2019-11-15T12:33:18-06:00 2018-12-31 410746749 CLIFTONLARSONALLEN LLP 4505 STEPHEN CIRCLE NW STE 200 CANTON OH 44718 990 2018-01-01 340726081 ASHTABULA COUNTY MEDICAL CENTER ASHT 4409972262 2420 LAKE AVENUE ASHTABULA OH 44004 DON KEPNER VP FINANCE/CFO 4409972262 2019-11-14 1 LISA HILLING P01624111 3304972000 67.137.57.251 2019-11-14 15:45:57 ES P 7BE7DF1651D6D8591F67A801A29A6D8D893E2ED2 12A6B3437D91A0C23DF0ED0A84D4C146BA3FB911 2018 2020-03-31 21:24:44Z MICHAEL HABOWSKI 2420 LAKE AVENUE ASHTABULA OH 44004 157940491 0 6026 X WWW.ACMCHEALTH.ORG X 1902 OH TO PROVIDE QUALITY HEALTHCARE TO POSITIVELY IMPACT THE HEALTH OF OUR COMMUNITY. 17 12 1319 187 303273 0 7610702 10927688 140354636 144371460 2764107 2185731 439872 425268 151169317 157910147 401515 300083 0 0 74586467 79118964 0 0 0 67928768 67668786 142916750 147087833 8252567 10822314 148606583 147662470 58806485 54867025 89800098 92795445 ASHTABULA COUNTY MEDICAL CENTER PROVIDES QUALITY HEALTHCARE TO POSITIVELY IMPACT THE HEALTH OF OUR COMMUNITY. 0 0 121191251 300083 144371460 ASHTABULA COUNTY MEDICAL CENTER (ACMC) IS A PRIVATE, NOT-FOR-PROFIT, COMMUNITY-ORIENTED MEDICAL CENTER THAT PROVIDES THE BEST POSSIBLE MEDICAL CARE THROUGH ALL PHASES OF LIFE TO THOSE SEEKING HELP. IN 2018 WE MET OUR MISSION OF MEETING OUR COMMUNITY'S HEALTH CARE NEEDS AS EVIDENCED BY APPROXIMATELY 33,851 EMERGENCY DEPARTMENT VISITS, 6,122 INPATIENT DISCHARGES, 1,227 INPATIENT SURGERIES, 6,712 OUTPATIENT SURGERIES, 359 BIRTHS, AND 73,302 RADIOLOGY PROCEDURES. 121191251 1 1 0 0 0 0 0 0 0 0 1 0 0 1 1 1 0 1 0 0 0 0 0 0 0 0 1 1 1 0 1 0 0 0 0 0 0 1 0 0 0 0 0 0 1 1 1 0 0 1 117 0 1319 1 1 1 0 0 0 0 0 0 0 0 0 0 0 X 17 12 0 1 0 0 1 1 1 1 1 0 0 1 1 1 1 1 1 1 1 0 OH X DON KEPNER VP FINANCECFO 4409972262 2420 LAKE AVENUE ASHTABULA OH 44004 X SUSAN STOCKER PHD CHAIRPERSON (THROUGH 2/14/18) 0.30 0.30 X X 0 0 0 NANCY KISTER VICE-CHAIRPERSON 0.30 0.30 X X 0 0 0 JOE GIANGOLA SECRETARY/TREASURER 0.30 0.30 X X 0 0 0 MICHAEL HABOWSKI PRESIDENT/CEO 40.00 0.30 X X 0 0 0 PEG CARLO BOARD MEMBER 0.30 0.30 X 0 0 0 BILL DINGLEDINE BOARD MEMBER 0.30 0.30 X 0 0 0 ELENA MARQUETTI BOARD MEMBER 0.30 0.30 X 0 0 0 REV VERNON PALO BOARD MEMBER 0.30 0.30 X 0 0 0 MARLENE SARTINI BOARD MEMBER 0.30 0.30 X 0 0 0 CRAIG SERNIK BOARD MEMBER 0.30 0.30 X 0 0 0 JIM TIMONERE BOARD MEMBER 0.30 0.30 X 0 0 0 RICHARD PARKER BOARD MEMBER 0.30 0.30 X 0 0 0 ROGER CORLETT BOARD MEMBER 0.30 0.30 X 0 0 0 KELLY HANCOCK BOARD MEMBER/CCF REPRESENTATIVE 0.30 0.30 X 0 0 0 JASON HERGENROEDER BOARD MEMBER/CCF REPRESENTATIVE 0.30 0.30 X 0 0 0 DANIEL KEATON MD BOARD MEMBER CHIEF OF STAFF (THROUGH 12/18) 60.00 0.30 X 190690 0 13944 SATHISH ADIGOPULA MD BOARD MEMBER/VICE-CHIEF OF STAFF 60.00 0.30 X 573379 0 17750 DON KEPNER VP FINANCE/CFO 40.00 0.60 X 0 0 0 JACQUELYN DIFIORE CNO 40.00 X 0 0 0 ALEXANDER TAICH MD PHYSICIAN 60.00 X 1166541 0 18400 NATHANIEL S FRANLEY MD PHYSICIAN 60.00 X 677328 0 15579 LAXMAN R CINGIREDDI MD PHYSICIAN 60.00 X 821609 0 16700 BRANDON L RAUDENBUSH MD PHYSICIAN 60.00 X 699893 0 15979 PAZHANIAANDI TIROUNILACANDIN MD PHYSICIAN 60.00 X 741460 0 17539 4870900 0 115891 82 0 1 0 AMERISOURCEBERGEN 25199 NETWORK PLACE CHICAGO IL 60673 MEDICAL 12661021 CLEVELAND CLINIC FOUNDATION PO BOX 931760 CLEVELAND OH 44193 ADMINISTRATIVE AND CLINICAL SERVICES 10224375 CARDINAL HEALTH MEDICAL PRODUCTS AND SER PO BOX 70539 CHICAGO IL 60673 MEDICAL 2935040 ANESTHESIA CONSULTANTS EFT 5168 STANSBURG ROAD SOLON OH 44139 MEDICAL 2655637 ARAMARK CORP 27310 NETWORK PLACE CHICAGO IL 60673 CAFETERIA AND DIETARY SERVICES 1897516 101 10850000 77688 10927688 NET PATIENT SERVICE REVENUE 624100 135688037 135688037 MISC OPERATING REVENUE 624100 8367724 8367724 REBATES AND REFUNDS 624100 315699 315699 144371460 1972584 1972584 121995 0 121995 121995 121995 243491 22835 7509 220656 -7509 213147 213147 PREMIER FITNESS 713940 303273 303273 303273 157910147 144371460 303273 2307726 300083 300083 1462901 1199579 263322 62562800 51301496 11261304 2255980 1849904 406076 8653007 7095466 1557541 4184276 3431106 753170 4570203 3747566 822637 209682 171939 37743 104625 85793 18832 12790194 10487960 2302234 408871 335274 73597 883174 724203 158971 1780753 1460217 320536 76247 62523 13724 38 31 7 1323250 1323250 4131822 3388094 743728 1893017 1552274 340743 SUPPLIES 22608610 18539060 4069550 BAD DEBT EXPENSE 8945982 8945982 EQUIP REPAIRS & MAINT 4834088 3963952 870136 LICENSES & PERMITS 2079124 1704882 374242 1029106 843867 185239 147087833 121191251 25896582 0 23410920 18341038 1822512 2143007 19275809 20766998 1432789 2065875 1456389 1960965 101046920 69766319 26442813 31280601 62961682 59677710 3009392 3146515 8794277 8279761 148606583 147662470 14629623 16983075 112545 65611 22468 0 44041849 37818339 58806485 54867025 X 89785796 92781143 14302 14302 89800098 92795445 148606583 147662470 X 10822314 -5404563 -2422404 X 0 1 X 1 0 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 1 8843 8843 0 PART II-B, LINE 1: TOTAL DUES OF $38,821 WERE PAID TO THE OHIO HOSPITAL ASSOCIATION BY ACMC, OF WHICH 4.6%% WERE RELATED TO LOBBYING ACTIVITIES. TOTAL DUES OF $31,049 WERE PAID TO THE AMERICAN HOSPITAL ASSOCIATION BY ACMC, OF WHICH 22.73% WERE RELATED TO LOBBYING ACTIVITIES. 