2018-05-09T13:35:23-05:00 2017-06-30 410746749 CLIFTONLARSONALLEN LLP 227 WEST TRADE STREET SUITE 800 CHARLOTTE NC 28202 990 2016-07-01 560554202 CALDWELL MEMORIAL HOSPITAL CALD 8287575100 321 MULBERRY STREET SW LENOIR NC 28645 SHAWN HARTLEY CFO 8287575100 2018-05-09 1 JOHN NORMAN P01506766 7049985200 2018-05-09 2016 2022-09-23 18:48:47Z LAURA J EASTON 321 MULBERRY STREET SW LENOIR NC 28645 130168973 0 X WWW.CALDWELLMEMORIAL.ORG X 1945 NC TO PROMOTE SAFE, EFFECTIVE, COMPASSIONATE MEDICAL CARE AND TO PROMOTE HEALTHY LIFESTYLES FOR OUR COMMUNITY. 15 11 949 162 1119343 -177436 10678503 8844951 115869333 121063888 130862 260134 305228 0 126983926 130168973 425 150 0 0 55744608 54282653 0 0 0 66219649 67102843 121964682 121385646 5019244 8783327 71662461 80768196 32818902 33141310 38843559 47626886 X TO PROMOTE SAFE, EFFECTIVE, COMPASSIONATE MEDICAL CARE AND TO PROMOTE HEALTHY LIFESTYLES FOR OUR COMMUNITY. 0 0 106024272 150 121078265 SINCE OPENING IN 1951, CALDWELL MEMORIAL HOSPITAL HAS CONTINUED TO GROW AND CHANGE IN ORDER TO BETTER MEET THE NEEDS OF OUR COMMUNITY. THE MISSION OF CALDWELL MEMORIAL HOSPITAL IS TO PROVIDE SAFE, EFFECTIVE, COMPASSIONATE CARE AND TO PROMOTE HEALTHY LIFESTYLES TO OUR COMMUNITY. ANCHORED BY A 110-BED ACUTE CARE FACILITY, CALDWELL MEMORIAL HOSPITAL'S SERVICES INCLUDE A VAST ARRAY OF MEDICAL AND SURGICAL SERVICES. AMONG SERVICES OFFERED, BUT BY NO MEANS A COMPLETE LIST, ARE CAROTID ARTERY STENTING; CARDIOVASCULAR AND ENDOVASCULAR CARE; RADIATION ONCOLOGY; COMPUTER-ASSISTED ORTHOPEDIC SURGERY; NEUROLOGY AND MEMORY CARE; PAIN MANAGEMENT; A FULLY STAFFED 24-HOUR EMERGENCY DEPARTMENT; CALDWELL PHYSICIANS CLINICS CONVENIENTLY LOCATED COUNTY-WIDE; **CONTINUED IN SCHEDULE O**DIAGNOSTIC SERVICES; OUTPATIENT SURGERY; PLUS URGENT CARE; AND THE QUEST 4 LIFE WELLNESS CENTER. MULTIPLE EDUCATIONAL AND COUNSELING PROGRAMS ARE AVAILABLE FOR A WIDE ARRAY OF HEALTHCARE NEEDS INCLUDING CANCER, DIABETES, NUTRITION, JOINT CARE, PRE-NATAL CLASSES AND PARENTING SKILLS. CALDWELL PHYSICIANS IS A DIVISION OF CALDWELL MEMORIAL HOSPITAL. WITH PRACTICES IN COMMUNITIES COUNTYWIDE, CALDWELL PHYSICIANS PROVIDES THE PRIMARY AND SPECIALTY HEALTHCARE, DIAGNOSTICS AND TREATMENTS THAT OUR COMMUNITY NEEDS IN CONVENIENT LOCATIONS NEAR THEIR HOMES. CALDWELL PHYSICIANS INCLUDES: ANDERSON MEDICAL PARK, ANDERSON PLUS URGENT CARE, BLOWING ROCK MEDICAL, BLOWING ROCK PLUS URGENT CARE, LAUREL PARK WOMEN'S HEALTH - LENOIR, LAUREL PARK WOMEN'S HEALTH - GRANITE FALLS, MULBERRY PEDIATRICS, ROBBINS MEDICAL PARK, ROBBINS PULMONOLOGY, ROBBINS EAR, NOSE, THROAT AND ALLERGY, ROBBINS PLUS URGENT CARE, ROBBINS CARDIOLOGY, ROBBINS SURGICAL, SOUTHFORK MEDICAL PARK, RIVERCREST MEDICAL PARK, RIVERCREST PLUS URGENT CARE, THE FALLS PEDIATRICS, WESTPOINTE MEDICAL PRACTICE, CALDWELL UROLOGY ASSOCIATES, CALDWELL FOOT & ANKLE, AND THE FALLS PEDIATRICS PLUS URGENT CARE. 0 106024272 1 1 0 1 0 0 0 0 0 0 1 1 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 1 140 0 1 949 1 1 1 0 0 0 0 0 0 0 0 0 X 15 11 0 0 0 0 1 1 1 1 1 0 0 1 1 1 1 1 1 1 1 0 NC X CFO 8287575100 321 MULBERRY STREET SW LENOIR NC 28645 MARK BATTS MD DIRECTOR 2.00 X 122400 0 0 MICHAEL CHAMBERLAIN DIRECTOR 2.00 X 0 0 0 RICK COFFEY DIRECTOR/ VICE CHAIRMAN 4.00 X 0 0 0 CHRIS ELLINGTON DIRECTOR (AS OF 1/1/17) 2.00 58.00 X 0 746797 292071 JOSEPH GIBBONS DIRECTOR 2.00 X 0 0 0 WILLIAM HOWARD III DIRECTOR 2.00 X 0 0 0 DOUG JOHNSON DIRECTOR (AS OF 1/1/17) 2.00 X 0 0 0 BILL JOHNSON DIRECTOR 2.00 X 0 0 0 JEFFREY KEVERLINE MD DIRECTOR 2.00 X 0 0 0 LEE LAYTON DIRECTOR 2.00 X 0 0 0 GARY