2018-08-16T17:00:05-05:00 2017-09-30 990 2016-10-01 540568001 CARILION STONEWALL JACKSON HOSPITAL CARI 5402245112 PO BOX 12385 ROANOKE VA 240252385 G Robert Vaughan Jr Assistant Treasurer 5402245137 2018-08-16 2016 2022-09-23 18:48:47Z Charles Carr PO BOX 12385 ROANOKE VA 240252385 73802616 0 X www.carilionclinic.org X 1955 VA Our mission is to improve the health of the communties we serve. 14 10 301 83 0 0 38626 75243 35735065 37065048 380710 1500239 759488 739972 36913889 39380502 23165 51798 0 0 14314144 15333876 0 0 0 20449703 21525880 34787012 36911554 2126877 2468948 50063487 51522443 27425541 23226278 22637946 28296165 X Our mission is to improve the health of the communities we serve through our commitment to a common purpose of better patient care, better community health, and lower cost. 0 0 32031634 51798 37422326 See Schedule O.Carilion Stonewall Jackson Hospital, part of Carilion Clinic, is a not-for-profit healthcare organization committed to improving health outcomes for every patient while advancing the quality of care in the community it serves. Located in Lexington VA, this 25-bed critical access facility provides a full range of inpatient and outpatient services, specializing in imaging services, surgical services and therapy services.Carilion Stonewall Jackson Hospital, a critical access hospital, exists to serve the health care needs of its community, regardless of patient ability to pay. Stonewall's acute hospital admitted 1,239 patients and provided 5,174 days of care during the year. Hospital programs include provision of nursing care; extensive outpatient and inpatient surgical and endoscopic services; respiratory therapy; and diagnostic imaging services including CT, MRI, mammography, ultrasound, DEXA scan and nuclear medicine. Stonewall provides a number of services targeting the specific health needs of its population, including diabetes management; home health; physical, speech, and occupational therapy programs; and cardiac and respiratory rehab. Stonewall also provides an emergency department with 24-hour care, emergency transportation, and a chest pain and stroke program. With 12,890 visits, Stonewall's emergency services are a critical component of the health safety net in its service area, acting as a key health provider for a significant number of uninsured patients, who comprise 18% percent of ED visits. Stonewall supports community screenings and education on chronic disease prevention and management, sponsoring 168 events touching over 2,154 people. In furtherance of its mission, Stonewall provides extensive uncompensated care. Stated at cost, charity and unreimbursed Medicaid costs for the year exceeded $2.7 million. 32031634 1 1 0 1 0 0 0 0 0 0 1 1 0 0 1 1 0 1 0 0 0 0 0 0 0 0 1 1 1 0 1 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 1 1 0 0 1 X 0 0 1 301 1 0 0 0 0 0 0 0 0 0 0 X 14 10 1 1 1 0 1 1 1 1 1 0 0 1 1 1 1 1 1 1 1 0 VA X The Corporation Attn H Kirk 5402245102 213 S Jefferson St Roanoke VA 24011 H Laurent Boetsch Jr DML Director 1.20 2.40 X 0 8700 0 Gregory M Cavallaro Director 1.20 X 0 0 0 James R Crews MD Director 1.20 X 0 0 0 Sidney S Evans Director 1.20 X 0 0 0 Paul G Faucher MD Director 1.20 48.80 X 0 480964 59758 Randy A Gallagher MD Director 1.20 48.80 X 0 334129 55154 Juliet D Gibson Director 1.20 X 0 0 0 Joseph E Hess Director 1.20 X 0 0 0 Lisa T Sprinkel Director 1.20 48.80 X 0 143172 117800 Kerri L Thornton Director 1.20 48.80 X 0 273390 266974 James L Williams Jr Director 1.20 X 0 0 0 Charles E Carr Director/Hospital VP 50.00 X X 225158 0 55846 H E Derrick Jr Director/Chair 2.50 0.50 X X 0 0 0 Farris P Hotchkiss Director/Secretary/Treasurer 1.20 X X 0 0 0 Richard R Teaff PhD Director/Vice Chair 1.20 X X 0 0 0 Donald B Halliwill Assistant Treasurer 0.30 49.70 X 0 575607 209478 Lauren J Schantz Assistant Secretary 1.00 49.00 X 0 73461 19376 G Robert Vaughan Jr Assistant Treasurer 0.30 49.70 X 0 356998 182289 Nancy Howell Agee CEO 2.00 48.00 X 0 1793622 2375890 Melina D Perdue EVP 2.00 48.00 X 0 1907232 268067 Steve C Arner EVP 2.00 48.00 X 0 529972 206940 Kathryn Bare Department Director 50.00 X 110489 0 40358 Lisa Craft RN Team Lead 50.00 X 119878 0 42217 Regina Donald Manager 50.00 X 155859 0 62539 Karen Lafon Manager 50.00 X 122982 0 45981 Phyllis Snyder RN Team Lead 50.00 X 104936 0 40113 Sinclair J Harcus MD Former Officer 0.00 50.00 X 0 236814 158362 Karen A Lyons MD Former Officer 0.00 50.00 X 999 210509 84018 840301 6924570 4291160 8 1 1 0 Solstas Lab Partners Group LLC PO Box 751337 Charlotte NC 282751337 Laboratory Services 1137869 GE Medical Systems PO Box 64094 Pittsburgh PA 15264 Maintenance Contracts 241082 Lexington Anesthesia Providers 4754 E State Road 64 Bradenton FL 34208 Anesthesia Services 145180 Trane PO Box 406469 Atlanta GA 303846469 Scheduled Maintenance Inspection 124370 4 18461 56782 75243 Net Patient Revenue 622110 37014564 37014564 Rent from Exempt Affiliates 531120 50484 50484 37065048 184090 184090 194994 0 194994 194994 194994 35738263 34422114 1316149 1316149 1316149 Contract Revenue 900099 217318 217318 Cafeteria Revenue 722514 187700 187700 Affiliate Income 900099 68885 68885 71075 71075 544978 39380502 37422326 0 1882933 51798 51798 284528 284528 11797410 11797410 997574 997574 1443595 1391909 51686 810769 791676 19093 4182670 4182670 2510 2510 2143 2143 21126 21126 3476553 3346104 130449 5327 5222 105 626634 618550 8084 80734 80734 586688 586635 53 75147 56023 19124 906418 906418 2201306 2201306 324758 196812 127946 Bad Debt 3288871 3288871 I/C Practice Subsidy 3184833 3184833 Medical Supplies 2461213 2460608 605 Dues & Subscriptions 34336 34036 300 64613 32972 31641 36911554 32031634 4879920 0 1224 1220 22529 23106 3680034 5505726 418180 416036 149184 133779 48619047 33890231 14886908 14728816 11755543 10651953 13799248 17580170 5350637 2481637 50063487 51522443 5106629 4114667 19105 19436666 18285475 634631 615687 2228510 210449 27425541 23226278 X 22637946 28296165 22637946 28296165 50063487 51522443 X 2468948 1230551 1958720 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 2143 2143 0 Part II-B, Line 1: A portion of dues paid to various hospital industry associations is attributable to lobbying activities. 