2013-07-31T12:53:59-05:00 2012-09-30 560747981 DIXON HUGHES GOODMAN LLP 500 RIDGEFIELD COURT ASHEVILLE NC 28806 990 2011-10-01 586001667 STEPHENS COUNTY HOSPITAL AUTHORITY STEP 7062824200 163 HOSPITAL DRIVE TOCCOA GA 30577 JEFFREY LAIRD 7062824200 2013-07-31 1 AMY BIBBY P00445891 8282542254 2011 2016-02-24 21:20:13Z EDWARD C GAMBRELL JR 163 HOSPITAL DRIVE TOCCOA GA 30577 56641131 0 X WWW.STEPHENSCOUNTYHOSPITAL.COM X 1945 GA PROVIDES INPATIENT, OUTPATIENT, OCCUPATIONAL, AND EMERGENCY CARE SERVICES FOR RESIDENTS OF STEPHENS COUNTY, GEORGIA AND SURROUNDING AREAS. 7 6 699 35 0 0 103533 10366 50404539 55537338 123786 158547 888770 934880 51520628 56641131 0 0 0 0 29860784 28160964 0 0 0 22098400 27741544 51959184 55902508 -438556 738623 43260957 42275649 16548621 14824690 26712336 27450959 X THE MISSION OF STEPHENS COUNTY HOSPITAL AUTHORITY IS TO PROVIDE HEALTH CARE AND RELATED SERVICES TO ENHANCE INDIVIDUAL HEALTH AND WELL BEING IN A MANNER THAT MEETS THE EXPECTATIONS OF PATIENTS AND OTHER CUSTOMERS; PRESERVES THE RIGHTS OF PATIENTS, EMPLOYEES AND OTHERS TO BE TREATED WITH DIGNITY, RESPECT AND CONCERN; PROVIDES PROFESSIONALLY AND TECHNICALLY PROFICIENT PERSONNEL IN AN EFFECTIVE AND RESOURCE EFFICIENT MANNER; UTILIZES ALL RESOURCES APPROPRIATELY TO CONTAIN COSTS AND TO PROVIDE FOR ADDITIONAL SERVICE OPPORTUNITIES; AND ALL PHASES OF OPERATIONS MUST BE CARRIED OUT IN AN ETHICAL MANNER. 0 0 51910340 55537338 STEPHENS COUNTY HOSPITAL AUTHORITY OPERATES 96 INPATIENT BEDS AND PROVIDES OUTPATIENT SERVICES TO A SERVICE AREA THAT EXTENDS BEYOND STEPHENS COUNTY TO SURROUNDING COUNTIES OF FRANKLIN, HART, HABERSHAM, RABUN, AND BANKS IN GEORGIA AND INTO NEIGHBORING OCONEE COUNTY IN SOUTH CAROLINA. STEPHENS COUNTY HOSPITAL AUTHORITY ALSO OPERATES A 92 BED PERSONAL CARE HOME. THE STEPHENS COUNTY HOSPITAL PARTICIPATES IN SEVERAL EMPLOYER SPONSORED HEALTH FAIRS AND ALSO SUPPORTS THE LOCAL EMPLOYERS IN THE "DRUGS DON'T WORK" PROGRAM. THE STEPHENS COUNTY HOSPITAL DOES NOT TURN ANY INDIVIDUAL DOWN FOR SERVICES BASED ON THE INABILITY TO PAY FOR SUCH SERVICES. 51910340 1 0 0 1 0 0 0 0 0 0 1 0 0 0 0 1 0 1 0 0 0 0 0 0 0 0 1 1 0 0 1 1 0 0 0 0 0 0 0 0 1 0 0 0 0 0 0 1 1 0 0 0 1 14 0 1 699 1 0 0 0 0 0 0 0 0 0 0 X 7 6 0 0 0 0 0 1 0 1 1 0 0 1 1 1 1 1 1 1 1 0 GA X JEFFREY B LAIRD CFO 7062824281 163 HOSPITAL DRIVE TOCCOA GA 30577 MARK G WILKINSON 2.00 X X 0 0 0 ROBERT W SLATE MD 2.00 X X 0 0 0 STANLEY W ROBERTS 2.00 X X 0 0 0 PAULA M DICKERSON 2.00 X 0 0 0 JON C WEST 2.00 X 0 0 0 GEORGE SANDERS 2.00 X 0 0 0 MAX BROCK 2.00 X 0 0 0 EDWARD C GAMBRELL 50.00 X 293788 0 34201 JEFFREY B LAIRD 50.00 X 98921 0 28299 FAYE M TAYLOR 50.00 X 106435 0 18448 TINA DEBORD 50.00 X 108244 0 21516 ANGELA R KING 40.00 X 