2016-09-26T08:33:49-07:00 2015-12-31 990 2015-01-01 341531817 ALLIANCE COMMUNITY HOSPITAL FOUNDATION ALLI 3305966000 200 E STATE ST ALLIANCE OH 44601 Dale Wells Chief Financial & Operating Officer 3305967066 2016-09-26 2015 2017-02-10 21:41:12Z Dale W Wells 200 E State St Alliance OH 44601 2937046 0 X X 1986 OH The Alliance Community Hospital Foundation's mission is to contribute to hospital fundraising, maintain community involvement and healthcare awareness, and grow as a philanthropic spirit of Alliance Community Hospital. 4 3 0 181 0 0 117017 157632 0 0 101687 294121 25800 22142 244504 473895 373683 223404 0 0 0 0 0 0 0 12347 10504 386030 233908 -141526 239987 2913103 2748063 0 0 2913103 2748063 To assist Alliance Community Hospital financially in its mission of delivering quality health care in the community, maintain community involvement and health care awareness. The Foundation also provides support to other local non-profits. 0 0 214793 214793 0 Alliance Community Hospital Foundation supports Alliance Community Hospital (ACH) for building and medical equipment expenses. Major purchases in 2015 include Hospice business office renovations, electronic medical record system expenses and training for $67,000, Pediatric expenditures of $36,000, Nutritional Services equipment of $15,000, a new shuttle for transporting patients and visitors at the hospital of $14,000, CT Scan equipment of $13,000, AED purchases of $12,000 and Therapy equipment totaling $9,000. The Foundation provides money for Pastoral support of $32,000. Smaller amounts of less than $5,000 for patient supplies at the Skilled Nursing facility were also disbursed in 2015. 8611 8611 0 The Foundation supports ACH by providing funds for indigent patient care and in 2015 they contributed $8,600 for prescription drug and medical expense assistance. 1916 0 0 The cost of informational brochures and cards for Visiting Nurse and Hospice patients and their families is another area of support afforded by the Foundation for ACH. 0 0 0 Other Program Services 0 0 0 225320 1 1 0 0 0 0 0 0 0 1 0 0 1 0 0 0 0 1 0 0 0 0 0 0 1 0 0 1 1 1 0 0 0 0 0 0 0 0 0 0 0 0 0 1 0 0 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 X 4 3 0 0 0 0 1 1 1 1 1 0 0 1 1 1 1 1 1 1 1 0 X X Dale W Wells 3305967066 200 E STATE ST ALLIANCE OH 44601 Mike Hoover President 1 3 X X 0 0 0 Ron Lyons Vice President 1 4 X X 0 0 0 David Lundgren Secretary 1 2 X X 0 0 0 Dale Wells Treasurer; CFO/COO, Alliance Community Hospital 2 46 X X 0 229436 29118 Stan Jonas CEO, Alliance Community Hospital 1 48 X 0 405056 25075 0 634492 54193 0 0 1 0 0 0 0 32191 47856 0 77585 1315 157632 0 88501 0 0 88501 0 0 0 0 0 0 0 0 0 0 2648183 0 2442563 0 205620 0 205620 0 0 205620 42730 32191 20588 22142 0 22142 0 473895 0 0 316263 214793 214793 8611 8611 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 6019 0 6019 0 0 0 0 0 0 0 0 0 235 0 235 0 2168 0 2168 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 166 0 166 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 General patient supplies & other expense 1916 1916 0 0 233908 225320 8588 0 28083 29967 2885020 2718096 2913103 2748063 0 0 X 627484 503819 1427823 1386273 857796 857971 2913103 2748063 2913103 2748063 239987 -405027 0 0 0 0 X 0 1 X 1 0 X X 1 Alliance Community Hospital 340714581 3 1 225320 0 1 225320 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 0 RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 857796 175 0 0 0 0 857971 857746 50 0 0 0 0 857796 857746 0 0 0 0 0 857746 857696 50 0 0 0 0 857746 857646 50 0 0 0 0 857696 0 1 0 0 0 Assets Limited As To Use: Internally Designated 24874 F Assets Limited As To Use:Externally Restricted 2244244 F Long Term Investments 448978 F 2718096 Schedule D, Part V, Line 4 The intended use of the organization's endowment funds is to hold the principal in perpetuity and use the interest for the general operations of the organization. Hospice 5k 30630 19231 11399 500 1274 0 1066 350 5796 Hospice Dance 23136 5960 17176 500 0 700 0 1700 134 1 21155 7000 14155 0 0 3490 4992 0 86 74921 32191 42730 1000 1274 4190 6058 2050 6016 20588 22142 1 Alliance Community Hospital 200 E State Street Alliance OH 44601 340714581 501(c)(3) 214793 0 actual cost Medical Equipment, renovations, systems updates, pastoral support, general patient care 1 0 Indigent Patient Care 46 8356 255 FMV Voice monitors Schedule I, Part I, Line 2 Alliance Community Hospital Foundation was created to benefit Alliance Community Hospital's (ACH) mission which is to provide care to all, regardless of ability to pay. Funds given to ACH are used to purchase medical equipment, contribute to hospital building improvements, and provide for patients needs. Alliance Community Hospital Foundation has not provided grants to organizations outside its control. Should ACHF provide grants outside its control, then ACHF will rely on the policy of lump sum funding preceeded by a grant application, approval from the Board, and then followed by a 6-month and annual evaluation of the project if needed and/or grant application funding based on reimbursement of actual expense(s) along with Board approval. 