2015-08-13T16:59:20-05:00 2014-09-30 410746749 CLIFTONLARSONALLEN LLP 227 WEST TRADE STREET SUITE 800 CHARLOTTE NC 28202 990 2013-10-01 560603900 ASHE MEMORIAL HOSPITAL INC ASHE 3368467101 200 HOSPITAL AVENUE JEFFERSON NC 28640 JOY MCCLURE CFO 3368467101 2015-08-13 1 JOHN NORMAN P01506766 7049985200 2013 2016-02-25 16:41:14Z X LAURA LAMBETH 200 HOSPITAL AVE JEFFERSON NC 28640 31903380 0 X WWW.ASHEMEMORIAL.ORG X 1939 NC ACUTE HOSPITAL CARE SERVICES PROVIDED TO THE RESIDENTS OF ASHE COUNTY, NC AND SURROUNDING AREAS. 18 16 344 64 0 0 915229 1383024 26424307 29316952 1156777 710611 380754 492793 28877067 31903380 14588 20336 0 0 16012422 15399236 0 0 285918 13032292 14835915 29059302 30255487 -182235 1647893 17339906 17508331 10380465 8917998 6959441 8590333 THE HOSPITAL'S MISSION STATEMENT IS ICARE, WHICH STANDS FOR INVESTMENT IN THE DEVELOPMENT OF PEOPLE, COMMITMENT TO CONTINUOUS IMPROVEMENT, ACCOUNTABILITY TO THOSE WE SERVE, RESPONSIVENESS TO THE HEALTH CARE NEEDS OF THE COMMUNITY, AND EXCELLENCE IN PRIMARY HEALTHCARE. 0 0 28107858 20336 30200762 ASHE MEMORIAL PROVIDES INPATIENT, OUTPATIENT, AND EMERGENCY CARE SERVICES FOR RESIDENTS OF ASHE COUNTY AND THE SURROUNDING AREAS. THE HOSPITAL PROVIDED A SIGNIFICANT AMOUNT OF COMMUNITY BENEFIT AND OUTREACH TO THE COUNTY AND SURROUNDING AREAS. BENEFIT AND OUTREACH PROGRAMS ARE PROVIDED IN CONJUNCTION WITH THE ASHE COUNTY HEALTH COUNCIL AND INDEPENDENTLY THROUGH VARIOUS DEPARTMENTS AND SERVICES. 28107858 1 1 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 1 0 1 1 1 0 0 0 0 0 1 1 0 0 0 1 66 0 1 344 1 0 0 0 0 0 0 0 0 0 0 X 18 16 0 1 0 0 1 1 1 1 1 0 0 1 1 1 1 1 1 1 1 0 NC X X CHARLES WRIGHT CFO 3368460798 200 HOSPITAL AVENUE JEFFERSON NC 28640 TOM EFFORD VP, PRESTIDENT NOVEMBER 2013-SEPT 2014 0.00 X X 0 0 0 EJ MILLER BOARD MEMBER 0.00 X 0 0 0 SUE HAMPTON BOARD MEMBER 0.00 X 0 0 0 STEPHEN SHOEMAKER BOARD MEMBER 0.00 X 0 0 0 GREG BOWER BOARD MEMBER 0.00 X 0 0 0 JANE LONON SECRETARY 0.00 X X 0 0 0 BRADLEY MCNEILL VP 0.00 X 0 0 0 CHARLES JONES BOARD MEMBER 0.00 X 0 0 0 DONNIE JOHNSON BOARD MEMBER 0.00 X 0 0 0 HOBIE DAVIS VP 0.00 X 0 0 0 JAN CADDELL TREASURER 0.00 X X 0 0 0 WALTER DAVIS BOARD MEMBER 0.00 X 0 0 0 DENNIS HOUCK BOARD MEMBER 0.00 X 0 0 0 BRETT T SUMMEY BOARD MEMBER 0.00 X 0 0 0 HORACE THOMPSON BOARD MEMBER 0.00 X 0 0 0 NANCY KAUTZ BOARD MEMBER 0.00 X 0 0 0 JIM GAMBILL PRESIDENT THROUGH OCT 2013 0.00 