2013-08-01T12:05:50-05:00 2012-09-30 560747981 DIXON HUGHES GOODMAN LLP 500 RIDGEFIELD COURT ASHEVILLE NC 28806 990 2011-10-01 560642846 HUGH CHATHAM MEMORIAL HOSPITAL INC HUGH 3365277000 180 PARKWOOD DR ELKIN NC 28621 DONALD E TRIPPEL 3365277000 2013-07-29 1 AMY BIBBY P00445891 8282542254 2011 2016-02-24 21:20:13Z DONALD E TRIPPEL 180 PARKWOOD DR ELKIN NC 28621 111646338 0 X WWW.HUGHCHATHAM.ORG X 1930 NC TO PROVIDE BIRTHING AND ACUTE CARE SERVICES IN ADDITION TO SKILLED NURSING, RETIREMENT COMMUNITY, HOME HEALTH, AND HOSPICE SERVICES PRIMARILY TO THE RESIDENTS OF AND SURROUNDING COUNTIES TO SURRY COUNTY, NORTH CAROLINA. 14 12 940 77 0 0 87503 269138 95978184 100519936 4908309 7800662 3008615 2751835 103982611 111341571 0 0 0 0 41959439 40669502 0 0 60427 57865308 62414883 99824747 103084385 4157864 8257186 188383176 200822149 99702548 99710683 88680628 101111466 X TO CONSISTENLY DELIVER EXCEPTIONAL QUALITY AND SERVICE BY DEMONSTRATING THE VALUES OF SERVICE, TEAMWORK, ACCOUNTABILITY, RESPECT, AND SAFE CARE. 0 0 96883004 100519936 NESTLED IN THE WESTERN PIEDMONT WINE COUNTRY OF NORTH CAROLINA, HUGH CHATHAM MEMORIAL HOSPITAL HAS PROVIDED HIGH QUALITY MEDICAL CARE FOR RESIDENTS OVER A DISTINGUISHED 80-YEAR HISTORY. A PRIVATE, NOT-FOR-PROFIT, 501(C)(3) HOSPITAL, HCMH EMPLOYS MORE THAN 840, AND IS SERVED BY MORE THAN 70 PHYSICIANS REPRESENTING 26 SPECIALTIES OR SUBSPECIALTIES. IN A RECENT NATIONAL PATIENT SATISFACTION SURVEY, THE HOSPITAL'S PATIENTS GAVE THE OUTPATIENT DEPARTMENT A 99% EXCELLENT RATING; THE EMERGENCY DEPARTMENT 94% AND THE OB/GYN SERVICES 98%. IN ADDITION, FOLLOWING A 2009 QUALITY EVALUATION, THE NATIONAL PRESS GANEY FIRM AWARDED THE HOSPITAL'S OUTPATIENT SURGERY DEPARTMENT A PRESTIGIOUS SUMMIT AWARD, RESERVED FOR CLIENTS WHO ACHIEVE AND MAINTAIN EXTRAORDINARY RESULTS. OVER THE YEARS, HCHM PATIENTS HAVE MADE THE HOSPITAL OUR REGIONS'S CHOICE FOR TECHNOLOGIES AND CARE. RECENT NATIONAL RANKINGS OF SEVERAL IMPORTANT MEASURES REINFORCE THIS CHOICE. THE JOINT COMMISSION AWARDED FULL ACCREDITATION TO THE HOSPITAL'S LABORATORY, AND THE NORTH CAROLINA NURSES ASSOCIATION (NCNA) GAVE HUGH CHATHAM MEMORIAL HOSPITAL THE COVETED HALLMARKS RECOGNITION. THIS AWARD AFFIRMS WHAT GENERATIONS OF PATIENTS HAVE KNOWN: THE NURSES AT HCMH ARE EXCELLENT, WORK WELL TOGETHER, AND ARE DEDICATED TO CARING FOR THEIR PATIENTS. HUGH CHATHAM MEMORIAL HOSPITAL HAS ONCE AGAIN BEEN RECOGNIZED BY ALLIANT MANAGEMENT SERVICES (AMS) FOR ACHIEVING OUTSTANDING LEVELS OF PATIENT AND PHYSICIAN SATISFACTION. HUGH CHATHAM EARNED THE SAME AWARD IN 2009 AND RECEIVED THE HONOR AT ALLIANT MANAGEMENT SERVICES' ANNUAL RECOGNITION CEREMONY LAST FALL IN LOUISVILLE, KENTUCKY. AS A RECIPIENT OF THE PATIENT SATISFACTION AWARD, HUGH CHATHAM MEMORIAL HOSPITAL EARNED TOP SCORES ON SURVEYS COMPLETED BY INPATIENTS, OUTPATIENTS AND PHYSICIANS. INPATIENT = 95TH PERCENTILE EMERGENCY DEPARTMENT = 95TH PERCENTILE OUTPATIENT DEPARTMENT = 99TH PERCENTILE - VISION STATEMENT -TO BE THE BEST