2017-11-12T15:17:44-06:00 2016-12-31 350921680 CROWE HORWATH LLP 330 E JEFFERSON BLVD P O BOX 7 SOUTH BEND IN 466240007 990 2016-01-01 202401676 COMMUNITY HOSPITAL OF LAGRANGE COUNTY INC COMM 2603738429 207 N TOWNLINE RD LAGRANGE IN 46761 JEANNE' WICKENS PH CFO 2603738407 2017-11-12 1 KENNETH J KEBER P00240883 5742323992 X 204.58.171.16 2017-11-12 15:43:23 ES P BD78C0151F32BCCEC501E79B474C54CD1328F117 BD78C0151F32BCCEC501E79B474C54CD1328F117 2016 2017-02-10 21:41:12Z MICHAEL J PACKNETT 10501 CORPORATE DRIVE FORT WAYNE IN 46845 37776826 0 X WWW.PARKVIEW.COM; WWW.PARKVIEWFOUNDATIONS.ORG X 2005 IN COMMUNITY HOSPITAL OF LAGRANGE COUNTY, INC. WORKS TO IMPROVE THE HEALTH OF OUR COMMUNITIES AND PROVIDES QUALITY HEALTH SERVICES TO ALL WHO ENTRUST THEIR CARE TO US. 12 7 227 29 0 0 50521 74337 35268909 37407710 845 11383 237933 246148 35558208 37739578 100827 63029 0 0 12072302 12537865 0 0 47258 21686298 22002922 33859427 34603816 1698781 3135762 26693136 27199140 29204534 29710538 -2511398 -2511398 X COMMUNITY HOSPITAL OF LAGRANGE COUNTY, INC. WORKS TO IMPROVE THE HEALTH OF OUR COMMUNITIES AND PROVIDES QUALITY HEALTH SERVICES TO ALL WHO ENTRUST THEIR CARE TO US. 0 0 28442793 63029 37407710 AS A NOT-FOR-PROFIT HOSPITAL, WE TAKE OUR MISSION TO HEART. COMMUNITY HOSPITAL OF LAGRANGE COUNTY, INC., D.B.A. PARKVIEW LAGRANGE HOSPITAL, EXISTS FOR ONE PURPOSE - TO IMPROVE THE HEALTH OF THE COMMUNITIES WE SERVE. COMMUNITY HOSPITAL OF LAGRANGE COUNTY, INC. GIVES BACK TO THE COMMUNITY IN THE FORM OF IMPROVED FACILITIES, EDUCATION AND OUTREACH PROGRAMS, FREE AND DISCOUNTED CARE, VOLUNTEERISM AND MUCH MORE. THE FOLLOWING ARE SOME OF THE WAYS COMMUNITY HOSPITAL OF LAGRANGE COUNTY, INC. IS REACHING OUT TO MAKE OUR NEIGHBORHOODS AND COMMUNITIES HEALTHIER:-FINANCIAL ASSISTANCE-PRIMARY HEALTH CARE / ACCESS (SEE SCHEDULE O FOR CONTINUATION)-HEALTH SCREENING AND PREVENTION-DISEASE MANAGEMENT-CONTRIBUTIONS TOWARD AND PARTICIPATION IN ECONOMIC DEVELOPMENT ACTIVITIESCOMMUNITY HOSPITAL OF LAGRANGE COUNTY, INC. IS A 25-BED CRITICAL ACCESS FACILITY THAT PROVIDES ACUTE-CARE SERVICES TO THE PEOPLE OF LAGRANGE COUNTY AND THE SURROUNDING AREA. THE VISION OF HOSPITAL LEADERSHIP HAS CONTINUED TO FOCUS ON EXPANDING ACCESS TO HEALTHCARE SERVICES AND HELPING TO IMPROVE THE HEALTH STATUS OF THOSE WHO LIVE AND WORK IN THE COMMUNITIES IT SERVES. AMONG THE SERVICES PROVIDED AT THE HOSPITAL ARE:-EMERGENCY CARE-INPATIENT MEDICAL/SURGICAL CARE-ELECTRONIC INTENSIVE CARE UNIT PROVIDING 24/7 ACCESS TO BOARD CERTIFIED INTENSIVE CARE SPECIALISTS-AMBULATORY AND INPATIENT SURGERY-ENDOSCOPY-ORTHOPEDIC SURGERY-INTENSIVE OUTPATIENT BEHAVIORAL HEALTH PROGRAM FOR SENIORS-OBSTETRICS/GYNECOLOGY SERVICES-OUTPATIENT AND INPATIENT REHABILITATION-ADVANCED, DIGITAL DIAGNOSTIC IMAGINGTHE ADDITION OF A 17,300 SQUARE FOOT MEDICAL OFFICE BUILDING ON ITS CAMPUS IN 2013 HAS ALLOWED FOR EXPANSION OF FULL-TIME AND VISITING MEDICAL SPECIALISTS, MAKING THESE SERVICES AVAILABLE LOCALLY FOR THE COMMUNITY. SPECIALTY MEDICAL SERVICES INCLUDE:-ON-SITE ONCOLOGY AND HEMATOLOGY SERVICES-CARDIOLOGY-COLON AND RECTAL SURGERY-GENERAL SURGERY-GYNECOLOGY-OBSTETRICS-ORTHOPEDIC SURGERY-PRENATAL GENETIC COUNSELING-PODIATRY-UROLOGY FINANCIAL ASSISTANCE:COMMUNITY HOSPITAL OF LAGRANGE COUNTY, INC.'S MISSION INCLUDES CARING FOR PATIENTS WHO DO NOT HAVE THE MEANS TO MEET THEIR FINANCIAL OBLIGATIONS. THE HOSPITAL PLACES ITS PRIORITY ON PROVIDING THE NECESSARY CARE, NOT ON THE PATIENT'S FINANCIAL ABILITY TO PAY FOR THEIR MEDICAL EXPENSES.PRIMARY HEALTH CARE / ACCESS:COMMUNITY HOSPITAL OF LAGRANGE COUNTY, INC. PROVIDES CLINICAL STAFF AND SUPPORT TO TARGETED POPULATIONS WITHIN LAGRANGE COUNTY, INCLUDING:-A FULL-TIME PLAIN CHURCH COORDINATOR SERVES AS A SINGLE POINT OF ACCESS FOR AMISH, MENNONITE AND OTHER PLAIN CHURCH MEMBERS WHO HAVE QUESTIONS ABOUT THE HEALTHCARE SERVICES AVAILABLE WITHIN THE PARKVIEW HEALTH SYSTEM. WHETHER THE QUESTION CONCERNS THE APPROXIMATE COST OF A PROCEDURE, THE SCHEDULING OF A DIAGNOSTIC TEST, OR A BILLING QUESTION, THE PLAIN CHURCH COORDINATOR ASSISTS INDIVIDUALS AND FAMILIES BY OBTAINING AN ANSWER.-A MEDICAL DIRECTOR TO PROVIDE SUPPORT FOR THE LAGRANGE COUNTY SHERIFF'S DEPARTMENT AND INMATES IN THE COUNTY JAIL.-A FULL-TIME ATHLETIC TRAINER IS PROVIDED, IN PARTNERSHIP WITH LAKELAND HIGH SCHOOL, TO MEET THE ON-SITE NEEDS OF STUDENT ATHLETES.-A PARTNERSHIP WITH THE LAGRANGE COUNTY COUNCIL ON AGING TO ASSIST WITH OPERATIONAL SUPPORT FOR THE COA'S TRANSPORTATION SERVICES TO ALL RESIDENTS OF LAGRANGE COUNTY. NEARLY HALF OF THE TRIPS THE COA PROVIDES ARE TO A PHYSICIAN FOR A CHECK-UP OR TO THE HOSPITAL FOR A TEST OR TREATMENT. TRANSPORTATION PROVIDED BY THE COA'S LCAT SERVICE IS FREE TO SENIORS RESIDING IN LAGRANGE COUNTY. HOMEMAKER SERVICES HELP WITH DAY-TO-DAY TASKS THAT, IN MANY CASES, COULD PUT THE SENIOR AT RISK OF A FALL OR OTHER INJURY.HEALTH SCREENING AND PREVENTION AND DISEASE MANAGEMENT:COMMUNITY HOSPITAL OF LAGRANGE COUNTY, INC. PROVIDES FREE AND LOW COST SERVICES, HEALTH SCREENINGS AND EDUCATION TO DIVERSE POPULATIONS IN OUR SERVICE AREA: -VOUCHERS REDEEMABLE FOR FRESH PRODUCE AT LOCAL, SEASONAL FARMERS' MARKETS ARE MADE AVAILABLE TO LOW INCOME FAMILIES. FUNDED THROUGH PARKVIEW LAGRANGE HOSPITAL'S COMMUNITY HEALTH IMPROVEMENT DOLLARS, VOUCHERS ARE PLACED WITH PRIMARY CARE PHYSICIANS IN LAGRANGE COUNTY FOR DISTRIBUTION TO FAMILIES IN NEED. -VOUCHERS REDEEMABLE FOR NINE MONTHS OF PRENATAL VITAMINS HAVE ALSO BEEN MADE AVAILABLE TO WOMEN THROUGH THE BIRTH PLANNER AT PARKVIEW LAGRANGE HOSPITAL, LAGRANGE COUNTY PRIMARY CARE PHYSICIANS AND OBSTETRICIANS, THE LAGRANGE COUNTY HEALTH DEPARTMENT, AND WIC. VOUCHERS ARE REDEEMABLE AT LOCAL PHARMACIES WHO THEN SUBMIT THEM TO THE HOSPITAL FOR REIMBURSEMENT THROUGH COMMUNITY HEALTH IMPROVEMENT FUNDS.-WELLNESS ON THE ROAD EVENTS BRINGS FREE AND LOW COST SCREENINGS OUT INTO THE COMMUNITY, IMPROVING ACCESS TO THESE SERVICES. AMONG THE SCREENINGS OFFERED ARE LOW COST BLOOD TESTS, HEARING SCREENINGS, MAMMOGRAMS AND MORE.-PARKVIEW LAGRANGE SENIOR CLUB PROVIDES HEALTH EDUCATION PROGRAMS AND ACTIVITIES TO IMPROVE THE HEALTH AND WELL-BEING OF SENIORS THROUGHOUT LAGRANGE COUNTY. TOPICS INCLUDE HEART DISEASE, FALL PREVENTION, CANCER, ETC.-HEALTH BOOTHS ARE PROVIDED AT LOCAL COMMUNITY EVENTS AND OFFER ACTIVITIES AND EDUCATION DESIGNED TO HELP PARTICIPANTS LIVE A HEALTHIER LIFE STYLE. INFORMATION PROVIDED INCLUDES CAR SEAT SAFETY, NUTRITION TIPS FOR ALL AGES, THE IMPORTANCE OF EXERCISE AND ACTIVITY IN IMPROVING AND MAINTAINING GOOD HEALTH, ETC.-PRE-PARTICIPATION PHYSICALS FOR STUDENT HIGH SCHOOL AND MIDDLE SCHOOL ATHLETES FROM ALL SCHOOL DISTRICTS IN LAGRANGE COUNTY. THIS ANNUAL EVENT PROVIDES SCREENINGS THAT MEET THE IHSAA REQUIREMENTS FOR STUDENT ATHLETES INCLUDING HEIGHT, WEIGHT, VISION, BLOOD PRESSURE, EKG, AND A PHYSICAL EXAM WITH A PHYSICIAN, ETC.-DIABETES SUPPORT GROUP - THIS MONTHLY GROUP IS TAUGHT BY A DIABETES EDUCATOR/PHARMACIST AND IS FREE AND OPEN TO ANY WHOSE LIVES ARE AFFECTED BY DIABETES. THE GROUP OFFERS EDUCATIONAL PROGRAMS ON MEDICATION MANAGEMENT, NUTRITION, NEUROPATHY, ETC., IN ADDITION TO OPEN DIALOGUE ABOUT ANY ISSUES SPECIFIC TO MEMBERS OF THE GROUP. 