2011-02-15T12:53:29-06:00 2010-09-30 DIXON HUGHES PLLC 500 Ridgefield Court Asheville NC 28806 990 2009-10-01 560554202 CALDWELL MEMORIAL HOSPITAL INCORPORATED CALD 8287575100 321 MULBERRY STREET SW LENOIR NC 28645 DONALD F GARDNER JR 8287575100 2011-02-15 1 Amy Bibby 8282542254 2009 2016-02-24 21:20:13Z DONALD F GARDNER JR 321 MULBERRY STREET SW LENOIR NC 28645 99561807 0 X WWW.CALDWELLMEMORIAL.ORG X 1945 NC TO PROVIDE HEALTH CARE SERVICES TO THE PEOPLE OF CALDWELL COUNTY. 11 10 1064 152 1147692 0 349010 80335 99930473 98412650 164102 143241 631357 878258 101074942 99514484 530220 203828 0 45956781 45581640 0 0 53695761 52509250 100182762 98294718 892180 1219766 52115509 50209672 19153766 15848627 32961743 34361045 THE MISSION OF CALDWELL MEMORIAL HOSPITAL IS TO PROMOTE SAFE, EFFECTIVE, COMPASSIONATE MEDICAL CARE AND TO PROMOTE HEALTHLY LIFESTYLES FOR OUR COMMUNITY. 0 0 85584408 97486357 CALDWELL MEMORIAL HOSPITAL IS PROUD TO PROVIDE THE QUALITY HEALTHCARE YOU TRUST AND THE CARING YOU DESERVE. SINCE OPENING IN 1951, CALDWELL MEMORIAL HOSPITAL HAS CONTINUED TO GROW AND CHANGE IN ORDER TO BETTER MEET THE NEEDS OF OUR COMMUNITY. THE MISSION OF CALDWELL MEMORIAL HOSPITAL IS TO PROVIDE SAFE, EFFECTIVE, COMPASSIONATE CARE AND TO PROMOTE HEALTHY LIFESTYLES TO OUR COMMUNITY. ANCHORED BY A 110-BED ACUTE CARE FACILITY, CALDWELL MEMORIAL HOSPITAL'S SERVICES INCLUDE CAROTID ARTERY STENTING; CARDIOVASCULAR AND ENDOVASCULAR CARE; RADIATION, MEDICAL AND SURGICAL ONCOLOGY; COMPUTER-ASSISTED ORTHOPAEDIC SURGERY; NEUROLOGY & MEMORY CARE, PAIN MANAGEMENT, A FULLY STAFFED 24-HOUR EMERGENCY DEPARTMENT; CALDWELL PHYSICIANS OFFICES CONVENIENTLY LOCATED COUNTY-WIDE; DIAGNOSTIC SERVICES; OUTPATIENT SURGERY; PLUS URGENT CARE; AND THE QUEST4LIFE WELLNESS CENTER, JUST TO NAME A FEW. MULTIPLE EDUCATIONAL AND COUNSELING PROGRAMS ARE AVAILABLE FOR A WIDE ARRAY OF HEALTHCARE NEEDS INCLUDING CANCER, DIABETES, NUTRITION, JOINT CARE, PRE-NATAL CLASSES AND PARENTING SKILLS. CALDWELL PHYSICIANS IS A DIVISION OF CALDWELL MEMORIAL HOSPITAL. WITH PRACTICES IN COMMUNITIES COUNTYWIDE, CALDWELL PHYSICIANS PROVIDES THE PRIMARY AND SPECIALTY HEALTHCARE, DIAGNOSTICS AND TREATMENTS THAT YOU NEED IN A CONVENIENT LOCATION CLOSE TO YOU. CALDWELL PHYSICIANS INCLUDES: CALDWELL ACUTE CARE SPECIALISTS, CALDWELL FAMILY CARE CENTER, CALDWELL INTERNAL MEDICINE, CALDWELL UROLOGY ASSOCIATES, THE FALLS MEDICAL PARK (INCLUDING PLUS URGENT CARE), THE FALLS NEUROLOGY & MEMORY CENTER, THE FALLS PEDIATRICS, THE FALLS PULMONARY CENTER, HALLMARK FAMILY PHYSICIANS, MAIN STREET MEDICAL PARK, MULBERRY PEDIATRICS, SOUTHFORK MEDICAL PARK AND WESTPOINTE MEDICAL PRACTICE. 