2012-08-13T14:30:34-05:00 2011-09-30 DIXON HUGHES GOODMAN LLP 500 RIDGEFIELD COURT ASHEVILLE NC 28806 990 2010-10-01 560603900 ASHE MEMORIAL HOSPITALINC ASHE 3368467101 200 HOSPITAL AVENUE JEFFERSON NC 28640 RAYMOND D WILLIAMS 3368467101 2012-08-13 1 AMY BIBBY 8282542254 2010 2016-02-24 21:20:13Z RAYMOND D WILLIAMS 200 HOSPITAL AVENUE JEFFERSON NC 28640 32488759 0 X WWW.ASHEMEMORIAL.ORG X 1939 NC ACUTE HOSPITAL CARE SERVICES PROVIDED TO THE RESIDENTS OF ASHE COUNTY, NC AND SURROUNDING AREA. 18 16 356 61 0 0 1262909 976258 30099449 31277161 31284 19446 579397 212723 31973039 32485588 0 0 0 0 16267441 16889710 0 0 213874 14756722 16232833 31024163 33122543 948876 -636955 15301324 18588566 7191263 10342629 8110061 8245937 X ASHE MEMORIAL HOSPITAL'S MISSION STATEMENT IS ICARE, WHICH STANDS FOR INVESTMENT IN THE DEVELOPMENT OF PEOPLE, COMMITMENT TO CONTINUOUS IMPROVEMENT, ACCOUNTABILITY TO THOSE WE SERVE, RESPONSIVENESS TO THE HEALTH CARE NEEDS OF THE COMMUNITY, AND EXCELLENCE IN PRIMARY HEALTH CARE. 0 0 30266491 31277161 ASHE MEMORIAL HOSPITAL PROVIDES INPATIENT, OUTPATIENT, AND EMERGENCY CARE SERVICES FOR RESIDENTS OF ASHE COUNTY AND THE SURROUNDING AREAS.RECENT PROJECTS COMPLETED THAT IMPROVED THE FACILITY AND THE SERVICES OFFERED TO THE COMMUNITY INCLUDED: (1) A NEW BUILDING COMPLETED ON THE CAMPUS OF ASHE MEMORIAL HOSPITAL, INC. TO HOUSE MOUNTAIN FAMILY CARE CENTER, OUR HOSPITAL-BASED RURAL HEALTH CLINIC, (2) ENHANCEMENTS AND ADDITIONS OF SOFTWARE TO ACHIEVE "MEANINGFUL USE" IN THE ELECTRONIC HEALTH RECORD PROJECT, (3) RENOVATION OF OFFICE SPACE THAT IS OCCUPIED BY MOUNT JEFFERSON FAMILY MEDICINE IN THE HOSPITAL-OWNED PHYSICIAN BUILDING, (4) NEW HOSPITAL-OWNED OB/GYN PRACTICE OPENED IN AN AREA WITHIN 3 MILES OF THE HOSPITAL, (5) NEW MEDICAL EQUIPMENT IN THE OPERATING ROOM AND FITNESS EQUIPMENT AT MOUNTAIN HEARTS, (6) NEW FURNITURE IN THE OUTPATIENT/EMERGENCY DEPARTMENT AREA, (7) ENHANCEMENT OF THE PHONE AND COMMUNICATIONS SYSTEM, AND (8) A FACELIFT TO THE CHAPEL LOCATED WITHIN THE HOSPITAL.THE HOSPITAL PROVIDED A SIGNIFICANT AMOUNT OF COMMUNITY BENEFIT AND OUTREACH TO THE COUNTY AND SURROUNDING AREAS. BENEFIT AND OUTREACH PROGRAMS ARE PROVIDED IN CONJUNCTION WITH THE ASHE COUNTY HEALTH COUNCIL AND INDEPENDENTLY THROUGH VARIOUS DEPARTMENTS AND SERVICES. OUR SIXTH COMMUNITY HEALTH FAIR WAS HELD DURING THE SUMMER. THIS PROJECT CONTINUES TO RECEIVE THE HIGHEST EVALUATION SCORES OF ANY SECTION OF THE BLUE RIDGE ELECTRIC ANNUAL MEETING. 