2014-02-11T06:28:54-06:00 2013-06-30 560747981 DIXON HUGHES GOODMAN LLP 500 RIDGEFIELD COURT ASHEVILLE NC 28806 990 2012-07-01 540551711 COMMUNITY MEMORIAL HEALTHCENTER COMM 4344473151 125 BUENA VISTA CIRCLE PO BOX 90 SOUTH HILL VA 23970 W SCOTT BURNETTE 4344473151 2014-02-11 1 AMY BIBBY P00445891 8282542254 2012 2015-11-30 17:44:51Z W SCOTT BURNETTE 125 BUENA VISTA CIRCLE PO BOX 90 SOUTH HILL VA 23970 89175714 0 X WWW.CMH-SH.ORG X 1954 VA TO PROVIDE EXCELLENCE IN THE DELIVERY OF HEALTHCARE 21 17 965 102 0 0 300137 909654 89696978 85015100 392461 620529 178488 429847 90568064 86975130 0 0 0 0 43558441 38848909 0 0 98309 47112476 46951329 90670917 85800238 -102853 1174892 55092201 58235784 13877788 15492858 41214413 42742926 X TO PROVIDE EXCELLENCE IN THE DELIVERY OF HEALTHCARE. 0 0 79255945 85444947 COMMUNITY MEMORIAL HEALTHCENTER (CMH) IS A VITAL COMPONENT OF THE SOUTHSIDE VIRGINIA AREA, PROVIDING QUALITY CARE TO OUR PATIENTS, SERVING AS A VITAL PART OF THE SAFETY NET AND ENHANCING COMMUNITY HEALTH. OUR MISSION IS TO PROVIDE EXCELLENCE IN THE DELIVERY OF HEALTHCARE. WE ARE LED BY A VOLUNTEER 21 MEMBER BOARD OF DIRECTORS WHO REPRESENT ALL OF THE AREAS WE SERVE. CMH IS DESIGNATED AS A SOLE COMMUNITY HOSPITAL BY MEDICARE WHICH MEANS THAT WE ARE LOCATED IN A RURAL AREA AND 35 MILES FROM OTHER HOSPITALS. WE ARE ALSO DESIGNATED A DISPROPORTIONATE SHARE HOSPITAL BY MEDICARE WHICH MEANS THAT WE PROVIDE CARE TO A HIGHER LEVEL OF LOW-INCOME INDIVIDUALS. OUR PRIMARY SERVICE AREA OF MECKLENBURG COUNTY RANKS BELOW THE STATE AVERAGE IN PER CAPITA INCOME AND ABOVE THE STATE AVERAGE IN ESTIMATED TOTAL POPULATION IN POVERTY %.WE OFFER A FULL SPECTRUM OF SERVICES TO THE COMMUNITY INCLUDING IN-PATIENT ACUTE CARE, POST ACUTE AND LONG TERM CARE, OUT-PATIENT SERVICES, HOME HEALTH AND HOSPICE. LOCATED IN A HEALTH PROFESSIONAL SHORTAGE AREA, WE OPERATE TWO RURAL HEALTH CLINICS THAT BRING NEEDED PRIMARY CARE SERVICES TO THE COMMUNITY. WE HAVE ALSO MADE THE DECISION TO OPERATE PRACTICES IN THE SPECIALTY AREAS OF ORTHOPEDICS, SURGICAL SERVICES, WOMEN'S HEALTH SERVICES, ENT AND PAIN MANAGEMENT AS THESE SPECIALTY SERVICES OTHERWISE MIGHT NOT BE AVAILABLE FOR OUR COMMUNITY WITHOUT SIGNIFICANT TRAVEL. MEDICAL STAFF PRIVILEGES ARE EXTENDED TO ALL QUALIFIED PHYSICIANS BUT RECRUITING TO A RURAL AREA COMES WITH MANY CHALLENGES. OUR EMERGENCY DEPARTMENT HAD OVER 21,000 PATIENT VISITS LAST YEAR AND SEES PATIENTS REGARDLESS OF THEIR ABILITY TO PAY. WE OFFER FINANCIAL ASSISTANCE TO OUR UNINSURED PATIENTS. UNINSURED PATIENTS QUALIFYING WITH INCOME BELOW THE FEDERAL POVERTY LEVEL ARE OFFERED FREE CARE. UNINSURED PATIENTS WITH FAMILY INCOME UP TO 300% OF THE FEDERAL POVERTY LEVEL ARE OFFERED SLIDING SCALE DISCOUNTS. INFORMATION ABOUT OUR FINANCIAL ASSISTANCE PROGRAM IS POSTED ON OUR WEB-SITE, POSTED IN ALL REGISTRATION WAITING AREAS, PROVIDED TO UNINSURED PATIENTS AT REGISTRATION AND INCLUDED AS A NOTE ON ALL STATEMENTS SENT TO UNINSURED PATIENTS. WE EMPLOY A FINANCIAL SPECIALIST WHOSE RESPONSIBILITY IS TO ASSIST UNINSURED PATIENTS WITH OUR FINANCIAL ASSISTANCE PROGRAMS AS WELL AS TO ASSIST THE PATIENTS WITH APPLYING AND QUALIFYING FOR OTHER COVERAGE SUCH AS DISABILITY OR MEDICAID. WITH THE HELP OF SEVERAL GRANTS, CMH HAS BEEN ABLE TO OFFER FREE MAMMOGRAMS AND BREAST EXAMS TO UNDERSERVED WOMEN IN THE AREA, AND ASSIST QUALIFYING PATIENTS WITHOUT PRESCRIPTIVE COVERAGE IN OBTAINING PRESCRIPTIVE MEDICATIONS. AS THE GRANTS DON'T COVER TOTAL PROGRAM EXPENSES, CMH MUST SUPPLEMENT THE COSTS TO PROVIDE THESE SERVICES TO THE COMMUNITY. LAST YEAR, OUR MEDICATION ASSISTANCE PROGRAM, THE PHARMACY CONNECTION, HELPED 341 PATIENTS OBTAIN MORE THAN 2,156 MEDICATIONS WITH A RETAIL VALUE OF MORE THAN $2 MILLION.AS A LOCALLY OWNED AND CONTROLLED ORGANIZATION, ALL SURPLUS FUNDS GO BACK INTO THE OPERATION OF THE HEALTHCENTER TO MAINTAIN THE FACILITY