2014-08-14T13:16:35-05:00 2013-09-30 410746749 CLIFTONLARSONALLEN LLP 101 N TRYON STREET SUITE 1000 CHARLOTTE NC 28246 990 2012-10-01 560530234 RANDOLPH HOSPITAL INC RAND 3366255151 364 WHITE OAK STREET ASHEBORO NC 27204 MURRAY S MARSH 3366255151 2014-08-14 1 JOHN NORMAN P01506766 7049985200 2012 2015-11-30 17:44:51Z STEVE E EBLIN 364 WHITE OAK STREET ASHEBORO NC 27203 119005674 0 X WWW.RANDOLPHHOSPITAL.ORG X 1928 NC OPERATION OF NONPROFIT HOSPITAL IN RANDOLPH COUNTY, NC 11 11 1325 234 7525 0 615714 156000 120787025 117393265 -328915 -222620 1766752 618106 122840576 117944751 2619 900 0 0 53127430 55508120 0 0 70897 72186397 74008191 125316446 129517211 -2475870 -11572460 152699418 138073733 75507546 68482453 77191872 69591280 X RANDOLPH HOSPITAL'S MISSION IS TO PROVIDE QUALITY HEALTH CARE AND TO PROMOTE HEALTH AND WELLNESS. 0 0 118615982 900 117393265 RANDOLPH HOSPITAL, A NOT-FOR-PROFIT, 145-BED COMMUNITY HOSPITAL WAS ESTABLISHED IN 1928 WITH THE APPROVAL OF A COOPERATIVE PLAN WITH THE DUKE ENDOWMENT AT A JOINT MEETING OF THE ASHEBORO ROTARY CLUB, THE KIWANIS CLUB, THE CHAMBER OF COMMERCE, THE TOWN COUNCIL AND INTERESTED CITIZENS. THE PLAN CALLED FOR THE BUILDING OF A 40-BED HOSPITAL. SEE SCHEDULE O FOR CONTINUATIONWITH A GRANT FROM THE DUKE ENDOWMENT AND CONTRIBUTIONS FROM THE COMMUNITY THAT EXCEEDED A $50,000 GOAL BY $10,000, RANDOLPH HOSPITAL WAS BUILT AND OPENED ON JULY 9, 1932. OVER THE NEXT 82 YEARS IT HAS GROWN TO 145 BEDS AND IS THE HEALTHCARE PROVIDER OF CHOICE FOR RANDOLPH COUNTY CITIZENS PROVIDING STATE-OF-THE-ART IMAGING SERVICES, ADVANCED SURGICAL PROCEDURES, COMPREHENSIVE CANCER SERVICES, MATERNITY CARE, HOME HEALTH AND MUCH MORE. WE ALSO OFFER COMMUNITY EDUCATION IN THE FORM OF SCREENINGS AND ON-SITE CLINICS FOR A VARIETY OF WELLNESS INITIATIVES AS WELL AS CAREGIVER SUPPORT SERVICES FOR THE COMMUNITIES WE SERVE. IN 2014, RANDOLPH HOSPITAL WAS RECOGNIZED BY PREMIER, INC. AS ONE OF ONLY 18 HOSPITALS IN THE UNITED STATES AND ONE OF ONLY TWO IN NORTH CAROLINA PROVIDING HIGH-VALUE HEALTHCARE AND ACHIEVING TOP PERFORMANCE IN ALL SIX OF THE AREAS MEASURED IN PREMIERS QUEST COLLABORATIVE: MORTALITY, HARM, READMISSIONS, COSTS, PATIENT EXPERIENCE AND EVIDENCE-BASED CARE. IN 2013, RANDOLPH CANCER CENTER RECEIVED THE OUTSTANDING ACHIEVEMENT AWARD FROM THE COMMISSION ON CANCER OF THE AMERICAN COLLEGE OF SURGEONS -- ONE OF ONLY THREE CENTERS IN NORTH CAROLINA TO ACHIEVE THIS HONOR. IT RECOGNIZED THE OUTSTANDING EFFORT AND COMMITMENT BY THE ENTIRE RANDOLPH CANCER CENTER TEAM FOR PROVIDING HIGH QUALITY CANCER CARE TO OUR PATIENTS AND IN MEETING AND EXCEEDING THE STANDARDS SET BY THE COC ACCREDITATION PROGRAM. IN 2012, RANDOLPH CANCER CENTER WAS RECOGNIZED