2011-02-05T08:19:12-06:00 2010-06-30 Blue & Co LLC One American Square 2200 Indianapolis IN 46282 990 2009-07-01 350811197 Fairbanks Hospital Inc FAIR 3178498222 8102 Clearvista Parkway Indianapolis IN 46256 Helene M Cross 3178498222 2011-02-05 1 Carrie A Merrill CPA 3176334705 2009 2016-02-24 21:20:13Z Helene M Cross 8102 Clearvista Parkway Indianapolis IN 46256 19792056 0 X www.fairbankscd.org X 1946 IN Nonprofit organization focused on recovery from alcohol and other drug problems. 16 15 316 150 0 0 2559822 2014741 15411954 16331698 67990 -45083 1379661 1303760 19419427 19605116 0 0 10564634 11283624 0 133222 6112435 6396557 16677069 17680181 2742358 1924935 21040786 22221301 2275538 1808198 18765248 20413103 FAIRBANKS IS A NONPROFIT ORGANIZATION FOCUSED ON RECOVERY FROM ALCOHOL AND OTHER DRUG PROBLEMS, SERVING AS A RESOURCE TO IMPROVE THE WELL-BEING OF INDIVIDUALS, FAMILIES AND COMMUNITIES BY OFFERING HOPE AND SUPPORT THROUGH ITS PROGRAMS AND SERVICES. 0 0 7420302 9161306 Adult Inpatient Services consisting of Detoxification, Rehabilitation and Residential Services. The Detoxification phase is a medically managed level of care where the extent of the patient's addiction is determined and the physical and psychological impact of that addiction is assessed and the appropriate treatment course is initiated. For the current fiscal year, Fairbanks Hospital had 7,853 Adult Detox Patient Days.The Rehabilitation Phase occurs when further inpatient stabilization/treatment is needed and requires continued medical supervision. The treatment process is multi-disciplinary and group oriented. For the current fiscal year, the Hospital had 3,873 adult rehab patient days. The Residential Program is for the patient who requires a restrictive environment to abstain from using but who is medically stable. The patient participates in no less than four hours of therapy daily and nursing care is provided, if needed. For the current fiscal year, the Hospital had 1,000 adult residential patient days. 1806229 2238484 Adolescent Inpatient Services consisting of Detoxification, Rehabilitation, and Residential Services. The Detoxification phase is a medically managed level of care where the extent of the patient's addiction is determined and the physical and psychological impact of that addiction is assessed and the appropriate treatment course is initiated. Adolescent guidance specialists are members of the treatment team. During this phase of care, various multi-disciplinary evaluations are completed. Families and other support individuals (school, probation, caseworkers, etc) are involved. For the current fiscal year, Fairbanks Hospital had 389 Adolescent Detox Patient Days.The Adolescent Rehab Phase is for patients needing further inpatient stabilization/treatment and requires medical supervision. This treatment process is multi-disciplinary and group oriented. An important part of the program includes family members of the patient. For the current fiscal year, the Hospital had 839 adolescent rehab patient days.The Residential Phase is for adolescents in need of stabilization and treatment. Treatment is multi-disciplinary and group-oriented. Adolescents receive information on developing social skills, communication, how to gain internal control over feeling, how to deal with anger, how to deal with peer pressure, and other development needs. For the current fiscal year, the Hospital had 4,182 adolescent residential patient days. 2630183 3242195 Adult Outpatient Services Program consisting of Partial Hospitalization (PHP) and Intensive Outpatient Program (IOP). The PHP program is six to seven hours per day Monday through Friday and is a multi-disciplinary and group oriented treatment program. It will contain evaluation and education. It allows the patient to experience life on the "outside" while being involved in a very intense level of treatment. For the current fiscal year, the Hospital had 6,317 PHP visits.IOP is available to those whose addiction is not so severe as to require inpatient or PHP services. The patients must demonstrate the ability to remain drug-free during the entire treatment course and indicate a willingness to become involved in a 12-step program. IOP patients generally meet for three hours, three times per week. IOP offers education and group therapy. For the current fiscal year, the Hospital had 11,227 IOP visits. 