2014-11-17T10:35:52-06:00 2013-12-31 550486667 Arnett Foster Toothman PLLC P O Box 2629 Charleston WV 25329 990 2013-01-01 550375433 Davis Memorial Hospital DAVI 3046363300 PO Box 1484 Elkins WV 26241 E Mark Doak President/CEO 3046363300 2014-11-14 1 Dale Carpenter P00189642 3043460441 2013 2015-11-30 17:44:51Z E Mark Doak PO Box 1484 Elkins WV 26241 95288336 0 X www.davishealthsystem.org X 1903 WV To provide quality health care to residents of Elkins, West Virginia and surrounding communities. 15 12 797 87 136689 61681 48410 31905 84706419 82560799 556200 554117 2167166 5469454 87478195 88616275 55979 54959 0 0 41410398 43822651 0 0 0 43901924 45582885 85368301 89460495 2109894 -844220 73499011 77353945 32318423 38737809 41180588 38616136 To provide patient friendly healthcare to its communities. 0 0 74994101 54959 82560799 The organization operated a 90 bed acute care hospital in Elkins, West Virginia.Charges foregone for charity care amounted to $7,837,243. 129588 The hospital provided community support by providing nutritious meals to residents of Elkins, WV. 89300 The hospital provided community support by sponsoring various health fairs and providing food or snacks for various community events to residents of Elkins, WV. 75212989 1 1 0 0 0 0 0 0 0 0 1 0 0 1 1 0 0 1 0 0 0 0 0 0 0 0 1 1 1 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 1 1 0 0 0 1 82 0 1 797 1 1 1 0 0 0 0 0 0 0 0 0 X 15 12 0 0 0 0 1 1 1 1 1 0 0 1 1 1 1 1 1 1 1 0 X Rebecca Hammer 3046373156 Gorman Avenue and Reed Street Elkins WV 26241 Hugh Hitchcock Board Member 1.00 2.00 X 0 0 0 William Hartman Vice-Chairman 2.00 2.00 X 0 0 0 Andrew Gongola Treasurer 2.00 2.00 X 0 0 0 George Scott Board Member 1.00 1.00 X 0 0 0 Bridgette Wilson Secretary 2.00 2.00 X 0 0 0 Connie Tenney Board Member 1.00 1.00 X 0 0 0 Terry White Board Member 1.00 1.00 X 0 0 0 Suzi Moore Board Member 1.00 1.50 X 0 0 0 Ashton Curtis DPM Board Member 1.00 1.00 X 0 0 0 Steve Toney MD Chairman 27.00 4.00 X 126789 13000 0 Tom Felton Board Member 1.00 1.00 X 0 0 0 James Triplett Board Member 1.00 1.00 X 0 0 0 Robert Digman PHD Board Member 1.00 4.00 X 0 0 0 Forrest Kelley Board Member 1.00 3.00 X 0 0 0 Deborah Tysor Board Member/RN 38.50 1.00 X 47305 0 16957 John Kabler Board Member 1.00 1.00 X 0 0 0 Paul Hartel Board Member/Physician 38.00 2.00 X 259529 0 19455 E Mark Doak President/CEO 29.00 11.00 X 294846 0 16957 Rebecca Hammer CFO 36.00 4.00 X 181252 0 8012 Mohamed M Fahim Physician 40.00 X 610798 0 18957 Donald R Fleming Physician 40.00 X 450000 0 19455 Charles K Kirkland Physician 40.00 X 412425 0 19455 Marshall Sklar Physician 40.00 X 450000 0 7012 John S Veach Physician 39.00 1.00 X 424575 0 8118 3257519 13000 134378 52 0 1 0 Executive Health Resources 15 Campus Blvd Newton Square PA 19073 Purchased Service 572465 Weatherby Locums PO Box 972633 Dallas TX 75397 Physician Locums 497171 Comphealth PO Box 972651 Dallas TX 75397 Physician Locums 442108 Smith Backhoe & Dozer Service 7 Eleventh Street Elkins WV 26241 Building Contractor 392742 Dunmire Consulting 13352 Paloma Dr Orlando FL 32837 Consulting 369204 22 31905 31905 Patient services 622110 82560799 82560799 82560799 189235 64485 124750 72170 0 72170 72170 4200 67970 7030152 6791 6655983 16078 374169 -9287 364882 364882 Litigation Settlement 900099 2100000 2100000 EHR Incentive 900099 1918427 1918427 Cafeteria 722210 852641 852641 526216 68004 458212 5397284 88616275 82560799 136689 5886882 54959 54959 977734 782676 195058 33164002 26547784 6616218 66608 53320 13288 7336387 5872778 1463609 2277920 1823475 454445 401876 401876 100205 100205 6384495 5110788 1273707 92843 92843 5571902 4560705 1011197 1894119 1516242 377877 1042202 834283 207919 270358 216422 53936 796259 637405 158854 5098480 4081333 1017147 977153 782211 194942 Bad debts 9234284 9234284 Medical supplies 9009539 9009539 0 Repairs and maintenance 1984811 1588841 395970 Unrelated business inco 16000 16000 2708359 2489944 218415 89460495 75212989 14247506 0 2583236 2884356 3555662 2509105 14811476 11164052 471464 696638 1822453 1658767 1221833 861919 106299507 70031482 30202831 36268025 6075488 6688047 3257741 3209023 9496827 11414013 73499011 77353945 10137892 11375912 373059 339644 8850000 7420000 2059043 