2016-08-09T14:29:36-05:00 2015-09-30 351178661 BLUE & CO LLC 500 N MERIDIAN ST SUITE 200 INDIANAPOLIS IN 46204 990 2014-10-01 351064295 DEKALB MEMORIAL HOSPITAL INC DEKA 2609254600 1316 EAST SEVENTH STREET AUBURN IN 46706 BRET CLAGHORN CPA CFO 2609254600 2016-08-09 1 AMBER KOCHER CPA P01286298 3176334705 2016-08-09 2014 2016-12-15 16:53:06Z DEKALB HEALTH CRAIG POLKOW 1316 EAST SEVENTH STREET AUBURN IN 46706 66047207 0 X WWW.DEKALBHEALTH.COM X 1964 IN TO PROVIDE ACUTE, SUBACUTE AND OUTPATIENT MEDICAL SERVICES TO RURAL NORTHEASTERN INDIANA. 14 14 699 40 63850 0 1079305 1006504 55894915 60695036 1774704 772705 720535 722920 59469459 63197165 213683 314565 0 0 31584235 34257538 0 0 396 29061696 27937706 60859614 62509809 -1390155 687356 69993674 68964946 20619005 21183481 49374669 47781465 X PROMOTE, PRESERVE, RESTORE HEALTH 0 0 56359116 314565 61151434 THE 56 INPATIENT BED HOSPITAL OPERATES IN A RURAL AREA. FOR FISCAL YEAR ENDED SEPTEMBER 30, 2015, THE TOTAL NUMBER OF ADMISSIONS WAS 2,327. THE TOTAL NUMBER OF EMERGENCY ROOM VISITS WAS 17,875. THE TOTAL NUMBER OF HOME HEALTH CARE VISITS WAS 6,593. THE HOSPITAL PROVIDES CHARITY CARE TO PATIENTS WHO MEET CERTAIN CRITERIA UNDER ITS CHARITY CARE POLICY. THE HOSPITAL DOES NOT PURSUE COLLECTION OF AMOUNTS DETERMINED TO BE CHARITY CARE WHICH WAS APPROXIMATELY $1,185,000 FOR THE YEAR.AT DEKALB HEALTH, OUR INVESTMENTS IN STATE-OF-THE-ART FACILITIES AND PARTNERSHIPS WITH TOP FAMILY PHYSICIANS AND SPECIALTY GROUPS MEAN THAT YOU NEVER HAVE TO LOOK PAST DEKALB COUNTY FOR THE VERY BEST CARE. OUR COMMITMENT IS ALSO REFLECTED IN OUR INVESTMENTS OF TIME, TALENTS, AND RESOURCES IN LOCAL SCHOOLS, BUSINESSES, CHARITABLE ORGANIZATIONS AND OTHER WORTHY CAUSES TO HELP ENSURE A HEALTHIER COMMUNITY. WE'RE PROUD TO BE YOUR NEIGHBOR, AND YOU CAN BE SURE WE'LL BE HERE, TAKING CARE OF YOU FOR GENERATIONS TO COME.THANKS TO THE VISION OF OUR LEADERSHIP, DEKALB HEALTH HAS TAKEN NUMEROUS STEPS FORWARD. WHILE MANY OF OUR MILESTONES ARE IN PLAIN SIGHT SUCH AS THE NEW ER, EICU, REGISTRATION AREA, IMAGING, LABORATORY, AND RESPIRATORY CENTERS; MANY OF OUR ACHIEVEMENTS ARE BEHIND THE SCENES. WE HAVE FORGED NEW PARTNERSHIPS WITH PHYSICIAN GROUPS, SO THAT PEOPLE IN OUR REGION NOW HAVE ACCESS TO ALMOST EVERY MEDICAL SPECIALTY RIGHT HERE ON OUR CAMPUS. WE HAVE ALSO MADE SIGNIFICANT INVESTMENTS IN NEW TECHNOLOGY, SUCH AS A STATE-OF-THE-ART MONITORING SYSTEM FOR CRITICALLY ILL PATIENTS AND THE MOVE TO ELECTRONIC MEDICAL RECORDS. MOST IMPORTANTLY, OUR PEOPLE CONTINUE TO DISTINGUISH THEMSELVES AS THE MOST COMPASSIONATE CAREGIVERS YOU'LL FIND ANYWHERE, AND WE CONTINUE TO DONATE TIME AND RESOURCES IN SUPPORT OF SCHOOLS, BUSINESSES, AND ORGANIZATIONS TO ENSURE A STRONG, HEALTHY COMMUNITY. AT DEKALB HEALTH, WE HAVE REARMED OUR COMMITMENT TO BEING YOUR INDEPENDENT, NOT-FOR-PROFIT COMMUNITY HOSPITAL. WITH EVERY NEW INVESTMENT, WE'RE BRINGING WORLD-CLASS HEALTHCARE HOME TO YOU.