2012-11-08T11:00:20-07:00 2011-12-31 990 2011-01-01 311156960 FAIRMONT GENERAL HOSPITAL INC FAIR 3043677100 1325 LOCUST AVENUE FAIRMONT WV 26554 Daniel Honerbrink 3043677100 2012-11-08 2011 2016-02-24 21:20:13Z DANIEL C HONERBRINK 1325 LOCUST AVENUE FAIRMONT WV 26554 96085535 0 X WWW.FGHI.COM X 1985 WV THE ORGANIZATION OPERATES A HOSPITAL THAT PROVIDES PATIENT CARE FOR THE COMMUNITY. 9 6 829 0 0 0 77070 27637 97231732 88876376 277399 337619 1720313 2389816 99306514 91631448 0 0 0 0 42379920 41178362 0 0 0 55608512 50278688 97988432 91457050 1318082 174398 60859034 54563136 39420010 39856835 21439024 14706301 THE ORGANIZATION IS A HOSPITAL WHICH PROVIDES INPATIENT AND OUTPATIENT CARE TO THE COMMUNITY, AS WELL AS HEALTH DIAGNOSTIC, INTERVENTION AND TREATMENT. 0 0 51512647 0 56783792 PATIENT CARE: THE HOSPITAL PROVIDES INPATIENT AND OUTPATIENT HOSPITAL CARE TO THE COMMUNITY, INCLUDING GENERAL MEDICAL, INTENSIVE/CARDIAC CARE, WOMEN'S AND CHILDREN'S HEALTHCARE SERVICES AND INPATIENT DRUG AND ALCOHOL REHAB. 4084733 0 475817 ANCILLARY SERVICES: THE HOSPITAL HAS ANCILLARY SERVICES WHICH PROVIDE THE NECESSARY DIRECT SUPPORT TO THE PATIENT CARE DEPARTMENTS. SOME OF THE ANCILLARY SERVICES INCLUDE HOUSEKEEPING, NUTRITION, AND STERILE SUPPLY. 4340877 0 17123817 HEALTH DIAGNOSTIC, INTERVENTION, AND TREATMENT: THE HOSPITAL ALSO OFFERS OUTPATIENT DIAGNOSTIC IMAGING SERVICES. SOME OF THE RADIOLOGY DEPARTMENT SERVICES INCLUDE RADIOLOGY DIAGNOSTIC, EKG, ULTRASOUND, MRI, NUCLEAR MEDICINE, CT SCAN AND PET SCAN. 4117585 0 14965889 LABORATORY SERVICES: THE HOSPITAL ALSO HAS SEVERAL LABORATORY DEPARTMENTS INCLUDING PATHOLOGY, HEMATOLOGY, MICROBIOLOGY, CHEMISTRY, LAB DIAGNOSTIC AND BLOODBANK. 1609466 0 1264015 WELLNESS CENTER: THE HOSPITAL OPERATES A WELLNESS CENTER FOR THE BENEFIT OF THE COMMUNITY TO PROMOTE OVERALL PHYSICAL WELL-BEING. 5727051 0 16229904 65665308 1 0 0 1 0 0 0 0 0 0 1 0 0 0 1 0 0 1 0 0 0 0 0 0 0 0 1 1 0 0 1 1 0 0 0 0 0 0 0 1 0 1 0 0 0 0 1 1 0 0 0 0 1 36 0 829 1 0 0 0 0 0 0 X 9 6 0 0 0 0 0 0 0 1 1 0 0 0 1 1 1 1 1 1 1 0 X DANIAL HONERBRINK CFO 3043677100 1325 LOCUST AVENUE FAIRMONT WV 26554 MIKE MARTIN 0 X 0 0 0 TONI NESSELROTTE 0 X 0 0 0 PATRICK BONASSO MD 0 X 0 0 0 RANDY ELLIOTT 0 X 0 0 0 JOEDY DARISTOTLE MD 0 X 0 0 0 REV WESLEY DOBBS 0 X 0 0 0 DAVID FOX 0 X 0 0 0 JOHN PANZA 0 X 0 0 0 ROBIN SMITH DC 0 X 0 0 0 WALTER OSBORNE 0 X 0 0 0 ROBERT MARQUARDT 40 X 294117 0 17588 DANIEL HONERBRINK 40 X 193023 0 1974 JOHN PETROV 40 X 166528 0 17058 MARGARET COSTER 40 X 133349 0 12711 TERESA BONASSO 40 X 121114 0 25248 KIMBERLY CHEUVRONT 40 X 116960 0 15378 LORI HELMICK 40 X 102468 0 23434 CAROL WEBER 40 X 101973 0 24306 MICHAEL SENGEWALT 0 X 105351 0 0 1334883 0 137697 9 1 1 0 THEREX INC DEPT AT 952740 ATLANTA GA 