2011-02-14T17:28:43-06:00 2010-06-30 Arnett & Foster PLLC P O Box 2629 Charleston WV 25329 990 2009-07-01 314446959 Sheltering Arms Hospital Foundation SHEL 7405935551 55 Hospital Drive Athens OH 45701 Kimberly Dettwiller 7405935551 2011-02-14 1 Harry C Harless 3043460441 2009 2016-02-24 21:20:13Z O'Bleness Memorial Hospital Larry Thornhill 55 Hospital Drive Athens OH 45701 78445372 0 X www.obleness.org X 1948 OH To operate an acute care hospital facility in Athens, Ohio. 14 12 575 227 450094 -1340070 310757 385025 63595420 73449385 385398 647625 7772932 1811881 72064507 76293916 175956 0 0 34103117 29823353 30000 0 0 37584962 41219934 71894035 71043287 170472 5250629 65489605 69420064 44033557 42951005 21456048 26469059 To operate an acute care hospital facility in Athens, Ohio for the citizens of Athens, Ohio and the surrounding communities and counties. 1 0 63622228 74288083 Patient care provided included 9,601 inpatient days of care to 2,844 acute patients; 26,548 emergency room visits; 112,106 other outpatient visits; 1,504 inpatient and outpatient surgeries; and 603 births. Procedures and tests performed included 822,406 lab tests; 31,230 x-rays; 2,562 ultrasounds; 1,826 nuclear medicine scans; 8,108 CT scans; 179 cardiovascular catheterizations; 17,620 physical therapy modalities; 39,619 cardiopulmonary procedures; 2,072 MRI's and 10,175 EKG's. The hospital also sponsored or participated in various health fairs or health screenings throughout the community and surrounding areas. Charges foregone for charity amounted to $6,805,291. 306010 453925 The O'Bleness Wound Care Center was opened in March 2010 in response to a growing need for local treatment of difficult wounds, in part due to the very high incidence of diabetes in the area. In certain cases, the center includes hyperbaric oxygen therapy as part of the treatment provided. The center is the only location in Southeastern Ohio offering this specific type of therapy. It therefore serves as a local convenience for those patients requiring daily treatments that would otherwise be forced to commute long distances on a frequent basis. The center served 175 patients during March 2010 - June 2010. 63928238 1 1 0 1 0 0 0 0 1 1 0 1 0 0 0 0 0 0 0 0 1 0 0 1 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 1 0 0 0 1 171 0 1 575 1 1 1 0 0 0 0 0 0 0 0 14 12 0 1 0 0 0 0 0 1 1 0 0 1 1 1 1 1 1 1 0 1 1 OH X X Kimberly Dettwiller 7405929298 55 Hospital Drive Athens OH 45701 Clifford Young 40.00 X X 145297 0 19226 James Riestenberg 2.00 X 0 0 0 Bick Weissenrieder 2.00 X 0 0 0 Robert Norris 2.00 X 0 0 0 Susan Quinn 2.00 X 0 0 0 Greg Blower 2.00 X 0 0 0 Shelley Conrath 2.00 X 0 0 0 Larry Corrigan 2.00 X 0 0 0 Ray Karr 2.00 X 0 0 0 Valarie Kinnard 2.00 X 0 0 0 Gerald Rubin 2.00 X 0 0 0 Steven Sloan 2.00 X 0 0 0 Michael Sostarich 2.00 X 0 0 0 Michael Clark 2.00 X 250179 0 7350 Kimberly Dettwiller 40.00 X 96361 0 29338 Amy Beech 40.00 X 109325 0 10181 Sandra Leasure 40.00 X 124238 0 18490 Herbert Carson 40.00 X 116965 0 10170 Richard Castrop 0.00 X 257959 0 26786 1100324 0 121541 6 1 1 0 Radiology Associates PO Box 2608 Athens OH 45701 Radiology 1088198 American Healthcare Solutions 1701 Kenneth Ave Arnold PA 15068 Interim CEO/Management 678328 Malone Medical Anesthesiology 227 1/2 West Union St Athens OH 45701 Anesthesiology 658140 Ohio University HDL Center 280 Athens OH 45701 Directorships 606749 Emergency Professionals PO Box 634850 Cincinnati OH 452634850 Hospitalists 568193 32 385025 385025 Patient services 622110 73381778 73381778 Rent-Appalachian Commu 631110 67607 67607 73449385 191840 191840 1259293 1173824 85469 85469 85469 1433417 977632 455785 455785 16305 439480 Pharmacy 561000 342101 342101 From K-1: Athens Medi 621500 256132 256132 Cafeteria 722210 243310 243310 884869 707212 177657 1726412 76293916 74742008 450094 716789 602116 539496 62620 21038005 18850052 2187953 1154988 1034869 120119 5086792 4557766 529026 1941452 1739541 201911 403699 361714 41985 387907 387907 223474 223474 8246 8246 9328195 8358063 970132 184953 165718 19235 11074832 9923049 1151783 155713 139519 16194 1235267 1106799 128468 112415 100724 11691 31364 28102 3262 2262300 2027021 235279 3869505 3467076 402429 1925408 1725166 200242 Bad debts 6698317 6698317 Repairs & Maintenance 