2013-05-13T15:03:51-05:00 2012-06-30 560747981 DIXON HUGHES GOODMAN LLP 500 RIDGEFIELD COURT ASHEVILLE NC 28806 990 2011-07-01 320090450 SOUTHERN CRESCENT HOSPITAL FOR SPECIALTY CARE INC SOUT 7708977600 11 UPPER RIVERDALE ROAD RIVERDALE GA 30274 BENNY WHITMORE 7708977600 2013-05-13 1 AMY BIBBY P00445891 8282542254 2011 2016-02-25 16:41:14Z BENNY WHITMORE 11 UPPER RIVERDALE ROAD RIVERDALE GA 30274 10886755 0 X N/A X 2002 GA THE MISSION OF SOUTHERN CRESCENT HOSPITAL FOR SPECIALTY CARE IS TO PROVIDE HIGH-QUALITY, LONG-TERM ACUTE CARE TO THE COMMUNITIES WE SERVE. 5 5 80 0 0 0 0 0 11938014 10882370 10450 2366 2486 2019 11950950 10886755 218286 261584 0 0 5541310 4690359 0 0 0 5530981 5379513 11290577 10331456 660373 555299 10487074 10759632 9913566 9630824 573508 1128808 X THE MISSION OF SOUTHERN CRESCENT HOSPITAL FOR SPECIALTY CARE IS TO PROVIDE HIGH-QUALITY, LONG-TERM ACUTE CARE TO THE COMMUNITIES WE SERVE. 0 0 8731909 261584 10882370 THE GOSPEL VALUES UNDERLYING THE MISSION STATEMENT CHALLENGES SOUTHERN CRESCENT HOSPITAL FOR SPECIALTY CARE TO MAKE CHOICES WHICH RESPOND TO THE PATIENT'S NEEDS IN PROVIDING THE NECESSARY SETTING FOR THE APPROPRIATE CONTINUUM OF CARE. SPECIAL CONSIDERATION IS GIVEN TO THOSE WHO ARE ECONOMICALLY DISADVANTAGED AND UNDERSERVED. THE HOSPITAL CARES FOR PATIENTS WHO ARE MEDICALLY COMPLEX AND MAY REQUIRE DAILY MONITORING: VENTILATOR DEPENDENT PATIENTS, OXYGEN DEPENDENT PATIENTS NEEDING RESPIRATORY REHABILITATION, PATIENTS WITH SLOW HEALING WOUNDS, PATIENTS BENEFITING FROM PHYSICAL, OCCUPATIONAL OR SPEECH THERAPY, AND FOR PATIENTS REQUIRING PALLIATIVE AND END OF LIFE CARE. THE MEDICAL AND THERAPEUTIC NEEDS OF THE PATIENTS ARE MET USING AN INTERDISCIPLINARY, HOLISTIC TEAM APPROACH INCORPORATING MEDICAL MANAGEMENT, PHYSICAL, RESPIRATORY, OCCUPATIONAL AND SPEECH THERAPIES IN AN EFFORT TO RESTORE INDIVIDUAL QUALITY OF LIFE TO AS HIGH A DEGREE AS POSSIBLE AND TO PROMOTE SELF-HELP AND INDEPENDENCE TO THE EXTENT FEASIBLE. THE SPIRITUAL NEEDS OF THE PATIENTS, FAMILIES, AND SIGNIFICANT OTHERS ARE PROVIDED FOR AS WELL. THE GROWTH AND DEVELOPMENT OF SOUTHERN CRESCENT HOSPITAL FOR SPECIALTY CARE IS DETERMINED BY THE HEALTH CARE NEEDS OF THE COMMUNITIES THAT IT SERVES, AVAILABLE RESOURCES, AND THE INTERRELATIONSHIP OF THOSE SERVING AND THOSE BEING SERVED. RESPONSIBLE STEWARDSHIP MANDATES THAT SOUTHERN CRESCENT HOSPITAL FOR SPECIALTY CARE SEARCH OUT NEW, EFFECTIVE MEANS TO DELIVER QUALITY HEALTH CARE AND TO PROMOTE WHOLENESS IN THE HUMAN PERSON FOR THOSE WHO REQUIRE THIS LONG-TERM ACUTE CONTINUUM OF CARE.THE VISION OF SOUTHERN CRESCENT HOSPITAL FOR SPECIALTY CARE IS TO PROVIDE HEALTH CARE THAT IS SPIRITUALLY ROOTED, FULLY INTEGRATED IN THE CONTINUUM OF CARE, SUPPORTIVE OF HEALTHIER COMMUNITIES, INNOVATIVE AND INTERDISCIPLINARY IN A HOLISTIC APPROACH TO CARE, AND COMPASSIONATE IN RESPONSE TO THE NEEDS OF PATIENTS IN THEIR LIFE JOURNEY. SOUTHERN CRESCENT HOSPITAL FOR SPECIALTY CARE'S APPROACH TO STRENGTHEN CURRENT MINISTRIES: TO IMPLEMENT INNOVATIVE APPROACHES TO CARING FOR THE WHOLE PERSON; TO INCREASE ACCESS TO