2012-05-14T14:39:28-05:00 2011-06-30 PLANTE & MORAN PLLC 65 EAST STATE STREET SUITE 600 COLUMBUS OH 43215 990 2010-07-01 310678022 SOUTHERN OHIO MEDICAL CENTER SOUT 7403567622 1248 KINNEYS LANE PORTSMOUTH OH 45662 DEAN WRAY 7403567622 2012-05-08 1 BERNIE OSTROWSKI 6148493000 2010 2016-02-24 21:20:13Z SEE SCHEDULE O MR RANDAL ARNETT 1805 27TH STREET PORTSMOUTH OH 45662 344235166 0 X WWW.SOMC.ORG X 1954 OH SOUTHERN OHIO MEDICAL CENTER IS AN ACUTE HEALTH CARE SYSTEM LOCATED IN PORTSMOUTH, OHIO. SOMC'S EXEMPT PURPOSE IS TO SERVE SOUTH CENTRAL OHIO AND NORTHEASTERN KENTUCKY WITH STATE-OF-THE-ART FACILITIES AND HEALTH CARE TECHNOLOGIES. 11 6 2479 2647 0 0 535488 555337 269548236 269717227 2884158 4556771 3387408 5073710 276355290 279903045 18401525 19877368 0 0 112908592 115992741 0 0 22658 135890611 135798503 267200728 271668612 9154562 8234433 393731647 415553074 203016851 194361513 190714796 221191561 X WE WILL MAKE A DIFFERENCE. AT SOMC, OUR MISSION IS TO MAKE A DIFFERENCE. WE STRIVE TO LIVE OUT THAT MISSION BY PROVIDING OUR REGION WITH THE HIGHEST QUALITY OF CARE, DELIVERED BY PROFESSIONALS WHO ARE AMONG THE BEST IN THEIR FIELDS. WE EXTEND THAT CARE AND PASSION TO MAKE A DIFFERENCE IN THE COMMUNITY BY BEING A VERY GOOD NEIGHBOR, EMPLOYER, AND COMMUNITY SUPPORTER. 0 0 215294249 19877368 273077525 SEE SCHEDULE OSOUTHERN OHIO MEDICAL CENTER TAKES PRIDE IN PARTNERING WITH THE LOCAL COMMUNITY TO PROVIDE THE BEST POSSIBLE HEALTH CARE TO THE RESIDENTS OF OUR AREA. WHETHER IT'S THROUGH ANNUAL COLLABORATIVE BLOOD DRIVES, PARTICIPATION DURING COUNTY FAIRS, OR ATTENDANCE AT MONTHLY SCHOOL BOARD MEETINGS, OUR EMPLOYEES GO ABOVE AND BEYOND TO CREATE LASTING RELATIONSHIPS IN AND OUTSIDE OUR HOSPITAL WALLS, HELPING US TRULY MAKE A DIFFERENCE IN THE LIVES OF THOSE AROUND US. IT'S THROUGH THESE RELATIONSHIPS THAT SOMC HAS BEEN RECOGNIZED FOR MANY OUTSTANDING ACCOMPLISHMENTS, RECEIVING SUCH NOTABLE HONORS OVER THE YEARS AS ANCC'S MAGNET RECOGNITION, OSHA'S VPP STAR STATUS, PRESS GANEY'S DISTINCTIVE WORKPLACE AWARD, AS WELL AS BEING NAMED ONE OF FORTUNE'S 100 BEST COMPANIES TO WORK FOR, A BEST EMPLOYER IN OHIO, AND ONE OF MODERN HEALTHCARE'S 100 BEST PLACES TO WORK.IT'S ALSO THROUGH THESE RELATIONSHIPS THAT MANY KEY DECISIONS ARE MADE AT SOMC. AS ONE OF OUR FIVE STRATEGIC VALUES, RELATIONSHIPS (PARTICULARLY THOSE BETWEEN CO-WORKERS, PHYSICIANS, VOLUNTEERS AND THE COMMUNITY) SHAPE MANY FACETS OF CUSTOMER SERVICE AND THE CARE THAT IS PROVIDED WITHIN THE HOSPITAL. IT IS OUR GOAL TO LISTEN AND PARTNER WITH CUSTOMERS TO MAKE A DIFFERENCE TO THOSE WE SERVE. PATIENTS AND FAMILY MEMBERS CAN PARTICIPATE IN THE HOSPITAL'S INPATIENT AND OUTPATIENT SATISFACTION SURVEY PROCESS, CONDUCTED BY A THIRD-PARTY VENDOR TO PROVIDE BENCHMARKED DATA THAT COMPARES SOMC AGAINST MANY HEALTHCARE FACILITIES ACROSS THE NATION. ADDITIONAL FEEDBACK IS ALSO OBTAINED THROUGH FOCUS GROUPS CONDUCTED BY THE SOMC COMMUNITY RELATIONS DEPARTMENT, AS WELL AS THE SOMC EXECUTIVE TEAM'S "OPEN DOOR POLICY," WHICH BOTH PROVIDE THE OPPORTUNITY TO GATHER SUGGESTIONS TO IMPROVE HOSPITAL SERVICES AND UNDERSTAND TECHNOLOGICAL NEEDS. IN ADDITION TO PERSONAL RELATIONSHIPS, SOMC ESTABLISHES WORKING RELATIONSHIPS WITH OTHER ORGANIZATIONS THROUGHOUT THE TRI-STATE TO FOCUS ON THE HEALTH AND WELLNESS OF THE COMMUNITY. SOMC AND ITS EMPLOYEES PARTICIPATE IN A VARIETY OF COMMUNITY-BASED ORGANIZATIONS INCLUDING THE OHIO RIVER VALLEY CHAPTER RED CROSS BOARD, THE CHAMBER OF COMMERCE, ROTARY CLUB, UNITED WAY, SOUTHERN OHIO PERFORMING ARTS ASSOCIATION, MAIN STREET PORTSMOUTH, THE PORTSMOUTH AREA ARTS COUNCIL, AS WELL AS AREA SCHOOL BOARDS, COMMITTEES AND CHURCHES. OTHER PARTICIPATORY PROGRAMS INCLUDE LEADERSHIP PORTSMOUTH, OHIO PARTNERSHIP FOR EXCELLENCE, TASK FORCE ON DOMESTIC VIOLENCE, PORTSMOUTH KIWANIS SERVICE CLUB, SCIOTO RESIDENTIAL SERVICES BOARD, PARAMEDIC ADVISORY BOARD, SALVATION ARMY, RIVER SWEEP, HABITAT FOR HUMANITY, SOUTHERN OHIO CORRECTIONAL FACILITY MINISTRIES, ARTHRITIS FOUNDATION, MEDICAL RESERVE CORP, PARISH NURSE NETWORK, SOUTHERN OHIO DIABETES COALITION, PORTSMOUTH BICENTENNIAL BOARD AND THE SOUTHERN OHIO CORRECTIONAL FACILITY COMMUNITY ADVISORY BOARD. MANY BENEFITS ARE CREATED THROUGH THESE PARTNERSHIPS INCLUDING SPONSORSHIPS FOR CULTURAL AFFAIRS, COMMUNITY HEALTH AND WELLNESS PROGRAMS, HEALTH SCREENINGS, EDUCATION, CHILDREN'S PROGRAMS AND YOUTH ACTIVITIES. ONE SUCH COLLABORATIVE EFFORT ALLOWS SOMC TO PROVIDE ADULT IMMUNIZATIONS FOR INFLUENZA TO HUNDREDS OF COMMUNITY MEMBERS EACH YEAR. NURSES AND PHYSICIANS VOLUNTEER THEIR TIME AND EFFORT TO TRAVEL AROUND THE AREA AND PROVIDE THIS SERVICE FREE OF CHARGE OR AT A REDUCED RATE TO THE MANY POPULATIONS WHO GREATLY BENEFIT FROM