28442793 1 1 0 1 0 0 0 0 0 0 1 0 0 0 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 0 0 0 0 0 0 0 1 0 0 0 1 X 29 0 1 227 1 0 0 0 0 0 1 1 0 0 0 0 X 12 7 1 0 0 0 1 1 1 1 1 0 0 1 1 1 1 1 1 1 1 0 IN X JEANNE' WICKENS 2603738407 10501 CORPORATE DRIVE FORT WAYNE IN 46845 ROBERT MYERS DIRECTOR/LGHOS PRESIDENT-PARTIAL YR 40.00 0.00 X X 114440 0 7573 JORDI DISLER DIRECTOR/CURRENT LGHOS PRESIDENT 40.00 0.00 X X 226244 0 59631 MICHAEL PACKNETT DIRECTOR/PH PRESIDENT & CEO 1.00 56.00 X X 0 2067010 712544 SHELBY COOPER DIRECTOR/PH PHYSICIAN 1.00 40.00 X 12000 154135 5951 LOREN HELMUTH DIRECTOR/PH PHYSICIAN 1.00 40.00 X 17150 521985 49723 MICHAEL MELLINGER DIRECTOR/POHCI PHYSICIAN 1.00 9.00 X 3250 38325 0 ROBERT BOND DIRECTOR 1.00 0.00 X 4500 0 0 STEVEN CHRISTNER DIRECTOR 1.00 0.00 X 3250 0 0 KEVIN LAMBRIGHT DIRECTOR/CHAIR 1.00 1.00 X 6750 2750 0 DENNIS LEHMAN DIRECTOR/TREASURER 1.00 0.00 X 4500 0 0 JOE PIERCE DIRECTOR 1.00 1.00 X 4500 1000 0 SHERRYL RHINESMITH DIRECTOR/VICE CHAIR 1.00 0.00 X 4750 0 0 PAUL YODER DIRECTOR 1.00 0.00 X 4250 0 0 JEANNE' WICKENS PH CHIEF FINANCIAL OFFICER 1.00 56.00 X 0 372369 79329 STANTON RISSER INTERIM PH CFO - PARTIAL YEAR/PH VP 1.00 56.00 X 0 318160 67612 BRENDA ARMENTROUT LGHOS MGR PHARMACY 40.00 0.00 X 167285 0 24686 ROBERT BLOOMFIELD LGHOS MGR SUPPORT SERVICE 39.00 0.00 X 121601 0 28057 TREVOR FRY LGHOS MGR ER 40.00 0.00 X 109782 0 29569 MICHAEL CHARLIER LGHOS MGR REHAB 40.00 0.00 X 109746 0 31334 ROSS ROBISON LGHOS PHARMACIST 48.00 0.00 X 104862 0 17475 1018860 3475734 1113484 9 0 1 0 PROFESSIONAL EMERGENCY PHYSICIANS INC PO BOX 12949 FORT WAYNE IN 46866 PHYSICIANS 1558276 PARKVIEW HOSPITAL INC 11109 PARKVIEW PLAZA DRIVE FORT WAYNE IN 46845 LABORATORY SERVICES 929437 GREAT LAKES ANESTHESIA PC 500 N NAPPANEE ST STE 11-B ELKHART IN 46514 ANESTHESIOLOGISTS 782068 NORTHEAST INTERNAL MEDICINE ASSOC INC 2500 N DETROIT STREET LAGRANGE IN 46761 HOSPITALISTS 336126 MED SOLUTIONS TEMP STAFFING 1010 N 102ND STREET SUITE 300 OMAHA NE 68114 NURSES 135895 5 233 10478 1850 15846 45930 1032 74337 NET PATIENT SERVICE 622000 36581279 36581279 PHARMACY 446110 395868 395868 EMS SUBSIDY 900099 349000 349000 INTERUNIT RENT 531120 22745 22745 POHCI MEDICAL SERVICES 621990 21105 21105 37713 37713 37407710 897 897 14074 33845 -19771 -19771 -19771 10486 0 10486 10486 10486 2080 10478 3403 -1323 -1323 CAFETERIA REVENUE 722210 254554 254554 GIFT SHOP REVENUE 453220 12688 12688 267242 37739578 37407710 0 257531 X 62479 62479 550 550 474370 474370 9129151 9083735 12111 33305 2934344 2919993 3827 10524 5020379 4367703 652586 90 1250 1000 250 995505 926806 66665 2034 571200 560212 10988 55055 37279 16965 811 13410 1958 11208 244 210464 210464 1498803 1487674 11129 91614 91614 CORP SERVICE ALLOCATION 4820000 4820000 BAD DEBT 3855698 3855698 MEDICAL SUPPLIES 2707481 2707481 PH SUBSIDY 2106195 2106195 55868 21952 33916 34603816 28442793 6113765 47258 1575 1676 930 38443 32 1584 4326471 4518967 263617 331673 18394 17166 32217504 14985626 16934324 17231878 5011241 5011241 136552 46512 26693136 27199140 1161704 2052307 19574388 18683453 95578 144535 8372864 8830243 29204534 29710538 X -2511398 -2511398 -2511398 -2511398 26693136 27199140 X 3135762 -3135762 X 0 1 X 1 0 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 0 0 0 0 0 0 0 0 1 3151 3151 0 PART II-B, LINE 1: REPRESENTS THE PORTION OF THE DUES PAID TO INDIANA HOSPITAL AND HEALTH ASSOCIATION, AMERICAN HOSPITAL ASSOCIATION AND NATIONAL RURAL HEALTH ASSOCIATION USED FOR LOBBYING ACTIVITIES. 282529 282529 13429858 3325922 10103936 29098 28460 638 16503299 10573321 5929978 1972720 1057923 914797 17231878 DUE TO/FROM INTERUNIT 2619007 EST MEDICARE/MEDICAID SETTLEMENTS 314995 NOTE PAYABLE TO PH 5896241 8830243 X PART X, LINE 2: PARKVIEW HEALTH SYSTEM, INC. AND SUBSIDIARIES - NOTES TO THE CONSOLIDATED FINANCIAL STATEMENTS TEXT OF THE FOOTNOTE TO THE ORGANIZATION'S FINANCIAL STATEMENTS THAT DESCRIBES THE LIABILITY FOR UNCERTAIN TAX POSITIONS UNDER FIN 48 (ASC 740): PAGE 16 OF ATTACHED FINANCIAL STATEMENTS. INCOME TAXES: THE INTERNAL REVENUE SERVICE HAS DETERMINED THAT THE CORPORATION AND CERTAIN AFFILIATED ENTITIES ARE TAX-EXEMPT ORGANIZATIONS AS DEFINED IN SECTION 501(C)3 OF THE INTERNAL REVENUE CODE. CERTAIN SUBSIDIARIES OF THE CORPORATION ARE TAXABLE ENTITIES, THE TAX EXPENSE AND LIABILITIES OF WHICH ARE NOT MATERIAL TO THE CONSOLIDATED FINANCIAL STATEMENTS. THE CORPORATION AND ITS TAX-EXEMPT AFFILIATED ENTITIES EACH FILE A FORM 990 (RETURN OF ORGANIZATION EXEMPT FROM INCOME TAX) ANNUALLY. WHEN THESE RETURNS ARE FILED, IT IS HIGHLY CERTAIN THAT SOME POSITIONS TAKEN WOULD BE SUSTAINED UPON EXAMINATION BY THE TAXING AUTHORITIES, WHILE OTHERS ARE SUBJECT TO UNCERTAINTY ABOUT THE MERITS OF THE POSITION TAKEN OR THE AMOUNT OF THE POSITION THAT WOULD ULTIMATELY BE SUSTAINED. EXAMPLES OF TAX POSITIONS COMMON TO HEALTH SYSTEMS INCLUDE SUCH MATTERS AS THE TAX-EXEMPT STATUS OF EACH ENTITY, THE CONTINUED TAX-EXEMPT STATUS OF BONDS, THE NATURE, CHARACTERIZATION AND TAXABILITY OF JOINT VENTURE INCOME, AND VARIOUS POSITIONS RELATING TO POTENTIAL SOURCES OF UNRELATED BUSINESS TAXABLE INCOME (REPORTED ON FORM 990T). AS OF DECEMBER 31, 2016 AND 2015, THERE ARE NO UNRECOGNIZED TAX BENEFITS RESULTING FROM UNCERTAIN TAX POSITIONS. FORMS 990 AND 990T FILED BY THE CORPORATION AND ITS TAX-EXEMPT AFFILIATED ENTITIES ARE SUBJECT TO EXAMINATION BY THE INTERNAL REVENUE SERVICE UP TO THREE YEARS FROM THE EXTENDED DUE DATE OF EACH RETURN. FORMS 990 AND 990T FILED BY THE CORPORATION AND ITS TAX-EXEMPT AFFILIATED ENTITIES ARE NO LONGER SUBJECT TO EXAMINATION FOR THE YEAR 2012 AND PRIOR. 1 1 X 1 X 0 1 1 0 1 1 522693 522693 0.01700 2164399 1782774 381625 0.01240 1959286 1093839 865447 0.02810 4646378 2876613 1769765 0.05750 97296 9143 88153 0.00290 68020 68020 0.00220 165316 9143 156173 0.00510 4811694 2885756 1925938 0.06260 10000 10000 0.00030 10000 10000 0.00030 1 3855698 52899 7818619 6441290 1377329 X 1 1 1 1 COMMUNITY HOSPITAL OF LAGRANGE COUNTY 207 N TOWNLINE RD LAGRANGE IN 46761 WWW.PARKVIEW.COM 14-005085-1 X X X X COMMUNITY HOSPITAL OF LAGRANGE COUNTY 1 0 0 1 X X X X X X X X X 16 1 1 1 1 X WWW.PARKVIEW.COM/LOCALHEALTHNEEDS X 1 16 1 WWW.PARKVIEW.COM/LOCALHEALTHNEEDS 0 1 X 200.000000000000 X X X X X 1 1 X X X 1 X WWW.PARKVIEW.COM X WWW.PARKVIEW.COM X WWW.PARKVIEW.COM X X X X X X 1 X 0 X X X X 1 X 0 0 COMMUNITY HOSPITAL OF LAGRANGE COUNTY PART V, SECTION B, LINE 5: THE RESEARCH TEAM WORKED TO ENSURE THAT THE NEEDS OF THE MEDICALLY UNDERSERVED, LOW-INCOME AND MINORITY POPULATIONS WERE TAKEN INTO ACCOUNT DURING THE COURSE OF THE COMMUNITY HEALTH NEEDS ASSESSMENT. THE SURVEY SAMPLE WAS STRATIFIED TO ENSURE THAT POPULATION SUBSETS WERE REPRESENTED ACCURATELY. SURVEYING OF PUBLIC HEALTH OFFICIALS, OTHER HEALTHCARE PROFESSIONALS AND VARIOUS SOCIAL SERVICE ORGANIZATIONS THAT SPECIALIZE IN AIDING VULNERABLE POPULATIONS IN THE SEVEN-COUNTY AREA WAS ALSO CONDUCTED. ADDITIONALLY, THE ASSESSMENT TEAM CONDUCTED TARGETED FOCUS GROUPS WITH POTENTIALLY VULNERABLE POPULATIONS, INCLUDING THE HISPANIC/LATINO AND AFRICAN AMERICAN POPULATIONS. THE AMISH POPULATION WAS RANDOMLY SURVEYED THROUGH A WRITTEN SURVEY. INFORMATION GAINED THROUGH FOCUS GROUPS AND WRITTEN SURVEYS HELPED TO GAIN INSIGHT INTO THE HEALTH NEEDS AND PERCEPTIONS OF THESE SUB-POPULATION GROUPS TO BETTER UNDERSTAND KEY PUBLIC HEALTH AND HEALTHCARE ISSUES. COMMUNITY HOSPITAL OF LAGRANGE COUNTY PART V, SECTION B, LINE 6A: PARKVIEW HOSPITAL, INC. (EIN 35-0868085); COMMUNITY HOSPITAL OF NOBLE COUNTY, INC. (EIN 35-2087092); HUNTINGTON MEMORIAL HOSPITAL, INC. (EIN 35-1970706); WHITLEY MEMORIAL HOSPITAL, INC. (EIN 35-1967665); PARKVIEW WABASH HOSPITAL, INC. (EIN 47-1753440) AND ORTHOPAEDIC HOSPITAL AT PARKVIEW NORTH, LLC (EIN 26-0143823). COMMUNITY HOSPITAL OF LAGRANGE COUNTY PART V, SECTION B, LINE 6B: PARKVIEW HEALTH SYSTEM, INC.