2018-11-01T13:38:10-05:00 2017-12-31 351178661 BLUE & CO LLC 9200 WORTHINGTON RD STE 200 WESTERVILLE OH 43082 990 2017-01-01 340719172 BARNESVILLE HOSPITAL ASSOCIATION INC DBA BARNESVILLE HOSPITAL BARN 7404253941 639 W MAIN STREEET BARNESVILLE OH 43713 WILLIE COOPER-LOHR CFO 7404253941 2018-11-01 1 MATTHEW DASTA P00544683 6148852583 2018-11-01 38.109.186.2 2018-11-01 07:51:32 ED P DA39A3EE5E6B4B0D3255BFEF95601890AFD80709 CBCE996F475CA3740CE88356C52AB1B9FF3D8150 2017 2019-02-21 02:37:17Z WILLIE COOPER-LOHR 639 W MAIN STREEET BARNESVILLE OH 43713 19154456 0 X WWW.BARNESVILLEHOSPITAL.COM X 1940 OH WE SERVICE THE HEALTH NEEDS OF THE COMMUNITY AND SURROUNDING COUNTIES. OUR COUNTY TO THE SOUTH OF US DOES NOT HAVE A HOSPITAL. THE COMMUNITY IS SERVICED WITH A 24 HOUR EMERGENCY DEPARTMENT, ACUTE INPATIENT SERVICES ALONG WITH SWING BED TO HELP THEM REMAIN CLOSE TO THEIR FAMILIES. WE ALSO HAVE A FULL SERVICE OUTPATIENT SEVICE. 14 12 305 158 0 0 515215 864698 18572198 17920246 76341 52575 1299073 316937 20462827 19154456 0 0 0 0 10922076 11685809 0 0 0 8073709 7785337 18995785 19471146 1467042 -316690 14403478 13925055 6634906 7474436 7768572 6450619 X BARNESVILLE HOSPITAL ASSOCIATION, INC. OPERATES IN A MANNER CONSISTENT WITH THE REQUIREMENTS OF REV RUL 69-545, THROUGH IT'S PROVISION OF HEALTH CARE SERVICES TO THE COMMUNITY, REGARDLESS OF ABILITY TO PAY. OUR MISSION IS TO IMPROVE THE COMMUNITY'S HEALTH THROUGH THE EFFICIENT PROVISION, COORDINATION AND INTEGRATION OF QUALITY HEALTH SERVICES, HEALTH EDUCATION AND RESEARCH. WE ALSO PROVIDE COMPASSIONATE, QUALITY HEALTH SERVICES ACCORDING TO THE PHYSICAL, SPIRITUAL, PHYCHOLOGICAL, SOCIAL, RELIGIOUS, ENVIRONMENTAL AND ECONOMIC NEEDS OF OUR COMMUNITIES. 0 0 17203447 17920246 IN 2017 BARNESVILLE HOSPITAL PROVIDED CARE FOR 612 INPATIENT ADMISSIONS RESULTING IN 2,437 PATIENT DAYS. WE ALSO PROVIDED 24,522 OUTPATIENT VISITS PLUS 7,712 EMERGENCY ROOM VISITS. BARNESVILLE HOSPITAL IS A CRITICAL ACCESS HOSPITAL AND PROVIDES EXTENSIVE INPATIENT AND OUTPATIENT CARE FOR MEMBERS OF THE COMMUNITY REGARDLESS OF THEIR ABILITY TO PAY. 17203447 1 1 0 1 0 0 0 0 0 0 1 0 1 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 1 0 1 42 0 1 305 1 0 0 0 0 0 0 0 0 0 0 X 14 12 0 0 0 0 0 0 0 1 1 0 0 1 1 1 1 1 1 1 1 0 OH X WILLIE COOPER-LOHR 7404253941 639 W MAIN STREEET BARNESVILLE OH 43713 C J BRADFIELD TREASURER 1.00 X X 0 0 0 R MELVIN MILBURN PRESIDENT 1.00 X X 0 0 0 DAVID HILLIARD DO BOARD MEMBER 40.00 X 169826 0 29104 KENT GALLAGHER VICE PRESIDENT 1.00 X X 0 0 0 