2013-02-13T07:50:09-06:00 2012-09-30 560747981 DIXON HUGHES GOODMAN LLP 500 RIDGEFIELD COURT ASHEVILLE NC 28806 990 2011-10-01 560554202 CALDWELL MEMORIAL HOSPITAL INC CALD 8287575100 321 MULBERRY STREET SW LENOIR NC 28645 DONALD J GARDNER JR 8287575100 2013-02-13 1 AMY BIBBY P00445891 8282542254 2011 2016-03-07 17:11:31Z LAURA J EASTON 321 MULBERRY STREET SW LENOIR NC 28645 111786727 0 X WWW.CALDWELLMEMORIAL.ORG X 1945 NC TO PROVIDE HEALTH CARE SERVICES TO THE PEOPLE OF CALDWELL COUNTY. 13 12 1032 118 1044806 0 300922 587466 92906792 108113225 -38184 315196 829331 2770840 93998861 111786727 0 0 0 0 46326781 48010542 0 0 0 51928832 61584350 98255613 109594892 -4256752 2191835 48429934 55838070 18493680 22891891 29936254 32946179 X THE MISSION OF CALDWELL MEMORIAL HOSPITAL IS TO PROMOTE SAFE, EFFECTIVE, COMPASSIONATE MEDICAL CARE AND TO PROMOTE HEALTHLY LIFESTYLES FOR OUR COMMUNITY. 0 0 94394178 111786727 CALDWELL MEMORIAL HOSPITAL IS PROUD TO PROVIDE THE QUALITY HEALTHCARE YOU TRUST AND THE CARING YOU DESERVE. SINCE OPENING IN 1951, CALDWELL MEMORIAL HOSPITAL HAS CONTINUED TO GROW AND CHANGE IN ORDER TO BETTER MEET THE NEEDS OF OUR COMMUNITY. THE MISSION OF CALDWELL MEMORIAL HOSPITAL IS TO PROVIDE SAFE, EFFECTIVE, COMPASSIONATE CARE AND TO PROMOTE HEALTHY LIFESTYLES TO OUR COMMUNITY. ANCHORED BY A 110-BED ACUTE CARE FACILITY, CALDWELL MEMORIAL HOSPITAL'S SERVICES INCLUDE A VAST ARRAY OF MEDICAL AND SURGICAL SERVICES. AMONG SERVICES OFFERED, BUT BY NO MEANS A COMPLETE LIST, ARE CAROTID ARTERY STENTING; CARDIOVASCULAR AND ENDOVASCULAR CARE; RADIATION ONCOLOGY; COMPUTER-ASSISTED ORTHOPEDIC SURGERY; NEUROLOGY AND MEMORY CARE; PAIN MANAGEMENT; A FULLY STAFFED 24-HOUR EMERGENCY DEPARTMENT; CALDWELL PHYSICIANS CLINICS CONVENIENTLY LOCATED COUNTY-WIDE; DIAGNOSTIC SERVICES; OUTPATIENT SURGERY; PLUS URGENT CARE; AND THE QUEST 4 LIFE WELLNESS CENTER. MULTIPLE EDUCATIONAL AND COUNSELING PROGRAMS ARE AVAILABLE FOR A WIDE ARRAY OF HEALTHCARE NEEDS INCLUDING CANCER, DIABETES, NUTRITION, JOINT CARE, PRE-NATAL CLASSES AND PARENTING SKILLS. CALDWELL PHYSICIANS IS A DIVISION OF CALDWELL MEMORIAL HOSPITAL. WITH PRACTICES IN COMMUNITIES COUNTYWIDE, CALDWELL PHYSICIANS PROVIDES THE PRIMARY AND SPECIALTY HEALTHCARE, DIAGNOSTICS AND TREATMENTS THAT OUR COMMUNITY NEEDS IN CONVENIENT LOCATIONS NEAR THEIR HOMES. CALDWELL PHYSICIANS INCLUDES: CALDWELL ACUTE CARE SPECIALISTS, EMPLOYER GROUP CLINIC, FALLS MEDICAL PRACTICE, FALLS NEUROLOGY AND MEMORY CENTER, FALLS PEDIATRICS, FALLS PLUS URGENT CARE, LAUREL PARK WOMEN'S CLINIC, MAIN STREET MEDICAL PRACTICE, MCBURNEY PRIMARY CARE, MULBERRY PEDIATRICS, OCCUPATIONAL HEALTH, ROBBINS CARDIOLOGY, ROBBINS PIEDMONT VISTA ENT, ROBBINS FAMILY PRACTICE, ROBBINS INTERNAL MEDICINE, ROBBINS PULMONOLOGY, ROBBINS PLUS URGENT CARE, SOUTHFORK MEDICAL PRACTICE AND WESTPOINTE MEDICAL PRACTICE. 94394178 1 1 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 0 0 0 1 0 0 0 0 0 0 0 0 0 1 1 1 0 0 1 118 0 1 1032 1 1 1 0 0 0 0 0 0 0 0 0 X 13 12 1 0 0 0 0 0 0 1 1 0 0 1 1 1 1 1 1 1 1 1 1 NC X DON GARDNER & CHRIS WASHBURN 8287575221 321 MULBERRY STREET SW LENOIR NC 28645 BOYD WILSON 1.00 X X 0 0 0 PARKER WILLIAMSON 1.00 X X 0 0 0 BILL JOHNSON 1.00 X X 0 0 0 GARY SHORE 1.00 X 0 0 0 ALEX BERNHARDT JR 1.00 X 0 0 0 DEBORAH MURRAY 1.00 X 0 0 0 PETER PURCELL MD 1.00 X 0 0 0 MARK BATTS MD 1.00 X 0 0 0 RICK COFFEY 1.00 X 0 0 0 MIKE CHAMBERLAIN 1.00 X 0 0 0 JOHN MCCORMICK MD 1.00 X 0 0 0 LAURA J EASTON 40.00 X 229534 0 81211 SHARON KIMBALL 40.00 X 135264 0 12573 DAVID HORN 40.00 X 119096 0 14642 DANNY MORGAN 40.00 X 107004 0 8828 REBECCA SMITH 40.00 X 159198 0 16941 DONALD GARDNER JR 40.00 X 168495 0 16360 JOHN POWELL MC 40.00 X 182861 0 14837 DAVID A LOWRY 40.00 X 397725 0 13826 DONALD E SCHMECHEL 40.00 X 328760 0 9261 RONALD H