(EIN 35-1972384); INDIANA PARTNERSHIP FOR HEALTHY COMMUNITIES (A PARTNERSHIP BETWEEN THE INDIANA UNIVERSITY RICHARD M. FAIRBANKS SCHOOL OF PUBLIC HEALTH AND THE POLIS CENTER AT IUPUI) AND CONDUENT HEALTHY COMMUNITIES INSTITUTE. COMMUNITY HOSPITAL OF LAGRANGE COUNTY PART V, SECTION B, LINE 11: SIGNIFICANT HEALTH NEEDS BEING ADDRESSED:OBESITY/HEALTHY LIFESTYLES: COMMUNITY HOSPITAL OF LAGRANGE COUNTY, INC. WILL CONTINUE ITS PARTNERSHIPS WITH COLE FAMILY CENTER YMCA WHICH WAS ESTABLISHED LATE IN 2014 TO ADDRESS THE OBESITY AND THE NEED FOR PHYSICAL ACTIVITY. IN ADDITION TO THE PARTNERSHIP BETWEEN THE YMCA AND THE HOSPITAL, IN THE LAGRANGE SATELLITE GROUP WELLNESS FACILITY, THE HOSPITAL HAS ALSO COMMITTED FUNDING TO ASSIST WITH THE IMPLEMENTATION OF A DIABETES PREVENTION LIFESTYLE PROGRAM IN PARTNERSHIP WITH THE COLE YMCA. PLANTING HEALTHY SEEDS, A CURRICULUM FOR 3RD AND 4TH GRADERS, IS A NEW PROGRAM THAT COMMUNITY HOSPITAL OF LAGRANGE COUNTY, INC. IS WORKING WITH THE SCHOOLS TO IMPLEMENT IN LAGRANGE COUNTY. PLANTING HEALTHY SEEDS IS THE PROGRAM THE HOSPITL WILL BE REPORTING ON. THE HOSPITAL IS BOLSTERING ITS EFFORTS IN AREAS DEEMED TO BE THE HIGHEST IMPACT FOR OBESITY PREVENTION. ANTICIPATED IMPACT INCLUDE THE FOLLOWING 1) PROVIDE CURRICULUM FOR ELEMENTARY AND MIDDLE SCHOOL STUDENTS AND PARENTS OF PRE-SCHOOL CHILDREN RELATED TO PHYSICAL ACTIVITY AND NUTRITION; 2) ENHANCE AND INCREASE PROVIDER-DIRECTED WELLNESS RESOURCES INCLUDING REFERRALS TO THE NEWLY ESTABLISHED DIABETES PREVENTION PROGRAM IN THE COMMUNITY.SUICIDE: IDENTIFIED STAFF AND COMMUNITY MEMBERS WITHIN LAGRANGE COUNTY WILL BE TRAINED IN AN EVIDENCE-BASED SUICIDE PREVENTION STRATEGY KNOWN AS QUESTION, PERSUADE AND REFER (QPR). THIS MATERIAL CAN BE TAUGHT IN A 90 TO 120-MINUTE PERIOD OF TIME AND PROVIDES THE TRAINEE WITH THE SKILLS AND KNOWLEDGE NEEDED FOR HOW TO RECOGNIZE AND RESPOND TO A MENTAL HEALTH CRISIS MUCH LIKE THAT OF CPR FOR THE HEART. THESE INSTRUCTORS WILL THEN TRAIN GROUPS OF PEOPLE WITHIN THE COMMUNITY. THIS TRAINING WILL BE PROVIDED FREE OF CHARGE WITH EDUCATIONAL BOOKLETS PROVIDED FOR PARTICIPANTS IN THIS LIFE-SAVING EDUCATION. PARTICIPANTS IN THIS TRAINING WILL ALSO RECEIVE EDUCATION ABOUT COMMUNITY RESOURCES AND WHERE TO SEND OTHERS FOR HELP. IN ADDITION, COMMUNITY HOSPITAL OF LAGRANGE COUNTY, INC. PARTNERS WITH THE THREE PUBLIC SCHOOL CORPORATIONS IN LAGRANGE COUNTY TO ADDRESS MENTAL HEALTH. THE HOSPITAL PROVIDES A LICENSED MENTAL HEALTH COUNSELOR TO THE SCHOOLS FOR FOUR HOURS EACH WEEK. OTHER HEALTH NEEDS NOT BEING ADDRESSED:-TOBACCO USE - PARKVIEW HEALTH IS A SOURCE OF SMOKING CESSATION PROGRAMS AND OPERATES A TOBACCO FREE CAMPUS. -DIABETES, CARDIOVASCULAR DISEASE AND CANCER - WHILE COMMUNITY HOSPITAL OF LAGRANGE COUNTY, INC. DID NOT SELECT THESE CHRONIC DISEASES AS TOP HEALTH PRIORITIES, OUR INTENT IS TO HELP TO PREVENT AND REDUCE THE PRESENCE OF CHRONIC CONDITIONS LIKE THE AFOREMENTIONED DISEASES BY ADDRESSING OBESITY THROUGH NUTRITION EDUCATION, INCREASED ACCESS TO HEALTHY FOODS, ACTIVE LIVING PROGRAMS AND EDUCATION ON OTHER HEALTHY LIFESTYLE HABITS. -DRUGS/ALCOHOL ABUSE AND ADDICTION - ONE OF COMMUNITY HOSPITAL OF LAGRANGE COUNTY, INC.'S HEALTH PRIORITIES IS MENTAL HEALTH. MANY INDIVIDUALS BEING ASSISTED AND REFERRED THROUGH PARKVIEW BEHAVIORAL HEALTH CARE NAVIGATION PROGRAM ARE AFFECTED BY DRUG AND ALCOHOL ABUSE, AS WELL AS ADDICTION. COMMUNITY HOSPITAL OF LAGRANGE COUNTY, INC. BELIEVES THIS NEEDS TO BE AN INTEGRAL PART OF THE MENTAL HEALTH INITIATIVE WHICH MEANS IT WILL BE ADDRESSED AS PART OF THE COMMUNITY RESPONSE. IN ADDITION, BOWEN CENTER AND NORTHEASTERN CENTER ARE ALSO ADDRESSING DRUG AND ALCOHOL ADDICTION THROUGH THE SERVICES THEIR RESPECTIVE ORGANIZATIONS ARE PROVIDING IN THE LOCAL COMMUNITY. -MATERNAL & CHILD HEALTH - COMMUNITY HOSPITAL OF LAGRANGE COUNTY, INC. CONTINUES TO PARTNER WITH THE LAGRANGE COUNTY HEALTH DEPARTMENT & WIC DEPARTMENT THROUGH THE BREAST FEEDING SUPPORT GROUP OFFERING SUPPORT AND GUIDANCE TO BREAST FEEDING MOMS. -ACCESS: AS PART OF PARKVIEW HEALTH'S STRATEGIC PLAN, COMMUNITY HOSPITAL OF LAGRANGE COUNTY, INC. CONTINUES ITS EFFORTS TO RECRUIT FAMILY PRACTICE AND SPECIALTY PHYSICIANS TO LAGRANGE COUNTY. 2 1 - PARKVIEW LAGRANGE EMS - CENTRAL 0982 N 00 EW LAGRANGE IN 46761 AMBULANCE SERVICE 2 - PARKVIEW LAGRANGE EMS - WEST 8175 W US 20 SHIPSHEWANA IN 46565 AMBULANCE SERVICE PART I, LINE 3C: EQUITY IN A HOME OTHER THAN THE PATIENT OR GUARANTOR'S PRIMARY RESIDENCE. PART I, LINE 7: PART I, LINE 7ACOMMUNITY HOSPITAL OF LAGRANGE COUNTY, INC. IS COMMITTED TO PROVIDING FINANCIAL ASSISTANCE TO PATIENTS UNABLE TO MEET THEIR FINANCIAL OBLIGATIONS. IT IS FURTHERMORE THE POLICY OF COMMUNITY HOSPITAL OF LAGRANGE COUNTY, INC. NOT TO WITHHOLD OR DENY ANY REQUIRED MEDICAL CARE AS A RESULT OF A PATIENT'S FINANCIAL INABILITY TO PAY HIS/HER MEDICAL EXPENSES.THE FINANCIAL ASSISTANCE COST REPORTED ON LINE 7A IS CALCULATED UNDER THE COST TO CHARGE RATIO METHODOLOGY. UNDER THIS METHOD, THE FINANCIAL ASSISTANCE CHARGES FOREGONE ARE MULTIPLIED BY THE RATIO OF COST TO CHARGES TO DETERMINE THE COST OF SERVICES RENDERED.PART I, LINE 7BCOMMUNITY HOSPITAL OF LAGRANGE COUNTY, INC. ACCEPTS ALL MEDICAID, MEDICAID MANAGED CARE, AND OUT-OF-STATE MEDICAID PATIENTS WITH THE KNOWLEDGE THAT THERE MAY BE SHORTFALLS. INTERNAL REVENUE SERVICE (IRS) REVENUE RULING 69-545 IMPLIES THAT TREATING MEDICAID PATIENTS IS A COMMUNITY BENEFIT. IRS REVENUE RULING 69-545, WHICH ESTABLISHED THE COMMUNITY BENEFIT STANDARD FOR NONPROFIT HOSPITALS, STATES THAT IF A HOSPITAL SERVES PATIENTS WITH GOVERNMENTAL HEALTH BENEFITS, INCLUDING MEDICAID, THEN THIS IS AN INDICATION THAT THE HOSPITAL OPERATES TO PROMOTE THE HEALTH OF THE COMMUNITY. THE UNREIMBURSED MEDICAID COST REPORTED ON LINE 7B IS CALCULATED UNDER THE COST TO CHARGE RATIO METHODOLOGY. UNDER THIS METHOD, THE MEDICAID CHARGES ARE MULTIPLIED BY THE RATIO OF COST TO CHARGES TO DETERMINE THE COST OF MEDICAID SERVICES RENDERED. THEN, THE COST OF MEDICAID SERVICES RENDERED IS DEDUCTED FROM THE REIMBURSEMENT RECEIVED FOR MEDICAID PATIENTS TO ARRIVE AT A GAIN/(LOSS) RELATIVE TO THESE PATIENTS.PART I, LINE 7CCOMMUNITY HOSPITAL OF LAGRANGE COUNTY, INC. ACCEPTS ALL MEANS-TESTED PATIENTS FROM THE HEALTHY INDIANA PLAN (HIP) WITH THE KNOWLEDGE THAT THERE MAY BE SHORTFALLS. INTERNAL REVENUE SERVICE (IRS) REVENUE RULING 69-545 IMPLIES THAT TREATING MEANS-TESTED PATIENTS IS A COMMUNITY BENEFIT. IRS REVENUE RULING 69-545, WHICH ESTABLISHED THE COMMUNITY BENEFIT STANDARD FOR NONPROFIT HOSPITALS, STATES THAT IF A HOSPITAL SERVES PATIENTS WITH GOVERNMENTAL HEALTH BENEFITS, INCLUDING HIP, THEN THIS IS AN INDICATION THAT THE HOSPITAL OPERATES TO PROMOTE THE HEALTH OF THE COMMUNITY. THE UNREIMBURSED HIP COST REPORTED ON LINE 7C IS CALCULATED UNDER THE COST TO CHARGE RATIO METHODOLOGY. UNDER THIS METHOD, THE HIP CHARGES ARE MULTIPLIED BY THE RATIO OF COST TO CHARGES TO DETERMINE THE COST OF HIP SERVICES RENDERED. THEN, THE COST OF HIP SERVICES RENDERED IS DEDUCTED FROM THE REIMBURSEMENT RECEIVED FOR HIP PATIENTS TO ARRIVE AT A GAIN/(LOSS) RELATIVE TO THESE PATIENTS.PART I, LINE 7EAMOUNTS PRESENTED ARE BASED ON ACTUAL SPEND FOR THOSE SERVICES AND BENEFITS PROVIDED DEEMED TO IMPROVE THE HEALTH OF THE COMMUNITIES IN WHICH WE SERVE AND CONFORM WITH THE MISSION OF OUR EXEMPT PURPOSE.PART I, LINE 7IIN KEEPING WITH OUR MISSION AND COMMITMENT TO THE COMMUNITIES IN WHICH WE SERVE, COMMUNITY HOSPITAL OF LAGRANGE COUNTY, INC. CONTINUES ITS TRADITION OF CONTRIBUTING TO NUMEROUS ORGANIZATIONS ON BOTH AN AS-NEEDED BASIS AND NEGOTIATED BASIS. AMOUNTS PRESENTED REPRESENT ACTUAL SPEND TO ORGANIZATIONS THROUGHOUT OUR COMMUNITIES. PART I, LN 7 COL(F): PERCENT OF TOTAL EXPENSECOMMUNITY HOSPITAL OF LAGRANGE COUNTY, INC. EXCLUDED $3,855,698 OF BAD DEBT EXPENSE. PART II, COMMUNITY BUILDING ACTIVITIES: DESCRIBE HOW THE ORGANIZATION'S COMMUNITY BUILDING ACTIVITIES, AS REPORTED, PROMOTES THE HEALTH OF THE COMMUNITIES THE ORGANIZATION SERVES.COMMUNITY HOSPITAL OF LAGRANGE