2018-08-03T08:59:28-05:00 2017-09-30 560747981 DIXON HUGHES GOODMAN LLP 500 RIDGEFIELD COURT ASHEVILLE NC 28806 990 2016-10-01 560642846 HUGH CHATHAM MEMORIAL HOSPITAL INC HUGH 3365277000 PARKWOOD DR ELKIN NC 28621 DONALD E TRIPPEL CFO 3365277000 2018-08-03 1 Amy Bibby P00445891 8282542254 2018-07-31 2016 2022-09-23 18:48:47Z DONALD E TRIPPEL PARKWOOD DR ELKIN NC 28621 121599270 0 X WWW.HUGHCHATHAM.ORG X 1930 NC TO PROVIDE BIRTHING AND ACUTE CARE SERVICES IN ADDITION TO SKILLED NURSING, RETIREMENT COMMUNITY, HOME HEALTH, AND HOSPICE SERVICES PRIMARILY TO THE RESIDENTS OF AND SURROUNDING COUNTIES TO SURRY COUNTY, NORTH CAROLINA. 16 15 981 90 0 0 40000 558003 104351357 106949671 8712152 12744415 978243 1013688 114081752 121265777 110597 78120 0 0 48573058 49426206 0 0 52453 59263212 58122535 107946867 107626861 6134885 13638916 216831875 233899728 91384923 85557057 125446952 148342671 X TO CONSISTENLY DELIVER EXCEPTIONAL QUALITY AND SERVICE BY DEMONSTRATING THE VALUES OF SERVICE, TEAMWORK, ACCOUNTABILITY, RESPECT, AND SAFE CARE. 0 0 99835200 78120 106949671 HUGH CHATHAM MEMORIAL HOSPITAL (HCMH) IS A NOT-FOR-PROFIT HOSPITAL LOCATED IN ELKIN, SURRY COUNTY, NORTH CAROLINA. IT IS THE SIXTH LARGEST EMPLOYER IN SURRY COUNTY AND IS RANKED AMONG TOP HOSPITALS NATIONWIDE FOR QUALITY BY THE JOINT COMMISSION. HCMH CARES FOR PATIENTS IN THE YADKIN VALLEY REGION IN NORTH CAROLINA, AND ALSO FOR THOSE WHO CHOOSE OUR CARE FROM SEVERAL COUNTIES IN VIRGINIA, INCLUDING CARROLL, GRAYSON AND PATRICK COUNTIES. HCMH IS FOCUSED ON PROVIDING COMMUNITY SUPPORT, CONSISTENT QUALITY, EXCELLENT SERVICE AND A REMARKABLE WORK ENVIRONMENT FOR OUR STAFF. DURING THE FISCAL YEAR, HCMH WAS NAMED AS A FINALIST IN THE "BEST PLACE TO WORK" BY THE TRIAD BUSINESS JOURNAL, BASED LARGELY ON A RANDOM SAMPLE OF 200 EMPLOYEES' RESPONSES TO A SURVEY THAT MEASURED 10 EMPLOYEE ENGAGEMENT CATEGORIES. HCMH HAS A WORKFORCE OF OVER 800 EMPLOYEES.In 2016, HCMH reported $114,081,752 in revenues. HCMH's community benefit was approximately $13,868,325 including $5,107,267 in charity care. THE HOSPITAL IS COMMITTED TO IMPROVING THE HEALTH OF OUR COMMUNITIES IN THE YADKIN VALLEY REGION OF NORTH CAROLINA, ONE PERSON AT A TIME. IT OFFERS A FULL CONTINUUM OF EMERGENCY, MEDICAL, SURGICAL, REHABILITATIVE AND BEHAVIORAL HEALTH SERVICES. TOP PROGRAMS INCLUDE CANCER SERVICES, CARDIOLOGY, GENERAL SURGERY, GASTROENTEROLOGY, IMAGING, NEUROLOGY, OBSTETRICS AND GYNECOLOGY, ORTHOPEDIC AND SPORTS MEDICINE, PULMONOLOGY AND REHABILITATION SERVICES. THE HOSPITAL ALSO HAS A CERTIFIED PRIMARY STROKE CENTER THAT HAS GOLD PLUS LEVEL DISTINCTION FROM THE AMERICAN HEART ASSOCIATION AND AMERICAN STROKE ASSOCIATION THE ONLY HOSPITAL IN REGION CERTIFIED AT THAT LEVEL. OUR COMMITMENT TO EXCELLENCE IN PATIENT CARE CONTINUED DURING THE YEAR. FOR EXAMPLE, HCMH EARNED "HEALTHCARE'S MOST WIRED" HOSPITAL STATUS AS ONE OF THE NATION'S HEALTH LEADERS IN INFORMATION TECHNOLOGY. DURING THE FISCAL YEAR, HCMH CONTINUED TO FOCUS ON ITS "GOING FOR ZERO" PATIENT SAFETY INITIATIVE GUIDED BY A VISION STATEMENT ENCOURAGING ALL EMPLOYEES AND MEDICAL STAFF TO, "IMAGINE PLACE WHERE COMMUNICATION IS CLEAR, EVERYONE CARES AND PATIENTS ARE ALWAYS SAFE." EDUCATION WAS PROVIDED TO STAFF IN THE USE OF BEST PRACTICE SAFETY COMMUNICATION METHODS "GREAT CATCHES" WAS CREATIVELY FACILITATED.ADDITIONALLY, WE WERE NAMED A "100 SAFE CARE HOSPITAL BY THE SAFECARE GROUP AS WELL AS THE 2016 REGION'S BEST HOSPITAL BY THE WOMEN'S CERTIFIED GROUP. THE AMERICAN HEART/STROKE ASSOCIATION AWARDED THE HUGH CHATHAM PRIMARY STROKE CENTER WITH THE