2016-05-03T09:08:32-05:00 2015-06-30 351178661 BLUE & CO LLC 500 N MERIDIAN ST SUITE 200 INDIANAPOLIS IN 46204 990 2014-07-01 350811197 FAIRBANKS HOSPITAL INC FAIR 3178498222 8102 CLEARVISTA PARKWAY INDIANAPOLIS IN 46256 BARBARA ELLIOTT VICE PRESIDENT & CFO 3175729450 2016-05-03 1 AMBER KOCHER CPA P01286298 3176334705 2016-05-02 2014 2016-08-17 19:52:53Z BARBARA ELLIOTT 8102 CLEARVISTA PARKWAY INDIANAPOLIS IN 46256 24017207 0 X WWW.FAIRBANKSCD.ORG X 1946 IN NONPROFIT ORGANIZATION FOCUSED ON RECOVERY FROM ALCOHOL AND OTHER DRUG PROBLEMS. 17 14 375 254 0 0 965897 838774 18955859 21402252 -51231 153924 1699189 1537192 21569714 23932142 599340 385709 0 0 14183709 15059101 0 0 213896 6276348 7248761 21059397 22693571 510317 1238571 27226497 28648402 2011444 2436725 25215053 26211677 X FAIRBANKS IS A NONPROFIT ORGANIZATION FOCUSED ON RECOVERY FROM ALCOHOL AND OTHER DRUG PROBLEMS, SERVING AS A RESOURCE TO IMPROVE THE WELL-BEING OF INDIVIDUALS, FAMILIES AND COMMUNITIES BY OFFERING HOPE AND SUPPORT THROUGH ITS PROGRAMS AND SERVICES. 0 0 8704192 0 10394139 ADULT INPATIENT SERVICES CONSISTING OF DETOXIFICATION, REHABILITATION AND RESIDENTIAL SERVICES. THE DETOXIFICATION PHASE IS A MEDICALLY MANAGED LEVEL OF CARE WHERE THE EXTENT OF THE PATIENT'S ADDICTION IS DETERMINED AND THE PHYSICAL AND PSYCHOLOGICAL IMPACT OF THAT ADDICTION IS ASSESSED AND THE APPROPRIATE TREATMENT COURSE IS INITIATED. FOR THE CURRENT FISCAL YEAR, FAIRBANKS HOSPITAL HAD 9,654 ADULT DETOX PATIENT DAYS.THE REHABILITATION PHASE OCCURS WHEN FURTHER INPATIENT STABILIZATION/TREATMENT IS NEEDED AND REQUIRES CONTINUED MEDICAL SUPERVISION. THE TREATMENT PROCESS IS MULTI-DISCIPLINARY AND GROUP ORIENTED. FOR THE CURRENT FISCAL YEAR, THE HOSPITAL HAD 2,406 ADULT REHAB PATIENT DAYS. THE RESIDENTIAL PROGRAM IS FOR THE PATIENT WHO REQUIRES A RESTRICTIVE ENVIRONMENT TO ABSTAIN FROM USING BUT WHO IS MEDICALLY STABLE. THE PATIENT PARTICIPATES IN NO LESS THAN FOUR HOURS OF THERAPY DAILY AND NURSING CARE IS PROVIDED, IF NEEDED. FOR THE CURRENT FISCAL YEAR, THE HOSPITAL HAD 1,287 ADULT RESIDENTIAL PATIENT DAYS. 3112507 0 3716810 ADULT OUTPATIENT SERVICES PROGRAM CONSISTING OF PARTIAL HOSPITALIZATION (PHP) AND INTENSIVE OUTPATIENT PROGRAM (IOP). THE PHP PROGRAM IS SIX TO SEVEN HOURS PER DAY MONDAY THROUGH FRIDAY AND IS A MULTI-DISCIPLINARY AND GROUP ORIENTED TREATMENT PROGRAM. IT WILL CONTAIN EVALUATION AND EDUCATION. IT ALLOWS THE PATIENT TO EXPERIENCE LIFE ON THE "OUTSIDE" WHILE BEING INVOLVED IN A VERY INTENSE LEVEL OF TREATMENT. FOR THE CURRENT FISCAL YEAR, THE HOSPITAL HAD 7,663 PHP VISITS.IOP IS AVAILABLE TO THOSE WHOSE ADDICTION IS NOT SO SEVERE AS TO REQUIRE INPATIENT OR PHP SERVICES. THE PATIENTS MUST DEMONSTRATE THE ABILITY TO REMAIN DRUG-FREE DURING THE ENTIRE TREATMENT COURSE AND INDICATE A WILLINGNESS TO BECOME INVOLVED IN A 12-STEP PROGRAM. IOP PATIENTS GENERALLY MEET FOR THREE HOURS, THREE TIMES PER WEEK. IOP OFFERS EDUCATION AND GROUP THERAPY. FOR THE CURRENT FISCAL YEAR, THE HOSPITAL HAD 10,357 VISITS. 