BY THE QUALITY ONCOLOGY PRACTICE INITIATIVE (QOPI) CERTIFICATION PROGRAM, AN AFFILIATE OF THE AMERICAN SOCIETY OF CLINICAL ONCOLOGY (ASCO). THE QOPI CERTIFICATION PROGRAM PROVIDES A THREE-YEAR CERTIFICATION FOR OUTPATIENT HEMATOLOGY-ONCOLOGY PRACTICES THAT MEET THE HIGHEST STANDARDS FOR QUALITY CANCER CARE. IN 2013, THE BREAST CENTER AT RANDOLPH HOSPITAL WAS GRANTED A THREE-YEAR FULL ACCREDITATION DESIGNATION BY THE NATIONAL ACCREDITATION PROGRAM FOR BREAST CENTERS (NAPBC), MAKING IT ONE OF ONLY 17 BREAST CENTERS IN NORTH CAROLINA WITH THE ACCREDITATION. NAPBC IS A PROGRAM ADMINISTERED BY THE AMERICAN COLLEGE OF SURGEONS. ACCREDITATION BY THE NAPBC IS ONLY GIVEN TO THOSE CENTERS THAT HAVE VOLUNTARILY COMMITTED TO PROVIDE THE HIGHEST LEVEL OF QUALITY BREAST CARE AND THAT UNDERGO A RIGOROUS EVALUATION PROCESS AND REVIEW OF THEIR PERFORMANCE. IN 2012, THE HUMAN MOTION INSTITUTE AT RANDOLPH HOSPITAL EARNED THE JOINT COMMISSION'S GOLD SEAL OF APPROVAL FOR ITS ORTHOPEDIC JOINT REPLACEMENT PROGRAMS FOR HIPS AND KNEES BY DEMONSTRATING COMPLIANCE WITH THE JOINT COMMISSION'S NATIONAL STANDARDS FOR HEALTH CARE QUALITY AND SAFETY IN DISEASE-SPECIFIC CARE. THE CERTIFICATION AWARD RECOGNIZES RANDOLPH HOSPITAL'S DEDICATION TO CONTINUOUS COMPLIANCE WITH THE JOINT COMMISSION'S STATE-OF-THE-ART STANDARDS. 118615982 1 1 0 1 0 0 0 0 0 1 1 0 0 1 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 0 0 0 1 198 0 1 1325 1 1 1 0 0 0 0 0 0 0 0 0 X 11 11 0 0 0 0 1 1 1 1 1 0 0 1 1 1 1 1 1 1 1 1 1 NC X X LORETTA LONG 3363283443 216A FOUST ST ASHEBORO NC 27203 X SAMUEL D CRANFORD JR 4.00 X X 0 0 0 ROBERT C SHAFFNER 3.00 X X 0 0 0 GLEN MAC PUGH 2.00 X X 0 0 0 MARY COOPER 2.00 X 0 0 0 ELBERT LASSITER 2.00 X 0 0 0 DIANE FROST 2.00 X 0 0 0 REYNOLDS LISK 2.00 X 0 0 0 CRANFORD KNOTT 2.00 X 0 0 0 MICHAEL C MILLER 2.00 X 0 0 0 SAMUEL A RANKIN JR 2.00 X 0 0 0 ROBERT S SHACKLEFORD JR 2.00 X 0 0 0 STEVE E EBLIN 38.00 2.00 X 280374 0 4505 MURRAY S MARSH 38.00 2.00 X 56975 0 982 DEVIN L GRIFFITH 40.00 X 176865 0 742 BARBARA E WOLFE 40.00 X 134802 0 1660 ROB S CLAUSER 38.00 2.00 X 100608 82805 3346 TREMONTEO CRAWFORD 40.00 X 148953 0 4091 LISA HAMPTON 40.00 X 146809 0 1196 MICHELLE LUTHER 40.00 X 136205 0 3320 WILLIAM WARD 40.00 X 134947 0 4991 ANGELA BURGESS 40.00 X 122242 0 8646 SANDRA L ALLEN 40.00 X 463575 0 2459 ROBERT E MORRISON 0.00 X 904643 0 824 LYNWOOD R WHITE 0.00 X 450088 0 1592 3257086 82805 38354 12 1 1 0 GREENSBORO RADIOLOGY PA 1331 N ELM ST SUITE 200 GREENSBORO NC 274011023 PROFESSIONAL RADIOLOGY SERVICES 3801745 EMPLOYEE BENEFITS SERVICES PO BOX 55210 INDIANAPOLIS IN 462050210 ADMINISTRATION OF EMPLOYEE BENEFITS 1443466 SODEXO INC & AFFILIATES PO BOX 536922 ATLANTA GA 303536922 FOOD