2020-11-02T12:38:46-06:00 2019-12-31 990 2019-01-01 540622371 CULPEPER MEMORIAL HOSPITAL INC CULP 3367182803 501 SUNSET LANE CULPEPER VA 22701 DONNA STATON PRESIDENT 5408298803 2020-10-31 170.98.106.254 2020-10-31 08:35:27 ED P DA39A3EE5E6B4B0D3255BFEF95601890AFD80709 A2315309B7343EB998963AA05290CF11231D17E5 2019 2021-01-29 14:40:06Z NOVANT HEALTH UVA HEALTH SYSTEM CULPEPER MEDICAL CENTER ALFRED E PILONG 501 SUNSET LANE CULPEPER VA 22701 118848652 0 X WWW.NOVANTHEALTHUVA.ORG X 1956 VA SEE SCHEDULE O 9 9 892 233 2152 -5850 114141 197988 115430967 117643000 568320 20700 1389611 986964 117503039 118848652 648319 606522 0 0 42948983 48776792 0 0 0 71760201 67125951 115357503 116509265 2145536 2339387 113450808 116694297 12463942 14288478 100986866 102405819 X THE MISSION OF NOVANT HEALTH UVA HEALTH SYSTEM 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 94590381 606522 118184419 CULPEPER MEMORIAL HOSPITAL, INC., DOING BUSINESS AS NOVANT HEALTH UVA HEALTH SYSTEM CULPEPER MEDICAL CENTER ("NHUVACMC") PROVIDES PROGRAMS AND ACTIVITIES THAT IMPROVE ACCESS TO HEALTHCARE AND IMPROVE HEALTH IN OUR COMMUNITY. NHUVACMC 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. NHUVACMC 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. NHUVACMC WORKS WITH LOCAL COMMUNITY COLLEGES TO PROVIDE TOURS, LECTURES, AND INTERNSHIPS FOR STUDENTS. NHUVACMC 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 2019, THERE WERE 11,933 PATIENT DAYS, WITH AN AVERAGE LENGTH OF STAY OF 3 DAYS, AND AN AVERAGE DAILY CENSUS OF 33. THERE WERE 3,466 DISCHARGES, 2,350 INPATIENT AND OUTPATIENT SURGERIES, 102,445 OUTPATIENT ENCOUNTERS AND 34,743 EMERGENCY DEPARTMENT VISITS. 94590381 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 1 892 1 1 1 0 0 0 0 0 0 0 0 0 0 0 X 9 9 0 0 0 0 1 1 0 1 1 0 0 1 1 1 1 1 1 0 0 1 1 VA X X KAREN DAUGHERTY 3367182803 2085 FRONTIS PLAZA BLVD WINSTON SALEM NC 27103 PILONG ALFRED SVP & CEO NHUVAHS 0.00 50.00 X 0 577400 86544 D'SOUZA JONATHAN CMO 50.00 0.00 X 358206 0 23894 HETMANSKI JEFF FMR CEO 50.00 0.00 X 291243 0 20566 SMITH DENNIS DIRECTOR CLINICAL INITIATIVES 45.00 0.00 X 194859 0 20513 SHIFFLETT MINDI CNO 50.00 0.00 X 183950 0 19281 EDWARDS SUSAN CHIEF HRO 50.00 0.00 X 165785 0 29429 COATES TEMPLE DIR. PROF. & ANCILLARY SVC 45.00 0.00 X 159378 0 28588 SPEELMAN STEVEN ADMIN DIRECTOR INFORMATION SYS 45.00 0.00 X 150435 0 27972 WHITE SARA ADMIN DIRECTOR OF FINANCE 45.00 0.00 X 156249 0 19155 SHIFFLETT TRACEY DIRECTOR OF REVENUE CYCLE 45.00 0.00 X 153877 0 10191 NAPPS CARL FMR COO 0.00 0.00 X 0 88007 5636 STATON DONNA PRESIDENT 50.00 0.00 X 8846 0 0 BARBER SALLY NAN VICE CHAIR 0.20 0.00 X X 0 0 0 BARRELL CHARLES CHAIR 0.20 0.20 X X 0 0 0 FERGUSON JAMES MD TRUSTEE 0.20 0.00 X 0 0 0 FITZGERALD LARRY VICE CHAIR / TREAS 0.20 0.20 X X 0 0 0 HARRINGTON RICHARD TRUSTEE 0.20 0.00 X 0 0 0 HINTON-JACKSON HORTENSE SEC 0.20 0.00 X X 0 0 0 LISCHKE DOUG TREASURER 0.20 0.00 X X 0 0 0 REYNOLDS THOMAS TRUSTEE 0.20 0.00 X 0 0 0 SYVERUD SCOTT MD TRUSTEE 0.20 0.00 X 0 0 0 1822828 665407 291769 50 1 1 0 UVA MEDICAL CENTER PO BOX 800778 CHARLOTTESVILLE VA 22908 CLINICAL SUPPORT 5209494 UVA PHYSICIANS GROUP 500 RAY C HUNT DR CHARLOTTESVILLE VA 22903 CLINICAL SUPPORT 3013930 AMERICAN ANESTHESIOLOGY PO BOX 281034 ATLANTA GA 30384 PHYSICIAN SERVICES 2228280 CRENSHAW CONSTRUCTION CO INC PO BOX 1805 CULPEPER VA 22701 ARCHITECTURAL SERVICES 1912003 WE BOWMAN CONSTRUCTION INC 3715 BELT BLVD RICHMOND VA 23234 ARCHITECTURAL SERVICES 974241 24 24736 173252 197988 NET PATIENT REVENUE 622110 117312053 117312053 PASS-THRU PATIENT REV 621111 330947 330947 117643000 20700 20700 137663 0 137663 137663 137663 MISCELLANEOUS REVENUE 900099 541419 541419 CAFETERIA MEALS 722514 305730 305730 CATERING 722320 2152 2152 849301 118848652 118184419 2152 464093 X 559390 559390 47132 47132 1101200 1101200 37478363 24360935 13117428 1328495 863521 464974 6156150 4001497 2154653 2712584 1763180 949404 212499 212499 13223342 12098276 1125066 160480 160480 1566441 1199601 366840 1122925 1122925 1761596 1691132 70464 6903 4487 2416 161602 105041 56561 6978761 6710790 267971 428855 84576 344279 PHARMACEUTICALS 14420128 14420128 BAD DEBT 10665062 10665062 MEDICAL SUPPLIES 9232653 9196237 36416 CONTRACT LABOR 3854948 2505716 1349232 3329756 3030275 299481 116509265 94590381 21918884 0 15799706 13831182 14200560 13780393 2124132 2693244 1534646 1078581 83458806 26137248 54291010 57321558 1025528 1194266 24471709 26795073 3517 0 113450808 116694297 10434684 10160314 2029258 4128164 12463942 14288478 X 100814195 102245289 172671 160530 100986866 102405819 113450808 116694297 X 2339387 -920434 X 0 0 0 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 0 0 0 0 0 0 0 0 1 4476 4476 0 PART II-B, LINE 1: LINE 1I DUES PAID TO CERTAIN ORGANIZATIONS WHICH INCLUDE A PORTION RELATED TO LOBBYING ACTIVITIES. 2830000 2830000 26468845 12019771 14449074 114364 114364 0 45871190 11321668 34549522 8174407 2681445 5492962 57321558 0 CH - DUE TO CWF LT COMMITMENT 1500000 OPERATING LEASE 2628164 4128164 X PART X, LINE 2: PART X, LINE 2: LIABILITY UNDER FIN 48 (ASC 740) FOOTNOTE THE AUDIT FOR NOVANT HEALTH UVA HEALTH SYSTEM 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, 2019 AND 2018. 