2012-03-13T18:22:12-05:00 2011-03-31 PLANTE & MORAN PLLC 750 TRADE CENTRE WAY STE 300 PORTAGE MI 49002 990 2010-04-01 382800065 HOLLAND COMMUNITY HOSPITAL HOLL 6163925141 602 MICHIGAN AVENUE HOLLAND MI 49423 DALE SOWDERS 6163925141 2012-03-07 1 OLIVER JURKOVIC 2695674500 2010 2016-02-24 21:20:13Z HOLLAND HOSPITAL DALE SOWDERS 602 MICHIGAN AVENUE HOLLAND MI 49423 187183397 0 X WWW.HOLLANDHOSPITAL.ORG X 1985 MI TO CONTINUOUSLY IMPROVE THE HEALTH OF THE COMMUNITIES WE SERVE IN THE SPIRIT OF HOPE, RESPECT, COMPASSION AND DIGNITY. 15 11 2125 510 1872592 235987 546534 878365 162715545 175390965 902669 -1249481 5935919 8221281 170100667 183241130 538055 770803 0 0 86869555 91784339 0 0 0 72140438 80341780 159548048 172896922 10552619 10344208 315558594 355240131 73001654 85527092 242556940 269713039 X TO CONTINUOUSLY IMPROVE THE HEALTH OF THE COMMUNITIES WE SERVE IN THE SPIRIT OF HOPE, RESPECT, COMPASSION AND DIGNITY. 0 0 142977465 770803 175390965 HOLLAND COMMUNITY HOSPITAL'S MISSION IS TO IMPROVE THE HEALTH OF THE COMMUNITIES IT SERVES. THIS UNWAVERING COMMITMENT TO PROVIDING THE HIGHEST QUALITY MEDICAL CARE HAS REMAINED STEADFAST SINCE THE HOSPITAL BEGAN. THIS 95-YEAR LEGACY OF PROVIDING EXCELLENT, COMPASSIONATE AND INCREASINGLY ADVANCED HEALTH CARE REGARDLESS OF PATIENTS' ABILITY TO PAY CONTINUES UNABATED.FIRST-RATE QUALITY TODAY, HOLLAND HOSPITAL IS NATIONALLY RECOGNIZED FOR QUALITY AND EXCELLENCE AND IS THE PROUD RECIPIENT OF NUMEROUS STATE AND NATIONAL QUALITY AWARDS. IN 2007, HOLLAND HOSPITAL RECEIVED THE PRESTIGIOUS MAGNET HOSPITAL DESIGNATION, A FIRST-IN-CLASS DISTINCTION AWARDED BY THE AMERICAN NURSES CREDENTIALING CENTER TO HOSPITALS THAT DEMONSTRATE THE HIGHEST DEGREE OF PATIENT-CARE EXCELLENCE. FOR LAKESHORE-AREA RESIDENTS, OUR MAGNET INSIGNIA IS ASSURANCE THAT THE CARE PATIENTS RECEIVE AT HOLLAND HOSPITAL IS THE VERY BEST - AMONG THE TOP 3 PERCENT OF CLINICAL PROGRAMS IN THE NATION. TOP 100 HOSPITALS' FIVE YEARS AND COUNTINGTHIS YEAR WAS THE SIXTH CONSECUTIVE YEAR THAT HOLLAND HOSPITAL WAS RANKED AMONG THE NATION'S "100 TOP HOSPITALS" BY THOMSON REUTERS. THIS DISTINCTION IS BASED ON AN INDEPENDENT, DATA-DRIVEN REVIEW OF MORE THAN 3,000 HOSPITALS. HOSPITALS DON'T APPLY TO BE ON THIS LIST; RATHER, THE STUDY RATES THEM BASED ON A BALANCED, UNBIASED COMPARISON. ONLY THOSE THAT DEMONSTRATE SUPERIOR PERFORMANCE ARE CONSIDERED, AND ONLY THE BEST 100 MAKE THE LIST. OUR HOSPITAL IS ONE OF LESS THAN 40 HOSPITALS TO MAKE THE LIST SIX TIMES, VALIDATING THE HIGH QUALITY CARE HOLLAND HOSPITAL OFFERS - AND WORKS DAILY TO ACHIEVE.TOP 4 PERCENT FOR 'BEST PRACTICES'"PROCESS OF CARE MEASURES" (OR "CORE MEASURES") ARE PROVEN BEST-PRACTICE STANDARDS FOR TREATING PATIENTS WITH CERTAIN MEDICAL CONDITIONS. HOW WELL EACH HOSPITAL APPLIES THESE LIFE-SAVING MEASURES IS TRACKED BY THE U.S. DEPARTMENT OF HEALTH & HUMAN SERVICES AND CAN BE VIEWED AT WWW.HOSPITALCOMPARE.HHS.GOV.RECENT DATA PLACE HOLLAND