2014-05-08T09:56:25-05:00 2013-06-30 DRAFFIN & TUCKER LLP PO BOX 71309 ALBANY GA 317081309 990 2012-07-01 580973772 DONALSONVILLE HOSPITAL INC DONA 2295245217 102 HOSPITAL CIRCLE DONALSONVILLE GA 398451100 HERMAN BROOKINS 2295245217 2014-05-15 true JACQUELINE G ATKINS 2298837878 2014-04-30 2012 2015-11-30 17:44:51Z HERMAN BROOKINS 102 HOSPITAL CIRCLE DONALSONVILLE GA 398451100 33122403 false X WWW.DONALSONVILLEHOSPITAL.ORG X 1977 GA DONALSONVILLE HOSPITAL OPERATES A 65-BED GENERAL ACUTE CARE HOSPITAL FOR THE COMMUNITY OF DONALSONVILLE, GEORGIA AND SURROUNDING AREAS REGARDLESS OF THEIR ABILITY TO PAY. 5 3 376 0 0 28346142 27470797 -161193 424862 2122656 1698215 30307605 29593874 5000000 6005000 0 15692617 16375203 0 0 11825396 12757263 32518013 35137466 -2210408 -5543592 49376758 47654792 3301292 3751778 46075466 43903014 DONALSONVILLE HOSPITAL OPERATES A 65-BED GENERAL ACUTE CARE HOSPITAL FOR THE COMMUNITY OF DONALSONVILLE, GEORGIA AND SURROUNDING AREAS REGARDLESS OF THEIR ABILITY TO PAY. false false 29375564 6005000 28503333 DONALSONVILLE HOSPITAL PROVIDES PRIMARY HEALTHCARE TO RESIDENTS OF SEMINOLE COUNTY AND SURROUNDING AREAS REGARDLESS OF THEIR ABILITY TO PAY. 29375564 true false false true false false false false false true true false true false false true true false false false false false false false false false true true true false true false false false true false false true false false false false false false false false false false true 32 0 376 true false false false false false false false false false false X 5 3 false false false false false false false true false false false true true true true false true true true false GA X X JAMES MOODY 2295245217 102 HOSPITAL CIRCLE DONALSONVILLE GA 398451100 HERMAN BROOKINS 40.00 X X 378465 0 34357 CHARLES H ORRICK 40.00 X X 221666 0 12789 BROADDUS SIMPSON 1.00 X X 8574 0 0 MITCH BLANKS 1.00 X 8574 0 0 WILLIAM BURKE CPA 1.00 X 8574 0 0 JAMES MOODY 40.00 X 192089 0 12637 MURDOC HENDERSON MD 50.00 X 336925 0 9482 JOSEPH WALKER SR MD 50.00 X 310000 0 9842 JESSICA NUNUZ MD 50.00 X 304140 0 3895 ANDREA ALEXANDER MD 50.00 X 272339 0 0 ROYCE CANNINGTON JR 50.00 X 210018 0 9842 2251364 92844 15 false true false NATIONAL EMERGENCY SERVICE PO BOX 65810 CHARLOTTE NC 28265 ER PHYSICIANS 999294 FRANKLIN SEIDELMANN PO BOX 67293 DETROIT MI 482674293 RADIOLIGIST 368180 MDA INC PO BOX 277185 ATLANTA GA 30384 LOCUMS COVERAGE 223947 CPSI PO BOX 850309 MOBILE AL 366850309 IT SUPPORT 221145 DRAFFIN & TUCKER LLP 2617 GILLIONVILLE ROAD ALBANY GA 31703 ACCOUNTING 179379 5 PROGRAM SERVICE REVENUE 621990 27470797 27470797 27470797 483368 483368 176406 94230 82176 82176 82176 3375793 3434299 -58506 -58506 -58506 EHR GRANT INCOME 621990 980888 980888 CAFETERIA 722513 583503 583503 MISCELLANEOUS REVENUE 621990 45123 45123 6525 6525 1616039 29593874 28503333 1090541 6005000 6005000 877725 