2014-07-22T06:24:34-05:00 2013-09-30 550486667 Arnett Foster Toothman PLLC P O Box 2629 Charleston WV 25329 990 2012-10-01 550356996 St Joseph's Hospital of Buckhannon Inc STJO 3044732000 1 Amalia Drive Buckhannon WV 26201 Sue Johnson-Phillippe 3044732000 2014-07-03 1 Harry C Harless P01042847 3043460441 2012 2015-11-30 17:44:51Z Sue Johnson-Phillippe 1 Amalia Drive Buckhannon WV 26201 43890439 0 X http://www.stj.net/ X 1989 WV We are inspired by the love of Christ to provide our community with quality health care in ways that respect the God-given dignity of each person and the sacredness of human life. 12 10 519 36 0 0 78938 274452 45780822 42531164 400576 639541 282402 436841 46542738 43881998 3044 6990 0 0 24786332 25881281 0 0 0 22413244 22260991 47202620 48149262 -659882 -4267264 31151609 25229230 35330359 31310243 -4178750 -6081013 X We are inspired by the love of Christ to provide our community with quality health care in ways that respect the God-given dignity of each person and the sacredness of human life. 0 0 40265650 6990 42531164 The Hospital provides impartial access to treatment or accommodation for care that is available or medically indicated regardless of race, creed, sex, national origin or source of payment. In order to enable our patients to lead healthy, productive lives, the hospital strives to supply a comprehensive range of acute inpatient, long-term and outpatient care, outreach clinics, home care and emergency room services including prevention, guidance, diagnosis, treatment, restoration, rehabilitation, and other efforts as may be required, to meet the health care needs of the community as the hospital resources will permit. Although payment for services rendered is essential to the operation and stability of the hospital, it is recognized that not all individuals possess the financial means to purchase essential medical services. Our mission is to serve the community with respect to providing health care services and health care education. In keeping with this commitment, the hospital will serve all members of its community regardless of means or source of payment. The hospital also operates physician clinics and durable medical equipment services centers. 40265650 1 1 0 0 0 0 0 0 0 0 1 0 0 0 1 0 0 1 0 0 0 0 0 0 0 0 1 1 0 0 1 0 0 0 1 0 0 0 0 1 0 0 0 0 1 1 1 0 0 1 28 0 1 519 1 0 0 0 0 0 0 0 0 0 0 X 12 10 0 0 0 0 1 1 1 1 1 0 0 0 1 1 1 1 1 1 1 0 X Renee Hofer 3044732185 1 Amalia Drive Buckhannon WV 26201 Sue Johnson-Phillippe 40.00 X X 0 257956 0 Sr Diane Bushee 1.00 X 0 0 0 Sr Marian Ruth Creamer 1.00 X 0 0 0 Steve Foster 1.00 X 0 0 0 Sr Mary Grace Barile 1.00 X 0 0 0 Sr Francesca Lowis 1.00 X 0 0 0 Michael G Sellards 1.00 40.00 X X 0 843106 40612 Terry Cronin 1.00 X 0 0 0 Bob Skinner 1.00 X 0 0 0 Robert Blake MD 1.00 X 0 0 0 Dennis Xander 