2014-05-28T13:23:24-05:00 2013-07-31 410746749 CLIFTONLARSONALLEN LLP 101 N TRYON STREET SUITE 1000 CHARLOTTE NC 28246 990 2012-08-01 753054855 MERCY RESTORATIVE CARE HOSPITAL INC MERC 7046678050 10200 MALLARD CREEK ROAD NO 300 CHARLOTTE NC 28262 DAN DUNMYER 7046678050 2014-05-22 1 JOHN NORMAN P01506766 7049985200 2012 2015-11-30 17:44:51Z CAROLINAS SPECIALTY HOSPITAL DAN DUNMYER 10200 MALLARD CREEK ROAD NO 300 CHARLOTTE NC 28262 21618955 0 X WWW.CSHNC.COM X 2002 NC TO PROVIDE LONG TERM ACUTE CARE SERVICES. 11 11 198 13 0 0 0 0 20451401 20822254 760622 768912 9089 27789 21221112 21618955 0 0 0 0 9038329 9569970 0 0 0 8906943 9475597 17945272 19045567 3275840 2573388 20240544 22867219 2448567 2292197 17791977 20575022 TO PROMOTE AND IMPROVE THE HEALTH STATUS OF THE COMMUNITY BY PROVIDING LONG TERM ACUTE CARE SERVICES. 0 0 15514613 21618955 PROVIDED LONG TERM ACUTE CARE SERVICES THROUGH THE OPERATION OF A 40 BED HOSPITAL-WITHIN-A-HOSPITAL. 15514613 1 0 0 0 0 0 0 0 0 0 1 0 0 1 1 1 1 0 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 0 0 0 0 1 197 0 1 198 1 0 0 0 0 0 0 0 0 0 0 X 11 11 0 1 0 0 0 0 0 1 1 0 0 1 1 1 1 1 1 1 1 0 NC X ACUITY HEALTHCARE LP 7048877285 10200 MALLARD CREEK ROAD NO 300 CHARLOTTE NC 28262 CURTIS COPENHAVER 2.00 X 0 0 0 DAVID THOMAS 1.00 X 0 0 0 ROBERT KING 1.00 X 0 0 0 NEAL ALEXANDER 1.00 X 0 0 0 LYSA LONG 1.00 X 0 0 0 EDWARD BETHEA 1.00 X 0 0 0 CHERYL ATKINSON 1.00 X 0 0 0 NANCY GEEDEY 1.00 X 0 0 0 DR SANFORD BENJAMIN 1.00 X 0 0 0 ELIZABETH STEGER 1.00 X 0 0 0 JOYCE KORZEN 1.00 X 0 0 0 DAN DUNMYER 40.00 X 0 0 0 JOANNE TYO 40.00 X 0 0 0 TESHIA DAVIS-CARR 40.00 X 0 0 0 HAJRUDIN BEGIC 40.00 X 136337 0 17116 KOHE LOMBADU 40.00 X 108929 0 9500 KIMBERLY SINGLETON 40.00 X 108934 0 5266 354200 0 31882 3 0 1 0 CMC MERCY HOSPITAL PO BOX 32861 CHARLOTTE NC 28232 MEDICAL SERVICES 3907803 ACUITY HEALTHCARE LP 10200 MALLARD CREEK RD SUITE 300 CHARLOTTE NC 28262 INSURANCE PAYMENTS 1650168 BLUE CROSS BLUE SHIELD PO BOX 580017 CHARLOTTE NC 28258 INSURANCE 1120832 CAROLINAS HEALTHCARE SYSTEMS PO BOX 32861 CHARLOTTE NC 28232 MEDICAL SUPPLIES 503610 MORRISON MANAGEMENT 5801 PEACHTREE DUNWOODY RD NE ATLANTA GA 30368 FOOD SERVICE 436019 15 PATIENT REVENUE 621400 20822254 20822254 20822254 768912 768912 27789 27789 27789 21618955 20822254 0 796701 X 6824157 5225791 1598366 2135401 2033537 101864 610412 610412 281520 281520 223747 223747 48045 48045 3728533 3641879 86654 85093 81869 3224 73471 