2011-11-14T12:12:33-06:00 2010-12-31 PLANTE & MORAN PLLC 65 EAST STATE ST STE 600 COLUMBUS OH 43215 990 2010-01-01 311072406 PIKE HEALTH SERVICES INC PIKE 7409476306 100 DAWN LANE WAVERLY OH 45690 CRAIG SOLLE 7409476306 2011-11-14 1 BERNIE OSTROWSKI 6148493000 2010 2016-02-24 21:20:13Z SEE SCHEDULE O CRAIG E SOLLE 100 DAWN LANE WAVERLY OH 45690 23471407 0 X WWW.PIKECOMMUNITYHOSPITAL.ORG X 1983 OH PIKE HEALTH SERVICES IS A 25-BED CRITICAL ACCESS HOSPITAL AND CLINIC LOCATED IN THE STATE OF OHIO IN PIKE COUNTY. INCLUDED IN THE BED COUNT ARE 21 ACUTE BEDS AND 4 INTENSIVE CARE BEDS WITH AUTHORIZATION FOR SWING BEDS ON AN AS NEEDED BASIS. PIKE HEALTH SERVICES HAD 727 INPATIENT ADMISSIONS, 501 SURGERY CASES ( INCLUDING AMBULATORY); 16,342 VISITS TO THE EMERGENCY DEPARTMENT. PIKE HEALTH SERVICES PROVIDED CHARITY CARE TO THE COMMUNITY IN THE AMOUNT OF $1,731,367 IN CHARGES FORGONE, BASED ON ESTABLISHED RATES, WITH 11.90% SELF PAY PATIENTS, WHO HAVE NO INSURANCE. 9 8 378 42 0 0 70597 290543 22812846 22084750 3642 4041 1055509 1049170 23942594 23428504 236 161 0 0 11951001 11541000 0 0 3104 12992012 11579102 24943249 23120263 -1000655 308241 13217652 13573166 10411417 10456285 2806235 3116881 X PIKE HEALTH SERVICES IS HIGH QUALITY; COMPASSIONATE HEALTHCARE; ACCESSIBLE TO THE COMMUNITY; COMMITTED TO EXCELLENCE; RESPECTFUL OF EACH INDIVIDUAL; AND FOUNDED ON SERVICE TO OTHERS. 0 0 20034735 161 22084750 SEE SCHEDULE OPIKE HEALTH SERVICES IS A 25-BED CRITICAL ACCESS HOSPITAL AND PHYSICIAN PRACTICE LOCATED IN THE STATE OF OHIO IN PIKE COUNTY. INCLUDED IN THE BED COUNT ARE 21 ACUTE BEDS AND 4 INTENSIVE CARE BEDS WITH AUTHORIZATION FOR SWING BEDS ON AN AS NEEDED BASIS. IN 2010, PIKE HEALTH SERVICES HAD 727 INPATIENT ADMISSIONS, 501 SURGERY CASES (INCLUDING AMBULATORY); AND 16,342 VISITS TO THE EMERGENCY DEPARTMENT. PIKE HEALTH SERVICES PROVIDED CHARITY CARE TO THE COMMUNITY IN THE AMOUNT OF $3,066,052, INCLUDING 11.90% SELF PAY PATIENTS, WHO HAVE NO INSURANCE.PIKE HEALTH SERVICE'S COMMUNITY OUTREACH ACTIVITY HAS SERVED 1,714 CITIZENS IN VARIOUS PROGRAMS THROUGHOUT PIKE COUNTY. DURING THE YEAR, THEY PARTICIPATED IN 4 HEALTH FAIRS AND 25 SCREENING AND EDUCATIONAL CLINICS FOR DIABETES, CHOLESTEROL AND ARTHRITIS. ADDITIONALLY THEY SUPPORT THE YOUNG RESIDENTS OF THE COUNTY IN VARIOUS PROGRAMS INCLUDING HEAD START AND CHILD SAFETY PRESENTATIONS. 