2019-08-15T07:29:04-05:00 2018-09-30 351178661 BLUE & CO LLC 500 N MERIDIAN ST SUITE 200 INDIANAPOLIS IN 46204 990 2017-10-01 350877575 GIBSON GENERAL HOSPITAL GIBS 8123853401 1808 SHERMAN DRIVE PRINCETON IN 47670 JARED STIMPSON CFO 8123853401 2019-08-14 1 MARGOT BURKE P01588992 3176334705 2019-08-14 47.227.233.166 2019-08-14 21:29:18 ED P DA39A3EE5E6B4B0D3255BFEF95601890AFD80709 B19D0506B86ED19F1A0FD2AFEEB91090E576B51F 2017 2019-02-21 02:37:17Z CLAUDIA A EISENMANN 1808 SHERMAN DRIVE PRINCETON IN 47670 31033680 0 X WWW.GIBSONGENERAL.COM X 1941 IN TO PROVIDE HIGH QUALITY, PATIENT-CENTERED, COST-EFFECTIVE CARE FOR PEOPLE IN THE COMMUNITY. 16 15 416 42 0 17594 227932 359833 29409953 30185432 14946 35584 466859 452831 30119690 31033680 0 0 0 0 16167844 17623885 0 0 0 12190528 14503013 28358372 32126898 1761318 -1093218 22282548 20894624 10940910 10646204 11341638 10248420 THE MISSION OF GIBSON GENERAL HOSPITAL AND THE SKILLED NURSING FACILITY IS TO PROVIDE HIGH QUALITY, PATIENT-CENTERED, COST-EFFECTIVE CARE FOR PEOPLE IN OUR COMMUNITY. 0 0 24310721 30358092 THE HOSPITAL'S MISSION IS TO PROVIDE HIGH QUALITY AND COST-EFFECTIVE HEALTHCARE, WHICH INCLUDES PATIENT, OUTPATIENT, AND EMERGENCY CARE SERVICES TO THE RESIDENTS OF THE SURROUNDING TRI-STATE AREA. ALL EXPENSES RELATE TO COSTS ASSOCIATED WITH PROVIDING THESE SERVICES, AND MAINLY INCLUDE SALARIES AND WAGES TO STAFF AND SUPPLIES COST. THERE WERE 356 ADMISSIONS AND 26,833 VISITS DURING THE YEAR. 24310721 1 1 0 1 0 0 0 0 0 0 1 0 0 0 1 1 0 1 0 0 0 0 0 0 0 0 1 1 0 0 1 0 0 0 0 0 0 1 0 0 0 0 0 0 1 1 1 0 0 1 71 0 1 416 1 1 1 0 0 0 0 0 0 0 0 0 X 16 15 0 1 0 0 0 1 0 1 1 0 0 1 1 1 1 1 1 1 1 0 IN X JARED STIMPSON 8123853401 1808 SHERMAN DRIVE PRINCETON IN 47670 ROBERT GIBSON JR BOARD CHAIRMAN 2.00 X X 0 0 0 MARION JOCHIM BOARD VICE-CHAIR 2.00 X X 0 0 0 J ROBERT KINKLE SECOND VICE-CHAIR 2.00 X X 0 0 0 MIKE WOOD SECRETARY 2.00 X X 0 0 0 SUSAN STRAUB TREASURER 2.00 X X 0 0 0 KRISHNA MURTHY MD CHIEF OF STAFF 2.00 X 0 0 0 GEORGE A BALLARD BOARD MEMBER 2.00 X 0 0 0 ALAN DOUGLAS BOARD MEMBER 2.00 X 0 0 0 JARED FLORENCE BOARD MEMBER 2.00 X 0 0 0 DR MICHAEL GREEN BOARD MEMBER 2.00 X 0 0 0 MS KRISHNA MD BOARD MEMBER 2.00 X 0 0 0 STEPHEN LANKFORD BOARD MEMBER 2.00 X 0 0 0 SHAWN MCCOY BOARD MEMBER 2.00 X 0 0 0 DEREK MCGRAW BOARD MEMBER 2.00 X 0 0 0 BRAD SCHMITT BOARD MEMBER 2.00 X 0 0 0 ALLEN WHITE MD BOARD MEMBER 2.00 X 0 0 0 EMMETT SCHUSTER CEO OCT'17-MAY'18 50.00 X 221129 0 16057 MIKE CARNEY INTERIM CEO MAY-SEP'18 50.00 X 0 0 0 CLAUDIA EISENMANN CEO-TERM BEGAN SEP'18 50.00 X 0 0 0 JAMES CHILDERS CFO-TERM ENDED MAY'18 50.00 X 153099 0 17887 LORI PHILLIPS CNO-TERM ENDED JAN'18 50.00 X 157900 0 190 PHILLIP ROSETT PHYSICIAN 40.00 X 316934 0 17465 COREY A POTTS CRNA 40.00 X 231378 0 25713 STEPHEN R SHOEMAKER PHYSICIAN 40.00 X 228476 0 19261 RICHARD M CLARK PHYSICIAN 40.00 X 222942 0 25805 KWABENA OWUSU-DEKYI PHYSICIAN 40.00 X 172249 0 19261 1704107 0 141639 12 0 1 1 BLAKE TITZER DO PC 12011 PROSPECT COURT EVANSVILLE IN 47720 MEDICAL PRO FEES 363617 