2021-08-11T14:01:15-05:00 2020-09-30 560747981 DIXON HUGHES GOODMAN LLP 500 RIDGEFIELD COURT ASHEVILLE NC 28806 990 2019-10-01 560525657 ALLEGHANY COUNTY MEMORIAL HOSPITAL INC ALLE 3363723226 PO BOX 9 SPARTA NC 28675 KATHRYN DOBY CHIEF ADMINISTRATIVE OFFICER 3363723226 2021-08-11 1 AMY BIBBY P00445891 8282542254 2021-08-09 2019 2022-09-23 18:48:47Z KATHRYN DOBY PO BOX 9 SPARTA NC 28675 16202161 0 X WWW.AMHSPARTA.ORG X 1948 NC TO PROVIDE TOP QUALITY HEALTH CARE SERVICES TO OUR LOCAL COMMUNITY AND SURROUNDING COMMUNITIES. SERVICES ARE PROVIDED TO ALL INDIVIDUALS REGARDLESS OF THEIR ABILITY TO PAY. 8 8 145 24 0 27061 511583 4367148 10478554 11654771 18066 30466 129543 149713 11137746 16202098 0 0 0 0 5561055 5316052 0 0 11162 7649521 7490697 13210576 12806749 -2072830 3395349 7822201 17075869 3570530 8891810 4251671 8184059 ALLEGHANY MEMORIAL HOSPITAL PROVIDES TOP QUALITY HEALTHCARE SERVICES, FACILITATES EDUCATION FOR HEALTHCARE NEEDS, AND COORDINATES HEALTHCARE SERVICES THAT EXCEEDS THE SCOPE OF OUR FACILITY. 0 0 10394677 11654771 ALLEGHANY MEMORIAL HOSPITAL PROVIDED NECESSARY HEALTHCARE SERVICES TO INDIVIDUALS IN THE COMMUNITY REGARDLESS OF THEIR ABILITY TO PAY. 10394677 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 0 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 1 1 0 0 0 1 63 0 1 145 1 1 1 0 0 0 0 0 0 0 0 0 0 0 X 8 8 1 1 0 0 0 0 0 1 1 0 0 1 1 1 1 1 1 1 1 0 NC X THE ORGANIZATION 3363723276 PO BOX 9 SPARTA NC 28675 APRIL MAINES CLINICAL DIRECTOR 41.00 X 5678 0 0 JIM BECKER TRUSTEE 1.00 X 0 0 0 WHITNEY IVEY TRUSTEE 1.00 X 0 0 0 ROCKY PROFITT TRUSTEE 1.00 X 0 0 0 JIM HOEKSTRA TRUSTEE 1.00 X 0 0 0 JENA FOLGER TRUSTEE 1.00 X 0 0 0 PAUL HAMMES TRUSTEE 1.00 X 0 0 0 DON TRIPPEL TRUSTEE 1.00 X 0 0 0 RICKY BROWN TRUSTEE 1.00 X 0 0 0 DR JOE AROCHA EX OFFICIO MEMBER 1.00 X 354681 0 17213 SHIRLEY RICHARDSON EX OFFICIO MEMBER 1.00 X 0 0 0 CRAIG JAMES PRESIDENT 40.00 X 200000 0 23233 KATHRYN DOBY CHIEF ADMIN OFFICER 40.00 X 0 0 0 CHRISTY KLEIN CLINICAL DIRECTOR 40.00 X 66541 0 3386 CRAIG JAMES EX OFFICIO MEMBER 1.00 X 0 0 0 KATHRYN DOBY EX OFFICIO MEMBER 1.00 X 0 0 0 PAM HOPPERS PHARMACIST 40.00 X 145466 0 16744 DR DWYNN GREENFIELD PHYSICIAN 40.00 X 119250 0 17136 891616 0 77712 4 0 1 0 ALLEGHANY EMERGENCY GROUP LLC PO BOX 677979 DALLAS TX 75267 ER PHYSICIANS 819714 NTHRIVE INC PO BOX 733492 DALLAS TX 75373 REVENUE CYCLE SOLUTIONS 582387 ODELL ASSOCIATES INC 212 S TRYON ST CHARLOTTE NC 28281 ARCHITECTURE 264305 