2012-11-15T10:42:14-07:00 2011-12-31 990 2011-01-01 314379443 ADENA HEALTH SYSTEM ADEN 7407794478 272 HOSPITAL ROAD CHILLICOTHE OH 456019031 Keith T Coleman 7407794273 2012-11-15 2011 2016-02-24 21:20:13Z Mark Shuter 272 Hospital Road Chillicothe OH 45601 379585231 0 X WWW.ADENA.ORG X 1895 OH "To Heal, To Educate, To Care". The Organization is a regional healthcare system with 1 hospital and several ambulatory centers, in addition to multiple physician practices. AHS offers a wide scope of diagnostic and rehabilitative services both for inpatients and outpatients, including comprehensive cardiology and cancer care. 14 9 2194 369 11689 -7278 13748492 4108646 360483761 366151182 3840247 5646835 1862741 1874178 379935241 377780841 126002 97223 0 0 187026318 194995529 0 0 0 167743075 184979996 354895395 380072748 25039846 -2291907 419282931 410696244 227217017 227847622 192065914 182848622 "To Heal, To Educate, To Care" is the mission of Adena Health System. Adena Health System is a regional healthcare system providing a wide scope of services to a 13 county area in south-central Ohio. 0 0 309026614 97223 355752489 Health Care Programs, General/Other: Routine hospital services - Room and board testing and monitoring by various ancillary specialties, physical therapy and surgical services. There were 14,464 inpatients and 911,771 outpatients treated in 2011. 4901053 0 5638728 Emergency Services - Treatment of emergency accident and illness as well as less urgent conditions in the absence of a family physician. The number of visits in 2011 was 53,870. 4081483 0 4759965 The Hospice and Home Health departments provide medical care, medications, home health needs, bereavement counseling prescriptions, food and shelter to patients. There were 12,357 Hospice patient days in 2011. 0 0 0 318009150 1 1 0 1 0 0 0 0 0 1 1 0 0 0 1 0 0 1 0 0 0 0 0 0 1 0 1 1 1 0 1 1 1 1 0 0 0 0 0 0 1 1 0 0 0 0 1 1 1 1 0 0 1 125 0 1 2194 1 1 1 0 0 0 0 0 0 0 0 0 X 14 9 0 0 0 0 1 1 1 1 1 0 0 1 1 1 1 1 1 1 1 0 X Dawn Bennett Johnson Int Controller 7407794200 272 HOSPITAL ROAD CHILLICOTHE OH 456019031 Deborah Barrington 2 X 0 0 0 Jack Berno 40 X 294408 0 12540 Steve Burkhardt 2 X 0 0 0 Doug Folzenlogen 40 X 424165 0 17916 James Grove 2 X 0 0 0 Chad Harris 2 X 0 0 0 Ralph D'Antoni 2 X 0 0 0 Mike Lilly 2 X 0 0 0 Gary Evans 2 X 0 0 0 Mathew Schmidt 2 X 0 0 0 Allen Shaw 40 X 222526 0 9864 Dave Strickland 2 X 0 0 0 Tom White 2 X 0 0 0 Noble Yoshida 2 X 0 0 0 Keith Coleman 40 X 329191 0 44649 Mark Shuter 40 X 725632 0 44702 Karen Bolton 40 X 235228 0 30503 John Fortney 40 X 365412 0 21816 Jeff Graham 40 X 258796 0 38750 Denise Minor 40 X 181872 0 28540 Barbara Purdom 40 X 152790 0 35844 Patricia Roam 40 X 155264 0 22990 Faitha Shelton 40 X 204185 0 40935 Elisabeth Williams 40 X 217602 0 20065 Jack Baker 40 X 598284 0 17916 Wayne Coats 40 X 390471 0 17916 Martha Livingston 40 X 150735 0 20993 Michele Federer 40 X 434472 0 5754 Satish Jetty 40 X 423608 0 17916 Mark Moffitt 40 X 194741 0 14133 Eric Perdue 40 X 152791 0 12607 Kirk Tucker 40 X 266823 0 17916 Anthony Freeman 40 X 938441 0 17896 Rob Bradley 40 X 897642 0 24066 Brian Cohen 40 X 2587948 0 18691 James Fleming 40 X 896961 0 25466 Thomas Lewis 40 X 987347 0 24066 Kort Gronbach 40 X 838216 0 21916 13525551 0 626366 221 0 1 0 Kings