2014-05-22T09:52:13-05:00 2013-09-30 550486667 Arnett Foster Toothman PLLC P O Box 2629 Charleston WV 25329 990 2012-10-01 550422958 Stonewall Jackson Memorial Hospital Company STON 3042698059 230 Hospital Plaza Weston WV 26452 Dodie Arbogast 3042698059 2014-05-12 1 Dale Carpenter P00189642 3043460441 2012 2016-03-07 17:11:31Z Avah L Stalnaker 230 Hospital Plaza Weston WV 26452 65670584 0 X www.stonewallhospital.com X 1959 WV It is the mission of Stonewall Jackson Memorial Hospital to provide excellent care to all we serve. 9 7 624 28 7200 6200 82859 117598 44112962 44302989 -438688 2115789 2105522 847812 45862655 47384188 31886 25450 0 0 25017884 25604524 0 0 0 20032437 22094204 45082207 47724178 780448 -339990 64514533 67994521 7412873 8168224 57101660 59826297 It is the mission of Stonewall Jackson Memorial Hospital to provide excellent care to all we serve. 0 0 37772068 44258638 Stonewall Jackson Memorial Hospital provides Acute medical and outpatient services to residents of Weston, West Virginia and surrounding communities which covers 10 different counties. Services included 8,769 days of inpatient care, 82,145 outpatient visits, 15,767 emergency room visits, 1,530 ambulatory surgery visits, 6,187 Home Health visits and 51,811 Physician Clinic visits. 15073 3450 17707 Annual Blood Screening: Stonewall Jackson Memorial Hospital provides all supplies and staff to operate the program. Excess revenue is forwarded to the local Rotary Club to promote charitable services. Other programs include: scoliosis screening at county elementary and middle schools, health fairs at the local senior citizens center, free sports physicals to middle and high school students, Children's Safety Day to promote healthy choices to children under 12 years of age, events for free osteoporosis screenings, events for free Dermascans to screen for skin cancer, Weston Walk-run to promote exercise as a way to improve cardiac health, free women's health screening for breast and cervical cancer, and free hearing screenings. 30397 22000 26644 William Adler Scholarship Fund - Stonewall Jackson Memorial Hospital sponsored program to provide scholarships to local graduating high school seniors who are pursuing a career in the health care field. It is hoped that this program will encourage more students to seek health care professions and lesson the health care staffing shortage. 37817538 1 1 0 0 0 0 0 0 0 0 1 0 0 0 0 1 1 0 0 0 0 0 0 0 1 0 1 1 0 1 1 0 0 0 0 0 0 0 0 0 0 0 0 0 1 1 1 0 0 1 145 0 1 624 1 1 1 0 0 0 0 1 1 0 0 0 0 X 9 7 0 1 0 0 0 0 0 1 1 0 0 1 1 1 1 1 1 1 1 0 X Dodie Arbogast 3042698050 230 Hospital Plaza Weston WV 264528558 John Law 1.00 X 0 0 0 Joseph Snead 37.50 X 231276 0 28036 R Gerald Wood 1.00 X 0 0 0 Denver Turner 1.00 X 0 0 0 Jean Bennett 1.00 X 0 0 0 J Robert Bennett 1.00 X 0 0 0 Robin Poling 1.00 X 0 0 0 John W Wyllie 37.50 X 399085 0 18834 David Gallien 1.00 X 0 0 0 Avah Stalnaker 37.50 X 264906 0 18834 Delphia Arbogast 37.50 X 122460 0 22547 Peter Edgerton 37.50 X 423455 0 18834 Doyle Sickles 37.50 X 447027 0 28785 Ronald Pearson 37.50 X 431400 0 12500 Virgil W McMillion 37.50 X 401670 0 28785 Shafic Sraj 37.50 X 396835 0 28785 3118114 0 205940 28 0 1 0 Staff Care Inc PO Box 281923 Atlanta GA 303841923 ER Physician Coverage 313924 Laboratory Corporation PO Box 12140 Burlington NC 27216 Laboratory Services 256795 Reliable Builders PO Box 122 Buckhannon WV 26201 Construction 242847 CPS PO Box 1000 Memphis TN 38148 Pharmacy Consulting 230671 Sodexo PO Box 936522 Atlanta GA 503536922 Maintenance 198073 8 24025 93573 117598 Patient Services 622110 44302989 44302989 44302989 1028989 1028989 38759 7200 88852 0 -50093 7200 -42893 7200 -50093 19261315 3009 18176075 1449 1085240 1560 1086800 1086800 20326 24025 20020 306 306 Sales tax refund 900099 419365 419365 Cafeteria sales 722310 176987 176987 Electronic health records revenue 900099 101750 101750 192297 192297 890399 47384188 44302989 7200 2956401 3450 3450 22000 22000 1099582 798516 301066 20749318 15068155 5681163 749167 544045 205122 1632935 1185837 447098 1373522 997452 376070 78256 78256 101818 101818 249184 249184 1811214 1315304 495910 199866 145143 54723 1638432 1189829 448603 135680 98531 37149 950999 690615 260384 69829 50710 19119 76100 55264 20836 2174789 1579332 595457 210433 152816 57617 Medical supplies 6756040 6756040 Bad debts 5238684 