[CONTINUE ON SCHEDULE O][CONTINUE PROGRAM SERVICE ACCOMPLISHMENTS FROM PAGE 2] WE CELEBRATE THE UNIQUE BOND THAT EXISTS BETWEEN THE HOSPITAL AND ITS COMMUNITY. OURS IS A RICH HERITAGE OF INDEPENDENCE, DETERMINATION AND A COMMITMENT TO TAKING CARE OF THE INDIVIDUALS AND FAMILIES WE SERVE. 56359116 1 1 0 1 0 0 0 0 0 1 1 0 0 0 1 0 0 1 0 0 0 0 0 0 0 0 1 1 1 0 1 0 0 0 0 0 0 0 0 0 0 0 0 1 1 0 0 0 1 147 0 1 699 1 1 1 0 0 0 0 0 0 0 0 0 X 14 14 0 0 0 0 1 1 1 1 1 0 0 1 1 1 1 1 1 1 1 0 IN X BRET CLAGHORN 2609254600 1316 E 7TH STREET AUBURN IN 46706 ROBERT MENZIE CHAIRPERSON 1.00 0.00 X X 0 0 0 MARK FOGT VICE CHAIRPERSON 1.00 0.00 X X 0 0 0 DOUGLAS MORROW OD SECRETARY 1.00 0.00 X X 0 0 0 RICHARD ALLEN DIRECTOR 1.00 0.00 X 0 0 0 TRINA CHAPMAN-SMITH DIRECTOR 1.00 0.00 X 0 0 0 CAROLINE DERROW DDS DIRECTOR 1.00 0.00 X 0 0 0 MATT FETTER DIRECTOR 1.00 0.00 X 0 0 0 BETH FREIDENBERGER DIRECTOR 1.00 0.00 X 0 0 0 JASON HANNA MD DIRECTOR 1.00 0.00 X 0 0 0 MARK MILLET DIRECTOR 1.00 0.00 X 0 0 0 SCOTT PFLUGHOEFT DIRECTOR 1.00 0.00 X 0 0 0 CARRIE RAVER DIRECTOR 1.00 0.00 X 0 0 0 DENNIS STOCKDALE DIRECTOR 1.00 0.00 X 0 0 0 TRENT STUCKEY DIRECTOR 1.00 0.00 X 0 0 0 FRED PRICE CEO (OCT'14-JAN'15) 40.00 0.00 X 281514 0 41670 EMILIO VAZQUEZ CMO/ INTERIM CEO (FEB-JUL'15) 40.00 0.00 X 330882 0 13000 CRAIG POLKOW CEO (AUG-SEPT'15) 0.00 0.00 X 0 0 0 AMY CROUCH CFO (OCT'14-JAN'15) 40.00 0.00 X 170521 0 8224 KENNETH CHAFFEE PHYSICIAN 40.00 0.00 X 343031 0 31052 PHILIP CHASE PHYSICIAN 40.00 0.00 X 342203 0 59424 BRET KUEBER PHYSICIAN 40.00 0.00 X 338853 0 38390 SCOTT ARMSTRONG PHYSICIAN 40.00 0.00 X 318401 0 43230 RICHARD TOUPIN PHYSICIAN 40.00 0.00 X 310844 0 38493 2436249 0 273483 27 0 1 0 FETTERS CONSTRUCTION 5417 CO RD 427 AUBURN IN 46706 CONSTRUCTION SERVICES 2974037 ASSOCIATED ANESTHESIOLOGISTS 5734 COVENTRY LN FORT WAYNE IN 46804 PHYSICIAN SERVICES 736856 MCKESSON TECHOLOGIES INC PO BOX 98347 CHICAGO IL 60693 TECHOLOGICAL SERVICES 733280 SOUTH BEND MEDICAL FOUNDATION 118 W EDISON RD MISHAWAKA IN 46545 LAB SERVICES 700386 ALLIED MEDICAL SERVICES INC 1133 CORPORATE DR STE B HOLLAND OH 43528 RESPIRATORY THERAPY/EEG SERVICES 523244 22 963379 43125 1006504 PATIENT SERVICE REVENUE 623990 55792980 55792980 PHARMACARE 621500 4085782 4085782 FINANCIAL SERVICES 900099 522917 522917 CAFETERIA SALES 722320 293357 233590 59767 60695036 339481 339481 595544 189981 405563 405563 405563 3093285 2660061 433224 433224 433224 CLEANING 812300 2360 2360 LAUNDRY 812300 1723 1723 313274 110602 202672 317357 63197165 61151434 63850 975377 314565 314565 536235 308983 227252 26297935 24594150 1703785 528613 491610 37003 5071337 5010424 60913 1823418 885302 