2014-08-13T08:18:40-05:00 2013-09-30 420714325 MCGLADREY LLP 1 S WACKER DRIVE STE 800 CHICAGO IL 60606 990 2012-10-01 562112733 The Outer Banks Hospital Inc OUTE 2528475129 2100 Stantonsburg Road Greenville NC 27835 David Hughes 2528475129 2014-08-13 1 Wayne Harder P00294296 3126343400 2012 2015-11-30 17:44:51Z Ronald Sloan 2100 Stantonsburg Road Greenville NC 27835 63613289 0 X www.theouterbankshospital.com X 2002 NC To provide a wide range of quality services to the residents and visitors of the Outer Banks. 10 9 360 52 0 0 0 0 49887752 62434669 62754 88388 74201 1079310 50024707 63602367 0 49500 0 0 19682933 21038717 0 0 0 20946321 33481470 40629254 54569687 9395453 9032680 60754128 59601069 6273475 7747736 54480653 51853333 To enhance the quality of life for the people and communities we serve, touch and support. 0 0 36231952 49500 49086390 Outpatient and Emergency Services:Provided emergency services to 22,691 patients 24 hours a day for 365 days. Provided outpatient diagnostic and therapeutic services to 22,522 patients. Performed 1,675 outpatient surgical procedures. 9852953 13348279 Inpatient Services:Provided inpatient care 24 hours a day for 365 days to 1,405 patients. Delivered 371 babies. Performed 544 inpatient surgical procedures. 46084905 1 0 0 1 0 0 0 0 0 0 1 0 1 0 1 1 0 1 0 0 0 0 0 0 0 0 1 1 1 1 1 0 0 0 0 0 0 0 0 0 0 0 0 1 1 0 0 0 1 0 0 360 1 0 0 0 0 0 0 0 0 0 0 X 10 9 0 0 0 0 1 1 1 1 1 0 0 0 0 0 0 1 1 0 X X Todd Warlitner 2528475129 2100 Stantonsburg Road Greenville NC 27835 Linda Palombo 2.00 0.00 X 0 0 0 Ernest Larkin 2.00 0.00 X 0 0 0 Beulah Charity Ashby 2.00 0.00 X 0 0 0 Christine Petzing MD 2.00 0.00 X 0 0 0 Roger Robertson 2.00 46.00 X 0 400870 90819 Terry Wheeler 2.00 0.00 X 0 0 0 Jody Midgette 2.00 0.00 X 0 0 0 Arthur Keeney 2.00 6.00 X 0 0 0 Steve Rodriquez 2.00 0.00 X 0 0 0 Bob Guanci 2.00 0.00 X 0 0 0 Todd Warlitner 40.00 0.00 X 141717 0 55650 Ronald Sloan 40.00 0.00 X 226561 0 59818 Judy Bruno 40.00 0.00 X 138081 0 48210 Gary Hunter 40.00 0.00 X 404254 0 40418 Monte Thompson 40.00 0.00 X 146345 0 29131 Mary Moseley 40.00 0.00 X 102297 0 37565 Edward Heise 40.00 0.00 X 124391 0 31976 Mary Terrell Parnell 40.00 0.00 X 125942 0 19206 1409588 400870 412793 10 0 1 0 Aviation Anesthesia Association Inc 158 Battlefield Court Manteo NC 27954 CRNA Staffing 312233 GE Medical Systems PO Box 402076 Atlanta GA 30384 Equipment Service/Repair 291373 Frank X Biondi PO Box 1464 Nags Head NC 27959 CRNA Staffing 271016 Shared Hospitals Services Corp 3530 Elmhurst Lane Portsmouth VA 23701 Contract Employees 199819 Shiftwise PO Box 70870 St Paul MN 55170 Staff Management 185804 9 Outpatient Revenue 622110 48803194 48803194 Inpatient Revenue 622110 13631475 13631475 62434669 99310 99310 191579 0 191579 191579 191579 10922 -10922 -10922 -10922 Employee Pharmacy 900099 363623 363623 I/C Environmental Services 900099 197225 197225 Cafeteria Meals 722210 91190 91190 235693 235693 887731 63602367 62434669 0 1167698 43500 43500 6000 6000 506359 478877 27482 16543108 15645249 897859 611588 600484 11104 2201080 2109471 91609 1176582 1104405 72177 16620 16620 41535 41535 12000 12000 4404093 3498954 905139 141753 141753 3568690 3568690 11076 11076 921334 921334 257933 257933 2370268 2370268 475712 475712 Bad Debt Expense 8527084 8527084 Chargeable Patient Supp 6432066 6432066 Shared Services Expense 6243509 6243509 Recruitment 57797 33802 23995 54569687 46084905 8484782 0 5001596 3925123 8203952 8954795 1028991 1149000 175039 204338 43234085 24678089 18402531 18555996 25789275 24838770 2152744 1973047 60754128 59601069 4561626 5779072 1711849 1968664 6273475 7747736 X 54480653 51853333 54480653 51853333 60754128 59601069 X 9032680 -11660000 X 0 1 X 1 0 X 0 0 0 0 0 0 0 0 1 12000 12000 0 Explanation of Lobbying Activities: Part II-B, Line 1: Dues to NCHA are allocated 25.23% to lobbying. 