DUBOW 40.00 X 293023 0 16745 PAUL D WARRICK 40.00 X 287781 0 8828 RAMESH L KRISHNARAJ 40.00 X 268457 0 14167 2677198 0 228219 49 0 1 0 CALDWELL FAMILY PHYSICIANS PA CONNELLY SPRINGS ROAD LENOIR NC 28645 PROFESSIONAL MEDICAL SERVICES 1097650 TIM BLINSON CONSTRUCTION 2377 MILLS COVE PLACE LENOIR NC 28645 MINOR CONTRUCTION PROJECTS 444989 DLP CARDIAC PARTNERS LLC (MEDCATH) 3700 ARCO CORPORATE OFFICE SUITE 4 CHARLOTTE NC 28273 CATH LAB PARTNER 352423 SIMPLER NORTH AMERICA LP PO BOX 643979 PITTSBURGH PA 152643979 LEAN-STRATEGIC ADVISORY WORK 222386 KAUFMAN HALL 5202 OLD ORCHARD ROAD SUITE N700 SKOKIE IL 60077 STRATEGIC PLANNING & FORECASTING 192394 9 575973 11493 587466 PATIENT SERVICES 621500 103082756 103082756 OTHER PATIENT REVENUE 900099 2832168 2832168 WELLNESS CENTER 713990 843653 843653 LAB SERVICES 621400 698570 636350 62220 JOINT VENTURE INCOME 541900 350090 211157 138933 305988 305988 108113225 232550 232550 213045 0 213045 213045 213045 82646 0 82646 82646 82646 MEANINGFUL USE INCENTI 900099 1695179 1695179 OTHER INCOME 900099 862616 862616 2557795 111786727 106762431 1044806 3392024 1206844 946214 260630 37583377 32308624 5274753 655331 561815 93516 6182279 5300065 882214 2382711 2042697 340014 88991 88991 36505 36505 11740506 7472443 4268063 288962 288962 5062204 4101819 960385 2337119 2337119 148119 92031 56088 450306 450306 4281848 4281848 1187236 1187236 MEDICAL SUPPLIES 17117700 16610575 507125 BAD DEBT EXPENSE 11817810 11817810 EQUIPMENT RENTAL & MAIN 6343567 4415480 1928087 MISCELLANEOUS 515368 468096 47272 168109 168109 109594892 94394178 15200714 0 6715 8582 4544071 7054007 10628701 12483899 279450 114361 2582996 2833180 1307785 836240 83859186 60565166 20303163 23294020 5319593 6534166 2039644 1289872 215310 109225 1202506 1280518 48429934 55838070 7732680 10296354 254528 88537 9377698 11245184 1128774 1261816 18493680 22891891 X 29936254 32946179 29936254 32946179 48429934 55838070 X 2191835 818090 X X 0 1 1 X 0 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 0 0 0 0 0 0 0 0 1 12244 12244 0 EXPLANATION OF LOBBYING ACTIVITIES: PART II-B, LINE 1: ANNUAL DUES WERE PAID TO THE NORTH CAROLINA HOSPITAL ASSOCIATION AND THE AMERICAN HOSPITAL ASSOCIATION, OF WHICH $12,244 WAS ESTIMATED TO BE EXPENDITURES USED IN LOBBYING ACTIVITIES BY THESE ORGANIZATIONS. 1137587 1137587 30207515 26822722 3384793 9117489 1266975 7850514 42762905 32475469 10287436 633690 633690 23294020 REFUNDS PAYABLE AND PATIENT DEPOSITS 536155 ESTIMATED THIRD PARTY SETTLEMENTS 550244 PHYSICIAN RECRUITMENT OBLIGATIONS 175417 1261816 111786727 109594892 2191835 818090 818090 3009925 112642817 818090 38000 856090 111786727 0 111786727 109632892 38000 38000 109594892 0 109594892 DESCRIPTION OF UNCERTAIN TAX POSITIONS UNDER FIN 48: PART X: THE HOSPITAL AND FOUNDATION ARE NOT-FOR-PROFIT CORPORATIONS AND HAVE BEEN RECOGNIZED AS TAX-EXEMPT, PURSUANT TO SECTION 501(C)(3) OF THE INTERNAL REVENUE CODE. NO PROVISION FOR INCOME TAXES HAS BEEN MADE IN THE ACCOMPANYING CONSOLIDATED FINANCIAL STATEMENTS. THE HOSPITAL'S LAB SERVICES TO NON-PATIENTS AND SALES FROM THE QUEST 4 LIFE WELLNESS CENTER CONSTITUTE UNRELATED BUSINESS INCOME UNDER THE INTERNAL REVENUE CODE. THE HOSPITAL AND FOUNDATION HAVE DETERMINED THAT THEY DO NOT HAVE ANY MATERIAL UNRECOGNIZED TAX BENEFITS OR OBLIGATIONS AS OF SEPTEMBER 30, 2012 AND 2011. FISCAL YEARS ENDING ON OR AFTER SEPTEMBER 30, 2009 REMAIN SUBJECT TO EXAMINATION BY FEDERAL AND STATE TAX AUTHORITIES. 1 1 1 X 1 X 225.000000000000 1 1 0 1 1 1235617 1235617 0.01260 11794625 7143706 4650919 0.04760 1233488 384986 848502 0.00870 14263730 7528692 6735038 0.06890 561722 561722 0.00570 561722 561722 0.00570 14825452 7528692 7296760 0.07460 1 4569728 1158995 24852869 25230067 -377198 X 1 1 1 1 CALDWELL MEMORIAL HOSPITAL