938116 169632 109757 59875 148182 718 147464 79094 79094 34267 34267 5286650 4888413 398237 394938 18730 376208 1513080 1241065 271619 396 1597782 1527350 70432 1260814 1125027 135787 249827 229194 20633 33728 27609 6119 383481 383481 4693464 4317987 375477 672863 250 672613 MEDICAL SUPPLIES 9757729 9757729 HAF ASSESSMENT FEE 1186561 1186561 COLLECTION FEES 266201 266201 LICENSE, ACCRED FEE & M 129542 338 129204 79871 57153 22718 62509809 56359116 6150297 396 33472 65743 2916386 0 8705294 8047115 2658 56794 23816 1490596 1596794 443764 692293 86746123 45914937 37349416 40831186 18811389 17575039 183905 132960 69993674 68964946 7332375 5894031 11817881 13946391 1468749 1343059 20619005 21183481 X 48353813 47294299 1020856 487166 49374669 47781465 69993674 68964946 X 687356 -1959608 -320952 X X 0 1 X 1 0 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 0 0 0 0 0 0 0 0 1 5138 5138 0 PART II-B, LINE 1: THE HOSPITAL PAID MEMBERSHIP DUES TO INDIANA HOSPITAL ASSOCIATION "IHA AND AMERICAN HOSPITAL ASSOCIATION "AHA" IN ADDITION TO INDIANA ASSOCIATION FOR HOME & HOSPICE CARE "IAHHC". IHA ATTRIBUTED 5.38% ($919); AHA ATTRIBUTED 22.80% ($3,877); AND IAHHC ATTRIBUTED 12% ($342) OF THE DUES TO LOBBYING EXPENSES TO TOTAL $5,138 ABOVE. 1020856 1051118 1584808 487166 1817 1057216 38177 1020856 108890 33375 34016 106432 1817 112897 76699 80706 108890 28679 84218 112897 1.00000 0 0 393118 393118 62076625 28830194 33246431 22495957 17084743 5411214 1780423 1780423 40831186 CAPITAL LEASE OBLIGATIONS 1193059 ESTIMATED THIRD PARTY SETTLEMENT 150000 1343059 61072319 -1959608 -320952 -2280560 63352879 34267 -189981 -155714 63197165 62665523 189981 189981 62475542 34267 34267 62509809 PART XI, LINE 2D - OTHER ADJUSTMENTS: NET UNREALIZED GAIN (LOSS) ON FAIR VALUE OF INTEREST SWAP -320,952. PART XI, LINE 4B - OTHER ADJUSTMENTS: RENTAL EXPENSES -189,981. PART XII, LINE 2D - OTHER ADJUSTMENTS: RENTAL EXPENSES 189,981. PART X, LINE 2 FIN 48 FOOTNOTE: NOT APPLICABLE. THE AUDITED FINANCIAL STATEMENTS DID NOT INCLUDE A FOOTNOTE REGARDING UNCERTAIN TAX POSITIONS UNDER FIN 48. HOWEVER, MANAGEMENT HAS EVALUTAED THE INCOME TAX POSITIONS UNDER THIS GUIDANCE AND BASED ON REVIEW, MANAGEMENT HAS NOT IDENTIFIED ANY MATERIAL UNCERTAIN TAX POSITIONS TO BE REPORTED OR DISCLOSED ON THE AUDITED FINANCIAL STATEMENTS ENDING SEPTEMBER 30, 2014. 1 1 1 X 1 X 1 1 0 1 1 544912 544912 0.00870 6541975 3680812 2861163 0.04580 7086887 3680812 3406075 0.05450 35891 35891 0.00060 25000 25000 0.00040 47336 47336 0.00080 108227 108227 0.00180 7195114 3680812 3514302 0.05630 20000 20000 0.00030 166619 166619 0.00270 1000 1000 0.00000 5700 5700 0.00010 193319 193319 0.00310 1 5403094 0 8174924 10122487 -1947563 X 1 1 1 1 DEKALB MEMORIAL HOSPITAL 1316 E 7TH STREET AUBURN IN 46706 WWW.DEKALBHEALTH.COM 