2026-09-15T06:54:43-05:00 2025-10-31 393647910 WIPFLI ADVISORY LLC 1502 LONDON ROAD SUITE 220 DULUTH MN 55812 990 2024-11-01 344477047 HENRY COUNTY HOSPITAL INC HENR 4195924015 1600 EAST RIVERVIEW NAPOLEON OH 43545 KRISTI BARND CEO 4195924015 2026-09-14 1 1 MICHAEL J PETERSON CPA P01833529 2187224705 2026-09-11 2024 KRISTI BARND 1600 EAST RIVERVIEW NAPOLEON OH 43545 37139225 0 X WWW.HENRYCOUNTYHOSPITAL.ORG X 1982 OH HENRY COUNTY HOSPITAL PROVIDES QUALITY HEALTHCARE AND WELLNESS SERVICES WHILE EMPHASIZING PATIENT CARE AND EXCELLENT CUSTOMER SERVICE. HENRY COUNTY HOSPITAL WILL BE THE HEALTHCARE PROVIDER OF CHOICE BY BEING THE BEST PLACE TO RECEIVE PATIENT-CENTERED CARE, WORK AND PRACTICE MEDICINE. 10 8 373 33 10195 0 386587 292508 32612880 35233676 3833 88946 1876440 1524095 34879740 37139225 111067 157586 0 0 18743019 18551574 0 0 110135 17739425 20784446 36593511 39493606 -1713771 -2354381 22641800 19662540 8030601 7304404 14611199 12358136 X HENRY COUNTY HOSPITAL PROVIDES QUALITY HEALTHCARE AND WELLNESS SERVICES WHILE EMPHASIZING PERSONALIZED PATIENT CARE AND EXCELLENT CUSTOMER SERVICE. 0 0 25656320 157586 20154010 OTHER SERVICES - PROVIDED BY HENRY COUNTY HOSPITAL ARE: MEDICAL IMAGING, INCLUDING X-RAY, CT SCANS, MRI, ULTRASOUND, DEXA, NUCLEAR MEDICINE, INTERVENTIONAL RADIOLOGY, VASCULAR LAB AND STRESS TESTING; PHARMACY SERVICES; REHAB SERVICES, INCLUDING PHYSICAL THERAPY, OCCUPATIONAL THERAPY, AND SPEECH THERAPY; ONCOLOGY SERVICES; INPATIENT AND INTENSIVE CARE SERVICES; WOMEN'S HEALTH SERVICES; CARDIAC REHAB, EKG, AND RESPIRATORY THERAPY, SLEEP CENTER, URGENT CARE, VASCULAR, ORTHOPEDICS, CARDIOLOGY, UROLOGY; AND MEDICATION MANAGEMENT TREATMENT. HENRY COUNTY HOSPITAL PROVIDED OVER 228 INPATIENTS ADMISSION WITH OVER 805 DAYS OF CARE, 51 SWING BED PATIENTS WITH OVER 670 DAYS OF CARE, 0 BIRTHS, AND OVER 71,628 VISITS IN 2025. 2537662 0 5424692 PHARMACY - IV INFUSIONS AND MEDICATIONS ARE PROVIDED CONTINUALLY TO PATIENTS PRESENTING INJURIES AND ILLNESSES REQUIRING TREATMENT AS PRESCRIBED BY LICENSE MEDICAL PROFESSIONALS. TOTAL PATIENT DOSES/INFUSIONS PROVIDED TOTALED OVER 89,140 FOR 2025. 2440523 0 5542547 LABORATORY - PROVIDING SERVICES FOR IP AND OP, EXTENDED CARE FACILITIES, PHYSICIAN OFFICES AND AREA BUSINESSES. THE LABORATORY PROVIDED OVER 118,989 BILLED TESTS IN 2025. 1713396 0 5038756 SURGERY - PROVIDING PRE-, INTRA-, AND POST PROCEDURE CARE FOR SURGICAL INPATIENTS AND OUTPATIENTS. INCLUDES GENERAL, ORTHOPEDIC, CATARACT, VEIN, UROLOGY, OBSTETRIC, GYNECOLOGICAL, PAIN, OPHTHALMIC AND ENDOSCOPIC PROCEDURES. SURGICAL CARE SERVICES PERFORMED OVER 1,890 PROCEDURES IN 2025. 1713396 0 5038756 32347901 1 1 0 1 0 0 0 0 0 1 1 0 0 0 1 1 0 1 0 0 0 0 0 0 0 0 1 1 1 0 1 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 0 0 0 1 90 0 373 1 1 1 0 0 0 0 0 0 0 0 0 0 0 X 10 8 0 0 0 0 0 0 0 1 1 0 0 1 1 1 1 1 1 1 1 1 1 OH X DIANE WALTHER 4915913826 1600 EAST RIVERVIEW NAPOLEON OH 43545 MARVIN BARLOW CHAIRMAN 4.00 X X 0 0 0 BRENT GERKEN VICE CHAIR 2.00 X X 0 0 0 JIM BURKHART SECRETARY 2.00 X X 0 0 0 DR MIKE CARPENTER TREASURER 2.00 X X 0 0 0 DR ERAST HAFTKOWYCZ BOARD MEMBER & OB/GYN 40.00 X 287233 0 20980 JOY ERMIE BOARD MEMBER 2.00 X 0 0 0 MELISSA PEPER FIRESTONE BOARD MEMBER 2.00 X 0 0 0 RICKY FRUTH BOARD MEMBER 2.00 X 0 0 0 KRISTI BARND CEO 40.00 X X 234609 0 18027 LYNDSEY LUCAS BOARD MEMBER 2.00 X 0 0 0 KELLEY WACHTMAN CNO 40.00 X 142616 0 37851 JAMES NOWACZYK CFO (TERM 03/25) 40.00 X 190590 0 28588 DIANE WALTHER CONTROLLER 40.00 X 107841 0 34557 RYAN LAUF PHYSICIAN FAMILY PRACTICE 40.00 X 341961 0 37272 JESSIE REYNOLDS PHYSICIAN FAMILY PRACTICE 40.00 X 204496 0 9475 AMANDA MANLY PHYSICIAN FAMILY PRACTICE 40.00 X 171591 0 7517 MICHELE JAKUTOWICZ PHARMACIST 40.00 X 153396 0 31282 SARAH HUBER MANAGER MEDICAL IMAGING 40.00 X 154695 0 30867 1989028 0 256416 15 0 1 0 ASHLAND EMERGENCY GROUP LLC PO BOX 677979 DALLAS TX 75267 EMERGENCY PHYSICIAN SERVICES 1143156 CLINICAL COLLEAGUES INC PO BOX 824246 PHILADELPHIA PA 19182 ANESTHESIOLOGIST-CRNA'S 1012789 NORTHWEST SURGICAL SPECIALTIES 999 ILLINOIS AVENUE MAUMEE OH 43537 SURGICAL SERVICES 462700 MEL LANZER COMPANY 2266 NORTH SCOTT ST NAPOLEON OH 43545 GENERAL CONTRACTOR 336657 PPS HOLDING INC 655 METRO PLACE SOUTH STE 450 DUBLIN OH 43017 PHARMACY 325806 15 251651 40857 292508 NET PATIENT REVENUE 623990 34530378 34520183 10195 340B REVENUE 623990 623645 623645 79653 79653 35233676 88946 88946 90560 0 90560 90560 90560 JOINT VENTURES 623990 936524 936524 CAFETERIA REVENUE 722514 162100 162100 334911 334911 1433535 37139225 36160005 10195 676517 X 157586 157586 554213 432198 122015 14760270 11186865 3494706 78699 336417 334737 1680 1633948 1625789 8159 1266726 1260400 6326 22776 22776 75825 75825 5499 5499 9491702 8084296 1407406 187367 11733 175634 300572 191062 109510 502491 446479 56012 17690 8730 8960 32753 26885 5868 189016 144032 44984 1131744 862400 269344 435936 332187 103749 DRUGS AND MEDICAL SUPPL 3755453 3754199 1254 BAD DEBT EXPENSE 3090812 3090812 FRANCHISE FEE 995118 995118 MINOR EQUIPMENT 262407 223214 39193 287285 174297 81552 31436 39493606 32347901 7035570 110135 1750 2100 6159242 4195189 5538416 4570155 836269 792582 387140 377258 27615694 20263558 6501172 7352136 1377945 1490928 515602 661537 1324264 220655 22641800 19662540 2869512 1824952 4414060 4049491 747029 1429961 8030601 7304404 X 13170724 10816343 1440475 1541793 14611199 12358136 22641800 19662540 X -2354381 101318 X X 0 1 X 1 0 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 0 0 0 0 0 0 0 0 1 5499 5499 0 PART II-B, LINE 1: REPRESENTS PORTION OF ANNUAL DUES PAID TO AMERICAN HOSPITAL ASSOCIATION AND OHIO HOSPITAL ASSOCIATION ESTIMATED TO PERTAIN TO LOBBYING ACTIVITIES. 50000 50000 50000 50000 50000 50000 50000 50000 50000 50000 0.00000 1.00000 0.00000 0 0 141813 141813 9460233 6999112 2461121 17833316 13264446 4568870 180332 180332 7352136 ESTIMATED THIRD-PARTY SETTLEMENTS 57396 FINANCE LEASE LIABILITY 1039696 OPERATING LEASE LIABILITY 219447 DUE TO RELATED PARTY 113422 1429961 X PART V, LINE 4: THE INTENDED USE OF THE ENDOWMENT FUNDS IS TO SUPPORT THE OPERATIONS OF THE HOSPITAL AS DIRECTED BY THE HOSPITAL BOARD. PART X, LINE 2: ACCOUNTING PRINCIPLES GENERALLY ACCEPTED IN THE UNITED STATES OF AMERICA REQUIRE