2019-11-11T15:04:50-06:00 2018-12-31 350921680 CROWE LLP 330 E JEFFERSON BLVD P O BOX 7 SOUTH BEND IN 466240007 990 2018-01-01 202401676 COMMUNITY HOSPITAL OF LAGRANGE COUNTY INC COMM 2603738429 207 N TOWNLINE RD LAGRANGE IN 46761 JEANNE' WICKENS PH CFO 2602669313 2019-11-11 1 KENNETH J KEBER P00240883 5742323992 204.58.171.16 2019-11-11 16:01:28 ES P B38744F01C9F8B49338464F7361C640636AC5E7B B38744F01C9F8B49338464F7361C640636AC5E7B 2018 2020-03-31 21:24:44Z MICHAEL J PACKNETT 10501 CORPORATE DRIVE FORT WAYNE IN 46845 43548007 0 X WWW.PARKVIEW.COM; WWW.PARKVIEWFOUNDATIONS.ORG X 2005 IN AS A COMMUNITY OWNED, NOT-FOR-PROFIT ORGANIZATION, COMMUNITY HOSPITAL OF LAGRANGE COUNTY, INC., AN AFFILIATE OF PARKVIEW HEALTH SYSTEM, INC., IS DEDICATED TO IMPROVING YOUR HEALTH AND INSPIRING YOUR WELL-BEING. 12 7 237 20 0 0 110332 129302 42376784 43112587 -4674 -10086 220439 194118 42702881 43425921 45652 41107 0 0 13077596 13298424 0 0 15042 27069112 27625755 40192360 40965286 2510521 2460635 26162922 26735508 28606950 29185596 -2444028 -2450088 X AS A COMMUNITY OWNED, NOT-FOR-PROFIT ORGANIZATION, COMMUNITY HOSPITAL OF LAGRANGE COUNTY, INC., AN AFFILIATE OF PARKVIEW HEALTH SYSTEM, INC., IS DEDICATED TO IMPROVING YOUR HEALTH AND INSPIRING YOUR WELL-BEING. 0 0 33581733 41107 43112587 COMMUNITY HOSPITAL OF LAGRANGE COUNTY, INC, D.B.A. PARKVIEW LAGRANGE HOSPITAL EXISTS FOR ONE PURPOSE: TO IMPROVE THE HEALTH OF THE COMMUNITIES WE SERVE. COMMUNITY HOSPITAL OF LAGRANGE COUNTY, INC. GIVES BACK TO THE COMMUNITY IN THE FORM OF IMPROVED FACILITIES, FREE AND DISCOUNTED CARE, EDUCATION AND OUTREACH PROGRAMS, VOLUNTEERISM AND MUCH MORE. USING INFORMATION FROM THE TRIANNUAL COMMUNITY HEALTH NEEDS ASSESSMENT, COMMUNITY HOSPITAL OF LAGRANGE COUNTY, INC., ALIGNS ITS OUTREACH PROGRAMS TO PRIORITIZE AND ADDRESS THE COMMUNITY'S NEEDS. SOME EXAMPLES INCLUDE:(SEE SCHEDULE O FOR CONTINUATION)-FINANCIAL ASSISTANCE-PRIMARY HEALTH CARE / ACCESS -HEALTH SCREENING AND PREVENTION-DISEASE MANAGEMENT-CONTRIBUTIONS TOWARD AND PARTICIPATION IN ECONOMIC DEVELOPMENT ACTIVITIESCOMMUNITY HOSPITAL OF LAGRANGE COUNTY, INC., D.B.A. PARKVIEW LAGRANGE HOSPITAL, IS A 25-BED CRITICAL ACCESS FACILITY THAT PROVIDES ACUTE-CARE SERVICES TO THE PEOPLE OF LAGRANGE COUNTY AND THE SURROUNDING AREA. THE VISION OF HOSPITAL LEADERSHIP HAS CONTINUED TO FOCUS ON EXPANDING ACCESS TO HEALTHCARE SERVICES AND HELPING TO IMPROVE THE HEALTH STATUS OF THOSE WHO LIVE AND WORK IN THE COMMUNITIES IT SERVES. AMONG THE SERVICES PROVIDED AT THE HOSPITAL ARE:-EMERGENCY CARE-INPATIENT MEDICAL/SURGICAL CARE-AMBULATORY AND INPATIENT SURGERY-ENDOSCOPY-ORTHOPEDIC SURGERY-INTENSIVE OUTPATIENT BEHAVIORAL HEALTH PROGRAM FOR SENIORS-OBSTETRICS/GYNECOLOGY SERVICES-OUTPATIENT AND INPATIENT REHABILITATION; OUTPATIENT CARDIAC REHABILITATION-ADVANCED, DIGITAL DIAGNOSTIC IMAGINGTHE 17,300 SQUARE FOOT MEDICAL OFFICE PLAZA ADJACENT TO THE HOSPITAL HAS ALLOWED FOR EXPANSION OF FULL-TIME AND VISITING MEDICAL SPECIALISTS, MAKING THESE SERVICES AVAILABLE LOCALLY. ON-SITE MEDICAL SERVICES INCLUDE:-ONCOLOGY AND HEMATOLOGY -CARDIOLOGY-COLON AND RECTAL SURGERY-GENERAL SURGERY-GYNECOLOGY-INFERTILITY-OBSTETRICS-OPHTHALMOLOGY-ORTHOPEDIC SURGERY-PODIATRY-PULMONOLOGY-UROLOGYFINANCIAL ASSISTANCE:COMMUNITY HOSPITAL OF LAGRANGE COUNTY, INC.'S MISSION INCLUDES CARING FOR PATIENTS WHO DO NOT HAVE THE MEANS TO MEET THEIR FINANCIAL OBLIGATIONS. THE HOSPITAL PLACES ITS PRIORITY ON PROVIDING THE NECESSARY CARE FOR EACH PATIENT, NOT ON THE PATIENT'S FINANCIAL ABILITY TO PAY FOR THEIR MEDICAL EXPENSES.PRIMARY HEALTH CARE / ACCESS:COMMUNITY HOSPITAL OF LAGRANGE COUNTY, INC. PROVIDES CLINICAL STAFF AND SUPPORT TO TARGETED POPULATIONS WITHIN LAGRANGE COUNTY, INCLUDING:-A FULL TIME PLAIN CHURCH COORDINATOR SERVES AS A RESOURCE FOR AMISH, MENNONITE AND OTHER PLAIN CHURCH MEMBERS WHO HAVE QUESTIONS ABOUT THE HEALTHCARE SERVICES AVAILABLE WITHIN THE PARKVIEW HEALTH SYSTEM. WHETHER THE QUESTION CONCERNS THE APPROXIMATE COST OF A PROCEDURE, THE SCHEDULING OF A DIAGNOSTIC TEST, OR A BILLING QUESTION, THE PLAIN CHURCH COORDINATOR ASSISTS INDIVIDUALS AND FAMILIES BY OBTAINING AN ANSWER.-A PARTNERSHIP WITH THE LAGRANGE COUNTY COUNCIL ON AGING (COA) TO ASSIST WITH OPERATIONAL SUPPORT FOR THE COA'S TRANSPORTATION SERVICES TO ALL RESIDENTS OF LAGRANGE COUNTY. NEARLY HALF OF THE TRIPS THE COA PROVIDES ARE TO A PHYSICIAN FOR A CHECK-UP OR TO THE HOSPITAL FOR A TEST OR TREATMENT. TRANSPORTATION PROVIDED BY THE COA'S LCAT SERVICE IS FREE TO SENIORS RESIDING IN LAGRANGE COUNTY. HEALTH SCREENING, PREVENTION, AND DISEASE MANAGEMENT: COMMUNITY HOSPITAL OF LAGRANGE COUNTY, INC. PROVIDES FREE AND LOW COST SERVICES, HEALTH SCREENINGS AND EDUCATION TO DIVERSE POPULATIONS IN OUR SERVICE AREA. THESE INCLUDE: -VOUCHERS REDEEMABLE FOR NINE MONTHS OF PRENATAL VITAMINS HAVE ALSO BEEN MADE AVAILABLE TO WOMEN THROUGH THE BIRTH PLANNER AT COMMUNITY HOSPITAL OF LAGRANGE COUNTY, INC., LAGRANGE COUNTY PRIMARY CARE PHYSICIANS AND OBSTETRICIANS, THE LAGRANGE COUNTY HEALTH DEPARTMENT, AND WIC. VOUCHERS ARE REDEEMABLE AT LOCAL PHARMACIES WHO THEN SUBMIT THEM TO THE HOSPITAL FOR REIMBURSEMENT THROUGH COMMUNITY HEALTH IMPROVEMENT FUNDS.-DIABETES SUPPORT GROUP - THIS MONTHLY GROUP IS TAUGHT BY A DIABETES EDUCATOR/PHARMACIST AND IS FREE AND OPEN TO ANY WHOSE LIVES ARE AFFECTED BY DIABETES. THE GROUP OFFERS EDUCATIONAL PROGRAMS ON MEDICATION MANAGEMENT, NUTRITION, NEUROPATHY, ETC., IN ADDITION TO OPEN DIALOGUE ABOUT ANY ISSUES SPECIFIC TO MEMBERS OF THE GROUP-SURVIVING LOSS BY SUICIDE SUPPORT GROUP - MEETING MONTHLY, THIS SUPPORT GROUP PROVIDES A COMPASSIONATE, HEALING ENVIRONMENT FOR ADULTS WHOSE LIVES HAVE BEEN AFFECTED BY THE LOSS OF A LOVED ONE DUE TO SUICIDE.-LOCAL HEALTH FAIRS PROVIDED BY THE HOSPITAL BRING FREE AND LOW COST SCREENINGS OUT INTO THE COMMUNITY, IMPROVING ACCESS TO THESE SERVICES. AMONG THE SCREENINGS OFFERED ARE LOW COST BLOOD TESTS, HEARING SCREENINGS, BALANCE ASSESSMENTS AND MORE.-HEALTH BOOTHS ARE PROVIDED AT LOCAL COMMUNITY EVENTS AND OFFER ACTIVITIES AND EDUCATION DESIGNED TO HELP PARTICIPANTS LIVE A HEALTHIER LIFE STYLE. INFORMATION PROVIDED INCLUDED EDUCATIONAL MATERIAL AND HEALTH TIPS ALIGNED TO THE SPECIFIC EVENT'S TARGET POPULATION, INCLUDING WOMEN, SENIORS, YOUNG FAMILIES, ETC. 33581733 1 1 0 1 0 0 0 0 0 0 1 0 0 0 1 1 0 1 0 0 0 0 0 0 1 0 1 1 1 0 1 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 0 0 0 1 X 35 0 1 237 1 0 0 0 0 0 1 1 0 0 0 0 0 0 X 12 7 1 0 0 0 1 1 1 1 1 0 0 1 1 1 1 1 1 0 0 0 IN X JEANNE' WICKENS 2602669313 10501 CORPORATE DRIVE FORT WAYNE IN 46845 JORDI DISLER DIRECTOR/LGHOS PRESIDENT 40.00 0.00 X X 241358 0 78454 MICHAEL PACKNETT DIRECTOR/PH PRESIDENT & CEO 1.00 56.00 X X 0 1447044 759330 SHELBY COOPER DIRECTOR/PH PHYSICIAN 1.00 40.00 X 17654 226644 26653 JAMIN YODER DIRECTOR/PH PHYSICIAN 1.00 40.00 X 11773 254634 44966 MICHAEL MELLINGER DIRECTOR/POHCI PHYSICIAN 1.00 1.00 X 1500 2250 0 ROBERT BOND DIRECTOR/VICE CHAIR 1.00 0.00 X 4750 0 0 STEVEN CHRISTNER DIRECTOR 1.00 0.00 X 4750 0 0 KEVIN LAMBRIGHT DIRECTOR 1.00 1.00 X 5357 750 0 DENNIS LEHMAN DIRECTOR/TREASURER 1.00 0.00 X 4357 0 0 SHERRYL RHINESMITH DIRECTOR/CHAIR 1.00 1.00 X 6250 2000 0 JOE URBANSKI DIRECTOR 1.00 0.00 X 4750 0 0 PAUL YODER DIRECTOR 1.00 0.00 X 4750 0 0 JEANNE' WICKENS PH CHIEF FINANCIAL OFFICER 1.00 56.00 X 0 869537 314918 JARED BEASLEY LGHOS VP PATIENT CARE 40.00 0.00 X 177521 0 36116 BRENDA ARMENTROUT