2017-11-13T14:48:39-06:00 2016-12-31 381357951 PLANTE & MORAN PLLC 250 S High St Suite 100 Columbus OH 43215 990 2016-01-01 341883284 LIMA MEMORIAL JOINT OPERATING COMPANY LIMA 4192283335 1001 BELLEFONTAINE AVENUE lima OH 45804 JOHN T FISCHBACH VICE-PRESIDENT/CFO 4192283335 2017-11-10 1 Bernie Ostrowski P00366367 6148493000 2017-11-10 74.113.40.52 2017-11-10 07:24:46 ES P DA39A3EE5E6B4B0D3255BFEF95601890AFD80709 CDA108602048A852A3C7A9C68094104E2D92ED46 2016 2017-02-10 21:41:12Z LIMA MEMORIAL HEALTH SYSTEM MICHAEL D SWICK 1001 BELLEFONTAINE AVENUE lima OH 45804 203647591 0 X www.limamemorial.org X 1999 OH AS ONE OF THE LARGEST NOT-FOR-PROFIT HEALTH CARE ORGANIZATIONS IN WEST CENTRAL OHIO, LIMA MEMORIAL HEALTH SYSTEM IS COMMITTED TO IMPROVING THE QUALITY OF LIFE IN OUR COMMUNITIES THROUGH COMPREHENSIVE HEALTH SERVICES. LIMA MEMORIAL IS CONTINUALLY IMPROVING ITS SERVICES AND FACILITIES BY KEEPING UP WITH THE LATEST TECHNOLOGIES, PROVIDING CONTINUING EDUCATION TO OUR HEALTH CARE TEAM AND UPDATING OUR FACILITIES. OUR PATIENT SATISFACTION NUMBERS CONTINUE TO IMPROVE AND WE CONTINUALLY ACHIEVE QUALITY SCORES THAT ARE BETTER THEN THE STATE AND NATIONAL AVERAGES. 12 11 1719 485 611395 -120020 75401 49868 186322857 199112046 1308940 1550656 1973047 2630495 189680245 203343065 401457 615563 0 0 77891724 82649070 0 0 78292 94446828 100091616 172740009 183356249 16940236 19986816 299784042 328758731 97209373 102624152 202574669 226134579 X WE ARE HERE TO IMPROVE THE QUALITY OF LIFE IN OUR COMMUNITIES THROUGH COMPREHENSIVE HEALTH SERVICES. 0 0 151326401 615563 201102436 AS ONE OF THE LARGEST NOT-FOR-PROFIT HEALTHCARE ORGANIZATIONS IN WEST CENTRAL OHIO, LIMA MEMORIAL HEALTH SYSTEM IS COMMITTED TO IMPROVING THE QUALITY OF LIFE IN OUR COMMUNITIES THROUGH COMPREHENSIVE HEALTH SERVICES. LIMA MEMORIAL IS CONTINUALLY IMPROVING ITS SERVICES AND FACILITIES BY KEEPING UP WITH THE LATEST TECHNOLOGIES, PROVIDING CONTINUING EDUCATION TO OUR HEALTHCARE TEAM AND UPDATING OUR FACILITIES. OUR PATIENT SATISFACTION NUMBERS CONTINUE TO IMPROVE AND WE CONTINUALLY ACHIEVE QUALITY SCORES THAT ARE BETTER THAN STATE AND NATIONAL AVERAGES.THE HEALTH SYSTEM PROVIDES COMPREHENSIVE HEALTHCARE THAT ALLOWS US TO CARE FOR PATIENTS FROM BIRTH THROUGH ELDER YEARS. THESE SERVICES INCLUDE, BUT ARE NOT LIMITED TO:- 24-HOUR EMERGENCY SERVICES INCLUDING LEVEL II TRAUMA- ACCREDITED CHEST PAIN CENTER- THE HEART AND VASCULAR INSTITUTE- COMMISSION ON CANCER ACCREDITED CANCER INSTITUTE- ORTHOPEDICS- OBSTETRICS, LEVEL II NURSERY AND PEDIATRICS- WOMEN'S HEALTH CENTER- ROBOTIC SURGERY PROGRAM- DIAGNOSTIC & IMAGING- LABORATORY- INPATIENT AND OUTPATIENT REHABILITATION SERVICES- NEUROSCIENCE PROGRAM- UROLOGYIN 2016, LIMA MEMORIAL CONTRIBUTED AN ESTIMATED $36 MILLION IN COMMUNITY VALUE IN TERMS OF COMMUNITY BENEFIT EXPENDITURES, CHARITY CARE AND GOVERNMENT-SPONSORED HEALTH CARE. THIS NUMBER NOT ONLY INDICATES OUR COMMITMENT TO OUR COMMUNITIES, BUT ALSO FULFILLS OUR PURPOSE AS A NOT-FOR-PROFIT ORGANIZATION BY POSITIVELY IMPACTING THE MEMBERS OF THE COMMUNITIES THAT WE SERVE. THOUSANDS OF PEOPLE HAVE BENEFITED FROM THE COMPASSIONATE CARE AND EXPERTISE OF OUR PHYSICIANS, NURSES, ASSOCIATES AND VOLUNTEERS.EXAMPLES OF PROGRAMS BENEFITING THE BROADER COMMUNITY INCLUDE, BUT ARE NOT LIMITED TO:- EMS OUTREACH & EDUCATION- GO RED - HEART HEALTH AWARENESS CAMPAIGN- COLORECTAL AWARENESS CAMPAIGN- JOURNEY TO REMEMBER RAISED FUNDS FOR LUNG CANCER DIAGNOSTICS- BREAST CANCER AWARENESS CAMPAIGN- KIDS CLINIC FOR CHILDREN WHO HAVE BEEN SEXUALLY ABUSED- CHILDREN'S DEVELOPMENTAL CENTER SUPPORT- BABY FAIR- CHEST PAIN CENTER- BONE DENSITY SCREENINGS- CARDIAC RISK ASSESSMENT SCREENINGS- PROSTATE CANCER AWARENESS CAMPAIGN & SCREENINGS- KIDNEY DISEASE SCREENINGS- SKIN CANCER SCREENINGS- CANCER RESOURCE CENTER- MEDICARE ELIGIBILITY PROGRAM- BREAST CANCER SURVIVOR SUPPORT GROUP- MENDED HEARTS SUPPORT GROUP- FAMILY BIRTH EDUCATION & CLINICS- DIABETIC EDUCATION- WOMEN'S RESOURCE CENTER- CONGESTIVE HEART FAILURE CLINIC- TV AND RADIO PSAS- BREASTFEEDING CLASS AND CLINIC- SMOKING CESSATION- COMMUNITY BLOOD DRIVESAS HEALTHCARE CONTINUES TO CHANGE, LIMA MEMORIAL WILL CONTINUE TO PROVIDE THE HIGHEST QUALITY OF CARE IN A FAMILY ATMOSPHERE TO OUR PATIENTS BY CONTINUALLY ADVANCING OUR SERVICES AND FACILITIES. IN ADDITION, THE HEALTH SYSTEM SUPPORTS OUR COMMUNITIES, NOT ONLY THROUGH COMPREHENSIVE HEALTHCARE, BUT THROUGH OUTREACH ACTIVITIES SUCH AS HEALTHCARE AWARENESS AND PREVENTION PROGRAMS, FREE PUBLIC HEALTH SCREENINGS, FINANCIAL SUPPORT FOR MANY COMMUNITY NON-PROFIT ORGANIZATIONS, AND OUTREACH TO THE UNDERSERVED.COMMUNITY BENEFIT DEFINITIONSLIMA MEMORIAL HEALTH SYSTEM'S 2016 COMMUNITY BENEFIT REPORT WAS PREPARED IN ACCORDANCE WITH THE REPORTING GUIDELINES PUBLISHED BY THE CATHOLIC HEALTH ASSOCIATION. COMMUNITY BENEFITS REPORTED BY THE HEALTH SYSTEM RESPOND TO AN