2017-08-11T13:58:17-05:00 2016-09-30 222428965 CITRIN COOPERMAN & COMPANY LLP 2 BETHESDA METRO CENTER 11TH FLOOR BETHESDA MD 20814 990 2015-10-01 540573701 FHI SERVICES FHIS 5406804100 98 ALEXANDRIA PIKE NO 43 WARRENTON VA 20186 CHRISTINE M CONNOLLY PRESIDENT & CEO 5406804100 2017-08-09 1 BRIAN J GIGANTI P00646609 3016549000 2015 2021-01-29 14:40:06Z CHRISTINE M CONNOLLY 98 ALEXANDRIA PIKE NO 43 WARRENTON VA 20186 97779526 0 X WWW.FAUQUIERHEALTH.ORG X 1954 VA OUR MISSION IS TO RESTORE, PROMOTE AND MAINTAIN THE HEALTH OF THE COMMUNITY. 15 15 0 15 0 0 0 0 3779894 8812189 7013195 14232081 265284 2248541 11058373 25292811 359700 1860398 0 0 0 0 0 0 0 246275 343358 605975 2203756 10452398 23089055 204244886 225399613 6690933 5313224 197553953 220086389 X OUR MISSION IS TO RESTORE, PROMOTE AND MAINTAIN THE HEALTH OF THE COMMUNITY. 0 0 1884982 1860398 11060730 FHI SERVICES IS A 501C (3) NON-PROFIT CORPORATION. FHI SERVICES IS GOVERNED BY THE SAME BOARD AND MANAGEMENT TEAM AS ITS PARENT ORGANIZATION, FHS SERVICES, AND ITS BROTHER/SISTER ORGANIZATION, THE FAUQUIER HEALTH FOUNDATION (DBA THE PATH FOUNDATION. THE THREE ENTITIES, COLLECTIVELY, ARE REFERRED TO AS THE ORGANIZATION". THE ORGANIZATION'S" MISSION IS TO STRENGTHEN THE HEALTH AND VITALITY OF THE COMMUNITIES OF FAUQUIER, RAPPAHANNOCK AND NORTHERN CULPEPER COUNTIES. FAUQUIER HOSPITAL IS OPERATED BY A JOINT VENTURE (FAUQUIER HOLDING COMPANY) OWNED IN PART BY FHI SERVICES (20%) AND LIFEPOINT HEALTH (80%). FHI SERVICES APPOINTS 50% OF THE MEMBERS OF THE FAUQUIER HOLDING COMPANY LLC'S GOVERNING BOARD REQUIRES FHI SERVICES CONSENT AND FHI SERVICES HAS MAJORITY GOVERNANCE WITH RESPECT TO ITEMS/ISSUES IMPACTING THE TAX-EXEMPT PURPOSE OF FHI SERVICES (CHARITABLE OVERRIDE PROVISION).THE COMMUNITY BENEFIT CONTRIBUTION OF FHI SERVICES INCLUDES PROGRAMS AND ACTIVITIES THAT IMPROVE ACCESS TO HEALTHCARE AND IMPROVE HEALTH IN OUR COMMUNITIES. ORGANIZATIONAL COMMITMENT TO PROVIDING A COMMUNITY BENEFIT INCLUDES: FAUQUIER HEALTH (FH) IS A 97 BED NOT-FOR-PROFIT ACUTE CARE FACILITY THAT PROVIDES COMPREHENSIVE HEALTH CARE SERVICES FOR THE COMMUNITIES IT SERVES. THE MISSION IS TO RESTORE, PROMOTE AND MAINTAIN THE HEALTH OF THE COMMUNITY.FH IS THE ONLY HOSPITAL IN THE PRIMARY SERVICE AREA OF FAUQUIER COUNTY WITH A POPULATION OF 83,195. THE SERVICE AREA IS GROWING AND AGING, WITH OVERALL PROJECTED GROWTH BETWEEN 2013-2018 OF 3.8% AND WITH A 45+ POPULATION COMPRISING 47% OF THE TOTAL IN 2018.ALL PATIENTS AT FH SHALL HAVE IMPARTIAL ACCESS TO TREATMENT OR ACCOMMODATIONS THAT ARE AVAILABLE OR MEDICALLY INDICATED, REGARDLESS OF RACE, CREED, SEX, NATIONAL ORIGIN, RELIGION, OR SOURCE OF PAYMENT FOR CARE. THE 24-HOUR EMERGENCY DEPARTMENT IS OPEN TO EVERYONE IN THE COMMUNITY, REGARDLESS OF ABILITY TO PAY. FH HAS AN OPEN MEDICAL STAFF WITH PRIVILEGES AVAILABLE TO ALL QUALIFIED PHYSICIANS IN THE AREA. THE MAJORITY OF THE MEMBERS OF OUR GOVERNING BODIES FOR FH ARE INDEPENDENT REPRESENTATIVES OF THE COMMUNITIES SERVED.FH PROVIDES MEDICAL OVERSIGHT, DIRECTION, AND ORDERS TO PARAMEDICS IN THE FIELD AND IN ROUTE TO THE HOSPITAL. OUR EMERGENCY DEPARTMENT OFFERS 24-HOUR ACCESS TO MEDICAL SERVICES AND HELICOPTER TRANSPORT FOR CRITICALLY ILL OR INJURED INDIVIDUALS.FH HAS A FINANCIAL ASSISTANCE PROGRAM THAT PROVIDES FREE CARE FOR PATIENTS WITHIN 200% OF THE FEDERAL POVERTY GUIDELINES AND DISCOUNTED CARE FOR PATIENTS WITHIN 300% OF THE FEDERAL POVERTY GUIDELINES.IN ADDITION, THROUGH A CONTINUING CARE FUND, FAUQUIER HEALTH OFFERS ASSISTANCE TO INDIVIDUALS WHO HAVE INADEQUATE FINANCIAL MEANS TO COVER THE COST OF POST-HOSPITALIZATION HEALTH SERVICES, SUCH AS NURSING CARE. TO HELP TRAIN AND EDUCATE HEALTH CARE PROFESSIONALS, FH WORKS WITH LOCAL COMMUNITY COLLEGES TO PROVIDE TOURS, LECTURES, AND INTERNSHIPS FOR STUDENTS. FH PARTICIPATES IN MEDICARE, MEDICAID, AND CHAMPUS/TRICARE STANDARD.TO ADDRESS THE GROWING AND CHANGING HEALTH CARE NEEDS RESULTING FROM THESE POPULATION CHANGES, FAUQUIER HEALTH CONTINUES TO SUPPORT TWENTY-ONE PHYSICIANS, AN ENDOCRINOLOGIST, TWO OBSTETRICS/GYNECOLOGISTS, THREE FAMILY MEDICINE PHYSICIANS, A RHEUMATOLOGIST, A NEUROLOGIST, AN INFECTIOUS DISEASE SPECIALIST, SEVEN INTERNAL MEDICINE PHYSICIANS, TWO UROLOGISTS, A HEMATOLOGIST/ONCOLOGIST AND TWO GENERAL SURGEONS.IN ADDITION, PARTNERSHIPS HAVE BEEN ESTABLISHED WITH LOCAL NON-PROFIT ORGANIZATIONS (E.G. FAUQUIER FREE CLINIC, THE CHAMBER OF COMMERCE, SCHOOLS AND CHURCHES) AND NATIONAL ORGANIZATIONS (E.G. THE AMERICAN CANCER SOCIETY) TO SUPPORT LOCAL EVENTS AND PROVIDE COMMUNITY HEALTH AND WELLNESS PROGRAMS. THESE COMMUNITY BENEFIT ACTIVITIES ARE COORDINATED BY A FULL-TIME COMMUNITY OUTREACH STAFF PERSON, SUPPORTED BY ADMINISTRATIVE AND CLINICAL DEPARTMENTS, AND AUXILIARY VOLUNTEERS AS NEEDED.IN ADDITION TO THE CONTRIBUTIONS MADE BY THE HOSPITAL, FHI SERVICES INVESTS IN THE COMMUNITY BY PROVIDING GRANTS RELATED TO THE FOUR PRIORITY AREAS STEMMING FROM THE COMMUNITY HEALTH NEEDS ASSESSMENT UNDERTAKEN BY FAUQUIER HEALTH OF CHILDHOOD WELLNESS, MENTAL HEALTH, SENIOR SERVICES AND ACCESS TO HEALTH. FHI SERVICES OFFERS SEVERAL GRANT CYCLES DURING THE YEAR TO HELP NONPROFITS AND GOVERNMENT AGENCIES BETTER THE COMMUNITIES IT SERVES. IN THE CURRENT YEAR, PROJECT AND PLANNING GRANTS WERE FUNDED. GENERAL OPERATIONS GRANTS ARE FUNDED ON A TWO YEAR CYCLE AND WERE NOT FUNDED IN FY2016.FHI SERVICES RECOGNIZES THAT FUNDING FOR PROJECTS AND PLANNING IS VERY IMPORTANT TO NONPROFITS. CAREFUL STRATEGIC PLANNING, BOARD CULTIVATION AND THE UNINTERRUPTED RUNNING OF CORE ORGANIZATIONAL ACTIVITIES ARE ESSENTIAL TO THE SUCCESS OF THRIVING COMMUNITY INSTITUTIONS. ANNUAL PLANNING GRANTS ARE OFFERED TO NONPROFITS AND PUBLIC AGENCIES WITH A TRACK RECORD OF COMMUNITY IMPACT AND SOUND FISCAL MANAGEMENT.THE KEY OBJECTIVES OF THE PROJECT AND PLANNING GRANTS ARE: - TO PROVIDE SUPPORT FOR EFFECTIVE AND ESSENTIAL PROGRAMS FOR NONPROFITS - TO ENCOURAGE NONPROFIT BOARDS AND STAFF TO ENGAGE IN CAPACITY BUILDING AND LEADERSHIP CULTIVATION. - TO FACILITATE CRITICAL, LONG-RANGE STRATEGIC PLANNING. 