PARK DIRECTOR (AS OF 1/1/17) 2.00 58.00 X 0 2030958 540181 EDWARD PEARCE MD DIRECTOR 2.00 X 0 0 0 GARY SHORE DIRECTOR/CHAIRMAN 4.00 X 0 0 0 CRISSY THOMAS DIRECTOR 2.00 X 0 0 0 BOYD WILSON DIRECTOR/SEC & TREAS 4.00 X 0 0 0 DAVID MASTERS MD DIRECTOR (THROUGH 12/16) 2.00 X 215796 0 25693 JOHN POWELL MD DIRECTOR 2.00 X 215929 0 31183 LAURA EASTON CEO 60.00 X X 324289 0 38233 REBECCA SMITH COO & CNO 60.00 X 231373 0 21485 SHAWN HARTLEY CFO (AS OF 9/15/16) 60.00 X 73740 0 4684 DONITA DAMRON VP PHYSICIAN SERVICES 60.00 X 164793 0 17837 RANDAL BAST MD MEDICAL PRACTICE PHYSICIAN 60.00 X 760780 0 30283 ROBERT DACUS MD MEDICAL PRACTICE PHYSICIAN 60.00 X 480958 0 28962 TERRI JAGGERS MD MEDICAL PRACTICE PHYSICIAN 60.00 X 471574 0 28247 DAVID EVANS MD MEDICAL PRACTICE PHYSICIAN 60.00 X 434472 0 29655 RUIHAI ZHOU MD MEDICAL PRACTICE PHYSICIAN 60.00 X 361331 0 26686 3857435 2777755 1115200 71 0 1 0 DLP CARDIAC PARTNERS LLC 3700 ARCO CORP OFFICE SUITE 450 CHARLOTTE NC 28273 CATH LAB 1932672 SODEXO INC AND AFFILIATES 9801 WASHINGTONIAN BLVD GAITHERSBURG MD 20878 WELLNESS PARTNER 1551133 WILLIAMS MULLEN 4721 EMPEROR BLVD DURHAM NC 27708 LEGAL 610560 UNIFOUR ANESTHESIA ASSOC PA 415 NORTH CENTER STREET SUITE 201 HICKORY NC 28601 ANESTHESIOLOGY GROUP 360164 DENTON DESIGN 1039 VISTA ROAD BLUE RAPIDS KS 66411 WEB DESIGN & MARKETING 352504 14 8553439 291512 8844951 PATIENT SERVICES 621500 111946371 111946371 QUEST4LIFE WELLNESS CENTER REVENU 713990 1119343 1119343 JOINT VENTURE INCOME 541900 86570 86570 LAB SERVICES 621400 331 331 7911273 7911273 121063888 245757 245757 14377 0 14377 14377 14377 130168973 119944545 1119343 260134 150 150 45400728 37822420 7578308 741100 617395 123705 5174885 4721630 453255 2965940 2706161 259779 18786 18786 47991 47991 9303 9303 6055785 3942307 2113478 337585 337585 940123 940123 973981 973981 2981703 2981703 366540 219923 146617 865 865 58696 58696 415872 415872 4760178 4760178 823162 823162 MEDICAL SUPPATIENT CARE 17347548 17347548 HOME OFFICE ALLOCATION 13754104 9627874 4126230 BAD DEBT EXPENSE 13741365 13741365 OTHER 3014384 3014384 1454872 1309400 145472 121385646 106024272 15361374 0 13146362 7683883 9881208 12052452 855014 1064995 3760277 3737249 647788 1804036 124073699 82833638 31208392 41240061 2428311 2712794 8453639 9112666 1281470 1119838 0 240222 71662461 80768196 21867437 24072687 5671435 4756818 0 5280030 4311805 32818902 33141310 X 38843559 47626886 38843559 47626886 71662461 80768196 8783327 0 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 9303 9303 0 PART II-B, LINE 1: ANNUAL DUES WERE PAID TO THE NORTH CAROLINA HOSPITAL ASSOCIATION AND THE AMERICAN HOSPITAL ASSOCIATION, AND A PERCENTAGE WAS ESTIMATED TO BE EXPENDITURES USED IN LOBBYING ACTIVITIES BY THESE ORGANIZATIONS. 1137587 1137587 48469529 34141161 14328368 56352909 47192837 9160072 18113674 1499640 16614034 41240061 DEFERRED FEE PLAN 1303725 C OTHER ASSETS 7808941 C 9112666 3RD PARTY 2767858 DEFERRED FEE PLAN LIABILITY 1303725 ASSETS LIMITED AS TO USE - OFFSET 240222 4311805 X PART X, LINE 2: THE FOLLOWING TAX FOOTNOTE COMES FROM THE CONSOLIDATED AUDIT REPORT FOR THE TAX PERIOD ENDING JUNE 30, 2017: THE HOSPITAL AND FOUNDATION ARE NONPROFIT CORPORATIONS AND HAVE BEEN RECOGNIZED AS TAX-EXEMPT, PURSUANT TO SECTION 501(C)(3) OF THE INTERNAL REVENUE CODE. NO PROVISION FOR INCOME TAXES HAS BEEN MADE IN THE ACCOMPANYING COMBINED FINANCIAL STATEMENTS. THE HOSPITAL AND FOUNDATION HAVE DETERMINED THAT THEY DO NOT HAVE ANY MATERIAL UNRECOGNIZED TAX BENEFITS OR OBLIGATIONS AS OF JUNE 30, 2017 AND 2016. FISCAL YEARS ENDED ON OR AFTER SEPTEMBER 30, 2012 REMAIN SUBJECT TO EXAMINATION BY FEDERAL AND STATE TAX AUTHORITIES. 