1356472 1215399 141073 HCAP & State hospital t 1298718 1298718 Property taxes 163378 146387 16991 Dues & subscriptions 116441 104331 12110 383330 340411 42919 71043287 63928238 7115049 0 244560 780975 2343585 17756071 191911 176636 11508669 9951468 776835 818262 867208 1023605 78994571 46259998 35284367 32734573 2620271 3403323 9082658 691205 2569541 2083946 65489605 69420064 7800320 7248688 29345000 28905000 1422596 1893163 5465641 4904154 44033557 42951005 X 20654269 25682555 191911 176636 609868 609868 21456048 26469059 65489605 69420064 X 0 1 1 X 0 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 0 0 0 0 0 0 0 0 1 1136 1136 0 Part II-B, Line 1i: Explanation of Other Lobbying Activities: Lobbying expenses relate to the portion of dues paid to the Ohio Hospital Association which is used for lobbying. 801779 -15275 786504 663242 138537 801779 0.22460 0.77540 0 0 2389777 2389777 27951497 14947779 13003718 40622385 29178948 11443437 8030912 2133271 5897641 32734573 Leased property deposits 4335332 Investment-Athens Surgery Center Ltd.: 58% owned 404651 Capital lease 164171 4904154 76293916 71043287 5250629 185409 -423027 -237618 5013011 76924585 1252927 1252927 75671658 622258 622258 76293916 72061448 1173832 1173832 70887616 155671 155671 71043287 Part XI, Line 8 - Other Adjustments: K-1 income/loss from investments: -422369. Changes in pledges receivable: -15275. Equity method income (loss) of subsidiaries: -20268. Income per books - Access Health Athens: 34885. Part XII, Line 2d - Other Adjustments: Rental Expenses: 1173824. From K-1: The Drugstore at O'Bleness LLC-Loss: 44218. From K-1: Access Health Athens LLC: 34885. Part XII, Line 4b - Other Adjustments: From K-1: Access Health Athens LLC: 16573. Federal Income Tax Refunds: 155671. From K-1: Access Surgery Center, LTD: 193882. From K-1: Athens Medical Laboratory Assoc.: 256132. Part XIII, Line 2d - Other Adjustments: Rental Expenses: 1173824. Rounding: 8. Part XIII, Line 4b - Other Adjustments: Income Tax refunds netted against expenses on Form 990: 155671. 1 1 X 1 X 0 1 1 1 0 0 3660930 1995741 1665189 0.02560 10795459 6228401 4567058 0.07020 14456389 8224142 6232247 0.09580 9888 55 9833 0.00020 675219 675219 685107 675274 9833 0.00020 15141496 8899416 6242080 0.09600 1 2748184 14468572 13869670 598902 X 1 1 O'Bleness Memorial Hospital

55 Hospital Dr Athens OH 45701

X X X X Part I, Line 3c: The hospital has more than one policy concerning free or discounted care.O'Bleness Memorial Hospital will offer and provide free care to any patient who meets the eligibility requirement for free care under the OCAP or HCAP financial assistance policies.The following steps will be used to determine eligibility for free care under OCAP (O'Bleness Care Assurance Program):1. A recipient of the Ohio Medicaid Program is not eligible. (OAC Rule 5 10 1 :3-2-07.17)2. If the patient is covered under a third-party insurer or a governmental program, the third party will be billed and any payment received will be applied to the account first. Any balance on the account will be considered for the OCAP write-off.3. OCAP assistance will be approved only when services are provided by O'Bleness Memorial Hospital. These services also include anesthesia professional fees, physician interpretation fees for cardiopulmonary services, and services provided in the O'Bleness Family Practice Clinic.4. Family income is between 100 to 150% of the federal poverty guidelines.FAMILY: Family shall be defined as the patient, the patient's spouse, and all of the patient's children, natural and adoptive under the age of eighteen who live at home. If the patient is under the age of eighteen the family shall include the patient, the patient's natural or adoptive parent(s) and the parent(s) children, natural or adoptive under the age of eighteen who live in the home. If the patient is a child of a minor parent who still resides in the home of the patient's grandparents, the family shall include only the parent(s) and any of the parent(s) natural or adoptive children who reside in the home. INCOME: Income shall be defined as the total salaries, wages and cash receipts before taxes: receipts that reflect reasonable deduction for business expenses shall be counted for both farm and non-farm