MANAGEMENT TO EVALUATE TAX POSITIONS TAKEN AND RECOGNIZE A TAX LIABILITY IF AN UNCERTAIN POSITION HAS BEEN TAKEN THAT MORE LIKELY THAN NOT WOULD NOT BE SUSTAINED UPON EXAMINATION BY VARIOUS FEDERAL AND STATE TAXING AUTHORITIES. MANAGEMENT HAS ANALYZED THE TAX POSITIONS TAKEN BY THE ORGANIZATION AND HAS CONCLUDED THAT AS OF OCTOBER 31, 2025 AND 2024, THERE ARE NO UNCERTAIN POSITIONS TAKEN OR EXPECTED TO BE TAKEN THAT WOULD REQUIRE RECOGNITION OF A LIABILITY OR DISCLOSURE IN THE ACCOMPANYING CONSOLIDATED FINANCIAL STATEMENTS. THE ORGANIZATION IS SUBJECT TO ROUTINE AUDITS BY TAXING JURISDICTIONS; HOWEVER, THERE ARE CURRENTLY NO AUDITS FOR ANY TAX PERIODS IN PROGRESS. 1 1 X 1 X 1 X 1 1 0 1 1 1215607 496657 718950 0.01970 4199804 3004985 1194819 0.03280 5415411 3501642 1913769 0.05250 87459 640 86819 0.00240 293534 284942 8592 0.00020 16774 16774 0.00050 397767 285582 112185 0.00310 5813178 3787224 2025954 0.05560 1 1166017 0 5128614 9402377 -4273763 X 1 1 1 1 HENRY COUNTY HOSPITAL 1600 EAST RIVERVIEW NAPOLEON OH 43545 WWW.HENRYCOUNTYHOSPITAL.ORG 1198 X X X HENRY COUNTY HOSPITAL INC 1 0 0 1 X X X X X X X X 24 1 0 1 1 X SEE SUPPLEMENTAL SECTION X X 1 24 1 SEE SUPPLEMENTAL SECTION 0 1 X 200.000000000000 400.000000000000 X X X X X X 1 1 X X X X 1 X HTTPS://WWW.HENRYCOUNTYHOSPITAL.ORG/PATIENTS-VISITORS/PATIENT-FINANCIAL-SER X HTTPS://WWW.HENRYCOUNTYHOSPITAL.ORG/PATIENTS-VISITORS/PATIENT-FINANCIAL-SER X HTTPS://WWW.HENRYCOUNTYHOSPITAL.ORG/PATIENTS-VISITORS/PATIENT-FINANCIAL-SER X X X X X X X 1 X 0 X X 1 X 0 0 HENRY COUNTY HOSPITAL INC PART V, SECTION B, LINE 5: 95% CONFIDENCE RATE THAT RESPONSES REPRESENT ENTIRE COUNTY. SEE EXPLANATION PARAGRAPH FOR PART VI, LINE 2, FOR ADDITIONAL INFORMATION REGARDING THE CHNA. HENRY COUNTY HOSPITAL INC PART V, SECTION B, LINE 6B: HENRY COUNTY HOSPITAL'S CHNA WAS CONDUCTED WITH THE HENRY COUNTY HEALTH DEPARTMENT, FOUR COUNTY ADAMHS BOARD, UNITED WAY OF HENRY COUNTY, AND COMMUNITY HEALTH SERVICES. HENRY COUNTY HOSPITAL INC PART V, SECTION B, LINE 7D: PART V, SECTION B, LINE 7A -HTTPS://WWW.HENRYCOUNTYHOSPITAL.ORG/PATIENTS-VISITORS/COMMUNITY-HEALTH-ASSESSMENT/PART V, SECTION B, LINE 10A - HTTPS://WWW.HENRYCOUNTYHOSPITAL.ORG/PATIENTS-VISITORS/COMMUNITY-HEALTH-ASSESSMENT/ HENRY COUNTY HOSPITAL INC PART V, SECTION B, LINE 11: THE HENRY COUNTY HEALTH PARTNERS: INITIAL EFFORTS WILL FOCUS IN THREE AREAS:A COMMUNITY HEATH ASSESSMENT WAS COMPLETED FOR 2025, THE DATA FROM THE SURVEY WAS PUBLISHED IN SEPTEMBER 2025. WORK GROUPS HAVE BEEN FORMED AND ARE CURRENTLY DETERMINING THE PRIORITIES BASED ON THE CHNA RESULTS. THE PRIORITIES FROM THE CHNA IN 2025 ARE AS FOLLOWS:1. FINANCIAL STABILITYA. THIS WORKGROUP HAS FOCUSED ON ENSURING THERE IS ADEQUATE HOUSING AND RESOURCES AVAILABLE TO HELP IMPROVE THE HEALTH OF THE COMMUNITY. THE CHIEF EXECUTIVE OFFICER OF HENRY COUNTY HOSPITAL SITS ON THIS COMMITTEE. MOST RECENTLY, WE HAVE WORKED AS A COMMUNITY TO ENSURE THAT THE COMMUNITY RESOURCE GUIDES ARE UPDATED AND OFFERED SUPPORT IN A LARGE HOUSING INITIATIVE THAT WILL BENEFIT THE COMMUNITY.2. PHYSICAL HEALTHA. THIS WORKGROUP HAS FOCUSED ON IMPROVING THE PHYSICAL HEALTH OF THE CITIZENS OF HENRY COUNTY. THE CHIEF NURSING OFFICER OF HENRY COUNTY HOSPITAL SITS ON THIS COMMITTEE. OVER THE LAST YEAR, WE HAVE FOCUSED ON INCREASING THE PROPORTION OF HEALTH CARE VISITS BY ADULTS BY INCREASING THE NUMBER OF ANNUAL WELLNESS VISITS COMPLETED IN OUR PRIMARY CARE OFFICE AND FOCUSED ON EDUCATION TO IMPROVE NUTRITION AND PHYSICAL EXERCISE. 