KENNETH PHILLIPS BOARD MEMBER 1.00 X 0 0 0 P K SOURI MD BOARD MEMBER 1.00 40.00 X 0 220014 18632 WILLIAM E FRANK JR BOARD MEMBER 1.00 X 0 0 0 ANGELA HANNAHS BOARD MEMBER 1.00 X 0 0 0 CHARLES BARDALL BOARD MEMBER 1.00 X 0 0 0 TOM JOHNSON BOARD MEMBER 1.00 X 0 0 0 NANCY MURPHY ENDING 7117 BOARD MEMBER 1.00 X 0 0 0 DELORES WELLS BEG 7117 BOARD MEMBER 1.00 X 0 0 0 AARON BRUGGEMAN BEG 2117 BOARD MEMBER 1.00 X 0 0 0 MELISSA HARTSHORN SECRETARY 40.00 X 0 0 0 CYNTHIA TOUVELLE CNO 40.00 X 103826 0 26523 WILLIE COOPER - LOHR CFO 40.00 X 106857 0 23791 DAVID PHILLIPS CEO 40.00 X 148248 0 24609 JOSEPH A JEFFRIES PHARMACIST 40.00 X 114642 0 29045 JANET LALLATHIN PHARMACIST 40.00 X 115479 0 33938 MARY B MAZOCH PHARMACIST 40.00 X 110206 0 19049 DR KEITH KNUPP PHYSICIAN 0.00 40.00 X 0 190601 33918 DR SHAUN ROE PHYSICIAN 0.00 40.00 X 0 277903 34675 869084 688518 273284 7 0 1 0 NES OHIO INC PO BOX 277001 ATLANTA GA 30384 ER PHYSICIANS 506902 INSIGHT HEALTH SERVICES PO BOX 847689 DALLAS TX 75284 MRI SERVICES 250057 PRECISION ANASTHESIA SERVICES LLC 66325 PLAINFIELD ROAD BELMONT OH 43718 CRNA SERVICES 214680 LAB CORP PO BOX 12140 BURLINGTON NC 27216 LAB SERVICES 162081 SLEEP CARE OF AMERICA LLC P O BOX 418 WORTHINGTON OH 43085 SLEEP STUDIES 125933 5 744698 90000 30000 864698 PROG.SERV.REVENUE-RELATED-990 900099 17920246 17920246 17920246 52575 52575 82360 0 82360 82360 82360 CAFETERIA 722210 100690 100690 MISCELLANEOUS 900099 81840 81840 AUXILIARY INCOME 900099 52047 52047 234577 19154456 17920246 0 369512 X 632784 556850 75934 7154180 6295678 858502 310007 272806 37201 3038002 2673442 364560 550836 484736 66100 15876 13971 1905 3302029 2905786 396243 14144 12447 1697 174191 153288 20903 108 95 13 1045202 919778 125424 23467 20651 2816 11429 10058 1371 41456 36481 4975 647400 569712 77688 191168 168228 22940 DRUGS AND MEDICAL SUPPL 1377596 1212284 165312 BAD DEBT 573642 573642 MISCELLANEOUS 219688 193325 26363 DUES & SUB. 94937 83545 11392 53004 46644 6360 19471146 17203447 2267699 0 571 571 236807 124401 2619293 2629634 401479 462335 189111 369311 19973201 15334186 4913365 4639015 2774115 2994919 101853 102606 1407574 1217426 1759310 1384837 14403478 13925055 2510168 2789643 1118720 1620630 3006018 3064163 6634906 7474436 X 7768572 6450619 7768572 6450619 14403478 13925055 X -316690 154816 -1156079 X X 0 1 X 1 0 X 0 0 0 0 0 0 0 0 1 3794 3794 0 PART II-B, LINE 1: PORTION OF ANNUAL MEMBERSHIP DUES PAID TO TRADE ASSOCIATIONS WITH A PORTION OF DUES ALLOCATED TO LOBBYING EXPENDITURES. 