2012-03-07T08:52:33-06:00 2011-09-30 DIXON HUGHES GOODMAN LLP 500 RIDGEFIELD COURT ASHEVILLE NC 28806 990 2010-10-01 560989789 HALIFAX REGIONAL MEDICAL CENTER INC HALI 2525358011 250 SMITH CHURCH ROAD ROANOKE RAPIDS NC 27870 SHERRY JENSEN 2525358011 2012-03-07 1 AMY BIBBY 8282542254 2010 2016-02-24 21:20:13Z WILL MAHONE 250 SMITH CHURCH ROAD ROANOKE RAPIDS NC 27870 104438739 0 X WWW.HALIFAXMEDICALCENTER.ORG X 1972 NC TO PROVIDE MEDICAL SERVICES TO THE RESIDENTS OF HALIFAX COUNTY AND SURROUNDING COUNTIES. 15 12 969 110 258294 -41442 138124 431163 100452858 102548054 379341 670004 709529 698525 101679852 104347746 0 0 0 0 41804281 42600232 0 0 0 55035846 58456445 96840127 101056677 4839725 3291069 74579254 81164352 35056228 42443699 39523026 38720653 X PLACING PATIENTS FIRST BY PROVIDING EXCELLENT AND COMPASSIONATE HEALTHCARE SERVICES. 0 0 94938263 102289760 PROVIDING QUALITY HEALTHCARE IS ONLY PART OF THE HOSPITAL'S CONTRIBUTION TO THE COMMUNITY. WITH OVER 1,000 EMPLOYEES, HALIFAX REGIONAL IS ONE OF THE REGION'S LARGEST EMPLOYERS. MANY OF THE APPROXIMATELY 60 PHYSICIANS ON THE HOSPITAL STAFF HIRE THEIR OWN EMPLOYEES AS WELL AND INVEST IN DEVELOPING THEIR PRACTICES, EXTENDING ECONOMIC IMPACT. THE MEDICAL CENTER PURCHASES MILLIONS OF DOLLARS OF GOODS AND SERVICES FROM THE REGION.WITH ITS ABUNDANT NATURAL RESOURCES AND STRATEGIC LOCATION, THE HOSPITAL'S MARKET IS DYNAMIC AND OFFERS EXCITING OPPORTUNITIES. AT HALIFAX REGIONAL, THE STAFF IS COMMITTED TO GROWING TO MEET THE EVOLVING HEALTHCARE NEEDS OF THE WONDERFUL PEOPLE WHO MAKE ITS REGION SPECIAL.SIGNIFICANT ACCOMPLISHMENTS INCLUDE: - TRANSITIONED TO A NEW MEDICAL DIRECTOR OF WOODSIDE WITH DR. MAMEDI, DR. SEKARAN BECAME THE DIRECTOR OF THE SLEEP LAB. - PLANNED AND OBTAINED FINANCING FOR THE OUTPATIENT, REGISTRATION, AND SURGERY PHASE I CONSTRUCTION AND RENOVATION PROJECT. - IMPLEMENTED MASTER FACILITY PLAN WITH GROUNDBREAKING OF OUTPATIENT, REGISTRATION, AND SURGERY PHASE I CONSTRUCTION AND RENOVATION PROJECT. - RECRUITED THREE PHYSICIAN PRACTICE MANAGEMENT SEMINARS FOR LOCAL PHYSICIANS STAFF. - REDUCED ENVIRONMENTAL SERVICES TURNAROUND TIME FOR CLEANING AN INPATIENT ROOM FROM AN AVERAGE OF 3.5 HOURS TO 60 MINUTES. - RECEIVED FIRST TIME ACCREDITATION OF OUR DIABETES PROGRAM THROUGH AMERICAN ASSOCIATION OF DIABETES EDUCATORS.IMPLEMENTED ELECTRONIC MEDICAL RECORD PROCESS IN THE EMERGENCY CARE CENTER. - REPLACED 200 OF OUR 600 PC'S AND LAPTOPS TO MAINTAIN CURRENT