2022-05-11T13:40:45-05:00 2021-06-30 KPMG LLP 303 PEACHTREE ST STE 2000 ATLANTA GA 30308 990 2020-07-01 331216751 Hughston Hospital Inc % MARIE GAFFNEY HUGH 7066606103 707 Center Street Columbus GA 31901 MARIE GAFFNEY VP CORPORATE FINANCE 4044251303 2022-05-10 true MARIE GAFFNEY 999009999 WHITNEY B HEBRON P01226647 4042223000 2022-05-10 2 2020 2022-09-23 18:48:47Z PIEDMONT COLUMBUS NORTHSIDE HOSPITAL MR M SCOTT HILL 707 Center Street Columbus GA 31901 96015417 false X www.piedmont.org X 2008 GA TO PROVIDE COMPASSIONATE AND SUSTAINABLE HEALTHCARE IN A PROGRESSIVE ENVIRONMENT. 10 8 565 425 0 0 2013015 0 89896892 95336996 265518 678421 0 0 92175425 96015417 0 0 0 0 31650759 34099316 0 0 0 58389797 54956911 90040556 89056227 2134869 6959190 85888308 85972460 68970475 57964802 16917833 28007658 TO PROVIDE HEALTHCARE MARKED BY COMPASSION AND SUSTAINABLE EXCELLENCE IN A PROGRESSIVE ENVIRONMENT, GUIDED BY PHYSICIANS, DELIVERED BY PROFESSIONALS, AND INSPIRED BY THE COMMUNITIES WE SERVE. false false 82830191 0 95336996 HUGHSTON HOSPITAL ("PH") IS A 100-BED FACILITY THAT SERVES THE CITY OF COLUMBUS IN MUSCOGEE COUNTY, GEORGIA. OUR PRIMARY CARE AND SPECIALTY PHYSICIANS ON THE MEDICAL STAFF MEET THE PROFESSIONAL CLINICAL NEEDS OF CHILDREN, ADULTS, AND SENIORS WITHIN THE CITY AND THE GREATER COLUMBUS MARKET, REGARDLESS OF ANY INDIVIDUAL'S ABILITY TO PAY FOR SERVICES. FOR THE YEAR ENDED JUNE 30, 2021, THE HOSPITAL HAD 3,848 IN-PATIENT ADMISSIONS WITH A TOTAL OF 22,120 DAYS OF IN-PATIENT HOSPITALIZATION. ER VISITS TOTALED 28,525 AND OUTPATIENT VISITS TOTALED 13,701. SURGICAL SERVICES WERE PROVIDED TO 4,983 PATIENTS. 82830191 true false false false false false false false false true false false false true true false true false false false false false false false false true true false false true false false false false false false false false false false false false false true false false false true X 0 0 565 true false false false false false false false false false false false false X 10 8 false false false false true true true true true false false false true true true true true true true false GA X MARIE GAFFNEY 4702716007 2727 PACES FERRY RD BLDG 2 STE 70 ATLANTA GA 30339 X Mr M Scott Hill Board Member & CEO CRHS 5.0 50.0 X X 0 2389396 83889 Mr Michael McAnder Treasurer (End 7/20) 1.0 54.0 X 0 1284929 72127 Ms Elizabeth Leddy Secretary 1.0 54.0 X 0 843802 126625 Mr Thomas Arnold Treasurer (Eff 7/20) 1.0 54.0 X 0 827550 92917 Dr Todd Jarrell MD Board Member 1.0 54.0 X 0 712811 29098 Ms Laura Drew COO 5.0 50.0 X 0 578926 17477 Mr Allen Holladay CFO 5.0 50.0 X 0 428688 18255 Ms Holly Lehmberg Exec. 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UNDER THE REQUIREMENTS OF ASC 740, TAX-EXEMPT ORGANIZATIONS MAY BE REQUIRED TO RECORD AN OBLIGATION AS THE RESULT OF A TAX POSITION THEY HAVE HISTORICALLY TAKEN ON VARIOUS UNCERTAIN TAX EXPOSURE ITEMS. THERE WERE NO MATERIAL UNCERTAIN TAX POSITIONS AT JUNE 30, 2021 AND 2020. true true X true X 300. true X true true false true true 1867963 1867963 0.02260 1191080 1350425 0 0.00000 1012087 18250 993837 0.01210 4071130 1368675 2861800 0.03470 4071130 1368675 2861800 0.03470 25000 0 25000 0.00010 25000 0 25000 0.00010 true 2995605 18692140 17963891 728249 X true true 1 1 HUGHSTON HOSPITAL INC 707 CENTER STREET COLUMBUS GA 31901 WWW.piedmont.org 106-659 X X X HUGHSTON HOSPITAL INC 1 false false true X X X X X X X X 18 true true false true X SEE PART V X X true 19 true SEE PART V false true X 300. 300. X true true X X X X true X SEE PART V X SEE PART V X SEE PART V X X X X X X true X false X X X X true X false false HUGHSTON HOSPITAL, INC.: Schedule H, PART V, SECTION B, LINE 5: COMMUNITY REPRESENTATION As a part of our process, we interviewed 31 key stakeholders and policy makers that represent public health, low-income populations, uninsured and uninsured persons, minorities, chronic conditions, older adults, and lawmakers. Further, in December 2018 and December 2019, 133 key stakeholders within the Piedmont Columbus Hospital community, including Hughston Hospital, provided their thoughts on community health, community assets and the role of the hospital in addressing unmet community health needs via a web survey. Below are the results of that survey. These interviews were conducted for people representing the entire region, including Muscogee County. Specifically, we interviewed representatives of local and regional public health entities, minority populations, faith-based communities, local business owners, the philanthropic community, mental health agencies, elected officials and individuals representing our most vulnerable patients. The Piedmont Healthcare board of directors and leadership from all 11 hospitals were actively informed and engaged throughout this process. Schedule H, PART V, SECTION B, LINE 6A: COMMUNITY HEALTH NEEDS ASSESSMENT THE COMMUNITY HEALTH NEEDS ASSESSMENT WAS CONDUCTED FOR PIEDMONT COLUMBUS REGIONAL HEALTHCARE SYSTEM, FEIN 58-1719994, WHICH INCLUDES THE MEDICAL CENTER, INC., FEIN 58-1685139, AND HUGHSTON HOSPITAL, INC., FEIN 33-1216751. Schedule H, PART V, SECTION B, LINE 7a: CHNA REPORT WEBSITE https://www.piedmont.org/media/file/PCR-FY19-CHNA-Strategy.pdf Schedule H, PART V, SECTION B, LINE 7d: PUBLIC AVAILABILITY OF CHNA IN ADDITION TO MAKING ITS CHNA AVAILABLE ON ITS WEBSITE AND BY REQUEST, HUGHSTON HOSPITAL SENT COPIES TO EACH PARTICIPANT IN THE CHNA PROCESS, DISTRIBUTED THE ASSESSMENTS TO COMMUNITY CENTERS AND OTHER LOCATIONS THAT PRIMARILY SERVE AN UNINSURED POPULATION, SENT COPIES TO LEGISLATIVE AND ELECTED OFFICIALS, AND WIDELY DISTRIBUTED THE ASSESSMENTS TO OTHER PIEDMONT HEALTHCARE HOSPITALS. Schedule H, PART V, SECTION B, LINE 10a: IMPLEMENTATION STRATEGY THE BOARD OF DIRECTORS FOR HUGHSTON HOSPITAL UNANIMOUSLY APPROVED ITS IMPLEMENTATION STRATEGY FOR THE THREE YEAR PERIOD BEGINNING WITH FY20 ON OCTOBER 3, 2019, WITHIN THE GRACE PERIOD FOLLOWING THE APPROVAL OF THE NEW COMMUNITY HEALTH NEEDS ASSESSMENT. THE FOLLOWING LINK IS FOR