2016-08-15T11:15:52-05:00 2015-09-30 560747981 DIXON HUGHES GOODMAN LLP 500 RIDGEFIELD COURT ASHEVILLE NC 28806 990 2014-10-01 576005963 KERSHAWHEALTH KERS 8037136268 PO BOX 1558 CAMDEN SC 290203737 MARC A QUIGLEY SECRETARY OF THE BOARD 8037136268 2016-08-15 1 AMY BIBBY P00445891 8282542254 2014 2016-09-27 15:27:22Z X DONNIE WEEKS FORMER CEO PO BOX 1558 CAMDEN SC 290203737 124317172 0 X WWW.KERSHAWHEALTH.ORG X 1952 SC OPERATES HEALTH CARE FACILITIES FOR THE BENEFIT OF THE COMMUNITY 8 8 1183 100 63695 38605 1589943 1315148 120643448 120984430 751841 708410 1157563 946144 124142795 123954132 462555 530729 0 0 54939950 55412809 0 0 261663 71304128 70746269 126706633 126689807 -2563838 -2735675 97678553 94985762 30008511 31405952 67670042 63579810 X KERSHAWHEALTH, ITS STAFF, AND AFFILIATED PHYSICIANS WILL WORK AS A TEAM TO IMPROVE THE HEALTH AND WELL-BEING OF THE RESIDENTS OF KERSHAW COUNTY AND SURROUNDING COMMUNITIES. 0 0 112795603 530729 120920735 KERSHAWHEALTH OWNS AND OPERATES A 121-BED ACUTE CARE FACILITY, A 96-BED LONG-TERM FACILITY, A HOME HEALTH/HOSPICE AGENCY, A RURAL HEALTH CLINIC, PHYSICIAN CLINICS, AND TWO MEDICAL COMPLEXES FOR THE BENEFIT OF KERSHAW COUNTY, SOUTH CAROLINA AND SURROUNDING COMMUNITIES. COMMUNITY BENEFITS ARE PROVIDED THROUGH A COLLABORATIVE EFFORT INVOLVING KERSHAWHEALTH, A BROAD SPECTRUM OF COMMUNITY ORGANIZATIONS, LOCAL GOVERNMENT AND BUSINESSES, THE SOUTH CAROLINA DEPARTMENT OF HEALTH AND ENVIRONMENTAL CONTROL, AND THE ARNOLD SCHOOL OF PUBLIC HEALTH AT THE UNIVERSITY OF SOUTH CAROLINA.SAM KARESH LONG-TERM CARE PROVIDED 33,757 DAYS OF CARE. HOME HEALTH PROVIDED 18,895 VISITS AND HOSPICE PROVIDED 9,192 DAYS OF CARE. KERSHAWHEALTH PROVIDED, AT COST, APPROXIMATELY $2,730,414 IN CHARITY CARE (NET OF REIMBURSEMENTS) AND INCURRED APPROXIMATELY $9,382,291 IN BAD DEBT WRITEOFFS AT COST. KERSHAWHEALTH GAVE CASH DONATIONS OF OVER $826,000.- SUPPORT GROUPS HOSTED 25 MEETINGSFOR CARE-GIVERS DIABETES STEPPING STONES (GRIEF SUPPORT) ALZHEIMER'S - NUTRITION CLASSES - DIABETES EDUCATION - OTHER ACTIVITIES SUCH AS CAR SEAT CHECK, SCHOOL SAFETY DAYS, CAR SEAT/HELMET DISTRIBUTIONS AND VARIOUS PRESENTATIONS AT LOCAL EVENTS WERE CONDUCTED AS A PART OF THE COLLABORATION WITH LIVEWELL KERSHAW, THE COMMUNITY CLINIC, CITY OF CAMDEN FIRE/POLICE DEPARTMENT, THE KERSHAW COUNTY SCHOOL DISTRICT AND OTHER LOCAL ORGANIZATIONS 112795603 1 1 0 1 0 0 0 0 0 0 1 0 0 0 1 1 1 0 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 0 0 0 1 185 0 1 1183 1 1 1 0 0 0 0 0 0 0 0 0 X 8 8 0 0 0 0 0 1 0 1 1 0 0 1 1 1 1 1 1 1 0 0 X DEBRA L JOHNSON 8037136797 1011 FAIR STREET CAMDEN SC 290203737 KAREN ECKFORD CO-CHAIRMAN 1.00 X X 420 0 0 TALLULAH HOLMSTROM MD CO-CHAIRMAN 1.00 X X 420 0 0 ERIC BOLAND BOARD MEMBER 1.00 X 420 0 0 STEVE HOLIDAY JR BOARD MEMBER 1.00 X 420 0 0 BOBBY T JONES BOARD MEMBER 1.00 X 420 0 0 DERIAL L OGBURN BOARD MEMBER 1.00 X 420 0 0 SUSAN OUTEN BOARD MEMBER 1.00 X 420 0 0 WAYNE TIDWELL BOARD MEMBER 1.00 X 420 0 0 TERRY GUNN CEO 40.00 X 325350 0 0 MIKE BUNCH EVP -COO/CFO 40.00 X 236104 0 105358 JEFFREY L ROBINSON PHYSICIAN 40.00 X 293546 0 21823 SHELLEY L JANSSEN PHYSICIAN 40.00 X 308381 0 37648 ROBERT E BULLARD PHYSICIAN 40.00 X 271268 0 35278 EDWARD A GILL PHYSICIAN 40.00 X 260593 0 18086 T BRIGHT WILLIAMSOM PHYSICIAN 40.00 X 390961 0 35096 DONNIE J WEEKS CEO (FORMER) THROUGH 01/14 40.00 X 675196 0 61000 GLORIA J KEEFFE CNO (FORMER) THROUGH 04/14 40.00 X 170991 0 2058 2935750 0 316347 50 1 1 0 PALMETTO HEALTH 293 GREYSTONE BLVD 2ND FLOOR COLUMBIA SC 29210 LABORATORY MANAGEMENT FEES 3817485 CAROLINA CARE PA 215 REDBAY ROAD ELGIN SC 29045 EMERGENCY PROFESSIONAL FEES 1737603 MAD MONKEY INC 1631 MAIN STREET COLUMBIA SC 29201 ADVERTISING 657251 WEATHERBY LOCUMS INC PO BOX 972633 DALLAS TX 753972633 HOSPITALIST PROFESSIONAL SERVICES 571592 NEXSEN PRUET LLC PO DRAWER 2426 COLUMBIA SC 29202 LEGAL SERVICES 461687 26 915594 399554 1315148 PATIENT SERVICE REVENUE 621110 120800330 120736635 63695 EHR MEANINGFUL USE 621110 184100 184100 120984430 1061792 1061792 176452 9658 166794 166794 166794 267759 85623 -267759 -85623 -353382 -353382 CAFETERIA 722210 457978 457978 MISCELLANEOUS REVENUES 900099 175125 175125 DISCOUNTS & REBATES 900099 146247 146247 779350 123954132 120920735 63695 1654554 X 530729 530729 846015 175843 670172 43829347 40155126 3494801 179420 1325428 1196539 123566 5323 6488318 5857371 604890 26057 2923701 2639390 272569 11742 1485832 1485832 65125 65125 124385 124385 18314412 13722110 4582889 9413 458083 378 457705 5811386 4433462 1348354 29570 3202 3202 1896117 1892015 4102 208739 155855 52746 138 1127461 1127461 4570921 4570921 582753 582753 BAD DEBT 18764582 18764582 MEDICAL SUPPLIES 15723254 15723254 FOOD 1243220 1243220 366797 24594 342203 126689807 112795603 13632541 261663 1706877 2100333 117454 117775 10416352 9971203 3369133 3796439 843294 1492118 114509497 69989843 44365416 44519654 34437882 29857863 2422145 3130377 97678553 94985762 8339468 7438734 19213295 18459274 1011503 409447 1444245 5098497 30008511 31405952 X 64521650 60954547 3148392 2625263 67670042 63579810 97678553 94985762 X -2735675 53136 -1407693 X X 0 1 X 1 0 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 0 0 0 0 0 0 0 0 1 8938 8938 0 PART II-B, LINE 1: THE ORGANIZATION IS A MEMBER OF THE AMERICAN HOSPITAL ASSOCIATION AND THE SOUTH CAROLINA HOSPITAL ASSOCIATION. THESE ORGANIZATIONS ENGAGE IN LOBBYING ACTIVITIES ON BEHALF OF THEIR MEMBERSHIP BODIES, AND EACH YEAR, SOME PORTION OF THE DUES PAID TO THESE ORGANIZATIONS IS ATTRIBUTED TO THOSE ENDEAVORS. FOR THE CURRENT YEAR, DUES ATTRIBUTABLE TO LOBBYING FOR THESE ORGANIZATIONS WAS APPROXIMATELY $8,900. 5543152 5543152 65675210 35252540 30422670 42124069 34737303 7386766 1167066 1167066 44519654 ESTIMATED THIRD PARTY OBLIGATIONS 1070386 NET PENSION OBLIGATION 4028111 5098497 X 105127959 53136 9658 62794 105065165 124385 18764582 18888967 123954132 107810498 9658 9658 107800840 124385 18764582 18888967 126689807 PART X, LINE 2: THE HOSPITAL IS A POLITICAL SUBDIVISION EXEMPT FROM FEDERAL AND STATE INCOME TAXES UNDER SECTION 115 OF THE INTERNAL REVENUE CODE. THE HOSPITAL IS ALSO EXEMPT UNDER SECTION 501(C)(3) OF THE INTERNAL REVENUE CODE FROM FEDERAL INCOME TAXES ON RELATED INCOME PURSUANT TO SECTION 501(A) OF THE CODE. THE HOSPITAL HAS DETERMINED THAT IT DOES NOT HAVE ANY MATERIAL UNRECOGNIZED TAX BENEFITS OR OBLIGATIONS AS OF SEPTEMBER 30, 2015. FISCAL YEARS ENDING ON OR AFTER SEPTEMBER 30, 2012 REMAIN SUBJECT TO EXAMINATION BY FEDERAL AND STATE TAX AUTHORITIES. PART XI, LINE 2D - OTHER ADJUSTMENTS: RENTAL EXPENSES 9,658. PART XI, LINE 4B - OTHER ADJUSTMENTS: BAD DEBT NET WITH REVENUES 18,764,582. PART XII, LINE 2D - OTHER ADJUSTMENTS: RENTAL EXPENSES 9,658. PART XII, LINE 4B - OTHER ADJUSTMENTS: BAD DEBT NET WITH REVENUES 18,764,582. 