5238684 Repairs and maintenance 1149144 834508 314636 Medicaid provider tax 491799 491799 761937 599508 162429 47724178 37817538 9906640 0 149289 48788 1606486 10991643 7261430 6867022 1051146 788779 301932 296128 34315651 22368689 10789711 11946962 41517511 35242542 195934 67668 1641094 1744989 64514533 67994521 5778236 6306619 92210 87254 1199213 1774351 343214 0 7412873 8168224 X 57101660 59826297 57101660 59826297 64514533 67994521 -339990 3064627 0 X 0 1 X 1 0 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 646015 646015 12405754 9517843 2887911 20251091 12850846 7400245 1012791 1012791 11946962 X 41436685 0 41436685 5947503 5947503 47384188 41776675 0 41776675 5947503 5947503 47724178 Description of Uncertain Tax Positions Under FIN 48: Part X, Line 2: The organization had no uncertain tax positions under Fin 48 as reported in the financial statements. Part XI, Line 4b - Other Adjustments: Investment expenses netted with revenue on the financial statements 249,184. Bad debt expense netted with revenue on the financial statements 5,238,684. Expenses netted with donation revenue on the financial statements 14,820. Grant expenses netted with grant revenue on the financial statements 25,450. Sales tax refund netted with expense on financial statements 419,365. Part XII, Line 4b - Other Adjustments: Investment expenses netted with revenue on the financial statements 249,184. Bad debt expense netted with revenue on the financial statements 5,238,684. Grant expenses netted with grant revenue on the financial statements 25,450. Expenses netted with donation revenue on the financial statements 14,820. Sales tax refund netted with expense on financial statements 419,365. Charity Golf Tournament 26644 17941 8703 900 7090 176 231 Rotary Blood Screening 17707 6084 11623 11623 44351 24025 20326 900 7090 176 11854 20020 306 1 1 X 0 0 1 1 1 0 0 921035 921035 0.02170 8080564 5881241 2199323 0.05180 9001599 5881241 3120358 0.07350 15 3000 12100 12100 0.00030 1 22 30397 26644 3753 0.00010 7483 7483 0.00020 16 3022 49980 26644 23336 0.00060 16 3022 9051579 5907885 3143694 0.07410 166426 166426 0.00390 166426 166426 0.00390 0 2334881 7934970 8163569 -228599 X 1 1 1 1 Stonewall Jackson Memorial Hospital

230 Hospital Plaza Weston WV 26452

X X X Stonewall Jackson Memorial Hospital 1 1 X 12 1 0 1 X X X X X 0 0 1 0 0 1 X X X X X X 1 1 X X X X 1 0 X X X X 1 0 1 Part I, Line 3c: WV food stamp eligibility guidelines are used. We also evaluate the patient's assets and the amount of medical debt. We have signs posted at Registration, around and in the Emergency Department and in all physician clinics. We send letters to patients who are not paying their bills and give the application to private pay inpatients. We also tell the patients during telephone conversations if the patient indicates he/she is not able to pay the bill or pay all of the bill. Part I, Line 7: The cost of charity care was estimated using a cost to charge ratio derived from Worksheet 2 of the Schedule H instructions.The unreimbursed cost of Medicaid was estimated using a cost to charge ratio derived from Worksheet 2 of the Schedule H instructions. 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 $ 5238684. Part II: We recruit physicians to this area based entirely on what services the patients need. Our goal is to be able to provide physicians who can address these needs in the community. Part III, Line 4: Patient accounts receivable are carried at the original charge less an estimate made 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. Part III, Line 9b: Our collections policy applies to all patients regardless of financial class or any other classification. During our collections process, if the patient indicates they do not have the ability to pay their bill, the credit staff offers exoneration. Stonewall Jackson Memorial Hospital Part V, Section B, Line 3: The Hospital took into account input from representatives from health department, schools, local businesses and town Mayor. Stonewall Jackson Memorial Hospital Part V, Section B, Line 7: Action has been taken on the top 5 Community Needs identified in the Community Health Needs Assessment. The remaining items were not addressed due to low community need. Stonewall Jackson Memorial Hospital Part V, Section B, Line 21: Charges are the same for all payers and private pay but