2011-02-10T12:01:08-06:00 2010-03-31 WITT MARES PLC 701 TOWN CENTER DRIVE SUITE 900 NEWPORT NEWS VA 236064287 990 2009-04-01 237424835 Chesapeake Hospital Corporation DBA Rappahannock General Hospital CHES 8044358582 PO Box 1449 Kilmarnock VA 22482 James M Holmes Jr 8044358582 2011-02-10 1 THOMAS R BROOKS 7578731587 X 2009 2016-02-24 21:20:13Z rappahanock general hospital James M Holmes Jr PO Box 1449 Kilmarnock VA 22482 36317989 0 X www.rgh-hospital.com X 1977 VA The organization operates an acute care general hospital. 12 10 428 115 3648 0 702423 521551 32746167 35664123 58726 25326 234559 -35697 33741875 36175303 0 0 18249769 18090632 0 74832 16598671 17607577 34848440 35698209 -1106565 477094 25138829 26378535 9140207 9878939 15998622 16499596 The organization operates an acute care general hospital. the hospital has a community based board of directors, has a open medical staff, operates an emergency room providing care to all regardless of ability to pay, and provides non-emergency services to any with the ability to pay including medicare and medicaid covered individuals. the organization is dedicated to the provision of quality, compassionate care to all patients in the most cost effective manner. this will be accomplished through the most effective use of available resources and will reflect ethical decisions, including the effective management of pain, made jointly by the patients, the family, and health care professionals involved in his care. 0 0 31033356 35656385 rappahanock general hospital is the only provider of inpatient and outpatient acute care services within a five county area. the hospital is licensed to operate 76 beds, including 48 medical/surgical beds, 7 intensive/critical care beds, 12 telemetry care beds and 10 psych beds. the hospital also offers our community major diagnostic and treatment capabilities; clinical and blood bank laboratory services; radiology services including diagnostic x-ray, digital mammography, digital flouroscopy, bone densitometry, arteriography, angiography with digital subtraction, noninvasive vascular laboratory, ultrasonography, nuclear medicine, mri, ct scanning, inpatient and same day surgery; respiratory therapy; physical therapy; home health, lithotripsy; and radiation therapy. 375009 chesapeake hospital corporation provided numerous services for the community which included, health fairs for different civic groups in the five county areas. the services offered by the hospital range from cholesterol, blood pressure, glucose, literature and cancer information and/or screenings. community benefits are provided through many reduced price services and free programs offered throughout the year based on activities and services which the hospital believes will serve a bona fide community health need. this includes the cancer treatment and education center support groups and education for patients and their families. the emergency department offers cpr, heart saver courses, and pediatric basis life support. we also sponsor a diabetic education course for people with diabetes and their families. the organization also volunteers staff and facilities for free sports physicals for secondary students in the area. 31408365 1 1 0 1 0 0 0 0 0 1 0 1 0 0 0 0 0 0 0 0 1 0 0 1 0 0 0 0 0 1 0 1 0 0 0 0 0 1 1 0 0 1 31 0 428 1 1 1 0 0 0 0 0 0 0 0 12 10 1 0 0 0 0 0 0 1 1 0 0 1 1 1 1 1 1 1 1 0 VA X Bernie Lockstampfor Jr 8044358000 101 harris road kilmarnock VA 22482 James M Holmes Jr 40.00 X X 0 280037 16577 Matthew Vogel MD 40.00 X 1550 179982 11344 J Randy Hester 40.00 X X 600 215629 14995 Bernard P Lockstampfor J 40.00 X X 750 169128 13788 James Carter Jr 1.00 X 0 0 1400 Jeff Chase Jr 1.00 X 1150 0 0 David H Charlton 1.00 X 0 0 600 Fredrick Cole 1.00 X 800 0 0 Elizabeth Crowther 1.00 X 1200 0 0 Edward P Harrow Jr 1.00 X 0 0 700 B H Hubbard III 1.00 X 0 0 1600 Garfield Parker 1.00 X 600 0 0 Wayne Penick 1.00 X 0 0 1300 Stephen Whiteway 1.00 X 0 0 0 Emerson L Gravatt 40.00 X 800 137970 11389 Ann Gumina 40.00 X 1050 125854 4872 John Headley 40.00 X 1150 100221 11538 Kevin McGrath MD 40.00 X 0 0 0 Alice Blackstone 1.00 X 0 0 0 John Deschamps 40.00 X 0 0 0 Richard Steelman 1.00 X 0 0 0 John B Dorsey 1.00 X 0 0 0 Paul Sutherland MD 40.00 X 305216 0 16795 Virginia Gale 40.00 X 226299 0 15435 Stephen Perkins 40.00 X 254402 0 16459 James Bryant 40.00 X 196429 0 11065 Barbara Perona 40.00 X 370002 0 10579 1361998 1208821 160436 5 0 1 0 chesapeake health services po box 1328 kilmarnock VA 22482 management services 1142560 diamond