2015-05-14T13:22:33-05:00 2014-06-30 560747981 DIXON HUGHES GOODMAN LLP PO BOX 1556 MORGANTOWN WV 265071556 990 2013-07-01 237441353 MONONGALIA COUNTY GENERAL HOSPITAL CO MONO 3045981242 1200 JD ANDERSON DRIVE MORGANTOWN WV 26505 DARIS ROSENCRANCE SR VP FINANCE/CFO 3045981242 2015-05-14 1 SUSAN S DULL P00233523 3042927343 2013 2016-02-25 16:41:14Z DARIS ROSENCRANCE 1200 JD ANDERSON DRIVE MORGANTOWN WV 26505 242996348 0 X WWW.MONHEALTHSYS.ORG X 1972 WV TO DELIVER THE BEST HEALTHCARE AND REMAIN THE PROVIDER OF CHOICE IN OUR REGIONAL SERVICE AREA BECAUSE OF OUR QUALITY, RESPECT, INTEGRITY, AND CREATIVITY, AS WELL AS OUR DEDICATION TO PATIENT SAFETY. 12 11 1783 250 1093190 -94559 2219507 1128571 227884607 237924600 1810479 2201284 -49392 -18097 231865201 241236358 610931 0 0 0 99936348 101756605 0 0 0 124304216 127223552 224851495 228980157 7013706 12256201 287523818 301279181 183547571 177290021 103976247 123989160 TO DELIVER THE BEST HEALTHCARE. 0 0 89673507 114460378 MONONGALIA GENERAL HOSPITAL CO. (MGH) PROVIDES A WIDE ARRAY OF OUTPATIENT SERVICES INCLUDING EMERGENCY DEPARTMENT (30,261 VISITS), OUTPATIENT SURGERY (10,002 SURGERIES), OUTPATIENT ORTHOPEDIC SURGERY (2,062 SURGERIES), PHYSICIAN OFFICES (43,537 VISITS), AND MANY OTHER SERVICES. SOME OTHER SERVICES INCLUDE CARDIAC CATHERIZATION, CT SCAN, MRI, NUCLEAR MEDICINE, AND ULTRASOUND. 81374639 103867601 MGH IS LICENSED FOR 189 INPATIENT BEDS WHICH ARE ALL PRIVATE ROOMS. MGH HAD 8,362 DISCHARGES FOR THE YEAR WITH A TOTAL OF 35,036 PATIENT DAYS. THERE WAS A NEW FAMILY BIRTH CENTER OPENED AND MGH HAD 1,110 DELIVERIES FOR THE YEAR. INPATIENT GENERAL SURGERY (2,025), ORTHOPEDIC SURGERY (1,342), AND OPEN HEART SURGERY (377) ARE ALSO OFFERED. 14496436 18503431 MGH HAS AN EMERGENCY DEPARTMENT SERVING MONONGALIA AND SURROUNDING COUNTIES WITH A TOTAL OF 29,721 VISITS DURING THE YEAR. 185544582 1 1 0 0 0 0 0 0 0 0 1 1 0 1 1 1 0 1 0 0 0 0 0 0 0 0 1 1 0 0 1 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 1 1 0 0 1 140 0 1 1783 1 0 0 0 0 0 0 0 0 X 12 11 0 0 0 0 0 0 0 1 1 0 0 1 1 1 1 1 1 1 1 1 1 WV X ZACH KERNS CONTROLLER 3045981242 1200 JD ANDERSON DRIVE MORGANTOWN WV 26505 DARRYL DUNCAN PRESIDENT/CEO 20.00 20.00 X X 0 478142 126630 SISTER NANCY WHITE TREASURER/SECRETARY 2.00 2.00 X X 0 0 0 GLENN ADRIAN DIRECTOR 2.00 2.00 X 0 0 0 TERRY SHAFFER DIRECTOR 2.00 2.00 X 0 0 0 PATRICK MARTIN DIRECTOR 2.00 2.00 X 0 0 0 JOHN BATTIN MD DIRECTOR 2.00 2.00 X 0 0 0 NATALIE STONE DIRECTOR 2.00 2.00 X 0 0 0 SARAH MINEAR CHAIRPERSON/DIRECTOR 2.00 2.00 X X 0 0 0 VINCE KOLANKO MD DIRECTOR 2.00 2.00 X 0 0 0 CAROL RUSHFORD DIRECTOR 2.00 2.00 X 0 0 0 