2022-11-15T16:11:16-06:00 2021-12-31 366055558 GRANT THORNTON LLP 1000 WILSON BOULEVARD SUITE 1400 ARLINGTON VA 22209 990 2021-01-01 540622371 UVA CULPEPER MEDICAL CENTER INC UVAC 5712841163 501 SUNSET LANE CULPEPER VA 20110 CHARLES CODER CFO 5408298803 2022-11-15 1 CHARLES CODER XXX-XX-XXXX MARY TORRETTA P00847851 7038477500 3 AAL1 IAL1 2021 2022-09-23 18:48:47Z X UVA CULPEPER MEDICAL CENTER CHARLES CODER 28 BLACKWELL PARK SUITE 303 WARRENTON VA 20186 137826197 0 X WWW.NOVANTHEALTHUVA.ORG X 1956 VA SEE SCHEDULE O 16 10 872 35 99 0 13669278 4136967 101074270 132216411 157248 19504 1128321 1453108 116029117 137825990 577208 594457 0 0 50053711 53262371 0 0 0 61841504 71792935 112472423 125649763 3556694 12176227 139556597 142018668 31884680 24827195 107671917 117191473 X THE MISSION OF UVA CULPEPER MEDICAL CENTER IS TO HELP PEOPLE ACHIEVE AND MAINTAIN OPTIMAL HEALTH BY PROVIDING THE BEST POSSIBLE HEALTH CARE SERVICES. WE WILL ALWAYS MAKE THE NEEDS OF OUR PATIENTS OUR TOP PRIORITY. 0 0 100393192 594457 133176404 UVA CULPEPER MEDICAL CENTER, INC., DOING BUSINESS AS UVA CULPEPER MEDICAL CENTER ("UVACMC") PROVIDES PROGRAMS AND ACTIVITIES THAT IMPROVE ACCESS TO HEALTHCARE AND IMPROVE HEALTH IN OUR COMMUNITY. UVACMC IS A 70-BED NON-PROFIT, ACUTE CARE HOSPITAL LOCATED IN CULPEPER, VA WITH COMPREHENSIVE SERVICES PROVIDING A 24 HOUR, PHYSICIAN STAFFED EMERGENCY DEPARTMENT, FAMILY BIRTH CENTER, SURGICAL SERVICES, INTENSIVE CARE UNIT AND MORE. UVACMC PROVIDES MEDICAL AND OTHER HEALTHCARE SERVICES TO PATIENTS REGARDLESS OF THEIR ABILITY TO PAY. OUR MISSION IS TO HELP PEOPLE ACHIEVE AND MAINTAIN OPTIMAL HEALTH BY PROVIDING THE BEST POSSIBLE HEALTHCARE SERVICES. WE ALWAYS MAKE THE NEEDS OF OUR PATIENTS OUR TOP PRIORITY. (SEE SCHEDULE O FOR CONTINUATION.)WE ALSO PARTNER WITH LOCAL NON-PROFIT ORGANIZATIONS (THE CHAMBER OF COMMERCE AND LOCAL SCHOOLS), TO SUPPORT LOCAL EVENTS AND PROVIDE HEALTH AND WELLNESS PROGRAMS. ALL UNINSURED PATIENTS, REGARDLESS OF INCOME LEVEL OR COUNTY OF RESIDENCE, RECEIVE A 20% DISCOUNT ON HOSPITAL SERVICES AND AN ADDITIONAL 15% DISCOUNT FOR PAYMENT WITHIN 30 DAYS. UVACMC WORKS WITH LOCAL COMMUNITY COLLEGES TO PROVIDE TOURS, LECTURES, AND INTERNSHIPS FOR STUDENTS. UVACMC PUBLISHES TWO MAJOR COMMUNITY NEWSLETTERS. "SIMPLY HEALTH AND "AGING WELL" ARE PUBLISHED 3 TIMES A YEAR; THEY REACH 50,000 HOMES IN CULPEPER AND SURROUNDING COUNTIES. DURING 2021, THERE WERE 12,712 PATIENT DAYS, WITH AN AVERAGE LENGTH OF STAY OF 4 DAYS, AND AN AVERAGE DAILY CENSUS OF 35. THERE WERE 3,040 DISCHARGES, 2,682 INPATIENT AND OUTPATIENT SURGERIES, 105,979 OUTPATIENT ENCOUNTERS AND 34,917 EMERGENCY DEPARTMENT VISITS. 100393192 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 1 1 1 0 0 0 0 0 0 0 0 0 0 0 0 0 1 1 1 0 0 1 75 0 1 872 1 1 1 0 0 0 0 0 0 0 0 0 0 0 X 16 10 0 0 1 0 1 1 1 1 1 0 0 1 1 1 1 1 1 0 0 1 1 VA X X CHARLES CODER 5712841163 28 BLACKWELL PARK SUITE 303 WARRENTON VA 20186 SALLY BARBER VICE CHAIR (END 6/30/21) 0.20 0.00 X X 0 0 0 CHARLES BARRELL CHR(END 6/30/21)/TRUSTEE(EFF 7/1/21) 0.20 0.00 X X 0 0 0 JAMES FERGUSON TRUSTEE (END 6/30/21) 0.20 0.00 X 0 0 0 RICHARD HARRINGTON TRUSTEE 0.20 0.00 X 0 0 0 HORTENSE HINTON-JACKSON TRUSTEE (END 6/30/21) 0.20 0.00 X 0 0 0 DOUGLAS LISCHKE TREAS (ENDS 6/30/21) 0.20 0.00 X X 0 553401 91842 THOMAS REYNOLDS SEC (ENDS 6/30/21) 0.20 0.00 X X 0 0 0 SCOTT SYVERUD TRUSTEE (END 6/30/21) 0.20 0.00 X 0 0 0 MARY FRANCES SOUTHERLAND TRUSTEE (EFF 7/1/21) 0.20 0.00 X 0 388370 81839 KIRSTEN GREEN MD TRUSTEE (EFF 7/1/21) 0.20 0.00 X 0 882841 106767 LISA ANN PEACOCK TRUSTEE (EFF 7/1/21) 0.20 0.00 X 0 0 0 MICHELLE METZGAR TRUSTEE (EFF 7/1/21) 0.20 0.00 X 0 0 0 STEVE DANZIGER CHAIR (EFF 7/1/21) 0.20 0.00 X X 0 0 0 CHRIS HEATON MD TRUSTEE (EFF 7/1/21) / PHYS UVA COMM GRP 0.20 45.00 X 0 454552 46058 JACKIE KRICK TRUSTEE (EFF 7/1/21) 0.20 0.00 X 0 0 0 KHOT VIKRAM MD TRUSTEE (EFF 7/1/21) 0.20 45.00 X 0 20869 0 MATT GUILFOYLE TRUSTEE (EFF 7/1/21) 0.20 0.00 X 0 0 0 STEPHEN NELSON TRUSTEE (EFF 7/1/21) 0.20 0.00 X 0 0 0 PAM KINCHELOE RN JD TRUSTEE (EFF 7/1/21) 0.20 0.00 X 0 0 0 BEN WAMPLER MD TRUSTEE (EFF 7/1/21) 0.20 0.00 X 0 0 0 SHIV KHANDELWAL MD TRUSTEE (EFF 7/1/21) 0.20 0.00 X 0 546607 49804 ROSS SWITKES MD TRUSTEE (EFF 7/1/21) 0.20 0.00 X 0 30420 0 ALFRED PILONG SVP & CEO 0.20 50.00 X 0 1081946 150118 DONNA STATON SYSTEM COO & PRESIDENT 50.00 0.00 X 367768 0 28455 JONATHAN D'SOUZA CHIEF MEDICAL OFFICER 1/1/21-2/20/21 50.00 0.00 X 170813 0 5602 NAEL HASAN CHIEF MEDICAL OFFICER EFF 2/20/21 50.00 0.00 X 215259 0 892 MINDI SHIFFLETT CNO & CLINICAL OPERATIONS OFFICER 50.00 0.00 X 231175 0 32090 MICHELLE STRIDER CHIEF QUALITY OFFICER 50.00 0.00 X 193959 0 24238 SUSAN EDWARDS SR DIR - HR/SUPPORT SERVICES 50.00 0.00 X 200785 0 32073 SARA WHITE SR DIR - FINANCE 50.00 0.00 X 210229 0 24498 PATRICIA SLATER COMPLIANCE RISK & PRIVACY OFFICER 50.00 0.00 X 166179 0 9711 DENNIS SMITH PHARMACY MANAGER 45.00 0.00 X 190531 0 19879 TEMPLE COATES DIR - PROFESSIONAL & ANCILLARY SERVICES 45.00 0.00 X 182846 0 31822 MARK UTZ DIR - PLANT ENGINEERING SERVICES 45.00 0.00 X 178224 0 20157 STEVEN SPEELMAN DIR - INFORMATION SYSTEMS 45.00 0.00 X 177130 0 26637 MARK CHANEY DIR - NURSING 45.00 0.00 X 162657 0 31090 2647555 3959006 813572 70 0 1 0 UNIVERSITY OF VIRGINIA PHYSICIANS GROUP 4105 LEWIS CLARK DRIVE CHARLOTTESVILLE VA 22911 CLINICAL SUPPORT 4583957 NOVANT HEALTH 2085 FRONTIS PLAZA BLVD WINSTON SALEM NC 27103 PURCHASED SERVICES 4170243 UVA MEDICAL CENTER PO BOX 800778 CHARLOTTESVILLE VA 22903 CLINICAL SUPPORT 3692455 AMERICAN ANESTHESIOLOGY PO BOX 281034 ATLANTA GA 30384 PHYSICIAN SUPPORT 1902571 QUALIVIS PO BOX 12384 DALLAS TX 75312 STAFFING SERVICES 1322011 40 4087673 