2012-10-29T08:50:21-05:00 2011-06-30 ADVENTIST HEALTH SYSTEM 900 HOPE WAY ALTAMONTE SPRINGS FL 32714 990 2010-07-01 510603966 TAKOMA REGIONAL HOSPITAL INC TAKO 4236362350 401 TAKOMA AVENUE GREENEVILLE TN 377434647 TOM VANDENHOVEN 4236362350 2012-10-26 ADVENTIST HEALTH SYSTEM - TAX DEPT 4073572349 2010 2016-02-24 21:20:13Z DANIEL WOLCOTT 401 TAKOMA AVENUE GREENEVILLE TN 377434647 49038834 0 X WWW.TAKOMA.ORG X 2006 TN THE PROVISION OF MEDICAL CARE TO THE COMMUNITY THROUGH THE OPERATION OF A 100 BED HOSPITAL. 19 15 530 70 -4435 -4535 1677 0 43856658 49020069 996288 18765 0 0 44854623 49038834 61436 0 0 0 24504899 26750518 0 0 0 20312567 24644375 44878902 51394893 -24279 -2356059 29735794 27954262 9623069 10076626 20112725 17877636 X TAKOMA REGIONAL HOSPITAL EXISTS TO EXTEND THE HEALING MINISTRY OF CHRIST BY CARING FOR THOSE WHO ARE ILL AND BY NURTURING THE HEALTH OF THE PEOPLE IN OUR COMMUNITIES. AS A MEMBER OF THE ADVENTIST HEALTH SYSTEM AND WELLMONT HEALTH SYSTEM, TAKOMA REGIONAL HOSPITAL (TRH) STRIVES TO CREATE EXCELLENT EXPERIENCES FOR EACH PERSON WHO CHOOSES TO ACCESS OUR SERVICES. TRH WILL BE A LEADER IN PATIENT SAFETY AND HEALTHCARE QUALITY. TRH WILL BE THE BEST PLACE TO WORK, PRACTICE MEDICINE, AND RECEIVE CARE. 0 0 46231883 49024504 TAKOMA REGIONAL HOSPITAL, INC. OPERATES A 100 BED ACUTE CARE HOSPITAL IN GREENEVILLE, TN. IN THE CURRENT YEAR, THERE WERE 2,275 ADMISSIONS AND 10,724 PATIENT DAYS. 46231883 1 1 0 1 0 0 0 0 0 1 0 0 0 1 0 0 0 0 0 0 0 0 0 0 0 1 1 0 0 1 0 0 0 1 0 0 1 0 0 0 0 0 0 0 0 0 0 0 1 60 0 1 530 1 1 1 0 0 0 0 0 0 0 0 0 X 19 15 1 0 0 0 1 1 0 1 1 0 0 1 1 1 1 1 1 1 1 1 1 TN X TOM VANDENHOVEN 4236362350 401 TAKOMA AVE GREENEVILLE TN 37743 RICHARD REINER 1.00 X 0 0 0 BOB BURGIN 1.00 X 0 0 0 MARGARET D DENARVAEZ 1.00 X 0 0 0 AL GILES 1.00 X 0 0 0 JOHN HOWARD 1.00 X 0 0 0 GARY MILLER 1.00 X 0 0 0 DANIEL WOLCOTT 50.00 X X 343624 0 68538 KELLY PETTIJOHN 1.00 X 0 0 0 RANDOLPH KARSTEN 1.00 X 0 0 0 JIMM BUNCH 1.00 X 0 0 0 ELIZABETH WARD 1.00 X 0 0 0 PATRICIA L SMITH EDD RN 1.00 X 0 0 0 MARK WILLIAMS 1.00 X 0 0 0 DON SMITH 1.00 X 0 0 0 CLAES SVENDSEN MD 50.00 X 202973 0 26516 JR MCKINNEY MD 50.00 X 164734 0 5341 RANDY RUMLEY 1.00 X 0 0 0 JOEY BALLARD 1.00 X 0 0 0 JAMES KILGORE PHD 1.00 X 0 0 0 ED WRIGHT 1.00 X 0 0 0 SHARON FOLK 1.00 X 0 0 0 DANIEL LEWIS MD 50.00 X 184527 0 26255 TOM VANDENHOVEN 50.00 X 153733 0 21410 FRED MYERS MD 50.00 X 162580 0 23030 TERESA L MARCUM 50.00 X 154506 0 39398 GORDON L MARSA MD 45.00 X 325702 0 28815 WILLIAM R BRIDGES MD 45.00 X 260079 0 30765 GREGORY S UHL MD 45.00 X 247477 0 29105 ROBERT W LOCKLEAR MD 45.00 X 222602 0 28240 WILLIAM C DIEBOLD MD 45.00 X 214062 0 27589 2636599 0 355002 24 0 1 1 WELLMONT PHYSICIAN SERVICES 1989 EAST STONE DR 2ND FLOOR KINGSPORT TN 37660 HOSPITALISTS/PHYSICIAN SERVICES 727417 ARUP LABORATORIES 500 CHIPETA WAY SALT LAKE CITY UT 84127 LAB SERVICES 194840 NIGHTHAWK RADIOLOGY 601 E FRONT AVE 502 COEUR DALENE ID 83814 RADIOLOGY SERVICES 115706 ASN INC 700 E OGDEN AVE 200 WESTMONT IL 60559 SLEEP STUDIES 109822 4 NET PATIENT REVENUE 900099 48897215 48897215 CAFETERIA REVENUE 900099 52751 52751 GIFT SHOP REVENUE 900099 40365 40365 MEDICAL OFFICE BUILDIN 531120 -4435 -4435 34173 34173 49020069 18765 18765 49038834 49024504 -4435 18765 1577165 1577165 18234935 18234935 669270 669270 4868610 4868610 1400538 1400538 113435 113435 5725924 4404851 1321073 157366 157366 4888208 4582556 305652 1739318 408596 1330722 2013761 2013761 100782 100782 160 160 6586 6586 2406167 2406167 261227 197550 63677 BAD DEBT EXPENSE 3315846 3315846 STATE TAX INDIGENT ASSE 2559459 2559459 REPAIRS & MAINTENANCE 1163158 1163158 PURCHASED SERVICES 53028 53028 139950 139950 51394893 46231883 5163010 0 3056 3282 3805119 3752181 5266763 5880402 68864 945422 1030751 205447 180240 41966274 25053325 18956882 16912949 0 0 553105 125593 29735794 27954262 3244224 3288182 6378845 6788444 9623069 10076626 X 20112725 17769148 108488 20112725 17877636 29735794 27954262 X -2356059 120970 X 0 0 0 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 0 0 0 0 0 0 0 0 1 9758 9758 0 EXPLANATION OF OTHER LOBBYING ACTIVITIES: PART II-B, LINE 1I: REPRESENTS THE AMOUNT OF TOTAL DUES PAID TO THE AMERICAN HOSPITAL ASSOCIATION, HOSPITAL ALLIANCE OF TENNESSEE, AND TENNESSEE HOSPITAL ASSOCIATION THAT IS COMPRISED OF LOBBYING EXPENDITURES. 253719 253719 16527322 7185838 9341484 23802520 17022220 6780300 1382713 845267 537446 16912949 CREDIT BALANCES IN A/R 404461 LEASES PAYABLE 80718 DUE TO AFFILIATED 2614339 OTHER CURRENT LIABILITIES 2306666 PAYABLE TO THIRD PARTIES 1382260 6788444 PART X - AS NOTED IN OUR RESPONSE TO FORM 990 PART VI, SECTION C, LINE 19, THE FINANCIAL STATEMENTS OF THE FILING ORGANIZATION ARE NOT CONSOLIDATED WITHIN THE FINANCIAL STATEMENTS OF EITHER OF ITS MEMBERS. ADDITIONALLY, THE FILING ORGANIZATION DID NOT RECEIVE A SEPARATE AUDITED FINANCIAL STATEMENT FOR THE 6/30/2011 TAX YEAR. ACCORDINGLY, THERE IS NO APPLICABLE FIN 48 FOOTNOTE FOR THIS FILING ORGANIZATION. 1 1 X 1 X 1 X 1 1 1 0 1 0 1019323 1019323 0.02120 4371399 4274711 96688 0.00200 5390722 4274711 1116011 0.02320 137500 137500 0.00290 15000 15000 0.00030 152500 152500 0.00320 5543222 4274711 1268511 0.02640 37000 37000 0.00080 37000 37000 0.00080 1 1026585 120971 11952554 10628200 1324354 X 1 1 1 1 TAKOMA REGIONAL HOSPITAL

401 TAKOMA AVENUE GREENEVILLE TN 37743

X X X NA FOR 2010 1 3 TAKOMA MEDICAL ASSOCIATES

438 E VANN ROAD GREENEVILLE TN 37743

PHYSICIAN SERVICES TAKOMA OUT PATIENT REHABILITATION

108W SUMMERS STREET GREENEVILLE TN 37743

REHABILITATION SERVICES GREENEVILLE URGENT CARE & OCCUPATIONAL

