2012-11-08T14:03:39-06:00 2011-12-31 350921680 CROWE HORWATH LLP 330 E JEFFERSON BLVD P O BOX 7 SOUTH BEND IN 466240007 990 2011-01-01 202401676 COMMUNITY HOSPITAL OF LAGRANGE COUNTY INC COMM 2603738407 207 N TOWNLINE RD LAGRANGE IN 46761 MICHAEL P BROWNING 2603738407 2012-11-08 1 KENNETH J KEBER P00240883 5742323992 2011 2016-02-25 16:41:14Z MICHAEL PACKNETT 10501 CORPORATE DRIVE FORT WAYNE IN 46845 28242147 0 X WWW.PARKVIEW.COM X 2005 IN COMMUNITY HOSPITAL OF LAGRANGE COUNTY, INC. WILL PROVIDE QUALITY HEALTH SERVICES TO ALL WHO ENTRUST THEIR CARE TO US AND WE WILL WORK TO IMPROVE THE HEALTH OF OUR COMMUNITIES. 11 6 228 47 -1310 -1310 107637 123961 27252786 27931695 -43854 4415 170448 175492 27487017 28235563 37716 47386 0 0 10295293 10085207 0 0 13021 17452693 17283830 27785702 27416423 -298685 819140 33293052 31837943 35526008 34120955 -2232956 -2283012 X COMMUNITY HOSPITAL OF LAGRANGE COUNTY, INC. WILL PROVIDE QUALITY HEALTH SERVICES TO ALL WHO ENTRUST THEIR CARE TO US AND WE WILL WORK TO IMPROVE THE HEALTH OF OUR COMMUNITIES. 0 0 22211810 47386 27938460 COMMUNITY HOSPITAL OF LAGRANGE COUNTY, INC. IMPROVED AND EXPANDED FACILITIES:COMMUNITY HOSPITAL OF LAGRANGE COUNTY, INC. OPENED ITS ALL-NEW $25 MILLION REPLACEMENT FACILITY IN JULY OF 2008. THE 25-BED CRITICAL ACCESS FACILITY FEATURES ALL PRIVATE ROOMS AND BLENDS THE LATEST IN HEALTHCARE TECHNOLOGY WITH AMENITIES THAT INCORPORATE THE UNIQUE FLAVOR OF LAGRANGE COUNTY. THE EMERGENCY DEPARTMENT IN THE NEW HOSPITAL IS THREE TIMES AS LARGE AS THAT OF THE OLD FACILITY. WITH FOUR PRIVATE EXAM ROOMS, TWO TRAUMA ROOMS AND THREE OBSERVATION ROOMS, EMERGENCY SERVICES ARE GREATLY ENHANCED AS ARE PATIENTS' COMFORT AND PRIVACY. TWO STATE-OF-THE-ART SURGICAL SUITES AND AN ADDITIONAL MINOR PROCEDURE ROOM PROVIDE THE RESOURCES TO EXPAND SURGICAL SERVICES TO INCLUDE ORTHOPAEDIC, GYNECOLOGIC AND OTHER PROCEDURES TO COMMUNITY HOSPITAL OF LAGRANGE COUNTY, INC. THAT WERE PREVIOUSLY UNAVAILABLE.NEW EQUIPMENT IN THE CRITICAL CARE UNIT INCORPORATES THE ELECTRONIC INTENSIVE CARE UNIT (EICU) SYSTEM WITH AN EICU ROBOT. THIS TECHNOLOGY BRINGS A HIGHER LEVEL OF CARE TO CRITICALLY ILL PATIENTS AND A GREATER PEACE OF MIND TO THEIR FAMILIES. MONITORING SYSTEMS BUILT INTO TWO OF THE HOSPITAL'S EICU ROOMS TRANSMIT PATIENT DATA TO THE LOCAL NURSING STATION DOWN THE HALL AND TO BOARD-CERTIFIED INTENSIVISTS OR CRITICAL CARE SPECIALISTS AT AN OFF-SITE LOCATION. THE EICU SYSTEM PROVIDES AN ADDITIONAL LEVEL OF SERVICE THAT MAKES IT POSSIBLE FOR MORE PATIENTS TO RECEIVE CARE LOCALLY.TECHNOLOGY IS ONLY A PIECE OF THE PICTURE. LOCAL AMISH WOODWORKERS WERE CONTRACTED TO CREATE HANDCRAFTED FURNISHINGS FOR THE MAIN LOBBY AND SECOND FLOOR WAITING AREA. FRAMED, LOCALLY MADE QUILTS AND ICONIC IMAGES OF LAGRANGE COUNTY PHOTOGRAPHED BY A LOCAL PHOTOGRAPHER SERVE AS ARTWORK THROUGHOUT THE FACILITY. FOR VISITORS FROM OUTSIDE THE COUNTY, THE AMBIENCE CREATED IS WARM AND WELCOMING; FOR PATIENTS AND VISITORS FROM LAGRANGE, THE FURNITURE AND ARTWORK OFFER SOMETHING FAMILIAR AND COMFORTING, A REMINDER OF HOME.COMMUNITY HEALTH IMPROVEMENT:AS A NOT-FOR-PROFIT HOSPITAL, WE TAKE OUR MISSION TO HEART. COMMUNITY HOSPITAL OF LAGRANGE COUNTY, INC. EXISTS FOR ONE PURPOSE - TO IMPROVE THE HEALTH OF THE COMMUNITIES WE SERVE. COMMUNITY HOSPITAL OF LAGRANGE COUNTY, INC. GIVES BACK TO THE COMMUNITY IN THE FORM OF IMPROVED FACILITIES, EDUCATION AND OUTREACH PROGRAMS, FREE AND DISCOUNTED CARE, VOLUNTEERISM AND MUCH MORE. THE FOLLOWING ARE SOME OF THE WAYS COMMUNITY HOSPITAL OF LAGRANGE COUNTY, INC. IS REACHING OUT TO MAKE OUR NEIGHBORHOODS AND COMMUNITIES HEALTHIER:-CHARITY CARE -COMMUNITY HEALTH IMPROVEMENT INITIATIVES-PRIMARY HEALTH CARE/ACCESS -HEALTH SCREENING AND PREVENTION -DISEASE MANAGEMENTCHARITY CARE:COMMUNITY HOSPITAL OF LAGRANGE COUNTY, INC.'S MISSION INCLUDES CARING FOR PATIENTS WHO DO NOT HAVE THE MEANS TO MEET THEIR FINANCIAL OBLIGATIONS. THE HOSPITAL PLACES ITS PRIORITY ON PROVIDING THE NECESSARY CARE, NOT ON THE PATIENT'S FINANCIAL ABILITY TO PAY FOR THEIR MEDICAL EXPENSES.COMMUNITY HEALTH IMPROVEMENT INITIATIVES:COMMUNITY HOSPITAL OF LAGRANGE COUNTY, INC. BECAME PART OF THE PARKVIEW FAMILY DURING 2005. THE PURPOSE OF COMMUNITY HOSPITAL OF LAGRANGE COUNTY, INC.'S COMMUNITY HEALTH IMPROVEMENT PROGRAM IS TO FUND COMMUNITY HEALTH IMPROVEMENT EFFORTS WITHIN THE SERVICE AREA OF COMMUNITY HOSPITAL OF LAGRANGE COUNTY, INC. THE HOSPITAL SETS ASIDE UP TO 10 PERCENT OF ITS NET INCOME ANNUALLY TO FUND COMMUNITY HEALTH INITIATIVES, AND PARTNERS WITH COMMUNITY ORGANIZATIONS TO ENCOURAGE HEALTHIER LIFESTYLES AMONG THE CITIZENS OF LAGRANGE COUNTY.KEY INITIATIVES INCLUDE:PLAIN CHURCH SERVICES:AMISH AND PLAIN CHURCH RESIDENTS MAKE UP NEARLY 40% OF THE POPULATION IN LAGRANGE COUNTY. FOR THE MEMBERS OF THESE FAITH-BASED COMMUNITIES - PARTICULARLY THE AMISH - EVERYDAY TRAVEL IS BY HORSE AND BUGGY OR BICYCLE; COMMUNICATIONS ARE FACE-TO-FACE OR THROUGH THE USE OF A COMMUNITY-OWNED, CENTRALLY LOCATED PHONE. COMMUNITY HOSPITAL OF LAGRANGE COUNTY, INC. PARTNERS WITH "HIRED DRIVERS" WHO SERVE THE AMISH POPULATION AS A COMMON FORM OF TRANSPORTATION TO AND FROM APPOINTMENTS AT THE HOSPITAL. RECOGNIZING THE DIVERSE CIRCUMSTANCES OF THESE COMMUNITIES, COMMUNITY HOSPITAL OF LAGRANGE COUNTY, INC. REPRESENTATIVES AND THE PLAIN CHURCH COORDINATOR HAVE BEEN WORKING CLOSELY WITH MEMBERS OF THE PLAIN CHURCH COMMUNITY FOR SEVERAL YEARS, HELPING TO IDENTIFY SPECIFIC HEALTH NEEDS AND DEVELOP SYSTEMS TO ADDRESS THEM. THE PLAIN CHURCH COORDINATOR SERVES AS A SINGLE POINT OF ACCESS FOR AMISH, MENNONITE AND OTHER PLAIN CHURCH MEMBERS WHO HAVE QUESTIONS ABOUT THE HEALTHCARE SERVICES AVAILABLE WITHIN THE PARKVIEW HEALTH SYSTEM. WHETHER THE QUESTION CONCERNS THE APPROXIMATE COST OF A PROCEDURE, THE SCHEDULING OF A DIAGNOSTIC TEST, OR A BILLING QUESTION, THE PLAIN CHURCH COORDINATOR WILL ASSIST INDIVIDUALS AND FAMILIES BY OBTAINING AN ANSWER.HEALTH EDUCATION AND INFORMATION:"HEALTHY VIEW" COMMUNITY NEWSLETTER IS MAILED QUARTERLY TO ALL HOUSEHOLDS IN LAGRANGE COUNTY. THE PUBLICATION OFFERS HEALTH INFORMATION ON LEADING TOPICS OF INTEREST INCLUDING CANCER, HEART DISEASE, DIABETES, AND MORE, AND MAKES READERS AWARE OF NEW SERVICES AT COMMUNITY HOSPITAL OF LAGRANGE COUNTY, INC. THE PUBLICATION IS OF PARTICULAR VALUE TO THE PLAIN CHURCH COMMUNITIES WHO DO NOT RECEIVE INFORMATION THROUGH TELEVISION, RADIO OR OTHER ELECTRONIC MEANS.PRIMARY HEALTH CARE ACCESS:COMMUNITY HOSPITAL OF LAGRANGE COUNTY, INC. PARTNERED WITH THE LAGRANGE COUNTY COUNCIL ON AGING TO ASSIST WITH OPERATIONAL SUPPORT FOR THE COA'S SERVICES TO SENIORS. THE COA PROVIDES