2013-05-15T13:36:14-05:00 2012-06-30 550486667 Arnett Foster Toothman PLLC P O Box 2629 Charleston WV 25329 990 2011-07-01 556000526 Grafton City Hospital GRAF 3042656401 500 Market Street Grafton WV 26354 Pat Shaw 3042656401 2013-05-09 1 Harry C Harless P01042847 3043460441 2011 2016-02-24 21:20:13Z Pat Shaw 500 Market Street Grafton WV 26354 17951920 0 X www.graftonhospital.com X 1972 WV To provide inpatient hospital care, outpatient services, emergency room services and long-term care to the residents of Taylor County, WV and surrounding communities. 10 10 486 0 0 0 36937 14264 18148089 17682050 57701 60991 163624 194615 18406351 17951920 0 0 0 0 12390184 12319097 0 0 0 5937894 5717781 18328078 18036878 78273 -84958 7617850 7043861 6205031 5991000 1412819 1052861 To provide inpatient hospital care, outpatient services, emergency room services and long-term care to the residents of Taylor County, WV and surrounding communities. 0 0 10822127 17682050 The Hospital provided health care services including 1,406 acute hospital days; 24,269 long-term care days; 2,027 swing-bed days; 23,475 rural health visits; and 394 surgeries. Additionally, the Hospital provided charity care without charge or at less than its established rates to patients who meet certain criteria under its charity care policy. Charges foregone for charity care during the year amounted to $958,658. 10822127 1 0 0 1 0 0 0 0 0 0 1 0 0 1 1 0 1 0 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 0 0 0 0 0 1 6 0 1 486 1 0 0 0 0 0 0 0 0 0 0 X 10 10 0 0 0 0 0 0 0 1 1 0 0 1 1 0 1 1 1 1 1 0 X The Organization 3042656401 500 Market Street Grafton WV 26354 John L Bord 1.00 X 0 0 0 John Whitescarver 1.00 X 0 0 0 Nancy Virginia Fowler 1.00 X 0 0 0 Paul Shroyer 1.00 X 0 0 0 Samuel M Santibanez MD 1.00 X 0 0 0 Ronald L Cole 1.00 X 0 0 0 Rusty Efaw 1.00 X 0 0 0 Wayne McDevitt 1.00 X 0 0 0 Mark Witkowski MD 1.00 X 0 0 0 Wanda Taylor 1.00 X 0 0 0 Pat Shaw 40.00 X 104835 0 3145 Brian Kelbaugh 40.00 X 90592 0 2718 Jeff Lilley 40.00 X 51826 0 1555 Joseph Duvert 40.00 X 244760 0 7343 Steven Smith 40.00 X 272654 0 8180 David Bender 40.00 X 242568 0 7281 Thomas Wilshire 40.00 X 239938 0 7198 James Woodford 40.00 X 140456 0 4214 1387629 0 41634 12 0 1 0 0 14264 14264 Net patient services 622110 17682050 17682050 17682050 60991 60991 3300 0 3300 3300 3300 Cafeteria 722212 77500 77500 Wellness revenue 900099 54335 54335 59480 59480 191315 17951920 17682050 0 255606 193301 110723 82578 9883416 5661221 4222195 242192 138728 103464 1275461 730584 544877 724727 415124 309603 7062 7062 35883 35883 955703 547427 408276 1671645 957518 714127 35198 20161 15037 391891 224475 167416 22754 13033 9721 97932 56095 41837 412524 236294 176230 458605 262689 195916 Medical supplies 804551 804551 Medicaid provider tax 381990 381990 Repairs & maintenance 261912 150023 111889 Dues & subscriptions 48605 27841 20764 131526 83650 47876 18036878 10822127 7214751 0 233677 312425 297664 90317 2635277 2529795 196341 202129 233636 238797 15351555 12669336 2740036 2682219 99926 160406 1181293 827773 7617850 7043861 3887669 3481192 993940 923932 437863 414617 885559 1171259 6205031 5991000 X 1412819 1052861 1412819 1052861 7617850 7043861 X -84958 -275000 X X 0 1 1 X 0 X 0 0 0 0 0 0 0 0 1 15583 15583 0 Explanation of Lobbying Activities: Part II-B, Line 1: Part II-B, Line(i), Other Lobbying Activities: Grafton City Hospital pays dues to the West Virginia Hospital Association. The West Virginia Hospital Association represents hospitals and health systems. For the year ended 06/30/11, the amount of dues related to lobbying activities was $15,583. 26597 26597 274995 7038963 5892409 1421549 7834494 6660320 1174174 176506 116607 59899 2682219 Estimated third-party payor settlements 784441 Other receivables 43332 827773 Capital leases 574239 Accrued pension 597020 1171259 17951920 18036878 -84958 -275000 -275000 -359958 17951920 0 17951920 0 17951920 18036878 0 18036878 0 18036878 Part XII, Line 4b - Other Adjustments: Other revenues netted with expenses on financial statements Part XI, Line 7 Prior Period Adjustment During the fiscal year ended June 30, 2012, an agreement was reached with the WV Medicaid Program to settle outstanding Medicaid Disproportionate payments for years prior to 2009. The agreement dictated that all hospitals would accept the DSH payment as "payment in full" with no additional settlement, regardless of the potential settlement being an outstanding "payable" or "receivable." That agreement reduced previously recorded third party payor settlements receivable DSH program by $275,000. The Hospital Board of Directors determined the most appropriate method to account for this adjustment was to restate beginning net assets at June 30, 2010. 1 1 1 X 1 X 1 1 0 0 1 1680 1003488 931215 72273 0.00400 3982328 3391131 591197 0.03280 1 1680 4985816 4322346 663470 0.03680 1 1680 4985816 4322346 663470 0.03680 1 1299043 4536981 4854371 -317390 X 1 1 1 1 Grafton City Hospital Inc

500 Market Street Grafton WV 25354