AND UPDATE EQUIPMENT AND TECHNOLOGY. IN THE PAST YEAR THIS HAS ALLOWED US TO PURCHASE EQUIPMENT FOR A NEW UROLOGY PRACTICE INCLUDING A CYSTOSCOPE TOWER, CYSTO PROCEDURAL TABLE AND MEDIVATOR UNIT TO SERVE THESE PATIENTS. WE ALSO UPDATED OUR COMPUTER SYSTEMS IN OUR LONG TERM CARE FACILITY.CMH ALSO BELONGS TO AND SUPPORTS 7 CHAMBERS OF COMMERCE AND PARTICIPATES IN THEIR COMMUNITY EVENTS. OUR INVOLVEMENT HELPS SUPPORT COMMUNITY GROWTH AND WE SHARE MANY HEALTH RELATED EVENT NOTICES AT THESE MEETINGS. WE ALSO SUPPORT MANY OF THEIR SPECIAL EVENTS AND LOCATE WELLNESS AND SCREENING BOOTHS THERE.HOSPITALS PLAY A CRITICAL ROLE IN THEIR COMMUNITY. AS MAJOR EMPLOYERS AND PURCHASERS, HOSPITALS ARE ENGINES OF ECONOMIC GROWTH AND STABILITY. A STRONG COMMUNITY HOSPITAL HELPS TO RECRUIT BUSINESS AND INDUSTRY TO THE AREA AND HELPS ATTRACT AND RETAIN COLLEGE GRADUATES AND SKILLED CRAFTSMEN. CMH IS THE LARGEST SINGLE EMPLOYER IN THE AREA PROVIDING JOBS AT A WIDE RANGE OF SKILL LEVELS FOR MORE THAN 900 PEOPLE FROM OVER 12 VIRGINIA AND NORTH CAROLINA LOCALITIES. WE CONTRIBUTE TO THE TAX BASE THROUGH WAGES, SALARIES AND BENEFITS TOTALING NEARLY $43 MILLION OVER THE PAST YEAR. CMH AND OUR EMPLOYEES PURCHASE GOODS AND SERVICES LOCALLY, CREATING INCOME AND JOBS FOR OTHER BUSINESSES IN THE COMMUNITY.BY PARTICIPATING ON THE TOWN REVITALIZATION COMMITTEE, CMH HAS BEEN ABLE TO PROVIDE SUPPORT TO EFFORTS TO MODERNIZE THE TOWN IN ORDER TO MAKE IT MORE ATTRACTIVE TO NEW BUSINESSES. BY PROVIDING JOBS IN THE REGION, RESIDENTS HAVE A BETTER OPPORTUNITY TO RECEIVE PREVENTATIVE CARE THROUGH THEIR HEALTH INSURANCE PROGRAMS. THE COMMUNITY IS ALSO INVESTED IN COMMUNITY MEMORIAL HEALTHCENTER. VOLUNTEERS ARE A VITAL PART OF OUR HEALTH CARE TEAM, GOVERNANCE AND FUNDRAISING. MORE THAN 100 VOLUNTEERS SERVE IN DIFFERENT CAPACITIES. THE MEN AND WOMEN OF OUR AUXILIARY VOLUNTEER THOUSANDS OF HOURS EACH YEAR AND PROVIDE A WIDE RANGE OF SERVICES TO STRENGTHEN OUR HOSPITAL AND ENHANCE THE QUALITY OF CARE FOR PATIENTS AND FAMILIES. THE COMMUNITY ALSO SUPPORTS THE OPERATION OF CMH BY SUPPORT OF THE CMH FOUNDATION. THE CMH FOUNDATION IS ALSO LED BY A VOLUNTEER BOARD OF DIRECTORS AND AIMS TO RAISE FUNDS TO ALLOW OUR HEALTHCENTER TO OFFER THE BEST POSSIBLE CARE AND MAINTAIN STATE-OF-THE-ART FACILITIES AND TECHNOLOGIES TO BETTER SERVE OUR COMMUNITY. 79255945 1 1 0 1 0 0 0 0 0 0 1 0 0 0 1 1 0 1 0 0 0 0 0 0 0 0 1 1 0 0 1 1 0 0 0 0 0 0 0 0 1 0 0 0 0 0 1 1 1 1 0 0 1 55 0 1 965 1 0 0 0 0 0 0 0 0 0 0 X 21 17 0 0 0 0 0 0 0 1 1 0 0 1 1 1 1 1 1 1 1 0 VA X HOSPITAL ADMINISTRATION 4344473151 125 BUENA VISTA CIRCLE SOUTH HILL VA 23970 W SCOTT BURNETTE 40.00 1.00 X X 375258 0 32725 DAVID BROWN 44.10 X 430596 0 26503 MANHAL SALEEBY 40.00 X 398353 0 15819 ANTHONY ADAMS 43.70 X 332091 0 15767 G NELSON BAIRD 1.00 X 0 0 0 EMILY BROOKS 1.00 X 0 0 0 STEVEN H CREEDLE 1.00 X 0 0 0 DIANNE DOOKHAN MD 1.00 X 0 0 0 CHARLES L DUCKWORTH 1.00 X 0 0 0 ROBERT H ENGLISH 1.00 X 0 0 0 SYLVIA HALL 1.00 X 0 0 0 ALFRED HARDEE 1.00 X 0 0 0 H BAGLEY HAWTHORNE 1.00 X 0 0 0 HENRY TYLER HOWERTON 1.00 X 0 0 0 LAVERNE JOLLY 1.00 X 0 0 0 JOHN LEE JR 1.00 X 0 0 0 WAYNE PARRISH 1.00 X 0 0 0 CINDY PECHT 1.00 X 0 0 0 JERRY REYNOLDS 1.00 X 0 0 0 ROBERT SATCHER SR 1.00 X 0 0 0 LEWIS THOMPSON 1.00 X 0 0 0 WILLAM WILKINSON 1.00 X 0 0 0 JOYCE TUDOR 1.00 X 0 0 0 WILLIAM WELLS JR 1.00 X 0 0 0 EMMETT WILLIAMS JR 1.00 X 0 0 0 KENNETH LIBBY JR 40.00 X 171643 0 18988 URSULA BUTTS 40.00 X 152874 0 18370 EDWARD BRANDENBURG JR 40.00 X 158045 0 18890 WILLOUGHBY HUNDLEY III 42.50 X 322888 0 15753 JAMES FOREST-LAM 43.30 X 322569 0 15747 DESIDERION RIMON 40.00 X 287155 0 15801 MICHAEL BROOKS 40.00 X 268035 0 12455 RAHUL WADNERKAR 43.30 X 243862 0 15729 3463369 0 222547 25 0 1 0 EAGLE HOSPITAL PHYSICIANS 16000 N DALLAS PARKWAY SUITE 450 DALLAS TX 75248 HOSPITAL SERVICES 2488272 MCV PHYSICIANS PO BOX 79203 BALTIMORE