1021 COLLIDGE STREET GREENEVILLE TN 37743

OUTPATIENT CLINIC PART I, LINE 7: THE AMOUNTS OF COSTS REPORTED IN THE TABLE IN LINE 7 OF PART I OF SCHEDULE H WERE DETERMINED BY UTILIZING A COST-TO-CHARGE RATIO DERIVED FROM WORKSHEET 2, RATIO OF PATIENT CARE COST-TO-CHARGES, CONTAINED IN THE SCHEDULE H INSTRUCTIONS. PART I, L7 COL(F): BAD DEBT EXPENSE OF $3,315,846 WAS INCLUDED ON FORM 990, PART IX, LINE 25, BUT SUBTRACTED FOR PURPOSES OF CALCULATING THE PERCENTAGE OF TOTAL EXPENSES IN COLUMN (F) OF LINE 7. PART II: TAKOMA REGIONAL HOSPITAL, INC. (THE HOSPITAL) IS INVOLVED WITH AND SUPPORTIVE OF VARIOUS OTHER COMMUNITY AGENCIES IN ITS SERVICE AREA THAT WORK COLLABORATIVELY TO HELP THOSE IN NEED AND TO IMPROVE THE HEALTH AND SAFETY OF THE RESIDENTS OF THE COMMUNITY. THE HOSPITAL PARTICIPATES WITH A NUMBER OF OTHER COMMUNITY ORGANIZATIONS. AS AN EXAMPLE, THE HOSPITAL IS AN ACTIVE PARTICIPANT IN THE GREENE COUNTY (TN) PARTNERSHIP. THE GREENE COUNTY PARTNERSHIP IS A LOCAL COMMUNITY ORGANIZATION WHOSE MISSION IS TO PROMOTE, PRESERVE, AND ENHANCE THE QUALITY OF LIFE AND ECONOMIC WELL BEING OF ALL GREENE COUNTY RESIDENTS BY PROVIDING COLLECTIVE LEADERSHIP AND SERVING AS A FACILITATOR, CATALYST AND UNIFYING FORCE TO ACHIEVE COMMON COMMUNITY GOALS. PART III, LINE 4: COSTING METHODOLOGY:THE AMOUNTS OF BAD DEBT EXPENSE, AT COST, REPORTED ON LINE 2 AND 3 OF SECTION A OF PART III WERE DETERMINED UTILIZING A RATIO OF PATIENT CARE COST TO CHARGES AS SHOWN ON WORKSHEET A CONTAINED IN THE INSTRUCTIONS FOR SCHEDULE H, PART III, LINE 3. DISCOUNTS AND PAYMENTS ON PATIENT ACCOUNTS ARE RECORDED AS ADJUSTMENTS TO REVENUE, NOT BAD DEBT EXPENSE. METHODOLOGY FOR DETERMINING THE ESTIMATED AMOUNT OF BAD DEBT EXPENSE THAT MAY REPRESENT PATIENTS WHO COULD HAVE QUALIFIED UNDER THE FILING ORGANIZATION'S CHARITY CARE POLICY:SELF-PAY PATIENTS ARE REQUIRED TO COMPLETE A PATIENT FINANCIAL ASSISTANCE APPLICATION SHORT FORM (PFAA). IF THE PFAA IS NOT COMPLETED AFTER REASONABLE ATTEMPTS TO OBTAIN IT ARE EXHAUSTED, PATIENT INFORMATION IS PROCESSED THROUGH A SCORER PRODUCT. THE SCORER PRODUCT UTILIZES PUBLICLY AVAILABLE DATA, SUCH AS CREDIT REPORTS, TO ASSESS AN INDIVIDUAL PATIENT'S FINANCIAL VIABILITY. PATIENTS WHO EARN A CERTAIN SCORE ON THE SCORER PRODUCT ARE CONSIDERED TO QUALIFY AS NON-STATE CHARITY PATIENTS. GENERALLY, $200 OF SUCH A PATIENT'S BILL IS WRITTEN OFF AS BAD DEBT EXPENSE, WHILE THE REMAINING PORTION OF THE PATIENT'S BILL IS CONSIDERED TO BE NON-STATE CHARITY. THE AMOUNT WRITTEN OFF AS BAD DEBT EXPENSE FOR THOSE PATIENTS WHO POTENTIALLY QUALIFY AS NON-STATE CHARITY USING THE SCORER PRODUCT IS THE AMOUNT SHOWN ON LINE 3 OF SECTION A OF PART III. RATIONALE FOR INCLUDING CERTAIN BAD DEBTS IN COMMUNITY BENEFIT:THE FILING ORGANIZATION IS DEDICATED TO THE VIEW THAT MEDICALLY NECESSARY HEALTH CARE FOR EMERGENCY AND NON-ELECTIVE PATIENTS SHOULD BE ACCESSIBLE TO ALL, REGARDLESS OF AGE, GENDER, GEOGRAPHIC LOCATION, CULTURAL BACKGROUND, PHYSICIAN MOBILITY, OR ABILITY TO PAY. THE FILING ORGANIZATION TREATS EMERGENCY AND NON-ELECTIVE PATIENTS REGARDLESS OF THEIR ABILITY TO PAY OR THE AVAILABILITY OF THIRD-PARTY COVERAGE. BY PROVIDING HEALTH CARE TO ALL WHO REQUIRE EMERGENCY OR NON-ELECTIVE CARE IN A NON-DISCRIMINATORY MANNER, THE FILING ORGANIZATION IS PROVIDING HEALTH CARE TO THE BROAD COMMUNITY IT SERVES. AS A 501(C)(3) HOSPITAL ORGANIZATION, THE FILING ORGANIZATION MAINTAINS A 24/7 EMERGENCY ROOM PROVIDING CARE TO ALL WHOM PRESENT. WHEN A PATIENT'S ARRIVAL AND/OR ADMISSION TO THE FACILITY BEGINS WITHIN THE EMERGENCY DEPARTMENT, TRIAGE AND MEDICAL SCREENING ARE ALWAYS COMPLETED PRIOR TO REGISTRATION STAFF PROCEEDING WITH THE DETERMINATION OF A PATIENT'S SOURCE OF PAYMENT. IF THE PATIENT REQUIRES ADMISSION AND CONTINUED NON-ELECTIVE CARE, THE FILING ORGANIZATION PROVIDES THE NECESSARY CARE REGARDLESS OF THE PATIENT'S ABILITY TO PAY. THE FILING ORGANIZATION'S OPERATION OF A 24/7 EMERGENCY DEPARTMENT THAT ACCEPTS ALL INDIVIDUALS IN NEED OF CARE PROMOTES THE HEALTH OF THE COMMUNITY THROUGH THE PROVISION OF CARE TO ALL WHOM PRESENT. CURRENT INTERNAL REVENUE SERVICE GUIDANCE THAT TAX-EXEMPT HOSPITALS MAINTAIN SUCH EMERGENCY ROOMS WAS ESTABLISHED TO ENSURE THAT EMERGENCY CARE WOULD BE PROVIDED TO ALL WITHOUT DISCRIMINATION. THE TREATMENT OF ALL AT THE FILING ORGANIZATION'S EMERGENCY DEPARTMENT IS A COMMUNITY BENEFIT. UNDER THE FILING ORGANIZATION'S CHARITY CARE POLICY, EVERY EFFORT IS MADE TO OBTAIN A PATIENT'S NECESSARY FINANCIAL INFORMATION TO DETERMINE ELIGIBILITY FOR CHARITY CARE. HOWEVER, NOT ALL PATIENTS WILL COOPERATE WITH SUCH EFFORTS AND A CHARITY CARE ELIGIBILITY DETERMINATION CAN NOT BE MADE. IN THIS CASE, A PATIENT'S PORTION OF A BILL THAT REMAINS UNPAID FOR A CERTAIN STIPULATED TIME PERIOD IS WHOLLY OR PARTIALLY CLASSIFIED AS BAD DEBT. BAD DEBTS ASSOCIATED WITH PATIENTS WHO HAVE RECEIVED CARE THROUGH THE FILING ORGANIZATION'S EMERGENCY DEPARTMENT SHOULD BE CONSIDERED TO BE COMMUNITY BENEFIT AS CHARITABLE HOSPITALS EXIST TO PROVIDE SUCH CARE IN PURSUIT OF THEIR PURPOSE OF MEETING THE NEED FOR EMERGENCY MEDICAL CARE SERVICES AVAILABLE TO ALL IN THE COMMUNITY. THE FILING ORGANIZATION DID NOT HAVE AUDITED FINANCIAL STATEMENTS; THEREFORE, THERE IS NOT A FOOTNOTE TO DESCRIBE BAD DEBT EXPENSE. PART III, LINE 8: COSTING METHODOLOGY:MEDICARE ALLOWABLE COSTS WERE CALCULATED USING A COST-TO-CHARGE RATIO. PART III, LINE 9B: AT THE TIME OF PATIENT REGISTRATION, NON-ELECTIVE SELF-PAY PATIENTS ARE INFORMED OF THE MINIMUM DISCOUNT AVAILABLE UNDER THE FILING ORGANIZATION'S SELF-PAY DISCOUNT POLICY. SUCH PATIENTS ARE ALSO