2018-05-15T09:29:11-05:00 2017-06-30 410746749 CLIFTONLARSONALLEN LLP 388 S MAIN STREET SUITE 403 AKRON OH 44311 990 2016-07-01 340714479 GRACE HOSPITAL GRAC 4402043500 2307 WEST 14TH STREET NO 2 CLEVELAND OH 441133698 RAJIVE KHANNA PRESIDENT AND CEO 2164563880 2018-05-14 1 LISA HILLING P01624111 3303760100 2016 2022-09-23 18:48:47Z RAJIVE KHANNA 2307 WEST 14TH STREET NO 2 CLEVELAND OH 441133698 12248215 0 X WWW.GRACEHOSPITAL.ORG X 1910 OH TO PROVIDE SPECIALIZED HEALTH CARE SERVICES FOR THOSE COPING WITH CATASTROPHIC ILLNESS AND INJURY. 11 8 182 8 0 0 454312 404947 16944249 11792667 15312 7467 42051 43134 17455924 12248215 594605 0 0 0 8618832 5680109 0 0 0 9935986 6466109 19149423 12146218 -1693499 101997 17220407 16561783 4573916 3254446 12646491 13307337 X TO SERVE AS A CENTER FOR EXCELLENCE IN THE PROVISION OF SPECIALIZED HEALTH CARE SERVICES AND COMFORT FOR PATIENTS AND FAMILIES COPING WITH CATASTROPHIC ILLNESS AND INJURY. 0 0 9701088 0 11792667 GRACE HOSPITAL IS A NOT-FOR-PROFIT, LONG-TERM ACUTE CARE HOSPITAL (LTACH) LOCATED IN CLEVELAND, OHIO DEDICATED TO PROVIDING PERSONALIZED CARE TO MEET THE NEEDS OF PATIENTS COPING WITH CATASTROPHIC OR CHRONIC INJURY OR ILLNESS REQUIRING EXTENDED HOSPITALIZATION. THE HOSPITAL WAS FOUNDED IN 1910 BY A GROUP OF PHYSICIANS WHO WERE COMMITTED TO MEETING THE HEALTHCARE NEEDS OF THE COMMUNITY. GRACE HOSPITAL HAS CONTINUOUSLY PROVIDED SERVICES FOR ITS PATIENTS. IN 1995, GRACE HOSPITAL EARNED APPROVAL TO BECOME THE FIRST CERTIFIED LONG-TERM ACUTE CARE HOSPITAL IN BOTH THE CITY OF CLEVELAND AND CUYAHOGA COUNTY. THE HOSPITAL PRESENTLY SPONSORS SEVERAL INPATIENT SERVICES INCLUDING COMPLEX MEDICAL, PULMONARY, REHABILITATION, VENTILATOR WEANING, LEFT VENTRICAL ASSIST DEVICE, TRANSPLANT SUPPORT, WOUND CARE, AND NEUROLOGICAL REHABILITATION PROGRAMS. THESE SERVICES ARE PROVIDED AT INPATIENT SATELLITES LOCATED WITHIN SOUTH POINTE AND BEDFORD HOSPITALS. GRACE HOSPITAL IS COMMITTED TO PROVIDING PERSONALIZED HEALTHCARE CHARACTERIZED BY QUALITY, ACCESSIBILITY, EFFICIENCY, AND COST EFFECTIVENESS. THE HOSPITAL IS SENSITIVE TO AGE, CULTURAL, AND ECONOMIC VARIATIONS, AND IS CONTINUOUSLY ASSESSED AND IMPROVED THROUGH A QUALITY MANAGEMENT PROGRAM. GRACE VOLUNTARILY MAINTAINS A CHARITY CARE POLICY THAT PROVIDES CARE TO INDIVIDUALS REGARDLESS OF ABILITY TO PAY. THE HOSPITAL IS ALSO COMMITTED TO EMPLOYING INDIVIDUALS TO MATCH CULTURAL DIVERSITY OF ITS PATIENT POPULATION. GRACE HOSPITAL IS INVOLVED IN MANY COMMUNITY ACTIVITIES, INCLUDING SPECIAL HEALTH-RELATED PRESENTATIONS AND EMPLOYEES WHO SERVE ON THE BOARDS OF OTHER HEALTHCARE AGENCIES. THE BOARD OF DIRECTORS, MEDICAL STAFF, AND MANAGEMENT OF GRACE HOSPITAL ARE COMMITTED TO THE PROVISION OF QUALITY SPECIALTY HEALTHCARE SERVICES AS A LONG-TERM HOSPITAL, AND FULFILLING A LEADERSHIP ROLE IN THE COMMUNITY. DESPITE CHALLENGING ECONOMIC TIMES, GRACE HOSPITAL HAS SUCCESSFULLY CONTINUED ITS ROLE OF COMMUNITY SERVICE AS ORIGINALLY ENVISIONED BY ITS FOUNDERS. 