2014-05-14T13:09:17-05:00 2013-06-30 550486667 Arnett Foster Toothman PLLC P O Box 2629 Charleston WV 25329 990 2012-07-01 556000526 Grafton City Hospital GRAF 3042657152 500 Market Street Grafton WV 26354 Pat Shaw 3042657152 2014-05-13 1 Dale Carpenter P00189642 3043460441 2012 2015-11-30 17:44:51Z Pat Shaw 500 Market Street Grafton WV 26354 17711203 0 X www.graftonhospital.com X 1972 WV To provide inpatient hospital care, outpatient services, emergency room services and long-term care to the residents of Taylor County, WV and surrounding communities. 10 9 340 0 0 0 14264 6475 17682050 16751836 60991 73964 194615 878928 17951920 17711203 0 14250 0 0 12319097 12063696 0 0 0 5717781 5757984 18036878 17835930 -84958 -124727 7043861 8883216 5991000 7955082 1052861 928134 To provide inpatient hospital care, outpatient services, emergency room services and long-term care to the residents of Taylor County, WV and surrounding communities. 0 0 10687308 16751836 The Hospital provided health care services including 5,559 emergency room visits, 1,400 acute hospital days; 23,110 long-term care days; 2,463 swing-bed days and 202 surgeries. The Hospital provided charity care without charge or at less than its established rates to patients who meet certain criteria under its charity care policy. Charges foregone for charity care during the year amounted to $1,045,634. Additionally, the Hospital's Rural Health Clinic recorded 19,524 visits for the year. 14250 14250 The organization provided several grants to community organizations including: a $12,500 grant for a high school football field, $1,500 for the sponsorship of a five mile run and $250 for Relay for Life. 10701558 1 0 0 1 0 0 0 0 0 0 1 0 0 1 1 0 1 0 0 0 0 0 0 0 0 0 1 1 1 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 10 0 1 340 1 0 0 0 0 0 0 0 0 0 0 X 10 9 0 0 0 0 0 0 0 1 1 0 0 1 1 1 1 1 1 1 1 0 X Susie Higgins 3042657412 500 Market Street Grafton WV 26354 John Whitescarver 1.00 X 0 0 0 Nancy Virginia Fowler 1.00 X 0 0 0 Wanda Taylor 1.00 X 0 0 0 Paul Shroyer 1.00 X 0 0 0 Christopher Villaraza II MD 40.00 X 191547 0 0 Ronald L Cole 1.00 X 0 0 0 Rusty Efaw 1.00 X 0 0 0 Wayne McDevitt 1.00 X 0 0 0 Mark Witkowski MD 1.00 X 0 0 0 John L Bord 1.00 X 0 0 0 Pat Shaw 40.00 X 114242 0 0 Susannah Higgins 40.00 X 73843 0 0 David Bender 40.00 X 260549 0 0 Joseph Duvert 40.00 X 245640 0 0 Steven Smith 40.00 X 276053 0 0 Thomas Wilshire 40.00 X 255028 0 0 James W Woodford 40.00 X 183851 0 0 1600753 0 0 13 0 1 0 US Nursing PO Box 4070 Clarksburg WV 26302 Outside Nursing Services 176894 Insight PO Box 847689 Dallas TX 752847689 Mobile MRI 133450 Odyssey Rehabilitation 415 Benedum Drive Bridgeport WV 26330 Rehab Services 124224 3 6475 6475 Net patient services 622110 16751836 16751836 16751836 73964 73964 4100 0 4100 4100 4100 EHR Incentive Payments 900099 629602 629602 Cafeteria 722212 73405 73405 Wellness revenue 900099 60398 60398 111423 111423 874828 17711203 16751836 0 952892 14250 14250 380565 218749 161816 9636909 5539295 4097614 236567 135979 100588 1048895 602905 445990 760760 437285 323475 37589 37589 47029 47029 1111345 638801 472544 1323124 760869 562255 110328 63417 46911 91983 52872 39111 27996 16092 11904 105823 60827 44996 423243 243280 179963 449856 258577 191279 Medical supplies 792575 792575 Repairs & maintenance 785594 451559 334035 Medicaid provider tax 354040 354040 Dues and subscriptions 45199 25980 19219 52260 34206 18054 17835930 10701558 7134372 0 312425 7663 90317 256974 2529795 1911558 202129 255662 238797 74080 16803146 13092580 2682219 3710566 160406 234370 827773 2432343 7043861 8883216 3481192 5463167 923932 849034 414617 382206 1171259 1260675 5991000 7955082 X 1052861 928134 1052861 928134 7043861 8883216 -124727 0 X 0 1 X 1 0 X 0 0 0 0 0 0 0 0 1 16959 16959 0 Explanation of Lobbying Activities: Part II-B, Line 1: Part II-B, Line(i), Other Lobbying Activities: Grafton City Hospital pays dues to the West Virginia Hospital Association. The West Virginia Hospital Association represents hospitals and health systems. For the year ended 06/30/13, the amount of dues related to lobbying activities was $16,959. 26597 26597 274995 7038963 6140873 1173085 8033808 6833649 1200159 1428783 118058 1310725 3710566 Estimated third-party payor settlements 2432343 2432343 Capital leases 515840 Accrued pension 744835 1260675 17711203 0 17711203 0 17711203 17835930 0 17835930 0 17835930 1 1 X 1 X 1 X 1 1 0 0 1048968 1367885 -318917 0.00000 4238615 3591953 646662 0.03950 5287583 4959838 327745 0.03950 5287583 4959838 327745 0.03950 1 972893 4330441 4631203 -300762 X 1 1 1 1 Grafton City Hospital Inc

500 Market Street Grafton WV 25354