self-employment.The following steps will be used to determine eligibility for free care under HCAP (Hospital Care Assurance Program):1. A completed application will be obtained from all patients seeking free care under HCAP.2. A patient must be a resident of the state of Ohio to be eligible for HCAP.3. O'Bleness Memorial Hospital will define income requirements using the Federal Poverty Guidelines as indicated yearly.4. O'Bleness Memorial Hospital will define a family as indicated in Baldwin's Ohio Administrative Code Chapter 5101:3-2-0717.5. The income provided by the applicant will be verified via sworn signature.6. A recipient of the Ohio Medicaid program is not eligible (OAC Rule:5101:3-2-0717)If a patient has insurance coverage, O'Bleness Memorial Hospital will first bill the insurance and receive a payment or a denial before the HCAP application is processed. Part I, Line 7: The cost of charity care, unreimbursed Medicaid and other means-tested government programs was estimated using a cost to charge ratio derived from Worksheet 2 of the Schedule H instructions.Costing Methodology used to determine the cost of community health improvement services and community benefit operations. The Hospital uses the computer software CBISA to track our programs that happen in the community or at the hospital for the community. The computer tracks direct expenses associated with the programs as well as any offsetting revenue that will decrease the community benefit. The system accounts for utilities used if the activity occurs at the facility (hospital). The system also accounts for any supplies used and the wages of any employee that is present at the activity. A hospital wide wage average is used in determining the amount of salary to use in the direct expenses. An attachment of the form available to our employees to account for a benefit has been added also. Part I, Line 7f: Part III, Line 4: Patient accounts receivables are carried at the original charge less an estimate made for doubtful or uncollectible accounts. The allowance is based upon a review of the outstanding balances aged by financial class. Management uses collection percentages based upon historical collection experience to determine collectibility. Management also reviews troubled, aged accounts to determine collection potential. Patient accounts receivables are written off when deemed uncollectible. Recoveries of accounts previously written off are recorded as a reduction to bad debt expense when received. Interest is not charged on patient accounts receivable.The cost of bad debt expense was estimated using a cost to charge ratio derived from Worksheet 2 of the Schedule H instructions. Part III, Line 8: Patients known to qualify for charity care or financial assistance are asked to fill out the paperwork associated with the programs we have available to patients with low income. Policies concerning the two programs has been attached. (OCAP, HCAP) We do not have a collections process for charity care patients and the full amount is written off to the associated program. This does not apply to patients that do not qualify for either of the programs. If it is determined that the patient is capable of paying for their medical care then at that point they are charged for the services. If failure to pay their medical bills occurs, at that point collection practices ensue. After a chance to pay their bill at a reduced price, they are reminded until ultimately debt collections. Part VI, Line 2: The hospital does not currently have an established assessment of the health needs of the communities it serves. However, in order to be compliant with future healthcare legislation, we are currently exploring options on how to best assess our communities and their health needs. Part VI, Line 3: The hospital informs patients of their eligibility for assistance in different ways. There is a sign in the admitting area that directs their attention to the fact that there is availiable care at a reduced fee or free of charge. On each data mailer that is sent out to patients, there is a section that informs them of the availability of this care. Any patient that comes in without insurance or proof of insurance is supplied a self-pay packet. In this packet is an outline on