2024-11-14T18:36:57-06:00 2023-12-31 861065772 DELOITTE TAX LLP 111 MONUMENT CIRCLE SUITE 4200 INDIANAPOLIS IN 46204 990 2023-01-01 550375433 DAVIS MEMORIAL HOSPITAL DAVI 3046363300 PO BOX 1484 ELKINS WV 26241 JEFF SANDENE EVP AND CFO 3046373196 2024-11-14 1 1 ANGELA M MOORE P00244342 3174648600 2023 2024-10-15 13:58:12Z MARK DOAK 107464208 0 X WWW.DAVISHEALTHSYSTEM.ORG X 1903 WV TO PROVIDE QUALITY HEALTH CARE TO RESIDENTS OF ELKINS, WEST VIRGINIA AND SURROUNDING COMMUNITIES. 11 3 1050 65 126294 70461 956495 39490 116357826 104381650 -1560117 369577 402621 2673491 116156825 107464208 64305 32619 0 0 56361884 66961917 0 0 0 81765266 69223645 138191455 136218181 -22034630 -28753973 85218888 50342111 50299505 84306469 34919383 -33964358 WE CARE FOR LIFE. 0 0 99919742 32619 105631906 THE ORGANIZATION OPERATED AN 80 BED ACUTE CARE HOSPITAL IN ELKINS, WEST VIRGINIA. 99919742 1 1 0 1 0 0 0 0 0 0 1 0 0 1 1 1 0 1 0 0 0 0 0 0 0 0 1 1 1 0 1 0 0 0 0 0 0 1 0 0 0 0 0 0 1 1 0 0 0 1 69 0 1 1050 1 1 1 0 0 0 0 0 0 0 0 0 0 0 X 11 3 0 0 0 0 1 1 1 1 1 0 0 1 1 1 1 1 1 1 1 0 X WILLIAM KOCH 3046373196 812 GORMAN AVE ELKINS WV 26241 AMANDA PENNINGTON MD BOARD MEMBER 40.00 0.00 X 488533 0 27396 VANCE JACKSON DHS CEO (END 06/24) 35.00 5.00 X X 315542 0 16877 MISHA PHILLIPS-LEE BOARD MEMBER 1.00 2.00 X 194879 0 20525 WILLIAM KOCH VP OF FINANCE AND CFO 25.00 15.00 X X 165014 0 1587 DREW PINGLEY MSN RN VICE CHAIRMAN 40.00 0.00 X X 107926 0 22941 DANNY FRANKE BOARD MEMBER (START 10/23) 14.00 2.00 X 2633 0 0 JAMES TRIPLETT CHAIRMAN 1.00 1.00 X X 0 0 0 CHAD SHOEMAKER BOARD MEMBER 1.00 0.00 X 0 0 0 CONNIE TENNEY BOARD MEMBER 1.00 0.00 X 0 0 0 DENISE CAMPBELL BOARD MEMBER 1.00 0.00 X 0 0 0 JOHANNA BIOLA MD BOARD MEMBER (END 03/23) 40.00 0.00 X 0 0 0 TOM FELTON BOARD MEMBER 1.00 0.00 X 0 0 0 THOMAS BENZ PHYSICIAN 40.00 0.00 X 803581 0 28309 MOHAMED FAHIM PHYSICIAN 40.00 0.00 X 646063 0 30019 GARRETT BUTLER PHYSICIAN 40.00 0.00 X 514699 0 28287 ARTHUR FINE PHYSICIAN 40.00 0.00 X 495095 0 23195 MICHAEL GALLOWAY PHYSICIAN 40.00 0.00 X 464847 0 25804 4198812 0 224940 106 0 1 0 WV GASTROENTEROLOGY & ENDOSCOPY PO BOX 2831 ELKINS WV 26241 GASTRO SURGICAL SERVICES 2354100 COMMONWEALTH ANESTHESIA PSC 425 LEWIS HARGETT CIRCLE LEXINGTON KY 40503 ANESTHESIA SERVICES 1490289 RICHARD TOPPING MD 1 FOREST BROOK DRIVE ELKINS WV 26241 ORTHOPEDIC SERVICES 1064388 LUCAS PAVLOVICH JR MD 1114 PINEVIEW DRIVE ELKINS WV 26241 ORTHOPEDIC SERVICES 1061244 MEDSTREAM ANESTHESIA PO BOX 63467 CHARLOTTE NC 282633467 ANESTHESIA SERVICES 950400 24 39490 39490 PATIENT SERVICES 622110 104381650 104381650 104381650 369577 309943 59634 203257 0 203257 