Medical Company PO Box 72483 Cleveland OH 44192 MRI Services 2495475 Tatum LLC PO BOX 847872 Dallas TX 752847872 Staffing Services 2304309 The Pendleton Group Inc 200 Chartwell Pt Road Seneca SC 29672 Consulting 1199419 Premier Health Care Services Inc 332 Congress Park Drive Dayton OH 45459 ER coverage, house coverage 996324 Medical Doctor Associates PO Box 277185 Atlanta GA 303847185 Medical Staffing Services 554357 17 0 65445 3000 3202905 253338 583958 0 4108646 Net Patient Service Revenue 622110 366151182 366151182 0 0 0 0 0 0 366151182 5782844 0 0 5782844 0 0 0 0 0 0 0 0 94150 0 0 0 94150 0 94150 0 0 94150 0 1443089 0 1579098 0 -136009 -136009 0 0 -136009 79520 3000 99496 -19976 0 -19976 147932 125796 22136 0 0 22136 Food & Nutrition 622110 1246679 0 0 1246679 Consulting Fees 622110 135984 135984 0 0 All Other Revenue 622110 395205 0 11689 383516 0 0 0 0 1777868 377780841 366287166 11689 7373340 97223 97223 8026932 4410494 3616438 147470030 131828677 15641353 8354135 6482809 1871326 22175516 19086603 3088913 8968916 7691914 1277002 29383186 21877063 7506123 807060 807060 120000 120000 1722 1722 1762453 13865 1748588 381935 284893 97042 142407 17385 125022 4111963 1915865 2196098 1848656 1227805 620851 9019457 6999099 2020358 18417236 11194064 7223172 2575008 2454503 120505 Operating Supplies 59821112 59499211 321901 0 Provision for Bad Debt 32710711 32710711 0 0 Repair, Maintenance & Rental 17025563 6125529 10900034 0 Taxes 2760090 0 2760090 0 4091437 4091437 380072748 318009150 62063598 0 11632 10848 77635482 75912428 4565558 4554026 47965899 44303899 0 0 0 6449362 5582037 2951771 3046536 342858768 186859504 143789834 155999264 127550069 114131981 0 0 0 8363324 7155225 419282931 410696244 30848157 32054059 0 0 179713947 178919218 0 0 0 0 16654913 16874345 227217017 227847622 X 191651223 182286137 414691 562485 0 0 192065914 182848622 419282931 410696244 X -2291907 -6925385 X 0 1 1 X 0 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 0 0 0 0 0 0 0 0 1 1722 1722 0 SchC_P2B_S00_L01 Schedule C, Part II-B, Line 1 The Ohio Hospital Association does lobbying on behalf of hospital related causes. This activity is paid for through dues paid to the Ohio Hospital Association. 979299 48900 30021 7757 0 0 1050463 859540 50593 101333 32167 0 0 979299 762259 170668 85016 0 158403 0 859540 615256 263999 641 18520 99117 0 762259 1 0 0 0 1 1 0 2393357 2393357 0 147803589 51828712 95974877 0 10308569 10021569 287000 0 154582477 120424628 34157849 0 27770776 4584595 23186181 155999264 Defined Benefit Plan Liability 9630427 Accrued Malpractice Insurance Long-term 7243918 16874345 SchD_P05_S00_L04 Schedule D, Part V, Line 4 Adena Health Foundation Endowment Funds are used to provide scholarships and offset operating expenses of PACCAR Medical Education Center. Charity Ball 15787 3000 12787 0 0 1325 1898 0 30413 Plant Sale 66733 0 66733 0 0 0 0 0 65860 0 82520 3000 79520 0 0 1325 1898 0 96273 99496 -19976 1 1 X 1 X 1 X 1 1 1 0 1 1 20418512 4761170 15657342 0.045 68156834 40022850 28133984 0.0808 0 0 0 0 0 0 88575346 44784020 43791326 0.1258 880827 0 880827 0.0025 0 0 0 0 0 0 0 0 0 0 0 0 98723 0 98723 0.0003 0 0 979550 0 979550 0.0028 0 0 89554896 44784020 44770876 0.1286 1 32710711 1635536 67477769 59421722 8056047 X 1 1 1 1 Adena Regional Medical Center