COMMUNITY HOSPITAL IN THE NATION, WITH SERVICE AS OUR GUIDING PRINCIPLE - GEOGRAPHIC SERVICE AREA AND TARGET POPULATIONS FOR COMMUNITY INITIATIVES - THE HOSPITAL'S PRIMARY SERVICE AREA INCLUDES NINE ZIP CODES COMPRISING ROUGHLY A FIFTEEN-MILE DIAMETER AROUND ELKIN, NORTH CAROLINA. THE SECONDARY SERVICE AREA INCLUDES AN ADDITIONAL FIVE ZIP CODES WIDENING THE DIAMETER TO THIRTY MILES AROUND ELKIN. BOTH OF THE ABOVE MARKETS INCLUDE PART, BUT NOT ALL, OF THE NORTH CAROLINA COUNTIES OF WILKES, ALLEGHANY, YADKIN AND SURRY AND THE ENTIRE POPULATION OF EACH COMMUNITY IS TARGETED FOR ALL SERVICES AND INITIATIVES. ADDITIONAL TARGET MARKETS INCLUDE PORTIONS OF THE SOUTH WESTERN VIRGINIA COUNTIES OF CARROLL, GRAYSON, AND PATRICK. - FUNDING OF INITIATIVE PROGRAMS -THE RESOURCES OF HUGH CHATHAM MEMORIAL HOSPITAL FUND THE PROGRAMS. - DETERMINING COMMUNITY PRIORITIES AND COLLABORATION -THROUGH A GRANT FROM THE DUKE ENDOWMENT, A COMMUNITY NEEDS ASSESSMENT SURVEY WAS CONDUCTED IN A RECENT YEAR. USING INFORMATION FROM THIS SURVEY, ADMISSIONS DATA AND VOLUME DATA FROM THE HOSPITAL, AND PARTNERSHIPS WITH YADKIN AND SURRY SENIOR CENTERS, SURRY COMMUNITY COLLEGE, AND OTHER AGENCIES, NEEDS ARE IDENTIFIED, PRIORITIES ESTABLISHED, AND LEADERSHIP ROLES ASSIGNED FROM WITHIN THE COLLABORATIVE GROUP. THE HOSPITAL'S BOARD OF TRUSTEES, PHYSICIANS, AND ADMINISTRATION MEET EACH YEAR TO DETERMINE STRATEGIC NEEDS OF THE COMMUNITY AT THEIR ANNUAL PLANNING RETREAT. - COMMUNITY SERVICE PROGRAMS SPONSORED BY HUGH CHATHAM MEMORIAL HOSPITAL --PATIENT EDUCATION PROGRAMS- LAMAZE AND CHILDBIRTH INFANT AND CHILD CPR BREASTFEEDING CARDIAC REHABILITATION WOMEN'S HEALTH EDUCATIONAL SEMINARS-COMMUNITY HEALTH SCREENINGS AND IMMUNIZATIONS- CANCER SCREENINGS (PROSTATE, BREAST, SKIN, COLON) CHOLESTEROL/GLUCOSE BLOOD PRESSURE/HEART RATE/OXYGEN SATURATION WEIGHT/BODY MASS INDEX FALLS ASSESSMENT BONE DENSITY TETANUS/FLU-HEALTH PROMOTION, OUTREACH, AND SUPPORT GROUPS- CANCER HEART AND SOUL LOOK GOOD FEEL BETTER CANCER SUPPORT HOSPICE GRIEF CAMP FOR CHILDREN BEREAVEMENT AND THE GRIEF PROCESS STROKE SUPPORT AMPUTEE SUPPORT ALZHEIMER'S SUPPORT CPR FOR INDUSTRY, DAY CARE WORKERS, AND LIFEGUARDS SENIOR FITNESS CLASSES CARDIAC REHABILITATIONDURING 2011, HUGH CHATHAM MEMORIAL HOSPITAL ACQUIRED NEW PHYSICIAN PRACTICES - A FAMILY PRACTICE, SURGICAL PRACTICE, AND ORTHOPEDIC PRACTICE. THE ORTHOPEDIC GROUP IS LOCATED CLOSE TO THE HOSPITAL AND SERVES INDIVIDUALS SPREAD ACROSS TWO COMMUNITIES. THE ORTHOPEDIC GROUP ALSO TRAVELS TO OTHER CRITICAL ACCESS FACILITIES TO OFFER THEIR SERVICES. THE FAMILY PRACTICE IS AN EXTENSION OF THE PRACTICE LOCATED IN JONESVILLE THAT OFFERS EXTENDED HOURS TO BETTER SERVE THE WORKING COMMUNITY.THE HOSPITAL ROLLED OUT THE PATIENT EDUCATION (HCTV) TO INCREASE PATIENT AWARENESS OF HEALTH CARE TOPICS. IT HAS SIX STREAMING CHANNELS WITH A VARIETY OF PATIENT EDUCATION TOPICS AS WELL AS THE VIDEO ON DEMAND OPTION SO PATIENTS CAN DIAL A NUMBER ON THE PHONE AND SELECT A VIDEO FROM A LIST