MEDICAL STAFFING SOLUTIONS LLC 9700 HWY 57 NORTH SUITE A EVANSVILLE IN 47725 RECRUITMENT 215114 MICHELLE SNYDER 328 N 2ND ST STE 102 VINCENNES IN 47591 MEDICAL PRO FEES 172000 SIGHTPATH MEDICAL LLC PO BOX 204253 DALLAS TX 75320 MEDICAL AND HEALTHCARE 159444 KAHN DEES DONOVAN KAHN PO BOX 3646 EVANSVILLE IN 47735 ATTORNEY 125769 7 142972 216861 359833 PATIENT SERVICE REVENUE 624100 27508320 27508320 LONG TERM CARE REVENUE 623000 2677112 2677112 30185432 35584 35584 69182 0 69182 69182 69182 CAFETERIA REVENUE 722210 137997 137997 245652 172660 72992 383649 31033680 30358092 0 315755 X 532127 532127 13310628 10101003 3209625 178131 135178 42953 2615335 1984693 630642 987664 749506 238158 1061621 1061621 141480 141480 4121128 3127390 993738 232868 232868 665261 504844 160417 2150209 1631724 518485 92760 70393 22367 318122 318122 1304781 1239542 65239 340348 258279 82069 MEDICAL & DRUG SUPPLIES 2530396 2530396 HAF EXPENSE 981811 981811 DUES & SUB. 486274 369018 117256 75954 75954 32126898 24310721 7816177 0 2793850 3566667 4146257 2613644 3285892 3143623 783371 711314 248364 261380 34026973 24077641 10288648 9949332 79926 67097 656240 581567 22282548 20894624 2175408 2180816 925541 708077 6060996 0 1045301 7246311 733664 511000 10940910 10646204 X 11292424 10196713 49214 51707 11341638 10248420 22282548 20894624 -1093218 0 X X 0 1 X 1 0 X 0 0 0 0 0 0 0 0 1 823 823 0 PART II-B, LINE 1: THE HOSPITAL PAID MEMBERSHIP DUES TO INDIANA HOSPITAL ASSOCATION "IHA". IHA ATTRIBUTED 7.12% ($823) OF THE DUES TO LOBBYING EXPENSES. 421244 421244 19966769 12300931 7665838 13629414 11776710 1852704 9546 9546 9949332 THIRD PARTY PAYABLE 511000 511000 X PART X, LINE 2: ACCOUNTING PRINCIPLES GENERALLY ACCEPTED IN THE UNITED STATES OF AMERICA REQUIRE MANAGEMENT TO EVALUATE TAX POSITIONS TAKEN BY THE HOSPITAL AND FOUNDATION AND RECOGNIZE A TAX LIABILITY IF THEY HAVE TAKEN AN UNCERTAIN POSITION THAT MORE LIKELY THAN NOT WOULD NOT BE SUSTAINED UPON EXAMINATION BY VARIOUS FEDERAL AND STATE TAXING AUTHORITIES. MANAGEMENT HAS ANALYZED THE TAX POSITIONS TAKEN BY THE HOSPITAL, FOUNDATION AND PAIN MANAGEMENT, AND HAS CONCLUDED THAT AS OF SEPTEMBER 30, 2018 AND 2017, THERE ARE NO UNCERTAIN POSITIONS TAKEN OR EXPECTED TO BE TAKEN THAT WOULD REQUIRE RECOGNITION OF A LIABILITY OR DISCLOSURE IN THE ACCOMPANYING CONSOLIDATED FINANCIAL STATEMENTS. THESE ENTITIES ARE SUBJECT TO ROUTINE AUDITS BY TAXING JURISDICTIONS; HOWEVER, THERE ARE CURRENTLY NO AUDITS FOR ANY TAX PERIODS IN PROGRESS. 1 1 X 1 X 149.000000000000 1 X 1 1 1 0 1 1 191138 191138 0.00590 6554549 2699493 3855056 0.12000 6745687 2699493 4046194 0.12590 6745687 2699493 4046194 0.12590 1 1911869 2990560 3240194 -249634 X 1 1 1 1 GIBSON GENERAL HOSPITAL INC 1808 SHERMAN DRIVE PRINCETON IN 47670 WWW.GIBSONGENERAL.COM 18-005019-1 X X X X GIBSON GENERAL HOSPITAL INC 0 0 1 X X X X X X X X X 15 1 0 1 1 X SEE PART V, PAGE 8 X X 1 15 1 SEE PART V, PAGE 8 0 1 X 149.000000000000 300.000000000000 X X X X 1 1 X X X 1 X SEE PART V, PAGE 8 X SEE PART V, PAGE 8 X SEE PART