2014-11-17T14:34:51-06:00 2013-12-31 310800053 Clark Schaefer Hackett & Co 10100 Innovation Drive Suite 400 Dayton OH 45342 990 2013-01-01 270712680 Beavercreek Medical Center BEAV 9373844550 2110 Leiter Road Miamisburg OH 45342 Clifton Patten KHN CFO 9373844550 2014-11-10 1 Herbert L Lemaster CPA P00039882 9372260070 2014-11-10 2013 2015-11-30 17:44:51Z The Indu and Raj Soin Medical Center Terry Burns 2110 Leiter Road Miamisburg OH 45342 75127567 0 X www.khnetwork.org X 2009 OH Provide quality healthcare to individuals and the community as a whole in a Judeo-Christian manner 12 6 0 188 0 0 14230 17107 31892630 74741484 195183 334471 0 0 32102043 75093062 0 9957 0 0 23145945 35316856 0 0 0 37041551 48584835 60187496 83911648 -28085453 -8818586 168211497 170025883 106541394 107382171 61670103 62643712 Provide quality healthcare to individuals and the community as a whole in a Judeo-Christian manner 0 0 72295861 9957 74307214 Care was provided for 4,161 discharges, adult & ped days of 14,544, and 45,893 outpatient visits. 72295861 1 1 0 0 0 0 0 0 0 0 1 0 0 0 1 1 0 1 0 0 0 0 0 0 0 0 1 1 0 1 1 1 0 0 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 X 12 6 0 0 0 0 0 0 0 1 1 0 0 1 1 1 1 1 1 1 1 0 X X CLIFTON PATTEN 9373844550 2110 LEITER ROAD MIAMISBURG OH 45342 Fred Manchur KHN CEO 1.00 39.00 X 0 1502051 1097514 Terri Day KHN President 1.00 39.00 X 0 1099707 1010230 Terry Burns Senior VP GMH/SOIN 40.00 X X 0 518583 43262 David Weigley Pres. Columbia Union Conference of SDA 1.00 X 0 0 0 Raj Attiken President, Ohio Conference of SDAs 1.00 X 0 0 0 Donald Harting Community Volunteer 1.00 X 0 0 0 Michael McCullough MD Physician 1.00 X 0 0 0 Thomas Peebles Community Volunteer 1.00 X 0 0 0 Phillip Parker Pres. Dayton Chamber of Commerce 1.00 X 0 0 0 Amol Soin MD Physician 1.00 X 0 0 0 Troy Tyner DO Physician 1.00 X 0 0 0 Stephen Zimmer Community Volunteer 1.00 X 0 0 0 Ronald Connovich GMH/SOIN VP of Finance & O 40.00 X 0 291696 29531 Belinda Mallett GMH/SOIN VP of Patient Car 40.00 X 0 281598 29184 James Porter Director - Facility 40.00 X 0 145321 18448 Jill Hope Pharmacist 40.00 X 0 135214 22107 Peggy Doyle Director of Nursing 40.00 X 0 124625 12178 Tim Garrity Pharmacist 40.00 X 0 124263 12074 Andrew Cain Pharmacist 40.00 X 0 123751 12076 Mark Smith FHH President beginning 6-2013 0.00 X 0 441936 38021 Greg Henderson Former Director & Officer 0.00 X 0 372572 11900 Tim Ko Former Officer 0.00 X 0 296713 27866 Steve Chavez Former Officer 0.00 X 0 277473 24137 0 5735503 2388528 0 1 1 0 0 17107 17107 Patient care services 622000 74741484 74307214 434270 74741484 191161 191161 144315 33500 0 34505 144315 -1005 143310 143310 75093062 74307214 0 768741 9957 9957 1043552 1043552 27131153 23603106 3528047 1141383 992961 148422 4311592 3750927 560665 1689176 1469521 219655 509353 509353 59202 8382 50820 1620 1620 5969735 4195263 1774472 310387 5789 304598 1428904 1374155 54749 997839 104227 893612 142158 128970 13188 71159 64441 6718 61050 60233 817 8798117 7981921 816196 12318819 11176009 1142810 488518 430611 57907 Medical supplies 12880322 12868728 11594 Physician services 3221371 3221371 Cost of goods sold 455943 455943 Minor equipment 307563 286975 20588 562775 106371 456404 83911648 72295861 11615787 0 6124841 8113463 1446264 1618629 57567 210463 166407075 19578777 147345175 146828298 11849333 11937635 1388317 1317395 168211497 170025883 7856450 8118493 98218510 98309517 466434 954161 106541394 107382171 X 61095103 62068712 575000 575000 61670103 62643712 168211497 170025883 X -8818586 -102756 9894951 X X 0 1 X 1 0 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 130385570 10131742 120253828 35151986 9447035 25704951 869519 869519 146828298 Estimated amounts due to third-party payors -98912 Professional self-insurance liability 1053073 954161 X Part X, Line 2: The Network completed an analysis of its tax positions in accordance with applicable accounting guidance and determined that no amounts were required to be recognized in the consolidated financial statements at December 31, 2013 or 2012. 