311922740 THERAPY SERVICES 1581869 SODEXO PO BOX 536922 ATLANTA GA 303536922 DIETARY MANAGEMENT 1095228 DIAMOND HEALTHCARE CORP PO BOX 85050 RICHMOND VA 23285 BEHAVIORAL MEDICINE SERVICES 929774 PREMIER ANESTHESIA LLC 2655 NORTHWINDS PARKWAY ALPHARETTA GA 30009 ANESTHESIA SERVICES 565414 FAIRMONT HOME REHABILITATION 1126 WORTHINGTON DRIVE BRIDGEPORT WV 26330 HOME HEALTH REHABILITATION SERVICES 520033 30 0 0 0 0 0 27637 0 27637 88876376 88876376 88876376 133179 0 0 133179 0 0 0 0 0 0 0 0 333609 0 0 0 333609 0 333609 0 0 333609 4045329 0 3830961 9928 214368 -9928 204440 0 0 204440 0 472938 613198 -140260 -140260 0 0 HEALTHPLEX FITNESS CENTER REVENUES 624100 1264015 1264015 0 0 LIFELINE REVENUE 624100 66583 66583 0 0 MEDICAID ELECTRONIC HEALTH RECORD REVENUE 624100 757597 757597 0 0 108272 108272 0 0 2196467 91631448 90932583 0 671228 1334883 1334883 26912890 19797750 7115140 1279848 896995 382853 9520603 6672615 2847988 2130138 1492930 637208 531997 498437 33560 447673 447673 252731 252731 0 9617264 6546561 3070703 441953 40238 401715 512537 130202 382335 2200836 676650 1524186 92442 55967 36475 1239187 868546 370641 4395045 2855772 1539273 798148 0 798148 BAD DEBT EXPENSE 13028753 13028753 0 0 REPAIRS AND MAINTENANCE 2006969 1056163 950806 TAXES AND ASSESSMENTS 1525388 0 1525388 SUPPLIES AND MATERIALS 10839253 9794820 1044433 2348512 1252909 1095603 91457050 65665308 25791742 0 77517 2923367 11972777 11308707 1902660 205208 1670504 1797893 1568906 1029642 93793331 63848857 33528448 29944474 9186381 6429722 951841 924123 60859034 54563136 12244253 14520835 16708035 16068946 5568121 3435648 4899601 5831406 39420010 39856835 X 21439024 14706301 0 0 0 0 21439024 14706301 60859034 54563136 X 174398 -6907121 X 0 1 1 X 0 X 0 0 0 0 0 1 11085 0 0 0 11085 0 SchC_P2B_S00_L01 Schedule C, Part II-B, Line 1 THE HOSPITAL PAYS MEMBERSHIP DUES TO AN ORGANIZATION THAT HAS VARIOUS LOBBYING EFFORTS. A PERCENTAGE OF THE TOTAL DUES IS ATTRIBUTED TO POLITICAL ACTIVITIES. 1169709 1442806 2612515 0 36538522 18034269 18504253 0 3194115 1803008 1391107 0 51378179 44011580 7366599 0 70000 0 70000 29944474 0 THIRD PARTY SETTLEMENTS 4417597 RELATED PARTY PAYABLE 50809 PROFESSIONAL & GENERAL INS. LIABILITY 1363000 5831406 91631448 91457050 174398 -414289 0 0 0 0 -414289 -239891 91830489 -414289 0 0 0 -414289 92244778 0 -613330 -613330 91631448 92070380 0 0 0 613330 613330 91457050 0 0 0 91457050 SchD_P12_S00_L04b Schedule D, Part XII, Line 4b COST OF GOODS SOLD - FOOD: -613,198 CLASSIFICATION OF REVENUES AS EXPENSES: -132 SchD_P13_S00_L02d Schedule D, Part XIII, Line 2d COST OF GOODS SOLD - FOOD: 613,198 REVENUES CLASSIFIED AS EXPENSES: 132 1 1 1 X 1 X 1 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 13028849 0 26635564 32037416 -5401852 X 1 0 1 1 FAIRMONT GENERAL HOSPITAL INC

