2022-05-10T12:08:34-05:00 2021-06-30 390859910 BAKER TILLY US LLP 101 WASHINGTON STREET EAST CHARLESTON WV 25329 990 2020-07-01 550422958 STONEWALL JACKSON MEMORIAL HOSPITAL STON 3042698059 230 HOSPITAL PLAZA WESTON WV 26452 RICK SCHERICH VP OF FINANCIAL SERVICES 3042698059 2022-05-09 1 RICK SCHERICH 999009999 DOLORES ROSE P01286262 3043460441 2022-05-09 3 AAL1 IAL1 2020 2022-09-23 18:48:47Z DAVID GOLDBERG 230 HOSPITAL PLAZA WESTON WV 26452 59845957 0 X WWW.STONEWALLHOSPITAL.COM X 1959 WV ENHANCE THE HEALTH OF THE COMMUNITIES WE SERVE, ONE PERSON AT A TIME. 12 8 494 15 16550 14539 71312 8131388 44190885 49400261 6146137 1262429 5919207 230140 56327541 59024218 22705 5820 0 0 26864550 24782276 0 0 0 28666514 27569351 55553769 52357447 773772 6666771 66727715 76538179 20760932 17241625 45966783 59296554 ENHANCE THE HEALTH OF THE COMMUNITIES WE SERVE, ONE PERSON AT A TIME. 0 0 43792601 49566823 STONEWALL JACKSON MEMORIAL HOSPITAL PROVIDES ACUTE MEDICAL AND OUTPATIENT SERVICES TO RESIDENTS OF WESTON, WEST VIRGINIA AND SURROUNDING COMMUNITIES WHICH COVERS 10 DIFFERENT COUNTIES. SERVICES INCLUDED 4,570 DAYS OF INPATIENT CARE, 77,352 OUTPATIENT VISITS, 10,749 EMERGENCY ROOM VISITS, 1,928 AMBULATORY SURGERY VISITS, AND 32,374 PHYSICIAN CLINIC VISITS. THE HOSPITAL HAD 171 DELIVERIES DURING THE YEAR IN WHICH APPROXIMATELY 65% WERE MEDICAID PATIENTS. MANY OF THESE BABIES HAD SIGNIFICANT SUBSTANCE ABUSE PROBLEMS. DUE TO THE DRUG ADDICTION PROBLEMS OF THE MOTHERS, VERY FEW OF THESE WOMEN HAVE RECEIVED PRENATAL CARE. 14751 5820 ANNUAL BLOOD SCREENING: STONEWALL JACKSON MEMORIAL HOSPITAL PROVIDES ALL SUPPLIES AND STAFF TO OPERATE THE PROGRAM. A PORTION OF THE EXCESS REVENUE IS FORWARDED TO THE LOCAL ROTARY CLUB TO PROMOTE CHARITABLE SERVICES. OTHER PROGRAMS INCLUDE: SCOLIOSIS SCREENING AT COUNTY ELEMENTARY AND MIDDLE SCHOOLS, HEALTH FAIRS AT THE LOCAL SENIOR CITIZENS CENTER, FREE SPORTS PHYSICALS TO MIDDLE AND HIGH SCHOOL STUDENTS, CHILDREN'S SAFETY DAY TO PROMOTE HEALTHY CHOICES TO CHILDREN UNDER 12 YEARS OF AGE, EVENTS FOR FREE OSTEOPOROSIS SCREENINGS, EVENTS FOR FREE DERMASCANS TO SCREEN FOR SKIN CANCER, WESTON WALK-RUN TO PROMOTE EXERCISE AS A WAY TO IMPROVE CARDIAC HEALTH, FREE WOMEN'S HEALTH SCREENING FOR BREAST AND CERVICAL CANCER, FREE VEIN SCREENINGS AND FREE HEARING SCREENINGS. REVENUE IS INCLUDED IN LINE 4A ABOVE. WILLIAM ADLER SCHOLARSHIP FUND - STONEWALL JACKSON MEMORIAL HOSPITAL SPONSORED PROGRAM TO PROVIDE SCHOLARSHIPS TO LOCAL GRADUATING HIGH SCHOOL SENIORS WHO ARE PURSUING A CAREER IN THE HEALTH CARE FIELD. IT IS HOPED THAT THIS PROGRAM WILL ENCOURAGE MORE STUDENTS TO SEEK HEALTH CARE PROFESSIONS AND LESSON THE HEALTH CARE STAFFING SHORTAGE. DUE TO COVID-19, THE SCHOLARSHIP FUND DID NOT OCCUR DURING THIS FISCAL