2014-08-13T09:21:08-05:00 2013-09-30 560747981 DIXON HUGHES GOODMAN LLP 500 RIDGEFIELD COURT ASHEVILLE NC 28806 990 2012-10-01 560525657 ALLEGHANY COUNTY MEMORIAL HOSPITAL INC ALLE 3363725511 PO BOX 9 SPARTA NC 28675 BRETT LIVERMAN 3363725511 2014-08-13 1 JEREMY NAESS P01306905 8282542254 2012 2015-11-30 17:44:51Z WARREN TAYLOR 233 DOCTORS STREET SPARTA NC 28675 12955336 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 14 197 54 95827 37018 258244 598335 11504672 11997145 59434 35453 415264 324403 12237614 12955336 0 0 0 0 5882773 6549813 0 0 7590 6776274 6990726 12659047 13540539 -421433 -585203 9391285 9223470 5085199 5508344 4306086 3715126 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 11579635 8833446 ALLEGHANY MEMORIAL HOSPITAL PROVIDED NECESSARY HEALTHCARE SERVICES TO INDIVIDUALS IN THE COMMUNITY REGARDLESS OF THEIR ABILITY TO PAY. CARE WAS PROVIDED THROUGH 669 INPATIENT AND SWING BED ADMISSIONS, 7,339 ER VISITS, 3,813 DAYS OF CARE, 11,857 X-RAYS, AND 57,575 LAB TESTS. ADDITIONALLY, WAKE FOREST SPECIALTY CLINIC, A PRIMARY CARE PROVIDER, WAS OPENED EFFECTIVE JULY 1, 2013. TOP QUALITY HEALTHCARE IS THE NUMBER ONE GOAL. 11579635 1 1 0 1 0 0 0 0 0 1 1 0 0 0 1 1 0 1 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 66 0 1 197 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 X BRETT LIVERMAN CFO 3363723276 PO BOX 9 SPARTA NC 28675 WARREN TAYLOR 1.00 X X 0 0 0 WALT MCMILLAN 1.00 X X 0 0 0 GEORGE WHITE 1.00 X X 0 0 0 FRANCES BUCKLE 1.00 X X 0 0 0 FIELDS R YOUNG JR 1.00 X X 0 0 0 PAT POLLEY 1.00 X 0 0 0 REX HALSEY 1.00 X 0 0 0 FRANK DOWELL 1.00 X 0 0 0 JOHN MILLER 1.00 X 0 0 0 H V LINDSEY 1.00 X 0 0 0 DAN R MURRAY 1.00 X 0 0 0 MARVIN MYERS 1.00 X 0 0 0 WHITNEY IVEY 1.00 X 0 0 0 TAMMY THORE MD 1.00 X 0 0 0 JOE AROCHA MD 40.00 X 133372 0 2144 ROCKY PROFITT 1.00 X 0 0 0 JIM HEITZENRATER 40.00 X 88795 0 29737 BRETT LIVERMAN 40.00 X 0 0 0 KATIE MYERS WOODLE 40.00 X 63976 0 20938 286143 0 52819 1 0 0 1 ALLEGHANY EMERGENCY PHYSICIANS PO BOX 20351 HOUSTON TX 77216 ER PHYSICIANS 481417 QUORUM HEALTH RESOURCES 105 CONTINENTAL PLACE BRENTWOOD TN 37027 MANAGEMENT COMPANY 356193 CPSI PO BOX 850309 MOBILE AL 36685 COMPUTER SUPPORT 240969 MEDCOST BENEFIT SERVICES PO BOX 24042 WINSTON NC 27114 TPA 193184 DAN SMITH PO BOX 185 SPARTA NC 28676 CRNA 176225 7 32381 318605 247349 598335 NET PATIENT REVENUE 621500 11816508 11720681 95827 MEANINGFUL USE INCENTIVE 621500 124713 124713 MRI GAP SUPPLEMENT 621500 55924 55924 11997145 13700 13700 76393 0 76393 76393 76393 19385 2368 0 0 19385 2368 21753 21753 CAFETERIA INCOME 900099 45609 45609 THRIFT SHOP 900099 29071 29071 PURCHASE DISCOUNTS 900099 19129 19129 154201 154201 248010 12955336 11901318 95827 359856 144525 12601 124698 7226 5085979 4485993 599986 963742 830216 133260 266 355567 306303 49166 98 131353 131353 78802 78802 69623 69623 1192522 910841 281681 19944 19944 1689167 1436470 252697 165780 165780 16195 12878 3317 109490 77899 31591 729558 729558 120984 2906 118078 MEDICAL SUPPLIES 1330539 1330539 BAD DEBT EXPENSE 1213967 1213967 MISCELLANEOUS 122802 63684 59118 13540539 11579635 1953314 7590 11792 315320 106186 147379 1325552 1521839 46911 39489 255290 274522 129594 83033 18650156 12901149 6361193 5749007 935098 902745 219669 190136 9391285 9223470 1734138 2011429 3081107 3084613 269954 412302 5085199 5508344 X 3940818 3349858 365268 365268 4306086 3715126 9391285 9223470 X -585203 55585 -61342 X X 0 1 X 1 0 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 0 0 0 0 0 0 0 0 1 940 940 0 EXPLANATION OF LOBBYING ACTIVITIES: 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 $940 OF DUES PAID ARE ALLOCATED TO LOBBYING EXPENDITURES. 362325 8033 370358 330226 32099 362325 356418 -26192 330226 331822 24596 356418 347127 -15305 331822 1.00000 0 0 351517 351517 6227235 3778907 2448328 1460715 981585 479130 10610439 8140657 2469782 250 250 5749007 CAPITAL LEASE OBLIGATION 199231 ESTIMATED THIRD PARTY PAYOR SETTLEMENTS 213071 412302 X DESCRIPTION OF INTENDED USE OF ENDOWMENT FUNDS: PART V, LINE 4: THE HOSPITAL'S ENDOWMENT CONSISTS OF FUNDS ESTABLISHED FOR A VARIETY OF PURPOSES TO SUPPORT HEALTH CARE SERVICES. DESCRIPTION OF UNCERTAIN TAX POSITIONS UNDER FIN 48: PART X, LINE 2: INCOME TAXES - THE HOSPITAL AND THE FOUNDATION ARE NOT-FOR-PROFIT CORPORATIONS AS DESCRIBED IN SECTION 501(C)(3) OF THE INTERNAL REVENUE CODE AND ARE EXEMPT FROM FEDERAL INCOME TAXES ON RELATED INCOME PURSUANT TO SECTION 501(A) OF THE CODE. NO PROVISION FOR INCOME TAXES HAS BEEN MADE IN THE ACCOMPANYING CONSOLIDATED FINANCIAL STATEMENTS. THE HOSPITAL AND FOUNDATION HAVE DETERMINED THAT THEY DO NOT HAVE ANY MATERIAL UNRECOGNIZED TAX BENEFITS OR OBLIGATIONS AS OF SEPTEMBER 30, 2013. FISCAL YEARS ENDING ON OR AFTER SEPTEMBER 30, 2010 REMAIN SUBJECT TO EXAMINATION BY FEDERAL AND STATE TAX AUTHORITIES. 1 1 X 1 X 1 X 1 1 1 0 1 1 106664 106664 0.00870 1221446 1089985 131461 0.01070 1328110 1089985 238125 0.01940 1328110 1089985 238125 0.01940 0 1213967 5287177 4850021 437156 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 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 2 ALLEGHANY ORTHOPEDIC CLINIC