877725 11820181 10654860 1165321 605908 529922 75986 2320780 1987891 332889 750609 586185 164424 669772 669772 165047 165047 3136 3136 70624 70624 2595173 2397354 197819 66426 66426 2247676 1548660 699016 451521 414180 37341 47736 27020 20716 57236 56504 732 1139697 1045444 94253 189551 118497 71054 MEDICAL SUPPLIES 3623428 3623428 REPAIR AND MAINTENANCE 519837 81558 438279 MISCELLANEOUS EXPENSE 394504 550 393954 PROVIDER FEE 285948 285948 229951 12563 217388 35137466 29375564 5761902 0 19050 11123 3579115 1730473 8495662 7873019 162111 142017 1328812 1623582 1000148 971885 124864 128114 26240232 14953706 12176670 11286526 2968754 4575579 18221241 18118498 1300331 1193976 49376758 47654792 3286826 3751778 14466 3301292 3751778 X 46075466 43903014 46075466 43903014 49376758 47654792 -5543592 3371140 X false true X true false X false false false false false false false false true 3136 3136 false SCHEDULE C, PART II-B, LINE 1 THE ORGANIZATION BELONGS TO A STATE HOSPITAL ASSOCIATION. A PORTION OF THE MEMBERSHIP DUES PAID TO THE ASSOCIATION ARE DEDICATED TO LOBBYING ACTIVITIES. 19404875 3456495 3305000 80671 19475699 25508972 -1018580 5000000 85517 19404875 18450580 7152931 94539 25508972 13861471 4660648 71539 18450580 18843153 -4920716 60966 13861471 1.00000 true false 686053 686053 3416817 11900526 7613161 7704182 343388 301752 41636 9880570 7038793 2841777 12878 12878 11286526 COMMUNITY FOUNDATION INVESTMENTS 18118498 F 18118498 22973066 3371140 3371140 19601926 9991948 9991948 29593874 28516658 28516658 6620808 6620808 35137466 INTENDED USES FOR ENDOWMENT FUNDS SCHEDULE D, PAGE 2, PART V, LINE 4 ENDOWMENT FUNDS CONSIST OF INVESTMENTS FOR THE DEFERRED COMPENSATION PLAN, MALPRACTICE INSURANCE AND COMMUNITY FOUNDATION. THE ORGANIZATION HAS ESTABLISHED A FUNDED DEFERRED COMPENSATION PLAN FOR CERTAIN KEY EMPLOYEES. MALPRACTICE INSURANCE IS A TRUST SET UP TO FUND POTENTIAL LIABILITIES UNDER THE HOSPITAL'S SELF INSURANCE PROGRAM. THE TRUSTEE IS SYNOVUS TRUST COMPANY, N.A. IN 2006, THE ORGANIZATION INVESTED FUNDS WITH THE COMMUNITY FOUNDATION OF SOUTH GEORGIA, INC. ("CFSG"), AN UNRELATED 501(C)(3) ORGANIZATION, WHICH ARE TO BE USED EXCLUSIVELY FOR THE CHARITABLE AND HEALTH PURPOSES OF THE COMMUNITY. THESE FUNDS ARE HELD BY CFSG AS DONOR-ADVISED FUNDS SUBJECT TO THE FILING ORGANIZATION'S EXCLUSIVE LEGAL CONTROL. LIABILITY UNDER FIN 48 FOOTNOTE SCHEDULE D, PAGE 3, PART X THE ORGANIZATION IS A NOT-FOR-PROFIT CORPORATION AND HAS BEEN RECOGNIZED AS TAX-EXEMPT PURSUANT TO SECTION 501(C)(3) OF THE INTERNAL REVENUE CODE. THE ORGANIZATION 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 ORGANIZATION 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 ORGANIZATION'S OPEN AUDIT PERIODS ARE FOR TAX YEARS ENDED 2010-2012. REVENUE AMOUNTS INCLUDED ON RETURN - OTHER SCHEDULE D, PAGE 4, PART XI, LINE 4B MEALS EXPENSE FOR SNF PATIENTS 