2014-08-15T08:34:22-05:00 2013-09-30 560747981 DIXON HUGHES GOODMAN LLP 111 FRANKLIN RD SE SUITE 501 ROANOKE VA 240112114 990 2012-10-01 540622371 CULPEPER MEMORIAL HOSPITAL INC CULP 5408294100 501 SUNSET LANE CULPEPER VA 22701 C GREG NAPPS 5408298803 2014-08-15 1 MICHAEL P NORTON P00430694 5409896144 2014-08-15 2012 2015-11-30 17:44:51Z CULPEPER REGIONAL HOSPITAL C GREG NAPPS 501 SUNSET LANE CULPEPER VA 22701 83278722 0 X WWW.CULPEPERHOSPITAL.COM X 1956 VA THE MISSION OF CULPEPER REGIONAL HOSPITAL IS TO HELP PEOPLE ACHIEVE AND MAINTAIN OPTIMAL HEALTH BY PROVIDING THE BEST POSSIBLE HEALTH CARE SERVICES. WE WILL ALWAYS MAKE THE NEEDS OF OUR PATIENTS OUR TOP PRIORITY. 14 13 779 250 10903 -10830 195488 278992 75253370 78820831 1860480 1868117 526567 2301389 77835905 83269329 4895 10615 0 0 34880505 37192194 0 0 0 39906355 45520741 74791755 82723550 3044150 545779 88224569 89196037 10752857 11406516 77471712 77789521 X THE MISSION OF CULPEPER REGIONAL HOSPITAL IS TO HELP PEOPLE ACHIEVE AND MAINTAIN OPTIMAL HEALTH BY PROVIDING THE BEST POSSIBLE HEALTH CARE SERVICES. WE WILL ALWAYS MAKE THE NEEDS OF OUR PATIENTS OUR TOP PRIORITY. 0 0 65502530 10615 81143056 THE COMMUNITY BENEFIT CONTRIBUTION OF CULPEPER REGIONAL HOSPITAL IS TO PROVIDE PROGRAMS AND ACTIVITIES THAT IMPROVE ACCESS TO HEALTH CARE AND IMPROVE HEALTH IN OUR COMMUNITY. CULPEPER REGIONAL HOSPITAL IS A 70-BED, NON-PROFIT, ACUTE CARE HOSPITAL WITH COMPREHENSIVE SERVICES PROVIDING A 24 HOUR, PHYSICIAN STAFFED EMERGENCY DEPARTMENT, FAMILY BIRTH CENTER, SURGICAL SERVICES, INTENSIVE CARE UNIT AND MORE. CRH PROVIDES MEDICAL AND OTHER HEALTH CARE SERVICES TO PATIENTS REGARDLESS OF THEIR ABILITY TO PAY. OUR MISSION IS TO HELP PEOPLE ACHIEVE AND MAINTAIN OPTIMAL HEALTH BY PROVIDING THE BEST POSSIBLE HEALTH CARE SERVICES. WE ALWAYS MAKE THE NEEDS OF OUR PATIENTS OUR TOP PRIORITY. WE ALSO PARTNER WITH LOCAL NON-PROFIT ORGANIZATIONS (THE CHAMBER OF COMMERCE AND LOCAL SCHOOLS), TO SUPPORT LOCAL EVENTS AND PROVIDE HEALTH AND WELLNESS PROGRAMS. ALL UNINSURED PATIENTS, REGARDLESS OF INCOME LEVEL OR COUNTY OF RESIDENCE, RECEIVE A 20% DISCOUNT ON HOSPITAL SERVICES AND AN ADDITIONAL 15% DISCOUNT FOR PAYMENT WITHIN 30 DAYS. CRH WORKS WITH LOCAL COMMUNITY COLLEGES TO PROVIDE TOURS, LECTURES, AND INTERNSHIPS FOR STUDENTS. CRH PUBLISHES TWO MAJOR COMMUNITY NEWSLETTERS. "SIMPLY HEALTH" AND "AGING WELL" ARE PUBLISHED 3 TIMES A YEAR; THEY REACH 50,000 HOMES IN CULPEPER AND SURROUNDING COUNTIES. FOR LINKS TO ADDITIONAL COMMUNITY BENEFIT INFORMATION, PLEASE SEE CULPEPER REGIONAL HOSPITAL'S WEBSITE: WWW.CULPEPERHOSPITAL.COM 65502530 1 1 0 0 0 0 0 0 0 0 1 0 0 1 1 1 0 1 0 0 0 0 0 0 0 0 1 1 1 1 1 1 0 0 0 0 0 0 0 0 0 1 0 0 0 0 0 1 1 0 0 0 1 30 0 1 779 1 1 1 0 0 0 0 0 0 0 0 0 X 14 13 0 0 0 0 0 0 0 1 1 0 0 1 1 1 1 1 1 1 1 1 1 X C GREG NAPPS 5408298803 501 SUNSET LANE CULPEPER VA 22701 R EDWARD HOWELL 2.00 X 0 0 0 LARRY FITZGERALD 2.00 X 0 0 0 ROBERT GIBSON MD 2.00 X 0 0 0 ROBERT A ROSEN MD 2.00 X 0 0 0 SHARON CLARK 2.00 X 0 0 0 NANCY DUNLAP MD 2.00 X 0 0 0 BRADLEY E HAWS 2.00 X 0 0 0 PATRICK HOGAN 2.00 X 0 0 0 TOM REYNOLDS MD 2.00 X X 0 0 0 CONSTANCE KINCHELOE 2.00 X X 0 0 0 CHARLES CRIST 2.00 X X 0 0 0 MICHAEL ARMM 2.00 X X 0 0 0 CHARLES BARRELL 2.00 X X 0 0 0 H LEE KIRK JR 40.00 X X 437300 0 33703 SAM MORGAN 