YEAR. 43807352 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 0 0 0 0 0 0 0 1 1 1 0 0 1 179 0 494 1 1 1 0 0 0 0 0 0 0 0 0 X 12 8 0 1 0 0 1 1 1 1 1 0 0 1 1 1 1 1 1 1 1 0 WV X RICK SCHERICH VP OF FINANCIAL SERVICES 3042698050 230 HOSPITAL PLAZA WESTON WV 264528558 ROBIN POLING CHAIRMAN 1.00 X X 0 0 0 C GREGORY CUNNINGHAM VICE CHAIRMAN 1.00 X X 0 0 0 KIMBERLY GUM SECRETARY/TREASURER 1.00 X X 0 0 0 DAVID GOLDBERG MHS PRESIDENT/CEO 1.00 49.00 X X 0 775610 5700 KEVIN STALNAKER EXECUTIVE/CAO 50.00 X X 0 218333 37382 JEREMY WILLIAMS MD DIRECTOR/CHIEF OF STAFF 1.00 X 0 0 0 JOHN LAW CPA DIRECTOR 1.00 X 0 0 0 DOYLE SICKLES MD DIRECTOR 1.00 X 569241 0 26640 GREGORY ST CLAIR DIRECTOR 1.00 X 0 0 0 JOSEPH SNEAD MD DIRECTOR 23.00 X 14540 0 0 R GERALD WOOD RPH DIRECTOR 1.00 X 0 0 0 DENVER TURNER DIRECTOR 1.00 X 0 0 0 RICK SCHERICH VP FINANCE 25.00 25.00 X 0 186531 32517 LISA SIMON CPA MHS VP FINANCE/CFO 1.00 49.00 X 0 361043 49359 AVAH STALNAKER CEO STONEWALL JACKSON MEMORIAL HOSPITAL 39.00 1.00 X 0 332157 9108 MICHAEL GREGORY DO PHYSICIAN 40.00 X 567419 0 53305 RONALD PEARSON MD PHYSICIAN 40.00 X 605313 0 36423 ROBERT HARRIS MD PHYSICIAN OB 40.00 X 420346 0 53300 TYLER HALL MD ED PHYSICIAN 40.00 X 378733 0 36107 ROBERT SNUFFER DO PHYSICIAN 40.00 X 340953 0 0 DARIS ROSENCRANCE MHS FORMER VP FINANCE/CFO 0.00 X 0 317827 9194 DARRYL DUNCAN MHS FORMER PRESIDENT/CEO 0.00 X 0 213610 0 2896545 2405111 349035 6 1 1 0 SODEXO INC & AFFILIATES PO BOX 536922 ATLANTA GA 50353 MAINTENANCE & DIETARY SERVICES 699531 SYNERGY SURGICALISTS 280 W KAGY BLVD SUITE D 320 BOZEMAN MT 59715 CONTRACT ORTHOPEDIC SURGEONS 606300 LEXX HEALTHCARE 9600 WEST SAMPLE R SUITE 300 CORAL SPRINGS FL 33065 CONTRACT PHYSICIANS 318100 FUSION MEDICAL STAFFING LLC PO BOX 82674 LINCOLN NE 68501 CONTRACT NURSES 266539 RN NETWORK PO BOX 974088 DALLAS TX 75397 CONTRACT NURSES 238923 12 5820 8062098 63470 8131388 PATIENT SERVICES 622110 49400261 49400261 49400261 778846 778846 85922 16550 42923 0 42999 16550 59549 16550 42999 1259463 775880 483583 483583 483583 6965 5820 2936 4029 4029 CAFETERIA 722310 154632 154632 VENDING MACHINE SALES 722310 2294 2294 9636 9636 166562 59024218 49566823 16550 1309457 X 5820 5820 20406447 17453634 2952813 531977 455000 76977 2379932 2035556 344376 1463920 1252091 211829 2571946 2571946 90127 90127 74228 74228 6381763 5458322 923441 198327 169629 28698 1438920 1168288 270632 1306105 1117112 188993 959687 820820 138867 47500 40627 6873 24495 20951 3544 2138595 1829140 309455 -680141 -581725 -98416 MEDICAL SUPPLIES 7182198 7182198 BAD DEBTS 2580201 2580201 REPAIRS AND MAINTENANCE 1193192 1020548 172644 MEDICAID PROVIDER TAX 692851 692851 1369357 1086289 283068 52357447 43807352 8550095 0 12283157 11029198 2152866 1266160 3439833 4354778 