49294 4136967 NET PATIENT REVENUE 622110 130987927 130987927 PASS-THRU PATIENT REVENUE 621111 1228484 1228484 132216411 19711 19711 310099 0 310099 310099 310099 207 -207 -207 -207 MISCELLANEOUS REVENUE 900099 959993 959993 CAFETERIA MEALS 722514 182917 182917 CATERING 722320 99 99 1143009 137825990 133176404 99 512520 X 578000 578000 16457 16457 2080319 2080319 39543731 25703426 13840305 1505295 978442 526853 7115462 4625050 2490412 3017564 1961417 1056147 133896 133896 20125175 17071241 3053934 16311 16311 1558978 1217138 341840 1190436 1190436 1576884 1513810 63074 1561 1015 546 74104 48168 25936 6471959 6224260 247699 1258987 113627 1145360 PHARMACEUTICALS 15844521 15844521 MEDICAL SUPPLIES 12504734 12447120 57614 BAD DEBT 7994688 7994688 REPAIRS AND MAINTENANCE 1804149 1781064 23085 1236552 1067001 169551 125649763 100393192 25256571 0 33613208 33759906 15064646 19996516 0 348354 2463799 2963206 1004429 1397250 74449838 20011052 57420053 54438786 3404716 3751664 23912743 23633260 2673003 1729726 139556597 142018668 26103302 19721033 5781378 5106162 31884680 24827195 X 107511485 117003701 160432 187772 107671917 117191473 139556597 142018668 X 12176227 -99777 -2556894 X 0 1 X 1 1 1 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 0 0 0 0 0 0 0 0 1 77 77 0 PART II-B, LINE 1: LINE 1I DUES PAID TO CERTAIN ORGANIZATIONS WHICH INCLUDE A PORTION RELATED TO LOBBYING ACTIVITIES. 6192309 6192309 26622297 12224936 14397361 114363 114363 0 36013565 5119796 30893769 5507304 2551957 2955347 54438786 0 THIRD PARTY PAYMENT PAYABLE 2886125 DUE TO AFFILIATES 500000 OPERATING LEASE 1720037 5106162 X PART X, LINE 2: PART X, LINE 2: LIABILITY UNDER FIN 48 (ASC 740) FOOTNOTE THE AUDIT FOR UVA COMMUNITY HEALTH AND ITS AFFILIATES IS PREPARED ON A CONSOLIDATED BASIS. THE COMPANY IS REQUIRED TO EVALUATE UNCERTAIN TAX POSITIONS. THIS EVALUATION INCLUDES A QUANTIFICATION OF TAX RISK IN AREAS SUCH AS UNRELATED BUSINESS TAXABLE INCOME. THIS EVALUATION DID NOT HAVE A MATERIAL EFFECT ON THE COMPANY'S CONSOLIDATED STATEMENTS OF OPERATIONS AND CHANGES IN NET ASSETS FOR THE YEARS ENDED DECEMBER 31, 2021 AND 2020. 1 1 1 X 1 X 0 1 1 0 1 1 4497202 0 4497202 0.03820 25846573 25846573 30343775 25846573 4497202 0.03820 42758 0 42758 0.00040 500000 0 500000 0.00420 542758 542758 0.00460 30886533 25846573 5039960 0.04280 1500 0 1500 0.00000 1500 1500 0.00000 1 7994688 0 42946805 54146978 -11200173 X 1 1 1 CULPEPER SURGERY CENTER LLC OUTPATIENT SURGERY CENTER 0.62670 0.00000 0.37330 1 1 UVACMC DBA UVA CULPEPER MEDICAL CENTER 501 SUNSET LANE CULPEPER VA 22701 WWW.NOVANTHEALTHUVA.ORG H1848 X X X UVA CULPEPER MEDICAL CENTER 1 0 0 1 X X X X X X X X X 20 1 0 0 1 X SEE SECTION C X 1 20 1 SEE SECTION C 0 1 X 200.000000000000 400.000000000000 X X X 1 1 X X X 1 X SEE SECTION C X SEE SECTION C X SEE SECTION C X X X X X X 1 X 0 X X X X 1 X 0 0 UVA CULPEPER MEDICAL CENTER PART V, SECTION B, LINE 3J: UVA CULPEPER MEDICAL CENTER:PART V, SECTION B, LINE 3E:SEVERAL SOCIAL, BEHAVIORAL, AND CLINICAL HEALTH NEEDS WERE IDENTIFIED THROUGH A COMMUNITY HEALTH NEEDS ASSESSMENT SURVEY. ONCE THE HEALTH NEEDS WERE IDENTIFIED, SURVEYS AND COMMUNITY MEETINGS WERE CONDUCTED TO ASK COMMUNITY MEMBERS AND STAKEHOLDERS TO RANK THE TOP HEALTH ISSUES ACCORDING TO YEARS OF POTENTIAL LIFE LOST AND MAGNITUDE OF THESE ISSUES. THE SCORES ARE CALCULATED TO RANK THE FOCUS AREAS AND PRIORITIZE THE IDENTIFIED HEALTH NEEDS. UVA CULPEPER MEDICAL CENTER PART V, SECTION B, LINE 5: WHILE CONDUCTING THE CHNA, THE HOSPITAL FACILITY SOLICITED INPUT FROM, AND CONSULTED WITH, A VARIETY OF COMMUNITY REPRESENTATIVES INCLUDING, BUT NOT LIMITED TO, REPRESENTATIVES OF CITY AND COUNTY GOVERNMENT INCLUDING HEALTH DEPARTMENTS, COMMUNITY-BASED ORGANIZATIONS, FOUNDATIONS, AND OTHER SOCIAL SERVICE AGENCIES. INPUT WAS GATHERED THROUGH A COLLABORATIVE COMMUNITY HEALTH NEEDS ASSESSMENT SURVEY AND DATA FROM THE VIRGINIA DEPARTMENT OF HEALTH. THE SCOPE OF EXPERTISE WAS BROAD AND INCLUDED SUCH AREAS AS PUBLIC HEALTH, MINORITY POPULATIONS, HEALTH DISPARITIES, AND SOCIAL SERVICES. WHERE POSSIBLE, WE HAVE LEVERAGED THE RESOURCES OF THE ORGANIZATION TO BEST ADDRESS THOSE NEEDS THAT ARE HIGHEST IN PRIORITY AND CONSISTENT ACROSS COMMUNITIES. UVA CULPEPER MEDICAL CENTER PART V, SECTION B, LINE 7D: UVA CULPEPER MEDICAL CENTERPART V, SECTION B, LINE 7BHTTPS://WWW.NOVANTHEALTHUVA.ORG/ABOUT-US/COMMUNITY-ENGAGEMENT/COMMUNITY-BENEFIT.ASPXUVA CULPEPER MEDICAL CENTERPART V, SECTION B, LINE 10AHTTPS://WWW.NOVANTHEALTHUVA.ORG/ABOUT-US/COMMUNITY-ENGAGEMENT/COMMUNITY-BENEFIT.ASPX UVA CULPEPER MEDICAL CENTER PART V, SECTION B, LINE 11: THE HOSPITAL FACILITY IS A PART OF UVA COMMUNITY HEALTH, AN INTEGRATED NOT-FOR-PROFIT HEALTH SYSTEM. THE FACILITY'S CHNA IDENTIFIED MULTIPLE NEEDS FOR THE COMMUNITY SERVED. THE NEEDS IDENTIFIED WERE REVIEWED AND PRIORITIZED BY HOSPITAL LEADERSHIP AND BOARD OF TRUSTEE MEMBERS; AS WELL AS, THE UVA MEDICAL CENTER AND UNIVERSITY OF VIRGINIA PHYSICIANS GROUP. NEEDS WERE EVALUATED BASED ON THE FACILITY'S SCOPE OF SERVICE, EXPERTISE, AVAILABILITY OF RESOURCES, AND THE FACILITY'S ABILITY TO IMPACT OVERALL POPULATION HEALTH. THE HOSPITAL FACILITY HAS ADOPTED AND EXECUTED AN IMPLEMENTATION STRATEGY THAT ADDRESSES THE PRIORITIZED COMMUNITY HEALTH NEEDS FROM THE CHNA. THE IMPLEMENTATION STRATEGY OUTLINES THE PLAN THAT THE HOSPITAL FACILITY WILL UNDERTAKE TO MEET THOSE HEALTH NEEDS IN ITS COMMUNITY. CERTAIN NEEDS THAT WERE IDENTIFIED BY THE CHNA HAVE NOT BEEN ADDRESSED. IT WAS DETERMINED THAT THERE ARE OTHER RESOURCES IN THE COMMUNITY THAT CAN MORE APPROPRIATELY ADDRESS THESE NEEDS BASED ON SCOPE OF SERVICES AND SKILL SET. FOR MORE DETAILED INFORMATION, REFER TO THE