2016-08-13T11:58:05-05:00 2015-09-30 990 2014-10-01 546074580 CARILION TAZEWELL COMMUNITY HOSPITAL CARI 5402245112 PO BOX 12385 ROANOKE VA 240252385 G Robert Vaughan Jr Assistant Treasurer 5402245137 2016-08-13 2014 2016-09-27 15:27:22Z Kathren R Dowdy PO BOX 12385 ROANOKE VA 240252385 15539952 0 X www.carilionclinic.org X 1968 VA The Hospital is committed to better patient care, better community health, and lower cost. 10 7 145 25 0 0 119137 2141 13449843 15353634 4550 4834 481487 179343 14055017 15539952 9330 9844 0 0 5132284 5725842 0 0 0 10027403 11320995 15169017 17056681 -1114000 -1516729 6584156 6511821 15662167 17127019 -9078011 -10615198 X Carilion Tazewell Community Hospital is committed to a common purpose of better patient care, better community health, and lower cost. 0 0 14741287 9844 15498512 See Schedule O.Carilion Tazewell Community Hospital, part of Carilion Clinic, is a not-for-profit healthcare organization committed to improving health outcomes for every patient while advancing the quality of care in the community it serves. This 56-bed hospital primarily serves the counties of Tazewell and Russell in Virginia, and Mercer and McDowell in West Virginia.Carilion Tazewell Community Hospital (CTCH) exists to serve the health care needs of its community, regardless of patient ability to pay. CTCH's acute hospital admitted 617 patients and provided 2,462 days of care during the year. Hospital programs include provision of nursing care; outpatient and inpatient surgical and endoscopic services; and diagnostic imaging services including CT, MRI, and mammography. CTCH provides a number of services targeting the specific health needs of its population, including physical, speech, and occupational therapy programs; home health services; bone density testing; and a cardiac rehab program. CTCH also provides an emergency department with 24-hour care and emergency transportation. With 10,728 visits, CTCH's emergency services are a critical component of the health safety net in its service area, acting as a key health provider for a significant number of uninsured patients who comprise nearly 18% percent of emergency department visits. CTCH supports community screenings and education on chronic disease management, sponsoring 29 events touching more than 718 people. In furtherance of its mission, CTCH provides extensive uncompensated care. Stated at cost, charity, charity-eligible bad debt, and unreimbursed Medicaid costs for the year totaled $1 million. 14741287 1 0 0 1 0 0 0 0 0 0 1 0 0 0 1 1 0 1 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 1 1 1 0 0 1 X 0 0 1 145 1 0 0 0 0 0 0 0 0 0 0 X 10 7 1 1 0 0 1 1 1 1 1 0 0 1 1 1 1 1 1 1 1 0 VA X The Corporation Attn J Wright 5402245112 213 S Jefferson St Roanoke VA 24011 D Michael Hymes Director 1.20 X 0 0 0 Kristie G Williams Director/Hospital Vice President 1.20 48.80 X 0 107895 42974 Peggy L Riley Director 1.20 X 0 0 0 Stephen R Rinehart MD Director 1.20 X 0 0 0 Kathren R Dowdy RN MSN Director/CEO 50.00 X 127731 0 29039 Antony D Roop Director 1.20 X 0 0 0 Heather S Shepardson Director 1.20 48.80 X 0 211884 20370 Nancye K Howell Director/Secretary/Treasurer 1.20 X X 0 0 0 James C Thompson Director/Chair 2.50 2.40 X X 0 7325 0 Charles E Green III Director/Vice Chair 1.20 X X 0 0 0 William J Flattery Director/Hospital Vice President 2.50 47.50 X X 0 294403 72637 Donald B Halliwill Assistant Treasurer/CFO/EVP 0.30 49.80 X 0 499817 226399 Michael D Rorrer MD Chief of Medical Staff 1.20 48.80 X 0 290537 119284 Lauren J Chen Assistant Secretary 1.00 49.00 X 0 51739 22622 G Robert Vaughan Jr Assistant Treasurer/SVP 0.30 49.80 X 0 277333 140269 Nancy Howell Agee CEO 2.00 48.00 X 0 1566770 1858023 Melina Perdue EVP 2.00 48.00 X 0 458395 488133 David Vance Pharmacy Manager 50.00 X 117584 0 17709 Randal Swatzyna Former Officer 0.00 X 0 143462 57238 245315 3909560 3094697 2 1 1 0 Solstas Lab Partners Group LLC PO Box 751337 Charlotte NC 28275 Laboratory Services 954036 MR Ramakrishnan MD 1745 Valley View Drive Big Stone Gap VA 24219 Physician Services 312000 Beck Therapy Services 2013 Bandy Road Cedar Bluff VA 24609 (PT) Therapy Services 208881 Stryker Sales Corporation PO Box 93276 Chicago IL 60673 Equipment Services 105481 4 2141 2141 Net Patient Revenue 622110 15353634 15353634 15353634 4834 4834 34465 0 34465 34465 34465 Affiliate Contract Revenue 900099 137600 137600 Court Cost Recovery 900099 6144 6144 1134 1134 144878 15539952 15498512 0 39299 X 9844 9844 155191 155191 4583222 4535347 47875 238929 238929 406529 396296 10233 341971 341971 1897152 1897152 50 50 1070 1070 2302439 2195406 107033 3154 1865 1289 276038 259334 16704 57443 57443 214882 214882 89245 84558 4687 175439 175439 670456 670456 229672 167750 61922 Bad Debt 3038473 3038473 I/C Practice Subsidy 1685338 1685338 Medical Supplies 642719 642719 Dues & Subscriptions 14793 14523 270 22632 9644 12988 17056681 14741287 2315394 0 925 925 25990 24116 1982358 1686466 1664 76932 60651 16196329 11458330 4486547 4737999 11404 0 6584156 6511821 1020311 991642 25388 43653 14616468 16091724 15662167 17127019 X -9078011 -10615198 -9078011 -10615198 6584156 6511821 X -1516729 -20458 X 0 1 X 1 1 1 X 0 0 0 0 0 0 0 0 1 1070 1070 0 Part II-B, Line 1: A portion of dues paid to the American Hospital Association and Virginia Hospital and Healthcare Association is attributable to lobbying activities. 