1 1 X 1 X 1 X 225.000000000000 1 1 0 1 1 4036485 4036485 0.03750 15400420 16420242 0 0.00000 19436905 16420242 4036485 0.03750 19436905 16420242 4036485 0.03750 1 3542020 1771010 57428300 51563034 5865266 X 1 1 1 AMERICAN HOME PATIENT HEALTHCARE 0.25000 0.75000 2 GUARDIAN HEALTHCARE HEALTHCARE 0.50000 0.50000 3 LAUREL PARK MOB MEDICAL OFFICE BUILDING 0.14900 0.85100 1 1 CALDWELL MEMORIAL HOSPITAL 321 MULBERRY STREET SW PO BOX 1890 LENOIR NC 28645 X X X DISPROPORTIONATE SHARE HOSPITAL CALDWELL MEMORIAL HOSPITAL 1 0 0 1 X X X X X X X X X 14 1 0 0 1 X HTTP://CALDWELLMEMORIAL.ORG/#PG-ABOUT X 1 14 1 HTTP://CALDWELLMEMORIAL.ORG/#PG-ABOUT 0 1 X 150.000000000000 225.000000000000 X 1 1 X X X X 1 X HTTP://CALDWELLMEMORIAL.ORG/FINANCIAL-ASSISTANCE-POLICY/ X HTTP://CALDWELLMEMORIAL.ORG/FINANCIAL-ASSISTANCE-POLICY/ X HTTP://CALDWELLMEMORIAL.ORG/FINANCIAL-ASSISTANCE-POLICY/ X X X X X X 1 0 1 X 0 0 CALDWELL MEMORIAL HOSPITAL PART V, SECTION B, LINE 5: CALDWELL MEMORIAL HOSPITAL (CMH) DEPLOYED A SURVEY TO LOCAL EXPERT ADVISORS TO GAIN INPUT ON LOCAL HEALTH NEEDS AND THE NEEDS OF PRIORITY POPULATIONS. LOCAL EXPERT ADVISORS WERE LOCAL INDIVIDUALS SELECTED ACCORDING TO CRITERIA REQUIRED BY THE FEDERAL GUIDELINES AND REGULATIONS AND THE HOSPITAL'S DESIRE TO REPRESENT THE REGION'S GEOGRAPHICALLY AND ETHNICALLY DIVERSE POPULATION. CMH RECEIVED INPUT FROM 19 LOCAL EXPERT ADVISORS REPRESENTING THE BROAD INTEREST OF THE COMMUNITY SERVED. IN ADDITION TO SURVEYING THE LOCAL EXPERT ADVISORS, CMH SOLICITED WRITTEN COMMENTS FROM THE COMMUNITY ABOUT ITS 2013 CHNA. CALDWELL MEMORIAL HOSPITAL PART V, SECTION B, LINE 11: THE HOSPITAL HAS IDENTIFIED THE FOLLOWING AREAS AS REPRESENTING THE SIGNIFICANT HEALTH NEEDS FOR CALDWELL COUNTY:1. MENTAL HEALTH AND SUBSTANCE ABUSE2. CHRONIC DISEASE3. OBESITY4. CANCER5. HEART DISEASETHE HOSPITAL HAS DEVELOPED IMPLEMENTATION STRATEGIES FOR THREE OF THE FIVE NEEDS (MENTAL HEALTH & SUBSTANCE ABUSE, CHRONIC DISEASE, AND CANCER; OBESITY AND HEART DISEASE ARE ADDRESSED WITHIN CHRONIC DISEASE) INCLUDING ACTIVITIES TO CONTINUE/PURSUE, COMMUNITY PARTNERS TO WORK ALONGSIDE, AND LEADING AND LAGGING INDICATORS TO TRACK. THE HOSPITAL ALSO IDENTIFIED FOURTEEN OTHER HEALTH NEEDS DURING ITS CHNA PROCESS, BUT DUE TO RESOURCE CONSTRAINTS, DID NOT DEVELOP STRATEGIES TO ADDRESS THOSE ADDITIONAL HEALTH NEEDS.THE HOSPITAL INTENDS TO ADRESS THE SIGNIFICANT HEALTH NEEDS IDENTIFIED ABOVE IN THE FOLLOWING WAY:MENTAL HEALTH AND SUBSTANCE ABUSETHE HOSPITAL INTENDS TO ADD AN IN-HOUSE PSYCHIATRIC UNIT THAT WILL RECRUIT PSYCHIATRISTS, COUNSELORS, SOCIAL WORKERS, AND MENTAL HEALTH TECHNICIANS TO MANAGE THE SERVICES AND IMPROVE ACCESS TO MENTAL HEALTH CARE. THE UNIT WILL ALSO INCLUDE AN OUTPATIENT PSYCHIATRIC CLINIC. THE HOSPITAL EXPECTS TO COLLABORATE WITH THE UNC HEALTH SYSTEM TO LEARN FROM OTHER FACILITIES AND IMPLEMENT THE BEST PROGRAM POSSIBLE. THE HOSPITAL WILL ALSO PILOT A PROGRAM WITH ONE PRIMARY CARE PHYSICIAN TO OFFER TELEMEDICINE PSYCHIATRIC SERVICES IN PARTNERSHIP WITH UNC. IF THE PILOT IS SUCCESSFUL, CMH WILL CONSIDER EXPANDING THE PROGRAM TO OTHER PROVIDERS. THE HOSPITAL WILL ALSO CONTINUE DISCUSSING OPTIONS FOR THE USE OF TELEPSYCHIATRY IN THE EMERGENCY DEPARTMENT. THE HOSPITAL WILL DEVELOP A SYSTEM-WIDE PROTOCOL FOR THE USE OF NARCAN IN EMERGENCY DEPARTMENT.CHRONIC DISEASE (ALSO INCLUDES OBESITY AND HEART DISEASE)THE HOSPITAL PLANS TO TAKE THE FOLLOWING STEPS TO ADDRESS THIS NEED:- WORKING