V, PAGE 8 X X X X X X 1 X 0 X X X X 1 X 0 0 GIBSON GENERAL HOSPITAL INC PART V, SECTION B, LINE 5: COMMUNITY INPUT: BETWEEN APRIL AND JULY 2015, THE HOSPITAL PARTNERED WITH THE INDIANA RURAL HEALTH ASSOCIATION (IRHA) TO CONDUCT A COMMUNITY HEALTH NEEDS ASSESSMENT TO IDENTIFY AREAS OF GREATEST NEED IN THE HOSPITAL'S SERVICE AREA THROUGH THE COLLECTION OF HEALTH DATA AND COMMUNITY INPUT ON THE COMMUNITY'S ASSETS, VALUES, AND WEAKNESSES. A FOCUS GROUP OF GIBSON COUNTY REPRESENTATIVES WAS ORGANIZED WHICH INCLUDED BUSINESS OWNERS, LOCAL OFFICIALS, HEALTHCARE PROVIDERS, MINORITY LEADERS, CLERGY, STUDENT REPRESENTATIVES, AND OTHER INTERESTED PARTIES. ADDITIONALLY, A 47-QUESTION SURVEY WAS DEVELOPED AND DISSEMINATED TO THE RESIDENTS OF GIBSON COUNTY AND PUBLICALLY VIA THE HOSPITAL'S WEBSITE, FACE-TO-FACE POLLING AT A POPULAR STORE IN PRINCETON, INDIANA, AND AT THE GIBSON COUNTY FAIR. GIBSON GENERAL HOSPITAL INC PART V, SECTION B, LINE 6B: INDIANA RURAL HEALTH ASSOCIATION GIBSON GENERAL HOSPITAL INC PART V, SECTION B, LINE 7D: CHNA LOCATION:THE CHNA REPORTS CAN BE LOCATED AT THE HOSPITAL'S WEBSITE LOCATED ON THE "COMMUNITY HEALTH NEEDS ASSESSMENT" PAGE LOCATED UNDER "ABOUT US". GIBSON GENERAL HOSPITAL INC PART V, SECTION B, LINE 11: THE COMMUNITY'S MOST SIGNIFICANT NEEDS AS UNCOVERED IN THE 2015 CHNA WERE RELATED TO FITNESS/ACTIVITY, CHRONIC DISEASE, MENTAL HEALTH SERVICES AVAILABILITY, LIVING CONDITIONS, AND DRUG USE.TO MEET THE FITNESS/ACTIVITY NEED, GGH WORKED WITH COMMUNITY ORGANIZATIONS TO EVALUATE WALKING/BIKING PATHS IN THE COMMUNITY. PRINCETON STELLAR CREATED PAVED PATHS THROUGHOUT PRINCETON AND GGH CREATED A WALKING ROUTE FOR EMPLOYEES. THE HOSPITAL ALSO CREATED A WELLNESS PROGRAM TO WORK WITH AREA BUSINESSES TO PROMOTE WELLNESS AND HEALTHY LIFESTYLES.TO MEET THE CHRONIC DISEASE NEED, THE HOSPITAL USED ITS WELLNESS PROGRAM AND SERVICE LINES TO FOCUS ON EDUCATION AND THE BENEFITS OF SCREENING AND EARLY DETECTION. THE HOSPITAL'S CERTIFIED DIABETES EDUCATOR STARTED OFFERING GROUP CLASSES.TO MEET THE MENTAL HEALTH SERVICES AVAILABILITY NEED, GGH IDENTIFIED SERVICES AND PROVIDERS AVAILABLE IN AND AROUND GIBSON COUNTY BY WORKING WITH COMMUNITY AGENCIES. THE HOSPITAL IS ALSO EXPLORING TELEMEDICINE OPTIONS FOR MENTAL HEALTH.TO MEET THE LIVING CONDITIONS NEED, GGH WORKED WITH COMMUNITY LEADERS TO EVALUATE THE MARKET FOR A HEALTHY LIVING FACILITY, SUCH AS A YMCA. THE COMMUNITY NOW HAS A LARGE FACILITY IN THE PLANS. THE HOSPITAL ALSO HAS ENHANCED AND GROWN ITS SWING BED PROGRAM TO IMPROVE LONG TERM RECOVERY CLOSE TO HOME.TO MEET THE DRUG USE/ABUSE NEED, THE HOSPITAL HAS PARTNERED WITH AGENCIES AND THE PRINCETON POLICE DEPARTMENT TO PROVIDE EDUCATION THROUGH SEMINARS AND PROGRAMS. GIBSON GENERAL HOSPITAL INC PART V, SECTION B, LINE 13H: OTHER ELIGIBLITY CRITERIA: IF AN INDIVIDUAL IS HOMELESS, DECEASED, RECENTLY FILED FOR OR COMPLETED BANKRUPTCY, OR MEETS SPECIAL CIRCUMSTANCES RELATED TO ABILITY TO PAY, THE INDIVIDUAL MAY BE ELIGIBLE FOR FINANCIAL ASSISTANCE. GIBSON GENERAL HOSPITAL