85584408 1 1 0 1 0 0 0 0 0 1 0 1 0 0 0 0 0 0 0 0 1 1 0 1 0 0 0 1 0 0 0 0 0 0 0 0 1 1 1 0 0 1 111 0 1 1064 1 1 1 0 0 0 0 0 0 0 0 11 10 1 0 0 0 0 0 0 1 1 0 0 1 1 1 1 1 1 1 1 1 1 NC X X X CHRIS WASHBURN 8287575221 321 MULBERRY STREET SW LENOIR NC 28645 STEVE LAMBRECHTS 1.00 X X 0 0 0 BOYD WILSON JR 1.00 X X 0 0 0 PARKER WILLIAMSON 1.00 X X 0 0 0 ALEX BERNHARDT JR 1.00 X 0 0 0 DEBORAH MURRAY 1.00 X 0 0 0 JOHN MCCORMICK MD 1.00 X 0 0 0 SHIRLEY ORRELL 1.00 X 0 0 0 BILL JOHNSON 1.00 X 0 0 0 PETER PURCELL MD 1.00 X 0 0 0 MARK BATTS MD 1.00 X 0 0 0 GARY SHORE 1.00 X 0 0 0 LAURA J EASTON 40.00 X 262323 0 12568 Donald Gardner Jr 40.00 X 204996 0 10182 Rebecca Smith 40.00 X 177340 0 4823 Danny Morgan 40.00 X 129629 0 8569 David Horn 40.00 X 142165 0 7773 SHARON KIMBALL 40.00 X 157769 0 2570 JOHN POWELL MD 40.00 X 186477 0 11739 DENNICE HERMAN MD 40.00 X 214139 0 9691 BRAIN BAUER MD 40.00 X 404682 0 7000 JOHN A DEW MD 40.00 X 306097 0 7000 David Lowry MD 40.00 X 361445 0 7000 Reginald Moore MD 40.00 X 300002 0 7000 RONALD H DUBOW 40.00 X 266866 0 7000 DR ERIC DRAVLAND 40.00 X 215580 0 10294 BOB FLOYD JR X 0 0 0 RENEE SIGMON X 0 0 0 FRED SOULE X 0 0 0 JIM SPONENBERG X 0 0 0 WILLIAM HOWARD III X 0 0 0 BRENT CAUSEY X 0 0 0 DON BARRIER X 0 0 0 MARK BATT MD X 0 0 0 GEORGE NICHOLS MD X 25000 0 0 3329510 0 113209 54 1 1 0 CALDWELL FAMILY PHYSICIANS PA 1766 CONNELLY SPRINGS RD LENOIR NC 28645 PROFESSIONAL MEDICAL SERVICES 1095030 WESTERN CAROLINA PATHOLOGY ASSOC INC PO BOX 680 LENOIR NC 28645 PATHOLOGY SERVICES & MEDICAL DIRECTOR OF 277767 CAROLINAS HEALTHCARE SYSTEM PO BOX 32861 CHARLOTTE NC 28232 SLEEP STUDIES 252425 DIXON HUGHES PLLC ONE WEST FOURTH STREET SUITE 700 WINSTONSALEM NC 27101 AUDIT AND ADVISORY WORK 193421 TIM BLINSON CONSTRUCTION 2377 MILLS COVE PLACE LENOIR NC 28645 MINOR CONTRUCTION PROJECTS 183672 6 80335 80335 PATIENT SERVICES 621500 95398303 95291716 106587 JOINT VENTURE INCOME 541900 1004886 845336 159550 OTHER PATIENT REVENUE 900099 934234 934234 WELLNESS CENTER 713990 881555 881555 CAFETERIA REVENUE 900099 193672 193672 98412650 117725 117725 113985 47323 66662 66662 66662 25516 25516 25516 25516 OTHER INCOME 900099 811596 811596 811596 99514484 96974164 1147692 1312293 203828 203828 1542753 404908 1137845 225874 221357 4517 35813567 31063336 4750231 12011 10151 1860 5567888 4698350 869538 2419547 2041686 377861 1128001 1128001 79462 79462 47280 47280 11583 11583 7837002 5366991 2470011 234823 234823 723282 585619 137663 2736752 2736752 140286 92656 47630 299465 299465 4830896 4830896 1257867 1257867 SUPPLIES 15075383 14625000 450383 BAD DEBT EXPENSE 12164443 12164443 EQUIPMENT RENTAL AND MA 4799028 3543468 1255560 RECRUITMENT 385770 385770 COLLECTIONS & BILLINGS 365397 365397 392530 298051 94479 98294718 85584408 12710310 0 6529 5860 13295018 10945320 13300190 10899837 2337738 2314862 1062418 1499782 68288295 51778571 17609530 16509724 3578732 2089272 2245172 2414814 2210383 52115509 50209672 7136837 6802970 153390 184156 3335566 2161973 8527973 6699528 