12 WILLIS ST SPARTA NC 28675

ORTHOPEDIC SURGEON OFFICE ALLEGHANY HEALTH SERVICES

PO BOX 9 SPARTA NC 28675

FAMILY PRACTICE PART I, LINE 7: WORKSHEET 2 OF THE 2012 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 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 $ 1213967. 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. 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 5C: THROUGH COORDINATED EFFORTS OF THE APPLACHIAN DISTRICT HEALTH DEPARTMENT 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 2012 WAS $34,046 VERSUS A NC STATE AVERAGE OF $45,195. THE UNEMPLOYMENT RATE IS AT ROUGHLY 10.6% AS OF 2012 VERSUS A STATEWIDE AVERAGE OF 9.5%. 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. REPORTS FILED WITH STATES PART VI, LINE 7 NC X X X 0 0 0 0 0 0 0 0 0 SUPPLEMENTAL INFORMATION PART III PART VII, LINE 5: THE ORGANIZATION HAS A MANAGEMENT AGREEMENT WITH QUORUM HEALTH RESOURCES TO PROVIDE ADMINISTRATIVE SERVICES BY PLACEMENT OF CEO AND CFO POSITIONS. THESE INDIVIDUALS ARE COMPENSATED BY AN UNRELATED ORGANIZATION FOR SERVICES PROVIDED TO THE FILING ORGANIZATION. SEE PART II. JOE AROCHA MD PHYSICIAN RECRUITMENT X 60000 39489 0 1 1 39489 FORM 990, PART VI, SECTION A, LINE 3 THE HOSPITAL ENTERED INTO A MANAGEMENT AGREEMENT WITH QUORUM HEALTH RESOURCES THAT ENTAILS THAT THEY WILL PERFORM MANAGEMENT AND ADMINISTRATIVE SERVICES FROM DAY TO DAY. THE ORGANIZATION CONTRACTS ITS EXECUTIVE DIRECTOR AND FINANCIAL DIRECTOR FROM QHR MANAGMENT, LLC. UNDER THE TERMS OF A MANAGEMENT AGREEMENT, MANAGEMENT SERVICES ARE PROVIDED TO THE ORGANIZATION BY QUORUM HEALTH RESOURCES. THESE SERVICES INCLUDE THE SUPERVISION OF ALL ASPECTS OF NORMAL OPERATIONS INCLUDING BUDGETING, HIRING OF EMPLOYEE, BILLING, PAYROLL, ACCOUNTS PAYABLE, AND OTHER MANAGEMENT RESPONSIBILITIES. 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. CHANGES IN NET ASSETS OR FUND BALANCES: FORM 990, PART XI, LINE 9: INTERCOMPANY ELIMINATION (EIN # 56-2012634) EQUITY TRANSFER TO FOUNDATION -61,342. 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 32381 CASH