2014-08-13T15:02:03-05:00 2013-09-30 410746749 CLIFTONLARSONALLEN LLP 101 N TRYON STREET SUITE 1000 CHARLOTTE NC 28246 990 2012-10-01 560554202 CALDWELL MEMORIAL HOSPITAL CALD 8287575100 321 MULBERRY STREET SW LENOIR NC 28645 STEPHEN RINALDI 8287575100 2014-08-13 1 JOHN NORMAN P01506766 7049985200 2012 2015-11-30 17:44:51Z LAURA J EASTON 321 MULBERRY STREET SW LENOIR NC 28645 120451103 0 X WWW.CALDWELLMEMORIAL.ORG X 1945 NC TO PROMOTE SAFE, EFFECTIVE, COMPASSIONATE MEDICAL CARE AND TO PROMOTE HEALTHY LIFESTYLES FOR OUR COMMUNITY. 12 11 964 120 1085240 0 587466 8575609 108113225 110959625 315196 172828 2770840 743041 111786727 120451103 0 0 0 0 48010542 52740572 0 0 0 61584350 63856297 109594892 116596869 2191835 3854234 55838070 60534899 22891891 24914453 32946179 35620446 X TO PROMOTE SAFE, EFFECTIVE, COMPASSIONATE MEDICAL CARE AND TO PROMOTE HEALTHY LIFESTYLES FOR OUR COMMUNITY. 0 0 97461798 108329125 SINCE OPENING IN 1951, CALDWELL MEMORIAL HOSPITAL HAS CONTINUED TO GROW AND CHANGE IN ORDER TO BETTER MEET THE NEEDS OF OUR COMMUNITY. THE MISSION OF CALDWELL MEMORIAL HOSPITAL IS TO PROVIDE SAFE, EFFECTIVE, COMPASSIONATE CARE AND TO PROMOTE HEALTHY LIFESTYLES TO OUR COMMUNITY. ANCHORED BY A 110-BED ACUTE CARE FACILITY, CALDWELL MEMORIAL HOSPITAL'S SERVICES INCLUDE A VAST ARRAY OF MEDICAL AND SURGICAL SERVICES. AMONG SERVICES OFFERED, BUT BY NO MEANS A COMPLETE LIST, ARE CAROTID ARTERY STENTING; CARDIOVASCULAR AND ENDOVASCULAR CARE; RADIATION ONCOLOGY; COMPUTER-ASSISTED ORTHOPEDIC SURGERY; NEUROLOGY AND MEMORY CARE; PAIN MANAGEMENT; A FULLY STAFFED 24-HOUR EMERGENCY DEPARTMENT; CALDWELL PHYSICIANS CLINICS CONVENIENTLY LOCATED COUNTY-WIDE; DIAGNOSTIC SERVICES; OUTPATIENT SURGERY; PLUS URGENT CARE; AND THE QUEST 4 LIFE WELLNESS CENTER. MULTIPLE EDUCATIONAL AND COUNSELING PROGRAMS ARE AVAILABLE FOR A WIDE ARRAY OF HEALTHCARE NEEDS INCLUDING CANCER, DIABETES, NUTRITION, JOINT CARE, PRE-NATAL CLASSES AND PARENTING SKILLS. CALDWELL PHYSICIANS IS A DIVISION OF CALDWELL MEMORIAL HOSPITAL. WITH PRACTICES IN COMMUNITIES COUNTYWIDE, CALDWELL PHYSICIANS PROVIDES THE PRIMARY AND SPECIALTY HEALTHCARE, DIAGNOSTICS AND TREATMENTS THAT OUR COMMUNITY NEEDS IN CONVENIENT LOCATIONS NEAR THEIR HOMES. CALDWELL PHYSICIANS INCLUDES: CALDWELL ACUTE CARE SPECIALISTS, EMPLOYER GROUP CLINIC, FALLS MEDICAL PRACTICE, FALLS PEDIATRICS, FALLS PLUS URGENT CARE, HALLMARK FAMILY PRACTICE, LAUREL PARK WOMEN'S CLINIC, MAIN STREET MEDICAL PRACTICE, MCBURNEY PRIMARY CARE, MULBERRY PEDIATRICS, OCCUPATIONAL HEALTH, ROBBINS CARDIOLOGY, ROBBINS PIEDMONT VISTA ENT, ROBBINS FAMILY PRACTICE, ROBBINS INTERNAL MEDICINE, ROBBINS PULMONOLOGY, ROBBINS PLUS URGENT CARE, ROBBINS SURGICAL, SOUTHFORK MEDICAL PRACTICE AND WESTPOINTE MEDICAL PRACTICE. 