30266491 1 1 0 1 0 0 0 0 0 1 0 1 0 1 1 0 0 0 0 0 0 0 0 0 0 1 1 0 0 1 0 0 0 1 0 0 0 1 0 0 0 0 0 1 1 0 0 0 1 49 0 1 356 1 0 0 0 0 0 0 0 0 0 0 X 18 16 1 1 0 0 1 1 1 1 1 0 0 1 1 1 1 1 1 1 1 0 NC X X JOY R MCCLURE CFO 3368467101 200 HOSPITAL AVENUE JEFFERSON NC 28640 X JAMES G GAMBILL JR 2.00 X X 0 0 0 GALE HURLEY 2.00 X X 0 0 0 DICK MILLER 2.00 X X 0 0 0 TOM EFFORD 2.00 X X 0 0 0 JAN CADDELL 2.00 X X 0 0 0 MARY ANN MOORE 2.00 X X 0 0 0 DR CHARLES JONES 2.00 X 0 0 0 TIM VANNOY 2.00 X 0 0 0 BRADLEY MCNEILL 2.00 X 0 0 0 BRETT T SUMMEY DDS 2.00 X 0 0 0 EDWARD J MILLER MD 2.00 X 18403 0 0 HOBART DAVIS 2.00 X 0 0 0 TOMMY HOWELL 2.00 X 0 0 0 STEPHEN SHOEMAKER 2.00 X 0 0 0 JANE LONON 2.00 X 0 0 0 MICHAEL MINCEY 2.00 X 0 0 0 SUE HAMPTON 2.00 X 0 0 0 NANCY KAUTZ 2.00 X 0 0 0 WALTER E DAVIS MD 2.00 X 0 0 0 JOE THORE 40.00 X X 92138 0 11971 SHERRY COX 40.00 X 66764 0 13266 JOY MCCLURE 40.00 X 85480 0 14566 JUDY DAVIS 40.00 X 78661 0 10148 SARA HOUSER 40.00 X 106052 0 13472 RD WILLIAMS 40.00 X 168674 0 18600 JAMES MICHAEL TAN 45.00 X 275225 0 27799 WILLIAM BLACKERBY 39.00 X 246133 0 13204 CB JONES JR 47.00 X 209013 0 22397 MARK SCOTT 46.00 X 203924 0 19452 STACI CHAMBERLAIN 40.00 X 188550 0 16218 1739017 0 181093 9 0 1 1 RESTORE RESPIRATORY CARE INC 200 GALLERIA PARKWAY SUITE 1800 ATLANTA GA 30339 RESPIRATORY THERAPY SERVICES 732202 ALLIANCE HEALTHCARE SERVICES PO BOX 96485 CHICAGO IL 606936485 MOBILE MRI SERVICES 379395 QUORUM HEALTH RESOURCES LLC 105 CONTINENTAL PLACE BRENTWOOD TN 370271018 HEALTHCARE MANAGEMENT SERVICES 325267 HERMITAGE ANESTHESIA PO BOX 1153 JEFFERSON NC 28640 ANESTHESIA SERVICES 225996 DEBORAH L SIDERS CRNA 200 HOSPITAL AVENUE JEFFERSON NC 28640 ANESTHESIA SERVICES 216100 11 130697 240067 605494 976258 PATIENT SERVICE REVENU 621400 30633603 30633603 PHARMACY 446110 356350 356350 LIFELINE RENTALS 900099 107070 107070 FITNESS CENTER 713940 102542 102542 OTHER REVENUES 900099 77596 77596 31277161 22617 22617 109913 109913 109913 109913 3171 -3171 -3171 -3171 CAFETERIA & VENDING 722210 173397 173397 INSURANCE REFUNDS/SETT 900099 16681 16681 PURCHASE DISCOUNTS 900099 2672 2672 -89940 -89940 102810 32485588 31277161 0 124105 1491966 596786 790742 104438 12290297 12038325 251972 372807 341777 28205 2825 1794589 1645218 135772 13599 940051 861807 71121 7123 114146 114146 68584 68584 49050 49050 3025001 2798660 226341 50775 10102 40165 508 5751548 5379030 347606 24912 325927 37357 288570 1011435 1011435 86695 71136 15559 166869 166869 1364328 1364328 310106 310106 BAD DEBTS 3528016 3528016 MISCELLANEOUS EXPENSES 215075 105539 49067 60469 RECRUITMENT 165278 165278 33122543 30266491 2642178 213874 1775020 1475185 407051 318633 2180453 2806350 645162 609786 197225 126083 