2012-08-13T15:56:16-05:00 2011-09-30 DIXON HUGHES GOODMAN LLP 500 RIDGEFIELD COURT ASHEVILLE NC 28806 990 2010-10-01 560642846 HUGH CHATHAM MEMORIAL HOSPITAL INC HUGH 3365277000 180 PARKWOOD DR ELKIN NC 28621 DONALD E TRIPPEL 3365277000 2012-08-11 1 AMY BIBBY 8282542254 2010 2016-02-24 21:20:13Z DAVID LOVING 180 PARKWOOD DR ELKIN NC 28621 104354004 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. 15 13 947 80 0 0 501575 87503 93765884 95978184 4031593 4908309 1519558 3008615 99818610 103982611 11228 0 0 0 41046303 41959439 0 0 24242 55128875 57865308 96186406 99824747 3632204 4157864 187391793 188383176 96629680 99702548 90762113 88680628 X TO CONSISTENLY DELIVER EXCEPTIONAL QUALITY AND SERVICE BY DEMONSTRATING THE VALUES OF SERVICE, TEAMWORK, ACCOUNTABILITY, RESPECT, AND SAFE CARE. 0 0 93247085 95978184 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 2010, HUGH CHATHAM MEMORIAL HOSPITAL OPENED A GI CLINIC, AS WELL AS, A DERMATOLOGY OFFICE IN ORDER TO BETTER SERVE THE COMMUNITY'S NEEDS. EMPLOYEES OF THE HOSPITAL ROUTINELY DONATE THEIR TIME TO THE HOSPITAL'S VARIOUS PROGRAMS, SUCH AS THE LOCAL GRACE CLINIC, IN ADDITION TO THE PROGRAMS LISTED ABOVE. 93247085 1 0 0 1 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 78 0 1 947 1 0 0 0 0 0 0 0 0 0 0 X 15 13 0 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 BOB BALL 1.00 X X 0 0 0 PHIL HARRIS 1.00 X X 0 0 0 DR STEVEN ISAACS 1.00 X 24000 0 0 MARK HEINER 1.00 X X 0 0 0 JAMES FREEMAN 1.00 X 0 0 0 FRED EIDSON 1.00 X 0 0 0 REBECCA MAYNARD 1.00 X 0 0 0 RAYMOND PARKER 1.00 X 12000 0 0 ALAN PAYNE 1.00 X 0 0 0 DR COURTENAY WHITMAN 1.00 X 0 0 0 DONNA THOMPSON 1.00 X 0 0 0 JL LOWE 1.00 X 0 0 0 CAROL JERNIGAN 1.00 X 0 0 0 MIKE STANLEY 1.00 X 0 0 0 BOB MIDKIFF 1.00 X 0 0 0 DAVID LOVING 40.00 X 349076 0 0 DONALD TRIPPEL 40.00 X 91380 0 4367 DOMINICK CARBONE JR 40.00 X 669421 0 20322 MURUGANATHAN SUBBIAH 40.00 X 259587 0 10221 CHRISTOPHER SPONGBERG 40.00 X 298760 0 5034 LAWRENCE NABORS 40.00 X 292670 0 1101 RIZWAN AHMED 40.00 X 401428 0 4765 2398322 0 45810 27 0 1 1 SODEXO INC PO BOX 536922 ATLANTA GA 30353 CONTRACT HOUSEKEEPING AND DIETARY 3152893 CARDINAL DISTRIBUTION PHARMACY 25025 NETWORK PLACE CHICAGO IL 60673 PHARMACY SUPPLIES & MEDICATIONS 1729496 CARDINAL HEALTH PO BOX 905867 CHARLOTTE NC 28290 PATIENT AND HOSPITAL SUPPLIES 1510646 NURSE ANESTHESIA OF NC - ELKIN PO BOX 6633 HIGH POINT NC 27262 ANESTHESIA SERVICES 1418829 HORIZON 265 PITT ROAD MOORESVILLE NC 28115 EQUIPMENT MAINTENANCE 1359727 75 87503 87503 PATIENT CARE SERVICES 621400 95141756 95141756 NET HOSPICE INVESTMENT 623000 836428 836428 95978184 2680048 2680048 1437384 371393 1065991 1065991 1065991 2228261 2228261 2228261 2228261 MISCELLANEOUS REVENUE 900099 1661125 1661125 CAFETERIA & VENDING 722210 281499 281499 1942624 103982611 95978184 0 