1884982 1 0 0 0 0 0 0 0 0 1 0 0 1 0 1 1 0 1 0 0 0 0 0 0 0 0 1 1 1 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 1 1 1 0 1 1 7 0 1 0 0 0 0 0 0 0 0 0 X 15 15 0 0 1 0 1 1 1 1 1 0 0 1 1 1 1 1 1 1 1 1 1 VA X LORNA MAGILL 5406804100 98 ALEXANDRIA PIKE SUITE 43 WARRENTON VA 20186 PATRICIA WOODWARD TRUSTEE 1.50 3.00 X 0 0 0 JOSHUA JAKUM MD TRUSTEE 1.50 3.00 X 0 0 0 KAREN WACHTMEISTER TRUSTEE 1.50 3.00 X 0 0 0 THOMAS TUCKER TRUSTEE 1.50 3.00 X 0 0 0 RICK GERHARDT TRUSTEE 1.50 3.00 X 0 0 0 SUSAN STRITTMATTER TRUSTEE 1.50 3.00 X 0 0 0 SUSAN RUBIN TRUSTEE 1.50 3.00 X 0 0 0 KEVIN CARTER TRUSTEE 1.50 3.00 X 0 0 0 MARSHALL DOELLER TRUSTEE 1.50 3.00 X 0 0 0 JANELLE DOWNES TRUSTEE 1.50 3.00 X 0 0 0 MARY LEIGN MCDANIEL TRUSTEE 1.50 3.00 X 0 0 0 MARK VAN DE WATER TRUSTEE 1.50 3.00 X 0 0 0 JOHN MCCARTHY CHAIR 1.50 3.00 X X 0 0 0 ROBIN GULICK VICE CHAIR 1.50 3.00 X X 0 0 0 RAYMOND KNOTT SECRETARY/TREASURER 1.50 3.00 X X 0 0 0 CHRISTINE CONNOLLY PRESIDENT & CEO 8.00 32.00 X 0 235651 38561 LORNA MAGILL CFO 11.00 44.00 X 0 124872 13723 0 360523 52284 0 0 1 0 0 INCOME FROM HOSPITAL VENTURE 900003 8812189 8812189 8812189 3151383 3151383 83567413 72486715 11080698 11080698 11080698 CHANGE IN RESERVE LIABILITY 900009 2248541 2248541 2248541 25292811 11060730 0 14232081 1860398 1860398 40949 40949 24390 24390 250726 250726 20925 20925 269 269 TAXES AND LICENSES 6099 3659 2440 2203756 1884982 318774 0 30302891 17237509 28431 0 8955914 8955914 11708 0 126290743 151466887 9064881 9546239 27234415 33046604 2355903 5146460 204244886 225399613 46179 564000 6690933 4703045 6690933 5313224 X 188458835 210527098 30237 13052 9064881 9546239 197553953 220086389 204244886 225399613 23089055 -556619 0 X 0 1 X 1 0 X 9064881 481358 9546239 9546225 -481344 9064881 9058046 697 751271 248020 15769 9546225 8623235 519 689130 238906 15932 9058046 7688981 616 1188611 240718 14255 8623235 1.00000 1 0 0 INVESTMENT IN FAUQUIER HOLDING 33046604 F 33046604 RESERVE LIABILITY 4703045 4703045 X PART V, LINE 4: THE FAUQUIER HOSPITAL ENDOWMENT FUND (THE TRUST) IS AN IRREVOCABLE TRUST CREATED BY THE CHICHESTER DUPONT FOUNDATION IN 1959. A LOCAL BANK WAS DESIGNATED AS THE TRUSTEE AND REMITS INCOME FROM THE TRUST TO THE HOSPITAL SEMIANNUALLY. THE INCOME MAY BE EMPLOYED BY THE HOSPITAL TO FURTHER ITS WORK IN SUCH MANNER AS THE BOARD OF TRUSTEES OF THE HOSPITAL DETERMINES. PART X, LINE 2: THE FOLLOWING IS THE TEXT OF THE FOOTNOTE TO THE ORGANIZATION'S CONSOLIDATED FINANCIAL STATEMENTS. IN THE FOOTNOTE, FHS SERVICES REFERS TO THE CONSOLIDATED GROUP AS A WHOLE WHICH INCLUDES FHS SERVICES,FHI SERVICES, AND FAUQUIER HEALTH FOUNDATION. FHS SERVICES, FHI SERVICES AND THE FAUQUIER HEALTH FOUNDATION ARE ALL EXEMPT FROM FEDERAL INCOME TAX UNDER SECTION 501(C)(3) OF THE IRC AS A PUBLIC CHARITY PURSUANT TO IRC SECTION 509(A). FEDERAL TAX LAW REQUIRES THAT THESE ENTITIES BE OPERATED IN A MANNER CONSISTENT WITH THEIR INITIAL EXEMPTION APPLICATION TO MAINTAIN THEIR EXEMPT STATUS. MANAGEMENT HAS ANALYZED THE OPERATIONS OF THESE ENTITIES AND CONCLUDED THAT THESE ENTITIES REMAIN IN COMPLIANCE WITH THE REQUIREMENTS FOR EXEMPTION. THE STATE IN WHICH THESE ENTITIES OPERATE ALSO PROVIDES A GENERAL EXCEPTION FROM STATE INCOME TAXATION FOR ORGANIZATIONS THAT ARE EXEMPT FROM FEDERAL INCOME TAXATION. HOWEVER, THESE ENTITIES ARE SUBJECT TO BOTH FEDERAL AND STATE INCOME TAXATION AT CORPORATE TAX RATES ON THEIR UNRELATED BUSINESS INCOME. THESE ENTITIES HAVE NO UNRECOGNIZED TAX BENEFITS. MANAGEMENT HAS ALSO CONSIDERED THE IMPACT OF UNRELATED BUSINESS ACTIVITIES AND HAS CONCLUDED THAT THESE ENTITIES ARE NOT SUBJECT TO UNRELATED BUSINESS TAX OR ANY OTHER TAXES THAT COULD BE IMPOSED BY THE IRC OR STATE TAXING AUTHORITIES. AS SUCH, NO PROVISION IS MADE FOR INCOME TAXES AND NO ASSET OR LIABILITY HAS BEEN RECOGNIZED FOR DEFERRED TAXES. 1 1 1 X 1 X 0 1 1 0 1 1 629864 629864 0.02820 1365227 1365962 -735 0.00000 1995091 1365962 629129 0.02820 213740 4138 209602 0.00940 100386 100386 0.00450 1875942 1875942 0.08400 2190068 4138 2185930 0.09790 4185159 1370100 2815059 0.12610 564 564 0.00000 298 298 0.00000 862 862 1 519317 146160 6275949 8296557 -2020608 X 1 1 1 1 THE FAUQUIER HOSPITAL 500 HOSPITAL DRIVE WARRENTON VA 20186 WWW.FAUQUIERHEALTH.ORG X X X THE FAUQUIER HOSPITAL 1 0 0 1 X X X X X X X X 13 1 0 0 1 X WWW.FAUQUIERHEALTH.ORG X X 1 14 1 WWW.FAUQUIERHEALTH.ORG 0 0 1 X 200.000000000000 X X X X 1 1 X X X 1 X WWW.FAUQUIERHEALTH.ORG X WWW.FAUQUIERHEALTH.ORG X WWW.FAUQUIERHEALTH.ORG X X X X 1 0 X X X X 1 X 0 0 THE FAUQUIER HOSPITAL PART V, SECTION B, LINE 5: FAUQUIER HOSPITAL CONSULTED WITH COMMUNITY HEALTH SOLUTIONS OF RICHMOND, VIRGINIA, TO CONDUCT THE HEALTH NEEDS ASSESSMENT.INPUT WAS REQUESTED FROM 60 COMMUNITY STAKEHOLDERS VIA AN ONLINE SURVEY INCLUDING PUBLIC AND PRIVATE SCHOOLS, THE LOCAL HEALTH DEPARTMENT,EMS,THE UNITED WAY, FAUQUIER FREE CLINIC, FAUQUIER FISH,PEOPLE HELPING PEOPLE AND THE LOCAL HEAD START PROGRAM. INFORMATION WAS RECEIVED FROM ORGANIZATIONS AND COMMUNITY LEADERS WITH PUBLIC HEALTH KNOWLEDGE. THIS INFORMATION HELPED DETERMINE THE HEALTH NEEDS OF THE COMMUNITY AND THE FEEDBACK WAS INCLUDED IN THE IMPLEMENTATION STRATEGY.THE INFORMATION DISCUSSED INCLUDED COMMUNITY HEALTH CONCERNS, COMMUNITY SERVICE GAPS,VULNERABLE/AT-RISK POPULATIONS, HEALTH ASSETS IN THE COMMUNITY, SERIOUS