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HOSPICE OF SURRY COUNTY INC: Form 990, tax year 2011

View the entire original 990 at ProPublica ↗

Organization
HOSPICE OF SURRY COUNTY INC (EIN 56-1346589)
Tax period
2011-10-01 to 2012-09-30
Filed
2013-02-06
IRS object ID
201320379349300802
Schema version
2011v1.2
Source
Download XML · Original 990 at ProPublica

Every field in the e-filed return. Faint text is the IRS element name, for citing.

Return header ReturnHeader

FieldValueIRS element (for citing)
Timestamp2013-02-06T06:55:00-06:00Timestamp
Tax Period End Date2012-09-30TaxPeriodEndDate

Preparer Firm PreparerFirm

FieldValueIRS element (for citing)
EIN560747981EIN

Preparer Firm Business Name PreparerFirmBusinessName

FieldValueIRS element (for citing)
Business Name Line1DIXON HUGHES GOODMAN LLPBusinessNameLine1

Preparer Firm US Address PreparerFirmUSAddress

FieldValueIRS element (for citing)
Address Line1500 RIDGEFIELD COURTAddressLine1
CityASHEVILLECity
StateNCState
ZIP Code28806ZIPCode
FieldValueIRS element (for citing)
Return Type990ReturnType
Tax Period Begin Date2011-10-01TaxPeriodBeginDate

Filer Filer

FieldValueIRS element (for citing)
EIN561346589EIN

Name Name

FieldValueIRS element (for citing)
Business Name Line1HOSPICE OF SURRY COUNTY INCBusinessNameLine1
FieldValueIRS element (for citing)
Name ControlHOSPNameControl
Phone3367892922Phone

US Address USAddress

FieldValueIRS element (for citing)
Address Line1401 TECHNOLOGY LANE NO 200AddressLine1
CityMOUNT AIRYCity
StateNCState
ZIP Code27030ZIPCode

Officer Officer

FieldValueIRS element (for citing)
NameDENISE WATSONName
TitleEXECUTIVE DIRECTORTitle
Phone3367892922Phone
Date Signed2013-02-06DateSigned
Authorize Third Party1AuthorizeThirdParty

Preparer Preparer

FieldValueIRS element (for citing)
NameAMY BIBBYName
PTINP00445891PTIN
Phone8282542254Phone
FieldValueIRS element (for citing)
Tax Year2011TaxYear
Build TS2016-02-25 16:41:14ZBuildTS

Form 990 IRS990

Doing Business As DoingBusinessAs

FieldValueIRS element (for citing)
Business Name Line1MOUNTAIN VALLEY HOSPICE AND PALLATIVE CAREBusinessNameLine1
FieldValueIRS element (for citing)
Name Of Principal Officer PersonDENISE WATSONNameOfPrincipalOfficerPerson

