2013-04-02T13:51:22-05:00 2012-06-30 560747981 DIXON HUGHES GOODMAN LLP 4510 COX ROAD SUITE 200 GLEN ALLEN VA 230603394 990 2011-07-01 540506309 CRIPPLED CHILDREN'S HOSPITAL CRIP 8042285874 2924 BROOK ROAD RICHMOND VA 232201298 LINDA E PEARSON 8042285874 2013-03-11 1 JANET L BROCKLEHURST CPA P00449539 8042827636 2011 2016-02-25 16:41:14Z CHILDREN'S HOSPITAL OF RICHMOND OF THE VCU HEALTH SYSTEM LINDA E PEARSON 2924 BROOK ROAD RICHMOND VA 232201298 26543653 0 X WWW.CHILDRENSHOSP-RICHMOND.ORG X 1920 VA CRIPPLED CHILDREN'S HOSPITAL IS A RESOURCE AND PROVIDER OF SPECIALIZED MEDICAL AND THERAPEUTIC SERVICES CUSTOMIZED TO MEET THE SPECIFIC NEEDS OF CHILDREN AND THEIR FAMILIES. OVER 9,000 CHILDREN WERE SERVED THIS PAST YEAR. WE CONTINUE TO FOCUS ON EXPANDING OUR CAPACITY TO SERVE. 9 3 413 154 0 0 759903 587018 26383453 25797231 4010 13602 37996 122326 27185362 26520177 0 0 0 0 21985911 21788558 0 0 0 7458753 7620891 29444664 29409449 -2259302 -2889272 18978176 18736550 8100730 13581019 10877446 5155531 X CH IS A RESOURCE AND PROVIDER OF SPECIALIZED MEDICAL AND THERAPEUTIC SERVICES CUSTOMIZED TO MEET THE SPECIFIC NEEDS OF CHILDREN AND THEIR FAMILIES. OVER 9,000 CHILDREN WERE SERVED THIS PAST YEAR. WE CONTINUE TO FOCUS ON EXPANDING OUR CAPACITY TO SERVE MORE CHILDREN. 0 0 8870497 10116565 THE TRANSITIONAL CARE UNIT IS THE HOSPITAL'S ONLY INPATIENT UNIT. IT HAS 47 BEDS AND PROVIDES LONG TERM CARE FOR CHILDREN UP TO THE AGE OF 21 WHO REQUIRE SPECIALIZED, AROUND THE CLOCK, NURSING CARE. THE UNIT HAD AN AVERAGE DAILY CENSUS OF 37 IN FISCAL YEAR 2012, SLIGHTLY DOWN FROM 38 IN FISCAL YEAR 2011 AND 100% OF THE REVENUE IN THIS PROGRAM COMES FROM VIRGINIA MEDICAID. THE TRANSITIONAL CARE UNIT WAS THE RECIPIENT OF THE 2012 "SILVER-ACHIEVEMENT IN QUALITY" NATIONAL QUALITY AWARD FROM THE AMERICAN HEALTH CARE ASSOCIATION. 8217090 9679317 THE HOSPITAL IS THE PREMIER PROVIDER OF OUTPATIENT PEDIATRIC PHYSICAL, OCCUPATIONAL AND SPEECH THERAPY IN CENTRAL VIRGINIA. OUTPATIENT THERAPY VISITS TOTALED 72,748 IN FISCAL YEAR 2012 WHICH IS AN INCREASE OF 1,114 VISITS FROM THE PRIOR YEAR. THERAPY SERVICES ARE OFFERED AT THE MAIN HOSPITAL IN THE CITY OF RICHMOND AND AT FOUR COMMUNITY THERAPY CENTERS LOCATED IN GLEN ALLEN, BON AIR, FREDERICKSBURG, AND PETERSBURG. 2481280 3856738 DENTAL PROGRAM SERVICES ARE PROVIDED FOR THE TYPICAL WELL-CHILD AND FOR CHILDREN WITH SPECIAL NEEDS. IN FISCAL YEAR 2012, THE DENTAL PROGRAM COMPLETED NEARLY 700 SURGERIES AND 5,000 CLINIC VISITS. THE DENTAL PROGRAM CONTINUES WITH A DENTAL OUTREACH PROGRAM TO TAKE IMPORTANT DENTAL EDUCATION AND MATERIALS TO AREA ELEMENTARY SCHOOLS. 