2012-11-15T14:35:22-06:00 2011-12-31 550486667 Arnett Foster Toothman PLLC P O Box 2629 Charleston WV 25329 990 2011-01-01 550375433 Davis Memorial Hospital DAVI 3046363300 PO Box 1484 Elkins WV 26241 E Mark Doak 3046363300 2012-11-15 1 Dale Carpenter P00189642 3043460441 2011 2016-02-24 21:20:13Z E Mark Doak PO Box 1484 Elkins WV 26241 83239306 0 X www.davishealthsystem.org X 1903 WV To provide quality health care to residents of Elkins, West Virginia and surrounding communities. 16 14 778 90 132139 68530 3441 52389 80376879 80470242 452923 646751 1089769 2066597 81923012 83235979 68159 78869 0 0 38390810 40134233 0 0 0 38169500 39922652 76628469 80135754 5294543 3100225 67787349 72031083 24024317 29753809 43763032 42277274 To provide patient friendly healthcare to its communities. 0 0 69351439 78869 80469722 The organization operated a 90 bed acute care hospital in Elkins, West Virginia.Charges foregone for charity care amounted to $7,976,035. The hospital provided community support by providing nutritious meals to residents of Elkins, WV. 310132 520 The hospital provided community support by sponsoring various health fairs and providing food or snacks for various community events to residents of Elkins, WV. 69661571 1 0 0 0 0 0 0 0 0 0 1 1 0 1 1 0 1 1 0 0 0 0 0 0 0 0 1 1 1 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 1 0 0 0 0 1 73 0 1 778 1 1 1 0 0 0 0 0 0 0 0 0 X 16 14 0 0 0 0 1 1 1 1 1 0 0 1 1 1 1 1 1 1 1 0 X Rebecca Hammer 3046373156 Gorman Avenue and Reed Street Elkins WV 26241 Hugh Hitchcock 2.00 X 0 0 0 William Hartman 2.00 X 0 0 0 Andrew Gongola 2.00 X 0 0 0 George Scott 2.00 X 0 0 0 Bridgette Wilson 1.00 X 0 0 0 Connie Tenney 1.00 X 0 0 0 Terry White 1.00 X 0 0 0 Suzi Moore 1.00 X 0 0 0 Ashton Curtis DPM 1.00 X 0 0 0 Steve Toney MD 1.00 X 1925 114823 0 Tom Felton 1.00 X 0 0 0 James Triplett 1.00 X 0 0 0 Nitesh Ratnakar MD 1.00 X 0 0 0 Robert Digman PHD 1.00 X 0 0 0 Forrest Kelley 1.00 X 0 0 0 Deborah Tysor 1.00 X 48834 0 17431 E Mark Doak 40.00 X 308039 0 20030 Rebecca Hammer 40.00 X 178891 0 17100 Mohamed M Fahim 40.00 X 606475 0 3695 Donald R Fleming 40.00 X 491224 0 22622 Charles K Kirkland 40.00 X 404955 0 22474 Mary A Scott 40.00 X 397182 0 11191 Anne L Banfield 40.00 X 355134 0 11163 2792659 114823 125706 41 0 1 0 Dunmire Consulting 13352 Paloma Dr Orlando FL 32837 Consulting 429723 Executive Health Resources 15 Campus Blvd Newton Square PA 19073 Purchased Service 309107 Weatherby Locums Inc PO Box 972633 Dallas TX 75397 Locums 249488 Alliance Healthcare PO Box 96485 Chicago IL 60693 PET/CT Scans 247420 Comphealth PO Box 972651 Dallas TX 75397 Contract Fees 227835 12 52389 52389 Patient services 622110 80470242 80470242 80470242 646178 59935 586243 70570 0 70570 70570 4200 66370 3900 3327 573 573 573 Pharmacy 446110 1096764 1096764 Cafeteria 722210 785685 785685 Management fees 900099 68004 68004 45574 45574 1996027 83235979 80470242 132139 2581209 78869 78869 529556 442338 87218 30433214 25420864 5012350 1399806 1169258 230548 5714302 4773156 941146 2057355 1718509 338846 735436 614310 121126 206110 206110 60030 60030 4091475 3417609 673866 144103 144103 5947825 5081252 866573 1358292 1134581 223711 1094295 914065 180230 263070 219742 43328 705280 589120 116160 4134470 3453523 680947 646606 540110 106496 Medical supplies 9475818 9475818 0 Bad debts 6775879 6775879 0 Repairs and maintenance 1787569 1493156 294413 State provider tax 1176611 1176611 0 1319783 1172801 146982 80135754 69661571 10474183 0 1274469 1236594 110573 5450640 10857253 11197748 586684 633770 1260271 1268315 513202 441972 88915390 61033709 23313928 27881681 9869164 11186704 11284143 3766827 8717662 8966832 67787349 72031083 8234225 12069445 9515000 8850000 1528246 626600 1308608 266510 3438238 7941254 24024317 29753809 X 43763032 42277274 43763032 42277274 67787349 72031083 X 3100225 -4585983 X X 0 1 1 X 0 X 106509 2044880 2151389 231721 32698149 25167682 7762188 50080726 35866027 14214699 3753405 3753405 27881681 3766827 F 3766827 Other receivables 207305 Due from affiliates 2567147 Bond issue costs, net of amortization 184472 Due from subsidiary 5501466 Estimated third party payor settlements 506442 8966832 Deferred investment income 405101 Deferred compensation payable 237658 Due to affilates 36811 Capital leases 5753723 Post retirement benefit obligation 