2016-08-15T15:08:07-05:00 2015-12-31 570381582 ELLIOTT DAVIS DECOSIMO LLCPLLC ONE 10TH STREET SUITE 400 AUGUSTA GA 30901 990 2015-01-01 454166209 UNIVERSITY MCDUFFIE MEDICAL CENTER INC UNIV 7068282406 1350 WALTON WAY AUGUSTA GA 30901 DAVID BELKOSKI CFO 7068282406 2016-08-15 1 JESSICA C CAIN CPA P01276209 7067229090 2015 2016-12-15 16:53:06Z JAMES R DAVIS 1350 WALTON WAY AUGUSTA GA 30901 24425351 0 X WWW.MRMC.ORG X 2012 GA THE MISSION OF THE UNIVERSITY MCDUFFIE COUNTY REGIONAL MEDICAL CENTER IS TO PROVIDE HEALTH CARE SERVICES WITH THE HELP OF OUR COMMUNITIES AND PARTNERS, AND ENRICH THE LIVES WE TOUCH BY PROVIDING COMPASSIONATE QUALITY CARE IN A COST EFFECTIVE MANNER. WE STRIVE TO BE UTILIZED AS THE HEALTHCARE PARTNER OF CHOICE FOR THE COMMUNITIES WE SERVE. 5 3 175 23 0 0 0 0 18699579 23476076 0 6000 455603 943275 19155182 24425351 500 166400 0 0 7713169 8732624 0 0 0 10788759 14951841 18502428 23850865 652754 574486 34835967 39485004 31006580 35081131 3829387 4403873 X THE MISSION OF THE UNIVERSITY MCDUFFIE COUNTY REGIONAL MEDICAL CENTER IS TO PROVIDE HEALTH CARE SERVICES WITH THE HELP OF OUR COMMUNITIES AND PARTNERS, AND ENRICH THE LIVES WE TOUCH BY PROVIDING COMPASSIONATE QUALITY CARE IN A COST EFFECTIVE MANNER. WE STRIVE TO BE UTILIZED AS THE HEALTHCARE PARTNER OF CHOICE FOR THE COMMUNITIES WE SERVE. 0 0 22233632 166400 24419351 UNIVERSITY MCDUFFIE COUNTY REGIONAL MEDICAL CENTER (UHM), A 25 BED FACILITY, CARRIED OUT MEDICAL-RELATED SERVICES TO THE COMMUNITY AND CONDUCTED HEALTH EDUCATION COURSES AND HEALTH FAIRS, PROVIDED EDUCATION LITERATURE AND SPONSORED ILLNESS SUPPORT GROUPS. STAFF MEMBERS SERVE ON A VARIETY OF BOARDS AND ARE INVOLVED IN CIVIC ENDEAVORS THAT PROMOTE HEALTH AND WELLNESS. UHM PROVIDED MEDICATION AND TRANSPORTATION TO AND FROM THE HOSPITAL FOR THOSE WHO ARE UNABLE TO PAY. UNCOMPENSATED CARE WAS PROVIDED AS WELL AS INDIGENT AND CHARITY CARE. A HOSPITAL-BASED PROGRAM ASSISTANCE COUNSELOR IS PROVIDED AT THE HOSPITAL'S EXPENSE IN ORDER TO ASSIST PATIENTS WITH QUALIFYING FOR MEDICARE DISABILITY, MEDICAID, SSI OR OTHER GOVERNMENT FINANCIAL ASSISTANCE PROGRAMS. FOR 2015, THE HOSPITAL HAD A TOTAL OF 2,130 PATIENT DAYS. 170 OF THESE PATIENT DAYS WERE FOR INDIGENT PATIENTS. OBSERVATION STAYS WERE 435 DAYS. OUTPATIENT VISITS WERE 30,860. OF THE TOTAL OUTPATIENT VISITS, 17,478 WERE FOR EMERGENCY CARE. WITHIN THESE INDICATORS ARE THE EFFORTS OF UNIVERSITY HOSPITAL MCDUFFIE TO SERVICE THE NEEDS OF THE COMMUNITY, WHICH INCLUDE THE INDIGENT. IN 2015 THE COST OF INDIGENT AND CHARITY CARE PROVIDED ALONG WITH MEDICAID SHORTFALLS WAS $4,984,089. UHM RECEIVED DISPROPORTIONATE SHARE (DSH) FUNDS OF $551,284 AND UPPER PAYMENT LIMIT (UPL) FUNDS OF $75,911 TO HELP OFFSET THESE COSTS.IN 2015, UHM PARTICIPATED IN THREE FREE COMMUNITY FAIRS: SAVANNAH LAKES VILLAGE RETIREMENT COMMUNITY, MCCORMICK SC, MCDUFFIE COUNTY HEALTH FAIR, THOMSON GA, AND GLASCOCK COUNTY HEALTH FAIR, GIBSON, GA.