HONOR, "GET WITH THE GUIDELINES GOLD PLUS STROKE CENTER: TARGET STROKE HONOR ROLL."FISCAL YEAR 2016 HIGHLIGHTS:DURING THE YEAR, HCMH HANDLED MORE THAN 30,000 EMERGENCY ROOM VISITS; 20,265 HOME HEALTH VISITS; AND MORE THAN 173,322 PATIENT VISITS TO ITS MEDICAL GROUP PRIMARY AND SPECIALTY CARE PRACTICES. THE HOSPITAL ALSO HANDLED MORE THAN 54,000 OUTPATIENT IMAGING VISITS; 6,406 RADIATION ONCOLOGY PROCEDURES AND MORE THAN 4,000 INPATIENT ADMISSIONS. TO HELP PATIENTS AND LOCAL COMMUNITIES TO GET BETTER AND STAY HEALTHY, HCMH EXPANDED ACCESS TO MEDICAL CARE BY OPENING AN EXPRESS CARE FACILITY IN DOBSON, NC, AND URGENT CARE CLINICS IN JONESVILLE AND YADKINVILLE, NC. THE JONESVILLE LOCATION INCLUDES X-RAY AND LABORATORY SERVICES AS WELL AS OCCUPATIONAL HEALTH SERVICES.HCMH ALSO HAS A HOME HEALTH PRACTICE, YADKIN VALLEY HOME HEALTH, TO SERVE HOMEBOUND PATIENTS IN SURRY, ALLEGHANY, WILKES AND YADKIN COUNTIES. THESE COUNTIES HAVE HIGH PERCENTAGES OF THE POPULATION WHO ARE ELDERLY, LOW-INCOME AND WHO LIVE IN RURAL AREAS OR SMALL TOWNS WHERE TRANSPORTATION TO MEDICAL CARE CAN BE DIFFICULT BECAUSE OF A LACK OF PUBLIC TRANSPORTATION OR MOUNTAINOUS ROADS THAT CAN BE HARD FOR ILL, ELDERLY PATIENTS AND THEIR CAREGIVERS TO NAVIGATE. REHABILITATION AND WELLNESS SERVICES DELIVERED THE COMMUNITY INCLUDED STROKE SCREENINGS AND THE ADDITION OF LAND- AND WATER-BASED EXERCISE CLASSES AT THE HCMH AQUATIC AND WELLNESS CENTER INCLUDING TAI CHI FOR ARTHRITIS AND YOGA CLASSES.HCMH ALSO CONTINUED TO OWN AND MANAGE PARKWOOD PLACE SENIOR INDEPENDENT LIVING APARTMENTS IN ELKIN, NORTH CAROLINA. AMENITIES AND SERVICES ARE DESIGNED TO GIVE RESIDENTS A SAFE, COMFORTABLE APARTMENT LIVING ENVIRONMENT THAT IS ALSO AFFORDABLE. ACTIVITIES INCLUDED SPONSORSHIP OF A FREE HEALTH FAIR AT YADKIN VALLEY SENIOR CENTER IN JONESVILLE.DURING THE YEAR, THE HOSPITAL DID SEVERAL OUTREACH ACTIVITIES. ONE EXAMPLE WAS PROVIDING BASELINE CONCUSSION SCREENINGS FOR ATHLETES FROM THREE HIGH SCHOOLS (ELKIN, STARMOUNT AND SURRY CENTRAL) IN A VARIETY OF SPORTS INCLUDING BASKETBALL, CHEERLEADING, FOOTBALL, SOCCER AND TENNIS. THROUGHOUT THE YEAR, TO TEACH PEOPLE TO RECOGNIZE STROKE WARNING SIGNS THAT OFTEN COME ON SUDDENLY, HCMH EDUCATED THE PUBLIC ABOUT AN ACRONYM CALLED F.A.S.T. FACE DROOPING, ARM WEAKNESS, SPEECH DIFFICULTY AND TIME TO CALL 9-1-1. THE HOSPITAL ALSO SUBSIDIZED LABORATORY AND IMAGING EXPENSES FOR GRACE CLINIC OF THE YADKIN VALLEY, A FREE CLINIC LOCATED IN ELKIN, NORTH CAROLINA THAT SEES PATIENTS AGES 18 TO 64 WITH NO MEDICAL INSURANCE AND WHO FALL UNDER THE INCOME AT OR LESS THAN 200 PERCENT OF THE FEDERAL POVERTY LEVEL. A FREE, MONTHLY SERIES OF CLASSES TAUGHT BY A REGISTERED DIETITIAN AND CERTIFIED DIABETES EDUCATOR WERE HELD AT THE HOSPITAL TO EDUCATE ADULTS ABOUT HOW TO KEEP DIABETES IN CONTROL. CLASSES LASTED 90 MINUTES AND MORE THAN 100 PEOPLE ATTENDED.SUPPORT FOR CANCER PATIENTS INCLUDED MASTECTOMY FITTERS GOING TO PATIENT'S HOMES AFTER SURGERY FOR A PROSTHESIS FITTING. THEY PROVIDE A "SOFTIE AND PILLOW FOR THE PATIENT'S COMFORT DURING THE RECOVERY PERIOD UNTIL THE PROSTHESIS IS READY FOR FITTING. OTHER WOMEN'S SERVICES COMMUNITY OUTREACH INCLUDED BIRTHING CLASSES AND BREASTFEEDING EDUCATION.HUGH CHATHAM CONTINUES TO BE A REGIONAL LEADER IN PROVIDING QUALITY, COMPASSIONATE CARE TO ITS PATIENTS. THE HEALTH SYSTEM PRIDES ITSELF ON ITS 2016 ACHIEVEMENTS IN ITS ADOPTED VISION, "TO BE THE BEST COMMUNITY HOSPITAL IN THE NATION, WITH SERVICE AS ITS GUIDING PRINCIPLE." 