MD 21279 ORTHOPEDIC/UROLOGICAL PHYSICIAN SERVICES 1048288 SOUTH HILL FAMILY MEDICINE PO BOX 659 / 514 WEST ATLANTIC ST SOUTH HILL VA 23970 PHYSICIAN OFFICE/MGMT SVCS FOR CHASE CIT 528000 STEPHEN GOERZ MD 120 COLEMAN COURT PAWLEYS ISLAND SC 29585 ANESTHESIA SERVICES 375000 MEDSTAT INC 9003 WALHALA CIRCLE RICHMOND VA 23236 ED PHYSICIAN SERVICES 331959 7 718396 191258 909654 PATIENT SERVICE REVENUE 621400 83253127 83253127 MEANINGFUL USE 900099 1449565 1449565 AUXILIARY REVENUE 900099 192933 192933 LIFELINE INCOME 900099 102764 102764 MEDICAL RECORDS 900099 16681 16681 30 30 85015100 449983 449983 84273 0 84273 84273 84273 2371130 2194253 6331 176877 -6331 170546 170546 MISCELLANEOUS 621400 323610 323610 DISCOUNTS AND REBATES 900099 21964 21964 345574 86975130 85444947 0 620529 2187010 1164816 1022194 412901 412901 28881334 27488345 1360050 32939 5111930 4719752 386829 5349 2255734 2082678 170696 2360 6825517 6297517 528000 333100 333100 42260 42260 47924 47924 7605424 6300184 1291929 13311 1836760 1418232 384400 34128 23887 23052 835 3464940 3247898 212350 4692 128511 111748 15325 1438 108913 82816 25855 242 112438 112438 2736551 2736551 616911 33009 583902 BAD DEBT EXPENSE 14859990 14859990 MEDICAL SUPPLIES 7933619 7933373 246 OTHER EXPENSE 224564 180625 40089 3850 RECRUITMENT 50020 50020 85800238 79255945 6445984 98309 2360 2310 17090513 17377906 10892584 11491737 717141 921330 990611 1046995 57298931 41769422 16515605 15529509 8219198 8827725 562402 2889228 101787 149044 55092201 58235784 5206611 6645303 3335861 3878377 5335316 4969178 13877788 15492858 X 41146807 42742926 5666 0 61940 0 41214413 42742926 55092201 58235784 1174892 353621 0 X X 0 1 X 1 0 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 0 0 0 0 0 0 0 0 1 12107 12107 0 EXPLANATION OF LOBBYING ACTIVITIES: PART II-B, LINE 1: THE ORGANIZATION WAS PART OF SEVERAL ASSOCIATIONS THAT ENGAGED IN LOBBYING ON BEHALF OF ITS MEMBERS. THE FOLLOWING IS A LIST OF THE ORGANIZATIONS AND MEMBER DUES USED FOR LOBBYING. VIRGINIA HOSPITAL & HEALTHCARE ASSOCIATION $6,076 AMERICAN HOSPITAL ASSOCIATION $4,667 VIRGINIA HEALTHCARE ASSOCIATION $1,029 VIRGINIA ASSOCIATION FOR HOMECARE & HOSPICE $335 1368245 1368245 23473860 17986612 5487248 1591402 965539 625863 29921201 22817271 7103930 944223 944223 15529509 PATIENT FUNDS 32467 INTEREST 4415 ESTIMATED LIABILITY FOR UNPAID CLAIMS 1245000 SETTLEMENTS DUE TO THIRD PARTY PROGRAMS 3687296 4969178 X 72707103 353621 -14579388 -14225767 86932870 42260 42260 86975130 70810037 31084 31084 70778953 42260 14979025 15021285 85800238 DESCRIPTION OF UNCERTAIN TAX POSITIONS UNDER FIN 48: PART X, LINE 2: THE HEALTHCENTER AND THE FOUNDATION ARE TAX-EXEMPT ORGANIZATIONS AS DESCRIBED IN SECTION 501(C)(3) OF THE INTERNAL REVENUE CODE; ACCORDINGLY, THE ACCOMPANYING COMBINED FINANCIAL STATEMENTS DO NOT REFLECT A PROVISION OR LIABILITY FOR FEDERAL AND STATE INCOME TAXES. THE HEALTHCENTER AND FOUNDATION HAVE DETERMINED THAT THEY DO NOT HAVE ANY MATERIAL UNRECOGNIZED TAX BENEFITS OR OBLIGATIONS AS OF JUNE 30, 2013. THE HEALTHCENTER AND FOUNDATION BELIEVE THEY ARE NO LONGER SUBJECT TO INCOME TAX EXAMINATIONS FOR YEARS PRIOR TO JUNE 30, 2010. PART XI, LINE 2D - OTHER ADJUSTMENTS: EXPENSES NET WITH REVENUES -14,979,025. FOUNDATION INCOME 1,118,448. AUDITOR ADJUSTMENT 125. CONTRIBUTION EXPENSE NET WITH REVENUES -718,936. PART XII, LINE 2D - OTHER ADJUSTMENTS: FOUNDATION EXPENSES 31,084. PART XII, LINE 4B - OTHER ADJUSTMENTS: EXPENSES NET WITH REVENUES 14,979,025. 1 1 1 X 1 X 0 1 0 1 1 1118261 1118261 0.01580 14666030 10029645 4636385 0.06540 15784291 10029645 5754646 0.08120 154818 154818 0.00220 158395 158395 0.00220 35370 35370 0.00050 348583 348583 0.00490 16132874 10029645 6103229 0.08610 910 910 0.00000 2837 2837 0.00000 3747 3747 0 4153842 977909 32259399 35001538 -2742139 X 1 0 1 1 COMMUNITY MEMORIAL HEALTHCENTER