9701088 1 1 0 0 0 0 0 0 0 0 1 1 0 1 1 1 0 1 0 0 0 0 0 0 0 0 1 1 0 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 1 0 0 0 1 45 0 182 1 0 0 0 0 0 0 0 0 0 0 X 11 8 0 0 0 0 1 1 1 1 1 0 0 1 1 1 1 1 1 1 1 0 OH X X MICHELLE HENNIS 2164563896 2307 WEST 14TH STREET 2 CLEVELAND OH 441133698 WILLARD E BARTEL CHAIRPERSON 1.00 1.00 X X 0 0 0 ROBERT A GREVEY VICE CHAIRPERSON 1.00 1.00 X X 0 0 0 REV JOSEPH D MCNULTY SECRETARY 1.00 1.00 X X 0 0 0 JEFFREY L CLOSE TREASURER 1.00 1.00 X X 0 0 0 GERALD L JEPPE DIRECTOR 1.00 1.00 X 0 0 0 NIZAR Z NADER MD DIRECTOR OF MEDICAL STAFF 4.00 1.00 X 47800 0 0 MP PATEL MD DIRECTOR 1.00 1.00 X 0 0 0 JUDITH Z PETERS DIRECTOR 1.00 1.00 X 0 0 0 DEEPAK RAHEJA MD DIRECTOR OF NEUROLOGY 5.00 1.00 X 40575 0 0 RICHARD RYMOND DIRECTOR 1.00 1.00 X 0 0 0 PAUL C VENIZELOS MD MEDICAL DIRECTOR (LAKEWOOD UNIT) 5.00 1.00 X 7304 0 0 RAJIVE KHANNA PRESIDENT & CEO - GRACE HOSPITAL 40.00 1.00 X 194193 0 6941 ROBERT P RANGE PRESIDENT & CEO - GRACE FOUNDATION 20.00 20.00 X 131250 0 0 MICHELLE HENNIS DIRECTOR OF FINANCE 40.00 1.00 X 121145 0 27498 BARBARA J MORAN CNO/COO 40.00 0.00 X 138775 0 346 JOHN H NICKELS MD FORMER DIRECTOR & DIRECTOR OF MEDICAL STAFF 40.00 0.00 X 12218 0 0 693260 0 34785 4 1 1 0 AMN HEALTHCARE INC PO BOX 910738 DALLAS TX 75391 EMPLOYMENT AGENCY 219032 FRESENIUS KABI USA LLC THREE CORPORATE DRIVE LAKE ZURICH IL 60047 MEDICAL DEVICES 183341 MAXIM HEALTHCARE SERVICES INC 12558 COLLECTIONS CENTER DR CHICAGO IL 60693 EMPLOYMENT AGENCY 134346 TREMONT MEDICAL DEVELOPMENT CORPORATION 2307 WEST 14TH STREET CLEVELAND OH 44113 GRACE FOUNDATION PRESIDENT & CEO 131250 4 404947 404947 PATIENT SERVICE REVENUE 624100 10874968 10874968 SPECIALTY HOSPITAL OF LORAIN SERV 624100 667204 667204 GRACE FOUNDATION MANAGEMENT FEE 624100 129535 129535 OTHER PROGRAM SERVICE REVENUE 624100 120960 120960 11792667 7467 7467 27900 0 27900 27900 27900 MISCELLANEOUS INCOME 900099 10734 10734 PARKING FEES 812930 4500 4500 15234 12248215 11792667 0 50601 X 576706 95679 481027 4174448 3804684 369764 549744 451301 98443 379211 311306 67905 97400 97400 24658 24658 3248708 2413575 835133 946023 772105 173918 30689 23470 7219 54742 54742 296351 241869 54482 206604 89074 117530 SUPPLIES-MEDICAL 1147254 1147254 EQUIP RENTAL & MAINT 291599 229089 62510 BAD DEBT EXPENSE 52955 52955 SUPPLIES-GENERAL 38008 