2014-05-14T16:04:50-05:00 2013-06-30 381357951 PLANTE & MORAN PLLC 65 EAST STATE ST STE 600 COLUMBUS OH 43215 990 2012-07-01 311045101 APPALACHIAN COMMUNITY VISITING NURSE ASSOCIATION HOSPICE AND HEALTH SERVICES APPA 7405935551 30 HERROLD AVENUE ATHENS OH 457012326 KEN DICKEN 7405935551 2014-05-14 1 BERNIE OSTROWSKI P00366367 6148493000 2012 2015-11-30 17:44:51Z GREG LONG 30 HERROLD AVENUE ATHENS OH 457012326 3602544 0 X WWW.ACVNA.ORG X 1982 OH WE ARE DEDICATED TO PROVIDING COST EFFECTIVE, HIGH QUALITY HOME HEALTH SERVICES TO THE PEOPLE IN OUR APPALACHIAN COMMUNITY. WE PROVIDE SERVICES TO MEDICAID CLIENTS THROUGH OHIO HOME CARE PROGRAMS AS WELL AS FOR CLIENTS WITH WORKERS' COMPENSATION, VETERAN'S ADMINISTRATION, MEDICARE AND OTHER PAYOR SOURCES. 3 2 104 48 0 0 99056 85108 3674576 3515715 2694 1721 0 0 3776326 3602544 0 0 0 0 2684106 2632504 0 0 5053 1231929 1214931 3916035 3847435 -139709 -244891 950851 958141 462839 649648 488012 308493 WE ARE SOUTHEASTERN OHIO'S PRIMARY SOURCE FOR QUALITY HOME CARE, STRIVING TO IDENTIFY AND FULFILL THE HEALTHCARE NEEDS OF OUR APPALACHIAN COMMUNITY. 0 0 3450657 0 3515715 THE ORGANIZATION PROVIDES CARE TO HOME BOUND, INDIGENT, AND TERMINALLY-ILL PATIENTS IN THE COMMUNITY. THE ORGANIZATION PROVIDES CARE TO PATIENTS WHO MEET CERTAIN CRITERIA UNDER ITS CHARITY CARE POLICY WITHOUT CHARGE OR AT AMOUNTS LESS THAN ITS ESTABLISHED RATES. TO ACCOMPLISH ITS CHARITABLE PURPOSE, THE ORGANIZATION PROVIDED 8,011 DAYS OF HOSPICE CARE, 30,184 HOURS OF HEALTH SERVICES AND 12,385 HOME HEALTH VISITS. 3450657 1 1 0 0 0 0 0 0 0 1 1 1 0 0 1 1 0 1 0 0 0 0 0 0 0 0 0 0 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 1 1 1 0 0 1 9 0 1 104 1 0 0 0 0 0 0 0 0 0 0 X 3 2 0 1 0 0 1 1 1 1 1 0 0 0 1 1 1 1 1 1 0 0 OH X KEN DICKEN 7405929298 55 HOSPITAL DRIVE ATHENS OH 45701 JAN HODSON 1.00 0.00 X 0 0 0 SUSAN CYRAN 1.00 0.00 X 0 0 0 RON STRICKMAKER 1.00 0.00 X 0 0 0 DAVID STROH 1.00 0.00 X X 0 0 0 MICHAEL TURNER 1.00 0.00 X X 0 0 0 KATHY TARANTELLI 1.00 0.00 X 0 0 0 RUTH ANN ALTHAUS 1.00 0.00 X X 0 0 0 DOREEN IRETON 1.00 0.00 X 0 0 0 SANDRA SHIREY 1.00 0.00 X 0 0 0 RAY STEPHENS 1.00 0.00 X X 0 0 0 CANDY KEMMERER 1.00 0.00 X 0 0 0 GREG LONG 40.00 0.00 X X 0 0 0 TERRI MCKINLEY 40.00 0.00 X 55355 0 0 THOMAS CAMPBELL 40.00 0.00 X 160156 0 0 215511 0 0 1 0 1 0 0 85108 85108 PATIENT SERVICES 621610 3515715 3515715 3515715 1721 1721 3602544 3515715 0 1721 64802 57512 7290 2163427 1920042 243385 40291 35859 4432 202312 179552 22760 161672 143484 18188 3122 3122 113781 100980 12801 11978 10630 1348 363642 322732 40910 7454 6616 838 87315 77492 9823 198947 176566 22381 2693 2390 303 1702 1511 191 28132 24967 3165 HOSPICE ROOM & BOARD 318674 318674 EMERGENCY RESPONSE SYST 64469 64469 TRAINING & CONT. EDUC./ 5506 4956 550 FUNDRAISING MAILING 5053 5053 2463 2225 238 3847435 