INFORMED OF THE FILING ORGANIZATION'S CHARITY CARE POLICY AND TOLD THAT THEY WILL BE REQUIRED TO SUBMIT NECESSARY FINANCIAL DATA IN ORDER TO POTENTIALLY RECEIVE ANY ADDITIONAL DISCOUNTS. PERCENTAGE DISCOUNTS ARE APPLIED TO A PATIENT'S ACCOUNT (FROM A 100% DISCOUNT TO A 30% DISCOUNT) BASED UPON THE PATIENT'S HOUSEHOLD INCOME AS A PERCENTAGE OF THE FEDERAL POVERTY GUIDELINES.UNDER THE FILING ORGANIZATION'S POLICIES, PAYMENT PLANS FOR PARTIAL CHARITY ACCOUNTS WILL BE INDIVIDUALLY DEVELOPED WITH THE PATIENT. PARTIAL CHARITY ACCOUNTS RESULT WHEN A FINANCIAL ASSISTANCE ELIGIBILITY DETERMINATION ALLOWS FOR A PERCENTAGE REDUCTION BUT LEAVES THE PATIENT WITH A SELF-PAY BALANCE. IF THE PATIENT COMPLIES WITH THE AGREED-UPON PAYMENT PLAN, THE FILING ORGANIZATION DOES NOT PURSUE ANY COLLECTION ACTION WITH RESPECT TO THE PATIENT. HOWEVER, IF A PATIENT DOES NOT MAKE ANY PAYMENTS FOR THREE CONSECUTIVE MONTHS, THE ACCOUNT MAY BE REFERRED FOR FURTHER COLLECTION ACTIVITY. THE FILING ORGANIZATION DOES NOT PURSUE COLLECTION OF AMOUNTS FROM PATIENTS DETERMINED TO QUALIFY FOR A 100% REDUCTION IN CHARGES UNDER ITS CHARITY CARE POLICY. SUPPLEMENTAL SCHEDULE TO SCHEDULE H, PART III, SECTION B RECONCILIATION OF SCHEDULE H REPORTED MEDICARE SURPLUS/(SHORTFALL) TO UNREIMBURSED MEDICARE COSTS ASSOCIATED WITH THE PROVISION OF SERVICESTO ALL MEDICARE BENEFICIARIES:THE MEDICARE REVENUE AND ALLOWABLE COSTS OF CARE REPORTED IN SECTION B OF PART III OF SCHEDULE H ARE BASED UPON THE AMOUNTS REPORTED IN THE FILING ORGANIZATION'S MEDICARE COST REPORT IN ACCORDANCE WITH THE IRS INSTRUCTIONS FOR SCHEDULE H. ON AN ANNUAL BASIS, THE FILING ORGANIZATION ALSO DETERMINES ITS TOTAL UNREIMBURSED COSTS ASSOCIATED WITH PROVIDING SERVICES TO ALL MEDICARE PATIENTS. THE PRIMARY RECONCILING ITEMS BETWEEN THE MEDICARE SURPLUS/(SHORTFALL) SHOWN ON LINE 7 OF SECTION B OF PART III OF SCHEDULE H AND THE FILING ORGANIZATION'S UNREIMBURSED COSTS OF SERVICES PROVIDED TO MEDICARE PATIENTS ARE AS FOLLOWS:- MEDICARE SURPLUS/(SHORTFALL) SHOWN ON LINE 7 OF SECTION B OF SCHEDULE H: $ 1,324,354- DIFFERENCE IN COSTING METHODOLOGY: 300,801- UNREIMBURSED COSTS INCURRED FOR SERVICES PROVIDED TO MEDICARE PATIENTS THAT ARE NOT INCLUDED IN THE ORGANIZATION'S MEDICARE COST REPORT: (1,798,908) -------------TOTAL UNREIMBURSED COSTS OF SERVING ALL MEDICARE PATIENTS: $ (173,753)AS INDICATED ABOVE, THE PRIMARY DIFFERENCES BETWEEN THE MEDICARE SURPLUS/(SHORTFALL) REPORTED ON SCHEDULE H, PART III, SECTION B, LINE 7 AND THE FILING ORGANIZATION'S TOTAL UNREIMBURSED COSTS ASSOCIATED WITH PROVIDING SERVICES TO ALL MEDICARE PATIENTS IS DUE TO A DIFFERENCE IN THE COSTING METHODOLOGY AND DIFFERENCES IN THE POPULATION OF MEDICARE PATIENTS WITHIN THE CALCULATION. THE COST METHODOLOGY UTILIZED IN CALCULATING THE TOTAL UNREIMBURSED COSTS ASSOCIATED WITH PROVIDING SERVICES TO ALL MEDICARE PATIENTS IS BASED UPON THE COST-TO-CHARGE RATIO OUTLINED IN WORKSHEET 2 OF THE SCHEDULE H INSTRUCTIONS. THE SAME COST-TO-CHARGE RATIO IS USED TO DETERMINE THE COSTS ASSOCIATED WITH SERVICES PROVIDED TO CHARITY CARE PATIENTS AND MEDICAID PATIENTS AS REPORTED IN SCHEDULE H, PART I, LINE 7. IN ADDITION, THE MEDICARE COST REPORT EXCLUDES SERVICES PROVIDED TO MEDICARE PATIENTS FOR PHYSICIAN SERVICES, SERVICES PROVIDED TO PATIENTS ENROLLED IN MEDICARE HMOS, AND CERTAIN SERVICES PROVIDED BY OUTPATIENT DEPARTMENTS OF THE FILING ORGANIZATION THAT ARE REIMBURSED ON A FEE SCHEDULE. PART VI, LINE 2: THE FILING ORGANIZATION DOES NOT CURRENTLY CONDUCT ANY FORMAL ANNUAL HEALTH CARE NEEDS ASSESSMENT. HOWEVER, A VARIETY OF PRACTICES AND PROCESSES ARE IN PLACE TO ENSURE THAT THE FILING ORGANIZATION IS RESPONSIVE TO THE HEALTH NEEDS OF ITS COMMUNITY. SUCH PRACTICES AND PROCESSES INVOLVE THE FOLLOWING:1. A HOSPITAL OPERATING/COMMUNITY BOARD COMPOSED OF INDIVIDUALS BROADLY REPRESENTATIVE OF THE COMMUNITY, COMMUNITY LEADERS, AND THOSE WITH SPECIALIZED MEDICAL TRAINING AND EXPERTISE;2. POST-DISCHARGE PATIENT FOLLOW-UP RELATED TO THE ON-GOING CARE AND TREATMENT OF PATIENTS WHO SUFFER FROM CHRONIC DISEASES; 3. SPONSORSHIP AND PARTICIPATION IN COMMUNITY HEALTH AND WELLNESS ACTIVITIES THAT REACH A BROAD SPECTRUM OF THE FILING ORGANIZATION'S COMMUNITY; AND 4. COLLABORATION WITH OTHER LOCAL COMMUNITY GROUPS TO ADDRESS THE HEALTH CARE NEEDS OF THE FILING ORGANIZATION'S COMMUNITY. PART VI, LINE 3: TAKOMA REGIONAL HOSPITAL HAS A PROCESS IN PLACE WHEREBY PATIENTS ARE INFORMED ABOUT THE HOSPITAL'S CHARITY CARE POLICY AND OTHER FORMS OF FINANCIAL ASSISTANCE, SUCH AS SELF-PAY DISCOUNTS. SIGNAGE IS POSTED IN THE EMERGENCY ROOM INDICATING THAT FINANCIAL ASSISTANCE IS AVAILABLE FOR THOSE SELF-PAY PATIENTS MEETING ELIGIBILITY REQUIREMENTS. AFTER EMTALA MEDICAL SCREENING AND STABILIZATION REQUIREMENTS ARE MET, REGISTRATION PERSONNEL WILL SECURE FINANCIAL INFORMATION ON AS MANY SELF-PAY PATIENTS AS POSSIBLE AT THE TIME OF SERVICE. FOR THOSE WHO APPEAR TO QUALIFY FOR MEDICAID OR UNDER THE HOSPITAL'S CHARITY CARE POLICY, THE FINANCIAL COUNSELORS WILL CONTINUE TO WORK WITH THOSE PATIENTS UNTIL FINAL ACCOUNT RESOLUTION IS ACHIEVED. ALL OTHER SELF-PAY PATIENTS ARE COVERED UNDER THIS PROCESS. AT ANY TIME DURING THE PROCESS THAT DATA IS PROVIDED SHOWING THAT A PATIENT QUALIFIES FOR ASSISTANCE UNDER THE CHARITY CARE POLICY THE DISCOUNTS EXTENDED UNDER THAT POLICY WILL BE APPLIED.AS PART OF THE BILLING PROCESS, THE HOSPITAL INCLUDES THE APPLICATION FOR CHARITY CARE ASSISTANCE ALONG WITH THE INITIAL PATIENT BILL. THE HOSPITAL'S CHARITY CARE APPLICATION IS ALSO AVAILABLE TO PATIENTS ON THE HOSPITAL'S WEB-SITE IN BOTH AN ENGLISH AND SPANISH