2014-11-14T09:37:57-06:00 2013-12-31 381357951 PLANTE & MORAN PLLC 65 EAST STATE ST STE 600 COLUMBUS OH 43215 990 2013-01-01 314379443 ADENA HEALTH SYSTEM ADEN 7407794478 272 HOSPITAL RD CHILLICOTHE OH 45601 ROBERT M ROSENBERGER CFO 7407794478 2014-11-11 1 BERNIE OSTROWSKI P00366367 6148493000 2013 2015-11-30 17:44:51Z ADENA REGIONAL MEDICAL CENTER MARK SHUTER 272 HOSPITAL RD CHILLICOTHE OH 45601 421025444 0 X WWW.ADENA.ORG X 1895 OH "TO HEAL, TO EDUCATE, TO CARE." THE REPORTING ORGANIZATION IS A REGIONAL HEALTHCARE SYSTEM WITH ONE HOSPITAL AND SEVERAL AMBULATORY CENTERS, IN ADDITION TO MULTIPLE PHYSICIAN PRACTICES. AHS OFFERS A WIDE SCOPE OF DIAGNOSTIC AND REHABILITATIVE SERVICES BOTH FOR INPATIENTS AND OUTPATIENTS, INCLUDING COMPREHENSIVE CARDIOLOGY AND CANCER CARE. FURTHERMORE, AHS IS THE SOLE MEMBER OF TWO CRITICAL ACCESS HOSPITALS, ADENA PIKE MEDICAL CENTER AND ADENA GREENFIELD MEDICAL CENTER, THAT FILE SEPARATELY. 14 8 2937 225 0 0 1407756 1444837 378441880 394211412 4729565 11247301 13256012 14001227 397835213 420904777 788202 1036812 0 0 210329286 212275721 0 0 0 190672229 182266631 401789717 395579164 -3954504 25325613 423361896 437413995 230072795 221591606 193289101 215822389 TO HEAL, TO EDUCATE, TO CARE. 0 0 343517234 1036812 400396444 HEALTH CARE PROGRAMS, GENERAL/OTHER: ROUTINE HOSPITAL SERVICES. THERE WERE 11,302 INPATIENTS AND 946,861 OUTPATIENTS IN 2013. EMERGENCY SERVICES - TREATMENT OF EMERGENCY ACCIDENT AND ILLNESS AS WELL AS LESS URGENT CONDITIONS IN THE ABSENCE OF A FAMILY PHYSICIAN. THERE WERE 48,240 EMERGENCY VISITS IN 2013. THE HOSPICE AND HOME HEALTH DEPARTMENTS PROVIDE MEDICAL CARE, MEDICATIONS, HOME HEALTH NEEDS, BEREAVEMENT COUNSELING PRESCRIPTIONS, FOOD AND SHELTER TO PATIENTS. THERE WERE 14,316 HOSPICE DAYS IN 2013. PHYSICIAN OFFICES: THERE WERE 345,181 PHYSICIAN OFFICE VISITS IN 2013. 343517234 1 1 0 1 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 1 1 1 0 0 0 1 0 0 1 1 0 0 0 0 1 1 1 1 0 0 1 117 0 1 2937 1 0 0 0 0 0 0 0 0 0 0 X 14 8 0 0 0 0 1 1 1 1 1 0 0 1 1 1 1 1 1 1 1 0 X ROBERT M ROSENBERGER CFO 7407797582 272 HOSPITAL ROAD CHILLICOTHE OH 456019031 JACK BERNO DIRECTOR/EMPLOYED M.D. 50.00 0.00 X 296805 0 10398 STEVEN BURKHARDT DIRECTOR/TREASURER 2.00 0.00 X X 0 0 0 RALPH D'ANTONI DIRECTOR 2.00 0.00 X 0 0 0 GARY EVANS DIRECTOR 2.00 0.00 X 0 0 0 JAMES GROVE DIRECTOR 2.00 0.00 X 0 0 0 MIKE LILLY DIRECTOR/SECRETARY 2.00 2.00 X X 0 0 0 WILBUR SEVER DIRECTOR/EMPLOYED M.D. 50.00 0.00 X 604071 0 31740 DAVE STRICKLAND DIRECTOR/CHAIRMAN 2.00 0.00 X X 0 0 0 TOM WHITE DIRECTOR/VICE CHAIR 2.00 0.00 X X 0 0 0 NOBLE YOSHIDA DIRECTOR 2.00 0.00 X 0 0 0 WAYNE COATS DIRECTOR/EMPLOYED M.D. 50.00 0.00 X 381301 0 23753 JERRY PHILLIPS DIRECTOR 2.00 0.00 X 0 0 0 JOSEPH SULZER DIRECTOR 2.00 0.00 X 0 0 0 GAIL TAYLOR DIRECTOR 2.00 0.00 X 0 0 0 DAWN BENNETT JOHNSON INTERIM CHIEF FINANCIAL OFFICER 46.00 4.00 X 299331 0 33134 MARK SHUTER CHIEF EXECUTIVE OFFICER 46.00 4.00 X 707173 0 72773 KEVIN MURPHY CHIEF FINANCIAL OFFICER (MAY-OCT) 46.00 4.00 X 159252 0 11479 NATALIE DI LONNO ASSISTANT GENERAL COUNSEL (JAN-AUG) 45.00 5.00 X 225737 0 31649 MICHELLE FEDERER EMPLOYED M.D. 50.00 0.00 X 239747 0 9995 JOHN FORTNEY CHIEF MEDICAL OFFICER 50.00 0.00 X 411104 0 33832 ANTHONY FREEMAN EMPLOYED M.D. 50.00 0.00 X 790348 0 24099 JUDITH HENSON CHIEF NURSING OFFICER 45.00 0.00 X 185785 0 33206 SATHISH JETTY EMPLOYED M.D. 49.00 1.00 X 439585 0 30271 MARTHA LIVINGSTON CHIEF BUSINESS DEVLOPMENT OFFICER 45.00 0.00 X 220911 0 41191 ERIC PERDUE CHIEF HUMAN RESOURCES 45.00 0.00 X 184524 0 15184 JOHN YOUNG EMPLOYED M.D. 50.00 0.00 X 1178982 0 29214 ERIC CECAVA MASTER BLACK BELT 45.00 0.00 X 160129 0 28651 GAIL GAMES VP EDUCATION AND DEVELOPMENT 45.00 0.00 X 156798 0 14038 MICHAEL GLANZMAN EXECUTIVE DIRECTOR PHYS. SERVICES 45.00 0.00 X 160462 0 28665 PATRICIA ROAM CHIEF COMPLIANCE OFFICER 45.00 0.00 X 173592 0 22663 BRIAN COHEN EMPLOYED M.D. 50.00 0.00 X 3078870 0 29887 HAVAL SAADLLA EMPLOYED M.D. 50.00 0.00 X 1202977 0 15099 DAVID JONES EMPLOYED M.D. 50.00 0.00 X 961922 0 0 THOMAS LEWIS EMPLOYED M.D. 50.00 0.00 X 949732 0 15099 MATHEW COSENZA EMPLOYED M.D. 50.00 0.00 X 875651 0 10111 ALLEN SHAW FORMER KEY EMPLOYEE, EMPLOYED M.D. 50.00 0.00 X 236123 0 10111 ETHELBERT BAKER FORMER KEY EMPLOYEE, EMPLOYED M.D. 50.00 0.00 X 601449 0 15099 BARBARA PURDOM FORMER KEY EMPLOYEE 45.00 0.00 X 158201 0 6931 FAITHA SHELTON FORMER KEY EMPLOYEE 45.00 0.00 X 135289 0 30314 KIRK TUCKER FORMER KEY EMPLOYEE, EMPLOYED M.D. 50.00 0.00 X 283052 0 15099 15458903 0 673685 246 1 1 0 CAPTIVE RADIOLOGY 6273 FRANK AVENUE NW NORTH CANTON OH 44720 MRI SERVICES 3144480 PRECYSE SOLUTIONS LLC PO BOX 11407 BIRMINGHAM AL 35246 MEDICAL TRANSCRIPTION SERVICES 2329277 TATUM LLC PO BOX 847872 DALLAS TX 752847872 STAFFING SERVICES 951533 MEDICAL DOCTOR ASSOCIATES PO BOX 277185 ATLANTA GA 303847185 MEDICAL STAFFING