2013-05-07T11:10:33-07:00 2012-06-30 990 2011-07-01 341041385 SALEM COMMUNITY HOSPITAL SALE 3303327214 1995 East State Street Salem OH 44460 Michael Giangardella 3303327214 2013-05-07 2011 2016-03-07 17:11:31Z Steven Ruwoldt 1995 East State Street Salem OH 44460 104204513 0 X www.salemhosp.com X 1913 OH Salem Community Hospital (SCH) is a 110-bed, not-for-profit rural facility, which provides a continuum of medical services to the residents of Columbiana and southern Mahoning counties, including inpatient and outpatient medical and surgical care, obstetrics, and gynecology, pediatrics, orthopedics, intensive care and a 15-bed skilled nursing facility. The Hospital also operates a full-time 24-hour Emergency Department, and treats all patients requiring medical care, irrespective of their financial means. The Hospital provides its services free of charge or on a sliding scale to uninsured/underinsured patients, regardless of race, creed, origin, handicap, age or ability to pay. 18 16 1023 234 2135699 0 118471 107383 92685567 96568019 4199313 6579676 557363 649381 97560714 103904459 19644 16655 0 0 48318558 46973971 0 0 0 46714552 49293617 95052754 96284243 2507960 7620216 204224659 200584570 42884461 58055743 161340198 142528827 SCH's mission is to provide high quality care to the sick and injured, on both an inpatient and outpatient basis, and address our patients' health care needs at each life stage, within our available resources. SCH seeks to provide a broad range of diagnostic, inpatient, outpatient and emergency services appropriate for a community hospital, while ensuring that sufficient, high-quality primary and specialty physician services are available and accessible to residents of our service area. 0 0 68788010 96568019 The Hospital's mission is to provide quality care to the sick and injured on both and inpatient and outpatient basis, and address our patients' healthcare needs at each life stage, within our available resources. SCH seeks to provide a broad range of diagnostic, inpatient, outpatient and emergency services appropriate for a community hospital, while ensuring that sufficient, high-quality primary and specialty physician services are available and accessible to residents of our service area. During fiscal year 2012, the Hospital provided comprehensive healthcare services including: 5,325 Admissions; 3,834 Surgeries; and 27,854 Emergency Department visits. In support of this commitment, the Hospital operates a full-time, 24-hour Emergency Department, and treats all patients requiring emergency medical care, irrespective of their financial means. The Hospital also accepts all patients covered by Medicare, Medicaid and General Assistance. Subsidized health services provided by the Hospital that are not self-sustaining include obstetric services and outpatient behavioral health.The Hospital's net costs for supporting these services is $1,151,920. If these programs were closed or not available to the community, the cost to the government or to another tax-exempt organization would increase. The Hospital also accepts all patients covered by Medicare, Medicaid and General Assistance. For fiscal year 2012, costs incurred by the Hospital for net charity care provided were $2,018,947 million, with unpaid costs of Medicaid representing $1,119,151 million, and unreimbursed costs from other governmental programs representing $2,342,251 million. These community benefits, arising from patient care provided by the Hospital are documented to help to relieve a governmental financial and programmatic burden as evidenced through the Hospital's charitable purpose. Community investment grants provided by the Hospital totaled $6,000 during FY 2012, and included financial support of a medication assistance program to the elderly or disadvantaged. 0 0 0 68788010 1 1 0 0 0 0 0 0 0 0 1 0 0 0 1 0 0 1 0 0 0 0 0 0 1 0 1 1 1 0 1 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 1 1 0 0 1 81 0 1 1023 1 1 1 0 0 0 0 0 X 18 16 0 0 0 0 0 0 0 1 1 0 0 1 1 1 1 1 1 1 0 0 X Michael Giangardella 3303327214 1995 East State Street Salem OH 44460 Catherine Hubbs 1 X X 0 0 0 Derek Hiscox 1 X X 0 0 0 Matt Bender 1 X X 0 0 0 Dick Wilk 1 X X 0 0 0 John Haller 1 X 0 0 0 Greg Bestic 1 X 0 0 0 Bill McDevitt 1 X 0 0 0 Peter Apicella MD 1 X 8500 0 0 Jon Rettig Sr 1 X 0 0 0 Dave Mollenkopf 1 X 0 0 0 Dave Gano 1 X 0 0 0 Jeffrey Cohen MD 1 X 0 0 0 John Dawson MD 1 X 7500 0 0 John Biastro 1 X 0 0 0 Todd Olson 1 X 0 0 0 Jon Vollnogle 1 X 0 0 0 Vicki Hall 1 X 0 0 0 Bart Brine MD 1 X 0 0 0 Howard E Rohleder 40 X 299650 0 126619 Anita Hackstedde 40 X 224255 0 47955 Mike Giangardella 40 X 