X X X X Grafton City Hospital 1 0 1 X X X X X X X 1 1 100.000000000000 1 200.000000000000 1 X X X 1 1 X X X X 1 0 X X X 1 X 1 1 Part I, Line 7: The cost of charity care was estimated using a cost to charge ratio derived from Worksheet 2 of the Schedule H instructions. Part I, Line 7, Column (f): The Bad Debt expense included on Form 990, Part IX, Line 25, Column (A), but subtracted for purposes of calculating the percentage in this column is $ 1463877. Part III, Line 4: Patient Accounts Receivable: Patient accounts receivable are carried at the original charge less an estimate made for doubtful or uncollectable accounts. The allowance is based upon a review of the outstanding balances aged by financial class. Management uses collection percentages based upon historical collection experience to determine collectability. Management also reviews troubled, aged accounts to determine collection potential. Patient accounts receivable are written off when deemed uncollectible. Recoveries of accounts previously written off are recorded as reduction to bad debt expense when received. Interest is not charged on patient accounts receivable. Grafton City Hospital Part V, Section B, Line 6i: Hospital management has made significant progress on needs addressed in the CHNA relating to: 1) Recruitment of physicians / Types of Hospital services 2) Barriers for Accessing Healthcare (lack of insurance) and Public Health Education. Grafton City Hospital Part V, Section B, Line 7: Needs that have not been addressed, to date are: 1) Lack of Available transportation and 2) Collaboration with area colleges to possibly establish para medical education programs for the training of nursing personnel, radiology technicians, etc. The transportation item was identified as a low priority need. CHNA findings that affect more individuals in the community were selected to be addressed ahead of the transportation need issue. The collaboration with the local Colleges is a very large inititiave that will take a great deal of planning and coordination with accrediting agencies and regulatory agencies. Therefore, it was decided to address other identified needs first as the college collaboration initiative will demand a large amount of resources. Grafton City Hospital Part V, Section B, Line 21: Charges are based on services rendered by charging amounts in the charge master used for all patients - Based on financial needs, patients are granted charity care for services rendered to them. After a review of their personal finances, an award of charity care is granted on their ability to pay. The amount granted can be from 10% to 100%. Once charity care is granted, charges for services for the proceeding six months and the following six months are written off based on the percent of charity care granted. Grafton City Hospital Part V, Section B, Line 22: Charges are based on services rendered by charging amounts in the charge master used for all patients - Based on financial needs, patients are granted charity care for services rendered to them. After a review of their personal finances, an award of charity care is granted on their ability to pay. The amount granted can be from 10% to 100%. Once charity care is granted, charges for services for the proceeding six months and the following six months are written off based on the percent of charity care granted. CHNA - Late Filing Part V, Section B, Line 1 Grafton City Hospital was late in filing its Community Health Needs Assessment (CHNA) as defined by code section 501 (r) -3. This narrative outlines the factors contributing to the late filing and the corrective actions taken by the hospital. The hospital engaged the accounting firm of Arnett Foster Toothman, PLLC (AFT) to assist with the preparation of their CHNA. In April, 2013 the process of identifying and assembling data needed for the preparation of the CHNA was begun. Thus, work was started on the CHNA prior to the end of the 2012 tax year (7/1/12 6/30/13) but not soon enough to complete the CHNA by June 30, 2013. The primary reason for the delayed start was a hospital-wide information system conversion that occurred over a period of six months spanning September 1, 2012 thru March 31, 2013. Grafton City Hospital is a rural Critical Access Hospital with limited monetary and personnel resources. The system conversion stretched all available funds and personnel to the point that other projects (the CHNA included) had to be delayed until the system conversion was completed. The Hospital believed the CHNA was not due until November 15, 2013. The CHNA was completed in January 2014 at which time the report was approved by the board, published on the hospital's website and the implementation strategy adopted based on the needs identified in the CHNA. The hospitals 990 tax return is under its second extension (due date May 15, 2014). The hospital has taken corrective action by completing and filing the CHNA, as well as adopting an implementation strategy. The hospital has also adopted a corrective action plan. In accordance with Notice 2014-3 and through discussions with its author, the Hospital has self-corrected the deficiencies as outlined above without being contacted by the Internal Revenue Service. The Hospital believes the deficiencies to be minor and inadvertent and, therefore, would not be considered to be egregious. As a result of the process, the Hospital is now aware of