13580 24428 31118 405 30713 12146218 9701088 2445130 0 495266 947812 1451979 692937 3249911 1517446 234771 188356 169686 153157 11818050 9534247 1982628 2283803 301494 307181 8859471 9418320 475201 1052771 17220407 16561783 2600599 1588909 1205946 1223066 767371 442471 4573916 3254446 X 3787020 3889017 8859471 9418320 12646491 13307337 17220407 16561783 X 101997 558849 X X 0 1 X 1 0 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 32151 32151 4922509 4252976 669533 145197 141826 3371 5608080 5139445 468635 1110113 1110113 2283803 BENEFICIAL INTEREST IN PERPETUAL TRUSTS 9418320 C 9418320 DUE FROM RELATED ORGANIZATIONS 1052771 1052771 EST SETTLEMENTS TO THIRD PARTIES 442471 442471 X PART X, LINE 2: THE HOSPITAL IS A NONPROFIT CORPORATION AND IS RECOGNIZED AS TAX-EXEMPT PURSUANT TO SECTION 501(C)(3) OF THE INTERNAL REVENUE CODE. THEREFORE, NO PROVISION HAS BEEN MADE FOR FEDERAL OR STATE INCOME TAXES ON THE ACCOMPANYING FINANCIAL STATEMENTS. 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 1 X 1 0 0 2959379 2690853 268526 0.02220 2959379 2690853 268526 0.02220 2959379 2690853 268526 0.02220 1 52955 52955 4856346 4787790 68556 X 1 1 1 6 GRACE HOSPITAL 20000 HARVARD AVENUE CLEVELAND OH 44122 WWW.GRACEHOSPITAL.ORG 1147 X LONG TERM ACUTE CARE GRACE HOSPITAL 1 0 0 1 X X X X X X 14 1 0 0 1 X WWW.GRACEHOSPITAL.ORG 1 14 1 WWW.GRACEHOSPITAL.ORG 0 1 X 100.000000000000 200.000000000000 X X X X 1 1 X 1 X WWW.GRACEHOSPITAL.ORG/BILLING.HTML X WWW.GRACEHOSPITAL.ORG/BILLING.HTML X WWW.GRACEHOSPITAL.ORG/BILLING.HTML X X X X X X X 1 X 0 X X X X 0 X X X 0 0 PART V, SECTION A: GRACE HOSPITAL HAD TWO LOCATIONS DURING THE FISCAL YEAR, AS FOLLOWS:GRACE SOUTH POINTE - 20000 HARVARD AVENUE, CLEVELAND, OH 44122GRACE BEDFORD - 44 BLAINE AVENUE, BEDFORD, OH 44146 GRACE HOSPITAL PART V, SECTION B, LINE 5: SURVEYS WERE SENT TO 2,000 ADULTS IN OUR COMMUNITY. 1,465 COMPLETED SURVEYS WERE RETURNED. IN ADDITION, OPINIONS WERE SOLICITED FROM HEALTH EXPERTS, COMMUNITY LEADERS, STAFF CAREGIVERS, AND PATIENTS WITHIN THE COMMUNITY. GRACE HOSPITAL PART V, SECTION B, LINE 11: THE CHNA IDENTIFIED THE FOLLOWING SIGNIFICANT NEEDS: 1. DIABETES-RELATED EDUCATION AND SUPPORT; 2. VENTILATOR WEANING AND RESULTS; 3. PALLIATIVE CARE AND ADVANCED DIRECTIVES1. PALLIATIVE CARE AND ADVANCED DIRECTIVES:- THE FIRST ACTION STEP - PHYSICIAN COMING ON BOARD- A PALLIATIVE CARE STRATEGIC PLAN IS IN DEVELOPMENT; ACTION STEPS WILL SUPPORT THE DIRECTION OF THIS PLAN- CONTINUE COMMUNITY-BASED EDUCATION EVENTS CONCERNING ADVANCE DIRECTIVES- TRANSPORTABLE PHYSICIAN ORDERS FOR PATIENT PREFERENCES- INITIATE EDUCATION (MC STRATEGY) CONCERNING INPATIENT PALLIATIVE