1507961 7941254 83235979 80135754 3100225 -398165 -4187818 -4585983 -1485758 76446372 138816 138816 76307556 6928423 6928423 83235979 73359875 0 73359875 6775879 6775879 80135754 Part XI, Line 8 - Other Adjustments: Equity method income of subsidiary -503,914. Change in pension funded status -1,814,837. Transfers to affiliates -1,855,339. Income per books: Premier Purchasing Partners 138,816. Income per K-1: Premier Purchasing Partners -152,544. Total to Schedule D, Part XI, Line 8: -4,187,818. Part XII, Line 2d - Other Adjustments: Income per books: Premier Purchasing Partners LP 138,816. Part XII, Line 4b - Other Adjustments: From K-1: Premier Purchasing Partners LP 152,544. Bad debt expense netted with revenue in financial statements 6,775,879. Part XIII, Line 4b - Other Adjustments: Bad debt expense netted with revenue in financial statements 6,775,879. 1 1 X 1 X 120.000000000000 1 X 1 1 0 1 1 3540912 51765 3489147 0.04760 12691675 8699312 3992363 0.05440 16232587 8751077 7481510 0.10200 311281 520 310761 0.00420 1100 1100 0.00000 3216513 1319634 1896879 0.02590 262395 262395 0.00360 3791289 1320154 2471135 0.03370 20023876 10071231 9952645 0.13570 3817 3817 0.00010 3817 3817 0.00010 0 3102675 19973106 20561025 -587919 X 1 1 1 1 Davis Memorial Hospital

PO Box 1484 Elkins WV 26241

X X X Davis Memorial Hospital 1 0 1 1 120.000000000000 1 300.000000000000 1 X X X X 1 1 X X X X X 1 X X X X 1 X X X X X X 1 X 0 1 Part I, Line 7: The cost of charity care was determined based on the hospital's cost accounting system. The total account cost and total account revenue for those receiving charity care are reported to come to a true cost associated with the accounts. The determined cost to charge ratio for the total account is then applied to the portion on charity care received.The cost of Medicaid was determined using the Hospital's cost accounting system. Accounts showing Medicaid as the primary payor along with total account cost was pulled, the cost to charge ratio was determined and applied to the total Medicaid revenue.The cost of subsidized health services was determined using the hospital's cost accounting system.Community benefit costs were determined from reports filled out by staff/managers involved to determine contributions. Participants supply labor cost as well as any labor costs involved in the community activity. Managers are supplied with community benefit forms. When they perform community service, they supply cost information and any offsetting revenue associated with the event. We have 1 staff member that compiles these forms on a monthly basis. Health professions education costs are compiled through the year and reported by the manager involved in the education opportunity or approving party. Part I, Line 7g: Subsidized health care services include clinics as well as OB/GYN/Labor/Delivery & Nursery services. Part I, Line 7, Column (f): The Bad Debt expense included on Form 990, Part IX, Line 25, Column (A), but subtracted for purposes of calculating the percentage in this column is $ 6775879. How the community benefit report is made available to the public Part I, Line 6b: Community benefit reports are inserted into regional newspapers, mailed to certain regional zip codes, and made available in common areas in Davis Health System facilities. Physician clinic costs included in subsidized services Part I, Line 7g The cost of physician clinics included in subsidized health services was $2,880,799. Part III, Line 4: Audited financial statement footnote relating to bad debt expense: Patient accounts receivable are carried at the original charge less an estimate made for doubtful or uncollectible accounts. The allowance is based upon a review of the outstanding balances aged by financial class. Management uses collection percentages based upon historical collection experience to determine collectibility. Management also reviews troubled, aged accounts to determine collection potential. Delinquency status is based on date of service. Patient accounts receivables are written off when deemed uncollectible. Recoveries of accounts previously written off are recorded as a reduction to bad debt expense when received.The cost of bad debts was determined based on the Hospital's cost accounting system and decision support system. All costs, direct