2015-08-04T15:44:14-05:00 2014-09-30 560747981 DIXON HUGHES GOODMAN LLP 500 RIDGEFIELD COURT ASHEVILLE NC 28806 990 2013-10-01 560642846 HUGH CHATHAM MEMORIAL HOSPITAL INC HUGH 3365277000 180 PARKWOOD DR ELKIN NC 28621 DONALD E TRIPPEL CFO 3365277000 2015-08-04 1 AMY BIBBY P00445891 8282542254 2013 2016-04-25 22:37:26Z DONALD E TRIPPEL 180 PARKWOOD DR ELKIN NC 28621 139271519 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 14 935 125 0 0 438903 51200 98113735 91818549 8202354 14688971 1555719 1408416 108310711 107967136 10227 182058 0 0 44845712 41295790 0 0 83480 59040409 56013215 103896348 97491063 4414363 10476073 202771204 208018399 92447047 88302120 110324157 119716279 X TO CONSISTENLY DELIVER EXCEPTIONAL QUALITY AND SERVICE BY DEMONSTRATING THE VALUES OF SERVICE, TEAMWORK, ACCOUNTABILITY, RESPECT, AND SAFE CARE. 0 1 90805709 182058 91818549 HUGH CHATHAM MEMORIAL HOSPITAL OFFERS A WIDE VARIEY OF SERVICES TO OUR COMMUNITY. WE OFFER WOMEN'S HEALTH EDUCATION SEMINARS, INFANT AND CHILD CPR CLASSES, LAMAZE AND CHILDBIRTH CLASSES, CARDIAC REHABILITATION, AND VARIOUS PATIENT EDUCATIONAL PROGRAMS. WE PARTICIPATE AND HOLD MANY COMMUNITY HEALTH SCREENINGS AND IMMUNIZATIONS, CANCER SCREENINGS (PROSTRATE, BREAST, SKIN, AND COLON), CHOLESTERAOL/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 OUR AREA NEEDS THROUGH THE STOP HUNGER FOOD DRIVE, MARCH OF DIMES, UNITED WAY, TRI C MINISTRIES, SUSAN G KOMEN WALKATHONS, SPECIAL OLYMPICS, AMERICAN CANCER SOCIETY, NATIONAL MS SOCIETY, AND A LOCAL ORGANIZATION TRIAD FIRST IN FAMILIES THAT HELPS CHILDREN IN NEED. THE HOSPITAL ALSO SPONSORS THE GRACE CLINIC, A LOCAL "FREE" CLINIC WHICH OPERATES ON DONATED SERVICES AND SUPPLIES. WE ARE PROVIDING STROKE EDUCATION AND OTHER HEALTHCARE EDUCATION TO LOCAL INDUSTRIES. WE HAVE ACHIEVED THE JOINT COMMISSION'S GOLD SEAL OF APPROVAL. WE HAVE DEMONSTRATED A HIGH LEVEL OF QUALITY CARE, TREATMENT AND PERFORMANCE MEASUREMENTS, INCLUDING COMPLIANCE WITH THE LINICAL PRACTICE QUIDELINES OF THE AMERICAN HEART ASSOCIATION, AND THE AMERICAN STROKE ASSOCATIONS. IN AUGUST, WE OPENED A NEW EXPRESS CARE IN THE COMMUNITY WHICH WAS VERY WELL RECEIVED. WE ALSO HAVE NEW PHYSICIANS IN THE BEHAVIORAL, PULMONOLGY, GASTRO, AND SURGERY SPECIALTIES.OVER THE YEARS, HCHM PATIENTS HAVE MADE THE HOSPITAL OUR REGIONS'S CHOICE FOR TECHNOLOGIES AND CARE. RECENT NATIONAL RANKINGS OF SEVERAL IMPORTANT MEASURES REINFORCE THIS CHOICE. THE RADIATION ONCOLOGY DEPARTMENT AT HUGH CHATHAM HAS BEEN AWARDED A THREE-YEAR TERM OF ACCREDITATION FROM THE AMERICAN COLLEGE OF RADIOLOGY (ACR). RADIATION ONCOLOGY IS THE PRACTICE OF USING HIGH-ENERGY RADIATION TO TREAT CANCER. THIS ACCREDITATION REPRESENTS THE HIGHEST LEVEL OF QUALITY CARE AND PATIENT SAFETY. IT IS ONLY AWARDED TO FACILITIES THAT MEET SPECIFIC PRACTICE GUIDELINES AND TECHNICAL STANDARDS DEVELOPED BY THE ACR. HUGH