1 1 1 X 1 X 0 1 1 0 1 1 3808490 0 3808490 0.03600 20831678 19697714 1133964 0.01070 24640168 19697714 4942454 0.04670 106055 0 106055 0.00100 517400 0 517400 0.00490 623455 623455 0.00590 25263623 19697714 5565909 0.05260 2394 0 2394 0.00000 2000 0 2000 0.00000 4394 4394 0.00000 1 10665062 0 37632313 49831828 -12199515 X 1 1 1 CULPEPER SURGERY CENTER LLC OUTPATIENT SURGERY CENTER 0.55670 0.44330 1 1 CMH DBA NHUVAHS CULPEPER MEDICAL CENTER 501 SUNSET LANE CULPEPER VA 22701 WWW.NOVANTHEALTHUVA.ORG H1848 X X X CULPEPER MEMORIAL HOSPITAL 1 0 0 1 X X X X X X X X X 17 1 0 0 1 X SEE SECTION C X 1 17 1 SEE SECTION C 0 1 X 100.000000000000 200.000000000000 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 CULPEPER MEMORIAL HOSPITAL PART V, SECTION B, LINE 3J: CULPEPER MEMORIAL HOSPITAL:PART V, SECTION B, LINE 3E:SEVERAL SOCIAL, BEHAVIORAL, AND CLINICAL HEALTH NEEDS WERE IDENTIFIED IN THE NEEDS ASSESSMENT. ONCE THE HEALTH NEEDS WERE IDENTIFIED, SURVEYS AND COMMUNITY MEETINGS WERE CONDUCTED IN WHICH THE VARIOUS COMMUNITY STAKEHOLDERS RANKED THE HEALTH ISSUES ACCORDING TO THE YEARS OF POTENTIAL LIFE LOST AND MAGNITUDE OF IMPACT. THE INFORMATION GATHERED WAS THEN MATRIXED AND SCORED IN ORDER TO RANK THE FOCUS AREAS AND PRIORITIZE THE IDENTIFIED HEALTH NEEDS. THE PRIORITIZED IDENTIFIED HEALTH NEEDS AND SUPPORTING DATA ARE THEN REVIEWED AND DELIBERATED UPON FURTHER BY THE BOARD. AN IMPLEMENTATION PLAN IS CREATED FOR CERTAIN OF THE PRIORITIZED, IDENTIFIED HEALTH NEEDS AND ASSESSED REGULARLY THROUGHOUT THE COMMUNITY HEALTH NEEDS ASSESSMENT LIFE CYCLE. COMMUNITY PARTNERS WHO ARE CURRENTLY DOING THE WORK ARE IDENTIFIED AS POTENTIAL PARTNERS FOR COLLABORATION ON THOSE IDENTIFIED NEEDS THAT ARE NOT PART OF THE IMPLEMENTATION PLAN. CULPEPER MEMORIAL HOSPITAL 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. CULPEPER MEMORIAL HOSPITAL PART V, SECTION B, LINE 7D: CULPEPER MEMORIAL HOSPITALPART V, SECTION B, LINE 7BHTTPS://WWW.NOVANTHEALTHUVA.ORG/ABOUT-US/COMMUNITY-ENGAGEMENT/COMMUNITY-BENEFIT.ASPXNAME OF HOSPITAL/GROUP (EX THE PRESBYTERIAN HOSPITAL)PART V, SECTION B, LINE 10AHTTPS://WWW.NOVANTHEALTHUVA.ORG/ABOUT-US/COMMUNITY-ENGAGEMENT/COMMUNITY-BENEFIT.ASPX CULPEPER MEMORIAL HOSPITAL PART V, SECTION B, LINE 11: THE HOSPITAL FACILITY(IES) IS/ARE A PART OF THE NOVANT HEALTH UVA HEALTH SYSTEM, 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 THE CHNA RESOURCE GROUP AND SUBSEQUENTLY BY EACH FACILITY'S BOARD. THEY EVALUATED EACH DOCUMENTED NEED AND ITS INTERSECTION WITH THE ORGANIZATION'S VISION, COMMITMENTS, AND KEY STRENGTHS BEFORE FURTHER PRIORITIZING THE HEALTH NEEDS AND AGREEING UPON THE TOP HEALTH PRIORITIES TO BE ADDRESSED. WHERE POSSIBLE, WE HAVE LEVERAGED THE SYSTEM'S STRENGTHS AND RESOURCES TO BEST ADDRESS THOSE NEEDS THAT ARE HIGHEST IN PRIORITY AND CONSISTENT ACROSS COMMUNITIES. NOVANT HEALTH AND EACH OF ITS HOSPITAL FACILITIES HAVE ADOPTED AND EXECUTED AN IMPLEMENTATION STRATEGY THAT ADDRESSES THE PRIORITIZED COMMUNITY HEALTH NEEDS FROM THE CHNAS. THE IMPLEMENTATION STRATEGIES OUTLINE THE PLAN THAT