2016-05-13T07:39:57-05:00 2015-06-30 580914992 DRAFFIN & TUCKER LLP PO BOX 71309 ALBANY GA 31708 990 2014-07-01 453957368 POLK MEDICAL CENTER INC POLK 7065096074 420 E SECOND AVENUE SUITE 102 ROME GA 301613210 RICHARD T SHEERIN CFO 7065096074 2016-05-15 true JACQUELINE G ATKINS P00861721 2298837878 2016-05-13 2014 2016-08-17 19:52:53Z KURT STUENKEL 304 TURNER MCCALL BLVD ROME GA 301620233 59066309 false X WWW.POLKMEDICALCENTER.ORG X 2011 GA PRIMARY INITIAL ACTIVITY OF THE CORPORATION WAS TO PROVIDE MANAGEMENT SERVICES AND MANAGEMENT DIRECTION TO AND FOR THE BENEFIT OF THE LICENSED OPERATOR OF THE HOSPITAL COMMENCING APRIL 1, 2012. EFFECTIVE NOVEMBER 6, 2014, THE CORPORATION BECAME THE LICENSED OPERATOR OF POLK MEDICAL CENTER, A 501(C)(3) ORGANIZATION, LOCATED IN CEDARTOWN, GA. PMC IS A 25-BED CRITICAL ACCESS HOSPITAL PROVIDING CARE TO THE COMMUNITY REGARDLESS OF THE ABILITY TO PAY. X 9 8 0 20 0 0 17632129 1076767 37 18708933 168750 0 6184394 0 0 24000 7675878 24000 14029022 -24000 4679911 22747433 46442977 22805933 41821566 -58500 4621411 X PRIMARY INITIAL ACTIVITY OF THE CORPORATION WAS TO PROVIDE MANAGEMENT SERVICES AND MANAGEMENT DIRECTION TO AND FOR THE BENEFIT OF THE LICENSED OPERATOR OF THE HOSPITAL COMMENCING APRIL 1, 2012. EFFECTIVE NOVEMBER 6, 2014, THE CORPORATION BECAME THE LICENSED OPERATOR OF POLK MEDICAL CENTER, A 501(C)(3) ORGANIZATION, LOCATED IN CEDARTOWN, GA. PMC IS A 25-BED CRITICAL ACCESS HOSPITAL PROVIDING CARE TO THE COMMUNITY REGARDLESS OF THE ABILITY TO PAY. true false 11127460 168750 17632166 PROVIDER OF MANAGEMENT SERVICES TO THE OPERATOR OF POLK MEDICAL CENTER (PMC), A 501(C)(3) HOSPITAL LOCATED IN CEDARTOWN, GA, LEASED AND OPERATED BY THE HOSPITAL AUTHORITY OF FLOYD COUNTY, A RELATED ORGANIZATION, UNTIL NOVEMBER 5, 2014. EFFECTIVE NOVEMBER 6, 2014, THE CORPORATION BECAME THE LICENSED OPERATOR OF PMC. 11127460 true false false true false false false false false false true false false false true true true true false false false false false false false false true true true false true false false false false false false false false false false false true false true false false false true 1 0 0 false false false false false false false false false false X 9 8 false false false false true true true true true false false true true true true true false false false false GA X RICHARD T SHEERIN 7065096074 304 TURNER MCCALL BLVD ROME GA 301610233 KURT STUENKEL PRESIDENT/SE 1.00 51.00 X X 0 1559023 49041 J SAM FREEMAN MEMBER 1.00 1.00 X 2750 4375 0 GEORGE A BOSWORTH MD MEMBER 1.00 1.00 X 500 5225 0 LARRY KUGLAR VICE CHAIRMA 1.00 1.00 X X 2250 2875 0 FRANK SHELLEY MEMBER 1.00 1.00 X 2500 2625 0 BRUCE CASEY MEMBER 1.00 0.00 X 2750 0 0 DARROLL FREEMAN MEMBER 1.00 0.00 X 2750 0 0 LEE CUMMINGS MEMBER 1.00 0.00 X 2500 0 0 HAROLD W WYATT JR CHAIRMAN 1.00 0.00 X X 2250 0 0 RICHARD T SHEERIN CFO 1.00 51.00 X 0 475853 37085 MATTHEW GORMAN POLK ADMINIS 40.00 X 0 229953 15695 DEANA OWEN PHARMACY DIR 40.00 X 157641 0 10489 SANDRA SMITH RN 40.00 X 123709 0 6860 CHRISTY LINDSEY PHARMACIST 40.00 X 119965 0 11991 CAROL WALDREP ER RN 40.00 X 117740 0 20697 LOVEJOY POY PHARMACIST 40.00 X 115527 0 21897 652832 2279929 173755 10 false true false ARAMARK MANAGEMENT SERVICE P O BOX 233 ROME GA 301610233 HOUSEKEEPING 270900 CERNER CORPORATION P O BOX 412702 KANSAS CITY MO 64141 IT SERVICES 260186 MORRISON MANAGEMENT SPECIALISTS P O BOX 102289 ATLANTA GA 30368 FOOD SERVICES 173489 ALLIED BARTON SECURITY SERVICES P O BOX 828854 PHILADELPHIA PA 19182 SECURITY 121342 4 NET PATIENT SERVICE REVENUE 623000 17632129 17632129 17632129 32530 32530 41401613 40357376 1044237 1044237 1044237 MISCELLANEOUS INCOME 623000 37 37 37 18708933 17632166 1076767 168750 168750 18250 18250 4715776 