321 MULBERRY STREET SW PO BOX 1890 LENOIR NC 28645

X X X DISPROPORTIONATE SHARE HOSPITAL NA FOR 2011 1 1 1 150.000000000000 1 225.000000000000 1 X X X X X X 1 1 X X X X X X 1 0 1 X 0 0 20 GEORGE M HANCOCK SURGERY CENTER

1031 MORGANTON BLVD LENIOR NC 28645

OUTPATIENT SURGERY CENTER FALLS MEDICAL PARK

4355 HICKORY BLVD GRANITE FALLS NC 28630

FALLS MEDICAL PRACTICE, FALLS NEURO & MEMORY, FALLS PEDIATRIC PRACTICE MAIN STREET MEDICAL PARK

589 MAIN STREET HUDSON NC 28638

MAIN STREET MEDICAL PRACTICE MULBERRY PEDIATRICS

401 MULBERRY STREET LENIOR NC 28645

MULBERRY PEDIATRIC PRACTICE ROBBINS MEDICAL PARK

322 MULBERRY STREET LENOIR NC 28645

ROBBINS ENT PRACTICE, FAMILY CARE, INTERNAL MEDICINE, AND URGENT CARE SOUTHFOLK MEDICAL PARK

1731 CONNELLY SPRINGS ROAD LENIOR NC 28645

SOUTHFOLK MEDICAL PRACTICE WESTPOINTE MEDICAL PRACTICE

2651 MORGANTON BLVD LENIOR NC 28645

WESTPOINTE MEDICAL PRACTICE THE CENTER FOR WOUND TREATMENT

401 MULBERRY STREET LENIOR NC 28645

WOUND CARE CENTER AMERICAN HOMEPATIENT OF UNIFOUR LLC

1929 TATE BLVD HICKORY NC 28602

DURABLE MEDICAL EQUIPMENT LTD. PARTNERSHIP JOINT VENTURE GUARDIAN HEALTH SERVICES LLC

1771 TATE BLVD SUITE 101 HICKORY NC 28602

HOME HEALTH AGENCY JOINT VENTURE HALLMARK FAMILY PHYSICIANS INC

321 MULBERRY STREET SE LENIOR NC 28645

FAMILY PHYSICIANS CALDWELL MEMORIAL SLEEP CENTER

270 PINE MOUNTAIN ROAD SUITE 1 HUDSON NC 28638

SLEEP CENTER CENTER FOR BREAST HEALTH

1031 MORGANTON BLVD SUITE B LENIOR NC 28645

BREAST HEALTH MCCREARY CANCER CENTER

212 MULBERRY STREET SW LENIOR NC 28645

RADIATION AND MEDICAL ONCOLOGY PAIN MANAGEMENT CENTER

1031 MORGANTON BLVD LENIOR NC 28645

PAIN MANAGEMENT FALLS PEDIATRICS

4355 HICKORY BLVD LOWER SUITE GRANITE FALLS NC 28630

PEDIATRIC CARE LAUREL PARK WOMEN'S HEALTH

222 MORGANTON BLVD SW LENIOR NC 28645

OBSTETRIC AND GYNECOLOGICAL CARE ROBBINS PULMONOLOGY

322 MULBERRY STREET SW LENIOR NC 28645

OUTPATIENT PULMONARY CLINIC QUEST4LIFE WELLNESS CENTER

1031 MORGANTON BLVD SW SUITE A LENIOR NC 28645

COMMUNITY WELLNESS FACILITY CENTER FOR DIABETES HEALTH

1031 MORGANTON BLVD SUITE A LENIOR NC 28645

DIABETES EDUCATION AND SUPPORT SERVICES PART I, LINE 7: THE ORGANIZATION USED WORKSHEET 2 OF THE 2011 SCHEDULE H INSTRUCTIONS TO COMPUTE A COST-TO-CHARGES RATIO USED TO CALCULATE CHARITY CARE AND UNREIMBURSED MEDICAID AT COST. THE HOSPITAL HAS, SINCE 1996, PARTICIPATED IN THE NORTH CAROLINA MEDICAID REIMBURSEMENT INITIATIVE (THE "MRI PLAN"). IN CONNECTION THEREWITH, THE HOSPITAL RECEIVED APPROXIMATELY $804,000 AND $1,076,000, RESPECTIVELY, FROM THE MRI PLAN DURING THE YEARS ENDED SEPTEMBER 30, 2012 AND 2011, AND RECOGNIZED AS NET REVENUE $1,073,000 AND $807,000, RESPECTIVELY. IN 2011, THE HOSPITAL RECOGNIZED AN ADDITIONAL $300,000 FROM THE ELIMINATION