19153766 15848627 X 32750079 34358100 211664 2945 32961743 34361045 52115509 50209672 X 0 1 1 X 0 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 0 0 0 0 0 0 0 0 1 11583 11583 0 Part II-B, Line 1i: Explanation of Other Lobbying Activities: ANNUAL DUES WERE PAID TO THE NORTH CAROLINA HOSPITAL ASSOCIATION AND THE AMERICAN HOSPITAL ASSOCIATION, OF WHICH $11,583 WAS DETERMINED TO BE EXPENDITURES USED IN LOBBYING ACTIVITIES BY THESE ORGANIZATIONS. 896747 896747 29412364 22783936 6628428 36127146 27985461 8141685 1852038 1009174 842864 16509724 REFUNDS PAYABLE AND PATIENT DEPOSITS 363984 CAPITAL LEASE 4132488 ESTIMATED THIRD PARTY SETTLEMENTS 1435818 PHYSICIAN RECRUITMENT OBLIGATIONS 767238 6699528 99514484 98294718 1219766 179536 179536 1399302 99741343 179536 179536 99561807 -47323 -47323 99514484 98342041 47323 47323 98294718 0 98294718 Part XII, Line 4b - Other Adjustments: RENTAL EXPENSES: -47323. Part XIII, Line 2d - Other Adjustments: RENTAL EXPENSES: 47323. 1 1 1 X 125.000000000000 1 X 145.000000000000 1 1 1 0 0 1608067 10000 1598067 0.01860 12619986 9691992 2927994 0.03400 1115929 565097 550832 0.00640 15343982 10267089 5076893 0.05900 91327 0 91327 0.00110 128201 128201 0.00150 211911 10000 201911 0.00230 431439 10000 421439 0.00490 15775421 10277089 5498332 0.06390 1 4479270 1119818 24360215 25494227 -1134012 X 1 1 CALDWELL MEMORIAL HOSPITAL INCORPORATED

321 MULBERRY STREET SW PO BOX 1890 LENOIR NC 28645

X X X Part III, Line 4: FINANCIAL STATEMENT FOOTNOTE:THE HOSPITAL HAS PROVIDED SERVICES TO PERSONS WHO HAVE NOT PAID FOR SUCH SERVICES EITHER BECAUSE THEY HAVE BEEN UNWILLING OR UNABLE TO PAY. EFFORTS ARE MADE BY THE HOSPITAL TO DETERMINE IF A PATIENT MEETS CHARITY POLICY GUIDELINES THAT ARE ESTABLISHED BY THE HOSPITAL. IF THESE GUIDELINES ARE MET AND CAN BE VERIFIED, THEN SUCH AMOUNTS ARE INCLUDED IN CHARITY CARE. UNTIL SUCH TIME, SUCH AMOUNTS ARE COMBINED IN BAD DEBTS BECAUSE THEY HAVE NOT BEEN VERIFIED OR DOCUMENTED AS CHARITY CARE DUE TO LACK OF SUPPORTING FINANCIAL INFORMATION. IN SOME CASES, PATIENTS WHO WOULD (OR COULD) QUALIFY FOR CHARITY CARE UNWILLING OR UNABLE TO PRODUCE THE NECESSARY INFORMATION TO SUBSTANTIATE THEIR QUALIFICATION. THUS, BAD DEBTS INCLUDE AMOUNTS THAT WOULD OTHERWISE QUALIFY FOR CHARITY CARE UNDER THE HOSPITAL'S GUIDELINES. THE ESTIMATED COST OF UNREIMBURSED SERVICES ATTRIBUTABLE TO BAD DEBTS - EFFECTIVELY "FREE" SERVICES PROVIDED TO PATIENTS - HAS BEEN DETERMINED BY APPLYING A COST TO CHARGE RATIO TO THE AMOUNT OF BAD DEBTS. SUCH ESTIMATED COSTS WERE $4,352,000 AND $4,550,000 IN 2010 AND 2009, RESPECTIVELY.COSTING METHODOLOGY:THE AMOUNTS DISCLOSED ON LINES 2 AND 3 OF PART III, SECTION A ARE REPORTED ON THE ORGANIZATION'S MOST RECENTLY FILED MEDICARE COST REPORT (FY 2009). THE ORGANIZATION HAS ESTIMATED THE AMOUNT OF UNREIMBURSED COSTS