2021-11-15T13:36:56-06:00 2020-12-31 410746749 CLIFTONLARSONALLEN LLP 227 WEST TRADE STREET SUITE 800 CHARLOTTE NC 28202 990 2020-01-01 842727303 AHSNF INC AHSN 7045125219 1000 BLYTHE BLVD CHARLOTTE NC 28203 ANTHONY C DEFURIO SECRETARY AND TREASURER 7045125219 2021-11-15 1 ANTHONY DEFURIO 999009999 JOHN NORMAN P01506766 7049985200 2021-11-14 0 AAL1 IAL1 2020 2022-09-23 18:48:47Z X KEN D HAYNES 1000 BLYTHE BLVD CHARLOTTE NC 28203 43712731 0 X N/A X 2019 NC THE CORPORATION OWNS THE ASSETS AND OPERATIONS OF FIVE SKILLED NURSING FACILITIES LOCATED IN AND AROUND CHARLOTTE, NC. THE FACILITIES PROVIDE SHORT-TERM NURSING AND REHABILITATION SERVICES, LONG-TERM CARE SERVICES, AND END OF LIFE CARE TO PATIENTS IN THE COMMUNITY. 3 0 0 13 0 0 1109928 42084897 -73 517898 43712650 0 0 26583854 0 0 31708754 58292608 -14579958 42778339 17141267 25637072 THE CORPORATION OWNS THE ASSETS AND OPERATIONS OF FIVE SKILLED NURSING FACILITIES LOCATED IN AND AROUND CHARLOTTE, NC. THE FACILITIES PROVIDE SHORT-TERM NURSING AND REHABILITATION SERVICES, LONG-TERM CARE SERVICES, AND END OF LIFE CARE TO PATIENTS IN THE COMMUNITY. 0 0 47258540 42602795 THE FACILITIES PROVIDE SHORT-TERM NURSING AND REHABILITATION SERVICES, LONG-TERM CARE SERVICES, AND END OF LIFE CARE TO PATIENTS IN THE COMMUNITY. DURING COVID, A COVID SPECIFIC UNIT WAS ESTABLISHED FOR THE CARE AND RECOVERY OF THESE PATIENTS WHICH WAS VERY BENEFICIAL TO THE BROADER HEALTHCARE COMMUNITY. 47258540 1 1 0 0 0 0 0 0 0 0 1 0 0 0 1 0 0 1 0 0 0 0 0 0 0 0 0 0 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 1 0 0 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 X 3 0 0 0 0 0 0 0 0 1 1 0 0 1 1 1 1 1 1 1 1 0 X RODNEY BALL 7045125219 PO BOX 32861 CHARLOTTE NC 28232 KEN D HAYNES PRESIDENT 1.00 49.00 X X 0 1972089 260459 ANTHONY C DEFURIO SECRETARY AND TREASURER 1.00 49.00 X X 0 2213785 272890 SCOTT C RISSMILLER MD DIRECTOR 1.00 49.00 X 0 1814679 226791 RODNEY BALL GROUP VP, CFO 2.00 48.00 X 0 615742 62414 ROSE COOK CFO UNTIL 1020 VP, FINANCE 2.00 48.00 X 0 446531 48955 COLLIN LANE ENTERPRISE SVP, FACILITIES MGMT GRP 5.00 45.00 X 0 701538 78167 MIKE STOLZENZBACH VP, FACILITY EXEC., CONT. CARE 15.00 35.00 X 0 326616 55033 SCHAREE LEE EXEC DIR - CONT CARE 50.00 0.00 X 0 168006 31603 SYLVIA OKUGO REGISTERED NURSE 55.00 X 0 202244 41448 ROSE SARFO-KANTANKA REGISTERED NURSE 57.00 X 0 142517 27384 COLIN CLODE EXEC. DIR - COMMUNITY MENTOR - LTC 50.00 X 0 145991 40709 MUNA ABRAHAM RN SUPERVISOR 52.00 X 0 131948 27341 LINDEN SCOTLAND EXEC DIR - COMM. MENTOR - LTC 40.00 X 0 117727 32814 0 8999413 1206008 0 0 1 0 HEALTHPRO HERITAGE LLC 536 OLD HOWELL RD GREENVILLE SC 29615 THERAPY SERVICES 3593586 SODEXO INC PO BOX 360170 PITTSBURGH PA 152516170 DIETARY SERVICES 3128630 ARAMARK HEALTHCARE SUPPORT SERVICES LLC PO BOX 978839 DALLAS TX 753978839 ENVIRONMENTAL SERVICES 833573 MORRISON MANAGEMENT SPECIALISTS INC PO BOX 102289 ATLANTA GA 303682289 DIETARY SERVICES 495417 4 1105813 4115 1109928 PATIENT SERVICES 621110 42084897 42084897 42084897 8 8 81 -81 -81 -81 OTHER REVENUE 900099 517898 517898 517898 43712650 42602795 0 -73 X 20920778 16736622 4184156 980721 784577 196144 3162634 2530107 632527 1519721 