PUBLICLY AVAILABLE IMPLEMENTATION PLAN AVAILABLE ON THE WEBSITE; REFER TO THE URL GIVEN PREVIOUSLY FOR THE POSTING OF THE PLAN. UVA CULPEPER MEDICAL CENTER PART V, SECTION B, LINE 13H: UVA CULPEPER MEDICAL CENTER:PART V, LINE 16A, FAP WEBSITE:HTTPS://WWW.NOVANTHEALTHUVA.ORG/PATIENTS--VISITORS/FINANCIAL-ASSISTANCE-FOR-THE-UNINSURED.ASPXPART V, LINE 16B, FAP APPLICATION:HTTPS://WWW.NOVANTHEALTHUVA.ORG/PATIENTS--VISITORS/FINANCIAL-ASSISTANCE-FOR-THE-UNINSURED.ASPXPART V, LINE 16C, FAP PLAIN LANGUAGE SUMMARY:HTTPS://WWW.NOVANTHEALTHUVA.ORG/PATIENTS--VISITORS/FINANCIAL-ASSISTANCE-FOR-THE-UNINSURED.ASPX 2 1 - CULPEPER SURGERY CENTER LLC 541 SUNSET LANE STE 201 CULPEPER VA 22701 AMBULATORY SURGERY CENTER 2 - UVA OUTPATIENT IMAGING CULPEPER LLC 501 SUNSET LANE CULPEPER VA 22701 IMAGING CENTER PART I, LINE 3C: OTHER CRITERIA BESIDES INCOME AND FPG USED IN DETERMINING ELIGIBILITY FOR FINANCIAL ASSISTANCE INCLUDE WHETHER THE PATIENT HAS ANY OF THE FOLLOWING ASSETS: CHECKING OR SAVINGS ACCOUNTS, STOCKS, BONDS, IRAS, 401KS, CDS, LIFE INSURANCE (CASH TO LOAN VALUE), REAL PROPERTY, OR PERSONAL PROPERTY SUCH AS VEHICLES, CAMPERS, OR MOBILE HOMES. PART I, LINE 6A: THE COMMUNITY BENEFIT REPORT IS PREPARED BY A RELATED ORGANIZATION. NOVANT HEALTH, INC. IS A MEMBER ORGANIZATION OF THE NOVANT HEALTH UVA HEALTH SYSTEM. IT PRODUCES A COMMUNITY BENEFIT REPORT, REFERRED TO AS A COMMUNITY IMPACT REPORT, REPRESENTING THE HEALTH SYSTEM AS A WHOLE INCLUDING THE FILING ORGANIZATION. THE REPORT CAN BE FOUND AT HTTPS://WWW.NOVANTHEALTH.ORG/HOME/ABOUT-US/COMMUNITY-ENGAGEMENT/OUR-IMPACT.ASPX. PLEASE NOTE THAT THE NUMERIC DATA IN THIS REPORT IS NOT BASED UPON THE FORM 990, SCHEDULE H CRITERIA, BUT RATHER IT HAS BEEN PREPARED IN ACCORDANCE WITH THE NORTH CAROLINA HOSPITAL ASSOCIATION REPORTING GUIDELINES. IT SHOULD NOT BE RELIED UPON AS THE ORGANIZATION'S FORM 990, SCHEDULE H COMMUNITY BENEFIT REPORT, ITS COMMUNITY HEALTH NEEDS ASSESSMENT OR COMMUNITY BENEFIT IMPLEMENTATION STRATEGY. PART I, LINE 7: THE COSTING METHODOLOGY USED TO CALCULATE AMOUNTS REPORTED IN LINE 7 WAS A COST-TO-CHARGE RATIO DERIVED FROM WORKSHEET 2, RATIO OF PATIENT CARE COST-TO-CHARGES. PART I, LN 7 COL(F): THE AMOUNT OF BAD DEBT REMOVED FROM TOTAL EXPENSES (DENOMINATOR) WAS $7,994,688. PART II, COMMUNITY BUILDING ACTIVITIES: THE ORGANIZATION'S COMMUNITY BUILDING ACTIVITIES ADDRESS THE UNDERLYING CAUSES OF HEALTH PROBLEMS AND IMPACTS THE HEALTH OF OUR COMMUNITY THROUGH PARTNERSHIPS WITH LOCAL AGENCIES DEDICATED TO IMPROVING THE LIVES OF ALL INDIVIDUALS. OUTREACH INCLUDES PROVIDING SUPPORT TO ORGANIZATIONS SUCH AS CHAMBERS OF COMMERCE AND OTHER LOCAL COMMUNITY ORGANIZATIONS, AND PROVIDING EDUCATION SCHOLARSHIPS AND TRAINING FOR COMMUNITY WORKFORCES. PART III, LINE 2: IMPLICIT PRICE CONCESSIONS (ANALOGOUS TO BAD DEBT EXPENSE) ARE DETERMINED BASED ON MANAGEMENT'S ASSESSMENT OF HISTORICAL AND EXPECTED NET COLLECTIONS, BUSINESS, AND ECONOMIC CONDITIONS, THE AGE OF THE ACCOUNTS, TRENDS IN FEDERAL AND STATE GOVERNMENTAL HEALTHCARE COVERAGE, AND OTHER COLLECTION INDICATORS. PART III, LINE 4: THE ORGANIZATION'S IMPLICIT PRICE CONCESSIONS (ANALOGOUS TO BAD DEBT EXPENSE) ON LINE 2 IS CALCULATED USING THE SAME METHODOLOGY AS CHARITY CARE AND OTHER COMMUNITY BENEFITS USING AN ENTITY SPECIFIC COST TO CHARGE RATIO (CCR). FOOTNOTE 2 (ACCOUNTS RECEIVABLE) ON PAGE 8 OF THE AUDITED FINANCIAL STATEMENTS DESCRIBES PRICE CONCESSIONS. PART III, LINE 8: THE METHODOLOGY USED TO DETERMINE THE MEDICARE ALLOWABLE COSTS REPORTED IN THE ORGANIZATION'S MEDICARE COST REPORT AS REFLECTED IN THE AMOUNT REPORTED IN PART III, LINE 6 IS DETERMINED BY FOLLOWING THE MEDICARE PRINCIPLES OF ALLOWABLE COSTS. COST FOR THE OVERHEAD DEPARTMENTS ARE STEPPED DOWN TO THE REMAINING COST CENTERS BASED ON STATISTICS FOR EACH OVERHEAD COST CENTER. ONCE THE STEP-DOWN PROCESS IS COMPLETE, A COST TO CHARGE RATIO ("CCR") IS DEVELOPED FOR EACH COST CENTER. THE CCR IS THEN APPLIED TO THE MEDICARE REVENUE BY COST CENTER AND TOTALED. IT SHOULD BE NOTED THAT THE MEDICARE COST REPORTS DO NOT ADDRESS ANY MANAGED CARE MEDICARE REVENUES, COSTS, OR RELATED SHORTFALL. THE TOTAL REVENUES REPORTED AS RECEIVED FROM MEDICARE IN LINE 5 OF SECTION B ARE ONLY REPRESENTATIVE OF MEDICARE FEE FOR SERVICE PAYMENTS RECEIVED. THE ALLOWABLE COSTS ON LINE 6 ARE SIGNIFICANTLY LOWER THAN THE ACTUAL EXPENDITURES. AS SUCH, THE SHORTFALL IS UNDERESTIMATED. EVERY HOSPITAL TREATS MEDICARE PATIENTS. SOME HOSPITALS ARE LOCATED IN HIGH MEDICARE POPULATION AREAS; OTHERS PROVIDE SERVICES DISPROPORTIONATELY USED BY MEDICARE PATIENTS. MEDICARE RATES AND NUMBERS OF MEDICARE PATIENTS ARE NOT NEGOTIATED. AS REIMBURSEMENT RATES DECLINE RELATIVE TO COSTS OF CARE, HOSPITALS CONTINUE TO SERVE THE MEDICARE POPULATION. WITHOUT THIS SERVICE THESE PATIENTS WOULD BECOME AN OBLIGATION ON THE GOVERNMENT. ANY UNREIMBURSED COSTS OF THIS CARE ARE A COMMUNITY BENEFIT PROVIDED BY THE HOSPITAL TO THE COMMUNITY AND GOVERNMENT. PART III, LINE 9B: THE FILING ORGANIZATION HAS A POLICY THAT OUTLINES PROCEDURES THE HOSPITAL MAY TAKE FOR NONPAYMENT INCLUDING INTERNAL AND EXTERNAL COLLECTION PRACTICES AND REPORTING TO CREDIT AGENCIES. THE POLICY STATES THAT REASONABLE EFFORTS TO DETERMINE ELIGIBILITY FOR FINANCIAL ASSISTANCE MUST BE MADE BEFORE THE ORGANIZATION, OR ANY EXTERNAL ORGANIZATION, ENGAGE IN AN EXTRAORDINARY COLLECTION ACTION.FOR PATIENTS WHO QUALIFY FOR FINANCIAL ASSISTANCE AND WHO ARE COOPERATING IN GOOD FAITH TO RESOLVE THEIR DISCOUNTED HOSPITAL BILLS, THE ORGANIZATION MAY OFFER EXTENDED PAYMENT PLANS, WILL NOT SEND UNPAID BILLS TO OUTSIDE COLLECTION AGENCIES, AND WILL CEASE ALL COLLECTION EFFORTS. PART VI, LINE 2: AT THE TIME THE CHNA WAS