4062983 652793 1085824 935516 150308 364544 320359 44185 402994 402994 83797 83797 2775 2775 461760 211381 250379 95434 3800 91634 208915 104894 104021 283069 27940 255129 665736 613542 52194 755377 690992 64385 7098 1391 5707 3467488 3195637 271851 220307 220307 MEDICAL SUPPLIES 643299 633676 9623 REPAIRS & MAINTENANCE 233638 139825 93813 MISCELLANEOUS EXPENSE 101305 379 100926 DUES & SUBSCRIPTIONS 29727 9069 20658 13159 4551 8608 14029022 11127460 2901562 0 560032 2141261 5036428 840000 211422 282660 418275 45697881 7629615 21624773 38068266 7293 22747433 46442977 1750 1185451 21559528 34173156 1244655 6462959 22805933 41821566 X -58500 4621411 -58500 4621411 22747433 46442977 4679911 X false true X true false X false false false false false false false false true 2775 2775 false SCHEDULE C, PART II-B, LINE 1 THE ORGANIZATION PAYS MEMBERSHIP DUES TO NATIONAL AND STATE ORGANIZATIONS. A PORTION OF THOSE DUES IS ALLOCATED TO LOBBYING ACTIVITIES IN WHICH THOSE ORGANIZATIONS PARTICIPATE. 838635 838635 33252083 2035946 31216137 11607163 5593669 6013494 38068266 DUE TO RELATED ORGANIZATIONS 5601627 THIRD PARTY PAYMENTS 861332 6462959 X 18708933 18708933 18708933 14029022 14029022 14029022 SCHEDULE D, PAGE 3, PART X PMCI IS A NOT-FOR-PROFIT CORPORATION THAT HAS BEEN RECOGNIZED AS TAX-EXEMPT PURSUANT TO SECTION 501(C)(3) OF THE INTERNAL REVENUE CODE. PMCI APPLIES ACCOUNTING POLICIES THAT PRESCRIBE WHEN TO RECOGNIZE AND HOW TO MEASURE THE FINANCIAL STATEMENT EFFECTS OF INCOME TAX POSITIONS TAKEN OR EXPECTED TO BE TAKEN ON ITS INCOME TAX RETURNS. THESE RULES REQUIRE MANAGEMENT TO EVALUATE THE LIKELIHOOD THAT, UPON EXAMINATION BY THE RELEVANT TAXING JURISDICTIONS, THOSE INCOME TAX POSITIONS WOULD BE SUSTAINED. BASED ON THAT EVALUATION, PMCI ONLY RECOGNIZES THE MAXIMUM BENEFIT OF EACH INCOME TAX POSITION THAT IS MORE THAN 50% LIKELY OF BEING SUSTAINED. TO THE EXTENT THAT ALL OR A PORTION OF THE BENEFITS OF AN INCOME TAX POSITION ARE NOT RECOGNIZED, A LIABILITY WOULD BE RECOGNIZED FOR THE UNRECOGNIZED BENEFITS, ALONG WITH ANY INTEREST AND PENALTIES THAT WOULD RESULT FROM DISALLOWANCE OF THE POSITION. SHOULD ANY SUCH PENALTIES AND INTEREST BE INCURRED, THEY WOULD BE RECOGNIZED AS OPERATING EXPENSES. BASED ON THE RESULTS OF MANAGEMENTS EVALUATION, NO LIABILITY IS RECOGNIZED IN THE ACCOMPANYING BALANCE SHEET FOR UNRECOGNIZED INCOME TAX POSITIONS. FURTHER, NO INTEREST OR PENALTIES HAVE BEEN ACCRUED OR CHARGED TO EXPENSE AS OF JUNE 30, 2015 AND 2014 OR FOR THE YEARS THEN ENDED. PMCIS TAX RETURNS ARE SUBJECT TO POSSIBLE EXAMINATION BY THE TAXING AUTHORITIES. FOR FEDERAL INCOME TAX PURPOSES, THE TAX RETURNS ESSENTIALLY REMAIN OPEN FOR POSSIBLE EXAMINATION FOR A PERIOD OF THREE YEARS AFTER THE RESPECTIVE FILING DEADLINES OF THOSE RETURNS. true true X true X 1.250000000000 true X 3.250000000000 true true true false true true 677243 677243 0.04830 3897983 3734724 163259 0.01160 4936 3903 1033 0.00010 4580162 3738627 841535 0.06000 5426 5426 0.00040 5426 5426 0.00040 4585588 3738627 846961 0.06040 true 7340131 4293977 5410597 5442996 -32399 X true true 1 1 POLK MEDICAL CENTER 2360 ROCKMART HIGHWAY CEDARTOWN GA 30125 WWW.POLKHOSPITAL.ORG 115-705 X X X X SWING BED SNF POLK MEDICAL CENTER 1 false false true X X X X X X X 13 true false false true X WWW.POLKHOSPITAL.ORG X X true 13 false true false true X 125.000000000000 325.000000000000 X X true true X X X X true X WWWPOLKHOSPITALORG X WWWPOLKHOSPITALORG X WWWPOLKHOSPITALORG X X X X X true X true X X X X true X false false FACILITY 1, POLK MEDICAL CENTER - PART V, LINE 5 THE INTERESTS OF THE COMMUNITIES WERE ENLISTED THROUGH A SURVEY PROCESS, COMMUNITY FORUMS, AND DIRECT INPUT FROM REPRESENTATIVES OF THE GEORGIA DEPARTMENT OF PUBLIC HEALTH. THE