CARE- CONTINUE NURSING EDUCATION CONSORTIUM ON END-OF-LIFE CARE- INITIATE END-OF-LIFE CARE EDUCATION FOR PHYSICIANS- COMMUNITY ACTION STEPS WITH PHYSICIANS THROUGH: - QUARTERLY PROVIDER MEETINGS - BOARD OF GOVERNORS - NEED TO KNOW EMAILS2. DIABETES-RELATED EDUCATION AND SUPPORT- CONTINUE DIABETES MANAGEMENT CLASSES THROUGH THE DIABETES CENTER- CONTINUE TO PROVIDE EDUCATION AND SELF-ASSESSMENT TOOL THROUGH THE WEBSITE3. VENTILATOR WEANING AND RESULTS- PROVIDE FAMILY WITH TRAINING AND ONGOING NEED OF PERSONS WITH PULMONARY DISEASE- VENTILATOR EDUCATION AND TRAINING FOR VENT DEPENDENT PATIENTS- TRAINING AND EDUCATION FOR "TRACH CARE AND SUCTIONING TO CARE GIVERS AND PATIENTS- VENTILATOR SUPPORT GROUPS LED BY PULMONOLOGIST AND CLINICAL PSYCHOLOGY- ONGOING SUPPORT AND EDUCATION THROUGH BETTER BREATHER CLUB GRACE HOSPITAL PART V, SECTION B, LINE 13H: THE FOLLOWING STRUCTURE WILL BE UTILIZED TO DETERMINE THE AMOUNT OF FREE CARE TO BE PROVIDED. HOUSEHOLD INCOME AND THE NUMBER OF PEOPLE LIVING IN THE HOUSEHOLD WILL BE THE TWO MAJOR CRITERIA USED TO DETERMINE IF A PATIENT IS ELIGIBLE FOR FREE CARE. EXTENUATING CIRCUMSTANCES SHOULD BE NOTED AND MAY INCLUDE INFORMATION SUPPLIED TO SUPPORT EXCEPTIONAL SCENARIOS INCLUDING A TERMINAL ILLNESS, DEATH OF A SPOUSE, OR CATASTROPHIC PROBLEMS. GRACE HOSPITAL PART V, SECTION B, LINE 16J: THE POLICY IS ATTACHED TO BILLING INVOICES. GRACE HOSPITAL PART V, SECTION B, LINE 21D: GRACE HOSPITAL OPERATES LONG TERM ACUTE CARE (LTAC) FACILITIES LOCATED ON A FLOOR OF TWO CLEVELAND CLINIC HOSPITALS. DUE TO THE TYPE OF SERVICES PROVIDED, GRACE HOSPITAL DOES NOT PROVIDE CARE FOR EMERGENCY MEDICAL CONDITIONS. IF FULL-SERVICE EMERGENCY ROOM CARE IS NEEDED, THE FACILITIES OF THE CLEVELAND CLINIC ARE AVAILABLE. PART I, LINE 3C: THE FOLLOWING STRUCTURE WILL BE UTILIZED TO DETERMINE THE AMOUNT OF FREE CARE TO BE PROVIDED. HOUSEHOLD INCOME AND THE NUMBER OF PEOPLE LIVING IN THE HOUSEHOLD WILL BE THE TWO MAJOR CRITERIA USED TO DETERMINE IF A PATIENT IS ELIGIBLE FOR FREE CARE. EXTENUATING CIRCUMSTANCES SHOULD BE NOTED AND MAY INCLUDE INFORMATION SUPPLIED TO SUPPORT EXCEPTIONAL SCENARIOS INCLUDING A TERMINAL ILLNESS, DEATH OF A SPOUSE, OR CATASTROPHIC PROBLEMS. PART I, LINE 6A: N/A PART I, LINE 7: THE AMOUNTS REPORTED ON LINE B WERE GENERATED FROM THE MEDICAID COST REPORT FILED FOR FISCAL YEAR 2017 AND THE HOSPITAL'S ACCOUNTING SYSTEM. THE AMOUNTS REPORTED INCLUDE GRACE HOSPITAL'S PROPORTIONATE SHARE FROM SPECIALTY HOSPITAL OF LORAIN. ACUTE CARE HOSPITAL SERVICES RENDERED TO MEDICAID PROGRAM BENEFICIARIES ARE PAID AT PROSPECTIVELY DETERMINED RATES. THESE RATES VARY ACCORDING TO A PATIENT CLASSIFICATION