LGHOS MGR PHARMACY 40.00 0.00 X 176540 0 26052 ROBERT BLOOMFIELD LGHOS MGR SUPPORT SERVICE 40.00 0.00 X 124978 0 29756 MICHAEL CHARLIER LGHOS MGR REHAB 39.00 1.00 X 111179 12673 26713 TREVOR FRY LGHOS MGR ER 40.00 0.00 X 116203 0 31831 ROSS ROBISON LGHOS PHARMACIST 35.00 1.00 X 112759 2319 27016 ROBERT MYERS FORMER OFFICER 0.00 0.00 X 208415 0 0 1334844 2817851 1401805 11 1 1 0 PROFESSIONAL EMERGENCY PHYSICIANS INC PO BOX 12949 FORT WAYNE IN 46866 PHYSICIANS 1787060 PARKVIEW HOSPITAL INC 11109 PARKVIEW PLAZA DRIVE FORT WAYNE IN 46845 LABORATORY SERVICES 1118465 GREAT LAKES ANESTHESIA PC 500 N NAPPANEE ST STE 11-B ELKHART IN 46514 ANESTHESIOLOGISTS 695853 NORTHEAST INTERNAL MEDICINE ASSOC INC 2500 N DETROIT STREET LAGRANGE IN 46761 HOSPITALISTS 396349 CLINICAL COLLEAGUES INC PO BOX 824246 PHILADELPHIA PA 19182 ANESTHESIOLOGISTS 307109 9 9909 27386 26681 65326 1038 129302 NET PATIENT SERVICE 622000 42236786 42236786 PHARMACY 446110 474632 474632 EMS SUBSIDY 900099 349000 349000 INTERUNIT RENT 531120 27923 27923 SPEECH THERAPY 621300 10263 10263 13983 13983 43112587 1559 1559 22782 90931 -68149 -68149 -68149 13300 24945 -11645 -11645 -11645 5220 9909 6210 -990 -990 CAFETERIA REVENUE 722210 251324 251324 GIFT SHOP REVENUE 453220 11933 11933 263257 43425921 43112587 0 184032 X 41107 41107 603253 603253 208415 208415 9335944 9322815 3501 9628 3150812 3146337 1193 3282 5948524 5166425 781044 1055 1071 962 109 959311 880536 78189 586 724498 704174 20324 46096 34498 11216 382 17306 13415 3891 376280 376280 1587708 1584674 3034 103304 103304 CORP SERVICE ALLOCATION 5615004 5615004 BAD DEBT 4961587 4961587 PH CLINICAL SUPPORT 3782980 3782980 MEDICAL SUPPLIES 3441643 3441643 60443 20996 39447 40965286 33581733 7368511 15042 1675 1675 71360 131690 1028 550 4626726 5534381 291508 386010 19066 50857 33046974 17530470 16138451 15516504 5011241 5011241 1867 102600 26162922 26735508 1680860 1715174 17860779 16999132 114092 82358 8951219 10388932 28606950 29185596 X -2444028 -2450088 -2444028 -2450088 26162922 26735508 X 2460635 -2466695 X 0 1 X 1 0 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 0 0 0 0 0 0 0 0 1 3535 3535 0 PART II-B, LINE 1: REPRESENTS THE PORTION OF THE DUES PAID TO INDIANA HOSPITAL AND HEALTH ASSOCIATION, AMERICAN HOSPITAL ASSOCIATION, NATIONAL RURAL HEALTH ASSOCIATION AND VARIOUS PROFESSIONAL ASSOCIATIONS USED FOR LOBBYING ACTIVITIES. 320702 320702 13534008 4148900 9385108 29098 29098 0 17184446 12149860 5034586 1978720 1202612 776108 15516504 DUE TO/FROM INTERUNIT 3738167 EST MEDICARE/MEDICAID SETTLEMENTS 754524 NOTE PAYABLE TO PH 5896241 10388932 X PART X, LINE 2: PARKVIEW HEALTH SYSTEM, INC. AND SUBSIDIARIES - NOTES TO THE CONSOLIDATED FINANCIAL STATEMENTS TEXT OF THE FOOTNOTE TO THE ORGANIZATION'S FINANCIAL STATEMENTS THAT DESCRIBES THE LIABILITY FOR UNCERTAIN TAX POSITIONS UNDER FIN 48 (ASC 740): PAGE 15 OF ATTACHED FINANCIAL STATEMENTS. INCOME TAXES: THE INTERNAL REVENUE SERVICE HAS DETERMINED THAT THE CORPORATION AND CERTAIN AFFILIATED ENTITIES ARE TAX-EXEMPT ORGANIZATIONS AS DEFINED IN SECTION 501(C)(3) OF THE INTERNAL REVENUE CODE. CERTAIN SUBSIDIARIES OF THE CORPORATION ARE TAXABLE ENTITIES, THE TAX EXPENSE AND LIABILITIES OF WHICH ARE NOT MATERIAL TO THE CONSOLIDATED FINANCIAL STATEMENTS. THE CORPORATION AND ITS TAX-EXEMPT AFFILIATED ENTITIES EACH FILE A FORM 990 (RETURN OF ORGANIZATION EXEMPT FROM INCOME TAX) ANNUALLY. WHEN THESE 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 ULTIMATELY BE SUSTAINED. EXAMPLES OF TAX POSITIONS COMMON TO HEALTH SYSTEMS INCLUDE SUCH MATTERS AS THE TAX-EXEMPT STATUS OF EACH ENTITY, THE CONTINUED TAX-EXEMPT STATUS OF BONDS, THE NATURE, CHARACTERIZATION AND TAXABILITY OF JOINT VENTURE INCOME, AND VARIOUS POSITIONS RELATING TO POTENTIAL SOURCES OF UNRELATED BUSINESS TAXABLE INCOME (REPORTED ON FORM 990T). AS OF DECEMBER 31, 2018 AND 2017, THERE ARE NO UNRECOGNIZED TAX BENEFITS RESULTING FROM UNCERTAIN TAX POSITIONS. FORMS 990 AND 990T FILED BY THE CORPORATION AND ITS TAX-EXEMPT AFFILIATED ENTITIES ARE SUBJECT TO EXAMINATION BY THE INTERNAL REVENUE SERVICE UP TO THREE YEARS FROM THE EXTENDED DUE DATE OF EACH RETURN. FORMS 990 AND 990T FILED BY THE CORPORATION AND ITS TAX-EXEMPT AFFILIATED ENTITIES ARE NO LONGER SUBJECT TO EXAMINATION FOR THE YEAR 2014 AND PRIOR. PADDLE FOR PARKVIEW 15129 9909 5220 6210 15129 9909 5220 6210 6210 -990 1 1 X 1 X 0 1 1 1 0 1 1 594386 0 594386 0.01650 3235237 1365392 1869845 0.05190 2708547 1397135 1311412 0.03640 6538170 2762527 3775643 0.10480 46827 2625 44202 0.00120 41292 0 41292 0.00110 88119 2625 85494 0.00230 6626289 2765152 3861137 0.10710 10000 0 10000 0.00030 10000 10000 0.00030 1 4961587 45972 7772997 7442415 330582 X 1 1 1 1 COMMUNITY HOSPITAL OF LAGRANGE COUNTY 207 N TOWNLINE RD LAGRANGE IN 46761 WWW.PARKVIEW.COM 14-005085-1 X X X X COMMUNITY HOSPITAL OF LAGRANGE COUNTY 1 0 0 1 X X X X X X X X X 16 1 1 1 1 X WWW.PARKVIEW.COM/LOCALHEALTHNEEDS X 1 16 1 WWW.PARKVIEW.COM/LOCALHEALTHNEEDS 0 1 X 200.000000000000 X X X X X 1 1 X X X 1 X HTTPS://WWW.PARKVIEW.COM/PATIENTS-VISITORS/FINANCIAL-ASSISTANCE X HTTPS://WWW.PARKVIEW.COM/PATIENTS-VISITORS/FINANCIAL-ASSISTANCE X HTTPS://WWW.PARKVIEW.COM/PATIENTS-VISITORS/FINANCIAL-ASSISTANCE X X X X X X 1 X 0 X X X X 1 X 0 0 COMMUNITY HOSPITAL OF LAGRANGE COUNTY PART V, SECTION B, LINE 5: PARKVIEW HEALTH SYSTEM, INC. INCLUDING COMMUNITY HOSPITAL OF LAGRANGE COUNTY, INC. CONDUCTED ITS LAST COMMUNITY HEALTH NEEDS ASSESSMENT IN 2016. OVER THE COURSE OF ADMINISTERING THIS COMMUNITY HEALTH NEEDS ASSESSMENT, THE INDIANA PARTNERSHIP FOR HEALTH COMMUNITIES (IN-PHC) RESEARCH TEAM WORKED TO ENSURE THAT THE NEEDS OF THE MEDICALLY UNDERSERVED, LOW-INCOME AND MINORITY POPULATIONS WERE TAKEN INTO ACCOUNT. THE 2016 COMMUNITY HEALTH NEEDS ASSESSMENT USED THREE SOURCES OF PRIMARY DATA: 1) A PHONE SURVEY OF THE COMMUNITY CONDUCTED ON BEHALF OF COMMUNITY HOSPITAL OF LAGRANGE COUNTY, INC. AND THE INDIANA PARTNERSHIP FOR HEALTHY COMMUNITIES (IN-PHC) BY THE EAGLETON CENTER FOR PUBLIC INTEREST POLLING (A CENTER OF RUTGERS UNIVERSITY) COMPLETED IN MARCH 2016; 2) AN ONLINE SURVEY DEVELOPED BY THE IN-PHC AND DISTRIBUTED BY THE HOSPITAL TO AREA PROVIDERS INCLUDING PUBLIC HEALTH OFFICIALS, OTHER HEALTHCARE PROFESSIONALS AND VARIOUS SOCIAL SERVICE ORGANIZATIONS THAT SPECIALIZE IN AIDING VULNERABLE POPULATIONS COMPLETED IN JUNE 2016; AND 3) FOCUS GROUPS WITH SPECIFIC VULNERABLE POPULATIONS, INCLUDING THE HISPANIC/LATINO AND AFRICAN AMERICAN POPULATIONS WERE CONDUCTED BY IN-PHC IN ALLEN, NOBLE AND KOSCIUSKO COUNTIES. FOR THE AMISH COMMUNITY IN LAGRANGE COUNTY, A WRITTEN SURVEY WAS DISTRIBUTED THROUGH COMMUNITY LEADERS. FOCUS GROUP AND WRITTEN SURVEY DATA COLLECTION WAS COMPLETED IN THE SUMMER OF 2016.CONDUENT'S HEALTHY COMMUNITIES INSTITUTE (HCI) DATA BASE WAS USED TO ACCESS SECONDARY DATA FOR THE SEVEN-COUNTY AREA. STATE AND NATIONAL DATA WAS OBTAINED THROUGH THE CENTERS FOR DISEASE CONTROL AND PREVENTION, COUNTY HEALTH RANKINGS, HEALTH INDICATORS WAREHOUSE, INDIANA STATE DEPARTMENT OF HEALTH, INDIANA UNIVERSITY CENTER FOR HEALTH POLICY AND THE U.S. CENSUS BUREAU. COMMUNITY HOSPITAL OF LAGRANGE COUNTY PART V, SECTION B, LINE 6A: PARKVIEW HOSPITAL, INC. (EIN 35-0868085); COMMUNITY HOSPITAL OF NOBLE COUNTY, INC. (EIN 35-2087092); HUNTINGTON MEMORIAL HOSPITAL, INC. (EIN 35-1970706); WHITLEY MEMORIAL HOSPITAL, INC. (EIN 35-1967665); PARKVIEW WABASH HOSPITAL, INC. (EIN 47-1753440) AND ORTHOPAEDIC HOSPITAL AT PARKVIEW NORTH, LLC (EIN 26-0143823). COMMUNITY HOSPITAL OF LAGRANGE COUNTY PART V, SECTION B, LINE 6B: PARKVIEW HEALTH SYSTEM, INC.