1107591 1113159 210693 88777 52790336 41658971 12034122 11131365 32378141 41013803 517129 658833 2604183 5882106 66727715 76538179 15636283 10512314 26318 5098331 4935306 0 1794005 20760932 17241625 X 45517322 58766444 449461 530110 45966783 59296554 66727715 76538179 X 6666771 6582351 80649 X X 0 1 X 1 0 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 0 0 0 0 0 1 5448 0 0 0 5448 0 PART II-B, LINE 1: A PORTION OF DUES PAID BY THE HOSPITAL TO THE AMERICAN HOSPITAL ASSOCATION AND THE WEST VIRGINIA HOSPITAL ASSOCIATION IS ATTRIBUTABLE TO LOBBYING. 7149601 7149601 13403703 12227441 1176262 31786169 29431530 2354639 450863 450863 11131365 OTHER RECEIVABLES 318495 DUE FROM STONEWALL HOME OXYGEN THERAPY 552861 ESTIMATED THIRD PARTY SETTLEMENTS 2523604 INSURANCE RECOVERIES RECEIVABLES 693141 OPERATING LEASE - RIGHT OF USE ASSET 1794005 5882106 OPERATING LEASE - RIGHT OF USE 1794005 1794005 X PART X, LINE 2: THE HEALTH SYSTEM FOLLOWS THE FASB'S AUTHORITATIVE GUIDANCE ON ACCOUNTING FOR UNCERTAINTY IN INCOME TAXES. THE GUIDANCE CLARIFIES THE ACCOUNTING FOR THE RECOGNITION AND MEASUREMENT OF THE BENEFITS OF INDIVIDUAL TAX POSITIONS IN THE CONSOLIDATED FINANCIAL STATEMENTS. TAX POSITIONS MUST MEET A RECOGNITION THRESHOLD OF MORE-LIKELY-THAN-NOT IN ORDER FOR THE BENEFIT OF THOSE TAX POSITIONS TO BE RECOGNIZED IN THE CONSOLIDATED FINANCIAL STATEMENTS. THE HEALTH SYSTEM HAS DETERMINED THAT NO MATERIAL UNRECOGNIZED TAX BENEFITS OR OBLIGATIONS EXIST. GENERALLY, TAX RETURNS FOR YEARS ENDED JUNE 30, 2018, AND THEREAFTER REMAIN SUBJECT TO EXAMINATION BY FEDERAL AND STATE TAX AUTHORITIES. 1 1 X 1 X 1 X 162.000000000000 1 1 1 0 0 973262 973262 10749264 8754035 1995229 0.04010 11722526 9727297 1995229 0.04010 14751 14751 0.00030 14751 14751 0.00030 11737277 9727297 2009980 0.04040 1 2580201 7395830 7349861 45969 X 1 1 1 1 STONEWALL JACKSON MEMORIAL HOSPITAL 230 HOSPITAL PLAZA WESTON WV 26452 X X X STONEWALL JACKSON MEMORIAL HOSPITAL 1 0 0 1 X X X X X X X X 18 1 0 1 1 X HTTPS://WWW2.STONEWALLJACKSONHOSPITAL.COM/DOCS/LEWIS_CO_HEALTH_DEPT.PDF X 1 18 1 HTTPS://WWW2.STONEWALLJACKSONHOSPITAL.COM/DOCS/LEWIS_CO_HEALTH_DEPT.PDF 0 1 X 150.000000000000 162.000000000000 X X X X X 1 1 X X X X 1 X HTTPS://WWW2.STONEWALLJACKSONHOSPITAL.COM/DOCS/SJMH_FINANCIAL_ASSISTANCE_PO X HTTPS://WWW2.STONEWALLJACKSONHOSPITAL.COM/DOCS/FINANCIAL_AID_APPLICATION_2. X HTTPS://WWW.STONEWALLJACKSONHOSPITAL.COM/ X X X X 1 X 0 X X X X 1 X 0 0 STONEWALL JACKSON MEMORIAL HOSPITAL PART V, SECTION B, LINE 5: THE HOSPITAL TOOK INTO ACCOUNT INPUT FROM COMMUNITY LEADERS AT THE HEALTH DEPARTMENT, SCHOOLS, LOCAL BUSINESSES AND THE TOWN MAYOR. THREE HUNDRED NINETY-TWO PEOPLE PARTICIPATED IN A SURVEY FROM JULY 2018 TO FEBRUARY 2019. THE SURVEY WAS PROMOTED IN THE LOCAL