1 1 X 1 X 1 X 1 1 0 1 1 5809384 0 5809384 0.06920 15126097 6617172 8508925 0.10140 20935481 6617172 14318309 0.17060 1209328 126609 1082719 0.01290 150310 150310 0.00180 1359638 126609 1233029 0.01470 22295119 6743781 15551338 0.18530 1 1223620 29367 16051980 19124263 -3072283 X 1 1 1 1 Beavercreek Medical Center 3535 Pentagon Boulevard Beavercreek OH 45431 ketteringhealth.org/soin/ X X X Beavercreek Medical Center 1 1 X X X X X X X X X 13 1 1 1 X http://www.ketteringhealth.org/aboutus X X X X X 1 0 1 1 100.000000000000 1 300.000000000000 1 X X X X X X 1 1 X X X X X X 1 0 X X X 1 X 0 1 Part V, Section A: The facility listed is required to be licensed, registered, or recognized as a healthcare facility under state law. Beavercreek Medical Center Part V, Section B, Line 3: Partners in the data review process and in the process for identifying and prioritizing community health needs and services are the Board of Trustees and executive leadership of Soin Medical Center, community health collaboratives featuring community, health, and business stakeholders/advocates organized by both Soin Medical Center, and the Greater Dayton Area Hospital Association with its member hospitals. These partners were consulted through the use of focus groups.To prepare the CHNA, primary and secondary data were collected in order to paint a detailed picture of the Soin Medical Center Service Area. Primary data is collected directly from first-hand experience and secondary data is data that has already been collected and archived by other organizations.For Soin's Community Health Needs Assessment, primary data were collected by surveying 975 Greene County adults using the Centers for Disease Control and Prevention's Behavioral Risk Factor Surveillance System (BRFSS). Secondary data were collected from sources such as the Ohio Hospital Association via the Greater Dayton Area Hospital Association, the Ohio Department of Health, the Health Resources and Services Administration(HRSA), the Bureau of the Census, and the Robert Wood Johnson Foundation, among others. Beavercreek Medical Center Part V, Section B, Line 4: Soin Medical Center partnered with member hospitals of the Greater Dayton Area Hospital Association and Wright State University to prepare the Community Health Needs Assessment (CHNA) for the hospital's service area. Beavercreek Medical Center Part V, Section B, Line 20d: The hospital provided a discount on medically necessary hospital services to uninsured patients who do not qualify under the charity care policy. Beavercreek Medical Center Part V, Section B, Line 22: The hospital charged patients an amount equal to gross charges in select circumstances. This includes, for example, claims with insurance denials for non-cooperation. Part I, Line 6a: The organization provides an annual community benefit report that is made available to the public. Part I, Line 7: Charity care is calculated using a cost to charge ratio following the methodology of Worksheet 2. Medical costs are calculated using a cost accounting system that addresses all patient segments. Subsidized health services is calculated based on the non-Medicare, Medicaid, and charity care proportion of departmental losses for the specific programs. Cash and in-kind contributions are calculated on the basis of direct expenditures. Part I, Line 7g: Subsidized health services represent the non-needs based and non-Medicare program losses of services the hospital offers. Part III, Line 4: A cost to charge ratio was used to determine the amount reported in Part III, line 2. An industry average was used to compute the amount on line 3. Discounts and payments on patient accounts reduce bad debt expense. Text of footnote describing bad debt expense is as follows:"Based on historical experience, a significant portion of the Network's uninsured patients will be unable or unwilling to pay for the services provided. Thus, the Network records a significant provision for bad debts related to uninsured patients in the period the services are provided." Part III, Line 8: The costing methodology used to determine Medicare costs is the the Medicare cost report. Medicare costs have not been included in Community Benefit in Part I. A reconciliation between Medicare program amounts reported in Section B and the total Medicare program is below: Revenues Costs (Shortfall)Medicare Section B $16,051,980 $19,124,263 ($3,072,283) Other Medicare Programs $ 5,767,262 7,567,976 ($1,800,714)Total Medicare Programs $21,819,242 $26,692,239 ($4,872,997)Other Medicare programs include Medicare Part C and other programs not reportable in the Medicare Cost Report. Part III, Line 9b: Financial Counselors work out a payment program for any amount due after the charity sliding scale discounts are applied. Collection procedures consistent with self-pay accounts are applied to these balances. Part VI, Line 3: SOIN informs and educates patients or persons who may be billed for patient care about their eligibility for assistance under federal, state or local government programs or under SOIN's charity care policy as follows:-SOIN has a financial assistance brochure that is included in all of the patient information kits given at the time of intake or registration into any facility or department.