2018-11-15T07:58:16-06:00 2017-12-31 410746749 CLIFTONLARSONALLEN LLP 4505 STEPHEN CIRCLE NW STE 200 CANTON OH 44718 990 2017-01-01 340726081 ASHTABULA COUNTY MEDICAL CENTER ASHT 4409972262 2420 LAKE AVENUE ASHTABULA OH 44004 DON KEPNER VP FINANCE/CFO 4409972262 2018-11-15 1 LISA HILLING P01624111 3304972000 67.137.57.251 2018-11-15 08:42:34 ES P 48FB96C2C824C9A755BE195929E44C7DF1071BED 357AE6C0FD0EA8FFB81A6260A488DEA7FDA04B84 2017 2019-02-21 02:37:17Z MICHAEL HABOWSKI 2420 LAKE AVENUE ASHTABULA OH 44004 156226765 0 6026 X WWW.ACMCHEALTH.ORG X 1902 OH TO PROVIDE QUALITY HEALTHCARE TO POSITIVELY IMPACT THE HEALTH OF OUR COMMUNITY. 16 11 1290 215 303387 0 15207469 7610702 136809625 140354636 1509736 2764107 495613 439872 154022443 151169317 3653000 401515 0 0 72204878 74586467 0 0 0 61742972 67928768 137600850 142916750 16421593 8252567 136482719 148606583 63128741 58806485 73353978 89800098 ASHTABULA COUNTY MEDICAL CENTER PROVIDES QUALITY HEALTHCARE TO POSITIVELY IMPACT THE HEALTH OF OUR COMMUNITY. 0 0 114969116 401515 140354636 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 2017 WE MET OUR MISSION OF MEETING OUR COMMUNITY'S HEALTH CARE NEEDS AS EVIDENCED BY APPROXIMATELY 34,502 EMERGENCY DEPARTMENT VISITS, 6,284 INPATIENT DISCHARGES, 1,344 INPATIENT SURGERIES, 6,604 OUTPATIENT SURGERIES, 377 BIRTHS, AND 72,285 RADIOLOGY PROCEDURES. 114969116 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 1 123 0 1290 1 1 1 0 0 0 0 0 0 0 0 0 X 16 11 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 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 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 JOSHUA MILLER BOARD MEMBER/CCF REPRESENTATIVE 0.30 0.30 X 0 0 0 DANIEL KEATON MD BOARD MEMBER/CHIEF OF STAFF 60.00 0.30 X 174293 0 12920 SATHISH ADIGOPULA MD BOARD MEMBER/VICE-CHIEF OF STAFF 60.00 0.30 X 473221 0 13809 DON KEPNER VP FINANCE/CFO 40.00 0.60 X 0 0 0 JACQUELYN DIFIORE CNO 40.00 0.00 X 0 0 0 ALEXANDER TAICH MD PHYSICIAN 60.00 0.00 X 1114301 0 15679 NATHANIEL S FRANLEY MD PHYSICIAN 60.00 0.00 X 748756 0 13940 LAXMAN R CINGIREDDI MD PHYSICIAN 60.00 0.00 X 820569 0 15597 MICHAEL J PAPSIDERO MD PHYSICIAN 60.00 0.00 X 602429 0 16777 PAZHANIAANDI TIROUNILACANDIN MD PHYSICIAN 60.00 0.00 X 587668 0 10822 4521237 0 99544 80 0 1 0 CLEVELAND CLINIC FOUNDATION PO BOX 931760 CLEVELAND OH 44193 ADMINISTRATIVE AND CLINICAL SERVICES 8508508 ANESTHESIA CONSULTANTS EFT 5168 STANSBURG ROAD SOLON OH 44139 MEDICAL 2655637 ARAMARK CORP 27310 NETWORK PLACE CHICAGO IL 60673 CAFETERIA AND DIETARY SERVICES 2082302 MEDIC MANAGEMENT GROUP INC 275 SPRINGSIDE DRIVE SUITE 100 AKRON OH 44333 PHYSICIAN BILLING 1257145 CLEVELAND CLINIC REFERENCE LAB PO BOX 74222 CLEVELAND OH 44194 MEDICAL 698030 18 7543170 67532 7610702 NET PATIENT SERVICE REVENUE 624100 133310682 133310682 MISC OPERATING REVENUE 624100 6753947 6753947 REBATES AND REFUNDS 624100 290007 290007 140354636 1694830 1694830 136485 0 136485 136485 136485 6126725 5035057 22391 1091668 -22391 1069277 1069277 PREMIER FITNESS 713940 303387 303387 303387 151169317 