430816 430816 28166293 18954067 9212226 18788816 13837095 4951721 1233122 1099069 134053 14728816 Investment in Co-Op 12869 C Investment - Stock 500 C Private Equity Securities 17566801 F 17580170 Qualified Pension Liability 210449 210449 X Part X, Line 2: Carilion recognizes a tax liability or asset for the estimated taxes payable or refundable on tax returns for current and prior years. Deferred tax assets and liabilities are recognized for the estimated future tax effects attributable to temporary differences between the financial statement carrying amounts of existing assets and liabilities and their respective tax bases and operating loss and tax credit carryforwards. Deferred tax assets and liabilities are measured using enacted tax rates expected to apply to taxable income in the years in which those temporary differences are expected to be recovered or settled. A tax benefit from an uncertain tax position is recognized when it is more likely than not that the position will be sustained upon examination, including resolutions of any related appeals or litigation processes, based on the technical merits. Uncertain tax positions may include the characterization of income, such as characterization of income as passive, a decision to exclude reporting taxable income in a tax return, or a decision to classify a transaction, entity, or other position in a tax return as tax exempt. 1 1 X 1 X 1 X 0 1 1 0 1 1 2383474 2383474 0.07140 1295679 971639 324040 0.00970 3679153 971639 2707514 0.08110 75 2151 19738 19738 0.00060 2 3 4392 4392 0.00010 22 17251 17251 0.00050 99 2154 41381 41381 0.00120 99 2154 3720534 971639 2748895 0.08230 26 1607 1607 0.00000 15 2173 2173 0.00010 28 8177 8177 0.00020 69 11957 11957 0.00030 0 3288871 12674894 13063233 -388339 X 1 1 1 1 Carilion Stonewall Jackson Hospital 1 Health Circle Lexington VA 24450 See Schedule O. H 1906 X X X X Carilion Stonewall Jackson Hospital 1 0 0 1 X X X X X X X X X 14 1 0 1 1 X See Part V, Section C X See Part V, Section C X X 1 15 1 See Part V, Section C 0 1 X 200.000000000000 400.000000000000 X X X X 1 1 X X X 1 X Part V, Section C X Part V, Section C X Part V, Section C X X X X X X 1 X 0 X X X X 1 X 0 0 Carilion Stonewall Jackson Hospital Part V, Section B, Line 5: Carilion Clinic's CHNAs are community-driven projects and success is highly dependent on the involvement of citizens, health and human service agencies, businesses, and community leaders. Community stakeholder collaborations known as "Community Health Assessment Teams" (CHAT) lead the CHNA projects. The CHAT consists of health and human service agency leaders, persons with special knowledge of or expertise in public health, the local health department, and leaders, representatives, or members of medically underserved populations, low-income persons, minority populations, and populations with chronic disease.The following organizations served on the CHAT for the 2015 (tax year 2014) Rockbridge Area CHNA (RACHNA): Buena Vista Public Schools, Central Shenandoah Health District, City of Lexington, First Baptist Church (Buena Vista), Healthy Communities Action Team, Heritage Hall, Let's Move Lexington, Maury River Home Care, Mayflower, Rockbridge Area Community Services, Rockbridge Area Health Center, Rockbridge Area Prevention Coalition, Rockbridge Area Transportation System, Rockbridge Area YMCA, Rockbridge County Schools, Rockbridge County Sheriff's Office, Valley Associates for Independent Living, Valley Program for Aging Services, Washington and Lee University, Washington and Lee University - Campus Kitchen, and Washington and Lee University - Shepherd Program.In addition to the CHAT, the RACHNA conducted stakeholder surveys, target population focus groups, and a community health survey. Target population focus groups were conducted with Don Tequilas staff, Maury River Senior Center, Maury River Senior Center (Meals Program), Rockbridge Area Community Services (Eagle's Nest Clubhouse), Rockbridge Area Health Center, TAP/ Headstart, and the Women Small Business Owners Group.The community health survey was made available to residents living in Rockbridge County, Lexington City, and Buena Vista City. Oversampling of the target populations occurred through targeted outreach efforts. In total, 474 surveys were collected. Carilion Stonewall Jackson Hospital Part V, Section B, Line 6b: Buena Vista Public Schools, Central Shenandoah Health District, City of Lexington, First Baptist Church (Buena Vista), Healthy Communities Action Team, Heritage Hall, Let's Move Lexington, Maury River Home Care, Mayflower, Rockbridge Area Community Services, Rockbridge Area Health Center, Rockbridge Area Prevention Coalition, Rockbridge Area Transportation System, Rockbridge Area YMCA, Rockbridge County Schools, Rockbridge County Sheriff's Office, Valley Associates for Independent Living, Valley Program for Aging Services, Washington and Lee University, Washington and Lee University - Campus Kitchen, and Washington and Lee University - Shepherd Program. Part V, Section B, Line 7: Line 7a: https://www.carilionclinic.org/locations/carilion-stonewall-jackson- hospital.Line 7b: https://www.carilionclinic.org/community-health-assessments.Line 7d: CHAT partner websites and social media. Part V, Section B, Line 10: Line 10a: https://www.carilionclinic.org/community-health-assessments. Part V, Section B, Line 11: CSJH and Rockbridge 2020 partnered to conduct the 2015 RACHNA and form the CHAT. Rockbridge 2020 is a community collaboration that brings together providers of health care and related services in the Rockbridge Area for the purpose of collaboration and planning for health care services over the next quarter of a century. In June 2015, the CHAT participated in a prioritization activity to determine the greatest needs in the service area based on the primary and secondary data collected during the assessment period. To quantitatively determine health needs, CHAT members were asked to rank the top ten pertinent community needs, with one being the most pertinent. Next, on a scale of 1-5, CHAT members were asked to assign a feasibility and potential impact score for each of the ranked needs. This information was used for CHAT strategic planning in the fall of 2015.The top ten priority areas that emerged from these findings include:1. Need for urgent care services 2. Value not placed on preventive care and chronic disease management3. High prevalence of obesity / overweight individuals4. Lack of exercise / physical activity5. Coordination of care 6. Poor eating habits / lack of nutrient dense foods in diet7. Chronic disease (diabetes, cardiovascular disease, hypertension, asthma)8. Stigma with mental health and substance abuse services9. Inappropriate