3. MENTAL HEALTHA. THIS WORKGROUP HAS FOCUSED ON IMPROVING THE MENTAL HEALTH OF THE CITIZENS OF HENRY COUNTY. THE MANAGER OF EMERGENCY CARE SERVICES AT HENRY COUNTY HOSPITAL SITS ON THIS COMMITTEE. THIS COMMITTEE CONTINUES TO WORK ON COLLECTING DATA ABOUT WHERE RESOURCES ARE NEEDED IN ORDER TO IMPROVE THE MENTAL HEALTH OF THE COMMUNITY. MOST OF 2026 HAS BEEN USED TO SURVEY COMMUNITY MEMBERS, WHILE ALSO INCLUDING OVERLAPPING AGENDA ITEMS FROM THE SUBSTANCE MISUSE WORKGROUP FROM THE LAST CHNA. HENRY COUNTY HOSPITAL INC PART V, SECTION B, LINE 16J: PAPER COPIES OF THE FAP ARE AVAILABLE AT ACCESS POINTS THROUGHOUT THE HOSPITAL, AS WELL AS AT THE SENIOR CENTER, HEALTH DEPARTMENT, JOBS & FAMILY SERVICES, CHURCHES, AND THE FISH PROGRAM (FOOD BANK). PART I, LINE 3C: IN ADDITION TO THE FPG, THE ORGANIZATION USES THE FOLLOWING CRITERIA TO DETERMINE ELIGIBILITY FOR FINANCIAL ASSISTANCE: A SLIDING SCALE FOR DISCOUNTED CARE IF THE PATIENT IS 201% TO 400% OF THE FEDERAL POVERTY GUIDELINES, MEDICAL INDIGENCY, INSURANCE STATUS, UNDERINSURANCE STATUS, AND RESIDENCY. PART I, LINE 7: THE COST TO CHARGE RATIO METHOD WAS USED TO CALCULATE THE CHARITY CARE AND CERTAIN OTHER COMMUNITY BENEFITS AT COST. PART I, LINE 7G: THE REPORTED SUBSIDIZED HEALTH SERVICES REPRESENTS THE SCHOOL NURSE PROGRAM. PART I, LINE 7, COLUMN (F): THE BAD DEBT EXPENSE INCLUDED ON FORM 990, PART IX, LINE 25, COLUMN (A), BUT SUBTRACTED FOR PURPOSES OF CALCULATING THE PERCENTAGE IN THIS COLUMN IS $ 3,090,812. PART II, COMMUNITY BUILDING ACTIVITIES: HENRY COUNTY HOSPITAL IS A GREAT COMMUNITY PARTNER, AND WE CONTINUE TO SUPPORT OUR LOCAL COMMUNITY WITH ONGOING EDUCATION AND RESOURCES. WE PARTICIPATED IN THE SYMPHONY OF TREES BY HAVING A MEMBER OF STAFF ON THE SYMPHONY OF TREES BOARD. THE SYMPHONY OF TREES IS A NON-PROFIT ORGANIZATION THAT PROVIDES SUPPORT TO THE CHILDREN OF HENRY COUNTY AND NORTHWEST OHIO THROUGH THREE BENEFITING AGENCIES: CASA OF NORTHWEST OHIO, THE CENTER FOR CHILD AND FAMILY ADVOCACY, AND HENRY COUNTY HOSPITAL.WE ARE ACTIVE IN THE FOLLOWING: NAPOLEON ROTARY CLUB, PARTICIPATING BY HAVING ONE STAFF MEMBER ON THE ROTARY EXECUTIVE BOARD. THIS ALLOWS THE HOSPITAL TO HAVE A PRESENCE AT WEEKLY MEETINGS AND MONTHLY BOARD MEETINGS, AS WELL AS PROVIDE SPEAKERS REGARDING HEALTHCARE TOPICS AT LEAST TWO TIMES PER YEAR; HENRY COUNTY CHAMBER OF COMMERCE - A MEMBER OF THE LEADERSHIP TEAM HOLDS A BOARD SEAT AND PARTICIPATES IN VARIOUS CHAMBER EVENTS; NAPOLEON TRIATHLON AND OTHER RACE SPONSORSHIPS PREMIER SPONSOR; HENRY COUNTY SENIOR CENTER ADVISORY COMMITTEE - A MEMBER OF THE LEADERSHIP TEAM HOLDS A COMMITTEE SEAT AND PARTICIPATES IN THE ANNUAL SENIOR CENTER HEALTH FAIR.TO IMPROVE HEALTHCARE ACCESS, HENRY COUNTY HOSPITAL COLLABORATES WITH THE