THE IMPLEMENTATION STRATEGY EFFECTIVE THROUGH JUNE 30, 2022. THE IMPLEMENTATION STRATEGY IS LOCATED AFTER THE COMMUNITY HEALTH NEEDS ASSESSMENT IN THE FOLLOWING LINK. https://www.piedmont.org/media/file/PCR-FY19-CHNA-Strategy.pdf Schedule H, PART V, SECTION B, LINE 11: ADDRESSING COMMUNITY HEALTH NEEDS PIEDMONT HEALTHCARE ACQUIRED HUGHSTON HOSPITAL IN THE MIDST OF ITS THREE YEAR CHNA AND IMPLEMENTATION STRATEGY CYCLE UNDER ITS PREVIOUS OWNER. PIEDMONT HEALTHCARE IN CONJUNCTION WITH HUGHSTON HOSPITAL DEVELOPED THE NEW IMPLEMENTATION STRATEGY TO ADDRESS THE REGION'S PRIORITY NEEDS DURING FY20-22. THE HUGHSTON HOSPITAL BOARD OF DIRECTORS UNANIMOUSLY APPROVED THE NEW CHNA ON JUNE 6, 2019. BASED ON THE CHNA, HUGHSTON HOSPITAL WILL FOCUS ON THE FOLLOWING: (1) INCREASE ACCESS TO APPROPRIATE AND AFFORDABLE HEALTH AND MENTAL CARE FOR ALL COMMUNITY MEMBERS, AND ESPECIALLY THOSE WHO ARE UNINSURED AND THOSE WITH LOW INCOMES; (2) REDUCE OPIOID AND RELATED SUBSTANCE ABUSE AND OVERDOSE DEATHS; (3) DECREASE DEATHS FROM CANCER AND INCREASE ACCESS TO CANCER PROGRAMMING FOR THOSE LIVING WITH THE DISEASE (4) DECREASE THE IMPACT OF AND DEATHS FROM STROKE; (5) REDUCE RATES OF OBESITY AND INCREASE ACCESS TO HEALTHY FOODS AND RECREATIONAL ACTIVITIES; AND (6) DECREASE PREVENTABLE INSTANCES OF DIABETES AND DECREASE THE NUMBER OF PATIENTS WITH UNCONTROLLED DIABETES. Schedule H, PART V, LINE 16A: FINANCIAL ASSISTANCE POLICY WEBSITE https://www.piedmont.org/media/file/Financial-Assistance-Policy.pdf Schedule H, PART V, LINE 16B: FINANCIAL ASSISTANCE POLICY WEBSITE https://www.piedmont.org/media/file/Financial-Assistance-Application.pdf Schedule H, PART V, LINE 16C: FAP PLAIN LANGUAGE SUMMARY WEBSITE https://www.piedmont.org/media/file/Financial-Assistance-Plain-Language-Su mmary-English.pdf SCHEDULE H, PART VI, LINE 1: REQUIRED DESCRIPTIONS PUBLIC AVAILABILITY OF COMMUNITY BENEFIT REPORT SCHEDULE H, PART I, LINE 6A WE REGULARLY REPORT TO THE COMMUNITY OUR COMMUNITY BENEFIT ACTIVITIES IN SEVERAL WAYS. EACH YEAR, WE PREPARE A SYSTEMWIDE COMMUNITY BENEFIT REPORT THAT IS AVAILABLE TO THE PUBLIC THROUGH PUBLICATION ON OUR WEBSITE. WE ALSO MAKE AVAILABLE COPIES OF OUR IRS FORM 990 SCHEDULE H ON OUR WEBSITE AND AVAILABLE TO ANYONE UPON REQUEST. WE ALSO PROVIDE INFORMATION ON COMMUNITY BENEFIT PROGRAMMING TO LOCAL, STATE, AND FEDERAL LAWMAKERS THROUGH OUR GOVERNMENT AFFAIRS OFFICE. PERCENT OF TOTAL EXPENSE SCHEDULE H, PART I, LINE 7(F) THE DENOMINATOR USED FOR THE CALCULATION OF COLUMN (F), PERCENT OF TOTAL EXPENSE, WAS THE AMOUNT OF TOTAL FUNCTIONAL EXPENSES ON FORM 990, PART IX, LINE 25, COLUMN (A) OF $89,056,227, LESS BAD DEBT EXPENSE OF $6,583,699 FROM FORM 990, PART IX, LINE 24(B). FINANCIAL ASSISTANCE AND CERTAIN OTHER COMMUNITY BENEFITS AT COST SCHEDULE H, PART I, LINE 7 A RATIO OF PATIENT CARE COST TO CHARGES, CONSISTENT WITH WORKSHEET 2, WAS USED TO REPORT THE AMOUNTS IN PART I, LINES 7A-7D. FOR AMOUNTS ON LINES 7E-7K, ACTUAL EXPENSES FOR EACH COMMUNITY BENEFIT ACTIVITY ARE TRACED AND REPORTED USING THE ORGANIZATION'S COST ACCOUNTING SYSTEM. BAD DEBT EXPENSE CALCULATION AND FOOTNOTE SCHEDULE H, PART III, LINES 2-4 The provision for bad debts is based upon leadership's assessment of historical and expected net collections considering business and economic conditions, trends in health care coverage and other collection indicators. Periodically, leadership assesses the adequacy of the allowance for doubtful accounts based upon historical write-off experience by payor category. The results of the review are then used to make any modifications to the provision for bad debts to establish an appropriate allowance for uncollectible receivables. BAD DEBT EXPENSE FOOTNOTE FROM CONSOLIDATED, AUDITED FINANCIAL STATEMENTS: THE PROVISION FOR BAD DEBTS IS BASED UPON MANAGEMENT'S ASSESSMENT OF HISTORICAL AND EXPECTED NET COLLECTIONS CONSIDERING BUSINESS AND ECONOMIC CONDITIONS, TRENDS IN HEALTH CARE COVERAGE, AND OTHER COLLECTION INDICATORS. PERIODICALLY, MANAGEMENT ASSESSES THE ADEQUACY OF THE ALLOWANCE FOR DOUBTFUL ACCOUNTS BASED UPON HISTORICAL WRITE-OFF EXPERIENCE BY PAYOR CATEGORY. THE RESULTS OF THIS REVIEW ARE THEN USED TO MAKE ANY MODIFICATIONS TO THE PROVISION FOR BAD DEBT TO ESTABLISH AN APPROPRIATE ALLOWANCE FOR UNCOLLECTIBLE RECEIVABLES. PNH PROVIDES CARE TO PATIENTS WHO MEET CERTAIN CRITERIA UNDER ITS CHARITY CARE POLICY WITHOUT CHARGE OR AT AMOUNTS LESS THAN ITS ESTABLISHED RATES. AMOUNTS DETERMINED TO QUALIFY AS CHARITY CARE ARE NOT REPORTED AS REVENUE. BAD DEBT METHODOLOGY SCHEDULE H, PART III, LINE 4 THE PROVISION FOR BAD DEBTS IS BASED UPON MANAGEMENT'S ASSESSMENT OF HISTORICAL AND EXPECTED NET COLLECTIONS CONSIDERING BUSINESS AND ECONOMIC CONDITIONS, TRENDS IN HEALTH CARE COVERAGE AND OTHER COLLECTION INDICATORS. PERIODICALLY, MANAGEMENT ASSESSES THE ADEQUACY OF THE ALLOWANCE FOR DOUBTFUL ACCOUNTS BASED UPON HISTORICAL WRITE-OFF EXPERIENCE BY PAYOR CATEGORY. THE RESULTS OF THE REVIEW ARE THEN USED TO MAKE ANY MODIFICATIONS TO THE PROVISION FOR BAD DEBTS TO ESTABLISH AN APPROPRIATE ALLOWANCE FOR UNCOLLECTIBLE RECEIVABLES. MEDICARE SHORTFALLS AS COMMUNITY BENEFIT SCHEDULE H, PART III, LINE 8 THE AMOUNT REPORTED ON PART III, LINE 6, WAS CALCULATED IN ACCORDANCE WITH SCHEDULE H INSTRUCTIONS BY UTILIZING THE ORGANIZATION'S ALLOWABLE MEDICARE COST AS REPORTED IN THE MEDICARE COST REPORT, WHICH IS BASED ON A COST TO CHARGE RATIO. HOWEVER, THE ALLOWABLE COSTS IN THE MEDICARE COST REPORT DO NOT REFLECT THE ACTUAL COST OF PROVIDING CARE TO PATIENTS SINCE THE MEDICARE COST REPORT EXCLUDES MANY DIRECT PATIENT CARE COSTS THAT ARE ESSENTIAL TO PROVIDE QUALITY HEALTHCARE FOR MEDICARE PATIENTS. FOR EXAMPLE, CERTAIN COVERAGE FEES TO PHYSICIANS, COST OF MEDICARE C AND D, AND OTHER SIMILAR DIRECT PATIENT CARE EXPENSES ARE SPECIFICALLY EXCLUDED FROM ALLOWABLE COST IN THE MEDICARE COST REPORT. THE ORGANIZATION BELIEVES THAT PIEDMONT NEWNAN HOSPITAL'S MEDICARE SHORTFALL REPORTED ON PART III, LINE 7 OF SCHEDULE H, SHOULD BE CONSIDERED A COMMUNITY