2018-04-02T18:55:18-05:00 2017-09-30 351178661 Blue & Co LLC 500 N Meridian St Suite 200 Indianapolis IN 46204 990 2016-10-01 350877575 Gibson General Hospital Inc GIBS 8123853401 1808 Sherman Drive Princeton IN 47670 emmett c schuster ceo 8123853401 2018-04-02 1 Amber Kocher CPA P01286298 3176334705 2018-04-02 184.0.71.246 2018-04-02 18:55:15 ED P DB79E0D6220D8C9E881682F2265FA72E8C0F7A33 48BB13F909289851469C7DA648BAC11FC748AA42 2016 2021-01-29 14:40:06Z emmett c schuster 1808 Sherman Drive Princeton IN 47670 30119690 0 X www.gibsongeneral.com X 1941 IN to provide high quality, patient-centered, cost-effective care for people in the community. 16 15 408 40 0 0 111233 227932 33111853 29409953 351120 14946 342938 466859 33917144 30119690 0 0 0 0 18255806 16167844 0 0 0 15836238 12190528 34092044 28358372 -174900 1761318 20555925 22282548 10599013 10940910 9956912 11341638 the mission of gibson general hospital and the skilled nursing facility is to provide high quality, patient-centered, cost-effective care for people in our community. 0 0 22554419 0 29620218 the hospital's mission is to provide high quality and cost-effective healthcare, which includes patient, outpatient, and emergency care services to the residents of the surrounding tri-state area. all expenses relate to costs associated with providing these services, and mainly include salaries and wages to staff and supplies cost. there were 323 admissions and 30,276 visits during the year. 22554419 1 1 0 0 0 0 0 0 0 0 1 0 0 0 1 0 0 1 0 0 0 0 0 0 0 0 1 1 0 0 1 1 0 0 0 0 0 0 0 0 1 0 0 0 0 0 0 1 1 1 0 0 1 72 0 1 408 1 0 0 0 0 0 0 0 0 0 0 X 16 15 0 1 1 0 0 1 0 1 1 0 0 1 1 1 1 1 1 1 1 1 0 IN X James Childers 8123853401 1808 Sherman drive princeton IN 47670 robert gibson jr board chairman 2.00 0.00 X X 0 0 0 marion jochim board vice-chair 2.00 0.00 X X 0 0 0 j robert kinkle second vice-chair 2.00 0.00 X X 0 0 0 mike wood secretary 2.00 0.00 X X 0 0 0 susan straub treasurer 2.00 0.00 X X 0 0 0 Krishna Murthy MD chief of staff 2.00 0.00 X 0 0 0 george a ballard board member 2.00 0.00 X 0 0 0 alan Douglas board member 1/1-9/30/17 2.00 0.00 X 0 0 0 Jared Florence board member 1/1-9/30/17 2.00 0.00 X 0 0 0 Dr michael green board member 2.00 0.00 X 0 0 0 MS Krishna MD board member 2.00 0.00 X 0 0 0 stephen lankford board member 2.00 0.00 X 0 0 0 Shawn McCoy board member 1/1-9/30/17 2.00 0.00 X 0 0 0 Derek McGraw board member 11/1/16-9/30/17 2.00 0.00 X 0 0 0 Henry brewster MD board member 10/1-11/1/16 2.00 0.00 X 0 0 0 Allen White MD board member 1/1-9/30/17 2.00 0.00 X 0 0 0 larry johnson board member 10/1-12/31/16 2.00 0.00 X 0 0 0 donald j hauke board member 10/1-12/31/16 2.00 0.00 X 0 0 0 sherri smith board member 10/1-12/31/16 2.00 0.00 X 0 0 0 george ankenbrand board member 10/1-12/31/16 2.00 0.00 X 0 0 0 emmett schuster chief executive officer 50.00 0.00 X 201713 0 17855 James Childers chief financial officer 50.00 0.00 X 82564 0 1423 lori phillips chief nursing officer 50.00 0.00 X 152359 0 159 Phillip Rosett Physician 40.00 0.00 X 359905 0 19374 corey a potts crna 40.00 0.00 X 252362 0 18120 stephen r shoemaker physician 40.00 0.00 X 242253 0 19298 richard m clark physician 40.00 0.00 X 241872 0 26239 Kwabena Owusu-Dekyi Physician 40.00 0.00 X 182418 0 19348 1715446 0 121816 12 0 1 0 Thomas Joseph MD 1808 Sherman drive princeton IN 47670 Medical pro fees 585640 blake titzer po box 130 inglefield IN 47618 medical pro fees 374542 philomina thuruthumaly md 1707 brentwood drive princeton IN 47670 medical pro fees 243750 Alliant Management Services 1280 B Meridian St Suite 400 Carmel IN 46032 Management Services 144661 Medical Staffing Solutions LLC 9700 HWY 57 North Suite A evansville IN 47725 Recruitment 142358 6 10432 217500 227932 Patient Service Revenue 624100 26803240 26803240 Long Term Care Revenue 623000 2606713 2606713 29409953 14946 14946 59192 0 59192 59192 59192 Cafeteria Revenue 722210 137150 137150 270517 210265 60252 407667 30119690 29620218 0 271540 X 436636 436636 12711518 11373177 1338341 177482 143267 34215 1915896 1530410 385486 926312 783563 142749 801552 801552 157894 157894 3292628 2499677 792951 156691 156691 650679 511440 139239 1860650 942580 918070 86056 78103 7953 295898 295898 1269751 1210143 59608 400544 42548 357996 Medical & Drug Supplies 2214265 2209999 4266 HAF Expense 625118 625118 Dues & Sub. 332653 105656 226997 46149 46149 28358372 22554419 5803953 0 1112783 2793850 3147978 4146257 3399288 3285892 756580 783371 273611 248364 35066130 24777482 11365493 10288648 79926 500192 656240 20555925 22282548 2488341 2175408 69297 925541 6714094 6060996 1327281 1045301 0 733664 10599013 10940910 X 9909971 11292424 46941 49214 9956912 11341638 20555925 22282548 X 1761318 -328480 -48112 X X 0 1 X 1 0 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 1 3810 3810 0 Part II-B, Line 1: The hospital paid membership dues to Indiana Hospital Assocation "IHA and American Hospital Association "AHA". IHA attributed 5.40% ($594) and AHA attributed 21.78% of the dues to lobbying expenses to total $3,810. 