- A $6,102 INVESTMENT, SERVING 350 PEOPLE.ALSO IN 2015, UHM PARTICIPATED IN THREE FREE BUSINESS AND INDUSTRY EVENTS: JEFFERSON ENERGY, WRENS, GA, MCCORKLE NURSERIES, DEARING GA, AND THE CITY OF THOMSON EMPLOYEES, THOMSON GA- A $9,915 INVESTMENT SERVING 235 PEOPLE. 22233632 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 0 0 0 0 0 0 0 0 0 0 0 0 0 1 0 0 0 1 34 0 175 1 0 0 0 0 0 0 0 0 0 0 X 5 3 0 0 0 0 0 0 0 1 1 0 1 1 1 1 1 1 1 1 1 1 0 GA X X DAVID A BELKOSKI CFO 7068282406 1350 WALTON WAY AUGUSTA GA 30901 X WILLIAM P DOUPE CHAIRMAN 2.00 X 0 0 0 ROBIN S DUDLEY DIRECTOR 2.00 X 0 0 0 JOHN BIELTZ MD DIRECTOR 2.00 X 0 0 0 EDWARD L BURR LEGAL ADVISOR 2.00 50.00 X 0 426610 47264 JAMES R DAVIS UHCS CEO 2.00 50.00 X 0 2038444 284307 DAVID A BELKOSKI UHCS & UHM CFO 2.00 50.00 X 0 645427 21095 SANDRA MCVICKER UHM CEO 50.00 X 0 308956 16663 CARLA DUFFIE CRNA 50.00 X 166816 0 18421 JESSE L RYAN CRNA 50.00 X 171639 0 13213 DANITA T KISER NURSE DIRECTOR MED/SERG ED 50.00 X 116720 0 14898 MARCIA V RODGERS PHARMACY MANAGER 50.00 X 109528 0 14841 564703 3419437 430702 4 0 1 0 JE DUNN CONSTRUCTION COMPANY 1001 LOCUST STREET KANSAS CITY MO 64106 CONSTRUCTION (NEW FACILITY) 945529 CROTHALL HEALTHCARE 13028 COLLECTION CENTER DRIVE CHICAGO IL 60693 EVS SERVICES 592783 CONVERGEONE NW 5806 PO BOX 1450 MINNEAPOLIS MN 55485 IT SERVICES 579655 ROBERT F POLGLASE MD PC 3696 INVERNESS WAY AUGUSTA GA 30907 PHYSICIAN SERVICES 287473 SIEMENS HEALTHCARE DIAGNOSTICS PO BOX 121102 DALLAS TX 75312 MAINTENANCE CONTRACT 241419 11 PATIENT SERVICE REVENUE 621990 23476076 23476076 23476076 6000 0 6000 6000 6000 ELECTRONIC HEALTH RECORD INCENTIV 900099 892856 892856 MISCELLANEOUS 900099 40491 40491 MEDICAL RECORDS 900099 9928 9928 943275 24425351 24419351 0 6000 166400 166400 370089 356544 13545 6215437 5987952 227485 83668 80606 3062 1680248 1618751 61497 383182 369158 14024 755848 755848 38255 38255 7884 7884 1656620 1595988 60632 10497 10497 21872 21071 801 184948 178179 6769 431303 415515 15788 2740 2640 100 894873 894873 2232523 2150813 81710 145302 139984 5318 BAD DEBT 5158401 5158401 MED/SURG SUPPLIES 2321822 2321822 REPAIRS & MAINTENANCE 627117 604165 22952 GENERAL SUPPLIES 190382 183414 6968 271454 126381 145073 23850865 22233632 1617233 0 721329 3390863 3008602 2948528 314349 38652 537779 477441 231728 246052 36045656 3795485 29737865 32250171 284315 133297 34835967 39485004 2963286 1741464 29581667 28043294 3758000 31006580 35081131 X 3829387 4403873 3829387 4403873 34835967 39485004 574486 0 X 0 1 X 1 0 X 0 0 0 0 0 0 0 0 1 7884 7884 0 PART II-B, LINE 1: DESCRIPTION OF LOBBYING ACTIVITY A PART OF VARIOUS ASSOCIATION DUES INCLUDE A PERCENTAGE ALLOCATION FOR EXPENDITURES ON LOBBYING ACTIVITIES. DUES PAID TO THE GEORGIA ALLIANCE OF COMMUNITY HOSPITALS AND THE AMERICAN HOSPITAL ASSOCIATION HAVE A LOBBY COMPONENT. FOR 2015 THESE FEES AMOUNTED TO $7884.47. 