PERFORMED, THE ORGANIZATION WAS PART OF NOVANT HEALTH UVA HEALTH SYSTEM, AN INTEGRATED NOT-FOR-PROFIT HEALTH SYSTEM. AS OF JULY 1, 2021, UVA MEDICAL CENTER TOOK FULL OWNERSHIP OF NHUVAHS, AT WHICH TIME THE SYSTEM TRANSITIONED ITS NAME TO UVA COMMUNITY HEALTH, INC. AND BEGAN THE PROCESS TO REBRAND ALL FACILITIES AND ENTITIES UNDER THE "UVA HEALTH" BRAND. UVA COMMUNITY HEALTH, INC. HAS A COMMUNITY BENEFIT DEPARTMENT ("CB DEPARTMENT") COMPRISED OF COMMUNITY BENEFIT PROFESSIONALS AND AN ASSOCIATED ADVISORY WORKING GROUP ("THE COMMUNITY BENEFIT GROUP") THAT INCLUDES REPRESENTATIVES FROM INTERNAL AUDIT, LEGAL, AND TAX. THE CB DEPARTMENT IS RESPONSIBLE FOR COORDINATING THE PREPARATION OF THE COMMUNITY HEALTH NEEDS ASSESSMENTS (CHNA) REPORTED IN PART V, SECTION B, FOR EACH HOSPITAL WITHIN UVA COMMUNITY HEALTH, INC. AS WELL AS FOR THE FILING ORGANIZATION. EACH HOSPITAL AND THE COMMUNITY BENEFIT GROUP WORK TOGETHER TO IDENTIFY ORGANIZATIONS AND RESOURCES WITHIN ITS COMMUNITY THAT CONTRIBUTE TO THE PROCESS. THESE ORGANIZATIONS AND RESOURCES INCLUDE PUBLIC HEALTH DEPARTMENTS, LOCAL COMMUNITY COALITIONS REPRESENTING THE MEDICALLY UNDERSERVED, UNITED WAY, LOCAL UNIVERSITIES, ETC. COMMUNITY HEALTH ASSESSMENTS PREPARED BY OTHER ORGANIZATIONS IN THE COMMUNITY ARE USED IN COMBINATION WITH INTERNAL HOSPITAL DATA AND INFORMATION COLLECTED FROM LOCAL AGENCIES TO PREPARE THE HOSPITAL'S CHNA. IN ADDITION TO ADDRESSING NEEDS IDENTIFIED THROUGH THE CHNA, EACH HOSPITAL MAY RESPOND TO REQUESTS FOR SPECIFIC COMMUNITY BENEFIT ACTIVITIES OR PROGRAMS FROM PUBLIC AGENCIES OR COMMUNITY GROUPS. PART VI, LINE 3: UVA CULPEPER MEDICAL CENTER HAS SEVERAL WAYS THAT IT INFORMS AND EDUCATES PATIENTS WHO MAY BE IN NEED AND ARE ELIGIBLE FOR ASSISTANCE. WHEN STAFF (CASHIER, FINANCIAL COUNSELOR, AND REGISTERS) ARE SPEAKING WITH A PATIENT THAT STATES THEY ARE NOT ABLE TO PAY, THE PATIENT IS ENCOURAGED TO APPLY FOR FINANCIAL ASSISTANCE. BROCHURES DESCRIBING THE FINANCIAL ASSISTANCE POLICY ARE PLACED IN OUR BILLING STATEMENTS, AS WELL AS THE APPLICABLE POVERTY GUIDELINES FOR QUALIFYING FOR FINANCIAL ASSISTANCE. IN ADDITION, FINANCIAL ASSISTANCE APPLICATIONS, AS WELL AS FAQS WITH RESPECT TO THE FINANCIAL ASSISTANCE POLICY, ARE HANDED OUT TO PATIENTS UPON REGISTRATION. THE HOSPITAL'S WEBSITE POSTS THE HOSPITAL'S FINANCIAL ASSISTANCE POLICY AND GUIDELINES FOR APPLYING. PART VI, LINE 4: UVA CULPEPER MEDICAL CENTER, INC. DBA UVA CULPEPER MEDICAL CENTERTHE ORGANIZATION DEFINES ITS COMMUNITY BY ITS PRIMARY SERVICE AREA. THE PRIMARY SERVICE AREA FOR UVA CULPEPER MEDICAL CENTER IS DEFINED BY THE ZIP CODES THAT REPRESENT 75% TO 85% OF THE HOSPITAL'S IN-PATIENT POPULATION. THESE ZIP CODES ALL FALL WITHIN CULPEPER COUNTY, VIRGINIA. BASED ON 2020 ESTIMATES, CULPEPER COUNTY HAD AN ESTIMATED 53,428 RESIDENTS. SPREAD ACROSS THE FOOTHILLS OF THE BLUE RIDGE MOUNTAINS' FIELDS OF THE NORTH CENTRAL PIEDMONT REGION, CULPEPER COUNTY, VIRGINIA POSSESSES A RURAL CHARACTER DISPLAYING THE NATURAL SPLENDOR OF RUSTIC VIRGINIA. CULPEPER COUNTY HAD SLIGHT POPULATION GROWTH OF ROUGHLY 12.7% SINCE THE 2010 US CENSUS. CHILDREN AND ADOLESCENTS (AGE 0-18) MAKE UP CLOSE TO ONE-QUARTER (24%) OF THE POPULATION IN CULPEPER COUNTY AND SENIORS (AGE 65 AND OVER) MAKE UP 16% OF THE POPULATION, WHICH IS EQUAL TO THE SENIOR POPULATION ESTIMATE FOR THE STATE OF VIRGINIA. NONWHITE MINORITIES CURRENTLY MAKE UP OVER ONE-THIRD (39%) OF THE RACIAL DEMOGRAPHIC IN CULPEPER COUNTY. THE SPECIFIC POPULATION GROUPS (ETHNIC AND CULTURAL) ARE AS FOLLOWS: WHITE NON-HISPANIC 74%; BLACK/AFRICAN-AMERICAN 14%; HISPANIC OR LATINO 12%; OTHER 11%. DATA TAKEN FROM THE 2019 US CENSUS BUREAU INCLUDES INDIVIDUALS THAT IDENTIFIED WITH MULTIPLE RACES; THEREFORE, THE PERCENTAGES EXCEED 100%. ACCORDING TO THE US CENSUS BUREAU DATA, THE MEDIAN HOUSEHOLD INCOME LEVEL WAS $67,696. THE POVERTY RATE FOR CULPEPER COUNTY IS 9.9.THIS IS THE ONLY ACUTE CARE FACILITY IN THE COMMUNITY. STATISTICAL INFORMATION WAS GATHERED FROM VARIOUS STATE AND FEDERAL SOURCES BUT PRIMARILY THE US CENSUS BUREAU. SPECIFIC REFERENCES AND OTHER SUPPORTING INFORMATION CAN BE FOUND IN THE ORGANIZATION'S MOST RECENT COMMUNITY BENEFIT IMPLEMENTATION PLAN AT: HTTPS://WWW.NOVANTHEALTHUVA.ORG/ABOUT-US/COMMUNITY-ENGAGEMENT/COMMUNITY-BENEFIT.ASPX#2020-2022-1337. PART VI, LINE 5: THE ORGANIZATION FURTHERS ITS EXEMPT PURPOSES BY DOING THE FOLLOWING:1. ADOPTING A FINANCIAL ASSISTANCE POLICY;2. REMAINING CERTIFIED BY THE U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES TO PROVIDE SERVICES TO ALL BENEFICIARIES OF MEDICARE, MEDICAID, AND OTHER GOVERNMENT PAYMENT PROGRAMS, AND PROVIDING SERVICES IN A NONDISCRIMINATORY MANNER TO SUCH BENEFICIARIES;3. OPERATING A FULL-TIME EMERGENCY ROOM WHICH IS OPEN TO AND ACCEPTS ALL PERSONS, REGARDLESS OF THEIR ABILITY TO PAY;4. MAINTAINING AN OPEN MEDICAL STAFF, SUBJECT TO EXCLUSIVE CONTRACTS FOR HOSPITAL-BASED SERVICES SUCH AS ANESTHESIOLOGY, RADIOLOGY, PATHOLOGY, HOSPITALIST, AND EMERGENCY DEPARTMENT SERVICES, TO THE EXTENT AN EXCLUSIVE CONTRACT FOR THOSE SERVICES IS REQUIRED TO OBTAIN PROPER STAFFING COVERAGE OR TO PERMIT A MORE EFFICIENT DELIVERY OF THOSE SERVICES WITHIN THE HOSPITAL FACILITY;5. MAINTAINING A GOVERNING BOARD CONSISTING PRIMARILY OF A BROAD CROSS-SECTION OF LEADERS IN THE COMMUNITY;6. ADOPTING AND APPLYING A CONFLICT OF INTEREST POLICY, WHICH APPLIES TO THE GOVERNING BOARD AND ORGANIZATION OFFICERS;7. PROVIDING HEALTH EDUCATION LECTURES AND WORKSHOPS;8. PARTICIPATING IN HEALTH FAIRS, AND PROVIDING EDUCATION ON SPECIFIC DISEASES OR CONDITIONS, AND HEALTH PROMOTION AND WELLNESS PROGRAMS TO THE COMMUNITIES IT SERVES;9. PROVIDING SUPPORT GROUPS AND SELF HELP PROGRAMS TO