1.00 X 0 0 0 Sr Gail Borgmeyer 1.00 X 0 0 0 Tom Moore 40.00 X 0 0 0 John Rollins 40.00 X 280376 0 6853 Susan Long 40.00 X 519418 0 6853 James Kim 40.00 X 468748 0 6853 Yaser Kalash 40.00 X 450006 0 6853 Salvatore Lanasa 40.00 X 496332 0 6853 Douglas E McKinney 40.00 X 319800 0 6853 2534680 1101062 81730 33 0 1 0 WVU Medical Corporation PO Box 740 Morgantown WV 26507 ER Physician Coverage 1024941 Employee Benefit Service PO Box 890144 Charlotte NC 28289 Third Party Administrator 817138 Nelson Mullins Riley & Scarborough LLP 949 3rd Ave Ste 200 Huntington WV 25701 Legal Services 480690 Odyssey Rehabilitation 415 Benedum Bridgeport WV 26330 Therapy Services 242284 Alliance Healthcare SVCS PO Box 96485 Chicago IL 60693 MRI Services Contract 213900 16 258707 6990 8755 75713 274452 Patient service revenue 622110 42129955 42129955 Medicare incentive payments 622110 401209 401209 42531164 643122 643122 298 298 50087 4860 45227 45227 45227 3581 -3581 -3581 -3581 Cafeteria and vending 722212 219266 219266 Pharmacy income 446110 48989 48989 Medical records revenue 900099 19750 19750 103311 103311 391316 43881998 42531164 0 1076382 6990 6990 408236 342428 65808 19433177 16300549 3132628 823765 690974 132791 3912638 3281921 630717 1303465 1093346 210119 482754 482754 597037 597037 35662 35662 6513 6513 2835525 2378438 457087 220128 220128 3432040 2878795 553245 469277 393630 75647 793750 665798 127952 56840 47677 9163 200926 168537 32389 1674882 1404891 269991 862657 723597 139060 Bad debt 6211048 6211048 Medical supplies 1602903 1344515 258388 Provider tax 849356 712440 136916 Dues and subscriptions 185736 155795 29941 1743957 1464281 279676 48149262 40265650 7883612 0 967360 423570 1597396 2121954 6381569 5425217 24247 12490 915298 1003064 1009940 965865 38654424 24052618 15815849 14601806 3899535 18399 472350 472350 68065 184515 31151609 25229230 10353589 11241740 22644 22293 213850 172948 2059275 380556 22681001 19492706 35330359 31310243 X -4254435 -6146854 50685 40841 25000 25000 -4178750 -6081013 31151609 25229230 X -4267264 32261 2332740 X 0 1 X 1 0 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 468833 468833 25131409 14543838 10587571 11856610 8621030 3235580 1197572 887750 309822 14601806 Accrued pension costs 7121030 Notes payable - related parties 2340983 Bonds reported on parent's return 8333910 Lease payable 485053 Accrued malpractice liability 499803 LT Debt 2003 series 589448 Medicare claims liability 122479 19492706 1 1 1 X 125.000000000000 1 X 1 1 0 1 0 919416 919416 0.02190 8232998 6595672 1637326 0.03900 201612 184329 17283 0.00040 9354026 6780001 2574025 0.06130 3555 7110 -3555 0.00000 3555 7110 -3555 9357581 6787111 2570470 0.06130 21406 21406 0.00050 21406 21406 0.00050 1 2719197 679799 5433800 5335780 98020 X 1 0 1 1 St Joseph's Hosptial of Buckhannon