NEWSPAPER, LOCAL RADIO STATIONS, SOCIAL MEDIA AND EMAIL. ANOTHER 70 PAPER SURVEYS WERE COMPLETED AT THE LEWIS COUNTY HEALTH DEPARTMENT, WAITING AREAS IN SJMH, PHYSICIAN OFFICES, SENIOR CENTER AND OTHER AREAS IN THE COUNTY. IN APRIL 2019, A STAFF MEMBER FROM SJMH COORDINATED TWO FOCUS GROUPS. PARTICIPANTS OF THE FOCUS GROUPS INCLUDED REPRESENTATIVES FROM THE LEWIS COUNTY HEALTH DEPARTMENT, DAY REPORT CENTER, THE WILLIAM R. SHARPE HOSPITAL, THE CITY OF WESTON AND THE HOSPITAL. STONEWALL JACKSON MEMORIAL HOSPITAL PART V, SECTION B, LINE 6B: LEWIS COUNTY HEALTH DEPARTMENT STONEWALL JACKSON MEMORIAL HOSPITAL PART V, SECTION B, LINE 11: DRUG ABUSE WAS THE NUMBER ONE HEALTH CONCERN OF THE RESIDENTS. THE OTHER CONCERNS IN ORDER OF IMPORTANCE: OBESITY, CANCER, HEART DISEASE, DIABETES, AND HIGH BLOOD PRESSURE. TO COMBAT DRUG ABUSE, SJMH'S EMERGENCY DEPARTMENT HAS ADOPTED THE WV HOSPITAL ASSOCIATION GUIDELINES FOR PRESCRIBING OPIATES. LEWIS COUNTY NOW HAS A DRUG COURT. ALL NURSING STAFF AT SJMH ARE REQUIRED TO COMPLETE CONTINUING EDUCATION ON "DRUG DIVERSION EDUCATION ON OPIATES". ALL SJMH PHARMACISTS MUST COMPLETE CONTINUING EDUCATION ON DRUG DIVERSION EDUCATION ON OPIATES, AND ALL SJMH PHYSICIANS ARE REGISTERED WITH THE WV BOARD OF PHARMACIES. THE SECOND CONCERN FOR THE COMMUNITY WAS OBESITY. TO COMBAT THIS, SJMH HAS AN ADULT FITNESS PROGRAM; CREATED A COUNTY-WIDE WALKING GROUP; AND THE THERAPY DEPARTMENT PROVIDED ANNUAL PHYSICALS FOR STUDENT ATHLETES AT NO COST. SJMH CREATED A SAFE WALKING PATH IN THE PARKING LOT, ESTABLISHED A WELLNESS COMMITTEE FOR EMPLOYEES, AND DOES NOT SERVE SODA POPS AT ACTIVITIES. SJMH COORDINATED WITH THE CITY OF WESTON TO REFURBISH PLAYGROUNDS IN THE AREA. STONEWALL JACKSON MEMORIAL HOSPITAL PART V, SECTION B, LINE 13H: PATIENTS WHOSE FAMILY INCOME EXCEEDS 162% OF THE FPL MAY BE ELIGIBLE TO RECEIVE DISCOUNTED RATES ON A CASE-BY-CASE BASIS BASED ON THEIR SPECIFIC CIRCUMSTANCES, SUCH AS CATASTROPHIC ILLNESS OR MEDICAL INDIGENCE, AT THE DISCRETION OF SJMH; HOWEVER THE DISCOUNTED RATES SHALL NOT BE GREATER THAN THE AMOUNTS GENERALLY BILLED TO (RECEIVED BY THE HOSPITAL FOR) COMMERCIALLY INSURED OR MEDICARE PATIENTS. PART I, LINE 3C: THE HEALTH RESOURCES AND SERVICES ADMINISTRATION ELIGIBILITY GUIDELINES ARE USED. WE ALSO EVALUATE THE PATIENT'S ASSETS AND THE AMOUNT OF MEDICAL DEBT. WE HAVE SIGNS POSTED AT REGISTRATION, AROUND AND IN THE EMERGENCY DEPARTMENT AND IN ALL PHYSICIAN CLINICS. WE SEND LETTERS TO PATIENTS WHO ARE NOT PAYING THEIR BILLS AND GIVE THE APPLICATION TO PRIVATE PAY INPATIENTS. WE ALSO TELL THE PATIENTS DURING TELEPHONE CONVERSATIONS IF THE PATIENT INDICATES HE/SHE IS NOT ABLE TO PAY THE BILL OR PAY ALL OF THE BILL. PART I, LINE 7: THE COST OF CHARITY CARE WAS ESTIMATED USING A COST TO CHARGE RATIO DERIVED FROM WORKSHEET 2 OF THE SCHEDULE H INSTRUCTIONS.THE UNREIMBURSED COST OF MEDICAID WAS ESTIMATED USING A COST TO CHARGE RATIO DERIVED FROM WORKSHEET 2 OF THE SCHEDULE H INSTRUCTIONS. 