IDENTIFIED COMMUNITY NEED AND MEET AT LEAST ONE OF THE FOLLOWING CRITERIA:- GENERATE A LOW OR NEGATIVE MARGIN;- RESPOND TO THE NEEDS OF SPECIAL POPULATIONS, SUCH AS MINORITIES, FRAIL, ELDERLY, POOR PERSONS WITH DISABILITIES, THE CHRONICALLY MENTALLY ILL, AND PERSONS WITH AIDS; AND-SUPPLY SERVICES OR PROGRAMS THAT WOULD LIKELY BE DISCONTINUED IF THE DECISION WERE MADE ON A PURELY FINANCIAL BASIS.THESE SERVICES INCLUDE:- COMMUNITY HEALTH SERVICES- HEALTH PROFESSIONS EDUCATION- SUBSIDIZED HEALTH SERVICES- RESEARCH ACTIVITIES- FINANCIAL CONTRIBUTIONS- COMMUNITY BUILDING ACTIVITIES- COMMUNITY BENEFIT OPERATIONS- COST OF CHARITY CARE- GOVERNMENT SPONSORED HEALTH CARE 151326401 1 1 0 1 0 0 0 0 0 0 1 0 0 1 1 1 0 1 0 0 0 0 0 0 0 0 1 1 1 0 1 1 0 0 0 0 0 0 0 0 1 0 0 0 0 0 0 1 1 1 0 0 1 278 0 1 1719 1 1 1 0 0 0 0 0 0 0 0 0 X 12 11 0 0 0 0 1 0 0 1 1 0 0 1 1 1 1 1 1 1 1 1 1 X MERI FOSTER 4192265197 1001 BELLEFONTAINE AVENUE LIMA OH 45804 JOHN H JOHNSON CHAIR 1.00 1.00 X X 0 0 0 KERMIT F STROH TREASURER 1.00 1.00 X X 0 0 0 BARRETT P RYDELL BOARD MEMBER 1.00 0.00 X 0 0 0 DEBRA MCCURDY BOARD MEMBER 1.00 0.00 X 0 0 0 ROBERT L THOMPSON BOARD MEMBER 1.00 0.00 X 0 0 0 PHILLIP R BUELL BOARD MEMBER 1.00 0.00 X 0 0 0 KATHLEEN M KRUEGER BOARD MEMBER 1.00 0.00 X 0 0 0 JAMES F BLAIR BOARD MEMBER 1.00 0.00 X 0 0 0 PRAVEEN K MALHOTRA BOARD MEMBER 1.00 0.00 X 0 0 0 SUSAN E PAYDEN BOARD MEMBER 1.00 0.00 X 0 0 0 KEVIN C WEBB BOARD MEMBER 1.00 0.00 X 0 0 0 RUTH WALL BOARD MEMBER 1.00 0.00 X 13290 0 0 MICHAEL D SWICK PRESIDENT/CEO (SEE SCH J) 34.00 6.00 X 579615 0 246377 ROBERT E ARMSTRONG JR SENIOR VP/COO (SEE SCH J) 30.00 10.00 X 343323 0 115851 JOHN T FISCHBACH VP OF FINANCE/CFO (SEE SCH J) 34.00 6.50 X 249220 0 54109 KHA H TRAN MD VP OF MEDICAL AFFAIRS (SEE SCH J) 20.00 20.00 X 292811 0 108309 ANN-MARIE JEAN POHL VICE PRESIDENT/CNO (SEE SCH J) 40.00 0.00 X 236520 0 62452 LYNN C CARPENTER EXECUTIVE DIRECTOR 40.00 0.00 X 151825 0 27492 DENISE G KIRALY DIRECTOR - HUMAN RESOURCS 40.00 0.00 X 155458 0 25430 MARK W RECKER DIRECTOR - PHARMACY 40.00 0.00 X 155017 0 16550 DENNIS E MORRIS PHYSICIAN ADVISOR 40.00 0.00 X 151600 0 13677 JAMES J STRAUB MANAGER - OUTPATIENT PHARMACY 40.00 0.00 X 137722 0 16026 2466401 0 686273 44 0 1 0 LIMA ANESTHESIA & PAIN TREATMENT PC PO BOX 33058 PALM BEACH GARDENS FL 33420 MEDICAL SERVICES 2623960 SODEXO INC & AFFILIATES 4880 PAYSPHERE CIRCLE CHICAGO IL 60674 FOOD & NUTRITION AND ENVIRONMENTAL SERVI 1833412 APOGEE MEDICAL MANAGEMENT INC 15059 N SCOTTSDALE ROAD SUITE 600 SCOTTSDALE AZ 85254 MEDICAL SERVICES 1492432 MARSHALL & MELHORN LLC FOUR SEAGATE EIGHTH FLOOR TOLEDO OH 43604 LEGAL SERVICES 1020936 EMERGENCY PHYSICIANS OF NW OHIO INC PO BOX 638133 CINCINNATI OH 45263 MEDICAL SERVICES 996040 43 41467 8401 49868 PATIENT SERVICE REV 621110 196885520 196885520 PHARMACY 900099 2097387 2097387 CLINIC REVENUE 621110 89591 89591 WELLNESS CENTER 900099 31895 31895 MEDICAL RECORDS 900099 4835 4835 2818 2818 199112046 1433415 1433415 987256 15595 971661 971661 971661 406172 288931 117241 117241 117241 MEANINGFUL USE REVENUE 900099 719067 719067 UBI- REFERENCE LAB 621500 611395 611395 CAFETERIA SALES 900099 28710 28710 299662 299662 1658834 203343065 201102436 611395 1579366 X 615563 615563 1714778 1714778 59935221 49884838 9996131 54252 1948756 1621974 325018 1764 14561024 12119324 2428520 13180 4489291 3736493 748734 4064 921732 921732 100006 100006 26272122 15064093 11208029 5885981 5272526 612962 493 2737482 2366280 369560 1642 312026 144348 167587 91 2281084 2281084 12560526 10857319 1703207 795795 519974 275821 MEDICAL SUPPLIES 29277158 29277158 BAD DEBT EXPENSE 12814372 12814372 EDUCATION & REWARDS 575697 149819 425830 48 Recruiting 569779 449781 119998 4987856 4151455 833643 2758 183356249 151326401 31951556 78292 22769091 21621649 275122 6638147 19500777 22253560 2429899 3057587 4337776 4439507 8301720 8162469 264349680 159183031 100687339 105166649 45366739 49336094 3116544 3391601 92999035 104691468 299784042 328758731 18238540 17651334 132000 132000 49475000 48185514 2819661 9692539 26544172 26962765 97209373 102624152 X 202503663 225997775 71006 136804 202574669 226134579 299784042 328758731 X 19986816 1100270 2472824 X X 0 1 X 1 0 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 0 0 0 0 0 0 0 0 1 9694 9694 0 Part II-B, Line 1: LOBBYING EXPENSES ARE INCURRED IN CONNECTION WITH THE DUES PAID TO THE OHIO HOSPITAL ASSOCIATION AND THE AMERICAN HOSPITAL ASSOCIATION. 