2024-10-29T09:12:22-05:00 2023-12-31 381357951 PLANTE & MORAN PLLC 250 HIGH STREET SUITE 100 COLUMBUS OH 43215 990 2023-01-01 341623769 JTD HOSPITAL FOUNDATION JTDH 4193943387 200 ST CLAIR STREET ST MARYS OH 45885 TRICIA A POHL CFO 4193943387 2024-10-28 1 1 AMY CIMINELLO P00796388 6148493000 2024-10-28 2023 2024-10-15 13:58:12Z TRICIA POHL 200 ST CLAIR STREET ST MARYS OH 45885 551332 0 X WWW.GRANDLAKEHEALTH.ORG X 1989 OH SEE SCHEDULE O FOR THE MISSION STATEMENT 12 11 0 30 0 0 373825 465318 0 0 312 0 25026 13952 399163 479270 322491 368399 0 0 0 0 0 0 307 23506 23420 345997 391819 53166 87451 1084041 1258652 193 0 1083848 1258652 TO SECURE FUNDS FOR THE BENEFIT OF JOINT TOWNSHIP DISTRICT MEMORIAL HOSPITAL'S EFFORTS TO MEET THE HEALTH CARE NEEDS OF OUR COMMUNITIES. 0 0 204313 194431 JTD HOSPITAL FOUNDATION COORDINATES THE FUNDRAISING ACTIVITIES FOR JOINT TOWNSHIP DISTRICT MEMORIAL HOSPITAL. DURING 2023, THE FOUNDATION ACCEPTED AND ADMINISTERED DONATIONS FOR 20 DIFFERENT PROJECTS/FUNDS. 19500 19500 THE FOUNDATION SEEKS FUNDS FOR SCHOLARSHIPS AND AWARDED $19,500 TO STUDENTS IN THE SURROUNDING COMMUNITIES TO HELP ASSURE AN ADEQUATE SUPPLY OF HEALTH CARE PROFESSIONALS. 154468 154468 GRAND LAKE HEALTH SYSTEM RECOGNIZES THE NEED FOR QUALITY END OF LIFE CARE BOTH FOR PATIENTS AND THEIR FAMILIES. THE FOUNDATION RAISED OVER $165,000 TO ASSIST GRAND LAKE HEALTH SYSTEM TO CONTINUE PROVIDING HOSPICE SERVICE TO THE COMMUNITY. OF THIS AMOUNT, $154,000 WAS USED IN 2023 TO HELP SUPPORT THE HOSPICE PROGRAM. 378281 1 1 0 0 0 0 0 0 0 1 0 0 0 0 0 0 0 1 0 0 0 0 0 0 1 1 0 1 1 1 0 0 0 0 0 0 0 0 0 0 0 0 0 1 0 0 0 1 2 1 1 0 0 0 0 0 0 1 1 0 0 0 0 0 0 X 12 11 0 0 0 0 0 0 0 1 1 0 0 1 1 1 1 1 1 0 0 0 X TRICIA A POHL 4193943387 200 ST CLAIR STREET ST MARYS OH 45885 DIANE PIEHL DIRECTOR 1.00 0.00 X 0 13575 5965 DAN BURKE CHAIR 1.00 0.00 X X 0 0 0 BEVERLY WILKER VICE CHAIR 1.00 0.00 X X 0 0 0 JON DERRYBERRY DIRECTOR 1.00 0.00 X 0 0 0 MAJOR BERNHOLD DIRECTOR 1.00 0.00 X 0 0 0 STEVE HARTWIG DIRECTOR 1.00 0.00 X 0 0 0 TIM QUELLHORST DIRECTOR 1.00 0.00 X 0 0 0 BRUCE SWONGER DIRECTOR 1.00 0.00 X 0 0 0 LINDA VOGEL DIRECTOR 1.00 0.00 X 0 0 0 JOHN WILDING DO DIRECTOR 1.00 0.00 X 0 0 0 TANYA TEMPLE DIRECTOR 1.00 0.00 X 0 0 0 LARRY HAMMOND DIRECTOR 1.00 0.00 X 0 0 0 CYNTHIA BERNING PRESIDENT 1.00 44.00 X 0 475591 37672 TRICIA POHL TREASURER 1.00 44.00 X 0 228874 54758 JULIE JACOBS SECRETARY 35.00 10.00 X 0 86740 39096 KEVIN HARLAN FORMER PRESIDENT 0.00 0.00 X 0 199767 0 0 1004547 137491 0 1 1 0 0 80569 384749 465318 23225 80569 38182 -14957 -14957 62789 