Address Principal Officer US AddressPrincipalOfficerUS

FieldValueIRS element (for citing)
Address Line1401 TECHNOLOGY LANE NO 200AddressLine1
CityMOUNT AIRYCity
StateNCState
ZIP Code27030ZIPCode
FieldValueIRS element (for citing)
Gross Receipts20982948GrossReceipts
Group Return For Affiliates0GroupReturnForAffiliates
Organization501c3XOrganization501c3
Web SiteWWW.MTNVALLEYHOSPICE.ORGWebSite
Type Of Organization CorporationXTypeOfOrganizationCorporation
Year Formation1982YearFormation
State Legal DomicileNCStateLegalDomicile
Activity Or Mission DescriptionTO IMPROVE THE QUALITY OF LIFE FOR THOSE WITH A LIMITED LIFE EXPECTANCY AND THEIR FAMILIESActivityOrMissionDescription
Nbr Voting Members Governing Body2NbrVotingMembersGoverningBody
Nbr Independent Voting Members2NbrIndependentVotingMembers
Total Nbr Employees264TotalNbrEmployees
Total Nbr Volunteers455TotalNbrVolunteers
Total Gross UBI0TotalGrossUBI
Net Unrelated Business Txbl Income0NetUnrelatedBusinessTxblIncome
Contributions Grants Prior Year295363ContributionsGrantsPriorYear
Contributions Grants Current Year283350ContributionsGrantsCurrentYear
Program Service Revenue Prior Year19163348ProgramServiceRevenuePriorYear
Program Service Revenue CY20654481ProgramServiceRevenueCY
Investment Income Prior Year9586InvestmentIncomePriorYear
Investment Income Current Year1884InvestmentIncomeCurrentYear
Other Revenue Prior Year8299OtherRevenuePriorYear
Other Revenue Current Year8431OtherRevenueCurrentYear
Total Revenue Prior Year19476596TotalRevenuePriorYear
Total Revenue Current Year20948146TotalRevenueCurrentYear
Grants And Similar Amnts Prior Year0GrantsAndSimilarAmntsPriorYear
Grants And Similar Amnts CY0GrantsAndSimilarAmntsCY
Benefits Paid To Members Prior Year0BenefitsPaidToMembersPriorYear
Benefits Paid To Members CY0BenefitsPaidToMembersCY
Salaries Etc Prior Year9444900SalariesEtcPriorYear
Salaries Etc Current Year10542309SalariesEtcCurrentYear
Total Prof Fundrsng Exp Prior Year0TotalProfFundrsngExpPriorYear
Total Prof Fundrsng Exp CY0TotalProfFundrsngExpCY
Total Fundrsng Exp Current Year0TotalFundrsngExpCurrentYear
Other Expense Prior Year8366969OtherExpensePriorYear
Other Expenses Current Year8660742OtherExpensesCurrentYear
Total Expenses Prior Year17811869TotalExpensesPriorYear
Total Expenses Current Year19203051TotalExpensesCurrentYear
Revenues Less Expenses Prior Year1664727RevenuesLessExpensesPriorYear
Revenues Less Expenses CY1745095RevenuesLessExpensesCY
Total Assets BOY10168532TotalAssetsBOY
Total Assets EOY12574777TotalAssetsEOY
Total Liabilities BOY2090367TotalLiabilitiesBOY
Total Liabilities EOY2751517TotalLiabilitiesEOY
Net Assets Or Fund Balances BOY8078165NetAssetsOrFundBalancesBOY
Net Assets Or Fund Balances EOY9823260NetAssetsOrFundBalancesEOY
Info In Schedule O Part IIIXInfoInScheduleOPartIII
Mission DescriptionTHE MISSION OF HOSPICE OF SURRY COUNTY, INC. DBA MOUNTAIN VALLEY HOSPICE AND PALLIATIVE CARE IS TO IMPROVE THE QUALITY OF LIFE TO THOSE WITH A LIMITED LIFE EXPECTANCY AND THEIR FAMILIES.MissionDescription
Significant New Program Services0SignificantNewProgramServices
Significant Change0SignificantChange
Expense16804421Expense
Revenue20654481Revenue
DescriptionTHE MISSION, VISION AND VALUES OF HOSPICE OF SURRY COUNTY, INC. CONTINUE TO DRIVE THE CARE AND SERVICES PROVIDED AND TO ENSURE DEDICATION TO DELIVERING THE HIGHEST QUALITY OF CARE POSSIBLE. HOSPICE OF SURRY PRIDES ITSELF IN ACHIEVING AND MAINTAINING A REGIONAL PRESENCE IN BOTH NORTH CAROLINA AND VIRGINIA SERVING PATIENTS AND FAMILIES IN A 16 COUNTY SERVICE AREA. HOSPICE OF SURRY IS CONTINUALLY ENHANCING ITS SERVICES, EXPANDING PROGRAMS, STARTING NEW PROGRAMS AND EDUCATING THE COMMUNITIES IT SERVES. IN ADDITION, HOSPICE OF SURRY FOSTERS NEW AND EXISTING RELATIONSHIPS WITH NURSING HOMES, RESIDENTIAL FACILITIES AND HOSPITALS TO SERVE PATIENTS ANYWHERE THEY MAY CALL HOME. IN 2012, HOSPICE OF SURRY SERVED MORE THAN 1,500 PATIENTS AND THEIR FAMILIES WITH AN AVERAGE DAILY CENSUS OF 306. IN ADDITION TO HOSPICE SERVICES, HOSPICE OF SURRY PROVIDES SERVICES TO PATIENTS AND FAMILIES THROUGH ITS NON-MEDICAL TRANSITIONS PROGRAM AND THROUGH A CONSULTATIVE PALLIATIVE CARE PROGRAM. IN ORDER TO MEET THE NEEDS OF ITS SPECIALTY POPULATIONS, HOSPICE OF SURRY OFFERS HOSPICE AND PALLIATIVE CARE SERVICES FOR PEDIATRIC PATIENTS THROUGH A KIDS PATH PROGRAM, HOSPICE AND PALLIATIVE CARE SERVICES TO VETERANS THROUGH ITS VETERANS PROGRAM AND PET PEACE OF MIND PROGRAM TO ENSURE PETS ARE CARE FOR WHEN A LOVED ONE IS DYING AND BEYOND. IN 2012, THE FOLLOWING HIGHLIGHTS ARE NOTED: -ADMISSIONS INCREASED 2%, -DAYS OF CARE INCREASED 12%, -TOTAL PATIENT REVENUE EXCEEDED $17 MILLION, -ACHIEVED OPERATING INCOME OF 7.6% OF NET PATIENT REVENUE, -ACHIEVED NET INCOME OF 9.2% OF NET PATIENT REVENUE, -COLLECTED OVER $99K OF OUTSTANDING PLEDGES, -RECEIVED $289K IN DONATIONS AND SUPPORT, -BECAME AN APPROVED PROVIDER OF CONTINUING NURSING EDUCATION BY THE NORTH CAROLINA NURSES ASSOCIATION AND IMPLEMENTED A NEW PATIENT SOFTWARE SYSTEM.Description
