POLK MEDICAL CENTER INC: Form 990, tax year 2012

View the entire original 990 at ProPublica ↗

Organization
POLK MEDICAL CENTER INC (EIN 45-3957368)
Tax period
2012-07-01 to 2013-06-30
Filed
2014-05-15
IRS object ID
201401359349300715
Schema version
2012v2.3
Source
Download XML · Original 990 at ProPublica

Every field in the e-filed return. Faint text is the IRS element name, for citing.

Return header ReturnHeader

FieldValueIRS element (for citing)
Timestamp2014-05-15T07:15:25-05:00Timestamp
Tax Period End Date2013-06-30TaxPeriodEndDate

Preparer Firm PreparerFirm

Preparer Firm Business Name PreparerFirmBusinessName

FieldValueIRS element (for citing)
Business Name Line1DRAFFIN & TUCKER LLPBusinessNameLine1

Preparer Firm US Address PreparerFirmUSAddress

FieldValueIRS element (for citing)
Address Line1PO BOX 71309AddressLine1
CityALBANYCity
StateGAState
ZIP Code317081309ZIPCode
FieldValueIRS element (for citing)
Return Type990ReturnType
Tax Period Begin Date2012-07-01TaxPeriodBeginDate

Filer Filer

FieldValueIRS element (for citing)
EIN453957368EIN

Name Name

FieldValueIRS element (for citing)
Business Name Line1POLK MEDICAL CENTER INCBusinessNameLine1
FieldValueIRS element (for citing)
Name ControlPOLKNameControl
Phone7065096074Phone

US Address USAddress

FieldValueIRS element (for citing)
Address Line1420 E SECOND AVENUEAddressLine1
Address Line2ROOM/SUITE 102AddressLine2
CityROMECity
StateGAState
ZIP Code301613210ZIPCode

Officer Officer

FieldValueIRS element (for citing)
NameRICHARD T SHEERINName
TitleCFOTitle
Phone7065096074Phone
Date Signed2014-05-15DateSigned
Authorize Third PartytrueAuthorizeThirdParty

Preparer Preparer

FieldValueIRS element (for citing)
NameJACQUELINE G ATKINSName
Phone2298837878Phone
Date Prepared2014-05-13DatePrepared
FieldValueIRS element (for citing)
Tax Year2012TaxYear
Build TS2015-11-30 17:44:51ZBuildTS

Form 990 IRS990

FieldValueIRS element (for citing)
Initial ReturnXInitialReturn
Name Of Principal Officer PersonKURT STUENKELNameOfPrincipalOfficerPerson

