2018-08-15T10:54:04-05:00 2017-09-30 550526247 WILSON KOZICKI & GWYNN PLLC 32 TWENTIETH STREET SUITE 300 WHEELING WV 26003 990 2016-10-01 340714643 BELMONT COMMUNITY HOSPITAL BELM 7406711200 4697 HARRISON STREET BELLAIRE OH 43906 JAMES B MURDY CFO 3042433681 2018-08-09 DENNIS A KOZICKI P00366642 3042322280 2018-08-09 2016 2022-09-23 18:48:47Z JAMES B MURDY ONE MEDICAL PARK WHEELING WV 26003 22494266 0 X WWW.WHEELINGHOSPITAL.ORG X 1903 OH TO PROVIDE NEEDED CARE TO THE COMMUNITY REGARDLESS OF AN INDIVIDUAL'S ABILITY TO PAY. 6 4 232 10 2605840 0 459922 157859 19911269 18812039 88298 91100 3680860 3373374 24140349 22434372 0 0 0 0 11352781 12592824 0 0 0 14909618 14833313 26262399 27426137 -2122050 -4991765 13465105 11994999 6753047 6293780 6712058 5701219 X BELMONT COMMUNITY HOSPITAL PROVIDES QUALITY MEDICAL HEALTHCARE TO PATIENTS FROM BELMONT COUNTY AND SURROUNDING COMMUNITIES REGARDLESS OF RACE, CREED, SEX, SEXUAL ORIENTATION, NATIONAL ORIGIN, HANDICAP, AGE OR ABILITY TO PAY. ALTHOUGH REIMBURSEMENT FOR SERVICES RENDERED IS CRITICAL TO THE OPERATIONS AND STABILITY OF THE HOSPITAL, IT IS RECOGNIZED THAT NOT ALL INDIVIDUALS POSSESS THE ABILITY TO PAY FOR ESSENTIAL MEDICAL SERVICES, AND OUR MISSION IS TO SERVE THE COMMUNITY WITH RESPECT TO PROVIDING HEALTHCARE EDUCATION. THEREFORE, IN KEEPING WITH BELMONT COMMUNITY HOSPITAL'S COMMITMENT TO SERVE ALL MEMBERS OF ITS COMMUNITY, FREE CARE OR SUBSIDIZED CARE, CARE PROVIDED TO PERSONS COVERED BY GOVERNMENT PROGRAMS AT OR BELOW COST, AND HEALTH ACTIVITIES AND PROGRAMS TO SUPPORT THE COMMUNITY WILL BE CONSIDERED WHERE THE NEED AND/OR INDIVIDUAL'S INABILITY TO PAY COEXIST. 0 0 26079595 18812039 BELMONT COMMUNITY HOSPITAL SERVED 616 INPATIENTS AND 84,728 OUTPATIENTS DURING THE PERIOD OCTOBER 1, 2016 THROUGH SEPTEMBER 30, 2017. 26079595 1 0 0 1 0 0 0 0 0 1 1 0 1 0 0 1 0 1 0 0 1 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 41 0 1 232 1 1 1 0 0 0 0 0 0 0 X 6 4 0 0 0 0 0 0 0 1 1 0 0 1 1 1 1 1 1 1 1 0 OH X JAMES B MURDY CFO 3042433681 ONE MEDICAL PARK WHEELING WV 26003 X ROBERT A BITTENGLE TRUSTEE 1.00 X 0 0 0 NELLIE T MAGYAR TRUSTEE 1.00 X 0 0 0 JEFFREY A PATEY TRUSTEE/CHIEF OF STAFF 41.00 X 0 248402 24275 BRUCE A ARCHER TRUSTEE 1.00 40.00 X 0 137692 34647 C GARY HILL PRESIDENT 1.00 X 0 0 0 RICHARD M POLINSKY VICE PRESIDENT/ SECRETARY/ TREASURER 1.00 X 0 0 0 JAMES B MURDY CHIEF FINANCIAL OFFICER 4.00 56.00 X 0 325355 47204 JOHN DEBLASIS ADMINISTRATOR 20.00 40.00 X 0 181957 22187 MARWAN YANES PHYSICIAN 40.00 X 211012 0 10798 SHASHI GUPTA PHYSICIAN 40.00 X 242792 0 23407 DANIEL B JONES PHYSICIAN 40.00 X 335096 0 23869 GEORGE CHOLAK PHYSICIAN 40.00 X 281003 0 1488 MAHESHWAR MUSUNURI PHYSICIAN 40.00 X 237893 0 28523 1307796 893406 216398 15 0 1 0 DEREK H ANDREINI MD 4697 HARRISON STREET BELLAIRE OH 43906 PHYSICIAN SERVICES 218125 QUEST DIAGNOSTICS 2249 COLLECTION CENTER DRIVE CHICAGO IL 60693 LAB TESTING 167941 NEUROBEHAVIORAL MEDICINE CONSULTANTS LLC 302 W MAIN STREET ST CLAIRSVILLE OH 43950 MEDICAL SERVICES 163800 