X X 0 0 0 BRANDON VANNOY BOARD MEMBER 0.00 X 0 0 0 DICK MILLER BOARD MEMBER 0.00 X 0 0 0 JOSEPH J LOZANO ER PHYSICIAN 57.00 X 296617 0 25487 TERRY J WILLIAMS JR PHYSICIAN 40.00 X 256274 0 27412 JAMES MICHAEL TAN ER PHYSICIAN 49.00 X 241944 0 28438 CB JONES JR PHYSICIAN ASSISTANT ER 57.00 X 187620 0 9617 WILLIAM C BLACKERBY ER PHYSICIAN 30.00 X 180722 0 17733 1163177 0 108687 5 0 1 0 RESTORE RESPIRATORY CARE INC 200 GALLERIA PARKWAY SUITE 1800 ATLANTA GA 30339 RESPIRATORY THERAPY 896443 ALLIANCE HEALTHCARE SERVICES PO BOX 96485 CHICAGO IL 60693 MRI LEASE 370125 HERMITAGE ANESTHESIA PO BOX 1153 JEFFERSON NC 28640 ANESTHESIA 225996 DEBORAH L KINCAID SIDERS 257 NEW BEGINNINGS WEST JEFFERSON NC 28694 ANESTHESIA 216000 CRNA PLUS PA 411 HWY 16 SOUTH JEFFERSON NC 28640 ANESTHESIA 216000 10 1383024 1383024 PATIENT SERVICE REVENUE 623000 28409654 28409654 OTHER OPERATING REVENUE 623000 539547 539547 PHARMACY 446110 304824 304824 FITNESS CENTER 713940 62927 62927 29316952 20104 20104 182914 0 182914 182914 182914 690507 0 690507 690507 690507 INSURANCE REFUNDS/SETTLEMENTS 900099 164348 164348 CAFETERIA & VENDING 722210 128913 128913 PURCHASE DISCOUNTS 900099 16618 16618 309879 31903380 30007459 0 512897 20336 20336 12975195 12709204 265991 1416884 1298999 107258 10627 1007157 923261 76242 7654 244812 244812 92744 92744 36020 36020 1612615 1491991 120624 41396 8238 32744 414 4543438 4249166 274592 19680 324363 37178 287185 955229 955229 38411 31517 6894 182342 182342 1606962 1606962 323412 323412 BAD DEBT EXPENSE 3837976 3837976 MISCELLANEOUS 880457 432047 200867 247543 RECRUITMENT 115738 115738 30255487 28107858 1861711 285918 2009633 2289460 722874 1900893 3138035 2900757 19269 17269 570135 723074 120984 161168 31346595 22241756 10358941 9104839 33745 33745 366290 377126 17339906 17508331 4983548 3742347 351059 374167 4098926 3530505 946932 1270979 10380465 8917998 X 6752920 8400247 206521 190086 6959441 8590333 17339906 17508331 X 1647893 -17001 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 0 PART II-B, LINE 1: THE ORGANIZATION IS A MEMBER OF THE NORTH CAROLINA HOSPITAL ASSOCIATION AND THE AMERICAN HOSPITAL ASSOCIATION. A PORTION OF THE MEMBERSHIP DUES PAID TO THESE ORGANIZATIONS IS ALLOCATED TO LOBBYING EXPENDITURES ON BEHALF OF ITS MEMBERSHIP BODY. 277913 277913 15588171 9570873 6017298 109022 21804 87218 14120183 11816835 2303348 1251306 832244 