Address Principal Officer US AddressPrincipalOfficerUS

FieldValueIRS element (for citing)
Address Line1304 TURNER MCCALL BLVDAddressLine1
CityROMECity
StateGAState
ZIP Code301620233ZIPCode
FieldValueIRS element (for citing)
Gross Receipts0GrossReceipts
Group Return For AffiliatesfalseGroupReturnForAffiliates
Organization501c3XOrganization501c3
Web SiteWWW.POLKMEDICALCENTER.ORGWebSite
Type Of Organization CorporationXTypeOfOrganizationCorporation
Year Formation2011YearFormation
State Legal DomicileGAStateLegalDomicile
Activity Or Mission DescriptionPRIMARY INITIAL ACTIVITY OF THE CORPORATION SHALL BE TO PROVIDE MANAGEMENT SERVICES AND MANAGEMENT DIRECTION TO AND FOR THE BENEFIT OF THE LICENSED OPERATOR OF THE HOSPITAL COMMENCING APRIL 1, 2012. IT IS ANTICIPATED THAT EVENTUALLY THE CORPORATION WILL BECOME THE LICENSED OPERATOR OF POLK MEDICAL CENTER, A 501(C)(3) ORGANIZATION, LOCATED IN CEDARTOWN, GA. PMC IS A 25-BED CRITICAL ACCESS HOSPITAL PROVIDING CARE TO THE COMMUNITY REGARDLESS OF THE ABILITY TO PAY.ActivityOrMissionDescription
Nbr Voting Members Governing Body9NbrVotingMembersGoverningBody
Nbr Independent Voting Members8NbrIndependentVotingMembers
Total Nbr Employees0TotalNbrEmployees
Total Gross UBI0TotalGrossUBI
Contributions Grants Current Year0ContributionsGrantsCurrentYear
Program Service Revenue CY0ProgramServiceRevenueCY
Investment Income Current Year0InvestmentIncomeCurrentYear
Other Revenue Current Year0OtherRevenueCurrentYear
Total Revenue Current Year0TotalRevenueCurrentYear
Grants And Similar Amnts CY0GrantsAndSimilarAmntsCY
Benefits Paid To Members CY0BenefitsPaidToMembersCY
Salaries Etc Current Year0SalariesEtcCurrentYear
Total Prof Fundrsng Exp CY0TotalProfFundrsngExpCY
Total Fundrsng Exp Current Year0TotalFundrsngExpCurrentYear
Other Expenses Current Year34500OtherExpensesCurrentYear
Total Expenses Current Year34500TotalExpensesCurrentYear
Revenues Less Expenses CY-34500RevenuesLessExpensesCY
Total Assets EOY3491343TotalAssetsEOY
Total Liabilities EOY3525843TotalLiabilitiesEOY
Net Assets Or Fund Balances EOY-34500NetAssetsOrFundBalancesEOY
Info In Schedule O Part IIIXInfoInScheduleOPartIII
Mission DescriptionPRIMARY INITIAL ACTIVITY OF THE CORPORATION SHALL BE TO PROVIDE MANAGEMENT SERVICES AND MANAGEMENT DIRECTION TO AND FOR THE BENEFIT OF THE LICENSED OPERATOR OF THE HOSPITAL COMMENCING APRIL 1, 2012. IT IS ANTICIPATED THAT EVENTUALLY THE CORPORATION WILL BECOME THE LICENSED OPERATOR OF POLK MEDICAL CENTER, A 501(C)(3) ORGANIZATION, LOCATED IN CEDARTOWN, GA. PMC IS A 25-BED CRITICAL ACCESS HOSPITAL PROVIDING CARE TO THE COMMUNITY REGARDLESS OF THE ABILITY TO PAY.MissionDescription
Significant New Program ServicesfalseSignificantNewProgramServices
Significant ChangefalseSignificantChange
DescriptionPROVIDES MANAGEMENT SERVICES TO THE OPERATOR OF POLK MEDICAL CENTER, A 501 (C)(3) HOSPITAL LOCATED IN CEDARTOWN, GA, CURRENTLY LEASED AND OPERATED BY THE HOSPITAL AUTHORITY OF FLOYD COUNTY, A RELATED ORGANIZATION.Description
Described In501 C3trueDescribedIn501C3
Schedule B RequiredfalseScheduleBRequired
Political ActivitiesfalsePoliticalActivities
Lobbying ActivitiesfalseLobbyingActivities
Subject To Proxy TaxfalseSubjectToProxyTax
Donor Advised FundsfalseDonorAdvisedFunds
Conservation EasementsfalseConservationEasements
Collections Of ArtfalseCollectionsOfArt
Credit CounselingfalseCreditCounseling
Term Or Permanent EndowmentsfalseTermOrPermanentEndowments
Report Land Bldg EquiptrueReportLandBldgEquip
Report Invest Oth SecuritiesfalseReportInvestOthSecurities
Report Prog Rel InvestfalseReportProgRelInvest
Report Other AssetsfalseReportOtherAssets
Report Other LiabilitiestrueReportOtherLiabilities
Report Fin48 FootnotetrueReportFin48Footnote
Independent Audit Financial StmtfalseIndependentAuditFinancialStmt
Consolidated Audit Financial StmttrueConsolidatedAuditFinancialStmt
SchoolfalseSchool
Foreign OfficefalseForeignOffice
Foreign ActivitiesfalseForeignActivities
More Than5000 K To OrganizationsfalseMoreThan5000KToOrganizations
More Than5000 K To IndividualsfalseMoreThan5000KToIndividuals
Professional FundraisingfalseProfessionalFundraising
Fundraising ActivitiesfalseFundraisingActivities
GamingfalseGaming
HospitalfalseHospital
Grants To OrganizationsfalseGrantsToOrganizations
Grants To IndividualsfalseGrantsToIndividuals
Schedule J RequiredtrueScheduleJRequired
Tax Exempt BondsfalseTaxExemptBonds
Excess Benefit TransactionfalseExcessBenefitTransaction
Prior Excess Benefit TransactionfalsePriorExcessBenefitTransaction
Loan To Officer Or DQPfalseLoanToOfficerOrDQP
Grant To Related PersonfalseGrantToRelatedPerson
Bsnss Rltnshp With OrganizationfalseBsnssRltnshpWithOrganization
Bsnss Rltnshp Thru Family MemberfalseBsnssRltnshpThruFamilyMember
Officer Entity With Bsnss RltnshpfalseOfficerEntityWithBsnssRltnshp
Deductible Non Cash ContributionsfalseDeductibleNonCashContributions
Deductible Contributions Of ArtfalseDeductibleContributionsOfArt
TerminatedfalseTerminated
Partial LiquidationfalsePartialLiquidation
Disregarded EntityfalseDisregardedEntity
Related EntitytrueRelatedEntity
Related Org Controlled EntityfalseRelatedOrgControlledEntity
Transfers To Exempt Non Chrtbl OrgfalseTransfersToExemptNonChrtblOrg
Activities Conducted PartnershipfalseActivitiesConductedPartnership
Schedule O RequiredtrueScheduleORequired
Number Forms Transmitted With10960NumberFormsTransmittedWith1096
Number W2 G Included0NumberW2GIncluded
Number Of Employees0NumberOfEmployees
Unrelated Business IncomefalseUnrelatedBusinessIncome
Foreign Financial AccountfalseForeignFinancialAccount
Prohibited Tax Shelter TransfalseProhibitedTaxShelterTrans
Taxable Party NotificationfalseTaxablePartyNotification
Non Deductible ContributionsfalseNonDeductibleContributions
Quid Pro Quo ContributionsfalseQuidProQuoContributions
Form8282 Property Disposed OffalseForm8282PropertyDisposedOf
Funds To Pay PremiumsfalseFundsToPayPremiums
Premiums PaidfalsePremiumsPaid
Indoor Tanning ServicesfalseIndoorTanningServices
Info In Schedule O Part VIXInfoInScheduleOPartVI
Nbr Voting Governing Body Members9NbrVotingGoverningBodyMembers
Number Independent Voting Members8NumberIndependentVotingMembers
Family Or Business RelationshipfalseFamilyOrBusinessRelationship
Delegation Of Management DutiesfalseDelegationOfManagementDuties
Changes To Organizing DocsfalseChangesToOrganizingDocs
Material Diversion Or MisusefalseMaterialDiversionOrMisuse
Members Or StockholderstrueMembersOrStockholders
Election Of Board MemberstrueElectionOfBoardMembers
Decisions Subject To ApprovaltrueDecisionsSubjectToApproval
Minutes Of Governing BodytrueMinutesOfGoverningBody
Minutes Of CommitteestrueMinutesOfCommittees
Officer Mailing AddressfalseOfficerMailingAddress
Local ChaptersfalseLocalChapters
Form990 Provided To Governing BodytrueForm990ProvidedToGoverningBody
Conflict Of Interest PolicytrueConflictOfInterestPolicy
Annual Disclosure Covered PersonstrueAnnualDisclosureCoveredPersons
Regular Monitoring EnforcementtrueRegularMonitoringEnforcement
Whistleblower PolicytrueWhistleblowerPolicy
Document Retention PolicyfalseDocumentRetentionPolicy
Compensation Process CEOfalseCompensationProcessCEO
Compensation Process OtherfalseCompensationProcessOther
Investment In Joint VenturefalseInvestmentInJointVenture
States Where Copy Of Return Is FiledGAStatesWhereCopyOfReturnIsFiled
Upon RequestXUponRequest