HOSPITAL AT THE 96TH PERCENTILE - MEANING WE'RE IN THE TOP 4 PERCENT OF HOSPITALS NATIONWIDE IN MEETING PROCESS OF CARE MEASURES. WE ARE ALSO AMONG THE FIRST HOSPITALS TO LEAD THE WAY IN PATIENT SAFETY THROUGH THE MICHIGAN HEALTH & HOSPITAL ASSOCIATION KEYSTONE CENTER FOR PATIENT SAFETY & QUALITY. LEADERS IN INNOVATIVE PRACTICESTHE HOSPITAL CONTINUES TO MEET THE GROWING HEALTH CARE NEEDS OF THE COMMUNITY BY PROVIDING EXPERIENCED SPECIALISTS, LEADING-EDGE TECHNOLOGY AND EXCEPTIONAL PATIENT CARE. ALTHOUGH THE HEALTH CARE LANDSCAPE CONTINUES TO CHANGE, HOLLAND HOSPITAL REMAINS AHEAD OF THE CURVE WITH FISCAL DISCIPLINE, EFFICIENT USE OF RESOURCES, AND WISE INVESTMENT IN NEW TECHNOLOGIES. MANY LAKESHORE RESIDENTS ARE BENEFITING FROM OUR RECENT FACILITY IMPROVEMENTS AS WELL AS SUCH CUTTING-EDGE TECHNOLOGIES AS DAVINCI ROBOT-ASSISTED SURGERY, DIGITAL MAMMOGRAPHY AND INTERVENTIONAL RADIOLOGY. DURING FISCAL YEAR 2011, HOLLAND HOSPITAL'S 320-MEMBER MEDICAL STAFF, 1,900 EMPLOYEES AND 500 VOLUNTEERS SERVED THE COMMUNITY BY PROVIDING:PATIENT DAYS 29,700DISCHARGES 7,700BIRTHS 1,800SURGERIES 14,300OUTPATIENT VISITS 344,600EMERGENCY ROOM VISITS 41,700URGENT CARE VISITS 33,000HOME HEALTH VISITS 43,000LAB TESTS 632,000RADIOLOGY PROCEDURES 104,000BEDS 209INNOVATIVE OUTREACH PROGRAMSIMPROVING THE HEALTH OF THE COMMUNITIES WE SERVE MEANS TAKING OUR SERVICES INTO THE COMMUNITY TO OFFER RESIDENTS CONVENIENT ACCESS TO HEALTH PROGRAMS AND EDUCATION. MORE PROGRAMS AND SERVICES ARE REACHING BEYOND HOSPITAL WALLS INTO THE COMMUNITY, WHETHER AT SCHOOLS, NEIGHBORHOODS OR BUSINESSES. RESIDENTS AND EMPLOYEES ALIKE CAN TAKE ADVANTAGE OF NUMEROUS PREVENTION AND WELLNESS OFFERINGS.HEALTH EDUCATION AND SERVICESRECOGNIZING THAT MEN AND WOMEN HAVE UNIQUE HEALTH NEEDS, HOLLAND HOSPITAL HAS RESPONDED TO THE COMMUNITY'S REQUEST FOR PROGRAMS THAT ADDRESS GENDER-RELATED HEALTH CONCERNS. OUR WOMEN'S MIDLIFE SERVICES IS DEVOTED ENTIRELY TO ADDRESSING THE PHYSICAL AND EMOTIONAL ISSUES OF MATURE WOMEN. CREATED BY WOMEN FOR WOMEN AND DIRECTED BY A CERTIFIED MENOPAUSE PRACTITIONER, WOMEN'S MIDLIFE SERVICES OFFERS THE LATEST INFORMATION ON MENOPAUSE AND RELATED ISSUES. INTERPRETATION SERVICESOUR ON-SITE INTERPRETERS, SPECIALLY TRAINED IN MEDICAL CONDITIONS IN ACCORDANCE WITH THE NATIONAL COUNCIL ON INTERPRETING IN HEALTH CARE, ARE AVAILABLE 24 HOURS A DAY TO FACILITATE COMMUNICATION BETWEEN PATIENTS AND PROVIDERS. IN THE PAST YEAR, STAFF HANDLED MORE THAN 23,500 INTERPRETATION REQUESTS. A NEW VIDEO CONFERENCING SYSTEM AT THE OFF-SITE URGENT CARE CENTER CONNECTS PATIENTS FACE-TO-FACE WITH INTERPRETERS IN MINUTES ELIMINATING DELAYS DUE TO TRAVEL TIME. DIABETES EDUCATION DIABETES IS A MAJOR HEALTH EPIDEMIC THAT WE CONTINUE TO ADDRESS THROUGH OUR DIABETES SELF-MANAGEMENT EDUCATION PROGRAM. WE ASSIST THOSE WITH DIABETES BY OFFERING INDIVIDUAL CONSULTATIONS AS WELL AS GROUP CLASSES. PARTICIPANTS LEARN ABOUT DIET AND NUTRITION, HOW TO TEST