33880 28909 28909 479270 0 0 13952 348899 348899 19500 19500 2688 2688 13089 9269 3820 6416 6416 1227 613 307 307 391819 378281 13231 307 343589 423536 100000 109999 640452 725117 1084041 1258652 193 193 0 X 77860 86596 1005988 1172056 1083848 1258652 1084041 1258652 87451 87353 0 X X 0 1 X 1 0 X 289876 266135 667701 373825 465318 2062855 289876 266135 667701 373825 465318 2062855 352169 1710686 310 219 234 312 1075 86326 96635 101795 93557 86014 464327 2528257 0.67660 0.74870 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 184631 10017 24204 2500 216352 166975 41309 -18361 5292 184631 62756 100100 4119 166975 63135 100 5916 6395 62756 54607 8528 63135 0.00000 1.00000 0.00000 0 0 0 PART V, LINE 4: THE NED & FERN JOHNS INPATIENT PSYCHIATRIC ENDOWMENT FUND THE INTENTION OF THIS FUND IS TO SUPPORT SPECIALIZED SERVICES TO THE INPATIENT PSYCHIATRIC CENTER. THIS ENDOWMENT FUND MAY BE UTILIZED TO SUPPORT SPECIALIZED SERVICES INCLUDING BUT NOT LIMITED TO MUSIC THERAPY, ART THERAPY, EDUCATION FOR PATIENTS, FAMILIES, AND THE COMMUNITY, ONGOING EDUCATIONAL NEEDS OF INPATIENT PSYCHIATRIC STAFF RELATED TO THE TYPE OF CARE, PROVIDED ON THIS UNIT, AND SUPPLIES SPECIFIC FOR INPATIENT PSYCH PATIENTS SUCH AS WEIGHTED BLANKETS, SENSORY BOXES, FIDGET BOARDS, OR OTHER ACTIVITIES THAT PROVIDE A SAFE SUPPORTIVE ENVIRONMENT AIMED AT HELPING PATIENTS ACHIEVE THEIR OPTIMAL LEVEL OF FUNCTIONING. THE HEINRICH FAMILY ENDOWMENT FUND THE HEINRICH FAMILY ENDOWMENT FUND HAS BEEN ESTABLISHED TO PROVIDE FUTURE INCOME TO SUPPORT JOINT TOWNSHIP DISTRICT MEMORIAL HOSPITAL'S EFFORTS TO MEET THE HEALTH CARE NEEDS OF OUR SURROUNDING COMMUNITIES. THE REQUEST FOR A GRANT MUST BE FOR AN ITEM OR SERVICE THAT WILL BENEFIT THE SAFETY, CARE, AND/OR COMFORT OF PATIENTS BEING CARED FOR BY JOINT TOWNSHIP DISTRICT MEMORIAL HOSPITAL. REQUESTS FOR FUNDS MAY ALSO BE REQUESTED TO SUPPORT A COMMUNITY PARTNERSHIP INITIATIVE THAT RELATES TO A NEED IDENTIFIED IN THE COMMUNITY HEALTH NEEDS ASSESSMENT. GOLF OUTING 53495 38295 15200 5720 5230 1708 HOSPICE GALA 49514 42274 7240 10102 1678 12490 103009 80569 22440 5720 15332 1678 14198 36928 -14488 62789 26607 73 7200 1 0.05000 62789 26607 73 7200 33880 28909 0 THE ACTIVITY INVOLVED WAS A RAFFLE IN WHICH THE PARTICIPANT PAID FOR A TICKET. THE WINNING TICKET RECEIVED THE PRIZE. THIS WAS A FUNDRAISER TO BENEFIT THE FOUNDATION'S MISSION. 