THE HOSPITAL FACILITY(IES) WILL UNDERTAKE TO MEET THOSE HEALTH NEEDS IN EACH OF ITS COMMUNITIES. CERTAIN NEEDS THAT WERE IDENTIFIED BY THE CHNA HAVE NOT BEEN ADDRESSED. CERTAIN OF THE NEEDS NOT ADDRESSED FALL OUTSIDE OF THE SCOPE OF TRADITIONAL HEALTHCARE (IE. DENTAL WORK) AND OTHERS ARE CANDIDATES FOR COLLABORATIVE WORK AND HAVE 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. CULPEPER MEMORIAL HOSPITAL PART V, SECTION B, LINE 13H: CULPEPER MEMORIAL HOSPITAL: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/PORTALS/541/FORMS/FINANCIAL%20ASSISTANCE%20FOR%20THE%20UNINSURED%20FORMS/2019/FINANCIAL-ASSISTANCE-APP/FAA_APP_ENGLISH.PDFPART V, LINE 16C, FAP PLAIN LANGUAGE SUMMARY:HTTPS://WWW.NOVANTHEALTHUVA.ORG/PORTALS/541/FORMS/FINANCIAL%20ASSISTANCE%20FOR%20THE%20UNINSURED%20FORMS/2019/PLAIN-LANGUAGE/NOVANT%20HEALTH%20ACUTE%20PLS%20ENGLISH%20-%20UVA.PDF 2 1 - CULPEPER SURGERY CENTER LLC 541 SUNSET LANE STE 201 CULPEPER VA 22701 AMBULATORY SURGERY CENTER 2 - NHUVAHS 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.NOVANTHEALTHUVA.ORG/ABOUT-US/COMMUNITY-INVOLVEMENT/COMMUNITY-BENEFIT.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: COSTS REPORTED IN THE TABLE FOR CHARITY CARE AND CERTAIN OTHER COMMUNITY BENEFITS AMOUNTS ARE CALCULATED USING AN ENTITY SPECIFIC COST TO CHARGE RATIO BASED ON WORKSHEET 2 (CCR). PART I, LN 7 COL(F): THE AMOUNT OF BAD DEBT REMOVED FROM TOTAL EXPENSES (DENOMINATOR) WAS $10,665,062. PART II, COMMUNITY BUILDING ACTIVITIES: THE ORGANIZATION'S COMMUNITY BUILDING ACTIVITIES ADDRESSES 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 LOCAL YMCA'S, UNITED WAY PARTNER AGENCIES, CHAMBERS OF COMMERCE AND OTHER LOCAL COMMUNITY ORGANIZATIONS, ASSISTING WITH COMMUNITY AND COUNTY COALITIONS, AND PROVIDING EDUCATION SEMINARS AND TRAINING FOR COMMUNITY WORKFORCES. THROUGH THESE OUTREACH METHODS WE ARE ABLE TO SUCCESSFULLY WORK TOWARDS BRIDGING THE GAP OF NEED WITHIN OUR IDENTIFIED IMPACTED COMMUNITIES. 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: THE ORGANIZATION IS PART OF NOVANT HEALTH UVA HEALTH SYSTEM, AN INTEGRATED NOT-FOR-PROFIT HEALTH SYSTEM. NOVANT HEALTH, INC. IS A MEMBER ORGANIZATION OF THE NOVANT HEALTH UVA HEALTH SYSTEM. NOVANT HEALTH, INC. IS A MEMBER ORGANIZATION OF THE NOVANT HEALTH UVA HEALTH SYSTEM. NOVANT HEATH, INC. HAS A COMMUNITY BENEFIT DEPARTMENT ("CBE DEPARTMENT") COMPRISED OF COMMUNITY BENEFIT PROFESSIONALS. THE CBE DEPARTMENT IS RESPONSIBLE FOR COORDINATING THE PREPARATION OF THE COMMUNITY HEALTH NEEDS ASSESSMENTS (CHNA) FOR EACH HOSPITAL WITHIN THE SYSTEM, INCLUDING THE CHNAS REPORTED IN PART V, SECTION B. EACH HOSPITAL AND THE CBE DEPARTMENT 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. THROUGH PARTNERSHIPS WITH OTHER COMMUNITY ORGANIZATIONS WE ARE ABLE TO DRAW INFERENCE OF THE NEEDS NOT MET WITHIN THE IMMEDIATE COMMUNITIES WE SERVE, AND MEET AND EXCEED THOSE COMMUNITY MEMBER'S NEEDS. 