9895888 3861447 3539481 7036982 6166884 32318423 38737809 X 41180588 38616136 41180588 38616136 73499011 77353945 X -844220 98181 -1818413 X 0 1 X 1 0 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 106509 2044880 2151389 231721 34221185 26984810 7468096 56249622 43046672 13202950 13445590 13445590 36268025 Other receivables 100701 Due from affiliates 3865640 Bond issue costs, net of amortization 126349 Due from subsidiary 7231323 Estimated third-party payor settlements 90000 11414013 Due to affilates 270239 Capital leases 4635220 Post retirement benefit obligation 1261425 6166884 79333273 -48718 -48718 79381991 9234284 9234284 88616275 80226211 0 80226211 9234284 9234284 89460495 Part XI, Line 2d - Other Adjustments: Decrease in retained earnings of unconsolidated subsidiary -48,718. Part XI, Line 4b - Other Adjustments: Bad debt expense netted with revenue in financial statements 9,234,284. Part XII, Line 4b - Other Adjustments: Bad debt expense netted with revenue in financial statements 9,234,284. 1 1 X 1 X 120.000000000000 1 X 1 1 0 0 2790515 2790515 0.03480 14996112 10215802 4780310 0.05960 17786627 10215802 7570825 0.09440 56106 56106 0.00070 2415 2415 0.00000 4650932 1539134 3111798 0.03880 218888 218888 0.00270 4928341 1539134 3389207 0.04220 22714968 11754936 10960032 0.13660 2081 2081 0.00000 2081 2081 1 4586669 0 17346901 17977450 -630549 X 1 1 1 1 Davis Memorial Hospital PO Box 1484 Elkins WV 26241 X X X Davis Memorial Hospital 1 1 X X X X X X X X 13 1 0 1 X X X 0 0 1 1 120.000000000000 1 300.000000000000 1 X X X X 1 1 X X X X X 1 0 X X X X 1 X 0 0 Davis Memorial Hospital Part V, Section B, Line 3: Selected stakeholders from the Hospital's service area provided valuable input through a series of individual interviews. Those interviewed included representatives from Elkins Fire Department and Elkins Emergency Medical Services, Randolph-Elkins Health Department and local health providers. These individuals were chosen because they provided diversified backgrounds and a range of perspectives on health care services available to the community. Davis Memorial Hospital Part V, Section B, Line 7: Financial constraints prevent the Hospital from addressing all of the needs identified in the Community Health Needs Assessment. Davis Memorial Hospital Part V, Section B, Line 14g: The policy is posted on the Davis Health System Website and is published annually in local newspapers. The policy is posted in all patient registration areas including ER, Admissions and OP testing. The procedure is also explained in financial counseling brochures available throughout the Health System and in physician offices. All employees are also notified via the internal website where it is posted. We also employ two financial counselors who work with and screen the uninsured and underinsured populations. We also have a financial advocate from health and human services. Davis Memorial Hospital Part V, Section B, Line 18e: The Hospital also screens patients through a third party database through the advisory board prior to placement with a collection agency. This scrub provides us with the likelihood the patient will qualify for Medicaid as well as screens the patients for our internal assistance policy. The presumptive charity adjustments are done as budgetary constraints allow to better identify the medically indigent and patients who have a need for assistance to prevent derogatory collection activity. Davis Memorial Hospital Part V, Section B, Line 20d: The hospital provides a straight 25% discount to uninsured individuals paying their balances. This discount is lower than any of our negotiated insurance contract rates. Part I, Line 7: The cost of charity care was determined based on the hospital's cost accounting system. The total account cost and total account revenue for those receiving charity care are reported to come to a true cost associated with the accounts. The determined cost to charge ratio for the total account is then applied to the portion on charity care received.The cost of Medicaid was determined using the Hospital's cost accounting system. Accounts showing Medicaid as the primary payer along with total account cost was pulled, the cost to charge ratio was determined