97461798 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 0 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 1 1 1 0 0 1 129 0 1 964 1 1 1 0 0 0 0 0 0 0 0 0 X 12 11 0 0 0 0 0 0 0 1 1 0 0 1 1 1 1 1 1 1 1 1 1 NC X STEPHEN RINALDI & CHRIS WASHBURN 8287575100 321 MULBERRY STREET SW LENOIR NC 28645 MARK BURREL BATTS MD 1.00 X 0 0 0 GEORGE ALEX BERNHARDT JR 1.00 X 0 0 0 MICHAEL MARK CHAMBERLAIN 1.00 X 0 0 0 RICHARD EUGENE COFFEY 1.00 X 0 0 0 LAURA JEAN EASTON 40.00 X X 280825 0 22140 WILLIAM RUSSELL JOHNSON 1.00 X 0 0 0 JAMES LEE LAYTON 1.00 X 0 0 0 DEBORAH LYN MURRAY 1.00 X 0 0 0 RICHARD EDWARD PEARCE MD 1.00 X 0 0 0 JOHN DAVID POWELL MD 40.00 X 220570 0 18445 PETER NELSON PURCELL MD 1.00 X 0 0 0 GARY EDWIN SHORE 1.00 X 0 0 0 PARKER TREVILIAN WILLIAMSON 1.00 X 0 0 0 BOYD CECIL WILSON JR 1.00 X 0 0 0 DANIEL D MORGAN 40.00 X X 140209 0 12186 DONALD FRANK GARDNER JR 40.00 X X 207417 0 17254 DAVID RAYMOND HORN 40.00 X X 152940 0 14778 REBECCA THOMPSON SMITH 40.00 X X 198464 0 17660 SHARON MARIE KIMBALL 40.00 X X 166395 0 12862 JOHN HOWARD EDMUNDS 40.00 X 455724 0 8828 DAVID A LOWRY 40.00 X 383533 0 14361 PAUL D WARRICK 40.00 X 359953 0 16872 MARK R BRADY 40.00 X 320331 0 11299 RONALD H DUBOW 40.00 X 295753 0 16839 3182114 0 183524 60 0 1 0 CALDWELL FAMILY PHYSICIANS CONNELLY SPRINGS ROAD LENOIR NC 28645 PROFESSIONAL MEDICAL SERVICES 1097650 DLP CARDIAC PARTNERS LLC 3700 ARCO CORPORATE OFFICE SUITE 45 CHARLOTTE NC 28273 CATH LAB PARTNER 757339 KAUFMAN HALL 5202 OLD ORCHARD ROAD SUITE N700 SKOKIE IL 60077 FORECASTING CONSULTANT 457873 TIM BLINSON CONSTRUCTION CO 2377 MILLS COVE PLACE LENOIR NC 28645 MINOR CONSTRUCTION CONTRACTOR 235486 PANDERA SYSTEMS 5325 PRIMROSE LAKE CIRCLE SUITE A TAMPA FL 33647 BUSINESS INTELLIGENCE CONSULTANT 158400 9 1075609 7500000 8575609 PATIENT SERVICES 621500 103755893 103755893 PHARMACY REVENUE 900099 3348616 3348616 QUEST4LIFE WELLNESS CENTER REVENU 713990 821685 821685 LAB SERVICES 621400 754866 679379 75487 JOINT VENTURE INCOME 541900 552929 364861 188068 1725636 1725636 110959625 172828 172828 213480 0 213480 213480 213480 MEANINGFUL USE INCENTIVE 900099 522352 522352 OTHER INCOME 900099 7209 7209 529561 120451103 108362229 1085240 2428025 42731358 36321654 6409704 10009214 8507832 1501382 13722926 8919902 4803024 362260 362260 2352012 2352012 1688065 1688065 168123 100874 67249 548215 548215 4447023 4447023 759050 759050 MEDICAL SUPPLIES 17956472 17956472 BAD DEBT EXPENSE 12128667 12128667 EQUIPMENT RENTALS AND