2906 70565 13938 13938 714998 673157 41841 84916 54706 30210 15402 15402 887 887 200957 200957 180215 180215 PATIENT CARE SUPPLIES 2637555 2637555 BAD DEBT EXPENSE 532822 532822 PATIENT CARE EQUIPMENT 247051 247051 406447 2168 404279 19045567 15514613 3530954 0 3227122 3300008 2921166 3403198 18077 23184 71186 205873 2638060 1434847 854519 1203213 12277199 13529192 871275 1202551 20240544 22867219 1694499 1538575 754068 753622 2448567 2292197 X 17791977 20575022 17791977 20575022 20240544 22867219 2573388 209657 0 X X 0 1 X 1 0 X 1 EXPLANATION OF LOBBYING ACTIVITIES: PART II-B, LINE 1: NONDEDUCTIBLE ASSOCIATION DUES 53812 46977 6835 1601755 914069 687686 982493 473801 508692 1203213 OTHER RECEIVABLES 386922 INVESTMENT IN JOINT VENTURE 760250 OTHER ASSETS 55379 1202551 THIRD PARTY RESERVE 753622 753622 X 21086133 0 21086133 532822 532822 21618955 18512745 0 18512745 532822 532822 19045567 DESCRIPTION OF UNCERTAIN TAX POSITIONS UNDER FIN 48: PART X, LINE 2: THE HOSPITAL IS A NOT-FOR-PROFIT CORPORATION AS DESCRIBED IN SECTION 501(C)(3) OF THE INTERNAL REVENUE CODE WITH EXEMPTION FROM FEDERAL INCOME TAXES ON RELATED INCOME PURSUANT TO SECTION 501(A) OF THE CODE. THE HOSPITAL'S INCOME TAX RETURNS ARE SUBJECT TO REVIEW AND EXAMINATION BY FEDERAL, STATE, AND LOCAL AUTHORITIES. MANAGEMENT IS NOT AWARE OF ANY ACTIVITIES THAT WOULD JEOPARDIZE THEIR TAX-EXEMPT STATUS. MANAGEMENT IS NOT AWARE OF ANY SIGNIFICANT ACTIVITIES THAT ARE SUBJECT TO TAX ON UNRELATED BUSINESS INCOME OR EXCISE OR OTHER TAXES. PART XI, LINE 4B - OTHER ADJUSTMENTS: PROVISION FOR DOUBTFUL ACCOUNTS (SHOWN AS EXPENSES ON 990) 532,822. PART XII, LINE 4B - OTHER ADJUSTMENTS: PROVISION FOR DOUBTFUL ACCOUNTS (SHOWN AS EXPENSES ON 990) 532,822. 1 1 1 X 1 X 0 1 0 0 162978 162978 0.00860 298882 129539 169343 0.00890 461860 129539 332321 0.01750 461860 129539 332321 0.01750 1 133259 15045770 12911400 2134370 X 1 0 1 ACUITY HEALTHCARE LP HOSPITAL MANAGEMENT 0.00000 0.00000 0.00000 1 1 MERCY RESTORATIVE CARE INC

10648 PARK ROAD CHARLOTTE NC 28210

X X MERCY RESTORATIVE CARE INC 1 1 X X X X X X 12 1 1 1 X X X X X X X 0 0 1 1 200.000000000000 0 0 1 1 X X 1 X X X X X 1 X X 0 X X X 0 0 PART I, LINE 3C: MERCY RESTORATIVE CARE HOSPITAL, INC. ("THE HOSPITAL") BUDGETS AMOUNTS FOR AND PROVIDES FREE OR DISCOUNTED CARE TO MEDICALLY INDIGENT IN ACCORDANCE WITH THE HOSPITAL'S FINANCIAL ASSISTANCE POLICY. THE GUIDLINE OF 200% OF FEDERAL POVERTY LEVEL IS