VERSION. ADDITIONALLY, THE HOSPITAL'S FINANCIAL COUNSELORS ARE AVAILABLE TO WORK WITH EVERY PATIENT DURING THE FIRST 120 DAYS OF THE BILLING PROCESS TO ASSIST THE PATIENT WITH COMPLETING CHARITY CARE APPLICATIONS AND INVESTIGATING OTHER POTENTIAL SOURCES OF THIRD-PARTY ASSISTANCE. THE DETERMINATION OF A PATIENT'S ELIGIBILITY FOR CHARITY CARE IS MADE ON A CASE-BY-CASE BASIS. VARIOUS FACTORS ARE CONSIDERED IN THAT DETERMINATION. EACH INDIVIDUAL PATIENT WHO IS IDENTIFIED AS POTENTIALLY BEING ELIGIBLE TO RECEIVE CHARITY CARE IS SEEN BY A FINANCIAL COUNSELOR AT THE HOSPITAL. THE FINANCIAL COUNSELOR WILL WORK WITH THE PATIENT TO MAKE SURE THAT OTHER SOURCES OF ASSISTANCE (PUBLIC OR OTHERWISE) HAVE BEEN SOUGHT TO THE FULLEST EXTENT POSSIBLE. WHEN OTHER FORMS OF ASSISTANCE ARE NOT AVAILABLE OR HAVE BEEN EXHAUSTED, THE HOSPITAL WILL GATHER CERTAIN FINANCIAL INFORMATION FROM THE PATIENT TO DETERMINE THE PATIENT'S ABILITY TO PAY BASED UPON LEVEL OF INCOME. PART VI, LINE 4: TAKOMA REGIONAL HOSPITAL (THE HOSPITAL) IS A 100-BED ACUTE CARE FACILITY THAT HAS PROVIDED QUALITY HEALTH CARE SERVICES TO THE RESIDENTS OF NORTHEASTERN TENNESSEE FOR OVER 81 YEARS. IN 1974, TAKOMA ADVENTIST HOSPITAL BECAME A MEMBER OF THE SOUTHERN ADVENTIST HEALTH AND HOSPITAL SYSTEM. MAY OF 2007 BROUGHT ADDITIONAL CHANGE TO TAKOMA WHEN WELLMONT HEALTH SYSTEM BOUGHT A 60% SHARE OF THE HOSPITAL AND TAKOMA ADVENTIST HOSPITAL BECAME TAKOMA REGIONAL HOSPITAL. THE HOSPITAL IS LOCATED IN THE FOOTHILLS OF THE GREAT SMOKEY MOUNTAINS IN HISTORIC GREENEVILLE, TENNESSEE. THE HOSPITAL'S PRIMARY MARKET HAS A POPULATION OF APPROXIMATELY 74,000, WITH AN ESTIMATED 13,000 OVER THE AGE OF 65.THE HOSPITAL IS A CRUCIAL COMMUNITY AND REGIONAL ASSET. TAKOMA REGIONAL HOSPITAL IS ONE OF TWO HOSPITALS IN GREENEVILLE, TN. THE NEAREST PROVIDER DOES NOT OFFER MANY OF THE SERVICES OFFERED AT THE HOSPITAL, SUCH AS HYPERBARIC MEDICINE THERAPY, WOUND CARE CLINIC, GERIATRIC PSYCHIATRIC INPATIENT SERVICES, OUTPATIENT BEHAVIORAL SERVICES, AND A CENTER FOR INPATIENT REHABILITATION. THE HOSPITAL IS ALSO THE LARGEST EMPLOYER IN THE CITY OF GREENEVILLE, TN.THE CITY OF GREENEVILLE, TN COVERS 15.1 SQUARE MILES. THE WEIGHTED AVERAGE HOUSEHOLD INCOME, BASED ON POPULATION, IN THE PRIMARY MARKET IS APPROXIMATELY $46,000. ABOUT 19% OF GREENE COUNTY'S RESIDENTS HAVE INCOMES BELOW THE FEDERAL POVERTY LEVEL. HIGH SCHOOL GRADUATES ACCOUNT FOR APPROXIMATELY 75% OF GREENE COUNTY, WITH AN ESTIMATED 13% HAVING A BACHELOR'S DEGREE OR HIGHER. GREENE COUNTY'S CURRENT UNEMPLOYMENT RATE IS ABOUT 13%. APPROXIMATELY 47% OF THE HOSPITAL'S PATIENTS DURING FISCAL YEAR 2010 WERE MEDICARE PATIENTS, ABOUT 18% WERE MEDICAID PATIENTS, ABOUT 7% WERE SELF-PAY PATIENTS, AND THE REMAINING PERCENTAGE WERE PATIENTS COVERED UNDER COMMERCIAL INSURANCE. APPROXIMATELY 64% OF THE HOSPITAL'S IN-PATIENTS ARE ADMITTED THROUGH THE EMERGENCY DEPARTMENT. PART VI, LINE 6: THE PROVISION OF COMMUNITY BENEFIT IS CENTRAL TO TAKOMA REGIONAL HOSPITAL'S MISSION OF SERVICE AND COMPASSION. RESTORING AND PROMOTING THE HEALTH AND QUALITY OF LIFE OF THOSE IN THE COMMUNITIES SERVED BY THE HOSPITAL IS A FUNCTION OF "EXTENDING THE HEALING MINISTRY OF CHRIST" AND EMBODIES THE HOSPITAL'S COMMITMENT TO ITS VALUES AND PRINCIPLES. THE HOSPITAL COMMITS SUBSTANTIAL RESOURCES TO PROVIDE A BROAD RANGE OF SERVICES TO BOTH THE UNDERPRIVILEGED AS WELL AS THE BROADER COMMUNITY. IN ADDITION TO THE COMMUNITY BENEFIT INFORMATION PROVIDED IN PARTS I, II AND III OF THIS SCHEDULE H, THE HOSPITAL CAPTURES THE BENEFITS PROVIDED TO ITS COMMUNITY THROUGH FAITH-BASED CARE. EXAMPLES OF SUCH BENEFITS INCLUDE THE COST ASSOCIATED WITH CHAPLAINCY CARE PROGRAMS AND MISSION PEER REVIEWS AND MISSION CONFERENCES. DURING THE CURRENT YEAR, HOSPITAL PROVIDED $40,037 OF BENEFIT WITH RESPECT TO THE FAITH-BASED AND SPIRITUAL NEEDS OF THE COMMUNITY IN CONJUNCTION WITH ITS OPERATION OF A COMMUNITY HOSPITAL. THE HOSPITAL ALSO PROVIDES BENEFITS TO ITS COMMUNITY'S INFRASTRUCTURE BY INVESTING IN CAPITAL IMPROVEMENTS TO ENSURE THAT FACILITIES AND TECHNOLOGY PROVIDE THE BEST POSSIBLE CARE TO THE COMMUNITY. DURING THE CURRENT YEAR, THE HOSPITAL EXPENDED $287,190 IN NEW CAPITAL IMPROVEMENTS. AS A FAITH-BASED MISSION-DRIVEN COMMUNITY HOSPITAL, THE HOSPITAL IS CONTINUALLY INVOLVED IN MONITORING ITS COMMUNITY, IDENTIFYING UNMET HEALTH CARE NEEDS AND DEVELOPING SOLUTIONS AND PROGRAMS TO ADDRESS THOSE NEEDS. IN ACCORDANCE WITH ITS CONSERVATIVE APPROACH TO FISCAL RESPONSIBILITY, SURPLUS FUNDS OF THE HOSPITAL ARE CONTINUALLY BEING INVESTED IN RESOURCES THAT IMPROVE THE AVAILABILITY AND QUALITY OF DELIVERY OF HEALTH CARE SERVICES AND PROGRAMS TO ITS COMMUNITY. PART VI, LINE 7: AS EXPLAINED IN OUR RESPONSE TO FORM 990, PART VI, SECTION A, LINE 6, TAKOMA REGIONAL HOSPITAL (TRH OR THE HOSPITAL) HAS TWO MEMBERS. THE MEMBERS ARE ADVENTIST HEALTH SYSTEM/SUNBELT, INC. AND WELLMONT HEALTH SYSTEM. TRH IS ABLE TO DRAW UPON THE EXPERTISE AND LEADERSHIP OF BOTH ITS HEALTH SYSTEM MEMBERS IN ITS EFFORT TO CREATE EXCELLENT PATIENT EXPERIENCES AND OFFER A BROAD SPECTRUM OF HEALTH SERVICES NEEDED IN ITS COMMUNITY.DURING ITS 2010 TAX YEAR, TRH WAS MANAGED BY ADVENTIST HEALTH SYSTEM SUNBELT HEALTHCARE CORPORATION (AHSSHC). AHSSHC IS AN ORGANIZATION EXEMPT FROM FEDERAL INCOME TAX UNDER IRC SECTION 501(C)(3). AHSSHC AND ITS SUBSIDIARY ORGANIZATIONS OPERATE 43 HOSPITALS IN 10 STATES THROUGHOUT THE U.S., PRIMARILY IN THE SOUTHEASTERN PORTION OF THE U.S. AHSSHC AND ITS SUBSIDIARIES ALSO OPERATE 16 NURSING HOME FACILITIES AND OTHER ANCILLARY HEALTH CARE PROVIDER FACILITIES, SUCH AS AMBULATORY SURGERY