1325769 1325769 25062084 626552 24435532 459170 44606 414564 8952466 3124327 5828139 246167 246167 32250171 DUE TO UNIVERSITY HEALTH SERVICES 3407521 LONG-TERM CAPITAL LEASE OBLIGATION 327694 DUE TO UNIVERSITY MEDICAL GROUP 22785 3758000 X PART X, LINE 2: FIN 48 FOOTNOTE ACCOUNTING FOR INCOME TAXES- UNIVERSITY MCDUFFIE COUNTY REGIONAL MEDICAL CENTER, INC. IS EXEMPT FROM FEDERAL INCOME TAX UNDER SECTION 501(A) AS ORGANIZATIONS DESCRIBED IN SECTION 501(C)(3) OF THE INTERNAL REVENUE CODE OF 1986, AS AMENDED. ACCORDINGLY, THE ACCOMPANYING FINANCIAL STATEMENTS DO NOT REFLECT A PROVISION OR LIABILITY FOR FEDERAL AND STATE INCOME TAXES. UNIVERSITY MCDUFFIE COUNTY REGIONAL MEDICAL CENTER, INC. HAS EVALUATED THEIR TAX POSITION AND DETERMINED THAT THEY DO NOT HAVE ANY MATERIAL UNRECOGNIZED TAX BENEFITS OR OBLIGATIONS AS OF DECEMBER 31, 2015. 1 1 1 X 1 X 1 1 0 1 1 1384015 297693 1086322 0.04550 2865633 2027204 838429 0.03520 4249648 2324897 1924751 0.08070 628485 204068 424417 0.01780 271299 0 271299 0.01140 899784 204068 695716 0.02920 5149432 2528965 2620467 0.10990 4518 0 4518 0.00020 4518 4518 0.00020 1 3492434 374603 2157363 4520986 -2363623 X 1 1 1 1 UNIV MCDUFFIE REGIONAL MEDICAL CENTER 2460 WASHINGTON ROAD NE THOMSON GA 308242199 WWW.MRMC.ORG 097-107 X X X SWING-BED CERTIFIED BY MEDICARE ON 11/15/15 UNIVERSITY HOSPITAL MCDUFFIE 1 0 0 1 X X X X X X X X X 13 1 0 0 1 X WWW.UNIVERSITYHEALTH.ORG X 1 14 1 WWW.UNIVERSITYHEALTH.ORG 1 0 1 X 200.000000000000 400.000000000000 X X X X 1 1 X X X 1 X WWW.UNIVERSITYHEALTH.ORG X X X 1 0 X X X 0 X X 0 0 UNIVERSITY HOSPITAL MCDUFFIE PART V, SECTION B, LINE 5: SUBSEQUENT TO THE SECONDARY DATA ASSESSMENT, THE COMMUNITY NEEDS ASSESSMENT TEAM ENTERED INTO DIALOGUE WITH KEY HOSPITAL ADMINISTRATORS, PHYSICIANS, THOSE WITH KNOWLEDGE/EXPERTISE IN PUBLIC HEALTH AND THOSE SERVING UNDERSERVED AND CHRONIC DISEASE POPULATIONS. DURING THIS PHASE, THE TEAM CONDUCTED INTERVIEWS IN WHICH RESPONDENTS WERE ABLE TO COMMENT AND DISCUSS GENERAL COMMUNITY HEALTH ISSUES OF THEIR SPECIFIC SERVICE AREA. THROUGH THESE NUMEROUS INTERVIEWS AND DISCUSSIONS, A SUMMARY OF COMMUNITY INPUT WAS CREATED. THIS SUMMARY WOULD EVENTUALLY BE USED TO HELP FOCUS IN ON PRIORITIES AND ULTIMATELY, IMPLEMENTATION STRATEGIES.RESPONDENTS INCLUDED ROBERT F. POLGLASE, M.D., MEDICAL DIRECTOR OF UTILIZATION AND REVENUE MANAGEMENT AT UNIVERSITY HEALTH MCDUFFIE, AMY JENKINS, HEALTH CARE SCIENCE INSTRUCTOR AT THOMSON HIGH SCHOOL, CATHY LINEBARGER, RN, MCDUFFIE COUNTY HEALTH DEPARTMENT, ROBIN DUDLEY, RN, UNIVERSITY HOSPITAL MCDUFFIE BOARD MEMBER, AMANDA JENKINS, SOCIAL WORKER AT UNIVERSITY HOSPITAL MCDUFFIE.ALL INPUT WAS COLLECTED FROM A SET OF QUESTIONS ASKED AND RESPONDENTS WERE ENCOURAGED TO ELABORATE ON ANY TOPICS THAT WERE SIGNIFICANT TO THEIR SERVICE OR TARGET POPULATIONS. UNIVERSITY HOSPITAL MCDUFFIE PART V, SECTION B, LINE 7D: AVAILABLE UPON