4209201 4209201 152337346 99303924 53033422 105264743 57931503 47333240 2538390 1947604 590786 105166649 Investments in Affiliated Org. 104691468 104691468 Accrued Pension Liability 3708025 Professional Liability Reserve 1788461 FIN 47 Asbestos Liability 2952385 Third Party Payor Settlements 4386046 Fair Value of Interest Rate Swap Ag 14127848 26962765 X Part X, Line 2: THE HEALTH SYSTEM, LIMA MEMORIAL HOSPITAL, LIMA MEMORIAL PROFESSIONAL CORPORATION, LIMA MEMORIAL HOSPITAL FOUNDATION, AND LIMA MEMORIAL HOSPITAL AUXILIARY ARE NOT-FOR-PROFIT CORPORATIONS AS DESCRIBED IN SECTION 501(C)(3) OF THE INTERNAL REVENUE CODE (THE "CODE") AND ARE EXEMPT FROM FEDERAL INCOME TAXES PURSUANT TO SECTION 501(A) OF THE CODE. ELM TREE FOUNDATION, THE FOR-PROFIT SUBSIDIARY, IS A TAXABLE CORPORATION. ELM TREE FOUNDATION HAD NET OPERATING LOSS CARRYFORWARDS OF $763,936 AND $657,739 ON ITS FILED INCOME TAX RETURNS IN 2016 AND 2015, RESPECTIVELY. ACCOUNTING PRINCIPLES GENERALLY ACCEPTED IN THE UNITED STATES OF AMERICA REQUIRE MANAGEMENT TO EVALUATE TAX POSITIONS TAKEN BY THE HEALTH SYSTEM AND TO RECOGNIZE A TAX LIABILITY IF THE HEALTH SYSTEM HAS TAKEN AN UNCERTAIN POSITION THAT MORE LIKELY THAN NOT WOULD NOT BE SUSTAINED UPON EXAMINATION BY THE INTERNAL REVENUE SERVICE OR OTHER APPLICABLE TAXING AUTHORITIES. 1 1 X 1 X 1 X 1 1 0 0 2035736 3827095 0 0.00000 29920219 21201156 8719063 0.05110 31955955 25028251 8719063 0.05110 13299272 0 13299272 0.07800 13299272 13299272 0.07800 45255227 25028251 22018335 0.12910 1 12814372 1153293 44036814 56189565 -12152751 X 1 1 1 LMHS WOMEN'S HEALTH CO-MANAGEMENT COMPANY LLC CO-MANAGEMENT 0.50000 0.50000 1 1 LIMA MEMORIAL HEALTH SYSTEM 1001 BELLEFONTAINE AVE LIMA OH 45804 X X X LIMA MEMORIAL HEALTH SYSTEM 1 0 0 1 X X X X X X X X X 13 1 0 0 1 X WWW.LIMAMEMORIAL.ORG 1 14 1 WWW.LIMAMEMORIAL.ORG 0 1 X 200.000000000000 400.000000000000 X X X X X 1 1 X X X 1 X HTTP://WWW.LIMAMEMORIAL.ORG/PATIENT-RESOURCES/FINANCIAL-ASSISTANCE X HTTP://WWW.LIMAMEMORIAL.ORG/PATIENT-RESOURCES/FINANCIAL-ASSISTANCE X HTTP://WWW.LIMAMEMORIAL.ORG/PATIENT-RESOURCES/FINANCIAL-ASSISTANCE X X X X X X 1 X 0 X X X X X 1 X 0 0 Part V, Section A: REV PROC 2015-21: CORRECTION OF ERRORTHE MOST RECENT COMMUNITY HEALTH NEEDS ASSESSMENT AND IMPLEMENTATION STRATEGY WERE APPROVED BY THE BOARD IN AUGUST 2017. BASED ON THE THREE YEAR CYCLE REQUIREMENTS UNDER IRC 501(R), THE REPORT SHOULD HAVE BEEN APPROVED BY THE BOARD IN 2016 IN ORDER TO MEET THE "CONDUCTED" REQUIREMENT UNDER THE REGULATIONS. UPON DISCOVERY OF THE MISSED "CONDUCTED" REQUIREMENT, LIMA MEMORIAL HEALTH SYSTEM QUICKLY BROUGHT THE COMMUNITY HEALTH NEEDS ASSESSMENT TO THE BOARD FOR APPROVAL IN AUGUST 2017. THE MOST RECENT COMMUNITY HEALTH NEEDS ASSESSMENT, AS WELL AS THE 2013 COMMUNITY HEALTH NEEDS ASSESSMENT, ARE MADE AVAILABLE ON THE HOSPITAL WEBSITE HTTP://WWW.LIMAMEMORIAL.ORG/COMMUNITY-HEALTH-NEEDS-ASSESSMENT/. TO ENSURE THAT THE THREE YEAR CYCLE REQUIREMENT IS CONSISTENTLY MET IN FUTURE YEARS, LIMA MEMORIAL HEALTH SYSTEM IS WORKING WITH ITS PARTNERING ORGANIZATIONS TO ESTABLISH A TIMELINE FOR INFORMATION GATHERING AND ANALYSIS THAT MEETS THE TIMELINE REQUIREMENT UNDER IRC 501(R). SINCE THE 2016 FORM 990 SCHEDULE H WILL NOT ALLOW 2017 TO BE NOTED AS THE DATE ON SCHEDULE H PART V, THE 2013 DATE IS PRESENTED. STATEMENTS ON THE SCHEDULE H APPLY TO THE MOST RECENTLY CONDUCTED COMMUNITY HEALTH NEEDS ASSESSMENT, WHICH IS THE 2017 COMMUNITY HEALTH NEEDS ASSESSMENT. LIMA MEMORIAL HEALTH SYSTEM Part V, Section B, Line 5: COMMUNITY MEMBERS FROM THE GROUPS, ORGANIZATIONS, AND SECTORS ESTABLISHED THE COMMUNITY SUSTAINABILITY ADVISORY COMMITTEE UNDER THE LIMA-ALLEN COUNTY REGIONAL PLANNING COMMISSION. THE COMMUNITY SUSTAINABILITY ADVISORY COMMITTEE WAS RESPONSIBLE FOR THE IMPLEMENTATION OF THE HEALTHY COMMUNITIES INSTITUTE SOFTWARE, WHICH HAS BEEN USED AS THE BASIS FOR THE COMMUNITY HEALTH NEEDS ASSESSMENT. THE HEALTHY COMMUNITIES INSTITUTE WEBSITE PROVIDED A LIST OF IDENTIFIED HEALTH CONDITIONS AND RELATED INDICATORS FOR ALLEN COUNTY. THE INFORMATION FOR AUGLAIZE AND PUTNAM COUNTIES WAS ANALYZED UNDER THE SAME QUARTILE SYSTEM.ORGANIZATION'S CONTACTED:ALLEN COUNTY ECONOMIC DEVELOPMENT GROUPALLEN COUNTY HEALTH DEPARTMENTLIMA/ALLEN COUNTY CHAMBER OF COMMERCESHAWNEE TOWNSHIP POLICEST. RITA'S MEDICAL CENTERUNITED WAY OF GREATER LIMA AND YMCAIN ADDITION, LEADERS, REPRESENTATIVES, OR MEMBERS OF MEDICALLY UNDERSERVED, LOW-INCOME AND MINORITY POPULATIONS AND POPULATIONS WITH CHRONIC DISEASE NEEDS WERE CONTACTED. THE HOSPITAL ALSO DERIVES ADDITIONAL INFORMATION FROM THE COMMUNITY HEALTH IMPROVEMENT PLAN COMMITTEE AND THE HEALTHY PEOPLE 2020 COMMITTEE. LIMA MEMORIAL HEALTH SYSTEM Part V, Section B, Line 11: THE HOSPITAL HAS ADOPTED AN IMPLEMENTATION STRATEGY FOR 2014-2016 THAT ADDRESSES THE COMMUNITY HEALTH NEEDS IDENTIFIED IN THE COMMUNITY HEALTH NEEDS ASSESSMENT. THIS REPORT IS POSTED ON THE HOSPITAL'S WEBSITE WWW.LIMAMEMORIAL.ORG WHICH IS PAIRED WITH THE HEALTH SYSTEM'S STRATEGIC PLAN. LIMA MEMORIAL HEALTH SYSTEM Part V, Section B, Line 20e: - CONSPICUOUS NOTICE ON BILLING STATEMENTS- PHONE CALLS 3 1 - MEDICAL PARK 525 EASTOWN RD LIMA OH 45807 MRI, CT 2 - YMCA - WELLNESS CENTER 345 S ELIZABETH ST LIMA OH 45801 WELLNESS CENTER 3 - HINO 951 COMMERCE PKWY LIMA OH 45804 