The Books Are In Care Of TheBooksAreInCareOf

FieldValueIRS element (for citing)
Name PersonRICHARD T SHEERINNamePerson
Telephone Number7065096074TelephoneNumber

Address US AddressUS

FieldValueIRS element (for citing)
Address Line1304 TURNER MCCALL BLVDAddressLine1
CityROMECity
StateGAState
ZIP Code301610233ZIPCode
FieldValueIRS element (for citing)
Info In Schedule O Part VIIXInfoInScheduleOPartVII

Form990 Part VII Section A Form990PartVIISectionA (10 entries)

TitleTitleAverage Hours Per WeekAverageHoursPerWeekAverage Hours Per Week RelatedAverageHoursPerWeekRelatedIndividual Trustee Or DirectorIndividualTrusteeOrDirectorOfficerOfficerReportable Comp From OrganizationReportableCompFromOrganizationReportable Comp From Related OrgsReportableCompFromRelatedOrgsOther CompensationOtherCompensation
KURT STUENKEL
PRESIDENT1.0042.00XX0140216170505
JERRY F NORMAN
MEMBER1.003.00X089500
J SAM FREEMAN
MEMBER1.002.00X068750
LARRY KUGLAR
MEMBER1.002.00X056250
FRANK SHELLEY
MEMBER1.002.00X056250
LEE CUMMINGS
MEMBER1.00X030000
DARROLL FREEMAN
MEMBER1.00X030000
BRUCE CASEY
MEMBER1.00X027500
HAROLD W WYATT JR
MEMBER1.00X023750
RICHARD T SHEERIN
CFO1.0042.00X043163050779
FieldValueIRS element (for citing)
Total Reportable Comp Frm Rltd Orgs1871991TotalReportableCompFrmRltdOrgs
Total Other Compensation121284TotalOtherCompensation
Formers ListedfalseFormersListed
Total Comp GT150 KtrueTotalCompGT150K
Compensation From Other SourcesfalseCompensationFromOtherSources

Total Revenue TotalRevenue

FieldValueIRS element (for citing)
Total Revenue Column0TotalRevenueColumn

Other Expenses OtherExpenses

FieldValueIRS element (for citing)
DescriptionBOARD EXPENSESDescription
Total34500Total
Management And General34500ManagementAndGeneral

Total Functional Expenses TotalFunctionalExpenses

FieldValueIRS element (for citing)
Total34500Total
Program Services0ProgramServices
Management And General34500ManagementAndGeneral
Fundraising0Fundraising

Other Notes Loans Receivable Net OtherNotesLoansReceivableNet

FieldValueIRS element (for citing)
EOY840000EOY
FieldValueIRS element (for citing)
Land Buildings Equipment Basis2651343LandBuildingsEquipmentBasis

Land Buildings Equipment Basis Net LandBuildingsEquipmentBasisNet

FieldValueIRS element (for citing)
EOY2651343EOY

Total Assets TotalAssets

FieldValueIRS element (for citing)
BOY0BOY
EOY3491343EOY

Other Liabilities OtherLiabilities

FieldValueIRS element (for citing)
EOY3525843EOY

Total Liabilities TotalLiabilities

FieldValueIRS element (for citing)
BOY0BOY
EOY3525843EOY
FieldValueIRS element (for citing)
Follow SFAS117XFollowSFAS117

Unrestricted Net Assets UnrestrictedNetAssets

FieldValueIRS element (for citing)
EOY-34500EOY

Total Net Assets Fund Balances TotalNetAssetsFundBalances

FieldValueIRS element (for citing)
BOY0BOY
EOY-34500EOY

Total Liab Net Assets Fund Balances TotalLiabNetAssetsFundBalances

FieldValueIRS element (for citing)
BOY0BOY
EOY3491343EOY
FieldValueIRS element (for citing)
Reconcilation Revenue Expenses-34500ReconcilationRevenueExpenses
Method Of Accounting AccrualXMethodOfAccountingAccrual
Accountant Compile Or ReviewfalseAccountantCompileOrReview
FS AuditedtrueFSAudited

FS Audited Basis FSAuditedBasis

FieldValueIRS element (for citing)
Financial Statement ConsolidatedXFinancialStatementConsolidated
FieldValueIRS element (for citing)
Audit CommitteetrueAuditCommittee
Federal Grant Audit RequiredfalseFederalGrantAuditRequired

Schedule A IRS990ScheduleA

FieldValueIRS element (for citing)
Hospital170b1 AiiiXHospital170b1Aiii

Schedule D IRS990ScheduleD

Other Land Buildings OtherLandBuildings

FieldValueIRS element (for citing)
Other Cost Or Other Basis2651343OtherCostOrOtherBasis
Book Value2651343BookValue
FieldValueIRS element (for citing)
Total Of Book Value Land Buildings2651343TotalOfBookValueLandBuildings

Other Liabilities OtherLiabilities

FieldValueIRS element (for citing)
DescriptionDUE TO RELATED ORGANIZATIONSDescription
Amount$3,525,843Amount
FieldValueIRS element (for citing)
Total Of Amounts3525843TotalOfAmounts
Footnote In Part XIIIXFootnoteInPartXIII