TECHNOLOGY. - EMPLOYEE CAMPAIGNS RAISED OVER $149,000 FOR THE UNITED WAY AND THE HALIFAX REGIONAL FOUNDATION. - COMPLETED SLEEP LAB RENOVATIONS AND EXPANDED TO SIX DAYS PER WEEK WITH NEW REGISTERED SLEEP LAB TECH. - COMPLETED PHASE I OF GI LAB RENOVATIONS. COMPLETED RENOVATION OF MEDICAL CENTER CHAPEL BY VOLUNTEERS. - CREDENTIALED ALL CARDIOLOGY ULTRASOUND STAFF. - THE MEDICAL CENTER AWARDED $47,000 IN TUITION REIMBURSEMENT. - INCREASED USE OF OBSERVATION STATUS OR OUR PATIENTS TO PREVENT READMISSIONS. - IMPLEMENTED JOINT VENTURE WITH RURAL HEALTH GROUP (RHG) FOR MEDICAL CENTER SCHEDULING STAFF TO PLAN FOLLOW UP APPOINTMENTS FOR RHG PATIENTS. - OPENED RENOVATED AREA IN ECC FOR BEHAVIORAL HEALTH PATIENTS TO INCREASE OVERALL CAPACITY. - EXPANDED THE USE OF AUTOMATED DISPENSING UNITES FOR PHARMACY IN AMBULATORY CARE UNIT, RADIOLOGY, AND POST ANESTHESIA CARE UNIT. - CREATED NEW PHARMACY TECHNICIAN POSITION IN SURGERY DEPARTMENT TO ASSIST NURSING AND ANESTHESIA STAFF. - INSTALLED UPFRONT INSURANCE VERIFICATION SOFTWARE TO IDENTIFY INSURANCE AND DEDUCTIONS FOR PATIENTS AND INCREASE CASH COLLECTIONS AND INSTALLED NEW SOFTWARE TO IDENTIFY PATIENT'S FINANCIAL STATUS TO QUALITY FOR CHARITY CARE STATUS. - CREATED NEW POSITIONS OF CLINICAL NURSE AUDITOR AND ACCESS NURSE TO IDENTIFY UTILIZATION STATUS OF PATIENTS AND INCREASE USE OF OBSERVATION STATUS AND DECREASE READMISSIONS. - HEALTHLINK DEVELOPMENT OF TWO NEW COMMUNITY SUPPORT GROUPS FOR CHILDHOOD OBESITY AND BARIATRIC SUPPORT. - LAUNCHED NEW PROCESS IMPROVEMENT PROJECT CALLED THE "PARTNERS PROJECT" UTILIZING FRONTLINE STAFF AND MANAGERS IN 7 WEEKLY TEAMS TO IMPROVE PATIENT FLOW AND PATIENT EXPERIENCE. 94938263 1 1 0 1 0 0 0 0 0 1 0 0 1 1 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 1 0 0 1 87 0 1 969 1 1 1 0 0 0 0 0 0 0 0 0 X 15 12 0 0 0 0 0 0 0 1 1 0 0 1 1 1 1 1 1 1 1 0 NC X X SHERRY JENSEN 2525358005 250 SMITH CHURCH ROAD ROANOKE RAPIDS NC 27870 VERNON BRYANT 1.00 X X 1100 0 0 BOB PATTERSON 1.00 X X 1000 0 0 TOM LYNCH 1.00 X X 1050 0 0 JAMES PIERCE 1.00 X X 800 0 0 JOHNNY DRAPER 1.00 X 1100 0 0 DR NATARAJAN RAJAN 1.00 X 0 0 0 DR GERARDO MARADIAGA 1.00 X 100 0 0 ERNEST L BARNER 1.00 X 700 0 0 DREWERY BEALE 1.00 X 900 0 0 WILLIAM HODGE 1.00 X 1100 0 0 REV JOHN W SMITH 1.00 X 250 0 0 EVELYN DAWSON 1.00 X 550 0 0 FANNIE GREEN 1.00 X 600 0 0 J HUGH BAZEMORE 1.00 X 1100 0 0 WILL MAHONE 40.00 X X 327913 0 67358 SHERRY JENSEN 40.00 X 217152 0 30925 KAREN DANIELS 40.00 