3644922 2151028 PHYSICIAN SPECIALTY SERVICES - PEDIATRIC PHYSICIAN SPECIALIST, NURSE PRACTITIONERS AND THERAPIST PROVIDE EVALUATION, DIAGNOSIS AND TREATMENT OF A WIDE VARIETY OF MEDICAL CONDITIONS IN OUR OUTPATIENT CENTER. CLINICS INCLUDE: PHYSICAL MEDICINE AND REHABILITATION; CEREBRAL PALSY; MUSCULAR DYSTROPHY; SPASTICITY AND SPINA BIFIDA. CHILDREN'S FEEDING PROGRAM - THE CHILDREN'S FEEDING PROGRAM IS DESIGNED TO HELP CHILDREN WHO HAVE A MEDICAL CONDITION THAT HAS AFFECTED THEIR FEEDING AND GROWTH. THE CHILD IS INITIALLY SEEN IN THE FEEDING CLINIC BY A TEAM OF SPECIALISTS WHO EVALUATE THE CHILD'S NEEDS AND MAKE RECOMMENDATIONS FOR TREATMENT AND/OR PROVIDES TIPS FOR THE FAMILY. TREATMENT PROGRAMS, EITHER OUTPATIENT OR DAY PATIENT, FOCUS ON ESTABLISHING APPROPRIATE FEEDING AND NUTRITIONAL HABITS. 3644922 2151028 23213789 1 1 0 0 0 0 0 0 0 1 1 0 0 1 1 1 0 1 0 0 0 0 0 0 0 0 1 1 0 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 1 0 0 0 0 1 34 0 1 413 1 0 0 0 0 0 0 0 0 0 0 X 9 3 0 0 0 0 1 1 1 1 1 0 0 1 1 1 1 1 1 1 1 0 VA X JAMES A DEYARMIN 8042285874 2924 BROOK ROAD RICHMOND VA 232201298 THOMAS S CAIN 1.00 X X 0 0 0 PONJOLA CONEY MD 1.00 X X 0 58095 7537 LINDA E PEARSON 1.00 X X 0 385454 46735 JOHN F DUVAL 1.00 X 0 573584 81610 SHELDON M RETCHIN MD 1.00 X 0 384524 29826 BRUCE K RUBIN MD 1.00 X 0 301687 53990 ANN E HONEYCUTT 1.00 X 0 0 0 HENRY L VALENTINE III 1.00 X 0 0 0 JOHN D WARD MD 1.00 X 0 419748 54539 LESLIE G WYATT 45.00 X 293928 0 35926 SHARON W DARBY 45.00 X 185349 0 24958 KAREN A BENNETT 45.00 X 149591 0 20401 MARK D NICOL 45.00 X 104751 0 22723 PATRICIA P ANDERSON 45.00 X 103005 0 18053 JAMES A DEYARMIN 45.00 X 125464 0 17516 GREGORY FRIEDMAN 45.00 X 110416 0 21219 SAMUEL G WEIDMAN 45.00 X 414425 0 24106 1486929 2123092 459139 8 1 1 0 MCV PHYSICIANS PO BOX 79203 BALTIMORE MD 212790203 CONTRACT PHYSICIANS 1014949 ARKANSAS COUNTRY ANESTHESIA 48180 KIPPER DRIVE MOSELEY VA 23120 CONTRACT PHYSICIANS 314750 SHELTERING ARMS HOSPITAL 8254 ATLEE ROAD MECHANICSVILLE VA 23116 OFFICE SPACE LEASE 114916 MEDSITES LLC 1005 SOPHIA STREET FREDERICKSBURG VA 22401 OFFICE SPACE LEASE 106421 4 587018 587018 PATIENT SERVICES 623000 25776231 25776231 INFANT SERVICES 621610 18000 18000 RESEARCH REVENUE 541700 3000 3000 25797231 7144 7144 14300 0 14300 14300 14300 14336 7878 6458 6458 6458 21249 15598 5651 5651 FOUNDATION REIMBURSEME 