140354636 303387 2900592 401515 401515 1495185 1226052 269133 58639292 48084219 10555073 2764267 2266699 497568 7596354 6229010 1367344 4091369 3354923 736446 4413230 3618849 794381 228825 187637 41188 67656 55478 12178 11478833 9412643 2066190 461567 378485 83082 871070 714277 156793 1671964 1371010 300954 117499 96349 21150 4120 3378 742 4955750 4955750 4160192 3411357 748835 2400786 1968645 432141 SUPPLIES 19877956 16299923 3578033 BAD DEBT EXPENSE 9826802 9826802 EQUIP REPAIRS & MAINT 4657221 3818921 838300 LICENSES & PERMITS 1858135 1523671 334464 877162 719273 157889 142916750 114969116 27947634 0 16962440 23410920 1580843 1822512 23594231 19275809 1259526 1432789 1882212 1456389 114036701 87593888 24709688 26442813 55923668 62961682 2812827 3009392 7757284 8794277 136482719 148606583 14609973 14629623 169053 112545 346331 22468 48003384 44041849 63128741 58806485 X 73339003 89785796 14975 14302 73353978 89800098 136482719 148606583 X 8252567 5189889 3003664 X 0 1 X 1 0 X 1 2979 2979 0 PART II-B, LINE 1: TOTAL DUES OF $37,078 WERE PAID TO THE OHIO HOSPITAL ASSOCIATION BY ACMC, OF WHICH 4.3%% WERE RELATED TO LOBBYING ACTIVITIES. TOTAL DUES OF $25,650 WERE PAID TO THE CENTER FOR HEALTH AFFAIRS BY ACMC, OF WHICH 5.4% WERE RELATED TO LOBBYING ACTIVITIES. 2518862 2518862 31451327 22707235 8744092 4223783 2958640 1265143 72617466 61928013 10689453 3225263 3225263 26442813 SELF-INSURANCE INVESTMENTS 5701745 DEFERRED COMPENSATION 2875723 DUE FROM AFFLIATES 216809 8794277 RESERVE FOR SELF-INSURANCE LIABILITIES 10487305 DEFERRED COMPENSATION 2875723 ACCRUED PENSION LIABILITY 7601944 DISTRIBUTION PAYABLE TO THE CLEVELAND CLINIC FOUNDATION 4955750 INVESTMENT FROM CLEVELAND CLINIC FOUNDATION 15000000 THIRD-PARTY PAYABLES 3121127 44041849 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 670870 670870 0.00500 22416359 16710605 5705754 0.04290 86949 5849509 0 0.00000 23174178 22560114 6376624 0.04790 5940162 5940162 0.04460 28454 28454 0.00020 259466 259466 0.00190 1515 1515 0.00000 6229597 6229597 0.04670 29403775 22560114 12606221 0.09460 1 9826802 0 32348541 32671756 -323215 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 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: THE ACMC 2016 CHNA IDENTIFIED SIX SIGNIFICANT COMMUNITY HEALTH NEEDS: - ACCESS TO AFFORDABLE HEALTHCARE - CHRONIC DISEASE AND OTHER HEALTH CONDITIONS - ECONOMIC DEVELOPMENT AND COMMUNITY CONDITIONS - HEALTH PROFESSIONS RECRUITMENT - HEALTHCARE FOR THE ELDERLY - WELLNESSASHTABULA COUNTY MEDICAL CENTER HAS A 114-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 BEGINNING IN 2017 AND CONTINUING THROUGH 2019.NEW STRATEGIC INITIATIVES1. ACCESS TO AFFORDABLE HEALTHCARE: IMPROVE ACCESS TO CARE, INCLUDING BOTH PRIMARY AND SPECIALTY CARE BY: A. COLLABORATING WITH COMMUNITY ORGANIZATIONS TO BRING REMOTE AREA MEDICAL TO ASHTABULA COUNTY TO PROVIDE A FREE THREE-DAY HEALTH EVENT, INCLUDING MEDICAL, DENTAL AND VISION SCREENINGSB. CONTINUING TO RECRUIT PRIMARY CARE (FAMILY MEDICINE, INTERNAL MEDICINE, PEDIATRICS, OBSTETRICS & GYNECOLOGY) PHYSICIANS TO THE COMMUNITY AND PLACING OFFICES IN SHORTAGE AREAS.