40.00 X 201189 0 10407 C GREG NAPPS 40.00 X 195537 0 23780 JANICE SUTER 40.00 X 155497 0 17577 DENNIS SMITH 40.00 X 146308 0 24992 MORTON CHILES MD 40.00 X 164750 0 18104 DEBRA O'CONNELL 40.00 X 160351 0 21981 TRACEY SHIFFELETT 40.00 X 129596 0 6961 1590528 0 157505 27 0 1 0 GILBANE BUILDING COMPANY 7 JACKSON WALKWAY PROVIDENCE RI 02903 ARCHITECTURE 3184385 WE BOWERS INC 506 SHAW RD STE 327 STERLING VA 20166 ARCHITECTURE 2514907 UVA PHYSICIANS GROUP 500 RAY C HUNT DR CHARLOTTESVILLE VA 22903 PHYSICIAN SUPPORT 1941330 RIDEGELINE PHYSICIAN SERVICES PLC 501 SUNSET LANE CULPEPER VA 22701 PHYSICIAN SUPPORT 849332 ANESTHESIA PROFESSIONAL 301 SUNSET LANE CULPEPER VA 22701 PHYSICIAN SUPPORT 799255 20 278992 278992 PATIENT SERVICES 622310 79540611 79540611 CSC K-1 622310 661942 661942 CMA K-1 622310 -1381722 -1381722 78820831 1836378 1836378 38958 9393 29565 29565 29565 29231 2508 0 0 29231 2508 31739 31739 OTHER REVENUE 622110 1979764 1979764 CAFETERIA 722210 281157 281157 OUTSIDE CATERING 722320 10903 10903 2271824 83269329 81143056 10903 1836378 X 10615 10615 1577821 1577821 27547334 19834080 7713254 564216 434446 129770 5328898 4103251 1225647 2173925 1673922 500003 294380 294380 109216 109216 10410 10410 191827 143870 47957 377328 377328 153107 153107 760040 380020 380020 845541 845541 139174 90463 48711 102592 102592 4858353 4858353 519405 498629 20776 BAD DEBT EXPENSE 12457174 10588598 1868576 MEDICAL & PHARMACY SUPP 11495392 10460807 1034585 PHYSICIAN FEES 4651935 4651935 PURCHASED SERVICES 3496700 2622525 874175 5058167 4202883 855284 82723550 65502530 17221020 0 4498583 4330151 8537721 6832959 482121 600488 1633761 1288659 1001214 824878 90188385 51698162 27471560 38490223 2840449 3204303 630786 660588 41128374 32963788 88224569 89196037 6748014 9733579 3017498 1672937 987345 0 10752857 11406516 X 75934659 76273640 1537053 1515881 77471712 77789521 88224569 89196037 X 545779 239090 -467060 X X 0 1 X 1 0 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 150000 150000 16902199 11557627 5344572 349097 347954 1143 60456280 38874181 21582099 12330809 918400 11412409 38490223 INVESTMENTS IN AFFILIATES -51979 OTHER RECEIVABLES 187081 DUE FROM AFFILIATES 30823210 SETTLEMENTS DUE FROM THIRD PARTY 489595 INTEREST IN CERTAIN NET ASSETS OF CULPEPER REGIONAL HEALTH SYSTEM 1515881 32963788 X DESCRIPTION OF UNCERTAIN TAX POSITIONS UNDER FIN 48: PART X, LINE 2: THE ORGANIZATION IS EXEMPT FROM FEDERAL INCOME TAXES UNDER SECTION 501(C)(3) OF THE INTERNAL REVENUE CODE; ACCORDINGLY, THE ACCOMPANYING FINANCIAL STATEMENTS DO NOT REFLECT A PROVISION OR LIABILITY FOR FEDERAL AND STATE INCOME TAXES. THE ORGANIZATION HAS DETERMINED THAT IT DOES NOT HAVE ANY MATERIAL UNRECOGNIZED TAX BENEFITS OR OBLIGATIONS AS OF SEPTEMBER 30, 2013. FISCAL YEARS ENDING ON OR AFTER 2010 REMAIN SUBJECT TO EXAMINATION BY FEDERAL AND STATE TAX AUTHORITIES. 1 1 1 X 1 X 1 0 1 1 2515442 2515442 0.03040 7282931 6131853 1151078 0.01390 9798373 6131853 3666520 0.04430 501935 501935 0.00610 1107353 1107353 0.01340 1609288 1609288 0.01950 11407661 6131853 5275808 0.06380 1 3877918 481721 25674317 32229804 -6555487 X 1 1 1 CULPEPER MED ASSOC MULTI-SPECIALTY MEDICAL PRACTICE 0.51000 2 CULPEPER SURG CENTER OUTPATIENT SURGICAL SERVICES 0.55110 0.44890 1 1 CULPEPER REGIONAL HOSPITAL