and indirect, are stepped down by department based onrevenue. Bad debt expense is reduced by bad debt recoveries and discounts for payment. Part III, Line 8: Medicare allowable costs were estimated using Worksheet B of the Schedule H instructions. None of the shortfall is considered to be community benefit since the deviation changes each year. Part III, Line 9b: Patients who indicate they have an inability to pay for their medical care are referred to the financial counselor and/or a Medicaid Eligibility Specialist. Patients who do meet financial assistance guidelines but demonstrate an inability to meet our minimum payment quidelines are given a reduced payment plan. Collection procedures regarding reduced payment plans follow the hospital's normal procedures. Patients with catastrophic illnesses are referred to the WV Catastrophic Illness Fund. Patients whose care is a refult of a crime will be referred to the WV Crime Victims Fund. Additional Medicare revenues and costs Part III, Section B, lines 5 and 6 Medicare revenues and costs not included on lines 5 and 6 include professional fees and HMO inpatient and outpatient care totaling $7,617,536. Davis Memorial Hospital Part V, Section B, Line 13g: The policy is posted on the Davis Health System Website and is published annually in local newspapers. The policy is posted in all patient registration areas including ER, Admissions and OP testing. The procedure is also explained in financial counseling brochures available throughout the Health System and in physician offices. All employees are also notified via the internal website where it is posted. We also employ 2 financial counselors who work with and screen the uninsured and underinsured populations. We also have a financial advocate from health and human services. Davis Memorial Hospital Part V, Section B, Line 15e: We are also screening patients through a third party database through the advisory board prior to placement with a collections agency. This scrub provides us with likelihood to qualify for medicaid as well as screens the patients for our internal assistance policy. The presumptive charity adjustments that are done as budgetary constraints allow to better identify medically indigent and patients who have a need for assistance to prevent derogatory collection activity. Davis Memorial Hospital Part V, Section B, Line 19d: The hospital provides a straight 25% discount to uninsured individuals paying their balances. This discount is lower than any of our negotiated insurance contract rates. Davis Memorial Hospital Part V, Section B, Line 21: All patients, including insurance companies, are billed at gross charges. Discounts are provided at the time of payment in full. Charity discounts are applied at the point of approval. Part VI, Line 2: Davis Health System relies heavily on data provided by the Bureau for Public Health; namely, the county Health Profiles that outline risk factors for chronic diseases. In addition, the Community Health Promotion Director gleans information and statistics from health screenings that are held for the public, as well as our employees. This information helps in planning future educational events and screenings. Part VI, Line 3: The information is posted in public areas within the hospital. The financial policy brochure is publicly displayed and posted on the internal network and the health system website. A patient advocate contacts worklists of medically indigent patients to help secure and provide education to affiliate and non-affiliate physician offices referring to Davis Memorial Hospital. Part VI, Line 4: The Hospital serves several rural counties in eastern West Virginia. Randolph county has a population of 29,405 with 16.9% having a bachelor's degree or higher and average household income of $32,027. Upshur county has a population of 24,254 with 15.5% having a bachelor's degree or higher, average household income of $35,255. Barbour county has a population of 16,589 with 12.1% having a bachelor's degree or higher, average household income of $34,547. Pocahontas county has a population of 8,719 with 12.5% having a bachelor's degree or higher, average household income of $30,757. Tucker county has a population of 7,141 with 13.2% having a bachelor's degree or higher, average household income of $33,630. Additionally, 17.8% of all West Virginians live below the poverty level. Davis Memorial is the only hospital in Randolph County. There is one critical access hospital in Pocahontas County and one general service hospital in Upshur County. Part VI, Line 5: The organization's health care facilities further its exempt purpose in the following ways. The organization's governing body is comprised of persons who reside in the organization's primary service area. The corporate by laws provide for Board representation from the counties surrounding Davis Memorial Hospital. The organization extends medical staff privileges to all qualified physicians in its community for some or all of its departments. The organization operates an emergency room available to all, regardless of ability to pay. Specialized services offered by the organization that are not available elsewhere include neurology, pain management, otolaryngology, pulmonology, critical care medicine, general surgery, internal medicine, obstetrics and gynecology, radiation oncology, medical oncology and hematology. The organization serves as a vehicle for attracting charitable support, as well as a source of community volunteer activities. The organization provides an internet link to its Community Benefit Report. Part VI, Line 6: Davis Health System's mission includes the delivery of healthcare services and programs that promote improved health for individuals and families. The quality of life of entire communities is impacted through these vital programs generally offered at little or no cost. Some of the health issues targeted by Davis Health System to the communities served by our organization include diabetes, obesity and weight management, tobacco use and heart disease, womens health, influenza, and, cancer and cancer prevention. Our outreach serves five primary West Virginia counties (Randolph, Tucker, Upshur, Barbour, and Pocahontas), with some overflow to neighboring counties as well. Several examples of projects that represent our commitment to advancing the emotional and physical health benefits to the people of these communities include: community health fairs, diabetes education programs and support groups, diabetes foot screenings, speaking engagements and presentations to schools, civic groups and other organizations, colon cancer screenings and education, community walking program, participation with the American Cancer Society's Relay for Life and March of Dimes, partnership with boards of education, influenza vaccination clinics, partnership with county health departments, drug take-back, smoking cessation classes and support and pap smear and breast examinations. 1 Randolph County Hooked on Fishing Not on Drugs PO Box 2293 Elkins WV 26241 501(c)(3) 13000 Support hooked on fishing, not on drugs programs Mountain State Forest Festival PO Box 388 Elkins WV 26241 550488261 501(c)(4) 5900 Event sponsorship United Hospital Center PO Box 1680 Clarksburg WV 26301 550525724 501(c)(3) 14650 Support program for sane exams and fees Randolph County Senior Center PO Box 727 Elkins WV 26241 550487683 501(c)(3) 5000 Country roads transit Procedure for Monitoring Grants in the U.S.: Part I, Line 2: Schedule I, Part I, Line 2: The organization grants money to other 501(c)(3) organizations and relies on the IRS's oversight of the grantees as they have an exemption from the IRS. X X 1 1 X X 0 1 0 0 0 0 0 0 0 E Mark Doak 307887 0 152 0 0 0 3220 0 19038 0 330297 0 0 0 Rebecca Hammer 178739 0 152 0 0 0 0 0 18444 0 197335 0 0 0 Mohamed M Fahim 606323 0 152 0 0 0 3695 0 3791 0 613961 0 0 0 Donald R Fleming 461072 0 30152 0 0 0 3488 0 22572 0 517284 0 0 0 Charles K Kirkland 404803 0 152 0 0 0 3340 0 21702 0 429997 0 0 0 Mary A Scott 333121 0 64061 0 0 0 3205 0 9900 0 410287 0 0 0 Anne L Banfield 285193 0 69941 0 0 0 3177 0 9900 0 368211 0 0 0 Part I, Line 4b Mark Doak participated in a 457 (f) plan. However, no amount was paid out in 2011. Form 990, Part VI, Section A, line 6 Davis Health System is the parent corporation of Davis Memorial Hospital. The bylaws of the corporation designate Davis Health System as the sole corporate member of Davis Memorial Hospital, and granting all rights to members of nonprofit corporations by the laws of the state of West Virginia. Form 990, Part VI, Section A, line 