2519092 2519092 36424291 23584265 12840026 4246007 3310609 935398 56615761 42871445 13744316 1241769 1241769 31280601 SELF-INSURANCE INVESTMENTS 5394343 DEFERRED COMPENSATION 2642535 DUE FROM AFFLIATES 242883 8279761 RESERVE FOR SELF-INSURANCE LIABILITIES 11136988 DEFERRED COMPENSATION 2642535 ACCRUED PENSION LIABILITY 5535866 DISTRIBUTION PAYABLE TO THE CLEVELAND CLINIC FOUNDATION 1323250 INVESTMENT FROM CLEVELAND CLINIC FOUNDATION 15000000 THIRD-PARTY PAYABLES 2179700 37818339 X PART X, LINE 2: WHEN TAX RETURNS ARE FILED, IT IS HIGHLY CERTAIN THAT SOME POSITIONS TAKEN WOULD BE SUSTAINED UPON EXAMINATION BY THE TAXING AUTHORITIES, WHILE OTHERS ARE SUBJECT TO UNCERTAINTY ABOUT THE MERITS OF THE POSITION TAKEN OR THE AMOUNT OF THE POSITION THAT WOULD BE ULTIMATELY SUSTAINED. IN ACCORDANCE WITH THE INCOME TAXES TOPIC OF THE FINANCIAL ACCOUNTING STANDARDS BOARD (FASB) ACCOUNTING STANDARDS CODIFICATION, THE BENEFIT OF A TAX POSITION IS RECOGNIZED IN THE FINANCIAL STATEMENTS IN THE PERIOD DURING WHICH, BASED ON ALL AVAILABLE EVIDENCE, MANAGEMENT BELIEVES IT IS MORE LIKELY THAN NOT THAT THE POSITION WILL BE SUSTAINED UPON EXAMINATION, INCLUDING THE RESOLUTION OF APPEALS OR LITIGATION PROCESSES, IF ANY. TAX POSITIONS TAKEN ARE NOT OFFSET OR AGGREGATED WITH OTHER POSITIONS. TAX POSITIONS THAT MEET THE MORE-LIKELY-THAN-NOT RECOGNITION THRESHOLD ARE MEASURED AS THE LARGEST AMOUNT OF TAX BENEFIT THAT IS MORE THAN 50% LIKELY OF BEING REALIZED UPON SETTLEMENT WITH THE APPLICABLE TAXING AUTHORITY. THE PORTION OF THE BENEFITS ASSOCIATED WITH TAX POSITIONS TAKEN THAT EXCEEDS THE AMOUNT MEASURED AS DESCRIBED ABOVE IS RECORDED AS A LIABILITY FOR UNRECOGNIZED TAX BENEFITS ALONG WITH ANY ASSOCIATED INTEREST AND PENALTIES THAT WOULD BE PAYABLE TO THE TAXING AUTHORITIES UPON EXAMINATION. 1 1 X 1 X 0 1 1 0 0 850894 850894 0.00620 23320599 17100177 6220422 0.04500 91859 1232040 0 0.00000 24263352 18332217 7071316 0.05120 4705320 4705320 0.03410 53408 53408 0.00040 235645 235645 0.00170 83 83 0.00000 4994456 4994456 0.03620 29257808 18332217 12065772 0.08740 1 8945982 0 31961811 31984530 -22719 X 1 1 1 1 ASHTABULA COUNTY MEDICAL CENTER 2420 LAKE AVENUE ASTHABULA OH 44004 WWW.ACMCHEALTH.ORG 360125 X X X ASHTABULA COUNTY MEDICAL CENTER 1 0 0 1 X X X X X X X X X 16 1 0 0 1 X WWW.ACMCHEALTH.ORG/ABOUT-US/COMMUNITY-HEALTH-NEEDS-ASSESSMENT/ X 1 16 1 WWW.ACMCHEALTH.ORG/ABOUT-US/COMMUNITY-HEALTH-NEEDS-ASSESSMENT/ 0 1 X 200.000000000000 X X 1 1 X X X X 1 X WWW.ACMCHEALTH.ORG/PATIENTS-VISITORS/FINANCIAL-SERVICES/ X WWW.ACMCHEALTH.ORG/PATIENTS-VISITORS/FINANCIAL-SERVICES/ X WWW.ACMCHEALTH.ORG/PATIENTS-VISITORS/FINANCIAL-SERVICES/ X X X X X 1 X 0 X X X X X 1 X 0 1 ASHTABULA COUNTY MEDICAL CENTER PART V, SECTION B, LINE 5: THE 2016 COMMUNITY HEALTH NEEDS ASSESSMENT RELIED ON MULTIPLE DATA SOURCES AND COMMUNITY INPUT GATHERED BETWEEN JANUARY AND JULY 2016. INPUT FROM 15 PERSONS REPRESENTING THE BROAD INTERESTS OF THE COMMUNITY WAS TAKEN INTO ACCOUNT THROUGH KEY INFORMANT INTERVIEWS. INTERVIEWS INCLUDED INDIVIDUALS WITH SPECIAL KNOWLEDGE OR EXPERTISE IN PUBLIC HEALTH, LOCAL PUBLIC HEALTH DEPARTMENTS, AGENCIES WITH CURRENT DATA OR INFORMATION ABOUT THE HEALTH AND SOCIAL NEEDS OF THE COMMUNITY, REPRESENTATIVES OF SOCIAL SERVICE ORGANIZATIONS, AND LEADERS, REPRESENTATIVES AND MEMBER OF MEDICALLY UNDERSERVED, LOW-INCOME, AND MINORITY POPULATIONS. SEE PAGE 60 OF THE 2016 CHNA REPORT FOR A LIST OF PARTICIPATING ORGANIZATIONS AND AGENCIES. ASHTABULA COUNTY MEDICAL CENTER PART V, SECTION B, LINE 11: ASHTABULA COUNTY MEDICAL CENTER HAS A 115-YEAR HISTORY OF PROVIDING SIGNIFICANT AMOUNTS OF COMMUNITY BENEFIT TO THE COMMUNITIES IT SERVES. ACMC WILL CONTINUE THIS COMMITMENT BY ALLOCATING APPROPRIATE HUMAN AND FINANCIAL RESOURCES TO MEET THOSE NEEDS THROUGH THE IMPLEMENTATION OF THE FOLLOWING STRATEGY: 1. IMPROVE ACCESS TO CARE, INCLUDING BOTH PRIMARY AND SPECIALTY CARE BY: A. CONTINUING TO RECRUIT PRIMARY CARE (FAMILY MEDICINE, INTERNAL MEDICINE, PEDIATRICS, OBSTETRICS & GYNECOLOGY) PHYSICIANS TO THE COMMUNITY AND PLACING OFFICES IN SHORTAGE AREAS. B. CONTINUING TO RECRUIT SPECIALTY PHYSICIANS TO THE COMMUNITY TO ENSURE COMMUNITY