421244 421244 20167380 11967826 8199554 14371559 12809656 1561903 105947 105947 10288648 Estimated third-party settlements 733664 733664 X Part X, Line 2: Accounting principles generally accepted in the United States of America require management to evaluate tax positions taken by the Hospital and Foundation and recognize a tax liability if they have taken an uncertain position 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 the Hospital, Foundation and Pain Management, and has concluded that as of September 30, 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 consolidated financial statements. These entities are subject to routine audits by taxing jurisdictions; however, there are currently no audits for any tax periods in progress. 1 1 1 X 149.000000000000 1 X 1 1 1 0 1 1 481858 481858 0.01700 5762596 3252641 2509955 0.08850 6244454 3252641 2991813 0.10550 6244454 3252641 2991813 0.10550 1 2490291 3029883 3371943 -342060 X 1 1 1 1 Gibson General Hospital Inc 1808 Sherman Drive princeton IN 47670 www.gibsongeneral.com 17-005019-1 X X X X gibson general hospital inc 0 0 1 X X X X X X X X 15 1 0 0 1 X www.gibsongeneral.com X X 1 15 1 www.gibsongeneral.com 0 1 X 149.000000000000 300.000000000000 X X X X 1 1 X X X 1 X http://www.gibsongeneral.com/docs/GGH_Financial_Assistance_Policy_final.pdf X http://www.gibsongeneral.com/docs/2017_FAP_Application_Final.pdf X http://www.gibsongeneral.com/docs/FAP_plain_language.pdf X X X X X X 1 0 X X X X 1 X 0 0 gibson general hospital inc Part V, Section B, Line 5: Community Input: Between April and July 2015, the hospital partnered with the Indiana Rural Health Association (IRHA) to conduct a community health needs assessment to identify areas of greatest need in the Hospital's service area through the collection of health data and community input on the community's assets, values, and weaknesses. A focus group of Gibson County representatives was organized which included business owners, local officials, healthcare providers, minority leaders, clergy, student representatives, and other interested parties. Additionally, a 47-question survey was developed and disseminated to the residents of Gibson County and publically via the Hospital's website, face-to-face polling at a popular store in Princeton, Indiana, and at the Gibson County Fair. gibson general hospital inc Part V, Section B, Line 7d: CHNA Location:The CHNA reports can be located at the Hospital's website located on the "Community Health Needs Assessment" page located under "About Us". gibson general hospital inc Part V, Section B, Line 11: Significant Needs Identified:There were six significant needs identified in the 2015 CHNA: 1) fitness/activity; 2) chronic disease prevention/ treatment; 3) mental health services availability; 4) healthcare access and quality; 5) living conditions; 6) drug and tobacco misuse. Hospital leadership prioritized the needs based on several factors including community input and evaluation of resources needed to address the top community needs. Obesity and assisted living are two areas that the hospital does not have the resources currently to meet the community concerns. gibson general hospital inc Part V, Section B, Line 13h: OTHER ELIGIBLITY CRITERIA: IF AN INDIVIDUAL IS HOMELESS, DECEASED, RECENTLY FILED FOR OR COMPLETED BANKRUPTCY, OR MEETS SPECIAL CIRCUMSTANCES related to ability to pay, THE INDIVIDUAL MAY BE ELIGIBLE FOR FINANCIAL ASSISTANCE. gibson general hospital inc Part V, Section B, Line 16j: Publicized Financial Assistance Policy: FAP, FAP application, and plain language summary can be located on the Hospital's website on the "Financial Assistance" page under "Patient Info drop down menu. Additionally, a spanish translation of the FAP application and plain language summary are available. 