M 7948558 5563991 2384567 STATE INCOME TAXES 1197089 1197089 577837 520053 57784 116596869 97461798 19135071 0 8582 5274917 7054007 12483899 16227879 114361 2833180 2994070 836240 818219 91008703 65114528 23294020 25894175 6534166 6846624 1417966 1289872 1061049 109225 1280518 55838070 60534899 10296354 11435151 88537 11245184 12423455 1261816 1055847 22891891 24914453 X 32946179 35620446 32946179 35620446 55838070 60534899 X 3854234 276846 -1456811 -2 X X 0 1 X 1 0 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 0 0 0 0 0 0 0 0 1 14193 14193 0 EXPLANATION OF LOBBYING ACTIVITIES: PART II-B, LINE 1: ANNUAL DUES WERE PAID TO THE NORTH CAROLINA HOSPITAL ASSOCIATION AND THE AMERICAN HOSPITAL ASSOCIATION, OF WHICH $14,193 WAS ESTIMATED TO BE EXPENDITURES USED IN LOBBYING ACTIVITIES BY THESE ORGANIZATIONS. 1232587 1232587 32537715 28185124 4352591 10419816 1328132 9091684 45798284 35601272 10197012 1020301 1020301 25894175 ESTIMATED THIRD PARTY SETTLEMENTS 364697 DEFERRED FEE PLAN LIABILITY 691150 1055847 X DESCRIPTION OF UNCERTAIN TAX POSITIONS UNDER FIN 48: PART X, LINE 2: THE HOSPITAL IS A NOT-FOR-PROFIT CORPORATION AND HAS BEEN RECOGNIZED AS TAX-EXEMPT, PURSUANT TO SECTION 501(C)(3) OF THE INTERNAL REVENUE CODE. NO PROVISION FOR INCOME TAXES HAS BEEN MADE IN THE ACCOMPANYING FINANCIAL STATEMENTS. THE HOSPITAL HAS DETERMINED THAT THEY DO NOT HAVE ANY MATERIAL UNRECOGNIZED TAX BENEFITS OR OBLIGATIONS AS OF SEPTEMBER 30, 2013. FISCAL YEARS ENDING ON OR AFTER SEPTEMBER 30, 2010 REMAIN SUBJECT TO EXAMINATION BY FEDERAL AND STATE TAX AUTHORITIES. 1 1 1 X 1 X 225.000000000000 1 1 0 1 1 15420285 6178364 9241921 0.08900 1379020 533302 845718 0.00810 16799305 6711666 10087639 0.09710 122378 122378 0.00120 552221 552221 0.00530 674599 674599 0.00650 17473904 6711666 10762238 0.10360 1 4938708 2874000 25883015 28643963 -2760948 X 1 1 1 1 CALDWELL MEMORIAL HOSPITAL

321 MULBERRY STREET SW PO BOX 1890 LENOIR NC 28645

X X X DISPROPORTIONATE SHARE HOSPITAL CALDWELL MEMORIAL HOSPITAL 1 1 X X X X X X X X 11 0 0 1 X X X X X X X X 1 0 1 1 150.000000000000 1 225.000000000000 1 X 1 1 X X X X X X 1 0 1 X 0 0 PART I, L7 COL(F): UNCOLLECTIBLE ACCOUNTS - THE HOSPITAL HAS PROVIDED SERVICES TO PERSONS WHO HAVE NOT PAID FOR SUCH SERVICES EITHER BECAUSE THEY HAVE BEEN UNWILLING OR UNABLE TO PAY. EFFORTS ARE MADE BY THE HOSPITAL TO DETERMINE IF A PATIENT MEETS CHARITY POLICY GUIDELINES THAT ARE ESTABLISHED BY THE HOSPITAL. IF THESE GUIDELINES ARE MET AND CAN BE VERIFIED, THEN SUCH AMOUNTS ARE INCLUDED IN CHARITY CARE. UNTIL SUCH TIME, SUCH AMOUNTS ARE COMBINED IN THE PROVISION FOR UNCOLLECTIBLE