THIS ANNUAL PREVENTIVE MEASURE. ANOTHER SUCH PROGRAM, KNOWN AS "LOVE YOUR HEART," REACHES MORE THAN 1,200 KINDERGARTEN STUDENTS EACH YEAR. DEVELOPED IN 2000 BY THE SOMC INTENSIVE CARE UNIT TO SPECIFICALLY PROMOTE EARLY CHILDHOOD HEALTHY HABITS, "LOVE YOUR HEART" USES CHARACTERS FROM THE WIZARD OF OZ TO TEACH CHILDREN HOW TO TAKE CARE OF THEIR HEARTS THROUGH HEALTHY EATING, EXERCISE AND FIVE OTHER HANDS-ON STATIONS. HOSPITAL EMPLOYEES, LOCAL NURSING STUDENTS, AND VOLUNTEERS FROM ALL OVER THE COMMUNITY PARTICIPATE IN PROVIDING EDUCATION DURING THIS ANNUAL BELOVED PROGRAM. THROUGH ITS CREATIVE MESSAGE AND INVENTIVE APPROACH, PARTICIPANTS TRULY FEEL THEY ARE MAKING A DIFFERENCE AND SERVING AS ROLE MODELS FOR HEALTHY LIVING. THE ICU STAFF WAS EVEN AWARDED THE AMERICAN ASSOCIATION OF CRITICAL CARE NURSES SEABURY AND SMITH NATIONAL COMMUNITY SERVICE AWARD FOR THIS EXTRAORDINARY PROGRAM.MANY OTHER WELLNESS-RELATED PROGRAMS AND SCREENINGS ARE ALSO CONDUCTED EACH YEAR BY MEMBERS OF THE SOMC COMMUNITY HEALTH AND WELLNESS DEPARTMENT, HELPING THOUSANDS OF COMMUNITY MEMBERS LEARN MORE ABOUT THEIR HEALTH. FOR THE PAST TWO YEARS, THE HOSPITAL HAS DEDICATED EACH MONTH TO A DIFFERENT HEALTH MESSAGE AND WORKS TO PROVIDE EVENTS THAT FOCUS INFORMATION ON THAT PARTICULAR AREA. FOR EXAMPLE, FEBRUARY IS ANNUALLY KNOWN AS HEART HEALTH MONTH, AND OFTEN FEATURES MANY PROGRAMS, SCREENINGS, COMMERCIALS, FLYERS, AND CHILDREN'S ACTIVITIES THAT FOCUS SPECIFICALLY ON THAT TOPIC AND ITS EDUCATION. CONDUCTING PROGRAMS IN THIS FASHION ALLOWS THE HOSPITAL TO DELIVER A CONSISTENT MESSAGE TO THE COMMUNITY, HELPING TO SUCCESSFULLY EDUCATE THOSE WE SERVE. AS ANOTHER MEANS OF PROMOTING HEALTHY EDUCATION, THE COMMUNITY HEALTH AND WELLNESS DEPARTMENT ACTIVELY SEEKS GRANTS THAT CAN BE USED TOWARD SPECIFIC COMMUNITY-WIDE PROGRAMS. A DIABETES GRANT EARNED THROUGH THE OHIO DEPARTMENT OF HEALTH IN 2010 HAS SINCE GROWN TO PROVIDE HUNDREDS OF COMMUNITY MEMBERS WITH A SOLID UNDERSTANDING OF THEIR DISEASE, AND HAS ALSO BEEN USED TO PROVIDE TIPS AND TOOLS TO MANAGE THEIR HEALTH FOR THE LONG-TERM. BOTH THE INPATIENT AND OUTPATIENT DIABETES DEPARTMENTS AT SOMC HAVE GREATLY BENEFITTED FROM THIS INCREASED AWARENESS AND HAVE SEEN A DRAMATIC POSITIVE TURN IN PATIENTS' GLUCOSE, WEIGHT AND A1C RESULTS SINCE THE PROGRAMMING'S IMPLEMENTATION. ADDITIONAL EDUCATION EFFORTS AND COMMUNITY SUPPORT IS ALSO PROVIDED BY THE PHYSICIANS, MEDICAL STUDENTS AND EMPLOYEES OF SOMC DURING MANY VOLUNTEER OPPORTUNITIES THAT ARE AVAILABLE THROUGHOUT THE YEAR, SUCH AS SPORTS PHYSICALS, AND SKIN, BREAST AND PROSTATE SCREENINGS. IN 2011 ALONE, THE COMMUNITY HEALTH AND WELLNESS DEPARTMENT AND OUR VOLUNTEERS WERE ABLE TO PROVIDE HEALTH AND SCREENING EVENTS, THUS TOUCHING THE LIVES OF MORE THAN 7,900 COMMUNITY MEMBERS. SOMC AND ITS EMPLOYEES ALSO GIVE BACK TO THE COMMUNITY THROUGH INTERNAL DONATION CAMPAIGNS AIMED AT RAISING FUNDS OR ITEMS FOR A SPECIFIC CAUSE. EACH YEAR, SOMC SELECTS CHAIRMEN TO LEAD THE ORGANIZATION'S UNITED WAY CAMPAIGN, WHICH DIRECTLY BENEFITS THE MORE THAN 15 LOCAL ORGANIZATIONS THAT MAKE UP THE SCIOTO COUNTY UNITED WAY PROGRAM. MORE THAN 98 PERCENT OF SOMC EMPLOYEES PARTICIPATE IN THE EVENT, CHOOSING TO MAKE DIRECT OR PAYROLL-DEDUCTED MONETARY CONTRIBUTIONS. LAST YEAR'S CAMPAIGN WAS THE HOSPITAL'S MOST SUCCESSFUL EVENT TO DATE. IN ADDITION TO THIS MONETARY CONTRIBUTION, SOMC ALSO SUPPORTS THE UNITED WAY THROUGH AN ANNUAL SCHOOL SUPPLY DRIVE. THROUGH THIS PROGRAM, SOMC EMPLOYEES HELP TO PROVIDE BASIC AND NECESSARY SUPPLIES TO THE STUDENTS OF 11 COUNTY SCHOOLS. ANYWHERE FROM 1,800 TO 3,500 ITEMS HAVE ANNUALLY BEEN COLLECTED IN THE PAST, TRULY SHOWING THAT SOMC INVESTS IN THE EDUCATION OF OUR COMMUNITY'S FUTURE GENERATIONS. THE VOLUNTEERS AND GUILDS OF THE SOMC FRIENDS COMMUNITY CENTER ALSO GIVE BACK TO THE COMMUNITY BY RAISING FUNDS TO PURCHASE MEDICAL EQUIPMENT, ASSISTING WITH PATIENT NEEDS AND PROVIDING VARIOUS COMMUNITY SERVICES TO AID IN MAKING A DIFFERENCE. TOGETHER, THESE IMPORTANT TEAMS ARE TRULY PROVING THAT SOMC CAN MAKE A DIFFERENCE. 