OF TOPICS.THE HOSPITAL INCREASED THEIR COMMUNITY RELATIONSHIP WITH LOCAL SCHOOLS BY PROVIDING HIGH SCHOOL STUDENT INTERNSHIPS AS PART OF THE CLASS CURRICULUM. STUDENTS CAME TO TEH HOSPITAL FOR A CLASS PERIOD DURING THE SCHOOL SEMESTER AND RECEIVED A GRADE FOR HIGH SCHOOL CREDIT.WILKES COMMUNITY COLLEGE ADDED THE HOSPITAL AS ONE OF THEIR CLINICAL SITES FOR NURSING STUDENTS.THE HOSPITAL TRAVELED TO TWO LOCAL INDUSTRIAL ORGANIZATIONS TO PROVIDE STROKE EDUCATION AND OTHER HEALTHCARE EDUCATION TO THE COMMUNITY. 96883004 1 0 0 1 0 0 0 0 0 0 1 0 0 0 1 1 0 1 0 0 0 0 0 0 0 0 1 1 0 0 1 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 1 0 0 0 1 77 0 1 940 1 0 0 0 0 0 0 0 0 0 0 X 14 12 1 1 0 0 0 0 0 1 1 0 0 1 1 1 1 1 1 1 1 0 NC X CHERYL PARDUE 3365277595 180 PARKWOOD DRIVE ELKIN NC 28621 MIKE STANLEY 1.00 X X 0 0 0 BOB MIDKIFF 1.00 X X 0 0 0 DAVID CLINE 1.00 X X 0 0 0 CAROL JERNIGAN 1.00 X X 0 0 0 DONNA THOMPSON 1.00 X X 0 0 0 MARK HEINER MD 1.00 X X 24000 0 0 BOB BALL 1.00 X 0 0 0 ERCEL CARTER 1.00 X 0 0 0 TERRY DARNELL 1.00 X 0 0 0 FRED EIDSON 1.00 X 0 0 0 JAMES FREEMAN 1.00 X 0 0 0 JL LOWE 1.00 X 0 0 0 RAYMOND PARKER 1.00 X 12000 0 0 GEORGE SAPPENFIELD 1.00 X 0 0 0 DAVID LOVING 40.00 X 349070 0 0 DONALD TRIPPEL 40.00 X 160365 0 29103 DOMINICK CARBONE MD 40.00 X 729773 0 16658 RIZWAN AHMEND MD 40.00 X 462958 0 16903 CHRISTOPHER SPONGBERG MD 40.00 X 316242 0 23603 LAWRENCE NABORS MD 40.00 X 296609 0 16903 ANDREW LEE MD 40.00 X 314351 0 7352 2665368 0 110522 27 0 1 1 SODEXO INC PO BOX 536922 ATLANTA GA 30353 DIETARY & HOUSEKEEPING SERVICES 3157698 CARDINAL HEALTH PO BOX 905867 CHARLOTTE NC 28290 PATIENT & HOSPITAL SUPPLIES 1725213 CARDINAL DISTRIBUTION PHARMACY 25025 NETWORK PLACE CHICAGO IL 60673 PHARMACY SUPPLIES & MEDICATIONS 1466479 HORIZON CSA LLC 265 PITT ROAD MOORESVILLE NC 28115 EQUIPMENT MAINTENANCE 1290169 SMITH & NEPHEW PO BOX 933782 ATLANTA GA 311933782 ORTHOPEDICS 1236017 82 269138 269138 PATIENT CARE SERVICES 621400 99645855 99645855 NET HOSPICE INVESTMENT 623000 874081 874081 100519936 5029561 5029561 1447200 304767 1142433 1142433 1142433 2755722 15379 0 0 2755722 15379 2771101 2771101 MISCELLANEOUS REVENUE 900099 1343776 1343776 CAFETERIA & VENDING 722210 265626 265626 1609402 111341571 100519936 0 10552497 972594 243149 680815 48630 31757423 30423497 1333926 458920 429989 28249 682 5238057 4907838 322436 7783 2242508 2101135 138041 3332 221018 221018 34525 34525 200776 200776 342602 342602 11745107 10584597 1160510 644056 10998 633058 9395770 9034773 360997 1285811 1285811 244839 198098 46741 3476139 3476139 7826307 7826307 208180 208180 BAD DEBT EXPENSE 18732965 18732965 MEDICAL SUPPLIES 4110171 4110171 PROVIDER TAX 2673990 2673990 MISCELLANEOUS EXPENSES 1272627 635367 637260 103084385 96883004 6140954 60427 12340946 13666198 569803 303824 8488207 8936839 1501315 1362916 3390699 3760849 151439829 67358333 89509492 84081496 66319058 79077370 4039055 4911602 2224601 4721055 188383176 200822149 8680779 8671659 79565000 78090000 