CARDIAC TREATMENT Part I, Line 7: COLUMN C, LINE 7A & 7B: THE HOSPITAL USED A COST-TO-CHARGE COSTING METHODOLOGY TO CALCULATE THE AMOUNTS REPORTED IN LINE 7. THE HOSPITAL DERIVED THE COST-TO-CHARGE RATIO FROM THE USE OF WORKSHEET 2.PART I, LINE 7E:IN ADDITION TO LIMA MEMORIAL JOINT OPERATING COMPANY'S COMMUNITY HEALTH IMPROVEMENT SERVICES AND COMMUNITY BENEFIT OPERATIONS, THIS LINE AMOUNT ALSO INCLUDES COMMUNITY BENEFIT PROVIDED BY LIMA MEMORIAL PROFESSIONAL CORPORATION, WHICH IS A RELATED ENTITY, IN AS MUCH AS LIMA MEMORIAL PROFESSIONAL CORPORATION'S ACTIVITY, ARE CARRIED ON IN A MANNER CONSISTENT WITH AND DIRECTLY IN CONNECTION WITH THE TAX EXEMPT PURPOSE OF LIMA MEMORIAL JOINT OPERATING COMPANY. Part I, Ln 7 Col(f): THE BAD DEBT EXPENSE INCLUDED ON FORM 990, PART IX, LINE 24B, COLUMN (A), BUT SUBTRACTED FOR PURPOSES OF CALCULATING THE PERCENTAGE OF THIS COLUMN IS $12,814,372. PART I, LINE 3B IN 2016, THE FPG FOR DISCOUNTED CARE INCREASED TO 400%. Part II, Community Building Activities: LIMA MEMORIAL HEALTH SYSTEM PROMOTES THE HEALTH OF OUR COMMUNITIES BY PROVIDING SERVICE REGARDLESS OF ABILITY TO PAY, FUNDING THROUGH SPONSORSHIP, HEALTH SCREENINGS AND EDUCATION. WE WORK WITH A NUMBER OF ORGANIZATIONS THROUGHOUT THE REGION, INCLUDING THE CHAMBER OF COMMERCE, TO PROMOTE THE ECONOMIC GROWTH OF THE COMMUNITY. WE ARE ACTIVELY INVOLVED WITH THE RHODES STATE SCHOOL OF NURSING, THE UNIVERSITY OF NORTHWEST OHIO, APOLLO CAREER CENTER, AS WELL AS CONTINUING EDUCATION AND TRAINING FOR EMTS AND PARAMEDICS. Part III, Line 2: BASED ON GROSS AS PRESENTED IN THE FINANCIAL STATEMENTS. Part III, Line 3: BAD DEBT IS ATTRIBUTABLE TO PATIENTS IDENTIFIED UNDER CHARITY CARE WAS ESTIMATED BY A THIRD PARTY THROUGH SCREENING OF BAD DEBT PATIENTS AT POVERTY LEVEL. THE HOSPITAL APPLIES ANY DISCOUNTS/PAYMENTS RECEIVED AGAINST PATIENTS ACCOUNTS BEFORE DETERMINING BAD DEBT EXPENSE. Part III, Line 4: ACCOUNTS RECEIVABLE FOR PATIENTS, INSURANCE COMPANIES AND GOVERNMENTAL AGENCIES ARE BASED ON GROSS CHARGES. AN ALLOWANCE FOR CONTRACTUAL ADJUSTMENTS AND INTERIM PAYMENT ADVANCES IS BASED ON EXPECTED PAYMENT RATES FROM PAYORS BASED ON CURRENT REIMBURSEMENT METHODOLOGIES. THIS AMOUNT ALSO INCLUDES AMOUNTS RECEIVED AS INTERIM PAYMENTS AGAINST UNPAID CLAIMS BY CERTAIN PAYORS. THE ALLOWANCE FOR CONTRACTUAL ADJUSTMENTS IS REPORTED AS PART OF THE PATIENT ACOUNTS RECEIVABLE AMOUNT ON THE CONSOLIDATED BALANCE SHEET. AN ALLOWANCE FOR UNCOLLECTIBLE ACCOUNTS IS ESTABLISHED ON AN AGGREGATE BASIS BY USING HISTORICAL WRITE-OFF RATE FACTORS APPLIED TO UNPAID ACCOUNTS BASED ON AGING. LOSS RATE FACTORS ARE BASED ON HISTORICAL LOSS EXPERIENCE AND ADJUSTED FOR ECONOMIC CONDITIONS AND OTHER TRENDS AFFECTING THE HOSPITAL'S ABILITY TO COLLECT OUTSTANDING AMOUNTS. UNCOLLECTIBLE AMOUNTS ARE WRITTEN OFF AGAINST THE ALLOWANCE FOR DOUBTFUL ACCOUNTS IN THE PERIOD THEY ARE DETERMINED TO BE UNCOLLECTIBLE. Part III, Line 8: SECTION B: BASED ON A COST-TO-CHARGE RATIO DETERMINED IN ACCORDANCE WITH THE MEDICARE COST REPORT REQUIREMENTS, THE COSTS OF PROVIDING CARE TO THE MEDICARE POPULATION IN 2016 WAS $56,189,565. THE PAYMENTS RELATED TO THESE SERVICES WERE $44,036,814. LEAVING A MEDICARE SHORTFALL OF $12,152,751 FOR THE YEAR. THE MEDICARE SHORTFALL IS A COMMUNITY BENEFIT BECAUSE PROVIDING SERVICES TO THE ELDERLY IS A TAX EXEMPT PURPOSE CONSISTENT WITH LIMA MEMORIAL JOINT OPERATING COMPANY'S OVERALL EXEMPT STATUS, AND THE HOSPITAL ACCEPTS THESE PATIENTS REGARDLESS OF ITS IMPACT ON OVERALL PROFITABILITY. Part III, Line 9b: ALL PATIENTS REGARDLESS OF THEIR ABILITY TO PAY ARE CHARGED THE SAME AMOUNT. THE FACILITY ATTEMPTS TO SCREEN ALL SELFPAY PATIENTS AND PROVIDES INFORMATION TO THEM CONCERNING CHARITY POLICIES. AT TIMES, PATIENTS ARE REQUESTED TO PROVIDE PROOF OF INCOME. OF THOSE PATIENTS THAT ARE NOT SCREENED AND DO NOT RETURN THE REQUIRED PAPERWORK, THEY ARE CHARGED FULL PRICE FOR THEIR SERVICE UNTIL PROOF OR A COMPLETED AND SIGNED APPLICATION IS RECEIVED. THE LEAST DISCOUNT RECEIVED IS 40% WHCIH IS LARGER THAN THE AVERAGE COMMERCIAL CSA Part VI, Line 2: LIMA MEMORIAL HEALTH SYSTEM (LMHS) REGULARLY PARTICIPATES IN COMPREHENSIVE COMMUNITY HEALTH NEEDS ASSESSMENTS TO IDENTIFY FAR-REACHING HEALTH NEEDS FACED BY PEOPLE IN THE COMMUNITIES SERVED BY THE HEALTH SYSTEM. ASSESSMENT RESULTS ARE EVALUATED OVER TIME AND SERVE AS THE BASIS TO DEVELOP NEW OR EXPANDED PLANS TO ADDRESS SERVICES IN RESPONSE TO NEEDS.LMHS JOINED OTHER AREA ORGANIZATIONS TO DEVELOP, IMPLEMENT AND UTILIZE THE 2014 ALLEN COUNTY COMMUNITY HEALTH NEEDS ASSESSMENT. THE NEEDS ASSESSMENT COLLECTED DATA FOR ALLEN COUNTY ADULTS (AGES 19 YEARS OF AGE AND OLDER) AND YOUTH (AGES 12 THROUGH 18) WHO PARTICIPATED IN A COUNTY-WIDE ASSESSMENT SURVEY DURING 2013-2014. THE FINDINGS ARE BASED ON SELF-ADMINISTERED SURVEYS USING A STRUCTURED QUESTIONNAIRE. THE QUESTIONS WERE MODELED AFTER