INC PART V, SECTION B, LINE 16J: PUBLICIZED FINANCIAL ASSISTANCE POLICY: FAP, FAP APPLICATION, AND PLAIN LANGUAGE SUMMARY CAN BE LOCATED ON THE HOSPITAL'S WEBSITE ON THE "FINANCIAL ASSISTANCE" PAGE UNDER "PATIENT INFO DROP DOWN MENU. ADDITIONALLY, A SPANISH TRANSLATION OF THE FAP APPLICATION AND PLAIN LANGUAGE SUMMARY ARE AVAILABLE. GIBSON GENERAL HOSPITAL: SCHEDULE H, PART V, LINE 7A, CHNA: HTTP://WWW.GIBSONGENERAL.COM/ABOUT-US/DOCUMENTS-ABOUT-US/2015-GIBSON_CHNA_W_APPENDICES_AND_IMPLEMENTATION_F GIBSON GENERAL HOSPITAL: SCHEDULE H, PART V, LINE 10A, IMPLEMENTATION STRATEGY:HTTP://WWW.GIBSONGENERAL.COM/ABOUT-US/DOCUMENTS-ABOUT-US/2015-GIBSON_CHNA_W_APPENDICES_AND_IMPLEMENTATION_F GIBSON GENERAL HOSPITAL: SCHEDULE H, PART V, LINE 16A, FAP WEBSITE:HTTP://WWW.GIBSONGENERAL.COM/FOR-YOU/PATIENTS-AND-VISITORS/PATIENTS/DOCUMENTS-PATIENTS/GGH_FINANCIAL_ASSISTANCE_POLICY_FINALGIBSON GENERAL HOSPITAL:PART V, LINE 16B, FAP APPLICATION WEBSITE:HTTP://WWW.GIBSONGENERAL.COM/FOR-YOU/PATIENTS-AND-VISITORS/PATIENTS/DOCUMENTS-PATIENTS/CHARITY-CARE-APPLICATION-2018GIBSON GENERAL HOSPITAL:PART V, LINE 26C, FAP PLAIN LANGUAGE SUMMARY WEBSITE:HTTP://WWW.GIBSONGENERAL.COM/FOR-YOU/PATIENTS-AND-VISITORS/PATIENTS/DOCUMENTS-PATIENTS/FAP_PLAIN_LANGUAGE 7 1 - STAR ONE REHAB 1808 SHERMAN DRIVE PRINCETON IN 47670 PHYSICAL THERAPY, OCCUPATIONAL THERAPY, SPEECH THERAPY 2 - PHYSICIAN OUTPATIENT CLINICS 1808 SHERMAN DRIVE PRINCETON IN 47670 SUBSIDIZED CARE PHYSICIAN PRACTICES 3 - LIFESTYLES DIABETES CENTER 1808 SHERMAN DRIVE PRINCETON IN 47670 DIABETES EDUCATION COUNSELING 4 - GGH - SKILLED NURSING FACILITY 1808 SHERMAN DRIVE PRINCETON IN 47670 SKILLED NURSING REHAB CENTER 5 - GGH-FAMILY PRACTICE 510 N MAIN ST PRINCETON IN 47670 FAMILY MEDICINE 6 - BRINK'S FAMILY PRACTICE 410 N MAIN ST PRINCETON IN 47670 FAMILY MEDICINE/ HOSPITALIST 7 - FORT BRANCH WELLNESS CLINIC 7851 S PROFESSIONAL DR FORT BRANCH IN 47648 FAMILY PRACTICE PART I, LINE 3C: GIBSON GENERAL HOSPITAL USES THE FOLLOWING FACTORS, IN ADDITION TO THE FPG, TO DETERMINE AN INDIVIDUAL'S ELIGIBILITY FOR FINANCIAL ASSISTANCE UNDER THE HOSPITAL'S FINANCIAL ASSISTANCE POLICY: MEDICAL INDECENCY, INSURANCE STATUS, AND UNDERINSURANCE STATUS. ADDITIONALLY, IF AN INDIVIDUAL IS HOMELESS, DECEASED, RECENTLY FILED FOR OR COMPLETED BANKRUPTCY, OR MEETS SPECIAL CIRCUMSTANCES RELATED TO ABILITY TO PAY, THE INDIVIDUAL MAY BE ELIGIBLE FOR FINANCIAL ASSISTANCE. PART I, LINE 7: GIBSON GENERAL HOSPITAL CALCULATED THE COST OF FINANCIAL ASSISTANCE AND MEANS-TESTED GOVERNMENT PROGRAMS, USING THE COST-TO-CHARGE RATIO DERIVED FROM SCHEDULE H, WORKSHEET 2, RATIO OF PATIENT CARE COST-TO-CHARGES. PART III, LINE 2: METHODOLOGY USED TO ESTIMATE BAD DEBT: MANAGEMENT ANALYZES THIRD-PARTY PAYOR SOURCES AND MAKES AN ESTIMATE BASED ON AGING OF ACCOUNTS, HISTORICAL LOSSES, CURRENT ECONOMIC CONDITIONS, AND OTHER FACTORS UNIQUE TO ITS SERVICE AREA. ADDITIONALLY, A SIGNIFICANT PROVISION IS ESTIMATED AND RECORDED FOR SELF-PAY PAYMENTS BASED ON PAST EXPERIENCE. PART III, LINE 3: THE