SUNNYSIDE CLEANING SERVICE LLC 198A MAIN STREET RAYLAND OH 43943 CLEANING SERVICES 134788 PHYSICIAN PROVIDERS INC 4485 TENCH ROAD SUITE 2320 SUWANEE GA 30024 PHYSICIANS 111848 5 157859 157859 GROSS PATIENT REVENUE 623990 51786513 51786513 CHARITY CARE 623990 -485091 -485091 BAD DEBT 623990 -1132547 -1132547 CONTRACTUAL ALLOWANCE 623990 -31356836 -31356836 18812039 92243 92243 145593 58741 86852 86852 86852 10 1153 -1143 -1143 -1143 OUTPATIENT PHARMACY 446110 2605840 2605840 OTHER 624210 608265 608265 CONVENIENCE 900099 72417 72417 3286522 22434372 18812039 2605840 858634 9910480 9862188 48292 43616 43409 207 1958624 1949325 9299 680104 676727 3377 59870 59870 53350 53350 839 839 4985816 4963566 22250 1083722 1083722 20885 1370 19515 27169 27169 842417 842417 556171 556171 PURCHASED SERVICES 6225895 5313009 912886 OTHER EXPENSES 660019 462581 197438 MEDICAL SERVICES 259800 259800 DUES, BOOKS, SUBSCRIPTI 57360 38141 19219 27426137 26079595 1346542 0 646642 1157830 105098 105519 2453924 1862144 708317 591743 598678 143162 23867335 19262523 4504387 4604812 3211619 3192546 1236440 337243 13465105 11994999 6645468 6247928 107579 45852 6753047 6293780 X 3495139 2503374 68038 68416 3148881 3129429 6712058 5701219 13465105 11994999 X -4991765 3980926 X X 0 1 X 1 0 X 0 0 0 0 0 0 0 0 1 839 839 0 Part II-B, Line 1: BELMONT COMMUNITY HOSPITAL IS A MEMBER OF THE OHIO HOSPITAL ASSOCIATION AND PAYS ANNUAL DUES. LOBBYING EXPENSES REPRESENT THE PORTION OF THE DUES PAID TO NATIONAL AND STATE HOSPITAL ASSOCIATIONS THAT ARE SPECIFICALLY ALLOCABLE TO LOBBYING. BELMONT COMMUNITY HOSPITAL DOES NOT PARTICIPATE IN OR INTERVENE IN (INCLUDING PUBLISHING OR DISTRIBUTING OF STATEMENTS) ANY POLITICAL CAMPAIGN ON BEHALF OF (OR IN OPPOSITION TO) ANY CANDIDATE FOR PUBLIC OFFICE. FOR 2017, THE PERCENTAGE OF OHA DUES RELATED TO LOBBYING ACTIVITIES IS 4.3%. 0 3148881 -19452 3129429 2463784 685097 3148881 1973170 490614 2463784 1532203 512811 71844 1973170 1603404 -16205 54996 1532203 1.00000 1 0 274164 274164 6550089 5228352 1321737 16409912 13630750 2779162 633170 403421 229749 4604812 DORIS C NARDELLA TRUST 63117 F MELLOTT TRUST 3129429 F 3192546 X Part V, Line 4: THE INCOME FROM THE ENDOWMENT FUND MUST BE USED FOR THE UPKEEP AND MAINTENANCE OF THE HOSPITAL. Part X, Line 2: FROM THE ATTACHED CONSOLIDATED AUDITED FINANCIAL STATEMENTS OF WHEELING HOSPITAL, INC. AND SUBSIDIARIES. INCOME TAXES- THE HOSPITAL, CCC, BELMONT HOSPITAL, THE FOUNDATION, WP, WHS, HCH, AND HCH FOUNDATION ALL QUALIFY AS TAX EXEMPT ORGANIZATIONS UNDER 501 C (3) OF THE US INTERNAL REVENUE CODE. WHH II IS TREATED AS A DISREGARDED ENTITY OF THE HOSPITAL. MFLTD IS A FOREIGN ENTITY, INCORPORATED IN THE CAYMAN ISLANDS. THE EFFECT OF INCOME TAXES ON MFLTD IN THE ACCOMPANYING CONSOLIDATED FINANCIAL STATEMENTS IS NOT MATERIAL. THE HOSPITAL DOES NOT HAVE ANY MATERIAL UNCERTAIN TAX POSITIONS AS OF SEPTEMBER 30, 2017 AND 2016. Central America and the Caribbean - Antigua & Barbuda, Aruba, Bahamas, 0 2 PROGRAM SERVICES CAPTIVE