RESIDENTS DO NOT HAVE TO LEAVE THE COMMUNITY TO RECEIVE CARE FROM A SPECIALIST. C. CONTINUING TO COLLABORATE WITH CLEVELAND CLINIC TO PROVIDE SPECIALTY CLINICS FOR SERVICES NOT AVAILABLE IN THE COMMUNITY. D. CONTINUING TO PROVIDE THE ACMC HEALTH EXPRESS FREE SHUTTLE SERVICE. E. EXPLORING COLLABORATION OPPORTUNITIES WITH ASHTABULA COUNTY DEPARTMENT OF JOB AND FAMILY SERVICES TO USE THE ASHTABULA COUNTY TRANSIT SYSTEM (ACTS) FOR MEDICAL APPOINTMENTS. F. COLLABORATING WITH ASHTABULA COUNTY DEPARTMENT OF JOB AND FAMILY SERVICES TO DEVELOP AND IMPLEMENT A PLAN TO ACCOMMODATE THE INCREASE IN MEDICAID RECIPIENTS IN MID-2014. G. CONTINUING TO OFFER FINANCIAL COUNSELING SERVICES TO ASSIST RESIDENTS IN QUALIFYING FOR PUBLIC ASSISTANCE AND ACMC'S CHARITY CARE PROGRAM. 2. DECREASE THE PREVALENCE OF DIET AND EXERCISE-RELATED ISSUES, INCLUDING HIGH RATES OF OBESITY BY: A. COLLABORATING WITH SCHOOLS TO OFFER AFTER-SCHOOL PROGRAMMING TO INCLUDE NUTRITION EDUCATION AND PHYSICAL ACTIVITY. B. CONTINUING TO PARTICIPATE IN COMMUNITY-BASED PROGRAMS (INCLUDING LONGEST DAY OF PLAY, PARTNERSHIP FOR A REVOLUTION) WITH A FOCUS ON HEALTHY LIFESTYLE HABITS. C. CONTINUING TO OFFER HEALTHY FOOD OPTIONS IN THE ACMC CAFETERIA AND VENDING MACHINES. D. CONTINUING TO OFFER COMMUNITY MEMBERSHIPS AT THE ACMC-OWNED FITNESS FACILITY, INCLUDING EXPLORING A PLAN TO OPEN THE FACILITY FREE OF CHARGE ON A LIMITED BASIS. E. CONTINUING TO OFFER EXERCISE CLASSES FOR CHILDREN (KID FIT, ZUMBAKIDS, ZUMBATOMIC, MOMMY AND ME) AT THE ACMC-OWNED FITNESS FACILITY. F. CONTINUING TO PUBLISH DIET AND NUTRITION-FOCUSED EDUCATIONAL ARTICLES IN THE MEDIA AND IN ACMC-PRODUCED PUBLICATIONS. G. IMPLEMENTING AN INCENTIVE PROGRAM FOR ACMC EMPLOYEES TO RECEIVE DISCOUNT/REBATE ON HEALTH INSURANCE PREMIUMS FOR ATTAINING SPECIFIED HEALTH METRICS, AND CONTINUING THE SHAPE UP AND GO PROGRAM FOR EMPLOYEES. 3. IMPROVE THE EFFECTIVENESS OF HEALTH EDUCATION INITIATIVES THAT EMPHASIZE THE RAMIFICATIONS OF HIGH-RISK HEALTH BEHAVIORS BY LAUNCHING PROMOTION CAMPAIGNS TO TEACH CHILDREN AND ADULTS THE RISKS ASSOCIATED WITH SMOKING, DRINKING, AND OBESITY. 4. DECREASE THE INCIDENCE OF WOMEN NOT RECEIVING FIRST TRIMESTER PRE-NATAL CARE AND THE INCIDENCE OF SMOKING IN PREGNANT WOMEN BY: A. COLLABORATING WITH HIGH SCHOOL GUIDANCE COUNSELORS AND NURSES TO PROVIDE EDUCATION REGARDING THE IMPORTANCE OF PRE-NATAL CARE. B. B. PROVIDING A FREE PREGNANCY TEST THROUGH SPLIT FLOW IN THE ACMC EMERGENCY DEPARTMENT, WITH REFERRAL AND APPOINTMENT SCHEDULING FOR OB/GYN FOLLOW UP. C. COLLABORATING WITH ASHTABULA DEPARTMENT OF JOB AND FAMILY SERVICES AND SOCIAL SERVICE AGENCIES (CATHOLIC CHARITIES, UNITED WAY) IN PROVIDING EDUCATION TO CLIENTS. D. OFFERING A SERIES OF SMOKING CESSATION CLASSES GEARED SPECIFICALLY TO PREGNANT WOMEN. E. PROVIDING FREE NICOTINE REPLACEMENT PATCHES TO PREGNANT WOMEN UNDER THE CARE OF AN ACMC PHYSICIAN. 5. IMPROVE HEALTH OUTCOMES, SPECIFICALLY MORBIDITY AND MORTALITY RATES, FOR HEART DISEASE AND CANCER BY: A. CONTINUING TO MAINTAIN CERTIFICATIONS IN STROKE, HEART FAILURE AND CHEST PAIN. B. EXPLORING EXPANDING ACCESS TO CARDIOLOGIST OFFICE VISITS BY PLACING A PHYSICIAN IN SATELLITE OFFICES IN VARIOUS PARTS OF THE COMMUNITY. C. CONTINUING TO OPERATE THE COMMUNITY'S ONLY DIAGNOSTIC CARDIAC CATHETERIZATION LABORATORY. D. RECRUITING A THIRD INVASIVE CARDIOLOGIST TO REDUCE WAIT TIME FOR INITIAL PHYSICIAN APPOINTMENT. E. EXPANDING HEART CARE SPECIALTY SERVICES TO INCLUDE A MONTHLY ELECTROPHYSIOLOGY SPECIALTY CLINIC. F. COLLABORATING WITH HIGH SCHOOLS TO OFFER SCREENING PROGRAMS FOR HIGH SCHOOL ATHLETES TO IDENTIFY HYPERTROPHIC CARDIOMYOPATHY. G. CONTINUING STAFF TRAINING IN THE USE OF ADVANCED TECHNOLOGY, INCLUDING CT, MRI AND PET CT, FOR EARLY DIAGNOSIS OF EARLY-STAGE HEART DISEASE AND CANCER. H. CONTINUING TO OFFER ANNUAL WOMEN'S HEART HEALTH AND WOMEN'S CANCER AWARENESS LUNCHEONS WITH A FOCUS ON PREVENTION AND TREATMENT TOPICS. I. EXPLORING TRANSPORTATION COLLABORATIONS WITH AMERICAN CANCER SOCIETY TO ASSIST COMMUNITY IN TRAVELING TO RADIATION ONCOLOGY APPOINTMENTS. J. EXPLORING COLLABORATION WITH CLEVELAND CLINIC TO ENROLL COMMUNITY RESIDENTS IN CLINICAL CANCER TRIALS. K. EXPLORING OPPORTUNITIES TO OFFER ADDITIONAL FREE SCREENINGS, INCLUDING HEMOCULT AND COLONOSCOPY.THE ADDITION OF THE NEW OR EXPANDED STRATEGIC INITIATIVES TO ADDRESS COMMUNITY HEALTH NEEDS WILL NOT DIMINISH ACMC'S COMMITMENT TO ITS CURRENT COMMUNITY BENEFIT PROGRAMS. THESE CURRENT PROGRAMS INCLUDE: A. CONTINUE TO OFFER DIABETES EDUCATION CLASSES AND SUPPORT GROUPS. B. CONTINUE TO PROVIDE LANGUAGE SUPPORT SERVICES TO NON-ENGLISH SPEAKING PATIENTS TO ENSURE EFFECTIVE COMMUNICATION AND APPROPRIATENESS