A TRANSPORTATION PROGRAM, HOMEMAKER SERVICES, A FOOD PANTRY AND MUCH MORE IN THEIR EFFORTS TO HELP SENIORS IN LAGRANGE COUNTY REMAIN INDEPENDENT IN THE HOMES OF THEIR CHOICE FOR AS LONG AS POSSIBLE. NEARLY HALF OF THE TRIPS THE COA OFFERS TO SENIORS ARE TO THEIR PHYSICIAN FOR A CHECK-UP OR TO THE HOSPITAL FOR A TEST OR TREATMENT. HOMEMAKER SERVICES HELP WITH DAY-TO-DAY TASKS THAT, IN MANY CASES, COULD PUT THE SENIOR AT RISK OF A FALL OR OTHER INJURY.HEALTH SCREENING AND PREVENTION AND DISEASE MANAGEMENT:COMMUNITY HOSPITAL OF LAGRANGE COUNTY, INC. PARTICIPATES IN NUMEROUS HEALTH FAIRS AND ACTIVITIES THROUGHOUT THE YEAR OFFERING FREE AND LOW COST HEALTH SCREENINGS AND INFORMATION TO DIVERSE POPULATIONS IN OUR SERVICE AREA, INCLUDING THE PLAIN CHURCH AND HISPANIC RESIDENTS AND SENIORS WHO RESIDE IN THE COUNTY. THESE EVENTS PROVIDE HEALTH EDUCATION, HEALTH SCREENINGS FOR DISEASE PREVENTION, AND PROMOTE HEALTHY LIFESTYLES. THE HOSPITAL ALSO PROVIDES SUPPORT GROUPS TO ASSIST PATIENTS AND FAMILIES IN MANAGING DISEASE. 22211810 1 1 0 1 0 0 0 0 0 0 1 0 0 0 1 0 0 1 0 0 0 0 0 0 1 0 1 1 1 1 1 1 0 0 0 0 0 0 0 0 0 1 0 0 0 0 0 1 0 0 0 0 1 X 29 0 1 228 1 1 1 0 0 0 0 1 1 0 0 0 0 X 11 6 1 0 0 0 1 1 1 1 1 0 0 1 1 1 1 1 1 1 1 0 IN X MICHAEL P BROWNING 2603738407 10501 CORPORATE DRIVE FORT WAYNE IN 46845 X ROBERT MYERS 40.00 X X 166857 0 46059 MICHAEL PACKNETT 1.00 X X 0 647552 166370 LISA BOOTH 1.00 X 17956 469133 17920 MIROSLAW FOLTYNIAK 1.00 X 11438 394658 45116 STEPHANIE GOUGH 1.00 X 4750 1250 0 KEVIN LAMBRIGHT 1.00 X 4500 0 0 DENNIS LEHMAN 1.00 X 4250 0 0 THOMAS MILLER 1.00 X 4500 0 0 GENE MORY 1.00 X 4500 0 0 JOE PIERCE 1.00 X 4250 1500 0 JOHN PRICE 1.00 X 6500 3250 0 MICHAEL BROWNING 1.00 X 0 399631 66886 BRENDA ARMENTROUT 40.00 X 120080 0 13896 JORDI DISLER 40.00 X 47565 54665 27002 MARK NAFZIGER 0.00 X 0 211886 816 STANTON RISSER 0.00 X 0 109511 22752 397146 2293036 406817 3 1 1 0 GREAT LAKES ANESTHESIA PC 500 N NAPPANEE ST STE 11-B ELKHART IN 46514 ANESTHESIOLOGISTS 177019 1 7012 15003 26276 19224 56446 123961 NET PATIENT SERVICE 622000 27420154 27420154 PHARMACY 446110 226578 226578 EMS SUBSIDY 900099 219600 219600 RENTAL INCOME FROM AFF 531120 50613 50613 SPEECH THERAPY 621300 12036 12036 2714 2714 27931695 1148 1148 2359 3669 -1310 -1310 -1310 3267 3267 3267 3267 2195 15003 2915 -720 -720 CAFETERIA REVENUE 722210 154363 154363 GIFT SHOP REVENUE 453220 12644 12644 MEDICAL STAFF CREDENTI 561499 3750 3750 6765 6765 177522 28235563 27938460 -1310 174452 X 40126 40126 7260 7260 277492 277492 7437606 7331362 97195 9049 2370109 2311398 55833 2878 3059993 2818148 241845 3554 3554 752757 722818 29128 811 492069 485211 6858 28118 17150 10685 283 10164 8244 1920 308284 308284 1877263 1877263 104216 104216 CORP SERVICE ALLOCATION 4432000 4432000 BAD DEBT 2926895 2926895 MEDICAL SUPPLIES 2149659 2149659 PH SUBSIDY 1043222 1043222 95636 57000 38636 27416423 22211810 5191592 13021 1250 1550 10519 150 10708 12309 2930266 3481626 179720 164458 46357 37511 29985559 7772700 24044028 22212859 1246 1246 5011241 5011241 1057717 914993 33293052 31837943 761858 716806 23088658 22441953 1079251 146480 10596241 10596241 0 219475 35526008 34120955 X -2232956 -2283012 -2232956 -2283012 33293052 31837943 X 819140 -869196 X 0 1 1 X 0 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 0 0 0 0 0 0 0 0 1 3023 3023 0 EXPLANATION OF OTHER LOBBYING ACTIVITIES: PART II-B, LINE 1I: A PORTION OF THE DUES PAID TO INDIANA HOSPITAL AND HEALTH ASSOCIATION AND AMERICAN HOSPITAL ASSOCIATION WERE USED FOR LOBBYING ACTIVITIES. 265000 265000 13245217 1340471 11904746 29098 18885 10213 14529128 5869179 8659949 1917116 544165 1372951 22212859 EST MEDICARE/MEDICAID SETTLEMENTS 219475 219475 LAGRANGE PADDLE 11850 10414 1436 1038 466 498 FESTIVAL OF TREES 5348 4589 759 913 17198 15003 2195 1038 466 1411 2915 -720 1 1 X 1 X 0 1 1 1 0 0 1103253 1103253 0.04500 2525654 1004610 1521044 0.06210 274773 221811 52962 0.00220 3903680 1226421 2677259 0.10930 40343 1020 39323 0.00160 6472 6472 0.00030 1043222 1043222 0.04260 30377 30377 0.00120 1120414 1020 1119394 0.04570 5024094 1227441 3796653 0.15500 10000 10000 0.00040 5000 5000 0.00020 50113 50113 0.00200 65113 65113 0.00260 1 2926895 198917 6110276 5858383 251893 X 1 1 1 1 COMMUNITY HOSPITAL OF LAGRANGE COUNTY

207 N TOWNLINE RD LAGRANGE IN 46761

X X X X COMMUNITY HOSPITAL OF LAGRANGE COUNTY 1 1 1 200.000000000000 0 0 1 1 X X 1 0 1 X 0 0 PART I, LINE 3C: ELIGIBILITY CRITERIA FOR FREE OR DISCOUNTED CARECOMMUNITY HOSPITAL OF LAGRANGE COUNTY, INC. PROVIDES DISCOUNTED CARE TO UNINSURED PATIENTS REGARDLESS OF THEIR ABILITY TO PAY. IF THE PATIENT ULTIMATELY QUALIFIES FOR CHARITY CARE USING THE 200% FPG, THE REMAINING BALANCE AFTER THE DISCOUNT IS WRITTEN OFF TO CHARITY. PART I, LINE 7: PART I, LINE 7ACOMMUNITY HOSPITAL OF LAGRANGE COUNTY, INC. IS COMMITTED TO PROVIDING CHARITY CARE TO PATIENTS UNABLE TO MEET THEIR FINANCIAL OBLIGATIONS. IT IS FURTHERMORE THE POLICY OF COMMUNITY HOSPITAL OF LAGRANGE COUNTY, INC. NOT TO WITHHOLD OR DENY ANY REQUIRED MEDICAL CARE AS A RESULT OF A PATIENT'S FINANCIAL INABILITY TO PAY HIS/HER MEDICAL EXPENSES.THE CHARITY CARE COST REPORTED ON LINE 7A IS CALCULATED UNDER THE COST TO CHARGE RATIO METHODOLOGY. UNDER THIS METHOD, THE CHARITY CARE CHARGES FOREGONE ARE MULTIPLIED BY THE RATIO OF COST TO CHARGES TO DETERMINE THE COST OF SERVICES RENDERED.PART I, LINE 7BCOMMUNITY HOSPITAL OF LAGRANGE COUNTY, INC. ACCEPTS ALL MEDICAID, MEDICAID MANAGED CARE, AND OUT-OF-STATE MEDICAID PATIENTS WITH THE KNOWLEDGE THAT THERE MAY BE SHORTFALLS. INTERNAL REVENUE SERVICE (IRS) REVENUE RULING 69-545 IMPLIES THAT TREATING MEDICAID PATIENTS IS A COMMUNITY BENEFIT. IRS REVENUE RULING 69-545, WHICH ESTABLISHED THE COMMUNITY BENEFIT STANDARD FOR NONPROFIT HOSPITALS, STATES THAT IF A HOSPITAL SERVES PATIENTS WITH GOVERNMENTAL HEALTH BENEFITS, INCLUDING MEDICAID, THEN THIS IS AN INDICATION THAT THE HOSPITAL OPERATES TO PROMOTE THE HEALTH OF THE COMMUNITY. THE UNREIMBURSED MEDICAID COST REPORTED ON LINE 7B IS CALCULATED UNDER THE COST TO CHARGE RATIO METHODOLOGY. UNDER THIS METHOD, THE MEDICAID CHARGES ARE MULTIPLIED BY THE RATIO OF COST TO CHARGES TO DETERMINE THE COST OF MEDICAID SERVICES RENDERED. THEN, THE COST OF MEDICAID SERVICES RENDERED IS DEDUCTED FROM THE REIMBURSEMENT RECEIVED FOR MEDICAID PATIENTS TO ARRIVE AT A GAIN/(LOSS) RELATIVE TO THESE PATIENTS.PART I, LINE 7CCOMMUNITY HOSPITAL OF LAGRANGE COUNTY, INC. ACCEPTS ALL MEANS-TESTED PATIENTS FROM THE HEALTHY INDIANA PLAN (HIP) WITH THE KNOWLEDGE THAT THERE MAY BE SHORTFALLS. INTERNAL REVENUE SERVICE (IRS) REVENUE RULING 69-545 