131425 0 19025 RONALD L REESE 45.00 X 125211 0 13573 KELLY R HART 40.00 X 113363 0 18874 977387 0 153936 13 0 1 0 MORRIS AND DICKSON LLC PO BOX 51367 SHREVEPORT LA 71135 LEGAL SERVICES 709276 US FOODSERVICE INC PO BOX 281945 ATLANTA GA 30384 FOODSERVICE 586326 CPSI PO BOX 850309 MOBILE AL 36685 IT SERVICES 453215 GE HEALTHCARE PO BOX 402076 ATLANTA GA 30384 MEDICAL SERVICES 285903 FMD LITHOTRIPSY SERVICES LLC 1850 LEE ROAD WINTER PARK FL 32789 MEDICAL SERVICES 262200 32 10366 10366 NET PATIENT REVENUE 622000 50849021 50849021 RESIDENT REVENUE 623000 2117041 2117041 MEANINGFUL USE MONIES 900099 1902127 1902127 AMBULANCE SERVICE SUBS 621910 621490 621490 PHYSICIAN BILLING FEES 622000 47659 47659 55537338 34281 34281 124266 0 124266 124266 124266 CAFETERIA SALES 900099 528099 528099 PHARMACY - EMPLOYEE CO 900099 214954 214954 MISCELLANEOUS 900099 191827 191827 934880 56641131 55537338 0 1093427 455245 22760 432485 22239649 20644546 1595103 587259 534793 52466 3342912 3044252 298660 1535899 1398680 137219 8887 8887 92000 92000 5001501 4457589 543912 35903 35903 6405106 5574846 830260 1639353 1639353 200 200 318862 318862 2369356 2369356 901526 901526 BAD DEBT 6994042 6994042 MEDICAL SUPPLIES 3319909 3319909 MEDICAID PROVIDER FEE T 653723 653723 MISCELLANEOUS 1176 1176 55902508 51910340 3992168 0 221366 1013533 4663840 4577315 9552509 9286172 1884179 1781992 1771530 1771476 382685 264430 62240562 40135841 23445235 22104721 1339613 1476010 43260957 42275649 5756382 5575970 8674903 7775220 2117336 1473500 16548621 14824690 X 24531770 25466324 2180566 1984635 26712336 27450959 43260957 42275649 738623 0 X 0 1 1 X 0 X 0 0 0 0 0 0 0 0 1 4100 4100 0 EXPLANATION OF LOBBYING ACTIVITIES: PART II-B, LINE 1: THIS AMOUNT REPRESENTS THE APPROXIMATE LOBBYING PORTION OF DUES PAID TO THE THE AMERICAN HOSPTIAL ASSOCIATION. 242888 242888 30410667 13913661 16497006 1175648 790812 384836 29554173 24963182 4590991 857186 468186 389000 22104721 56641131 55902508 738623 738623 48993366 0 48993366 7647765 7647765 56641131 48254743 0 48254743 7647765 7647765 55902508 DESCRIPTION OF UNCERTAIN TAX POSITIONS UNDER FIN 48: PART X: INCOME TAXES- THE HOSPITAL AND SCEP ARE NOT-FOR-PROFIT ORGANIZATIONS AS DESCRIBED IN SECTION 501(C)(3) OF THE INTERNAL REVENUE CODE AND ARE EXEMPT FROM FEDERAL INCOME TAXES ON RELATED INCOME PURSUANT TO SECTION 501(A) OF THE CODE. ACCORDINGLY, NO PROVISION FOR STATE OR FEDERAL INCOME TAXES HAS BEEN PRESENTED IN THE ACCOMPANYING CONSOLIDATED FINANCIAL STATEMENTS. THE HOSPITAL AND SCEP HAVE EVALUATED THEIR TAX POSITIONS AND HAVE DETERMINED THAT THEY DO NOT HAVE ANY MATERIAL UNRECOGNIZED TAX BENEFITS OBLIGATIONS AS OF SEPTEMBER 30, 2012. NOTHING IS CURRENTLY UNDER REVIEW. FISCAL YEARS ENDING ON AND AFTER SEPTEMBER 30, 2009 REMAIN SUBJECT TO EXAMINATION BY FEDERAL AND STATE TAX AUTHORITIES. PART XII, LINE 4B - OTHER ADJUSTMENTS: MEDICARE PROVIDER FEES NETTED WITH REVENUE 653,723. BAD DEBT EXPENSE NETTED WITH REVENUE 6,994,042. PART XIII, LINE 4B - OTHER ADJUSTMENTS: MEDICARE PROVIDER FEES NETTED WITH REVENUE 653,723. BAD DEBT EXPENSE NETTED WITH REVENUE 6,994,042. 