SURVEY PROCESS WAS COMPLETED ON A CONVENIENCE BASIS AT PUBLIC EVENTS USING AN INSTRUMENT DESIGNED TO CAPTURE THE PUBLIC'S PERCEPTION OF HEALTH AND HEALTHCARE SERVICES IN THE COMMUNITY. THE SURVEY INSTRUMENT AND RESULTS ARE INCLUDED IN THE CHNA. THE COMMUNITY IS ALSO REPRESENTED IN THIS REPORT THROUGH PRIMARY DATA COLLECTED AT PUBLIC INPUT MEETINGS IN EACH COUNTY. CARE WAS TAKEN TO INCLUDE A CROSS-SECTION OF THE COMMUNITIES WITH REPRESENTATIVES FROM BUSINESS, HEALTHCARE, NON-PROFIT AGENCIES, PUBLIC HEALTH, LOCAL GOVERNMENT, AND EDUCATIONAL INSTITUTIONS. DISTRICT PUBLIC HEALTH REPRESENTATIVES WERE ASKED TO REVIEW THE RAW DATA COLLECTED AND PROVIDED ASSISTANCE DEVELOPING THE PRIORITIES FOR EACH COUNTY INCLUDED IN THIS REPORT. FACILITY 1, POLK MEDICAL CENTER - PART V, LINE 7D THE 2013 CHNA HAS BEEN DISTRIBUTED UPON REQUEST TO OTHER NON-PROFIT AGENCIES IN THE AREA TO ASSIST WITH GRANTS. COPIES HAVE ALSO BEEN MADE AVAILABLE TO ELECTED OFFICIALS, CHAMBERS OF COMMERCE, AND EDUCATIONAL INSTITUTIONS IN THE AREA. FACILITY 1, POLK MEDICAL CENTER - PART V, LINE 11 THE ORGANIZATION HAS PRIORITIZED COMMUNICATING THE NEEDS OF THE COMMUNITY - NOT JUST WITHIN POLK COUNTY BUT THROUGHOUT THE COMMUNITY AS A WHOLE. POLK MEDICAL CENTER CONTINUES TO WORK TOWARDS ADDRESSING THE PRIORITIZED NEEDS IN THE CHNA. FACILITY 1, POLK MEDICAL CENTER - PART V, LINE 22D THE ORGANIZATION UTILIZED A SLIDING SCALE BASED ON FEDERAL POVERTY GUIDELINES. PART I, LINE 7 - COSTING METHODOLOGY EXPLANATION THE DATA REPORTED IN THIS AREA IS REPORTED AS INSTRUCTED BY CATHOLIC HEALTH ASSOCIATION'S "A GUIDE FOR PLANNING AND REPORTING COMMUNITY BENEFITS, 2008". SEE ALSO THE DESCRIPTION FOR PART III, LINE 2. PART III, LINE 2 - BAD DEBT EXPENSE METHODOLOGY AMOUNTS INCLUDED ON PART III LINE 2 REPRESENT THE AMOUNT OF CHARGES CONSIDERED UNCOLLECTIBLE AFTER REASONABLE ATTEMPTS TO COLLECT, AND WRITTEN OFF TO BAD DEBT EXPENSE. PART III, LINE 3 BAD DEBT EXPENSE, PATIENTS ELIGIBLE FOR ASSISTANCE THE FIGURE ON PART III LINE 3 REPRESENTS MANAGEMENT'S ESTIMATE (APPROXIMATELY 58.5%) BASED ON AN ANALYSIS OF SELF-PAY PATIENTS' ABILITY TO PAY THEIR OUTSTANDING ACCOUNT. THIS ANALYSIS INCLUDES REVIEWING THE PATIENT'S CREDIT HISTORY, INCOME LEVELS AND OVERALL COLLECTIBILITY OF THE ACCOUNT. BAD DEBT EXPENSE FOOTNOTE TO FINANCIAL STATEMENTS ACCOUNTS RECEIVABLE ARE REDUCED BY AN ALLOWANCE FOR DOUBTFUL ACCOUNTS. IN EVALUATING THE COLLECTABILITY OF ACCOUNTS RECEIVABLE, PMCI ANALYZES ITS PAST HISTORY AND IDENTIFIES TRENDS FOR EACH OF ITS MAJOR PAYOR SOURCES OF REVENUE TO ESTIMATE THE APPROPRIATE ALLOWANCE FOR DOUBTFUL ACCOUNTS AND PROVISION FOR BAD DEBTS. MANAGEMENT REGULARLY REVIEWS DATA ABOUT THESE MAJOR PAYOR SOURCES OF REVENUE IN EVALUATING THE SUFFICIENCY OF THE ALLOWANCE FOR DOUBTFUL ACCOUNTS. FOR RECEIVABLES ASSOCIATED WITH SERVICES PROVIDED TO PATIENTS WHO HAVE THIRD-PARTY COVERAGE, PMCI ANALYZES CONTRACTUALLY DUE AMOUNTS, SERVICE DATES, AND SERVICE TYPE AND PROVIDES AN ALLOWANCE FOR DOUBTFUL ACCOUNTS AND A PROVISION FOR BAD DEBTS, IF NECESSARY, BASED ON THE ANTICIPATED REIMBURSEMENT. MANAGEMENT ALSO REVIEWS SUBSEQUENT COLLECTION ACTIVITY TO ASSESS THE ACCURACY OF THE ALLOWANCE ESTIMATED. FOR RECEIVABLES ASSOCIATED WITH SELF-PAY PATIENTS (WHICH INCLUDES BOTH PATIENTS WITHOUT INSURANCE AND PATIENTS WITH DEDUCTIBLE AND COPAYMENT BALANCES DUE FOR WHICH THIRD-PARTY COVERAGE EXISTS FOR PART OF THE BILL), PMCI RECORDS A SIGNIFICANT PROVISION FOR BAD DEBTS IN THE PERIOD OF SERVICE ON THE BASIS OF PRIOR PAYMENTS, SERVICE DATE, SERVICE TYPE, AND ITS PAST EXPERIENCE, WHICH INDICATES THAT MANY PATIENTS ARE UNABLE OR UNWILLING TO PAY THE PORTION OF THEIR BILL FOR WHICH THEY ARE FINANCIALLY RESPONSIBLE. THE DIFFERENCE BETWEEN THE STANDARD RATES AND