and applied to the total Medicaid revenue.The cost of subsidized health services was determined using the hospital's cost accounting system.Community benefit costs were determined from reports filled out by staff/managers involved to determine contributions. Participants supply labor cost as well as any labor costs involved in the community activity. Managers are supplied with community benefit forms. When they perform community service, they supply cost information and any offsetting revenue associated with the event. We have one staff member that compiles these forms on a monthly basis. Health professions education costs are compiled through the year and reported by the manager involved in the education opportunity or approving party. Part I, Line 7g: Subsidized health care services include clinics as well as OB/GYN/Labor/Delivery & Nursery services. 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 $ 9,234,284. Part I, Line 7g The cost of physician clinics included in subsidized health services was $3,112,899. Part II, Community Building Activities: Davis Health System's mission includes the delivery of healthcare services and programs that promote improved health for individuals and families. The quality of life of entire communities is impacted through these vital programs generally offered at little or no cost. Some of the health issues targeted by Davis Health System to the communities served by our organization include diabetes, obesity and weight management, tobacco use and heart disease, women's health, influenza, and cancer and cancer prevention. Our outreach serves five primary West Virginia counties (Randolph, Tucker, Upshur, Barbour, and Pocahontas), with some overflow to neighboring counties as well. Several examples of projects that represent our commitment to advancing the emotional and physical health benefits to the people of these communities include: community health fairs, diabetes education programs and support groups, diabetes foot screenings, speaking engagements and presentations to schools, civic groups and other organizations, colon cancer screenings and education, community walking program, participation with the American Cancer Society's Relay for Life and March of Dimes, partnership with boards of education, influenza vaccination clinics, partnership with county health departments, drug take-back, smoking cessation classes and support and pap smear and breast examinations. Part III, Line 4: Audited financial statement footnote relating to bad debt expense: 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 collectibility. Management also reviews troubled, aged accounts to determine collection potential. Delinquency status is based on date of service. Patient accounts receivables are written off when deemed uncollectible. Recoveries of accounts previously written off are recorded as a reduction to bad debt expense when received.The cost of bad debts was determined based on the Hospital's cost accounting system and decision support system. All costs, direct and indirect, are stepped down by department based on revenue. Bad debt expense is reduced by bad debt recoveries and discounts for payment. Part III, Line 8: Medicare allowable costs were estimated using Worksheet B of the Schedule H instructions. None of the shortfall is considered to be community benefit since the deviation changes each year. Part III, Line 9b: Patients who indicate they have an inability to pay for their medical care are referred to the financial counselor and/or a Medicaid Eligibility Specialist. Patients who do meet financial assistance guidelines but demonstrate an inability to meet our minimum payment guidelines are given a reduced payment plan. Collection procedures regarding reduced payment plans follow the hospital's normal procedures. Patients with catastrophic illnesses are referred to the WV Catastrophic Illness Fund. Patients whose care is a result of a crime will be referred to the WV Crime Victims Fund. Part VI, Line 2: Davis Health System relies heavily on data provided by the Bureau for Public Health; namely, the county Health Profiles that outline risk factors for chronic diseases. In addition, the Community Health Promotion Director gleans