HENRY COUNTY TRANSPORTATION NETWORK TO PROVIDE FREE TRANSPORTATION FOR PATIENTS TO AND FROM HENRY COUNTY HOSPITAL. THE HOSPITAL ALSO SUPPORTS THE LOCAL SCHOOL DISTRICTS BY OFFERING YEARLY SPORTS PHYSICALS TO STUDENTS AND VARIOUS HEALTHCARE EDUCATION.DURING POISON PREVENTION WEEK, A PHARMACY LEADER PRESENTED AT LOCAL KINDERGARTEN CLASSES, WHICH INCLUDED FREE EDUCATIONAL ACTIVITY BOOKS, STICKERS, AND MAGNETS. THE FOLLOWING WELLNESS OPPORTUNITIES WERE OFFERED: KEEPING OUR GIRLS SAFE (KOGS) SELF-DEFENSE COURSES, QUARTERLY CPR CLASSES, SAFE SITTER, MENTAL HEALTH FIRST AID TRAINING, AMERICAN RED CROSS BLOOD DRIVES, AND THE TEDDY BEAR CLINIC.THE HOSPITAL CONTINUES TO PROVIDE EDUCATION ON HEALTH TOPICS THROUGH THE LOCAL RADIO STATION, SOCIAL MEDIA, AND A FREE PUBLICATION MAILED TO EVERY HOME IN THE COUNTY. THE HOSPITAL CONTINUES TO BE ACTIVE AT THE HENRY COUNTY FAIR, HENRY COUNTY RELAY FOR LIFE, FULTON COUNTY FAIR, AND UNITED WAY OF HENRY COUNTY. PART III, LINE 2: MANAGEMENT ESTIMATES AN ALLOWANCE FOR UNCOLLECTIBLE ACCOUNTS RECEIVABLE BASED ON AN EVALUATION OF HISTORICAL LOSSES, CURRENT ECONOMIC CONDITIONS, AND OTHER FACTORS UNIQUE TO THE HOSPITAL'S CUSTOMER BASE. PART III, LINE 3: NO OTHER BAD DEBT AMOUNTS HAVE BEEN INCLUDED AS COMMUNITY BENEFIT. THE HOSPITAL HAS A DETAILED FINANCIAL ASSISTANCE POLICY WHICH STATES THAT, TO PARTICIPATE IN CHARITY CARE, CANDIDATES MUST COOPERATE FULLY. IN ADDITION, THE HOSPITAL EDUCATES PATIENTS WITH LIMITED ABILITY TO PAY REGARDING FINANCIAL ASSISTANCE. FOR THIS REASON, THE ORGANIZATION BELIEVES IT ACCURATELY CAPTURES ALL CHARITY CARE DEDUCTIONS PROVIDED ACCORDING TO THE FINANCIAL ASSISTANCE POLICY, AND THE AMOUNT OF BAD DEBT EXPENSE ATTRIBUTABLE TO PATIENTS ELIGIBLE UNDER THE ORGANIZATION'S CHARITY CARE POLICY IS NEGLIGIBLE. PART III, LINE 4: THE FOOTNOTE EXPLAINING THE METHODOLOGY USED TO ESTIMATE THE AMOUNT OF THE ORGANIZATION'S BAD DEBT CAN BE FOUND ON PAGE 10 OF THE AUDITED FINANCIAL STATEMENTS UNDER THE HEADING "ACCOUNTS RECEIVABLE." PART III, LINE 8: HENRY COUNTY HOSPITAL PROVIDES CARE TO THE MEDICARE POPULATION OF HENRY COUNTY, OHIO, AND THE SURROUNDING AREA. IF THE HOSPITAL DID NOT PARTICIPATE IN MEDICARE, THOSE PATIENTS WOULD NEED TO SEEK CARE OUTSIDE OF HENRY COUNTY. THE MEDICARE SHORTFALL IS A BENEFIT THAT HENRY COUNTY HOSPITAL PROVIDES TO THE MEDICARE BENEFICIARIES IN THE COMMUNITY HENRY COUNTY HOSPITAL SERVES. THE SOURCE USED TO DETERMINE THE AMOUNT OF MEDICARE ALLOWABLE COSTS REPORTED FOR PART III, SECTION B, MEDICARE HAS BEEN PROVIDED FROM THE YEAR ENDED OCTOBER 31, 2025 REPORT: HOSPITAL STATEMENT OF REIMBURSABLE COST. PART III, LINE 9B: PER THE FINANCIAL ASSISTANCE POLICY: NO PATIENT SEEKING MEDICAL SERVICES THAT CAN BE PROVIDED BY THE HOSPITAL WILL BE DENIED ACCESS TO THOSE SERVICES SOLELY BECAUSE OF THE INABILITY TO PAY FOR THOSE SERVICES. IF THE PATIENT IS KNOWN TO QUALIFY FOR FINANCIAL ASSISTANCE, THE HOSPITAL DOES NOT SEND THEM TO COLLECTIONS BUT WORKS WITH THE PATIENT TO COMPLETE THE REQUIRED FINANCIAL ASSISTANCE APPLICATION. PART VI, LINE 2: EVERY THREE YEARS HENRY COUNTY HOSPITAL WORKS IN CONJUNCTION WITH THE HENRY