2018-08-10T15:30:07-05:00 2017-09-30 560747981 DIXON HUGHES GOODMAN LLP 500 RIDGEFIELD COURT ASHEVILLE NC 28806 990 2016-10-01 560525657 ALLEGHANY COUNTY MEMORIAL HOSPITAL INC ALLE 3363723226 PO BOX 9 SPARTA NC 28675 BRETT LIVERMAN CFO 3363723226 2018-08-10 1 Amy Bibby P00445891 8282542254 2018-08-10 2016 2022-09-23 18:48:47Z CRAIG JAMES PO BOX 9 SPARTA NC 28675 12821089 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. 14 13 180 54 58598 25692 264910 230469 13468248 12421844 -4533 16770 179608 152006 13908233 12821089 0 0 0 0 7136442 6649564 0 0 0 6997812 6901883 14134254 13551447 -226021 -730358 7701308 7245717 5697619 5962576 2003689 1283141 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 11436005 0 12363246 ALLEGHANY MEMORIAL HOSPITAL PROVIDED NECESSARY HEALTHCARE SERVICES TO INDIVIDUALS IN THE COMMUNITY REGARDLESS OF THEIR ABILITY TO PAY. 56 SWING BED ADMISSIONS, 6740 ER VISITS, 1,932 DAYS OF CARE, 11,966 X-RAYS, AND 56,160 LAB TESTS. 11436005 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 1 0 0 1 45 0 1 180 1 1 1 0 0 0 0 0 0 0 0 0 X 14 13 0 1 0 0 0 0 0 1 1 0 0 1 1 1 1 1 1 1 1 0 NC X BRETT LIVERMAN CFO 3363723276 PO BOX 9 SPARTA NC 28675 WARREN TAYLOR CHAIRMAN 1.00 X X 0 0 0 ROCKY PROFITT VICE CHAIRMAN 1.00 X X 0 0 0 GEORGE WHITE FINANCE CHAIR 1.00 2.00 X X 0 0 0 FRANCES BUCKLE SECRETARY 1.00 X X 0 0 0 JOHN MILLER VICE SECRETARY 1.00 X 0 0 0 PAT POLLEY TRUSTEE 1.00 X 0 0 0 Mary-Emma Beres MD TRUSTEE 1.00 X 0 0 0 FRANK DOWELL TRUSTEE 1.00 X 0 0 0 Roger Choate TRUSTEE 1.00 X 0 0 0 JIM BECHER TRUSTEE 1.00 X 0 0 0 Paul Demmink TRUSTEE 1.00 X 0 0 0 WHITNEY IVEY TRUSTEE 1.00 X 0 0 0 Karen Leys TRUSTEE 1.00 X 0 0 0 JOE AROCHA MD TRUSTEE/EMPLOYED PHYSICIAN 40.00 X 330643 0 20444 ELIZABETH JONES FNP 40.00 X 72134 0 15712 CRAIG JAMES CEO 40.00 X 195713 0 19298 BRETT LIVERMAN CFO 40.00 X 97632 0 9181 WENDY ORTON CNO 40.00 X 92604 0 24672 DWYNN GREENFIELD PHYSICIAN 40.00 X 182501 0 24672 PAM HOOPERS PHARMACIST 40.00 X 100214 0 12293 1071441 0 126272 4 0 1 0 ALLEGHANY EMERGENCY GROUP LLC (SCHUMACHE PO BOX 82368 LAFAYETTE LA 70598 ER PHYSICIANS 683591 MEDCOST BENEFIT SERVICES PO BOX 24042 WINSTON NC 27114 TPA 291963 HUGH CHATHAM HOSPITAL PO BOX 560 ELKIN NC 28621 ORTHOPEDIC SERVICES 241186 Comphealth po box 972651 Dallas TX 75397 SURGEON 158376 DAN SMITH PO BOX 185 SPARTA NC 28675 CRNA 109075 5 212610 10351 7508 230469 NET PATIENT REVENUE 621500 12364325 12305727 58598 MRI GAP SUPPLEMENT 621500 57519 57519 12421844 11997 11997 39773 0 39773 39773 39773 4736 37 0 0 4736 37 4773 4773 CAFETERIA INCOME 900099 33558 33558 PURCHASE DISCOUNTS 900099 26249 26249 52426 52426 112233 12821089 12363246 58598 168776 878033 771220 106813 4362357 3556416 805941 1046710 864397 182313 362464 299331 63133 225000 225000 9674 9674 63618 63618 1059557 929852 129705 146515 129473 17042 928122 649767 278355 133611 133611 21850 17608 4242 133519 74849 58670 523561 523561 126344 126344 MEDICAL SUPPLIES 2201174 2201174 BAD DEBT EXPENSE 1251262 1251262 MISCELLANEOUS 78076 33484 44592 13551447 11436005 2115442 0 140278 332312 5756 6002 1958111 1632843 307777 325012 54247 40954 19292466 15003534 4642862 4288932 549069 593073 43208 26589 7701308 7245717 2600482 2702266 2790239 2835212 306898 425098 5697619 5962576 X 1638421 917873 365268 365268 2003689 1283141 7701308 7245717 X -730358 44766 10880 -45836 X X 0 1 X 1 0 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 0 0 0 0 0 0 0 0 1 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. 