CENTERS AND DIAGNOSTIC IMAGING CENTERS. AHSSHC PROVIDES EXECUTIVE LEADERSHIP AND OTHER PROFESSIONAL SUPPORT SERVICES TO TAKOMA REGIONAL HOSPITAL. PROFESSIONAL SUPPORT SERVICES INCLUDE AMONG OTHERS CORPORATE COMPLIANCE, LEGAL, HUMAN RESOURCES, REIMBURSEMENT, RISK MANAGEMENT, AND TAX AS WELL AS TREASURY FUNCTIONS. THE PROVISION OF THESE EXECUTIVE AND SUPPORT SERVICES ON A CENTRALIZED BASIS BY AHSSHC PROVIDES AN APPROPRIATE BALANCE BETWEEN PROVIDING TAKOMA REGIONAL HOSPITAL WITH MISSION-DRIVEN CONSISTENT LEADERSHIP AND SUPPORT WHILE ALLOWING THE HOSPITAL ORGANIZATION TO FOCUS ITS RESOURCES ON MEETING THE SPECIFIC HEALTH CARE NEEDS OF THE COMMUNITY IT SERVES. THE READER OF THIS FORM 990 SHOULD KEEP IN MIND THAT THIS REPORTING ENTITY MAY DIFFER IN CERTAIN AREAS FROM THAT OF A STAND-ALONE HOSPITAL ORGANIZATION DUE TO ITS MANAGEMENT BY AHSSHC. THE FILING ORGANIZATION BENEFITS FROM REDUCED COSTS DUE TO ITS AFFILIATION WITH AHSSHC, SUCH AS LARGE GROUP PURCHASING DISCOUNTS, AND THE AVAILABILITY OF INTERNAL RESOURCES SUCH AS INTERNAL LEGAL COUNSEL. TAKOMA REGIONAL HOSPITAL PAYS A MANAGEMENT FEE TO AHSSHC FOR THE INTERNAL SERVICES PROVIDED BY AHSSHC. AS A RESULT, MANAGEMENT FEE EXPENSE REPORTED BY TAKOMA REGIONAL HOSPITAL MAY APPEAR GREATER IN RELATION TO MANAGEMENT FEE EXPENSE THAT MAY BE REPORTED BY A SINGLE STAND-ALONE HOSPITAL WITH NO SUCH AFFILIATION. THE SINGLE STAND-ALONE HOSPITAL WOULD LIKELY REPORT COSTS ASSOCIATED WITH MANAGEMENT AND OTHER PROFESSIONAL SERVICES ON VARIOUS EXPENSE LINE ITEMS IN ITS STATEMENT OF REVENUE AND EXPENSE AS OPPOSED TO REPORTING SUCH COSTS IN ONE OVERALL MANAGEMENT FEE EXPENSE. X X X X X 1 1 0 0 0 0 0 1 0 0 0 DANIEL WOLCOTT 222755 0 36076 0 84793 0 24131 0 44407 0 412162 0 0 0 CLAES SVENDSEN MD 188122 0 10263 0 4588 0 10389 0 16127 0 229489 0 0 0 JR MCKINNEY MD 164484 0 52 0 198 0 5143 0 198 0 170075 0 0 0 DANIEL LEWIS MD 180382 0 52 0 4093 0 9731 0 16524 0 210782 0 0 0 TOM VANDENHOVEN 129429 0 23656 0 648 0 7736 0 13674 0 175143 0 0 0 FRED MYERS MD 158375 0 276 0 3929 0 8282 0 14748 0 185610 0 0 0 TERESA L MARCUM 133656 0 18941 0 1909 0 7706 0 31692 0 193904 0 0 0 GORDON L MARSA MD 281374 0 33872 0 10456 0 13343 0 15472 0 354517 0 0 0 WILLIAM R BRIDGES MD 253429 0 52 0 6598 0 13343 0 17422 0 290844 0 0 0 GREGORY S UHL MD 240436 0 36 0 7005 0 13058 0 16047 0 276582 0 0 0 ROBERT W LOCKLEAR MD 154822 0 63788 0 3992 0 12057 0 16183 0 250842 0 0 0 WILLIAM C DIEBOLD MD 209554 0 52 0 4456 0 9955 0 17634 0 241651 0 0 0 PART I, LINE 1A AS DISCUSSED IN OUR RESPONSE TO SECTION B, PART VI, QUESTION 15A & B, THE FILING ORGANIZATION IS 40% OWNED BY ADVENTIST HEALTH SYSTEM/SUNBELT, INC. (AHSSI). AHSSI IS PART OF THE SYSTEM OF HEALTHCARE ORGANIZATIONS KNOWN AS ADVENTIST HEALTH SYSTEM (AHS). THE FILING ORGANIZATION IS MANAGED BY ADVENTIST HEALTH SYSTEM SUNBELT HEALTHCARE CORPORATION (AHSSHC), THE PARENT ORGANIZATION OF AHSSI. IN CONJUNCTION WITH THE MANAGEMENT AGREEMENT WITH AHSSHC, MEMBERS OF THE FILING ORGANIZATION'S EXECUTIVE MANAGEMENT TEAM THAT HOLD THE POSITION OF VICE-PRESIDENT OR ABOVE ARE COMPENSATED BY AND ON THE PAYROLL OF AHSSHC. AHSSHC IS EXEMPT FROM FEDERAL INCOME TAX UNDER IRC SECTION 501(C)(3). THE FILING ORGANIZATION REIMBURSES AHSSHC FOR THE SALARY AND BENEFIT COST OF THOSE EXECUTIVES ON THE PAYROLL OF AHSSHC THAT PROVIDE SERVICES AND ARE ON THE MANAGEMENT TEAM OF THE FILING ORGANIZATION. FOR ADMINISTRATIVE EASE, EXECUTIVE EMPLOYEES ON THE PAYROLL OF AHSSHC WHO PROVIDE SERVICES FOR THE FILING ORGANIZATION RECEIVE REIMBURSEMENTS OF TRAVEL AND OTHER BUSINESS-RELATED EXPENSES FROM THE FILING ORGANIZATION. TRAVEL FOR COMPANIONS: AHSSHC HAS A CORPORATE EXECUTIVE POLICY THAT PROVIDES A BENEFIT TO ALLOW FOR A TRAVELING AHSSHC EXECUTIVE TO HAVE HIS OR HER SPOUSE ACCOMPANY THE EXECUTIVE ON TWO BUSINESS TRIPS EACH YEAR. TYPICALLY, REIMBURSEMENT IS ONLY PROVIDED TO VICE PRESIDENTS AND ABOVE AND IS LIMITED TO ONE BUSINESS TRIP PER YEAR AND THE ANNUAL AHS PRESIDENT'S COUNCIL BUSINESS MEETING. THE AHSSHC CORPORATE EXECUTIVE SPOUSAL TRAVEL POLICY WAS ORIGINALLY APPROVED AND REVIEWED BY THE AHSSHC BOARD STRATEGY & COMPENSATION COMMITTEE, AN INDEPENDENT BODY OF THE AHSSHC BOARD OF DIRECTORS. ALL SPOUSAL TRAVEL COSTS REIMBURSED TO THE EXECUTIVE ARE CONSIDERED TAXABLE COMPENSATION TO THE EXECUTIVE. TAX INDEMNIFICATION AND GROSS-UP PAYMENTS: AHS HAS A SYSTEM-WIDE POLICY ADDRESSING GROSS-UP PAYMENTS PROVIDED IN CONNECTION WITH EMPLOYER-PROVIDED BENEFITS/OTHER TAXABLE ITEMS. UNDER THE POLICY, CERTAIN TAXABLE BUSINESS-RELATED REIMBURSEMENTS (I.E. TAXABLE BUSINESS-RELATED MOVING EXPENSES, TAXABLE ITEMS PROVIDED IN CONNECTION WITH EMPLOYMENT) PROVIDED TO ANY EMPLOYEE MAY BE GROSSED-UP AT A 25% RATE UPON APPROVAL OF THE FILING ORGANIZATION'S CEO AND CFO. ADDITIONALLY, EMPLOYEES AT THE DIRECTOR LEVEL AND ABOVE ARE ELIGIBLE FOR GROSS-UP PAYMENTS ON GIFTS RECEIVED FOR BOARD OF DIRECTOR SERVICES. DISCRETIONARY SPENDING ACCOUNT: A NOMINAL DISCRETIONARY SPENDING AMOUNT WAS PROVIDED IN THE CURRENT YEAR TO ALL ELIGIBLE EXECUTIVES WHO ATTEND THE ANNUAL AHS PRESIDENT'S COUNCIL BUSINESS MEETING ($500 PER EXECUTIVE). ELIGIBLE EXECUTIVES INCLUDE ALL AHSSHC VICE PRESIDENTS AND ABOVE AND ALL AHSSHC SUBSIDIARY ORGANIZATION CEOS AND REGIONAL CFOS. THE PAYMENT PROVIDED TO EACH EXECUTIVE WAS CONSIDERED TAXABLE COMPENSATION TO THE EXECUTIVE. HOUSING ALLOWANCE OR RESIDENCE FOR PERSONAL USE: AHSSHC HAS A CORPORATE EXECUTIVE POLICY THAT ADDRESSES ASSISTANCE TO EXECUTIVES WHO HAVE BEEN RELOCATED BY THE COMPANY DURING THE YEAR. RELOCATION ASSISTANCE PROVIDED TO EXECUTIVES MAY INCLUDE RELOCATION ALLOWANCES