2013-11-14T18:03:14-06:00 2012-12-31 381357951 PLANTE & MORAN PLLC 65 EAST STATE ST STE 600 COLUMBUS OH 43215 990 2012-01-01 314379443 ADENA HEALTH SYSTEM ADEN 7407794478 272 HOSPITAL RD CHILLICOTHE OH 45601 DAWN BENNETT-JOHNSON 7407794478 2013-11-12 1 BERNIE OSTROWSKI P00366367 6148493000 2012 2016-02-24 21:20:13Z ADENA REGIONAL MEDICAL CENTER MARK SHUTER 272 HOSPITAL RD CHILLICOTHE OH 45601 397945385 0 X WWW.ADENA.ORG X 1895 OH "TO HEAL, TO EDUCATE, TO CARE." THE 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. 14 9 3213 299 0 0 4108646 1407756 366151182 378441880 5646835 4729565 1874178 13256012 377780841 397835213 97223 788202 0 0 194995529 210329286 0 0 0 184979996 190672229 380072748 401789717 -2291907 -3954504 410696244 423361896 227847622 230072795 182848622 193289101 X SEE SCHEDULE O"TO HEAL, TO EDUCATE, TO CARE." THE 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. 0 0 350424425 788202 381381339 HEALTH CARE PROGRAMS, GENERAL/OTHER: ROUTINE HOSPITAL SERVICES. THERE WERE 13,188 INPATIENTS AND 917,307 OUTPATIENTS IN 2012.EMERGENCY SERVICES - TREATMENT OF EMERGENCY ACCIDENT AND ILLNESS AS WELL AS LESS URGENT CONDITIONS IN THE ABSENCE OF A FAMILY PHYSICIAN. THERE WERE 49,535 EMERGENCY VISITS IN 2012.THE HOSPICE AND HOME HEALTH DEPARTMENTS PROVIDE MEDICAL CARE, MEDICATIONS, HOME HEALTH NEEDS, BEREAVEMENT COUNSELING PRESCRIPTIONS, FOOD AND SHELTER TO PATIENTS. THERE WERE 10,612 HOSPICE DAYS IN 2012.PHYSICIAN OFFICES: THERE WERE 358,492 PHYSICIAN OFFICE VISITS IN 2012. 350424425 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 1 142 0 1 3213 1 0 0 0 0 0 0 0 0 0 0 X 14 9 0 0 0 0 1 1 1 1 1 0 0 1 1 1 1 1 1 1 1 0 X DAWN BENNETT JOHNSON INTERIM CFO 7407794200 272 HOSPITAL ROAD CHILLICOTHE OH 456019031 DEBORAH BARRINGTON 2.00 0.00 X 0 0 0 JACK BERNO 50.00 0.00 X 296346 0 12909 STEVEN BURKHARDT 2.00 0.00 X X 0 0 0 RALPH D'ANTONI 2.00 0.00 X 0 0 0 GARY EVANS 2.00 0.00 X 0 0 0 JAMES GROVE 2.00 0.00 X 0 0 0 CHAD HARRIS 2.00 0.00 X X 0 0 0 MIKE LILLY 2.00 2.00 X X 0 0 0 MATTHEW SCHMIDT 2.00 0.00 X 0 0 0 WILBUR SEVER 50.00 0.00 X 712322 0 31814 ALLEN SHAW 50.00 0.00 X 212563 0 10149 DAVE STRICKLAND 2.00 0.00 X X 0 0 0 TOM WHITE 2.00 0.00 X 0 0 0 NOBLE YOSHIDA 2.00 0.00 X 0 0 0 DAWN BENNETT JOHNSON 46.00 4.00 X 48654 0 0 KEITH COLEMAN 46.00 4.00 X 369508 0 75281 MARK SHUTER 46.00 4.00 X 727072 0 192602 ETHELBERT BAKER 50.00 0.00 X 648635 0 31160 KAREN BOLTON 45.00 6.00 X 270933 0 12460 LLOYD COATS 50.00 0.00 X 378884 0 28526 NATALIE DI LONNO 45.00 6.00 X 167141 0 29465 MICHELLE FEDERER 50.00 0.00 X 389253 0 16305 JOHN FORTNEY 50.00 0.00 X 422907 0 50313 ANTHONY FREEMAN 50.00 0.00 X 875659 0 31160 JEFFREY GRAHAM 50.00 0.00 X 163818 0 8048 JUDITH HENSON 50.00 0.00 X 160902 0 30312 SATHISH JETTY 50.00 2.00 X 413122 0 18514 MARTHA LIVINGSTON 50.00 0.00 X 184162 0 24452 DENISE MINOR 50.00 0.00 X 178775 0 6864 MARK MOFFITT 50.00 0.00 X 150505 0 33829 ERIC PERDUE 50.00 0.00 X 169658 0 31434 BARBARA PURDOM 50.00 0.00 X 316734 0 21310 FAITHA SHELTON 