SYSTEM THAT IS BASED ON CLINICAL, DIAGNOSTIC AND OTHER FACTORS. CAPITAL COSTS FOR MEDICAID INPATIENT SERVICES ARE REIMBURSED BASED ON A COST REIMBURSEMENT METHODOLOGY. THE HOSPITAL IS REIMBURSED FOR COST REIMBURSABLE ITEMS AT A TENTATIVE RATE WITH FINAL SETTLEMENT DETERMINED AFTER SUBMISSION OF ANNUAL COST REPORTS AND AUDITS THEREOF BY THE FISCAL INTERMEDIARY. PART I, LINE 7G: N/A 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 $ 52,955. PART II, COMMUNITY BUILDING ACTIVITIES: N/A PART III, LINE 2: THE AMOUNT REPORTED ON LINE 2 REPRESENTS THE PROVISION FOR DOUBTFUL ACCOUNTS REPORTED ON THE 2017 AUDITED FINANCIAL STATEMENTS, PLUS BAD DEBT RECOVERIES, WHICH WERE NETTED AGAINST BAD DEBT EXPENSE AS STATED IN NOTE 2 TO THE AUDITED FINANCIAL STATEMENTS. PART III, LINE 3: THE AMOUNT REPORTED ON LINE 3 REPRESENTS CHARGES WRITTEN OFF FOR SELF-PAY INDIVIDUALS WHO LIKELY WOULD QUALIFY FOR FINANCIAL ASSISTANCE UNDER THE HOSPITAL'S FINANCIAL ASSISTANCE POLICY BUT FOR WHOM INSUFFICIENT INFORMATION WAS OBTAINED TO DETERMINE THEIR ELIGIBILITY. THIS AMOUNT WAS DETERMINED BASED ON REVIEW OF BAD DEBT WRITE-OFFS DURING THE YEAR. PART III, LINE 4: SEE NOTE 2 ON PAGES 13-14 OF THE ATTACHED AUDITED FINANCIAL STATEMENTS FOR INFORMATION ABOUT THE ORGANIZATION'S BAD DEBT EXPENSE. PART III, LINE 8: MEDICARE SHORTFALL IS NOT TREATED AS COMMUNITY BENEFIT. THE AMOUNTS REPORTED WERE GENERATED FROM THE MEDICARE COST REPORT FILED FOR FISCAL YEAR 2017. INPATIENT ACUTE CARE SERVICES AND OUTPATIENT SERVICES RENDERED TO MEDICARE PROGRAM BENEFICIARIES ARE PAID AT PROSPECTIVELY DETERMINED RATES PER DISCHARGE. THESE RATES VARY ACCORDING TO A PATIENT CLASSIFICATION SYSTEM THAT IS BASED ON CLINICAL, DIAGNOSTIC, AND OTHER FACTORS. INPATIENT NONACUTE CARE SERVICES RELATED TO MEDICARE BENEFICIARIES ARE PAID BASED ON A COST REIMBURSEMENT METHODOLOGY. THE HOSPITAL IS REIMBURSED FOR COST REIMBURSABLE ITEMS AT TENTATIVE RATES WITH FINAL SETTLEMENT AFTER SUBMISSION OF ANNUAL COST REPORTS AND AUDITS THEREOF BY THE MEDICARE FISCAL INTERMEDIARY. PART III, LINE 9B: FREE CARE WILL BE EXTENDED TO THOSE WHO QUALIFY FOR THESE REASONS: THE PATIENT IS UNINSURED, THE PATIENT IS NOT ELIGIBLE FOR MEDICAID OR PENDING MEDICAID APPROVAL, THE PATIENT IS DETERMINED TO BE UNABLE TO PAY FOR SERVICES PROVIDED, THE PATIENT IS UNABLE TO ACCEPT AN INSTALLMENT PAYMENT ARRANGEMENT, THE PATIENT IS BELOW 200% OF THE FEDERAL POVERTY GUIDELINES, AND THE PATIENT IS A HARDSHIP CASE AS DESIGNATED BY THE PHYSICIAN AND GRACE HOSPITAL. THE PATIENT WILL NEED TO COMPLETE A CHARITY CARE FORM AND RETURN TO GRACE HOSPITAL FOR DETERMINATION OF FREE CARE. GRACE HOSPITAL STAFF OR ITS BILLING