COUNTY HEALTH DEPARTMENT AND OTHER COMMUNITY PARTNERS TO COMPLETE A COMPREHENSIVE COMMUNITY HEALTH ASSESSMENT. THIS COMMUNITY HEALTH ASSESSMENT PROVIDES VITAL INFORMATION TO THE HOSPITAL AND ENABLES HEALTH PROFESSIONALS TO DETERMINE THE NEEDS OF THE COMMUNITY. FROM THE COMMUNITY HEALTH ASSESSMENT, THE FOLLOWING PRIORITIES WERE DETERMINED:- FINANCIAL STABILITY - PHYSICAL HEALTH - MENTAL HEALTH INDIVIDUAL WORK GROUPS HAVE BEEN ASSIGNED TO WORK ON EACH OF THE ABOVE PRIORITIES. THESE WORK GROUPS DEVELOP A GOAL FOR EACH PRIORITY AND CARRY OUT TACTICS THAT HELP IMPACT THE SPECIFIC GOAL THEY HAVE BEEN ASSIGNED. SPECIFIC OBJECTIVES/PROGRAMS WILL BE IDENTIFIED TO HELP MEET THE DETERMINED GOALS PART VI, LINE 3: AT THE TIME OF SERVICE, EACH SELF-PAY PATIENT IS GIVEN A PACKET UPON DISCHARGE. THE PACKET INCLUDES AN HCAP APPLICATION (<100% FEDERAL POVERTY GUIDELINES) WITH DIRECTIONS, FINANCIAL ASSISTANCE PROGRAM INFORMATION, INCOME GUIDELINES FOR PROGRAMS, AND THE CONTACT INFORMATION FOR THE FINANCIAL COUNSELOR. EACH BILLING STATEMENT THAT IS SENT OUT TO PATIENTS CONTAINS THE HOSPITAL HCAP APPLICATION AND FINANCIAL COUNSELOR CONTACT INFORMATION. SIGNAGE IS ALSO POSTED IN THE HOSPITAL PER STATE OF OHIO REQUIREMENTS REGARDING FREE CARE. PART VI, LINE 4: HENRY COUNTY IS LOCATED IN NORTHWEST OHIO, COMPOSED OF THIRTEEN TOWNSHIPS AND NINE MUNICIPALITIES. HENRY COUNTY IS RICH IN AGRICULTURE, BUSINESS, CHURCHES, SCHOOLS, AND COMMUNITY ORGANIZATIONS. THE POPULATION OF HENRY COUNTY IS APPROXIMATELY 27,536. THE RACIAL MAKEUP OF THE COUNTY WAS 96% NON-HISPANIC WHITE, 1% BLACK OR AFRICAN AMERICAN, 9% HISPANIC, AND 2% FROM TWO OR MORE RACES. THE MEDIAN INCOME FOR A HOUSEHOLD IN THE COUNTY WAS $79,267. ABOUT 7.3% OF THE POPULATION WERE BELOW THE POVERTY LINE. PART VI, LINE 5: HENRY COUNTY HOSPITAL IS ACTIVE IN THE COMMUNITY BY PARTICIPATING IN HEALTH FAIRS, PROVIDING EDUCATION TO THE COMMUNITY, PROVIDING SCHOOL NURSES IN ALL FOUR SCHOOL SYSTEMS IN THE COUNTY, SUPPORTING OUR PATIENTS WITH TRANSPORTATION NEEDS, AND PROMOTING FITNESS AND WELLNESS CLASSES. THE HOSPITAL SUPPORTS THE EMPLOYEES BY PROMOTING WELLNESS ACTIVITIES, SUCH AS BREAK FOR HEALTH, RACE REIMBURSEMENT, HEALTHY RECIPES, FREE HEALTH SCREENINGS AND MENTAL HEALTH RESOURCES. OUR BOARD OF TRUSTEES IS MADE UP OF COMMUNITY MEMBERS WHO ACT IN THE BEST INTEREST OF OUR PATIENT POPULATION. EACH MEMBER BRINGS A UNIQUE PERSPECTIVE FROM THEIR POSITIONS IN THE COMMUNITY THAT ENABLES THEM TO BE ACTIVELY ENGAGED IN ADMINISTERING THEIR DUTIES AS A BOARD. THE HOSPITAL WORKS COLLABORATIVELY WITH THE HENRY COUNTY HEALTH DEPARTMENT, THE UNITED WAY, AND OTHERS IN PROMOTING HEALTHY LIVING. SENIOR LEADERS IN THE ORGANIZATION PARTICIPATE ON THE FOLLOWING BOARDS AND COMMITTEES THAT CONTINUE TO MEET THE NEEDS OF THE RESIDENTS OF HENRY COUNTY AND SURROUNDING AREAS: AMERICAN CANCER SOCIETY, VOLUNTEER LEADERSHIP COUNCIL, HENRY COUNTY HEALTH PARTNERS, SYMPHONY OF TREES BOARD OF DIRECTORS, LION'S CLUB, SENIOR CENTER ADVISORY COMMITTEE, STRATEGIC PLANNING COMMITTEE, UNITED WAY COMMITTEE, ACCESS TO HEALTHCARE WORK GROUP, HENRY COUNTY CHAMBER OF COMMERCE, CANCER