215294249 1 1 0 1 0 0 0 0 1 1 0 0 0 1 0 0 1 0 0 0 0 0 0 1 0 1 1 1 1 1 1 0 0 0 0 0 0 0 0 0 1 1 0 0 0 0 1 1 1 1 0 1 127 0 1 2479 1 0 0 0 0 0 1 0 0 0 0 0 X 11 6 0 0 0 0 0 0 0 1 1 0 0 1 1 1 1 1 1 1 1 0 OH X RICHARD GILCHER 7403567622 1248 KINNEYS LANE PORTSMOUTH OH 45662 ROBERT E DEVER 1.00 X X 0 0 0 RANDAL ARNETT 40.00 X X 681059 0 300785 STEVEN A CONLEY 1.00 X 0 0 0 GARY DUZAN 1.00 X X 0 0 0 DAVID HANZEL MD 1.00 X 0 0 0 GEORGE LAWSON 1.00 X X 0 0 0 RITA RICE-MORRIS PHD 1.00 X 0 0 0 JOHN TURJOMAN MD 1.00 X X 0 0 0 ERNESTO BANALAGAY MD 1.00 X X 20959 0 0 DAVID FOWLER 1.00 X 0 0 0 GEORGE V JOHNSON MD 1.00 X 0 0 0 JAMES W STAKER 1.00 X 0 0 0 DEAN WRAY 40.00 X 345786 0 125933 KENDALL L STEWART 40.00 X 1537137 0 33645 CLAUDIA L BURCHETT 40.00 X 260525 0 116783 VICKI A NOEL 40.00 X 211813 0 74955 LEEANN L SAMMONS 40.00 X 188092 0 65533 BENJAMIN L GILL 40.00 X 124267 0 26158 RORY E PHILLIPS 40.00 X 186621 0 39178 JEREMY K JANNEY 40.00 X 143047 0 32241 CRAIG E GILLILAND 40.00 X 142703 0 33767 TERRY A JOHNSON 40.00 X 168765 0 8955 VALERIE DECAMP 40.00 X 134721 0 36354 4021228 0 868129 50 0 1 0 REHABCARE GROUP INC 7733 FORSYTH BLVD SUITE 1700 ST LOUIS MO 63105 MANAGEMENT SERVICES 5787460 UNITED COLLECTION BUREAU INC 4100 HORIZON DR SUITE 101 COLUMBUS OH 43220 PATIENT ACCOUNT BILLING 1821924 MAYO COLLABORATIVE SERVICES 200 SW FIRST STREET ROCHESTER MN 55905 LABORATORY TESTING 1419563 EMERGENCY PHYSICIANS MEDICAL GROUP PC 2000 GREEN AVE ANN ARBOR MI 48105 EMERGENCY DEPARTMENT PH 848526 TL BLACKBURN CO PO BOX 1463 PORTSMOUTH OH 45662 CONSTRUCTION 725575 27 62181 70315 171769 251072 98715 555337 PATIENT SERVICES 621300 264944783 264944783 PHARMACY INCOME 900099 3834641 3834641 RENTAL INCOME 531110 937803 937803 269717227 4173401 4173401 39134 39134 39134 39134 64388240 252478 63539714 717634 848526 -465156 383370 383370 50308 62181 74773 -24465 -24465 LIFE CENTER 900099 1600240 1600240 CAFETERIA SALES 900099 1430229 1430229 LAB SERVICES 900099 548138 548138 1480434 1211920 268514 5059041 279903045 273077525 0 6270183 19848574 19848574 28794 28794 4152951 4152951 82108094 62637327 19470767 5091828 3883881 1207947 18195288 13933551 4261737 6444580 4915717 1528863 14775 14775 402000 402000 169420 169420 20616566 16079063 4537503 2204543 2204543 49001173 37376471 11624702 1345534 578534 767000 9888987 7542992 2345995 463109 310177 152932 366142 128430 237712 8614509 7426568 1187941 17620863 15191600 2429263 1002288 1002288 BAD DEBT EXPENSE 21371308 21371308 OHIO FRANCHISE TAX 1474259 1474259 PHYSICIAN RECRUITMENT 485128 485128 BIO MEDICAL EXPENSE 185022 185022 TRAINING & EDUCATION 51281 34727 16554 521596 129554 369384 22658 271668612 215294249 56351705 22658 7150 7240 12285182 17773237 29100 3465 28215477 28695733 280827 144790 4091909 3956968 1252384 1328905 313724739 141924789 180158493 171799950 140134533 171057210 14961588 5369172 1567184 1979080 10747820 13437324 393731647 415553074 26081243 18977979 155380402 152834169 2117591 1965017 19437615 20584348 203016851 194361513 X 190685696 221188096 29100 3465 190714796 221191561 393731647 415553074 X 8234433 22242332 X X 0 1 1 X 1 1 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 0 0 0 0 0 0 0 0 1 5334 5334 0 EXPLANATION OF OTHER LOBBYING ACTIVITIES: PART II-B, LINE 1I: MEMBERSHIP DUES IN THE AMOUNT OF $43,123 AND $60,181 WERE PAID TO THE AMERICAN HOSPITAL ASSOCIATION AND THE OHIO HOSPITAL ASSOCIATION, RESPECTIVELY. OF THESE DUES, $2,156 AND $3,178 WERE RELATED TO LOBBYING ACTIVITIES. 1618097 72131 104428 43103 1751553 1640677 75282 -62236 35626 1618097 1555536 65883 51298 32039 1640678 1.00000 0.00000 0.00000 1 0 3988758 3988758 95044854 28708950 66335904 142559 92956 49603 108953956 41784878 67169078 105594612 71338005 34256607 171799950 PENSION LIABILITY 9288716 COST REPORT SETTLEMENTS 5549776 INTERCOMPANY PAYABLES 30011 ACCRUED SELF-INSURED LIABILITY 3359773 CERP DEFERRED COMP LIABILITY 2356072 20584348 DESCRIPTION OF INTENDED USE OF ENDOWMENT FUNDS: PART V, LINE 4: ENDOWMENT FUNDS ARE TO BE SPENT AT THE BOARD'S DISCRETION, AND ARE INTENDED TO BE RETAINED FOR FUTURE NEEDS OF THE ORGANIZATION. THE ENDOWMENT FUNDS ARE HELD AND ADMINISTERED BY THE SCIOTO FOUNDATION. HIKE FOR HOSPICE 54926 54926 5515 20477 GOLF TOURNAMENT - LIFE CENTER 25501 25501 936 6844 4225 4 32062 7255 24807 36776 112489 62181 50308 6451 6844 61478 74773 -24465 1 1 X 1 X 125.000000000000 1 X 125.000000000000 1 1 1 0 1 1 5279 8130943 1385954 6744989 0.02690 45872879 30502337 15370542 0.06140 5279 54003822 31888291 22115531 0.08830 36097 148048 42358 105690 0.00040 1262884 1262884 0.00500 198786 198786 0.00080 36097 1609718 42358 1567360 0.00620 41376 55613540 31930649 23682891 0.09450 0 7907384 264561 72149068 73692433 -1543365 X 1 0 1 1 SOUTHERN OHIO MEDICAL CENTER

1805 27TH STREET PORTSMOUTH OH 45662

X X X X X NA 1 5 URGENT CARE

8770 OHIO RIVER ROAD WHEELERSBURG OH 45694

URGENT CARE SOMC CANCER CENTER

1121 KINNEYS LANE PORTSMOUTH OH 45662

CANCER TREATMENT & CARE HOSPICE IN-PATIENT

2201 25TH STREET PORTSMOUTH OH 45662

HOSPICE IN-PATIENT HEALTH CARE CENTER

1212 18TH STREET PORTSMOUTH OH 45662

HEALTH CARE CENTER WOUND HEALING & SLEEP LAB

1745 27TH STREET PORTSMOUTH OH 45662