HEALTH CARE FOR THE POOR AND UNDERSERVED THROUGH ADVOCACY AND OTHER INITIATIVES; TO MAKE A CONTRIBUTION TO CREATING HEALTHY COMMUNITIES; AND TO CREATE A WORK ENVIRONMENT FILLED WITH HOPE, DIGNITY, AND MUTUAL RESPECT.COMMUNITY BENEFITSIN SUPPORT OF ITS MISSION AND PHILOSOPHY REGARDING SOCIAL ACCOUNTABILITY, SOUTHERN CRESCENT HOSPITAL FOR SPECIALTY CARE PROVIDES CARE TO PATIENTS WHO BEAR A SIGNIFICANT HEALTH-CARE FINANCIAL BURDEN RELATIVE TO THEIR FINANCIAL RESOURCES. SOUTHERN CRESCENT HOSPITAL FOR SPECIALTY CARE CLASSIFIES THE RESOURCES UTILIZED FOR THE CARE OF PATIENTS BEARING A SIGNIFICANT HEALTH CARE FINANCIAL BURDEN AS COMPARED TO THEIR RESOURCES AS CHARITY CARE. CHARITY CARE INCLUDES THE COST OF SERVICES PROVIDED TO PERSONS WHO CANNOT AFFORD HEALTH CARE BECAUSE OF THE FINANCIAL BURDEN OF THE HEALTH CARE SERVICES AND/OR WHO ARE UNINSURED OR UNDERINSURED. CHARITY CARE IS PROVIDED WITHOUT CHARGE OR AT A CHARGE THAT IS LESS THAN THE USUAL CHARGE FOR SUCH SERVICES. THE DETERMINATION AS TO THE AMOUNT TO BE CHARGED, IF ANY, IS MADE ACCORDING TO A PATIENT'S ABILITY TO PAY, CONSIDERATION OF THE PATIENT'S ASSETS AND LIABILITIES, AND DETERMINED BY THE ESTABLISHED ELIGIBILITY CRITERIA BASED ON THE MOST CURRENT FEDERAL POVERTY GUIDELINES. A FINANCIALLY INDIGENT PATIENT IS ONE WHO IS UNINSURED OR UNDERINSURED AND WHOSE ECONOMIC CIRCUMSTANCES PLACE THEM AT OR UNDER 200% OF THE FEDERAL POVERTY GUIDELINES. A MEDICALLY INDIGENT PATIENT IS A PERSON WHOSE MEDICAL OR HOSPITAL BILLS AFTER PAYMENT BY THIRD-PARTY PAYERS EXCEEDS 25% OF THEIR ANNUAL GROSS INCOME. NO PATIENT IS REFUSED NECESSARY MEDICAL CARE ON THE BASIS OF THEIR INABILITY TO PAY.IN ADDITION TO UNCOMPENSATED COSTS, SOUTHERN CRESCENT HOSPITAL FOR SPECIALTY CARE SUPPORTS AND PARTICIPATES IN COMMUNITY BENEFIT PROGRAMS DESIGNED TO POSITIVELY IMPACT THE HEALTH STATUS OF THE COMMUNITIES SERVED.REIMBURSED GOVERNMENT SPONSORED PROGRAMSIN ADDITION TO THE PROVISION OF CARE WITHOUT EXPECTATION OF PAYMENT (CHARITY CARE), SOUTHERN CRESCENT HOSPITAL FOR SPECIALTY CARE PROVIDES SERVICES TO PERSONS COVERED UNDER GOVERNMENT SPONSORED PROGRAMS, INCLUDING MEDICARE, TRICARE (FORMERLY CHAMPUS WHICH PROVIDES CIVILIAN HEALTH CARE BENEFITS TO MILITARY PERSONNEL, MILITARY RETIREES AND THEIR DEPENDENTS, AND SOME MEMBERS OF THE RESERVE COMPONENT) AND TRICARE FOR LIFE (A MEDICARE SUPPLEMENT INSURANCE PROGRAM AVAILABLE TO INDIVIDUALS WHO HAD BEEN ELIGIBLE FOR TRICARE). AS ALREADY CITED, SOUTHERN CRESCENT HOSPITAL FOR SPECIALTY CARE PROVIDED MEDICAL SERVICES TO PERSONS COVERED UNDER THE FEDERAL MEDICARE PROGRAM WHICH, IN FACT, COMPRISED THE LARGEST SINGLE PAYER CLASSIFICATION OF PATIENTS SERVED BY THIS HEALTH SYSTEM. THE PAYMENT RATE FOR INPATIENT SERVICES IS ON A PER DISCHARGE RATE, CALCULATED BASED ON THE DIAGNOSTIC-RELATED GROUP INTO WHICH THE PATIENT IS CATEGORIZED. NUMBER OF PATIENTS SERVED BY THE LTACH: 294NUMBER OF PATIENT DAYS OF CARE PROVIDED BY THE LTACH: 7,294NUMBER OF PATIENT DAYS OF CHARITY CARE PROVIDED BY THE LTACH: 164CHARITY CARE COST: $ 168,252TOTAL PROGRAM SERVICE EXPENSES (GRANTS $261,584) $ 8,683,519 8731909 1 0 0 1 0 0 0 0 0 0 1 0 0 0 1 0 0 0 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 0 0 0 0 0 1 30 0 1 80 1 0 0 0 0 0 0 0 0 0 0 X 5 5 0 1 0 0 0 1 0 1 0 0 0 1 1 1 1 1 1 1 0 0 GA X MIKE MURRAY 7132772300 1700 WEST LOOP SOUTH STE 1100A HOUSTON TX 77027 BENNY R WHITMORE 2.00 X X 3812 0 0 WILLIAM E CASEY 1.00 X 5539 0 0 RONALD M DODSON 1.00 X 2679 0 0 MARGARET L MANOS 1.00 X 4365 0 0 MITCH JOHNSON 1.00 X 6060 0 0 JAN HAMILTON-CRAWFORD 40.00 X 196223 0 26063 218678 0 26063 1 0 1 1 SOUTHERN REGIONAL MEDICAL CENTER 1100 UPPER RIVERDALE ROAD SW RIVERDALE GA 30274 ANCILLIARY HOSPITAL SERVICES 1212809 CHRISTUS CONTINUING CARE DBA CDHS 919 HIDDEN RIDGE IRVING TX 75038 MANAGEMENT SERVICES 642936 PRECISE HEALTHCARE SOLUTIONS LLC 5300 MEMORIAL DR STE 134 STONE MOUNTAIN GA 30083 CONTRACT LABOR 254737 NELSON MULLINS RILEY & SCARBOROUGH LLP 1320 MAIN STREET COLUMBIA COLUMBIA SC 29201 LEGAL FEES 233048 ALLIANCE NURSE CORE INC 240 SMITHSTONE PATH FAYETTEVILLE GA 30214 CONTRACT LABOR 172437 6 NET PATIENT SERVICE 623000 10882370 10882370 10882370 2366 2366 TRANSCRIPTION FEES 561499 2019 2019 2019 10886755 10882370 0 4385 261584 261584 244741 244741 3778052 3577111 200941 116300 103344 12956 263133 233820 29313 288133 256035 32098 666871 666871 99463 99463 2361 2361 2098212 2037648 60564 12903 12903 406669 362103 44566 601744 601744 76500 16335 60165 84817 2372 82445 145670 145670 119048 89286 29762 MEDICAL SUPPLIES 1022721 1002323 20398 BAD DEBT 42534 42534 10331456 8731909 1599547 0 7555589 8256181 1944726 1523664 47899 59263 68868 74883 1977646 1138750 869992 838896 0 6745 10487074 10759632 935853 885864 7457 8977713 8737503 9913566 9630824 X 573508 1128808 573508 1128808 10487074 10759632 555299 0 X 0 0 0 X 0 0 0 0 0 0 0 0 1 2361 2361 0 EXPLANATION OF LOBBYING ACTIVITIES: PART II-B, LINE 1: THE HOSPITAL IS A MEMBER OF THE NATIONAL ASSOCIATION OF LONG TERM HOSPITALS AND THE GEORGIA HOSPITAL ASSOCIATION. THESE ORGANIZATIONS ENGAGE IN LOBBYING EFFORTS ON BEHALF OF THEIR MEMBERSHIP BODIES, AND EACH YEAR, A PORTION OF THE DUES PAID TO THESE ORGANIZATIONS IS ALLOCATED TO LOBBYING EXPENDITURES. FOR THE CURRENT YEAR, DUES ALLOCATED TO LOBBYING WAS APPROXIMATELY $2,361. 21250 14875 6375 1956396 1123875 832521 838896 DUE TO SOUTHERN REGIONAL 77770 DUE TO CHRISTUS DUBUIS HEALTH SYSTEM 250589 LITIGATION ACCRUAL 8409144 8737503 10886755 10331456 555299 555299 10886755 0 10886755 0 10886755 10331456 0 10331456 0 10331456 1 1 1 X 1 X 1 1 1 0 1 1 324823 324823 0.03160 324823 324823 0.03160 9684 9684 0.00090 245000 245000 0.02380 254684 254684 0.02470 579507 579507 0.05630 1 14304 X 1 1 1 1 SOUTHERN CRESCENT HOSP FOR SPEC CARE

11 UPPER RIVERDALE ROAD RIVERDALE GA 30274

