2013-08-15T14:36:06-05:00 2012-09-30 861065772 Deloitte Tax LLP 420 North 20th St Suite 2400 Birmingham AL 35203 990 2011-10-01 560845796 Cumberland County Hospital System Inc CUMB 9106154829 PO Box 2000 Fayetteville NC 283022000 SANDRA WILLIAMS CFO 9106154829 2013-08-15 1 Charles B Freeman II P00430353 2053216000 2011 2016-02-24 21:20:13Z Sandra Williams PO Box 2000 Fayetteville NC 283022000 1023560960 0 X www.capefearvalley.com X 1956 NC Cumberland County Hospital System, Inc. exists to meet the health care needs of the residents of Cumberland and Bladen counties, and the surrounding area in North Carolina. 20 20 6592 460 -18838 -18838 750077 473794 747761734 802320052 16528780 10908415 7789242 11056199 772829833 824758460 183391 254315 0 0 355490906 379001606 0 0 0 386053651 422299786 741727948 801555707 31101885 23202753 865155354 929405691 520277668 524539582 344877686 404866109 Cumberland County Hospital System, Inc. exists to meet the health care needs of the residents of Cumberland and Bladen counties, and the surrounding area in North Carolina. 0 0 762679170 254315 802320052 As part of meeting the health care needs of the service area, CCHS, Inc. admitted 35,095 patients, provided 218,379 patient days of care, had 148,576 emergency room visits and had over 463,400 outpatient visits for other services. 762679170 1 1 0 1 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 0 0 0 0 0 0 0 1 1 1 0 0 0 1 515 0 1 6592 1 1 1 1 CJ 0 0 0 0 0 0 0 0 1 1 0 X 20 20 0 0 0 0 0 1 0 1 1 0 0 1 1 1 1 1 1 1 1 1 0 NC X James Dupe 9106154829 PO Box 2000 Fayetteville NC 283022000 Jeannette Council 2.00 X 0 0 0 Jerry Dean 2.00 X 0 0 0 Mary Dickey 2.00 X 0 0 0 Kenneth Edge 2.00 X 0 0 0 Marshall Faircloth 2.00 X 0 0 0 Bradley Broussard 2.00 X 0 0 0 Jimmy Keefe 2.00 X 0 0 0 Ed Melvin 2.00 X 0 0 0 Marion Gillis Olion 2.00 X 0 0 0 Divyang Patel 2.00 X 0 0 0 Rueben Rivers 2.00 X 0 0 0 Bryant Murphy 2.00 X 0 0 0 Sanjeev Slehria 2.00 X 0 0 0 Charles Evans 2.00 X 0 0 0 Jennifer Twaddell 2.00 X 0 0 0 Denise Mahone Wyatt 2.00 X 0 0 0 James Martin 2.00 X 0 0 0 Lucy Jones 2.00 X 0 0 0 Donald L Porter 2.00 X X 0 0 0 Earnest Curry 2.00 X X 0 0 0 John Henley 2.00 X X 0 0 0 Billy King 2.00 X X 0 0 0 Michael Nagowski 55.00 X 711907 0 86332 Sandra Williams 55.00 X 468184 0 19977 William Pryor 55.00 X 286208 0 22080 Richard Osenbach 55.00 X 752498 0 20945 John Whitley 55.00 X 750968 0 10301 John Spitalieri 55.00 X 721030 0 18498 Stuart Shelton 55.00 X 598400 0 26469 Alden Reine 55.00 X 516306 0 18572 Joyce Korzen 0.00 X 270000 0 0 Michael Harrington 0.00 X 432304 0 25977 5507805 0 249151 387 1 1 0 Simpli Fi Managed Services 1834 Sally Hill Farms Blvd Florence SC 29501 Professional Services 4821844 Aramark Clinical Technology Services 12483 Collection Ctr Drive Chicago IL 60693 Professional Services 4556019 Allied