THEIR BLOOD SUGAR, AND MANAGING THE DISEASE WITH MEDICATION. COMMUNITY OUTREACH PROGRAMS THE CENTER FOR GOOD HEALTH OFFERS A WEALTH OF EDUCATIONAL CLASSES AND PRESENTATIONS FOR CHILDREN, ADULTS AND SENIORS. IN FY 2010, THE CENTER OFFERED 600 CLASSES AND EVENTS WITH APPROXIMATELY 11,000 PARTICIPANTS. RECENTLY, IN RESPONSE TO TODAY'S EMPHASIS ON IMPROVING WORKER HEALTH TO BOOST EFFECTIVENESS AND REDUCE HEALTH CARE COSTS, THE CENTER JOINED FORCES WITH MANY AREA BUSINESSES TO TAKE ITS WORKSITE WELLNESS PROGRAM DIRECTLY TO EMPLOYEES. SERVING THE UNDERSERVED WITH THE FACE OF HOLLAND PROJECTIN OTTAWA COUNTY, THE CHALLENGING ECONOMIC TIMES HAVE LEFT SOME 30,000 ADULTS AND CHILDREN WITH NO OR INSUFFICIENT HEALTH INSURANCE TO COVER THEIR FAMILY'S MEDICAL EXPENSES. IN RESPONSE, THE HOLLAND HOSPITAL FOUNDATION INTENSIFIED ITS EFFORTS TO "SERVE THE UNDERSERVED" BY FOCUSING FINANCIAL SUPPORT ON TWO VITAL PROGRAMS: THE HOLLAND COMMUNITY HEALTH CENTER AND THE SCHOOL NURSING PROGRAM. THE FOUNDATION IS THE SOLE SOURCE OF FUNDING FOR THE SCHOOL NURSING PROGRAM, INVESTING $50,000 PER SCHOOL YEARLY, AND CONTRIBUTED $750,000 TO THE OPERATION OF THE COMMUNITY HEALTH CENTER. HOLLAND COMMUNITY HEALTH CENTERDEMAND IS RISING DRAMATICALLY (BY ABOUT 800 PATIENTS PER YEAR) FOR SERVICES OF THE HOLLAND COMMUNITY HEALTH CENTER, WHICH PROVIDES HEALTH CARE FOR PEOPLE WHO ARE UNDER AND UNINSURED. IN 2010, THE COMMUNITY HEALTH CENTER SERVED NEARLY 4,731 PATIENTS, NEARLY HALF OF THEM CHILDREN WITH 10,724 VISITS. MOST OF THESE VISITS FOCUSED ON WOMEN'S AND CHILDREN'S HEALTH CARE NEEDS, DIABETES MANAGEMENT AND ELDER CARE. EACH YEAR THE COMMUNITY HEALTH CENTER ACQUIRES OVER $365,000 WORTH OF FREE MEDICATIONS FOR PATIENTS WHO CANNOT AFFORD THEM. THE SCHOOL NURSING PROGRAMSCHOOL NURSING PROVIDES SERVICES TO HOLLAND, WEST OTTAWA AND HAMILTON PUBLIC SCHOOLS. SCHOOL YEAR 2010-2011 THEY SERVICED 8,000 STUDENTS, 34,825 HEALTH OFFICE VISITS, ADMINISTERED 12,665 MEDICATIONS AND REFERRED 440 STUDENTS FOR MEDICAL, DENTAL, VISION, OR SOCIAL CONCERNS. THEY PROVIDED OVER 200 EDUCATIONAL SESSIONS. UNCOMPENSATED MEDICAL COSTS OUR COMMITMENT TO CARING FOR MEMBERS OF OUR COMMUNITY WHO ARE UNINSURED OR UNDERINSURED CONTINUES TO BE ONE OF THE BIGGEST FINANCIAL CHALLENGES FOR THE HOSPITAL. IN FY 2011, HOLLAND HOSPITAL PROVIDED UNREIMBURSED CARE TO OUR PATIENTS AT A COST OF $32.4 MILLION, A 16 PERCENT INCREASE OVER THE PREVIOUS YEAR. BAD DEBT ALONE STAYED CONSISTENT DURING 2011, ROSE OVER 30 PERCENT IN 2010 AND 50% IN 2009 - A REFLECTION OF THE CONTINUED ECONOMIC ENVIRONMENT AND GROWTH IN UNEMPLOYMENT.HOLLAND HOSPITAL TAKES ITS FIDUCIARY RESPONSIBILITY SERIOUSLY, AND WORKS VERY HARD TO BALANCE THE CURRENT HEALTH CARE NEEDS OF THE COMMUNITY WITH OUR RESPONSIBILITY TO REMAIN FINANCIALLY VIABLE FOR GENERATIONS TO COME. COMMUNITY OUTREACH IS AN IMPORTANT PART OF OUR MISSION AND IT TAKES GREAT EFFORT TO FREE UP RESOURCES TO BE ABLE TO INVEST IN THESE