CHATHAM IS THE PROUD RECIPIENTS OF THE WOMEN'S CHOICE AWARD DISTINGUISHING IT AS ONE OF AMERICA'S BEST HOSPITALS FOR PATIENT EXPERIENCE IN OBSTETRICS. THE HOSPITAL WON THIS HONOR BY DEMONSTRATING EXCEPTIONAL SERVICE IN MEETING THE UNIQUE NEEDS AND PREFERENCES OF WOMEN, AND BY RECEIVING AN EXTRAORDINARY RECOMMENDATION RATING BY WOMEN FROM ACROSS THE REGION.THE PRIMARY STROKE CENTER AT HCMH HAS ACHIEVED THE JOINT COMMISSION'S GOLD SEAL OF APPROVAL. THIS NATIONAL CERTIFICATION RECOGNIZES THE CENTER'S EFFORTS TO FOSTER BETTER OUTCOMES FOR STROKE CARE.TO ACHIEVE THIS DISTINCTION, THE PRIMARY STROKE CENTER HAS DEMONSTRATED A HIGH LEVEL OF QUALITY CARE, TREATMENT AND PERFORMANCE MEASUREMENTS, INCLUDING COMPLIANCE WITH THE CLINICAL PRACTICE GUIDELINES OF THE AMERICAN HEART ASSOCIATION AND THE AMERICAN STROKE ASSOCIATION. - VISION STATEMENT -TO BE THE BEST COMMUNITY HOSPITAL IN THE NATION, WITH SERVICE AS OUR GUIDING PRINCIPLE - GEOGRAPHIC SERVICE AREA AND TARGET POPULATIONS FOR COMMUNITY INITIATIVES - THE HOSPITAL'S PRIMARY SERVICE AREA INCLUDES NINE ZIP CODES COMPRISING ROUGHLY A FIFTEEN-MILE DIAMETER AROUND ELKIN, NORTH CAROLINA. THE SECONDARY SERVICE AREA INCLUDES AN ADDITIONAL FIVE ZIP CODES WIDENING THE DIAMETER TO THIRTY MILES AROUND ELKIN. BOTH OF THE ABOVE MARKETS INCLUDE PART, BUT NOT ALL, OF THE NORTH CAROLINA COUNTIES OF WILKES, ALLEGHANY, YADKIN AND SURRY AND THE ENTIRE POPULATION OF EACH COMMUNITY IS TARGETED FOR ALL SERVICES AND INITIATIVES. ADDITIONAL TARGET MARKETS INCLUDE PORTIONS OF THE SOUTH WESTERN VIRGINIA COUNTIES OF CARROLL, GRAYSON, AND PATRICK. - FUNDING OF INITIATIVE PROGRAMS -THE RESOURCES OF HUGH CHATHAM MEMORIAL HOSPITAL FUND THE PROGRAMS. - DETERMINING COMMUNITY PRIORITIES AND COLLABORATION -THROUGH A GRANT FROM THE DUKE ENDOWMENT, A COMMUNITY NEEDS ASSESSMENT SURVEY WAS CONDUCTED IN A RECENT YEAR. USING INFORMATION FROM THIS SURVEY, ADMISSIONS DATA AND VOLUME DATA FROM THE HOSPITAL, AND PARTNERSHIPS WITH YADKIN AND SURRY SENIOR CENTERS, SURRY COMMUNITY COLLEGE, AND OTHER AGENCIES, NEEDS ARE IDENTIFIED, PRIORITIES ESTABLISHED, AND LEADERSHIP ROLES ASSIGNED FROM WITHIN THE COLLABORATIVE GROUP. THE HOSPITAL'S BOARD OF TRUSTEES, PHYSICIANS, AND ADMINISTRATION MEET EACH YEAR TO DETERMINE STRATEGIC NEEDS OF THE COMMUNITY AT THEIR ANNUAL PLANNING RETREAT. - COMMUNITY SERVICE PROGRAMS SPONSORED BY HUGH CHATHAM MEMORIAL HOSPITAL --PATIENT EDUCATION PROGRAMS- LAMAZE AND CHILDBIRTH INFANT AND CHILD CPR BREASTFEEDING CARDIAC REHABILITATION WOMEN'S HEALTH EDUCATIONAL SEMINARS-COMMUNITY HEALTH SCREENINGS AND IMMUNIZATIONS- CANCER SCREENINGS (PROSTATE, BREAST, SKIN, COLON) CHOLESTEROL/GLUCOSE BLOOD PRESSURE/HEART RATE/OXYGEN SATURATION WEIGHT/BODY MASS INDEX FALLS ASSESSMENT BONE DENSITY TETANUS/FLU-HEALTH PROMOTION, OUTREACH, AND SUPPORT GROUPS- 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 