MANAGEMENT SERVICES 1208656 MCNEARY INSURANCE CONSULTING DBA MCNEA 6525 MORRISON BLVD SUITE 200 CHARLOTTE NC 28211 INSURANCE CONSULTING 1119932 ARAMARK 12483 COLLECTIONS CENTER DRIVE CHICAGO IL 60693 BIOMEDICAL ENGINEERING 1068623 65 156000 156000 PATIENT SERVICE REVENUE 621400 114405392 114405392 CANCER CENTER REVENUES 621400 1014389 1014389 1973484 1973484 117393265 838303 838303 511490 0 511490 511490 511490 1060923 -1060923 -1060923 -1060923 COFFEE/GIFT SHOP 453220 99091 99091 PREMIER PARTNERSHIP 900009 7525 7525 106616 117944751 117393265 7525 387961 900 900 2750398 2750398 40955123 37075718 3837696 41709 834332 707770 125766 796 7623419 6467003 1149141 7275 3344848 2837459 504197 3192 566078 375030 191048 132887 131554 1333 59929 59929 12072498 12048571 22853 1074 325134 234140 83431 7563 7477803 6499203 973900 4700 1539936 1484741 55195 3073812 2913385 160427 423672 362407 59775 1490 22692 22692 1759640 1759640 6818282 6818282 519923 519923 BAD DEBTS 30195995 30195995 MEDICAL SUPPLIES 8072325 8072325 MISCELLANEOUS 742649 740721 163 1765 RECRUITMENT 204936 204936 129517211 118615982 10830332 70897 4397436 5827649 21613959 5798795 0 21785392 15830200 2990893 2847945 1295095 805931 146555522 83277141 65056594 63278381 19804569 23417787 4104513 4912015 11650967 15355030 152699418 138073733 9806813 9443463 47177798 45080267 18522935 13958723 75507546 68482453 X 75983761 68374953 1208111 1216327 77191872 69591280 152699418 138073733 X -11572460 356282 3615586 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 12996 12996 0 EXPLANATION OF LOBBYING ACTIVITIES: PART II-B, LINE 1: THE AMOUNT REFERENCED ABOVE REPRESENTS A PORTION OF THE DUES PAID TO THE NORTH CAROLINA HOSPITAL ASSOCIATION AND THE AMERICAN HOSPITAL ASSOCIATION THAT IS ATTRIBUTABLE TO LOBBYING. PART IV, SUPPLEMENTAL INFORMATION: THE HOSPITAL IS A MEMBER OF THE AMERICAN HOSPITAL ASSOCIATION (AHA) AND THE NORTH CAROLINA HOSPITAL ASSOCIATION (NCHA). BOTH ASSOCIATIONS PERFORM LOBBYING OF STATE AND LOCAL GOVERNMENTS ON BEHALF OF THEIR MEMBERSHIP BODIES, AND A PORTION OF THE DUES PAID TO EACH ASSOCIATION IS ATTRIBUTABLE TO THOSE LOBBYING EXPENDITURES. FOR THE FISCAL YEAR, THE PORTION OF DUES ATTRIBUTABLE TO LOBBYING WAS ESTIMATED AT $______. 1634877 1634877 1634877 1634877 1529736 105141 1634877 1.00000 0 0 3232061 3232061 79023373 36240782 42782591 56595010 46202194 10392816 7705078 834165 6870913 63278381 OTHER RECEIVABLES 784747 ESTIMATED THIRD-PARTY SETTLEMENTS 3583229 ASSETS LIMITED AS TO USE 1216327 INVESTMENT IN AFFILIATES 306541 DUE FROM AFFILIATES 9066080 OTHER LONG-TERM ASSETS 398106 15355030 OTHER LONG-TERM LIABILITIES 282136 MINIMUM PENSION LIABILITY 5309970 INTEREST RATE SWAP 2711912 