X LONG-TERM ACUTE CARE HOSPITAL SOUTHERN CRESCENT HOSP FOR SPEC CARE 1 1 1 200.000000000000 1 400.000000000000 1 X X X X X X 1 1 X X 1 0 0 X X 0 0 PART I, LINE 3C: IN ADDITION TO PROVIDING CHARITY CARE BASED ON THE FEDERAL POVERTY GUIDELINES, THE HOSPITAL PROVIDES CARE TO MEDICALLY INDIGENT PATIENTS WHOSE MEDICAL OR HOSPITAL BILLS AFTER PAYMENT BY THIRD-PARTY PAYERS EXCEED 25% OF THE PATIENT'S ANNUAL GROSS INCOME AND THE PATIENT IS UNABLE TO PAY THE REMAINING BILL. PART I, LINE 7: WORKSHEET 2 OF THE 2011 SCHEDULE H INSTRUCTIONS WAS USED TO DERIVE A COST-TO-CHARGES RATIO USED TO CALCULATE AMOUNTS OF COMMUNITY BENEFIT EXPENSE AT COST FOR PART I, LINE 7. 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 $ 42534. PART III, LINE 4: SOUTHERN CRESCENT HOSPITAL FOR SPECIALTY CARE FOLLOWS IN PRINCIPLE HEALTHCARE FINANCIAL MANAGEMENT ASSOCIATION STATEMENT NO. 15. THE SYSTEM HAS ADOPTED AN UNCOMPENSATED CARE POLICY WHERE REVENUE FROM SERVICES PROVIDED TO THE UNINSURED IS RECOGNIZED AT THE TIME OF SERVICE, AND AN OFFSETTING ALLOWANCE FOR VOLUNTARY FREE CARE IS RECORDED. ACCORDINGLY, ALL ACCOUNTS RECEIVABLE FROM THE UNINSURED HAVE BEEN FULLY RESERVED IN THE ALLOWANCE FOR VOLUNTARY FREE CARE. THE ORGANIZATION DOES NOT ISSUE AUDITED FINANCIAL STATEMENTS. THE ORGANIZATION USES SCHEDULE H, WORKSHEET A TO DETERMINE THE BAD DEBT EXPENSE AT COST REPORTED ON SCHEDULE H, PART III, SECTION A, LINE 2 USING THE COST-TO-CHARGE RATIO CALCULATED ON FORM 990, SCHEDULE H, WORKSHEET 2, LINE 11. THE ORGANIZATION'S TOTAL BAD DEBT EXPENSE ATTRIBUTABLE TO PATIENT CHARGES (TOTAL OF ALL HOSPITAL FACILITIES) IS IN ACCORDANCE WITH THE ORGANIZATION'S FINANCIAL STATEMENTS. BAD DEBT EXPENSE IS NET OF: (1) CONTRACTUAL ALLOWANCES, (2) PAYMENTS RECEIVED AND (3) RECOVERIES OF BAD DEBT PREVIOUSLY WRITTEN OFF.ALL UNPAID PATIENT BALANCES ATTRIBUTABLE TO PATIENTS ELIGIBLE UNDER THE ORGANIZATION'S CHARITY CARE POLICY OR PATIENTS FOR WHOM SUFFICIENT INFORMATION WAS NOT OBTAINED TO MAKE A DETERMINATION OF THEIR ELIGIBILITY ARE WRITTEN OFF AS CHARITY CARE AND NOT TO BAD DEBT EXPENSE. PART III, LINE 8: THE ORGANIZATION USED AN INTERNAL EVALUATION PROCESS TO DETERMINE COSTS OF CARE RELATING TO MEDICARE PAYMENTS. PART III, LINE 9B: SOUTHERN CRESCENT HOSPITAL DOES NOT OUTSOURCE PATIENT BALANCES TO A THIRD PARTY DEBT COLLECTION AGENCY. ALL COLLECTIONS ARE DONE BY IN-HOUSE COLLECTORS USING COLLECTION LETTERS. PATIENTS ARE NOT SUBJECT TO HARASSMENT OR LEGAL ACTION DUE TO THEIR INCAPACITY TO PAY. PATIENTS THAT ARE UNABLE TO PAY ARE SENT CHARITY CARE INFORMATION.UPON ADMISSION, PATIENTS WHO HAVE NO INSURANCE COVERAGE AND NO ABILITY TO PAY WILL BE GIVEN CONSIDERATION FOR CHARITY CARE. EVERY EFFORT WILL BE MADE TO OBTAIN THE APPROPRIATE FINANCIAL DOCUMENTATION TO DETERMINE THE ABILITY TO PAY FOR SERVICES. PATIENTS RECEIVE PRIVATE LETTERS/BILLS EACH MONTH INDICATING THEIR BALANCE DUE. PATIENTS WHO HAVE NOT MADE PAYMENTS FOR A 30-DAY PERIOD WILL RECEIVE A LETTER REQUESTING PAYMENT. PATIENTS WHO ARE UNABLE TO PAY THEIR BALANCE WILL BE CONSIDERED FOR CHARITY CARE IF APPROPRIATE. COLLECTION EFFORTS WILL CONTINUE FOR 120 DAYS WITH THE PATIENT/GUARANTOR RECEIVING AT LEAST THREE LETTERS REQUESTING PAYMENT WITHIN SAID 120 DAY PERIOD. ACCOUNTS THAT ARE NOT DEEMED ELIGIBLE FOR CHARITY CARE OR MEDICAL INDIGENCE WILL BE WRITTEN OFF AS BAD DEBT FOLLOWING THE 120 DAY COLLECTION PERIOD. SOUTHERN CRESCENT HOSP. FOR SPEC. CARE PART V, SECTION