1 1 X 1 X 138.000000000000 1 X 1 1 1 0 0 6761278 4030864 2730414 0.02160 14864821 14581366 283455 0.00220 21626099 18612230 3013869 0.02380 38561 38561 0.00030 826600 826600 0.00650 865161 865161 0.00680 22491260 18612230 3879030 0.03060 310910 310910 0.00250 310910 310910 0.00250 1 18764582 9382291 27334335 30300576 -2966241 X 0 1 1 KERSHAWHEALTH 1315 ROBERTS STREET CAMDEN SC 29020 X X X DISPROPORTIONATE SHARE HOSPITAL KERSHAWHEALTH 1 0 0 1 X X X X X X X X X 12 1 0 0 1 X SEE DISCLOSURE FOR URL X 1 12 1 HTTP://WWW.LIVEWELLKERSHAW.ORG/ 0 0 1 X 138.000000000000 400.000000000000 X X 1 1 X X 1 X X X 0 0 X X X X X 1 X 0 0 KERSHAWHEALTH PART V, SECTION B, LINE 5: THE HOSPITAL FACILITY COLLABORATED WITH SEVERAL ORGANIZATIONS THAT ARE LISTED IN DETAIL ON THE CHNA. KERSHAWHEALTH PART V, SECTION B, LINE 7D: WEBSITE URLHTTP://WWW.KERSHAWHEALTH.ORG/MEDIA/22067/LWK-CHNA-REPORT.PDFNEWSPAPER AND CIVIC ORGANIZATION MEETINGS KERSHAWHEALTH PART V, SECTION B, LINE 11: THE TOP PRIORITIES ADDRESSED IN THIS CHNA WERE IDENTIFIED AS" NUTRITION/PHYSICAL ACTIVITY/OBESITY THE OBJECTIVES TO ADDRESSING THIS NEED INCLUDE: ENCOURAGING ACTIVITY ON BREAKS AT WORK, IMPROVING NEIGHBORHOOD SAFETY TO ENCOURAGE PHYSICIAL ACTIVITY, RECREATION DEPARTMENT TO PROVIDE A WIDE RANGE OF ACTIVITIES FOR ALL AGES, DEVELOPING COMMUNITY GARDENS, DEVELOPING MOBIL MARKET TO ACCESS "FOOD DESERTS, AND EXPANDING FARM TO SCHOOL PROGRAMS. ACCESS TO APPROPRIATE CARETHE OBJECTIVES TO ADDRESSING THIS NEED INCLUDE: IDENTIFYING STRATEGIES TO INCREASE TRANSPORTATION, IDENTIFYING STRATEGIES TO INCREASE PRIMARY CARE IN RURAL AREAS, PROVIDING RESEARCH GRANTS FOR VOUCHER-BASED PROGRAMS, AND COLLABORATING WITH COMMUNITY HEALTH CARE CENTERS TO DEVELOP STRATEGIES THAT HELP RECRUIT AND PROVIDE EQUAL OPPORTUNITIES FOR STUDENTS WORKING TOWARDS MEDICAL DEGREES. SMOKINGTHE OBJECTIVES TO ADDRESSING THIS NEED INCLUDE: IDENTIFYING COMMUNITY EDUCATION CAMPAIGN, ASSESSING ANY CURRENT POLICIES, ENGAGING KEY STAKEHOLDERS, AND PLANNING FOR POLICY IMPLEMENTATION.SEXUAL ACTIVITY & TEEN HEALTHTHE OBJECTIVES TO ADDRESSING THIS NEED INCLUDE: DEVELOPING STRATEGIES TO ADDRESS PRIMARY PREVENTION IN SCHOOLS, COACHING ADULT LEADERSHIP, BUILDING A NETWORK OF ADVOCATES FOR POLICY CHANGE, AND EDUCATING THE CORRELATION BETWEEN SEXUAL ABUSE AND TEEN PREGNANCY.THE OTHER RISK FACTORS THAT WERE IDENTIFIED INCLUDE: PROVERTY/DISPARITIES, CHRONIC LOWER/RESPIRATORY DISEASE, AND ACCIDENTS. DUE TO THE BROAD SCOPE OF POVERTY AND DISPARITIES, IT WAS NOT CHOSEN SPECIFICALLY AS A PRIORITY AREA, BUT INSTEAD, WAS INCORPORATED INTO THE STRATEGIES THE GROUP WOULD UNDERTAKE WITHIN EACH OF THE 4 CHOSEN PRIORITY AREAS.WITH REGARDS TO CHRONIC LOWER/RESPIRATORY DISEASE, IT WAS NOT SPECIFIED AS TO HOW MANY CASES WERE LINKED TO SMOKING (FIRST OR SECOND-HAND SMOKE), WHICH WAS SELECTED AS A PRIORITY. WHILE NO DIRECT CORRELATION COULD BE MADE, THE GROUP FELT THAT TARGETING FIRST AND SECOND-HAND SMOKING PREVENTION STRATEGIES COULD INDIRECTLY IMPACT THIS ISSUE. BOTH STRATEGIC ISSUES WILL CONTINUE TO BE MONITORED IN FUTURE ASSESSMENTS.ACCIDENTS WERE NOT CHOSEN AS AN AREA DUE TO ITS BROAD AND INCONSISTENT DEFINITION. THEREFORE IT WAS UNCLEAR AS TO WHAT TYPES OF ACCIDENTS HAD THE LARGEST IMPACT ON HEALTH OUTCOMES. THE GROUP ALSO NOTED THAT WITH REGARDS TO MOTOR VEHICLE ACCIDENTS AND DUI-RELATED DEATHS, THE KERSHAW COUNTY LAW