Total Program Service Expense16804421TotalProgramServiceExpense
Described In501 C31DescribedIn501C3
Schedule B Required1ScheduleBRequired
Political Activities0PoliticalActivities
Lobbying Activities1LobbyingActivities
Subject To Proxy Tax0SubjectToProxyTax
Donor Advised Funds0DonorAdvisedFunds
Conservation Easements0ConservationEasements
Collections Of Art0CollectionsOfArt
Credit Counseling0CreditCounseling
Term Or Permanent Endowments0TermOrPermanentEndowments
Report Land Bldg Equip1ReportLandBldgEquip
Report Invest Oth Securities0ReportInvestOthSecurities
Report Prog Rel Invest0ReportProgRelInvest
Report Other Assets0ReportOtherAssets
Report Other Liabilities1ReportOtherLiabilities
Report Fin48 Footnote1ReportFin48Footnote
Independent Audit Financial Stmt1IndependentAuditFinancialStmt
Consolidated Audit Financial Stmt0ConsolidatedAuditFinancialStmt
School0School
Foreign Office0ForeignOffice
Foreign Activities0ForeignActivities
More Than5000 K To Organizations0MoreThan5000KToOrganizations
More Than5000 K To Individuals0MoreThan5000KToIndividuals
Professional Fundraising0ProfessionalFundraising
Fundraising Activities1FundraisingActivities
Gaming0Gaming
Hospital0Hospital
Grants To Organizations0GrantsToOrganizations
Grants To Individuals0GrantsToIndividuals
Schedule J Required1ScheduleJRequired
Tax Exempt Bonds0TaxExemptBonds
Excess Benefit Transaction0ExcessBenefitTransaction
Prior Excess Benefit Transaction0PriorExcessBenefitTransaction
Loan To Officer Or DQP0LoanToOfficerOrDQP
Grant To Related Person0GrantToRelatedPerson
Bsnss Rltnshp With Organization0BsnssRltnshpWithOrganization
Bsnss Rltnshp Thru Family Member1BsnssRltnshpThruFamilyMember
Officer Entity With Bsnss Rltnshp0OfficerEntityWithBsnssRltnshp
Deductible Non Cash Contributions0DeductibleNonCashContributions
Deductible Contributions Of Art0DeductibleContributionsOfArt
Terminated0Terminated
Partial Liquidation0PartialLiquidation
Disregarded Entity0DisregardedEntity
Related Entity0RelatedEntity
Related Org Controlled Entity0RelatedOrgControlledEntity
Transaction Related Entity0TransactionRelatedEntity
Transfers To Exempt Non Chrtbl Org0TransfersToExemptNonChrtblOrg
Activities Conducted Partnership0ActivitiesConductedPartnership
Schedule O Required1ScheduleORequired
Number Forms Transmitted With1096102NumberFormsTransmittedWith1096
Number W2 G Included0NumberW2GIncluded
Compliance With Backup Witholding1ComplianceWithBackupWitholding
Number Of Employees264NumberOfEmployees
Employment Tax Returns Filed1EmploymentTaxReturnsFiled
Unrelated Business Income0UnrelatedBusinessIncome
Foreign Financial Account0ForeignFinancialAccount
Prohibited Tax Shelter Trans0ProhibitedTaxShelterTrans
Taxable Party Notification0TaxablePartyNotification
Non Deductible Contributions0NonDeductibleContributions
Quid Pro Quo Contributions0QuidProQuoContributions
Form8282 Property Disposed Of0Form8282PropertyDisposedOf
Funds To Pay Premiums0FundsToPayPremiums
Premiums Paid0PremiumsPaid
Form1098 C Filed1Form1098CFiled
Indoor Tanning Services0IndoorTanningServices
Info In Schedule O Part VIXInfoInScheduleOPartVI
Nbr Voting Governing Body Members2NbrVotingGoverningBodyMembers
Number Independent Voting Members2NumberIndependentVotingMembers
Family Or Business Relationship0FamilyOrBusinessRelationship
Delegation Of Management Duties0DelegationOfManagementDuties
Changes To Organizing Docs0ChangesToOrganizingDocs
Material Diversion Or Misuse0MaterialDiversionOrMisuse
Members Or Stockholders1MembersOrStockholders
Election Of Board Members1ElectionOfBoardMembers
Decisions Subject To Approval1DecisionsSubjectToApproval
Minutes Of Governing Body1MinutesOfGoverningBody
Minutes Of Committees1MinutesOfCommittees
Officer Mailing Address0OfficerMailingAddress
Local Chapters0LocalChapters
Form990 Provided To Governing Body1Form990ProvidedToGoverningBody
Conflict Of Interest Policy1ConflictOfInterestPolicy
Annual Disclosure Covered Persons1AnnualDisclosureCoveredPersons
Regular Monitoring Enforcement1RegularMonitoringEnforcement
Whistleblower Policy1WhistleblowerPolicy
Document Retention Policy1DocumentRetentionPolicy
Compensation Process CEO1CompensationProcessCEO
Compensation Process Other1CompensationProcessOther
Investment In Joint Venture0InvestmentInJointVenture
Other WebsiteXOtherWebsite
Upon RequestXUponRequest

