2011-10-03T11:52:27-07:00 2010-12-31 990 2010-01-01 340714581 ALLIANCE COMMUNITY HOSPITAL ALLI 3305966000 200 East State Street Alliance OH 446014341 Dale Wells 3305967066 2011-10-03 2010 2016-03-07 17:11:31Z Dale Wells 200 E State Street Alliance OH 44601 100796092 0 X www.achosp.org X 1901 OH Alliance Community Hospital is an acute care hospital providing care to all, regardless of ability to pay. The most significant activities include inpatient and outpatient care, surgical procedures, radiology, skilled nursing facility, lab and emergency treatment. 14 12 1234 450 26364 0 56236 199715 95805165 99744128 -29805 11102 5622952 832711 101454548 100787656 0 0 0 0 51118612 53119832 0 0 0 43452439 49051319 94571051 102171151 6883497 -1383495 110648857 108955337 65215843 64784574 45433014 44170763 Alliance Community Hospital's (ACH) mission is to provide our patients and guests with a safe, comforting, and healing environment. This mission is accomplished through our Planetree philosophy of caring, and provides for all patients to receive the appropriate care - physical, spiritual and social - regardless of their ability to pay. 0 0 18775891 0 8740135 Inpatient Health Care Programs: In 2010, ACH provided medical services to patients from Alliance and surrounding communities who have health conditions such as Congestive Heart Failure (CHF), Chronic Obstructive Pulmonary Disorder (COPD) and others. ACH admitted 4,618 patients (which includes 401 births) who received a total of 22,591 days of care from our staff. A total of $18.8 million of our resources was spent to provide inpatient care. 10775344 0 14969921 Surgical Procedures: ACH provides surgical services to patients with a 24-hour availability to all. In 2010, ACH provided surgical procedures to 23,377 patients expending $10.8 million to provide these services. 8247418 0 14457754 Radiology Services: ACH's radiology services included Imaging, Womens Wellness, Ultrasound, MRI, Nuclear Medicine, and CT Scans. ACH provides a full service Radiology Department for Alliance and the surrounding communities that is used not only for the routine daily images, but also to service our Emergency Room 24 hours a day, 7 days per week. ACH is also providing women's wellness services to promote women's health in our service area. In 2010, ACH provided 69,704 tests costing $8.2 million 49992536 0 61572704 All other program services 49992536 0 61572704 87791189 1 1 0 0 0 0 0 0 0 0 1 0 0 0 0 0 0 1 0 0 0 0 0 0 0 0 1 1 0 0 1 1 0 1 0 0 0 1 0 0 0 0 0 0 0 0 1 1 1 1 0 0 1 149 0 1234 1 1 1 0 0 0 0 1 1 0 0 0 0 X 14 12 0 0 0 0 0 0 0 1 1 0 1 1 1 1 1 1 1 1 1 1 0 X Dale Wells 3305967066 200 E State Street Alliance OH 446014341 Don McAlister 1 X X 0 0 0 David Lundgren 1 X X 0 0 0 Woody McCallum 1 X X 0 0 0 Ron Lyons 1 X X 0 0 0 Stan Jonas 40 X X 379677 0 27002 Dan Davia 1 X 0 0 0 Teresa GoldenMcClelland 1 X 0 0 0 John Gross 1 X 0 0 0 Mike Hoover 1 X 0 0 0 Scott Ingledue 1 X 0 0 0 Dr Duane Kuentz 1 X 0 0 0 Dr Debra Lehrer 1 X 0 0 0 Gary Wagner 1 X 0 0 0 Dr David Mungo 40 X X 848737 0 14143 Dale Wells 40 X 163215 0 18989 Dr Steven Deutch 40 X 473710 0 15443 Dr Daniel Mitchell 40 X 216539 73544 16465 Dr David Kanagy 40 X 455961 0 16643 Dr John Park 40 X 435989 0 14143 2973828 73544 122828 18 0 1 0 Anesthesia Associates of Alliance LLC PO Box 182255 Columbus OH 432182255 Anesthesiologists 993627 Salem Surgical Services LLC 2241 Porter Rd Atwater OH 44201 Lithotripsy and Medical Director Services 686850 Healthcare Services Management DBA HSM Consulting 1 Batterymarch Park Suite 403 Quincy MA 02169 Consulting Services 468644 ARUP Laboratories Inc 500 Chipeta Way PO Box 27964 Salt Lake City UT 84127 Lab Services 452644 BKD LLP PO Box 5367 Cincinnati OH 45201 Home Health Billing 326927 12 0 0 0 197510 0 2205 0 199715 Patient Revenue 622000 98413759 98413759 0 0 Cafeteria 722100 635165 0 0 635165 Other Hospital Services 900099 579498 0 0 579498 Program Related Investment Income 900099 75247 