THE COMMUNITIES IT SERVES;10. PROVIDING COMMUNITY-BASED CLINICAL SERVICES, INCLUDING WITHOUT LIMITATION, HEALTH SCREENINGS AND CLINICS FOR UNINSURED OR UNDERINSURED PERSONS TO THE COMMUNITIES IT SERVES;11. PROVIDING HEALTHCARE SUPPORT SERVICES, INCLUDING WITHOUT LIMITATION, INFORMATION AND REFERRAL TO COMMUNITY SERVICES, CASE MANAGEMENT OF UNDERINSURED AND UNINSURED PERSONS, TELEPHONE INFORMATION SERVICES AND ASSISTANCE TO ENROLL IN PUBLIC PROGRAMS, SUCH AS MEDICAID TO THE COMMUNITIES IT SERVES;12. PROVIDING CASH AND IN-KIND CONTRIBUTIONS TO NONPROFIT COMMUNITY HEALTHCARE ORGANIZATIONS IN THE COMMUNITIES IT SERVES; AND13. GENERALLY PROMOTING THE HEALTH, WELLNESS, AND WELFARE OF THE COMMUNITIES IT SERVES BY PROVIDING QUALITY HEALTHCARE SERVICES AT REASONABLE COST.FOR SPECIFIC EXAMPLES OF THIS ORGANIZATION'S COMMUNITY BENEFIT ACTIVITIES, WHICH FURTHER THE ORGANIZATION'S EXEMPT PURPOSES (AND THOSE OF ALL HOSPITALS AND HEALTHCARE FACILITIES IN THE SAME HEALTHCARE SYSTEM), PLEASE SEE THE NOVANT HEALTH COMMUNITY BENEFIT REPORT, LOCATED AT HTTPS://WWW.NOVANTHEALTHUVA.ORG/ABOUT-US/COMMUNITY-ENGAGEMENT/COMMUNITY-BENEFIT.ASPXPLEASE NOTE THAT THE NUMERIC INFORMATION IN THIS REPORT IS NOT BASED UPON THE FORM 990, SCHEDULE H CRITERIA, BUT RATHER IT HAS BEEN PREPARED IN ACCORDANCE WITH THE NORTH CAROLINA HOSPITAL ASSOCIATION REPORTING GUIDELINES. PART VI, LINE 6: THE ORGANIZATION IS AN INTEGRAL PART OF UVA COMMUNITY HEALTH AND THE RECTORS AND VISITORS OF THE UNIVERSITY OF VIRGINIA, BOTH NOT-FOR-PROFIT INTEGRATED GROUPS OF HOSPITALS, PHYSICIAN CLINICS, OUTPATIENT CENTERS AND OTHER HEALTHCARE SERVICE PROVIDERS. EACH HOSPITAL PROVIDES SUBSTANTIAL COMMUNITY BENEFIT TO THE COMMUNITY IT SERVES, AS REPORTED INDIVIDUALLY ON EACH HOSPITAL'S FORM 990, SCHEDULE H. THE SYSTEM'S COMMUNITY BENEFIT AS A WHOLE IS DOCUMENTED IN A SYSTEM-WIDE COMMUNITY BENEFIT REPORT, LOCATED AT HTTP://WWW.NOVANTHEALTH.ORG/HOME/ABOUT-US/COMMUNITY-ENGAGEMENT/OUR-IMPACT.ASPX. PLEASE NOTE THAT THE NUMERIC INFORMATION IN THIS REPORT IS NOT BASED UPON THE FORM 990, SCHEDULE H CRITERIA, BUT RATHER IT HAS BEEN PREPARED IN ACCORDANCE WITH THE NORTH CAROLINA HOSPITAL ASSOCIATION REPORTING GUIDELINES. THERE ARE SIGNIFICANT COMMUNITY BENEFIT ACTIVITIES WITHIN NOVANT HEALTH WHICH MAY NOT BE REPORTABLE ON A SCHEDULE H BECAUSE THEY ARE NOT CONDUCTED BY AN ENTITY WHICH OWNS OR OPERATES A HOSPITAL.IN ADDITION TO HOSPITALS, UVA COMMUNITY HEALTH INC. INCLUDES A PHYSICIAN ORGANIZATION WITH PRACTICES IN VIRGINIA AND A HOSPITAL FOUNDATION WHICH SUPPORTS AND ENHANCES THE ACTIVITIES IN THOSE HOSPITALS' COMMUNITIES. FURTHER, UVA COMMUNITY HEALTH INC. INCLUDES AMBULATORY SURGERY CENTERS, IMAGING CENTERS, REHABILITATION CENTERS, AND OTHER OUTPATIENT FACILITIES; ALL DEDICATED TO PROMOTING THE HEALTH OF THEIR RESPECTIVE COMMUNITIES. PART VI, LINE 7: STATE FILING OF COMMUNITY BENEFIT REPORT UVA CULPEPER MEDICAL CENTER FILES A COMMUNITY BENEFIT REPORT WITH THE VIRGINIA HOSPITAL AND HEALTHCARE ASSOCIATION IN ACCORDANCE WITH THEIR REPORTING GUIDELINES FOR PURPOSES OF ADVOCACY AND THE STATE'S REPORTING REQUIREMENTS. 1 CULPEPER WELLNESS FOUNDATION INC 311 S EAST STREET NO 100 CULPEPER VA 22701 521366700 501(C)(3) 510000 0 COMMUNITY OUTREACH GERMANNA COMMUNITY COLLEGE EDUCATIONAL FOUNDATION PO BOX 1430 LOCUST GROVE VA 22508 541379348 501(C)(3) 10000 0 COMMUNITY OUTREACH ORANGE COUNTY FREE CLINIC INC 101 C WOODMARK STREET ORANGE VA 22960 251922019 501(C)(3) 10000 0 COMMUNITY OUTREACH PEOPLE INCORPORATED OF VIRGINIA 1173 WEST MAIN STREET ABINGDON VA 24210 540763686 501(C)(3) 8000 0 COMMUNITY OUTREACH RAPP CENTER FOR EDUCATION PO BOX 3549 SPERRYVILLE VA 22740 474370354 501(C)(3) 10000 0 COMMUNITY OUTREACH PIEDMONT REGIONAL DENTAL CLINIC PO BOX 151 ORANGE VA 22960 270625764 501(C)(3) 10000 0 COMMUNITY OUTREACH 6 0 SCHOLARSHIP 3 1500 MAMMOGRAMS 12 4721 PATIENT TRANSPORTATION 45 10236 FMV TRANSPORTATION PART I, LINE 2: PROCEDURES FOR MONITORING THE USE OF GRANT FUNDS THE FILING ORGANIZATION IS PART OF THE INTEGRATED HEALTHCARE SYSTEM OPERATED BY THE RECTORS AND VISITORS OF THE UNIVERSITY OF VIRGINIA ON BEHALF OF IT'S MEDICAL CENTER. UVA COMMUNITY HEALTH, INC. BYLAWS AUTHORIZE IT TO ESTABLISH CERTAIN POLICIES FOR ALL OF ITS SUBSIDIARIES WITHIN THE SYSTEM. UVA COMMUNITY HEALTH HAS ESTABLISHED A SYSTEM-WIDE CORPORATE POLICY WITH STANDARDIZED GUIDELINES THAT ARE TO BE USED IN REVIEWING THE ELIGIBILITY AND SELECTION OF GRANTEES RECEIVING CERTAIN EXEMPT PURPOSE FUNDS. THE FILING ORGANIZATION MAINTAINS DOCUMENTATION OF THE ELIGIBILITY AND SELECTION CRITERIA AND RECORDS OF THE AMOUNTS ARE MAINTAINED VIA THE GENERAL LEDGER. FUNDS ARE GENERALLY NOT TRACKED AFTER BEING GRANTED, AS THE ORIGINAL ELIGIBILITY AND SELECTION CRITERIA HAVE ALREADY BEEN MET. 0 1 0 0 0 0 0 1 0 ALFRED PILONG SVP & CEO 0 524123 0 516734 0 41089 0 116327 0 33791 0 1232064 0 0 KIRSTEN GREEN MD TRUSTEE (EFF 7/1/21) 0 799322 0 75690 0 7829 0 81114 0 25653 0 989608 0 0 DOUGLAS LISCHKE TREAS (ENDS 6/30/21) 0 411645 0 110000 0 31756 0 62941 0 28901 0 645243 0 0 SHIV KHANDELWAL MD TRUSTEE (EFF 7/1/21) 0 361529 0 175000 0 10078 0 25117 0 24688 0 596412 0 0 CHRIS HEATON MD TRUSTEE (EFF 7/1/21) / PHYS UVA COMM 0 372161 0 63360 0 19031 0 14644 0 31414 0 500610 0 7500 MARY FRANCES SOUTHERLAND TRUSTEE (EFF 7/1/21) 0 307569 0 64000 0 16801 0 17943 0 63896 0 470209 0 0 DONNA STATON SYSTEM COO & PRESIDENT 255369 0 96419 0 15980 0 14730 0 13725 0 396223 0 0 0 MINDI SHIFFLETT CNO & CLINICAL OPERATIONS OFFICER 182991 0 47922 0 262 0 9786 0 22304 0 263265 0 0 0 SARA WHITE SR DIR - FINANCE 169498 0 27599 0 13132 0 10600 0 13898 0 234727 0 0 0 SUSAN EDWARDS SR DIR - HR/SUPPORT SERVICES 161578 0 28531 0 10676 0 