501 SUNSET LANE CULPEPER VA 22701

X X X CULPEPER REGIONAL HOSPITAL 1 1 X X X X X X X X X 10 1 0 1 X X X X X X X 1 0 1 1 200.000000000000 1 300.000000000000 1 X X X X X 1 1 X X X X X X 1 0 1 X 0 0 11 CULPEPER MEDICAL ASSOCIATES LLC

14115 LOVERS LANE STE 100 CULPEPER VA 22701

CMA CORPORATE OFFICE WILDERNESS MEDICAL CENTER

4376 GERMANNA HIGHWAY LOCUST GROVE VA 22508

PHYSICIAN PRACTICE CMA SURGICAL SERVICES

541 SUNSET LANE STE 303 CULPEPER VA 22701

PHYSICIAN PRACTICE PEDIATRIC CARE OF CULPEPER

540 A SUNSET LANE CULPEPER VA 22701

PHYSICIAN PRACTICE COMMONWEALTH MEDICAL

1043 OAKLAWN DRIVE CULPEPER VA 22701

PHYSICIAN PRACTICE CULPEPER FAMILY PRACTICE ASSOC

1200 SUNSET LANE STE 2210 CULPEPER VA 22701

PHYSICIAN PRACTICE PEDIATRIC MEDICAL ASSOCIATES

633 SUNSET LANE STE C CULPEPER VA 22701

PHYSICIAN PRACTICE CULPEPER PEDIATRIC SERVICES

633 SUNSET LANE STE A CULPEPER VA 22701

PHYSICIAN PRACTICE CMA FAMILY PHYSICIANS

16240 BENNET RD CULPEPER VA 22701

PHYSICIAN PRACTICE MADISON PRIMARY CARE

1007 COMMERCE LANE ROCHELLE VA 22738

PHYSICIAN PRACTICE CULPEPER SURGERY CENTER

541 SUNSET LANE CULPEPER VA 22701

SURGERY CENTER PART I, LINE 6A: CULPEPER REGIONAL HOSPITAL, INC PREPARES ITS OWN COMMUNITY BENEFIT REPORT. PART I, LINE 7: THE COSTING METHODOLOGY USED TO CALCULATE AMOUNTS REPORTED IN LINE 7 WAS A COST-TO-CHARGE RATIO DERIVED FROM WORKSHEET 2, RATIO OF PATIENT CARE COST-TO-CHARGES. PART I, LINE 7G: IT IS PART OF THE CULPEPER REGIONAL HOSPITAL'S MISSION TO ENSURE AVAILABILITY OF HEALTH CARE SERVICES TO PATIENTS IN THE COMMUNITY, 24 HOURS A DAY, 7 DAYS A WEEK, REGARDLESS OF THE PATIENTS ABILITY TO PAY. CULPEPER REGIONAL HOSPITAL IS A SMALL COMMUNITY HOSPITAL LOCATED IN A RURAL AREA THAT HAS DIFFICULTY ATTRACTING AND RETAINING PHYSICIANS. IN ORDER TO ENSURE 24/7 COVERAGE OF INPATIENT INTERNAL MEDICAL SERVICES, EMERGENCY SERVICES, AND MULTI-SPECIALTY SERVICES WITHIN THE COMMUNITY (EACH OF WHICH IS AN IDENTIFIED COMMUNITY NEED), CULPEPER REGIONAL HOSPITAL PROVIDES PHYSICIAN SUBSIDIES TO ATTRACT AND KEEP PHYSICIANS IN THE COMMUNITY. IF CULPEPER REGIONAL HOSPITAL DID NOT PROVIDE THESE SUBSIDIZED HEALTH SERVICES, COMMUNITY MEMBERS WOULD OFTEN BE FORCED TO LEAVE THE COMMUNITY TO RECEIVE CARE. THESE SUBSIDIZED HEALTH SERVICES COSTS HAVE NOT BEEN INCLUDED IN THE SHORTFALLS LISTED FOR MEDICAID OR MEDICARE, OR AS ANOTHER COMMUNITY BENEFIT OR COMMUNITY BUILDING ACTIVITY REPORTED IN PART I, LINE 7 OR PART II. PART I, L7 COL(F): THE ORGANIZATION REMOVED THE BAD DEBT EXPENSE FROM THE TOTAL EXPENSE PRIOR TO THE CALCULATIONS. PART III, LINE 4: THE COSTING METHODOLOGY USED TO CALCULATE AMOUNTS REPORTED IN LINE 2 WAS A COST-TO-CHARGES RATIO DERIVED FROM WORKSHEET 2, RATIO OF PATIENT CARE COST-TO-CHARGES, WHICH WAS MULTIPLIED AGAINST THE HOSPITAL'S BAD DEBT EXPENSE TO ARRIVE AT THE HOSPITAL'S BAD DEBT EXPENSE AT COST.IN ORDER TO ESTIMATE THE HOSPITAL'S BAD DEBT EXPENSE, AT COST, ATTRIBUTABLE TO PATIENTS UNDER THE ORGANIZATION'S CHARITY CARE POLICY, THE HOSPITAL USED THE FOLLOWING METHODOLOGY. FIRST, FOR EACH ACCOUNT ATTRIBUTABLE TO A SELF PAY PATIENT THAT HAD A BALANCE IN EXCESS OF $5,000, THE HOSPITAL USES A SOFTWARE PROGRAM THAT PULLS INFORMATION FROM VARIOUS SOURCES TO PREDICT WHETHER THE