561499 45000 45000 MISCELLANEOUS 900099 29676 29676 MED RECORDS FEE 623000 9417 9417 18282 18282 102375 26520177 25803648 0 129511 596495 447371 149124 16451223 13957539 2493684 1032440 818595 213845 2508481 2141559 366922 1199919 1019753 180166 292954 292954 1392 1392 60900 60900 1952061 1517833 434228 2300 1741 559 498188 231567 266621 55197 41215 13982 835888 374836 461052 41418 31796 9622 87715 70821 16894 982393 736795 245598 145803 145803 RESIDENT CARE 2619725 1810750 808975 DUES & LICENSES 25008 9697 15311 MISCELLANEOUS 19949 1921 18028 29409449 23213789 6195660 0 1756318 2309119 2927 4421 3080504 3061679 167051 169591 97272 89817 38349721 28155792 10831580 10193929 3042524 2907994 18978176 18736550 2667281 2549038 5433449 11031981 8100730 13581019 X 7881171 2285114 944253 542895 2052022 2327522 10877446 5155531 18978176 18736550 X -2889272 -2832643 X X 0 1 1 X 0 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 2996275 563458 -102298 587018 2870417 2609947 541132 605099 759903 2996275 2563739 597294 41040 592126 2609947 3089602 1034025 82059 1641947 2563739 0.00000 0.81000 0.19000 1 0 54914 54914 17574281 10150741 7423540 477715 169428 308287 19845143 17443954 2401189 397668 391669 5999 10193929 OTHER CURRENT ASSETS 26181 EQUITY INTEREST IN FOUNDATION NET ASSETS 2870417 DEPOSITS 11396 2907994 SETTLEMENTS DUE TO THIRD-PARTY PAYORS 1524273 PENSION LIABILITY 4187852 DUE TO AFFILIATES 4838997 OTHER LIABILITES 84034 PATIENT CREDIT BALANCES 365137 PATIENT ACCOUNT REFUNDS 24629 UNCLAIMED CHECKS 7059 11031981 DESCRIPTION OF INTENDED USE OF ENDOWMENT FUNDS: PART V, LINE 4: THE HOSPITAL HAS RECORDED ITS BENEFICIAL INTEREST IN CERTAIN TEMPORARILY AND PERMANENTLY RESTRICTED NET ASSETS OF THE FOUNDATION THAT ARE TO BENEFIT THE HOSPITAL. TEMPORARILY RESTRICTED NET ASSETS IN THE FOUNDATION OF $542,895 AND $944,253 AT JUNE 30, 2012 AND 2011, RESPECTIVELY, ARE AVAILABLE FOR THE PURCHASE OF CAPITAL ASSETS AND TO SUPPORT THE OPERATIONS OF THE HOSPITAL. PERMANENTLY RESTRICTED NET ASSETS IN THE FOUNDATION OF $2,327,522 AND $2,052,022 AT JUNE 30, 2012 AND 2011, RESPECTIVELY, ARE INVESTMENTS TO BE HELD IN PERPETUITY, THE INCOME FROM WHICH IS EXPENDABLE TO SUPPORT PROGRAMS AT THE HOSPITAL. THE HOSPITAL RECEIVED FROM THE FOUNDATION $587,018 AND $759,903 IN 2012 AND 2011, RESPECTIVELY, TO SUPPORT OPERATIONS OF THE HOSPITAL AND FOR THE PURCHASE OF CAPITAL ASSETS. DESCRIPTION OF UNCERTAIN TAX POSITIONS UNDER FIN 48: PART X: CHILDRENS HOSPITAL IS INCLUDED IN