ROGER KING MD DIRECTOR 2.00 2.00 X 0 0 0 HELEN BLEVINS DIRECTOR 2.00 2.00 X 0 0 0 DARIS ROSENCRANCE SENIOR VP FINANCE/CFO 20.00 20.00 X 0 289248 41134 KEE LEE SURGEON 40.00 X 697132 0 18300 FAISAL BUKEIRAT SURGEON 40.00 X 417511 0 33086 ALEXANDER NAGY SURGEON 40.00 X 624955 0 39086 WILLIAM C MCBEE SURGEON 40.00 X 813339 0 33942 JAMIE LESNOCK SURGEON 40.00 X 460447 0 38336 3013384 767390 330514 65 0 1 0 AAWV-MGH LLC PO BOX 3466 CHARLESTON WV 25334 ANESTHESIA GROUP 1756402 KAUFMAN HALL & ASSOCIATES 75 REMITTANCE DR SUITE 1030 CHICAGO IL 60675 CONSULTANTS 1031449 SPECIALTYCARE CARDIOVASCULAR PO BOX 11407 BIRMINGHAM AL 352461614 MEDICAL PROFESSIONAL SERVICE 949431 PARIS HEALTHCARE LINEN SERVICE 67 HOOVER AVENUE DUBOIS PA 15801 LINEN SERVICE 770189 SANJAY BHARTI MD PLLC 177 WINDWOOD DRIVE MORGANTOWN WV 26505 HOSPITALIST GROUP SERVICES 538542 19 1128571 1128571 PATIENT SERVICE REVENUE 621990 145118167 145118167 MEDICARE/MEDICAID REVENUE 621990 90753592 90753592 OUTSIDE LAB SERVICES 621500 1093190 1093190 OTHER PROGRAM REVENUE 621990 959651 959651 237924600 531598 531598 1994549 12500 296722 40641 1697827 -28141 1669686 1669686 1404530 1422627 -18097 -18097 241236358 236831410 1093190 2183187 78115035 62492028 15623007 5341033 4272826 1068207 12787815 10230252 2557563 5512722 4410178 1102544 863948 863948 63271 63271 404083 404083 11266683 6760010 4506673 1144459 572230 572229 3570246 2142148 1428098 4864735 2918841 1945894 2554888 2043910 510978 37653 15061 22592 14248 5699 8549 5854969 5093823 761146 14342688 7171344 7171344 2783130 1391565 1391565 MEDICAL SUPPLIES & EQUI 51312126 51312126 BAD DEBTS 13340034 13340034 MEDICAID TAX 5873058 5873058 EQUIPMENT RENTAL & MAIN 3442609 2754087 688522 5490724 2745362 2745362 228980157 185544582 43435575 0 6549178 9848558 8689917 8277514 31764398 41468533 5723970 6422710 2543555 2265221 269231718 144474241 132774209 124757477 81255797 89511002 18222794 18728166 287523818 301279181 17399896 18525100 100452515 99092466 13450000 13225000 52245160 46447455 183547571 177290021 X 96980399 116744131 6610107 6859018 385741 386011 103976247 123989160 287523818 301279181 X 12256201 7444736 311976 X 0 1 X 1 1 1 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 162676642 66530718 96145924 106384863 77943523 28441340 170213 170213 124757477 INVESTMENTS - LEVEL 2 89511002 F 89511002 UNAMORTIZED BOND ISSUE COSTS 1226335 RECEIVABLES-PATIENTS-SPECIAL PAYMENT ARRANGEMENTS 1536175 OTHER RECEIVABLES 3107015 DUE FROM AFFILIATED ENTITES 248678 RESTRICTED INTEREST IN FOUNDATION MON GENERAL HOSPITAL 12151513 PHYSICIAN LOANS RECEIVABLE 458450 18728166 ACCRUAL FOR