SLEEP LAB PART I, LINE 3C: NOT APPLICABLE PART I, LINE 6A: NOT APPLICABLE PART I, LINE 7: CHARITY CARE COSTS WERE CALCULATED USING A COST TO CHARGE RATIO USING THE WORKSHEET 2 METHOD TO CALCULATE THE COST TO CHARGE RATIO. MEDICAID COSTS WERE CALCULATED USING A COST TO CHARGE RATIO USING THE WORKSHEET 3 METHOD TO CALCULATE THE COST TO CHARGE RATIO. MEDICAID GROSS CHARGES WERE TAKEN FROM THE MEDICAID COST REPORT WHILE EXCLUDING REQUIRED ITEMS PER THE SCHEDULE H INSTRUCTIONS FOR WORKSHEET 3. PART I, LINE 7G: NOT APPLICABLE PART I, L7 COL(F): THE TOTAL PERCENTAGE CALCULATED ON LINE 7 IS BASED ON TOTAL EXPENSES FROM FORM 990, PART IX, LESS BAD DEBT EXPENSE FROM PART IX OF $21,371,308. PART II: NOT APPLICABLE PART III, LINE 4: TOTAL BAD DEBT EXPENSE RECORDED AT GROSS CHARGES EXCLUDES AMOUNTS KNOWN TO QUALIFY FOR CHARITY DISCOUNTS. ANY PARTIAL PAYMENTS THAT ARE SUBSEQUENTLY RECEIVED ARE APPLIED AS AN OFFSET TO BAD DEBT AT CHARGES. BAD DEBT AT COST IS CALCULATED USING THE HOSPITAL'S COST-TO-CHARGE RATIO. THIS RATIO IS CALCULATED AS THE TOTAL OPERATING EXPENSES, LESS BAD DEBT, MEDICAL EDUCATION AND RECRUITMENT COSTS, AND EXPENSES OF OTHER PROGRAMS NOT COSTED, DIVIDED BY GROSS PATIENT REVENUE. NONE OF THE BAD DEBT AT COST IS TREATED AS A COMMUNITY BENEFIT. THE ESTIMATED AMOUNT OF BAD DEBT AT COST ATTRIBUTABLE TO PATIENTS ELIGIBLE UNDER THE ORGANIZATION'S CHARITY CARE POLICY REPRESENTS ACCOUNTS THAT WERE DEEMED TO BE BAD DEBT WHICH SUBSEQUENTLY APPLIED FOR FINANCIAL ASSISTANCE. THE ACCOUNTS BELIEVED TO QUALIFY FOR CHARITY CARE HOWEVER WERE NOT MOVED FROM BAD DEBTS.FOOTNOTE TO FINANCIAL STATEMENTS: 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 ORGANIZATION'S ABILITY TO COLLECT OUTSTANDING AMOUNTS. UNCOLLECTIBLE AMOUNTS ARE WRITTEN OFF AGAINST THE ALLOWANCE FOR DOUBTFUL ACCOUNTS IN THE PERIOD THEY ARE DETERMINED TO BE UNCOLLECTIBLE. PART III, LINE 8: MEDICARE COSTS WERE TAKEN FROM THE MEDICARE COST REPORT, WHICH USES A COST TO CHARGE RATIO ALLOWED UNDER MEDICARE COST REPORT METHODOLOGY. NONE OF THE SHORTFALL IS TREATED AS COMMUNITY BENEFIT. PART III, LINE 9B: WE TREAT ALL PATIENTS THE SAME. IF THERE IS INSURANCE COVERAGE, WE BILL THE CLAIMS FOR PAYMENT. IF THERE IS NO INSURANCE - OR IF THERE IS A BALANCE REMAINING AFTER INSURANCE PAYS - THE PATIENT IS SENT THE SAME AMOUNT OF STATEMENTS OVER A PERIOD OF TIME, PHONE ATTEMPTS ARE MADE AND, IF THERE IS NO RESPONSE TO OUR EFFORTS, THE ACCOUNTS ARE PLACED WITH OUTSIDE AGENCIES FOR COLLECTION. PART VI, LINE 2: THE COMMUNITY RELATIONS AND THE WORKFORCE DEVELOPMENT DEPARTMENTS CONDUCT ANNUAL FOCUS GROUPS WITH OUR KEY CUSTOMERS AS WELL AS EVALUATE THE DISEASE PROCESSES EFFECTING OUR COMMUNITY. DATA FOR THESE DISEASE PROCESSES IS COLLECTED THROUGH INTERNAL DATABASES AS WELL AS THROUGH THE CDC AND PORTSMOUTH HEALTH DEPARTMENT. COMMUNITY FOCUS GROUPS ARE CONTRACTED THROUGH A THIRD PARTY VENDOR AND ARE HELD EACH YEAR AFTER SOUTHERN OHIO MEDICAL CENTER'S STRATEGIC PLANNING PROCESS. PART VI, LINE 3: SOMC CONTRACTS WITH ELIGIBILITY ASSISTANCE PROGRAM (EAP) WHOSE STAFF IS LOCATED ON-SITE TO SEE PATIENTS INHOUSE, OFFER ASSISTANCE WITH APPLICATIONS FOR OHIO MEDICAID, HCAP AND/OR CHARITY FUNDING. THEY ALSO CONTACT OUTPATIENTS WITH LARGE BALANCES TO OFFER THE SAME ASSISTANCE. EACH BILLING STATEMENT MAILED TO PATIENTS ALSO OFFERS THE FINANCIAL ASSISTANCE APPLICATION (FOR HCAP AND CHARITY FUNDING) FOR THE PATIENT TO COMPLETE AND RETURN TO THE BUSINESS OFFICE. PART VI, LINE 4: SOUTHERN OHIO MEDICAL CENTER IS LOCATED ALONG THE OHIO RIVER IN RURAL SOUTHERN OHIO. SOMC'S LARGEST PAYING GROUP ARE MEDICARE AND MEDICAID RECIPIENTS. NATIONAL CENSUS DATA SHOWS THE SCIOTO COUNTY RESIDENTS HAVE A MEAN HOUSEHOLD INCOME NEARLY $20,000 LESS THAN THE NATIONAL AVERAGE, AS WELL AS 16.9% OF FAMILIES BELOW POVERTY LEVEL, WHICH IS ALMOST DOUBLE THAT OF THE NATIONAL AVERAGE OF 9.6%. PROFESSIONAL RESEARCH CONSULTANTS (PRC) FOUND THAT 26.2% OF ADULTS, AGE 18-64, LACK HEALTHARE INSURANCE COVERAGE IN SCIOTO COUNTY. THIS NEARLY DOUBLES THE STATE OF OHIO'S PERCENTAGE OF 14.6%. SOUTHERN OHIO MEDICAL CENTER PROVIDED MORE THAN $22 MILLION IN CHARITY CARE OVER THE LAST YEAR. PART VI, LINE 6: SOUTHERN OHIO MEDICAL CENTER TAKES PRIDE IN PARTNERING WITH THE LOCAL COMMUNITY TO PROVIDE THE BEST POSSIBLE HEALTH CARE TO THE RESIDENTS OF OUR AREA. WHETHER IT'S THROUGH ANNUAL COLLABORATIVE BLOOD DRIVES, PARTICIPATION DURING COUNTY FAIRS, OR ATTENDANCE AT MONTHLY SCHOOL BOARD MEETINGS, OUR EMPLOYEES GO ABOVE AND BEYOND TO CREATE LASTING RELATIONSHIPS IN AND OUTSIDE OUR HOSPITAL WALLS, HELPING US TRULY MAKE A DIFFERENCE IN THE LIVES OF THOSE AROUND US. IT'S THROUGH THESE RELATIONSHIPS THAT SOMC HAS BEEN RECOGNIZED FOR MANY OUTSTANDING ACCOMPLISHMENTS, RECEIVING SUCH NOTABLE HONORS OVER THE YEARS AS ANCC'S MAGNET RECOGNITION, OSHA'S VPP STAR STATUS, PRESS GANEY'S DISTINCTIVE WORKPLACE