TO ASSIST WITH DUPLICATE HOUSING EXPENSES. RELOCATION ASSISTANCE IS ADMINISTERED PER AHSSHC POLICY BY AN EXTERNAL RELOCATION COMPANY. ANY TAXABLE REIMBURSEMENTS MADE TO EXECUTIVES IN CONNECTION WITH RELOCATION ASSISTANCE ARE TREATED AS WAGES TO THE EXECUTIVE AND ARE SUBJECT TO ALL PAYROLL WITHHOLDING AND REPORTING REQUIREMENTS. HEALTH OR SOCIAL CLUB DUES OR INITIATION FEES: AHSSHC HAS A CORPORATE EXECUTIVE POLICY THAT ADDRESSES BUSINESS DEVELOPMENT EXPENDITURES. UNDER THIS POLICY, CERTAIN AHS ELIGIBLE EXECUTIVES MAY BE REIMBURSED FOR MEMBER DUES AND USAGE CHARGES FOR A COUNTRY CLUB OR OTHER SOCIAL CLUB UPON AUTHORIZATION. CLUB MEMBERSHIPS MUST BE RECOMMENDED BY THE CEO OF THE AHS HOSPITAL ORGANIZATION AND APPROVED BY THE CHAIRMAN OF THE BOARD OF DIRECTORS OF THE ORGANIZATION. IN ADDITION, THE PROPOSED MEMBERSHIP MUST BE APPROVED ANNUALLY BY THE AHSSHC BOARD STRATEGY & COMPENSATION COMMITTEE, AN INDEPENDENT COMMITTEE OF THE BOARD OF DIRECTORS OF AHSSHC. ELIGIBLE EXECUTIVES ARE LIMITED TO CERTAIN SENIOR LEVEL EXECUTIVES (HOSPITAL ORGANIZATION CEOS, THE CEO OF THE NURSING HOME DIVISION OF AHS, SENIOR VICE PRESIDENTS AT THREE LARGE HOSPITAL ORGANIZATIONS, REGIONAL CEOS AND CFOS AND THE PRESIDENT AND SENIOR VICE PRESIDENTS OF AHSSHC). IN THE CURRENT YEAR, FOR THIS FILING ORGANIZATION, ONE EXECUTIVE WAS ELIGIBLE TO RECEIVE REIMBURSEMENT FOR CLUB FEES. EACH AHS EXECUTIVE WHO IS APPROVED FOR A CLUB MEMBERSHIP MUST SUBMIT AN ANNUAL REPORT TO THE AHSSHC BOARD STRATEGY & COMPENSATION COMMITTEE THAT DESCRIBES HOW THE MEMBERSHIP BENEFITED THEIR ORGANIZATION DURING THE PRECEDING YEAR. PART I, LINE 6 THE FILING ORGANIZATION'S PHYSICIAN COMPENSATION FORMULA IS DESIGNED TO RESULT IN TOTAL COMPENSATION THAT WOULD BE REASONABLE FOR EACH PHYSICIAN. SINCE IMPLEMENTING THE PRODUCTIVITY-BASED INCENTIVE COMPENSATION MODEL, THE FINANCIAL LOSSES FROM THE OPERATIONS OF ORGANIZATION'S PHYSICIAN PRACTICES HAVE SIGNIFICANTLY DECREASED, AND ESTABLISHED PHYSICIAN PRACTICES HAVE GENERALLY BECOME PROFITABLE. THE FILING ORGANIZATION UTILIZES NATIONAL SURVEY PRODUCTIVITY, COST, AND COMPENSATION DATA IN FORMULATING ALL ASPECTS OF THE COMPENSATION PLAN. PHYSICIAN COMPENSATION ARRANGEMENTS INCLUDE A CEILING OR REASONABLE MAXIMUM ON THE AMOUNT A PHYSICIAN MAY EARN. THE FILING ORGANIZATION'S EMPLOYED PHYSICIANS ENTER INTO A WRITTEN AGREEMENT THAT REQUIRES THE PHYSICIANS TO PROVIDE MEDICAL CARE TO INDIVIDUALS WHO ARE REFERRED BY THE FILING ORGANIZATION. PURSUANT TO THE AGREEMENT, AN INDIVIDUAL MAY NOT BE REJECTED AS A PATIENT BY A PHYSICIAN DUE TO RACE, SEX, AGE, COLOR, CREED, NATIONAL ORIGIN OR INABILITY TO PAY. THE FILING ORGANIZATION'S COMPENSATION ARRANGEMENT DOES NOT USE A METHOD OF COMPENSATION THAT IS BASED UPON A PERCENTAGE OF THE ORGANIZATION'S NET INCOME. RATHER, UNDER THE COMPENSATION ARRANGEMENT, PHYSICIAN BASE SALARY IS SET BASED ON FAIR MARKET VALUE BENCHMARKS, AND ANY ADDITIONAL COMPENSATION IS BASED ON A PERCENTAGE OF THE PRACTICE/LOCATION NET REVENUE. SUPPLEMENTAL INFORMATION PART III PART I, QUESTION 3: AS NOTED IN OUR RESPONSE TO QUESTION 15 OF PART VI OF FORM 990, THE INDIVIDUAL WHO SERVES AS THE CEO OF THE FILING ORGANIZATION IS COMPENSATED BY ADVENTIST HEALTH SYSTEM SUNBELT HEALTHCARE CORPORATION (AHSSHC) FOR THAT INDIVIDUAL'S ROLE IN SERVING AS THE CEO. COMPENSATION AND BENEFITS PROVIDED TO THIS INDIVIDUAL ARE DETERMINED PURSUANT TO POLICIES, PROCEDURES, AND PROCESSES OF AHSSHC THAT ARE DESIGNED TO ENSURE COMPLIANCE WITH THE INTERMEDIATE SANCTIONS LAWS AS SET FORTH IN IRC SECTION 4958. AHSSHC USES ALL OF THE FOLLOWING TO ESTABLISH COMPENSATION OF THE CEO: - COMPENSATION COMMITTEE; - INDEPENDENT COMPENSATION CONSULTANT; - COMPENSATION SURVEY OR STUDY; AND - APPROVAL BY THE BOARD OR COMPENSATION COMMITTEE. SUPPLEMENTAL INFORMATION PART III FORM 990, PART VII, SECTION A, LINE 5: AS DISCUSSED IN OUR RESPONSE TO SCHEDULE J, PART I, LINE 1A; 40% OF THE MEMBERSHIP INTEREST IN THE FILING ORGANIZATION IS HELD BY ADVENTIST HEALTH SYSTEM/SUNBELT, INC.(AHSSI). AHSSI IS A WHOLLY-OWNED SUBSIDIARY OF ADVENTIST HEALTH SYSTEM SUNBELT HEALTHCARE CORPORATION (AHSSHC). BOTH AHSSI AND AHSSHC ARE ORGANIZATIONS EXEMPT FROM FEDERAL INCOME TAX UNDER IRC SECTION 501(C)(3). THE FOLLOWING INDIVIDUAL OFFICERS AND KEY EMPLOYEES OF THE FILING ORGANIZATION ARE ON THE PAYROLL OF AND COMPENSATED BY AHSSHC FOR SERVICES PROVIDED TO THE FILING ORGANIZATION: - DANIEL WOLCOTT - TOM VANDENHOVEN - FRED MYERS - TERESA MARCUM THE TYPE AND AMOUNT OF COMPENSATION PAID TO EACH OF THE INDIVIDUALS LISTED ABOVE BY AHSSHC FOR SERVICES RENDERED TO THE FILING ORGANIZATION IS DETAILED IN PART II OF THIS SCHEDULE J. CLAES SVENDSEN MD EMPLOYMENT RELATED X 100000 10083 0 0 1 DANIEL LEWIS MD EMPLOYMENT RELATED X 125000 58781 0 0 1 68864 LORI VANDENHOVEN FAMILY OF BOARD MEMBER 30281 EMPLOYEE COMPENSATION 0 FORM 990, PART IV, LINE 20B: TAKOMA REGIONAL HOSPITAL, INC. (TRH OR THE HOSPITAL) DID NOT UNDERGO AN INDEPENDENT FINANCIAL STATEMENT AUDIT FOR ITS TAX YEAR BEGINNING JULY 1, 2010 AND ENDING JUNE 30, 2011. TRH IS A NOT-FOR-PROFIT MEMBERSHIP ORGANIZATION WITH TWO MEMBERS. THE MEMBERS OF THE FILING ORGANIZATION ARE ADVENTIST HEALTH SYSTEM /SUNBELT, INC. (AHSSI) AND WELLMONT HEALTH SYSTEM (WHS) (COLLECTIVELY, THE MEMBERS). BOTH AHSSI AND WHS ARE NOT-FOR-PROFIT CORPORATIONS THAT ARE EXEMPT FROM FEDERAL INCOME TAX UNDER INTERNAL REVENUE CODE (IRC) SECTION 501(C)(3). EACH OF THE TWO MEMBERS HAS THE RIGHT TO ELECT, APPOINT OR REMOVE ANY THREE OF THE SIX MEMBERS OF THE BOARD OF DIRECTORS OF TRH. BASED UPON THIS DIVISION OF CONTROL OVER THE POWER TO APPOINT THE