COUNTY PROVIDES SUPPORT FOR LOCAL ECONOMIC DEVELOPMENT PROGRAMS. THESE EFFORTS ARE ALIGNED WITH OF THE HEALTH SYSTEM'S STRATEGIC INVOLVEMENT IN THE NORTHEAST INDIANA REGIONAL PARTNERSHIP'S VISION 2020, A REGIONAL INITIATIVE DESIGNED TO TRANSFORM NORTHEAST INDIANA INTO A TOP GLOBAL COMPETITOR BY FOCUSING ON A COMMON MISSION TO DEVELOP, ATTRACT AND RETAIN TALENT. VISION 2020'S PRIORITIES ARE TIED TO EDUCATION/WORKFORCE, BUSINESS CLIMATE, ENTREPRENEURSHIP, INFRASTRUCTURE AND QUALITY OF LIFE FOR THE ELEVEN-COUNTY REGION IN NORTHEAST INDIANA. PROMOTION OF ECONOMIC DEVELOPMENT IN LAGRANGE COUNTY IS A PART OF A COLLECTIVE PLAN TO IMPROVE THE QUALITY OF LIFE AND ULTIMATELY THE OVERALL HEALTH AND WELL-BEING OF THE COMMUNITY. PART III, LINE 2: THE AMOUNT REPORTED IS CONSISTENT WITH THE AMOUNT REPORTED ON THE ORGANIZATION'S AUDITED FINANCIAL STATEMENTS UNDER THE GENERALLY ACCEPTED ACCOUNTING STANDARDS.DISCOUNTS AND PAYMENTS ON PATIENT ACCOUNTS (BAD DEBT RECOVERIES) ARE FACTORED INTO THE ALLOWANCE FOR BAD DEBT ESTIMATION PROCESS. PART III, LINE 3: COSTING METHODOLOGY USED:UNCOLLECTIBLE PATIENT ACCOUNTS ARE CHARGED AGAINST THE PROVISION FOR BAD DEBT IN ACCORDANCE WITH THE POLICIES OF COMMUNITY HOSPITAL OF LAGRANGE COUNTY, INC. HOWEVER, DURING THE COLLECTION PROCESS THERE IS A CONTINUOUS EFFORT TO DETERMINE IF THE PATIENT QUALIFIES FOR FINANCIAL ASSISTANCE. THEREFORE, ONCE AN UNCOLLECTIBLE ACCOUNT HAS BEEN CHARGED OFF AND IT IS DETERMINED THROUGH THE COLLECTION PROCESS THAT THE PATIENT QUALIFIES FOR FINANCIAL ASSISTANCE, THE UNCOLLECTIBLE ACCOUNT IS RECLASSIFIED TO CHARITY CARE AND ALL COLLECTION EFFORTS CEASE. PATIENTS ARE ELIGIBLE TO APPLY FOR FINANCIAL ASSISTANCE AT ANY TIME, INCLUDING PATIENTS WHOSE ACCOUNTS HAVE BEEN PLACED IN A BAD DEBT AGENCY. THE AMOUNT REFLECTED ON LINE 3 WAS CALCULATED BY TOTALING THE ACCOUNTS PREVIOUSLY WRITTEN OFF TO BAD DEBT AND PLACED WITH A COLLECTION AGENCY, BUT SUBSEQUENTLY RECLASSIFIED AS CHARITY CARE DURING THE TAX YEAR. THE ACCOUNTS WERE RECLASSIFIED AS CHARITY CARE DUE TO THE FACT THAT PATIENTS APPLIED FOR, AND WERE APPROVED FOR, FINANCIAL ASSISTANCE AFTER THE ACCOUNTS WERE PLACED WITH A BAD DEBT AGENCY. PART III, LINE 4: BAD DEBT EXPENSE - PARKVIEW HEALTH SYSTEM, INC. AND SUBSIDIARIES - NOTES TO THE CONSOLIDATED FINANCIAL STATEMENTSTEXT OF THE FOOTNOTE TO THE ORGANIZATION'S FINANCIAL STATEMENTS THAT DESCRIBES BAD DEBT EXPENSE OR THE PAGE NUMBER ON WHICH THIS FOOTNOTE IS CONTAINED IN THE ATTACHED FINANCIAL STATEMENTS:PAGE 14 OF ATTACHED FINANCIAL STATEMENTS. PART III, LINE 8: COMMUNITY BENEFIT & METHODOLOGY FOR DETERMINING MEDICARE COSTSSUBSTANTIAL SHORTFALLS TYPICALLY ARISE FROM PAYMENTS THAT ARE LESS THAN THE COST TO PROVIDE THE CARE OR SERVICES AND DO NOT INCLUDE ANY AMOUNTS RELATING TO INEFFICIENT OR POOR MANAGEMENT. COMMUNITY HOSPITAL OF LAGRANGE COUNTY, INC. ACCEPTS ALL MEDICARE PATIENTS, AS REFLECTED ON THE YEAR-END MEDICARE COST REPORT, WITH THE KNOWLEDGE THAT THERE MAY BE SHORTFALLS. INTERNAL REVENUE SERVICE (IRS) REVENUE RULING 69-545 IMPLIES THAT TREATING MEDICARE PATIENTS IS A COMMUNITY BENEFIT. IRS REVENUE RULING 69-545, WHICH ESTABLISHED THE COMMUNITY BENEFIT STANDARD FOR NONPROFIT HOSPITALS, STATES THAT IF A HOSPITAL SERVES PATIENTS WITH GOVERNMENTAL HEALTH BENEFITS, INCLUDING MEDICARE, THEN THIS IS AN INDICATION THAT THE HOSPITAL OPERATES TO PROMOTE THE HEALTH OF THE COMMUNITY. HOWEVER, MEDICARE PAYMENTS REPRESENT A PROXY OF COST CALLED THE "UPPER PAYMENT LIMIT." IT HAS HISTORICALLY BEEN ASSUMED THAT UPPER PAYMENT LIMIT PAYMENTS DO NOT GENERATE A SHORTFALL. AS A RESULT, COMMUNITY HOSPITAL OF LAGRANGE COUNTY, INC. HAS TAKEN THE POSITION NOT TO INCLUDE THE MEDICARE SHORTFALLS OR SURPLUSES AS PART OF COMMUNITY BENEFIT. COMMUNITY HOSPITAL OF LAGRANGE COUNTY, INC. RECOGNIZES THAT THE SHORTFALL OR SURPLUS FROM MEDICARE DOES NOT INCLUDE THE COSTS AND REVENUES ASSOCIATED WITH MEDICARE ADVANTAGE PATIENTS. AS SUCH, THE TOTAL SHORTFALL OR SURPLUS OF MEDICARE IS UNDERSTATED DUE TO THE COSTS AND REVENUES ASSOCIATED WITH MEDICARE ADVANTAGE PATIENTS NOT BEING INCLUDED IN THE COMMUNITY BENEFIT DETERMINATION. PART III, LINE 9B: IF THE PATIENT CANNOT PAY IN FULL, THE OPTION OF A LOW INTEREST LOAN IS AVAILABLE WITH THE SAME DISCOUNT OFFERED FOR CASH PAYMENTS AS LONG AS THE LOAN IS ARRANGED WITHIN 30 DAYS OF THE FIRST GUARANTOR STATEMENT. IF THE PATIENT DEFAULTS ON THE LOAN, THE DISCOUNT WILL BE REVERSED AND THE PATIENT'S ACCOUNT WILL BE PLACED IN A COLLECTION AGENCY.INTEREST-FREE PAYMENTS WITH PAY-OUT NOT TO EXCEED TWELVE (12) MONTHS ARE AVAILABLE. THE MINIMUM MONTHLY PAYMENT IS $25.FINANCIAL ASSISTANCE MAY BE AVAILABLE FOR THOSE PATIENTS WHO CANNOT PAY THEIR BILL. THOSE OPTIONS ARE GOVERNMENTAL ASSISTANCE OR FREE CARE THROUGH THE HOSPITAL FINANCIAL ASSISTANCE PROGRAM. THE HEALTH SYSTEM FINANCIAL ASSISTANCE POLICY IS AVAILABLE ON PARKVIEW.COM OR BY VISITING ANY HOSPITAL CASHIER OFFICE OR BY CALLING PATIENT ACCOUNTING AT 260.373.7770 OR TOLL FREE 855.814.0012. A PATIENT MAY APPLY FOR FINANCIAL ASSISTANCE ANYTIME DURING THE APPLICATION PERIOD. FAILURE TO MAKE ARRANGEMENTS AS LISTED ABOVE OR FAILURE TO APPLY FOR AND RECEIVE APPROVAL UNDER THE FINANCIAL ASSISTANCE POLICY MAY RESULT IN THE ACCOUNT BEING PLACED IN A COLLECTION AGENCY DUE TO NON-PAYMENT. THE COLLECTION AGENCY MAY REPORT THE ACCOUNT TO ONE OR ALL THREE CREDIT REPORTING AGENCIES WHICH MAY ULTIMATELY ADVERSELY AFFECT THE PATIENT'S CREDIT SCORE. ADDITIONALLY, THE COLLECTION AGENCY MAY SUE AND OBTAIN A JUDGMENT AGAINST THE PATIENT FOR NON-PAYMENT. THESE ACTIONS WILL NOT OCCUR UNTIL 120 DAYS AFTER THE PATIENT IS SENT THEIR FIRST FOLLOW-UP STATEMENT INDICATING THE AMOUNT THEY OWE.A PATIENT MAY APPLY FOR FINANCIAL ASSISTANCE AT ANY TIME DURING THE APPLICATION PERIOD, EVEN THOUGH THEY HAVE BEEN PLACED IN A COLLECTION AGENCY. IF THE PATIENT WAS SENT THEIR FIRST NOTICE ON THE ACCOUNT FOR WHICH THEY ARE APPLYING FOR FREE CARE BETWEEN 120 DAYS AND THE END OF THE APPLICATION PERIOD, THE ACTIONS ABOVE WILL BE SUSPENDED UNTIL THE FREE CARE APPLICATION ELIGIBILITY IS DETERMINED. PART VI, LINE 2: DESCRIBE HOW THE ORGANIZATION ASSESSES THE HEALTH CARE NEEDS OF THE COMMUNITIES IT SERVES.PARKVIEW HEALTH SYSTEM, INC. INCLUDING COMMUNITY HOSPITAL OF LAGRANGE COUNTY, INC. CONDUCTED A COMMUNITY HEALTH NEEDS ASSESSMENT (CHNA) FOR THE SEVEN COUNTIES (ALLEN, HUNTINGTON, KOSCIUSKO, LAGRANGE, NOBLE, WABASH AND WHITLEY) WHERE PARKVIEW HAS HOSPITALS. ADDITIONALLY, PARKVIEW HEALTH SYSTEM, INC. PARTNERED WITH THE INDIANA PARTNERSHIP FOR HEALTHY COMMUNITIES (IPHC) TO COMPLETE MUCH OF THE FIELD WORK. IPHC CONDUCTED THE RANDOMLY SELECTED COMMUNITY MEMBER SURVEY TO OBTAIN PRIMARY DATA. THE SURVEY INSTRUMENT USED FOR THIS STUDY WAS LARGELY BASED ON THE CENTERS FOR DISEASE CONTROL AND PREVENTION BEHAVIORAL RISK FACTOR SURVEILLANCE SYSTEM. OUR SURVEY INCLUDED CUSTOMIZED QUESTIONS ADDRESSING GAPS IN INDICATOR DATA RELATIVE TO NATIONAL HEALTH PROMOTION AND DISEASE PREVENTION OBJECTIVES AND OTHER RECOGNIZED HEALTH ISSUES. IPHC ASSISTED WITH SURVEYING PUBLIC HEALTH, OTHER HEALTHCARE PROFESSIONALS, SOCIAL SERVICE AGENCIES AND OTHER COMMUNITY GROUP REPRESENTATIVES. THEY ALSO CONDUCTED SECONDARY DATA RESEARCH, DATA ANALYSIS AND FACILITATED PRIORITIZATION OF IDENTIFIED HEALTH ISSUES. A COLLECTIVE SECONDARY DATA BASE PROVIDED BY CONDUENT HEALTHY COMMUNITIES INSTITUTE WAS ALSO USED TO DETERMINE HEALTH ISSUES FOR EACH COUNTY IN THE SEVEN-COUNTY AREA. OTHER STATE AND NATIONAL SECONDARY SOURCES INCLUDED CENTERS FOR DISEASE CONTROL AND PREVENTION, COUNTY HEALTH RANKINGS, HEALTH INDICATORS WAREHOUSE, INDIANA STATE DEPARTMENT OF HEALTH, INDIANA UNIVERSITY CENTER FOR HEALTH POLICY AND THE US