29969830 19276806 8553105 10693024 515315 520187 300072 1290365 727921 748953 15301324 18588566 4261323 6070650 326641 385335 1915044 3833259 688255 53385 7191263 10342629 X 7973451 8001227 136610 244710 8110061 8245937 15301324 18588566 X -636955 772831 X 0 1 1 X 0 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 0 0 0 0 0 0 0 0 1 3969 3969 0 EXPLANATION OF OTHER LOBBYING ACTIVITIES: PART II-B, LINE 1I: THE ORGANIZATION IS A MEMBER OF THE NORTH CAROLINA HOSPITAL ASSOCIATION AND THE AMERICAN HOSPITAL ASSOCIATION. A PORTION OF THE MEMBERSHIP DUES PAID TO THESE ORGANIZATIONS IS ALLOCATED TO LOBBYING EXPENDITURES ON BEHALF OF ITS MEMBERSHIP BODY. THE AMOUNT OF DUES ALLOCATED TO LOBBYING EXPENDITURES WAS $3,969. 277913 277913 14979278 7757125 7222153 1099553 694941 404612 13580688 10824740 2755948 32398 32398 10693024 INVESTMENT IN HOME HEALTH PROJECT 1145486 C DUE FROM FOUNDATION 144879 C 1290365 ESTIMATED THIRD-PARTY PAYOR SETTLEMENTS 53385 53385 32485588 33122543 -636955 -403 1209210 -435976 772831 135876 32488356 -403 -403 32488759 -3171 -3171 32485588 33561690 439147 439147 33122543 0 33122543 DESCRIPTION OF UNCERTAIN TAX POSITIONS UNDER FIN 48: PART X: THE HOSPITAL AND FOUNDATION 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 CONSOLIDATED FINANCIAL STATEMENTS DO NOT REFLECT A PROVISION OR LIABILITY FOR FEDERAL AND STATE INCOME TAXES. THE ORGANIZATION HAS DETERMINED THAT IT DOES NOT HAVE ANY MATERIAL UNRECOGNIZED TAX BENEFITS OR OBLIGATIONS AS OF SEPTEMBER 30, 2011 AND 2010. FISCAL YEARS ENDING ON AND AFTER SEPTEMBER 30, 2008, REMAIN SUBJECT TO EXAMINATION BY FEDERAL AND STATE TAX AUTHORITIES. PART XI, LINE 8 - OTHER ADJUSTMENTS: NET ASSETS RELEASED FROM RESTRICTION -435,976. PART XII, LINE 4B - OTHER ADJUSTMENTS: LOSS ON SALE OF EQUIPMENT -3,171. PART XIII, LINE 2D - OTHER ADJUSTMENTS: LOSS ON SALE OF EQUIPMENT 3,171. NET ASSETS RELEASED FROM RESTRICTION 435,976. 1 1 X 1 X 1 X 1 1 0 1 1 615140 0 615140 0.02080 5105855 4970961 134894 0.00460 31291 31291 0.00110 5752286 4970961 781325 0.02650 42829 42829 0.00140 3681 3681 0.00010 46510 46510 0.00150 5798796 4970961 827835 0.02800 13739 13739 0.00050 13739 13739 0.00050 0 1717085 686830 11693171 12250503 -557332 X 1 1 1 1 ASHE MEMORIAL HOSPITAL

200 HOSPITAL AVENUE JEFFERSON NC 28640

X X X X CRITICAL ACCESS HOSPITAL NA IN 2010 PER IRS ANNOUNCEMENT 2011-37 1 3 AMH SEGRAVES CARE CENTER

200 HOSPITAL AVENUE JEFFERSON NC 28640

SKILLED NURSING MOUNTAIN FAMILY CARE CENTER

200 HOSPITAL AVENUE JEFFERSON NC 28640

RURAL HEALTH CLINIC AMH ASHE WOMEN'S CENTER

200 HOSPITAL AVENUE JEFFERSON NC 28640