REPRESENTATIVES WILL HELP THE PATIENT COMPLETE THE FORM ON REQUEST. ULTIMATELY, IT IS THE PATIENT'S RESPONSIBILITY TO COMPLETE THE FORM. HE/SHE WILL CONTINUE TO BE FULLY RESPONSIBLE FOR THE BILL UNTIL A DETERMINATION IS MADE. DOCUMENTED PROOF OF INCOME IS REQUIRED. PART VI, LINE 2: THE HOSPITAL PRESENTLY SPONSORS SEVERAL INPATIENT SERVICES INCLUDING COMPLEX MEDICAL, PULMONARY, REHABILITATION, VENTILATOR WEANING, LEFT VENTRICAL ASSIST DEVICE, TRANSPLANT SUPPORT, WOUND CARE, AND NEUROLOGICAL REHABILITATION PROGRAMS. THESE SERVICES ARE PROVIDED AT INPATIENT SATELLITES LOCATED WITHIN BEDFORD AND SOUTH POINTE HOSPITALS. GRACE HOSPITAL IS COMMITTED TO PROVIDING PERSONALIZED HEALTHCARE CHARACTERIZED BY QUALITY, ACCESSIBILITY, EFFICIENCY, AND COST EFFECTIVENESS. THE HOSPITAL IS SENSITIVE TO AGE, CULTURAL, AND ECONOMIC VARIATIONS, AND IS CONTINUOUSLY ASSESSED AND IMPROVED THROUGH A QUALITY MANAGEMENT PROGRAM. GRACE VOLUNTARILY MAINTAINS A CHARITY CARE POLICY THAT PROVIDES CARE TO INDIVIDUALS REGARDLESS OF ABILITY TO PAY. THE HOSPITAL IS ALSO COMMITTED TO EMPLOYING INDIVIDUALS TO MATCH CULTURAL DIVERSITY OF ITS PATIENT POPULATION. GRACE HOSPITAL IS INVOLVED IN MANY COMMUNITY ACTIVITIES, INCLUDING SPECIAL HEALTH-RELATED PRESENTATIONS AND EMPLOYEES WHO SERVE ON THE BOARDS OF OTHER HEALTHCARE AGENCIES. THE BOARD OF DIRECTORS, MEDICAL STAFF, AND MANAGEMENT OF GRACE HOSPITAL ARE COMMITTED TO THE PROVISION OF QUALITY SPECIALTY HEALTHCARE SERVICES AS A LONG-TERM HOSPITAL, AND FULFILLING A LEADERSHIP ROLE IN THE COMMUNITY. DESPITE CHALLENGING ECONOMIC TIMES, GRACE HOSPITAL HAS SUCCESSFULLY CONTINUED ITS ROLE OF COMMUNITY SERVICE AS ORIGINALLY ENVISIONED BY ITS FOUNDERS. PART VI, LINE 3: INFORMATION ABOUT ELIGIBILITY FOR ASSISTANCE UNDER FEDERAL, STATE OR LOCAL GOVERNMENT PROGRAMS IS DESCRIBED ON THE PATIENT'S BILL. THE PATIENT WILL NEED TO COMPLETE A CHARITY CARE FORM AND RETURN TO GRACE FOR DETERMINATION OF FREE CARE. GRACE STAFF OR ITS BILLING REPRESENTATIVES WILL HELP THE PATIENT COMPLETE THE FORM ON REQUEST. PART VI, LINE 4: GRACE HOSPITAL IS A LONG-TERM ACUTE CARE HOSPITAL (LTACH) DEDICATED TO PROVIDING HIGH QUALITY PRIMARY AND SECONDARY HEALTH CARE SERVICES TO MEET THE NEEDS OF LOCAL COMMUNITIES IN NORTHEAST OHIO. PART VI, LINE 5: GRACE HOSPITAL PROMOTES HEALTH, WELLNESS AND ECONOMIC DEVELOPMENT IN THE TREMONT, OHIO AREA. THIS IS THE GEOGRAPHIC AREA THE HOSPITAL HAS HISTORICALLY SERVED. THE FACILITY ON WEST 14TH STREET INCLUDES OUTPATIENT, INPATIENT, AND DIAGNOSTIC AND REHABILITATIVE CARE PROGRAMS DIRECTED TOWARD THE HEALTH AND WELLNESS NEEDS OF THE ADULT POPULATION. PART VI, LINE 6: N/A PART VI, LINE 7 N/A X 0 0 