1694182 1694182 28168800 15546555 12622245 13355250 9131534 4223716 15853 15853 18555996 Due to third party payors 1683664 Reserve for professional liability losses 285000 1968664 X Description of Uncertain Tax Positions Under FIN 48: Part X, Line 2: The Outer Banks Hospital, Inc. has been determined to qualify as a tax-exempt organization under Section 501(c)(3) of the Internal Revenue Code. The Outer Banks Hospital, Inc. has reviewed its tax positions for all open years and has concluded that no material liabilities exist as of September 30, 2013 and 2012. The Outer Banks Hospital files tax returns with the U.S. federal and State of North Carolina jurisdictions. With few exceptions, The Outer Banks Hospital is no longer subject to U.S. federal examinations by tax authorities for years before 2009. 1 1 X 1 X 1 X 1 1 1 0 1 1 1677106 0 1677106 0.03070 4848248 3967712 880536 0.01610 0 0 6525354 3967712 2557642 0.04680 16 6965 1139404 14646 1124758 0.02060 3 22 47602 0 47602 0.00090 0 0 0 0 0 0 0 0 6 14736 236254 0 236254 0.00430 25 21723 1423260 14646 1408614 0.02580 25 21723 7948614 3982358 3966256 0.07260 1 11941 0 11941 0.00020 1 16289 0 16289 0.00030 1 14135 0 14135 0.00030 3 42365 42365 0.00080 1 3243884 0 16766126 16274263 491863 X 1 1 1 The Outer Banks Hospital Medical Office Building LLC Provision of space for providing Health Care 1.00000 0.00000 0.00000 2 Outer Banks Professional Services LLC Provision of Primary and Urgent Health Care 1.00000 0.00000 0.00000 1 1 The Outer Banks Hospital Inc

4800 South Croatan Highway Nags Head NC 27959

X X X The Outer Banks Hospital Inc 1 1 X X X X X X X X 12 1 0 1 X X X X X X X X X X 0 0 1 1 200.000000000000 1 200.000000000000 1 X X X X X X 1 1 X X X X 1 0 X X X X 1 X 0 0 Part I, Line 6a: In addition to the Community Benefit Report for TOBH, information regarding this entity is found in the annual report for University Health Systems of Eastern Carolina d/b/a Vidant Health. Part I, Line 7: Costs were calculated using the estimated cost to charge ratio from The North Carolina Hospital Association's Advocacy Needs Data Initiative which is the standard for reporting community benefits in North Carolina. Part I, L7 Col(f): In connection with the Presumptive Eligibility consideration of the Affordable Care Act, The Outer Banks Hospital does not reflect any bad debt in connection with FAP-eligible patients. These patients are presumed to be part of the Medicaid population and afforded coverage as such. Part II: The community building activities of The Outer Banks Hospital involve services that are otherwise not provided by other organizations in the patient area. Part III, Line 4: The financial statements of The Outer Banks Hospital are presented on a consolidated basis as part of the consolidated financial statements of Vidant Health; the text of the footnote from page 20 is presented below:Patient Accounts ReceivablePatient Accounts Receivable are reported net of estimated allowances for contractual adjustments and allowances for bad debts. Estimated allowances for bad debts are approximately $135.1 million and $112.7 million as of September 30, 2013 and 2012, respectively. Part III, Line 8: The shortfall of Medicare revenue to Medicare was calculated according to the cost to charge ratio. Allowable costs of care should be considered community benefit because in the area served by TOBH, there are no other providers available to provide the required services. Therefore, the care would become a government obligation and is treated as a community benefit provided by TOBH. Part III, Line 9b: Recommended patient accounts will continue to go through the accounts receivable billing cycle as normal. When the account reaches the customer service/collections manager, financial counseling supervisor or patient accounts supervisor, based on the information given, a decision will be made whether to proceed with collection or refer the