PROGRAMS AND COVER INCREASING COSTS FROM UNCOMPENSATED CARE.2011 COMMUNITY BENEFIT SUMMARY - $36.4 MILLION TOTAL COMMUNITY BENEFIT UNPAID COST OF MEDICAID $9,000,000UNPAID COST OF MEDICARE $6,500,000CHARITY CARE $6,700,000 BAD DEBT $10,200,000OTHER COMMUNITY BENEFITS (NOTE A) $4,000,000NOTE A - OTHER COMMUNITY BENEFITS INCLUDE:* COMMUNITY EDUCATION & OUTREACH PROGRAMS* CASH, IN-KIND DONATIONS & CONTRIBUTIONS* HOLLAND COMMUNITY HEALTH CENTER* HEALTH PROFESSIONAL EDUCATION & RESEARCH 142977465 1 1 0 0 1 0 0 0 0 1 1 0 0 1 1 0 1 0 0 0 0 0 0 1 1 1 1 1 0 1 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 1 1 1 0 0 1 166 0 1 2125 1 1 1 0 0 0 0 1 1 0 0 1 0 0 0 0 X 15 11 1 0 0 0 0 0 0 1 1 0 1 1 0 1 1 1 1 1 1 1 1 1 MI X TERRY STEELE 6163925141 602 MICHIGAN AVE HOLLAND MI 49423 DALE M SOWDERS 40.00 X X X 518957 0 128941 LESLIE BROWN 1.00 X 0 0 0 BARBARA DEPREE MD 30.00 X 160159 0 20512 CHUCK DEPREE 1.00 X 0 0 0 BECCA DERNBERGER 1.00 X 0 0 0 WILLIAM FRAUENHEIM MD 1.00 X 0 0 0 ROGER GAMACHE 1.00 X 0 0 0 DON KOMEJAN 1.00 X 0 0 0 KRIS MANOS 1.00 X 0 0 0 GREG MAYBURY 1.00 X 0 0 0 DAWN GARCIA WARD 1.00 X 0 0 0 JANE CLARK 1.00 X 0 0 0 JAMES STROOP 1.00 X 0 0 0 MARK STID 5.00 X X 9363 0 0 DAN RINK 1.00 X 0 0 0 TERRY L STEELE 40.00 X 311306 0 61907 CHARLES D KOHLRUSS 40.00 X 247622 0 51712 PATTI VANDORT 40.00 X 251387 0 47302 MARK L PAWLAK 40.00 X 219247 0 47346 WILLIAM L VANDERVLIET MD 20.00 X 124124 0 32842 ROBERT J BATES MD 40.00 X 549973 0 41404 MICHAEL A TRAVER MD 40.00 X 392403 0 39344 BRADLEY L WILLOUGHBY MD 40.00 X 360900 0 39190 JOHN K LUDLOW MD 40.00 X 404264 0 20908 DERICK JOHNSON 40.00 X 187639 0 3989 3737344 0 535397 52 0 1 0 LAKEWOOD CONSTRUCTION 11253 JAMES STREET HOLLAND MI 49424 CONSTRUCTION 4055475 ARAMARK CORPORATION 12483 COLLECTIONS CENTER DRIVE CHICAGO IL 60693 CONTRACTED SERVICES 3362638 ELZINGA AND VOLKERS INC 86 E 6TH ST HOLLAND MI 49423 CONSTRUCTION 3041892 LAKESHORE CAMPUS LLC 161 OTTAWA AVENUE NW STE 104161 O GRAND RAPIDS MI 49503 LANDLORD - RENT 899380 LAKESIDE ENT 577 MICHIGAN AVE HOLLAND MI 49423 BILLING SERVICES 805456 31 182014 696351 878365 NET PATIENT REVENUE 621110 175390965 175390965 175390965 2178658 2178658 271673 271673 271673 271673 459386 3887525 -3428139 -3428139 -3428139 75037 182014 27397 47640 47640 20295 27345 -7050 -7050 MISCELLANEOUS REVENUE 900099 4734719 4734719 PHO/LAB ACTIVITY 621500 1872592 1872592 CAFETERIA AND HOME MEA 722210 904430 904430 397277 397277 7909018 183241130 175390965 1872592 5099208 770803 770803 2304413 186675 2117738 70091394 60391678 9699716 1351842 1351842 18036690 17622251 414439 1124650 4624 1120026 131700 20550 111150 704372 704372 1244697 1244697 585362 30891 554471 1034301 613589 420712 2403038 2403038 2658138 2653867 4271 310432 292448 17984 336487 197842 138645 2175220 2175220 9715604 8928726 786878 1190975 65988 1124987 SUPPLIES 27067068 26896663 170405 CONTRACT LABOR 12974342 8606629 4367713 PROVISION FOR BAD DEBTS 