50.00 0.00 X 180755 0 36632 KIRK TUCKER 50.00 0.00 X 334123 0 18514 JOHN YOUNG 50.00 0.00 X 1068225 0 25555 BRIAN COHEN 50.00 0.00 X 2832624 0 25555 JAMES FLEMING 50.00 0.00 X 807493 0 31160 KORT GRONBACH 50.00 0.00 X 881950 0 31056 THOMAS LEWIS 50.00 0.00 X 857194 0 31160 MICHAEL VIETTI 50.00 0.00 X 859383 0 31160 DOUGLAS FOLZENLOGEN 50.00 0.00 X 366196 0 18514 15445496 0 946213 241 1 1 0 KINGS MEDICAL COMPANY PO BOX 72483 CLEVELAND OH 44192 MRI SERVICES 2076641 TATUM LLC PO BOX 847872 DALLAS TX 752847872 STAFFING SERVICES 2015565 MEDICAL DOCTOR ASSOCIATES PO BOX 277185 ATLANTA GA 303847185 MEDICAL STAFFING SERVICES 1179196 INTERIM PHYSICIANS LLC PO BOX 790379 STLOUIS MO 631790379 MEDICAL STAFFING SERVICES 852164 THE PENDLETON GROUP INC 200 CHARTWELL PT ROAD SENECA SC 29672 CONSULTING 433402 17 31975 2380 764428 436386 172587 1407756 NET PATIENT SVC REV 622110 378441880 378441880 378441880 4719893 4719893 2907253 0 2907253 2907253 2907253 15716 6044 9672 9672 9672 48213 2380 51180 -2967 -2967 138874 52948 85926 85926 EHR IMPLEMENTATION 622110 4764713 4764713 FOOD & NUTRITION 622110 1436317 1436317 CONSULTING FEES 622110 1389659 1389659 2675111 1463874 1211237 10265800 397835213 381381339 0 15046118 788202 788202 16517745 13203787 3313958 148997610 143901231 5096379 10115119 7849333 2265786 34698812 25952193 8746619 657529 563909 93620 669957 669957 120000 120000 39757298 21874406 17882892 290336 216160 74176 14257718 9114450 5143268 4592377 4592377 12595407 12595407 964520 664089 300431 8833304 6854644 1978660 22409705 13620701 8789004 2819530 2687582 131948 MEDICAL SUPPLIES 61183546 61183546 0 0 BAD DEBT EXPENSE 25522738 25522738 0 0 OVERHEAD ALLOCATION -4001736 -760330 -3241406 0 401789717 350424425 51365292 0 10848 10343 75912428 75023140 4554026 4877872 44303899 38926587 159180 5582037 5150603 3046536 9902850 365946902 209445403 155999265 156501499 114131981 114226562 7155224 18583260 410696244 423361896 32054059 36977454 178919218 178918450 16874345 14176891 227847622 230072795 X 182286137 192560681 562485 728420 182848622 193289101 410696244 423361896 X -3954504 6000793 8394190 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 1756 1756 0 EXPLANATION OF LOBBYING ACTIVITIES: 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. 1050463 1142201 169101 192806 2168959 979299 48900 30021 7757 1050463 859540 50593 101333 32167 979299 762259 170668 85016 158403 859540 615256 263999 641 18520 99117 0 762259 1.00000 0 0 2648975 2648975 165766734 59180475 106586259 10302964 10302964 0 179653398 135086368 44567030 7574831 4875596 2699235 156501499 ACCRUED MALPRACTICE INSURANCE - LT 7152468 DEFINED BENEFIT PLAN LIABILITY 7024423 14176891 X DESCRIPTION OF INTENDED USE OF ENDOWMENT FUNDS: PART V, LINE 4: ADENA HEALTH FOUNDATION ENDOWMENT FUNDS ARE USED TO PROVIDE SCHOLARSHIPS AND PURCHASE CAPITAL FOR PACCAR MEDICAL EDUCATION CENTER. DESCRIPTION OF UNCERTAIN TAX POSITIONS UNDER FIN 48: PART X, LINE 2: ACCOUNTING PRINCIPLES GENERALLY ACCEPTED IN THE