203257 16656 186601 CAFETERIA 722514 1479917 1479917 TAX REFUND 900099 603249 603249 MANAGEMENT FEES 900099 50004 50004 337064 337064 2470234 107464208 105631906 126294 1666518 X 32619 32619 1363853 864819 499034 49010374 31075140 17935234 1387406 879690 507716 9944873 6305582 3639291 5255411 3332212 1923199 113452 113452 249344 249344 343639 343639 20305561 18887769 1417792 192542 192542 223722 141877 81845 7900000 5009022 2890978 2216631 1405463 811168 243572 154438 89134 2501330 1585980 915350 4142443 2626531 1515912 1174805 177673 997132 MEDICAL SUPPLIES 16297419 16297419 BAD DEBTS 7406459 7406459 REPAIRS AND MAINTENANCE 2321604 1472021 849583 FOOD & NUTRITION 1458757 1458757 2132365 806271 1326094 136218181 99919742 36298439 0 3862841 5639442 139058 26831 12831713 17177198 1156082 1436856 1689242 1733259 855584 791198 3194714 363211 41653104 2831503 7832086 1188349 -1381207 -1381207 16580385 20898682 85218888 50342111 30973951 23126209 -65659 12413561 56303320 6977652 4876940 50299505 84306469 X 34919383 -33964358 34919383 -33964358 85218888 50342111 -28753973 -40129768 0 X 0 1 X 1 0 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 0 0 0 0 0 0 0 0 1 8163 8163 0 PART II-B, LINE 1: THE ORGANIZATION PAYS MEMBERSHIP FEES TO THE AMERICAN HOSPITAL ASSOCIATION, WHICH PARTICIPATES IN LOBBYING ACTIVITIES. 906906 906906 1730105 160200 1569905 557703 203011 354692 2831503 ESTIMATED THIRD-PARTY PAYOR SETTLEMENTS 4708729 OTHER RECEIVABLES 1439485 DUE FROM SUBSIDIARY 14750468 20898682 DUE TO AFFILATES 4755635 OPERATING LEASES 121305 4876940 X PART X, LINE 2: THE IRS HAS DETERMINED THAT THE SYSTEM ENTITIES ARE EXEMPT FROM INCOME TAXES UNDER SECTION 501(C)(3) OF THE CODE AND APPLICABLE STATE STATUTES, EXCEPT FOR MHC, FHE, CMC, AND HFI, WHICH ARE CORPORATIONS SUBJECT TO INCOME TAX. THE SYSTEM DOES NOT HAVE ANY MATERIAL UNCERTAIN TAX POSITIONS AS OF DECEMBER 31, 2023. TAX RETURNS FOR THE YEAR ENDED JUNE 30, 2019, ARE OPEN FOR THE MHS ENTITIES AND TAX RETURNS FOR THE YEAR ENDED DECEMBER 31, 2020, ARE OPEN FOR CAMC ENTITIES. 1 1 X 1 X 120.000000000000 1 X 1 1 1 0 1 1 2495340 75365 2419975 0.01880 25832901 14632082 11200819 0.08700 28328241 14707447 13620794 0.10580 5638 10 5628 0.00000 93343 93343 0.00070 4176551 2017263 2159288 0.01680 62969 62969 0.00050 4338501 2017273 2321228 0.01800 32666742 16724720 15942022 0.12380 1 19033410 18116632 18116632 X 1 1 1 1 DAVIS MEMORIAL HOSPITAL PO BOX 1484 ELKINS WV 26241 X X X DAVIS MEMORIAL HOSPITAL 1 0 0 1 X X X X X X X X X 22 1 0 0 1 X SEE PART V, PAGE 8 X 1 22 1 SEE PART V, PAGE 8 0 1 X 120.000000000000 300.000000000000 X X X X 1 1 X X X X 1 X SEE