{CORRELATES TO HEALTH PROFESSIONS RECRUITMENT NEED}C. 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.{CORRELATES TO HEALTH PROFESSIONS RECRUITMENT NEED}D. CONTINUING TO COLLABORATE WITH CLEVELAND CLINIC TO PROVIDE SPECIALTY CLINICS FOR SERVICES NOT AVAILABLE IN THE COMMUNITY.E. CONTINUING TO PROVIDE THE ACMC HEALTH EXPRESS FREE SHUTTLE SERVICE.F. CONTINUING TO OFFER ACMC EXPRESS CARE, A LOW-COST, WALK-IN OPTION FOR CARE OF MINOR ILLNESS AND INJURY.2. CHRONIC DISEASE: DECREASE THE PERCENTAGE OF ADULTS WITH HYPERTENSION BY: A. OFFERING FREE BLOOD PRESSURE SCREENINGS AT ACMC EXPRESS CARE LOCATIONS.B. LAUNCHING A COMMUNITY AWARENESS CAMPAIGN DETAILING THE RISKS OF HYPERTENSION AND WAYS TO REDUCE HIGH BLOOD PRESSURE.C. PARTICIPATING IN THE CENTER FOR HEALTH AFFAIR'S 7-COUNTY REGIONAL OBESITY INITIATIVE.3. CHRONIC DISEASE: DECREASE THE PERCENTAGE OF ADULTS WITH PRE-DIABETES AND DIABETES BY: A. EXPLORING THE INCORPORATION OF PRE-DIABETES SCREENING AT ALL PRIMARY CARE APPOINTMENTS.B. LAUNCHING A COMMUNITY AWARENESS CAMPAIGN DETAILING THE RISKS OF DIABETES, HOW TO PREVENT/SLOW ONSET OF DIABETES, AND HOW TO SUCCESSFULLY MANAGE DIABETES TO ENSURE HIGH QUALITY OF LIFE.C. CONTINUING TO COLLABORATE WITH CLEVELAND CLINIC TO OFFER ENDOCRINOLOGY AND PEDIATRIC ENDOCRINOLOGY SPECIALTY CLINICS.D. PARTICIPATING IN THE CENTER FOR HEALTH AFFAIR'S 7-COUNTY REGIONAL OBESITY INITIATIVE.4. CHRONIC DISEASE: INCREASE THE PERCENTAGE OF ADULTS OVER AGE 50 WHO RECEIVE SCREENING FOR COLORECTAL CANCER BY: A. PARTICIPATING IN THE AMERICAN CANCER SOCIETY'S 80% BY 2018 INITIATIVE.B. LAUNCHING A COMMUNITY AWARENESS CAMPAIGN DETAILING THE IMPORTANCE OF REGULAR COLONOSCOPY.5. HEALTHCARE FOR THE ELDERLY: INCREASE MEDICATION COMPLIANCE AND REDUCE UNNECESSARY HOSPITALIZATIONS BY: A. EXPLORING THE CREATION/COORDINATION OF A VOLUNTEER "ADOPT A GRANDPARENT" PROGRAM.6. MATERNAL AND INFANT HEALTH: DECREASE THE PERCENTAGE OF LOW BIRTH WEIGHT BIRTHS BY: A. DECREASING THE INCIDENCE OF WOMEN NOT RECEIVING FIRST TRIMESTER PRE-NATAL CARE BY OFFERING IN-OFFICE NURSE VISITS.B. OFFERING A SERIES OF SMOKING CESSATION CLASSES GEARED SPECIFICALLY TO PREGNANT WOMEN.C. PROVIDING FREE NICOTINE REPLACEMENT PATCHES TO PREGNANT WOMEN UNDER THE CARE OF AN ACMC PHYSICIAN.7. MENTAL HEALTH AND ADDICTION: DECREASE THE NUMBER OF SUICIDES BY: A. EXPLORING THE INCORPORATION OF STANDARDIZED DEPRESSIONS/SUICIDE SCREENING FOR ALL PATIENTS AGE 12 AND OLDER.B. WORKING WITH SCHOOL DISTRICTS TO IMPLEMENT AN SOS SIGNS OF SUICIDE IN MIDDLE AND HIGH SCHOOLS.C. WORKING WITH ASHTABULA COUNTY HEALTH DEPARTMENT ON VARIOUS INITIATIVES THAT RESULT FROM THE ASHTABULA COUNTY NEEDS ASSESSMENT.8. MENTAL HEALTH AND ADDICTION: DECREASE THE PERCENTAGE OF PERSONS AGE 12 AND OLDER WHO HAVE USED OR ARE DEPENDENT ON AN ILLICIT DRUG BY: A. PROVIDING TRAINING TO PROVIDERS ON GUIDELINES FOR PRESCRIBING OPIATES AND USE OF OARRS.B. EXPLORING THE INCORPORATION OF SCREENING FOR DRUG USE AND ABUSE FOR ALL PATIENTS AGE 12 AND OLDER. ONGOING INITIATIVESTHE 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 PARTICIPATE IN VARIOUS ECONOMIC DEVELOPMENT AND COMMUNITY IMPROVEMENT INITIATIVES TO ENHANCE THE STANDARD OF LIVING AND QUALITY OF LIFE FOR ASHTABULA COUNTY RESIDENTS {CORRELATES TO ECONOMIC DEVELOPMENT AND COMMUNITY CONDITIONS}.B. CONTINUE ROBUST PROVIDER RECRUITMENT INITIATIVES TO MEET THE PRIMARY AND SPECIALTY CARE GAPS IN ASHTABULA COUNTY.