20034735 1 1 0 1 0 0 0 0 0 1 0 0 1 1 0 1 0 0 0 0 0 0 0 0 0 1 0 0 0 1 0 0 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 35 0 1 378 1 0 0 0 0 0 0 0 0 0 0 X 9 8 0 0 0 0 0 0 0 1 1 0 0 1 1 1 1 1 1 1 0 0 OH X CRAIG SOLLE 7409476310 100 DAWN LANE WAVERLY OH 45690 CATHERINE FARINET 37.50 X 194338 0 14259 TONY FISH 0.10 X X 0 0 0 VAL FRANCIS 0.10 X X 0 0 0 LINDA B SHOEMAKER 0.10 X X 0 0 0 MELBY WILLIAMS 0.10 X X 0 0 0 TOD BURKITT 0.10 X 0 0 0 DENNIS MILLER 0.10 X 0 0 0 MARGARET FOILL 0.10 X 0 0 0 REV RONALD HINES 0.10 X 0 0 0 CRAIG E SOLLE 37.50 X 113918 0 19081 LINDA JAMES 37.50 X 74129 0 10713 SHARON NOVAK 37.50 X 78329 0 10830 TINA PERKO 37.50 X 67269 0 10529 CINDY INGRAM 37.50 X 213071 0 25308 DAVID KESSLER 37.50 X 215191 0 6161 ERIC CRAWFORD 37.50 X 160748 0 22075 ELLIS FRAZIER 37.50 X 175798 0 9702 CHERYL SMITH 37.50 X 102532 0 3339 1395323 0 131997 7 0 1 0 PREMIER HEALTHCARE PO BOX 631606 CINCINNATI OH 452631606 ED PHYSICIAN COVERAGE 699400 INNER OFFICE 80 ERIE STREET CORTLAND OH 44410 MEDICAL TRANSCRIPTION 224446 QUEST DIAGNOSTICS 2249 COLLECTION CENTER DRIVE CHICAGO IL 60693 LAB TESTING 203826 PHILLIPS MEDICAL PO BOX 100355 ATLANTA GA 303840355 MAINTENANCE 158760 SIEMENS MEDICAL SOLUTIONS DEPT AT 40065 ATLANTA GA 31192 MAINTENANCE 153048 5 242447 48096 290543 PROGRAM SERVICES 900099 22084750 22084750 22084750 1041 1041 12450 42903 -30453 -30453 -30453 3000 3000 3000 3000 COUNTY TAX LEVY 900099 1008339 1008339 CAFETERIA REVENUE 900099 71284 71284 1079623 23428504 22084750 0 1053211 161 161 717912 717912 8237463 7355917 880214 1332 1525409 1385940 139469 442166 430235 11931 618050 509136 108914 36412 36412 79515 79515 3118416 2650471 466871 1074 17738 17738 2298204 1946048 351508 648 4288 4288 392742 353468 39274 17636 10427 7209 511698 460528 51170 1142031 1027462 114569 173220 173220 BAD DEBT EXPENSE 3663690 3663690 DUES & SUBSCRIPTIONS 58608 14886 43722 BILLING EXPENSE 20883 20883 CONTINUING EDUCATION 19911 16653 3258 LAB EXPENSE 7814 7814 16296 7796 8450 50 23120263 20034735 3082424 3104 160011 109731 236630 14378 2066889 1756848 45210 31710 227193 245475 131702 207346 25196973 16918282 8795795 8278691 1254786 1255047 85164 95975 214272 1577965 13217652 13573166 2689011 3007420 5715000 5270000 480370 1527036 2178865 10411417 10456285 X 2806235 3116881 2806235 3116881 13217652 13573166 X 308241 2405 X X 0 1 1 X 0 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 0 0 0 0 0 0 0 0 0 0 1 737 737 0 EXPLANATION OF OTHER LOBBYING ACTIVITIES: PART II-B, LINE 1I: OHIO HOSPITAL ASSOCIATION STRATEGIC ISSUES AND ENERGY LITIGATION ASSESSMENT. 