1215777 303944 6473 6473 7319929 5855943 1463986 190658 152526 38132 52732 42186 10546 899735 719788 179947 44242 35394 8848 661152 661152 3463689 2770951 692738 130941 104753 26188 INTERCOMPANY EXPENSES 14470112 11576090 2894022 FOOD & HOUSEKEEPING SUP 1615318 1292254 323064 MEDICAL SUPPLIES 1373455 1373455 BAD DEBT EXPENSE 1113554 1113554 366764 293411 73353 58292608 47258540 11034068 0 15667 7490871 750 35017 69432286 34196252 0 35236034 0 42778339 1572738 0 15568529 0 17141267 X 0 0 0 0 0 25637072 0 25637072 0 42778339 X -14579958 40217030 X 0 1 X 1 1 1 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 2193138 2193138 47311899 24061721 23250178 17935527 9121588 8813939 1991722 1012943 978779 35236034 DUE TO AFFILIATES 15568529 15568529 0 1 0 0 0 0 0 0 0 ANTHONY C DEFURIO SECRETARY AND TREASURER 0 1175449 0 997725 0 40611 0 249619 0 23271 0 2486675 0 0 KEN D HAYNES PRESIDENT 0 1022193 0 915276 0 34620 0 223623 0 36836 0 2232548 0 0 SCOTT C RISSMILLER MD DIRECTOR 0 877443 0 904575 0 32661 0 194269 0 32522 0 2041470 0 0 COLLIN LANE ENTERPRISE SVP, FACILITIES MGMT GRP 0 443399 0 232638 0 25501 0 48036 0 30131 0 779705 0 0 RODNEY BALL GROUP VP, CFO 0 372714 0 231775 0 11253 0 37589 0 24825 0 678156 0 0 ROSE COOK CFO UNTIL 1020 VP, FINANCE 0 263455 0 144464 0 38612 0 30843 0 18112 0 495486 0 0 MIKE STOLZENZBACH VP, FACILITY EXEC., CONT. CARE 0 235733 0 89056 0 1827 0 23299 0 31734 0 381649 0 0 SYLVIA OKUGO REGISTERED NURSE 0 187261 0 5750 0 9233 0 12545 0 28903 0 243692 0 0 SCHAREE LEE EXEC DIR - CONT CARE 0 135774 0 21086 0 11146 0 12199 0 19404 0 199609 0 0 COLIN CLODE EXEC. DIR - COMMUNITY MENTOR - LTC 0 121204 0 24521 0 266 0 11691 0 29018 0 186700 0 0 ROSE SARFO-KANTANKA REGISTERED NURSE 0 140006 0 2250 0 261 0 10330 0 17054 0 169901 0 0 MUNA ABRAHAM RN SUPERVISOR 0 123761 0 2250 0 5937 0 9607 0 17734 0 159289 0 0 LINDEN SCOTLAND EXEC DIR - COMM. MENTOR - LTC 0 117375 0 0 0 352 0 7212 0 25602 0 150541 0 0 PART I, LINE 4B CERTAIN EXECUTIVES PARTICIPATE IN OR RECEIVE PAYMENTS FROM SUPPLEMENTAL NON-QUALIFIED RETIREMENT PLANS. THE DETERMINATION OF THE AMOUNT OF THE NON-QUALIFIED RETIREMENT PLANS FOLLOWED THE FILING ORGANIZATION'S COMPENSATION PROCEDURES AS OUTLINED IN PART VI, SECTION B, LINE 15 OF THE FORM 990. THE FOLLOWING OFFICERS RECEIVED PAYMENTS FROM NON-QUALIFIED RETIREMENT PLANS IN 2020: COLLIN LANE $4,552 RODNEY BALL $1,869 ROSE COOK $1,597 FORM 990, PART VI, SECTION B, LINE 11B THE ORGANIZATION'S BOARD OF DIRECTORS RECEIVE COPIES OF THE FORM 990 WITH SUFFICIENT TIME TO PERMIT REVIEW, COMMENT, AND QUESTIONS PRIOR TO ITS FILING. IF MODIFICATIONS ARE REQUIRED FOLLOWING SUCH REVIEW AND COMMENT, THE REVISED FORM 990 IS REDISTRIBUTED TO ALL DIRECTORS PRIOR TO ITS FILING WITH THE IRS, ALONG WITH A REPORT NOTING THE MODIFICATIONS. FORM 990, PART VI, SECTION B, LINE 12C THE CONFLICT OF INTEREST POLICY APPLIES TO COVERED INDIVIDUALS, AND INCLUDES ALL AHSNF, INC TEAMMATES IN THEIR PERFORMANCE OF THE ADMINISTRATION, TEACHING, PATIENT CARE AND OTHER BUSINESS OPERATIONS OF THE ORGANIZATION AND TO NON-EMPLOYEES WHO ARE APPOINTED BY AHSNF, INC TO REPRESENT ITS INTEREST ON VARIOUS COMMITTEES OR IN OTHER DECISION MAKING