190057 0 111950 Barbara Hirst 40 X 163492 0 97762 Keith Meredith 40 X 137440 0 31627 Mark LItalien 40 X 121557 0 96129 Doreen Sheck 41.30 X 116804 0 23357 Stephen Ferenchak 40.80 X 114227 0 42798 Donald Hughes 41.65 X 111226 0 79942 1494708 0 658139 17 0 1 0 Inpatient Medical Services Inc 822 Kumho Drive Suite 202 Fairlawn OH 44333 Medical Services 853806 Associates in Anesthesiology Inc PO Box 2190 Youngstown OH 44504 Medical Services 852119 Laboratory Corporation of America PO box 12140 Burlington NC 27216 Laboratory services 409450 Paris Healthcare Linen Service 67 Hoover Avenue PO Box 1043 Dubois PA 15801 Linen Service 389703 Alliance Healthcare Services PO Box 96485 Chicago IL 60693 Healthcare Services 362750 14 0 0 30627 0 0 76756 0 107383 Patient Service Revenue 622000 94432320 94432320 0 0 Patient Service Revenue 621500 1034093 0 1034093 0 Patient Service Revenue 621610 1101606 0 1101606 0 0 0 0 0 96568019 6579676 0 0 6579676 0 0 0 0 0 0 0 0 311555 0 278598 0 32957 0 32957 0 0 32957 0 0 12473 30627 21456 -8983 0 -8983 Dietary Income 900099 527222 527222 0 0 Chart Fees/Medical Records 900099 30184 30184 0 0 Gift Shop Income 900099 13267 13267 0 0 54734 54734 0 0 625407 103904459 95057727 2135699 6603650 16655 16655 1016316 1016316 36295376 26954252 9341124 614909 511444 103465 6231528 4246682 1984846 2815842 2048012 767830 9134 9134 45676 45676 7722413 4732363 2990050 420307 420307 17679557 15490173 2189384 2862186 2862186 4224657 2888978 1335679 163816 20789 143027 267857 267857 8699716 6082383 2617333 853757 802035 51722 Bad Debts 4994244 4994244 0 0 State Franchise Fee 1350297 0 1350297 0 96284243 68788010 27496233 0 3512178 3814525 7856791 7190157 3263 1632 648671 655430 3623721 3754447 161845922 95791145 69169409 66054777 119221171 118933147 189455 180455 204224659 200584570 9085818 10522085 32100000 30850000 1381643 922282 317000 15761376 42884461 58055743 X 161340198 142408827 0 120000 0 0 161340198 142528827 204224659 200584570 X 7620216 -26431587 X 0 1 1 X 0 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 1908632 0 1908632 91289555 0 45639832 45649723 1477707 0 1082514 395193 65405215 0 49068799 16336416 1764813 0 0 1764813 66054777 Early Retirement 13000 Deferred Liability 270000 Pension Liability 15478376 15761376 Dinner Party 43100 30627 12473 0 0 0 11073 1400 8983 0 0 43100 30627 12473 0 0 0 11073 1400 8983 21456 -8983 1 1 1 X 1 X 1 1 0 1 1 3492225 1473278 2018947 0.021 4019927 2900776 1119151 0.0116 7228640 4886389 2342251 0.0243 0 0 14740792 9260443 5480349 0.0569 54 14227 140646 9086 131560 0.0014 21 417 480336 0 480336 0.005 3414024 2262104 1151920 0.012 42 4900 60466 0 60466 0.0006 117 19544 4095472 2271190 1824282 0.0190 117 19544 18836264 11531633 7304631 0.0759 2 25 1200 1200 0.00001 8 220 8737 8737 0.00009 5 1819 19006 19006 0.0002 3 204 3016 3016 0.00003 4 126 3222 3222 0.00003 6 9008 9008 0.00009 8 3600 3600 0.00004 5 329 32145 32145 0.00034 41 2723 79934 0 79934 0.00083 0 2193434 211269 18340938 28794877 -10453939 X 1 0 1 1 Salem Community Hospital

1995 East State Street Salem OH 44460

X 15 bed skilled nursing facility Salem Community Hospital 1 1 1 150 1 350 1 X X X X X 1 1 X X 1 X X X 1 X X X X X 1 X 0 0 SchH_P01_S00_L06a Schedule H, Part I, Line 6a Salem Community Hospital prepares an Annual Report that is distributed to the community in paper format as well as being posted on the Hospital's website at www.salemhosp.com. The Annual Report includes a summary of the Hospital's statement of expenses and uncompensated care. This community benefit information is provided in an effort to document its tax exempt purpose and demonstrate the benefits provided for the broader community as determined by community need. SchH_P01_S00_L07 Schedule H, Part I, Line 7 Costs are determined by applying the ratio of cost to charges to gross charges. Beyond charity care, "Other Benefits" reported include community health improvement services and community benefit operations, with community building activities listed in Part II. The Hospital seeks opportunities to further its tax exempt purpose by providing a wide variety of benefits for the broader community, such as community health improvement services, community benefit operations and community building activities. Examples of these programs include, but are not limited to: participation in community health needs assessments and grant-writing activities for improved community health; health professionals education for nurses, therapists (physical, occupational, speech, and respiratory), medical imaging technologists and dietitians; financial and in-kind contributions for summer feeding