99835200 1 0 0 1 0 0 0 0 0 0 1 0 0 0 1 1 0 1 0 0 0 0 0 0 0 0 1 1 1 0 1 1 0 1 0 0 0 0 0 0 1 0 0 0 0 0 0 1 1 0 0 0 1 118 0 1 981 1 0 0 0 0 0 0 0 0 0 0 X 16 15 0 1 0 0 0 0 0 1 1 0 0 1 1 1 1 1 1 1 1 0 NC X CHERYL PARDUE 3365277595 PO BOX 560 ELKIN NC 28621 Darnell Terry Chairman 1.00 X X 0 0 0 Ashman Ann Vice Chairman 1.00 X X 0 0 0 Cline David Treasurer 1.00 X X 0 0 0 Thompson Donna Secretary 1.00 1.00 X X 0 0 0 Johnson Dr Bill Asst Secretary/Treasurer 1.00 X X 0 0 0 Austin Kevin BOARD MEMBER 1.00 X 0 0 0 Ball Bob BOARD MEMBER 1.00 X 0 0 0 Cartwright Dr Stephanie BOARD MEMBER 1.00 X 0 0 0 Castillejo Dr Alvaro BOARD MEMBER 1.00 X 0 0 0 Midkiff Bob BOARD MEMBER 1.00 X 0 0 0 Norman Mike BOARD MEMBER 1.00 X 0 0 0 Parker Raymond BOARD MEMBER 1.00 X 0 0 0 Robertson David BOARD MEMBER 1.00 X 0 0 0 Smith Willena BOARD MEMBER 1.00 X 0 0 0 Snyder Dr Jonathan BOARD MEMBER 1.00 X 0 0 0 Paul Hammes CEO 40.00 2.00 X 325000 0 22900 Donald Trippel CFO 40.00 X 234705 0 24987 Mary Blackburn CPO 40.00 X 153852 0 31211 Paula Moore Former CNO 0.00 X 191505 0 25558 Carbone Dominick MD Physician 40.00 1.00 X 732548 0 33631 Jonathan Snyder MD Physician 40.00 1.00 X 552121 0 37903 Sarba Kundu MD Physician 40.00 X 680214 0 39076 Muragananthan Subbiah MD Physician 40.00 X 541548 0 38966 Marc Stevens MD Physician 40.00 X 530909 0 12018 3942402 0 266250 54 1 1 0 SODEXO INC PO BOX 536922 ATLANTA GA 30353 DIETARY & HOUSEKEEPING SERVICES 3138750 CARDINAL HEALTH PO BOX 905867 CHARLOTTE NC 28290 PATIENT & HOSPITAL SUPPLIES 1984222 CARDINAL DISTRIBUTION PHARMACY 25025 NETWORK PLACE CHICAGO IL 60673 PHARMACY SUPPLIES & MEDICATIONS 1888391 HORIZON CSA LLC 265 PITT ROAD MOORESVILLE NC 28115 EQUIPMENT MAINTENANCE 1740792 SMITH AND NEPHEW ORTHO PO BOX 933782 ATLANTA GA 31933 MEDICAL SUPPLIES 1291885 75 558003 558003 PATIENT CARE SERVICES 621400 106619156 106619156 OTHER OPERATING REVENUE 621400 351465 351465 EHR MEANINGFUL USE REVENUE 621400 156372 156372 NET HOSPICE INVESTMENT 623000 -177322 -177322 106949671 3811450 3811450 1304037 298702 1005335 1005335 1005335 8967756 0 34791 8967756 -34791 8932965 8932965 CAFETERIA & VENDING 722210 8353 8353 8353 121265777 106949671 0 13758103 X 78120 78120 865235 216309 605665 43261 56319 56319 39842981 37525019 2317962 663339 615060 47575 704 5385009 4993082 386212 5715 2613323 2423123 187427 2773 302140 302140 56227 56227 198701 198701 587335 587335 14748364 13192267 1556097 252825 111620 141205 8536656 8169724 366932 1681778 1681778 236491 207115 29376 2495480 2495480 6444072 6444072 -183065 -183065 BAD DEBT EXPENSE 14305066 14305066 MEDICAL SUPPLIES 4062640 4062640 PROVIDER TAX 2977432 2977432 MISCELLANEOUS 985280 464039 521241 435113 435113 107626861 99835200 7739208 52453 12215793 12693512 9651796 9526802 915540 907403 2193722 1746165 152501168 87508775 67655569 64992393 117274977 136591000 4656695 5332400 2267783 2110053 216831875 233899728 9909143 10285634 67005000 64465427 14470780 10805996 91384923 85557057 X 122440964 145238124 3005988 3104547 125446952 148342671 216831875 233899728 X 13638916 6082202 3174601 X X 0 1 X 1 0 X 0 1 0 0 0 0 0 0 1 0 0 Part II-B, Line 1: PART II-B, LINE 1I: THE ORGANIZATION IS A MEMBER OF THE AMERICAN HOSPITAL ASSOCIATION (AHA) AND THE NORTH CAROLINA HOSPITAL ASSOCIATION (NCHA). THESE ORGANIZATIONS ENGAGE IN LOBBYING EFFORTS TO LEGISLATIVE BODIES ON BEHALF OF THEIR MEMBERSHIP BASES. EACH YEAR, A PORTION OF MEMBERSHIP DUES PAID TO THESE ORGANIZATIONS IS ALLOCATED TO LOBBYING ENDEAVORS. FOR THE CURRENT YEAR, THE PORTION OF DUES PAID ALLOCATED TO LOBBYING IS APPROXIMATELY $ 11,900. 