1325 LOCUST AVENUE FAIRMONT WV 26554

X X X FAIRMONT GENERAL HOSPITAL INC 1 SchH_P01_S00_L07 Schedule H, Part I, Line 7 COSTING METHODOLOGY IS COST TO CHARGE RATIO USING THE 2011 FILED MEDICARE COST REPORT. SchH_P03_S0A_L04 Schedule H, Part III, Section A, Line 4 PATIENT ACCOUNTS RECEIVABLE ARE CARRIED AT THE ORIGINAL CHARGE LESS AN ESTIMATE MADE FOR DOUBTFUL OR UNCOLLECTIBLE ACCOUNTS. IN EVALUATING THE COLLECTABILITY OF ACCOUNTS RECEIVABLE, THE HOSPITAL ANALYZES ITS PAST HISTORY AND IDENTIFIES TRENDS FOR EACH OF ITS MAJOR PAYOR SOURCES OF REVENUE TO ESTIMATE THE APPROPRIATE ALLOWANCE FOR DOUBTFUL ACCOUNTS AND PROVISION FOR BAD DEBTS. 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 REVIEW TROUBLED, AGED ACCOUNTS TO DETERMINE COLLECTION POTENTIAL. FOR RECEIVABLES ASSOCIATED WITH SELF-PAY PATIENTS (WHICH INCLUDES BOTH PATIENTS WITHOUT INSURANCE AND PATIENTS WITH DEDUCTIBLE AND COPAYMENT BALANCES DUE FOR WHICH THIRD-PARTY COVERAGE EXISTS FOR PART OF THE BILL), THE HOSPITAL RECORDS A SIGNIFICANT PROVISION FOR BAD DEBTS IN THE PERIOD OF SERVICE ONT HE BASIS OF ITS PAST EXPERIENCE, WHICH INDICATES THAT MANY PATIENTS ARE UNABLE OR UNWILLING TO PAY THE PORTION OF THEIR BILL FOR WHICH THEY ARE FINANCIALLY RESPONSIBLE. THE DIFFERENCE BETWEEN THE STANDARD RATES (OR THE DISCOUNTED RATES IF NEGOTIATED) AND THE AMOUNTS ACTUALLY COLLECTED AFTER ALL REASONABLE COLLECTION EFFERTS HAVE BEEN EXHAUSTED IS CHARGED OFF AGAINST THE ALLOWANCE FOR DOUBTFUL ACCOUNTS. RECOVERIES OF ACCOUNTS PREVIOUSLY WRITTEN OFF ARE RECORDED AS A REDUCTION TO THE PROVISION FOR BAD DEBT EXPENSE WHEN RECEIVED. INTEREST IS NOT CHARGED ON PATIENT ACCOUNTS RECEIVABLE. SchH_P03_S0B_L08 Schedule H, Part III, Section B, Line 8 THE HOSPITAL PROVIDES CARE TOT HE COMMUNITY AT A COST IN EXCESS OF THE PAYMENT RECEIVED FOR MEDICARE PATIENTS. THIS ABSORPTION OF COSTS BENEFITS THE COMMUNITY THE ORGANIZATION SERVES. LINE 6 WAS DETERMINED USING THE COST TO CHARGE RATIO OF 1.202806 FROM THE 2011 MEDICARE COST REPORT FROM WORKSHEET D-1. THE TITLE XVIII PPS HOSPITAL GENERAL INPATIENT ROUTINE SERVICE COST TO CHARGE RATIO WAS MULTIPLIED BY THE MEDICARE RECEIPTS IN LINE 5. SchH_P03_S0C_L09b Schedule H, Part III, Section C, Line 9b THE ORGANIZATION'S DEBT COLLECTION POLICY IS TITLED TEH CREDIT ADN COLLECTION POLICY. IT DISCUSSSES NON-DISCRIMINATION OF SERVICE, PAYMENT RESPONSIBILITIES, INSURED PATIENTS, PRE-ADMISSION PROGRAM, PRE-ADMISSION DEPOSITS, THIRD PARTY LITIGATION, PAYMENT ARRANGEMENTS, PAYMENT AGREEMENTS AND REFERRED FOR OUTSIDE COLLECTION AND LEGAL ACTION. THERE IS NO DISCUSSION OF CHARITY CARE IN THIS POLICY. HOWEVER, THE ORGANIZATION DOES HAVE A SEPARATE CHARITY CARE POLICY. SchH_P06_S00_L02 