HOSPITAL DOES NOT PURSUE COLLECTION AMOUNTS DETERMINED TO QUALIFY AS CHARITY CARE. THESE AMOUNTS ARE NOT REPORTED AS NET PATIENT REVENUE BECAUSE THE HOSPITAL DOES NOT PURSUE COLLECTION OF AMOUNTS DETERMINED TO QUALIFY AS CHARITY CARE. GIBSON GENERAL HOSPITAL DOES NOT ATTRIBUTE ANY BAD DEBT EXPENSE TO PATIENTS ELIGIBLE UNDER THE ORGANIZATION'S FINANCIAL ASSISTANCE POLICY (FAP), THEREFORE NO PORTION OF BAD DEBT ATTRIBUTABLE TO FAP-ELIGIBLE INDIVIDUALS IS CONSIDERED A COMMUNITY BENEFIT. PART III, LINE 4: AUDITED FINANCIAL STATEMENT FOOTNOTE:FOOTNOTE TO ORGANIZATION'S FINANCIAL STATEMENTS THAT DESCRIBES BAD DEBT EXPENSE IS LOCATED ON PAGE 8 OF THE AUDITED FINANCIAL STATEMENTS WITHIN THE NOTE "ALLOWANCE FOR UNCOLLECTIBLE ACCOUNTS". PART III, LINE 8: MEDICARE SHORTFALL:THE HOSPITAL IS A CRITICAL ACCESS HOSPITAL AND IS REIMBURSED 101%, LESS 2% SEQUESTRATION, OF MEDICARE ALLOWANCE COSTS FOR INPATIENT SERVICES, SWING BED, AND OUTPATIENT PART B SERVICES. THE REVENUE SHORTFALL IS THE DIFFERENCE BETWEEN THE ALLOWABLE COST FOR THE SKILLED NURSING FACILITY AND THE PPS REIMBURSEMENT ALLOWED FOR THAT SKILLED NURSING FACILITY. THE SOURCE USED TO DETERMINE THE AMOUNT OF MEDICARE ALLOWABLE COSTS REPORTED FOR PART III, SECTION B, MEDICARE HAS BEEN PROVIDED FROM THE YEAR ENDED SEPTEMBER 30, 2018: HOSPITAL STATEMENT OF REIMBURSABLE COST. PART III, LINE 9B: COLLECTION PRACTICES:COLLECTION PRACTICES ARE APPLIED TO ALL PATIENTS AT GIBSON GENERAL HOSPITAL. ONCE PATIENTS RECEIVE SERVICES, THE PATIENTS' ACCOUNTS ARE BILLED TO THE APPROPRIATE INSURANCE COMPANY. ONCE PAYMENT IS RECEIVED FROM THE INSURANCE COMPANY, THE REMAINING BALANCE, IF ANY, BECOMES THE PATIENT'S RESPONSIBILITY. NOTIFICATION OF THE BALANCE DUE IS SENT VIA WRITTEN CORRESPONDENCE. IF THE BALANCE IS NOT PAID AND THE ACCOUNT DOES NOT QUALIFY FOR FINANCIAL ASSISTANCE, THE ACCOUNT IS SENT TO A COLLECTION AGENCY TO CONTINUE EFFORTS TO COLLECT THE REMAINING BALANCE DUE. IF THE BALANCE DUE IS NOT PAID WITHIN A CERTAIN NUMBER OF MONTHS, THE ACCOUNT IS RETURNED TO THE HOSPITAL AND THE ACCOUNT IS WRITTEN OFF AS UNCOLLECTIBLE. PART VI, LINE 2: ASSESSING COMMUNITY NEEDS:IN ADDITION TO COMPLETING A CHNA EVERY THREE YEARS, THE HOSPITAL'S LEADERSHIP IS COMPRISED OF COMMUNITY MEMBERS WHO ENGAGE IN DAILY CONVERSATIONS WITH OTHER COMMUNITY MEMBERS AND LEADERS REGARDING THE COMMUNITY THEY LIVE IN AND ITS NEEDS. THESE CONVERSATIONS SUPPLEMENT THE UNDERSTANDING OF THE COMMUNITY'S HEALTH NEEDS IDENTIFIED IN THE CHNA. HOSPITAL LEADERSHIP ALSO USES STRATEGIC PLANNING TO SPONSOR AND ENGAGE IN COMMUNITY ACTIVITIES THAT HELPS LEADERSHIP ASSESS THE HEALTH CARE NEEDS OF THE COMMUNITY THE HOSPITAL SERVES. PART VI, LINE 3: PATIENT EDUCATION OF ELIGIBILITY FOR ASSISTANCE: THE HOSPITAL DISPLAYS POSTERS IN THE CENTRAL REGISTRATION AND EMERGENCY ROOM WAITING-AREA NOTIFYING PATIENTS THAT THEY WILL BE SEEN REGARDLESS OF THEIR ABILITY TO PAY AND FINANCIAL ASSISTANCE IS AVAILABLE TO UNINSURED AND UNDERINSURED IN COMPLIANCE WITH EMTALA. THE FINANCIAL ASSISTANCE POLICY (FAP), FAP