programs and community food pantries, blood drives, social services for vulnerable populations (including assistance with medications, transportation, limited English proficiency and referrals to support systems); community health education for breast health, cancer, diabetes, obesity prevention, advance directives and women's health; and community health fairs and free clinical screenings for high blood pressure, cholesterol, blood sugar, bone density and pulmonary lung functions. Many of these educational programs, screenings, health fairs and outreach activities are provided in outlying school districts and communities within the Hospital's defined geographic service area, in an effort to increase regional access to health services and health resources for people of all ages. It is estimated that approximately 19,544 area residents participated in community benefit programs and/or events provided and/or sponsored by the Salem Community Hospital. The Hospital also provides a free, telephone emergency response service for over 220 area residents, enabling elderly and physically disadvantaged individuals to live independently in their homes. SchH_P01_S00_L07g Schedule H, Part I, Line 7g Costs for subsidized health services include those attributable to providing womens's obstetric services and outpatient behavioral health services. There are no health services attributable to a physician clinic. SchH_P02_S00_L00 Schedule H, Part II During the taxable year, the Hospital participated in 41 different community building activities in an effort to address the root causes of area health problems, such as those related to poverty and the environment. The Hospital participated in the Salem Area Industrial and Development Council and several area Chambers of Commerce activities; provided community support related to youth asset development through the Coordinated Action for School Health (CASH) Coalition and was a leading collaborative partner in disaster readiness; assisted in environmental improvements related to community medications disposals; offered leadership development and training related to cultural skills and language skills training for those with limited English proficiency; represented the Hospital on diverse community coalitions related to improving community health; advocated for community health improvements on the local and state levels on behalf of improving access to health care; and assisted with workforce development related to participation in community workforce boards, partnerships with area universities to address the health care work force shortage, and providing many school-based programs on health care careers, including offering teen and college student mentoring opportunities. The Hospital continues to serve as a community resource and partner for regional non-profit organizations, by providing collaborative programming with agencies such as the American Cancer Society, American Diabetes Association, American Heart Association, American Red Cross, Columbiana County Community Action Agency, Columbiana County and Salem City Departments of Health, Coordinated Action for School Health, Hospice of the Valley, Kent State University- Salem Campus, March of Dimes, Northeast Ohio Workforce Development, Northeast Ohio Medical University, Retried Senior Volunteer Program-Medication Assistance, Salem Area Visiting Nurses Association, and Salem Community Center. In addition, the Hospital makes financial and in-kind contributions to many of these not-for-profit organizations through event sponsorships, less the cost of benefits received; meeting space; and grant writing services to assist local health agencies in acquiring resources to address barriers to access SchH_P03_S0A_L04 Schedule H, Part III, Section A, Line 4 Excerpt from footnote: "The Hospital reports patient accounts receivable for services rendered at net realizable amounts from third-party payers, patients and others. The Hospital provides an allowance for doubtful accounts based upon a review of outstanding receivables, historical collection information and existing economic conditions. As a service to the patient, the Hospital bills third-party payers directly and bills the patient when the patient's liability is determined. Patient accounts receivable are due in full when billed. Accounts are considered delinquent and subsequently written off as bad debts based on individual credit evaluation and specific circumstances of the account. " The cost of bad debts was determined by applying the Hospital's cost to charge ratio to the charges that were written off to bad debt. The Hospital