DUE TO AFFILIATES 5005056 INVESTMENT IN AFFILIATES 649649 13958723 X DESCRIPTION OF INTENDED USE OF ENDOWMENT FUNDS: PART V, LINE 4: THIS IS A DONATION FROM ANNIS S. KEMP THAT IS RESTRICTED. DESCRIPTION OF UNCERTAIN TAX POSITIONS UNDER FIN 48: PART X, LINE 2: THE HOSPITAL, RMA, RSG AND FOUNDATION ARE EXEMPT FROM FEDERAL INCOME TAXES UNDER SECTION 501(C)(3) OF THE INTERNAL REVENUE CODE. CPSC IS A LIMITED LIABILITY COMPANY THAT DOES NOT PRODUCE TAXABLE INCOME TO ITS NON-FOR-PROFIT OWNER. THE ORGANIZATIONS HAVE DETERMINED 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 X 1 X 1 X 0 1 0 1 1 2802028 2802028 0.02820 16834424 11155059 5679365 0.05720 19636452 11155059 8481393 0.08540 30607 30607 0.00030 5619 5000 619 0.00000 145000 -145000 0.00000 360259 360259 0.00360 396485 150000 246485 0.00390 20032937 11305059 8727878 0.08930 2563 5000 -2437 0.00000 2563 5000 -2437 1 30195995 25666596 23704303 28381488 -4677185 X 1 1 3 RANDOLPH CANCER CENTER LLC CANCER CENTER OUT PATIENT 0.60000 5 CENTRAL PIEDMONT SURGERY CENTER LLC SURGERY CENTER 0.73000 1 1 RANDOLPH HOSPITAL INCORPORATED

364 WHITE OAK STREET ASHEBORO NC 27204

WWW.RANDOLPHHOSPITAL.ORG X X X RANDOLPH HOSPITAL 1 1 X X X X X X X X X 12 1 0 1 X X X X X X X X X X X 0 0 1 1 200.000000000000 1 300.000000000000 0 1 1 X X 1 X 0 X X 1 0 0 3 RANDOLPH MEDICAL ASSOCIATES

218-C FOUST STREET ASHEBORO NC 27203

WHOLLY OWNED PHYSICIAN PRACTICE (MULTIPLE LOCATIONS) RANDOLPH SPECIALTY GROUP

138 DUBLIN SQUARE ROAD SUITE A ASHEBORO NC 27203

WHOLLY OWNED PRACTICE(MULTIPLE LOCATIONS) RANDOLPH CANCER CENTER

373 N FAYETTEVILLE STREET ASHEBORO NC 27203

JOINT VENTURE 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 $ 30195995. PART III, LINE 4: THE ORGANIZATION'S FINANCIAL STATEMENTS DO NOT INCLUDE A FOOTNOTE ON BAD DEBT. BAD DEBT EXPENSE WAS OBTAINED FROM AUDITED FINANCIAL STATEMENTS. THE ORGANIZATION ESTIMATES FROM HISTORICAL PERSPECTIVE AND EXPERIENCE THAT APPROXIMATELY 85% OF BAD DEBT EXPENSE MAY BE ATTRIBUTABLE TO COMMUNITY BENEFIT PART III, LINE 8: COSTS AND TOTAL REVENUES RECEIVED FROM MEDICARE REPORTED ON LINES 5 AND 6 ARE CALCULATED FROM THE ORGANIZATION'S MEDICARE COST REPORT. PART III, LINE 9B: OUR COLLECTION AGENCIES ARE TO OFFER TO ALL PATIENTS THE FINANCIAL ASSISTANCE APPLICATION TO BE COMPLETED AND RETURNED TO RH FOR PROCESSING; IF AWARDED FINANCIAL ASSISTANCE RH WILL NOTIFY THE COLLECTION VENDORS TO DISCONTINUE COLLECTION EFFORTS RANDOLPH HOSPITAL PART V, SECTION B, LINE 3: METHODOLOGY, DATA COLLECTION & ANALYSIS IN THE FALL OF 2012, THE RANDOLPH COUNTY HEALTH DEPARTMENT JOINED WITH RANDOLPH HOSPITAL, TO ESTABLISH THE ASSESSMENT FRAMEWORK AND A TIMELINE FOR DATA COLLECTION AND ANALYSIS, PRIORITIZATION