2014-08-14T15:20:47-05:00 2013-09-30 560747981 DIXON HUGHES GOODMAN LLP 111 FRANKLIN RD SE SUITE 501 ROANOKE VA 240112114 990 2012-10-01 521366700 CULPEPER REGIONAL HEALTH SYSTEM CULP 5408298803 501 SUNSET LANE CULPEPER VA 227010592 H LEE KIRK JR 5408298803 2014-08-06 1 MICHAEL P NORTON P00430694 5409896144 2014-08-06 2012 2015-11-30 17:44:51Z H LEE KIRK JR 501 SUNSET LANE CULPEPER VA 22701 4549913 0 X WWW.CULPEPERHOSPITAL.COM X 1985 VA THE ORGANIZATION'S MISSION IS TO SUPPORT THE MISSION OF CULPEPER REGIONAL HOSPITAL. 12 12 0 0 0 0 390364 430790 1645493 2556265 101106 338070 928976 710191 3065939 4035316 348023 539958 0 0 1537972 2279077 0 0 16867 1623992 1865785 3509987 4684820 -444048 -649504 24212021 25679856 405694 1105330 23806327 24574526 THE MISSION OF CULPEPER REGIONAL HEALTH SYSTEM IS TO SUPPORT THE ACTIVITIES THAT CARRY OUT THE CHARITABLE PURPOSES OF CULPEPER MEMORIAL HOSPITAL, DBA CULPEPER REGIONAL HOSPITAL. 0 0 1785747 2000197 POWELL WELLNESS CENTER, LLC, (PWC) A WHOLLY-OWNED SUBSIDIARY AND DISREGARDED ENTITY, BEGAN OPERATIONS IN AUGUST 2007 AND OPERATES A WELLNESS CENTER CONSISTENT WITH, AND IN SUPPORT OF, THE MISSION OF CULPEPER MEMORIAL HOSPITAL, DBA CULPEPER REGIONAL HOSPITAL. 454877 454877 CRHS FOUNDATION WAS ORGANIZED AND IS OPERATED FOR THE PURPOSE OF SOLICITING, RECEIVING, AND ADMINISTERING GIFTS, GRANTS AND CONTRIBUTIONS FOR THE BENEFIT OF CULPEPER MEMORIAL HOSPITAL, DBA CULPEPER REGIONAL HOSPITAL. 1289870 85081 1353296 CRHS MANAGES REAL ESTATE PROPERTIES, AN AUXILIARY, A FREE CLINICAND PROVIDES SCHOLARSHIPS FOR THE PURPOSE OF PROMOTING THE VISION& MISSION OF CULPEPER MEMORIAL HOSPITAL, DBA CULPEPER REGIONALHOSPITAL. CULPEPER PHYSICIANS GROUP, LLC (DBA CULPEPER ENT), A WHOLLY-OWNED SUBSIDIARY AND DISREGARDED ENTITY, BEGAN OPERATIONS AS A PHYSICIAN PRACTICE, IN SEPTEMBER 2012. THE PRACTICE, WHICH SPECIALIZES IN THE MEDICAL AND SURGICAL TREATMENT OF EAR, NOSE AND THROAT CONDITIONS, WITH AUDIOLOGY AND HEARING DEVICE SERVICES, PROVIDES EXCELLENT PATIENT CARE IN A MANNER CONSISTENT WITH, AND IN SUPPORT OF, THE MISSION OF CULPEPER MEMORIAL HOSPITAL, DBA CULPEPER REGIONAL HOSPITAL. 3530494 1 1 0 0 0 0 0 0 0 0 1 1 0 0 1 1 0 1 0 0 0 0 0 0 1 0 0 1 1 1 0 0 0 0 0 0 0 0 0 0 0 0 1 1 1 0 0 0 1 11 0 1 0 0 0 0 0 0 1 1 0 0 0 0 X 12 12 0 0 0 0 0 0 0 1 1 0 0 1 1 1 1 1 1 1 1 0 X H LEE KIRK JR 5408298803 501 SUNSET LANE CULPEPER VA 227010592 CONSTANCE KINCHELOE 4.00 X 0 0 0 CHARLES CRIST 4.00 X 0 0 0 SHARON CLARK 1.00 X 0 0 0 CATHY ZIELINKSI 2.00 X 0 0 0 HB SEDWICK 2.00 X 0 0 0 BREVARD WALLACE MD 2.00 X 0 0 0 DR ROBERT A ROSEN 2.00 X 0 0 0 NANCY CANNON 2.00 X 0 0 0 BARBARA WEBER 2.00 X 0 0 0 MICHAEL ARMM 4.00 X 0 0 0 CHARLES BARRELL 4.00 X 0 0 0 TOM REYNOLDS MD 5.00 X 0 0 0 SAMUEL MORGAN 8.00 X 0 201189 10407 H LEE KIRK JR 12.00 X 0 437300 33703 C GREG