978046 0 1167937 ADOLESCENT INPATIENT SERVICES CONSISTING OF DETOXIFICATION, REHABILITATION, AND RESIDENTIAL SERVICES. THE DETOXIFICATION PHASE IS A MEDICALLY MANAGED LEVEL OF CARE WHERE THE EXTENT OF THE PATIENT'S ADDICTION IS DETERMINED AND THE PHYSICAL AND PSYCHOLOGICAL IMPACT OF THAT ADDICTION IS ASSESSED AND THE APPROPRIATE TREATMENT COURSE IS INITIATED. ADOLESCENT GUIDANCE SPECIALISTS ARE MEMBERS OF THE TREATMENT TEAM. DURING THIS PHASE OF CARE, VARIOUS MULTI-DISCIPLINARY EVALUATIONS ARE COMPLETED. FAMILIES AND OTHER SUPPORT INDIVIDUALS (SCHOOL, PROBATION, CASEWORKERS, ETC) ARE INVOLVED. FOR THE CURRENT FISCAL YEAR, FAIRBANKS HOSPITAL HAD 415 ADOLESCENT DETOX PATIENT DAYS.THE ADOLESCENT REHAB PHASE IS FOR PATIENTS NEEDING FURTHER INPATIENT STABILIZATION/TREATMENT AND REQUIRES MEDICAL SUPERVISION. THIS TREATMENT PROCESS IS MULTI-DISCIPLINARY AND GROUP ORIENTED. AN IMPORTANT PART OF THE PROGRAM INCLUDES FAMILY MEMBERS OF THE PATIENT. FOR THE CURRENT FISCAL YEAR, THE HOSPITAL HAD 428 ADOLESCENT REHAB PATIENT DAYS.THE RESIDENTIAL PHASE IS FOR ADOLESCENTS IN NEED OF STABILIZATION AND TREATMENT. TREATMENT IS MULTI-DISCIPLINARY AND GROUP-ORIENTED. ADOLESCENTS RECEIVE INFORMATION ON DEVELOPING SOCIAL SKILLS, COMMUNICATION, HOW TO GAIN INTERNAL CONTROL OVER FEELING, HOW TO DEAL WITH ANGER, HOW TO DEAL WITH PEER PRESSURE, AND OTHER DEVELOPMENT NEEDS. FOR THE CURRENT FISCAL YEAR, THE HOSPITAL HAD 1,517 ADOLESCENT RESIDENTIAL PATIENT DAYS. 5605655 385709 6694011 OTHER PROGRAM SERVICES INCLUDING YOUNG ADULT INPATIENT SERVICES AND ADOLESCENT OUTPATIENT SERVICES.YOUNG ADULT INPATIENT SERVICES CONSISTING OF DETOXIFICATION, REHABILITATION, AND RESIDENTIAL SERVICES FOR MALES BETWEEN THE AGES OF 19-23. THE DETOXIFICATION PHASE IS A MEDICALLY MANAGED LEVEL OF CARE WHERE THE EXTENT OF THE PATIENT'S ADDICTION IS DETERMINED AND THE PHYSICAL AND PSYCHOLOGICAL IMPACT OF THAT ADDICTION IS ASSESSED AND THE APPROPRIATE TREATMENT COURSE IS INITIATED. YOUNG ADULT GUIDANCE SPECIALISTS ARE MEMBERS OF THE TREATMENT TEAM. DURING THIS PHASE OF CARE, VARIOUS MULTI-DISCIPLINARY EVALUATIONS ARE COMPLETED. FAMILIES AND OTHER SUPPORT INDIVIDUALS (SCHOOL, PROBATION, CASEWORKERS, ETC) ARE INVOLVED. FOR THE CURRENT FISCAL YEAR, FAIRBANKS HOSPITAL HAD 1,490 YOUNG ADULT DETOX PATIENT DAYS. THE YOUNG ADULT REHAB PHASE IS FOR PATIENTS NEEDING FURTHER INPATIENT STABILIZATION/TREATMENT AND REQUIRE MEDICAL SUPERVISION. THIS TREATMENT PROCESS IS MULTI-DISCIPLINARY AND GROUP ORIENTED. AN IMPORTANT PART OF THE PROGRAM INCLUDES FAMILY MEMBERS OF THE PATIENT. FOR THE CURRENT FISCAL YEAR, THE HOSPITAL HAD 739 YOUNG ADULT REHAB PATIENT DAYS.THE RESIDENTIAL PHASE IS FOR YOUNG ADULTS IN NEED OF STABILIZATION AND TREATMENT. TREATMENT IS MULTI-DISCIPLINARY AND GROUP ORIENTED. YOUNG ADULTS RECEIVE INFORMATION ON DEVELOPING SOCIAL SKILLS, COMMUNICATION, HOW TO GAIN INTERNAL CONTROL OVER FEELING, HOW TO DEAL WITH ANGER, HOW TO DEAL WITH PEER PRESSURE, AND OTHER DEVELOPMENT NEEDS. FOR THE CURRENT FISCAL YEAR, THE HOSPITAL HAD 1,656 YOUNG ADULT RESIDENTIAL PATIENT DAYS.ADOLESCENT OUTPATIENTS SERVICES PROGRAM SERVED 981 PHP VISITS AND 1,499 IOP VISITS DURING THE CURRENT FISCAL YEAR. YOUNG ADULT OUTPATIENT SERVICES PROGRAM SERVED 2,024 PHP VISITS AND 1,777 IOP VISITS DURING THE CURRENT FISCAL YEAR. ADULT HALFWAY HOUSE SERVED 1,058 PATIENT DAYS DURING THE CURRENT FISCAL YEAR. FAIRBANKS HOSPITAL PROVIDED 3,127 PATIENT DAYS AT LAVERNA LODGE FOR MEN, 1,050 PATIENT DAYS AT LAVERNA LODGE FOR WOMEN, AND 30,764 PATIENT DAYS AT SUPPORTED LIVING FACILITIES DURING THE CURRENT FISCAL YEAR. 5605655 385709 6694011 18400400 1 1 0 0 0 0 0 0 0 1 1 0 0 0 1 1 0 1 0 0 0 0 0 0 1 0 1 1 1 0 1 0 0 0 0 0 0 0 1 0 0 0 0 0 1 1 0 0 0 1 34 0 1 375 1 0 0 0 0 0 1 1 0 0 0 0 X 17 14 0 0 0 0 0 0 0 1 1 0 0 1 1 1 1 1 1 1 0 0 IN X BARBARA ELLIOTT 3175729450 