Form990 Schedule D Part XIII Form990ScheduleDPartXIII

FieldValueIRS element (for citing)
IdentifierLIABILITY UNDER FIN 48 FOOTNOTEIdentifier
Return ReferenceSCHEDULE D, PAGE 3, PART XReturnReference
ExplanationTHE CORPORATION IS A NOT-FOR-PROFIT CORPORATION THAT HAS BEEN RECOGNIZED AS TAX-EXEMPT PURSUANT TO SECTION 501(C)(3) OF THE INTERNAL REVENUE CODE. THE CORPORATION APPLIES ACCOUNTING POLICIES THAT PRESCRIBE WHEN TO RECOGNIZE AND HOW TO MEASURE THE FINANCIAL STATEMENT EFFECTS OF INCOME TAX POSITIONS TAKEN OR EXPECTED TO BE TAKEN ON ITS INCOME TAX RETURNS. THESE RULES REQUIRE MANAGEMENT TO EVALUATE THE LIKELIHOOD THAT, UPON EXAMINATION BY THE RELEVANT TAXING JURISDICTIONS, THOSE INCOME TAX POSITIONS WOULD BE SUSTAINED. BASED ON THAT EVALUATION, THE HOSPITAL ONLY RECOGNIZES THE MAXIMUM BENEFIT OF EACH INCOME TAX POSITION THAT IS MORE THAN 50% LIKELY OF BEING SUSTAINED. TO THE EXTENT THAT ALL OR A PORTION OF THE BENEFITS OF AN INCOME TAX POSITION ARE NOT RECOGNIZED, A LIABILITY WOULD BE RECOGNIZED FOR THE UNRECOGNIZED BENEFITS, ALONG WITH ANY INTEREST AND PENALTIES THAT WOULD RESULT FROM DISALLOWANCE OF THE POSITION. SHOULD ANY SUCH PENALTIES AND INTEREST BE INCURRED, THEY WOULD BE RECOGNIZED AS OPERATING EXPENSES. BASED ON THE RESULTS OF MANAGEMENT'S EVALUATION, NO LIABILITY IS RECOGNIZED IN THE ACCOMPANYING BALANCE SHEET FOR UNRECOGNIZED INCOME TAX POSITIONS. FURTHER, NO INTEREST OR PENALTIES HAVE BEEN ACCRUED OR CHARGED TO EXPENSE AS OF JUNE 30, 2013 AND 2012 OR FOR THE YEARS THEN ENDED. THE HOSPITAL'S OPEN AUDIT PERIODS ARE FOR TAX YEARS ENDED 2010-2012.Explanation

Schedule J IRS990ScheduleJ

FieldValueIRS element (for citing)
Severance PaymentfalseSeverancePayment
Supplemental Nonqual Retire PlantrueSupplementalNonqualRetirePlan
Equity Based Comp ArrangementfalseEquityBasedCompArrangement
Comp Based On Revenue Of Filing OrgfalseCompBasedOnRevenueOfFilingOrg
Comp Based On Revenue Related OrgsfalseCompBasedOnRevenueRelatedOrgs
Comp Based Net Earnings Filing OrgfalseCompBasedNetEarningsFilingOrg
Comp Based Net Earnings Relate OrgstrueCompBasedNetEarningsRelateOrgs
Any Non Fixed PaymentsfalseAnyNonFixedPayments
Initial Contract ExceptionfalseInitialContractException

Form990 Schedule J Part II Form990ScheduleJPartII (2 entries)

TitleTitleComp Based On Related OrgsCompBasedOnRelatedOrgsBonus Related OrgsBonusRelatedOrgsOther Compensation Related OrgsOtherCompensationRelatedOrgsDeferred Comp Related OrgsDeferredCompRelatedOrgsNontaxable Benefits Related OrgsNontaxableBenefitsRelatedOrgsTotal Compensation Related OrgsTotalCompensationRelatedOrgs
KURT STUENKEL
PRESIDENT56205027704556306645476250291472666
RICHARD T SHEERIN
CFO304665113251137143494715832482409

Form990 Schedule J Part III Form990ScheduleJPartIII (4 entries)

IdentifierIdentifierReturn ReferenceReturnReferenceExplanationExplanation
RELATED ORG METHODS USED FOR COMPENSATION EXPLANATIONSCHEDULE J, PAGE 1, PART I, LINE 3NONE OF THE INDIVIDUAL BOARD MEMBERS OR OFFICERS ARE COMPENSATED BY THE FILING ORGANIZATION AND THE ORGANIZATION MUST RELY ON THE METHODS EMPLOYED BY THE RELATED ORGANIZATION, FHMI, TO DETERMINE REASONABLE COMPENSATION FOR THE INDIVIDUALS.
SEVERANCE, NONQUALIFIED, AND EQUITY-BASED PAYMENTSSCHEDULE J, PAGE 1, PART I, LINE 4KURT STUENKEL 0 534,087 0
COMPENSATION CONTINGENT UPON NET EARNINGS OF RELATED ORGSCHEDULE J, PAGE 1, PART I, LINE 6BBONUS/INCENTIVE AWARDS: ALL MEMBERS OF THE EXECUTIVE TEAM FOR FHMI PARTICIPATE IN AN INCENTIVE COMPENSATION PLAN UNDER WHICH ANNUAL YEAR-END BONUSES ARE PAID BASED ON INDIVIDUAL AND CORPORATE-WIDE ACHIEVEMENT OF SPECIFIC GOALS AND OBJECTIVES. ONE OF THE GOALS RELATES TO THE ORGANIZATION'S NET INCOME. THESE BONUSES ARE A CASH-BASED SYSTEM.
OTHER ADDITIONAL INFORMATIONSCHEDULE J, PART IIIMR. STUENKEL AND MR. SHEERIN ARE COMPENSATED BY FLOYD HEALTHCARE MANAGEMENT, INC. (EIN:58-1973570) FOR SERVICES AS THE CEO AND CFO, RESPECTIVELY, OF FLOYD HEALTHCARE MANAGEMENT, INC. THEY RECEIVE NO COMPENSATION FROM THE FILING ORGANIZATION. FOR AN EXPLANATION OF THE EXECUTIVE COMPENSATION PLAN OF FLOYD HEALTHCARE MANAGEMENT, INC., SEE THE SCHEDULE O RESPONSE TO FORM 990, PART VI, LINES 15A AND 15B. THE CEO PARTICIPATES IN A SUPPLEMENTAL EXECUTIVE RETIREMENT PLAN (SERP) WHICH IS FUNDED ANNUALLY IN AN AMOUNT WHICH, WHEN ADDED TO OTHER SOURCES OF RETIREMENT INCOME, WILL AFFORD A RETIREMENT INCOME AT A TARGETED PERCENTAGE OF PRE-RETIREMENT COMPENSATION. THE SERP IS A NON-QUALIFIED RETIREMENT PLAN, AND AS SUCH THE ANNUAL FUNDING PAYMENTS PAID INTO IT ARE TAXABLE TO THE PARTICIPANT IN THE YEAR IN WHICH MADE. EFFECTIVE WITH CALENDAR YEAR 2009, MR. STUENKEL'S SERP IS A CASH-BASED PROGRAM. ADDITIONALLY, OF THE 1,402,161 LISTED AS COMPENSATION FOR MR. STUENKEL, 277,045 REPRESENTS A PERFORMANCE BASED PAYMENT ARISING FROM THE 2012 PERFORMANCE PERIOD AND 534,087 REPRESENTS THE NONQUALIFIED SERP PLAN. ACCORDINGLY, MR. STUENKEL'S SALARY FOR 2012 WOULD HAVE BEEN 591,029 EXCLUDING THE 2012 PORTION OF THE INCENTIVE BASED PAYMENT AND THE SERP PLAN AMOUNT.