AWARD, AS WELL AS BEING NAMED ONE OF FORTUNE'S 100 BEST COMPANIES TO WORK FOR, A BEST EMPLOYER IN OHIO, AND ONE OF MODERN HEALTHCARE'S 100 BEST PLACES TO WORK.IT'S ALSO THROUGH THESE RELATIONSHIPS THAT MANY KEY DECISIONS ARE MADE AT SOMC. AS ONE OF OUR FIVE STRATEGIC VALUES, RELATIONSHIPS (PARTICULARLY THOSE BETWEEN CO-WORKERS, PHYSICIANS, VOLUNTEERS AND THE COMMUNITY) SHAPE MANY FACETS OF CUSTOMER SERVICE AND THE CARE THAT IS PROVIDED WITHIN THE HOSPITAL. IT IS OUR GOAL TO LISTEN AND PARTNER WITH CUSTOMERS TO MAKE A DIFFERENCE TO THOSE WE SERVE. PATIENTS AND FAMILY MEMBERS CAN PARTICIPATE IN THE HOSPITAL'S INPATIENT AND OUTPATIENT SATISFACTION SURVEY PROCESS, CONDUCTED BY A THIRD-PARTY VENDOR TO PROVIDE BENCHMARKED DATA THAT COMPARES SOMC AGAINST MANY HEALTHCARE FACILITIES ACROSS THE NATION. ADDITIONAL FEEDBACK IS ALSO OBTAINED THROUGH FOCUS GROUPS CONDUCTED BY THE SOMC COMMUNITY RELATIONS DEPARTMENT, AS WELL AS THE SOMC EXECUTIVE TEAM'S "OPEN DOOR POLICY," WHICH BOTH PROVIDE THE OPPORTUNITY TO GATHER SUGGESTIONS TO IMPROVE HOSPITAL SERVICES AND UNDERSTAND TECHNOLOGICAL NEEDS. IN ADDITION TO PERSONAL RELATIONSHIPS, SOMC ESTABLISHES WORKING RELATIONSHIPS WITH OTHER ORGANIZATIONS THROUGHOUT THE TRI-STATE TO FOCUS ON THE HEALTH AND WELLNESS OF THE COMMUNITY. SOMC AND ITS EMPLOYEES PARTICIPATE IN A VARIETY OF COMMUNITY-BASED ORGANIZATIONS INCLUDING THE OHIO RIVER VALLEY CHAPTER RED CROSS BOARD, THE CHAMBER OF COMMERCE, ROTARY CLUB, UNITED WAY, SOUTHERN OHIO PERFORMING ARTS ASSOCIATION, MAIN STREET PORTSMOUTH, THE PORTSMOUTH AREA ARTS COUNCIL, AS WELL AS AREA SCHOOL BOARDS, COMMITTEES AND CHURCHES. OTHER PARTICIPATORY PROGRAMS INCLUDE LEADERSHIP PORTSMOUTH, OHIO PARTNERSHIP FOR EXCELLENCE, TASK FORCE ON DOMESTIC VIOLENCE, PORTSMOUTH KIWANIS SERVICE CLUB, SCIOTO RESIDENTIAL SERVICES BOARD, PARAMEDIC ADVISORY BOARD, SALVATION ARMY, RIVER SWEEP, HABITAT FOR HUMANITY, SOUTHERN OHIO CORRECTIONAL FACILITY MINISTRIES, ARTHRITIS FOUNDATION, MEDICAL RESERVE CORP, PARISH NURSE NETWORK, SOUTHERN OHIO DIABETES COALITION, PORTSMOUTH BICENTENNIAL BOARD AND THE SOUTHERN OHIO CORRECTIONAL FACILITY COMMUNITY ADVISORY BOARD. MANY BENEFITS ARE CREATED THROUGH THESE PARTNERSHIPS INCLUDING SPONSORSHIPS FOR CULTURAL AFFAIRS, COMMUNITY HEALTH AND WELLNESS PROGRAMS, HEALTH SCREENINGS, EDUCATION, CHILDREN'S PROGRAMS AND YOUTH ACTIVITIES. ONE SUCH COLLABORATIVE EFFORT ALLOWS SOMC TO PROVIDE ADULT IMMUNIZATIONS FOR INFLUENZA TO HUNDREDS OF COMMUNITY MEMBERS EACH YEAR. NURSES AND PHYSICIANS VOLUNTEER THEIR TIME AND EFFORT TO TRAVEL AROUND THE AREA AND PROVIDE THIS SERVICE FREE OF CHARGE OR AT A REDUCED RATE TO THE MANY POPULATIONS WHO GREATLY BENEFIT FROM THIS ANNUAL PREVENTIVE MEASURE. ANOTHER SUCH PROGRAM, KNOWN AS "LOVE YOUR HEART," REACHES MORE THAN 1,200 KINDERGARTEN STUDENTS EACH YEAR. DEVELOPED IN 2000 BY THE SOMC INTENSIVE CARE UNIT TO SPECIFICALLY PROMOTE EARLY CHILDHOOD HEALTHY HABITS, "LOVE YOUR HEART" USES CHARACTERS FROM THE WIZARD OF OZ TO TEACH CHILDREN HOW TO TAKE CARE OF THEIR HEARTS THROUGH HEALTHY EATING, EXERCISE AND FIVE OTHER HANDS-ON STATIONS. HOSPITAL EMPLOYEES, LOCAL NURSING STUDENTS, AND VOLUNTEERS FROM ALL OVER THE COMMUNITY PARTICIPATE IN PROVIDING EDUCATION DURING THIS ANNUAL BELOVED PROGRAM. THROUGH ITS CREATIVE MESSAGE AND INVENTIVE APPROACH, PARTICIPANTS TRULY FEEL THEY ARE MAKING A DIFFERENCE AND SERVING AS ROLE MODELS FOR HEALTHY LIVING. THE ICU STAFF WAS EVEN AWARDED THE AMERICAN ASSOCIATION OF CRITICAL CARE NURSES SEABURY AND SMITH NATIONAL COMMUNITY SERVICE AWARD FOR THIS EXTRAORDINARY PROGRAM.MANY OTHER WELLNESS-RELATED PROGRAMS AND SCREENINGS ARE ALSO CONDUCTED EACH YEAR BY MEMBERS OF THE SOMC COMMUNITY HEALTH AND WELLNESS DEPARTMENT, HELPING THOUSANDS OF COMMUNITY MEMBERS LEARN MORE ABOUT THEIR HEALTH. FOR THE PAST TWO YEARS, THE HOSPITAL HAS DEDICATED EACH MONTH TO A DIFFERENT HEALTH MESSAGE AND WORKS TO PROVIDE EVENTS THAT FOCUS INFORMATION ON THAT PARTICULAR AREA. FOR EXAMPLE, FEBRUARY IS ANNUALLY KNOWN AS HEART HEALTH MONTH, AND OFTEN FEATURES MANY PROGRAMS, SCREENINGS, COMMERCIALS, FLYERS, AND CHILDREN'S ACTIVITIES THAT FOCUS SPECIFICALLY ON THAT TOPIC AND ITS EDUCATION. CONDUCTING PROGRAMS IN THIS FASHION ALLOWS THE HOSPITAL TO DELIVER A CONSISTENT MESSAGE TO THE COMMUNITY, HELPING TO SUCCESSFULLY EDUCATE THOSE WE SERVE. AS ANOTHER MEANS OF PROMOTING HEALTHY EDUCATION, THE COMMUNITY HEALTH AND WELLNESS DEPARTMENT ACTIVELY SEEKS GRANTS THAT CAN BE USED TOWARD SPECIFIC COMMUNITY-WIDE PROGRAMS. A DIABETES GRANT EARNED THROUGH THE OHIO DEPARTMENT OF HEALTH IN 2010 HAS SINCE GROWN TO PROVIDE HUNDREDS OF COMMUNITY MEMBERS WITH A SOLID UNDERSTANDING OF THEIR DISEASE, AND HAS ALSO BEEN USED TO PROVIDE TIPS