2013-05-15T08:42:52-05:00 2012-06-30 EISNERAMPER LLP 2015 LINCOLN HIGHWAY PO BOX 988 EDISON NJ 08818 990 2011-07-01 010553478 EAST MOUNTAIN HOSPITAL INC % MICHAEL VOORHEES EAST 9082811439 PO BOX 1029 BELLE MEAD NJ 085021029 MICHAEL VOORHEES 2013-05-15 true RICHARD SACKIN CPA 7322871000 2011 2016-02-24 21:20:13Z MICHAEL VOORHEES PO BOX 1029 BELLE MEAD NJ 085021029 4396600 false X eastmountainhospital.com X 2003 NJ EAST MOUNTAIN HOSPITAL IS AN INPATIENT PSYCHIATRIC HOSPITAL. 8 6 65 0 200 0 5965089 4390394 745 1003 6473 4318 5972507 4395715 0 250 0 0 2329729 2294354 0 0 0 1973070 2054185 4302799 4348789 1669708 46926 2485440 2745485 1548119 1761238 937321 984247 TOGETHER WE WILL PROVIDE A SAFE, STRUCTURED, THERAPEUTIC COMMUNITY TO TREAT ADULTS WHO HAVE BEHAVIORAL AND SUBSTANCE ABUSE PROBLEMS AND RETURN THEM TO THEIR FAMILIES OR THE NEXT LEVEL OF CARE AS SOON AS POSSIBLE. false false 3791182 250 4390394 PSYCHIATRIC HOSPITAL WHICH CARED FOR 425 INPATIENTS AND HAD A TOTAL OF 5,341 PATIENT DAYS. 3791182 true false false false false false false false false false true false false false true true true false false false false false false false false false true true false false true false false false false false false false false false false false false false false false false false false true 3 0 true 65 true false false false false false false false false false false X 8 6 false false false false false false false true true false false true true true true true true true true false NJ X X MICHAEL VOORHEES 9082811439 40 EAST MOUNTAIN ROAD BELLE MEAD NJ 085021029 X MARY PAWLIKOWSKI X 0 BOHDAN CEHELYK MD 40.0 X X 258934 0 41253 MICHAEL VOORHEES 40.0 X X 111568 28379 DAVID CENTAFONT X ENRICO DEGIRONIMO X RANDOLPH JACOBSON X X PATRICIA TOOLE X X SUSAN BONFIELD X 370502 0 69632 2 false true false CARRIER CLINIC PO BOX 147 BELLE MEAD NJ 08502 ADMIN/CLINICAL 866350 SODEXO INC PO BOX 905374 CHARLOTTE NC 28290 DIETARY/HOUSEKEEPING 140926 2 0 NET PATIENT REVENUE 624100 4390394 4390394 4390394 1003 1003 0 0 0 0 2690 885 1805 1805 0 LABOR SUPPORT 900099 1655 1655 PURCHASING DISCOUNT 900099 286 286 ADMINISTRATIVE FEE 900099 264 264 308 308 2513 4395715 4390394 5321 X 0 250 250 0 0 354060 236902 117158 0 1556666 1542596 14070 65861 61337 4524 155949 129666 26283 161818 151349 10469 78744 69547 9197 8400 8400 32385 32385 0 0 0 866350 599282 267068 795 795 30935 20633 10302 1889 1889 0 248448 244499 3949 1688 1688 0 1645 1251 394 0 0 5576 5576 111578 97250 14328 PATIENT RELATED 438667 438667 DIETARY/ENVIRONMENTAL SVS 167263 167263 BAD DEBTS 12083 12083 MISCELLANEOUS 47739 16919 30820 4348789 3791182 557607 0 1815766 2027980 0 0 0 0 542062 582452 0 0 0 0 0 0 0 0 81332 94349 98231 57527 46280 40704 0 0 0 0 0 0 0 0 0 0 2485440 2745485 308795 345716 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1239324 1415522 1548119 1761238 X 937321 984247 0 0 0 