2019-11-15T07:36:40-06:00 2018-12-31 990 2018-01-01 540622371 CULPEPER MEMORIAL HOSPITAL INC CULP 3367182803 501 SUNSET LANE CULPEPER VA 22701 JEFF HETMANSKI PRESIDENT 5408298803 2019-11-11 170.98.106.254 2019-11-11 14:39:31 ES P 0EB4CE1ACD44DB279B6C2D9A8476B20948576B96 A2315309B7343EB998963AA05290CF11231D17E5 2018 2020-03-31 21:24:44Z NOVANT HEALTH UVA HEALTH SYSTEM CULPEPER MEDICAL CENTER ALFRED E PILONG 501 SUNSET LANE CULPEPER VA 22701 120692311 0 X WWW.NOVANTHEALTHUVA.ORG X 1956 VA SEE SCHEDULE O 7 7 833 231 4218 -3054 140534 114141 106159792 115430967 202571 568320 975809 1389611 107478706 117503039 697819 648319 0 0 39337926 42948983 0 0 0 65513928 71760201 105549673 115357503 1929033 2145536 111305148 113450808 12367790 12463942 98937358 100986866 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 96564797 648319 116396615 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 2018, THERE WERE 11,293 PATIENT DAYS, WITH AN AVERAGE LENGTH OF STAY OF 3 DAYS, AND AN AVERAGE DAILY CENSUS OF 31. THERE WERE 3,274 DISCHARGES, 2,390 INPATIENT AND OUTPATIENT SURGERIES, 94,365 OUTPATIENT ENCOUNTERS AND 33,226 EMERGENCY DEPARTMENT VISITS. 96564797 1 1 0 1 0 0 0 0 0 0 1 0 0 0 1 0 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 76 0 1 833 1 1 1 0 0 0 0 0 0 0 0 0 0 0 X 7 7 1 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 BARBER SALLY NAN TRUSTEE 2.00 X 0 0 0 BARRELL CHARLES CHAIR 2.00 X X 0 0 0 CLARK SHARON SEC 2.00 X X 0 0 0 FERGUSON JAMES MD TRUSTEE 2.00 X 0 0 0 FITZGERALD LARRY VICE CHAIR / TREAS 2.00 X X 0 0 0 HINTON-JACKSON HORTENSE TRUSTEE 2.00 X 0 0 0 SYVERUD SCOTT MD TRUSTEE 2.00 X 0 0 0 HETMANSKI JEFF CEO 60.00 X 242215 0 23775 CONKLIN MARGARET FMR CNO 60.00 X 0 193034 26761 D'SOUZA JON CMO 60.00 X 251484 0 7573 EDWARDS SUSAN CHIEF HRO 60.00 X 152907 0 32154 SHIFFLETT MINDI CNO 60.00 X 173982 0 24647 REYNOLDS THOMAS FMR CMO 60.00 X 90431 0 7852 COATES TEMPLE DIR. PROF. & ANCILLARY SERVICES 40.00 X 165663 0 32933 SHIFFLETT TRACEY DIRECTOR OF REVENUE CYCLE 40.00 X 149678 0 11659 SMITH DENNIS DIRECTOR OF PHARMACY NH UVA 40.00 X 194145 0 26301 WEST VIRGINIA PHARMACY MANAGER 40.00 X 145886 0 22738 WHITE SARA ADMIN DIRECTOR OF FINANCE 40.00 X 147324 0 21822 NAPPS CARL FMR PRES & COO/TRUSTEE 60.00 X 0 431238 35671 1713715 624272 273886 43 1 1 0 UVA PHYSICIANS GROUP 500 RAY C HUNT DR CHARLOTTESVILLE VA 22903 CLINICAL SUPPORT 3888031 UVA MEDICAL CENTER PO BOX 800778 CHARLOTTESVILLE VA 22908 CLINICAL SUPPORT 3788115 AMERICAN ANESTHESIOLOGY PO BOX 281034 ATLANTA GA 30384 PHYSICIAN SERVICES 2131708 WE BOWMAN CONSTRUCTION INC 3715 BELT BLVD RICHMOND VA 23234 ARCHITECTURAL SERVICES 1454927 PCM FILE 55327 LOS ANGELES CA 90074 ARCHITECTURAL SERVICES 1146430 23 114141 114141 NET PATIENT REVENUE 622310 115008612 115008612 SURGICAL CENTER INCOME 622310 422355 422355 115430967 78994 78994 139126 0 139126 139126 139126 3678598 3189272 489326 489326 489326 