utilization of ED / urgent care for primary care, dental and mental health services10. Lack of knowledge of community resourcesSignificant Health Needs to be Addressed -CSJH plans to address the community health needs identified in the 2015 RACHNA through its community outreach programs, health safety-net partnerships, and through its financial and in-kind support of Rockbridge 2020. CSJH will address the need for: urgent care services; general wellness; coordination of care; and access to mental health counseling / substance abuse services.The number one need identified in the 2015 RACHNA for the Rockbridge Area was the need for urgent care services. To respond to this need, Carilion Clinic has opened a VelocityCare in the Rockbridge Area. CSJH plans to address the other identified needs through its partnership with Rockbridge 2020. Specific goals, strategies and tactics are outlined in the Rockbridge 2020 Strategic Plan. The team determined evaluation measures in 2016 and will implement the strategic plan through 2018.Carilion Clinic and CSJH also addressed community needs by providing additional outreach services, including health education, flu shots, and health screenings to the target populations. Education available to the community includes free presentations on the topics of cancer prevention, diabetes prevention, fitness/exercise, food safety, health/stroke, healthy lifestyles, nutrition, smoking cessation, and stress. Efforts are focused on underserved areas to address general wellness and healthy lifestyles. CSJH also addressed community needs identified in the assessment through health safety-net partnerships, including financial and in-kind assistance through community grants and sponsorships. Priority Areas Not being Addressed and the ReasonsCSJH uses the CHAT, Rockbridge 2020, and the prioritization of needs activity to set priority areas. Priority areas not identified by the CHAT will not be actively addressed as part of this implementation strategy. Priority areas will be reconsidered every three years as part of the CHNA process. Part V, Section B, Line 13h: Presumptive eligibility Part V, Section B, Line 16: Line 16a: https://www.carilionclinic.org/billing/financial-assistance.Line 16b: https://www.carilionclinic.org/billing/financial-assistance.Line 16c: https://www.carilionclinic.org/billing/financial-assistance. 2 1 - Lexington Medical Building West 108 Houston Street Lexington VA 24450 Physician Offices 2 - Carilion Clinic Family Medicine 146 South Main Street Lexington VA 24450 Physician Offices Part I, Line 3c: Patients' eligibility is determined by family size, family income, real property equity and liquid assets, and status as uninsured or underinsured. Families with family income below 200% of the FPG and assets below $15,000 receive 100% adjustment under FAP. Families with family income greater than 200% of the FPG but less than 400% of the FPG or assets above $15,000 receive a partial adjustment under FAP. The partial adjustment matches the AGB percentage for each service area. Part I, Line 6a: Information on community benefit is reported annually through a consolidated report prepared by Carilion Clinic (EIN 54-1190771). Printed copies of this report are distributed throughout communities served by hospitals affiliated with Carilion Clinic. Additionally, the community benefit report is available on Carilion Clinic's website: www.carilionclinic.org/community-health-assessments. Part I, Line 7: Part I, Line 7 a-b - Ratio of cost-to-charges was used to calculate the expense.Part I, Line 7, Column 7(f) calculation: Bad debt expense in the amount of $3,288,871 is subtracted from total expenses to derive total expenses for the calculation.Line 7e - Community Health Improvement Services and Community Benefit Operations:This line is calculated at actual cost. As part of its mission to educate the public about health risks and steps that can be taken to improve health, Carilion Stonewall Jackson Hospital (CSJH) provides health fairs and presentations at various community locations that provide an opportunity to educate individuals about improving health and quality of life. Additional health improvement services include blood drives and assistance with enrollment in public medical programs such as Medicaid. Community benefit operations include the cost associated with tracking community health improvement activities as well as time spent coordinating Rockbridge 2020.Line 7f - Health Professions Education: This line is reported at actual cost. In-kind support is provided by CSJH staff taking time to educate students before the students shadow them. Additionally, a tour and education was provided to high school nursing program students.Line 7g - Subsidized Health Services: N/A.Line 7h - Research: N/A.Line 7i - Cash and In-Kind Contributions: This line is reported at actual cost. Carilion has long been committed to improving the health of the communities we serve. We know that significant change doesn't happen alone, but takes a community of partners working together towards common goals. Our dedication to this mission is evidenced by the support we provide to various nonprofit partners, furthering their efforts to positively impact health. Contributions of various amounts, both financial and in-kind, are made each year to organizations directly impacting the issues identified in our triennial Community Health Needs Assessment as well as to organizations addressing a variety of social determinants that impact people's health. Support provided helps with access to healthy foods, care and emergency medicine in addition to a multitude of other community health improvement goals. Part II, Line 1 - 8 Part II, Line 1:Physical Improvements- N/A.Part II, Line 2:Economic Development-Financial support was provided to Main Street Lexington, the Lexington, Buena Vista and Rockbridge Chamber of Commerce, and the Alleghany-Highlands Chamber of Commerce and Tourism toward their goals of working with existing businesses, helping develop new business and improving the economic climate of the area. Part II, Line 3: Community Support- Research demonstrates the strong connection between social determinants of health such as transportation, housing, and education and the overall health and well-being of communities. Support is provided in a variety of ways for non-profit organizations that address barriers to good health that arise from these social determinants. Through