CENSUS BUREAU. CHNA REPORTS WERE PRESENTED TO AND ADOPTED BY THEIR RESPECTIVE HOSPITAL BOARD OF DIRECTORS IN 2016. COMMUNITY HOSPITAL OF LAGRANGE COUNTY, INC. REPRESENTATIVES MAINTAIN ON-GOING RELATIONSHIPS THROUGHOUT OUR COMMUNITIES AND MEET REGULARLY WITH ORGANIZATIONS THAT SHARE THE MISSION OF IMPROVING THE HEALTH AND INSPIRING THE WELL-BEING OF OUR COMMUNITIES. HEALTH ISSUES IDENTIFIED IN THE SURVEY INCLUDED: OBESITY, TOBACCO USE, MATERNAL/CHILD HEALTH, DIABETES, CARDIOVASCULAR DISEASE, DRUG/ALCOHOL USE, CANCER, HEALTHCARE ACCESS, MENTAL HEALTH AND CHRONIC KIDNEY DISEASE.THE PRIORITIZATION OF HEALTH ISSUES WAS CONDUCTED USING A MODIFIED HANLON METHOD WHICH TAKES INTO ACCOUNT THE SIZE OF THE HEALTH PROBLEM, SERIOUSNESS OF THE HEALTH PROBLEM AND THE EFFECTIVENESS OF INTERVENTIONS. THIS METHOD, CALLED THE BASIC PRIORITY RATING SYSTEM (BPRS) IS RECOMMENDED BY THE NATIONAL ASSOCIATION OF COUNTY AND CITY HEALTH OFFICIALS (NACCHO) FOR THE PURPOSE OF PRIORITIZING COMMUNITY HEALTH NEEDS. FROM THE LIST OF HEALTH ISSUES IDENTIFIED, THREE TOP HEALTH PRIORITIES WERE SELECTED THROUGH APPLYING THE PEARL TEST WHICH IS DESIGNED TO SCREEN OUT IMPRACTICAL OR IMPRACTICABLE INTERVENTIONS BASE ON KEY FEASIBILITY FACTORS. THESE PRIORITIES ARE: 1) OBESITY/HEALTHY LIFESTYLES; 2) DRUG AND ALCOHOL USE; 3) MENTAL HEALTH.OTHER WAYS THAT COMMUNITY HOSPITAL OF LAGRANGE HOSPITAL, INC. IDENTIFIES OR VERIFIES COMMUNITY HEALTH NEEDS: -OTHER COMMUNITY NEEDS ASSESSMENTS CONDUCTED BY LOCAL ORGANIZATIONS -OBSERVATIONS BY HEALTHCARE PROFESSIONALS WHO WORK WITH VULNERABLE POPULATIONS-SPECIFIC REQUESTS PROMPTED BY OBSERVATION BY OTHER PROFESSIONALS IN THE COMMUNITY PART VI, LINE 3: DESCRIBE HOW THE ORGANIZATION INFORMS AND EDUCATES PATIENTS AND PERSONS WHO MAY BE BILLED FOR PATIENT CARE ABOUT THEIR ELIGIBILITY FOR ASSISTANCE UNDER FEDERAL, STATE OR LOCAL GOVERNMENT PROGRAMS OR UNDER THE ORGANIZATION'S FINANCIAL ASSISTANCE POLICY.SIGNAGE AND BROCHURES ARE POSTED AND AVAILABLE AT ALL HOSPITAL POINTS OF REGISTRATION AND IN THE EMERGENCY DEPARTMENT. PATIENTS ARE OFFERED PLAIN LANGUAGE SUMMARIES OF THE FINANCIAL ASSISTANCE POLICY DURING THE REGISTRATION PROCESS AND IN EACH FOLLOW UP STATEMENT SENT TO THE PATIENT. PATIENT STATEMENTS WILL INDICATE HOW A PATIENT CAN OBTAIN FINANCIAL ASSISTANCE APPLICATIONS AND WHO THEY CAN CONTACT FOR ASSISTANCE. PART VI, LINE 4: DESCRIBE THE COMMUNITY THE ORGANIZATION SERVES, TAKING INTO ACCOUNT THE GEOGRAPHIC AREA AND DEMOGRAPHIC CONSTITUENTS IT SERVES.COMMUNITY HOSPITAL OF LAGRANGE COUNTY, INC. PRIMARILY SERVES THE LAGRANGE COUNTY COMMUNITIES OF LAGRANGE, HOWE, SHIPSHEWANA, TOPEKA, AND WOLCOTTVILLE. AS THE ONLY HOSPITAL IN THIS COUNTY, COMMUNITY HOSPITAL OF LAGRANGE COUNTY, INC. ALSO SERVES, TO A LIMITED EXTENT, SURROUNDING COMMUNITIES. LAGRANGE COUNTY HAS APPROXIMATELY 39,110 RESIDENTS, PRIMARILY CAUCASIAN. THE COUNTY'S UNEMPLOYMENT RATE IS 3.4%. THE MEDIAN INCOME IN LAGRANGE COUNTY IS $49,964. PLAIN CHURCH RESIDENTS, INCLUDING MEMBERS OF THE AMISH COMMUNITY, MAKE UP NEARLY 44% OF THE POPULATION IN LAGRANGE COUNTY. FOR THE MEMBERS OF THESE FAITH-BASED COMMUNITIES, PARTICULARLY THE AMISH, EVERYDAY TRAVEL IS BY HORSE AND BUGGY OR BICYCLE; COMMUNICATIONS ARE FACE-TO-FACE OR THROUGH THE USE OF A COMMUNITY-OWNED, CENTRALLY LOCATED PHONE. LAGRANGE COUNTY ALSO SERVES A LARGE NUMBER OF HISPANIC RESIDENTS, REPRESENTING APPROXIMATELY 4.0% OF THE OVERALL POPULATION OF THE COUNTY. PART VI, LINE 5: PROVIDE ANY OTHER INFORMATION IMPORTANT TO DESCRIBING HOW THE ORGANIZATION'S HOSPITAL FACILITIES OR OTHER HEALTH CARE FACILITIES FURTHER ITS EXEMPT PURPOSE BY PROMOTING THE HEALTH OF THE COMMUNITY (E.G. OPEN MEDICAL STAFF, COMMUNITY BOARD, USE OF SURPLUS FUNDS, ETC.).COMMUNITY HOSPITAL OF LAGRANGE COUNTY, INC.'S BOARD OF DIRECTORS IS COMPOSED OF MEMBERS, OF WHICH SUBSTANTIALLY ALL ARE INDEPENDENT COMMUNITY MEMBERS. A MAJORITY OF THE BOARD RESIDES IN COMMUNITY HOSPITAL OF LAGRANGE COUNTY, INC.'S PRIMARY SERVICE AREA. COMMUNITY HOSPITAL OF LAGRANGE COUNTY, INC. ALSO EXTENDS MEDICAL STAFF PRIVILEGES TO ALL QUALIFIED PHYSICIANS IN THE COMMUNITY. PEOPLE THROUGHOUT THE COMMUNITY CAN COUNT ON COMMUNITY HOSPITAL OF LAGRANGE COUNTY, INC. TO BE STANDING BY WITH EMERGENCY CARE 24 HOURS A DAY, 365 DAYS A YEAR. THE EMERGENCY DEPARTMENT IS STAFFED WITH BOARD-CERTIFIED EMERGENCY CARE PHYSICIANS AND A NURSING STAFF THAT IS TRAINED AND EXPERIENCED IN EMERGENCY CARE. FURTHERMORE, NO PATIENT IS EVER DENIED TREATMENT, REGARDLESS OF THEIR ABILITY TO PAY.COMMUNITY HOSPITAL OF LAGRANGE COUNTY, INC. GIVES BACK TO THE COMMUNITY IN THE FORM OF IMPROVED FACILITIES, EDUCATION AND OUTREACH PROGRAMS, FREE AND DISCOUNTED CARE, VOLUNTEERISM AND MUCH MORE. THE FOLLOWING ARE SOME OF THE WAYS COMMUNITY HOSPITAL OF LAGRANGE COUNTY, INC. IS REACHING OUT TO MAKE OUR NEIGHBORHOODS AND COMMUNITIES HEALTHIER:PATIENT & FAMILY ADVISORY COUNCIL: IN 2016, PARKVIEW LAGRANGE HOSPITAL CONTINUED ITS PARTNERSHIP WITH PATIENTS AND PATIENT'S FAMILY MEMBERS THROUGH THE HOSPITAL'S PATIENT & FAMILY ADVISORY COUNCIL. THE PFAC MEMBERS PROVIDED FEEDBACK ABOUT ISSUES, PROCESSES AND OPPORTUNITIES THAT WOULD IMPROVE THE PATIENT EXPERIENCE AT PARKVIEW LAGRANGE.A FEW OF THE TOPICS DISCUSSED WITH PFAC MEMBERS WERE:-A DISCUSSION OF HOW LAGRANGE COUNTY CONSUMERS WOULD BEST UTILIZE VIRTUAL HEALTH AND HOW TO BEST MEET THEIR NEEDS THROUGH THIS HEALTH CARE DELIVERY MODEL. -PROCESSES FOR IMPROVEMENT OF PATIENT COMMUNICATION IN THE EMERGENCY ROOM.-FINALIZATION OF THE COMMUNICATION CARDS FOR OUTPATIENT SURGERY PATIENTS TO ENSURE POTENTIAL SIDE EFFECTS AND PAIN MANAGEMENT IS COMMUNICATED IN LAY TERMS.THE COMMUNITY HEALTH IMPROVEMENT (CHI) INITIATIVE OF COMMUNITY HOSPITAL OF LAGRANGE COUNTY, INC. IS A PROGRAM THAT PROVIDES GRANT SUPPORT FOR COMMUNITY HEALTH INITIATIVES DELIVERED BY NOT-FOR-PROFIT COMMUNITY ORGANIZATIONS THAT SHARE THE HOSPITAL'S MISSION TO ENCOURAGE HEALTHIER LIFESTYLES AMONG THE CITIZENS OF LAGRANGE COUNTY. THE FOLLOWING WERE AMONG THE CHI INITIATIVES FUNDED IN 2016:-THE HOSPITAL CONTINUED ITS PARTNERSHIP WITH COLE FAMILY CENTER YMCA IN 2016, TO FACILITATE ACCESS TO GROUP WELLNESS ACTIVITIES IN LAGRANGE COUNTY AT A YMCA SATELLITE SITE IN SILVEUS INSURANCE'S LOWER LEVEL IN LAGRANGE. -HEALTH AND SAFETY DAY CAMP IS SPONSORED BY THE HOSPITAL IN PARTNERSHIP WITH LAGRANGE COUNTY'S THREE PUBLIC SCHOOL DISTRICTS, THE SHERRIFF'S DEPARTMENT OF LAGRANGE COUNTY AND OTHER IMPORTANT AGENCIES WITHIN THE COUNTY. SAFETY DAY CAMP IS HOSTED AT EACH ELEMENTARY SCHOOL FOR ALL THE SCHOOL'S FOURTH GRADE STUDENTS AND PROVIDES THEM WITH INTERACTIVE EDUCATION ABOUT TOPICS SUCH AS:--BIKE AND ROAD SAFETY - THE HOSPITAL PROVIDES EACH STUDENT WITH A FREE SAFETY VEST--CPR--WATER SAFETY--INTERNET SAFETY AND "STRANGER DANGER"--FIRST AIDDURING 2016, THE HEALTH AND SAFETY DAY CAMP REACHED OVER 500 FOURTH GRADE STUDENTS.-THE HOSPITAL'S CHI FUNDING CONTINUED TO PROVIDED AUTOMATED EXTERNAL DEFIBRILLATORS (AED) FOR THE COUNTY'S FIRST RESPONDERS' VEHICLES. THE HOSPITAL PROVIDED AED'S AND TRAINING ON THEIR USE TO THE MONGO AND HOWE VOLUNTEER FIRE DEPARTMENTS, AND FULFILLED THE 2015 COMMITMENT OF AED'S FOR THE WOLCOTTVILLE, TOPEKA AND LAGRANGE TOWN MARSHALLS, AND THE LAGRANGE COUNTY SHERIFF'S DEPARTMENT.-EXPECTANT MOTHERS IN THE FIRST TRIMESTER OF THEIR PREGNANCY WERE PROVIDED WITH ACCESS TO FREE PRENATAL VITAMINS THROUGH A CHI INITIATIVE AND PARTNERSHIPS WITH PHARMACIES IN LAGRANGE COUNTY. VOUCHERS FOR THE VITAMINS COULD BE PICKED UP THROUGH THE WOMAN'S LAGRANGE COUNTY PRIMARY CARE PHYSICIAN, THROUGH PARKVIEW LAGRANGE HOSPITAL'S BIRTH PLANNER OR THE COMPASSION PREGNANCY CENTER IN LAGRANGE COUNTY.