IMPLIES THAT TREATING MEANS-TESTED PATIENTS IS A COMMUNITY BENEFIT. IRS REVENUE RULING 69-545, WHICH ESTABLISHED THE COMMUNITY BENEFIT STANDARD FOR NONPROFIT HOSPITALS, STATES THAT IF A HOSPITAL SERVES PATIENTS WITH GOVERNMENTAL HEALTH BENEFITS, INCLUDING HIP, THEN THIS IS AN INDICATION THAT THE HOSPITAL OPERATES TO PROMOTE THE HEALTH OF THE COMMUNITY. THE UNREIMBURSED HIP COST REPORTED ON LINE 7C IS CALCULATED UNDER THE COST TO CHARGE RATIO METHODOLOGY. UNDER THIS METHOD, THE HIP CHARGES ARE MULTIPLIED BY THE RATIO OF COST TO CHARGES TO DETERMINE THE COST OF HIP SERVICES RENDERED. THEN, THE COST OF HIP SERVICES RENDERED IS DEDUCTED FROM THE REIMBURSEMENT RECEIVED FOR HIP PATIENTS TO ARRIVE AT A GAIN/(LOSS) RELATIVE TO THESE PATIENTS.PART I, LINE 7EAMOUNTS PRESENTED ARE BASED ON ACTUAL SPEND FOR THOSE SERVICES AND BENEFITS PROVIDED DEEMED TO IMPROVE THE HEALTH OF THE COMMUNITIES IN WHICH WE SERVE AND CONFORM WITH THE MISSION OF OUR EXEMPT PURPOSE.PART I, LINE 7FAMOUNTS PRESENTED ARE BASED UPON ACTUAL SPEND AND ARE IN CONFORMITY WITH AGREED UPON COMMITMENTS WITH THE VARIOUS EDUCATIONAL PROGRAMS.PART I, LINE 7IIN KEEPING WITH OUR MISSION AND COMMITMENT TO THE COMMUNITIES IN WHICH WE SERVE, COMMUNITY HOSPITAL OF LAGRANGE COUNTY, INC. CONTINUES ITS TRADITION OF CONTRIBUTING TO NUMEROUS ORGANIZATIONS ON BOTH AN AS-NEEDED BASIS AND NEGOTIATED BASIS. AMOUNTS PRESENTED REPRESENT ACTUAL SPEND TO ORGANIZATIONS THROUGHOUT OUR COMMUNITIES. PART I, LINE 7G: SUBSIDIZED HEALTH SERVICES COMMUNITY HOSPITAL OF LAGRANGE COUNTY, INC. INCLUDED $1,043,222 IN COSTS ATTRIBUTABLE TO PHYSICIAN CLINICS AS SUBSIDIZED HEALTH SERVICES. PART I, L7 COL(F): PERCENT OF TOTAL EXPENSESCOMMUNITY HOSPITAL OF LAGRANGE COUNTY, INC. EXCLUDED $2,926,895 OF BAD DEBT EXPENSE. PART II: DESCRIBE HOW THE ORGANIZATION'S COMMUNITY BUILDING ACTIVITIES, AS REPORTED, PROMOTES THE HEALTH OF THE COMMUNITIES THE ORGANIZATION SERVES.COMMUNITY HOSPITAL OF LAGRANGE COUNTY, INC. SUPPORTS PHYSICIAN RECRUITMENT ACTIVITIES TO ASSIST IN TIMELY RESPONSE TO PATIENT CARE NEEDS IN THE COMMUNITY. THESE RECRUITMENT ACTIVITIES ARE BASED ON RESULTS OF A PERIODIC PHYSICIAN NEEDS ASSESSMENT. COMMUNITY HOSPITAL OF LAGRANGE COUNTY, INC. DEVELOPS A PHYSICIAN RECRUITMENT PLAN TO ADDRESS POTENTIAL GAPS IN PATIENT COVERAGE. COMMUNITY HOSPITAL OF LAGRANGE COUNTY, INC. STRIVES TO BRING THE BEST INTEGRATED, QUALITY, AND COST EFFECTIVE CARE AND INNOVATIVE TECHNOLOGY TO OUR COMMUNITIES. IN DOING SO, WE FOCUS OUR EFFORTS ON RECRUITING AN EXCEPTIONAL TEAM OF PHYSICIANS. EVERY MEMBER OF COMMUNITY HOSPITAL OF LAGRANGE COUNTY, INC.'S HEALTHCARE TEAM IS RESPONSIBLE FOR NURTURING AN ENVIRONMENT OF EXCELLENCE AS THE BEST PLACE FOR CO-WORKERS TO WORK, PHYSICIANS TO PRACTICE MEDICINE, AND PATIENTS TO RECEIVE CARE. WE ARE COMMITTED TO PROVIDING EXCEPTIONAL CUSTOMER SERVICE TO ALL PEOPLE. WE KNOW HOW IMPORTANT CLINICAL, SERVICE AND OPERATIONAL EXCELLENCE IS TO THE SUCCESS OF COMMUNITY HOSPITAL OF LAGRANGE COUNTY, INC., AND WE RECOGNIZE HOW IMPORTANT OUR SUCCESS IS TO THE COMMUNITY. PART III, LINE 4: BAD DEBT EXPENSE - FINANCIAL STATEMENT FOOTNOTETEXT OF THE FOOTNOTE TO THE ORGANIZATION'S FINANCIAL STATEMENTS THAT DESCRIBES BAD DEBT EXPENSE:THE CORPORATION'S ESTIMATION OF THE ALLOWANCE FOR DOUBTFUL ACCOUNTS IS BASED PRIMARILY UPON THE TYPE AND AGE OF THE PATIENT ACCOUNTS RECEIVABLE AND THE EFFECTIVENESS OF COLLECTION EFFORTS. PH'S POLICY IS TO RESERVE A PORTION OF ALL SELF-PAY RECEIVABLES, INCLUDING AMOUNTS DUE FROM THE UNINSURED AND AMOUNTS RELATED TO CO-PAYMENTS AND DEDUCTIBLES, AS CHARGES ARE RECORDED. ACCOUNTS RECEIVABLE BALANCES ARE REVIEWED MONTHLY AS TO THE EFFECTIVENESS OF PH'S RESERVE POLICIES AND VARIOUS ANALYTICS TO SUPPORT THE BASIS FOR ITS ESTIMATES. THESE EFFORTS PRIMARILY CONSIST OF REVIEWING THE FOLLOWING: HISTORICAL WRITE-OFF AND COLLECTION EXPERIENCE USING A HINDSIGHT, OR LOOK-BACK, APPROACH; REVENUE AND VOLUME TRENDS BY PAYOR, PARTICULARLY THE SELF-PAY COMPONENTS; CHANGES IN THE AGING AND PAYOR MIX OF ACCOUNTS RECEIVABLE, INCLUDING INCREASED FOCUS ON ACCOUNTS DUE FROM THE UNINSURED AND ACCOUNTS THAT REPRESENT CO-PAYMENTS AND DEDUCTIBLES DUE FROM PATIENTS; CASH COLLECTIONS AS A PERCENTAGE OF NET PATIENT REVENUE LESS BAD DEBT EXPENSE; TRENDING OF DAYS REVENUE IN ACCOUNTS RECEIVABLE; AND VARIOUS ALLOWANCE COVERAGE STATISTICS. COSTING METHODOLOGY USED:UNCOLLECTIBLE PATIENT ACCOUNTS ARE CHARGED AGAINST THE ALLOWANCE FOR UNCOLLECTIBLE ACCOUNTS IN ACCORDANCE WITH THE POLICIES OF COMMUNITY HOSPITAL OF LAGRANGE COUNTY, INC. HOWEVER, DURING THE COLLECTION PROCESS THERE IS A CONTINUOUS EFFORT TO DETERMINE IF THE PATIENT QUALIFIES FOR CHARITY. THEREFORE, ONCE AN UNCOLLECTIBLE ACCOUNT HAS BEEN CHARGED OFF AND IT IS DETERMINED THROUGH THE COLLECTION PROCESS THAT THE PATIENT QUALIFIES FOR CHARITY CARE, THE UNCOLLECTIBLE ACCOUNT IS RECLASSIFIED TO CHARITY AND ALL COLLECTION EFFORTS CEASE. PATIENTS ARE ELIGIBLE TO APPLY FOR FREE CARE AT ANY TIME, INCLUDING PATIENTS WHOSE ACCOUNTS HAVE BEEN PLACED IN A BAD DEBT AGENCY. THE AMOUNT REFLECTED ON LINE 3 WAS CALCULATED BY TOTALING THE ACCOUNTS PREVIOUSLY WRITTEN OFF TO BAD DEBT AND PLACED WITH A COLLECTION AGENCY, BUT SUBSEQUENTLY RECLASSIFIED AS FREE CARE DURING THE 2011 CALENDAR YEAR. THE ACCOUNTS WERE RECLASSIFIED AS FREE CARE DUE TO THE FACT THAT PATIENTS APPLIED FOR, AND WERE APPROVED FOR, FREE CARE AFTER THE ACCOUNTS WERE PLACED WITH A BAD DEBT AGENCY. COMMUNITY HOSPITAL OF LAGRANGE COUNTY, INC. PROVIDES HEALTH CARE SERVICES THROUGH VARIOUS PROGRAMS THAT ARE DESIGNED, AMONG OTHER THINGS, TO ENHANCE THE HEALTH OF THE COMMUNITY AND IMPROVE THE HEALTH OF AT-RISK POPULATIONS. IN ADDITION, COMMUNITY HOSPITAL OF LAGRANGE COUNTY, INC. PROVIDES SERVICES INTENDED TO BENEFIT THE POOR AND UNDERSERVED, INCLUDING THOSE PERSONS WHO CANNOT AFFORD HEALTH INSURANCE DUE TO INADEQUATE RESOURCES OR WHO ARE UNINSURED OR UNDERINSURED. PART III, LINE 8: COMMUNITY BENEFIT & METHODOLOGY FOR DETERMINING MEDICARE COSTSSUBSTANTIAL SHORTFALLS TYPICALLY ARISE FROM PAYMENTS THAT ARE LESS THAN THE COST TO PROVIDE THE CARE OR SERVICES AND DO NOT INCLUDE ANY AMOUNTS RELATING TO INEFFICIENT OR POOR MANAGEMENT. COMMUNITY HOSPITAL OF LAGRANGE COUNTY, INC. ACCEPTS ALL MEDICARE PATIENTS, AS REFLECTED ON THE YEAR-END MEDICARE COST REPORT, WITH THE KNOWLEDGE THAT THERE MAY BE SHORTFALLS. INTERNAL REVENUE SERVICE (IRS) REVENUE RULING 69-545 IMPLIES THAT TREATING MEDICARE PATIENTS IS A COMMUNITY BENEFIT. IRS REVENUE RULING 69-545, WHICH ESTABLISHED THE COMMUNITY BENEFIT STANDARD FOR NONPROFIT HOSPITALS, STATES THAT IF A HOSPITAL SERVES PATIENTS WITH GOVERNMENTAL