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. ORGANIZATIONAL PARTNERSHIPS ESTABLISHED BY THE COMMUNITY BENEFIT DEPARTMENT ARE OFTEN LEVERAGED TO ADDRESS NEEDS THAT WERE IDENTIFIED IN THE CHNA, BUT WERE UNADDRESSED BY THE FACILITY IMPLEMENTATION PLAN. PART VI, LINE 3: CULPEPER HOSPITAL 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: CULPEPER MEMORIAL HOSPITAL, INC. DBA NOVANT HEALTH UVA HEALTH SYSTEM CULPEPER MEDICAL CENTERTHE ORGANIZATION DEFINES ITS COMMUNITY BY ITS PRIMARY SERVICE AREA. THE PRIMARY SERVICE AREA FOR NOVANT HEALTH UVA HEALTH SYSTEM CULPEPER MEDICAL CENTER IS DEFINED BY THE ZIP CODES THAT REPRESENT MORE THAN 75% OF THE HOSPITAL'S IN-PATIENT POPULATION. THESE ZIP CODES ALL FALL WITHIN CULPEPER COUNTY, VIRGINIA. BASED ON 2016 ESTIMATES, CULPEPER COUNTY IS THE 37TH OUT OF 133 COUNTIES IN THE STATE OF VIRGINIA WITH JUST OVER 50,000 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 HAS EXPERIENCED SMALL, BUT STEADY POPULATION GROWTH (7.3%) SINCE THE 2010 US CENSUS. CHILDREN AND ADOLESCENTS (AGE 0-18) MAKE UP AN ESTIMATE OF JUST OVER ONE-THIRD (31.5%) OF THE POPULATION IN CULPEPER COUNTY AND SENIORS (AGE 65 AND OVER) MAKE UP 14.7% OF THE POPULATION. NONWHITE MINORITIES CURRENTLY MAKE UP 30.5% OF THE RACIAL DEMOGRAPHIC IN CULPEPER COUNTY. THE SPECIFIC POPULATION GROUPS (ETHNIC AND CULTURAL) ARE AS FOLLOWS: WHITE NON-HISPANIC 79.5%; BLACK/AFRICAN-AMERICAN 15.1%; HISPANIC OR LATINO 10.1%; OTHER 5.3%. DATA TAKEN FROM THE 2016 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 $66,697. THE POVERTY RATE FOR CULPEPER COUNTY IS 10.2%.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 HEALTH NEEDS ASSESSMENT AT: HTTPS://WWW.NOVANTHEALTHUVA.ORG/ABOUT-US/COMMUNITY-ENGAGEMENT/COMMUNITY-BENEFIT.ASPX 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 NOVANT HEALTH UVA HEALTH SYSTEM AND NOVANT HEALTH (COLLECTIVELY KNOWN AS "THE SYSTEM"), BOTH ARE 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/COMPANY-INFORMATION/FINANCIAL-PROFILE/COMMUNITY-BENEFIT-REPORT.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. 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. 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, NOVANT HEALTH UVA HEALTH SYSTEM INCLUDES A PHYSICIAN ORGANIZATION WITH PRACTICES IN VIRGINIA AND A HOSPITAL FOUNDATION WHICH SUPPORTS AND ENHANCES THE ACTIVITIES IN THOSE HOSPITALS' COMMUNITIES. FURTHER, NOVANT HEALTH UVA HEALTH SYSTEM 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 CULPEPER MEMORIAL HOSPITAL 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 RAPPAHANNOCK GOODWILL INDUSTRIES INC 4701 