THE CONSOLIDATED FINANCIAL STATEMENTS OF THE AUTHORITY: THE AUTHORITY RECOGNIZES THE EFFECT OF INCOME TAX POSITIONS ONLY IF THOSE POSITIONS ARE MORE LIKELY THAN NOT OF BEING SUSTAINED. RECOGNIZED INCOME TAX POSITIONS ARE MEASUREED AT THE LARGEST AMOUNT THAT IS GREATER THAN 50% LIKELY OF BEING REALIZED. CHANGES IN RECOGNITION OR MEASUREMENT ARE REFLECTED IN THE PERIOD IN WHICH THE CHANGE IN JUDGMENT OCCURS. AT JUNE 30, 2012 AND 2011, THE AUTHORITY HAS NO INCOME TAX POSITIONS THAT ARE NOT CONSIDERED GREATER THAN 50% LIKELY OF BEING REALIZED. 1 1 1 X 1 X 1 1 0 1 0 1 11 18994 0 18994 0.00060 1 1349 14407803 12469617 1938186 0.06590 2 1360 14426797 12469617 1957180 0.06650 58 27366 188733 0 188733 0.00640 16 2301 129155 0 129155 0.00440 4 1796 1428327 321886 1106441 0.03760 78 31463 1746215 321886 1424329 0.04840 80 32823 16173012 12791503 3381509 0.11490 1 81973 0 36556 36556 X 1 1 1 1 CRIPPLED CHILDREN'S HOSPITAL

2924 BROOK ROAD RICHMOND VA 23220

X X X PEDIATRIC LONG TERM CARE CRIPPLED CHILDREN'S HOSPITAL 1 0 1 1 100.000000000000 1 200.000000000000 1 X X X X X X 1 1 X X 1 X 1 X X X 0 X X 0 0 PART I, LINE 6A: THE HOSPITAL PROVIDED A COMMUNITY BENEFIT REPORT TO AN ASSOCIATION WHICH INCLUDED THE RESULTS WITH OTHER LOCAL HOSPITALS IN A PUBLISHED REPORT. THROUGH ITS MANY PUBLICATIONS AND WEBSITES, THE HOSPITAL AND CHILDREN'S HOSPITAL FOUNDATION REPORT THE ACTIVITIES THAT SUPPORT THE COMMUNITY. PART I, LINE 7: COST IS USED TO DETERMINE THE AMOUNT OF COMMUNITY BENEFIT FOR EACH CATEGORY. COST IS DETERMINED BY USING EITHER A COST ACCOUNTING METHODOLOGY OR A COST TO CHARGE RATIO. PART I, LINE 7G: THE COST OF CERTAIN PHYSICIAN CLINICS THAT MET THE DEFINITION OF A SUBSIDIZED HEALTHCARE SERVICE IS INCLUDED IN SUBSIDIZED HEALTHCARE SERVICES. PART III, LINE 4: REVENUE FROM THE MEDICAID PROGRAM ACCOUNTED FOR APPROXIMATELY 69% OF THE HOSPITAL'S NET PATIENT SERVICE REVENUE FOR THE YEAR ENDED JUNE 30, 2012. AMOUNTS NOT EXPECTED TO BE PAID ARE RESERVED AND CHARGED TO BAD DEBT EXPENSE. THE AMOUNT REPORTED AS BAD DEBT EXPENSE IS AT COST AND IS BASED ON A COST TO CHARGE RATIO. NO ATTEMPT HAS BEEN MADE TO DETERMINE THE AMOUNT IN BAD DEBT EXPENSE THAT COULD HAVE BEEN ELIGIBLE FOR CHARITY CARE. THE HOSPITAL WILL REFER TO A CONTRACTED COLLECTION AGENCY ACCOUNTS WHERE THE RESPONSIBLE PARTY HAS NOT ATTEMPTED TO RESOLVE THE BALANCE DUE. THE HOSPITAL DOES NOT ENTER INTO PAYMENT PLANS WHERE THE RESPONSIBLE PARTY IS ATTEMPTING TO RESOLVE OUTSTANDING BALANCES. THE BAD DEBT EXPENSE