information and statistics from health screenings that are held for the public, as well as our employees. This information helps in planning future educational events and screenings. Part VI, Line 3: The information is posted in public areas within the hospital. The financial policy brochure is publicly displayed and posted on the internal network and the health system website. A patient advocate contacts work lists of medically indigent patients to help secure and provide education to affiliate and non-affiliate physician offices referring to Davis Memorial Hospital. Part VI, Line 4: The Hospital serves several rural counties in eastern West Virginia. Randolph County has a population of 29,415 with 18% having a bachelor's degree or higher and average household income of $37,350. Upshur County has a population of 24,665 with 15.4% having a bachelor's degree or higher, average household income of $41,214. Barbour County has a population of 16,770 with 11.7% having a bachelor's degree or higher, average household income of $36,087. Pocahontas County has a population of 8,669 with 15.7% having a bachelor's degree or higher, average household income of $32,381. Tucker County has a population of 6,968 with 16% having a bachelor's degree or higher, average household income of $36,445. Additionally, 17.6% of all West Virginians live below the poverty level. Davis Memorial is the only hospital in Randolph County. There is one critical access hospital in Barbour County, one critical access hospital in Pocahontas County and one general service hospital in Upshur County. Part VI, Line 5: The organization's health care facilities further its exempt purpose in the following ways. The organization's governing body is comprised of persons who reside in the organization's primary service area. The corporate by laws provide for Board representation from the counties surrounding Davis Memorial Hospital. The organization extends medical staff privileges to all qualified physicians in its community for some or all of its departments. The organization operates an emergency room available to all, regardless of ability to pay. Specialized services offered by the organization that are not available elsewhere include neurology, pain management, otolaryngology, pulmonology, lithotripsy, sleep studies, PET, digital mammography, critical care medicine, general surgery, internal medicine, obstetrics and gynecology, radiation oncology, medical oncology and hematology. An advanced telemedicine initiative at Davis Health System provides additional specialized services in partnership with other health care providers, nursing homes and larger medical institutions - providing greater medical access to patients in more rural areas of the state. The organization serves as a vehicle for attracting charitable support, as well as a source of community volunteer activities. Student volunteers, youth volunteers and an active adult volunteer program support the mission of the health system by enhancing patient care and programs. A 2013 Community Benefit Report is now available via a link on the Hospital's website. 1 Randolph County Hooked on Fishing Not on Drugs PO Box 2293 Elkins WV 26241 501(c)(3) 13000 Support hooked on fishing, not on drugs programs Country Roads Transit PO Box 727 Elkins WV 26241 501(c)(3) 10000 Event sponsorship Part I, Line 2: The organization grants money to other 501(c)(3) organizations and relies on the IRS's oversight of the grantees as they have an exemption from the IRS. X 1 1 X X X X 0 1 0 0 0 0 0 0 0 Paul Hartel Board Member/Physician 259529 0 0 0 0 0 0 0 21664 0 281193 0 0 0 E Mark Doak President/CEO 294846 0 0 0 0 0 0 0 19449 0 314295 0 0 0 Rebecca Hammer CFO 181252 0 0 0 0 0 0 0 9569 0 190821 0 0 0 Mohamed M Fahim Physician 610798 0 0 0 0 0 0 0 23206 0 634004 0 0 0 Donald R Fleming Physician 450000 0 0 0 0 0 0 0 23273 0 473273 0 0 0 Charles K Kirkland Physician 412425 0 0 0 0 0 0 0 22074 0 434499 0 0 0 Marshall Sklar Physician 450000 0 0 0 0 0 0 0 10830 0 460830 0 0 0 John S Veach Physician 424575 0 0 0 0 0 0 0 11588 0 436163 0 0 0 Part I, Line 4b Mark Doak participated in a 457(f) plan. However, no amount was paid in 2013. Form 990, Part VI, Section A, line 6 Davis Health System