244450 244450 13218083 7183991 6034092 18000 5900 12100 10894524 9467706 1426818 821916 260685 561231 8278691 OTHER RECEIVABLES 1422071 DEFERRED FINANCING COSTS 155894 1577965 CAPITAL LEASE OBLIGATION 995380 ESTIMATED THIRD-PARTY PAYOR SETTLEMENTS 407794 LINE OF CREDIT 725075 OTHER NOTES PAYABLE 50616 2178865 23428504 23120263 308241 2405 2405 310646 23412121 2405 -61691 -59286 23471407 -42903 -42903 23428504 23101475 42903 42903 23058572 61691 61691 23120263 PART XII, LINE 2D - OTHER ADJUSTMENTS: CHARITY CARE & BAD DEBT EXPENSES -61,691. PART XII, LINE 4B - OTHER ADJUSTMENTS: RECLASS RENTAL EXPENSES -42,903. PART XIII, LINE 2D - OTHER ADJUSTMENTS: RECLASS RENTAL EXPENSES 42,903. PART XIII, LINE 4B - OTHER ADJUSTMENTS: CHARITY CARE & BAD DEBT EXPENSES 61,691. 1 1 X 1 X 1 X 1 1 0 1 1 2100158 1506783 593375 0.03050 5090719 2705884 2384835 0.12260 7190877 4212667 2978210 0.15310 7190877 4212667 2978210 0.15310 6 1714 20412 1500 18912 0.00100 6 1714 20412 1500 18912 0.00100 1 1731737 0 6781375 6717912 63463 X 1 1 1 1 PIKE COMMUNITY HOSPITAL

100 DAWN LANE WAVERLY OH 45690

X X X X NOT APPLICABLE 1 1 PIKE MEDICAL & PROFESSIONAL ASSOCIATES

100 DAWN LANE WAVERLY OH 45690

PRACTICES OWNED BY PHS PART I, LINE 3C: N/A PART I, LINE 7: TOTAL COMMUNITY BENEFIT EXPENSE RELATED TO CHARITY CARE WAS CALCULATED USING A COST-TO-CHARGE RATIO AS CALCULATED USING SCHEDULE H WORKSHEET 2. TOTAL COMMUNITY BENEFIT RELATED TO MEDICAID WAS CALCULATED FROM THE MEDICAID COST REPORT.PART I, LINE 7, COLUMN (F): THE PERCENTAGE OF TOTAL EXPENSES WAS CALCULATED BASED ON TOTAL EXPENSES LESS BAD DEBT AS REPORTED ON FORM 990, PART IX. PART I, L7 COL(F): CHARITY CARE AND OTHER COMMUNITY BENEFITS AS A PERCENTAGE OF EXPENSES IS CALCULATED USING TOTAL EXPENSES FROM FORM 990, PART IX LESS BAD DEBT EXPENSE OF $3,663,690 FROM PART IX. PART II: THE HEALTH OF THE COMMUNITY IS PROMOTED THROUGH NUMEROUS SCREENING AND EDUCATION ACTIVIES FOR DIABETES, CHOLESTEROL AND OTHER CIRCULATORY DISEASES. THE EDUCATION IS PROVIDED BY THE HOSPITAL AND OTHER HEALTH PROMOTING GROUPS IN THE COMMUNITY. ADDITIONALLY, THE HOSPITAL PARTICIPATES IN HEALTH FAIRS AND CLINICS FOR SENIOR GROUPS AND LOCAL BUSINESSES. 