USED, BASED UPON INCOME PROVIDED BY THE PATIENT ON THE FINANCIAL APPLICATION TO DETERMINE ELIGIBILITY. PROOF OF INCOME IS REQUIRED OF PATIENTS: W-2, COPIES OF PAYROLL CHECKS, TAX RETURNS, AND/OR BANK STATEMENTS, IF AVAILABLE. PART I, LINE 7G: ACUITY HEALTHCARE, LP. (THE MANAGEMENT COMPANY) PERFORMS SERVICES THEN BILLS THE HOSPITAL ACCORDINGLY. PART I, L7 COL(F): THE HOSPITAL DOES NOT HAVE A PROCESS FOR ESTIMATING THAT AMOUNT OF BAD DEBT EXPENSE ATTRIBUTABLE TO PATIENTS ELIGIBLE UNDER THE HOSPITAL'S CHARITY CARE POLICY. CHARITY DISCOUNTS ARE ADJUSTED OFF AND NOT INCLUDED IN BAD DEBTS. ANY PAYMENTS RECEIVED ARE NOT INCLUDED IN BAD DEBT EXPENSE ON ANY PATIENT. PART II: THE HOSPITAL DOES NOT ENGAGE IN ANY COMMUNITY BUILDING ACTIVITES DUE TO THE NATURE OF ITS EXISTENCE. PART III, LINE 4: THE HOSPITAL PROVIDES AN ALLOWANCE FOR DOUBTFUL ACCOUNTS USING MANAGEMENT'S JUDGMENT AND HISTORICAL EXPERIENCE. PATIENTS ARE NOT REQUIRED TO PROVIDE COLLATERAL FOR SERVICES RENDERED. PAYMENT FOR SERVICES IS GENERALLY REQUIRED WITHIN 30 DAYS RECEIPT OF INVOICE OR CLAIM SUBMITTED. SELF-PAY ACCOUNT BALANCES PAST DUE MORE THAN 180 DAYS ARE CLASSIFIED AS UNCOLLECTIBLE. FEDERAL REGULATIONS REQUIRE A 120-DAY PERIOD OF COLLECTION EFFORTS ON MEDICARE ACCOUNTS BEFORE BEING CLASSIFIED AS UNCOLLECTIBLE. IN ADDITION, AN ALLOWANCE IS ESTIMATED FOR OTHER ACCOUNTS RECEIVABLE BASED ON HISTORICAL EXPERIENCE OF THE HOSPITAL. AT JULY 31, 2013 AND 2012, THE ALLOWANCE FOR DOUBTFUL ACCOUNTS WAS APPROXIMATELY $253,000 AND $663,000, RESPECTIVELY. PART III, LINE 8: MEDICARE INPATIENT ACUTE-CARE SERVICES PROVIDED BY THE HOSPITAL ARE PAID AT PROSPECTIVELY DETERMINED RATES PER DISCHARGE BASED PRIMARILY ON THE PATIENT'S DIAGNOSIS AND MARKET AREA WAGES. MEDICARE PAYS FOR THE OPERATING AND CAPITAL COSTS ASSOCIATED WITH HOSPITAL INPATIENT STAYS IN LONG TERM CARE HOSPITALS. PATIENTS MUST HAVE AN AVERAGE MEDICARE LENGTH OF STAY GREATER THAN 25 DAYS. PART III, LINE 9B: THE HOSPITAL DOES NOT PURSUE COLLECTIONS FROM PATIENTS THAT ARE ELIGIBLE FOR FINANCIAL ASSISTANCE. MERCY RESTORATIVE CARE, INC. PART V, SECTION B, LINE 3: THE HOSPITAL RELIED HEAVILIY ON THE WORK PERFORMED BY THE MECKLENBURG COUNTY HEALTH DEPARTMENT IN COMPILING INFORMATION FOR THE CHNA. THE COUNTY DEVELOPED A HEALTH OPINION SURVEY FOR MECKLENBURG COUNTY RESIDENTS. THE SURVEY WAS OFFERED IN ENGLISH AND SPANISH AND WAS MADE AVAILABLE ONLINE THROUGH SURVEY MONKEY. THE COUNTY ALSO PROVIDED