10438 0 21635 0 232858 0 0 0 MICHELLE STRIDER CHIEF QUALITY OFFICER 158151 0 23956 0 11852 0 10038 0 14200 0 218197 0 0 0 NAEL HASAN CHIEF MEDICAL OFFICER EFF 2/20/21 214997 0 0 0 262 0 0 0 892 0 216151 0 0 0 TEMPLE COATES DIR - PROFESSIONAL & ANCILLARY SERVI 151404 0 19819 0 11623 0 9688 0 22134 0 214668 0 0 0 DENNIS SMITH PHARMACY MANAGER 168826 0 20491 0 1214 0 10483 0 9396 0 210410 0 0 0 STEVEN SPEELMAN DIR - INFORMATION SYSTEMS 151824 0 20002 0 5304 0 9601 0 17036 0 203767 0 0 0 MARK UTZ DIR - PLANT ENGINEERING SERVICES 137065 0 19531 0 21628 0 7638 0 12519 0 198381 0 0 0 MARK CHANEY DIR - NURSING 138326 0 18434 0 5897 0 9012 0 22078 0 193747 0 0 0 JONATHAN D'SOUZA CHIEF MEDICAL OFFICER 1/1/21-2/20/21 59379 0 100367 0 11067 0 3669 0 1933 0 176415 0 0 0 PATRICIA SLATER COMPLIANCE RISK & PRIVACY OFFICER 148452 0 16939 0 788 0 8970 0 741 0 175890 0 0 0 PART I, LINE 3 EFFECTIVE JANUARY 1, 2022 THE RECTOR AND VISITORS OF THE UNIVERSITY OF VIRGINIA ON BEHALF OF ITS MEDICAL CENTER WILL ASSUME RESPONSIBILITY FOR THE PROCESS PREVIOUSLY SUPPORTED BY NOVANT HEALTH, INC. THAT IS OUTLINED BELOW. THE FILING ORGANIZATION IS AN INTEGRAL PART OF NOVANT HEALTH UVA HEALTH SYSTEM ("THE SYSTEM") AND RELIES UPON NOVANT HEALTH, INC., A SUPPORTING ORGANIZATION OF THE SYSTEM, TO USE THE PROCESS DESCRIBED IN PART VI, LINE 15A/15B OF THIS RETURN TO ESTABLISH COMPENSATION FOR CERTAIN EXECUTIVES. THIS PROCESS ADHERES TO THE REQUIREMENTS SET FORTH TO SECURE THE REBUTTABLE PRESUMPTION OF REASONABLENESS AND INCLUDES A REVIEW AND APPROVAL BY INDEPENDENT AND DISINTERESTED MEMBERS OF A COMPENSATION COMMITTEE, CONSULTATION WITH INDEPENDENT COMPENSATION CONSULTANTS, THE UTILIZATION OF THIRD-PARTY COMPARABILITY DATA SUCH AS PUBLISHED COMPENSATION SURVEYS, AND CONTEMPORANEOUS SUBSTANTIATION OF THE DELIBERATION AND DECISION. PART I, LINE 4B - SUPPLEMENTAL NONQUALIFIED RETIREMENT PLANS: THE SUPPLEMENTAL EXECUTIVE RETIREMENT PLAN ("SERP") IS INTENDED TO SUPPORT RETENTION OF KEY EXECUTIVES, AND TO OFFER COMPETITIVE TOTAL COMPENSATION. ELIGIBLE EXECUTIVES WILL BE NOMINATED BY THE CEO AND APPROVED BY THE NOVANT HEALTH COMPENSATION AND LEADERSHIP COMMITTEE ("THE COMMITTEE") TO PARTICIPATE. GENERALLY, ANNUAL CONTRIBUTIONS TO THE PLAN OR PAYMENTS TO PARTICIPANTS WILL BE BASED ON A PERCENTAGE OF THE PARTICIPANT'S BASE SALARY AS OF JANUARY 1ST OF THE PREVIOUS PLAN YEAR AND ARE REPORTED IN COLUMN (C) OF SCHEDULE J. PRIOR TO MAKING THE CONTRIBUTIONS OR PAYMENTS, THE COMMITTEE WILL APPROVE THE AMOUNTS AS TO REASONABLENESS, WHEN COMBINED WITH ALL OTHER ANNUAL COMPENSATION. A 3 YEAR CLASS-YEAR VESTING PERIOD WILL APPLY UP TO AGE 62, WHEN ALL MONEY WOULD BE VESTED AND PAID OUT TO THE PARTICIPANT. OTHERWISE, VESTING WILL OCCUR ON JANUARY 1ST OF EACH YEAR FOR THE APPROPRIATE CLASS-YEAR VESTING PERIOD. THE COMMITTEE REVIEWS, APPROVES, AND OVERSEES ALL ASPECTS AND ALL ELEMENTS OF EXECUTIVE COMPENSATION AND BENEFITS. PART I, LINE 7: NONFIXED PAYMENT DEPENDING ON INDIVIDUAL PERFORMANCE, SOME EMPLOYEES MAY BE ELIGIBLE FOR PERFORMANCE BONUSES IN ADDITION TO THEIR REGULAR COMPENSATION. THE AWARDING OF ANY COMPENSATION BONUS CONSIDERS THE INDIVIDUAL'S GOALS AND THE GOALS OF THE ORGANIZATION AS A WHOLE. ANY POTENTIAL BONUS IS CONSIDERED WHEN EVALUATING AN EMPLOYEE'S TOTAL COMPENSATION FOR REASONABLENESS. FORM 990, PI, L1: ORGANIZATION'S MISSION OR MOST SIGNIFICANT ACTIVITIES UVA CULPEPER MEDICAL CENTER UVA CULPEPER MEDICAL CENTER, INC. DOING BUSINESS AS UVA CULPEPER MEDICAL CENTER IS AN INTEGRAL PART OF UVA COMMUNITY HEALTH, INC. ("UVACH"). UVACH IS A NOT-FOR-PROFIT INTEGRATED SYSTEM OF HOSPITALS, PHYSICIAN CLINICS, OUTPATIENT CENTERS, AND OTHER HEALTHCARE SERVICES PROVIDERS (COLLECTIVELY KNOWN AS "UVA COMMUNITY HEALTH"). IN 2016, NOVANT HEALTH, INC. AND THE UNIVERSITY OF VIRGINIA MEDICAL CENTER ("UVA MEDICAL CENTER") FORMED A JOINT OPERATING COMPANY CALLED NOVANT HEALTH UVA HEALTH SYSTEM ("NHUVAHS"), WHICH INCLUDED CULPEPER MEDICAL CENTER, HAYMARKET MEDICAL CENTER, PRINCE WILLIAM MEDICAL CENTER, LAKE MANASSAS CANCER CENTER, CATON MERCHANT HOUSE, AND A NETWORK OF PHYSICIAN CLINICS STAFFED BY AN EMPLOYED MEDICAL GROUP. AS OF JULY 1, 2021, UVA MEDICAL CENTER TOOK FULL OWNERSHIP OF NHUVAHS, AT WHICH TIME THE SYSTEM TRANSITIONED ITS NAME TO UVA COMMUNITY HEALTH, INC. AND BEGAN THE PROCESS TO REBRAND ALL FACILITIES AND ENTITIES UNDER THE "UVA HEALTH" BRAND. THIS INCLUDES THE RENAMED UVA CULPEPER MEDICAL CENTER IN OCTOBER OF 2021. GENERAL INFORMATION UVA CULPEPER MEDICAL CENTER IS LOCATED IN CULPEPER, VA. THE HOSPITAL IS FOCUSED ON PROVIDING COMMUNITY SUPPORT, CONSISTENT QUALITY, EXCELLENT CARE AND A REMARKABLE WORK ENVIRONMENT FOR OUR TEAM MEMBERS. WE ARE COMMITTED TO MEETING THE HEALTH CARE NEEDS OF RESIDENTS OF CULPEPER, ORANGE, MADISON AND SURROUNDING COUNTIES IN VIRGINIA, ONE PERSON AT A TIME. IN ADDITION TO OUR QUALITY OF SERVICES AND COMPREHENSIVE CATEGORIES OF SERVICES, WE'RE VERY PROUD OF OUR PATIENT FINANCIAL SERVICES PROGRAM. WE WORK WITH CUSTOMERS TO HELP QUALIFY THEM FOR PUBLIC ASSISTANCE, ESTABLISH A REASONABLE PAYMENT PLAN, DISCOUNT THEIR BILL OR PROVIDE THEM WITH FREE CHARITY CARE. COMMUNITY ENGAGEMENT COMMUNITY OUTREACH IS A CRITICAL COMPONENT TO THE MISSION OF UVA CULPEPER MEDICAL CENTER. BEYOND OUR PROVISION OF QUALITY HEALTHCARE SERVICES, WE SUPPORT OTHER COMMUNITY ORGANIZATIONS THAT PROVIDE HEALTH SERVICES, EDUCATION, AND ASSISTANCE TO UNINSURED AND VULNERABLE POPULATIONS, AS WELL AS THE OVERALL COMMUNITY. SOME RECIPIENT ORGANIZATIONS INCLUDE CULPEPER WELLNESS FOUNDATION, CULPEPER FREE CLINIC, ORANGE COUNTY FREE CLINIC, COME AS YOU ARE (CAYA), SERVICES TO ABUSED FAMILIES (SAFE), GERMANNA FOUNDATION, MENTAL HEALTH