THE AMOUNTS ACTUALLY COLLECTED AFTER ALL REASONABLE COLLECTION EFFORTS HAVE BEEN EXHAUSTED IS CHARGED OFF AGAINST THE ALLOWANCE FOR DOUBTFUL ACCOUNTS. PMCIS ALLOWANCE FOR DOUBTFUL ACCOUNTS FOR SELF-PAY PATIENTS WAS 96% OF SELF-PAY ACCOUNTS RECEIVABLE AT JUNE 30, 2015. IN ADDITION, THE HOSPITALS SELF-PAY WRITE OFFS, INCLUDING WRITE OFFS FOR CHARITY AND INDIGENT PATIENTS WAS 10,000,000. PART III, LINE 8 - MEDICARE EXPLANATION MEDICARE ALLOWABLE COSTS ARE COMPUTED IN ACCORDANCE WITH COST REPORTING METHODOLOGIES UTILIZED ON THE MEDICARE COST REPORT AND IN ACCORDANCE WITH RELATED REGULATIONS. INDIRECT COSTS ARE ALLOCATED TO DIRECT SERVICE AREAS USING THE MOST APPROPRIATE STATISTICAL BASIS. PART III, LINE 9B - COLLECTION PRACTICES EXPLANATION FOR PATIENTS RECEIVING ONLY A PORTION OF THEIR BILL AS CHARITY, THE REMAINING PORTION OF THE BILL IS TREATED THE SAME AS ALL OTHER PATIENTS IN REGARDS TO COLLECTIONS. PART VI, LINE 2 - NEEDS ASSESSMENT POLK MEDICAL CENTER (PMC) COMPLETED A HEALTH CARE NEEDS ASSESSMENT IN POLK COUNTY IN FISCAL YEAR 2013. THIS INCLUDED A RANDOM PAPER SURVEY OF RESIDENTS IN THE COUNTY AS WELL AS INTERVIEWS WITH COMMUNITY LEADERS AND HEALTH CARE PROFESSIONALS AND FOCUS GROUPS. IN ADDITION, THE AUTHORITY DEVELOPS A STRATEGIC PLAN THAT IS UPDATED ANNUALLY. THE STRATEGIC PLAN TAKES INTO CONSIDERATION HEALTH NEEDS FOR OUR SERVICE AREA IN ADDITION TO UTILIZATION OF SERVICES, COMMUNITY PARTICIPATION, AND QUALITY OF SERVICES PROVIDED. PART VI, LINE 3 - PATIENT EDUCATION OF ELIGIBILITY FOR ASSISTANCE POLK COMMUNICATES THIS INFORMATION THROUGH SIGNAGE IN THE EMERGENCY CARE CENTER, PATIENT REGISTRATION AREAS, IN THE BUSINESS/PATIENT FINANCIAL SERVICES OFFICES, AND IN THE OFFICES OF OUR FINANCIAL COUNSELORS. DURING TIMES OF PREADMISSION AS WELL AS ON-SITE REGISTRATION THE ACCESS/REGISTRATION STAFF DISCUSSES POLICIES WITH THE PATIENT/PATIENT'S FAMILY IF APPROPRIATE. AFTER DISCHARGE AND DURING THE "COLLECTION" PERIOD OUR STAFF ONCE AGAIN DISCUSSES OUR FINANCIAL ASSISTANCE POLICIES. IN ADDITION THERE IS A DEMONSTRATED WORD-OF-MOUTH COMMUNICATION OF THESE POLICIES THROUGH OUR PATIENT POPULATION. PART VI, LINE 4 - COMMUNITY INFORMATION POLK COUNTY HAS AN ESTIMATED 41,133 RESIDENTS AND IS PART OF A THREE-COUNTY AREA SERVED BY FLOYD POLK MEDICAL CENTER, A 25-BED CRITICAL ACCESS HOSPITAL WITH EMERGENCY MEDICINE, SURGERY AND DIAGNOSTIC IMAGING CAPABILITIES, FLOYD MEDICAL CENTER, A 304-BED ACUTE CARE SAFETY NET HOSPITAL, AND A THIRD, HCA-OWNED HOSPITAL. THE POPULATION BASE IS APPROXIMATELY 72.3% CAUCASIAN, 13.0% AFRICAN AMERICAN, 12.8% HISPANIC OR LATINO AND 3.4% OTHER RACES. NORTHWEST GEORGIA IS A MEDICAL AND EDUCATION HUB. MANUFACTURING IS THE COUNTY'S LARGEST INDUSTRY. THE TOP 10 EMPLOYERS ARE: "MEGGITT POLYMERS AND COMPOSITES "POLK COUNTY SCHOOL DISTRICT "HON COMPANY "TIP TOP POULTRY "AT&T COMMUNICATIONS "POLK COUNTY GOVERNMENT "ANGELICA TEXTILE SERVICES "JEFFERSON SOUTHERN CORPORATION "WAL-MART "EBY-BROWN THE MEDIAN PER HOUSEHOLD INCOME IS 39,208. AN ESTIMATED 23.4% OF THE POLK COUNTY POPULATION IS BELOW THE POVERTY LEVEL AND ABOUT 70.8 PERCENT OF POLK RESIDENTS OWN THEIR OWN HOMES. PART VI, LINE 5 - PROMOTION OF COMMUNITY HEALTH POLK MEDICAL CENTER GENERATES MORE THAN 43.6 MILLION IN ECONOMIC ACTIVITY IN THE STATE, INCLUDING 12.1 MILLION IN ANNUAL PAYROLL AND BENEFITS. POLK HAS ABOUT 100 FULL AND PART-TIME EMPLOYEES. POLK MEDICAL CENTER IS A CRITICAL ACCESS HOSPITAL PROVIDING THE FOLLOWING SERVICES TO THE POLK COUNTY AND NORTHERN HARALSON COUNTY COMMUNITIES. "BREAST HEALTH "CARDIAC REHABILITATION "CARDIOLOGY "DIAGNOSTIC RADIOLOGY "EMERGENCY ROOM "EMERGENCY MEDICAL SERVICES "FAMILY MEDICINE AND URGENT CARE "HOSPICE "OUTPATIENT REHAB AND SPORTS MEDICINE "SENIOR ENRICHMENT