0 0 0 0 0 0 0 0 0 Stan Jonas CEO, Alliance Community Hospital 0 387057 0 0 0 17999 0 6625 0 20655 0 432336 0 0 Dale Wells Treasurer; CFO/COO, Alliance Community Hospital 0 211436 0 0 0 18000 0 5926 0 24649 0 260011 0 0 Schedule J, Part I, Line 3 Alliance Community Hospital Foundation's Schedule J lists Dale Wells and Stan Jonas, employees of Alliance Community Hospital, a related organiztion. Their compensation is determined using all six methods listed in Part I, line 3. Form 990, Part VI, Section A, Line 1a The governing body of Alliance Community Hospital Foundation (per its Code of Regulations) has delegated authority to the Board of Alliance Citizens' Health Association (the Member), a related organization, as follows: 1.) Power to elect and remove members of the Board of Trustees and/or Officers of the corporation. 2.) Approve the annual operating budgets; capital expenditures budgets; capital expenditures or dispositions of capital assets with a value in excess of such limits as shall be set from time to time by the Member; any action which requires Certificate of Need approval from the State Health Planning Development Agency; and any purchase, sale, lease, disposition, or hypothecation of real property. 3.) The incurrence of any obligation(s), liability(ies), and/or debt(s) requiring a mortgage on or security interest in any part of the assets of the corporation. 4.) Power to determine, upon dissolution of the corporation, the organization or organizations to which its remaining assets will be distributed. Form 990, Part VI, Section A, Line 6 See Schedule O comment for Part VI question 1a above. Form 990, Part VI, Section A, Line 7a See Schedule O comment for Part VI question 1a above. Form 990, Part VI, Section A, Line 7b See Schedule O comment for Part VI question 1a above. Form 990, Part VI, Section B, Line 11b The Form 990 is reviewed by the CFO of Alliance Community Hospital, a related organization. Prior to filing, the 990 is also distributed to the Board of Trustees for their review and comments. It is then discussed as part of the financial report at the next Board meeting where any questions/concerns can be addressed. Form 990, Part VI, Section B, Line 12c Members of the Board of Trustees are required to annually review and sign a conflict of interest policy. Under that policy, the Board member (i) has a duty to disclose any conflict, and (ii) must recuse themselves from a vote and or decision when such conflict arises. If this policy is violated, then the Board shall take appropriate action which may include an investigation and disciplinary action. Form 990, Part VI, Section B, Line 15 No compensation is paid directly by Alliance Community Hospital Foundation; however, certain officers and top officials of this organization are compensated by Alliance Community Hospital, a related organization. That compensation is determined by an independent (noncompensated) committee from the Board of Trustees. This committee annually reviews compensation by obtaining market surveys of the positions. Form 990, Part VI, Section C, Line 17 Ohio does not require the Form 990 to be filed with the Ohio Attorney General's Office. Instead, a "Verification of Filing with the Internal Revenue Service" form is completed stating that we did file Form 990 by the required due date. Form 990, Part VI, Section C, Line 19 The organization makes its governing documents available to the public via the Ohio Secretary of State's website. Financial statements are available in the NRMSIR filing database at www.emma.msrb.org. The conflict of interest policy is available upon request. Alliance Citizens' Health Association 200 E State St Alliance OH 44601 341531815 Manage Health Facil OH 501(C)(3) Sch A, 11b, II N/A 0 Alliance Community Hospital 200 E State St Alliance OH 44601 340714581 Community Hospital OH 501(C)(3) Sch A, Ln 3 Alliance Citizens' Health Assn 0 Alliance Comm Hospital Auxiliary 200 E State St Alliance OH 44601 340777659 Volunteer Services OH 501(C)(3) Sch A, 11c, III-FI N/A 0 Alliance Health Institute 200 E State St Alliance OH 44601 341932972 Support ACH OH 501(C)(3) Sch A, 11a, I Alliance Citizens' Health Assn 0 Caring Hands 885 Sawburg Rd Alliance OH 44601 341505340 Private Duty Nursing OH 501(C)(3) Sch A, Line 9 Alliance Citizens' Health Assn 0 Alliance Health Partners 200 E State St Alliance OH 44601 341884059 PHO OH N/A C 0 Alliance Medical Associates Inc 200 E State St Alliance OH 44601 911889215 ER Physicians OH N/A C 0 Health Alliance Inc 200 E State St Alliance OH 44601 341531993 Urgent Care Centers OH N/A C 0 0 1 1 0 0 0 0 0 0 0 0 1 0 1 1 1 0 0 0