0 0 0 0 0 0 0 RAJIVE KHANNA PRESIDENT & CEO - GRACE HOSPITAL 194193 0 0 0 0 0 0 0 6941 0 201134 0 0 0 JOHN H NICKELS MD FORMER DIRECTOR & DIRECTOR OF MEDICAL STAFF 12218 0 0 0 0 0 0 0 0 0 12218 0 0 0 FORM 990, PART VI, SECTION A, LINE 6 THE SOLE MEMBER OF GRACE HOSPITAL IS THE GRACE FOUNDATION FOR HEALTH, WELLNESS & EDUCATION. FORM 990, PART VI, SECTION A, LINE 7A THE BOARD OF DIRECTORS OF GRACE HOSPITAL CONSISTS OF THE INDIVIDUALS ELECTED TO THE BOARD OF DIRECTORS OF THE GRACE FOUNDATION FOR HEALTH, WELLNESS & EDUCATION, THE SOLE MEMBER. FORM 990, PART VI, SECTION A, LINE 7B THE FOLLOWING ACTIONS REQUIRE APPROVAL OF THE SOLE MEMBER: (A) AMENDMENT OR RESTATEMENT OF THE ARTICLES OR CODE OF REGULATIONS; (B) MERGER, CONSOLIDATION, REORGANIZATION OR DISSOLUTION; (C) SALE, LEASE, DISPOSITION, PLEDGE, GIFT OR ENCUMBRANCE OF ANY INTEREST IN REAL OR PERSONAL PROPERTY, EXCEPT IN ACCORDANCE WITH THE ESTABLISHED POLICIES FOR SUCH MATTERS APPROVED FROM TIME TO TIME IN ADVANCE BY THE MEMBER; (D) AGGREGATE BORROWING FOR ANY ONE YEAR PERIOD IN EXCESS OF $250,000; (E) THE FORMULATION OF AN INITIAL OR ANY CHANGE IN ANY SUBSEQUENT, FORMAL OR INFORMAL STATEMENT OF GRACE HOSPITAL'S PURPOSES OR OBJECTIVES; (F) THE APPROVAL OR ADOPTION OF THE ANNUAL AND ANY SPECIAL OPERATING AND CAPITAL BUDGETS; (G) ANY EXPENDITURE OF A NATURE THAT WAS NOT ANTICIPATED OR REFLECTED IN A BUDGET APPROVED IN ADVANCE OF SUCH EXPENDITURE BY THE MEMBER AND ANY EXPENDITURE THAT EITHER SINGLY OR WHEN AGGREGATED WITH ALL OTHER SIMILAR AMOUNTS THROUGHOUT THE FISCAL YEAR EXCEEDS 10 PERCENT OF THE AMOUNT BUDGETED FOR SUCH EXPENDITURE OR CLASS OF EXPENDITURES PURSUANT TO A BUDGET APPROVED IN ADVANCE OF SUCH EXPENDITURE BY THE MEMBER; (H) ANY EXPENDITURE OF THE PRINCIPAL OF OR INCOME FROM ANY FUND OR FUNDS IN ANY MANNER THAT IS INCONSISTENT WITH ANY RESTRICTIONS IMPOSED ON SUCH FUND OR FUNDS BY DONORS, BY THE MEMBER, OR BY THE BOARD OF DIRECTORS; (I) ANY ARRANGEMENT OR THE TERMINATION OF ANY SUCH ARRANGEMENT WITH ANY BANK, TRUST COMPANY, BROKERAGE FIRM, INVESTMENT ADVISOR OR SIMILAR INSTITUTION TO MANAGE THE ASSETS AND INVESTMENT OF THE ASSETS OF GRACE HOSPITAL; AND (J) THE APPOINTMENT OF AN INDEPENDENT AUDITOR. FORM 990, PART VI, SECTION B, LINE 11B THE HOSPITAL CONTRACTED WITH AN OUTSIDE ACCOUNTING FIRM FOR THE PREPARATION OF THE FORM 990. THE HOSPITAL PROVIDED MATERIAL BASED ON REQUESTS FROM THE ACCOUNTING FIRM. MOST OF THE INFORMATION WAS PROVIDED BY THE DIRECTOR OF FINANCE. THE FINAL FORM WAS REVIEWED BY THE DIRECTOR OF FINANCE AND THE CEO. A COPY OF THE FORM 990 WAS PROVIDED TO THE BOARD OF DIRECTORS. FORM 990, PART VI, SECTION B, LINE 12C THE