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.BAD DEBT AT COST WAS CALCULATED USING A COST-TO-CHARGE RATIO. GROSS CHARGES WERE BASED ON STANDARD RATES LESS AMOUNTS COLLECTED. WE DO NOT BELIEVE BAD DEBT SHOULD BE INCLUDED AS A COMMUNITY BENEFIT. NONE OF THE BAD DEBT AT COST COULD BE ATTRIBUTED TO PATIENTS ELIGIBLE UNDER THE FINANCIAL ASSISTANCE POLICY. ON A REGULAR BASIS, AMOUNTS INCLUDED IN BAD DEBT THAT COULD QUALIFY FOR FINANCIAL ASSISTANCE ARE RECLASSED OUT OF BAD DEBT TO HCAP OR CHARITY CARE. PART III, LINE 8: MEDICARE ALLOWABLE COSTS WERE CALCULATED FROM THE MEDICARE COST REPORT. WE DO NOT BELIEVE THE COST OF MEDICARE SHOULD BE INCLUDED AS A COMMUNITY BENEFIT. MEDICARE ALLOWABLE COSTS REPORTED ON THE COST REPORT WERE DETERMINED USING A COST-TO-CHARGE RATIO IN ACCORDANCE WITH MEDICARE REQUIREMENTS. PART III, LINE 9B: IN-HOUSE FINANCIAL COUNSELORS WILL BEGIN FOLLOW-UP ON ALL SELF-PAY ACCOUNTS DUE TO THE HOSPITAL WITHIN 30 DAYS OF BILLING. THEY WILL UTILIZE ALL REASONABLE EFFORTS TO OBTAIN PAYMENT. AFTER 60 DAYS OF COLLECTION EFFORTS, THE FINANCIAL COUNSELOR WILL REVIEW THE ACCOUNT AND RECOMMEND FURTHER COLLECTION EFFORTS. THE MANAGER OF PATIENT ACCOUNTS WILL REVIEW ALL ACCOUNTS FOR APPROVAL TO OUTSIDE COLLECTION AND BAD DEBT WRITE-OFF. THE MANAGER OF PATIENT ACCOUNTS IS AUTHORIZED TO WRITE OFF ACCOUNTS UNDER $500. ACCOUNT BALANCES OF $500 TO $5,000 MUST BE AUTHORIZED BY THE VICE PRESIDENT OF FINANCE, AND BALANCES OVER $5,000 REQUIRE THE AUTHORIZATION OF THE CEO. PART VI, LINE 2: PIKE PROVIDES SCREENING ACTIVITIES THROUGHOUT THE COMMUNITY. THERE IS A LARGE POPULATION OF SENIORS AND MEDICARE RECIPIENTS WHO BENEFIT. PIKE ALSO PARTNERS WITH THE YMCA TO PROVIDE DIABETES SCREENINGS. THERE IS NO FORMAL NEEDS ASSESSMENT HOWEVER FOR THE FUTURE THE HOSPITAL IS IN THE PROCESS OF DEVELOPING A MORE COMPREHENSIVE ASSESSMENT BASED ON SURVEYS TO MEMBERS OF THE COMMUNITY. PART VI, LINE 3: ELIGIBILITY FOR ASSISTANCE SIGNAGE IS POSTED THROUGHOUT THE HOSPITAL. ALL PATIENTS WITHOUT THIRD PARTY COVERAGE ARE GIVEN CHARITY APPLICATIONS AT THE TIME OF REGISTRATION. PART VI, LINE 4: PIKE COMMUNITY HOSPITAL SERVES A POPULATION OF 28,000 PEOPLE IN PIKE COUNTY, OHIO. THE UNEMPLOYMENT RATE IN PIKE COUNTY IS 15.6% AND THE PER CAPITA INCOME IS $24,300. 