believes that this cost is a community benefit because patients ,who would likely qualify for assistance under the Hospital's Charity Care policy,do not or are unwilling to,provide documentation of their eligibility for charity care and are therefore classified as bad debt. The Hospital is very willing to work out payment arrangements and discounted fees;however,those patients who do not respond to repeated offers of assistance are categorized as bad debt expense. Had information been made available to make a determination of their eligibility,the Hospital believes that many of the patients classified as bad debt ,would qualify for charity care. This judgement is based on the economic conditions of our area and specific knowledge of the patients involved SchH_P03_S0B_L08 Schedule H, Part III, Section B, Line 8 The costs were obtained from the Hospital's Medicare Cost Report. The Hospital incurred costs in excess of $28.79 million to care for and treat Medicare beneficiaries,while receiving reimbursement of approximately $18.34 million,leaving a shortfall of $10.45. This was a direct health care benefit provided by the Hospital to the local Medicare beneficiaries who live in the surrounding communities. SchH_P03_S0C_L09b Schedule H, Part III, Section C, Line 9b Per the Hospital's Charity Care policy,the Hospital will not pursue collection for non-payment of bills against individuals who demonstrate that they have neither sufficient income nor assets to meet their financial obligations. SchH_P05_S0B_L03 Schedule H, Part V, Section B, Line 3 For the 2009 Columbiana County Needs Assessment, a community survey questionnaire was developed by the Ohio University's Voinovich School of Leadership and Public Affairs, and the surveys were distributed throughout the county, with 702 households responding. In addition, two senior citizen focus groups were held with 43 senior citizens participating. SchH_P05_S0B_L13 Schedule H, Part V, Section B, Line 13 The availability of free or discounted care is provided on billing statements sent to patients. SchH_P05_S0B_L19 Schedule H, Part V, Section B, Line 19 The Hospital's uninsured/underinsured policy provides discounts to patients based on the patients income( up to 350% of the Federal pverty level). The amount of the discount is based on the gross charges,with the discount level increasing as the charges increase. SchH_P06_S00_L02 Schedule H, Part VI, Line 2 SCH formally assesses the healthcare needs of the communities that it serves on a minimum of a triennial basis, and does so in collaboration with other community health providers. The most recent comprehensive, county-wide needs assessment was published in January 2009, and included collaboration with organizations such as the Hospital, Community Action Agency, Columbiana County Family and Children First Council, Columbiana County Job and Family Services, Ohio Department of Health, East Liverpool City Hospital and the Family Recovery Counseling Center. Quantitative and qualitative research for the study was performed by Ohio University's Voinovich School Research Team. The geographic area of the needs assessment encompassed Ohio's Columbiana County, most of which is within Salem Community Hospital's Service Area, and prioritized the public, primary and specialty health care needs of community members from birth through end-of-life care. Input from community members was obtained through written surveys, along with focus group interviews of senior citizens. Needs identified as priorities from the 2009 county-wide assessment included: cost and lack of insurance, need for prescription medication assistance and lack of access to primary care and specialty physicians. Interventions occurring as a result included financial support of the county-wide medication assistance program, which yielded increased access to medications through the pharmaceutical companies; and ongoing recruitment and retention of primary care and specialty physicians. Each participating organization developed an action plan to address the identified needs of their consumers with consideration of the resources available. The Hospital carried forward its implementation strategies by including them in its annual Organizational Goals. In addition, the Hospital is a collaborative partner in other types of needs assessments, such as the school health asset study, through the Search Institute, conducted on an annual basis with area school districts. During this past fiscal year, Salem Community Hospital also participated in a tri-county health needs assessment and development of an implementation plan for