2546331 2546331 89727476 38031677 51695799 9186285 8116230 1070055 50119443 41360868 8758575 921633 921633 64992393 INTEREST PAYABLE 477225 ESTIMATED THIRD-PARTY PAYOR SETTLEMENTS 5076214 PHYSICIAN GUARANTEE 218651 INTEREST RATE SWAP 4970979 RESIDENT TRUST FUNDS 62927 10805996 X Part X, Line 2: THE HOSPITAL, FOUNDATION, AND AUXILIARY ARE NOT-FOR-PROFIT CORPORATIONS AS DESCRIBED IN SECTION 501(C)(3) OF THE INTERNAL REVENUE CODE AND ARE EXEMPT FROM FEDERAL INCOME TAXES ON RELATED INCOME PURSUANT TO SECTION 501(A) OF THE CODE; ACCORDINGLY, THE ACCOMPANYING FINANCIAL STATEMENTS DO NOT REFLECT A PROVISION OR LIABILITY FOR FEDERAL AND STATE INCOME TAXES. THE HOSPITAL HAS DETERMINED THAT IT DOES NOT HAVE ANY MATERIAL UNRECOGNIZED TAX BENEFITS OR OBLIGATIONS AS OF SEPTEMBER 30, 2017. FISCAL YEARS ENDING ON OR AFTER SEPTEMBER 30, 2013 REMAIN SUBJECT TO EXAMINATION BY FEDERAL AND STATE TAX AUTHORITIES. 1 1 X 1 X 1 X 1 1 1 0 1 1 1667708 1667708 0.01790 11943952 11792460 151492 0.00160 13611660 11792460 1819200 0.01950 7390 7390 0.00010 132587 132587 0.00140 640227 640227 0.00690 780204 780204 0.00840 14391864 11792460 2599404 0.02790 4 2541 895 895 0.00000 4 2541 895 895 0.00000 1 4119859 1441951 78020286 77501741 518545 X 1 0 1 1 HUGH CHATHAM MEMORIAL HOSPITAL 180 PARKWOOD DRIVE ELKIN NC 28621 X X X DISPROPORTIONATE SHARE HOSPITAL HUGH CHATHAM MEMORIAL HOSPITAL 1 0 0 1 X X X X X X X X X 16 1 0 0 1 X SEE DISCLOSURE X 1 15 1 SEE DISCLOSURE 0 1 X 200.000000000000 200.000000000000 X X X X X X 1 1 X X X X 1 X see disclosure X SEE DISCLOSURE X SEE DISCLOSURE X X X X X X 1 X 0 X X X 1 X 0 0 HUGH CHATHAM MEMORIAL HOSPITAL Part V, Section B, Line 5: EXPERTS IN THE FIELD OF PUBLIC HEALTH, HOSPICE CARE, NURSES, PHYSICIANS, CASE MANAGEMENT, EDUCATION, AND PHILANTHROPY WERE CHOSEN FOR THE FOCUS GROUP. THE FOCUS GROUPS WERE DESIGNED AROUND THE KEY ISSUES THAT EMERGED FROM THE MEETINGS. HUGH CHATHAM MEMORIAL HOSPITAL Part V, Section B, Line 11: Hugh Chatham Memorial Hospital will continue to play a leading role in addressing the health needs of those within our community, with a special focus on the underserved. As such, community benefit planning is integrated into our hopsital's annual planning and budgeting processes to ensure we continue to effectively support community benefits. PART V, SECTION B, LINE 7A: http://www.hughchatham.org/assets/forms/2016-Community-Health-Needs-Assessment PART V, SECTION B, LINE 10a http://www.hughchatham.org/about/community-health/ 21 1 - YADKIN VALLEY HOME HEALTH 213 WINSTON RD ELKIN NC 28642 HOME HEALTH 2 - TRI COUNTY ORTHOPEDIC AND SPORTS MEDICINE 400 JOHNSON RIDGE RD ELKIN NC 28621 PHYSICIAN OFFICE 3 - YADKIN VALLEY UROLOGY 200 JOHNSON RIDGE MEDICAL PARK ELKIN NC 28621 PHYSICIAN OFFICE 4 - YADKIN VALLEY ADULT MEDICINE 500 CHATHAM MEDICAL PARK ELKIN NC 28621 PHYSICIAN OFFICE 5 - CLINGMAN MEDICAL CENTER 3369 CLINGMAN RD ELKIN NC 28670 PHYSICIAN OFFICE 6 - YADKIN VALLEY GASTROENTEROLOGY 201 WEST MAIN STREET ELKIN NC 28621 PHYSICIAN OFFICE 7 - JONESVILLE URGENT CARE CENTER 546 WINSTON ROAD MT VIEW NC 28642 PHYSICIAN OFFICE 8 - G I CLINIC 201 WEST MAIN STREET ELKIN NC 28621 PROCEDURE CLINIC 9 - YADKIN VALLEY DERMATOLOGY 201A ELDON PARK DRIVE ELKIN NC 28621 PHYSICIAN OFFICE 10 - HUGH CHATHAM FAMILY MEDICINE ELKIN 600 CHATHAM MEDICAL PARK ELKIN NC 28621 PHYSICIAN OFFICE 11 - HUGH CHATHAM SURICAL 201B ELDON PARK DRIVE ELKIN NC 28621 PHYSICIAN OFFICE 12 - HUGH CHATHAM NEUROLOGY 100 CHATHAM MEDICAL PARK ELKIN NC 28621 PHYSICIAN OFFICE 13 - HUGH CHATHAM BEHAVIORAL 690 PARKWOOD MEDICAL PARK ELKIN NC 28621 PHYSICIAN OFFICE 14 - YADKIN VALLEY PULMONARY 180 PARKWOOD DRIVE ELKIN NC 28621 PHYSICIAN OFFICE 15 - HUGH