545,184 GRANTS/ASSISTANCE 6,005,000 INVESTMENT MANAGEMENT FEES 70,624 NET UNREALIZED GAIN/LOSS ON INVESTMENTS NOT IN REVENUES 3,371,140 EXPENSE AMOUNTS INCLUDED ON RETURN - OTHER SCHEDULE D, PAGE 4, PART XII, LINE 4B GRANTS/ASSISTANCE 6,005,000 INVESTMENT MANAGEMENT FEES 70,624 MEALS EXPENSE FOR SNF PATIENTS 545,184 true true X true X false true true false true true 1780079 1780079 0.05070 1520476 1561248 -40772 23793 21544 2249 0.00010 3324348 1582792 1741556 0.05080 21537 21537 0.00060 6005000 6005000 0.17090 6026537 6026537 0.17150 9350885 1582792 7768093 0.22230 true 3433427 4032796 4503107 -470311 X true true 1 1 DONALSONVILLE HOSPITAL INC

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102 HOSPITAL CIRCLE DONALSONVILLE GA 317451100

SNF OTHER TESTING METHODS FOR FREE OR DISCOUNTED CARE PART I LINE 3C ALL INDIVIDUALS THAT DO NOT HAVE THIRD PARTY COVERAGE ARE GIVEN A 15 DISCOUNT IF THEY DO NOT QUALIFY FOR FREE CARE COSTING METHODOLOGY EXPLANATION PART I LINE 7 COSTS FOR PART I LINE 7A AND 7B AND PART III SECTION A LINE 2 WERE CALCULATED USING THE RATIO OF PATIENT CARE COST TO CHARGES CALCULATED ON WORKSHEET 2 OTHER COSTS WERE OBTAINED FROM THE ORGANIZATIONS ACCOUNTING RECORDS BAD DEBT EXPENSE EXPLANATION PART III LINE 4 AMOUNTS INCLUDED ON PART III LINE 2 REPRESENT THE AMOUNT OF CHARGES CONSIDERED UNCOLLECTIBLE AFTER REASONABLE ATTEMPTS TO COLLECT AND WRITTEN OFF TO BAD DEBT EXPENSE AUDITED FINANCIAL STATEMENT FOOTNOTE ACCOUNTS RECEIVABLE ARE REDUCED BY AN ALLOWANCE FOR DOUBTFUL ACCOUNTS IN EVALUATING THE COLLECTABILITY OF ACCOUNTS RECEIVABLE THE ORGANIZATION ANALYZES ITS PAST HISTORY AND IDENTIFIES TRENDS FOR EACH OF ITS MAJOR PAYOR SOURCES OF REVENUE TO ESTIMATE THE APPROPRIATE ALLOWANCE FOR DOUBTFUL ACCOUNTS AND PROVISION FOR BAD DEBTS MANAGEMENT REGULARLY REVIEWS DATA ABOUT THESE MAJOR PAYOR SOURCES OF REVENUE IN EVALUATING THE SUFFICIENCY OF THE ALLOWANCE FOR DOUBTFUL ACCOUNTS FOR RECEIVABLES ASSOCIATED WITH SERVICES PROVIDED TO PATIENTS WHO HAVE THIRDPARTY COVERAGE THE ORGANIZATION ANALYZES CONTRACTUALLY DUE AMOUNTS AND PROVIDES AN ALLOWANCE FOR DOUBTFUL ACCOUNTS AND A PROVISION FOR BAD DEBTS IF NECESSARY FOR EXAMPLE FOR EXPECTED UNCOLLECTIBLES DEDUCTIBLES AND COPAYMENTS ON ACCOUNTS FOR WHICH THE THIRDPARTY PAYOR HAS NOT YET PAID OR FOR PAYORS WHO ARE KNOWN TO BE HAVING FINANCIAL DIFFICULTIES THAT MAKE THE REALIZATION OF AMOUNTS DUE UNLIKELY FOR RECEIVABLES ASSOCIATED WITH SELFPAY PATIENTS WHICH INCLUDES BOTH PATIENTS WITHOUT INSURANCE AND PATIENTS WITH DEDUCTIBLE AND COPAYMENT BALANCES DUE FOR WHICH THIRDPARTY COVERAGE EXISTS FOR PART OF THE BILL THE ORGANIZATION RECORDS A SIGNIFICANT PROVISION FOR BAD DEBTS IN THE PERIOD OF SERVICE ON THE BASIS OF ITS PAST EXPERIENCE WHICH INDICATES THAT MANY PATIENTS ARE UNABLE OR UNWILLING TO PAY THE PORTION OF THEIR BILL FOR WHICH THEY ARE FINANCIALLY RESPONSIBLE