14-005041-1 X X X DEKALB MEMORIAL HOSPITAL INC 1 0 0 1 X X X X X X X X X 12 1 0 1 1 X HTTPS://WWW.DEKALBHEALTH.COM/IMAGES/PDFS/2012%20DEKALB%20COUNTY%20CHN%20REP X 1 12 1 HTTPS://WWW.DEKALBHEALTH.COM/IMAGES/PDFS/CHNA-REPORT-2013-FINAL.PDF 0 0 1 X 200.000000000000 350.000000000000 X X X X X 1 1 X X X 1 X HTTP://WWW.DEKALBHEALTH.COM/IMAGES/PDFS/FINANCIAL_ASSISTANCE/FINANCIAL-ASSI X HTTP://WWW.DEKALBHEALTH.COM/IMAGES/PDFS/FINANCIAL_ASSISTANCE/FINANCIAL_ASSI X HTTP://WWW.DEKALBHEALTH.COM/INDEX.PHP/PATIENTSVISITORS/PATIENT-INFORMATION/ X X X X 1 0 X X X X 1 X 0 0 DEKALB MEMORIAL HOSPITAL, INC. PART V, SECTION B, LINE 5: THE HOSPITAL FACILITY TOOK INTO ACCOUNT INPUT FROM PERSONS WHO REPRESENT THE COMMUNITY THROUGH COMMUNITY SURVEYS SENT TO HOUSEHOLDS IN DEKALB COUNTY, PROVIDER SURVEYS SENT, AND FEEDBACK COLLECTED FROM KEY CONSTITUENTS. DEKALB MEMORIAL HOSPITAL, INC. PART V, SECTION B, LINE 6B: THE ASSESSMENT WAS NOT CONDUCTED WITH OTHER HOSPITALS, BUT WAS PART OF A COLLABORATIVE EFFORT WITH DEKALB COUNTY HEALTH DEPT AND IPFW CENTER FOR SOCIAL RESEARCH. DEKALB MEMORIAL HOSPITAL, INC. PART V, SECTION B, LINE 7D: THE COMMUNITY HEALTH NEEDS ASSESSMENT IS AVAILABLE AT WWW.DEKALBHEALTH.COM LOCATED UNDER THE DROP DOWN MENU "COMMUNITY". PART V, SECTION B, LINE 16 FINANCIAL ASSISTANCE POLICY WEBSITE AVAILABILITY DEKALB MEMORIAL HOSPITAL, INC. PART V, SECTION B, LINE 16A WEBSITE: HTTP://WWW.DEKALBHEALTH.COM/IMAGES/PDFS/FINANCIAL_ASSISTANCE/FINANCIAL-ASSI DEKALB MEMORIAL HOSPITAL, INC. PART V, SECTION B, LINE 16B WEBSITE: HTTP://WWW.DEKALBHEALTH.COM/IMAGES/PDFS/FINANCIAL_ASSISTANCE/FINANCIAL_ASSI DEKALB MEMORIAL HOSPITAL, INC. PART V, SECTION B, LINE 16C WEBSITE: HTTP://WWW.DEKALBHEALTH.COM/INDEX.PHP/PATIENTSVISITORS/PATIENT-INFORMATION/ PART I, LINE 3C: THE ORGANIZATION USES THE FEDERAL POVERTY GUIDELINES WHEN DETERMINING ELIGIBILITY FOR DISCOUNTED CARE BETWEEN 200% AND 350% OF THE FEDERAL POVERTY LIMIT (FPL) AS FOLLOWS: PATIENTS WITH INCOME BETWEEN 200% AND 250% OF THE FPL ARE ELIGIBLE FOR A 75% WRITE-OFF; PATIENTS WITH INCOME BETWEEN 250% AND 300% OF THE FPL ARE ELIGIBLE FOR A 50% WRITE-OFF; AND PATIENTS WITH INCOME BETWEEN 300% AND 350% OF THE FPT ARE ELIGIBLE FOR A 30% WRITE-OFF. PART II, COMMUNITY BUILDING ACTIVITIES: COMMUNITY BUILDING ACTIVITIES.THE HOSPITAL GIVES BACK THROUGH FINANCIAL AND EDUCATIONAL EFFORTS AND THROUGH VOLUNTEERING, AWARENESS INITIATIVES AND SUPPORT GROUPS. SOME OF THE MANY COMMUNITY EDUCATION PROGRAMS FOR CHILDREN AND ADULTS INCLUDE: PRENATAL EDUCATION, ACLS, CPR, AND FIRST AID TRAINING, DIABETES EDUCATION, SMOKING CESSATION AND WEIGHT MANAGEMENT. SOME OF THE COMMUNITY OUTREACH ACTIVITIES INCLUDE INVOLVEMENT IN: COMMUNITY AND WORKPLACE HEALTH & WELLNESS FAIRS, PRESENTATIONS TO COMMUNITY GROUPS, SPORTS PHYSICALS, ORGAN