UNITED STATES OF AMERICA REQUIRE MANAGEMENT TO EVALUATE TAX POSITIONS TAKEN BY THE 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, 2012 AND 2011, 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, 2009. CHARITY BALL 18172 2380 15792 1403 849 16094 PLANT SALE 32421 32421 32834 50593 2380 48213 1403 849 48928 51180 -2967 1 1 X 1 X 1 X 1 1 0 1 1 17682745 6383959 11298786 0.03000 68482397 44184191 24298206 0.06460 86165142 50568150 35596992 0.09460 670854 670854 0.00180 1016884 492733 524151 0.00140 54926 54926 0.00010 1742664 492733 1249931 0.00330 87907806 51060883 36846923 0.09790 26177 26177 0.00010 26177 26177 0.00010 1 25522738 0 67706848 62723307 4983541 X 0 1 1 ADENA REGIONAL MEDICAL CENTER

272 HOSPITAL RD CHILLICOTHE OH 45601

X X X ADENA REGIONAL MEDICAL CENTER 1 1 1 100.000000000000 1 400.000000000000 1 X X X X X X 1 1 X X X X X 1 0 1 X 0 0 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 URGENT CARE

55 CENTENNIAL BLVD CHILLICOTHE OH 45601

AMBULATORY CARE CENTER ADENA HEALTH CENTER - WAVERLY

12340 STATE ROUTE 104 WAVERLY OH 45690

AMBULATORY CARE CENTER ADENA HEALTH CENTER - JACKSON

1000 VETERANS DRIVE JACKSON OH 45640

AMBULATORY CARE CENTER ADENA HOME CARE SERVICES

111 W WATER STREET CHILLICOTHE OH 45601

HOME HEALTH CARE AND HOSPICE 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. PART I, L7 COL(F): BAD DEBT EXPENSE OF $25,522,738 WAS DEDUCTED FROM TOTAL OPERATING EXPENSES WHEN CALCULATING THE PERCENTAGES IN THIS COLUMN. PART III, LINE 4: 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 39% OF THE AMOUNT BOOKED AS BAD DEBT EXPENSE RELATED TO UNCOMPENSATED CHARITY CARE. THE HOSPITAL RECLASSED $16,422,776 FROM BAD DEBT EXPENSE TO CHARITY CARE. BAD DEBT EXPENSE BEFORE THIS RECLASS WAS $41,945,514 LEAVING $25,522,738 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 INCURRED A SHORTFALL OF $8,939,227 IN 2012. THE PHYSICIAN MEDICARE ADVANTAGE PLAN INCURRED A SHORTFALL OF $3,843,410 IN 2012. 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 PAYER 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. 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 100% FPL 2. 90% WRITE-OFF - BETWEEN 101 - 150% OF FPL 3. 75% WRITE-OFF - BETWEEN 151 - 250% OF FPL 4. 50% WRITE-OFF - BETWEEN 251 - 350% FPL 5. 25% WRITE-OFF BETWEEN 351 - 400% FPL 6. 0% WRITE-OFF - GREATER THAN 400% 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. SCHEDULE H, SECTION B, PART V, LINE 15 THE HOSPITAL'S FAP DISCUSSES, AT A HIGH LEVEL, ACTIONS THE HOSPITAL MAKE TAKE IN COLLECTION EFFORTS. THE HOSPITAL IS IN PROCESS OF FINALIZING A SEPARATE BILLING AND COLLECTION POLICY. FURTHERMORE, THE HOSPITAL HAS AUTOMATED PARAMETERS IN IT'S SOFTWARE TO ENSURE PROPER BILLING AND COLLECTION PRACTICES ARE FOLLOWED. SCHEDULE H, PART VI, LINE 2 THE STUDY COMPLETED BY THE OHIO STATE UNIVERSITY'S COLLEGE OF PUBLIC HEALTH'S CENTER FOR PUBLIC HEALTH PRACTICE REFLECTS THE COMMUNITY HEALTH STATUS OF ADENA HEALTH SYSTEM'S SERVICE REGION. ADENA ALSO MEASURES