10177735 10177735 OTHER 4065083 16352 4048731 UTILITIES 2442576 2080237 362339 172896922 142977465 29919457 0 14558816 16963554 9111669 7398459 19551882 27719373 3210356 3404455 2590516 1925640 205466677 88431937 108188679 117034740 125388579 158892019 31098572 19938178 1859525 1963713 315558594 355240131 10558229 14250975 59163091 66245245 8200 3272134 5030872 73001654 85527092 X 241860472 269017048 296468 295991 400000 400000 242556940 269713039 315558594 355240131 X 10344208 16811891 X X 0 1 1 X 0 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 48 640615 641092 297858 1 1 7516110 7516110 96654335 33848438 62805897 12822444 625984 12196460 88473788 53957515 34516273 117034740 INVESTMENTS IN AFFILIATED ENTITIES 2999986 F INVESTMENT IN JOINT VENTURE 16938192 F 19938178 PROFESSIONAL LIABILITY INSURANCE 2876128 COST REPORT SETTLEMENT PAYABLE 1771944 OTHER LONG-TERM LIABILITIES 382800 5030872 183241130 172896922 10344208 14490505 2321386 16811891 27156099 214765647 14490505 14310245 28800750 185964897 704372 -3428139 -2723767 183241130 189542125 17349575 17349575 172192550 704372 704372 172896922 DESCRIPTION OF UNCERTAIN TAX POSITIONS UNDER FIN 48: PART X: THE HOSPITAL HAS ADOPTED ACCOUNTING STANDARDS RELATED TO UNCERTAIN TAX POSITIONS AND, ACCORDINGLY, REVIEWED ALL TAX POSITIONS. THE EVALUATED POTENTIAL EXPOSURE RELATED TO UNCERTAIN TAX POSITIONS WAS FOUND TO BE IMMATERIAL. PART XI, LINE 8 - OTHER ADJUSTMENTS: UNREALIZED LOSS IN JOINT VENTURE 2,712,613. TRANSFER TO AFFILIATE -391,227. PART XII, LINE 2D - OTHER ADJUSTMENTS: REVENUE FROM ENTITIES NOT REPORTED ON THIS RETURN 12,472,632. UNREALIZED LOSS IN JOINT VENTURE -875,000. ELIMINATIONS FOR EARNINGS IN OTHER ENTITIES 2,712,613. PART XII, LINE 4B - OTHER ADJUSTMENTS: ASSET DISPOSAL RECLASSIFIED FROM EXPENSE -3,428,139. PART XIII, LINE 2D - OTHER ADJUSTMENTS: EXPENSES FROM ENTITIES NOT REPORTED ON THIS RETURN 14,796,436. ASSET DISPOSAL RECLASSIFIED FROM EXPENSE 3,428,139. UNREALIZED LOSS IN JOINT VENTURE -875,000. CULINARY CABARET 152841 95317 57524 9884 GALA 104210 86697 17513 750 16763 257051 182014 75037 750 26647 27397 47640 20295 20625 6720 1 0.95000 20295 20625 6720 27345 -7050 MI 1 0 1 0 0.00000 1.00000 COLLEEN PERDOK 602 MICHIGAN AVE HOLLAND MI 49423 0 COLLEEN PERDOK 0 FOUNDATION COORDINATOR X 0 SCHEDULE G, PART III, LINE 16: INCLUDED IN COLLEEN PERDOK'S RESPONSIBILITIES IS THE ROLE OF GAMING MANAGER HOWEVER THE AMOUNT OF COMPENSATION ALLOCATED TO THIS ROLE IS MINIMAL. 1 1 1 X 1 X 1 1 1 0 1 1 3017831 3017831 0.01750 21920061 18501429 3418632 0.01980 24937892 18501429 6436463 0.03730 178642 38696 139946 0.00080 288886 288886 0.00170 411877 341836 70041 0.00040 2405887 2405887 0.01390 3285292 380532 2904760 0.01680 28223184 18881961 9341223 0.05410 3 4560 4560 0.00000 1 746807 224772 522035 0.00300 1 478229 478229 0.00280 5 1229596 224772 1004824 0.00580 0 4587309 727432 24761006 28997643 -4236637 X 1 1 1 1 HOLLAND HOSPITAL