OF CARE. C. CONTINUE TO SUPPORT A TOBACCO-FREE ENVIRONMENT THROUGH ACMC'S SMOKE FREE CAMPUS, HIRING POLICIES, AND SMOKING CESSATION PROGRAMS. D. CONTINUE TO PROVIDE INPATIENT AND OUTPATIENT MENTAL HEALTH SERVICES, AS WELL AS AN INTENSIVE OUTPATIENT PSYCHIATRY PROGRAM. E. CONTINUE TO PROVIDE FREE HEALTH SCREENINGS AND REFERRAL FOR TREATMENT. F. CONTINUE TO PROVIDE FINANCIAL COUNSELOR SERVICES TO ASSIST PATIENTS IN QUALIFYING FOR MEDICAL ASSISTANCE. G. CONTINUE TO OFFER A CHARITY CARE PROGRAM.ASHTABULA COUNTY MEDICAL CENTER CANNOT ADDRESS ALL OF THE HEALTH NEEDS PRESENT IN THE COMMUNITY. TO ENSURE ACMC REMAINS FINANCIALLY VIABLE AND IN A POSITION TO ENHANCE CURRENT SERVICES, DEVELOP NEW SERVICES AND CONTINUE TO PROVIDE A WIDE RANGE OF COMMUNITY BENEFITS, THE HOSPITAL'S IMPLEMENTATION STRATEGY FOCUS WILL NOT ADDRESS THE FOLLOWING NEEDS:DENTAL HEALTH: AS AN ACUTE CARE HOSPITAL, ACMC DOES NOT HAVE THE EXPERTISE TO ADDRESS BASIC DENTAL HEALTH.ACCIDENTS/UNINTENTIONAL INJURIES: THIS COMMUNITY HEALTH ISSUE IS BEYOND THE SCOPE OF ACMC, AND IS BEING ADDRESSED BY OTHERS.BIRTHS TO UNWED MOTHERS: THIS COMMUNITY HEALTH ISSUE IS BEYOND THE SCOPE OF ACMC, AND IS BEING ADDRESSED BY FAITH-BASED AND SOCIAL SERVICE AGENCIES.ALCOHOL ABUSE/EXCESSIVE BINGE DRINKING: THIS ISSUE IS BEYOND THE SCOPE OF ACMC AND IS BEING ADDRESSED BY OTHERS.SUICIDE: THIS COMMUNITY HEALTH ISSUE IS BEING ADDRESSED BY OTHERS, INCLUDING THE ASHTABULA COUNTY DEPARTMENT OF HEALTH AND A TASK FORCE FORMED FOLLOWING THE COMPLETION OF THE COUNTY'S COMMUNITY NEEDS ASSESSMENT.ACCESS TO HEALTHY FOODS: OTHER THAN WHAT IS OFFERED INSIDE THE WALLS OF OUR FACILITY, THIS ISSUE IS BEYOND THE SCOPE OF THE HOSPITAL AND THE HOSPITAL DOES NOT HAVE SUFFICIENT RESOURCES TO MAKE A MEANINGFUL IMPACT. ASHTABULA COUNTY MEDICAL CENTER PART V, SECTION B, LINE 20E: THE ORGANIZATION PROVIDES NOTIFICATION REGARDING THE FAP THROUGH SIGNAGE AND OTHER MECHANISMS. THERE ARE A NUMBER OF WRITTEN CORRESPONDENCES THAT GO OUT TO PATIENTS OVER THE COURSE OF 120 DAYS ONCE THE PATIENT RESPONSIBILITY IS DETERMINED FOR THE AMOUNT DUE RELATED TO SERVICES PROVIDED.PART V, SECTION B, LINE 20C: IF AN INCOMPLETE FAP APPLICATION IS RECEIVED, THE ORGANIZATION'S FINANCIAL COUNSELORS CONTACT THE PATIENT FOR ADDITIONAL INFORMATION. ASHTABULA COUNTY MEDICAL CENTER PART V, SECTION B, LINE 24: ALL PATIENTS ARE CHARGED THE SAME, STANDARD RATE, FOR A PARTICULAR SERVICE. 7 1 - JEFFERSON FAMILY HEALTH CENTER 234 NORTH CHESTNUT STREET JEFFERSON OH 44047 FAMILY HEALTH CENTER 2 - CONNEAUT FAMILY HEALTH CENTER 354 W MAIN ROAD CONNEAUT OH 44030 FAMILY HEALTH CENTER 3 - ASHTABULA WOMEN'S HEALTH CENTER 524 W 24TH STREET ASHTABULA OH 44004 WOMEN'S HEALTH CENTER 4 - ACMC CENTER FOR DIGESTIVE HEALTH 2112 LAKE AVENUE ASHTABULA OH 44004 GASTROENTEROLOGY HEALTH CENTER 5 - GENEVA FAMILY HEALTH CENTER 1028 S BROADWAY GENEVA OH 44041 FAMILY HEALTH CENTER 6 - ASHTABULA FAMILY HEALTH CENTER 2259 LAKE AVENUE ASHTABULA OH 44004 FAMILY HEALTH CENTER 7 - THE ASHTABULA CLINIC 2422 LAKE AVENUE ASHTABULA OH 44004 PAIN MANAGEMENT, OCCUPATIONAL HEALTH PART I, LINE 3C: TO QUALIFY FOR THE HOSPITAL CARE ASSURANCE PROGRAM, AN INDIVIDUAL MUST (A) BE A RESIDENT OF THE STATE OF OHIO, (B) NOT BE ENROLLED IN THE MEDICAID (INCLUDING MEDICAID HMO) PROGRAM, AND (C) HAVE FAMILY/HOUSEHOLD INCOME LESS THAN 200% OF FEDERAL POVERTY GUIDELINES. IN ADDITION, BEFORE GRANTING FINANCIAL ASSISTANCE, THE HOSPITAL HAS THE RIGHT TO REQUIRE (A) PROOF OF INCOME, (B) A WRITTEN STATEMENT FOR CLAIMS OF $0 INCOME, (C) INFORMATION ABOUT HSA AND HFSA ACCOUNTS, AND/OR (D) THAT AN INDIVIDUAL APPLY FOR MEDICAID. PART I, LINE 6A: N/A PART I, LINE 7: ACMC ESTIMATED CHARITY CARE COSTS BY CALCULATING A RATIO OF COST TO GROSS CHARGES AND THEN MULTIPLYING THAT RATIO BY THE GROSS UNCOMPENSATED CHARGES ASSOCIATED WITH PROVIDING CARE TO CHARITY PATIENTS.ACMC IS PAID A PROSPECTIVELY DETERMINED RATE FOR THE MAJORITY OF INPATIENT ACUTE CARE AND OUTPATIENT, SKILLED NURSING, AND REHABILITATION SERVICES PROVIDED FOR MEDICAID. THESE RATES VARY ACCORDING TO A PATIENT CLASSIFICATION SYSTEM THAT IS BASED ON CLINICAL, DIAGNOSTIC, AND OTHER FACTORS. MEDICAID PAYMENTS FOR CAPITAL ARE RECEIVED ON A COST REIMBURSEMENT METHODOLOGY. PAYMENTS ARE RECEIVED ON A PROSPECTIVE BASIS FOR ACMC'S MEDICAL EDUCATION COSTS, SUBJECT TO CERTAIN LIMITS. PROVISION FOR ESTIMATED RETROACTIVE ADJUSTMENTS, IF ANY, RESULTING FROM REGULATORY MATTERS OR OTHER ADJUSTMENTS UNDER PAYMENT AGREEMENTS ARE ESTIMATED IN THE PERIOD THE RELATED SERVICES ARE PROVIDED. PART I, LINE 7G: ACMC PROVIDES AN ATHLETIC TRAINER TO FOUR HIGH SCHOOLS AT NO COST TO THE SCHOOL DISTRICTS FOR THIS SERVICE. PART I, LINE 7, COLUMN (F): THE