BENEFIT AS THE IRS COMMUNITY BENEFIT STANDARD INCLUDES THE PROVISION OF CARE TO ELDERLY AND MEDICARE PATIENTS. IRS REVENUE RULING 69-545 PROVIDES, IN PART, THAT HOSPITALS SERVING PATIENTS WITH GOVERNMENTAL HEALTH INSURANCE, SUCH AS MEDICARE, IS AN INDICATION THE HOSPITAL OPERATES TO PROMOTE HEALTH IN THE COMMUNITY. MEDICARE ACCOUNTED FOR 52.69% OF HUGHSTON HOSPITAL'S PATIENT SERVICE REVENUE. ADDITIONALLY, CHARITY CARE ACCOUNTED FOR AN ADDITIONAL 2.29% OF HUGHSTON HOSPITAL'S PATIENT SERVICE REVENUE. HUGHSTON HOSPITAL'S POLICY IS TO TREAT MEDICARE PATIENTS, REGARDLESS OF THE EXTENT TO WHICH MEDICARE ACTUALLY PAYS FOR THE TREATMENT. FOR MANY SERVICES, MEDICARE'S REIMBURSEMENT IS LESS THAN THE COST OF THE CARE PROVIDED, RESULTING IN SHORTFALLS THAT ARE TO BE ABSORBED BY THE HOSPITAL IN HONOR OF HUGHSTON HOSPITAL'S COMMITMENT TO TREAT ELDERLY PATIENTS. MANY OF THESE PATIENTS LIVE ON A LOW, FIXED INCOME, AND WOULD QUALIFY FOR FINANCIAL ASSISTANCE OR OTHER MEANS-TESTED PROGRAMS, ABSENT FROM THEIR ENROLLMENT IN MEDICARE. COLLECTION PRACTICES SCHEDULE H, PART III, LINE 9(B) INITIAL SCREENINGS OF ALL INPATIENT, EMERGENCY, AND SURGERY ENCOUNTERS, AS WELL AS MOST OUTPATIENT VISITS, ARE CONDUCTED BY FINANCIAL COUNSELORS IN ORDER TO IDENTIFY ANY AVAILABLE INSURANCE OR OTHER COVERAGE FOR EACH PATIENT. COUNSELORS CONTACT PATIENTS AND THEIR FAMILIES DIRECTLY, EITHER IN PERSON OR BY LETTER, TO ASSIST THE FAMILY IN IDENTIFYING ANY PROGRAMS FOR WHICH THE PATIENT/SERVICE MAY QUALIFY (INCLUDING MEDICAID, STATE CHILDREN'S HEALTH INSURANCE PROGRAM ("SCHIP"), PRIVATE OR GOVERNMENT INSURANCE COVERAGE, AND CHARITY ASSISTANCE). IF THE FAMILY CANNOT BE TIMELY LOCATED OR IS UNCOOPERATIVE, RELATED ACCOUNTS ARE TRANSFERRED TO AN INTERNAL COLLECTION DEPARTMENT FOR FURTHER ATTEMPTS TO OBTAIN PAYMENT OR, IF THE PATIENT MAY QUALIFY FOR ASSISTANCE, TO SECURE A FINANCIAL ASSISTANCE APPLICATION. THE ORGANIZATION'S DEBT COLLECTION POLICY AND PROCEDURES PROHIBIT ANY COLLECTION EFFORTS FOR THE PORTION OF A PATIENT ACCOUNT BALANCE THAT QUALIFIES FOR FINANCIAL ASSISTANCE UNDER THE ORGANIZATION'S CHARITY CARE POLICY. SCHEDULE H, PART VI, LINE 2: NEEDS ASSESSMENT As a designated 501(c)(3) nonprofit hospital, Hughston Hospital is required by the Internal Revenue System to provide to conduct a triennial community health needs assessment (CHNA), in accordance with regulations put forth by the IRS following the 2010 Patient Protection and Affordable Care Act (ACA). Through this assessment, we hope to better understand local health challenges, identify health trends in our community, determine gaps in the current health delivery system and craft a plan to address those gaps and the identified health needs. In FY19, Hughston Hospital conducted its third triennial CHNA. As in the past, hospital conducted a joint CHNA for both its campuses. FY21 was Year Two of the hospital's three-year CHNA implementation strategy. Our CHNA was led by the Piedmont Healthcare community benefits team, with significant input and direction from Piedmont Columbus leadership, including the hospital's community outreach team. Process The CHNA started first with a definition of our community, of which we determined was our home county, due to the impact of our tax-exempt status. Generally speaking, property taxes make up the largest segment of a hospital's tax exemption, which impacts county revenues. Because of this, we aim to ensure that we are providing ample benefit to our county and its residents. Additionally, we take into consideration patient origin, and especially that of our lower-income patients, such as those who qualify for financial assistance or receive insurance coverage through Medicaid. Our secondary communities are considered the areas in which we have the highest concentration of patients fitting that criterion, including ones from nearby communities. Once we established our primary and secondary communities, we conducted an analysis of available public health data. This included resources from: US Census, US Health and Human Services' Community Health Status Indicators, US Department of Agriculture, Economic Research Service, National Center for Education Statistics, Kaiser Family Foundation's State Health Facts, American Heart Association, County Health Rankings and Georgia Online Analytical Statistical Information System (OASIS). All figures within the CHNA were for 2017, unless otherwise noted. Health indicators are estimates provided by County Health Rankings and hospital data were internally sourced. An internal survey was also conducted throughout the healthcare system for both clinical and non-clinical employees. Information was gathered on knowledge and understanding of community benefit and current programs, as well as suggestions for how we can better serve our patients and communities. Nearly 900 employees spanning the system responded. Additionally, we conducted a community-based survey in which local stakeholders were asked their thoughts on unmet community health needs and our role in addressing those needs. These stakeholders included local leaders, nonprofit representatives, elected officials, and those with a unique knowledge of the challenges vulnerable populations face. We also evaluated previous community benefit, hospital and community interventions identified in our last CHNA implementation strategies through three lenses: impact, outcomes, and sustainability. Interventions and programming considered to have a high score on all three were included in this CHNA and our subsequent strategy. This included our charitable clinic-hospital partnerships, and our heart- and stroke-focused community programming. In March 2019, our community outreach team convened a meeting of key stakeholders to discuss health challenges and needs in the local community. Among the 47 stakeholders present were representatives from MercyMed of Columbus charitable clinic, Valley Healthcare System, the Muscogee County School District, the Muscogee County Health