48753 48753 7070975 4388399 2682576 8417180 6886074 1531106 659421 183857 475564 4737999 Due to Affiliate 15986405 Pension-Qualified Liability/Accrued 105319 16091724 X Part X, Line 2: Carilion had no material unrecognized tax benefits and no adjustments to its consolidated financial statements were required as of and for the years ended September 30, 2015 and 2014. Carilion does not expect that unrecognized tax benefits will materially increase within the next 12 months. 1 1 X 1 X 1 X 0 1 1 0 1 1 941383 941383 0.06720 588377 481299 107078 0.00760 1529760 481299 1048461 0.07480 6 468 8386 0 8386 0.00060 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 6 468 8386 8386 0.00060 6 468 1538146 481299 1056847 0.07540 0 0 0 0 2 250 1691 0 1691 0.00010 3 0 3358 0 3358 0.00020 0 0 0 0 0 0 0 0 18 0 2489 0 2489 0.00010 0 0 0 0 0 0 0 0 0 0 0 0 23 250 7538 7538 0.00040 0 3038473 4279002 4516794 -237792 X 1 1 1 1 Carilion Tazewell Community Hospital 141 Ben Bolt Avenue Tazewell VA 24651 www.carilionclinic.org H 1907 X X X Carilion Tazewell Community Hospital 1 0 0 1 X X X X X X X X X 12 1 0 1 1 X See Part V, Section C X www.carilionclinic.org/about/chna X X 1 12 1 www.carilionclinic.org/about/chna 0 0 1 X 200.000000000000 400.000000000000 X X 1 1 X X X 1 X www.carilionclinic.org X www.carilionclinic.org X www.carilionclinic.org X X X X X 1 X 0 X X X X X 1 X 0 0 Carilion Tazewell Community Hospital Part V, Section B, Line 5: Carilion Clinic's CHNAs are community-driven projects and success is highly dependent on the involvement of citizens, health and human service agencies, businesses, and community leaders. Community stakeholder collaborations known as "Community Health Assessment Teams" (CHAT) lead the CHNA projects. The CHAT consists of health and human service agency leaders, persons with special knowledge of or expertise in public health, the local health department, and leaders, representatives, or members of medically underserved populations, low-income persons, minority populations, and populations with chronic disease.The following organizations served on the CHAT for the 2013 Tazewell Community Health Needs Assessment: Appalachian Agency for Senior Citizens (AASC), Board of Supervisors, Southwest Virginia Community Health Clinic, general dentistry, Health Department, Clinch Valley Medical Center, Bluefield Regional Medical Center, family medicine, Veterans, Local Outpatient Clinic, Four Seasons YMCA, Clinch Valley Community Action, Tazewell County Schools, local pharmacy, Richlands News Press, Lillies of the Field, Department of Social Services, Carilion Tazewell Home Health, Family Crisis, Tazewell Chief of Police, TASK (Taking Action for Special Kids), Crisis Pregnancy (The Abel Crisis Center), Heritage Hall, SWVA Community College, Tazewell Library, Social Services.In addition to the CHAT, the CHNA conducted stakeholder surveys, target population focus groups, and a community health survey. Target population focus groups were conducted with Tazewell Elementary School, Student Center Vocational School (TASK Group), Tazewell Head Start, and the Four Seasons YMCA. The community health survey was made available to residents living in Tazewell. Oversampling of the target populations occurred through targeted outreach efforts. In total, 744 surveys were collected. Carilion Tazewell Community Hospital Part V, Section B, Line 6b: Appalachian Agency for Senior Citizens (AASC), Board of Supervisors, Southwest Virginia Community Health Clinic, general dentistry, Health Department, Clinch Valley Medical Center, Bluefield Regional Medical Center, family medicine, Veterans, Local Outpatient Clinic, Four Seasons YMCA, Clinch Valley Community Action, Tazewell County Schools, local pharmacy, Richlands News Press, Lillies of the Field, Department of Social Services, Carilion Tazewell Home Health, Family Crisis, Tazewell Chief of Police, TASK (Taking Action for Special Kids), Crisis Pregnancy (The Abel Crisis Center), Heritage Hall, SWVA Community College, Tazewell Library, Social Services. Carilion Tazewell Community Hospital Part V, Section B, Line 7d: 7a: www.carilionclinic.org/hospitals/carilion-tazewell-community-hospital.7d: The 2013 Tazewell CHNA was also posted to CHAT partner websites