2018-11-15T15:35:45-06:00 2017-12-31 351178661 BLUE & CO LLC 9200 WORTHINGTON RD STE 200 WESTERVILLE OH 43082 990 2017-01-01 311518658 POMERENE HOSPITAL FKA JOEL POMERENE FOUNDATION POME 3306741015 981 WOOSTER RD MILLERSBURG OH 446541094 JASON JUSTUS CHIEF FINANCIAL OFFICER 3306741015 2018-11-15 1 NANCY KIRCHNER P00386751 6148852583 2018-11-15 38.109.186.2 2018-11-15 14:34:04 ES P DA39A3EE5E6B4B0D3255BFEF95601890AFD80709 CBCE996F475CA3740CE88356C52AB1B9FF3D8150 2017 2019-02-21 02:37:17Z JASON JUSTUS 981 WOOSTER RD MILLERSBURG OH 446541094 35640505 0 X WWW.POMERENEHOSPITAL.ORG X 1937 OH WE WILL BE A LEADER AND PARTNER IN PROVIDING HIGH QUALITY , COST EFFECTIVE HEALTH CARE FOR ALL RESIDENTS OF GREATER HOLMES COUNTY. 16 15 419 53 0 0 96739 20006 34693438 34987043 33768 35126 572498 598330 35396443 35640505 15225 36144 0 0 16990378 17616306 0 0 0 18632914 19169051 35638517 36821501 -242074 -1180996 29390450 28403596 3243720 3355357 26146730 25048239 HOLMES COUNTY'S COMMUNITY HOSPITAL. WE PROVIDE HIGH-QUALITY, COST EFFECTIVE HEALTHCARE SERVICES TO OUR COMMUNITY. 0 0 24906049 36144 35271825 NOT-FOR-PROFIT HOSPITAL THAT PROVIDED ACUTE CARE INPATIENT AND OUTPATIENT SERVICES TO THE HOLMES COUNTY AREA. WE PROVIDED THIS THROUGH MEDICAL, SURGICAL, MATERNAL, AND NURSERY INPATIENT SERVICES. OUTPATIENT SERVICES INCLUDE LABORATORY, RADIOLOGY, REHABILITATION, AND RESPIRATORY SERVICES. POMERENE HOSPITAL PROVIDED 11,892 ED VISITS, 2,127 DISCHARGES, AND 41,944 OUTPATIENT REGISTRATIONS 24906049 1 1 0 0 0 0 0 0 0 0 1 0 0 1 0 1 0 1 0 0 0 0 0 0 0 0 1 1 1 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 1 0 0 0 1 63 0 1 419 1 0 0 0 0 0 0 0 0 0 0 X 16 15 0 0 0 0 0 0 0 1 1 0 0 1 1 1 1 1 1 1 1 0 OH X JASON JUSTUS 3306741015 981 WOOSTER RD MILLERSBURG OH 44654 CRAIG MULLER TRUSTEE 1.00 X 0 0 0 SHASTA MAST TRUSTEE 1.00 X 0 0 0 DAVE FINLEY TRUSTEE 1.00 X 0 0 0 LEROY YODER TRUSTEE 1.00 X 0 0 0 ROMAN RABER TRUSTEE 1.00 X 0 0 0 DAN MATHIE CHAIRMAN 1.00 X X 0 0 0 MIKE STEPHENS TRUSTEE 1.00 X 0 0 0 JEREMY KAUFFMAN TRUSTEE 1.00 X 0 0 0 ERNEST HERSHBERGER VICE CHAIRMAN 1.00 X X 0 0 0 JANE GRAVEN SECRETARY 1.00 X X 0 0 0 ELLIE RAMSEYER TREASURER 1.00 X X 0 0 0 MELVIN YODER TRUSTEE 1.00 X 0 0 0 TONY SNYDER CEO 1.00 40.00 X X 270000 0 0 MARY HOXWORTH TRUSTEE 1.00 X 0 0 0 JERRY SCHLABACH TRUSTEE 1.00 X 0 0 0 DR YASSER OMRAN EX-OFFICIO 1.00 X 0 0 0 JASON JUSTUS CFO 40.00 X 168000 0 0 DR ALEXANDROS W NICOLOZAKES PHYSICIAN 40.00 X 357035 0 27755 DR MICHAEL T SCHELL PHYSICIAN 40.00 X 353664 0 26755 DONNA J AUGUSTINE PHYSICIAN 40.00 X 203261 0 11015 DWIGHT J MCFADDEN PHYSICIAN 40.00 X 141119 0 10420 DR ZANE CRAIG PHYSICIAN 40.00 X 149937 0 5361 1643016 0 81306 8 0 1 0 POMERENE EMERGENCY PHYSICIANS 2624 MACNAUGHTEN RD NORTH CANTON OH 44720 ED PHYSICIANS 1912656 TRI - COUNTY ANESTHESIA PO BOX 20451 COLUMBUS OH 43220 ANESTHESIA SERVICES 910752 FAMMILY PROPERTIES 6214 SR 83 MILLERSBURG OH 44654 LEASING SERVICES 286321 ALLIANCE IMAGING PO BOX 96485 CHICAGO OH 60693 MRI SERVICES 212523 QUEST DIAGNOSTICS 12436 COLLECTION CENTER