The Books Are In Care Of TheBooksAreInCareOf

Name Business NameBusiness

FieldValueIRS element (for citing)
Business Name Line1RON PARDUEBusinessNameLine1
FieldValueIRS element (for citing)
Telephone Number3367892922TelephoneNumber

Address US AddressUS

FieldValueIRS element (for citing)
Address Line1401 TECHNOLOGY LANE STE 200AddressLine1
CityMOUNT AIRYCity
StateNCState
ZIP Code27030ZIPCode

Form990 Part VII Section A Form990PartVIISectionA (7 entries)

TitleTitleAverage Hours Per WeekAverageHoursPerWeekIndividual Trustee Or DirectorIndividualTrusteeOrDirectorOfficerOfficerReportable Comp From OrganizationReportableCompFromOrganizationReportable Comp From Related OrgsReportableCompFromRelatedOrgsOther CompensationOtherCompensationKey EmployeeKeyEmployee
WILLIAM B JAMES
CHAIRMAN1.00XX000
DON TRIPPEL
TREASURER1.00XX000
ROBERT HETRICK
SECRETARY1.00XX000
DAVID LOVING
VICE CHAIRMAN1.00XX000
SYLVIA DENISE WATSON
EXECUTIVE DIRECTOR40.00X126465017006
RONNIE G PARDUE
CFO40.00X11320707786
GLENN D GOLASZEWSKI
MEDICAL DIRECTOR40.00176887014417X
FieldValueIRS element (for citing)
Total Reportable Comp From Org416559TotalReportableCompFromOrg
Total Reportable Comp Frm Rltd Orgs0TotalReportableCompFrmRltdOrgs
Total Other Compensation39209TotalOtherCompensation
Number Individuals GT100 K3NumberIndividualsGT100K
Formers Listed0FormersListed
Total Comp GT150 K1TotalCompGT150K
Compensation From Other Sources0CompensationFromOtherSources

Contractor Compensation ContractorCompensation (5 entries)

Address Line1AddressOfContractor/AddressUS/AddressLine1CityAddressOfContractor/AddressUS/CityStateAddressOfContractor/AddressUS/StateZIP CodeAddressOfContractor/AddressUS/ZIPCodeDescription Of ServicesDescriptionOfServicesCompensationCompensation
BLUE CROSS BLUE SHIELD
PO BOX 580017CHARLOTTENC28258INSURANCE1426372
CENTRAL CONTINUING CARE
1287 NEWSOME STREETMT AIRYNC27030HEALTH CARE649849
WISE HOSPICE OPTIONS
1733 NORMAL HILLEDMONDOK73034PHARMACY573409
GOLDEN LIVING CENTER - SURRY
542 ALLRED MILL RDMT AIRYNC27030HEALTH CARE434301
HUGH CHATHAM MEMORIAL HOSPITAL
PO BOX 560ELKINNC28621HEALTH CARE395895
FieldValueIRS element (for citing)
Number Of Contractors GT100 K21NumberOfContractorsGT100K
Federated Campaigns45181FederatedCampaigns
All Other Contributions238169AllOtherContributions
Total Contributions283350TotalContributions

Program Service Revenue ProgramServiceRevenue

FieldValueIRS element (for citing)
DescriptionPATIENT SERVICE REVENUDescription
Business Code623000BusinessCode
Total Revenue Column20654481TotalRevenueColumn
Related Or Exempt Function Income20654481RelatedOrExemptFunctionIncome
FieldValueIRS element (for citing)
Total Program Service Revenue20654481TotalProgramServiceRevenue

Investment Income InvestmentIncome

FieldValueIRS element (for citing)
Total Revenue Column1884TotalRevenueColumn
Exclusion$1,884ExclusionAmount
FieldValueIRS element (for citing)
Gross Income Fundraising Events43233GrossIncomeFundraisingEvents
Fundraising Direct Expenses34802FundraisingDirectExpenses

Net Income From Fundraising Events NetIncomeFromFundraisingEvents

FieldValueIRS element (for citing)
Total Revenue Column8431TotalRevenueColumn
Exclusion$8,431ExclusionAmount

Total Revenue TotalRevenue

FieldValueIRS element (for citing)
Total Revenue Column20948146TotalRevenueColumn
Related Or Exempt Function Income20654481RelatedOrExemptFunctionIncome
Unrelated Business Revenue0UnrelatedBusinessRevenue
Exclusion$10,315ExclusionAmount

Comp Current Officers Directors CompCurrentOfficersDirectors

FieldValueIRS element (for citing)
Total520733Total
Program Services93245ProgramServices
Management And General427488ManagementAndGeneral

Comp Disqual Persons CompDisqualPersons

FieldValueIRS element (for citing)
Total32522Total
Program Services32522ProgramServices

Other Salaries And Wages OtherSalariesAndWages

FieldValueIRS element (for citing)
Total7232408Total
Program Services6282376ProgramServices
Management And General950032ManagementAndGeneral

Pension Plan Contributions PensionPlanContributions

FieldValueIRS element (for citing)
Total63700Total
Program Services52430ProgramServices
Management And General11270ManagementAndGeneral

Other Employee Benefits OtherEmployeeBenefits

FieldValueIRS element (for citing)
Total2094684Total
Program Services1724071ProgramServices
Management And General370613ManagementAndGeneral

Payroll Taxes PayrollTaxes

FieldValueIRS element (for citing)
Total598262Total
Program Services492411ProgramServices
Management And General105851ManagementAndGeneral

Fees For Services Legal FeesForServicesLegal

FieldValueIRS element (for citing)
Total5177Total
Management And General5177ManagementAndGeneral

Fees For Services Accounting FeesForServicesAccounting

FieldValueIRS element (for citing)
Total61025Total
Management And General61025ManagementAndGeneral

Fees For Services Invst Mgmnt Fees FeesForServicesInvstMgmntFees

FieldValueIRS element (for citing)
Total150Total
Management And General150ManagementAndGeneral