PART V, PAGE 8 X SEE PART V, PAGE 8 X SEE PART V, PAGE 8 X X X X X 1 X 0 X X X X X 1 X 0 0 DAVIS MEMORIAL HOSPITAL PART V, SECTION B, LINE 5: INPUT WAS SOLICITED FROM THOSE REPRESENTING THE BROAD INTERESTS OF THE COMMUNITY IN AUGUST 2022. DISCUSSIONS INCLUDED THE HEALTH NEEDS OF THE COMMUNITY, BARRIERS TO HEALTH CARE ACCESS, OPPORTUNITIES FOR IMPROVEMENT, PERCEPTION OF DAVIS MEDICAL CENTER AND FEEDBACK ON THE HOSPITAL'S INITIATIVES. KEY STAKEHOLDERS APPROACHED FOR INPUT INCLUDED COMMUNITY HEALTH CENTERS, COLLEGES, NON-PROFIT ORGANIZATIONS, EMERGENCY MEDICAL SERVICES, HEALTH DEPARTMENTS, DEVELOPMENT AUTHORITIES, CHAMBER OF COMMERCE, STATE AND LOCAL GOVERNMENT AGENCIES, ETC., AS WELL AS PUBLIC OFFICIALS AND CHURCH LEADERS. DAVIS MEMORIAL HOSPITAL PART V, SECTION B, LINE 11: THE PRIMARY HEALTH CONCERN IS SUBSTANCE ABUSE FOLLOWED BY MENTAL HEALTH ISSUES. OTHER HEALTH CONCERNS INCLUDE:1. SUBSTANCE ABUSE2. MENTAL HEALTH3. CHRONIC DISEASE MANAGEMENT (COPD)4. FOOD INSECURITY5. TRANSPORTATION INSECURITYTHE HOSPTIAL HAS MANY COMMUNTIY OUTREACH PROGRAMS SUCH AS: 100 MILES IN 100 DAYS; MULTIPHASIC BLOOD TESTS, BIKE RODEO, HEALTH FAIRS, ETC. LAUREL PLACE PROVIDES GERIATRIC INPATIENT PSYCHIATRY. THE HOSPITAL WILL CONTINUE TO COLLABORATE WITH EXTERNAL PARTNERS ON STRATEGIES AND POLICIES THAT WILL POSITIVELY IMPACT THE LOCAL DRUG EPIDEMIC.THE HOSPITAL WILL CONTINUE TO BUILD ON THE DAVIS MEDICAL CENTER NUTRITION/POPULATION HEALTH COLLABORATION FOR DIABETES PREVENTION PROGRAM AND INCREASE THE NUMBER OF PARTICIPANTS YEAR OVER YEAR. DAVIS MEMORIAL HOSPITAL PART V, SECTION B, LINE 16J: THE FINANCIAL ASSISTANCE POLICY IS POSTED IN ALL PATIENT REGISTRATION AREAS INCLUDING ER, ADMISSIONS AND OP TESTING. THE PROCEDURE IS ALSO EXPLAINED IN FINANCIAL COUNSELING BROCHURES AVAILABLE THROUGHOUT THE HEALTH SYSTEM AND IN PHYSICIAN OFFICES. ALL EMPLOYEES ARE ALSO NOTIFIED VIA THE INTERNAL WEBSITE WHERE IT IS POSTED. WE ALSO EMPLOY TWO FINANCIAL COUNSELORS WHO WORK WITH AND SCREEN THE UNINSURED AND UNDERINSURED POPULATIONS. WE ALSO HAVE A FINANCIAL ADVOCATE FROM HEALTH AND HUMAN SERVICES. DAVIS MEMORIAL HOSPITAL PART V, SECTION B, LINE 20E: THE HOSPITAL ALSO SCREENS PATIENTS THROUGH A THIRD PARTY DATABASE THROUGH THE ADVISORY BOARD PRIOR TO PLACEMENT WITH A COLLECTION AGENCY. THIS SCRUB PROVIDES US WITH THE LIKELIHOOD THE PATIENT WILL QUALIFY FOR MEDICAID AS WELL AS SCREENS THE PATIENTS FOR OUR INTERNAL ASSISTANCE POLICY. THE PRESUMPTIVE CHARITY ADJUSTMENTS ARE DONE AS BUDGETARY CONSTRAINTS ALLOW TO BETTER IDENTIFY THE MEDICALLY INDIGENT AND PATIENTS WHO HAVE A NEED FOR ASSISTANCE TO PREVENT DEROGATORY COLLECTION