B, LINE 11H: IN ADDITION TO PROVIDING CHARITY CARE BASED ON THE FEDERAL POVERTY GUIDELINES, THE HOSPITAL PROVIDES CARE TO MEDICALLY INDIGENT PATIENTS WHOSE MEDICAL OR HOSPITAL BILLS, AFTER PAYMENT BY THIRD-PARTY, PAYERS EXCEED 25% OF THE PATIENT'S ANNUAL GROSS INCOME AND THE PATIENT IS UNABLE TO PAY THE REMAINING BILL. SOUTHERN CRESCENT HOSP. FOR SPEC. CARE PART V, SECTION B, LINE 13G: PROVIDE THE GRANT APPLICATION FOR ASSISTANCE AFTER EVALUATING THE PATIENT'S FINANCIAL STATUS PRIOR TO ADMISSION. PART VI, LINE 2: SOUTHERN CRESCENT HOSPITAL OF SPECIALTY CARE HAS DEVELOPED THE 2012 COMMUNITY BENEFIT PLAN BASED UPON PRIORITIZATION OF THE COMMUNITY HEALTH NEEDS ASSESSMENT AND STRIVES TO ENSURE BEST PRACTICES AND STANDARDS OF CARE ARE MET. HEALTHCARE PRIORITIES INCLUDE: 1) PRIMARY CARE ACCESS, 2) GEOGRAPHIC DISPARITIES, 3) UNDER/UNINSURED/WORKING POOR, 4) ACCESS TO INFORMATION/REFERRALS, 5) CARDIOVASCULAR DISEASE, DIABETES, RESPIRATORY CANCER AND OTHER CHRONIC DISEASES, 6) SENIOR POPULATION, AND 7) 45-64 YEAR OLD POPULATION GROUPAN ADDITIONAL AREA OF FOCUS OVERLAPPING MANY OF THESE PRIORITIES IS THE ALREADY HIGH AND INCREASING PERCENTAGE OF CONSOLIDATED METROPOLITAN STATISTICAL AREA (CMSA) RESIDENTS OF HISPANIC DESCENT. BARRIERS TO ACCESS HEALTHCARE INCLUDE: 1) LIMITED ACCESS, 2) INABILITY TO PAY FOR SERVICES, 3) LACK OF TRANSPORTATION, AND 4) LANGUAGE BARRIERS AND CULTURAL DIFFERENCES SOCIOECONOMIC FACTORS IMPACTING ACCESS TO HEALTHCARE INCLUDE: 1) LACK OF EMPLOYMENT OPPORTUNITIES, 2) INCREASED NUMBER OF RESIDENTS WITH MEDIAN INCOME OF < $25,000, 3) OVER-UTILIZATION OF EMERGENCY DEPARTMENT (ED) FOR PRIMARY CARE SERVICES, AND 4) DIMINISHED HEALTH COVERAGE PART VI, LINE 3: ALL PATIENTS ARE ASSESSED DURING THE REGISTRATION PROCESS. PATIENTS IDENTIFIED AS POSSIBLE CHARITY CASES WILL BE ASKED TO COMPLETE AN APPLICATION FOR FINANCIAL ASSISTANCE. PATIENTS WHO MAY QUALIFY FOR FINANCIAL ASSISTANCE FROM A GOVERNMENTAL PROGRAM BUT ARE NOT CURRENTLY ENROLLED ARE REFERRED TO THE APPROPRIATE PROGRAM. PATIENTS WHO CAN PROVE ELIGIBILITY FOR MEDICAID BUT ARE NOT PATIENTS IN A MEDICAID-APPROVED HOSPITAL WILL BE DEEMED AS INDIGENT AND AUTOMATICALLY QUALIFY FOR CHARITY CARE. PATIENTS ADMITTED TO THE HOSPITAL WITH MEDICARE AS THE ONLY INSURANCE WILL BE MONITORED AS MEDICARE DAYS NEAR DEPLETION. THIRTY DAYS PRIOR TO THE END OF THE MEDICARE COVERAGE, AN INTERVIEW AND AN APPLICATION FOR FINANCIAL ASSISTANCE WILL BE REQUESTED AS APPROPRIATE. THESE PATIENTS ARE ASSESSED AS TO MEETING THE GUIDELINES FOR RECEIVING CHARITY CARE IF THE STAY SHOULD EXCEED MEDICARE COVERAGE LIMITS. AS SOON AS SUFFICIENT INFORMATION IS AVAILABLE CONCERNING THE PATIENT'S FINANCIAL RESOURCES AND ELIGIBILITY FOR GOVERNMENT ASSISTANCE, A DETERMINATION IS MADE CONCERNING THE PATIENT'S ELIGIBILITY FOR CHARITY. NO COLLECTION EFFORT IS PURSUED ON A CHARITY ACCOUNT AFTER SUCH DETERMINATIONS ARE MADE. PART VI, LINE 4: THE ORGANIZATION SERVES THE PATIENTS IN THE SOUTHERN CRESCENT OF THE METRO ATLANTA AREA. OUR PRIMARY SERVICE AREA INCLUDES CLAYTON COUNTY, FAYETTE COUNTY, HENRY COUNTY, AND