PHYSICIANS OFFICES PART I, LINE 6A: THE COMMUNITY BENEFIT REPORT WAS PREPARED ON THE ORGANIZATION'S BEHALF WITH ASSISTANCE FROM THE NORTH CAROLINA HOSPITAL ASSOCIATION, AND THE FINAL REPORT WAS MADE AVAILABLE TO THE PUBLIC ON THE NCHA'S WEBSITE. PART I, LINE 7: THE ORGANIZATION USED AN INTERNALLY-DERIVED RATIO OF COSTS TO CHARGES OF 48.67% TO CALCULATE CHARITY CARE AND UNREIMBURSED MEDICAID TREATMENTS AT COST. PART I, L7 COL(F): THE AMOUNT ON FORM 990, PART IX, LINE 25 CONTAINS A BAD DEBT EXPENSE OF $ 3,528,016 THAT HAS BEEN OMITTED FOR PURPOSES OF CALCULATING THE AMOUNT ON PART I, LINE 7, COL (F). PART III, LINE 4: THE ORGANIZATION DID NOT HAVE A FOOTNOTE IN THE CURRENT AUDITED FINANCIALS THAT DESCRIBES BAD DEBT EXPENSE.THE ORGANIZATION USED AN INTERNALLY-DERIVED RATIO OF COSTS TO CHARGES OF 48.67% TO CALCULATE BAD DEBT AT COST.THE ORGANIZATION ESTIMATES THAT APPROXIMATELY 40% OF BAD DEBTS AT COST COULD BE ATTRIBUTABLE TO PATIENTS THAT COULD BE ELIGIBLE FOR FINANCIAL ASSISTANCE. THIS ESTIMATE IS BASED ON EXPERIENCE AND HISTORICAL DATA. IN THE COMMUNITY WE SERVE, A NUMBER OF OLDER PATIENTS THAT FAIL TO QUALIFY FOR MEDICAID OR MEDICARE BENEFITS DECLINE TO PROVIDE THE FINANCIAL INFORMATION REQUIRED TO QUALIFY A PATIENT FOR OUR ASSISTANCE POLICY, IN ADDITION, THERE IS A GROWING DIFFICULTY IN OBTAINING THE INFORMATION FROM YOUNGER PATIENTS, DESPITE THE HOSPITAL'S BEST ATTEMPTS AT OBTAINING THIS INFORMATION. AS A RESULT, MANY UNPAID MEDICAL CHARGES ULTIMATELY END UP BEING CHARGED TO BAD DEBT DUE TO UNAVAILABLE INFORMATION IN THE CURRENT YEAR. PART III, LINE 8: AMOUNTS REPORTED ON PART III, LINES 5 AND 6 ARE DERIVED FROM THE ORGANIZATION'S MEDICARE COST REPORT. PART III, LINE 9B: WHEN A PATIENT HAS QUALIFIED FOR FINANCIAL ASSISTANCE BASED ON FINANCIAL STATUS, AND THERE IS A CO-PAY AMOUNT DUE AND PAYABLE BY THE PATIENT, THE AMOUNT DUE FROM THE PATIENT IS THE ONLY AMOUNT THAT MAY BE SENT OUT FOR COLLECTION. THE HOSPITAL UTILIZES A THIRD-PARTY SERVICE FOR THE MAJORITY OF ITS COLLECTIONS. THE REMAINDER OF THE BILL IS WRITTEN OFF TO CHARITY CARE. THE HOSPITAL SUPPORTS THE ASHE HEALTHY CAROLINIANS TASK FORCE WHICH HAS BEEN INSTRUMENTAL IN THE ASSESSMENT AND PLANNING TO MEET COMMUNITY NEEDS FOR THE LAST 17 YEARS. SOME OF THE PROJECTS HAVE INCLUDED THE IMPLEMENTATION OF A SCHOOL BASED HEALTH CENTER IN OUR ONLY MIDDLE SCHOOL IN THE COUNTY, PROVIDING ACCESS TO CARE BY SUPPORT OF THE ASHE COUNTY FREE MEDICAL CLINIC, AND THE PRESENT DEVELOPMENT OF NETWORK TO ASSURE ACCESS TO CARE FOR THE UNINSURED AND UNDERINSURED IN THE COUNTY. PART VI, LINE 2: THE HOSPITAL