SERVICES 533462 SOUTHEAST OHIO ACUTES PO BOX 8500-1607 PHILADELPHIA PA 19178 DIALYSIS SERVICES 527162 25 2870 733285 117805 590877 1444837 NET PATIENT SVC REV 622110 394211412 394211412 394211412 1807906 1807906 3303674 0 3303674 3303674 3303674 9495042 16191 0 71838 9495042 -55647 9439395 9439395 44499 2870 48829 -4330 -4330 EHR IMPLEMENTATION 622110 3680590 3680590 FOOD & NUTRITION 622110 1649608 1649608 CONSULTING FEES 622110 1213889 1213889 4157796 1290553 2867243 10701883 420904777 400396444 0 19063496 1036812 1036812 7554938 5323956 2230982 163613548 149049135 14564413 8528510 6618124 1910386 32578725 24251404 8327321 791156 678511 112645 865489 865489 165900 165900 36299057 21779296 14519761 393863 374725 19138 16558974 10610104 5948870 5464932 5464932 13867342 13867342 1205999 766523 439476 8944137 6940651 2003486 20484680 12450664 8034016 4088137 3896821 191316 MEDICAL SUPPLIES 57856406 57856406 BAD DEBT EXPENSE 24602699 24602699 OVERHEAD ALLOCATION -9322140 -2050871 -7271269 395579164 343517234 52061930 0 10343 10833 75023140 80148561 4877872 8306431 38926587 46093123 159180 40242 5150603 5336782 9902850 10280125 373513923 225651503 156501499 147862420 114226562 125793671 18583260 13541807 423361896 437413995 36977454 41713521 178918450 171764259 14176891 8113826 230072795 221591606 X 192560681 214840183 728420 982206 193289101 215822389 423361896 437413995 X 25325613 1964186 -4756511 X 0 1 X 1 1 1 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 0 0 0 0 0 0 0 0 1 1032 1032 0 PART II-B, LINE 1: THE OHIO HOSPITAL ASSOCIATION DOES LOBBYING ON BEHALF OF HOSPITAL RELATED CAUSES. THIS ACTIVITY IS PAID FOR THROUGH DUES PAID TO THE OHIO HOSPITAL ASSOCIATION. 2168959 358513 156716 222082 2462106 1050463 1142201 169101 192806 2168959 979299 48900 30021 7757 1050463 859540 50593 101333 32167 979299 762259 170668 85016 158403 859540 1.00000 0 0 2648975 2648975 167263384 66716785 100546599 10302964 10302964 0 185590259 143471765 42118494 7708341 5159989 2548352 147862420 ACCRUED MALPRACTICE INSURANCE - LT 7446735 DEFINED BENEFIT PLAN LIABILITY 667091 8113826 X PART V, LINE 4: ADENA HEALTH FOUNDATION ENDOWMENT FUNDS ARE USED TO PROVIDE SCHOLARSHIPS AND PURCHASE CAPITAL FOR PACCAR MEDICAL EDUCATION CENTER. THESE FUNDS ARE HELD BY ADENA HEALTH SYSTEM AND ARE ADMINISTERED BY ADENA HEALTH FOUNDATION. PART X, LINE 2: ACCOUNTING PRINCIPLES GENERALLY ACCEPTED IN THE UNITED STATES OF AMERICA REQUIRE MANAGEMENT TO EVALUATE TAX POSITIONS TAKEN BY THE SYSTEM AND RECOGNIZE A TAX LIABILITY IF THE SYSTEM 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 SYSTEM AND HAS CONCLUDED AS OF DECEMBER 31, 2013 AND 2012, THERE ARE NO UNCERTAIN POSITIONS TAKEN OR EXPECTED TO BE TAKEN THAT WOULD REQUIRE RECOGNITION OF A LIABILITY OR DISCLOSURE IN THE CONSOLIDATED FINANCIAL STATEMENTS. THE SYSTEM IS SUBJECT TO ROUTINE AUDITS BY TAXING JURISDICTIONS; HOWEVER, THERE ARE CURRENTLY NO AUDITS FOR ANY TAX PERIODS IN PROGRESS. MANAGEMENT BELIEVES THAT IT IS NO LONGER SUBJECT TO INCOME TAX EXAMINATIONS FOR YEARS PRIOR TO DECEMBER 31, 2010. CHARITY BALL 19050 2870 16180 1141 1434 16844 PLANT SALE 28319 28319 29410 47369 2870 44499 1141 1434 46254 48829 -4330 1 1 X 1 X 1 X 1 1 1 0 1 1 16289349 4973178 11316171 0.03050 75512983 41866994 33645989 0.09070 91802332 46840172 44962160 0.12120 477781 477781 0.00130 329363 329363 0.00090 46267 46267 0.00010 853411 853411 0.00230 92655743 46840172 45815571 0.12350 223667 223667 0.00060 223667 223667 0.00060 0 24602699 0 65145960 55704629 9441331 X 1 0 1 1 ADENA REGIONAL MEDICAL CENTER 272 HOSPITAL RD CHILLICOTHE OH 45601 WWW.ADENA.ORG STATE REGIS X X X ADENA REGIONAL MEDICAL CENTER 1 1 X X X X X X X X X 13 1 1 1 X ADENA.ORG/INSIDE/PAGE.DT/CHNA X X X X X X X X X X 1 0 1 1 200.000000000000 1 400.000000000000 1 X X X X X X 1 1 X X X X X X 1 0 X X X 1 X 0 0 ADENA REGIONAL MEDICAL CENTER PART V, SECTION B, LINE 3: IN MAY OF 2013, ADENA REGIONAL MEDICAL CENTER CAPTURED THE BROAD INTERESTS OF THE COMMUNITY FOR THE CHNA THROUGH TWO METHODS: SURVEY AND INTERVIEWS. A HEALTH NEEDS SURVEY WAS WIDELY DISTRIBUTED TO THE ROSS COUNTY COMMUNITY THROUGH PAPER AND WEB FORM. IN ADDITION TO THE SURVEYS, INTERVIEWS WITH LOCAL COMMUNITY LEADERS, INCLUDING CIVIC, PUBLIC HEALTH AND EMERGENCY RESPONSE WERE REQUESTED AND/OR CONDUCTED TO GAIN FURTHER KNOWLEDGE OF SURVEY TOPICS. ADENA REGIONAL MEDICAL CENTER PART V, SECTION B, LINE 4: THE CHNA FOR ADENA REGIONAL MEDICAL CENTER WAS CONDUCTED IN COLLABORATION WITH WITH TWO OTHER HOSPITAL FACILITIES THAT ARE PART OF THE ADENA HEALTH SYSTEM: ADENA GREENFIELD MEDICAL CENTER AND ADENA PIKE MEDICAL CENTER. ADENA REGIONAL MEDICAL CENTER PART V, SECTION B, LINE 5D: HARD COPIES OF THE CHNA REPORT WERE PRINTED AND SENT TO COMMUNITY LEADERS AND AGENCIES. ADENA REGIONAL MEDICAL CENTER PART V, SECTION B, LINE 7: PLEASE SEE THE BELOW URL TO ACCESS