2013-02-06T06:55:00-06:00 2012-09-30 560747981 DIXON HUGHES GOODMAN LLP 500 RIDGEFIELD COURT ASHEVILLE NC 28806 990 2011-10-01 561346589 HOSPICE OF SURRY COUNTY INC HOSP 3367892922 401 TECHNOLOGY LANE NO 200 MOUNT AIRY NC 27030 DENISE WATSON 3367892922 2013-02-06 1 AMY BIBBY P00445891 8282542254 2011 2016-02-25 16:41:14Z MOUNTAIN VALLEY HOSPICE AND PALLATIVE CARE DENISE WATSON 401 TECHNOLOGY LANE NO 200 MOUNT AIRY NC 27030 20982948 0 X WWW.MTNVALLEYHOSPICE.ORG X 1982 NC TO IMPROVE THE QUALITY OF LIFE FOR THOSE WITH A LIMITED LIFE EXPECTANCY AND THEIR FAMILIES 2 2 264 455 0 0 295363 283350 19163348 20654481 9586 1884 8299 8431 19476596 20948146 0 0 0 0 9444900 10542309 0 0 0 8366969 8660742 17811869 19203051 1664727 1745095 10168532 12574777 2090367 2751517 8078165 9823260 X THE 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. 0 0 16804421 20654481 THE 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. 16804421 1 1 0 1 0 0 0 0 0 0 1 0 0 0 1 1 1 0 0 0 0 0 0 0 1 0 0 0 0 1 0 0 0 0 0 0 1 0 0 0 0 0 0 0 0 0 0 0 1 102 0 1 264 1 0 0 0 0 0 0 0 0 0 1 0 X 2 2 0 0 0 0 1 1 1 1 1 0 0 1 1 1 1 1 1 1 1 0 X X RON PARDUE 3367892922 401 TECHNOLOGY LANE STE 200 MOUNT AIRY NC 27030 WILLIAM B JAMES 1.00 X X 0 0 0 DON TRIPPEL 1.00 X X 0 0 0 ROBERT HETRICK 1.00 X X 0 0 0 DAVID LOVING 1.00 X X 0 0 0 SYLVIA DENISE WATSON 40.00 X 126465 0 17006 RONNIE G PARDUE 40.00 X 113207 0 7786 GLENN D GOLASZEWSKI 40.00 X 176887 0 14417 416559 0 39209 3 0 1 0 BLUE CROSS BLUE SHIELD PO BOX 580017 CHARLOTTE NC 28258 INSURANCE 1426372 CENTRAL CONTINUING CARE 1287 NEWSOME STREET MT AIRY NC 27030 HEALTH CARE 649849 WISE HOSPICE OPTIONS 1733 NORMAL HILL EDMOND OK 73034 PHARMACY 573409 GOLDEN LIVING CENTER - SURRY 542 ALLRED MILL RD MT AIRY NC 27030 HEALTH CARE 434301 HUGH CHATHAM MEMORIAL HOSPITAL PO BOX 560 ELKIN NC 28621 HEALTH CARE 395895 21 45181 238169 283350 PATIENT SERVICE REVENU 623000 20654481 20654481 20654481 1884 1884 43233 34802 8431 8431 20948146 20654481 0 10315 520733 93245 427488 32522 32522 7232408 6282376 950032 63700 52430 11270 2094684 1724071 370613 598262 492411 105851 5177 5177 61025 61025 150 150 3799027 3745209 53818 167268 167268 466798 363731 103067 229359 229359 440395 440395 743266 602106 141160 73654 71943 1711 52851 52851 455179 455179 33411 33411 MEDICAL SUPPLIES 2000688 2000688 BAD DEBT 132494 132494 19203051 16804421 2398630 0 3202012 5199398 52219 1889282 1964471 37077 40548 248103 179883 6736222 1886555 4703321 4849667 376 226 36142 340584 10168532 12574777 1251463 1375517 800000 800000 38904 576000 2090367 2751517 X 8025946 9823260 52219 0 8078165 9823260 10168532 12574777 1745095 0 X X 0 1 1 X 0 X 878613 761122 174234 295363 283350 2392682 878613 761122 174234 295363 283350 2392682 384935 2007747 42722 15330 5880 9586 1884 75402 2468084 82125419 0.81350 0.85900 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 0 0 0 0 0 0 0 0 1 2693 2693 0 EXPLANATION OF LOBBYING ACTIVITIES: PART II-B, LINE 1: A 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 CARE 261343 261343 2468724 220934 2247790 4006155 1665621 2340534 4849667 CAPITAL LEASE OBLIGATION 278000 INSURANCE CLAIMS PAYABLE 298000 576000 20948146 19203051 1745095 1745095 20948146 0 20948146 0 20948146 19203051 0 19203051 0 19203051 DESCRIPTION OF UNCERTAIN TAX POSITIONS UNDER FIN 48: PART X: INCOME 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. TOUR DE MAYBERRY 13238 13238 6085 CLUTCHES & CLUBS 11282 11282 4227 7 18713 18713 24490 43233 43233 34802 34802 8431 X X 0 0 0 0 0 0 0 0 0 GLENN D GOLASZEWSKI 171787 0 5100 0 0 0 0 0 14417 0 191304 0 0 0 DEBRA TRIPPEL SPOUSE OF CURRENT OFFICER 33522 COMPENSATION AS EMPLOYEE 0 FORM 990, PART VI, SECTION A, LINE 6 THE ORGANIZATION HAS TWO MEMBERS, HUGH CHATHAM MEMORIAL HOSPITAL, INC, AND THE NORTHERN HOSPITAL DISTRICT OF SURRY COUNTY. FORM 990, PART VI, SECTION A, LINE 7A THE 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 7B THE 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 11 THE 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 12C BOARD 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 15 SALARY 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 18 RECENT 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 19 PHOTOCOPIES 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 2C THE PROCESS HAS NOT CHANGED FROM THE PREVIOUS YEAR.