HEALTH ISSUES ON THE HORIZON, AND WAYS TO PROMOTE BETTER HEALTH IN THE COMMUNITY. THE FAUQUIER HOSPITAL PART V, SECTION B, LINE 7D: IN ADDITION TO SHARING THE COMMUNITY HEALTH NEEDS ASSESSMENT ON THE FAUQUIER HEALTH WEBSITE, IT WAS DISTRIBUTED TO: THE COMMUNITY STAKEHOLDERS WHO WERE INVITED TO TAKE PART IN THE ONLINE SURVEY; THE WARRENTON OFFICE OF THE RAPPAHANNOCK RAPIDAN HEALTH DEPARTMENT AS WELL AS ANYONE WHO REQUESTS A COPY OF THE ASSESSMENT. THE FAUQUIER HOSPITAL PART V, SECTION B, LINE 11: FAUQUIER HEALTH'S HEALTH NEEDS ASSESSMENT IDENTIFIED AND EVALUATED THE GLOBAL COMMUNITY HEALTH NEEDS OF OUR PRIMARY SERVICE AREA OF FAUQUIER AND RAPPAHANNOCK COUNTIES. OF THE MANY COMMUNITY SERVICE GAPS AND HEALTH NEEDS IDENTIFIED, FAUQUIER HEALTH CHOSE THE AREA OF GREATEST NEED AND WHERE THE GREATEST IMPACT COULD BE MADE. THOSE TOPICS ARE TRANSPORTATION, HEALTH EDUCATION, AGING SERVICES AND EARLY DETECTION AND SCREENING IN ADDITION TO LEADING CAUSES OF DEATH, WHICH ARE: CANCER, HEART DISEASE, DIABETES AND ALZHEIMER'S. CHILDHOOD OBESITY, A COMMUNITY HEALTH CONCERN IS ALSO BEING ADDRESSED. TO ADDRESS HEALTH EDUCATION AND LEADING CAUSES OF DEATH, THE HOSPITAL HOSTS FREE, MONTHLY HEALTH LECTURES ON VARIOUS TOPICS IDENTIFIED IN THE ASSESSMENT SUCH AS CANCER, HEART DISEASE, LYME DISEASE, MENOPAUSE, OSTEOPOROSIS, DIABETES, CONGESTIVE HEART FAILURE AND CHRONIC OBSTRUCTIVE PULMONARY DISEASE. THE ANNUAL HEALTH FAIR PROVIDES HEALTH SCREENINGS FOR B/P, CHOLESTEROL, BLOOD GLUCOSE, BMI, AND PSA SCREENINGS. FAUQUIER HEALTH ADDRESSES DIABETES, BY PROVIDING DIABETES EDUCATION INCLUDING SUPPORT GROUPS, SELF-MANAGEMENT CLASSES, SCREENINGS AND COUNSELING. FREE MAMMOGRAMS ARE PROVIDED TO WOMEN TURNING 40 TO PROVIDE BREAST CANCER SCREENINGS. TO ADDRESS AGING SERVICES, FAUQUIER HEALTH FACILITATES SUPPORT GROUPS FOR ALZHEIMER'S, DEMENTIA, CANCER, CAREGIVERS AND DIABETES. IN ADDITION, FAUQUIER PARTNERS WITH THE LOCAL COMMUNITY SERVICE BOARD AND AGING TOGETHER TO HOST MEDICARE/MEDICAID COUNSELING AND A FALLS SYMPOSIUM AND ALZHEIMER'S/DEMENTIA WORKSHOP. FAUQUIER HEALTH PARTNERED WITH FAUQUIER COMMUNITY CHILD CARE TO ADDRESS CHILDHOOD OBESITY THROUGH AN 8 WEEK SUMMER CAMP PROGRAM THAT HIGHLIGHTED PHYSICAL ACTIVITY AND NUTRITION. OTHER HEALTH NEEDS IDENTIFIED THAT THE HOSPITAL IS NOT ADDRESSING ARE HANDLED BY OTHER LOCAL ORGANIZATIONS OR GOVERNMENT ENTITIES. AM EXAMPLEIS SOCIAL SERVICES. DENTAL CARE IS NOT THE EXPERTISE OF THE HOSPITAL SO IT IS ADDRESSED BY THE LOCAL FREE CLINIC. BEHAVIORAL HEALTH IS CURRENTLY ADDRESSED BY THE LOCAL COMMUNITY SERVICES BOARD, HOWEVER THE HOSPITAL IS EXPLORING INITIATIVES TO ADDRESSTHE NEED IN THE COMMUNITY. THE HOSPITAL SUPPORTS THE LOCAL FREE CLINIC FINANCIALLY AND WITH DONATED LAB AND RADIOLOGY SERVICES TO PROVIDE CARE TO THE UNINSURED POPULATION. THE RESULTS OF THE HEALTH NEEDS ASSESSMENT ARE CONTINUALLY BEING REVIEWED AND CONSIDERED BY FAUQUIER HOSPITAL LEADERSHIP. THE FAUQUIER HOSPITAL PART V, SECTION B, LINE 16I: IN ADDITION TO PUBLISHING THE FINANCIAL ASSISTANCE POLICY ON THE HOSPITAL'S WEBSITE, SIGNAGE IS POSTED STRATEGICALLY THROUGHOUT THE HOSPITAL (INCLUDING ALL INPATIENT, OUTPATIENT, ANCILLARY AND EMERGENCY DEPARTMENT REGISTRATION OFFICES) WHICH INDICATES THAT FINANCIAL ASSISTANCE IS AVAILABLE AND PROVIDES CONTACT INFORMATION FOR FINANCIAL COUNSELORS WHO CAN HELP WITH THE APPLICATION PROCESS. NOTIFICATIONS REGARDING THE POLICY ARE AVAILABLE IN BOTH ENGLISH AND SPANISH, THE PRIMARY LANGUAGES SPOKEN BY THE POPULATION SERVED BY FAUQUIER HOSPITAL. REPRESENTATIVES OF OUR FINANCIAL ASSISTANCE ELIGIBILITY PARTNERS, MEDASSIST, ALSO DIRECTS ALL PATIENTS WHO ARE SCREENED FOR STATE OR FEDERAL ASSISTANCE PROGRAMS BUT DO NOT QUALIFY TO THE HOSPITAL FINANCIAL COUNSELORS FOR HOSPITAL CHARITYSCREENING. THE FAUQUIER HOSPITAL PART V, SECTION B, LINE 22D: AMOUNTS CHARGED TO A PATIENT ELIGIBLE FOR FINANCIAL ASSISTANCE UNDER THIS POLICY WILL BE BASED ON THE APPLICABLE DISCOUNT STATED IN THE FINANCIAL ASSISTANCE DISCOUNT GUIDELINES TABLE MULTIPLIED BY THE GROSS CHARGES OTHERWISE BILLABLE TO THE PATIENT. THESE DISCOUNTS HAVE BEEN ESTABLISHED IN A MANNER THAT IS INTENDED TO ENSURE THAT, FOR PURPOSES OF INTERNAL REVENUE CODE SECTION 501(R), A PATIENT ELIGIBLE FOR FINANCIAL ASSISTANCE UNDER THIS POLICY IS NOT CHARGED MORE THAN THE AMOUNT GENERALLY BILLED TO INDIVIDUALS WHO HAVE INSURANCE COVERING SUCH CARE ("AGB"). FAUQUIER HOSPITAL HAS INITIALLY ELECTED TO CALCULATE AGB USING THE "LOOK BACK METHOD" DESCRIBED IN APPLICABLE TREASURY REGULATIONS, BASED ON CLAIMS APPROVED BY MEDICARE AND PRIVATE INSURERS DURING A 12-MONTH MEASUREMENT PERIOD. FURTHER INFORMATION ABOUT THE AGB PERCENTAGE CURRENTLY IN USE AND A DESCRIPTION OF HOW SUCH AGB PERCENTAGE WAS CALCULATED MAY BE OBTAINED IN WRITING AND FREE OF CHARGE BY SENDING A WRITTEN REQUEST TO FAUQUIER HOSPITAL - PATIENT FINANCIAL SERVICES, 500 HOSPITAL DRIVE, WARRENTON , VA 20186 . THIS INFORMATION MAY ALSO BE DOWNLOADED AT WWW.FAUQUIERHEALTH.ORG . 