WORKS WITH THE APPALACHIAN DISTRICT HEALTH DEPARTMENT TO ASSESS COMMUNITY NEEDS, USING PRIMARY AND SECONDARY DATA EVERY THREE YEARS. IN ADDITION, THE ASHE HEALTHY CAROLINIANS ASSESSES COMMUNITY NEEDS INFORMALLY ON AN ONGOING BASIS USING OPINION SURVEYS AND SECONDARY DATA. IT PRESENTS THIS DATA ON A REGULAR BASIS TO THE COMMUNITY FOR PLANNING OF SERVICES BY LOCAL GOVERNMENT AND NON-PROFITS. PART VI, LINE 3: THE HOSPITAL PRINTS INFORMATIONAL PACKETS AND SUPPORTS THE COMMUNITY OUTREACH DEPARTMENT TO EDUCATE THE PUBLIC ABOUT ELIGIBILITY FOR ASSISTANCE UNDER FEDERAL, STATE OR LOCAL GOVERNMENT PROGRAMS AND THE HOSPITAL'S FINANCIAL ASSITANCE POLICY. THE ORGANIZATION'S FINANCIAL ASSISTANCE POLICY IS POSTED ON A PUBLIC WEB SITE MAINTAINED BY THE NORTH CAROLINA HOSPTIAL ASSOCIATION. ASHE MEMORIAL PROVIDES FISCAL AND SUPERVISORY MANAGEMENT FOR SEVERAL FEDERAL AND STATE PROGRAMS, INCLUDING THE ASHE/ALLEGHANY FARMWORKERS HEALTH PROGRAM, AND THE ASHE MEDICATION ASSISTANCE PROGRAM. IN ADDITION, IT PROVIDES OVERSIGHT AND FISCAL MANAGEMENT FOR AN ENDOWMENT FUND TO PROVIDE ASSISTANCE TO THOSE AFFECTED BY CANCER IN THE COMMUNITY.UNINSURED PATIENTS ARE INFORMED OF FINANCIAL ASSISTANCE AT REGISTRATION, DURING THE VISIT, AND UPON DISCHARGE. BOTH UNINSURED AND UNDER-INSURED PATIENTS RECEIVE INFORMATION ON THE BACK OF BILLING STATEMENTS OF FINANCIAL ASSISTANCE ROUTES THAT PATIENTS MAY TAKE IF THEY CANNOT PAY PART OR ALL OF THEIR BILL. STATEMENTS ARE SENT OUT BETWEEN 4 DAYS AFTER DISCHARGE AND/OR WITHIN A WEEK AFTER INSURANCE HAS ADJUDICATED THE CLAIM. THERE ARE ALSO SIGNS AND PLACARDS IN THE REGISTRATION AREA INDICATING THAT FINANCIAL ASSISTANCE IS AVAILABLE. PART VI, LINE 4: THE HOSPITAL SERVES ASHE COUNTY NORTH CAROLINA, AN ISOLATED, ECONOMICALLY DEPRESSED, RURAL COUNTY IN THE NORTHWEST MOUNTAINS OF NORTH CAROLINA. HAVING A POPULATION OF APPROXIMATELY 26,450 AND AN UNEMPLOYMENT RATE OF 12.3% IN 2010, IT CONTINUES TO EXPAND THE NUMBER OF PERSONS BELOW THE POVERTY RATE, WHICH IN 2010 WAS 20% OF THE POPULATION OF ASHE COUNTY, COMPARED TO THE STATE AVERAGE OF 17.4%. THE PER CAPITA PERSONAL INCOME IS $31,965, WELL BELOW THE STATE AVERAGE OF $43,417. ASHE MEMORIAL IS THE ONLY HOSPITAL IN ASHE COUNTY. PART VI, LINE 6: THE ORGANIZATION EXTENDS PRIVILEDGES TO LOCAL PHYSICIANS AND MEDICAL STAFF IN MOST DEPARTMENTS OF THE HOSPITAL. THE ORGANIZATION'S GOVERNING BODY CONSISTS PRIMARILY OF PERSONS WHO RESIDE IN THE ORGANIZATION'S PRIMARY SERVICE AREA AND WHO ARE NEITHER EMPLOYEES OR INDEPENDENT CONTRACTORS OF THE HOSPITAL. ASHE MEMORIAL HOSPITAL IS ORGANIZED AS A 501(C)(3) ORGANIZATION. THE