339397 28644 22023 346018 332289 28772 21664 339397 373947 -41658 332289 370358 3589 373947 362325 8033 370358 1.00000 0 0 351517 351517 6363118 4465951 1897167 1460715 1321308 139407 11102294 9216275 1886019 14822 14822 4288932 CAPITAL LEASE OBLIGATION 99710 ESTIMATED THIRD PARTY PAYOR SETTLEMENTS 325388 425098 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, 2017. 1 1 X 1 X 1 X 1 1 1 0 1 1 48669 48669 0.00360 1362114 1099851 262263 0.01940 1410783 1099851 310932 0.02300 1410783 1099851 310932 0.02300 0 1251262 5800509 5454657 345852 X 1 0 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 14 1 0 1 1 X http://amhsparta.org/publications.html X X 1 15 0 1 0 1 X 100.000000000000 200.000000000000 X X X X 1 1 X X X X 1 X http://amhsparta.org/publications.html X http://amhsparta.org/publications.html 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. 3 1 - ALLEGHANY ORTHOPEDIC CLINIC 12 WILLIS ST SPARTA NC 28675 ORTHOPEDIC SURGEON OFFICE 2 - ALLEGHANY HEALTH SERVICES PO BOX 9 SPARTA NC 28675 FAMILY PRACTICE 3 - ALLEGHANY SPECIALITY CLINIC PO BOX 11 SPARTA NC 28677 UROLOGY AND PULMONOLOGY CLINIC, Part I, Line 7: WORKSHEET 2 OF THE 2016 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 2008 was $33,234 va s NC state average of $44,797. The unemployment rate is at roughly 10.9% as of November 2010 vs a statewide average of 9.9%. 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 IS NOT PART OF AN AFFILIATED HEALTH CARE SYSTEM. Part VI, Line 7, Reports Filed With States NC X X X 0 0 0 0 0 0 0 0 0 JOE AROCHA MD TRUSTEE/EMPLOYED PHYSICIAN 178984 0 151659 0 0 0 0 0 20444 0 351087 0 0 0 CRAIG JAMES CEO 195713 0 0 0 0 0 0 0 19298 0 215011 0 0 0 DWYNN GREENFIELD PHYSICIAN 182501 0 0 0 0 0 0 0 24672 0 207173 0 0 0 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 (see note 5). For the years ended September 30, 2017 and 2016, management fees expensed to WFBMC were approximately $225,000 and $206,000, respectively. Other fees expensed to WFBMC were approximately $267,000 and $120,000 during 2017 and 2016, respectively. At September 30, 2017 and 2016, approximately $735,000 and $308,000, 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 XI, line 9: EQUITY TRANSFER TO FOUNDATION -45,836. FORM 990, PART XII, LINE 2C: THE PROCESS HAS NOT CHANGED FROM THE PRIOR YEAR. ALLEGHANY MEMORIAL HOSPITAL FOUNDATION INC 233 DOCTORS STREET SPARTA NC 28675 562012634 PROMOTES AND SUPPORTS THE HOSPITAL NC 501(c)(3) Line 12a, I 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 1 1 1 1 0 1 0 0 ALLEGHANY MEMORIAL HOSPITAL FOUNDATION INC C 212610 CASH