CHICAGO IL 60693 LABORATORY SERVICES 196354 10 20000 6 20006 PROG.SERV.REVENUE-RELATED-990 900099 34987043 34987043 34987043 35126 35126 313548 0 313548 313548 313548 MISCELLANEOUS 900099 197426 197426 PURCHASE DISCOUNTS 900099 87356 87356 284782 35640505 35271825 0 348674 X 36144 36144 14057064 9277662 4779402 2616883 1727143 889740 942359 621957 320402 199988 131992 67996 98695 65139 33556 7842722 5176197 2666525 198305 130881 67424 196304 129561 66743 289841 191295 98546 1558699 1028741 529958 241234 159214 82020 10444 6893 3551 261 172 89 1377502 909151 468351 300473 198312 102161 MEDICAL AND OTHER SUPPL 4080413 2693073 1387340 BAD DEBT EXPENSE 1739910 1739910 FRANCHISE FEE 529430 349424 180006 DIETARY 134716 88913 45803 370114 244275 125839 36821501 24906049 11915452 0 1033 1133 4484127 3159451 4570542 5092971 486956 514170 552519 490944 37535485 27161936 10939186 10373549 8356087 8771378 29390450 28403596 1786096 2053445 177624 162912 1280000 1139000 3243720 3355357 X 26146730 25048239 26146730 25048239 29390450 28403596 -1180996 82505 0 X X 0 1 X 1 0 X 631987 631987 17248084 10749943 6498141 92684 54690 37994 19562730 16357303 3205427 10373549 OTHER RECEIVABLES 145908 INVESTMENT IN JOINT VENTURES 5144 THIRD PARTY RECEIVABLE -151464 ASSETS WHOSE USE IS LIMITED 8771790 8771378 X PART X, LINE 2: THE HOSPITAL, FOUNDATION AND HPHC ARE ORGANIZED AS TAX-EXEMPT ORGANIZATIONS UNDER SECTION 501(C)(3) OF THE INTERNAL REVENUE CODE. ACCOUNTING PRINCIPLES GENERALLY ACCEPTED IN THE UNITED STATES OF AMERICA REQUIRE MANAGEMENT TO EVALUATE TAX POSITIONS TAKEN BY THE ORGANIZATION 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, THERE ARE NO UNCERTAIN POSITIONS TAKEN OR EXPECTED TO BE TAKEN THAT WOULD REQUIRE RECOGNITION OF A LIABILITY OR DISCLOSURE IN THE ACCOMPANYING CONSOLIDATED FINANCIAL STATEMENTS. THE ORGANIZATION HAS FILED ALL REQUIRED FEDERAL AND STATE INCOME TAX RETURNS FOR PERIODS THROUGH DECEMBER 31, 2016 AND IS SUBJECT TO ROUTINE AUDITS BY TAXING JURISDICTIONS. HOWEVER, AS OF THE DATE THE FINANCIAL STATEMENTS WERE AVAILABLE TO BE ISSUED, THERE WERE NO AUDITS FOR ANY TAX PERIODS IN PROGRESS. THESE INCOME TAX RETURNS ARE GENERALLY OPEN TO EXAMINATION BY THE RELEVANT TAXING AUTHORITIES FOR A PERIOD OF THREE YEARS FROM THE LATER OF THE DATE THE RETURN WAS FILED OR ITS DUE DATE (INCLUDING APPROVED EXTENSIONS). 1 1 1 X 1 X 175.000000000000 1 1 1 0 1 1 278474 278474 0.00800 4741062 2413821 2327241 0.66600 5019536 2413821 2605715 0.67400 36144 36144 0.00100 36144 36144 0.00100 5055680 2413821 2641859 0.67500 68704 68704 0.00190 38365 38365 0.00100 107069 107069 0.00290 1 1739910 4428978 5065359 -636381 X 1 1 POMERENE HOSPITAL 981 WOOSTER MILLERSBURG OH 44654 WWW.POMERENE.ORG X X POMERENE HOSPITAL 1 1 1 X X X X X X X X 17 1 0 1 1 X HTTP://WWW.POMERENEHOSPITAL.ORG/ X 1 17 1 HTTP://WWW.POMERENEHOSPITAL.ORG 0 1 X 100.000000000000 175.000000000000 X X X X X X 1 1 X X X X 1 X HTTP://WWW.POMERENEHOSPITAL.ORG X HTTP://WWW.POMERENEHOSPITAL.ORG X HTTP://WWW.POMERENEHOSPITAL.ORG X X X X X 1 X 0 X 1 0 0 POMERENE HOSPITAL PART V, SECTION B, LINE 6B: HOLMES COUNTY HEALTH DISTRICT PART III, LINE 3: 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. 