DONATION, AND EMS STANDBY FOR MULTIPLE PUBLIC EVENTS. MANY OF THE PROGRAMS FINANCIALLY SUPPORTED PROVIDE INCREASED OPPORTUNITIES TO HELP PARTICIPANTS BE PHYSICALLY ACTIVE AND HEALTHY. PART III, LINE 2: SECTION A. BAD DEBT EXPENSE. METHOD FOR ESTIMATING BAD DEBT EXPENSE AMOUNT ON PART III, LINE 2: HOSPITAL MANAGEMENT ANALYZES PAST HISTORY AND IDENTIFIES TRENDS FOR EACH MAJOR PAYER SOURCE OF REVENUE TO ESTIMATE THE APPROPRIATE ALLOWANCE FOR DOUBTFUL ACCOUNTS AND PROVISION FOR BAD DEBT EXPENSE. ACCOUNTS ARE CONSIDERED DELINQUENT AND SUBSEQUENTLY WRITTEN OFF AS BAD DEBTS BASED ON INDIVIDUAL CREDIT EVALUATION AND SPECIFIC CIRCUMSTANCES OF THE ACCOUNT. THE ESTIMATED AMOUNT OF THE HOSPITAL'S BAD DEBT EXPENSE (AT COST) ATTRIBUTABLE TO PATIENTS THAT MIGHT HAVE BEEN ELIGIBLE UNDER THE HOSPITAL'S CHARITY CARE POLICY WAS DETERMINED BY COMPUTING A PERCENTAGE OF DOLLAR AMOUNT TOTALS OF ACCOUNTS APPROVED FOR ASSISTANCE TO TOTAL APPLICATIONS AND THEN APPLIED THE PERCENTAGE TO THE APPLICATIONS THAT WERE DENIED DUE TO INCOMPLETE INFORMATION TO COME UP WITH AN ESTIMATE OF WHAT WOULD HAVE QUALIFIED IF THE INFORMATION HAD BEEN RECEIVED. THE RATIONALE BEING THAT HAD THE INFORMATION BEEN RECEIVED, THOSE ACCOUNTS WOULD HAVE BEEN APPROVED. PART III, LINE 3: EXPLANATION FOR RATIONAL FOR INCLUDING OTHER BAD DEBT AMOUNT IN COMMUNITY BENEFIT ON PART III, LINE 3: NO OTHER BAD DEBT AMOUNTS HAVE BEEN INCLUDED AS COMMUNITY BENEFIT. THE HOSPITAL HAS A DETAILED FINANCIAL ASSISTANCE POLICY. IN ADDITION, THE HOSPITAL EDUCATES PATIENTS WITH LIMITED ABILITY TO PAY REGARDING FINANCIAL ASSISTANCE. FOR THIS REASON, THE ORGANIZATION BELIEVES IT ACCURATELY CAPTURES ALL CHARITY CARE DEDUCTIONS PROVIDED ACCORDING TO THE FINANCIAL ASSISTANCE POLICY AND THE AMOUNT OF BAD DEBT EXPENSE ATTRIBUTABLE TO PATIENTS ELIGIBLE UNDER THE ORGANIZATION'S CHARITY CARE POLICY IS NEGLIGIBLE. PART III, LINE 4: THE TEXT TO THE AUDITED FINANCIAL STATEMENT FOOTNOTE DESCRIBING BAD DEBT EXPENSE AND ITS PRESENTATION IS INCLUDED IN FOOTNOTE 1 "PATIENT ACCOUNTS RECEIVABLE" ON PAGES 8. PART III, LINE 8: THE SOURCE USED TO DETERMINE THE AMOUNT OF MEDICARE ALLOWABLE COSTS REPORTED FOR PART III, SECTION B, MEDICARE HAS BEEN PROVIDED FROM THE YEAR ENDED SEPTEMBER 30, 2015: HOSPITAL STATEMENT OF REIMBURSABLE COST PART III, LINE 9B: THE HOSPITAL'S COLLECTION PRACTICES FOR THOSE QUALIFYING FOR FINANCIAL ASSISTANCE INCLUDE: (1) DESIGNATING THE ACCOUNTS QUALIFYING FOR FINANCIAL ASSISTANCE IN THE ACCOUNTS RECEIVABLE SYSTEM AS CHARITY CARE; (2)EXCLUDING THE ACCOUNTS FROM BAD DEBT WRITE OFFS; AND (3) EXCLUDING THE ACCOUNTS FROM BEING REPORTED TO ANY COLLECTION AGENCIES. PART VI, LINE 2: ASSESSING COMMUNITY NEED.THE HOSPITAL ASSESSES THE HEALTH CARE NEEDS OF THE COMMUNITY THROUGH PERIODIC FOCUS GROUP SURVEYS BY OUTSIDE