66199 66199 13254465 9957330 3297135 505541 189103 316438 6146996 5187753 959243 4639015 EQUITY IN BELMONT COUNTY HEALTH SERVICES 1217426 F 1217426 RELATED PARTY RECEIVABLES 1136872 THIRD PARTY RECEVIABLE 247965 1384837 ACCRUED PENSION COSTS 3064163 3064163 X PART X, LINE 2: ACCOUNTING PRINCIPLES GENERALLY ACCEPTED IN THE UNITED STATES OF AMERICA REQUIRE MANAGEMENT TO EVALUATE TAX POSITIONS TAKEN AND RECOGNIZE A TAX LIABILITY IF AN UNCERTAIN POSITION HAS BEEN TAKEN 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 THESE ENTITIES, AND HAS CONCLUDED THAT AS OF DECEMBER 31, 2017 AND 2016, THERE ARE NO UNCERTAIN POSITIONS TAKEN OR EXPECTED TO BE TAKEN THAT WOULD REQUIRE RECOGNITION OF A LIABILITY OR DISCLOSURE IN THE ACCOMPANYING FINANCIAL STATEMENTS. THE ENTITIES ARE SUBJECT TO ROUTINE AUDITS BY TAXING JURISDICTIONS; HOWEVER, THERE ARE CURRENTLY NO AUDITS FOR ANY TAX PERIODS IN PROGRESS. SCHEDULE D, PART X, LINE 1 THE HOSPITAL HAS A NON-CONTRIBUTORY DEFINED BENEFIT PENSION PLAN FOR EMPLOYEES WHO MEET CERTAIN REQUIREMENTS AS TO AGE AND LENGTH OF SERVICE. THE PLAN PROVIDES PENSION BENEFITS THAT ARE BASED ON THE EMPLOYEE'S COMPENSATION DURING THEIR PERIOD OF CREDITED SERVICE. 1 1 1 X 1 X 1 1 0 1 1 87170 87170 0.00450 3717566 1715003 2002563 0.10280 3804736 1715003 2089733 0.10730 78296 78296 0.00400 934568 934568 0.04800 1012864 1012864 0.05200 4817600 1715003 3102597 0.15930 1 573642 2645657 2610561 35096 X 1 1 1 1 BARNESVILLE HOSPITAL ASSOCIATION INC 639 W MAIN ST BARNESVILLE OH 43713 X BARNESVILLE HOSPITAL ASSOCIATION 1 0 0 1 X X X X X X X X X 16 1 0 0 1 WWW.BARNESVILLEHOSPITAL.COM X 1 16 1 WWW.BARNESVILLEHOSPITAL.COM 0 1 X 100.000000000000 250.000000000000 X X X X X X 1 1 X X X X X 1 X WWW.BARNESVILLEHOSPITAL.COM X WWW.BARNESVILLEHOSPITAL.COM X WWW.BARNESVILLEHOSPITAL.COM X X X X X X 1 0 X X 1 X 0 1 BARNESVILLE HOSPITAL ASSOCIATION PART V, SECTION B, LINE 5: MET WITH FOCUS GROUPS FROM DIFFERENT COMMUNITIES AND MET WITH THE TRANSIT OIL AND GAS WORKERS. BARNESVILLE HOSPITAL ASSOCIATION PART V, SECTION B, LINE 11: NUTRITION & WEIGHT STATUS: THROUGH 21ST CENTURY GRANT, WORK WITH LOCAL SCHOOLS ON HEALTHY DIET EDUCATION.OFFER EDUCATION PROGRAMS TO ADDRESS THE TOP HEALTH RISK FACTORS WHICH CAN BE POSITIVELY INFLUENCED BY DIET- HEART DISEASE AND DIABETES. PARTNER WITH RIESBECK'S TO PROVIDE EDUCATION ON NUTRITION PROGRAMS SUCH AS LABEL READING EDUCATION, PREPARING HEALTHY SCHOOL LUNCHES, ETC.FACILITATE A WEIGHT LOSS PROGRAM FOR EMPLOYEES AND COMMUNITY MEMBERSPHYSICAL ACTIVITY: CONDUCT FITNESS SCREENINGS IN