THE DIFFERENCE BETWEEN THE STANDARD RATES OR THE DISCOUNTED RATES IF NEGOTIATED AND THE AMOUNTS ACTUALLY COLLECTED AFTER ALL REASONABLE COLLECTION EFFORTS HAVE BEEN EXHAUSTED IS CHARGED OFF AGAINST THE ALLOWANCE FOR DOUBTFUL ACCOUNTS THE ORGANIZATIONS ALLOWANCE FOR DOUBTFUL ACCOUNTS FOR SELFPAY PATIENTS REMAINED AT 85 OF SELFPAY ACCOUNTS RECEIVABLE AT JUNE 30 2012 AND AT JUNE 30 2013 IN ADDITION THE ORGANIZATIONS SELFPAY WRITEOFFS INCREASED 400000 FROM 3000000 FOR FISCAL YEAR 2012 TO 3400000 FOR FISCAL YEAR 2013 THE ORGANIZATION HAS NOT CHANGED ITS CHARITY CARE OR UNINSURED DISCOUNT POLICIES DURING FISCAL YEARS 2013 OR 2012 THE ORGANIZATION DOES NOT MAINTAIN A MATERIAL ALLOWANCE FOR DOUBTFUL ACCOUNTS FROM THIRDPARTY PAYORS NOR DOES IT HAVE SIGNIFICANT WRITEOFFS FROM THIRDPARTY PAYORS MEDICARE EXPLANATION PART III LINE 8 MEDICARE ALLOWABLE COSTS ARE COMPUTED IN ACCORDANCE WITH COST REPORTING METHODOLOGIES UTILIZED ON THE MEDICARE COST REPORT AND IN ACCORDANCE WITH RELATED REGULATIONS INDIRECT COSTS ARE ALLOCATED TO DIRECT SERVICE AREAS USING THE MOST APPROPRIATE STATISTICAL BASIS COLLECTION PRACTICES EXPLANATION PART III LINE 9B OUR PATIENT FINANCIAL SERVICES DEPARTMENT VISITS PATIENTS WHO HAVE NO INSURANCE TO DISCUSS ASSISTANCE AND REFER THOSE PATIENTS TO OUR LOCAL DFCS OFFICE TO OBTAIN ASSISTANCE WITH APPLYING FOR MEDICAID AND OTHER FINANCIAL ASSISTANCE OUR PATIENT FINANCIAL SERVICES DEPARTMENT WHICH DOES SELFPAY BILLING AND COLLECTION INFORMS PATIENTS ABOUT OUR FINANCIAL ASSISTANCE PROGRAM AND ASSISTS THEM IN MAKING AN APPLICATION BILLING STATEMENTS PROVIDE A MESSAGE AND TELEPHONE NUMBER TO CALL IF THE PATIENT HAS DIFFICULTY MAKING PAYMENT FOR PATIENTS WHO QUALIFY AS INDIGENT AND CHARITY PATIENTS THERE IS NO FINANCIAL OBLIGATION THOSE PATIENTS WHO DO NOT QUALIFY AS INDIGENT AND CHARITY PATIENTS AND DONT HAVE ANY 3RD PARTY COVERAGE ARE SENT STATEMENTS AND LETTERS WHERE THEY ARE PAST DUE 30 60 AND 90 DAYS IF PAYMENT ARRANGEMENTS ARE STILL NOT MADE AFTER 90 DAYS THEN THOSE ACCOUNTS ARE REFERRED TO COLLECTIONS BEFORE REFERRAL TO A COLLECTION AGENCY OUR COLLECTION DEPARTMENT EXAMINES THE ACCOUNTS FOR POSSIBLE 3RD PARTY COVERAGE IF NO 3RD PARTY COVERAGE EXISTS THEN WE MOVE FORWARD WITH OUR NORMAL INHOUSE COLLECTION PROCEDURES NEEDS ASSESSMENT PART VI A COMMUNITY HEALTH NEEDS ASSESSMENT WAS COMPLETED IN FISCAL YEAR 2013 INFORMATION WAS SOLICITED FROM VARIOUS INDIVIDUALS REPRESENTING THE INTERESTS OF THE COMMUNITY BY MEANS OF FOCUS GROUPS EXTERNAL STATISTICS AND INTERNAL DATA THE ORGANIZATION CONDUCTS VARIOUS TYPES OF ASSESSMENTS TO DETERMINE THE COMMUNITYS NEEDS FOR HEALTH SERVICES OUR ORGANIZATION COLLABORATES WITH THE CITIZENS OF SEMINOLE AND SURROUNDING COUNTIES TO IDENTIFY THE NEEDS OF THE COMMUNITY COMMUNITY RESEARCH HAS SHOWN THAT THE SERVICES FOR WHICH THE CITIZENS OF SEMINOLE AND SURROUNDING COUNTIES TURN