(EIN 35-1972384); INDIANA PARTNERSHIP FOR HEALTHY COMMUNITIES (A PARTNERSHIP BETWEEN THE INDIANA UNIVERSITY RICHARD M. FAIRBANKS SCHOOL OF PUBLIC HEALTH AND THE POLIS CENTER AT IUPUI) AND CONDUENT HEALTHY COMMUNITIES INSTITUTE. COMMUNITY HOSPITAL OF LAGRANGE COUNTY PART V, SECTION B, LINE 11: SIGNIFICANT HEALTH NEEDS BEING ADDRESSED:OBESITY/HEALTHY LIFESTYLES: COMMUNITY HOSPITAL OF LAGRANGE COUNTY, INC. CONTINUES ITS PARTNERSHIP WITH COLE FAMILY CENTER YMCA TO ADDRESS OBESITY AND THE NEED FOR PHYSICAL ACTIVITY THROUGH THE OPERATION OF SATELLITE GROUP WELLNESS EXERCISE CLASSES. PLANTING HEALTHY SEEDS, A CURRICULUM FOR 3RD AND 4TH GRADERS, IS A PROGRAM THAT COMMUNITY HOSPITAL OF LAGRANGE COUNTY, INC. IN COLLABORATION WITH THE LAGRANGE COUNTY SCHOOLS, CONDUCTED THROUGHOUT THE 2018/2019 SCHOOL YEAR TO TEACH YOUTH ABOUT EATING A HEALTHY DIET, AND FACILITATE THE SCHOOLS MEETING THEIR CURRICULUM GOALS. COMMUNITY HOSPITAL OF LAGRANGE COUNTY IMPLEMENTED A FOOD PHARMACY PROGRAM IN 2018 TO REDUCE THE NEGATIVE EFFECTS OF OBESITY (HEALTH AND ECONOMIC) AND THE RELATED CHRONIC DISEASES, SUCH AS DIABETES, THROUGH EDUCATION AND HEALTHY EATING PRACTICES. PATIENTS MUST BE REFERRED BY THEIR DOCTOR, HAVE TYPE 2 DIABETES, AND A BMI>30 TO PARTICIPATE. FOOD PHARMACY IS A 6-MONTH, 18-CLASS INTENSIVE PROGRAM THAT HELPS PATIENTS MAKE LASTING CHANGES IN THEIR DIET AND MEDICATION MANAGEMENT. MENTAL HEALTH:WITH DEATHS BY SUICIDE IN LAGRANGE COUNTY NEARLY DOUBLING EACH YEAR SINCE 2015, THE NEED FOR SUICIDE PREVENTION ON A BROAD SCALE WAS IDENTIFIED AS A HIGH PRIORITY. WITH ASSISTANCE FROM PARKVIEW BEHAVIORAL HEALTH, AN EVIDENCE-BASED SUICIDE PREVENTION STRATEGY KNOWN AS QUESTION, PERSUADE AND REFER (QPR) WAS SELECTED AS THE TOOL TO BE USED IN TRAINING A BROAD SPECTRUM OF ADULTS IN LAGRANGE COUNTY. THIS FREE EDUCATION PROGRAM HAS CONTINUED TO RAISE AWARENESS IN OUR COMMUNITY THROUGHOUT 2018, INSTRUCTING AN ADDITIONAL 419 PEOPLE THROUGHOUT LAGRANGE COUNTY. IN 2017, COMMUNITY HOSPITAL OF LAGRANGE'S QPR TEAM ESTABLISHED A PEER-LED SUPPORT GROUP FOR THOSE IMPACTED BY THE LOSS OF A LOVED ONE BY SUICIDE. THIS SUPPORT GROUP HAS CONTINUED IN 2018. IN ADDITION, COMMUNITY HOSPITAL OF LAGRANGE COUNTY, INC. PARTNERS WITH THE THREE PUBLIC SCHOOL CORPORATIONS IN LAGRANGE COUNTY TO ADDRESS MENTAL HEALTH. THE HOSPITAL PROVIDES A LICENSED MENTAL HEALTH COUNSELOR WHO IS PRESENT IN THE SCHOOLS FOR FOUR HOURS A WEEK IN EACH OF THE THREE COUNTY SCHOOLS ON A WEEKLY BASIS THROUGHOUT THE SCHOOL YEAR. OVER 100 STUDENTS RECEIVED ACCESS TO A MENTAL HEALTH COUNSELOR BY THE END OF THE 2018.OTHER HEALTH NEEDS NOT BEING ADDRESSED:-TOBACCO USE/SMOKING - PARKVIEW HEALTH IS A SOURCE OF SMOKING CESSATION PROGRAMS AND OPERATES A TOBACCO FREE CAMPUS. IN 2018 BREAK FREE FROM SMOKING CLASSES WERE TAUGHT BY CERTIFIED TRAINERS TO MEMBERS OF THE COMMUNITY FREE OF CHARGE EVERY QUARTER. THIS IS A 7-WEEK, 8-SESSION CLASS SERIES THAT PROVIDES SUPPORT AND EDUCATION TO HELP PEOPLE GET TOBACCO FREE. -DIABETES, CARDIOVASCULAR DISEASE AND CANCER - WHILE COMMUNITY HOSPITAL OF LAGRANGE COUNTY, INC. DID NOT SELECT THESE CHRONIC DISEASES AS TOP HEALTH PRIORITIES, OUR INTENT IS TO HELP PREVENT AND REDUCE THE PRESENCE OF CHRONIC CONDITIONS LIKE THE AFOREMENTIONED DISEASES BY ADDRESSING OBESITY THROUGH NUTRITION EDUCATION, INCREASED ACCESS TO HEALTHY FOODS, ACTIVE LIVING PROGRAMS AND EDUCATION INVOLVING OTHER HEALTHY LIFESTYLE HABITS.-DRUGS AND ALCOHOL ABUSE AND ADDICTION - ONE OF COMMUNITY HOSPITAL OF LAGRANGE COUNTY, INC.'S HEALTH PRIORITIES IS MENTAL HEALTH. MANY INDIVIDUALS BEING ASSISTED AND REFERRED THROUGH PARKVIEW BEHAVIORAL HEALTH CARE NAVIGATION PROGRAM ARE AFFECTED BY DRUG AND ALCOHOL ABUSE, AS WELL AS ADDICTION. COMMUNITY HOSPITAL OF LAGRANGE COUNTY, INC. BELIEVES THIS NEEDS TO BE AN INTEGRAL PART OF THE MENTAL HEALTH INITIATIVE WHICH MEANS IT WILL BE ADDRESSED AS PART OF THE COMMUNITY RESPONSE. IN ADDITION, BOWEN CENTER AND NORTHEASTERN CENTER ARE ALSO ADDRESSING DRUG AND ALCOHOL ADDICTION THROUGH THE SERVICES THEIR RESPECTIVE ORGANIZATIONS ARE PROVIDING IN THE LOCAL COMMUNITY. -MATERNAL CHILD AND INFANT HEALTH - COMMUNITY HOSPITAL OF LAGRANGE COUNTY, INC. CONTINUES TO PARTNER WITH THE LAGRANGE COUNTY HEALTH DEPARTMENT & WIC DEPARTMENT THROUGH THE BREAST FEEDING SUPPORT GROUP OFFERING SUPPORT AND GUIDANCE TO BREAST FEEDING MOMS. -HEALTHCARE COST AND ACCESS: AS PART OF PARKVIEW HEALTH'S STRATEGIC PLAN, COMMUNITY HOSPITAL OF LAGRANGE COUNTY, INC. CONTINUES ITS EFFORTS TO RECRUIT FAMILY PRACTICE AND SPECIALTY PHYSICIANS TO LAGRANGE COUNTY. 2 1 - PARKVIEW LAGRANGE EMS - CENTRAL 0982 N 00 EW LAGRANGE IN 46761 AMBULANCE SERVICE 2 - PARKVIEW LAGRANGE EMS - WEST 8175 W US 20 SHIPSHEWANA IN 46565 AMBULANCE SERVICE PART I, LINE 3C: EQUITY IN A HOME OTHER THAN THE PATIENT OR GUARANTOR'S PRIMARY RESIDENCE. PART I, LINE 6A: THE RELATED ENTITIES OF PARKVIEW HEALTH SYSTEM, INC. (EIN 35-1972384); PARKVIEW HOSPITAL, INC. (EIN 35-0868085); COMMUNITY HOSPITAL OF LAGRANGE COUNTY, INC. (EIN 20-2401676); COMMUNITY HOSPITAL OF NOBLE COUNTY, INC. (EIN 35-2087092); HUNTINGTON MEMORIAL HOSPITAL, INC. (EIN 35-1970706); WHITLEY MEMORIAL HOSPITAL, INC. (EIN 35-1967665) AND PARKVIEW WABASH HOSPITAL, INC. (EIN 47-1753440) PREPARED A COMBINED REPORT TO THE COMMUNITY DETAILING COMMUNITY BENEFIT PROGRAMS AND SERVICES. PART I, LINE 7: PART I, LINE 7ATHE FINANCIAL ASSISTANCE COST REPORTED ON LINE 7A IS CALCULATED UNDER THE COST TO CHARGE RATIO METHODOLOGY. UNDER THIS METHOD, THE FINANCIAL ASSISTANCE CHARGES FOREGONE ARE MULTIPLIED BY THE RATIO OF COST TO CHARGES TO DETERMINE THE COST OF SERVICES RENDERED.PART I, LINE 7BCOMMUNITY HOSPITAL OF LAGRANGE COUNTY, INC. ACCEPTS ALL MEDICAID, MEDICAID MANAGED CARE, AND OUT-OF-STATE MEDICAID PATIENTS WITH THE KNOWLEDGE THAT THERE MAY BE SHORTFALLS. INTERNAL REVENUE SERVICE (IRS) REVENUE RULING 69-545 IMPLIES THAT TREATING MEDICAID PATIENTS IS A COMMUNITY BENEFIT. IRS REVENUE RULING 69-545, WHICH ESTABLISHED THE COMMUNITY BENEFIT STANDARD FOR NONPROFIT HOSPITALS, STATES THAT IF A HOSPITAL SERVES PATIENTS WITH GOVERNMENTAL HEALTH BENEFITS, INCLUDING MEDICAID, THEN THIS IS AN INDICATION THAT THE HOSPITAL OPERATES TO PROMOTE THE HEALTH OF THE COMMUNITY. THE UNREIMBURSED MEDICAID COST REPORTED ON LINE 7B IS CALCULATED UNDER THE COST TO CHARGE RATIO METHODOLOGY. UNDER THIS METHOD, THE MEDICAID CHARGES ARE MULTIPLIED BY THE RATIO OF COST TO CHARGES TO DETERMINE THE COST OF MEDICAID SERVICES RENDERED. THEN, THE COST OF MEDICAID SERVICES RENDERED IS DEDUCTED FROM THE REIMBURSEMENT RECEIVED FOR MEDICAID PATIENTS TO ARRIVE AT A GAIN/(LOSS) RELATIVE TO THESE PATIENTS.PART I, LINE 7CCOMMUNITY HOSPITAL OF LAGRANGE COUNTY, INC. ACCEPTS ALL MEANS-TESTED PATIENTS FROM THE HEALTHY INDIANA PLAN (HIP) WITH THE KNOWLEDGE THAT THERE MAY BE SHORTFALLS. INTERNAL REVENUE SERVICE (IRS) REVENUE RULING 69-545 IMPLIES THAT TREATING MEANS-TESTED PATIENTS IS A COMMUNITY BENEFIT. IRS REVENUE RULING 69-545, WHICH ESTABLISHED THE COMMUNITY BENEFIT STANDARD FOR NONPROFIT HOSPITALS, STATES THAT IF A HOSPITAL SERVES PATIENTS WITH GOVERNMENTAL HEALTH BENEFITS, INCLUDING HIP, THEN THIS IS AN INDICATION THAT THE HOSPITAL OPERATES TO PROMOTE THE HEALTH OF THE COMMUNITY. THE