Barton Security Services PO Box 534265 Atlanta GA 303534265 Security Services 3158754 AMN Healthcare Inc 2735 Collection Ctr Drive Chicago IL 60693 Professional Services 2715639 Fayetteville Kidney Center PO Box 101518 Atlanta GA 30392 Professional Services 2367652 85 134332 339462 473794 Patient Service Rev. 900099 789307358 789307358 Ancillary Medical Ser. 900099 12866160 12866160 Education/Outreach 611710 146534 146534 802320052 8989473 8989473 50582 13135 37447 37447 13807 23640 200604519 103788 198771665 17700 1832854 86088 1918942 1918942 Purchase Rebates, Dis. 812900 6328267 6328267 Cafeteria and Parking 900099 3582650 3582650 Employee Daycare Rev. 621110 1140480 1140480 -32645 -32645 11018752 824758460 802320052 -18838 21983452 254315 254315 1595000 1435500 159500 299661753 299661753 13870781 12483703 1387078 43872269 39485042 4387227 20001803 18001623 2000180 6545940 5891346 654594 1521638 1369474 152164 438146 394331 43815 95000 95000 1202501 1082251 120250 3999299 3599369 399930 10607603 9546843 1060760 12046330 10841697 1204633 183493 165144 18349 785754 707179 78575 13436654 12092989 1343665 33053695 29748326 3305369 16942152 15247937 1694215 Medical supplies 114451507 103006356 11445151 Bad Debt 112779248 112779248 Purchased services 19586933 17628240 1958693 Contract labor 18714537 16843083 1871454 55909356 50318421 5590935 801555707 762679170 38876537 0 2089182 25364839 58317021 53332889 101542779 93594183 9101968 8609183 6038843 4936431 685019767 381838811 297534152 303180956 235082670 266819448 155448739 173567762 865155354 929405691 65444177 85488984 131933 180715 298476441 292262366 156225117 146607517 520277668 524539582 X 0 0 0 0 333749175 393737598 344877686 404866109 865155354 929405691 X 23202753 36785670 X 0 1 1 X 0 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 0 1 0 0 0 0 1 95000 0 0 95000 0 0 0 21109573 21109573 395245393 177477018 217768375 1495897 589518 906379 256645850 194709108 61936742 10523054 9063167 1459887 303180956 Other Receivables 13662396 Self Insurance Trusts 42361525 Trusts - Bond Funds 21303836 Other Assets 8077190 Construction in Progress 40075761 Derivative Instrument 48087054 173567762 Estimated Prof Liability & Worker Comp Costs 52056129 Due to Payor Agencies 46464334 Derivative Instrument 48087054 146607517 1 1 X 1 X 1 X 500.000000000000 1 0 1 1 19819000 1538000 18281000 0.02650 56912000 37093500 19818500 0.02880 0.00000 76731000 38631500 38099500 0.05530 75000 75000 0.00010 3550000 3442000 108000 0.00020 31663000 16098000 15565000 0.02260 0.00000 20000 20000 0.00000 35308000 19540000 15768000 0.02290 112039000 58171500 53867500 0.07820 0.00000 0.00000 0.00000 0.00000 0.00000 170000 170000 0.00020 0.00000 55000 55000 0.00010 0.00000 225000 225000 0.00030 0 31450000 192801617 226635055 -33833438 X 1 1 3 1 Bladen County Hospital

