2013-08-07T09:04:06-05:00 2012-09-30 550486667 Arnett Foster Toothman PLLC P O Box 2629 Charleston WV 25329 990 2011-10-01 550440086 Pleasant Valley Hospital PLEA 3046754340 2520 Valley Drive Pt Pleasant WV 25550 Richard Hogan 3046754340 2013-08-05 1 Harry C Harless P01042847 3043460441 2011 2016-02-24 21:20:13Z Thomas Schauer 2520 Valley Drive Pt Pleasant WV 25550 71783453 0 X www.pvalley.org X 1955 WV Provide quality inpatient and outpatient healthcare to the community regardless of ability to pay. Provide a wellness center to promote community health through fitness programs. 19 15 940 0 1300 0 193897 53248 69702851 70786499 96525 34913 953340 870872 70946613 71745532 17997 15637 0 0 40775854 39867268 0 0 0 32513865 33177217 73307716 73060122 -2361103 -1314590 41613039 40584241 17709086 17965499 23903953 22618742 To operate an acute care hospital facility for the citizens of Point Pleasant, West Virginia and the surrounding communities and counties. 0 0 61251085 15637 70485060 The hospital provided 42,598 acute, nursery, and skilled nursing days; 120,817 outpatient visits; 17,359 emergency room visits; 2,178 ambulatory surgeries; 1,446 observation visits; 13,954 home health visits; 1,447 hospice visits; and 56,270 physician office visits. 119417 222222 The hospital operates a wellness center which provides community health education and fitness programs that are available to hospital employees and all residents of the surrounding communities. 61370502 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 1 0 0 0 0 0 0 0 1 1 1 0 0 0 0 0 1 0 0 0 0 1 48 0 1 940 1 1 1 0 0 0 0 0 0 0 X 19 15 1 0 0 0 0 0 0 1 1 0 0 1 1 1 1 1 1 1 1 0 X Richard Hogan CFO 3046754340 2520 Valley Drive Point Pleasant WV 25550 Mario Liberatore 3.00 X 0 0 0 Peter Allinder 3.00 X 0 0 0 Annette Boyles 3.00 X 0 0 0 Charles Lanham 3.00 X 0 0 0 Michael Lieving 3.00 X 0 0 0 Scott Barnitz 3.00 X 0 0 0 Mike Bartrum 3.00 X 0 0 0 Jack Buxton OD 3.00 X 0 0 0 Clayton Faber 3.00 X 0 0 0 Randall Hawkins MD 3.00 X 0 0 0 William Tatterson 3.00 X 0 0 0 Thomas Willoughby 3.00 X 0 0 0 C Dallas Kayser 3.00 X 0 0 0 Dorsel Keefer 3.00 X 0 0 0 James Lockhart DDS 3.00 X 0 0 0 William Knight 3.00 X 0 0 0 James Rossi 3.00 X 0 0 0 R Michael Shaw 3.00 X 0 0 0 Lanes Williamson 3.00 X 0 0 0 Thomas Schauer 40.00 X 181400 0 33309 Hugh Collins 40.00 X 165977 0 27272 William A Barker Jr 40.00 X 161646 0 24886 Robert Lewis MD 40.00 X 649027 0 39507 James Toothman MD 40.00 X 641052 0 39517 Ori Tzuk MD 40.00 X 607439 0 39517 Clifford Roberson MD 40.00 X 558355 0 27902 Stephen Rerych MD 40.00 X 425879 0 39517 3390775 0 271427 28 0 1 0 NAPS Inc 714 1/2 Lee St Charleston WV 25301 Anesthesia 550506 Quest Diagnostics PO Box 740709 Atlanta GA 30374 Laboratory 542846 Crest Services 735 Plaza Blvd 210 Coppell TX 75019 Biomedical 321598 Comphealth Inc PO Box 972651 Dallas TX 75019 Healthcare provider staffing 222900 Ohio Valley Sleep Diagnostice Rt 1 Box 55 Claylick Rd Ripley WV 25271 Sleep lab 165800 9 4196 49052 53248 Patient Services 622110 70388546 70388546 Wellness Center 621111 222222 222222 From K-1: Premier Pur 900099 97814 96514 1300 Electronic health reco 900099 77917 77917 70786499 34913 34913 429410 37921 391489 391489 391489 Cafeteria & vending 722212 355155 355155 Gift shop 453220 50755 50755 Purchase discounts 900099 17304 17304 56169 56169 479383 71745532 70707282 1300 983702 15637 15637 415180 333057 82123 27937690 22411615 5526075 741334 594698 146636 8854729 7103264 1751465 1918335 1538888 379447 98836 98836 35837 35837 4400373 3529979 870394 337754 270946 66808 4869232 3901059 968173 699283 560965 138318 1009279 809644 199635 423362 339621 83741 480824 385717 95107 2858025 2292708 565317 1677859 1345978 331881 Bad debts 9055497 9055497 Medical supplies 3513356 3513356 Medicaid provider tax 1774109 1774109 Repairs & maintenance 1452525 1165216 287309 491066 428548 62518 73060122 61370502 11689620 0 916195 578367 7017663 8628887 11499660 9426373 123040 202913 1182891 1276175 551306 662721 73895356 56425222 18787759 17470134 224441 0 162927 138290 1147157 2200381 41613039 40584241 5378062 6435935 7830000 7110000 4501024 4419564 17709086 17965499 X 23903953 22618742 23903953 22618742 41613039 40584241 X -1314590 29379 X 0 1 1 X 0 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 1254831 1254831 320643 24103788 15623686 8800745 