1 1 1 X 125.000000000000 1 X 1 1 1 0 0 2869749 2253751 615998 0.01260 2985799 2270723 715076 0.01460 4887374 3762695 1124679 0.02300 10742922 8287169 2455753 0.05020 1480690 1284429 196261 0.00400 1480690 1284429 196261 0.00400 12223612 9571598 2652014 0.05420 1 2253480 500000 10757764 14852986 -4095222 X 1 1 1 1 STEPHENS COUNTY HOSPITAL

163 HOSPITAL DRIVE TOCCOA GA 30577

X X X DISPROPORTIONATE SHARE HOSPITAL STEPHENS COUNTY HOSPITAL 1 0 1 1 125.000000000000 1 200.000000000000 1 X 1 1 X X X X X X 1 0 1 X 0 0 2 THE CLARY CARE CENTER

249 HOSPITAL DRIVE TOCCOA GA 30577

ADVANCED PERSONAL CARE FACILITY THE WILKINSON CENTER

269 HOSPITAL DRIVE TOCCOA GA 30577

PERSONAL CARE FACILITY PART I, LINE 7G: THE HOSPITAL OPERATES A COUNTY AMBULANCE. PART I, LINE 7, COLUMN (F): THE BAD DEBT EXPENSE INCLUDED ON FORM 990, PART IX, LINE 25, COLUMN (A), BUT SUBTRACTED FOR PURPOSES OF CALCULATING THE PERCENTAGE IN THIS COLUMN IS $ 6994042. PART III, LINE 4: THE ORGANIZATION'S AUDITED FINANCIAL STATEMENTS DO NOT INCLUDE A FOOTNOTE OF BAD DEBT EXPENSE. THE BAD DEBT EXPENSE AT COST ON PART III, LINE 2 WAS COMPUTED BY USING THE PERCENTAGE OF THE AUDITED FINANCIAL STATEMENT EXPENSES DIVIDED BY TOAL GROSS PATIENT REVENUE. THE ORGANIZATION ESTIMATED THE AMOUNT OF BAD DEBT ATTRIBUTABLE TO CHARITY CARE BASED ON PRIOR EXPERIENCE. PART III, LINE 8: A VERY HIGH PERCENTAGE OF THOSE PATIENTS COVERED BY MEDICARE DUE TO AGE OR DISABILITY ARE ALSO MEDICALLY INDIGENT AS EVIDENCED BY A LARGE PERCENTAGE OF THAT POPULATION WITH MEDICAID AS THE SECONDARY COVERAGE. PART III, LINE 9B: PATIENTS WHO ARE KNOWN TO QUALIFY FOR CHARITY CARE, FREE CARE, OR ANOTHER FORM OF FINANCIAL ASSISTANCE ARE NOT CONTACTED UNLESS ADDITIONAL INFORMATION IS NEEDED FOR QUALIFICATION OR THE CONTINUOUS OF QUALIFICATION FOR SAID PROGRAM. PART VI, LINE 2: THE ORGANIZATION UTILIZED MANY OUTSIDE COMPILATIONS OF DATA TO ASSESS THE HEALTH NEEDS OF THE POPULATION WE SERVE. THERE ARE MANY SOURCES AVAILABLE ON THE INTERNET THAT DEPICT THE ILLNESSES HISTORICALLY TREATED IN THE COMMUNITY. WE ALSO UTILIZE INTERNAL DATA AS TO WHAT HEALTH ISSUES ARE BEING TREATED BY OUR HOSPITAL. GEORGIA HOSPITAL ASSOCIATION COMMUNITY COMPLETED A PROFILE AND NEEDS ASSESSMENT FOR OUR SERVICE AREA WITHIN THE PAST TWO YEARS AND PROVIDED THAT TO OUR ORGANIZATION. PART VI, LINE 