THE NEEDS OF COMMUNITIES AND POPULATIONS BASED ON APPLICATIONS IT RECEIVES FROM AREA NONPROFIT ORGANIZATIONS, INCLUDING SCHOOLS. THE STUDY'S COMMON FINDINGS SHOW THAT THOSE LIVING IN ADENA'S SERVICE REGION ARE AMONG OHIO'S MOST VULNERABLE POPULATIONS. OUR COMMUNITY FACES UNIQUE HEALTH RISKS AND BARRIERS AS A RESULT OF SOCIAL STATUS, HUMAN CAPITAL, SOCIAL CAPITAL AND RISK. MANY REQUIRE SPECIAL SERVICES AND/OR ENHANCED OUTREACH. A SERIOUS THREAT TO THE OVERALL HEALTH OF PEOPLE IN ADENA'S SERVICE AREA IS OBESITY. THE MAJORITY OF PEOPLE IN OUR SERVICE REGION ARE OVERWEIGHT OR OBESE. OVERWEIGHT AND OBESE PEOPLE ARE AT RISK OF DEVELOPING CONDITIONS SUCH AS DIABETES, HYPERTENSION AND HIGH CHOLESTEROL, AMONG OTHER CONDITIONS THAT LEAD TO CHRONIC DISEASE. CHILDREN ARE AT SIMILAR RISKS FOR HEALTH PROBLEMS WHEN OVERWEIGHT OR OBESE, WHICH COULD HAVE A LONG TERM IMPACT ON THEIR LIVES. THE INCIDENCE OF DIABETES, CANCER AND HEART DISEASE ARE PROMINENT IN ADENA'S PATIENT POPULATION. MORTALITY STUDIES COMPARING ADENA'S SERVICE REGION TO U.S, OHIO AND PEER COUNTY RATES SHOW DEATH RATES FROM CARDIOVASCULAR DISEASE AND CANCER ARE OF CONCERN. COUNTY HEALTH RANKINGS DATA INDICATES THAT NINE OF TWELVE COUNTIES IN THE ADENA SERVICE REGION RANK IN THE BOTTOM 25 PERCENT IN HEALTH OUTCOMES. THE MAJORITY OF OUR COMMUNITY OUTREACH EFFORTS ARE FOCUSED ON EDUCATING OUR PATIENTS ON THE IMPORTANCE OF BETTER HEALTHCARE, POSITIVE LIFESTYLE DECISIONS AND DISEASE PREVENTION - AND GUIDING THEM ON THEIR HEALTHCARE JOURNEY. SCHEDULE H, 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% 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. SCHEDULE H, PART VI, LINE 4 ADENA HEALTH SYSTEM SERVES THE NEEDS OF MORE THAN 500,000 PEOPLE IN 12 COUNTIES IN SOUTH CENTRAL OHIO. ADENA REGIONA MEDICAL CENTER IS LOCATED IN CHILLICOTHE, OHIO. CHILLICOTHE IS A CITY OF 21,700 LOCATED IN ROSS COUNTY AND SERVES A POPULATION OF APPROXIMATELY 78,800 RESIDENTS. THE FOLLOWING DETAILS THE NUMBER OF PEOPLE IN THE ADENA SERVICE REGION GROUP BY VULNERABILITIES. 18.9% NO HIGH SCHOOL DIPLOMA 6.8% UNEMPLOYED 43.9% DEPRESSION 8% RECENT DRUG USER, 32% OBESE, DISABILITY PREVALENCE RATES ARE 16.7% - 22% POVERTY LEVELS RANGE FROM 11.1% TO 27.7%. THE POVERTY RATE RANGE FOR OHIO IS 8.1% TO 21.2%. A HIGH PROPORTION OF ADENA PATIENTS HAVE NO OR LIMITED HEALTH INSURANCE COVERAGE, THESE INCLUDE: 23.4% UNINSURED 12.3% MEDICARE BENEFICIARIES 27.5% MEDICAID BENEFICIARIES DATA SHOWS THAT NEARLY 25 PERCENT OF ADENA'S SERVICE REGION RESIDENTS ARE UNINSURED. WHILE SLIGHTLY BELOW THE STATE AVERAGE OF 16%, THIS PERCENTAGE MAY INCREASE DUE TO THE ECONOMIC CLIMATE AND UNEMPLOYMENT RATES. FACTORS THAT MAY CONTRIBUTE TO THE REGION'S MORBIDITY AND MORTALITY RATES. SCHEDULE H, PART VI, LINE 5 ADENA HEALTH SYSTEM SERVES NEARLY A HALF-MILLION PATIENTS IN OHIO'S APPALACHIAN REGION. MANY PEOPLE IN THE REGION STRUGGLE WITH OBESITY, DIABETES AND HEART DISEASE. IN ADDITION, POVERTY LEVELS IN THE REGION ARE AMONG THE HIGHEST IN THE STATE. MANY