support of local partners, Carilion is able to help provide better education for children and families as well as nutrition, physical activity opportunities, and resources for our neighbors in need, removing obstacles to good health.Part II, Line 4:Environmental Improvements-N/A.Part II, Line 5:Leadership Development-N/A.Part II, Line 6:Coalition Building-Participation and in-kind support was provided for Rockbridge Area Prevention Coalition, HCAT Child Obesity Coalition, Lexington Emergency Preparedness Coalition, the Community Hospice Retreat and the Crisis Intervention Team. Part II, Line 7: Community Health Improvement-N/A.Part II, Line 8:Workforce Development-N/A. Part III, Line 2: Carilion Stonewall Jackson Hospital estimates bad debt expense by reserving a percentage of all self-pay patient accounts receivable by aging category, based on collection history, adjusted for expected recoveries and, if present, anticipated changes in trends. Part III, Line 4: Accounts receivable are reduced by an allowance for amounts that could become uncollectible in the future. Carilion Stonewall Jackson Hospital estimates the allowance for doubtful accounts by reserving a percentage of all self-pay patient accounts receivable by aging category, based on collection history, adjusted for expected recoveries and, if present, anticipated changes in trends. Carilion Stonewall Jackson Hospital collects substantially all of its third-party insured receivables, which include receivables from governmental agencies and commercial insurers. Part III, Line 8: Medicare allowable costs are determined from the Medicare cost report using the cost-to-charges ratio. The Hospital does not consider a Medicare shortfall as a community benefit. Part III, Line 9b: When accounts receivable efforts are exhausted, the account may be placed with a collection agency and Extraordinary Collection Actions (ECA) may be considered. Accounts will not be placed with a collection agency prior to 120 days from the date the first billing statement is provided except when mailings are returned with no forwarding address and combining multiple accounts of varying age with those already transferred or for legal verification regarding other liabilities. Reasonable efforts will be made to identify appropriate forwarding addresses.When a Financial Assistance Application (FAA) is received during the application period (within 240 days after the date the first billing statement is provided), but after initiation of ECAs, all ECAs will be suspended. Best efforts will be made to process completed applications within 30 days of receipt of the application; financial assistance eligibility will be determined and communicated to the individual. Incomplete applications must be completed within 30 days of the initial notification of additional items required; otherwise, the application will be deemed incomplete and closed. If an individual is eligible for financial assistance, ECAs, other than the sale of debt, will be reversed and any payments related to eligible care refunded to the extent no longer owed. ECAs will be reinstated if the individual is not eligible for financial assistance or does not complete the FAA by the deadline.At least 30 days before initiating an ECA, Carilion will send the patient written notice of intended ECA(s), a plain language summary explaining financial assistance available and the process for determining eligibility, and the deadline for applying for assistance. Carilion will also attempt to call individuals at least 30 days before initiating an ECA to make them aware of the financial assistance available and how to obtain assistance with the application process.Carilion shall enter into a written contract with any collection agency to which it refers bad debt. The contract will obligate the collection agency to observe and comply with Carilion's obligations under this Policy and the Financial Assistance Policy. A collection agency to which bad debt is referred for collection may not engage in any ECAs without the prior written consent of Carilion.After making reasonable efforts to determine if a patient qualifies for Financial Assistance and the patient either does not qualify for Financial Assistance or fails to submit an application as requested, within 240 days from the date the first billing statement is provided, Carilion may engage in one or more of the following ECAs: 1. Place a lien on an individual's property; 2. Attach or seize an individual's bank account or any other personal property; 3. Commence a civil action against an individual; 4. Garnish an individual's wages; 5. Sell an individual's debt to another party; or 6. Report the account to credit agencies.Individual account balances greater than $5,000 are not sent to a collection agency. These are handled through the Debt Recovery Department (DRD) for verification of Financial Assistance status before further collection activity occurs. DRD will also investigate any accounts that require special handling. For example, when the billing office becomes aware that a patient is deceased, auto accident or any other unique circumstances requiring special handling, the accounts are placed with the Debt Recovery Department.When all collection efforts have been exhausted, all hospital accounts will be returned and closed as uncollectible. No further collection activity is taken at that time. Accounts with satisfactory payment arrangements, legal activity or accounts with pending payment will be considered active and are not returned. Part VI, Line 2: Needs Assessment:Carilion Clinic's community health improvement process was adapted from Associates in Process Improvement's the Model for Improvement and the Plan-Do-Study-Act (PDSA) cycle developed by Walter Shewhart. It consists of five distinct steps: (1) conducting the CHNA, (2) strategic planning, (3) creating the implementation strategy, (4) program implementation, and (5) evaluation. This cycle is repeated every three years to comply with IRS requirements. Carilion Clinic fosters community development in its CHNA process and community health improvement process by using the Strive Collective Impact Model for the CHAT. This evidence-based model focuses on "the commitment of a group of important players from different sectors to a common agenda for solving a specific social problem(s) and has been proven to lead to large-scale changes. It focuses on relationship building between organizations and