BAD DEBT EXPENSE INCLUDED ON FORM 990, PART IX, LINE 25, COLUMN (A), BUT SUBTRACTED FOR PURPOSES OF CALCULATING THE PERCENTAGE IN THIS COLUMN IS $ 8,945,982. PART I, LINE 7C: ACMC PARTICIPATES IN THE HOSPITAL CARE ASSURANCE PROGRAM (HCAP) TO FINANCIALLY SUPPORT THOSE HOSPITALS THAT SERVICE A DISPROPORTIONATE SHARE OF LOW-INCOME PATIENTS UNABLE TO PAY FOR CARE. HCAP FUNDS BASIC, MEDICALLY NECESSARY HOSPITAL SERVICES FOR PATIENTS WHOSE FAMILY INCOME IS AT OR BELOW THE FEDERAL POVERTY LEVEL, WHICH INCLUDES MEDICAID PATIENTS AND PATIENTS WITHOUT HEALTH INSURANCE. PART I, LINE 7E: ACMC PROVIDES A SIGNIFICANT RECRUITING SUBSIDY AND GUARANTEE FOR ALL NEW PHYSICIANS THE HOSPITAL RECRUITS. IN ADDITION, THE HOSPITAL PROVIDES A GUARANTEE AFTER THE INITIAL RECRUITMENT FOR SOME PHYSICIANS DUE TO THE PRESSING NEED FOR THE PHYSICIAN'S SPECIALTY. WITHOUT THE HOSPITAL DOING THIS, ACMC WOULD NOT BE ABLE TO PROVIDE MANY OF THESE SERVICES LOCALLY. THE RECRUITMENT AND GUARANTEE COSTS ACMC INCURS REDUCES GEOGRAPHIC AND FINANCIAL BARRIERS TO ACCESSING HEALTH CARE AND IMPROVES THE AVAILABILITY OF HEALTH SERVICES IN THE AREA ACMC SERVES. PART III, LINE 2: TOTAL BAD DEBT EXPENSE FOR THE ENTIRE HOSPITAL COMPLEX IS EQUAL TO THE TOTAL GROSS CHARGES WRITTEN OFF AS REPORTED ON THE 2018 MEDICARE COST REPORT. PART III, LINE 3: ASHTABULA COUNTY MEDICAL CENTER DOES NOT HAVE A METHOD TO REASONABLY ESTIMATE THE PORTION OF BAD DEBT EXPENSE ATTRIBUTABLE TO PATIENTS WHO WOULD QUALIFY FOR FINANCIAL ASSISTANCE BUT DID NOT COMPLETE AN APPLICATION. PART II: N/A PART III, LINE 4: SEE THE "NET PATIENT SERVICE REVENUE AND PATIENT RECEIVABLES" PARAGRAPHS IN NOTE 1 ON PAGES 11-12 IN THE ATTACHED AUDITED FINANCIAL STATEMENTS.ACMC PROVIDES CARE TO PATIENTS WHO DO NOT HAVE THE ABILITY TO PAY AND WHO QUALIFY FOR CHARITY SERVICES PURSUANT TO ESTABLISHED POLICIES OF ACMC. CHARITY SERVICES ARE DEFINED AS THOSE FOR WHICH PATIENTS HAVE THE OBLIGATION AND WILLINGNESS TO PAY BUT DO NOT HAVE THE ABILITY TO DO SO. ACMC DOES NOT INCLUDE CHARITY CARE IN NET PATIENT SERVICE REVENUE. PART III, LINE 8: MEDICARE SURPLUS IS NOT TREATED AS COMMUNITY BENEFIT. THE AMOUNTS REPORTED WERE GENERATED FROM THE MEDICARE COST REPORT FILED FOR 2018. ACMC IS PAID A PROSPECTIVELY DETERMINED RATE FOR THE MAJORITY OF INPATIENT ACUTE CARE AND OUTPATIENT, SKILLED NURSING, AND REHABILITATION SERVICES PROVIDED FOR MEDICARE. THESE RATES VARY ACCORDING TO A PATIENT CLASSIFICATION SYSTEM THAT IS BASED ON CLINICAL, DIAGNOSTIC, AND OTHER FACTORS. MEDICARE PAYMENTS FOR CAPITAL ARE RECEIVED ON A PROSPECTIVE BASIS. PAYMENTS ARE RECEIVED ON A PROSPECTIVE BASIS FOR ACMC'S MEDICAL EDUCATION COSTS, SUBJECT TO CERTAIN LIMITS. ACMC IS PAID FOR COST REIMBURSABLE ITEMS AT A TENTATIVE RATE, WITH FINAL SETTLEMENT DETERMINED AFTER SUBMISSION OF ANNUAL COST REPORTS BY ACMC AND AUDITS THEREOF BY THE MEDICARE FISCAL INTERMEDIARY. PROVISION FOR ESTIMATED RETROACTIVE ADJUSTMENTS, IF ANY, RESULTING FROM REGULATORY MATTERS OR OTHER ADJUSTMENTS UNDER PAYMENT AGREEMENTS ARE ESTIMATED IN THE PERIOD THE RELATED SERVICES ARE PROVIDED.LAWS AND REGULATIONS GOVERNING MEDICARE ARE COMPLEX AND SUBJECT TO INTERPRETATION AS WELL AS SIGNIFICANT REGULATORY ACTION, AND, IN THE NORMAL COURSE OF BUSINESS, ACMC IS SUBJECT TO CONTRACTUAL REVIEWS AND AUDITS. AS A RESULT, THERE IS AT LEAST A REASONABLE POSSIBILITY THAT RECORDED ESTIMATES WILL CHANGE IN THE NEAR TERM. ACMC BELIEVES IT IS IN COMPLIANCE WITH APPLICABLE LAWS AND REGULATIONS GOVERNING THE MEDICARE PROGRAM AND THAT ADEQUATE PROVISIONS HAVE BEEN MADE FOR ANY ADJUSTMENTS THAT MAY RESULT FROM FINAL SETTLEMENTS. PART III, LINE 9B: REASONABLE EFFORTS ARE PERFORMED TO DETERMINE THE PATIENT'S ELIGIBILITY UNDER THE HOSPITAL'S FAP AND THE HOSPITAL DOES NOT PERFORM DEBT COLLECTION PROCEDURES BEFORE MAKING THESE REASONABLE EFFORTS. THIS IS ACHIEVED THROUGH THE HCAP APPLICATION. DOCUMENTATION OF THE PATIENT OR FAMILY INCOME FOR HCAP ELIGIBILITY WILL BE BASED UPON A BEST EVIDENCE METHODOLOGY. HOSPITAL EMPLOYEES WILL PROCEED THROUGH THE FOLLOWING IN AN EFFORT TO SECURE THE BEST EVIDENCE AVAILABLE FOR THE PATIENT OR GUARANTOR AT THE TIME OF THEIR ENCOUNTER. 