INSURANCE COMPANY 349606 0 2 0 0 0 2 349606 0 349606 0 0 0 0 0 0 Part I, line 3: ACCRUAL 1 1 1 X 1 X 1 1 0 0 112127 112127 0.00410 5529270 2724752 2804518 0.10230 5641397 2724752 2916645 0.10640 3197 3197 0.00010 3197 3197 0.00010 5644594 2724752 2919842 0.10650 1 530372 2497 3165608 5109471 -1943863 X 1 1 1 1 BELMONT COMMUNITY HOSPITAL 4697 HARRISON STREET BELLAIRE OH 43906 X X X BELMONT COMMUNITY HOSPITAL 1 0 0 1 X X X X X X X X X 15 1 0 0 1 X WWW.WHEELINGHOSPITAL.ORG X 1 16 0 1 0 1 X 200.000000000000 400.000000000000 X X X X 1 1 X X X X 1 X WWW.WHEELINGHOSPITAL.ORG X WWW.WHEELINGHOSPITAL.ORG X WWW.WHEELINGHOSPITAL.ORG X X X X X 1 X 0 X X X 1 X 0 0 BELMONT COMMUNITY HOSPITAL Part V, Section B, Line 5: INTERVIEWS WERE CONDUCTED OVER A THREE DAY PERIOD IN LATE AUGUST AND THE BEGINNING OF SEPTEMBER 2016 WITH SELECTED STAKEHOLDERS FROM THE WHEELING SERVICE AREA TO DISCUSS THE COMMUNITY HEALTH NEEDS IN THE WHEELING SERVICE AREA. THE FOLLOWING IDEAS WERE DISCUSSED:-POPULATION AND ECONOMIC TRENDS IN BOTH THE PRIMARY AND SECONDARY SERVICE AREAS AND FUTURE EXPECTATIONS-CURRENT PERCEPTIONS ABOUT OVERALL HEALTH CARE IN THE SERVICE AREA INCLUDING WHEELING HOSPITAL'S HEALTH CARE-WHEELING HOSPITAL'S CURRENT OPERATIONS AND THE EXTENT TO WHICH THESE SERVICES ARE MEETING COMMUNITY NEEDS-THE QUALITY AND ACCESS OF PRIMARY CARE SERVICES, EMERGENCY SERVICES, INPATIENT SERVICES, LONG TERM CARE SERVICES AND PUBLIC HEALTH SERVICES IN THE SERVICE AREA-WHEELING HOSPITAL'S POSSIBLE ROLES FOR MEETING FUTURE HEALTH CARE NEEDS FOR COMMUNITY HEALTH SERVICES-POTENTIAL FOR SUCCESS IN EXPANDING SERVICES AT WHEELING HOSPITAL AND THE CHALLENGES FACED IN EXPANDING SERVICES IN THE AREAA VARIETY OF VARIOUS COMMUNITY REPRESENTATIVES WERE INTERVIEWED, INCLUDING THE DIRECTOR OF NURSING FROM BELMONT COMMUNITY HOSPITAL, THE WHEELING HOSPITAL DIRECTOR OF FAMILY MEDICINE, THE WHEELING HEALTH DEPARTMENT'S DEPUTY HEALTH COMMISSIONER, A LOCAL CATHOLIC CHARITIES' REPRESENTATIVE, AND THE ADMINISTRATOR OF BISHOP J. HODGES CONTINUOUS CARE CENTER. THESE INDIVIDUALS WERE CHOSEN BECAUSE THEY PROVIDED A RANGE OF PERSPECTIVES ON THE STATE OF THE COMMUNITY AND HEALTH CARE, AS WELL AS PROVIDING DIVERSIFIED BACKGROUNDS. ADDITIONALLY, A MONTH LONG ONLINE SURVEY WAS CONDUCTED BY THE HOSPITAL IN ORDER TO GATHER INFORMATION FROM RECENT PATIENTS AND/OR THEIR FAMILY MEMBERS. THEY WERE ASKED TO RATE THEIR EXPERIENCE AS WELL AS COMMENT ON EXISTING OR NEEDED SERVICES. BELMONT COMMUNITY HOSPITAL Part V, Section B, Line 11: BELMONT COMMUNITY HOSPITAL IS A SMALL FACILITY WITH LIMITED FINANCIAL RESOURCES AND, AS SUCH, IS NOT FINANCIALLY CAPABLE OF HIRING IN EVERY AREA OF MEDICAL PRACTICE LISTED IN THE CHNA OR ESTABLISHING PROJECTS THAT ADDRESS THE NEEDS FOR THE AREA'S AGING POPULATION. IT SHOULD BE NOTED THAT BELMONT COMMUNITY HOSPITAL COLLABORATES WITH ITS PARENT HOSPITAL, WHEELING HOSPITAL, INC. ON RECRUITING INITIATIVES. THE PARENT HOSPITAL ALSO HAS TAKEN ON FEASIBILITY STUDIES IN RELATION TO THE PROJECTS THAT ADDRESS