AND TOOLS TO MANAGE THEIR HEALTH FOR THE LONG-TERM. BOTH THE INPATIENT AND OUTPATIENT DIABETES DEPARTMENTS AT SOMC HAVE GREATLY BENEFITTED FROM THIS INCREASED AWARENESS AND HAVE SEEN A DRAMATIC POSITIVE TURN IN PATIENTS' GLUCOSE, WEIGHT AND A1C RESULTS SINCE THE PROGRAMMING'S IMPLEMENTATION. ADDITIONAL EDUCATION EFFORTS AND COMMUNITY SUPPORT IS ALSO PROVIDED BY THE PHYSICIANS, MEDICAL STUDENTS AND EMPLOYEES OF SOMC DURING MANY VOLUNTEER OPPORTUNITIES THAT ARE AVAILABLE THROUGHOUT THE YEAR, SUCH AS SPORTS PHYSICALS, AND SKIN, BREAST AND PROSTATE SCREENINGS. IN 2011 ALONE, THE COMMUNITY HEALTH AND WELLNESS DEPARTMENT AND OUR VOLUNTEERS WERE ABLE TO PROVIDE HEALTH AND SCREENING EVENTS, THUS TOUCHING THE LIVES OF MORE THAN 7,900 COMMUNITY MEMBERS. SOMC AND ITS EMPLOYEES ALSO GIVE BACK TO THE COMMUNITY THROUGH INTERNAL DONATION CAMPAIGNS AIMED AT RAISING FUNDS OR ITEMS FOR A SPECIFIC CAUSE. EACH YEAR, SOMC SELECTS CHAIRMEN TO LEAD THE ORGANIZATION'S UNITED WAY CAMPAIGN, WHICH DIRECTLY BENEFITS THE MORE THAN 15 LOCAL ORGANIZATIONS THAT MAKE UP THE SCIOTO COUNTY UNITED WAY PROGRAM. MORE THAN 98 PERCENT OF SOMC EMPLOYEES PARTICIPATE IN THE EVENT, CHOOSING TO MAKE DIRECT OR PAYROLL-DEDUCTED MONETARY CONTRIBUTIONS. LAST YEAR'S CAMPAIGN WAS THE HOSPITAL'S MOST SUCCESSFUL EVENT TO DATE. IN ADDITION TO THIS MONETARY CONTRIBUTION, SOMC ALSO SUPPORTS THE UNITED WAY THROUGH AN ANNUAL SCHOOL SUPPLY DRIVE. THROUGH THIS PROGRAM, SOMC EMPLOYEES HELP TO PROVIDE BASIC AND NECESSARY SUPPLIES TO THE STUDENTS OF 11 COUNTY SCHOOLS. ANYWHERE FROM 1,800 TO 3,500 ITEMS HAVE ANNUALLY BEEN COLLECTED IN THE PAST, TRULY SHOWING THAT SOMC INVESTS IN THE EDUCATION OF OUR COMMUNITY'S FUTURE GENERATIONS. THE VOLUNTEERS AND GUILDS OF THE SOMC FRIENDS COMMUNITY CENTER ALSO GIVE BACK TO THE COMMUNITY BY RAISING FUNDS TO PURCHASE MEDICAL EQUIPMENT, ASSISTING WITH PATIENT NEEDS AND PROVIDING VARIOUS COMMUNITY SERVICES TO AID IN MAKING A DIFFERENCE. TOGETHER, THESE IMPORTANT TEAMS ARE TRULY PROVING THAT SOMC CAN MAKE A DIFFERENCE. PART VI, LINE 7: SOUTHERN OHIO MEDICAL CENTER IS A SINGLE ACUTE CARE PROVIDER OF HEALTH SERVICES AT TWO FACILITIES IN THE PORTSMOUTH, OHIO AREA. SOMC IS THE PARENT ORGANIZATION OF FRIENDS OF SOMC, SOMC MEDICAL CARE FOUNDATION, INC., SOMC TITLE HOLDING COMPANY, AND THE SOLE BENEFICIARY OF SOMC FOUNDATION.THE FRIENDS OF SOMC RENDER SERVICE TO SOUTHERN OHIO MEDICAL CENTER OF PORTSMOUTH, OHIO AND ITS PATIENTS AND ASSIST THE HOSPITAL IN PROMOTING HEALTH AND WELFARE OF THE COMMUNITY IN ACCORDANCE WITH THE OBJECTIVES ESTABLISHED BY THE GOVERNING BOARD OF TRUSTEES OF SOUTHERN OHIO MEDICAL CENTER. IN ADDITION, THE FRIENDS OF SOMC CREATE, RECEIVE AND MAINTAIN A FUND OR FUNDS OF REAL OR PERSONAL PROPERTY OR BOTH, TO USE AND APPLY THE WHOLE OR ANY PART OF THE INCOME THEREFROM AND THE PRINCIPAL THEREOF EXCLUSIVELY FOR THE USE AND BENEFIT OF SOUTHERN OHIO MEDICAL CENTER.SOMC MEDICAL CARE FOUNDATION IS ORGANIZED AND OPERATES EXCLUSIVELY FOR CHARITABLE, EDUCATIONAL AND SCIENTIFIC PURPOSES FOR THE BENEFIT OF SOMC, AN OHIO NON-PROFIT CORPORATION INCLUDING (A) PROVIDING MEDICAL, SURGICAL AND OTHER HEALTH CARE AND TREATMENT OF THE SICK, DISABLED, AND INJURED, REGARDLESS OF RACE, COLOR, RELIGION, NATIONAL ORIGIN, AGE, HANDICAP, SEX, OR THE ABILITY TO PAY FOR SERVICES; (B) CONDUCTING EDUCATIONAL ACTIVITIES RELATED TO HEALTHCARE AND TREATMENT OF THE SICK, DISABLED, INJURED AND TO PROMOTE AND CARRY ON MEDICAL, SCIENTIFIC AND CLINICAL RESEARCH RELATED TO HEALTH CARE AND TREATMENT OF THE SICK, DISABLED, AND INJURED; AND (C) ENGAGING IN ANY LAWFUL ACTIVITIES FOR WHICH CORPORATIONS MAY BE FORMED UNDER CHAPTER 1785 OF THE OHIO REVISED CODE THAT ARE NOT CONSISTNET WITH THE FOREGOING.SOMC TITLE HOLDING COMPANY OWNS AND MANAGES REAL ESTATE ON BEHALF OF SOUTHERN OHIO MEDICAL CENTER.SOMC FOUNDATION SUPPORTS SOUTHERN OHIO MEDICAL CENTER WITH FINANCIAL TRANSFERS. 1 AMERICAN RED CROSS 614 GLOVER ST PORTSMOUTH OH 45662 314414096 501(C)(3) 23000 YEARLY PLEDGE AND SPONSORSHIP DINNER. NOTRE DAME SCHOOLS 2220 SUNRISE AVE PORTSMOUTH OH 45662 311652882 501(C)(3) 12840 DEVELOPMENT FUND, GOLF TEAM SPONSOR, BID YOUR HEART OUT DONATION. PORTSMOUTH RIVER DAYS INC PO BOX 132 PORTSMOUTH OH 45662 314395524 501(C)(3) 8000 SPONSORSHIP OF RIVER DAYS COMMUNITY FESTIVAL. SHAWNEE STATE UNIVERSITY 940 2ND STREET PORTSMOUTH OH 45662 237073017 501(C)(3) 8100 VARIOUS SPONSORSHIPS AND DONATIONS. SOUTHERN OHIO GROWTH PARTNERSHIP PO BOX 509 PORTSMOUTH OH 45662 311068766 501(C)(3) 5000 PROGRAM DONATION. LITERACY COUNCIL OF SOUTHERN OHIO 940 2ND STREET PORTSMOUTH OH 45662 316401779 501(C)(3) 5611 MATCHING DONATION - PROGRAM SERVICES. PORTSMOUTH AREA ARTS COUNCIL PO BOX 1258 PORTSMOUTH OH 45662 