2011-02-03T10:29:21-06:00 2010-09-30 DIXON HUGHES PLLC 500 Ridgefield Court Asheville NC 28806 990 2009-10-01 561346589 HOSPICE OF SURRY COUNTY INC HOSP 3367892922 401 TECHNOLOGY LANE No 200 MOUNT AIRY NC 27030 DENISE WATSON 3367892922 2011-02-03 1 Amy Bibby 8282542254 2009 2016-02-24 21:20:13Z MOUNTAIN VALLEY HOSPICE AND PALLATIV DENISE WATSON 401 TECHNOLOGY LANE No 200 MOUNT AIRY NC 27030 16636417 0 X www.mtnvalleyhospice.org X 1982 NC TO IMPROVE THE QUALITY OF LIFE FOR THOSE WITH A LIMITED LIFE EXPECTANCY AND THEIR FAMILIES 2 2 226 385 0 0 761122 174234 13153948 16435540 15330 5880 8376 529 13938776 16616183 0 0 6940171 8429015 0 0 6573490 7378638 13513661 15807653 425115 808530 9326026 9400574 3721042 2987136 5604984 6413438 THE MISSION OF HOSPICE OF SURRY COUNTY, INC. DBA MOUNTAIN VALLEY HOSPICE AND PALLIATIVE CARE IS TO IMPROVE THE QUALITY OF LIFE TO THOSE WITH A LIMITED LIFE EXPECTANCY AND THEIR FAMILIES. 0 0 13959250 16435540 The mission, vision and values of Hospice of Surry County, Inc. are the drivers of the care and services provided. Hospice of Surry is a leader in the delivery of hospice services and is dedicated to delivering the very best care to patients and their families. Hospice of Surry is continually enhancing its services, expanding programs and educating the communities we serve. In 2010, Hospice of Surry provided services in 16 counties in North Carolina and Virginia. Hospice of Surry has grown into a regional provider with a strong presence in each of the communities served. In 2010, the following highlights are noted: Admissions increased 20%, Days of Care increased 12%, Total patient revenue exceeded $13 million, Achieved operating income of 4.8% of patient revenue, Achieved net income of 6.1% of patient revenue, Achieved Medicare certification for the Stuart, Virginia location. 13959250 1 1 0 0 0 0 0 0 0 1 1 0 0 0 0 0 0 0 0 0 0 0 0 1 0 0 0 0 0 0 1 0 0 0 0 0 0 0 0 0 0 1 124 0 226 1 0 0 0 0 0 0 0 0 0 1 2 2 0 0 0 0 1 1 1 1 1 0 0 1 1 1 1 1 1 1 1 0 X X RON PARDUE 3367892922 401 TECHNOLOGY LANE STE 200 MOUNT AIRY NC 27030 WILLIAM B JAMES 1.00 X X 0 0 0 DON TRIPPel 1.00 X X 0 0 0 ROBERT HETRICK 1.00 X X 0 0 0 STUART POSTON 1.00 X X 0 0 0 DAVID LOVING 1.00 X X 0 0 0 RANDOLPH F HARRISON 1.00 X X 0 0 0 SYLVIA DENISE WATSON 40.00 X 115540 0 16581 RONNIE G PARDUE 40.00 X 110880 0 2597 GLENN D GOLASZEWSKI 40.00 X 145483 0 14671 371903 0 33849 3 0 1 0 BLUE CROSS BLUE SHIELD PO BOX 580017 CHARLOTTE NC 28258 INSURANCE 1188783 JOHN S CLARK COMPANY LLC PO BOX 1468 MOUNT AIRY NC 27030 CONSTRUCTION 497087 HOSPISCRIPT INC PO BOX 933273 ATLANTA GA 31193 PHARMACY 441047 NORTHERN HOSPITAL OF SURRY COUNTY PO BOX 1101 MT AIRY NC 27030 HEALTH CARE 432625 HUGH CHATHAM MEMORIAL HOSPITAL PO BOX 560 ELKIN NC 286212495 HEALTH CARE 362985 15 174234 174234 PATIENT SERVICE REVENU 623000 16435540 16435540 16435540 5880 5880 20763 20234 529 529 16616183 16435540 0 6409 405752 144139 261613 41848 41848 5964897 4859008 1105889 60887 60887 1484128 1484128 471503 471503 14552 14552 54128 54128 150 150 2510932 2506679 4253 140283 178 140105 2735914 2637331 98583 102090 100688 1402 378840 378840 483077 393851 89226 53173 47385 5788 122465 59311 63154 457923 457923 31104 31104 BAD DEBT 284447 284447 