3: THERE ARE SIGNS AT EVERY CHECK-IN POINT WITHIN THE HOSPITAL AS WELL AS PAMPHLETS GIVEN OUT TO EVERY PATIENT REGISTERED WHO HAS NO THIRD PARTY COVERAGE. ALSO, DURING COLLECTION EFFORTS BY IN-HOUSE STAFF, PATIENTS ARE INFORMED OF AND ENCOURAGED TO FILL OUT APPLICATIONS FOR FINANCIAL ASSISTANCE FOR THOSE WITHOUT 3RD PARTY COVERAGE. PART VI, LINE 4: STEPHENS COUNTY HOSPITAL SERVES A RURAL POPULATION OF GEORGIA. ACCORDING TO THE LATEST DATA AVAILABLE FOR 2010, OF THE STEPHENS COUNTY RESIDENTS THAT REQUIRED THE SERVICES OF A HOSPITAL DURING THE YEAR, 26.9% HAD PRIMARY COVERAGE FROM MEDICARE, 27.2% HAD PRIMARY COVERAGE FROM A MEDICAID PROGRAM AND OVER 8% HAD NO 3RD PARTY COVERAGE AT ALL. THE MAJOR ILLNESSES TREATED WERE CHRONIC OBSTRUCTIVE PULMONARY DISEASE, UNCONTROLLED DIABETES AND CONGESTIVE HEART FAILURE. PART VI, LINE 5: STEPHENS COUNTY HOSPITAL AUTHORITY APPLIES ALL FUNDS AVAILABLE TO THE PROVISION OF PATIENT CARE, PATIENT AND COMMUNITY HEALTH EDUCATION, RETIREMENT OF DEBT RELATED TO THE PURCHASE OF FIXED ASSETS UTILIZED IN THE PROVISION OF PATIENT CARE AND THE OUTRIGHT PURCHASE OF EQUIPMENT FOR THE EXPRESSED PURPOSE OF HEALTH CARE FOR OUR COMMUNITY AND SUUROUNDING SERVICE AREA. THE STEPHENS COUNTY HOSPITAL AUTHORITY'S GOVERNING BODY INCLUDES INDIVIDUALS WHO RESIDE IN THE ORGANIZATION'S PRIMARY SERVICE AREA AND WHO ARE NEITHER EMPLOYEES OR INDEPENDENT CONTRACTORS OF THE ORGANIZATION NOR FAMILY MEMBERS THEREOF. THE STEPHENS COUNTY HOSPITAL AUTHORITY EXTENDS MEDICAL STAFF PRIVILEGES TO ALL QUALIFIED PHYSICIANS IN THE COMMUNITY FOR SOME OR ALL OF ITS DEPARTMENTS. THE STEPHENS COUNTY HOSPITAL AUTHORITY PROVIDES CARE AND EDUCATION TO ANY INDIVIDUAL IN THE COMMUNITY AND SURROUNDING SERVICE AREA THAT SEEKS IT WITHOUT REGARD TO THAT PERSON'S ABILITY TO PAY FOR SUCH SERVICES. X X X 0 0 0 0 0 1 0 0 0 EDWARD C GAMBRELL 278178 0 8410 0 7200 0 8909 0 25292 0 327989 0 0 0 ANGELA R KING 131425 0 0 0 0 0 3915 0 15110 0 150450 0 0 0 PART I, LINE 6 PER CONTRACTUAL EMPLOYMENT AGREEMENT, THE CEO RECEIVES A YEAR-END BONUS OF 1% OF NET EARNINGS AS SHOWN ON THE STEPHENS COUNTY HOSPITAL AUTHORITY'S AUDITED CONSOLIDATED STATEMENTS OF REVENUES, EXPENSES, AND CHANGES IN NET ASSETS. DURING THE FISCAL YEAR 2011, BONUS PAYMENT WAS CALCULATED BASED ON FISCAL YEAR 2010 AUDITED STATEMENTS, WHICH SHOWED A NET INCOME OF $841,038 RESULTING IN $8,410 IN BONUS PAYMENT. HOSPITAL AUTHORITY OF STEPHENS COUNTY GEORGIA SERIES 2006 586001667 858753DE3 2006-10-10 4000000 CONSTRUCTION & RENOVATION OF PATIENT ROOMS 0 0 0 HOSPITAL AUTHORITY OF STEPHENS COUNTY GEORGIA SERIES 2010 586001667 2010-12-16 4740000 CURRENT REFUNDING 0 0 0 4000000 858233 168861 3831139 2007 0 0 1 1 915000 4740000 814586 135318 4604682 