ESTIMATED PROFESSIONAL AND GENERAL LIABILITY COSTS 5793313 DUE TO MONONGALIA HEALTH SYSTEM, INC. 318402 INTEREST RATE SWAP AGREEMENT 10802537 ACCRUED PENSION COSTS 28355383 UNAMORTIZED BOND PREMIUM 630176 CAPITAL LEASE 547644 46447455 X 236939943 7444736 -13031855 -5587119 242527062 404083 -1694787 -1290704 241236358 216927030 1694787 1694787 215232243 404083 13343831 13747914 228980157 PART X, LINE 2: THE HOSPITAL FOLLOWS THE FASB'S AUTHORITATIVE GUIDANCE ON ACCOUNTING FOR UNCERTAINTY IN INCOME TAXES. THE GUIDANCE CLARIFIES THE ACCOUNTING FOR THE RECOGNITION AND MEASUREMENT OF THE BENEFITS OF INDIVIDUAL TAX POSITIONS IN THE FINANCIAL STATEMENTS. TAX POSITIONS MUST MEET A RECOGNITION THRESHOLD OF MORE-LIKELY-THAN-NOT IN ORDER FOR THE BENEFIT OF THOSE TAX POSITIONS TO BE REOCOGNIZED IN THE FINANCIAL STATEMENTS. THE HOSPITAL HAS DETERMINED THAT NO MATERIAL UNRECOGNIZED TAX BENEFITS OR OBLIGATIONS EXIST AS OF JUNE 30, 2014. PART XI, LINE 2D - OTHER ADJUSTMENTS: BAD DEBT NETTED WITH REVENUE ON AUDITED FINANCIAL STATEMENTS -13,340,034. MINIMUM PENSION OBLIGATION REDUCTION 22,298. CHANGE IN FAIR VALUE OF INTEREST RATE SWAPS -292,426. CHANGE IN BENEFICIAL INTEREST IN FOUNDATION 582,104. OTHER RECLASSES OF MISCELLANEOUS REVENUE AND EXPENSE -3,797. PART XI, LINE 4B - OTHER ADJUSTMENTS: COST OF CAFETERIA FOOD NETTED WITH REVENUE ON FORM 990 -1,422,627. EMPLOYEE DISCOUNTS ON CAFETERIA PURCHASES INCL. IN EMPLOYEE BENEFITS ON 990 -272,160. PART XII, LINE 2D - OTHER ADJUSTMENTS: EMPLOYEE DISCOUNTS ON CAFETERIA PURCHASES INCL. IN EMPLOYEE BENEFITS ON 990 272,160. CHANGE IN BENEFICIAL INTEREST IN FOUNDATION COST OF CAFETERIA FOOD NETTED WITH REVENUE ON FORM 990 1,422,627. PART XII, LINE 4B - OTHER ADJUSTMENTS: BAD DEBT NETTED WITH REVENUE ON AUDITED FINANCIAL STATEMENTS 13,340,034. OTHER RECLASSES OF MISCELLANEOUS REVENUE AND EXPENSE 3,797. 1 1 1 X 0 1 1 0 1 1 2437388 2437388 0.01060 22393115 7800691 14592424 0.06370 24830503 7800691 17029812 0.07430 632077 632077 0.00280 632077 632077 0.00280 25462580 7800691 17661889 0.07710 0 5050567 505057 56027946 67169059 -11141113 X 1 1 1 1 MONONGALIA GENERAL HOSPITAL 1200 JD ANDERSON DRIVE MORGANTOWN WV 26505 X X X MONONGALIA GENERAL HOSPITAL 1 1 X X X X X X X X 13 1 1 1 X HTTP://MONGENERAL.COM/MAIN/HOME.ASPX X X X X X X 0 0 1 1 200.000000000000 0 1 X X X 1 1 X X X X 1 0 X X X 1 X 0 0 MONONGALIA GENERAL HOSPITAL PART V, SECTION B, LINE 3: THE CONSULTANT ASSISTING WITH THE CHNA IDENTIFIED KEY INFORMANTS FROM A VARIETY OF SECTORS INCLUDING PUBLIC HEALTH AND MEDICAL PROVIDERS, COMMUNITY RESOURCES, AND RELIGIOUS ORGANIZATION. MONONGALIA GENERAL HOSPITAL