account for approval of charity care. The process will occur as follows: I. Financial counselors will try to locate third party payors. If not eligible for any third party coverage (including charities), they may, based upon the financial information received, recommend the patient for charity care. II. Patient counselors will review for any third party payors and verify employment and assets. A charity care application will need to be completed along with tax return, pay stubs, social security award letter and other financial information as may be required. III. The patient accounts supervisor, financial counseling supervisor or customer service/collections manager, based upon account balance and the information given, will make a decision whether to proceed with collection or refer the patient account for approval for charity care.Presumptive eligibility for charity care - there are occasions in which a patient may appear eligible for a charity care discount, but there is no financial assistance information available to support financial aid. A. Some patients are presumed to be eligible for charity care discounts on the basis of individual life circumstances (e.g., homelessness, patients with no income, bankruptcy, deceased patients with no estate or spouse, etc). B. Through the assistance of a third party vendor and certain algorithms, in conjuction with our charity policy guidelines, all accounts, prior to outside collection agency referral, will be tested for presumptive charity. C. The accounts deemed charity will be adjusted and the remaining accounts will be referred to an outside collection agency. D. Once the agency has had the accounts for six months and has deemed them uncollectible, the accounts with balances of $1,200 or greater will remain with the agency and be kept on the patient's credit file. E. The accounts returned to the hospital will be placed in a unique financial class and will not be pursued for collections. The Outer Banks Hospital, Inc. Part V, Section B, Line 3: The CHNA document is the culmination of a partnership between the Dare County Department of Public Health (DCDPH) and The Outer Banks Hospital (TOBH). In communities where there is an active Healthy Carolinians coalition, the CHNA partnership also usually includes that entity. Healthy Carolinians is "a network of public-private partnerships across North Carolina that shares the common goal of helping all North Carolinians to be healthy." The members of local coalitions are representatives of the agencies and organizations that serve the health and human service needs of the local population, as well as representatives from businesses, communities of faith, schools and civic groups. In Dare County, the local Healthy Carolinians coalition is Healthy Carolinians of the Outer Banks (HCOB). The community health assessment, which is both a process and a document, investigates and describes the current health status of the community, what has changed since the last assessment, and what still needs to change to improve the health of the community. The process involves the collection and analysis of a large range of data, including demographic, socioeconomic and health statistics, environmental data, and professional and public opinion. The document is a summary of all the available evidence and serves as a resource until the next assessment. The completed CHNA serves as the basis for prioritizing the community's health needs, and culminates in planning to meet those needs. The Outer Banks Hospital, Inc. Part V, Section B, Line 5c: The CHNA is available at: https://www.vidanthealth.com/uploadedFiles/UHSEastMain/UHS_East/CHNA_reports/TOBH%20CHNA%202013.pdf The Outer Banks Hospital, Inc. Part V, Section B, Line 7: Certain community needs may not be fully documented or addressed in the Community Health Needs Assessment. These needs are generally