125 BUENA VISTA CIRCLE PO BOX 90 SOUTH HILL VA 23970

X X X SKILLED NURSING/LONG TERM CARE FACILITY COMMUNITY MEMORIAL HEALTHCENTER 1 1 X X X X X X X X 1 0 1 X X X X X X X X 0 0 1 1 100.000000000000 1 300.000000000000 1 X X X 1 1 X X X X X X 1 0 1 X 0 0 7 CMH WOMEN'S HEALTH SERVICES LLC

140 EAST FERRELL STREET SOUTH HILL VA 23970

HEALTHCARE PRACTICE CMH ORTHOPEDIC SERVICES LLC

420 BRACEY LANE SOUTH HILL VA 23970

HEALTHCARE PRACTICE CMH SURGICAL SERVICES LLC

416 DURANT STREET SOUTH HILL VA 23970

HEALTHCARE PRACTICE CMH PAIN MANAGEMENT SERVICES LLC

413 BRACEY LANE SOUTH HILL VA 23970

HEALTHCARE PRACTICE CLARKSVILLE PRIMARY CARE CENTER

61 BURLINGTON DRIVE CLARKSVILLE VA 23927

RHC CHASE CITY PRIMARY CARE CENTER LLC

200 E 5TH STREET CHASE CITY VA 23924

RHC CMH EAR NOSE THROAT & ALLERGY LLC

518 W ATLANTIC STREET SOUTH HILL VA 23970

HEALTHCARE PRACTICE PART I, LINE 7: THE ORGANIZATION USED WORKSHEET 2 OF THE 2012 SCHEDULE H INSTRUCTIONS IN DETERMINING THE COSTS ASSOCIATED WITH UNCOMPENSATED CARE. PART I, LINE 7, COLUMN (F): THE BAD DEBT EXPENSE INCLUDED ON FORM 990, PART IX, LINE 25, COLUMN (A), BUT SUBTRACTED FOR PURPOSES OF CALCULATING THE PERCENTAGE IN THIS COLUMN IS $ 14859990. PART III, LINE 4: BAD DEBT FOR PURPOSES OF LINE 2 IS PRESENTED AT ESTIMATED COST. THE COST OF THE BAD DEBT CHARGES WAS CALCULATED USING IRS WORKSHEET 2, RATIO OF PATIENT CARE COST TO CHARGES.RATIONALE FOR INCLUDING A PORTION OF BAD DEBT AS COMMUNITY BENEFIT:THE ESTIMATED AMOUNT OF BAD DEBT EXPENSE ATTRIBUTABLE TO PATIENTS OTHERWISE ELIGIBLE UNDER THE CHARITY CARE POLICY WAS DETERMINED BY REVIEWING THE "EMPLOYER" ON ALL PATIENT ACCOUNTS THAT WERE WRITTEN OFF TO BAD DEBT EXPENSE. THOSE ACCOUNTS THAT LISTED NO EMPLOYER WERE ASSUMED TO HAVE QUALIFIED UNDER THE CHARITY POLICY BECAUSE OF LACK OF INCOME FROM BEING UNEMPLOYED.FINANCIAL STATEMENT FOOTNOTE FOR BAD DEBT:DURING FISCAL YEAR 2013, THE HEALTHCENTER ADOPTED FASB ACCOUNTING STANDARDS UPDATE 2011-07, PRESENTATION AND DISCLOSURE OF PATIENT SERVICE REVENUE, PROVISIONS FOR BAD DEBTS, AND THE ALLOWANCE FOR DOUBTFUL ACCOUNTS FOR CERTAIN HEALTH CARE ENTITIES. IN CONJUNCTION WITH THE ADOPTION, THE HEALTHCENTER RECLASSIFIED THE PROVISION FOR BAD DEBTS ASSOCIATED WITH PATIENT SERVICE REVENUE FROM AN OPERATING EXPENSE TO A DEDUCTION FROM PATIENT SERVICE REVENUE (NET OF CONTRACTUAL ALLOWANCES AND DISCOUNTS). THE 2012 PROVISION FOR BAD DEBTS HAS BEEN RECLASSIFIED TO CONFORM WITH THE 2013 PRESENTATION. ACCORDINGLY, THE PROVISION FOR BAD DEBT IS INCLUDED AS A COMPONENT OF NET PATIENT SERVICE REVENUE IN THE COMBINED STATEMENTS OF OPERATIONS FOR 2013 AND 2012. PART III, LINE 8: MEDICARE ALLOWABLE COST WAS CALCULATED USING A COMBINATION OF COST FROM FILED FY 2013 MEDICARE COST REPORT; COST TO CHARGE RATIOS FROM FILED FY 2013 MEDICARE COST REPORT; AND A CALCULATION OF DIRECT COSTS PLUS ALLOCATED OVERHEAD. THE SHORTFALL IS RELATED TO PROVIDING SERVICES TO OUR RURAL COMMUNITY THAT OUR BOARD OF DIRECTORS HAS DETERMINED TO BE NECESSARY FOR THE BENEFIT OF THE COMMUNITY. THESE SERVICES INCLUDE OPERATING PHYSICIAN PRACTICES BECAUSE THE SERVICES WOULD NOT BE AVAILABLE LOCALLY IF NOT PROVIDED BY THE ORGANIZATION. COMMUNITY MEMORIAL HEALTHCENTER COULD CEASE TO PROVIDE THE SERVICES BUT OUR COMMUNITY WOULD THEN BE