SURVEY INSTRUMENTS USED BY THE CENTERS FOR DISEASE CONTROL AND PREVENTION FOR THEIR NATIONAL AND STATE BEHAVIORAL RISK FACTOR SURVEILLANCE SYSTEM AND YOUTH RISK BEHAVIOR SURVEILLANCE SYSTEM.THE SURVEY ASSESSED THE FOLLOWING AREAS: COMMUNITY CONCERNS AND SERVICES, PHYSICAL HEALTH ISSUES AND BEHAVIORAL HEALTH ISSUES. FOR AREAS OUTSIDE OF ALLEN COUNTY, LIMA MEMORIAL UTILIZES DATA FROM ADDITIONAL COUNTY-BASED NEEDS ASSESSMENT WHEN AVAILABLE. SURVEY RESULTS ARE BEING USED TO SHAPE COMMUNITY OUTREACH EFFORTS.IN 2016, LIMA MEMORIAL WAS INVOLVED WITH THE COMMUNITY HEALTH IMPROVEMENT PLANNING COMMITTEE THROUGH PARTICIPATION AND FUNDING IN CONJUNCTION WITH THE CITY OF LIMA AND THE ALLEN COUNTY YMCA. A PORTION OF THIS PROGRAM IS DEDICATED TO REVIEWING THE NEEDS AND RISKS OF ALLEN COUNTY. OBESITY, ESPECIALLY CHILDHOOD OBESITY, WAS DETERMINED TO BE A SIGNIFICANT HEALTH RISK. LIMA MEMORIAL HEALTH SYSTEM IS PART OF THE ACTIVATE ALLEN COUNTY LEADERSHIP COMMITTEE, WHICH ADDRESSES A VARIETY OF HEALTH-RELATED NEEDS IN THE COMMUNITIES WE SERVE. THIS COMMITTEE IS COMMITTED TO REDUCING OBESITY AND SMOKING IN LIMA AND ALLEN COUNTY BY PROMOTING HEALTHY EATING, ACTIVE LIVING AND A TOBACCO-FREE LIFESTYLE.ASSESSMENT SUMMARYDESIRED OUTCOMES FOR ALLEN COUNTY RESIDENTS: REDUCE RISK FOR CHRONIC DISEASE, REDUCE POOR BIRTH OUTCOMES (E.G. LOW BIRTHWEIGHT AND PRETERM DELIVERIES), REDUCE INFANT MORTALITY, REDUCE SUICIDE RATE, REDUCE SUBSTANCE ABUSE, AND INCREASE ACCESS TO HEALTH CARE. Part VI, Line 3: ALL PATIENTS OF LIMA MEMORIAL HOSPITAL ARE EDUCATED ON THE HOSPITAL'S CHARITY CARE PROGRAM DURING THE REGISTRATION PROCESS VIA WALL-POSTED STATEMENTS, HOSPTIAL PERSONNEL INQUIRIES, ETC. INFORMATION REGARDING THE HOSPITIAL'S CHARITY CARE IS ALSO FOUND ON LIMA MEMORIAL'S WEBSITE. STATEMENTS GOING TO PATIENTS ALSO IDENTIFY THIS PROGRAM. Part VI, Line 4: AS OF THE CENSUS OF 2000, THERE WERE 108,473 PEOPLE, 40,066 HOUSEHOLDS, AND 28,208 FAMILIES RESIDING IN THE COUNTY. THE POPULATION DENSITY WAS 268 PEOPLE PER SQUARE MILE. THERE WERE 44,245 HOUSING UNITS AT AN AVERAGE DENSITY OF 109 PER SQUARE MILE. THE RACIAL MAKEUP OF THE COUNTY WAS 84.95% CAUCASIAN, 12.19% AFRICAN AMERICAN, 0.21% NATIVE AMERICAN, 0.55% ASIAN, 0.01% PACIFIC ISLANDER, 0.63% FROM OTHER RACES, AND 1.45% FROM TWO OR MORE RACES. 1.42% OF THE POPULATION WERE HISPANIC/LATINO, 33.8% WERE GERMAN, 14.2% AMERICAN, 8.8% IRISH AND 6.6% ENGLISH ANCESTRY ACCORDING TO THE CENSUS 2000. THERE 40,646 HOUSEHOLDS OUT OF WHICH 32.9% HAD CHILDREN UNDER THE AGE OF 18 LIVING WITH THEM, 53% WERE MARRIED COUPLES LIVING TOGETHER, 12.4% HAD A FEMALE HOUSEHOLDER WITH NO HUSBAND PRESENT AND 30.6% WERE NON-FAMILIES. 26.3% OF ALL HOUSEHOLDS WERE MADE UP OF INDIVIDUALS AND 11.2% HAD SOMEONE LIVING ALONE WHO WAS 65 YEARS OF AGE OR OLDER. THE AVERAGE HOUSEHOLD SIZE WAS 2.52 AND THE AVERAGE FAMILY SIZE WAS 3.05. IN THE COUNTY THE POPULATION WAS SPREAD OUT WITH 25.9% UNDER THE AGE OF 18, 9.9% FROM 18 TO 24, 27.6% FROM 25 TO 44, 22.4% FROM 45 TO 64, AND 14.2% WHO WERE 65 YEARS OF AGE OR OLDER. THE MEDIAN AGE WAS 36 YEARS. FOR EVERY 100 FEMALES THERE WERE 100 MALES. FOR EVERY 100 FEMALES AGE 18 AND OVER THERE WERE 98 MALES. THE MEDIAN INCOME FOR A HOUSEHOLD IN THE COUNTY WAS $37,408 AND THE MEDIAN INCOME FOR A FAMILY WAS $44,723. MALES HAD A MEDIAN INCOME OF $35,546 VERSUS $23,537 FOR FEMALES. THE PER CAPITA INCOME FOR THE COUNTY WAS $17,511. ABOUT 9.6% OF FAMILIES AND 12.1% OF THE POPULATION WERE BELOW THE POVERTY LINE, INCLUDING 17% OF THOSE UNDER AGE 18 AND 9.6% OF THOSE AGE 65 OR OVER. LIMA MEMORIAL HEALTH SYSTEM SERVES A 10 COUNTY AREA THAT INCLUDES MORE THAN 475,000 PEOPLE. THE COUNTIES INCLUDE ALLEN, AUGLAIZE, PUTNAM, HANCOCK, MERCER, HARDIN, LOGAN, SHELBY, PAULDING AND VAN WERT. THE MEDIAN HOUSEHOLD INCOME FOR THE REGION IS $44,300. 24% IF RESIDENTS ARE UNDER 18 YEARS OLD, WHILE 14.5% OF RESIDENTS ARE 65 YEARS OLD OR OLDER. 95.4% OF OUR ENTIRE SERVICE AREA IS CAUCASIAN, WHILE 2.75% ARE AFRICAN AMERICAN. IN OUR PRIMARY SERVICE AREA OF ALLEN COUNTY 85.6% ARE CAUCASIAN, WHILE 11.7% ARE AFRICAN AMERICAN. THE REGION IS PRIMARILY RURAL WITH SMALL COMMUNITIES. THE LARGEST CITY IN THE REGION IS LIMA WITH A POPULATION OF 38,771. Part VI, Line 5: LIMA MEMORIAL HEALTH SYSTEM CONTINUES TO INCREASE OUR COMMUNITY INVESTMENT THROUGH PARTICIPATION AND SPONSORSHIP OF LOCAL AND REGIONAL EVENTS THAT PROMOTE HEALTHY LIFESTYLE CHOICES, PREVENTATIVE CARE AND CHRONIC DISEASE MANAGEMENT.BEYOND THE NUMBERS: KEY COMMUNITY BENEFIT ACTIVITIES OF 2016LIMA MEMORIAL HEALTH SYSTEM DEVELOPS PROGRAMS AND SERVICES TO ADDRESS COMMUNITY HEALTH NEEDS AND MAKES INVESTMENTS IN INITIATIVES THAT ALIGN WITH OUR MISSION, VISION AND VALUES. MUCH OF LIMA MEMORIAL HEALTH SYSTEM'S COMMUNITY BENEFIT INVESTMENT FOR 2016 WAS IN THE AREA OF CHARITABLE CARE AND WELLNESS. THIS ENABLED THOSE WITHOUT INSURANCE OR WITH LIMITED