healthcare corp po box 85050 richmond VA 23285 program management service 903448 chas lunsford po box 2571 roanoke VA 24010 general insurance 551450 Dr Richard Carpenter PO Box 3391 Martinsville VA 241153391 health insurance 120000 jackson & coker po box 277638 atlanta GA 30384 placement services 117876 6 521551 521551 Net Patient Revenue 623000 30192879 30192879 Physician Practice Ser 623000 5098277 5098277 Cafeteria 900099 214940 214940 collection fees 900099 82204 82204 Other Revenue 623000 68085 68085 7738 7738 35664123 14326 14326 106989 142686 -35697 -35697 -4090 -31607 11000 11000 11000 11000 36175303 35656385 3648 -6281 11633 11633 15090493 13528126 1562367 229318 229318 1682077 1682077 1077111 1077111 1060720 1060720 69417 69417 110000 110000 3196931 2713547 483384 27989 27989 34171 34171 664011 664011 127629 100911 26718 223992 223992 1201188 1201188 401047 401047 Supplies 6306639 6216117 90522 Bad Debts 2464842 2464842 Repairs & Rentals 1379840 717701 662139 Dues & Subscriptions 173192 70976 102216 Recruitment 66885 66885 99084 16345 7907 74832 35698209 31408365 4215012 74832 259258 399150 9604714 10333818 1016494 953599 372636 565034 30780037 21483187 9120156 9296850 49669 49669 4715902 4780415 25138829 26378535 3262172 3777948 342796 1430534 5535239 4670457 9140207 9878939 X 15923212 16400306 75410 99290 15998622 16499596 25138829 26378535 X 0 1 1 X 0 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 0 0 0 0 0 1 7392 0 0 0 7392 0 Part II-B, Line 1i: Explanation of Other Lobbying Activities: 24% of vhha and aha dues paid by the hospital are attributable to lobbying. 1045796 1045796 10649099 6412588 4236511 115110 97440 17670 18136493 14425563 3710930 833539 547596 285943 9296850 assets whose use is limited 127147 due from cps 1641 due from cmg 4032291 due from rghf and auxillary 371269 Deferred financing costs 85579 Due from CHS 145140 Other Receivables 17348 4780415 Note payable-siemens 1108007 due to chs 3562450 4670457 36175303 35698209 477094 23880 23880 500974 36317989 142686 142686 36175303 0 36175303 35840895 142686 142686 35698209 0 35698209 Part X: Description of Uncertain Tax Positions Under FIN 48: Schedule D Line 2. RHS, the Hospital, CMG and the Foundation are not-for-profit corporations as described in Section 501(c)(3) of the Internal Revenue Code (the Code) and are exempt from Federal income taxes on related income pursuant to Section 501(a) of the Code. CPS is a wholly-owned, taxable subsidiary of RHS. RHS is subject to income taxes on profits, if any, from CPS. Effective 2009, FASB Accounting Standards Codification 740 prescribes a recognition threshold and measurement attribute for the financial statement recognition and measurement of a tax position taken or expected to be taken in a tax return. RHS's management has evaluated the impact of the standard to its financial statements, but does not anticipate a material effect. RHS is not aware of any material uncertain tax positions and has not accrued the effect of any uncertain tax positions as of March 31, 2010. Part XI, Line 8 - Other Adjustments: Donations temporarily restricted net assets: 38847. Direct Payments temporarily restricted net assets: -15541. Interest income temporarily restricted net assets : 574. Part XII, Line 2d - Other Adjustments: rental expenses: 142686. Part XIII, Line 2d - Other Adjustments: rental expenses: 142686. 1 1 1 X 0 1 1 1 0 1 1 532403 532403 0.01490 107166 107166 0.00300 639569 639569 0.01790 375009 375009 0.01050 375009 375009 0.01050 1014578 1014578 0.02840 838 375009 375009 0.01050 838 375009 375009 0.01050 1 1367987 0 16058649 17554252 -1495603 X 1 1 Chesapeake Health Services Management services 0.00000 0.00000 0.00000 rappahanock general hospital

101 harris road kilmarnock VA 22482

X Part I, Line 3c: Determination of charity will be made through knowledge of the medical and social-economic situation and its various financial implications; an interview with patient (responsible party) and investigation of financial resources. The decision will be based on cooperative medical, social service, and administrative judgment. Part I, Line 7: Costing method is overall cost to charge ratio from Medicare Cost Report. No bad debt is included in the calculation. Part III, Line 4: Patient Accounts Receivable are recorded at established billing rates when patient services are rendered. Provisions for uncollectible accounts and contractual adjustments are recorded as deductions from patient accounts receivable to reduce recorded amounts