REQUEST UNIVERSITY HOSPITAL MCDUFFIE PART V, SECTION B, LINE 11: ESTABLISH A RURAL HEALTH CLINIC COMMUNITY COLLABORATION TO NOT ONLY INITIATE PROGRAMS, BUT TO SEE THEM THROUGH TO BE EFFECTIVE LOCAL PHYSICIANS TO PROVIDE EDUCATION ON ISSUES AND NEEDS ON A REGULAR BASIS OFFER SLIDING SCALE FEE BASED ON SERVICES OTHER ORGANIZATIONS WERE/ARE PROVIDING THE SERVICES. UHM IS A SMALL RURAL HOSPITAL AND WILL WORK IN OTHER AREAS AS FUNDS ARE AVAILABLE. UNIVERSITY HOSPITAL MCDUFFIE PART V, SECTION B, LINE 21D: INCLUDED IN ICCP POLICY UNIVERSITY HOSPITAL MCDUFFIE PART V, SECTION B, LINE 22D: USED THE UNWEIGHTED AVERAGE OF COMMERICIAL INSURANCES AND MEDICARE PART I, LINE 7: EXPLANATION OF COSTING METHODOLOGYUSED COST TO CHARGE RATIO CALCULATED USING WORKSHEET 2 --THE OPTIONAL WORKSHEETS PROVIDED TO ASSIST IN PREPARATION OF SCHEDULE H. PART II, COMMUNITY BUILDING ACTIVITIES: THE COMMUNITY BUILDING ACTIVITIES REPORTED ARE SUPPORT FOR THE VARIOUS CHAMBERS OF COMMERCE FOR THE COMMUNITIES THAT UH SERVES. IN SUPPORTING THESE ORGANIZATIONS, UH CAN SUPPORT THE DEVELOPMENT OF OUR COMMUNITY BY BRINGING IN NEW INDUSTRIES, AND JOBS, INCREASING THE AVERAGE HOUSEHOLD INCOME, IMPROVING LIVING CONDITIONS, AND IMPACTING OVERALL GENERAL HEALTH. PART III, LINE 2: FOR RECEIVABLES ASSOCIATED WITH SELFPAY PATIENTS (WHICH INCLUDES BOTH PATIENTS WITHOUT INSURANCE AND PATIENTS WITH DEDUCTIBLE AND COPAYMENT BALANCES DUE FOR WHICH THIRD-PARTY COVERAGE EXISTS FOR PART OF THE BILL), UHS RECORDS PROVISION FOR BAD DEBTS IN THE PERIOD OF SERVICE ON THE BASIS OF ITS PAST EXPERIENCE, WHICH INDICATES THAT MANY PATIENTS ARE UNABLE OR UNWILLING TO PAY THE PORTION OF THEIR BILL FOR WHICH THEY ARE FINANCIALLY RESPONSIBLE. THE DIFFERENCE BETWEEN THE STANDARD RATES (OR THE DISCOUNTED RATES) AND THE AMOUNTS ACTUALLY COLLECTED AFTER ALL REASONABLE COLLECTION EFFORTS HAVE BEEN EXHAUSTED IS CHARGED OFF AGAINST THE ALLOWANCE FOR DOUBTFUL ACCOUNTS. RECOVERIES OF ACCOUNTS PREVIOUSLY WRITTEN OFF ARE RECORDED AS A REDUCTION TO THE PROVISION FOR BAD DEBT EXPENSE WHEN RECEIVED. PART III, LINE 3: BAD DEBT SHOULD BE INCLUDED AS A COMMUNITY BENEFIT SINCE THE SERVICES THAT INCUR BAD DEBT ARE PROVIDED BY THE HOSPITAL TO PROMOTE THE WELL-BEING OF THE COMMUNITY. THESE SERVICES ARE RENDERED IN CONJUNCTION WITH THE HOSPITAL'S CHARITABLE TAX-EXEMPT PURPOSES. THERE IS NO LOCAL SUPPORT FOR UNINSURED PATIENTS; THEREFORE, THE SERVICES PROVIDED BY THE HOSPITAL RELIEVE THE HEALTH CARE BURDENS OF THE LOCAL GOVERNMENTS. PART III, LINE 4: BAD DEBT EXPENSEPAGE 7-8 OF THE AUDITED CONSOLIDATED FINANCIAL STATEMENT FOR UNIVERSITY HEALTH, INC. PART III, LINE 8: EXPLANATION OF SHORTFALL AS COMMUNITY BENEFITTHE SERVICES PROVIDED TO THE MEDICARE BENEFICIARIES ARE TO PROMOTE THE WELL-BEING OF THE COMMUNITY WHICH IS PART OF THE HOSPITAL'S CHARITABLE TAX-EXEMPT PURPOSE. THE MEDICARE DIFFERENCE BETWEEN COST AND MEDICARE REIMBURSEMENT