MARKET STREET SUITE A FREDERICKSBURG VA 22408 540808744 501(C)(3) 9400 COMMUNITY OUTREACH CULPEPER COUNTY CHAMBER OF COMMERCE 629 SPERRYVILLE PIKE CULPEPER VA 22701 540640609 501(C)(6) 15590 COMMUNITY OUTREACH CULPEPER WELLNESS FOUNDATION INC 311 S EAST STREET NO 100 CULPEPER VA 22701 521366700 501(C)(3) 505000 COMMUNITY OUTREACH 2 1 TEAM MEMBER ASSISTANCE (EMPLOYEE EMERGENCY FUND) 3 1500 SCHOLARSHIP 4 2000 MAMMOGRAMS 91 41151 MEDICATION TO INDIGENT PATIENTS 60 1801 FMV MEDICATION PATIENT ASSISTANCE 16 480 WIGS PATIENT TRANSPORTATION 8 200 FMV TRANSPORTATION PART I, LINE 2: PROCEDURES FOR MONITORING THE USE OF GRANT FUNDS THE FILING ORGANIZATION DOES NOT PROVIDE GRANTS. 1 1 0 0 0 0 0 0 0 PILONG ALFRED SVP & CEO NHUVAHS 0 378432 0 100000 0 98968 0 60862 0 25682 0 663944 0 0 D'SOUZA JONATHAN CMO 290358 0 67848 0 0 0 14346 0 9548 0 382100 0 0 0 HETMANSKI JEFF FMR CEO 202721 0 79868 0 8654 0 12384 0 8182 0 311809 0 0 0 SMITH DENNIS DIRECTOR CLINICAL INITIATIVES 182200 0 12659 0 0 0 11203 0 9310 0 215372 0 0 0 SHIFFLETT MINDI CNO 174973 0 8977 0 0 0 0 0 19281 0 203231 0 0 0 EDWARDS SUSAN CHIEF HRO 156614 0 7571 0 1600 0 10128 0 19301 0 195214 0 0 0 COATES TEMPLE DIR. PROF. & ANCILLARY SVC 147136 0 8332 0 3910 0 9400 0 19188 0 187966 0 0 0 SPEELMAN STEVEN ADMIN DIRECTOR INFORMATION SYS 139386 0 7147 0 3902 0 8869 0 19103 0 178407 0 0 0 WHITE SARA ADMIN DIRECTOR OF FINANCE 146895 0 7371 0 1983 0 9146 0 10009 0 175404 0 0 0 SHIFFLETT TRACEY DIRECTOR OF REVENUE CYCLE 142708 0 7258 0 3911 0 8732 0 1459 0 164068 0 0 0 NAPPS CARL FMR COO 0 0 0 0 0 88007 0 0 0 5636 0 93643 0 0 PART I, LINE 3 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, LINES 4A-B PART I, LINES 4A-C: SEVERANCE, NONQUALIFIED, AND EQUITY-BASED PAYMENTS SEVERANCE NAPPS, CARL $89,423 NONQUALIFIED NONE EQUITY-BASED NONE PART I, LINE 4A - SEVERANCE PLAN: ELIGIBLE EXECUTIVES MAY RECEIVE SEVERANCE PAY THAT IS BASED ON ANNUAL COMPENSATION FOR A SPECIFIED PERIOD OF TIME. THE SEVERANCE PAY WOULD BE PAID ONLY IN THE EVENT OF CERTAIN TYPES OF EMPLOYMENT TERMINATION, AND IS FURTHER CONTINGENT ON THE SATISFACTION OF OTHER CONDITIONS SUCH AS COMPLIANCE WITH A NON-COMPETITION COVENANT. ANY CURRENT YEAR PAYMENTS HAVE BEEN INCLUDED IN THE COMPENSATION AMOUNTS REPORTED IN PART VII AND IN COLUMN (B)(III) OF SCHEDULE J. THE COMPENSATION AND LEADERSHIP COMMITTEE OF THE NOVANT HEALTH BOARD REVIEWS, APPROVES, AND OVERSEES ALL ASPECTS AND ALL ELEMENTS OF EXECUTIVE COMPENSATION AND BENEFITS, INCLUDING THE AMOUNTS AWARDED UNDER THIS SEVERANCE PLAN. 