ACCOUNTS BECAUSE THEY HAVE NOT BEEN VERIFIED OR DOCUMENTED AS CHARITY CARE DUE TO LACK OF SUPPORTING FINANCIAL INFORMATION. IN SOME CASES, PATIENTS WHO WOULD (OR COULD) QUALIFY FOR CHARITY CARE ARE UNWILLING OR UNABLE TO PRODUCE THE NECESSARY INFORMATION TO SUBSTANTIATE THEIR QUALIFICATION. THUS, THE PROVISION FOR UNCOLLECTIBLE ACCOUNTS INCLUDE AMOUNTS THAT WOULD OTHEWISE QUALIFY FOR CHARITY CARE UNDER THE HOSPITAL'S GUIDELINES.THE ESTIMATED COST OF UNREIMBURSED SERVICES ATTRIBUTABLE TO THE PROVISION FOR UNCOLLECTIBLE ACCOUNTS - EFFECTIVELY "FREE" SERVICES PROVIDED TO PATIENTS - HAS BEEN DETERMINED BY APPLYING A COST TO CHARGE RATIO TO THE AMOUNT OF THE PROVISION FOR UNCOLLECTIBLE ACCOUNTS. PART III, LINE 9B: THE HOSPITAL DOES NOT SUBJECT ANY PATIENTS TO A COLLECTION AGENCY WHO HAS QUALIFIED FOR FINANCIAL ASSISTANCE GUIDELINES. CALDWELL MEMORIAL HOSPITAL PART V, SECTION B, LINE 3: ANALYSIS OF INFORMATION REGARDING HEALTH STATUS, RISK FACTORS, ACCESS TO CARE AND COMMUNITY ASSETS/RESOURCES WAS COMPLETED. PRIMARY DATA WAS COLLECTED USING A TWO-STAGE CLUSTER SAMPLING SYSTEM TO IDENTIFY SEVEN (7) INTERVIEW SITES. TWO (2) PERSON TEAMS THEN CONDUCTED SITE SURVEYS/INTERVIEWS IN THE SEVEN LOCATIONS INCLUDING DEMOGRAPHICS (RACE, EDUCATION, INCOME, EMPLOYMENT LEVEL) QUALITY OF LIFE, COMMUNITY IMPROVEMENT, HEALTH INFORMATION, PERSONAL HEALTH, ACCESS TO CARE AND EMERGENCY PREPAREDNESS. OVER 200 SURVEYS WERE COLLECTED. OTHER DATA USED IN ANALYZING THE COMMUNITY NEEDS INCLUDED NORTH CAROLINA STATE CENTER FOR HEALTH STATISTICS, U.S. CENSUS BUREAU, U. S. ENVIRONMENTAL PROTECTION AGENCY, NORTH CAROLINA DEPARTMENT OF LABOR AND NORTH CAROLINA PUBLIC HEALTH. INFORMATION FROM VARIOUS LOCAL EDUCATION, LAW ENFORCEMENT AND SOCIAL SERVICE AGENCIES WAS ALSO INCLUDED IN ANALYSIS. CALDWELL MEMORIAL HOSPITAL PART V, SECTION B, LINE 5C: PRESENTED AT THE COUNTY BOARD OF HEALTH MEETING, PUBLIC FORUM PART VI, LINE 2: IN COLLABORATION WITH THE CALDWELL COUNTY HEALTH DEPARTMENT AND OTHER COMMUNITY AGENCIES (SCHOOL SYSTEM, SOCIAL SERVICES, TOWNSHIPS/MUNICIPALITIES AND UNINSURED CLINIC) CALDWELL MEMORIAL HOSPITAL COMPLETED A FORMAL 2011-2014 COMMUNITY HEALTH NEEDS ASSESSMENT (CHNA). IT HAD BEEN OVER FIVE YEARS SINCE A COMMUNITY HEALTH ASSESSMENT HAD BEEN COMPLETED, THOUGH MANY EFFORTS FOCUSED ON THE HEALTH OF COMMUNITY HAD BEEN ONGOING. COMMUNITY SURVEYS (FACE TO FACE SURVEYS WITH RESIDENTS) WERE CONDUCTED IN AREAS OF THE COUNTY IDENTIFIED USING A TWO CLUSTER SAMPLING METHOD. OTHER DATA USED IN ANALYZING THE COMMUNITY NEEDS INCLUDED NORTH CAROLINA STATE CENTER FOR HEALTH STATISTICS, U.S. CENSUS