INCOME GENERATED BY THE PROVISION OF SERVICES IS USED TO SUPPORT THE ONGOING OPERATIONS OF THE ORGANIZATION. ANY SURPLUS FUNDS GENERATED FROM OPERATIONS ARE UTILIZED TO FUND IMPROVEMENTS TO THE PHYSICAL PLANT AND TO SUPPORT THE PROVISION OF SERVICES TO INDIVIDUAL PATIENTS WHO ARE UNABLE TO PAY FOR THIER CARE.ASHE MEMORIAL HOSPITAL PROVIDES A MONTHLY OPPORTUNITY FOR THE PUBLIC TO HAVE THEIR BLOOD SUGAR AND CHOLESTEROL LEVELS CHECKED WITH A FASTING BLOOD DRAW. THE HOSPITAL CHARGES $20 FOR THIS SERVICE. THE SERVICE REQUIRES THE FOLLOWING FROM HOSPITAL STAFF: (1) MOUNTAIN HEARTS RECEPTIONIST - SETS APPOINTMENTS (2) LAB PHLEBOTOMIST - BLOOD DRAW (3) REGISTRATION CLERK - REGISTERS PATIENT IN THE HOSPITAL PATIENT SYSTEM (4) LAB TECH - RUNS THE TESTS (5) LAB TECH - PRINTS RESULTS AND MAILS TO PATIENT. THE RESULTING COST TO THE HOSPITAL IS $20.00 PER SCREENING. THE PROGRAM WAS DESIGNED TO BREAK EVEN IN ORDER TO PROVIDE THIS VALUABLE SERVICE AT AN AFFORDABLE COST.ASHE MEMORIAL HOSPITAL, IN CONJUNCTION WITH OUR JEFFERSONS ROTARY CLUB, PROVIDES AN ANNUAL OPPORTUNITY FOR THE MEN OF OUR COUNTY TO HAVE THEIR PSA TEST AND PROSTATE EXAM FREE OF CHARGE. THE SERVICE REQUIRES THE FOLLOWING FROM HOSPITAL STAFF: (1) COMMUNITY OUTREACH AND PUBLIC RELATIONS - ADVERTISING AND EDUCATION TO PUBLIC, (2) SCHEDULING DEPARTMENT - SETS APPOINTMENTS FOR BLOOD DRAW, (3) MOUNTAIN HEARTS RECEPTIONIST - SETS APPOINTMENT FOR EXAM, (4) LAB PHLEBOTOMIST - BLOOD DRAW, (5) REGISTRATION CLERK - REGISTERS PATIENT IN THE HOSPITAL PATIENT SYSTEM, (6) LAB TECH - RUNS THE TESTS, (7) COMMUNITY OUTREACH COORDINATOR - ENTERS DEMOGRAPHICS INTO TRACKING SYSTEM, (8) CEO AND CFO - MANAGE PATIENT AND CHART FLOW, (9) COMMUNITY OUTREACH COORDINATOR - ENTERS RESULTS INTO TRACKING SYSTEM, GENERATES AND MAILS RESULT LETTERS TO PATIENTS.DR. JAMES HAMBY DONATES HIS TIME TO CONSULT AND CONDUCT EXAMS.THE HOSPITAL SUPPORTS THE ASHE HEALTHY CAROLINIANS TASK FORCE WHICH HAS BEEN INSTRUMENTAL IN THE ASSESSMENT AND PLANNING TO MEET COMMUNITY NEEDS FOR THE LAST 18 YEARS. SOME OF THE PROJECTS HAVE INCLUDED THE IMPLEMENTATION OF A SCHOOL BASED HEALTH CENTER IN OUR ONLY MIDDLE SCHOOL IN THE COUNTY, PROVIDING ACCESS TO CARE BY SUPPORT OF THE ASHE COUNTY FREE MEDICAL CLINIC, AND THE PRESENT DEVELOPMENT OF NETWORK TO ASSURE ACCESS TO CARE FOR THE UNINSURED AND UNDERINSURED IN THE COUNTY. PART VI, LINE 7: THE ORGANIZATION IS NOT PART OF AN AFFILIATED HEALTH CARE SYSTEM. REPORTS FILED WITH STATES PART VI, LINE 7 NC X 1 0 X X X 0 0 0 0 0 0 0 0 0 RD WILLIAMS 161414 0 0 0 7260 0 5109 0 13491 0 187274 0 0 0 JAMES