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. FORM 990, PI, L1: ORGANIZATION'S MISSION OR MOST SIGNIFICANT ACTIVITIES CULPEPER MEMORIAL HOSPITAL DOING BUSINESS AS NOVANT HEALTH UVA HEALTH SYSTEM CULPEPER MEDICAL CENTER ("NHUVACMC") IS AN INTEGRAL PART OF THE NOVANT HEALTH UVA HEALTH SYSTEM ("NHUVAHS"). NHUVAHS WAS FORMED IN 2016 BY NOVANT HEALTH AND THE UNIVERSITY OF VIRGINIA HEALTH SYSTEM, AND IS A REGIONAL NONPROFIT, INTEGRATED HEALTHCARE NETWORK OF PHYSICIAN CLINICS, OUTPATIENT CENTERS, AND HOSPITALS THAT SERVES PATIENTS AND COMMUNITIES IN VIRGINIA. NHUVACMC RECEIVES STRATEGIC PLANNING, ADMINISTRATIVE AND OTHER SUPPORT FROM NOVANT HEALTH, INC., A MEMBER OF THE NOVANT HEATH UVA HEALTH SYSTEM. GENERAL INFORMATION NOVANT HEALTH UVA HEALTH SYSTEM CULPEPER MEDICAL CENTER, LOCATED IN CULPEPER, VA, 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, AND MADISON 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 PATIENTS TO HELP QUALIFY THEM FOR PUBLIC ASSISTANCE, ESTABLISH A REASONABLE PAYMENT PLAN, DISCOUNT THEIR BILL, OR PROVIDE FREE CARE FOR THOSE THAT QUALIFY FOR FINANCIAL ASSISTANCE. COMMUNITY OUTREACH COMMUNITY OUTREACH IS A CRITICAL COMPONENT TO THE MISSION OF NOVANT HEALTH UVA HEALTH SYSTEM 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/FREE CLINIC OF CULPEPER, ORANGE COUNTY FREE CLINIC, GIRLS ON THE RUN PIEDMONT, CULPEPER LITERACY COUNCIL, AGING TOGETHER, COME AS YOU ARE, AND AMERICAN CANCER SOCIETY. CULPEPER MEDICAL CENTER OFFERED SUPPORT GROUPS FOR WOMEN WHO HAVE LOST A NEWBORN OR PREGNANCY, AND CANCER PATIENTS AND THEIR CAREGIVERS. IT ALSO PROVIDED COMMUNITY EDUCATION ABOUT ACCESS TO HEALTHCARE SERVICES, CANCER SERVICES, HEART DISEASE, STROKE, AND DIABETES. 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 NOVANT HEALTH UVA HEALTH SYSTEM CULPEPER MEDICAL CENTER. NEW TECHNOLOGY & SERVICES WOMEN'S SERVICES ARE UNDERGOING AN EXPANSION AT NOVANT HEALTH UVA HEALTH SYSTEM CULPEPER MEDICAL CENTER. UVA OBSTETRICS AND GYNECOLOGY, A DEPARTMENT OF NOVANT HEALTH UVA HEALTH SYSTEM CULPEPER MEDICAL CENTER, LOCATED ON THE CAMPUS OF NHUVACMC WILL BE RELOCATING TO A LARGER, NEWLY RENOVATED SPACE ON CAMPUS. THE NEW SPACE PROVIDES GREATER ACCESS TO CARE FOR PATIENTS WITH IMPROVED PARKING, MORE EXAM ROOMS AND APPOINTMENTS, ONSITE MATERNAL FETAL MEDICINE AND ULTRA SOUND, AS WELL AS THE ADDITION OF NEW PHYSICIANS AND MID-LEVEL PROVIDERS. IN 2019, NOVANT HEALTH UVA HEALTH SYSTEM CULPEPER MEDICAL CENTER WAS GRANTED COPN APPROVAL FOR A NEW FREE STANDING IMAGING CENTER TO BE LOCATED IN THE HEART OF THE DOWNTOWN CULPEPER SUPPORTING THE TOWN'S MAIN STREET REVITALIZATION PROJECT. THE NEW IMAGING CENTER IS EXPECTED TO OPEN IN 2020 AND WILL PROVIDE RESIDENTS OF CULPEPER AND SURROUNDING COUNTIES WITH INCREASED OPTIONS FOR IMAGING SERVICES. AWARDS, RECOGNITIONS & CERTIFICATIONS/RECERTIFICATIONS -BEGINNING IN 2017, NOVANT HEALTH UVA HEALTH SYSTEM CULPEPER MEDICAL CENTER FAMILY BIRTH CENTER PROVIDERS SUCCESSFULLY REDUCED THE NUMBER