2021-08-16T11:55:42-05:00 2020-09-30 351178661 BLUE & CO LLC 500 N MERIDIAN ST SUITE 200 INDIANAPOLIS IN 46204 990 2019-10-01 350877575 GIBSON GENERAL HOSPITAL GIBS 8123853401 1808 SHERMAN DRIVE PRINCETON IN 47670 RICHARD HARNING CFO 8123853401 2021-08-16 1 NATHAN A RODGERS CPA P01568275 3176334705 2021-08-16 2019 2022-09-23 18:48:47Z DEACONESS GIBSON HOSPITAL RICHARD HARNING 1808 SHERMAN DRIVE PRINCETON IN 47670 34679253 0 X WWW.DEACONESS.COM X 1941 IN TO PROVIDE HIGH QUALITY, PATIENT-CENTERED, COST-EFFECTIVE CARE FOR PEOPLE IN THE COMMUNITY. 14 9 436 50 0 0 394337 530678 32342769 33690553 115553 46851 297027 411171 33149686 34679253 0 0 0 0 17603397 17033259 0 0 0 15511704 19211449 33115101 36244708 34585 -1565455 24802023 35967803 14519018 27250253 10283005 8717550 THE MISSION OF GIBSON GENERAL HOSPITAL AND THE SKILLED NURSING FACILITY IS TO PROVIDE HIGH QUALITY, PATIENT-CENTERED, COST-EFFECTIVE CARE FOR PEOPLE IN OUR COMMUNITY. 0 0 26517609 0 33821634 THE HOSPITAL'S MISSION IS TO PROVIDE HIGH QUALITY AND COST-EFFECTIVE HEALTHCARE, WHICH INCLUDES PATIENT, OUTPATIENT, AND EMERGENCY CARE SERVICES TO THE RESIDENTS OF THE SURROUNDING TRI-STATE AREA. ALL EXPENSES RELATE TO COSTS ASSOCIATED WITH PROVIDING THESE SERVICES, AND MAINLY INCLUDE SALARIES AND WAGES TO STAFF AND SUPPLIES COST. THERE WERE 379 ADMISSIONS AND 35,767 VISITS DURING THE YEAR. 26517609 1 1 0 1 0 0 0 0 0 0 1 0 0 0 1 1 0 1 0 0 0 0 0 0 0 0 1 1 0 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 1 1 0 0 0 1 43 0 1 436 1 0 0 0 0 0 0 0 0 0 0 0 0 X 14 9 0 1 1 0 1 1 1 1 1 0 0 1 1 1 1 1 1 1 1 0 IN X CHERYL A WATHEN 8124503296 600 MARY STREET EVANSVILLE IN 47747 J ROBERT KINKLE CHAIR 2.00 0.00 X X 0 0 0 MIKE WOOD FIRST VICE-CHAIR 2.00 0.00 X X 0 0 0 SUSAN STRAUB SECOND VICE-CHAIR 2.00 0.00 X X 0 0 0 STEPHEN LANKFORD TREASURER 2.00 0.00 X X 0 0 0 GEORGE A BALLARD SECRETARY 2.00 0.00 X X 0 0 0 MS KRISHNA MD CHIEF OF STAFF 2.00 0.00 X 0 0 0 HENRY BREWSTER BOARD MEMBER 2.00 0.00 X 0 0 0 JARED FLORENCE BOARD MEMBER 2.00 55.00 X 0 422931 104873 MARION JOCHIM BOARD MEMBER 2.00 0.00 X 0 0 0 MARY KEY BOARD MEMBER 2.00 0.00 X 0 0 0 SHAWN MCCOY BOARD MEMBER 2.00 53.00 X 0 1194039 246069 DEREK MCGRAW BOARD MEMBER 2.00 0.00 X 0 0 0 ALLEN WHITE MD BOARD MEMBER 2.00 51.00 X 0 492803 138333 GREG WRIGHT BOARD MEMBER 2.00 0.00 X 0 0 0 CLAUDIA EISENMANN CEO 50.00 0.00 X 0 335355 9972 LOIS MORGAN CNO 50.00 0.00 X 0 197183 16526 JARED STIMPSON CFO 50.00 0.00 X 0 250966 22584 JANET JAMES CAO 50.00 0.00 X 18379 0 0 COREY A POTTS CRNA 40.00 0.00 X 231502 0 18816 BRUCE BRINK PHYSICIAN 40.00 0.00 X 209719 0 19000 RICHARD CLARK PHYSICIAN 40.00 0.00 X 240890 0 9791 ADRIAN CARTER PHYSICIAN 40.00 0.00 X 233929 0 9686 DAVID PURSOM PHYSICIAN 40.00 0.00 X 265525 0 28571 1199944 2893277 624221 10 0 1 0 GREAT LAKES EMERGENCY PHYSICIANS 1602 AVENUE Q LUBBOCK TX 79401 MEDICAL PRO FEES 1027667 MID WEST HOSPITAL 1602 AVENUE Q LUBBOCK TX 79401 MEDICAL PRO FEES 343979 COMPREHENSIVE PHARMACY 655 METRO PLACE SOUTH DUBLIN OH 43017 PHARMACY SERVICES 286700 TRIAGE LLC PO BOX 3291 OMAHA NE 68103 STAFFING 201896 MAQBOOL AHMED MD 5326 CLAIRBORN CT NEWBURGH IN 47630 MEDICAL PRO FEES 149800 8 24667 506011 530678 PATIENT SERVICE REVENUE 624100 33690553 33690553 33690553 46851 46851 63920 0 63920 63920 63920 340B PHARMACY REVENUE 624100 123633 123633 CAFETERIA REVENUE 722210 112360 112360 111258 7448 103810 347251 34679253 33821634 0 326941 X 801881 801881 