233667 232812 855 44619887 38724408 5895479 3362540 1844316 1518224 17470134 Bond issue costs 15706 Due from related parties 302199 Other receivables 1839184 Accrued interest 43292 2200381 Capital lease agreements 1887232 Estimated third party payor settlements 2532332 4419564 71745532 73060122 -1314590 29379 29379 -1285211 71787148 139430 139430 71647718 97814 97814 71745532 73072359 12237 12237 73060122 0 73060122 Part XI, Line 8 - Other Adjustments: Income per K-1: Premier Purchasing Partners -97,814. Distribution: Premier Purchasing Partners 127,193. Total to Schedule D, Part XI, Line 8: 29,379. Part XII, Line 2d - Other Adjustments: Distributions from Premier Purchasing Partners 127,193. Depreciation included in rental expenses on 990 12,237. Part XII, Line 4b - Other Adjustments: From K-1: Premier Purchasing Partners 97,814. Part XIII, Line 2d - Other Adjustments: Depreciation included in rental expenses on 990 12,237. 1 1 X 1 X 1 X 100.000000000000 1 1 0 1 1 346196 346196 0.00540 14719691 13316122 1403569 0.02190 15065887 13316122 1749765 0.02730 56883 6359 50524 0.00080 1131256 1131256 0.01770 50116 50116 0.00080 1238255 6359 1231896 0.01930 16304142 13322481 2981661 0.04660 13994 13994 0.00020 1107 1107 0.00000 2955 2955 0.00000 154212 154212 0.00240 10112 10112 0.00020 182380 182380 0.00280 1 3667476 794571 11358499 10236850 1121649 X 1 1 1 1 Pleasant Valley Hospital

2520 Valley Drive Pt Pleasant WV 25550

X X X Skilled nursing facility Pleasant Valley Hospital 1 1 1 100.000000000000 1 100.000000000000 1 X X X 1 1 X X X X 1 0 1 X 0 0 1 Pleasant Valley Hospital Nursing & Rehab

640 Sand Hill Road Point Pleasant WV 25550

Skilled nursing facility Part I, Line 7: The cost of charity care and unreimbursed Medicaid were estimated using a cost to charge ratio derived from Worksheet 2 of the Schedule H Instructions.The cost of (1) community health improvement services and community bnefit operations, (2) health professions education, and (3) cash and in-kind contributions was obtained from the hospital's accounting records. 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 $ 9055497. Part II: Our weight loss challenge gives the community the ability to use our wellness services. Our wellness services includes cardio and weight lifting machines and certified exercise physiologists. Blood pressure, weight, body fat were monitored before the challenge and after the challenge. This promotes a healthly lifestyle in the community. Mason County is a medically underserved area and the hospital spends money for recruitment for this area. The amount shown for workforce development is the amount paid to recruit new physicians to the area. How these activities promote the health of the communities served Part II - Community Building Activities Representation on boards of coalitions that build community capacity and share ideas. Part III, Line 4: 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. Patient accounts receivable are written off when deemed uncollectible. Recoveries of accounts previously written off are recorded as a reduction to bad debt expense when received. Interest is not charged on patient accounts receivable.Cost of bad debts was estimated using a cost to charge ratio derived from Worksheet 2 of the Schedule H instructions. Part III, Line 8: Medicare allowable costs were estimated using Worksheet B of the Schedule H instructions. Part III, Line 9b: Pleasant Valley Hospital has a charity care policy and a Collection and Bad Debt policy that discusses qualifying and eligibility for charity care, collection practices and handling of bad debt accounts. It is a practice to handle all patient accounts in the same manner/precedent. Patients are sent monthly statements - even while applying and pending financial assistance and will continue to receive statements until determination is made. Once determination is made the account balance or the % portion of the account balance is adjusted to "Financial Assistance". Pleasant Valley Hospital Part V, Section B, Line 13g: The policy is discussed with patients before they are discharged. Copy of the policy is provided to patients prior to discharge. Pleasant Valley Hospital Part V, Section B, Line 19d: Charges to bill patients are based on income level, asset level, and medical indigency. These were for patients who