7916924 476456 123683 333519 19254 32849197 31083552 1765645 544882 510245 34322 315 5824494 5454247 366882 3365 2264410 2120468 142634 1308 230691 230691 191061 191061 186449 186449 11620383 10626565 993818 658844 10856 647988 13864476 13430785 433691 1172405 1172405 235915 202325 33590 3263924 3263924 8321566 8321566 163773 163773 BAD DEBT EXPENSE 16122230 16122230 MISCELLANEOUS EXPENSES 1143140 640461 502679 RECRUITMENT 690451 690451 99824747 93247085 6553420 24242 6179810 12340946 569803 8923725 8488207 1342850 1501315 3811686 3390699 151654785 62145293 93782661 89509492 67394460 66319058 3206690 4039055 2749911 2224601 187391793 188383176 7525858 8680779 80985000 79565000 8118822 11456769 96629680 99702548 X 91262113 89245373 -500000 -564745 90762113 88680628 187391793 188383176 X 4157864 -6239349 X X 0 1 1 X 0 X 0 1 0 0 0 0 1 75833 0 1 6909 82742 0 EXPLANATION OF OTHER LOBBYING ACTIVITIES: PART II-B, LINE 1I: PART II-B, LINE 1G: THE ORGANIZATION RETAINS THE SERVICES OF RUSS REID, AN AGENCY EXCLUSIVELY DEDICATED TO ADVOCACY OF NONPROFIT ORGANIZATIONS, TO ACCOMPANY AND ASSIST OFFICERS AND KEY MANAGEMENT PERSONNEL ON TRIPS TO WASHINGTON, D.C. TO DISCUSS HEALTHCARE LEGISLATION RELEVANT TO THE ORGANIZATION. 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 $ 6,909. 2530463 2530463 92545290 22476727 70068563 9038259 4415273 4622986 47307051 35253293 12053758 233722 233722 89509492 INTEREST PAYABLE 1080418 ESTIMATED THIRD-PARTY PAYOR SETTLEMENTS 3871310 PHYSICIAN GUARANTEE 437417 INTEREST RATE SWAP 5979816 RESIDENT TRUST FUNDS 87808 11456769 103982611 99824747 4157864 -36908 -6202441 -6239349 -2081485 98612707 -36908 -5704389 -5741297 104354004 -371393 -371393 103982611 100569876 745129 745129 99824747 0 99824747 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, 2011. FISCAL YEARS ENDING ON OR AFTER SEPTEMBER 30, 2008 REMAIN SUBJECT TO EXAMINATION BY FEDERAL AND STATE TAX AUTHORITIES. PART XI, LINE 8 - OTHER ADJUSTMENTS: CHANGE IN VALUE OF SWAP AGREEMENT -2,556,807. TRANSFER OF EQUITY TO FOUNDATION -143,444. RECOGNIZED LOSSES ON IMPAIRMENTS -3,502,190. PART XII, LINE 2D - OTHER ADJUSTMENTS: REVENUES OF CONSOLIDATED AFFILIATES 498,052. TRANSFER OF EQUITY TO FOUNDATION -143,444. CHANGE IN VALUE OF SWAP AGREEMENT -2,556,807. RECOGNIZED LOSSES ON IMPAIRMENTS -3,502,190. PART XII, LINE 4B - OTHER ADJUSTMENTS: DIRECT RENTAL EXPENSES -371,393. PART XIII, LINE 2D - OTHER ADJUSTMENTS: DIRECT RENTAL EXPENSES 371,393. EXPENSES OF CONSOLIDATED AFFILIATES 373,736. 1 1 X 1 X 1 X 1 1 1 0 1 1 1433349 0 1433349 0.01710 10958598 8354738 2603860 0.03110 12391947 8354738 4037209 0.04820 35929 35929 0.00040 37736 37736 0.00050 215992 215992 0.00260 289657 289657 0.00350 12681604 8354738 4326866 0.05170 5365478 1877917 23589433 23308077 281356 X 1 0 1 1 HUGH CHATHAM MEMORIAL HOSPITAL