X 181182 0 31034 MICHAEL ADCOCK 40.00 X 171067 0 37189 STEVEN HILL 40.00 X 218514 0 37100 KENNETH HARTZ 40.00 X 196086 0 42924 CLAUDE DEITTRICH 40.00 X 194194 0 21033 STEVEN ULSAS 40.00 X 196854 0 3661 JOHN CAMPBELL 40.00 X 185905 0 41802 1899217 0 313026 28 0 1 0 HALIFAX EMERGENCY GROUP 9820 DEPRAM RD ZEBULON NC 27597 ED PHYSICIAN SERVICES 3927764 THEREX INC DEPT AT 952740 ATLANTA GA 31192 PT CONTRACT SERVICES 1419407 COMP HEALTH INC 6440 MILLROCK DR SALT LAKE CITY UT 84121 CONTRACT NURSING 565977 SOUTHEAST ACUTE CARE PO BOX 565 STATEBORO GA 30419 DIALYSIS SERVICES 329150 DIVERSIFIED CLINICAL SERVICES 4500 SALISBURY RD JACKSONVILLE FL 32216 CONTRACT MEDICAL SERVICE 121232 6 43558 387605 431163 NET PATIENT SERVICE RE 541380 101711004 101711004 OTHER PATIENT SERVICES 900099 516244 258310 257934 PURCHASE DISCOUNTS 541900 307752 307392 360 PHARMACY 446110 13054 13054 102548054 664285 664285 58866 90768 -31902 -31902 -31902 5944 225 -225 5944 5719 5719 FOOD/VENDING REVENUE 900099 552374 552374 COFFEE SHOP 453000 178053 178053 730427 104347746 102289760 258294 1368529 961179 485765 475414 64060 64060 33433403 30522574 2910829 1460828 1317230 143598 4232502 3816450 416052 2448260 2207598 240662 258220 258220 154574 154574 127755 127755 14025 14025 12457557 12391925 65632 207774 207774 17611329 16799995 811334 667840 667840 1088630 1088630 201039 163930 37109 793817 793817 3272746 3272746 730756 500982 229774 BAD DEBT EXPENSE 20619065 20619065 RECRUITMENT 162129 162129 MISCELLANEOUS EXPENSES 89189 17882 71307 101056677 94938263 6118414 0 9860154 8060547 4178130 2188820 13322408 12807176 1116735 1174571 1094848 1118829 67270731 45010982 22441539 22259749 8854799 16875432 89574 79725 13621067 16599503 74579254 81164352 9441088 8899131 15460376 21179840 10154764 12364728 35056228 42443699 X 39506357 38493632 16669 227021 39523026 38720653 74579254 81164352 X 3291069 -4093442 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 14025 14025 0 EXPLANATION OF OTHER LOBBYING ACTIVITIES: PART II-B, LINE 1I: THE ORGANIZATION IS A MEMBER OF THE AMERICAN HOSPITAL ASSOCIATION AND THE NORTH CAROLINA HOSPITAL ASSOCIATION. A PORTION OF DUES PAID TO THESE ORGANIZATIONS IS ALLOCATED TO LOBBYING EFFORTS ON BEHALF OF THE MEMBERSHIP BODY. THE PORTION OF DUES PAID TO THESE ORGANIZATIONS FOR THE YEAR THAT CONSTITUED LOBBYING WAS APPROXIMATELY $ 14,025. 