qualified for financial assistance. The Hospital also gave self-pay patients prompt pay discounts of of gross charges. Pateints were not denied financial assistance because the applications were incomplete. The applications were put on hold until the missing information was obtained. Part VI, Line 2: The Hospital participates in the State of West Virginia Abeyance program. We prepare reports for this probran identifying our community benefit programs. This information is reported to the West Virginia Healthcare Authority which makes its records available to the publice. Part VI, Line 3: The process in place offers the uninsured and underinsured patient the ability to apply for charity care through a formal application process established by reviewing both income and expense to make a final determination of eligibility. It requires proper verification of income through a pay stub, tax return, etc. It is also verified that the patient is not eligible for a state assisted program via a denial letter from the program or verification through the state caseworker. The patient will either be contacted by the Business Office or will contact the Business Office during the collection and statement process to discuss financial arrangements regarding their patient account. All options of payments will be discussed and charity care offered as an alternative option after screening the patient's financial ability to make payment. Part VI, Line 4: Pleasant Valley Hospital is a rural hospital in Point Pleasant, WV. Pleasant Valley Hospital serves mainly the people of Mason and Jackson County, WV and Meigs and Gallia County, OH. We are a federally designated medically underserved area. Mason County has 27,179 residents, the median household income is $36,468, and 17.8% are below poverty levels. Jackson County has 29,234 residents, the median household income is $43,191, and 16.7% are below poverty levels. Meigs County has 23,593 residents, the median household income is $33,708, and 21.3% are below poverty levels. Gallia County has 30,708 residents, the median household income is $36,918 and 20% are below poverty levels. Medicaid patients made up 23.8% of our total discharges and 16.3% of our total outpatient visits in FY 2012. Uninsured patients made up 4.6% of our total discharges and 4.3% of our total outpatient visits in FY 2012. There is one other not-for-profit hospital within 15 miles of PVH. They serve many of the same areas that we do. Part VI, Line 5: The majority of the organization's governing body is comprised of persons who reside in the organization's primary service area, who are neither employees or contractors of the organization, nor family members thereof. The hospital extends medical staff privileges to all qualified physicians in its community. The hospital provides a 24 hour emergency room and is available to all regardless of the ability to pay. All the services provided by the hospital are provided regardless of the ability to pay. The hospital has an auxiliary that helps our patients and visitors if they need a wheelchair when they arrive or if they need dirctions on where to go within the Hospital. The hospital provides Breast Cancer Screenings/Mammograms free to patients who cannot pay for the service. The hospital has a fitness center for the community and it also conducts many health fairs throughout the year. The hospital provides many health screenings throughout the year in addition to a nutritional program. Our SNF provides transportation for its residents to health facilities. The hospital has support groups for members of the community. The hospital donates money to the community for various projects. 1 Mason County Board of Education 1200 Main Street Point Pleasant WV 25550 556000353 501(c)(3) 10000 High school athletic program support 1 0 X X 1 1 X X X X 0 0 0 0 0 0 0 0 0 Thomas Schauer 180903 0 101 0 396 0 15088 0 19019 0 215507 0 0 0 Hugh Collins 40979 0 0 0 124998 0 15125 0 12512 0 193614 0 0 0 William A Barker Jr 161149 0 101 0 396 0 6665 0 19019 0 187330 0 0 0 Robert Lewis MD 435911 0 213062 0 54 0 21296 0 19501 0 689824 0 0 0 James Toothman MD 157198 0 483794 0 60 0 21296 0 19187 0 681535 0 0 0 Ori Tzuk MD 525000 0 82301 0 138 0 21296 0 20359 0 649094 0 0 0 Clifford Roberson MD 524992 0 32601 0 762 0 21296 0 8743 0 588394 0 0 0 Stephen Rerych MD 