0 1 0 1.00000 0.00000 JOINT TOWNSHIP DISTRICT MEMORIAL HOSPITAL 200 ST CLAIR STREET ST MARYS OH 45822 0 JULIE JACOBS 0 OVERALL SUPERVISION AND MANAGEMENT OF RAFFLE X 0 1 JOINT TOWNSHIP DISTRICT MEMORIAL HOSPITAL 200 ST CLAIR STREET ST MARYS OH 45885 341623770 501(C)(3) 348899 0 GENERAL SUPPORT TO FURTHER HEALTHCARE OF THE COMMUNITY 1 0 HEALTHCARE SCHOLARSHIPS FOR STUDENTS IN THE COMMUNITY 20 19500 PART I, LINE 2: JTD HOSPITAL FOUNDATION IS A SUPPORTING ORGANIZATION OF THE JOINT TOWNSHIP DISTRICT MEMORIAL HOSPITAL. THE FOUNDATION WORKS DIRECTLY WITH THE HOSPITAL ON A MULTITUDE OF PROGRAMS THAT ARE IDENTIFIED AS NEEDS BY THE HOSPITAL. WHEN GRANTS ARE AWARDED TO THE HOSPITAL, THE RECEIVING DEPARTMENT IMPLEMENTS AND MONITORS THE PROGRAM. THE EXECUTIVES FOR THE FOUNDATION ARE THE SAME AS THE HOSPITAL AND MONITOR THAT THE FUNDS ARE BEING APPROPRIATELY USED. PART III, COLUMN (B): INDIVIDUALS FOR SCHOLARSHIP AWARDS ARE CHOSEN BASED ON OBJECTIVE AND NON-DISCRIMINATORY CRITERIA WHICH ARE CONSISTENT WITH THE OVERALL TAX EXEMPT PURPOSES OF THE ORGANIZATION. TO BE ELIGIBLE AND CONSIDERED FOR THE NURSING SCHOLARSHIP AND THE LANDEN PHLIPOT NURSING SCHOLARSHIP THE APPLICANT MUST BE A HIGH SCHOOL SENIOR OR CURRENT COLLEGE STUDENT WHO HAS BEEN ACCEPTED TO A SCHOOL OF NURSING. OTHER FACTORS SUCH AS GEOGRAPHICAL LOCATION, GPA, AWARDS, SCHOOL AND COMMUNITY INVOLVEMENT, ESSAY, AND FINANCIAL NEED WILL BE CONSIDERED. THE CINDY BRUNS SCHOLARSHIP IS GIVEN TO A GRAND LAKE HEALTH SYSTEM EMPLOYEE WHO IS PURSUING THEIR COLLEGE EDUCATION. THE RECIPIENTS OF THESE SCHOLARSHIPS ARE DETERMINED THROUGH AN INTERVIEW PROCESS BY THE SCHOLARSHIP COMMITTEE. THE GLHS FAMILY SCHOLARSHIPS ARE $1,000 AWARDS MADE TO (6) AREA HIGH SCHOOL GRADUATING SENIORS PURSUING A DEGREE IN ANY ALLIED HEALTH FIELD. THE APPLICANTS ARE REVIEWED FOR GPA, SCHOOL INVOLVEMENT, AREA OF INTENDED STUDY, GEOGRAPHICAL LOCATION, VOLUNTEERING AND FINANCIAL NEED. EACH HIGH SCHOOL OFFICE SUBMITS THE NAME OF THEIR RECIPIENT FOR THIS AWARD. THE GLHS MEDICAL SCHOLARSHIP (1) IS AWARDED YEARLY TO THE APPLICANT WHO MEETS THE REQUIRED CRITERIA RELATED TO GEOGRAPHICAL HIGH SCHOOL LOCATION, AREA OF INTENDED STUDY, GPA, EVIDENCE OF CONSECUTIVE YEARS OF EDUCATION, ENROLLED IN PRE-MED OR MED SCHOOL, AND IS IN GOOD STANDING WITH THE MEDICAL COLLEGE. THE ACTIVE MEDICAL STAFF OF JOINT TOWNSHIP DISTRICT MEMORIAL HOSPITAL WILL PROVIDE THE JTD HOSPITAL FOUNDATION WITH INFORMATION REGARDING THEIR COMMITTEE'S CHOSEN CANDIDATE(S) FOR A JTDMH MEDICAL SCHOLARSHIP. THE CRITERIA USED TO DETERMINE THE RECIPIENT OF THIS SCHOLARSHIP MAY BE BASED ON, BUT NOT LIMITED TO, THE APPLICANT'S ACADEMIC MERIT (MINIMUM OVERALL GPA), FINANCIAL NEED, GEOGRAPHIC AREA OF RESIDENCE, SPECIALTY SERVICE OF STUDY, AND SCHOOL BEING ATTENDED. 