THE NEED FOR THE AREA'S AGING POPULATION. THE PARENT HOSPITAL IS LOCATED LESS THAN 9 MILES FROM BELMONT COMMUNITY HOSPITAL.WHEELING HOSPITAL, INC. HAS TAKEN ON FEASIBILITY STUDIES IN RELATION TO THE PROJECTS THAT ADDRESS THE NEED FOR ADDITIONAL ASSISTED LIVING AND/OR INDEPENDENT LIVING COMMUNITIES FOR THE AREA'S AGING POPULATION. SIGNIFICANT FURTHER REVIEW AND CONSIDERATION IS REQUIRED BEFORE HOSPITAL MANAGEMENT WILL MAKE A DECISION REGARDING MOVING FORWARD WITH SUCH FACILITIES. THIS REMAINS AN AREA OF FOCUS AND INTEREST AND THE HOSPITAL IS COMMITTED TO EXPLORING OPTIONS IN THIS REGARD. ADDITIONALLY, WHEELING HOSPITAL, INC. IS BUILDING A REPLACEMENT FOR THE BISHOP HODGES CONTINUOUS CARE CENTER (SNF/ICF) FACILITY ON ITS CAMPUS THAT IS EXPECTED TO BE COMPLETED IN THE FALL OF 2018. THIS WILL BE A STATE OF THE ART FACILITY WITH PRIVATE ROOMS AND BATHS, LARGE ROOMS AND A DE-INSTITUTIONALIZED THEME OF DECOR. THE WHEELING HOSPITAL, INC. CHNA DATED SEPTEMBER, 2016 IDENTIFIED MULTIPLE AREAS THAT SHOULD BE THE FOCUS FOR FURTHER SERVICE DEVELOPMENT IN THE COMMUNITY. THE FOLLOWING SUMMARY PRESENTS THOSE FINDINGS AS WELL AS THE PLANS AND ACTIONS FROM FY 2017 FOR IMPLEMENTATION OR, WHEN APPLICABLE, THE REASONS FOR NOT IMPLEMENTING SAME. SEE ATTACHED "BELMONT HOSPITAL CHNA IMPLEMENTATION PLAN" FOR ADDITIONAL DETAILS ON HOW THE HOSPITAL, IN CONJUNCTION WITH RESOURCES FROM ITS PARENT COMPANY, WHEELING HOSPITAL, INC. IS ADDRESSING THE NEEDS IDENTIFIED IN THE CHNA. PART V, LINE 16G IN ADDITION TO PROVIDING THE FULL FAP UPON REQUEST, A SUMMARY IS POSTED IN THE HOSPITAL FACILITY'S EMERGENCY ROOMS AND WAITING ROOMS. ALSO, SIGNAGE AND LITERATURE HAS BEEN DEPLOYED IN POINTS OF THE FACILITY, AND IN PHYSICIAN OFFICES, TO EDUCATE PATIENTS ABOUT THE FAP PROGRAM. Part I, Line 7: THE RATIO FROM WORKSHEET 2 OF THE SCHEDULE H INSTRUCTIONS WAS USED. Part I, Ln 7 Col(f): PART III, LINE 2. NO BAD DEBT EXPENSE WAS INCLUDED ON FORM 990, PART IX, LINE 25, COLUMN (A), AS BAD DEBT WAS REPORTED AS A REDUCTION TO NET PATIENT SERVICE REVENUE. THE PERCENTAGE FROM WORKSHEET 2 WAS USED TO CALCULATE THE AMOUNT OF THE ORGANIZATION'S BAD DEBT EXPENSE AT COST REFLECTED ON LINE 2. THIS RATIO WAS APPLIED TO THE TOTAL BAD DEBT EXPENSE (BAD DEBT WRITE OFF) INCLUDED IN NET PATIENT SERVICES REVENUE. DISCOUNTS TO PATIENT ACCOUNTS ARE RECORDED AS CONTRACTUAL WRITE-OFF'S AND NOT AS BAD DEBT. THEREFORE, THE CALCULATED BAD DEBT EXPENSE DOES NOT INCLUDE ANY PORTION OF PATIENT'S CHARGES THAT WERE DISCOUNTED.PART III, LINE 3. THE ESTIMATED AMOUNT OF BAD DEBT EXPENSE THAT COULD REASONABLY BE ATTRIBUTABLE TO PATIENTS WHO LIKELY WOULD QUALIFY FOR FINANCIAL ASSISTANCE UNDER THE HOSPITAL'S CHARITY CARE POLICY WAS CALCULATED BY APPLYING THE PERCENTAGE OF CHARITY TO GROSS PATIENT REVENUE TO THE TOTAL BAD DEBT EXPENSE AT COST. Part III, Line 4: BELMONT COMMUNITY HOSPITAL DOES NOT HAVE SEPARATE AUDITED FINANCIAL STATEMENTS. HOWEVER, CONSOLIDATED FINANCIAL STATEMENTS ARE PREPARED FOR WHEELING HOSPITAL, INC. (BELMONT