how to obtain free or discounted care; the packet also details the parameters of each program. If any of our employees are asked in admissions or during their care if there are any options available for payment of their care, the employees will describe to the patients the programs available or provide them with materials on how to apply and be accepted into the free or discounted care programs. Part VI, Line 4: O'Bleness Memorial Hospital is a community hospital in a rural area of Appalachia. Our primary service area includes the communities within Athens County, Ohio, which has been identified by the Appalachian Regional Commission as an ARC-Designated Distressed County. According to the United States Census Bureau, the population of Athens County in 2009 was 63,073. The average income of $30,190 is not truly representative of the population, as the community includes a major university. Athens County has the highest poverty level of any county in Ohio, as 32.8% of community residents have incomes at or below the federal poverty guideline. Uninsured individuals in Athens County represent 18.8% of the population. The hospital's patient population includes 8.69% who are uninsured and 22% who are Medicaid recipients. Located within O'Bleness' primary service area of Athens County is one additional hospital, Doctors Hospital of Nelsonville affiliated with OhioHealth based in Columbus, Ohio. Portions of the patient population are also served by eight other hospitals in Washington, Gallia, Jackson, Hocking, Fairfield and Ross counties in Ohio and Wood County in West Virginia, as well as three major health systems with multiple facilities in Franklin County, Ohio. Three townships in Athens County have been designated as Medically Underserved Areas/Populations by the U.S. Department of Health and Human Services: Lodi, Waterloo and Trimble. Part VI, Line 6: At O'Bleness Memorial Hospital it is our goal to give access to any person in our community to modern day healthcare at a cost effective price. As the only hospital in Athens, we strive to give help where help is needed. To further our commitment to the community and our exempt purpose we engage in many activities. Our board is compiled of people who reside in our community without a conflict of interest with the hospital. We believe the more diverse the board, the better they will be able to identify the needs of the community. They have no connection to the organization nor are contracted with the hospital. They provide their consult and guidance out of the pure desire to see their community be afforded the same quality of care as bigger markets. We extend medical privileges to qualified physicians that have a desire to practice within our facilities. We continue to search for programs and activities that will be new to the community in order to give the population variety and health oriented alternatives. Funds are used to purchase capital equipment that is vital in keeping up with an ever evolving medical world. It is also used to fund activities inside and outside of the hospital that involves the community on various levels whether it be a health fair or an interactive exercise program. We have many volunteers from the community that are instrumental in carrying out various activities. Part VI, Line 7: The O'Bleness Health System is designed to offer the most comprehensive medical attention in a mainly centralized location to the community in which we live. The affiliates of the system work together in a collaborative effort to increase the efficiency and cost of healthcare to the patient. The O'Bleness Memorial Hospital is the main component of the health system. At the hospital we offer a variety of inpatient and outpatient services. The Emergency Department is operational 24 hours a day 7 days a week. We offer care to anyone regardless of ability to pay. We are the only fully functional hospital in the community. It is our goal not to exclude anyone from our community that is in need of care. The Athens Medical Lab (AML) is an affiliate of the system that is a medical reference lab that offers convenience and cost efficiency for the patient. This allows us to keep patients close to home and speed up result time. The Athens Medical Associates (AMA) is