APPLICATION, AND PLAIN LANGUAGE SUMMARY ARE AVAILABLE ON THE HOSPITAL'S WEBSITE AT GIBSONGENERAL.COM; AVAILABLE UPON REQUEST, WITHOUT CHARGE, AT THE BUSINESS OFFICE, ADMISSIONS, AND VIA MAIL; PLAIN LANGUAGE SUMMARY IS CONSPICUOUSLY DISPLAYED IN THE HOSPITAL AND CLINIC WAITING-AREAS; AND, THE PLAIN LANGUAGE SUMMARY IS PROVIDED TO EACH PERSON UPON ADMISSION TO THE HOSPITAL. ANY PATIENTS WITHOUT INSURANCE OR WITH A BALANCE DUE AFTER INSURANCE IS BILLED ARE PROVIDED A PLAIN LANGUAGE SUMMARY, FAP APPLICATION, AND CONTACT INFORMATION FOR THE HOSPITAL'S PATIENT FINANCIAL COUNSELOR BY MAIL. PART VI, LINE 4: COMMUNITY INFORMATION/ COMMUNITY SERVED:THE HOSPITAL'S PRIMARY SERVICE AREA INCLUDES GIBSON COUNTY, INDIANA. GIBSON COUNTY IS LOCATED IN SOUTHWESTERN, INDIANA, AND IS LARGELY RURAL WITH AGRICULTURE AND COAL MINING AS PRIMARY INDUSTRIES. GIBSON COUNTY, INDIANA, IS APPROXIMATELY 146 MILES SOUTHWEST OF INDIANAPOLIS AND 25 MILES NORTH OF EVANSVILLE, INDIANA, WITH AN ESTIMATED POPULATION OF 33,700. IN 2016 THE POPULATION MEDIAN AGE WAS 40.4 YEARS WITH FORTY-FIVE PERCENT (45%) OF THE POPULATION AGE 45 AND OLDER. THE POVERTY RATE WAS 10.8% AND THE MEDIAN HOUSEHOLD ANNUAL INCOME WAS $54,690. APPROXIMATELY 75-80% OF THE HOSPITAL'S PATIENT POPULATION UTILIZES MEDICARE, MEDICAID, AND/OR OTHER GOVERNMENT-SUBSIDIZED PROGRAMS. TRADITIONALLY, THE HOSPITAL HAS BEEN RELIED UPON AS A SAFETY NET HOSPITAL FOR OLDER PATIENTS, LOW-INCOME PATIENTS, AND PATIENTS WITH LIMITED MEANS TO TRAVEL TO THE LARGER CITY OF EVANSVILLE, INDIANA. PART VI, LINE 5: COMMUNITY HEALTH PROMOTION:THE HOSPITAL PARTICIPATES IN MANY ORGANIZATIONS AND ACTIVITIES DESIGNED TO IMPROVE THE HEALTH AND WELFARE OF THE SURROUNDING COMMUNITY. IN ADDITION TO PARTICIPATION ON VARIOUS BOARDS AND CIVIC ORGANIZATIONS FOCUSED ON ECONOMIC DEVELOPMENT, THE HOSPITAL'S LEADERSHIP PARTICIPATES IN THE INDIANA PATIENT SAFETY COALITION, THE DEPARTMENT OF HOMELAND SECURITY, DISTRICT 10 EMERGENCY PREPAREDNESS AND NATIONAL INCIDENT MANAGEMENT SAFETY PROGRAMS. AS MEMBERS OF THE INDIANA RURAL HEATH ASSOCIATION AND THE INDIANA STATE RURAL HEALTH NETWORK, THE HOSPITAL PARTICIPATES IN PROGRAMS DESIGNED TO ASSIST RURAL HEALTHCARE ORGANIZATIONS STATEWIDE AND HAS ASSISTED IN OBTAINING AND IMPLEMENTING COMMUNICATION, INFORMATION SHARING, AND OTHER ACTIVITIES TO IMPROVE THE ACCESS TO HEALTHCARE IN GIBSON COUNTY AND THE SURROUNIDNG AREAS. PART VI, LINE 6: AFFILIATED HEALTH CARE SYSTEM:GIBSON GENERAL HOSPITAL BECAME AFFILIATED WITH DEACONESS HEALTH SYSTEM IN DECEMBER 2016 COOPERATING TO PROVIDE HEALTH CARE SERVICES TO THEIR COMMUNITIES. ADDITIONALLY, THE HOSPITAL DOES PARTICIPATE IN SEVERAL COALITIONS AND COOPERATIVES WITH OTHER PROVIDERS AND OFTEN COLLABORATES WITH THE LARGER SYSTEM IN THE EVANSVILLE AREA TO PROVIDE ACCESS TO SERVICES THE HOSPITAL CANNOT PROVIDE SUCH AS CARDIAC AND NEUROLOGICAL SURGERY. X X X 0 0 0 0 0 0 0 0 0 EMMETT SCHUSTER CEO OCT'17-MAY'18 220880 0 0 0 249 0 0 0 16057 0 237186 0 0 0 JAMES CHILDERS CFO-TERM ENDED MAY'18 152850 0 0 0 249 