COMMUNITY HOSPITAL IS WHOLLY OWNED BY WHEELING HOSPITAL, INC.). THE BAD DEBT FOOTNOTE FROM THE CONSOLIDATED WHEELING HOSPITAL, INC. 9/30/2017 AUDITED FINANCIAL STATEMENT IS AS FOLLOWS:THE BAD DEBT REFLECTED ON THE FINANCIAL STATEMENTS IS THE GROSS AMOUNT OF THE ACCOUNTS DEEMED UNCOLLECTIBLE. THIS WOULD BE FOR ACCOUNTS THAT HAVE HAD NO PAYMENT FOR 60 DAYS AND HAVE HAD A MINIMUM OF STATEMENTS PRODUCED. THEREFORE, THE BAD DEBT AMOUNTS WOULD BE AFTER ANY DISCOUNTS OR PATIENT PAYMENTS HAVE BEEN APPLIED. THE PROVISION FOR BAD DEBTS, WHICH RELATES ENTIRELY TO COMMERCIAL, OTHER AND SELF-PAY PAYERS, IS BASED UPON MANAGEMENT'S ASSESSMENT OF HISTORICAL AND EXPECTED NET COLLECTIONS CONSIDERING BUSINESS AND ECONOMIC CONDITIONS, TRENDS IN HEALTH CARE COVERAGE, AND OTHER COLLECTION INDICATORS. PERIODICALLY THROUGHOUT THE YEAR, MANAGEMENT ASSESSES THE WRITE-OFF EXPERIENCE BY PAYER. THE RESULTS OF THIS REVIEW ARE THEN USED TO MAKE MODIFICATIONS TO THE PROVISION FOR BAD DEBTS TO ESTABLISH AN APPROPRIATE ALLOWANCE FOR UNCOLLECTIBLE ACCOUNTS. THE PROVISION FOR BAD DEBTS AS A PERCENTAGE OF NET PATIENT REVENUES WAS 4.29% AND 2.96% FOR THE YEARS ENDED SEPTEMBER 30, 2017 AND 2016, RESPECTIVELY.PROVISIONS FOR BAD DEBT FOR 2017 AND 2016 INCLUDE: GOVERNMENT AND STATE PROVISION, COMMERCIAL, OTHER, AND SELF PAY AND WERE $16,111,541 AND $10,408,036, RESPECTIVELY. Part III, Line 8: THE COSTS REFLECTED IN LINE 6 ARE THE ALLOWABLE INPATIENT COSTS FROM WORKSHEET D-1 AND ALLOWABLE OUTPATIENT COSTS FROM D, PART V OF THE 12/31/16 CMS COST REPORT. THIS REPORT WAS USED AS BELMONT COMMUNITY HOSPITAL'S COST REPORT IS FILED ON A CALENDAR YEAR BASIS, AND 12/31/16 CMS COST REPORT IS THE CALENDAR YEAR FILING THAT WOULD FALL IN THE FISCAL YEAR REPORTED ON FORM 990. NONE OF THE SHORTFALL ON LINE 7 IS TREATED AS COMMUNITY BENEFIT. DESPITE THE FACT THAT THE PROGRAM SERVES ALL ELDERLY AND DISABLED BENEFICIARIES AND COULD REPRESENT COMMUNITY BENEFIT, IT IS NOT TREATED AS COMMUNITY BENEFIT TO BE CONSISTENT WITH THE PRESENTATION OF THE CONSOLIDATED AUDITED FINANCIAL STATEMENTS. Part III, Line 9b: BELMONT COMMUNITY HOSPITAL'S COLLECTION POLICY HAS BEEN ESTABLISHED TO DEFRAY THE COSTS OF MEDICALLY NECESSARY SERVICES FOR THOSE PATIENTS WHO MEET CERTAIN GUIDELINES AND HAVE NO OTHER MEDICAL FUNDING SOURCES. INPATIENT, OUTPATIENT, EMERGENCY ROOM SERVICES, PROFESSIONAL SERVICES OF EMPLOYED PHYSICIANS AND PRESCRIPTION DRUGS ON AN ACUTE/EMERGENT BASIS ARE ELIGIBLE FOR FINANCIAL ASSISTANCE/CHARITY CARE. THE FINANCIAL ASSISTANCE/CHARITY CARE APPLICATION MUST BE SIGNED BYTHE APPLICANT ATTESTING TO THE TRUTHFULNESS AND ACCURACY OF THE INFORMATION PROVIDED. CERTAIN DENIAL LETTERS ARE REQUIRED IN ORDER TO BE ELIGIBLE FOR CHARITY CARE. ELIGIBILITY IS DETERMINED BY REFERENCING THE FINANCIAL ASSISTANCE/CHARITY CARE MATRIX, WHICH IS BASED ON THE FEDERAL POVERTY GUIDELINES FOR THE MOST CURRENT YEAR AVAILABLE. THOSE APPROVED APPLICANTS WHO ARE AT OR BELOW 200% OF THE FEDERAL POVERTY GUIDELINES AND HAVE PROVIDED THE REQUIRED