8102 CLEARVISTA PARKWAY INDIANAPOLIS IN 46256 X FARAZ ABBASI CHAIRMAN 1.00 0.00 X X 0 0 0 TOM FLOWERS VICE CHAIR 1.00 0.00 X X 0 0 0 KEVIN MURPHY TREASURER 1.00 0.00 X X 0 0 0 CAROL BROWN LUKEMEYER BOARD MEMBER 1.00 0.00 X X 0 0 0 PATRICK CARR BOARD MEMBER 1.00 0.00 X 0 0 0 DAVID CORBITT BOARD MEMBER 1.00 0.00 X 0 0 0 MARISSA MANLOVE BOARD MEMBER 1.00 0.00 X 0 0 0 WILLIAM MCKAY II BOARD MEMBER 1.00 1.00 X 0 0 0 ANN MERKEL BOARD MEMBER 1.00 0.00 X 0 0 0 SENATOR PAT MILLER BOARD MEMBER 1.00 0.00 X 0 0 0 BEVERLY PITTS BOARD MEMBER 1.00 0.00 X 0 0 0 JOHN RYAN BOARD MEMBER 1.00 0.00 X 0 0 0 KARL STOUT BOARD MEMBER 1.00 0.00 X 0 0 0 ANDRIAN TAKACS BOARD MEMBER 1.00 0.00 X 0 0 0 JOHN WANTZ BOARD MEMBER 1.00 0.00 X 0 0 0 RONDA SHREWSBURY WEYBRIGHT BOARD MEMBER 1.00 0.00 X 0 0 0 RICHARD COLLINS BOARD MEMBER (RESIGNED 4'15) 1.00 0.00 X 0 0 0 JOHN HAYES MD BOARD MEMBER (RESIGNED 2'15) 1.00 0.00 X 0 0 0 JANE WARDLE BOARD MEMBER (RESIGNED 8'14) 1.00 1.00 X 0 0 0 MARK MONSON PRESIDENT/CEO (7'14 - 9'14) 38.40 1.60 X X 215529 0 19165 BARBARA ELLIOTT INTERIM PRESIDENT/CEO (10'14 - 6'15) 36.00 4.00 X X 146804 0 32581 KENT BROWN PRESIDENT/CEO (HIRED 6'15) 0.00 0.00 X X 0 0 0 DR DENNIS RHYNE INTERIM MEDICAL DIRECTOR (7'14-3'15) 40.00 0.00 X 250031 0 22474 DR ANDREW SONDERMAN PHYSICIAN 40.00 0.00 X 196539 0 35511 JENNIFER HORSTMAN CNO/CIO 40.00 0.00 X 111217 0 15202 SHARON BAKER DIRECTOR OF SUPPORT SERVIC 40.00 0.00 X 108715 0 8411 1028835 0 133344 6 0 1 0 SODEXO INC & AFFILIATES 4880 PAYSPHERE CIRCLE CHICAGO IL 60674 FOOD SERVICES MGMT 972561 SOUTH BEND MEDICAL FOUNDATION PO BOX 2030 MISHAWAKA IN 46546 REFERRAL LAB SERVICE 368381 PROGRESSIVE HOMECARE SERVICES PO BOX 6069-DEPT 178 INDIANAPOLIS IN 46206 PHARMACY SERVICES 334376 NETSMART TECHNOLOGIES PO BOX 823519 PHILADELPHIA PA 19182 SOFTWARE IMPLEMENTATION AND SUPPORT 316626 COMMUNITY HEALTH NETWORK 8180 CLEARVISTA PKWY INDIANAPOLIS IN 46256 IT SERVICES 187798 7 66032 103687 669055 838774 PATIENT SERVICE REVENUE 621300 21402252 21402252 21402252 162711 162711 144600 0 144600 144600 144600 8787 -8787 -8787 -8787 95725 66032 76278 19447 19447 ASSISTED LIVING PROGRAM 624229 708586 708586 EHR INCENTIVE 900099 355268 355268 GIFT SHOP & CAFETERIA REVENUE 453220 191053 191053 118238 70777 47461 1373145 23932142 21972897 0 1120471 X 385709 385709 915942 207216 708726 10394769 9007892 1261939 124938 343402 289061 50214 4127 2524825 2127432 367922 29471 880163 740882 128702 10579 95131 95131 66703 66703 35081 35081 2659848 1784678 851242 23928 338746 326916 11378 452 154451 95376 58856 219 1184283 1122963 61320 52063 49526 1796 741 62337 21030 38193 3114 13099 13099 1070216 990185 80031 307260 238247 69013 SUPPLIES 724669 702375 22163 131 EQUIPMENT MAINTENANCE A 159163 144203 14960 0 PRINTING AND PUBLICATIO 43136 15115 23060 4961 POSTAGE AND SHIPPING 27727 14232 13495 0 254848 89182 154431 11235 22693571 18400400 4079275 213896 153554 610552 3580953 4869137 1536 532 4511593 4166705 638141 620281 23507261 10227431 13317994 13279830 4847866 4978544 174860 122821 27226497 28648402 1327088 1661531 121878 450000 408211 234356 245105 2011444 2436725 X 25030187 26000614 184866 211063 25215053 26211677 27226497 28648402 X 1238571 11761 -253708 X X 0 1 X 1 0 X SCHEDULE A, PART I, LINE 3: FAIRBANKS HOSPITAL, INC. HAS BEEN DETERMINED BY THE IRS TO BE A PUBLIC CHARITY UNDER IRS CODE SECTION 170(B)(1)(A)(III). PER SCHEDULE H INSTRUCTIONS ONLY