and social media. Carilion Tazewell Community Hospital Part V, Section B, Line 11: Each member of the CHAT in attendance reviewed the list of needs identified from the primary and secondary research and prioritized the top ten issues based upon the magnitude and severity of the need. Then a determination was made as to ability to focus resources on each issue, and the likelihood of improvement. These rankings were analyzed and combined into the following list:1. Substance Abuse Prevalence2. Obesity Prevalence/Lack of Exercise3. Access to Primary Care4. Mental Health Disorders/access to psychiatric services5. High cost of Services to the UninsuredThe findings clearly demonstrate the need to address substance abuse and psychiatric issues, and obesity prevalence, as well as access to primary care. The high cost of services to the uninsured is impactful to vulnerable populations and was seen by the CHAT to have high feasibility to address. To address the needs of the community, Carilion Tazewell Community Hospital will develop a multi-disciplinary team to ensure that resources are aligned with the needs identified during the Community Health Needs Assessment. The team will initially consist of CTCH employees, but add membership from community agencies as needed to ensure improvements are achieved in the identified areas of focus. In addition, the Town and County of Tazewell recently completed a workshop to kickoff a vision for economic development for the area. This project will lead to the creation of a strategic plan for the town. CTCH will actively participate in this project, in particular on the Community Health subgroup. This will provide a forum for alignment of community resources with identified community needs. Activities recommended for this group are very consistent with the CHNA findings: pilot and experiment with approaches to addressing prescription drug abuse and the Tazewell Wellness Movement.Lastly, ongoing processes will be developed to track progress of improvements.Multiple other needs were identified during the CHNA process, including dental care for children, access to vision care, transportation and access to in-home care. Dental care is being addressed via the development of a new dental school, already under development. The process used by the CHAT to prioritize needs identified access to vision, transportation and in-home care as lower priorities. The number of items was limited to the top five so that resources are focused and effective. Carilion Tazewell Community Hospital Part V, Section B, Line 20e: Prior to initiating other actions and in the absence of eligibility information (financial assistance application) provided by the patient, processes were applied to accounts to determine presumptive eligibility for financial assistance. Carilion Tazewell Community Hospital Part V, Section B, Line 22d: Carilion Tazewell Community Hospital determined the maximum amount it could charge FAP-eligible individuals using a look-back method that included information from Medicare, Medicare Advantage, and commercial payors. Part V, Section B, Line 16 Financial Assistance Policy Website Availability Carilion Tazewell Community Hospital Part V, Section B, line 16a website: www.carilionclinic.org Carilion Tazewell Community Hospital Part V, Section B, line 16b website: www.carilionclinic.org Carilion Tazewell Community Hospital Part V, Section B, line 16c website: www.carilionclinic.org Part I, Line 3c: Patients were evaluated based on income, family size, liquid assets and real property. Patients whose income was below 200% of FPG, retirement accounts were below $10,000, remaining liquid assets were below $3,000, with no countable equity in non-residential real property were eligible for 100% adjustment.Patients whose income was above 200% of the FPG but less that 400% of the FPG and/or whose retirement accounts were above $10,000, remaining liquid assets were above $3,000 and had countable equity in non-residential real property were eligible for a discount.Uninsured patient hospital accounts received an Uninsured discount of 20% prior to billing the patient. If the patient qualified under the Financial Assistance Policy, the uninsured discount was reversed. Those patients that qualified for a discount (not 100%) were given a discount based on the amount generally billed calculation and may also receive an additional discount based on the eligibility criteria. Part I, Line 6a: Information on community benefit is reported annually through a consolidated report prepared by Carilion Clinic. Printed copies of this report are distributed throughout communities served by hospitals affiliated with Carilion Clinic. Additionally, the community benefit report is available on Carilion Clinic's website. Part I, Line 7: Ratio of