those which other organizations share an overlap with The Outer Banks Hospital. TOBH is not equipped to handle all needs and has prioritized those that it can fully address. The Outer Banks Hospital, Inc. Part V, Section B, Line 14g: The full policy is not available on the facility website. In lieu of the policy, a concise summary is provided with pertinent details and phone numbers for additional information. Part VI, Line 2: The organization assesses community need in conjunction with the state affiliated county health departments and other local health care organizations. See also Schedule H, Part V, Section B, lines 1-7 Part VI, Line 3: Information is available on the organization's website and at registration for patients. In addition, face-to-face financial counseling is available to patients and their families in the central business office. Part VI, Line 4: See Schedule O, Part III Part VI, Line 5: See Schedule O, Part III Part VI, Line 6: See Schedule O, Part III Reports Filed With States Part VI, Line 7 NC 1 Scholarships 6 6000 Procedure for Monitoring Grants in the U.S.: Part I, Line 2: Schedule I, Part I, Line 2: The Outer Banks Hospital has a Community Benefits Grants Review Committee consisting of local representatives to guide the support and grantmaking process. Scholarships are provided through the health careers program, with scholarship funds provided directly to the students' institutions. X X X X 0 1 0 0 0 0 0 0 0 Roger Robertson 0 362398 0 36780 0 1692 0 70556 0 20263 0 491689 0 0 Todd Warlitner 132804 0 8913 0 0 0 15235 0 40415 0 197367 0 0 0 Ronald Sloan 197438 0 29123 0 0 0 23473 0 36345 0 286379 0 0 0 Judy Bruno 129245 0 8836 0 0 0 14577 0 33633 0 186291 0 0 0 Gary Hunter 403754 0 500 0 0 0 0 0 40418 0 444672 0 0 0 Monte Thompson 145845 0 500 0 0 0 0 0 29131 0 175476 0 0 0 Edward Heise 123891 0 500 0 0 0 0 0 31976 0 156367 0 0 0 Part I, Line 3 The Top Management Official is the President who is an employee of TOBH. The compensation is determined by the Compensation and Benefits Committee of the Vidant Health Board using comparative data from like organizations and input from consultants. This process is performed every two years, the last year being 2012. It will be performed again in fiscal year 2014. Compensation of other officers and key employees is also determined by the Compensation and Benefits Committee of the VH Board using comparative data from like organizations and input from consultants. This process is performed every two years, the last year being 2012. It will be performed again in fiscal year 2014. All compensation discussions and actions are documented and approved in the minutes of the Committee. Part I, Line 4b The following individual participated in a supplemental non-qualified retirement plan during the year. The yearly change of such plan is included in their compensation per Schedule J, Part II, column C: - Roger Robertson, $19,716 Form 990, Part VI, Section A, line 6 According to the Organization's amended and restated bylaws, Article II, the Organization has two members, East Carolina Health and Chesapeake Hospital Authority. Form 990, Part VI, Section A, line 7a The members elect the Board of Directors. Form 990, Part VI, Section A, line 7b The following actions shall not be taken without unanimous consent of the members: possess property, invest funds, additional capital contributions, admit members, merger or dissolution, amendment, certificate of need litigation, sale of assets, and business of the Corporation. Form 990, Part VI, Section B, line 11 The Form 990 is made available to Board Members by posting to a Board Member's website. Any Board Member who does not have the ability to access the return in this manner will receive a copy via electronic or regular mail. The return is also reviewed by the Chief Financial Officer, Chief General Counsel and the Chief Audit and