932707 932707 31861428 22151790 9709638 1281997 891314 390683 31596902 21967878 9629024 1597697 1597697 22259749 OTHER RECEIVABLES 1819744 DUE FROM ROANOKE VALLEY HEALTH SERVICES, INC. 14344942 UNAMORTIZED BOND ISSUANCE COSTS 434817 16599503 THIRD PARTY PAYOR SETTLEMENT 2284451 PENSION PLAN CONTRIBUTION LIABILITY 10080277 12364728 104347746 101056677 3291069 -8016 -4085426 -4093442 -802373 100345072 -8016 -3994658 -4002674 104347746 0 104347746 101147445 90768 90768 101056677 0 101056677 DESCRIPTION OF UNCERTAIN TAX POSITIONS UNDER FIN 48: PART X: THE MEDICAL CENTER IS EXEMPT FROM FEDERAL INCOME TAXES UNDER SECTION 501(C)(3) OF THE INTERNAL REVENUE CODE; ACCORDINGLY, THE ACCOMPANYING COMBINED FINANCIAL STATEMENTS DO NOT REFLECT A PROVISION OR LIABILITY FOR FEDERAL AND STATE INCOME TAXES. THE MEDICAL CENTER HAS DETERMINED THAT IT DOES NOT HAVE ANY MATERIAL UNRECOGNIZED TAX BENEFITS OR OBLIGATIONS AS OF SEPTEMBER 30, 2011 AND 2010. THE MEDICAL CENTER BELIEVES IT IS NO LONGER SUBJECT TO INCOME TAX EXAMINATIONS FOR YEARS PRIOR TO SEPTEMBER 30, 2008. PART XI, LINE 8 - OTHER ADJUSTMENTS: CHANGE IN VALUE OF DEFINED PENSION PLAN -3,455,395. TRANSFER OF EQUITY -630,031. PART XII, LINE 2D - OTHER ADJUSTMENTS: RENTAL EXPENSES 90,768. CHANGE IN VALUE OF DEFINED PENSION PLAN -3,455,395. TRANSFER OF EQUITY -630,031. PART XIII, LINE 2D - OTHER ADJUSTMENTS: RENTAL EXPENSES NET W/ REVENUES 90,768. 1 1 1 X 1 X 1 1 1 0 1 1 963890 963890 0.01200 15038330 12093018 2945312 0.03660 16002220 12093018 3909202 0.04860 1131302 351224 780078 0.00970 858703 0 858703 0.01070 4547 4547 0.00010 1994552 351224 1643328 0.02050 17996772 12444242 5552530 0.06910 6 6687 6687 0.00010 1 762 762 0.00000 2 22000 22000 0.00030 9 29449 29449 0.00040 1 6587539 790500 39184240 39071668 112572 X 1 1 1 1 HALIFAX REGIONAL MEDICAL CENTER

250 SMITH CHURCH ROAD ROANOKE RAPIDS NC 27870

X X X DISPROPORTIONATE SHARE HOSPITAL NA FOR 2010 1 1 HALIFAX HEALTHLINK

1620 E 10TH ST 148 ROANOKE RAPIDS NC 27870

COMMUNITY EDUCATION PART I, LINE 7: THE ORGANIZATION CALCULATES AN INTERNAL COST-TO-CHARGES RATIO USED TO COMPUTE CHARITY CARE, UNREIMBURSED MEDICAID, AND SUBSIDIZED HEALTH SERVICES AT COST FOR PURPOSES OF PART I, LINE 7. PART I, LINE 7G: SUBSIDIZED HEALTH SERVICES REPORTED ON LINE 7(G) INCLUDE A PSYCH UNIT AND LABOR/DELIVERY UNIT. PART I, L7 COL(F): THE TOTAL EXPENSE LISTED ON FORM 990, PART XI, LINE 25 CONTAINS BAD DEBT EXPENSE OF $20,619,065 WHICH HAS BEEN REMOVED FOR PURPOSES OF THE CALCULATION OF CHARITY CARE PERCENTAGE FOR PART I, LINE 