75247 0 0 Patient Education 900099 40459 40459 0 0 0 0 0 0 99744128 3870 0 0 3870 0 0 0 0 0 0 0 0 446249 0 0 0 446249 0 446249 0 0 446249 0 15668 0 8436 0 7232 7232 0 0 7232 0 Deferred Revenue Earned 900099 360000 360000 0 0 Catering 722320 26364 0 26364 0 Other 900099 98 98 0 0 0 0 0 0 386462 100787656 98889563 26364 1672014 0 0 0 0 0 0 0 0 598116 0 598116 0 0 0 0 0 42368725 36322515 6046210 0 1391221 1192687 198534 0 5757293 4935701 821592 0 3004477 2558197 446280 0 339613 176440 163173 0 363649 125 363524 0 93520 0 93520 0 0 0 0 0 0 0 0 0 0 0 1078685 676182 402503 0 427534 408319 19215 0 20931559 19795173 1136386 0 948473 814067 134406 0 0 0 0 0 2032042 1801189 230853 0 356618 308956 47662 0 0 0 0 0 0 0 0 0 2195522 1858509 337013 0 0 0 0 0 4343724 3676962 666762 0 1308746 1168519 140227 0 Purchased Services 6970058 4816341 2153717 0 Provision for Uncollectible Accounts 5501896 5501896 0 0 Change in Fair Value of Interest Rate 1038799 879343 159456 0 Loss on Extinguishment of Debt 801928 678832 123096 0 Minor Equipment 192162 158775 33387 0 126791 62461 64330 0 102171151 87791189 14379962 0 6871631 3489932 10743830 12448103 58333 2862374 2452005 783570 853360 595725 882767 113086054 29662332 81925090 83423722 134100 134100 6732537 5213015 110648857 108955337 10277818 10541822 3240000 2880000 51698025 51362752 65215843 64784574 X 45220607 43930522 212407 240241 0 0 45433014 44170763 110648857 108955337 X -1383495 121244 X 0 1 1 X 0 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 0 15562377 15562377 0 63191007 8337362 54853645 0 0 0 0 0 27769504 19040631 8728873 0 6563166 2284339 4278827 83423722 100787656 102171151 -1383495 0 0 0 0 0 0 -1383495 99306696 0 0 0 366999 366999 98939697 0 1847959 1847959 100787656 100690191 0 0 0 366999 366999 100323192 0 1847959 1847959 102171151 SchD_P12_S00_L02d Schedule D, Part XII, Line 2d Net Assets Released from Restriction $366,999. SchD_P12_S00_L04b Schedule D, Part XII, Line 4b Fixed Asset Gain $7,232 Interest Swap Rate $1,038,799 and Loss on Extinguishment of Debt $801,928 SchD_P13_S00_L02d Schedule D, Part XIII, Line 2d Net Assets Released from Restriction $366,999 SchD_P13_S00_L04b Schedule D, Part XIII, Line 4b Fixed Asset Gain $7,232 Interest Swap Rate $1,038,799 and Loss on Extinguishment of Debt $801,928 1 1 X 1 X 1 X 1 1 0 1 1 2640104 553439 2086655 0.0216 12399193 9312983 3086210 0.0319 7 5 2 0.00 0 0 15039304 9866427 5172867 0.0535 203286 0 203286 0.0021 477154 298279 178875 0.0019 42059578 28976300 13083278 0.1353 0 0 0 0 101977 67984 33993 0.0004 0 0 42841995 29342563 13499432 0.1397 0 0 57881299 39208990 18672299 0.1932 13834 0 13834 0.0001 0 0 13834 0 13834 0.0001 1 2725909 1166973 12422893 12606624 -183731 X 1 1 1 1 Alliance Community Hospital

200 E State Street Alliance OH 44601

X X X Visiting Nurse Association, Hospice, Skilled Nursing Facility Alliance Community Hospital 1 0 1 1 100 1 300 1 X X X X X 1 1 X X X X X 1 X X X 1 X X X X X X X 1 X 0 0 3 Alliance Community Medical Foundation

200 E State Street Alliance OH 44601

Physician Practices SchH_P01_S00_L06a Schedule H, Part I, Line 6a Alliance Community Hospital's (ACH) community benefit report is contained in a report prepared by Alliance Community Hospital Foundation, a related organization. SchH_P01_S00_L07 Schedule H, Part I, Line 7 ACH's cost accounting system was used to calculate the amounts reported in the table for line 7. The cost accounting system addresses all patient segments specific to ACH. Where applicable, a cost to charge ratio was used and the ratio was derived from Worksheet 2, Ratio of Patient Care Cost-to-Charges. SchH_P01_S00_L072f Schedule H, Part I, Line 7, Column f Bad debt expense included on form 990 Part IX line 25 column (A) is $5,501,896 and is subtracted from total expense for purposes of calculating the percentage in this column. SchH_P01_S00_L07g Schedule H, Part I, Line 7g Subsidized health services data on line 7g does not include any costs attributable