PART V, SECTION B, LINE 7: MONONGALIA COUNTY GENERAL HOSPITAL (MGH) WAS NOT ABLE TO ADDRESS ALL OF THE NEEDS IDENTIFIED IN THE COMMUNITY HEALTH NEEDS ASSESSMENT DUE TO VARIOUS REASONS. MENTAL HEALTH AND DRUG ABUSE WERE MAJOR CONCERNS RAISED IN THE ASSESSMENT. HOWEVER, THE HOSPITAL DOES NOT OFFER THESE SERVICES. THE ASSESSMENT WAS CO-SPONSORED WITH THE WEST VIRGINIA UNIVERSITY HOSPITALS (WVUH), ANOTHER HOSPITAL IN THE COMMUNITY. WVUH OWNS A REGIONAL REFERRAL CENTER FOR TREATMENT OF PSYCHIATRIC ILLNESS AND DRUG ADDICTION. MGH BELIEVES WVUH IS BETTER SUITED TO ADDRESS THE MENTAL HEALTH AND DRUG ADDICTION NEEDS IDENTIFIED IN THE COMMUNITY. MONONGALIA GENERAL HOSPITAL PART V, SECTION B, LINE 20D: THE HOSPITAL IS SUBJECT TO MEDICARE REGULATIONS THAT REQUIRE PARTICIPATING HOSPITALS TO CHARGE ALL PATIENTS THE SAME FOR THE SAME SERVICES. THE HOSPITAL IS ALSO SUBJECT TO RATE REVIEW BY THE WEST VIRGINIA HEALTHCARE AUTHORITY. UNDER RATE REVIEW THE HOSPITAL ANNUALLY SUBMITS A RATE APPLICATION, ALONG WITH THE CHARGEMASTER, FOR APPROVAL. THOUGH CHARGES ARE THE SAME FOR EACH PATIENT, THE AMOUNT BILLED TO INDIVIDUAL PATIENTS IS DETERMINED BASED ON NEGOTIATED RATE FOR INSURED PATIENTS, A 20% DISCOUNT FOR PRIVATE PAY PATIENTS, AND NO CHARGES FOR THOSE ELIGIBLE UNDER THE FINANCIAL ASSISTANCE POLICY. THE HOSPITAL DOES NOT MAINTAIN A SLIDING FEE SCALE. FOR THOSE PATIENTS THAT ARE ELIGIBLE UNDER THE FINANCIAL ASSISTANCE POLICY (LESS THAN 200% FEDERAL POVERTY GUIDELINES), 100% OF CHARGES ARE WRITTEN OFF, THUS CHARGING THOSE ELIGIBLE INDIVIDUALS $0. PART I, LINE 7: THE HOSPITAL USED A COST-TO-CHARGE RATIO DERIVED FROM THE MEDICARE COST REPORT FOR TOTAL PROGRAM COSTS AND TOTAL PROGRAM CHARGES TO ESTIMATE THE OVERALL COST-TO-CHARGE RATIO (CCR). THIS CCR WAS USED IN COMPUTATIONS FOR UNREIMBURSED MEDICAID AND CHARITY CARE. PART III, LINE 2: THE AMOUNT OF BAD DEBT EXPENSE IS CALCULATED BY APPLYING THE COST-TO-CHARGE RATIO TO THE CHARGES WRITTEN OFF TO BAD DEBT DURING THE TAX YEAR. RECOVERIES OF PREVIOUSLY WRITTEN OFF PATIENT RECEIVABLES ARE RECORDED WHEN RECEIVED. THE HOSPITAL DOES NOT REQUIRE COLLATERAL OR OTHER SECURITY ON ITS RECEIVABLES. PART III, LINE 3: THE HOSPITAL USES A CONSULTANT TO REVIEW THE HOSPITAL'S BAD DEBT ACCOUNTS. THE CONSULTANT USES A PROPRIETARY PRESUMPTIVE ELIGIBILITY PREDICTIVE MODEL THAT INCORPORATES PUBLIC RECORD DATA TO CALCULATE A SOCIO-ECONOMIC AND FINANCIAL CAPICITY SCORE WHICH IS THEN USED TO CLASSIFY PATIENTS THAT WOULD LIKELY MEET THE FINANCIAL ASSISTANCE GUIDELINES HAD THEY FILLED OUT THE NECESSARY PAPERWORK. THE HOSPITAL APPLIED THIS PERCENTAGE TO THE BAD DEBT (AT COST) TO