OF TREATING MEDICARE PATIENTS FOR FY 2010 TO BE $25,494,227. Part III, Line 8: WITH COUNTYWIDE DOUBLE-DIGIT UNEMPLOYMENT AND A POPULATION ALREADY HEAVILY DEPENDENT UPON MEDICARE AND MEDICAID, THE ENTIRETY OF THE MEDICARE SHORTFALL (REPORTED IN LINE 7) IS COMMUNITY BENEFIT, EQUATING DIRECTLY TO "FREE" CARE PROVIDED BY CALDWELL MEMORIAL. Part VI, Line 2: CALDWELL MEMORIAL ACTIVELY ENGAGES WITH OUR COMMUNITY PARTNERS TO ASSESS THE HEALTH CARE NEEDS OF CALDWELL COUNTY, NORTH CAROLINA. MEMBERS OF OUR STAFF SERVE AS PART OF THE ADVISORY GROUP FOR THE COMMUNITY HEALTH ASSESSMENT PERFORMED EVERY FOUR YEARS BY PUBLIC HEALTH. (THE LAST STUDY WAS PERFORMED IN 2007.) WE COMPARE THIS HEALTH AND BEHAVIORAL DATA TO THAT OF OUR STATE AND NATION AND EVALUATE THE COMMUNITY'S NEEDS BASED ON NUMBER AND SEVERITY OF CASES OF ANY PARTICULAR ILLNESS, INCIDENCE, OR DISEASE. Part VI, Line 3: CALDWELL MEMORIAL HOSPITAL POSTS OUR CHARITY CARE POLICY ON OUR WEBSITE AND UPDATES IT ANNUALLY. OUR FINANCIAL COUNSELORS WORK CLOSELY WITH OUR PATIENTS TO HELP THEM DETERMINE THEIR ELIGIBILITY AND UNDERSTAND THEIR FINANCIAL OBLIGATIONS. Part VI, Line 4: CALDWELL COUNTY, NORTH CAROLINA IS ONE OF THE WESTERN-MOST COUNTIES IN THE STATE. WE ARE A NORTH CAROLINA DEPARTMENT OF COMMERCE-DESIGNATED TIER 1 COUNTY, INDICATING THAT OUR COUNTY IS ONE OF THE MOST ECONOMICALLY DISTRESSED IN THE STATE. OUR POPULATION IS 80,000. APPROXIMATELY 15% OF OUR POPULATION IS BELOW THE FEDERALLY-DESIGNATED POVERTY LEVEL. ON AVERAGE 15% OF OUR POPULATION IS UNEMPLOYED. Part VI, Line 5: N/A Part VI, Line 6: N/A Part VI, Line 7: N/A 1 HELPING HANDS CLINIC 810 HARPER AVE NW LENOIR NC 28645 562076541 501(C)(3) 54150 ACTUAL COST PHARMACEUTICALS TO PROVIDE PERSCRIPTIONS AND/OR MEDICAL SUPPLIES TO INDIGENT CLINIC PATIENTS. HELPING HANDS CLINIC 810 HARPER AVE NW LENOIR NC 28645 562076541 501(C)(3) 149678 ESTIMATED COST COST OF FREE CARE TO PROVIDE FREE SERVICES TO INDIGENT CLINIC PATIENTS. 1 0 Procedure for Monitoring Grants in the U.S.: Part I, Line 2: Schedule I, Part I, Line 2: MONITORING THE USE OF ASSISTANCE IS DONE ON A DEPARTMENTAL BASIS. EACH DEPARTMENT INVOLVED HAS AN EMPLOYEE RESPONSIBLE TO OVERSEE AND MONITOR ASSISTANCE PROVIDED. X 1 1 X X X X X 0 1 0 0 0 1 0 0 0 LAURA J EASTON 213953 0 48370 0 0 0 5290 0 7278 0 274891 0 0 0 Donald Gardner Jr 137528 0 42268 0 25200 0 6120 0 4062 0 215178 0 0 0 Rebecca Smith 105251 0 28834 0 43255 0 2700 0 2123 0 182163 0 0 0 SHARON KIMBALL 129681 0 28088 0 0 0 1170 0 1400 0 160339 0 0 0 JOHN POWELL MD 169601 0 0 0 16876 0 7290 0 4449 0 198216 0 0 0 DENNICE HERMAN MD 185866 0 0 0 28273 0 5590 0 4101 0 223830 0 0 0 BRAIN BAUER MD 404682 0 0 0 0 0 0 0 7000 0 411682 0 0 0 JOHN A DEW MD 306097 0 0 0 0 0 0 0 7000 0 313097 0 0 0 David Lowry MD 361445 0 0 0 0 0 0 0 7000 0 368445 0 0 0 Reginald Moore MD 300002 0 0 0 