272 Hospital Rd Chillicothe OH 45601

X X X Adena Regional Medical Center 1 1 1 100 1 400 1 X X X X X X 1 1 X X X X X 0 0 X 1 X 0 0 15 Adena Health Pavilion

4437 State Route 159 Chillicothe OH 45601

Physician Offices Adena Medical Office Building

4439 State Route 159 Chillicothe OH 45601

Physician Offices Adena Urgent Care

55 Centennial Blvd Chillicothe OH 45601

Ambulatory Care Center Adena Health Center - Waverly

12340 State Route 104 Waverly OH 45690

Ambulatory Care Center Adena Health Center - Jackson

1000 Veterans Drive Jackson OH 45640

Ambulatory Care Center Adena Home Care Services

111 W Water Street Chillicothe OH 45601

Home Health Care and Hospice Adena Rehabilitation and Wellness Center

445 Shawnee Lane Chillicothe OH 45601

Outpatient Rehabilitation Center Adena Family Medicine - Oak Hill

315 Washington Street Oak Hill OH 45656

Physician Offices Adena Pickaway-Ross Family Physicians

100 N Walnut Street Chillicothe OH 45601

Physician Offices Adena Family Medicine - Circleville

798 N Court Street Circleville OH 43113

Physician Offices Adena Counseling Center

445 Shawnee Lane Chillicothe OH 45601

Mental Health Counseling Adena Family Medicine of Chillicothe

626 Central Center Chillicothe OH 45601

Physician Offices Adena Ross Urology

8 Medical Drive Chillicothe OH 45601

Physician Offices Adena Family Medicine - Greenfield

536 Mirabeau Street Greenfield OH 45123

Physician Offices Adena Family Medicine - Washington CH

308 Highland Avenue Suite C Washington Court House OH 43160

Physician Offices SchH_P01_S00_L03c Schedule H, Part I, Line 3c We have inserted the wording from our 2011 audited consolidated financial statements that deals with charity care. "The System provides care to patients who meet certain criteria under its charity care policy without charge or at amounts less than established rates. Because the System does not pursue collection of amounts determined to qualify as charity care, they are not reported as net patient revenue. Charity care is determined based on established policies, using patient income and assets to determine payment liability. The amount reflects the cost of free or discounted health services, net of contributions and other revenues received, as direct assistance for the provision of charity care." SchH_P01_S00_L06a Schedule H, Part I, Line 6a Annually, Adena Health System provides a Community Benefit Report to the community of Chillicothe listing all system services and accomplishments including community benefit services. SchH_P01_S00_L07 Schedule H, Part I, Line 7 The cost-to-charge ratio derived from Worksheet 2 was used to convert charges to costs in Line 7a and 7b. Actual costs were used in Line 7e. SchH_P01_S00_L072f Schedule H, Part I, Line 7, Column f Bad debt expense of $32,710,711 was deducted from total operating expenses when calculating the percentages in this column. SchH_P03_S0A_L04 Schedule H, Part III, Section A, Line 4 All self pay claims are turned over to a collection vendor. The vendor determines if the claim is charity after the patient supplies appropriate documentation. However, the hospital believes that 5% of the bad debt expense in Part III, Line 2 are amounts that would be attributable to patients under the hospital's financial assistance policy. The 5% is only a rough estimate at this time. The system is reviewing options to better estimate this for 2012 activity. We do not have separate financial statements for Adena Health System. It is included in the consolidated statements. The billing for Adena Health System is centralized and billing and collection procedures are uniform between the two hospitals in the system. The footnote in our financial statements includes the following about our bad debt expense and allowance for uncollectibles. "An allowance for uncollectible accounts is established on an aggregate basis by using historical write-off factors applied to unpaid accounts based on aging. Loss rate factors are based on historical loss experience and adjusted for economic conditions and other trends affecting the System's ability to collect outstanding amounts. Uncollectible accounts are written off against the allowance for doubtful accounts in the period they are determined to be uncollectible." SchH_P03_S0B_L08 Schedule H, Part III, Section B, Line 8 The Medicare Advantage plan incurred a shortfall of $8,693,699 in 2011. Our service area is a very rural 13 county area in southern Ohio. The population is an aging population which results in Medicare as our largest payer group. In addition, the economic conditions that result from Appalachian designation create a recruiting issue. To combat this issue, we are forced to not only employ physicians but must pay a premium to get them to agree to serve the area's residents. Based on these issues, we believe service to our Medicare population is a community benefit. Also, the hospital used the methodology required for completing the Medicare Cost Report when determining the amount on Part III - Line 6. SchH_P03_S0C_L09b Schedule H, Part III, Section C, Line 9b The system's collection based bad debt policy clearly states "if agencies identify accounts that qualify for charity care or financial assistance, they are to cease further collection activities and return accounts to Adena Health System for disposition. SchH_P05_S0B_L19 Schedule H, Part V, Section B, Line 19 The patient is initially charged regular hospital rates for services performed. The patient then completes an Application for Financial Aid form and returns it to the financial counselors. HCAP/charity adjustments are administered based on proof of income and the tables of the Federal Poverty Limits (FPL) in the following manner: 1. 