CHATHAM FAMILY MED BOOMER 156 BOOMER COMMUNITY CENTER RD BOOMER NC 28606 PHYSICIAN OFFICE 16 - HUGH CHATHAM FAMILY MED MT VIEW 5229 ROCK CREEK RD MT VIEW NC 28602 PHYSICIAN OFFICE 17 - HUGH CHATHAM WOMEN'S CENTER 150 PARKWOOD DRIVE MT VIEW NC 28621 PHYSICIAN OFFICE 18 - HUGH CHATHAM PODIATRIC MEDICINE AND SURGER 150 CHATHAM MEDICAL PARK MT VIEW NC 28621 PHYSICIAN OFFICE 19 - HUGH CHATHAM EXPRESS CARE DOBSON 911 E ATKINS ST DOBSON NC 28621 PHYSICIAN OFFICE 20 - PARKWOOD PLACE RETIREMENT CENTER 601 JOHNSON RIDGE RD ELKIN NC 28621 RETIREMENT CENTER 21 - HUGH CHATHAM FAMILY MEDICINE INDEPEDENCE 127 EAST MAIN STREET INDEPENDENCE VA 24348 PHYSICIAN OFFICE Part I, Line 7: THE ORGANIZATION'S INTERNAL COST ACCOUNTING SYSTEM WAS USED TO COMPUTE A COST-TO-CHARGES RATIO THAT WAS USED TO CALCULATE COSTS USED IN PART I, LINE 7. Part I, Ln 7 Col(f): THE TOTAL EXPENSE AMOUNT LISTED ON FORM 990, PART IX, LINE 26 CONTAINS BAD DEBT EXPENSE OF $14,305,066 THAT WAS REMOVED FOR THE PURPOSE OF CALCULATING TOTAL CHARITY CARE PERCENTAGE ON LINE 7, COLUMN (F). PART I, LINE 6A: THE HOSPITAL'S COMMUNITY BENEFIT REPORT IS FILED THROUGH THE MEDICAL CARE COMMISSION OF NORTH CAROLINA. Part II, Community Building Activities: HUGH CHATHAM MEMORIAL HOSPITAL PROVIDES ALL LOCAL SCHOOLS WITH FREE HAND SANITIZERS WITH FLU PREVENTION BROCHURES EVERY FALL AND SUNCREEN WITH MELANOMA AWARENESS BROCHURES EVERY SPRING. Part III, Line 4: THE ORGANIZATION'S FINANCIAL STATEMENTS DO NOT CONTAIN 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 AN INTERNALLY COMPUTED COST-TO-CHARGES RATIO FROM THE ORGANIZATION'S COST ACCOUNTING SYSTEMS.DUE TO THE FACT THAT APPROXIMATELY 30% OF THE SURROUNDING COMMUNITY'S RESIDENTS ARE CONSIDERED TO BE LIVING BELOW THE POVERTY LINE, IN COMBINATION WITH THE FACT THAT THE UNEMPLOYMENT PERCENTAGE FOR THE AREA IS APPROXIMATELY 12.7%, THE ORGANIZATION FEELS THAT APPROXIMATELY 35% OF BAD DEBT IS AN APPROPRIATE ESTIMATION OF THE AMOUNT OF BAD DEBT THAT MAY CONSTITUTE A COMMUNITY BENEFIT. Part III, Line 8: AN INTERNAL COST-TO-CHARGE RATIO WAS USED TO COMPUTE MEDICARE ALLOWABLE COSTS OF CARE ON PART III, LINE 6. Part III, Line 9b: HCMH MAKES EVERY EFFORT TO EVALUATE PATIENTS PRIOR TO PLACEMENT WITH A COLLECTIONS AGENCY TO SEE IF THEY ARE QUALIFIED FOR MEDICAID OR HOSPITAL CHARITY CARE. WE HAVE AN IN-HOUSE EMPLOYEE DESIGNATED TO ASSISTING PATIENTS ELIGIBLE FOR MEDICAID AND/OR FINANCIAL ASSISTANCE. AT THE POINT OF THE PATIENT NOT BEING ELIGIBLE AND FAILURE TO RESPOND FOR OUR PAYMENT PLAN OPTIONS, THE ACCOUNT IS PLACED WITH A COLLECTION AGENCY AND THE AGENCY MAKES AN EFFORT FOR 30 DAYS PRIOR TO PLACING ON THE CREDIT SCORE, TO OBTAIN PAYMENT. Part VI, Line 2: The organization tracks the results of Health Screenings provided through its health fairs and looks for trends. These screenings provide insight into further medical needs of the community members. The fairs are held periodically through the year and are attended by hundreds of people who are offered various health screenings. The organization also subscribes to national affiliated organizations that provide data on regional health needs. The last couple of years our focus has been on stroke education, with stroke certification for our facility. Various health fairs for specific groups, reaching into the business community with educational materials and screenings being provided. We have provided presentations to the senior center in our area concerning diseases that affect their age groups. Part VI, Line 3: FINANCIAL ASSISTANCE EDUCATION IS MADE AVAILABLE AT ADMISSION AND ON THE WEBSITE. AT