11456769 12949024 99702548 99710683 X 89245373 101695377 -564745 -583911 88680628 101111466 188383176 200822149 X 8257186 4173652 X X 0 1 1 X 0 X 0 1 0 0 0 0 0 0 1 7118 7118 0 EXPLANATION OF LOBBYING ACTIVITIES: PART II-B, LINE 1: PART II-B, LINE 1I: THE ORGANIZATION IS A MEMBER OF THE AMERICAN HOSPITAL ASSOCIATION (AHA) AND THE NORTH CAROLINA HOSPITAL ASSOCIATION (NCHA). THESE ORGANIZATIONS ENGAGE IN LOBBYING EFFORTS TO LEGISLATIVE BODIES ON BEHALF OF THEIR MEMBERSHIP BASES. EACH YEAR, A PORTION OF MEMBERSHIP DUES PAID TO THESE ORGANIZATIONS IS ALLOCATED TO LOBBYING ENDEAVORS. FOR THE CURRENT YEAR, THE PORTION OF DUES PAID ALLOCATED TO LOBBYING IS APPROXIMATELY $7,118. 2530463 2530463 93114473 25814272 67300201 9038259 5177475 3860784 46560216 36366586 10193630 196418 196418 84081496 INTEREST PAYABLE 1146887 ESTIMATED THIRD-PARTY PAYOR SETTLEMENTS 4594704 PHYSICIAN GUARANTEE 316348 INTEREST RATE SWAP 6789826 RESIDENT TRUST FUNDS 101259 12949024 111341571 103084385 8257186 5688780 -1515128 4173652 12430838 96744423 5688780 -20590695 -14901915 111646338 -304767 -304767 111341571 84313585 304767 304767 84008818 19075567 19075567 103084385 DESCRIPTION OF UNCERTAIN TAX POSITIONS UNDER FIN 48: PART X: THE HOSPITAL, FOUNDATION, AND AUXILIARY ARE NOT-FOR-PROFIT CORPORATIONS AS DESCRIBED IN SECTION 501(C)(3) OF THE INTERNAL REVENUE CODE AND ARE EXEMPT FROM FEDERAL INCOME TAXES ON RELATED INCOME PURSUANT TO SECTION 501(A) OF THE CODE; ACCORDINGLY, THE ACCOMPANYING FINANCIAL STATEMENTS DO NOT REFLECT A PROVISION OR LIABILITY FOR FEDERAL AND STATE INCOME TAXES. THE HOSPITAL HAS DETERMINED THAT IT DOES NOT HAVE ANY MATERIAL UNRECOGNIZED TAX BENEFITS OR OBLIGATIONS AS OF SEPTEMBER 30, 2012. FISCAL YEARS ENDING ON OR AFTER SEPTEMBER 30, 2009 REMAIN SUBJECT TO EXAMINATION BY FEDERAL AND STATE TAX AUTHORITIES. PART XI, LINE 8 - OTHER ADJUSTMENTS: CHANGE IN VALUE OF SWAP AGREEMENT -810,010. TRANSFER OF EQUITY TO FOUNDATION, NET -70,706. RECOGNIZED LOSSES ON IMPAIRMENTS -307,170. FOUNDATION'S UNREALIZED GAINS -327,242. TOTAL TO SCHEDULE D, PART XI, LINE 8: -1,515,128. PART XII, LINE 2D - OTHER ADJUSTMENTS: BAD DEBT EXPENSE NET WITH REVENUES -18,732,965. TRANSFER OF EQUITY TO FOUNDATION -70,706. CHANGE IN VALUE OF SWAP AGREEMENT -810,010. RECOGNIZED LOSSES ON IMPAIRMENTS -307,170. FOUNDATION UNREALIZED GAINS -327,242. INVESTMENT MANAGEMENT FEE -342,602. PART XII, LINE 4B - OTHER ADJUSTMENTS: DIRECT RENTAL EXPENSES -304,767. PART XIII, LINE 2D - OTHER ADJUSTMENTS: DIRECT RENTAL EXPENSES 304,767. PART XIII, LINE 4B - OTHER ADJUSTMENTS: BAD DEBT EXPENSE NET WITH REVENUES 18,732,965. INVESTMENT MANAGEMENT FEE 342,602. 1 1 X 1 X 1 X 1 1 1 0 1 1 1876504 1876504 0.02220 14320809 13073582 1247227 0.01480 16197313 13073582 3123731 0.03700 40460 40460 0.00050 183791 183791 0.00220 591255 591255 0.00700 815506 815506 0.00970 17012819 13073582 3939237 0.04670 3000 3000 0.00000 3000 3000 5890457 2061660 75168909 74981533 187376 X 1 0 1 1 HUGH CHATHAM MEMORIAL HOSPITAL