100% write-off and HCAP eligible - less than 100% FPL 2. 90% write-off - between 101 - 150% of FPL 3. 75% write-off - between 151 - 250% of FPL 4. 50% write-off - between 251 - 350% FPL 5. 25% write-off between 351 - 400% FPL 6. 0% write-off - greater than 400% FPL. Management decided to limit the discount to those under the 400% FPL, based on management's experience at other institutions along with a cursory review of hospitals in the local market. SchH_P06_S00_L02 Schedule H, Part VI, Line 2 A recent study with the Ohio State University's College of Public Health's Center for Public Health Practice reflects the community health status of Adena Health System's service region. In addition, a study by Ohio University's Voinovich School of Leadership and Public Affairs developed a snapshot assessment of the communities served by Adena Health System. Adena also measures the needs of communities and populations based on applications it receives from area nonprofit organizations, including schools. The study's common findings show that those living in Adena's service region are among Ohio's most vulnerable populations. Our community faces unique health risks and barriers as a result of social status, human capital, social capital and risk. Many require special services and/or enhanced outreach. A serious threat to the overall health of people in Adena's service area is obesity. The majority of people in our service region are overweight or obese. Overweight and obese people are at a higher risk of developing conditions such as diabetes, hypertension and high cholesterol, among other conditions that lead to chronic disease. Children are at similar risk for health problems when overweight or obese, which could have a long term impact on their lives. The incidence of diabetes, cancer and heart disease are prominent in Adena's patient population. Mortality studies comparing Adena's service region to U.S., Ohio and peer county rates show death rates from cardiovascular disease and cancer are of concern. County Health Rankings data indicates that six of eight counties in the Adena service region rank in the bottom 25 percent in health outcomes. The majority of our community outreach efforts are focused on educating our patients on the importance of better healthcare, positive lifestyle decisions and disease prevention - and guiding them on their healthcare journey. SchH_P06_S00_L03 Schedule H, Part VI, Line 3 The availability of financial assistance is communicated in the following manner: 1. Statements from Adena as well as collection vendors explain and list the 100% guidelines on the backside of the statement. 2. There is signage explaining the program at all the registration areas. 3. A contracted vendor supplies staff at the Cashier area to explain options available to the patient. 4. We send an application with the self-pay discount letters in case the patient/guarantor can't set up a payment plan. 5. The Customer Service staff is educated on all the options and can explain the programs when patients call. 6. Our physician offices, as well as collection vendors have financial aid applications available. 7. Lastly, we utilize a "hindsight" vendor that screens all bad debt accounts, after the year-end, against the state Medicaid eligibility and Federal Poverty Guidelines to attempt one last effort to obtain financial assistance for individuals. SchH_P06_S00_L04 Schedule H, Part VI, Line 4 Adena Health System serves the needs of more than 500,000 people in 13 counties in south-central Ohio.The following details the number of people in the Adena service region group by vulnerabilities 16.7% No high school diploma 12.2% Unemployed 3.1% Work disabled 6.1% Major depression 6.5% Recent drug user More than 18 percent of those living in Adena's service area live under poverty level averages, which range from 14.2 percent to 22.9 percent. The poverty rate for all of Ohio is 15.1 percent. A high proportion of Adena patients have no or limited health insurance coverage, these include: 9.6% Uninsured 16.6% Medicare beneficiaries 24.7% Medicaid beneficiaries Data shows that nearly 10 percent of Adena service region residents are uninsured. While slightly below the state average of 13 percent, this percentage may increase due to the economic climate and unemployment rates. Eight counties included in the report have been designated as Medically Underserved Areas and/or populations. These shortages may result in a lack of both preventive care and treatment services - factors that may contribute to the region's morbidity and mortality rates. SchH_P06_S00_L05 Schedule H, Part VI, Line 5 Adena Health System serves nearly a half-million patients in Ohio's Appalachian