WOMBLE BOND DICKINSON LLP PO BOX 601879 CHARLOTTE NC 28260 ATTORNEYS 234303 ALLEGIANCE BENEFIT PLAN MANAGEMENT PO BOX 3018 MISSOULA MT 59806 TPA 188029 6 3999415 367733 4367148 NET PATIENT REVENUE 621500 10438418 10438418 HHS STIMULUS 621500 1179836 1179836 MRI GAP SUPPLEMENT 621500 36517 36517 11654771 1974 1974 66947 63 66884 66884 66884 24852 3640 0 0 24852 3640 28492 28492 MISCELLANEOUS 900099 46113 46113 PURCHASE DISCOUNTS 900099 35562 35562 CAFETERIA INCOME 900099 1154 1154 82829 16202098 11654771 0 180179 X 286169 11162 263845 11162 4130839 3590609 540230 47578 38874 8704 551985 451001 100984 299481 244692 54789 350004 350004 3861 3861 69187 69187 1892922 1388673 504249 104022 86277 17745 935092 596409 338683 132903 132903 9363 7794 1569 2084 2084 549173 549173 115759 115759 MEDICAL SUPPLIES 2068172 2068172 BAD DEBT EXPENSE 1189537 1189537 MISCELLANEOUS 68618 39401 29217 12806749 10394677 2400910 11162 580657 5771651 10075 11969 1606764 1644695 293235 261153 121753 84742 25238857 16683538 4378464 8555319 333096 337974 71716 498157 336650 7822201 17075869 3556156 5052354 3777783 14374 61673 3570530 8891810 X 3886403 7818791 365268 365268 4251671 8184059 7822201 17075869 X 3395349 -4645 541684 X X 0 0 0 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 0 0 0 0 0 0 0 0 1 3000 3000 0 PART II-B, LINE 1: THE HOSPITAL IS A MEMBER OF THE AMERICAN HOSPITAL ASSOCIATION AND THE NORTH CAROLINA HOSPITAL ASSOCIATION. DUES PAID TO THESE ORGANIZATIONS ARE ALLOCATED IN PART TO LOBBYING EFFORTS ON BEHALF OF THEIR MEMBERSHIP BODIES. FOR THE YEAR, APPROXIMATELY $3,000 OF DUES PAID ARE ALLOCATED TO LOBBYING EXPENDITURES. 333096 26454 21576 337974 344875 9664 21443 333096 346018 21292 22435 344875 339397 28644 22023 346018 332289 28772 21664 339397 0 0 351517 351517 10053171 4915042 5138129 1460715 1458891 1824 12303411 10309605 1993806 1070043 1070043 8555319 CAPITAL LEASE OBLIGATION 61673 61673 X PART V, LINE 4: THE HOSPITAL'S ENDOWMENT CONSISTS OF FUNDS ESTABLISHED FOR A VARIETY OF PURPOSES TO SUPPORT HEALTH CARE SERVICES. PART X, LINE 2: THE HOSPITAL AND THE FOUNDATION ARE NOT-FOR-PROFIT CORPORATIONS AS DESCRIBED IN SECTION 501(C)(3) OF THE INTERNAL REVENUE CODE ("IRC") AND ARE EXEMPT FROM FEDERAL INCOME TAXES ON RELATED INCOME PURSUANT TO SECTION 501(A) OF THE CODE. NO PROVISION FOR INCOME TAXES HAS BEEN MADE IN THE ACCOMPANYING CONSOLIDATED FINANCIAL STATEMENTS. THE HOSPITAL AND FOUNDATION HAVE DETERMINED THAT THEY DO NOT HAVE ANY MATERIAL UNRECOGNIZED TAX BENEFITS OR OBLIGATIONS AS OF SEPTEMBER 30, 2020. 