ENFORCEMENT AGENCIES ARE ALREADY TARGETING THIS AREA. KERSHAWHEALTH PART V, SECTION B, LINE 16I: SELF PAY INPATIENTS ARE VISITED BY A FINANCIAL COUNSELOR TO DISCUSS ELIGIBILITY FOR GOVERNMENT PROGRAMS OR FINANCIAL ASSISTANCE. ALL SELF-PAY PATIENTS ARE CALLED BY AN ADVOCATE TO DISCUSS ELIGIBILITY FOR GOVERNMENT PROGRAMS OR FINANCIAL ASSISTANCE. WHEN PATIENTS CALL TO DISCUSS BILLS, THEY ARE INFORMED OF THE POLICY. KERSHAWHEALTH PART V, SECTION B, LINE 20E: FINANCIAL COUNSELOR MEETS WITH SELF PAY INPATIENST. CONTRACTED AGENCY CALLS ALL SELF PAY PATIENTS TO DISCUSS FINANCIAL ASSISTANCE. INCLUDED IN PATIENT INFORMATION BOOK. KERSHAWHEALTH PART V, SECTION B, LINE 22D: THE HOSPITAL USED FEDERAL POVERTY GUIDELINES TO DETERMINE THE MAXIMUM AMOUNTS CHARGED TO INDIVIDUALS ELIGIBLE FOR FINANCIAL ASSISTANCE. 12 KERSHAWHEALTH 1315 ROBERTS ST CAMDEN SC 29020 DISPROPORTIONATE SHARE HOSPITAL KERSHAWHEALTH KARESH LONG TERM CARE 1315 ROBERTS ST CAMDEN SC 29020 SKILLED NURSING/LONG-TERM CARE KERSHAWHEALTH HEALTHCARE PLACE AT BETHUN 103 S MAIN ST BETHUNE SC 29009 RURAL HEALTH CLINIC KERSHAWHEALTH HOSPICE 124 BATTLESHIP RD CAMDEN SC 29020 HOSPICE CARE KERSHAWHEALTH HOME HEALTH 124 BATTLESHIP RD CAMDEN SC 29020 HOME HEALTH CARE KERSHAWHEALTH PRIMARY CARE AT ELGIN 40 PINNACLE PARKWAY BLDG 111 ELGIN SC 29045 PHYSICIAN CLINIC KERSHAWHEALTH PRIMARY CARE AT CAMDEN 1111 MILL ST CAMDEN SC 29020 PHYSICIAN CLINIC KERSHAWHEALTH URGENT CARE AT ELGIN 40 PINNACLE PARKWAY BLDG 111 ELGIN SC 29045 URGENT CARE KERSHAWHEALTH PULMONOLOGY CLINIC 1218 ROBERTS STREET CAMDEN SC 29020 PHYSICIAN CLINIC KERSHAWHEALTH GASTROENTEROLOGY 1303 MONUMENT SQUARE CAMDEN SC 29020 PHYSICIAN CLINIC KERSHAWHEALTH INFECTIOUS DISEASE CLINIC 40 PINNACLE PARKWAY BLDG 111 ELGIN SC 29045 PHYSICIAN CLINIC KERSHAWHEALTH KERSHAWHEALTH SURGERY ASSO 1102 ROBERTS STREET CAMDEN SC 29020 PHYSICIAN CLINIC PART I, LINE 7: THE ORGANIZATION USED WORKSHEET 2 OF THE 2014 SCHEDULE H INSTRUCTIONS TO COMPUTE A RATIO OF COST TO CHARGES FOR PURPOSES OF THIS LINE. PART I, LN 7 COL(F): THE AMOUNT ON FORM 990, PART IX, LINE 25 INCLUDES BAD DEBT EXPENSE OF $ 18,764,582 THAT HAS BEEN REMOVED FOR PURPOSES OF CALCULATING PERCENT OF TOTAL EXPENSE. PART II, COMMUNITY BUILDING ACTIVITIES: KERSHAWHEALTH INCURRED EXPENSE IN 2014 FOR LOAN FORGIVENESS ASSOCIATED WITH PHYSICIANS PREVIOUSLY RECRUITED WHO CONTINUED TO MEET THEIR OBLIGATIONS IN THE MEDICALLY UNDERSERVED SERVICE AREA AS WELL AS EXPENSE ASSOCIATED WITH CONTINUED RECRUITMENT EFFORTS FOR THE MEDICALLY UNDERSERVED SERVICE AREA. PART III, LINE 4: BAD DEBTS ON PART III, LINE 2 ARE PRESENTED AT GROSS CHARGES PER THE ORGANIZATION'S AUDITED FINANCIAL STATEMENTS.THE HOSPITAL PROVIDES SERVICES PRIMARILY TO THE RESIDENTS OF KERSHAW COUNTY, SOUTH CAROLINA AND SURROUNDING COUNTIES WITHOUT COLLATERAL. AN ALLOWANCE FOR UNCOLLECTIBLE ACCOUNTS IS PROVIDED IN AN AMOUNT EQUAL TO THE ESTIMATED LOSSES TO BE INCURRED IN COLLECTION OF THE RECEIVABLES. THE ALLOWANCE IS BASED ON HISTORICAL COLLECTION EXPERIENCES AND A REVIEW OF THE CURRENT STATUS OF THE EXISTING RECEIVABLES.THE ORGANIZATION ESTIMATES THAT APPROXIMATELY 50% OF ITS BAD DEBTS MAY BE ATTRIBUTABLE TO PATIENTS ELIGIBLE UNDER THE ORGANIZATION'S CHARITY CARE POLICY. THERE ARE A NUMBER OF IMPEDIMENTS TO OBTAINING THE NECESSARY DATA TO QUALIFY A PATIENT FOR CHARITY CARE. THE HOSPITAL MAKES EVERY EFFORT TO OBTAIN THIS INFORMATION