Schedule O IRS990ScheduleO

General Explanation GeneralExplanation (8 entries)

IdentifierIdentifierReturn ReferenceReturnReferenceExplanationExplanation
ORGANIZATION'S MISSIONFORM 990 - ORGANIZATION'S MISSIONPRIMARY INITIAL ACTIVITY OF THE CORPORATION SHALL BE TO PROVIDE MANAGEMENT SERVICES AND MANAGEMENT DIRECTION TO AND FOR THE BENEFIT OF THE LICENSED OPERATOR OF THE HOSPITAL COMMENCING APRIL 1, 2012. IT IS ANTICIPATED THAT EVENTUALLY THE CORPORATION WILL BECOME THE LICENSED OPERATOR OF POLK MEDICAL CENTER, A 501(C)(3) ORGANIZATION, LOCATED IN CEDARTOWN, GA. PMC IS A 25-BED CRITICAL ACCESS HOSPITAL PROVIDING CARE TO THE COMMUNITY REGARDLESS OF THE ABILITY TO PAY.
CLASSES OF MEMBERS OR STOCKHOLDERSFORM 990, PAGE 6, PART VI, LINE 6FLOYD HEALTHCARE MANAGEMENT, INC. (FHMI), A RELATED ORGANIZATION, HAS THE POWER TO APPOINT EIGHT OF THE NINE MEMBER GOVERNING BODY WHILE THE PRESIDENT/CEO OF FHMI IS THE FINAL MEMBER OF THE BOARD.
ELECTION OF MEMBERS AND THEIR RIGHTSFORM 990, PAGE 6, PART VI, LINE 7AFLOYD HEALTHCARE MANAGEMENT, INC. (FHMI), A RELATED ORGANIZATION, HAS THE POWER TO APPOINT EIGHT OF THE NINE MEMBER GOVERNING BODY WHILE THE PRESIDENT/CEO OF FHMI IS THE FINAL MEMBER OF THE BOARD.
DECISIONS SUBJECT TO APPROVAL OF MEMBERSFORM 990, PAGE 6, PART VI, LINE 7BPRIOR APPROVAL OF FHMI IS REQUIRED FOR ANY OF THE FOLLOWING ACTIONS: DISSOLUTION; SALE, MERGER OR DISPOSITION; ADOPTION OF CAPITAL OR OPERATING BUDGETS; SELECT OR REMOVE THE ADMINISTRATOR; INCUR INDEBTEDNESS IN EXCESS OF 1,000,000; TAKE ANY ACTION ON THE LEASE OR CONTRACT BETWEEN THE CORPORATION AND CEDARTOWN-POLK COUNTY HOSPITAL AUTHORITY; AMEND THE CORPORATE ARTICLES OF INCORPORATION OR BYLAWS.
ORGANIZATION'S PROCESS USED TO REVIEW FORM 990FORM 990, PAGE 6, PART VI, LINE 11BTHE ORGANIZATION'S CEO, CFO, CONTROLLER, LEGAL COUNSEL AND EMPLOYEES OF FHMI REVIEW THE FORM 990 FOR FINANCIAL AND DISCLOSURE ACCURACY. PRIOR TO ITS FILING, A COPY OF THE ORGANIZATION'S 990 RETURN IS POSTED ON THE BOARD OF DIRECTORS' SECURE WEBSITE FOR THEIR REVIEW. MANAGEMENT WILL SEND AN EMAIL NOTIFYING MEMBERS OF ITS POSTING.
ENFORCEMENT OF CONFLICTS POLICYFORM 990, PAGE 6, PART VI, LINE 12CPOLK MEDICAL CENTER, INC. (PMCI) HAS A WRITTEN POLICY RESPECTING CONFLICTS OF INTEREST AND DISCLOSURE OF SAME. GENERALLY SPEAKING, THE POLICY REQUIRES ANY "COVERED PERSON" WHO BELIEVES HE/SHE HAS A CONFLICT OF INTEREST TO: -DISCLOSE THE EXISTENCE AND NATURE OF THE CONFLICT OF INTEREST (INCLUDING ALL FACTS KNOWN RESPECTING THE SUBJECT MATTER) TO THE CHAIRMAN OF THE BOARD; -PLAY NO PART, DIRECTLY OR INDIRECTLY, IN THE DELIBERATION OR VOTE OF THE BOARD OF DIRECTORS WITH RESPECT TO THE DETERMINATION OF WHETHER A CONFLICT OF INTEREST EXISTS; AND -ABSENT HIMSELF/HERSELF FROM THAT PORTION OF THE MEETING AT WHICH THE CONFLICT OF INTEREST IS DISCUSSED. THE DEFINITION OF A "COVERED PERSON" INCLUDES ALL BOARD MEMBERS, OFFICERS AND MEMBERS OF SENIOR MANAGEMENT OF FHMI. WHEN A COVERED PERSON DISCLOSES A POTENTIAL CONFLICT OF INTEREST TO THE BOARD CHAIRMAN, THE CHAIRMAN IS OBLIGED TO BRING THE MATTER TO THE ATTENTION OF THE FULL BOARD. THE BOARD DETERMINES WHETHER A CONFLICT OF INTEREST ACTUALLY EXISTS. IF THE BOARD DETERMINES THAT THERE IS A CONFLICT OF INTEREST, THE TRANSACTION OR MATTER GIVING RISE TO THE CONFLICT OF INTEREST MAY NOT PROCEED UNLESS THE BOARD DETERMINES, BY A MAJORITY VOTE, THAT, DESPITE THE CONFLICT OF INTEREST, THE TRANSACTION/MATTER IS NEVERTHELESS IN THE CORPORATION'S BEST INTEREST AND IS FAIR AND REASONABLE TO THE CORPORATION. IN ADDITION TO THE REQUIREMENT THAT A COVERED PERSON DISCLOSE A POTENTIAL CONFLICT OF INTEREST AT THE TIME IT ARISES, EACH COVERED PERSON IS ALSO REQUIRED TO SUBMIT, ON AN ANNUAL BASIS, A `CONFLICT AND DISCLOSURE OF INTEREST QUESTIONNAIRE'. THIS MULTI-QUESTION DOCUMENT SERVES AS A REMINDER AND PROMPTS EACH COVERED PERSON TO PONDER THOSE AREAS AND SITUATIONS WHERE A POTENTIAL