12109336 10231913 1877423 172057 140069 31988 2803003 1546631 1256372 1146982 948101 198881 1296666 356895 939771 34229 34229 5310659 4180887 1129772 191015 758 190257 655922 481175 174747 2704423 1310617 1393806 83874 73665 10209 231938 174181 57757 2068894 1553698 515196 337790 44902 292888 MEDICAL & DRUG SUPPLIES 3671449 3638004 33445 DUES & SUB. 1514138 1003274 510864 1110452 832839 277613 36244708 26517609 9727099 0 4456119 9908824 2694008 3701882 3643535 4607298 689106 725941 703024 672034 16306192 174680 12543193 16131512 51325 69801 21713 150511 24802023 35967803 2848560 4784617 473844 91833 10094721 17888189 1101893 4485614 14519018 27250253 X 10231680 8717550 51325 0 10283005 8717550 24802023 35967803 -1565455 0 X X 0 1 X 1 0 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 0 0 0 0 0 0 0 0 1 865 865 0 PART II-B, LINE 1: THE HOSPITAL PAID MEMBERSHIP DUES TO INDIANA HOSPITAL ASSOCATION "IHA". IHA ATTRIBUTED 7.00% ($) OF THE DUES TO LOBBYING EXPENSES. 421244 421244 7385359 48163 7337196 8438655 126517 8312138 60934 60934 16131512 THIRD PARTY PAYABLE 4485614 4485614 X PART X, LINE 2: ACCOUNTING PRINCIPLES GENERALLY ACCEPTED IN THE UNITED STATES OF AMERICA REQUIRE MANAGEMENT TO EVALUATE TAX POSITIONS TAKEN BY THE COMPANY AND RECOGNIZE A TAX LIABILITY IF THE COMPANY HAS TAKEN AN UNCERTAIN POSITION THAT MORE LIKELY THAN NOT WOULD NOT BE SUSTAINED UPON EXAMINATION BY VARIOUS FEDERAL AND STATE TAXING AUTHORITIES. MANAGEMENT HAS ANALYZED THE TAX POSITIONS TAKEN BY THE COMPANY AND HAS CONCLUDED THAT AS OF SEPTEMBER 30, 2020 AND 2019, THERE ARE NO UNCERTAIN POSITIONS TAKEN OR EXPECTED TO BE TAKEN THAT WOULD REQUIRE RECOGNITION OF A LIABILITY OR DISCLOSURE IN THE ACCOMPANYING CONSOLIDATED FINANCIAL STATEMENTS. THE COMPANY IS SUBJECT TO ROUTINE AUDITS BY TAXING JURISDICTIONS; HOWEVER, THERE ARE CURRENTLY NO AUDITS FOR ANY TAX PERIODS IN PROGRESS. 1 1 X 1 X 149.000000000000 1 X 1 1 1 0 1 1 272610 272610 0.00750 2852827 1800225 1052602 0.02900 3125437 1800225 1325212 0.03650 3125437 1800225 1325212 0.03650 1 2214784 11541538 12103316 -561778 X 1 1 1 1 GIBSON GENERAL HOSPITAL INC 1808 SHERMAN DRIVE PRINCETON IN 47670 WWW.GIBSONGENERAL.COM 20-005019-1 X X X X GIBSON GENERAL HOSPITAL INC 0 0 1 X X X X X X X X X 18 1 0 1 1 X SEE PART V, PAGE 8 X X 1 18 1 SEE PART V, PAGE 8 0 1 X 149.000000000000 300.000000000000 X X X X 1 1 X X X 1 X SEE PART V, PAGE 8 X SEE PART V, PAGE 8 X SEE PART V, PAGE 8 X X X X X X 1 X 0 X X X 1 X 0 0 GIBSON GENERAL HOSPITAL INC PART V, SECTION B, LINE 5: THE HOSPITAL COLLABORATED WITH A RANGE OF PUBLIC HEALTH AND SOCIAL SERVICE PARTNERS TO ENSURE THAT DIVERSE SCIENTIFIC AND COMMUNITY-BASED INSIGHTS WERE INCLUDED IN ITS 2018 COMMUNITY HEALTH NEEDS ASSESSMENT. KEY PARTNERS WERE THE UNIVERSITY OF EVANSVILLE, INDIANA UNIVERSITY SCHOOL OF PUBLIC HEALTH, INDIANA UNIVERSITY CENTER FOR SURVEY RESEARCH AND MEASURES MATTER, LLC. A 24-QUESTION SURVEY WAS CREATED BASED ON INPUT FROM THESE PARTNERS AND OTHER HEALTH CARE FACILITIES ACROSS THE STATE OF INDIANA. THE SURVEY WAS MAILED TWICE VIA USPS TO RESIDENTS OF GIBSON COUNTY, WAS EMAILED TO BUSINESS LEADERS VIA THE LOCAL CHAMBER OF COMMERCE AND MADE AVAILABLE ONLINE VIA THE HOSPITAL'S WEBSITE. IN ADDITION, A FOCUS GROUP OF GIBSON COUNTY REPRESENTATIVES WAS ORGANIZED WHICH INCLUDE HEALTHCARE PROVIDERS, SOCIAL SERVICE ORGANIZATIONS, AND OTHER INTERESTED PARTIES. GIBSON GENERAL HOSPITAL INC PART V, SECTION B, LINE 6B: INDIANA RURAL HEALTH ASSOCIATION GIBSON GENERAL HOSPITAL INC PART V, SECTION B, LINE 7D: CHNA LOCATION:THE CHNA REPORTS CAN BE LOCATED AT THE HOSPITAL'S WEBSITE LOCATED ON THE "COMMUNITY HEALTH NEEDS ASSESSMENT" PAGE LOCATED UNDER "ABOUT US". GIBSON GENERAL HOSPITAL INC PART V, SECTION B, LINE 11: THE COMMUNITY'S MOST SIGNIFICANT NEEDS AS UNCOVERED IN THE 2018 CHNA WERE RELATED TO MENTAL HEALTH, SUBSTANCE ABUSE, CHRONIC DISEASE AND OBESITY.TO MEET THE MENTAL HEALTH NEED, GGH IDENTIFIED SERVICES AND PROVIDERS AVAILABLE IN AND AROUND GIBSON COUNTY. THE HOSPITAL HAS LOOKED FOR OPPORTUNITIES TO PARTNER WITH LOCAL SERVICES TO PROMOTE MENTAL HEALTH IN THE COMMUNITY (VIA TRAINING, SPONSORSHIPS, ETC.). THE HOSPITAL IS ALSO EXPLORING THE DEVELOPMENT OF TELEMEDICINE SERVICES FOR OUTPATIENT MENTAL HEALTH.TO MEET THE SUBSTANCE ABUSE NEED, GGH IS WORKING TO INCREASE AWARENESS OF SUBSTANCE ABUSE ISSUES WITHIN THE COMMUNITY THROUGH EDUCATIONAL PROGRAMS (SEMINARS, EVENTS, INFORMATION, ETC.). THE HOSPITAL IS ALSO WORKING TO ADOPT POLICIES AND PROCEDURES TO FURTHER LIMIT THE PRESCRIPTION OF NARCOTICS IN THE EMERGENCY DEPARTMENT AND PHYSICIAN OFFICES.TO MEET THE CHRONIC DISEASE NEED, THE HOSPITAL IS USING ITS SERVICE LINES TO FOCUS ON EDUCATION AND THE BENEFITS OF SCREENING AND EARLY DETECTION. IN ADDITION, THE HOSPITAL HAS PUSHED FREE SKIN CANCER SCREENINGS, ITS FREE MAMMOGRAM PROGRAM, AND LOOKED INTO OTHER COMMUNITY SCREENING EVENTS. THE HOSPITAL'S CERTIFIED DIABETES EDUCATOR ALSO OFFERS A SUPPORT GROUP.TO MEET THE OBESITY NEED, GGH HAS BEEN LOOKING TO IDENTIFY COMMUNITY PARTNERS WHO ARE FOCUSING ON OBESITY, NUTRITION AND WELLNESS. IT IS ALSO PROVIDING EDUCATION THROUGH EVENTS, HEALTH EDUCATION AND NEWSLETTERS TO PROMOTE HEALTHY EATING, ACTIVITY, AND MORE. THE HOSPITAL HAS ALSO CREATED INTERNAL WELLNESS CHALLENGES TO PROVIDE FURTHER EDUCATION TO STAFF. GIBSON GENERAL HOSPITAL INC PART V, SECTION B, LINE 13H: OTHER ELIGIBLITY CRITERIA: IF AN INDIVIDUAL IS HOMELESS, DECEASED, RECENTLY FILED FOR OR COMPLETED BANKRUPTCY, OR MEETS SPECIAL CIRCUMSTANCES RELATED TO ABILITY TO PAY, THE INDIVIDUAL MAY BE ELIGIBLE FOR FINANCIAL ASSISTANCE. GIBSON GENERAL HOSPITAL INC PART V, SECTION B, LINE 16J: PUBLICIZED FINANCIAL ASSISTANCE POLICY: FAP, FAP APPLICATION, AND PLAIN LANGUAGE SUMMARY CAN BE LOCATED ON THE HOSPITAL'S WEBSITE ON THE "FINANCIAL ASSISTANCE" PAGE UNDER "PATIENTS AND VISITORS". ADDITIONALLY, A SPANISH TRANSLATION OF THE FAP APPLICATION AND PLAIN LANGUAGE SUMMARY ARE AVAILABLE. GIBSON GENERAL HOSPITAL, INC.: SCHEDULE H, PART V, LINE 7A:HTTPS://WWW.DEACONESS.COM/ABOUT-US/COMMUNITY-HEALTH-NEEDS-ASSESSMENT GIBSON GENERAL HOSPITAL, INC.: SCHEDULE H, PART V, LINE 10A:HTTPS://WWW.DEACONESS.COM/ABOUT-US/COMMUNITY-HEALTH-NEEDS-ASSESSMENT GIBSON GENERAL HOSPITAL, INC.: SCHEDULE H, PART V, LINE 16A:HTTPS://WWW.DEACONESS.COM/PAY-MY-BILL/FINANCIAL-ASSISTANCESCHEDULE H, PART V, LINE 16A:HTTPS://WWW.DEACONESS.COM/PAY-MY-BILL/FINANCIAL-ASSISTANCESCHEDULE H, PART V, LINE 16A:HTTPS://WWW.DEACONESS.COM/PAY-MY-BILL/FINANCIAL-ASSISTANCE 7 1 - STAR ONE REHAB 1808 SHERMAN DRIVE PRINCETON IN 47670 PHYSICAL THERAPY, OCCUPATIONAL THERAPY, SPEECH THERAPY 2 - PHYSICIAN OUTPATIENT CLINICS 1808 SHERMAN DRIVE PRINCETON IN 47670 SUBSIDIZED CARE PHYSICIAN PRACTICES 3 - LIFESTYLES DIABETES CENTER 1808 SHERMAN DRIVE PRINCETON IN 47670 DIABETES EDUCATION COUNSELING 4 - GGH - SKILLED NURSING FACILITY 1808 SHERMAN DRIVE