MISCELLANEOUS REVENUE 900099 709346 709346 CAFETERIA MEALS 722514 280619 280619 EHR INCENTIVE 900099 256302 256302 4218 4218 1250485 117503039 116396615 4218 988065 586755 586755 61564 61564 1007020 1007020 33353916 21680045 11673871 1176590 764784 411806 5058775 3288204 1770571 2352682 1529243 823439 346949 346949 11522045 9935364 1586681 413503 413503 1801158 1212101 589057 1122058 1122058 1553733 1553733 10458 10458 137508 137508 104 104 7314284 7314284 501401 398224 103177 UBI TAXES -3568 -3568 DRUGS 14757438 14757438 BAD DEBT 14630780 14630780 MEDICAL SUPPLIES 9401252 9401252 8251098 7915361 335737 115357503 96564797 18792706 0 11188911 15799706 13556936 14200560 1931880 2124132 1128342 1534646 74622873 20331863 53497237 54291010 4301032 0 949619 1025528 24751191 24471709 0 3517 111305148 113450808 9860342 10434684 2507448 2029258 12367790 12463942 X 98474853 100814195 462505 0 172671 98937358 100986866 111305148 113450808 X 2145536 -554628 458600 X 0 1 X 1 0 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 10205 10205 0 PART II-B, LINE 1: LINE 1I DUES PAID TO CERTAIN ORGANIZATIONS WHICH INCLUDE A PORTION RELATED TO LOBBYING ACTIVITIES. 2830000 2830000 24568833 11560463 13008370 114364 114364 0 38577898 5997703 32580195 8531778 2659333 5872445 54291010 0 CH - DUE TO CWF LT COMMITMENT 2000000 OTHER LIABILITIES 29258 2029258 1 1 1 X 1 X 0 1 1 0 1 1 5656537 5656537 0.05620 10440343 7453431 2986912 0.02970 16096880 7453431 8643449 0.08590 97619 97619 0.00100 707 707 0.00000 508504 508504 0.00500 606830 606830 0.00600 16703710 7453431 9250279 0.09190 1200 1200 0.00000 24488 24488 0.00020 485 485 0.00000 26173 26173 0.00020 1 14630780 0 35190020 44914730 -9724710 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 HTTPS://WWW.NOVANTHEALTHUVA.ORG X 1 17 1 HTTPS://WWW.NOVANTHEALTHUVA.ORG 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 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. 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 11: THE HOSPITAL FACILITY IS A PART OF 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 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. 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 WEBSITE:HTTPS://WWW.NOVANTHEALTHUVA.ORG/PATIENTS--VISITORS/FINANCIAL-ASSISTANCE-FOR-THE-UNINSURED.ASPXPART V, LINE 16C, FAP PLAIN LANGUAGE SUMMARY WEBSITE:HTTPS://WWW.NOVANTHEALTHUVA.ORG/PATIENTS--VISITORS/FINANCIAL-ASSISTANCE-FOR-THE-UNINSURED.ASPX 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: 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 BAD DEBT EXPENSE INCLUDED ON FORM 990, PART IX, LINE 25(A), BUT SUBTRACTED FOR PURPOSES OF CALCULATING THE PERCENTAGE IN THIS COLUMN IS $14,630,780. 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 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 6 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. 