310916197 501(C)(3) 4700 1427 FMV DONATION OF PRINTED MATERIAL SPONSORSHIP OF "DICKENS OF A CHRISTMAS" AND "RESPECT IS A MAGIC WORD." SCIOTO COUNTY JUNIOR FAIR 602 7TH STREET COURTHOUSE ROOM 7 PORTSMOUTH OH 45662 311115810 501(C)(3) 6500 SPONSORSHIP OF CIRCUS AND BUYER'S RECOGNITION DINNER. SOMC MEDICAL CARE FOUNDATION INC 1248 KINNEYS LANE PORTSMOUTH OH 45662 311374523 501(C)(3) 19574646 INTERCOMPANY SUPPORT. SOUTHERN OHIO PERFORMING ARTS PO BOX 1122 PORTSMOUTH OH 45662 311346687 501(C)(3) 15000 SPONSORSHIP OF "BROADWAY SERIES." CIVIC FORUM 5466 STATE RT 139 PORTSMOUTH OH 45662 312339573 501(C)(3) 10000 SPELLING BEE AND FIREWORKS ON JULY 4TH. SOUTHERN OHIO MUSEUM PO BOX 990 PORTSMOUTH OH 45662 310914613 501(C)(3) 5750 SPONSORSHIP OF "CREAM OF THE CROP" AND DONATIONS. PIKE COUNTY YMCA 400 PRIDE DRIVE WAVERLY OH 45690 311665134 501(C)(3) 6127 RELATIONSHIPS AND DONATIONS. 13 0 EMPLOYEE RELIEF FUND 16 28794 PROCEDURE FOR MONITORING GRANTS IN THE U.S.: PART I, LINE 2: SCHEDULE I, PART I, LINE 2: SOUTHERN OHIO MEDICAL CENTER MAY MAKE CONTRIBUTIONS IN SUPPORT OF ORGANIZATIONS IN THE COMMUNITY. FOR GRANTS TO INDIVIDUALS LISTED IN PART III, FUNDS ARE DONATED BY EMPLOYEES AND MATCHED BY SOUTHERN OHIO MEDICAL CENTER. IN THE EVENT THAT AN EMPLOYEE EXPERIENCES AN EMERGENCY WHERE THEY ARE IN SERIOUS FINANCIAL NEED, A COMMITTEE MAY APPROVE GRANTS FROM THE EMPLOYEE RELIEF FUND. X 0 0 X X X X X 0 1 0 0 0 0 0 0 0 RANDAL ARNETT 488017 0 165763 0 27279 0 278475 0 22310 0 981844 0 0 0 DEAN WRAY 257114 0 70500 0 18172 0 106175 0 19758 0 471719 0 0 0 KENDALL L STEWART 304212 0 79371 0 1153554 0 14700 0 18945 0 1570782 0 425226 0 CLAUDIA L BURCHETT 210887 0 48717 0 921 0 92798 0 23985 0 377308 0 0 0 VICKI A NOEL 168156 0 43301 0 356 0 48811 0 26144 0 286768 0 0 0 LEEANN L SAMMONS 149033 0 38754 0 305 0 41054 0 24479 0 253625 0 0 0 RORY E PHILLIPS 157034 0 29449 0 138 0 13408 0 25770 0 225799 0 0 0 JEREMY K JANNEY 133275 0 9718 0 54 0 7371 0 24870 0 175288 0 0 0 CRAIG E GILLILAND 119888 0 22473 0 342 0 8797 0 24970 0 176470 0 0 0 TERRY A JOHNSON 168627 0 0 0 138 0 8431 0 524 0 177720 0 0 0 VALERIE DECAMP 114088 0 20495 0 138 0 10884 0 25470 0 171075 0 0 0 PART I, LINE 1A THE ORGANIZATION PAYS A COUNTRY CLUB MEMBERSHIP ON THE CEO'S BEHALF AS A MEANS FOR THE CEO TO NETWORK WITH PHYSICIANS. NONE OF THE COUNTRY CLUB MEMBERSHIP DUES WERE TREATED AS TAXABLE COMPENSATION TO THE CEO. PART I, LINE 1B SOUTHERN OHIO MEDICAL CENTER DOES NOT FOLLOW A WRITTEN POLICY FOR REIMBURSEMENT OR A PROVISION OF THE BENEFIT. THE ORGANIZATION PAYS THE COUNTRY CLUB MEMBERSHIP DIRECTLY ON BEHALF OF THE CEO, SO NO REIMBURSEMENT POLICY IS IN PLACE. THE CEO'S EMPLOYMENT CONTRACT SETS FORTH THE DECISION FOR THE ORGANIZATION TO FOLLOW TO PROVIDE THE PAYMENT OF THE COUNTRY CLUB DUES AS A BENEFIT TO THE CEO. PART I, LINE 4B THE ORGANIZATION MADE CONTRIBUTIONS TO A SERP FOR THE FOLLOWING INDIVIDUALS: RANDAL ARNETT: 261,325 DEAN WRAY: 91,475 CLAUDIA BURCHETT: 71,795 VICKI NOEL: 35,834 LEEANN SAMMONS: 31,512 THE SERP PLAN IS AVAILABLE ONLY TO INDIVIDUALS WHO HAVE HELD AN EXECUTIVE POSITION FOR ONE YEAR. THE SERP WILL VEST UPON THE EXECUTIVE REACHING A SPECIFIED AGE. IF AN EXECUTIVE SEVERS EMPLOYMENT OR IS TERMINATED, A NONCOMPETE AGREEMENT IS IN PLACE FOR 2 YEARS. THE EXECUTIVE FORFEITS ANY SERP PAYMENTS IF HE/SHE DOES NOT CONFORM TO THE NONCOMPETE AGREEMENT. THE AMOUNTS LISTED ABOVE ARE INCLUDED IN COMPENSATION REPORTED IN SCHEDULE J, PART II, COLUMN C. KENDALL STEWART'S SERP WAS PAID OUT DURING THE CALENDAR YEAR IN THE AMOUNT OF $1,132,698. THE PAY OUT IS INCLUDED IN COMPENSATION REPORTED IN SCHEDULE J, PART II, COLUMN B(III). COUNTY OF SCIOTO OHIO 316400086 808878FN7 2008-07-23 150783464 HOSPITAL ADDITION & RENOVATIONS AND CURRENT REFUNDING OF 2006 BONDS 0 0 0 4880000 178743134 10911546 2835022 127600000 1619626 7850000 27628899 2009 1 0 1 1 0 0 0 0 1 0.00000 0.00000 0.00000 1 0 0 0 0 0 0 PART II, LINE 1: RETIRED CUSIP 808878FL1 ($2,380,000) AND CUSIP 808878FM9 ($2,500,000). PART II, LINE 3: INCLUDES ISSUE PRICE PLUS UNSPENT PROCEEDS FROM 2006 BONDS, INTEREST EARNINGS ON CONSTRUCTION FUND AFTER 7/23/08, INTEREST EARNINGS ON EXPENSE FUND, INTEREST EARNINGS ON CAPITALIZED INTEREST FUND, AND INTEREST EARNINGS ON DSRF. PART II, LINE 5: INCLUDES INTEREST EARNINGS ON THE CAPITALIZED INTEREST FUND, WHICH WERE USED TO PAY CAPITALIZED INTEREST ON THE 2008 BONDS. PART II, LINE 6: $127,600,000 OF PROCEEDS WERE USED TO CURRENTLY REFUND THE 2006 BONDS. THE ESCROW FUND WAS EXPENDED ON THE DATE OF ISSUANCE OF THE SERIES 2008 BONDS (7/23/08). PART II, LINE 7: INCLUDES UNDERWRITER'S DISCOUNT PLUS SERIES 2008 PROCEEDS DEPOSITED IN 2008 EXPENSE FUND. PART II, LINE 9: INCLUDES QUALIFIED HEDGE TERMINATION PAYMENT PLUS NON-QUALIFIED HEDGE TERMINATION PAYMENT RELATED TO THE 2006 SERIES BONDS. PART II, LINE 10: INCLUDES UNSPENT PROCEEDS FOR 2006 BONDS PLUS INTEREST EARNINGS ON THE CONSTRUCTION FUND. PART III, LINE 3: ALL MANAGEMENT CONTRACTS COMPLY WITH SAFE HARBOR REVENUE PROCEDURE 97-13. BANNON HOWLAND & DEVER BOARD CHAIR ROBERT DEVER IS SENIOR PARTNER OF BANNON, HOWLAND, & DEVER 240000 $20,000 PER MONTH RETAINER AS GENERAL COUNSEL TO SOUTHERN OHIO MEDICAL CENTER AND ITS RELATED ENTITIES. 