14 1 - THE VILLA AT SUFFIELD MEADOWS 6735 SUFFIELD LANE WARRENTON VA 20187 ASSISTED LIVING 2 - FAUQUIER HEALTH REHABILITATION AND NU 360 HOSPITAL DRIVE WARRENTON VA 20186 NURSING HOME 3 - FAUQUIER HEALTH WELLNESS CENTER 419 HOLIDAY COURT SUITE 200 WARRENTON VA 20186 WELLNESS CENTER 4 - FAUQUIER HEALTH HOME CARE SERVICES 170 W SHIRLEY AVE WARRENTON VA 20186 HOME CARE 5 - FAUQUIER HEALTH SLEEP CENTER 493 BLACKWELL ROAD SUITE 317-A WARRENTON VA 20186 SLEEP CENTER 6 - WOUND HEALING CENTER 493 BLACKWELL ROAD SUITE 317-A WARRENTON VA 20186 WOUND CENTER 7 - FAUQUIER HOSPITAL-MEDICAL IMAGING SERVIC 493 BLACKWELL ROAD SUITE 119 WARRENTON VA 20186 MEDICAL IMAGING 8 - HEMATOLOGYONCOLOGY 500 HOSPITAL DRIVE WARRENTON VA 20186 PHYSICIAN SERVICE 9 - INFECTIOUS DISEASES RHEUMATOLOGYENDO 550 HOSPITAL DRIVE WARRENTON VA 20186 PHYSICIAN SERVICE 10 - OBSTETRICS AND GYNECOLOGY 253 VETERNAS DRIVE SUITE 210 WARRENTON VA 20186 PHYSICIAN SERVICE 11 - FAMILY PRACTICE AT BEALETON 6200 STATION DRIVE BEALETON VA 22712 PHYSICIAN SERVICE 12 - INTERNAL MEDICINE AT LAKE MANASSAS 7915 LAKE MANASSAS DR 101 GAINESVILLE VA 20155 PHYSICIAN SERVICE 13 - NEUROLOGY 384 HOSPITAL DRIVE WARRENTON VA 20186 PHYSICIAN SERVICE 14 - PIEDMONT INTERNAL MEDICINE 419 HOLIDAY COURT SUITE 200 WARRENTON VA 20186 PHYSICIAN SERVICE PART I, LINE 3C: ALL PATIENTS WHOSE ANNUAL HOUSEHOLD INCOME LEVELS ARE AT OR BELOW 200% OF THE FEDERAL POVERTY GUIDELINES (FPG),ARE ELIGIBLE FOR FREE CARE. THIS PROCESS REQUIRES AN APPLICATION AND VERIFICATION OF ALL SOURCES OF INCOME. IN ADDITION,ALL PATIENTS WHOSE INCOME IS BETWEEN 200-300% OF FPG ARE ELIBLE FOR DISCOUNTED CARE. BEFORE FINAL COLLECTION ACTION, ACCOUNTS ARE PUT THROUGH CREDIT SCORING SOFTWARE TO HELP IDENTIFY THOSE PATIENTS WHO MIGHT BE ELIGIBLE FOR FINANCIAL ASSISTANCE BUT HAVE NOT CONTACTED OUR OFFICE UP TO THAT POINT. IF THE SOFTWARE INDICATES THAT THE PATIENT'S INCOME LEVEL MEETS FINANCIAL ASSISTANCE ELIGIBILITY, THE ACCOUNT IS PRESUMPTIVELY WRITTEN OFF TO CHARITY AND FURTHER COLLECTION ACTIVITY IS NOT PURSUED.PART I, LINE 7THE HOSPITAL FACILITY WAS CONTRIBUTED TO FAUQUIER HOLDING COMPANY, LLC AS PART OF THE LIFEPOINT TRANSACTION IN TAX YEAR 2013. FHI SERVICESRETAINS A 20% OWNERSHIP INTEREST IN FAUQUIER HOLDING COMPANY, LLC, AND APPOINTS 50% OF THE MEMBERS OF THE GOVERNING BOARD AND MAINTAINS RESERVE POWERS OVER EXEMPT ACTIVITIES OF THE JOINT VENTURE. FAUQUIER HOLDING COMPANY, LLC HAS A CALENDAR YEAR FISCAL YEAR AND ISSUES ITSFORM K-1 BASED UPON THE CALENDAR YEAR. AS A RESULT, THE INFORMATION PROVIDED IN PART I LINE 7 AND PART II REFLECTS THE OPERATIONS REFLECTED ON THE K-1 ISSUED BY FAUQUIER HOLDING COMPANY, LLC, WHICH IS 20% OF THE TOTAL COSTS INCURRED BY FAUQUIER HOSPITAL, FOR ITS YEAR ENDING WITHIN FHI SERVICES' FISCAL YEAR ( FROM JANUARY 1, 2015 THROUGH DECEMBER 31, 2015). FHI SERVICES' FISCAL YEAR WAS 10/1/2015 - 9/30/2016. PART II, COMMUNITY BUILDING ACTIVITIES: COMMUNITY BUILDING ACTIVITIES SUPPORT THE HEALTH OF THE COMMUNITY BY OFFERING ENVIRONMENTAL IMPROVEMENTS AND COMMUNITY SUPPORT.ENVIRONMENTAL IMPROVEMENTS - FAUQUIER HEALTH'S ANNUAL MEDICATION AND SHARPS COLLECTION EVENTS HELPS TO SAFELY DISPOSE OF 300 GALLONS OF SHARPS AND 550 LBS OF MEDICATIONS. RATHER THAN COMMUNITY MEMBERS FLUSHING MEDICATIONS INTO THE GROUND WATER OR DISPOSING OF SHARPS AT THE LANDFILL, FAUQUIER HEALTH COLLECTS THEM AND WORKS WITH A MEDICAL WASTE MANAGEMENT COMPANY THAT DISPOSES OF THE ITEMS.COMMUNITY SUPPORT ACTIVITIES INCLUDED MED SHARPS,EMERGENCY DRUG SUPPLIES AND DISASTER ASSISTANCE. PART III, LINE 2: THE AMOUNT OF ORGANIZATION'S BAD DEBT EXPENSE WAS ESTIMATED BY MULTIPLYING THE TOTAL BAD DEBT EXPENSE FOR FAUQUIER HEALTH BY THE COST-TO-CHARGE RATIO CALCULATED IN WORKSHEET II. THE AMOUNT REPORTED IS 20% OF THIS COST WHICH IS THE FHI SERVICES INTEREST IN THE FAUQUIER HOLDING COMPANY, LLC. PART III, LINE 3: BAD DEBT EXPENSE ATTRIBUTABLE TO PATIENTS ELIGIBLE UNDER THE ORGANIZATION'S FINANCIAL ASSISTANCE POLICY WAS ESTIMATED BY USING THE TOTAL BAD DEBT EXPENSE FOR FAUQUIER HEALTH MULTIPLIED BY THE COST-TO-CHARGE RATIO TO CALCULATE COST. THE BAD DEBT EXPENSE AT COST IS MULTIPLIED BY 29% WHICH IS THE ESTIMATED PERCENTAGE ATTRIBUTABLE TO PATIENTS THAT WOULD QUALIFY FOR FINANCIAL ASSISTANCE UNDER THE HOSPITAL'S POLICY. THE AMOUNT REPORTED IS 20% OF THIS COST WHICH IS THE FHI SERVICES INTEREST IN THE FAUQUIER HOLDING COMPANY, LLC. PART III, LINE 4: ACCOUNTS RECEIVABLE ARE REPORTED NET OF ALLOWANCES FOR THE EXCESS OF CHARGES OVER THE PAYMENTS ON PATIENT ACCOUNTS TO BE RECEIVED FROM THIRD PARTY PAYERS AND ESTIMATES OF UNCOLLECTIBLE AMOUNTS. THE SYSTEM'S POLICY IS TO WRITE-OFF ALL PATIENT ACCOUNTS THAT HAVE BEEN IDENTIFIED AS UNCOLLECTABLE. ANY ALLOWANCE FOR DOUBTFUL ACCOUNTS IS RECORDED FOR ACCOUNTS NOT YET WRITTEN OFF THAT MAY BECOME UNCOLLECTABLE IN FUTURE PERIODS BASED ON MANAGMENT'S ASSESSMENT OF HISTORICAL AND EXPECTED NET COLLECTIONS FOR EACH OF ITS MAJOR PAYERS. MANAGEMENT REGULARLY REVIEWS DATA ABOUT THESE MAJOR PAYER SOURCES OF REVENUE IN EVALUATING THE SUFFICIENCY OF THE ALLOWANCE FOR DOUBTFUL ACCOUNTS. NET PATIENT SERVICE REVENUE IS REPORTED AT THE ESTIMATED NET REALIZABLE AMOUNTS FROM PATIENTS, THIRD-PARTY PAYERS , AND OTHERS FOR SERVICES RENDERED, AND INCLUDE ESTIMATED RETROACTIVE REVENUE ADJUSTMENTS DUE TO FUTURE AUDITS, REVIEWS AND INVESTIGATIONS. RETROACTIVE ADJUSTMENTS ARE CONSIDERED IN THE RECOGNITION OF REVENUE ON AN ESTIMATED BASIS IN THE PERIOD THE RELATED SERVICES ARE RENDERED, AND SUCH AMOUNTS ARE ADJUSTED IN FUTURE PERIODS AS ADJUSTMENTS BECOME KNOWN OR AS YEARS ARE NO LONGERSUBJECT TO SUCH AUDITS, REVIEWS AND INVESTIGATIONS. FAUQUIER HOSPITAL PERIODICALLY EMPLOYED CREDIT SCORING SOFTWARE TO HELP IDENTIFY PATIENTS THAT MIGHT BE ELIGIBLE FOR FINANCIAL ASSISTANCE UNDER THE HOSPITAL'S FINANCIAL ASSISTANCE POLICY, WHICH HAD NOT COMPLETED A FINANCIAL ASSISTANCE APPLICATION. IF THE SOFTWARE INDICATED THAT THE PATIENT'S INCOME LEVEL MET FINANCIAL ASSISTANCE ELIGIBILITY UNDER THE HOSPITAL'S FINANCIAL ASSISTANCE POLICY, THEN THE ACCOUNT WAS WRITTEN OFFTO CHARITY AND FURTHER COLLECTION ACTIVITY WAS NOT PURSUED. AS A RESULT OF THE PERIODIC USE OF SUCH CREDIT SCORING SOFTWARE THROUGHOUT THE YEAR, IT IS DIFFICULT TO ESTIMATE THE AMOUNT OF THE BAD DEBT EXPENSE ATTRIBUTABLETO PATIENTS THAT MIGHT QUALIFY FOR FINANCIAL ASSISTANCE UNDER THE HOSPITAL'S FINANCIAL ASSISTANCE POLICY. PART