HEALTH BENEFITS, INCLUDING MEDICARE, THEN THIS IS AN INDICATION THAT THE HOSPITAL OPERATES TO PROMOTE THE HEALTH OF THE COMMUNITY. HOWEVER, MEDICARE PAYMENTS REPRESENT A PROXY OF COST CALLED THE "UPPER PAYMENT LIMIT." IT HAS HISTORICALLY BEEN ASSUMED THAT UPPER PAYMENT LIMIT PAYMENTS DO NOT GENERATE A SHORTFALL. AS A RESULT, COMMUNITY HOSPITAL OF LAGRANGE COUNTY, INC. HAS TAKEN THE POSITION NOT TO INCLUDE THE MEDICARE SHORTFALLS OR SURPLUSES AS PART OF COMMUNITY BENEFIT. COMMUNITY HOSPITAL OF LAGRANGE COUNTY, INC. RECOGNIZES THAT THE SHORTFALL OR SURPLUS FROM MEDICARE DOES NOT INCLUDE THE COSTS AND REVENUES ASSOCIATED WITH MEDICARE ADVANTAGE PATIENTS. AS SUCH, THE TOTAL SHORTFALL OR SURPLUS OF MEDICARE IS UNDERSTATED DUE TO THE COSTS AND REVENUES ASSOCIATED WITH MEDICARE ADVANTAGE PATIENTS NOT BEING INCLUDED IN THE COMMUNITY BENEFIT DETERMINATION. PART III, LINE 9B: COLLECTION PRACTICES FOR PATIENTS ELIGIBLE FOR CHARITY CARETHE LAST PARAGRAPH OF THE PAYMENT POLICY STATES:"FINANCIAL ASSISTANCE MAY BE AVAILABLE FOR THOSE PATIENTS WHO CANNOT PAY THEIR BILL. THOSE OPTIONS ARE WELFARE ASSISTANCE OR FREE CARE THROUGH THE HOSPITAL CHARITY PROGRAM. (SEE CHARITY CARE POLICY.) PATIENTS WILL BE INSTRUCTED TO CONTACT A COUNSELOR TO DISCUSS THE AVAILABLE OPTIONS."ADDITIONALLY, THERE IS AN ONGOING EFFORT THROUGHOUT THE COLLECTION PROCESS TO SCREEN FOR MEDICAID ELIGIBILITY AND THE NEED FOR PROVIDING CHARITY CARE APPLICATIONS TO PATIENTS. IF A PATIENT MAY BE ELIGIBLE FOR MEDICAID, THE HOSPITAL PROVIDES A SERVICE TO OUR PATIENTS THAT HELPS THEM APPLY FOR MEDICAID WITH THE STATE IN WHICH THEY RESIDE. IF A PATIENT IS APPROVED FOR CHARITY CARE, THEIR ACCOUNT IS WRITTEN OFF AND COLLECTION EFFORTS CEASE. COMMUNITY HOSPITAL OF LAGRANGE COUNTY PART V, SECTION B, LINE 10: ELIGIBILITY CRITERIA FOR FREE OR DISCOUNTED CARECOMMUNITY HOSPITAL OF LAGRANGE COUNTY, INC. PROVIDES DISCOUNTED CARE TO UNINSURED PATIENTS REGARDLESS OF THEIR ABILITY TO PAY. IF THE PATIENT ULTIMATELY QUALIFIES FOR CHARITY CARE USING THE 200% FPG, THE REMAINING BALANCE AFTER THE DISCOUNT IS WRITTEN OFF TO CHARITY. COMMUNITY HOSPITAL OF LAGRANGE COUNTY PART V, SECTION B, LINE 19D: FULL WRITEOFFS ARE PROVIDED TO PATIENTS WHOSE INCOME FALLS UNDER 200% OF THE FPG. ON CHARITY CARE PATIENTS WITH RESIDUAL SELF-PAY BALANCES AFTER INSURANCE PROCESSED AND PAID OR DENIED THEIR CLAIM, 100% OF THE REMAINING ACCOUNT BALANCE AFTER INSURANCE PAYMENTS AND CONTRACTUAL ADJUSTMENTS IS WRITTEN OFF TO CHARITY CARE. PART VI, LINE 2: DESCRIBE HOW THE ORGANIZATION ASSESSES THE HEALTH CARE NEEDS OF THE COMMUNITIES IT SERVES.PARKVIEW HEALTH SYSTEM, INC., INCLUDING COMMUNITY HOSPITAL OF LAGRANGE COUNTY, INC., AND IN CONJUNCTION WITH THE ALLEN COUNTY - FORT WAYNE HEALTH DEPARTMENT, IS CURRENTLY CONDUCTING A COMMUNITY HEALTH NEEDS ASSESSMENT FOR THE FIVE COUNTY SERVICE AREA IN WHICH PARKVIEW HOSPITALS RESIDE. IN ADDITION, PARKVIEW HEALTH SYSTEM, INC. HAS PARTNERED WITH THE TECHNICAL ASSISTANCE PROGRAM OF PURDUE UNIVERSITY AND THE SOCIAL RESEARCH DEPARTMENT OF INDIANA UNIVERSITY - PURDUE UNIVERSITY OF FORT WAYNE (IPFW) TO COMPLETE MUCH OF THE FIELD WORK. IPFW IS CONDUCTING THE COMMUNITY SURVEY AND PROVIDING DATA ANALYSIS AND INCORPORATING SECONDARY DATA INTO THE ASSESSMENT. PURDUE UNIVERSITY IS ASSISTING WITH THE PUBLIC HEALTH AND OTHER HEALTH CARE PROFESSIONALS SURVEY. PARKVIEW HEALTH SYSTEM, INC. PLANS TO COMPLETE THE COMMUNITY HEALTH NEEDS ASSESSMENT AND THE DEVELOPMENT AND ADOPTION OF AN IMPLEMENTATION STRATEGY DURING 2013. THE INFORMATION FROM THIS SURVEY WILL BE A VALUABLE TOOL TO MEETING THE NEEDS OF, AND IMPROVING THE HEALTH OF, THE COMMUNITIES WE SERVE. IN ADDITION, THEY HELP US IDENTIFY OPPORTUNITIES FOR COLLABORATION AMONG COMMUNITY ORGANIZATIONS AND LEADERS. COMMUNITY HOSPITAL OF LAGRANGE COUNTY, INC. REPRESENTATIVES HAVE RELATIONSHIPS THROUGHOUT THE COMMUNITY AND MEET REGULARLY WITH VARIOUS ORGANIZATIONS THAT SHARE COMMUNITY HOSPITAL OF LAGRANGE COUNTY, INC.'S MISSION OF IMPROVING THE HEALTH OF THE COMMUNITIES. PART VI, LINE 3: DESCRIBE HOW THE ORGANIZATION INFORMS AND EDUCATES PATIENTS AND PERSONS WHO MAY BE BILLED FOR PATIENT CARE ABOUT THEIR ELIGIBILITY FOR ASSISTANCE UNDER FEDERAL, STATE OR LOCAL GOVERNMENT PROGRAMS OR UNDER THE ORGANIZATION'S FINANCIAL ASSISTANCE POLICY.-AT POINT OF REGISTRATION OR SCHEDULING, IF A PATIENT EXPRESSES THEIR INABILITY TO PAY, THE REGISTRAR OR SCHEDULER WILL REFER THE PATIENT TO A FINANCIAL COUNSELOR OR WILL PROVIDE FINANCIAL COUNSELING CONTACT INFORMATION IN THE FORM OF A BUSINESS CARD TO THE PATIENT OUTSIDE OF NORMAL BUSINESS HOURS.-SIGNAGE IN THE EMERGENCY DEPARTMENT AND CASHIER AREAS INFORMS THE PATIENT OF THEIR RIGHT TO RECEIVE CARE REGARDLESS OF THEIR ABILITY TO PAY AND TELLS THEM THEY MAY BE ELIGIBLE FOR GOVERNMENTAL ASSISTANCE.-THE PATIENT'S INITIAL STATEMENT INSTRUCTS THE PATIENT TO CALL THE PATIENT ACCOUNTING DEPARTMENT IF THEY CANNOT PAY IN FULL. THE PATIENT ACCOUNTING CALL CENTER COLLECTORS SCREEN FOR THE APPLICABILITY OF GOVERNMENT ASSISTANCE AND OFFER FREE CARE APPLICATIONS TO PATIENTS WHO CANNOT AFFORD TO PAY THEIR BILLS.-THE ONLINE ACCOUNT MANAGER OF COMMUNITY HOSPITAL OF LAGRANGE COUNTY, INC.'S WEBSITE (WWW.PARKVIEW.COM) CONTAINS INFORMATION ON HOW TO CONTACT THE PATIENT ACCOUNTING DEPARTMENT FOR PAYMENT OPTIONS OR FREE CARE ELIGIBILITY.-ALL UNINSURED OR UNDERINSURED PATIENTS WHO ARE INPATIENT OR OBSERVATION STATUS ARE VISITED BY FINANCIAL COUNSELORS. THE FINANCIAL COUNSELORS PROVIDE PAYMENT OPTIONS, INCLUDING SCREENING FOR THE APPLICABILITY OF GOVERNMENT ASSISTANCE, AS WELL AS OFFERING FREE CARE APPLICATIONS TO PATIENTS WHO CANNOT AFFORD TO PAY THEIR BILLS.