OF OUR PATIENTS ARE IN NEED FINANCIALLY AND IN TERMS OF HEALTH COVERAGE. ADENA AND ITS EMPLOYEES RECOGNIZE THE VALUE OF OUR HEALTHCARE SERVICES FOR THOSE OUR COMMUNITIES, IN ADDITION TO THE VARIETY OF NEEDS MANY OF OUR PATIENTS HAVE. TO MEET THOSE NEEDS, ADENA AND ITS EMPLOYEES PARTICIPATED IN THE FOLLOWING ACTIVITIES AND SERVICES TO ENHANCE THE HEALTH AND WELL-BEING OF THE PATIENTS WE SERVE. HOPE CLINIC: ABOUT 18 PERCENT OF ROSS COUNTY RESIDENTS, OR NEARLY ONE-IN-FIVE, HAVE NO FORM OF HEALTH INSURANCE. TO ENSURE ACCESS TO HEALTH CARE, THE HOPE CLINIC OF ROSS COUNTY WAS IN DEVELOPMENT IN 2011 (OPENING IN JANUARY 2012). ADENA WAS INVOLVED IN THE PLANNING AND PREPARATION. ONCE OPEN, ADENA PHYSICIANS AND NURSES WILL VOLUNTEER THEIR TIME AT THE CLINIC, PROVIDING FREE HEALTH CARE TO THOSE NEEDING IT THE MOST. ADENA (PACCAR) MEDICAL EDUCATION CENTER: BASIC FIRST AID AND CPR COURSES PROVIDED TO ORGANIZATIONS WITHIN THE REGION SERVED BY ADENA HEALTH SYSTEM. THE COURSES HELP EDUCATE THE PUBLIC ABOUT WHAT THEY CAN DO WHEN FACED WITH A MEDICAL EMERGENCY, UNTIL PROFESSIONAL HELP ARRIVES. AMONG THOSE WHO HAVE TAKEN ADVANTAGE OF THE COURSES ARE AREA ORGANIZATIONS INCLUDING: BIG BROTHERS AND BIG SISTERS, KENWORTH TRUCKING, MCDONALD'S RESTAURANTS, ROSS COUNTY ENGINEER'S OFFICE, ROSS COUNTY HEALTH DEPARTMENT AND SOUTHERN OHIO EYE SURGERY CENTER. IN ADDITION TO FIRST AID AND CPR COURSES, ADENA'S COMMUNITY COURSE OFFERINGS INCLUDE ADVANCED CARDIAC LIFE SUPPORT AND A NEONATAL RESUSCITATION PROGRAM. ATHLETIC TRAINERS: TO ENSURE THE SAFETY AND HEALTH OF LOCAL TEEN ATHLETES, ADENA PROVIDES ATHLETIC TRAINERS FREE-OF-CHARGE TO SEVEN HIGH SCHOOLS IN FOUR COUNTIES IN ITS SERVICE REGION. ADENA SPORTS MEDICINE PHYSICIANS ARE AVAILABLE ON SATURDAY MORNING'S TO EVALUATE LOCAL ATHLETES' INJURIES. THE HEALTH SYSTEM'S ATHLETIC TRAINERS ALSO PROVIDE COMMUNITY EDUCATIONAL PROGRAMS, INCLUDING REHABILITATION AND NUTRITION EDUCATION, CPR CLASSES AND SCHOOL SPORTS PHYSICALS. IN ADDITION, OUR TRAINERS PROVIDE FREE SERVICES AT COMMUNITY EVENTS INCLUDING: GUS MACKER 3-ON-3 TOURNAMENT, OHSAA BASEBALL ALL-STAR TOURNAMENT, AND VARIOUS OTHER EVENTS. EMPLOYEES GIVING BACK: COATS FOR KIDS: FOR THE FOURTH YEAR, ADENA EMPLOYEES RAISED HUNDREDS OF COATS FOR CHILDREN FROM LOW-INCOME HOMES THROUGHOUT OUR SERVICE REGION. MORE THAN 300 NEW OR GENTLY USED COATS WERE DONATED IN 2012. FOOD PANTRY ASSISTANCE: ADENA'S STRATEGY DIVISION PACKED 700 BAGS OF GROCERIES (4,900 CANS) AT THE GOOD SAMARITAN FOOD PANTRY, AS A WAY OF HELPING THE LESS FORTUNATE IN THE AREA DURING THANKSGIVING. THE UNEMPLOYMENT RATE FOR THE REGION IS HIGHER THAN AVERAGE AND THE FOOD PANTRY IS CRUCIAL IN FEEDING MANY FAMILIES. PEDIATRIC AUCTION: STAFF OF ADENA PEDIATRICS HELD AN IN-HOUSE CHARITY AUCTION WITH PROCEEDS GOING TO NEEDY CHILDREN IN THE COMMUNITY. MORE THAN $1,600 WAS RAISED AND DONATED TO 15 CHILDREN WHO WERE IDENTIFIED BY THE SALVATION ARMY AS HAVING SIGNIFICANT NEED. RAISING AWARENESS OF SEXUAL VIOLENCE: ADENA PARTNERED