0 0 0 17887 0 170986 0 0 0 LORI PHILLIPS CNO-TERM ENDED JAN'18 157147 0 0 0 753 0 0 0 190 0 158090 0 0 0 PHILLIP ROSETT PHYSICIAN 315751 0 0 0 1183 0 0 0 17465 0 334399 0 0 0 COREY A POTTS CRNA 231378 0 0 0 0 0 0 0 25713 0 257091 0 0 0 STEPHEN R SHOEMAKER PHYSICIAN 227561 0 0 0 915 0 0 0 19261 0 247737 0 0 0 RICHARD M CLARK PHYSICIAN 222147 0 0 0 795 0 0 0 25805 0 248747 0 0 0 KWABENA OWUSU-DEKYI PHYSICIAN 171496 0 0 0 753 0 0 0 19261 0 191510 0 0 0 FORM 990, PART VII, LINE 5: NAME OF UNRELATED ORGANIZATION: DEACONESS HOSPITAL, INC. TWO INDIVIDUALS WERE PAID BY THE UNRELATED ORGANIZATION. 1) EMMETT SCHUSTER TYPE & AMOUNT OF COMPENSATION: BASE COMPENSATION: $220,880 OTHER REPORTABLE COMPENSATION: $249 NONTAXABLE BENEFITS: $16,057 2) JAMES CHILDERS TYPE & AMOUNT OF COMPENSATION: BASE COMPENSATION: $152,850 OTHER REPORTABLE COMPENSATION: $249 NONTAXABLE BENEFITS: $17,887 LEANN COOPER SEE PART V 51490 COMPENSATION PAID BY GGH 0 SCHEDULE L, PART IV, LINE 1B LEANN COOPER IS THE EXECUTIVE DIRECTOR OF GIBSON GENERAL HEALTH FOUNDATION AND IS THE DAUGHTER OF BOARD MEMBER DR. MICHAEL GREEN. THE HOSPITAL COMPENSATES FOR THE SALARY OF THE EXECUTIVE DIRECTOR OF THE GIBSON GENERAL HEALTH FOUNDATION. FORM 990, PART VI, SECTION A, LINE 1 EXECUTIVE COMMITTEE DELEGATED AUTHORITY: THE EXECUTIVE COMMITTEE WILL EXERCISE ALL AUTHORITY OF THE BOARD OF TRUSTEES BETWEEN REGULAR BOARD MEETINGS DURING ALL EMERGENCY SITUATIONS (IMMEDIATE ACTION THAT COULD RESULT IN A SERIOUS NEGATIVE IMPACT UPON THE ORGANIZATION) AND/OR WHEN THE NON-EMERGENCY ACTION(S) RESULT IN COMMITMENT TO A CAPITAL INVESTMENT OR LEASE LESS THAN $50,000. FORM 990, PART VI, SECTION A, LINE 3 MANAGEMENT DUTIES: THE CEO, CNO AND CFO OF THE ORGANIZATION ARE EMPLOYEED AND PROVIDED, SUBJECT TO APPROVAL OF THE BOARD OF TRUSTEES, BY DEACONESS HOSPITAL, INC., AN INDIANA NOT FOR PROFIT CORPORATION AS OF DECEMBER 2016. FORM 990, PART VI, SECTION A, LINE 7A POWER TO ELECT OR APPOINT: THE ORGANIZATION GOVERNING DOCUMENTS ALLOWS FOR THE COUNTY COMMISSIONERS OF GIBSON COUNTY, INDIANA TO SELECT ONE (1) MEMBER OF THE BOARD OF TRUSTEES; DEACONESS HOSPITAL, INC TO SELECT THREE (3) MEMBERS OF THE BOARD OF TRUSTEES; AND, THE MAYOR OF PRINCETON, INDIANA, THE PRESIDENT OF GIBSON GENERAL HOSPITAL FOUNDATION, AND THE CHIEF OF STAFF OF GIBSON GENERAL HOSPITAL SERVE AS EX-OFFICIO MEMBERS. FORM 990, PART VI, SECTION B, LINE 11B FORM 990 REVIEW PROCESS: THE PROCESS OF REVIEW THE FORM 990 INCLUDES A DETAILED REVIEW OF THE FORM AND REQUIRED SCHEDULES BY THE CHIEF FINANCIAL OFFICER. EACH VOTING MEMBER OF THE GOVERNING BODY RECEIVES A COPY OF THE FORM 990 INCLUDING REQUIRED SCHEDULES, AS ULTIMATELY FILED WITH THE IRS, PRIOR TO FILING. FORM 990, PART VI, SECTION B, LINE 12C CONFLICT OF INTEREST POLICY: THE CONFLICT OF INTEREST POLICY IS INCLUDED WITHIN THE BYLAW OF THE ORGANIZATION AND COVERS ALL BOARD OF TRUSTEES. THE POLICY PROVIDES PROCEDURES TO PREVENT THOSE WITH DUALITY OF INTEREST OR POSSIBLE CONFLICTS OF INTEREST FROM PARTICIPATING IN ANY ACTION THAT COULD