CORRECTLY AND TIMELY; HOWEVER DUE TO THE LIMITATION ON THE AVAILABILITY OF INFORMATION AND THE WILLINGNESS TO PROVIDE IT, IT IS ASSUMED THAT SOME ELIGIBLE PATIENTS ARE CHARGED TO BAD DEBT. THE HOSPITAL EXAMINED ITS GROSS CHARGES FOR SELF-PAY PATIENTS FOR WHOM ALL INFORMATION WAS AVAILABLE AND DETERMINED THE PORTION OF CHARGES THAT WERE WRITTEN OFF TO CHARITY CARE. PART III, LINE 8: ALL SHORTFALL SHOULD BE CONSIDERED COMMUNITY BENEFIT AS THE GOVERNMENT SHOULD BEAR THE COST OF A GOVERNMENT PROGRAM, AND DOES NOT, LEAVING HOSPITALS TO BEAR THE UNREIMBURSED COST OF THE PROGRAM. PART III, LINE 9B: THE COLLECTION PROCESS IS SYSTEM-AUTOMATED AND ADJUSTS ACCORDING TO A MATRIX SET UP FOR EACH FINANCIAL CLASS. ADJUSTMENTS FOR FINANCIAL ASSISTANCE ARE MADE UPON APPROVAL, AND THE SYSTEM GENERATES STATEMENTS TO THE PATIENT (IF A PATIENT BALANCE REMAINS) AFTER A CERTAIN NUMBER OF DAYS FROM FINAL BILL DATE (I.E. DATE PATIENT BECOMES LIABLE AFTER ALL OTHER PAYMENTS/ADJUSTMENTS HAVE BEEN MADE). PART VI, LINE 2: AS PART OF A STATE COLLABORATIVE, THE HOSPITAL PARTICIPATED IN A HEALTH SYSTEM PROFILE PERFORMED BY THE SOUTH CAROLINA RURAL HEALTH RESEARCH CENTER, UNIVERSITY OF SOUTH CAROLINA FOR THE SOUTH CAROLINA HOSPITAL ASSOCIATION. THE OBJECTIVE WAS TO IDENTIFY ACCESS TO AND UTILIZATION OF HEALTHCARE FOR THE UNINSURED. THE RESULT OF THE PROFILE WAS IMPLEMENTATION OF A PROGRAM CALLED ACCESSHEALTH SC FOR SEVERAL COUNTIES, INCLUDING KERSHAW. THE PROGRAM IS FUNDED THROUGH A GRANT FROM THE DUKE ENDOWMENT WITH KERSHAWHEALTH BEING THE PASS-THRU ORGANIZATION FOR KERSHAW COUNTY. ACCESSHEALTH'S FOCUS IS TO DEVELOP A COMMUNITY NETWORK OF CARE FOR THE LOW-INCOME, UNINSURED IN THE COUNTY. THE HOSPITAL CONDUCTED A COMMUNITY HEALTH NEEDS ASSESSMENT TO IDENTIFY HEALTH NEEDS OF ALL CITIZENS. AS OF THE FILING OF THIS RETURN, THE REPORT IS IN DRAFT. PART VI, LINE 3: ALL SELF PAY, URGENT CARE, AND INPATIENT PATIENTS ARE OFFERED A FINANCIAL ASSISTANCE APPLICATION BEFORE DISCHARGE. IN ADDITION, ALL INPATIENTS ARE VISITED FACE-TO-FACE BY A REPRESENSENTATIVE TO DISCUSS FINANCIAL NEEDS AND INFORMATION IS INCLUDED IN THE PATIENT INFORMATION BOOKLET. INFORMATION IS GATHERED TO ASSESS QUALIFICATION FOR MEDICAID, A MEDICALLY INDIGENT ASSISTANCE PROGRAM, OR HOSPITAL CHARITY. THE INFORMATION IS GIVEN TO A SOCIAL WORKER FOR APPLICATION OF AND DETERMINATION FOR THE APPROPRIATE SOURCE. A PHONE BASED TRANSLATION SYSTEM IS AVAILABLE FOR NON-ENGLISH SPEAKING PATIENTS. A CONTRACTED AGENCY CALLS ALL SELF PAY PATIENTS TO DISCUSS FINANCIAL ASSISTANCE AND OTHER PROGRAMS. ON THE WEBSITE UNDER THE BILLING SECTION IS INFORMATION REGARDING WHO TO CONTACT FOR QUESTIONS ABOUT FINANCIAL ASSISTANCE. PART VI, LINE 4: THE ORGANIZATION'S SERVICE AREA IS DEFINED AS ELEVEN ZIP CODES SURROUNDING THE HOSPITAL IN CAMDEN, SC, LOCATED IN KERSHAW COUNTY. THE POPULATION OF THE COUNTY WAS ESTIMATED AT 62,516 IN 2013. THE COUNTY LAND AREA OF APPROXIMATELY 740 SQUARE MILES WAS THE 23RD LARGEST COUNTY IN POPULATION AMONG THE 46 COUNTIES IN THE STATE OF SOUTH CAROLINA BUT WAS THE SEVENTH FASTEST GROWING ONE, ACCORDING TO THE 2000 CENSUS. GEOGRAPHICALLY, THE COUNTY BORDERS RICHLAND COUNTY TO THE WEST, HOME OF THE STATE CAPITAL, COLUMBIA. ETHNIC DEMOGRAPHICS IN 2013: 69.0% WHITE/CAUCASIAN, NON-HISPANIC 24.6% AFRICAN-AMERICAN, NON-HISPANIC 4.2% HISPANIC/LATINO 2.2% OTHER THE UNEMPLOYMENT LEVEL IN 2013 WAS 6.7% VERSUS