0 937321 984247 2485440 2745485 46926 X false true true X false X 80441 39832 40609 17790 17695 95 40704 0 DUE TO CARRIER CLINIC 105981 ACCRUED PENSION 45444 DUE TO THIRD PARTIES 1264097 1415522 4395715 4348789 46926 46926 4396600 885 885 4395715 4395715 4349674 885 885 4348789 4348789 PART X, QUESTION #2 THE HOSPITAL IS AN ORGANIZATION DESCRIBED IN SECTION 501(C)(3) OF THE INTERNAL REVENUE CODE AND, THEREFORE, IS EXEMPT FROM FEDERAL INCOME TAXES PURSUANT TO SECTION 501(A) OF THE CODE. THERE ARE CERTAIN TRANSACTIONS THAT COULD BE DEEMED UNRELATED BUSINESS INCOME AND WOULD RESULT IN A TAX LIABILITY. MANAGEMENT REVIEWS TRANSACTIONS USING A THRESHOLD OF MORE LIKELY THAN NOT TO ESTIMATE POTENTIAL TAX LIABILITIES. IT IS MANAGEMENT'S ESTIMATION THAT THERE ARE NO MATERIAL TAX LIABILITIES THAT NEED TO BE RECORDED. PART XII, LINE 2D FUNDRAISING EXPENSE $885 PART XIII, LINE 2D FUNDRAISING EXPENSE $885 true true X true X true X 100 true true true false false 9298 9298 0.00210 9298 9298 0.00210 250 250 0.00010 250 250 0.00010 9548 9548 0.00220 270 270 0.00010 270 270 0.00010 true 5973 0 1556253 1578254 -22001 X true false 1 1 EAST MOUNTAIN HOSPITAL INC

PO BOX 1029 BELLE MEAD NJ 085021029

X EAST MOUNTAIN HOSPITAL INC 1 true true 100 true 100 true X X X X true true X X true false true X X false false PART V, SECTION B, LINE 13G THE EMH PATIENT HANDBOOK INFORMS PATIENTS THAT THEY HAVE THE RIGHT TO TREATMENT WITHOUT DISCRIMINATION BASED ON THEIR ABILITY TO PAY OR SOURCE OF PAYMENT. IN ADDITION TO BEING INCLUDED IN THE PATIENT'S HANDBOOK THAT IS DISTRIBUTED TO EVERY PATIENT, A FINANCIAL COUNSELOR MEETS WITH THE PATIENTS ON BEHALF OF EMH DURING THEIR STAY, WHEREBY SOME INFORMATION IS VERIFIED AND IF UPON INITIAL ASSESSMENT OF THE FINANCIAL COUNSELOR OR UPON THE PATIENT'S REQUEST, THE COUNSELOR DISCUSSES THE FINANCIAL ASSISTANCE (FA) POLICY WITH THE PATIENT AND ASSISTS THE PATIENT IN COMPLETING THE APPLICATION FORM FOR FA. THE PATIENT IS THEN ADVISED TO SUBMIT THE NECESSARY FINANCIAL INFORMATION TO COMPLETE THE REVIEW OF THE APPLICATION. PART V, SECTION B, LINE 19D PATIENTS WHO ARE RESIDENTS OF NEW JERSEY AND DO NOT HAVE INSURANCE ARE BILLED PURSUANT TO NEW JERSEY STATE BILLING REGULATIONS. ALL PATIENTS REGARDLESS OF RESIDENCY ARE ABLE TO APPLY FOR FINANCIAL ASSISTANCE. PART I, LINE 7, COLUMN F BAD DEBT EXPENSE FOR THE YEAR ENDED JUNE 30, 2012 IS $12,083 AND IS EXCLUDED FROM TOTAL EXPENSES FOR CALCULATING THE PERCENTAGE OF TOTAL EXPENSE. PART I, LINE 7 THE COST-TO-CHARGE RATIO USED FOR PART I, LINE 7 IS BASED ON WORKSHEET 2, RATIO OF PATIENT CARE COST-TO-CHARGES. PART III, LINE 4 PATIENT ACCOUNTS RECEIVABLE ARE RECORDED AT THE REIMBURSED OR CONTRACTED AMOUNT AND DO NOT BEAR INTEREST. THE ALLOWANCE FOR DOUBTFUL ACCOUNTS IS THE HOSPITAL'S BEST ESTIMATE OF THE AMOUNT OF PROBABLE CREDIT LOSSES IN THE HOSPITAL'S EXISTING PATIENT ACCOUNTS