region. Many people in the region struggle with obesity, diabetes and heart disease. In addition, poverty levels in the region are among the highest in the state. Many of our patients are in need financially and in terms of health coverage. Adena and its employees recognize the value of our healthcare services for those our communities, in addition to the variety of needs many of our patients have. To meet those needs, Adena and its employees participated in the following activities and services to enhance the health and well-being of the patients we serve. Hope Clinic: About 18 percent of Ross County residents, or nearly one-in-five, have no form of health insurance. To ensure access to health care, the Hope Clinic of Ross County was in development in 2011 (opening in January 2012). Adena was involved in the planning and preparation. Once open, Adena physicians and nurses will volunteer their time at the Clinic, providing free health care to those needing it the most. Adena (PACCAR) Medical Education Center: Basic First Aid and CPR courses provided to organizations within the region served by Adena Health System. The courses help educate the public about what they can do when faced with a medical emergency, until professional help arrives. Among those who have taken advantage of the courses are area organizations including: Big Brothers and Big Sisters, Kenworth Trucking, McDonald's Restaurants, Ross County Engineer's Office, Ross County Health Department and Southern Ohio Eye Surgery Center. In addition to First Aid and CPR courses, Adena's community course offerings include Advanced Cardiac Life Support and a Neonatal Resuscitation Program. Athletic Trainers: To ensure the safety and health of local teen athletes, Adena provides athletic trainers free-of-charge to seven high schools in four counties in its service region. Adena sports medicine physicians are available on Saturday morning's to evaluate local athletes' injuries. The Health System's athletic trainers also provide community educational programs, including rehabilitation and nutrition education, CPR classes and school sports physicals. In addition, our trainers provide free services at community events including: Gus Macker 3-on-3 tournament, OHSAA Baseball All-star tournament, and various other events. Employees Giving Back: Coats for Kids: For the fourth year, Adena employees raised hundreds of coats for children from low-income homes throughout our service region. More than 300 new or gently used coats were donated in 2011. Food Pantry Assistance: Adena's Strategy Division packed 700 bags of groceries (4,900 cans) at the Good Samaritan Food Pantry, as a way of helping the less fortunate in the area during Thanksgiving. The unemployment rate for the region is higher than average and the food pantry is crucial in feeding many families. Pediatric Auction: Staff of Adena Pediatrics held an in-house charity auction with proceeds going to needy children in the community. More than $1,600 was raised and donated to 15 children who were identified by the Salvation Army as having significant need. Raising Awareness of Sexual Violence: Adena partnered with the Ross County Sexual Assault Response Team to host "Take a Walk in Her Shoes" event to raise money and awareness to the problem of sexual violence in the region. $2,000 was raised to train volunteer sexual assault victim advocates. Free Mammograms: Hundreds of uninsured and underinsured women in Adena's service region received mammograms as part of the "A Promise to Keep" program. The Health System applied for grant funding to help cover some cost of the program, which is vital in finding breast cancer early. Women in Appalachia are typically diagnosed in more advanced stages of the disease, due to lack of insurance or education on the importance of mammography. Kid Shape: Obesity is a major health concern in Adena's service area. To help children and their families learn about eating healthy and lose weight, Adena dieticians teach the eight-week Kid Shape course. The Adena Health Foundation covers 2/3 of the cost of the program to ensure participation is not costly. Eighty-seven percent of KidShape participants lose weight and 80% of participants keep the weight off after two years. Adena Weigh: To combat obesity in our community, Adena sponsors a weight loss and lifestyle coaching program with a registered dietitian to improve the health of our patients and staff. A registered dietitian assesses the client's diet quality and makes recommendations for health improvement and weight loss. Patients learn their body mass index, waist circumference, health risks based on your eating habits, diet improvement and determine a weight loss goal. Donation to Open Community Pool: When the City of Chillicothe did not have the funds to open the community swimming pool, Adena stepped up with a $20,000 donation. Many in the community do not have the means to air condition their homes, and the pool serves as a way for families to stay cool in the hot weather, as well as offers the health benefits involved in swimming and being active. Community Education: Adena personnel participate in numerous health screenings and health education events to promote