7a Davis Health System is the parent corporation of Davis Memorial Hospital. The bylaws of the corporation designate Davis Health System as the sole corporate member of Davis Memorial Hospital, and granting all rights to members of nonprofit corporations by the laws of the state of West Virginia. Form 990, Part VI, Section A, line 7b Davis Health System is the parent corporation of Davis Memorial Hospital. The bylaws of the corporation designate Davis Health System as the sole corporate member of Davis Memorial Hospital, and granting all rights to members of nonprofit corporations by the laws of the state of West Virginia. Form 990, Part VI, Section B, line 11 The 990 will be distributed to all board members. It will be presented and discussed at a Board of Trustees meeting or a Finance Committee meeting, whichever occurs first after the completion of Form 990. If the Finance Committee meeting is the first to occur, all members of the Board of Trustees will be encouraged to attend the Finance Committee where the Form is to be discussed. Form 990, Part VI, Section B, line 12c The Davis Health System Conflict of Interest Policy requires that each director, officer, and committee member with board delegated powers shall annually sign a statement which affirms the person has received a copy of the conflict of interest policy and reads and understands the policy. Board members complete the statement in January of each year. The conflict of interest statements are reviewed by the Executive Committee. In addition to board members, senior staff are required to annually prepare a conflict of interest statement. Form 990, Part VI, Section B, line 15 The Compensation Committee of the Board of Trustees is responsible for the oversight of the compensation for the senior staff. A consultant (Yaffe & Company) is engaged who facilitates the annual evaluation process for determining compensation for executives. The consultant coordinates a series of meetings, leads discussions on the chief executive officer's performance evaluation, presents market analysis information for key positions and provides recommendations for salary levels based on that information. The committee makes their decision using the guidance of the consultant. Form 990, Part VI, Section C, line 19 The Board of Trustees adopted a Record Keeping and Disclosure Policy in January of 2003. The policy provides for disclosure of corporate and financial records not covered by governmental or contractual agreements. Any request for financial or other corporate documents are submitted to the Executive Committee of the Board of Trustees and decisions are made on a case by case basis. The Compliance Code of Conduct Policy includes standards relating to conflicts of interest within the organization. This information is shared with the public, being posted on the website in addition to being distributed to all patients admitted to the hospital. Changes in Net Assets or Fund Balances: Form 990, Part XI, line 5: Net unrealized losses on investments: -398,165. Equity method income of subsidiary -503,914. Change in pension funded status -1,814,837. Transfers to affiliates -1,855,339. Income per books: Premier Purchasing Partners 138,816. Income per K-1: Premier Purchasing Partners -152,544. Total to Form 990, Part XI, Line 5: -4,585,983. Clarification of 'yes' response Form 990, Part XII, Line 2C The organization has not changed its selection or oversight process in the past year. Broaddus Hospital Association Inc PO Box 930 Philippi WV 26416 550379108 Hospital WV 501(c)(3) Line 3 N/A 0 Davis Health System Inc PO Box 1484 Elkins WV 26241 550737655 Health System WV 501(c)(3) Line 11b, II N/A 0 Davis Health System Foundation PO Box 1188 Elkins WV 26241 320185772 Supporting organization to health care organization WV 501(c)(3) Line 9 N/A 0 Health Facilities Inc 909 Gorman Avenue Elkins WV 26241 550516937 Health Care WV C -503914 10133023 1.00000 Central WV Medcorp Inc PO Box 2630 Elkins WV 26241 550739314 Physician Offices WV C Elkins Regional Health Partners Physician Hospital Organization Inc PO Box 2632 Elkins WV 26241 550746206 Hospital Organization WV C 1 1 0 0 0 0 0 0 0 0 1 0 0 0 0 0 0 0 Health Facilities Inc A 201444 Cash - FMV Central WV Medcorp Inc B 1649417 Cash - FMV Health Facilities Inc K 50004 Cash - FMV