RECEIVABLE. THE HOSPITAL DETERMINES THE ALLOWANCE BASED ON HISTORICAL WRITE-OFF EXPERIENCE. THE HOSPITAL REVIEWS ITS ALLOWANCE FOR DOUBTFUL ACCOUNTS PERIODICALLY. PAST DUE BALANCES ARE REVIEWED INDIVIDUALLY FOR COLLECTIBILITY. ACCOUNT BALANCES ARE CHARGED OFF AGAINST THE ALLOWANCE AFTER ALL MEANS OF COLLECTION HAVE BEEN EXHAUSTED AND THE POTENTIAL FOR RECOVERY IS CONSIDERED REMOTE. PART VI, SUPPLEMENTAL INFORMATION 2 NEEDS ASSESSMENT AS PART OF EAST MOUNTAIN HOSPITALS'S (EMH) STRATEGIC PLANNING PROCESS, THE HOSPITAL GATHERS AND INCORPORATES NATIONAL, STATE, AND CLINICAL INDUSTRY DATA IN THE DEVELOPMENT OF CLINICAL SERVICES AND EDUCATIONAL FORUMS. EMH IS A PARTICIPATORY MEMBER OF THE NEW JERSEY ASSOCIATION OF MENTAL HEALTH. THIS ORGANIZATION ALSO PROVIDES BEHAVIORAL HEALTH AND ADDICTION INFORMATION RELEVANT TO THE COMMUNITY'S NEEDS. EMH RECEIVES MANY TELEPHONE CALLS FROM THE GENERAL PUBLIC ON A REGULAR BASIS, REQUIRING REFERRALS TO AND INFORMATION REGARDING COMMUNITY RESOURCES, OTHER TREATMENT CENTERS OUTSIDE THE AREA, SUPPORT GROUPS, SELF-HELP GROUPS, ETC. INFORMATION IS PROVIDED WITHOUT CHARGE. IT IS THROUGH THIS CONTACT WITH THE COMMUNITY THAT ENABLES EMH TO UNDERSTAND WHAT SERVICES ARE NEEDED THROUGHOUT THE GEOGRAPHIC AREA. PART VI, SUPPLEMENTAL INFORMATION 3 PATIENT EDUCATION UNDER A SERVICE AGREEMENT WITH CARRIER CLINIC, A PATIENT SERVICE REPRESENTATIVE MEETS WITH EACH EMH PATIENT, IF THEY ARE MENTALLY CAPABLE, AND/OR A DESIGNATED FAMILY MEMBER OR GUARDIAN INDIVIDUALLY AND ADVISES THEM THAT THEY CAN APPLY FOR CHARITY CARE FOR THEIR SELF PAY BALANCES IF THEY HAVE LIMITED INCOME. THE PATIENT SERVICE REPRESENTATIVE PROVIDES CHARITY CARE APPLICATIONS TO THE PATIENT ACCORDINGLY. PART VI, SUPPLEMENTAL INFORMATION 4 COMMUNITY INFORMATION EMH SERVES THE ENTIRE STATE OF NEW JERSEY; HOWEVER, THE MAIN PATIENT POPULATION IS FROM SUBURBAN AREAS. THE MAIN SOURCE OF ADMISSIONS IN 2011/2012 WAS FROM SOMERSET, MIDDLESEX, OCEAN, CAPE MAY AND CAMDEN COUNTIES, ALL LOCATED IN NEW JERSEY. OF THESE FIVE COUNTIES, AN AVERAGE OF 8.42% OF THE POPULATION FALLS BELOW POVERTY LEVEL. MANY PATIENTS WHO ARE DISCHARGED FROM EMH DO NOT HAVE THE MEANS TO TRAVEL HOME AND AN EMH EMPLOYEE WILL DRIVE THEM TO THEIR HOME WITHOUT CHARGE. PART II, LINE 3 COMMUNITY BUILDING ACTIVITIES EMH IS A MEMBER OF SOMERSET COUNTY'S "ADOPT-A-ROAD" PROGRAM WHICH SUPPORTS THE COMMUNITY'S ONGOING EFFORT TO KEEP ITS ROADS MORE ATTRACTIVE AND SAFE. EMH STAFF IS RESPONSIBLE FOR A TWO MILE STRETCH OF ROAD AND SPENT APPROXIMATELY FOUR HOURS DURING THE YEAR COLLECTING TRASH. X X X false false false false false false false false false BOHDAN CEHELYK MD 237934 0 0 0 21000 0 16000 25253 300187 0 0 0 SCHEDULE J, PART II DR. BOHDAN CEHELYK'S OTHER REPORTABLE COMPENSATION OF $21,000 REPRESENTS A PENSION CONTRIBUTION THAT FAILED DISCRIMINATION TESTING, RETIREMENT AND OTHER DEFERRED COMPENSATION