PROPERTY/SALES TAXES 9560 9560 15807653 13959250 1848403 0 1639415 1945728 436649 208969 1924895 2092544 27180 29386 95314 203523 6049724 1135508 5196069 4914216 1045 867 5459 5341 9326026 9400574 1121942 1245242 1700000 1600000 899100 141894 3721042 2987136 X 5168335 6204469 436649 208969 5604984 6413438 9326026 9400574 X 0 1 1 X 0 X 1318386 1109758 878613 761122 174234 4242113 1318386 1109758 878613 761122 174234 4242113 872758 3369355 43659 71818 42722 15330 5880 179409 4421522 65656867 0.76200 0.75320 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 261343 261343 2468724 97497 2371227 0 3319657 1038011 2281646 0 4914216 CAPITAL LEASE OBLIGATION 141894 141894 16616183 15807653 808530 -76 -76 808454 16616107 -76 -76 16616183 0 16616183 15807653 0 15807653 0 15807653 BARBEQUE,ANNUAL YADKIN COUNTY 5606 5606 3345 TOUR DE MAYBERRY 7077 7077 6401 4 8080 8080 10488 20763 20763 20234 20234 529 X X 0 0 0 0 0 0 0 0 0 GLENN D GOLASZEWSKI 140483 0 5000 0 0 0 0 0 14671 0 160154 0 0 0 DEBRA TRIPPEL SPOUSE OF CURRENT OFFICER 41848 COMPENSATION AS EMPLOYEE 0 Form 990, Part VI, Section A, line 6 THE ORGANIZATION HAS TWO MEMBERS, HUGH CHATHAM MEMORIAL HOSPITAL, INC AND THE NORTHERN HOSPITAL DISTRICT OF SURRY COUNTY. Form 990, Part VI, Section A, line 7a THE GOVERNING BODY CONSISTS OF REPRESENTATIVES APPOINTED BY THE ORGANIZATION'S MEMBERS, HUGH CHATHAM MEMORIAL HOSPITAL AND THE NORTHERN HOSPITAL DISTRICT OF SURRY COUNTY. Form 990, Part VI, Section A, line 7b THE GOVERNING BODY CONSISTS OF REPRESENTATIVES APPOINTED BY THE ORGANIZATION'S MEMBERS, HUGH CHATHAM MEMORIAL HOSPITAL AND THE NORTHERN HOSPITAL DISTRICT OF SURRY COUNTY. DECISIONS OF THE REPRESENTATIVES ARE SUBJECT TO APPROVAL OF THE MEMBER ORGANIZATIONS. Form 990, Part VI, Section B, line 11 THE RETURN WAS PREPARED BY AN INDEPENDENT ACCOUNTING FIRM WITH ASSISTANCE AND INFORMATION PROVIDED BY MANAGEMENT. UPON COMPLETION OF THE FORM 990, THE ORGANIZATION'S MANAGEMENT REVIEWED THE FORM 990. THE FORM 990 WAS THEN PROVIDED TO THE MEMBERS FOR THEIR REVIEW PRIOR TO SUBMISSION TO THE IRS. Form 990, Part VI, Section B, line 12c Board of Members, Advisory Board and hospice staff submit a form to disclose personal or financial interests that could possibly interfere with their duties and responsibilities to the Organization. Disclosure forms are submitted at the time of hire or Board appointment, annually and/or whenever a potential conflict arises. Failure to disclose existing or potential conflicts of interest is grounds for termination of employment or Board appointment. Form 990, Part VI, Section B, line 15 Salary ranges are established for each paid position in the organization. Each salary range has a minimum and maximum amount. The Members determine the salary for the Executive Director, CFO and Medical Director of the organization. The Exceutive Director and CFO determine the salary ranges for other paid positions in the organization. Salary ranges are reviewed annually and benchmarked against industry data. Form 990, Part VI, Section C, line 18 RECENT FILINGS 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 WWW.GUIDESTAR.ORG. 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 WRITTEN REQUEST AT THE ORGANIZATION'S ADMINISTRATIVE OFFICE.