DOCUMENTATION ARE ELIGIBLE TO RECEIVE CHARITY CARE, AND THOSE WHO ARE FROM 201% TO 400% OF THOSE LIMITS ARE ELIGIBILE FOR DISCOUNTS. IN REGARDS TO COLLECTION PRACTICES FOR PATIENTS WHO ARE ELIGIBLE FOR FINANCIAL ASSISTANCE (I.E. "CHARITY FOR A PORTION OF THEIR BILL") FROM THE HOSPITAL: THE HOSPITAL'S BILLING AND COLLECTION POLICIES NOTE THAT HOSPITAL PERSONNEL ARE TO OBTAIN THE DETAILS OF EACH PATIENT'S FINANCIAL SITUATION AND ASSIST EACH PATIENT BY PROVIDING THEM WITH THE VARIOUS SETTLEMENT OPTIONS THAT THE HOSPITAL MAKES AVAILABLE. FOR PATIENTS WHO ARE FAP-ELIGIBLE FOR A PORTION OF THEIR BILL, THIS GENERALLY MEANS THAT A PATIENT FINANCIAL COUNSELOR WILL ARRANGE A PAYMENT PLAN THAT IS MANAGEABLE FOR THE PATIENT. PART IV. LINE 7 BELMONT COMMUNITY HOSPITAL DOES NOT FILE A COMMUNITY BENEFIT REPORT WITH THE STATE OF OHIO, OR ANY OTHER STATE. Part VI, Line 2: BELMONT COMMUNITY HOSPITAL ENGAGED ARNETT CARBIS TOOTHMAN TO PERFORM A FORMAL NEEDS ASSESSMENT TO ASSESS THE HEALTH CARE NEEDS FOR THE COMMUNITY THAT IT SERVES. THIS ASSESSMENT WAS COMPLETED AND DATED SEPTEMBER 2016. AN IMPLEMENTATION PLAN WAS ESTABLISHED BY BELMONT COMMUNITY IN RESPONSE TO THE CHNA. ONGOING COMMUNITY HEALTH FAIRS, CPR CLASSES, DIABETES EDUCATION AND HEALTHY LIFESTYLE SEMINARS ARE THE PRIMARY METHOD OF GAUGING COMMUNITY HEALTH NEEDS THROUGHOUT THE YEAR. MANY OF THESE PROGRAMS ARE COORDINATED WITH WHEELING HOSPITAL, INC. Part VI, Line 3: INFORMATION IS INCLUDED ON THE BACK OF PATIENT INVOICES REGARDING THE HCAP PROGRAM. SELF PAY ACCOUNTS OVER $500 ARE SCREENED BY THE MEDICAL ADVOCACY SERVICES FOR HEALTHCARE (MASH) SERVICE OFF SITE FOR GOVERNMENT PROGRAM ELIGIBILITY. IN ADDITION, SELF PAY PATIENTS ARE CONTACTED BY THE PATIENT ACCOUNTING DEPARTMENT TO DISCUSS MEANS OF PAYMENT. IF THE PATIENT STATES THAT THEY DO NOT HAVE THE MEANS TO PAY, BCH STAFF REVIEWS OTHER OPTIONS, SUCH AS PAYMENT PLAN, CHARITY OR DISCOUNT. THE HOSPITAL'S FAP (FINANCIAL ASSISTANCE POLICY) IS ALSO INCLUDED ON THE HOSPITAL'S WEBSITE ALONG WITH A COPY OF A FAP APPLICATION AND A PLAIN LANGUAGE SUMMARY OF THE FAP. A PLAIN LANGUAGE SUMMARY OF THE FAP IS ALSO AVAILABLE IN VARIOUS LOCATIONS THROUGHOUT THE HOSPITAL AND NOTICES ARE POSTED IN VARIOUS LOCATIONS WITHIN THE HOSPITAL TO NOTIFY PATIENTS OF THE FAP. Part VI, Line 4: BELMONT COMMUNITY HOSPITAL PREDOMINANTLY SERVICES THE WHEELING METROPOLITAN STATISTICAL AREA. THE PRIMARY SERVICES AREA INCLUDES ONE COUNTY IN THE NORTHERN PANHANDLE OF WEST VIRGINIA (OHIO COUNTY) AND ONE COUNTY IN OHIO (BELMONT COUNTY), WITH A TOTAL POPULATION OF APPROXIMATELY 110,064.THE RACIAL MAKEUP OF THE MSA AS OF THE 2016 CENSUS WAS 93.45% WHITE, 3.85% AFRICAN AMERICAN, 0.65% ASIAN, 0.20% NATIVE AMERICAN, WITH THE REMAINDER FROM OTHER RACES OR A COMBINATION OF TWO OR MORE RACES.THE MEDIAN HOUSEHOLD INCOME FOR 2016 WAS APPROXIMATELY $43,353, WHILE THE MEDIAN HOUSEHOLD INCOME FOR THE UNITED STATES WAS APPROXIMATELY $55,322. THE BELOW POVERTY LEVEL PERCENTAGE FOR 2016 WAS APPROXIMATELY 15.75%, WHILE