CARDIAC REHABILITATION 90805709 1 1 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 87 0 1 935 1 0 0 0 0 0 0 0 0 0 0 X 16 14 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 BOB MIDKIFF CHAIRMAN 1.00 X X 0 0 0 MIKE STANLEY VICE CHAIRMAN 1.00 X X 0 0 0 DAVID CLINE TREASURER 1.00 X X 0 0 0 CAROL JERNIGAN SECRETARY 1.00 X X 0 0 0 TERRY DARNELL ASST. SECRETARY/ASST. TREA 1.00 X X 0 0 0 DOMINICK CARBONE MD CHIEF OF STAFF 40.00 X 764714 0 24445 PHIL HARRIS BOARD MEMBER 1.00 X 0 0 0 ERCEL CARTER BOARD MEMBER 1.00 X 0 0 0 FRED EIDSON BOARD MEMBER 1.00 X 0 0 0 JAMES FREEMAN BOARD MEMBER 1.00 X 0 0 0 JL LOWE JR BOARD MEMBER 1.00 X 0 0 0 ALAN PAYNE BOARD MEMBER 1.00 X 0 0 0 GEORGE SAPPENFIELD BOARD MEMBER 1.00 X 0 0 0 BARBARA MYERS BOARD MEMBER 1.00 X 0 0 0 KEVIN AUSTIN BOARD MEMBER 1.00 X 0 0 0 BOB BALL BOARD MEMBER 1.00 X 0 0 0 PAUL HAMMES CEO 40.00 2.00 X 90667 0 0 DONALD TRIPPEL CFO 40.00 X 169261 0 11581 RIZWAN AHMED MD PHYSICIAN 40.00 X 525441 0 19703 ANDREW LEE MD PHYSICIAN 40.00 X 439466 0 23225 JONATHAN SNYDER MD PHYSICIAN 40.00 X 587551 0 19131 MURUGANANTHAN SUBBIAH MD PHYSICIAN 40.00 X 320146 0 20522 WILLIAM JOHNSON MD PHYSICIAN 40.00 X 350410 0 19127 DAVID LOVING FORMER CEO 0.00 X 224517 0 0 3472173 0 137734 36 1 1 1 SODEXO INC PO BOX 536922 ATLANTA GA 30353 DIETARY & HOUSEKEEPING SERVICES 3503543 CARDINAL HEALTH PO BOX 905867 CHARLOTTE NC 28290 PATIENT & HOSPITAL SUPPLIES 1809486 CARDINAL DISTRIBUTION PHARMACY 25025 NETWORK PLACE CHICAGO IL 60673 PHARMACY SUPPLIES & MEDICATIONS 1558253 HORIZON CSA LLC 265 PITT ROAD MOORESVILLE NC 28115 EQUIPMENT MAINTENANCE 1460416 AMERICAN INTEGRATED MANAGEMENT PO BOX 6633 HIGH POINT NC 27262 MANAGEMENT SERVICE 1144992 76 41851 9349 51200 PATIENT CARE SERVICES 621400 92013446 92013446 EHR MEANINGFUL USE REVENUE 621400 646158 646158 OTHER OPERATING REVENUE 621400 35089 35089 NET HOSPICE INVESTMENT 623000 -79606 -79606 NURSING CENTER 621400 -796538 -796538 91818549 2018607 2018607 1354558 209066 1145492 1145492 1145492 35614768 8150913 26095752 4999565 9519016 3151348 12670364 12670364 CAFETERIA & VENDING 722210 262924 262924 262924 107967136 91818549 0 16097387 X 182058 182058 1316124 329031 921287 65806 31236975 30128345 1108630 292317 273503 18223 591 6166557 5769563 384528 12466 2283817 2136788 142412 4617 334879 334879 123656 123656 172469 172469 442800 442800 12035682 10701024 1334658 506545 33237 473308 6192338 5683623 508715 1574877 1574877 213478 199654 13824 3106839 3106839 6922675 6922675 223644 223644 BAD DEBT EXPENSE 17239039 17239039 MEDICAL SUPPLIES 4021951 4021951 PROVIDER TAX 1672223 1672223 MISCELLANEOUS EXPENSES 953742 607635 346107 276378 276378 97491063 90805709 6601874 83480 8865853 10212540 91543 2990 9109092 7914767 1352757 1300862 3011821 2644962 147851303 75298581 81063475 72552722 91624644 106000758 4237520 4350905 3414499 3037893 202771204 208018399 8428459 8474731 76560000 69825000 7458588 10002389 92447047 88302120 X 108553977 117894899 1770180 1821380 110324157 119716279 202771204 208018399 X 10476073 1038871 -2122822 X X 0 1 X 1 0 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 0 1 0 0 0 0 0 0 1 12155 12155 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 $ 12,100. 