to a physician clinic; thus there are no cost to report in Part VI. SchH_P02_S00_L00 Schedule H, Part II ACH's Hospitalilty Program is a 16 week program offered annually during the spring school semester. It is geared to teach handicapped high school students job, life, and personal skills. Students are mentored by an ACH colleague. SchH_P03_S0A_L04 Schedule H, Part III, Section A, Line 4 Line 2, Bad debt expense at cost was calculated by multiplying bad debt expense per the audited financial statements times the cost to charge ratio derived from Worksheet 2. Line 3, estimated bad debt expense attributable to patients eligible under ACH's charity care policy, was calculated based on the estimated percentage determined by reviewing patient demographics, historical collections rates, current economic conditions, and employee experience in our patient accounts and credit department. SchH_P03_S0B_L08 Schedule H, Part III, Section B, Line 8 Part III lines 5 & 6 were derived based on Worksheet B, thus presenting the Medicare shortfall (based on Medicare Cost Report data) excluding subsidized programs included on Part I line 7g. The shortfall showing on Part III line 7 should be considered community benefit since ACH provided benefit greater than the reimbursement for services. SchH_P03_S0C_L09b Schedule H, Part III, Section C, Line 9b ACH's collection practices for patients identified as qualifying for charity care would be based on the account balance net of the charity write-off. As long as the patient makes a minimal monthly payment, the account is considered current. If payment is not received monthly, a call from our credit department will be made along with receiving a monthly statement. If payment is then received, the account returns to "current". If there are six consecutive months without payment, then the account is turned over to our collection agency to attempt to collect the balance due. SchH_P06_S00_L02 Schedule H, Part VI, Line 2 ACH has played an active role in a county-wide health needs assessment group who is addressing the health care needs of the community from a local perspective. Members of the group include other health care and health-related nonprofit organizations. The top three community health needs are identified based on a recent study as 1)access to health, 2)behavior health, and 3)childhood obesity. The group is in the process of deciding who will collect and analyze the data, and creating an action plan based on the results. The goal is to begin implementation of the action plan by the beginning of 2012. SchH_P06_S00_L03 Schedule H, Part VI, Line 3 During the registration process, the patient's initial financial responsibility is determined based on insurance coverage, deductibles, etc. supplied by the patient. If it is determined that the patient will be partially or fully responsible for their medical charges, then the patient will receive personal credit counseling. ACH follows EMTALA standards for emergency room visits. A Patient Billing brochure is available in the admissions and emergency room areas to all patients. The brochure provides information on financial assistance along with phone numbers so that an individual can speak to a member of the patient billing team and/or set up a personal appointment for financial assistance. In addition, monthly billing statements include a financial assistance application on the back plus phone numbers for assistance. We refer patients who we believe are eligible for Medicaid to RevCare which is an agency specializing in Medicaid eligibility and application so the patient receives the financial expertise needed for financial assistance. SchH_P06_S00_L04 Schedule H, Part VI, Line 4 Alliance Community Hospital is located in Alliance, Ohio and serves Stark, Mahoning, Carroll and other surrounding counties. The geographic service area is made up of urban, suburban, and rural areas. In 2010, our patient charges consisted of the