0 1 0 0 0 0 0 0 0 CYNTHIA BERNING PRESIDENT 0 439906 0 35685 0 0 0 6000 0 31672 0 513263 0 0 TRICIA POHL TREASURER 0 222874 0 6000 0 0 0 24248 0 30510 0 283632 0 0 KEVIN HARLAN FORMER PRESIDENT 0 0 0 0 0 199767 0 0 0 0 0 199767 0 199767 PART I, LINE 4B KEVIN HARLAN, THE FORMER PRESIDENT, HAS RECEIVED A PAYOUT FROM THE NON QUALIFIED RETIREMENT PLAN OF $199,767 IN THE CURRENT YEAR DUE TO HIS DEPARTURE FROM JOINT TOWNSHIP DISTRICT MEMORIAL HOSPITAL. THE PLAN IS A SUPPLEMENTAL NONQUALIFIED RETIREMENT PLAN MAINTAINED BY A RELATED ORGANIZATION FOR KEY EMPLOYEES OF THE RELATED ORGANIZATION. THERE IS AN INCENTIVE BONUS PLAN AND A PRODUCTION COMPENSATION PLAN. VESTING HAPPENS OVER A 5 YEAR TIME FRAME IF THE CONTRIBUTION WAS MADE TO THE PRODUCTION COMPENSATION PLAN. THERE ARE CERTAIN CIRCUMSTANCES WHERE A PARTICIPANT WILL FORFEIT ANY AND ALL OF THE COMPANY CONTRIBUTIONS MADE INTO THE PLAN INCLUDING ENGAGING IN ACTIVITIES WHICH ARE DEEMED TO BE SIGNIFICANTLY COMPETITIVE WITH THE COMPANY WITHIN A 50 MILE RADIUS OF ANY EXISTING OFFICE, IF IT IS DEEMED THE PARTICIPANT ACTED IN A DISHONEST WAY, BREACHES HIS OR HER FIDUCIARY OBLIGATIONS, CONVICTED OF A FELONY INVOLVING SIGNIFICANT MORAL TURPITUDE, OR OTHER ACTS WHICH WOULD CAUSE THE COMPANY SUBSTANTIAL HARM. PART I, LINE 3: COMPENSATION PAID TO THE ORGANIZATION'S PRESIDENT IS ESTABLISHED BY A RELATED ORGANIZATION AND INCLUDES USE OF A COMPENSATION COMMITTEE, INDEPENDENT COMPENSATION CONSULTANT, FORM 990 OF OTHER ORGANIZATIONS, COMPENSATION SURVEYS, AND APPROVAL BY THE BOARD OR COMPENSATION COMMITTEE. FORM 990, PART I, LINE 1 MISSION STATEMENT THE PRIMARY EXEMPT PURPOSE OF THE JTD HOSPITAL FOUNDATION IS TO RAISE FUNDS FOR JOINT TOWNSHIP DISTRICT MEMORIAL HOSPITAL, A 501(C)(3) COMMUNITY HOSPITAL. THE FOUNDATION COORDINATES ALL FUNDRAISING ACTIVITIES ON BEHALF OF THE HOSPITAL AND ADMINISTERS ALL DONATED FUNDS. FORM 990, PART VI, SECTION B, LINE 11B A COPY OF FORM 990 IS PROVIDED TO THE BOARD-DESIGNATED COMMITTEE FOR THEIR REVIEW PRIOR TO FILING. THE BOARD-DESIGNATED COMMITTEE WILL REPORT THEIR REVIEW AND RECOMMENDATION OF FILING FORM 990 TO THE FULL BOARD OF DIRECTORS. FORM 990 IS MADE AVAILABLE TO ALL MEMBERS OF THE BOARD OF DIRECTORS PRIOR TO FILING. FORM 990, PART VI, SECTION B, LINE 12C THE CONFLICT OF INTEREST POLICY COVERS ALL BOARD MEMBERS, OFFICERS, AND MANAGERS OF GRAND LAKE HEALTH SYSTEM. ANNUALLY, THESE INDIVIDUALS, AS WELL AS, NEW BOARD MEMBERS WHEN THEY FIRST JOIN, PROVIDE THE PRESIDENT OF THE CORPORATION AN UPDATED LISTING OF ALL