MICHAEL TAN 275225 0 0 0 0 0 12315 0 15484 0 303024 0 0 0 WILLIAM BLACKERBY 246133 0 0 0 0 0 4224 0 8980 0 259337 0 0 0 CB JONES JR 209013 0 0 0 0 0 15522 0 6875 0 231410 0 0 0 MARK SCOTT 203924 0 0 0 0 0 15141 0 4311 0 223376 0 0 0 STACI CHAMBERLAIN 188550 0 0 0 0 0 9427 0 6791 0 204768 0 0 0 PART I, LINE 1A THE HOSPITAL PAYS FOR MEMBERSHIP DUES TO THE JEFFERSON ROTARY CLUB FOR CERTAIN KEY OFFICERS. THE PURPOSE OF THE ROTARY CLUB IS TO BRING TOGETHER BUSINESS AND PROFESSIONAL LEADERS TO PROVIDE HUMANITARIAN SERVICE, ENCOURAGE HIGH ETHICAL STANDARDS IN ALL VOCATIONS, AND HELP BUILD GOODWILL AND PEACE IN THE WORLD. AMOUNTS ARE BILLED DIRECTLY TO THE ORGANIZATION. THE HOSPITAL ALSO PAYS DUES TO JEFFERSON LANDING GOLF CLUB FOR CERTAIN KEY OFFICERS. ALL INVOICES ARE PAID DIRECTLY BY THE ORGANIZAITON. SUPPLEMENTAL INFORMATION PART III COMPENSATION FROM AN UNRELATED ORGANIZATION (SEE FORM 990, PART VII, LINE 5): RAYMOND D. WILLIAMS IS COMPENSATED THROUGH QUORUM HEALTH RESOURCES, LLC, AN UNRELATED ORGANIZATION, FOR HIS SERVICES AS CEO OF THE HOSPITAL. PLEASE SEE THE RESPONSE TO FORM 990, PART VI, LINE 15A FOR MORE DETAILS. SARA HOUSER ACCUMULATED STUDENT LOAN, TO BE PAID BACK THROUGH EMPLOYMENT X 8017 23269 0 1 1 23269 DRAGO PROPERTIES LLC OWNED BY OFFICER JOE THORE 23700 RENTAL PAYMENTS FOR STORAGE SPACE 0 JMG ENERGY SOLUTIONS INC OWNED AND OPERATED BY FAMILY MEMBER OF BOARD MEMBER JAMES GAMBILL 196530 PURCHASE OF FUEL, OIL, AND ENERGY SERVICES 0 FORM 990, PART VI, SECTION A, LINE 2 BOARD MEMBERS RICHARD MILLER AND JOE THORE HAVE A BUSINESS RELATIONSHIP. FORM 990, PART VI, SECTION A, LINE 3 THE CEO OF THE HOSPITAL IS CONTRACTED FOR HIS SERVICE THROUGH QUORUM HEALTH RESOURCES, LLC (QHR) BY THE BOARD OF TRUSTEES. SEE THE RESPONSE TO PART VI, LINE 15A FOR FURTHER DETAILS. FORM 990, PART VI, SECTION A, LINE 6 THE HOSPITAL IS ORGANIZED AS A STOCK CORPORATION, AND SHARES OF STOCK ARE SOLD TO MEMBERS OF THE COMMUNITY AND ARE FREELY TRANSFERABLE, BUT HAVE NO CAPITAL VALUE. SHAREHOLDERS DO NOT RECEIVE DIVIDENDS. FORM 990, PART VI, SECTION A, LINE 7A TRUSTEES SHALL BE ELECTED BY THE SHAREHOLDERS OF THE CORPORATION AT THE ANNUAL MEETING OF THE MEMBERSHIP. EACH SELECTED TRUSTEE SHALL HOLD OFFICE FOR A TERM OF THREE YEARS AND UNTIL HIS SUCCESSOR IS SELECTED AND QUALIFIED. FORM 990, PART VI, SECTION A, LINE 7B THE ORGANIZATION CANNOT SELL REAL PROPERTY WITHOUT APPROVAL BY THE SHAREHOLDERS. PLEASE SEE THE RESPONSE TO LINE 6 ABOVE. FORM 990, PART VI, SECTION B, LINE 11 THE RETURN WAS PREPARED BY AN INDEPENDENT ACCOUNTING FIRM WITH THE ASSISTANCE AND OVERSIGHT OF MANAGEMENT. PRIOR