OF HEALTH CONCERNS AND DEVELOPMENT OF ACTION PLANS. DATA COLLECTION AND ANALYSIS TOOK PLACE FROM JANUARY - JULY 2013. PRIMARY DATA WAS COLLECTED FROM THE COMMUNITY IN THREE WAYS: DISTRIBUTION OF PAPER SURVEYS MAILED RANDOMLY TO RESIDENTS ACROSS THE COUNTY, AN INTERNET SURVEY AND A COMMUNITY LEADER QUESTIONNAIRE.PRIMARY DATA2013 RANDOLPH COUNTY HEALTH OPINION SURVEYTELEPHONE SURVEYS HAVE BEEN CONDUCTED IN YEARS PAST, HOWEVER, BECAUSE MANY PEOPLE NOW REPLACE LANDLINE PHONE SERVICE WITH CELL PHONES OR USE UNLISTED PHONE NUMBERS, IT WAS FELT THAT A PHONE SURVEY WOULD NOT BE REPRESENTATIVE OF THE COUNTY. WITH TECHNOLOGY CONTINUING TO ADVANCE, MORE OF AN EMPHASIS WAS PLACED ON ON-LINE SURVEYS, ALTHOUGH PAPER SURVEYS WERE STILL AN IMPORTANT TOOL. SURVEYS WERE MAILED TO RESIDENTS ACROSS THE COUNTY USING A RANDOM SAMPLE METHOD. THROUGH UTILIZATION OF RANDOLPH COUNTY'S ADDRESS DATABASE, EVERY FIFTIETH (50TH) ADDRESS WAS RANDOMLY SELECTED. OVER FIVE HUNDRED (525) SURVEYS, INCLUDING A SELF-ADDRESSED, STAMPED ENVELOPE WERE MAILED TO SELECTED ADDRESSES. IN ADDITION TO THE MAILED SURVEYS, THEY WERE ALSO DISTRIBUTED TO AGENCIES AND ORGANIZATIONS WITHIN THE COUNTY USING THE CONVENIENCE SAMPLE METHOD. SUCH AGENCIES INCLUDED: RANDOLPH COMMUNITY COLLEGE, RANDOLPH COUNTY SENIOR ADULTS ASSOCIATION, LIBERTY EARLY CHILDHOOD CENTER, RANDOLPH COUNTY PARTNERSHIP FOR CHILDREN, THE LATINO COALITION OF RANDOLPH COUNTY AND SEVERAL CHURCHES. ALL SURVEYS DISTRIBUTED WERE IN BOTH ENGLISH AND SPANISH. OF THE 3,500 TOTAL DISTRIBUTED SURVEYS, 1,570 WERE RETURNED FOR A RESPONSE RATE OF 45%. SURVEY RESPONSES WERE ANALYZED FOR FREQUENCY OF RESPONSE USING SURVEY MONKEY. (IT SHOULD BE NOTED THAT NOT EVERY RESPONDENT ANSWERED EVERY QUESTION.) THE SURVEYS WERE NOT FULLY COMPLETED BY ALL INDIVIDUALS, RESULTING IN MISSING DATA ON VARIOUS QUESTIONS. INTERNET SURVEY IN COLLABORATION WITH THE RANDOLPH COUNTY GOVERNMENT IT, AN INTERNET SURVEY WAS DEVELOPED USING SURVEY MONKEY. THE INTERNET SURVEY WAS ACCESSIBLE THROUGH THE RANDOLPH COUNTY GOVERNMENT WEBSITE. IN AN EFFORT TO PROMOTE THE INTERNET SURVEY, LAMINATED INFORMATION CARDS WERE DISPLAYED IN BOTH ENGLISH AND SPANISH AT VARIOUS BUSINESSES, WHICH INCLUDED CHURCH BULLETINS.COMMUNITY LEADER/SERVICE PROVIDER QUESTIONNAIRESTO ENSURE A SOLID REPRESENTATION FROM KEY SECTORS, THE STAKEHOLDER QUESTIONNAIRE WAS SENT TO DEPARTMENT HEADS AND DIRECTORS FROM VARIOUS AGENCIES OR REPRESENTATIVES WITHIN THE COUNTY. SURVEY RESULTS ARE INCLUDED IN THE APPENDIX SECTION OF THIS DOCUMENT. SECONDARY DATA THE MAJOR SOURCE FOR SECONDARY DATA IN THE 2013 RANDOLPH COUNTY COMMUNITY HEALTH ASSESSMENT INCLUDED:- NORTH CAROLINA STATE CENTER FOR HEALTH STATISTICS- NORTH CAROLINA