WITH THE ROSS COUNTY SEXUAL ASSAULT RESPONSE TEAM TO HOST "TAKE A WALK IN HER SHOES" EVENT TO RAISE MONEY AND AWARENESS TO THE PROBLEM OF SEXUAL VIOLENCE IN THE REGION. $2,000 WAS RAISED TO TRAIN VOLUNTEER SEXUAL ASSAULT VICTIM ADVOCATES. FREE MAMMOGRAMS: HUNDREDS OF UNINSURED AND UNDERINSURED WOMEN IN ADENA'S SERVICE REGION RECEIVED MAMMOGRAMS AS PART OF THE "A PROMISE TO KEEP" PROGRAM. THE HEALTH SYSTEM APPLIED FOR GRANT FUNDING TO HELP COVER SOME COST OF THE PROGRAM, WHICH IS VITAL IN FINDING BREAST CANCER EARLY. WOMEN IN APPALACHIA ARE TYPICALLY DIAGNOSED IN MORE ADVANCED STAGES OF THE DISEASE, DUE TO LACK OF INSURANCE OR EDUCATION ON THE IMPORTANCE OF MAMMOGRAPHY. KID SHAPE: OBESITY IS A MAJOR HEALTH CONCERN IN ADENA'S SERVICE AREA. TO HELP CHILDREN AND THEIR FAMILIES LEARN ABOUT EATING HEALTHY AND LOSE WEIGHT, ADENA DIETICIANS TEACH THE EIGHT-WEEK KID SHAPE COURSE. THE ADENA HEALTH FOUNDATION COVERS 2/3 OF THE COST OF THE PROGRAM TO ENSURE PARTICIPATION IS NOT COSTLY. EIGHTY-SEVEN PERCENT OF KIDSHAPE PARTICIPANTS LOSE WEIGHT AND 80% OF PARTICIPANTS KEEP THE WEIGHT OFF AFTER TWO YEARS. ADENA WEIGH: TO COMBAT OBESITY IN OUR COMMUNITY, ADENA SPONSORS A WEIGHT LOSS AND LIFESTYLE COACHING PROGRAM WITH A REGISTERED DIETITIAN TO IMPROVE THE HEALTH OF OUR PATIENTS AND STAFF. A REGISTERED DIETITIAN ASSESSES THE CLIENT'S DIET QUALITY AND MAKES RECOMMENDATIONS FOR HEALTH IMPROVEMENT AND WEIGHT LOSS. PATIENTS LEARN THEIR BODY MASS INDEX, WAIST CIRCUMFERENCE, HEALTH RISKS BASED ON YOUR EATING HABITS, DIET IMPROVEMENT AND DETERMINE A WEIGHT LOSS GOAL. DONATION TO OPEN COMMUNITY POOL: WHEN THE CITY OF CHILLICOTHE DID NOT HAVE THE FUNDS TO OPEN THE COMMUNITY SWIMMING POOL, ADENA STEPPED UP WITH A $10,000 DONATION. MANY IN THE COMMUNITY DO NOT HAVE THE MEANS TO AIR CONDITION THEIR HOMES, AND THE POOL SERVES AS A WAY FOR FAMILIES TO STAY COOL IN THE HOT WEATHER, AS WELL AS OFFERS THE HEALTH BENEFITS INVOLVED IN SWIMMING AND BEING ACTIVE. COMMUNITY EDUCATION: ADENA PERSONNEL PARTICIPATE IN NUMEROUS HEALTH SCREENINGS AND HEALTH EDUCATION EVENTS TO PROMOTE BETTER HEALTH AND LIFESTYLE CHOICES TO THOSE LIVING IN OUR SERVICE AREA. THESE INCLUDE VISITS TO SCHOOLS, SENIOR CENTER, COMMUNITY ORGANIZATIONS, AND MORE. HEALTHCARE CAREER EVENT: ADENA HOSTS A HEALTHCARE CAREER NIGHT FOR STUDENTS IN GRADES 7 THROUGH 12. AT THE EVENT, COLLEGES AND UNIVERSITIES PRESENT INFORMATION ABOUT CAREERS IN HEALTHCARE AND THE CURRICULUM AVAILABLE FOR STUDENTS. INFORMATION PRESENTED IN BREAKOUT SESSIONS INCLUDE: EMS, MEDICAL ASSISTANT, MEDICAL OFFICE, MEDICAL THERAPIES, NON-DIRECT PATIENT CARE, NURSING, PHYSICIAN, PHYSICIAN ASSISTANT, PHARMACY, RADIOLOGY RESPIRATORY AND SIMULATION - VIRTUAL HOSPITAL. SCHEDULE H, 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 MANSION & GARDENS SOCIETY 848 ADENA ROAD CHILLICOTHE OH 45601 271330314 501(C)(3) 10000 SPONSORSHIP TO HELP MANAGE THE ADENA HISTORICAL MANSION. CITY OF CHILLICOTHE 35 S PAINT STREET CHILLICOTHE OH 45601 316400221 GOVERNMENT 