private pay patients are given a 20% discount off of charges if the bill is paid within 30 days of the statement date. Stonewall Jackson Memorial Hospital Part V, Section B, Line 22: Charges are the same for all payers and private pay but private pay patients are given a 20% discount off of charges if the bill is paid within 30 days of the statement date. Part VI, Line 3: We have signs posted at Registration, around and in the Emergency Department and in all physician clinics. We send letters to patients who are not paying their bills. We give the application to Private Pay inpatients. We tell the patients when during telephone conversations if the patient indicates he/she is not able to pay the bill or pay all of the bill. Part VI, Line 4: Stonewall Jackson Memorial Hospital serves a relatively large rural population of about 65,000 people with an average household income of $32,000. 30% of the population is disabled. Approximately 30% are Medicaid Eligible or are uninsured. We are the largest hospital in our service area, which includes two other hospitals, one being a Critical Access Hospital. We are located in a federally-designated medically underserved area. Part VI, Line 5: Stonewall Jackson Memorial Hospital (SJMH) is a 70 bed rural acute hospital located in Lewis county West Virginia. SJMH is the only hospital located in the county as such it is solely responsible for the healthcare of this rural community. SJMH provides 24 hours Emergency Room and Obstetrics services and provides care regardless of the patient's ability to pay. The majority of the governing body is comprised of community members. Medical privileges are offered to all qualified physicians in the community and SJMH has worked diligently to provide other physician services by expanding the services they provide.SJMH continues to make capital improvement to the facility and expand patient care services to meet the needs of the community. 1 Nursing School Scholarships for recent high school graduates. 22 22000 FMV - Cash 1 X X X X 0 0 0 0 0 0 0 0 0 Joseph Snead 231276 0 0 0 0 0 11751 0 18441 0 261468 0 0 0 John W Wyllie 399085 0 0 0 0 0 12500 0 8568 0 420153 0 0 0 Avah Stalnaker 255590 0 0 0 9316 0 12500 0 8568 0 285974 0 0 0 Peter Edgerton 423455 0 0 0 0 0 12500 0 8568 0 444523 0 0 0 Doyle Sickles 447027 0 0 0 0 0 12500 0 18519 0 478046 0 0 0 Ronald Pearson 431400 0 0 0 0 0 12500 0 0 0 443900 0 0 0 Virgil W McMillion 401670 0 0 0 0 0 12500 0 18337 0 432507 0 0 0 Shafic Sraj 396835 0 0 0 0 0 12500 0 18519 0 427854 0 0 0 Form 990, Part VI, Section A, line 3 Management duties customarily are performed under the direct supervision of officers, directors, trustees or key employees, but the Hospital has contracted out the management duties of the Maintenance department. The manager of the Maintenance department (also considered a department head) is employed by the Maintenance company. All other Maintenance staff are employees of the Hospital. The Hospital contracts out the management duties of the Pharmacy department. The manager of the Pharmacy department (also considered a department head) is employed by the Pharmacy company. All other Pharmacy staff are employees of the Hospital. Form 990, Part VI, Section B, line 11 The process the Hospital uses to review their 990 before filing with the IRS is the CFO is responsible for reviewing the form 990 for completeness and accuracy. A completed copy is provided for the board. It is then signed and submitted to the IRS. Form 990, Part VI, Section B, line 12c All board members disclose possible conflicts of interest prior to appointment and periodically throughout their terms as trustees. Form 990, Part VI, Section B, line 15 The Hospital obtains salary survey data. Performance evaluations are done on each of these personnel & financial conditions are considered. Form 990, Part VI, Section C, line 19 The Hospital places a publication in the local newspaper stating the governing documents, conflicts of interest policy and financial statements are available upon request. The policies and procedures are on the Stonewall Jackson website. Stonewall Home Oxygen Therapy Inc 100 Market Place Mall Suite 8 Weston WV 26452 550754278 Oxygen Therapy Services WV N/A C -128266 381702 1.00000 1 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 Stonewall Home Oxygen Therapy Inc A 7200 FMV - Cash