1. A COMPLETED HCAP APPLICATION INCLUSIVE OF THE PATIENT OR GUARANTOR'S SIGNATURE.2. A COMPLETED HCAP APPLICATION, WHICH INCLUDES THE SIGNATURE OF THE PATIENT REPRESENTATIVE SECURING THE INFORMATION FROM THE RESPONSIBLE PARTY.IF THE APPLICATION CANNOT BE SECURED AT THE TIME OF THE ENCOUNTER, THE RESPONSIBLE PARTY WILL BE PROVIDED WITH A RETURN ENVELOPE. THEY WILL BE ASKED TO PROVIDE THIS INFORMATION UPON THEIR RETURN TO THEIR HOME. IN THE EVENT THAT THE INFORMATION IS RECEIVED, IT IS TO BE REVIEWED AND CONSIDERED AGAINST THE ABOVE-DEFINED ELIGIBILITY DETERMINATION CRITERIA. IF IT IS NOT RETURNED WITHIN 14 DAYS OF DISCHARGE, ACMC CONTACTS THE PATIENT VIA TELEPHONE TO COMPLETE THE APPLICATION. FOR OUTPATIENT HOSPITAL SERVICES, THE ELIGIBILITY DETERMINATION IS EFFECTIVE FOR NINETY DAYS FROM THE INITIAL SERVICE DATE. DURING THIS PERIOD A NEW ELIGIBILITY DETERMINATION NEED NOT BE COMPLETED. ELIGIBILITY FOR INPATIENT HOSPITAL SERVICES MUST BE DETERMINED SEPARATELY FOR EACH ADMISSION, UNLESS THE PATIENT IS READMITTED WITHIN FORTY-FIVE DAYS OF DISCHARGE FOR THE SAME UNDERLYING CONDITION. ELIGIBILITY FOR RECIPIENTS OF THE DISABILITY ASSISTANCE PROGRAM MUST BE VERIFIED ON A MONTHLY BASIS. IN THE EVENT THE PATIENT DOES NOT COMPLETE AN APPLICATION DURING THE ENCOUNTER, AND AS A RESULT OF THE HCAP COMMUNICATION, PATIENT STATEMENTS, OR RESULT OF COLLECTION EFFORTS, HOSPITAL STAFF WILL COMPLETE THE HCAP APPLICATION, OVER THE TELEPHONE OR IN-PERSON, ON BEHALF OF THE RESPONSIBLE PARTY. PART VI, LINE 2: ACMC USES MARKET DATA THAT REFLECTS ACTUAL PATIENT VISITS (DATA THAT IS SUBMITTED TO THE OHIO HOSPITAL ASSOCIATION BY ALL HOSPITALS IN THE STATE). MANAGEMENT REVIEWS THE NUMBER OF PATIENTS FROM THE MARKET WHO LEAVE ASHTABULA COUNTY FOR HEALTHCARE, AND WHAT SERVICES THEY LEAVE FOR. ACMC CONDUCTS A MEDICAL STAFF DEVELOPMENT PLAN (APPROXIMATELY EVERY THREE YEARS) IN WHICH PHYSICIANS ARE ASKED ABOUT THEIR PRACTICE PLANS (PLANNING TO RETIRE, BECOME EMPLOYED, GO INDEPENDENT, EXPAND) AND WHAT SPECIALISTS ARE NEEDED IN THE COMMUNITY TO BETTER SERVE THEIR PATIENTS. THIS HELPS GUIDE THE PHYSICIAN RECRUITMENT EFFORTS TO ENSURE THE HOSPITAL IS MEETING THE HEALTH NEEDS OF THE MARKET. MEMBERS OF THE MANAGEMENT TEAM ACTIVELY SERVE ON THE BOARDS OF COMMUNITY ORGANIZATIONS, MANY OF WHICH HAVE A MISSION TO ADDRESS COMMUNITY NEED; HEALTHCARE BEING ONE OF THOSE NEEDS (COMMUNITY ACTION, SALVATION ARMY, UNITED WAY, CATHOLIC CHARITIES, SENIOR ADVOCACY AND PROTECTIVE NETWORK, ETC.). EVERY 3 YEARS ACMC CONDUCTS A COMMUNITY HEALTH NEEDS ASSESSMENT. THE FINDINGS FROM THAT ASSESSMENT ARE USED TO DEVELOP AN IMPLEMENTATION PLAN TO ADDRESS THE KEY HEALTH NEEDS IN THE COMMUNITY. PART VI, LINE 3: INFORMATION ABOUT ELIGIBILITY FOR ASSISTANCE UNDER FEDERAL, STATE OR LOCAL GOVERNMENT PROGRAMS IS DESCRIBED ON THE PATIENT'S BILL, THE POLICY IS POSTED ON THE HOSPITAL'S WEBSITE AND IS ALSO AVAILABLE UPON REQUEST. THE NOTICE, BOTH IN ENGLISH AND SPANISH, IS POSTED AT THE FOLLOWING LOCATIONS: EMERGENCY DEPARTMENT, ALL ADMISSIONS/REGISTRATION AREAS, PATIENT FINANCIAL SERVICES DEPARTMENT. ACMC FINANCIAL COUNSELORS MEET WITH ANY PATIENT THAT MAY NEED ANY FORM OF FINANCIAL AID PRIOR TO DISCHARGE AND EDUCATE THEM ON FINANCIAL ASSISTANCE. PART VI, LINE 4: AFFILIATED WITH THE CLEVELAND CLINIC, ACMC IS THE LARGEST AND MOST ADVANCED HOSPITAL IN ASHTABULA COUNTY. ACMC OPENS THE DOOR TO THE WORLD'S BEST HEALTHCARE BY APPLYING CLEVELAND CLINIC'S CLINICAL INFORMATION AND STATE-OF-THE-ART STANDARDS OF CARE. THE PRIMARY MARKET IS COMPRISED OF THE FOLLOWING ZIP CODES: 44004, 44005, 44010, 44030, 44032, 44041, 44048, 44068, 44082. THE SECONDARY MARKET IS COMPRISED OF THE FOLLOWING ZIP CODES: 44003, 44076, 44084, 44085, 44093, 44099. THE PAYER MIX IS 50.7% MEDICARE, 24.1% MEDICAID, 22.0% COMMERCIAL, 1.6% SELF PAY, 1.6% OTHER. 80% OF THE MARKET HAS ONLY A HIGH SCHOOL DIPLOMA; 11% HAVE A COLLEGE DEGREE. THE MEDIAN HOUSEHOLD INCOME IS APPROXIMATELY $40,000; WITH PER CAPITA INCOME AT APPROXIMATELY $19,000. PART VI, LINE 5: ACMC IS AN ACTIVE PARTICIPANT AND SPONSOR OF EVENTS LIKE RELAY FOR LIFE AND AMERICAN HEART WALK AND SPONSOR OF HEALTH-RELATED EVENTS OF COMMUNITY ORGANIZATIONS (EXAMPLE: ZONTA WOMEN'S HEALTH DAY). ACMC PUBLISHES A COMMUNITY MAGAZINE TWICE A YEAR WITH HEALTHCARE INFORMATION AND TIPS FOR HEALTHY LIVING. THE WEBSITE CONTAINS HEALTH INFORMATION AND DOWNLOADABLE RESOURCES. THE HOSPITAL HOLDS A WOMEN'S HEART HEALTH EVENT EACH YEAR AND HELD A MEN'S EVENT FOR THE FIRST TIME IN 2017. ACMC STAFF MAKE MONTHLY PRESENTATIONS AT SENIOR CENTERS IN ASHTABULA, CONNEAUT AND JEFFERSON. ACMC PARTICIPATES IN NUMEROUS HEALTH FAIRS AND COMMUNITY EVENTS AT WHICH THE HOSPITAL PROVIDES FREE SCREENINGS (BLOOD PRESSURE, BLOOD SUGAR, BODY MASS INDEX, BACK STRENGTH, CHOLESTEROL). STAFF (PHYSICIANS, CLINICIANS, ETC.) APPEAR ON LOCAL CABLE TV SHOW 2X/MONTH TO SHARE HEALTH INFORMATION. ACMC OFFERS SUPPORT GROUPS (EXAMPLES CANCER, DIABETES AND COPD). THE HOSPITAL IS WORKING WITH AMERICAN CANCER SOCIETY TO OFFER REACH TO RECOVERY, LOOK GOOD FEEL BETTER AND OTHER PROGRAMS IN ASHTABULA COUNTY. ACMC ALSO PROVIDES AN ATHLETIC TRAINER TO FOUR HIGH SCHOOLS (NO COST TO THE SCHOOL DISTRICTS FOR THIS