GOVERNING BODY OF THE HOSPITAL, BOTH OF THE MEMBERS ACCOUNT FOR THEIR INTEREST IN TRH USING THE EQUITY METHOD AND DO NOT CONSOLIDATE TRH INTO THEIR OWN FINANCIAL STATEMENTS OR FINANCIAL STATEMENT AUDITS. IRC SECTION 6033(B)(15)(B) STATES THAT A FORM 990 FILING ORGANIZATION THAT IS SUBJECT TO THE REQUIREMENTS OF IRC SECTION 501(R) MUST ATTACH A COPY OF ITS AUDITED FINANCIAL STATEMENTS (OR, IN THE CASE OF ANY ORGANIZATION THE FINANCIAL STATEMENTS OF WHICH ARE INCLUDED IN A CONSOLIDATED FINANCIAL STATEMENT WITH OTHER ORGANIZATIONS, SUCH CONSOLIDATED FINANCIAL STATEMENT). IRS ANNOUNCEMENT 2011-37 STATES THAT A HOSPITAL ORGANIZATION MUST ATTACH ITS MOST RECENT AUDITED FINANCIAL STATEMENTS TO ITS 2010 FORM 990 IF ITS TAX YEAR BEGAN AFTER MARCH 23, 2010, REGARDLESS OF WHETHER IT COMPLETES PART V, B OF SCHEDULE H OF FORM 990. TRH WOULD BE REQUIRED TO ATTACH AN AUDITED SEPARATE OR APPLICABLE CONSOLIDATED FINANCIAL STATEMENT FOR ITS TAX YEAR BEGINNING JULY 1, 2010 IF IT HAD RECEIVED AN AUDIT FOR THIS FILING PERIOD OR WAS INCLUDED IN A CONSOLIDATED FINANCIAL STATEMENT OF EITHER OF ITS TWO MEMBERS. HOWEVER, AS NOTED ABOVE, TRH DID NOT RECEIVE A SEPARATE AUDITED FINANCIAL STATEMENT FOR ITS TAX YEAR BEGINNING JULY 1, 2010 AND ENDING JUNE 30, 2011 NOR WAS IT INCLUDED IN A CONSOLIDATED FINANCIAL STATEMENT OF EITHER OF ITS TWO MEMBERS. ACCORDINGLY, THERE IS NO APPLICABLE AUDITED FINANCIAL STATEMENT TO ATTACH TO THIS FORM 990. TO DATE, THE HOSPITAL IS NOT AWARE OF ANY GUIDANCE THAT HAS BEEN ISSUED BY THE IRS THAT ADDRESSES A SITUATION IN WHICH A HOSPITAL ORGANIZATION SUBJECT TO THE REQUIREMENTS OF SECTION 501(R) DOES NOT RECEIVE A SEPARATE AUDITED FINANCIAL STATEMENT AND IS NOT INCLUDED IN A CONSOLIDATED FINANCIAL STATEMENT WITH OTHER ORGANIZATIONS. THERE IS NO STATED REQUIREMENT IN IRC SECTIONS 501(R) OR 6033(B)(15) THAT REQUIRES A FINANCIAL STATEMENT AUDIT FOR A HOSPITAL ORGANIZATION SUBJECT TO THE PROVISIONS OF SECTION 501(R). BY THE INCLUSION OF THIS EXPLANATORY STATEMENT, TRH BELIEVES THAT IT HAS MET THE REQUIREMENTS FOR A PROPERLY COMPLETED FORM 990 AND HAS INCLUDED ALL INFORMATION REQUIRED TO BE PROVIDED ON ALL SCHEDULES OF FORM 990. FORM 990, PART VI, SECTION A, LINE 2 ELIZABETH WARD AND GARY MILLER - BUSINESS RELATIONSHIP ELIZABETH WARD AND BOB BURGIN - BUSINESS RELATIONSHIP ELIZABETH WARD AND MARGARET DENARVAEZ - BUSINESS RELATIONSHIP MARK WILLIAMS AND SHARON FOLK - BUSINESS RELATIONSHIP FORM 990, PART VI, SECTION A, LINE 6 TAKOMA REGIONAL HOSPITAL, INC. (THE FILING ORGANIZATION) HAS TWO MEMBERS. THE MEMBERS OF THE FILING ORGANIZATION ARE ADVENTIST HEALTH SYSTEM/SUNBELT, INC. (AHSSI) AND WELLMONT HEALTH SYSTEM (WHS). BOTH AHSSI AND WHS ARE NOT-FOR-PROFIT CORPORATIONS THAT ARE EXEMPT FROM FEDERAL INCOME TAX UNDER INTERNAL REVENUE CODE (IRC) SECTION 501(C)(3). THERE ARE NO OTHER CLASSES OF MEMBERSHIP IN THE FILING ORGANIZATION. FORM 990, PART VI, SECTION A, LINE 7A THE BOARD OF DIRECTORS OF THE FILING ORGANIZATION ARE APPOINTED BY AHSSI AND WHS, THE TWO MEMBERS OF THE FILING ORGANIZATION. EACH OF THE TWO MEMBERS HAS THE RIGHT TO ELECT, APPOINT OR REMOVE ANY THREE OF THE SIX MEMBERS OF THE BOARD OF DIRECTORS OF THE FILING ORGANIZATION. IN ADDITION, THE MEMBERS OF THE FILING ORGANIZATION APPOINT THE MEMBERS OF THE FILING ORGANIZATION'S HOSPITAL COMMUNITY BOARD. FORM 990, PART VI, SECTION B, LINE 11 THE FILING ORGANIZATION'S CURRENT YEAR FORM 990 WAS REVIEWED BY THE BOARD OF DIRECTORS PRIOR TO ITS FILING WITH THE IRS. THE REVIEW CONDUCTED BY THE BOARD OF DIRECTORS DID NOT INCLUDE THE REVIEW OF ANY SUPPORTING WORKPAPERS THAT WERE USED IN PREPARATION OF THE CURRENT YEAR FORM 990, BUT DID INCLUDE A REVIEW OF THE ENTIRE FORM 990 AND ALL SUPPORTING SCHEDULES. FORM 990, PART VI, SECTION B, LINE 12C THE CONFLICT OF INTEREST POLICY OF THE FILING ORGANIZATION APPLIES TO MEMBERS OF ITS BOARD OF DIRECTORS, HOSPITAL COMMUNITY BOARD, AND ITS PRINCIPAL OFFICERS (TO BE KNOWN AS INTERESTED PERSONS). IN CONNECTION WITH ANY ACTUAL OR POSSIBLE CONFLICT OF INTERESTS, ANY INTERESTED PERSON MUST DISCLOSE THE EXISTENCE OF ANY FINANCIAL INTEREST WITH THE FILING ORGANIZATION AND MUST BE GIVEN THE OPPORTUNITY TO DISCLOSE ALL MATERIAL FACTS CONCERNING THE FINANCIAL INTEREST/ARRANGEMENT TO THE BOARD OF DIRECTORS/HOSPITAL COMMUNITY BOARD OF THE FILING ORGANIZATION OR TO ANY MEMBERS OF A COMMITTEE WITH BOARD DELEGATED POWERS THAT IS CONSIDERING THE PROPOSED TRANSACTION OR ARRANGEMENT. SUBSEQUENT TO ANY DISCLOSURE OF ANY FINANCIAL INTEREST/ARRANGEMENT AND ALL MATERIAL FACTS, AND AFTER ANY DISCUSSION WITH THE RELEVANT BOARD MEMBER OR PRINCIPAL OFFICER, THE REMAINING MEMBERS OF THE BOARD OF DIRECTORS/HOSPITAL COMMUNITY BOARD OR COMMITTEE WITH BOARD DELEGATED POWERS SHALL DISCUSS, ANALYZE, AND VOTE UPON THE POTENTIAL FINANCIAL INTEREST/ARRANGEMENT TO DETERMINE IF A CONFLICT OF INTEREST EXISTS. ACCORDING TO THE FILING ORGANIZATION'S CONFLICT OF INTEREST POLICY, AN INTERESTED PERSON MAY MAKE A PRESENTATION TO THE BOARD OF DIRECTORS/HOSPITAL COMMUNITY BOARD (OR COMMITTEE WITH BOARD DELEGATED POWERS), BUT AFTER SUCH PRESENTATION, SHALL LEAVE THE MEETING DURING THE DISCUSSION OF, AND THE VOTE ON, THE TRANSACTION OR ARRANGEMENT THAT RESULTS IN A CONFLICT OF INTEREST. EACH INTERESTED PERSON, AS DEFINED UNDER THE FILING ORGANIZATION'S CONFLICT OF INTEREST POLICY, SHALL ANNUALLY SIGN A STATEMENT WHICH AFFIRMS THAT SUCH PERSON HAS RECEIVED A COPY OF THE CONFLICT OF INTERESTS POLICY, HAS READ AND UNDERSTANDS THE POLICY, HAS AGREED TO COMPLY WITH THE POLICY, AND UNDERSTANDS THAT THE FILING ORGANIZATION IS A CHARITABLE ORGANIZATION THAT