following financial classes: 19% from individuals on Means-tested government programs or uninsured; 28% from commercial insurance, health maintenance and preferred provider organizations; and 53% from Medicare programs. Persons below the poverty level was 15.5% per the latest census data available at www.census.gov. For the three-county area, the average household size was 2.43 and the average household income was $39,065. Persons under the age of 18 accounted for 22.4% of the population, and 16.5% of the population was 65 years and older. SchH_P06_S00_L05 Schedule H, Part VI, Line 5 ACH in conjunction with its Foundation promote the health of the community by giving back both time and dollars to charitable organizations such as the local YMCA, Alliance Neighborhood Center, the Stark County Interagency Council on Homelessness, the Alliance Area Develpment Foundation and others. Carnation Days in the Park allowed volunteers to offer free blood pressure screenings, and health information/handouts. The hospital's Health Caring Resources Library offers free blood pressure screenings to the community each week as well as a reference library for medical questions. A mock disaster drill gave our community emergency and police departments a chance to test and enhance its response efforts. Several community health fairs were offered by renting booth space at the local mall where shoppers could pick up information about services and free seminars offered by ACH. Our Foundation staff served on the Stark County Minority Health coalition committee and contributed time for compiling information and printing programs for the 2010 Minority Health kick-off dinner. Our volunteer department coordinates ACH's participation in a local high school health sciences technology program, a Hospitality program which offers mentoring to local handicapped high school students, Federal Work study programs with the local university, and volunteer training to local high school students. X X X X X X 0 0 0 0 0 0 0 0 0 Stan Jonas 363177 0 0 0 16500 0 16351 0 17557 0 413585 0 0 0 Dale Wells 163215 0 0 0 0 0 8393 0 12925 0 184533 0 0 0 Dr David Mungo 783509 0 48728 0 16500 0 8000 0 7562 0 864299 0 0 0 Dr Steven Deutch 473710 0 0 0 0 0 8000 0 11579 0 493289 0 0 0 Dr David Kanagy 412204 0 27257 0 16500 0 8000 0 14371 0 478332 0 0 0 Dr John Park 435989 0 0 0 0 0 8000 0 6143 0 450132 0 0 0 Dr Daniel Mitchell 216539 73544 0 0 0 0 8000 0 14525 0 239064 73544 0 0 City of Alliance Ohio 346000043 018744AA0 2008-01-25 51150000 Refund the 2003 bond issue 0 0 0 City of Alliance Ohio 346000043 2010-12-28 16350000 Refund a portion of the refunded 2003 bond issue 0 0 0 17120000 0 51150000 2259788 0 0 0 0 0 44016542 0 0 2005 1 0 1 1 0 0 16350000 0 0 0 200000 0 0 0 16150000 0 2005 1 0 1 1 0 0 0 0 0 0.001 0.001 1 0 0 0 0 0 0 0 1 0 1 1 JP Morgan Chase 24.8 0 0 0 0 0 0 0 0 0 0 0 Dr David Kanagy Sign On Bonus X 25000 25000 0 1 1 Dr Steven Deutch Sign On Bonus X 50000 33333 0 1 1 58333 F990_P06_S0B_L11a Form 990, Part VI, Section B, Line 11a The Form 990 is reviewed by the CFO of Alliance Community Hospital and the Hospital also hires an independent accounting firm to review the Form 990 and schedules. Prior to filing, the 990 is also distributed to the Board of Trustees for their review and comments. It is then discussed as part of the financial report at the next board meeting where any questions/concerns can be addressed F990_P06_S0B_L12c Form 990, Part VI, Section B, Line 12c Members of the Board of Trustees are required to annually review and sign a conflict of interest policy. Under that policy, the Board member (i) has a duty to disclose any conflict, and (ii) must recuse themselves from a vote and or decision when such conflict arises. If this policy is violated, then the Board shall take appropriate action which may include an investigation and disciplinary action. F990_P06_S0B_L15 Form 990, Part VI, Section B, Line 15 Compensation of officers is