cost-to-charges was used to calculate the expense.Part I, Line 7, column (f) calculation -- Bad debt expense is subtracted from total expenses for the calculation. Part I, Line 7 Part I, Line 7e:Community Health Improvement: This line is calculated at cost. As part of its mission to educate the public about health risks and steps that can be taken to improve health through health fairs and presentations offered at various community locations. These events provide an opportunity to educate individuals about improving health and quality of life. Additional health improvement services include assistance with enrollment in public medical programs such as Medicaid. Community benefit operations include the cost associated with tracking community health improvement activities. Part II Line 2: Economic DevelopmentSupport was provided to the Tazewell Area Chamber of Commerce and Business to Business event. Line 3: Community SupportSupport was provided to United Way of Southwest VA, Four Seasons YMCA, Clinch Valley Community Action, and a shoe drive. Line 6: Coalition BuildingParticipation and in-kind support provided for the Four Season YMCA, Special Needs in Disaster meetings, Children's Day and TRIAD meetings. Part III, Line 2: Carilion Tazewell Community Hospital estimates bad debt expense by reserving a percentage of all self-pay accounts receivable by aging category, based on collection history, adjusted for expected recoveries and, if present, anticipated changes in trends. The percentage used to reserve for all self-pay accounts is based on Carilion's collection history. Part III, Line 4: Accounts receivable are reduced by an allowance for amounts that could become uncollectible in the future. Carilion Tazewell Community Hospital estimates the allowance for doubtful accounts by reserving a percentage of all self-pay accounts receivable by aging category, based on collection history, adjusted for expected recoveries and, if present, anticipated changes in trends. Carilion Tazewell Community Hospital collects substantially all of its third-party insured receivables, which include receivables from governmental agencies. Part III, Line 8: Medicare allowable costs are determined from the Medicare cost report using the cost-to-charges ratio. The Hospital does not consider a Medicare shortfall as a community benefit. Part III, Line 9b: Patient accounts not identified as qualifying for financial assistance under the Financial Assistance Policy and procedures are evaluated against Presumptive eligibility criteria using a third party vendor software prior to moving the accounts to collections at 120 days. Those that qualify as "presumed charity" are adjusted.Patient accounts that are not adjusted to "presumed charity" are sent to the collection agency. The agency delays any extraordinary collections practices for an additional 120 days from the first billing statement. Patients may apply for financial assistance at any time during the 240 day application period. Part VI, Line 2: Needs Assessment:Carilion Clinic's community health improvement process was adapted from Associates in Process Improvement's the Model for Improvement and the Plan-Do-Study-Act (PDSA) cycle developed by Walter Shewhart. It consists of five distinct steps: (1) conducting the CHNA, (2) strategic planning, (3) creating the implementation strategy, (4) program implementation, and (5) evaluation. This cycle is repeated every three years to comply with IRS requirements. Carilion Clinic fosters community development in its CHNA process and community health improvement process by using the Strive Collective Impact Model for the CHAT. This evidence-based model focuses on "the commitment of a group of important players from different sectors to a common agenda for solving a specific social problem(s) and has been proven to lead to large-scale changes. It focuses on relationship building between organizations and the progress towards shared strategies. Carilion also addresses community health needs through health safety-net partnerships, including financial and in-kind assistance through community grants and sponsorships. Part VI, Line 3: Eligibility Assistance:Education of the Financial Assistance Policy is provided to patients at all hospital admission and ambulatory areas in the form of signage, a summary of the policy which includes contact information, available financial assistance applications and is included in the inpatient handbook. Hospital social workers and customer service representatives provide patients with verbal information on availability of assistance. Each patient statement and letters regarding patient financial responsibility includes information on the Financial Assistance Policy and who to contact for additional information. Applications, the Policy and a Plain