180 PARKWOOD DRIVE ELKIN NC 28621

X X X DISPROPORTIONATE SHARE HOSPITAL HUGH CHATHAM MEMORIAL HOSPITAL 1 1 1 150.000000000000 1 200.000000000000 1 X X X X X X X 1 1 X X X X X X 1 X X X 0 1 X 0 0 12 HUGH CHATHAM NURSING CENTER

700 JOHNSON RIDGE ROAD ELKIN NC 28621

NURSING FACILITY YADKIN VALLEY HOME HEALTH

213 WINSTON ROAD JONESVILLE NC 28642

HOME HEALTH YADKIN VALLEY ADULT MEDICINE

500 CHATHAM MEDICAL PARK ELKIN NC 28621

PHYSICIANS OFFICES CLINGMAN MEDICAL CENTER

3369 CLINGMAN ROAD RONDA NC 28670

PHYSICIANS OFFICES YADKIN VALLEY UROLOGY

200 JOHNSON RIDGE MEDICAL PARK ELKIN NC 28621

PHYSICIANS OFFICES HUGH CHATHAM FAMILY MEDICINE JONESVILLE

112 N SWAIM STREET JONESVILLE NC 28642

PHYSICIANS OFFICES YADKIN VALLEY GASTROENTEROLOGY

201 WEST MAIN STREET ELKIN NC 28621

PHYSICIANS OFFICES G I CLINIC

201 WEST MAIN STREET ELKIN NC 28621

PHYSICIANS OFFICES YADKIN VALLEY DERMATOLOGY

690 PARKWOOD MEDICAL PARK ELKIN NC 28621

PHYSICIANS OFFICES FOOTHILLS FAMILY MEDICINE

600 CHATHAM MEDICAL PARK ELKIN NC 28621

PHYSICIANS OFFICES HUGH CHATHAM FAMILY MEDICINE ELKIN

101 CLAREMONT MEDICAL PARK ELKIN NC 28621

PHYSICIANS OFFICES HUGH CHATHAM SURGICAL

201 B CLAREMONT MEDICAL PARK ELKIN NC 28621

PHYSICIANS OFFICES PART I, LINE 7: THE ORGANIZATION'S INTERNAL COST ACCOUNTING SYSTEM WAS USED TO COMPUTE A COST-TO-CHARGES RATIO THAT WAS USED TO CALCULATE COSTS USED IN PART I, LINE 7. PART I, L7 COL(F): THE TOTAL EXPENSE AMOUNT LISTED ON FORM 990, PART IX, LINE 26 CONTAINS BAD DEBT EXPENSE OF $18,732,965 THAT WAS REMOVED FOR THE PURPOSE OF CALCULATING TOTAL CHARITY CARE PERCENTAGE ON LINE 7, COLUMN (F). PART I, LINE 6A: THE HOSPITAL'S COMMUNITY BENEFIT REPORT IS FILED THROUGH THE MEDICAL CARE COMMISSION OF NORTH CAROLINA. PART II: HUGH CHATHAM MEMORIAL HOSPITAL PROVIDES ALL LOCAL SCHOOLS WITH FREE HAND SANITIZERS WITH FLU PREVENTION BROCHURES EVERY FALL AND SUNCREEN WITH MELANOMA AWARENESS BROCHURES EVERY SPRING. PART III, LINE 4: THE ORGANIZATION'S FINANCIAL STATEMENTS DO NOT CONTAIN A FOOTNOTE ON BAD DEBT EXPENSE. THE BAD DEBT EXPENSE AT COST ON PART III, LINE 2 WAS COMPUTED BY USING THE GROSS BAD DEBT EXPENSE PER AUDITED FINANCIAL STATEMENTS REDUCED TO COST USING AN INTERNALLY COMPUTED COST-TO-CHARGES RATIO FROM THE ORGANIZATION'S COST ACCOUNTING SYSTEMS.DUE TO THE FACT THAT APPROXIMATELY 30% OF THE SURROUNDING COMMUNITY'S RESIDENTS ARE CONSIDERED TO BE LIVING BELOW THE POVERTY LINE, IN COMBINATION WITH THE FACT THAT THE UNEMPLOYMENT PERCENTAGE FOR THE AREA IS APPROXIMATELY 12.7%, THE ORGANIZATION FEELS THAT APPROXIMATELY 35% OF BAD DEBT IS AN APPROPRIATE ESTIMATION OF THE AMOUNT OF BAD DEBT THAT MAY CONSTITUTE A COMMUNITY BENEFIT. PART III, LINE 8: AN INTERNAL COST-TO-CHARGE RATIO WAS USED TO COMPUTE MEDICARE ALLOWABLE COSTS OF CARE ON PART III, LINE 6. PART III, LINE 9B: HCMH MAKES EVERY EFFORT TO EVALUATE PATIENTS PRIOR TO PLACEMENT WITH A COLLECTIONS AGENCY TO SEE IF THEY ARE QUALIFIED FOR MEDICAID OR HOSPITAL CHARITY CARE. WE HAVE AN IN-HOUSE EMPLOYEE DESIGNATED TO ASSISTING PATIENTS ELIGIBLE FOR MEDICAID AND/OR FINANCIAL ASSISTANCE. AT THE POINT OF THE PATIENT NOT BEING ELIGIBLE AND FAILURE TO RESPOND FOR OUR PAYMENT PLAN OPTIONS, THE ACCOUNT IS PLACED WITH A COLLECTION AGENCY AND THE AGENCY