INSURANCE TO ACCESS MEDICAL CARE AND SCREENING HEALTH TESTS.BEYOND THAT FOCUS ARE PROGRAMS AND SERVICES THAT BENEFIT EVERY RESIDENT AND SUPPORT THE FAR REACHING GOAL OF A HEALTHIER WEST CENTRAL OHIO. LIMA MEMORIAL HEALTH SYSTEM CANNOT MEET ALL OF THE HEALTHCARE NEEDS WITHOUT THE ENGAGEMENT AND SUPPORT OF KEY STAKEHOLDERS INCLUDING OUR MEDICAL STAFF AND OTHER COMMUNITY ORGANIZATIONS.COMMUNITY HEALTH SERVICESIN 2016, LIMA MEMORIAL HEALTH SYSTEM PROVIDED AND/OR PARTICIPATED IN NUMEROUS COMMUNITY HEALTH SERVICE PROGRAMS. INCLUDED IN THIS CATEGORY ARE HEALTH AND WELLNESS EDUCATION, HEALTH SCREENINGS, COMMUNITY DEVELOPMENT AND SERVICES TO HELP PEOPLE ADOPT HEALTHY LIFESTYLE CHANGES. ALSO INCLUDED ARE THE MYRIAD OF SUPPORT GROUP ACTIVITIES THAT HELP PATIENTS AND THEIR FAMILIES MANAGE CHRONIC HEALTH CONDITIONS.KEY INITIATIVES THE PAST YEAR INCLUDE DIAGNOSTIC HEART AND VASCULAR SCREENINGS FOR AT-RISK ADULTS, CHILDHOOD DIABETES EDUCATION IN AREA SCHOOLS, INJURY PREVENTION AND AWARENESS, BREAST AND LUNG SCREENINGS AND HEALTHY EATING EVENTS.A THIRD SUBSET OF THIS CATEGORY INCLUDES HEALTH CARE SUPPORT SERVICES, OR THOSE SERVICES THAT ARE PROVIDED TO ASSIST COMMUNITY MEMBERS IN ACCESSING BOTH INFORMATION AND THE MEDICAL CARE THAT THEY NEED. CHIEF AMONG THE HEALTH SYSTEM'S SUPPORT INITIATIVES ARE THE FINANCIAL COUNSELORS THAT ENSURE THAT PATIENTS WHO ARE STRUGGLING FINANCIALLY AND/OR LACK MEDICAL INSURANCE ARE AFFORDED THE CARE THAT THEY NEED.HEALTH PROFESSIONS EDUCATIONLIMA MEMORIAL HEALTH SYSTEM BELIEVES THAT HAVING HIGHLY TRAINED MEDICAL PERSONNEL BENEFITS EVERYONE IN THE COMMUNITY. BEYOND ONGOING EDUCATION FOR PHYSICIANS, NURSES, TECHNICIANS, AND OTHER CLINICIANS, THE HEALTH SYSTEM SUPPORTED NUMEROUS SPECIAL INITIATIVES IN 2016 TO FURTHER CAPABILITIES OF AREA MEDICAL PERSONNEL.OUR SCHOOLS OF NURSING PROGRAM PROVIDED A TRAINING SITE FOR OVER 450 NURSING STUDENTS IN 2016. LIMA MEMORIAL HEALTH SYSTEM ALSO PROVIDES EDUCATIONAL SUPPORT IN THE MEDICAL COMMUNITY BY PROVIDING HUNDREDS OF HOURS OF TRAINING FOR AREA EMT'S AND PARAMEDICS. FINANCIAL CONTRIBUTIONSLIMA MEMORIAL PROVIDES BOTH CASH AND IN-KIND SUPPORT TO INDIVIDUALS AND OTHER COMMUNITY ORGANIZATIONS. THE SPONSORSHIP FUND PROVIDES FUNDING SUPPORT TO WEST CENTRAL OHIO PROGRAMS THAT ADDRESS IDENTIFIED COMMUNITY NEEDS AND SERVE VULNERABLE POPULATIONS. IN 2016, LIMA MEMORIAL CONTRIBUTED TO MORE THAN 55 ORGANIZATIONS INCLUDING MARCH OF DIMES, YMCA OF LIMA, AMERICAN CANCER SOCIETY, THE UNITED WAY AND THE AMERICAN RED CROSS.COMMUNITY BENEFIT OPERATIONSFOR 2016, COMMUNITY BENEFITS EXPENSES RECORDED INCLUDES THE REPORT ON THE HEALTH SYSTEM'S COMMUNITY BENEFIT INVESTMENT. THE APPLICABLE COSTS FOR STAFF ENGAGING IN ACTUAL COMMUNITY BENEFIT SERVICES AND PROGRAMMING ARE REPORTED WITHIN SPECIFIC INITIATIVES AND ACTIVITIES.CHARITY CAREIN ACCORDANCE WITH REPORTING REQUIREMENTS, LIMA MEMORIAL'S CHARITY CARE EXPENSE IS BASED UPON COSTS VERSUS CHARGES. CHARITY CARE INCLUDES LIMA MEMORIAL'S TRADITIONAL INPATIENT AND EMERGENCY SERVICES. UPON APPROVAL FOR FINANCIAL ASSISTANCE, ALL HOSPITAL CARE IN THE ENSUING SIX MONTH PERIOD IS INCLUDED. THIS APPROACH ENSURES THAT ASSISTANCE IS PORTABLE AND THAT PATIENTS HAVE ACCESS TO NEEDED MEDICAL SERVICES BY MAKING A SINGLE APPLICATION.A KEY GOAL IS TO IDENTIFY COMMUNITY MEMBERS IN NEED SOONER. THE RESULT IS MORE CHARITY CARE AND FEWER BAD DEBTS.GOVERNMENT SPONSORED HEALTHCAREPAYMENT SHORTFALLS FOR PUBLIC INSURANCE PROGRAMS, INCLUDING MEDICAID AND MEDICARE, WERE $23,388,787 IN 2016. Part VI, Line 6: LIMA MEMORIAL HEALTH SYSTEM DEVELOPS PROGRAMS AND SERVICES TO ADDRESS COMMUNITY HEALTH NEEDS TO SUPPORT THE GOAL OF A HEALTHIER WEST CENTRAL OHIO. SEE SCHEDULE R FOR RELATED ENTITIES WITHIN LIMA MEMORIAL HEALTH SYSTEM THAT WORK TOGETHER TO SUPPORT THE COMMUNITY. Part VI, Line 7, Reports Filed With States OH 1 LIMA MEMORIAL FOUNDATION 1001 BELLEFONTAINE AVE LIMA OH 45804 341707570 501(C)3 7500 HEALTH INITIATIVE AUGLAIZE COUNTY AGRICULTURAL SOCIETY 101 FAIRVIEW DR WAPAKONETA OH 45895 344427752 501(C)3 17196 COMMUNITY DEVELOPMENT AMERICAN CANCER SOCIETY 250 WILLIAMS ST NW ATLANTA GA 30303 131788491 501(C)3 15000 COMMUNITY DEVELOPMENT/HEALTH AND WELLNESS ALLEN COUNTY AGRICULTURAL SOCIETY 2750 HARDING HWY LIMA OH 45804 346570403 501(C)3 19750 COMMUNITY DEVELOPMENT LIMA AREA FAMILY YMCA 345 S ELIZABETH ST LIMA OH 45801 344431173 501(C)3 267994 COMMUNITY DEVELOPMENT/HEALTH AND WELLNESS UNITED WAY 616 S COLLETT ST SUITE 101 LIMA OH 45805 344466356 501(C)3 17191 COMMUNITY DEVELOPMENT ALLEN COUNTY VISIONARIES PO BOX 176 LIMA OH 45802 341740545 501(C)3 15000 COMMUNITY DEVELOPMENT/HEALTH AND WELLNESS AMERICAN HEART ASSOCIATION 7272 GREENVILLE AVE Dallas TX 75231 135613797 501(C)3 10000 COMMUNITY DEVELOPMENT/HEALTH AND WELLNESS ALLEN ECONOMIC DEVELOPMENT GROUP-MAKERFEST 144 S MAIN ST LIMA OH 45801 341833790 501(C)3 10000 COMMUNITY