ESTIMATE THE TOTAL DOLLAR AMOUNT OF BAD DEBT EXPENSE ATTRIBUTABLE TO PATIENTS ELIGIBLE UNDER THE FINANCIAL ASSISTANCE POLICY. THE COMMUNITY IN THE HOSPITAL'S SERVICE AREA DEPENDS ON THE HOSPITAL TO DELIVER HEALTH CARE AND MEET THEIR MEDICAL NEEDS REGARDLESS OF ABILITY TO PAY, HEALTH INSURANCE STATUS, OR MEDICARE COVEREAGE OF COST FOR PROVIDING THE NEEDED SERVICES. THE HOSPITAL FEELS THAT THIS PORTION OF BAD DEBTS SHOULD BE CONSIDERED AS A COMMUNITY BENEFIT. PART III, LINE 4: TEXT OF AUDITED FINANCIAL STATEMENTS: PATIENT ACCOUNTS RECEIVABLE ARE CARRIED ON THE BASIS OF TOTAL PATIENT CHARGES. THE ALLOWANCES INCLUDE ESTIMATES FOR ACCOUNTS, WHICH MAY ULTIMATELY PROVE UNCOLLECTIBLE, AND THIRD PARTY CONTRACTUAL AND DISCOUNT ARRANGEMENTS. MANAGEMENT DETERMINES THE ALLOWANCE FOR UNCOLLECTIBLE ACCOUNTS BY IDENTIFYING ESTIMATED THIRD PARTY CONTRACTUAL DISCOUNTS AND ALLOWANCES AND BY USING HISTORICAL EXPERIENCE APPLIED TO AN AGING OF ACCOUNTS. PATIENT RECEIVABLES ARE WRITTEN OFF WHEN DEEMED UNCOLLECTIBLE. PART III, LINE 8: MEDICARE ALLOWABLE COSTS WERE CALCULATED USING A COST-TO-CHARGE RATIO. THE COSTS ARE ALLOCATED TO THE VARIOUS DEPARTMENTS USING A STEP-DOWN APPROACH AND REMOVING ANY COSTS THAT ARE NOT ALLOWABLE UNDER MEDICARE RULES.THE ORGANIZATION IS A TAX EXEMPT, NOT-FOR-PROFIT ENTITY THAT SERVES MONONGALIA AND SURROUNDING COUNTIES' PATIENT POPULATION REGARDLESS OF THEIR MEANS TO PAY OR HEALTH INSURANCE STATUS. MEDICARE PATIENTS IN THE HOSPITAL'S SERVICE AREA DEPEND ON THE ORGANIZATION TO DELIVER THEIR HEALTH CARE AND MEET THEIR MEDICAL NEEDS REGARDLESS OF MEDICARE COVERAGE OF COST FOR PROVIDING THE NEEDED SERVICE. SINCE THE ORGANIZATION CONSTANTLY WORKS TO OPERATE AS COST EFFICIENTLY AS POSSIBLE, THE HOSPITAL FEELS STRONGLY THAT THE MEDICARE SHORTFALL SHOULD BE INCLUDED AS A COMMUNITY BENEFIT. PART III, LINE 9B: THERE ARE PROVISIONS IN THE DEBT COLLECTION POLICY TO BE FOLLOWED FOR PATIENTS KNOWN TO QUALIFY FOR CHARITY CARE OR FINANCIAL ASSISTANCE. THE POLICY STATES THAT FINANCIAL ASSISTANCE SHALL BE OFFERED TO THE ORGANIZATION'S UNINSURED AND UNDERINSURED PATIENTS ON A NONDISCRIMINATORY BASIS TO MEET THE NEEDS OF THE COMMUNITY. CHARITY CARE REQUESTS WILL BE REVIEWED AND EVALUATED BY THE CFO AND DIRECTOR OF PATIENT ACCOUNTING FOR APPROVAL. PATIENTS THAT QUALIFY FOR 100% CHARITY CARE ARE NOT PURSUED FOR COLLECTION. PATIENTS THAT QUALIFY FOR PARTIAL ASSISTANCE HAVE THEIR BALANCE REDUCED ACCORDINGLY AND NORMAL COLLECTION EFFORTS ARE USED TO COLLECT THE BALANCE. PART VI, LINE 2: THE NEEDS OF THE COMMUNITY WERE ASSESSED BASED ON DISCUSSIONS AMONGST MANAGEMENT AND BOARD MEMBERS DURING