REGISTRATION THERE ARE BROCHURES WITH FINANCIAL ASSISTANCE INFORMATION MADE AVAILABLE. SIGNAGE IS LOCATED THROUGHOUT THE FACILITY TO INFORM AND EDUCATE THE PUBLIC OF THEIR FINANCIAL RIGHTS. HUGH CHATHAM MEMORIAL HOSPITAL OFFERS A LANGUAGE LINE FOR THE NON-ENGLISH SPEAKING COMMUNITY AND PHONETREE ASSISTANCE WHERE NEEDED. Part VI, Line 4: The primary service area of the hospital includes nine zip codes. Roughly a fifteen mile diameter around Elkin, NC. The secondary service area includes an additional five zip codes widening the diamter to thirty miles around Elkin. Both of theses markets include part, but not all, of the North Carolina counties of Wilkes, Alleghany, Yadkin and Surry. Southern Virginia counties of Grayson, Patrick, and Carroll are also included. 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 NOT EMPLOYEES, INDEPENDENT CONTRAcTORS, NOR FAMILY MEMBERS OF EMPLOYEES OR INDEPENDENT CONTRACTORS. IN ADDITION, THE ORGANIZATION EXTENDS MEDICAL STAFF PRIVILEGES TO ALL QUALIFIED PHYSICIANS IN THE COMMUNITY FOR SOME OF ITS DEPARTMENTS.HCMH OFFERS A WIDE VARIEY OF SERVICES TO OUR COMMUNITY, SUCH AS WOMEN'S HEALTH EDUCATION SEMINARS,INFANT AND CHILD CPR CLASSES, LAMAZE AND CHILDBIRTH CLASSES, CARDIAC REHABILITATION, AND VARIOUS PATIENT EDUCATIONAL PROGRAMS. THE HOSPITAL PARTICIPATES IN AND HOSTS MANY COMMUNITY HEALTH SCREENINGS AND IMMUNIZATIONS, CANCER SCREENINGS (PROSTATE, BREAST, SKIN, AND COLON), AS WELL AS SCREENINGS IN THE FOLLOWING AREAS: CHOLESTEROL/GLUCOSE, BLOOD PRESSURE, HEART RATE,OXYGEN SATURATION, WEIGHT AND BODY MASS INDEX ASSESSMENT, FALLS ASSESSMENT, BONE DENSITY TESTING, TETANUS AND FLU CLINICS. THE EMPLOYEES AT HCMH ARE COMMITTED TO THE AREA'S NEEDS. COMMITTMENT IS DEMONSTRATED THROUGH PARTICIPATION IN THE FOLLOWING: THE STOP HUNGER FOOD DRIVE, MARCH OF DIMES, UNITED WAY, TRI C MINISTRIES, SUSAN G. KOMEN WALKATHONS, SPECIAL OLYMPICS, THE AMERICAN CANCER SOCIETY, THE NATIONAL MS SOCIETY, AND A LOCAL ORGANIZATION TRIAD FIRST IN FAMILIES THAT HELPS CHILDREN IN NEED.HCMH IS COMMITTED TO THE PROMOTION OF HEALTH, OUTREACH, AND SUPPORT GROUPS. THE HOSPITAL SPONSORS THE FOLLOWING:CANCER HEART AND SOUL, LOOK GOOD FEEL BETTER CANCER SUPPORT, HOSPICE GRIEF CAMP FOR CHILDREN, BEREAVEMENT AND THE GRIEF PROCESS, STROKE SUPPORT, AMPUTEE SUPPORT, ALZHEIMER'S SUPPORT, CPR FOR INDUSTRY, DAY CARE WORKERS, AND LIFEGUARDS, SENIOR FITNESS CLASSES, AND CARDIAC REHABILITATION CLASSES. HCMH ALSO HOLDS "LUNCH AND LEARNS" WHICH ARE OFFERED TO THE COMMUNITY PROMOTING DIFFERENT TOPICS OF HEALTH RELATED INTEREST.THE HOSPITAL ALSO SPONSORS THE GRACE CLINIC WHICH IS A LOCAL FREE CLINIC WHICH OPERATES ON DONATED SERVICES AND SUPPLIES. Part VI, Line 6: THE HOSPITAL IS NOT PART OF AN AFFILIATED HEALTH CARE SYSTEM. Part VI, Line 7, Reports Filed With States NC 1 HUGH CHATHAM MEMORIAL HOSPITAL FOUNDATION INC 180 PARKWOOD DRIVE ELKIN NC 28621 562049537 501(C)(3) 69863 OPERATIONAL SUPPORT 1 Part I, Line 2: GRANTS ARE MADE IN ACCORDANCE WITH HUGH CHATHAM MEMORIAL HOSPITAL'S MISSION STATEMENT TO CONSISTENLY DELIVER EXCEPTIONAL QUALITY AND SERVICE BY DEMONSTRATING THE VALUES OF SERVICE, TEAMWORK, ACCOUNTABILITY, RESPECT, AND SAFE CARE. X 0 0 X X X X 1 0 0 0 0 1 0 0 0 Paul Hammes CEO 325000 0 0 0 0 0 7878 0 15022 0 347900 0 0 0 Donald Trippel CFO 209705 0 25000 0 0 0 8459 0 16528 0 259692 0 0 0 Mary Blackburn CPO 153852 0 0 0 0 0 6836 0 24375 0 185063 0 0 0 Paula Moore Former CNO 191505 0 0 0 0 0 7361 0 18197 0 217063 0 0 0 Carbone Dominick MD Physician 514502 0 218046 0 0 0 16932 0 16699 0 766179 0 0 0 Jonathan Snyder MD