CONSULTANTS WHICH ARE PREPARED EVERY 3 YEARS TO ASSESS THE NEEDS OF THE COMMUNITY. THESE SURVEYS INCLUDE INPUT FROM INDIVIDUALS, HEALTH PROFESSIONALS, GOVERNMENTAL HEALTH CARE OFFICIALS AS WELL AS REPRESENTATIVES FROM DEKALB HOSPITAL. THE SURVEY SOLICITS INPUT ON THE HEALTH CARE NEEDS INCLUDING OBESITY, PREVENTIVE MEDICINE, VACCINATIONS, CARDIOVASCULAR, ETC. THESE NEEDS AND CONCERNS ARE EVALUATED AND APPROPRIATE PLANS ARE PUT INTO ACTION TO DEAL WITH THE MOST PRESSING ISSUES. CUSTOMER SATISFACTION SURVEYS ARE ALSO USED TO IDENTIFY UNMET HEALTHCARE NEEDS OF THE COMMUNITY.RECENTLY, IN THE FALL OF 2012, IPFW CENTER FOR SOCIAL RESEARCH FINALIZED AND REPORTED ON THE COMMUNITY HEALTH NEEDS ASSESSMENT THEY CONDUCTED ON BEHALF OF THE DEKALB COUNTY HEALTH DEPARTMENT AND DEKALB HEALTH. THIS SURVEY IS A TOOL THE HOSPITAL IS USING AS ONE OF THE KEY COMPONENETS FOR COMMUNITY OUTREACH STRATEGIES. THIS SURVEY IN ADDITION TO FEEBACK RECEIVED FROM KEY CONSTITUENTS I.E. THE UNITED WAY OF DEKALB COUNTY, COMMUNITY FOUNDATION OF DEKALB COUNTY, CHILDREN FIRST CENTER, PURDUE EXTENSION OFFICE, SCHOOLS, PHYSICIAN OFFICES, HOSPITAL DEPARTMENT MANAGERS, AND OTHERS HELPED TO IDENTIFY THE HEALTH CARE NEEDS OF THE COMMUNITY. PART VI, LINE 3: PATIENT EDUCATION OF ASSISTANCE ELIGIBILITY.PATIENTS ARE PROVIDED INFORMATION REGARDING THE CHARITY CARE POLICIES WHEN ADMITTED TO DEKALB HOSPITAL. FINANCIAL AID GUIDELINES ARE ALSO INCLUDED WITH THE BILLING STATEMENTS. SIGNS OUTLINING THE FINANCIAL AID POLICIES AND APPLICATIONS ARE ALSO LOCATED IN NUMEROUS AREAS THROUGHOUT THE HOSPITAL. ALL NON-INSURED PATIENTS ARE STRONGLY ENCOURAGED TO MEET WITH A FINANCIAL COUNSELOR TO REVIEW ALL OPTIONS AVAILABLE TO THEM INCLUDING MEDICARE, MEDICAID, CHARITY CARE, LOAN AND PAYMENT PROGRAMS. DEKALB HOSPITAL STAFF WILLINGLY ASSIST PATIENTS WITH QUALIFICATION CRITERIA AND COMPLETION OF APPLICATIONS FOR SUCH PROGRAMS, WHERE APPLICABLE. PART VI, LINE 4: COMMUNITY DESCRIPTION.DEKALB MEMORIAL HOSPITAL IS THE SOLE COMMUNITY HOSPITAL LOCATED IN DEKALB COUNTY, SERVING DEKALB, PORTIONS OF STEUBEN, LAGRANGE, NOBLE, AND ALLEN COUNTIES IN ADDITION TO SEVERAL BORDER TOWNS OF HICKSVILLE AND EDGERTON IN NORTHWEST OHIO. THE PRIMARY SERVICE AREA POPULATION OF DEKALB MEMORIAL HOSPITAL IS APPROXIMATELY 42,000 WITH APPROXIMATELY 98% RECORDED AS WHITE. DEKALB HAS SEEN AN INCREASE IN THE UNINSURED AND UNDERINSURED WITH A REPORTED AMOUNT OF 12.1% OF RESIDENTS LIVING BELOW THE POVERTY LEVEL. THE DEMOGRAPHIC AREA SERVED BY DEKALB MEMORIAL HOSPITAL IS MADE UP OF A MEDIAN HOUSEHOLD INCOME OF APPROXIMATELY $46,000, THE MEDIAN AGE IS 38 AND CONTAINS PRIMARILY A BLUE COLLAR AND AGRICULTURAL WORKFORCE. PART VI, LINE 5: COMMUNITY HEALTH PROMOTION.THE ORGANIZATION FURTHERS ITS EXEMPT PURPOSE BY PROMOTING HEALTH OF THE COMMUNITY