THE COMMUNITY BODY COMPOSITION ANALYSIS, FLEXIBILITY TESTING, GRIP STRENGTH AND BLOOD PRESSURE.PROVIDE FITNESS OPPORTUNITIES FOR EMPLOYEES AND COMMUNITY MEMBERS SUCH AS EXERCISE CLASSES, PREPARING FOR 5K, WATER AEROBICS, ETC. TOBACCO USE: PROVIDE RESOURCES TO EMPLOYEES AND COMMUNITY MEMBERS REGARDING TOBACCO CESSATION STRATEGIES AND PROGRAMS AVAILABLE LOCALLY. COLLABORATE WITH OTHER ORGANIZATIONS WHO ARE OFFERING SMOKING CESSATION PROGRAM.EDUCATION:HOSPITAL WILL OFFER HEALTH AND WELLNESS PROGRAMS EMPHASIZING PROPER NUTRITION, THE IMPORTANCE OF EXERCISE AND THE BENEFITS OF SMOKING CESSATION. OFFER COMMUNITY WELLNESS PROGRAM ON TOPICS PERTINENT TO COMMUNITY MEMBERS.MENTAL HEALTH, DRUGS ABUSE & ALCOHOL IN THE COMMUNITY:PROVIDE DRUG TAKE BACK PROGRAMS ON AN ANNUAL BASIS AS A MEANS TO EDUCATE THE COMMUNITY ON THE NEED TO REDUCE THE AVAILABILITY OF UNWANTED MEDICATION IN THE HOME AND IN THE COMMUNITY AND TO OFFER A SAFE AND CONFIDENTIAL WAY TO DISPOSE OF MEDICATIONS.PROVIDE A DROP BOX IN THE HOSPITAL LOBBY TO ALLOW COMMUNITY MEMBERS A VEHICLE TO DISPOSE OF UNWANTED MEDICATIONS AND SYRINGES ON AN AS NEEDED BASIS.COLLABORATE WITH THE BELMONT COUNTY HEALTH DEPARTMENT TO PROVIDE EDUCATION REGARDING NARCAN FOR COMMUNITY MEMBERS AND HEALTH CARE PROFESSIONALS AND TO PROVDE NARCAN FREE OF CHARGE THROUGH THE PROJECT DAWN PROGRAM.EXPLORE FEASIBILITY OF OFFERING A MEDICALLY ASSISTED TREATMENT OUTPATIENT PROGRAM FOR THOSE SUFFERING FROM ADDICTION. WORK WITH CROSSROADS COUNSELING TO DETERMINE FEASIBILITY OF OFFERING COUNSELING IN OUR SERVICE AREA FOR THOSE WITH SUBSTANCE ABUSE. PROVIDE AN ADDICTIONS CLINIC.PROVIDE SPACE FOR ALCOHOLIC ANONYMOUS TO MEET AT THE HOSPITAL. EXPLORE FEASIBILITY OF TELE-PSYCH TO ASSIST PATIENTS WHO ARE IN A CRISIS IN THE EMERGENCY DEPARTMENT OR WHEN ADMITTED AS AN INPATIENT.DEVELOP REFERRAL BROCHURE INCLUDING MENTAL HEALTH RESOURCES IN SERVICE AREA WHICH CAN BE PROVIDED TO PATIENTS AND FAMILY MEMBERS.EDUCATE STAFF AS TO THE ROLE A HOSPITAL'S MEDICAL SOCIAL WORKER CAN PLAY IN ASSISTING WITH APPROPRIATE REFERRALS FOR COUNSELING AND IN ASSISTING IN PSYCHIATRIC PLACEMENTS WHEN WARRANTED. ACCESS TO HEALTH CARE: DEVELOP A GUIDE FOR PATIENTS AND THEIR FAMILIES AS TO AVAILABLE TRANSPORTATION SERVICES ALREADY AVAILABLE.CONTINUE TO NETWORK WITH OTHER COMMUNITY ORGANIZATIONS REGARDING THE NEED AND OPTIONS FOR TRANSPORTATION. ACTIVELY WORK WITH OHIO HILLS HEALTH SERVICES FINANCIAL COUNSELORS TO PROVIDE EDUCATION AND ASSISTANCE REGARDING ACCESSING AND OPTIONS REGARDING INSURANCE