ORGANIZATIONS THAT OPERATE AT LEAST ONE FACILITY THAT IS, OR IS REQUIRED TO BE, LICENSED, REGISTERED, OR SIMILARLY RECOGNIZED BY A STATE AS A HOSPITAL IS REQUIRED TO COMPLETE THIS SCHEDULE. FAIRBANK HOSPITAL, INC. IS A PRIVATE MENTAL HEALTH INSTITUTION AND CERTIFIED AS AN ADDICTIONS SERVICE PROVIDER. FAIRBANKS HOSPITAL IS NOT LICENSED BY THE INDIANA STATE DEPARTMENT OF HEALTH AS A HOSPITAL, BUT IS RECOGNIZED BY THE CENTERS FOR MEDICAID AND MEDICARE AS AN ACUTE CARE HOSPITAL. THE COMPLETION OF SCHEDULE H IS NOT REQUIRED; HOWEVER, FAIRBANKS' MANAGEMENT HAS DECIDED TO COMPLETE SCHEDULE H TO PROVIDE INFORMATION TO THE COMMUNITY REGARDING ITS FINANCIAL ASSISTANCE, COMMUNITY BENEFITS, AND FACILITY INFORMATION. RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 861341 434001 345679 949663 898546 405239 442444 861341 924344 2368777 2394575 898546 873382 440636 429 390103 924344 892895 391777 5733 417023 873382 0.77770 0.00000 0.22230 0 0 781388 781388 15356069 5963715 9392354 7369804 4263716 3106088 13279830 ESTIMATED THIRD PARTY SETTLEMENTS 245105 245105 X 24020181 11761 76278 88039 23932142 0 23932142 22769849 76278 76278 22693571 0 22693571 PART V, LINE 4: TEMPORARILY RESTRICTED NET ASSETS ARE THOSE ASSETS WHOSE USE HAS BEEN LIMITED BY DONORS FOR A SPECIFIC OPERATING OR CAPITAL PURPOSE. BOARD DESIGNATED FUNDS ARE SET ASIDE BY THE BOARD FOR SPECIFIC PURPOSES INCLUDING CHARITY CARE. PART X, LINE 2: ACCOUNTING PRINCIPLES GENERALLY ACCEPTED IN THE UNITED STATES OF AMERICA REQUIRE MANAGEMENT TO EVALUATE TAX POSITIONS TAKEN BY FAIRBANKS AND THE SCHOOL AND RECOGNIZE A TAX LIABILITY IF FAIRBANKS OR THE SCHOOL HAS TAKEN AN UNCERTAIN POSITION THAT MORE LIKELY THAN NOT WOULD NOT BE SUSTAINED UPON EXAMINATION BY VARIOUS FEDERAL AND STATE TAXING AUTHORITIES. MANAGEMENT HAS ANALYZED THE TAX POSITIONS TAKEN BY FAIRBANKS AND THE SCHOOL, AND HAS CONCLUDED THAT AS OF JUNE 30, 2015 AND 2014, THERE ARE NO UNCERTAIN POSITIONS TAKEN OR EXPECTED TO BE TAKEN THAT WOULD REQUIRE RECOGNITION OF A LIABILITY OR DISCLOSURE IN THE ACCOMPANYING FINANCIAL STATEMENTS. PART XI, LINE 2D - OTHER ADJUSTMENTS: FUNDRAISING EVENT ACTIVITY 76,278. PART XII, LINE 2D - OTHER ADJUSTMENTS: FUNDRAISING EVENT ACTIVITY 76,278. CIRCLE OF HOPE DINNER 141920 52835 89085 0 1563 19005 31018 4187 10937 ALUMNI GOLF OUTING 19837 13197 6640 0 430 6516 0 0 2622 161757 66032 95725 1993 25521 31018 4187 13559 76278 19447 1 1 0 1 X 0 1 0 1 0 920063 920063 0.04050 1208634 1430671 -222037 0.00000 2128697 1430671 698026 0.04050 1462796 5845 1456951 0.06420 139025 139025 0.00610 1601821 5845 1595976 0.07030 3730518 1436516 2294002 0.11080 1 1764057 0 2682198 2084500 597698 X 1 1 1 1 FAIRBANKS HOSPITAL INC 8102 CLEARVISTA PARKWAY INDIANAPOLIS IN 46256 WWW.FAIRBANKSCD.ORG X LICENSED PRIVATE MENTAL HEALTH INSTITUTION FAIRBANKS HOSPITAL INC 1 0 0 1 X X X X X X X X 12 1 0 0 1 X HTTP://WWW.FAIRBANKSCD.ORG X X 1 12 1 HTTP://WWW.FAIRBANKSCD.ORG/FILES/COMMUNITY%20NEEDS%20ASSESSMENT.PPT 0 0 1 X 250.000000000000 X X X X X 1 1 X X X X 1 X HTTP://WWW.FAIRBANKSCD.ORG/WP-CONTENT/UPLOADS/F-7-CHARITY-CARE.PDF X HTTP://WWW.FAIRBANKSCD.ORG/WP-CONTENT/UPLOADS/F-7-CHARITY-CARE.PDF X HTTP://WWW.FAIRBANKSCD.ORG/PROGRAMS/CATEGORY/COST-AND-INSURANCE/ X X X X 1 0 X X X X 0 X X X 0 0 FAIRBANKS HOSPITAL, INC PART V, SECTION B, LINE 5: IN CONDUCTING ITS MOST RECENT CHNA THE HOSPITAL TOOK INTO ACCOUNT INPUT FROM PERSONS WHO REPRESENTED THE COMMUNITY IT