0 0 0 0 7000 0 307002 0 0 0 RONALD H DUBOW 266866 0 0 0 0 0 0 0 7000 0 273866 0 0 0 DR ERIC DRAVLAND 205277 0 0 0 10303 0 5200 0 5094 0 225874 0 0 0 Part I, Line 1a THE ORGANIZATION HAS A COUNTRY CLUB MEMBERSHIP IN THE CEO'S NAME. THE MEMBERSHIP IS USED STRICTLY FOR BUSINESS PURPOSES. Part I, Line 4a LAURA J EASTON (CEO) HAS A SECURED BENEFIT PLAN; THE AMOUNT FOR 2009 WAS $66,928. Part I, Line 6 SENIOR MANAGEMENT HAS AN INCENTIVE PROGRAM WHICH IS PARTIALLY EARNED BASED ON PROFIT MARGIN AND DAYS CASH ON HAND. THE EARNED INCENTIVE IS REVIEWED BY THE HR COMMITTEE OF THE BOARD AND APPROVED ANNUALLY. EMPLOYED PHYSICIANS ARE PAID ON A PRODUCTIVITY BASIS BASED ON RVU'S GENERATED IN THEIR PRACTICE OPERATIONS. THESE ARE TIED TO MGMA BENCHMARKS. LAURA EASTON SECURED BENEFIT PLAN DEFERRED COMPENSATION LOAN X 0 189168 0 1 1 PETER PURCELL MD START UP AGREEMENT/INCOME GUARANTEE X 350000 37376 0 1 1 226544 Form 990, Part VI, Section A, line 2 BOYD WILSON, JR. AND PARKER WILLIAMSON HAVE A BUSINESS RELATIONSHIP. PARKER WILLIAMSON AND DEBORAH MURRAY HAVE A BUSINESS RELATIONSHIP. Form 990, Part VI, Section B, line 11 THE FORM 990 WAS REVIEWED IN-DEPTH BY THE AUDIT AND COMPLIANCE COMMITTEE AND THEN PRESENTED TO THE FULL BOARD DURING THE AUDIT AND COMPLIANCE REPORT. THE FULL BOARD RECEIVED A COPY OF THE FORM 990 FOR THEIR REVIEW AND FOR ANY QUESTIONS. THE FULL BOARD VOTED FOR A FINAL APPROVAL OF THE FORM 990. Form 990, Part VI, Section B, line 12c THE AUDIT AND COMPLIANCE COMMITTEE ANNUALLY REVIEWS THE CONFLICT OF INTEREST STATEMENTS. THE MINUTES OF BOARD MEETINGS REFLECT ANY DECLARED CONFLICT OF INTERESTS AND ARE REVIEWED ON A REGULAR BASIS. THE CEO, CFO/CCO, AND BOARD CHAIR ARE OBSERVANT TO ANY POTENTIAL CONFLICTS OF INTERESTS, AS WELL AS THE CHAIR OF VARIOUS BOARD COMMITTEES. Form 990, Part VI, Section B, line 15 THE ORGANIZATION COMPLETES THE REBUTTABLE PRESUMPTION OF REASONABLENESS AS DESCRIBED IN TREASURY REGULATION 4958(6)(C) FOR EACH OFFICER AND KEY EMPLOYEE. THIS PROCESS IS PERFORMED BY AN OUTSIDE INDEPENDENT ENGAGED COMPENSATION SPECIALIST. THE FINDINGS ARE THEN PRESENTED TO THE HR COMMITTEE OF THE BOARD. THE FINDINGS ARE ULTIMATELY APPROVED BY THE BOARD. Form 990, Part VI, Section C, line 19 THE ORGANIZATION MAKES THESE DOCUMENTS AVAILABLE UPON REQUEST. THE ORGANIZATION CAN BE CONTACTED VIA THE ORGANIZATION'S WEBSITE. HALLMARK FAMILY PHYSICIANS INC 1766 CONNELLY SPRINGS ROAD LENOIR NC 28645 202088324 PHYSCIAN PRACTICE NC -296 0 N/A CALDWELL MEMORIAL HOSPITAL FOUNDATION INC PO Box 1890 LENOIR NC 28645 581935514 FOUNDATION NC 501(C)(3) 7 N/A GUARDIAN HEALTH SERVICE LLC 343 SECOND STREET HICKORY NC 28601 752950776 HOME HEALTHCARE NC N/A RELATED 4042102 1641733 0 1 0 0 1 0 0 0 0 0 0 0 0 1 1 0 1 0 0 0 CALDWELL MEMORIAL HOSPITAL FOUNDATION O 214031 CALDWELL MEMORIAL HOSPITAL FOUNDATION C 213148