MAKES AN EFFORT FOR 30 DAYS PRIOR TO PLACING ON THE CREDIT SCORE, TO OBTAIN PAYMENT. PART VI, LINE 2: THE ORGANIZATION TRACKS THE RESULTS OF HEALTH SCREENINGS PROVIDED THROUGH ITS QUARTERLY HEALTH FAIRS AND LOOKS FOR TRENDS. THESE SCREENINGS PROVIDE INSIGHT INTO FURTHER MEDICAL NEEDS OF THE COMMUNITY MEMBERS. THE FAIRS ARE HELD QUARTERLY AND ARE ATTENDED BY HUNDREDS OF PEOPLE WHO ARE OFFERED THIRTEEN DIFFERENT TYPES OF SCREENS. ADDITIONALLY, THE ORGANIZATION SUBSCRIBES TO NATIONAL AFFILIATED ORGANIZATIONS THAT PROVIDE DATA ON REGIONAL HEALTH NEEDS. LAST YEAR, THIS DATA SHOWED A RISE IN STROKE RELATED DEATHS. SUBSEQUENTLY, HCMH FOCUSED ON STROKE EDUCATION AND PREVENTION AT ALL LOCAL EVENTS, FAIRS, FESTIVALS, ETC (EXAMPLES INCLUDE KIDSFEST, HEARTFEST, AND SCREENINGS SPECIFICALLY HELD FOR OUR EMPLOYEES). PART VI, LINE 3: FINANCIAL ASSISTANCE EDUCATION IS MADE AVAILABLE AT ADMISSION AND ON THE WEBSITE. AT REGISTRATION THERE ARE BROCHURES WITH FINANCIAL ASSISTANCE INFORMATION MADE AVAILABLE. SIGNAGE IS LOCATED THROUGHOUT THE FACILITY TO INFORM AND EDUCATE THE PUBLIC OF THEIR FINANCIAL RIGHTS. HUGH CHATHAM MEMORIAL HOSPITAL OFFERS A LANGUAGE LINE FOR THE NON-ENGLISH SPEAKING COMMUNITY AND PHONETREE ASSISTANCE WHERE NEEDED. PART VI, LINE 4: THE PRIMARY SERVICE AREA OF THE HOSPITAL INCLUDES NINE ZIP CODES--ROUGHLY A FIFTEEN MILE DIAMETER AROUND ELKIN, NC. THE SECONDARY SERVICE AREA INCLUDES AN ADDITIONAL FIVE ZIP CODES WIDENING THE DIAMETER TO THIRTY MILES AROUND ELKIN. BOTH OF THESE MARKETS INCLUDE PART, BUT NOT ALL, OF THE NORTH CAROLINA COUNTIES OF WILKES, ALLEGHANY, YADKIN, AND SURRY. SOUTHERN VIRGINIA COUNTIES OF GRAYSON, PATRICK, AND CARROLL ARE ALSO INCLUDED. THESE AREAS HAVE BEEN SEVERELY AFFECTED BY THE ECONOMIC CLIMATE OF THE PAST YEAR. THE AREA CURRENTLY HAS AN UNEMPLOYMENT PERCENTAGE OF 12.7%. DOBSON, NC, WHICH IS IN THE CENTER OF SURRY COUNTY, IS A FEDERALLY DESIGNATED MEDICALLY UNDERSERVED AREA. HUGH CHATHAM IS THE ONLY HOSPITAL IN THE PRIMARY SERVICE AREA. PART VI, LINE 5: A MAJORITY OF THE ORGANIZATION'S GOVERNING BODY IS COMPRISED OF PERSONS WHO RESIDE IN THE ORGANIZATION'S PRIMARY SERVICE AREA AND WHO ARE NEITHER EMPLOYEES NOR INDEPENDENT CONTRACTORS OF THE ORGANIZATION, NOR FAMILY MEMBERS THEREOF. IN ADDITION, THE ORGANIZATION EXTENDS MEDICAL STAFF PRIVILEGES TO ALL QUALIFIED PHYSICIANS IN THE COMMUNITY FOR SOME OF ITS DEPARTMENTS.HCMH OFFERS A WIDE VARIEY OF SERVICES TO OUR COMMUNITY, SUCH AS WOMEN'S HEALTH EDUCATION SEMINARS,INFANT AND CHILD CPR CLASSES, LAMAZE AND CHILDBIRTH CLASSES, CARDIAC REHABILITATION, AND VARIOUS PATIENT EDUCATIONAL PROGRAMS. THE HOSPITAL PARTICIPATES IN AND HOSTS MANY COMMUNITY HEALTH SCREENINGS AND IMMUNIZATIONS, CANCER SCREENINGS (PROSTRATE, BREAST, SKIN, AND COLON), AS WELL AS SCREENINGS IN THE FOLLOWING AREAS: CHOLESTEROL/GLUCOSE, BLOOD PRESSURE, HEART RATE,OXYGEN SATURATION, WEIGHT AND BODY MASS INDEX ASSESSMENT, FALLS ASSESSMENT, BONE DENSITY TESTING, TETANUS AND FLU CLINICS. THE EMPLOYEES AT HCMH ARE COMMITTED TO THE AREA'S NEEDS. COMMITTMENT IS DEMONSTRATED THROUGH PARTICIPATION IN THE FOLLOWING: THE STOP HUNGER FOOD DRIVE, MARCH OF DIMES, UNITED WAY, TRI C MINISTRIES, SUSAN G. KOMEN WALKATHONS, SPECIAL OLYMPICS, THE AMERICAN CANCER SOCIETY, THE NATIONAL