2013-05-08T15:41:38-05:00 2012-06-30 381357951 PLANTE & MORAN PLLC 65 EAST STATE ST STE 600 COLUMBUS OH 43215 990 2011-07-01 311045101 APPALACHIAN COMMUNITY VISITING NURSE ASSOCIATION HOSPICE AND HEALTH SERVICES APPA 7405935551 30 HERROLD AVENUE ATHENS OH 457012326 DEHORAH SECHKAR 7405935551 2013-05-02 1 BERNIE OSTROWSKI P00366367 6148493000 2011 2016-03-07 17:11:31Z TERRI MCKINLEY 30 HERROLD AVENUE ATHENS OH 457012326 3776326 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. 11 11 114 48 0 0 133112 99056 3758424 3674576 2286 2694 0 0 3893822 3776326 0 0 0 0 2404202 2684107 0 0 1902 1237155 1231929 3641357 3916036 252465 -139710 952589 950851 378372 462839 574217 488012 X 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 879593 0 1543115 THE ORGANIZATION PROVIDES CARE TO HOME BOUND, INDIGENT, AND TERMINALLY-ILL PATIENTS IN THE COMMUNITY. TO ACCOMPLISH ITS CHARITABLE PURPOSE, THE ORGANIZATION PROVIDED 9,255 DAYS OF HOSPICE CARE. THE ORGANIZATION PROVIDES CARE TO PATIENTS WHO MEET CERTAIN CRITERIA UNDER ITS CHARITY CARE POLICY WHITOUT CHARGE OR AT AMOUNTS LESS THAN ITS ESTABLISHED RATES. 490500 0 621990 THE ORGANIZATION PROVIDES CARE TO HOME BOUND, INDIGENT, AND TERMINALLY-ILL PATIENTS IN THE COMMUNITY. TO ACCOMPLISH ITS CHARITABLE PURPOSE, THE ORGANIZATION PROVIDED 28,669 HOURS OF HEALTH SERVICES. THE ORGANIZATION PROVIDES CARE TO PATIENTS WHO MEET CERTAIN CRITERIA UNDER ITS CHARITY CARE POLICY WHITOUT CHARGE OR AT AMOUNTS LESS THAN ITS ESTABLISHED RATES. 1058109 0 1477128 THE ORGANIZATION PROVIDES CARE TO HOME BOUND, INDIGENT, AND TERMINALLY-ILL PATIENTS IN THE COMMUNITY. TO ACCOMPLISH ITS CHARITABLE PURPOSE, THE ORGANIZATION PROVIDED 13,659 HOME HEALTH VISITS. THE ORGANIZATION PROVIDES CARE TO PATIENTS WHO MEET CERTAIN CRITERIA UNDER ITS CHARITY CARE POLICY WHITOUT CHARGE OR AT AMOUNTS LESS THAN ITS ESTABLISHED RATES. 1086519 0 32343 OTHER- MAJORITY OF EXPENSE INCLUDES STAFF COSTS FOR MISCELLANEOUS SERVICES 1086519 32343 3514721 1 1 0 0 0 0 0 0 0 1 1 1 0 0 0 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 6 0 1 114 1 0 0 0 0 0 0 0 0 0 0 X 11 11 0 0 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 X 0 0 0 SUSAN CYRAN 1.00 X 0 0 0 RON STRICKMAKER 1.00 X 0 0 0 DAVID STROH 1.00 X X 0 0 0 MICHAEL TURNER 1.00 X X 0 0 0 KATHY TARANTELLI 1.00 X 0 0 0 RUTH ANN ALTHAUS 1.00 X X 0 0 0 DOREEN IRETON 1.00 X 0 0 0 SANDRA SHIREY 1.00 X 0 0 0 RAY STEPHENS 1.00 X X 0 0 0 CANDY KEMMERER 1.00 X 0 0 0 DEBORAH SECHKAR 40.00 X 81455 0 1352 THOMAS CAMPBELL 40.00 X 154079 0 29 235534 0 1381 1 0 1 0 0 10132 88924 99056 PATIENT SERVICES 621610 3674576 3674576 3674576 2694 2694 3776326 3674576 0 2694 87343 77517 9826 2205152 1957073 248079 210044 186414 23630 181568 161142 20426 350 350 98146 87104 11042 16774 14887 1887 389251 345460 43791 1258 1116 142 86603 76860 9743 216548 192187 