2001 1 0 1 1 0 0 0 0 0.00000 0.00000 0.00000 1 0 0 0 0 0.00000 0.00000 0.00000 1 0 0 0 0 0 0 0 0 0 0 0 1 PART II, LINE 11, OTHER SPENT PROCEEDS THE AMOUNTS PRESENTED ON PART II, LINE 11 REPRESENT PROCEEDS SPENT TO REFUND SERIES 2001A AND 2001B ISSUES. CONSTANCE RICE SISTER OF GEORGE SANDERS (BOARD MEMBER) 78744 COMPENSATION FOR DUTIES AS SURGICAL SERVICES MANAGER 0 FORM 990, PART VI, SECTION A, LINE 7A SERVICE ON THE BOARD OF TRUSTEES FOR THE HOSPITAL AUTHORITY IS A NON-COMPENSATED POSITION. EVERY POSITION ON THE AUTHORITY IS APPOINTED/ELECTED FOR A SIX YEAR TERM. EACH POSITION IS ELECTED BY THE CURRENT TRUSTEES FROM A SLATE OF THREE NOMINATIONS MADE FROM THE COUNTY COMMISSION. THE SAME PROCESS IS UTILIZED IF A POSITION BECOMES VACANT AT ANYTIME PRIOR TO THE COMPLETION OF A SIX YEAR TERM AND IS FOR THE REMAINDER OF SAID TERM. FORM 990, PART VI, SECTION B, LINE 11 A COPY OF THE FORM 990 WAS REVIEWED BY EACH VOTING BOARD MEMBER. AT A REGULAR SCHEDULED BOARD MEETING, THE GOVERNING BOARD FULLY DISCUSSED THE FORM 990. THE ENTIRE BOARD VOTED AND APPROVED THE FORM 990 AS PRESENTED. FORM 990, PART VI, SECTION B, LINE 12C THE ORGANIZATION CONDUCTS PERIODIC REVIEWS OF EXISTING BUSINESS RELATIONSHIPS AND INITIAL REVIEWS OF ANY NEW BUSINESS RELATIONSHIPS. FORM 990, PART VI, SECTION B, LINE 15 THE AUTHORITY SETS AND REVIEWS THE COMPENSATION PACKAGE OF THE CEO USING COMPARABLE DATA PROVIDED BY THE GEORGIA HOSPITAL ASSOCIATION ON CEO COMPENSATION AT SIMILAR SIZED HOSPITALS IN GEORGIA. CONSIDERATION IS ALSO GIVEN TO THE LEVEL OF EXPERIENCE AND OVER ALL PERFORMANCE OF THE HOSPITAL. THIS SAME PROCESS IS USED THROUGHOUT THE ORGANIZATION IN SETTING AND REVIEWING PAY SCALES FOR ALL JOBS INCLUDING THAT OF ANY "KEY EMPLOYEES." COMPARISON DATA IS USED TO SET A PAY SCALE AND THE LEVEL OF EXPERTISE AND EXPERIENCE IN THE JOB DUTIES DETERMINE THE POINT WITHIN THAT SCALE COMPENSATION IS SET. FORM 990, PART VI, SECTION C, LINE 18 RECENT FILINGS OF THE FORM 990 ARE AVAILABLE ONLINE AT WWW.GUIDESTAR.ORG. FORM 990, PART VI, SECTION C, LINE 19 THE STEPHENS COUNTY HOSPITAL AUTHORITY MAKES ITS GOVERNING DOCUMENTS, CONFLICT OF INTEREST POLICY, AND FINANCIAL STATEMENTS AVAILABLE TO THE PUBLIC UPON REQUEST. IN ADDITION, RECENT FILINGS OF THE FORM 990 ARE AVAILABLE ONLINE AT WWW.GUIDESTAR.ORG. STEPHENS COUNTY EMERGENCY PHYSICIANS INC 163 HOSPITAL DRIVE TOCCOA GA 30577 020692996 PROVIDE EMERGENCY ROOM PHYSICIANS TO STEPHENS COUNTY HOSPITAL GA 501(C)(3) 7 N/A 1 STEPHENS COUNTY HOSPITAL FOUNDATION INC 163 HOSPITAL DRIVE TOCCOA GA 30577 208089919 FUNDRAISING ACTIVITIES FOR STEPHENS COUNTY HOSPITAL GA 501(C)(3) 11 N/A 1 0 0 0 0 0 0 0 0 0 0 0 1 1 1 0 0 0 0 STEPHENS COUNTY EMERGENCY PHYSICIANS INC L 1315875 CASH