TO THE ORGANIZATION FOR ARE EMERGENCY SERVICES DIAGNOSTIC TESTS AND XRAYS AND ALSO GENERAL MEDICAL CARE OTHER SERVICES FOR WHICH THEY TURN TO US AS A MAJOR PROVIDER ARE MINOR SURGERY PEDIATRIC CARE GENERAL SURGERY AND OBSTETRICAL CARE THIS INFORMATION COMBINED WITH OUR EXTENSIVE COLLABORATIONS AND OUR ROLE AS A LEADER IN THE COMMUNITY PROVIDES US THE MEANS TO UNDERSTAND AND ADDRESS THE COMMUNITYS NEEDS AND ENSURES OUR OUTREACH PROGRAMS ARE FOCUSED ON THE POPULATIONS WHO NEED OUR SERVICES THE MOST OUR BOARD OF DIRECTORS WORKS CLOSELY WITH THE LOCAL CIVIC ORGANIZATIONS ELECTED OFFICIALS AND COMMUNITY LEADERS TO DETERMINE WHAT THE HEALTHCARE NEEDS ARE OF OUR COMMUNITY PATIENT EDUCATION OF ELIGIBILITY FOR ASSISTANCE PART VI THE BOARD HAS CLEARLY WRITTEN INDIGENT AND FINANCIAL AID POLICIES THAT ARE AVAILABLE THROUGH THE BUSINESS OFFICE SIGNS ARE PROMINENTLY POSTED ON THE AVAILABILITY OF FREE AND FINANCIAL AID PATIENT EDUCATION ON THE ORGANIZATIONS INDIGENTCHARITY AND FINANCIAL AID PROGRAMS ARE CONDUCTED DURING PREREGISTRATION THROUGH OUR PATIENT FINANCIAL SERVICES DEPARTMENT FOR PATIENTS THAT DO NOT HAVE ANY 3RD PARTY COVERAGE BROCHURES ARE PROMINENTLY DISPLAYED AT EACH REGISTRATION BOOTH THE BUSINESS OFFICE CONTINUOUSLY PROVIDES INFORMATION TO THE BUSINESS OFFICE MANAGERS OF OUR LOCAL PHYSICIANS PRACTICES PHONE CALLS AND LETTERS ARE SENT TO ALL PATIENTS THAT ARE NOT INTERVIEWED AT THE TIME OF ADMISSION EXPLAINING OUR FINANCIAL ASSISTANCE PROGRAMS OUR EMERGENCY DEPARTMENT IS OPERATED 247 AND OPEN TO ALL PERSONS REGARDLESS OF ABILITY TO PAY THE BOARD HAS CLEARLY WRITTEN INDIGENTCHARITY AND FINANCIAL AID POLICIES THAT ARE AVAILABLE THROUGH THE BUSINESS OFFICE SIGNS ARE PROMINENTLY POSTED ON THE AVAILABILITY OF FREE CARE AND FINANCIAL AID COMMUNITY INFORMATION PART VI THE ORGANIZATION SERVES A PREDOMINATELY RURAL AREA IN SEMINOLE COUNTY IN ITS BROADEST BOUNDARIES DONALSONVILLE IS THE ECONOMIC AND MEDICAL HUB FOR THE REGION AND THE ORGANIZATION DRAWS FROM A POPULATION OF APPROXIMATELY 9000 RESIDENTS FOR MAJOR HEALTH CARE SERVICES THE REGION IS MARKED BY VAST DICHOTOMIES OF WEALTH EDUCATION AND HEALTH STATUS THE ORGANIZATION SERVES A POPULATION THAT HAS A HIGH PROPORTION OF LOWINCOME INDIVIDUALS ABOUT 2201 OF FAMILIES AND 2549 OF THE POPULATION WERE BELOW THE POVERTY LINE HEALTH OF COMMUNITY IN RELATION TO EXEMPT PURPOSE PART VI OUR BOARD OF DIRECTORS WORKS CLOSELY WITH THE LOCAL CIVIC ORGANIZATIONS ELECTED OFFICIALS AND COMMUNITY LEADERS TO DETERMINE WHAT THE HEALTHCARE NEEDS ARE OF OUR COMMUNITY WE HAVE PARTICIPATED IN VARIOUS LOCAL HEALTH FAIRS TO PROMOTE GOOD HEALTH AND PROVIDE SCREENING MECHANISMS FOR DETECTING HIGH BLOOD PRESSURE ABNORMAL BLOOD SUGAR LEVELS AND HIGH CHOLESTEROL THESE ARE THE MOST PRESSING AND PREVENTABLE DISEASES IN OUR COMMUNITY WE WORK CLOSELY WITH THE LOCAL HEALTH DEPARTMENT TO ASSIST THEM WITH THE