BUREAU, U. S. ENVIRONMENTAL PROTECTION AGENCY, NORTH CAROLINA DEPARTMENT OF LABOR AND NORTH CAROLINA PUBLIC HEALTH. INFORMATION FROM VARIOUS LOCAL EDUCATION, LAW ENFORCEMENT AND SOCIAL SERVICE AGENCIES WAS ALSO INCLUDED IN ANALYSIS. THE NORTH CAROLINA HEALTHY PEOPLE 20/20 OBJECTIVES WERE ALSO PART OF THE ANALYSIS. ONGOING FEEDBACK FROM THE COMMUNITY AND OTHER HEALTH CARE AGENCIES (MENTAL HEALTH SERVICES, SCHOOL SYSTEM, SOCIAL SERVICE AGENCIES, HEALTH CARE CLINICS AND ECONONIC DEVELOPMENT GROUPS WAS ALSO CONSIDERED IN THE DEVELOPMENT OF COMMUNITY PLANS. A COMMUNITY ADVISORY GROUP (COMPRISED OF AGENCIES NOTED ABOVE AND COMMUNITY MEMBERS) REVIEWED DATA AND IDENTIFED THREE HEALTH OBJECTIVES FOR THE COUNTY BOARD OF HEALTH; SUBSTANCE ABUSE, TEEN PREGNANCY, AND HIGH SCHOOL DROP OUT RATE. IT WAS FELT THAT EACH OF THESE DIRECTLY CONTRIBUTE TO THE HEALTH OF OUR RESIDENTS.IN ADDITION TO THE NOTED THREE OBJECTIVES CMH HAS ADOPTED OTHER AREAS OF FOCUS FOR THE HEALTH OF OUR COMMUNITY. THESE INCLUDE HEALTHY LIVING (EXERCISE AND NUTRITION), OCCUPATIONAL HEALTH, MENTAL HEALTH AND HEALTH SCREEINGS BASED ON THE DATA COLLECTED IN THE COMMUNITY HEALTH ASSESSMENT. PART VI, LINE 3: CALDWELL MEMORIAL HOSPITAL (CMH) PROVIDES NEEDED HEALTHCARE SERVICES TO ANYONE REGARDLESS OF THAT PERSON'S ABILITY TO PAY. CMH'S CHARITY CARE POLICY IS DESIGNED TO ASSIST PATIENTS WHO ARE FINANCIALLY UNABLE TO PAY FOR HEALTHCARE SERVICES. THE POLICY CAN BE FOUND ON THE CMH PUBLIC WEBSITE. CMH DISPLAYS INFORMATION REGARDING THE AVAILABILITY OF FINANCIAL ASSISTANCE AND CHARITY CARE IN ITS EMERGENCY ROOM, REGISTRATION AREAS IN THE HOSPITAL AND CLINICS, FINANCIAL COUNSELOR OFFICES. A LINK IS ALSO PROVIDED ON THE HOSPITAL'S WEBSITE TO THE AVAILABILITY OF FINANCIAL ASSISTANCE AND ITS CHARITY CARE POLICY, ALONG WITH AN ON-LINE APPLICATION. INPATIENT CASE MANAGERS ALSO PROVIDE INFORMATION TO THE PATIENTS REGARDING AVAILABLE PROGRAMS AND THE ORGANIZAITONS FINANCIAL POLICY. CONSULTATION WITH FINANCIAL COUNSELORS IS ALSO AVAILABLE TO ALL PATIENTS AS NEEDED. PART VI, LINE 4: THE PRIMARY SERVICE AREA FOR CALDWELL MEMORIAL HOPSITAL IS CALDWELL COUNTY WITH A LIMITED NUMBER OF PATIENTS FROM THE SURROUNDING COUNTIES OF BURKE, WATAUGA AND CATAWBA. CALDWELL COUNTY IS IN THE NORTHWEST SECTION OF NORTH CAROLINA IN THE FOOTHILLS OF THE BLUE RIDGE MOUNTAINS AND IS BOUNDED ON THE NORTHWEST BY WATAUGA COUNTY, ON THE NORTHEAST BY WILKES COUNTY, ON THE EAST BY ALEXANDER COUNTY, ON THE SOUTH BY CATAWBA AND BURKE COUNTIES AND ON THE WEST BY BURKE AND AVERY COUNTIES.T. TODAY, THERE ARE NINE INCORPORATED MUNICIPALITIES IN THE COUNTY: LENOIR, HUDSON, GRANITE FALLS, CEDAR ROCK, CAJAHS MOUNTAIN, GAMEWELL, SAWMILLS AND PARTS OF BLOWING ROCK AND RHODHISS. POPULATION IS JUST OVER 80, 000. MEDIAN INCOME IS $36, 936. POPULATION MAKEUP IS 92.2% WHITE, 5.2% BLACK, 4.7% HISPANIC AND 2.6% OTHER. MEDIAN AGE IS 37.5 YEARS. 