III, LINE 8: THE SHORTFALL FOR MEDICARE IS NOT CURRENTLY INCLUDED/CONSIDERED IN COMMUNITY BENEFIT. HOWEVER, THE SHORTFALL IS DUE TO THE REIMBURSEMENT FROM MEDICARE FALLING SHORT OF THE COST INCURRED TO PROVIDE CARE TO THE MEDICARE POPULATION SERVED BY THE FAUQUIER HOSPITAL. AS WITH THE SHORTFALL EXPERIENCED FOR THE MEDICAID POPULATION, THE MEDICARE SHORTFALL SHOULD BE CONSIDERED A COMMUNITY BENEFIT AS WELL. IT IS PART OF THE ORGANIZATION'S MISSION TO PROVIDE THE BEST POSSIBLE CARE TO PATIENTS WITHIN OUR COMMUNITY, AND THE ORGANIZATION BELIEVES PROVIDING SUCH CARE HAS IMPROVED THE OVERALL HEALTH OF THE COMMUNITY. BY PROVIDING SUCH CARE TO MEDICARE PATIENTS, THE GOVERNMENT'S BURDEN FOR CARING FOR SUCH INDIVIDUALS IS LESSENED. THE MEDICARE COST REPORT WAS UTILIZED AS OUTLINED IN THE SCHEDULE H,PART III, SECTION B, WORKSHEET B, WHICH UTILIZES THE COST TO CHARGE RATIO DEVELOPED WITHIN THE MEDICARE COST REPORT TO DETERMINE THE ALLOWABLE COST. PART III, LINE 9B: FAUQUIER HOSPITAL'S FINANCIAL ASSISTANCE POLICY CONTAINS THE FOLLOWING PROVISION ON COLLECTION PRACTICES FOR THOSE PATIENTS WHO QUALIFY FOR FINANCIAL ASSISTANCE: FAUQUIER HOSPITAL MANAGEMENT SHALL DEVELOP POLICIES AND PROCEDURES FOR INTERNAL AND EXTERNAL COLLECTION PRACTICES (INCLUDING ACTIONS THE HOSPITAL MAY TAKE IN THE EVENT OF NON-PAYMENT,INCLUDING COLLECTIONS ACTION AND REPORTING TO CREDIT AGENCIES) THAT TAKE INTO ACCOUNT THE EXTENT TO WHICH THE PATIENT QUALIFIES FOR CHARITY CARE OR DISCOUNTED CARE; A PATIENT'S GOOD FAITH EFFORTS TO APPLY FOR GOVERNMENTALASSISTANCE PROGRAMS OR FINANCIAL ASSISTANCE FROM FAUQUIER HOSPITAL, AND APATIENT'S GOOD FAITH EFFORT TO COMPLY WITH HIS OR HER PAYMENT AGREEMENTSWITH FAUQUIER HOSPITAL. FAUQUIER HOSPITAL WILL NOT IMPOSE EXTRAORDINARY COLLECTIONS ACTIONS SUCH AS LAWSUITS, WAGE GARNISHMENTS, ARRESTS, BODY ATTACHMENTS, LIENS ON RESIDENCES, OR OTHER SIMILAR LEGAL ACTIONS AGAINSTANY PATIENT WITHOUT FIRST MAKING REASONABLE EFFORTS TO DETERMINE WHETHERTHAT PATIENT IS ELIGIBLE FOR FINANCIAL ASSISTANCE UNDER THIS FINANCIAL ASSISTANCE POLICY. "REASONABLE EFFORTS" INCLUDE NOTIFICATIONS BY THE HOSPITAL OF THIS FINANCIAL ASSISTANCE POLICY UPON ADMISSION AND IN WRITTEN AND ORAL COMMUNICATIONS WITH THE PATIENT REGARDING THE PATIENT'S BILL,INCLUDING INVOICES AND TELEPHONE CALLS BEFORE COLLECTION ACTION OR REPORTING TO CREDIT AGENCIES IS INITIATED. IF A PATIENT IS FOUND TO QUALIFY FOR FINANCIAL ASSISTANCE AFTER COLLECTION ACTIONS HAVE STARTED, ALL COLLECTION ACTIVITY IS IMMEDIATELY STOPPED, NOTIFICATIONS ARE SENT TO THE CREDIT BUREAU IF NECESSARY AND PATIENTS ARE NOT CHARGED FOR COLLECTION FEES.IF A PATIENT IS FOUND TO QUALIFY FOR FINANCIAL ASSISTANCE AFTER MAKING PAYMENTS TOWARDS THEIR BALANCE, THE PAYMENTS ARE REFUNDED TO THE PATIENT. PART VI, LINE 2: FAUQUIER HEALTH ASSESSES THE HEALTH NEEDS OF THE COMMUNITY BY CONDUCTING A HEALTH NEEDS ASSESSMENT EVERY THREE YEARS AS WELL AS CONTINUALLY COMMUNICATING WITH THE COMMUNITY STAKEHOLDERS WHO ARE SERVING OUR AREAS RESIDENTS. FOR EXAMPLE, FAUQUIER HEALTH MEETS REGULARLY WITH THE FAUQUIER FREE CLINIC LEADERSHIP AND PROVIDES FINANCIAL AND IN-KIND ASSISTANCE TO THE CLINIC WHICH SERVES THE UNINSURED IN FAUQUIER AND RAPPAHANNOCK COUNTIES. PART VI, LINE 3: NOTIFICATION OF FAUQUIER HOSPITAL'S FINANCIAL ASSISTANCE PROGRAM IS DISSEMINATED BY VARIOUS MEANS, INCLUDING NOTIFICATION OF CONTACT INFORMATION FOR FINANCIAL COUNSELORS ON ALL OF OUR BILLING STATEMENTS AND SIGNAGE IN ALL OF OUR PATIENT REGISTRATIONS AREAS. THE POLICY ITSELF IS AVAILABLE ON THE HOSPITAL WEBSITE, WHICH ALSO PROVIDES CONTACT INFORMATION FOR OUR FINANCIAL COUNSELORS. REQUESTS FOR FINANCIAL ASSISTANCE MAY BE MADE AT ANY POINT IN THE COLLECTION CYCLE. EVERY BILLING STATEMENT RECEIVED BY A PATIENT INCLUDES THE FOLLOWING LANGUAGE:"IN MEETING YOUR FINANCIAL OBLIGATIONS FOR THE CARE PROVIDED BY FAUQUIER HOSPITAL WE ASK THAT YOU WORK WITH US ON ANY BILLS THAT YOU ARE HAVING DIFFICULTY PAYING.YOU WILL FIND OUR STAFF UNDERSTANDING AND EAGER ,TO HELP YOU." THIS MESSAGE IS FOLLOWED BY A LIST OF TELEPHONE NUMBERS THAT THE PATIENT MAY CALL TO REACH THE ORGANIZATION'S FINANCIAL COUNSELING STAFF, HOURS OF OPERATION,AND AN EMAIL ADDRESS. WHEN PATIENTS CALL THE FINANCIAL COUNSELING TELEPHONE NUMBER, THEY ARE PROMPTED TO SELECTIONS TO REACH THE STAFF MEMBER THAT IS MOST LIKELY ABLE TO HELP THEM I.E.: UNINSURED, SPANISH SPEAKING, BILLING QUESTIONS, ETC. IN ADDITION,UNINSURED INPATIENTS AND THOSE WITH MEDICARE INSURANCE AND NO SECONDARY CARRIER ARE CONTACTED USUALLY WITH A PERSONAL VISIT IN THEIR HOSPITAL ROOM) BY AN EMPLOYEE OF ONE OF OUR PARTNERS, MEDASSIST.THE MEDASSIST PERSONNEL SCREEN THESE PATIENTS FOR ELIGIBILITY FOR AVAILABLE STATE OR FEDERAL PROGRAMS. IF THESE PATIENTS DO NOT MEET CRITERIA FOR THESE PROGRAMS, THEY ARE THEN REFERRED TO A FINANCIAL COUNSELOR FOR SCREENING FOR THE HOSPITAL'S FINANCIAL ASSISTANCE PROGRAM. UNINSURED PATIENTS WHO VISIT OUR EMERGENCY DEPARTMENT ARE ALSO GIVEN A PACKET OF INFORMATION THAT INCLUDES A FINANCIAL ASSISTANCE APPLICATION AND A BUSINESS CARD WITH THE NAME AND CONTACT INFORMATION FOR ONE OF OUR FINANCIAL COUNSELORS. LASTLY, WE DO USE CREDIT SCORING SOFTWARE TO HELP IDENTIFY PATIENTS WHO MIGHT QUALIFY FOR FINANCIAL ASSISTANCE BUT HAVE NOT CONTACTED OUR OFFICE. OUR FINANCIAL ASSISTANCE POLICY STATES THAT WE MAY USE THIS KIND OF SOFTWARE, WHICH USES INFORMATION FROM CREDIT BUREAUS AND SCREENS PATIENTS AGAINST THE CRITERIA OF OUR FINANCIAL ASSISTANCE POLICY. PART VI, LINE 4: FAUQUIER HOSPITAL (FH)IS A 97-BED, NOT-FOR-PROFIT,ACUTE CARE FACILITY ESTABLISHED IN 1954 TO PROVIDE COMPREHENSIVE HEALTH CARE SERVICES TO THE RURAL COMMUNITIES IT SERVES. OUR MISSION IS TO RESTORE, PROMOTE AND MAINTAIN THE HEALTH OF OUR COMMUNITY. FAUQUIER HOSPITAL IS THE ONLY HOSPITAL IN OUR PRIMARY SERVICE AREA, WHICH INCLUDES FAUQUIER AND MINOR PORTIONS OF FIVE SURROUNDING COUNTIES. THE PRIMARY SERVICE AREA HAS A POPULATION OF 83,195.THE AVERAGE HOUSEHOLD INCOME IS $114,633.7.1% OF THE COMMUNITY RESIDENTS HAVE INCOMES BELOW THE FEDERAL POVERTY GUIDELINE. 