TO SUBMISSION TO THE IRS, THE BOARD PLANNING AND FINANCE COMMITTEE REVIEWED THE RETURN AND MADE RECOMMENDATIONS FOR APPROVAL TO THE FULL BOARD. THE FULL BOARD OF TRUSTEES AUTHORIZED THE RETURN FOR SUBMISSION TO THE IRS. FORM 990, PART VI, SECTION B, LINE 12C ALL VOTING BOARD MEMBERS ARE REQUIRED TO REVIEW AND SIGN A CONFLICT OF INTEREST SURVEY AND RETURN TO THE BOARD CHAIRMAN. THE SURVEY INCLUDES A DISCLOSURE STATEMENT AND A REVIEW OF THE POLICY. FORM 990, PART VI, SECTION B, LINE 15 THE HOSPITAL CEO IS AN EMPLOYEE THROUGH CONTRACT MANAGEMENT SERVICE QUORUM HEALTH RESOURCES, LLC (QHR), AN UNRELATED CORPORATION. QHR PROVIDES COMPARATIVE SALARY RANGES FROM UP TO THREE SOURCES OF HOSPITALS OF SIMILAR NET REVENUES AND RECOMMENDS TO THE BOARD OF TRUSTEES ANY SALARY ADJUSTMENT FOR THE CEO. APPROVAL BY THE BOARD IS REQUIRED. FOR OTHER KEY EMPLOYEES, THERE IS A REVIEW PROCESS ANNUALLY BY THE CHIEF HUMAN RESOURCES OFFICER USING THE NORTH CAROLINA HEALTHCARE HUMAN RESOURCES ASSOCIATION COMPENSATION AND BENEFITS SURVEY. BASE RATES ARE COMPARED TO THE SURVEY RESULTS, INCORPORATED INTO THE BUDGET BY THE CEO, CFO, AND CHRO, AND SUBMITTED FOR BOARD APPROVAL. 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 ONLINE AT GUIDESTAR.ORG, A NON-PROFIT WEBSITE. 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. IN ADDITION, THE HOSPITAL WIDELY DISTRIBUTES AN ANNUAL REPORT TO THE COMMUNITY. PLEASE CONTACT THE ADMINISTRATIVE OFFICE FOR FURTHER DETAILS. SEE FORM 990, PART VI, LINE 20. AVERAGE HOURS WORKED FOR RELATED ORGANIZATIONS: FORM 990, PART VII, LINE 1: BOARD MEMBER AND OFFICER JOE THORE WORKED AN AVERAGE OF 5 HOURS PER WEEK FOR ASHE MEMORIAL FOUNDATION, A RELATED ORGANIZATION. CHANGES IN NET ASSETS OR FUND BALANCES: FORM 990, PART XI, LINE 5: NET UNREALIZED LOSSES ON INVESTMENTS: -403. PRIOR PERIOD ADJUSTMENTS: 1,209,210. NET ASSETS RELEASED FROM RESTRICTION -435,976. TOTAL TO FORM 990, PART XI, LINE 5: 772,831. BOARD MEMBER COMPENSATION: FORM 990, PART VII, LINE 1: ASHE MEMORIAL HOSPITAL DOES NOT COMPENSATE MEMBERS FOR THEIR SERVICE AS DIRECTORS OF THE BOARD. ALL COMPENSATION LISTED ON PART VII, LINE 1, COLUMN (D) FOR BOARD MEMBERS WAS PAID FOR VARIOUS MEDICAL SERVICES RENDERED TO THE ORGANIZATION. AMH ASHE WOMEN'S CENTER LLC 200 HOSPITAL AVENUE JEFFERSON NC 28640 451482188 PHYSICIANS PRACTICE NC 97650 147120 ASHE MEMORIAL HOSPITAL ASHE MEMORIAL HOSPITAL FOUNDATION INC 200 HOSPITAL AVE JEFFERSON NC 28640 582078244 FUNDRAISING NC 501(C)(3) 11A ASHE MEMORIAL HOSPITAL 0 0 0 1 0 0 0 0 0 0 0 0 0 1 1 1 1 0 0 ASHE MEMORIAL HOSPITAL FOUNDATION INC C 130697