CONFLICT MIGHT EXIST. ADDITIONALLY, ANY PROPOSED TRANSACTION AT PMCI WHICH INVOLVES AN "INSIDER" (I.E., A BOARD MEMBER, OFFICER, MANAGER, ETC.) IS SCRUTINIZED, WITH THE ASSISTANCE OF CORPORATE LEGAL COUNSEL, FROM THE STANDPOINT OF WHETHER THE TRANSACTION WILL RESULT IN ANY EXCESS BENEFIT TO THE INSIDER. TYPICALLY THIS INVOLVES OBTAINING APPROPRIATE DATA REGARDING COMPARABILITY WHICH IS PROVIDED TO THE BOARD FOR ITS USE IN DETERMINING THAT THE CONSIDERATION BEING PAID TO THE INSIDER AS A PART OF THE TRANSACTION IS REASONABLE AND DOES NOT EXCEED THE VALUE OF THE BENEFIT RECEIVED BY PMCI.
GOVERNING DOCUMENTS DISCLOSURE EXPLANATIONFORM 990, PAGE 6, PART VI, LINE 19UPON REQUEST, THE ORGANIZATION MAKES ITS GOVERNING DOCUMENTS, CONFLICT OF INTEREST POLICY, AND FINANCIAL STATEMENTS AVAILABLE AT THE ADMINISTRATIVE OFFICES OF THE CORPORATION.
RELATED ORGANIZATIONSFORM 990, PAGE 7, PART VIIFORM 990, PART VI, LINE 15 - COMPENSATION PROCESS FOR OFFICERS THE ORGANIZATION DOES NOT PAY COMPENSATION TO ANY OFFICER OR EMPLOYEE. THE ORGANIZATION HAS NO EMPLOYEES. TWO INDIVIDUALS SERVE AS THE ORGANIZATION'S CORPORATE OFFICERS - KURT STUENKEL AS CEO AND RICK SHEERIN AS CFO; BUT NEITHER MR. STUENKEL NOR MR. SHEERIN ARE PAID ANY COMPENSATION FOR THIS SERVICE BY THE ORGANIZATION. RATHER, MR. STUENKEL AND MR. SHEERIN RECEIVE THEIR COMPENSATION SOLELY FROM FLOYD HEALTHCARE MANAGEMENT, INC., A RELATED ORGANIZATION. THE COMPENSATION FOR MR. STUENKEL AND MR. SHEERIN REPORTED IN PART II OF SCHEDULE J IS COMPENSATION PAID TO THEM BY FLOYD HEALTHCARE MANAGEMENT, INC. THE FOLLOWING IS AN EXPLANATION OF THE PROCESS UTILIZED BY FLOYD HEALTHCARE MANAGEMENT, INC. TO DETERMINE THE COMPENSATION IT PAYS ITS EXECUTIVES. IT IS THE RESPONSIBILITY OF THE COMPENSATION COMMITTEE OF FLOYD HEALTHCARE MANAGEMENT, INC. BOARD TO ACTIVELY MANAGE AND MONITOR EXECUTIVE COMPENSATION. TO DO SO, THE COMMITTEE HAS ESTABLISHED THE FOLLOWING OBJECTIVES FOR THE EXECUTIVE COMPENSATION PROGRAM: -PROVIDE A COMPETITIVE TOTAL COMPENSATION EARNING OPPORTUNITY TO RECRUIT, RETAIN, AND REWARD THE EXECUTIVES NEEDED TO MEET THE COMMUNITY'S HEALTHCARE NEEDS, NOW AND IN THE FUTURE; -PROVIDE PAY OPPORTUNITIES THAT WILL REWARD THE EXECUTIVE TEAM WHEN ORGANIZATIONAL PERFORMANCE IN KEY AREAS IS DEMONSTRATED; -INCENTIVE COMPENSATION UNDER THE EXECUTIVE INCENTIVE COMPENSATION PLAN IS PAYABLE ONLY IN THE EVENT THE ORGANIZATION'S OPERATING MARGIN FROM OPERATING REVENUE EXCEEDS CERTAIN PARAMETERS ESTABLISHED BY THE COMPENSATION COMMITTEE; -ENSURE THAT THE COMPENSATION PROGRAMS ARE EASY FOR ALL INTERESTED PARTIES TO UNDERSTAND. ANNUALLY, THE COMMITTEE REVIEWS THE APPROPRIATENESS OF THE TOTAL COMPENSATION PROVIDED TO EACH EXECUTIVE: -AS RELATED TO THE COMPETITIVE MARKET PAY RATES; -AS RELATED TO THE INDIVIDUAL'S ROLE AND RESPONSIBILITY IN THE ORGANIZATION; -AS IT PERTAINS TO VARIABLE OR INCENTIVE EARNING OPPORTUNITIES RELATING TO THE PERFORMANCE OF THE ORGANIZATION. TO DETERMINE THE MARKET RATES FOR EACH POSITION, THE COMMITTEE UTILIZES AN OUTSIDE CONSULTANT TO SURVEY COMPARABLE ORGANIZATIONS TO DEVELOP AN APPROPRIATE RANGE OF PAY FOR EACH EXECUTIVE POSITION. THIS RANGE GENERALLY REFLECTS THE PAY PRACTICES AND LEVELS OF COMPARABLE ORGANIZATIONS IN GEORGIA, THE SOUTHEAST, AND ACROSS THE COUNTRY. SPECIFICALLY, THE COMMITTEE REVIEWS DATA FOR MARKET RATES OF BASE SALARY AND TOTAL COMPENSATION (THE COMBINATION OF BASE SALARY AND BONUSES). AFTER REVIEWING THIS DATA, THE COMMITTEE ASSESSES THE APPROPRIATENESS OF THE BASE PAY LEVELS FOR EACH EXECUTIVE WITHIN A RANGE THAT GENERALLY REFLECTS INDUSTRY NORMS. IN ADDITION TO MONITORING BASE SALARIES, THE COMMITTEE IS RESPONSIBLE FOR ADMINISTERING THE EXECUTIVE INCENTIVE COMPENSATION PROGRAM. THE PROGRAM IS DESIGNED TO: -FURTHER ALIGN EXECUTIVE PAY WITH THE STRATEGIC AND OPERATIONAL ACHIEVEMENTS OF THE ORGANIZATION; -WHEN THE ORGANIZATION ACHIEVES RESULTS IN KEY AREAS OF