49.4% ARE MALES AND 50.6% FEMALES. UNEMPLOYEMENT IN 10.2012 WAS 10.2%. PART VI, LINE 5: CALDWELL MEMORIAL HOSPITAL PROVIDES FINANCIAL SUPPORT TO TWO COMMUNITY AGENCIES. THE HELPING HANDS CLINIC (PROVIDING CARE TO THE UNINSURED) AND THE SATIE AND J. E. BROYHILL CALDWELL SENIOR CENTER (FOCUS ON THE LIVES AND ADVOCACY FOR SENIORS). OTHER COMMUNITY INVOLVEMENT INCLUDES BUT IS NOT LIMITED TO: 1. ANNUAL PROSTATE SCREENING FOR CALDWELL COUNTY RESIDENTS (AVERAGING 100+ MEN SCREENED ANNUALLY)2. HEALTH FAIRS THROUGHOUT THE YEAR FOCUSING ON WELLNESS, HEALTH EATING, GETTING FIT, SCREENINGS FOR CHOLESTEROL, HYPERTENSION, DIABETES, ETC. 3. SUPPORT AND INVOLVEMENT IN THE CALDWELL COMMUNITY GARDENS WHICH HELPS FOSTER COMMUNITY GARDENING IN CALDWELL COUNTY, NC AS A STRATEGY TO HELP OUR COMMUNITY EAT SMART BY INCREASING AFFORDABLE ACCESS TO HEALTHY FOODS AND SUSTAINABILITY 4. REPRESENTATION BY ORGANIZATION REPRESENTATIVES ON LOCAL HEALTH CARE RELATED BOARDS (CC BOARD OF HEALTH, CC HOSPICE AND PALLIATIVE CARE, CC CHILD PROTECTION TEAM)5. ESTABLISHMENT OF CALDWELL COUNTY MENTAL HEALTH WORK GROUP. MEMBERSHIP INCLUDES CMH, LOCAL LME, MOBILE CRISIS AND LAW ENFORCEMENT AGENCIES WORKING TOWARDS IMPROVING MENTAL HEALTH CARE IN CALDWELL COUNTY 6. ESTABLISHMENT OF CALDWELL MEMORIAL HEALTHWORKS WHICH IS OCCUPATIONAL, INDUSTRIAL, AND WORKER'S COMPENSATION MEDICINE DESIGNED TO ASSIST EMPLOYERS TOWARD THESE TRIPLE AIM GOALS OF IMPROVING THE QUALITY OF HEALTHCARE, ACCESS TO HEALTHCARE AND PATIENT SATISFACTION. PART VI, LINE 6: CALDWELL MEMORIAL HOSPITAL, INC. IS A PRIVATE, NOT-FOR-PROFIT HEALTH CARE ORGANIZATION LOCATED IN LENOIR, NORTH CAROLINA. CALDWELL BECAME A MEMBER OF THE UNIVERSITY OF NORTH CAROLINA HEALTH CARE SYSTEM ON MAY 1, 2013. PRIOR TO MAY 1, 2013, CALDWELL WAS AN INDEPENDENT, PRIVATE, NOT-FOR-PROFIT AND UNAFFILIATED HEALTH ORGANIZATION. CALDWELL HAS A 62 YEAR HISTORY OF PROVIDING EXCELLENT HEALTH SERVICES TO THE RESIDENTS AND VISITORS OF CALDWELL AND SURROUNDING COUNTIES. CALDWELL PROVIDES COMPREHENSIVE CARE AND SERVICES AT A NUMBER OF DIFFERENT LOCATIONS IN CALDWELL COUNTY. THESE INCLUDE:1. THE MAIN CAMPUS WHICH INCLUDES A 110 BED ACUTE CARE HOSPITAL, OUTPATIENT DIAGNOSTIC SERVICES, EMERGENCY ROOM AND INPATIENT AND OUTPATIENT SURGICAL SERVICES. 