602 MICHIGAN AVE HOLLAND MI 49423

X X X X NOT REQUIRED 1 10 HH SERVICES LLC

602 MICHIGAN AVE HOLLAND MI 49423

PHYSICIAN OFFICE HH SERVICES - STAGEMAN LLC

602 MICHIGAN AVE HOLLAND MI 49423

PHYSICIAN OFFICE HH SERVICES - BATES ET AL LLC

602 MICHIGAN AVE HOLLAND MI 49423

PHYSICIAN OFFICE HH SERVICES - HOLLAND PROFESSIONAL SERVI

602 MICHIGAN AVE HOLLAND MI 49423

PHYSICIAN OFFICE HH SERVICES - ORT LLC

602 MICHIGAN AVE HOLLAND MI 49423

PHYSICIAN OFFICE HOLLAND HOSPITAL PHYSICIAN CLINIC

602 MICHIGAN AVE HOLLAND MI 49423

NOT ACTIVE HH SERVICES - SOUTH WASHINGTON

602 MICHIGAN AVE HOLLAND MI 49423

PHYSICIAN OFFICE HH SERVICES SOUTH WASHINGTON

602 MICHIGAN AVE HOLLAND MI 49423

PHYSICIAN OFFICE LAKESHORE HEALTH PARTNERS - FAMILY MED

602 MICHIGAN AVE HOLLAND MI 49423

PHYSICIAN OFFICE LAKESHORE HEALTH PARTNERS

602 MICHIGAN AVE HOLLAND MI 49423

PHYSICIAN OFFICE PART II: THE HEALTH OF OUR COMMUNITY IS SIMPLY A REFLECTION OF THE HEALTH OF EACH INDIVIDUAL WITHIN OUR COMMUNITY. TO ACHIEVE THE HIGHEST LEVEL OF PERSONAL HEALTH, INDIVIDUALS MUST HAVE ACCESS TO THE APPROPRIATE TOOLS, BEST HEALTH INFORMATION AND LOCAL MEDICAL EXPERTISE. OUR OUTREACH TO THE COMMUNITY PROVIDES ACCESS TO THESE VITAL COMPONENTS. FROM HEALTH SCREENINGS AND COMMUNITY PRESENTATIONS TO CHARITABLE CARE FOR THE UNINSURED/UNDERINSURED, OUR GOAL IS TO HELP EACH INDIVIDUAL REACH HIS/HER MAXIMUM PERSONAL HEALTH POTENTIAL AND, IN THE PROCESS, CREATE AN OVERALL HEALTHIER COMMUNITY. PART III, LINE 4: AN ALLOWANCE FOR UNCOLLECTIBLE ACCOUNTS IS ESTABLISHED ON AN AGGREGATE BASIS BY USING HISTORICAL WRITE-OFF RATE 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 HOSPITAL'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. TO DETERMINE BAD DEBTS AT COST, THE COST TO CHARGE RATIOS FROM THE 3/31/10 MEDICARE COST REPORT FOR IP, OP AND PSYCH WERE APPLIED TO EACH OF THE RESPECTABLE BAD DEBT TOTALS FROM WORKSHEET E FROM THE COST REPORT AND AN AVERAGE COST TO CHARGE RATIO DERIVED. THIS RATIO THEN WAS APPLIED TO THE TOTAL BAD DEBT (NOT INCLUDING CHARITY CARE) EXPENSE FROM THE TRIAL BALANCE TO COME UP WITH AN ESTIMATION OF BAD DEBTS AT COST.THE HOSPITAL MAINTAINS RECORDS TO IDENTIFY AND MONITOR THE LEVEL OF CARE IT PROVIDES. THESE RECORDS INCLUDE THE AMOUNT OF CHARGES FORGONE FOR SERVICES AND SUPPLIES FURNISHED UNDER ITS CHARITY CARE POLICY. THE HOSPITAL ALSO MAINTAINS RECORDS OF THE COST OF SERVICES PROVIDED TO MEDICARE AND MEDICAID RECIPIENTS NOT COVERED BY GOVERNMENTAL REIMBURSEMENT AS WELL AS THE COST OF OTHER PROGRAMS DESIGNED TO PROMOTE COMMUNITY HEALTH NOT COVERED BY INSURANCE. TRADITIONAL CHARITY CARE COVERS SERVICES PROVIDED TO PEOPLE WHO CANNOT AFFORD TO PAY. CHARITY CARE IS DETERMINED BASED ON ESTABLISHED POLICIES, USING PATIENT INCOME AND ASSETS TO DETERMINE PAYMENT ABILITYTHERE IS A POTENTIAL THAT SOME ACCOUNTS WRITTEN OFF AS BAD DEBTS COULD HAVE BEEN ELIGIBLE UNDER THE ORGANIZATIONS CHARITY CARE POLICY, HOWEVER DUE TO INADEQUATE APPLICATIONS FILED OR NEVER RETURNED GET WRITTEN OFF TO BAD DEBTS INSTEAD. THE ESTIMATED AMOUNT OF THE ORGANIZATION'S BAD DEBT EXPENSE (AT COST) ATTRIBUTABLE TO PATIENTS ELIGIBLE UNDER THE ORGANIZATION'S CHARITY CARE POLICY WAS APPROXIMATELY $46,000. THIS WAS DERIVED BY REVIEWING NOTES ON FILES FOR POTENTIAL CHARITY CARE CASES FOR THE LAST QUARTER OF THE YEAR AND APPLYING THAT AVERAGE TO THE TOTAL POPULATION AND THEN APPLYING THE COSTING METHODOLOGY DISCUSSED ABOVE. PART III, LINE 8: COSTING METHODOLOGY IS A COST TO CHARGE RATIO AS DEFINED BY THE IRS 990 INSTRUCTIONS. THE SHORTFALL SHOULD BE CONSIDERED A COMMUNITY