425016 0 101 0 762 0 21296 0 19878 0 467053 0 0 0 The County Commission of Mason County WV 556000352 575194BM6 2003-06-17 7805000 To refund Series 1993 bonds 0 0 0 The County Commission of Mason County WV 556000352 575194CH6 2006-10-12 3895000 Capital improvements & equipment acquisition 0 0 0 2630000 7805000 7021907 156100 626993 2003 0 0 1 1 1960000 3895000 389500 77900 3427600 2008 0 0 1 1 0 0 0 0 1 0 0 0 0 1 0 0 0 0 0 0 0 0 0 0 0 0 Lee Anne Kayser Family member of C. Dallas Kayser, Hospital Trustee 50245 Wages 0 Carrie Dillard MD Family member of James Lockhart, Hospital trustee 150111 Wages 0 Heather Lloyd Family member of James Lockhart, Hospital Trustee 34892 Fees for service-independent contractor 0 Jane Zirkle Family member of Mike Lieving, Hospital Trustee 23103 Wages 0 Wes Lieving DO Family member of Mike Lieving, Hospital Trustee 229027 Wages 0 Peoples Bank James Lockhart, Hospital Trustee, is a board member of the bank 832 Interest bearing checking accounts 0 Peoples Bank Dorsal Keefer, Hospital Truste, is a board member of the bank 832 Interest bearing checking accounts 0 Peoples Bank R. Michael Shaw, Hospital Trustee, is a board member of the bank 832 Interest bearing checking accounts 0 Ohio Valley Bank Mario Liberatore, Hospital Trustee, is an officer of the bank 30629 Interest on certificates of deposit 0 Ohio Valley Bank Lannes Williamson, Hospital Trustee, is a board member of the bank 30629 Interest on certificates of deposit 0 Farmers Bank Michael Lieving, Hospital Trustee, is an officer of the bank 3034 Interest on certificates of deposit 0 Carrie Dillard MD Family member of James Lockhart, Hospital Trustee 10000 Matching grant funds received to pay student loans. The hospital is in a federally designated medically underserved area. To aid in physician recruitment, the hospital received grant funds. The grant funds were paid directly to the educatinal institution. 0 Form 990, Part VI, Section A, line 2 Dallas Kayser, Charles Lanham, and Michael Shaw have a business relationship. Mario Liberatore and Lannes Williamson have a business relationship. Dallas Kayers's spouse and James Rossi have a business relationship. Form 990, Part VI, Section B, line 11 The 990 is prepared by the Hospital's independent accountants. It is then reviewed by the CFO and CEO and a copy is provided to the governing board before it is filed with the IRS. Form 990, Part VI, Section B, line 12c Each board member fills out a questionnaire at the end of the fiscal year. The questionnaire has questions on it that determine independence status and other relationships between board members and between the board member and the hospital. This helps in determining possible conflicts that may arise. In addition, the board members must sign a conflict of interest policy that requires them with due diligence to state that they have a conflict of interest when that conflict arises. The board member must leave the board meeting during discussions and voting. Form 990, Part VI, Section B, line 15 The compensation committee is made up of independent board members. These members are appointed by the board. The compensation committee decides the compensation of the CEO and VPs. The compensation committee consults with an independent consultant to determine a fair compensation for the CEO and VPs based on peer data. The Compensation committee has used this study to determine base salary for the CEO and VPs. The CEO contract is taken back to the board for final approval. Form 990, Part VI, Section C, line 19 These documents are available upon request for inspection at the hospital or by mailing a copy upon request. Changes in Net Assets or Fund Balances: Form 990, Part XI, line 5: Income per K-1: Premier Purchasing Partners -97,814. Distribution: Premier Purchasing Partners 127,193. Total to Form 990, Part XI, Line 5: 29,379. Pleasant Valley Hospital Foundation Inc 2420 Valley Dr Pt Pleasant WV 25550 200120079 Fundraising WV 501(c)(3) Line 9 N/A 0 Pleasant Valley Hospital Health Foundation Inc 2420 Valley Dr Pt Pleasant WV 25550 550649849 Scholarships/Healthcare WV 501(c)(3) Line 11b, II N/A 0 Pleasant Valley Home Medical Equipment Viand St Pt Pleasant WV 25550 550653315 Retail - Medical equipment sales & rental WV N/A C 328688 1636801 1.00000 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0