Department and Columbus Consolidated Government. The goal of this meeting was to establish community consensus on top unmet health needs the hospital should address. Finally, we conducted direct interviews with 31 state and regional stakeholders and policymakers, with each representing a specific group that tends to be adversely impacted by issues of health equity. These groups included but are not limited to Georgians for a Healthy Future, Georgia Watch, ConsiderHealth, the Community Foundation for Greater Atlanta, the Georgia Charitable Care Network, the Medical Association of Georgia and Healthy Mothers, Healthy Babies. Additionally, we sought and received feedback on our CHNA from public health. Our priorities With each priority, we work to achieve greater health equity by reducing the impact of poverty and other socioeconomic indicators. This means that health equity is built into each priority, and that is demonstrated through our implementation strategies. Our chosen priorities were, in no order: . Increase access points for appropriate and affordable health care for all community members, and especially those who are uninsured and those with low incomes; . Decrease deaths from cancer and increase access to cancer programming for those with living the disease; . Decrease preventable instances of diabetes and decrease the number of patients with uncontrolled diabetes; . Reduce rates of obesity and increase access to healthy foods and recreational activities; . Decrease the impact of and deaths from stroke; and . Reduce opioid and related substance abuse and overdose deaths. The chosen priorities were recommended by the community benefit department with sign-off from hospital and board leadership. The following criteria were used to establish the priorities: . The number of persons affected; . The seriousness of the issue; . Whether the health need particularly affected persons living in poverty or reflected health disparities; and, . Availability of community and/or hospital resources to address the need. The priorities we chose reflected a collective agreement on what hospital leadership, staff and the community felt was most important and within our ability to positively impact the issue. While the priorities reflect clinical access and certain conditions, all priorities are viewed through the lens of health disparities, with particular attention paid to improving outcomes for those most vulnerable due to income and race. This community health needs assessment was unanimously approved by the Piedmont Columbus Regional Board of Directors on June 06, 2019. Our implementation strategy was developed in partnership with hospital leadership and community stakeholders to address the identified priorities in our FY19 community health needs assessment. The implementation strategy was designed to be executed over a three-year period and included specific metrics by which we would be able to evaluate our work and its impact. The implementation strategy was developed by utilizing community feedback from the assessment in partnership with the system community benefits department, our leadership, and our board of directors. As mentioned above, we included proven and successful interventions and programming, investing further in work we felt was successful in addressing unmet health needs. The CHNA implementation strategy was unanimously approved October 03, 2019. SCHEDULE H, PART VI, LINE 3: PATIENT EDUCATION OF ELIGIBILITY FOR ASSIST. We understand that not everyone can pay their hospital bill due to their insurance status or a limited income, and because of this, we offer financial assistance to qualifying patients. Notification about financial assistance includes, but is not limited to, a dedicated contact number, notices in patient bills, within the Conditions of Admission form, and posted notices in key areas of the hospital. These locations are the emergency room, at admitting and registration departments, our business office, and patient financial services office that are located on site. We also publish and widely publicize a plain language summary of this financial assistance care policy on our website, as well as the full policy. Referral of patients for financial assistance may be made by any staff or medical staff member at the hospital, including physicians, nurses, financial counselors, social workers, case managers, chaplains, and religious sponsors. A request for financial assistance may be made by the patient or a family member, close friend, or associate of the patient, subject to applicable privacy laws. Additionally, we provide copies of our financial assistance policy to our partner clinics and others who work closely with low-income populations. We help our partners understand the policy and how it relates to their populations and receive feedback in ways our financial assistance programming could be improved. Finally, Piedmont Healthcare annually publishes a directory of services and programs for low-income community members, and within this resource guide are extensive directions and advice on how to apply for our patient financial assistance program. Also, in this guide is information on how to apply for certain government assistance programs, resources to help prepare and file tax returns, as well as detailed resources for local sliding scale and free mental, dental and health resources. This guide is widely distributed to the community via hardcopy, is available within our hospitals and is digitally available online. The guide is available in both English and Spanish. SCHEDULE H, PART VI, LINE 4: COMMUNITY INFORMATION We are in Muscogee County, where an average 195,739 people lived in the 216.44 square mile area between 2015 and 2019. Muscogee County is 97 percent urban and 3 percent rural. The population density for this area, estimated at 904.37 persons per square mile, is greater than the national average population density of 94 persons per square mile. The population