PROGRAMS THAT THEY FACILITATE THROUGHOUT THE YEAR OUR BOARD HAS HAD IN PLACE FOR 20 YEARS A SCHOLARSHIP PROGRAM FOR PHYSICIANS AND OTHER HEALTHCARE PROFESSIONALS WE HAVE BEEN FORTUNATE TO HAVE MANY OF OUR LOCAL RESIDENTS FINISH MEDICAL SCHOOL NURSING SCHOOL AND OTHER PROFESSIONAL CERTIFICATIONS AND COME BACK TO DONALSONVILLE TO PRACTICE AND WORK IN OUR LOCAL HEALTHCARE COMMUNITY THE PHYSICIAN SCHOLARSHIP PROGRAM HAS PRODUCED 4 OF OUR CURRENT 12 MEMBER MEDICAL STAFF WE ALSO HAVE 5 IN THE PROGRAM THAT ARE SCHEDULED TO COME BACK TO OUR COMMUNITY OVER THE NEXT 10 YEARS THIS TYPE OF PROGRAM HAS HELPED KEEP HEALTHCARE AVAILABLE AND ACCESSIBLE TO OUR RURAL COMMUNITY IT HAS ENABLED US TO START NEW SERVICES THAT WOULD NOT HAVE EXISTED OTHERWISE OUR BOARD IS DEDICATED TO PLANNING AND PREPARING FOR THIS RURAL COMMUNITY TO HAVE EASILY ACCESSIBLE HEALTHCARE FOR MANY YEARS TO COME DONALSONVILLE HOSPITAL INC LINE NUMBER 1 PART V LINE 3 PART V LINE 3 DONALSONVILLE HOSPITAL STARTED THE PROCESS OF ASSESSING THE NEEDS OF THE COMMUNITY BY GETTING INPUT FROM THE LOCAL PHYSICIANS THERE ARE 13 LOCAL PHYSICIANS THAT ARE ACTIVE ON THE MEDICAL STAFF AT DONALSONVILLE HOSPITAL 4 BOARD CERTIFIED GENERAL SURGEONS 2 OBGYNS 3 PEDIATRICIANS 2 FAMILY PRACTICE AND 1 DERMATOLOGIST THE MEDICAL STAFF IS MADE UP OF A WIDE VARIETY OF PRIMARY CARE PHYSICIANS MANAGEMENT OF THE HOSPITAL HAS ALWAYS HAD AN EXTREMELY CLOSE WORKING RELATIONSHIP WITH THE MEDICAL STAFF ONE KEY COMPONENT OF ASSESSING THE NEEDS OF THE LOCAL COMMUNITY IS TO GET INPUT FROM THE MEDICAL STAFF ALL PHYSICIANS HAVE BEEN WILLING TO GIVE FEEDBACK AND INPUT ON THE HEALTH NEEDS OF THE COMMUNITY THE HOSPITAL BOARD OF DIRECTORS HAS A BROAD RANGE OF COMMUNITY INVOLVEMENT AND LEADERSHIP ROLES THERE ARE 5 MEMBERS OF THE BOARD AND OF THE FIVE 2 ARE INVOLVED WITH LOCAL COUNTY AND CITY GOVERNMENTS AS A COUNTY COMMISSIONER AND CITY COUNCILMAN ALSO THE BOARD OF DIRECTORS HAS 2 OTHER MEMBERS INVOLVED WITH OTHER NONPROFITS AND IS ACTIVE COMMUNITY LEADERS THE OTHER BOARD MEMBER HAS A VAST KNOWLEDGE AND EXPERIENCE IN THE AGRICULTURAL AREA WHICH MAKES UP A MAJOR PART OF INDUSTRY AND RESIDENTS OF SEMINOLE COUNTY THE BOARD OF DIRECTORS THOUGHT THAT THERE SHOULD BE 2 ADDITIONAL MEMBERS ADDED TO THE CHNA PANEL THAT WOULD HELP WITH ASSESSING THE NEEDS OF THE COMMUNITY A LOCAL COUNTY COMMISSIONER WHO IS ALSO A COPASTOR OF VISION FAITH OUTREACH MINISTRIES WAS ADDED THE COUNTY COMMISSIONER HAS ACCESS AND CONTACT WITH A LARGE PORTION OF INDIVIDUALS THAT ARE MINORITY UNDERSERVED AND NEEDY ALSO THE BOARD OF DIRECTORS WANTED INPUT FROM THE LOCAL HEALTH DEPARTMENT DIRECTOR THE HOSPITAL HAS WORKED WITH THE DIRECTOR FOR YEARS ADDRESSING THE NEEDS OF THE LOCAL HEALTH DEPARTMENT BY PROVIDING FUNDS FOR SPECIFIC PROGRAMS PRESENTED BY THE DIRECTOR FOR MEDICAL XHELP FOR NEEDY LOCAL RESIDENTS FIRST STATISTICS WERE GATHERED FROM