2016-08-15T07:29:40-05:00 2015-09-30 550486667 Arnett Carbis Toothman LLP P O Box 2629 Charleston WV 25329 990 2014-10-01 273128197 Highland-Clarksburg Hospital Inc HIGH 3049693100 3 Hospital Plaza Clarksburg WV 26301 Shelly Giaquinto CFO 3049693107 2016-08-11 1 Tessa W Carr P01291277 3043460441 2014 2016-09-27 15:27:22Z X Michael Casdorph 3 Hospital Plaza Clarksburg WV 26301 15352047 0 X www.highlandhosp.com/clarksburg/ X 2010 WV To provide psychiatric care to adults and children. 8 5 344 4 0 0 70982 14756 7485709 15293830 0 0 -6232 43461 7550459 15352047 0 0 0 0 6204967 9335203 0 0 0 4868387 7793187 11073354 17128390 -3522895 -1776343 48735823 47780383 37955995 38794984 10779828 8985399 To provide psychiatric care to adults and children. 0 0 8331695 15334591 Highland-Clarksburg Hospital, Inc. (HCHI) is a non-profit organization formed in 2011 to develop and operate a behavioral health hospital in Harrison County, WV. HCHI began generating operating revenues after October 29, 2013, the date of the Joint Commission Accreditation. The Hospital provides psychiatric care to north central West Virginia and surrounding communities. The facility has 90 inpatient beds and 16 Crisis Stabilization beds open. The hospital has 150 licensed beds as approved with the certificate of need through the WV Healthcare Authority. During the year HCHI provided 18,704 days of inpatient psychiatric care. 8331695 1 1 0 0 0 0 0 0 0 0 1 0 0 0 1 1 1 0 0 0 0 0 0 0 0 0 1 1 0 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 27 0 344 1 0 0 0 0 0 0 0 0 0 0 X 8 5 0 0 0 0 0 0 0 1 1 0 0 0 1 1 1 1 1 1 1 0 X Shelly Giaquinto 3049693107 3 Hospital Plaza Clarksburg WV 26301 James H Dissen Chairman/President/CEO 1.00 X X 0 136030 757 Mike Casdorph Secretary/Treasurer 40.00 5.00 X X 0 101092 757 Margaret Bailey Board Member 1.00 X 0 0 0 Martin Howe Board Member 1.00 X 0 0 0 Paul Howe Board Member 1.00 X 0 0 0 Greg Gordon Board Member 1.00 X 0 0 0 Cynthia Persily Board Member 1.00 X 0 0 0 Joe Elliot Board Member 1.00 X 0 0 0 Nancy M Giaquinto CFO 40.00 X 69346 0 5594 G Eric Carpenter Interim COO 40.00 X 40797 0 2140 Marilou B Patalinjug Tyner Chief Medical Officer 40.00 X 345023 0 5594 Christi L Cooper-Lehki Physician 40.00 X 117775 0 0 Toni B Goodykoontz Physician 40.00 X 328555 0 0 Gregory A Rock Pharmacist 40.00 X 116697 0 0 Paula Herndon Chief Nurse Executive 40.00 X 103244 0 9884 Emmylou McDaniel Advance Nurse Practitioner 40.00 X 109560 0 11915 1230997 237122 36641 6 0 1 0 Security America PO Box 4525 Charleston WV 25364 Security Services 416097 Alpha Technologies PO Box 1114 Scott Depot WV 25560 Contracted IT 119161 2 14756 14756 Patient services 622110 15293830 15293830 15293830 2700 0 2700 2700 2700 Commissary Revenue 722210 20219 20219 Lunch Revenue 722210 18627 18627 Rebates & Other 900099 1915 1915 40761 15352047 15334591 0 2700 644030 298637 345393 7481143 3469006 4012137 1873 869 1004 656870 304591 352279 551287 255632 295655 48585 48585 79314 79314 75872 75872 1528985 708990 819995 108216 50180 58036 610186 282943 327243 1068133 495293 572840 51713 23979 27734 3473 1610 1863 1436885 666284 770601 1210519 561318 649201 238837 110749 128088 Medical Supplies 365007 365007 Healthcare Provider Tax 361413 361413 Repairs & Maintenance 311997 144673 167324 Bad debt expense 175539 175539 118513 54982 63531 17128390 8331695 8796695 0 567506 1016899 32500 17500 1888583 1526895 47399 56121 160530 181321 46031986 2062257 45005291 43969729 1034014 1011918 48735823 47780383 1226918 1885930 5000 35599175 35718418 1124902 1190636 37955995 38794984 X 10779828 8985399 10779828 8985399 48735823 47780383 X -1776343 -18086 X X 0 1 X 1 1 1 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 300000 300000 45324271 1975217 43349054 407715 87040 320675 43969729 Related party payables 1160665 Leases payable 29971 1190636 X 15176508 0 15176508 175539 175539 15352047 16970937 18086 18086 16952851 175539 175539 17128390 Part X, Line 2: HCHI is exempt from Federal and state income taxes under Section 501(c)(3) of the