THE 2013 IMPLEMENTATION STRATEGY.ADENA.ORG/INSIDE/PAGE.DT/CHNA ADENA REGIONAL MEDICAL CENTER PART V, SECTION B, LINE 18E: PATIENTS HAVE 120 DAYS FROM THE TIME THEIR ACCOUNT GOES TO "SELF-PAY" TO PAY IN FULL OR MAKE PAYMENT ARRANGEMENTS. ON THE 121ST DAY, THEY ARE SENT TO A COLLECTION AGENCY WHO WILL DO CREDIT REPORTING. COLLECTION AGENCIES REQUIRE ADENA MANAGEMENT APPROVAL TO PURSUE LEGAL ACTION. ADENA REGIONAL MEDICAL CENTER PART V, SECTION B, LINE 20D: THE PATIENT IS INITIALLY CHARGED REGULAR HOSPITAL RATES FOR SERVICES PERFORMED. THE PATIENT THEN COMPLETES AN APPLICATION FOR FINANCIAL AID FORM AND RETURNS IT TO THE FINANCIAL COUNSELORS, EMPLOYED BY AN OUTSIDE AGENCY. HCAP/CHARITY ADJUSTMENTS ARE ADMINISTERED BASED ON PROOF OF INCOME AND THE TABLES OF THE FEDERAL POVERTY LIMITS (FPL) AND THE MAXIMUM AMOUNT CHARGED IS CALCULATED IN THE FOLLOWING MANNER: 1. 100% WRITE-OFF AND HCAP ELIGIBLE - LESS THAN OR EQUAL TO 200% FPL 2. 60% WRITE-OFF - BETWEEN 201% - 400% OF FPL. MANAGEMENT DECIDED TO LIMIT THE DISCOUNT TO THOSE UNDER THE 400% FPL, BASED ON MANAGEMENT'S EXPERIENCE AT OTHER INSTITUTIONS ALONG WITH A CURSORY REVIEW OF HOSPITALS IN THE LOCAL MARKET. 15 ADENA HEALTH PAVILION 4437 STATE ROUTE 159 CHILLICOTHE OH 45601 PHYSICIAN OFFICES ADENA MEDICAL OFFICE BUILDING 4439 STATE ROUTE 159 CHILLICOTHE OH 45601 PHYSICIAN OFFICES ADENA HEALTH CENTER - WAVERLY 12340 STATE ROUTE 104 WAVERLY OH 45690 AMBULATORY CARE CENTER ADENA URGENT CARE 55 CENTENNIAL BLVD CHILLICOTHE OH 45601 AMBULATORY CARE CENTER ADENA HOME CARE SERVICES 111 W WATER STREET CHILLICOTHE OH 45601 HOME HEALTH CARE AND HOSPICE ADENA HEALTH CENTER - JACKSON 1000 VETERANS DRIVE JACKSON OH 45640 AMBULATORY CARE CENTER ADENA REHABILITATION AND WELLNESS CENTER 445 SHAWNEE LANE CHILLICOTHE OH 45601 OUTPATIENT REHABILITATION CENTER ADENA FAMILY MEDICINE - OAK HILL 315 WASHINGTON STREET OAK HILL OH 45656 PHYSICIAN OFFICES ADENA PICKAWAY-ROSS FAMILY PHYSICIANS 100 N WALNUT STREET CHILLICOTHE OH 45601 PHYSICIAN OFFICES ADENA FAMILY MEDICINE - CIRCLEVILLE 798 N COURT STREET CIRCLEVILLE OH 43113 PHYSICIAN OFFICES ADENA COUNSELING CENTER 445 SHAWNEE LANE CHILLICOTHE OH 45601 MENTAL HEALTH COUNSELING ADENA FAMILY MEDICINE OF CHILLICOTHE 626 CENTRAL CENTER CHILLICOTHE OH 45601 PHYSICIAN OFFICES ADENA ROSS UROLOGY 8 MEDICAL DRIVE CHILLICOTHE OH 45601 PHYSICIAN OFFICES ADENA FAMILY MEDICINE - GREENFIELD 536 MIRABEAU STREET GREENFIELD OH 45123 PHYSICIAN OFFICES ADENA FAMILY MEDICINE - WASHINGTON CH 308 HIGHLAND AVENUE SUITE C WASHINGTON COURT HOU OH 43160 PHYSICIAN OFFICES PART I, LINE 7: THE COST-TO-CHARGE RATIO DERIVED FROM WORKSHEET 2 WAS USED TO CONVERT CHARGES TO COSTS IN LINE 7A AND 7B. ACTUAL COSTS WERE USED IN LINE 7E, 7F & 7I. PART I, LN 7 COL(F): BAD DEBT EXPENSE OF $24,602,699 WAS DEDUCTED FROM TOTAL OPERATING EXPENSES WHEN CALCULATING THE PERCENTAGES IN THIS COLUMN. PART II, COMMUNITY BUILDING ACTIVITIES: THE COMMUNITY BUILDING ACTIVITIES PROMOTE ECONOMIC DEVELOPMENT IN DOWNTOWN CHILLICOTHE. THE HOSPITAL IS HELPING FUND A HISTORIC BUILDING REHABILITATION PROJECT WHICH WILL IN TURN HELP REVITALIZE THE DOWNTOWN CHILLICOTHE BUSINESS DISTRICT AS WELL AS PROMOTE JOB GROWTH. THE BUILDING WILL ALSO PROVIDE HOUSING FOR ADENA PHYSICIAN RESIDENTS AND MEDICAL STUDENTS WHICH ENABLES THE HEALTH SYSTEM TO INCREASE PROVIDER ACCESS WITHIN THE SERVICE AREA. PART III, LINE 2: THE BAD DEBT EXPENSE LISTED ON PART III, LINE 2 IS DERIVED FROM THE FINANCIAL STATEMENTS. PART III, LINE 3: IN DETERMINING THE APPROPRIATE AMOUNT TO BE RECORDED ON PART III, LINE 3, ALL SELF PAY CLAIMS ARE TURNED OVER TO A COLLECTION VENDOR. THE VENDOR DETERMINES IF THE CLAIM IS CHARITY AFTER THE PATIENT SUPPLIES APPROPRIATE DOCUMENTATION. HOWEVER, THE HOSPITAL HAD AN OUTSIDE CREDIT AGENCY REVIEW TWO MONTHS OF BAD DEBT TRANSACTIONS AND DETERMINED THAT 27% OF THE AMOUNT BOOKED AS BAD DEBT EXPENSE RELATED TO UNCOMPENSATED CHARITY CARE. THE HOSPITAL RECLASSED $9,204,382 FROM BAD DEBT EXPENSE TO CHARITY CARE. BAD DEBT EXPENSE BEFORE THIS RECLASS WAS $33,807,081 LEAVING $24,602,699 AS BAD DEBT EXPENSE. BASED ON THIS ANALYSIS AND RECLASS, THE HOSPITAL ESTIMATES THAT $0 OF THE BAD DEBT EXPENSE REPORTED IN PART III LINE 2 ARE AMOUNTS THAT WOULD BE ATTRIBUTABLE TO PATIENTS UNDER THE HOSPITAL'S FINANCIAL ASSISTANCE POLICY. PART III, LINE 4: WE DO NOT HAVE SEPARATE FINANCIAL STATEMENTS FOR ADENA REGIONAL MEDICAL CENTER. IT IS INCLUDED IN THE CONSOLIDATED STATEMENTS OF ADENA HEALTH SYSTEM. THE FOOTNOTE IN OUR FINANCIAL STATEMENTS INCLUDES THE FOLLOWING ABOUT OUR BAD DEBT EXPENSE AND ALLOWANCE FOR UNCOLLECTIBLES. "AN ALLOWANCE FOR UNCOLLECTIBLE ACCOUNTS IS ESTABLISHED ON AN AGGREGATE BASIS BY USING HISTORICAL WRITE-OFF FACTORS APPLIED TO UNPAID ACCOUNTS BASED ON AGING. LOSS RATE FACTORS ARE BASED ON HISTORICAL LOSS EXPERIENCE AND ADJUSTED FOR ECONOMIC CONDITIONS AND OTHER