10000 SPONSORSHIP OF THE COMMUNITY POOL. CHILLICOTHE EDUCATION FOUNDATION 45 EAST MAIN STREET CHILLICOTHE OH 45601 311480939 501(C)(3) 6000 SPONSORSHIP OF THE "LEADER-IN-ME" PROGRAM FOR CITY SCHOOLS. ADENA HEALTH FOUNDATION 272 HOSPITAL ROAD CHILLICOTHE OH 45601 753008742 501(C)(3) 478880 PAYMENT OF ORGANIZATION EXPENSES ADENA HEALTH FOUNDATION 272 HOSPITAL ROAD CHILLICOTHE OH 45601 753008742 501(C)(3) 100000 SUPPORT THE VOLUNTEER SCHOLARSHIP FUND AND PURCHASE EQUIPMENT/SUPPLIES ADENA HEALTH FOUNDATION 272 HOSPITAL ROAD CHILLICOTHE OH 45601 753008742 501(C)(3) 139992 TO HELP FUND ADENA HEALTH FOUNDATION'S OPERATING EXPENSES THE CHESSLER GROUP INC 9639 KINSMAN ROAD MATERIALS PARK OH 44073 341632120 26177 RESTORE HISTORICAL BUILDING 4 1 PROCEDURE FOR MONITORING GRANTS IN THE U.S.: PART I, LINE 2: SCHEDULE I, 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 X 1 1 0 0 0 0 0 0 0 JACK BERNO 292192 0 0 0 4154 0 0 0 21812 0 318158 0 0 0 WILBUR SEVER 685991 0 0 0 26331 0 654 0 32691 0 745667 0 0 0 ALLEN SHAW 211131 0 0 0 1432 0 0 0 16065 0 228628 0 0 0 KEITH COLEMAN 366383 0 0 0 3125 0 55419 0 29295 0 454222 0 0 0 MARK SHUTER 710977 0 0 0 16095 0 160198 0 33935 0 921205 0 0 0 ETHELBERT BAKER 645493 0 0 0 3142 0 0 0 32802 0 681437 0 0 0 KAREN BOLTON 95962 0 0 0 174971 0 1023 0 13822 0 285778 0 0 0 LLOYD COATS 377841 0 0 0 1043 0 0 0 29945 0 408829 0 0 0 NATALIE DI LONNO 166399 0 0 0 742 0 10636 0 28048 0 205825 0 0 0 MICHELLE FEDERER 388541 0 0 0 712 0 0 0 17506 0 406759 0 0 0 JOHN FORTNEY 418314 0 0 0 4593 0 31799 0 28204 0 482910 0 0 0 ANTHONY FREEMAN 872590 0 0 0 3069 0 0 0 32665 0 908324 0 0 0 JEFFREY GRAHAM 163372 0 0 0 446 0 2853 0 11243 0 177914 0 0 0 JUDITH HENSON 160062 0 0 0 840 0 9859 0 24092 0 194853 0 0 0 SATHISH JETTY 410927 0 0 0 2195 0 0 0 27359 0 440481 0 0 0 MARTHA LIVINGSTON 183303 0 0 0 859 0 16781 0 12195 0 213138 0 0 0 DENISE MINOR 31141 0 0 0 147634 0 0 0 8785 0 187560 0 0 0 MARK MOFFITT 149634 0 0 0 871 0 27253 0 12342 0 190100 0 0 0 ERIC PERDUE 169348 0 0 0 310 0 29484 0 6639 0 205781 0 0 0 BARBARA PURDOM 132783 0 14000 0 169951 0 857 0 25831 0 343422 0 0 0 FAITHA SHELTON 180090 0 0 0 665 0 16361 0 26307 0 223423 0 0 0 KIRK TUCKER 333589 0 0 0 534 0 0 0 26841 0 360964 0 0 0 JOHN YOUNG 1055414 0 10256 0 2555 0 0 0 27472 0 1095697 0 0 0 BRIAN COHEN 2830899 0 0 0 1725 0 0 0 27607 0 2860231 0 0 0 JAMES FLEMING 804897 0 0 0 2596 0 0 0 32528 0 840021 0 0 0 KORT GRONBACH 880999 0 0 0 951 0 0 0 32221 0 914171 0 0 0 THOMAS LEWIS 820302 0 0 0 36892 0 0 0 32256 0 889450 0 0 0 MICHAEL VIETTI 822084 0 33333 0 3966 0 0 0 32702 0 892085 0 0 0 DOUGLAS FOLZENLOGEN 365050 0 0 0 1146 0 0 0 25866 0 392062 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, LINES 4A-B LINE 4A: KAREN BOLTON, DENISE MINOR, AND BARBARA PURDOM WERE ALL KEY EMPLOYEES IN 2012. ALL ARE RECEIVING 12 MONTHS OF SEVERANCE AND THEN A 6 MONTH BRIDGE IF STILL NOT EMPLOYED. AT ANY TIME AFTER THE INITIAL 12 MONTHS, AHS WOULD REDUCE PAY IF EMPLOYED AT A LESSER RATE. KAREN BOLTON