OUR INTERNAL DATA BASE EXAMINING THE PATIENTS THAT HAVE VISITED DONALSONVILLE HOSPITAL IN THE PAST 2 YEARS THE DATA GATHERING INCLUDED INFORMATION THAT TRACKED THE TOP DIAGNOSES FOR PATIENTS THAT VISITED THE HOSPITAL THESE REPORTS WERE EVALUATED AND THE CHNA PANEL UTILIZED THEM ALONG WITH STATISTICS GATHERED FROM GHA U S CENSUS BUREAU AMERICAN DIABETES ASSOCIATION THE GEORGIA DEPARTMENT OF COMMUNITY HEALTH THE GEORGIA DEPARTMENT OF PUBLIC HEALTH SEMINOLE COUNTY HEALTH DEPARTMENT AND NATIONAL CANCER INSTITUTE THESE STATS WERE USED TO DETERMINE WHAT THE HEALTH NEEDS OF SEMINOLE COUNTY RESIDENTS ARE AND TO DETERMINE WHICH NEEDS COULD THE HOSPITAL BE SUCCESSFUL AT IMPLEMENTING SOME STRATEGY TO IMPROVE AFTER LOOKING AT ALL OF THE DATA GATHERED THE CHNA PANEL DETERMINED THAT THE HEALTH NEEDS THAT COULD BE IMPROVED BY THE HOSPITAL INPUT WERE AS FOLLOWS 1DIABETESHYPERTENSION DISEASE 2OBESITY IN ADULTS 3CANCER 4MENTAL HEALTH DONALSONVILLE HOSPITAL INC LINE NUMBER 1 PART V LINE 7 PART V LINE 7 DONALSONVILLE HOSPITAL INC IS STILL LOOKING AT THE MENTAL HEALTH NEEDS AND SUBMITTING ANOTHER APPLICATION FOR GERIATRIC PSYCHIATRIC BEDS DONALSONVILLE HOSPITAL INC LINE NUMBER 1 PART V LINE 12H PART V LINE 12H ALL PATIENTS ARE CHARGED EQUALLY REGARDLESS OF ANY OF THE ABOVE THOSE INDIVIDUALS WITHOUT THIRD PARTY COVERAGE ARE GIVEN A 15 DISCOUNT IF THEY DO NOT QUALIFY FOR FREE CARE DONALSONVILLE HOSPITAL INC LINE NUMBER 1 PART V LINE 20D PART V LINE 20D THE HOSPITAL DISCOUNTED GROSS CHARGES FOR PATIENTS WITHOUT THIRD PARTY INSURANCE COVERAGE BY FIFTEEN PERCENT THIS PERCENTAGE IS THE AVERAGE DISCOUNT GIVEN TO INSURANCE COMPANIES true COMMUNITY FOUNDATION OF SOUTH GA IN 135 N BROAD STREET THOMASVILLE GA 31792 582210876 3 6005000 COMMUNITY HEALTH 1 PROCEDURES FOR MONITORING THE USE OF GRANT FUNDS INSIDE THE UNITED STATES SCHEDULE I, PAGE 1, PART I, LINE 2 THE FUNDS ARE GIVEN TO THE 501(C)(3) ORGANIZATION WITH THE INTENT THAT THE RECIPIENT WILL USE THE FUNDS FOR THEIR TAX EXEMPT PURPOSE. THE FUNDS ARE DONOR-DESIGNATED AND MUST BE APPROVED BY THE BOARD CHAIRMAN BEFORE DISTRIBUTED. X X false false false false false false false false false HERMAN BROOKINS 361575 16890 22500 11857 412822 CHARLES H ORRICK 208996 12670 152 12637 234455 JAMES MOODY 179419 12670 12637 204726 MURDOC HENDERSON MD 336925 9482 346407 JOSEPH WALKER SR MD 310000 9842 319842 JESSICA NUNUZ MD 304140 3895 308035 ANDREA ALEXANDER MD 231657 40682 272339 ROYCE CANNINGTON JR 210018 9842 219860 OTHER ADDITIONAL INFORMATION SCHEDULE J, PART III PART I, LINE 4 - DEFERRED COMPENSATION PLAN 457(B) THE ORGANIZATION HAS ESTABLISHED A DEFERRED COMPENSATION PLAN FOR CERTAIN KEY EMPLOYEES. THE 457(B) PLAN IS A NON-QUALIFIED RETIREMENT PLAN THAT ALLOWS A MAXIMUM SALARY DEFERRAL OF THE LESSER OF 17,000 OR ONE-THIRD OF AN EMPLOYEE'S SALARY. BEAU CANNINGTON PHYSICIAN'S SON SCHOLARSHIP LOAN X 