TRENDS AFFECTING THE SYSTEM'S ABILITY TO COLLECT OUTSTANDING AMOUNTS. UNCOLLECTIBLE ACCOUNTS ARE WRITTEN OFF AGAINST THE ALLOWANCE FOR DOUBTFUL ACCOUNTS IN THE PERIOD THEY ARE DETERMINED TO BE UNCOLLECTIBLE. AN ALLOWANCE FOR CONTRACTUAL ADJUSTMENTS AND INTERIM PAYMENT ADVANCES IS ESTABLISHED BASED ON EXPECTED PAYMENT RATES FROM PAYORS UTILIZING CURRENT REIMBURSEMENT METHODOLOGIES AND PAYMENT RATES. THIS AMOUNT ALSO INCLUDES AMOUNTS RECEIVED AS INTERIM PAYMENTS AGAINST UNPAID CLAIMS BY CERTAIN PAYORS. FOR RECEIVABLES ASSOCIATED WITH SELF-PAY PATIENTS (WHICH INCLUDES BOTH PATIENTS WITHOUT INSURANCE AND PATIENTS WITH DEDUCTIBLE AND COPAYMENT BALANCES DUE FOR WHICH THIRDPARTY COVERAGE EXISTS FOR PART OF THE BILL), THE SYSTEM RECORDS A SIGNIFICANT PROVISION FOR BAD DEBTS IN THE PERIOD OF SERVICE ON THE BASIS OF ITS PAST EXPERIENCE, WHICH INDICATES THAT MANY PATIENTS ARE UNABLE OR UNWILLING TO PAY THE PORTION OF THEIR BILL FOR WHICH THEY ARE FINANCIALLY RESPONSIBLE. THE DIFFERENCE BETWEEN THE STANDARD RATES (OR THE DISCOUNTED RATES, IF NEGOTIATED) AND THE AMOUNTS ACTUALLY COLLECTED AFTER ALL REASONABLE COLLECTION EFFORTS HAVE BEEN EXHAUSTED IS CHARGED OFF AGAINST THE ALLOWANCE FOR DOUBTFUL ACCOUNTS IN THE PERIOD THEY ARE DETERMINED TO BE UNCOLLECTIBLE." PART III, LINE 8: THE HOSPITAL MEDICARE ADVANTAGE PLAN AND THE PHYSICIAN MEDICARE ADVANTAGE PLAN INCURRED A SHORTFALL OF <$17,425,457> IN 2013. THIS SHORTFALL COMBINED WITH THE LONGFALL FROM TRADITIONAL MEDICARE SOURCES OF $9,441,331 RESULTS IN A NET MEDICARE SHORTFALL OF <$7,984,126>.OUR SERVICE AREA IS A RURAL 13 COUNTY AREA IN SOUTHERN OHIO. THE POPULATION IS AN AGING POPULATION WHICH RESULTS IN MEDICARE AS OUR LARGEST PAYOR GROUP. IN ADDITION, THE ECONOMIC CONDITIONS THAT RESULT FROM APPALACHIAN DESIGNATION CREATE A RECRUITING ISSUE. TO COMBAT THE ISSUE, WE ARE FORCED TO NOT ONLY EMPLOY PHYSICIANS BUT MUST PAY A PREMIUM TO GET THEM TO AGREE TO SERVE THE AREA'S RESIDENTS. BASED ON THESE ISSUES, WE BELIEVE SERVICE TO OUR MEDICARE POPULATION IS A COMMUNITY BENEFIT. ALSO, THE HOSPITAL USED THE METHODOLOGY REQUIRED FOR COMPLETING THE MEDICARE COST REPORT WHEN DETERMINING THE AMOUNT ON PART III - LINE 6. PART III, LINE 9B: THERE ARE TWO TIERS: 100% CHARITY FOR UP TO OR EQUAL TO 200% OF FEDERAL POVERTY LEVELS AND 60% FOR 201%-400% OF FEDERAL POVERTY LEVELS. PART VI, LINE 3: THE AVAILABILITY OF FINANCIAL ASSISTANCE IS COMMUNICATED IN THE FOLLOWING MANNER: 1. STATEMENTS FROM ADENA AS WELL AS COLLECTION VENDORS EXPLAIN AND LIST THE 100% AND 60% ASSISTANCE GUIDELINES ON THE BACKSIDE OF THE STATEMENT. 2. THERE IS SIGNAGE EXPLAINING THE PROGRAM AT ALL THE REGISTRATION AREAS. 3. A CONTRACTED VENDOR SUPPLIES STAFF AT THE CASHIER AREA TO EXPLAIN OPTIONS AVAILABLE TO THE PATIENT. 4. WE SEND AN APPLICATION WITH THE SELF-PAY DISCOUNT LETTERS IN CASE THE PATIENT/GUARANTOR CAN'T SET UP A PAYMENT PLAN. 5. THE CUSTOMER SERVICE STAFF IS EDUCATED ON ALL THE OPTIONS AND CAN EXPLAIN THE PROGRAMS WHEN PATIENTS CALL. 6. OUR PHYSICIAN OFFICES, AS WELL AS COLLECTION VENDORS HAVE FINANCIAL AID APPLICATIONS AVAILABLE. 7. LASTLY, WE UTILIZE A "HINDSIGHT" VENDOR THAT SCREENS ALL BAD DEBT ACCOUNTS, AFTER THE YEAR-END, AGAINST THE STATE MEDICAID ELIGIBILITY AND FEDERAL POVERTY GUIDELINES TO ATTEMPT ONE LAST EFFORT TO OBTAIN FINANCIAL ASSISTANCE FOR INDIVIDUALS. PART VI, LINE 4: ROSS COUNTY, HOME TO ADENA REGIONAL MEDICAL CENTER, IS LOCATED IN SOUTH CENTRAL OHIO. IT IS PART OF 2 CONGRESSIONAL DISTRICTS (2ND AND THE 15TH) AND ONE OF OHIO'S 32 APPALACHIAN COUNTIES. IT CONTAINS THE POPULATION PATTERNS AND DISTINCT ECONOMIC CONDITIONS INHERENT OF THIS REGION OF THE U.S AND FACES SIMILAR CHALLENGES TO IMPROVE THE LIVES OF ITS 78,868 RESIDENTS. THESE INCLUDE LOW EDUCATIONAL ATTAINMENT PERCENTAGES AND HIGH RATES OF UNEMPLOYMENT AND POVERTY. THE TOTAL POPULATION OF ROSS COUNTY REPRESENTS 15% OF THE TOTAL ADENA HEALTH SYSTEM SERVICE REGION AND IS THE PRIMARY PLACE OF RESIDENCE FOR 80% OF THE PATIENTS IT SERVES. THE COUNTY, AS WELL AS THE REMAINDER OF THE 12 COUNTY SERVICE REGION, HAS SIMILAR DEMOGRAPHICS AS THE STATE OF OHIO AND U.S. OVER 64% OF THE POPULATION IS BETWEEN THE AGES OF 19 AND 64 AND 13% OF THE POPULATION IS OVER THE AGE OF 65. THE MAJORITY OF THE POPULATION IS WHITE WITH AFRICAN AMERICANS MAKING UP THE MAJORITY OF THE REGION'S MINORITY POPULATION.THE 28,158 HOUSEHOLDS IN ROSS COUNTY REPRESENT 14.7% OF THE HOUSEHOLDS IN ADENA HEALTH SYSTEM'S 12-COUNTY SERVICE REGION. THE AVERAGE HOUSEHOLD SIZE IS 2.54 PEOPLE, COMPARABLE WITH THE REST OF OHIO AND THE U.S. THE AVERAGE FAMILY SIZE IS AS WELL WITH 3.05 PEOPLE. A LITTLE MORE THAN 50% OF THE POPULATION IS NOW MARRIED WHICH IS COMPARABLE WITH OHIO AND NATIONAL AVERAGES. MORE THAN 14% ARE DIVORCED WHICH IS NOTICEABLY HIGHER THAN BOTH THE STATE AND NATIONAL AVERAGES. MORE THAN 16% OF THE ADULTS IN ROSS COUNTY