2535984 2821097 Adolescent outpatients services program served 1,181 PHP visits and 3,054 IOP visits during the current fiscal year. Adult halfway house served 1,447 patient days and adolescent TLC/Howse program served 1,903 patients during the current fiscal year. Fairbanks Hospital provided 70 outpatient counseling sessions, provided 3,259 patient days at Laverna Lodge, and provided 23,501 patient days at supported living facilities during the current fiscal year. 2535984 2821097 14392698 1 1 0 0 0 0 0 0 1 1 0 1 0 0 0 0 0 0 1 0 1 0 0 1 0 0 0 0 0 0 0 1 0 0 0 0 0 1 1 0 0 1 35 0 316 1 0 0 0 0 0 1 1 0 0 0 16 15 0 0 0 0 1 0 0 1 1 0 0 1 1 1 1 1 1 1 0 0 IN X Barbara Elliott CFO 3175729450 8102 Clearvista Parkway Indianapolis IN 46256 Phyllis Land Usher 1.00 X X 0 0 0 Richard Collins 1.00 X X 0 0 0 Thomas Craig 1.00 X X 0 0 0 Leah Mannweiler 1.00 X X 0 0 0 Faraz Abbasi 1.00 X 0 0 0 Thomas Carroll 1.00 X 0 0 0 Luke Kenley 1.00 X 0 0 0 Peggy Magee 1.00 X 0 0 0 Marni McKinney 1.00 X 0 0 0 Dorothy May 1.00 X 0 0 0 Malcolm Pownall 1.00 X 0 0 0 Christopher Stack MD 1.00 X 0 0 0 Karl Stout 1.00 X 0 0 0 James Terry Jr 1.00 X 0 0 0 Jane Wardle 1.00 X 0 0 0 Helene Cross 40.00 X X 209278 0 18590 Barbara Elliott 40.00 X 120945 0 22152 Timothy Kelly 32.00 X 191647 0 12822 Cynthia Leigh 40.00 X 128469 0 19824 Rebecca Kelly 40.00 X 117961 0 1480 Aaron Whitman 40.00 X 109079 0 5974 Charlotte Pontius 40.00 X 102085 0 11653 979464 0 92495 7 0 1 0 Food Management Services Inc 11770 Haynes Bridge Road Alpharetta GA 30009 Food Services Mgmt 363748 Progressive Homecare Services 8930 Bash Street Indianapolis IN 46256 Pharmacy Services 261323 South Bend Medical Foundation 530 N Lafayette Blvd South Bend IN 46601 Referral Lab Service 239335 Community Health Network 1500 N Ritter Avenue Indianapolis IN 46219 IT Services 146463 4 110730 556319 1347692 2014741 Patient Service Revenu 621300 16331698 16331698 16331698 47932 47932 144600 144600 144600 144600 93015 -93015 -93015 -93015 60290 110730 93925 -33635 -33635 Other Revenue 900099 576576 450995 125581 Outside Counseling Ser 624100 509019 509019 Gift Shop Revenue 453220 80430 80430 26770 26770 1192795 19605116 17463082 0 127293 650340 320116 330224 8164182 6790814 1287174 86194 224818 182103 40467 2248 1608236 1296017 296268 15951 636048 515199 114489 6360 90588 90588 53662 53662 1612923 1109364 494986 8573 322483 312794 9689 128594 77524 50132 938 793232 728651 64581 54468 52959 1509 76452 41940 32372 2140 8342 8342 687461 632464 54997 233796 175377 57390 1029 Bad Debt 1306176 1306176 Supplies 590453 580206 9995 252 Equipment Maintenance a 161559 146938 14621 Printing and Publicatio 83415 33313 47284 2818 Postage and Shipping 41769 22832 16509 2428 151184 59569 87324 4291 17680181 14392698 3154261 133222 970055 631252 5551479 5636887 341052 248104 2951497 3317315 338938 270019 18615584 6844975 10630284 11770609 257481 347115 21040786 22221301 1768824 1548529 143978 132443 362736 127226 2275538 1808198 X 18285643 20131123 479605 281980 18765248 20413103 21040786 22221301 X 0 1 1 X 1 1 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 424006 1288061 67990 800357 979700 979700 732482 47932 867219 892895 0.31500 0.68500 0 0 588805 588805 12525210 3791398 8733812 4840836 3053577 1787259 660733 660733 11770609 Estimated