a multi physician practice that offers a variety of services to patients. AMA is comprised of a multifaceted OB/GYN practice, an orthopedic surgeon, and a Family Practice clinic that serves numerous members of the community. There is also the ACVNAHHS (Appalachian Community Visiting Nurses Association, Hospice and Health Services). This affiliate provides hospice services to not only Athens County but surrounding counties. They are also providers of visiting nurses that serve our clients out of the comfort of their own home. X 1 0 0 0 0 0 0 0 0 Clifford Young 145297 0 0 0 0 0 11269 0 9363 0 165929 0 0 0 Michael Clark 250179 0 0 0 0 0 7350 0 24 0 257553 0 0 0 Richard Castrop 257959 0 0 0 0 0 11250 0 16941 0 286150 0 0 0 Part I, Line 4a Richard Castrop received a severance payment for $207,321. County of Athens Ohio 316400063 047075BA3 2003-08-21 31263724 Bond refunding, hospital construction & renovation 0 0 31263724 2936689 625274 2005 0 0 1 1 0 0 0 0 0 1 0 0 0 0 0 0 Form 990, Part III, line 2 New Program Services The O'Bleness Wound Care Center was opened in March 2010 in response to a growing need for local treatment of difficult wounds, in part due to the very high incidence of diabetes in the area. In certain cases, the center includes hyperbaric oxygen therapy as part of the treatment provided. The center is the only location in Southeastern Ohio offering this specific type of therapy. It therefore serves as a local convenience for those patients requiring daily treatments that would otherwise be forced to commute long distances on a frequent basis. The center served 175 patients during March 2010 - June 2010. Form 990, Part VI, Section A, line 3 Sheltering Arms Hospital Foundation Inc. entered into a management agreement with OhioHealth Hospital Management Services, LLC, an Ohio nonprofit limited liability company, effective August 1, 2010 for a five year term. OhioHealth Hospital Management Services, LLC is a wholly owned subsidiary of OhioHealth Corporation, an Ohio nonprofit corporation that is exempt from federal income tax under Section 501(c)(3) of the IRS. Prior to this agreement, Sheltering Arms Hospital Foundation, Inc. had entered into a management agreement with American Healthcare Solutions for Interim Management Services beginning October 14, 2008 through May 19, 2010. Form 990, Part VI, Section B, line 11 Vice President of Finance reviews the Form 990 throughout the preparation process as well as conducting a final review of Form 990 prior to filing. The final version of the Form 990 is presented to the Board of Directors to review. Form 990, Part VI, Section B, line 12c All officers and directors annually disclose interests that could give rise to conflicts. Form 990, Part VI, Section B, line 15a Compensation of the executive director is determined by a compensation committee with the full board's approval. Form 990, Part VI, Section C, line 18 O'Bleness Memorial Hospital makes its Form 1023, Form 990 and Form 990-T available for public inspection upon request. Its Form 990 is also available at the Guidestar.org website. Form 990, Part VI, Section C, line 19 O'Bleness Memorial Hospital makes its governing documents, conflict of interest policy, and financial statements available in hardcopy upon request. Form 990, Part XI, Line 2c Audit oversight There was no change in the oversight of the audit versus prior year. Form 990, Line 6 Volunteers O'Bleness had 83 community volunteers, 138 college students and 6 junior volunteers during fiscal year 2010. Total wage value according to the Bureau of Labor Statistics- $497,940 (based on non-farm labor plus benefits). Schedule D, Part X, Line 2 Fin 48 Footnote There was no Fin 48 footnote included on the financial statements of the organization. Athens Medical Associates LLC 55 Hospital Dr Athens OH 45701 020734615 Physician services OH -1551984 1146560 N/A Athens Surgery Center Ltd 75 Hospital Dr Athens OH 45701 550840856 Outpatient surgery OH N/A Related 127085 341912 0 0 Athens Medical Laboratory Associates Inc 400 E State Street Athens OH 45701 311381808 Medical laboratory OH N/A S 256132 731094 1.00000 The Drugstore at O'Bleness LLC 55 Hospital Dr Athens OH 45701 030598042 Drugstore OH N/A S -44218 1.00000 0 0 0 1 0 0 0 0 1 0 0 0 0 0 0 0 0 0