THROUGH THE AFFORDABLE CARE ACT. PROMOTE THE AVAILABILITY OF BARNESVILLE HOSPITAL'S FINANCIAL COUNSELOR WHO CAN REFER PATIENTS TO APPROPRIATE RESOURCES TO ASSIST WITH MEDICAL BILLS AND EXPLORE OPTIONS TO ASSIST PATIENTS WITH OUTSTANDING MEDICAL BILLS. CONTINUE TO RECRUIT AND PROVIDE PRIMARY CARE AND SPECIALTY PHYSICIANS TO MEET THE NEEDS OF THOSE RESIDENTS IN SERVICE AREAS.EXPLORE TELE-MEDICINE AS AN OPTION TO HAVE SPECIALIST READILY AVAILABLE TO SERVE OUR RURAL REGION.EXPLORE FEASIBILITY OF URGENT CARE TO MEET THE NEEDS OF AREA RESIDENTS AND SPECIFICALLY THE TRANSIENT WORKERS ASSOCIATED WITH OIL AND GAS.EDUCATE COMMUNITY ON SERVICES AVAILABLE AT BARNESVILLE HOSPITAL. BARNESVILLE HOSPITAL ASSOCIATION PART V, SECTION B, LINE 13B: EVERY SELF PAY PATIENT RECEIVES 20% OFF THEIR INVOICE WHETHER THEY ARE ELIGIBLE FOR THE FINANCIAL ASSISTANCE OR NOT. BARNESVILLE HOSPITAL ASSOCIATION PART V, SECTION B, LINE 15E: CAN FILL OUT THE FORM PROVIDED IN THE REGISTRATION PACKET, ON LINE OR CALL THE FINANCIAL COUNSELOR FOR ASSISTANCE. BARNESVILLE HOSPITAL ASSOCIATION PART V, SECTION B, LINE 16J: FINANCIAL COUNSELOR PERSONALLY CALLS SELF PAY PATIENTS AND OFFERS THEM AN APPLICATION TO APPLY FOR FAP. BARNESVILLE HOSPITAL ASSOCIATION PART V, SECTION B, LINE 24: THE GROSS CHARGES FOR ANY INDIVIDUAL SERVICE ARE ALL THE SAME. SELF PAY PATIENTS RECEIVE A 20% DISCOUNT AND PATIENTS WITH ANY TYPE OF INSURANCE ARE GIVEN THE DISCOUNT NEGOTIATED IN THE CONTRACT. MEDICARE AND MEDICAID RECEIVE THE MEDICARE AND MEDICAID CONTRACTUALS. PART I, LN 7 COL(F): THE HOSPITAL HAS A DETAILED FINANCIAL ASSISTANCE POLICY WHICH STATES THAT TO PARTICIPATE IN CHARITY CARE CANDIDATES MUST COOPERATE FULLY. IN ADDITION THE HOSPITAL EDUCATES PATIENTS WITH LIMITED ABILITY TO PAY REGARDING FINANCIAL ASSISTANCE. FOR THIS REASON THE ORGANIZATION BELIEVES THAT IT ACCURATELY CAPTURES ALL CHARITY CARE DEDUCTIONS PROVIDED ACCORDING TO THE FINANCIAL ASSISTANCE POLICY AND THE AMOUNT OF BAD DEBT EXPENSE ATTRIBUTABLE TO PATIENTS ELIGIBLE UNDER THE ORGANIZATION'S CHARITY CARE POLICY IS NEGLIGIBLE. PART III, LINE 2: THE ORGANIZATION PROVIDES CARE WITHOUT CHARGE OR AT AMOUNTS LESS THAN ITS ESTABLISHED RATES TO PATIENTS WHO MEET CERTAIN CRITERIA UNDER ITS CHARITY CARE POLICY. BECAUSE THE ORGANIZATION DOES NOT COLLECT AMOUNTS DEEMED TO BE CHARITY CARE, THEY ARE NOT REPORTED AS REVENUE. OF THE ORGANIZATION'S TOTAL REPORTED EXPENSES (APPROXIMATELY $22,412,000 AND $22,270,000 DURING 2017 AND 2016 RESPECTIVELY), AN ESTIMATED $115,000 AND $125,000 AROSE