419062 9104839 MEDICARE/MEDICAID DUE 1261881 UNCLAIMED CHECKS 9098 1270979 X PART X, LINE 2: THE HOSPITAL AND FOUNDATION ARE NOT-FOR-PROFIT CORPORATIONS AS DESCRIBED IN SECTION 501(C)(3) OF THE INTERNAL REVENUE CODE AND ARE EXEMPT FROM FEDERAL INCOME TAXES ON RELATED INCOME PURSUANT TO SECTION 501(A) OF THE CODE. ACCORDINGLY, THE ACCOMPANYING CONSOLIDATED FINANCIAL STATEMENTS DO NOT REFLECT A PROVISION OR LIABILITY FOR FEDERAL AND STATE INCOME TAXES. THE ORGANIZATION HAS DETERMINED THAT IT DOES NOT HAVE ANY MATERIAL UNRECOGNIZED TAX BENEFITS OR OBLIGATIONS AS OF SEPTEMBER 30, 2015 AND 2014. FISCAL YEARS ENDING ON AND AFTER SEPTEMBER 30, 2011, REMAIN SUBJECT TO EXAMINATION BY FEDERAL AND STATE TAX AUTHORITIES. 1 1 X 1 X 1 X 1 1 0 1 1 548915 548915 0.01810 3723303 2627478 1095825 0.03620 374114 364303 9811 0.00030 4646332 2991781 1654551 0.05460 12803 12803 0.00040 5277 5277 0.00020 18080 18080 0.00060 4664412 2991781 1672631 0.05520 7123 7123 0.00020 7123 7123 0.00020 1 1769423 707769 13017666 13772626 -754960 X 1 0 1 1 ASHE MEMORIAL HOSPITAL 200 HOSPITAL AVENUE JEFFERSON NC 28640 X X X X CRITICAL ACCESS HOSPITAL ASHE MEMORIAL HOSPITAL INC 1 1 X X X X X X X X X 12 1 1 1 X X X X X X X X X X 1 0 1 1 15000.000000000000 1 25000.000000000000 1 X X X X X X X 1 1 X X X X X X 1 X X 1 X X X X X X 1 X 0 0 ASHE MEMORIAL HOSPITAL INC. PART V, SECTION B, LINE 3: THE HOSPITAL CONDUCTED TWO SURVEYS TO SOLICIT FEEDBACK FROM PERSONS WHO REPRESENT THE COMMUNITY. FIRST, THE HOSPITAL CONDUCTED A YOUTH RISK BEHAVIOR SURVEY BY SURVEYING MIDDLE SCHOOL STUDENTS IN THE AREA ABOUT BEHAVIORS THAT AFFECT THEIR HEALTH. SECOND, THE HOSPITAL CONDUCTED THE COMMUNITY OPINION SURVEY IN EACH APPALACHIAN DISTRICT COUNTY (ALLEGHANY, ASHE AND WATAUGA) THROUGH THE COLLECTION OF PAPER SURVEYS AND DISTRIBUTION OF A LINK ON AREA WEBSITES THROUGH SURVEY MONKEY. ADDITIONALLY, LOCAL MEDIA OUTLETS SUPPORTED THE PROMOTION OF THE SURVEY THROUGH ON-AIR INTERVIEWS, PRESS RELEASE STORIES, AND PAID ADVERTISING ON THE RADIO. ASHE MEMORIAL HOSPITAL INC. PART V, SECTION B, LINE 4: ALLEGHANY MEMORIAL HOSPITALAPPALACHIAN REGIONAL HEALTHCARE SYSTEMS 2 MOUNTAIN FAMILY CARE CENTER 200 HOSPITAL AVENUE JEFFERSON NC 28640 RURAL HEALTH CLINIC AMH ASHE WOMEN'S CENTER 420 E 2ND STREET WEST JEFFERSON NC 28694 PHYSICIANS OFFICES PART I, LINE 6A: NCHA PART I, LN 7 COL(F): THE ORGANIZATION RECOGNIZES PATIENT SERVICE