2015-08-14T09:14:28-05:00 2014-09-30 560747981 DIXON HUGHES GOODMAN LLP 500 RIDGEFIELD COURT ASHEVILLE NC 28806 990 2013-10-01 560525657 ALLEGHANY COUNTY MEMORIAL HOSPITAL INC ALLE 3363725511 PO BOX 9 SPARTA NC 28675 SIGNING OFFICER CFO 3363725511 2015-08-13 1 AMY BIBBY P00445891 8282542254 2013 2016-04-25 22:37:26Z WARREN TAYLOR 233 DOCTORS STREET SPARTA NC 28675 13140544 0 X WWW.AMHSPARTA.ORG X 1948 NC TO PROVIDE TOP QUALITY HEALTH CARE SERVICES TO OUR LOCAL COMMUNITY AND SURROUNDING COMMUNITIES. SERVICES ARE PROVIDED TO ALL INDIVIDUALS REGARDLESS OF THEIR ABILITY TO PAY. 15 14 186 54 147248 59411 598335 253898 11997145 12493022 35453 36501 324403 357123 12955336 13140544 0 0 0 0 6549813 6364486 0 0 406 6990726 6863102 13540539 13227588 -585203 -87044 9223470 9136350 5508344 5546331 3715126 3590019 ALLEGHANY MEMORIAL HOSPITAL PROVIDES TOP QUALITY HEALTHCARE SERVICES, FACILITATES EDUCATION FOR HEALTHCARE NEEDS, AND COORDINATES HEALTHCARE SERVICES THAT EXCEEDS THE SCOPE OF OUR FACILITY. 0 0 11318775 0 12345774 ALLEGHANY MEMORIAL HOSPITAL PROVIDED NECESSARY HEALTHCARE SERVICES TO INDIVIDUALS IN THE COMMUNITY REGARDLESS OF THEIR ABILITY TO PAY. CARE WAS PROVIDED THROUGH 2,064 INPATIENT AND 579 SWING BED ADMISSIONS, 7,049 ER VISITS, 2,064 DAYS OF CARE, 12,149 X-RAYS, AND 56,720 LAB TESTS. ADDITIONALLY, WAKE FOREST SPECIALTY CLINIC, A PRIMARY CARE PROVIDER, WAS OPENED EFFECTIVE JULY 1, 2014. TOP QUALITY HEALTHCARE IS THE NUMBER ONE GOAL. 11318775 1 1 0 1 0 0 0 0 0 1 1 0 0 1 1 0 0 0 0 0 0 0 0 0 0 0 1 1 0 0 1 0 0 0 1 0 0 0 0 0 0 0 0 0 1 1 1 0 0 1 61 0 1 186 1 1 1 0 0 0 0 0 0 0 0 0 X 15 14 0 1 0 0 0 0 0 1 1 0 0 1 1 1 1 1 1 1 1 0 NC X BRETT LIVERMAN CFO 3363723276 PO BOX 9 SPARTA NC 28675 WARREN TAYLOR CHAIRMAN 1.00 X X 0 0 0 WALT MCMILLAN VICE CHAIRMAN (END JUL 14) 1.00 X X 0 0 0 ROCKY PROFITT VICE CHAIRMAN (BEG JUN 14) 1.00 X X 0 0 0 GEORGE WHITE FINANCE CHAIR 1.00 X X 0 0 0 JOHN MILLER SECRETARY 1.00 X X 0 0 0 FIELDS R YOUNG JR VICE SECRETARY 1.00 X X 0 0 0 PAT POLLEY TRUSTEE 1.00 X 0 0 0 REX HALSEY TRUSTEE 1.00 X 0 0 0 FRANK DOWELL TRUSTEE 1.00 X 0 0 0 FRANCES BUCKLE TRUSTEE 1.00 X 0 0 0 JIM BECKER TRUSTEE 1.00 X 0 0 0 DAN R MURRAY TRUSTEE 1.00 X 0 0 0 WHITNEY IVEY TRUSTEE 1.00 X 0 0 0 TAMMY THORE MD TRUSTEE 1.00 X 0 0 0 JOE AROCHA MD TRUSTEE/EMPLOYED PHYSICIAN 40.00 X 414525 0 21300 BRENT LAMMERS CEO (JAN '14 THRU. AUG '14) 40.00 X 0 0 0 BRETT LIVERMAN CFO 40.00 X 105535 0 18413 WENDY ORTON CNO 40.00 X 106024 0 22699 DWYNN GREENFIELD PHYSICIAN 40.00 X 171360 0 22849 TRACY BOTTOMLEY PHARMACIST 40.00 X 140384 0 22811 937828 0 108072 5 0 1 0 ALLEGHANY EMERGENCY PHYSICIANS PO BOX 20351 HOUSTON TX 77216 ER PHYSICIANS 637437 MEDCOST BENEFIT SERVICES PO BOX 24042 WINSTON NC 27114 TPA 565449 HUGH CHATHAM HOSPITAL (SNYDER) PO BOX 560 ELKIN NC 28621 ORTHOPEDIC SERVICES 243432 CPSI PO BOX 850309 MOBILE AL 36685 COMPUTER SUPPORT 226822 QUORUM HEALTH RESOURCES 105 CONTINENTAL PLACE BRENTWOOD TN 37027 MANAGEMENT COMPANY 217452 9 58193 130605 65100 253898 NET PATIENT REVENUE 621500 12448878 12301630 147248 MRI GAP SUPPLEMENT 621500 44144 44144 12493022 8563 8563 83250 0 83250 83250 83250 27938 0 27938 27938 27938 CAFETERIA INCOME 900099 41315 41315 THRIFT SHOP 900099 28806 28806 PURCHASE DISCOUNTS 900099 23423 23423 180329 180329 273873 13140544 12345774 147248 393624 X 559773 435825 123948 4597275 3988452 608823 855863 752717 102856 290 351575 302693 48766 116 168198 168198 43468 43468 48902 48902 2022166 1707138 315028 16567 3 16564 792511 552795 239716 175788 175788 19533 14294 5239 102248 76387 25861 608693 608693 117668 117668 MEDICAL SUPPLIES 1341488 1341488 BAD DEBT EXPENSE 1310929 1310929 MISCELLANEOUS 94943 51573 43370 13227588 11318775 1908407 406 315320 30724 147379 154067 1521839 1912681 39489 30305 274522 297829 83033 72044 18800628 13509842 5749007 5290786 902745 807147 190136 540767 9223470 9136350 2011429 2543728 3084613 2881591 412302 121012 5508344 5546331 X 3349858 3224751 365268 365268 3715126 3590019 9223470 9136350 X -87044 21062 -59125 X X 0 0 0 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 0 0 0 0 0 0 0 0 1 1488 1488 0 PART II-B, LINE 1: THE HOSPITAL IS A MEMBER OF THE AMERICAN HOSPITAL ASSOCIATION AND THE NORTH CAROLINA HOSPITAL ASSOCIATION. DUES PAID TO THESE ORGANIZATIONS ARE ALLOCATED IN PART TO LOBBYING EFFORTS ON BEHALF OF THEIR MEMBERSHIP BODIES. FOR THE YEAR, APPROXIMATELY $1,488 OF DUES PAID ARE ALLOCATED TO LOBBYING EXPENDITURES. 370358 3589 373947 362325 8033 370358 330226 32099 362325 356418 -26192 330226 331822 24596 356418 0.02320 0.97680 0 0 351517 351517 6253118 3956611 2296507 1460715 1067576 393139 10732394 8485655 2246739 2884 2884 5290786 OTHER RECEIVABLES 36671 ESTIMATED THIRD PARTY PAYOR SETTLEMENTS 504096 540767 CAPITAL LEASE OBLIGATION 121012 121012 PART V, LINE 4: THE HOSPITAL'S ENDOWMENT CONSISTS OF FUNDS ESTABLISHED FOR A VARIETY OF PURPOSES TO SUPPORT HEALTH CARE SERVICES. 1 1 X 1 X 1 X 1 1 1 0 1 1 64284 64284 0.00490 1328066 1093946 234120 0.01770 1392350 1093946 298404 0.02260 1392350 1093946 298404 0.02260 0 1310929 6382595 5055167 1327428 X 1 0 1 1 ALLEGHANY MEMORIAL HOSPITAL 233 DOCTORS STREET SPARTA NC 28675 X X X X ALLEGHANY COUNTY MEMORIAL HOSPITAL 1 1 X X X X X X X X 11 1 0 1 SEE DISCLOSURE X X X X X X 1 0 1 1 100.000000000000 1 200.000000000000 1 X X X X X 1 1 X X 1 0 1 X 0 0 ALLEGHANY COUNTY MEMORIAL HOSPITAL PART V, SECTION B, LINE 3: COMMUNITY INPUT WAS TAKEN INTO ACCOUNT THROUGH COORDINATED EFFORTS WITH AND BETWEEN THE APPALACHIAN DISTRICT HEALTH DEPARTMENT AND OTHER COMMUNITY PROVIDERS. ALLEGHANY COUNTY MEMORIAL HOSPITAL PART V, SECTION B, LINE 5D: THROUGH COORDINATED EFFORTS OF THE APPLACHIAN DISTRICT HEALTH DEPARTMENT ALLEGHANY COUNTY MEMORIAL HOSPITAL PART V, SECTION B, LINE 20D: THE ORGANIZATION USE THE SAME CHARGE FOR ALL PATIENTS INSURED OR UNINSURED. 