SHOULD BE ALLOWED AS COMMUNITY BENEFIT SINCE PROVIDERS CANNOT NEGOTIATE RATES WITH CENTERS FOR MEDICARE/MEDICAID SERVICES (CMS). CMS REGULATES THAT THE REIMBURSEMENT BE FEDERAL BUDGET NEUTRAL THUS PLACING THE COST OF THE CARING FOR MEDICARE BENEFICIARIES AS A COST TO THE HOSPITALS. PART III, LINE 9B: PROVISIONS ON COLLECTION PRACTICES FOR QUALIFIED PATIENTSAS OUTSTANDING BALANCES AGE, STATEMENT MESSAGES, COLLECTION LETTERS AND/OR TELEPHONE CALLS MAY BE USED AT APPROPRIATE INTERVALS DETERMINED BY THE PATIENT ACCOUNTING/COLLECTION DEPARTMENT. THE PATIENT ACCOUNTING/COLLECTION DEPARTMENT RECOGNIZES THAT THERE ARE OCCASIONS WHEN A PATIENT IS NOT FINANCIALLY ABLE TO PAY HIS OR HER MEDICAL BILL IN FULL AND/OR THE PATIENT IS EXPERIENCING FINANCIAL HARDSHIP. THE HOSPITAL HAS ESTABLISHED A CATASTROPHIC POLICY WHICH ALLOWS FOR THE COLLECTION DEPARTMENT TO APPLY THE INDIGENT CRITERIA AND WRITE-OFF AS MEDICALLY INDIGENT. AND AT ANY POINT DURING THE COLLECTION PROCESS IF A PATIENT STATES OR PATIENT ACCOUNTING/COLLECTIONS BELIEVES THAT THE PATIENT CANNOT AFFORD TO PAY, THEN AN INDIGENT/CHARITY CARE APPLICATION IS BEGUN BY THE COLLECTION DEPARTMENT WHERE DISCOUNTS MAY BE GIVEN. PART VI, LINE 2: NEEDS ASSESSMENTUHM WORKS WITH ER PERSONNEL AND AREA HEALTH DEPARTMENT DIRECTOR TO IDENTIFY NEEDS BASED ON PATIENTS SEEKING HELP THROUGH THE EMERGENCY ROOM AND HEALTH DEPARTMENT. PART VI, LINE 3: PATIENT EDUCATION OF ELIGIBILITY FOR ASSISTANCEREGISTRARS INFORM PATIENT OF FINANCIAL ASSISTANCE PROGRAMS. ALSO, THERE ARE SIGNS POSTED IN ER AND REGISTRATION AREAS WHICH DENOTE THE AVAILABILITY OF ASSISTANCE WITH HOSPITAL BILLS. IN ADDITION, UHM UTILIZES THE SERVICES OF RCA (RESOURCE CENTER OF AMERICA) WHICH AIDS PATIENTS IN GETTING CERTIFIED FOR SSI AND MEDICAID. PART VI, LINE 4: COMMUNITY INFORMATION"MCDUFFIE COUNTY IS A COUNTY LOCATED IN THE U.S. STATE OF GEORGIA. IT WAS CREATED ON OCTOBER 18, 1870, FROM COLUMBIA AND WARREN COUNTIES' TERRITORIES. AS OF 2010, THE POPULATION WAS 21,875. THE 2012 CENSUS ESTIMATE SHOWED A POPULATION OF 21,663. WIKIPEDIAAREA: 226 SQ MILES (688.9 SQ KM) FOUNDED: 1870POPULATION: 21,673 (2011)UNEMPLOYMENT RATE: 9.1% (APRIL 2013)"HOUSING STATUS:TOTAL: 9,319OCCUPIED: 8,289OWNER-OCCUPIED: 5,651POPULATION IN OWNER-OCCUPIED: 14,637 (NUMBER OF INDIVIDUALS)RENTER-OCCUPIED: 2,638POPULATION IN RENTER-OCCUPIED: 6,920 (NUMBER OF INDIVIDUALS)HOUSEHOLDS WITH INDIVIDUALS UNDER 18: 3,042VACANT: 1,030VACANT (FOR RENT): 314VACANT (FOR SALE): 107 PART VI, LINE 5: COLLABORATION WITH/SUPPORT OF COMMUNITY ORGANIZATIONS THROUGH SEVERAL SURROUNDING CHAMBERS OF COMMERCE. - SEE PART II ABOVE.SEE PAGE 25 OF THE CHNA FOR THE LIST OF AGENCIES THAT UNIVERSITY HOSPITAL MCDUFFIE WORKS WITH TO SUPPORT AND PROMOTE HEALTH IN OUR COMMUNITY. PART VI, LINE 6: UHM GOVERNING BOARD MEMBERS ARE COMPRISED OF CITZENS WHO RESIDE IN THE UHM'S PRIMARY SERVICE AREA AND ARE NEITHER EMPLOYEES NOR CONTRACTORS OF UHM. UHM BOARD MEMBERS ARE ACTIVE IN THE COMMUNITY AND ARE EAGER TO IMPROVE THE HEALTH AND WELFARE OF THE COMMUNITY. UHM EXTENDS MEDICAL STAFF PRIVILEGES TO ALL QUALIFIED PHYSICIANS IN OUR COMMUNITY FOR ALL OF THE UH DEPARTMENTS. 