ACTIVITY. PART V, SECTION B, LINE 7A HTTPS://WWW.DAVISHEALTHSYSTEM.ORG/CONTENT/UPLOADS/DAVISHEALTHSYSTEM.ORG/FILES/2023_DMC_CHNA.PDF PART V, SECTION B, LINE 10A HTTPS://WWW.DAVISHEALTHSYSTEM.ORG/CONTENT/UPLOADS/DAVISHEALTHSYSTEM.ORG/FILES/2023_DMC_CHNA.PDF PART V, SECTION B, LINE 16A HTTPS://WWW.DAVISHEALTHSYSTEM.ORG/PATIENTS-VISITORS/FINANCIAL-COUNSELING PART V, SECTION B, LINE 16B HTTPS://WWW.DAVISHEALTHSYSTEM.ORG/PATIENTS-VISITORS/FINANCIAL-COUNSELING PART V, SECTION B, LINE 16C HTTPS://WWW.DAVISHEALTHSYSTEM.ORG/PATIENTS-VISITORS/FINANCIAL-COUNSELING 2 1 - DIRECT CARE OF ELKINS 720 BEVERLY PIKE ELKINS WV 26241 MEDICAL CLINIC 2 - BUCKHANNON MEDICAL CENTER 11 NORTH LOCUST STREET BUCKHANNON WV 26201 MEDICAL CLINIC 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 $ 7,406,459. PART II, COMMUNITY BUILDING ACTIVITIES: DAVIS HEALTH SYSTEM'S MISSION INCLUDES THE DELIVERY OF HEALTHCARE SERVICES AND PROGRAMS THAT PROMOTE IMPROVED HEALTH FOR INDIVIDUALS AND FAMILIES. THE QUALITY OF LIFE OF ENTIRE COMMUNITIES IS IMPACTED THROUGH THESE VITAL PROGRAMS GENERALLY OFFERED AT LITTLE OR NO COST. SOME OF THE HEALTH ISSUES TARGETED BY DAVIS HEALTH SYSTEM TO THE COMMUNITIES SERVED BY OUR ORGANIZATION INCLUDE DIABETES, OBESITY AND WEIGHT MANAGEMENT, TOBACCO USE AND HEART DISEASE, WOMEN'S HEALTH, INFLUENZA, AND CANCER AND CANCER PREVENTION. OUR OUTREACH SERVES FIVE PRIMARY WEST VIRGINIA COUNTIES (RANDOLPH, TUCKER, UPSHUR, BARBOUR, AND POCAHONTAS), WITH SOME OVERFLOW TO NEIGHBORING COUNTIES AS WELL. SEVERAL EXAMPLES OF PROJECTS THAT REPRESENT OUR COMMITMENT TO ADVANCING THE EMOTIONAL AND PHYSICAL HEALTH BENEFITS TO THE PEOPLE OF THESE COMMUNITIES INCLUDE: COMMUNITY HEALTH FAIRS, DIABETES EDUCATION PROGRAMS AND SUPPORT GROUPS, DIABETES FOOT SCREENINGS, SPEAKING ENGAGEMENTS AND PRESENTATIONS TO SCHOOLS, CIVIC GROUPS AND OTHER ORGANIZATIONS, COLON CANCER SCREENINGS AND EDUCATION, COMMUNITY WALKING PROGRAM, PARTICIPATION WITH THE AMERICAN CANCER SOCIETY'S RELAY FOR LIFE AND MARCH OF DIMES, PARTNERSHIP WITH BOARDS OF EDUCATION, INFLUENZA VACCINATION CLINICS, PARTNERSHIP WITH COUNTY HEALTH DEPARTMENTS, DRUG TAKE-BACK, SMOKING CESSATION CLASSES AND SUPPORT AND PAP SMEAR AND BREAST EXAMINATIONS. PART III, LINE 2: BAD DEBT EXPENSE AS REPORTED ON AUDITED FINANCIAL STATEMENTS. PART III, LINE 4: AUDITED FINANCIAL STATEMENT FOOTNOTE RELATING TO BAD DEBT EXPENSE: PATIENT ACCOUNTS RECEIVABLE ARE CARRIED AT THE ORIGINAL CHARGE LESS AN ESTIMATE MADE FOR DOUBTFUL OR UNCOLLECTIBLE ACCOUNTS. 