THE STATE LEVEL OF 7.6%. THE AVERAGE INCOME WAS $ 44,787 VERSUS STATE LEVEL OF $44,310. KERSHAW COUNTY INCLUDES FOUR MEDICALLY UNDERSERVED AREAS. PART VI, LINE 5: A MAJORITY OF THE ORGANIZATION'S GOVERNING BODY IS COMPRISED OF PERSONS WHO RESIDE IN THE ORGANIZATION'S PRIMARY SERVICE AREA AND WHO ARE NEITHER EMPLOYEES NOR INDEPENDENT CONTRACTORS OF THE ORGANIZATION. THE HOSPITAL EXTENDS MEDICAL STAFF PRIVILEDGES TO ALL QUALIFIED PHYSICIANS IN ITS COMMUNITY TO ITS DEPARTMENTS. KERSHAWHEALTH USES ALL SURPLUS FUNDS TO PURCHASE NEW AND IMPROVED EQUIPMENT, PROVIDE ADDITIONAL SERVICES, IMPROVE EXISTING SERVICES OR FACILITIES, RECRUIT NEEDED PHYSICIANS TO THE AREA, ALL IN ORDER TO PROVIDE QUALITY HEALTH CARE TO THE RESIDENTS OF KERSHAW AND SURROUNDING COUNTIES.SEE PROGRAM SERVICE ACCOMPLISHMENTS FOR ACTIVITIES AT HEALTH RESOURCE CENTER. KERSHAWHEALTH CLOSED ITS HEALTH RESOURCE CENTER IN 2011 IN ORDER TO MORE EFFECTIVELY DEPLOY RESOURCES OUT INTO THE COMMUNITY. THE FOCUS OF THESE EFFORTS WILL BE THE LAUNCH OF THE HEALTHY KERSHAW COUNTY INITIATIVE WITH A GOAL OF MAKING THE COUNTY THE HEALTHIEST IN SOUTH CAROLINA. THIS IS A COLLABORATIVE EFFORT INVOLVING KERSHAWHEALTH, A BROAD SPECTRUM OF COMMUNITY ORGANIZATIONS, LOCAL GOVERNMENT AND BUSINESSES, THE SOUTH CAROLINA DEPARTMENT OF HEALTH AND ENVIRONMENTAL CONTROL, AND THE ARNOLD SCHOOL OF PUBLIC HEALTH AT THE UNIVERSITY OF SOUTH CAROLINA. IN ADDITION TO THOSE ACTIVITIES, KERSHAWHEALTH IS ACTIVE IN THE COMMUNITY AND LEADS AND PARTICIPATES IN DISASTER/EMERGENCY EXERCISES WITH OTHER COUNTY AGENCIES. WE OFFER PROGRAMS TO COUNTY EMPLOYEES SUCH AS CPR CLASSES. INFECTION CONTROL AND DIABETES EDUCATORS PARTICIPATE IN PRESENTATIONS TO COMMUNITY GROUPS AND SCHOOLS WITHIN KERSHAW COUNTY. KERSHAWHEALTH ACTIVELY PARTICIPATES IN RECRUITING NEEDED PHYSICIANS TO THIS SERVICE AREA WHICH INCLUDES MEDICALLY UNDERSERVED AREAS. WE FINANCIALLY SUPPORT THE COMMUNITY CLINIC OF KERSHAW COUNTY WHICH SERVES INDIGENT PATIENTS. WE AND OUR EMPLOYEES SUPPORT THE UNITED WAY THROUGH AN ANNUAL GIVING CAMPAIGN. KERSHAWHEALTH OWNS AND OPERATES THE COUNTY AMBULANCE SERVICE WHICH OPERATES AT A SIGNIFICANT DEFICIT. KERSHAWHEALTH SUBSIDIZES THE COUNTY 911 DISPATCHER SALARY AND FUNDS A PERSONAL TRAINER FOR THE SCHOOL SYSTEM. PART VI, LINE 6: THE ORGANIZATION IS NOT A MEMBER OF AN AFFILIATED HEALTH CARE SYSTEM. PART VI, LINE 7, REPORTS FILED WITH STATES SC 1 KERSHAW COUNTY 1121 BROAD ST CAMDEN SC 29020 576000368 GOVERNMENT 41197 911 DISPATCHER SALARY KERSHAW COUNTY SCHOOL DISTRICT 2029 WEST DEKALB ST CAMDEN SC 29020 576000369 GOVERNMENT 45000 ATHLETIC TRAINER SALARY KERSHAW COUNTY COMMUNITY CLINIC 110C E DEKALB ST STE 1B CAMDEN SC 29020 571074191 501(C)(3) 90000 FINANCIAL ASSISTANCE UNITED WAY OF KERSHAW COUNTY PO BOX 737 CAMDEN SC 29021 570717334 501(C)(3) 11000 CONTRIBUTION SANDHILLS MEDICAL FOUNDATION PO BOX 366 MCBEE SC 29101 570672342 501(C)(3) 10627 PASSTHRU GRANT 5 PART I, LINE 2: THE ORGANIZATION WORKS CLOSELY WITH THE ORGANIZATIONS RECEIVING THE FUNDS AND ENSURES THAT THE FUNDS ARE USED IN ACCORDANCE WITH THE OPERATIONS INTENDED. IN ADDITION, THE ORGANIZATION INCURS EXPENSES ON BEHALF OF THE HOSPITAL FOUNDATION TO ADVANCE HEALTH CARE IN KERSHAW COUNTY TO PROVIDE FOR FUNDRAISING EFFORTS ON BEHALF OF THE ORGANIZATION. X X 1 1 X X X X 1 1 0 0 0 1 0 0 0 TERRY GUNN CEO 325350 0 0 0 0 0 0 0 0 0 325350 0 0 0 MIKE BUNCH EVP -COO/CFO 236104 0 0 0 0 0 87054 0 18304 0 341462 0 69554 0 JEFFREY L ROBINSON PHYSICIAN 262296 0 31250 0 0 0 17500 0 4323 0 315369 0 0 0 SHELLEY L JANSSEN PHYSICIAN 258786 0 49595 0 0 0 17500 0 20148 0 346029 0 0 0 ROBERT E BULLARD PHYSICIAN 240018 0 31250 0 0 0 23000 0 12278 0 306546 0 0 0 EDWARD A GILL PHYSICIAN 202139 0 8572 0 49882 0 0 0 18086 0 278679 0 0 0 T BRIGHT WILLIAMSOM PHYSICIAN 383122 0 7839 0 0 0 23000 0 12096 0 426057 0 0 0 DONNIE J WEEKS CEO (FORMER) THROUGH 01/14 675196 0 0 0 0 0 61000 0 0 0 736196 0 38000 0 GLORIA J KEEFFE CNO (FORMER) THROUGH 04/14 164584 0 6407 0 0 0 2058 0 0 0 173049 0 0 0 PART I, LINE 1A THE ORGANIZATION'S CEO, AS PART OF HIS EMPLOYMENT AGREEMENT, IS PROVIDED A VEHICLE, SOCIAL CLUB DUES FOR BUSINESS PURPOSES, AND A PERSONAL LIFE INSURANCE POLICY, THE VALUE OF WHICH IS ADDED TO HIS REPORTABLE W-2 COMPENSATION. PART I, LINES 4A-B COMPENSATION RECEIVED BY DONNIE WEEKS DURING 2014 REPRESENTS SEVERANCE PAY IN CONNECTION WITH HIS POSITION AS CEO. SOME OFFICERS OF THE ORGANIZATION PARTICIPATE IN A SUPPLEMENTAL NONQUALIFIED EXECUTIVE RETIREMENT PLAN. DEFERRALS TO THIS PLAN FOR THE CURRENT YEAR ARE SCHEDULED TO BE PAID OUT BEGINNING IN 2015. THESE AMOUNTS ARE REPRESENTED IN PART II, COLUMN (C). FOR THE CURRENT YEAR, THE FOLLOWING ALLOCATIONS WERE MADE: DONNIE WEEKS: $ 38,000 MICHAEL BUNCH: 69,554 PART I, LINE 6 THE COMPENSATION OF SOME OFFICERS OF THE ORGANIZATION IS BASED ON INCENTIVES COMPENSATION FACTORS (ICF) ESTABLISHED JOINTLY BY THE CEO AND THE COMPENSATION COMMITTEE OF THE BOARD OF DIRECTORS. ONE OF THE FACTORS IS THE PROFIT MARGIN OF THE ORGANIZATION. BONUS COMPENSATION UNDER THIS PROGRAM IS COMPUTED AS A PERCENTAGE OF BASE SALARY, AS DEFINED BELOW: CEO: 40% CFO: 30% COO: 30% CNO: 20% PRESENTLY, THE SAME INDIVIDUAL HOLDS BOTH THE CFO AND COO POSITION, AND THE BONUS IS CALCULATED AT 30%. A KERSHAWHEALTH 576005963 2012-05-04 4462957 REFUNDING, CAP. EXPENDITURE 0 0 0 B SC JOBS-ECONOMIC DEVELOPMENT AUTHORITY 570960018 83703ELM5 2008-07-31 19141352 CAPITAL EXPENDITURE 0 0 0 A 2391256 4462957 2202962 1531799 728195 2013 1 1 0 1 B 385000 19563625 1893585 459000 17211040 2010 0 0 1 1 A 0 0 0 0 0 0 0 B 0 1 0 0 0.00600 0.00600 0 0 0 A 0 1 0 0 0 0 0 0 0 B 0 0 0 1 0 0 0 0 0 A 0 B 0 DATE REBATE COMPUTATION PERFORMED ISSUER NAME: SC JOBS-ECONOMIC DEVELOPMENT AUTHORITY DATE THE REBATE COMPUTATION WAS PERFORMED: 05/16/2014 SCHEDULE K, PART II, LINE 11, OTHER SPENT PROCEEDS: THE AMOUNT PRESENT ON LINE 11 FOR BOND (A) REPRESENTS AMOUNT USED TO CURRENTLY REFUND AND ADVANCE REFUND PRIOR BONDS ISSUES DATED AS FOLLOWS: BONDS ISSUED 8/25/2006; CURRENT REFUNDING; $ 640,945 BONDS ISSUED 2/25/2009; ADVANCE REFUNDING; $ 890,854 FORM 990 PART IV LN 20B THE ORGANIZATION WILL BE RECEIVING AUDITED FINANCIAL STATEMENTS FOR THE 09/30/2015 PERIOD. THE FINANCIAL STATEMENTS WERE NOT ISSUED PRIOR TO THE FILING OF THE FORM 990 AND THEREFORE ARE NOT ATTACHED. FORM 990, PART VI, SECTION A, LINE 1 AN EXECUTIVE COMMITTEE IS COMPOSED OF THE CHAIRMAN OF THE BOARD, THE VICE CHAIRMAN, THE CHAIR OF THE FINANCE COMMITTEE, THE CHAIR OF THE STRATEGIC PLANNING COMMITTEE AND ANY OTHER BOARD MEMBERS APPOINTED BY THE CHAIRMAN, NOT EXCEEDING A TOTAL OF FOUR BOARD MEMBERS. THE CHAIRMAN OF THE BOARD CHAIRS THE MEETINGS OF THE COMMITTEE. WHEN THE FULL BOARD IS NOT IN SESSION, THE EXECUTIVE COMMITTEE HAS THE POWER AND AUTHORITY OF THE BOARD TO