ORGANIZATION'S CONFLICT OF INTEREST POLICY APPLICES TO DIRECTORS, OFFICERS, EMPLOYEES, AGENTS, VOLUNTEERS, AND ANY MEDICAL STAFF MEMBERS WITH ADMINISTRATIVE RESPONSIBILITIES. ANY INDIVIDUAL WHO HAS AN INTEREST, DIRECT OR INDIRECT, IN A CONTRACT OR OTHER TRANSACTION THAT IS PRESENTED TO THE BOARD OF DIRECTORS OR A COMMITTEE THEREOF, IS REQUIRED TO GIVE PROMPT, FULL AND FRANK DISCLOSURE OF THEIR INTEREST PRIOR TO THE BODY'S ACTING ON SUCH CONTRACT OR TRANSACTION. THE CONTRACT OR TRANSACTION WILL BE AUTHORIZED, APPROVED OR RATIFIED ONLY UPON A FAVORABLE VOTE OF AT LEAST TWO-THIRDS OF DIRECTORS PRESENT. THE INTERESTED PERSON MAY NOT VOTE ON, USE THEIR PERSONAL INFLUENCE ON, NOR PARTICIPATE (OTHER THAN TO PRESENT FACTUAL INFORMATION OR TO RESPOND TO QUESTIONS) IN THE DISCUSSIONS REGARDING THE CONTRACT OR TRANSACTION. THE BOARD MEMBERS COMPLETED CONFLICT OF INTEREST STATEMENTS IN OCTOBER 2016. FORM 990, PART VI, SECTION B, LINE 15 THE COMPENSATION OF THE ORGANIZATION'S CEO IS DETERMINED BY THE BOARD OF DIRECTORS. THE CEO RECEIVES SALARY COMPARABILITY INFORMATION FROM MODERN HEALTHCARE AND CLEVELAND MAGAZINE. SINCE GRACE IS A SMALL HOSPITAL, THE SALARIES IN EFFECT AT GRACE ARE ALWAYS BELOW THE OTHER HOSPITALS IN THE AREA. SALARY ADJUSTMENTS ARE RECEIVED WHEN THE HOSPITAL PROVIDES A COST OF LIVING ADJUSTMENT TO ALL STAFF OR WHEN THERE IS A CHANGE IN THE EMPLOYEE'S RESPONSIBILITIES. FORM 990, PART VI, SECTION C, LINE 19 THE ORGANIZATION MAKES ITS GOVERNING DOCUMENTS, CONFLICT OF INTEREST POLICY, AND FINANCIAL STATEMENTS AVAILABLE TO THE PUBLIC UPON REQUEST. FORM 990, PART IX, LINE 11G OTHER FEES: PROGRAM SERVICE EXPENSES 0. MANAGEMENT AND GENERAL EXPENSES 835,133. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 835,133. MEDICAL SERVICES: PROGRAM SERVICE EXPENSES 2,413,575. MANAGEMENT AND GENERAL EXPENSES 0. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 2,413,575. FORM 990, PART XI, LINE 9: CHANGE IN VALUE OF BENEFICIAL INTEREST IN PERPETUAL TRUSTS 558,849. FORM 990, PART XII, LINE 2C THE ORGANIZATION HAS NOT CHANGED ITS OVERSIGHT OR THE SELECTION PROCESS DURING THE TAX YEAR. THE GRACE FOUNDATION FOR HEALTH WELLNESS & EDUCATION 2307 WEST 14TH STREET 2 CLEVELAND OH 441133698 273418360 SUPPORTING ORGANIZATION OH 501(C)(3) LINE 12C, III-FI N/A 0 SPECIALTY HOSPITAL OF LORAIN 254 CLEVELAND AVENUE AMHERST OH 44001 341902731 HOSPITAL OH 501(C)(3) LINE 3 N/A 0 THE GRACE CENTER PROPERTY LLC 2307 WEST 14TH STREET 2 CLEVELAND OH 441133698 473431477 REAL ESTATE OH N/A GRACE CENTER PROPERTY HOLDING LLC 2307 WEST 14TH STREET 2 CLEVELAND OH 441133698 473494723 HOLDING COMPANY OH N/A C 0 0 0 0 1 0 0 0 0 0 0 0 0 0 1 1 0 0 0 0