-There is information posted in all of the admitting and registration areas about charity care and financial assistance.-During the registration process there is specific scripting to ask patients if they would like to disclose family size and income to screen them for federal/state/local and hospital based charity/assistance programs. This is done regardless of insured or uninsured status. This data is available for future visits as well.-SOIN has the reporting capability to review and screen any patient who may have been admitted during registration "off hours" for eligibility and assistance.-SOIN contracts with an outside agency for patient assistance in the application process.-The back of the patient statement shows the current and prior year Federal Poverty Guidelines and has the Financial Assistance Form to complete and mail in for consideration for SOIN's HCAP or Charity Sliding Scale program. SOIN's patient account representatives in customer service screen patients that are unable to pay their bill for the various financial assistance programs. Part VI, Line 4: KHN serves a population of approximately 1,631,000 in its primary and secondary service area. The nine county service area includes Butler, Clark, Clinton, Darke, Greene, Miami, Montgomery, Preble and Warren counties. Out of this service area, approximately 11.2% of area residents have income below $15,000. 10.3% have income between $15,000 and $24,000 and 27.3% have income between $25,000 and $49,000. Portions of Clark, Darke and Preble counties have been identified as medically underserved by the Health Resources and Services Administration. This nine county area is served by 15 hospitals, 8 of which are part of Kettering Health Network. Part VI, Line 5: SOIN furthers its exempt purpose by promoting the health of the community by:-Retaining a Board of Directors with a majority (excluding employees and contractors) living in the primary service area;-Extending medical staff privileges to all qualified physicians in its community for a majority of its departments.-Utilizing surplus funds to help support ongoing improvements in patient care through equipment upgrades and establishment of new programs. Part VI, Line 6: SOIN promotes the health of the communities served as described below:-SOIN, a part of the Kettering Health Network, is dedicated to the creation and maintenance of community wellness programs, support groups and health education programs. SOIN provides numerous screenings, family-focused classes, donations and education programs to ensure the long-term well-being of people living in the community.-Kettering Affiliated Health Services, Inc. includes Sycamore Glen Health Center, Sycamore Glen Retirement Community, and Kettering Breast Evaluation Centers. These health care areas provide services to the surrounding communities which complement those services provided by SOIN as part of the Kettering Health Network.-Medical research is supported through the Innovation Center, cultivating new technologies and fostering best practices among partners from industry, academia and health care. Part VI, Line 7, Reports Filed With States OH 0 Employee hardship 12 9957 Part III, column (b) Actual number of employees 0 1 0 0 0 0 0 0 0 Fred Manchur KHN CEO 0 1125462 0 276700 0 99889 0 1081190 0 16324 0 2599565 0 0 Terri Day KHN President 0 822095 0 147708 0 129904 0 976975 0 33255 0 2109937 0 0 Terry Burns Senior VP GMH/SOIN 0 425203 0 78214 0 15166 0 13987 0 29275 0 561845 0 0 Ronald Connovich GMH/SOIN VP of Finance & O 0 247966 0 43452 0 278 0 12302 0 17229 0 321227 0 0 Belinda Mallett GMH/SOIN VP of Patient Car 0 235630 0 42966 0 3002 0 13987 0 15197 0 310782 0 0 James Porter Director - Facility 0 131638 0 12756 0 927 0 6508 0 11940 0 163769 0 0 Jill Hope Pharmacist 0 132771 0 2443 0 0 0 5957 0 16150 0 157321 0 0 Mark Smith FHH President beginning 6-2013 0 366785 0 73847 0 1304 0 13987 0 24034 0 479957 0 0 Greg Henderson Former Director & Officer 0 372572 0 0 0 0 0 0 0 11900 0 384472 0 0 Tim Ko Former Officer 0 256742 0 39405 0 566 0 11522 0 16344 0 324579 0 0 Steve Chavez Former Officer 0 247841 0 28542 0 1090 0 6917 0 17220 0 301610 0 0 Part I, Line 3 Compensation is established by a related organization. The process of determining compensation of CEO's, executive directors, officers, and key employees is to have an independent board approve the compensation. The compensation is determined to be reasonable compared to independent