2295845 2295845 86722295 28789231 57933064 8643809 6307966 2335843 48708723 40201384 8507339 1480631 1480631 72552722 INTEREST PAYABLE 701362 ESTIMATED THIRD-PARTY PAYOR SETTLEMENTS 5391320 PHYSICIAN GUARANTEE 344523 INTEREST RATE SWAP 3499570 RESIDENT TRUST FUNDS 65614 10002389 X 89186503 1038871 403180 1442051 87744452 442800 19779884 20222684 107967136 79794381 209066 209066 79585315 17905748 17905748 97491063 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, 2014. FISCAL YEARS ENDING ON OR AFTER SEPTEMBER 30, 2011 REMAIN SUBJECT TO EXAMINATION BY FEDERAL AND STATE TAX AUTHORITIES. PART XI, LINE 2D - OTHER ADJUSTMENTS: JOINT VENTURE INCOME FROM ACCOUNT WITH SWAP 194,114. DIRECT RENTAL EXPENSE 209,066. PART XI, LINE 4B - OTHER ADJUSTMENTS: CHANGE IN VALUE OF SWAP AGREEMENT 1,260,543. BAD DEBT EXPENSE NET WITH REVENUES 17,239,039. RECOGNIZED LOSSES ON IMPAIRMENTS 1,056,393. GRANTS/CONTRIBUTIONS TO FOUNDATION 223,909. PART XII, LINE 2D - OTHER ADJUSTMENTS: DIRECT RENTAL EXPENSES 209,066. PART XII, LINE 4B - OTHER ADJUSTMENTS: BAD DEBT EXPENSE NET WITH REVENUES 17,239,039. INVESTMENT MANAGEMENT FEE 442,800. GRANTS/CONTRIBUTIONS TO FOUNDATION 223,909. 1 1 X 1 X 1 X 1 1 1 0 1 1 1992917 1992917 0.02480 12189234 8735514 3453720 0.04300 14182151 8735514 5446637 0.06780 47239 47239 0.00060 229587 229587 0.00290 518882 518882 0.00650 795708 795708 0.01000 14977859 8735514 6242345 0.07780 1 5404439 1891554 74228376 74509126 -280750 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 1 X X X X X X X X X 12 1 0 1 X HTTP://WWW.HUGHCHATHAM.ORG/ABOUT-COMMUNIT X X X X X X X X X 1 0 1 1 200.000000000000 1 200.000000000000 1 X X X X X X X 1 1 X X X X X X 1 0 1 X 0 0 HUGH CHATHAM MEMORIAL HOSPITAL PART V, SECTION B, LINE 3: 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. 18 HUGH CHATHAM NURSING CENTER 700 JOHNSON RIDGE ROAD ELKIN NC 28621 NURSING FACILITY YADKIN VALLEY HOME HEALTH 213 WINSTON ROAD JONESVILLE NC 28642 HOME HEALTH YADKIN VALLEY ADULT MEDICINE 500 CHATHAM MEDICAL PARK ELKIN NC 28621 PHYSICIANS OFFICES CLINGMAN MEDICAL CENTER 3369 CLINGMAN ROAD RONDA NC 28670 PHYSICIANS OFFICES YADKIN VALLEY UROLOGY 200 JOHNSON RIDGE MEDICAL PARK ELKIN NC 28621 PHYSICIANS OFFICES HUGH CHATHAM FAMILY MEDICINE JONESVILLE 112 N SWAIM STREET JONESVILLE NC 28642 PHYSICIANS OFFICES YADKIN VALLEY GASTROENTEROLOGY 201 WEST MAIN STREET ELKIN NC 28621 PHYSICIANS OFFICES G I CLINIC 201 WEST MAIN STREET ELKIN NC 28621 PHYSICIANS OFFICES YADKIN VALLEY DERMATOLOGY 690 PARKWOOD MEDICAL PARK