7, COLUMN (F). PART II: HOSPITAL EMPLOYEES ROUTINELY DEVOTE THEIR TIME TO SERVICE ON THE CITY COUNCIL AND THE LOCAL CHAMBER OF COMMERCE TO PROMOTE COMMUNITY ECONOMIC DEVELOPMENT. IN ADDITION, HOSPITAL EMPLOYEES ALSO DEVOTED TIME TO EMERGENCY PREPAREDNESS CAUSES, AND THE HOSPITAL GAVE TO SUPPORT THE ROANOKE VALLEY CHAMBER'S BUILDING FUND AND THE BUSINESS EDUCATION PARTNERSHIP.IN THE TAX YEAR, THE HOSPITAL WORKED TO RECRUIT TWO OB-GYN PHYSICIANS TO THE AREA. PART III, LINE 4: THERE IS NOT A FOOTNOTE IN THE FINANCIAL STATEMENTS TO DESCRIBE THE BAD DEBT EXPENSE.THE METHODOLOGY USED TO DETERMINE BAD DEBT AT COST IS THE ANDI METHODOLOGY WHICH USES A FACILITY WIDE COST TO CHARGE RATIO AS DESCRIBED IN THE 2010 NCHA COMMUNITY BENEFITS GUIDELINES.THE PERCENTAGE OF THE POPULATION BELOW THE POVERTY LINE IN OUR SERVICE AREA IS APPROXIMATELY 25%. BASED ON OUR PAST EXPERIENCE WITH PATIENTS WITH UNPAID CHARGES, ABOUT 10 TO 12% WOULD QUAILFY FOR CHARITY CARE IF THE APPROPRIATE DOCUMENTATION WERE RETURNED. PART III, LINE 8: APPROXIMATELY 50% OF THE HOSPITAL'S TOTAL CHARGES ARE FROM MEDICARE. APPROXIMATELY 16% OF THE POPULATION OF HALIFAX COUNTY IS AGE 65 AND OVER. THE HOSPITAL HAS A RESPONSIBILITY TO THE COMMUNITY TO PROVIDE QUALITY CARE, AND THE SHORTFALL FOR OUR MEDICARE COST OF CARE SHOULD BE CONSIDERED A COMMUNITY BENEFIT. PART III, LINE 9B: HALIFAX REGIONAL MEDICAL CENTER WORKS TO QUALIFY PATIENTS FOR FINANCIAL ASSISTANCE BEFORE ASSIGNING UNPAID ACCOUNTS TO OUTSIDE COLLECTION AGENCIES. THE HOSPITAL PURCHASED SOFTWARE SERIVCES THIS YEAR TO MAKE IT EASIER TO QUALIFY PATIENTS FOR CHARITY CARE. WE ALSO WORK WITH VANGUARD SERVICES TO HELP PATIENTS QUALIFY FOR MEDICAID AND OTHER INSURANCES. HRMC STRIVES TO HELP PATIENTS QUALIFY FOR APPROPRIATE FINANCIAL ASSISTANCE BEFORE SENDING ACCOUTNS TO BAD DEBT COLLECTION AGENCIES. THE COMMUNITY HEALTH IMPROVEMENTS SERVICES NOTES ON PART I, LINE 7(E) INCLUDE THE FOLLOWING; PART VI, LINE 2: THE HOSPITAL WORKS CLOSELY WITH THE LOCAL HEALTH DEPARTMENTS TO DETERMINE THE HEALTH NEEDS OF OUR COMMUNITY. CASE MANAGERS ALSO PROVIDE FEEDBACK INFORMATION ON OUR PATIENT NEEDS. OUR BOARD OF DIRECTORS IS COMPRISED OF LOCAL COMMUNITY LEADERS AND HAS VALUABLE INFORMATION ABOUT THE NEEDS OF OUR COMMUNITY. RECENTLY, THE HOSPITAL HAS BEGUN WORKING WITH THE AREA HEALTH DEPARTMENTS AND OTHER AGENCIES ON OUR COMMUNITY HEALTH ASSESSMENT REQUIRED IN FY'13. PART VI, LINE 3: THE HOSPITAL'S CHARITY CARE POLICY IS POSTED