PAPER COPIES IN ENGLISH AND SPANISH TO THOSE THAT COULD NOT ACCESS THE ONLINE VERSIONS. LINKS TO THE ONLINE SURVEY WERE SENT VIA EMAIL TO EOMPLOYEES OF THE TOP 5 EMPLOYERS IN MECKLENBURG COUNTY, ELECTED OFFICIALS, HEADS OF NEIGHBORHOOD ASSOCIATIONS AND THROUGH OTHER VARIOUS CONTACT LISTS. ALL RECIPIENTS WERE ENCOURAGED TO SHARE THE LINK AMONG THEIR OWN CONTACTS. PATER COPIES WERE DELIVERED TO ELEVEN LOCAL LIBRARIES RESPRESENTING ALL GEOGRAPHIC ARES OF THE COUNTY. FINALLY THERE WAS ALSO TARGETED DISTRIBUTION OF PAPER COPIES TO REACH SPECIFIC POPULATIONS, SUCH AS SENIOR CENTERS, SAFETY-NET CLINICS, HOMELESS SHELTERS, HEALTH EDUCATION CLASS FOR LATINAS, AN AFRICAN AMERICAN MALE YOUTH GROUP, AND AN ORGANIZATION THAT WORKS WITH INCARCERATED INDIVIDUALS. MERCY RESTORATIVE CARE, INC. PART V, SECTION B, LINE 4: NOVANT HEALTHCARE, CAROLINAS HEALTHCARE SYSTEM MERCY RESTORATIVE CARE, INC. PART V, SECTION B, LINE 7: BEING A SMALL SPECIALIZED ORGANIZATION, THE HOSPITAL HAS LIMITED RESOURCES TO ADDRESS THE MANY SIGNIFICANT NEEDS OF OUR COMMUNITY. AS SUCH, THE HOSPITAL IDENTIFIED CERTAIN NEEDS THAT IT BELIEVED IT COULD MOST GREATLY IMPACT OVER THE COMING YEARS. THOSE NEEDS INCLUDE CHRONIC DISEASE PREVENTION AND ACCESS TO CARE. MERCY RESTORATIVE CARE, INC. PART V, SECTION B, LINE 10: THE HOSPITAL DOES NOT OFFER DISCOUNTED CARE; INSTEAD, THE HOSPITAL OFFERS CHARITY CARE TO ALL PATIENTS WHO ARE ELIGIBLE TO PARTICIPATE. FOR THOSE THAT DO NOT HAVE INSURANCE, OR ARE NOT ELIGIBLE FOR MEDICARE OR MEDICAID, THE HOSPITAL'S CHARITY CARE POLICY STATES THAT THE HOSPITAL WILL PROVIDE THOSE INDIVIDUALS WITH UNCOMPENSATED CARE (CONSISTENT WITH THE HOSPITAL'S RESOURCES). PATIENTS WHO ARE DEEMED ELIGIBLE UNDER THE HOSPITAL'S GUIDELINES TO RECEIVE UNCOMPENSATED CARE MAY APPLY FOR RELIEF FROM RESPONSIBILITY FOR ALL OR A PORTION OF THE AMOUNT THEY OWE FOR SERVICES RENDERED BY THE HOSPITAL. MERCY RESTORATIVE CARE, INC. PART V, SECTION B, LINE 16E: DEFAULT JUDGEMENT ON PATIENT THAT RECEIVED INSURANCE FUNDS FOR HOSPITAL SERVICES AND WOULD NOT PAY THE HOSPITAL MERCY RESTORATIVE CARE, INC. PART V, SECTION B, LINE 17E: DEFAULT JUDGEMENT ON PATIENT THAT RECEIVED INSURANCE FUNDS FOR HOSPITAL SERVICES AND WOULD NOT PAY THE HOSPITAL MERCY RESTORATIVE CARE, INC. PART V, SECTION B, LINE 18E: PATIENT RECEIVED INSURANCE FUNDS AND WAS NOT ELIGIBLE FOR FINANCIAL ASSISTANCE MERCY RESTORATIVE CARE, INC. PART V, SECTION B, LINE 19C: THE HOSPITAL