increased by 9 percent between 2010 and 2020. Between 2015 and 2019, about 43 percent of all Muscogee County residents were white, 46 percent were African American, 3 percent were Asian, and 1 percent were Native American/Alaskan Native and Pacific Islanders. The Latino population increased by 36 percent between 2010 and 2020. The median age of people living within the county was 34, and the county skews slightly female. A quarter of the population were 18 or younger, 13 percent were over the age of 65 and 62 percent were between ages 18 and 64. In Muscogee County, 14 percent of the population over 18 identify as a veteran and 18 percent of those identified as have a disability. About 2 percent of the population had limited English proficiency, which references the populations aged 5 and older who speak a language other than English at home and speak English less than "very well." Most of those households spoke Spanish. About 5 percent of the population were born outside of the United States and are considered foreign born, and a total 2 percent of county residents do not hold US citizen status. This data point does not include individuals who may hold Green Card permissions. Twenty-one percent of the county - about 39,000 people - lived in poverty between 2015 and 2019. During that same time, 29 percent of children in Muscogee County lived in poverty, a figure that has steadily increased over the last ten years. It is significantly higher than the state average of 18.5 percent. Nearly 78 percent of public-school children were eligible for the free or reduced priced lunch program during the 2018-2019 school year, which is higher than the 2014-15 state average of 62 percent. Twenty-six percent of the population has, at a minimum, attended some college, with 35 percent having obtained an associate degree or higher. Twenty-seven percent graduated high school only and 12 percent of the population did not graduate high school. The Muscogee County graduation rate (ACGR) between 2015 and 2019 was 86 percent. Fifty-three percent of children aged 3 and 4 were enrolled in preschool, on average, during that time. From 2015-19 there were about 7 percent of young people not enrolled in school and were also unemployed. In Muscogee County, between 2015 and 2019, there were an average 72,759 households. Of those households, 56 percent were occupied by renters. Non-family households equated to 38 percent, and the rest were lived in by families. Single female family households held higher at 18 percent as compared to single male family households, which was 5 percent. Of all households in Muscogee County, 38 percent were married family households. The percent of all households with children in In Muscogee County was 32 percent and married family households with children was 17 percent. Thirty-seven percent of households had housing costs that exceeded more than 30 percent of total household income between 2015 and 2019, indicating a cost burdened household more likely to face overall financial difficulty. Two-thirds of all rental households were cost burdened, which is a significant number. Owner-occupied households with a mortgage that were cost burdened was 31 percent. Housing quality of occupied units with one or more substandard condition was high at 38 percent with 4 percent of households completely lacked kitchen facilities and 3 percent lacked telephone services. Less than one percent of households lacked plumbing facilities. In Muscogee County, 12 percent of county residents were uninsured in 2019. Roughly 22 percent of the population received SNAP benefits. For every 1,000 teen girls aged 15 to 18 in Muscogee County, roughly 39 gave birth to a child on average each year between 2013 and 2019. Children born to teens are statistically much more likely to experience adverse health and socioeconomic issues as they grow older. Approximately, 12 percent of all live births were considered low birth weight births. Violence is an issue in Muscogee County. Homicide was the second leading cause of premature death for all races. The violent crime rate is far above both state and national averages, with about 607 violent crimes per every 100,000 people as of 2016. The annual property crime rate for 2016 was 5,650 incidences of crime per 100,000 people. In 2019, there were on average 12 recreation and fitness facilities per 100,000 people. There were 117 fast food restaurants in Muscogee County that year, a number down from the year before. Twenty-one percent of census tracts (11 tracts) in Muscogee County were considered a food desert. A food desert is an area where it is difficult to buy affordable and/or good-quality fresh food. As of 2019, there were about 19 grocery store establishments per 100,000 people in Muscogee County and 11 retailers per 10,000 people that were SNAP-authorized food stores. Various health behavior indicators showed that 18 percent of adults reported excessive drinking of alcohol and 16 percent binge drinking in the last 30 days. In 2018, about 19 percent of adults were current smokers. There were nearly 28 percent of adults who reported having no leisure time for physical activity. There were 677 people per 100,000 that lived with HIV in 2018. HIV is a life-threatening communicable disease that disproportionately affects minority populations and may also indicate the prevalence of unsafe sex practices. The Muscogee rate is slightly higher than the state average and nearly double the national average. Chlamydia incidence was much higher than both state averages and nearly double national averages in 2018, with 887 infections per 100,000 people. In Muscogee County, cancer incidence rate was at 490 cases per 100,000 people. Breast cancer had the highest incidence during this period, with 133 cases per every 100,000 people and 148 new cases annually on average. Prostate cancer followed second highest rate at 130.5 cases per 100,000 people with 125 new cases annually. Next, lung and bronchus cancer