1 1 X 1 X 1 X 1 1 1 0 1 1 25097 25097 0.00200 1214005 772201 441804 0.03450 1239102 772201 466901 0.03650 1239102 772201 466901 0.03650 0 1189538 4007967 4223117 -215150 X 1 1 1 1 ALLEGHANY MEMORIAL HOSPITAL 233 DOCTORS STREET SPARTA NC 28675 X X X X ALLEGHANY COUNTY MEMORIAL HOSPITAL 1 0 0 1 X X X X X X X X 17 1 0 1 1 X HTTPS://AMHSPARTA.ORG/ABOUT-US/ X X 1 17 1 HTTPS://AMHSPARTA.ORG/ABOUT-US/ 0 1 X 100.000000000000 200.000000000000 X X X X 1 1 X X X X 1 X HTTPS://AMHSPARTA.ORG/PATIENT-AND-FAMILY-RESOURCES/ X HTTPS://AMHSPARTA.ORG/PATIENT-AND-FAMILY-RESOURCES/ X X X X 1 X 0 X X X 1 X 0 0 ALLEGHANY COUNTY MEMORIAL HOSPITAL PART V, SECTION B, LINE 5: COMMUNITY INPUT WAS TAKEN INTO ACCOUNT THROUGH COORDINATED EFFORTS WITH AND BETWEEN THE APPALACHIAN DISTRICT HEALTH DEPARTMENT AND OTHER COMMUNITY PROVIDERS. ALLEGHANY COUNTY MEMORIAL HOSPITAL PART V, SECTION B, LINE 6B: THE COMMUNITY HEALTH NEEDS ASSESSMENT WAS CONDUCTED IN CONJUCTION WITH ALLEGHANY COUNTY. ALLEGHANY COUNTY MEMORIAL HOSPITAL PART V, SECTION B, LINE 7D: THROUGH COORDINATED EFFORTS OF THE APPLACHIAN DISTRICT HEALTH DEPARTMENT ALLEGHANY COUNTY MEMORIAL HOSPITAL PART V, SECTION B, LINE 11: THE ORGANIZATION HAS DEVELOPED AN ACTION PLAN WITH VARIOUS COMMUNITY PARTNERS TO ADDRESS COMMUNITY NEEDS. AREAS ADDRESSED INCLUDE CHRONIC DISEASE MANAGEMENT AND AWARENESS, TOBACCO USES, AND DIABETES PREVENTION & EDUCATION. THESE NEEDS WERE IDENTIFIED IN THE COMMUNITY HEALTH NEEDS ASSESSMENT PROCESS. SEE IMPLEMENTATION STRATEGY FOR DETAILS ON HOW THE NEEDS WILL BE ADDRESSED. ALLEGHANY COUNTY MEMORIAL HOSPITAL PART V, SECTION B, LINE 20E: THE ORGANIZATION WILL PROVIDE INFORMATION RELATING TO ITS FINANCIAL POLICY WHEN PATIENTS INQUIRE ABOUT POTENTIAL ASSISTANCE. 4 1 - ALLEGHANY ORTHOPEDIC CLINIC PO BOX 9 SPARTA NC 28675 ORTHOPEDIC SURGEON OFFICE 2 - ALLEGHANY HEALTH SERVICES PO BOX 9 SPARTA NC 28675 FAMILY PRACTICE 3 - ALLEGHANY SPECIALITY CLINIC PO BOX 9 SPARTA NC 28675 UROLOGY AND PULMONOLOGY CLINIC, 4 - ALLEGHANY FAMILY MEDICINE PO BOX 9 SPARTA NC 28675 FAMILY PRACTICE PART I, LINE 7: WORKSHEET 2 OF THE 2019 SCHEDULE H INSTRUCTIONS WAS USED TO COMPUTE A COST-TO-CHARGES RATIO USED TO CALCULATE CHARITY CARE/FINANCIAL ASSISTANCE AND UNREIMBURSED MEDICAID AT COST FOR PURPOSES OF PART I, LINE 7A AND 7B. PART III, LINE 4: THE ORGANIZATION'S FINANCIAL STATEMENTS DO NOT INCLUDE A FOOTNOTE