DEVELOPMENT APOLLO EDUCATIONAL FOUNDATION 3325 SHAWNEE RD LIMA OH 45806 341624092 501(C)3 25000 COMMUNITY DEVELOPMENT COMMUNITY HEALTH SERVICES 410 BIRCHARD AVENUE FREMONT OH 43420 341120194 501(C)3 142500 COMMUNITY DEVELOPMENT/HEALTH AND WELLNESS HEALTHY PEOPLE 2020 219 E MARKET ST LIMA OH 45801 341856056 501(C)3 11000 HEALTH INITIATIVE 12 0 Part I, Line 2: IN MOST CASES THE EFFECTIVE USE OF FUNDS IS EVIDENT THROUGH THE POSITIVE RESULTS OF THE PROGRAMS WE FUND. IN ADDITION, LIMA MEMORIAL HAS BOARD REPRESENTATION ON MOST OF THE ORGANIZATIONS WE SUPPORT. IF THIS IS NOT THE CASE WE DO ASK FOR THEIR BUSINESS PLAN AND A LIST OF EXPENDITURES. X 1 1 X X X X X 0 1 0 0 0 0 0 0 0 MICHAEL D SWICK PRESIDENT/CEO (SEE SCH J) 352679 0 213202 0 13734 0 223681 0 22696 0 825992 0 0 0 ROBERT E ARMSTRONG JR SENIOR VP/COO (SEE SCH J) 233499 0 102708 0 7116 0 93155 0 22696 0 459174 0 0 0 JOHN T FISCHBACH VP OF FINANCE/CFO (SEE SCH J) 231105 0 12500 0 5615 0 54109 0 0 0 303329 0 0 0 KHA H TRAN MD VP OF MEDICAL AFFAIRS (SEE SCH J) 202210 0 84376 0 6225 0 78738 0 29571 0 401120 0 0 0 ANN-MARIE JEAN POHL VICE PRESIDENT/CNO (SEE SCH J) 163915 0 67771 0 4834 0 62452 0 0 0 298972 0 0 0 LYNN C CARPENTER EXECUTIVE DIRECTOR 133288 0 14000 0 4537 0 4796 0 22696 0 179317 0 0 0 DENISE G KIRALY DIRECTOR - HUMAN RESOURCS 147958 0 7500 0 0 0 1774 0 23656 0 180888 0 0 0 MARK W RECKER DIRECTOR - PHARMACY 141021 0 13200 0 796 0 4722 0 11828 0 171567 0 0 0 DENNIS E MORRIS PHYSICIAN ADVISOR 151600 0 0 0 0 0 4597 0 9080 0 165277 0 0 0 JAMES J STRAUB MANAGER - OUTPATIENT PHARMACY 125622 0 12100 0 0 0 4198 0 11828 0 153748 0 0 0 Part I, Line 1a LIMA MEMORIAL JOINT OPERATING COMPANY PROVIDES SOCIAL CLUB DUES TO THE CEO; THEY ARE TREATED AS TAXABLE COMPENSATION. Part I, Line 4b THE FOLLOWING INDIVIDUALS PARTICIPATED IN AN IRC 457(F) NON-QUALIFIED DEFERRED COMPENSATION PLAN. THIS PLAN IS FUNDED BY THE HOSPITAL AND VESTS WITH SERVICE THEREFORE IS SUBJECT TO RISK OF FORFEITURE. ROBERT E. ARMSTRONG, JR.: $51,305 MICHAEL D. SWICK: $181,831 KHA H. TRAN, MD: $36,888 ANN-MARIE JEAN POHL: $21,698 JOHN FISCHBACH: $18,532 A OHIO HIGHER EDUCATION FACILITY COMM 346849674 2014-02-20 50215000 CONSTRUCTION OF HOSPITAL FACILITIES 0 0 0 A 50215000 1385653 7183784 41645563 2014 1 0 0 1 A 0 1 1 0 0 0.01900 0.01900 0 0 1 A 0 0 1 0 1 1 PNC BANK NATIONAL ASSOCIATION 30.400000000000 0 0 0 0 0 A 1 JJ JOHNSON J.J. JOHNSON IS THE SON OF BOARD MEMBER JOHN JOHNSON 64285 EMPLOYMENT 0 GINA M FISCHBACH GINA M. FISCHBACH IS THE WIFE OF VP/CFO JOHN T. FISCHBACH 59406 EMPLOYMENT 0 Form 990, Part VI, Section A, line 6 THE MEMBERS ARE LIMA MEMORIAL HOSPITAL AND PH VENTURES, INC., WHOSE SOLE MEMBER IS PROMEDICA HEALTH SYSTEM, BOTH OHIO NONPROFIT CORPORATIONS. Form 990, Part VI, Section B, line 11b THE AUDIT COMMITTEE OF THE BOARD REVIEWS AND APPROVES THE FORM 990, AND A COPY OF THE FORM 990 IS PROVIDED TO THE BOARD, PRIOR TO FILING. THIS PROCESS HAS NOT CHANGED FROM THE PRIOR YEAR. Form 990, Part VI, Section B, line 12c EACH TRUSTEE, PRINCIPAL OFFICER, AND MEMBER OF A COMMITTEE WITH BOARD-DELEGATED POWERS SHALL ANNUALLY SIGN A STATEMENT WHICH AFFIRMS THAT SUCH PERSON: 1) HAS RECEIVED A COPY OF THE CONFLICTS OF INTEREST POLICY; 2) HAS READ AND UNDERSTANDS THE POLICY; 3) HAS AGREED TO COMPLY WITH THE POLICY; AND 4) UNDERSTANDS THAT THE CORPORATION IS A CHARITABLE ORGANIZATION AND THAT IN ORDER TO MAINTAIN ITS FEDERAL TAX EXEMPTION, IT MUST ENGAGE PRIMARILY IN ACTIVITIES WHICH ACCOMPLISH ONE OR MORE OF ITS TAX-EXEMPT PURPOSES. IF THE BOARD OR COMMITTEE HAS REASONABLE CAUSE TO BELIEVE THAT A MEMBER HAS FAILED TO DISCLOSE ACTUAL OR POSSIBLE CONFLICTS OF INTEREST, IT SHALL INFORM THE MEMBER OF THE BASIS FOR SUCH BELIEF AND AFFORD THE MEMBER AN OPPORTUNITY TO EXPLAIN THE ALLEGED FAILURE TO DISCLOSE. IF, AFTER HEARING THE RESPONSE OF THE MEMBER AND MAKING SUCH FURTHER INVESTIGATION AS MAY BE WARRANTED IN THE CIRCUMSTANCES, THE BOARD OR COMMITTEE DETERMINES THAT THE MEMBER HAS IN FACT FAILED TO DISCLOSE AN ACTUAL OR POSSIBLE CONFLICT OF INTEREST, IT SHALL TAKE APPROPRIATE DISCIPLINARY AND CORRECTIVE ACTION. Form 990, Part VI, Section B, line 15 THE PROCESS FOR DETERMINING THE ORGANIZATION'S CEO, OTHER OFFICERS AND KEY EMPLOYEES' COMPENSATION INCLUDES: 1) REVIEW AND APPROVAL BY THE COMPENSATION COMMITTEE; 2) THE UTILIZATION OF AN INDEPENDENT COMPENSATION CONSULTANT; 3) COMPARABLE DATA; AND 4) CONTEMPORANEOUS DOCUMENTATION. THIS PROCESS WAS LAST COMPLETED IN 2016. Form 990, Part VI, Section C, line 19 THE GOVERNING DOCUMENTS AND CONFLICT OF INTEREST POLICY ARE CURRENTLY NOT AVAILABLE TO THE PUBLIC. THE FINANCIAL STATEMENTS ARE FILED WITH THE RETURN AS REQUIRED. Form 990, Part IX, line 11g PURCHASE SERVICE: Program service expenses 2,733,488. Management and general expenses 3,691,555. Fundraising expenses 0. Total expenses 6,425,043. HEARING AID REPAIR: Program