HAVE NOT GRADUATED FROM HIGH SCHOOL. THIS PERCENTAGE IS HIGHER THAN BOTH THE OHIO (12.2%) AND NATIONAL (14.6%) AVERAGES, BUT IS LOWER THAN THE AVERAGE FOR THE 12-COUNTY SERVICE REGION (18.9%). MORE THAN 10% OF THE POPULATION OF ROSS COUNTY IS ESTIMATED TO BE FUNCTIONALLY ILLITERATE, OR LACKING THE READING AND WRITING SKILLS SUFFICIENT FOR ORDINARY PRACTICAL NEEDS.WHILE THE UNEMPLOYMENT RATE IN ROSS COUNTY (7.9%) IS COMPARABLE TO THE U.S. AVERAGE, IT CONTINUES TO BE HIGHER THAN BOTH THE REGIONAL (6.8%) AND STATE (6%) AVERAGES. IN ADDITION, MORE THAN 43.4% OF THE POPULATION IS NOT IN THE WORKFORCE. THIS IS HIGHER THAN THE STATE (35.4%) AND NATIONAL AVERAGES (35.2%). THE TOP FIVE EMPLOYMENT INDUSTRIES IN ROSS COUNTY ARE MANAGEMENT/PROFESSIONAL OCCUPATIONS (28%), EDUCATION/HEALTHCARE SERVICES (24.6%), SALES (23%), PRODUCTION/TRANSPORTATION SERVICES (19.7%), AND SERVICE OCCUPATIONS (18.9%). ROSS COUNTY HAS MORE PEOPLE EMPLOYED IN PRODUCTION, TRANSPORTATION AND MATERIAL MOVING OCCUPATIONS (19.7%) THAN THE REGIONAL, STATE AND NATIONAL AVERAGES. THE COUNTY HAS ABOUT HALF AS MANY (5.4%) PROFESSIONAL, SCIENTIFIC AND MANAGEMENT SERVICES PROFESSIONALS AS OHIO (9.1%) AND THE U.S. (10.5%).THE PER CAPITA, MEDIAN AND MEAN HOUSEHOLD INCOMES IN ROSS COUNTY OHIO ARE MUCH LOWER THAN THE STATE AND U.S. AVERAGES, BUT HIGHER THAN REGIONAL AVERAGE. POVERTY RATES ARE ALSO HIGHER THAN STATE AND NATIONAL AVERAGES BUT LOWER THAN THE REST OF THE REGION. ACCESS TO EMPLOYMENT IN ROSS COUNTY IS HIGHER THAN OTHER COUNTIES IN THE REGION.THERE ARE 7,697 CIVILIAN VETERANS LIVING IN ROSS COUNTY, ACCOUNTING FOR ALMOST 10% OF THE REGION'S POPULATION. THE TOTAL CIVILIAN VETERANS WITHIN THE ADENA HEALTH SYSTEM 12-COUNTY SERVICE REGION REPRESENT 5% OF OHIO'S TOTAL CIVILIAN VETERAN POPULATION. ROSS COUNTY ALSO HAS A VETERAN'S ADMINISTRATION HOSPITAL LOCATED 4.5 MILES FROM ADENA REGIONAL MEDICAL CENTER.ROSS COUNTY AND ITS ENTIRE SURROUNDING SERVICE REGION HAVE A HIGHER PREVALENCE OF DISABILITY THAN THE REST OF OHIO. SEVEN OF THE 12 COUNTIES IN THE SERVICE REGION HAVE DISABILITY PREVALENCE RATES OF 16.7% - 22%. ROSS COUNTY'S PREVALENCE RATE IS BETTER (14.8% - 16.6%) BUT STILL WORSE THAN THE REST OF OHIO (13.4% - 14.7%). PART VI, LINE 5: ADENA REGIONAL MEDICAL CENTER WORKS TO PROMOTE THE HEALTH OF ITS COMMUNITY THROUGH A VARIETY OF MEANS, INCLUDING BOARD MEMBERS, ADMINISTRATION, EMPLOYEES, AND VOLUNTEERS. THE 2013 BOARD OF TRUSTEES OF ADENA HEALTH SYSTEM WAS COMPRISED OF 14 MEMBERS. THREE OR 21 % OF THE BOARD MEMBERS ARE EMPLOYEES OF ADENA HEALTH SYSTEM. ALL OR 100% OF THE BOARD MEMBERS RESIDE WITHIN THE SERVICE REGION. THE ORGANIZATION BUDGETS FUNDS FOR THE PURPOSE OF COMMUNITY BENEFIT, MEDICAL EDUCATION, AND CHARITY CARE. THESE FUNDS ARE ALLOCATED TO DEPARTMENTAL BUDGETS AT THE BEGINNING OF EACH FISCAL YEAR AND OVERSEEN BY DEPARTMENT DIRECTORS. USE OF THE FUNDS IS GUIDED BY ORGANIZATIONAL FISCAL POLICY. PART VI, LINE 6: FOUNDED IN 1895, ADENA HEALTH SYSTEM IS AN INDEPENDENT, NOT-FOR-PROFIT HEALTHCARE ORGANIZATION BASED IN CHILLICOTHE, OH. THE HEALTH SYSTEM INCLUDES THREE HOSPITALS AND SIX REGIONAL CLINICS, WITH A TOTAL OF 311 BEDS. ADENA SERVES THE NEEDS OF NEARLY 500,000 PEOPLE IN 13 COUNTIES, LIVING IN OHIO'S APPALACHIAN REGION. OUR FACILITIES INCLUDE: ADENA REGIONAL MEDICAL CENTER: A 261-BED INPATIENT HOSPITAL IN CHILLICOTHE, OH FEATURING AN EMERGENCY DEPARTMENT, DIAGNOSTIC AND TREATMENT SERVICES, ADVANCED SURGICAL SUITES, INTENSIVE/CARDIAC CARE, MEDICAL OFFICE BUILDING AND THE ADENA HEALTH PAVILION, WHICH INCLUDES OUTPATIENT SURGERY, PHYSICIAN OFFICES AND THE ADENA SLEEP CENTER. IN 2011, ADENA INVESTED $21 MILLION IN THE CONSTRUCTION OF A 35,000 SQUARE-FOOT CANCER CENTER TO PROVIDE PATIENTS WITH ACCESS TO CANCER DIAGNOSIS AND TREATMENT AT A FACILITY NEAR THEIR HOMES. THE CANCER CENTER OPENED IN JANUARY 2012. GREENFIELD AREA MEDICAL CENTER AND PIKE HEALTH SERVICES, INC.: BOTH ARE CRITICAL ACCESS HOSPITALS, EACH WITH A 25-BED INPATIENT FACILITY IN GREENFIELD, OH AND WAVERLY, OH, RESPECTIVELY. EACH FEATURES AN EMERGENCY DEPARTMENT, INPATIENT CARE INCLUDING REHABILITATION AND MEDICAL/SURGICAL, DIAGNOSTIC AND TREATMENT SERVICES, AS WELL AS FAMILY PRACTICE AND SPECIALTY PHYSICIANS. THESE TWO HOSPITALS DIRECTLY BENEFIT HIGHLAND COUNTY (GREENFIELD AREA MEDICAL CENTER) AND PIKE COUNTY (PIKE HEALTH SERVICES, INC.) AS WELL AS SURROUNDING COMMUNITIES. ADENA HEALTH CENTERS: LOCATED IN CHILLICOTHE AND WITH REGIONAL SITES IN CIRCLEVILLE, JACKSON, OAK HILL, WASHINGTON COURT HOUSE AND WAVERLY, OH. OUR HEALTH CENTERS INCLUDE PHYSICIAN OFFICES, DIAGNOSTIC AND TREATMENT SERVICES, PHYSICAL, OCCUPATION AND SPEECH THERAPIES. URGENT CARE SERVICES ARE OFFERED IN CHILLICOTHE AND WAVERLY. ADENA HOME CARE AND HOSPICE: PROVIDES HIGHLY PERSONALIZED, QUALITY CARE TO PATIENTS OF FOUR SERVICE LINES -- HOME HEALTH, HOSPICE, HOME