Schedule H, Part VI, Line 2 THE ORGANIZATION WORKS WITH OTHER VARIOUS ORGANIZATIONS IN THE COMMUNITY TO PROVIDE MULTI-PHASIC AND LAB TESTING FOR THE PUBLIC. THE ORGANIZATION ALSO UTILIZES STELLITE LOCATIONS AND ADJUSTS ITS HOURS OF SERVICE TO APPROPRIATELY SERVICE THE COMMUNITY'S NEEDS. THE ORGANIZATION ALSO CONDUCTS HEALTH FAIRS AT VARIOUS LOCATIONS THROUGHOUT THE COMMUNITY DURING THE YEAR. SchH_P06_S00_L03 Schedule H, Part VI, Line 3 THE ORGANIZATION EMPLOYS A PATIENT ELIGIBILITY ADVOCATE IN ITS PATIENT ACCOUNTING DEPARTMENT. THIS EMPLOYEE WORKS WITH PATIENTS TO ASSIST THEM WITH THEIR ELIGIBILITY AND FILING FOR STATE AND FEDERAL GOVERNMENTAL PROGRAMS. THIS EMPLOYEE ALSO WORKS WITH OTHER INDIVIDUALS WHO ARE ON THE ORGANIZATION'S FINANCIAL COUNSELING STAFF. IF A PATIENT IS DETERMINED NOT ELIGIBLE FOR GOVERNMENT PROGRAMS, THEY ARE TAKEN TO A FINANCIAL COUNSELOR WHO WILL ASSESS HIS OR HER ELIGIBILITY FOR FINANCIAL ASSISTANCE OR CHARITY CARE. SchH_P06_S00_L04 Schedule H, Part VI, Line 4 THE ORGANIZATION SERVES MARION COUNTY AND OTHER SURROUNDING AREAS IN NORTH CENTRAL WEST VIRGINIA. THE AREA SERVED IS A SMALL, RURAL COMMUNITY. X X X X X 1 0 0 0 0 0 0 0 0 ROBERT MARQUARDT 294117 0 0 0 0 0 0 0 17588 0 311705 0 0 0 DANIEL HONERBRINK 193023 0 0 0 0 0 0 0 1974 0 194997 0 0 0 JOHN PETROV 166528 0 0 0 0 0 0 0 17058 0 183586 0 0 MARGARET COSTER 133349 0 0 0 0 0 0 0 12711 0 146060 0 0 0 TERESA BONASSO 121114 0 0 0 0 0 0 0 25248 0 146362 0 0 0 KIMBERLY CHEUVRONT 116960 0 0 0 0 0 0 0 15378 0 132338 0 0 0 MICHAEL SENGEWALT 105351 0 0 0 0 0 0 0 0 0 105351 0 0 0 LORI HELMICK 102468 0 0 0 0 0 0 0 23434 0 125902 0 0 0 CAROL WEBER 101973 0 0 0 0 0 0 0 24306 0 126279 0 0 0 SchJ_P01_S00_L04 Schedule J, Part I, Line 4 MICHAEL SENGEWALT, FORMER VP FINANCE/CFO, RECEIVED $105,351 IN SEVERANCE PAY IN FISCAL YEAR 2011. MR. SENGEWALT WAS NO LONGER EMPLOYED BY THE ORGANIZATION IN MID 2010. MARION COUNTY COMMISSION 556000346 2007-07-01 13700000 DESIGN, CONSTRUCTION AND EQUIPPING OF HEALTHPLEX FACILITY 0 1 0 WEST VIRGINIA HOSPITAL FINANCE AUTHORITY 621256910 2008-02-01 4385000 REFUND THE SERIES 1994 BONDS, FUND DEBT SERVICE RESERVE FUND, PAY ISSUANCE COSTS 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 0 0 0 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 PATRICK BONASSO MD DR BONASSO IS THE SECRETARY OF THE BOARD OF DIRECTORS 2241 THE ORGANIZATION PROVIDES PHYSICIAN STAFFING TO THE PRIVATE MEDICAL PRACTICE OF DR BONASSO. THE NET REVENUES GENERATED BY THESE PHYSICIANS ARE OFFSET BY PRIVATE PHYSICIAN EXPENSES. 0 JOEDY DARISTOTLE MD DR DARISTOTLE IS ON THE BOARD OF DIRECTORS 2241 DR DARISTOTLE HAS MEDICAL STAFF PRIVILEGES AT THE ORGANIZATION. 