180 PARKWOOD DRIVE ELKIN NC 28621

X X X DISPROPORTIONATE SHARE HOSPITAL NA IN 2010 PER IRS ANNOUNCEMENT 2011-37 1 13 HCMH REGIONAL REHALILITATION CENTER

700 JOHNSON RIDGE ROAD ELKIN NC 28621

INPATIENT REHAB 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

112 N SWAIM STREET JONESVILLE NC 28642

PHYSICIANS OFFICES SOUTHWEST VIRGINIA ORTHOPEDICS

502 SOUTH MAIN STREET GALAX VA 24333

PHYSICIANS OFFICES YADKIN VALLEY GASTROENTEROLOGY

201 WEST MAIN STREET ELKIN NC 28621

PHYSICIANS OFFICES YADKIN VALLEY PULMONARY & CRITICAL CARE

520 CHATHAM MEDICAL PARK ELKIN NC 28621

PHYSICIANS OFFICES G I CLINIC

201 WEST MAIN STREET ELKIN NC 28621

PROCEDURE CLINIC YADKIN VALLEY DERMATOLOGY

690 PARKWOOD MEDICAL PARK ELKIN NC 28621

PHYSICIANS OFFICES FOOTHILLS FAMILY MEDICINE

600 CHATHAM MEDICAL PARK ELKIN NC 28621

PHYSICIANS OFFICES PART I, LINE 7: WORKSHEET 2 OF THE 2010 SCHEDULE H INSTRUCTIONS 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 $16,122,230 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 III, LINE 4: THE ORGANIZATION'S FINANCIAL STATEMENTS DO NOT INCLUDE A FOOTNOTE ON BAD DEBT. 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 THE COST TO CHARGE RATIO CALCULATED THROUGH WORKSHEET 2 PROVIDED IN THE INSTRUCTIONS TO SCHEDULE H.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. 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 6: 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 AREAS NEEDS. COMMITTMENT IS DEMONSTRATED THRU 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 7: 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 344276 0 0 0 4800 0 0 0 0 0 349076 0 0 0 DOMINICK CARBONE JR 363871 0 305190 0 360 0 12279 0 8043 0 689743 0 0 0 MURUGANATHAN SUBBIAH 230246 0 29125 0 216 0 4285 0 5936 0 269808 0 0 0 CHRISTOPHER SPONGBERG 232837 0 21799 0 44124 0 3401 0 1633 0 303794 0 0 0 LAWRENCE NABORS 189369 0 102269 0 1032 0 0 0 1101 0 293771 0 0 0 RIZWAN AHMED 391236 0 0 0 10192 0 928 0 3837 0 406193 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 2010 WERE: MARY BLACKBURN: $ 7,526.90 SUSAN BRISCOE 14,690.33 CHARLOTTE LAWSON 11,351.68 JEFF SEAFORD 11,369.48 DONALD TRIPPEL: 18,561.32 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 2003-04-01 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 5295000 40932286 4379113 529906 1878294 21551473 11100000 2005 1 0 1 1 595000 46267755 3493414 435743 513249 42448072 2010 0 0 1 1 0 0 0 0 1 0.00000 0.00000 0.00000 1 0 0 0 0 1 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 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, WHICH IS TO EXPIRE IN JUNE 2011, 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 MEMBER 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 LOSSES ON INVESTMENTS: -36,908. CHANGE IN VALUE OF SWAP AGREEMENT -2,556,807. TRANSFER OF EQUITY TO FOUNDATION -143,444. RECOGNIZED LOSSES ON IMPAIRMENTS -3,502,190. TOTAL TO FORM 990, PART XI, LINE 5: -6,239,349. 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 1 0 0 0 0 0 0 0 0 0 0 1 1 0 1 0 0 HUGH CHATHAM MEMORIAL HOSPITAL FOUNDATION INC B 143444 CASH