IS BASED UPON THE COST TO CHARGE RATIO. PART III, LINE 8: MEDICARE ALLOWABLE COST IS FROM THE LOW UTILIZATION MEDICARE COST REPORT. PART III, LINE 9B: A FINANCIAL COUNSELOR ASSISTS PATIENTS IN UNDERSTANDING AVAILABILITY OF COMMUNITY OR GOVERNMENTAL ASSISTANCE PROGRAMS, AS WELL AS THE HOSPITAL'S CHARITY CARE POLICY. PATIENT FAMILIES RECEIVE NOTIFICATION THROUGH THE PATIENT BOOKLET AS A NEW PATIENT. CRIPPLED CHILDREN'S HOSPITAL PART V, SECTION B, LINE 19D: FREE CARE IS PROVIDED TO ELIGIBLE PARTICIPANTS AT 100% OF FPG. BETWEEN 100% AND 200% OF FPG, PATIENTS ARE RESPONSIBLE FOR EITHER 10% OR 20% OF THEIR PATIENT BILL. PATIENTS CAN QUALIFY FOR A 70% DISCOUNT WHEN THEY MEET CERTAIN REQUIREMENTS TO BE DEEMED MEDICALLY INDIGENT. THE HOSPITAL ALSO OFFERS A SELF-PAY RATE (APPROXIMATELY 40% OF CHARGES, SIMILAR TO WHAT MEDICAID PAYS) TO UNINSURED PATIENTS BEYOND THOSE WHO QUALIFY FOR CHARITY CARE. PATIENTS CAN ALSO MAKE MONTHLY PAYMENTS, INTEREST FREE, FOR 18 MONTHS. PART VI, LINE 3: SEE PART III, LINE 9B EXPLANATION. PART VI, LINE 4: SEE PART V EXPLANATION. PART VI, LINE 5: SEE PART V EXPLANATION. 1 1 0 0 0 0 0 0 0 0 LINDA E PEARSON 0 328302 0 51680 0 5472 0 38820 0 7915 0 432189 0 0 JOHN F DUVAL 0 565676 0 0 0 7908 0 68539 0 13071 0 655194 0 0 SHELDON M RETCHIN MD 0 380166 0 0 0 4358 0 26289 0 3537 0 414350 0 0 BRUCE K RUBIN MD 0 298900 0 0 0 2787 0 51732 0 2258 0 355677 0 0 JOHN D WARD MD 0 357567 0 55457 0 6724 0 51732 0 2807 0 474287 0 0 LESLIE G WYATT 242979 0 27790 0 23159 0 24755 0 11171 0 329854 0 0 0 SHARON W DARBY 167654 0 0 0 17695 0 16966 0 7992 0 210307 0 0 0 KAREN A BENNETT 135999 0 0 0 13592 0 14139 0 6262 0 169992 0 0 0 SAMUEL G WEIDMAN 150227 0 20000 0 244198 0 16302 0 7804 0 438531 0 0 0 PART I, LINE 3 COMPENSATION OF THE EXECUTIVE DIRECTOR IS DETERMINED BY THE LEADERSHIP OF VCUHS PART I, LINE 4A SAMUEL WEIDMAN RECEIVED SEVERANCE PAYMENTS OF $196,227 FORM 990, PART VI, SECTION A, LINE 6 ALSO LINES 7A AND 7B - THE SOLE MEMBER OF THE CORPORATION IS VIRGINIA COMMONWEALTH UNIVERSITY HEALTH SYSTEM AUTHORITY (VCUHS), A STATUTORY AUTHORITY CREATED UNDER THE CODE OF VIRGINIA. VCUHS HAS THE EXCLUSIVE RIGHT AND POWER TO ELECT, APPOINT, OR REMOVE THE MEMBERS OF THE CORPORATION'S BOARD OF DIRECTORS AS PROVIDED IN THE BYLAWS. THE BOARD OF DIRECTORS OF VCUHS SHALL ACT ON VCUHS'S BEHALF IN EXERCISING VCUHS'S RESERVED POWERS OVER THE CORPORATION. CERTAIN COMMITTEES OF THE BOARD OF DIRECTORS OF VCUHS SHALL OVERSEE THE ACTIVITIES OF THE CORPORATION. FORM 