OF RESERVES FOR MRI PLAN YEARS 2009 THROUGH 2010, WHICH MANAGEMENT DETERMINED WERE NO LONGER NECESSARY BASED ON SEVERAL FACTS, PRIMARILY WRITTEN CONFIRMATION FROM THE STATE IN JULY 2010 THAT IT WOULD NOT RETROSPECTIVELY SETTLE ANY OF THESE PLAN YEARS. FURTHERMORE, THE NORTH CAROLINA DIVISION OF MEDICAL ASSISTANCE COMPLETED DISPROPORTIONATE SHARE HOSPITAL ("DSH") AUDITS THROUGH 2008. THOSE AUDITS SHOW NO OVERPAYMENTS IN AGGREGATE BASED ON THE CENTER FOR MEDICARE AND MEDICAID SERVICES ("CMS") FINAL REGULATIONS PUBLISHED IN THE DECEMBER 19, 2008 FEDERAL REGISTER.IN APRIL 2012, CMS APPROVED A NORTH CAROLINA MEDICAID ASSESSMENT PLAN TO REDUCE THE GAP BETWEEN MEDICAID AND UNINSURED COSTS AND PAYMENTS (THE "GAP PLAN") RETROACTIVE TO JANUARY 1, 2011. UNDER THE GAP PLAN, PROVIDERS PERIODICALLY PAY AN ASSESSMENT TO THE STATE OF NORTH CAROLINA AND PERIODICALLY RECEIVE MEDICAID PAYMENTS FROM THE STATE OF NORTH CAROLINA. IN 2012, THE STATE COLLECTED ASSESSMENTS AND MADE PAYMENTS FOR THE THREE QUARTERS ENDING SEPTEMBER 30, 2011 AND THE FOUR QUARTERS ENDING SEPTEMBER 30, 2012. DURING 2012, THE HOSPITAL PAID ASSESSMENTS OF APPROXIMATELY $3,474,000, WHICH WERE RECORDED AS OTHER EXPENSE IN THE CONSOLIDATED STATEMENT OF OPERATIONS, AND RECEIVED PAYMENTS OF APPROXIMATELY $6,829,000, OF WHICH $6,429,000 WAS RECORDED AS NET PATIENT REVENUE. PART I, L7 COL(F): FOR PURPOSES OF CALCULATING PERCENT OF TOTAL EXPENSE FOR LINE 7, COLUMN (F), TOTAL EXPENSE FROM FORM 990, PART IX, LINE 25 HAS BEEN ADJUSTED TO REMOVE $11,817,810 BAD DEBT EXPENSE. PART III, LINE 4: FINANCIAL STATEMENT FOOTNOTE:THE HOSPITAL HAS PROVIDED SERVICES TO PERSONS WHO HAVE NOT PAID FOR SUCH SERVICES EITHER BECAUSE THEY HAVE BEEN UNWILLING OR UNABLE TO PAY. EFFORTS ARE MADE BY THE HOSPITAL TO DETERMINE IF A PATIENT MEETS CHARITY POLICY GUIDELINES THAT ARE ESTABLISHED BY THE HOSPITAL. IF THESE GUIDELINES ARE MET AND CAN BE VERIFIED, THEN SUCH AMOUNTS ARE INCLUDED IN CHARITY CARE. UNTIL SUCH TIME, SUCH AMOUNTS ARE COMBINED IN BAD DEBTS BECAUSE THEY HAVE NOT BEEN VERIFIED OR DOCUMENTED AS CHARITY CARE DUE TO LACK OF SUPPORTING FINANCIAL INFORMATION. IN SOME CASES, PATIENTS WHO WOULD (OR COULD) QUALIFY FOR CHARITY CARE ARE UNWILLING OR UNABLE TO PRODUCE THE NECESSARY INFORMATION TO SUBSTANTIATE THEIR QUALIFICATION. THUS, BAD DEBTS INCLUDE AMOUNTS THAT WOULD OTHERWISE QUALIFY FOR CHARITY CARE UNDER THE HOSPITAL'S GUIDELINES. THE ESTIMATED COST OF UNREIMBURSED SERVICES ATTRIBUTABLE TO BAD DEBTS - EFFECTIVELY "FREE" SERVICES PROVIDED TO PATIENTS - HAS BEEN DETERMINED BY APPLYING A COST TO CHARGE RATIO TO THE AMOUNT OF BAD DEBTS. SUCH ESTIMATED COSTS WERE APPROXIMATELY $4,636,000 AND $4,682,000 IN THE YEARS ENDED SEPTEMBER 30, 2012 AND 2011, RESPECTIVELY.COSTING METHODOLOGY:THE AMOUNTS DISCLOSED ON