BOARD AND COMMITTEE MEETINGS. THE BOARD OF DIRECTORS IS SELECTED FROM A CROSS-SECTION OF COMMUNITY MEMBERS, WHICH PROVIDES OPINIONS FROM VARYING DEMOGRAPHICS. PART VI, LINE 3: THE ORGANIZATION HAS FINANCIAL COUNSELORS AVAILABLE TO EDUCATE PATIENTS ON THE ELIGIBILITY OF ASSISTANCE. PART VI, LINE 4: THE ORGANIZATION SERVES PRIMARILY MONONGALIA COUNTY; HOWEVER, THERE IS UTILIZATION BY MANY SURROUNDING COUNTIES AS WELL. MONONGALIA COUNTY HAS APPROXIMATELY 100,000 RESIDENTS, OF WHICH A SIZEABLE PORTION ARE STUDENTS AT WEST VIRGINIA UNIVERSITY (SOME BUT NOT ALL OF THE 30,000 ARE INCLUDED IN THE COUNT). MONONGALIA COUNTY IS PROJECTED TO GROW OVER THE NEXT FIVE YEARS, AS OPPOSED TO THE STATE OF WEST VIRGINIA WHICH IS PROJECTED TO DECLINE IN POPULATION. THE COUNTY'S RACIAL AND ETHNIC CHARACTERISTICS ARE FAIRLY SIMILAR TO THE NATION AS A WHOLE, WITH APPROXIMATELY 9% IDENTIFIED AS MINORITIES. THE COUNTY'S MEDIAN HOUSEHOLD INCOME IS HIGHER THAN THAT OF WV, BUT LESS THAN THE U.S. AS A WHOLE. THE COUNTY ALSO HAS A LOWER UNEMPLOYMENT RATE THAN WV AND LOWER THAN THE U.S. AS A WHOLE. THERE IS CURRENTLY ONE OTHER HOSPITAL SERVING MONONGALIA COUNTY AND THERE ARE NO FEDERALL MEDICALLY UNDERSERVED AREAS OR POPULATIONS PRESENT IN THE COMMUNITY. PART VI, LINE 5: THE ORGANIZATION HAS AN OPEN MEDICAL STAFF SERVING A MULTITUDE OF SPECIALITIES. THE BOARD OF DIRECTORS IS COMPRISED OF VARIOUS MEMBERS OF THE COMMUNITY AS REQUIRED UNDER ITS BY-LAWS. AN EXAMPLE OF THE ORGANIZATION USING ITS SURPLUS FUNDS IS THROUGH SPONSORSHIP OF AN ANNUAL HEALTH FAIR AT THE LOCAL MALL, IN WHICH THOUSANDS OF CITIZENS FROM THE LOCAL COMMUNITY COME TO LEARN ABOUT SERVICES OFFERED AND ARE PROVIDED THE OPPORTUNITY TO RECEIVE MULTIPHASIC BLOODWORK FOR A NOMINAL FEE. PART VI, LINE 6: THE ORGANIZATION IS PART OF MONONGALIA HEALTH SYSTEMS, INC. WHICH INCLUDES THE FOLLOWING OTHER HEALTH CARE ENTITIES IN THE COMMUNITY: MONONGALIA EMERGENCY MEDICAL SERVICES, INC., MON ELDER SERVICES, INC. DBA THE VILLAGE AT HERITAGE POINT, AND MON HEALTH CARE INC. MONONGALIA EMERGENCY MEDICAL SERVICES, INC. IS A NOT-FOR-PROFIT ENTITY WHICH PROVIDES AMBULANCE SERVICES TO THE COMMUNITY AND IS THE PRIMARY EMERGENCY CONTACT TRANSPORT SERVICE FOR 911 CALLS IN THE COUNTY. MON ELDER SERVICES, INC. IS A NOT-FOR-PROFIT RESIDENTIAL AND ASSISTED LIVING PROVIDER. MON HEALTH CARE INC. IS A FOR-PROFIT DURABLE MEDICAL EQUIPMENT RETAILER. PART VI, LINE 7, REPORTS FILED WITH STATES WV X X X X X 0 1 0 0 0 0 0 1 0 DARRYL DUNCAN PRESIDENT/CEO 0 457636 0 0 0 20506 0 98059 0 28571 0 604772 0 0 DARIS ROSENCRANCE SENIOR VP FINANCE/CFO 0 252593 0 0 0 36655 0 13148 0 27986 0 330382 