BENEFIT DUE TO ITS REPRESENTATION OF COST OF A PORTION OF SERVICES PROVIDED TO THE COMMUNITY WITHOUT PAYMENT. PART III, LINE 9B: ANY BALANCE DEEMED PATIENT RESPONSIBILITY (AFTER INSURANCE PAYMENT/DETERMINATION AND AFTER ANY APPLICABLE DISCOUNT OR CHARITY) IF NOT PAID WILL RECEIVE A MINIMUM OF 2 STATEMENTS. AT DAY 60 AN EARLY OUT AGENCY WORKS THE ACCOUNT FOR HOLLAND HOSPITAL A MINIMUM OF 90 DAYS. THE ACCOUNT WILL BE HELD ON HOLLAND HOSPITAL'S "BOOKS" UNTIL IT HAS AGED TO A MINIMUM OF 180 DAYS FROM DISCHARGE. AT THIS TIME THE ACCOUNT IS ELIGIBLE AND WILL BE REVIEWED TO BE SENT TO A COLLECTION AGENCY. HOLLAND HOSPITAL IS COMMITTED TO SERVING THE HEALTH CARE NEEDS OF EVERY PERSON IN OUR COMMUNITY. WE DO SO WILLINGLY. IT IS OUR RESPONSIBILITY TO HELP INDIVIDUALS PREVENT ILLNESS, RECOVERY FROM INJURY, AND IMPROVE THEIR OVERALL HEALTH STATUS. WE TAKE THAT RESPONSIBILITY VERY SERIOUSLY. THE COMMUNITY BENEFITS WE PROVIDE THROUGH DIRECT MEDICAL CARE, OUTREACH AND EDUCATION ARE AN INVESTMENT IN OUR COMMUNITY'S WELL BEING. IT'S AN INVESTMENT TOWARD A BETTER FUTURE FOR THOSE WE SERVE. PART VI, LINE 2: IN COLLABORATION WITH THE OTTAWA COUNTY HEALTH DEPARTMENT AND THE UNITED WAY, A COMMUNITY ASSISSMENT IS PERFORMED. THE UNITED WAY PUBLISHES THEIR ASSESSMENT EVERY 5 YEARS (LAST ONE IN 2008) AND THE OTTAWA COUNTY HEALTH DEPARTMENT PUBLISHES THEIR YOUTH ASSESSMENT EVERY 2 YEARS (LAST ONE IN 2008) AND EVERY 3 YEARS FOR ADULTS (LAST ONE IN 2007) PART VI, LINE 3: OUR FINANCIAL ASSISTANCE PROGRAM IS LOCATED ON OUR WEBSITE. ALSO, OUR COLLECTORS, CUSTOMER SERVICE EMPLOYEES, OR ANY OTHER HOLLAND HOSPITAL EMPLOYEE WITH WHOM THE PATIENT MIGHT HAVE CONTACT, OUR MEDICAID ELIGIBILITY VENDOR, AND THE EARLY OUT AGENCIES INFORM PATIENTS OF THE POLICY. ALL OF THE ABOVE MENTIONED SOURCES CAN AND DO MAIL FINANCIAL ASSISTANCE APPLICATIONS TO THE PATIENTS FOR CONVENIENCE. PART VI, LINE 4: HOLLAND HOSPITAL'S PRIMARY SERVICE AREA (PSA) CONSISTS OF EIGHT ZIP CODES THAT FALL WITHIN ALLEGAN AND OTTAWA COUNTIES OF MICHIGAN. WE ALSO SERVE RESIDENTS IN OUR EXTENDED SERVICE AREA (ESA) WHICH TOGETHER WITH THE PSA COMPRISES A TOTAL POPULATION OF NEARLY 250,000. OUR PSA POPULATION COMPRISES ALL AGE GROUPS, SKEWING OLDER IN THE CITY OF HOLLAND AND YOUNGER IN THE GROWING AREAS OUTSIDE THE CITY. THE AREA ALSO ENCOMPASSES A WIDE RANGE OF RACIAL AND ETHNIC BACKGROUNDS. THE CITY OF HOLLAND DIFFERS SUBSTANTIALLY FROM THE SURROUNDING COUNTIES IN RACIAL/ETHNIC COMPOSITION. OVER 22% OF HOLLAND CITY RESIDENTS ARE HISPANIC/LATINO, CONTRASTED WITH ABOUT 6-8% IN OTTAWA AND ALLEGAN COUNTIES. HOLLAND ALSO SHOWS A GREATER PERCENTAGE OF ASIAN RESIDENTS (3.6%) THAN OTHER AREAS OF THE STATE AND PROPORTIONALLY MORE BLACK/AFRICAN AMERICANS (2.5%) LIVE IN HOLLAND THAN IN ADJACENT COUNTIES. PART VI, LINE 6: HOLLAND HOSPITAL, ALONG WITH OTHER MICHIGAN HOSPITALS, PROVIDES DIRECT PATIENT CARE TO THOSE WHO CANNOT AFFORD IT. THOUGH THE AMOUNT OF CHARITABLE CARE AND BAD DEBT HAS RISEN STEEPLY IN THE PAST FEW YEARS DUE PRIMARILY TO A STRUGGLING ECONOMY, HOLLAND HOSPITAL HAS REMAINED TRUE TO ITS MISSION TO CONTINUALLY IMPROVE THE HEALTH OF THE COMMUNITIES WE SERVE IN THE SPIRIT OF HOPE, COMPASSION, RESPECT AND DIGNITY. AROUND-THE-CLOCK MEDICAL CARE IS AVAILABLE TO ALL IN NEED. ADDITIONAL URGENT CARE SERVICES HAVE BEEN ADDED AND COMMUNITY HEALTH OUTREACH EFFORTS HAVE BEEN INCREASED. ALL OF THIS HAS BEEN DONE TO ENHANCE THE WELL BEING OF THE COMMUNITY, WITH LITTLE OR NO COST TO THOSE WE SERVE. REPORTS FILED WITH STATES PART VI, LINE 7 MI 1 COMMUNITY HEALTH CENTER 602 MICHIGAN AVENUE HOLLAND MI 49423 