FROM PROVIDING SERVICES TO CHARITY PATIENTS. THE ESTIMATED COSTS OF PROVIDING CHARITY SERVICES ARE BASED ON A CALCULATION WHICH APPLIES A RATIO OF COSTS TO CHARGES TO THE GROSS UNCOMPENSATED CHARGES ASSOCIATED WITH PROVIDING CARE TO CHARITY PATIENTS. THE RATIO OF COST TO CHARGES IS CALCULATED BASED ON THE ORGANIZATION'S TOTAL EXPENSES DIVIDED BY GROSS PATIENT SERVICE REVENUE. THE ORGANIZATION PARTICIPATES IN THE HOSPITAL CARE ASSURANCE PROGRAM (HCAP) WHICH PROVIDES FOR ADDITIONAL PAYMENTS TO HOSPITALS THAT PROVIDE A DISPROPORTIONATE SHARE OF UNCOMPENSATED SERVICES TO THE INDIGENT AND UNINSURED. HCAP REVENUE IS RECORDED IN NET PATIENT SERVICE REVENUE ON THE CONSOLIDATED STATEMENTS OF OPERATIONS AND CHANGES IN NET ASSETS. NET AMOUNTS RECEIVED THROUGH THIS PROGRAM TOTALED APPROXIMATELY $896,000 AND $761,000 FOR 2017 AND 2016, RESPECTIVELY. THE HOSPITAL HAS A DETAILED FINANCIAL ASSISTANCE POLICY WHICH STATES THAT TO PARTICIPATE IN CHARITY CARE CANDIDATES MUST COOPERATE FULLY. IN ADDITION THE HOSPITAL EDUCATES PATIENTS WILL LIMITED ABILITY TO PAY REGARDING FINANCIAL ASSISTANCE. FOR THIS REASON THE ORGANIZATION BELIEVESTHAT IT ACCURATELY CAPTURES ALL CHARITY CARE DEDUCTIONS PROVIDED ACCORDING TO THE FINANCIAL ASSISTANCE POLICY AND THE AMOUNT OF BAD DEBT EXPENSE ATTRIBUTABLE TO PATIENTS ELIGIBLE UNDER THE ORGANIZATION'S CHARITY CARE POLICY IS NEGLIGIBLE. PART III, LINE 3: THE COST WAS DETERMINED BY COST TO CHARGE RATIO ON THE COST REPORT. THIS IS AN AGING COMMUNITY AND THEY DESERVE THE BEST CARE AVAILABLE EVEN THOUGH WE HAVE TO SUPPLEMENT THE COST. 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 DECEMBER 31, 2017 HOSPITAL COST REPORT. PART III, LINE 8: SURPLUS/ (SHORTFALL): THE COST WAS DETERMINED BY COST TO CHARGE RATIO ON THE COST REPORT. THIS IS AN AGING COMMUNITY AND THEY DESERVE THE BEST CARE AVAILABLE EVEN THOUGH WE HAVE TO SUPPLEMENT THE COST.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 DECEMBER 31, 2017 HOSPITAL STATEMENT OF REIMBURSABLE COST. PART III, LINE 9B: EVERY SELF PAY PATIENT RECEIVES A FINANCIAL AID PACKET WITH PAYMENT OPTIONS AND AN APPLICATION FOR FINANCIAL ASSISTANCE. AS A FOLLOW-UP THE FINANCIAL COUNSELOR PERSONALLY CONTACTS ANY SELF-PAY PATIENT PRESENTING DURING THE WEEK DAYS. PATIENTS ARE BILLED MONTHLY FOR BALANCES NOT COVERED BY INSURANCE, ELIGIBLE FOR FREE CARE OR ELIGIBLE FOR CHARITY DISCOUNTS. AFTER THREE MONTHLY STATEMENTS, IF NO PAYMENTS ARE RECEIVED OR THE PATIENT HAS NOT CONTACTED THE FINANCIAL COUNSELOR, A FINAL NOTICE IS SENT SAYING THEY