SERVED INCLUDING THOSE WITH SPECIAL KNOWLEDGE THROUGH FIVE FOCUS GROUPS. THE GROUPS WERE DETERMINED THROUGH DISCUSSION WITH ACADEMIC AND HEALTHCARE EXPERTS WHO HAVE KNOWLEDGE OF THE SUBSTANCE IMPACTED POPULATION IN THE INDIANAPOLIS METROPOLITAN AREA. THE FIRST GROUP CONSISTED OF ADDICTION SERVICE PROVIDERS FOR LOW INCOME AND MINORITY POPULATIONS; THE SECOND GROUP WAS COMPOSED OF COMMUNITY STAKEHOLDERS FROM THE STATE CRIMINAL JUSTICE DEPARTMENT, TASK FORCE ON DRUG FREE MARION COUNTY, HALFWAY HOUSES, PRIMARY MEDICAL CARE COALITION, AND EMPLOYEE ASSISTANCE PROGRAMS. ADOLESCENTS ATTENDING THE RECOVERY HIGH SCHOOL COMPRISED THE THIRD GROUP; PARENTS OF ADOLESCENTS WHO HAD RECEIVED ADDICTION TREATMENT SERVICES WERE IN THE FOURTH, AND THE FIFTH GROUP CONSISTED OF ADULT PATIENTS WHO HAD SUCCESSFULLY COMPLETED INPATIENT TREATMENT. FOCUS GROUP QUESTIONS INCLUDED IDENTIFICATION OF STRENGTHS AND WEAKNESSES IN THE ADDICTION TREATMENT SYSTEM, BARRIERS TO SERVICES, GAPS IN SERVICES, AND RECOMMENDATIONS FOR THE SYSTEM OF CARE. FAIRBANKS HOSPITAL, INC PART V, SECTION B, LINE 7D: THE HOSPITAL FACILITY'S CHNA IS AVAILABLE TO THE PUBLIC ON THE HOSPITAL'S WEBSITE AT WWW.FAIRBANKSCD.ORG UNDER "ABOUT US AND CLICK ON "COMMUNITY NEEDS ASSESSMENT OR ENTER THE FOLLOWING WEB ADDRESS INTO THE BROWSER: HTTP://WWW.FAIRBANKSCD.ORG/FILES/COMMUNITY%20NEEDS%20ASSESSMENT.PPT FAIRBANKS HOSPITAL, INC PART V, SECTION B, LINE 11: THE HOSPITAL FACILITY IDENTIFIED NINE SIGNIFICANT NEEDS IN ITS 2012 IMPLEMENTATION STRATEGY. THE HOSPITAL FACILITY HAS ADDRESSED SIX OF THOSE NEEDS OVER THE PRIOR TWO TAX YEARS. THE THREE REMAINING NEEDS WERE COLLABORATIVE IN NATURE AND REQUIRED COMPREHENSIVE PLANNING OF WHICH ALL THREE NEEDS WILL BE ADDRESSED BY THE END OF TAX YEAR 2015 (FISCAL YEAR ENDING JUNE 30, 2016). FAIRBANKS HOSPITAL, INC PART V, SECTION B, LINE 22D: INDIVIDUALS QUALIFYING FOR CHARITY CARE WILL RECEIVE A REDUCTION TO CHARGES CALLED A CHARITY CARE WRITE-OFF DETERMINED BY CRITERIA LISTED IN THE CHARITY CARE POLICY WHICH PROVIDES FOR A 50%, 60%, OR 70% REDUCTION IN CHARGES. PART V, SECTION B, LINE 16 FINANCIAL ASSISTANCE POLICY WEBSITE AVAILABILITY FAIRBANKS HOSPITAL, INC PART V, SECTION B, LINE 16A WEBSITE: HTTP://WWW.FAIRBANKSCD.ORG/WP-CONTENT/UPLOADS/F-7-CHARITY-CARE.PDF FAIRBANKS HOSPITAL, INC PART V, SECTION B, LINE 16B WEBSITE: HTTP://WWW.FAIRBANKSCD.ORG/WP-CONTENT/UPLOADS/F-7-CHARITY-CARE.PDF FAIRBANKS HOSPITAL, INC PART V, SECTION B, LINE 16C WEBSITE: HTTP://WWW.FAIRBANKSCD.ORG/PROGRAMS/CATEGORY/COST-AND-INSURANCE/ 3 LAVERNA LODGE 8102 CLEARVISTA PARKWAY INDIANAPOLIS IN 46256 DRUG & ALCOHOL RESIDENTIAL REHAB - SEPARATE LOCATION FOR MEN & WOMEN SUPPORTED LIVING PROGRAM 8102 CLEARVISTA PARKWAY INDIANAPOLIS IN 46256 ADULT HALFWAY HOUSE & DRUG & ALCOHOL SUPPORTED LIVING PLAINFIELD ADDICTIONS TREATMENT FACILITY 6100 CLARKS CREEK RD STE 102 104 PLAINFIELD IN 46168 OUTPATIENT CENTER PART I, LINE 7: FAIRBANKS USES THE IRS WORKSHEETS PROVIDED IN THE INSTRUCTIONS FOR FORM 990, SCHEDULE H TO CALCULATE A SINGLE COST TO CHARGE RATIO WHICH IS APPLIED TO THE CHARGES FOR FINANCIAL ASSISTANCE AND OTHER BENEFITS TO PROVIDE AMOUNTS AT COST. PART I, LN 7 COL(F): EFFECTIVE JULY 1, 2012, FAIRBANKS ADOPTED ACCOUNTING STANDARDS UPDATE (ASU)2011-07, HEALTHCARE ENTITIES (TOPIC 954), "PRESENTATION AND DISCLOSURE OF PATIENT SERVICE REVENUE, PROVISION FOR BAD DEBTS, AND THE ALLOWANCE FOR DOUBTFUL ACCOUNTS FOR CERTAIN