ON BAD DEBT EXPENSE. THE BAD DEBT EXPENSE AT COST ON PART III, LINE 2 WAS COMPUTED BY USING THE GROSS BAD DEBT EXPENSE PER AUDITED FINANCIAL STATEMENTS REDUCED TO COST USING THE COST TO CHARGE RATIO CALCULATED THROUGH WORKSHEET 2 PROVIDED IN THE INSTRUCTIONS TO SCHEDULE H. PART III, LINE 8: THE ORGANIZATION USED CALCULATIONS FROM ITS MEDICARE COST REPORT TO DETERMINE MEDICARE ALLOWABLE COSTS FOR PART III. PART III, LINE 9B: A PATIENT IS DETERMINED INDIGENT IF THEY MEET THE ELIGIBILITY REQUIREMENTS FOR ALLEGHANY MEMORIAL HOSPITAL'S UNCOMPENSATED CARE PROGRAMS. PART VI, LINE 2: THE HOSPITAL IS PART OF THE APPALACHIAN DISTRICT CHA TEAM, WHICH INCLUDES LEADERSHIP FROM ALLEGHANY MEMORIAL HOSPITAL, ALLEGHANY LIVES, ASHE MEMORIAL HOSPITAL, ASHE COUNTY HEALTH COUNCIL/HEALTHY CAROLINIANS, APPALACHIAN REGIONAL HEALTHCARE SYSTEM, WATAUGA HEALTHY CAROLINIANS, AND WESTERN YOUTH NETWORK. TOGETHER, THE TEAM DEVELOPED A MULTI-PHASE PLAN FOR CONDUCTING A COMMUNITY HEALTH NEEDS ASSESSMENT. THE PHASES INCLUDED: (1) A RESEARCH PHASE TO IDENTIFY, COLLECT AND REVIEW DEMOGRAPHIC, SOCIOECONOMIC AND HEALTH DATA; (2) A SURVEY PHASE TO SOLICIT INFORMATION AND OPINION FROM THE GENERAL PUBLIC; (3) A STAKEHOLDER SURVEY PHASE TO GATHER INFORMATION AND OPINION FROM LOCAL COMMUNITY LEADERS AND HEALTH AND HUMAN SERVICE AGENCIES; AND (4) A DATA SYNTHESIS AND ANALYSIS PHASE. THESE PHASES HELPED DESIGN THE COMPONENTS OF THE COMMUNITY HEALTH ASSESSMENT. THE CURRENT ASSESSMENT WAS COMPLETED IN 2015. ALLEGHANY'S LOCAL PRIORITY ISSUE IS THE ACCESS AND AFFORDABILITY OF HEALTHCARE SERVICES. PART VI, LINE 3: THE ORGANIZATION IDENTIFIES ELIGIBLE PATIENTS THROUGH THE REGISTRATION AND COLLECTION PROCESS. EACH ELIGIBLE PATIENT IS GIVEN INSTRUCTIONS AND AN APPLICATION TO COMPLETE AND RETURN TO THE ORGANIZATION. PART VI, LINE 4: THE PRIMARY AND SECONDARY SERVICE AREAS INCLUDE APPROXIMATELY 18,000 IN BOTH NORTHWESTERN NC AND SOUTHWESTERN VA. APPROXIMATELY 4,000 INDIVIDUALS IN THE PRIMARY AND SECONDARY SERVICE AREAS ARE OVER AGE 65. THE CLOSEST FACILITY IS APPROXIMATELY 30 MINUTES AWAY DOWN MOUNTAINOUS TERRAIN. THE HOSPITAL IS LOCATED IN A PRIMARY CARE HEALTH PROFESSIONAL SHORTAGE AREA AND A MEDICALLY UNDERSERVED AREA ACCORDING TO HRSA. THE MEDIAN HOUSEHOLD AS OF 2015 WAS $33,352 WITH NC STATE AVERAGE OF $50,797. PART VI, LINE 5: A MAJORITY OF THE ORGANIZATION'S GOVERNING BODY IS COMPRISED OF PERSONS WHO RESIDE IN THE ORGANIZATION'S PRIMARY SERVICE AREA AND WHO ARE