ON THE WEBSITE AND ON SIGNAGE THROUGHTOUT THE HOSPITAL FACILITY. OUR COLLECTORS ARE FAMILIAR WITH THE POLICY AND APPLY IT AS APPROPRIATE WHEN COLLECTING PATIENT ACCOUNTS. TO REDUCE THE LIKELIHOOD OF QUALIFIED CHARITABLE RECIPIENTS ESCAPING BENEFITS UNDER THE POLICY, WE HAVE IMPLEMENTED SOFTWARE THIS YEAR THAT ALLOWS OUR STAFF TO MORE EASILY IDENTIFY QUALIFIED CASES. PART VI, LINE 4: THE HOSPITAL'S PRIMARY SERVICE AREA CONSISTS OF HALIFAX COUNTY AND NORTHAMPTON COUNTY, NORTH CAROLINA. THE POPULATION OF HALIFAX COUNTY IN 2010 WAS 54,691. THE PERSONS OVER 65 YEARS OF AGE WAS 16.2% AND PEOPLE LIVING BELOW THE POVERTY LEVEL IS ESTIMATED AT 23.8%.NORTHAMPTON COUNTY POPULATION IN 2010 WAS 22,099. PEOPLE OVER 65 YEARS OF AGE WAS 19.6%. THE UNEMPLOYMENT RATE IN BOTH COUNTIES IS APPROXIMATELY 12%. 80% OF HRMC'S REVENUE MIX COMES FROM MEDICARE, MEDICAID, AND SELF PAY. PART VI, LINE 6: HALIFAX REGIONAL MEDICAL CENTER WORKS CLOSELY WITH THE AREA COUNTY HEALTH DEPARTMENTS TO DO COMMUNITY HEALTH ASSESSMENTS AND DETERMINE HEALTH NEEDS IN THE AREA. HRMC ALSO WORKS CLOSELY WITH THE RURAL HEALTH GROUP AND HAS IMPLEMENTED A CASE MANAGEMENT PROGRAM FOR HEART FAILURE PATIENTS. HRMC PROVIDES COMMUNTIY HEALTH INFORMATION, EDUCATION, AND EXERCISE THROUGH OUR HEALTHLINKS IN THE LOCAL MALL. ON THE HRMC WEBSITE, THERE IS A LINK TO SIGN UP FOR FREE HEALTHED EMAILS THAT CONTAIN FREE TIPS FOR A HEALTHY LIFESTYLE AND NOTICES ABOUT HEALTHY ACTIVITIES AND EDUCATION.A MAJORITY OF THE ORGANIZATION'S GOVERNING BODY IS COMPRISED OF PERSONS WHO RESIDE IN THE ORGANIZATION'S PRIMARY SERVICE AREA AND WHO ARE NEITHER EMPLOYEES NOR INDEPENDENT CONTRACTORS OF THE ORGANIZATION NOR FAMILY MEMBERS THEREOF. THE ORGANIZATION EXTENDS MEDICAL STAFF PRIVILEDGES TO ALL QUALIFIED PHYSICIANS IN THE COMMUNITY FOR MANY OF ITS DEPARTMENTS.ANY SURPLUS OF FUNDS IS REINVESTED INTO THE HOSPITAL BY PURCHASE NEW EQUIPMENT AND REPLACE EXISTING EQUIPMENT, UPDATE THE BUILDING STRUCTURE, AND IMPROVE OPERATIONS. WE ALSO USE FUNDS TO IMPROVE QUALITY OF CARE AND PROVIDE EDUCATIONAL OPPORTUNITIES FOR STAFF MEMBERS. PART VI, LINE 7: THE ORGANIZATION IS NOT PART OF AN AFFILIATED HEALTH CARE SYSTEM. REPORTS FILED WITH STATES PART VI, LINE 7 NC X X X X X 0 1 0 0 0 0 0 1 0 WILL MAHONE 261320 0 52297 0 14296 0 38500 0 28858 0 395271 0 0 0 SHERRY JENSEN 186489 0 30663 0 0 0 15059 0 15866 0 248077 0 0 0 KAREN DANIELS 155840 0 25342 0 0 0 22000 0 9034 0 212216 0 0 0 MICHAEL ADCOCK 146387 