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 $ 2,580,201. PART III, LINE 4: 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 COLLECTABILITY. MANAGEMENT ALSO REVIEWS TROUBLED, AGED ACCOUNTS TO DETERMINE COLLECTION POTENTIAL. PATIENT ACCOUNTS RECEIVABLE ARE WRITTEN OFF WHEN DEEMED UNCOLLECTIBLE. RECOVERIES OF ACCOUNTS PREVIOUSLY WRITTEN OFF ARE RECORDED AS A REDUCTION TO BAD DEBT EXPENSE WHEN RECEIVED. INTEREST IS NOT CHARGED ON PATIENT ACCOUNTS RECEIVABLE. PART III, LINE 8: THE MEDICARE COST REPORT WAS USED TO DETERMINE REVENUE ALLOWABLE COSTS ASSOCIATED WITH THE REVENUE. PART III, LINE 9B: OUR COLLECTIONS POLICY APPLIES TO ALL PATIENTS REGARDLESS OF FINANCIAL CLASS OR ANY OTHER CLASSIFICATION. DURING OUR COLLECTIONS PROCESS, IF THE PATIENT INDICATES THEY DO NOT HAVE THE ABILITY TO PAY THEIR BILL, THE CREDIT STAFF OFFERS EXONERATION. PART VI, LINE 2: THE ASSESSMENT WAS CONDUCTED IN THREE PHASES: THE FIRST PHASE WAS ATTAINING BACKGROUND INFORMATION ON THE HEALTHCARE PROBLEMS OF THE LOCAL AREA AND STATE. THE SECOND PHASE WAS A SURVEY CONDUCTED ONLINE AND BY PAPER. THE LAST PHASE WAS A FOCUS GROUP CONDUCTED BY AN EXPERIENCED MEDIATOR. PART VI, LINE 3: WE HAVE SIGNS POSTED AT REGISTRATION, AROUND AND IN THE EMERGENCY DEPARTMENT, AND IN ALL PHYSICIAN CLINICS. WE SEND LETTERS TO PATIENTS WHO ARE NOT PAYING THEIR BILLS. WE GIVE THE APPLICATION TO PRIVATE PAY INPATIENTS. WE TELL THE PATIENTS DURING TELEPHONE CONVERSATIONS, IF THE PATIENT INDICATES HE/SHE IS NOT ABLE TO PAY THE BILL OR PAY ALL OF THE BILL. PART VI, LINE 4: STONEWALL JACKSON MEMORIAL HOSPITAL SERVES A RELATIVELY LARGE RURAL POPULATION OF ABOUT 65,000 PEOPLE WITH AN AVERAGE HOUSEHOLD INCOME OF $32,000. 30% OF THE POPULATION IS DISABLED. APPROXIMATELY 30% ARE MEDICAID ELIGIBLE OR ARE UNINSURED. WE ARE THE LARGEST HOSPITAL IN OUR SERVICE AREA, WHICH INCLUDES TWO OTHER HOSPITALS, ONE BEING A CRITICAL ACCESS HOSPITAL. WE ARE LOCATED IN A FEDERALLY-DESIGNATED MEDICALLY UNDERSERVED AREA. PART VI, LINE 5: STONEWALL JACKSON MEMORIAL HOSPITAL (SJMH) IS A 70 BED RURAL ACUTE CARE HOSPITAL LOCATED IN LEWIS COUNTY WEST VIRGINIA. SJMH IS THE ONLY HOSPITAL LOCATED IN THE COUNTY AS SUCH IT IS SOLELY RESPONSIBLE FOR THE HEALTHCARE OF THIS RURAL COMMUNITY. SJMH PROVIDES A 24 HOUR EMERGENCY ROOM AND OBSTETRICS SERVICES AND PROVIDES CARE REGARDLESS OF THE PATIENT'S ABILITY TO PAY. THE MAJORITY OF THE GOVERNING BODY IS COMPRISED OF COMMUNITY MEMBERS. MEDICAL PRIVILEGES ARE OFFERED TO ALL QUALIFIED PHYSICIANS IN THE COMMUNITY AND SJMH HAS WORKED DILIGENTLY TO PROVIDE OTHER PHYSICIAN SERVICES BY EXPANDING THE SERVICES THEY PROVIDE.SJMH CONTINUES TO MAKE CAPITAL IMPROVEMENT TO THE FACILITY AND EXPAND PATIENT CARE SERVICES TO MEET THE NEEDS OF THE COMMUNITY. 