DEPARTMENT OF HEALTH & HUMAN SERVICES- LINC: LOG INTO NORTH CAROLINA- CECIL G. SHEPS CENTER FOR HEALTH SERVICES RESEARCH- US CENSUS DEPARTMENT- UNITED STATES CENSUS BUREAU- UNITED STATES DEPARTMENT OF COMMERCEAS APPLICABLE, RANDOLPH COUNTY STATISTICS HAVE BEEN COMPARED WITH STATE STATISTICS AS WELL AS FOUR PEER COUNTIES. THESE PEER COUNTIES WERE IDENTIFIED BASED UPON AGE, RACE AND POVERTY CHARACTERISTICS, AND ARE SELECTED FROM A GROUP OF COUNTIES WITHIN THE SAME POPULATION RANGE AS THE SUBJECT COUNTY. FOR RANDOLPH COUNTY, THE FOLLOWING FOUR PEER COUNTIES WERE IDENTIFIED: CRAVEN, DAVIDSON, HARNETT AND JOHNSTON. THEREFORE, IN ADDITION TO NORTH CAROLINA STATISTICS, THESE FOUR COUNTIES WERE USED FOR COMPARISON THROUGHOUT THE ASSESSMENT PROCESS. RANDOLPH HOSPITAL PART V, SECTION B, LINE 5C: BOTH RANDOLPH COUNTY AND RANDOLPH HOSPITAL WEBSITES WILL POST THE COMMUNITY HEALTH NEEDS ASSESSMENT AND EXECUTIVE SUMMARY. THE ASSESSMENT WILL ALSO BE IN ALL SEVEN RANDOLPH COUNTY LIBRARIES. THIRTY DATA BOOKS AND 500 EXECUTIVE SUMMARIES WILL BE ORDERED AND PRINTED FOR DISTRIBUTION THROUGHOUT THE COMMUNITY. RANDOLPH HOSPITAL PART V, SECTION B, LINE 7: BASED ON PRIMARY DATA RESULTS, EMPLOYMENT OPPORTUNITIES, AFFORDABLE HOUSING, CRIME AND AVAILABILITY OF POSITIVE TEEN ACTIVITIES WERE MAJOR CONCERNS OF THE PUBLIC. HOWEVER, THE ADVISORY TEAM DECIDED THESE WERE NOT AREAS IN WHICH RANDOLPH HOSPITAL OR THE RANDOLPH COUNTY HEALTH DEPARTMENT COULD IMPACT. RANDOLPH HOSPITAL PART V, SECTION B, LINE 18E: THE HOSPITAL ESTABLISHES DURING PRE-REGISTRATION WHETHER A PATIENT IS COVERED BY INSURANCE. IF THE PATIENT IS NOT COVERED BY INSURANCE, THE HOSPITAL MAKES THE PATIENT AWARE OF THE FAP. 1 X X X X X 0 1 0 0 0 0 0 0 0 STEVE E EBLIN 280014 0 0 0 360 0 0 0 4505 0 284879 0 0 0 DEVIN L GRIFFITH 176685 0 0 0 180 0 0 0 742 0 177607 0 0 0 ROB S CLAUSER 100488 64087 0 18628 120 90 0 0 3346 0 103954 82805 0 0 TREMONTEO CRAWFORD 148149 0 0 0 804 0 0 0 4091 0 153044 0 0 0 SANDRA L ALLEN 193457 0 268313 0 1805 0 0 0 2459 0 466034 0 0 0 ROBERT E MORRISON 145882 0 756853 0 1908 0 0 0 824 0 905467 0 0 0 LYNWOOD R WHITE 169191 0 279618 0 1279 0 0 0 1592 0 451680 0 0 0 PART I, LINE 4B THE AMOUNTS REPRESENTED AS DEFERRED COMPENSATION ON SCHEDULE J HAVE BEEN ACCRUED AND/OR PAID TO THE INDIVIDUALS. THE AMOUNT REPRESENTS VESTED BENEFITS WHICH MAY BE PAID IN FUTURE YEARS, DEPENDING ON THE INDIVIDUAL'S LIFE SPAN AND OTHER FACTORS WHICH COULD RESULT IN FORFEITURE OF THE BENEFIT. DURING 1998, THE HOSPITAL ESTABLISHED A SUPPLEMENTAL EXECUTIVE RETIREMENT PLAN TO COVER HIGHLY COMPENSATED EMPLOYEES. THIS PLAN INCLUDED A NONQUALIFIED SUPPLEMENTAL RETIREMENT PLAN, A NONQUALIFIED DEFERRED COMPENSATION PLAN (REVISED IN 2005) AND