0 PORTSMOUTH INSURANCE AGENCY BOARD MEMBER GARY DUZAN IS A PARTNER OF PORTSMOUTH INSURANCE AGENCY 299092 INSURANCE PROVIDER 0 US BANK BOARD MEMBER DAVID FOWLER IS AN OFFICER AT US BANK'S PORTSMOUTH BRANCH 108406 SERVICE CHARGES, INTEREST, AND FEES ASSOCIATED WITH SEVERAL DIFFERENT BANK ACCOUNTS. 0 X LAB INTERFACE 1 48400 FMV X CLOTHING, FURNISHINGS, FOOD FOR PATIENTS 1 50315 COST OF DONATED ITEMS 0 0 0 0 FORM 990, PART VI, SECTION B, LINE 11 FORM 990 INFORMATION IS COMPILED IN THE ACCOUNTING DEPARTMENT THEN SENT TO THE INDEPENDENT TAX ACCOUNTANTS TO ANALYZE THE INFORMATION AND COMPLETE THE TAX RETURN. THE FORM IS THEN REVIEWED BY FINANCIAL STAFF, TIED OUT TO THE TRIAL BALANCE, AND E-MAILED TO THE BOARD. IN ADDITION, THE CFO PRESENTS FORM 990 TO THE BOARD EXECUTIVE COMPENSATION COMMITTEE BEFORE FILING WITH THE IRS. FORM 990, PART VI, SECTION B, LINE 12C CONFLICT OF INTEREST STATEMENTS ARE FILLED OUT ANNUALLY IN JANUARY FOR OFFICERS AND FOR NEW AND RETURNING BOARD MEMBERS. COMPLETED CONFLICT OF INTEREST STATEMENTS ARE REVIEWED BY THE AUDIT & COMPLIANCE COMMITTEE. ANY CONFLICTS ARE DOCUMENTED IN THE MINUTES AND ADDRESSED. CONFLICTS OF INTEREST ARE RAISED BY OFFICERS OR BOARD MEMBERS ONCE THEY ARE KNOWN BY THE INDIVIDUAL. BOARD MEMBERS ABSTAIN FROM VOTING IF A CONFLICT IS IDENTIFIED THAT THE BOARD MEMBER IS INVOLVED WITH. FORM 990, PART VI, SECTION B, LINE 15 AN INDEPENDENT CONSULTANT ANNUALLY PROVIDES THE BOARD COMPENSATION COMMITTEE WITH COMPARABLE DATA AND OTHER FACTS WHICH ARE USED BY THE COMMITTEE TO DETERMINE EXECUTIVE PAY PHILOSOPHY. THE DECISIONS REGARDING OFFICER COMPENSATION ARE DOCUMENTED IN THE BOARD COMPENSATION COMMITTEE MINUTES, AS WELL AS THE BOARD MEETING MINUTES. THIS COMMITTEE DETERMINES THE CEO'S PAY AND SETS PAY RANGES FOR THE OTHER EXECUTIVES. THE PROCESS WAS LAST UNDERTAKEN DURING 2011. FORM 990, PART VI, SECTION C, LINE 19 SOUTHERN OHIO MEDICAL CENTER PROVIDES ITS FINANCIAL STATEMENTS TO THE PUBLIC THROUGH THE FILING OF ITS FORM 990 AS WELL AS ITS BOND DISCLOSURE. GOVERNING DOCUMENTS AND THE CONFLICT OF INTEREST POLICY ARE MADE AVAILABLE TO THE PUBLIC ON SOUTHERN OHIO MEDICAL CENTER'S WEBSITE. CHANGES IN NET ASSETS OR FUND BALANCES: FORM 990, PART XI, LINE 5: NET UNREALIZED GAINS ON INVESTMENTS: 16,374,032. CHANGE IN ACTUARIAL VALUE OF PENSION 5,868,300. TOTAL TO FORM 990, PART XI, LINE 5: 22,242,332. FORM 990, PART XI, LINE 2C: THE ORGANIZATION HAS A COMMITTEE RESPONSIBLE FOR OVERSIGHT OF THE AUDIT AND SELECTION OF AN INDEPENDENT ACCOUNTANT. THE PROCESS HAS NOT CHANGED FROM THE PRIOR YEAR. FORM 990, PAGE 1, LINE C: DOING BUSINESS AS: SOMC CANCER CENTER, SOMC HOME HEALTH SERVICES, SOMC L.I.F.E. CENTER, RIVERVIEW RETIREMENT CENTER, SOMC URGENT CARE CENTER, SOMC HOSPICE CENTER, SOMC WOUND HEALING CENTER. SOMC FOUNDATION INC 1805 27TH STREET PORTSMOUTH OH 45662 311564440 HOLD INVESTMENTS FOR BENEFIT OF SOUTHERN OHIO MEDICAL CENTER OH 501(C)(3) LINE 11A, I N/A 1 THE FRIENDS OF SOUTHERN OHIO MEDICAL CENTER 1805 27TH STREET PORTSMOUTH OH 45662 310677520 FUNDRAISING OH 501(C)(3) LINE 11A, I N/A 1 SOMC MEDICAL CARE FOUNDATION INC 1248 KINNEYS LANE PORTSMOUTH OH 45662 311374523 MEDICINE AND SURGERY OH 501(C)(3) LINE 11A, I N/A 1 SOUTHERN OHIO MEDICAL CENTER TITLE HOLDING COMPANY 1805 27TH STREET PORTSMOUTH OH 45662 311417566 MANAGE REAL ESTATE OH 501(C)(2) N/A N/A 1 0 1 1 0 0 0 0 0 0 1 1 1 0 1 1 1 1 1 SOMC MEDICAL CARE FOUNDATION B 19574646 ACCRUAL TRANSACTIONS SOMC MEDICAL CARE FOUNDATION J 238639 RENTAL CHARGES PER CONTRACT SOMC MEDICAL CARE FOUNDATION K 52369 COST PER CONTRACT SOMC MEDICAL CARE FOUNDATION L 142581 COST PER CONTRACT SOMC MEDICAL CARE FOUNDATION N 29118611 ALLOCATION OF COSTS SOMC MEDICAL CARE FOUNDATION O 16421024 ALLOCATION OF COSTS SOMC MEDICAL CARE FOUNDATION P 8293102 ALLOCATION OF COSTS SOMC TITLE HOLDING COMPANY J 1675127 RENTAL CHARGES PER CONTRACT SOMC TITLE HOLDING COMPANY P 1608877 ALLOCATION OF COSTS THE FRIENDS OF SOUTHERN OHIO MEDICAL CENTER C 50315 COST OF DONATED ITEMS THE FRIENDS OF SOUTHERN OHIO MEDICAL CENTER N 127733 ALLOCATION OF COSTS THE FRIENDS OF SOUTHERN OHIO MEDICAL CENTER P 127733 ALLOCATION OF COSTS SOMC TITLE HOLDING COMPANY N 308074 ALLOCATION OF COSTS