MS SOCIETY, AND A LOCAL ORGANIZATION TRIAD FIRST IN FAMILIES THAT HELPS CHILDREN IN NEED.HCMH IS COMMITTED TO THE PROMOTION OF HEALTH, OUTREACH, AND SUPPORT GROUPS. THE HOSPITAL SPONSORS THE FOLLOWING:CANCER HEART AND SOUL, LOOK GOOD FEEL BETTER CANCER SUPPORT, HOSPICE GRIEF CAMP FOR CHILDREN, BEREAVEMENT AND THE GRIEF PROCESS, STROKE SUPPORT, AMPUTEE SUPPORT, ALZHEIMER'S SUPPORT, CPR FOR INDUSTRY, DAY CARE WORKERS, AND LIFEGUARDS, SENIOR FITNESS CLASSES, AND CARDIAC REHABILITATION CLASSES. HCMH ALSO HOLDS "LUNCH AND LEARNS" WHICH ARE OFFERED TO THE COMMUNITY PROMOTING DIFFERENT TOPICS OF HEALTH RELATED INTEREST.THE HOSPITAL ALSO SPONSORS THE GRACE CLINIC WHICH IS A LOCAL FREE CLINIC WHICH OPERATES ON DONATED SERVICES AND SUPPLIES. PART VI, LINE 6: THE HOSPITAL IS NOT PART OF AN AFFILIATED HEALTH CARE SYSTEM. REPORTS FILED WITH STATES PART VI, LINE 7 NC X X X X 0 0 0 0 0 1 0 0 0 DAVID LOVING 344270 0 0 0 4800 0 0 0 0 0 349070 0 0 0 DONALD TRIPPEL 144007 0 15000 0 1358 0 22000 0 7103 0 189468 0 0 0 DOMINICK CARBONE MD 380511 0 348902 0 360 0 9800 0 6858 0 746431 0 0 0 RIZWAN AHMEND MD 420037 0 42729 0 192 0 9800 0 7103 0 479861 0 0 0 CHRISTOPHER SPONGBERG MD 280749 0 35133 0 360 0 16500 0 7103 0 339845 0 0 0 LAWRENCE NABORS MD 205773 0 89252 0 1584 0 9800 0 7103 0 313512 0 0 0 ANDREW LEE MD 314111 0 0 0 240 0 249 0 7103 0 321703 0 0 0 PART I, LINE 6 MEMBERS OF THE ADMINISTRATIVE DEPARTMENT ARE ELIGIBLE FOR AN ADMINISTRATIVE BONUS BASED ON THE FINANCIAL PERFORMANCE OF THE PRIOR YEAR. AMOUNTS PAID OUT TO INDIVIDUALS LISTED ON PART VII OF THE FORM 990 FOR 2011 WERE: DONALD TRIPPEL: $15,000 THE PHYSICIANS IN CHARGE OF THE UROLOGY PRACTICE, GASTROENTEROLOGY PRACTICE, AND CLINGMAN CLINIC ARE ELIGIBLE TO RECEIVE A PORTION OF THE NET PROFIT FROM THEIR PRACTICE UP TO 20% OF THEIR BASE SALARY. ANOTHER PHYSICIAN IN CHARGE OF THE HOSPITALIST GROUP IS ELIGIBLE TO RECEIVE UP TO 20% OF THEIR BASE SALARY DEPENDING ON PERFORMANCE MEASURES OF THE HOSPITALIST GROUP. AMOUNTS PAID OUT TO INDIVIDUALS LISTED ON PART VII OF THE FORM 990 FOR 2011 WERE: DOMINICK CARBONE, MD $348,902 RIZWAN AHMEND, MD 42,729 CHRISTOPHER SPONGBERG, MD 35,133 LAWRENCE NABORS, MD 89,252 SUPPLEMENTAL INFORMATION PART III COMPENSATION FROM AN UNRELTED ORGANIZATION: CEO DAVID LOVING IS COMPENSATED BY AN OUTSIDE MANAGEMENT COMPANY, ALLIANT MANAGEMENT GROUP. NORTH CAROLINA MEDICAL CARE COMMISSION 521309402 657902F31 2003-04-23 39673032 REFUNDING, NEW STRUCTURES, EQUIPMENT 0 0 0 NORTH CAROLINA MEDICAL CARE COMMISSION 521309402 65821DAF8 2008-09-24 45455000 NEW STRUCTURES, EQUIPMENT 0 0 0 6150000 40932286 4414510 529906 1878294 21551473 11100000 2005 1 0 1 1 1215000 46276755 3493414 435743 513249 42448072 2010 0 0 1 1 0 0 0 0 0.00000 0.00000 0.00000 1 0 0 0 0 0.00000 0.00000 0.00000 1 0 0 0 0 0 0 0 1 1 WELLS FARGO 30.000000000000 1 0 0 0 0 SCH K, PART II, LINE 11, COLUMN A THE OTHER SPENT PROCEEDS OF $11,100,000 WERE USED TO CURRENTLY REFUND PRIOR BONDS ISSUED ON 05-08-1996. FORM 990, PART VI, SECTION A, LINE 2 BOARD MEMBER RAYMOND PARKER IS AN ATTORNEY AND HAS BUSINESS RELATIONSHIPS WITH OTHER BOARD MEMBERS AND KEY EMPLOYEES. FORM 990, PART VI, SECTION A, LINE 3 THE HOSPITAL ENTERED INTO A MANAGEMENT AGREEMENT IN JUNE 2006 WITH ALLIANT, AN UNRELATED