internal Revenue Code and similar state statutes relating to not-for-profit organizations. Accounting principles generally accepted in the United States of America require the management of HCHI to evaluate tax positions taken by HCHI. Management has evaluated HCHI's tax positions and did not become aware of any course of action on services or events that might adversely affect the entity's tax status. Therefore, no provision or liability for income taxes has been included in the financial statements. Part XI, Line 4b - Other Adjustments: Bad debts netted with revenue on financial statements 175,539. Part XII, Line 2d - Other Adjustments: Nondeductible expenses 18,086. Fundraising expenses Part XII, Line 4b - Other Adjustments: Bad debts netted with revenue on financial statements 175,539. 1 1 X 1 X 1 X 1 1 0 0 388240 388240 0.02290 3626625 3626625 9846072 9846072 13860937 13472697 388240 0.02290 13860937 13472697 388240 0.02290 2347825 2347825 0.13850 7250 7250 0.00040 1508 1508 0.00010 4270 4270 0.00030 2755 2755 0.00020 5000 5000 0.00030 2368608 2368608 0.13980 1 131129 1 0 1 1 Highland-Clarksburg Hospital Inc 3 Hospital Place Clarksburg WV 26301 X Inpatient mental health Highland-Clarksburg Hospital Inc 1 0 0 1 X X X X X X X X X 13 1 0 0 1 X http://www.highlandhosp.com/clarksburg/ X 1 13 1 https://highlandhospitalwv.com/health-assessment/ 0 0 1 X 100.000000000000 200.000000000000 1 1 X X X X 1 X https://highlandhospitalwv.com/financial-policy/ X https://highlandhospitalwv.com/financial-policy/ X https://highlandhospitalwv.com/financial-policy/ X X X X X 1 X 0 X X X X 1 X 0 0 Highland-Clarksburg Hospital, Inc. Part V, Section B, Line 5: Interviews were conducted with internal and external stakeholders and included individuals from the following organizations: Clarksburg Mission, Harrison County Commission, Harrison County Chamber of Commerce, Harrison-Clarksburg Health Department, Health Access, Inc. (free clinic), Harrison County Child Advocate Center, Harrison County DHHR, and Harrison County Board of Education. Part V, Section B, Line 16 Financial Assistance Policy Website Availability Highland-Clarksburg Hospital, Inc. Part V, Section B, line 16a website: https://highlandhospitalwv.com/financial-policy/ Highland-Clarksburg Hospital, Inc. Part V, Section B, line 16b website: https://highlandhospitalwv.com/financial-policy/ Highland-Clarksburg Hospital, Inc. Part V, Section B, line 16c website: https://highlandhospitalwv.com/financial-policy/ Part I, Line 7, Column (f): The Bad Debt expense included on Form 990, Part IX, Line 25, Column (A), but subtracted for purposes of calculating the percentage in this column is $ 175,539. Part III, Line 2: The bad debt expense was estimated using a cost-to-charge ratio derived from Worksheet 2 of the Schedule H instructions. Part III, Line 9b: Former patients with delinquent private pay accounts will be notified and given the option of paying the account in full or participating in a predefined monthly payment plan. Former patients will be notified of their financial obligation for services redndered by receiving monthly statements with balance due. Former patients who did not wish to apply during their hospitalization will be given another opportunity to apply for charity care or sliding fee scale financial assistance program during the collection process. All private pay accounts will be reviewed to determine the last date of payment. The colletion specialist will attempt to contact the debtor by phone to setup a payment arrangement. The collection specialist wil also remind the patient or responsible party of the hospital charity care and sliding fee scale financial assistance programs. The collection specialist will document all conversations with the debtor in the patient's billing database. If the patient should apply for the charity care or sliding fee scale financial assistance programs within 240 days from the date of the first billing statement, and it is determined that the patient qualifies for one of the assistance