0 J MIKE MARTIN MR MARTIN IS THE CHAIRMON OF THE ORGANIZATIONS BOARD OF DIRECTORS 59145 MR MARTIN IS THE PRESIDENT OF FK EVEREST, AN ELECTRICAL CONTRACTING VENDOR. THE ORGANIZATION UTILIZES THIS VENDOR FOR SPECIAL PROJECTS. 0 F990_P06_S0B_L11b Form 990, Part VI, Section B, Line 11b THE TAX RETURN IS PREPARED BY THE HOSPITAL ACCOUNTING DEPARTMENT. THE RETURN IS REVIEWED BY BOTH THE CONTROLLER AND THE CHIEF FINANCIAL OFFICER. F990_P06_S0B_L12c Form 990, Part VI, Section B, Line 12c ANNUALLY, THE ORGANIZATION WILL RECEIVE A CONFLICT OF INTEREST DISCLOSURE FROM ALL BOARD MEMBERS, HOSPITAL DIRECTORS, MANAGERS, AND OTHER SENIOR MANAGEMETN LEADERSHIP TEAM MEMBERS. THE BOARD WILL REVIEW THESE TO DETERMINE IF ANYONE HAS A POTENTIAL CONFLICT OF INTEREST. F990_P06_S0B_L15 Form 990, Part VI, Section B, Line 15 THE COMPENSATION COMMITTEE OF THE BOARD REVIEW ANNUALLY THE COMPENSATION OF THE CEO. THE CEO WILL REVIEW ANNUALLY THE COMPENSATION OF SENIOR MANAGEMENT. F990_P06_S0C_L19 Form 990, Part VI, Section C, Line 19 THE HOSPITAL'S FORMS 1023 AND ANNUAL 990 ARE AVAILABLE FOR PUBLIC INSPECTION UPON REQUEST. ANY INQUIRIES FROM THE PUBLIC ARE TOLD TO ADDRESS THEIR REQUEST IN WRITING TO THE CHIEF FINANCIAL OFFICER, AND THE HOSPITAL WILL PROVIDE COPIES AS REQUESTED. F990_P11_S00_L05 Form 990, Part XI, Line 5 EQUITY TRANSFERS TO RELATED ORGANIZATIONS (FAIRMONT PHYSICIANS NETWORK AND FAIRMONT MANAGEMENT SERVICES ORGANIZATION): $6,592,832; CHANGE IN UNREALIZED GAINS/LOSSES: $414,289; JOINT VENTURE REVENUE NOT INCLUDED IN 990 (DUE TO SEPARATE ENTITY - MHE): ($100,000) FAIRMONT MANAGEMENT SERVICES ORGANIZATION 211 MARION SQUARE FAIRMONT WV 26554 550739131 OFFICE MANAGEMENT SERVICES FOR PHYSICIANS IN MARION COUNTY WV 699692 420373 FAIRMONT GENERAL HOSPITAL INC MARION COUNTY PHYSICIANS-HOSPITAL ORGANIZATION INC 1325 LOCUST AVENUE FAIRMONT WV 26554 550737630 NETWORK OF PHYSICIAN AND HOSPITAL SERVICE CONTRACTING WV 0 0 FAIRMONT GENERAL HOSPITAL INC MARION HEALTH ENTERPRISES INC 1325 LOCUST AVENUE FAIRMONT WV 26554 541916408 50% OF JOINT VENTURE OF DURABLE HOME MEDICAL EQUIPMENT COMPANY WV 100000 957305 50 PERCENT OWNED BY FAIRMONT GENERAL HOSPITAL INC FAIRMONT PHYSICIANS NETWORK 211 MARION SQUARE FAIRMONT WV 26554 550738905 NETWORK OF PHYSICIANS WV 6678803 1328551 FAIRMONT GENERAL HOSPITAL INC FAIRMONT GENERAL HOSPITAL VOLUNTEER ASSOCIATION INC 1325 LOCUST AVENUE FAIRMONT WV 26554 550369033 ORGANIZES VOLUNTEER SERVICES FOR THE HOSPITAL WV N/A PROFESSIONAL AND GENERAL LIABILITY SELF-COVERAGE 1325 LOCUST AVENUE FAIRMONT WV 26554 550622861 ADMINISTERS THE SELF-INSURANCE COVERAGE FOR THE HOSPITAL AND ITS EMPLOYEES WV N/A FAIRMONT GENERAL HOSPITAL FOUNDATION INC 1325 LOCUST AVENUE FAIRMONT WV 26554 550666256 FUNDRAISING ORGANIZATION FOR THE HOSPITAL WV N/A 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0