-OUTBOUND PHONE CALLS ARE MADE TO PATIENTS TO SET UP PAYMENT ARRANGEMENTS. IF A PATIENT CANNOT MAKE PAYMENT ON THEIR ACCOUNT, THEY WILL BE SCREENED FOR THE APPLICABILITY OF GOVERNMENT ASSISTANCE. ADDITIONALLY, FREE CARE APPLICATIONS WILL BE OFFERED TO PATIENTS WHO CANNOT AFFORD TO PAY THEIR BILLS.IF A PATIENT'S ACCOUNT IS PLACED WITH A COLLECTION AGENCY, THE AGENCY IS INSTRUCTED TO SCREEN FOR FREE CARE IF THE PATIENT EXPRESSES THEIR INABILITY TO PAY. PART VI, LINE 4: DESCRIBE THE COMMUNITY THE ORGANIZATION SERVES, TAKING INTO ACCOUNT THE GEOGRAPHIC AREA AND DEMOGRAPHIC CONSTITUENTS IT SERVES.COMMUNITY HOSPITAL OF LAGRANGE COUNTY, INC. PRIMARILY SERVES THE LAGRANGE COUNTY COMMUNITIES OF LAGRANGE, SHIPSHEWANA, TOPEKA, AND WOLCOTTVILLE. AS THE ONLY HOSPITAL IN THIS COUNTY, COMMUNITY HOSPITAL OF LAGRANGE COUNTY, INC. ALSO SERVES, TO A LIMITED EXTENT, SURROUNDING COMMUNITIES. LAGRANGE COUNTY HAS APPROXIMATELY 37,382 RESIDENTS, PRIMARILY CAUCASIAN. THE COUNTY'S UNEMPLOYMENT RATE IS 9.6%. THE MEDIAN INCOME IN LAGRANGE COUNTY IS $57,200. AMISH AND PLAIN CHURCH RESIDENTS MAKE UP NEARLY 40% OF THE POPULATION IN LAGRANGE COUNTY. FOR THE MEMBERS OF THESE FAITH-BASED COMMUNITIES, PARTICULARLY THE AMISH, EVERYDAY TRAVEL IS BY HORSE AND BUGGY OR BICYCLE; COMMUNICATIONS ARE FACE-TO-FACE OR THROUGH THE USE OF A COMMUNITY-OWNED, CENTRALLY LOCATED PHONE. LAGRANGE ALSO SERVICES A LARGE NUMBER OF HISPANIC RESIDENTS. PART VI, LINE 5: PROVIDE ANY OTHER INFORMATION IMPORTANT TO DESCRIBING HOW THE ORGANIZATION'S HOSPITAL FACILITIES OR OTHER HEALTH CARE FACILITIES FURTHER ITS EXEMPT PURPOSE BY PROMOTING THE HEALTH OF THE COMMUNITY (E.G. OPEN MEDICAL STAFF, COMMUNITY BOARD, USE OF SURPLUS FUNDS, ETC.).COMMUNITY HOSPITAL OF LAGRANGE COUNTY, INC.'S BOARD OF DIRECTORS IS COMPOSED OF MEMBERS, OF WHICH SUBSTANTIALLY ALL ARE INDEPENDENT COMMUNITY MEMBERS. A MAJORITY OF THE BOARD RESIDES IN COMMUNITY HOSPITAL OF LAGRANGE COUNTY, INC.'S PRIMARY SERVICE AREA. COMMUNITY HOSPITAL OF LAGRANGE COUNTY, INC. ALSO EXTENDS MEDICAL STAFF PRIVILEGES TO ALL QUALIFIED PHYSICIANS IN THE COMMUNITY. PEOPLE THROUGHOUT THE COMMUNITY CAN COUNT ON COMMUNITY HOSPITAL OF LAGRANGE COUNTY, INC. TO BE STANDING BY WITH EMERGENCY CARE 24 HOURS A DAY, 365 DAYS A YEAR. THE EMERGENCY DEPARTMENT IS STAFFED WITH BOARD-CERTIFIED EMERGENCY CARE PHYSICIANS AND A NURSING STAFF THAT IS TRAINED AND EXPERIENCED IN EMERGENCY CARE. FURTHERMORE, NO PATIENT IS EVER DENIED TREATMENT, REGARDLESS OF THEIR ABILITY TO PAY.ADDITIONALLY, COMMUNITY HOSPITAL OF LAGRANGE COUNTY, INC. OPENED ITS ALL-NEW $25 MILLION REPLACEMENT FACILITY IN JULY OF 2008. THE 25-BED CRITICAL ACCESS FACILITY FEATURES ALL PRIVATE ROOMS AND BLENDS THE LATEST IN HEALTHCARE TECHNOLOGY WITH AMENITIES THAT INCORPORATE THE UNIQUE FLAVOR OF LAGRANGE COUNTY. LOCAL AMISH WOODWORKERS WERE CONTRACTED TO CREATE HANDCRAFTED FURNISHINGS FOR THE MAIN LOBBY AND SECOND FLOOR WAITING AREA. FRAMED, LOCALLY MADE QUILTS AND ICONIC IMAGES OF LAGRANGE COUNTY PHOTOGRAPHED BY A LOCAL PHOTOGRAPHER SERVE AS ARTWORK THROUGHOUT THE FACILITY. FOR VISITORS FROM OUTSIDE THE COUNTY, THE AMBIENCE CREATED IS WARM AND WELCOMING; FOR PATIENTS AND VISITORS FROM LAGRANGE, THE FURNITURE AND ARTWORK OFFERS SOMETHING FAMILIAR AND COMFORTING, A REMINDER OF HOME.COMMUNITY HOSPITAL OF LAGRANGE COUNTY, INC. GIVES BACK TO THE COMMUNITY IN THE FORM OF IMPROVED FACILITIES, EDUCATION AND OUTREACH PROGRAMS, FREE AND DISCOUNTED CARE, VOLUNTEERISM AND MUCH MORE. THE FOLLOWING ARE SOME OF THE WAYS COMMUNITY HOSPITAL OF LAGRANGE COUNTY, INC. IS REACHING OUT TO MAKE OUR NEIGHBORHOODS AND COMMUNITIES HEALTHIER:-COMMUNITY HEALTH IMPROVEMENT INITIATIVES: COMMUNITY HOSPITAL OF LAGRANGE COUNTY, INC. BECAME PART OF THE PARKVIEW HEALTH SYSTEM, INC. FAMILY DURING 2005. THE PURPOSE OF COMMUNITY HOSPITAL OF LAGRANGE COUNTY, INC.'S COMMUNITY HEALTH IMPROVEMENT PROGRAM IS TO FUND COMMUNITY HEALTH IMPROVEMENT EFFORTS WITHIN ITS SERVICE AREA. THE HOSPITAL ANNUALLY FUNDS COMMUNITY HEALTH INITIATIVES AND PARTNERS WITH COMMUNITY ORGANIZATIONS TO ENCOURAGE HEALTHIER LIFESTYLES AMONG THE CITIZENS OF LAGRANGE COUNTY.-PLAIN CHURCH SERVICES: AMISH AND PLAIN CHURCH RESIDENTS MAKE UP A LARGE PART OF THE POPULATION IN LAGRANGE COUNTY. RECOGNIZING THE DIVERSE CIRCUMSTANCES OF THESE COMMUNITIES, COMMUNITY HOSPITAL OF LAGRANGE COUNTY, INC. REPRESENTATIVES HAVE BEEN WORKING CLOSELY WITH MEMBERS OF THE PLAIN CHURCH COMMUNITY FOR SEVERAL YEARS, HELPING TO IDENTIFY SPECIFIC NEEDS AND DEVELOP SYSTEMS TO ADDRESS THEM. THE MOST RECENT INITIATIVE IS THE ADDITION OF A PLAIN CHURCH COORDINATOR POSITION AT COMMUNITY HOSPITAL OF LAGRANGE COUNTY, INC. THE PLAIN CHURCH COORDINATOR SERVES AS A SINGLE POINT OF ACCESS FOR AMISH, MENNONITE AND OTHER PLAIN CHURCH MEMBERS WHO HAVE QUESTIONS ABOUT THE AVAILABILITY OF HEALTHCARE SERVICES. WHETHER THE QUESTION CONCERNS THE APPROXIMATE COST OF A PROCEDURE, THE SCHEDULING OF A DIAGNOSTIC TEST, OR A BILLING QUESTION, THE PLAIN CHURCH COORDINATOR WILL ASSIST THE CALLER IN OBTAINING AN ANSWER.-HEALTH EDUCATION AND INFORMATION: "HEALTHY VIEW" COMMUNITY NEWSLETTER IS MAILED QUARTERLY TO ALL HOUSEHOLDS IN LAGRANGE COUNTY. THE PUBLICATION OFFERS HEALTH INFORMATION ON LEADING TOPICS OF INTEREST INCLUDING CANCER, HEART DISEASE, DIABETES, AND MORE, AND MAKES READERS AWARE OF NEW SERVICES AT COMMUNITY HOSPITAL OF LAGRANGE COUNTY, INC. THE PUBLICATION IS OF PARTICULAR VALUE TO THE PLAIN CHURCH COMMUNITIES WHO DO NOT RECEIVE INFORMATION THROUGH TELEVISION, RADIO OR OTHER ELECTRONIC MEANS.-PRIMARY HEALTH CARE ACCESS: COMMUNITY HOSPITAL OF LAGRANGE COUNTY, INC. PARTNERED WITH THE LAGRANGE COUNTY COUNCIL ON AGING (COA) TO ASSIST WITH OPERATIONAL SUPPORT FOR THE COA'S SERVICES TO SENIORS. THE COA PROVIDES A TRANSPORTATION PROGRAM, HOMEMAKER SERVICES, A FOOD PANTRY AND MUCH MORE IN THEIR EFFORTS TO HELP SENIORS IN LAGRANGE COUNTY REMAIN INDEPENDENT IN THE HOMES OF THEIR CHOICE FOR AS LONG AS POSSIBLE. NEARLY HALF OF THE TRIPS THE COA OFFERS TO SENIORS ARE TO THEIR PHYSICIANS FOR CHECK-UPS OR TO THE HOSPITAL FOR TESTS OR TREATMENTS. HOMEMAKER SERVICES HELP WITH DAY-TO-DAY TASKS THAT, IN MANY CASES, COULD PUT THE SENIOR AT RISK OF A FALL OR OTHER INJURY. -HEALTH SCREENING AND PREVENTION AND DISEASE MANAGEMENT: COMMUNITY HOSPITAL OF LAGRANGE COUNTY, INC. PARTICIPATES IN NUMEROUS HEALTH FAIRS AND ACTIVITIES THROUGHOUT THE YEAR OFFERING FREE AND LOW COST HEALTH SCREENINGS AND INFORMATION TO DIVERSE POPULATIONS IN OUR SERVICE AREA, INCLUDING THE PLAIN CHURCH AND HISPANIC RESIDENTS AND SENIORS WHO RESIDE IN THE COUNTY. THESE EVENTS PROVIDE HEALTH EDUCATION AND SCREENINGS FOR DISEASE PREVENTION AND PROMOTE HEALTHY LIFESTYLES. THE HOSPITAL ALSO PROVIDES SUPPORT GROUPS TO ASSIST PATIENTS AND FAMILIES IN MANAGING DISEASE. PART VI, LINE 6: IF THE ORGANIZATION IS PART OF AN AFFILIATED HEALTH CARE SYSTEM, DESCRIBE THE RESPECTIVE ROLES OF THE ORGANIZATION AND ITS AFFILIATES IN PROMOTING THE HEALTH OF THE COMMUNITIES SERVED.PARKVIEW HEALTH SYSTEM, INC. (PARKVIEW), A HEALTH CARE SYSTEM SERVING NORTHEAST INDIANA, INCLUDES THE NOT-FOR-PROFIT HOSPITALS OF PARKVIEW HOSPITAL, INC., COMMUNITY HOSPITAL OF LAGRANGE COUNTY, INC., COMMUNITY HOSPITAL OF NOBLE COUNTY, INC., WHITLEY MEMORIAL HOSPITAL, INC. AND HUNTINGTON MEMORIAL HOSPITAL, INC. AS WELL AS 60% OWNERSHIP IN THE JOINT VENTURE OF ORTHOPAEDIC HOSPITAL AT PARKVIEW NORTH, LLC. PARKVIEW IS GUIDED BY A MISSION TO IMPROVE THE HEALTH OF THE COMMUNITIES IT SERVES. PARKVIEW CONTRIBUTES TO THE SUCCESS OF NORTHEAST INDIANA BY EFFICIENTLY OPERATING ITS FACILITIES, DELIVERING HIGH QUALITY HEALTHCARE SERVICES TO ITS PATIENTS, AND PROVIDING SUPPORT TO LOCAL BUSINESSES AND ACTIVITIES. PARKVIEW SEEKS TO CREATE ALIGNMENT OPPORTUNITIES TO DELIVER COMPREHENSIVE HIGH-QUALITY CARE THAT BENEFITS ITS PATIENTS, COMMUNITIES, PHYSICIANS, AND CO-WORKERS.PARKVIEW PRIDES ITSELF IN NOT ONLY OFFERING THE HIGHEST LEVEL OF CARE TO ITS PATIENTS BUT ALSO IN PROVIDING A WORKPLACE THAT IS SECOND TO NONE FOR ITS PHYSICIANS, NURSES AND STAFF. PARKVIEW'S MISSION IS TO PROVIDE QUALITY HEALTH SERVICES TO ALL WHO ENTRUST THEIR CARE TO US AND WILL WORK TO IMPROVE THE HEALTH OF OUR COMMUNITIES. PARKVIEW BELIEVES THAT THE COMMUNITIES IT SERVES SHOULD ALL HAVE THE PEACE OF MIND THAT COMES WITH ACCESS TO COMPASSIONATE, HIGH-QUALITY HEALTH CARE, REGARDLESS OF WHETHER THE CARE IS DELIVERED IN A RURAL OR URBAN SETTING. 