Language summary are available free of charge to the patient. These items will be mailed to the patient if the patient failed to obtain the documents at the time of service. The Financial Assistance Policy as well as the Plain Language summary and application is available on the web site.Carilion also employs an Eligibility staff that counsel patients on federal and state programs. The staff completes applications for Medicaid, Social Security, Social Security Disability, and Medicare and provides support services in ensuring the applications are processed correctly based on federal and state policy. In addition, the Eligibility staff is Certified Application Counsels and will assist patients in enrollment in the Marketplace. Eligibility staff will also complete Carilion's financial assistance and counsel patients on the requirements for financial assistance. Part VI, Line 4: Community Information:Carilion Tazewell Community Hospital is a 56-bed facility in Tazewell, the county seat and geographic center of this southwest Virginia County, also known as Tazewell. Tazewell County is within the valley and ridge province of the Appalachian Highlands between the Appalachian Mountains on the southeast and the Cumberland Plateau and the Allegheny mountains on the northwest. The county contains 520 square miles and a population of 43,452. Approximately 21.8% of adults under age 64 and 8.7% of children who live in the Tazewell County are uninsured. Additionally, 18.3% of residents live below the poverty level and 23% of adults 25 years of age or older did not graduate from high school. 18.5% of residents are 65 years of age or older. Part VI, Line 5: Promotion of Community Health:Carilion Tazewell Community Hospital serves all patients regardless of their ability to pay. The Hospital's governing Board is elected annually and the majority of members are neither employees nor contractors of the Hospital. Medical staff privileges are extended to qualified providers. In addition to clinical care, the hospital works to achieve its mission through the education of health professionals and the community. Any surplus funds are reinvested in new technology, clinical initiatives, education and charitable efforts. This includes providing free, discounted and subsidized care as well as critical medical services that operate at a loss. Carilion Tazewell Community Hospital has been very involved in the development and implementation of a wellness center through both financial and in-kind support over several years. The Four Seasons YMCA, located on a parcel of land adjacent to the hospital, provides fitness and social activities. Part VI, Line 6: Affiliated System:Carilion Tazewell Community Hospital is wholly owned and operated by Carilion Clinic, a not-for-profit healthcare organization based in Roanoke, Virginia. Through a comprehensive network of hospitals, primary and specialty physician practices and other complementary services, quality care is provided close to home for more than 870,000 Virginians. With an enduring commitment to the health of the region, care is advanced through medical education and research and assistance is provided to help the community stay healthy. Carilion Clinic employs 685 physicians representing more than 70 specialties who provide care at 241 practice sites. To advance education of health professionals, Jefferson College of Health Sciences, within Carilion Medical Center, is a professional health sciences college offering Associate's, Bachelor's, and Master's degree programs. During fiscal year 2015, 800 undergraduate and 262 graduate students were enrolled. Carilion Clinic, through Carilion Medical Center, works in cooperation with Virginia Tech Carilion School of Medicine to provide medical education opportunities to the community. There are 13 accredited residency programs (Carilion / OMNEE Emergency Medicine Dermatology, General Hospital Dentistry, Emergency Medicine, Family Medicine, Internal Medicine, Neurosurgery, Obstetrics/Gynecology, Pediatrics, Plastic Surgery, Podiatry, Psychiatry and Surgery) and 11 accredited fellowship programs (Addiction Psychology, Adult Joint Reconstruction, Cardiovascular Disease, Child and Adolescent Psychiatry, Gastroenterology, Geriatric Medicine, Geriatric Psychiatry, Hospice and Palliative Care, Infectious Disease, Interventional Cardiology, and Pulmonary Critical Care). Advanced clinical technology and programs include CyberKnife Stereotactic Radiosurgery, DaVinci Robotic Surgical System, 60 bed neonatal intensive care unit, hybrid operating room, Carilion Clinic Children's Hospital, Cancer Center, Spine Center, and comprehensive cardiothoracic, vascular and orthopedic surgery programs. Carilion Roanoke Memorial Hospital serves as a Level One Trauma Center with EMS services that include three EMS helicopters, six first-response vehicles and 38 Advanced Life Support Ambulances. An additional benefit to the community is Carilion Clinic's economic contribution to the region. As the area's largest employer, jobs are provided for more than 12,100 residents of the region. 