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 REVIEWS TROUBLED, AGED ACCOUNTS TO DETERMINE COLLECTION POTENTIAL. DELINQUENCY STATUS IS BASED ON DATE OF SERVICE. PATIENT ACCOUNTS RECEIVABLES ARE WRITTEN OFF WHEN DEEMED UNCOLLECTIBLE. RECOVERIES OF ACCOUNTS PREVIOUSLY WRITTEN OFF ARE RECORDED AS A REDUCTION TO BAD DEBT EXPENSE WHEN RECEIVED. PART III, LINE 8: MEDICARE ALLOWABLE COSTS AND REVENUES ARE FROM THE MEDICARE COST REPORT. PART III, LINE 9B: PATIENTS WHO INDICATE THEY HAVE AN INABILITY TO PAY FOR THEIR MEDICAL CARE ARE REFERRED TO THE FINANCIAL COUNSELOR AND/OR A MEDICAID ELIGIBILITY SPECIALIST. PATIENTS WHO DO MEET FINANCIAL ASSISTANCE GUIDELINES BUT DEMONSTRATE AN INABILITY TO MEET OUR MINIMUM PAYMENT GUIDELINES ARE GIVEN A REDUCED PAYMENT PLAN. COLLECTION PROCEDURES REGARDING REDUCED PAYMENT PLANS FOLLOW THE HOSPITAL'S NORMAL PROCEDURES. PATIENTS WITH CATASTROPHIC ILLNESSES ARE REFERRED TO THE WV CATASTROPHIC ILLNESS FUND. PATIENTS WHOSE CARE IS A RESULT OF A CRIME WILL BE REFERRED TO THE WV CRIME VICTIMS FUND. PART VI, LINE 2: DAVIS HEALTH SYSTEM RELIES HEAVILY ON DATA PROVIDED BY THE BUREAU FOR PUBLIC HEALTH; NAMELY, THE COUNTY HEALTH PROFILES THAT OUTLINE RISK FACTORS FOR CHRONIC DISEASES. IN ADDITION, THE COMMUNITY HEALTH PROMOTION DIRECTOR GLEANS INFORMATION AND STATISTICS FROM HEALTH SCREENINGS THAT ARE HELD FOR THE PUBLIC, AS WELL AS OUR EMPLOYEES. THIS INFORMATION HELPS IN PLANNING FUTURE EDUCATIONAL EVENTS AND SCREENINGS. PART VI, LINE 3: THE INFORMATION IS POSTED IN PUBLIC AREAS WITHIN THE HOSPITAL. THE FINANCIAL POLICY BROCHURE IS PUBLICLY DISPLAYED AND POSTED ON THE INTERNAL NETWORK AND THE HEALTH SYSTEM WEBSITE. A PATIENT ADVOCATE CONTACTS WORK LISTS OF MEDICALLY INDIGENT PATIENTS TO HELP SECURE AND PROVIDE EDUCATION TO AFFILIATE AND NON-AFFILIATE PHYSICIAN OFFICES REFERRING TO DAVIS MEMORIAL HOSPITAL. PART VI, LINE 4: THE HOSPITAL SERVES SEVERAL RURAL COUNTIES IN EASTERN WEST VIRGINIA. RANDOLPH COUNTY HAS A POPULATION OF 27,932 WITH 15.7% HAVING A BACHELOR'S DEGREE OR HIGHER AND AVERAGE HOUSEHOLD INCOME OF $45,206. UPSHUR COUNTY HAS A POPULATION OF 23,816 WITH 16.2% HAVING A BACHELOR'S DEGREE OR HIGHER, AVERAGE HOUSEHOLD INCOME OF $40,802. BARBOUR COUNTY HAS A POPULATION OF 15,465 WITH 13.9% HAVING A BACHELOR'S DEGREE OR HIGHER, AVERAGE HOUSEHOLD INCOME OF $38,906. POCAHONTAS COUNTY HAS A POPULATION OF 7,869 WITH 13.6% HAVING A BACHELOR'S DEGREE OR HIGHER, AVERAGE HOUSEHOLD INCOME OF $37,642. TUCKER COUNTY HAS A POPULATION OF 6,762 WITH 19.5% HAVING A BACHELOR'S DEGREE OR HIGHER, AVERAGE HOUSEHOLD INCOME OF $47,527. ADDITIONALLY, 16.8% OF ALL WEST VIRGINIANS LIVE BELOW THE POVERTY LEVEL. DAVIS MEMORIAL IS THE ONLY HOSPITAL IN RANDOLPH COUNTY. THERE IS ONE CRITICAL ACCESS HOSPITAL