TO HAVE ALL PRACTICES CERTIFIED AS PATIENT-CENTERED MEDICAL HOMES - BRINGING IN INTENSIVIST CARE MANAGER- ADDING OUTPATIENT NUTRITION AND DIABETES SERVICES TO ADDITIONAL PRIMARY CARE PRACTICES- ENHANCING MAMMOGRAPHY SERVICES BY ADDING 3D MAMMOGRAPHYCANCERTHE HOSPITAL PLANS TO TAKE THE FOLLOWING STEPS TO ADDRESS THIS NEED: - ENHANCING MAMMOGRAPHY SERVICES BY ADDING 3D MAMMOGRAPHY SCHEDULE H, PART V, SECTION B, LINES 4 AND 9 PREVIOUSLY, CALDWELL HAD REPORTED THAT THE LAST COMMUNITY HEALTH NEEDS ASSESSMENT AND IMPLEMENTATION PLAN HAD BEEN ADOPTED IN THE 2013 TAX YEAR (FISCAL YEAR ENDING JUNE 30, 2014). HOWEVER, THE CHNA AND IMPLEMENTATION PLAN WAS NOT ACTUALLY ADOPTED UNTIL THE 2014 TAX YEAR (FISCAL YEAR ENDING JUNE 30, 2015). BECAUSE CALDWELL WAS ACQUIRED BY UNC HEALTH CARE ON MAY 20, 2013, CALDWELL (AS A NEWLY ACQUIRED ORGANIZATION) HAD A GRACE PERIOD TO COMPLY WITH THE CHNA AND IMPLEMENTATION PLAN REQUIREMENTS UNTIL THE LAST DAY OF THE SECOND TAXABLE YEAR BEGINNING AFTER THE ACQUISITION DATE. THE ADOPTION OF BOTH TOOK PLACE IN A TIMELY FASHION DURING (AND PRIOR TO THE END OF) THE JUNE 30, 2015 YEAR END. THUS, SCHEDULE H, PART V, SECTION B, LINES 6 AND 9 HAVE BEEN UPDATED TO REFLECT THAT THE LAST CHNA AND IMPLEMENTATION PLANS WERE ADOPTED IN THE 2014 TAX YEAR. THE NEXT CHNA/IMPLEMENTATION PLAN CYCLE IS DUE BY THE END OF THE JUNE 30, 2018 YEAR END. NEXT YEAR'S FORM 990 WILL REFLECT THAT CALDWELL DID ADOPT BOTH THE CHNA AND THE IMPLEMENTATION PLAN BEFORE THE JUNE 30, 2018 YEAR END. 9 1 - COMMUNITY PHARMACY 321 MULBERRY STREET SW LENOIR NC 28645 RETAIL/EMPLOYEE PHARMACY 3 - QUEST 4 LIFE WELLNESS CENTER 1031 MORGANTON BLVD LENOIR NC 28645 WELLNESS CENTER 4 - CALDWELL PHYSICIANS NETWORK 321 MULBERRY STREET SW LENOIR NC 28645 PHYSICIAN PRACTICE 5 - CALDWELL MEMORIAL SLEEP CENTER 270 PINE MOUNTAIN ROAD HUDSON NC 28638 SLEEP CENTER 6 - THE CENTER FOR WOUND MANAGEMENT 401 MULBERRY STREET LENOIR NC 28645 WOUND CARE CENTER 7 - GEORGE M HANCOCK SURGERY CENTER 1031 MORGANTON BLVD LENOIR NC 28645 OP SURGERY CENTER 8 - CENTER FOR DIABETES HEALTH 1031 MORGANTON BLVD LENOIR NC 28645 DIABETES EDUCATION AND SUPPORT 9 - PAIN MANAGEMENT CENTER 1031 MORGANTON BLVD LENOIR NC 28645 PAIN MANAGEMENT 10 - LAUREL PARK BREAST CENTER COLLEGE AVENUE LENOIR NC 28645 BREAST HEALTH PART I, LINE 3C: CALDWELL PROVIDES CARE TO PATIENTS WHO MEET CERTAIN CRITERIA UNDER ITS CHARITY CARE POLICY WITHOUT CHARGE OR AT AMOUNTS LESS THAN ITS ESTABLISHED RATES. BECAUSE CALDWELL DOES NOT PURSUE COLLECTION OF AMOUNTS DETERMINED TO QUALIFY AS CHARITY CARE, THEY ARE NOT REPORTED AS NET PATIENT SERVICE REVENUE. THE CRITERIA FOR CHARITY CARE, WHILE NOT ALL INCLUSIVE, CONSIDERS THE PATIENT'S INCOME, THEIR FINANCIAL STATUS INCLUDING THE EXTENT OF FINANCIAL OBLIGATIONS FOR HEALTH CARE SERVICES, AND ANY OTHER PERTINENT FACTORS DEEMED APPROPRIATE BY CALDWELL IN ASSESSING THE PATIENT'S ABILITY TO PAY FOR THEIR SERVICES. PART I, LINE 7: WORKSHEET FROM SCHEDULE H INSTRUCTIONS IS USED TO COMPUTE A COST-TO-CHARGE RATIO TO CALCULATE CHARITY CARE AND UNREIMBURSED MEDICAID AT COST. PART I, LN 7 COL(F): UNCOLLECTIBLE ACCOUNTS - THE HOSPITAL HAS PROVIDED SERVICES TO PERSONS WHO HAVE NOT PAID FOR SUCH SERVICES EITHER BECAUSE THEY HAVE BEEN UNWILLING OR UNABLE TO PAY. EFFORTS ARE MADE BY THE HOSPITAL TO DETERMINE IF A PATIENT MEETS CHARITY POLICY GUIDELINES THAT ARE ESTABLISHED BY THE HOSPITAL. IF THESE GUIDELINES ARE MET AND CAN BE VERIFIED, THEN SUCH AMOUNTS ARE INCLUDED IN CHARITY CARE. UNTIL SUCH TIME, SUCH AMOUNTS ARE COMBINED IN THE PROVISION FOR