2012-05-14T16:05:39-05:00 2011-06-30 PLANTE & MORAN PLLC 65 EAST STATE ST STE 600 COLUMBUS OH 43215 990 2010-07-01 311045101 APPALACHIAN COMMUNITY VISITING NURSE ASSOCIATION HOSPICE AND HEALTH SERVICES APPA 7405935551 30 HERROLD AVENUE ATHENS OH 457012326 DEBORAH SECHKAR 7405935551 2012-05-11 1 BERNIE OSTROWSKI 6148493000 2010 2016-02-24 21:20:13Z DEBORAH SECHKAR 30 HERROLD AVENUE ATHENS OH 457012326 3893822 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. 10 10 84 68 0 0 230286 133112 3901744 3758424 2100 2286 0 0 4134130 3893822 0 0 0 0 2347628 2404202 0 0 1853 1275923 1237158 3623551 3641360 510579 252462 872521 952589 555073 378372 317448 574217 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 3274497 0 3758424 THE ORGANIZATION PROVIDES CARE TO HOME BOUND, INDIGENT, AND TERMNIALLY-ILL PATIENTS IN THE COMMUNITY. TO ACCOMPLISH ITS CHARITABLE PURPOSE, THE ORGANIZATION PROVIDED 9,889 DAYS OF HOSPICE CARE, 21,227 HOURS OF HEALTH SERVICES AND 11,676 HOME HEALTH VISITS. THE ORGANIZATION PROVIDES CARE TO PATIENTS WHO MEET CERTAIN CRITERIA UNDER ITS CHARITY CARE POLICY WITHOUT CHARGE OR AT AMOUNTS LESS THAN ITS ESTABLISHED RATES. 3274497 1 1 0 0 0 0 0 0 1 1 0 0 0 0 1 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 1 1 0 0 1 8 0 1 84 1 0 0 0 0 0 0 0 0 0 0 X 10 10 0 0 0 0 1 1 1 1 1 0 0 1 1 1 1 1 1 1 0 0 OH X KEN DICKEN 7405929205 55 HOSPITAL DRIVE ATHENS OH 45701 LARRY CORRIGAN 1.00 X 0 0 0 TRACY MARX 1.00 X 0 0 0 RON STRICKMAKER 1.00 X X 0 0 0 DAVID STROH 1.00 X X 0 0 0 MICHAEL TURNER 1.00 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 DEBORAH SECHKAR 40.00 X 69308 0 705 THOMAS CAMPBELL 40.00 X 126903 0 0 196211 0 705 1 0 0 0 0 16388 116724 133112 PATIENT SERVICES 621610 3758424 3758424 3758424 2286 2286 3893822 3758424 0 2286 74485 66106 8379 1963782 1742857 220925 211540 187742 23798 154395 137026 17369 1782 1782 113669 100881 12788 18357 16292 2065 385069 341749 43320 1490 1322 168 84496 74990 9506 160348 142309 18039 8555 7592 963 15 15 10018 8891 1127 29245 25955 3290 HOSPICE ROOM & BOARD 330043 330043 BAD DEBTS 43018 43018 EMERGENCY RESPONSE 34815 34815 DUES & SUBSCRIPTIONS 5749 5195 554 TRAINING & CONT. EDUC. 5516 4896 620 4973 2818 302 1853 3641360 3274497 365010 1853 238984 212702 64734 70317 519337 635151 11069 14048 16892 13656 834548 827833 16733 6715 4772 0 0 872521 952589 265845 378372 289228 0 555073 378372 X 315192 571963 2256 2254 317448 574217 872521 952589 X 252462 4307 X X 0 1 1 X 0 X 259800 269104 153022 230286 133112 1045324 3512978 3468287 3524933 3901744 3758424 18166366 3772778 3737391 3677955 4132030 3891536 19211690 0 0 0 19211690 3456 2180 2425 2100 2286 12447 3456 2180 2425 2100 2286 12447 15504 15504 3776234 3739571 3695884 4134130 3893822 19239641 0.99850 0.99830 0.00060 0.00060 X SCHEDULE A, PART II, LINE 12, EXPLANATION OF OTHER INCOME: BAD DEBT RECOVERY RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 2259 2 2261 2257 2 2259 2251 6 2257 1.00000 0 0 834548 827833 6715 6715 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: O'BLENESS MEMORIAL HOSPITAL AND THE APPALACHIAN COMMUNITY VISITING NURSE ASSOCIATION HOSPICE AND HEALTH SERVICES, INC. ARE EXEMPT FROM FEDERAL TAXES UNDER SECTION 501(A) AS AN ORGANIZATION DESCRIBED IN SECTION 501(C)(3) OF THE INTERNAL REVENUE CODE. ATHENS MEDICAL LABORATORY ASSOCIATES, INC., ATHENS SURGERY CENTER, LTD., AND ATHENS MEDICAL ASSOCIATES, LLC ARE FOR-PROFIT SUBSIDIARIES SUBJECT TO FEDERAL INCOME TAXES. FEDERAL INCOME TAX EXPENSE IS NOT MATERIAL TO THE CONSOLIDATED FINANCIAL STATEMENTS. THE HOSPITAL FILES FEDERAL, STATE, AND APPLICABLE LOCAL TAX RETURNS AND IS NO LONGER SUBJECT TO RELATED EXAMINATIONS BY TAX AUTHORITIES FOR THE YEARS BEFORE FISCAL YEAR 2008. 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 GOVERANCE 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 PRESIDENT/CEO REVIEWS THE FORM 990 PRIOR TO SIGNING AND SUBMITTING TO THE IRS. FORM 990, PART VI, SECTION B, LINE 12C WHENEVER A TRUSTEE FEELS THAT A CONFLICT OF INTEREST SITUATION IS OR MAY BE INVOLVED, THE TRUSTEE IS TO PROMPTLY AND FULLY DISCLOSE THE FACTS RELATED TO THE CONFLICT. TRUSTEES ARE REQUIRED TO DISCLOSE POSSIBLE CONFLICTS OF INTEREST TO THE FULL BOARD OF TRUSTEES. WHENEVER CONFLICTS ARE DISCLOSED TO THE FULL BOARD, THE BOARD DISCUSSES THE POSSIBLE CONFLICT AND DECIDES ON A COURSE OF ACTION, SUCH AS RESTRICTIONS ON VOTING AND PARTICIPATION. CONFLICT OF INTEREST STATEMENTS FOR BOARD MEMBERS ARE SIGNED YEARLY. OFFICERS MUST ALSO DISCLOSE CONFLICTS AS THEY ARISE. IF A CONFLICT ARISES, THE BOARD WILL DETERMINE NECESSARY ACTION. 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. FORM 990, PART VI, SECTION C, LINE 18 FORM 1023 AND 990 ARE AVAILABLE 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 SEEKS LEGAL COUNSEL TO ENSURE COMPLIANCE WITH ORGANIZATION GUIDELINES. A WRITTEN REQUEST MUST BE SUBMITTED TO THE ORGANIZATION ASKING TO VIEW THESE DOCUMENTS. CHANGES IN NET ASSETS OR FUND BALANCES: FORM 990, PART XI, LINE 5: NET UNREALIZED GAINS ON INVESTMENTS: 4,307. 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 ATHENS MEDICAL LABORATORY ASSOCIATES INC 400 E STATE STREET ATHENS OH 45701 311381808 MEDICAL LABORATORY OH N/A S THE DRUGSTORE AT O'BLENESS LLC 55 HOSPITAL DRIVE ATHENS OH 45701 030598042 DRUGSTORE 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 265000 LOAN AGREEMENT