PORTIONS OF SOUTH FULTON COUNTY. THE SOUTHERN CRESCENT IS A LARGE DIVERSE COMMUNITY AND THE ORGANIZATION OFFERS SERVICES TO MEET THESE VARIED NEEDS. THE STATE OF GEORGIA HAS 11% PERSONS 65 YEARS AND OVER AND 16.5% PERSONS BELOW POVERTY LEVEL. CLAYTON COUNTY HAS 6.9% PERSONS 65 YEARS AND OVER AND 18.4% PERSONS BELOW POVERTY LEVEL. FAYETTE COUNTY HAS 13.9% PERSONS 65 YEARS AND OVER AND 5.9% PERSONS BELOW POVERTY LEVEL. HENRY COUNTY HAS 8.8% PERSONS 65 YEARS AND OVER AND 9.5% PERSONS BELOW POVERTY LEVEL. FULTON COUNTY HAS 9.2% PERSONS 65 YEARS AND OVER AND 15.9% PERSONS BELOW POVERTY LEVEL. PART VI, LINE 5: SURPLUS FUNDS ARE APPLIED EITHER TO COMMUNITY CHARITY CARE NEEDS OR TO OTHER EXEMPT ORGANIZATIONS IN THEIR MISSION TO SUPPORT COMMUNITY NEEDS. ADDITIONALLY, A MAJORITY OF THE GOVERNING BOARD OF THE HOSPITAL IS COMPRISED OF LOCAL PEOPLE FROM THE COMMUNITY TO ENSURE THAT RESIDENTS ARE REPRESENTED. THE HOSPITAL EXTENDS MEDICAL STAFF PRIVILEGES TO ALL QUALIFIED PHYSICIANS IN ITS COMMUNITY. PART VI, LINE 6: THE ORGANIZATION IS NOT PART OF AN AFFILIATED HEALTHCARE SYSTEM. REPORTS FILED WITH STATES PART VI, LINE 7 GA 1 SOUTHSIDE MEDICAL CENTER INC 1046 RIDGE AVENUE SW ATLANTA GA 30315 581131002 501(C)(3) 200000 OPERATIONAL SUPPORT TO PROMOTE EXEMPT PURPOSE SOUTHERN REGIONAL MEDICAL CENTER FOUNDATION 11 UPPER RIVERDALE ROAD RIVERDALE GA 30274 581983516 501(C)(3) 45000 SPONSOR EVENT PROVIDING SCREENINGS TO COMMUNITY AND HELP PURCHASE MRI FOR SOUTHERN REGIONAL MEDICAL CENTER ARTS CLAYTON GALLERY 136 MAIN STREET JONESBORO GA 30236 581727604 501(C)(3) 6900 SUPPORT CHILDREN'S LOCAL ART PROGRAM 3 0 PROCEDURE FOR MONITORING GRANTS IN THE U.S.: PART I, LINE 2: SCHEDULE I, PART I, LINE 2: THE GRANT TO SOUTHSIDE MEDICAL CENTER, INC., A TAX EXEMPT ENTITY, WAS APPROVED BY THE BOARD AND DOCUMENTED IN THE BOARD MINUTES AND IS MADE ACCORDING TO AN AGREEMENT EFFECTIVE 11/14/2008 BETWEEN SOUTHSIDE MEDICAL CENTER, INC. AND SOUTHERN CRESCENT HOSPITAL FOR SPECIALTY CARE. THE AGREEMENT STATES THAT SOUTHERN CRESCENT HOSPITAL WILL PROVIDE IN TOTAL FINANCIAL ASSISTANCE UP TO $400,000 DURING THE THREE YEAR TERM OF THE AGREEMENT TO COVER OPERATION SHORTFALLS AND A ONE-TIME START UP COST REIMBURSEMENT. THE AGREEMENT WAS ENTERED INTO SO THAT SOUTHSIDE MEDICAL CENTER WOULD BE ABLE TO SERVE THE UNDERSERVED PATIENT COMMUNITY WITHIN THE SERVICE AREAS OF SOUTHERN CRESCENT HOSPITAL REGARDLESS OF THE PATIENT'S ABILITY TO PAY. SOUTHSIDE MEDICAL CENTER IS REQUIRED TO SUBMIT AN ITEMIZATION OF COSTS TO BE APPROVED BY SOUTHERN CRESCENT PRIOR TO EACH PAYMENT. X 0 0 0 0 0 1 0 0 0 JAN HAMILTON-CRAWFORD 163842 0 32381 0 0 0 19337 0 6726 0 222286 0 0 0 PART I, LINE 6 CHRISTUS CONTINUING CARE (CCC), THE MANAGEMENT ORGANIZATION, MAINTAINS A PAY FOR PERFORMANCE PLAN APPLICABLE TO EMPLOYEES OF CCC. AWARDS ARE DETERMINED AT THE END OF EACH FISCAL YEAR. TO BE ELIGIBLE TO RECEIVE AN AWARD, A PARTICIPANT MUST: 1) HAVE BEEN A PLAN PARTICIPANT DURING THE FISCAL YEAR ON WHICH THE AWARDS ARE BASED; 2) HAVE MET BASIC BEHAVORIAL EXPECTATIONS OF MANAGEMENT PERSONNEL; 3) HAVE RECEIVED