had an incidence rate of 64.8 cases per 100,000 people with 132 new cases annually. Colon and rectum cancer had an incidence rate of 48.2 cases per 100,000 people with 97 new cases annually. Lastly, melanoma had an incidence rate of 20.4 cases per 100,000 people with 40 new cases annually. Chronic condition health indicators for Muscogee County showed that 5 percent of Medicare beneficiaries had asthma, 33 percent had diabetes, 28 percent had heart disease and 68 percent had high blood pressure. Twelve percent of adults diagnosed with diabetes in 2019. In Muscogee County, cancer was the number one cause of both age-adjusted and premature death between 2015 and 2019. Age-adjusted allows communities with different age structures to be compared. Premature death is when death happens before the average age for a given community. Muscogee County reported a total of 24,564 COVID-19 cases in 2021 and 666 COVID-19 related deaths. About 41 percent of adults were fully vaccinated and 13 percent of adults were hesitant about receiving the vaccine. The COVID-19 vaccine Coverage index (CVAC) ranks states and counties on barriers to coverage through 28 indicators across 5 themes: historic under vaccination, sociodemographic barriers, resource-constrained health system, healthcare accessibility barriers, and irregular care-seeking behaviors. The CVAC can help contextualize progress to widespread COVID-19 vaccine coverage, identifying underlying community-level factors that could be driving suboptimal rollout to inform precision solutions. Muscogee County had a vaccine coverage index of 0.70 as reported by the CDC in 2021. Sources for all statistics in this section: U.S. Census 2017 ACS Demographic and Housing Estimate, University of Wisconsin Population Health Institute, County Health Rankings, 2018, with indicators ranging from 2012 to 2019, the Centers for Disease Control and Prevention, and the Georgia Online Analytical Statistical Information System. SCHEDULE H, PART VI, LINE 5: PROMOTION OF COMMUNITY HEALTH In FY21, we actively promoted the health of our community through community-based health screenings, our mobile unit, educational activities, community-building activities, the operation of a 24-hour emergency department available to the entire community, the operation of an emergency room open to all members of the community without regard to ability to pay, a governance board composed of community members, use of surplus revenue for facilities improvement, patient care, and medical training, education, and research, the provision of inpatient hospital care for all persons in the community able to pay, including those covered by Medicare and Medicaid, and an open medical staff with privileges available to all qualifying physicians. It's important to note that COVID-19 had a significant impact on our proactive community benefit programs, as we canceled most in-person events and classes as of early March 2020, and many have not resumed. We created programming responsive to the pandemic, including our migration to online platforms for vital community-based programming. We prioritized increasing access to care by utilizing a patient and family advisory council to provide meaningful input on critical areas of consideration. We created a steering committee to increase access to care by assisting with clinical policies and guidelines for the operations of the mobile unit. The committee focused on critical components to increase access to care for high-risk populations identified in the CHNA and discussed how to utilize hospital services for the community during the pandemic. After COVID-19 cases significantly decreased, we resumed a modified schedule with the mobile unit. We continued weekly clinics at Safe House and Valley Rescue to target indigent populations and provided education to assist with vaccine hesitancy and offer vaccines. We deployed a mobile unit clinic team comprised of a family practice resident, a pharmacy resident, and a registered nurse to conduct weekly clinics to reduce emergency admissions. COVID-19 significantly impacted the mobile unit activities and was suspended for 12 months until March 2021. The mobile unit served 287 indigent patients between March 1, 2020, and July 1, 2021. There were 50 patient encounters from Valley Rescue and Safe House clinics. At the same time, one was an emergency department referral, and we referred 19 patients to community partners for a follow-up. Before the mobile unit resumed in March, there were 24 mobile unit patients seen in the emergency department. After March, we saw 13 mobile unit patients in the emergency department. The mobile unit social worker assisted 21 patients with additional personal needs. We prioritized decreasing deaths from cancer and increasing access to cancer programming by increasing local awareness of and local opportunities for lung cancer screening. We continued distributing a brochure titled "Lung Cancer Screening, Shared Decision-Making Guide." The instructional guide explains the details of our Low-Dose CT Scan Lung Cancer Screening. There has been a total of 651 patients in the Lung Cancer Screening program. We also worked to address cultural barriers to cancer prevention and education for the Latino community. We conducted two screening events for colorectal and prostate cancer by outreaching to Latino and African American churches in local counties. The effectiveness of outreach quality depended on the number of Latino participants at the annual free prostate cancer screenings. In 2021, the prostate cancer screening event had 4.16 percent Hispanic/Latino participants, a decline from the previous year, when we had a higher rate of Hispanic/Latino population participation. The Prostate-Specific Antigen (PSA) test cost $69, and the total cost for the 2021 screening event was $3,312. We worked with the community to overcome barriers to screenings and increasing cancer screenings for colorectal, prostate, and skin cancer. We