REVENUE ASSOCIATED WITH SERVICES PROVIDED TO PATIENTS WHO HAVE THIRD-PARTY PAYOR COVERAGE ON THE BASIS OF CONTRACTUAL RATES FOR THE SERVICES RENDERED. FOR UNINSURED PATIENTS THAT DO NOT QUALIFY FOR CHARITY CARE, THE ORGANIZATION RECOGNIZES REVENUE ON THE BASIS OF ITS STANDARD RATES FOR SERVICES PROVIDED (OR ON THE BASIS OF DISCOUNTED RATES, IF NEGOTIATED OR PROVIDED BY POLICY). ON THE BASIS OFHISTORICAL EXPERIENCE, A SIGNIFICANT PORTION OF THE ORGANIZATIONS UNINSURED PATIENTS WILL BE UNABLE OR UNWILLING TO PAY FOR THE SERVICES PROVIDED. THUS, THE ORGANIZATION RECORDS A SIGNIFICANT PROVISION FOR BAD DEBTS RELATED TO UNINSURED PATIENTS IN THE PERIOD THE SERVICES ARE PROVIDED. PART III, LINE 9B: THE POLICY DOES NOT SPECIFICALLY ADDRESS THIS ISSUE BUT WE NORMALLY PROVIDE THE CHARITY CARE DISCOUNT PRIOR TO SENDING TO BAD DEBT IF THE PATIENT QUALIFIES FOR CHARITY IN PART BUT FAILS TO PAY THEIR PORTION DUE. X X X 0 0 0 0 0 0 0 0 0 JOSEPH J LOZANO ER PHYSICIAN 296617 0 0 0 0 0 0 0 25487 0 322104 0 0 0 TERRY J WILLIAMS JR PHYSICIAN 256274 0 0 0 0 0 0 0 27412 0 283686 0 0 0 JAMES MICHAEL TAN ER PHYSICIAN 241944 0 0 0 0 0 0 0 28438 0 270382 0 0 0 CB JONES JR PHYSICIAN ASSISTANT ER 187620 0 0 0 0 0 0 0 9617 0 197237 0 0 0 WILLIAM C BLACKERBY ER PHYSICIAN 180722 0 0 0 0 0 0 0 17733 0 198455 0 0 0 PART I, LINE 3 COMPENSATION FROM AN UNRELATED ORGANIZATION (SEE FORM 990, PART VII, LINE 5). RAYMOND D WILLIAMS IS COMPENSATED THROUGH QUORUM HEALTH RESOURCES, LLC, AN UNRELATED ORGANIZATION, FOR HIS SERVICES AS CEO OF THE HOSPITAL. PLEASE SEE THE RESPONSE TO FORM 990, PART VI, LINE 15A FOR MORE DETAILS. SARA HOUSER TUITION LOAN FROM AMH TO MRS. HOUSER X 25936 17269 0 1 1 17269 CHARLES W JONES MD BOARD MEMBER 237913 DR. JONES WAS PAID BY AMH FOR SURGERY CALL FOR THE AMOUNT OF $237,913. 0 FORM 990, PART VI, SECTION A, LINE 3 SEE NOTE FOR PART VI, LINE 15. FORM 990, PART VI, SECTION A, LINE 6 THE HOSPITAL IS ORGANIZED AS A STOCK CORPORATION, AND SHARES OF STOCK ARE SOLD TO MEMBERS OF THE COMMUNITY AND ARE FREELY TRANSFERABLE, BUT HAVE NO CAPITAL VALUE. SHAREHOLDERS DO NOT RECEIVE DIVIDENDS. FORM 990, PART VI, SECTION A, LINE 7A TRUSTEES SHALL BE ELECTED BY THE SHAREHOLDERS OF THE CORPORATION AT THE ANNUAL MEETING OF THE MEMBERSHIP. EACH SELECTED TRUSTEE SHALL HOLD OFFICE FOR A TERM OF THREE YEARS AND UNTIL HIS SUCCESSOR IS ELECTED AND QUALIFIED. FORM 990, PART VI, SECTION