0 1 0 0 0 0 0 0 0 Kristie G Williams Director/Hospital Vice President 0 99128 0 2500 0 6267 0 23483 0 19491 0 150869 0 0 Kathren R Dowdy RN MSN Director/CEO 117479 0 2500 0 7752 0 28266 0 773 0 156770 0 0 0 Heather S Shepardson Director 0 177241 0 34398 0 245 0 18160 0 2210 0 232254 0 0 William J Flattery Director/Hospital Vice President 0 217782 0 67000 0 9621 0 57819 0 14818 0 367040 0 0 Donald B Halliwill Assistant Treasurer/CFO/EVP 0 374141 0 72188 0 53488 0 204059 0 22340 0 726216 0 0 Michael D Rorrer MD Chief of Medical Staff 0 272754 0 12216 0 5567 0 102789 0 16495 0 409821 0 0 G Robert Vaughan Jr Assistant Treasurer/SVP 0 227155 0 44697 0 5481 0 119382 0 20887 0 417602 0 0 Nancy Howell Agee CEO 0 936377 0 281435 0 348958 0 1840194 0 17829 0 3424793 0 341789 Melina Perdue EVP 0 379288 0 72188 0 6919 0 470677 0 17456 0 946528 0 0 David Vance Pharmacy Manager 115988 0 1500 0 96 0 3968 0 13741 0 135293 0 0 0 Randal Swatzyna Former Officer 0 85211 0 7500 0 50751 0 52715 0 4523 0 200700 0 0 Part I, Line 3 Executive compensation, including that of the organization's Chief Executive Officer, is reviewed annually by the Carilion Clinic Compensation Committee. This committee is made up of Board members of Carilion Clinic, a related organization, who do not have a conflict of interest with any of the executives being reviewed. This review was performed in September and October 2014. A similar review was last performed in October 2015. This review included review of a comprehensive report from an outside compensation consultant specializing in healthcare organizations for select positions and the prior year's report on all of the reviewed positions. The reports reviewed by the Committee included a detailed comparison of total compensation and each element thereof, including base salary, bonuses and other cash compensation, and benefits, including deferred and retirement benefits. Compensation was compared to a peer group of organizations similar in size and structure to the organization, which was reviewed by the Compensation Committee. Detailed minutes of the meetings of the Compensation Committee are kept and approved at the next meeting of the Committee, setting forth the deliberations and decisions regarding executive compensation. Part I, Line 4b Select members of management participate in a Pension Restoration Plan. This plan provides a benefit equal to the normal retirement benefit that would be payable to the participant were it not for the Qualified plan's legislative restrictions on compensation and payable benefits, less the actual benefits under the Qualified plan. Entitlement to benefits and consequent lump sum payment occurs upon the earliest of (i) attaining age 65 while employed by Carilion Clinic, (ii) 24 months following involuntary separation from service without reasonable cause, (iii) disability, or (iv) voluntary separation or involuntary separation with reasonable cause prior to attaining age 65 if the participant does not enter into competition with Carilion Clinic during the 24-month period following the participant's separation from service. Upon the death of the participant, the plan shall pay the participant's beneficiary according to plan terms. Select members of management participate in an Executive Flexible Benefit Plan, in which an allowance is provided to the participant for use in obtaining certain insurance benefits. The allowance is determined annually as a percentage of salary at Carilion Clinic's discretion. The amount of allowance in excess of elected benefits is credited to a capital accumulation account (CAA) with a deferred vesting date of at least two years from the first day of the plan year. The CAA shall be distributed in a lump sum upon the earliest of (i) remaining employed by Carilion until the deferred vesting date for such account; (ii)disability; (iii) 24 months following involuntary separation from service without reasonable cause, except that Carilion at its discretion may make a partial tax distribution upon separation; or (iv) 24 months following voluntary or involuntary separation from service with reasonable cause if the participant does not enter into competition with Carilion Clinic during the 24-month period following separation from service. Upon the death of the participant, the plan shall pay the participant's beneficiary according to plan terms. Select members of management participate in a Defined Contribution Supplemental Executive Retirement Plan (DC SERP) in which the employer at the