REPORTED SEVERANCE COMPENSATION IN 2012 OF $174,619, DENISE MINOR REPORTED SEVERANCE COMPENSATION IN 2012 OF $147,330, AND BARBARA PURDOM REPORTED SEVERANCE COMPENSATION IN 2012 OF $169,517. LINE 4B: MEMBERS OF THE EXECUTIVE TEAM PARTICIPATE IN A 457(F) NON-QUALIFIED DEFERRED COMPENSATION PLAN ESTABLISHED BY THE ORGANIZATION. THE FOLLOWING MEMBERS OF THE EXECUTIVE TEAM THAT ARE LISTED ON FORM 990, PART VII, SECTION A, LINE 1A PARTICIPATED IN THE PLAN: - KEITH COLEMAN - JOHN FORTNEY - MARK MOFFITT - ERIC PERDUE - MARK SHUTER 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 3370000 196850421 10920538 1366439 487668 55557232 2010 1 0 1 1 B 613965 30087491 411604 28391799 1284088 2012 0 0 0 1 A 0 1 0 0 0.00000 0.00000 0.00000 0 0 1 B 0 0 0 0 0.00000 0.00000 0.00000 0 0 1 A 0 0 0 0 0 0 1 BAYERISCHE LANDESBANK 3.000000000000 1 0 0 B 0 0 0 0 1 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. THOMAS LEWIS PHYSICIAN RECRUITMENT X 95000 57796 0 1 1 MICHAEL VIETTI PHYSICIAN RECRUITMENT X 100000 51282 0 1 1 WILBUR SEVER PHYSICIAN RECRUITMENT X 190000 24846 0 1 1 JOHN YOUNG PHYSICIAN RECRUITMENT X 40000 10256 0 1 1 DOUGLAS FOLZENLOGEN PHYSICIAN RETENTION X 15000 15000 0 1 1 159180 HORIZON TELCOM INC BUSINESS VENDOR OF AHS 839386 PHONE SERVICE 0 ROBIN BERNO SPOUSE OF DIRECTOR JACK BERNO 93860 EMPLOYEE COMPENSATION 0 DEAN KUCHTA SPOUSE OF KEY EMPLOYEE KAREN BOLTON 69681 EMPLOYEE COMPENSATION 0 JENNIFER WHITE DAUGHTER-IN-LAW OF BOARD DIRECTOR TOM WHITE 114213 EMPLOYEE COMPENSATION 0 BRITTEN YOUNG SPOUSE OF KEY EMPLOYEE JOHN YOUNG 517048 EMPLOYEE COMPENSATION 0 LOIS JETTY SPOUSE OF KEY EMPLOYEE SATISH JETTY 209404 EMPLOYEE COMPENSATION 0 MICHELLE PERDUE SPOUSE OF KEY EMPLOYEE ERIC PERDUE 63061 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 THE NOVEMBER 4TH 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 15TH 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 ANY KEY EMPLOYEES HAVE THEIR COMPENSATION REVIEWED ON A BI-ANNUAL BASIS IN CONJUNCTION WITH OTHER MANAGEMENT POSITIONS BY THE HUMAN RESOURCE DEPARTMENT RESPONSIBLE FOR EMPLOYEE COMPENSATION. VARIOUS MARKET SURVEYS ARE USED AS APPROPRIATE FOR THE APPLICABLE POSITIONS AND RECOMMENDATIONS FOR SALARY SCALE CHANGES ARE APPROVED BY THE HUMAN RESOURCES COMMITTEE OF THE ADENA HEALTH SYSTEM BOARD OF DIRECTORS. SPECIFIC WAGE INCREASES FOR INDIVIDUALS ARE BASED ON THE EMPLOYEE MEETING AGREED UPON DEVELOPMENTAL AND PERFORMANCE-BASED GOALS FOR THE FISCAL YEAR. THE PROCESS WAS LAST UNDERTAKEN DURING 2012 AND ALSO IN APRIL/JUNE 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. CHANGES IN NET ASSETS OR FUND BALANCES: FORM 990, PART XI, LINE 9: TRANSFERS TO AFFILIATED ORGANIZATION -137,978. PENSION RELATED CHANGES OTHERE THAN NET PERIODIC COSTS 8,406,397. INTERCOMPANY RECEIPTS ELIMINATED IN CONSOLIDATION -3,954. ADENA VAC INCOME NOT INCLUDED IN AUDITED NET ASSETS -86,776. VAC WOMEN'S BOARD GRANT 100,000. COURT DIALYSIS K-1 ACTIVITY 116,501. 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