X X X X Grafton City Hospital 1 0 1 1 100.000000000000 1 200.000000000000 1 X X X 0 1 X X X X 1 X X X X 1 X X X X X X X 1 X 0 0 Part I, Line 7: The cost of charity care was estimated using a cost to charge ratio derived from Worksheet 2 of the Schedule H instructions. Part II: The organization's health care facilities further its exempt purpose in the following ways: The organization's governing body is comprised of persons who reside in the organization's primary service area and are neither employees or contractors of the organization, nor family members thereof. The organization extends medical staff privileges to all qualified providers in its community for some or all of its departments. The organization operates an emergency room available to all, regardless of ability to pay. Specialized services offered by the organization that are not available elsewhere include pulmonology, critical care medicine, general surgery, internal medicine, obstetrics and gynecology, and family medicine. The organization serves as a vehicle for attracting charitable support, as well as a source of community volunteer activities. Part III, Line 4: Patient Accounts Receivable: Patient accounts receivable are carried at the original charge less an estimate made for doubtful or uncollectable accounts. The allowance is based upon a review of the outstanding balances aged by financial class. Management uses collection percentages based upon historical collection experience to determine collectibility. Management also reviews troubled, aged accounts to determine collection potential. Patient accounts receivable are written off when deemed uncollectible. Recoveries of accounts previously written off are recorded as reduction to bad debt expense when received. Interest is not charged on patient accounts receivable. Part VI, Line 2: To assess the health care needs of the population base of Grafton City Hospital, the facility is heavily involved with the areas community forums. Through this venue the hospital takes the inquiries that are voiced and applies an economic forecast to the program to verify its stability. The facility also uses the Bureau for Public Health, for risk factors that would have an impact on the lives of the population that Grafton City Hospital serves. Part VI, Line 3: The patient population is educated and informed of the financial assistance programs through the financial counselors and admission personnel. The hospital also has this information published in the public areas within the hospital. Part VI, Line 4: The main population the facility serves is Taylor County. Grafton City Hospital is the only hospital within its county. Taylor County has a population of 16,898, with a estimated median household income of $34,192 as compared to WV estimated median household income of $37,435. Taylor County cost of living index is at 81.5 as compared to the United States average of 100.0. Part VI, Line 5: The organization's health care facilities further its exempt purpose in the following ways: The organization's governing body is comprised of persons who reside in the organization's primary service area and are neither employees or contractors of the organization, nor family members thereof. The organization extends medical staff privileges to all qualified providers in its community for some or all of its departments. The organization operates an emergency room available to all, regardless of ability to pay. Specialized services offered by the organization that are not available elsewhere include pulmonology, critical care medicine, general surgery, internal medicine, obstetrics and gynecology, and family medicine. The organization serves as a vehicle for attracting charitable support, as well as a source of community volunteer activities. X X X 0 0 0 0 0 0 0 0 0 Joseph Duvert 244760 0 0 0 0 0 7343 0 0 0 252103 0 0 0 Steven Smith 272654 0 0 0 0 0 8180 0 0 0 280834 0 0 0 David Bender 242568 0 0 0 0 0 7281 0 0 0 249849 0 0 0 Thomas Wilshire 239938 0 0 0 0 0 7198 0 0 0 247136 0 0 0 Form 990, Part VI, Section B, line 11 The form 990 will be reviewed by the CEO and CFO before it is filed. A copy of the final form 990 will be provided to the board of directors prior to filing. Form 990, Part VI, Section B, line 12c Trustees are made aware of the conflict of interest policy. Should a Trustee feel there is a subject in which they have a conflict, they recuse themself from the discussion and any possible action. Form 990, Part VI, Section B, line 15 A compensation committeee determines the compensation of the CEO and other officers by comparing salaries with other hospitals located in West Virginia Critical Access Hospital Network with board approval. Form 990, Part VI, Section C, line 18 The organization makes its governing documents, conflict of interest policy and financial statements available to the public upon request. 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 5: Prior period adjustments: -275,000. Process for oversight of the audit Form 990, Page 12, line 2c explanation The organization has not changed its process for oversight of the audit since last year.