discretion of Carilion Clinic's Compensation Committee makes a contribution to an account established on its books for each eligible participant. If a participant ceases to be a participant prior to the vesting date, the account shall be forfeited. A lump sum distribution shall be made upon the participant's vesting date, death, or disability. Payments during the calendar year under these plans included the following: Nancy Howell Agee $341,789 Form 990, Part I, Line 6 Volunteers staff the gift shop and volunteer in various departments doing clerical work, supporting community events, and service related tasks. Form 990, Part V, Line 1a 1099s are issued on Carilion Tazewell Community Hospital's behalf by Carilion Services, Inc., a related organization providing management and administrative services, including payment processing. Form 990, Part VI, Section A, line 1 The organization has one member. The sole member, Carilion Clinic, is entitled to elect one class of directors having 80% of the vote on any issue. The remaining class of directors, which has 20% of the vote on any issue, come from the local community and elect their own successors. Certain actions require the majority vote of both classes. Form 990, Part VI, Section A, line 2 1. Nancy Howell Agee, Lauren J. Chen, Donald B. Halliwill, Melina D. Perdue, Heather S. Shepardson, G. Robert Vaughan, Jr., William J. Flattery, and Kristie G. Williams - Business relationship due to each serving as officers, directors, and/or employees of the same related organizations. Form 990, Part VI, Section A, line 3 Certain management and related services for the organization are provided by the management and employees of Carilion Services, Inc., a related and supporting organization of the filing organization. Form 990, Part VI, Section A, line 6 The organization has a single member. The sole member is Carilion Clinic, a charitable tax-exempt organization which serves as the parent company of the Carilion Clinic integrated health care delivery system. The sole member is entitled to elect directors having 80% of the vote on any issue. Form 990, Part VI, Section A, line 7a The organization has one member. The sole member, Carilion Clinic, is entitled to elect one class of directors having 80% of the vote on any issue. The remaining class of directors, which has 20% of the vote on any issue, come from the local community and elect their own successors. Form 990, Part VI, Section A, line 7b Under the laws of the Commonwealth of Virginia, certain extraordinary actions require member approval, such as mergers, consolidations, liquidations, and the sale of substantially all of the assets of the organization. Form 990, Part VI, Section B, line 11 The Form 990 is prepared by Carilion's internal Tax Department and reviewed by internal Accounting management. Several days prior to filing, all Board Members are notified by email of its availability on Carilion's Board portal and encouraged to call with any questions they might have. Form 990, Part VI, Section B, line 12c Our organization monitors and reviews proposed and current transactions for conflicts on interest in a variety of ways. At the governing board level, we have board members complete an initial (upon appointment) and annual conflict of interest questionnaire to disclose actual or potential conflicts. Board members are required to update their disclosure as needed in between questionnaires. All disclosures are reviewed by the Organizational Integrity & Compliance Office and as needed escalated to the appropriate leaders/board members for further discussion/review. If a disclosure is viewed as an actual or potential conflict, an action is recommended to the Audit & Compliance Committee of the Carilion Clinic Board and are implemented as approved. Actions can include recusal in discussion/voting at board meetings, limitation/termination of the transaction, removal from board appointment or other appropriate controls. In addition, at any time, board members are encouraged to disclose any potential conflicts as they arise at a board meeting and to recuse themselves as deemed appropriate. The same process takes place as described above for key employees (upon hire and annually thereafter), including all Officers, members of the management team, physicians/mid-level practitioners, pharmacists and key supply chain buyers. After review and further discussion as needed, action may be required to manage an actual conflict or to reduce the appearance of such as approved by Organizational Integrity & Compliance Office and other key management team members. As needed, the governing board leaders are notified of any conflicts which may impact board proceedings. Form 990, Part VI, Section B, line 15 Executive compensation is reviewed annually by the