SERVICE). ADDITIONALLY, ACMC PARTICIPATES WITH LOCAL SOCIAL SERVICE AGENCIES ON THEIR PROGRAMS THAT ARE DESIGNED TO IMPROVE THE HEALTH AND WELL-BEING OF ASHTABULA COUNTY RESIDENTS. EXAMPLES INCLUDE: FEED THE HOPE, COMMUNITY GARDEN AT CONNEAUT HUMAN RESOURCE CENTER, PRODUCE DISTRIBUTION WITH GENEVA FOOD PANTRY, BRIDGES OUT OF POVERTY. PART VI, LINE 6: ACMC IS AN AFFILIATE OF THE CLEVELAND CLINIC. THE CLEVELAND CLINIC HEALTH SYSTEM ENGAGES IN MANY COMMUNITY OUTREACH PROGRAMS, INCLUDING INITIATIVES DESIGNED TO SERVE THE VULNERABLE AND AT-RISK POPULATIONS IN OUR COMMUNITIES. CLEVELAND CLINIC'S OUTREACH PROGRAMS RANGE FROM FREE HEALTH SCREENINGS AND CLINICAL SERVICES TO ENROLLMENT ASSISTANCE FOR GOVERNMENT-FUNDED HEALTH PROGRAMS. COMMUNITY OUTREACH PROGRAMS ARE ALSO THOSE PROGRAMS THAT IMPROVE ACCESS TO HEALTH SERVICES. CLEVELAND CLINIC CAREGIVERS COLLABORATE WITH COMMUNITY ORGANIZATIONS TO PROVIDE A CONTINUUM OF CARE THAT SUPPORTS ECONOMICALLY AND MEDICALLY UNDERSERVED AREAS. THE 2016 COMMUNITY BENEFIT REPORT PUBLISHED BY THE CLEVELAND CLINIC STATED $808.7 MILLION WAS SPENT BY THE CLEVELAND CLINIC IN 2016 ON COMMUNITY BENEFIT PROGRAMS. PART VI, LINE 7: N/A 1 ASHTABULA REGIONAL HOME HEALTH SERVICES PO BOX 1428 ASHTABULA OH 440051428 341143158 501(C)(3) 300000 GENERAL OPERATING SUPPORT 1 0 PART I, LINE 2: DON KEPNER, THE VICE PRESIDENT AND CFO OF THE ASHTABULA COUNTY MEDICAL CENTER, IS AN EMPLOYEE OF THE CLEVELAND CLINIC. THIS OVERLAP IN RESPONSIBILITY ENSURES PROPER USE OF DISTRIBUTED FUNDS. X X X 0 0 0 0 0 0 0 0 0 DANIEL KEATON MD BOARD MEMBER CHIEF OF STAFF (THROUGH 12/18) 190420 0 0 0 270 0 7194 0 6750 0 204634 0 0 0 SATHISH ADIGOPULA MD BOARD MEMBER/VICE-CHIEF OF STAFF 573199 0 0 0 180 0 11000 0 6750 0 591129 0 0 0 ALEXANDER TAICH MD PHYSICIAN 1166361 0 0 0 180 0 11000 0 7400 0 1184941 0 0 0 NATHANIEL S FRANLEY MD PHYSICIAN 613188 0 0 0 64140 0 11000 0 4579 0 692907 0 0 0 LAXMAN R CINGIREDDI MD PHYSICIAN 821195 0 0 0 414 0 9950 0 6750 0 838309 0 0 0 BRANDON L RAUDENBUSH MD PHYSICIAN 666560 0 33333 0 0 0 11000 0 4979 0 715872 0 0 0 PAZHANIAANDI TIROUNILACANDIN MD PHYSICIAN 741298 0 0 0 162 0 11000 0 6539 0 758999 0 0 0 PART I, LINE 3 SALARIES ARE REVIEWED APPROXIMATELY EVERY TWO YEARS. SALARIES ARE COMPARED TO LOCAL, REGIONAL, AND NATIONAL MARKET RATES AND IN CONJUNCTION WITH THE CEO AND CFO TO DETERMINE COMPENSATION. WHEN OPENINGS FOR KEY POSITIONS BECOME AVAILABLE, THE HUMAN RESOURCES DEPARTMENT EXAMINES THE MARKET RATES TO DETERMINE A STARTING SALARY. KIMBERLY GIANGOLA FAMILY MEMBER OF JOSEPH GIANGOLA, ACMC TRUSTEE 30381 EMPLOYMENT AGREEMENT WITH ACMC 0 BRITTANY GILBERT FAMILY MEMBER OF PEG CARLO, ACMC TRUSTEE 68138 EMPLOYMENT AGREEMENT WITH ACMC 0 FORM 990, PART VI, SECTION A, LINE 3 THE CLEVELAND CLINIC FOUNDATION HOLDS AND EXERCISES A MANAGEMENT AGREEMENT WITH ACMC. FORM 990, PART VI, SECTION A, LINE 6 THE CLEVELAND CLINIC FOUNDATION IS THE SOLE SPECIAL MEMBER OF ASHTABULA COUNTY MEDICAL CENTER. FORM 990, PART VI, SECTION A, LINE 7A THE BOARD MEMBERS ARE APPOINTED BY THE CLEVELAND CLINIC FOUNDATION, THE SPECIAL MEMBER. FORM 990, PART VI, SECTION A, LINE 7B THE FOLLOWING MATTERS REQUIRE THE APPROVAL OF THE CLEVELAND CLINIC FOUNDATION, THE SPECIAL MEMBER: (A) CHANGES TO THE ARTICLES OF INCORPORATION OR THE CODE OF REGULATIONS THAT WOULD HAVE A MATERIAL ADVERSE IMPACT ON THE SPECIAL MEMBER'S RIGHTS; (B) ANY AFFILIATION OF ACMC OR ITS SUBSIDIARIES OR AFFILIATES WITH ANY OTHER HOSPITAL, HOSPITAL SYSTEM, OR HEALTH CARE SYSTEM WHICH INCLUDES HOSPITALS AS PART OF SUCH SYSTEM; (C) ANY MATERIAL CHANGE TO ACMC'S OPERATION OR PURPOSE SUCH THAT ACMC'S PRINCIPAL ACTIVITY CEASES TO BE AN ACUTE CARE INPATIENT HOSPITAL OF NO LESS THAN 200 LICENSED BEDS; (D) SELECTION OF ACMC'S PRESIDENT/CEO; AND (E) REVIEW AND COORDINATION WITH ACMC OF ALL MANAGED CARE AND EMPLOYER CONTRACTS. FORM 990, PART VI, SECTION B, LINE 11B THE FORM 990 REPORT IS PUBLISHED TO THE BOARD OF DIRECTORS' WEBSITE PRIOR TO FILING. FORM 990, PART VI, SECTION B, LINE 12C EACH TRUSTEE, PRINCIPAL OFFICER, MEMBER OF A COMMITTEE WITH BOARD-DELEGATED POWERS, AND KEY EMPLOYEE SHALL ANNUALLY SIGN A STATEMENT, WHICH AFFIRMS THAT SUCH PERSON HAS RECEIVED A COPY OF THE CONFLICTS OF INTEREST POLICY, HAS READ AND UNDERSTANDS THE POLICY, HAS AGREED TO COMPLY WITH THE POLICY, AND UNDERSTANDS THAT THE CORPORATION IS A CHARITABLE ORGANIZATION AND THAT IN ORDER TO MAINTAIN ITS FEDERAL TAX EXEMPTION IT MUST ENGAGE PRIMARILY IN ACTIVITIES WHICH ACCOMPLISH ONE OR MORE OF ITS TAX-EXEMPT PURPOSES. IF A PERSON COVERED BY THE CONFLICT OF INTEREST POLICY BELIEVES HE OR SHE HAS A POTENTIAL CONFLICT OF INTEREST, THAT PERSON IS TO DISCLOSE THE CONFLICT TO THE BOARD. AFTER