the progress towards shared strategies.CSJH works directly with Rockbridge 2020, a local health collaborative, to address needs identified in the CHNA. Using the collective impact model, the partnership represents cross-sector stakeholders and leaders who are working to implement cost-effective programs resulting in improved health outcomes.Carilion Clinic also addresses community health needs through health safety-net partnerships, including financial and in-kind assistance through community grants and sponsorships. Part VI, Line 3: Availability of Financial Assistance is provided to the patient at hospital admission and ambulatory areas in the form of signage, a plain language summary which includes contact information, financial assistance application and documentation in the inpatient handbook. Patient Access staff, Hospital social workers and customer service representatives verbally inform patients on availability of assistance. Each patient statement and patient financial responsibility letter includes information on the Financial Assistance policy including who to contact for additional information and location of in-person assisters. The Application, the Policy, and the plain language summary are available free of charge to the patient. They are available by mail and on the web site if the patient did not receive written information at the time of service. Financial Assistance policy and application are also distributed to community partners through electronic mailing groups.Carilion Clinic employs an Eligibility staff that counsel patients on federal and state programs. The staff completes applications for Medicaid, Social Security, Social Security Disability and Medicare. The staff provides support services ensuring the applications are processed correctly based on federal and state policy. In addition, the Eligibility staff is trained as Certified Application Counselors and will assist patients in enrollment in the insurance exchange Marketplace. Eligibility staff will also complete Carilion's financial assistance application and counsel patient on the requirements for financial assistance. Part VI, Line 4: Community Information:Located at the southern end of the Shenandoah Valley in west central Virginia, Rockbridge County is classified as a rural county with 22,307 people according to the 2010 Census. It is bounded on the west by the Alleghany Mountains and on the east by the Blue Ridge Mountains. The county's rolling hills and 58,000 acres of national forest comprise much of its 616 square miles. There are 37 persons per square mile, which is significantly lower than the state average of 203 persons per square mile. Rockbridge County is surrounded by the counties of Bath, Augusta, Amherst, Bedford, and Alleghany. Highways 81 and 64 provide ready access to neighboring markets and services.The independent cities of Buena Vista and Lexington lie within the county limits. Buena Vista has 6,650 residents and Lexington has 7,042 according to the 2010 Census. Lexington, the county seat, is situated in the center of the county. It is the heart of much of the county's educational, retail, commercial and governmental activities. Buena Vista is located six miles east of Lexington and is considered the industrial and manufacturing core of the county. Both the cities of Buena Vista and Lexington are classified as mixed urban areas. With land areas of 7 square miles and 2.5 square miles respectively, there are 992 persons per square mile in Buena Vista and 2,820 persons per square mile in Lexington. The incorporated towns of Glasgow, Goshen, Brownsburg, Natural Bridge Station, Raphine and Fairfield are located within the county limits. Carilion Stonewall Jackson Hospital (CSJH) is located in Lexington, Virginia. In fiscal year 2014, CSJH served 13,438 unique patients. Patient origin data revealed that in fiscal year 2014, 84.05% of patients served by CSJH lived in the following localities: Lexington City (37.18%), Rockbridge County (22.47%), and Buena Vista City (24.39%). According to the 2011-2015 American Community Survey, the median income for Buena Vista was $29,097, Lexington was $34,017, and Rockbridge was $48,901. There were 20.2%, 13.9%, and 28.4% residents living below the Federal Poverty Level in Lexington City, Rockbridge County, and Buena Vista City respectively. 6.5% of residents in Lexington, 13.2% in Rockbridge, and 16.8% in Buena Vista did not have health insurance. There are no other hospitals except CSJH in the area. Rockbridge County is designated a Medically Underserved Area (MUA) and a Health Professional Shortage Area (HPSA) for primary care, dental and mental health service. Part VI, Line 5: Promotion of Community Health:Carilion Stonewall Jackson Hospital serves all patients regardless of their ability to pay. The Hospital's governing Board is elected annually and the majority of members are neither employees nor contractors of the Hospital. Medical staff privileges are extended to qualified providers. In addition to clinical care, the Hospital works to achieve its mission through the education of health professionals and the community. Any surplus funds are reinvested in new technology, clinical initiatives, education and charitable efforts. This includes providing free, discounted and subsidized care as well as critical medical services that operate at a loss. Part VI, Line 6: Affiliated System:Carilion Stonewall Jackson Community Hospital is 80% owned by Carilion Clinic, a not-for-profit health care organization based in Roanoke, Virginia. Through our comprehensive network of hospitals, primary and specialty physician practices, and complementary services, we provide exceptional care for nearly 1 million Virginians. Our enduring commitment is to a healthier region. We advance care through medical education and research, help our community stay healthy, and inspire it to grow stronger.To advance education of health professionals, Jefferson College of Health Sciences is a private higher education institution that "prepares, within a scholarly environment, ethical, knowledgeable, competent and caring healthcare professionals." The College focuses on providing healthcare education and is a part of Carilion Clinic. Founded in 1914 as the Jefferson Hospital School of Nursing, Jefferson College now provides more than 1,100 students with opportunities to become part of the healthcare profession, serving communities from southwest Virginia to the Shenandoah