IN BARBOUR COUNTY, ONE CRITICAL ACCESS HOSPITAL IN POCAHONTAS COUNTY AND ONE GENERAL SERVICE HOSPITAL IN UPSHUR COUNTY. PART VI, LINE 5: THE ORGANIZATION'S HEALTH CARE FACILITIES FURTHER ITS EXEMPT PURPOSE IN THE FOLLOWING WAYS. THE ORGANIZATION'S GOVERNING BODY IS COMPRISED OF PERSONS WHO RESIDE IN THE ORGANIZATION'S PRIMARY SERVICE AREA. THE CORPORATE BY LAWS PROVIDE FOR BOARD REPRESENTATION FROM THE COUNTIES SURROUNDING DAVIS MEMORIAL HOSPITAL. THE ORGANIZATION EXTENDS MEDICAL STAFF PRIVILEGES TO ALL QUALIFIED PHYSICIANS IN ITS COMMUNITY FOR SOME OR ALL OF ITS DEPARTMENTS. THE ORGANIZATION OPERATES AN EMERGENCY ROOM AVAILABLE TO ALL, REGARDLESS OF ABILITY TO PAY. SPECIALIZED SERVICES OFFERED BY THE ORGANIZATION THAT ARE NOT AVAILABLE ELSEWHERE INCLUDE NEUROLOGY, PAIN MANAGEMENT, OTOLARYNGOLOGY, PULMONOLOGY, LITHOTRIPSY, SLEEP STUDIES, PET, DIGITAL MAMMOGRAPHY, CRITICAL CARE MEDICINE, GENERAL SURGERY, INTERNAL MEDICINE, OBSTETRICS AND GYNECOLOGY, RADIATION ONCOLOGY, MEDICAL ONCOLOGY AND HEMATOLOGY. AN ADVANCED TELEMEDICINE INITIATIVE AT DAVIS HEALTH SYSTEM PROVIDES ADDITIONAL SPECIALIZED SERVICES IN PARTNERSHIP WITH OTHER HEALTH CARE PROVIDERS, NURSING HOMES AND LARGER MEDICAL INSTITUTIONS - PROVIDING GREATER MEDICAL ACCESS TO PATIENTS IN MORE RURAL AREAS OF THE STATE. THE ORGANIZATION SERVES AS A VEHICLE FOR ATTRACTING CHARITABLE SUPPORT, AS WELL AS A SOURCE OF COMMUNITY VOLUNTEER ACTIVITIES. STUDENT VOLUNTEERS, YOUTH VOLUNTEERS AND AN ACTIVE ADULT VOLUNTEER PROGRAM SUPPORT THE MISSION OF THE HEALTH SYSTEM BY ENHANCING PATIENT CARE AND PROGRAMS. 1 MOUNTAIN STATE FOREST FESTIVAL PO BOX 388 ELKINS WV 26241 550488261 501(C)(3) 10000 0 GENERAL SUPPORT ELKINS YMCA 400 DAVIS AVENUE ELKINS WV 26241 550376877 501(C)(3) 5500 0 GENERAL SUPPORT 2 0 PART I, LINE 2: THE ORGANIZATION GRANTS MONEY TO OTHER 501(C)(3) ORGANIZATIONS AND RELIES ON THE IRS'S OVERSIGHT OF THE GRANTEES AS THEY HAVE AN EXEMPTION FROM THE IRS. X 1 1 X X X 0 0 0 0 0 0 0 0 0 THOMAS BENZ PHYSICIAN 799591 0 0 0 3990 0 3300 0 25009 0 831890 0 0 0 MOHAMED FAHIM PHYSICIAN 642567 0 0 0 3496 0 3300 0 26719 0 676082 0 0 0 GARRETT BUTLER PHYSICIAN 511546 0 0 0 3153 0 3300 0 24987 0 542986 0 0 0 ARTHUR FINE PHYSICIAN 475743 0 16667 0 2685 0 2586 0 20609 0 518290 0 0 0 AMANDA PENNINGTON MD BOARD MEMBER 488533 0 0 0 0 0 3300 0 24096 0 515929 0 0 0 MICHAEL GALLOWAY PHYSICIAN 461416 0 0 0 3431 0 2875 0 22929 0 490651 0 0 0 VANCE JACKSON DHS CEO (END 06/24) 314560 0 0 0 982 0 2024 0 14853 0 332419 0 0 0 MISHA PHILLIPS-LEE BOARD MEMBER 194879 0 0 0 0 0 1782 0 18743 0 215404 0 0 0 WILLIAM KOCH VP OF FINANCE AND CFO 164424 0 0 0 590 0 