better health and lifestyle choices to those living in our service area. These include visits to schools, senior center, community organizations, and more. Healthcare Career Event: Adena hosts a healthcare career night for students in grades 7 through 12. At the event, colleges and universities present information about careers in healthcare and the curriculum available for students. Information presented in breakout sessions include: EMS, Medical Assistant, Medical Office, Medical Therapies, Non-Direct Patient Care, Nursing, Physician, Physician Assistant, Pharmacy, Radiology, Respiratory and Simulation - Virtual Hospital. SchH_P06_S00_L06 Schedule H, Part VI, Line 6 Founded in 1895, Adena Health System is an independent, not-for-profit healthcare organization based in Chillicothe, OH. The Health System includes two hospitals and six regional clinics, with a total of 286 beds. Adena serves the needs of nearly 500,000 people in 13 counties, living in Ohio's Appalachian region. Our facilities include: Adena Regional Medical Center: A 261-bed inpatient hospital in Chillicothe, OH featuring an emergency department, diagnostic and treatment services, advanced surgical suites, intensive/cardiac care, medical office building and the Adena Health Pavilion, which includes outpatient surgery, physician offices and the Adena Sleep Center. In 2011, Adena invested $21 million in the construction of a 35,000 square-foot Cancer Center to provide patients with access to cancer diagnosis and treatment at a facility near their homes. The Cancer Center opened in January 2012. Adena Greenfield Medical Center: A critical access hospital and 25-bed inpatient facility in Greenfield, OH features an emergency department, inpatient rehabilitation unit and medical/surgical, diagnostic and treatment services, as well as family practice and specialty physicians, directly benefiting Highland County and surrounding communities. Adena Health Centers: Located in Chillicothe and with regional sites in Circleville, Jackson, Oak Hill, Washington Court House and Waverly, OH. Our health centers include physician offices, diagnostic and treatment services, physical, occupation and speech therapies. Urgent care services are offered in Chillicothe and Waverly. Adena Home Care and Hospice: Provides highly personalized, quality care to patients of four service lines -- home health, hospice, home respiratory and home infusion. Adena Rehabilitation and Wellness Center: Provides physical, occupational, massage and industrial rehabilitation, as well as orthopaedics, sports medicine, women's health, vestibular, fibromyalgia and chronic pain programs, as well as industrial and specialized hand programs. Adena Counseling Center: Provides a wide range of outpatient counseling services, including group, individual and family counseling. A variety of support groups also meet at the center. Off-Campus Physician Offices: A number of physician offices are located throughout the region served by Adena. These include offices for family physicians, endocrinologists, gerontologists and urologists. Telemedicine: In 2011, the Health System continued its affiliation with the Southern Ohio Health Care Network (SOHCN), a partnership of the region's three largest healthcare providers -- Adena, O'Blenness Health System and Holzer Consolidated Health Systems. This partnership has resulted in the construction of an expansive fiber optic broadband telecommunications network to serve the healthcare and educational needs of people living in Ohio's Appalachian region. Through this technology, telemedicine is enabling patients to be on Adena's campus, but treated by physicians outside the region. Adena has telemedicine relationships with Ohio State University Medical Center, Riverside Methodist Hospital, and Nationwide Children's Hospital in Columbus. 1 City of Chillicothe 35 S Paint Street Chillicothe OH 45601 316400221 501(c)(3) 20100 Book Sponsorship of the community pool and DARE Run Adena Mansion & Gardens Society 848 Adena Road Chillicothe OH 45601 271330314 501(c)(3) 10000 Book Sponsorship to help manage the Adena historical mansion. Chillicothe Education Foundation 45 East Main Street Chillicothe OH 45601 311480939 501(c)(3) 9000 Book Sponsorship of the "Leader-in-Me" program for the Chillicothe City Schools. South Central Ohio Big Brothers and Big Sisters 173 West Second Street Chillicothe OH 45601 310968026 501(c(3) 5207 Book Sponsorship of community based program for volunteer mentors. 