1 LAGRANGE COUNTY COUNCIL ON AGING 125 FENN ST SUITE 4 LAGRANGE IN 46761 237455893 501 ( C ) 3 12000 MEDICAL TRANSPORTATION LAGRANGE COUNTY ECONOMIC DEVELOPMENT 304 N TOWNLINE ROAD LAGRANGE IN 46764 800309463 501 ( C ) 3 10000 PROGRAMS 2 0 MEDICATION ASSISTANCE 69 5811 EMPLOYEE ASSISTANCE FUND 3 1449 PROCEDURE FOR MONITORING GRANTS IN THE U.S.: PART I, LINE 2: SCHEDULE I, PART I, LINE 2: COMMUNITY HEALTH IMPROVEMENT FUNDING PARTNER ORGANIZATIONS ARE REQUIRED TO SUBMIT AN ANNUAL PROGRESS REPORT RELATED TO PROGRAM FUNDING. PARTNER ORGANIZATIONS ARE REQUIRED TO RE-APPLY FOR FUNDING ON AN ANNUAL BASIS. 1 1 0 0 0 0 0 0 0 ROBERT MYERS 165986 0 0 0 871 0 28296 0 17763 0 212916 0 0 0 MICHAEL PACKNETT 0 644714 0 0 0 2838 0 154444 0 11926 0 813922 0 0 LISA BOOTH 17956 465676 0 0 0 3457 271 7079 390 10180 18617 486392 0 0 MIROSLAW FOLTYNIAK 11438 374102 0 0 0 20556 759 26191 512 17654 12709 438503 0 0 MICHAEL BROWNING 0 369144 0 0 0 30487 0 46620 0 20266 0 466517 0 0 MARK NAFZIGER 0 0 0 0 0 211886 0 0 0 816 0 212702 0 0 STANTON RISSER 0 108116 0 1000 0 395 0 5580 0 17172 0 132263 0 0 PART I, LINE 3 RELATED ORGANIZATION, PARKVIEW HEALTH SYSTEM, INC., USES THE FOLLOWING TO ESTABLISH THE COMPENSATION OF COMMUNITY HOSPITAL LAGRANGE COUNTY, INC.'S CEO/EXECUTIVE DIRECTOR: COMPENSATION COMMITTEE (BOARD OF RELATED ORGANIZATION PARKVIEW HEALTH SYSTEM, INC.) INDEPENDENT COMPENSATION CONSULTANT FORM 990 OF OTHER ORGANIZATIONS COMPENSATION SURVEY OR STUDY APPROVAL BY THE BOARD OR COMPENSATION COMMITTEE (BOARD OR RELATED ORGANIZATION PARKVIEW HEALTH SYSTEM, INC.) PART I, LINES 4A-B SEVERANCE PAYMENT - MARK NAFZIGER $212,180 ELIMINATION OF PH EVP & COO POSITION SUPPLEMENTAL NONQUALIFIED RETIREMENT PLAN PAYMENTS TAXABLE - NONE PARTICIPANTS DEFERRED - MICHAEL BROWNING $46,020; JORDI DISLER $5,654; ROBERT MYERS $19,873; MICHAEL PACKNETT $137,294 INDIANA HEALTH AND EDUCATIONAL FACILITY FINANCING AUTHORITY 351611409 45479RCF2 2007-03-15 24930000 SEE PART VI 0 0 0 2435000 25942463 1074019 208535 154519 24505390 2008 0 0 1 1 0 1 1 1 0 0.00000 0.00000 0.00000 1 0 1 0 0 0 1 X SCHEDULE K, PART 1,A,F DESCRIPTION OF PURPOSE CONSTRUCTION OF NEW HOSPITAL FACILITY FOR COMMUNITY HOSPITAL OF LAGRANGE COUNTY, INC. IN LAGRANGE INDIANA SCHEDULE K, PART II, 3, A TOTAL PROCEEDS OF ISSUE THIS AMOUNT INCLUDES INTEREST EARNED ON PROJECT, COST OF ISSUANCE AND CAPITALIZED INTEREST FUNDS. SCHEDULE K, PART III, LINES 4-6 PRIVATE BENEFIT USE COMMUNITY HOSPITAL OF LAGRANGE COUNTY, INC. CLOSELY MONITORS THE LEVEL OF PRIVATE USE AT OUR BOND FINANCED FACILITIES. THE LEVEL OF EQUITY PROVIDED BY COMMUNITY HOSPITAL OF LAGRANGE COUNTY, INC. FOR THIS FACILITY IS MORE THAN SUFFICIENT TO COVER THE LOW LEVEL OF PRIVATE USE OCCURRING WITHIN THE FACILITY CONSTRUCTED IN PART WITH BOND FINANCING. J O MORY INC ENTITY OF WHICH GENE MORY WAS SERVING AS AN OFFICER 503573 VENDOR ARRANGEMENTS - TRANSACTIONS WERE ENTERED INTO AT ARM'S LENGTH. 0 FORM 990, PART VI, SECTION A, LINE 2 DIRECTORS THOMAS MILLER AND JOE PIERCE HAVE A BUSINESS RELATIONSHIP. FORM 990, PART VI, SECTION A, LINE 6 THE ORGANIZATION IS ORGANIZED AS A NOT-FOR-PROFIT CORPORATION. PURSUANT TO THE ORGANIZATION'S GOVERNING DOCUMENTS, PARKVIEW HEALTH SYSTEM, INC. EIN 35-1972384 IS THE SOLE MEMBER OF COMMUNITY HOSPITAL OF LAGRANGE COUNTY, INC. WITH CERTAIN RESERVED POWERS. FORM 990, PART VI, SECTION A, LINE 7A THE CORPORATE MEMBER, PARKVIEW HEALTH SYSTEM, INC. EIN 35-1972384, SHALL HAVE THE FOLLOWING RESERVED POWERS AS DEFINED IN THE NETWORK AGREEMENT: (A) APPOINT AND REMOVE, WITH OR WITHOUT CAUSE, MEMBERS OF THE BOARD SUBJECT TO THE COMPOSITION REQUIREMENTS REGARDING COMMUNITY AND PHYSICIAN REPRESENTATION SET FORTH IN ARTICLE V, SECTION 2; (B) APPOINT AND REMOVE, WITH OR WITHOUT CAUSE, THE CHAIR AND VICE CHAIR OF THE BOARD AND THE CHIEF OPERATING OFFICER OF THE CORPORATION; (C) APPROVE AND/OR REQUIRE THE ADOPTION OF AMENDMENTS TO THE ARTICLES OF INCORPORATION OR BYLAWS OF THE CORPORATION OR ANY SUBSIDIARY OR AFFILIATE OF THE CORPORATION; (D) APPROVE AND/OR REQUIRE THE ESTABLISHMENT, ACQUISITION, DIVESTITURE, DISSOLUTION, CLOSURE, MERGER, CONSOLIDATION, CHANGE IN CORPORATE MEMBERSHIP, AFFILIATION OR CORPORATE REORGANIZATION OF THE CORPORATION OR ANY SUBSIDIARY OR AFFILIATE OF THE CORPORATION; (E) APPROVE AND ADOPT THE STRATEGIC PLAN AND ANY AMENDMENTS THERETO FOR THE CORPORATION AND ANY SUBSIDIARY OR AFFILIATE OF THE CORPORATION; (F) APPROVE AND/OR REQUIRE THE INCURRENCE OF ANY DEBT, INCLUDING THE ISSUANCE OF ANY BONDS, PROPOSED BY THE CORPORATION OR ANY SUBSIDIARY OR AFFILIATE OF THE CORPORATION IN EXCESS OF LIMITS SPECIFIED IN THE POLICY OF THE CORPORATE MEMBER; (G) APPROVE AND/OR REQUIRE THE APPROVAL OF CONTRACTS OR LOANS OBLIGATING THE CORPORATION TO EXPEND OR REPAY AN AMOUNT IN EXCESS OF LIMITS SPECIFIED IN THE POLICY OF THE CORPORATE MEMBER; (H) APPROVE AND/OR REQUIRE THE SALE, LEASE, EXCHANGE, MORTGAGE, PLEDGE, TRANSFER, ENCUMBRANCE OR OTHER DISPOSITION OF PROPERTY AND ASSETS OF THE CORPORATION IN EXCESS OF LIMITS SPECIFIED IN THE POLICY OF THE CORPORATE MEMBER; (I) APPROVE AND ADOPT THE CAPITAL BUDGET, OPERATING BUDGET, FINANCIAL PLANS AND ANY AMENDMENTS THERETO FOR THE CORPORATION AND ANY SUBSIDIARY OR AFFILIATE TO THE CORPORATION; (J) APPROVE AND/OR REQUIRE THE ADOPTION OF A MANAGED CARE POLICY FOR THE CORPORATION AND ANY SUBSIDIARY OR AFFILIATE OF THE CORPORATION, INCLUDING NETWORK PARTICIPATION, PARTICIPATION IN ANY MANAGED CARE AGREEMENT AND PARTICIPATION IN ANY OTHER HEALTH CARE SERVICE ARRANGEMENTS; (K) APPOINT AND REMOVE AUDITORS, ATTORNEYS AND OTHER PROFESSIONAL ADVISORS FOR THE CORPORATION AND ANY SUBSIDIARY OR AFFILIATE OF THE CORPORATION; (L) DEVELOP, APPROVE AND/OR REQUIRE THE ADOPTION OF MEDICAL STAFF QUALITY ASSURANCE STANDARDS, UTILIZATION REVIEW STANDARDS, CRITERIA, POLICIES AND