ASSOCIATION, AND PIEDMONT CRUSH. IN 2021, UVA CULPEPER MEDICAL CENTER HOSTED VIRTUAL EDUCATION SESSIONS FOR THE COMMUNITY WHICH INCLUDED THE FOLLOWING: - WEIGHT MANAGEMENT - VACCINE FACTS FOCUS ON THE FOLLOWING COMMUNITIES BLACK AND AFRICAN AMERICAN, HISPANIC/LATINO AND VETERANS AND FAMILIES - BALANCE AND FALL PREVENTION - CAREER PARTNERS - HIGH SCHOOL MEDICAL CAREER DISCOVERY PROGRAM - MENTAL AND PHYSICAL HEALTH FOR 55+ COMMUNITY - BREAST HEALTH UVA CULPEPER MEDICAL CENTER ALSO OFFERED VIRTUAL SUPPORT GROUPS FOR WOMEN WHO HAVE LOST A NEWBORN OR PREGNANCY AND CANCER PATIENTS AND THEIR CAREGIVERS. IT PROVIDED COMMUNITY EDUCATION ABOUT ACCESS TO HEALTHCARE SERVICES, CANCER SERVICES, HEART DISEASE, STROKE, DIABETES AND COVID-19. WE ALSO OFFERED A SUPPORT GROUP SESSION FOR THOSE SEEKING HELP WITH STRESS MANAGEMENT AND DEPRESSION. OTHER INITIATIVES INCLUDED: - CREATED AND DISTRIBUTED CULTURAL AND LITERACY AWARE VACCINE EDUCATION - COVID-19 COMMUNITY VACCINE CLINICS - SUPPORTED PHYSICAL ACTIVITY BY SUPPORTING NONPROFIT-LED COMMUNITY 5K - DRUG TAKE BACK DAY EVENTS HELD IN PARTNERSHIP WITH LOCAL POLICE IN APRIL AND OCTOBER - CULPEPERFEST: PROVIDED FREE BLOOD PRESSURE SCREENINGS, STROKE AND HEART HEALTH INFORMATION. PART OF OUR ONGOING COMMITMENT TO PATIENTS AND THE COMMUNITY IS OFFERING FREE HEALTH SCREENINGS AND PARTNERING WITH OUR PHYSICIAN SPECIALISTS IN THE FIELDS OF CARDIOLOGY, ORTHOPEDICS AND WOMEN'S HEALTH TO PROVIDE FREE EDUCATION TO MEMBERS OF OUR COMMUNITY. MAMMOGRAPHY SCREENINGS FOR COMMUNITY MEMBERS IN NEED, REGARDLESS OF THEIR ABILITY TO PAY, IS MADE POSSIBLE THROUGH THE PAMPER ME PINK MAMMOGRAPHY FUND, BASED AT UVA CULPEPER MEDICAL CENTER. EVENTS TIED TO THIS ANNUAL FUNDRAISER WERE HELD VIRTUALLY IN OCTOBER 2021. NEW TECHNOLOGY & SERVICES IN JANUARY 2021, UVA CULPEPER MEDICAL CENTER EXPANDED ITS OBSTETRICS AND GYNECOLOGY CLINIC AS WELL AS ITS CARDIOLOGY CLINIC. UVA OBSTETRICS AND GYNECOLOGY, A DEPARTMENT OF UVA CULPEPER MEDICAL CENTER ADDED A SECOND ULTRASOUND ROOM TO SERVE THE NEEDS OF WOMEN AT ALL STAGES OF LIFE, PARTICULARLY THOSE OF CHILDBEARING AGE TO SUPPORT HEALTHY PREGNANCY AND PRENATAL CARE. UVA CARDIOLOGY, A DEPARTMENT OF UVA CULPEPER MEDICAL CENTER EXPANDED TO ADD TWO ADDITIONAL EXAM ROOMS AND A FRONT OFFICE AREA. THE CARDIOLOGY CLINIC ALSO ONBOARDED A NEW CARDIOLOGY WITH EXTENSIVE EXPERTISE IN HEART FAILURE TO SERVE THE NEEDS OF THE COMMUNITY. IN APRIL 2021, UVA CULPEPER MEDICAL CENTER INTRODUCED A MOBILE POSITRON EMISSION TOMOGRAPHY (PET) AND COMPUTED TOMOGRAPHY (CT) SCAN UNIT AS PART OF THE CANCER CARE PROGRAM. THIS TECHNOLOGY ENSURES PATIENTS CAN STAY LOCAL TO CULPEPER FOR DIAGNOSTIC IMAGING TO IDENTIFY TUMORS AND LOCATIONS OF TUMORS. THE TWO TESTS ARE COMBINED INTO ONE EXAM WHICH ENABLES A SINGLE CONVENIENT VISIT FOR THE PATIENTS, WHO PREVIOUSLY HAD TO TRAVEL TO RECEIVE THIS TYPE OF IMAGING. IN NOVEMBER 2021, UVA CULPEPER MEDICAL CENTER INTRODUCED A NEW ROBOTIC TECHNOLOGY FOR MINIMALLY INVASIVE SPINE SURGERY. THIS TECHNOLOGY OFFERS RESIDENTS OF THE CULPEPER REGION A FASTER PROCEDURE AND FASTER RECOVERY TIME WHEN TREATING A VARIETY OF CONDITIONS, INCLUDING BUT NOT LIMITED TO HERNIATED DISCS, PINCHED NERVES, ARTHRITIS, SPINE FRACTURE OR OTHER SPINE TRAUMA. AWARDS, RECOGNITIONS & CERTIFICATIONS/RECERTIFICATIONS - RECEIVED AN 'A' GRADE IN THE LEAPFROG GROUP'S FALL AND SPRING 2021 HOSPITAL SAFETY GRADE - VIRGINIA MATERNITY CENTER BREASTFEEDING-FRIENDLY DESIGNATION BY THE VIRGINIA DEPARTMENT OF HEALTH - BABY FRIENDLY DESIGNATION BY THE WORLD HEALTH ORGANIZATION AND THE UNITED NATIONS CHILDREN'S FUND - NAMED ONE OF THE 100 BEST "HOSPITALS FOR SPECIALTY CARE" BY HEALTHGRADES FOR TWO AREAS OF ORTHOPEDICS: JOINT REPLACEMENT AND ORTHOPEDIC SURGERY - EARNED A PERFECT SCORE IN THE CENTERS FOR DISEASE CONTROL AND PREVENTION'S MATERNITY PRACTICES IN INFANT NUTRITION AND CARE (MPINC) SURVEY - THE JOINT COMMISSION ACUTE HEART ATTACK READY INITIAL ACCREDITATION - THE JOINT COMMISSION TOTAL HIP AND KNEE RECERTIFICATION ACCREDITATION UVA CULPEPER MEDICAL CENTER IS FULLY ACCREDITED BY THE JOINT COMMISSION, AN INDEPENDENT ORGANIZATION THAT EVALUATES A HEALTHCARE ORGANIZATION'S PERFORMANCE IN AREAS THAT MOST AFFECT PATIENT HEALTH AND SAFETY. UVA CULPEPER MEDICAL CENTER BREAST CENTER IS ACCREDITED BY THE NATIONAL ACCREDITATION PROGRAM FOR BREAST CENTERS BY THE AMERICAN COLLEGE OF SURGEONS. ACCREDITATION IS GRANTED TO CENTERS THAT HAVE VOLUNTARILY COMMITTED TO PROVIDE THE HIGHEST QUALITY OF CARE TO PATIENTS WITH BREAST DISEASES AND THAT UNDERGO A RIGOROUS EVALUATION AND REVIEW OF ITS PERFORMANCE AND COMPLIANCE WITH THE NATIONAL ACCREDITATION PROGRAM FOR BREAST CENTERS. UVA CULPEPER MEDICAL CENTER IS ACCREDITED BY THE INTERSOCIETAL COMMISSION FOR THE ACCREDITATION OF VASCULAR LABORATORIES, ENSURING QUALITY PATIENT CARE FOR VASCULAR TESTING. COMMUNITY BENEFIT REPORT HTTPS://WWW.NOVANTHEALTH.ORG/HOME/ABOUT-US/COMMUNITY-ENGAGEMENT/OUR-IMPA CT.ASPX THE COMMUNITY BENEFIT REPORT, REFERRED TO AS A COMMUNITY IMPACT REPORT, PREPARED BY NOVANT HEALTH IS A SYSTEM-WIDE REPORT THAT INCLUDES QUALITATIVE AND QUANTITATIVE INFORMATION. PLEASE NOTE THAT THE NUMERIC DATA IN THIS REPORT IS NOT BASED UPON THE FORM 990, SCHEDULE H CRITERIA, BUT RATHER IT HAS BEEN PREPARED IN ACCORDANCE WITH THE NORTH CAROLINA HOSPITAL ASSOCIATION REPORTING GUIDELINES. IT SHOULD NOT BE RELIED UPON AS THE ORGANIZATION'S FORM 990, SCHEDULE H COMMUNITY BENEFIT REPORT, ITS COMMUNITY HEALTH NEEDS ASSESSMENT OR COMMUNITY BENEFIT IMPLEMENTATION STRATEGY. FORM 990, PART VI, SECTION A, LINE 4 THE ORGANIZATION AMENDED ITS ARTICLES OF INCORPORATION SO THAT THE SOLE MEMBER OF THE ORGANIZATION WAS UVA COMMUNITY