1 Amalia Drive Buckhannon WV 26201

X X X Skilled Nursing Facility, Outpatient Physician Clinic St Joseph's Hospital of Buckhannon Inc 1 1 X X X X X X X X 12 1 0 1 X X X X X X X X X 1 0 1 1 125.000000000000 1 200.000000000000 1 X X X X X X 1 1 X X X 1 0 X X X 1 X 0 0 5 St Joseph's Hospital

1 Amalia Drive Buckhannon WV 26201

Skilled nursing facility St Joseph's Hospital

1 Amalia Drive Buckhannon WV 26201

Physician Clinics St Joseph's Hospital

1 Amalia Drive Buckhannon WV 26201

DME Services St Joseph's Hospital

1 Amalia Drive Buckhannon WV 26201

Home Health St Joseph's Hospital

1 Amalia Drive Buckhannon WV 26201

Hospice Part I, Line 3c: Uncompensated Care Procedure: 1) Anyone applying for uncompensated care will be required to fill out an Uncompensated Care Application. This can be done in the following manner: a) The admissions clerk can take the application at the time of the admission. b) The Credit/Collection department can take the application when doing financial assessment. c) The application can be taken any time during the billing cycle. d) The application can be mailed to the patient. 2) Anyone applying for uncompensated care will be required to provide the hospital with proof of income. The proof of income can be as listed: a) Tax return from most recent year of filing, check stubs from the last three months or a check stub showing year-to-date earnings. b) A statement of earnings from the employer or source of income. c) Medicaid denial letter or verification through WVDHHR screening website. The associate will insure that Medicaid eligibility is solicited. If appropriate documentation is not attached, application will be denied. d) Listing of all assets, ATV's, Boats, Campers, Property, Stocks, Bonds, CD's etc. The most current months bank statement is required. 3) The Business Office Manager or his/her designee will make all determinations: a) The Monthly income is listed and multiplied by 12. b) The chart is referenced to determine uncompensated eligibility. c) If eligible, this is noted and signed by the associate. d) If not eligible, expense information is analyzed. Non-discretionary expenses are considered necessities of life or job (shelter, food, utilities, car loan, etc.). e) Comparison of expenses to income determines disposable income for payment of a hospital debt. f) Total expenses are then totaled, with the same expense to income comparison. g) Accounts will be required to have asset information verified with the county assessor's office. If cash convertible asset information is exactly twice the amount of the patient portion of the St. Joseph's Hospital bill or more, applicant is not eligible for assistance. If substantial hard assets exist, they will be considered.4) A patient will be notified if Uncompensated Care is denied or a percentage is granted. 5) Accounts approved for uncompensated care will be written off using the appropriate forms and codes.6) Medicare accounts that are written off to Uncompensated Care must be listed on the Medicare bad Debt Compliance Checklist. Medicare accounts will be required to have asset information verified with the county assessors office.7) Determination for Uncompensated Care will be based on annual income guidelines (see attachment). Determination will be made at the end of each month.8) St. Joseph's Hospital will make medically necessary services available on an inpatient or outpatient basis to individuals who cannot afford to pay for such services.9) Accounts that have been referred to a collection agency will not be eligible for consideration. Part I, Line 7, Column (f): The Bad Debt expense included on Form 990, Part IX, Line 25, Column (A), but subtracted for purposes of calculating the percentage in this column is $ 6211048. Part II: The recruitment of physicians to this community is vital for the health of the community. Part III, Line 4: Patient accounts receivable: Patient accounts receivable are carried at the net realizable value less an estimate for doubtful or uncollectible accounts. The allowance is based upon a review of the outstanding balances, aged by financial class. Management uses collection percentages, based upon historical collection experience, to determine collectability. Management also reviews troubled, aged accounts to determine collection potential. Patient accounts receivable are written off when deemed uncollectible. Recoveries of accounts previously written off are recorded as a reduction to bad debt expense when received. Interest is not charged on patient accounts receivable.Upshur County WV is the primary service area for St. Joseph's Hospital. The 2010 census showed that 19.3% of the population in Upshur county to be below poverty level. Thus, 19.3% of the bad debt cost was used to calculate the estimated amount of the Organization's bad debt expense attributable to patients under the