OF ELECTIVE INDUCTIONS AND CESAREAN DELIVERIES PERFORMED BEFORE 39 WEEKS OF PREGNANCY TO ZERO, WHERE IT REMAINS TODAY. THIS GOAL WAS PREVIOUSLY RECOGNIZED BY THE MARCH OF DIMES FOR GIVING BABIES A HEALTH START IN LIFE. -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. RE-DESIGNATED IN 2019 AS "BABY-FRIENDLY" BY BABY FRIENDLY USA. -NAMED ONE OF THE 100 BEST "HOSPITALS FOR SPECIALTY CARE" BY HEALTHGRADES FOR TWO AREAS OF ORTHOPEDICS: JOINT REPLACEMENT AND ORTHOPEDIC SURGERY. ACCREDITATION NOVANT HEALTH UVA HEALTH SYSTEM 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. COMMUNITY BENEFIT REPORT HTTPS://WWW.NOVANTHEALTHUVA.ORG/ABOUT-US/COMMUNITY-ENGAGEMENT/COMMUNITY- BENEFIT.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. IN THIS REPORT, THE NOVANT HEALTH SYSTEM'S COMMUNITY BENEFIT WAS APPROXIMATELY $993,000,000, INCLUDING $152,000,000 IN FINANCIAL ASSISTANCE FOR 2019. 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 CORPORATION HAS NOVANT HEALTH UVA HEALTH SYSTEM AS ITS SOLE MEMBER. FORM 990, PART VI, SECTION A, LINE 7A FORM 990, PART VI, SECTION A, LINE 7A: ELECTION OF MEMBERS AND THEIR RIGHTS THE BOARD OF NOVANT HEALTH UVA HEALTH SYSTEM APPOINTS THE BOARD OF CULPEPER MEMORIAL HOSPITAL, INC. FORM 990, PART VI, SECTION B, LINE 11B FORM 990, PART VI, SECTION B, LINE 11: ORGANIZATION'S PROCESS TO REVIEW FORM 990 THE REVIEW OF THE 990 IS PERFORMED BY THE CONTROLLER AND CHIEF FINANCIAL OFFICER AND THEN BY THE PRESIDENT; THE PRESIDENT BEING THE ONE RESPONSIBLE FOR SIGNING THE 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: 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 ORGANIZATION MAKES ITS GOVERNING DOCUMENTS, CONFLICT OF INTEREST POLICY, AND FINANCIAL STATEMENTS AVAILABLE TO THE PUBLIC UPON REQUEST. FORM 990, PART IX, LINE 11G OUTSIDE SERVICES: PROGRAM SERVICE EXPENSES 4,421,658. MANAGEMENT AND GENERAL EXPENSES 972,027. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 5,393,685. CONTRACTED SERVICES: PROGRAM SERVICE EXPENSES 111,590. MANAGEMENT AND GENERAL EXPENSES 4,650. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 116,240. COLLECTION SERVICE: PROGRAM SERVICE EXPENSES 0. MANAGEMENT AND GENERAL EXPENSES 148,337. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 148,337. CREDENTIALING FEES: PROGRAM SERVICE EXPENSES 98. MANAGEMENT AND GENERAL EXPENSES 52. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 150. PROFESSIONAL PHYSICIAN SERVICES: PROGRAM SERVICE EXPENSES 7,564,930. MANAGEMENT AND GENERAL EXPENSES 0. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 7,564,930. FORM 990, PART XI, LINE 9: CONTRIBUTIONS: 500,000. PARTNERSHIPS: -63,590. AFFILIATE TRANSFERS: -1,936,245. BOOK ADJUSTMENT: 579,401. 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