REQUIRED TO TRAVEL UP TO AN HOUR TO RECEIVE THE SERVICES IN ANOTHER COMMUNITY. PART III, LINE 9B: COMMUNITY MEMORIAL HEALTHCENTER'S COLLECTION POLICY STATES THAT ALL UNINSURED PATIENTS WILL BE REFERRED TO OUR FINANCIAL SPECIALIST TO BE SCREENED FOR FINANCIAL ASSISTANCE CONSISTENT WITH OUR INDIGENT AND CHARITY CARE PROGRAMS. INFORMATION IS PROVIDED UPON REGISTRATION TO ALL UNINSURED PATIENTS INFORMING THEM OF OUR FINANCIAL ASSISTANCE PROGRAMS. A NOTE IS ALSO INCLUDED ON STATEMENTS SENT TO UNINSURED PATIENTS REGARDING HOW TO REQUEST INFORMATION ABOUT FINANCIAL ASSISTANCE. THE POLICY FURTHER STATES THAT WE WILL UNDERTAKE REASONABLE EFFORTS TO ENSURE THAT FINANCIAL ASSISTANCE WAS OFFERRED BEFORE ANY COLLECTION AGENCY ASSIGNMENT. COMMUNITY MEMORIAL HEALTHCENTER PART V, SECTION B, LINE 1J: THE NEEDS ASSESSMENT ALSO DESCRIBED INSIGHT FROM COMMUNITY STAKEHOLDERS REGARDING IMPORTANT HEALTH CONCERNS, SIGNIFICANT SERVICE GAPS, SPECIALTY SERVICE GAPS, AND IDEAS FOR ADDRESSING THESE CONCERNS AND GAPS. COMMUNITY MEMORIAL HEALTHCENTER PART V, SECTION B, LINE 3: THE HEALTHCENTER TOOK INPUT FROM COMMUNITY STAKEHOLDERS THAT INCLUDED REPRESENTATIVES OF SERVICE ORGANIZATIONS, BUSINESSES, COMMUNITY LEADERS, SCHOOLS, CHURCH LEADERS, MEDICAL SERVICE ORGANIZATIONS, AND PHYSICIANS. COMMUNITY MEMORIAL HEALTHCENTER PART V, SECTION B, LINE 7: THE NEED FOR INCREASED CARDIOLOGY AND PULMONOLOGY SERVICES WERE IDENTIFIED AND HAVE BEEN INCLUDED IN OUR FUTURE AFFILIATION PLANS. PART VI, LINE 2: A COMMUNITY NEEDS ASSESSMENT IS CONDUCTED ONCE EVERY THREE YEARS. WE WORK WITH LOCAL PARTNERS AND AGENCIES TO GATHER DATA TO COMPLETE AN ECONOMIC AND WORKFLOW PROFILE OF THE SERVICE AREA. FEEDBACK FROM THE COMMUNITY IS SOUGHT BY UTILIZING FOCUS GROUPS, COMMUNITY FORUMS AND BY MEETINGS WITH OTHER HEALTH CARE PROVIDERS. INFORMATION IS ALSO SOUGHT FROM THE MEMBERS OF THE BOARD OF DIRECTORS WHO REPRESENT THE COMMUNITIES WE SERVE. PART VI, LINE 3: COMMUNITY MEMORIAL HEALTHCENTER TAKES MANY STEPS TO ENSURE THAT ITS COMMUNITY IS MADE AWARE OF THE FINANCIAL ASSISTANCE PROGRAMS AVAILABLE TO IT. OUR POLICY FOR FINANCIAL ASSISTANCE, INCLUDING THE APPLICATION, IS AVAILABLE ON OUR WEBSITE. A NOTICE THAT THE FINANCIAL ASSISTANCE IS AVAILABLE IS POSTED AT EACH REGISTRATION AREA. OUR PATIENT FINANCIAL BROCHURE, WHICH DESCRIBES OUR REGISTRATION REQUIREMENTS, BILLING PROCESS AND FINANCIAL ASSISTANCE PROGRAMS, IS PROVIDED TO EACH UNISNSURED PATIENT AT REGISTRATION AND IS ALSO AVAILABLE IN ALL REGISTRATION AREAS AND WAITING ROOMS. THE HOSPITAL EMPLOYS A FINANCIAL SPECIALIST WHOSE RESPONSIBILITY IS TO ASSIST OUR PATIENTS WITH OUR FINANCIAL ASSISTANCE PROGRAMS AND WITH OTHER TYPES OF HEALTHCARE COVERAGE INCLUDING MEDICAID AND DISABILITY APPLICATIONS. THE BUSINESS CARD FOR THE FINANCIAL SPECIALIST IS PROVIDED TO EACH UNISNSURED PATIENT AT REGISTRATION. THE FINANCIAL SPECIALIST ATTEMPTS TO VISIT EACH UNINSURED PATIENT WHO HAS BEEN ADMITTED AS AN INPATIENT TO THE HEALTHCENTER WHILE THEY ARE STILL A PATIENT TO DISCUSS FINANCIAL ASSISTANCE PROGRAMS. A NOTE IS INCLUDED ON EACH STATEMENT THAT IS SENT TO AN UNINSURED PATIENT NOTIFYING THEM OF FINANCIAL PROGRAM AND WHO THEY CAN CONTACT FOR ASSISTANCE. PART VI, LINE 4: COMMUNITY MEMORIAL HEALTHCENTER IS A RURAL, NON-PROFIT HEALTH SYSTEM LOCATED