Fees For Services Other FeesForServicesOther

FieldValueIRS element (for citing)
Total3799027Total
Program Services3745209ProgramServices
Management And General53818ManagementAndGeneral

Advertising Advertising

FieldValueIRS element (for citing)
Total167268Total
Management And General167268ManagementAndGeneral

Office Expenses OfficeExpenses

FieldValueIRS element (for citing)
Total466798Total
Program Services363731ProgramServices
Management And General103067ManagementAndGeneral

Information Technology InformationTechnology

FieldValueIRS element (for citing)
Total229359Total
Program Services229359ProgramServices

Occupancy Occupancy

FieldValueIRS element (for citing)
Total440395Total
Program Services440395ProgramServices

Travel Travel

FieldValueIRS element (for citing)
Total743266Total
Program Services602106ProgramServices
Management And General141160ManagementAndGeneral

Conferences Meetings ConferencesMeetings

FieldValueIRS element (for citing)
Total73654Total
Program Services71943ProgramServices
Management And General1711ManagementAndGeneral

Interest Interest

FieldValueIRS element (for citing)
Total52851Total
Program Services52851ProgramServices

Depreciation Depletion DepreciationDepletion

FieldValueIRS element (for citing)
Total455179Total
Program Services455179ProgramServices

Insurance Insurance

FieldValueIRS element (for citing)
Total33411Total
Program Services33411ProgramServices

Other Expenses OtherExpenses (2 entries)

DescriptionDescriptionTotalTotalProgram ServicesProgramServices
MEDICAL SUPPLIES20006882000688
BAD DEBT132494132494

Total Functional Expenses TotalFunctionalExpenses

FieldValueIRS element (for citing)
Total19203051Total
Program Services16804421ProgramServices
Management And General2398630ManagementAndGeneral
Fundraising0Fundraising

Savings And Temp Cash Investments SavingsAndTempCashInvestments

FieldValueIRS element (for citing)
BOY3202012BOY
EOY5199398EOY

Pledges And Grants Receivable PledgesAndGrantsReceivable

FieldValueIRS element (for citing)
BOY52219BOY

Accounts Receivable AccountsReceivable

FieldValueIRS element (for citing)
BOY1889282BOY
EOY1964471EOY

Inventories For Sale Or Use InventoriesForSaleOrUse

FieldValueIRS element (for citing)
BOY37077BOY
EOY40548EOY

Prepaid Expenses Deferred Charges PrepaidExpensesDeferredCharges

FieldValueIRS element (for citing)
BOY248103BOY
EOY179883EOY
FieldValueIRS element (for citing)
Land Buildings Equipment Basis6736222LandBuildingsEquipmentBasis
Land Bldg Equipment Accum Deprec1886555LandBldgEquipmentAccumDeprec

Land Buildings Equipment Basis Net LandBuildingsEquipmentBasisNet

FieldValueIRS element (for citing)
BOY4703321BOY
EOY4849667EOY

Investments Pub Traded Securities InvestmentsPubTradedSecurities

FieldValueIRS element (for citing)
BOY376BOY
EOY226EOY

Other Assets Total OtherAssetsTotal

FieldValueIRS element (for citing)
BOY36142BOY
EOY340584EOY

Total Assets TotalAssets

FieldValueIRS element (for citing)
BOY10168532BOY
EOY12574777EOY

Accounts Payable Accrued Expenses AccountsPayableAccruedExpenses

FieldValueIRS element (for citing)
BOY1251463BOY
EOY1375517EOY

Mort Notes Pybl Secured Invest Prop MortNotesPyblSecuredInvestProp

FieldValueIRS element (for citing)
BOY800000BOY
EOY800000EOY

Other Liabilities OtherLiabilities

FieldValueIRS element (for citing)
BOY38904BOY
EOY576000EOY

Total Liabilities TotalLiabilities

FieldValueIRS element (for citing)
BOY2090367BOY
EOY2751517EOY
FieldValueIRS element (for citing)
Follow SFAS117XFollowSFAS117

Unrestricted Net Assets UnrestrictedNetAssets

FieldValueIRS element (for citing)
BOY8025946BOY
EOY9823260EOY

Temporarily Restricted Net Assets TemporarilyRestrictedNetAssets

FieldValueIRS element (for citing)
BOY52219BOY
EOY0EOY

Total Net Assets Fund Balances TotalNetAssetsFundBalances

FieldValueIRS element (for citing)
BOY8078165BOY
EOY9823260EOY

Total Liab Net Assets Fund Balances TotalLiabNetAssetsFundBalances

FieldValueIRS element (for citing)
BOY10168532BOY
EOY12574777EOY
FieldValueIRS element (for citing)
Reconcilation Revenue Expenses1745095ReconcilationRevenueExpenses
Reconcilation Other Changes0ReconcilationOtherChanges
Info In Schedule O Part XIIXInfoInScheduleOPartXII
Method Of Accounting AccrualXMethodOfAccountingAccrual
Accountant Compile Or Review0AccountantCompileOrReview
FS Audited1FSAudited
Audit Committee1AuditCommittee
Financial Statement SeparateXFinancialStatementSeparate
Federal Grant Audit Required0FederalGrantAuditRequired

Schedule A IRS990ScheduleA

FieldValueIRS element (for citing)
Publicly Supported Org170b1 AviXPubliclySupportedOrg170b1Avi