RESPIRATORY AND HOME INFUSION. ADENA REHABILITATION AND WELLNESS CENTER: PROVIDES PHYSICAL, OCCUPATIONAL, MASSAGE AND INDUSTRIAL REHABILITATION, AS WELL AS ORTHOPEDICS, SPORTS MEDICINE, WOMEN'S HEALTH, VESTIBULAR, FIBROMYALGIA AND CHRONIC PAIN PROGRAMS, AS WELL AS INDUSTRIAL AND SPECIALIZED HAND PROGRAMS. ADENA COUNSELING CENTER: PROVIDES A WIDE RANGE OF OUTPATIENT COUNSELING SERVICES, INCLUDING GROUP, INDIVIDUAL AND FAMILY COUNSELING. A VARIETY OF SUPPORT GROUPS ALSO MEET AT THE CENTER. OFF-CAMPUS PHYSICIAN OFFICES: A NUMBER OF PHYSICIAN OFFICES ARE LOCATED THROUGHOUT THE REGION SERVED BY ADENA. THESE INCLUDE OFFICES FOR FAMILY PHYSICIANS, ENDOCRINOLOGISTS, GERONTOLOGISTS AND UROLOGISTS. TELEMEDICINE: IN 2011, THE HEALTH SYSTEM CONTINUED ITS AFFILIATION WITH THE SOUTHERN OHIO HEALTH CARE NETWORK (SOHCN), A PARTNERSHIP OF THE REGION'S THREE LARGEST HEALTHCARE PROVIDERS -- ADENA, O'BLENESS HEALTH SYSTEM AND HOLZER CONSOLIDATED HEALTH SYSTEMS. THIS PARTNERSHIP HAS RESULTED IN THE CONSTRUCTION OF AN EXPANSIVE FIBER OPTIC BROADBAND TELECOMMUNICATIONS NETWORK TO SERVE THE HEALTHCARE AND EDUCATIONAL NEEDS OF PEOPLE LIVING IN OHIO'S APPALACHIAN REGION. THROUGH THIS TECHNOLOGY, TELEMEDICINE IS ENABLING PATIENTS TO BE ON ADENA'S CAMPUS, BUT TREATED BY PHYSICIANS OUTSIDE THE REGION. ADENA HAS TELEMEDICINE RELATIONSHIPS WITH OHIO STATE UNIVERSITY MEDICAL CENTER, RIVERSIDE METHODIST HOSPITAL, AND NATIONWIDE CHILDREN'S HOSPITAL IN COLUMBUS. 1 ADENA HEALTH FOUNDATION 272 HOSPITAL ROAD CHILLICOTHE OH 45601 753008742 501(C)(3) 416116 PAYMENT OF ORGANIZATION EXPENSES PIKE COMMUNITY HOSPITAL FOUNDATION 100 DAWN LANE WAVERLY OH 45690 311072406 501(C)(3) 10000 DIABETES TESTING PARTNERSHIP PROJECT WITH YMCA KIWANIS CLUB OF CHILLICOTHE 213 S PAINT STREET CHILLICOTHE OH 45601 311356976 501(C)(3) 5000 SOUTHERN PLAYGROUND CONSTRUCTION PROJECT ADENA HEALTH FOUNDATION 272 HOSPITAL ROAD CHILLICOTHE OH 45601 753008742 501(C)(3) 140004 TO PROVIDE ADDITIONAL FUNDIND TO THE AHF BOARD OF TRUSTEES' FUND THE CHESLER GROUP INC 9639 KINSMAN ROAD MATERIALS PARK OH 44073 341632120 223667 RESTORE HISTORIC BUILDING ADENA HEALTH FOUNDATION 272 HOSPITAL ROAD CHILLICOTHE OH 45601 753008742 501(C)(3) 220621 SUPPORT THE VOLUNTEER SCHOLARSHIP FUND AND PURCHASE EQUIPMENT/SUPPLIES 3 1 PART I, LINE 2: DECISIONS TO DONATE TO COMMUNITY PROJECTS ARE BROUGHT TO CEO FOR APPROVAL FROM MEMBERS OF SENIOR LEADERSHIP AND/OR THE STRATEGY DEPARTMENT. THE AMOUNTS ARE NOT SO SIGNIFICANT THAT THEY NEED TO BE APPROVED BY THE BOARD OF TRUSTEES. A BLANKET AMOUNT IS BUDGETED FOR THE FISCAL YEAR AND CONSIDERED AS EACH REQUEST IS MADE. X X 1 1 X X X X 1 0 0 0 0 0 0 0 0 JACK BERNO DIRECTOR/EMPLOYED M.D. 292607 0 0 0 4198 0 0 0 12693 0 309498 0 0 0 WILBUR SEVER DIRECTOR/EMPLOYED M.D. 602691 0 0 0 1380 0 16641 0 18873 0 639585 0 0 0 WAYNE COATS DIRECTOR/EMPLOYED M.D. 380023 0 0 0 1278 0 8654 0 18414 0 408369 0 0 0 DAWN BENNETT JOHNSON INTERIM CHIEF FINANCIAL OFFICER 234338 0 64000 0 993 0 21410 0 14110 0 334851 0 0 0 MARK SHUTER CHIEF EXECUTIVE OFFICER 689331 0 0 0 17842 0 61049 0 15394 0 783616 0 0 0 KEVIN MURPHY CHIEF FINANCIAL OFFICER (MAY-OCT) 128819 0 0 0 30433 0 4280 0 9461 0 172993 0 0 0 NATALIE DI LONNO ASSISTANT GENERAL COUNSEL (JAN-AUG) 194929 0 0 0 30808 0 12931 0 25457 0 264125 0 0 0 MICHELLE FEDERER EMPLOYED M.D. 239345 0 0 0 402 0 9995 0 1407 0 251149 0 0 0 JOHN FORTNEY CHIEF MEDICAL OFFICER 405872 0 0 0 5232 0 23434 0 12880 0 447418 0 0 0 ANTHONY FREEMAN EMPLOYED M.D. 787450 0 0 0 2898 0 9000 0 18873 0 818221 0 0 0 JUDITH HENSON CHIEF NURSING OFFICER 184843 0 0 0 942 0 13831 0 21623 0 221239 0 0 0 SATHISH JETTY EMPLOYED M.D. 438406 0 0 0 1179 0 15172 0 17947 0 472704 0 0 0 MARTHA LIVINGSTON CHIEF BUSINESS DEVLOPMENT OFFICER 210999 0 0 0 9912 0 26845 0 17263 0 265019 0 0 0 ERIC PERDUE CHIEF HUMAN RESOURCES 184182 0 0 0 342 0 15184 0 2908 0 202616 0 0 0 JOHN YOUNG EMPLOYED M.D. 1176550 0 0 0 2432 0 16346 0 16098 0 1211426 0 0 0 ERIC CECAVA MASTER BLACK BELT 159372 0 0 0 757 0 9933 0 20759 0 190821 0 0 0 GAIL GAMES VP EDUCATION AND DEVELOPMENT 156188 0 0 0 610 0 14038 0 1995 0 172831 0 0 0 MICHAEL GLANZMAN EXECUTIVE DIRECTOR PHYS. SERVICES 160279 0 0 0 183 0 9290 0 21318 0 191070 0 0 0 PATRICIA ROAM CHIEF COMPLIANCE OFFICER 163303 0 0 0 10289 0 15490 0 8303 0 197385 0 0 0 BRIAN COHEN EMPLOYED M.D. 3076260 0 0 0 2610 0 17500 0 15617 0 3111987 0 0 0 HAVAL SAADLLA EMPLOYED M.D. 1178902 0 0 0 24075 0 0 0 18902 0 1221879 0 0 0 DAVID JONES EMPLOYED M.D. 953476 0 6667 0 1779 0 0 0 2966 0 964888 0 0 0 THOMAS LEWIS EMPLOYED M.D. 925879 0 0 0 23853 0 0 0 18873 0 968605 0 0 0 MATHEW COSENZA EMPLOYED M.D. 871649 0 0 0 4002 0 0 0 13471 0 889122 0 0 0 ALLEN SHAW FORMER KEY EMPLOYEE, EMPLOYED M.D. 235347 0 0 0 776 0 0 0 11977 0 248100 0 0 0 ETHELBERT BAKER FORMER KEY EMPLOYEE, EMPLOYED M.D. 598275 0 0 0 3174 0 0 0 18873 0 620322 0 0 0 BARBARA