3 ALLEGHANY ORTHOPEDIC CLINIC 12 WILLIS ST SPARTA NC 28675 ORTHOPEDIC SURGEON OFFICE ALLEGHANY HEALTH SERVICES PO BOX 9 SPARTA NC 28675 FAMILY PRACTICE ALLEGHANY SPECIALITY CLINIC PO BOX 11 SPARTA NC 28677 UROLOGY AND PULMONOLOGY CLINIC, PART I, LINE 7: WORKSHEET 2 OF THE 2013 SCHEDULE H INSTRUCTIONS WAS USED TO COMPUTE A COST-TO-CHARGES RATIO USED TO CALCULATE CHARITY CARE/FINANCIAL ASSISTANCE AND UNREIMBURSED MEDICAID AT COST FOR PURPOSES OF PART I, LINE 7A AND 7B. PART III, LINE 4: THE ORGANIZATION'S FINANCIAL STATEMENTS DO NOT INCLUDE A FOOTNOTE ON BAD DEBT EXPENSE. THE BAD DEBT EXPENSE AT COST ON PART III, LINE 2 WAS COMPUTED BY USING THE GROSS BAD DEBT EXPENSE PER AUDITED FINANCIAL STATEMENTS REDUCED TO COST USING THE COST TO CHARGE RATIO CALCULATED THROUGH WORKSHEET 2 PROVIDED IN THE INSTRUCTIONS TO SCHEDULE H. PART III, LINE 8: THE ORGANIZATION USED CALCULATIONS FROM ITS MEDICARE COST REPORT TO DETERMINE MEDICARE ALLOWABLE COSTS FOR PART III. PART III, LINE 9B: A PATIENT IS DETERMINED INDIGENT IF THEY MEET THE ELIGIBILITY REQUIREMENTS FOR ALLEGHANY MEMORIAL HOSPITAL'S UNCOMPENSATED CARE PROGRAMS. PART VI, LINE 2: THE HOSPITAL IS PART OF THE APPALACHIAN DISTRICT CHA TEAM, WHICH INCLUDES LEADERSHIP FROM ALLEGHANY MEMORIAL HOSPITAL, ALLEGHANY LIVES, ASHE MEMORIAL HOSPITAL, ASHE COUNTY HEALTH COUNCIL/HEALTHY CAROLINIANS, APPALACHIAN REGIONAL HEALTHCARE SYSTEM, WATAUGA HEALTHY CAROLINIANS, AND WESTERN YOUTH NETWORK. TOGETHER, THE TEAM DEVELOPED A MULTI-PHASE PLAN FOR CONDUCTING A COMMUNITY HEALTH NEEDS ASSESSMENT. THE PHASES INCLUDED: (1) A RESEARCH PHASE TO IDENTIFY, COLLECT AND REVIEW DEMOGRAPHIC, SOCIOECONOMIC AND HEALTH DATA; (2) A SURVEY PHASE TO SOLICIT INFORMATION AND OPINION FROM THE GENERAL PUBLIC; (3) A STAKEHOLDER SURVEY PHASE TO GATHER INFORMATION AND OPINION FROM LOCAL COMMUNITY LEADERS AND HEALTH AND HUMAN SERVICE AGENCIES; AND (4) A DATA SYNTHESIS AND ANALYSIS PHASE. THESE PHASES HELPED DESIGN THE COMPONENTS OF THE COMMUNITY HEALTH ASSESSMENT. THE CURRENT ASSESSMENT WAS COMPLETED IN 2014. ALLEGHANY'S LOCAL PRIORITY ISSUE IS THE ACCESS AND AFFORDABILITY OF HEALTHCARE SERVICES. PART VI, LINE 3: THE ORGANIZATION IDENTIFIES ELIGIBLE PATIENTS THROUGH THE REGISTRATION AND COLLECTION PROCESS. EACH ELIGIBLE PATIENT IS GIVEN INSTRUCTIONS AND AN APPLICATION TO COMPLETE AND RETURN TO THE ORGANIZATION. PART VI, LINE 4: THE PRIMARY AND SECONDARY SERVICE AREAS INCLUDE APPROXIMATELY 18,000 IN BOTH