3450657 391725 5053 35094 141587 712760 561379 11521 29853 34406 834548 831991 4258 2557 157365 187382 0 30830 950851 958141 362839 414648 100000 235000 462839 649648 X 331052 122372 156960 186121 488012 308493 950851 958141 X -244891 -2 65374 X X 0 1 X 1 0 X 153022 230286 133112 99056 85108 700584 3540437 3901744 3758424 3747453 3515715 18463773 3693459 4132030 3891536 3846509 3600823 19164357 0 231042 231042 231042 231042 18933315 2425 2100 2286 2694 1721 11226 2425 2100 2286 2694 1721 11226 3695884 4134130 3893822 3849203 3602544 19175583 0.98740 0.99940 0.00060 0.00060 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 159228 30017 189245 2261 156967 159228 2259 2 2261 2257 2 2259 2251 6 2257 1.00000 1 0 834548 831991 2557 2557 BOARD DESIGNATED INVESTMENTS 79030 C TEMPORARILY RESTRICTED GRANTS 108352 C 187382 SHELTERING ARMS HOSPITAL FOUNDATION LOAN PAYABLE 235000 235000 X DESCRIPTION OF INTENDED USE OF ENDOWMENT FUNDS: PART V, LINE 4: THE ENDOWMENTS ARE INTENDED FOR THE SUPPORT OF THE ORGANIZATION'S HEALTHCARE ACTIVITIES. DESCRIPTION OF UNCERTAIN TAX POSITIONS UNDER FIN 48: PART X, LINE 2: ACCOUNTING PRINCIPLES GENERALLY ACCEPTED IN THE UNITED STATES OF AMERICA REQUIRE MANAGEMENT TO EVALUATE TAX POSITIONS TAKEN BY THE HOSPITAL AND RECOGNIZE A TAX LIABILITY IF THE HOSPITAL HAS TAKEN AN UNCERTAIN POSITION THAT MORE LIKELY THAN NOT WOULD NOT BE SUSTAINED UPON EXAMINATION BY THE IRS OR OTHER APPLICABLE TAXING AUTHORITIES. MANAGEMENT HAS ANALYZED THE TAX POSITIONS TAKEN BY THE HOSPITAL AND HAS CONCLUDED THAT AS OF JUNE 30, 2013, THERE ARE NO UNCERTAIN POSITIONS TAKEN OR EXPECTED TO BE TAKEN THAT WOULD REQUIRE RECOGNITION OF A LIABILITY OR DISCLOSURE IN THE FINANCIAL STATEMENTS. THE HOSPITAL IS SUBJECT TO ROUTINE AUDITS BY TAXING JURISDICTIONS; HOWEVER, THERE ARE CURRENTLY NO AUDITS FOR ANY TAX PERIODS IN PROGRESS. MANAGEMENT BELIEVES IT IS NO LONGER SUBJECT TO INCOME TAX EXAMINATIONS FOR YEARS PRIOR TO JUNE 30, 2009. 0 0 0 0 0 0 0 0 0 THOMAS CAMPBELL 160156 0 0 0 0 0 0 0 0 0 160156 0 0 0 PART I, LINE 3 THE CEO IS COMPENSATED THROUGH AN UNRELATED MANAGEMENT COMPANY, OHIOHEALTH HOSPITAL MANAGEMENT SERVICES, LLC. THE CONTRACT WITH THE MANAGEMENT COMPANY IS REVIEWED AND APPROVED BY THE BOARD. THE COMPENSATION FOR THE CEO IS REVIEWED AND APPROVED BY THE MANAGEMENT COMPANY. FORM 990, PART VI, SECTION A, LINE 3 THE ORGANIZATION ENTERED INTO A MANAGEMENT AGREEMENT WITH HOMEREACH, AN OHIO NOT-FOR-PROFIT CORPORATION, EFFECTIVE NOVEMBER 6, 2012 AND EXPIRING SEPTEMBER 30, 2014. HOMEREACH IS A WHOLLY OWNED SUBSIDIARY OF OHIOHEALTH CORPORATION, AN OHIO NONPROFIT CORPORATION THAT IS EXEMPT FROM FEDERAL INCOME TAX UNDER SECTION 501(C)(3). THE MANAGEMENT AGREEMENT REQUIRES THE MANAGEMENT COMPANY TO PERFORM MANAGEMENT SERVICES AND OVERSIGHT OF DAILY OPERATIONS,IT AND SUPPORT