UNREIMBURSED HIP COST REPORTED ON LINE 7C IS CALCULATED UNDER THE COST TO CHARGE RATIO METHODOLOGY. UNDER THIS METHOD, THE HIP CHARGES ARE MULTIPLIED BY THE RATIO OF COST TO CHARGES TO DETERMINE THE COST OF HIP SERVICES RENDERED. THEN, THE COST OF HIP SERVICES RENDERED IS DEDUCTED FROM THE REIMBURSEMENT RECEIVED FOR HIP PATIENTS TO ARRIVE AT A GAIN/(LOSS) RELATIVE TO THESE PATIENTS.PART I, LINE 7EAMOUNTS PRESENTED ARE BASED ON ACTUAL SPEND FOR THOSE SERVICES AND BENEFITS PROVIDED DEEMED TO IMPROVE THE HEALTH OF THE COMMUNITIES IN WHICH WE SERVE AND CONFORM WITH THE MISSION OF OUR EXEMPT PURPOSE.PART I, LINE 7FAMOUNTS PRESENTED ARE BASED UPON ACTUAL SPEND AND ARE IN CONFORMITY WITH AGREED UPON COMMITMENTS WITH THE VARIOUS EDUCATIONAL PROGRAMS.PART I, LINE 7IIN KEEPING WITH OUR MISSION AND COMMITMENT TO THE COMMUNITIES IN WHICH WE SERVE, COMMUNITY HOSPITAL OF LAGRANGE COUNTY, INC. CONTINUES ITS TRADITION OF CONTRIBUTING TO NUMEROUS ORGANIZATIONS ON BOTH AN AS-NEEDED BASIS AND NEGOTIATED BASIS. AMOUNTS PRESENTED REPRESENT ACTUAL SPEND TO ORGANIZATIONS THROUGHOUT OUR COMMUNITIES. PART I, LN 7 COL(F): PERCENT OF TOTAL EXPENSECOMMUNITY HOSPITAL OF LAGRANGE COUNTY, INC. EXCLUDED $4,961,587 OF BAD DEBT EXPENSE. PART II, COMMUNITY BUILDING ACTIVITIES: DESCRIBE HOW THE ORGANIZATION'S COMMUNITY BUILDING ACTIVITIES, AS REPORTED, PROMOTES THE HEALTH OF THE COMMUNITIES THE ORGANIZATION SERVES.COMMUNITY HOSPITAL OF LAGRANGE COUNTY, INC., D.B.A. PARKVIEW LAGRANGE HOSPITAL, PROVIDES SUPPORT FOR LOCAL ECONOMIC DEVELOPMENT PROGRAMS. THESE EFFORTS ARE ALIGNED OF THE HEALTH SYSTEM'S STRATEGIC INVOLVEMENT IN THE NORTHEAST INDIANA REGIONAL PARTNERSHIP'S VISION 2020, AN INITIATIVE DESIGNED TO TRANSFORM NORTHEAST INDIANA INTO A TOP GLOBAL COMPETITOR BY FOCUSING ON A COMMON MISSION TO DEVELOP, ATTRACT AND RETAIN TALENT. VISION 2020'S PRIORITIES ARE TIED TO EDUCATION/WORKFORCE, BUSINESS CLIMATE, ENTREPRENEURSHIP, INFRASTRUCTURE AND QUALITY OF LIFE FOR THE TWELVE-COUNTY REGION IN NORTHEAST INDIANA. PROMOTION OF ECONOMIC DEVELOPMENT IN LAGRANGE COUNTY IS A PART OF A COLLECTIVE PLAN TO IMPROVE THE QUALITY OF LIFE AND ULTIMATELY THE OVERALL HEALTH AND WELL-BEING OF THE COMMUNITY.COMMUNITY HOSPITAL OF LAGRANGE COUNTY, INC. SUPPORTS ECONOMIC DEVELOPMENT IN THE COUNTY THROUGH THE FOLLOWING INITIATIVES:- GRANT SUPPORT FOR KEY AGENCIES IN LAGRANGE COUNTY, INCLUDING THE ECONOMIC DEVELOPMENT CORPORATION- SPONSORSHIP OF INTERNSHIPS AND JOB-SHADOWING PROGRAMS FOR STUDENTS FROM LOCAL HIGH SCHOOLS AND AREA COLLEGES PLANNING TO PURSUE A CAREER IN THE HEALTHCARE RELATED FIELD- ACTIVE REPRESENTATION BY COMMUNITY HOSPITAL OF LAGRANGE COUNTY LEADERSHIP ON THE BOARDS OF NEARLY FORTY COMMUNITY NON-PROFIT AND CIVIC AGENCIES IN LAGRANGE COUNTY AND THE SURROUNDING AREA, INCLUDING:4H CLUB OF LAGRANGE COUNTYAMERICAN MEDICAL TECHNOLOGIST INDIANA STATE BOARD MEMBERBOARD PRESIDENT FOR DEKALB CENTRAL SCHOOLSCHURCH OF GOD GOVERNANCE BOARDCOMMUNITY CORRECTIONS LAGRANGE COUNTYCOMMUNITY IMPROVEMENT LEAGUE OF STROH - TRUSTEE FORMED COMMITTEECOUNCIL ON AGING BOARD MEMBERDEPUTY CORONER, LAGRANGEDRUG FREE LAGRANGE COUNTY TASKFORCEHABITAT FOR HUMANITY BOARD OF DIRECTORS MEMBERHOWE VOLUNTEER FIRE DEPARTMENTIMPACT - HEATH OCCUPATIONS EDUCATION ADVISORY COMMITTEEINSTRUCTOR FOR ONLINE BUSINESS CLASSESJUNIOR ACHIEVEMENT BOARD, LAGRANGE COUNTYLAGRANGE COUNTY CHAMBER OF COMMERCE BOARD OF DIRECTORSLAGRANGE COUNTY COMMISSIONERLAGRANGE COUNTY COMMUNITY FOUNDATION BOARD OF DIRECTORSLAGRANGE COUNTY ECONOMIC DEVELOPMENT CORPORATION BOARD OF DIRECTORSLAGRANGE COUNTY HEALTH BOARD MEMBERLAGRANGE COUNTY JUDICIAL COMMITTEELAGRANGE COUNTY PARK BOARDLAGRANGE COUNTY REGIONAL UTILITY DISTRICTLAGRANGE COUNTY TRAILS COMMITTEELAGRANGE/NOBLE JOINT DRAINAGE BOARDMEMBER OF PRAIRIE HEIGHTS FFA ALUMNIMERIDIAN SUN LODGE #76, PART OF THE FREE MASONSMIDDLEBURY FOOD PANTRYNEW LEAVES ADVISOR - NEW COMMITTEE IN LAGRANGE COUNTY TO FACILITATE AND COORDINATE COMMUNITY RESOURCESNORTHEAST INDIANA SOLID WASTE DISTRICT BOARDPARKVIEW LAGRANGE HOSPITAL ADOPT-A-HIGHWAY PROGRAMPERSONNEL ADVISORY COMMITTEEPURDUE EXTENSION OFFICE WELLNESS COMMITTEE, LAGRANGE COUNTYQPR INSTRUCTORREMC MEMBER ADVISORY COMMITTEESURVIVING LOSS BY SUICIDE - FOUNDER AND SUPPORTER OF LAGRANGE COUNTY SUICIDE SUPPORT GROUPUNITED FUND BOARDYOUTH FOR CHRIST SUPPORTER IN ALLEN AND LAGRANGE COUNTIES, HELPED FACILITATE PROGRAMMING IN LAGRANGE COUNTY PART III, LINE 2: THE AMOUNT REPORTED IS CONSISTENT WITH THE AMOUNT REPORTED ON THE ORGANIZATION'S AUDITED FINANCIAL STATEMENTS UNDER THE GENERALLY ACCEPTED ACCOUNTING STANDARDS.DISCOUNTS AND PAYMENTS ON PATIENT ACCOUNTS (BAD DEBT RECOVERIES) ARE FACTORED INTO THE ALLOWANCE FOR BAD DEBT ESTIMATION PROCESS. PART III, LINE 3: COSTING METHODOLOGY USED:UNCOLLECTIBLE PATIENT ACCOUNTS ARE CHARGED AGAINST THE PROVISION FOR BAD DEBT IN ACCORDANCE WITH THE POLICIES OF COMMUNITY HOSPITAL OF LAGRANGE COUNTY, INC. HOWEVER, DURING THE COLLECTION PROCESS THERE IS A CONTINUOUS EFFORT TO DETERMINE IF THE PATIENT QUALIFIES FOR FINANCIAL ASSISTANCE. THEREFORE, ONCE AN UNCOLLECTIBLE ACCOUNT HAS BEEN CHARGED OFF AND IT IS DETERMINED THROUGH THE COLLECTION PROCESS THAT THE PATIENT QUALIFIES FOR FINANCIAL ASSISTANCE, THE UNCOLLECTIBLE ACCOUNT IS RECLASSIFIED TO CHARITY CARE AND ALL COLLECTION EFFORTS CEASE. PATIENTS ARE ELIGIBLE TO APPLY FOR FINANCIAL ASSISTANCE AT ANY TIME, INCLUDING PATIENTS WHOSE ACCOUNTS HAVE BEEN PLACED IN A BAD DEBT AGENCY. THE AMOUNT REFLECTED ON LINE 3 WAS CALCULATED BY TOTALING THE ACCOUNTS PREVIOUSLY WRITTEN OFF TO BAD DEBT AND PLACED WITH A COLLECTION AGENCY, BUT SUBSEQUENTLY RECLASSIFIED AS CHARITY CARE DURING THE TAX YEAR. THE ACCOUNTS WERE RECLASSIFIED AS CHARITY CARE DUE TO THE FACT THAT PATIENTS APPLIED FOR, AND WERE APPROVED FOR, FINANCIAL ASSISTANCE AFTER THE ACCOUNTS WERE PLACED WITH A BAD DEBT AGENCY. PART III, LINE 4: BAD DEBT EXPENSE - PARKVIEW HEALTH SYSTEM, INC. AND SUBSIDIARIES - NOTES TO THE CONSOLIDATED FINANCIAL STATEMENTSTEXT OF THE FOOTNOTE TO THE ORGANIZATION'S FINANCIAL STATEMENTS THAT DESCRIBES BAD DEBT EXPENSE OR THE PAGE NUMBER ON WHICH THIS FOOTNOTE IS CONTAINED IN THE ATTACHED FINANCIAL STATEMENTS:PAGE 12 OF ATTACHED FINANCIAL STATEMENTS. PART III, LINE 8: COMMUNITY BENEFIT & METHODOLOGY FOR DETERMINING MEDICARE COSTSSUBSTANTIAL SHORTFALLS TYPICALLY ARISE FROM PAYMENTS THAT ARE LESS THAN THE COST TO PROVIDE THE CARE OR SERVICES AND DO NOT INCLUDE ANY AMOUNTS RELATING TO INEFFICIENT OR POOR MANAGEMENT. COMMUNITY HOSPITAL OF LAGRANGE COUNTY, INC. ACCEPTS ALL MEDICARE PATIENTS, AS REFLECTED ON THE YEAR-END MEDICARE COST REPORT, WITH THE KNOWLEDGE THAT THERE MAY BE SHORTFALLS. INTERNAL REVENUE SERVICE (IRS) REVENUE RULING 69-545 IMPLIES THAT TREATING MEDICARE PATIENTS IS A COMMUNITY BENEFIT. IRS REVENUE RULING 69-545, WHICH ESTABLISHED THE COMMUNITY BENEFIT STANDARD FOR NONPROFIT HOSPITALS, STATES THAT IF A HOSPITAL SERVES PATIENTS WITH GOVERNMENTAL HEALTH BENEFITS, INCLUDING MEDICARE, THEN THIS IS AN INDICATION THAT THE HOSPITAL OPERATES TO PROMOTE THE HEALTH OF THE COMMUNITY. HOWEVER, MEDICARE PAYMENTS REPRESENT A PROXY OF COST CALLED THE "UPPER PAYMENT LIMIT." IT HAS HISTORICALLY BEEN ASSUMED THAT UPPER PAYMENT LIMIT PAYMENTS DO NOT GENERATE A SHORTFALL. AS A RESULT, COMMUNITY HOSPITAL OF LAGRANGE COUNTY, INC. HAS TAKEN THE POSITION NOT TO INCLUDE THE MEDICARE SHORTFALLS OR SURPLUSES AS PART OF COMMUNITY BENEFIT. COMMUNITY