CORPORATION WHEREBY THE MANAGEMENT COMPANY WILL PERFORM MANAGEMENT AND ADMINISTRATION SERVICES ON A DAY-TO-DAY BASIS AND PROVIDE A CHIEF EXECUTIVE OFFICER. THE AGREEMENT CALLS FOR A BASE MANAGEMENT FEE OF APPROXIMATELY $220,000 IN THE FIRST YEAR WITH ANNUAL INCREASES TO APPROXIMATE THE INCREASE IN CONSUMER PRICE INDEX. IN ADDITION TO THE ANNUAL FEE, THE HOSPITAL IS REQUIRED TO PAY THE SALARIES, BONUSES AGREED UPON BY THE BOARD, AND ALL FRINGE BENEFITS OF THE MANAGEMENT COMPANY'S KEY PERSONNEL WHO PERFORM THE ADMINISTRATIVE DUTIES. FORM 990, PART VI, SECTION B, LINE 11 THE RETURN WAS PREPARED BY AN INDEPENDENT ACCOUNTING FIRM WITH SUPERVISION AND ASSISTANCE BY MANAGEMENT. UPON COMPLETION, THE RETURN WAS REVIEWED BY MANAGEMENT AND DELIVERED TO THE FINANCE COMMITTEE OF THE BOARD OF DIRECTORS FOR APPROVAL. THE RETURN WAS THEN PRESENTED AT A SCHEDULED MEETING OF THE BOARD OF DIRECTORS BY A REPRESENTATIVE OF THE ACCOUNTING FIRM, AND EACH VOTING MEMBER OF THE BOARD WAS PROVIDED A COPY FOR DISCUSSION AND QUESTIONS. FOLLOWING THE MEETING AND A PERIOD OF TIME FOR COMMENT, THE RETURN WAS FILED WITH THE IRS. FORM 990, PART VI, SECTION B, LINE 12C ANNUALLY, ALL VOTING BOARD MEMBERS ARE PRESENTED WITH THE GOVERNANCE POLICIES CONCERNING THE ORGANIZATION'S CONFLICT OF INTEREST POLICY. UPON REVIEW AND DISCUSSION CONCERNING RELATIONSHIPS WITH THE ORGANIZATION, ITS AFFILIATES, OR AMONGST EACH OTHER, THE BOARD MEMBERS ARE REQUIRED TO COMPLETE AND RETURN THE POLICY STATEMENT TO THE ADMINISTRATION. THESE STATEMENTS ARE REVIEWED BY THE BOARD CHAIR AND ARE PRESENTED TO THE AUDITORS DURING THE ANNUAL AUDIT. FORM 990, PART VI, SECTION B, LINE 15 A REPRESENTATIVE FROM ALLIANT, THE OUTSIDE MANAGEMENT COMPANY, MEETS WITH THE BOARD TO REVIEW AND APPROVE SALARIES FOR THE CEO AND OTHER OFFICERS. THE SALARIES OF THE TOP EXECUTIVE AND OTHER MEMBERS OF THE ADMINISTRATIVE DEPARTMENT ARE DETERMINED IN THE CONTRACT NEGOTIATIONS. A REVIEW OF ALL SALARIES, TOP TO BOTTOM, WAS DONE THROUGH THE ADMINISTRATIVE TEAM. FORM 990, PART VI, SECTION C, LINE 18 PHOTOCOPIES OF THE FORM 990 ARE AVAILABLE UPON REQUEST AT THE ORGANIZATION'S ADMINISTRATIVE OFFICE. FORM 990, PART VI, SECTION C, LINE 19 PHOTOCOPIES OF THE ORGANIZATION'S GOVERNING DOCUMENTS, CONFLICT OF INTEREST POLICY, AND FINANCIAL STATEMENTS ARE AVAILABLE UPON REQUEST AT THE ORGANIZATION'S ADMINISTRATIVE OFFICE. CHANGES IN NET ASSETS OR FUND BALANCES: FORM 990, PART XI, LINE 5: NET UNREALIZED GAINS ON INVESTMENTS: 5,688,780. CHANGE IN VALUE OF SWAP AGREEMENT -810,010. TRANSFER OF EQUITY TO FOUNDATION, NET -70,706. RECOGNIZED LOSSES ON IMPAIRMENTS -307,170. FOUNDATION'S UNREALIZED GAINS -327,242. TOTAL TO FORM 990, PART XI, LINE 5: 4,173,652. FORM 990, PART XII, LINE 2C: THE PROCESS HAS NOT CHANGED FROM THE PRIOR YEAR. HUGH CHATHAM MEMORIAL HOSPITAL FOUNDATION INC 180 PARKWOOD DRIVE ELKIN NC 28621 562049537 FUNDRAISING NC 501(C)(3) LINE 11A, I HUGH CHATHAM MEMORIAL HOSPITAL 1 HUGH CHATHAM MEMORIAL HOSPITAL AUXILIARY 180 PARKWOOD DRIVE ELKIN NC 28621 561199949 THRIFT/GIFT SHOP NC 501(C)(3) LINE 11A, I HUGH CHATHAM MEMORIAL HOSPITAL 1 0 0 0 0 0 0 0 0 0 0 0 0 1 1 0 1 1 1 HUGH CHATHAM MEMORIAL HOSPITAL FOUNDATION INC Q 143606 CASH HUGH CHATHAM MEMORIAL HOSPITAL FOUNDATION INC R 72900 CASH