-THE HOSPITAL CONTINUED ITS PARTNERSHIP WITH THE LAGRANGE COUNTY COUNCIL ON AGING (COA) TO ASSIST WITH OPERATIONAL SUPPORT FOR THE COA'S SERVICES TO SENIORS. THE COA PROVIDES A TRANSPORTATION PROGRAM, HOMEMAKER SERVICES, A FOOD PANTRY AND MUCH MORE IN THEIR EFFORTS TO HELP SENIORS IN LAGRANGE COUNTY REMAIN INDEPENDENT IN THE HOMES OF THEIR CHOICE FOR AS LONG AS POSSIBLE. NEARLY HALF OF THE TRIPS THE COA OFFERS TO SENIORS ARE TO THEIR PHYSICIANS FOR CHECK-UPS OR TO THE HOSPITAL FOR TESTS OR TREATMENTS. HOMEMAKER SERVICES HELP WITH DAY-TO-DAY TASKS THAT, IN MANY CASES, COULD PUT THE SENIOR AT RISK OF A FALL OR OTHER INJURY. THE HOSPITAL'S PLAIN CHURCH COORDINATOR SERVES AS A SINGLE POINT OF ACCESS FOR AMISH, MENNONITE AND OTHER PLAIN CHURCH MEMBERS WHO HAVE QUESTIONS ABOUT THE AVAILABILITY OF HEALTHCARE SERVICES. WHETHER THE QUESTION CONCERNS THE APPROXIMATE COST OF A PROCEDURE, THE SCHEDULING OF A DIAGNOSTIC TEST, OR A BILLING QUESTION, THE PLAIN CHURCH COORDINATOR WILL ASSIST THE CALLER IN OBTAINING AN ANSWER.AMISH, MENNONITE AND OTHER PLAIN CHURCH RESIDENTS CONTINUE TO MAKE UP A LARGE PART OF THE POPULATION IN LAGRANGE COUNTY. RECOGNIZING THE DIVERSE CIRCUMSTANCES OF THESE COMMUNITIES, COMMUNITY HOSPITAL OF LAGRANGE COUNTY, INC. REPRESENTATIVES CONTINUE TO WORK CLOSELY WITH MEMBERS OF THE PLAIN CHURCH COMMUNITY, HELPING TO IDENTIFY SPECIFIC NEEDS AND DEVELOP SYSTEMS TO ADDRESS THEM. COMMUNITY HOSPITAL OF LAGRANGE COUNTY, INC. PARTICIPATES IN NUMEROUS HEALTH FAIRS AND ACTIVITIES THROUGHOUT THE YEAR OFFERING FREE AND LOW COST HEALTH SCREENINGS AND INFORMATION TO DIVERSE POPULATIONS IN OUR SERVICE AREA, INCLUDING THE PLAIN CHURCH AND HISPANIC RESIDENTS AND SENIORS WHO RESIDE IN THE COUNTY. THESE EVENTS PROVIDE HEALTH EDUCATION AND SCREENINGS FOR DISEASE PREVENTION AND PROMOTE HEALTHY LIFESTYLES. THE HOSPITAL ALSO PROVIDES SUPPORT GROUPS TO ASSIST PATIENTS AND FAMILIES IN MANAGING DISEASE. THE FOLLOWING ARE INITIATIVES PROVIDED IN 2016:-PARKVIEW LAGRANGE HOSPITAL SENIOR CLUB PROVIDED AREA SENIORS WITH EDUCATIONAL PROGRAMS, SCREENINGS, AND SOCIAL ACTIVITIES THROUGHOUT THE YEAR.-WELLNESS ON THE ROAD (WOTR) BROUGHT LOW COST BLOOD TESTS, DIABETES AND CANCER INFORMATION AND SCREENINGS TO RESIDENTS THROUGHOUT LAGRANGE COUNTY. THESE SCREENING AND EDUCATIONAL EVENTS WERE HELD IN THE TOWNS OF LAGRANGE, HOWE, SHIPSHEWANA AND TOPEKA.-FREE MONTHLY DIABETES SUPPORT GROUPS PROVIDE DIABETIC PATIENTS AND THEIR FAMILY MEMBERS WITH INFORMATION, EDUCATION AND COUNSELING ABOUT THE MANY ASPECTS OF THIS CHRONIC DISEASE. PART VI, LINE 6: IF THE ORGANIZATION IS PART OF AN AFFILIATED HEALTH CARE SYSTEM, DESCRIBE THE RESPECTIVE ROLES OF THE ORGANIZATION AND ITS AFFILIATES IN PROMOTING THE HEALTH OF THE COMMUNITIES SERVED.PARKVIEW HEALTH SYSTEM, INC. (PARKVIEW), A HEALTHCARE SYSTEM SERVING NORTHEAST INDIANA AND NORTHWEST OHIO THROUGH OUR HOSPITALS AND PHYSICIAN CLINICS, INCLUDES THE NOT-FOR-PROFIT HOSPITALS OF PARKVIEW HOSPITAL, INC.; COMMUNITY HOSPITAL OF LAGRANGE COUNTY, INC.; COMMUNITY HOSPITAL OF NOBLE COUNTY, INC.; PARKVIEW WABASH HOSPITAL, INC.; WHITLEY MEMORIAL HOSPITAL, INC.; HUNTINGTON MEMORIAL HOSPITAL, INC.; AS WELL AS 60 PERCENT OWNERSHIP IN THE JOINT VENTURE OF ORTHOPAEDIC HOSPITAL AT PARKVIEW NORTH, LLC. PARKVIEW CONTRIBUTES TO THE SUCCESS OF THE REGION BY EFFECTIVELY MANAGING ITS FACILITIES, EFFICIENTLY PROVIDING AND DELIVERING ITS SERVICES, AND SUPPORTING LOCAL BUSINESSES AND ACTIVITIES. PARKVIEW SEEKS TO CREATE ALIGNMENT OPPORTUNITIES TO DELIVER COMPREHENSIVE HIGH-QUALITY CARE THAT BENEFIT PATIENTS, PHYSICIANS, CO-WORKERS AND COMMUNITIES. EACH HOSPITAL ENTITY ENGAGES IN COMMUNITY OUTREACH CUSTOMIZED TO MEET THE UNIQUE NEEDS OF THEIR RESPECTIVE COMMUNITIES. AFFILIATE HOSPITALS WORK TOGETHER AND SHARE PROGRAMMING AND MESSAGING WHERE COMMON COMMUNITY HEALTH ISSUES ARE IDENTIFIED. FROM THE LIST OF HEALTH ISSUES IN THE SEVEN-COUNTY AREA, THE HEALTH PRIORITY OF OBESITY/HEALTHY LIFESTYLE PROMOTION AND EDUCATION INCLUDING GOOD NUTRITION, ACCESS TO AND CONSUMPTION OF HEALTHY FOODS AND AN ACTIVE LIFESTYLE WAS SELECTED BY ALL AFFILIATE HOSPITALS. PARKVIEW PRIDES ITSELF IN NOT ONLY OFFERING THE HIGHEST LEVEL OF CARE TO ITS PATIENTS, BUT ALSO IN PROVIDING AN EXCELLENT WORKPLACE FOR ITS PHYSICIANS, NURSES AND STAFF. PARKVIEW'S MISSION AND VISION IS AS FOLLOWS: AS A COMMUNITY OWNED, NOT-FOR-PROFIT ORGANIZATION, PARKVIEW HEALTH IS DEDICATED TO IMPROVING YOUR HEALTH AND INSPIRING YOUR WELL-BEING BY: 1) TAILORING A PERSONALIZED HEALTH JOURNEY TO ACHIEVE YOUR UNIQUE GOALS, 2) DEMONSTRATING WORLD-CLASS TEAMWORK AS WE PARTNER WITH YOU ALONG THAT JOURNEY 3) PROVIDING THE EXCELLENCE, INNOVATION AND VALUE YOU SEEK IN TERMS OF CONVENIENCE, COMPASSION, SERVICE, COST AND QUALITY. PARKVIEW BELIEVES THAT THE COMMUNITIES IT SERVES SHOULD ALL HAVE THE PEACE OF MIND THAT COMES WITH ACCESS TO COMPASSIONATE, HIGH-QUALITY HEALTHCARE, REGARDLESS OF WHETHER THE CARE IS DELIVERED IN A RURAL OR URBAN SETTING. PART VI, LINE 7, REPORTS FILED WITH STATES IN PART VI, LINE 7: A COPY OF FORM 990, SCHEDULE H IS FILED WITH THE INDIANA STATE DEPARTMENT OF HEALTH. 1 LAGRANGE COUNTY COUNCIL ON AGING 125 FENN ST SUITE 4 LAGRANGE IN 46761 237455893 501 ( C ) 3 15000 MEDICAL TRANSPORTATION LAGRANGE COUNTY ECONOMIC DEVELOPMENT 304 N TOWNLINE ROAD LAGRANGE IN 46764 800309463 501 ( C ) 3 10000 BUSINESS DEVELOPMENT AND EMPLOYMENT PROGRAMS PARKVIEW HOSPITAL INC 11109 PARKVIEW PLAZA DRIVE FORT WAYNE IN 46845 350868085 501 ( C ) 3 9000 HOME HEALTH & HOSPICE PROGRAM FOR SERVICE AREA OF COMMUNITY HOSPITAL OF LAGRANGE COUNTY, INC. 3 0 PART I, LINE 2: COMMUNITY HEALTH IMPROVEMENT FUNDING PARTNER ORGANIZATIONS ARE REQUIRED TO SUBMIT AN ANNUAL PROGRESS REPORT RELATED TO PROGRAM FUNDING. PARTNER ORGANIZATIONS ARE REQUIRED TO RE-APPLY FOR FUNDING ON AN ANNUAL BASIS. X 1 1 0 1 0 0 0 0 0 1 0 JORDI DISLER DIRECTOR/CURRENT LGHOS PRESIDENT 167116 0 50559 0 8569 0 39497 0 20134 0 285875 0 7742 0 MICHAEL PACKNETT DIRECTOR/PH PRESIDENT & CEO 0 999068 0 525000 0 542942 0 669350 0 43194 0 2779554 0 419516 SHELBY COOPER DIRECTOR/PH PHYSICIAN 12000 151869 0 0 0 2266 0 0 0 5951 12000 160086 0 0 LOREN HELMUTH DIRECTOR/PH PHYSICIAN 17150 437238 0 60332 0 24415 590 17960 992 30181 18732 570126 0 0 JEANNE' WICKENS PH CHIEF FINANCIAL OFFICER 0 329339 0 15000 0 28030 0 60171 0 19158 0 451698 0 0 STANTON RISSER INTERIM PH CFO - PARTIAL YEAR/PH VP 0 193037 0 116196 0 8927 0 40555 0 27057 0 385772 0 6041 BRENDA ARMENTROUT LGHOS MGR PHARMACY 145961 0 20096 0 1228 0 15016 0 9670 0 191971 0 0 0 PART I, LINE 1A TAX INDEMNIFICATION AND GROSS-UP PAYMENTS - TAX ON TAXABLE GIFT CERTIFICATE PAID TO: BRENDA ARMENTROUT $15 PART I, LINE 3 RELATED ORGANIZATION, PARKVIEW HEALTH SYSTEM, INC., USES THE FOLLOWING TO ESTABLISH THE COMPENSATION OF COMMUNITY HOSPITAL LAGRANGE COUNTY, INC.'S CEO/EXECUTIVE DIRECTOR: COMPENSATION COMMITTEE OF RELATED ORGANIZATION PARKVIEW HEALTH SYSTEM, INC. INDEPENDENT COMPENSATION CONSULTANT COMPENSATION SURVEY OR STUDY APPROVAL BY THE BOARD OR COMPENSATION COMMITTEE OF RELATED ORGANIZATION PARKVIEW HEALTH SYSTEM, INC. PART I, LINE 4B SUPPLEMENTAL NONQUALIFIED RETIREMENT PLAN PAYMENTS TAXABLE - JORDI DISLER $7,742; ROBERT MYERS $10,589; MICHAEL PACKNETT $419,516; STANTON RISSER $6,041 PARTICIPANTS DEFERRED - THE FOLLOWING INDIVIDUALS HAVE AN AMOUNT INCLUDED IN SCHEDULE J, PART II, COLUMN (C) FOR AN AMOUNT EARNED BUT NOT YET VESTED UNDER ONE OF PARKVIEW'S DEFERRED COMPENSATION PLANS. BENEFITS EARNED UNDER THE PLANS WILL FUND THE EMPLOYEES' EVENTUAL RETIREMENT BENEFIT. THESE BENEFITS ARE PROVIDED IN EXCHANGE FOR ALL OF THE EMPLOYEES' YEARS OF SERVICE TO THE ORGANIZATION, AND THE COST OF THE BENEFITS MAY VARY FROM YEAR TO YEAR. THE AMOUNTS ARE AT