PRINCETON IN 47670 SKILLED NURSING REHAB CENTER 5 - GGH-FAMILY PRACTICE 510 N MAIN ST PRINCETON IN 47670 FAMILY MEDICINE 6 - BRINK'S FAMILY PRACTICE 410 N MAIN ST PRINCETON IN 47670 FAMILY MEDICINE/ HOSPITALIST 7 - FORT BRANCH WELLNESS CLINIC 7851 S PROFESSIONAL DR FORT BRANCH IN 47648 FAMILY PRACTICE PART I, LINE 3C: GIBSON GENERAL HOSPITAL USES THE FOLLOWING FACTORS, IN ADDITION TO THE FPG, TO DETERMINE AN INDIVIDUAL'S ELIGIBILITY FOR FINANCIAL ASSISTANCE UNDER THE HOSPITAL'S FINANCIAL ASSISTANCE POLICY: MEDICAL INDECENCY, INSURANCE STATUS, AND UNDERINSURANCE STATUS. ADDITIONALLY, IF AN INDIVIDUAL IS HOMELESS, DECEASED, RECENTLY FILED FOR OR COMPLETED BANKRUPTCY, OR MEETS SPECIAL CIRCUMSTANCES RELATED TO ABILITY TO PAY, THE INDIVIDUAL MAY BE ELIGIBLE FOR FINANCIAL ASSISTANCE. PART I, LINE 7: GIBSON GENERAL HOSPITAL CALCULATED THE COST OF FINANCIAL ASSISTANCE AND MEANS-TESTED GOVERNMENT PROGRAMS, USING THE COST-TO-CHARGE RATIO DERIVED FROM SCHEDULE H, WORKSHEET 2, RATIO OF PATIENT CARE COST-TO-CHARGES. PART III, LINE 2: METHODOLOGY USED TO ESTIMATE BAD DEBT: MANAGEMENT ANALYZES THIRD-PARTY PAYOR SOURCES AND MAKES AN ESTIMATE BASED ON AGING OF ACCOUNTS, HISTORICAL LOSSES, CURRENT ECONOMIC CONDITIONS, AND OTHER FACTORS UNIQUE TO ITS SERVICE AREA. ADDITIONALLY, A SIGNIFICANT PROVISION IS ESTIMATED AND RECORDED FOR SELF-PAY PAYMENTS BASED ON PAST EXPERIENCE. PART III, LINE 3: THE HOSPITAL DOES NOT PURSUE COLLECTION AMOUNTS DETERMINED TO QUALIFY AS CHARITY CARE. THESE AMOUNTS ARE NOT REPORTED AS NET PATIENT REVENUE BECAUSE THE HOSPITAL DOES NOT PURSUE COLLECTION OF AMOUNTS DETERMINED TO QUALIFY AS CHARITY CARE. GIBSON GENERAL HOSPITAL DOES NOT ATTRIBUTE ANY BAD DEBT EXPENSE TO PATIENTS ELIGIBLE UNDER THE ORGANIZATION'S FINANCIAL ASSISTANCE POLICY (FAP), THEREFORE NO PORTION OF BAD DEBT ATTRIBUTABLE TO FAP-ELIGIBLE INDIVIDUALS IS CONSIDERED A COMMUNITY BENEFIT. PART III, LINE 4: AUDITED FINANCIAL STATEMENT FOOTNOTE:FOOTNOTE TO ORGANIZATION'S FINANCIAL STATEMENTS THAT DESCRIBES BAD DEBT EXPENSE IS LOCATED ON PAGE 8 OF THE AUDITED FINANCIAL STATEMENTS WITHIN THE NOTE "ALLOWANCE FOR UNCOLLECTIBLE ACCOUNTS". PART III, LINE 8: MEDICARE SHORTFALL:THE HOSPITAL IS A CRITICAL ACCESS HOSPITAL AND IS REIMBURSED 101%, LESS 2% SEQUESTRATION, OF MEDICARE ALLOWANCE COSTS FOR INPATIENT SERVICES, SWING BED, AND OUTPATIENT PART B SERVICES. THE REVENUE SHORTFALL IS THE DIFFERENCE BETWEEN THE ALLOWABLE COST FOR THE SKILLED NURSING FACILITY AND THE PPS REIMBURSEMENT ALLOWED FOR THAT SKILLED NURSING FACILITY. THE SOURCE USED TO DETERMINE THE AMOUNT OF MEDICARE ALLOWABLE COSTS REPORTED FOR PART III, SECTION B, MEDICARE HAS BEEN PROVIDED FROM THE YEAR ENDED SEPTEMBER 30, 2020: HOSPITAL STATEMENT OF REIMBURSABLE COST. PART III, LINE 9B: COLLECTION PRACTICES:COLLECTION PRACTICES ARE APPLIED TO ALL PATIENTS AT GIBSON GENERAL HOSPITAL. ONCE PATIENTS RECEIVE SERVICES, THE PATIENTS' ACCOUNTS ARE BILLED TO THE APPROPRIATE INSURANCE COMPANY. ONCE PAYMENT IS RECEIVED FROM THE INSURANCE COMPANY, THE REMAINING BALANCE, IF ANY, BECOMES THE PATIENT'S RESPONSIBILITY. NOTIFICATION OF THE BALANCE DUE IS SENT VIA WRITTEN CORRESPONDENCE. IF THE BALANCE IS NOT PAID AND THE ACCOUNT DOES NOT QUALIFY FOR FINANCIAL ASSISTANCE, THE ACCOUNT IS SENT TO A COLLECTION AGENCY TO CONTINUE EFFORTS TO COLLECT THE REMAINING BALANCE DUE. IF THE BALANCE DUE IS NOT PAID WITHIN A CERTAIN NUMBER OF MONTHS, THE ACCOUNT IS RETURNED TO THE