THE BELOW POVERTY LEVEL PERCENTAGE WAS APPROXIMATELY 12.70% FOR THE UNITED STATES. Part VI, Line 5: A MAJORITY OF THE HOSPITAL'S BOARD MEMBERS ARE RESIDENTS OF THE PRIMARY SERVICE AREA AND ARE NEITHER EMPLOYEES NOR CONTRACTORS OF THE HOSPITAL.IN ADDITION, THE HOSPITAL EXTENDS MEDICAL STAFF PRIVILEGES TO ANY QUALIFIED PHYSICIAN IN THE COMMUNITY. Part VI, Line 6: BELMONT COMMUNITY HOSPITAL IS AN AFFILIATE OF WHEELING HOSPITAL, INC., OFFERING PRIMARY CARE AND SELECTED SPECIALTY SERVICES FOR THE RESIDENTS OF THE UPPER OHIO VALLEY. X X 0 0 0 1 0 0 0 0 0 JEFFREY A PATEY TRUSTEE/CHIEF OF STAFF 0 248300 0 102 0 0 0 1872 0 22403 0 272677 0 0 BRUCE A ARCHER TRUSTEE 0 112591 0 25101 0 0 0 7595 0 27052 0 172339 0 0 JAMES B MURDY CHIEF FINANCIAL OFFICER 0 250253 0 75102 0 0 0 19772 0 27432 0 372559 0 0 JOHN DEBLASIS ADMINISTRATOR 0 156856 0 25101 0 0 0 11486 0 10701 0 204144 0 0 MARWAN YANES PHYSICIAN 210909 0 103 0 0 0 0 0 10798 0 221810 0 0 0 SHASHI GUPTA PHYSICIAN 212146 0 30646 0 0 0 1502 0 21905 0 266199 0 0 0 DANIEL B JONES PHYSICIAN 334994 0 102 0 0 0 0 0 23869 0 358965 0 0 0 GEORGE CHOLAK PHYSICIAN 280901 0 102 0 0 0 0 0 1488 0 282491 0 0 0 MAHESHWAR MUSUNURI PHYSICIAN 173144 0 64749 0 0 0 1307 0 27216 0 266416 0 0 0 Part I, Line 5 MUSUNURI'S INCENTIVES ARE BASED ON NET INCOME. GUPTA'S INCENTIVES ARE BASED ON CASH RECEIPTS. OVERALL PHYSICIAN COMPENSATION WAS DETERMINED TO BE REASONABLE. PART II: THE REPORTABLE COMPENSATION FROM RELATED ORGANIZATIONS FOR JAMES B MURDY IS FOR SERVICES RENDERED AS CFO FOR THE FILING ORGANIZATION AND THE RELATED ORGANIZATION. THE MAJORITY OF HIS TIME IS SPENT AT THE RELATED ORGANIZATION. EXPLANATION: THE REPORTABLE COMPENSATION FROM RELATED ORGANIZATIONS FOR JOHN DEBLASIS IS FOR SERVICES RENDERED AS ADMINISTRATOR FOR THE FILING ORGANIZATION. HIS TIME IS SPENT EVENLY BETWEEN THE FILING ORGANIZATION AND THE RELATED ORGANIZATION. EXPLANATION: THE REPORTABLE COMPENSATION FROM RELATED ORGANIZATION FOR BRUCE ARCHER IS FOR SERVICES RENDERED AS ADMINISTRATOR FOR THE FILING ORGANIZATION AND THE RELATED ORGANIZATION. THE MAJORITY OF HIS TIME IS SPENT AT THE RELATED ORGANIZATION. NONE OF THE WAGES PAID ARE RELATED TO BEING A TRUSTEE ON THE BOARD OF DIRECTORS. Form 990, Part VI, Section B, line 11b AN OUTSIDE CPA FIRM IS HIRED TO REVIEW THE 990, IN ADDITION TO INTERNAL PERSONNEL AND THE EXECUTIVE TEAM PRIOR TO FILING THE RETURN. COPIES OF THE 990 ARE SENT TO ALL BOARD MEMBERS PRIOR TO FILING THE RETURN. Form 990, Part VI, Section B, line 12c ALL MEMBERS OF THE BOARD OF DIRECTORS AND OFFICERS RECEIVE A COPY OF THE CONFLICT OF INTEREST POLICY ANNUALLY. RECIPIENTS ARE ANNUALLY ASKED TO ACKNOWLEDGE THEY HAVE READ THE POLICY, IDENTIFY ANY AREAS OF CONFLICT AND RETURN THE SIGNED DISCLOSURE FORM TO BELMONT COMMUNITY HOSPITAL. RESPONSES ARE REVIEWED AND IDENTIFIED. CONFLICTS ARE REFERRED TO THE BOARD OF DIRECTORS FOR DISCUSSION AND APPROVAL. EMPLOYEES ARE REQUIRED TO COMPLETE A CONFLICT OF INTEREST QUESTIONNAIRE AT HIRING AND WHEN A CHANGE