SERVICES, BILLING AND COLLECTION SERVICES, AND COMPLIANCE WITH LAWS AND REGULATIONS. FORM 990, PART VI, SECTION A, LINE 6 SHELTERING ARMS HOSPITAL FOUNDATION, INC. D/B/A O'BLENESS MEMORIAL HOSPITAL IS THE SOLE MEMBER OF THE ORGANIZATION. FORM 990, PART VI, SECTION A, LINE 7A THE SOLE MEMBER HAS THE RIGHT TO ELECT OR APPOINT MEMBERS OF THE GOVERNING BODY. FORM 990, PART VI, SECTION A, LINE 7B GOVERNANCE DECISIONS OF THE ORGANIZATION, SUCH AS APPROVAL OF THE ELECTION OR REMOVAL OF MEMBERS OF THE GOVERNING BODY AND DECISIONS TO DISSOLVE, ARE RESERVED FOR THE SOLE MEMBER. FORM 990, PART VI, SECTION B, LINE 11 THE FORM 990 WILL NOT BE REVIEWED BY THE BOARD. THE FORM IS REVIEWED BY AN OFFICER OF THE ORGANIZATION BEFORE FILING. FORM 990, PART VI, SECTION B, LINE 12C ANNUAL CONFLICTS OF INTEREST SURVEYS (OR QUESTIONNAIRES) ARE COMPLETED AND SIGNED BY BOARD MEMBERS. CONFLICTS THAT ARISE THROUGHOUT THE YEAR ARE TO BE DISCLOSED TO THE BOARD AND NECESSARY ACTION WILL BE DETERMINED BY THE BOARD. POSSIBLE RESOLUTION COULD INCLUDE RESTRICTIONS ON VOTING AND PARTICIPATION OF ORGANIZATION BUSINESS BEFORE THE BOARD. FORM 990, PART VI, SECTION B, LINE 15A COMPENSATION FOR THE DIRECTOR IS REVIEWED BY AN EVALUATION COMMITTEE APPOINTED BY THE BOARD AND IS NEGOTIATED DURING THIS REVIEW. THIS EVALUATION IS PERFORMED ANNUALLY. THE LAST EVALUATION WAS IN 2013. THERE ARE NO OTHER OFFICERS OR KEY EMPLOYEES THAT ARE COMPENSATED BY THE ORGANIZATION. FORM 990, PART VI, SECTION C, LINE 19 IF REQUESTS ARE MADE FROM THE PUBLIC TO VIEW THE ORGANIZATION'S GOVERNING DOCUMENTS, THE ORGANIZATION COMPLIES WITH THE IRS PUBLIC INSPECTION REQUIREMENTS FOR FORM 990, FORM 990-T, FORM 1023, GOVERNING DOCUMENTS, CONFLICT OF INTEREST POLICY, AND FINANCIAL STATEMENTS. REQUESTS FROM THE PUBLIC FOR ANY OTHER DOCUMENTS MUST BE IN WRITING AND LEGAL COUNSEL ENSURES COMPLIANCE AS REQUIRED. CHANGES IN NET ASSETS OR FUND BALANCES: FORM 990, PART XI, LINE 9: NET ASSETS RELEASED FROM RESTRICTION 36,213. TEMPORARILY RESTRICTED NET ASSETS RECLASS FROM OPERATING CASH ACCOUNT 29,161. FORM 990, PART XII, LINE 2C THE AUDIT IS OVERSEEN BY A COMMITTEE OF THE SHELTERING ARMS HOSPITAL FOUNDATION AND THIS HAS NOT CHANGED SINCE THE PRIOR YEAR. SHELTERING ARMS HOSPITAL FOUNDATION 55 HOSPITAL DRIVE ATHENS OH 45701 314446959 PATIENT CARE OH 501(C)(3) HOSPITAL N/A 0 ATHENS SURGERY CENTER LTD 75 HOSPITAL DRIVE ATHENS OH 45701 550840856 OUTPATIENT SURGERY OH N/A O'BLENESS MEMORIAL PAIN MANAGEMENT CLINIC LLC 55 HOSPITAL DRIVE ATHENS OH 45701 454587317 PAIN CLINIC OH N/A ATHENS MEDICAL LABORATORY ASSOCIATES INC 265 WEST UNION STREET SUITE B ATHENS OH 45701 311381808 MEDICAL LABORATORY OH N/A S 0 0 0 0 0 1 0 0 0 0 1 0 0 1 0 0 1 0 1 0 SHELTERING ARMS HOSPITAL FOUNDATION J 67200 LEASE AGREEMENT SHELTERING ARMS HOSPITAL FOUNDATION E 235000 LOAN AGREEMENT