to net realizable value. Contractual adjustments represent the difference between established billing rates and amounts reimbursed (principally from federal and state governments under Medicare and Medicaid and other commercial insurers including Anthem). Part III, Line 8: Costing method is cost to charge ratio from Medicare Report. Shortfall of medicare payments received directly benefit the community citizens. Part III, Line 9b: Patients who qualify for charity care or financial assistance are asked to meet with a financial counselor to determine financial need. If charity guidelines are met, then patient accounts are adjusted accordingly. Part V: This organization has no other facilities other than the one listed on part V. Schedule H, Part I, Line 6a:The organization files a community benefit report in Virginia. Part VI, Line 2: The organization looks at the area's population, age, income and financial needs of the area. Part VI, Line 3: The hospital has a charity policy, financial counseling program and brochures provided to patients to inform and educate patients and their families about eligibility for assistance. Part VI, Line 4: The organization serves the Middle Peninsula-Northern Neck Counties of Virginia. These counties include:County Population Sq. Miles 65 Plus Per capita incomeLancaster 11,567 231 28.5% $24,663Northumberland 12,259 286 26.2% $22,917Richmond Co. 8,809 216 17.7% $16,675Westmoreland 16,718 253 19.0% $19,473Mathews 9,207 252 21.6% $23,610Middlesex 10,731 130 25.7% $22,708 Part VI, Line 5: The organization supports the loss incurred by its sister company Chesapeake Medical Group (CMG). CMG represents several groups of physicians including Family Practice, Pediatrics, GYN, surgery and others, that were not able to survive without the assistance from RGH. CMG has the only pediatric services in the area. CMG provides physician care regardless of the insurance while other physicians in the area no longer accept new Medicaid patients. CMG also provides coverage for those patients with no insurance. Part VI, Line 6: Chesapeake hospital corporation provided numerous services for the community which included, health fairs for different civic groups in the five county areas. the services offered by the hospital range from cholesterol, blood pressure, glucose, literature and cancer information and/or screenings. community benefits are provided through many reduced price services and free programs offered throughout the year based on activities and services which the hospital believes will serve a bona fide community health need. this includes the cancer treatment and education center support groups and education for patients and their families. the emergency department offers cpr, heart saver courses, and pediatric basis life support. we also sponsor a diabetic education course for people with diabetes and their families. the organization also volunteers staff and facilities for free sports physicals for secondary students in the area. Part VI, Line 7: As a not-for-profit healthcare organization, it is the purpose and responsibility to provide outstanding care to everyone who needs it, regardless of their ability to pay. RGH's operations are significantly impacted by charity care and the Medicare/Medicaid shortfalls. In addition to the essential health care services provided that Rappahannock Health System (RHS)provides to our community, the Heath System has a significant economic impact on our community. RHS is the largest employer in Lancaster county, providing jobs for more than 500 people who live in Kilmarnock and the surrounding areas. RHS has several affiliates. One is the Chesapeake Medical Group which provides quality, compassionate, cost effective primary medical care services to the Kilmarnock area. Chesapeake Health Services manages the various entities. Chesapeake Pharmacy Services, Inc. provides pharmacy services for the area while Rappahannock General Hospital Foundation assists in providing fundraising abilities. X X X X 0 0 0 0 0 0 0 1 0 James M Holmes Jr 0 279071 0 0 0 966 0 4937 0 11040 0 296014 0 0 Matthew Vogel MD 1550 179982 0 0 0 0 0 5399 0 5945 1550 191326 0 0 J Randy Hester 600 213823 0 0 0 1806 0 4577 0 10018 600 230224 0 0 Bernard P Lockstampfor Jr 750 168162 0 0 0 966 0 4044 0 9744 750 182916 0 0 Emerson L Gravatt 800 135198 0 0 0 2772 0 3141 0 8248 800 149359 0 0 Paul Sutherland MD 305216 0 0 0 0 0 6367 0 10428 0 322011 0 0 0 Virginia Gale 226299 0 0 0 0 0 5471 0 9964 0 241734 0 0 0 Stephen Perkins 254402 0 