A "PERFORMING WELL" OVERALL RATING ON HIS/HER ANNUAL PERFORMANCE FEEDBACK/REVIEW FOR THAT FISCAL YEAR; AND 4)EITHER BE EMPLOYED IN A MANAGERIAL POSITION ON THE LAST DAY OF THE FISCAL YEAR OR HAVE TERMINATED EMPLOYMENT WITH CCC DURING THE FISCAL YEAR DUE TO DEATH, DISABILITY, RETIREMENT ON OR AFTER AGE 55, INVOLUNTARY TERMINATION AS A RESULT OF ELIMINATION OF SUCH PARTICIPANT'S EMPLOYMENT POSITION, OR THE ACCEPTANCE OF AN INVOLUNTARY TRANSFER TO AN INELIGIBLE POSITION. FINALLY, ANY PREREQUISITE TARGET (I.E. REGIONAL TRIGGERS) ESTABLISHED MUST BE ACHIEVED BEFORE AWARDS ARE GRANTED. PLAN PARTICIPANTS IN ANY OTHER LUMP-SUM INCENTIVE AWARD, BONUS OR SUCCESS SHARING PLAN SPONSORED BY THE ORGANIZATION AT THE SAME TIME THEY PARTICIPATE IN THE PLAN UNLESS APPROVED BY ADMINISTRATION. THE BOARD FOR SOUTHERN CRESCENT HOSPITAL FOR SPECIALTY CARE DOES NOT SPECIFICALLY APPROVE THE COMPENSATION OF THE CEO BUT INSTEAD APPROVES THE PROCESS FOR DETERMINING THE COMPENSATION USED BY CCC. SUPPLEMENTAL INFORMATION PART III COMPENSATION FROM UNRELATED ORGANIZATIONS: JAN HAMILTON-CRAWFORD RECEIVED COMPENSATION FROM CHRISTUS DUBUIS HEALTH SYSTEM, AN UNRELATED ORGANIZATION, THAT MANAGES SOUTHERN CRESCENT HOSPITAL FOR SPECIALTY CARE AND WHO LEASES THEIR EMPLOYEES TO PERFORM SERVICES FOR THE FILING ORGANIZATION. SHE RECEIVED NO DIRECT COMPENSATION FROM SOUTHERN CRESCENT HOSPITAL FOR SPECIALTY CARE. COMPENSATION REPORTED ON PART II REFLECTS AN AMOUNT OF TOTAL COMPENSATION ALLOCATED TO SERVICES PERFORMED SPECIFICALLY FOR THE FILING ORGANIZATION. FORM 990, PART VI, SECTION A, LINE 3 SOUTHERN CRESCENT HOSPITAL IS MANAGED BY CHRISTUS CONTINUING CARE (D/B/A "CHRISTUS DUBUIS HEALTH SYSTEM"). THE EMPLOYEES OF CHRISTUS DUBUIS HEALTH SYSTEM ARE LEASED TO SOUTHERN CRESCENT HOSPITAL TO PERFORM SERVICES. ALL EMPLOYEE POLICIES OF CHRISTUS DUBUIS HEALTH SYSTEM APPLY TO EMPLOYEES WORKING WITHIN CHRISTUS DUBUIS HEALTH SYSTEM AND EMPLOYEES LEASED TO SOUTHERN CRESCENT HOSPITAL. FORM 990, PART VI, SECTION A, LINE 7A THE ORGANIZATION HAS NO OFFICIAL MEMBERS; HOWEVER, SOUTHERN REGIONAL HEALTH SYSTEM, A GEORGIA NONPROFIT CORPORATION, APPOINTED THE INITIAL BOARD, AND RETAINS THE RIGHT TO APPOINT UP TO TWO MEMBERS. FORM 990, PART VI, SECTION A, LINE 8B THERE ARE NO COMMITTEES WITH AUTHORITY TO ACT ON BEHALF OF THE GOVERNING BODY. FORM 990, PART VI, SECTION B, LINE 11 THE RETURN IS PREPARED BY AN INDEPENDENT ACCOUNTING FIRM. THE ORGANIZATION REVIEWS THE PREPARED RETURN FOR ACCURACY. UPON COMPLETION OF THE FINAL FORM 990 BY THE INDEPENDENT ACCOUNTING FIRM, THE 990 IS SUBMITTED TO THE BOARD OF DIRECTORS FOR REVIEW AND APPROVAL PRIOR TO FILING THE RETURN WITH THE INTERNAL REVENUE SERVICE. FORM 990, PART VI, SECTION B, LINE 12C THE ORGANIZATION MAINTAINS SEPARATE CONFLICT OF INTEREST POLICIES FOR EMPLOYEES OF THE ORGANIZATION AND FOR THE MEMBERS OF THE BOARD OF DIRECTORS. BOTH POLICIES REQUIRE ANNUAL DISCLOSURE OF ANY CONFLICTS OF INTEREST. THE EMPLOYEE POLICY INCLUDES OFFICERS, MEDICAL DIRECTORS AND OTHER DIRECTORS, AND ALL OTHER ASSOCIATES. THE EMPLOYEE DISCLOSURE IS