programs, the Hospital's collection representative will contact the collection agency and instruct that the account be removed from collection and that the credit bureau be notified to remove the balance from the patient's credit report. Part VI, Line 2: The Hospital assesses the health care needs of the community it serves by first considering services offered by healthcare providers in the area, population trends, socio-economic demographics and the region's overall sufficiency of mental healthcare providers in the community. The Hospital obtains data from numerous health organizations and conducts interviews with community leaders and hospital staff. This information is used to determine the future health needs of the community. Since the Hospital is a licensed psychiatric hospital, the primary focus is on needs that relate to mental health services. Part VI, Line 4: The Hospital is located in Clarksburg, a north central city of West Virginia, four hours west of Washington, D.C., and less than two hours south of Pittsburgh, Pennsylvania. The Hospital's primary service area consists of the following West Virginia Counties: Harrison, Marion, Upshur, Monongalia, Lewis, Randolph, Wood, Taylor, Barbour and Doddridge. The population of the total service area is projected to steadily increase through 2030. The largest increase in population is projected in Monongalia County. Marion, Randolph, Taylor and Upshur Counties are projected to remain stable during the projection period. Harrison, Lewis and Wood Counties are projected to steadily decline during the period. The estimated 2013 population for the service area was 427,302. Residents of the primary service area are predominantly White/Caucasians (95.99%) followed by Black/African American (1.70%). Housing is generally stable and comparable between the service area and the state. Nearly 22% of West Virginia's veterans live in the service area. The service area and the State of West Virginia has a higher percentage of those below the poverty level than that of the United States. All counties in the service area had a higher percentage of adults living in poverty than the average for the United States which was 14.9%. Monongalia County was 22.6% and the other Counties in the service area were comparable to the statewide average of 17.6%. The median household and family income for the service area Counties ranged from a low in Doddridge County of $31,261 to a high of $42,734. The median income is $40,400 for West Virginia and $53,046 for the United States. 0 0 0 0 0 0 0 0 0 Marilou B Patalinjug Tyner Chief Medical Officer 345023 0 0 0 0 0 0 0 8566 0 353589 0 0 0 Toni B Goodykoontz Physician 328555 0 0 0 0 0 0 0 0 0 328555 0 0 0 Form 990, Part VI, Section B, line 11 The 990 is received from the accounting firm and reviewed by the CEO and CFO to make sure nothing is omitted. The CFO then signs the return and mails it to all regulatory and tax authorities. Form 990, Part VI, Section B, line 12c The Quality Control Director keeps a copy of the policy on file, with all board members signing a copy every year. Also, as situations arise, board members will excuse themselves from any vote that may have a conflict of interest. Form 990, Part VI, Section B, line 15 The board of directors approves compensation for the CEO and CFO using a separate finance committee and comparative data. Form 990, Part VI, Section C, line 18 The organizing documents and the Form 990 are available through direct inquiry of the fiscal office of the organization. Form 990, Part VI, Section C, line 19 The governing documents, conflict of interest policy and the financial statements are available through direct inquiry of the fiscal office of the organization. Form 990, Part XI, line 9: Nondeductible expenses-Penalties -18,086. Form 990, Part XII, Line 2C Highland Hospital Association, a related entity, has a separate finance committee, which oversees the audits of all of the members of Highland Health System, including Highland-Clarksburg Hospital, Inc.