0 0 0 0 6253 0 10206 0 270861 0 0 0 James Bryant 196429 0 0 0 0 0 5123 0 5942 0 207494 0 0 0 Barbara Perona 370002 0 0 0 0 0 6865 0 3714 0 380581 0 0 0 Supplemental Information Part III portion of physician contracts payments are variable based on cash collect northern neck state bank See Schedule O bank accts 0 chesapeake bank See Schedule O loans 0 Form 990, Part V, line 7g The organization did not receive any contributions of qualified intellectual property. Form 990, Part VI, Section A, line 2 See schedule L detail for business relationships. Form 990, Part VI, Section B, line 11 When the completed form 990 comes back from the outside tax preparers, it is reviewed by the chesapeake health services (chs) vice president-finance or chs controller for accuracy. once it is determined to be the final draft, the package is given to the president. The president will schedule a meeting of the chs board's executive committee which consists of the chairman-chesapeake health services board, chairman-chesapeake hospital corporation board, finance committee chairman, and a member of the chs board. the executive committee reviews the return in detail and recommends that the board of directors accept it. at the next schedules rgh board meeting (or a called meeting if necessary to mail the return on time). the form 990 is discussed with copies being available for any other b0ard member to review. once this meeting and approval of the form 990 have taken place, the return is signed and e filed. Form 990, Part VI, Section B, line 12c all documents are available to the public for review in administration during regular business hours, monday through friday. all board members sign a conflict of interest statement once a year stating they will make the board aware if there is a conflict of interest. Form 990, Part VI, Section B, line 15 the chesapeake health services (chs) executive salary committee of the board of directors meets at least annually to review the compensation of the ceo, officers and other key employees. these are shared positions with chesapeake health services, rappahannock general hospital, rappahannock general hospital foundation and chesapeake medical group. the chs president will schedule a meeting of the board's executive salary committee which consists of the chairman-chesapeake health services board, chairman-chesapeake hospital corporation board, finance committee chairman, and a member of the chs board. the chs executive committee reviews the current salary and benefits of each officer and key employee and recommends adjustments as necessary. their review consists of comparing the salary and benefits to a periodic survey done by an outside third party or hospital related circulations. if it has been determined that no increases will be given in the fiscal year, no meeting will take place. Form 990, Part VI, Section C, line 19 All governing documents, conflict of interest policy, and financial statements are made available upon request in the Administration office. Form 990, Part XI, Line 2c The organization does have a committee who assumes the responsibility for oversight of the audit and the process remains unchanged during the year. Form 990 Schedule L Business Relationships c wayne penick is a chesapeake hospital corporation board member and board vice chairman and is employed by northern neck state bank which chesapeake hospital corporation does business with. James m holmes jr is an officer of chesapeake hospital corporation and is board member of chesapeake bank. chesapeake health services 101 harris road kilmarnock VA 22482 541513371 parent VA 501(c)(3) 11 N/A rappahanock general hosp fnd 101 harris road kilmarnock VA 22482 541210450 supporting organization VA 501(c)(3) 11 N/A chesapeake medical group 101 harris road kilmarnock VA 22482 541857174 healthcare services VA 501(c)(3) 11 N/A chesapeake pharmacy services 101 harris road kilmarnock VA 22482 541822516 pharmacy VA N/A C 1 1 0 1 1 0 0 0 1 0 1 1 0 1 1 1 1 1 chesapeake health services L 995317 chesapeake medical group P 388393 chesapeake pharmacy services inc P 24008 rappahannock general hospital foundation B 411872 Chesapeake Health Services R 141000 chesapeake medical group D 4032291 chesapeake pharmacy services inc D 1641 Chesapeake Health Services E 145140 rappahannock general hospital foundation D 316869 Chesapeake Health Services E 3562450 chesapeake medical group I 45600 chesapeake pharmacy services inc I 9600 chesapeake medical group K 29336 chesapeake medical group L 221999