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 THE NOVANT HEALTH SYSTEM 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: 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 WHICH INCLUDES CULPEPER COUNTY. CULPEPER COUNTY IS SPREAD ACROSS THE FOOTHILLS OF THE BLUE RIDGE MOUNTAINS' FIELDS OF THE NORTH CENTRAL PIEDMONT REGION AND IS MORE RURAL IN NATURE. ACCORDING TO THE US CENSUS BUREAU DATA, THE MEDIAN HOUSEHOLD INCOME LEVEL WAS $102,382.ACCORDING TO SG2 DATA, THE SPECIFIC POPULATION GROUPS (ETHNIC AND CULTURAL) FOR THE PRIMARY SERVICE AREAS ARE AS FOLLOWS:PRIMARY SERVICE AREAETHNICITY POPULATION % OF POPULATIONWHITE 39,538 71.99%BLACK/AFRICAN AMERICAN 7,541 13.73%HISPANIC/LATINO 5,222 9.51%ASIAN/PACIFIC ISLANDERS 732 1.33%OTHER 1,886 3.43%TOTAL POPULATION 54,919 100%ACCORDING TO SG2 DATA, THE AGE BREAKDOWN FOR THE PRIMARY SERVICE AREAS IS AS FOLLOWS:PRIMARY SERVICE AREAAGE GROUP POPULATION % OF POPULATION0-17 13,301 24.22%18-64 32,782 59.69%65+ 8,836 16.09%TOTAL POPULATION 54,919 100.00% 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 PROVIDES 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-INVOLVEMENT/COMMUNITY-BENEFIT.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. 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 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 HTTPS://WWW.NOVANTHEALTHUVA.ORG/ABOUT-US/COMMUNITY-INVOLVEMENT/COMMUNITY-BENEFIT.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, 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. 0 COME AS YOU ARE INC PO BOX 3457 WARRENTON VA 20188 821635037 501(C)(3) 5500 COMMUNITY OUTREACH CULPEPER COUNTY CHAMBER OF COMMERCE 629 SPERRYVILLE PIKE CULPEPER VA 22701 540640609 501(C)(6) 6341 COMMUNITY OUTREACH CULPEPER WELLNESS FOUNDATION INC 311 S EAST STREET NO 100 CULPEPER VA 22701 521366700 501(C)(3) 505504 COMMUNITY OUTREACH ORANGE COUNTY FREE CLINIC INC 101 C WOODMARK STREET ORANGE VA 22960 251922019 501(C)(3) 23500 COMMUNITY OUTREACH THE BOYS & GIRLS CLUB OF FAUQUIER INC 169 KEITH STREET WARRENTON VA 20186 541815587 501(C)(3) 10000 COMMUNITY OUTREACH MENTAL HEALTH ASSOCIATION OF FAUQUIER COUNTY INC 50 CULPEPER ST RM/STE 1-B WARRENTON VA 20186 521215685 501(C)(3) 12500 COMMUNITY OUTREACH 5 1 TEAM MEMBER ASSISTANCE (EMPLOYEE EMERGENCY FUND) 3 763 SCHOLARSHIP 4 2000 MAMMOGRAMS 123 55976 MEDICATION TO INDIGENT PATIENTS 45 1408 FMV MEDICATION ONCOLOGY PATIENT ASSISTANCE 1 35 FMV WIG PATIENT TRANSPORTATION 22 1382 FMV TRANSPORTATION PART I, LINE 2: PROCEDURES FOR MONITORING THE USE OF GRANT FUNDS THE FILING ORGANIZATION DOES NOT PROVIDE GRANTS. X X X 1 0 0 0 0 0 0 0 0 HETMANSKI JEFF CEO 236590 0 5625 0 0 0 13387 0 10388 0 265990 0 0 0 CONKLIN MARGARET FMR CNO 0 115376 0 9250 0 68408 0 4994 0 21767 0 219795 0 0 D'SOUZA JON CMO 223484 0 28000 0 0 0 0 0 7573 0 259057 0 0 0 EDWARDS SUSAN CHIEF HRO 142959 0 9948 0 0 0 9524 0 22630 0 185061 0 0 0 SHIFFLETT MINDI CNO 171042 0 2940 0 0 0 1661 0 22986 0 198629 0 