CARE ALLIANCE, AND HENRY COUNTY CIC. PART VI, LINE 6: N/A 0 HENRY COUNTY HOSPITAL FOUNDATION INC 1600 EAST RIVERVIEW NAPOLEON OH 43545 341919852 501(C)(3) 111500 0 SUPPORT THE WORK OF THE FOUNDATION 1 0 1 X X X X 0 0 0 0 0 0 0 0 0 RYAN LAUF PHYSICIAN FAMILY PRACTICE 316687 0 0 0 25274 0 2799 0 34473 0 379233 0 0 0 DR ERAST HAFTKOWYCZ BOARD MEMBER & OB/GYN 283691 0 0 0 3542 0 8666 0 12314 0 308213 0 0 0 KRISTI BARND CEO 234360 0 0 0 249 0 6402 0 11625 0 252636 0 0 0 JAMES NOWACZYK CFO (TERM 03/25) 189399 0 0 0 1191 0 5572 0 23016 0 219178 0 0 0 JESSIE REYNOLDS PHYSICIAN FAMILY PRACTICE 181733 0 12500 0 10263 0 1557 0 7918 0 213971 0 0 0 SARAH HUBER MANAGER MEDICAL IMAGING 153963 0 0 0 732 0 4492 0 26375 0 185562 0 0 0 MICHELE JAKUTOWICZ PHARMACIST 152973 0 0 0 423 0 4767 0 26515 0 184678 0 0 0 KELLEY WACHTMAN CNO 142356 0 0 0 260 0 3409 0 34442 0 180467 0 0 0 AMANDA MANLY PHYSICIAN FAMILY PRACTICE 149039 0 15000 0 7552 0 1716 0 5801 0 179108 0 0 0 A HENRY COUNTY OHIO 346400633 2020-11-20 6875000 $6,875,000 COUNTY OF HENRY, OHIO, HOSPITAL REFUNDING BONDS 0 0 0 A 3051000 6875000 137500 6737500 2020 1 0 1 1 A 0 0 0 0 0 0 1 A 0 1 0 0 0 0 0 0 0 A 1 ADDITIONAL MISSION STATEMENT LANGUAGE PEOPLE CENTERED. WE ARE FAMILY AND FRIENDS TAKING CARE OF FAMILY AND FRIENDS. WE OFFER PERSONALIZED SERVICES THAT INCLUDE FAMILY MEMBERS IN THE PATIENT'S CARE. DECISIONS AT ALL LEVELS OF THE ORGANIZATION ARE BASED ON WHAT IS BEST FOR THE PATIENT. WE CREATE A FAMILY-FRIENDLY, FLEXIBLE ENVIRONMENT FOR STAFF TO WORK. TRANSPARENCY AND OPEN FEEDBACK CREATE A POSITIVE CULTURE FOR STAFF TO PROVIDE SERVICES AND CELEBRATE ACHIEVEMENTS. EXCELLENCE DRIVEN. WE STRIVE FOR EXCELLENCE IN EVERYTHING THAT WE DO. OUR FOCUS IS ON "GETTING IT RIGHT" EVERY TIME AT ALL LEVELS OF THE ORGANIZATION. WE CREATE A NON-PUNITIVE CULTURE THAT IS COMMITTED TO ELIMINATING DEFECTS QUICKLY IN ORDER TO PROVIDE SAFE, QUALITY CARE TO ALL PATIENTS. COMMUNITY FOCUSED. WE EXIST TO SUPPORT THE COMMUNITY'S HEALTHCARE NEEDS. OUR GOAL IS TO PROVIDE AFFORDABLE HEALTHCARE AND WELLNESS SERVICES LOCALLY, SO PATIENTS CAN REMAIN WITHIN HENRY COUNTY FOR CARE REGARDLESS OF THEIR ABILITY TO PAY. WE COLLABORATE WITH LOCAL ORGANIZATIONS TO IMPROVE THE HEALTH AND WELL-BEING OF THE COMMUNITY, ALWAYS. THESE VALUES ARE INGRAINED IN OUR CULTURE AND ARE THE FOUNDATION OF HENRY COUNTY HOSPITAL. FORM 990, PART VI, SECTION B, LINE 11B THE FINANCE COMMITTEE OF THE BOARD REVIEWS THE FORM 990 BEFORE FILING AT A REGULARLY SCHEDULED MEETING, TYPICALLY THE FOURTH MONDAY OF THE MONTH. THE FORM 990 THEN GOES TO THE FULL BOARD AT THE FOLLOWING BOARD MEETING FOR REVIEW, TYPICALLY THE FIRST MONDAY OF THE MONTH. FORM 990, PART VI, SECTION B, LINE 12C THE WRITTEN CONFLICT OF INTEREST POLICY IS REGULARLY AND CONSISTENTLY MONITORED AND COMPLIANCE ENFORCED BY THE COMPLIANCE OFFICER. THE SCOPE OF THIS POLICY INCLUDES BOARD MEMBERS, THE LEADERSHIP TEAM, MEDICAL STAFF, AND EMPLOYEES. THE POLICY IS IN PLACE TO IDENTIFY POTENTIAL CONFLICTS OF INTEREST AND PROVIDE A MECHANISM TO MANAGE POTENTIAL CONFLICTS OF INTERESTS. THE COVERED PERSONS ARE TO IDENTIFY POTENTIAL