HEALTHCARE ENTITIES," WHICH REQUIRES CERTAIN HEALTHCARE ENTITIES TO PRESENT THE PROVISION FOR BAD DEBTS RELATING TO PATIENT SERVICE REVENUE AS A DEDUCTION FROM PATIENT SERVICE REVENUE IN THE CONSOLIDATED STATEMENTS OF OPERATIONS AND CHANGES IN NET ASSETS RATHER THAN AS AN OPERATING EXPENSE. ADOPTION OF THIS STANDARD HAS NO IMPACT ON ITS FINANCIAL POSITION, RESULTS OF OPERATIONS, OR CASH FLOWS. PART III, LINE 4: BAD DEBT EXPENSE FOOTNOTE TO AUDITED FINANCIAL STATEMENTS IS LOCATED ON PAGES 7 AND 8 OF THE ATTACHED AUDITED FINANCIAL STATEMENTS UNDER THE HEADING "ALLOWANCE FOR DOUBTFUL ACCOUNTS". PART III, LINE 8: MEDICARE ALLOWABLE COSTS ARE CALCULATED BY USING THE RATIO OF COST TO CHARGES. THE SOURCE USED TO DETERMINE THE AMOUNT OF MEDICARE ALLOWABLE COSTS REPORTED FOR PART III, SECTION B, MEDICARE HAS BEEN PROVIDED FROM THE YEAR ENDED JUNE 30, 2015: HOSPITAL STATEMENT OF REIMBURSABLE COST. PART III, LINE 9B: WHEN AN ACCOUNT IS IDENTIFIED AS UNCOLLECTIBLE, IT BECOMES BAD DEBT. IF THE FINANCIAL POSITION OF THE IDENTIFIED INDIVIDUAL'S ACCOUNT HAS BEEN VERIFIED AS BEING IN A FINANCIAL POSITION OF 250% FEDERAL POVERTY LEVEL, THE ACCOUNT WILL BE RECLASSED AS CHARITY CARE. PART VI, LINE 2: FAIRBANKS ENGAGED THE SERVICES OF THE INDIANA UNIVERSITY CENTER FOR HEALTH POLICY TO CONDUCT COMMUNITY FOCUS GROUPS. THE GROUPS WERE DETERMINED THROUGH DISCUSSION WITH ACADEMIC AND HEALTHCARE EXPERTS WHO HAVE KNOWLEDGE OF THE SUBSTANCE IMPACTED POPULATION IN THE INDIANAPOLIS METROPOLITAN AREA. FIVE SEPARATE FOCUS GROUPS WERE DEVELOPED. THE FIRST GROUP CONSISTED OF ADDICTION SERVICE PROVIDERS FOR LOW INCOME AND MINORITY POPULATIONS; THE SECOND GROUP WAS COMPOSED OF COMMUNITY STAKEHOLDERS FROM THE STATE CRIMINAL JUSTICE DEPARTMENT, TASK FORCE ON DRUG FREE MARION COUNTY, HALFWAY HOUSES, PRIMARY MEDICAL CARE COALITION, AND EMPLOYEE ASSISTANCE PROGRAMS. ADOLESCENTS ATTENDING THE RECOVERY HIGH SCHOOL COMPRISED THE THIRD GROUP; PARENTS OF ADOLESCENTS WHO HAD RECEIVED ADDICTION TREATMENT SERVICES WERE IN THE FOURTH, AND THE FIFTH GROUP CONSISTED OF ADULT PATIENTS WHO HAD SUCCESSFULLY COMPLETED INPATIENT TREATMENT. FOCUS GROUP QUESTIONS INCLUDED IDENTIFICATION OF STRENGTHS AND WEAKNESSES IN THE ADDICTION TREATMENT SYSTEM, BARRIERS TO SERVICES, GAPS IN SERVICES, AND RECOMMENDATIONS FOR THE SYSTEM OF CARE. PART VI, LINE 3: THOSE INDIVIDUALS SEEKING ADMISSION TO FAIRBANKS HAVE THE OPPORTUNITY TO MEET WITH A FINANCIAL COUNSELOR TO DETERMINE WHAT RESOURCES ARE AVAILABLE. IN ADDITION, AN INFORMATION BOOKLET IS GIVEN TO THE FAMILIES DURING THE ADMISSION PROCESS WHICH NOTES THAT CHARITY CARE IS AVAILABLE. LASTLY, SIGNS ARE VISIBLE TO PATIENTS IN THE ACCESS DEPARTMENT WHERE ADMISSIONS TAKE PLACE. FAIRBANKS USES THE LOCAL MEDIA TO ASSIST IN EDUCATING THE PUBLIC CONCERNING PREVENTION, INTERVENTION AND TREATMENT. ALSO, FAIRBANKS PARTICIPATES IN NATIONAL ALCOHOL AWARENESS MONTH, RECOVERY MONTH COMMUNITY ACTIVITIES, AND PROVIDES COMMUNITY EDUCATION THROUGH THE SUSAN LI CONFERENCE. PART VI, LINE 4: FOR THE FISCAL YEAR ENDED JUNE 30, 2015, 20,760 PERSONS WERE SERVED; 59% FROM UNITED WAY OF CENTRAL INDIANA COUNTIES, 23% SURROUNDING COUNTIES, 14% REMAINING INDIANA COUNTIES, AND 4% OUT OF STATE. PART VI, LINE 5: THE ORGANIZATION FURTHERS ITS EXEMPT PURPOSE BY PROMOTING HEALTH OF THE COMMUNITY THROUGH THE FOLLOWING: THE ORGANIZATION'S GOVERNING BODY IS COMPRISED OF A MAJORITY OF INDEPENDENT PERSONS WHO RESIDE