501 South Poplar Street Elizabethtown NC 28337

X X X 2 Highsmith Rainey Hospital

150 Robeson Street Fayetteville NC 28301

X Long Term Acute Care Hospital 3 Cape Fear Valley Health System

1638 Owen Drive Fayetteville NC 28304

X X X Bladen County Hospital 1 1 1 200.000000000000 1 500.000000000000 1 X X X 1 1 X X X 1 1 X X 1 X 0 0 Highsmith Rainey Hospital 2 1 1 200.000000000000 1 500.000000000000 1 X X X 1 1 X X X 1 1 X X 1 X 0 0 Cape Fear Valley Health System 3 1 1 200.000000000000 1 500.000000000000 1 X X X 1 1 X X X 1 1 X X 1 X 0 0 41 CFV-Rehabilitation Center

1638 Owen Drive Fayetteville NC 28304

Rehabilitation Center Cumberland Cty EMS of CFV

610 Gillespie Street Fayetteville NC 28306

Emergency Medical Services CFV Behavior Health Center

3425 Melrose Road Fayetteville NC 28304

Behavior Health Center CFV Detox Center

1724 Roxie Avenue Fayetteville NC 28304

Detoxication Center Healthplex Wellness Center

1930 Skibo Road Fayetteville NC 28304

Rehabilitation Center Health Pavilion North

6387 Ramsey Street Fayetteville NC 28311

Outpatient services Valley Medial Assoc - Cape Fear Valley

1638 Owen Drive Fayetteville NC 28304

Family Practice Highsmith-Rainey Express Care

150 Robeson Street Fayetteville NC 28311

Express Care Cape Fear Valley Express Care

1638 Owen Drive Fayetteville NC 28304

Express Care Cape Fear Valley OBGYN

1341 Walther Reed Road Fayetteville NC 28304

OB/Gyn services Health Pavilion North Express Care

6287 Ramsey Street Fayetteville NC 28301

Express Care Cape Fear Valley Sleep Medicine

1213 Walter Reed Road Fayetteville NC 28304

Sleep Center Health Pavilion North Family Care

6387 Ramsey Street Fayetteville NC 28311

Family Practice Hope Mills Family Care

4092 Professional Drive Hope Mills NC 28348

Family Practice Cape Fear Valley Neurology

3308 Melrose Road Fayetteville NC 28304

Neurology Cape Fear Valley Perinatology

2109 Valleygate Drive Fayetteville NC 28304

Perinatology Behavioral Health Center

3425 Melrose Rd Fayetteville NC 28304

Mental Health Clinic Inpatient Valley Medial Associates - Highsmith

101 Robeson Street Fayetteville NC 28301

Family Practice Cape Fear Valley Urology

2301 Robeson Street Suite 203 Fayetteville NC 28305

Urology Hoke Family Medical Center

405 South Main Street Raeford NC 28376

Family Practice Senior Health Services

101 Robeson Street Suite 202 Fayetteville NC 28310

Geriatrics Bladen Medial Assoc- Elizabethtown

300 A East McKay Street Elizabethtown NC 28337

Family Practice Stedman Medical Care

114 Forte Road Stedman NC 28391

Family Practice Cape Fear Valley Neurosurgery

3308 Melrose Road Fayetteville NC 28304

Neurosurgery Outpatient Cape Fear Valley Wound Care Center

101 Robeson St Suite 210 Fayetteville NC 28301

Wound Center Cape Fear Valley Pediatric Care

1262 Oliver Street Fayetteville NC 28304

Pediatric Care Westside Medical Care

1463 Pamalee Drive Fayetteville NC 28303

Family Practice CFV Infectious Disease Care

101 Robeson Street Suite 300 Fayetteville NC 28301

Infectious Disease Cape Fear Valley Internal Medicine

101 Robeson Street Suite 300 Fayetteville NC 28301

Internal Medicine Women's Health Specialists

300 East McKay Street Suite F Elizabethtown NC 28337

OB/GYN CFV Pediatric Endocrinology

101 Robeson Street Suite 410 Fayetteville NC 28301

Diabetes & Endocrinology outpatient Three Rivers Medical Center

580 West McLean Street St Pauls NC 28384

Family Practice Bladen Medial Assoc - Bladenboro

106 Fourth Street Bladenboro NC 28302

Family Practice Bladen Medial Associates - Dublin

16 3rd Street Dublin NC 28332

Family Practice Diabetes & Endocrine Center

101 Robeson Street Suite 405 Fayetteville NC 28301

Diabetes & Endocrinology outpatient Cape Fear Valley Pediatric Care

6387 Ramsey Street Fayetteville NC 28311

Pediatric Care Behavioral Health Clinic

3425 Melrose Rd Fayetteville NC 28304

Mental Health Outpatient care Convenient Care for Hoke

104 Southern Avenue Raeford NC 28376

Family Practice Walmart Clinic Hoke

4545 Fayetteville Rd Raeford NC 28376

Express Care Phillips Internal Medicine

507 Doctors Drive Elizabethtown NC 28337

Internal Medicine Bladen Surgical Specialist

107 East Dunham Street Elizabethtown NC 28377