PATIENT THAT HAD RECEIVED THE CARE LIKELY WOULD QUALIFY UNDER THE HOSPITAL'S FINANCIAL ASSISTANCE POLICY. IF THE SOFTWARE PROGRAM IDENTIFIED A PATIENT AS LIKELY QUALIFYING FOR THE FINANCIAL ASSISTANCE, THE HOSPITAL PRESUMES THE PATIENT'S ELIGIBILITY UNDER THE FINANCIAL ASSISTANCE POLICY AND WRITES OFF THE AMOUNT TO CHARITY. THEN, THE HOSPITAL EXAMINES THE OUTSTANDING SELF PAY ACCOUNTS THAT HAVE A BALANCE OF LESS THAN $5,000. THE HOSPITAL DOES NOT USE THE AFOREMENTIONED SOFTWARE PROGRAM TO DETERMINE WHETHER THE PATIENTS INCURRING THESE ACCOUNTS ARE LIKELY TO QUALIFY FOR FINANCIAL ASSISTANCE. AS A RESULT, THESE ACCOUNTS ARE INCLUDED IN THE HOSPITAL'S BAD DEBT EXPENSE, IF THEY ARE NOT PAID UPON. FINALLY, THE HOSPITAL APPLIES THE PERCENTAGE OF SELF-PAY ACCOUNTS WITH A BALANCE IN EXCESS OF $5,000 THAT ARE PRESUMED TO QUALIFY FOR FINANCIAL ASSISTANCE (APPROXIMATELY 20%) TO THE BAD DEBT EXPENSE ATTRIBUTABLE TO THE SELF-PAY ACCOUNTS UNDER $5,000 TO ESTIMATE THE BAD DEBT EXPENSE ATTRIBUTABLE TO PATIENTS WHO LIKELY WOULD QUALIFY FOR FINANCIAL ASSISTANCE UNDER THE HOSPITAL'S CHARITY CARE POLICY IF SUFFICIENT INFORMATION HAD BEEN MADE AVAILABLE TO MAKE A DETERMINATION OF ELIGIBILITY. THIS BAD DEBT EXPENSE WAS THEN MULTIPLIED BY THE COST-TO-CHARGE RATIO CALCULATED PURSUANT TO WORKSHEET 2 TO DETERMINE THE BAD DEBT EXPENSE AT COST ATTRIBUTABLE TO PATIENTS LIKELY ELIGIBLE UNDER THE ORGANIZATION'S FINANCIAL ASSISTANCE POLICY.THE HOSPITAL'S BAD DEBT EXPENSE, AT COST, ATTRIBUTABLE TO PATIENTS THAT LIKELY QUALIFY FOR FINANCIAL ASSISTANCE SHOULD BE CONSIDERED A COMMUNITYBENEFIT PROVIDED BY THE HOSPITAL. ALTHOUGH THE HOSPITAL HAS MADE A STRONG EFFORT TO PROVIDE PRESUMPTIVE CHARITY CARE TO SELF-PAY PATIENTS, IT IS NOT FEASIBLE FOR THE HOSPITAL TO MAKE A CHARITY CARE DETERMINATION WITH RESPECT TO ALL OF THE PATIENTS THAT DO NOT COMPLETE THE FINANCIAL APPLICATION PROCESS, PARTICULARLY WITH RESPECT TO SMALL BALANCES. SINCE THESE PATIENTS WOULD HAVE QUALIFIED UNDER THE FINANCIAL ASSISTANCE POLICY IF THEY WOULD HAVE COMPLETED THE APPLICATION, THE BAD DEBT EXPENSE ASSOCIATED WITH TREATING THEM SHOULD STILL BE TREATED AS A COMMUNITY BENEFIT. THE LACK OF COMPLETION OF THE FINANCIAL ASSISTANCE POLICY SHOULD NOT ALTER THE CHARACTER OF THE COST. PART III, LINE 8: THE COSTING METHOLODOGY USED TO DETERMINE THE MEDICARE SHORTFALL REPORTED ON LINE 7 WAS CALCULATED USING THE COST-TO-CHARGE RATIO FROM THE MEDICARE COST REPORT AND THEREFORE ONLY INCLUDE ALLOWABLE COSTS AS DEFINED BY MEDICARE.THE ORGANIZATION'S SHORTFALL, AS REPORTED IN SCHEDULE H, PART III, SECTION B, 7, SHOULD BE CONSIDERED A COMMUNITY BENEFIT. ALTHOUGH PROVIDING THE BEST POSSIBLE CARE TO OUR MEDICARE PATIENTS CREATES A FINANCIAL LOSS, PART OF THE MISSION OF OUR ORGANIZATION IS TO SERVE ELDERLY PATIENTS WITHIN THE COMMUNITY, AND WE BELIEVE PROVIDING SUCH CARE HAS CONTRIBUTED TO THE IMPROVEMENT OF COMMUNITY HEALTH. FURTHERMORE, BY PROVIDING THE BEST POSSIBLE CARE TO OUR MEDICARE PATIENTS, WE RELIEVE THE GOVERNMENT AND OTHER SURROUNDING HOSPITALS OF THE FINANCIAL BURDEN OF TREATING THESE PATIENTS INSURED BY THE PROGRAM NOW. PART III, LINE 9B: CULPEPER REGIONAL HOSPITAL MANAGEMENT SHALL DEVELOP POLICIES AND PROCEDURES FOR INTERNAL AND EXTERNAL COLLECTION