Valley and beyond. The School's graduates are building healthier tomorrows in our region and across the country every day. More information is available at www.jchs.edu.The Virginia Tech Carilion School of Medicine joins the basic science, life science, bioinformatics, and engineering strengths of Virginia Tech with the medical practice and medical education experience of Carilion Clinic to develop the next generation of physician thought leaders. The School uses an innovative patient-centered curriculum that focuses on small-group learning and hands-on experiences, with extensive research and interprofessionalism training.Part VI, Line 7: N/A 0 Young Mens' Christian Association of Roanoke Valley Inc PO Box 2130 Roanoke VA 24009 540515736 501(c)(3) 17976 Kids in the Kitchen program Washington & Lee University Campus Kitchen Washington Lee University Lexington VA 24450 540505977 501(c)(3) 5000 General Support City of Lexington 300 E Washington St Lexington VA 24450 546001392 City of Lexington 5000 Farmers Market Program 3 0 1 0 0 0 0 0 1 0 Paul G Faucher MD Director 0 372205 0 98624 0 10135 0 55647 0 4111 0 540722 0 0 Randy A Gallagher MD Director 0 308897 0 19459 0 5773 0 49460 0 5694 0 389283 0 0 Lisa T Sprinkel Director 0 133188 0 3000 0 6984 0 109838 0 7962 0 260972 0 0 Kerri L Thornton Director 0 228135 0 43242 0 2013 0 261716 0 5258 0 540364 0 0 Charles E Carr Director/Hospital VP 186802 0 35555 0 2801 0 50382 0 5464 0 281004 0 0 0 Donald B Halliwill Assistant Treasurer 0 464019 0 107317 0 4271 0 196448 0 13030 0 785085 0 0 G Robert Vaughan Jr Assistant Treasurer 0 300771 0 48281 0 7946 0 168199 0 14090 0 539287 0 0 Nancy Howell Agee CEO 0 1189180 0 358500 0 245942 0 2363574 0 12316 0 4169512 0 235766 Melina D Perdue EVP 0 398604 0 91010 0 1417618 0 256356 0 11711 0 2175299 0 1403798 Steve C Arner EVP 0 426986 0 98146 0 4840 0 192610 0 14330 0 736912 0 0 Kathryn Bare Department Director 106618 0 3000 0 871 0 39684 0 674 0 150847 0 0 0 Lisa Craft RN Team Lead 115005 0 400 0 4473 0 31748 0 10469 0 162095 0 0 0 Regina Donald Manager 144352 0 2000 0 9507 0 56656 0 5883 0 218398 0 0 0 Karen Lafon Manager 120299 0 2000 0 683 0 35483 0 10498 0 168963 0 0 0 Sinclair J Harcus MD Former Officer 0 190453 0 43430 0 2931 0 148743 0 9619 0 395176 0 0 Karen A Lyons MD Former Officer 999 153636 0 53256 0 3617 0 82702 0 1316 999 294527 0 0 Part I, Line 3 The Organization's majority member, Carilion Clinic, serves as the parent company of the Carilion Clinic integrated health care delivery system. Executive compensation, including that of the Hospital Vice President, is reviewed annually by the Carilion Clinic Board of Directors Compensation Committee. This Committee is made up of Board members of Carilion Clinic who do not have a conflict of interest with any of the executives being reviewed. This review was performed in September 2017. In addition, the Compensation Committee annually reviews the compensation philosophy for all executive leaders. This review included review of a comprehensive report from an outside compensation consultant specializing in healthcare organizations for select positions and the prior year's report on all of the reviewed positions. The reports reviewed by the Committee included a detailed comparison of total compensation and each element thereof, including base salary, bonuses and other cash compensation, and benefits, including deferred and retirement benefits. Compensation was compared to both a national and regional peer group of organizations similar in size and structure to the organization, the list of which was reviewed by the Compensation Committee. The Compensation Committee maintained detailed minutes of its meetings, setting forth the deliberations and decisions of the Committee regarding the compensation of these executives. Part I, Line 4b Select members of management participate in a Pension Restoration Plan. This Plan provides a benefit equal to the normal retirement benefit that would be payable to the participant were it not for the Qualified Plan's legislative restrictions on compensation and payable benefits, less the actual benefits under the Qualified Plan. Entitlement to benefits and consequent lump sum payment occurs upon attaining age 65 while employed by Carilion Clinic, disability, or 24 months following certain qualifying separations from service. Upon the death of the participant, the Plan shall pay the participant's beneficiary according to Plan terms. Select members of management participate in an Executive Flexible Benefit Plan, in which an allowance is provided to the participant for use in obtaining certain insurance benefits. The allowance is determined annually as a percentage of salary at Carilion Clinic's discretion. The amount of allowance in excess of elected benefits is credited to a capital accumulation account (CAA) with a deferred vesting date of at least two years from the first day of the plan year. The CAA shall be distributed in a lump sum upon vesting while employed by Carilion, disability, or 24 months following certain qualifying separations from service. Upon the death of the participant, the Plan shall pay the participant's beneficiary according to Plan terms. Beginning in the year in which the participant attains age 67, a pro-rated portion of the award is paid monthly. Select members of management participate in a Defined Contribution Supplemental Executive Retirement Plan (DC SERP) in which the employer at the discretion of Carilion Clinic's Board of Directors Compensation Committee makes a contribution to an account established on its books for each eligible participant. If a participant ceases to be a participant prior to the vesting date, the account shall be forfeited. A lump sum distribution shall be made upon the participant's vesting date, death, or disability. Payments during the calendar year under these plans included the following: Nancy Howell Agee $235,766 Melina Perdue $1,403,798 Part I, Line 7 The organization pays annual bonus compensation to management based on scorecard performance. While the scorecard contains a formula as a basis for determining overall performance, senior managers have discretion to include additional elements in their assessment of managers reporting to them. In addition, for top management, the actual bonus awarded is in the discretion of the Carilion Clinic Board of Directors Compensation Committee, although it is based on the scorecard measures. A Economic