Surgical Specialist Part I, Line 6a: Cumberland County Hospital System files a community benefit report annually in the state of North Carolina to the North Carolina Hospital Association. Part II: Cumberland County Hospital System, Inc. ("CCHS") reported coalition building and workforce development details in the Community Building Activities Part II. Coalition building promotes the health of the communities it serves by networking with other community agencies to address the health and safety issues of the community. The employees of CCHS utilize their clinical expertise to collaborate with other community agencies and county and state health departments to provide education and other initiatives that benefit the health of people in the community. Workforce development activities include the recruitment of physicians and other health professionals to medical shortage areas. Part III, Line 4: A patient's record is reviewed for possible charity care and if the patient does not qualify for charity and the patient does not pay, their charges are written-off as bad debt. Amounts in line 2 are determined by calculating a cost-to-charge ratio. Total expenses (less bad debts and other operating revenue) are divided into total gross patient revenue. Total bad debt charges are multiplied by this percentage. Part III, Line 8: Cumberland County Hospital Systems, Inc. treats the total shortfall of Medicare reimbursement compared to the amount of computed Medicare allowable costs as a community benefit. The hospital improves access to patient care by providing services regardless of a patient's ability to pay or the hospital's ability to receive full cost reimbursement for services. The hospital also relieves the government of a financial burden when it provides care to publicly insured patients where reimbursement is less than cost of providing the service. Part III, Line 9b: If patients are determined to qualify for charity, then the account is written-off to charity rather than to bad debt. Bladen County Hospital Part V, Section B, Line 13g: See the response to Part VI, Line 3 Highsmith Rainey Hospital Part V, Section B, Line 13g: See the response to Part VI, Line 3 Cape Fear Valley Health System Part V, Section B, Line 13g: See the response to Part VI, Line 3 Bladen County Hospital Part V, Section B, Line 19d: Patients are charged at the hospital Usual Customary and Reasonable rates minus 30%. Highsmith Rainey Hospital Part V, Section B, Line 19d: Patients are charged at the hospital Usual Customary and Reasonable rates minus 30%. Cape Fear Valley Health System Part V, Section B, Line 19d: Patients are charged at the hospital Usual Customary and Reasonable rates minus 30%. Part VI, Line 2: The mission of Cape Fear Valley Health System is to strengthen the health and well-being of the greater Cape Fear Valley region through high-quality, compassionate care provided to all who need it. As a community not-for-profit organization, we take seriously our responsibility to invest our resources and energies into understanding and meeting the diverse health care needs of all, and ensure that everyone, regardless of their ability to pay, receive the care they need. The Senior Administrative team serves in various capacities on several local community boards and groups. As members of these various groups, they are able to gain insight to needs of the community. Our community partners are critical to helping us improve the health and well-being of the Cape Fear Valley region. Together, we can combine resources and strengths, positively impacting the greatest number of people. By working closely with the community leaders, we also build a greater sense of community and a shared commitment toward our common goal of improving the community's health. The results help us to determine our short and long term priorities as well as strategies for improving community health. Those community groups and partners CCCC, SRAHEC, CCMAP, Chamber of Commerce, Fayetteville Area PR Alliance, Cumberland County Education Foundation, Communities in Schools of NC, Fort Bragg Regional Alliance, Care Clinic, and the Methodist University Physician Assistant program. Part VI, Line 3: Uninsured patients are screened at the time of registration for their ability to pay for their health care services. If the patient has no ability to pay and is deemed ineligible for governmental programs (Medicare, Medicaid, etc.) then they are informed of the Hospital Charity program. They are provided with an application and a listing of the appropriate documents necessary to establish eligibility for the Hospital Charity program. All