24361 1130 1003 127 750 750 2457 2181 276 31611 28055 3556 HOSPICE ROOM & BOARD 267499 267499 BAD DEBTS 74820 74820 EMERGENCY RESPONSE SYST 28360 28360 DUES AND SUBSCRIPTIONS 8920 8061 859 7452 4982 568 1902 3916036 3514721 399413 1902 212702 35094 70317 0 635151 712760 14048 11521 13656 29853 834548 830290 6715 4258 0 157365 952589 950851 378372 362839 0 100000 378372 462839 X 571963 331052 2254 156960 574217 488012 952589 950851 X -139710 53504 X X 0 1 1 X 0 X 269104 153022 230286 133112 99056 884580 3468287 3540437 3901744 3758424 3747453 18416345 3737391 3693459 4132030 3891536 3846509 19300925 0 0 0 19300925 2180 2425 2100 2286 2694 11685 2180 2425 2100 2286 2694 11685 3739571 3695884 4134130 3893822 3849203 19312610 0.99940 0.99830 0.00060 0.00060 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 2261 156967 159228 2259 2 2261 2257 2 2259 2251 6 2257 1.00000 1 0 834548 830290 4258 4258 BOARD DESIGNATED INVESTMENTS 70259 C DONOR RESTRICTED INVESTMENTS 87106 C 157365 SHELTERING ARMS HOSPITAL FOUNDATION LOAN PAYABLE 100000 100000 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: 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, 2012, 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. X X 0 0 0 0 0 0 0 0 0 THOMAS CAMPBELL 154079 0 0 0 0 0 0 0 29 0 154108 0 0 0 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 CHIEF FINANCIAL OFFICER REVIEWS THE FORM 990 PRIOR TO SIGNING AND SUBMITTING TO THE IRS. THE ORGANIZATION IS CONTROLLED BY SHELTERING ARMS HOSPITAL FOUNDATION. WHILE THE BOARD DID NOT REVIEW THE FORM 990 FOR THIS FILING YEAR, THE ORGANIZATION, THROUGH SHELTERING ARMS HOSPITAL FOUNDATION, WILL BE IMPLEMENTING A BOARD REVIEW FOR NEXT YEAR'S FORM 990. FORM 990, PART VI, SECTION B, LINE 12C ANNUAL CONFLICTS OF INTEREST 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 PRESIDENT/CEO 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 2011. THERE ARE NO OTHER OFFICERS OR KEY EMPLOYEES THAT ARE COMPENSATED BY THE ORGANIZATION. FORM 990, PART VI, SECTION C, LINE 18 FORM 1023 AND 990 ARE AVAIABLE UPON REQUEST. FORM 990, PART VI, SECTION C, LINE 19 IF REQUESTS ARE MADE FROM THE PUBLIC TO VIEW THE ORGANIZATION'S GOVERNING DOCUMENTS, CONFLICT OF INTEREST POLICY OR FINANCIAL STATEMENTS, THE ORGANIZATION COMPLIES WITH THE IRS PUBLIC INSPECTION REQUIREMENTS FOR FORM 990. 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 5: NET UNREALIZED LOSSES ON INVESTMENTS: -6,595. NET ASSETS RELEASED FROM RESTRICTION -94,607. TEMPORARILY RESTRICTED NET ASSETS RECLASS FROM OPERATING CASH ACCOUNT 154,706. TOTAL TO FORM 990, PART XI, LINE 5: 53,504. FORM 990, PART XI, 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 1 0 0 0 0 1 0 1 0 0 1 0 1 0 SHELTERING ARMS HOSPITAL FOUNDATION J 67200 LEASE AGREEMENT SHELTERING ARMS HOSPITAL FOUNDATION E 100000 LOAN AGREEMENT