PRACTICES (INCLUDING ACTIONS THE HOSPITAL MAY TAKE IN THE EVENT OF NON-PAYMENT, INCLUDING COLLECTIONS ACTIONS AND REPORTING TO CREDIT AGENCIES) THAT TAKE INTO ACCOUNT THE EXTENT TO WHICH THE PATIENT QUALIFIES FOR CHARITY, A PATIENT'S GOOD FAITH EFFORT TO APPLY FOR A GOVERNMENTAL PROGRAM OR FOR CHARITY FROM CULPEPPER REGIONAL HOSPITAL, AND A PATIENT'S GOOD FAITH EFFORT TO COMPLY WITH HIS OR HER PAYMENT AGREEMENTS WITH CULPEPPER REGIONAL HOSPITAL. FOR PATIENTS WHO QUALIFY FOR CHARITY AND WHO ARE COOPERATING IN GOOD FAITH TO RESOLVE THEIR DISCOUNTED HOSPITAL BILLS, CULPEPPER REGIONAL HOSPITAL MAY OFFER EXTENDED PAYMENT PLANS, WILL NOT SEND UNPAID BILLS TO OUTSIDE COLLECTION AGENCIES, AND WILL CEASE ALL COLLECTION EFFORTS. CULPEPPER REGIONAL HOSPITAL WILL NOT IMPOSE EXTTRAORDINARY COLLECTIONS ACTIONS WITHOUT FIRST MAKING REASONABLE EFFORTS TO DETERMINE WHETHER THAT PATIENT IS ELIGIBLE FOR CHARITY CARE UNDER THIS FINANCIAL ASSISTANCE POLICY. REASONABLE EFFORTS SHALL INCLUDE VALIDATING THAT THE PATIENT OWES THE UNPAID BILLS AND THAT ALL SOURCES OF THIRD-PARTY PAYMENTS HAVE BEEN IDENTIFIED AND BILLED BY THE HOSPITAL,DOCUMENTATION THAT CULPEPPER REGIONAL HOSPITAL HAS OR HAS ATTEMPTED TO OFFER THE PATIENT THE OPPORTUNITY TO APPLY FOR CHARITY CAR PURSUANT TO THIS POLICY AND THAT THE PATIENT HAS NOT COMPLIED WITH THE HOSPITAL'S APPLICATION REQUIREMENTS AND DOCUMENTATION THAT THE PATIENT HAS BEEN OFFERED A PAYMENT PLAN BUT HAS NOT HONORED THE TERMS OF THAT PLAN. CULPEPER REGIONAL HOSPITAL PART V, SECTION B, LINE 14G: THE POLICY IS GIVEN TO ALL SELF-PAY PATIENTS. PART VI, LINE 2: IN AUGUST 2011, CULPEPER REGIONAL HOSPITAL (CRH) CONTRACTED WITH COMMUNITY HEALTH SOLUTIONS, INC. TO CONDUCT A COMMUNITY NEEDS ASSESSMENT (CHNA) FOR ITS PRIMARY AND SECONDARY SERVICE AREAS, WHICH INCLUDE CULPEPER, MADISON AND ORANGE COUNTIES. IN AN EFFORT TO GENERATE COMMUNITY INPUT AND GAIN A COMPREHENSIVE UNDERSTANDING OF OUR HEALTH NEEDS AND SERVICE GAPS, WE ASKED FOR INPUT FROM APPROXIMATELY 100 KEY STAKEHOLDERS. WE HAD A 41% COMPLETION RATE FOR THE SURVEYS THAT WERE DISTRIBUTED TO THE ABOVE STAKEHOLDERS. AFTER COMPLETION OF THE NEEDS ASSESSMENT, IN NOVEMBER 2011, CRH INVITED THE KEY STAKEHOLDERS AND OTHER COMMUNITY MEMBERS TO A PUBLIC FORUM TO SHARE FINDINGS FROM THE REPORT AND ENGAGE STAKEHOLDERS IN VALUABLE DIALOGUE AROUND IDENTIFIED HEALTH CONCERNS. IDEAS WERE DISCUSSED AND SYNTHESIZED TO PRODUCE A COMMUNITY-BASED PRIORITY LIST.AT THE CONCLUSION OF THE CHNA PROCESS, CRH IDENTIFIED THE FOLLOWING KEY AREAS OF FOCUS: CHILDHOOD OBESITY ADULT OBESITY DIABETES HEART DISEASE & STROKE MENTAL ILLNESSCRH'S IMPLEMENTATION STRATEGY FOR THE ABOVE INCLUDED: EXPANSION OF THE DROP IT! HEALTHY LIVING AND WEIGHT LOSS CHALLENGE, A 12-WEEK PROGRAM AND HEALTH FAIR IN PARTNERSHIP WITH GERMANNA COMMUNITY COLLEGE NURSING PROGRAM. IN ADDITION TO THE KICK-OFF HEALTH FAIR OFFERED IN CULPEPER, IN 2013 WE ADDED A HEALTH FAIR IN MADISON COUNTY. BOTH INCLUDE FREE HEALTH SCREENINGS SUCH AS CHOLESTEROL, A1C, BLOOD PRESSURE, AS WELL AS INFORMATION ON NUTRITION AND LIVING AN ACTIVE LIFESTYLE. CRH OFFERS REGULAR COMMUNITY OUTREACH SEMINARS RELATED TO THE TREATMENT AND MANAGEMENT OF CHRONIC DISEASE AND LIVING A HEALTHY LIFESTYLE. CRH HAS A NEWLY