Development Authority of the City of Roanoke VA 541106038 770082AW5 2012-02-09 25008562 Refunding of Series 2000 and 2002A Bonds, Issuance Costs, Capital Projects 0 0 0 A 4955000 25008562 285199 24723363 1 0 1 1 A 0 1 1 1 0 0.01380 0.01380 0 0 1 A 0 0 0 1 0 0 0 0 1 A 1 Date Rebate Computation Performed Issuer Name: Economic Development Authority of the City of Roanoke, VA Date the Rebate Computation was Performed: 04/04/2013 Schedule K Part II Bond Proceeds All bond issues multiple entities across multiple jurisdictions; therefore, proceeds allocated to multiple hospitals. Form 990, Part I, Line 6: Volunteers greet and assist visitors, answer phones, help with general restocking of supplies, transport of patients, make up swing bed packages, make up IV kits for nursing. Volunteers take patients back to the pre-op rooms prior to surgery. Volunteers provide escort service; assist with mailings, resource materials, special projects; assist the Emergency Department staff by maintaining the waiting room desk and helping to facilitate good customer service; Volunteers run the gift shop, purchase all items they sell in gift shop. They stock inventory, answer the phone, maintaining records, decorating the shop and assuring tidiness. Voulnteers take fresh fruit around to all the break rooms three times a week. Areas the Volunteers assist in are: Physical Therapy, Cardiac Rehab; Visitor's Desk,waiting area desks, ED and Fit for Life. Form 990, Part V, Line 1a 1099s are issued on Carilion Stonewall Jackson Hospital's behalf by Carilion Services, Inc., a related organization providing management and administrative services, including payment processing. Form 990, Part VI, Section A, line 1 The Board consists of eleven (11) to fifteen (15) members divided into two (2)classes: the Carilion Class which consists of three (3) members and the Stonewall Class which consists of eight (8) to twelve (12) members. The Carilion Class has 80% of the vote on any issue that properly comes before the Board and the Stonewall Class has 20% of the vote on any issue that properly comes before the Board. Form 990, Part VI, Section A, line 2 Nancy Howell Agee, Steve Arner, Paul Faucher, M.D., Randy A. Gallagher, M.D., Donald B. Halliwill, Melina D. Perdue, Lauren J. Schantz, Lisa T. Sprinkel, Kerri L. Thornton, and G. Robert Vaughan, Jr. - Business relationship due to each serving as officers, directors, and/or employees of the same related organizations. Form 990, Part VI, Section A, line 3 Certain management and related services for the organization are provided by the management and employees of Carilion Services, Inc., a related and supporting organization of the filing organization. Some or all of the compensation of the following individuals listed in Part VII, Section A was provided by Carilion Services Inc.: Nancy Howell Agee, Steve Arner, Donald B. Halliwill, Melina D. Perdue, Lauren J. Schantz, Lisa T. Sprinkel, Kerri L. Thornton, and G. Robert Vaughan, Jr. Form 990, Part VI, Section A, line 4 The filing organization's bylaws were revised to modify the term limits of Stonewall Class of directors. Form 990, Part VI, Section A, line 6 The organization has two (2) members. Carilion Clinic, a charitable tax-exempt health care organization, has an 80% membership interest and is entitled to elect directors having 80% of the vote on any issue. The Stonewall Jackson Community Foundation, a tax-exempt community foundation which supports health care within the local community, has a 20% membership interest and is entitled to elect directors having 20% of the vote on any issue. Form 990, Part VI, Section A, line 7a The organization has two (2) members. Carilion Clinic, a charitable tax-exempt health care organization, has an 80% membership interest. Carilion Clinic is entitled to appoint all three (3) members of the Carilion Class of directors; the Carilion Class has 80% of the vote on any issue that properly comes before the Board. The Stonewall Jackson Community Health Foundation, a tax-exempt community foundation which supports health care within the local community, has a 20% membership interest. The Stonewall Jackson Community Health Foundation is entitled to appoint one (1) member of the Stonewall Class of directors. The remaining members of the Stonewall Class include one (1) ex officio director (Chief of the Carilion Stonewall Jackson Hospital Medical Staff) and six (6) to (10) members of the local community, who elect their own successors. The Stonewall Class has 20% of the vote on any issue that properly comes before the Board. Form 990, Part VI, Section A, line 7b Under the laws of the Commonwealth of Virginia, certain extraordinary actions require member approval, such as mergers, consolidations, liquidations, and the sale of substantially all of the assets of the organization. See also Schedule O disclosure for Form 990, Part VI, Section A, Line 7a. Form 990, Part VI, Section B, line 11b The Form 990 was prepared by Carilion's internal Tax Department with input from various Carilion departments as applicable, and reviewed by internal Accounting management. Several days prior to filing, all Board Members were notified via email of its availability on Carilion's Board portal, which is the mechanism used to disseminate meeting materials to the directors, and were encouraged to call with any questions they might have. Form 990, Part VI, Section B, line 12c Our organization monitors and reviews proposed and current transactions for conflicts of interest in a variety of ways. At the governing board level, we have board members complete an initial (upon appointment) and annual conflict of interest questionnaire to disclose actual or potential conflicts. Board members are required to update their disclosure as needed in between questionnaires. All disclosures are reviewed by the Organizational Integrity & Compliance Office and as needed escalated to the appropriate leaders/board members for further discussion/review. If a disclosure is viewed as an actual or potential conflict, an action is recommended to the Audit & Compliance Committee of the Carilion Clinic Board and implemented as approved. Actions can include recusal in discussion/voting at board meetings, limitation/termination of the transaction, removal from board appointment or other appropriate controls. In addition, at any time, board members are encouraged to disclose any potential conflicts as they arise at a board meeting and to recuse themselves