service expenses 4,795. Management and general expenses 0. Fundraising expenses 0. Total expenses 4,795. PROF PURCHASE SERVICE: Program service expenses 4,463,766. Management and general expenses 676. Fundraising expenses 0. Total expenses 4,464,442. PS - TRAVELERS: Program service expenses 158,843. Management and general expenses 0. Fundraising expenses 0. Total expenses 158,843. CONSULTING: Program service expenses 45,414. Management and general expenses 98,359. Fundraising expenses 0. Total expenses 143,773. COLLECTION: Program service expenses 0. Management and general expenses 761,143. Fundraising expenses 0. Total expenses 761,143. RENTAL: Program service expenses 1,126,064. Management and general expenses 572,608. Fundraising expenses 0. Total expenses 1,698,672. COPIER RENTAL: Program service expenses 0. Management and general expenses 177,667. Fundraising expenses 0. Total expenses 177,667. CELL PHONE RENTAL: Program service expenses 57,691. Management and general expenses 0. Fundraising expenses 0. Total expenses 57,691. SERVICE CONTRACTS: Program service expenses 1,351,018. Management and general expenses 5,244,613. Fundraising expenses 0. Total expenses 6,595,631. FREIGHT: Program service expenses 0. Management and general expenses 310,837. Fundraising expenses 0. Total expenses 310,837. WASTE: Program service expenses 870. Management and general expenses 56,260. Fundraising expenses 0. Total expenses 57,130. COURTESY TRANSPORT-PARKING: Program service expenses 142,584. Management and general expenses 0. Fundraising expenses 0. Total expenses 142,584. CLEANING: Program service expenses 62,444. Management and general expenses 84,969. Fundraising expenses 0. Total expenses 147,413. MAINTENANCE: Program service expenses 1,500. Management and general expenses 0. Fundraising expenses 0. Total expenses 1,500. PHYSICIAN FEES: Program service expenses 4,738,521. Management and general expenses 209,342. Fundraising expenses 0. Total expenses 4,947,863. CORPORATE FEE: Program service expenses 177,095. Management and general expenses 0. Fundraising expenses 0. Total expenses 177,095. Form 990, Part XI, line 9: IMPLEMENTATION OF NEW ACCOUNTING PRONOUNCEMENT -4,832. INVESTMENT IN LMHS WOMEN'S HEALTH CO-MANAGEMENT K-1 -5,215. RESTRICTED CONTRIBUTIONS 2,538,401. PROCEEDS FROM SALE OF NCOPS -55,530. FORM 990, PART XI, LINE 2C EXPLANATION: THE AUDIT COMMITTEE ASSUMES RESPONSIBILITY FOR THE OVERSIGHT OF THE AUDIT AND THE SELECTION OF THE INDEPENDENT ACCOUNTANT. THIS PROCESS HAS NOT CHANGE FROM THE PRIOR YEAR. FORM 990, SUPPLEMENTAL FINANCIAL INFORMATION THE CALCULATION RECONCILES THE ORGANIZATION'S OPERATIONS TO THE LIMA MEMORIAL HEALTH SYSTEM'S CONSOLIDATED FINANCIAL STATEMENTS. GAIN (LOSS) FROM OPERATIONS LMH $ 18,237,295 LMP $(12,520,838) ELM TREE $ 84,232 FOUNDATION $ 28,669 TOTAL GAIN (LOSS) FROM OPERATIONS $ 5,829,358 NON-OPERATING REVENUES, NET* $ 2,207,748 INTEREST RATE SWAP $ 755,203 AUDITED EXCESS REVENUE $ 8,792,309 NET ASSETS RELEASED FROM RESTRICTION $ - PPA $ - NET $ 8,792,309 OTHER 990 ADJUSTMENTS WOMEN'S HEALTH K-1 $ 5,215 UNREALIZED GAIN/LOSS $( 1,088,060) CARDINAL HEALTH K-1 $( 68,262) TOTAL OTHER 990 ADJUSTMENTS $(1,151,107) NET $ 7,641,202 LMJOC 990 $ 19,999,037 LMPC 990 $(12,520,450) ELM TREE 1120 $ 81,902 LMH 990EZ $( 68,262) LM FOUNDATION 990 $140,896 LM AUXILIARY 990 $8,078 NET TAX RETURNS $ 7,641,201 DIFFERENCE: FINANCIAL STATEMENTS VS TAX RETURN $ 1 * INCLUDES UNREALIZED GAIN/LOSS OF $1,088,060 LIMA MEMORIAL HOSPITAL 1001 BELLEFONTAINE AVENUE LIMA OH 45804 344434676 HEALTHCARE OH 501(C)(3) 170(B)(1)(A)(III) LIMA MEMORIAL JOINT OPERATING COMPANY 1 LIMA MEMORIAL HOSPITAL FOUNDATION 1001 BELLEFONTAINE AVENUE LIMA OH 45804 341707570 SUPPORTING ORGANIZATION FOR LIMA MEMORIAL HOSPITAL OH 501(C)(3) 509(a)(3) LIMA MEMORIAL JOINT OPERATING COMPANY 1 LIMA MEMORIAL HOSPITAL AUXILIARY 1001 BELLEFONTAINE AVENUE LIMA OH 45804 341694632 SUPPORTING ORGANIZATION FOR LIMA MEMORIAL HOSPITAL OH 501(C)(3) 509(a)(3) LIMA MEMORIAL JOINT OPERATING COMPANY 1 LIMA MEMORIAL PROFESSIONAL CORPORATION 1001 BELLEFONTAINE AVENUE LIMA OH 45804 341935236 HEALTHCARE OH 501(C)(3) 170(B)(1)(A)(III) LIMA MEMORIAL JOINT OPERATING COMPANY 1 LMHS WOMEN'S HEALTH CO-MANAGEMENT COMPANY LLC 1001 BELLEFONTAINE AVE LIMA OH 45804 271023520 WOMEN'S HEALTH CO-MANAGEMENT OH LIMA MEMORIAL JOINT OPERATING COMPANY RELATED 5215 86412 0 1 0.50000 ELM TREE FOUNDATION 1220 EAST ELM STREET LIMA OH 45804 341417720 RENTAL REAL ESTATE OH LIMA MEMORIAL JOINT OPERATING COMPANY C 1056714 6555797 1.00000 1 0 1 0 0 0 0 0 0 0 1 1 0 0 1 1 1 1 1 1 LIMA MEMORIAL HOSPITAL FOUNDATION S 2545301 EQUITY TRANSFER LIMA MEMORIAL PROFESSIONAL CORPORATION R 12059275 EQUITY TRANSFER LIMA MEMORIAL PROFESSIONAL CORPORATION J 988162 LEASE CONTRACT ELM TREE FOUNDATION K 357762 LEASE CONTRACT ELM TREE FOUNDATION Q 150000 CASH TRANSACTION