ACCREDITED (2013) DIABETES CARE, SELF-MANAGEMENT, AND EDUCATION PROGRAM CALLED TAKE CONTROL OF DIABETES. WE ALSO SPONSOR A DIABETES SUPPORT GROUP AND FREE COMMUNITY CLASSES. CRH HOSTS A MONTHLY FARMERS MARKET FROM MAY TO OCTOBER OFFERING FRESH FRUITS AND VEGETABLES. CRH LAUNCHED A NEW STROKE ALERT AND MANAGEMENT SYSTEM CALLED STROKE TELEMEDICINE AND TELE-EDUCATION (STAT) IN JANUARY 2012. IN ADDITION TO THE LAUNCH, WE HELD A DEMONSTRATION AND EDUCATION EVENT FOR EMS PERSONNEL. CRH LAUNCHED THE SILVER SCREEN PROGRAM IN THE SPRING OF 2013, WHICH SCREENS PATIENTS FOR MENTAL ILLNESS AT THREE ACCESS POINT IN THE ORGANIZATION. IF A PATIENT ANSWERS YES TO ANY OF THE QUESTIONS, THEY ARE PROVIDED WITH A CARD THAT LISTS COMMUNITY RESOURCES. CRH DEVELOPS ARTICLES FOR OUR QUARTERLY MAGAZINE, SIMPLY HEALTH, RELATED TO THE TREATMENT AND MANAGEMENT OF CHRONIC DISEASE AND LIVING A HEALTHY LIFESTYLE. CRH FINANCIALLY SUPPORTS AND ACTIVELY PARTICIPATES ON COMMUNITY RELATIONS COMMITTEES IN CULPEPER, MADISON AND ORANGE COUNTIES.IN ADDITION TO THE ABOVE, CRH HAS ADDRESSED SOME OF THE IDENTIFIED SERVICE GAPS FROM THE CHNA PROCESS: AGING SERVICES ACTIVE PARTNERSHIP WITH AGING TOGETHER, INCLUDING SPONSORSHIP OF FALLS SYMPOSIUM. ALSO, HOSTED A COMMUNITY SEMINAR ON AGING AND BRAIN HEALTH. HEALTH CARE COVERAGE SELF-PAY PATIENTS - PATIENTS WHO HAVE NO INSURANCE COVERAGE WILL AUTOMATICALLY RECEIVE A 20 PERCENT DISCOUNT AT THE TIME OF SERVICE. THIS DISCOUNT IS GRANTED PRIOR TO ANY PAYMENT ARRANGEMENTS AND/OR FINANCIAL ASSISTANCE YOU MAY BE QUALIFIED TO RECEIVE. UNINSURED PATIENTS, WHO PAY THEIR ACCOUNT IN FULL WITHIN 30 DAYS OF THE DATE LISTED ON THE INITIAL STATEMENT, WILL QUALIFY FOR AN ADDITIONAL 15 PERCENT DISCOUNT. FREE CLINIC OF CULPEPER (FINANCIALLY SUPPORTED BY CRH) - PATIENTS ARE UNINSURED RESIDENTS OF THE TOWN OR COUNTY OF CULPEPER WHO HAVE MET THE ELIGIBILITY REQUIREMENTS OF THE CLINIC. THEY ARE ADULTS BETWEEN THE AGES OF 19 AND 64 WHO ARE WORKING, SEEKING EMPLOYMENT OR DISABLED THAT HAVE INCOME AT OR BELOW 200% OF THE FEDERAL POVERTY LEVEL. DENTAL CARE/ORAL CARE ACTIVE PARTNERSHIP WITH PIEDMONT REGIONAL DENTAL CLINIC AND SUPPORT OF THE CULPEPER DENTAL CLINIC. TRANSPORTATION FINANCIAL SUPPORT OF COMMUNITY TRANSPORTATION PROGRAMS. PART VI, LINE 3: CULPEPER REGIONAL HOSPITAL HAS SEVERAL WAYS THAT IT INFORMS AND EDUCATES PATIENTS WHO MAY BE IN NEED AND ARE ELIGIBLE FOR ASSISSTANCE. WHEN STAFF (CASHIER, FINANCIAL COUNSELOR, AND REGISTERS) ARE SPEAKING WITH A PATIENT THAT STATES THEY ARE NOT ABLE TO PAY, THE PATIENT IS ENCOURAGED TO APPLY FOR FINANCIAL ASSISTANCE. BROCHURES DESCRIBING THE FINANCIAL ASSISTANCE POLICY ARE PLACED IN OUR BILLING STATEMENTS, AS WELL AS THE APPLICABLE POVERTY GUIDELINES FOR QUALIFYING FOR FINANCIAL ASSISTANCE. IN ADDITION, FINANCIAL ASSISTANCE APPLICATIONS, AS WELL AS FAQS WITH RESPECT TO THE FINANCIAL ASSISTANCE POLICY, ARE HANDED OUT TO PATIENTS UPON REGISTRATION. THE HOSPITAL'S WEBSITE POSTS THE HOSPITAL'S FINANCIAL ASSISTANCE POLICY AND GUIDELINES FOR APPLYING. PART VI, LINE 4: CULPEPER REGIONAL HOSPITAL CURRENTLY DEFINES ITS PRIMARY AND SECONDARY SERVICE AREAS AS FOLLOWS: THE PRIMARY SERVICE AREA INCLUDES CULPEPER COUNTY, AND THE SECONDARY SERVICE AREA INCLUDES MADISON