Carilion Clinic Compensation Committee. This committee is made up of Board members of Carilion Clinic who do not have a conflict of interest with any of the executives being reviewed. With respect to Carilion Clinic, the Compensation Committee reviews the compensation of the Board of Governors which includes the President and Chief Executive Officer, Executive Vice Presidents, Chief Financial Officer, Chief Medical Officer, and Chairs of the Clinical Departments. For the fiscal year covered by this return, the Compensation Committee also used the same process to review the compensation of other Disqualified Individuals, including the Hospital Vice Presidents. This review was performed in September and October 2014. A similar review was last performed in October 2015. This review included review of a comprehensive report from an outside compensation consultant specializing in healthcare organizations for select positions and the prior year's report on all of the reviewed positions. The reports reviewed by the Committee included a detailed comparison of total compensation and each element thereof, including base salary, bonuses and other cash compensation, and benefits, including deferred and retirement benefits. Compensation was compared to a peer group of organizations similar in size and structure to the organization, which list was reviewed by the Compensation Committee. Detailed minutes of the meetings of the Compensation Committee are kept and approved at the next meeting of the Committee, setting forth the deliberations and decisions regarding the compensation of these executives. In addition, the Compensation Committee annually reviews the compensation plan and philosophy for all vice presidents and senior vice presidents, as well as all employed physicians and physicians in leadership roles. Form 990, Part VI, Section C, line 19 The organization's governing documents, conflict of interest statement and financial statements are not generally available to the public, but are released from time to time upon request. The Articles of Incorporation are available from the Virginia State Corporation Commission. The consolidated audited financial statements of Carilion Clinic and of the Obligated Group are released annually to the local newspaper. Limited financial information is available on our website. Form 990, Part IX, Line 11g Column B Professional/ Physcian Services: $1,548,655 Purchase Services: $267,372 Contract Fees/Consulting: $34,629 Patient Transportation: $1,240 Repairs and Maintenance: $343,510 Total Other Fees Column B: $2,195,406 Form 990, Part IX, Line 11g Column C Purchase Services: $107,033 Total Other Fees Column C: $107,033 Form 990, Part XI, line 9: Pension-Related Changes -20,458. Carilion Clinic PO Box 12385 Roanoke VA 24025 541190771 Supporting organization VA 501(c)(3) Line 11a, I N/A 0 Carilion Clinic Foundation PO Box 12385 Roanoke VA 24025 541190773 Supporting organization VA 501(c)(3) Line 11b, II Carilion Clinic 1 Carilion Franklin Memorial Hospital PO Box 12385 Roanoke VA 24025 540480606 Healthcare VA 501(c)(3) Line 3 Carilion Clinic 1 Carilion Giles Community Hospital PO Box 12385 Roanoke VA 24025 540549603 Healthcare VA 501(c)(3) Line 3 Carilion Clinic 1 Carilion Medical Center PO Box 12385 Roanoke VA 24025 540506332 Healthcare VA 501(c)(3) Line 3 Carilion Clinic 1 Carilion New River Valley Medical Center PO Box 12385 Roanoke VA 24025 540553805 Healthcare VA 501(c)(3) Line 3 Carilion Clinic 1 Carilion Services Inc PO Box 12385 Roanoke VA 24025 541190879 Supporting organization VA 501(c)(3) Line 11a, I Carilion Clinic 1 Carilion Stonewall Jackson Hospital PO Box 12385 Roanoke VA 24025 540568001 Healthcare VA 501(c)(3) Line 3 Carilion Clinic 1 Carilion Clinic Medicare Shared Savings Company LLC PO Box 12385 Roanoke VA 24025 455235473 Medicare HMO VA 0 0 Franklin County Ventures LLC PO Box 12385 Roanoke VA 24025 474365316 Real estate VA 0 0 Community Medical Associates LLP PO Box 12385 Roanoke VA 24025 541517662 Real estate VA 0 0 Carilion Clinic Medicare Resources LLC PO Box 12385 Roanoke VA 24025 263729975 Medicare HMO VA C 1 CHS Inc PO Box 12385 Roanoke VA 24025 541725732 Services VA C 1 Carilion Behavioral Health Inc PO Box 12385 Roanoke VA 24025 203136891 Healthcare VA C 1 Carilion Emergency Services Inc PO Box 12385 Roanoke VA 24025 542033006 Healthcare VA C 1 SCA Credit Services Inc PO Box 12385 Roanoke VA 24025 541180398 Collection agency VA C 1 Carilion Healthcare Corporation PO Box 12385 Roanoke VA 24025 541586601 Healthcare VA C 1 MedKey Inc PO Box 12385 Roanoke VA 24025 541645357 Financing services VA C 1 0 0 0 0 1 0 0 0 0 0 0 1 1 0 0 0 0 0 0 CHS Inc E 1477164 Cash Carilion Medical Center L 137600 Cost Carilion Medical Center M 1792185 Cost Carilion Services Inc M 2118901 Cost CHS Inc M 248921 Cost