HOSPITAL OF LAGRANGE COUNTY, INC. RECOGNIZES THAT THE SHORTFALL OR SURPLUS FROM MEDICARE DOES NOT INCLUDE THE COSTS AND REVENUES ASSOCIATED WITH MEDICARE ADVANTAGE PATIENTS. AS SUCH, THE TOTAL SHORTFALL OR SURPLUS OF MEDICARE IS UNDERSTATED DUE TO THE COSTS AND REVENUES ASSOCIATED WITH MEDICARE ADVANTAGE PATIENTS NOT BEING INCLUDED IN THE COMMUNITY BENEFIT DETERMINATION. PART III, LINE 9B: IF THE PATIENT CANNOT PAY IN FULL, THE OPTION OF A LOW INTEREST LOAN IS AVAILABLE WITH THE SAME DISCOUNT OFFERED FOR CASH PAYMENTS AS LONG AS THE LOAN IS ARRANGED WITHIN 30 DAYS OF THE FIRST GUARANTOR STATEMENT. IF THE PATIENT DEFAULTS ON THE LOAN, THE DISCOUNT WILL BE REVERSED AND THE PATIENT'S ACCOUNT WILL BE PLACED IN A COLLECTION AGENCY.INTEREST-FREE PAYMENTS WITH PAY-OUT NOT TO EXCEED TWELVE (12) MONTHS ARE AVAILABLE. THE MINIMUM MONTHLY PAYMENT IS $25.FINANCIAL ASSISTANCE MAY BE AVAILABLE FOR THOSE PATIENTS WHO CANNOT PAY THEIR BILL. THOSE OPTIONS ARE GOVERNMENTAL ASSISTANCE OR FREE CARE THROUGH THE HOSPITAL FINANCIAL ASSISTANCE PROGRAM. THE HEALTH SYSTEM FINANCIAL ASSISTANCE POLICY IS AVAILABLE ON PARKVIEW.COM OR BY VISITING ANY HOSPITAL CASHIER OFFICE OR BY CALLING PATIENT ACCOUNTING AT 260.266.6700 OR TOLL FREE 855.814.0012. A PATIENT MAY APPLY FOR FINANCIAL ASSISTANCE ANYTIME DURING THE APPLICATION PERIOD. FAILURE TO MAKE ARRANGEMENTS AS LISTED ABOVE OR FAILURE TO APPLY FOR AND RECEIVE APPROVAL UNDER THE FINANCIAL ASSISTANCE POLICY MAY RESULT IN THE ACCOUNT BEING PLACED IN A COLLECTION AGENCY DUE TO NON-PAYMENT. THE COLLECTION AGENCY MAY REPORT THE ACCOUNT TO ONE OR ALL THREE CREDIT REPORTING AGENCIES WHICH MAY ULTIMATELY ADVERSELY AFFECT THE PATIENT'S CREDIT SCORE. ADDITIONALLY, THE COLLECTION AGENCY MAY SUE AND OBTAIN A JUDGMENT AGAINST THE PATIENT FOR NON-PAYMENT. THESE ACTIONS WILL NOT OCCUR UNTIL 120 DAYS AFTER THE PATIENT IS SENT THEIR FIRST FOLLOW-UP STATEMENT INDICATING THE AMOUNT THEY OWE.A PATIENT MAY APPLY FOR FINANCIAL ASSISTANCE AT ANY TIME DURING THE APPLICATION PERIOD, EVEN THOUGH THEY HAVE BEEN PLACED IN A COLLECTION AGENCY. IF THE PATIENT WAS SENT THEIR FIRST NOTICE ON THE ACCOUNT FOR WHICH THEY ARE APPLYING FOR FREE CARE BETWEEN 120 DAYS AND THE END OF THE APPLICATION PERIOD, THE ACTIONS ABOVE WILL BE SUSPENDED UNTIL THE FREE CARE APPLICATION ELIGIBILITY IS DETERMINED. PART VI, LINE 2: DESCRIBE HOW THE ORGANIZATION ASSESSES THE HEALTH CARE NEEDS OF THE COMMUNITIES IT SERVES, IN ADDITION TO ANY CHNAS REPORTED IN PART V, SECTION B.IN ADDITION TO IDENTIFYING HEALTH NEEDS THROUGH THE TRIENNIAL COMMUNITY HEALTH NEEDS ASSESSMENT, COMMUNITY HOSPITAL OF LAGRANGE COUNTY, INC. IDENTIFIES AND VERIFIES COMMUNITY HEALTH NEEDS THROUGH THE FOLLOWING:-OTHER COMMUNITY NEEDS ASSESSMENTS CONDUCTED BY LOCAL ORGANIZATIONS-USE OF CONDUENT'S HEALTHY COMMUNITIES INSTITUTE SECONDARY DATA PLATFORM -OBSERVATIONS BY HEALTHCARE PROFESSIONALS WHO WORK WITH VULNERABLE POPULATIONS-SPECIFIC REQUESTS PROMPTED BY OTHER PROFESSIONALS IN THE COMMUNITYHOSPITAL REPRESENTATIVES MAINTAIN ON-GOING RELATIONSHIPS THROUGHOUT THE COMMUNITY AND MEET REGULARLY WITH ORGANIZATIONS THAT SHARE THE MISSION OF IMPROVING THE HEALTH AND INSPIRING THE WELL-BEING OF THE COMMUNITY WE SERVE. PART VI, LINE 3: DESCRIBE HOW THE ORGANIZATION INFORMS AND EDUCATES PATIENTS AND PERSONS WHO MAY BE BILLED FOR PATIENT CARE ABOUT THEIR ELIGIBILITY FOR ASSISTANCE UNDER FEDERAL, STATE OR LOCAL GOVERNMENT PROGRAMS OR UNDER THE ORGANIZATION'S FINANCIAL ASSISTANCE POLICY.SIGNAGE AND BROCHURES ARE POSTED AND AVAILABLE AT ALL HOSPITAL POINTS OF REGISTRATION AND IN THE EMERGENCY DEPARTMENT. PATIENTS ARE OFFERED PLAIN LANGUAGE SUMMARIES OF THE FINANCIAL ASSISTANCE POLICY DURING THE REGISTRATION PROCESS AND IN EACH FOLLOW UP STATEMENT SENT TO THE PATIENT. PATIENT STATEMENTS WILL INDICATE HOW A PATIENT CAN OBTAIN FINANCIAL ASSISTANCE APPLICATIONS AND WHO THEY CAN CONTACT FOR ASSISTANCE. PART VI, LINE 4: DESCRIBE THE COMMUNITY THE ORGANIZATION SERVES, TAKING INTO ACCOUNT THE GEOGRAPHIC AREA AND DEMOGRAPHIC CONSTITUENTS IT SERVES.COMMUNITY HOSPITAL OF LAGRANGE COUNTY, INC., PRIMARILY SERVES THE LAGRANGE COUNTY COMMUNITIES OF LAGRANGE, TOPEKA, SHIPSHEWANA, WOLCOTTVILLE, AND HOWE. AS THE ONLY HOSPITAL IN THIS COUNTY, COMMUNITY HOSPITAL OF LAGRANGE COUNTY, INC., ALSO SERVES, TO A LIMITED EXTENT, SURROUNDING COMMUNITIES IN ELKHART COUNTY, IN, AND CASS, ST. JOSEPH, AND BRANCH COUNTIES, MI.IN 2018, THE POPULATION OF LAGRANGE COUNTY WAS APPROXIMATELY 39,330. ACCORDING TO USCENSUS.GOV, 94% OF THE RESIDENTS ARE CAUCASIAN (NON-HISPANIC) AND 4.1% HISPANIC. THE MEDIAN INCOME IN LAGRANGE COUNTY IS $58,336 WITH AN UNEMPLOYMENT RATE HOLDING STEADY AT 3.3%. 7.8% OF THE POPULATION ARE LIVING IN POVERTY. PLAIN CHURCH RESIDENTS, INCLUDING MEMBERS OF THE AMISH COMMUNITY, MAKE UP NEARLY 44% OF THE POPULATION OF LAGRANGE COUNTY. FOR THE MEMBERS OF THESE FAITH-BASED COMMUNITIES, TRAVEL IS BY HORSE AND BUGGY OR BICYCLE; COMMUNICATIONS ARE EITHER FACE-TO-FACE OR THROUGH THE USE OF A COMMUNITY-OWNED, CENTRALLY LOCATED PHONE. PART VI, LINE 5: PROVIDE ANY OTHER INFORMATION IMPORTANT TO DESCRIBING HOW THE ORGANIZATION'S HOSPITAL FACILITIES OR OTHER HEALTH CARE FACILITIES FURTHER ITS EXEMPT PURPOSE BY PROMOTING THE HEALTH OF THE COMMUNITY (E.G. OPEN MEDICAL STAFF, COMMUNITY BOARD, USE OF SURPLUS FUNDS, ETC.).THE MAJORITY OF THE COMMUNITY HOSPITAL OF LAGRANGE COUNTY, INC. BOARD OF DIRECTORS IS COMPRISED OF INDEPENDENT COMMUNITY MEMBERS WHO RESIDE IN THE HOSPITAL'S PRIMARY SERVICE AREA. THE HOSPITAL ALSO EXTENDS MEDICAL STAFF PRIVILEGES TO ALL QUALIFIED PHYSICIANS IN THE COMMUNITY. PEOPLE THROUGHOUT THE COMMUNITY CAN COUNT ON COMMUNITY HOSPITAL OF LAGRANGE COUNTY, INC. TO BE STANDING BY WITH EMERGENCY CARE 24 HOURS A DAY, 365 DAYS A YEAR. THE EMERGENCY DEPARTMENT IS STAFFED WITH BOARD-CERTIFIED PHYSICIANS AND A NURSING STAFF THAT IS TRAINED AND CERTIFIED IN EMERGENCY CARE. FURTHERMORE, NO PATIENT IS EVER DENIED TREATMENT, REGARDLESS OF THEIR ABILITY TO PAY.COMMUNITY HOSPITAL OF LAGRANGE COUNTY, INC. GIVES BACK TO THE COMMUNITY IN THE FORM OF IMPROVED FACILITIES, EDUCATION AND OUTREACH PROGRAMS, FREE AND DISCOUNTED CARE, VOLUNTEERISM AND MUCH MORE. THE FOLLOWING ARE SOME OF THE WAYS COMMUNITY HOSPITAL OF LAGRANGE COUNTY, INC. IS REACHING OUT TO MAKE OUR NEIGHBORHOODS AND COMMUNITIES HEALTHIER:PATIENT & FAMILY ADVISORY COUNCIL: IN 2018, COMMUNITY HOSPITAL OF LAGRANGE COUNTY CONTINUED ITS PARTNERSHIP WITH PATIENTS AND PATIENT FAMILY MEMBERS THROUGH THE HOSPITAL'S PATIENT & FAMILY ADVISORY COUNCIL (PFAC). THE PFAC MEMBERS PROVIDED FEEDBACK ABOUT PROCESSES AND COMMUNICATION OPPORTUNITIES THAT WOULD IMPROVE THE PATIENT EXPERIENCE. AN AREA IMPACTED BY THE PFAC'S INVOLVEMENT DURING 2018 WAS:-A DISCUSSION ABOUT COMMUNITY HOSPITAL OF LAGRANGE COUNTY'S CARDIAC REHAB PROGRAM LED TO THE DEVELOPMENT OF AN ABBREVIATED PROGRAM SPECIFIC TO MEET THE NEEDS OF THE COMMUNITY'S PLAIN CHURCH / AMISH POPULATION. THE TRADITIONAL CARDIAC REHAB PROGRAM WAS A DETERRENT TO THIS COMMUNITY, SO MOST OFTEN IT WAS NOT BEING UTILIZED AS A SERVICE. BASED ON PFAC MEMBERS INPUT, THIS ABBREVIATED PROGRAM ALLOWS AMISH MEMBERS TO PARTICIPATE IN A PER CLASS FEE, REQUIRES A LOWER NUMBER OF MINIMUM VISITS, AND PROVIDES EXERCISES THAT CAN BE COMPLETED AT HOME. THIS HAS RESULTED IN AN INCREASE OF PARTICIPANTS FROM THE PLAIN CHURCH / AMISH POPULATION IN THE CARDIAC REHAB PROGRAM.