NORTHWESTERN NC AND SOUTHWESTERN VA. APPROXIMATELY 4,000 INDIVIDUALS IN THE PRIMARY AND SECONDARY SERVICE AREAS ARE OVER AGE 65. THE CLOSEST FACILITY IS APPROXIMATELY 30 MINUTES AWAY DOWN A MOUNTAINOUS TERRAIN. THE HOSPITAL IS LOCATED IN A PRIMARY CARE HEALTH PROFESSIONAL SHORTAGE AREA AND A MEDICALLY UNDERSERVED AREA ACCORDING TO HRSA. THE MEDIAN HOUSEHOLD INCOME AS OF 2008 WAS $33,234 VERSUS A NC STATE AVERAGE OF $44,797. THE UNEMPLOYMENT RATE IS AT ROUGHLY 10.9% AS OF 2010 VERSUS A STATEWIDE AVERAGE OF 9.9%. 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. IN ADDITION, THE ORGANIZATION EXTENDS HOSPITAL PRIVILEDGES TO ALL QUALIFIED LOCAL PHYSICIANS FOR THE MAJORITY OF ITS DEPARTMENTS. PART VI, LINE 6: THE HOSPITAL IS NOT PART OF AN AFFILIATED HEALTH CARE SYSTEM. PART VI, LINE 7, REPORTS FILED WITH STATES NC PART V, LINE 5A: HTTP://WWW.AMHSPARTA.ORG/PUBLICATIONS.HTML X X X 0 0 0 0 0 0 0 0 0 JOE AROCHA MD TRUSTEE/EMPLOYED PHYSICIAN 160000 0 230375 0 24150 0 0 0 21300 0 435825 0 0 0 DWYNN GREENFIELD PHYSICIAN 151790 0 3220 0 16350 0 0 0 22849 0 194209 0 0 0 TRACY BOTTOMLEY PHARMACIST 140384 0 0 0 0 0 0 0 22811 0 163195 0 0 0 JOE AROCHA MD PHYSICIAN RECRUITMENT X 60000 30305 0 1 1 30305 FORM 990, PART VI, SECTION A, LINE 3 THE HOSPITAL ENTERED HAD MANAGEMENT AGREEMENTS WITH ALLIANT THAT ENTAILS THAT THEY WILL PERFORM MANAGEMENT AND ADMINISTRATIVE SERVICES FROM DAY TO DAY. THE ORGANIZATION CONTRACTS ITS EXECUTIVE DIRECTOR AND FINANCIAL DIRECTOR FROM ALLIANT AND QUORUM DURING THE YEAR. UNDER THE TERMS OF A MANAGEMENT AGREEMENTS, MANAGEMENT SERVICES ARE PROVIDED TO THE ORGANIZATION BY ALLIANT AND QUORUM. THESE SERVICES INCLUDE THE SUPERVISION OF ALL ASPECTS OF NORMAL OPERATIONS INCLUDING BUDGETING, HIRING OF EMPLOYEE, BILLING, PAYROLL, ACCOUNTS PAYABLE, AND OTHER MANAGEMENT RESPONSIBILITIES. BRETT LIVERMAN, CFO RECEIVED COMPENSATION FROM QUORUM IN THE AMOUNT OF $55,903 AND COMPENSATION FROM ALLIANT IN THE AMOUNT OF $33,987 FOR THE 2013 YEAR. THESE AMOUNTS HAVE BEEN REPORTED IN COMBINATION WITH THE COMPENSATION RECEIVED DIRECTLY FROM THE HOSPITAL ON PART VII OF THE RETURN TO REFLECT HIS TOTAL COMPENSATION RECEIVED FROM SERVICES PROVIDED TO THE ORGANIZATION. FORM 990, PART VI, SECTION B, LINE 11 THE RETURN WAS PREPARED BY AN INDEPENDENT ACCOUNTANT WITH ASSISTANCE AND OVERSIGHT BY MANAGEMENT. PRIOR TO THE FILING DATE OF THE FORM 990, A COPY OF THE FORM 990 WAS PROVIDED TO EACH VOTING BOARD OF TRUSTEE. THE ENTIRE VOTING BOARD OF TRUSTEES REVIEWED THE FORM 990. AFTER A DISCUSSION PERIOD AND QUESTION & ANSWER PERIOD WITH ASSISTANCE FROM FORM 990 PREPARER, THE BOARD OF TRUSTEES VOTED TO APPROVE AND ACCEPT THE FORM 990 AS PRESENTED. FORM 990, PART VI, SECTION B, LINE 12C THE HOSPITAL HAS AN ETHICS AND COMPLIANCE POLICY