0 0 KEE LEE SURGEON 697132 0 0 0 0 0 0 0 18300 0 715432 0 0 0 FAISAL BUKEIRAT SURGEON 413803 0 0 0 3708 0 5100 0 27986 0 450597 0 0 0 ALEXANDER NAGY SURGEON 446349 0 156300 0 22306 0 5100 0 33986 0 664041 0 0 0 WILLIAM C MCBEE SURGEON 634961 0 175000 0 3378 0 5100 0 28842 0 847281 0 0 0 JAMIE LESNOCK SURGEON 457101 0 0 0 3346 0 5100 0 33236 0 498783 0 0 0 PART I, LINE 4B PART 1, LINE 4B: DARRYL DUNCAN DEFERRED $92,959 IN COMPENSATION UNDER A 457(F) PLAN. DARIS ROSENCRANCE DEFERRED $8,239 IN COMPENSATION UNDER A 457(F) PLAN. PART 1, LINE 7: AS PART OF THE CEO AND CFO COMPENSATION PACKAGES, A PORTION OF THEIR SALARY IS PLACED "AT RISK". PAYMENT OF THIS PORTION IS CONTINGENT ON MEETING ANNUAL GOALS ESTABLISHED BY THE BOARD OF DIRECTORS. SCH J, PART II THE CEO, VP OF MEDICAL AFFAIRS AND OUTSIDE COUNSEL CONSIDER INDUSTRY STANDARDS AND BENCHMARKS AND PERFORM A FMV ANALYSIS WHEN DRAFTING EMPLOYMENT CONTRACTS FOR THE PHYSICIANS AND SURGEONS OF THE ORGANIZATION TO ENSURE THAT COMPENSATION IS NOT IN EXCESS OF FMV. A MONONGALIA COUNTY BUILDING COMMISSION 550714648 610208BL3 2005-06-01 62696073 CONSTRUCTION AND EXPANSION OF FACILITIES 0 0 0 B MONONGALIA COUNTY BUILDING COMMISSION 550714648 610208CK4 2011-04-20 9515218 REFUND A PORTION OF VARIABLE RATE BONDS 0 0 0 C MONONGALIA COUNTY BUILDING COMMISSION 550714648 610208BR0 2008-02-13 48145000 CONSTRUCTION AND EXPANSION OF FACILITIES 0 0 0 A 62696073 4473125 820241 57402707 2009 0 0 1 1 B 9515218 9324914 190305 2011 0 1 0 1 C 11585000 48145000 13151213 705242 34288545 2009 0 1 0 1 A 0 0 0 0 0 0 0 B 0 0 0 0 0 0 0 C 0 0 0 0 0 0 0 A 0 0 0 1 0 0 0 0 0 B 0 0 0 1 0 0 0 0 0 C 0 0 0 1 1 1 RAYMOND JAMES 32.400000000000 0 0 0 0 0 A 0 B 0 C 0 PART IV, LINE 2C, COLUMN A THE FUNDS DID NOT EARN MORE THAN THE INTEREST ON THE BONDS; THEREFORE, A REBATE COMPUTATION WAS NOT NECESSARY. FORM 990, PART VI, SECTION B, LINE 11 THE GOVERNING BODY IS PROVIDED A COPY OF THE FORM 990 FOR THEIR REVIEW PRIOR TO SUBMISSION. THE BOARD MEMBERS ARE ASKED TO INFORM MANAGEMENT OF ANY QUESTIONS OR REVISIONS THEY MAY HAVE. IF CHANGES ARE MADE, BASED ON BOARD MEMBER'S REVISIONS, MANAGEMENT REDISTRIBUTES A FINAL VERSION TO ALL BOARD MEMBERS. FORM 990, PART VI, SECTION B, LINE 12C ANNUALLY, A CONFLICT OF INTEREST QUESTIONNAIRE IS SENT OUT TO ALL BOARD MEMBERS AND OFFICERS. THE BOARD AND OFFICERS THEN REVIEWS ALL RESPONSES FOR POSSIBLE CONFLICTS OF INTEREST. IF A CONFLICT IS NOTED, THE BOARD MEMBERS DETERMINE IN WHICH DECISIONS THE CONFLICTED MEMBER SHALL NOT PARTICIPATE. FORM 990, PART VI, SECTION B, LINE 15 LINE 15A - ANNUALLY, A CONSULTANT COMPILES A MARKET DATA REPORT ON