Compliance Officer of University Health Systems prior to filing. Form 990, Part VI, Section B, line 12 All Officers, Board Members and Key Employees are required to complete a yearly comprehensive conflict of interest questionnaire. These responses are reviewed by legal counsel and any potential or actual conflicts are brought to the Board for disposition. Board Members are instructed to report any potential conflicts arising during the year for review. Board Members are required to recuse themselves from voting on issues in which they are deemed to have a conflict. Form 990, Part VI, Section B, line 15 The Top Management Official is the President who is an employee of The Outer Banks Hospital, Inc. The compensation is determined by the Compensation and Benefits Committee of the Vidant Health Board using comparative data from like organizations and input from consultants. This process is performed every two years, the last year being 2012. It will be performed again in fiscal year 2014. Compensation of other officers and key employees is also determined by the Compensation and Benefits Committee of the VH Board using comparative data from like organizations and input from consultants. This process is performed every two years, the last year being 2012. It will be performed again in fiscal year 2014. All compensation discussions and actions are documented and approved in the minutes of the Committee. 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. Changes in Net Assets or Fund Balances: Form 990, Part XI, line 9: Net asset transfers to/from related parties -11,660,000. Outer Banks Professional Svcs LLC 604 Amanda Street Manteo NC 27954 270484506 Family Practice NC -998694 844397 N/A Outer Banks Medical Office Building LLC 4810 South Croatan Highway Nags Head NC 27959 161740979 Medical Office Building NC -686094 3996520 N/A University Health Systems of Eastern Carolina (DBA Vidant Health) 2100 Stantonsburg Road Greenville NC 27835 562141073 Healthcare NC 501(c)(3) Line 11c, III-FI N/A 0 Pitt County Memorial Hospital Inc (DBA Vidant Medical Center) 2100 Stantonsburg Road Greenville NC 27835 560585243 Hospital NC 501(c)(3) Line 3 Vidant Health 0 Surgicenter Services of Pitt Inc 102 Bethesda Drive Greenville NC 27835 561690553 Healthcare NC 501(c)(3) Line 11b, II Vidant Medical Center 0 East Carolina Health Inc (DBA Vidant Community Hospitals - Central) 2100 Stantonsburg Road Greenville NC 27835 562003393 Hospital NC 501(c)(3) Line 3 Vidant Health 0 East Carolina Health-Bertie (DBA Vidant Bertie Hospital) 2100 Stantonsburg Road Greenville NC 27835 562072002 Hospital NC 501(c)(3) Line 3 Vidant Health 0 East Carolina Health-Chowan (DBA Vidant Chowan Hospital) 2100 Stantonsburg Road Greenville NC 27835 562101090 Hospital NC 501(c)(3) Line 3 Vidant Health 0 East Carolina Health-Heritage (DBA Vidant Edgecombe Hospital) 2100 Stantonsburg Road Greenville NC 27835 562093700 Hospital NC 501(c)(3) Line 3 Vidant Health 0 East Carolina Health-Beaufort (DBA Vidant Beaufort Hospital) 2100 Stantonsburg Road Greenville NC 27835 452436270 Hospital NC 501(c)(3) Line 3 Vidant Health 0 Duplin General Hospital (DBA Vidant Duplin Hospital) 2100 Stantonsburg Road Greenville NC 27835 566011594 Hospital NC 501(c)(3) Line 3 Vidant Health 0 East Carolina Health Inc (DBA Vidant Roanoke-Chowan Hospital) 2100 Stantonsburg Road Greenville NC 27835 264634725 Hospital NC 501(c)(3) Line 3 Vidant Health 0 Pungo District Hospital Corporation (DBA Vidant Pungo Hospital) 2100 Stantonsburg Road Greenville NC 27835 560518757 Hospital NC 501(c)(3) Line 3 Vidant Health 0 0 0 0 0 0 0 0 0 0 1 0 0 1 0 0 1 0 1 0 Vidant Medical Center P 3577706 Actual Cash Payment East Carolina Health Inc Q 6996000 Actual Cash Payment Vidant Medical Group J 94582 Actual Cash Payment Vidant Medical Group M 3202488 Actual Cash Payment Vidant Chowan Hospital P 218205 Actual Cash Payment