HOSPITAL AND THE ACCOUNT IS WRITTEN OFF AS UNCOLLECTIBLE. PART VI, LINE 2: ASSESSING COMMUNITY NEEDS:IN ADDITION TO COMPLETING A CHNA EVERY THREE YEARS, THE HOSPITAL'S LEADERSHIP IS COMPRISED OF COMMUNITY MEMBERS WHO ENGAGE IN DAILY CONVERSATIONS WITH OTHER COMMUNITY MEMBERS AND LEADERS REGARDING THE COMMUNITY THEY LIVE IN AND ITS NEEDS. THESE CONVERSATIONS SUPPLEMENT THE UNDERSTANDING OF THE COMMUNITY'S HEALTH NEEDS IDENTIFIED IN THE CHNA. HOSPITAL LEADERSHIP ALSO USES STRATEGIC PLANNING TO SPONSOR AND ENGAGE IN COMMUNITY ACTIVITIES THAT HELPS LEADERSHIP ASSESS THE HEALTH CARE NEEDS OF THE COMMUNITY THE HOSPITAL SERVES. PART VI, LINE 3: PATIENT EDUCATION OF ELIGIBILITY FOR ASSISTANCE: THE HOSPITAL DISPLAYS POSTERS IN THE CENTRAL REGISTRATION AND EMERGENCY ROOM WAITING-AREA NOTIFYING PATIENTS THAT THEY WILL BE SEEN REGARDLESS OF THEIR ABILITY TO PAY AND FINANCIAL ASSISTANCE IS AVAILABLE TO UNINSURED AND UNDERINSURED IN COMPLIANCE WITH EMTALA. THE FINANCIAL ASSISTANCE POLICY (FAP), FAP APPLICATION, AND PLAIN LANGUAGE SUMMARY ARE AVAILABLE ON THE HOSPITAL'S WEBSITE AT GIBSONGENERAL.COM; AVAILABLE UPON REQUEST, WITHOUT CHARGE, AT THE BUSINESS OFFICE, ADMISSIONS, AND VIA MAIL; PLAIN LANGUAGE SUMMARY IS CONSPICUOUSLY DISPLAYED IN THE HOSPITAL AND CLINIC WAITING-AREAS; AND, THE PLAIN LANGUAGE SUMMARY IS PROVIDED TO EACH PERSON UPON ADMISSION TO THE HOSPITAL. ANY PATIENTS WITHOUT INSURANCE OR WITH A BALANCE DUE AFTER INSURANCE IS BILLED ARE PROVIDED A PLAIN LANGUAGE SUMMARY, FAP APPLICATION, AND CONTACT INFORMATION FOR THE HOSPITAL'S PATIENT FINANCIAL COUNSELOR BY MAIL. PART VI, LINE 4: COMMUNITY INFORMATION/ COMMUNITY SERVED:THE HOSPITAL'S PRIMARY SERVICE AREA INCLUDES GIBSON COUNTY, INDIANA. GIBSON COUNTY IS LOCATED IN SOUTHWESTERN, INDIANA, AND IS LARGELY RURAL WITH AGRICULTURE AND COAL MINING AS PRIMARY INDUSTRIES. GIBSON COUNTY, INDIANA, IS APPROXIMATELY 146 MILES SOUTHWEST OF INDIANAPOLIS AND 25 MILES NORTH OF EVANSVILLE, INDIANA, WITH AN ESTIMATED POPULATION OF 33,700. IN 2016 THE POPULATION MEDIAN AGE WAS 40.4 YEARS WITH FORTY-FIVE PERCENT (45%) OF THE POPULATION AGE 45 AND OLDER. THE POVERTY RATE WAS 10.8% AND THE MEDIAN HOUSEHOLD ANNUAL INCOME WAS $54,690. APPROXIMATELY 75-80% OF THE HOSPITAL'S PATIENT POPULATION UTILIZES MEDICARE, MEDICAID, AND/OR OTHER GOVERNMENT-SUBSIDIZED PROGRAMS. TRADITIONALLY, THE HOSPITAL HAS BEEN RELIED UPON AS A SAFETY NET HOSPITAL FOR OLDER PATIENTS, LOW-INCOME PATIENTS, AND PATIENTS WITH LIMITED MEANS TO TRAVEL TO THE LARGER CITY OF EVANSVILLE, INDIANA. PART VI, LINE 5: COMMUNITY HEALTH PROMOTION:THE HOSPITAL PARTICIPATES IN MANY ORGANIZATIONS AND ACTIVITIES DESIGNED TO IMPROVE THE HEALTH AND WELFARE OF THE SURROUNDING COMMUNITY. IN ADDITION TO PARTICIPATION ON VARIOUS BOARDS AND CIVIC ORGANIZATIONS FOCUSED ON ECONOMIC DEVELOPMENT, THE HOSPITAL'S LEADERSHIP PARTICIPATES IN THE INDIANA PATIENT SAFETY COALITION, THE DEPARTMENT OF HOMELAND SECURITY, DISTRICT 10 EMERGENCY PREPAREDNESS AND NATIONAL INCIDENT MANAGEMENT SAFETY PROGRAMS. AS MEMBERS OF THE INDIANA RURAL HEATH ASSOCIATION AND THE INDIANA STATE RURAL HEALTH NETWORK, THE HOSPITAL PARTICIPATES IN PROGRAMS DESIGNED TO ASSIST RURAL HEALTHCARE ORGANIZATIONS STATEWIDE AND HAS ASSISTED IN OBTAINING AND IMPLEMENTING COMMUNICATION, INFORMATION SHARING, AND OTHER ACTIVITIES TO IMPROVE THE ACCESS TO HEALTHCARE IN GIBSON COUNTY AND THE SURROUNIDNG AREAS. PART VI, LINE 6: AFFILIATED HEALTH CARE