ELKIN NC 28621 PHYSICIANS OFFICES HUGH CHATHAM NEUROLOGY 100 CHATHAM MEDICAL PARK ELKIN NC 28621 PHYSICIANS OFFICES HUGH CHATHAM FAMILY MEDICINE ELKIN 101 CLAREMONT MEDICAL PARK ELKIN NC 28621 PHYSICIANS OFFICES HUGH CHATHAM SURGICAL 201 B CLAREMONT MEDICAL PARK ELKIN NC 28621 PHYSICIANS OFFICES TRI COUNTY ORTHOPEDIC & SPORTS MEDICINE 400 JOHNSON RIDGE RD ELKIN NC 28621 PHYSICIANS OFFICES HUGH CHATHAM BEHAVORIAL 690 PARKWOOD MEDICAL PARK ELKIN NC 28621 PHYSICIANS OFFICES YADKIN VALLEY PULMONARY 180 PARKWOOD DRIVE ELKIN NC 28621 PHYSICIANS OFFICES HUGH CHATHAM FAMILY MEDICINE BOOMER 156 BOOMER COMMUNITY CENTER RD BOOMER NC 28606 PHYSICIANS OFFICES HUGH CHATHAM FAMILY MEDICINE MT VIEW 5229 ROCK CREEK RD MT VIEW NC 28602 PHYSICIANS OFFICES EXPRESS CARE NORTH BRIDGE STREET ELKIN NC 28621 PROCEDURE CLINIC 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 $17,239,039 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 QUARTERLY HEALTH FAIRS AND LOOKS FOR TRENDS. THESE SCREENINGS PROVIDE INSIGHT INTO FURTHER MEDICAL NEEDS OF THE COMMUNITY MEMBERS. THE FAIRS ARE HELD QUARTERLY 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, SUCH AS "KIDSFEST, HEARTFEST, AND SCREENINGS SPECIFICALLY HELD FOR OUR EMPLOYEES. WE SPONSER SUPPORT GROUPS, LUNCH AND LEARN SESSIONS FOR THE COMMUNITY ALSOTHE ORGANIZATION TRACKS THE RESULTS OF HEALTH SCREENINGS PROVIDED THROUGH ITS QUARTERLY HEALTH FAIRS AND LOOKS FOR TRENDS. THESE SCREENINGS PROVIDE INSIGHT INTO FURTHER MEDICAL NEEDS OF THE COMMUNITY MEMBERS. THE FAIRS ARE HELD QUARTERLY 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, SUCH AS "KIDSFEST, HEARTFEST, AND SCREENINGS SPECIFICALLY HELD FOR OUR EMPLOYEES. ALSO, WE SPONSER SUPPORT GROUPS, LUNCH AND LEARN SESSIONS FOR THE COMMUNITY. 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 DIAMETER TO THIRTY MILES AROUND ELKIN. BOTH OF THESE 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. THESE AREAS HAVE BEEN SEVERELY AFFECTED BY THE ECONOMIC CLIMATE OF THE PAST YEAR. THE AREA CURRENTLY HAS AN UNEMPLOYMENT PERCENTAGE OF 12.7%. DOBSON, NC, WHICH IS IN THE CENTER OF SURRY COUNTY, IS A FEDERALLY DESIGNATED MEDICALLY UNDERSERVED AREA. HUGH CHATHAM IS THE ONLY HOSPITAL IN THE PRIMARY SERVICE AREA. 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, NOR FAMILY MEMBERS THEREOF. 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) 182058 OPERATIONAL SUPPORT 1 X X X X 0 0 0 0 0 1 0 0 0 DOMINICK CARBONE MD CHIEF OF STAFF 497635 0 267079 0 0 0 12676 0 11769 0 789159 0 0 0 DONALD TRIPPEL CFO 169261 0 0 0 0 0 5071 0 6510 0 180842 0 0 0 RIZWAN AHMED MD PHYSICIAN 482865 0 42576 0 0 0 10437 0 9266 0 545144 0 0 0 ANDREW LEE MD PHYSICIAN 273973 0 165493 0 0 0 9341 0 13884 0 462691 0 0 0 JONATHAN SNYDER MD PHYSICIAN 446549 0 141002 0 0 0 5104 0 14027 0 606682 0 0 0 MURUGANANTHAN SUBBIAH MD PHYSICIAN 251346 0 68800 0 0 0 7272 0 