0 0 COATES TEMPLE DIR. PROF. & ANCILLARY SERVICES 162457 0 3206 0 0 0 9999 0 22935 0 198597 0 0 0 SHIFFLETT TRACEY DIRECTOR OF REVENUE CYCLE 146899 0 2779 0 0 0 8710 0 2950 0 161338 0 0 0 SMITH DENNIS DIRECTOR OF PHARMACY NH UVA 190380 0 3765 0 0 0 11685 0 14616 0 220446 0 0 0 WEST VIRGINIA PHARMACY MANAGER 143231 0 2655 0 0 0 8797 0 13941 0 168624 0 0 0 WHITE SARA ADMIN DIRECTOR OF FINANCE 144507 0 2817 0 0 0 8819 0 13004 0 169147 0 0 0 NAPPS CARL FMR PRES & COO/TRUSTEE 0 147487 0 90200 0 193551 0 11165 0 24506 0 466909 0 0 PART I, LINE 4A PART I, LINES 4A-C: SEVERANCE, NONQUALIFIED, AND EQUITY-BASED PAYMENTS SEVERANCE NONQUALIFIED EQUITY-BASED CONKLIN, MARGARET 49,808 NAPPS, CARL 143,077 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. 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 HEALTH 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, COME AS YOU ARE AND AMERICAN CANCER SOCIETY. CULPEPER MEDICAL CENTER OFFERED SUPPORT GROUPS FOR WOMEN WHO HAVE LOST A NEWBORN OR PREGNANCY, AS WELL AS FOR CANCER PATIENTS AND THEIR LOVED ONES. IT ALSO PROVIDED COMMUNITY EDUCATION ABOUT ACCESS TO HEALTHCARE SERVICES, CANCER SERVICES, HEART DISEASE AND STROKE AND DIABETES. PART OF OUR ONGOING COMMITMENT TO PATIENTS AND THE COMMUNITY IS OFFERING FREE SCREENINGS FOR GLUCOSE, BODYMASS INDEX (BMI), BLOOD PRESSURE AND CHOLESTEROL AS WELL AS 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 ULTRASOUND, AS WELL AS THE ADDITION OF NEW PHYSICIANS AND MID-LEVEL PROVIDERS. IN 2018, NHUVACMC 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 PROVIDING RESIDENTS OF CULPEPER AND SURROUNDING COUNTIES WITH OPTIONS FOR IMAGING SERVICES. AWARDS, RECOGNITIONS & CERTIFICATIONS/RECERTIFICATIONS -NOVANT HEALTH UVA HEALTH SYSTEM CULPEPER MEDICAL CENTER EARLY ELECTIVE DELIVERIES REMAINED AT ZERO PERCENT FOR 2018. A GOAL RECOGNIZED BY THE MARCH OF DIMES FOR GIVING MORE BABIES A HEALTHY START IN LIFE IN 2017. AT THE CULPEPER MEDICAL CENTER FAMILY BIRTH CENTER, PROVIDERS HAVE SUCCESSFULLY REDUCED THE NUMBER OF ELECTIVE INDUCTIONS AND CESAREAN DELIVERIES PERFORMED BEFORE 39 WEEKS OF PREGNANCY TO ZERO PERCENT. -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 2018 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-INVOLVEMENT/COMMUNITY -BENEFIT.ASPX THE COMMUNITY BENEFIT 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 $884,000,000, INCLUDING $155,000,000 IN FINANCIAL ASSISTANCE FOR 2018. FORM 990, PART VI, SECTION A, LINE 2 FAMILY AND/OR BUSINESS RELATIONSHIPS BUSINESS RELATIONSHIP SALLY NAN BARBER LARRY FITZGERALD BUSINESS RELATIONSHIP SCOTT SYVERUD LARRY FITZGERALD 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). 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 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 XI, LINE 9: CONTRIBUTIONS: 500,000. PARTNERSHIPS: -46,400. BOOK ADJUSTMENT: 5,000. 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