partnered with the West Central Georgia Cancer Coalition for a community-wide drive-through Colorectal Cancer Screening. Piedmont Columbus Regional used Community Educational Events to distribute Stool Screening FIT Kits. In FY21, 159 FIT kits were distributed, 67 kits returned, and six came back positive. The patients that received positive kits received follow-up care. We provided surveys to measure outreach quality for the event, and we mainly received positive feedbacks. We prioritized decreasing the impact of and deaths from stroke by increasing EMS as the preferred mode of transportation by 10 percent over the next three years. We increased EMS as the preferred mode of arrival for stroke patients by 13 percent in FY21 by increasing the community's knowledge of the stroke survival campaign of F.A.S.T. During FY20, EMS as the method of arrival was 62 percent for all stroke encounters and, in FY21, it was 75 percent, which is evidence of the success of the campaign. We prioritized reducing rates of obesity and increasing access to healthy foods and recreational activities by supporting healthy food access for low-income children. Our community outreach department partnered with Amerigroup to host two Mobile Market Day events despite challenging COVID-19 protocols. We targeted families from the surrounding area in at-risk populations identified in the CHNA and provided fresh fruit, vegetables, and educational materials. We prioritized decreasing preventable instances of diabetes and the number of patients with uncontrolled diabetes by increasing the number of Outpatients Diabetes Self-Management Education attendees. Due to COVID-19, we suspended the Outpatient Diabetes Self-Management Education program following the February 8, 2020, class. Later in the year, we moved the course to the virtual platform Zoom. In-person courses resumed in November 2021. We also worked to address uncontrolled diabetes by continuing the accredited Diabetes Prevention Program, focusing on at-risk populations as identified in our CNHA. A total of three participants in Cohort III of the Diabetes Prevention Program completed the program in September 2021, meeting all completion criteria. This program was offered virtually and in person to accommodate CDC guidelines. Finally, we incorporated and initiated a glycemic management/diabetes management rotation with medical and pharmacy residents, which remained active throughout 2020, despite the COVID-19 pandemic. Due to the pandemic and the suspension of all Community Outreach activities this past year, Hughston Hospital assisted with the following: . Performed COVID-19 screenings at PCR Midtown and J.B.A.C.C. from March 2020 to March 2021. . Coordinated three COVID-19 vaccination clinics with follow-up clinics to administer second doses of the Moderna vaccine. Piedmont Columbus Regional also served as vaccinators in the clinics. SCHEDULE H, PART VI, LINE 6: AFFILIATED HEALTH CARE SYSTEM We are part of Piedmont Healthcare, a regional not-for-profit organization, and the parent company of 16 hospitals, the Piedmont Physicians Group, the Piedmont Heart Institute, the Piedmont Clinic, and the Piedmont Healthcare Foundation. Our community relations team works directly with the community. Our community benefit department oversees the community benefit activities on behalf of all hospitals throughout the system, and this includes conducting the triennial CHNA and subsequent implementation strategy, ensuring the financial assistance policy is communicated to the community, maintaining the community benefit webpage, authoring the community benefit annual report, preparing board materials, developing and executing the community benefit grants program and compiling all community benefit figures. Each hospital and certain departments of Piedmont Healthcare execute community benefit programming, such as our revenue department, which oversees the financial assistance program. SCHEDULE H, PART VI, LINE 7: STATE FILING OF COMMUNITY BENEFIT REPORT We are not required to file a community benefit report, however, we are required to file with the Georgia Department of Community Health information on our indigent and charity care, as well as our Medicaid and Medicare shortfalls. false true false false false false false false false Mr M Scott Hill Board Member & CEO CRHS 0 566596 0 363536 0 1459264 0 62775 0 21114 0 2473285 0 45675 Dr Todd Jarrell MD Board Member 0 580211 0 0 0 132600 0 14067 0 15031 0 741909 0 0 Mr Allen Holladay CFO 0 306585 0 104383 0 17720 0 17100 0 1155 0 446943 0 0 Ms Laura Drew COO 0 323914 0 107947 0 147065 0 5175 0 12302 0 596403 0 0 Ms Holly Lehmberg Exec. Dir. - Nursing 183878 0 37308 0 213 0 8374 0 660 0 230433 0 0 0 Ms Diane Morris DIRECTOR - SURG. SVCS 148419 0 20798 0 1598 0 10278 0 7607 0 188700 0 0 0 Ms Judith Hill CLINICAL PHARMACIST 129098 0 425 0 27402 0 7826 0 18935 0 183686 0 0 0 MS Timara Rembert CLINICAL PHARMACIST 120371 0 425 0 23464 0 9021 0 18918 0 172199 0 0 0 Ms Kelly Altman CLINICAL PHARMACIST 121110 0 425 0 34088 0 9880 0 18443 0 183946 0 0 0 Mr Michael McAnder Treasurer (End 7/20) 0 357162 0 0 0 927767 0 66931 0 5196 0 1357056 0 498228 Mr Thomas Arnold Treasurer (Eff 7/20) 0 424857 0 245916 0 156777 0 79670 0 13247 0 920467 0 62570 Ms Elizabeth Leddy Secretary 0 459494 0 335067 0 49241 0 109035 0 17590 0 970427 0 0 SCHEDULE J, PART I, LINE 3: COMPENSATION OF THE CEO/EXECUTIVE DIRECTOR THE COMPENSATION FOR THE PRESIDENT/CEO OF HUGHSTON HOSPITAL IS SET BY THE ENTITY'S PARENT, PIEDMONT HEALTHCARE, INC. PLEASE SEE THE SCHEDULE O NARRATIVE FOR FORM 990, PART VI, SECTION B, LINE 15A & 15B FOR ADDITIONAL INFORMATION. SCHEDULE J, PART I, LINE 4B: Supplemental Compensation Information THE FOLLOWING INDIVIDUALS RECEIVED PAYMENTS FROM THEIR SUPPLEMENTAL EXECUTIVE RETIREMENT PLANS: M. SCOTT HILL $45,675 MICHAEL MCANDER $498,228 THOMAS ARNOLD $62,570 ELIZABETH LEDDY PARTICIPATED IN SUPPLEMENTAL NONQUALIFIED RETIREMENT PLANS BUT DID NOT RECEIVE CURRENT