TRANSACT ALL REGULAR BUSINESS OF THE ORGANIZATION, SUBJECT TO ANY PRIOR LIMITATIONS IMPOSED BY THE BOARD OR BY STATUTE. IF NECESSARY, THE BOARD ENUMERATES AND DELINEATES THE DUTIES AND POWERS OF THE EXECUTIVE COMMITTEE BY RESOLUTION. FORM 990, PART VI, SECTION A, LINE 7A MEMBERS OF THE BOARD ARE APPOINTED BY THE KERSHAW COUNTY COUNCIL FOR TERMS OF SIX YEARS AND UNTIL THEIR SUCCESSORS ARE APPOINTED AND QUALIFIED. ALL APPOINTEES TO THE BOARD ARE TO BE RESIDENTS OF KERSHAW COUNTY, SOUTH CAROLINA WITH AT LEAST ONE MEMBER FROM EACH OF THE FOUR TOWNSHIPS. FORM 990, PART VI, SECTION B, LINE 11 THE RETURN WAS PREPARED BY AN INDEPENDENT ACCOUNTANT WITH ASSISTANCE AND OVERSIGHT BY MANAGEMENT. A DIGITAL COPY OF THE COMPLETED FORM 990 WAS PROVIDED TO EACH VOTING BOARD MEMBER PRIOR TO FILING WITH THE IRS. FORM 990, PART VI, SECTION B, LINE 12C THE ORGANIZATION'S CONFLICT OF INTEREST POLICY IS COVERED IN THE CODE OF CONDUCT AND ANNUAL COMPLIANCE EDUCATION. IT IS ALSO MADE AVAILABLE ON THE ORGANIZATION'S INTRANET WHICH CAN BE ACCESSED BY ALL EMPLOYEES. POTENTIAL CONFLICT DISCLOSURES ARE PRESENTED TO THE BOARD COMPLIANCE COMMITTEE AND THE COMMITTEE DETERMINES WHETHER OR NOT A CONFLICT EXISTS. FORM 990, PART VI, SECTION B, LINE 15A THE BOARD OF TRUSTEES FROM TIME TO TIME ENGAGES AN INDEPENDENT CONSULTANT TO PROVIDE COMPARISON ANALYSIS FOR COMPENSATION LEVELS FOR THE CEO. THE EXECUTIVE COMMITTEE OF THE BOARD DETERMINES AND APPROVES THE COMPENSATION FOR THE CEO OF THE ORGANIZATION. A MARKET ANALYSIS IS CONDUCTED BY HUMAN RESOURCES FOR ALL OTHER LEADERSHIP EMPLOYEES AND COMPENSATION LEVELS ARE APPROVED BY THE CEO. FORM 990, PART VI, SECTION C, LINE 18 PHOTOCOPIES OF THE FORM 990 ARE AVAILABLE UPON REQUEST AT THE ORGANIZATION'S ADMINISTRATIVE OFFICE. IN ADDITION, RECENT FILINGS OF THE FORM 990 ARE AVAILABLE ONLINE AT WWW.GUIDESTAR.ORG. FORM 990, PART VI, SECTION C, LINE 19 THE ORGANIZATION'S GOVERNING DOCUMENTS, CONFLICT OF INTEREST POLICY, AND FINANCIAL STATEMENTS ARE MADE AVAILABLE TO THE PUBLIC UPON REQUEST AT THE ORGANIZATION'S ADMINISTRATIVE OFFICE. PLEASE SEE PART VI, LINE 20. FORM 990, PART IX, LINE 11G PURCHASED SERVICES: PROGRAM SERVICE EXPENSES 6,617,278. MANAGEMENT AND GENERAL EXPENSES 1,070,038. FUNDRAISING EXPENSES 9,244. TOTAL EXPENSES 7,696,560. PROFESSIONAL FEES: PROGRAM SERVICE EXPENSES 3,528,645. MANAGEMENT AND GENERAL EXPENSES 2,889,473. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 6,418,118. CONSULTANTS: PROGRAM SERVICE EXPENSES 79,380. MANAGEMENT AND GENERAL EXPENSES 21,757. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 101,137. MAINTENANCE CONTRACTS: PROGRAM SERVICE EXPENSES 3,397,450. MANAGEMENT AND GENERAL EXPENSES 218,056. FUNDRAISING EXPENSES 169. TOTAL EXPENSES 3,615,675. OUTSIDE FEES: PROGRAM SERVICE EXPENSES 20,387. MANAGEMENT AND GENERAL EXPENSES 0. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 20,387. OTHER PROFESSIONAL FEES: PROGRAM SERVICE EXPENSES 78,970. MANAGEMENT AND GENERAL EXPENSES 383,565. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 462,535. FORM 990, PART XI, LINE 9: ADJUSTMENT FOR GASB 68 - PENSION LIABILITY -1,407,693. FORM 990, PART XII, LINE 2C: THE PROCESS HAS NOT CHANGED FROM THE PRIOR YEAR. HOSPITAL AUXILIARY OF KERSHAW COUNTY MEMORIAL HOSPITAL PO BOX 428 CAMDEN SC 29020 570384831 FOUNDATION/ FUNDRAISING SC 501(C)(3) GOV'T N/A 0 0 0 1 0 0 0 0 0 0 0 0 0 1 0 0 1 0 0 0