is the parent corporation of Davis Memorial Hospital. The bylaws of the corporation designate Davis Health System as the sole corporate member of Davis Memorial Hospital, and granting all rights to members of nonprofit corporations by the laws of the state of West Virginia. Form 990, Part VI, Section A, line 7a Davis Health System is the parent corporation of Davis Memorial Hospital. The bylaws of the corporation designate Davis Health System as the sole corporate member of Davis Memorial Hospital, and granting all rights to members of nonprofit corporations by the laws of the state of West Virginia. Form 990, Part VI, Section A, line 7b Davis Health System is the parent corporation of Davis Memorial Hospital. The bylaws of the corporation designate Davis Health System as the sole corporate member of Davis Memorial Hospital, and granting all rights to members of nonprofit corporations by the laws of the state of West Virginia. Form 990, Part VI, Section B, line 11 The 990 will be distributed to all board members. It will be presented and discussed at a Board of Trustees meeting or a Finance Committee meeting, whichever occurs first after the completion of Form 990. If the Finance Committee meeting is the first to occur, all members of the Board of Trustees will be encouraged to attend the Finance Committee where the Form is to be discussed. Form 990, Part VI, Section B, line 12c The Davis Health System Conflict of Interest Policy requires that each director, officer, and committee member with board delegated powers shall annually sign a statement which affirms the person has received a copy of the conflict of interest policy and reads and understands the policy. Board members complete the statement in January of each year. The conflict of interest statements are reviewed by the Executive Committee. In addition to board members, senior staff are required to annually prepare a conflict of interest statement. Form 990, Part VI, Section B, line 15 The Compensation Committee of the Board of Trustees is responsible for the oversight of the compensation for the senior staff. A consultant (Yaffe & Company) is engaged who facilitates the annual evaluation process for determining compensation for executives. The consultant coordinates a series of meetings, leads discussions on the chief executive officer's performance evaluation, presents market analysis information for key positions and provides recommendations for salary levels based on that information. The committee makes their decision using the guidance of the consultant. Form 990, Part VI, Section C, line 19 The Board of Trustees adopted a Record Keeping and Disclosure Policy in January of 2003. The policy provides for disclosure of corporate and financial records not covered by governmental or contractual agreements. Any request for financial or other corporate documents are submitted to the Executive Committee of the Board of Trustees and decisions are made on a case by case basis. The Compliance Code of Conduct Policy includes standards relating to conflicts of interest within the organization. This information is shared with the public, being posted on the website in addition to being distributed to all patients admitted to the hospital. Form 990, Part XI, line 9: Equity method income of subsidiary -48,718. Change in pension funded status 0. Transfers to affiliates -1,769,695. Broaddus Hospital Association Inc PO Box 930 Philippi WV 26416 550379108 Hospital WV 501(c)(3) Line 3 N/A 0 Davis Health System Inc PO Box 1484 Elkins WV 26241 550737655 Health System WV 501(c)(3) Line 11b, II N/A 0 Davis Health System Foundation PO Box 1188 Elkins WV 26241 320185772 Supporting organization to health care organization WV 501(c)(3) Line 9 N/A 0 Health Facilities Inc 909 Gorman Avenue Elkins WV 26241 550516937 Health Care WV C -48718 11917044 1.00000 0 Central WV Medcorp Inc PO Box 2630 Elkins WV 26241 550739314 Physician Offices WV C 0 Elkins Regional Health Partners Physician Hospital Organization Inc PO Box 2632 Elkins WV 26241 550746206 Hospital Organization WV C 0 1 1 0 0 0 0 0 0 0 1 1 0 0 1 1 1 1 1 0 Health Facilities Inc A 59634 Cash - FMV Central WV Medcorp Inc B 199598 Cash - FMV Health Facilities Inc P 53604 Cash - FMV