IN THE ORGANIZATION'S PRIMARY SERVICE AREA. SURPLUS OF FUNDS WHEN AVAILABLE ARE USED TO IMPROVE THE PATIENT CARE AND MEDICAL EDUCATION OF THE STAFF; AND A PERCENTAGE OF OPERATING INCOME IS RESTRICTED FOR PATIENT SCHOLARSHIP FUNDS. FAIRBANKS USES THE LOCAL MEDIA TO ASSIST IN EDUCATING THE PUBLIC CONCERNING PREVENTION, INTERVENTION AND TREATMENT. THE ORGANIZATION ALSO PARTICIPATES IN NATIONAL ALCOHOL AWARENESS MONTH, RECOVERY MONTH COMMUNITY ACTIVITIES AND PROVIDES COMMUNITY EDUCATION THROUGH THE SUSAN LI CONFERENCE. PART VI, LINE 6: N/A - ORGANIZATION IS NOT PART OF AN AFFILIATED HEALTH CARE SYSTEM. 1 HOPE ACADEMY 8102 CLEARVISTA PARKWAY INDIANAPOLIS IN 46256 203094377 385709 COST DEBT FORGIVENESS GENERAL SUPPORT 1 0 PART I, LINE 2: THERE WERE NO GRANT FUNDS GREATER THAN $5,000 AWARDED DURING THE YEAR. ASSISTANCE WAS PROVIDED ONLY TO A 501(C)(3) PUBLIC CHARITY FOR GENERAL SUPPORT. X X X X X 0 0 0 0 0 0 0 0 0 MARK MONSON PRESIDENT/CEO (7'14 - 9'14) 215529 0 0 0 0 0 0 0 19165 0 234694 0 0 0 BARBARA ELLIOTT INTERIM PRESIDENT/CEO (10'14 - 6'15) 146804 0 0 0 0 0 8555 0 24026 0 179385 0 0 0 DR DENNIS RHYNE INTERIM MEDICAL DIRECTOR (7'14-3'15) 250031 0 0 0 0 0 13726 0 8748 0 272505 0 0 0 DR ANDREW SONDERMAN PHYSICIAN 196539 0 0 0 0 0 11241 0 24270 0 232050 0 0 0 SCHEDULE J, PART II MR. MARK MONSON IS COMPENSATED BY FAIRBANKS HOSPITAL, INC. FOR HIS DUTIES AS PRESIDENT/CEO OF THE HOSPITAL. A PORTION OF HIS COMPENSATION RECEIVED FROM FAIRBANKS HOSPITAL, INC. IS ALLOCATED TO HOPE ACADEMY FOR DUTIES PROVIDED. FOR FY 2015, 4% OF MR. MONSONS' HOURS (55 ANNUALLY) OR SALARIES AND BENEFITS TOTALING $9,388 ARE ALLOCATED TO HOPE ACACDEMY. MS. BARBARA ELLIOTT IS COMPENSATED FROM FAIRBANKS HOSPITAL, INC. FOR HER DUTIES AS VICE PRESIDENT AND CFO OF THE HOSPITAL. A PORTION OF HER COMPENSATION RECEIVED FROM FAIRBANKS HOSPITAL, INC. IS ALLOCATED TO HOPE ACADEMY FOR DUTIES PROVIDED. FOR FY 2015, 10% OF MS. ELLIOTT'S HOURS (208 ANNUALLY) OR SALARIES AND BENEFITS TOTALING $17,939 ARE ALLOCATED TO HOPE ACACDEMY. UNITED HEALTHCARE SEE PART V 2662365 PART V BELOW 0 KRIEG DEVAULT LLP SEE PART V 54713 PART V BELOW 0 SCH L, PART IV, BUSINESS TRANSACTIONS INVOLVING INTERESTED PERSONS: (A) NAME OF PERSON: UNITED HEALTHCARE(B) RELATIONSHIP BETWEEN INTERESTED PERSON AND ORGANIZATION:ENTITY OF WHICH A CURRENT OFFICER SERVED AS BOARD MEMBER FOR FAIRBANKS HOSPITAL(D) DESCRIPTION OF TRANSACTION: UNITED HEALTHCARE IS A THIRD PARTY INSURANCE PAYOR TO FAIRBANKS HOSPITAL.(A) NAME OF PERSON: KRIEG DEVAULT, LLP(B) RELATIONSHIP BETWEEN INTERESTED PERSON AND ORGANIZATION:PARTNERSHIP OF WHICH A CURRENT PARTNER SERVES AS A BOARD MEMBER OF FAIRBANKS HOSPITAL(D) DESCRIPTION OF TRANSACTION: KRIEG DEVAULT, LLP PROVIDES LEGAL SERVICES TO FAIRBANKS HOSPITAL. THE TRANSACTION IS PAYMENT FOR LEGAL FEES DURING THE YEAR. FORM 990, PART VI, SECTION B, LINE 11 THE PROCESS OF REVIEWING THE FORM 990 INCLUDES A DETAILED REVIEW OF THE FORM 990 AND REQUIRED SCHEDULES BY THE CHIEF EXECUTIVE OFFICER, CHIEF FINANCIAL OFFICER, AND BOARD FINANCE COMMITTEE. EACH VOTING MEMBER OF THE GOVERNING BODY REVIEWS AND APPROVES THE FORM 990 AT THE BOARD OF DIRECTOR MEETING PRIOR TO FILING WITH THE IRS. FORM 990, PART VI, SECTION B, LINE 12C THE BOARD MEMBERS MUST COMPLETE A CONFLICT OF INTEREST FORM ANNUALLY. BOARD MEMBERS WHO HAVE A POTENTIAL FOR CONFLICT MUST RECUSE THEMSELVES FROM VOTING ON SUBJECTS THAT MIGHT POSE A CONFLICT. THE CORPORATE