third party settlements 127226 127226 19605116 17680181 1924935 -277080 -277080 1647855 19699041 93925 93925 19605116 0 19605116 17774106 93925 93925 17680181 0 17680181 Part V, Line 4: Description of Intended Use of Endowment Funds: Temporarily restricted net assets are those assets whose use has been limited by donors for a specific operating or capital purpose. Board designated funds are set aside by the Board for specific purposes including charity care. Part XI, Line 8 - Other Adjustments: Net Asset Transfers: -277080. Part XII, Line 2d - Other Adjustments: Fundraising Event Expenses: 93925. Part XIII, Line 2d - Other Adjustments: Fundraising Event Expenses: 93925. Circle of Hope Dinner 119820 66250 53570 33623 20837 30558 Alumni Golf Outing 51200 44480 6720 1447 5291 102 2067 171020 110730 60290 1447 5291 33725 20837 32625 93925 -33635 1 1 0 1 X 0 1 1 0 1 0 938104 938104 0.05730 33618 11410 22208 0.00140 971722 11410 960312 0.05870 717888 9494 708394 0.04330 717888 9494 708394 0.04330 1689610 20904 1668706 0.10200 1 677452 0 1765059 1567488 197571 X 1 1 Fairbanks Hopsital

8102 Clearvista Parkway Indianapolis IN 46256

X Laverna Lodge

8102 Clearvista Parkway Indianapolis IN 46256

Drug & Alcohol Residential Rehab Supported Living Program

8102 Clearvista Parkway INdianapolis IN 46256

Adult Halfway House and Drug & Alcohol Supported Living Part III, Line 4: No footnote was noted on the audited financial statements describing bad debt expense. Bad debts at cost are calculated by using the ratio of cost to charges. Part III, Line 8: Medicare allowable costs are calculated by using the ratio of cost to charges. Part III, Line 9b: When an account is identified as uncollectible, it becomes bad debt. If the financial position of the identified individual's account has been discovered as being in a financial position of 250% Federal Poverty Level, the account will be reclassed as charity care. Community Benefit Report: Fairbanks does not file a community benefit report for the public at this time but does maintain an internal report that could be reviewed upon request. Facility Information: Addresses for Laverna Lodge and Supported Living Program have been omitted to protect the privacy of the patients receiving care at those locations. Part VI, Line 2: Fairbanks participates in the development of the community assessment process, which is headed up by United Way of Central Indiana. The organization uses information/demographics related to the substance abuse field to help guide the growth and development. Helene Cross, CEO, is on the Community Planning Committee and Fairbanks also participates in the Focus Groups. Part VI, Line 3: Those individuals who are seeking admission to Fairbanks have the opportunity to meet with a financial counselor to determine what resources are available. In addition, an informational booklet is given to families during the admission process which notes that charity care is available. Part VI, Line 4: For the fiscal year ended June 30, 2010, 15,665 persons were served; 58% from United Way of Central Indiana Counties; 24% surrounding counties; 17% remaining Indiana counties and 1% out of state. Part VI, Line 5: None noted. Part VI, Line 6: Fairbanks uses the local media to assist in educating the public concerning prevention, intervention and treatment. The organization also participates in National Alcohol Awareness month, Recovery month community activities and provides community education through the Susan Li conference. Part VI, Line 7: N/A X X X X X 0 0 0 0 0 1 0 0 0 Helene Cross 169278 0 40000 0 0 0 11523 0 7067 0 227868 0 0 0 Timothy Kelly 182697 0 8950 0 0 0 0 0 12822 0 204469 0 0 0 Part I, Line 6 Management and Staff Incentive Program for FY 10 Staff Incentive: Staff Incentive payout was calculated based on an operating margin percentage