PROGRAM "SUB-ACUTE REHABILITATION PROGRAM "SURGERY "SKILLED NURSING UNIT "WOUND CARE "URGENT CARE POLK MEDICAL CENTER IS COMMITTED TO PROVIDING HEALTH CARE SERVICES TO ALL INDIVIDUALS REGARDLESS OF ABILITY TO PAY. IN FY 2015, POLK MEDICAL CENTER PROVIDED 2.54 MILLION IN UNREIMBURSED CARE TO INDIVIDUALS. THE POLK MEDICAL CENTER PHARMACY PROVIDED PRESCRIPTION DRUGS AT NO OR MINIMAL COST TO INDIGENT PATIENTS BEING DISCHARGED FROM INPATIENT CARE OR THE EMERGENCY ROOM AT A COST OF 1,239.61 DURING FY 2015. POLK MEDICAL CENTER CO-WORKERS AND VOLUNTEERS CONTRIBUTED 158 HOURS TO REACH MORE THAN 5,000 POLK COUNTY RESIDENTS THROUGH COMMUNITY ENDEAVORS AT AN EXPENSE OF 6,420 IN FY 2015: "CONDUCTING HEALTH FAIRS "PROVIDING SCHOOL-BASED EDUCATION PROGRAMS TO STUDENTS ABOUT AUTOMOBILE SAFETY, BICYCLE SAFETY, SAFE PLAY AND CAREERS "PROVIDING DIABETES EDUCATION "PROVIDING HEART DISEASE EDUCATION "PROVIDING MEDICAL SUPPORT AT SPORTS AND COMMUNITY EVENTS POLK MEDICAL CENTER IS MANAGED BY POLK MEDICAL CENTER INC. (PMCI), A GEORGIA NON-PROFIT CORPORATION CREATED IN 2011 BY FLOYD HEALTHCARE MANAGEMENT INC. (FHMI). PMCI'S INITIAL PURPOSE WAS TO SERVE AS THE DAY-TO- DAY MANAGER OF THE OPERATIONS OF POLK MEDICAL CENTER, AND TO THAT END, IT WAS A PARTY TO A MANAGEMENT SERVICES CONTRACT WITH THE HOSPITAL AUTHORITY OF FLOYD COUNTY THROUGH NOVEMBER 5, 2014. PMCI AND FHMI CONSTRUCTED A NEW HOSPITAL FACILITY IN CEDARTOWN TO REPLACE THE EXISTING POLK MEDICAL CENTER THAT WAS PLACED INTO SERVICE ON NOVEMBER 6, 2014. WHEN THE NEW FACILITY OPENED, THE AUTHORITY LEASE WITH CEDARTOWN-POLK AUTHORITY ENDED AND PMCI BEGAN TO OPERATE THE NEW FACILITY PURSUANT TO A NEW 35-YEAR LEASE WITH CEDARTOWN-POLK AUTHORITY. WHEN THE AUTHORITY'S LEASE WITH CEDARTOWN-POLK AUTHORITY ENDED, THE ASSETS, LIABILITIES AND OPERATIONS OF POLK MEDICAL CENTER TRANSFERRED TO CEDARTOWN-POLK AUTHORITY. PART VI, LINE 6 - AFFILIATED HEALTH CARE SYSTEM THE CEDARTOWN-POLK COUNTY HOSPITAL AUTHORITY IS A HOSPITAL AUTHORITY CREATED AND ORGANIZED UNDER THE GEORGIA HOSPITAL AUTHORITIES LAW. IT IS THE OWNER OF POLK MEDICAL CENTER A 25-BED, CRITICAL ACCESS HOSPITAL LOCATED IN CEDARTOWN, GA. THE POLK AUTHORITY CONSISTS OF A SELF-PERPETUATING SIX- PERSON BOARD, ALL OF WHOM ARE POLK COUNTY RESIDENTS. IN 2011 THE POLK AUTHORITY SOLICITED PROPOSALS RESPECTING THE LEASE AND OPERATION OF POLK MEDICAL CENTER. FLOYD HEALTHCARE MANAGEMENT INC. (FHMI) AND THE HOSPITAL AUTHORITY OF FLOYD COUNTY (HAFC) JOINTLY RESPONDED TO THE REQUEST FOR PROPOSALS BY SUBMITTING A PROPOSAL UNDER WHICH THE FOLLOWING TRANSACTIONS AND UNDERTAKINGS WOULD OCCUR: (1) HAFC WOULD LEASE POLK MEDICAL CENTER FROM THE POLK AUTHORITY AND OPERATE IT FOR A PERIOD OF UP TO FIVE YEARS; (2) FHMI WOULD CREATE A NON-PROFIT CORPORATION TO BE CALLED POLK MEDICAL CENTER INC. (PMCI), WHICH WOULD HAVE A BOARD OF DIRECTORS COMPRISED OF NINE PERSONS APPOINTED BY FHMI, THREE OF WHOM WOULD BE RESIDENTS OF FLOYD COUNTY AND SIX OF WHOM WOULD BE RESIDENTS OF POLK COUNTY; (3) PMCI WOULD BE ENGAGED BY HAFC TO MANAGE THE DAY-TO-DAY OPERATION OF POLK MEDICAL CENTER DURING THE TERM OF THE AFORESAID FIVE-YEAR LEASE; (4) PMCI AND FHMI WOULD UNDERTAKE TO CONSTRUCT A NEW, 25-BED REPLACEMENT HOSPITAL ON LAND ALREADY OWNED BY THE POLK AUTHORITY ON THE OUTSKIRTS OF CEDARTOWN, WITH CONSTRUCTION TO BE COMPLETED WITHIN FIVE YEARS; AND (5) UPON COMPLETION OF CONSTRUCTION, THE FIVE-YEAR LEASE WOULD TERMINATE, AND OWNERSHIP OF THE NEW HOSPITAL WOULD RESIDE IN THE POLK AUTHORITY, WHICH WOULD IN TURN LEASE IT TO PMCI FOR A PERIOD OF 35 YEARS. THE FOREGOING PROPOSAL WAS ACCEPTED BY THE POLK AUTHORITY, AND IN LATE 2011, AGREEMENTS BY AND AMONG FHMI, PMCI, HAFC AND THE POLK AUTHORITY WERE EXECUTED, INCLUDING THE FIVE-YEAR LEASE