22.9% OF THE POPULATION FALL BELOW THE FEDERAL POVERTY LEVEL. FINANCIAL UTILIZATION AT THE HOSPITAL IS 44% MEDICARE, 25% MEDICAID, 16% COMMERCIAL AND 15% SELF PAY. PART VI, LINE 6: PIKE HEALTH SERVICES, INC. STRIVES TO MEET THE HEALTHCARE NEEDS OF ITS COMMUNITY. PIKE HEALTH SERVICE'S COMMUNITY OUTREACH ACTIVITY INCLUDES PARTICIPATION IN HEALTH FAIRS, SCREENINGS, AND EDUCATIONAL CLINICS FOR DIABETES, CHOLESTEROL AND ARTHRITIS. ADDITIONALLY, THEY SUPPORT THE YOUNG RESIDENTS OF THE COUNTY IN VARIOUS PROGRAMS INCLUDING HEAD START AND CHILD SAFETY PRESENTATIONS. PART VI, LINE 7: N/A REPORTS FILED WITH STATES PART VI, LINE 7 OH X X X 0 0 0 0 0 0 0 0 0 CATHERINE FARINET 194338 0 0 0 0 0 5722 0 8537 0 208597 0 0 0 CINDY INGRAM 213071 0 0 0 0 0 6000 0 19308 0 238379 0 0 0 DAVID KESSLER 215191 0 0 0 0 0 6000 0 161 0 221352 0 0 0 ERIC CRAWFORD 160748 0 0 0 0 0 2807 0 19268 0 182823 0 0 0 ELLIS FRAZIER 175798 0 0 0 0 0 1171 0 8531 0 185500 0 0 0 CINDY INGRAM-TU TUITION ASSISTANCE, TO BE FORGIVEN WITH HOURS WORKED OVER 7 YEARS. X 127960 31710 0 1 1 CATHERINE FARINET START-UP EXPENSES, TO BE FORGIVEN WITH HOURS WORKED X 12000 0 1 1 31710 FORM 990, PART VI, SECTION B, LINE 11 THE CEO REVIEWS FORM 990 AND THE BOARD WILL BE PRESENTED WITH A COPY OF FORM 990 PRIOR TO FILING. FORM 990, PART VI, SECTION B, LINE 12C OFFICERS, BOARD MEMBERS, AND KEY EMPLOYEES ARE REQUIRED TO REVIEW AND DISCLOSE CONFLICTS OF INTEREST BY AN ANNUAL FORM SIGN-OFF. THROUGHOUT THE YEAR, BOARD MEMBERS ARE REQUIRED TO DISCLOSE ANY CONFLICT OF INTERESTS THAT ARISE AND MUST REFRAIN FROM VOTING ON ANY ISSUES IN WHICH A CONFLICT OF INTEREST IS PRESENT. FORM 990, PART VI, SECTION B, LINE 15A INDIVIDUAL BOARD MEMBERS EVALUATE THE CEO ANNUALLY, AND THEN COME TOGETHER FOR RECOMMENDATIONS AS TO THE CEO'S COMPENSATION. OTHER OFFICERS' COMPENSATION IS REVIEWED ANNUALLY BY THE CEO. THE ORGANIZATION USES A WRITTEN EMPLOYEE CONTRACT AND UTILIZES THE OHIO HOSPITAL ASSOCIATION'S COMPENSATION STUDIES TO DETERMINE COMPENSATION LEVELS. FORM 990, PART VI, SECTION C, LINE 18 THE ORGANIZATION'S FORM 1023 AND FORM 990 ARE AVAILABLE FOR PUBLIC INSPECTION UPON REQUEST. FORM 990, PART VI, SECTION C, LINE 19 THE GOVERNING DOCUMENTS, CONFLICT OF INTEREST POLICY, AND FINANCIAL STATEMENTS ARE AVAILABLE UPON REQUEST. CHANGES IN NET ASSETS OR FUND BALANCES: FORM 990, PART XI, LINE 5: NET UNREALIZED GAINS ON INVESTMENTS: 2,405. FORM 990, PART XI, LINE 2C: THE BOARD OF DIRECTORS OVERSEES THE AUDIT PROCESS AND APPROVES THE INDEPENDENT AUDIT FIRM. THIS PROCESS HAS NOT CHANGED FROM PRIOR YEARS. DOING BUSINESS AS: FORM 990, PAGE 1, LINE C PIKE COMMUNITY HOSPITAL; PIKE MEDICAL & SURGICAL ASSOCIATES