17.2% OF FAUQUIER HOSPITAL'S PATIENTS ARE MEDICAID RECIPIENTS OR SELF-PAY. THE FOLLOWING DISTRICTS WITHIN FAUQUIER COUNTY ARE CONSIDERED MUA/P BY THE HEALTH RESOURCES AND SERVICES ADMINISTRATION(HRSA): LEE DISTRICT AND MARSHALL DISTRICT. PART VI, LINE 5: FAUQUIER HEALTH PROMOTES THE HEALTH OF THE COMMUNITY BY: - ENSURING THAT THE MAJORITY (78%) OF THE INDIVIDUALS SERVING ON THE FAUQUIER HOSPITAL BOARD OF DIRECTORS RESIDE IN THE PRIMARY SERVICE AREA AND ARE NOT EMPLOYEES OR CONTRACTORS OF THE ORGANIZATION.- EXTENDING MEDICAL STAFF PRIVILEGES TO ALL QUALIFIED PHYSICIANS IN THE COMMUNITY WHO ARE INTERESTED. - FAUQUIER HEALTH USES SURPLUS FUNDS TO IMPROVE PATIENT CARE BY UPGRADING THE TOOLS NEEDED TO CARE FOR PATIENTS AND PLANNING FOR IMPROVEMENTS. FAUQUIER HEALTH CONTINUES TO SUPPORT TWENTY-ONE EMPLOYED PHYSICIANS, AN ENDOCRINOLOGIST, TWO OBSTETRICS/GYNECOLOGISTS, THREE FAMILY MEDICINE PHYSICIANS, A RHEUMATOLOGIST, A NEUROLOGIST, AN INFECTIOUS DISEASE SPECIALIST, A HEMATOLOGIST/ONCOLOGIST, TWO UROLOGISTS, AND SEVEN INTERNISTS. A HOME HEALTH DISEASE MANAGEMENT TRAINING PROGRAM (TO INCLUDE CONGESTIVE HEART FAILURE, CHRONIC OBSTRUCTIVE PULMONARY DISEASE AND DIABETES) WAS IMPLEMENTED FOR PATIENTS. A TRANSITIONS TO HOME PROGRAM WAS DEVELOPED TO ADDRESS CHRONIC DISEASE MANAGEMENT AND READMISSION RATES FOR PATIENTS. PLANS DEVELOPED FOR A NEONATAL INTENSIVE CARE UNIT WERE ALSO PERFORMED.- FH PARTNERS WITH LOCAL NON-PROFIT ORGANIZATIONS(E.G. FAUQUIER FREE CLINIC, THE CHAMBER OF COMMERCE, SCHOOLS AND CHURCHES) AND NATIONAL ORGANIZATIONS (E.G. THE AMERICAN CANCER SOCIETY) TO SUPPORT LOCAL EVENTSAND PROVIDE COMMUNITY HEALTH AND WELLNESS PROGRAMS. THESE COMMUNITY BENEFITS ACTIVITIES ARE COORDINATED BY A FULL-TIME COMMUNITY OUTREACH STAFF PERSON, SUPPORTED BY ADMINISTRATIVE AND CLINICAL DEPARTMENTS, AND OUR AUXILIARY VOLUNTEERS AS NEEDED. - TO HELP TRAIN AND EDUCATE HEALTH CARE PROFESSIONALS, FH WORKS WITH LOCAL COMMUNITY COLLEGES TO PROVIDE TOURS, LECTURES, AND INTERNSHIPS FOR STUDENTS; FH STAFF PROVIDED APPROXIMATELY 29,487 HOURS AT A COST OF APPROXIMATELY $487.623. - ADDITIONALLY, THE ORGANIZATION PROVIDES ASSISTANCE TO THE FAUQUIER FREE CLINIC (FFC). FFC PROVIDES PRIMARY HEALTH AND DENTAL CARE TO UNINSURED RESIDENTS OF FAUQUIER AND RAPPAHANNOCK COUNTIES. FH PROVIDED LABORATORY, CARDIOLOGY/NEUROLOGY/PULMONARY SERVICES, AND RADIOLOGY SERVICES AT NO CHARGE TO FCC PATIENTS FOR A TOTAL COST OF $192,455. A TOTAL OF 708 HOURSOF FREE CLINICAL CARE WERE PROVIDED BY COMMUNITY PHYSICIANS AND CLINICAL STAFF. IN ADDITION, FH CONTRIBUTED $2,500 IN UNRESTRICTED FUNDS. COMMUNITY HEALTH EDUCATION, SCREENINGS AND OUTREACH PROGRAMS: FAUQUIER HEALTH PROVIDED 74 HEALTH EDUCATION SEMINARS (WHICH INCLUDE CLASSES AND LECTURES) AND HEALTH SCREENINGS AT 11 LOCAL EVENTS. FH ALSO PROVIDES SPEAKERS FOR LOCAL SCHOOLS AND COMMUNITY ORGANIZATIONS TO BUILD RELATIONSHIPS WITHIN THE COMMUNITY, PROMOTE COLLABORATION IN MANAGING HEALTH AND WELLNESS, AND EDUCATE THE COMMUNITY ON THE HEALTH SYSTEM.HEALTH EDUCATION THROUGH ADVERTISING, MEDIA, AND PUBLICATIONS: FH HAS TWO PUBLICATIONS, ONE IS A COMMUNITY NEWSLETTER, HEALTHY HAPPENINGS, INTENDED TO EDUCATE THE PUBLIC ABOUT HEALTH ISSUES AND HEALTH CARE AND HOSPITAL SERVICES. PUBLISHED QUARTERLY, IT REACHES 101,000 HOMES IN FAUQUIER AND SURROUNDING COUNTIES. THE SECOND IS A SENIOR LIVING PUBLICATION THAT IS PUBLISHED TWICE A YEAR AND REACHES 42,000 INDIVIDUALS WHO ARE AGE 55 AND OLDER. THE COST TO FH FOR PUBLICATION AND DISTRIBUTION OF THESE NEWSLETTERS IN FY15 WAS $426,225.EMERGENCY SERVICES. FH PROVIDES MEDICAL OVERSIGHT, DIRECTION, AND ORDERS TO PARAMEDICS IN THE FIELD AND IN ROUTE TO THE HOSPITAL. OUR EMERGENCY DEPARTMENT OFFERS 24-HOUR ACCESS TO MEDICAL SERVICES AND HELICOPTER TRANSPORT FOR CRITICALLY ILL OR INJURED INDIVIDUALS.SUPPORT GROUPS AND COMMUNITY GROUPS. FH SPONSORED, ASSISTED, OR PROVIDED MEETING SPACE FOR FIVE SUPPORT GROUPS THAT MET WEEKLY OR MONTHLY, AT A COST TO FH OF $11,681. ADDITIONALLY, FH PROVIDED MEETING SPACE OR CASH DONATIONS FOR SEVERAL NON-PROFIT COMMUNITY GROUPS, (E.G. THE AMERICAN RED CROSS, FAUQUIER FREE CLINIC AND AMERICAN CANCER SOCIETY FAUQUIER CHAPTER), WITH A FAIR MARKET VALUE OF $44,905 FOR THE MEETING SPACE AND TOTAL CASH DONATIONS IN THE AMOUNT OF $11,500. FH EMPLOYEES PROVIDED REPRESENTATION ON COMMUNITY BOARDS AND COALITIONS AT AN EXPENSE OF $8,820.PHYSICIAN REFERRAL. THE HOSPITAL ASSISTED 1,304 PEOPLE THROUGH THE PHYSICIAN REFERRAL PROGRAM, WHICH HELPS THE COMMUNITY WITH QUESTIONS ON PHYSICIANS, APPOINTMENTS, CLASSES AND PROGRAMS REGISTRATION, AND HEALTH RESOURCES AVAILABLE THROUGH THE HOSPITAL OR IN THE COMMUNITY. PART VI, LINE 6: THE 80% OWNER OF FAUQUIER HOSPITAL IS LIFEPOINT HEALTH, A LEADING HEALTHCARE COMPANY DEDICATED TO MAKING COMMUNITIES HEALTHIER WITH FACILITIES IN 22 STATES. FHI SERVICES HAS A 20% OWNERSHIP INTEREST IN FAUQUIER HOLDING COMPANY, LLC, WHICH OPERATES FAUQUIER HOSPITAL ALONG WITH LIFEPOINT HEALTH WHICH MAINTAINS AN 80% OWNERSHIP INTEREST. 