ARE BEING SENT TO A SECONDARY BILLING COMPANY. THEY WILL TRY TO COLLECT FOR ANOTHER 90 DAYS. PART VI, LINE 2: WE GO INTO THE COMMUNITY AND PERFORM SURVEYS FOR NEEDS ASSESSMENT. ALSO GET INPUT FROM AREA PHYSICIANS, PATIENTS, STAFF AND OTHER BUSINESS FACILITIES. PART VI, LINE 3: THE PATIENT FINANCIAL COUNSELOR MEETS WITH ANYONE THAT PRESENTS IF THEY DO NOT HAVE INSURANCE. WE ALSO HAVE IT ON OUR WEBSITE AND POSTED IN THE HOSPITAL. OUR STAFF GOES INTO THE COMMUNITY AND SPEAKS TO DIFFERENT ORGANIZATIONS ABOUT OUR CHARITY AND FREE CARE POLICIES; TELLING THEM WHAT IS AVAILABLE. A FINANCIAL FORM IS GIVEN TO EACH SELF PAY PATIENT THAT REGISTERS AND THE FINANCIAL COUNSELOR'S TELEPHONE NUMBER IS ON ALL INVOICES TO THE PATIENTS. PART VI, LINE 4: BARNESVILLE HOSPITAL IS LOCATED IN AN ECONOMICALLY DEPRESSED APPALACHAIN AREA IN SOUTHEASTERN OHIO. WE SERVE SEVERAL COUNTIES AND THE COUNTY TO THE SOUTH OF US HAVE NO HOSPITAL. IT IS AN AGING COMMUNITY WITH A LOT OF RESIDENTS UNDER THE FEDERAL POVERTY LEVEL. WE HAVE LITTLE INDUSTRY WITH THE HOSPITAL BEING THE LARGEST EMPLOYER IN THE COMMUNITY AND THE SCHOOLS ARE SECOND LARGEST. PART VI, LINE 5: OUR BOARD CONSIST OF COMMUNITY MEMBERS AND THE MAJORITY OF OUR MEDICAL STAFF ARE FROM THE COMMUNITY. IT IS VERY IMPORTANT TO BARNESVILLE HOSPITAL TO PROMOTE THE HEALTH OF THE COMMUNITY BY ORGANIZING COMMUNITY HEALTH SCREENINGS AND EDUCATION FOR OUR COMMUNITY. WE HAVE AN AGING COMMUNITY AND EVERY EFFORT IS MADE TO ASSIST THEM WITH THEIR HEALTHCARE NEEDS. X X X X 0 0 0 0 0 0 0 0 0 DAVID HILLIARD DO BOARD MEMBER 169826 0 0 0 0 0 13922 0 15182 0 198930 0 0 0 P K SOURI MD BOARD MEMBER 0 220014 0 0 0 0 0 0 0 18632 0 238646 0 0 DAVID PHILLIPS CEO 148248 0 0 0 0 0 1705 0 22904 0 172857 0 0 0 DR KEITH KNUPP PHYSICIAN 0 190601 0 0 0 0 0 13000 0 20918 0 224519 0 0 DR SHAUN ROE PHYSICIAN 0 277903 0 0 0 0 0 6500 0 28175 0 312578 0 0 FORM 990, PART VI, SECTION B, LINE 11B AFTER THE INITIAL REVIEW IT IS REVIEWED BY THE FINANCE COMMITTEE OF THE BARNESVILLE HOSPITAL BOARD OF TRUSTEES FOR REVIEW AND COMMENT. THEN IT IS APPROVED BY THE HOSPITAL BOARD. FORM 990, PART VI, SECTION B, LINE 12C THE WRITTEN CONFLICT OF INTEREST POLICY IS REGULARLY AND CONSISTENTLY MONITORED AND COMPLIANCE ENFORCED BY THE CORPORATE COMPLIANCE OFFICER WHO REPORTS TO THE BOARD. THE SCOPE OF THIS POLICY INCLUDES ALL EMPLOYEES PLUS CONTRACTED EMPLOYEES AND BOARD MEMBERS. THE POLICY IS IN PLACE TO DEFINE SITUATIONS THAT MIGHT OCCUR AND COULD RESULT IN A CONFLICT OF INTEREST BETWEEN AN EMPLOYEE OR BOARD