THROUGH THE FOLLOWING: AN OPEN MEDICAL STAFF, CORPORATE BOARD MADE UP OF 30 COMMUNITY MEMBERS THAT SELECT THE BOARD OF DIRECTORS, AND THE USE OF SURPLUS FUNDS TO PROVIDE HIGH QUALITY HEALTHCARE SERVICES TO THE CITIZENS RESIDING IN ITS SERVICE AREAIN ADDITION, MANY OF THE HOSPITAL'S MANAGERS AND STAFF DONATE THEIR TIME TO SUPPORT ST. MARTIN'S HEALTHCARE CLINIC (FOR UNINSURED) AS WELL AS SERVE ON UNITED WAY, CHAMBER OF COMMERCE, ECONOMIC DEVELOPMENT BOARDS, AND JUNIOR ACHIEVEMENT. NONPERISHABLE FOOD ITEMS THAT ARE LEFT OVER AFTER THE HEATLHY HALLOWEEN FAIR AND/OR PLAY-LEARN-SOAR ARE DONATED TO A LOCAL FOOD BANK OR BOOMERANG BACKPACK PROGRAM. PART VI, LINE 6: AFFILIATED HEALTH CARE SYSTEM.THE ORGANIZATNION IS NOT PART OF AN AFFILIATED HEALTH CARE SYSTEM. PART VI, LINE 7, REPORTS FILED WITH STATES IN 1 YMCA 310 N MAIN STREET AUBURN IN 46706 350868958 501C3 145000 PROGRAM SUPPORT FORT WAYNE MEDICAL EDUCATION PROGRAM 50 BROADWAY FORT WAYNE IN 46802 356049685 501C3 25000 PROGRAM SUPPORT DEKALB COUNTY ECONOMIC DEVELOPMENT PARTNERS 4483 COUNTY ROAD 19 AUBURN IN 46706 364577514 501C3 10000 COMMUNITY SUPPORT NORTHEAST INDIANA REGIONAL PARTNERSHIP 200 E MAIN STREET FORT WAYNE IN 46802 351984702 501C6 10000 PROGRAM SUPPORT REGIONAL CHAMBER OF NORTHEAST INDIANA 6714 POINTE INVERNESS WAY FORT WAYNE IN 46804 311222476 501C6 75000 STUDENT LEADERSHIP PROGRAM UNITED WAY OF DEKALB COUNTY PO BOX 307 AUBURN IN 46706 351065714 501C3 10000 PROGRAM SUPPORT DEKALB CHAMBER PARTNERSHIP 208 S JACKSON ST AUBURN IN 46706 350154290 501C3 5000 PROGRAM SUPPORT DEKALB COUNTY HEALTH DEPARTMENT 220 E SEVENTH ST AUBURN IN 46706 GOV'T 34565 COST FLU MIST VACINES PROGRAM SUPPORT 4 3 PART I, LINE 2: THE AMOUNT OF ASSISTANCE LISTED IN PART II ARE GENERAL CONTRIBUTIONS FOR GENERAL PROGRAM SUPPORT. THE HOSPITAL DOES NOT MONITOR THE USE OF FUNDS ONCE DISTRIBUTED TO THESE ORGANIZATIONS. 0 0 0 0 0 0 0 0 0 FRED PRICE CEO (OCT'14-JAN'15) 262326 0 18360 0 828 0 12567 0 29103 0 323184 0 0 0 EMILIO VAZQUEZ CMO/ INTERIM CEO (FEB-JUL'15) 269137 0 58505 0 3240 0 13000 0 0 0 343882 0 0 0 AMY CROUCH CFO (OCT'14-JAN'15) 166517 0 0 0 4004 0 8224 0 0 0 178745 0 0 0 KENNETH CHAFFEE PHYSICIAN 340655 0 0 0 2376 0 13000 0 18052 0 374083 0 0 0 PHILIP CHASE PHYSICIAN 340655 0 0 0 1548 0 13000 0 46424 0 401627 0 0 0 BRET KUEBER PHYSICIAN 233335 0 104978 0 540 0 13000 0 25390 0 377243 0 0 0 SCOTT ARMSTRONG PHYSICIAN 260371 0 51764 0 6266 0 13000 0 30230 0 361631 0 0 0 RICHARD TOUPIN PHYSICIAN 264415 0 36294 0 10135 0 13000 0 25493 0 349337 0 0 0 FORM 990, PART I, DOING BUSINESS AS: DEKALB HEALTH DEKALB HEALTH HOME CARE DEKALB HEALTH HOSPICE DEKALB HEALTH MEDICAL GROUP DEKALB HEALTH MEDICAL GROUP - BUTLER DEKALB HEALTH MEDICAL GROUP - GARRETT DEKALB HEALTH MEDICAL GROUP - ARMSTRONG DEKALB HEALTH MEDICAL