determined by an independent (non-compensated) committee from the Board of Trustees. This committee annually reviews compensation by obtaining market surveys of the positions. F990_P06_S0C_L17 Form 990, Part VI, Section C, Line 17 Ohio does not require the Form 990 to be filed with the Ohio Attorney General's Office. Instead, a "Verification of Filing with the Internal Revenue Service" form is completed stating that we did file Form 990 by the required due date. F990_P06_S0C_L19 Form 990, Part VI, Section C, Line 19 The organization makes its governing documents available to the public via the Ohio Secretary of State's website. Financial statements are available in the NRMSIR filing database at www.emma.msrb.org. The conflict of interest policy is available upon request. F990_P11_S00_L05 Form 990, Part XI, Line 5 Restricted contributions received of $394,833 less net assets released from restriction of $366,999 plus net transfers from affiliates of $100,000 less change in fair value of interest rate swap agreement of $6,590 equals a $121,244 increase in Net Assets at 12/31/2010. Alliance Community Medical Foundation 200 E State Street Alliance OH 44601 263646817 Physician offices OH 3855224 1154270 N/A Alliance Citizens' Health Association 200 E State Street Alliance OH 44601 341531815 Manage Healthcare Facilities OH 501(c)(3) Sch A, Line 11b, II N/A 0 Alliance Community Hospital Foundation 200 E State Street Alliance OH 44601 341531817 Fundraising OH 501(c)(3) Sch A, Line 11a, I N/A 0 Alliance Community Hospital Auxiliary 200 E State Street Alliance OH 44601 340777659 Volunteer services OH 501(c)(3) Sch A, Ln 11c,III-FI N/A 0 Caring Hands Inc 885 Sawburg Rd Alliance OH 44601 341505340 Private Duty Nursing OH 501(c)(3) Sch A, Ln 11c,III-FI N/A 0 Alliance Health Institute 200 E State Street Alliance OH 44601 341932972 Support ACH and its charitable purpose OH 501(c)(3) Sch A, Line 11a,I N/A 0 Alliance Health Partners 200 E State Street Alliance OH 44601 341884059 Phys. Hospital Org OH N/A C Alliance Hospitalist Group 200 E State Street Alliance OH 44601 203188585 Physician Offices OH N/A C Alliance Community Radiologists Inc 200 E State Street Alliance OH 44601 205698786 Physician Offices OH N/A C Alliance Medical Associates Inc 200 E State Street Alliance OH 44601 911889215 Physician Offices OH N/A C Alliance Pulmonary Associates Inc 200 E State Street Alliance OH 44601 204083441 Physician Offices OH N/A C Health Alliance Inc 200 E State Street Alliance OH 44601 341531993 Urgent Care OH N/A C NEO Surgical Associates Inc 200 E State Street Alliance OH 44601 200760723 Physician Offices OH N/A C Alliance Obstetrics Physicians Inc 200 E State Street Alliance OH 44601 203095412 Physician Offices OH N/A C 1 0 1 1 0 0 0 0 1 0 0 1 1 1 1 0 0 1 Alliance Community Radiologists Inc a-i 27046 Interest is calculated monthly and equals prime interest rate at the beginning of the year plus 1 percent times the loan balance. Alliance Hospitalist Group a-i 1771 Interest is calculated monthly and equals prime interest rate at the beginning of the year plus 1 percent times the loan balance. Alliance Pulmonary Associates Inc a-i 22739 Interest is calculated monthly and equals prime interest rate at the beginning of the year plus 1 percent times the loan balance. NEO Surgical Associates Inc a-i 9551 Interest is calculated monthly and equals prime interest rate at the beginning of the year plus 1 percent times the loan balance. Alliance Pulmonary Associates Inc a-iv 18263 Fair value based on area rentals of similar square footage and type of facility. Alliance Community Radiologists Inc d 361000 Current year loan advances Alliance Pulmonary Associates Inc d 369000 Current year loan advances NEO Surgical Associates Inc d 167000 Current year loan advances Alliance Hospitalist Group o 746000 Current year subsidy to cover entitiy's expenses. Alliance Medical Associates Inc o 149500 Current year subsidy to cover entitiy's expenses.