patients receive a copy of our Charity Care Application accompanying the first billing statement. Part VI, Line 4: Cumberland County Hospital System, Inc. ("CCHS") doing business as Cape Fear Valley Medical Center ("CFVMC") is the flag ship of Cape Fear Valley Health System ("CFVHS"). CFVHS operates a variety of healthcare facilities from its headquarters in Fayetteville, North Carolina including a tertiary acute care hospital, a long-term acute care hospital, a critical access hospital, an inpatient rehabilitation facility, county emergency medical services, an outpatient psychiatric facility, a detoxification facility, a wellness center, 14 primary care clinics, 16 specialty care clinics, 5 walk-in clinics, and Health Pavilion North, an outpatient complex.Cape Fear Valley Health System serves a six-county service area made up of the five counties contiguous to Cumberland County, NC, which is its Primary Service Area. Per information from the 2012 Census Data, Cumberland has a population of over 324,000 residents; this was a growth of 6.9% from the 2000 Census Data. Approximately 53.5% of the 324,000 residents in our primary service area are minorities, compared to 35.3% for the state. Part VI, Line 5: Chronic diseases like diabetes and obesity are increasing within our community. Our facility has opened a diabetes and endocrine clinic to help those patients diagnosed with diabetes. Our healthplex provides both nutritional and exercise programs to help those in the community address the problem of obesity. The goal is to help all residents learn to manage their conditions and live healthier lives by addressing the challenges associated with these conditions. Example of Program at Cape Fear Valley:Cape Fear Valley Health System's Take Charge of Your Health Program began as an initiative to close the healthcare gap between African-Americans and non-Hispanic Whites in Cumberland County through public service announcements, health fairs, screenings and speaking engagements. It has since broadened its focus to all of Cumberland County. Darvin Jones is the Coordinator of Take Charge of Your Health Program. He serves on the Board of Directors of Community Health Interventions & Sickle Cell Agency, a non-profit that works with individuals with sickle cell disease, hypertension and diabetes. Darvin is also a member of the Cumberland County Council for Healthy Living, a group assembled by the Health Department, and the Cumberland County Schools School Health Advisory Council. Take Charge of Your Health is affiliated with Eat Smart, Move More North Carolina, a statewide initiative.At Cape Fear Valley Health System, it is important to us to give back to our community. In addition to employee United Way donations and volunteer time, our employees participate in a variety of community service initiatives, to include Habitat for Humanity and the Friends of Cancer River Walk. Last year our employees gave over $185,000 in donations to various community organizations. Part VI, Line 6: Cumberland County Hospital System is a stand-alone health care organization and is not a part of an affiliated health care system. Reports Filed With States Part VI, Line 7 NC 1 Cape Fear Valley Health Foundation PO Box 87526 Fayetteville NC 28304 561947017 501(c)(3) 254065 General Support 1 0 Procedure for Monitoring Grants in the U.S.: Part I, Line 2: Schedule I, Part I, Line 2: Cumberland County Hospital System awards grants to patients for purposes of assisting them in paying various bills and other expenses which the patients cannot pay due to their excessive medical expenses required for treating illness. Patients apply and applications are reviewed by hospital social workers. Any funds granted are not paid directly to the organization for which patient owes the bill and/or expense. X X X X 1 0 0 0 0 0 0 0 0 Michael Nagowski 476544 0 206574 0 28789 0 61914 0 24418 0 798239 0 0 0 Sandra Williams 331925 0 110695 0 25564 0 9900 0 10077 0 488161 0 0 0 William Pryor 232380 0 52702 0 1126 0 3689 0 18391 0 308288 0 0 0 Richard Osenbach 716248 0 16500 0 19750 0 4900 0 16045 0 773443 0 0 0 John Whitley 723646 0 25000 0 2322 0 0 0 10301 0 761269 0 0 0 John Spitalieri 720195 0 0 0 835 0 0 0 18498 0 739528 0 0 0 Stuart Shelton 383838 0 169157 0 45405 0 9900 0 16569 0 624869 0 0 0 Alden Reine 450496 0 65000 0 810 0 0 0 18572 0 534878 0 0 0 Joyce Korzen 0 0 0 0 270000 0 0 0 0 0 270000 0 0 0 Michael Harrington 