4 0 SchI_P01_S00_L02 Schedule I, Part I, Line 2 Each grantee is required to submit 2 progress reports and a final report with an accounting for the use of funds. In addition to progress reports, Community Health staff visit each grantee at least twice during the project period. Summary reports are prepared for the for the Health System's Board of Trustees. X X 1 1 X X 1 0 0 0 0 1 0 0 0 Jack Berno 292617 0 0 0 1791 0 0 0 14161 0 308569 0 0 0 Doug Folzenlogen 406788 0 9286 0 8091 0 0 0 19553 0 443718 0 0 0 Allen Shaw 221974 0 0 0 552 0 0 0 11070 0 233596 0 0 0 Mark Shuter 662349 0 31951 0 31332 0 24895 0 21537 0 772064 0 0 0 Keith Coleman 303600 0 22409 0 3182 0 24084 0 22295 0 375570 0 0 0 Jack Baker 597167 0 0 0 1117 0 0 0 19646 0 617930 0 0 0 Karen Bolton 203812 0 22207 0 9209 0 16700 0 15321 0 267249 0 0 0 Wayne Coats 382575 0 0 0 7896 0 0 0 19595 0 410066 0 0 0 Michele Federer 417675 0 0 0 16797 0 0 0 7433 0 441905 0 0 0 John Fortney 327547 0 21679 0 16186 0 0 0 23546 0 388958 0 0 0 Jeff Graham 235879 0 20096 0 2821 0 20497 0 19965 0 299258 0 0 0 Satish Jetty 400691 0 20096 0 2821 0 0 0 19581 0 443189 0 0 0 Denise Minor 167143 0 12440 0 2289 0 8625 0 21191 0 211688 0 0 Mark Moffitt 154547 0 0 0 40194 0 9287 0 5528 0 209556 0 0 Eric Perdue 146088 0 6591 0 112 0 11307 0 2311 0 166409 0 0 0 Barbara Purdom 124134 0 17322 0 11334 0 11391 0 26161 0 190342 0 0 0 Patricia Roam 130145 0 14566 0 10553 0 12100 0 11877 0 179241 0 0 0 Faitha Shelton 193609 0 10320 0 256 0 17691 0 24676 0 246552 0 0 Kirk Tucker 266594 0 0 0 229 0 0 0 19595 0 286418 0 0 0 Elisabeth Williams 12088 0 0 0 205514 0 0 0 20279 0 237881 0 0 Martha Livingston 139393 0 10844 0 498 0 8781 0 13234 0 172750 0 0 0 Brian Cohen 2570488 0 0 0 17460 0 0 0 20421 0 2608369 0 0 0 Thomas Lewis 963790 0 4359 0 19198 0 0 0 25796 0 1013143 0 0 0 Rob Bradley 880800 0 0 0 16842 0 0 0 25796 0 923438 0 0 0 James Fleming 886571 0 0 0 10390 0 0 0 25796 0 922757 0 0 0 Kort Gronbach 821265 0 0 0 16951 0 0 0 23646 0 861862 0 0 Anthony Freeman 928336 0 0 0 10105 0 0 0 19575 0 958016 0 0 0 SchJ_P01_S00_L01a Schedule J, Part I, Line 1a Adena Health System provides for a membership to the local Country Club for all Officers and Key Employees. This benefit is taxed. SchJ_P01_S00_L04 Schedule J, Part I, Line 4 Elisabeth Williams was terminated as Chief Strategy Officer for Adena Health System in January 2011 and is being paid severance bi-weekly for 18 months. SchJ_P01_S00_L06 Schedule J, Part I, Line 6 The Adena Health System Management Incentive Plan was established to communicate strategic performance priorities to the management team and to encourage the highest level of performance in the delivery of health care services. The Incentive Award is funded by an Incentive Pool based upon Margin Percentage recommended by Management and approved by the Executive Compensation Committee. The Incentive Pool shall be based upon the percentage of "salary at risk" and number of participants for each eligibility level. Prior to the beginning of each Plan Year, organizational goals shall be developed to support and further the accomplishments of the System's mission, strategic plan, financial goals and business outcomes. At the end of each Plan Year, Management, with the support of the CFO and CHRO shall submit a report summarizing the performance level of the System and the recommended funding level for the Incentive Pool. This proposal is approved by the Executive Compensation Committee. County of Ross Ohio 316400085 778260EX3 2008-09-17 141346983 Current refunding of 2001 and 2006 issues 0 0 0 County of Ross Ohio 316400085 2010-09-15 29985000 Infusion Center and Interventional Radiology 0 0 0 1420000 0 196850065 10920538 0 0 1366439 487668 0 55557232 0 0 2010 1 0 1 1 0 0 30070554 0 0 0 411604 0 0 18554400 0 11104550 2012 0 0 0 1 0 1 0 0 0 0 0 1 0 0 0 0 0 0 0 1 0 0 0 1 Bayerische Landesbank 3 1 0 0 0 1 0 0 0 0 SchK_P02_S00_L03 Schedule K, Part II, Line 3 Represents original issue plus unspent proceeds from issue 2006 plus investment earning through December 2011. This is for the 2008 issue. SchK_P02_S00_L06 Schedule K, Part II, Line 6 2001 and 2006 issues were refunded on October 29, 2008. Included $116,560,000 of principal and $149,427 of interest. This is for the 2008 issue. SchK_P02_S00_L11 Schedule K, Part II, Line 11 $11,750,000 of issue was used to pay off qualified hedged related to the 2001 and 2006 bonds. This is for the 2008 issue. SchK_P03_S00_L02 Schedule K, Part III, Line 2 Adena Health System leases approximately 300 square feet to a for profit company that operates a coffee kioske. This is considered deminimus space and so 0% was put in Line 4 of Part III. This is for the 2008 issue. SchK_P04_S00_L04a Schedule K, Part IV, Line 4a Proceeds invested in GIC from 2006 issue - Unused portion transfers to 2008 issue. The GIC matured in July 2009; this was 36 months after the date of issue. This is for the 2008 issue. SchK_P05_S00_L00 Schedule K, Part V While no formal written policy or procedures were in place in 2011, our bond counsel was routinely involved in decisions related to our bonds. In addition, in 2012, we have engaged our bond counsel to help us prepare the necessary written procedures. This is for the 2008 and 2010 issues. Horizon Telcom Inc Business vendor of AHS 931628 Payment for telephone service 0 Robin Berno Spouse of Dir. Jack Berno 97275 Employee Compensation 0 Kristin Davis Daught. of COO J.Graham 23963 Employee compensation 0 Dean Kuchta Spouse of K.E Karen Bolton 84575 Employee compensation 0 Tracy Coats Spouse of K.E Lloyd Coats 7560 Employee Compensation 0 Lois Jetty Spouse of K.E. Satish Jetty 192475 Employee Compensation 0 Michele Perdue Spouse of K.E Eric Perdue 60804 Employee compensation 0 Jennifer Strickland Spouse of B.M. David Strickland 28382 Employee Compensation 0 Jennifer White Daugh in-law of B.M Tom White 100971 Employee compensation 0 SchL_P04_S00_L00 Schedule L, Part IV Steve Burkhardt