as deemed appropriate. The same process takes place as described above for key employees (upon hire and annually thereafter), including all Officers, members of the management team, physicians/mid-level practitioners, pharmacists and key supply chain buyers. After review and further discussion as needed, action may be required to manage an actual conflict or to reduce the appearance of such as approved by Organizational Integrity & Compliance Office and other key management team members. As needed, the governing board leaders are notified of any conflicts which may impact board proceedings. Form 990, Part VI, Section B, line 15 The organization has two (2) members. Carilion Clinic, a charitable tax-exempt health care organization, has an 80% membership interest and is entitled to elect directors having 80% of the vote on any issue. The Stonewall Jackson Community Foundation, a tax-exempt community foundation which supports health care within the local community, has a 20% membership interest and is entitled to elect directors having 20% of the vote on any issue. Executive compensation is reviewed annually by the Carilion Clinic Board of Directors Compensation Committee. This Committee is made up of Board Members of Carilion Clinic who do not have a conflict of interest with any of the executives being reviewed. With respect to Carilion Clinic, the Compensation Committee reviews the compensation of the Board of Governors annually, which includes the President and Chief Executive Officer, Executive Vice Presidents, Chief Financial Officer, Chief Medical Officer, select Senior Vice Presidents, and physician Chairs of the Clinical Departments. This review was performed in November 2016 (President and CEO) and September 2017 (all others). For the fiscal year covered by this return, the Compensation Committee also used the same process to review the compensation of Senior Vice Presidents and other Disqualified Individuals, including the Hospital Vice Presidents, which was performed in September and November 2017. In addition, the Compensation Committee annually reviews the compensation philosophy for all executive leaders, which includes Vice Presidents, Senior Vice Presidents, Executive Vice Presidents, and the CEO, as well as the compensation philosophy for all employed physicians and physicians in leadership roles. Some officers of the organization who are not compensated in their capacity as an officer but rather in their role as employee in a position not mentioned above are not subject to Committee review. This review included review of a comprehensive report from an outside compensation consultant specializing in healthcare organizations for select positions and the prior year's report on all of the reviewed positions. The reports reviewed by the Committee included a detailed comparison of total compensation and each element thereof, including base salary, bonuses and other cash compensation, and benefits, including deferred and retirement benefits. Compensation was compared to both a national and regional peer group of organizations similar in size and structure to the organization, which list was reviewed by the Compensation Committee. The Compensation Committee maintained detailed minutes of its meetings, setting forth the deliberations and decisions of the Committee regarding the compensation of these executives. Form 990, Part VI, Section C, line 19 The organization's governing documents, conflict of interest statement, and financial statements are not generally available to the public, but are released from time to time upon request. The Articles of Incorporation are available from the Virginia State Corporation Commission. The consolidated audited financial statements of Carilion Clinic and of the Obligated Group are released to the local newspaper when requested. Limited financial information is available on our website. Form 990, Part XI, line 9: Pension-related changes other than net periodic pension costs 1,958,720. Form 990, Schedule H, Part V, Section A, Line 1: https://carilionclinic.org/locations/carilion-stonewall-jackson-hospital Carilion Clinic PO Box 12385 Roanoke VA 24025 541190771 Supporting organization VA 501(c)(3) Line 12b, II N/A 0 Carilion Clinic Foundation PO Box 12385 Roanoke VA 24025 541190773 Fundraising VA 501(c)(3) Line 7 Carilion Clinic 1 Carilion Franklin Memorial Hospital PO Box 12385 Roanoke VA 24025 540480606 Healthcare VA 501(c)(3) Line 3 Carilion Clinic 1 Carilion Giles Community Hospital PO Box 12385 Roanoke VA 24025 540549603 Healthcare VA 501(c)(3) Line 3 Carilion Clinic 1 Carilion Medical Center PO Box 12385 Roanoke VA 24025 540506332 Healthcare VA 501(c)(3) Line 3 Carilion Clinic 1 Carilion New River Valley Medical Center PO Box 12385 Roanoke VA 24025 540553805 Healthcare VA 501(c)(3) Line 3 Carilion Clinic 1 Carilion Services Inc PO Box 12385 Roanoke VA 24025 541190879 Supporting organization VA 501(c)(3) Line 12b, II Carilion Clinic 1 Carilion Tazewell Community Hospital PO Box 12385 Roanoke VA 24025 546074580 Healthcare VA 501(c)(3) Line 3 Carilion Clinic 1 SJH Community Health Foundation 1 Health Circle Lexington VA 24450 203592795 Supporting organization VA 501(c)(3) Line 12c, III-FI N/A 0 Carilion Clinic Medicare Shared Savings Company LLC PO Box 12385 Roanoke VA 24025 455235473 Medicare HMO VA N/A Franklin County Ventures LLC PO Box 12385 Roanoke VA 24025 474365316 Real estate VA N/A Community Medical Associates LLP PO Box 12385 Roanoke VA 24025 541517662 Real estate VA N/A Carilion Clinic Medicare Resources LLC PO Box 12385 Roanoke VA 24025 263729975 Medicare HMO VA N/A C 1 CHS Inc PO Box 12385 Roanoke VA 24025 541725732 Services VA N/A C 1 Carilion Behavioral Health Inc PO Box 12385 Roanoke VA 24025 203136891 Healthcare VA N/A C 1 Carilion Emergency Services Inc PO Box 12385 Roanoke VA 24025 542033006 Healthcare VA N/A C 1 SCA Credit Services Inc PO Box 12385 Roanoke VA 24025 541180398 Collection Agency VA N/A C 1 Carilion Healthcare Corporation PO Box 12385 Roanoke VA 24025 541586601 Healthcare VA N/A C 1 MedKey Inc PO Box 12385 Roanoke VA 24025 541645357 Financing Services VA N/A C 1 1 0 0 1 1 0 0 0 0 1 0 1 1 0 0 0 0 0 0 Carilion Medical Center A 1380 Cost Carilion Healthcare Corporation A 108086 Cost Carilion Medical Center L 67702 Cost Carilion Medical Center M 1566923 Cost Carilion Services Inc M 4882874 Cost CHS Inc M 146855 Cost Carilion Healthcare Corporation M 2120309 Cost Carilion Services Inc A 49104 Cost