{CORRELATES TO HEALTH PROFESSIONS RECRUITMENT}C. CONTINUE TO OFFER WELLNESS PROGRAMMING THROUGH THE HOSPITAL-OWNED FITNESS CENTER AND THROUGH COLLABORATIVE INITIATIVES WITH LOCAL BUSINESSES. {CORRELATES TO WELLNESS}D. CONTINUE TO SUPPORT A TOBACCO-FREE ENVIRONMENT THROUGH ACMC'S SMOKE FREE CAMPUS, HIRING POLICIES, AND SMOKING CESSATION PROGRAMS. {CORRELATES TO CHRONIC DISEASE AND OTHER CONDITIONS; WELLNESS}E. CONTINUE TO PROVIDE INPATIENT AND OUTPATIENT MENTAL HEALTH SERVICES, AS WELL AS AN INTENSIVE OUTPATIENT PSYCHIATRY PROGRAM. {CORRELATES TO MENTAL HEALTH AND ADDICTION}F. CONTINUE RELATIONSHIP WITH GLENBEIGH {CORRELATES TO MENTAL HEALTH AND ADDICTION}G. CONTINUE TO PROVIDE FREE HEALTH SCREENINGS AND REFERRAL FOR TREATMENT.{CORRELATES TO ACCESS TO AFFORDABLE HEALTHCARE}H. CONTINUE TO PROVIDE FINANCIAL COUNSELOR SERVICES TO ASSIST PATIENTS IN QUALIFYING FOR MEDICAL ASSISTANCE.{CORRELATES TO ACCESS TO AFFORDABLE HEALTHCARE}I. CONTINUE TO OFFER A CHARITY CARE PROGRAM.{CORRELATES TO ACCESS TO AFFORDABLE HEALTHCARE}PLANNED COLLABORATIONSACMC'S STRATEGY WILL BE IMPLEMENTED, AS APPROPRIATE, WITH COMMUNITY PARTNERS INCLUDING, BUT NOT LIMITED TO:" ASHTABULA COUNTY DEPARTMENT OF HEALTH" ASHTABULA COUNTY COMMISSIONERS" CITY MANAGERS" SCHOOL DISTRICTS" CENTER FOR HEALTH AFFAIRS" CLEVELAND CLINIC" GLENBEIGH" FAITH-BASED ORGANIZATIONS" COMMUNITY-BASED (NON-PROFIT) ORGANIZATIONS" KENT STATE UNIVERSITY AT ASHTABULAASHTABULA 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 ON THE PRIORITIES OUTLINED EARLIER IN THIS DOCUMENT AND WILL NOT ADDRESS THE FOLLOWING NEEDS:DENTAL HEALTH: AS AN ACUTE CARE HOSPITAL, ACMC DOES NOT HAVE THE EXPERTISE TO ADDRESS BASIC DENTAL HEALTH. TRANSPORTATION: OTHER THAN CONTINUING TO OPERATE ACMC HEALTH EXPRESS, A FREE SHUTTLE SERVICE AVAILABLE TO PATIENTS SEEKING CARE AT ANY ACMC LOCATION OR PROVIDER LOCATION, TRANSPORTATION IS A BROADER COMMUNITY ISSUE AND BEYOND THE SCOPE OF THE HOSPITAL.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.PRE-TERM BIRTHS: AS OF THE TIMING OF THIS IMPLEMENTATION STRATEGY, OVER 50% OF BABIES BORN TO WOMEN RESIDING IN ASHTABULA COUNTY ARE NOT DELIVERED AT ACMC. THERE IS LITTLE IMPACT ACMC CAN MAKE FOR PATIENTS NOT UNDER OUR CARE. 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. 5 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 4 - ASHTABULA WOMEN'S HEALTH CENTER 524 W 24TH STREET ASHTABULA OH 44004 WOMEN'S HEALTH CENTER 5 - GASTROENTEROLOGY HEALTH CENTER 2112 LAKE AVENUE ASHTABULA OH 44004 GASTROENTEROLOGY HEALTH CENTER 7 - GENEVA FAMILY HEALTH CENTER 1028 S BROADWAY GENEVA OH 44041 FAMILY HEALTH CENTER 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 $ 9,826,802. 