1 AGING TOGETHER PO BOX 367 CULPEPER VA 22701 462046459 501(C)(3) 25000 CAPACITY BUILDING FUNDING TO SUPOORT THE ORGANIZATION DURING A TRANSITION IN LEADERSHIP. BOYS AND GIRLS CLUB OF FAUQUIER INC 169 KEITH STREET WARRENTON VA 20186 541815587 501(C)(3) 40000 SUPPORT FOR THE SERVICE OFFERINGS AND OPERATING PLAN FOR A YOUTH AFTER SCHOOL PROGRAM. COMMUNITY TOUCH INC 10499 JERICHO RD BEALETON VA 22712 201369506 501(C)(3) 10000 FUNDING TO CREATE A STRATEGIC PLANNING GRANT TO CREATE A COMPREHENSIVE MARKETING PLAN. THE OBJECTIVE OF THE PLAN WAS TO ENHANCE THE ORGANIZATION'S VISIBILITY TO REACH THE TARGET CLIENT BASE AS WELL AS INCREASE FUTURE DONOR SUPPORT. FAUQUIER COMMUNITY CHILD CARE INC 400 HOLIDAY CT SUITE 105 WARRENTON VA 20186 541590790 501(C)(3) 34500 FUNDING TO ASSIST IN IMPLEMENTING THE HEALTHY EATING AND PHYSICAL ACTIVITY STANDARDS IN ASSOCIATION WITH THE NATIONAL AFTER SCHOOL ASSOCIATION. FAUQUIER COUNTY COMMUNITY DEVELOPMENT 29 ASHBY ST 3RD FLOOR WARRENTON VA 20186 546001274 FAUQUIER COUNTY 50000 FUNDING FOR THE COMMUNITY CONVERSATIONS STRATEGIC PLANNING PROCESS TO INVOLVE COMMUNITY MEMBERS IN UNDERSTANDING AND RESPONDING TO EXTERNAL FORCES AND INTERNAL CHANGES AFFECTING THE COUNTY OVER THE UPCOMING DECADES, AND INFORM THE COUNTY'S COMPREHENSIVE PLAN UPDATE. FAUQUIER COUNTY PUBLIC LIBRARY 11 WINCHESTER ST WARRENTON VA 20186 546001274 FAUQUIER COUNTY 25000 FUNDING FOR A COMMUNITY ASSESSMENT TO ASSIST THE LIBRARY AND COUNTY IN PLANNING FOR FUTURE LIBRARY RESOURCES AND SERVICES. FAUQUIER COUNTY PUBLIC SCHOOLS (FCPS)-VPI 430 E SHIRLEY AVE WARRENTON VA 20186 546001276 FAUQUIER COUNTY 15000 SUPPORT FOR THE PLANNING OF A FOUR WEEK SUMMER PROGRAM TO BE OFFERED IN JULY 2017. RISING KINDERGARTENERS WHO ARE IDENTIFIED AS POTENTIALLY BEING AT RISK WILL BE IDENTIFIED TO PARTICIPATE. FCPS- FAUQUIER REACHES FOR EXCELLENCE IN SOCIAL HEALTH 430 E SHIRLEY AVE WARRENTON VA 20186 546001276 FAUQUIER COUNTY 100000 FUNDING FOR THE FRESH PROGRAM TO SUPPORT A CULTURE OF HEALTH AND FITNESS FOR STUDENTS ATTENDING FAUQUIER COUNTY PUBLIC SCHOOLS. FAUQUIER EXCELLENCE IN EDUCATION FOUNDATION PO BOX 512 WARRENTON VA 20188 541433026 501(C)(3) 96500 FUNDING TO IMPROVE THE BUILDING AND GROUNDS OF THE OUTDOOR LAB LOCATED AT FAUQUIER HIGH SCHOOL. FAUQUIER FREE CLINIC INC PO BOX 3138 WARRENTON VA 20188 541669652 501(C)(3) 370000 FUNDING TO SUPPORT THE IMPLEMENTATION OF INTEGRATED MENTAL HEALTH CARE SERVICES. IMPLEMENT A TELE-PSYCHIATRY PROGRAM AND PROVIDE REMOTE MENTAL HEALTH SERVICES TO FILL GAPS IN LOCAL RESOURCES. FAUQUIER FREE CLINIC INC PO BOX 3138 WARRENTON VA 20188 541669652 501(C)(3) 52700 FUNDING TO ADD NEW CAPACITY TO ADDRESS THE SHORTAGE OF ORAL HEALTH RESOURCES IN THE REGION. FAUQUIER HABITAT FOR HUMANITY PO BOX 3189 WARRENTON VA 20188 541595774 501(C)(3) 6150 FUNDING TO PROVIDE FINANCIAL AND NUTRITIONAL EDUCATION FOR FAMILIES. LORD FAIRFAX COMMUNITY COLLEGE FOUNDATION LFCC FOUNDATION CORRON 2013 173 SKIRMISHER LN MIDDLETOWN VA 22645 510247624 501(C)(3) 75000 FUNDING FOR AN ASSOCIATE OF APPLIED SCIENCE IN EMERGENCY MEDICAL SERVICES (EMS) DEGREE AND PARAMEDIC CAREER STUDIES CERTIFICATE PROGRAM. MENTAL HEALTH ASSOCIATION OF FAUQUIER COUNTY PO BOX 3549 WARRENTON VA 20188 521215685 501(C)(3) 33000 FUNDING TO ALLOW FOR PLANNING TO INTEGRATE BEHAVIORIAL HEALTH SERVICES INTO MEDICAL SERVICES. MOUNTAIN VISTA GOVERNOR'S SCHOOL FOUNDATION 6480 COLLEGE ST WARRENTON VA 20187 800367061 501(C)(3) 60000 FUNDING FOR A 10TH GRADE COHORT TO INCREASE THE NUMBER AND ENHANCE THE OPPORTUNITIES FOR STUDENTS ATTENDING MVGS. PIEDMONT ENVIRONMENTAL COUNCIL PO BOX 460 WARRENTON VA 20188 540935569 501(C)(3) 64336 FUNDING TO ORGANIZE A COLLABORATIVE PLANNING EFFORT IN REMINGTON TO BUILD ON ITS COMMUNITY ASSETS AND OFFER TRANSPORTATION AND RECREATIONAL OPTIONS, SUCH AS TRAILS, SIDEWALKS, BIKE ROUTES, AND PARK PROJECTS THAT RECONNECT THE COMMUNITY TO ENCOURAGE ACTIVE LIVING. RAPPHOME PO BOX 193 WASHINGTON VA 22747 475254378 501(C)(3) 50000 FUNDING TO SUPPORT ACTIONS AND GOALS IDENTIFIED FOR THE EXPANSION OF A RURAL SENIOR VILLAGE PILOT PROGRAM. RAPPAHANNOCK COUNTY PUBLIC SCHOOLS 6 SCHOOLHOUSE RD WASHINGTON VA 22747 546001554 RAPPAHANNOCK COUNTY 10550 A GRANT TO PROVIDE ALL RCPS STAFF WITH HEALTH AND WELLNESS ORIENTED SUPPLIES AT THE 2016-2017 ACADEMIC YEAR CONVOCATION DAY TO LAUNCH THE COMMIT TO BE FIT INITIATIVE. RAPPAHANNOCK COUNTY SCHOOLS 6 SCHOOLHOUSE RD WARRENTON VA 22747 546001554 RAPPAHANNOCK COUNTY 100000 FUNDING FOR THE COMMIT TO BE FIT PROGRAM. VOLTRAN FAUQUIER DEPT OF SOCIAL SERVICES 320 HOSPITAL HILL STE 11 WARRENTON VA 20186 271352660 501(C)(3) 15000 FUNDING FOR A STRATEGIC PLAN TO DEVELOP POLICIES AND PROCEDURES TO INCREASE CAPACITY AND SUSTAINABILITY OF THE ORGANIZATION. WINDY HILL FOUNDATION PO BOX 1593 MIDDLEBURG VA 20118 541244012 501(C)(3) 60000 FUNDING FOR THE CONSTRUCTION AND OUTFITTING OF FIVE FULLY-ACCESIBLE "RESIDENTIAL" UNITS. 14 2 PART I, LINE 2: ORGANIZATIONS SEEKING GRANT FUNDING MUST SUBMIT A PROPOSAL BUDGET AND, IN MOST CASES, A BUDGET, DURING THE APPLICATION PROCESS. APPLICANTS TO 12-MONTH GRANTS MUST SUBMIT ORGANIZATION FINANCIALS AND A FORM 990. THE GRANT AGREEMENT SPECIFIES THAT FUNDS MAY ONLY BE USED IN CONFORMITY WITH THE ORIGINAL PROPOSAL AND ANY SUBSTANTIAL CHANGES MUST BE REQUESTED AND APPROVED IN WRITING. TWELVE MONTH COMPETITIVE GRANTS REQUIRE GRANTEES TO FILE A WRITTEN SIX-MONTH INTERIM REPORT AND/OR FINAL REPORTS DESCRIBING GRANT ACTIVITIES AND/OR EXPENDITURES, FOLLOWING THE END OF THE GRANT TERM. RECIPIENTS OF SHORT TERM "MAKE IT HAPPEN" GRANTS FILE A FINAL REPORT DESCRIBING GRANT ACTIVITY AND/OR EXPENDITURES WITHIN THIRTY DAYS OF GRANT CLOSURE. IN THE CASE OF A SUCCESSFUL PROPOSAL, THE PROJECT AND ITS BUDGET SUBMITTED AT THE TIME OF APPLICATION FORM THE BASIS OF THE GRANT AGREEMENT. THE REPORTING SUBMITTED IS REVIEWED AND EVALUATED BY THE ORGANIZATION'S PROGRAM STAFF. 