2. THE HANCOCK SURGERY CENTER INCORPORATING OUTPATIENT SURGERY AND PAIN MANAGEMENT. ADJACENT IS THE CENTER FOR BREAST HEALTH AND THE AMBULATORY INFUSION CENTER.3. THE QUEST4LIFE WELLNESS CENTER IS A STATE OF THE ART FITNESS CENTER OPEN TO THE PUBLIC ON A MEMBERSHIP BASIS. IN ADDITION, OUTPATIENT THERAPY SERVICES ARE HOUSED ADJACENT TO THE QUEST4LIFE, AS IS THE CENTER FOR DIABETES HEALTH.4. THE MCCREARY CANCER CENTER HOUSING MEDICAL AND RADIATION ONCOLOGIC SERVICES AND CT SCAN. 5. A MULTI-SPECIALTY GROUP PRACTICE (CALDWELL PHYSICIAN NETWORK CPN) CONSISTING OF APPROXIMATELY 55 PROVIDERS (PHYSICIANS AND MID-LEVEL PROVIDERS) LOCATED IN EIGHT LOCATIONS THROUGHOUT CALDWELL COUNTY. SERVICES INCLUDE GENERAL AND FAMILY PRACTICE, INTERNAL MEDICINE, PEDIATRICS, OBSTETRICS AND GYNECOLOGY, CARDIOLOGY, PULMONOLOGY, GASTROENTEROLOGY, GENERAL SURGERY, URGENT CARE AND DIAGNOSTIC SERVICES. REPORTS FILED WITH STATES PART VI, LINE 7 NC 1 X X X X X 0 1 0 1 0 0 0 0 0 LAURA JEAN EASTON 224353 0 56472 0 0 0 13312 0 8828 0 302965 0 0 0 JOHN DAVID POWELL MD 220570 0 0 0 0 0 9617 0 8828 0 239015 0 0 0 DANIEL D MORGAN 116487 0 23722 0 0 0 3358 0 8828 0 152395 0 0 0 DONALD FRANK GARDNER JR 164798 0 42619 0 0 0 8426 0 8828 0 224671 0 0 0 DAVID RAYMOND HORN 123760 0 29180 0 0 0 5950 0 8828 0 167718 0 0 0 REBECCA THOMPSON SMITH 160750 0 37714 0 0 0 8832 0 8828 0 216124 0 0 0 SHARON MARIE KIMBALL 134290 0 32105 0 0 0 4034 0 8828 0 179257 0 0 0 JOHN HOWARD EDMUNDS 455724 0 0 0 0 0 0 0 8828 0 464552 0 0 0 DAVID A LOWRY 383533 0 0 0 0 0 5533 0 8828 0 397894 0 0 0 PAUL D WARRICK 359953 0 0 0 0 0 8044 0 8828 0 376825 0 0 0 MARK R BRADY 320331 0 0 0 0 0 2471 0 8828 0 331630 0 0 0 RONALD H DUBOW 295753 0 0 0 0 0 8011 0 8828 0 312592 0 0 0 PART I, LINE 4B LAURA EASTON (CEO) HAS A SECURED BENEFIT PLAN WHICH IS INCLUDED IN THE STUDY COMPLETED BY THE INDEPENDENT COMPENSATION CONSULTANT; THE LOAN UNDER THIS ARRANGEMENT IS RECORDED ON THE FINANCIAL STATEMENTS AND FULLY SECURED BY LIFE INSURANCE ON THE LIFE OF THE CEO. PART I, LINE 5 SENIOR MANAGEMENT HAS AN INCENTIVE PROGRAM WHICH IS PARTIALLY EARNED BASED ON PROFIT MARGIN AND DAYS CASH ON HAND. THE EARNED INCENTIVE IS REVIEWED BY THE HR COMMITTEE OF THE BOARD AND APPROVED ANNUALLY; EMPLOYED PHYSICIANS ARE PAID ON A PRODUCTIVITY BASIS BASED ON RVU'S GENERATED IN THEIR PRACTICE OPERATIONS. THESE ARE TIED TO MGMA BENCHMARKS. SUPPLEMENTAL INFORMATION PART III SCHEDULE J, LINE 2: AN EXPENSE REPORT TO INCLUDE RECIEPTS MUST BE SUBMITTED AND AUTHORIZED USING THE AUTHORIZATION MATRIX. FORM 990, PART VI, SECTION A, LINE 1 THE EXECUTIVE/FINANCE COMMITTEE SHALL HAVE THE POWER TO TRANSACT ALL REGULAR BUSINESS OF THE HOSPITAL DURING THE PERIOD BETWEEN THE MEETINGS OF