AND ORANGE COUNTIES, PLUS THE ZIP CODES OF 22923 (BARBOURSVILLE) AND 22942 (GORDONSVILLE). THE POPULATION ESTIMATE FOR 2013 FOR THIS AREA IS 106,050, WITH 52,746 MALES AND 53,304 FEMALES. PROJECTED POPULATION FOR 2018 IS 110,349, WHICH IS A 4.1% CHANGE. THE AVERAGE HOUSEHOLD INCOME FOR THIS AREA IS $73,581. POPULATION DISTRIBUTION BY AGE IS AS FOLLOWS: 0-17 YEARS 24.0%, 18-34 YEARS 18.8%, 35-54 YEARS 27.9%, 55+ YEARS 29.5%. RACE/ETHNICITY DISTRIBUTION IS AS FOLLOWS: WHITE NON-HISPANIC 76.5%, BLACK NON-HISPANIC 12.8%, HISPANIC 6.7%, ASIAN & PACIFIC IS. NON-HISPANIC 1.1%, ALL OTHERS 2.8%. EDUCATION LEVELS ARE AS FOLLOWS: LESS THAN HIGH SCHOOL 6.5%, SOME HIGH SCHOOL 10.4%, HIGH SCHOOL DEGREE 33.5%, SOME COLLEGE/ASSOC. DEGREE 27.3%, BACHELOR DEGREE OR GREATER 22.3%. PART VI, LINE 5: CULPEPER REGIONAL HOSPITAL PROMOTES THE HEALTH OF ITS COMMUNITY IN SEVERAL WAYS. FIRST, THE HOSPITAL PROVIDES MEDICAL STAFF PRIVILEGES TO QUALIFIED PHYSICIANS FOR ITS DEPARTMENTS. ADDITIONALLY, ALL FINANCIAL SURPLUSES GENERATED BY THE HOSPITAL ARE USED EXCLUSIVELY TO IMPROVE PATIENT CARE SERVICES AND TO FURTHER THE CHARITABLE PURPOSES OF ORGANIZATION. PART VI, LINE 6: CULPEPER REGIONAL HOSPITAL IS PART OF AN AFFILIATED HEALTH CARE SYSTEM THAT PROVIDES AN ARRAY OF HEALTH CARE SERVICES TO ITS COMMUNITY. THE HOSPITAL IS AFFILIATED WITH CULPEPER REGIONAL HEALTH SYSTEM, A RELATED TAX-EXEMPT ORGANIZATION THAT HOLDS A 51% INTEREST IN THE HOSPITAL. ADDITIONALLY, THE UNIVERSITY OF VIRGINIA (A SECTION 501(C)(3) TAX-EXEMPT ORGANIZATION) HOLDS A 49% INTEREST IN THE HOSPITAL ON BEHALF OF ITS MEDICAL CENTER.THE HOSPITAL IS AN ACUTE CARE HOSPITAL, WHICH IS A SOLE COMMUNITY PROVIDER. THE HOSPITAL PROVIDES ESSENTIAL HEALTH CARE SERVICES TO THE COMMUNITY, INCLUDING EMERGENCY SERVICES, WHICH WOULD NOT OTHERWISE BE PROVIDED DUE TO THEIR UNPROFITABLE NATURE. OTHERWISE, THESE HEALTH CARE SERVICES WOULD NEED TO BE PROVIDED BY ANOTHER TAX-EXEMPT ORGANIZATION OR DIRECTLY BY THE GOVERNMENT. IN ADDITION, CULPEPER REGIONAL HEALTH SYSTEM UNDERTAKES A NUMBER OF ACTIVITIES THAT BENEFIT THE COMMUNITY. FOR INSTANCE, CULPEPER REGIONAL HEALTH SYSTEM RUNS A FREE 12-WEEK PROGRAM DESIGNED TO HELP MEMBERS OF THE COMMUNITY LIVE A HEALTHIER LIFESTYLE, NAMED DROP IT! THE HEALTHY LIVING AND WEIGHT LOSS CHALLENGE. THE PROGRAM INCLUDES A HEALTH FAIR WITH HEALTH SCREENINGS, INTERACTIVE FITNESS DEMONSTRATIONS, NUTRITIONAL INFORMATION AND OTHERHEALTH AND WELLNESS BOOTHS. THE PROGRAM ALSO INCLUDES GROUP EXERCISE CLASSES, HELD EACH MONDAY DURING THE 12 WEEKS. FOR EACH POUND A PARTICIPANT LOSES DURING THE PROGRAM, A DESIGNATED AMOUNT IS DONATED TO BENEFIT ALLIED AND NURSING HEALTH PROGRAMS IN THE REGION. 0 CULPEPER REGIONAL HEALTH SYSTEM PO BOX 592 CULPEPER VA 22701 521366700 28216 FREE CLINIC SCHOLARSHIPS FOR STUDIES IN THE MEDICAL FIELD 3 10615 X 1 1 X X X 0 0 0 0 0 0 0 0 0 H LEE KIRK JR 321567 0 100733 0 15000 0 10000 0 23703 0 471003 0 0 0 SAM MORGAN 182575 0 18614 0 0 0 7261 0 3146 0 211596 0 0 0 C GREG NAPPS 181591 0 13946 0 0 0 2579 0 21201 0 219317 0 0 0 JANICE SUTER 139639 0 15858 0 0 0 5712 0 11865 0 173074 0 0 0 DENNIS SMITH 146308 0 0 0 0 0 4376 0 20616 0 171300 0 0 0 MORTON CHILES MD 147358 0 17392 0 0 0 6110 0 11994 0 182854 0 0 0 DEBRA