A SPLIT-DOLLAR LIFE INSURANCE PLAN. THE SUPPLEMENTAL EXECUTIVE RETIREMENT PLAN PROVIDES ADDITIONAL BENEFITS TO SUPPLEMENT BENEFITS EARNED UNDER THE ORGANIZATIONS BROADER DEFINED BENEFIT PENSION PLAN. IN 2005, THE HOSPITAL INSTITUTED A NONQUALIFIED DEFERRED COMPENSATION PLAN. THE PURPOSE OF THIS PLAN IS TO PROVIDE ADDITIONAL RETENTION INCENTIVES AND RETIREMENT SECURITY FOR CERTAIN MEMBERS OF THE HOSPITAL'S SENIOR MANAGEMENT TEAM AND TO ALLOW FOR THE DEFERRAL OF COMPENSATION OF THOSE ELIGIBLE MEMBERS OF ITS SENIOR MANAGEMENT. THIS IS INTENDED TO BE A NONQUALIFIED PLAN. PARTICIPANTS ARE 100% VESTED AFTER 30 YEARS OF SERVICE OR AT AGE 67. THE SPLIT-DOLLAR LIFE INSURANCE AGREEMENT INVOLVES THE PAYMENT OF PREMIUMS BY THE HOSPITAL FOR A LIFE INSURANCE POLICY, THE BENEFITS OF WHICH ARE SPLIT BETWEEN THE EMPLOYEES' BENEFICIARIES AND THE HOSPITAL UP TO THE AMOUNT OF PREMIUMS PAID. PREMIUMS PAID UNDER THIS PLAN WILL CONTINUE UNTIL THE AGREEMENT IS TERMINATED OR UPON THE DEATH OF THE INSURED EMPLOYEES. FORM 990, PART VI, SECTION A, LINE 1 THERE STANDS AN EXECUTIVE COMMITTEE CONSISTING OF THE CHAIRMAN, VICE CHAIRMAN, CHAIRMAN-ELECT, THE SECRETARY, THE CHAIRMAN OF THE FINANCE, AUDIT, INVESTMENT AND RETIREMENT COMMITTEE, AND UP TO TWO OTHER DIRECTORS AS DESIGNATED BY THE CHAIRMAN. THE COMMITTEE HAS AND MAY EXERCISE THE AUTHORITY OF THE BOARD IN THE MANAGEMENT OF THE ORGANIZATION, TO THE EXTENT PERMITTED BY LAW, DURING THE INTERVALS BETWEEN MEETINGS OF THE BOARD. FORM 990, PART VI, SECTION A, LINE 6 THE CORPORATION SHALL HAVE ONE CLASS OF MEMBERS CONSISTING OF AT LEAST 23 MEMBERS AND NEVER CONSISTING OF MORE THAN 30 MEMBERS. FOUR MEMBERS SHALL BE EX OFFICIO, AS INDICATED BELOW. THE REMAINDER SHALL BE ELECTED AS PROVIDED IN DETAIL IN THE BYLAWS. THE PRINCIPAL CRITERION FOR SELECTION OF CORPORATE MEMBERS SHALL BE THE PERSON'S QUALIFICATIONS TO EVENTUALLY SERVE AS A DIRECTOR OF RANDOLPH HOSPITAL, AS SET FORTH IN SECTION 22 OF THE BYLAWS. AS CANDIDATES BECOME AVAILABLE, THE MEMBERS MAY EXPAND OR CONTRACT THEIR NUMBER, WITHIN THE LIMITS STATED ABOVE, IN ORDER TO PROVIDE AN ADEQUATE POOL OF MEMBERS WHO ARE QUALIFIED TO SERVE AS DIRECTORS. IN ADDITION TO THE ELECTED MEMBERS, THE MAYOR OF ASHEBORO, NORTH CAROLINA, THE CHAIRMAN OF THE BOARD OF COMMISSIONERS OF RANDOLPH COUNTY, NORTH CAROLINA, THE RANDOLPH COUNTY SUPERINTENDENT OF SCHOOLS AND THE COUNTY HEALTH OFFICER OF RANDOLPH COUNTY, NORTH CAROLINA, SHALL BE EX OFFICIO MEMBERS OF THE CORPORATION. FORM 990, PART VI, SECTION A, LINE 7A THE DIRECTORS SHALL BE ELECTED BY THE MEMBERS AT THE ANNUAL MEETING OF THE MEMBERS FROM NOMINATIONS RECEIVED BOTH FROM THE GOVERNANCE COMMITTEE AND FROM THE FLOOR AT THE ANNUAL MEETING OF THE