Mahoning, Columbiana and Trumbull Counties, the hospital partners of which included Humility of Mary Health Partners, Akron Children's Hospital and Salem Community Hospital, along with the Mahoning County, Columbiana County, East Liverpool City and Salem City Health Departments. Because the scope of the tri-county needs assessment was so broad, Salem Community Hospital used the preliminary findings from this needs assessment to launch a new county-wide needs assessment in the summer of 2012, targeted toward the specific needs of Columbiana County residents. SchH_P06_S00_L03 Schedule H, Part VI, Line 3 The Hospital includes on all billing statements information regarding the availability of free care programs and the required income guidelines . This information is also posted on the Hospital's website ,along with the charity care policies. SchH_P06_S00_L04 Schedule H, Part VI, Line 4 The Hospital's rural service area includes Columbiana County, excluding Yellow Creek and East Liverpool Townships, and the five lower townships of Mahoning county, which is officially designated as part of the Appalachian region. Columbiana County is also designated as Medically Underserved (MUP), and as a dental and mental health care Health Professional Shortage Area (HPSA). Columbiana County residents are older than their state and national counterparts, and the Service Area is characterized by a declining social and economic base, which impacts the area's health status problems and health service utilization. Columbiana County has a large percentage of adults who are unable to afford to see a doctor compared to other US counties, and the county is not meeting the Healthy People 2020 goals for health insurance coverage for children and adults. Poverty is also a factor with almost one-half of the county's population at or below 200% of the federal poverty level. Area residents experience higher death rates for chronic diseases, such as heart disease, cerebrovascular disease, diabetes and chronic obstructive pulmonary disease. The overall cancer mortality rate in Columbiana County is significantly higher than surrounding counties and the state of Ohio, especially related to colorectal, kidney, leukemia, liver and lung cancers, and lymphoma. The county rates of death attributable to diabetes mellitus are approximately 25% higher than the state. The area also has a low educational attainment rate, with 15.5% of adults over age 25 having no high school diploma, and less than 12% of adults having a Bachelor's or Master's degree. SchH_P06_S00_L05 Schedule H, Part VI, Line 5 The Hospital's mission is to provide quality care to the sick and injured on both and inpatient and outpatient basis, and address our patients' healthcare needs at each life stage, within our available resources. SCH seeks to provide a broad range of diagnostic, inpatient, outpatient and emergency services appropriate for a community hospital, while ensuring that sufficient, high-quality primary and specialty physician services are available and accessible to residents of our service area. Medical staff privileges are extended to qualified physicians in the Hospital's Service Area, based on documented community need for the medical service and the Hospital's resources to provide the service. During fiscal year 2012, the Hospital provided comprehensive healthcare services including: 5,325 Admissions; 3,834 Surgeries; and 27,854 Emergency Department visits. In support of this commitment, the Hospital operates a full-time, 24-hour Emergency Department, and treats all patients requiring emergency medical care, irrespective of their financial means. The Hospital also accepts all patients covered by Medicare, Medicaid and General Assistance. Subsidized health services provided by the Hospital that are not self-sustaining include obstetric services and outpatient behavioral health. The Hospital's net costs for supporting these services is $1,151,920. If these programs were closed or not available to the community, the cost to the government or to another tax-exempt organization would increase. The Hospital also accepts all patients covered by Medicare, Medicaid and General Assistance. For fiscal year 2012, costs incurred by the Hospital for net charity care provided were $2,018,947 million, with unpaid costs of Medicaid representing $1,119,151 million, and unreimbursed costs from other governmental programs representing $2,342,251 million. These community benefits, arising from patient care provided by the Hospital are documented to help to relieve a governmental financial and programmatic burden as evidenced through the