PERFORMANCE, TO APPROPRIATELY REWARD EXECUTIVES ACCORDING TO THAT PROGRAM; THE COMMITTEE HAS ALSO ESTABLISHED SUPPLEMENTAL EXECUTIVE RETIREMENT PROGRAMS (SERPS). THESE SERPS WERE DESIGNED WITH THE ADVICE AND HELP OF CONSULTANTS AND ARE DESIGNED TO RETAIN AND REWARD EXECUTIVES WITH RETIREMENT OPPORTUNITIES THAT ARE CONSISTENT WITH MARKET PRACTICES IN GEORGIA, THE SOUTHEAST, AND ACROSS THE COUNTRY. IN 2001, THESE PLANS VESTED TWO EXECUTIVES. IT IS THE PHILOSOPHY OF THE FHMI BOARD THAT THE COMBINATION OF THE INCENTIVE EARNING OPPORTUNITY, THE BASE SALARY, AND THE SERPS WILL PROVIDE A COMPETITIVE COMPENSATION LEVEL TO EACH EXECUTIVE THAT REFLECTS THE MARKET FOR EACH POSITION AND ORGANIZATION PERFORMANCE. THE COMMITTEE HAS DEVELOPED THE PROGRAM TO RECRUIT, RETAIN, AND REWARD EXECUTIVES IN ORDER TO MEET THE PRESENT AND FUTURE NEEDS OF THE ORGANIZATION TO PROVIDE A HIGH QUALITY OF PATIENT CARE TO THE COMMUNITY IN A COST EFFECTIVE MANNER. AFFILIATIONS AND COMMITMENTS: THE CEDARTOWN-POLK COUNTY HOSPITAL AUTHORITY (POLK AUTHORITY) IS A HOSPITAL AUTHORITY CREATED AND ORGANIZED UNDER THE GEORGIA HOSPITAL AUTHORITIES LAW. IT IS THE OWNER OF POLK MEDICAL CENTER A 25-BED, CRITICAL ACCESS HOSPITAL LOCATED IN CEDARTOWN, GA. THE POLK AUTHORITY CONSISTS OF A SELF- PERPETUATING SEVEN-PERSON BOARD, ALL OF WHOM ARE POLK COUNTY RESIDENTS. IN 2011 THE POLK AUTHORITY SOLICITED PROPOSALS RESPECTING THE LEASE AND OPERATION OF POLK MEDICAL CENTER. FLOYD HEALTHCARE MANAGEMENT INC. (FHMI) AND THE HOSPITAL AUTHORITY OF FLOYD COUNTY (HAFC) JOINTLY RESPONDED TO THE REQUEST FOR PROPOSALS BY SUBMITTING A PROPOSAL UNDER WHICH THE FOLLOWING TRANSACTIONS AND UNDERTAKINGS WOULD OCCUR: (1) HAFC WOULD LEASE POLK MEDICAL CENTER FROM THE POLK AUTHORITY AND OPERATE IT FOR A PERIOD OF UP TO FIVE YEARS; (2) FHMI WOULD CREATE A NON-PROFIT CORPORATION TO BE CALLED POLK MEDICAL CENTER INC. (PMCI), WHICH WOULD HAVE A BOARD OF DIRECTORS COMPRISED OF NINE PERSONS APPOINTED BY FHMI, THREE OF WHOM WOULD BE RESIDENTS OF FLOYD COUNTY AND SIX OF WHOM WOULD BE RESIDENTS OF POLK COUNTY; (3) PMCI WOULD BE ENGAGED BY HAFC TO MANAGE THE DAY-TO-DAY OPERATION OF POLK MEDICAL CENTER DURING THE TERM OF THE AFORESAID FIVE-YEAR LEASE; (4) PMCI AND FHMI WOULD UNDERTAKE TO CONSTRUCT A NEW, 25-BED REPLACEMENT HOSPITAL ON LAND ALREADY OWNED BY THE POLK AUTHORITY ON THE OUTSKIRTS OF CEDARTOWN, WITH CONSTRUCTION TO BE COMPLETED WITHIN FIVE YEARS; AND (5) UPON COMPLETION OF CONSTRUCTION, THE FIVE-YEAR LEASE WOULD TERMINATE, AND OWNERSHIP OF THE NEW HOSPITAL WOULD RESIDE IN THE POLK AUTHORITY, WHICH WOULD IN TURN LEASE IT TO PMCI FOR A PERIOD OF 35 YEARS. THE FOREGOING PROPOSAL WAS ACCEPTED BY THE POLK AUTHORITY, AND IN LATE 2011, AGREEMENTS BY AND AMONG FHMI, PMCI, HAFC AND THE POLK AUTHORITY WERE EXECUTED, INCLUDING THE FIVE-YEAR LEASE AGREEMENT AND A HOSPITAL CONSTRUCTION AGREEMENT. ON APRIL 1, 2012 THE FIVE-YEAR LEASE AGREEMENT COMMENCED AT WHICH TIME HAFC BECAME THE LICENSED OPERATOR OF POLK MEDICAL CENTER, WITH THE NEWLY CREATED PMCI ENGAGED TO PROVIDE DAY-TO-DAY MANAGEMENT OF THE HOSPITAL'S OPERATION. FHMI IS A NOT-FOR-PROFIT CORPORATION CREATED IN 1991 BY HAFC. FROM NOV. 26, 1991, THROUGH DEC. 31, 1997, FHMI MANAGED AND SUPERVISED FLOYD MEDICAL CENTER AND ALL OTHER FACILITIES, PROJECTS AND PROGRAMS OF HAFC PURSUANT TO A MANAGEMENT AGREEMENT. EFFECTIVE JAN. 1, 1998, THE AFORESAID MANAGEMENT AGREEMENT WAS CONVERTED TO A LEASE AGREEMENT UNDER WHICH ALL FACILITIES, PROJECTS AND PROGRAMS OF HAFC WERE LEASED TO FHMI. AT THAT TIME, FHMI BECAME THE LICENSED OPERATOR OF ALL SUCH FACILITIES, PROJECTS AND PROGRAMS. FHMI IS GOVERNED BY AN EIGHTEEN MEMBER BOARD OF DIRECTORS, THREE OF WHOM MUST BE MEMBERS OF HAFC. ADDITIONALLY, FHMI HAS CONTRACTUALLY COMMITTED THAT AT LEAST TWO OF ITS DIRECTORS WILL BE FLOYD COUNTY COMMISSIONERS AND TWO OF ITS DIRECTORS WILL BE CEDARTOWN-POLK COUNTY HOSPITAL AUTHORITY MEMBERS.