MEMBER AND THE HOSPITAL. THE COVERED PERSONS ARE TO REFRAIN FROM SOLICITING HOSPITAL PATIENTS, PHYSICIANS, STAFF, ETC.; OR ANYTHING THAT COULD RESULT IN A PERSONAL GAIN FOR THE EMPLOYEE OR BOARD MEMBER OR THEIR IMMEDIATE FAMILIES. A SELF DISCLOSURE FROM COVERED PERSONS TO THE CORPORATE COMPLIANCE OFFICER IS REQUIRED ON ANY POTENTIAL CONFLICTS OF INTEREST. THE COVERED PERSONS ARE TO RECUSE THEMSELVES FROM PARTICIPATING IN ANY DELIBERATION OR DECISIONS ON SUCH TRANSACTIONS. THE CORPORATE COMPLIANCE OFFICER WILL REVIEW/RESEARCH THE CONFLICTS DISCLOSED. FORM 990, PART VI, SECTION B, LINE 15 BARNESVILLE HOSPITAL BOARD OF DIRECTORS HAS A COMPENSATION COMMITTEE THAT SETS THE COMPENSATION FOR THE CEO AND REVIEWS ALL PAY CHANGES FOR ANY OTHER EMPLOYEES WHETHER IT IS A SEPARATE INCREASE OR AN ALL EMPLOYEE INCREASE. THE BOARD USES A MANUAL PUBLISHED BY AN INDEPENDENT THIRD-PARTY AS A SOURCE TO DETERMINE REASONABLE COMPENSATION AMOUNTS FOR THE EXECUTIVE COMMITTEE AND ALL OTHER EMPLOYEES. PAY CHANGES ARE APPROVED OR REJECTED BY THE FULL BOARD AND IS DOCUMENTED IN THE BOARD OF DIRECTOR MINUTES. FORM 990, PART VI, SECTION C, LINE 19 THE 990 IS THE ONLY DOCUMENT MADE AVAILABLE TO THE PUBLIC. IF ANYONE WANTS TO REVIEW THE 990 THEY MAY CONTACT THE ADMINISTRATIVE OFFICE IN PERSON, BY TELEPHONE OR MAIL. WE WILL MAKE THE DOCUMENTS AVAILABLE AT THAT TIME. IF THE PERSON PRESENTS IN PERSON WE WILL TRY TO ACCOMODATE THEM THAT DAY. FORM 990, PART IX, LINE 11G PURCHASED SERVICES: PROGRAM SERVICE EXPENSES 2,905,786. MANAGEMENT AND GENERAL EXPENSES 396,243. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 3,302,029. FORM 990, PART XI, LINE 9: TRANSFERS -934,568. PENSION RELATED CHANGES 84,240. FORGIVENESS OF DEBT -305,751. FORM 990 PART XII, LINE 2C THE PROCESS HAS NOT CHANGED FROM THE PRIOR YEAR. BELMONT PROFESSIONAL ASSOCIATES INC 639 W MAIN ST BARNESVILLE OH 43713 311352493 PHYSICIAN PRACTICE OH 501(C)(3) LINE 3 BARNESVILLE HOSPITAL 0 BARNESVILLE HOSPITAL FOUNDATION 639 W MAIN ST BARNESVILLE OH 43713 113804786 SUPPORT FOR HOSPITAL OH 501(C)(3) LINE 12B, II N/A 0 SOUTHEASTERN HOME CARE LLC 1700 EDISON DRIVE MILFORD OH 45150 271219638 HOME HEALTH SERVICES OH PARTNERSHIP 0 0 0.17000 BELMONT CO HEALTH SERVICES INC 639 W MAIN ST BARNESVILLE OH 43713 341566526 RETAIL PHARMACY OH BARNESVILLE HOSPITAL C 100 100 1.00000 0 0 1 1 0 0 0 0 0 0 0 1 0 0 0 0 1 0 0 0 BELMONT PROFESSIONAL ASSOCIATES B 934568 CASH VALUE BARNESVILLE HOSPITAL FOUNDATION C 544891 CASH VALUE BARNESVILLE HOSPITAL FOUNDATION P 57793 CASH VALUE