AGREEMENT AND A HOSPITAL CONSTRUCTION AGREEMENT. ON APRIL 1, 2012 THE FIVE-YEAR LEASE AGREEMENT COMMENCED AT WHICH TIME HAFC BECAME THE LICENSED OPERATOR OF POLK MEDICAL CENTER, WITH THE NEWLY CREATED PMCI ENGAGED TO PROVIDE DAY-TO-DAY MANAGEMENT OF THE HOSPITAL'S OPERATION. EFFECTIVE NOVEMBER 5, 2014, THE AUTHORITY'S LEASE FOR POLK MEDICAL CENTER FROM THE CEDARTOWN-POLK COUNTY HOSPITAL AUTHORITY ENDED. ACCORDINGLY, THE OPERATIONS, ASSETS AND LIABILITIES OF POLK MEDICAL CENTER TRANSFERRED TO CEDARTOWN-POLK AUTHORITY. FHMI IS A NOT-FOR-PROFIT CORPORATION CREATED IN 1991 BY THE HAFC. FROM NOVEMBER 26, 1991, THROUGH DECEMBER 31, 1997, FHMI MANAGED AND SUPERVISED FLOYD MEDICAL CENTER AND ALL OTHER FACILITIES, PROJECTS AND PROGRAMS OF THE HAFC PURSUANT TO A MANAGEMENT AGREEMENT. EFFECTIVE JANUARY 1, 1998, THE AFORESAID MANAGEMENT AGREEMENT WAS CONVERTED TO A LEASE AGREEMENT UNDER WHICH ALL FACILITIES, PROJECTS AND PROGRAMS OF HAFC WERE LEASED TO FHMI. AT THAT TIME, FHMI BECAME THE LICENSED OPERATOR OF ALL SUCH FACILITIES, PROJECTS AND PROGRAMS. FHMI IS GOVERNED BY AN EIGHTEEN MEMBER BOARD OF DIRECTORS, THREE OF WHOM MUST BE MEMBERS OF THE HAFC. ADDITIONALLY, FHMI HAS CONTRACTUALLY COMMITTED THAT AT LEAST TWO OF ITS DIRECTORS WILL BE FLOYD COUNTY COMMISSIONERS AND TWO OF ITS DIRECTORS WILL BE CEDARTOWN-POLK COUNTY HOSPITAL AUTHORITY MEMBERS. FLOYD EMERGENCY PHYSICIANS LLC IS A WHOLLY OWNED SUBSIDIARY OF FHMI WHOSE SOLE PURPOSE IS TO PROVIDE A PHYSICIAN AND MID-LEVEL STAFFING SOLUTION IN THE FLOYD MEDICAL CENTER EMERGENCY CARE CENTER AND THE POLK MEDICAL CENTER EMERGENCY DEPARTMENT. THE FLOYD HEALTHCARE FOUNDATION IS A 501(C)(3) NOT-FOR-PROFIT ORGANIZATION THAT WORKS TO IMPROVE THE HEALTH OF THE COMMUNITIES SERVED BY FLOYD MEDICAL CENTER AND POLK MEDICAL CENTER BY DEVELOPING RELATIONSHIPS AND RAISING FUNDS TO BUILD AND SUPPORT PROGRAMS AND SERVICES THAT MEET IDENTIFIED NEEDS AND FURTHER OUR MISSION. GOVERNED BY ITS OWN VOLUNTEER BOARD OF DIRECTORS AND MANAGED BY A PROFESSIONAL STAFF, THE FOUNDATION RAISES SUPPORT THROUGH VOLUNTEER-LED INITIATIVES THAT PROVIDE FUNDING NOT ONLY FOR FLOYD MEDICAL CENTER BUT ALSO FOR PROGRAMS THAT SEEK TO IMPROVE THE HEALTH OF OUR COMMUNITY. FLOYD HEALTHCARE RESOURCES, INC. - A NONPROFIT ORGANIZATION WHICH FACILITATES THE OPERATIONS OF FMC FOR THE BENEFIT OF CITIZENS LOCATED IN FLOYD COUNTY AND THE NORTHWEST GEORGIA REGION. HOSPITAL AUTHORITY OF FLOYD COUNTY SELF INSURANCE TRUST (TRUST) - A NONPROFIT ORGANIZATION THAT SUPPORTS THE HAFC. THIS ORGANIZATION PROVIDED FUNDING TO SATISFY MALPRACTICE AND COMPREHENSIVE GENERAL PATIENT CLAIMS AGAINST HAFC AND FHMI. THE TRUST WAS TERMINATED IN AUGUST 2014. true CEDARTOWN-POLK COUNTY HOSPITAL AUTH 424 NORTH MAIN STREET CEDARTOWN GA 301252644 580603152 GOV 168500 CASH CONSTRUCT H2O/SEWER SCHEDULE I, PAGE 1, PART I, LINE 2 POLK MEDICAL CENTER, INC. ENTERED INTO A CONTRACT WITH THE CITY OF CEDARTOWN TO MAKE ANNUAL CONTRIBUTIONS TO THE CITY FOR THE CONSTRUCTION OF NEW WATER AND SEWAGE INFRASTRUCTURE FOR THE NEW HOSPITAL. PURSUANT TO THE AGREEMENT, PMC WILL MAKE PAYMENTS FOR 20 YEARS. ON AN ANNUAL BASIS, MANAGEMENT REVIEW AND RECONCILES THE ACTIVITY. false true false false false false false false false KURT STUENKEL PRESIDENT/SECRETARY 646282 294288 618453 19409 29632 1608064 RICHARD T SHEERIN CFO 348998 123583 3272 15583 21502 512938 MATTHEW GORMAN POLK ADMINISTRATOR 175178 54528 247 15695 245648 DEANA OWEN PHARMACY DIRECTOR 137966 19419 256 10489 168130 SCHEDULE J, PAGE 1, PART I, LINE 3 NONE OF THE INDIVIDUAL BOARD MEMBERS OR OFFICERS ARE COMPENSATED BY THE FILING ORGANIZATION AND THE ORGANIZATION MUST RELY ON THE METHODS EMPLOYED BY THE RELATED ORGANIZATION, FHMI, TO DETERMINE REASONABLE COMPENSATION FOR THE