2013-08-15T06:56:52-05:00 2012-09-30 550486667 Arnett Foster Toothman PLLC P O Box 2629 Charleston WV 25329 990 2011-10-01 550462730 Community Health Association dba Jackson General Hospital COMM 3043722731 PO Box 720 Pinnell Street Ripley WV 25271 Stephanie L McCoy 3043722731 2013-08-07 1 Mark Pendleton P01040856 3043460441 2011 2016-02-25 16:41:14Z Jackson General Hospital Stephanie L McCoy PO Box 720 Pinnell Street Ripley WV 25271 27949329 0 X www.jacksongeneral.com X 1964 WV To promote the general health and welfare of citizens of Jackson County, West Virginia and surrounding areas by furthering all legitimate methods for the prevention and treatment of disease and the positive promotion of health, both personal and public. 15 15 344 54 0 0 186141 142086 26998052 27446673 113226 595 379003 359975 27676422 27949329 0 0 0 0 14555573 14432364 0 0 0 13114710 13293009 27670283 27725373 6139 223956 7741929 10891778 8592796 11518689 -850867 -626911 To promote the general health and welfare of citizens of Jackson County, West Virginia and surrounding areas by furthering all legitimate methods for the prevention and treatment of disease and the positive promotion of health, both personal and public. 0 0 21637488 27404058 Services provided included 5,045 inpatient days, 12,194 emergency room visits, and 14,392 rural health clinic visits. Charity care for the year amounted to $1,684,042. 92385 42615 The organization provided several community health improvement services including a patch 21 program, free breast cancer screenings, lunch and learn programs, patient/community resource center, free sports physicals, prostate screenings, cardiac kids, advance directives presentations, CPR classes, diabetic counseling, dinner discussions, health fairs, aid the Jackson County Drug Coalition, and various other programs. 21729873 1 1 0 0 0 0 0 0 0 0 1 0 0 0 1 0 1 0 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 0 0 0 0 0 1 35 0 1 344 1 0 0 0 0 0 0 0 0 0 0 X 15 15 0 0 0 0 0 0 0 1 1 0 0 1 1 1 1 1 1 1 1 0 X Angela D Frame CFO 3043731476 PO Box 720 Pinnell St Ripley WV 25271 Gareth Smith 1.00 X 0 0 0 John Gorrell 1.00 X 0 0 0 Dr James G Gaal 1.00 X 0 0 0 Mitch Carmichael 1.00 X 0 0 0 Lee Corder 1.00 X 0 0 0 Naoma Fisher 1.00 X 0 0 0 Dr James T Hughes 1.00 X 0 0 0 Luke Hunter 1.00 X 0 0 0 Keith Rake 1.00 X 0 0 0 Todd Ritchie 1.00 X 0 0 0 Becky Scarberry 1.00 X 0 0 0 Debbie Sisson 1.00 X 0 0 0 Dick Waybright 1.00 X 0 0 0 Tom Weyer 1.00 X 0 0 0 Rob Fisher 1.00 X 0 0 0 Stephanie McCoy 40.00 X 155984 0 17802 Angela D Frame 40.00 X 88417 0 17802 Jeffrey Barton 80.00 X 298151 0 21486 Paul Burke 80.00 X 264237 0 7933 Michael Mcintosh 80.00 X 237393 0 0 Edward Stewart 80.00 X 273344 0 7933 Paul Nielsen 80.00 X 242515 0 15001 1560041 0 87957 8 0 1 0 Alliance Healthcare Services PO Box 96485 Chicago IL 25281 MRI Services 356136 Anthony J McEldowney PO Box 720 Ripley WV 25271 Orthopedic Surgeon 251250 Haven Ltd 1 Haven Lane Kenna WV 25248 Emergency Physicians 216852 NAPS Inc 2215 Smith Road Charleston WV 25339 Anesthesia Services 124668 Kimberly Ann Burgess PO Box 11690 Charleston WV 25339 Orthopedic Surgeon 115781 5 13500 63828 64758 142086 Patient services 621990 27252363 27252363 Walmart clinic 621990 194310 194310 27446673 595 595 94886 0 94886 94886 94886 Cafeteria & Vending 722210 138244 138244 Rebates 900099 16775 16775 Retail Pharmacy 446110 12490 12490 97580 97580 265089 27949329 27446673 0 360570 274069 197933 76136 10863050 7845295 3017755 25540 18445 7095 2475341 1787691 687650 794364 573690 220674 180694 180694 108017 108017 2634483 1997325 637158 88771 64110 24661 1414034 1021215 392819 204181 147460 56721 332364 240033 92331 14106 10187 3919 232856 168169 64687 531347 383739 147608 426278 307858 118420 Bad Debts 4036762 4036762 Medical Supplies 1927995 1927995 Medicaid Provider Tax 679376 679376 Dues & Subscriptions 70864 51178 19686 410881 271412 139469 27725373 21729873 5995500 0 89473 71609 453681 483659 3846869 7332066 179438 180890 114386 237650 14721069 12150295 2958017 2570774 100065 15130 7741929 10891778 5191742 5426855 2175000 1856167 500000 476112 726054 3759555 8592796 11518689 X -850867 -626911 -850867 -626911 7741929 10891778 223956 0 X X 0 1 1 X 0 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 92189 92189 5524932 4588838 936094 8683671 7212388 1471283 420277 349069 71208 2570774 Capital leases 118635 SIR limit on malpractice claims 3410463 Estimated third-party payor settlements 140274 Line of credit 90183 3759555 27949329 27725373 223956 223956 23881810 14819 14819 23866991 4082338 4082338 27949329 23643035 0 23643035 4082338 4082338 27725373 Part XII, Line 2d - Other Adjustments: Foundation income 14,819. Part XII, Line 4b - Other Adjustments: Bad debts netted against income in financial statements 4,036,762. Grant expenses netted with grant revenue in financial statements 45,576. Part XIII, Line 4b - Other Adjustments: Grant expenses netted with grant revenue in financial statements 45,576. Bad debts netted against income in financial statements 4,036,762. 1 1 1 X 0 0 1 1 0 1 1 567329 567329 0.02050 3787440 2731556 1055884 0.03810 4354769 2731556 1623213 0.05860 23 1508 72385 42615 29770 0.00110 23 1508 72385 42615 29770 0.00110 23 1508 4427154 2774171 1652983 0.05970 0 1320021 6255619 6118983 136636 X 1 1 1 1 Jackson General Hospital

PO Box 720 Ripley WV 25271