IN SOUTH CENTRAL VIRGINIA. WE SERVE THE RURAL COUNTIES OF MECKLENBURG, BRUNWICK AND LUNENBURG IN VIRGINIA AS WELL AS WARREN COUNTY, NORTH CAROLINA. OUR PRIMARY MARKET AREA IS MECKLENBURG COUNTY. MECKLENBURG COUNTY HAS A POPULATION OF 32,727. THE PER CAPITA INCOME OF $19,795 IS ABOUT TWO-THIRDS OF THE STATE AVERAGE. THE ESTIMATED TOTAL POPULATION IN POVERTY PERCENTAGE IS 21% - WELL ABOVE THE STATE AVERAGE OF 11%. COMMUNITY MEMORIAL HEALTHCENTER QUALIFIES AS A SOLE COMMUNITY HOSPITAL FOR MEDICARE REGULATIONS AS THE CLOSEST HOSPITAL IS 35 MILES AWAY. PART VI, LINE 5: COMMUNITY MEMORIAL HEALTHCENTER (CMH) IS A VITAL COMPONENT OF THE SOUTHSIDE VIRGINIA AREA, PROVIDING QUALITY CARE TO OUR PATIENTS, SERVING AS A VITAL PART OF THE SAFETY NET AND ENHANCING COMMUNITY HEALTH. OUR MISSION IS TO PROVIDE EXCELLENCE IN THE DELIVERY OF HEALTHCARE. WE ARE LED BY A VOLUNTEER 21 MEMBER BOARD OF DIRECTORS WHO REPRESENT ALL OF THE AREAS WE SERVE. CMH IS DESIGNATED AS A SOLE COMMUNITY HOSPITAL BY MEDICARE WHICH MEANS THAT WE ARE LOCATED IN A RURAL AREA AND 35 MILES FROM OTHER HOSPITALS. WE ARE ALSO DESIGNATED A DISPROPORTIONATE SHARE HOSPITAL BY MEDICARE WHICH MEANS THAT WE PROVIDE CARE TO A HIGHER LEVEL OF LOW-INCOME INDIVIDUALS. OUR PRIMARY SERVICE AREA OF MECKLENBURG COUNTY RANKS BELOW THE STATE AVERAGE IN PER CAPITA INCOME AND ABOVE THE STATE AVERAGE IN ESTIMATED TOTAL POPULATION IN POVERTY PERCENTAGE.WE OFFER A FULL SPECTRUM OF SERVICES TO THE COMMUNITY INCLUDING IN-PATIENT ACUTE CARE, POST ACUTE AND LONG TERM CARE, OUT-PATIENT SERVICES, HOME HEALTH AND HOSPICE. LOCATED IN A HEALTH PROFESSIONAL SHORTAGE AREA, WE OPERATE TWO RURAL HEALTH CLINICS THAT BRING NEEDED PRIMARY CARE SERVICES TO THE COMMUNITY. WE HAVE ALSO MADE THE DECISION TO OPERATE PRACTICES IN THE SPECIALTY AREAS OF ORTHOPEDICS, SURGICAL SERVICES, WOMEN'S HEALTH SERVICES, ENT AND PAIN MANAGEMENT AS THESE SPECIALTY SERVICES OTHERWISE MIGHT NOT BE AVAILABLE FOR OUR COMMUNITY WITHOUT SIGNIFICANT TRAVEL. MEDICAL STAFF PRIVILEGES ARE EXTENDED TO ALL QUALIFIED PHYSICIANS BUT RECRUITING TO A RURAL AREA COMES WITH MANY CHALLENGES. OUR EMERGENCY DEPARTMENT HAD OVER 21,000 PATIENT VISITS LAST YEAR AND SEES PATIENTS REGARDLESS OF THEIR ABILITY TO PAY. WE OFFER FINANCIAL ASSISTANCE TO OUR UNINSURED PATIENTS. UNINSURED PATIENTS QUALIFYING WITH INCOME BELOW THE FEDERAL POVERTY LEVEL ARE OFFERED FREE CARE. UNINSURED PATIENTS WITH FAMILY INCOME UP TO 300% OF THE FEDERAL POVERTY LEVEL ARE OFFERED SLIDING SCALE DISCOUNTS. INFORMATION ABOUT OUR FINANCIAL ASSISTANCE PROGRAM IS POSTED ON OUR WEB-SITE, POSTED IN ALL REGISTRATION WAITING AREAS, PROVIDED TO UNINSURED PATIENTS AT REGISTRATION AND INCLUDED AS A NOTE ON ALL STATEMENTS SENT TO UNINSURED PATIENTS. WE EMPLOY A FINANCIAL SPECIALIST WHOSE RESPONSIBILITY IS TO ASSIST UNINSURED PATIENTS WITH OUR FINANCIAL ASSISTANCE PROGRAMS AS WELL AS TO ASSIST THE PATIENTS WITH APPLYING AND QUALIFYING FOR OTHER COVERAGE SUCH AS DISABILITY OR MEDICAID. WITH THE HELP OF SEVERAL GRANTS, CMH HAS BEEN ABLE TO OFFER FREE MAMMOGRAMS AND BREAST EXAMS TO UNDERSERVED WOMEN IN THE AREA, AND ASSIST QUALIFYING PATIENTS WITHOUT PRESCRIPTIVE COVERAGE IN OBTAINING PRESCRIPTIVE MEDICATIONS. AS THE GRANTS DON'T COVER TOTAL PROGRAM EXPENSES, CMH MUST SUPPLEMENT THE COSTS