Physician 455789 0 96332 0 0 0 12788 0 25115 0 590024 0 0 0 Sarba Kundu MD Physician 509890 0 170324 0 0 0 13879 0 25197 0 719290 0 0 0 Muragananthan Subbiah MD Physician 493288 0 48260 0 0 0 13265 0 25701 0 580514 0 0 0 Marc Stevens MD Physician 444890 0 47019 0 39000 0 12018 0 0 0 542927 0 0 0 Part I, Line 1a Highest paid employee, Dr. Stevens, received a housing allowance in his contract, for a specified amount which was taxable in his income. Part I, Line 4a Paula Moore, CNO: $61,542 Part I, Line 6 THE PHYSICIANS IN CHARGE OF THE UROLOGY PRACTICE, GASTROENTEROLOGY PRACTICE, AND DERMATOLOGY CLINIC ARE ELIGIBLE TO RECEIVE A PORTION OF THE NET PROFIT FROM THEIR PRACTICE. ANY PROFITS RESULTING FROM PHYSICIANS' PROFESSIONAL SERVICES AFTER ALL THE PRACTICE AND PHYSICIAN EXPENSES, SHALL BE SHARED. THE PHYSICIANS RECEIVE UP TO AN 85% ALLOCATION WITH THE REMAINDER GOING TO THE EMPLOYER. THE HOSPITALIST BONUS IS BASED ON PERFORMANCE GOALS AND MAY BE UP TO AS MUCH AS 20% OF THEIR SALARY. ANOTHER PHYSICIAN IN CHARGE OF THE HOSPITALIST GROUP IS ELIGIBLE TO RECEIVE UP TO 20% OF THEIR BASE SALARY DEPENDING ON PERFORMANCE MEASURES OF THE HOSPITALIST GROUP. AMOUNTS PAID OUT TO INDIVIDUALS LISTED ON PART VII OF THE FORM 990 FOR 2015 WERE: DOMINICK CARBONE, MD $217,725 JONATHAN SNYDER, MD 12,000 MARC STEVENS, MC 100,000 SARBA KUNDA, MD 198,600 MURUGANANTHAN SUBBIAH, MD 54,548 FORM 990, PART VII, SECTION A, LINE 1: COMPENSATION FROM AN UNRELATED ORGANIZATION: CEO PAUL HAMES IS COMPENSATED BY AN OUTSIDE MANAGEMENT COMPANY, ALLIANT MANAGEMENT GROUP. THE COMPENSATION PAID BY THE UNRELATED ORGANIZATION IS INCLUDED ON FORM 990, PART VII, SECTION A, LINE 1. THE DETAILS ARE AS FOLLOWS: PAUL HAMES: $ 300,000 A NORTH CAROLINA MEDICAL CARE COMMISSION 521309402 65821DAF8 2008-09-24 45455000 NEW STRUCTURES, EQUIPMENT 1 0 0 B NORTH CAROLINA MEDICAL CARE COMMISSION 521309402 2015-12-16 25495000 REFUNDING REVENUE BONDS 0 0 0 A 4695000 42235000 46276755 3493414 435743 513249 42448072 2010 0 0 1 1 B 1650000 25214951 280049 25214951 0 0 1 1 A 0 0 0 0 0 0 0 B 0 0 0 0 0 0 0 A 0 0 0 1 1 1 WELLS FARGO 30.000000000000 1 0 0 0 0 B 0 0 0 1 1 0 0 0 0 A 0 B 0 Date Rebate Computation Performed Issuer Name: NORTH CAROLINA MEDICAL CARE COMMISSION Date the Rebate Computation was Performed: 08/28/2013 SCH K, PART II, LINE 11, COLUMN A THE OTHER SPENT PROCEEDS OF $11,100,000 WERE USED TO CURRENTLY REFUND PRIOR BONDS ISSUED ON 05-08-1996. LAURA OAKES RELATED TO BOARD MEMBER BOB MIDKIFF 56319 COMPENSATED AS DIRECTOR OF MARKETING 0 Form 990, Part VI, Section A, line 1 THE EXECUTIVE COMMITTEE SHALL BE COMPOSED OF THE OFFICERS OF THE BOARD, THE IMMEDIATE PAST CHAIRMAN AND ONE (1) OR MORE ADDITIONAL MEMBERS WHO WILL BE NOMINATED BY THE CHAIRMAN FOR THE ELECTION BY THE BOARD OF TRUSTEES. WHEN THE BOARD IS NOT IN SESSION, THE EXECUTIVE COMMITTEE SHALL HAVE THE POWER AND AUTHORITY OF THE BOARD TO TRANSACT ALL REGULAR BUSINESS OF THE CORPORATION, SUBJECT TO ANY PRIOR LIMITATIONS IMPOSED BY THE BOARD OR BY STATUTE. THE EXECUTIVE COMMITTEE SHALL ALSO ANNUALLY REVIEW THE PERFORMANCE, COMPENSATION AND TERMS OF EMPLOYEMENT OF THE CHIEF EXECUTIVE OFFICER AND MAKE RECOMMENDATIONS TO THE BOARD CONCERNING COMPENSATION AND TERMS OF THE EMPLOYMENT OF THE CHIEF EXECUTIVE OFFICER. Form 990, Part VI, Section A, line 3 THE HOSPITAL ENTERED INTO A MANAGEMENT AGREEMENT IN JUNE 2006 WITH ALLIANT, AN UNRELATED CORPORATION WHEREBY THE MANAGEMENT COMPANY WILL PERFORM MANAGEMENT AND ADMINISTRATION SERVICES ON A DAY-TO-DAY BASIS AND PROVIDE A CHIEF EXECUTIVE OFFICER. THE AGREEMENT CALLS FOR A BASE