13250 0 340668 0 0 0 WILLIAM JOHNSON MD PHYSICIAN 350410 0 0 0 0 0 5100 0 14027 0 369537 0 0 0 DAVID LOVING FORMER CEO 174517 0 50000 0 0 0 0 0 0 0 224517 0 0 0 PART I, LINE 6 THE PHYSICIANS IN CHARGE OF THE UROLOGY PRACTICE, GASTROENTEROLOGY PRACTICE, AND CLINGMAN 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 2013 WERE: DOMINICK CARBONE, MD $267,079 RIZWAN AHMEND, MD 42,576 ANDREW LEE, MD 165,493 JONATHAN SNYDER, MD 141,002 MURUGANANTHAN SUBBIAH, MD 68,800 FORM 990, PART VII, SECTION A, LINE 1: COMPENSATION FROM AN UNRELATED ORGANIZATION: PAST CEO DAVID LOVING AND CURRENT CEO PAUL HAMES ARE 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: DAVID LOVING: BASE COMPENSATION $ 174,517 PAUL HAMES: BASE COMPENSATION $ 90,667 A NORTH CAROLINA MEDICAL CARE COMMISSION 521309402 657902F31 2003-04-23 39673032 REFUNDING, NEW STRUCTURES, EQUIPMENT 0 0 0 B NORTH CAROLINA MEDICAL CARE COMMISSION 521309402 65821DAF8 2008-09-24 45455000 NEW STRUCTURES, EQUIPMENT 1 0 0 A 7965000 41094212 2658335 529906 1878294 21551473 11100000 2005 1 0 1 1 B 2525000 42930000 46276755 3493414 435743 513249 42448072 2010 0 0 1 1 A 0 0 0 0 0.00000 0.00000 0.00000 0 1 0.13870 1 1 B 0 0 0 0 0.00000 0.00000 0.00000 0 0 0 A 0 0 0 1 0 0 0 0 0 B 0 0 0 1 1 1 WELLS FARGO 30.000000000000 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: 06/13/2013 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 OAKS FAMILY MEMBER OF BOARD MEMBER BOB MIDKIFF 54413 COMPENSATION AS AN EMPLOYEE OF THE ORGANIZATION 0 FORM 990, PART III, LINE 3 THE ORGANIZATION SOLD THE HUGH CHATHAM NURSING CENTER IN MAY 2014 TO AN OUTSIDE COMPANY. 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 11 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 5,463,327. MANAGEMENT AND GENERAL EXPENSES 0. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 5,463,327. CONTRACT LABOR: PROGRAM SERVICE EXPENSES 1,345,731. MANAGEMENT AND GENERAL EXPENSES 0. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 1,345,731. MAINTENANCE CONTRACTS: PROGRAM SERVICE EXPENSES 3,040,514. MANAGEMENT AND GENERAL EXPENSES 0. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 3,040,514. CENTRALIZED BILLING: PROGRAM SERVICE EXPENSES 566,879. MANAGEMENT AND GENERAL EXPENSES 0. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 566,879. OTHER FEES: PROGRAM SERVICE EXPENSES 284,573. MANAGEMENT AND GENERAL EXPENSES 1,334,658. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 1,619,231. FORM 990, PART XI, LINE 9: CHANGE IN VALUE OF SWAP AGREEMENT -1,260,543. RECOGNIZED LOSSES ON IMPAIRMENTS -1,056,393. JV INCOME FROM ACCOUNT WITH SWAP 194,114. 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 11A, 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 11A, I HUGH CHATHAM MEMORIAL HOSPITAL 1 1 1 1 0 0 0 0 0 0 0 0 0 0 1 1 0 1 1 1 HUGH CHATHAM MEMORIAL HOSPITAL FOUNDATION INC B 182058 CASH