the practices and procedures necessary to eliminate any future deficiencies. The Hospital believes the deficiencies had no effect on affected persons and that once the deficiencies were discovered, which was in November 2013, efforts were made to make timely corrections as described above. Based upon the above discussion, the Hospital believes it would not be subject to the excise tax under IRS Code Section 4959 and has not filed Form 4720. Part VI, Line 2: To assess the health care needs of the population base of Grafton City Hospital, the facility is heavily involved with the areas community forums. Through this venue the hospital takes the inquiries that are voiced and applies an economic forecast to the program to verify its stability. The facility also uses the Bureau for Public Health, for risk factors that would have an impact on the lives of the population that Grafton City Hospital serves. Part VI, Line 3: The patient population is educated and informed of the financial assistance programs through the financial counselors and admission personnel. The hospital also has this information published in the public areas within the hospital. Part VI, Line 4: The facility is a rural 25-bed Critical Access Hospital located in Grafton, WV. The service area has been defined based on patient days, discharges and charges compiled by Zip code during the preparation of the latest Community Health Needs Assessment (Dec., 2013). The service area is concentrated in Grafton, WV and spans the counties of Taylor, Preston and Barbour. There are two other hospitals located within the service area. These are Preston Memorial Hospital and Broaddus Hospital. Both of these hospitals are rural 25-bed Critical Access Hospitals. The population coverage by the service area is approximately 65,000 based on the 2010 Census information. 2011 data from the U.S. Dept. of Agriculture show that 17.60% of Taylor county residents, 16.80% for Preston county residents and 22.80% of Barbour county residents are living in poverty. The median household income for Taylor, Preston and Barbour counties is $39,142, $43,434 and $33,158, respectively. The Median household income for the State of WV is $38,482 (based on 2011 data). The combined Medicare and Medicaid population is approximately 20% for both Preston and Barbour counties. The combined Medicare and Medicaid population in Taylor county is approximately 35%. All three counties in the hospital's primary service area are designated "shortage areas" by the U.S. Department of Health and Human Services. The counties are desiginated HPSA's (Health Professional Shortage Area) for primary care, dental and mental health services. All three counties are also designated as MUA's and/or MUP's (Medically Underserved Areas/Populations). Part VI, Line 5: The organization's health care facilities further its exempt purpose in the following ways: The organization's governing body is comprised of persons who reside in the organization's primary service area and are neither employees nor contractors of the organization, nor family members thereof. The organization extends medical staff privileges to all qualified providers in its community for some or all of its departments. The organization operates an emergency room available to all, regardless of ability to pay. Specialized services offered by the organization that are not available elsewhere include pulmonology, critical care medicine, general surgery, internal medicine, obstetrics and gynecology, and family medicine. The organization serves as a vehicle for attracting charitable support, as well as a source of community volunteer activities. 0 Taylor County Board of Education 71 Utt Drive Grafton WV 26354 550549257 Taylor Co. BOE 12500 For high school football field X X X 0 0 0 0 0 0 0 0 0 Christopher Villaraza II MD 191547 0 0 0 0 0 0 0 0 0 191547 0 0 0 David Bender 260549 0 0 0 0 0 0 0 0 0 260549 0 0 0 Joseph Duvert 245640 0 0 0 0 0 0 0 0 0 245640 0 0 0 Steven Smith 276053 0 0 0 0 0 0 0 0 0 276053 0 0 0 Thomas Wilshire 255028 0 0 0 0 0 0 0 0 0 255028 0 0 0 James W Woodford 183851 0 0 0 0 0 0 0 0 0 183851 0 0 0 Form 990, Part VI, Section B, line 11 The form 990 will be reviewed by the CEO and CFO before it is filed. A copy of the final form 990 will be provided to the board of directors prior to filing. Form 990, Part VI, Section B, line 12c Trustees are made aware of the conflict of interest policy. Should a Trustee feel there is a subject in which they have a conflict, they recuse themselves from the discussion and any possible action. Form 990, Part VI, Section B, line 15 A compensation committee determines the compensation of the CEO and other officers by comparing salaries with other hospitals located in West Virginia Critical Access Hospital Network with board approval. Form 990, Part VI, Section C, line 18 The organization makes its governing documents, conflict of interest policy and financial statements available to the public upon request. 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.