Gifts Grants Contrib Received170 GiftsGrantsContribReceived170

FieldValueIRS element (for citing)
Current Tax Year Minus4 Years878613CurrentTaxYearMinus4Years
Current Tax Year Minus3 Years761122CurrentTaxYearMinus3Years
Current Tax Year Minus2 Years174234CurrentTaxYearMinus2Years
Current Tax Year Minus1 Year295363CurrentTaxYearMinus1Year
Current Tax Year283350CurrentTaxYear
Total2392682Total

Total170 Total170

FieldValueIRS element (for citing)
Current Tax Year Minus4 Years878613CurrentTaxYearMinus4Years
Current Tax Year Minus3 Years761122CurrentTaxYearMinus3Years
Current Tax Year Minus2 Years174234CurrentTaxYearMinus2Years
Current Tax Year Minus1 Year295363CurrentTaxYearMinus1Year
Current Tax Year283350CurrentTaxYear
Total2392682Total
FieldValueIRS element (for citing)
Amounts Subst Contributors Total384935AmountsSubstContributorsTotal
Public Support Total1702007747PublicSupportTotal170

Gross Investment Income170 GrossInvestmentIncome170

FieldValueIRS element (for citing)
Current Tax Year Minus4 Years42722CurrentTaxYearMinus4Years
Current Tax Year Minus3 Years15330CurrentTaxYearMinus3Years
Current Tax Year Minus2 Years5880CurrentTaxYearMinus2Years
Current Tax Year Minus1 Year9586CurrentTaxYearMinus1Year
Current Tax Year1884CurrentTaxYear
Total75402Total
FieldValueIRS element (for citing)
Total Support2468084TotalSupport
Gross Receipts From Admissions Etc82125419GrossReceiptsFromAdmissionsEtc
Public Support Pertcentage1700.81350PublicSupportPertcentage170
Public Support Pertcent Prior Year0.85900PublicSupportPertcentPriorYear
Thirty Three Percnt Tests CY170XThirtyThreePercntTestsCY170

Schedule B IRS990ScheduleB

Contributor Info ContributorInfo

FieldValueIRS element (for citing)
Contributor NumberRESTRICTEDContributorNumber

Contributor Name Business ContributorNameBusiness

FieldValueIRS element (for citing)
Business Name Line1RESTRICTEDBusinessNameLine1

Contributor Address US ContributorAddressUS

FieldValueIRS element (for citing)
Address Line1RESTRICTEDAddressLine1
Address Line2RESTRICTEDAddressLine2
CityRESTRICTEDCity
StateRESTRICTEDState
ZIP CodeRESTRICTEDZIPCode
FieldValueIRS element (for citing)
Aggregate ContributionsRESTRICTEDAggregateContributions

Schedule C IRS990ScheduleC

FieldValueIRS element (for citing)
Volunteers0Volunteers
Paid Staff Or Management0PaidStaffOrManagement
Media Advertisements0MediaAdvertisements
Mailings Members0MailingsMembers
Publications Or Broadcast0PublicationsOrBroadcast
Grants Other Organizations0GrantsOtherOrganizations
Direct Contact Legislators0DirectContactLegislators
Rallies Demonstrations0RalliesDemonstrations
Other Activities1OtherActivities
Other Activities$2,693OtherActivitiesAmount
Total Lobbying Expenditures IIB2693TotalLobbyingExpendituresIIB
Not Described In501c30NotDescribedIn501c3

Form990 Schedule C Part IV Form990ScheduleCPartIV

FieldValueIRS element (for citing)
IdentifierEXPLANATION OF LOBBYING ACTIVITIES:Identifier
Return ReferencePART II-B, LINE 1:ReturnReference
ExplanationA PORTION OF THE ANNUAL MEMBERSHIP DUES TO THE FOLLOWING ORGANIZATIONS WERE USED FOR LOBBYING ACTIVITIES: NHPCO ASSOCIATION OF HOME & HOSPICE CARE NATIONAL ASSOCIATION FOR HOME CARE & HOSPICE VIRGINIA ASSOCIATION FOR HOSPICES AND PALLIATIVE CAREExplanation

Schedule D IRS990ScheduleD

Land Land

FieldValueIRS element (for citing)
Other Cost Or Other Basis261343OtherCostOrOtherBasis
Book Value261343BookValue

Buildings Buildings

FieldValueIRS element (for citing)
Other Cost Or Other Basis2468724OtherCostOrOtherBasis
Depreciation220934Depreciation
Book Value2247790BookValue

Equipment Equipment

FieldValueIRS element (for citing)
Other Cost Or Other Basis4006155OtherCostOrOtherBasis
Depreciation1665621Depreciation
Book Value2340534BookValue
FieldValueIRS element (for citing)
Total Of Book Value Land Buildings4849667TotalOfBookValueLandBuildings

Other Liabilities OtherLiabilities (2 entries)