O'CONNELL 145883 0 14468 0 0 0 5730 0 16251 0 182332 0 0 0 PART I, LINE 1A THE ORGANIZATION PROVIDES HEALTH/SOCIAL CLUB DUES AS A BENEFIT FOR THE PRESIDENT/CEO. THE VALUE OF THIS BENEFIT IS INCLUDED ON THE CEO'S FORM W-2 AS WAGE INCOME. A INDUSTRIAL DEVELOP AUTHORITY OF TOWN CULPEPER VA 541312068 000000000 2003-12-23 8262873 HEALTH FACILITIES REV BOND 03 0 0 0 A 5903476 8302651 125000 2914778 5262573 2004 1 0 1 1 A 0 0 0 0 0 0 0 A 0 0 0 0 0 0 0 0 0 RIDGELINE PHYSICIAN SERVICES PLC ROBERT ROSEN, BOARD MEMBER, IS PARTNER IN ORGANIZATION. 849332 COMPENSATION PAID FOR PHYSICIAN SUPPORT SERVICES. 0 FORM 990, PART VI, SECTION B, LINE 11 THE REVIEW OF THE 990 IS PERFORMED BY THE CHIEF FINANICAL OFFICER AND CONTROLLER, THE FINANCE COMMITTEE AND THEN BY THE PRESIDENT AND CHIEF EXECUTIVE OFFICER. THE CEO BEING THE REPSONSIBLE ONE FOR SIGNING THE 990. FORM 990, PART VI, SECTION B, LINE 12C AT THE BEGINNING OF EACH MEETING OF THE BOARD BEGINS WITH VOLUNTARY VERBAL SELF-DISCLOSURE OF ANY CONFLICTS WITH ANY ITEMS ON THE AGENDA. AS ADDITONAL ISSUES ARISE DURING THE COURSE OF THE MEETING, A SIMILAR SELF-DISCLOSURE IS EXPECTED TO BE MADE. CHALLENGES BY PARTICIPANTS ARE ENCOURAGED IF SELF-DISCLOSURES ARE NOT FORTH-COMING. DURING THE COURSE OF DOING BUSINESS, IF CONFLICTS ARE SUSPECTED BY ANYONE, THEY ARE ENCOURAGED TO NOTIFY THE CEO OF THEIR SUSPICIONS. THE CEO WILL INVESTIGATE, EMPLOYING LEGAL COUNSEL AS NECESSARY, AND WILL RESOLVE AS APPROPRIATE. UTLMATELY IT IS THE RESPONSIBILTY OF THE CEO AND THE CHAIRMAN OF THE BOARD TO ENFORCE THE POLICY. FORM 990, PART VI, SECTION B, LINE 15 CEO, VP'S AND CORPORATE COMPLIANCE OFFICERS & ADDED QUALITY AND SAFETY OFFICER FOR THE FALL 2012 REVIEW. CRH HAS HISTORICALLY USED YAFFE AND IN 2012 CONVERTED TO SULLIVAN COTTER FOR OUTSIDE OBJECTIVE REVIEW OF EXECUTIVE COMPENSATION . THE PRACTICE HAS BEEN TO UPDATE MARKET DATA EVERY TWO YEARS, 2010 & 2012. THIS INFORMATION IS PROVIDED TO THE CRH EXECUTIVE/COMPENSATION COMMITTEE, WITH A SENSITIVITY TO HAVING APPROPRIATE COMPOSITION OF INDEPENDENT TRUSTEES. CHANGES IN COMPENSATION ARE THEN REPORTED TO THE FULL CRH BOARD 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: BOOK LOSS ON PARTNERSHIPS -1,164,700. K-1 CMA LOSS 1,381,722. K-1 CSC -662,914. RECLASS OF INTEREST IN NET ASSETS OF FOUNDATION -21,172. ROUNDING 4. FORM 990, PART XI, LINE 2C THE PROCESS OF FINANCIAL STATEMENT REVIEW AND OVERSIGHT HAS NOT CHANGED FROM THE PRIOR YEAR. CULPEPER REGIONAL HEALTH SYSTEM 501 SUNSET LANE CULPEPER VA 22701 541366700 MGMT VA 501(C)(3) LINE 11A, I N/A 0 UVA PHYSICIANS GROUP 500 RAY C HUNT DR CHARLOTTESVILLE VA 22903 541124769 PHYSICIANS SUPPORT VA 501(C)(3) LINE 9 UVASTATE OF VA 1 CULPEPER SURGERY CENTER LLC 541 SUNSET LANE CULPEPER VA 22701 HEALTHCARE VA CULPEPER HOSPITAL RELATED 2324728 1706135 0 0 0.55110 CULPEPER MEDICAL ASSOCIATES 100 SAUNDERS STREET CULPEPER VA 22701 MEDICAL SERVICES VA CULPEPER HOSPITAL RELATED 2726381 291823 0 0 0.51000 CULPEPER PHYSICIAN HOSPITAL ORGANIZATION PO BOX 592 CULPEPER VA 22701 541703526 MEMBERSHIP ORGANIZATION VA CULPEPER HOSPITAL C 396188 231147 0.63500 0 0 1 1 0 0 0 0 0 0 1 1 0 0 1 1 1 1 0 0 CULPEPER PHYSICIAN HOSPITAL ORGANIZATION N 363836 COST CULPEPER REGIONAL HEALTH SYSTEM P 1621125 COST