872 0 715 0 166601 0 0 0 PART I, LINE 1A THE HOSPITAL WILL REIMBURSE FOR ALL OF THE REASONABLE TRAVEL, LODGING AND MEAL EXPENSES INCURRED BY THE CEO'S SPOUSE FOR TWO BUSINESS-RELATED MEETINGS OR CONFERENCES PER YEAR. PART I, LINE 3: THE COMPENSATION COMMITTEE OF THE BOARD OF TRUSTEES IS RESPONSIBLE FOR THE OVERSIGHT OF THE COMPENSATION FOR THE SENIOR STAFF. A CONSULTANT (YAFFE & COMPANY) IS ENGAGED WHO FACILITATES THE ANNUAL EVALUATION PROCESS FOR DETERMINING COMPENSATION FOR EXECUTIVES. THE CONSULTANT COORDINATES A SERIES OF MEETINGS, LEADS DISCUSSIONS ON THE CHIEF EXECUTIVE OFFICER'S PERFORMANCE EVALUATION, PRESENTS MARKET ANALYSIS INFORMATION FOR KEY POSITIONS AND PROVIDES RECOMMENDATIONS FOR SALARY LEVELS BASED ON THAT INFORMATION. THE COMMITTEE MAKES THEIR DECISION USING THE GUIDANCE OF THE CONSULTANT. RICHARD CAMPBELL FAMILY MEMBER OF DENISE CAMPBELL 11974 EMPLOYMENT 0 MATT LEE FAMILY MEMBER OF MISHA PHILLIPS-LEE 246507 EMPLOYMENT 0 CHRISTIE SHOEMAKER FAMILY MEMBER OF CHAD SHOEMAKER 109135 EMPLOYMENT 0 FORM 990, PART VI, SECTION A, LINE 6 DAVIS MEMORIAL HOSPITAL'S BOARD MEMBERS ARE ELECTED OR APPOINTED BY DAVIS HEALTH SYSTEM, INC. FORM 990, PART VI, SECTION A, LINE 7A DAVIS MEMORIAL HOSPITAL'S BOARD MEMBERS ARE ELECTED OR APPOINTED BY DAVIS HEALTH SYSTEM, INC. FORM 990, PART VI, SECTION A, LINE 7B DAVIS HEALTH SYSTEM, INC. IS DAVIS MEMORIAL HOSPITAL'S SOLE MEMBER AND HAS RESERVED POWERS UNDER DAVIS MEMORIAL HOSPITAL'S GOVERNING DOCUMENTS, WHICH PROVIDE THAT DECISIONS OF DAVIS MEMORIAL HOSPITAL'S GOVERNING BODY, SUCH AS ELECTION OF OFFICERS, APPROVAL OF ANNUAL BUDGETS AND BORROWINGS, ARE SUBJECT TO APPROVAL BY THE SOLE MEMBER. THE SOLE MEMBER ALSO HAS ALL APPROVAL POWERS PROVIDED TO MEMBERS OF WEST VIRGINIA NONPROFIT CORPORATIONS UNDER STATE LAW. FORM 990, PART VI, SECTION B, LINE 11B THE 990 WILL BE DISTRIBUTED TO ALL BOARD MEMBERS. IT WILL BE PRESENTED AND DISCUSSED AT A BOARD OF TRUSTEES MEETING OR A FINANCE COMMITTEE MEETING, WHICHEVER OCCURS FIRST AFTER THE COMPLETION OF FORM 990. IF THE FINANCE COMMITTEE MEETING IS THE FIRST TO OCCUR, ALL MEMBERS OF THE BOARD OF TRUSTEES WILL BE ENCOURAGED TO ATTEND THE FINANCE COMMITTEE WHERE THE FORM IS TO BE DISCUSSED. FORM 990, PART VI, SECTION B, LINE 12C THE DAVIS HEALTH SYSTEM CONFLICT OF INTEREST POLICY REQUIRES THAT EACH DIRECTOR, OFFICER, AND COMMITTEE MEMBER WITH BOARD DELEGATED POWERS SHALL ANNUALLY SIGN A STATEMENT WHICH AFFIRMS THE PERSON HAS RECEIVED A COPY OF THE CONFLICT OF INTEREST POLICY AND READS AND UNDERSTANDS THE POLICY. BOARD MEMBERS COMPLETE THE STATEMENT IN JANUARY OF EACH YEAR. THE CONFLICT OF INTEREST STATEMENTS