EXECUTIVE CEO COMPENSATION. THIS REPORT IS THEN REVIEWED BY THE INDEPENDENT EXECUTIVE COMMITTEE TO DETERMINE COMPENSATION FOR THE INDIVIDUAL. LINE 15B - ANNUALLY, A CONSULTANT COMPILES A MARKET DATA REPORT ON EXECUTIVE CFO AND COO COMPENSATION. THIS REPORT IS THEN REVIEWED BY THE INDEPENDENT EXECUTIVE COMMITTEE TO DETERMINE COMPENSATION FOR THE INDIVIDUALS. FORM 990, PART VI, SECTION C, LINE 19 THE GOVERNING DOCUMENTS, CONFLICT OF INTEREST POLICY, AND FINANCIAL STATEMENTS ARE KEPT ON-SITE AT MONONGALIA GENERAL HOSPITAL AND ARE MADE AVAILABLE UPON REQUEST. FORM 990, PART XI, LINE 9: CHANGE IN THE MINIMUM PENSION LIABILITY 22,298. CHANGE IN THE BENEFICIAL INTEREST IN THE FOUNDATION NETTED WITH REVENUE 582,104. CHANGE IN INTEREST RATE SWAP LIABILITY NETTED WITH REVENUE -292,426. MONONGALIA HEALTH SYSTEM INC 1200 JD ANDERSON DRIVE MORGANTOWN WV 26505 550621551 PARENT/MANAGEMENT COMPANY WV 501(C)(3) LINE 11A, I MONONGALIA HEALTH SYSTEMS INC 0 MONONGALIA EMERGENCY MEDICAL SERVICES INC 1200 JD ANDERSON DRIVE MORGANTOWN WV 26505 550725494 EMERGENCY AMBULANCE WV 501(C)(3) LINE 9 MONONGALIA HEALTH SYSTEMS INC 1 MON ELDER SERVICES INC 1200 JD ANDERSON DRIVE MORGANTOWN WV 26505 311520863 CONTINUING CARE RETIREMENT WV 501(C)(3) LINE 9 MONONGALIA HEALTH SYSTEMS INC 1 THE FOUNDATION OF MONONGALIA GENERAL HOSPITAL INC 1200 JD ANDERSON DRIVE MORGANTOWN WV 26505 550570338 RAISE FUNDS FOR MONONGALIA GENERAL HOSPITAL WV 501(C)(3) LINE 7 N/A 1 PRESTON HEALTH CARE CORPORATION 300 SOUTH PRICE STREET KINGWOOD WV 26537 550747067 MONITOR OPERATIONS OF SUBSIDIARIES WV 501(C)(3) LINE 3 MONONGALIA HEALTH SYSTEMS INC 1 PRESTON MEMORIAL HOSPITAL 300 SOUTH PRICE STREET KINGWOOD WV 26537 311097818 HOSPITAL WV 501(C)(3) LINE 3 MONONGALIA HEALTH SYSTEMS INC 1 PRESTON MEMORIAL MEDICAL GROUP 300 SOUTH PRICE STREET KINGWOOD WV 26537 550717988 PRIMARY AND URGENT CARE WV 501(C)(3) LINE 9 MONONGALIA HEALTH SYSTEMS INC 1 PRESTON MEMORIAL HOSPITAL FOUNDATION INC 300 SOUTH PRICE STREET KINGWOOD WV 26537 550740121 RAISE FUNDS FOR PRESTON MEMORIAL HOSPITAL WV 501(C)(3) LINE 7 MONONGALIA HEALTH SYSTEMS INC 1 MON HEALTH CARE INC 1200 JD ANDERSON DRIVE MORGANTOWN WV 26505 550654973 HOME MEDICAL EQUIPMENT WV MONONGALIA HEALTH SYSTEM INC C 1 0 0 0 0 0 0 0 0 0 1 1 0 1 0 0 1 1 0 0 MONONGALIA HEALTH SYSTEM INC P 3405730 FMV MONONGALIA HEALTH SYSTEM INC Q 1100605 FMV THE FOUNDATION OF MON GENERAL HOSPITAL C 1000000 FMV MON HEALTHCARE EQUIPMENT SUPPLY Q 539951 FMV MON COUNTY EMERGENCY SERVICES Q 301587 FMV MON ELDER SERVICES INC Q 265002 FMV THE FOUNDATION OF MON GENERAL HOSPITAL Q 155567 FMV MONONGALIA HEALTH SYSTEM INC J 54635 FMV