COMPLIANCE OFFICER REVIEWS ANY POTENTIAL CONFLICTS THAT ARE REPORTED. FORM 990, PART VI, SECTION B, LINE 15A ALL CURRENT MEMBERS OF THE BOARD OF DIRECTORS ARE GIVEN A WRITTEN EVALUATION FORM TO RATE THE CEO. ALL INFORMATION IS THEN COMPILED IN A FINAL REPORT AND PRESENTED BY THE BOARD CHAIR TO THE CEO. FOR COMPENSATION, WE COMPILE DATA PROVIDED BY OUR INDEPENDENT AUDITORS FROM THE INDIANA HOSPITAL ASSOCIATION, OTHER MENTAL HEALTH PROVIDERS, AND NAATP (NATIONAL ASSOCIATION OF ADDICTION TREATMENT PROVIDERS) TO ENSURE THE SALARY IS COMPETITIVE AND REASONABLE. MEMBERS OF THE EXECUTIVE COMPENSATION COMMITTEE OF THE BOARD OF DIRECTORS MEET TO DISCUSS AND REVIEW THE DATA AND MAKE A FINAL DECISION REGARDING COMPENSATION THAT IS THEN REVIEWED AND APPROVED BY THE EXECUTIVE COMMITTEE OF THE BOARD OF DIRECTORS. DURING THE TAX YEAR AN ADDITIONAL PROCESS WAS USED TO DETERMINE COMPENSATION FOR THE NEWLY HIRED CEO WHICH INCLUDED THE BOARD OF DIRECTORS ENGAGING A THIRD PARTY SEARCH FIRM, WITT KIEFFER, TO MANAGE THE 2015 CEO SEARCH. WITT KIEFFER CONDUCTED A THOROUGH SALARY REVIEW OF THE INDIANAPOLIS AND MIDWEST REGION FOR BEHAVIORAL HEALTH, ADDICTION AND HOSPITAL SYSTEMS FOR COMPARABLE DATA. THE SOURCES CITED INCLUDED A 2013 NATIONAL ACUTE CARE HOSPITAL WITH LESS THAN $50 MILLION IN NET REVENUE, MERCER'S CEO COMPENSATION STUDY OF FEDERALLY QUALIFIED HEALTH CENTER'S WITH REVENUES OVER $25 MILLION AND THEIR OWN CEO SEARCHES IN THE LAST 12 MONTHS. THE EXECUTIVE COMMITTEE OF THE BOARD USED THIS DATA IN DETERMINING THE FINAL COMPENSATION OFFER TO OUR CEO CANDIDATE. FORM 990, PART VI, SECTION C, LINE 19 THE ORGANIZATION'S GOVERNING DOCUMENTS, CONFLICT OF INTEREST POLICY, AND DETAILED FINANCIAL STATEMENT INFORMATION IS AVAILABLE TO THE PUBLIC UPON REQUEST. THE AUDITED FINANCIAL STATEMENTS ARE ATTACHED TO THE FORM 990 PER REGULATION 1.6033-2(A)(2)(II)(L)(1). ADDITIONALLY, SUMMARY FINANCIAL STATEMENT INFORMATION IS AVAILABLE IN THE ANNUAL REPORTS ON THE ORGANIZATION'S WEBSITE. FORM 990, PART VII, SECTION A, LINE 1A: RELATED ORGANIZATION HOURS MR. MARK MONSON IS COMPENSATED FROM FAIRBANKS HOSPITAL, INC. FOR HIS DUTIES AS PRESIDENT/CEO OF THE HOSPITAL. A PORTION OF HIS COMPENSATION RECEIVED FROM FAIRBANKS HOSPITAL, INC. IS ALLOCATED TO HOPE ACADEMY FOR DUTIES PROVIDED. FOR FY 15, 4% MR. MONSON'S HOURS (55 HOURS ANNUALLY) OR SALARIES AND BENEFITS TOTALING $9,388 ARE ALLOCATED TO HOPE ACADEMY. MS. BARBARA ELLIOTT IS COMPENSATED FROM FAIRBANKS HOSPITAL, INC. FOR FY 15, 10% OF HER HOURS (208 HOURS ANNUALLY) OR SALARIES AND BENEFITS TOTALING $17,939 ARE ALLOCATED TO HOPE ACADEMY. FORM 990, PART IX, LINE 11G PURCHASE SERVICES: PROGRAM SERVICE EXPENSES 1,784,678. MANAGEMENT AND GENERAL EXPENSES 851,242. FUNDRAISING EXPENSES 23,928. TOTAL EXPENSES 2,659,848. FORM 990, PART XI, LINE 9: NET ASSETS TRANSFERRED TO HOPE ACADEMY -253,708. FORM 990, PART XI, LINE 2C: AUDIT OVERSIGHT THE ORGANIZATION UTILIZES THE AUDIT AND FINANCE COMMITTEE OF THE BOARD OF DIRECTORS TO OVERSEE THE AUDIT PROCEDURES AND SELECTION OF THE INDEPENDENT ACCOUNTING FIRM. THE RECOVERY HIGH SCHOOL AT FAIRBANKS INC DBA HOPE ACADEMY 8102 CLEARVISTA PARKWAY INDIANAPOLIS IN 46256 203094377 CHARTER SCHOOL IN 501(C)(3) LINE 2 FAIRBANKS HOSPITAL INC 1 0 1 0 1 0 0 0 0 0 1 0 1 0 1 1 0 1 0 0 THE RECOVERY HIGH SCHOOL AT FAIRBANKS INC DBA HOPE ACADEMY B 639415 COST THE RECOVERY HIGH SCHOOL AT FAIRBANKS INC DBA HOPE ACADEMY J 144600 COST