CAPACITIES OR WHOSE CONTRACTUAL RELATIONSHIP WITH THE ORGANIZATION REQUIRES COMPLIANCE WITH THIS POLICY. DUE TO THE NATURE OF COIS, THE ACTIVITIES OF A COVERED INDIVIDUAL'S FAMILY MEMBER(S) MAY ALSO BE RELEVANT TO PROVIDE THE CORPORATE COMPLIANCE DEPARTMENT WITH A FULL ACCOUNTING OF RELATIONSHIPS THAT MAY INFLUENCE OR APPEAR TO INFLUENCE DECISIONS MADE ON BEHALF OF ATRIUM HEALTH. "COVERED INDIVIDUAL" IS DEFINED AS ANY AHSNF, INC TEAMMATE IN HIS/HER PERFORMANCE OF THE ADMINISTRATION, TEACHING, PATIENT CARE AND OTHER BUSINESS OPERATIONS OF AHSNF, INC AND TO NON-EMPLOYEES WHO ARE APPOINTED BY AHSNF, INC TO REPRESENT ITS INTEREST ON VARIOUS COMMITTEES OR IN OTHER DECISION MAKING CAPACITIES OR WHOSE CONTRACTUAL RELATIONSHIP WITH ATRIUM HEALTH REQUIRES COMPLIANCE WITH THIS POLICY. A COVERED INDIVIDUAL, REGARDLESS OF LEVEL, WHO BELIEVES A RELATIONSHIP MAY GIVE RISE TO A COI SHOULD WORK WITH RELEVANT LEADERS, THE CORPORATE COMPLIANCE DEPARTMENT AND OTHER DEPARTMENTS AS NEEDED TO PROPERLY EVALUATE, DISCLOSE AND MANAGE ANY POTENTIAL COIS. AHSNF, INC. REQUIRES TEAMMATES AT A DIRECTOR LEVEL OR ABOVE TO COMPLETE AN ANNUAL DISCLOSURE. THESE DISCLOSURES ARE REVIEWED AND ANY NECESSARY RESOLUTION IS ADDRESSED. WHEN A POTENTIAL CONFLICT OF INTEREST IS IDENTIFIED AND DETERMINED TO REQUIRE MANAGEMENT IN ORDER TO REDUCE OR ELIMINATE THE CONFLICT, AHSNF, INC TAKES STEPS TO MANAGE/RESOLVE THE CONFLICT. RESTRICTIONS IMPOSED FOR AN ACTUAL CONFLICT ARE ADJUSTED TO ADDRESS THE ACTUAL CONFLICT. CONFLICT OF INTEREST ARE DOCUMENTED IN MULTIPLE DATABASES, DEPENDENT UPON THE COVERED INDIVIDUAL'S LEVEL AND REPORTING STRUCTURE. FAILURE OF A COVERED INDIVIDUAL TO COMPLY MAY RESULT IN DISCIPLINARY ACTION AND/OR SANCTIONS; EXAMPLES OF POSSIBLE SANCTIONS INCLUDE FORMAL REPRIMAND; SUSPENSION AND/OR TERMINATION OF MEDICAL STAFF PRIVILEGES; AND/OR ANY OTHER ENFORCEMENT ACTION MANDATED BY THE APPLICABLE GOVERNMENT GRANTING AGENCY OR AHSNF, INC ADMINISTRATION. FORM 990, PART VI, SECTION B, LINE 15 AHSNF, INC. IS AN INTEGRATED PART OF THE CHARLOTTE-MECKLENBURG HOSPITAL AUTHORITY ("CMHA." DBA ATRIUM HEALTH), ONE OF THE NATION'S LEADING AND MOST INNOVATIVE HEALTHCARE ORGANIZATIONS. THE FILING ORGANIZATION PAYS NO COMPENSATION TO OFFICERS, DIRECTORS AND KEY EMPLOYEES. ALL COMPENSATION PAID TO OFFICERS, DIRECTORS AND KEY EMPLOYEES WAS PAID BY CMHA. COMPENSATION PAID TO THESE INDIVIDUALS IS REVIEWED AND APPROVED IN ACCORDANCE WITH CMHA'S COMPENSATION POLICIES AND PROCEDURES WHICH INCLUDE INDEPENDENT COMPENSATION CONSULTANTS, COMPENSATION SURVEYS AND STUDIES TO DETERMINE THE APPROPRIATENESS OF EACH OFFICER'S AND DIRECTOR'S COMPENSATION. FORM 990, PART VI, SECTION C, LINE 19 FILED ON MSRB WEBSITE (EMMA) AS PART OF CMHA ANNUAL INFORMATION STATEMENT. FORM 990, PART IX, LINE 11G OTHER PROFESSIONAL SERVICES: PROGRAM SERVICE EXPENSES 5,855,943. MANAGEMENT AND GENERAL EXPENSES 1,463,986. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 7,319,929. FORM 990, PART XI, LINE 9: BEGINNING NET ASSET CONTRIBUTIONS 40,217,030. THE CHARLOTTE-MECKLENBURG HOSPITAL AUTHORITY PO BOX 32861 CHARLOTTE NC 28203 580529945 HEALTHCARE NC 115 N/A N/A 0 0 0 1 0 0 0 0 0 0 0 1 0 1 1 1 1 0 1 1