-FOOD PHARMACY: IN 2018, COMMUNITY HOSPITAL OF LAGRANGE COUNTY CONTINUED TO OFFER ITS FOOD PHARMACY PROGRAM TO A COHORT OF PATIENTS REFERRED BY THEIR FAMILY PHYSICIAN. EDUCATION IS PROVIDED TO PATIENTS WHO HAVE BEEN DIAGNOSED WITH TYPE II DIABETES AND OBESITY. NINE PATIENTS COMPLETED THIS PROGRAM IN 2018. PATIENTS WENT THROUGH 18 WEEKLY SESSIONS OVER A SIX-MONTH PERIOD WHERE TOPICS SUCH AS MEDICATION MANAGEMENT, AND HOW TO SHOP AND COOK HEALTHY WERE COVERED. PATIENTS ARE SEEN BY A REGISTERED DIETITIAN, A PHARMACIST AND A NURSE AT THESE SESSIONS TO RECEIVE EDUCATION AND GUIDANCE ON MAKING LASTING LIFESTYLE CHANGES. AS A RESULT, PATIENTS WHO COMPLETED THIS PROGRAM HAD AN AVERAGE A1C DECREASE OF 1.7, AND AN AVERAGE WEIGHT LOSS OF 4.3 LBS. THE COMMUNITY HEALTH IMPROVEMENT (CHI) INITIATIVE OF COMMUNITY HOSPITAL OF LAGRANGE COUNTY, INC. IS A PROGRAM THAT PROVIDES GRANT SUPPORT FOR COMMUNITY HEALTH INITIATIVES DELIVERED BY NOT-FOR-PROFIT COMMUNITY ORGANIZATIONS THAT SHARE THE HOSPITAL'S MISSION TO ENCOURAGE HEALTHIER LIFESTYLES AMONG THE CITIZENS OF LAGRANGE COUNTY AND PROVIDE SERVICES THAT ARE NOT AVAILABLE THROUGH THE HOSPITAL. THE FOLLOWING WERE AMONG THE CHI INITIATIVES FUNDED IN 2018:MENTAL HEALTH:THE NUMBER OF DEATHS BY SUICIDE IN LAGRANGE COUNTY WAS A CONTINUING CONCERN IN 2018, AND THE NEED FOR TRAINING LAY PEOPLE IN SUICIDE PREVENTION CONTINUES. WITH ASSISTANCE FROM PARKVIEW BEHAVIORAL HEALTH, AN EVIDENCE-BASED SUICIDE PREVENTION STRATEGY KNOWN AS QUESTION, PERSUADE AND REFER (QPR) CONTINUED TO BE USED TO TRAIN A BROAD SPECTRUM OF ADULTS IN LAGRANGE COUNTY. CHI FUNDING WAS USED TO PURCHASE QPR TRAINING MATERIALS THAT WERE MADE AVAILABLE, FREE OF CHARGE, TO ADULTS IN THE COMMUNITY THAT WERE TRAINED IN QPR. BY THE END OF 2018, THE HOSPITAL HAD PROVIDED OVER 500 ADULTS WITH THIS SUICIDE PREVENTION TRAINING.IN 2017, COMMUNITY HOSPITAL OF LAGRANGE'S QPR TEAM ESTABLISHED A PEER-LED SUPPORT GROUP FOR THOSE IMPACTED BY THE LOSS OF A LOVED ONE BY SUICIDE. THIS MONTHLY SUPPORT GROUP WAS CONTINUED THROUGHOUT 2018.IN ADDITION, COMMUNITY HOSPITAL OF LAGRANGE COUNTY, INC. PARTNERS WITH THE THREE PUBLIC SCHOOL CORPORATIONS IN LAGRANGE COUNTY TO ADDRESS MENTAL HEALTH. THE HOSPITAL PROVIDES A LICENSED MENTAL HEALTH COUNSELOR TO EACH OF THE SCHOOLS FOUR HOURS EACH WEEK.OBESITY:-THE HOSPITAL CONTINUED ITS PARTNERSHIP WITH COLE FAMILY CENTER YMCA IN 2018, TO FACILITATE ACCESS TO GROUP WELLNESS ACTIVITIES IN LAGRANGE COUNTY AT A YMCA SATELLITE SITE IN HOWE LAGRANGE INSURANCE AGENCY'S LOWER LEVEL IN LAGRANGE. HEALTH AND SAFETY:-COMMUNITY HOSPITAL OF LAGRANGE COUNTY, INC. CONTINUES TO PROVIDE SUPPORT FOR THE HEALTH AND SAFETY DAY CAMP THAT IS LED BY THE SHERRIFF'S DEPARTMENT OF LAGRANGE COUNTY AND OTHER IMPORTANT AGENCIES WITHIN THE COUNTY. SAFETY DAY CAMP IS HOSTED AT EACH ELEMENTARY SCHOOL FOR ALL THE SCHOOL'S FOURTH GRADE STUDENTS. HOSPITAL CO-WORKERS VOLUNTEER AS TRAINERS FOR SAFETY DAY CAMP, PROVIDING STUDENTS WITH INTERACTIVE EDUCATION ABOUT A VARIETY OF COMMON SAFETY TOPICS. WE ALSO PROVIDE EACH STUDENT WITH A REFLECTIVE SAFETY VEST. -EXPECTANT MOTHERS IN THE FIRST TRIMESTER OF THEIR PREGNANCY WERE PROVIDED WITH ACCESS TO FREE PRENATAL VITAMINS THROUGH A CHI INITIATIVE AND PARTNERSHIPS WITH PHARMACIES IN LAGRANGE COUNTY. VOUCHERS FOR THE VITAMINS COULD BE PICKED UP THROUGH THE WOMAN'S LAGRANGE COUNTY PRIMARY CARE PHYSICIAN, THROUGH PARKVIEW LAGRANGE HOSPITAL'S BIRTH PLANNER OR THE COMPASSION PREGNANCY CENTER IN LAGRANGE COUNTY.ACCESS:-THE HOSPITAL CONTINUED ITS PARTNERSHIP WITH THE LAGRANGE COUNTY COUNCIL ON AGING (COA) TO ASSIST WITH OPERATIONAL SUPPORT FOR THE COA'S SERVICES TO SENIORS. THE COA PROVIDES A TRANSPORTATION PROGRAM, HOMEMAKER SERVICES, A FOOD PANTRY AND MUCH MORE IN THEIR EFFORTS TO HELP SENIORS IN LAGRANGE COUNTY REMAIN INDEPENDENT IN THE HOMES OF THEIR CHOICE FOR AS LONG AS POSSIBLE. NEARLY HALF OF THE TRIPS THE COA OFFERS TO SENIORS ARE TO THEIR PHYSICIANS FOR CHECK-UPS OR TO THE HOSPITAL FOR TESTS OR TREATMENTS. HOMEMAKER SERVICES HELP WITH DAY-TO-DAY TASKS THAT, IN MANY CASES, COULD PUT THE SENIOR AT RISK OF A FALL OR OTHER INJURY. PART VI, LINE 6: IF THE ORGANIZATION IS PART OF AN AFFILIATED HEALTH CARE SYSTEM, DESCRIBE THE RESPECTIVE ROLES OF THE ORGANIZATION AND ITS AFFILIATES IN PROMOTING THE HEALTH OF THE COMMUNITIES SERVED.PARKVIEW HEALTH SYSTEM, INC. (PARKVIEW), A HEALTHCARE SYSTEM SERVING NORTHEAST INDIANA AND NORTHWEST OHIO THROUGH OUR HOSPITALS AND PHYSICIAN CLINICS, INCLUDES THE NOT-FOR-PROFIT HOSPITALS OF PARKVIEW HOSPITAL, INC.; COMMUNITY HOSPITAL OF LAGRANGE COUNTY, INC.; COMMUNITY HOSPITAL OF NOBLE COUNTY, INC.; PARKVIEW WABASH HOSPITAL, INC.; WHITLEY MEMORIAL HOSPITAL, INC.; HUNTINGTON MEMORIAL HOSPITAL, INC.; AS WELL AS 60 PERCENT OWNERSHIP IN THE JOINT VENTURE OF ORTHOPAEDIC HOSPITAL AT PARKVIEW NORTH, LLC. PARKVIEW CONTRIBUTES TO THE SUCCESS OF THE REGION BY EFFECTIVELY MANAGING ITS FACILITIES, EFFICIENTLY PROVIDING AND DELIVERING ITS SERVICES, AND SUPPORTING LOCAL BUSINESSES AND ACTIVITIES. PARKVIEW SEEKS TO CREATE ALIGNMENT OPPORTUNITIES TO DELIVER COMPREHENSIVE HIGH-QUALITY CARE THAT BENEFIT PATIENTS, PHYSICIANS, CO-WORKERS AND COMMUNITIES. EACH HOSPITAL ENTITY ENGAGES IN COMMUNITY OUTREACH CUSTOMIZED TO MEET THE UNIQUE NEEDS OF THEIR RESPECTIVE COMMUNITIES. AFFILIATE HOSPITALS WORK TOGETHER AND SHARE PROGRAMMING AND MESSAGING WHERE COMMON COMMUNITY HEALTH ISSUES ARE IDENTIFIED. AS A COLLECTIVE GROUP, ALL AFFILIATE HOSPITALS HAVE CAREFULLY CHOSEN TO FOCUS ON THE HEALTH PRIORITY OF OBESITY AND THE PROMOTION OF A HEALTHY LIFESTYLE. THIS INCLUDES EDUCATION ON GOOD NUTRITION, CONSUMPTION AND ACCESS TO HEALTHY FOODS, AND AN ACTIVE LIFE STYLE. THE ABOVE FOCUS WAS SELECTED FROM A LIST OF HEALTH ISSUES THAT RESIDE IN THE SEVEN-COUNTY AREA.PARKVIEW PRIDES ITSELF IN NOT ONLY OFFERING THE HIGHEST LEVEL OF CARE TO ITS PATIENTS, BUT ALSO IN PROVIDING AN EXCELLENT WORKPLACE FOR ITS PHYSICIANS, NURSES, AND STAFF. PARKVIEW'S MISSION AND VISION IS AS FOLLOWS: AS A COMMUNITY OWNED, NOT-FOR-PROFIT ORGANIZATION, PARKVIEW HEALTH IS DEDICATED TO IMPROVING YOUR HEALTH AND INSPIRING YOUR WELL-BEING BY: 1) TAILORING A PERSONALIZED HEALTH JOURNEY TO ACHIEVE YOUR UNIQUE GOALS, 2) DEMONSTRATING WORLD-CLASS TEAMWORK AS WE PARTNER WITH YOU ALONG THAT JOURNEY 3) PROVIDING THE EXCELLENCE, INNOVATION AND VALUE YOU SEEK IN TERMS OF CONVENIENCE, COMPASSION, SERVICE, COST AND QUALITY. PARKVIEW BELIEVES THAT THE COMMUNITIES IT SERVES SHOULD ALL HAVE THE PEACE OF MIND THAT COMES WITH ACCESS TO COMPASSIONATE, HIGH-QUALITY HEALTHCARE, REGARDLESS OF WHETHER THE CARE IS DELIVERED IN A RURAL OR URBAN SETTING. PART VI, LINE 7, REPORTS FILED WITH STATES IN PART VI, LINE 7: A COPY OF FORM 990, SCHEDULE H IS FILED WITH THE INDIANA STATE DEPARTMENT OF HEALTH. 