DescriptionDescriptionAmountAmount
CAPITAL LEASE OBLIGATION$278,000
INSURANCE CLAIMS PAYABLE$298,000
FieldValueIRS element (for citing)
Total Of Amounts576000TotalOfAmounts
Total Revenue20948146TotalRevenue
Total Expenses19203051TotalExpenses
Excess Or Deficit For Year1745095ExcessOrDeficitForYear
Excess Or Deficit Per FS1745095ExcessOrDeficitPerFS
Tot Revenue Etc Audited Fincl Stmt20948146TotRevenueEtcAuditedFinclStmt
Revenue Not Rptd F9900RevenueNotRptdF990
Revenue Subtotal20948146RevenueSubtotal
Revenue Not Rptd On Fin Stmt0RevenueNotRptdOnFinStmt
Total Revenue Per Form99020948146TotalRevenuePerForm990
Tot Expenses Etc Audited Fincl Stmt19203051TotExpensesEtcAuditedFinclStmt
Expenses Not Rptd F9900ExpensesNotRptdF990
Expenses Subtotal19203051ExpensesSubtotal
Expenses Not Rptd On Fin Stmt0ExpensesNotRptdOnFinStmt
Total Expenses Per Form99019203051TotalExpensesPerForm990

Form990 Schedule D Part XIV Form990ScheduleDPartXIV

FieldValueIRS element (for citing)
IdentifierDESCRIPTION OF UNCERTAIN TAX POSITIONS UNDER FIN 48:Identifier
Return ReferencePART X:ReturnReference
ExplanationINCOME TAXES- THE HOSPICE IS A NOT-FOR-PROFIT ORGANIZATION THAT HAS BEEN RECOGNIZED BY THE FEDERAL REVENUE SERVICE AS TAX-EXEMPT UNDER THE INTERNAL REVENUE CODE SECTION 501(C)(3). THE HOSPICE FOLLOWS THE FINANCIAL ACCOUNTING STANDARDS BOARD'S ("FASB") AUTHORITATIVE GUIDANCE ON ACCOUNTING FOR UNCERTAINTY IN INCOME TAXES. THE GUIDANCE CLARIFIES THE ACCOUNTING FOR THE RECOGNITION AND MEASUREMENT OF THE BENEFITS OF INDIVDUAL TAX POSITIONS IN THE FINANCIAL STATEMENTS. TAX POSITIONS MUST MEET A RECOGNITION THRESHOLD OF MORE-LIKELY -THAN-NOT IN ORDER FOR THE BENEFIT OF THOSE TAX POSITIONS TO BE RECOGNIZED IN THE HOSPICE'S FINANCIAL STATEMENTS. THE HOSPICE HAS DETERMINED THAT IT DOES NOT HAVE ANY MATERIAL UNRECOGNIZED TAX BENEFITS OR OBLIGATIONS AS OF SEPTEMBER 30, 2012.Explanation

Schedule G IRS990ScheduleG

Events Information EventsInformation

FieldValueIRS element (for citing)
Name Of Event1TOUR DE MAYBERRYNameOfEvent1
Gross Receipts Event113238GrossReceiptsEvent1
Gross Revenue Event113238GrossRevenueEvent1
Other Direct Expenses Event16085OtherDirectExpensesEvent1
Name Of Event2CLUTCHES & CLUBSNameOfEvent2
Gross Receipts Event211282GrossReceiptsEvent2
Gross Revenue Event211282GrossRevenueEvent2
Other Direct Expenses Event24227OtherDirectExpensesEvent2
Total Number Of Other Events7TotalNumberOfOtherEvents
Gross Receipts Other Events18713GrossReceiptsOtherEvents
Gross Revenue Other Events18713GrossRevenueOtherEvents
Other Direct Expenses Other Events24490OtherDirectExpensesOtherEvents
Gross Receipts Total43233GrossReceiptsTotal
Gross Revenue Total Events43233GrossRevenueTotalEvents
Other Direct Expenses Total Events34802OtherDirectExpensesTotalEvents
Direct Expense Summary Events34802DirectExpenseSummaryEvents
Net Income Summary8431NetIncomeSummary

Schedule J IRS990ScheduleJ

FieldValueIRS element (for citing)
Compensation SurveyXCompensationSurvey
Board Or Committee ApprovalXBoardOrCommitteeApproval
Severance Payment0SeverancePayment
Supplemental Nonqual Retire Plan0SupplementalNonqualRetirePlan
Equity Based Comp Arrangement0EquityBasedCompArrangement
Comp Based On Revenue Of Filing Org0CompBasedOnRevenueOfFilingOrg
Comp Based On Revenue Related Orgs0CompBasedOnRevenueRelatedOrgs
Comp Based Net Earnings Filing Org0CompBasedNetEarningsFilingOrg
Comp Based Net Earnings Relate Orgs0CompBasedNetEarningsRelateOrgs
Any Non Fixed Payments0AnyNonFixedPayments
Initial Contract Exception0InitialContractException

Form990 Schedule J Part II Form990ScheduleJPartII

FieldValueIRS element (for citing)
Name PersonGLENN D GOLASZEWSKINamePerson
Base Compensation Filing Org171787BaseCompensationFilingOrg
Comp Based On Related Orgs0CompBasedOnRelatedOrgs
Bonus Filing Org5100BonusFilingOrg
Bonus Related Orgs0BonusRelatedOrgs
Other Compensation Filing Org0OtherCompensationFilingOrg
Other Compensation Related Orgs0OtherCompensationRelatedOrgs
Deferred Comp Filing Org0DeferredCompFilingOrg
Deferred Comp Related Orgs0DeferredCompRelatedOrgs
Nontaxable Benefits Filing Org14417NontaxableBenefitsFilingOrg
Nontaxable Benefits Related Orgs0NontaxableBenefitsRelatedOrgs
Total Compensation Filing Org191304TotalCompensationFilingOrg
Total Compensation Related Orgs0TotalCompensationRelatedOrgs
Comp Report Prior990 Filing Org0CompReportPrior990FilingOrg
Comp Report Prior990 Related Orgs0CompReportPrior990RelatedOrgs