PURDOM FORMER KEY EMPLOYEE 0 0 0 0 158201 0 0 0 7485 0 165686 0 0 0 FAITHA SHELTON FORMER KEY EMPLOYEE 134875 0 0 0 414 0 12878 0 19225 0 167392 0 0 0 KIRK TUCKER FORMER KEY EMPLOYEE, EMPLOYED M.D. 282452 0 0 0 600 0 0 0 17826 0 300878 0 0 0 PART I, LINE 1A ADENA HEALTH SYSTEM PROVIDES FOR A MEMBERSHIP TO THE LOCAL COUNTRY CLUB FOR ALL OFFICERS AND KEY EMPLOYEES. THIS BENEFIT IS GROSSED UP AND TAXED AND RECEIVED BY SEVEN OF THE OFFICERS AND KEY EMPLOYEES. PART I, LINE 4A LINE 4A: VARIOUS EMPLOYEES THAT WERE PREVIOUSLY LISTED IN PART VII, SECTION A, LINE 1A RECEIVED SEVERANCE DURING 2013. - KAREN BOLTON REPORTED SEVERANCE COMPENSATION OF $68,014 IN 2013. - NATALIE DI IONNO REPORTED SEVERANCE COMPENSATION OF $10,350 IN 2013. - BARBARA PURDOM REPORTED SEVERANCE COMPENSATION OF $160,205 IN 2013. - MARK MOFFIT REPORTED SEVERANCE COMPENSATION OF $37,500 IN 2013. ALL AFOREMENTIONED FORMER EMPLOYEES HAD SIMILIAR SEVERANCE PACKAGES. ALL ARE RECEIVING 12 MONTHS OF SEVERANCE AND THEN A 6 MONTH BRIDGE IF NOT EMPLOYED. AT ANY TIME AFTER THE INTIAL 12 MONTHS, AHS WOULD REDUCE PAY IF EMPLOYED AT A LESSER RATE. A COUNTY OF ROSS OHIO 316400085 778260EX3 2008-09-17 141346983 CURRENT REFUNDING OF 2001 AND 2006 ISSUES 0 0 0 B COUNTY OF ROSS OHIO 316400085 2010-09-15 29985000 INFUSION CENTER AND INTERVENTIONAL RADIOLOGY 0 0 0 A 5245000 196856019 10920538 1366439 487668 2010 1 0 1 1 B 1457323 30087491 411604 29675887 2012 0 0 1 1 A 0 0 0 0 0 0 1 B 0 1 0 0 0 0 1 A 0 0 0 1 0 0 1 BAYERISCHE LANDESBANK 3.000000000000 1 0 0 B 0 0 0 0 0 0 0 0 0 A 1 B 1 SCHEDULE K, PART II, LINE 6 2001 AND 2006 ISSUES WERE REFUNDED ON OCTOBER 29, 2008. INCLUDED $116,560,000 OF PRINCIPAL AND $149,427 OF INTEREST. THIS IS FOR THE 2008 ISSUE. SCHEDULE K, PART II, LINE 11 $11,750,000 OF ISSUE WAS USED TO PAY OFF QUALIFIED HEDGED RELATED TO THE 2001 AND 2006 BONDS. THIS IS FOR THE 2008 ISSUE. SCHEDULE K, PART III, LINE 2 ADENA HEALTH SYSTEM LEASES APPROXIMATELY 300 SQUARE FEET TO A FOR PROFIT COMPANY THAT OPERATES A COFFEE KIOSK. THIS IS CONSIDERED DEMINIMUS SPACE AND SO 0% WAS PUT IN LINE 4 OF PART III. THIS IS FOR THE 2008 ISSUE. THE LEASE CEASED IN FALL OF 2012. SCHEDULE K, PART IV, LINE 4A PROCEEDS INVESTED IN GIC FROM 2006 ISSUE - UNUSED PORTION TRANSFERS TO 2008 ISSUE. THE GIC MATURED IN JULY 2009; THIS WAS 36 MONTHS AFTER THE DATE OF ISSUE. THIS IS FOR THE 2008 ISSUE. SCHEDULE K, PART IV, LINE 2C THE DATE THE LAST REBATE COMPUTATION WAS PERFORMED IS OCTOBER 31, 2013. DOUGLAS FOLZENLOGEN PHYSICIAN RETENTION X 15000 15000 0 1 1 HAVAL SAADLLA PHYSICIAN RETENTION X 85000 13704 0 1 1 DAVID JONES PHYSICIAN RETENTION X 20000 11538 0 1 1 40242 HORIZON TELCOM INC BUSINESS VENDOR OF AHS 802599 PHONE SERVICE 0 ROBIN BERNO SPOUSE OF DIRECTOR JACK BERNO 100571 EMPLOYEE COMPENSATION 0 JENNIFER WHITE DAUGHTER-IN-LAW OF BOARD DIRECTOR TOM WHITE 127392 EMPLOYEE COMPENSATION 0 BRITTEN YOUNG SPOUSE OF KEY EMPLOYEE JOHN YOUNG 477564 EMPLOYEE COMPENSATION 0 JENNIFER STRICKLAND RELATIVE OF CHAIR DAVID STRICKLAND 28579 EMPLOYEE COMPENSATION 0 MICHELLE PERDUE SPOUSE OF KEY EMPLOYEE ERIC PERDUE 65192 EMPLOYEE COMPENSATION 0 SCHEDULE L, PART IV STEVE BURKHARDT THE TREASURER OF HORIZON TELCOM, INC. REGULARLY ABSTAINS FROM VOTING AND REMOVES HIMSELF FROM DISCUSSIONS CONCERNING HORIZON TELCOM, INC. FORM 990, PART VI, SECTION A, LINE 6 THE ORGANIZATION IS COMPOSED OF 9 MEMBER CHURCHES. ALL OF THE CHURCHES ARE IN THE CHILLICOTHE, OHIO AREA. 1.FIRST PRESBYTERIAN CHURCH 2.SALEM COMMUNITY CHURCH 3.ORCHARD HILL UNITED CHURCH OF CHRIST 4.TABERNACLE BAPTIST CHURCH 5.ST. MARY'S CATHOLIC CHURCH 6.TRINITY UNITED METHODIST CHURCH 7.ST. PAUL'S EPISCOPAL CHURCH 8.WALNUT STREET UNITED METHODIST CHURCH 9.ST. PETER'S CATHOLIC CHURCH FORM 990, PART VI, SECTION A, LINE 7A THE CORPORATE MEMBER CHURCHES MAY ONLY ELECT ONE PERSON PER CHURCH TO ACT AS THEIR TRUSTEE. THE TRUSTEES AT LARGE GET APPOINTED AS FOLLOWS. SECTION 3.03 OF THE CODE OF REGULATIONS OF AHS - "THE BOARD SHALL ELECT SIX (6) AT-LARGE TRUSTEE POSITIONS. TWO OF THESE POSITIONS SHALL BE FILLED WITH PHYSICIANS WHO ARE MEMBERS OF THE ACTIVE MEDICAL STAFF RECOMMENDED BY THE MEDICAL STAFF IN ACCORDANCE WITH THE MEDICAL STAFF BYLAWS. WHEN A VACANCY OCCURS AMONG THE FOUR (4) AT LARGE TRUSTEES, WITH THE EXCEPTION OF MEMBERS ELIGIBLE FOR REAPPOINTMENT, THE TRUSTEE COMMITTEE SHALL NOMINATE TO THE BOARD A CANDIDATE FOR THE VACANT POSITION." FORM 990, PART VI, SECTION A, LINE 7B SECTION 2.04 RIGHTS OF THE CORPORATE MEMBERS: (A) THE RIGHT TO ELECT NINE TRUSTEES OF THE CORPORATION AS SPECIFIED IN THESE BYLAWS. (B) THE RIGHT TO APPROVE ANY LEASE, SALE EXCHANGE, TRANSFER, OR OTHER DISPOSITION OF ALL OR SUBSTANTIALLY ALL OF THE ASSETS OF THE CORPORATION. (C) THE RIGHT TO APPROVE ANY PROPOSED MERGER OR CONSOLIDATION OF THE CORPORATION. (D) THE RIGHT TO APPROVE ANY PROPOSED DISSOLUTION OF THE CORPORATION. (E) THE