CONFLICTS AND NOT PARTICIPATE IN DISCUSSIONS AND DECISIONS RELATED TO THE IDENTIFIED CONFLICTS. A SELF-DISCLOSURE FORM COVERED PERSONS TO THE COMPLIANCE OFFICER AND THE BOARD IS REQUIRED ON ANY POTENTIAL CONFLICTS OF INTEREST. THE COVERED PERSONS ARE TO RECUSE FROM PARTICIPATING IN ANY DELIBERATION OR DECISIONS ON SUCH TRANSACTIONS. FORM 990, PART VI, SECTION B, LINE 15 THE CEO'S COMPENSATION IS DETERMINED BY BOARD OF DIRECTORS REVIEW. THE BOARD OF DIRECTORS USES THE OHIO HOSPITAL ASSOCIATION COMPENSATION DATA, COMPARABLE DATA OF OUR SURROUNDING HOSPITALS, AND INTERNAL EQUITY TO DETERMINE THE COMPENSATION OF THE CEO. THE FINAL DETERMINATION OF THE COMPENSATION IS APPROVED BY BOARD VOTE. THE COMPENSATION OF OTHER OFFICERS OR KEY EMPLOYEES OF THE ORGANIZATION IS DONE BY SIMILAR REVIEW OF COMPARABLE WAGE DATA FROM THE OHIO HOSPITAL ASSOCIATION AND THE HOSPITAL COUNCIL OF NORTHWEST OHIO. THE MANAGER OF HUMAN RESOURCES MAKES A COMPENSATION RECOMMENDATION BASED ON THE DATA AND INTERNAL EQUITY TO THE CEO. THE CEO AUTHORIZES THE COMPENSATION BASED ON THE DATA AND THE RECOMMENDATION. FORM 990, PART VI, SECTION C, LINE 19 THE ORGANIZATION DOES NOT MAKE GOVERNING DOCUMENTS, CONFLICTS OF INTEREST POLICY OR FINANCIAL STATEMENTS AVAILABLE TO THE PUBLIC. FORM 990, PART IX, LINE 11G EMERGENCY CARE FEES: PROGRAM SERVICE EXPENSES 1,203,271. MANAGEMENT AND GENERAL EXPENSES 0. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 1,203,271. LABORATORY FEES: PROGRAM SERVICE EXPENSES 908,077. MANAGEMENT AND GENERAL EXPENSES 0. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 908,077. ANESTHESIA FEES: PROGRAM SERVICE EXPENSES 1,128,020. MANAGEMENT AND GENERAL EXPENSES 0. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 1,128,020. SURGICAL FEES: PROGRAM SERVICE EXPENSES 1,020,447. MANAGEMENT AND GENERAL EXPENSES 0. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 1,020,447. MEDICAL IMAGING FEES: PROGRAM SERVICE EXPENSES 745,555. MANAGEMENT AND GENERAL EXPENSES 0. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 745,555. OTHER FEES: PROGRAM SERVICE EXPENSES 3,078,926. MANAGEMENT AND GENERAL EXPENSES 1,407,406. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 4,486,332. FORM 990, PART XI, LINE 9: INTEREST IN FOUNDATION NET ASSETS 112,983. OTHER CHANGES IN NET ASSETS -11,665. FORM 990, PART XII, LINE 2C: OVERSIGHT OF AUDIT: THE FINANCE COMMITTEE OF THE BOARD OF DIRECTORS ASSUMES RESPONSIBILITY FOR THE OVERSIGHT OF THE AUDIT OF THE FINANCIAL STATEMENTS AND NO PROCESSES HAVE CHANGED FROM THE PRIOR YEAR. HENRY COUNTY HOSPITAL FOUNDATION 1600 EAST RIVERVIEW NAPOLEON OH 43545 341919852 TO RAISE FUNDS AND PROVIDE FINANCIAL ASSISTANCE TO HENRY COUNTY HOSPITAL OH 501(C)(3) LINE 12A, I 0 HENRY COUNTY PAIN MANAGEMENT LLC 1600 EAST RIVERVIEW NAPOLEON OH 43545 462262320 MEDICAL PAIN MANAGEMENT OH HENRY COUNTY HOSPITAL INC RELATED 2314172 827691 0 1 0.51000 0 1 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 VANTAGE HEALTHCARE OF OHIO LLC 950 W WOOSTER ST BOWLING GREEN OH 43402 472124397 HOSPITALS WORKING TOGETHER FOR COST SAVINGS/REVENUE ENHANCEMENT OH 0 1313 13944 0 1 0.12500