OF $16,000 REPRESENTS EAST MOUNTAIN HOSPITAL'S CONTRIBUTION INTO THE TARGET BENEFIT PLAN, AN ERISA PLAN. NONTAXABLE BENEFITS OF $25,253 REPRESENTS HOSPITALIZATION, MEDICAL, DENTAL AND PRESCRIPTION PLAN INSURANCE COVERAGE AS WELL AS LIFE INSURANCE AND LONG-TERM DISABILITY INSURANCE PAID BY EAST MOUNTAIN HOSPITAL. FORM 990, PART VI, SECTION B, LINE 11 THE FORM 990 IS PREPARED BY INTERNAL FINANCIAL STAFF, IS REVIEWED BY AN OUTSIDE CPA CONSULTING FIRM AND IS THEN REVIEWED BY THE BOARD OF TRUSTEES IN ADVANCE OF THE FILING WITH THE IRS. THIS REVIEW IS DOCUMENTED IN THE BOARD OF TRUSTEE MINUTES. FORM 990, PART VI, SECTION B, LINE 12C EACH TRUSTEE AND OFFICER ANNUALLY SIGNS A STATEMENT WHICH AFFIRMS THAT SUCH PERSON HAS RECEIVED A COPY OF THE CONFLICT OF INTEREST POLICY, HAS READ AND UNDERSTANDS THE POLICY, HAS AGREED TO COMPLY WITH THE POLICY AND UNDERSTANDS EAST MOUNTAIN HOSPITAL IS CHARITABLE AND IN ORDER TO MAINTAIN ITS FEDERAL TAX EXEMPTION, IT MUST ENGAGE PRIMARILY IN ACTIVITIES WHICH ACCOMPLISH ITS TAX-EXEMPT PURPOSE. FORM 990, PART VI, SECTION B, LINE 15 EAST MOUNTAIN HOSPITAL UTILIZES THE NEW JERSEY HOSPITAL ASSOCIATION, SULLIVAN AND COTTER, NJMHA, MODERN HEALTHCARE PUBLICATIONS AND OTHER VARIOUS SALARY SURVEYS FOR MARKET COMPARISONS. THE INFORMATION IS THEN PROVIDED TO THE BOARD OF TRUSTEES TO ENSURE THE SALARIES ARE WITHIN APPROPRIATE MARKET AND NONPROFIT EXECUTIVE COMPENSATION BASES. THE BOARD REVIEWS THE REASONABLENESS OF THE SALARY STRUCTURE FOR OFFICERS WITHIN THE ORGANIZATION AND ALSO REVIEWS AND ESTABLISHES THE REBUTTABLE PRESUMPTION OF REASONABLENESS FOR THESE SALARIES ANNUALLY. FORM 990, PART VI, SECTION C, LINE 19 EAST MOUNTAIN HOSPITAL PROVIDES DOCUMENTS TO THE PUBLIC UPON REQUEST. THE IRS FORM 990 IS ALSO ACCESSIBLE FROM GUIDESTAR ON THE INTERNET. FORM 990, PART VII, SECTION B, INDEPENDENT CONTRACTORS EAST MOUNTAIN HOSPITAL PURCHASED ADMINISTRATIVE AND PROGRAM-RELATED SUPPORT SERVICES IN AN ARM'S-LENGTH TRANSACTION FROM CARRIER CLINIC AS PER THE DULY EXECUTED SERVICE AGREEMENT BETWEEN THE TWO ENTITIES. FOR THE FISCAL YEAR ENDED JUNE 30, 2012, THE TOTAL COST OF THESE SERVICES AMOUNTED TO $866,350 - $599,282 FOR PROGRAM-RELATED SERVICES AND $267,068 FOR VARIOUS BUSINESS SUPPORT FUNCTIONS SUCH AS FINANCIAL REPORTING, BILLING, INFORMATION TECHNOLOGY, HUMAN RESOURCES, AND OTHER BUSINESS FUNCTIONS. FORM 990, PART IX, LINE 11G EAST MOUNTAIN HOSPITAL PURCHASED ADMINISTRATIVE AND PROGRAM-RELATED SUPPORT SERVICES IN AN ARM'S-LENGTH TRANSACTION FROM CARRIER CLINIC AS PER THE DULY EXECUTED SERVICE AGREEMENT BETWEEN THE TWO ENTITIES. FOR THE FISCAL YEAR ENDED JUNE 30, 2012, THE TOTAL COST OF THESE SERVICES AMOUNTED TO $866,350 - $599,282 FOR PROGRAM-RELATED SERVICES AND $267,068 FOR VARIOUS BUSINESS SUPPORT FUNCTIONS SUCH AS FINANCIAL REPORTING, BILLING, INFORMATION TECHNOLOGY, HUMAN RESOURCES, AND OTHER BUSINESS FUNCTIONS.