SYSTEM:GIBSON GENERAL HOSPITAL BECAME AFFILIATED WITH DEACONESS HEALTH SYSTEM IN DECEMBER 2016 COOPERATING TO PROVIDE HEALTH CARE SERVICES TO THEIR COMMUNITIES. ADDITIONALLY, THE HOSPITAL DOES PARTICIPATE IN SEVERAL COALITIONS AND COOPERATIVES WITH OTHER PROVIDERS AND OFTEN COLLABORATES WITH THE LARGER SYSTEM IN THE EVANSVILLE AREA TO PROVIDE ACCESS TO SERVICES THE HOSPITAL CANNOT PROVIDE SUCH AS CARDIAC AND NEUROLOGICAL SURGERY. X 0 0 X X X X X X 0 1 0 0 0 0 0 0 0 JARED FLORENCE BOARD MEMBER 0 317573 0 59474 0 45884 0 71923 0 32950 0 527804 0 0 SHAWN MCCOY BOARD MEMBER 0 807381 0 211960 0 174698 0 208646 0 37423 0 1440108 0 0 ALLEN WHITE MD BOARD MEMBER 0 354348 0 67459 0 70996 0 107329 0 31004 0 631136 0 0 CLAUDIA EISENMANN CEO 0 273322 0 60000 0 2033 0 1141 0 8831 0 345327 0 0 LOIS MORGAN CNO 0 161171 0 34000 0 2012 0 0 0 16526 0 213709 0 0 JARED STIMPSON CFO 0 159157 0 66456 0 25353 0 0 0 22584 0 273550 0 0 COREY A POTTS CRNA 231502 0 0 0 0 0 0 0 18816 0 250318 0 0 0 BRUCE BRINK PHYSICIAN 209719 0 0 0 0 0 0 0 19000 0 228719 0 0 0 RICHARD CLARK PHYSICIAN 240890 0 0 0 0 0 0 0 9791 0 250681 0 0 0 ADRIAN CARTER PHYSICIAN 233929 0 0 0 0 0 0 0 9686 0 243615 0 0 0 DAVID PURSOM PHYSICIAN 265525 0 0 0 0 0 0 0 28571 0 294096 0 0 0 PART I, LINE 1A SOCIAL CLUB DUES ARE PAID FOR SHAWN MCCOY FOR ORGANIZATION BUSINESS ONLY. ANY PERSONAL USE OF THE CLUB MUST BE PAID BY THE EMPLOYEE. PART I, LINE 4B SEVERANCE, NONQUALIFIED, AND EQUITY-BASED PAYMENTS: SEVERANCE NONQUALIFIED EQUITY-BASED SHAWN MCCOY $ -0- $ 19,000 $ -0- ALLEN WHITE, MD $ -0- $ 19,000 $ -0- MARC J. FLORENCE $ -0- $ 19,000 $ -0- PART I, 4B: SHAWN MCCOY: SUPPLEMENTAL ACCUMULATION ACCOUNT CONTRIBUTIONS OF $182,870. SUPPLEMENTAL ACCUMULATION ACCOUNT PAYOUT OF $158,381. ALLEN WHITE, MD: SUPPLEMENTAL ACCUMULATION ACCOUNT CONTRIBUTIONS OF $60,588. SUPPLEMENTAL ACCUMULATION ACCOUNT PAYOUT OF $64,881. MARC J. FLORENCE: SUPPLEMENTAL ACCUMULATION ACCOUNT CONTRIBUTIONS OF $52,390. SUPPLEMENTAL ACCUMULATION ACCOUNT PAYOUT OF $42,296. FORM 990, PART VI, SECTION A, LINE 3 MANAGEMENT DUTIES: PRIOR TO DEACONESS HEALTH SYSTEM BECOMING THE SOLE MEMBER OF THE ORGANIZATION ON SEPTEMBER 1, 2020; THE CEO, CNO AND CFO OF THE ORGANIZATION WERE EMPLOYEED AND PROVIDED, SUBJECT TO APPROVAL OF THE BOARD OF TRUSTEES, BY DEACONESS HOSPITAL, INC., AN INDIANA NOT FOR PROFIT CORPORATION AS OF DECEMBER 2016. FORM 990, PART VI, SECTION A, LINE 4 THE FOLLOWING CHANGES WERE MADE TO THE ORGANIZATION'S BYLAWS DURING THE FISCAL YEAR. - THE CORPORATION SHALL HAVE A SINGLE MEMBER, DEACONESS HEALTH SYSTEM, INC., AN INDIANA NONPROFIT CORPORATION. - THE SOLE MEMBER HAS THE POWER TO APPOINT AND REMOVE EACH MEMBER OF THE BOARD OF TRUSTEES. - KEY DECISIONS RESERVED TO THE SOLE MEMBER. - TERMINATION OF THE MANAGEMENT AGREEMENT SERVICES ENTERED BETWEEN THE HOSPITAL AND DEACONESS HOSPITAL, INC. FORM 990, PART VI, SECTION A, LINE 6 CLASSES OF MEMBERS OR STOCKHOLDERS: DEACONESS HEALTH SYSTEM, INC., A TAX EXEMPT 501(C)(3) ORGANIZATION, IS THE SOLE CORPORATE MEMBER OF GIBSON GENERAL HOSPITAL. FORM 990, PART VI, SECTION A, LINE 7A POWER TO ELECT OR APPOINT: DEACONESS HEALTH SYSTEM, THE SOLE MEMBER OF THE ORGANIZATION AS OF SEPTEMBER 1, 2020, HAS THE POWER TO APPOINT AND REMOVE EACH MEMBER. THE ORGANIZATION GOVERNING DOCUMENTS ALLOWS FOR THE COUNTY COMMISSIONERS OF GIBSON COUNTY, INDIANA TO SELECT ONE (1) MEMBER OF THE BOARD OF TRUSTEES; THREE (3) REPRESENTATIVES FROM THE