200602574 501(C)(3) 746804 0 N/A N/A OPERATIONAL CASH FLOW TO BREAK-EVEN LAKESHORE ADVANTAGE CORP 201 W WASHINGTON ZEELAND MI 49464 061708014 501(C)(3) 10000 0 N/A N/A FINANCIAL CONTRIBUTIONS 2011 UNIVERSITY OF MICHIGAN 3003 SOUTH STADIUM ANN ARBOR MI 48109 386006309 115 9500 0 N/A N/A FINANCIAL CONTRIBUTIONS 2011 3 0 PROCEDURE FOR MONITORING GRANTS IN THE U.S.: PART I, LINE 2: SCHEDULE I, PART I, LINE 2: THE HOSPITAL RECIEVES THEIR MONTHLY INTERNAL FINANCIALS AND A COPY OF THE AUDITED STATEMENTS ANNUALLY. X X X 0 0 0 0 0 0 0 0 0 DALE M SOWDERS 396864 0 108516 0 13577 0 72932 0 56009 0 647898 0 0 0 BARBARA DEPREE MD 160009 0 150 0 0 0 0 0 20512 0 180671 0 0 0 TERRY L STEELE 227344 0 49665 0 34297 0 22727 0 39180 0 373213 0 0 0 CHARLES D KOHLRUSS 180752 0 39486 0 27384 0 12597 0 39115 0 299334 0 0 0 PATTI VANDORT 175032 0 38236 0 38119 0 13540 0 33762 0 298689 0 0 0 MARK L PAWLAK 173867 0 37979 0 7401 0 12306 0 35040 0 266593 0 0 0 WILLIAM L VANDERVLIET MD 124124 0 0 0 0 0 6546 0 26296 0 156966 0 0 0 ROBERT J BATES MD 549973 0 0 0 0 0 0 0 41404 0 591377 0 0 0 MICHAEL A TRAVER MD 392403 0 0 0 0 0 0 0 39344 0 431747 0 0 0 BRADLEY L WILLOUGHBY MD 360900 0 0 0 0 0 0 0 39190 0 400090 0 0 0 JOHN K LUDLOW MD 404264 0 0 0 0 0 7855 0 13053 0 425172 0 0 0 DERICK JOHNSON 187639 0 0 0 0 0 2722 0 1267 0 191628 0 0 0 MICHIGAN STATE HOSPITAL FINANCE AUTHORTIY 382889417 59465E7A5 2004-08-01 21744478 CONSTRUCTION OF NEW BUILDING 0 0 0 MICHIGAN STATE HOSPITAL FINANCE AUTHORTIY 382889417 59465E7A5 2004-08-01 22000000 CONSTRUCTION OF NEW BUILDING 0 0 0 MICHIGAN STATE HOSPITAL FINANCE AUTHORITY 800596186 2010-08-11 23500000 CONSTRUCTION OF NEW BUILDING 0 0 0 22000000 1722767 250000 22000000 2008 0 0 1 1 22000000 225000 22000000 2008 0 0 1 1 23500000 9376581 14123419 2011 1 0 0 1 0 0 0 0 0.00000 0.00000 0.00000 1 0 0 0 0 0.00000 0.00000 0.00000 1 0 0 0 0 0.00000 0.00000 0.00000 1 1 0 0 0 0 0 1 1 0 0 0 0 0 0 0 0 0 0 FORM 990, PART VI, SECTION A, LINE 2 BARBARA DEPREE, A BOARD MEMBER AND EMPLOYEE, IS CHUCK DEPREE'S SISTER-IN-LAW. CHUCK DEPREE IS ALSO A BOARD MEMBER. FORM 990, PART VI, SECTION B, LINE 11 A COPY OF THE 990 IS PROVIDED TO CFO PRIOR TO CEO SIGNING. FORM 990, PART VI, SECTION B, LINE 12C THE BOARD OF DIRECTORS, ADMINISTRATION, DIRECTORS AND MANAGERS FILL OUT A CONFLICT OF INTEREST DISCLOSURE FORM ANNUALLY. THESE FORMS ARE COLLECTED BY THE COMPLIANCE OFFICE, INVESTIGATED AND THEN MAINTAINED BY HUMAN RESOURCES. THE BYLAWS SPECIFICALLY STATE THAT A BOARD MEMBER WHO HAS A CONFLICT OF INTEREST AS TO A MATTER BEFORE THE BOARD SHOULD NOT VOTE OR USE PERSONAL INFLUENCE WITH OTHER BOARD MEMBERS. THE MINUTES OF THE BOARD MEETING SHALL DISCLOSE THE MEMBER'S ABSITINENCE FROM VOTING ON THE MATTER. FORM 990, PART VI, SECTION B, LINE 15 THE ORGANIZATION USES CONSULTANTS TO REVIEW THE EXECUTIVE COMPENSATION PROGRAM ANNUALLY AND RECOMMEND UPDATES/INCREASES AS DICTATED BY THE MARKET. COMPENSATION IS SET FOR EACH POSITION WITH ESTABLISHED TARGETS USING NATIONAL AND REGIONAL DATA FOR SIMILAR HOSPITALS. THIS POLICY IS BOARD APPROVED AND HAS AN ONGOING REVIEW PROCESS WHICH IS COMPARATIVE AND DATA-DRIVEN. THE MOST RECENT YEAR THIS PROCESS WAS UNDERTAKEN WAS FISCAL YEAR 2011. FORM 990, PART VI, SECTION C, LINE 19 DOCUMENTS ARE AVAILABLE UPON REQUEST CHANGES IN NET ASSETS OR FUND BALANCES: FORM 990, PART XI, LINE 5: NET UNREALIZED GAINS ON INVESTMENTS: 14,490,505. UNREALIZED GAIN/LOSS IN JOINT VENTURE TRANSFER TO AFFILIATE FORM 990, PART XII, LINE 2C: THE PROCESS HAS NOT CHANGED FROM THE PRIOR YEAR. 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