PROCEDURES FOR THE CORPORATION AND ANY SUBSIDIARY OR AFFILIATE OF THE CORPORATION; (M) APPROVE AND/OR REQUIRE THE ADOPTION OF ANY ACTION TO CHANGE THE CORPORATION FROM A GENERAL, ACUTE CARE COMMUNITY HOSPITAL OR TO CLOSE THE CORPORATION'S CURRENT LOCATION; (N) APPROVE EACH ANNUAL LIST OF PROPOSED DONEES AND AMOUNTS OF DONATIONS OR GRANTS NOT INCLUDED IN THE ANNUAL BUDGET, AND MAKE PROPOSALS TO DEVIATE THEREFROM THROUGHOUT EACH YEAR IN EXCESS OF LIMITS SPECIFIED IN THE POLICY OF THE CORPORATE MEMBER; AND (O) APPROVE AND/OR REQUIRE THE ADOPTION OF ANY ACTION THAT IS INCONSISTENT WITH THE POLICY OF THE CORPORATE MEMBER. FORM 990, PART VI, SECTION A, LINE 7B SEE SCHEDULE O EXPLANATION FOR FORM 990, PART VI, SECTION A, LINE 7A FORM 990, PART VI, SECTION B, LINE 11 PURSUANT TO PARKVIEW HEALTH SYSTEM INC.'S BYLAWS, THE SYSTEM AUDIT COMMITTEE MAY ACT ON BEHALF OF THE CORPORATION TO PROVIDE REVIEW OF THE CORPORATION AND ITS SUBSIDIARY CORPORATIONS' FORM 990 FILINGS. COMMUNITY HOSPITAL OF LAGRANGE COUNTY, INC. IS A SUBSIDIARY CORPORATION OF PARKVIEW HEALTH SYSTEM, INC. AN ELECTRONIC COPY OF THE ORGANIZATION'S FINAL FORM 990 (INCLUDING REQUIRED SCHEDULES) WAS PROVIDED TO EACH VOTING MEMBER OF THE ORGANIZATION'S GOVERNING BODY, PRIOR TO FILING WITH THE IRS. ON OCTOBER 10, 2012, THE SYSTEM AUDIT COMMITTEE REVIEWED THE FORM 990 AS ULTIMATELY FILED WITH THE IRS. THIS REVIEW INCLUDED A PRESENTATION BY THE ORGANIZATION'S TAX PREPARER TO HIGHLIGHT THE SIGNIFICANT AREAS ON THE FORM 990 AND SUPPLEMENTAL SCHEDULES. FORM 990, PART VI, SECTION B, LINE 12C AS DESCRIBED IN ARTICLE IX SECTION 6, OF THE PARKVIEW HEALTH SYSTEM, INC. (PH) BYLAWS, PH ADOPTED PH'S COMPLIANCE POLICY FOR THE ORGANIZATION AND ITS NOT-FOR-PROFIT RELATED ORGANIZATIONS (AND AS LIKEWISE NOTED IN THEIR BYLAWS) WHEN ADDRESSING CONFLICTS OR POTENTIAL CONFLICTS OF INTEREST. THIS COMPLIANCE POLICY (COMPLIANCE POLICY #14) REQUIRES THAT EACH BOARD MEMBER, BOARD COMMITTEE MEMBER, AND KEY MANAGEMENT PERSONNEL MUST ANNUALLY COMPLETE A CONFLICT OF INTEREST FORM. THIS INFORMATION IS PROVIDED TO THE CHAIRMAN OF THE BOARD (FOR BOARD AND BOARD COMMITTEE MEMBERS) AND TO SENIOR MANAGEMENT (FOR KEY MANAGEMENT PERSONNEL). IN ADDITION, AS TO THE CONDUCT OF BOARD MEETINGS, THE FOLLOWING PROCESS IS FOLLOWED: "WHENEVER A PH OR PH AFFILIATE BOARD OR BOARD COMMITTEE IS CONSIDERING A TRANSACTION OR ARRANGEMENT WITH AN ORGANIZATION, ENTITY OR INDIVIDUAL IN WHICH A PERSON COVERED BY THIS POLICY HAS A FINANCIAL OR CONFLICTING INTEREST, THE FOLLOWING SHALL OCCUR: 1. THE INTERESTED PERSON MUST DISCLOSE THE FINANCIAL OR CONFLICTING INTEREST AND ALL MATERIAL FACTS TO THE PH OR PH AFFILIATE BOARD OR BOARD COMMITTEE; 2. THE INTERESTED PERSON WITH THAT FINANCIAL OR CONFLICTING INTEREST MAY MAKE A PRESENTATION AT THE BOARD OR BOARD COMMITTEE MEETING REGARDING THE TRANSACTION OR ARRANGEMENT. HOWEVER, HE/SHE SHALL LEAVE THE MEETING DURING THE DISCUSSION OF, AND THE VOTE ON, THE TRANSACTION OR ARRANGEMENT THAT RESULTS IN THE FINANCIAL OR CONFLICTING INTEREST; AND 3. THE PH OR PH AFFILIATE BOARD OR BOARD COMMITTEE MUST APPROVE THE TRANSACTION OR ARRANGEMENT BY A MAJORITY VOTE OF THE BOARD MEMBERS PRESENT AT A MEETING THAT HAS A QUORUM, NOT INCLUDING THE VOTE OF THE INTERESTED PERSON. IN ADDITION, THE FOLLOWING CONSIDERATIONS SHOULD BE MADE: 4. IF APPROPRIATE, THE PH OR PH AFFILIATE BOARD OR BOARD COMMITTEE MAY APPOINT A DISINTERESTED PERSON OR COMMITTEE TO INVESTIGATE ALTERNATIVES TO THE PROPOSED TRANSACTION OR ARRANGEMENT; AND 5. IN ORDER TO APPROVE THE TRANSACTION, THE PH OR PH AFFILIATE BOARD OR BOARD COMMITTEE MUST FIRST FIND, BY A MAJORITY VOTE OF THE DISINTERESTED BOARD MEMBERS, THAT THE PROPOSED TRANSACTION OR ARRANGEMENT IS IN THE BEST INTERESTS OF AND FOR THE BENEFIT OF PH AND/OR PH AFFILIATES AND THE PROPOSED TRANSACTION IS FAIR AND REASONABLE TO PH AND/OR PH AFFILIATES AND, AFTER REASONABLE INVESTIGATION, THAT THE PH AND/OR PH AFFILIATES CANNOT OBTAIN A MORE ADVANTAGEOUS TRANSACTION OR ARRANGEMENT WITH REASONABLE EFFORTS UNDER THE CIRCUMSTANCES." FORM 990, PART VI, SECTION B, LINE 15 TO THE EXTENT THAT THE ORGANIZATION HAS VICE PRESIDENT OR ABOVE, THE ORGANIZATION USED A PROCESS FOR DETERMINING COMPENSATION OF THE CEO, OFFICERS, AND KEY EMPLOYEES. THE PROCESS INCLUDES CONSULTATIONS WITH AN INDEPENDENT COMPENSATION ADVISOR; REVIEW, AND APPROVAL BY THE GOVERNING BODY; AND CONTEMPORANEOUS DOCUMENTATION AND RECORDKEEPING WITH RESPECT TO DELIBERATIONS AND DECISIONS REGARDING THE COMPENSATION ARRANGEMENTS. IN 2011, THE BOARD OF PARKVIEW HEALTH SYSTEM, INC. REVIEWED AND APPROVED ALL EXECUTIVE COMPENSATION, BENEFITS AND PERQUISITES FOR THE 2011 COMPENSATION PACKAGE, PURSUANT TO THE PARKVIEW HEALTH BYLAWS. THE COMPENSATION PACKAGE WAS APPROVED BY A MAJORITY OF INDEPENDENT BOARD MEMBERS. PARKVIEW'S INDEPENDENT CONSULTANT PREPARES A COMPETITIVE COMPENSATION ANALYSIS USING DATA FROM MULTIPLE PUBLISHED SURVEYS PREPARED BY INDEPENDENT FIRMS FOR POSITIONS THAT ARE FUNCTIONALLY COMPARABLE IN SIMILAR-SIZED HEALTH SYSTEMS AND HOSPITAL ORGANIZATIONS ON BOTH A REGIONAL AND NATIONAL BASIS. THE INDEPENDENT CONSULTANT PROVIDES A STATEMENT OF REASONABLENESS OF THE COMPENSATION PROVIDED TO THE CEO AS WELL AS ALL EXECUTIVES AT THE VICE PRESIDENT LEVEL AND ABOVE. ALL DATA IS SHARED WITH THE BOARD OF DIRECTORS. THE BOARD APPROVES ANY CHANGES IN COMPENSATION FOR THE CEO AND HIS DIRECT REPORTS. APPROVAL IS ALSO PROVIDED FOR THE MERIT BUDGET FOR THE ENTIRE ORGANIZATION. THE BOARD REVIEWS AND APPROVES THE MANAGEMENT INCENTIVE COMPENSATION PLAN (MICP). WHILE THE BOARD CONSIDERED THE ISSUE OF MERIT INCREASES AND MICP, NO MERIT INCREASES OR MICP WERE APPROVED FOR 2011. OFFICES OR POSITIONS REVIEWED AT THE 2011 MEETING: PRESIDENT AND CEO PH EXECUTIVE VICE PRESIDENT STRATEGIC DIRECTION AND BUSINESS DEVELOPMENT EXECUTIVE VICE PRESIDENT PARKVIEW HEALTH/COO PARKVIEW HOSPITAL CHIEF PHYSICIAN EXECUTIVE PARKVIEW PHYSICIANS' GROUP CHIEF PHYSICIAN EXECUTIVE SENIOR VICE PRESIDENT OPERATIONS / SERVICE EXCELLENCE SENIOR VICE PRESIDENT HUMAN RESOURCES SENIOR VICE PRESIDENT AND GENERAL COUNSEL SENIOR VICE PRESIDENT PATIENT CARE SENIOR VICE PRESIDENT OPERATIONS SENIOR VICE PRESIDENT AND CHIEF INFORMATION OFFICER SENIOR VICE PRESIDENT/COO ORTHOPEDIC HOSPITAL SENIOR VICE PRESIDENT/COO COMMUNITY HOSPITALS - HUNTINGTON SENIOR VICE PRESIDENT/COO COMMUNITY HOSPITALS - LAGRANGE SENIOR VICE PRESIDENT/COO COMMUNITY HOSPITALS - NOBLE SENIOR VICE PRESIDENT/COO COMMUNITY HOSPITALS - WHITLEY SENIOR VICE PRESIDENT/COO PHYSICIAN PRACTICES SENIOR VICE PRESIDENT AND CHIEF FINANCIAL OFFICER SENIOR VICE PRESIDENT REVENUE CYCLE