ORGANIZATION'S SOLE MEMBER; THE MAYOR OF PRINCETON, INDIANA; THE PRESIDENT OF GIBSON GENERAL HOSPITAL FOUNDATION; THE CHIEF OF STAFF OF GIBSON GENERAL HOSPITAL TO SERVE AS EX-OFFICIO MEMBER; AND TWO MEMBERS OF THE MEDICAL COMMUNITY. FORM 990, PART VI, SECTION A, LINE 7B THE FOLLOWING GOVERNANCE DECISIONS ARE RESERVED TO THE SOLE MEMBER OF THE ORGANIZATION, DEACONESS HEALTH SYSTEM. - APPROVAL OF ANNUAL OR LONG-TERM CAPITAL BUDGETS, OPERATING BUDGETS AND STRATEGIC PLANS, OR ANY EXPENDITURE IN EXCESS OF $150,000 NOT INCLUDED IN AN APPROVED BUDGET. - THE SALE OR TRANSFER OF SUBSTANTIALLY ALL OF THE ASSETS OF THE CORPORATION OR OF ANY KEY OPERATIONAL ASSETS. - THE FILING OF BANKRUPTCY OR SIMILAR INSOLVENCY PROCESS WITH RESPECT TO THE CORPORATION. - ANY TRANSFER OF SUBSTANTIAL MANAGEMENT RESPONSIBILITY WITH RESPECT TO THE CORPORATION. - ANY AMENDMENT TO THE CORPORATION'S ARTICLES OF INCORPORATION OR BYLAWS. - ANY BORROWING EQUAL TO OR GREATER THAN $150,000, OR ANY AMENDMENT TO FINANCING OR LOAN DOCUMENTS TO WHICH THE CORPORATION IS A PARTY. - ANY DECISION TO CHANGE THE NAME OF THE HOSPITAL, CHANGE THE HOSPITAL CAMPUS FROM A CRITICAL ACCESS HOSPITAL STATUS, RELOCATE OR SUBSTANTIALLY REDUCE OR TERMINATE SERVICES TO THE COMMUNITY. - ANY DECISION TO REDUCE THE LEVEL OF CHARITABLE SERVICES TO THE COMMUNITY. - ANY DECISION RELATING TO THE TERMINATION OF THE CORPORATION'S EMPLOYEE RETIREMENT PLAN. - ADOPTION OF ANY POLICIES RELATING TO THE OPERATION OF THE BOARD, THE CORPORATION, OR THE HOSPITAL THAT ARE INCONSISTENT WITH POLICIES OF DEACONESS. - ANY OF THE FOREGOING ACTIONS BY THE CORPORATION AS THE OWNER, MEMBER OF ANY OF THE CORPORATION'S SUBSIDIARIES OR AFFILIATES, INCLUDING THE HOSPITAL. FORM 990, PART VI, SECTION B, LINE 11B FORM 990 REVIEW PROCESS: THE PROCESS OF REVIEWING THE FORM 990 INCLUDES A DETAILED REVIEW OF THE FORM AND REQUIRED SCHEDULES BY THE CHIEF FINANCIAL OFFICER. EACH VOTING MEMBER OF THE GOVERNING BODY RECEIVES A COPY OF THE FORM 990 INCLUDING REQUIRED SCHEDULES, AS ULTIMATELY FILED WITH THE IRS, PRIOR TO FILING. FORM 990, PART VI, SECTION B, LINE 12C CONFLICT OF INTEREST POLICY: THE CONFLICT OF INTEREST POLICY IS INCLUDED WITHIN THE BYLAW OF THE ORGANIZATION AND COVERS ALL BOARD OF TRUSTEES. THE POLICY PROVIDES PROCEDURES TO PREVENT THOSE WITH DUALITY OF INTEREST OR POSSIBLE CONFLICTS OF INTEREST FROM PARTICIPATING IN ANY ACTION THAT COULD PERSONALLY BENEFIT THE INDIVIDUAL TRUSTEE. THE CEO AND/OR BOARD COMPLIANCE OFFICER REVIEW ANNUAL WRITTEN AND SIGNED CONFLICT OF INTEREST STATEMENTS THAT PROVIDE ANY DUALITY OF INTEREST OR POSSIBLE CONFLICTS OF INTEREST DISCLOSED BY ALL BOARD OF TRUSTEES. THE INDIVIDUAL TRUSTEE WILL AGAIN DISCLOSE TO THE BOARD WHEN THE INTEREST BECOMES A MATTER OF BOARD ACTION AND RECUES HIMSELF OR HERSELF FROM VOTING ON THE RELATED ISSUE. THE BOARD MEETING MINUTES DOCUMENT THE DISCLOSURE MADE, WHO ABSTAINED FROM VOTING, AND THE QUORUM SITUATION. FORM 990, PART VI, SECTION B, LINE 15 COMPENSATION PROCESS: CEO: THE CEO EVALUATION COMMITTEE, CONSISTING OF FOUR INDEPENDENT AND BOARD CHAIR APPOINTMENT TRUSTEE MEMBERS, EVALUTATES THE PERFORMANCE OF THE CEO ON AN ANNUAL BASIS AND MAKES COMPENSATION-RELATED RECOMMENDATIONS TO THE BOARD PRIOR TO THE CEO'S ANNUAL REVIEW DATE FOR APPROVAL. THE EVALUATION COMMITTEE USES A COMPENSATION CONSULTANT, COMPENSATION SURVEY, AND COMPARATIVE DATA FROM SIMLIAR ORGANIZATION TO DETERMINE THE CEO'S COMPENSATION