RISK AND WILL NOT BE PAID UNLESS AND UNTIL EACH EMPLOYEE HAS PROVIDED SUBSTANTIAL FUTURE SERVICES TO THE ORGANIZATION. BENEFITS UNDER THE PLANS VEST AT THE TIME SET FORTH IN THE PLAN DOCUMENTS AND ARE FORFEITED IF THE EMPLOYEES TERMINATE EMPLOYMENT BEFORE SATISFYING THOSE PLAN CONDITIONS. JORDI DISLER $17,017; MICHAEL PACKNETT $645,500; STANTON RISSER $22,005; JEANNE' WICKENS $57,021 PART I, LINE 7 MANAGEMENT INCENTIVE COMPENSATION PLAN (MICP) AND PHYSICIAN AND PROVIDER INCENTIVE COMPENSATION PLAN (PICP) ARE ANNUAL INCENTIVE PROGRAMS. SYSTEM GOALS ARE APPROVED BY THE BOARD. AT CONCLUSION OF THE PLAN YEAR, RESULTS ARE SHARED WITH THE BOARD AND THE EXECUTIVE COMMITTEE OF THE BOARD APPROVES FINAL PAYMENT. A INDIANA HEALTH AND EDUCATIONAL FACILITY FINANCING AUTHORITY 351611409 45479RCF2 2007-03-15 24930000 SEE PART VI 0 0 0 A 6120000 25930446 1074006 208535 154519 24493386 2008 0 0 1 1 A 0 1 1 1 0 0.00000 0.00000 0.00000 1 0 1 A 0 0 0 1 1 0 0 0 1 A 1 SCHEDULE K, PART I,A,F: CONSTRUCTION OF NEW HOSPITAL FACILITY FOR COMMUNITY HOSPITAL OF LAGRANGE COUNTY, INC. IN LAGRANGE, INDIANA SCHEDULE K, PART II,3,A: THIS AMOUNT INCLUDES INTEREST OF $1,000,446. EARNED ON PROJECT, COST OF ISSUANCE AND CAPITALIZED INTEREST FUNDS. SCHEDULE K, PART III, LINES 4-6: AS PART OF OUR EFFORTS TO MONITOR AND ENSURE THAT THERE IS NO PRIVATE USE AT OUR BOND FINANCED FACILITIES, WE CONTRIBUTE EQUITY TO FINANCE A PORTION OF OUR NEW MONEY PROJECTS. SCHEDULE K, PART III, LINE 7: THE BOND IS NOT A PRIVATE ACTIVITY BOND BECAUSE IT DOES NOT MEET THE PRIVATE BUSINESS USE TEST. SCHEDULE K, PART IV, COLUMN A, LINE 2C: REBATE COMPUTATION WAS PERFORMED ON APRIL 13, 2010. FORM 990, PART V, LINES 1A AND 2A: PARKVIEW HEALTH SYSTEM, INC. (PH), EIN 35-1972384, IS THE COMMON PAYING AGENT FOR THE FILING ORGANIZATION, COMMUNITY HOSPITAL OF LAGRANGE COUNTY, INC., EIN 20-2401676. THEREFORE, ALL APPLICABLE IRS TAX FILINGS, INCLUDING FORMS 1099, 1096, W-2 AND W-3 ARE REPORTED AND FILED BY PH. THE TOTAL NUMBER REPORTED IN BOX 3 OF FORM 1096 AND FILED BY THE COMMON PAYING AGENT, PH, FOR THE YEAR ENDED DECEMBER 31, 2016 WAS 573. THE TOTAL NUMBER OF EMPLOYEES REPORTED ON FORM W-3 AND FILED BY THE COMMON PAYING AGENT, PH, FOR THE YEAR ENDED DECEMBER 31, 2016 WAS 12,046. FOR PURPOSES OF COMPLETING FORM 990, PART V, LINE 1A AND 2A, THE NUMBER REPORTED FOR THE COMMUNITY HOSPITAL OF LAGRANGE COUNTY, INC. WAS 29 AND 227 RESPECTIVELY. FORM 990, PART VI, SECTION A, LINE 2 DIRECTORS KEVIN LAMBRIGHT AND JOE PIERCE HAVE A BUSINESS RELATIONSHIP. FORM 990, PART VI, SECTION A, LINE 6 THE ORGANIZATION IS ORGANIZED AS A NOT-FOR-PROFIT CORPORATION. PURSUANT TO THE ORGANIZATION'S GOVERNING DOCUMENTS, PARKVIEW HEALTH SYSTEM, INC. EIN 35-1972384 IS THE SOLE MEMBER OF COMMUNITY HOSPITAL OF LAGRANGE COUNTY, INC. WITH CERTAIN RESERVED POWERS. FORM 990, PART VI, SECTION A, LINE 7A THE CORPORATE MEMBER, PARKVIEW HEALTH SYSTEM, INC. EIN 35-1972384, SHALL HAVE THE FOLLOWING RESERVED POWERS: (I) APPOINT AND REMOVE, WITH OR WITHOUT CAUSE, MEMBERS OF THE BOARD SUBJECT TO THE COMPOSITION REQUIREMENTS REGARDING COMMUNITY AND PHYSICIAN REPRESENTATION SET FORTH IN ARTICLE V, SECTION 2; (II) APPOINT AND REMOVE, WITH OR WITHOUT CAUSE, THE CHAIR AND VICE CHAIR OF THE BOARD AND THE PRESIDENT OF THE CORPORATION; (III) APPROVE AND/OR REQUIRE THE ADOPTION OF AMENDMENTS TO THE ARTICLES OF INCORPORATION OR BYLAWS OF THE CORPORATION OR ANY SUBSIDIARY OR AFFILIATE OF THE CORPORATION; (IV) APPROVE AND/OR REQUIRE THE ESTABLISHMENT, ACQUISITION, DIVESTITURE, DISSOLUTION, CLOSURE, MERGER, CONSOLIDATION, CHANGE IN CORPORATE MEMBERSHIP, AFFILIATION OR CORPORATE REORGANIZATION OF THE CORPORATION OR ANY SUBSIDIARY OR AFFILIATE OF THE CORPORATION; (V) APPROVE AND ADOPT THE STRATEGIC PLAN AND ANY AMENDMENTS THERETO FOR THE CORPORATION AND ANY SUBSIDIARY OR AFFILIATE OF THE CORPORATION; (VI) APPROVE AND/OR REQUIRE THE INCURRENCE OF ANY DEBT, INCLUDING THE ISSUANCE OF ANY BONDS, PROPOSED BY THE CORPORATION OR ANY SUBSIDIARY OR AFFILIATE OF THE CORPORATION IN EXCESS OF LIMITS SPECIFIED IN THE POLICY OF THE CORPORATE MEMBER; (VII) APPROVE AND/OR REQUIRE THE APPROVAL OF CONTRACTS OR LOANS OBLIGATING THE CORPORATION TO EXPEND OR REPAY AN AMOUNT IN EXCESS OF LIMITS SPECIFIED IN THE POLICY OF THE CORPORATE MEMBER; (VIII) APPROVE AND/OR REQUIRE THE SALE, LEASE, EXCHANGE, MORTGAGE, PLEDGE, TRANSFER, ENCUMBRANCE OR OTHER DISPOSITION OF PROPERTY AND ASSETS OF THE CORPORATION IN EXCESS OF LIMITS SPECIFIED IN THE POLICY OF THE CORPORATE MEMBER; (IX) APPROVE AND ADOPT THE CAPITAL BUDGET, OPERATING BUDGET, FINANCIAL PLANS AND ANY AMENDMENTS THERETO FOR THE CORPORATION AND ANY SUBSIDIARY OR AFFILIATE OF THE CORPORATION; (X) APPROVE AND/OR REQUIRE THE ADOPTION OF A MANAGED CARE POLICY FOR THE CORPORATION AND ANY SUBSIDIARY OR AFFILIATE OF THE CORPORATION, INCLUDING NETWORK PARTICIPATION, PARTICIPATION IN ANY MANAGED CARE AGREEMENT AND PARTICIPATION IN ANY OTHER HEALTH CARE SERVICE ARRANGEMENTS; (XI) APPOINT AND REMOVE AUDITORS, ATTORNEYS AND OTHER PROFESSIONAL ADVISORS FOR THE CORPORATION AND ANY SUBSIDIARY OR AFFILIATE OF THE CORPORATION; (XII) DEVELOP, APPROVE AND/OR REQUIRE THE ADOPTION OF MEDICAL STAFF QUALITY ASSURANCE STANDARDS, UTILIZATION REVIEW STANDARDS, CRITERIA, POLICIES AND PROCEDURES FOR THE CORPORATION AND ANY SUBSIDIARY OR AFFILIATE OF THE CORPORATION; (XIII) APPROVE AND/OR REQUIRE THE ADOPTION OF ANY ACTION TO CHANGE THE CORPORATION FROM A GENERAL, ACUTE CARE COMMUNITY HOSPITAL OR TO CLOSE THE CORPORATION'S CURRENT LOCATION; (XIV) APPROVE EACH ANNUAL LIST OF PROPOSED DONORS AND AMOUNTS OF DONATIONS OR GRANTS NOT INCLUDED IN THE ANNUAL BUDGET, AND MAKE PROPOSALS TO DEVIATE THEREFROM THROUGHOUT EACH YEAR IN EXCESS OF LIMITS SPECIFIED IN THE POLICY OF THE CORPORATE MEMBER; AND (XV) APPROVE AND/OR REQUIRE THE ADOPTION OF ANY ACTION THAT IS INCONSISTENT WITH THE POLICY OF THE CORPORATE MEMBER. FORM 990, PART VI, SECTION A, LINE 7B SEE SCHEDULE O EXPLANATION FOR FORM 990, PART VI, SECTION A, LINE 7A FORM 990, PART VI, SECTION B, LINE 11B PURSUANT TO PARKVIEW HEALTH SYSTEM INC.'S BYLAWS, THE SYSTEM AUDIT COMMITTEE MAY ACT ON BEHALF OF THE CORPORATION TO PROVIDE REVIEW OF THE CORPORATION AND ITS SUBSIDIARY CORPORATIONS' FORM 990 FILINGS. COMMUNITY HOSPITAL OF LAGRANGE COUNTY, INC. IS A SUBSIDIARY CORPORATION OF PARKVIEW HEALTH SYSTEM, INC. AN ELECTRONIC COPY OF THE ORGANIZATION'S FINAL FORM 990 (INCLUDING REQUIRED SCHEDULES) WAS PROVIDED TO EACH VOTING MEMBER OF THE ORGANIZATION'S GOVERNING BODY, PRIOR TO FILING WITH THE IRS. ON OCTOBER 25, 2017, THE SYSTEM AUDIT COMMITTEE REVIEWED THE FORM 990 AS ULTIMATELY FILED WITH THE IRS. THIS REVIEW INCLUDED A PRESENTATION BY THE ORGANIZATION'S TAX PREPARER TO HIGHLIGHT THE SIGNIFICANT AREAS ON THE FORM 990 AND SUPPLEMENTAL SCHEDULES. FORM 990, PART VI, SECTION B, LINE 12C AS DESCRIBED IN ARTICLE IX SECTION 6, OF THE PARKVIEW HEALTH SYSTEM, INC. (PH) BYLAWS, PH ADOPTED PH'S COMPLIANCE POLICY FOR THE ORGANIZATION AND ITS NOT-FOR-PROFIT RELATED ORGANIZATIONS (AND AS LIKEWISE NOTED IN THEIR BYLAWS) WHEN ADDRESSING CONFLICTS OR POTENTIAL CONFLICTS OF INTEREST. THIS COMPLIANCE POLICY (COMPLIANCE POLICY #14) REQUIRES THAT EACH BOARD MEMBER, BOARD COMMITTEE MEMBER, AND KEY MANAGEMENT PERSONNEL MUST ANNUALLY COMPLETE A CONFLICT OF INTEREST FORM. THIS INFORMATION IS PROVIDED TO THE CHAIRMAN OF THE BOARD (FOR BOARD AND BOARD COMMITTEE MEMBERS) AND TO SENIOR MANAGEMENT (FOR KEY MANAGEMENT PERSONNEL). IN ADDITION, AS TO THE CONDUCT OF BOARD MEETINGS, THE FOLLOWING PROCESS IS FOLLOWED: "WHENEVER A PH OR PH AFFILIATE BOARD OR BOARD COMMITTEE IS CONSIDERING A TRANSACTION OR ARRANGEMENT WITH AN ORGANIZATION, ENTITY OR INDIVIDUAL IN WHICH A PERSON COVERED BY THIS POLICY HAS A FINANCIAL OR CONFLICTING INTEREST, THE FOLLOWING SHALL OCCUR: 1. THE INTERESTED PERSON MUST DISCLOSE THE FINANCIAL OR CONFLICTING INTEREST AND ALL MATERIAL FACTS TO THE PH OR PH AFFILIATE BOARD OR BOARD COMMITTEE; 2. THE INTERESTED PERSON WITH THAT FINANCIAL OR CONFLICTING INTEREST MAY MAKE A PRESENTATION AT THE BOARD OR BOARD COMMITTEE MEETING REGARDING THE TRANSACTION OR ARRANGEMENT HOWEVER, HE/SHE SHALL LEAVE THE MEETING DURING THE DISCUSSION OF, AND THE VOTE ON, THE TRANSACTION OR ARRANGEMENT THAT RESULTS IN THE FINANCIAL OR CONFLICTING INTEREST; AND 3. THE PH OR PH AFFILIATE BOARD OR BOARD COMMITTEE MUST APPROVE THE TRANSACTION OR ARRANGEMENT BY A MAJORITY VOTE OF THE BOARD MEMBERS PRESENT AT A MEETING THAT HAS A QUORUM, NOT INCLUDING THE VOTE OF THE INTERESTED PERSON. THE INTERESTED PERSON MAY NOT VOTE ON THE MATTER. A. UPON THE REQUEST OF PH OR PH AFFILIATE BOARD OR BOARD COMMITTEE, THE MATTER MAY BE DELEGATED TO THE PH COMPLIANCE COMMITTEE FOR EVALUATION, RECOMMENDATION AND/OR DETERMINATION. 