UNCOLLECTIBLE ACCOUNTS BECAUSE THEY HAVE NOT BEEN VERIFIED OR DOCUMENTED AS CHARITY CARE DUE TO LACK OF SUPPORTING FINANCIAL INFORMATION. IN SOME CASES, PATIENTS WHO WOULD (OR COULD) QUALIFY FOR CHARITY CARE ARE UNWILLING OR UNABLE TO PRODUCE THE NECESSARY INFORMATION TO SUBSTANTIATE THEIR QUALIFICATION. THUS, THE PROVISION FOR UNCOLLECTIBLE ACCOUNTS INCLUDE AMOUNTS THAT WOULD OTHEWISE QUALIFY FOR CHARITY CARE UNDER THE HOSPITAL'S GUIDELINES.THE ESTIMATED COST OF UNREIMBURSED SERVICES ATTRIBUTABLE TO THE PROVISION FOR UNCOLLECTIBLE ACCOUNTS - EFFECTIVELY "FREE" SERVICES PROVIDED TO PATIENTS - HAS BEEN DETERMINED BY APPLYING A COST TO CHARGE RATIO TO THE AMOUNT OF THE PROVISION FOR UNCOLLECTIBLE ACCOUNTS. PART III, LINE 2: THE COST FOR BAD DEBT EXPENSES WAS CALCULATED BY APPLYING THE COST-TO-CHARGE RATIO FOR THE YEAR TO THE GROSS BAD DEBT CHARGES FOR THE YEAR. PART III, LINE 3: THE ESTIMATE FOR BAD DEBT EXPENSES ATTRIBUTABLE TO PATIENTS ELIGIBLE UNDER THE FINANCIAL ASSISTANCE POLICY WAS CALCULATED BY APPLYING THE COST-TO-CHARGE RATIO FOR THE YEAR TO THE GROSS BAD DEBT CHARGES ATTRIBUTABLE TO UNINSURED PATIENTS DURING THE YEAR. PART III, LINE 9B: THE HOSPITAL DOES NOT SUBJECT ANY PATIENTS TO A COLLECTION AGENCY WHO HAS QUALIFIED FOR FINANCIAL ASSISTANCE GUIDELINES. PART VI, LINE 2: FEDERAL REGULATIONS SURROUNDING CHNA REQUIRE LOCAL INPUT FROM REPRESENTATIVES OF PARTICULAR DEMOGRAPHIC SECTORS. FOR THIS REASON, THE HOSPITAL DEVELOPED A STANDARD PROCESS OF GATHERING COMMUNITY INPUT. IN ADDITION TO GATHERING DATA FROM THE ABOVE SOURCES:- WE DEPLOYED A CHNA "ROUND 1" SURVEY TO OUR LOCAL EXPERT ADVISORS TO GAIN INPUT ON LOCAL HEALTH NEEDS AND THE NEEDS OF PRIORITY POPULATIONS. LOCAL EXPERT ADVISORS WERE LOCAL INDIVIDUALS SELECTED ACCORDING TO CRITERIA REQUIRED BY THE FEDERAL GUIDELINES AND REGULATIONS AND THE HOSPITAL'S DESIRE TO REPRESENT THE REGION'S GEOGRAPHICALLY AND ETHNICALLY DIVERSE POPULATION. WE RECEIVED COMMUNITY INPUT FROM 19 LOCAL EXPERT ADVISORS. SURVEY RESPONSES STARTED JUNE 2, 2017, AND ENDED WITH THE LAST RESPONSE ON JUNE 12, 2017.- INFORMATION ANALYSIS AUGMENTED BY LOCAL OPINIONS SHOWED HOW CALDWELL COUNTY RELATES TO ITS PEERS IN TERMS OF PRIMARY AND CHRONIC NEEDS AND OTHER ISSUES OF UNINSURED PERSONS, LOW-INCOME PERSONS, AND MINORITY GROUPS. RESPONDENTS COMMENTED ON WHETHER THEY BELIEVE CERTAIN POPULATION GROUPS ("PRIORITY POPULATIONS") NEED HELP TO IMPROVE THEIR CONDITION, AND IF SO, WHO NEEDS TO DO WHAT TO IMPROVE THE CONDITIONS OF THESE GROUPS.WHEN THE ANALYSIS WAS COMPLETE, WE PUT THE INFORMATION AND SUMMARY CONCLUSIONS BEFORE OUR LOCAL EXPERT ADVISORS WHO WERE ASKED TO AGREE OR DISAGREE WITH THE SUMMARY CONCLUSIONS. THEY WERE FREE TO AUGMENT POTENTIAL CONCLUSIONS WITH ADDITIONAL COMMENTS OF NEED. CONSULTATION WITH LOCAL EXPERTS OCCURRED AGAIN VIA AN INTERNET-BASED SURVEY (EXPLAINED BELOW) BEGINNING JUNE 22, 2017, AND ENDING JUNE 30, 2017.HAVING TAKEN STEPS TO IDENTIFY POTENTIAL COMMUNITY NEEDS, THE LOCAL EXPERTS THEN PARTICIPATED IN A STRUCTURED COMMUNICATION TECHNIQUE CALLED A "WISDOM OF CROWDS" METHOD. THE PREMISE OF THIS APPROACH RELIES ON A PANEL OF EXPERTS WITH THE ASSUMPTION THAT THE COLLECTIVE WISDOM OF PARTICIPANTS IS SUPERIOR TO THE OPINION OF ANY ONE INDIVIDUAL, REGARDLESS OF THEIR PROFESSIONAL CREDENTIALS.IN THE CALDWELL MEMORIAL HOSPITAL PROCESS, EACH LOCAL EXPERT HAD THE OPPORTUNITY TO INTRODUCE NEEDS PREVIOUSLY UNIDENTIFIED AND TO CHALLENGE CONCLUSIONS DEVELOPED FROM THE DATA ANALYSIS. WHILE THERE WERE A FEW OPINIONS OF THE DATA CONCLUSIONS NOT BEING COMPLETELY