comparability data. The approval of the amounts is documented in the Board minutes within the appropriate time frame. At year end the organization reviews executive compensation by comparing the amounts approved to the amounts paid. Part I, Line 4b The Network has a Supplemental Executive Retirement Plan available only to a certain class of management. A County of Greene Ohio 316000271 394650BV6 2009-11-03 97931091 Construct and equip a hospital 0 0 0 A 100120465 10609250 2633592 1612304 85213731 51588 2012 0 0 1 1 A 0 0 1 1 1 1 0.00000 0.00000 0.00000 0 0 1 A 0 0 1 0 0 0 0 0 1 A 1 Form 990, Part VI, Section B, line 11 A tax specialist is engaged to review the 990. The 990 is reviewed and accepted by the audit committee which reports this to the governing body (board). Form 990, Part VI, Section B, line 12c The Network regularly and consistently monitors and enforces compliance with the conflict of interest policy by making it part of the employees' annual reviews. Employees must certify that they have read the conflict of interest policy and have disclosed any potential conflicts and agree to immediately notify Corporate Integrity if one should arise. Board members are required to annually review the Network's policy, sign a conflict of interest statement, and notify the Network if a conflict should arise. Form 990, Part VI, Section B, line 15 The process of determining compensation of CEO's, executive directors, officers, and key employees is to have an independent board approve the compensation. The compensation is determined to be reasonable compared to independent comparability data. The approval of the amounts is documented in the Board minutes within the appropriate time frame. At year end the organization reviews executive compensation by comparing the amounts approved to the amounts paid. Form 990, Part VI, Section C, line 19 The organization's governing documents, conflict of interest policy, and financial statements are available upon request. Form 990, Part XI, line 9: Net transfers from affiliate 9,894,951. Part III, Line 2c The Board of Trustees is responsible for the oversight of the independent audit. This process is consistent with the prior year. Part IX, Lines 7, 8, 9, 10 Salaries, retirement plan contributions, other benefits, and payroll taxes are paid by and allocated from Kettering Medical Center. Alliance Physicians Inc 2110 Leiter Road Miamisburg OH 45342 311175717 Physician Services OH 501(c)(3) 509(a)(3) Kettering Adventist Healthcare 0 Dayton Osteopathic Hospital 2110 Leiter Road Miamisburg OH 45342 310564121 Hospital OH 501(c)(3) 509(a)(1) Kettering Adventist Healthcare 0 The Fort Hamilton Hospital 2110 Leiter Road Miamisburg OH 45342 310536662 Hospital OH 501(c)(3) 509(a)(1) Kettering Adventist Healthcare 0 Fort Hamilton Hospital Foundation 2110 Leiter Road Miamisburg OH 45342 452036966 Fundraising OH 501(c)(3) 509(a)(3) The Fort Hamilton Hospital 0 Greene Foundation 2110 Leiter Road Miamisburg OH 45342 310886949 Fundraising OH 501(c)(3) 509(a)(3) Greene Memorial Hospital 0 Greene Memorial Hospital 2110 Leiter Road Miamisburg OH 45342 310809436 Hospital OH 501(c)(3) 509(a)(1) Kettering Adventist Healthcare 0 Greene Memorial Hospital Services Inc 2110 Leiter Road Miamisburg OH 45342 311358549 Physician Services OH 501(c)(3) 509(a)(3) Kettering Adventist Healthcare 0 Greene Oaks 2110 Leiter Road Miamisburg OH 45342 310999724 Senior Healthcare Facilities OH 501(c)(3) 509(a)(2) Kettering Affiliated Health Services Inc 0 Kettering Adventist Healthcare 2110 Leiter Road Miamisburg OH 45342 311051688 Management OH 501(c)(3) 509(a)(3) N/A 0 Kettering Affiliated Health Services Inc 2110 Leiter Road Miamisburg OH 45342 311127485 Health Services OH 501(c)(3) 509(a)(3) Kettering Adventist Healthcare 0 Kettering Medical Center 2110 Leiter Road Miamisburg OH 45342 310621866 Hospital OH 501(c)(3) 509(a)(1) Kettering Adventist Healthcare 0 Kettering Medical Center Foundation 2110 Leiter Road Miamisburg OH 45342 237419897 Fundraising OH 501(c)(3) 509(a)(3) Kettering Medical Center 0 Kettcor 2110 Leiter Road Miamisburg OH 45342 311078381 Health Services OH N/A C 0 0 0 0 0 0 0 0 0 0 1 0 0 1 1 1 1 0 0 1 Alliance Physicians Inc J FMV Alliance Physicians Inc M FMV Greene Foundation M FMV Kettering Adventist Healthcare M FMV Kettering Medical Center M FMV Kettering Medical Center N FMV Greene Memorial Hospital O FMV Kettering Medical Center O FMV Kettering Medical Center P FMV Kettering Medical Center S 9894951 FMV Part V, Line 2 Kettering Medical Center is a conduit through which revenue is received and expenses are paid.