1 FAMILY YMCA OF THOMSON 510 HILL STREET THOMSON GA 30824 580566254 501(C)(3) 166400 FMV DONATED PROPERTY TO SUPPORT THE MISSION OF THE FAMILY YMCA OF THOMSON 1 X 1 1 X X X X X 0 1 0 0 0 0 1 0 0 EDWARD L BURR LEGAL ADVISOR 0 315200 0 88216 0 23194 0 35375 0 11889 0 473874 0 0 JAMES R DAVIS UHCS CEO 0 651992 0 207253 0 1179199 0 269085 0 15222 0 2322751 0 0 DAVID A BELKOSKI UHCS & UHM CFO 0 408448 0 130710 0 106269 0 7982 0 13113 0 666522 0 0 SANDRA MCVICKER UHM CEO 0 247569 0 38124 0 23263 0 7250 0 9413 0 325619 0 0 CARLA DUFFIE CRNA 166389 0 325 0 102 0 4756 0 13665 0 185237 0 0 0 JESSE L RYAN CRNA 156055 0 325 0 15259 0 4673 0 8540 0 184852 0 0 0 PART I, LINE 1A SOCIAL CLUB DUES- THE RELATED ORGANIZATION PAYS MEMBERSHIP FEES FOR THE CEO (JAMES DAVIS) TO SAGE VALLEY AND THE AUGUSTA COUNTRY CLUB. THESE MEMBERSHIP FEES ARE PAID SO THE ORGANIZATION CAN HAVE ACCESS TO THE MEETING FACILITIES AND CATERING SERVICES THESE ORGANIZATIONS PROVIDE FOR MEETINGS THAT ARE HELD OFF CAMPUS. ANY PERSONAL USE, RELATED TO THESE MEMBERSHIPS, IS INCLUDED IN THE WAGES OF THE CEO. PART I, LINE 4B JAMES R. DAVIS - SERP - $261,080 DAVID BELKOSKI - ROTH IUL - $56,036 SANDRA MCVICKER - ROTH IUL - $12,500 - SECT 162 - $7,784 PLEASE NOTE THAT ALL OF THE BENEFITS LISTED ABOVE ARE INCLUDED IN THE TOTALS REPORTED ON FORM 990, SCHEDULE VII AS REPORTABLE COMPENSATION OR OTHER COMPENSATION AND HAVE BEEN INCLUDED IN THE INDIVIDUALS' W-2, WITH THE EXCEPTION OF THE SERP FOR JAMES R. DAVIS. PART I, LINE 6 THE BONUS PLAN FOR MANAGEMENT IS CALCULATED BASED ON STRATEGIC INITIATIVES AS DETERMINED BY THE COMPENSATION COMMITTEE. THESE INITIATIVES ARE GOALS THAT MUST BE ACHIEVED DURING THE YEAR IN ORDER FOR BONUS PAYOUT. FOR 2015 THESE INITIATIVES WERE WEIGHTED AS DISPLAYED IN THE FOLLOWING SCHEDULE: UNIVERSITY HEALTH SERVICES, INC 2015 STRATEGIC INITIATIVES WEIGHT QUALITY 15% ACHIEVE NRC OVERALL RATING OF CARE SCORE 15% ACHIEVE AGGREGATE COMPOSITE CORE MEASURE SCORE FOR (VTE, STROKE, EARLY DELIVERIES AND IMMUNIZATIONS) GROWTH 10% INCREASE ADMISSIONS FROM AIKEN AND COLUMBIA COUNTIES OVER 2014 LEVELS SAFETY 15% MINIMIZE THE NUMBER OF HOSPITAL ACQUIRED CONDITIONS PER 1000 DISCHARGES PEOPLE 15% ACHIEVE EMPLOYEE TURNOVER RATE FOR UHS AFFORDABILITY 25% ACHIEVE OPERATING MARGIN FOR UNIVERSITY HEALTH, INC SERVICE 5% INCREASE THE NUMBER OF ACTIVE MYCHART ACCOUNTS 100% EACH GOAL THAT WAS ACHIEVED REPRESENTED THAT PERCENTAGE OF BONUS PAYOUT OUT OF A POSSIBLE 100% BASED ON A THRESHOLD LEVEL, TARGET LEVEL, OR AN EXCEED LEVEL. FORM 990, PART VI, SECTION B, LINE 11 FORM 990 REVIEW PROCESS A COPY OF THE FORM 990 AND ALL RELATED SCHEDULES WAS PROVIDED TO THE