LINES 2 AND 3 OF PART III, SECTION A ARE REPORTED ON THE ORGANIZATION'S MOST RECENTLY FILED MEDICARE COST REPORT (FY 2011). THE ORGANIZATION HAS ESTIMATED THE AMOUNT OF UNREIMBURSED COSTS OF TREATING MEDICARE PATIENTS FOR FY 2011 TO BE $6,832,000. PART III, LINE 8: WITH COUNTYWIDE DOUBLE-DIGIT UNEMPLOYMENT AND A POPULATION ALREADY HEAVILY DEPENDENT UPON MEDICARE AND MEDICAID, THE ENTIRETY OF THE MEDICARE SHORTFALL (REPORTED IN LINE 7) IS COMMUNITY BENEFIT, EQUATING DIRECTLY TO "FREE" CARE PROVIDED BY CALDWELL MEMORIAL. N/A FOR 2011 PART V, SECTION B, LINE 3: ANALYSIS OF INFORMATION REGARDING HEALTH STATUS, RISK FACTORS, ACCESS TO CARE AND COMMUNITY ASSETS/RESOURCES WAS COMPLETED. PRIMARY DATA WAS COLLECTED USING A TWO-STAGE CLUSTER SAMPLING SYSTEM TO IDENTIFY SEVEN INTERVIEW SITES. TWO-PERSON TEAMS THEN CONDUCTED SITE SURVEYS/INTERVIEWS IN THE SEVEN LOCATIONS INCLUDING DEMOGRAPHICS (RACE, EDUCATION, INCOME, EMPLOYMENT LEVEL) QUALITY OF LIFE, COMMUNITY IMPROVEMENT, HEALTH INFORMATION, PERSONAL HEALTH, ACCESS TO CARE AND EMERGENCY PREPAREDNESS. OVER 200 SURVEYS WERE COLLECTED. OTHER DATA USED IN ANALYZING THE COMMUNITY NEEDS INCLUDED NORTH CAROLINA STATE CENTER FOR HEALTH STATISTICS, U.S. CENSUS BUREAU, U.S. ENVIRONMENTAL PROTECTION AGENCY, NORTH CAROLINA DEPARTMENT OF LABOR, AND NORTH CAROLINA PUBLIC HEALTH. INFORMATION FROM VARIOUS LOCAL EDUCATION, LAW ENFORCEMENT, AND SOCIAL SERVICE AGENCIES WAS ALSO INCLUDED IN ANALYSIS. N/A FOR 2011 PART V, SECTION B, LINE 5C: IN ADDITION TO BEING MADE AVAILABLE UPON REQUEST FROM THE HOSPITAL FACILITY, THE NEEDS ASSESSMENT WAS PRESENTED AT THE COUNTY BOARD OF HEALTH MEETING. PART VI, LINE 2: IN COLLABORATION WITH THE CALDWELL COUNTY HEALTH DEPARTMENT AND OTHER COMMUNITY AGENCIES (SCHOOL SYSTEM, SOCIAL SERVICES, TOWNSHIPS/MUNICIPALITIES AND UNINSURED CLINIC) CALDWELL MEMORIAL HOSPITAL COMPLETED A FORMAL 2011-2014 COMMUNITY HEALTH ASSESSMENT (CHA). IT HAD BEEN OVER FIVE YEARS SINCE A COMMUNITY HEALTH ASSESSMENT HAD BEEN COMPLETED, THOUGH MANY EFFORTS FOCUSED ON THE HEALTH OF COMMUNITY HAD BEEN ONGOING. COMMUNITY SURVEYS (FACE-TO-FACE SURVEYS WITH RESIDENTS) WERE CONDUCTED IN AREAS OF THE COUNTY IDENTIFIED USING A TWO CLUSTER SAMPLING METHOD. OTHER DATA USED IN ANALYZING THE COMMUNITY NEEDS INCLUDED NORTH CAROLINA STATE CENTER FOR HEALTH STATISTICS, U.S. CENSUS BUREAU, U.S. ENVIRONMENTAL PROTECTION AGENCY, NORTH CAROLINA DEPARTMENT OF LABOR, AND NORTH CAROLINA PUBLIC HEALTH. INFORMATION FROM VARIOUS LOCAL EDUCATION, LAW ENFORCEMENT AND SOCIAL SERVICE AGENCIES WAS ALSO INCLUDED IN ANALYSIS. THE NORTH CAROLINA HEALTHY PEOPLE 20/20 OBJECTIVES WERE ALSO PART OF THE ANALYSIS. ONGOING FEEDBACK FROM THE COMMUNITY AND OTHER HEALTH CARE AGENCIES (MENTAL HEALTH SERVICES, SCHOOL SYSTEM, SOCIAL SERVICE