X X X Jackson General Hospital 1 1 X X X X X X X X X 11 1 0 1 X X 1 1 1 200.000000000000 0 1 X X X X X X X 1 1 X X 1 X X X 1 X X X X X X X X 1 X 0 0 Part I, Line 3c: The organization determines eligiblity for discounted care on a case-by-case basis based on ineligibility for other coverage, income and prepay or "quick pay" discounts. Community benefit report Schedule H, Part I, line 6a Community leaders and other health care providers in the community who were involved in Community Needs Assessment were provided copies of the final report. This report is available to the general public upon request. Part I, Line 7: The cost of charity care, Medicaid at cost and other means tested goverment programs were estimated using a cost to charge ratio derived from Worksheet 2 of the Schedule H instructions. 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.In order to claim a receivable as a bad debt, it must be established that the debt relates to covered services and is derived from deductible, coinsurance amounts and/or noncovered services that ABN has been signed by patient and processed by Medicare as patient responsible, reasonable collection efforts were made, that the debt was actually uncollectible when claimed, and that sound business judgment indicates there is no likelihood of future recovery. Part III, Line 9b: We use the same policy and procedure for all patients, regardless of whether we know they have/had qualified in the past. Any patient that presents for assistance will go through the same application process. Even if they have been previously approved. This is required in case of any financial changes to assure patient still qualifies for assistance, no change in employment or insurance acquired. Once a patient qualifies for charity care, and service is provided, we issue a financial assistance card effective with first date service is performed. This card is valid at our facility only, for services up to 6 months. The patient must re-apply once additional services are performed after terminiation date. Once approved and within valid time frames if these patients present for services they are then registered as Charity Care instead of Self Pay. Jackson General Hospital Part V, Section B, Line 11h: We publicize that the application is available and for assistance to call. We also list on the back of our statements our notice of charity applications, discounts, etc. with contact information. Jackson General Hospital Part V, Section B, Line 13g: Jackson General Hospital Financial Counselors attempt to call patients and uses scripting that includes notifying the patient of charity applications, prompt pay discounts, contract agreements, etc. Jackson General Hospital Part V, Section B, Line 15e: Jackson General Hospital places claims with collection agency if they are over 120 days old with no response or any type of contact from the patient or guarantor. Jackson General Hospital Part V, Section B, Line 16e: Our collection agency reports any non payments to the credit bureau, also may file against an estate. Jackson General Hospital Part V, Section B, Line 17e: Jackson General Hospital Staff also attempts to call the patient and/or send a pre-bad debt letter to the patient advising if no response is received, their account may be turned over to an outside agency. Jackson General Hospital Part V, Section B, Line 19d: All our patients are charged the same fee for all services, whether insured or uninsured. We do offer prompt pay discounts for same day services/payment in full at 40% of charges for uninsured patients. Every patient underinsured or uninsured has the opportunity to discounts once the first statement is received. Balances over $100.00 if paid within first 30 days of statement can qualify for 25% discount, within 60 days of statement it drops to 15% discount. Note: For emergency patients financials are not discussed the day of service but once the patient is triaged/medical assessed the patient can make a payment (charges are not complete) then once the statement is complete the patient will qualify for the same 40% option. Part VI, Line 2: Jackson General Hospital assesses the health needs of the communities it serves through community needs assessments, patient satisfaction survey results, the complaint resolution process, and through interviews with the medical staff, employees, vendors and guests, as well as through collaboration with the local health department, EMS, county nursing homes and home health agencies. The latest formal Community Needs Assessment was performed in 2012. Part VI, Line 3: The organization has a Resource Center Coordinator that educates and discusses federal/state and/or local government guideline options with all Inpatients/Observations patients.The organization posts, at each point of registration, all services advising of prompt pay discounts, charity care program and discounted care program. Every statement has on the back stating how to inquire about charity assistance program and/or discount opportunities.Once statements are received, the organization's Financial Counselors attempt to contact every Self Pay individual for discussion of their payment options. Part VI, Line 4: Jackson County is a rural community with a population of 29,211. As of February 2012, the unemployment rate in Jackson County was 10.6%. The median household income in 2010 for Jackson County was $41,405, with 17.8% of residents below the federal poverty guideline. 