Schedule L IRS990ScheduleL

Form990 Schedule L Part IV Form990ScheduleLPartIV

Name Of Interested Person NameOfInterestedPerson

FieldValueIRS element (for citing)
Name PersonDEBRA TRIPPELNamePerson
FieldValueIRS element (for citing)
RelationshipSPOUSE OF CURRENT OFFICERRelationship
Amount Of Transaction33522AmountOfTransaction
Description Of TransactionCOMPENSATION AS EMPLOYEEDescriptionOfTransaction
Sharing Of Revenues0SharingOfRevenues

Schedule O IRS990ScheduleO

General Explanation GeneralExplanation (9 entries)

Return ReferenceReturnReferenceExplanationExplanation
FORM 990, PART VI, SECTION A, LINE 6THE ORGANIZATION HAS TWO MEMBERS, HUGH CHATHAM MEMORIAL HOSPITAL, INC, AND THE NORTHERN HOSPITAL DISTRICT OF SURRY COUNTY.
FORM 990, PART VI, SECTION A, LINE 7ATHE GOVERNING BODY CONSISTS OF REPRESENTATIVES APPOINTED BY THE ORGANIZATION'S MEMBERS, HUGH CHATHAM MEMORIAL HOSPITAL AND THE NORTHERN HOSPITAL DISTRICT OF SURRY COUNTY.
FORM 990, PART VI, SECTION A, LINE 7BTHE GOVERNING BODY CONSISTS OF REPRESENTATIVES APPOINTED BY THE ORGANIZATION'S MEMBERS, HUGH CHATHAM MEMORIAL HOSPITAL AND THE NORTHERN HOSPITAL DISTRICT OF SURRY COUNTY. DECISIONS OF THE REPRESENTATIVES ARE SUBJECT TO APPROVAL OF THE MEMBER ORGANIZATIONS.
FORM 990, PART VI, SECTION B, LINE 11THE RETURN WAS PREPARED BY AN INDEPENDENT ACCOUNTING FIRM WITH ASSISTANCE AND INFORMATION PROVIDED BY MANAGEMENT. UPON COMPLETION OF THE FORM 990, THE ORGANIZATION'S MANAGEMENT REVIEWED THE FORM 990. THE FORM 990 WAS THEN PROVIDED TO THE MEMBERS FOR THEIR REVIEW PRIOR TO SUBMISSION TO THE IRS.
FORM 990, PART VI, SECTION B, LINE 12CBOARD OF MEMBERS, ADVISORY BOARD AND HOSPICE STAFF SUBMIT A FORM TO DISCLOSE PERSONAL OR FINANCIAL INTERESTS THAT COULD POSSIBLY INTERFERE WITH THEIR DUTIES AND RESPONSIBILITIES TO THE ORGANIZATION. DISCLOSURE FORMS ARE SUBMITTED AT THE TIME OF HIRE OR BOARD APPOINTMENT, ANNUALLY AND/OR WHENEVER A POTENTIAL CONFLICT ARISES. FAILURE TO DISCLOSE EXISTING OR POTENTIAL CONFLICTS OF INTEREST IS GROUNDS FOR TERMINATION OF EMPLOYMENT OR BOARD APPOINTMENT.
FORM 990, PART VI, SECTION B, LINE 15SALARY RANGES ARE ESTABLISHED FOR EACH PAID POSITION IN THE ORGANIZATION. EACH SALARY RANGE HAS A MINIMUM AND MAXIMUM AMOUNT. THE MEMBERS DETERMINE THE SALARY FOR THE EXECUTIVE DIRECTOR, CFO AND MEDICAL DIRECTOR OF THE ORGANIZATION. THE EXECUTIVE DIRECTOR AND CFO DETERMINE THE SALARY RANGES FOR OTHER PAID POSITIONS IN THE ORGANIZATION. SALARY RANGES ARE REVIEWED ANNUALLY AND BENCHMARKED AGAINST INDUSTRY DATA.
FORM 990, PART VI, SECTION C, LINE 18RECENT FILINGS OF THE FORM 990 ARE AVAILABLE UPON REQUEST AT THE ORGANIZATION'S ADMINISTRATIVE OFFICE. IN ADDITION, RECENT FILINGS OF THE FORM 990 ARE AVAILABLE ONLINE AT WWW.GUIDESTAR.ORG.
FORM 990, PART VI, SECTION C, LINE 19PHOTOCOPIES OF THE ORGANIZATION'S GOVERNING DOCUMENTS, CONFLICT OF INTEREST POLICY, AND FINANCIAL STATEMENTS ARE AVAILABLE UPON WRITTEN REQUEST AT THE ORGANIZATION'S ADMINISTRATIVE OFFICE.
FORM 990, PART XII, LINE 2CTHE PROCESS HAS NOT CHANGED FROM THE PREVIOUS YEAR.