THE BOARD OF DIRECTORS, SUBJECT TO ANY PRIOR LIMITATION IMPOSED BY THE BOARD OF DIRECTORS. FORM 990, PART VI, SECTION B, LINE 11 THE FORM 990 WAS PREPARED BY AN INDEPENDENT ACCOUNTANT WITH ASSISTANCE AND OVERSIGHT BY MANAGEMENT. THE FULL BOARD RECEIVED A COPY OF THE FORM 990 FOR THEIR REVIEW AND FOR ANY QUESTIONS. THE FULL BOARD VOTED FOR A FINAL APPROVAL OF THE FORM 990. FORM 990, PART VI, SECTION B, LINE 12C THE AUDIT AND COMPLIANCE COMMITTEE OF THE BOARD ANNUALLY REVIEWS THE CONFLICT OF INTEREST STATEMENTS. MINUTES OF BOARD MEETINGS REFLECT ANY DECLARED CONFLICT OF INTEREST. FORM 990, PART VI, SECTION B, LINE 15 THE ORGANIZATION COMPLETES THE REBUTTABLE PRESUMPTION OF REASONABLENESS AS DESCRIBED IN TREASURY REGULATION 4958(6)(C) FOR EACH OFFICER AND KEY EMPLOYEE. THIS PROCESS IS PERFORMED BY AN OUTSIDE INDEPENDENT COMPENSATION SPECIALIST. THE CONSULTANT'S FINDINGS ARE PRESENTED TO THE HR COMMITTEE OF THE BOARD AND ARE ULTIMATELY APPROVED BY THE FULL BOARD. FORM 990, PART VI, SECTION C, LINE 18 PHOTOCOPIES OF THE FORM 990 ARE AVAILABLE UPON REQUEST AT THE ORGANIZATION'S ADMINISTRATIVE OFFICE. IN ADDITION, RECENT FILINGS OF THE FORM 990 ARE AVAILABLE ON GUIDESTAR.ORG. FORM 990, PART VI, SECTION C, LINE 19 THE ORGANIZATION MAKES ITS GOVERNING DOCUMENTS, FINANCIAL STATEMENTS, AND CONFLICT OF INTEREST POLICY AVAILABLE UPON REQUEST. PLEASE USE THE ORGANIZATION'S "CONTACT US" LINK ON ITS WEBSITE FOR REQUESTS. CHANGES IN NET ASSETS OR FUND BALANCES: FORM 990, PART XI, LINE 9: EXPENDED FOR RESTRICTED PURPOSES -1,026,956. NET ASSETS RELEASED FROM RESTRICTION 1,019,724. NET ASSETS RELEASED FOR OPERATIONS 7,230. FORM 990, PART XII, LINE 2C: THE PROCESS HAS NOT CHANGED FROM THE PRIOR YEAR. AUDITED FINANCIAL STATEMENTS FOR YEAR ENDED SEPTEMBER 30, 2013 ATTACHMENT TO SCHEDULE H AS A RESULT OF AN AFFILIATION WITH THE UNIVERSITY OF NORTH CAROLINA HEALTH CARE SYSTEM ON MAY 1, 2013, CALDWELL MEMORIAL HOSPITAL CONDUCTED A FIVE MONTH AUDIT OF ITS FINANCIAL STATEMENTS ENDING SEPTEMBER 30, 2013. CALDWELL MEMORIAL HOSPITAL DID NOT CONDUCT A TWELVE MONTH AUDIT OF ITS BOOKS THAT WOULD COINCIDE WITH THIS TAX RETURN. AS A RESULT, THE AUDITED FINANCIAL STATEMENTS ATTACHED TO THIS RETURN REFLECT THE FIVE MONTHS ENDING SEPTEMBER 30, 2013. CALDWELL MEMORIAL HOSPITAL FOUNDATION INC PO BOX 1890 LENOIR NC 28645 581935514 FOUNDATION NC 501(C)(3) LINE 7 CALDWELL MEMORIAL HOSPITAL INC 1 GUARDIAN HEALTH SERVICE LLC 343 SECOND STREET HICKORY NC 28601 752950776 HOME HEALTHCARE NC RELATED -3982 991122 0 1 0 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 CALDWELL MEMORIAL HOSPITAL FOUNDATION C 1075609