Schedule R IRS990ScheduleR

Form990 Schedule R Part II Form990ScheduleRPartII (3 entries)

Address Line1AddressUS/AddressLine1CityAddressUS/CityStateAddressUS/StateZIP CodeAddressUS/ZIPCodeEINEINPrimary ActivitiesPrimaryActivitiesLegal Domicile StateLegalDomicileStateExempt Code SectionExemptCodeSectionPublic Charity StatusPublicCharityStatusBusiness Name Line1DirectControllingEntityName/BusinessNameLine1Controlled OrgControlledOrgBusiness Name Line2NameOfDisregardedEntity/BusinessNameLine2Business Name Line2DirectControllingEntityName/BusinessNameLine2
FLOYD HEALTHCARE MANAGEMENT INC
304 TURNER MCCALL BLVDROMEGA301620233581973570ACUTE CAREGA501C33NAfalse
HOSPITAL AUTHORITY OF FLOYD COUNTY
304 TURNER MCCALL BLVDROMEGA301620233586001173HEALTHCAREGA501C33NAfalse
HOSPITAL AUTHORITY OF FLOYD COUNTY
304 TURNER MCCALL BLVDROMEGA301620233586140617TRUSTGA501C311DFHMIfalseSELF INSURANCE TRUSTFLOYD HEALTHCARE MANAGEMENT INC
FieldValueIRS element (for citing)
Receipt Of Int Ann Rents RoyaltiesfalseReceiptOfIntAnnRentsRoyalties
Gift Grant Or Cap Contr To Other OrgfalseGiftGrantOrCapContrToOtherOrg
Gift Grant Or Cap Contr Fr Other OrgfalseGiftGrantOrCapContrFrOtherOrg
Loans Or Guarantees To Other OrgfalseLoansOrGuaranteesToOtherOrg
Loans Or Guarantees From Other OrgtrueLoansOrGuaranteesFromOtherOrg
Dividends Related OrganizationfalseDividendsRelatedOrganization
Sale Of Assets To Other OrgfalseSaleOfAssetsToOtherOrg
Purchase Of Assets From Other OrgfalsePurchaseOfAssetsFromOtherOrg
Exchange Of AssetsfalseExchangeOfAssets
Rental Of Facilities To Other OrgsfalseRentalOfFacilitiesToOtherOrgs
Rental Of Facilities Fr Other OrgsfalseRentalOfFacilitiesFrOtherOrgs
Perform Of Services For Other OrgstruePerformOfServicesForOtherOrgs
Perform Of Services By Other OrgstruePerformOfServicesByOtherOrgs
Sharing Of FacilitiestrueSharingOfFacilities
Sharing Of Paid EmployeestrueSharingOfPaidEmployees
Reimbursement Paid To Other OrgfalseReimbursementPaidToOtherOrg
Reimbursement Paid By Other OrgfalseReimbursementPaidByOtherOrg
Other Transfer To Other OrgfalseOtherTransferToOtherOrg
Other Transfer From Other OrgfalseOtherTransferFromOtherOrg

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