AGENCIES, HEALTH CARE CLINICS AND ECONONIC DEVELOPMENT GROUPS) WAS ALSO CONSIDERED IN THE DEVELOPMENT OF COMMUNITY PLANS. A COMMUNITY ADVISORY GROUP (COMPRISED OF AGENCIES NOTED ABOVE AND COMMUNITY MEMBERS) REVIEWED DATA AND IDENTIFED THREE HEALTH OBJECTIVES FOR THE COUNTY BOARD OF HEALTH: SUBSTANCE ABUSE, TEEN PREGNANCY, AND HIGH SCHOOL DROPOUT RATE. IT WAS FELT THAT EACH OF THESE DIRECTLY CONTRIBUTES TO THE HEALTH OF OUR RESIDENTS. IN ADDITION TO THE THREE NOTED OBJECTIVES, CMH HAS ADOPTED OTHER AREAS OF FOCUS FOR THE HEALTH OF OUR COMMUNITY. THESE INCLUDE HEALTHY LIVING (EXERCISE AND NUTRITION), OCCUPATIONAL HEALTH, MENTAL HEALTH AND HEALTH SCREEINGS BASED ON THE DATA COLLECTED IN THE COMMUNITY HEALTH ASSESSMENT. PART VI, LINE 3: CALDWELL MEMORIAL HOSPITAL (CMH) PROVIDES NEEDED HEALTHCARE SERVICES TO ANYONE REGARDLESS OF THAT PERSON'S ABILITY TO PAY. CMH'S CHARITY CARE POLICY IS DESIGNED TO ASSIST PATIENTS WHO ARE FINANCIALLY UNABLE TO PAY FOR HEALTHCARE SERVICES. THE POLICY CAN BE FOUND ON THE CMH PUBLIC WEBSITE. CMH DISPLAYS INFORMATION REGARDING THE AVAILABILITY OF FINANCIAL ASSISTANCE AND CHARITY CARE IN ITS EMERGENCY ROOM, REGISTRATION AREAS IN THE HOSPITAL AND CLINICS, AND FINANCIAL COUNSELOR OFFICES. A LINK IS ALSO PROVIDED ON THE HOSPITAL'S WEBSITE TO THE AVAILABILITY OF FINANCIAL ASSISTANCE AND ITS CHARITY CARE POLICY, ALONG WITH AN ON-LINE APPLICATION. INPATIENT CASE MANAGERS ALSO PROVIDE INFORMATION TO THE PATIENTS REGARDING AVAILABLE PROGRAMS AND THE ORGANIZAITONS FINANCIAL POLICY. CONSULTATION WITH FINANCIAL COUNSELORS IS ALSO AVAILABLE TO ALL PATIENTS AS NEEDED. PART VI, LINE 4: THE PRIMARY SERVICE AREA FOR CALDWELL MEMORIAL HOPSITAL IS CALDWELL COUNTY WITH A LIMITED NUMBER OF PATIENTS FROM THE SURROUNDING COUNTIES OF BURKE, WATAUGA AND CATAWBA. CALDWELL COUNTY IS IN THE NORTHWEST SECTION OF NORTH CAROLINA IN THE FOOTHILLS OF THE BLUE RIDGE MOUNTAINS AND IS BOUNDED ON THE NORTHWEST BY WATAUGA COUNTY, ON THE NORTHEAST BY WILKES COUNTY, ON THE EAST BY ALEXANDER COUNTY, ON THE SOUTH BY CATAWBA AND BURKE COUNTIES, AND ON THE WEST BY BURKE AND AVERY COUNTIES. TODAY, THERE ARE NINE INCORPORATED MUNICIPALITIES IN THE COUNTY: LENOIR, HUDSON, GRANITE FALLS, CEDAR ROCK, CAJAHS MOUNTAIN, GAMEWELL, SAWMILLS AND PARTS OF BLOWING ROCK AND RHODHISS. POPULATION IS JUST OVER 80,000. MEDIAN INCOME IS $36,936. POPULATION MAKEUP IS 92.2% WHITE, 5.2% BLACK, 4.7% HISPANIC AND 2.6% OTHER. MEDIAN AGE IS 37.5 YEARS. 49.4% ARE MALES AND 50.6% FEMALES. UNEMPLOYMENT IN 2012 WAS 10.2%. PART VI, LINE 5: CALDWELL MEMORIAL HOSPITAL PROVIDES FINANCIAL SUPPORT TO TWO COMMUNITY AGENCIES: THE HELPING HANDS CLINIC (PROVIDING CARE TO THE UNINSURED) AND THE SATIE AND J. E. BROYHILL CALDWELL SENIOR CENTER (FOCUS ON THE LIVES AND ADVOCACY FOR SENIORS). OTHER COMMUNITY INVOLVEMENT INCLUDES BUT IS NOT LIMITED TO:1. ANNUAL PROSTATE SCREENING FOR CALDWELL COUNTY RESIDENTS (AVERAGING 100+ MEN SCREENED ANNUALLY). 