356885 0 56682 0 18737 0 9900 0 16077 0 458281 0 0 0 Part I, Line 4a Joyce Korzen received severance in the amount of $270,000 during the calendar year ending December 31, 2011. Part I, Line 6 A component of the CEO's bonus at year end is dependent on the financial standing of the organization. No specific percentage is tied to net income. North Carolina Medical Care Commission 521309402 6579022Y7 2006-05-04 37995351 Construction and Equipment 0 0 0 North Carolina Medical Care Commission 521309402 65821DAL5 2008-09-23 285335000 To refund bonds issued 5/4/2006, and to fund building costs 0 0 0 26455000 39439715 5428427 2974844 352680 683338 12370 35416483 2008 0 0 1 1 3645000 285335000 15875409 3722838 10007178 260250000 2008 1 0 1 1 0 0 1 1 0 1 0 0 1 1 0 0.00380 0.00380 1 0 0 0 0 0 1 0 1 0 1 Morgan Stanley 1.100000000000 1 0 1 Schedule K Supplental Information Differences between the issue price (Part I) and total proceeds (Part II, line 3) are due to investment earnings. Part II, line 4, column A - The amount shown here consists of debt services fund deposits. Part II, line 4, column B - the amount here consists of $11,360,393 of debt services fund deposits plus $4,515,015 in a reasonably required reserve or replacement fund. Form 990, Part VI, Section A, line 7a The Board of Trustees of Cumberland County Hospital System shall be comprised of seven trustees who are the seven members of the Cumberland County Board of Commissioners. The Board of Trustees will also have eight at large trustees who are appointed by the Board of Commissioners. The remaining five at large members are appointed by the Board of Trustees. Form 990, Part VI, Section B, line 11 The process the organization uses to review the Form 990 consists of providing the Form 990 to the Cumberland County Hospital System's Board of Trustees by electronic copy. Board Members will be given time to do a thorough review before the filing date of August 15, 2013. Form 990, Part VI, Section B, line 12c Cumberland County Hospital System, Inc. regularly and consistently monitors and enforces compliance with the conflict of interest policy in that any director, principal officer, or member of a committee with governing board delegated powers, who has a direct or indirect financial interest, must disclose the existence of the financial interest and be given the opportunity to disclose all material facts to the directors and members of the committees with governing board delegated powers considering the proposed transaction or arrangement. The remaining individuals on the governing board or committee meeting will decide if conflicts of interest exist. Each director, principal officer and member of a committee with governing board delegated powers annually signs a statement which affirms such person has received a copy of the conflicts of interest policy, has read and understands the policy, has agreed to comply with the policy, and understands that the organization is charitable and in order to maintain its federal tax exemption it must engage primarily in activities which accomplish its tax-exempt purpose. Form 990, Part VI, Section B, line 15 A human resources consulting firm is retained by Cumberland County Hospital Systems, Inc. to review the competitiveness and reasonableness of the compensation provided to the CEO and other top management personnel. Form 990, Part VI, Section C, line 19 Provided upon request. Changes in Net Assets or Fund Balances: Form 990, Part XI, line 5: Net unrealized gains on investments: 22,683,432. Prior period adj. related to Bladen Hospital purchase: 14,102,238. Total to Form 990, Part XI, Line 5: 36,785,670. Cape Fear Insurance LTD PO Box 30600 SMB West Bay Road F Grand Cayman CJ 980449284 Insurance CJ 13533846 33143632 100 Bladen County Healthcare LLC PO Box 2000 Fayetteville NC 28302 800164702 Health Services NC 38626233 21391200 100 Cumberland Health Affiliates LLC PO Box 2000 Fayetteville NC 28302 562275588 Health Services NC 0 0 100 Valley Health Facilities LLC PO Box 2000 Fayetteville NC 28302 204268819 Health Services NC 0 0 100 Highsmith-Rainey Medical Arts Center Assoc PO Box 2000 Fayetteville NC 28302 561747424 Rental Association NC Cumberland County Hospital C 215361 995712 1.00000 Cumberland Health Partners Inc PO Box 2000 Fayetteville NC 28302 562043978 Behavioral Health Care NC Cumberland County Hospital C 1.00000 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0