RIGHT TO APPROVE ANY PROPOSED CHANGE TO THE FUNDAMENTAL PURPOSE OF THE CORPORATION AS STATED IN SECTION 1.01. (F) THE RIGHT TO APPROVE ANY PROPOSED AMENDMENTS TO THE CODE OF REGULATIONS. FORM 990, PART VI, SECTION B, LINE 11 THE 990 WAS REVIEWED AT A BOARD MEETING, AND COPIES OF THE FORM 990 WERE PROVIDED TO THE BOD MEMBERS. ADDITIONALLY, COPIES OF THE 990 WERE MADE AVAILABLE ON THE HOSPITAL'S BOARD PORTAL AND IN ADMINISTRATION OFFICE UNTIL THE NOVEMBER 15 FILING DATE. FORM 990, PART VI, SECTION B, LINE 12C THE CORPORATE COMPLIANCE OFFICE OF ADENA HEALTH SYSTEM ANNUALLY COORDINATES THE DISTRIBUTION AND RETURN OF THE CONFLICT OF INTEREST STATEMENTS. THE CORPORATE COMPLIANCE OFFICE IS RESPONSIBLE FOR REVIEWING THE RESPONSES AND COMMUNICATING ANY EXTRA STEPS THAT NEED TO TAKE PLACE REGARDING ANY OF THE RESPONSES. AT EVERY BOARD MEETING AND COMMITTEE OF THE BOARD, THE AGENDA ITEM OF CONFLICT OF INTEREST IS INCLUDED AND CALLED OUT. CONFLICTED BOARD MEMBERS ABSTAIN FROM VOTING ON THE PARTICULAR ITEMS. ANY MEMBER ABSTAINING FROM VOTING IS DOCUMENTED IN THE MINUTES. ALL ADENA HEALTH SYSTEM WORKFORCE MEMBERS AND BOARD MEMBERS ARE SUBJECT TO THE CONFLICT OF INTEREST POLICY. FORM 990, PART VI, SECTION B, LINE 15 THE TOP MANAGEMENT OFFICIAL AT ADENA HEALTH SYSTEM, ALONG WITH OFFICERS/KEY EMPLOYEES, HAVE THEIR COMPENSATION REVIEWED ON AN ANNUAL BASIS THROUGH THE EXECUTIVE COMPENSATION COMMITTEE OF THE BOARD OF TRUSTEES THROUGH THE USE OF AN INDEPENDENT THIRD PARTY EXECUTIVE COMPENSATION COMPANY. THE INDEPENDENT THIRD PARTY COMPENSATION COMPANY UTILIZES MULTIPLE INDEPENDENT COMPENSATION SURVEYS TO EVALUATE BOTH BASE COMPENSATION AND TOTAL CASH COMPENSATION AGAINST LIKE ORGANIZATIONS. RECOMMENDATIONS FOR CHANGE ARE MADE BY THE INDEPENDENT THIRD PARTY EXECUTIVE COMPENSATION COMPANY AND PRESENTED TO THE EXECUTIVE COMPENSATION COMMITTEE FOR CONSIDERATION. FINAL DECISIONS, WHETHER THEY BE APPROVAL OR DENIAL, ARE MADE BY THE COMMITTEE. THE PROCESS WAS LAST UNDERTAKEN IN JUNE OF 2013. SPECIFIC MERIT INCREASES FOR INDIVIDUALS ARE BASED UPON THE EMPLOYEE MEETING AGREED UPON DEVELOPMENTAL GOALS, PERFORMANCE-BASED GOALS, BEHAVIORS AND ESSENTIAL FUNCTIONS OF THEIR JOB FOR THE FISCAL YEAR. THE MERIT PROCESS WAS LAST UNDERTAKEN IN APRIL OF 2013. FORM 990, PART VI, SECTION C, LINE 19 THE ORGANIZATION PREPARES AN ANNUAL REPORT TO THE PUBLIC WHICH INCLUDES ITS STATEMENT OF REVENUES AND EXPENSES. ADDITIONALLY, ITS GOVERNING DOCUMENTS AND CONFLICT OF INTEREST POLICY IS AVAILABLE UPON REQUEST. THE FINANCIAL STATEMENTS ARE AVAILABLE ON GUIDESTAR.ORG AS PART OF THE ANNUAL FORM 990 FILING. FORM 990, PART XI, LINE 9: TRANSFERS TO AFFILIATED ORGANIZATION -13,147,529. PENSION RELATED CHANGES OTHERE THAN NET PERIODIC COSTS 7,489,511. INTERCOMPANY RECEIPTS ELIMINATED IN CONSOLIDATION 317,359. ADENA VAC INCOME NOT INCLUDED IN AUDITED NET ASSETS 1,460. VAC WOMEN'S BOARD GRANT 220,621. COURT DIALYSIS K-1 ACTIVITY - BOOK TO TAX DIFFERENCE -47,132. NET ASSETS RELEASED FROM RESTRICTION 479,602. TEMPORARILY RESTRICTED EXPENDITURES -70,403. ADENA MEDICAL GROUP LLC DEPT L637 COLUMBUS OH 43260 271370967 HEALTHCARE PROVIDERS OH -42653888 6957362 ADENA HEALTH SYSTEM ADENA HOSPICE LLC 272 HOSPITAL ROAD CHILLICOTHE OH 45601 275340755 HEALTHCARE PROVIDERS OH -556932 310048 ADENA HEALTH SYSTEM ADENA HOME HEALTH 272 HOSPITAL ROAD CHILLICOTHE OH 45601 273752730 HEALTHCARE PROVIDERS OH -2487703 597172 ADENA HEALTH SYSTEM ADENA HOME INFUSIONHOME RESPIRATORY 272 HOSPITAL ROAD CHILLICOTHE OH 45601 273752854 HEALTHCARE PROVIDERS OH -267075 1284950 ADENA HEALTH SYSTEM ADENA PHARMACY 272 HOSPITAL ROAD CHILLICOTHE OH 45601 451138187 HEALTHCARE PROVIDERS OH -239361 408650 ADENA HEALTH SYSTEM GREENFIELD AREA MEDICAL CETNER 550 MIRABEAU ST GREENFIELD OH 45123 310993422 HOSPITAL OH 501(C)(3) 3 ADENA HEALTH SYSTEM 1 ADENA HEALTH FOUNDATION 272 HOSPITAL ROAD CHILLICOTHE OH 45601 753008742 FUNDRAISING OH 501(C)(3) 11A ADENA HEALTH SYSTEM 1 SOUTHERN OHIO HEALTHCARE NETWORK 272 HOSPITAL ROAD CHILLICOTHE OH 45601 261566590 FIBEROPTIC NETWORK GRANTS OH 501(C)(3) 11A ADENA HEALTH SYSTEM 1 PIKE HEALTH SERVICES INC 100 DAWN LANE WAVERLY OH 45690 311072406 HOSPITAL OH 501(C)(3) 3 ADENA HEALTH SYSTEM 1 ADENA CARE 272 HOSPITAL ROAD CHILLICOTHE OH 45601 453980850 PROVIDE EMPLOYEE HEALTH INSURANCE OH ADENA HEALTH SYSTEM C 1150428 1.00000 1 0 1 1 0 0 0 0 0 0 0 0 0 0 0 1 1 0 1 1 GREENFIELD AREA MEDICAL CENTER R 380947 BOOK VALUE ADENA HEALTH FOUNDATION B 776741 CASH CONTRIBUTION ADENA HEALTH FOUNDATION C 733285 GRANT/CASH RECEIVED SOUTHERN OHIO HEALTHCARE NETWORK P 145038 BOOK VALUE ADENA HEALTH FOUNDATION O 294472 TIMESHEET ALLOCATION GREENFIELD AREA MEDICAL CENTER O 7548857 TIMESHEET ALLOCATION SOUTHERN OHIO HEALTHCARE NETWORK S 1257628 BOOK VALUE PIKE HEALTH SERVICES INC O 10462176 TIMESHEET ALLOCATION PIKE HEALTH SERVICES INC R 12033297 BOOK VALUE