1 PARKVIEW HOSPITAL INC 11109 PARKVIEW PLAZA DRIVE FORT WAYNE IN 46845 350868085 501(C)(3) 13500 HOME HEALTH & HOSPICE PROGRAM FOR SERVICE AREA OF COMMUNITY HOSPITAL OF LAGRANGE COUNTY, INC. LAGRANGE COUNTY ECONOMIC DEVELOPMENT 304 N TOWNLINE ROAD LAGRANGE IN 46764 800309463 501(C)(3) 10000 BUSINESS DEVELOPMENT AND EMPLOYMENT PROGRAMS LAGRANGE COUNTY COUNCIL ON AGING INC PO BOX 107 LAGRANGE IN 46761 237455893 501(C)(3) 10000 TRANSPORT PROGRAM AND ASSIST INDIVIDUALS TO REMAIN INDEPENDENT IN THEIR HOMES 3 0 PART I, LINE 2: COMMUNITY HEALTH IMPROVEMENT FUNDING PARTNER ORGANIZATIONS ARE REQUIRED TO SUBMIT AN ANNUAL PROGRESS REPORT RELATED TO PROGRAM FUNDING. PARTNER ORGANIZATIONS ARE REQUIRED TO RE-APPLY FOR FUNDING ON AN ANNUAL BASIS. X 1 1 1 1 0 0 0 0 0 1 0 JORDI DISLER DIRECTOR/LGHOS PRESIDENT 183787 0 48062 0 9509 0 56023 0 22431 0 319812 0 8584 0 MICHAEL PACKNETT DIRECTOR/PH PRESIDENT & CEO 0 1060073 0 345323 0 41648 0 723342 0 35988 0 2206374 0 0 SHELBY COOPER DIRECTOR/PH PHYSICIAN 17654 196937 0 15509 0 14198 340 4359 1586 20368 19580 251371 0 0 JAMIN YODER DIRECTOR/PH PHYSICIAN 11773 206233 0 46565 0 1836 716 15485 1271 27494 13760 297613 0 0 JEANNE' WICKENS PH CHIEF FINANCIAL OFFICER 0 642848 0 176468 0 50221 0 284505 0 30413 0 1184455 0 28885 JARED BEASLEY LGHOS VP PATIENT CARE 147123 0 29923 0 475 0 24011 0 12105 0 213637 0 0 0 BRENDA ARMENTROUT LGHOS MGR PHARMACY 158099 0 16461 0 1980 0 15789 0 10263 0 202592 0 0 0 ROBERT BLOOMFIELD LGHOS MGR SUPPORT SERVICE 112017 0 12021 0 940 0 11530 0 18226 0 154734 0 0 0 MICHAEL CHARLIER LGHOS MGR REHAB 84185 399 11103 0 15891 12274 3137 358 20842 2376 135158 15407 0 0 ROBERT MYERS FORMER OFFICER 0 0 0 0 208415 0 0 0 0 0 208415 0 208415 0 PART I, LINE 1A TAX INDEMNIFICATION AND GROSS-UP PAYMENTS - TAX ON TAXABLE GIFT: TREVOR FRY $13 PART I, LINE 3 RELATED ORGANIZATION, PARKVIEW HEALTH SYSTEM, INC., USES THE FOLLOWING TO ESTABLISH THE COMPENSATION OF COMMUNITY HOSPITAL LAGRANGE COUNTY, INC.'S CEO/EXECUTIVE DIRECTOR: COMPENSATION COMMITTEE OF RELATED ORGANIZATION PARKVIEW HEALTH SYSTEM, INC. INDEPENDENT COMPENSATION CONSULTANT FORM 990 OF OTHER ORGANIZATIONS COMPENSATION SURVEY OR STUDY APPROVAL BY THE BOARD OR COMPENSATION COMMITTEE OF RELATED ORGANIZATION PARKVIEW HEALTH SYSTEM, INC. PART I, LINES 4A-B SEVERANCE PAYMENT MICHAEL CHARLIER $10,842 SUPPLEMENTAL NONQUALIFIED RETIREMENT PLAN PAYMENTS TAXABLE - JORDI DISLER $8,584; ROBERT MYERS $208,415; JEANNE' WICKENS $28,885 PARTICIPANTS DEFERRED - THE FOLLOWING INDIVIDUALS HAVE AN AMOUNT INCLUDED IN SCHEDULE J, PART II, COLUMN (C) FOR AN AMOUNT EARNED BUT NOT YET VESTED UNDER ONE OF PARKVIEW'S DEFERRED COMPENSATION PLANS. BENEFITS EARNED UNDER THE PLANS WILL FUND THE EMPLOYEES' EVENTUAL RETIREMENT BENEFIT. THESE BENEFITS ARE PROVIDED IN EXCHANGE FOR ALL OF THE EMPLOYEES' YEARS OF SERVICE TO THE ORGANIZATION, AND THE COST OF THE BENEFITS MAY VARY FROM YEAR TO YEAR. THE AMOUNTS ARE AT RISK AND WILL NOT BE PAID UNLESS AND UNTIL EACH EMPLOYEE HAS PROVIDED SUBSTANTIAL FUTURE SERVICES TO THE ORGANIZATION. BENEFITS UNDER THE PLANS VEST AT THE TIME SET FORTH IN THE PLAN DOCUMENTS AND ARE FORFEITED IF THE EMPLOYEES TERMINATE EMPLOYMENT BEFORE SATISFYING THOSE PLAN CONDITIONS. JARED BEASLEY $16,874; JORDI DISLER $31,238; MICHAEL PACKNETT $698,592; JEANNE' WICKENS $274,192 PART I, LINE 7 MANAGEMENT INCENTIVE COMPENSATION PLAN (MICP) AND PHYSICIAN AND PROVIDER INCENTIVE COMPENSATION PLAN (PICP) ARE ANNUAL INCENTIVE PROGRAMS. SYSTEM GOALS ARE APPROVED BY THE BOARD. AT CONCLUSION OF THE PLAN YEAR, RESULTS ARE SHARED WITH THE BOARD AND THE EXECUTIVE COMMITTEE OF THE BOARD APPROVES FINAL PAYMENT. A INDIANA HEALTH AND EDUCATIONAL FACILITY FINANCING AUTHORITY 351611409 45479RCF2 2007-03-15 24930000 SEE PART VI 0 0 0 A 7835000 25930446 1074006 208535 154519 24493386 2008 0 0 1 1 A 0 1 1 1 0 0.00000 0.00000 0.00000 0 0 1 A 0 0 0 1 1 0 0 0 1 A 1 SCHEDULE K, PART I,A,F: CONSTRUCTION OF NEW HOSPITAL FACILITY FOR COMMUNITY HOSPITAL OF LAGRANGE COUNTY, INC. IN LAGRANGE, INDIANA SCHEDULE K, PART II,3,A: THIS AMOUNT INCLUDES INTEREST OF $1,000,446. EARNED ON PROJECT, COST OF ISSUANCE AND CAPITALIZED INTEREST FUNDS. SCHEDULE K, PART III, LINES 4-6: AS PART OF OUR EFFORTS TO MONITOR AND ENSURE THAT THERE IS NO PRIVATE USE AT OUR BOND FINANCED FACILITIES, WE CONTRIBUTE EQUITY TO FINANCE A PORTION OF OUR NEW MONEY PROJECTS. SCHEDULE K, PART III, LINE 7: BECAUSE PARKVIEW MONITORS THE PRIVATE BUSINESS USE PERCENTAGE FOR EACH BOND ISSUE, TO ENSURE THAT THE PRIVATE BUSINESS USE LIMIT IS NOT EXCEEDED, PARKVIEW DOES NOT CALCULATE THE AMOUNT OF PRIVATE PAYMENTS. SCHEDULE K, PART IV, COLUMN A, LINE 2C: REBATE COMPUTATION WAS PERFORMED ON APRIL 13, 2010. FORM 990, PART V, LINES 1A AND 2A: PARKVIEW HEALTH SYSTEM, INC. (PH), EIN 35-1972384, IS THE COMMON PAYING AGENT FOR THE FILING ORGANIZATION, COMMUNITY HOSPITAL OF LAGRANGE COUNTY, INC., EIN 20-2401676. THEREFORE, ALL APPLICABLE IRS TAX FILINGS, INCLUDING FORMS 1099, 1096, W-2 AND W-3 ARE REPORTED AND FILED BY PH. THE TOTAL NUMBER REPORTED IN BOX 3 OF FORM 1096 AND FILED BY THE COMMON PAYING AGENT, PH, FOR THE YEAR ENDED DECEMBER 31, 2018 WAS 568. THE TOTAL NUMBER OF EMPLOYEES REPORTED ON FORM W-3 AND FILED BY THE COMMON PAYING AGENT, PH, FOR THE YEAR ENDED DECEMBER 31, 2018 WAS 13,593. FOR PURPOSES OF COMPLETING FORM 990, PART V, LINE 1A AND 2A, THE NUMBER REPORTED FOR THE COMMUNITY HOSPITAL OF LAGRANGE COUNTY, INC. WAS 35 AND 237 RESPECTIVELY. FORM 990, PART VI, SECTION A, LINE 1 THE EXECUTIVE COMMITTEE SHALL BE COMPOSED OF THE OFFICERS OF THE BOARD, THE PRESIDENT OF THE CORPORATION, THE PRESIDENT/CHIEF EXECUTIVE OFFICER OF THE CORPORATE MEMBER OR HIS/HER DESIGNEE, THE CURRENT PRESIDENT OF THE MEDICAL STAFF AND SUCH OTHER PERSONS AS IDENTIFIED BY THE CHAIR OF THE BOARD, EACH OF WHOM SHALL BE ENTITLED TO VOTE. IN NO EVENT SHALL THE MEMBERS OF THE EXECUTIVE COMMITTEE EXCEED EIGHT (8) PEOPLE. THE EXECUTIVE COMMITTEE MAY ACT ON BEHALF OF THE CORPORATION IN ANY MATTER WHEN THE BOARD IS NOT IN SESSION, REPORTING TO THE BOARD FOR ITS RATIFICATION OF ITS ACTION. THE CHAIR OF THE BOARD SHALL SERVE AS CHAIR OF THE EXECUTIVE COMMITTEE. MEETINGS OF THE EXECUTIVE COMMITTEE MAY BE CALLED BY THE CHAIR OR BY THREE (3) MEMBERS. FORM 990, PART VI, SECTION A, LINE 2 DIRECTORS KEVIN LAMBRIGHT AND JOE URBANSKI HAVE A BUSINESS RELATIONSHIP. FORM 990, PART VI, SECTION A, LINE 6 THE ORGANIZATION IS ORGANIZED AS A NOT-FOR-PROFIT CORPORATION. PURSUANT TO THE ORGANIZATION'S GOVERNING DOCUMENTS, PARKVIEW HEALTH SYSTEM, INC. EIN 35-1972384 IS THE SOLE MEMBER OF COMMUNITY HOSPITAL OF LAGRANGE COUNTY, INC. WITH CERTAIN RESERVED POWERS. FORM 990, PART VI, SECTION A, LINE 7A THE CORPORATE MEMBER, PARKVIEW HEALTH SYSTEM, INC. EIN 35-1972384, SHALL HAVE THE FOLLOWING RESERVED POWERS: (I) APPOINT AND REMOVE, WITH OR WITHOUT CAUSE, MEMBERS OF THE BOARD SUBJECT TO THE COMPOSITION REQUIREMENTS REGARDING COMMUNITY AND PHYSICIAN REPRESENTATION SET FORTH IN ARTICLE V, SECTION 2; (II) APPOINT AND REMOVE, WITH OR WITHOUT CAUSE, THE CHAIR AND VICE CHAIR OF THE BOARD AND THE PRESIDENT OF THE CORPORATION; (III) APPROVE AND/OR REQUIRE THE ADOPTION OF AMENDMENTS TO THE ARTICLES OF INCORPORATION OR BYLAWS OF THE CORPORATION OR ANY SUBSIDIARY OR AFFILIATE OF THE CORPORATION; (IV) APPROVE AND/OR REQUIRE THE ESTABLISHMENT, ACQUISITION, DIVESTITURE, DISSOLUTION, CLOSURE, MERGER, CONSOLIDATION, CHANGE IN CORPORATE MEMBERSHIP, AFFILIATION OR CORPORATE REORGANIZATION OF THE CORPORATION OR ANY SUBSIDIARY OR AFFILIATE OF THE CORPORATION; (V) APPROVE AND ADOPT THE STRATEGIC PLAN AND ANY AMENDMENTS THERETO FOR THE CORPORATION AND ANY SUBSIDIARY OR AFFILIATE OF THE CORPORATION; (VI) APPROVE AND/OR REQUIRE THE INCURRENCE OF ANY DEBT, INCLUDING THE ISSUANCE OF ANY BONDS, PROPOSED BY THE CORPORATION OR ANY SUBSIDIARY OR AFFILIATE OF THE CORPORATION IN EXCESS OF LIMITS SPECIFIED IN THE POLICY OF THE CORPORATE MEMBER; (VII) APPROVE AND/OR REQUIRE THE APPROVAL OF CONTRACTS OR LOANS OBLIGATING THE CORPORATION TO EXPEND OR