A, LINE 7B THE ORGANIZATION CANNOT SELL REAL PROPERTY WITHOUT APPROVAL BY THE SHAREHOLDERS. PLEASE SEE THE RESPONSE TO LINE 6 ABOVE. FORM 990, PART VI, SECTION B, LINE 11 THE RETURN WAS PREPARED BY AN INDEPENDENT ACCOUNTING FIRM WITH THE ASSISTANCE AND OVERSIGHT OF MANAGEMENT. PRIOR TO SUBMISSION TO THE IRS, THE FINANCE COMMITTEE WAS INFORMED BY THE CEO AND CFO THAT THE RETURNS WOULD BE FILED TIMELY. FORM 990, PART VI, SECTION B, LINE 12C ALL VOTING MEMBERS ARE REQUIRED TO REVIEW AND SIGN A CONFLICT OF INTEREST SURVEY AND RETURN TO THE BOARD CHAIRMAN. THE SURVEY INCLUDES A DISCLOSURE STATEMENT AND A REVIEW OF THE POLICY. FORM 990, PART VI, SECTION B, LINE 15 THE HOSPITAL HAS BEEN MANAGED BY HCA AND/OR QUORUM HEALTH RESOURCES, LLC (QHR) SINCE 1982. THE CONTRACT EXPIRED IN AUGUST 2013 AND WAS NOT RENEWED BY THE BOARD OF TRUSTEES. SUBSEQUENTLY, THE BOARD OF TRUSTEES OF THE HOSPITAL CONTRACTED WITH NOVANT HEALTH SHARED SERVICES WITH THE EFFECTIVE DATE OF AUGUST 2013. NOVANT WAS TO ALSO EMPLOY THE CEO WITH A VERY SIMILAR CONTRACT AS HAD BEEN ADMINISTERED THROUGH THE YEARS BY QHR. SINCE A NON-COMPETE CLAUSE WAS IN THE QHR CONTRACT FOR THE PERSONNEL, THE QHR CEO WAS HIRED AT ANOTHER QHR FACILITY AND LEFT ASHE MEMORIAL HOSPITAL, INC. IN MAY 2013. THE PRESENT COO ACTED AS THE CEO UNTIL THE NOVANT CEO WAS HIRED AND PUT IN PLACE IN JULY 2013. EVEN THOUGH THE ACTUAL CONTRACT WITH NOVANT DID NOT BEGIN UNTIL AUGUST, THE BOARD OF TRUSTEES AGREED FOR THE CEO TO BEGIN THE ORIENTATION PERIOD EARLIER. FORM 990, PART VI, SECTION C, LINE 19 PHOTOCOPIES OF THE FORM 990 ARE AVAILABLE UPON REQUEST AT THE ORGANIZATION'S ADMINISTRATIVE OFFICE. IN ADDITION, THE HOSPITAL WIDELY DISTRIBUTES AN ANNUAL REPORT TO THE COMMUNITY. PLEASE CONTACT THE ADMINISTRATIVE OFFICE FOR FURTHER DETAILS. SEE FORM 990, PART VI, LINE 20. FORM 990, PART XI, LINE 9: MISCEL. -17,001. FORM 990, PART XII, LINE 2C: NO CHANGE FROM PRIOR YEAR. REASON FOR AMENDING RETURN THE ORGANIZATION IS AMENDING THIS RETURN TO PROPERLY LIST ITS OFFICERS, DIRECTORS, TRUSTEES, KEY EMPLOYEES AND FIVE HIGHEST COMPENSATED EMPLOYEES. AMH ASHE WOMEN'S CENTER LLC 420 E 2ND STREET WEST JEFFERSON NC 28694 451482188 PHYSICIANS PRACTICE NC ASHE MEMORIAL HOSPITAL ASHE MEMORIAL HOSPITAL FOUNDATION INC 200 HOSPITAL AVE JEFFERSON NC 28640 582078244 FUNDRAISING NC 501(C)(3) 11A ASHE MEMORIAL HOSPITAL 0 0 0 1 0 0 0 0 0 0 0 0 0 1 1 1 0 1 0 1