2012-03-05T06:26:39-06:00 2011-06-30 Arnett & Foster PLLC P O Box 2629 Charleston WV 25329 990 2010-07-01 556000526 Grafton City Hospital GRAF 3042656401 500 Market Street Grafton WV 26354 Pat Shaw 3042656401 2012-03-02 1 Harry C Harless 3043460441 2010 2016-02-24 21:20:13Z Pat Shaw 500 Market Street Grafton WV 26354 18361765 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 10 520 0 0 0 44895 36937 17255915 18103503 6783 57701 129700 163624 17437293 18361765 0 0 0 0 11597682 12390185 0 0 0 5776298 5937893 17373980 18328078 63313 33687 7108950 7617850 5729818 6205031 1379132 1412819 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 10996847 18103503 The Hospital provided health care services including 1,783 acute hospital days; 24,374 long-term care days; 2,162 swing-bed days; 22,245 rural health visits; and 290 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 $1,440,345. 10996847 1 1 0 1 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 4 0 1 520 1 0 0 0 0 0 1 1 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 Brian Kelbaugh 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 Jeff Lilley 40.00 X 138852 0 4166 Brian Kelbaugh 40.00 X 94811 0 2844 Pat Shaw 40.00 X 86854 0 2606 Joseph Duvert 40.00 X 258560 0 7757 Steven Smith 40.00 X 238764 0 7163 David Bender 40.00 X 225502 0 6765 Thomas Wilshire 40.00 X 256463 0 7694 James Woodford 40.00 X 190117 0 5704 1489923 0 44699 13 0 1 0 0 36937 36937 Net patient services 622110 18103503 18103503 18103503 57701 57701 2875 2875 2875 2875 Cafeteria 722212 70386 70386 Wellness revenue 900099 44586 44586 45777 45777 160749 18361765 18103503 0 221325 314710 186308 128402 9689229 5736024 3953205 218863 129567 89296 1511507 894812 616695 655876 388279 267597 9814 9814 41031 41031 834878 494248 340630 2689054 1591920 1097134 49288 29178 20110 371755 220079 151676 19678 11649 8029 110870 65635 45235 440521 260788 179733 455339 269561 185778 Medicaid provider tax 414083 414083 0 Repairs & maintenance 281600 166707 114893 Dues & subscriptions 60444 35783 24661 Physician recruitment 18810 18810 0 Professional developmen 16813 9953 6860 123915 73463 50452 18328078 10996847 7331231 0 163444 233677 145549 297664 2587745 2635277 245239 196341 208476 233636 14996848 12256812 3174355 2740036 51700 99926 532442 1181293 7108950 7617850 3245560 3887669 1060764 993940 469422 437863 954072 885559 5729818 6205031 X 1379132 1412819 1379132 1412819 7108950 7617850 33687 0 X X 0 1 1 X 0 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 0 0 0 0 0 0 0 0 1 15600 15600 0 Explanation of Other Lobbying Activities: Part II-B, Line 1i: 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 $15,600. 26597 26597 274995 7179796 5847251 1607540 7515460 6409561 1105899 2740036 Estimated third-party payor settlements 1145204 Other receivables 36089 1181293 Capital leases 379395 Accrued pension 506164 885559 18361765 18328078 33687 0 33687 18361765 0 18361765 0 18361765 18328078 0 18328078 0 18328078 1 1 1 X 1 X 1 1 0 0 1 1695 1175712 885023 290689 0.01770 1 1695 1175712 885023 290689 0.01770 1 1695 1175712 885023 290689 0.01770 1 1199445 4410561 4801731 -391170 X 1 1 1 1 Grafton City Hospital Inc

500 Market Street Grafton WV 25354

X X X X Grafton City Hospital Inc 1 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 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 $ 1941477. 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. Grafton City Hospital, Inc. Part V, Section B, Line 19d: Prompt pay discount policy of 25% 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 16,328, 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 81.0 as compared to the United States average of 100.0. Part VI, Line 6: 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 258560 0 0 0 0 0 7757 0 0 0 266317 0 0 0 Steven Smith 238764 0 0 0 0 0 7163 0 0 0 245927 0 0 0 David Bender 225502 0 0 0 0 0 6765 0 0 0 232267 0 0 0 Thomas Wilshire 256463 0 0 0 0 0 7694 0 0 0 264157 0 0 0 James Woodford 190117 0 0 0 0 0 5704 0 0 0 195821 0 0 0 Form 990, Part VI, Section B, line 11 The Form 990 will be reviewed by the CEO and CFO and 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. Clarification of 'yes' response Form 990, Part XII, Line 2C The organization has not changed its process for oversight of the audit since last year.