MEMBERS. IF ANY DIRECTORS SHALL SERVE ONE-YEAR TERMS, AND SHALL CONTINUE TO SERVE UNTIL THEIR SUCCESSORS ARE ELECTED. DIRECTORS MAY BE RE-ELECTED. ANY DIRECTOR MAY BE REMOVED FROM OFFICE AT ANY TIME, WITH OR WITHOUT CAUSE, BY A MAJORITY VOTE OF THE MEMBERS OF THE CORPORATION. FORM 990, PART VI, SECTION A, LINE 7B CHANGES TO THE BYLAWS, SALE OR MERGER OF THE HOSPITAL MUST BE APPROVED BY THE MEMBERS. FORM 990, PART VI, SECTION B, LINE 11 THE 990, ALONG WITH A SUMMARY OF KEY ELEMENTS AND DISCLOSURES, IS PROVIDED TO THE BOARD INVITING QUESTIONS AND COMMENTS PRIOR TO FILING. FORM 990, PART VI, SECTION B, LINE 12C RANDOLPH HOSPITAL HAS A FULL TIME CORPORATE COMPLIANCE OFFICER CHARGED WITH EDUCATING THE BOARD, OFFICERS, AND OTHER EMPLOYEES ON THE CONFLICT OF INTEREST POLICY. ALL NEW EMPLOYEES ARE GIVEN INFORMATION UPON ORIENTATION, AND ALL CURRENT EMPLOYEES ARE REQUIRED TO TAKE ANNUAL EDUCATION ON COMPLIANCE WITH THE POLICY. THERE IS A MONTHLY CORPORATE COMPLIANCE MEETING TO UPDATE KEY INDIVIDUALS ON NEW ISSUES AND NEW INFORMATION REGARDING CORPORATE COMPLIANCE. THE BOARD OF DIRECTORS IS REQUIRED ANNUALLY TO READ, SIGN, AND REMIT A COPY OF THE POLICY TO THE BOARD CHAIR. ALL BOARD MEMBERS ARE AWARE OF THE POLICY AND IN CASE OF ANY CONFLICT OF INTEREST, THEY WILL RECUSE THEMSELVES. FORM 990, PART VI, SECTION B, LINE 15 RANDOLPH HOSPITAL CONTRACTS WITH AN INDEPENDENT COMPENSATION CONSULTANT TO DETERMINE APPROPRIATE COMPENSATION LEVELS FOR EXECUTIVES THAT IS COMMENSURATE WITH ORGANIZATIONS OR SIMILAR SIZE AND STRUCTURE. A COMPENSATION COMMITTEE OF THE BOARD HAS FINAL DETERMINATION OF COMPENSATION LEVELS FOR TOP EXECUTIVES. FORM 990, PART VI, SECTION C, LINE 18 PHOTOCOPIES OF THE FORM 990 ARE AVAILABLE UPON REQUEST AT THE ORGANIZATION'S ADMINSTRATIVE OFFICE. IN ADDITION, RECENT FILINGS OF THE FORM 990 ARE AVAILABLE ONLINE AT WWW.GUIDESTAR.ORG 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 VII ROBERT CLAUSER IS THE EXECUTIVE DIRECTOR OF RANDOLPH MEDICAL ASSOCIATES AND RANDOLPH SPECIALTY GROUP PRACTICE AND SPLITS HIS TIME BETWEEN THESE TWO ENTITIES. HIS TITLE WITH THE HOSPITAL IS VP OF PHYSICIAN PRACTICE AND EMPLOYEE HEALTH. CHANGES IN NET ASSETS OR FUND BALANCES: FORM 990, PART XI, LINE 9: CHANGE IN VALUE OF INTEREST RATE SWAP 1,852,820. CHANGE IN PENSION LIABILITY 1,795,986. OTHER CHANGES IN NET ASSETS -25,695. PREMIER PARTNERSHIP -7,525. RANDOLPH CANCER CENTER 364 WHITE OAK STREET ASHEBORO NC 27204 562181482 HEALTHCARE NC 501(C)(3) LINE 11A, I RANDOLPH HOSPITAL INC 1 CENTRAL PIEDMONT SURGERY CENTER LLC 11221 ROE AVE SUITE 320 LEAWOOD KS 66211 234317497 HEALTHCARE KS 0 0 0 1 0 1 0 0 0 0 0 1 0 0 0 0 1 0 1 1 0 CENTRAL PIEDMONT SURGERY CENTER B 289460 CONTRIBUTION CALL