DISCLOSURE OF THE FINANCIAL INTEREST AND ALL MATERIAL FACTS, AND AFTER ANY DISCUSSION WITH THE INTERESTED PERSON, HE OR SHE SHALL LEAVE THE BOARD OR COMMITTEE MEETING WHILE THE DETERMINATION OF A CONFLICT OF INTEREST IS DISCUSSED AND VOTED UPON. THE REMAINING BOARD OR COMMITTEE MEMBERS SHALL DECIDE IF A CONFLICT OF INTEREST EXISTS. THE DISCLOSING PERSON MAY MAKE A PRESENTATION REGARDING THE PROPOSED TRANSACTION/POTENTIAL CONFLICT OF INTEREST AT THE BOARD OR COMMITTEE MEETING, BUT AFTER SUCH PRESENTATION, HE OR SHE SHALL LEAVE THE MEETING DURING THE DISCUSSION OF, AND THE VOTE ON, THE PROPOSED TRANSACTION OR ARRANGEMENT THAT RESULTS IN THE CONFLICT OF INTEREST. THE CHAIRPERSON OF THE BOARD OR COMMITTEE SHALL, IF APPROPRIATE, APPOINT A DISINTERESTED PERSON OR COMMITTEE TO INVESTIGATE ALTERNATIVES TO THE PROPOSED TRANSACTION OR ARRANGEMENT. AFTER EXERCISING DUE DILIGENCE, THE BOARD OR COMMITTEE SHALL DETERMINE WHETHER THE CORPORATION CAN OBTAIN A MORE ADVANTAGEOUS TRANSACTION OR ARRANGEMENT WITH REASONABLE EFFORTS FROM A PERSON OR ENTITY THAT WOULD NOT GIVE RISE TO A CONFLICT OF INTEREST. IF A MORE ADVANTAGEOUS TRANSACTION OR ARRANGEMENT IS NOT REASONABLY ATTAINABLE UNDER CIRCUMSTANCES THAT WOULD NOT GIVE RISE TO A CONFLICT OF INTEREST, THE BOARD OR COMMITTEE SHALL DETERMINE BY A MAJORITY VOTE OF THE DISINTERESTED TRUSTEES WHETHER THE TRANSACTION OR ARRANGEMENT IS IN THE CORPORATION'S BEST INTEREST AND FOR ITS OWN BENEFIT AND WHETHER THE TRANSACTION IS FAIR AND REASONABLE TO THE CORPORATION AND SHALL MAKE ITS DECISION AS TO WHETHER TO ENTER INTO THE TRANSACTION OR ARRANGEMENT IN CONFORMITY WITH SUCH DETERMINATION. IF THE BOARD OR COMMITTEE HAS REASONABLE CAUSE TO BELIEVE THAT A MEMBER HAS FAILED TO DISCLOSE ACTUAL OR POSSIBLE CONFLICTS OF INTEREST, IT SHALL INFORM THE MEMBER OF THE BASIS FOR SUCH BELIEF AND AFFORD THE MEMBER AN OPPORTUNITY TO EXPLAIN THE ALLEGED FAILURE TO DISCLOSE. IF, AFTER HEARING THE RESPONSE OF THE MEMBER AND MAKING SUCH FURTHER INVESTIGATION AS MAY BE WARRANTED IN THE CIRCUMSTANCES, THE BOARD OR COMMITTEE DETERMINES THAT THE MEMBER HAS IN FACT FAILED TO DISCLOSE AN ACTUAL OR POSSIBLE CONFLICT OF INTEREST, IT SHALL TAKE APPROPRIATE DISCIPLINARY AND CORRECTIVE ACTION. FORM 990, PART VI, SECTION B, LINE 15 SALARIES ARE REVIEWED APPROXIMATELY EVERY TWO YEARS. SALARIES ARE COMPARED TO LOCAL, REGIONAL, AND NATIONAL MARKET RATES AND IN CONJUNCTION WITH THE CEO AND CFO TO DETERMINE COMPENSATION. WHEN OPENINGS FOR KEY POSITIONS BECOME AVAILABLE, THE HUMAN RESOURCES DEPARTMENT EXAMINES THE MARKET RATES TO DETERMINE A STARTING SALARY. FORM 990, PART VI, SECTION C, LINE 19 ALL REQUESTS ARE SENT TO THE CEO FOR DISTRIBUTION. FORM 990, PART VII, SECTION A THE FOLLOWING OFFICERS WORKING FULL-TIME FOR ACMC ARE EMPLOYED BY THE CLEVELAND CLINIC AND ARE COMPENSATED THROUGH EMPLOYMENT AGREEMENTS WITH THE CLEVELAND CLINIC: MICHAEL HABOWSKI, PRESIDENT/CEO; DON KEPNER, VP FINANCE/CFO; JACQUELYN DIFIORE, CNO. IN ADDITION, OTHER EXECUTIVES WORK FULL TIME FOR ACMC AND ARE EMPLOYED BY THE CLEVELAND CLINIC, THOSE EXECUTIVES ARE LEW HUTCHISON, VP OF OPERATIONS AND QUALITY AND JONATHAN FORBES, DIRECTOR OF HUMAN RESOURCES. FORM 990, PART XI, LINE 9: EQUITY INCOME IN AFFLIATE 137,123. EFFECT OF RECOGNITION PROVISION AT MEASUREMENT DATE OF PENSION OBLIGATION -2,559,527. FEDERAL ELECTIONS SECTION 1.263(A)-1(F) DE MINIMIS SAFE HARBOR ELECTION ASHTABULA COUNTY MEDICAL CENTER 2420 LAKE AVENUE ASHTABULA, OH 44004 EMPLOYER IDENTIFICATION NUMBER: 34-0726081 FOR THE YEAR ENDING DECEMBER 31, 2018. ASHTABULA COUNTY MEDICAL CENTER IS MAKING THE DE MINIMIS SAFE HARBOR ELECTION UNDER REG. SEC. 1.263(A)-1(F). ASHTABULA COUNTY MEDICAL CENTER FOUNDATION 2420 LAKE AVENUE ASHTABULA OH 44004 341392784 SUPPORT THE ASHTABULA COUNTY MEDICAL CENTER OH 501(C)(3) LINE 12A, I ASHTABULA COUNTY MEDICAL CENTER 1 ROCK CREEK MEDICAL CENTER (DBA GLENBEIGH HEALTH SOURCES) 2863 STATE ROUTE 45 ROCK CREEK OH 44084 341789783 OPERATE AND MAINTAIN A HOSPITAL AND OUTPATIENT CENTERS OH 501(C)(3) LINE 3 ASHTABULA COUNTY MEDICAL CENTER 1 ASHTABULA REGIONAL HOME HEALTH SERVICES 3949 JEFFERSON ROAD ASHTABULA OH 44004 341143158 HOME HEALTH SERVICES OH 501(C)(3) LINE 10 ASHTABULA COUNTY MEDICAL CENTER 1 0 1 1 0 0 0 0 0 0 0 0 0 0 1 1 0 1 1 1 ASHTABULA COUNTY MEDICAL CENTER FOUNDATION Q 204449 CASH RECEIVED ASHTABULA REGIONAL HOME HEALTH SERVICES Q 164465 CASH RECEIVED ASHTABULA REGIONAL HOME HEALTH SERVICES B 300000 CASH CONTRIBUTED ROCK CREEK MEDICAL CENTER (DBA GLENBEIGH HEALTH SOURCES) Q 998917 CASH RECEIVED ROCK CREEK MEDICAL CENTER (DBA GLENBEIGH HEALTH SOURCES) C 10500000 CASH RECEIVED ASHTABULA COUNTY MEDICAL CENTER FOUNDATION C 350000 CASH RECEIVED