4. WHENEVER A FINANCIAL OR CONFLICTING INTEREST IS ADDRESSED BY A PH OR PH AFFILIATE BOARD, NOTICE SHALL BE GIVEN TO THE PH COMPLIANCE OFFICER / GENERAL COUNSEL." FORM 990, PART VI, SECTION B, LINE 15 REGARDING LINES 15A AND 15B, TO THE EXTENT THAT THE ORGANIZATION HAS VICE PRESIDENT OR ABOVE, THE ORGANIZATION USED A PROCESS FOR DETERMINING COMPENSATION OF THE CEO, OFFICERS, AND KEY EMPLOYEES. THE PROCESS INCLUDES CONSULTATIONS WITH AN INDEPENDENT COMPENSATION ADVISOR AND THE REVIEW OF APPROPRIATE COMPARABILITY DATA; REVIEW AND APPROVAL BY THE COMPENSATION COMMITTEE OF THE GOVERNING BODY CONSISTING OF MEMBERS WHO DO NOT HAVE A CONFLICT OF INTEREST CONCERNING THE COMPENSATION; AND CONTEMPORANEOUS DOCUMENTATION AND RECORDKEEPING WITH RESPECT TO DELIBERATIONS AND DECISIONS REGARDING THE COMPENSATION ARRANGEMENTS. IN 2016, THE BOARD OF PARKVIEW HEALTH SYSTEM, INC. REVIEWED AND APPROVED ALL EXECUTIVE COMPENSATION, BENEFITS AND PERQUISITES FOR THE 2016 COMPENSATION PACKAGE, PURSUANT TO THE PARKVIEW HEALTH BYLAWS. THE COMPENSATION PACKAGE WAS APPROVED BY A MAJORITY OF INDEPENDENT BOARD MEMBERS. PARKVIEW'S INDEPENDENT CONSULTANT PREPARES A COMPETITIVE COMPENSATION ANALYSIS USING DATA FROM MULTIPLE PUBLISHED SURVEYS PREPARED BY INDEPENDENT FIRMS FOR POSITIONS THAT ARE FUNCTIONALLY COMPARABLE IN SIMILAR-SIZED HEALTH SYSTEMS AND HOSPITAL ORGANIZATIONS ON BOTH A REGIONAL AND NATIONAL BASIS. THE INDEPENDENT CONSULTANT PROVIDES A STATEMENT OF REASONABLENESS OF THE COMPENSATION PROVIDED TO THE CEO AS WELL AS ALL EXECUTIVES AT THE VICE PRESIDENT LEVEL AND ABOVE. ALL DATA IS SHARED WITH THE BOARD OF DIRECTORS. THE BOARD APPROVES ANY CHANGES IN COMPENSATION FOR THE CEO AND HIS DIRECT REPORTS. APPROVAL IS ALSO PROVIDED FOR THE SALARY BUDGET FOR THE ENTIRE ORGANIZATION. THE BOARD REVIEWS AND APPROVES THE PLAN DOCUMENTS FOR THE MANAGEMENT INCENTIVE COMPENSATION PLAN (MICP) AND THE PHYSICIAN AND PROVIDER INCENTIVE COMPENSATION PLAN (PICP). OFFICES OR POSITIONS REVIEWED AT THE 2016 MEETING: PRESIDENT AND CHIEF EXECUTIVE OFFICER PARKVIEW HEALTH EXECUTIVE VICE PRESIDENT CHIEF PHYSICIAN EXECUTIVE CHIEF OPERATING OFFICER PARKVIEW HEALTH CHIEF EXPERIENCE OFFICER PHYSICIAN EXECUTIVE OFFICER PARKVIEW PHYSICIANS GROUP PRESIDENT PARKVIEW REGIONAL MEDICAL CENTER AND AFFILIATES CHIEF CLINICAL INTEGRATION OFFICER CHIEF FINANCIAL OFFICER CHIEF INFORMATION OFFICER SENIOR VICE PRESIDENT GENERAL COUNSEL SENIOR VICE PRESIDENT CHIEF OPERATING OFFICER PARKVIEW PHYSICIANS GROUP CHIEF QUALITY AND SAFETY OFFICER SENIOR VICE PRESIDENT REVENUE CYCLE AND PAYOR STRATEGIES CHIEF HUMAN RESOURCES OFFICER CHIEF NURSING EXECUTIVE SENIOR VICE PRESIDENT STRATEGIC INITIATIVES CHIEF ACADEMIC AND RESEARCH OFFICER CHIEF MEDICAL INFORMATICS OFFICER CHIEF MEDICAL OFFICER PARKVIEW PHYSICIANS GROUP MEDICAL DIRECTOR COMMUNITY HOSPITALS MEDICAL DIRECTOR INTEGRATION AND DEVELOPMENT CHIEF OPERATING OFFICER - RANDALLIA CHIEF NURSING OFFICER - PARKVIEW REGIONAL MEDICAL CENTER AND AFFILIATES PRESIDENT - PARKVIEW CANCER CENTER SENIOR VICE PRESIDENT CHIEF OPERATING OFFICER SERVICE LINE LEADER BEHAVIORAL HEALTH SENIOR VICE PRESIDENT CHIEF OPERATING OFFICER SERVICE LINE LEADER ORTHO SENIOR VICE PRESIDENT CHIEF OPERATING OFFICER SERVICE LINE LEADER HEART INSTITUTE SENIOR VICE PRESIDENT CHIEF OPERATING OFFICER SERVICE LINE LEADER CANCER INSTITUTE SENIOR VICE PRESIDENT SERVICE LINE LEADER SENIOR VICE PRESIDENT DELIVERY SYSTEM INTEGRATION SENIOR VICE PRESIDENT FACILITY DESIGN AND OVERSIGHT SENIOR VICE PRESIDENT HEALTH AND WELL-BEING SENIOR VICE PRESIDENT PARKVIEW PHYSICIANS GROUP OPERATIONS DEPLOYMENT SENIOR VICE PRESIDENT SUPPLY AND SUPPORT SERVICES PRESIDENT COMMUNITY HOSPITALS VICE PRESIDENT CLINICAL INTEGRATION VICE PRESIDENT CONSTRUCTION VICE PRESIDENT EMPLOYEE STRATEGIES VICE PRESIDENT FINANCE VICE PRESIDENT MARKETING/COMMUNICATIONS/COMMUNITY RELATIONS VICE PRESIDENT NURSING RANDALLIA VICE PRESIDENT OPERATIONS - CANCER INSTITUTE VICE PRESIDENT PATIENT CARE SERVICES COMMUNITY HOSPITALS VICE PRESIDENT PARKVIEW PHYSICIANS GROUP FINANCE VICE PRESIDENT PARKVIEW PHYSICIANS GROUP PHYSICIAN PRACTICES VICE PRESIDENT STRATEGY AND BUSINESS DEVELOPMENT VICE PRESIDENT SURGICAL SERVICES PARKVIEW REGIONAL MEDICAL CENTER AND AFFILIATES VICE PRESIDENT CLINICAL OPERATIONS - PARKVIEW PHYSICIANS GROUP VICE PRESIDENT INFORMATION SECURITY VICE PRESIDENT INTERNAL AUDIT VICE PRESIDENT TECHNOLOGY VICE PRESIDENT PATIENT CARE SERVICES - COMMUNITY HOSPITALS FORM 990, PART VI, SECTION C, LINE 19 COPIES OF THE ORGANIZATION'S GOVERNING DOCUMENTS, CONFLICT OF INTEREST POLICY, AND FINANCIAL STATEMENTS ARE AVAILABLE UPON REQUEST. FORM 990, PART IX, LINE 11G OTHER: PROGRAM SERVICE EXPENSES 1,979,746. MANAGEMENT AND GENERAL EXPENSES 64,009. FUNDRAISING EXPENSES 90. TOTAL EXPENSES 2,043,845. PHYSICIAN PROFESSIONAL FEES: PROGRAM SERVICE EXPENSES 2,387,957. MANAGEMENT AND GENERAL EXPENSES 0. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 2,387,957. CONTRACTED MEDICAL SERVICES: PROGRAM SERVICE EXPENSES 0. MANAGEMENT AND GENERAL EXPENSES 336,000. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 336,000. COLLECTION EXPENSE: PROGRAM SERVICE EXPENSES 0. MANAGEMENT AND GENERAL EXPENSES 252,577. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 252,577. FORM 990, PART IX, LINES 5-10: PARKVIEW HEALTH SYSTEM, INC., EIN 35-1972384, SERVES AS THE COMMON PAYING AGENT FOR ALL TAX-EXEMPT ORGANIZATIONS OF THE SYSTEM. SALARIES AND WAGES OF EMPLOYEES WORKING FOR THESE ORGANIZATIONS ARE CHARGED DIRECTLY TO THE ORGANIZATIONS IN WHICH THEY WORK. THE ACTUAL EXPENSES FOR PAYROLL TAXES, EMPLOYEE BENEFITS, AND PENSION PLAN CONTRIBUTIONS ARE REFLECTED ON THE BOOKS OF PARKVIEW HEALTH SYSTEM, INC. FOR FINANCIAL REPORTING PURPOSES. TO ACCOUNT FOR BENEFIT COSTS ON THE BOOKS OF THE OTHER TAX EXEMPT ORGANIZATIONS, AN ALLOCATION METHODOLOGY IS UTILIZED TO CHARGE THESE ORGANIZATIONS WITH AN ESTIMATE OF THE OVERALL COSTS, REFERRED TO AS A "BENEFIT ALLOCATION" FROM PARKVIEW HEALTH SYSTEM, INC. THE ALLOCATION DOES NOT DISTINGUISH BETWEEN THE COSTS OF THE VARIOUS COMPONENTS (I.E. PAYROLL TAXES, EMPLOYEE BENEFITS, AND PENSION PLAN CONTRIBUTIONS). THEREFORE, FOR PURPOSES OF THE FORM 990, PART IX, THE TOTAL BENEFIT ALLOCATION FOR THE EMPLOYEES' SALARIES AND WAGES REPORTED ON LINE 7 IS REFLECTED ON LINE 9 AND NOT ALLOCATED BETWEEN LINES 8 OR 10. FOR PURPOSES OF THE FORM 990, PART IX, LINES 5 AND 6 REFLECT COMPENSATION AND BENEFIT AMOUNTS REPORTED IN PART VII. FORM 990, PART XI, LINE 9: CURRENT YEAR EARNINGS TRANSFERRED TO PARENT -3,135,762. 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