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 2017 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 2017. 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 PHYSICIAN SATISFACTION SURVEY EVERY OTHER YEAR; ONE COMPONENT OF THE SURVEY IS TO OBTAIN PHYSICIAN INPUT INTO WHAT SERVICES/SPECIALTIES ARE NEEDED. ACMC CONDUCTS A MEDICAL STAFF DEVELOPMENT PLAN (APPROXIMATELY EVERY THREE YEARS) IN WHICH COMMUNITY 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. EVERYONE ON THE ADMINISTRATIVE TEAM IS ASSIGNED TO 8-12 PHYSICIANS WITH WHOM THEY HAVE REGULAR CONVERSATIONS ABOUT THEIR PRACTICE NEEDS, COMMUNITY NEEDS, ETC. 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 CONTRACTS WITH A 3RD PARTY VENDOR TO CONDUCT 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, 23.8% MEDICAID, 22.3% COMMERCIAL, 1.5% SELF PAY, 1.7% 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 WOMEN'S HEALTH EVENTS EACH YEAR (HEART AND CANCER) 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 TWICE PER 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 2017 STATE OF THE CLINIC REPORT PUBLISHED BY THE CLEVELAND CLINIC STATED $809 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) 400000 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 174023 0 0 0 270 0 6923 0 5997 0 187213 0 0 0 SATHISH ADIGOPULA MD BOARD MEMBER/VICE-CHIEF OF STAFF 473059 0 0 0 162 0 10800 0 3009 0 487030 0 0 0 ALEXANDER TAICH MD PHYSICIAN 1114139 0 0 0 162 0 10800 0 4879 0 1129980 0 0 0 NATHANIEL S FRANLEY MD PHYSICIAN 628257 0 60000 0 60499 0 10030 0 3910 0 762696 0 0 0 LAXMAN R CINGIREDDI MD PHYSICIAN 820299 0 0 0 270 0 9600 0 5997 0 836166 0 0 0 MICHAEL J PAPSIDERO MD PHYSICIAN 600143 0 0 0 2286 0 10800 0 5977 0 619206 0 0 0 PAZHANIAANDI TIROUNILACANDIN MD PHYSICIAN 587506 0 0 0 162 0 10800 0 22 0 598490 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. EVERY YEAR THE TYPICAL SALARY HAS A 2% MERIT RATE INCREASE. KIMBERLY GIANGOLA FAMILY MEMBER OF JOSEPH GIANGOLA, ACMC TRUSTEE 29668 EMPLOYMENT AGREEMENT WITH ACMC 0 BRITTANY GILBERT FAMILY MEMBER OF PEG CARLO, ACMC TRUSTEE 65924 EMPLOYMENT AGREEMENT WITH ACMC 0 PENNY PALFY FAMILY MEMBER OF SUSAN STOCKER, PH.D., ACMC TRUSTEE 13557 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. EVERY YEAR THE TYPICAL SALARY HAS A 2% MERIT RATE INCREASE. 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 FORM 990, PART XI, LINE 9: EQUITY INCOME IN AFFLIATE 196,565. EFFECT OF RECOGNITION PROVISION AT MEASUREMENT DATE OF PENSION OBLIGATION 2,807,099. 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, 2017. 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 181230 CASH RECEIVED ASHTABULA REGIONAL HOME HEALTH SERVICES Q 195792 CASH RECEIVED ASHTABULA REGIONAL HOME HEALTH SERVICES B 400000 CASH CONTRIBUTED ROCK CREEK MEDICAL CENTER (DBA GLENBEIGH HEALTH SOURCES) Q 915589 CASH RECEIVED ROCK CREEK MEDICAL CENTER (DBA GLENBEIGH HEALTH SOURCES) C 7000000 CASH RECEIVED ASHTABULA COUNTY MEDICAL CENTER FOUNDATION C 543170 CASH RECEIVED