ARE REVIEWED BY THE EXECUTIVE COMMITTEE. IN ADDITION TO BOARD MEMBERS, SENIOR STAFF ARE REQUIRED TO ANNUALLY PREPARE A CONFLICT OF INTEREST STATEMENT. FORM 990, PART VI, SECTION B, LINE 15 THE COMPENSATION COMMITTEE OF THE BOARD OF TRUSTEES IS RESPONSIBLE FOR THE OVERSIGHT OF THE COMPENSATION FOR THE SENIOR STAFF. A CONSULTANT (YAFFE & COMPANY) IS ENGAGED WHO FACILITATES THE ANNUAL EVALUATION PROCESS FOR DETERMINING COMPENSATION FOR EXECUTIVES. THE CONSULTANT COORDINATES A SERIES OF MEETINGS, LEADS DISCUSSIONS ON THE CHIEF EXECUTIVE OFFICER'S PERFORMANCE EVALUATION, PRESENTS MARKET ANALYSIS INFORMATION FOR KEY POSITIONS AND PROVIDES RECOMMENDATIONS FOR SALARY LEVELS BASED ON THAT INFORMATION. THE COMMITTEE MAKES THEIR DECISION USING THE GUIDANCE OF THE CONSULTANT. FORM 990, PART VI, SECTION C, LINE 19 THE BOARD OF TRUSTEES ADOPTED A RECORD KEEPING AND DISCLOSURE POLICY IN JANUARY OF 2003. THE POLICY PROVIDES FOR DISCLOSURE OF CORPORATE AND FINANCIAL RECORDS NOT COVERED BY GOVERNMENTAL OR CONTRACTUAL AGREEMENTS. ANY REQUEST FOR FINANCIAL OR OTHER CORPORATE DOCUMENTS ARE SUBMITTED TO THE EXECUTIVE COMMITTEE OF THE BOARD OF TRUSTEES AND DECISIONS ARE MADE ON A CASE BY CASE BASIS. THE COMPLIANCE CODE OF CONDUCT POLICY INCLUDES STANDARDS RELATING TO CONFLICTS OF INTEREST WITHIN THE ORGANIZATION. THIS INFORMATION IS SHARED WITH THE PUBLIC, BEING POSTED ON THE WEBSITE IN ADDITION TO BEING DISTRIBUTED TO ALL PATIENTS ADMITTED TO THE HOSPITAL. FORM 990, PART IX, LINE 11G ADMINISTRATIVE SERVICES: PROGRAM SERVICE EXPENSES 1,096,016. MANAGEMENT AND GENERAL EXPENSES 1,417,792. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 2,513,808. ANESTHESIA SERVICES: PROGRAM SERVICE EXPENSES 2,258,689. MANAGEMENT AND GENERAL EXPENSES 0. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 2,258,689. EMERGENCY SERVICES: PROGRAM SERVICE EXPENSES 5,829,480. MANAGEMENT AND GENERAL EXPENSES 0. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 5,829,480. LAB SERVICES: PROGRAM SERVICE EXPENSES 2,345,000. MANAGEMENT AND GENERAL EXPENSES 0. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 2,345,000. SURGICAL SERVICES: PROGRAM SERVICE EXPENSES 3,177,027. MANAGEMENT AND GENERAL EXPENSES 0. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 3,177,027. RADIOLOGY SERVICES: PROGRAM SERVICE EXPENSES 267,269. MANAGEMENT AND GENERAL EXPENSES 0. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 267,269. MEDICAL SERVICES: PROGRAM SERVICE EXPENSES 3,914,288. MANAGEMENT AND GENERAL EXPENSES 0. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 3,914,288. 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