MUST PRIMARILY ENGAGE IN ACTIVITIES WHICH ACCOMPLISH ONE OR MORE OF ITS EXEMPT PURPOSES. THE FILING ORGANIZATION'S CONFLICT OF INTEREST POLICY ALSO REQUIRES THAT PERIODIC REVIEWS SHALL BE CONDUCTED TO ENSURE THAT THE FILING ORGANIZATION OPERATES IN A MANNER CONSISTENT WITH ITS CHARITABLE PURPOSES. FORM 990, PART VI, SECTION B, LINE 15 ADVENTIST HEALTH SYSTEM/SUNBELT, INC. (AHSSI) HOLDS A 40% MEMBER INTEREST IN THE FILING ORGANIZATION. THE TOP-TIER PARENT OF AHSSI IS ADVENTIST HEALTH SYSTEM SUNBELT HEALTHCARE CORPORATION (AHSSHC). AHSSHC IS THE PARENT ORGANIZATION OF A HEALTHCARE SYSTEM, KNOWN AS ADVENTIST HEALTH SYSTEM, THAT OPERATES HOSPITALS, NURSING HOME FACILITIES, AND OTHER HEALTHCARE PROVIDER ORGANIZATIONS. AHSSHC IS EXEMPT FROM FEDERAL INCOME TAX UNDER IRC SECTION 501(C)(3) PURSUANT TO A GROUP RULING ISSUED TO THE GENERAL CONFERENCE OF SEVENTH-DAY ADVENTISTS. THE INDIVIDUALS WHO SERVE AS THE CEO, CFO OR VICE PRESIDENT OF THE FILING ORGANIZATION ARE COMPENSATED BY AHSSHC FOR SERVICES PROVIDED TO THE FILING ORGANIZATION. COMPENSATION AND BENEFITS PROVIDED TO THESE INDIVIDUALS IS DETERMINED PURSUANT TO POLICIES, PROCEDURES, AND PROCESSES OF AHSSHC THAT ARE DESIGNED TO ENSURE COMPLIANCE WITH THE INTERMEDIATE SANCTIONS LAWS AS SET FORTH IN IRC SECTION 4958. AHSSHC HAS TAKEN STEPS TO ENSURE THAT PROCESSES ARE IN PLACE TO SATISFY THE REBUTTABLE PRESUMPTION OF REASONABLENESS STANDARD AS SET FORTH IN TREASURY REGULATION 53.4958-6 WITH RESPECT TO ITS ACTIVE EXECUTIVE-LEVEL POSITIONS. THE AHSSHC BOARD STRATEGY AND COMPENSATION COMMITTEE (THE COMMITTEE) SERVES AS THE GOVERNING BODY FOR ALL EXECUTIVE COMPENSATION MATTERS. THE COMMITTEE IS COMPOSED OF CERTAIN MEMBERS OF THE BOARD OF TRUSTEES (THE BOARD) OF AHSSHC. VOTING MEMBERS OF THE COMMITTEE INCLUDE ONLY INDIVIDUALS WHO SERVE ON THE BOARD AS INDEPENDENT REPRESENTATIVES OF THE COMMUNITY, WHO HOLD NO EMPLOYMENT POSITIONS WITH AHSSHC AND WHO DO NOT HAVE RELATIONSHIPS WITH ANY OF THE INDIVIDUALS WHOSE COMPENSATION IS UNDER THEIR REVIEW THAT IMPACTS THEIR BEST INDEPENDENT JUDGMENT AS FIDUCIARIES OF AHSSHC. THE COMMITTEE'S ROLE IS TO REVIEW AND APPROVE ALL COMPONENTS OF THE EXECUTIVE COMPENSATION PLAN OF AHSSHC. AS AN INDEPENDENT GOVERNING BODY WITH RESPECT TO EXECUTIVE COMPENSATION, IT SHOULD BE NOTED THAT THE COMMITTEE WILL OFTEN CONFER IN EXECUTIVE SESSIONS ON MATTERS OF COMPENSATION POLICY AND POLICY CHANGES. IN SUCH EXECUTIVE SESSIONS, NO MEMBERS OF MANAGEMENT OF AHSSHC ARE PRESENT. THE COMMITTEE IS ADVISED BY AN INDEPENDENT THIRD PARTY COMPENSATION ADVISOR. THIS ADVISOR PREPARES ALL THE BENCHMARK STUDIES FOR THE COMMITTEE. COMPENSATION LEVELS ARE BENCHMARKED WITH A NATIONAL PEER GROUP OF OTHER NOT-FOR-PROFIT HEALTHCARE SYSTEMS AND HOSPITALS OF SIMILAR SIZE AND COMPLEXITY TO AHS AND EACH OF ITS AFFILIATED ENTITIES. THE FOLLOWING PRINCIPLES GUIDE THE ESTABLISHMENT OF INDIVIDUAL EXECUTIVE COMPENSATION: - THE SALARY OF THE PRESIDENT/CEO OF AHS WILL NOT EXCEED THE 40TH PERCENTILE OF COMPARABLE SALARIES PAID BY SIMILARLY SITUATED ORGANIZATIONS; AND - OTHER EXECUTIVE SALARIES SHALL BE ESTABLISHED USING MARKET MEDIANS. THE COMPENSATION PHILOSOPHY, POLICIES, AND PRACTICES OF AHSSHC ARE CONSISTENT WITH THE ORGANIZATION'S FAITH-BASED MISSION AND CONFORM TO APPLICABLE LAWS, REGULATIONS, AND BUSINESS PRACTICES. AS A FAITH-BASED ORGANIZATION SPONSORED BY THE SEVENTH-DAY ADVENTIST CHURCH (THE CHURCH), AHSSHC'S PHILOSOPHY AND PRINCIPLES WITH RESPECT TO ITS EXECUTIVE COMPENSATION PRACTICES REFLECT THE CONSERVATIVE APPROACH OF THE CHURCH'S MISSION OF SERVICE AND WERE DEVELOPED IN COUNSEL WITH THE CHURCH'S LEADERSHIP. FORM 990, PART VI, SECTION C, LINE 19 THE FINANCIAL STATEMENTS OF THE FILING ORGANIZATION ARE NOT GENERALLY MADE AVAILABLE TO THE PUBLIC AS A WHOLE. AS NOTED PREVIOUSLY IN OUR RESPONSES TO QUESTION 6 OF SECTION A OF PART VI OF THIS FORM 990, THE FILING ORGANIZATION HAS TWO MEMBERS. AS NEITHER MEMBER IS CONSIDERED TO CONTROL THE FILING ORGANIZATION; THE FINANCIAL STATEMENTS OF THE FILING ORGANIZATION ARE NOT CONSOLIDATED WITHIN THE FINANCIAL STATEMENTS OF EITHER MEMBER. EACH MEMBER ACCOUNTS FOR ITS PROPORTIONATE OWNERSHIP SHARE OF THE EQUITY OF THE FILING ORGANIZATION IN ITS FINANCIAL STATEMENTS. THE FILING ORGANIZATION DOES NOT GENERALLY MAKE ITS GOVERNING DOCUMENTS OR CONFLICT OF INTEREST POLICY AVAILABLE TO THE PUBLIC. CHANGES IN NET ASSETS OR FUND BALANCES: FORM 990, PART XI, LINE 5: DONATED PROPERTY 4,444. TRANSFER FROM FOUNDATION 8,037. DONOR RESTRICTED FUNDS 108,489. TOTAL TO FORM 990, PART XI, LINE 5: 120,970. PART VI, SECTION A, LINE 1A THE GOVERNMENT AND MANAGEMENT OF THE AFFAIRS OF TAKOMA REGIONAL HOSPITAL (TRH) IS VESTED IN ITS BOARD OF DIRECTORS. THE BOARD OF DIRECTORS HAS SUPERVISION, CONTROL AND DIRECTION OF THE MANAGEMENT, AFFAIRS AND PROPERTY OF THE CORPORATION; SHALL DETERMINE ITS POLICIES AND PERIODICALLY REVIEW THEM, AND SHALL ACTIVELY PURSUE ITS POLICIES AND OBJECTIVES AND SUPERVISE THE DISBURSEMENT OF ITS FUNDS. THE BOARD OF DIRECTORS IS COMPOSED OF SIX INDIVIDUALS AND VOTES ON ALL MATTERS THAT COME BEFORE THIS GOVERNING BODY. THE BYLAWS OF TRH ALSO PROVIDE FOR A HOSPITAL COMMUNITY BOARD THAT MAY INCLUDE UP TO FIFTEEN VOTING MEMBERS. THE HOSPITAL COMMUNITY BOARD IS APPOINTED BY THE MEMBERS OF TRH, NAMELY ADVENTIST HEALTH SYSTEM/SUNBELT, INC. AND WELLMONT HEALTH SYSTEM. THE HOSPITAL COMMUNITY BOARD IS RESPONSIBLE TO OVERSEE THE OPERATION OF THE HOSPITAL AND POSSESSES ALL POWER RELATED TO THE MEDICAL STAFF OF THE HOSPITAL, INCLUDING THE POWER TO APPROVE ALL BYLAWS, RULES AND REGULATIONS WITH RESPECT TO THE MEDICAL STAFF.