THAT EACH BOARD MEMBER MUST FOLLOW. THIS POLICY IS REINFORCED EACH YEAR AT A REGULAR BOARD MEETING. ALL BOARD MEMBERS SIGN A COMPLIANCE STATEMENT AT THAT BOARD MEETING THAT STATES THE BOARD MEMBER WILL ABIDE BY THE POLICY. FORM 990, PART VI, SECTION B, LINE 15 THE BOARD OF TRUSTEES EXECUTIVE COMMITTEE HAS ESTABLSHED AND APPROVED AN EXECUTIVE COMPENSATION COMMITTEE THAT REVIEWS AND MONITORS COMPENSATION RECOMMENDATIONS FOR ALL OFFICERS, KEY EMPLOYEES, AND HIGHLY COMPENSATED EMPLOYEES. MULTIPLE SOURCES (AT LEAST THREE) OF INDEPENDENT COMPARISON DATA FROM ORGANIZATIONS OF SIMILAR SIZE, REVENUE, GEOGRAPHIC LOCATION, ORGANIZATION MISSION, AND OFFICER/STAFF RESPONSIBILITIES ARE USED TO DETERMINE COMPENSATION RECOMMENDATIONS. SALARY RATES FOR OFFICER, KEY EMPLOYEES, ETC. ARE FAIR AND EQUITABLE BASED ON COMPARISON DATA SOURCES. THE EXECUTIVE COMPENSATION COMMITTEE MAINTAINS DOCUMENTATION TO SHOW THAT THE COMPENSATION REVIEW PROCESS WAS GIVEN APPROPRIATE DUE DILIGENCE IN REGARD TO DISCUSSION, MEMBERS PRESENT, USE OF COMPARISON DATA AND HOW IT WAS OBTAINED, DATE OF APPROVAL, VIEWS OF DISSENTING MEMBERS, AND THAT ADEQUATE TIME WAS ALLOTTED FOR DISCUSSION BEFORE MAKING DETERMINATIONS. ALL COMPENSATION PACKAGE RECOMMENDATIONS DEVELOPED BY THE EXECUTIVE COMPENSATION COMMITTEE ARE APPROVED BY THE ENTIRE BOARD. FORM 990, PART VI, SECTION C, LINE 18 THE ORGANIZATION MAKES IT'S FORM 990 AVAILABLE TO THE PUBLIC UPON REQUEST. ADDITIONALLY, RECENT COPIES OF THE FORM CAN BE ACCESSED ON GUIDESTAR.ORG. FORM 990, PART VI, SECTION C, LINE 19 THE ORGANIZATION MAKES ITS GOVERNING DOCUMENTS, CONFLICT OF INTEREST POLICY, AND FINANCIAL STATEMENTS AVAILABLE TO THE PUBLIC UPON REQUEST. FORM 990, PART IX, LINE 11G CONSULTANT FEES: PROGRAM SERVICE EXPENSES 24,900. MANAGEMENT AND GENERAL EXPENSES 0. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 24,900. PURCHASED SERVICES: PROGRAM SERVICE EXPENSES 694,988. MANAGEMENT AND GENERAL EXPENSES 315,028. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 1,010,016. OTHER PROFESSIONAL FEES: PROGRAM SERVICE EXPENSES 987,250. MANAGEMENT AND GENERAL EXPENSES 0. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 987,250. FORM 990, PART XI, LINE 9: EQUITY TRANSFER TO FOUNDATION -59,125. FORM 990, PART XII, LINE 2C: THE PROCESS HAS NOT CHANGED FROM THE PRIOR YEAR. ALLEGHANY MEMORIAL HOSPITAL FOUNDATION INC 233 DOCTORS STREET SPARTA NC 28675 562012634 PROMOTES AND SUPPORTS THE HOSPITAL NC 501(C)(3) LINE 11A, I ALLEGHANY COUNTY MEMORIAL HOSPITAL INC 1 ALLEGHANY HEALTH SERVICES 233 DOCTORS STREET SPARTA NC 28675 201189450 COMMUNITY HEALTH SERVICES NC 501(C)(3) LINE 3 ALLEGHANY COUNTY MEMORIAL HOSPITAL INC 1 0 0 1 0 0 0 0 0 0 0 0 1 1 1 1 0 1 0 0 ALLEGHANY MEMORIAL HOSPITAL FOUNDATION INC C 58193 CASH