BUSINESSES OR OTHER ORGANIZATIONS OF WHICH HE OR SHE IS A TRUSTEE, OFFICER, DIRECTOR, MEMBER, PARTNER, OWNER, GENERAL MANAGER, SUBSTANTIAL SHAREHOLDER, EMPLOYEE OR FOR WHICH HE OR SHE ACTS AS AN AGENT. WHEN A CONFLICT OF INTEREST IS IDENTIFIED, THE DETERMINATION IS MADE AND DISCUSSED OPENLY AT THE BOARD LEVEL. THE INDIVIDUAL IS THEN PROHIBITED FROM PARTICIPATING IN THE BOARD'S DELIBERATIONS AND DECISIONS. FORM 990, PART VI, SECTION B, LINE 15 THE SALARY AMOUNT FOR THE PRESIDENT IS REVIEWED AND APPROVED BY A RELATED ENTITY'S, JOINT TOWNSHIP DISTRICT MEMORIAL HOSPITAL, BOARD EXECUTIVE COMMITTEE. THE EXECUTIVE COMMITTEE USES THE OHIO HOSPITAL ASSOCIATION'S ANNUAL CHIEF EXECUTIVE OFFICER COMPENSATION SURVEY, ARTHUR J. GALLAGHER & CO. (AN INDEPENDENT COMPENSATION CONSULTANT), ANNUAL NATIONAL HEALTHCARE LEADERSHIP COMPENSATION SURVEY, OTHER 990'S FILED BY OTHER HOSPITALS, AND INPUT FROM THE FOLLOWING: INTEGRATED HEALTHCARE STRATEGIES, BOARD OF TRUSTEES, AND BOARD EXECUTIVE COMMITTEE TO DETERMINE THE PRESIDENT'S SALARY. THE BOARD CHAIR WRITES A MEMO TO THE DIRECTOR OF FINANCIAL SERVICES. DOCUMENTATION REGARDING THE PRESIDENT'S SALARY AND RECORD KEEPING REGARDING DELIBERATIONS IS KEPT BY THE BOARD EXECUTIVE COMMITTEE. SALARY AMOUNTS FOR OFFICERS AND OTHER KEY EMPLOYEES ARE REVIEWED AND APPROVED BY THE PRESIDENT. THE PRESIDENT REFERENCES THE OHA COMPENSATION SALARY SURVEY. THE PRESIDENT IS APPROVED BY THE BOARD OF DIRECTORS TO PERFORM THIS PROCESS. FURTHERMORE, THE PRESIDENT IS COMPLETELY INDEPENDENT FROM ALL OFFICERS AND KEY EMPLOYEES. THIS PROCESS WAS LAST COMPLETED IN DECEMBER 2023. FORM 990, PART VI, SECTION C, LINE 19 THE ORGANIZATION MAKES ITS GOVERNING DOCUMENTS, CONFLICT OF INTEREST POLICY, AND FINANCIAL STATEMENTS AVAILABLE TO THE PUBLIC UPON REQUEST. FORM 990, PART XII, LINE 2C EXPLANATION THE FINANCE COMMITTEE OF A RELATED ENTITY, JOINT TOWNSHIP DISTRICT MEMORIAL HOSPITAL, ASSUMES RESPONSIBILITY FOR THE OVERSIGHT OF THE AUDIT AND THE SELECTION OF THE INDEPENDENT ACCOUNTANT. THIS PROCESS HAS NOT CHANGED SINCE LAST YEAR. JOINT TOWNSHIP DISTRICT MEMORIAL HOSPITAL 200 ST CLAIR STREET ST MARYS OH 45885 341623770 HEALTH CARE SERVICES OH 501(C)(3) LINE 3 N/A 0 JTDMH PAIN MANAGEMENT LLC 200 CLAIR ST ST MARYS OH 45885 465353958 PAIN MANAGEMENT OH N/A 0 0 JTDM FAMILY PRACTICE INC 200 ST CLAIR STREET ST MARYS OH 45885 341689161 PHYSICIANS PROVIDING MEDICAL SERVICES OH N/A C 1 0 1 0 0 0 0 0 0 0 0 0 0 0 1 1 1 0 0 1 JOINT TOWNSHIP DISTRICT MEMORIAL HOSPITAL B 349097 CASH JOINT TOWNSHIP DISTRICT MEMORIAL HOSPITAL S 65262 CASH