7% of the hospital's patients are uninsured and 13% are covered by Medicaid.Jackson County is designated a medically underserved area. Surrounding counties are also federally designated to be medically underseved areas either entirely or partially, including Cabell County, Kanawha County, Mason County and Roane County. Part VI, Line 5: Jackson General Hospital has a governing board comprised largely of independent community members representing the makeup of the area we serve. Jackson General Hospital is privileged to have an open medical staff comprised of qualified physicians who work with us to provide care to our community. All qualified physicians who are granted privileges to serve must undergo thorough and comprehensive credentialing and ongoing peer review processes. Jackson General Hospital reinvests all surplus funds back in to the community we serve though expanded health services, new and updated technologies, and facility improvements. In fiscal year 2012, Jackson General Hospital expended more than $232,000 for capital projects, most notably for a new General Electric X-Ray room and Sterilization equipment for the Surgery Department. Jackson General Hospital provides an emergency room 24 hours per day open to all those in need of emergency care, regardless of patient's ability to pay. Specialized services provided at Jackson General Hospital include general surgery, anesthesia, urology, ophthalmology, ENT, and emergency services. Jackson General Hospital is helped through the charitable efforts of the Jackson General Hospital Foundation Board and JGH Hospital Auxiliary. The report of community benefit is included as a written report and summarizes activities and programs to improve health including proactive community health services conducted during the prior year. The annual report is simply a snapshot of how the organization distinguishes itself in its vision to be the outstanding rural healthcare provider in WV through recruitment and retention of high quality medical staff and employees, through reasonable investment in new technology, and through networking with local and regional healthcare partners and to have a key leadership role in providing high quality acute care services and improve the health status of the community through outreach, networking, and implementation of community based programs. The Jackson General Hospital Community Benefit Report can be found at www.jacksongeneral.com.Jackson General Hospital provides a full range of inpatient and outpatient services to the people of Jackson and surrounding counties. The hospital conducts all activities and serves its health care purpose without regard to race, color, creed, religion, gender, orientation, disability, age or national origin. Jackson General Hospital collaborates with communities, churches, businesses, and other health care organizations to facilitate and strengthen accessibility of quality comprehensive health care services for all, particularly the vulnerable and underserved populations. JGH also supports local community health services, offering convenient locations for primary and urgent care, mobile outreach programs, and other outreach services such as free health physicals, health fair activities offering basic lab testing at cost, as well as free patient education on an outpatient basis. Jackson General Hospital is dedicated to improving the health status of the community through programs that place needed services where they are needed the most, with special attention and preference given to programs that support and benefit the health and welfare of the poor and underserved. Jackson General Hospital is one of the community's largest private employers. Part VI, Line 6: The organization is not part of an affiliated health care system. X X X X X 0 0 0 0 0 0 0 0 0 Stephanie McCoy 155984 0 0 0 0 0 0 0 18843 0 174827 0 0 0 Jeffrey Barton 298151 0 0 0 0 0 0 0 22836 0 320987 0 0 0 Paul Burke 264237 0 0 0 0 0 0 0 9283 0 273520 0 0 0 Michael Mcintosh 237393 0 0 0 0 0 0 0 1350 0 238743 0 0 0 Edward Stewart 273344 0 0 0 0 0 0 0 9283 0 282627 0 0 0 Paul Nielsen 242515 0 0 0 0 0 0 0 16352 0 258867 0 0 0 Form 990, Part VI, Section B, line 11 The 990 is reviewed by the CEO and CFO and a copy is provided to members of the finance/executive committee before it is filed with the IRS. Form 990, Part VI, Section B, line 12c The organization requires all board members, officers, key employees, and committee members to annually review and fill out a form which verifies compliance with the written conflict of interest policy. The signing of this document occurs immediately after the annual meeting. Form 990, Part VI, Section B, line 15 The finance committee of the board of directors and the CEO meet annually to discuss compensation of senior administrative staff. Several reliable external sources are used to gather data for this meeting including economic data and comparable salaries. A decision is then made after thorough discussion. Form 990, Part VI, Section C, line 19 The governing documents, conflict of interest policy and financial statements are available to anyone in the public upon request. Also, the financial statements are published as a legal advertisement annually in the Jackson Herald/Star News. Clarification of 'yes' response Form 990, Part XII, Line 2C The Organization has not changed its selection or oversight process in the past year.