ACCURATE, MOST OF THE COMMENTS AGREED WITH OUR FINDINGS. WE DEVELOPED A LIST OF ALL NEEDS IDENTIFIED BY ANY OF THE ANALYZED DATA. THE LOCAL EXPERTS THEN ALLOCATED 100 POINTS AMONG THE LIST OF HEALTH NEEDS, INCLUDING THE OPPORTUNITY TO LIST ADDITIONAL NEEDS THAT WERE NOT IDENTIFIED FROM THE DATA.WE DIVIDED THE RANKED NEEDS INTO TWO GROUPS: "SIGNIFICANT AND "OTHER IDENTIFIED NEEDS." THE SIGNIFICANT NEEDS WERE PRIORITIZED BASED ON TOTAL POINTS CAST BY THE LOCAL EXPERTS IN DESCENDING ORDER, FURTHER RANKED BY THE NUMBER OF LOCAL EXPERTS CASTING ANY POINTS FOR THE NEED. BY OUR DEFINITION, A SIGNIFICANT NEED HAD TO INCLUDE ALL RANK ORDERED NEEDS UNTIL AT LEAST FIFTY PERCENT (50%) OF ALL POINTS WERE INCLUDED AND TO THE EXTENT POSSIBLE, REPRESENTED POINTS ALLOCATED BY A MAJORITY OF VOTING LOCAL EXPERTS. THE DETERMINATION OF THE BREAK POINT -- "SIGNIFICANT" AS OPPOSED TO "OTHER" -- WAS A QUALITATIVE INTERPRETATION BY THE CALDWELL MEMORIAL HOSPITAL EXECUTIVE TEAM WHERE A REASONABLE BREAK POINT IN RANK ORDER OCCURRED. PART VI, LINE 3: CALDWELL MEMORIAL HOSPITAL (CMH) PROVIDES NEEDED HEALTHCARE SERVICES TO ANYONE REGARDLESS OF THAT PERSON'S ABILITY TO PAY. CMH'S CHARITY CARE POLICY IS DESIGNED TO ASSIST PATIENTS WHO ARE FINANCIALLY UNABLE TO PAY FOR HEALTHCARE SERVICES. THE POLICY CAN BE FOUND ON THE CMH PUBLIC WEBSITE. CMH DISPLAYS INFORMATION REGARDING THE AVAILABILITY OF FINANCIAL ASSISTANCE AND CHARITY CARE IN ITS EMERGENCY ROOM, REGISTRATION AREAS IN THE HOSPITAL AND CLINICS, FINANCIAL COUNSELOR OFFICES. A LINK IS ALSO PROVIDED ON THE HOSPITAL'S WEBSITE TO THE AVAILABILITY OF FINANCIAL ASSISTANCE AND ITS CHARITY CARE POLICY, ALONG WITH AN ON-LINE APPLICATION. INPATIENT CASE MANAGERS ALSO PROVIDE INFORMATION TO THE PATIENTS REGARDING AVAILABLE PROGRAMS AND THE ORGANIZAITONS FINANCIAL POLICY. CONSULTATION WITH FINANCIAL COUNSELORS IS ALSO AVAILABLE TO ALL PATIENTS AS NEEDED. PART VI, LINE 4: THE PRIMARY SERVICE AREA FOR CALDWELL MEMORIAL HOSPITAL IS CALDWELL COUNTY WITH A LIMITED NUMBER OF PAITENTS FROM THE SURROUNDING COUNTIES OF BURKE, WATAUGA, AND CATAWBA. CALDWELL COUNTY IS IN THE NW SECTION OF NC IN THE FOOTHILLS OF THE BLUE RIDGE MOUNTAINS AND IS BOUNDED ON THE NW BY WATAUGA COUNTY, ON THE NE BY WILKES COUNTY, ON THE EAST BY ALEXANDER COUNTY, ON THE SOUTH BY CATAWBA AND BURKE COUNTIES, AND ON THE WEST BY BURKE AND AVERY COUNTIES. TODAY THERE ARE NINE INCORPORATED MUNICIPALITIES IN THE COUNTY: LENOIR, HUDSON, GRANITE FALLS, CEDAR ROCK, CAJAHS MOUNTAIN, GAMEWELL, SAWMILLS, AND PARTS OF BLOWING ROCK AND RHODHISS. POPULATION IS JUST OVER 81,000. MEDIAN INCOME IS $39,528. POPULATION MAKEUP IS 87.4% WHITE, 5.3% HISPANIC, 4.8% HISPANIC AND 2.4% OTHER. MEDIAN AGE IS 43.9 YEARS. 49.4%% ARE MALES AND 50.6% FEMALES. PART VI, LINE 5: CALDWELL MEMORIAL HOSPITAL PROVIDES FINANCIAL SUPPORT TO 2 COMMUNITY AGENCIES: THE HELPING HANDS CLINIC (PROVIDING CARE TO THE UNINSURED) AND THE SATIE AND JE BROYHILL CALDWELL SENIOR CENTER (FOCUS ON THE LIVES AND ADVOCACY OF SENIORS). OTHER COMMUNITY INVOLVEMENT INCLUDES BUT NOT LIMITED TO: ANNUAL PROSTATE SCREENING, HEALTH FAIRS, SUPPORT AND INVOLVEMENT IN THE CALDWELL COMMUNITY GARDEN WHICH HELPS FOSTER COMMUNITY GARDENING, REPRESENTATION BY ORGANIZATION REPRESENTATIVES ON LOCAL HEALTH CARE RELATED BOARDS (BOARD OF HEALTH, HOSPICE, AND CHILD PROTECTION TEAM.) CALDWELL MEMORIAL HEALTHWORKS WHICH IS OCCUPATIONSL, INDUSTRIAL AND WORKER'S COMP MEDICINE DESIGNED TO ASSIST EMPLOYERS TOWARD IMPROVING QUALITY OF HEALTHCARE. PART VI, LINE 6: CALDWELL MEMORIAL HOSPITAL IS PART OF THE