YEAR PAYMENTS. Form 990, PART V, LINE 1A: NUMBER OF FORMS 1099 FILED ALL CALENDAR YEAR 2020 FORMS 1099 WERE FILED ON BEHALF OF HUGHSTON HOSPITAL BY ITS SOLE MEMBER, PIEDMONT HEALTHCARE, INC. (EIN 58-1503902) PURSUANT TO AN AGREEMENT WITH THE IRS TO FILE ALL FORMS 1099 FOR THE PIEDMONT HEALTHCARE SYSTEM ON A COMBINED BASIS. FORM 990, PART VI, SECTION A, LINE 6: ORGANIZATION'S SOLE MEMBER PIEDMONT HEALTHCARE, INC. (EIN 58-1503902) IS THE SOLE MEMBER OF HUGHSTON HOSPITAL, INC. FORM 990, PART VI, SECTION A, LINE 7A: ELECTION OF GOVERNING BODY THE BOARD OF PIEDMONT HEALTHCARE, PIEDMONT COLUMBUS REGIONAL HEALTH SYSTEM'S SOLE MEMBER, APPOINTS THE MEMBERS OF THE BOARD OF DIRECTORS OF HUGHSTON HOSPITAL, INC. FORM 990 PART VI, SECTION A, LINE 7B: DECISIONS OF GOVERNING BODY HUGHSTON HOSPITAL'S BOARD POLICIES AND DECISIONS MUST BE FILED, IMMEDIATELY AFTER ADOPTION, WITH THE SECRETARY OF THE PIEDMONT HEALTHCARE BOARD OF DIRECTORS. SUCH POLICIES AND DECISIONS OF THE HUGHSTON HOSPITAL BOARD OF DIRECTORS ARE NOT SUBJECT TO THE APPROVAL OF OR RATIFICATION BY THE PIEDMONT HEALTHCARE BOARD, BUT SHOULD THE NEED ARISE, THEY MAY BE RESCINDED BY THE PIEDMONT HEALTHCARE BOARD THROUGH A MAJORITY VOTE OF ITS DIRECTORS. FORM 990 PART VI, LINE 11B: 990 REVIEW PROCESS INFORMATION NEEDED TO PREPARE HUGHSTON HOSPITAL'S FORM 990 IS COMPILED BY INDIVIDUALS IN THE ORGANIZATION'S FINANCE DEPARTMENT. THE INFORMATION IS REVIEWED BY HUGHSTON HOSPITAL'S CONTROLLER AND VP/CFO. THE 990 IS THEN PREPARED INTERNALLY BY PIEDMONT HEALTHCARE, INC.'S TAX DEPARTMENT AND SUBMITTED TO AN EXTERNAL TAX PREPARER FOR REVIEW. PRIOR TO FILING, COPIES OF FORM 990 ARE PROVIDED TO THE BOARD OF DIRECTORS OF PIEDMONT HEALTHCARE, INC., THE ORGANIZATION'S SOLE MEMBER, FOR BOARD REVIEW. Form 990, Part VI, Line 12c: CONFLICT OF INTEREST POLICY COMPLIANCE WITH THE ORGANIZATION'S CONFLICT OF INTEREST POLICY IS MONITORED AND ENFORCED BY ORGANIZATION MANAGEMENT IN COORDINATION WITH PIEDMONT HEALTHCARE'S CHIEF COMPLIANCE OFFICER. ALL SENIOR LEADERS, BOARD MEMBERS, PHYSICIAN EMPLOYEES, NURSE PRACTITIONERS/PHYSICIAN ASSISTANTS AND EMPLOYEES AND NON-EMPLOYEES ENGAGED IN RESEARCH ARE REQUIRED TO ANNUALLY DISCLOSE ALL MATTERS WHICH COULD POTENTIALLY CONSTITUTE A CONFLICT OF INTEREST. MATTERS DISCLOSED UNDER THE POLICY MUST BE REVIEWED IN WRITING BY THE PIEDMONT HEALTHCARE CONFLICT OF INTEREST COMMITTEE IN ORDER TO DETERMINE WHETHER A CONFLICT EXISTS AND, IF SO, WHETHER TO ELIMINATE OR MANAGE THE CONFLICT. ALL BOARD MEMBERS AND EMPLOYEES OF HUGHSTON HOSPITAL, INC. ARE PROVIDED TRAINING ON CONFLICT OF INTEREST ISSUES, INCLUDING REPORTING REQUIREMENTS, AT NEW EMPLOYEE ORIENTATION AND AT LEAST ANNUALLY THEREAFTER. NONCOMPLIANCE WITH THE CONFLICT OF INTEREST POLICY MUST BE REPORTED TO PIEDMONT HEALTHCARE'S CHIEF COMPLIANCE OFFICER FOR INVESTIGATION, AND REMEDIAL STEPS MUST BE TAKEN AS APPROPRIATE UNDER THE PIEDMONT HEALTHCARE DISCIPLINARY POLICIES. FORM 990, PART VI, LINE 15A: EXECUTIVE COMPENSATION COMPENSATION FOR EXECUTIVES OF HUGHSTON HOSPITAL IS SET BY THE BOARD OF DIRECTORS OF PIEDMONT HEALTHCARE, INC. THE PIEDMONT HEALTHCARE, INC., BOARD OF DIRECTOR'S EXECUTIVE PERFORMANCE AND COMPENSATION COMMITTEE ("THE COMMITTEE") IS COMPOSED OF AT LEAST THREE MEMBERS OF THE PHC BOARD OF DIRECTORS, SERVING TERMS OF THREE YEARS, AND THE MAJORITY OF WHICH ARE COMMUNITY DIRECTORS WHO GENERALLY DO NOT HAVE CONFLICTS OF INTEREST RELATED TO FULFILLMENT OF THE DUTIES AS OUTLINED BELOW. THE COMMITTEE OVERSEES EXECUTIVE PERFORMANCE AND COMPENSATION ON BEHALF OF THE PHC BOARD, SUBJECT TO THE ULTIMATE AUTHORITY AND OVERSIGHT OF THE BOARD. THE COMMITTEE ALSO FORMULATES POLICIES AND MAKES DECISIONS IN ORDER TO ENSURE A HIGH LEVEL OF EXECUTIVE PERFORMANCE. THE COMMITTEE IS AUTHORIZED TO ACT ON BEHALF OF THE PHC BOARD AS SET OUT IN ITS CHARTER, AND THE COMMITTEE IS ALSO CHARGED WITH PROVIDING RECOMMENDATIONS AND PERIODIC REPORTS TO THE PHC BOARD REGARDING EXECUTIVE PERFORMANCE AND COMPENSATION. ALL DECISIONS AND COMPARABILITY DATA ARE DOCUMENTED IN THE COMMITTEE MEETING MINUTES. FUNCTIONS OF THE COMMITTEE - ASSESS AND IMPLEMENT POLICIES REGARDING PERFORMANCE, COMPENSATION AND BENEFITS OF THE PRESIDENT/CEO AND OTHER EXECUTIVES AS DETERMINED BY THE COMMITTEE - SELECT AN EXECUTIVE COMPENSATION CONSULTANT WHO REPORTS TO THE COMMITTEE - ANNUALLY REVIEW THE PRESIDENT/CEO SUCCESSION PLAN - FORMULATE AND IMPLEMENT ANNUAL PERFORMANCE OBJECTIVES FOR THE PRESIDENT/CEO, AND REVIEW AND APPROVE ANNUALLY RECOMMENDATIONS FROM THE PRESIDENT/CEO RELATING TO COMPENSATION, PERFORMANCE OBJECTIVES, AND SUCCESSION PLANS FOR EVP EXECUTIVES - ANNUALLY ASSESS PRESIDENT/CEO PERFORMANCE; IF NECESSARY, IMPLEMENT ACTION PLAN WITH PRESIDENT/CEO INPUT TO IMPROVE HIS/HER PERFORMANCE; ADJUST COMPENSATION AS APPROPRIATE; THE COMMITTEE CHAIR SHALL CONSULT WITH THE PHC GOVERNANCE COMMITTEE CHAIR AND THE PHC BOARD CHAIR AND SHALL COORDINATE THE ANNUAL PERFORMANCE REVIEW OF THE PHC PRESIDENT/CEO, UNLESS THE PHC BOARD CHAIR HAS A REAL OR PERCEIVED CONFLICT OF INTEREST, IN WHICH CASE THE COMMITTEE CHAIR SHALL DETERMINE THE PROPER REVIEW PROCESS - REVIEW AND APPROVE LONG-TERM AND SHORT-TERM GOALS TO BE USED IN CONNECTION WITH EVP COMPENSATION PROGRAMS AS RECOMMENDED BY THE PRESIDENT/CEO AND VALIDATED BY THE COMPENSATION CONSULTANT - PERIODICALLY REVIEW COMPENSATION, IF ANY, FOR THE PHC BOARD CHAIR AND ALL BOARD CHAIRS OF THE PHC SUBSIDIARIES - ESTABLISH OTHER POLICIES AND PROCEDURES, AND PERFORM OTHER TASKS, RELATED TO EXECUTIVE PERFORMANCE AND COMPENSATION, INCLUDING BUT NOT LIMITED TO, APPROVAL OF EXECUTIVE EMPLOYMENT CONTRACTS AND BENEFITS - PERIODICALLY REPORT SIGNIFICANT DECISIONS AND ANY ADDITIONAL REQUESTED INFORMATION TO THE PHC BOARD. FORM 990, PART VI, SECTION C, LINE 19: DOCUMENTS AND POLICIES GOVERNING DOCUMENTS, CONFLICT OF INTEREST POLICY, AND FINANCIAL STATEMENTS ARE AVAILABLE UPON REQUEST. THESE DOCUMENTS SHOULD BE REQUESTED FROM PIEDMONT HEALTHCARE, INC.'S LEGAL COUNSEL. 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