GOVERNING BOARD BEFORE FILING IN ELECTRONIC FORM. AN EMAIL WAS SENT TO ALL MEMBERS OF THE GOVERNING BODY CONTAINING A LINK TO A PASSWORD-PROTECTED WEBSITE ON WHICH THE ENTIRE 990 COULD BE VIEWED. THE EMAIL EXPLAINED THAT THE FORM 990 WAS AVAILABLE FOR REVIEW ON THE WEBSITE. FORM 990, PART VI, SECTION B, LINE 12C EXPLANATION OF MONITORING AND ENFORCEMENT CONFLICTS DUTY TO DISCLOSE: IN CONNECTION WITH ANY ACTUAL OR POSSIBLE CONFLICT OF INTEREST, AN INTERESTED PERSON MUST DISCLOSE THE EXISTENCE OF THE FINANCIAL INTEREST AND BE GIVEN THE OPPORTUNITY TO DISCLOSE ALL MATERIAL FACTS TO THE DIRECTORS AND MEMBERS OF COMMITTEES WITH GOVERNING BOARD DELEGATED POWERS CONSIDERING THE PROPOSED TRANSACTION ARRANGEMENT. DETERMINING WHETHER A CONFLICT EXISTS: AFTER DISCLOSURE OF THE FINANCIAL INTEREST AND ALL MATERIAL FACTS, AND AFTER ANY DISCUSSION WITH THE INTERESTED PERSON, THE INTERESTED PERSON WILL LEAVE THE GOVERNING BOARD OR COMMITTEE MEETING WHILE THE GOVERNING BOARD OR COMMITTEE DISCUSSES AND VOTES ON A DETERMINATION OF WHETHER A CONFLICT OF INTEREST EXISTS. THE REMAINING BOARD OR COMMITTEE MEMBERS WILL DECIDE IF A CONFLICT OF INTEREST EXISTS. PROCEDURES FOR ADDRESSING THE CONFLICT OF INTEREST: AN INTERESTED PERSON MAY MAKE A PRESENTATION AT THE GOVERNING BOARD OR COMMITTEE MEETING BUT, AFTER THE PRESENTATION, SUCH INTERESTED PERSON WILL LEAVE THE MEETING DURING THE DISCUSSION OF, AND THE VOTE ON, THE TRANSACTION OR ARRANGEMENT INVOLVING THE POSSIBLE CONFLICT OF INTEREST. THE CHAIRPERSON OR THE GOVERNING BOARD OR COMMITTEE WILL, IF APPROPRIATE, APPOINT A DISINTERESTED PERSON OR COMMITTEE TO INVESTIGATE ALTERNATIVES TO THE PROPOSED TRANSACTION OR ARRANGEMENT. AFTER EXERCISING DUE DILIGENCE, THE GOVERNING BOARD OR COMMITTEE WILL DETERMINE WHETHER THE CORPORATION CAN OBTAIN WITH REASONABLE EFFORTS A MORE ADVANTAGEOUS TRANSACTION OR ARRANGEMENT FROM A PERSON OR ENTITY THAT WOULD NOT GIVE RISE TO A CONFLICT OF INTEREST. IF A MORE ADVANTAGEOUS TRANSACTION OR ARRANGEMENT IS NOT REASONABLY POSSIBLE UNDER CIRCUMSTANCES NOT PRODUCING A CONFLICT OF INTEREST, THE GOVERNING BOARD OR COMMITTEE WILL DETERMINE BY A MAJORITY VOTE OF THE DISINTERESTED DIRECTORS WHETHER THE TRANSACTION OR ARRANGEMENT IS IN THE CORPORATION'S BEST INTEREST, FOR ITS OWN BENEFIT, AND WHETHER IS IT FAIR AND REASONABLE. IN CONFORMITY WITH THE ABOVE DETERMINATION, IT WILL MAKE ITS DECISION AS TO WHETHER TO ENTER INTO THE TRANSACTION OR ARRANGEMENT. VIOLATION OF THE CONFLICT OF INTEREST POLICY: IF THE GOVERNING BOARD OR COMMITTEE HAS REASONABLE CAUSE TO BELIEVE THAT A MEMBER OF SUCH BOARD OR COMMITTEE HAS FAILED TO DISCLOSE AN ACTUAL OR POSSIBLE CONFLICT OF INTEREST, IT WILL INFORM THE MEMBER OF THE BASIS FOR SUCH BELIEF AND AFFORD THE MEMBER AN OPPORTUNITY TO EXPLAIN THE ALLEGED FAILURE TO DISCLOSE. IF, AFTER HEARING THE MEMBER'S RESPONSE AND MAKING FURTHER INVESTIGATIONS AS WARRANTED BY THE