UNC HEALTHCARE SYSTEM. UNC HEALTH CARE IS A NOT-FOR-PROFIT INTEGRATED HEALTH CARE SYSTEM OWNED BY THE STATE OF NORTH CAROLINA AND BASED IN CHAPEL HILL. ORIGINALLY ESTABLISHED NOV. 1, 1998, UNC HEALTH CARE CURRENTLY COMPRISES UNC HOSPITALS AND ITS PROVIDER NETWORK, THE CLINICAL PROGRAMS OF THE UNC SCHOOL OF MEDICINE, AND NINE AFFILIATE HOSPITALS AND HOSPITAL SYSTEMS ACROSS THE STATE. COLLECTIVELY, THIS GROUP OF HEALTH CARE PROVIDERS WORKS TOGETHER TO MAKE SURE THAT ALL OF THE COMMUNITIES SERVED RECEIVED THE HIGHEST QUALITY OF CARE. PART VI, LINE 7, REPORTS FILED WITH STATES NC 1 X X X X X 0 1 0 1 0 0 0 0 0 CHRIS ELLINGTON DIRECTOR (AS OF 1/1/17) 0 527349 0 91578 0 127870 0 272019 0 20052 0 1038868 0 81588 GARY PARK DIRECTOR (AS OF 1/1/17) 0 810343 0 140626 0 1079989 0 520598 0 19583 0 2571139 0 1052629 DAVID MASTERS MD DIRECTOR (THROUGH 12/16) 192941 0 22362 0 493 0 8048 0 17645 0 241489 0 0 0 JOHN POWELL MD DIRECTOR 200205 0 15388 0 336 0 10886 0 20297 0 247112 0 0 0 LAURA EASTON CEO 272111 0 41816 0 10362 0 15900 0 22333 0 362522 0 0 0 REBECCA SMITH COO & CNO 184016 0 26077 0 21280 0 11538 0 9947 0 252858 0 0 0 DONITA DAMRON VP PHYSICIAN SERVICES 144339 0 20333 0 121 0 4517 0 13320 0 182630 0 0 0 RANDAL BAST MD MEDICAL PRACTICE PHYSICIAN 757459 0 2875 0 446 0 7950 0 22333 0 791063 0 0 0 ROBERT DACUS MD MEDICAL PRACTICE PHYSICIAN 458647 0 21849 0 462 0 8665 0 20297 0 509920 0 0 0 TERRI JAGGERS MD MEDICAL PRACTICE PHYSICIAN 470829 0 0 0 745 0 7950 0 20297 0 499821 0 0 0 DAVID EVANS MD MEDICAL PRACTICE PHYSICIAN 407956 0 25623 0 893 0 9358 0 20297 0 464127 0 0 0 RUIHAI ZHOU MD MEDICAL PRACTICE PHYSICIAN 358266 0 2635 0 430 0 7950 0 18736 0 388017 0 0 0 PART I, LINE 4B DURING THE CALENDAR YEAR 2016, THE FOLLOWING INDIVIDUALS RECEIVED DISTRIBUTIONS FROM A NON-QUALIFIED SUPPLEMENTAL RETIREMENT PLAN (457(F)): CHRIS ELLINGTON (DIRECTOR) $81,588, GARY PARK (DIRECTOR) $1,052,629 IN ADDITION, CHRIS ELLINGTON EARNED COMPENSATION UNDER THE PLAN TOTALING $166,417, WHICH IS PAYABLE IN THE FUTURE. LAURA EASTON (CEO) HAS A SECURED BENEFIT PLAN WHICH IS INCLUDED IN THE STUDY COMPLETED BY THE INDEPENDENT COMPENSATION CONSULTANT; THE LOAN UNDER THIS ARRANGEMENT IS RECORDED ON THE FINANCIAL STATEMENTS AND FULLY SECURED BY LIFE INSURANCE ON THE LIFE OF THE CEO. PART I, LINE 5 SENIOR MANAGEMENT HAS AN INCENTIVE PROGRAM WHICH IS PARTIALLY EARNED BASED ON PROFIT MARGIN AND DAYS CASH ON HAND. THE EARNED INCENTIVE IS REVIEWED BY THE HR COMMITTEE OF THE BOARD AND APPROVED ANNUALLY; EMPLOYED PHYSICIANS ARE PAID ON A PRODUCTIVITY BASIS BASED ON RVU'S GENERATED IN THEIR PRACTICE OPERATIONS. THESE ARE TIED TO MGMA BENCHMARKS. FORM 990, PART VI, SECTION A, LINE 1 THE EXECUTIVE/FINANCE COMMITTEE SHALL HAVE THE POWER TO TRANSACT ALL REGULAR BUSINESS OF THE HOSPITAL DURING THE PERIOD BETWEEN THE MEETINGS OF THE BOARD OF DIRECTORS, SUBJECT TO ANY PRIOR LIMITATION IMPOSED BY THE BOARD OF DIRECTORS. FORM 990, PART VI, SECTION A, LINE 6 THE UNIVERSITY OF NORTH CAROLINA HEALTH CARE SYSTEM IS A MEMBER. FORM 990, PART VI, SECTION A, LINE 7A THE UNIVERSITY OF NORTH CAROLINA HEALTH CARE SYSTEM IS A MEMBER AND THEY HAVE THE POWER TO APPOINT BOARD MEMBERS AND APPROVE GOVERNANCE DECISIONS. FORM 990, PART VI, SECTION A, LINE 7B THE UNIVERSITY OF NORTH CAROLINA HEALTH CARE SYSTEM AS A MEMBER HAS APPROVAL RIGHTS TO ALL GOVERNANCE DECISIONS. FORM 990, PART VI, SECTION B, LINE 11B THE FORM 990 WAS PREPARED BY AN INDEPENDENT ACCOUNTANT WITH ASSISTANCE AND OVERSIGHT BY MANAGEMENT. THE FULL BOARD RECEIVED A COPY OF THE FORM 990 FOR THEIR REVIEW