2. HEALTH FAIRS THROUGHOUT THE YEAR FOCUSING ON WELLNESS, HEALTH EATING, GETTING FIT, SCREENINGS FOR CHOLESTEROL, HYPERTENSION, DIABETES, ETC. 3. SUPPORT AND INVOLVEMENT IN THE CALDWELL COMMUNITY GARDENS WHICH HELPS FOSTER COMMUNITY GARDENING IN CALDWELL COUNTY, NC AS A STRATEGY TO HELP OUR COMMUNITY EAT SMART BY INCREASING AFFORDABLE ACCESS TO HEALTHY FOODS AND SUSTAINABILITY. 4. REPRESENTATION BY ORGANIZATION REPRESENTATIVES ON LOCAL HEALTH CARE RELATED BOARDS (CC BOARD OF HEALTH, CC HOSPICE AND PALLIATIVE CARE, CC CHILD PROTECTION TEAM). 5. ESTABLISHMENT OF CALDWELL COUNTY MENTAL HEALTH WORK GROUP. MEMBERSHIP INCLUDES CMH, LOCAL LME, MOBILE CRISIS AND LAW ENFORCEMENT AGENCIES WORKING TOWARDS IMPROVING MENTAL HEALTH CARE IN CALDWELL COUNTY. 6. ESTABLISHMENT OF CALDWELL MEMORIAL HEALTHWORKS WHICH IS OCCUPATIONAL, INDUSTRIAL, AND WORKER'S COMPENSATION MEDICINE DESIGNED TO ASSIST EMPLOYERS TOWARD THESE TRIPLE AIM GOALS OF IMPROVING THE QUALITY OF HEALTHCARE, ACCESS TO HEALTHCARE AND PATIENT SATISFACTION. 7. THE MAJORITY OF THE ORGANIZATION'S GOVERNING BODY IS COMPRISED OF PERSONS WHO RESIDE IN THE HOSPITAL'S PRIMARY SERVICE AREA AND WHO ARE NEITHER EMPLOYEES NOR INTERESTED PERSONS. 8. THE HOSPITAL EXTENDS STAFF PRIVILEDGES TO ALL QUALIFIED PHYSICIANS IN THE COMMUNITY. 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 1 1 X X X X X 0 1 0 0 0 1 0 0 0 LAURA J EASTON 220084 0 9450 0 0 0 72383 0 8828 0 310745 0 0 0 REBECCA SMITH 139573 0 3125 0 16500 0 8113 0 8828 0 176139 0 0 0 DONALD GARDNER JR 163304 0 5191 0 0 0 7532 0 8828 0 184855 0 0 0 JOHN POWELL MC 182861 0 0 0 0 0 6009 0 8828 0 197698 0 0 0 DAVID A LOWRY 397725 0 0 0 0 0 4998 0 8828 0 411551 0 0 0 DONALD E SCHMECHEL 328760 0 0 0 0 0 433 0 8828 0 338021 0 0 0 RONALD H DUBOW 277523 0 0 0 15500 0 7917 0 8828 0 309768 0 0 0 PAUL D WARRICK 287781 0 0 0 0 0 0 0 8828 0 296609 0 0 0 RAMESH L KRISHNARAJ 259007 0 0 0 9450 0 5339 0 8828 0 282624 0 0 0 PART I, LINE 1A MEMBERSHIPS AT THE ORGANIZATION'S ON-SITE QUEST 4 LIFE FITNESS CENTER ARE PROVIDED TO CERTAIN OFFICERS AND KEY EMPLOYEES. THE FITNESS CENTER IS OPERATED DIRECTLY BY THE ORGANIZATION. PART I, LINE 4B LAURA EASTON (CEO) HAS A SECURED BENEFIT PLAN WHICH IS INCLUDED IN THE STUDY COMPLETED BY THE INDEPENDENT COMPENSATION CONSULTANT. THE LOAN UNDER THIS ARRANGEMENT IS RECORDED ON THE ORGANIZATION'S AUDITED FINANCIAL STATEMENTS AND FULLY SECURED BY A LIFE INSURANCE POLICY ON THE LIFE OF THE CEO. PART I, LINE 6 SENIOR MANAGEMENT HAS AN INCENTIVE PROGRAM WHICH IS PARTIALLY EARNED BASED ON PROFIT MARGIN AND DAYS CASH ON HAND. THE EARNED INCENTIVE IS REVIEWED BY THE HR COMMITTEE OF THE