0 LOUDONVILLE-PERRYSVILLE SCHOOL DISTRICT 210 EAST MAIN STREET LOUDONVILLE OH 44842 501C3 6021 COMMUNITY SUPPORT HOLMES COUNTY ECONOMIC DEVELOPMENT 2 COURT STREET SUITE 16 MILLERSBURG OH 44654 501C3 5000 COMMUNITY SUPPORT 2 0 1 X X X X X 0 0 0 0 0 0 0 0 0 TONY SNYDER CEO 270000 0 0 0 0 0 0 0 0 0 270000 0 0 0 JASON JUSTUS CFO 168000 0 0 0 0 0 0 0 0 0 168000 0 0 0 DR ALEXANDROS W NICOLOZAKES PHYSICIAN 357035 0 0 0 0 0 13408 0 14347 0 384790 0 0 0 DR MICHAEL T SCHELL PHYSICIAN 353664 0 0 0 0 0 11631 0 15124 0 380419 0 0 0 DONNA J AUGUSTINE PHYSICIAN 203261 0 0 0 0 0 7833 0 3182 0 214276 0 0 0 DWIGHT J MCFADDEN PHYSICIAN 141119 0 0 0 0 0 5585 0 4835 0 151539 0 0 0 DR ZANE CRAIG PHYSICIAN 149937 0 0 0 0 0 0 0 5361 0 155298 0 0 0 FORM 990, PART VI, SECTION B, LINE 11B THE PROCESS OF REVIEWING THE FORM 990 ENTAILS A DETAILED REVIEW BY THE ORGANIZATION'S ACCOUNTING DEPARTMENT. THE GOVERNING BODY RECEIVES AN ELECTRONIC COPY OF THE FORM 990 INCLUDING REQUESTED SCHEDULES, AS ULTIMATELY FILED WITH THE IRS, FOR REVIEW AND APPROVAL PRIOR TO FILING WITH THE IRS. FORM 990, PART VI, SECTION B, LINE 12C UPON APPOINTMENT, AND THEREAFTER ANNUALLY, THROUGH SIGNED ACKNOWLEDGEMENT OF THE CONFLICT OF INTEREST AGREEMENT, OR AT THE TIME WHEN AN ACTUAL OR POTENTIAL CONFLICT OF INTEREST MAY ARISE, THE COVERED PERSON MUST IDENTIFY AND DISCLOSE AT ANY MEETING ALL MATERIAL FACTS AND DETAILS RELATING TO THE ACTUAL OR POTENTIAL CONFLICT OF INTEREST SO THAT THE DISINTERESTED POMERENE DECISION MAKERS ARE ABLE TO MAKE AN OBJECTIVE BUSINESS DETERMINATION CONSISTENT WITH POMERENE'S MISSION AND PURPOSE. ANY COVERED PERSON WITH AN ACTUAL OR POTENTIAL CONFLICT OF INTEREST MUST NOT VOTE OR USE HIS/HER PERSONAL INFLUENCE WITH RESPECT TO ANY VOTE OR ACTION TAKEN BY POMERENE DECISION MAKERS VOTING ON THE PROPOSED MATTER, CONTRACT, TRANSACTION OR BUSINESS ARRANGEMENT. FORM 990, PART VI, SECTION B, LINE 15 THE BOARD OF TRUSTEES CONDUCTS A PERIODIC REVIEW OF THE CHIEF EXECUTIVE OFFICER'S PERFORMANCE AND COMPENSATION DURING AN EXECUTIVE SESSION OF THE BOARD. FORM 990, PART VI, SECTION C, LINE 19 DOCUMENTS ARE MADE AVAILABLE UPON REQUEST. FORM 990, PART IX, LINE 11G PROFESSIONAL FEES: PROGRAM SERVICE EXPENSES 4,004,032. MANAGEMENT AND GENERAL EXPENSES 2,062,683. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 6,066,715. PURCHASED SERVICES: PROGRAM SERVICE EXPENSES 1,172,165. MANAGEMENT AND GENERAL EXPENSES 603,842. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 1,776,007. FORM 990, PART XII, LINE 2C THE PROCESS HAS NOT CHANGED FROM THE PRIOR YEAR. POMERENE HEALTH FOUNDATION 981 WOOSTER RD MILLERSBURG OH 44654 346004044 FUNDRAISING FOR HOSPITAL OH 501(C)(3) LINE 3 0 HEALTH PROFESSIONALS OF HOLMES COUNTY 981 WOOSTER RD MILLERSBURG OH 44654 300329769 LEASING OF PROFESSIONAL SERVICES OH 501(C)(3) LINE 3 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 0 1 0 0