MANAGEMENT FEE OF APPROXIMATELY $220,000 IN THE FIRST YEAR WITH ANNUAL INCREASES TO APPROXIMATE THE INCREASE IN CONSUMER PRICE INDEX. IN ADDITION TO THE ANNUAL FEE, THE HOSPITAL IS REQUIRED TO PAY THE SALARIES, BONUSES AGREED UPON BY THE BOARD, AND ALL FRINGE BENEFITS OF THE MANAGEMENT COMPANY'S KEY PERSONNEL WHO PERFORM THE ADMINISTRATIVE DUTIES. Form 990, Part VI, Section B, line 11b THE RETURN WAS PREPARED BY AN INDEPENDENT ACCOUNTING FIRM WITH SUPERVISION AND ASSISTANCE BY MANAGEMENT. UPON COMPLETION, THE RETURN WAS REVIEWED BY MANAGEMENT AND DELIVERED TO THE FINANCE COMMITTEE OF THE BOARD OF DIRECTORS FOR APPROVAL. THE RETURN WAS THEN PRESENTED AT A SCHEDULED MEETING OF THE BOARD OF DIRECTORS BY A REPRESENTATIVE OF THE ACCOUNTING FIRM, AND EACH VOTING MEMBER OF THE BOARD WAS PROVIDED A COPY FOR DISCUSSION AND QUESTIONS. FOLLOWING THE MEETING AND A PERIOD OF TIME FOR COMMENT, THE RETURN WAS FILED WITH THE IRS. Form 990, Part VI, Section B, line 12c ANNUALLY, ALL VOTING BOARD MEMBERS ARE PRESENTED WITH THE GOVERNANCE POLICIES CONCERNING THE ORGANIZATION'S CONFLICT OF INTEREST POLICY. UPON REVIEW AND DISCUSSION CONCERNING RELATIONSHIPS WITH THE ORGANIZATION, ITS AFFILIATES, OR AMONGST EACH OTHER, THE BOARD MEMBERS ARE REQUIRED TO COMPLETE AND RETURN THE POLICY STATEMENT TO THE ADMINISTRATION. THESE STATEMENTS ARE REVIEWED BY THE BOARD CHAIR AND ARE PRESENTED TO THE AUDITORS DURING THE ANNUAL AUDIT. Form 990, Part VI, Section B, line 15 A REPRESENTATIVE FROM ALLIANT, THE OUTSIDE MANAGEMENT COMPANY, MEETS WITH THE BOARD TO REVIEW AND APPROVE SALARIES FOR THE CEO AND OTHER OFFICERS. THE SALARIES OF THE TOP EXECUTIVE AND OTHER MEMBERS OF THE ADMINISTRATIVE DEPARTMENT ARE DETERMINED IN THE CONTRACT NEGOTIATIONS. A REVIEW OF ALL SALARIES, TOP TO BOTTOM, WAS DONE THROUGH THE ADMINISTRATIVE TEAM. Form 990, Part VI, Section C, line 18 PHOTOCOPIES OF THE FORM 990 ARE AVAILABLE UPON REQUEST AT THE ORGANIZATION'S ADMINISTRATIVE OFFICE. Form 990, Part VI, Section C, line 19 PHOTOCOPIES OF THE ORGANIZATION'S GOVERNING DOCUMENTS, CONFLICT OF INTEREST POLICY, AND FINANCIAL STATEMENTS ARE AVAILABLE UPON REQUEST AT THE ORGANIZATION'S ADMINISTRATIVE OFFICE. Form 990, Part IX, line 11g CONTRACT SERVICES: Program service expenses 5,554,893. Management and general expenses 797,787. Fundraising expenses 0. Total expenses 6,352,680. CONTRACT LABOR: Program service expenses 2,829,045. Management and general expenses 335,191. Fundraising expenses 0. Total expenses 3,164,236. MAINTENANCE CONTRACTS: Program service expenses 3,581,435. Management and general expenses 436. Fundraising expenses 0. Total expenses 3,581,871. CENTRALIZED BILLING: Program service expenses 1,035,155. Management and general expenses 0. Fundraising expenses 0. Total expenses 1,035,155. OTHER FEES: Program service expenses 191,739. Management and general expenses 422,683. Fundraising expenses 0. Total expenses 614,422. Form 990, Part XI, line 9: CHANGE IN VALUE OF SWAP AGREEMENT 3,447,664. RECOGNIZED LOSSES ON IMPAIRMENTS -709,009. JV INCOME FROM ACCOUNT WITH SWAP 295,024. RELEASE OF RESTRICTED ASSETS 101,270. PRIOR PERIOD ADJUSTMENT 39,652. FORM 990, PART XII, LINE 2C: THE PROCESS HAS NOT CHANGED FROM THE PRIOR YEAR. HUGH CHATHAM MEMORIAL HOSPITAL FOUNDATION INC 180 PARKWOOD DRIVE ELKIN NC 28621 562049537 FUNDRAISING NC 501(c)(3) Line 12a, I HUGH CHATHAM MEMORIAL HOSPITAL 1 HUGH CHATHAM MEMORIAL HOSPITAL AUXILIARY 180 PARKWOOD DRIVE ELKIN NC 28621 561199949 THRIFT/GIFT SHOP NC 501(c)(3) Line 12a, I HUGH CHATHAM MEMORIAL HOSPITAL 1 1 0 1 0 0 0 0 0 0 0 0 0 0 1 1 0 1 1 1