NEITHER EMPLOYEES NOR INDEPENDENT CONTRACTORS OF THE ORGANIZATION. IN ADDITION, THE ORGANIZATION EXTENDS HOSPITAL PRIVILEDGES TO ALL QUALIFIED LOCAL PHYSICIANS FOR THE MAJORITY OF ITS DEPARTMENTS. PART VI, LINE 6: THE HOSPITAL BECAME PART OF AN AFFLIATED HEALTH SYSTEM. PART VI, LINE 7, REPORTS FILED WITH STATES NC X X X 1 0 0 0 0 0 0 0 0 DR JOE AROCHA EX OFFICIO MEMBER 354681 0 0 0 0 0 0 0 17213 0 371894 0 0 0 CRAIG JAMES PRESIDENT 200000 0 0 0 0 0 8000 0 15233 0 223233 0 0 0 PAM HOPPERS PHARMACIST 145466 0 0 0 0 0 4667 0 12077 0 162210 0 0 0 PART I, LINE 4A CRAIG JAMES, CEO TERM MARCH 2020 SEVERANCE PAY $83,300 IN 2020 WENDY ORTON, CNP TERM OCT 2018 $7,739.2 SEVERANCE PAY ISSUED IN 2019 FORM 990, PART VI, SECTION A, LINE 2 JULIE TUCKER IS THE SISTER OF JOHNNY WISHON AND WAS PAID $53,057. FORM 990, PART VI, SECTION A, LINE 3 THE HOSPITAL ENTERED INTO A FIVE-YEAR PURCHASED SERVICES AGREEMENT WITH WAKE FOREST UNIVERSITY BAPTIST MEDICAL CENTER ("WFBMC") ON APRIL 1, 2015. AFTER THE INITIAL FIVE-YEAR TERM, THE AGREEMENT WILL AUTOMATICALLY RENEW FOR ONE YEAR TERMS. THIS AGREEMENT ALLOWS WFBMC TO PROVIDE VARIOUS ADMINISTRATIVE AND CLINICAL SERVICES TO THE HOSPITAL. THE HOSPITAL ALSO OBTAINED A $500,000 LINE OF CREDIT FROM WFBMC ON APRIL 7, 2015. AS OF FEBRUARY 2, 2018, THIS SERVICE AGREEMENT WAS TERMINATED AND THE LINE OF CREDIT WAS REPAID. FOR THE YEARS ENDED SEPTEMBER 30, 2018 AND 2017, MANAGEMENT FEES EXPENSED TO WFBMC WERE APPROXIMATELY $75,000 AND $225,000, RESPECTIVELY. OTHER FEES EXPENSED TO WFBMC WERE APPROXIMATELY $159,000 AND $267,000 DURING 2018 AND 2017, RESPECTIVELY. AT SEPTEMBER 30, 2018 AND 2017, APPROXIMATELY $947,000 AND $735,000, RESPECTIVELY, REMAINED PAYABLE TO WFBMC. FORM 990, PART VI, SECTION B, LINE 11B THE RETURN WAS PREPARED BY AN INDEPENDENT ACCOUNTANT WITH ASSISTANCE AND OVERSIGHT BY MANAGEMENT. PRIOR TO THE FILING DATE OF THE FORM 990, A COPY OF THE FORM 990 WAS PROVIDED TO EACH VOTING BOARD OF TRUSTEE. AFTER A DISCUSSION PERIOD AND QUESTION & ANSWER PERIOD WITH ASSISTANCE FROM FORM 990 PREPARER, THE BOARD OF TRUSTEES VOTED TO APPROVE AND ACCEPT THE FORM 990 AS PRESENTED. FORM 990, PART VI, SECTION B, LINE 12C THE HOSPITAL HAS AN ETHICS AND COMPLIANCE POLICY THAT EACH BOARD MEMBER MUST FOLLOW. THIS POLICY IS REINFORCED EACH YEAR AT A REGULAR BOARD MEETING. ALL BOARD MEMBERS SIGN A COMPLIANCE STATEMENT AT THAT BOARD MEETING THAT STATES THE BOARD MEMBER WILL ABIDE BY THE POLICY. FORM 990, PART