Organization's financial assistance policy.The cost of bad debt expense was determined using the cost to charge ratio.The amount of bad debt expense attributable to patients under the financial assistance policy is estimated to be 25% of bad debt expense using patient accounting department's personal experience. Part III, Line 9b: Prior to an account going to collections, especially if it is a self-pay patient, the Organization checks Medicaid and charity eligibility. St. Joseph's hospital requires all self-pay patients to talk to a financial counselor to determine qualification for charity care and Medicaid programs. Self-pay patients are required to show proof that they have been denied by Medicaid. After it is determined that self-pay patients do not qualify for assistance, and if they are still unable to pay their bills, they are set up on a payment plan suited to their income level. Only when a self-pay patient falls behind on his/her payments and it is certain he or she does not qualify for assistance are they sent to a collection agency. St. Joseph's Hospital of Buckhannon, Inc Part V, Section B, Line 12h: Debt to income ratio St. Joseph's Hospital of Buckhannon, Inc Part V, Section B, Line 20d: Patients with no insurance coverage are considered self-pay patients. Those patients are automatically given a 15% uninsured discount from gross charges, based on commercial insurance average. Part VI, Line 2: St. Joseph's Hospital has contracted with an outside company to perform the community wide needs assessment survey and has translated this information into the Community Health Needs Assessment Report which outlines actions taken. In addition, an outside company performs post admission surveys for all inpatients. This survey includes questions regarding whether the patient's needs were met during the stay, and the hospital reviews this HCAHPS data to determine what services may need to be added based on that data. Part VI, Line 4: St. Joseph's Hospital is located in a small town in a rural, mountainous region of West Virginia. The hospital serves its home county (with a population of approximately 24,477 residents), as well as parts of five surrounding counties. The population served is an aging population with growing health concerns. In St. Joseph's Hospital's home county, 17.0% of the population is below the poverty level and only 15.4% have a college degree. The teen pregnancy rate is 32%. Part VI, Line 5: St. Joseph's hospital promotes the health of the community by maintaining an open medical staff, using community members on its board of directors, providing support of community health activities (blood screenings, health fair, flu shot clinics, etc.). The Hospital has also been actively recruiting both primary care providers and specialists to meet the health care needs of our service area. Part VI, Line 6: St. Joseph's Hospital of Buckhannon, Inc. is a not-for-profit health care facility wholly sponsored by Pallottine Health Services, Inc. (PHS). Pallottine Health Services is a ministry of the Pallottine Missionary Sisters and includes both St. Joseph Hospital of Buckhannon, West Virginia and St. Mary's Medical Center of Huntington, West Virginia. Both of these hospitals are committed to the core values of compassion, hospitality, reverence, interdependence, stewardship, and trust. PHS files a community benefit report every three years in West Virginia. St. Joseph's Hospital is included in this community benefit report. 1 X X X X X X 0 1 0 0 0 0 0 0 0 Sue Johnson-Phillippe 0 239556 0 10000 0 8400 0 0 0 0 0 257956 0 0 Michael G Sellards 0 583185 0 121616 0 138305 0 24209 0 26293 0 893608 0 98825 John Rollins 280376 0 0 0 0 0 0 0 7309 0 287685 0 0 0 Susan Long 519418 0 0 0 0 0 0 0 7801 0 527219 0 0 0 James Kim 468748 0 0 0 0 0 0 0 10936 0 479684 0 0 0 Yaser Kalash 450006 0 0 0 0 0 0 0 13451 0 463457 0 0 0 Salvatore Lanasa 496332 0 0 0 0 0 0 0 7309 0 503641 0 0 0 Douglas E McKinney 319800 0 0 0 0 0 0 0 7567 0 327367 0 0 0 Part I, Line 4b During the 2013 fiscal year, Michael Sellards, an officer of the Organization who is paid by a related organization, received payment of $98,825.04 under a supplemental non-qualified retirement plan (SERP). Joseph Reed MD Former board member Purchase of a building X 220500 172948 0 1 1 172948 X Medical Equipment 1 75713 Replacement cost 0 1 0 Form 990, Part VI, Section A, line 6 The Organization is a membership (not a stock) corporation under West Virginia State law. The Organization's sole corporate member is Pallottine Health Services, a related not-for-profit organization. Form 990, Part VI, Section A, line 7a In accordance with the terms and requirements of its governing documents (i.e. bylaws), on an annual basis, the Organization's current board members recommend the list of candidates for membership to the governing body for the subsequent term to the