1 ROTARY CLUB OF WESTON PO BOX 222 WESTON WV 26452 550371556 501(C)4 5820 TO HELP THE ROTARY SUPPORT VARIOUS CHILDREN'S PROGRAMS IN LEWIS COUNTY. 0 1 1 1 0 0 0 0 0 0 0 DAVID GOLDBERG MHS PRESIDENT/CEO 0 532081 0 112500 0 131029 0 5700 0 0 0 781310 0 0 RONALD PEARSON MD PHYSICIAN 569255 0 25000 0 11058 0 14250 0 22173 0 641736 0 0 0 MICHAEL GREGORY DO PHYSICIAN 558029 0 1600 0 7790 0 14250 0 39055 0 620724 0 0 0 DOYLE SICKLES MD DIRECTOR 532626 0 0 0 36615 0 14250 0 12390 0 595881 0 0 0 ROBERT HARRIS MD PHYSICIAN OB 312213 0 67500 0 40633 0 14250 0 39050 0 473646 0 0 0 TYLER HALL MD ED PHYSICIAN 372613 0 0 0 6120 0 14250 0 21857 0 414840 0 0 0 LISA SIMON CPA MHS VP FINANCE/CFO 0 359753 0 0 0 1290 0 42474 0 6885 0 410402 0 0 AVAH STALNAKER CEO STONEWALL JACKSON MEMORIAL HOSPI 0 295372 0 0 0 36785 0 5700 0 3408 0 341265 0 0 ROBERT SNUFFER DO PHYSICIAN 340953 0 0 0 0 0 0 0 0 0 340953 0 0 0 DARIS ROSENCRANCE MHS FORMER VP FINANCE/CFO 0 86508 0 0 0 231319 0 8009 0 1185 0 327021 0 0 KEVIN STALNAKER EXECUTIVE/CAO 0 217330 0 0 0 1003 0 26000 0 11382 0 255715 0 0 RICK SCHERICH VP FINANCE 0 186531 0 0 0 0 0 18455 0 14062 0 219048 0 0 DARRYL DUNCAN MHS FORMER PRESIDENT/CEO 0 166691 0 0 0 46919 0 0 0 0 0 213610 0 0 PART I, LINE 3 THE CEO'S COMPENSATION IS PAID BY MONONGALIA HEALTH SYSTEM. MONONGALIA HEALTH SYSTEM USES THE FOLLOWING METHODS TO ESTABLISH THE COMPENSATION OF THE CEO: -COMPENSATION COMMITTEE -INDEPENDENT COMPENSATION CONSULTANT -COMPENSATION SURVEY OR STUDY -APPROVAL BY THE BOARD OR COMPENSATION COMMITTEE. PART I, LINES 4A-B THE FOLLOWING INDIVIDUALS DEFERRRED THE FOLLOWING AMOUNTS UNDER A 457(F) PLAN - DAVID GOLDBERG ($109,029) AND LISA SIMON ($36,774). THE FOLLOWING INDIVIDUALS RECEIVED A SEVERANCE PAYMENT - DARIS ROSENCRANCE ($230,783) AND AVAH STALNAKER ($30,454). FORM 990, PART VI, SECTION A, LINE 3 MANAGEMENT DUTIES CUSTOMARILY ARE PERFORMED UNDER THE DIRECT SUPERVISION OF OFFICERS, DIRECTORS, TRUSTEES OR KEY EMPLOYEES, BUT THE HOSPITAL HAS CONTRACTED OUT THE MANAGEMENT DUTIES OF THE MAINTENANCE DEPARTMENT. THE MANAGER OF THE MAINTENANCE DEPARTMENT (ALSO CONSIDERED A DEPARTMENT HEAD) IS EMPLOYED BY THE MAINTENANCE COMPANY. ALL OTHER MAINTENANCE STAFF ARE EMPLOYEES OF THE HOSPITAL. THE HOSPITAL CONTRACTS OUT THE MANAGEMENT DUTIES OF THE PHARMACY DEPARTMENT. THE MANAGER OF THE PHARMACY DEPARTMENT (ALSO CONSIDERED A DEPARTMENT HEAD) IS EMPLOYED BY THE PHARMACY COMPANY. ALL OTHER PHARMACY STAFF ARE EMPLOYEES OF THE HOSPITAL. THE HOSPITAL CONTRACTS OUT THE MANAGEMENT DUTIES OF THE DIETARY DEPARTMENT. THE MANAGER OF THE DIETARY