PERSONALLY BENEFIT THE INDIVIDUAL TRUSTEE. THE CEO AND/OR BOARD COMPLIANCE OFFICER REVIEW ANNUAL WRITTEN AND SIGNED CONFLICT OF INTEREST STATEMENTS THAT PROVIDE ANY DUALITY OF INTEREST OR POSSIBLE CONFLICTS OF INTEREST DISCLOSED BY ALL BOARD OF TRUSTEES. THE INDIVIDUAL TRUSTEE WILL AGAIN DISCLOSE TO THE BOARD WHEN THE INTEREST BECOMES A MATTER OF BOARD ACTION AND RECUES HIMSELF OR HERSELF FROM VOTING ON THE RELATED ISSUE. THE BOARD MEETING MINUTES DOCUMENT THE DISCLOSURE MADE, WHO ABSTAINED FROM VOTING, AND THE QUORUM SITUATION. FORM 990, PART VI, SECTION B, LINE 15 COMPENSATION PROCESS: CEO: THE CEO EVALUATION COMMITTEE, CONSISTING OF FOUR INDEPENDENT AND BOARD CHAIR APPOINTMENT TRUSTEE MEMBERS, EVALUTATES THE PERFORMANCE OF THE CEO ON AN ANNUAL BASIS AND MAKES COMPENSATION-RELATED RECOMMENDATIONS TO THE BOARD PRIOR TO THE CEO'S ANNUAL REVIEW DATE FOR APPROVAL. THE EVALUATION COMMITTEE USES A COMPENSATION CONSULTANT, COMPENSATION SURVEY, AND COMPARATIVE DATA FROM SIMLIAR ORGANIZATION TO DETERMINE THE CEO'S COMPENSATION PACKAGE. ALL DELIBERATION AND DECISIONS ARE DOCUMENTED IN THE EVALUATION COMMITTEE'S MINUTES. OFFICERS AND/OR KEY EMPLOYEES: ANNUAL REVIEWS FOR TOP MANAGEMENT OFFICIALS ARE CONDUCTED BY THE CEO. THE COMPENSATION IS ANNUALLY REVIEWED AND APPROVED BY THE BOARD OF TRUSTEES. FORM 990, PART VI, SECTION C, LINE 19 THE HOSPITAL'S GOVERNING DOCUMENTS, CONFLICT OF INTEREST POLICY, AND FINANCIAL STATEMENTS ARE AVAILABLE TO THE PUBLIC UPON WRITTEN REQUEST AND BOARD OF TRUSTEES APPROVAL. WRITTEN REQUESTS SHOULD BE SENT TO ATTN: JAMES CHILDERS, AT THE ADDRESS LISTED ON PAGE 1 OF THE FORM 990. FORM 990, PART VI, LINE 16B, JOINT VENTURE POLICY: THE ORGANIZATION DOES NOT HAVE A FORMAL WRITTEN POLICY ON EVALUATING PARTICIPATION IN A JOINT VENTURE, HOWEVER, THE ORGANIZATION PERFORMS DUE DILIGENCE AND INVOLVES LEGAL COUNSEL TO REVIEW ANY PARTNERSHIPS ENSURING THAT THE JOINT VENTURE WOULD BE ORGANIZED AND OPERATED IN A MANNER CONSISTENT WITH THE HOSPITAL'S EXEMPT PURPOSE AND STATUS. FORM 990, PART IX, LINE 11G PURCHASED SERVICES: PROGRAM SERVICE EXPENSES 1,288,726. MANAGEMENT AND GENERAL EXPENSES 409,497. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 1,698,223. PROFESSIONAL FEES - MEDICAL: PROGRAM SERVICE EXPENSES 1,567,988. MANAGEMENT AND GENERAL EXPENSES 498,233. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 2,066,221. OTHER FEES: PROGRAM SERVICE EXPENSES 270,676. MANAGEMENT AND GENERAL EXPENSES 86,008. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 356,684. FORM 990, PART XII, LINE 2C, OVERSIGHT OF AUDIT: THE BOARD OF TRUSTEES ASSUMES RESPONSIBILITY FOR OVERSIGHT OF THE AUDIT OF THE FINANCIAL STATEMENTS AND SELECTION OF THE INDEPENDENT ACCOUNTANT; AND NO PROCESSES HAVE CHANGED FROM PRIOR YEAR. GIBSON GENERAL HEALTH FOUNDATION INC 1808 SHERMAN DRIVE PRINCETON IN 47670 350950175 PHILANTHROPIC SUPPORT OF THE HOSPITAL IN 501(C)(3) LINE 12A, I GIBSON GENERAL 1 0 0 1 0 0 0 0 0 0 0 0 0 0 1 1 0 0 0 0 GIBSON GENERAL HEALTH FOUNDATION INC C 142972 ACTUAL AMOUNT