TO PROVIDE THESE SERVICES TO THE COMMUNITY. LAST YEAR, OUR MEDICATION ASSISTANCE PROGRAM, THE PHARMACY CONNECTION, HELPED 341 PATIENTS OBTAIN MORE THAN 2,156 MEDICATIONS WITH A RETAIL VALUE OF MORE THAN $2 MILLION.AS A LOCALLY OWNED AND CONTROLLED ORGANIZATION, ALL SURPLUS FUNDS GO BACK INTO THE OPERATION OF THE HEALTHCENTER TO MAINTAIN THE FACILITY AND UPDATE EQUIPMENT AND TECHNOLOGY. IN THE PAST YEAR THIS HAS ALLOWED US TO PURCHASE EQUIPMENT FOR A NEW UROLOGY PRACTICE INCLUDING A CYSTOSCOPE TOWER, CYSTO PROCEDURAL TABLE AND MEDIVATOR UNIT TO SERVE THESE PATIENTS. WE ALSO UPDATED OUR COMPUTER SYSTEMS IN OUR LONG TERM CARE FACILITY.CMH ALSO BELONGS TO AND SUPPORTS 7 CHAMBERS OF COMMERCE AND PARTICIPATES IN THEIR COMMUNITY EVENTS. OUR INVOLVEMENT HELPS SUPPORT COMMUNITY GROWTH AND WE SHARE MANY HEALTH RELATED EVENT NOTICES AT THESE MEETINGS. WE ALSO SUPPORT MANY OF THEIR SPECIAL EVENTS AND LOCATE WELLNESS AND SCREENING BOOTHS THERE.HOSPITALS PLAY A CRITICAL ROLE IN THEIR COMMUNITY. AS MAJOR EMPLOYERS AND PURCHASERS, HOSPITALS ARE ENGINES OF ECONOMIC GROWTH AND STABILITY. A STRONG COMMUNITY HOSPITAL HELPS TO RECRUIT BUSINESS AND INDUSTRY TO THE AREA AND HELPS ATTRACT AND RETAIN COLLEGE GRADUATES AND SKILLED CRAFTSMEN. CMH IS THE LARGEST SINGLE EMPLOYER IN THE AREA PROVIDING JOBS AT A WIDE RANGE OF SKILL LEVELS FOR MORE THAN 900 PEOPLE FROM OVER 12 VIRGINIA AND NORTH CAROLINA LOCALITIES. WE CONTRIBUTE TO THE TAX BASE THROUGH WAGES, SALARIES AND BENEFITS TOTALING NEARLY $43 MILLION OVER THE PAST YEAR. CMH AND OUR EMPLOYEES PURCHASE GOODS AND SERVICES LOCALLY, CREATING INCOME AND JOBS FOR OTHER BUSINESSES IN THE COMMUNITY.BY PARTICIPATING ON THE TOWN REVITALIZATION COMMITTEE, CMH HAS BEEN ABLE TO PROVIDE SUPPORT TO EFFORTS TO MODERNIZE THE TOWN IN ORDER TO MAKE IT MORE ATTRACTIVE TO NEW BUSINESSES. BY PROVIDING JOBS IN THE REGION, RESIDENTS HAVE A BETTER OPPORTUNITY TO RECEIVE PREVENTATIVE CARE THROUGH THEIR HEALTH INSURANCE PROGRAMS. THE COMMUNITY IS ALSO INVESTED IN COMMUNITY MEMORIAL HEALTHCENTER. VOLUNTEERS ARE A VITAL PART OF OUR HEALTH CARE TEAM, GOVERNANCE AND FUNDRAISING. MORE THAN 100 VOLUNTEERS SERVE IN DIFFERENT CAPACITIES. THE MEN AND WOMEN OF OUR AUXILIARY VOLUNTEER THOUSANDS OF HOURS EACH YEAR AND PROVIDE A WIDE RANGE OF SERVICES TO STRENGTHEN OUR HOSPITAL AND ENHANCE THE QUALITY OF CARE FOR PATIENTS AND FAMILIES. THE COMMUNITY ALSO SUPPORTS THE OPERATION OF CMH BY SUPPORT OF THE CMH FOUNDATION. THE CMH FOUNDATION IS ALSO LED BY A VOLUNTEER BOARD OF DIRECTORS AND AIMS TO RAISE FUNDS TO ALLOW OUR HEALTHCENTER TO OFFER THE BEST POSSIBLE CARE AND MAINTAIN STATE-OF-THE-ART FACILITIES AND TECHNOLOGIES TO BETTER SERVE OUR COMMUNITY. PART VI, LINE 6: THE ORGANIZATION IS NOT PART OF AN AFFILIATED HEALTH CARE SYSTEM. REPORTS FILED WITH STATES PART VI, LINE 7 VA X X 0 0 X X X X 0 0 0 0 0 0 0 1 0 W SCOTT BURNETTE 328148 0 19890 0 27220 0 16500 0 16225 0 407983 0 0 0 DAVID BROWN 330883 0 12750 0 86963 0 14000 0 12503 0 457099 0 0 0 MANHAL SALEEBY 369843 0 0 0 28510 0 0 0 15819 0 414172 0 0 0 ANTHONY ADAMS 293005 0 0 0 39086 0 0 0 15767 0 347858 0 0 0 KENNETH LIBBY JR 154562 0 2784 0 14297 0 6500 0 12488 0 190631 0 0 0 URSULA BUTTS 138445 0 3875 0 10554 0 5889 0 12481 0 171244 0 0 0 EDWARD BRANDENBURG JR 147063 0 2584 0 