DEPARTMENT (ALSO CONSIDERED A DEPARTMENT HEAD) IS EMPLOYED BY THE DIETARY COMPANY. THE CERTIFIED DIETARY MANAGER AND THE DIETITIAN ARE ALSO THE EMPLOYEES OF THE DIETARY COMPANY. ALL OTHER DIETARY STAFF ARE EMPLOYEES OF THE HOSPITAL. FORM 990, PART VI, SECTION A, LINE 6 MONONGALIA HEALTH SYSTEM, INC., A WEST VIRGINIA NON-PROFIT CORPORATION, IS THE SOLE MEMBER OF THE HOSPITAL. FORM 990, PART VI, SECTION A, LINE 7A STONEWALL JACKSON MEMORIAL HOSPITAL BOARD MEMBERS ARE ELECTED OR APPOINTED BY MONONGALIA HEALTH SYSTEM. FORM 990, PART VI, SECTION A, LINE 7B STONEWALL JACKSON MEMORIAL HOSPITAL'S BOARD SHALL GIVE NOTICE TO MONONGALIA HEALTH SYSTEM AND RECEIVE ITS APPROVAL BEFORE ACTING ON ANY OF THE FOLLOWING MATTERS: (A) AMENDMENT OF THE ARTICLES OF INCORPORATION OF THE HOSPITAL OR THE BYLAWS; (B) SALE, LEASE OR EXCHANGE OF ALL OR SUBSTANTIALLY ALL OF THE PROPERTY OR ASSETS OF THE HOSPITAL AND ANY EXPENDITURE IN EXCESS OF $750,000; (C) MERGER OR CONSOLIDATION WITH ANY OTHER CORPORATION; (D) ELECTION TO DISSOLVE THE HOSPITAL ENTITY; (E) APPROVAL OF THE BUDGET OF THE HOSPITAL; (F) APPROVAL IN ADVANCE OF THE HIRING OF THE PRESIDENT OF THE HOSPITAL. FORM 990, PART VI, SECTION B, LINE 11B THE GOVERNING BODY IS PROVIDED A COPY OF THE FORM 990 FOR THEIR REVIEW PRIOR TO SUBMISSION. THE BOARD MEMBERS ARE ASKED TO INFORM MANAGEMENT OF ANY QUESTIONS OR REVISIONS THEY MAY HAVE. IF CHANGES ARE MADE, BASED ON BOARD MEMBER'S REVISIONS, MANAGEMENT REDISTRIBUTES A FINAL VERSION TO ALL BOARD MEMBERS. FORM 990, PART VI, SECTION B, LINE 12C ANNUALLY, A CONFLICT OF INTEREST QUESTIONNAIRE IS SENT OUT TO ALL BOARD MEMBERS. THE BOARD THEN REVIEWS ALL RESPONSES FOR POSSIBLE CONFLICTS OF INTEREST. IF A CONFLICT IS NOTED, THE BOARD MEMBERS DETERMINE WHICH DECISIONS THE CONFLICTED MEMBERS SHALL NOT PARTICIPATE IN. FORM 990, PART VI, SECTION B, LINE 15 ANNUALLY, A CONSULTANT COMPILES A MARKET DATA REPORT ON EXECUTIVE CEO COMPENSATION. THIS REPORT IS THEN REVIEWED BY THE EXECUTIVE COMMITTEE TO DETERMINE COMPENSATION FOR THE INDIVIDUAL. FORM 990, PART VI, SECTION C, LINE 19 THE HOSPITAL PLACES A PUBLICATION IN THE LOCAL NEWSPAPER STATING THE GOVERNING DOCUMENTS, CONFLICTS OF INTEREST POLICY AND FINANCIAL STATEMENTS ARE AVAILABLE UPON REQUEST. FORM 990, PART IX, LINE 11G PHYSICIAN CONSULTING: PROGRAM SERVICE EXPENSES 1,937,300. MANAGEMENT AND GENERAL EXPENSES 327,753. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 2,265,053. LAB SERVICES: PROGRAM SERVICE EXPENSES 1,247,443. MANAGEMENT AND GENERAL EXPENSES 211,043. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 1,458,486. OTHER CONSULTING SERVICES: PROGRAM SERVICE EXPENSES 2,273,579. MANAGEMENT AND GENERAL EXPENSES 384,645. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 2,658,224. FORM 990, PART XI, LINE 9: NET ASSET TRANSFER AND CHANGE OF BENEFICIAL INTEREST HELD BY OTHERS 80,649. FORM 990, PART XII, LINE 2C: THE ORGANIZATION'S FINANCE COMMITTEE OF THE BOARD OF DIRECTORS SELECTS THE INDEPENDENT ACCOUNTANT. THIS PROCESS REMAINS UNCHANGED FROM PRIOR YEARS. MONONGALIA HEALTH SYSTEM 1200 JD ANDERSON DRIVE MORGANTOWN WV 26505 550621551 PARENT/MANAGEMENT COMPANY WV 501(C)(3) LINE 12C, III-FI 0 MONONGALIA COUNTY GENERAL HOSPITAL CO 1200 JD ANDERSON DRIVE MORGANTOWN WV 26505 237441353 HOSPITAL WV 501(C)(3) LINE 3 MONONGALIA HEALTH SYSTEM INC 0 MON ELDER SERVICES INC 1200 JD ANDERSON DRIVE MORGANTOWN WV 26505 311520863 RETIREMENT COMMUNITY WV 501(C)(3) LINE 12C, III-FI MONONGALIA HEALTH SYSTEM INC 0 THE FOUNDATION OF MONONGALIA GENERAL HOSPITAL 1200 JD ANDERSON DRIVE MORGANTOWN WV 26505 550570338 RAISE FUNDS FOR MONONGALIA GENERAL HOSPITAL WV 501(C)(3) LINE 7 MONONGALIA COUNTY GENERAL HOSPITAL CO 0 PRESTON MEMORIAL HOSPITAL 300 SOUTH PRICE STREET KINGWOOD WV 26537 311097818 HOSPITAL WV 501(C)(3) LINE 3 MONONGALIA HEALTH SYSTEM INC 0 PRESTON MEMORIAL MEDICAL GROUP 300 SOUTH PRICE STREET KINGWOOD WV 26537 550717988 PRIMARY AND URGENT CARE WV 501(C)(3) LINE 3 PRESTON MEMORIAL HOSPITAL 0 PRESTON MEMORIAL HEALTH FOUNDATION 300 SOUTH PRICE STREET KINGWOOD WV 26537 550740121 RAISE FUNDS FOR PRESTON HOSPITAL WV 501(C)(3) LINE 12B, II PRESTON MEMORIAL HOSPITAL 0 AUXILIARY OF MONONGALIA GENERAL HOSPITAL 1200 JD ANDERSON DRIVE MORGANTOWN WV 26505 550362965 RAISE FUNDS FOR MONONGALIA GENERAL HOSPITAL WV 501(C)(3) LINE 12A, I MONONGALIA COUNTY GENERAL HOSPITAL CO 0 LIABILITY INSURANCE TRUST FOR MONONGALIA HEALTH SYSTEM 1200 JD ANDERSON DRIVE MORGANTOWN WV 26505 550689535 LIABILITY INSURANCE TRUST WV 501(C)(3) LINE 12A, I MONONGALIA HEALTH SYSTEM INC 0 MON HEALTH MARION NEIGHBORHOOD HOSPITAL 140 MIDDLETOWN LOOP WHITEHALL WV 26554 853994078 HOSPITAL WV 501(C)(3) LINE 3 MONONGALIA HEALTH SYSTEM INC 0 MGH SURGERY LLC 2000 MON HEALTH MEDICAL PARK DR MORGANTOWN WV 26505 472736896 SURGERY CENTER WV N/A 0 0 MON HEALTH CARE INC 1200 JD ANDERSON DRIVE MORGANTOWN WV 26508 550654973 HOME MEDICAL EQUIPMENT PROVIDER WV N/A C 0 STONEWALL HOME OXYGEN THERAPY INC 100 MARKET PLACE MALL SUITE 8 WESTON WV 26452 550754278 OXYGEN THERAPY SERVICES WV STONEWALL JACKSON MEMORIAL HOSPITAL C -71931 351612 1.00000 1 FAIRMONT HOME EQUIPMENT AND SUPPLY 1200 JD ANDERSON DRIVE MORGANTOWN WV 26505 550763259 EQUIPMENT RENT & SVC WV N/A C 0 MORGANTOWN PHYSICAL THERAPY ASSOC INC 943 MAPLE DRIVE MORGANTOWN WV 26505 550614636 REHABILITATION SERVICES WV N/A C 0 CARE PARTNER'S INC 511 BURROUGHS STREET SUITE 102 MORGANTOWN WV 26505 550754326 HOME HEALTH WV N/A C 0 1 0 0 0 0 0 0 0 1 0 0 0 1 0 1 1 1 0 0 STONEWALL HOME OXYGEN THERAPY INC A 16550 FMV - CASH