990, PART VI, SECTION A, LINE 7A SEE RESPONSE TO PAGE 6, PART VI, LINE 6 FORM 990, PART VI, SECTION A, LINE 7B SEE RESPONSE TO PAGE 6, PART VI, LINE 6 FORM 990, PART VI, SECTION B, LINE 11 A PDF COPY OF THE 990 IS SENT TO ALL THE BOARD MEMBERS FOR REVIEW AND A PERIOD OF TIME IS ALLOTED FOR REIVEW COMMENTS BY THE BOARD MEMBERS. FORM 990, PART VI, SECTION B, LINE 12C ALL OFFICERS, TRUSTEES AND KEY EMPLOYEES SHALL DISCLOSE A POTENTIAL CONFLICT TO THE CHAIRMAN OF THE BOARD OR COMPLIANCE OFFICER FOR INVESTIGATION AND RESOLUTION. UPON APPOINTMENT TO THE BOARD OR EMPLOYMENT AND ANNUALLY THEREAFTER, OFFICERS, TRUSTEES AND KEY EMPLOYEES SHALL COMPLETE AN AFFIRMATION STATEMENT AND DISCLOSURE FORM FOR REVIEW BY THE BOARD. FORM 990, PART VI, SECTION B, LINE 15 AN OUTSIDE CONSULTANT IS USED TO COMPLETE A REVIEW AND ESTABLISH RANGES TO BE USED BY THE COMPENSATION COMMITTEE OF THE BOARD OF TRUSTEES. THE REVIEW INCLUDES ALL SENIOR MANAGEMENT POSITIONS (CEO, EVP/CFO, VP OF CLINICAL OPERATIONS/CNO, VP OF HR AND COMPLIANCE OFFICER). FORM 990, PART VI, SECTION C, LINE 19 THE PUBLIC VIEWING DOCUMENT IS AVAILABLE FOR INSPECTION AT THE MAIN HOSPITAL LOCATION UPON REQUEST. CHANGES IN NET ASSETS OR FUND BALANCES: FORM 990, PART XI, LINE 5: CHANGE IN PLAN ASSETS AND BENEFIT OBLIGATION OF PENSION PLAN -2,706,785. CHANGE IN VALUE OF SPLIT-INTEREST AGREEMENTS -125,858. TOTAL TO FORM 990, PART XI, LINE 5: -2,832,643. FORM 990, PART XII, LINE 2C THE BOARD HAS NOT CHANGED THE OVERSIGHT OF ITS PROCESS FOR THE ORGANIZATION'S AUDIT OR SELECTION OF THE INDEPENDENT ACCOUNTANT. FUNDRAISING EXPENSES FORM 990, PART IX, LINE 25D THE HOSPITAL DOES NOT PERFORM FUNDRAISING FUNCTIONS. THE CHILDREN'S HOSPITAL FOUNDATION RAISES FUNDS FOR CHILDREN'S SERVICES IN THE RICHMOND AREA AND DONATES TO THE HOSPITAL EACH YEAR. VIRGINIA COMMONWEALTH UNIVERSITY HEALTH SYSTEM AUTHORITY (VCUHS) PO BOX 980152 RICHMOND VA 23298 541848065 PARENT - ACADEMIC MEDICAL CTR - MCV HOSPITALS VA 501(C)(1) N/A 0 MCV ASSOCIATED PHYSICIANS DBA MCV PHYSICIANS PO BOX 980620 RICHMOND VA 232980510 541581185 GROUP PRACTICE OF PROFESSIONALS SUPPORTING MEDICAL TEACHING VA 501(C)(3) LINE 11A, I VCUHS 0 UNIVERSITY HEALTH SERVICES INC (UHS) PO BOX 980152 RICHMOND VA 23298 541790550 SUPPORT EDUCATIONAL & SCIENTIFIC ACTIVITIES OF VA COMMONWEALTH UNIVERSITY VA 501(C)(3) LINE 11A, I VCUHS 0 UHS MANAGED CARE INC PO BOX 980152 RICHMOND VA 23298 541790554 PROVIDE HEALTHCARE VA 501(C)(3) LINE 9 UHS 0 0 0 0 0 0 0 0 0 1 0 0 0 0 1 1 1 0 0