NAPPS 8.00 X 0 195537 23780 0 834026 67890 0 0 1 0 0 13082 30072 28216 359420 430790 PWC MEMBERSHIP DUES 713940 1627788 1627788 CULPEPER PHYSICIAN GRO 900099 860156 860156 PWC ASSESSMENT FEES 713940 68321 68321 2556265 277013 277013 878682 464614 414068 414068 414068 61057 0 61057 61057 61057 24003 30072 49983 -25980 -25980 OTHER REVENUE 622110 254288 254288 PWC CAFE 722210 22948 22948 MISC. REVENUE-RELATED- 900099 18015 18015 26852 26852 322103 4035316 3353493 0 251033 421695 421695 118263 118263 1934772 1516135 418637 321887 254365 67522 22418 22418 66675 66675 19259 19259 67238 67238 24650 24650 305412 18962 286450 220728 195673 21442 3613 94475 83351 11124 21808 21808 403993 398135 5858 50299 47292 3007 UTILITIES 117998 117998 REPAIRS AND MAINTENANCE 70644 70608 36 DUES & SUBSCRIPTIONS 8713 8713 MINOR EQUIPMENT 8623 8041 582 385270 190883 181133 13254 4684820 3530494 1137459 16867 736900 831262 44279 215824 87054 64529 9755 13640 16871 14547 20345002 5369917 15371946 14975085 6713755 7573986 1188537 1800319 54034 42924 136630 24212021 25679856 229460 236279 15628 14973 160606 854078 405694 1105330 X 22806433 23421971 833880 986541 166014 166014 23806327 24574526 24212021 25679856 X -649504 557538 16913 843252 X X 0 1 X 1 0 X X X X 0 0 0 CULPEPER MEMORIAL HOSPITAL DBA CULPEPPER REGIONAL HOSPITAL 540622371 03 1 1 1 278992 1 278992 RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 2378632 2378632 13302347 3565674 9736673 5939 1485 4454 3850792 1757019 2093773 807292 45739 761553 14975085 INVESTMENTS IN AFFILIATES 96176 C ASSETS WHOSE USE IS LIMITED 1704143 C 1800319 DUE TO CMH 827888 ANNUITY PAYABLE 26190 854078 X DESCRIPTION OF UNCERTAIN TAX POSITIONS UNDER FIN 48: PART X, LINE 2: MANAGEMENT HAS RECEIVED A TAX DETERMINATION LETTER FROM THE INTERNAL REVENUE SERVICE INDICATING THAT CRHS AND THE HOSPITAL ARE EXEMPT FROM FEDERAL INCOME TAXES UNDER SECTION 501(C)(3) OF THE INTERNAL REVENUE CODE AS ORGANIZATIONS OTHER THAN A PRIVATE FOUNDATION. FEDERAL TAX LAW REQUIRES THAT CRHS AND THE HOSPITAL BE OPERATED IN A MANNER CONSISTENT WITH ITS EXEMPTION APPLICATION IN ORDER TO MAINTAIN ITS EXEMPT STATUS. MANAGEMENT HAS ANALYZED THE OPERATIONS OF CRHS AND THE HOSPITAL AND CONCLUDED THAT THEY REMAIN IN COMPLIANCE WITH THE REQUIREMENTS FOR EXEMPTION. CRHS AND THE HOSPITAL ARE ALSO EXEMPT FROM STATE INCOME TAXES UNDER APPLICABLE STATE STATUTES. THE SYSTEM HAS DETERMINED THAT IT DOES NOT HAVE ANY MATERIAL UNRECOGNIZED TAX BENEFIT OR OBLIGATION AS OF SEPTEMBER 30, 2013. FISCAL YEARS ENDING ON OR AFTER SEPTEMBER 30, 2010, REMAIN SUBJECT TO EXAMINATION BY FEDERAL AND STATE AUTHORITIES. GALA 28875 12936 15939 20129 6000 10203 GOLF 25200 17136 8064 2266 4213 7172 54075 30072 24003 2266 24342 6000 17375 49983 -25980 1 CULPEPER REGIONAL HOSPITAL 501 SUNSET LANE