0 24680 0 0 0 16500 0 20689 0 208256 0 0 0 STEVEN HILL 218514 0 0 0 0 0 21725 0 15375 0 255614 0 0 0 KENNETH HARTZ 196086 0 0 0 0 0 22000 0 20924 0 239010 0 0 0 CLAUDE DEITTRICH 194194 0 0 0 0 0 447 0 20586 0 215227 0 0 0 STEVEN ULSAS 196854 0 0 0 0 0 0 0 3661 0 200515 0 0 0 JOHN CAMPBELL 185905 0 0 0 0 0 21174 0 20628 0 227707 0 0 0 PART I, LINE 4B THE ORGANIZATION PROVIDES A SUPPLEMENTAL NON-QUALIFIED ANNUITY PLAN TO THE CEO. FOR 2010, WILL MAHONE ACCRUED $14,148 UNDER THIS PLAN. IT IS REPORTED ON SCHEDULE J, PART II, COLUMN B(III) AS OTHER REPORTABLE COMPENSATION. PART I, LINE 7 THE OFFICERS LISTED BELOW ARE RECIPIENTS OF NON-FIXED PAYMENTS FROM THE ORGANIZATION. THE CEO AND VICE PRESIDENT RECEIVE AT-RISK SALARY PAYMENTS FROM THE ORGANIZATION BASED ON REACHING BALANCED SCORECARD OBJECTIVES. THE AMOUNT AVAILABLE IS THE AT-RISK SALARY AVAILABLE FOR THE INDIVIDUAL POSITIONS. FOR 2010, THE FOLLOWING OFFICERS RECEIVED PAYMENTS UNDER THIS PLAN: WILL MAHONE $ 52,262 SHERRY JENSEN 30,633 KAREN DANIELS 25,302 MICHAEL ADCOCK 24,665 NORTH CAROLINA MEDICAL CARE COMMISSION 521309402 NONEAVAIL 2011-07-28 6500000 CAPITAL ACQUISITION 0 0 0 6500332 26543 130000 927183 5572140 2011 0 0 0 1 0 0 0 0 1 0.00000 0.00000 0.00000 1 0 1 0 0 0 1 PAULA ELIAS DAUGHTER-IN-LAW OF DREWERY BEALE, BOARD MEMBER 33839 COMPENSATION AS AN EMPLOYEE OF ORGANIZATION 0 MARIA MARADIAGA SPOUSE OF GERARDO MARADIAGA, BOARD MEMBER 30221 COMPENSATION AS AN EMPLOYEE OF ORGANIZATION 0 FORM 990, PART VI, SECTION B, LINE 11 THE RETURN WAS PREPARED BY AN INDEPENDENT ACCOUNTING FIRM WITH ASSISTANCE AND INFORMATION PROVIDED BY MANAGEMENT. THE HOSPITAL PROVIDED EVERY VOTING BOARD MEMBER A COPY OF THE DRAFT 990 PRIOR TO A SCHEDULED MEETING. DETAILS OF THE RETURN WERE DISCUSSED WITH MANAGEMENT AND THE FINANCE COMMITTEE OF THE BOARD, WHO THEN DELIVERED A REPORT TO THE FULL BOARD PRIOR TO FILING THE RETURN WITH THE IRS. FORM 990, PART VI, SECTION B, LINE 12C (BYLAWS, ARTICLE 2, SECTION 3) "ANY DUALITY OF INTEREST OR POSSIBLE CONFLICT OF INTEREST ON THE PART OF ANY GOVERNING BOARD MEMBER SHALL BE DISCLOSED TO THE OTHER MEMBERS OF THE BOARD OF DIRECTORS AND MADE A MATTER OF RECORD THROUGH AN ANNUAL PROCEDURE AND ALSO WHEN THE INTEREST BECOMES A MATTER OF BOARD ACTION. ANY GOVERNING BOARD MEMBER HAVING A DUALITY OF INTEREST OR POSSIBLE CONFLICT OF INTEREST ON ANY MATTER SHALL NOT VOTE OR USE PERSONAL INFLUENCE ON THAT MATTER, AND SHALL NOT BE COUNTED IN DETERMINING THE