St. Joseph's Hospital board of directors. The Pallottine Health Services board of directors will approve and elect these candidates to serve as the organization's board of directors. Form 990, Part VI, Section A, line 7b Pallottine Health Services, as the sole corporate member, also has the right to approve or ratify significant decisions of the Organization's governing body including the amendment of bylaws and charters, removal of members of the governing body, and the decision to dissolve the organization. Form 990, Part VI, Section B, line 11 The Form 990 is reviewed by the organization's management (A team comprised of representatives of the finance and administration departments) in consultation with an accounting firm (Arnett Foster Toothman). The financial review is based on the organization's audited financial statements for the relevant time period. Before the Form 990 is filed with the IRS, the finance committee of the organization's board of directors reviews the Form 990. Relevant portion of the form 990 are transmitted to the board before the return is filed. Form 990, Part VI, Section B, line 12c Upon employment and annually thereafter, each key employee and officer of the organization is required to complete a conflict of interest and disclosure form, providing sufficient information about his/her personal interests and relationships so the organization can (1) determine whether any potential or actual conflicts of interest may exist, and (2) monitor work or service assignments to avoid placing the key employee, officer or director in a position where there may be an appearance (potential or actual) of a conflict of interest or a question of objectivity. The completed conflict of interest and disclosure forms for directors are returned to the organization. These members are monitored and not assigned any projects that would create any potential conflict of interest. The determination of conflict of interest would be made at the PHS board level. Any board member with a potential conflict recuses himself or herself from all discussions regarding the conflict. Form 990, Part VI, Section B, line 15 Pallottine Health Services (PHS), the organization's single member, regularly provides documentation to PHS's compensation committee with respect to the compensation of the Organization's officers and key employees for review and approval. Such information includes comparable data from similar size tax-exempt organizations in Buckhannon, West Virginia and surrounding communities as well as compensation for these positions (as disclosed on Form 990) with other organizations in the health care industry that are of similar size, demographics, and geography. Review and approval of the compensation arrangement by the officers/executive committee is documented. 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 at its office at 1 Amalia Drive, Buckhannon, WV 26201. A nominal fee is charged if copies are requested. Changes in Net Assets or Fund Balances: Form 990, Part XI, line 9: Change in pension plan funded status 2,342,764. Additional revenue adjusted through net assets on financial statements -10,024. Clarification of 'no' response Form 990, Part IV, Question 24A St. Joseph's Hospital is part of the obligated group for tax-exempt bonds held by Pallottine Health Services. All bonds are reported on the Pallottine Health Services Form 990 for the year ended 9/30/13. Pallottine Health Services 2900 First Avenue Huntington WV 25702 550688201 Parent - management WV 501(C)(3) 11a N/A 0 Pallottine Missionary Sisters 1 Amalia Drive Buckhannon WV 26201 431783315 Church MO 501(C)(3) 1 N/A 0 St Mary's Medical Center 2900 First Avenue Huntington WV 25702 550357050 Hospital WV 501(C)(3) 3 Pallottine Health Services 0 St Mary's Medical Center Foundation 2900 First Avenue Huntington WV 25702 141887211 Foundation WV 501(C)(3) 11b St Mary's Medical Center 0 St Joseph's Foundation of Buckhannon 1 Amalia Drive Buckhannon WV 26201 550727650 Foundation WV 501(C)(3) 11c St Joseph's Hospital of Buckhannon 1 St Mary's Occupational Health and Medical Services 2900 First Avenue Huntington WV 25702 542136110 Medical Services WV N/A Tri-State MRI 2900 First Avenue Huntington WV 25702 550669726 Medical Services WV N/A Claire-Frances Health Services 200 Mall Road Suite 3 Ashland KY 41101 311517507 Medical Services WV N/A Huntington Area MRI 2900 First Avenue Huntington WV 25702 261877332 Medical Services WV N/A Upshur Medical Management Services 1 Amalia Drive Buckhannon WV 26201 550727649 Inactive WV Saint Joseph's Hospital C 1.00000 1 Vanguard Financial Services 2900 First Avenue Huntington WV 25702 450496141 Collection Agency WV N/A C 0 0 0 1 0 1 0 0 0 0 0 0 0 1 0 1 1 0 0 0 St Joseph's Foundation of Buckhannon Inc C 258707 Internal accounting records St Joseph's Foundation of Buckhannon Inc O 54807 Internal accounting records