100000 142017 false true true 142017 BRIAN BROOKINS FAM BD MEMBER 193776 COMPENSATION false ADDITIONAL INFORMATION SCHEDULE L PART V BRIAN BROOKINS AN EMPLOYEE OF THE ORGANIZATION IS THE SON OF HERMAN BROOKINS WHO IS THE CHAIRMAN OF THE BOARD AND CEO DOCUMENTATION BY COMMITTEE FORM 990, PAGE 6, PART VI, LINE 8B THE ORGANIZATION DOES NOT HAVE ANY COMMITTEES WITH AUTHORITY TO ACT ON BEHALF OF THE GOVERNING BODY. ORGANIZATION'S PROCESS USED TO REVIEW FORM 990 FORM 990, PAGE 6, PART VI, LINE 11B THE INDEPENDENT ACCOUNTING FIRM THAT PREPARES THE FORM 990 (BASED UPON INFORMATION PROVIDED BY THE ORGANIZATION) PROVIDES A COPY OF THE RETURN TO BE REVIEWED BY MANAGEMENT. UPON REVIEW, THE FORM 990 AND RELATED SCHEDULES ARE PROVIDED TO ALL BOARD MEMBERS FOR REVIEW AND FEEDBACK. ONCE THE FORM 990 IS REVIEWED BY ALL APPLICABLE PARTIES, A COPY OF THE FINAL VERSION IS PROVIDED TO ALL MEMBERS OF THE GOVERNING BODY PRIOR TO FILING. ENFORCEMENT OF CONFLICTS POLICY FORM 990, PAGE 6, PART VI, LINE 12C THE ORGANIZATION HAS A WRITTEN POLICY RESPECTING CONFLICTS OF INTEREST AND DISCLOSURE OF SAME. GENERALLY SPEAKING, THE POLICY REQUIRES ANY "COVERED PERSON" WHO BELIEVES HE 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 -RECUSE HIMSELF 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 THE ORGANIZATION. 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 WHO DETERMINES WHETHER A CONFLICT OF INTEREST ACTUALLY EXISTS. IF A CONFLICT OF INTEREST EXISTS, 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 ORGANIZATION'S BEST INTEREST AND IS FAIR AND REASONABLE TO THE ORGANIZATION. IN ADDITION TO THE REQUIREMENT TO DISCLOSE A POTENTIAL CONFLICT OF INTEREST AT THE TIME IT ARISES, EACH MUST SUBMIT ANNUALLY A `CONFLICT AND DISCLOSURE OF INTEREST QUESTIONNAIRE'. COMPENSATION PROCESS FOR TOP OFFICIAL FORM 990, PAGE 6, PART VI, LINE 15A THE BOARD OF DIRECTORS REVIEWS AND APPROVES THE COMPENSATION FOR THE CEO. THE BOARD USES COMPARABLE COMPENSATION DATA FOR SIMILARLY QUALIFIED PERSONS AT SIMILARLY SIZED ORGANIZATIONS AND SALARY SURVEYS TO DETERMINE THE COMPENSATION FOR THE CEO. THE CEO, A VOTING MEMBER OF THE BOARD, IS DISMISSED FROM THE MEETING DURING THE REVIEW OF HIS COMPENSATION. THIS PROCESS WAS LAST UNDERTAKEN FOR THE CEO IN 2006. COMPENSATION PROCESS FOR OFFICERS FORM 990, PAGE 6, PART VI, LINE 15B THE BOARD OF DIRECTORS MEET REGULARLY ON A MONTHLY BASIS AND THE SALARY DECISIONS ARE REVIEWED BY THE BOARD. NO PUBLIC DISCLOSURE EXPLANATION FORM 990, PAGE 6, PART VI, LINE 18 INDIVIDUALS CAN VISIT THE OFFICE OF THE CFO AND INSPECT THE FORM 990 GOVERNING DOCUMENTS DISCLOSURE EXPLANATION FORM 990, PAGE 6, PART VI, LINE 19 THE ORGANIZATION WILL MAKE AVAILABLE ITS GOVERNING DOCUMENTS, CONFLICT OF INTEREST POLICY, AND FINANCIAL STATEMENTS TO ANY MEMBER OF THE PUBLIC WHO MAKES THEIR REQUEST AT THE ADMINISTRATIVE OFFICE OF THE FILING ENTITY.