0 0 0 0 0 0 0 0 0 CHRISTINE CONNOLLY PRESIDENT & CEO 0 203151 0 30000 0 2500 0 24206 0 14355 0 274212 0 0 PART I, LINE 3 THE CEO AND CFO ARE COMPENSATED BY THE FAUQUIER HEALTH FOUNDATION (DBA THE PATH FOUNDATION). THE ORGANIZATIONS" BOARD ADOPTED A COMPENSATION POLICY FOR ITS CEO AND CFO. AN EXECUTIVE COMPENSATION COMMITTEE OF INDEPENDENT DIRECTORS OF THE BOARD OF THE ORGANIZATION" WAS ESTABLISHED TO REVIEW THE COMPENSATION FOR ALL EMPLOYEES SPECIFIED AS HAVING A SUBSTANTIAL INFLUENCE OVER THE ORGANIZATION AND WHO RECEIVE REMUNERATION FROM THE ORGANIZATION". THE EXECUTIVE COMPENSATION COMMITTEE IS ADVISED BY AN INDEPENDENT COMPENSATION CONSULTANT, WHICH OPINES TO THE COMPENSATION COMMITTEE THAT THE LEVEL OF COMPENSATION PAID AND THE PROCESS BY WHICH COMPENSATION IS ESTABLISHED MEET APPLICABLE IRS REASONABLENESS AND "SAFE HARBOR' STANDARDS. THE OUTSIDE COMPENSATION CONSULTANT PROVIDES DATA OF COMPENSATION PROVIDED AT SIMILAR ORGANIZATIONS TO ENSURE THAT THE ORGANIZATION DOES NOT COMPENSATE IN EXCESS OF MARKET NORMS. FORM 990, PART VI, SECTION A, LINE 4 THE BY-LAWS WERE AMENDED EFFECTIVE AUGUST 2016 AS FOLLOWS: ARTICLE IV - TRUSTEES: ADDED IN FIRST PARAGRAPH: EFFECTIVE AT THE 2016 ANNUAL MEETING, THE NUMBER OF TRUSTEES SHALL NOT EXCEED 15. SYSTEM BOARD IS REPLACED BY FHS BOARD. LAST SENTENCE FROM FIRST PARAGRAPH IS REDACTED. ARTICLE IX - JOINT COMMITTEE OF FHS SERVICES, FHI SERVICES AND FHF: ADDED IN FIRST PARAGRAPH: THE PRESIDENT OF FHS SERVICES, FHI SERVICES AND FHF SHALL SERVE EX OFFICIO AS A NON-VOTING MEMBER OF THIS COMMITTEE. THE CHAIR SHALL BE A DIRECTOR. INVESTMENT & FINANCE COMMITTEE: ADDED: SHOULD THE CHAIR BE ABSENT FROM A MEETING, A BOARD MEMBER SHALL CHAIR THE MEETING. FORM 990, PART VI, SECTION A, LINE 6 FHS SERVICES IS THE PARENT OF THE ORGANIZATION AND THE FAUQUIER HEALTH FOUNDATION (DBA THE PATH FOUNDATION) IS A BROTHER/SISTER OF THE ORGANIZATION. FORM 990, PART VI, SECTION A, LINE 7A THE FHS SERVICES BOARD OF DIRECTORS ELECTS THE MEMBERS OF FHI SERVICES. FORM 990, PART VI, SECTION A, LINE 7B THE FAUQUIER HEALTH FOUNDATION (DBA THE PATH FOUNDATION) REQUIRES THE APPROVAL OF THE FHS SERVICES BOARD, TO ELECT, APPOINT, OR REMOVE DIRECTORS AND IMPLEMENT AMENDMENTS TO THE ARTICLES OF INCORPORATION. FORM 990, PART VI, SECTION B, LINE 11 THE ORGANIZATION PREPARES THE FORM 990 WITH ASSISTANCE FROM AN OUTSIDE ACCOUNTING FIRM. ONCE A DRAFT OF THE FORM 990 IS COMPLETED, IT IS SUBMITTED TO MANAGEMENT OF THE ORGANIZATION FOR REVIEW AND COMMENTS. AFTER INCORPORATING CHANGES FROM MANAGEMENT, MATERIALLY COMPLETE DRAFT FORMS 990 ARE MADE AVAILABLE TO THE BOARD OF THE ORGANIZATION. COMMENTS OR QUESTIONS RECEIVED FROM THE BOARD ARE INCORPORATED INTO A FINAL FORM 990, WHICH IS SIGNED BY THE PRESIDENT/CEO, CHRISTINE CONNOLLY. FORM 990, PART VI, SECTION B, LINE 12C UNDER THE CONFLICT OF INTEREST POLICY, ALL BOARD MEMBERS, MANAGEMENT, AND KEY EMPLOYEES COMPLETE AN ANNUAL DISCLOSURE FORM REGARDING BUSINESS RELATIONSHIPS THAT HE OR SHE, OR ANY FAMILY MEMBER, HAS WITH ANY OTHER COMPANY THAT DOES BUSINESS WITH THE ORGANIZATION, AS WELL AS ANY BUSINESS RELATIONSHIPS BETWEEN AND AMONG THE BOARD MEMBERS , MANAGEMENT , AND KEY EMPLOYEES. THE ANNUAL DISCLOSURE STATEMENTS ARE REVIEWED BY INDEPENDENT LEGAL COUNSEL, AND THE AUDIT AND COMPLIANCE COMMITTEE, WHO IS ULTIMATELY RESPONSIBLE IF A CONFLICT EXISTS. ANY SUCH CONFLICTS WOULD BE REPORTED TO THE FULL BOARD. IN ADDITION , ANY PERSON WHO IS COVERED BY THE CONFLICT OF INTEREST POLICY HAS AN ONGOING OBLIGATION TO DISCLOSE THE EXISTENCE OF ANY ACTUAL OR POTENTIAL CONFLICT TO THE BOARD OR THE BOARD COMMITTEE IN WHICH THE MATTER ARISES. FINALLY, THE ORGANIZATION MONITORS BOARD MEMBER ELIGIBILITY FOR ANY POTENTIAL CONFLICTS , IN ORDER TO AVOID SUCH CONFLICTS FROM OCCURRING IN THE FIRST PLACE. AN OPPORTUNITY IS GIVEN AT THE START OF EACH MEETING TO DISCLOSE ANY CONFLICT OF INTEREST. FORM 990, PART VI, SECTION B, LINE 15 THE CEO AND CFO ARE COMPENSATED BY THE FAUQUIER HEALTH FOUNDATION (DBA THE PATH FOUNDATION). THE ORGANIZATIONS" BOARD ADOPTED A COMPENSATION POLICY FOR ITS CEO AND CFO. AN EXECUTIVE COMPENSATION COMMITTEE OF INDEPENDENT DIRECTORS OF THE BOARD OF THE ORGANIZATION" WAS ESTABLISHED TO REVIEW THE COMPENSATION FOR ALL EMPLOYEES SPECIFIED AS HAVING A SUBSTANTIAL INFLUENCE OVER THE ORGANIZATION AND WHO RECEIVE REMUNERATION FROM THE ORGANIZATION". THE EXECUTIVE COMPENSATION COMMITTEE IS ADVISED BY AN INDEPENDENT COMPENSATION CONSULTANT, WHICH OPINES TO THE COMPENSATION COMMITTEE THAT THE LEVEL OF COMPENSATION PAID AND THE PROCESS BY WHICH COMPENSATION IS ESTABLISHED MEET APPLICABLE IRS REASONABLENESS AND "SAFE HARBOR' STANDARDS. THE OUTSIDE COMPENSATION CONSULTANT PROVIDES DATA OF COMPENSATION PROVIDED AT SIMILAR ORGANIZATIONS TO ENSURE THAT THE ORGANIZATION DOES NOT COMPENSATE IN EXCESS OF MARKET NORMS. FORM 990, PART VI, SECTION C, LINE 19 THE ORGANIZATION MAKES ITS GOVERNING DOCUMENTS, CONFLICT OF INTEREST POLICY AND FINANCIAL STATEMENTS AVAILABLE TO THE PUBLIC UPON REQUEST. FORM 990 PART XII, LINE 2C THE ORGANIZATION HAS NOT CHANGED ITS OVERSIGHT PROCESS DURING TAX YEAR. FHS SERVICES 98 ALEXANDRIA PIKE WARRENTON VA 20186 541416705 MANAGEMENT COORDINATION VA 501(C)(3) LINE 11C, III-F1 NONE 0 FAUQUIER HEALTH FOUNDATION (DBA PATH FOUNDATION) 98 ALEXANDRIA PIKE WARRENTON VA 20186 300219424 COMMUNITY HEALTH VA 501(C)(3) LINE 7 FHS SERVICES 1 0 0 0 0 0 1 0 0 0 0 1 0 1 1 1 0 0 1 0 FAUQUIER HEALTH FOUNDATION(DBA PATH FOUNDATION) R 2480000 FMV FAUQUIER HOLDING COMPANY LLC 330 SEVEN SPRINGS WAY BRENTWOOD TN 37027 901001620 HEALTHCARE TN RELATED 1 4101348 33187285 0 0 0.20000 PART VI THE 2015 K-1 IS MARKED AS FINAL DUE TO A TECHNICAL TERMINATION AT 12/31/2015 WITH A CHANGE TO THE 80% PARTNER. THE PARTNERSHIP CONTINUES AT 1/1/2016 AS NORMAL.