REVIEWED BY THE EMPLOYEE'S IMMEDIATE SUPERVISOR. IN ADDITION, KEY LEADERS MUST CERTIFY ANNUALLY THEIR RECEIPT AND UNDERSTANDING OF THE CONFLICT OF INTEREST POLICY. IF ANY CONFLICTS ARE PRESENT, THE EMPLOYEE AND THE ORGANIZATION'S ADMINISTRATION WILL IMPLEMENT A MUTUALLY AGREED UPON PLAN TO RESOLVE THE CONFLICT. IN ADDITION, THE ORGANIZATION IMPLEMENTS AN INTEGRITY PROGRAM TO SUPPORT AND MAINTAIN THE CORPORATE INTEGRITY OF THE ORGANIZATION. THE POLICY FOR THE MEMBERS OF THE BOARD OF DIRECTORS REQUIRES ANY BOARD MEMBER, UPON DETERMINATION OF A CONFLICT OF INTEREST, TO ABSENT HIMSELF OR HERSELF WITHOUT COMMENT FROM NOT ONLY THE VOTE BUT ALSO FROM THE DELIBERATION. BOARD MEMBERS ARE NOT ALLOWED TO BE EMPLOYED BY THE ORGANIZATION UNLESS THEY HAVE FIRST RESIGNED FROM THE BOARD. IN ADDITION, AT THE BEGINNING OF EACH BOARD MEETING, THE BOARD CHAIR ASKS THE BOARD MEMBERS TO REVIEW THE AGENDA AND SHARE ANY POTENTIAL CONFLICTS OF INTEREST PRIOR TO THE BEGINNING OF BUSINESS. FORM 990, PART VI, SECTION B, LINE 15A THE SALARY FOR THE PRESIDENT/CHAIRMAN OF THE BOARD OF DIRECTORS WAS DETERMINED WHEN THE ORGANIZATION WAS INCORPORATED AND WAS BASED ON COMPARATIVE SALARIES FROM PREVIOUS BOARD ASSIGNMENTS. IN DETERMINING THE SALARY FOR THE CEO, THE BOARD APPROVED PROCEDURES USED BY THE MANAGEMENT ORGANIZATION, CHRISTUS CONTINUING CARE (CCC). CCC USES THE SAME PROCEDURE FOR THE CEO AS IS USED FOR ALL OTHER EMPLOYEES. THE HUMAN RESOURCES DEPARTMENT USES CITY AND STATE SALARY SURVEYS AVAILABLE TO THE PUBLIC AND COMPARATIVE SALARY RATES USED IN THE VARIOUS HOST HOSPITALS. THE SALARY RATES ARE PERIODICALLY REVIEWED BY THE HUMAN RESOURCES DEPARTMENT AND REVISED BASED ON CHANGES IN THE MARKET PLACE. A SURVEY WAS CONDUCTED BY SULLIVAN COTTER IN 2010 CONFIRMING CURRENT SALARY LEVELS ARE COMPARABLE TO OTHER ORGANIZATIONS AND REASONABLE. FORM 990, PART VI, SECTION C, LINE 18 PHOTOCOPIES OF THE FORM 1023 AND RECENT FILINGS OF THE FORM 990 ARE AVAILABLE UPON REQUEST AT THE ORGANIZATION'S ADMINISTRATIVE OFFICE. FORM 990, PART VI, SECTION C, LINE 19 FINANCIAL STATEMENTS ARE MADE AVAILABLE UPON REQUEST. FORM 990, PART V, LINE 2: SOUTHERN CRESCENT HOSPITAL FOR SPECIALTY CARE ENTERED INTO A MANAGEMENT AGREEMENT WITH CHRISTUS DUBUIS HEALTH SYSTEM, AN UNRELATED ORGANIZATION. AS PROVIDED BY THE MANAGEMENT AGREEMENT, CHRISTUS DUBUIS HEALTH SYSTEM AGREES TO PROVIDE TO THE HOSPITAL AN ADMINISTRATOR AND ALL OTHER EMPLOYEES REQUIRED TO STAFF THE HOSPITAL. SOUTHERN CRESCENT HOSPITAL FOR SPECIALTY CARE PAYS DIRECTLY FROM THEIR BANK ACCOUNT THE SALARIES OF ALL EMPLOYEES OTHER THAN THE ADMINISTRATOR AND REIMBURSES CHRISTUS DUBUIS HEALTH SYSTEM FOR THE SALARY EXPENSE OF THE ADMINISTRATOR AND THE PAYROLL TAXES AND EMPLOYEE BENEFITS ASSOCIATED WITH THE ADMINISTRATOR AND ALL OTHER EMPLOYEES. UNDER THIS ARRANGEMENT THERE ARE NO EMPLOYEES OF SOUTHERN CRESCENT HOSPITAL AND THUS NO FORMS W-2 ISSUED BY SOUTHERN CRESCENT HOSPITAL FOR SPECIALTY CARE; HOWEVER, THE EXPENSES RELATED TO THESE EMPLOYEES ARE SHOWN AS SALARY, PAYROLL TAX AND EMPLOYEE BENEFIT EXPENSES ON FORM 990 PART IX.