HEALTH, INC. ('UVACH'). THE ACTION WAS APPROVED BY THE BOARD AND LEGAL DOCUMENTS REFLECTING THE CHANGE TO THE GOVERNANCE WERE FILED WITH THE STATE OFFICE. FORM 990, PART VI, SECTION A, LINE 6 FORM 990, PART VI, SECTION A, LINE 6: CLASSES OF MEMBERS OR STOCKHOLDERS THE CORPORATION IS A NONPROFIT CORPORATION WITH MEMBERS (OR A MEMBER). THE SOLE MEMBER, UVACH HAS CERTAIN RIGHTS AND POWERS WITH REGARD TO THE CORPORATION. FORM 990, PART VI, SECTION A, LINE 7A FORM 990, PART VI, SECTION A, LINE 7A: ELECTION OF MEMBERS AND THEIR RIGHTS AS THE SOLE MEMBER OF THE ORGANIZATION, UVACH HAS THE POWER TO APPOINT ALL MEMBERS OF THE GOVERNING BODY OF UVA CULPEPER MEDICAL CENTER. FORM 990, PART VI, SECTION A, LINE 7B AS THE SOLE MEMBER, UVACH HAS THE POWER TO APPROVE CERTAIN TRANSACTIONS, ACTIONS AND CHANGES TO THE ORGANIZATION'S ARTICLES OF INCORPORATION AND BYLAWS. FORM 990, PART VI, SECTION B, LINE 11B FORM 990, PART VI, SECTION B, LINE 11: ORGANIZATION'S PROCESS TO REVIEW FORM 990 THE BOARD HAS DELEGATED REVIEW OF THE FORM 990 TO UVA COMMUNITY HEALTH'S BOARD OF TRUSTEES' AUDIT AND COMPLIANCE COMMITTEE ("THE COMMITTEE"), WHICH OVERSEES TAX MATTERS FOR ENTITIES IN THE UVA COMMUNITY HEALTH SYSTEM. THE COMMITTEE IS THE REVIEW BODY FOR ALL OF THE FORM 990S FILED FOR ORGANIZATIONS WITHIN THE UVA COMMUNITY HEALTH SYSTEM. THE COMMITTEE MEETS BEFORE THE FORM 990S ARE FILED WITH THE IRS AND AFTER ALL BOARD MEMBERS HAVE BEEN PROVIDED A PAPER OR ELECTRONIC COPY OF THE FORM 990 AND A SUMMARY OF ITS CONTENTS. THE VICE PRESIDENT OF TAX AND LEGAL COUNSEL FOR UVA COMMUNITY HEALTH ATTEND THE MEETING TO ANSWER ANY QUESTIONS AND ADDRESS ANY SIGNIFICANT DISCLOSURES WITHIN THE FORM 990. FORM 990, PART VI, SECTION B, LINE 12C FORM 990, PART VI, SECTION B, LINE 12C: MONITORING AND ENFORCEMENT OF COI THE ORGANIZATION'S TRUSTEE CONFLICT OF INTEREST POLICY APPLIES TO ALL TRUSTEES, PRINCIPAL OFFICERS OR MEMBERS OF A COMMITTEE WITH BOARD DELEGATED POWERS. ALL TRUSTEES ARE SENT AN ANNUAL DISCLOSURE QUESTIONNAIRE. THE BEGINNING OF EACH MEETING OF THE BOARD BEGINS WITH VOLUNTARY VERBAL SELF-DISCLOSURE OF ANY CONFLICTS WITH ANY ITEMS ON THE AGENDA. AS ADDITIONAL ISSUES ARISE DURING THE COURSE OF THE MEETING, A SIMILAR SELF-DISCLOSURE IS EXPECTED. CHALLENGES BY PARTICIPANTS ARE ENCOURAGED IF SELF-DISCLOSURES ARE NOT FORTH-COMING. DURING THE COURSE OF DOING BUSINESS, IF CONFLICTS ARE SUSPECTED BY ANYONE, THEY ARE ENCOURAGED TO NOTIFY THE CEO OF THEIR SUSPICIONS. THE CEO WILL INVESTIGATE, EMPLOYING LEGAL COUNSEL AS NECESSARY, AND WILL RESOLVE AS APPROPRIATE. ULTIMATELY IT IS THE RESPONSIBILITY OF THE CEO AND THE CHAIRMAN OF THE BOARD TO ENFORCE THE POLICY. FORM 990, PART VI, SECTION B, LINE 15 FORM 990, PART VI, SECTION B, LINE 15A/15B: EFFECTIVE JANUARY 1, 2022 THE RECTOR AND VISITORS OF THE UNIVERSITY OF VIRGINIA ON BEHALF OF ITS MEDICAL CENTER WILL ASSUME RESPONSIBILITY FOR THE PROCESS PREVIOUSLY SUPPORTED BY NOVANT HEALTH, INC. THAT IS OUTLINED BELOW. THE FILING ORGANIZATION IS AN INTEGRAL PART OF THE NOVANT HEALTH UVA HEALTH SYSTEM ("THE SYSTEM"), WHICH IS SUPPORTED BY NOVANT HEALTH, INC. ("NOVANT HEALTH"), ONE OF ITS MEMBERS. NOVANT HEALTH SUPPORTS THE SYSTEM BY PROVIDING A COMPENSATION REVIEW AND APPROVAL PROCESS TO CERTAIN SYSTEM ENTITIES. THE PROCESS IS CONDUCTED BY THE INDEPENDENT AND DISINTERESTED MEMBERS OF THE NOVANT HEALTH, INC. BOARD OF TRUSTEES (WHO COMPRISE THE COMPENSATION AND LEADERSHIP COMMITTEE OF THE BOARD) WHO REVIEW, APPROVE, AND OVERSEE ALL ASPECTS OF COMPENSATION AND BENEFITS FOR CERTAIN LEADERS AND EXECUTIVES ("EXECUTIVES") SERVING AS OFFICERS, INCLUDING THE TOP MANAGEMENT OFFICIAL, OR KEY EMPLOYEES FOR CERTAIN ENTITIES WITHIN THE SYSTEM. THE COMMITTEE WORKS WITH AN INDEPENDENT COMPENSATION CONSULTANT AND USES THIRD PARTY COMPARABILITY DATA FOR FUNCTIONALLY SIMILAR POSITIONS AT SIMILARLY SITUATED ORGANIZATIONS TO ENSURE THAT TOTAL COMPENSATION AND BENEFITS FOR EACH EXECUTIVE IS REASONABLE FOR THAT EXECUTIVE'S POSITION. THE COMMITTEE REVIEWS AND APPROVES EXECUTIVE COMPENSATION AND BENEFITS ANNUALLY, CONSISTENT WITH THE WRITTEN EXECUTIVE COMPENSATION PHILOSOPHY OF NOVANT HEALTH, AND IN A MANNER THAT QUALIFIES FOR THE REBUTTABLE PRESUMPTION OF REASONABLENESS, THEREBY ASSURING THAT TOTAL COMPENSATION AND BENEFITS PROVIDED TO EACH EXECUTIVE IS REASONABLE. FORM 990, PART VI, SECTION C, LINE 19 FORM 990, PART VI, SECTION C, LINE 19: GOVERNING DOCUMENTS DISCLOSURE THE AUDITED CONSOLIDATED FINANCIAL STATEMENTS CONTAIN ALL ORGANIZATIONS IN THE UVA COMMUNITY HEALTH SYSTEM ARE AVAILABLE UPON REQUEST. THE GOVERNING DOCUMENTS AND CONFLICT OF INTEREST POLICY ARE MADE AVAILABLE TO THE EXTENT REQUIRED BY LAW. FORM 990, PART IX, LINE 11G OUTSIDE SERVICES: PROGRAM SERVICE EXPENSES 5,944,053. MANAGEMENT AND GENERAL EXPENSES 1,092,776. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 7,036,829. CONTRACTED SERVICES: PROGRAM SERVICE EXPENSES 95,702. MANAGEMENT AND GENERAL EXPENSES 3,988. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 99,690. COLLECTION SERVICE: PROGRAM SERVICE EXPENSES 0. MANAGEMENT AND GENERAL EXPENSES 196,406. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 196,406. PROFESSIONAL PHYSICIAN SERVICES: PROGRAM SERVICE EXPENSES 7,761,497. MANAGEMENT AND GENERAL EXPENSES 0. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 7,761,497. CONTRACT LABOR: PROGRAM SERVICE EXPENSES 3,269,989. MANAGEMENT AND GENERAL EXPENSES 1,760,764. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 5,030,753. FORM 990, PART XI, LINE 9: CHANGE IN RESTRICTED CONTRIBUTIONS -250. CONTRIBUTIONS 500,000. DEBT FORGIVENESS -2,785,834. PARTNERSHIPS -270,810. 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