VI, SECTION B, LINE 15 THE BOARD OF TRUSTEES EXECUTIVE COMMITTEE HAS ESTABLSHED AND APPROVED AN EXECUTIVE COMPENSATION COMMITTEE THAT REVIEWS AND MONITORS COMPENSATION RECOMMENDATIONS FOR ALL OFFICERS, KEY EMPLOYEES, AND HIGHLY COMPENSATED EMPLOYEES. MULTIPLE SOURCES (AT LEAST THREE) OF INDEPENDENT COMPARISON DATA FROM ORGANIZATIONS OF SIMILAR SIZE, REVENUE, GEOGRAPHIC LOCATION, ORGANIZATION MISSION, AND OFFICER/STAFF RESPONSIBILITIES ARE USED TO DETERMINE COMPENSATION RECOMMENDATIONS. SALARY RATES FOR OFFICER, KEY EMPLOYEES, ETC. ARE FAIR AND EQUITABLE BASED ON COMPARISON DATA SOURCES. THE EXECUTIVE COMPENSATION COMMITTEE MAINTAINS DOCUMENTATION TO SHOW THAT THE COMPENSATION REVIEW PROCESS WAS GIVEN APPROPRIATE DUE DILIGENCE IN REGARD TO DISCUSSION, MEMBERS PRESENT, USE OF COMPARISON DATA AND HOW IT WAS OBTAINED, DATE OF APPROVAL, VIEWS OF DISSENTING MEMBERS, AND THAT ADEQUATE TIME WAS ALLOTTED FOR DISCUSSION BEFORE MAKING DETERMINATIONS. ALL COMPENSATION PACKAGE RECOMMENDATIONS DEVELOPED BY THE EXECUTIVE COMPENSATION COMMITTEE ARE APPROVED BY THE ENTIRE BOARD. FORM 990, PART VI, SECTION C, LINE 18 THE ORGANIZATION MAKES IT'S FORM 990 AVAILABLE TO THE PUBLIC UPON REQUEST. ADDITIONALLY, RECENT COPIES OF THE FORM CAN BE ACCESSED ON GUIDESTAR.ORG. 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 IX, LINE 11G CONSULTANT FEES: PROGRAM SERVICE EXPENSES 3,300. MANAGEMENT AND GENERAL EXPENSES 82,082. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 85,382. PURCHASED SERVICES: PROGRAM SERVICE EXPENSES 1,232,698. MANAGEMENT AND GENERAL EXPENSES 400,867. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 1,633,565. OTHER PROFESSIONAL FEES: PROGRAM SERVICE EXPENSES 152,675. MANAGEMENT AND GENERAL EXPENSES 21,300. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 173,975. FORM 990, PART XI, LINE 9: EQUITY TRANSFER FROM AFFILIATES 600,000. EQUITY TRANSFER TO FOUNDATION -58,316. FORM 990, PART XII, LINE 2C: JOINT VENTURE PURCHASE BY HUGH CHATHAM HOSPITAL & WAKE FOREST FEB 2018 ALLEGHANY MEMORIAL HOSPITAL FOUNDATION INC 233 DOCTORS STREET SPARTA NC 28675 562012634 PROMOTES AND SUPPORTS THE HOSPITAL NC 501(C)(3) LINE 12B, II ALLEGHANY COUNTY MEMORIAL HOSPITAL INC 1 ALLEGHANY HEALTH SERVICES 233 DOCTORS STREET SPARTA NC 28675 201189450 COMMUNITY HEALTH SERVICES NC 501(C)(3) LINE 3 ALLEGHANY COUNTY MEMORIAL HOSPITAL INC 1 0 0 1 0 0 0 0 0 0 0 0 0 1 1 1 0 1 0 0 ALLEGHANY MEMORIAL HOSPITAL FOUNDATION INC C 3996450 CASH