PACKAGE. ALL DELIBERATION AND DECISIONS ARE DOCUMENTED IN THE EVALUATION COMMITTEE'S MINUTES. OFFICERS AND/OR KEY EMPLOYEES: ANNUAL REVIEWS FOR TOP MANAGEMENT OFFICIALS ARE CONDUCTED BY THE CEO. THE COMPENSATION IS ANNUALLY REVIEWED AND APPROVED BY THE BOARD OF TRUSTEES. FORM 990, PART VI, SECTION C, LINE 19 THE HOSPITAL'S GOVERNING DOCUMENTS, CONFLICT OF INTEREST POLICY, AND FINANCIAL STATEMENTS ARE AVAILABLE TO THE PUBLIC UPON WRITTEN REQUEST AND BOARD OF TRUSTEES APPROVAL. WRITTEN REQUESTS SHOULD BE SENT TO ATTN: JAMES CHILDERS, AT THE ADDRESS LISTED ON PAGE 1 OF THE FORM 990. FORM 990, PART VI, LINE 16B, JOINT VENTURE POLICY: THE ORGANIZATION DOES NOT HAVE A FORMAL WRITTEN POLICY ON EVALUATING PARTICIPATION IN A JOINT VENTURE, HOWEVER, THE ORGANIZATION PERFORMS DUE DILIGENCE AND INVOLVES LEGAL COUNSEL TO REVIEW ANY PARTNERSHIPS ENSURING THAT THE JOINT VENTURE WOULD BE ORGANIZED AND OPERATED IN A MANNER CONSISTENT WITH THE HOSPITAL'S EXEMPT PURPOSE AND STATUS. FORM 990, PART IX, LINE 11G PURCHASED SERVICES: PROGRAM SERVICE EXPENSES 2,489,167. MANAGEMENT AND GENERAL EXPENSES 672,630. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 3,161,797. PROFESSIONAL FEES - MEDICAL: PROGRAM SERVICE EXPENSES 1,551,759. MANAGEMENT AND GENERAL EXPENSES 419,321. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 1,971,080. OTHER FEES: PROGRAM SERVICE EXPENSES 139,961. MANAGEMENT AND GENERAL EXPENSES 37,821. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 177,782. FORM 990, PART XII, LINE 2C, OVERSIGHT OF AUDIT: THE BOARD OF TRUSTEES ASSUMES RESPONSIBILITY FOR OVERSIGHT OF THE AUDIT OF THE FINANCIAL STATEMENTS AND SELECTION OF THE INDEPENDENT ACCOUNTANT; AND NO PROCESSES HAVE CHANGED FROM PRIOR YEAR. DEACONESS HEALTH SYSTEM INC 600 MARY STREET EVANSVILLE IN 47747 351532889 HEALTHCARE IN 501(C)(3) LINE 12A, I N/A 0 DEACONESS HOSPITAL INC 600 MARY STREET EVANSVILLE IN 47747 350593390 HEALTHCARE IN 501(C)(3) LINE 3 DEACONESS HEALTH SYSTEM INC 0 DEACONESS REGIONAL HEALTHCARE SERVICES 600 MARY STREET EVANSVILLE IN 47747 810693478 HEALTHCARE IN 501(C)(3) LINE 3 DEACONESS HEALTH SYSTEM INC 0 DEACONESS VNA PLUS LLC 610 E WALNUT ST EVANSVILLE IN 47713 465223267 HEALTHCARE IN 501(C)(3) LINE 10 DEACONESS HEALTH SYSTEM INC 0 DEACONESS SPECIALTY PHYSICIANS INC 600 MARY STREET EVANSVILLE IN 47747 824503095 HEALTHCARE IN 501(C)(3) LINE 3 DEACONESS HEALTH SYSTEM INC 0 DEACONESS HEALTH KENTUCKY INC 600 MARY STREET EVANSVILLE IN 47747 830966826 HEALTHCARE IN 501(C)(3) LINE 3 DEACONESS HEALTH SYSTEM INC 0 METHODIST HEALTH INC 1305 N ELM STREET HENDERSON KY 42420 610461753 HEALTHCARE KY 501(C)(3) LINE 3 DEACONESS HEALTH SYSTEM INC 0 DEACONESS CLINIC INC 421 CHESNUT STREET PRINCETON IN 47713 263083364 HEALTHCARE IN 501(C)(3) LINE 3 DEACONESS HEALTH SYSTEM INC 0 GIBSON GENERAL HEALTH FOUNDATION INC 1808 SHERMAN DR PRINCETON IN 47670 350950175 SUPPORT GIBSON HOSPITAL IN 501(C)(3) LINE 12A, I DEACONESS GIBSON HOSPITAL 0 HENDERSON REGIONAL HOSPITAL FOUNDATION 1305 N ELM STREET HENDERSON KY 42420 610944432 SUPPORT METHODIST HOSPITAL KY 501(C)(3) LINE 12A, I N/A 0 UNION COUNTY METHODIST HOSPITAL FOUNDATION 4604 US HWY 60 WEST MORGANFIELD KY 42437 611230297 SUPPORT METHODIST HOSPITAL KY 501(C)(3) LINE 12A, I N/A 0 HEALTHCARE RESOURCE SOLUTIONS LLC 600 MARY STREET EVANSVILLE IN 47747 833275390 HEALTHCARE IN N/A 0 0 1 0 0 0 0 0 0 0 0 0 0 1 1 1 0 0 0 GIBSON GENERAL HEALTH FOUNDATION INC C 24667 ACTUAL AMOUNT