7 1 - Star One Rehab 1808 Sherman Drive Princeton IN 47670 Physical therapy, occupational therapy, speech therapy 2 - Physician Outpatient Clinics 1808 Sherman Drive Princeton IN 47670 Subsidized Care Physician Practices 4 - Lifestyles Diabetes Center 1808 Sherman Drive Princeton IN 47670 Diabetes Education Counseling 5 - GGH - Skilled Nursing Facility 1808 Sherman Drive Princeton IN 47670 Skilled Nursing Rehab Center 6 - GGH-Family Practice 516 N Main St Princeton IN 47670 Family Medicine 7 - Brink's Family Practice 410 N Main St Princeton IN 47670 Family Medicine/ Hospitalist 8 - Fort Branch Wellness Clinic 7851 S Professional DR Fort Branch IN 47648 Family Practice Part III, Line 2: Methodology used to estimate bad debt: Management analyzes third-party payor sources and makes an estimate based on aging of accounts, historical losses, current economic conditions, and other factors unique to its service area. Additionally, a significant provision is estimated and recorded for self-pay payments based on past experience. Part III, Line 4: Audited Financial Statement Footnote:Footnote to organization's financial statements that describes bad debt expense is located on page 8 of the audited financial statements within the note "Allowance for Uncollectible Accounts". Part III, Line 8: Medicare Shortfall:the hospital is a critical access hospital and is reimbursed 101%, less 2% sequestration, of medicare allowance costs for inpatient services, swing bed, and outpatient part b services. the revenue shortfall is the difference between the allowable cost for the skilled nursing facility and the pps reimbursement allowed for that skilled nursing facility. 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 September 30, 2017: Hospital Statement of Reimbursable Cost. Part III, Line 9b: Collection Practices:Collection practices are applied to all patients at gibson general hospital. Once patients receive services, the patients' accounts are billed to the appropriate insurance company. Once payment is received from the insurance company, the remaining balance, if any, becomes the patient's responsibility. Notification of the balance due is sent via written correspondence. If the balance is not paid and the account does not qualify for financial assistance, the account is sent to a collection agency to continue efforts to collect the remaining balance due. If the balance due is not paid within a certain number of months, the account is returned to the hospital and the account is written off as uncollectible. Part VI, Line 2: ASSESSING COMMUNITY NEEDS:IN ADDITION TO COMPLETING A CHNA EVERY THREE YEARS, THE HOSPITAL'S Leadership is COMPRISED OF COMMUNITY MEMBERS who engage in daily conversations with other community members and leaders regarding the community they live in and its needs. These conversations supplement THE UNDERSTANDING OF THE COMMUNITY'S HEALTH NEEDS identified in the CHNA. Hospital Leadership also uses strategic planning to sponsor and engage in community activities that helps Leadership assess the health care needs of the community the hospital serves. Part VI, Line 3: Patient Education of Eligibility for Assistance: The hospital displays posters in the central registration and emergency room waiting-area notifying patients that they will be seen regardless of their ability to pay and financial assistance is available to uninsured and underinsured in compliance with emtala. The financial assistance policy (FAP), FAP application, and plain language summary are available on the hospital's website at gibsongeneral.com; available upon request, without charge, at the Business office, admissions, and via mail; Plain language summary is conspicuously displayed in the Hospital and Clinic waiting-areas; and, the plain language summary is provided to each person upon admission to the Hospital. Any patients without insurance or with a balance due after insurance is billed are provided a plain language summary, FAP application, and contact information for the Hospital's patient financial counselor by mail. Part VI, Line 4: Community Information/ Community Served:The Hospital's primary service area includes Gibson County, Southwest Pike County, and Posey County, Indiana. The counties are located in Southwestern, Indiana, and are largely rural with agriculture and coal mining as primary industries. Gibson County, Indiana, is approximately 146 miles southwest of Indianapolis and 25 miles north of Evansville, Indiana, with an estimated population of 33,700. In 2016 the population median age was 40.4 years with forty-five percent (45%) of the population age 45 and older. The poverty rate was 10.8% and the median household annual income was $54,690. Pike County, Indiana, is approximately 55 miles southwest of Indianapolis and 50 miles north of Evansville, Indiana, with an estimated population of 12,431. In 2016 the population median age was 44.1 years with forty-nine percent (49%) of the population age 45 and older. The poverty rate was 11.4% and the median household annual income was $49,578. Posey County, Indiana, is approximately 200 miles southwest of Indianapolis and 20 miles west of Evansville, Indiana, with an estimated population of 25,476. In 2016 the population median age was 42.5 years with forty-seven percent (47%) of the population age 45 and older. The poverty rate was 8.4% and the median household annual income was $61,619.Approximately 75-80% of the hospital's patient population utilizes medicare, medicaid, and/or other government-subsidized programs. Traditionally, the hospital has been relied upon as a safety net hospital for older patients, low-income patients, and patients with limited means to travel to the larger city of Evansville, Indiana. Part VI, Line 5: Community Health Promotion:the hospital participates in many organizations and activities designed to improve the health and welfare of the surrounding community. in addition to participation on various boards and civic organizations focused on economic development, the hospital's leadership participates in the indiana patient safety coalition, the department of homeland security, district 10 emergency preparedness and national incident management safety programs. as members of the indiana rural heath association and the indiana state rural health network, the hospital participates in programs designed to assist rural healthcare organizations statewide and has assisted in obtaining and implementing communication, information sharing, and other activities to improve the access to healthcare in gibson county and the surrounidng areas. Part VI, Line 6: Affiliated Health Care System:gibson general hospital became affiliated with Deaconess Health System in December 2016 cooperating to provide health care services to their communities. Additionally, the hospital does participate in several coalitions and cooperatives with other providers and often collaborates with the larger system in the evansville area to provide access to services the hospital cannot provide such as cardiac and neurological surgery. X X X 0 0 0 0 0 0 0 0 0 emmett schuster chief executive officer 200859 0 0 0 854 0 0 0 17855 0 219568 0 0 0 lori phillips chief nursing officer 151730 0 0 0 629 0 0 0 159 0 152518 0 0 0 Phillip Rosett Physician 358615 0 0 0 1290 0 0 0 19374 0 379279 0 0 0 corey a potts crna 252362 0 0 0 0 0 0 0 18120 0 270482 0 0 0 stephen r shoemaker physician 241338 0 0 0 915 0 0 0 19298 0 261551 0 0 0 richard m clark physician 241077 0 0 0 795 0 0 0 26239 0 268111 0 0 0 Kwabena Owusu-Dekyi Physician 182418 0 0 0 0 0 0 0 19348 0 201766 0 0 0 A city of princeton 356001169 2005-06-01 7100000 capital improvements 0 0 0 B city of princeton 356001169 2007-10-01 2096000 energy conservation project 0 0 0 C city of princeton 356001169 2008-12-01 2500000 renovations - emergency department 0 0 0 A 7100000 55566 7044434 2009 0 1 1 1 B 2096000 2096000 2008 0 0 1 1 C 2500000 31500 2468500 2009 0 0 1 1 A 0 0 0 0 0.00000 0.00000 0 0 1 B 0 0 0 0 0.00000 0.00000 0 0 1 C 0 0 0 0 0.00000 0.00000 0 0 1 A 0 0 1 0 1 0 0 0 1 B 0 0 1 0 1 0 0 0 1 C 0 0 1 0 1 0 0 0 1 A 1 B 1 C 1 leann cooper See Part V 52688 compensation paid by ggh 0 Schedule L, Part IV, Line 1b leann cooper is the executive director of gibson general health foundation and is the daughter of board member dr. michael green. the hospital compensates for the salary of the executive director of the gibson general health foundation. Form 990, Part VI, Section A, line 1 Executive Committee Delegated Authority: The Executive Committee will exercise all authority of the Board of Trustees between regular board meetings during all emergency situations (immediate action that could result in a serious negative impact upon the Organization) and/or when the non-emergency action(s) result in commitment to a capital investment or lease less than $50,000. Form 990, Part VI, Section A, line 3 Management Duties: The CEO and CFO of the Organization are employeed and provided, subject to approval of the board of Trustees, by Deaconess Hospital, Inc., an Indiana not for profit corporation as of December 2016. Form 990, Part VI, Section A, line 4 Significant Organization Document Changes During the Year: In December 2016, the Organization amended its Articles of Incorporation and Bylaws allowing for 2 elected officials of Gibson County (one county commissioner and the Mayor of Princeton, indiana), Gibson General Hospital Foundation President, the Organization's Chief of Staff, and three Deaconess Hospital delegates to serve