INDIVIDUALS. COMPENSATION DETERMINATION BY FHMI INCLUDES AN INDEPENDENT COMPENSATION COMMITTEE, INDEPENDENT COMPENSATION CONSULTANT AND SURVEYS, AND BOARD APPROVAL. THESE METHODS ARE WELL DOCUMENTED. SCHEDULE J, PAGE 1, PART I, LINE 4 KURT STUENKEL 0 608,759 0 SCHEDULE J, PART III MR. STUENKEL AND MR. SHEERIN ARE COMPENSATED BY FLOYD HEALTHCARE MANAGEMENT, INC. (EIN: 58-1973570) FOR SERVICES AS THE CEO AND CFO, RESPECTIVELY, OF FLOYD HEALTHCARE MANAGEMENT, INC. THEY RECEIVE NO COMPENSATION FROM THE FILING ORGANIZATION. THE CEO PARTICIPATES IN A SUPPLEMENTAL EXECUTIVE RETIREMENT PLAN (SERP) WHICH IS FUNDED ANNUALLY IN AN AMOUNT WHICH, WHEN ADDED TO OTHER SOURCES OF RETIREMENT INCOME, WILL AFFORD A RETIREMENT INCOME AT A TARGETED PERCENTAGE OF PRE-RETIREMENT COMPENSATION. THE SERP IS A NON-QUALIFIED RETIREMENT PLAN, AND AS SUCH THE ANNUAL FUNDING PAYMENTS PAID INTO IT ARE TAXABLE TO THE PARTICIPANT IN THE YEAR IN WHICH MADE. EFFECTIVE WITH CALENDAR YEAR 2009, MR. STUENKEL'S SERP IS A CASH-BASED PROGRAM. ADDITIONALLY, OF THE 1,599,022 LISTED AS W-2 COMPENSATION FOR MR. KURT STUENKEL ON PART VII SECTION A COLUMN (D), 608,759 REPRESENTS THE NONQUALIFIED SERP PLAN. ACCORDINGLY, MR. STUENKEL'S SALARY FOR 2014 WOULD HAVE BEEN 950,263 EXCLUDING THE 2014 SERP PLAN AMOUNT. BONUS/INCENTIVE PAY ALL MEMBERS OF THE EXECUTIVE TEAM FOR FHMI PARTICIPATE IN AN INCENTIVE COMPENSATION PLAN UNDER WHICH ANNUAL YEAR-END BONUSES ARE PAID BASED ON INDIVIDUAL AND CORPORATE-WIDE ACHIEVEMENT OF SPECIFIC GOALS AND OBJECTIVES. ONE OF THE GOALS RELATES TO THE RELATED ORGANIZATION'S NET INCOME. THE BONUSES ARE AWARDED ON A CASH-BASED SYSTEM. CASH TRANSFER 2015-06-30 168500 FMV 580603152 CEDARTOWN-POLK COUNTY HOSPITAL AUTH 424 NORTH MAIN STREET CEDARTOWN GA 301252644 GOV false false false false FORM 990 - ORGANIZATION'S MISSION PRIMARY INITIAL ACTIVITY OF THE CORPORATION WAS TO PROVIDE MANAGEMENT SERVICES AND MANAGEMENT DIRECTION TO AND FOR THE BENEFIT OF THE LICENSED OPERATOR OF THE HOSPITAL COMMENCING APRIL 1, 2012. EFFECTIVE NOVEMBER 6, 2014, THE CORPORATION BECAME THE LICENSED OPERATOR OF POLK MEDICAL CENTER, A 501(C)(3) ORGANIZATION, LOCATED IN CEDARTOWN, GA. PMC IS A 25-BED CRITICAL ACCESS HOSPITAL PROVIDING CARE TO THE COMMUNITY REGARDLESS OF THE ABILITY TO PAY. FORM 990, PAGE 2, PART III, LINE 2 ABIDING BY TERMS OF AN AGREEMENT WITH CEDARTOWN-POLK COUNTY HOSPITAL AUTHORITY (CEDARTOWN-POLK AUTHORITY), PMCI OBTAINED A CERTIFICATE OF NEED TO BUILD A NEW HOSPITAL WHICH WOULD BE OWNED BY CEDARTOWN-POLK AUTHORITY AND REPLACE THE CURRENT FACILITIES AT POLK MEDICAL CENTER AT NO COST TO CEDARTOWN-POLK AUTHORITY. CONSTRUCTION OF THE NEW HOSPITAL WAS COMPLETED IN NOVEMBER 2014. ON NOVEMBER 6, 2014 THE NEW FACILITY OPENED, AT WHICH TIME, A LEASE AGREEMENT BECAME EFFECTIVE BETWEEN PMCI AND CEDARTOWN-POLK AUTHORITY TO LEASE ALL OF THE ASSETS ASSOCIATED WITH POLK MEDICAL CENTER, A CRITICAL ACCESS HOSPITAL PROVIDING INPATIENT AND OUTPATIENT SERVICES. THE LEASE HAS A 35 YEAR TERM AND AN EFFECTIVE DATE OF NOVEMBER 6, 2014, AT WHICH TIME THE ASSETS AND OPERATIONS OF POLK MEDICAL CENTER TRANSFERRED TO PMCI. FORM 990, PAGE 6, PART VI, LINE 6 FLOYD HEALTHCARE MANAGEMENT, INC. (FHMI), A RELATED ORGANIZATION, HAS THE POWER TO APPOINT EIGHT OF THE NINE MEMBER GOVERNING BODY WHILE THE PRESIDENT/CEO OF FHMI IS THE FINAL MEMBER OF THE BOARD. FORM 990, PAGE 6, PART VI, LINE 7A FLOYD HEALTHCARE MANAGEMENT, INC. (FHMI), A RELATED ORGANIZATION, HAS THE POWER TO APPOINT EIGHT OF THE NINE MEMBER GOVERNING BODY WHILE THE PRESIDENT/CEO OF FHMI IS THE FINAL MEMBER OF THE BOARD. FORM 990, PAGE 6, PART VI, LINE 7B PRIOR APPROVAL OF FHMI IS REQUIRED FOR ANY OF THE FOLLOWING ACTIONS: DISSOLUTION; SALE, MERGER OR DISPOSITION; ADOPTION