CIRCUMSTANCES, THE GOVERNING BOARD OR COMMITTEE DETERMINES THE MEMBER HAS FAILED TO DISCLOSE AN ACTUAL OR POSSIBLE CONFLICT OF INTEREST, IT WILL TAKE APPROPRIATE DISCIPLINARY AND CORRECTIVE ACTION. FORM 990, PART VI, SECTION B, LINE 15 COMPENSATION REVIEW & APPROVAL PROCESS - OFFICERS & KEY EMPLOYEES THE ORGANIZATION FOLLOWS THE PROCESS DESCRIBED IN TREASURY REGULATION 53.4958-6(C) FOR ESTABLISHING THE REBUTTABLE PRESUMPTION OF REASONABLENESS IN THE REVIEW, APPROVAL, AND DOCUMENTATION OF OFFICER, KEY MANAGEMENT, AND DIRECTOR COMPENSATION. THE CEO AND CFO ARE PAID BY UNIVERSITY HEALTH SERVICES, INC. (58-1581103). ANNUALLY, A COMPENSATION COMMITTEE OF THE UNIVERSITY HEALTH SERVICES (UHS), COMPRISED OF THREE INDEPENDENT BOARD MEMBERS, REVIEWS THE COMPENSATION OF THE CEO AND OTHER SENIOR MANAGEMENT MEMBERS. THE REVIEW IS CONDUCTED IN THE CONTEXT OF A BOARD APPROVED EXECUTIVE COMPENSATION PHILOSOPHY. BOTH THE DEVELOPMENT OF THE COMPENSATION PHILOSOPHY AND THE REVIEWS INVOLVE THE ADVICE AND ASSISTANCE OF AN INDEPENDENT COMPENSATION CONSULTING FIRM. MINUTES OF THE COMPENSATION COMMITTEE ARE RECORDED. THE COMPENSATION COMMITTEE REPORTS TO THE UHS BOARD EXECUTIVE COMMITTEE. FORM 990, PART VI, SECTION C, LINE 19 OTHER ORGANIZATION DOCUMENTS PUBLICLY AVAILABLE THE IRS FORM 990 IS ALSO AVAILABLE ON WWW.GUIDESTAR.ORG FORM 990, PART VII: COMPENSATION EXPLAINED JAMES R. DAVIS COMPENSATION PAID BY UNIVERSITY HEALTH SERVICES, INC. (58-1581103) EDWARD L. BURR COMPENSATION PAID BY UNIVERSITY HEALTH SERVICES, INC. (58-1581103) DAVID A. BELKOSKI COMPENSATION PAID BY UNIVERSITY HEALTH SERVICES, INC. (58-1581103) SANDRA MCVICKER COMPENSATION PAID BY UNIVERSITY HEALTH SERVICES, INC. (58-1581103) RICHMOND COUNTY HOSPITAL AUTHORITY 1350 WALTON WAY AUGUSTA GA 30901 586001901 LEASED FACILITIES GA 501(C)(3) LINE 3 N/A 0 UNIVERSITY HEALTH SERVICES INC 1350 WALTON WAY AUGUSTA GA 30901 581581103 HOSPITAL GA 501(C)(3) LINE 3 UNIVERSITY HEALTH INC 0 UNIVERSITY HEALTH CARE FOUNDATION 2100 CENTRAL AVENUE SUITE D-1 AUGUSTA GA 30904 581343550 PHILANTHROPY GA 501(C)(3) LINE 7 UNIVERSITY HEALTH INC 0 UNIVERSITY HEALTH INC 1350 WALTON WAY AUGUSTA GA 30901 581581102 CONSOLIDATING PARENT GA 501(C)(3) LINE 9 N/A 0 AUGUSTA RESOURCE CENTER ON AGING INC 4275 OWENS RD EVANS GA 30809 581728812 NONPROFIT LIFE CARE COMMUNITY GA 501(C)(1) LINE 9 UNIVERSITY HEALTH INC 0 UNIVERSITY HOSPICE INC 1350 WALTON WAY AUGUSTA GA 30901 275008428 END OF LIFE SUPPORT GA 501(C)(3) LINE 9 UNIVERSITY HEALTH INC 0 UNIVERSITY EXTENDED CARE INC 1350 WALTON WAY AUGUSTA GA 30901 581581105 SKILLED NURSING HOME GA 501(C)(3) LINE 3 UNIVERSITY HEALTH INC 0 UNIVERSITY HEALTH RESOURCES I 1350 WALTON WAY AUGUSTA GA 30901 581601372 SVCS TO PHY GA UNIVERSITY HEALTH INC C 0 UNIVERSITY HOSPITAL OF AIKEN INC 1350 WALTON WAY AUGUSTA GA 30901 472713774 HOSPITAL SC UNIVERSITY HEALTH INC C 0 0 0 0 0 1 0 0 0 0 0 0 0 0 0 1 1 0 0 0