GROUP - PEDIATRICS FORM 990, PART VI, SECTION A, LINE 6 THE ORGANIZATION HAS CORPORATE BOARD MEMBERS CONSISTING OF 30 COMMUNITY MEMBERS. FORM 990, PART VI, SECTION A, LINE 7A THE ORANIZATION HAS CORPORATE BOARD MEMBERS CONSISTING OF 30 COMMUNITY MEMBERS. FOURTEEN MEMBERS WERE ELECTED BY THE CORPORATE BOARD AND SERVED AS THE ORGANIZATIONS GOVERNING BODY DURING FISCAL YEAR 2015. FORM 990, PART VI, SECTION A, LINE 7B NOMINATIONS AND APPROVAL FOR VACANCIES ON THE GOVERNING BOARD ARE SUBJECT TO APPROVAL BY CORPORATE MEMBERS. ALL BUSINESS DECISIONS OF THE GOVERNING BODY ARE RATIFIED BY ANNUAL RESOLUTION OF THE CORPORATE BOARD. FORM 990, PART VI, SECTION B, LINE 11 THE 990 PROCESS INCLUDES A DETAIL REVIEW BY THE ACCOUNTING MANAGER, CHIEF FINANCIAL OFFICER AND CHIEF EXECUTIVE OFFICER. A COPY OF THE FORM 990 IS PROVIDED TO THE AUDIT AND FINANCE COMMITTEE FOR REVIEW. A REPORT OF THE COMMITTEE'S REVIEW AND COPY OF THE FORM 990 INCLUDING REQUESTED SCHEDULES, AS ULTIMATELY FILED WITH THE IRS, ARE PROVIDED TO THE BOARD OF DIRECTORS PRIOR TO FILING WITH THE IRS. FORM 990, PART VI, SECTION B, LINE 12C THE CONFLICT OF INTEREST STATEMENTS ARE COMPLETED ANNUALLY BY ALL BOARD MEMBERS AND STAFF. THE ANNUAL STATEMENTS ARE REVIEWED BY THE BOARD CHAIR. WHEN CONDUCTING ORGANIZATION BUSINESS AND A CONFLICT ARISES, THE BOARD OR STAFF MEMBER INVOLVED ABSTAINS FROM VOTING ON RELATED MATTERS. DOCUMENTATION ON THIS MATTER IS KEPT IN THE BOARD MINUTES. FORM 990, PART VI, SECTION B, LINE 15 AN INDEPENDENT COMPENSATION COMMITTEE, A SUB-COMMITTEE OF THE BOARD, REVIEWS AND APPROVES THE COMPENSATION OF THE CHIEF EXECUTIVE OFFICER, CHIEF FINANCIAL OFFICER AND OTHER KEY EMPLOYEES; THIRD PARTY AND MARKET DATA ARE UTILIZED AS COMPARABLE DATA; AND, DELIBERATION OF THESE DECISIONS ARE DOCUMENTED IN THE COMMITTEE'S MINUTES. FORM 990, PART VI, SECTION C, LINE 19 THE CONFLICT OF INTEREST POLICY, GOVERNING DOCUMENTS, AND FINANCIAL STATEMENTS ARE AVAILABLE UPON REQUEST. IN ADDITION, THE ARTICLES OF INCORPORATION CAN BE VIEWED ON THE WEBSITE FOR THE INDIANA SECRETARY OF STATE AND THE MOST CURRENT FINANCIAL STATEMENTS ARE ATTACHED TO THIS FORM 990. FORM 990, PART XI, LINE 9: CHANGE IN FAIR VALUE OF INTEREST RATE SWAP AGREEMENT -320,952. FORM 990, PART XII, LINE 2C, OVERSIGHT OF AUDIT: THE AUDIT COMMITTEE ASSUMES RESPONSIBILITY FOR OVERSIGHT OF THE AUDIT OF THE FINANCIAL STATEMENTS AND SELECTION OF THE INDEPENDENT ACCOUNTANT; AND NO PROCESSES HAVE CHANGED FROM PRIOR YEAR. DEKALB MEMORIAL PHARMACARE LLC 1314 E 7TH STREET AUBURN IN 46706 273514342 RETAIL PHARMACY IN 104860 528054 DEKALB MEMORIAL HOSPITAL DEKALB COMM HOSPITAL FOUNDATION 212 WEST 7TH STREET AUBURN IN 46706 356047817 FOUNDATION IN 501(C)3 LINE 11 DEKALB MEMORIAL HOSPITAL 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0