CULPEPER VA 22701 540622371 278992 FMV DONATIONS FROM FOUNDATION FOR PROPERTY AND EQUIPMENT SCHOLARSHIPS 43 118263 PROCEDURE FOR MONITORING GRANTS IN THE U.S.: PART I, LINE 2: SCHEDULE I, PART I, LINE 2: PART I LINE 2 LOCAL SCHOLARSHIPS TWO GRADUATING HIGH SCHOOL STUDENTS FROM EACH OF THE TWO CULPEPER HIGH SCHOOLS WHO ARE PURSUING A NURSING OR OTHER MEDICAL CAREER ARE ELIGIBLE TO APPLY FOR SCHOLARSHIPS AWARDED BY THE FOUNDATION. APPLICANTS MUST SUBMIT AN APPLICATION THAT INCLUDES AN ESSAY EXPLAINING THEIR DESIRE TO PURSUE THE DESIGNATED AREA OF STUDY. GUIDANCE STAFF AT THE RESPECTIVE HIGH SCHOOLS REVIEW APPLICATIONS AND SELECT THE WINNERS. PART I, LINE 2 CRHS SCHOLARSHIPS: EMPLOYEES OF CRH & CRHS THAT ARE EMPLOYED FULL-TIME, PART-TIME OR LEASED AND HAVE BEEN ACCEPTED INTO A PROGRAM IDENTIFIED AS AN AREA OF NEED WITHIN THE ORGANIZATION ARE ELIGIBLE TO APPLY FOR ASSISTANCE FROM CRHS. APPLICANTS MUST: - APPLY PRIOR TO COMMENCEMENT OF THE COURSE OR PROGRAM OF STUDY - COMPLETE AN APPLICATION, INCUDING A 400-500 WORD ESSAY - PROVIDE COURSE REGISTRATION, TUITION BILL AND OTHER DOCUMENTATION SUPPORTING REQUEST - PROVIDE LETTER OF ACCEPTANCE INTO PROGRAM, AS APPLICABLE - PROVIDE TRANSCRIPTS AND MAINTAIN A MINIMUM GPA OF 3.0 THE EDUCATION ASSISTANCE COMMITTEE REVIEWS ALL APPLICATIONS AND APPROVES THE ASSISTANCE REQUEST BASED ON THE APPLICANT'S COURSE OF STUDY AND EDUCATION TRACK AS RELEVANT TO THE NEEDS OF CRHS. ASSISTANCE IS GRANTED ANNUALLY AND PAID BY SEMESTERS. APPROVALS ARE ONLY VALID FOR COURSES APPROVED EACH SEMESTER AND THE RECIPIENT MUST SUBMIT APPLICATIONS FOR RENEWAL EACH SEMESTER, ALONG WITH TRANSCRIPTS OF THE PREVIOUS SEMESTER'S GRADES TO ENSURE THE MINIMUM GPA OF 3.0 IS BEING MET. TUITION ASSISTANCE AMOUNTS ARE INTENDED TO COVER TUITION, FEES, BOOKS AND OTHER NECESSARY ITEMS NEEDED TO COMPLETE THE COURSES. DOCUMENTATION OF PROOF OF COST IS NECESSARY. 0 0 0 0 0 0 0 0 0 SAMUEL MORGAN 0 182575 0 18614 0 0 0 7261 0 3146 0 211596 0 0 H LEE KIRK JR 0 321567 0 100733 0 15000 0 10000 0 23703 0 471003 0 0 C GREG NAPPS 0 181591 0 13946 0 0 0 2579 0 21201 0 219317 0 0 SUPPLEMENTAL INFORMATION PART III TOP MANAGEMENT COMPENSATION CRHS RELIES UPON CMH, DBA CULPEPER REGIONAL HOSPITAL, WHICH USES AN INDEPENDENT COMPENSATION CONSULTANT, WRITTEN EMPLOYMENT CONTRACT, COMPENSATION STUDY OR SURVEY, AND APPROVAL BY BOARD OR COMPENSATION COMMITTEE ESTABLISH THE COMPENSATION OF THE CEO. FORM 990, PART VI, SECTION B, LINE 11 REVIEWING THE 990 PART VI, LINE 11 THE FORM 990 IS PREPARED WITH ASSISTANCE FROM AN OUTSIDE ACCOUNTING FIRM, AND REVIEWED BY THE CHIEF FINANCIAL OFFICER AND CONTROLLER OF THE HOSPITAL, AS WELL BY A SUBCOMMITTEE OF THE BOARD OF DIRECTORS, AS APPOINTED, OF THE ORGANIZATION. A COPY OF THE FORM 990 IS MADE AVAILABLE TO EACH OF THE ORGANIZATION'S BOARD MEMBERS