REPAY AN AMOUNT IN EXCESS OF LIMITS SPECIFIED IN THE POLICY OF THE CORPORATE MEMBER; (VIII) APPROVE AND/OR REQUIRE THE SALE, LEASE, EXCHANGE, MORTGAGE, PLEDGE, TRANSFER, ENCUMBRANCE OR OTHER DISPOSITION OF PROPERTY AND ASSETS OF THE CORPORATION IN EXCESS OF LIMITS SPECIFIED IN THE POLICY OF THE CORPORATE MEMBER; (IX) APPROVE AND ADOPT THE CAPITAL BUDGET, OPERATING BUDGET, FINANCIAL PLANS AND ANY AMENDMENTS THERETO FOR THE CORPORATION AND ANY SUBSIDIARY OR AFFILIATE OF THE CORPORATION; (X) APPROVE AND/OR REQUIRE THE ADOPTION OF A MANAGED CARE POLICY FOR THE CORPORATION AND ANY SUBSIDIARY OR AFFILIATE OF THE CORPORATION, INCLUDING NETWORK PARTICIPATION, PARTICIPATION IN ANY MANAGED CARE AGREEMENT AND PARTICIPATION IN ANY OTHER HEALTH CARE SERVICE ARRANGEMENTS; (XI) APPOINT AND REMOVE AUDITORS, ATTORNEYS AND OTHER PROFESSIONAL ADVISORS FOR THE CORPORATION AND ANY SUBSIDIARY OR AFFILIATE OF THE CORPORATION; (XII) DEVELOP, APPROVE AND/OR REQUIRE THE ADOPTION OF MEDICAL STAFF QUALITY ASSURANCE STANDARDS, UTILIZATION REVIEW STANDARDS, CRITERIA, POLICIES AND PROCEDURES FOR THE CORPORATION AND ANY SUBSIDIARY OR AFFILIATE OF THE CORPORATION; (XIII) APPROVE AND/OR REQUIRE THE ADOPTION OF ANY ACTION TO CHANGE THE CORPORATION FROM A GENERAL, ACUTE CARE COMMUNITY HOSPITAL OR TO CLOSE THE CORPORATION'S CURRENT LOCATION; (XIV) APPROVE EACH ANNUAL LIST OF PROPOSED DONORS AND AMOUNTS OF DONATIONS OR GRANTS NOT INCLUDED IN THE ANNUAL BUDGET, AND MAKE PROPOSALS TO DEVIATE THEREFROM THROUGHOUT EACH YEAR IN EXCESS OF LIMITS SPECIFIED IN THE POLICY OF THE CORPORATE MEMBER; AND (XV) APPROVE AND/OR REQUIRE THE ADOPTION OF ANY ACTION THAT IS INCONSISTENT WITH THE POLICY OF THE CORPORATE MEMBER. FORM 990, PART VI, SECTION A, LINE 7B SEE SCHEDULE O EXPLANATION FOR FORM 990, PART VI, SECTION A, LINE 7A FORM 990, PART VI, SECTION B, LINE 11B PURSUANT TO PARKVIEW HEALTH SYSTEM INC.'S BYLAWS, THE SYSTEM AUDIT COMMITTEE MAY ACT ON BEHALF OF THE CORPORATION TO PROVIDE REVIEW OF THE CORPORATION AND ITS SUBSIDIARY CORPORATIONS' FORM 990 FILINGS. COMMUNITY HOSPITAL OF LAGRANGE COUNTY, INC. IS A SUBSIDIARY CORPORATION OF PARKVIEW HEALTH SYSTEM, INC. AN ELECTRONIC COPY OF THE ORGANIZATION'S FINAL FORM 990 (INCLUDING REQUIRED SCHEDULES) WAS PROVIDED TO EACH VOTING MEMBER OF THE ORGANIZATION'S GOVERNING BODY, PRIOR TO FILING WITH THE IRS. ON OCTOBER 2, 2019, THE SYSTEM AUDIT COMMITTEE REVIEWED THE FORM 990 AS ULTIMATELY FILED WITH THE IRS. THIS REVIEW INCLUDED A PRESENTATION BY THE ORGANIZATION'S TAX PREPARER TO HIGHLIGHT THE SIGNIFICANT AREAS ON THE FORM 990 AND SUPPLEMENTAL SCHEDULES. FORM 990, PART VI, SECTION B, LINE 12C AS DESCRIBED IN ARTICLE IX SECTION 6, OF THE PARKVIEW HEALTH SYSTEM, INC. (PH) BYLAWS, PH ADOPTED PH'S COMPLIANCE POLICY FOR THE ORGANIZATION AND ITS NOT-FOR-PROFIT RELATED ORGANIZATIONS (AND AS LIKEWISE NOTED IN THEIR BYLAWS) WHEN ADDRESSING CONFLICTS OR POTENTIAL CONFLICTS OF INTEREST. THIS COMPLIANCE POLICY (COMPLIANCE POLICY #14) REQUIRES THAT EACH BOARD MEMBER, BOARD COMMITTEE MEMBER, AND KEY MANAGEMENT PERSONNEL MUST ANNUALLY COMPLETE A CONFLICT OF INTEREST FORM. THIS INFORMATION IS PROVIDED TO THE CHAIRMAN OF THE BOARD (FOR BOARD AND BOARD COMMITTEE MEMBERS) AND TO SENIOR MANAGEMENT (FOR KEY MANAGEMENT PERSONNEL). IN ADDITION, AS TO THE CONDUCT OF BOARD MEETINGS, THE FOLLOWING PROCESS IS FOLLOWED: "WHENEVER A PH OR PH AFFILIATE BOARD OR BOARD COMMITTEE IS CONSIDERING A TRANSACTION OR ARRANGEMENT WITH AN ORGANIZATION, ENTITY OR INDIVIDUAL IN WHICH A PERSON COVERED BY THIS POLICY HAS A FINANCIAL OR CONFLICTING INTEREST, THE FOLLOWING SHALL OCCUR: 1. THE INTERESTED PERSON MUST DISCLOSE THE FINANCIAL OR CONFLICTING INTEREST AND ALL MATERIAL FACTS TO THE PH OR PH AFFILIATE BOARD OR BOARD COMMITTEE; 2. THE INTERESTED PERSON WITH THAT FINANCIAL OR CONFLICTING INTEREST MAY MAKE A PRESENTATION AT THE BOARD OR BOARD COMMITTEE MEETING REGARDING THE TRANSACTION OR ARRANGEMENT HOWEVER, HE/SHE SHALL LEAVE THE MEETING DURING THE DISCUSSION OF, AND THE VOTE ON, THE TRANSACTION OR ARRANGEMENT THAT RESULTS IN THE FINANCIAL OR CONFLICTING INTEREST; AND 3. THE PH OR PH AFFILIATE BOARD OR BOARD COMMITTEE MUST APPROVE THE TRANSACTION OR ARRANGEMENT BY A MAJORITY VOTE OF THE BOARD MEMBERS PRESENT AT A MEETING THAT HAS A QUORUM, NOT INCLUDING THE VOTE OF THE INTERESTED PERSON. THE INTERESTED PERSON MAY NOT VOTE ON THE MATTER. A. UPON THE REQUEST OF PH OR PH AFFILIATE BOARD OR BOARD COMMITTEE, THE MATTER MAY BE DELEGATED TO THE PH COMPLIANCE COMMITTEE FOR EVALUATION, RECOMMENDATION AND/OR DETERMINATION. 4. WHENEVER A FINANCIAL OR CONFLICTING INTEREST IS ADDRESSED BY A PH OR PH AFFILIATE BOARD, NOTICE SHALL BE GIVEN TO THE PH COMPLIANCE OFFICER / GENERAL COUNSEL." FORM 990, PART VI, SECTION B, LINE 15 LINES 15A AND 15B ARE ANSWERED NO IN ACCORDANCE WITH THE IRS INSTRUCTIONS. TO THE EXTENT THAT THE ORGANIZATION HAS VICE PRESIDENT OR ABOVE, THE COMPENSATION COMMITTEE OF RELATED ORGANIZATION, PARKVIEW HEALTH SYSTEM, INC., DETERMINES THE COMPENSATION OF THE CEO, OFFICERS, AND KEY EMPLOYEES. FORM 990, PART VI, SECTION C, LINE 19 COPIES OF THE ORGANIZATION'S GOVERNING DOCUMENTS, CONFLICT OF INTEREST POLICY, AND FINANCIAL STATEMENTS ARE AVAILABLE UPON REQUEST. FORM 990, PART IX, LINE 11G OTHER: PROGRAM SERVICE EXPENSES 766,777. MANAGEMENT AND GENERAL EXPENSES 91,462. FUNDRAISING EXPENSES 1,055. TOTAL EXPENSES 859,294. PHYSICIAN PROFESSIONAL FEES: PROGRAM SERVICE EXPENSES 2,812,622. MANAGEMENT AND GENERAL EXPENSES 363,167. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 3,175,789. LAB SERVICES: PROGRAM SERVICE EXPENSES 1,118,465. MANAGEMENT AND GENERAL EXPENSES 0. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 1,118,465. COLLECTION EXPENSE: PROGRAM SERVICE EXPENSES 0. MANAGEMENT AND GENERAL EXPENSES 326,415. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 326,415. TEMPORARY HELP: PROGRAM SERVICE EXPENSES 468,561. MANAGEMENT AND GENERAL EXPENSES 0. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 468,561. FORM 990, PART IX, LINES 5-10: PARKVIEW HEALTH SYSTEM, INC., EIN 35-1972384, SERVES AS THE COMMON PAYING AGENT FOR ALL TAX-EXEMPT ORGANIZATIONS OF THE SYSTEM. SALARIES AND WAGES OF EMPLOYEES WORKING FOR THESE ORGANIZATIONS ARE CHARGED DIRECTLY TO THE ORGANIZATIONS IN WHICH THEY WORK. THE ACTUAL EXPENSES FOR PAYROLL TAXES, EMPLOYEE BENEFITS, AND PENSION PLAN CONTRIBUTIONS ARE REFLECTED ON THE BOOKS OF PARKVIEW HEALTH SYSTEM, INC. FOR FINANCIAL REPORTING PURPOSES. TO ACCOUNT FOR BENEFIT COSTS ON THE BOOKS OF THE OTHER TAX EXEMPT ORGANIZATIONS, AN ALLOCATION METHODOLOGY IS UTILIZED TO CHARGE THESE ORGANIZATIONS WITH AN ESTIMATE OF THE OVERALL COSTS, REFERRED TO AS A "BENEFIT ALLOCATION" FROM PARKVIEW HEALTH SYSTEM, INC. THE ALLOCATION DOES NOT DISTINGUISH BETWEEN THE COSTS OF THE VARIOUS COMPONENTS (I.E. PAYROLL TAXES, EMPLOYEE BENEFITS, AND PENSION PLAN CONTRIBUTIONS). THEREFORE, FOR PURPOSES OF THE FORM 990, PART IX, THE TOTAL BENEFIT ALLOCATION FOR THE EMPLOYEES' SALARIES AND WAGES REPORTED ON LINE 7 IS REFLECTED ON LINE 9 AND NOT ALLOCATED BETWEEN LINES 8 OR 10. FOR PURPOSES OF THE FORM 990, PART IX, LINES 5 AND 6 REFLECT COMPENSATION AND BENEFIT AMOUNTS REPORTED IN PART VII. FORM 990, PART XI, LINE 9: CURRENT YEAR EARNINGS TRANSFERRED TO PARENT -2,444,210. ASSET TRANSFERS/ADJUSTMENTS -22,211. DOUBTFUL PLEDGE EXPENSE -274. 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