QUORUM FOR THE MEETING, EVEN WHERE PERMITTED BY LAW. THE MINUTES OF THE MEETING SHALL REFLECT THAT A DISCLOSURE WAS MADE, THE ABSTENTION FROM VOTING, AND THE QUORUM SITUATION. ANY EXISTING OR APPARENT CONFLICT OF INTEREST WILL BE REFERRED TO THE EXECUTIVE COMMITTEE OF THE BOARD FOR RESOLUTION." THE CONFLICT OF INTEREST POLICY IS REVIEWED ANNUALLY. BOARD MEMBERS AND HOSPITAL MANAGEMENT PERSONNEL ARE REQUIRED TO COMPLETE A CONFLICT OF INTEREST QUESTIONNAIRE EACH YEAR. FORM 990, PART VI, SECTION B, LINE 15 THE ORGANIZATION ENGAGES AN OUTSIDE INDEPENDENT CONSULTANT FOR REVIEW OF COMPENSATION PACKAGES. THE CONSULTANT USES COMPARABLE POSITIONS AND BENCHMARKS TO EVALUATE THE SALARIES FOR THE CEO AND VICE PRESIDENTS. THE EXECUTIVE COMMITTEE OF THE BOARD OF DIRECTORS REVIEWS THE CONSULTANT'S RECOMMENDATIONS, AND THE FULL BOARD APPROVES THE COMPENSATION PACKAGE SELECTED FOR THE CEO. THE CONSULTATION PROCESS FOR OTHER OFFICERS INVOLVES THE INDEPENDENT CONSULTANTS; HOWEVER, THE CEO HAS FINAL APPROVAL OVER COMPENSATION PACKAGES FOR VICE PRESIDENTS AND BELOW. FORM 990, PART VI, SECTION C, LINE 18 PHOTOCOPIES OF THE FORM 990 ARE AVAILABLE UPON REQUEST AT THE ORGANIZATION'S ADMINISTRATIVE OFFICE. IN ADDITION, RECENT FILINGS OF THE FORM 990 ARE AVAILABLE ONLINE AT WWW.GUIDESTAR.ORG. FORM 990, PART VI, SECTION C, LINE 19 PHOTOCOPIES OF THE ORGANIZATION'S GOVERNING DOCUMENTS, CONFLICT OF INTEREST POLICY, AND FINANCIAL STATEMENTS ARE AVAILABLE UPON WRITTEN REQUEST AT THE ORGANIZATION'S ADMINISTRATIVE OFFICE. CHANGES IN NET ASSETS OR FUND BALANCES: FORM 990, PART XI, LINE 5: NET UNREALIZED LOSSES ON INVESTMENTS: -8,016. CHANGE IN VALUE OF DEFINED PENSION PLAN -3,455,395. TRANSFER OF EQUITY -630,031. TOTAL TO FORM 990, PART XI, LINE 5: -4,093,442. FORM 990, PART XII, LINE 2C: THE PROCESS HAS NOT CHANGED FROM THE PRIOR YEAR. HALIFAX REGIONAL MEDICAL CENTER FOUNDATION INC 250 SMITH CHURCH ROAD ROANOKE RAPIDS NC 27870 561698825 FUNDRAISING FOR ASSOCIATED CHARITABLE ORGANIZATION NC 501(C)(3) LINE 7 HALIFAX REGIONAL MEDICAL CENTER INC 1 ROANOKE VALLEY HEALTH SERVICES INC 250 SMITH CHURCH ROAD ROANOKE RAPIDS NC 27870 561925492 HEALTHCARE NC 501(C)(3) LINE 3 HALIFAX REGIONAL MEDICAL CENTER INC 1 1 1 1 1 0 0 0 0 0 0 0 1 0 0 0 0 1 0 ROANOKE VALLEY MEDICAL SERVICES A 5000 FMV RENT ROANOKE VALLEY MEDICAL SERVICES B 630031 CASH ROANOKE VALLEY MEDICAL SERVICES Q 2828609 NET INTERCO. TRANS. ROANOKE VALLEY MEDICAL SERVICES D 14344942 INTERCO. A/R