OCCURS THAT MAY BE A CONFLICT OF INTEREST. Form 990, Part VI, Section B, line 15 OFFICERS AND KEY EMPLOYEES COMPENSATION IS REVIEWED BY A BELMONT COMMUNITY HOSPITAL COMMITTEE. THE COMMITTEE REVIEWS NATIONAL, REGIONAL AND LOCAL COMPENSATION SURVEYS. ADDITIONALLY, YEARS OF SERVICE ARE ALSO TAKEN INTO ACCOUNT. Form 990, Part VI, Section C, line 19 GOVERNING DOCUMENTS, CONFLICT OF INTEREST POLICY, AND FINANCIAL STATEMENTS ARE AVAILABLE UPON REQUEST. PART VII, SECTION A, 1A (E) THE REPORTABLE COMPENSATION FROM RELATED ORGANIZATIONS FOR JAMES B MURDY IS FOR SERVICES RENDERED AS CFO FOR THE FILING ORGANIZATION AND THE RELATED ORGANIZATION. THE MAJORITY OF HIS TIME IS SPENT AT THE RELATED ORGANIZATION. THE REPORTABLE COMPENSATION FROM RELATED ORGANIZATIONS FOR JOHN DEBLASIS IS FOR SERVICES RENDERED AS ADMINISTRATOR FOR THE FILING ORGANIZATION AND FOR OTHER SERVICES TO THE RELATED ORGANIZATION. THE REPORTABLE COMPENSATION FROM RELATED ORGANIZATIONS FOR BRUCE ARCHER IS FOR SERVICES RENDERED AS ADMINISTRATOR FOR THE FILING ORGANIZATION AND FOR OTHER SERVICES TO THE RELATED ORGANIZATION. THE MAJORITY OF HIS TIME IS SPENT AT THE RELATED ORGANIZATION. NONE OF THE WAGES PAID ARE RELATED TO BEING A TRUSTEE ON THE BOARD OF DIRECTORS. Form 990, Part XI, line 9: REVALUATION OF PERMANENTLY RESTRICTED FOR OTHER-THAN-TEMPORARY IMPAIRMENT -19,452. TEMPORARILY RESTRICTED CONTRIBUTIONS 378. FORGIVENESS OF DEBT 4,000,000. FORM 990, PART XII, LINE 2C: THE PROCESS HAS NOT CHANGED. SCHEDULE F, PART I, LINE 3: MOUNTAINEER FREEDOM, LTD SELLS INSURANCE PREMIUMS TO BELMONT COMMUNITY HOSPITAL. MOUNTAINEER FREEDOM, LTD IS SOLEY OWNED BY THE PARENT COMPANY, WHEELING HOSPITAL. BELMONT COMMUNITY HOSPITAL DOES NOT HAVE ANY DIRECT OWNERSHIP IN MOUNTAINEER FREEDOM, LTD. WHEELING HOSPITAL INC ONE MEDICAL PARK WHEELING WV 26003 550357057 HOSPITAL WV 501C(3) 3 0 BELMONT COMMUNITY HOSPITAL AUXILIARY 4697 HARRISON STREET BELLAIRE OH 43906 346567473 SUPPORT FOR HOSPITAL OH 501C(3) 10 0 THE MEDICAL PARK FOUNDATION ONE MEDICAL PARK WHEELING WV 26003 550744690 CHURCH WV 501C(3) 1 WHEELING HOSPITAL INC 1 HARRISON COMMUNITY HOSPITAL 951 EAST MARKET STREET CADIZ OH 43907 341571750 HOSPITAL OH 501C(3) 3 WHEELING HOSPITAL INC 1 WH HOLDINGS II LLC ONE MEDICAL PARK WHEELING WV 26003 273193246 PURCHASE REAL ESTATE WV 501C(3) 10 WHEELING HOSPITAL INC 1 MOUNTAINEER FREEDOM LIMITED ONE MEDICAL PARK WHEELING WV 26003 981217988 CAPTIVE INSURANCE COMPANY CJ WHEELING HOSPITAL INC C 1 WHEELING HOLDINGS I LLC ONE MEDICAL PARK WHEELING WV 26003 273193207 PURCHASE REAL ESTATE WV WHEELING HOSPITAL INC C 1 0 0 0 0 1 0 0 0 1 1 1 1 1 1 1 1 1 1 1 WHEELING HOSPITAL INC K 105577 ACTUAL AMOUNT WHEELING HOSPITAL INC M 421053 ACTUAL AMOUNT WHEELING HOSPITAL INC O 1052175 ACTUAL AMOUNT WHEELING HOSPITAL INC P 1520746 ACTUAL AMOUNT SCHEDULE R SEE NOTES TO THE CONSOLIDATED FINANCIAL STATEMENTS (FOOTNOTE 1. CORPORATE ORGANIZATION) FROM THE ATTACHED CONSOLIDATED AUDITED FINANCIAL STATEMENTS OF WHEELING HOSPITAL, INC. AND SUBSIDIARIES.