOCIATION PO BOX 4002902 DES MOINES IA 50340 135613797 501(C)(3) 6000 N/A N/A PROGRAM SUPPORT SAINT MARY'S FOUNDATION 200 JEFFERSON SE GRAND RAPIDS MI 49503 381779602 501(C)(3) 6000 N/A N/A PROGRAM SUPPORT 5 0 X X X X 0 1 0 0 0 0 0 1 0 KENT RIDDLE PRESIDENT 731626 0 109148 0 0 0 519950 0 16710 0 1377434 0 0 0 INGRID CHESLEK CHIEF OPERATING OFFICER 385736 0 56250 0 0 0 117100 0 16710 0 575796 0 0 0 BENJAMIN BRUINSMA PHYSICIAN, M.D. 391959 0 114214 0 0 0 22800 0 21007 0 549980 0 0 0 DR MICHAEL JAKUBOWSKI MD DIRECTOR 439043 0 63000 0 0 0 22800 0 21007 0 545850 0 0 0 WILLIAM VANDENBERG PHYSICIAN, M.D. 296786 0 124379 0 0 0 22800 0 11839 0 455804 0 0 0 STUART YABLON PHYSICIAN, M.D. 370591 0 8200 0 0 0 19915 0 10479 0 409185 0 0 0 JEFFREY GARBER CHIEF STRATEGY OFFICER 319107 0 48000 0 0 0 17100 0 10479 0 394686 0 0 0 MARSHALL POOLE PHYSICIAN, D.O. 302581 0 44756 0 0 0 21527 0 18444 0 387308 0 0 0 RANDALL DENEFF CFO 280318 0 56250 0 0 0 22800 0 16710 0 376078 0 0 0 PART I, LINE 4B MARY FREE BED REHABILITATION HOSPITAL (MFB) MAINTAINS A SUPPLEMENTAL RETIREMENT PLAN (SERP) FOR A SELECT GROUP OF EXECUTIVES OF MFB AND ITS AFFILIATED ENTITIES. THIS SERP IS AN UNFUNDED, NONQUALIFIED DEFERRED COMPENSATION PLAN THAT IS INTENDED TO COMPLY WITH SECTION 457(F) OF THE INTERNAL REVENUE CODE. BENEFITS UNDER THIS SERP IS TAXABLE TO THE PARTICIPATING EXECUTIVES WHEN SUCH AMOUNTS ARE VESTED. KENT RIDDLE AND INGRID CHESLEK ARE PARTICIPANTS OF THIS PLAN. THERE WERE NO SERP PAYMENTS DURING THE YEAR. PART I, LINE 7 ALL MARY FREE BED REHABILITATION HOSPITAL EMPLOYEES HAVE AN ANNUAL EVALUATION AND ARE ELIGIBLE FOR A PERFORMANCE BONUS BASED ON MEETING CERTAIN INDIVIDUAL AND TEAM GOALS. THE BOARD OF DIRECTORS DETERMINES AND VOTES ON THE DISCRETIONARY BONUS. A KENT HOSPITAL FINANCE AUTHORITY 382350002 2012-10-26 14000000 PARTIAL FUNDING OF NEW HOSPITAL ADDITION 0 0 0 B KENT HOSPITAL FINANCE AUTHORITY 364142114 2014-12-18 8500000 PARTIAL FUNDING OF EXISTING HOSPITAL RENOVATION 0 0 0 A 11474972 14000000 14000000 0 0 1 1 B 8500000 8500000 8500000 0 0 1 1 A 0 0 0 0 0.00000 0.00000 0.00000 0 0 0 B 0 0 0 0 0.00000 0.00000 0.00000 0 0 0 A 0 1 0 0 0 0 0 0 0 B 0 0 0 1 0 0 0 0 0 A 1 B 1 DATE REBATE COMPUTATION PERFORMED ISSUER NAME: KENT HOSPITAL FINANCE AUTHORITY DATE THE REBATE COMPUTATION WAS PERFORMED: 12/01/2018 FORM 990, PART VI, SECTION A, LINE 6 THE ORGANIZATION HAS ONE SHAREHOLDER, MARY FREE BED GUILD, AS DICTATED BY THE BY-LAWS. FORM 990, PART VI, SECTION A, LINE 7A THE SOLE SHAREHOLDER, MARY FREE BED GUILD, HOLDS 50% OF THE BOARD POSITIONS WHICH EXERCISE THE RIGHT TO ELECT HOSPITAL BOARD MEMBERS. FORM 990, PART VI, SECTION A, LINE 7B THE SOLE SHAREHOLDER MUST APPROVE CERTAIN HOSPITAL BOARD TRANSACTIONS SUCH AS REAL ESTATE TRANSACTIONS. FORM 990, PART VI, SECTION B, LINE 11B THE FORM 990 IS REVIEWED BY THE CFO PRIOR TO FILING. AFTER COMPLETION OF THE RETURN, RETURN WILL BE POSTED TO AN INTERNAL WEBSITE PORTAL FOR ALL BOARD MEMBERS TO REVIEW BEFORE FILING. FORM 990, PART VI, SECTION B, LINE 12C CONFLICT OF INTEREST POLICIES ARE UPDATED ANNUALLY BY ALL BOARD MEMBERS, OFFICERS, AND STAFF. PROCESS IS ADMINISTERED OUT OF THE EXECUTIVE ADMINISTRATION OFFICE. ANY DISCLOSED CONFLICTS OF INTEREST WOULD BE DISCLOSED TO THE BOARD OF DIRECTORS AND ASSURANCES OBTAINED THAT NO ILLEGAL OR SUBSIDIZED ACTIVITIES ARE OCCURRING. ALL DISCLOSURES ARE REVIEWED BY THE HOSPITAL'S COMPLIANCE COMMITTEE. IF A CONFLICT OF INTEREST IS EXPOSED, THE INDIVIDUAL WHO IS THE SUBJECT OF THE CONFLICT IS EXCUSED FROM THE MEETING SO THE REST OF THE BOARD MAY DISCUSS THE ISSUE AND TAKE APPROPRIATE ACTION. FORM 990, PART VI, SECTION B, LINE 15 THE EXECUTIVE COMMITTEE OF THE BOARD OF TRUSTEES DETERMINES THE COMPENSATION FOR THE HOSPITAL'S PRESIDENT AND MEDICAL DIRECTOR. MARKET SURVEY DATA OF COMPARABLE SALARIES IS USED TO ESTABLISH BASE SALARY. FORM 990S OF SIMILAR ORGANIZATIONS ARE ALSO USED TO ESTABLISH COMPENSATION FOR THE PRESIDENT AND THE MEDICAL DIRECTOR. AN INCENTIVE PLAN WITH SPECIFIC MEASURES AND WEIGHTINGS FOR FINANCIAL, QUALITY, CUSTOMER SATISFACTION, AND INDIVIDUAL GOALS IS ALSO IN PLACE FOR THE PRESIDENT AND MEDICAL DIRECTOR. THIS PROCESS WAS MOST RECENTLY UNDERTAKEN IN 2020. FORM 990, PART VI, SECTION C, LINE 19 GOVERNING DOCUMENTS AND CONFLICT OF INTEREST POLICY ARE NOT AVAILABLE FOR PUBLIC INSPECTION. FINANCIAL STATEMENTS ARE SUMMARIZED IN AN ANNUAL REPORT WHICH IS AVAILABLE TO THE PUBLIC. FORM 990, PART XI, LINE 9: TRANSFER TO AFFILIATE -842,912. FORM 990, PART XII, LINE 2C: THERE HAS BEEN NO CHANGE IN PROCESS FROM PRIOR YEAR. 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