OF CAPITAL OR OPERATING BUDGETS; SELECT OR REMOVE THE ADMINISTRATOR; INCUR INDEBTEDNESS IN EXCESS OF 1,000,000; TAKE ANY ACTION ON THE LEASE OR CONTRACT BETWEEN THE CORPORATION AND CEDARTOWN-POLK COUNTY HOSPITAL AUTHORITY; AMEND THE CORPORATE ARTICLES OF INCORPORATION OR BYLAWS. FORM 990, PAGE 6, PART VI, LINE 11B THE ORGANIZATION'S CEO, CFO, CONTROLLER, LEGAL COUNSEL AND EMPLOYEES OF FHMI REVIEW THE FORM 990 FOR FINANCIAL AND DISCLOSURE ACCURACY. PRIOR TO ITS FILING, A COPY OF THE ORGANIZATION'S 990 RETURN IS POSTED ON THE BOARD OF DIRECTORS' SECURE WEBSITE FOR THEIR REVIEW. MANAGEMENT WILL SEND AN EMAIL NOTIFYING MEMBERS OF ITS POSTING. FORM 990, PAGE 6, PART VI, LINE 12C POLK MEDICAL CENTER, INC. (PMCI) HAS A WRITTEN POLICY RESPECTING CONFLICTS OF INTEREST AND DISCLOSURE OF SAME. GENERALLY SPEAKING, THE POLICY REQUIRES ANY "COVERED PERSON" WHO BELIEVES HE/SHE HAS A CONFLICT OF INTEREST TO: -DISCLOSE THE EXISTENCE AND NATURE OF THE CONFLICT OF INTEREST (INCLUDING ALL FACTS KNOWN RESPECTING THE SUBJECT MATTER) TO THE CHAIRMAN OF THE BOARD; -PLAY NO PART, DIRECTLY OR INDIRECTLY, IN THE DELIBERATION OR VOTE OF THE BOARD OF DIRECTORS WITH RESPECT TO THE DETERMINATION OF WHETHER A CONFLICT OF INTEREST EXISTS; AND -ABSENT HIMSELF/HERSELF FROM THAT PORTION OF THE MEETING AT WHICH THE CONFLICT OF INTEREST IS DISCUSSED. THE DEFINITION OF A "COVERED PERSON" INCLUDES ALL BOARD MEMBERS, OFFICERS AND MEMBERS OF SENIOR MANAGEMENT OF FHMI. WHEN A COVERED PERSON DISCLOSES A POTENTIAL CONFLICT OF INTEREST TO THE BOARD CHAIRMAN, THE CHAIRMAN IS OBLIGED TO BRING THE MATTER TO THE ATTENTION OF THE FULL BOARD. THE BOARD DETERMINES WHETHER A CONFLICT OF INTEREST ACTUALLY EXISTS. IF THE BOARD DETERMINES THAT THERE IS A CONFLICT OF INTEREST, THE TRANSACTION OR MATTER GIVING RISE TO THE CONFLICT OF INTEREST MAY NOT PROCEED UNLESS THE BOARD DETERMINES, BY A MAJORITY VOTE, THAT, DESPITE THE CONFLICT OF INTEREST, THE TRANSACTION/MATTER IS NEVERTHELESS IN THE CORPORATION'S BEST INTEREST AND IS FAIR AND REASONABLE TO THE CORPORATION. IN ADDITION TO THE REQUIREMENT THAT A COVERED PERSON DISCLOSE A POTENTIAL CONFLICT OF INTEREST AT THE TIME IT ARISES, EACH COVERED PERSON IS ALSO REQUIRED TO SUBMIT, ON AN ANNUAL BASIS, A `CONFLICT AND DISCLOSURE OF INTEREST QUESTIONNAIRE'. THIS MULTI-QUESTION DOCUMENT SERVES AS A REMINDER AND PROMPTS EACH COVERED PERSON TO PONDER THOSE AREAS AND SITUATIONS WHERE A POTENTIAL CONFLICT MIGHT EXIST. ADDITIONALLY, ANY PROPOSED TRANSACTION AT PMCI WHICH INVOLVES AN "INSIDER" (I.E., A BOARD MEMBER, OFFICER, MANAGER, ETC.) IS SCRUTINIZED, WITH THE ASSISTANCE OF CORPORATE LEGAL COUNSEL, FROM THE STANDPOINT OF WHETHER THE TRANSACTION WILL RESULT IN ANY EXCESS BENEFIT TO THE INSIDER. TYPICALLY THIS INVOLVES OBTAINING APPROPRIATE DATA REGARDING COMPARABILITY WHICH IS PROVIDED TO THE BOARD FOR ITS USE IN DETERMINING THAT THE CONSIDERATION BEING PAID TO THE INSIDER AS A PART OF THE TRANSACTION IS REASONABLE AND DOES NOT EXCEED THE VALUE OF THE BENEFIT RECEIVED BY PMCI. FORM 990, PAGE 6, PART VI, LINE 19 THE ORGANIZATION MAKES ITS GOVERNING DOCUMENTS, CONFLICT OF INTEREST POLICY AND FINANCIAL STATEMENTS AVAILABLE TO THE PUBLIC WHEN THE REQUEST IS MADE AT THE ADMINISTRATIVE OFFICE OF THE FILING CORPORATION. FLOYD HEALTHCARE MANAGEMENT INC 304 TURNER MCCALL BLVD ROME GA 301620233 581973570 ACUTE CARE GA 501C3 3 NA false HOSPITAL AUTHORITY OF FLOYD COUNTY 304 TURNER MCCALL BLVD ROME GA 301620233 586001173 HEALTHCARE GA 501C3 3 NA false HOSP AUTH OF FLOYD CO SELF INS TRST 304 TURNER MCCALL BLVD ROME GA 301620233 586140617 TRUST GA 501C4 FHMI FLOYD HEALTHCARE MANAGEMENT INC false false false false false true false false false false false false true true true true false false false false