as board trustees in addition to two medical professionals and other trustees selected for two year terms by the board. Form 990, Part VI, Section A, line 7a Power to Elect or Appoint: The organization governing documents allows for the County Commissioners of Gibson County, Indiana to select one (1) member of the board of trustees; Deaconess Hospital, INC to select three (3) members of the board of trustees; and, the Mayor of Princeton, Indiana, the President of Gibson General Hospital Foundation, and the Chief of Staff of Gibson General Hospital serve as ex-officio members. Form 990, Part VI, Section B, line 11b Form 990 Review Process: The process of review the Form 990 includes a detailed review of the form and required schedules by the Chief Financial Officer. Each voting member of the governing body receives a copy of the Form 990 including required schedules, as ultimately filed with the IRS, prior to filing. Form 990, Part VI, Section B, line 12c Conflict of Interest Policy: The conflict of interest policy is included within the Bylaw of the Organization and covers all board of trustees. The policy provides procedures to prevent those with duality of interest or possible conflicts of interest from participating in any action that could personally benefit the individual trustee. The CEO and/or Board Compliance Officer review annual written and signed conflict of interest statements that provide any duality of interest or possible conflicts of interest disclosed by all board of trustees. The Individual Trustee will again disclose to the board when the interest becomes a matter of Board action and recues himself or herself from voting on the related issue. The board meeting minutes document the disclosure made, who abstained from voting, and the quorum situation. Form 990, Part VI, Section B, line 15 Compensation Process: CEO: The CEO Evaluation Committee, consisting of four independent and board chair appointment trustee members, evalutates the performance of the CEO on an annual basis and makes compensation-related recommendations to the Board prior to the CEO's annual review date for approval. The Evaluation Committee uses a compensation consultant, compensation survey, and comparative data from simliar organization to determine the CEO's Compensation package. All deliberation and decisions are documented in the evaluation committee's minutes. Officers and/or Key Employees: Annual reviews for top management officials are conducted by the CEO. The compensation is annually reviewed and approved by the board of trustees. Form 990, Part VI, Section C, line 19 the hospital's governing documents, conflict of interest policy, and financial statements are available to the public upon written request and board of trustees approval. Written requests should be sent to Attn: James Childers, at the address listed on page 1 of the Form 990. Form 990, Part VI, Line 16b, Joint Venture Policy: The organization does not have a formal written policy on evaluating participation in a joint venture, however, the organization performs due diligence and involves legal counsel to review any partnerships including the pain management services ensuring that the joint venture would be organized and operated in a manner consistent with the hospital's exempt purpose and status. Form 990, Part IX, line 11g Purchased Services: Program service expenses 1,401,218. Management and general expenses 444,496. Fundraising expenses 0. Total expenses 1,845,714. Professional Fees - Medical: Program service expenses 874,541. Management and general expenses 277,423. Fundraising expenses 0. Total expenses 1,151,964. Other Fees: Program service expenses 223,918. Management and general expenses 71,032. Fundraising expenses 0. Total expenses 294,950. Form 990, Part XI, line 9: Change in Joint Venture -48,112. Form 990, Part XII, Line 2C, Oversight of Audit: The board of trustees assumes responsibility for oversight of the audit of the financial statements and selection of the independent accountant; and no processes have changed from prior year. Gibson General Health Foundation Inc 1808 Sherman drive princeton IN 47670 350950175 philanthropic support of the hospital IN 501(c)(3) Line 12a, I Gibson General 1 gibson general hospital pain management llc 1808 sherman drive princeton IN 47670 472156126 pain management services IN related 36717 12281 0 0 0.51000 0 0 1 0 0 0 0 0 0 0 0 0 0 1 1 0 0 0 0 Form 990, Schedule R, Part III, Line 1 Gibson General Hospital Pain Management, LLC was dissolved during 2017 and all amounts will be liquidated prior to September 30, 2017.