BOARD AND APPROVED ANNUALLY. EMPLOYED PHYSICIANS ARE PAID ON A PRODUCTIVITY BASIS BASED ON RVU'S GENERATED IN THEIR PRACTICE OPERATIONS. THESE ARE TIED TO MGMA BENCHMARKS. PAUL WARRICK START UP LOAN X 324600 114361 0 1 1 114361 FORM 990, PART VI, SECTION A, LINE 1 THE EXECUTIVE/FINANCE COMMITTEE SHALL HAVE THE POWER TO TRANSACT ALL REGULAR BUSINESS OF THE HOSPITAL DURING THE PERIOD BETWEEN THE MEETINGS OF THE BOARD OF DIRECTORS, SUBJECT TO ANY PRIOR LIMITATION IMPOSED BY THE BOARD OF DIRECTORS. FORM 990, PART VI, SECTION A, LINE 2 GARY SHORE AND BILL JOHNSON HAVE A BUSINESS RELATIONSHIP. FORM 990, PART VI, SECTION B, LINE 11 THE FORM 990 WAS PREPARED BY AN INDEPENDENT ACCOUNTANT WITH ASSISTANCE AND OVERSIGHT BY MANAGEMENT. IT WAS REVIEWED IN DETAIL BY THE AUDIT AND COMPLIANCE COMMITTEE AND PRESENTED TO THE FULL BOARD DURING THE AUDIT AND COMPLIANCE REPORT. THE FULL BOARD RECEIVED A COPY OF THE FORM 990 FOR THEIR REVIEW AND FOR ANY QUESTIONS. THE FULL BOARD VOTED FOR A FINAL APPROVAL OF THE FORM 990. FORM 990, PART VI, SECTION B, LINE 12C THE AUDIT AND COMPLIANCE COMMITTEE OF THE BOARD ANNUALLY REVIEWS THE CONFLICT OF INTEREST STATEMENTS. MINUTES OF BOARD MEETINGS REFLECT ANY DECLARED CONFLICT OF INTEREST. FORM 990, PART VI, SECTION B, LINE 15 THE ORGANIZATION COMPLETES THE REBUTTABLE PRESUMPTION OF REASONABLENESS AS DESCRIBED IN TREASURY REGULATION 4958(6)(C) FOR EACH OFFICER AND KEY EMPLOYEE. THIS PROCESS IS PERFORMED BY AN OUTSIDE INDEPENDENT COMPENSATION SPECIALIST. THE CONSULTANT'S FINDINGS ARE PRESENTED TO THE HR COMMITTEE OF THE BOARD AND ARE ULTIMATELY APPROVED BY THE FULL BOARD. FORM 990, PART VI, SECTION C, LINE 18 PHOTOCOPIES OF THE FORM 990 ARE AVAILABLE UPON REQUEST AT THE ORGANIZATION'S ADMINISTRATIVE OFFICE. IN ADDITION, RECENT FILINGS OF THE FORM 990 ARE AVAILABLE ON GUIDESTAR.ORG. FORM 990, PART VI, SECTION C, LINE 19 THE ORGANIZATION MAKES ITS GOVERNING DOCUMENTS, FINANCIAL STATEMENTS, AND CONFLICT OF INTEREST POLICY AVAILABLE UPON REQUEST. PLEASE USE THE ORGANIZATION'S "CONTACT US" LINK ON ITS WEBSITE FOR REQUESTS. CHANGES IN NET ASSETS OR FUND BALANCES: FORM 990, PART XI, LINE 5: NET UNREALIZED GAINS ON INVESTMENTS: 818,090. FORM 990, PART XII, LINE 2C: THE PROCESS HAS NOT CHANGED FROM THE PRIOR YEAR. CALDWELL MEMORIAL HOSPITAL FOUNDATION INC PO BOX 1890 LENOIR NC 28645 581935514 FOUNDATION NC 501(C)(3) LINE 7 CALDWELL MEMORIAL HOSPITAL INC 1 GUARDIAN HEALTH SERVICE LLC 343 SECOND STREET HICKORY NC 28601 752950776 HOME HEALTHCARE NC N/A RELATED -12673 1895777 0 1 HALLMARK FAMILY PHYSICIANS INC 1766 CONNELLY SPRINGS ROAD LENOIR NC 28645 202088324 PHYSICIAN PRACTICE NC N/A 0 0 1 0 0 0 0 0 0 0 0 1 1 0 1 0 0 0 CALDWELL MEMORIAL HOSPITAL FOUNDATION C 575973 CASH CALDWELL MEMORIAL HOSPITAL FOUNDATION O 186911 ACTUAL COSTS