the Treasurer of Horizon Telcom, Inc. regularly abstains from voting and removes himself from discussions concerning Horizon Telcom, Inc. F990_P06_S0A_L06 Form 990, Part VI, Section A, Line 6 The organization is composed of 9 member churches. All of the churches are in the Chillicothe, Ohio area. F990_P06_S0A_L07a Form 990, Part VI, Section A, Line 7a The corporate member churches may only elect one person per church to act as their Trustee.The Trustee at Large get appointed as follows. Section 3.03 of the code of Regulations of AHS - "The Board shall elect six (6) at-large Trustee positions. Two of these positions shall be filled with physicians who are members of the active Medical Staff recommended by the Medical Staff in accordance with the Medical Staff bylaws.When a vacancy occurs among the four (4) at large Trustees, with the exception of members eligible for reappointment, the Trustee Committee shall nominate to the board a candidate for the vacant position." F990_P06_S0A_L07b Form 990, Part VI, Section A, Line 7b Section 2.04 Rights of the Corporate Members: (a). The right to elect nine trustees of the Corporation as specified in these Bylaws. (b) The right to approve any lease, sale exchange, transfer,or other disposition of all or substantially all of the assets of the Corporation. (c). The right to approve any proposed merger or consolidation of the Corporation. (d).The right to approve any proposed dissolution of the Corporation. (e).The right to approve any proposed change to the fundemental purpose of the corporation as stated in Section 1.01. (f).The right to approve any proposed amendments to the Code of Regulations. F990_P06_S0B_L11b Form 990, Part VI, Section B, Line 11b The 990 was reviewed with the trustees at a board meeting prior to filing. Each board member was provided with a copy of the 990. F990_P06_S0B_L12c Form 990, Part VI, Section B, Line 12c The Corporate Compliance Office of Adena Health System annually coordinates the distribution and return of the conflict of interest statements. The Corporate Compliance Officer is responsible for reviewing the responses and communicating any extra steps that need to take place regarding any of the responses. At every Board meeting and committee of the Board, the agenda item of conflict of interest is included and called out. Conflict Board members abstain from voting on the particular items.All Adena Health System employees and board members are subject to the Conflict of Interest policy. F990_P06_S0B_L15 Form 990, Part VI, Section B, Line 15 Compensation is determined through market surveys on all executives (including CEO). The market surveys are conducted by a 3rd party- Mercer. Mercer makes recommendations to the Executive Compensation Committee which is a subcommittee of the board. The CEO is not present for the CEO recommendation for integrity purposes. The Executive Compensation Committee approves the salary and all aspects of compensation. The Chief Human Resources Officer works with the Human Resources department to implement any changes. The CEO contract is a 8 year contract. The Committee reviews and approves all aspects of the contract which must be approved and signed by all parties prior to processing the changes.The process was last undertaken in March 20, 2012. F990_P06_S0C_L19 Form 990, Part VI, Section C, Line 19 The organization prepares an annual report to the public which includes its statement of revenues and expenses. Additionally, its governing documents and conflict of interest policy is available upon request. The financial statements are not available. F990_P11_S00_L05 Form 990, Part XI, Line 5 1. Change in unrealized investment not included in audited financial statements ($4,261,231). 2. Pension-related Changes Other Than Net Periodic Cost ($2,658,994). 3. Women's Board/VAC net revenue of ($5,160) is included in the 990 return. Adena Medical Group LLC Dept L637 Columbus OH 43260 271370967 Healthcare providers OH -28933900 6311092 Adena Health System Adena Hospice LLC Adena Health System Sole MBR 272 Hospital Road Chillicothe OH 45601 275340755 Healthcare provider OH 17307 1071178 Adena Health System Adena Home Infusion DME and Respiratory LLC Adena Health System Sole MBR Chillicothe OH 45601 273752854 Healthcare provider OH 212477 1304690 Adena Health System Adena Home Health LLC Adena Health System Sole MBR Chillicothe OH 45601 273752730 Healthcare provider OH -366138 2645869 Adena Health System Greenfield Area Medical Center 550 Mirabeau St Greenfield OH 45123 310993422 Hospital OH 501(c((3) 3 Adena Health System 1 Adena Health Foundation 272 Hospital Road Chillicothe OH 45601 753008742 Fundraising OH 501(c)(3) 11a Adena Health System 1 Southern Ohio Healthcare Network 272 Hospital Road Chillicothe OH 45601 261566590 Fiberoptic Network Grants OH 501(c)(3) 11a Adena Health System 1 Adena Care 272 Hospital Road Chillicothe OH 45601 453980850 Provide employee health insurance to organizations OH Adena Health System C 0 0 1 0 0 1 0 0 0 0 0 0 0 0 0 0 0 1 0 0 0 Greenfield Area Medical Center c 3202905 Book Value Adena Health Foundation c 698275 Book Value Adena Health Foundation o 342315 Book Value Southern Ohio Healthcare Network o 366047 Book Value