8398 0 6387 0 12503 0 176935 0 0 0 WILLOUGHBY HUNDLEY III 283756 0 0 0 39132 0 0 0 15753 0 338641 0 0 0 JAMES FOREST-LAM 274096 0 0 0 48473 0 0 0 15747 0 338316 0 0 0 DESIDERION RIMON 269731 0 0 0 17424 0 0 0 15801 0 302956 0 0 0 MICHAEL BROOKS 261647 0 0 0 6388 0 0 0 12455 0 280490 0 0 0 RAHUL WADNERKAR 234622 0 0 0 9240 0 0 0 15729 0 259591 0 0 0 PART I, LINE 1B THE ORGANIZATION HAS A BOARD APPROVED PLAN FOR THE CRITERIA AND AMOUNTS. THE PLAN IS REVIEWED EVERY THREE YEARS BY A COMPENSATION CONSULTANT. PART I, LINE 7 THE CEO AND OFFICERS HAVE AN INCENTIVE PLAN APPROVED ANNUALLY IN ADVANCE BY THE CORPORATE COMPLIANCE COMMITTEE OF THE BOARD. A THE INDUSTRIAL DEVELOPMENT AUTHORITY OF THE TOWN OF SOUTH HILL 546001614 2006-03-30 1170000 ACQUIRING CERTAIN EQUIPMENT 0 0 0 B THE INDUSTRIAL DEVELOPMENT AUTHORITY OF THE TOWN OF SOUTH HILL 546001614 2003-12-19 4000000 CURRENT REFUNDING 0 0 0 A 815108 1170000 1170000 2006 0 0 1 1 B 2108398 4000000 4000000 1995 1 0 1 1 A 0 0 0 0 0.00000 0.00000 0.00000 0 0 0 A 0 0 1 0 0 0 0 0 0 B 0 0 1 0 1 0 0 0 0 PART II, LINE 11: OTHER SPENT PROCEEDS THE AMOUNT ON LINE 11 FOR BOND B REPRESENTS AMOUNTS USED TO CURRENTLY REFUND A PRIOR ISSUE DATED IN 1995. JUDY BRANDENBURG SPOUSE OF EDWARD BRANDENBURG, VP PROFESSIONAL SERVICES 59958 EMPLOYEE COMPENSATION 0 MICHAEL BROOKS SPOUSE OF EMILY Y. BROOKS, BOARD TRUSTEE 268035 EMPLOYEE COMPENSATION 0 MARI ADAMS SPOUSE OF ANTHONY C. ADAMS MD, BOARD TRUSTEE 84908 EMPLOYEE COMPENSATION 0 FORM 990, PART VI, SECTION A, LINE 1 THE EXECUTIVE COMMITTEE SHALL CONSIST OF THE CHAIRMAN OF THE BOARD AS CHAIRMAN, THE VICE CHAIRMAN, THE PRESIDENT, THE SECRETARY, THE TREASURER, THE CURRENT CHIEF OF STAFF, THE CHAIRMAN OF ANY STANDING COMMITTEE OF THE BOARD NOT PREVIOUSLY ENUMERATED AND NOT MORE THAN THREE APPOINTED DIRECTORS AND GENERAL COUNSEL TO THE HEALTHCENTER, WHO SHALL SERVE AS A NON-VOTING MEMBER. THE COMMITTEE SHALL CARRY OUT THE DUTIES AND EXERCISE THE POWER AND AUTHORITY OF THE BOARD WHEN THE BOARD IS NOT IN SESSION. FORM 990, PART VI, SECTION B, LINE 11 THE FINANCE COMMITTEE REVIEWED THE FORM 990 PRIOR TO ITS SUBMISSION AS PART OF ITS FEBRUARY COMMITTEE MEETING. THE ORGANIZATION MADE COPIES OF THE FORM 990 AVAILABLE TO THE ENITRE BOARD AS PART OF ONE OF ITS REGULARLY SCHEDULED MEETINGS AS WELL AS AVAILABLE VIA A SECURED WEBSITE. FORM 990, PART VI, SECTION B, LINE 12C THE ORGANIZATION REQUIRES ITS BOARD OF DIRECTORS AND OFFICERS TO SIGN A CONFLICT OF INTEREST POLICY ANNUALLY. BOARD MEMBERS ARE RESPONSIBLE FOR DISCLOSING POTENTIAL CONFLICTS AS THEY ARISE. IF A CONFLICT OF INTEREST ARISES, THE BOARD MEMBER IN CONFLICT ABSTAINS FROM VOTING ON THE MATTER. FORM 990, PART VI, SECTION B, LINE 15 COMPENSATION FOR THE CEO AND OTHER OFFICERS IS REVIEWED BY THE BOARD CORPORATE COMPLIANCE COMMITTEE. THE COMMITTEE UTILIZES COMPARATIVE DATA AND A CONSULANT TO MAKE RECOMMENDATIONS FOR COMPENSATION. RECOMMENDATIONS ARE REVIEWED BY THE FULL BOARD OF DIRECTORS. FORM 990, PART VI, SECTION C, LINE 19 COMMUNITY MEMORIAL HEALTHCENTER'S GOVERNING DOCUMENTS, FINANCIAL STATEMENTS, AND CONFLICT OF INTEREST POLICY ARE MADE AVAILABLE TO THE PUBLIC UPON REQUEST. FORM 990, PART XII, LINE 2C: THIS PROCESS HAS NOT CHANGED FROM THE PRIOR YEAR. 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