AND FOR ANY QUESTIONS. THE FULL BOARD VOTED FOR A FINAL APPROVAL OF THE FORM 990. FORM 990, PART VI, SECTION B, LINE 12C THE AUDIT AND COMPLIANCE COMMITTEE OF THE BOARD ANNUALLY REVIEWS THE CONFLICT OF INTEREST STATEMENTS. MINUTES OF BOARD MEETINGS REFLECT ANY DECLARED CONFLICT OF INTEREST. FORM 990, PART VI, SECTION B, LINE 15 THE ORGANIZATION COMPLETES THE REBUTTABLE PRESUMPTION OF REASONABLENESS AS DESCRIBED IN TREASURY REGULATION 4958(6)(C) FOR EACH OFFICER AND KEY EMPLOYEE. THIS PROCESS IS PERFORMED BY AN OUTSIDE INDEPENDENT COMPENSATION SPECIALIST. THE CONSULTANT'S FINDINGS ARE PRESENTED TO THE HR COMMITTEE OF THE BOARD AND ARE ULTIMATELY APPROVED BY THE FULL BOARD. FORM 990, PART VI, SECTION C, LINE 18 PHOTOCOPIES OF THE FORM 990 ARE AVAILABLE UPON REQUEST AT THE ORGANIZATION'S ADMINISTRATIVE OFFICE. IN ADDITION, RECENT FILINGS OF THE FORM 990 ARE AVAILABLE ON GUIDESTAR.ORG. FORM 990, PART VI, SECTION C, LINE 19 THE ORGANIZATION MAKES ITS GOVERNING DOCUMENTS, FINANCIAL STATEMENTS, AND CONFLICT OF INTEREST POLICY AVAILABLE UPON REQUEST. PLEASE USE THE ORGANIZATION'S "CONTACT US" LINK ON ITS WEBSITE FOR REQUESTS. FORM 990, PART XII, LINE 2C NO CHANGE FROM PRIOR YEAR. UNC HEALTH CARE SYSTEM 101 MANNING DRIVE CHAPEL HILL NC 27514 562206970 HEALTHCARE NC SECTION 115 NO 0 UNC HOSPITALS 211 FRIDAY CENTER DRIVE SUITE 2029 CHAPEL HILL NC 27517 561118388 HEALTHCARE NC SECTION 115 NO 0 CALDWELL MEMORIAL HOSPITAL FOUNDATION INC PO BOX 1890 LENOIR NC 28645 581935514 SUPPORT OF CALDWELL MEMORIAL HOSPITAL NC 501(C )(3) 7 NO 0 CHATHAM HOSPITAL INC PO BOX 649 SILER CITY NC 27344 560611546 HEALTHCARE NC 501(C )(3) 3 NO 0 HIGH POINT REGIONAL HEALTH 601 N ELM STREET HIGH POINT NC 27261 560532309 HEALTHCARE NC 501(C )(3) 3 NO 0 HIGH POINT REGIONAL HEALTH SERVICES INC 601 N ELM STREET HIGH POINT NC 27261 561497163 HEALTHCARE NC 501(C )(3) 11 NO 0 HIGH POINT REGIONAL HEALTH FOUNDATION INC 601 N ELM STREET HIGH POINT NC 27261 272854711 SUPPORT OF HIGH POINT REGIONAL HEALTH NC 501(C )(3) 11 NO 0 REX HEALTHCARE INC 4420 LAKE BOONE TRAIL RALEIGH NC 27607 561509129 HEALTHCARE NC 501(C )(3) 11 NO 0 REX HOSPITAL INC 4420 LAKE BOONE TRAIL RALEIGH NC 27607 561509260 HEALTHCARE NC 501(C )(3) 3 NO 0 THE REX HEALTHCARE FOUNDATION INC 4420 LAKE BOONE TRAIL RALEIGH NC 27607 566052117 SUPPORT OF REX HOSPITAL, INC. NC 501(C )(3) 11 NO 0 UNCPN 1600 PERIMETER PARK DRIVE STE 225 MORRISVILLE NC 27560 271081647 HEALTHCARE NC SECTION 115/501(C )( 9 NO 0 HIGH POINT SURGERY CENTER 600 NORTH LINDSAY STREET HIGH POINT NC 27260 561867005 HEALTHCARE NC RELATED 0 0 REX SURGERY CENTER OF CARY 4420 LAKE BOONE TRAIL RALEIGH NC 27607 273684056 ASC NC RELATED 0 0 JRH VENTURES LLC 4420 LAKE BOONE TRAIL RALEIGH NC 27607 274092967 MED CAMPUS DEVELOPMENT NC RELATED 0 0 REX HEALTH VENTURES I LP 4420 LAKE BOONE TRAIL RALEIGH NC 27607 371690478 VENTURE CAPITAL INVST NC RELATED 0 0 ORTHOPAEDIC SURGERY CENTER OF RALEIGH LLC 4420 LAKE BOONE TRAIL RALEIGH NC 27607 271740526 ORTHOPAEDIC SURGERY NC RELATED 0 0 TRO VENTURES LLC 4420 LAKE BOONE TRAIL RALEIGH NC 27607 821330195 HEALTHCARE NC REX HOSPITAL RELATED 0 0 HIGH POINT HEALTHCARE VENTURES INC 601 N ELM STREET HIGH POINT NC 27261 561343468 HOLDING COMPANY NC C 0 REX ENTERPRISES COMPANY INC 4420 LAKE BOONE TRAIL RALEIGH NC 27607 271740526 OPERATIONS SUPPORT NC C 0 UNC PHYSICIANS NETWORK GROUP PRACTICES LLC 1600 PERIMETER PARK DRIVE SUITE 225 MORRISVILLE NC 27560 461416986 HEALTHCARE NC C 0 0 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 CALDWELL MEMORIAL HOSPITAL FOUNDATION C 1724122 CASH