range between 5-10%. These monies were then allocated on a per share basis based on the number of hours worked. The incentive payout occurred in August, 2010. Management Incentive: For Fiscal Year ended June 30, 2010, management incentive was a flat amount by position and dependent on meeting an operating margin percentage. In addition, the incentive payment was contingent on obtaining specific organizational goals. Richard Collins Board Member 1405470 Mr. Collins is Senior Vice President of Pricing, Underwriting and Health Care Economics for UnitedHealthcare. Fairbanks purchases employee benefits from UnitedHealthcare Insurance Company. Mr. Collins has direct control and responsibility for setting prices on policies nationwide. However, Mr. Collins will not take part in rate setting activity for Fairbanks. The transaction amount equals the amount Fairbanks paid UnitedHealthcare for employee healthcare premiums during the current fiscal year. 0 Leah Mannweiler board Member 60510 Ms. Mannweiler is a partner with the firm of Krieg Devault, LLP. The firm provides legal services to Fairbanks. 0 Thomas Craig Board Member 236040 Mr. Craig is a Vice President at Old National Bank with which Fairbanks has a financial relationship. However, Mr. Craig is not directly involved with managing that relationship. The transaction amount equals the amount Fairbanks holds in investments at this bank. 0 Form 990, Part VI, Section A, line 6 Fairbanks Hospital, Inc. is incorporated as a nonprofit, public benefit corporation under the laws of the State of Indiana. The Corporation does not have members. Form 990, Part VI, Section B, line 11 The Form 990 was reviewed and approved by the Executive Committee of the Board of Directors on 1/26/2011. Form 990, Part VI, Section B, line 12c The Board members must complete a conflict of interest form annually. Board members who have a potential for conflict must recuse themselves from voting on subjects that might pose a conflict. The Corporate Compliance Officer reviews any potential conflicts that are reported. Form 990, Part VI, Section B, line 15a All current members of the Board of Directors are given a written evaluation form to rate the CEO. All information is then compiled in a final report and presented by the Board chair to the CEO. For compensation, we compile data provided by our independent auditors from the Indiana Hospital Association, other Mental Health Providers, and NAATP (National Association of Addiction Treatment Providers) to ensure the salary is competitive and reasonable. Members of the Executive Compensation Committee of the Board of Directors meet to discuss and review the data and make a final decision regarding compensation that is then reviewed and approved by the Executive Committee of the Board of Directors. Form 990, Part VI, Section C, line 19 Summary financial information is available on the organization's website, reported in the Annual Reports. Detailed financial information, governing documents, and conflict of interest policy is available to the public upon request. Form 990, Part XI, Line 2c Audit Oversight The organization utilizes an audit committee to oversee the audit procedures and selection of the independent accounting firm. Schedule H, Part V Facility Information Addresses for Laverna Lodge and Supported Living Program have been omitted to protect the privacy of the patients receiving care at those locations. The Recovery High School at Fairbanks Inc dba Hope Academy 8102 Clearvista Parkway Indianapolis IN 46256 203094377 Charter School IN 501(c)(3) Line 2 Fairbanks Hospital Inc 0 1 0 1 0 0 0 0 1 0 1 0 1 1 0 1 0 0 The Recovery High School at Fairbanks Inc dba Hope Academy B 266755 The Recovery High School at Fairbanks Inc dba Hope Academy D 132100 The Recovery High School at Fairbanks Inc dba Hope Academy I 144600