DOES NOT HAVE AN EMERGENCY ROOM. MERCY RESTORATIVE CARE, INC. PART V, SECTION B, LINE 20D: THE HOSPITAL DID NOT PROVIDE CARE FOR ANY EMERGENCY MEDICAL CONDITIONS. PART VI, LINE 2: MERCY RESTORATIVE CARE HOSPITAL, INC. D/B/A CAROLINAS SPECIALTY HOSPITAL (THE "HOSPITAL") IS A 40-BED LONG-TERM ACUTE CARE HOSPITAL. THE HOSPITAL WAS INCORPORATED UNDER THE LAWS OF NORTH CAROLINA FOR THE PURPOSE OF PROMOTING AND IMPROVING THE HEALTH STATUS OF THE COMMUNITY BY DEVELOPING AND PROVIDING LONG-TERM ACUTE CARE SERVICES FOR THE BENEFIT OF CITIZENS OF MECKLENBURG AND SURROUNDING COUNTIES. THE HOSPITAL BEGAN OPERATIONS IN JANUARY 2003. PART VI, LINE 3: THE HOSPITAL HAS A CHARITY CARE PROGRAM FOR THOSE WHO QUALIFY BASED ON INCOME STANDARDS. THE HOSPITAL PROVIDES FINANCIAL ASSISTANCE APPLICATIONS. CHARITY CARE POLICY IS AVAILABLE ON WEB SITE. PART VI, LINE 4: THE HOSPITAL PROVIDES SERVICES PRIMARILY TO THE RESIDENTS OF MECKLENBURG COUNTY, NORTH CAROLINA AND SURROUNDING COUNTIES, WITHOUT COLLATERAL OR OTHER PROOF OF ABILITY TO PAY. PART VI, LINE 5: THE HOSPITAL SPONSORED A HEALTHCARE CONVENTION. PART VI, LINE 6: THE HOSPITAL IS HOUSED IN ANOTHER HOSPITAL BUT ARE SEPARATE FOR PURPOSES OF SPONSORSHIP AND COMMUNITY RELATED HEALTHCARE EVENTS. X 0 0 0 0 0 0 0 0 0 HAJRUDIN BEGIC 133713 0 1160 0 1464 0 3686 0 13430 0 153453 0 0 0 FORM 990, PART VI, SECTION A, LINE 3 THE CEO AND CFO ARE EMPLOYED THROUGH A MANAGEMENT CONTRACT WITH ACUITY HEALTHCARE, LP. AS SUCH, THEIR COMPENSATION INFORMATION IS NOT REQUIRED ON PART VII. FORM 990, PART VI, SECTION B, LINE 11 A COPY OF FORM 990 WAS PROVIDED TO THE BOARD BY E-MAIL. MANAGEMENT PERFORMED A COMPLETE REVIEW. FORM 990, PART VI, SECTION B, LINE 12C IF A BOARD MEMBER IS FOUND TO HAVE A CONFLICT, THEY ABSTAIN FROM THE VOTING PROCESS. FORM 990, PART VI, SECTION B, LINE 15 A CONFLICT-FREE BOARD DETERMINES APPROPRIATE COMPENSATION, RELYING ON COMPARABLE INFORMATION. BOARD REVIEWS AND DECIDES CEO ANNUAL COMPENSATION THROUGH CLOSED BOARD SESSION. ONE BOARD MEMBER IS AN HR RESPRESENTATIVE AND PARTICIPATES IN DISCUSSIONS. FORM 990, PART VI, SECTION C, LINE 19 GOVERNING DOCUMENTS AND FINANCIAL STATEMENTS ARE NOT AVAILABLE TO THE PUBLIC. OTHER FEES FORM 990, PART IX, LINE 11G PURCHASED SERVICES: PROGRAM SERVICE EXPENSES 3,641,879. MANAGEMENT AND GENERAL EXPENSES 86,654. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 3,728,533. 990, PART XII, LINE 2C NO CHANGE IN METHOD FROM PRIOR YEAR.