Hospital's charitable purpose. In order to provide services efficiently and cost-effectively, the Hospital also utilizes an active volunteer base, with 234 community members donating over 17,153 hours of volunteer service annually. In addition, the Hospital's Board of Directors is comprised of 18 community volunteers from the Hospital's Service Area, who perform fiduciary responsibilities through monthly committee and Board activities. The Hospital actively seeks opportunities to further its tax exempt purpose through community health improvement and community benefit operations that provide treatment and/or promote health in response 1 Retired Senior Vounteer Program 966 1/2 North Market Street PO Box 355 Lisbon OH 44432 341902451 501(c)(3) 6000 Medical Assistance Program 1 0 SchI_P01_S00_L02 Schedule I, Part I, Line 2 The allocation and utilization of grant funds are monitored through the required tracking and reporting of specific outcomes by each grantee,along with site visits to the respective grantee organization. Grantee organizations are also required to submit either itemized invoices for subcontracted services and/or a detailed outcome report listing the number and types of services provided and the number of clients served. X X X X 0 1 0 0 0 0 0 0 0 Howard E Rohleder 299650 0 0 0 0 0 114795 0 11824 0 426269 0 0 Anita Hackstedde 224255 0 0 0 0 0 37313 0 10642 0 272210 0 0 Mike Giangardella 190057 0 0 0 0 0 101308 0 10642 0 302007 0 0 Barbara Hirst 163492 0 0 0 0 0 91850 0 5912 0 261254 0 0 Keith Meredith 137440 0 0 0 0 0 25252 0 6375 0 169067 0 0 Mark LItalien 121557 0 0 0 0 0 77004 0 19125 0 217686 0 0 Doreen Sheck 116804 0 0 0 0 0 10055 0 13302 0 140161 0 0 Stephen Ferenchak 114227 0 0 0 0 0 30048 0 12750 0 157025 0 0 0 Donald Hughes 111226 0 0 0 0 0 62205 0 17737 0 191168 0 0 0 SchJ_P01_S00_L03 Schedule J, Part I, Line 3 The President's compensation is determined by the Board of Director's, based upon the recommendation of the Board's Executive Committee. The Committee evaluates market data through statewide salary surveys as well as targeted regional survey data. Their decision is documented in their minutes. This process was last completed during the fiscal year ending June 30,2012. SchJ_P01_S00_L04 Schedule J, Part I, Line 4 A non-qualified deferred compensation plan exists for the CEO. There were no employer contributions to the plan during the fiscal year. City Of Salem Ohio 346002560 794424BY6 2005-09-15 37000000 Hospital Facility Construction 0 1 0 4900000 0 37000000 0 824965 0 241580 168740 1800 27596755 9200000 0 2008 0 1 1 1 0 1 0 0 0.0112 0 0.0112 1 0 1 0 0 0 1 F990_P06_S0B_L11b Form 990, Part VI, Section B, Line 11b The final 990 is available for review by the governing body via email,prior to filing. F990_P06_S0B_L12c Form 990, Part VI, Section B, Line 12c On an annual basis,Directors and key employees disclose potential business or professional relationships they may have with the organization and/or other Directors/Key employees. In situations when a Director has a conflict,they may participate in the discussion,but leave the room prior to final discussion and vote. F990_P06_S0B_L15 Form 990, Part VI, Section B, Line 15 The President's compensation is determined by the Board of Directors ,based upon the recommendation of the Board's Executive Committee. The committee evaluates market data through statewide salary surveys,as well as targeted regional survey data. Their decision is documented in their minutes. This process was last completed during the fiscal year ended June 30,2012. F990_P06_S0C_L19 Form 990, Part VI, Section C, Line 19 As a private not-for-profit organization,Salem Community Hospital does not make its governing documents or financial statements generally available to the public ,although the federal form 990 is available for review upon request. F990_P11_S00_L05 Form 990, Part XI, Line 5 Change in unrealized losses on other than trading securities of ( $7,314,161),defined benefit pension plan net loss of ($17,915,523),fund balance transfer to related organization of ($1,321,903),increase in restricted assets of $120,000. SCH Professional Corporation 1995 East State Street Salem OH 44460 341764515 Physician Offices OH 501(c)(3) 11 N/A Salem Medical Arts & Development Corporation 2020 East State Street Salem OH 44460 341049534 Office Rent OH N/A C 1 0 1 0 0 0 0 0 0 1 1 1 0 1 1 0 0 0 0 SCH Professional Corporation n 85766 % of time spent SCH Professional Corporation b 1233463 actual expenditures SCH Professional Corporation i 88440 actual expenditures Salem Medical Arts & Development Corporation k 10400 Actual expenditures