FOR THEIR REVIEW AND COMMENT PRIOR TO FILING. FORM 990, PART VI, SECTION B, LINE 12C MONITORING CONFLICTS OF INTEREST PART VI, SECTION B, 12C THE ORGANIZATION HAS ADOPTED A CONFLICT OF INTEREST POLICY ADOPTED BY CULPEPER REGIONAL HOSPITAL. ANNUALLY, EACH BOARD MEMBER MUST DISCLOSE ANY CONFLICTS OF INTEREST WITH THE ORGANIZATION OR ANY OTHER BOARD MEMBERS. IN ADDITION TO THE ANNUAL DISCLOSURE, EACH MEETING OF THE BOARD BEGINS WITH A VOLUNTARY VERBAL SELF-DISCLOSURE OF ANY CONFLICTS WITH ANY ITEMS ON THE AGENDA. AS ADDITIONAL ISSUES ARISE DURING THE COURSE OF A MEETING, A SIMILAR SELF-DISCLOSURE IS EXPECTED TO BE MADE. IF SELF-DISCLOSURES ARE NOT FORTH-COMING, THE BOARD MEMBERS ARE ENCOURAGED TO RAISE THE POSSIBILITY OF POTENTIAL CONFLICTS WITH REGARD TO OTHER BOARD MEMBERS. DURING THE COURSE OF DOING BUSINESS, IF CONFLICTS ARE SUSPECTED BY ANYONE AFFILIATED WITH THE ORGANIZATAION WITH REGARD TO KEY EMPLOYEES, OFFICERS, OR BOARD MEMBERS, THEY ARE ENCOURAGED TO NOTIFY THE CHIEF EXECUTIVE OFFICER OF THEIR SUSPICIONS. THE CEO WILL INVESTIGATE, EMPLOYING LEGAL COUNSEL AS NECESSARY, AND WILL RESOLVE AS APPROPRIATE. ULTIMATELY IT IS THE RESPONSIBILITY OF THE CHIEF EXECUTIVE OFFICER AND THE CHAIRMAN OF THE BOARD TO ENFORCE THE POLICY. FORM 990, PART VI, SECTION B, LINE 15 TOP MANAGEMENT COMPENSATION CRHS RELIES UPON CMH, DBA CULPEPER REGIONAL HOSPITAL, WHICH USES AN INDEPENDENT COMPENSATION CONSULTANT, WRITTEN EMPLOYMENT CONTRACT, COMPENSATION SURVEY OR STUDY, AND APPROVAL BY BOARD OR COMPENSATION COMMITTEE TO ESTABLISH THE COMPENSATION OF THE CEO. FORM 990, PART VI, SECTION C, LINE 19 THIS 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: K-1 PHYSICIANS OFFICE BUILDING -26,842. EQUITY TRANSFER FROM RELATED PARTY-CULPEPER HOSPITAL 860,488. BAD DEBT 9,606. FORM 990, PART XII, LINE 2C THE AUDIT COMMITTEE RESPONSIBILITY & OVERSIGHT PROCESS HAS NOT CHANGED FROM THE PRIOR YEAR. FORM 990, PART V, LINE 2A SALARIES INCURRED BY CULPEPER REGIONAL HOSPITAL, ON BEHALF OF THIS FILING ENTITY CULPEPER REGIONAL HEALTH SYSTEM & ITS SUBSIDIARIES, ARE ALLOCATED APPROPRIATELY. THE ALLOCATED WAGES & BENEFITS APPEAR AS EXPENSES ON THIS FORM 990, PART IX, LINES 7 & 9, HOWEVER, ALL WAGES ARE PAID BY, AND FORM W-2S ARE ISSUED THROUGH, THE HOSPITAL. POWELL WELLNESS CENTER 1005 GOLF DRIVE CULPEPER VA 22701 204803079 WELLNESS CENTER VA 2330197 9257040 CRHS CULPEPER PHYSICIANS GROUP LLC 501 SUNSET LANE CULPEPER VA 22701 455590868 PHYSICIAN PRACTICE VA 878171 322467 CRHS CULPEPER REGIONAL HOSPITAL 501 SUNSET LANE CULPEPER VA 22701 540622371 COMMUNITY HOSPITAL VA 501(C)(3) 170B1 (A) III CRHS 1 CULPEPER PHYSICIAN HOSPITAL ORGANIZATION PO BOX 592 CULPEPER VA 22701 541703526 MEMBERSHIP ORGANIZATION VA CMH C 0 0 1 1 0 0 0 0 0 0 1 0 1 0 1 1 1 0 0 0 CULPEPER REGIONAL HOSPITAL J 345798 FMV