MANAGEMENT SENIOR VICE PRESIDENT FACILITY DESIGN AND OVERSIGHT SENIOR VICE PRESIDENT STRATEGIC INITIATIVES MEDICAL DIRECTOR PARKVIEW PHYSICIANS' GROUP MEDICAL DIRECTOR COMMUNITY HOSPITALS MEDICAL DIRECTOR HEALTH PLAN SERVICES VICE PRESIDENT - PATIENT CARE - LAGRANGE VICE PRESIDENT - PATIENT CARE - NOBLE VICE PRESIDENT - PATIENT CARE - WHITLEY VICE PRESIDENT/ADMINISTRATOR PRIMARY CARE PRACTICE GROUP VICE PRESIDENT CHANGING SPACES CONSTRUCTION/PROJECT MANAGEMENT VICE PRESIDENT PLANNING AND DECISION SUPPORT VICE PRESIDENT STRATEGIC AND BUSINESS DEVELOPMENT VICE PRESIDENT HEALTH INFORMATION MANAGEMENT VICE PRESIDENT/ADMINISTRATOR SPECIALTY PRACTICE GROUP VICE PRESIDENT SPECIAL PROJECTS VICE PRESIDENT PARKVIEW PHYSICIANS' GROUP FINANCE VICE PRESIDENT SUPPLY CHAIN COO PARKVIEW HEART INSTITUTE EXECUTIVE DIRECTOR PARKVIEW OUTPATIENT ENTERPRISE EXECUTIVE DIRECTOR WOMEN'S AND CHILDREN'S SERVICES EXECUTIVE DIRECTOR CANCER SERVICES CORPORATE DIRECTOR MARKETING, COMMUNICATIONS, COMMUNITY RELATIONS CORPORATE DIRECTOR DIETETICS/FOOD SERVICES FORM 990, PART VI, SECTION C, LINE 19 COPIES OF THE ORGANIZATION'S GOVERNING DOCUMENTS, CONFLICT OF INTEREST POLICY, AND FINANCIAL STATEMENTS ARE AVAILABLE UPON REQUEST. COMMON PAYING AGENT FOR FILING ORGANIZATION FORM 990, PART V, LINE 1A, 2A AND PART VII, SECTION B, LINE 2: PARKVIEW HEALTH SYSTEM, INC. (PH), EIN 35-1972384, IS THE COMMON PAYING AGENT FOR THE FILING ORGANIZATION, COMMUNITY HOSPITAL OF LAGRANGE COUNTY, INC., EIN 20-2401676. THEREFORE, ALL APPLICABLE IRS TAX FILINGS, INCLUDING FORMS 1099, 1096, W-2 AND W-3 ARE REPORTED AND FILED BY PH. THE TOTAL NUMBER REPORTED IN BOX 3 OF FORM 1096 AND FILED BY THE COMMON PAYING AGENT, PH, FOR THE YEAR ENDED DECEMBER 31, 2011 WAS 501. THE TOTAL NUMBER OF EMPLOYEES REPORTED ON FORM W-3 AND FILED BY THE COMMON PAYING AGENT, PH, FOR THE YEAR ENDED DECEMBER 31, 2011 WAS 8,034. FOR PURPOSES OF COMPLETING FORM 990, PART V, LINE 1A AND 2A, THE NUMBER REPORTED FOR THE COMMUNITY HOSPITAL OF LAGRANGE COUNTY, INC. WAS 29 AND 228 RESPECTIVELY. AS REFLECTED IN PART VII, SECTION B, APPROXIMATELY 1 INDEPENDENT CONTRACTOR RECEIVED MORE THAN $100,000 IN COMPENSATION FOR SERVICES FROM COMMUNITY HOSPITAL OF LAGRANGE COUNTY, INC. AVERAGE HOURS PER WEEK DEVOTED TO RELATED ORGANIZATIONS FORM 990, PART VII, SECTION A, COLUMN B: MICHAEL PACKNETT (DIRECTOR/PH CEO) AND MICHAEL BROWNING (PH SVP & CFO)DEVOTED APPROXIMATELY 40 HOURS PER WEEK TO PARKVIEW HEALTH SYSTEM, INC. (PH), AND ONE HOUR PER WEEK TO EACH OF THE FOLLOWING TAX-EXEMPT AND TAXABLE ORGANIZATIONS RELATED TO PH: PARKVIEW HOSPITAL, INC. (PVHOS) PARKVIEW OCCUPATIONAL HEALTH CENTERS, INC. (POHCI) HUNTINGTON MEMORIAL HOSPITAL, INC. (HMHOS) COMMUNITY HOSPITAL OF LAGRANGE COUNTY, INC. (LGHOS)- FILING ORGANIZATION COMMUNITY HOSPITAL OF NOBLE COUNTY, INC. (NBHOS) WHITLEY MEMORIAL HOSPITAL, INC. (WMHOS) PARKVIEW FOUNDATION, INC. (PVFND) PARKVIEW HUNTINGTON HOSPITAL FOUNDATION, INC. (HMFND) COMMUNITY HOSPITAL OF NOBLE COUNTY FOUNDATION, INC. (NBFND) WHITLEY MEMORIAL HOSPITAL FOUNDATION, INC. (WMFND) PARKVIEW PROFESSIONAL PROGRAMS, INC. (PPP) MIDWEST COMMUNITY HEALTH ASSOCIATES, INC. (MCHA) ORTHOPAEDIC HOSPITAL AT PARKVIEW NORTH, LLC (ORTHO) MANAGED CARE SERVICES, LLC (MCS) FOUNDATION SURGERY AFFILIATE OF FORT WAYNE, LLC (ISCLC) PARKVIEW IMAGING HUNTINGTON, LLC (PIHLC) LISA BOOTH (DIRECTOR/PH PHYSICIAN) DEVOTED APPROXIMATELY ONE HOUR PER WEEK TO LGHOS, AND 40 HOURS PER WEEK TO PH. MIROSLAW FOLTYNIAK (DIRECTOR/PH PHYSICIAN) DEVOTED APPROXIMATELY ONE HOUR PER WEEK TO LGHOS, AND 40 HOURS PER WEEK TO PH. STEPHANIE GOUGH (DIRECTOR/TREASURER) DEVOTED APPROXIMATELY ONE HOUR PER WEEK TO LGHOS, AND ONE HOUR PER WEEK TO PH. JOE PIERCE (DIRECTOR/VICE CHAIR) DEVOTED APPROXIMATELY ONE HOUR PER WEEK TO LGHOS, AND ONE HOUR PER WEEK TO PH. JOHN PRICE (DIRECTOR/CHAIR) DEVOTED APPROXIMATELY ONE HOUR PER WEEK TO LGHOS, AND ONE HOUR PER WEEK TO PH. JORDI DISLER (LGHOS VP PATIENT CARE) DEVOTED APPROXIMATELY 40 HOURS PER WEEK TO LGHOS FOR PARTIAL YEAR UPON TRANSFER TO LGHOS, AND 40 HOURS PER WEEK FOR PARTIAL YEAR TO PVHOS PRIOR TO TRANSFER TO LGHOS. STANTON RISSER (FORMER: OFFICER/INTERIM PH CFO / CURRENT: PH EMPLOYEE/CONTROLLER) DEVOTED APPROXIMATELY 40 HOURS PER WEEK TO PH. SALARIES AND WAGES, OTHER EMPLOYEE BENEFITS AND PAYROLL TAXES FORM 990, PART IX, LINES 5-10: PARKVIEW HEALTH SYSTEM, INC., EIN 35-1972384, SERVES AS THE COMMON PAYING AGENT FOR ALL TAX-EXEMPT ORGANIZATIONS OF THE SYSTEM. SALARIES AND WAGES OF EMPLOYEES WORKING FOR THESE ORGANIZATIONS ARE CHARGED DIRECTLY TO THE ORGANIZATIONS IN WHICH THEY WORK. THE ACTUAL EXPENSES FOR PAYROLL TAXES, EMPLOYEE BENEFITS, AND PENSION PLAN CONTRIBUTIONS ARE REFLECTED ON THE BOOKS OF PARKVIEW HEALTH SYSTEM, INC. FOR FINANCIAL REPORTING PURPOSES. TO ACCOUNT FOR BENEFIT COSTS ON THE BOOKS OF THE OTHER TAX EXEMPT ORGANIZATIONS, AN ALLOCATION METHODOLOGY IS UTILIZED TO CHARGE THESE ORGANIZATIONS WITH AN ESTIMATE OF THE OVERALL COSTS, REFERRED TO AS A "BENEFIT ALLOCATION" FROM PARKVIEW HEALTH SYSTEM, INC. THE ALLOCATION DOES NOT DISTINGUISH BETWEEN THE COSTS OF THE VARIOUS COMPONENTS (I.E. PAYROLL TAXES, EMPLOYEE BENEFITS, AND PENSION PLAN CONTRIBUTIONS). THEREFORE, FOR PURPOSES OF THE FORM 990, PART IX, THE TOTAL BENEFIT ALLOCATION FOR THE EMPLOYEES' SALARIES AND WAGES REPORTED ON LINE 7 IS REFLECTED ON LINE 9 AND NOT ALLOCATED BETWEEN LINES 8 OR 10. FOR PURPOSES OF THE FORM 990, PART IX, LINES 5 AND 6 REFLECT COMPENSATION AND BENEFIT AMOUNTS REPORTED IN PART VII. CHANGES IN NET ASSETS OR FUND BALANCES: FORM 990, PART XI, LINE 5: ASSET ADJUSTMENTS/TRANSFERS -50,055. CURRENT YEAR EARNINGS TRANSFERRED TO PARENT -818,777. PLEDGE WRITE-OFF -364. TOTAL TO FORM 990, PART XI, LINE 5: -869,196. PARKVIEW HEALTH SYSTEM INC 10501 CORPORATE DRIVE FORT WAYNE IN 46845 351972384 HEALTH CARE IN 501(C)(3) LINE 11C, III-FI N/A 0 COMMUNITY HOSPITAL OF NOBLE COUNTY INC 401 SAWYER ROAD KENDALLVILLE IN 46755 352087092 HOSPITAL CARE IN 501(C)(3) LINE 3 PARKVIEW HEALTH SYSTEM INC 0 PARKVIEW OCCUPATIONAL HEALTH CENTERS INC 2200 RANDALLIA DRIVE FORT WAYNE IN 46805 352064353 OCCUP HEALTH IN 501(C)(3) LINE 3 PARKVIEW HEALTH SYSTEM INC 0 PARKVIEW HOSPITAL INC 2200 RANDALLIA DRIVE FORT WAYNE IN 46805 350868085 HOSPITAL CARE IN 501(C)(3) LINE 3 PARKVIEW HEALTH SYSTEM INC 0 WHITLEY MEMORIAL HOSPITAL INC 1260 E STATE ROAD 205 COLUMBIA CITY IN 46725 351967665 HOSPITAL CARE IN 501(C)(3) LINE 3 PARKVIEW HEALTH SYSTEM INC 0 HUNTINGTON MEMORIAL HOSPITAL INC 2001 STULTS ROAD HUNTINGTON IN 46750 351970706 HOSPITAL CARE IN 501(C)(3) LINE 3 PARKVIEW HEALTH SYSTEM INC 0 0 0 1 0 1 0 0 0 1 0 0 0 0 0 1 0 0 1